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AT  THE 


USIVUBSITV  OF 
TORONTO  PRESS 


MEDICAL  RECORD 


A    Weekly  yoiirnal  of  Medicine  and  Surgery 


EDITKl  I     BY 

GEORGE    E.   SHRADY,   A.M.,   M.D. 

SURr.EON    TO   ST.    FRANXIS   HOSPITAL,    NEW    YORK  ;    CONSULTING    SLRGEON   TO    THE    NEW    YORK  CANCER    HOSPITAL.    Tel   THE   COLUMBUS 

HOSPITAL.    NEW     YORK,     TO    THE    NEW    YORK    RED   CROSS    HOSPITAL,     AND     CONSULTING     PHYSICIAN-IN-CHIEF 

TO    THE    HOSPITALS    OF     IHE    HEALTH    IIEP.-VRTMENT    OF   THE    CITY'    I  IF   NEW    YORK 


lloUunc   32 

JULY    3.   1897— DECEMBER    25,    1S97 


NEW    YORK 

WILLLA.M     WOOD     AND     COMPANY 
1897 


tA 


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Thk  t'l  BLisnKRti'  Printino  Company. 

_,-^  irnJ  ,,v  Lafayetl,-  Pla<\-. 

Nkw  York.. 


LIST   OF   CONTRIBUTORS  TO   VOL.    LII 


Aakun,   Dk.   Charlks   D..  Detroit, 

Mich. 
Abbe,  Dr.  Robert,  New  York. 
Acer,    Dr.    Louis    C'.,     Brooklyn, 

N.  Y. 
AiKiN,  Dr.  J.  M.,  Omaha,  Neb. 
Allen,     Dr.    Charles    \\'.,     New 

York. 
Allen,  Dr.  J.  Q.,  Montrose,  Col. 
Allport,  Dr.  Frank,  Chicago,  111. 
Ames,  Dr.  Delano,  Baltimore,  Md. 
Anderson,  Dr.  R.  Harcocrt,  New 

York. 
Atlee,  Dr.  L.  \V..  C.  -S.  Navy. 

Bailey,  Dr.  Williajc  Curtiss,  New 
York. 

Baketel,  Dr.  H.  S.,  Derry,  N.  H. 

Baldwin,  Dr.  J.  F.,  Columbus,  O. 

Balleray,  Dr.  G.  H.,  Paterson,  N.J. 

Banks,  Dr.  W.  Mi^hell,  Liver- 
pool, Eng. 

Bard,  Dr.  Cephas  L.,  Ventura,  Cal. 

Barton,  Dr.  Joshia  Lindi.f.y,  New 
York. 

Battle,  Dr.  S.  Westrav.  Asheville. 
N.  C. 

Bell,  Dr.  John  N.,  Detroit,  Mich. 

Berg,  Dr.  Albert  A.,  New  York. 

Besser,  Dr.  Herman,  New  York. 

Bird,  Dr.  U.  S.,  Tampa,  Fla. 

Bishop,  Dr.  Louis  Faugeres.  New 
York. 

Blackford,  Dr.  C.  M.,  Jr..  At- 
lanta, Ga. 

Blanchard,  Mr.  W.  \L.  .\shland. 
Va. 

Bleyle.  Dr.  Her.man  ('.,  Newark, 
N.  J. 

Block,  Dr.  J.,  Kansas  City,  Mo. 

Bogardus,  Dr.  F.  \V.,  Poplar 
Ridge,  N.  Y. 

Brazeau,  Dr.  G.  N.,  Fond  du  Lac, 
Wis. 

Breiter,  Dr.  Nathan,  New  York. 

Bridges,  Dr.  W.  O.,  Omaha,  Neb. 

Brinton,  Dr.  John  H.,  Philadel- 
phia, Pa. 

Brcjvvn,  Dr.  Adolph  G.,  Red  Bank, 
N.  J. 

Brown,  Dr.  J.  C,  Smethport,  Pa. 

Brown,  Dr.  Sanger,  Chicago,  111. 

Browning,  Dr.  Charles  C.,  High- 
land, Cal. 

Brunton,  Dr.  T.  Lauder,  London, 
Eng. 

Buck,  Dr.  Albert  H.,  New  York. 

BucKE,  Dr.  R.  M.,  London,  Ont. 

Burrall,  Dr.  F.  A.,  New  York. 

Caglieri,  Dr.  Guido  F.,  -San  Fran- 
cisco, Cal. 

Campbell,  Dr. Given,  St.  Louis,  Mo. 

Cantrell,  Dr.  J.  Abbotp,  Phila- 
delphia, Pa. 

Carhart,  Dr.  William  Mkrle 
D'Aurignk,  New  York. 


Ca-ssidy,    Dr.    Patrick,     Norw'ich, 

Conn. 
Cattell,    Dr.    Henry    W.,   Pliila- 

delphia,  Pa. 
Cha.mberlin,  Dr.  E.  C.,New  York 
Champlin,  Dr.  S.  H.,  Chicago,  111. 
Chappell,  Dr.    Walter    F.  ,   New 

York. 
Chetwood,  Dk.  Charles  H.,  New 

York. 
Cheyne,    Mr.     Watson,     London, 

Eng. 
ClarKj  Dr.  F.  H  ,  Brooklyn,  N.  \'. 
Clark,  Dr.  L.  Pierce,  Sonyea,  N.Y. 
Colby,    Dr.    C,    D.    W.,   Jackson, 

Mich. 
CoLEY,  Dr.  William  B.,  New  York. 
Corbett,    Dr.   John   W.,  Camden, 

S.   C. 
Cordier,  Dr.  .A.   H.,  Kansas  Citv, 

Mo. 
Cragin,     Dr.     Edward     B.,    New 

York. 
Cronkhh  E,  Dk.  C.  C,  Marion,  Ind. 
Cross,  Dr.  J.  G.,  Rochester,  N.  Y. 

Daley,  Dr.  R.  N.,  Boston,  Mass. 

Dana,  Dr.  Charles  L.,  New  York. 

Davis,  Dr.  Byron  B.,  Omaha,  Neb. 

Davis,  Dr.  Will  B.  ,  Pueblo,  Col. 

Davison,  Dr.  William  A.,  Butte, 
Mont. 

De  B.\un,  Dr.  Edwin,  Passaic,  N.  J. 

Deitrich,  Dr.  W.  A.,  Lookout 
Mountain,  Tenn. 

Donovan,  Dr.  Alfred  Q.,  Eliza- 
beth. N.  J. 

Dowd,  Dr.  Charles  N.,  New  York. 

Dowling,  Dr.  John  F.  ,  Hartford, 
Conn. 

Drescher,  Mr.  .August,  Newark, 
N.    J. 

Edwards,  Dr.  Joseph    F.  ,  .Atlantic 

City,  N.  J." 
Ellis,  Dr    Richard,  New  York. 
Ensign,  Dr.  O.  S.,  Ontario,  Cal. 
Epley,  Dr.  F".  W.,  New  Richmond, 

Wis. 
F.RDMANN,  Dr.  John  F.  ,  New  York. 
Erwin,  Dr.  R.  W.,  Bay  City,  Mich. 
Ettinger,  Dr.  Leo,  New  York. 

Fehleisen,  Dr.   F.,  San  Francisco, 

Cal. 
Fischer,  Dr.  Louis,  New  York. 
Flagg,  Dr.  Cora  Hosmer,  Boston, 

Mass. 
Fleming,     Dr.     Luke,    Tarrvtown, 

N.  Y. 
Follett,  Dr. a.  C,  Schenevus,  N.N". 
Fonde,  Dr.  Kieth,  Citronelle,  Ala. 
Fort,  Dr.  J.  A.,  Paris,  France. 
Frank,  Dr.  Jacob,  Chicago,  III. 
Fuld,  Dr.  Joseph  E.,  New  York. 
Fulton,  Dr.  Henry  I).,  Pittsburg, 

Pa. 


F'URNISS,  Dr.  H.  W  . ,  Indianapolis, 
Ind. 

Gall.ant,  Dr.  .A.  ER.NE.sr,  New 
York. 

Gikbs,  Dr.  W.  S.,  Omaha,  Neb. 

Gibson,  Dr.  C.  L.  ,  New  York. 

GiFFORD,  Dr.  Harold,  Omaha,  Neb. 

Gleitsmann.  Dr.  J.  W  .  New  York. 

Goelet,  Dr.  Augustix  H..  New- 
York. 

Goldha.mmer,  Dr.  Adolph.  New- 
York 

GoLTMAN.  Dr.  Abr.\ham.  New  York. 

GoTTHEiL.  Dr.  WiLLiA-M  S. ,  Ncw 
York. 

Grandin,  Dr.  F.gi;ert  H.,  New 
York. 

Graves,  Dr. Marvin  .\.. Waco,  Tex. 

Greene,  Dr.  J.  H.,  Dubuque,    la. 

GuiTERAs,  Dr.  Ramon.  New  York. 

Hall,  Dr.  A.  Llewellyn,  Fair 
Haven,  N.  Y. 

Hall,  Dr.  J.  N.,  Denver,  Col. 

Halliday,  Dr.  Andrew,  Shubena- 
cadie,  N.  S. 

Harris,  Dr.  Thomas  J.,  New  York. 

HARRist)N.  Mr.  Reginald,  London, 
Eng. 

Hawkins,  Dr.  Iho.mas  H..  Den- 
ver, Col. 

Hemmeter,  Dr.  John  C.  Balti- 
more, Md. 

Henson,  Dr.  J.  W. .  Richmond.  \n. 

HiLLis,  Dr.  T.  J.,  New  York.  ■ 

Huddlestun,  Dr.  J.  H.,  New  York. 

Hughes,  Dr.  Oliver  J.  D..  Me~.- 
den.  Conn. 

Hutchinson.  Dr.  \\'oods,  Buffalo. 
N.  Y. 

Ill,  Dr    Edward  J.,  Newark,  N.  J. 
Inglis,  Dr.   David,   Detroit,  Mich. 
Irwell,    Mr.   LaW'Rence,    Buffalo, 
N.  Y. 

Jacobi,  Dr.  a..  New  York. 
Jacobi,   Dr.    Mary    Putnam,   .New 

York. 
Jenkins,    Dr.     J.     F.,    'i'ecumseh, 

Mich. 
Jewett,  Dr.  H.  S.,  Dayton,  Ohio. 
Jonas,  Dr.  A.   F. ,  Omaha,  Neb. 
Jones,  Dr.  Mary  A.   Di.xon.   New 

York. 

Kammerer,  Dr.  F'red.,  New  York. 
Kemp,  Dr.  Robert  Coleman,  New 

York. 
K.ILMER,    Dk.      Thkron     W.,    New 

York. 
King,  Dr.  G.  W.,  Helena,  Mont. 
KiNGSLEY,  Dr.  B.   F.,  San  Antonio, 

Te.xas. 
KiNNEAR,    Dr.    Beverley    Oliver, 

New  York. 


COXTRIBLTORS    TO    VOL.     LII. 


Knapp,  Dr.  Mark  I.,  New  Y<jrk. 
Knight,  Dr.  N.,  Ashland,  Va. 
Knopf,  Dr.  S.  A.,  \ew  York. 
KoPLiK,  Dr.  Henry,  New  York. 
KosER,  Dk.  S.  S.,  William.sport,  Pa. 
KvDD,  ]JR.   Mary   Mitchki.i,,   New 
York. 

Langdon,  Dr.  Iharlks  H.,  I'ough- 

keepsie,  N.  Y. 
Leitch,     Mary     and      Margarkt, 

Roxbury,  Mass. 
Lewis,  Dr.  Charles  H.,  New  ^ork. 
Levien,  Dr.    Henry,  New  York. 
LovELAND,     Dr.      B.     C.     Clifton 

Springs,  N.  Y. 
Lynch,  Dr.  Junius  F.,  Norfolk,  Ya. 

McBuRNEY,  Dr.  Charles,  New- 
York. 

McCooK,  Dr.  John  H.,  Hartford, 
Conn. 

McGiLLicuDDY,  Dr.  T.  J.,  New- 
York. 

Manley,  Dr.  Thomas  H.,  New 
York. 

Marshall,  Dr.  D.  T.,  New  York. 

MASseY,  Dr.  G.  Betton,  Philadel- 
phia, Pa. 

Matthews,  Dr.  A.  C,  New  York. 

Maxson,  Dr.  Edwin  R.,  Syracuse, 
N.  Y. 

May,  Dr. William  H.,Syracuse,N.Y. 

Meirowitz,  Dr.  Philip,  New  York. 

Melvin,  Dr.  J.  Tracey,  Saguache, 
Cal. 

Mereness,Dr.Seth  A., Albany, N.Y. 

Meyer,  Dr.  Willy,  New  York. 

Milbury,  Dr.  Frank  S.,  Brooklyn, 
N.  Y. 

Milligan,  Dr.  E.  T.,  Detroit,  Mich. 

Milton,  Mr.  HERBERT.Cairo, Egypt. 

Mitchell,  Dr.  Clifford,  Chicago, 
111. 

Mitchell,  Dr.  Hubbard  Winslow, 
New  York. 

Moore, Dr. Yeranus  A.,Ithaca,N.Y. 

Morris,  Mr. Malcolm, London, Eng. 

MosER,  Dr.  W.,  Brooklyn,  N.  Y. 

Mover,  Dr. Harold  N., Chicago, 111. 

MuiR,  Dr.  Joseph,  New  York. 

MuNDE,  Dr.  Paul  F.,  New  York. 

Murdock,  Dr.  G.  W.,  ("old  Spring, 
N.  Y. 

Murphy,  Dk.  Wai.ikr  d.,  East 
Hartford,  Conn. 

Newman.  Dr.  Robert,  New  York. 

NiCHOL,  Dr.  Rawlings,  New  York. 

Nichols,  Dr.  J.  B., Washington, D.C. 

Nieschang,  Dr.  Charles  C.  F., 
Fort  Wayne,  Ind. 

Nobles,  Dr.  Newman  T.  B.,  Cleve- 
land, Ohio. 

NoYES,  Dr.  Henry  !)..  New  \'ork. 

O'Neill,  Dr.  J.  A.,  New  York. 
OsLER,  Dr.  William,  Baltimore.Md. 

Palier,  Dr.  E.,  New  York. 

Paquin,  Dr.  Paul,  St.  Louis,  Mo. 

Park,  Dr.  Roswell,  Buflfalo,  N.  Y. 

Patterson,  Dr.  A.  Bethune,  At- 
lanta, Ga. 

Peterson,  Dr.  Fredkkick.  Ni-w 
York. 


I'iFFARD,  Dr.  Henry  G,  New  York. 
Poole,  Dr.  Herman,  New  York. 
Porteous,   Dr.    J.    Lindsay,   Yon- 

kers,  N.  Y. 
Porter,  Dr.  H.  R  ,  Bismarck,  N.  D. 
Posr,  Dr   Sarah  E, ,  Brooklyn, N.Y. 
Powers.  Dr    F.,  Westport,  Conn. 
Pkait,  Dr.  Frank  P.. Jackson, Mich. 
Prentiss,  Dr.  D.    W.,  Washington, 

1)    C. 
Price,  Dr.  N.  Gordon,  New  York. 
Pryor,  Dr.  W.  R.,  New  York. 
Purringtox,  Mr.  W.  A.,  New  York. 

Reese,  Dr.  F.  D.,  Cortland,  N.  Y. 
Renner,  Dr.  W.  ScoTT,Buffalo,N.  Y. 
Ritchie,  Dr.  H.  P.,  St.  Paul,  Minn. 
Robinson, Dr.  William  J., New  York. 
Roddick.  Dr.  T.  G.,  Montreal,  Can. 
Rodman,  DR.C.S.,Waterbury,Conn. 
Rosenberry,     Dr.     A.    B,    .\rbor 

Vita?,  Wis. 
RuMER,  Dr.  J.    F.,  Davison,  Mich. 
Rupp,  Dr.  .\dolph.  New  "\'ork. 

Sanarelli,  Dr.  Guiseppe,  Monte- 
video, Uruguay. 

Savidge,  Dr.  Eugene  Colenl^n, 
New  York. 

S.AXE,  Dr.  George  G.,  Watertown, 
S.  D. 

ScHAPPS,  Dr.  John  C,  Pueblo,  Col. 

Schlatter,  Dr.  Carl,  Zurich, 
Switzerland. 

Sebring,  Dr.W.  C.,Pine  Bush,N.Y. 

Senn,  Dr.  Emanuel  j., Chicago,  111. 

Senn,  Dr.  N.,  Chicago,  111. 

Shaffer, Dr. Newton  M.,New  York. 

Shradv,  Dr.  George  F.,  New  York. 

SiFF,  Dr.  H  ,  New  York. 

Smith,  Dr.  E.  H.,  Santa  Clara,  Cal. 

Smith,  Dr.  William  T.,  Hanover, 
N.  H. 

Somers,  Dr.E.M.,  Ogdensburg,N.Y. 

Sparks,  Dr.  Agnes,  Brooklyn,  N.  Y. 

Spratlixg,  Dr.  Edgar  J.,  Fishkill 
Landing,  N.  Y. 

Spratling,  Dr.  William  P..  Son- 
yea,  N.  V. 

Squires,  Dr.    H.  S.,  Mexico,  Mex. 

Stark,  Dr.  Henry  S.,  New  York. 

Starr,  Dr.    M.  Allen,  New  York. 

Stedman.  Dr.  Thomas  L. ,  New- 
York. 

Stern,  Dr.  .\rthur,  Elizabeth, 
N.   J. 

Stern,   Dr.   Heinrich,  New  York. 

Stewart,  Dr.  A.  H.,  Philadelphia, 
Pa. 

Sth.es,  Dr.  Ch.  Wardell,  Wash- 
ington, D.  C. 

Stinson,  Dr.  J.  Coplin,  San  Fran- 
cisco, Cal. 

Sti'dy,  Dr.  Joseph  N.,  Cambridge 
City,  Ind. 

Svmonds,  Dr.  Brandrei'h,  New- 
York. 

Tarver,  Dr.  F.   E.  .  .Augusta,  Ga. 
Taulbee,  Dr.  J.    B, .   Mt     Sterling. 

Ky. 
THO^LsoN,    Dk,    William    H.,   .New 

York. 
Tcinn,  Dr.  George  Bell,  Glasgow, 

Scotland. 


Trent,  Dr.  Joi;n  H.,  Brooklyn, 
N.  Y 

Trumbull,  Dr.  John,  Valparaiso, 
Chile. 

Tyrrell,  Dr.  Frederick  D.,  Sac- 
ramento, Cal. 

\ALENriNE,  Dr.  I-erd.  C,  Ne-w 
York. 

Vanderhoof,  Dr.  F.  D.  ,  Phelps, 
N.  Y. 

Van  Schaick,  ])r.  George  G. , 
New  York. 

Vedin,  Dr.  Augu.sta,  New  York. 

Von  Ramdohr,  Dr.  C.  A.,  New- 
York. 

Von  Wedekind,  Dr.  L.  L.,  U.  S. 
Navy. 

Wade,  Dr.  .\lfred  S.  Perth,  On- 
tario. 

Wagner,  Dr.  Clinton,  New  York. 

Warner,  Dr.  Charles  B. ,  Port 
Henry,  N.  Y. 

Washburn,  Dr.  W.  ,  New-  York. 

Weir,  Dr.  James,  Jr.,  Ow-ensboro, 
Ky. 

Weisenberg,  Dr.  Berthold,  Mil- 
waukee, Wis. 

White,  Dr.  Charles  A.,  Washing- 
ton, D.  C. 

Whitcomb,  Dr.  J.  L.  C.  Liberty. 
N.  Y. 

Wolff,  Dr.  .\rthur  J.,  Hartford, 
Conn. 

Woodbridge,  Dr.  John  F'i.iot, 
Cleveland,  Ohio. 

Yankauer,  Dr.  Sidney,  New  York. 

Z.\p;  fe.  Dr.  Fred.  C.,  Chicago,  111. 

Soi/c-ties  of  which  Reports  have  heeeit 
Publishid. 

.American  Association  of  Genito- 
urinary Surgeons. 

American  Association  of  Obstet- 
ricians AND  GyNECOLOGIS-TS. 

.\merican  Medical  .Association. 

.American  Public  Health  Associa- 
tion. 

British  Medical  Association. 

CONGRE.SS  OF  American  Physicians 
AND  Surgeons. 

Medical  and  Chirurgical  Fac- 
ulty OF  the  State  of  Mary- 
land. 

Medical  Society  of  New  Jersey. 

Medical  Society  of  the  County  . 
jifNew-  York. 

Mississippi  Valley  Medical  .As- 
sociation. 

New  York  .Academy  of  Medicine. 

New  York  County  Medical  .As- 
sociation. 

New  York  Medico-Chirukgicai. 
Society. 

New-  York  Neitrolck-.ical  Society-. 

New  York  Pathological  Society. 

New  York  State  Medical  .A.s.so- 
CIA  rioN. 

Southern  Surgical  and  Gyn.-e- 
col.ogicai.  .a.ssociation 

TwELt-TH   InTERNATION  \l.  MkDK  AL 

Congress. 


Medical  Record 

A  Weekly  yoiirnal  of  Medicine  and  Surgery 


Vol.  52,  No.  I. 
Whole  No.  1391. 


New  York,   July  3,    1S97. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©viginal  Articles. 

THE    PROBLEMS    WHICH     MOST    PERPLEX 
THE   SURGEON.' 

By   ROSWELL   PARK,    A.M..    M.D., 

PROFESSOR    OF    Si;RGERV,     MEDICAL    DEPASTllENT,     L-Sn"ERSmi'    OF   BUFFALO. 

The  more  conversant  one  becomes  with  the  literature 
and  accumulated  knowledge  of  others  concerning  the 
topics  which  especially  interest  him,  and  the  more  he 
pursues  his  studies  within  restricted  lines,  the  more 
difficult  it  becomes  to  select  a  subject  of  which  he  may 
legitimately  treat  before  such  an  audience  as  this.  It 
is  therefore  with  not  a  little  hesitation,  and  yet  with 
the  highest  appreciation  of  the  honor  done  me  in  invit- 
ing me  to  address  you  on  this  occasion,  that  I  have 
concluded  to  invite  your  attention  to  some  of  the  prob- 
lems which  the  medical  profession  as  a  class,  and 
particularly  those  who  practise  surger}%  are  to-day 
most  often  called  upon  to  confront,  which  still  seem  so 
obscure  that  when  asked  for  explanations  we  have  to 
confess  absolute  ignorance,  and  state  that  we  sadly 
need  light  from  any  and  every  source. 

We  have  a  right  to  view  with  the  greatest  satisfac- 
tion and  pride  the  progress  which  has  been  made  both 
in  the  theor}-  and  practice  of  surgerj",  and  particularly 
in  that  branch  of  general  surger\-  spoken  of  as  surgical 
patholog}-.  And  just  here  I  may  be  permitted  to  re- 
mind you  that,  according  to  the  best  standards  of  the 
day,  patholog}"  is  not  distinct  from  but  must  be  a  part 
of  surgery — else  would  the  surgeon  lose  the  explana- 
tion of  both  the  lesion  which  he  is  treating  and  of  the 
reason  for  his  treatment.  I  think,  then,  that  of  all  the 
factors  that  can  be  mentioned  as  having  conspired  to 
put  surgery  where  it  is  to-day,  the  most  conspicuous  is 
the  recognition  which  surgeons  have  given  to  surgical 
patholog)".  In  consequence  I  may  repeat  here  the 
statement  which  I  often  make,  and  which  may  well 
challenge  contradiction — "that  of  all  the  branches  of 
applied  science,  none  has  made  more  rapid  progress 
during  the  last  tw-enty-five  years  than  surgery,  save 
only  electricit)-." 

It  being  admittedly  then  so  impossible  to  dissociate 
theory  from  practice,  the  active  thinker  finds  himself 
sadly  hampered  in  treating  actual  disease,  when  he 
fails  to  understand  either  its  nature  or  the  bodily  con- 
ditions which  have  permitted  its  occurrence,  or  both. 
Among  the  so-called  surgical  diseases  we  are  familiar 
with  the  active  causative  agents  in  nearly  all  instances, 
but  we  are  far  from  familiar  with  those  physical  con- 
ditions of  the  body  which  seem  at  one  time  to  invite 
and  at  another  prevent  infection.  This  might  bring 
up  before  us  the  whole  question  of  susceptibility  and 
immunitj',  over  which  physicians  and  surgeons  must 
undoubtedly  vex  themselves  for  yet  many  years  before 
the  intricate  problems  involved  are  regarded  as  settled 
— if,  indeed,  a  happy  solution  be  ever  reached.  Upon 
these  subjects  I  have  more  than  once  addressed  my 
colleagues  in  various  other  societies,  and  do  not  now 
purpose  to  take  them  up  again.     Nevertheless  there  is 

'  The  address  in  surgen-  before  the  Michigan  State  Medical 
Societ}-,  Grand  Rapids,  May  13,  1697. 


one  aspect  even  of  these  questions  which  it  might  be 
well  to  present  to  you  as  one  of  universal  interest,  one 
which  calls  for  much  careful  study,  in  which  the  yoimg 
workers  of  this  or  any  other  society  might  profitably 
concern  themselves. 

I  have  long  been  convinced  that  the  susceptibility 
and  immunity  of  a  patient  about  to  undergo  a  given 
operation  are  influenced  not  alone  by  the  state  of  his 
excretor}-  organs  and  his  freedom  from  toxamia  of  any 
description,  but  also  by  the  anaesthetic  required  for 
the  successful  and  easy  performance  of  the  same,  and 
its  effects  as  manifested  through  his  own  blood.  We 
have  had  many  careful  observations  made  with  refer- 
ence to  the  effect  of  chloroform  and  ether  upon  the 
action  of  the  heart,  the  blood  pressure,  etc.,  and  their 
effect  upon  the  kidneys  and  the  elimination  of  the 
drug,  as  well  as  upon  the  temperature  of  the  individ- 
ual. 

Illustrative  of  careful  studies  of  this  kind  is  the  re- 
search concerning  the  latter  recently  published  by  Dr. 
Dudley  Allen,'  of  Cleveland,  by  all  of  which  our  clin- 
ical knowledge  concerning  the  effect  of  anasthetics 
has  been  materially  augmented.  I  cannot  conceive  it 
possible,  however,  that  the  amount  of  chloroform,  for 
example,  required  to  keep  a  patient  anaesthetized  for  an 
hour,  and  which  is  still  being  eliminated  at  the  end  of 
the  second  day,  as  evinced  by  the  odor  emanating  from 
both  his  lungs  and  person,  can  be  so  long  retained  in 
solution  in  his  blood  without  more  or  less  perceptibly 
affecting  its  germicidal  properties,  as  well  as  perhaps 
some  of  the  other  phj-sical  attributes  pertaining  to  this 
vital  fluid.  It  may  be  that  absence  of  this  interfer- 
ence with  its  powers  may  account  for  escape  from  se- 
rious infection  after  extensive  accidental  lesions,  while 
fatal  infection  occurs  sometimes,  in  spite  of  great  cau- 
tion observed,  during  the  performance  of  operations 
under  anesthesia.  To  this  conviction  I  confess  I  have 
been  moved  not  so  much  by  experimental  evidence  as 
by  clinical  obser\"ations  and  certain  general  knowl- 
edge. What  is  needed  in  this  regard  is  exact  labora- 
tor}-  investigation,  by  which,  for  instance,  the  blood  of 
a  healthy  patient,  about  to  undergo  some  protracted 
operation,  should  be  first  examined  a  day  or  two  be- 
forehand, by  the  spectroscope  and  by  several  other 
laboratory  tests,  to  determine  the  exact  proportion  of 
hemoglobin  and  of  red  and  white  corpuscles,  while  it 
should  also  be  carefully  tested  regarding  its  bacteri- 
cidal powers.  This  entire  and  elaborate  series  of  ex- 
aminations should  then  be  repeated  some  six,  twelve, 
and  twent\"-four  hours  after  the  operation,  while  in  a 
general  way  the  aneesthetic  employed  and  the  amount 
of  blood  lost  should  be  noted.  I  am  willing  to  ven- 
ture a  prophecy  that  after  a  sufficient  number  of  such 
researches  have  been  carefully  collated  important  de- 
ductions can  be  made,  and  that  it  will  be  found  that 
prolonged  anaesthesia  does  increase  susceptibility  to 
infection  or  reduce  immunit}-,  as  you  may  like  to  put 
it;  which  facts  having  been  established,  we  may  then 
be  in  better  position  to  fortifs'  our  patients  against  this 
now  known  and  recognized  danger.  All  of  this  inves- 
tigation, however,  will  require  tremendous  time  and 
patience  on  the  part  of  more  than  one  obser^-er,  and 
can    be    carried   on   only    in    some    institution    well 

'  American  Journal  of  the  Medical  Sciences,  March,  iSgj. 


MEDICAL    RECORD. 


[July  3,  189-7 


equipped  for  the  purpose.  There  i.s  here,  I  am  sure, 
a  chance  for  young  men  to  distinguish  themselves  if 
they  will  devote  themselves  to  the  task. 

One  of  the  most  important  problems  before  us  to-day 
seems  to  be  with  regard  to  the  actual  cause  of  death 
in  numerous  cases  of  acute  and  gangrenous  ajjpendi- 
citis,  in  which  almost  from  the  outset  the  expressions 
of  to.xsemia  and  sepsis  are  overwhelming.  I  have  seen 
too  many  cases  of  this  kind  not  to  be  conversant  with 
the  gross  findings.  Nevertheless  I  am  still  unable,  as 
I  think  is  every  one  else,  really  to  explain  the  intense 
toxicity  that  characterizes  them.  This  is  not  merely 
a  question  of  stercora;mia  from  intestinal  paralysis, 
which  undoubtedly  makes  up  a  considerable  part  of 
such  a  case,  but  to  this  there  is  added  something  more 
overpowering  and  not  included  in  the  ordinary  expres- 
sions of  intestinal  auto-intoxication.  I  know  of  no 
chemical  researches  which  have  been  made  upon  the 
pus  removed  from  large  peri-appendical  abscesses, 
but  for  my  own  part  suspect  that  some  of  the  sulphur 
compounds  generated  under  these  circumstances,  hav- 
ing more  or  less  to  do  with  the  allyl  group,  may  be 
blamed  for  a  part  of  the  poisoning  of  which  I  am 
speaking. 

Much  may  be  explained  in  one  direction  by  the 
coprostatic  acute  obstruction  so  frequently  met  with 
in  these  cases,  and  to  which  I  believe  I  was  one  of  the 
first  to  call  attention.  Indeed,  in  the  light  of  our  pres- 
ent knowledge,  this  form  of  obstruction,  due  to  causes 
proceeding  from  the  appendix,  needs  to  be  mentioned 
as  by  all  means  the  most  common  form  of  acute  stran- 
gulation of  the  bowels,  although  it  is  one  too  often 
overlooked  by  the  profession  at  large,  and  not  figuring 
with  its  deserved  prominence  even  in  recent  text-books 
and  literature.  This  is  due  in  some  cases  to  intestinal 
paralysis,  in  others  to  adhesions  and  interference  with 
motility.  If  personal  experience  may  be  in  this  mat- 
ter any  criterion,  I  should  say  in  all  cases  of  acute 
strangulation  accompanied  by  septic  symptoms,  and  in 
the  absence  of  something  definite  pointing  to  lesion  in 
another  locality,  the  wisest  and  in  the  long  run  the 
safest  course  would  be  to  make  the  preliminary  incision 
in  the  right  iliac  fossa.  In  so  doing  the  surgeon 
will  be  right  four  times  for  every  error  that  he  may 
make. 

The  extreme  toxicity  of  all  cases  of  putrid  peritoni- 
tis is  not  to  be  explained  alone  by  the  capacity  of  the 
peritoneum  for  absorption.  Neither  is  this  toxicity 
made  known  by  general  symptoms  alone.  The  poisons 
so  rapidly  generated  seem  noxious  to  all  the  cells  with 
which  they  come  into  contact;  hence  gangrene  or  ne- 
crosis of  involved  surfaces  appears  very  early.  Nu- 
merous expressions  of  this  fact  may  be  seen  in  cases 
in  which  the  appendix  is  not  at  fault.  Nevertheless  it  is 
in  the  appendix  that  it  has  struck  me  as  most  conspic- 
uous. Every  surgeon  of  experience  has,  moreover, 
noted  instances  of  fulminating  appendicitis,  in  which 
when  seen  early  the  serous  covering  was  not  com- 
promised to  any  such  extent.  It  is  probable  that  un- 
der these  circumstances  the  same  necrosis  of  the  mu- 
cosa has  extended  over  a  more  or  less  wide  area  inside 
of  the  caecum,  and  that  this  is  the  reason  why  after  the 
removal  of  the  appendi.v  and  temporary  improvement, 
the  septic  and  gangrenous  processes  continue  and  cause 
the  death  of  the  patient  two  or  three  days  later.  Such 
cases  as  this  must  continue  to  be  among  the  opprobria 
of  surger}%  unless  we  open  the  ca;cum  and,  if  this  con- 
dition be  found,  resect  a  sufficient  amount  of  it  to 
eradicate  the  difficulty. 

Since  the  publication  of  Dieulafoy's  masterly  chap- 
ter on  this  subject,'  it  has  been  established  that  the 
appendix  becomes  troublesome  only  when  its  lumen  is 
occluded,  and  that  when  it  once  becomes  a  closed  cav- 
ity it  is  simply  a  question  of  the  virulence  of  its  con- 
'  Manuel  tie  Path.  Int. ,  vol.  iii. 


tained  bacteria  whether  a  small  or  fatal  dose  of  toxins 
shall  be  produced. 

Reflecting  upon  the  similarity  of  acute  cases  of  this 
character  to  those  of  diphtheria,  in  which  beneath  an 
area  of  membrane  the  deadly  development  of  germs  is 
going  on,  the  toxins  peculiar  to  this  disease  being  rapid- 
ly produced,  and  not  failing  to  note  the  beautiful  and 
life-saving  virtues  of  antitoxin  as  an  antidote  to  the 
depressing  poisons,  I  have  been  led  to  query  whether 
an  antitoxin  could  not  be  produced  which  should  have 
a  similar  effect  in  cases  of  acute  stercorarmia.  While 
the  colon  bacillus  is  not  necessarily  the  sole  agent  in 
producing  intestinal  toxaemia,  it  is  nevertheless  known 
to  be  that  usually  at  fault.  Acting  upon  this  fact,  I 
am  now  endeavoring  to  immunize  animals  to  the  prop- 
erties of  this  organism,  in  order  to  see  whether  their 
serum  may  possess  virtues  by  which  we  may  overcome 
the  depression  and  intestinal  paralysis  that  bring  some 
cases  of  acute  appendicitis  to  the  grave.  Researches 
in  this  direction  are  now  going  on  in  my  laboratorj-  at 
home.  It  is  quite  likely  that  antistreptococcic  serum 
may  have  also  to  be  used  in  these  cases. 

Cancer. — But  the  most  complex  of  all  problems  in 
surgical  pathology  to-day,  and  that  upon  which  we  most 
need  light,  is  with  regard  to  the  nature  and  causes  of 
cancer;  and  to  this  topic  the  remainder  of  this  paper 
shall  be  devoted. 

The  indefinitely  sustained  power  of  certain  cells  to 
grow  and  multiply  in  excess  of  normal  requirements, 
which  is  Williams'  definition  of  the  essential  feature 
of  cancer  formation,  is  common  alike  to  vegetables 
and  animals  of  any  save  the  simplest  type.  That  can- 
cer appears  more  prevalent  among  domestic  rather 
than  wild  animals  is  a  fact  too  commonly  stated  as  an 
evidence  of  the  effect  of  domestication.  Were  the 
same  number  of  wild  animals  taken  at  random  and 
carefully  examined,  I  think  cancer  would  be  found  to 
be  equally  prevalent  in  the  wild  state.  Among  ani- 
mals sarcomata  are  much  more  widely  diffused  than 
carcinomata,  while  according  to  Rayer,  carnivorous 
animals  are  more  prone  to  cancer  than  the  herbivorous, 
just  the  opposite  being  true  in  cases  of  tuberculosis. 
In  the  vegetable  kingdom  it  is  hard  to  draw  distinc- 
tions between  various  grades  of  malignancy,  yet  that 
tumors  kill  a  large  proportion  of  trees  and  vegetables 
will  not  be  disputed  by  those  who  have  studied  the 
subject.  Furthermore,  if  the  method  of  death  be  stud- 
ied, it  will  be  seen  to  resemble  in  all  essential  partic- 
ulars that  which  produces  ulceration,  star\-ation,  and 
finally  death  in  animals  and  in  man. 

Those  particularly  interested  in  the  general  study  of 
cancer — and  who  is  not? — should  be  promptly  referred 
at  once  to  the  various  writings  of  Rodger  Williams, 
who  has  shown  himself  a  most  painstaking  and  com- 
prehensive student  of  the  subject.  To  hmi  I  gladly 
acknowledge  my  indebtedness  for  much  that  has  been 
of  the  greatest  value  to  me,  some  of  which  appears  in 
this  paper. 

Influence  of  Sex. — According  to  the  statistics  col- 
lected by  him  for  the  twenty-five .  years  previous  to 
1872,  for  ever)-  100  males  dying  of  cancer,  229  females 
perished  from  the  same  disease.  Of  deaths  from  all 
causes  the  proportion  among  the  males  was  about  1  to 
100,  among  the  females  i  to  41.  In  later  years  this 
disproportion  has  become  less  marked.  Women  are 
still  more  suLi'ct  to  non-malignant  growths.  Of  can- 
cer in  women  Jie  breast  is  involved  in  40  per  cent., 
the  uterus  in  34  per  cent.,  all  other  parts  of  the  body 
making  up  the  other  26  per  cent.  In  males  the  parts 
about  the  mouth  yield  about  40  per  cent,  of  the  cases. 
He  collected  1,878  consecutive  cases  of  breast  cancer 
in  both  sexes,  in  only  16  of  which  was  the  mammary 
gland  in  the  male  involved. 

This  great  discrepancy  holds  good  mainly  with  re- 
gard to  carcinoma.     When  we  come  to  sarcoma,  there 


July  3,  1897] 


MEDICAL    RECORD. 


is  but  very  little  difference  between  the  sexes,  all  of 
which  Williams  interprets  as  being  due  to  biological 
peculiarities  pertaining  to  the  reproductive  and  nutri- 
tive organs.  Thus  mammar}'  carcinoma  is  most  prone 
to  arise  when  post-embryonic  developmental  activity 
is  greatest. 

Influence  of  Age. — In  the  evolution  of  cancer,  this 
can  be  accurately  stated  only  by  comparison  of  mortal- 
ity rates  with  the  number  of  healthy  individuals  liv- 
ing. After  the  ages  studied  are  estimated  in  this 
way,  it  appears  that  the  liability  to  carcinoma  increases 
with  each  successive  decade  until  the  seventy-hftli 
year.  Further  study  shows  that  the  most  characteristic 
feature  in  this  increase  is  not  mere  advance  in  years, 
but  disproportionate  increase  in  the  post-meridian 
years.  By  a  most  instructive  diagram  Williams  shows 
that  the  most  prolific  cancer-producing  age  is  that  be- 
tween the  fifty-fifth  and  sixty-fifth  years  of  life.  In 
other  words,  during  the  years  when  the  forces  of 
growth  are  most  active  the  tendency  to  carcinoma  is 
small.  With  the  period  of  tissue  and  organic  maturity 
begins  the  liability  to  the  disease,  which  increases 
until  about  the  sixtieth  year.  That  the  uterus  and 
breast  are  attacked  at  an  earlier  age  than  other  organs 
is  because  they  have  become /(/j'jV  with  the  conclusion 
of  child-bearing  life.  With  the  waning  of  develop- 
mental activities  the  danger  of  cancer  increases,  to 
pass  away  only  when  the  organs  have  undergone  com- 
plete physiological  atrophy.  The  same  statement  can 
be  made  with  regard  to  liability  to  known  infections, 
whether  cancer  be  an  infection  or  not. 

Race,  Complexion,  etc. — Williams  has  carefully 
studied  the  complexion  of  three  hundred  and  eighty- 
four  cancer  patients,  his  investigations  showing  him 
that,  especially  among  females,  there  is  greater  liabil- 
ity to  this  disease  in  brunettes  than  in  blondes,  and 
this  in  spite  of  the  fact  that  the  blonde  t)'pe  prevails 
among  the  population  generally.  He  puts  the  fre- 
quency of  the  disease  as  being  about  twice  as  common 
in  brunettes  as  in  blondes.  Beddoe  furthermore 
states  that  red-haired  individuals  are  even  more  exempt 
than  others  of  light  complej:ion.  Our  own  census  re- 
turns show  that  cancer  is  twice  as  frequent  among 
whites  as  among  blacks;  and  among  whites,  in  this 
country  at  least,  and  taking  it  at  large,  Billings  finds 
that  the  Irish  and  German  are  the  most  liable. 

That  the  disease  is  said  to  be  ver)-  rare  in  Iceland, 
Greenland,  Turkey,  and  Greece,  has  of  course  but  lit- 
tle interest  for  us  in  this  country.  It  is  exceedingly 
prevalent  in  China;  three  per  cent,  of  the  patients  in 
the  Hong-Kong  Hospital  suffer  from  the  disease.  It 
is  said  that  cancer  of  the  stomach  is  extremely  rare 
among  the  Chinese.  In  India  also  the  disease  as  a 
whole  is  somewhat  rare.  This  may  be  misleading, 
however,  because  most  of  the  people  are  averse  to  op- 
erations for  anything  except  calculus  and  cataract. 
Certainly  in  the  tropics,  the  world  round,  the  disease 
is  less  common  than  in  the  temperate  zone,  though  I 
have  often  said  that  we  who  live  in  western  New  York 
live  really  in  the  tropic  of  cancer,  because  the  disease 
is  so  extremely  prevalent  with  us. 

Family  History. — One  of  the  vexed  questions  of 
to-day  about  cancer  concerns  its  heredity.  Williams 
carefully  studied  one  hundred  and  thirtj'-six  cases  of 
breast  cancer,  and  discovered  a  historj'  of  disease  in 
the  family  in  one-fourth  of  the  number.  So  far  as  I 
have  studied  my  own  case  histories,  I  think  my  pro- 
portion in  which  there  is  a  family  historv'  of  this 
disease  to  be  a  little  larger  even  than  Williams'. 
Any  such  statement  as  this  means  a  strikingly  high 
proportion  of  inherited  lesion,  no  matter  what  this 
may  be.  Deformities,  defects,  and  supernumerary 
organs  are  not  transmitted  from  parent  to  offspring 
in  anything  like  twenty  five  per  cent,  of  instances. 
Moreover,  in  some  cases  there  is  a  history  of  multiple 


instances  in  the  same  family,  which  have  not  yet 
been  sufficiently  analyzed  to  yield  positive  deduc- 
tions. It  must  be  said  that  numerous  cases  occurring 
within  one  family,  all  of  whose  members  live  closely 
together,  is  fully  as  much  of  an  argument  for  the  para- 
sitic nature  of  the  disease  as  is  its  repeated  occurrence 
in  the  so-called  cancer  houses.  I  know,  for  instance, 
of  a  house  in  a  little  town  in  western  New  York,  in 
which  during  three  successive  generations  of  inhabi- 
tants, deaths  from  cancer  have  occurred,  these  being 
really  among  different  people  of  the  same  family,  but 
not  so  arranged  as  to  be  directly  transmitted  by  inher- 
itance. 

If  cancer  is  transmissible  by  heredity  and  is  not  an 
infection,  it  should  tend  to  die  out  in  the  course  of 
transmission,  as  do  all  abnormalites.  Thus,  out  of 
three  hundred  marriages  in  which  both  husbands  and 
wives  were  deaf  and  dumb,  in  only  five  per  cent,  of  the 
cases  were  the  off'spring  similarly  affected;  while  of 
three  hundred  and  ten  deaf  mutes  married  to  those  who 
could  hear,  the  proportion  of  affected  offspring 
amounted  only  to  one  in  one  hundred  and  thirty-five 
(Buxton). 

Another  element  of  uncertainty  pertains  to  the  fact 
that  cancer  is  rather  a  disease  of  adult  life,  and  it  is 
not  yet  established  whether  offspring  bom  before  the 
appearance  of  the  disease  inherit  any  liability  to  it. 
Williams  reports  two  instances  in  which  both  parents 
were  cancerous,  who  produced  seven  children,  of  whom 
two  died  of  cancer;  also  seven  marriages  in  which  only 
one  parent  was  cancerous,  from  which  resulted  sixty- 
two  children,  of  whom  ten  had  the  disease.  Six  mar- 
riages between  those  of  whose  parents  none  were  can- 
cerous, but  in  whose  families  there  was  a  history  of 
cancer,  resulted  in  fort)-one  children,  of  whom  eight 
became  cancerous. 

In  this  connection  it  is  worth  while  to  remind  you 
of  Broca's  celebrated  report,  of  the  twenty-six  descend- 
ants of  a  cancerous  patient  who  attained  or  exceeded 
the  age  of  fifty,  of  whom  fifteen  died  of  the  disease. 
It  is  of  interest  also  to  remember  that  in  families  re- 
turning a  cancer  history,  there  will  be  a  disproportion- 
ately large  number  of  non-malignant  tumors  and  cysts. 
Here,  too,  as  in  other  instances,  one  generation  may 
totally  escape,  while  the  disease  appears  in  the  second 
or  even  the  third.  When  inherited  it  appears  much 
oftener  in  females  than  in  male  relatives.  Of  interest, 
too,  is  Williams'  conclusion  that  a  large  proportion  of 
cancer  patients  are  the  surviving  members  of  tubercu- 
lous families,  and  history  aff"ords  the  corollary  that  no 
condition  which  can  be  inherited  better  predisposes  to 
cancer  than  that  which  also  predisposes  to  tuberculo- 
sis. It  appears,  moreover,  that  in  families  in  which 
cancer  has  prevailed  there  is  a  striking  evidence  of 
fecundity,  the  average  number  of  children  throughout 
being  4.6  to  a  family,  while  in  one  hundred  and  ten 
cancer  families  which  ^^■illiams  studied  the  children 
averaged  8.8. 

The  General  Health  of  Cancer  Patients. — Cancers 
appear  to  prevail  largely  in  those  who  are  subjects  of 
hypernutrition,  and  this  is  true  even  of  those  who  are 
sur^'ivors  of  tuberculous  families,  to  which  there  is  no 
exception.  Beneke  has  described  cancer  patients  as- 
having  large  hearts  and  arteries  with  small  lungs,, 
which  is  just  the  reverse  of  the  condition  met  with 
among  those  predisposed  to  tuberculous  disease 
Moreover,  nutrition  rarely  suffers  until  late,  at  least 
among  cancer  patients,  save  in  those  whose  alimentary 
organs  are  involved. 

There  is  a  general  belief  that  a  vegetable  diet  ex- 
empts from  cancer,  as  compared  with  flesh  eating;  this 
may  possibly  be  explained  by  the  fact  that  the  majority 
of  a  community  among  whom  cancer  is  relatively  rare 
cannot  afford  a  meat  diet,  or  it  may  be  that  a  flesh  diet 
actually  predisposes    to    the  disease.     According    to 


MEDICAL    RECORD. 


[July  3,  1897 


Beneke,  cancers  are  rare  in  prisons,  where  animal 
food  is  not  freely  furnished  and  where  the  work  is 
liard.  Nevertheless,  vegetarians  are  not  exempt  from 
the  disease.  Indulgence  in  alcohol,  if  it  has  any 
effect,  seems  rather  protective  than  otherwise. 

Some  writers  attach  great  importance  to  brain  ex- 
haustion, wear  and  tear  of  the  nervous  system,  due  to 
the  habits  of  society  people  of  the  day,  as  causes  of 
cancer.  In  spite  of  Williams'  disclaimer,  I  am  in- 
duced to  think  that  brain  fag  certainly  does  so  inter- 
fere with  nutrition  as  to  have  a  causative  relation  to 
the  disease.  Moore's  view  can  be  pretty  generally 
accepted  "that  cancer  is  eminently  a  disease  of  per- 
sons whose  previous  life  has  been  healthy,  and  whose 
nutritive  vigor  gives  them  otherwise  a  prospect  of  long 
life." 

Prevalence  of  Cancer  and  Its  Increase. — In  1840, 
in  England,  the  proportion  of  deaths  from  cancer  to 
the  total  mortality  rate  was  i  in  129;  in  1880  this  had 
risen  to  i  in  28,  which  shows  that  in  England  the 
death  rate  from  cancer  is  now  about  four  times  greater 
than  fifty  years  ago.  Williams  estimates  that  at  least 
40,000  persons  are  now  suffering  from  cancer  in  Eng- 
land and  Wales,  whereas  in  1840  the  number  was  only 
about  5,500.  Should  the  disease  increase  in  the  fu- 
ture at  the  same  relative  rate,  it  will  become  one  of 
the  commonest  of  all.  This  augmented  mortality  cor- 
responds with  increase  of  population  in  wealth  and 
improvement  in  general  sanitary  conditions.  In  Ire- 
land, where  this  happy  condition  of  affairs  does  not 
■obtain  to  a  corresponding  extent,  the  cancer  death  rate 
has  been  much  smaller  and  has  shown  no  such  marked 
increase.  In  1861,  in  England,  there  were  376  deaths 
from  cancer  to  the  million  of  population;  twenty-five 
years  later  there  were  610.  During  this  quarter  of  a 
century  the  number  of  deaths  from  phthisis  per  million 
has  diminished  to  three-fifths  of  the  number  at  its  com- 
mencement. 

In  the  twenty  years  from  1870  to  1890  the  increase 
in  mortality  from  cancer  in  England  is  as  follows;  In 
1870,  384  to  the  million;  in  1880,  468;  in  1890,  590. 
Accepting  these  published  figures  from  the  registrar- 
general's  report,  it  would  appear  that  the  mortality  has 
increased  by  53  per  cent.  Nevertheless,  it  is  not  quite 
so  bad  as  this,  because  the  diagnosis  of  obscure  cases 
is  now  more  accurate  than  it  was  twenty-five  years  ago. 

From  a  tabulation  of  the  deaths  within  our  own 
State  of  New  York  during  ten  years,  from  1885  to 
1895,  I  find  that  during  this  time  there  have  been  re- 
ported 30,692  deaths  from  cancer.  Doubtless  in  a 
few  of  these  cases  there  may  have  been  a  mistake  in 
diagnosis,  which  will,  however,  be  abundantly  atoned 
for,  and  more,  by  the  deaths  which  were  really  due  to 
cancer  and  ascribed  to  some  other  cause.  In  1885 
there  were  1,882  deaths  from  this  cause;  in  1890, 
2,878;  and  in  1895,  3,454.  In  other  words,  in  the 
last  year  of  this  decade  the  total  number  of  deaths  from 
cancer  was  twice  that  of  its  first  year — which  m.ay  be 
interpreted  as  meaning  that  the  death  rate  has  increased 
much  more  rapidly  than  has  the  population.  During 
this  same  decade,  also,  the  number  of  deaths  from  all 
causes  has  increased  only  from  80,000  to  121,000. 
During  the  last  five  years  of  this  decade  epidemic  in- 
fluenza alone  caused  35,000  of  the  121,000  deaths.  It 
•will  therefore  be  seen  how  rapidly  the  cancer  death 
rate  is  creeping  up. 

In  1892  Haviland  published  a  monograph,  in  Lon- 
don, on  the  "Geographical  Description  of  Heart  Dis- 
ease, t'ancer,  and  Phthisis  in  England  and  Wales,"'  in 
which  he  maintained  that  where  cancer  is  most  preva- 
lent the  country  is  low  and  traversed  by  rivers,  which 
frequently  flood  the  adjoining  country ;  whereas  cancer 
is  relatively  scarce  in  mountainous  regions  or  where 
floods  do  not  occur,  and  where  the  subsoil  is  either 
hard  or  absorbent.     Thus  he  found  that  the  Thames 


runs  through  a  vast  cancer  field,  excepting  only  where 
the  chalk  crops  out.  Williams,  however,  states  that 
this  cannot  be  true  of  all  low-lying  countries,  and  seeks 
to  explain  the  prevalence  of  the  disease  in  the  valley 
of  the  Thames  by  conditions  of  life  peculiar  to  its 
population.  He  calls  attention  to  the  fact  that  cancer 
mortality  is  lowest  where  the  struggle  for  existence  is 
hardest,  the  population  densest,  the  general  mortality 
highest,  the  average  duration  of  life  shortest,  where 
sanitation  is  least  perfect,  and  the  death  rate  from  tu- 
berculosis highest — in  other  words,  among  the  work- 
ing classes — whereas  the  cancer  mortality  is  greatest 
among  the  agricultural  community,  where  people  are 
well-to-do,  and  where  the  standard  of  health  is  high- 
est and  of  life  easiest.  He  believes  the  most  potent 
factors  in  the  causation  of  cancer  to  be  high  feeding 
and  easy  living,  and  that  the  farmer  is  in  general  bet- 
ter off  than  the  city  laborer,  but  more  liable  to  cancer. 
So,  too,  in  London,  where  the  cancer  rate  is  highest, 
it  is  significant  that  this  is  particularly  true  of  those 
parts  where  the  wealthy  most  abound. 

Causes. — When  we  come  to  consider  more  in  detail 
the  causes  of  cancer,  we  shall  have  to  discard  without 
the  slightest  hesitation  most  of  the  theories  which  have 
figured  in  time  past.  We  shall,  in  fact,  find  ourselves 
narrowed  down  practically  to  two.  Cells  arrange  and 
disport  themselves  as  they  do  when  they  form  a  can- 
cer either  in  accordance  with  laws  of  heredity  and 
atavism,  showing  ever  a  tendency  to  revert  to  earlier 
and  simpler  forms,  or  else  because  they  are  provoked 
to  rebellion  by  the  presence  of  intruding  and  extrinsic 
elements;  in  other  words,  we  must  explain  cancer  and 
tumor  formation  either  on  the  embryonal  and  evolu- 
tionary basis  or  consider  it  a  parasitic  disease. 

The  traumatic  origin  of  cancer  must  be  based  upon 
stronger  evidence  than  exists  to-day  if  it  is  to  hold 
good  for  other  than  exceptional  instances.  Undoubt- 
edly men  are  very  much  more  subject  to  injury  than 
are  women,  yet  are  not  half  so  liable  to  the  disease. 
Surely  men  are  injured  in  the  thoracic  region  oftener 
than  are  women,  yet  they  suffer  from  cancer  of  this 
region  only  in  proportion  of  i  to  115  or  120.  If 
mammary  cancer  were  really  caused  by  injur}-,  the  ex- 
ternal parts  would  be  certainly  more  frequently  affect- 
ed, whereas  the  reverse  is  true.  Cancer  for  the  most 
part  begins  as  a  solitary  aft'ection,  which  would  not 
be  the  case  were  it  of  traumatic  origin.  If  injury 
be  made  to  figure  at  all  as  a  cause  of  cancer,  it  must 
be  mainly  as  a  cause  of  sarcoma,  since  sarcoma  can  be 
once  in  a  while  traced  to  such  accident.  In  this  con- 
sideration I  would  put  epithelioma  in  a  distinct  cate- 
gory, since  I  firmly  believe  that  prolonged  irritation 
of  a  surface  covered  by  squamous  epithelium  and  fre- 
quently infected  may  produce  an  epithelioma  as  an  ex- 
pression of  this  fact. 

That  there  seems  to  be,  in  some  cases  at  least,  a  par- 
ticular association  between  cancer  and  previous  disease 
of  the  parts  cannot  be  denied  after  Volkman's  record 
of  two  hundred  and  twenty-three  cases,  from  various 
sources,  of  primary  cutaneous  cancer  of  the  extremi- 
ties, in  eighty-eight  per  cent,  of  which  he  found  that 
there  had  been  pre-existing  disease  of  the  part  in- 
volved ;  though  it  must  be  said  that  others  have  not 
found  anything  like  the  same  percentage  of  relation- 
ship. At  best,  then,  we  can  only  say  that  chronic 
nutritive  or  infectious  lesion  cannot  necessarily  be 
regarded  as  antecedents  of  cancer. 

Rindrieisch  long  ago  called  attention  to  what  he 
called  the  infectiousness  of  epithelial  cells.  If  it  can 
be  shown  that  he  spoke  with  prophetic  accuracy,  then 
the  parasitic  theory  of  cancer  is  established.  If,  on 
the  other  hand,  this  was  but  a  happy  expression  show- 
ing how  epithelial  cells  react. upon  each  other,  then  the 
phrase  has  no  meaning  and  was  simply  an  allusion  to 
the  metastatic  spread  of  cancer. 


July  3,  1897] 


MEDICAL    RECORD. 


Certainly  the  appearances  in  epithelial  cells  which 
have  been  irritated  by  coccidia  are  quite  analogous  to 
those  presented  by  cancer  cells.  The  effect  of  the  in- 
tracellular growth  of  coccidia  is  to  produce  a  hyper- 
trophy, especially  of  the  nuclei,  which  often  assume  a 
volume  greater  than  that  of  the  original  cells,  only  to 
later  completely  atrophy.  In  other  words,  hypertrophy 
precedes  degeneration.  This  is  true  of  the  majority  of 
cancer  cells  as  well.  It  is  not  alone  that  the  parasitic 
nature  of  certain  bodies  found  in  cancer  cells  is  insist- 
ed upon  by  some  and  denied  by  others.  It  is  also 
true  that  abnormal  cells  develop  side  by  side  with 
normal,  that  nuclei  are  frequently  fused  together,  that 
protoplasmic  filaments  are  compressed  by  cells  which 
have  not  become  keratinized,  and  that  from  this  series 
of  changes  result  nests  of  epidermic  pearly  bodies 
whose  constitution  and  appearance  are  abnormal.  This 
is  particularly  true  when  the  transformation  of  young 
epithelium  into  horny  cells  takes  place  centripetally 
instead  of  centrifugally.  It  is  very  ditficult  to  explain 
the  appearances  brought  out  by  Soudakewitch,  who 
fi-xed  his  tissues  in  osmic  acid  and  colored  the  coccidia 
with  logwood,  or,  after  fixing  by  Flemming's  solution, 
found  by  means  of  the  ordinary  aniline  stains  that  tiiey 
took  on  a  color  different  from  that  of  the  cellular  ele- 
ments. 

Two  Russian  observers,  Sawtschenko  and  Podwys- 
sowski,  have  done  a  large  amount  of  work  in  this  direc- 
tion, which  has  partly  failed  of  recognition  because  of 
its  inaccessibility  in  their  language.  The  former  has 
found  that  those  bodies  which  he  considers  to  be  spo- 
rozoa  of  cancer  have  no  proper  membrane,  their  pro- 
toplasm being  limited  only  by  the  vacuoles  in  which 
it  is  more  or  less  free,  it  often  happening  that  it  is  re- 
solved into  that  of  surrounding  cancer  cells.  In  its 
adult  form  their  parasite  is  regular  and  rounded,  gran- 
ular in  protoplasm,  and  more  dense  than  that  of  the 
neoplastic  cells;  its  nucleus  plain,  round,  with  chro- 
matic meshes.  This  nucleus  is  decomposed  into  shreds, 
as  sporulation  proceeds,  each  of  which  particles  be- 
comes surrounded  with  protoplasm  to  form  a  new  spore, 
which  in  time  forsakes  the  cell  in  which  it  has  thus 
been  developed,  to  invade  others  and  spread  the  lesion. 
These  characteristic  appearances  should  be  looked  for 
at  the  margins  of  tumors  where  the  tissue  is  young  and 
the  process  active,  instead  of  in  the  central  portions 
where  nothing  is  going  on  but  degeneration.  Under 
the  influence  of  these  recent  researches  of  Sawtschenko 
the  parasitic  theory,  at  first  considered  so  seductive 
and  a  little  later  so  disappointing,  becomes  again  the 
subject  of  renewed  interest.  By  some  such  theory 
alone  can  miliary  carcinomatosis  be  explained. 

The  common  solitariness  of  cancer  invasion  in  man 
is  frequently  emphasized  as  an  argument  against  the 
parasitic  theory.  As  the  disease  has  been  more  care- 
fully studied,  it  is  now  universally  conceded  that  can- 
cers may  originate  by  multiple  foci,  while  such  condi- 
tions as  general  carcinomatosis  and  sarcomatosis, 
corresponding  so  perfectly  to  miliar)-  tuberculosis, 
seem  to  establish  that  the  disease  processes  not  only 
disseminate  similarly,  but  both  have  living  agents  for 
their  primary  causes.  Not  much  comfort  for  either 
party  can  be  derived  from  the  fact  that  multiple  and 
widely  different  neoplasms  may  be  met  with  coinciden- 
tally.  Thus  sarcoma  and  carcinoma  may  be  progress- 
ing in  the  same  patient  at  the  same  time,  while  either 
may  be  connected  with  or  be  independent  of  syphilitic 
or  tuberculous  disease.  Nor  can  anything  really  relia- 
ble be  yet  learned  from  a  source  which,  did  it  exist, 
would  crown  all  others  by  its  validity,  for  it  must  be 
acknowledged  that  attempts  to  inoculate  cancer  have 
been  abortive  in  at  least  ninety-nine  per  cent,  of  in- 
stances. There  is  much  reason  for  going  over  all  this 
ground  again,  and  so  far  improving  upon  previous  ex- 
periments as  to  transplant  tissue  from  the  patient  into 


the  nearest  possible  like  tissue  of  the  animal.  The 
old  experiments  made  by  Alibert  and  others  were 
never  successful,  nor  is  it  known  that  any  surgeon  has 
ever  inoculated  himself  with  cancer  during  an  opera- 
tion. There  are  but  few  authentic  instances  of  trans- 
mission to  the  husband  from  cancer  of  the  uterus. 
Still  about  the  mouth  and  perineum,  especially  where 
mucous  surfaces  lie  closely  in  contact  with  each  other, 
there  is  much  reason  to  think  the  disease  has  been 
spread  from  one  part  to  another.  Nevertheless,  ex- 
perimental auto-inoculations  have  almost  all  failed,  in 
spite  of  the  fact  that  eroded  surfaces  do  become  in- 
fected by  constant  contact  with  discharge  from  can- 
cerous sores. 

Morau  reported,  in  1885,  the  inoculation  of  frag- 
ments from  an  epithelial  cancer  of  a  white  mouse  into 
ten  other  mice  of  the  same  kind,  with  formation  of 
cancerous  nodules  in  eight,  which  themselves  were 
used  for  the  inoculation  of  yet  other  animals,  and 
with  success.  But  he  did  more  than  this:  he  placed 
healthy  mice  in  cages  over  a  pan  containing  turpen- 
tine and  camphor,  by  which  they  were  kept  free  from 
insects  and  remained  in  perfect  health.  In  other 
cages  he  placed  healthy  mice  along  with  bedbugs. taken 
from  the  cages  of  cancerous  mice,  and  obser\-ed  that 
after  a  few  months  all  the  animals  infected  with  these 
insects  were  suffering  from  cancer. 

The  germ  theory  of  cancer  has  assumed  among  cer- 
tain Italian  observers  the  form  of  a  yeast  theor}-,  i.e., 
it  has  been  ascribed  to  the  presence  of  blastomycetee, 
and  organisms  of  this  kind  certainly  have  been  culti- 
vated as  coming  from  malignant  tumors.  Neverthe- 
less, inoculation  experiments  with  them  have  not  yet 
been  completely  successful. 

In  a  paper  presented  before  the  eleventh  congress  of 
Italian  surgeons  in  Rome,  October  of  last  year,  Ron- 
cali  summed  up  our  present  knowledge  with  regard  to 
the  etiology  of  cancer  briefly  as  follows: 

1.  In  the  cell  protoplasm  and  the  connective  tissues 
of  cancer  are  found  bodies,  not  of  intrinsic  but  of  ex- 
trinsic origin. 

2.  These  are  in  appearance  similar  to  the  coccidia 
which  have  been  found  in  the  cells  of  epitheliomata 
and  sarcomata. 

3.  They  are  morphologically  identical  with  blasto- 
mycetes  found  in  animals  which  have  been  inoculated 
with  pure  cultures  of  organized  ferments,  and  resist 
acids  and  alkalies  as  do  experimental  blastomycetes. 
They  occur  only  in  malignant  growths  in  mankind:  in 
such  growths  they  are  found  only  at  the  periphery 
where  growth  is  still  active,  and  not  in  the  centre 
where  degeneration  has  taken  place.  They  are  situ- 
ated either  in  the  cell  protoplasm  or  between  the  fibres, 
rarely  in  the  nuclei.  They  stain  in  the  ordinary  fash- 
ion, and  can  often  be  obtained  from  tumors  both  in 
man  and  in  animals,  and  can  be  grown  in  pure  cul- 
ture. When  these  cultivated  products  are  inoculated, 
they  force  themselves  into  the  cells  and  into  the  fibres, 
producing  the  same  appearances  as  in  those  tumors  in 
which  they  are  naturally  found.  They  moreover  show 
the  reaction  of  cellulose,  which  is  a  proof  that  they  are 
not  a  degenerative  product.  Moreover,  it  is  known 
that  certain  blastomycetes  when  inoculated  produce 
hy]5erplastic  rather  than  inflammatory  changes. 

Nevertheless,  Roncali  did  not  consider  the  parasitic 
nature  of  cancer  to  be  definitely  determined.  It  is  of 
interest  to  know  that  Maftuci  and  Sirleo  had  found 
similar  bodies  and  formed  conclusions  which  were  in 
no  essential  respect  dift'erent  from  those  of  Roncali. 
They  were  somewhat  inclined,  nevertheless,  to  suspect 
that  the  blastomycetes  might  be  present  as  the  result 
of  a  secondary  infection  rather  than  as  a  primary  caus- 
ative agent.' 

'  Centralblatt  fiir  Chirurgie.  No.  50,  1896:  Centralblt.  f.  Bak- 
teriol.,  No.  10,  1897. 


MEDICAL    RECORD. 


[July  3,  1897 


Whatever  there  be  to  the  germ  theory  of  cancer,  it 
meets  with  this  additional  difficulty,  that  it  is  even  to- 
day almost  impossible  to  state  just  what  tumors  should 
be  considered  malignant  and  what  not.  The  adeno- 
mata which  develop  so  frequently  in  the  mammae,  the 
ovaries,  the  liver,  and  kidneys,  seem  to  be  peculiarly 
liable  to  subsequent  malignant  degeneration,  while  the 
frequent  recurrence  of  adenoma  of  the  breast  is  as  well 
known  as  its  conversion  into  carcinoma.  Whether 
this  conversion  is  due  to  infection  or  not  is  another 
thing  to  be  established.  The  dissemination  of  adeno- 
matous and  papillomatous  masses  around  the  inner 
surface  of  the  peritoneum  or  along  ordinary  paths,  by 
way  of  the  lymphatics  or  vessels,  is  another  feature 
of  malignancy  which  deser\-es  further  investigation. 
Is  this  dissemination  by  implantation,  by  infection,  or 
by  what?  Certainly  dissemination  of  normal  epithe- 
lium is  common  and  is  not  known  to  produce  cancer. 
Klebs  concludes  that  an  embryonic  condition  of  a 
part  predisposes  it  to  tumor  formation,  but  that  the 
real  malignancy  of  tumors  is  due  to  a  modification  of 
their  cells.  The  mere  presence  of  cancer  cells  in  a 
part  seems  to  stimulate  the  surrounding  tissue  to 
growth  in  an  altogether  inexplicable  way.  According 
to  Klebs,  the  principal  change  in  an  epithelial  cell 
which  is  becoming  cancerous  is  hypermitosis,  which 
itself  depends  upon  hypernutrition.  It  is  characteris- 
tic of  malignant  growths,  that  karj'okinesis  becomes 
both  exaggerated  and  irregular,  the  epithelial  cells 
being  fed  by  the  leucocytes,  while  the  membrane  of 
the  nucleus  becomes  thinner,  showing  the  process 
going  on  within  to  better  advantage.  Characteristic 
also  is  it  that  metamorphosis  of  the  nuclei  and  forma- 
tion of  new  nuclei  follow  one  another  in  the  same  cell. 
Klebs  views  the  cancerous  process  there  as  going 
through  the  following  stages:  first,  chronic  irritation 
or  active  inflammation  induced  by  mechanical,  chem- 
ical, or  bacterial  agencies;  this  is  followed  by  the 
emigration  of  leucocytes  and  the  progressive  develop- 
ment of  other  cells,  which  have  lost  their  faculty  of 
normal  cell  reproduction  because  of  hypermitotic  ac- 
tivity. He  suggests  as  a  remedy  to  use  inhibiting  sub- 
stances possessed  of  negative  chemiotaxis,  by  which 
the  leucocytes  should  be  repelled  and  hypernutrition 
prevented.  He  thinks  that  possibly  the  toxins  of  ery- 
sipelas have  some  such  power. 

Williams  makes  what  at  first  might  seem  a  strong 
argument  against  the  parasitic  nature  of  cancer,  by 
showing  that  in  all  other  infectious  lesions,  say  among 
the  infectious  granulomata,  there  is  an  identity  of 
structure  and  arrangement  always  visible,  whereas  in 
cancer  of  different  organs  or  tissues  the  widest  differ- 
ences of  microscopic  appearances  are  met  with.  This 
argument  can  be  offset,  however,  by  another  still 
stronger,  to  the  eff^ect  that  in  true  carcinoma,  at  least, 
no  new  cells  are  introduced,  nor  new  tissues  formed, 
save  in  the  sense  of  being  a  reduplication  of  those 
already  existent.  On  the  other  hand,  in  sarcoma  there 
is  an  abnormal  tj-pe  of  cell  met  with,  which  has  no 
business  among  the  healthy  cells  of  the  body  any  more 
than  has  a  giant  cell  containing  tubercle  bacilli.  If, 
therefore,  his  argument  is  good  in  one  way,  it  loses  its 
force  in  the  other  direction. 

The  other  side  of  this  question  is  that  which  takes 
no  note  of  parasites,  considering  the  bodies  or  parti- 
cles regarded  as  such  by  some  to  be  new-cell  degener- 
ations or  artefacts,  or  else,  if  germs,  as  present  only 
by  accident.  The  evolutionist's  view  of  cancer  is  not 
necessarily  that  of  the  comparative  pathologist,  though 
the  latter  may  hold  to  the  former's  notions  in  this  re- 
gard. My  friend.  Dr.  Woods  Hutchinson,  our  profes- 
sor of  this  department,  would  summarize  it  about  as 
follows:  The  evolutionary  view  of  cancer  began  un- 
consciously in  the  famous  theory  of  Cohnheim's '"  rests" 
or  "  Schlummer-zellen"  ;    i.e.,  little   islands  or  foci  of 


cells,  embedded  in  the  adult  tissues,  which  have  re- 
tained a  more  primitive  or  unspecialized  character, 
with  its  accompanying  powers  of  independent  growth. 
Gradually,  however,  as  the  individuality  and  indepen- 
dence of  the  component  cells  of  the  body  became  more 
adequately  grasped,  pathologists  began  to  realize  that 
it  was  not  necessary  to  imagine  the  presence  of  any 
undeveloped  or  embrjonic  cells,  but  that  any  adult 
cell  had  the  power  of  relapsing  to  the  primitive  condi- 
tion and  initiating  the  neoplastic  process.  In  fact, 
cancer,  like  all  other  neoplasms  and  the  processes  of 
repair,  came  to  be  regarded  as  a  reversion.  That  in- 
dividual cells  of  all  descriptions  possess  reproductive 
powers  is  clearly  shown  by  the  rapid  multiplication 
of,  for  instance,  the  muscular  fibres  of  the  uterus  dur- 
ing pregnancy,  or  the  heart  in  hypertrophy,  the  lym- 
phatics in  ansemia,  or  the  connective-tissue  corpuscles 
in  the  healing  of  wounds.  The  reproductive  processes 
from  a  biologic  standpoint  may  be  divided,  according 
to  their  results,  into,  first,  those  in  which  the  product 
is  perfect,  the  daughter  cells  in  everj'  respect  the 
equals  of  the  parent  cells;  and,  second,  those  in  which 
this  result  falls  short,  the  daughter  cells  being  inferior 
in  rank  or  vitality  to  the  parent  cells.  Each  of  these 
is  again  divided  into  two^ — those  whose  products  are 
useful  to  the  body  as  a  whole,  and  those  which  are  not. 
So  that  we  have  four  great  processes  of  cell-breeding 
going  on:  (i)  Those  in  which  the  new  cells  are  per- 
fect (true  to  type)  and  of  utility  to  the  organism,  such 
as  genuine  hypertrophy,  leucocytosis,  etc.  (2)  Those 
in  which  the  new  cells  '"  breed  true,"  but  are  of  no 
utility  to  the  organism,  as  the  benign  tumors.  (3) 
Those  in  which  the  new  cells  are  imperfect,  but  of 
value  to  the  body,  as  in  scar  tissue.  (4)  Those  in 
which  the  resulting  cells  are  of  lower  grade  or  vitalitj', 
and  of  no  utilit)'  to  the  organism,  as  in  sarcoma  and 
carcinoma. 

In  fact,  cancer  is  regarded  as  an  abortive  attempt  of 
gland  epithelium  to  reproduce  itself,  i.e.,  a  parody 
upon  gland  tissue.  Its  "sin,"  its  essential  pathologic 
character,  lies  in  the  fact  that  its  cells  breed  with  an 
utter  disregard  of  the  welfare  of  the  body  as  a  whole. 
Its  danger  obtains  in  that  their  offspring  are  so  imma- 
ture and  degenerate  as  sooner  or  later  surely  to  break 
down,  decay,  and  poison  the  lymph  current.  Sarcoma 
is  a  similar  process  on  the  part  of  some  mesoblastic 
tissue  cells.  Supposing  this  statement  of  the  nature 
of  cancer  growth  accepted,  can  evolutionary  pathology 
offer  any  explanation  for  the  setting  up  of  this  process 
in  any  particular  group  of  cells?  The  evolutionist  be- 
lieves that  it  can.  The  one  factor  which  is  univer- 
sally admitted  as  predisposing  to  cancer  is  senility. 
It  is  emphatically  a  disease  of  middle  or  old  age. 

Just  as  soon  as  the  food  supply  begins  to  be  cut  off 
from  the  peripheral  organs  and  tissues,  the  liability  to 
this  process  is  immensely  increased.  The  same  thing 
will  be  found  to  be  true  of  the  organs  most  commonly 
attacked.  In  a  large  majorit)-  of  cases  these  will  be 
found  to  be  either  functionally  senile  or  ancestrally 
either  in  a  condition  of  progressive  atrophy  or  of 
marked  instabilit}-.  As  instances  of  the  first  class  are 
the  mammar)'  glands  and  uterus,  which  after  the  fail- 
ure or  disappearance  of  their  function  become  the  site 
of  nearly  eighty  per  cent,  of  all  cases  of  cancer  in  the 
female.  As  an  instance  in  which  botli  predisposing  fac- 
tors coexist,  we  have  the  lips  and  tongue,  in  which  both 
the  atrophic  changes  consequent  upon  the  loss  of  the 
teeth  and  the  "  border-line"  character  of  the  epithe- 
lium, poised  between  mucous  and  cutaneous  possibil- 
ities, as  it  were,  unite  to  render  its  cancer  record  next 
in  darkness.  For  ancestral  instability  few  localities 
can  compare  with  the  pylorus,  the  old  gizzard  region, 
and  here  again  we  have  a  most  frequent  site  of  carci- 
noma. All  of  these  facts  seem  dependent  upon  one 
common  biologic  law,  and  that  is  that  lowered   nutri- 


July  3.  1897] 


MEDICAL    RECORD. 


tion,  whether  individual  or  ancestral,  means  increased 
liabilit)-  to  cancerous  change:  that  just  as  soon  as  any 
organ  or  tissue  finds  itself  being  slowly  cut  off  from 
its  nutritive  supplies,  it  is  apt  to  begin  breeding  on  its 
own  account,  like  plants  running  to  seed  in  poor  soil, 
in  a  desperate  endeavor  to  hold  their  own — in  short, 
that  cancer  is  literally  a  "  rebellion  of  the  cells,"  as 
Jonathan  Hutchinson  has  termed  it,  and,  like  many 
another  rebellion,  is  chiefly  provoked  by  starvation 
and  want. 

It  will  be  seen,  then,  that  the  problem  of  the  nature 
of  cancer  and  of  its  cure  is  a  most  complex  one,  and 
must  be  studied  from  many  sides.  Permit  me  to  indi- 
cate in  some  degree,  and  yet  at  present  in  a  purely  sug- 
gestive way,  how  we  may  profitably  approach  it. 

First  of  all  from  the  statistical  side;  this  must  in- 
clude a  careful  histor}'  of  each  case,  including  that  of 
the  family.  One  of  the  difficulties  met  right  here  is 
that  of  getting  an  accurate  or  reliable  family  history. 
The  influence  of  alleged  injuries  or  previous  inflam- 
mation of  the  part  involved  must  be  carefully  weighed. 
We  need  to  make  out  especially  whether  only  a  can- 
cerous diathesis  can  be  inherited,  or  only  the  active 
disease,  or  both ;  for  instance,  a  woman  aged  fort}"-five 
develops  a  cancer — is  her  daughter  of  twent}"  years  of 
age  any  more  liable  than  any  other  girl  or  not? 

We  need  next  to  study  it  by  localities,  especially 
those  of  reasonably  fixed  proportions,  as  in  the  rural 
districts,  in  order  to  know  whether  it  is  really  or  only 
apparently  on  the  increase.  Moreover,  it  should  be 
established,  if  possible,  whether  the  numerical  increase 
is  due  solely  to  more  accurate  diagnosis  or  has  an  ac- 
tual basis  of  realit}'.  The  question  of  so-called  cancer 
houses  must  be  carefully  studied,  and  positive  evi- 
dence secured.  In  such  instances  there  must  be  a 
careful  scrutiny  of  evidence  to  show  whether  this  is 
due  to  anything  more  than  mere  coincidence. 

Next  we  should  determine  in  what  race  and  under 
what  social  conditions  the  disease  is  most  prevalent. 
This  will  also  necessarily  bring  up  the  question  of  di- 
etetic habits.  Is  it  more  prevalent,  for  instance,  among 
brain  workers  or  other  wage  earners,  among  vegeta- 
rians or  meat  eaters  ? 

A  study  of  localities  must  comprise  also  an  estima- 
tion of  the  physical  environment — what  the  climatic 
conditions,  what  the  geological  formation,  what  espe- 
cially the  drinking-water  supply.  Not  that  this  is 
so  imjwrtant  for  a  single  small  localit}-;  but  if  it  be 
shown  that  where  the  disease  is  prevalent  similar 
physical  conditions  exist,  it  means  a  great  deal  accom- 
plished toward  the  final  explanation  for  which  we  seek. 

Besides  the  statistical  study  of  the  disease  and  the 
external  conditions  surrounding  cancer  patients,  the 
problem  must  also  be  attacked  by  a  careful  laborator)- 
study  of  fluids  and  tissues.  First,  to  establish  wheth- 
er the  disease  is  primarily  local  or  systemic.  Such  a 
study  is,  of  course,  inseparable  from  the  other  exami- 
nations to  be  immediately  spoken  of.  Excretions,  espe- 
cially the  renal,  must  be  carefully  investigated ;  among 
other  reasons,  to  ascertain  whether  the  diminution  of 
urea  usually  noted  in  these  cases  is  to  be  regarded  as 
among  their  causative  or  consequential  features.  The 
blood  must  be  studied  with  the  spectroscope  as  well  as 
by  all  the  other  modem  means  of  examining  this  fluid. 
Its  haemoglobin  and  other  physical  constituents  must 
be  carefully  estimated,  and  its  corpuscles  frequently 
examined.  The  presence  of  sugar  or  of  peptone  in  the 
blood  must  also  be  as  frequently  determined.  Then 
the  tissues  of  the  tumor  itself  must  be  carefully  inves- 
tigated, chemically,  histologically,  and  bacteriologi- 
cally.  The  whole  question  of  inoculabilit\-  of  cancer 
fragments  must  be  again  gone  over  most  carefully,  with 
particular  effort  to  imitate  natural  and  original  condi- 
tions as  nearly  as  possible.  If  cancer  really  be  a  par- 
asitic disease,  it  is  only  a  question  of  time  when  the 


parasite  may  be  cultivated  in  pure  culture  and  iiiocu- 
lated  with  success.  It  does  not  follow  necessarily 
that  any  of  the  culture  media  now  in  use  will  suffice 
for  this  purpose;  to  settle  this  question  we  must  learn 
how  to  cultivate  sporozoa  and  all  the  other  reputed 
parasitic  growths  outside  of  the  body,  and  at  first 
without  any  reference  to  those  whose  agency  in  this 
direction  we  suspect. 

Finally,  the  problem  must  be  attacked  also  from 
the  side  of  comparative  patholog}-,  i.e.,  from  the  evolu- 
tionist's and  embr\-ologist's  standpoint.  To  this  effect 
we  must  begin  with  the  lower  forms  of  life,  and  deter- 
mine the  causes  which  operate  to  produce  neoplasms 
in  them.  We  must  begin  even  lower  down  in  the  veg- 
etable kingdom  than  those  trees  which  produce  tumors 
(x)lomata)  as  the  result  of  climatic  conditions  or  par- 
asitic vegetables  or  insects.  We  must  then  look  up- 
ward along  the  scale,  in  order  to  determine  whether 
tumors,  including  cancers,  are  entitled  to  be  regarded 
as  reversions  to  earlier  and  simpler  cell  forms,  or  sim- 
pler t}-pes  of  cell  arrangement,  or  whether  it  can  be 
sho\\Ti  that  they  never  assume  malignant  characteris- 
tics save  when  provoked  thereto  by  the  irritation  of 
parasites. 

All  of  this  means  not  merely  a  painstaking  and 
almost  discouraging  task  from  the  outset,  but  it  means 
more  than  can  be  accomplished  by  any  individual 
working  alone.  It  requires  the  collective  efforts  of 
numerous  men  versed  in  all  the  branches  of  biological 
study,  and  possessed  of  such  training  in  logic  as  shall 
permit  of  no  false  deductions;  it  is,  in  other  words,  an 
enormous  task,  but  not  necessarily  a  hopeless  one.  If 
any  inquir}-  into  that  which  affects  man's  health  and 
welfare  deser^-es  to  be  undertaken  by  the  State  or  the 
government  at  large,  it  certainly  is  this.  I  am  far 
from  making  light  of  the  studies  into  which  the  gene- 
ral government  has  entered  regarding  diseases  of 
plants  and  animals,  the  establishment  of  bureaus  of 
animal  industr}-,  the  detection  of  trichinosis,  etc.,  by 
all  of  which  great  benefit  has  accrued  to  our  people 
generally  and  the  spread  of  disease  been  notably  lim- 
ited. Xor  would  I  discourage  in  any  sense  the  publi- 
cation of  a  State's  reports  concerning  the  mineralogy, 
geolog}-,  and  natural  historj'  of  its  territor}-,  by  which 
knowledge  of  greatest  importance  is  collected  only  to 
be  suitably  distributed.  But  I  claim  that  we  have  in 
this  matter  of  cancer  to  deal  with  a  disease  of  horrible 
nature,  of  almost  inevitable  fatal  it}",  of  common  occur- 
rence, which  is  certainly  on  the  increase,  and  that  at 
present  we  are  helpless  to  combat  it  as  we  ought.  The 
people  naturally  look  to  us  both  for  explanation  and 
for  relief;  we  do  the  best  we  can,  but  this  is  often  very 
little.  If  the  lives  of  our  cattle  are  of  value,  how 
much  more  so  the  lives  of  our  citizens.  In  what  more 
humane  or,  from  the  merely  financial  aspect,  in  what 
more  satisfactor)-  work  could  a  government  engage 
than  by  the  employment  of  experts  competent  for  this 
work,  endeavoring,  no  matter  how  long  it  may  take,  to 
settle  this  problem?  When  the  real  cause  or  causes 
of  cancer  are  known  and  understood,  then  and  not  un- 
til then  can  a  rational,  early,  non-operative,  and  suc- 
cessful treatment  be  applied. 

It  would  hardly  be  fair  to  dismiss  this  most  gloomy 
and  unpromising  of  all  the  problems  which  present 
themselves  to  us,  without  asking,  in  conclusion, 
whether  any  measure,  drugs  or  otherwise,  can  be  re- 
garded as  either  certain  or  having  any  efficacy  as 
against  this  dread  disease?  To  this,  first  of  all,  I 
would  say  that  in  a  great  majorit}-  of  cases  cancer  ap- 
pears to  us  as  a  local  affection,  which,  could  it  be 
reached  early  enough  and  attacked  radically  enough, 
might  be  extirpated.  There  is  no  question  but  what 
early  and  extensive  operations  in  select  cases  give  per- 
manent relief.  To  bring  about  this  happy  result,  how- 
ever, requires  the  lucky  coincidence  by  which  an  in- 


MEDICAL    RECORD. 


[July 


telligent  patient  goes  early  to  an  intelligent  physician, 
and  has  his  or  her  trouble  recognized  at  a  time  when 
sweeping  operation  can  be  made  with  prospect  of  suc- 
cess. It  requires  also  that  the  disease  shall  be  located 
in  some  accessible  part  of  the  body,  in  order  both  that 
diagnosis  may  be  more  exact  and  operation  justifiable 
— e.xcept  those  trifling  growths  upon  the  surface  which 
may  be  removed  by  caustic  pastes,  if  one  prefer  such 
a  course.  The  treatment  by  cancer  pastes,  especially 
the  removal  of  large  masses  by  this  means,  is  alike 
unscientific,  barbarous,  and  damnable.  It  bespeaks 
the  meeting  of  two  cowards — the  patient  who  is  afraid 
of  the  knife,  and  the  pseudo-surgeon  who  is  afraid  to 
use  it.  Could  the  real  truth  be  known  about  institu- 
tions where  this  method  is  practised  as  a  specialty,  it 
would  be  far  more  discreditable  both  to  intelligence 
and  to  the  honesty  of  those  who  manage  them  than  is 
generally  appreciated. 

But  what  should  be  said  of  operations  in  hopeless 
cases?  I  maintain  that  one  has  a  right,  and  a  duty  to 
the  patient  as  well,  to  operate  in  absolutely  hopeless 
cases  for  either  one  or  more  of  the  four  following  rea- 
sons, providing  the  patient  willingly  consent.  These 
are:  (i)  The  relief  of  pain;  (2)  the  avoidance  of  con- 
stant hemorrhage;  (3)  the  affording  of  a  temporary 
respite;  and  (4)  the  removal  of  foul  sloughing 
growths,  which  are  an  offence  alike  to  patient  and 
family.  In  cases  coming  under  either  one  of  these 
heads,  the  propriety  of  an  operation  may  be  submitted 
to  the  judgment  of  intelligent  people,  and  to  the  unin- 
telligent the  choice  of  that  which  one  may  think  well 
to  advise. 

A  study  of  the  causes  of  cancer  being  so  inseparable 
from  a  discussion  of  the  cell  doctrine,  one  cannot  but 
feel  that  if  there  be  drugs  which  influence  cell  nutri- 
tion and  cell  activity,  it  is  among  them  that  we  must 
look  for  internal  remedies  which  may  have  a  palliative 
or  curative  effect.  First  among  these  I  place  the  time- 
honored  remedy  arsenic,  which,  so  far  as  I  know,  can 
vie  only  with  one  of  the  latest  aspirants  to  honor, 
namely,  nuclein,  for  which  we  shall  be  ever  deeply  in- 
debted to  Vaughan  and  his  colleagues  in  the  Univer- 
sity of  Michigan— these  being  the  two  remedies  which 
more  than  any  others  possess  these  properties.  We 
certainly  lack  exact  studies  demonstrating  their  power 
in  this  direction,  but  this  is  another  of  the  investiga- 
tions to  be  taken  up  when  this  ideal  research  labora- 
tor):,  at  which  I  have  hinted,  is  formally  organized. 
It  is  difficult  to  say  positively  whether  any  true  cancer 
has  ever  disappeared  completely  under  the  influence  of 
either  of  these  remedies.  Nevertheless,  I  have  per- 
sonally seen  remarkable  retrocession  of  large  and  bulky 
tumors  after  the  use  of  arsenic  internally,  and  most  en- 
couraging reports  have  of  late  come  from  those  who 
have  been  using  nuclein  for  this  purpose.  Still  it  is 
well  known  that  spontaneous  resolution  of  tumors  is 
believed  in  by  not  a  few  men  of  greatest  eminence, 
while  for  myself  personally  its  possibility  seems  to 
have  been  clearly  demonstrated  in  more  than  one  case 
under  my  observation.  Certain  it  is,  however,  that  in 
some  instances  one  must  either  allow  this  spontaneous 
retrocession  to  have  occurred,  or  ascribe  the  wonderful 
change  to  the  influence  of  certain  drugs.  For  my  own 
part,  also,  I  have  such  faith  in  the  virtues  of  arsenic 
that  I  prefer  to  keep  all  my  patients  more  or  less 
steadily  under  the  influence  of  the  drug  in  some  form 
for  months  after  operation,  while  it  has  seemed  to  me 
that  I  have  obtained  the  best  results  by  using  a  com- 
bination of  arsenic,  gold,  and  mercury,  in  connection 
with  the  three  haloid  elements,  chlorine,  iodine,  and 
bromine.  Whether  the  benefit  which  in  my  observa- 
tions of  this  compound  has  really  occurred  is  due  to 
the  influence  of  one  or  more  of  its  components  upon 
cell  activity,  or  to  the  fact  that  the  combination  cer- 
tainly serves  as  an  ideal  internal  antiseptic,  1  will  not 


attempt  to  say.  At  all  events  there  is  more  rapid  res- 
toration of  haemoglobin,  disappearance  of  the  anamia 
due  to  poikilocytosis,  as  well  as  of  the  leucocytosis 
which  is  a  feature  of  the  cancerous  cachexia,  than  I 
have  known  of  after  using  any  other  drug. 

Lastly,  without  stopping  to  mention  any  of  the  other 
drugs  recently  or  in  time  past  lauded  for  this  purpose, 
all  of  which  have  so  far  proved  disappointing,  I  would 
only  mention  the  modern  treatment  of  cancer  by  the 
use  of  toxins  of  erysipelas.  Having  experimented 
diligently  with  the  toxins  and  without  other  effect  save 
to  prove  their  general  inefficacy,  I  am  compelled  to 
say  that  in  most  respects  the  treatment  has  proved  a 
disappointment,  the  results  in  most  of  the  cases  under 
my  observation  having  been  negative:  while  for  every 
instance  in  which  more  or  less  benefit  has  resulted,  I 
could  bring  two  or  three  to  bear  in  which  positive  in- 
jur)- has  resulted.  It  may  be,  however,  that  we  are  on 
the  right  track  in  this  matter  or  near  it,  and  need 
mainly  to  enlarge  our  observation  and  still  further  use 
our  reason. 


CLINICAL    REMARKS    ON    SOME    SUPPURA- 
TIONS   OF   THE    URINARY    APPARATUS. 

By   REGINALD   HARRISON,    F.R.C.S., 

PRESIDENT   OF   THE    MEDICAL   SOCIETY   OF   LOSDO.S, 

I  HAVE  selected  for  consideration  some  points  which 
seem  to  arise  out  of  the  pathology  of  certain  suppura- 
tive processes  as  observed  in  the  urinarj-  organs  in 
relation  to  the  more  modern  treatment  of  surgical 
lesions  and  infections  as  generally  practised. 

I  shall  first  illustrate  my  observations  by  taking  the 
most  common  as  well  as  the  farthest-reaching  cause 
of  suppurations  of  the  urinar)-  organs,  as  occurring  in 
the  form  of  primary  gonorrhceal  infections  in  the  male 
and  the  female,  and  as  secondarj-  developments  in 
other  parts  of  the  genito-urinary  system,  as  more  fre- 
quently observed  in  the  latter  sex. 

The  advances  that  have  been  made  in  connection 
with  the  bacteriolog}'  of  the  urinar}'  organs,  in  refer- 
ence more  particularly  to  the  kind  and  e.xtent  of  these 
infections,  has  already  led  to  some  useful  applications 
in  the  way  of  treatment,  which  I  will  briefly  notice. 
The  investigations  of  Guyon,  Janet,  Halle',  and  others 
of  the  French  school,  more  particularly  as  regards  the 
life  history  and  cultivation  of  these  micro-organisms, 
are  of  much  interest  and  importance.  It  is,  however, 
to  the  practical  aspect  of  the  subject  that  I  shall  con- 
fine my  remarks. 

The  first  point  that  strikes  one  is  that  many  of  the 
cases  spoken  of  as  instances  of  chronic  suppurative 
urethritis  or  gleet  represent  a  far  more  extensive  in- 
vasion than  is  generally  supposed  to  be  the  case.  In 
this  lies,  I  have  no  doubt,  an  explanation  of  the  diffi- 
culty that  is  not  unfrequently  experienced  in  bringing 
cases  of  this  kind  to  a  successful  and  sjieedy  termina- 
tion. Many  gleets  are  merely  reinfections  of  the  ure- 
thra from  a  bladder  which  serves  the  purpose  of  a 
medium  for  bacterial  cultivation.  So  long  as  a  gonor- 
rhcea  is  confined  to  the  area  of  the  urethra,  as  defined 
by  that  portion  of  the  canal  which  lies  in  front  of  the 
compressor  urethra  or  "  cut-off"  muscle,  the  task  of 
successfully  combating  the  infecting  suppuration  is 
not  usually  a  difficult  one.  The  disease  is  within  lim- 
its which  can  be  readily  acted  upon  by  various  agen- 
cies, administered  either  locally  or  by  internal  medi- 
cation, and  its  course  is  generally  limited  both  in 
severity  and  duration.  When,  however,  these  boun- 
daries are  exceeded  and  the  bladder  is  invaded,  it  is 
not  easy  to  prevent  reinfection  taking  pla;e  as  if  from 
an  extraneous  source.  Hence  the  disease  may  be  al- 
most indefinitely  protracted. 


July  3,  1897] 


MEDICAL    RECORD. 


Nor  is  invasion  of  the  bladder  in  this  ^vay  uncom- 
mon or  necessarily  indicated  by  acute  symptoms,  such 
as  would  unmistakably  draw  attention  to  the  occur- 
rence. In  most  instances  of  this  the  prostate  is  the 
only  part  of  the  urinarj-  apparatus  that  shows  any 
active  indication  of  contact  with  the  septic  products, 
the  mucous  membrane  of  the  bladder,  though  harbor- 
ing them,  being  singularly  insensitive  to  bacterial  in- 
fluences. That  infection  occurs  in  this  way,  may  be 
readily  demonstrated.  When  the  bladder  has  been 
thus  infected,  the  conditions  of  the  urinarj'  organs, 
particularly  during  the  night,  are  extremely  favorable 
for  bacterial  cultivations,  a  circumstance  which  I  be- 
lieve may  explain  the  constancy  and  degree  of  matu- 
tinal suppuration  exuded  by  the  urethra,  which  is  a 
prominent  symptom  in  thi^  class  of  cases. 

It  is  rare,  I  believe,  for  gonorrhceal  organisms  to 
make  their  way  up  the  ureters  and  to  invade  the  kid- 
neys, a  fact  which  is  no  doubt  due  to  the  guarded 
manner  in  which  these  ducts  enter  the  bladder  and 
the  constancy  of  the  downward  flow  of  the  urine. 
That  renal  infection  and  urethral  inflammation,  suffi- 
cient to  cause  a  pyelitis  of  the  former  and  a  contrac- 
tion or  stricture  of  the  latter,  can  occur  has  been 
demonstrated  as  possible.  Some  years  ago  I  exam- 
ined the  body  of  a  middle-aged  man  who  died  from 
acute  single  pyelitis  rapidly  following  upon  a  first  at- 
tack of  gonorrhoea.  The  ureter  of  the  kidney  involved 
was  extremely  dilated,  a  circumstance  which  was  be- 
lieved to  be  due  to  the  patient  having  been  in  the 
habit  for  some  years  previously  of  passing  renal  cal- 
culi. The  opposite  kidney  was  much  congested.  Mr. 
W  G.  Nash '  has  recorded  a  case  of  strictured  ureter 
which  was  probabl)"  caused  in  this  way.  In  the  female 
the  widespread  effects  of  the  gonorrhceal  infection  are 
ver\-  generally  recognized. 

The  suspicion,  however,  that  the  bladder  may  be 
infected  with  micro-organisms  should  be  made  a  mat- 
ter of  proof,  and  this  can  generally  be  done.  For  this 
purpose  care  should  be  taken  to  obtain  a  specimen  of 
the  urine  as  it  exists  in  the  bladder,  minus  any  con- 
taminations it  may  pick  up  in  its  transit  along  the 
urethra.  The  first  pwrtion  of  the  urine  passed  should 
be  rejected  as  probably  containing  the  flushings  of 
the  canal,  the  balance  being  separately  collected  as 
representing  the  constituents  of  what  may  be  called 
vesical  urine.  When  it  is  possible  a  catheter  speci- 
men should  be  obtained  in  accordance  with  the  direc- 
tions of  the  Clinical  Research  Association,  if  there 
are  reasons  for  believing  that  the  bladder  is  infected. 
In  this  way  gonococci  may  be  detected  in  vesical  urine 
in  cases  of  gonorrhcea. 

The  mere  fact  that  the  urine  is  shown  to  contain 
bacteria  does  not  necessarily  imply  that  the  individual 
is  capable  of  inoculating  another  with  gonorrhcta. 
\\'hen,  however,  the  gonococcus  is  discovered  in  the 
urine  or  the  discharges  of  the  patient,  as  is  not  unfre- 
quently  the  case,  I  do  not  think  there  can  be  any  doubt 
as  to  the  possibilit)-  of  its  transference  to  some  one 
else.  The  bacteriological  examination  of  these  secre- 
tions may  furnish  important  evidence  in  determining 
whether  a  person  who  has  been  comparatively  recently 
infected  should  be  allowed  to  marr\-.  So  long  as  these 
conveyors  of  infection  can  be  detected  in  the  urine  or 
the  discharges,  so  long  may  we  expect  that  transfer- 
ence of  the  disease  is  apt  to  follow. 

In  these  cases  of  secondary  infection  of  the  bladder 
caused  by  extension  from  the  urethra,  I  have  for  some 
time  placed  much  reliance  upon  the  irrigation  of  the 
bladder  and  urethra  with  antiseptics  as  described  by 
Dr.  Janet,'  with  some  modifications.  The  object  is 
attained  in  the  following  manner:  My  apparatus  con- 
sists of  an  ordinar}-  hydrostatic  bladder  tank,  holding 

'  Brit.  Med.  Jour.,  .\pril  S,  1S93. 

'Jour,  des  Malad.  Gen.-Urin.,  Paris,  iSg6. 


about  one  pint  of  water  and  fitted  with  a  nozzle  to 
which  a  No.  8  Jacques  rubber  catheter  is  attached. 
The  tank  is  elevated  about  six  feet  from  the  ground, 
and  is  filled  with  warm  water  ccntaining  thirtj-  min- 
ims of  Condy's  fluid  to  a  pint  of  the  latter.  For  lubri- 
cating the  catheter  I  use  carbolized  vaseline. 

The  patient,  having  emptied  his  bladder  spontane- 
ously, is  placed  in  the  recumbent  position  and  the 
catheter  is  then  passed.  Before  the  nozzle  of  the  irri- 
gator is  connected  with  the  catheter  as  it  lies  in  the 
bladder,  the  fluid  is  allowed  to  run  off  for  a  few  sec- 
onds so  as  to  insure  that  there  is  no  free  air  in  the 
tube  of  the  apparatus.  Then  the  connection  is  made 
and  the  fluid  is  allowed  to  flow  into  the  bladder  by 
degrees,  until  the  patient  is  conscious  of  feeling  dis- 
tention. I  generally  use  from  twelve  to  sixteen  ounces 
for  this  purpose,  allowing  it  to  enter  the  bladder  in 
jets  of  about  three  or  four  ounces  at  a  time.  In  this 
way  the  feeling  of  any  sudden  or  extreme  fulness  is 
avoided  and  the  entire  area  of  the  mucous  membrane 
of  the  bladder  is  unfolded  and  opened  out  and  thus 
comes  in  contact  with  the  permanganate  solution. 
When  a  sufficient  degree  of  bladder  distention  is  ob- 
tained the  catheter  is  slowly  removed,  care  being  taken 
not  to  allow  the  fluid  to  escape.  I  then  usually  lightly 
palpate  the  bladder  above  the  pubes  with  the  hand  be- 
fore the  patient  stands  up.  This  he  should  then  do 
and  proceed  to  empty  his  bladder  of  its  contents  by 
his  natural  efforts.  Thus  not  only  is  the  bladder 
washed  out  but  the  whole  urethra  is  flushed  in  a  man- 
ner that  is  impossible  with  any  other  artificial  method. 
As  the  patient  is  voiding  the  contents  of  his  bladder 
it  is  well  to  direct  him  suddenly  to  interrupt  the  out- 
flow once  or  twice  by  pressure  with  the  finger  on  the 
penile  urethra.  In  this  way  the  lacunae  of  the  canal 
are  also  distended  and  flushed  by  the  irrigating  fluid. 
This  completes  the  process,  which  may  be  repeated 
once  or  twice  in  the  twent}--four  hoiu-s,  until  the  urine 
and  the  urethral  mucus  are  found  free  from  organ- 
isms. Most  patients  after  proper  instruction  will  be 
able  to  carr}-  out  all  these  details.  On  the  conclusion 
of  each  irrigation  the  patient  should  rest  for  a  time  in 
the  recumbent  position. 

I  have  referred  only  to  the  permanganate  of  potassium 
in  great  dilution  as  the  flushing  agent  for  use  in  these 
cases.  Half  a  drachm  of  Condy's  solution,  as  I  have 
already  mentioned,  gradually  increased  to  a  drachm 
in  a  pint  of  water,  has  given  me  good  results.  Neu- 
tral sulphate  of  quinine  (one  grain  to  the  ounce) 
may  also  be  used.  More  rarely  I  have  employed 
nitrate  of  silver  (one-si.\teenth  of  a  grain  to  the 
ounce),  and  perchloride  of  mercury.  The  last  some- 
times produces  a  good  deal  of  pain  even  when  it 
is  used  only  in  the  proportion  of  one  in  ten  thou- 
sand. I  have  no  doubt  that  for  aborting  infections 
the  perchloride  is  the  most  effective.  When  used  for 
the  latter  purpwase  in  the  proportion  of  one  in  ten  thou- 
sand, and  after  the  solution  has  been  spontaneously 
voided  from  the  bladder,  as  in  the  act  of  micturition, 
the  bladder  may  be  refilled  with  a  strained  solution  of 
albimiin,  say,  that  yielded  by  one  fresh  egg,  in  a  pint 
of  tepid  or  nearly  cold  water.  If  this  is  done  and  the 
albuminoid  solution  voided  from  the  bladder,  any 
pain,  smarting,  or  spasm  that  the  perchloride  solution 
produced  at  once  ceases.  Similarly  a  weak  solution 
of  chloride  of  sodium  injected  into  the  bladder  after 
a  solution  of  nitrate  of  silver  has  been  used  for  this 
purpose,  not  only  removes  any  irritation  the  latter 
may  provoke  but  coats  over  the  inflamed  mucous  mem- 
branes with  a  thin  layer  of  chloride  of  silver  which 
often  affords  much  relief  when  cystitis  is  present. 
Probably  there  is  no  better  bactericide  than  nitrate 
of  silver  in  these  cases,  but  it  requires  to  be  used  with 
the  precautions  I  have  mentioned,  when  good  results 
may  be  obtained. 


MEDICAL    RECORD. 


[July  3,  1897 


In  this  class  of  cases,  in  which  suppuration  proceeds 
directly  from  infection,  the  internal  administration  of 
bactericides  may  be  advantageously  combined  with 
the  local  treatment  I  have  just  referred  to.  In  ren- 
dering the  urine  not  only  sterile  and  destructive  to  the 
life  of  the  gonococcus  there  are  no  more  effectual  agen- 
cies than  some  of  those  which  are  derived  from  the 
vegetable  kingdom.  I  refer  more  particularly  to  those 
volatile  oils  which  are  so  largely  eliminated  by  the 
kidneys,  among  which  I  may  instance  sandalwood,  co- 
paiba, cubebs,  and  other  similar  drugs.  By  these  it 
is  possible  so  to  saturate  the  urine  as  to  render  the 
existence  of  certain  forms  of  infecting  bacteria  impos- 
sible. I  shall,  however,  later  on  refer  to  other  methods 
employed  for  sterilizing  the  urine,  which  may  also  be 
utilized  in  connection  with  the  treatment  of  infecting 
forms  of  urethritis  and  cystitis. 

I  will  now  proceed  to  notice  other  forms  of  urinary 
suppurations,  which  may  be  best  illustrated  by  certain 
cases  of  prostatic  obstruction.  Though  the  urine  is 
in  these  instances  usually  purulent  and  charged  with 
bacteria,  the  latter  are  not  infective  in  the  same  sense 
as  those  I  have  previously  referred  to  in  connection 
with  a  specific  form  of  urinary  suppuration.  On  the 
other  hanJ  it  must  be  remembered  that  these  micro- 
organisms are  readily  capable  of  transference  from  one 
individual  to  another  through  the  medium  of  catheters 
and  instruments  of  this  kind,  and  thus  they  may  be 
regarded  as  the  factors  in  the  causation  of  very  exten- 
sive and  far  reaching  suppurations  in  these  parts. 

The  principles  of  treatment  in  this  class  of  suppura- 
tions are  the  same  as  those  I  have  already  referred  to, 
subject  to  certain  modifications  which  I  will  proceed 
to  notice.  Putting  aside  the  consideration  of  the  pre- 
cise means  which  these  cases  often  require  for  me- 
chanically emptying  the  bladder  and  thus  preventing 
decomposition  of  the  urine  taking  place,  the  restora- 
tion of  the  secretion  to  its  normal  state  will  be  mainly 
brought  about  by  the  employment  of  antiseptics  in  the 
manner  indicated.  The  more  or  less  atonic  condition 
of  the  bladder  in  these  obstructi\e  cases  seldom  per- 
mits us  to  employ  the  process  of  auto-irrigation  as 
previously  described,  and  we  must  therefore  for  this 
purpose  avail  ourselves  of  one  or  other  of  the  methods 
usually  practised. 

In  ottering  a  few  remarks  on  the  toilette  of  the 
bladder  I  will  do  so  in  reference  (i)  to  the  disposi- 
tion' of  the  parts  requiring  ablution,  (2)  to  the  mech- 
anism employed,  and  (3)  to  the  composition  of  the 
cleansing  fiuid.  Most  of  us,  I  think,  will  admit  that 
we  are  disposed  to  draw  our  ideas  relative  to  the  proc- 
ess of  washing  out  the  bladder  from  the  natural  state 
of  the  parts,  such  as  we  see  in  anatomical  plates.  If, 
however,  we  take  for  our  guidance  the  majority  of 
pathological  specimens  illustrating  the  obstructive 
diseases  of  these  parts,  we  shall  at  once  recognize  the 
difficulties  that  beset  us  in  our  endeavor  to  wash  out 
these  examples,  as  we  should  do  in  the  case  of  a  pint 
pitcher.  Take,  for  instance,  the  hypertrophied  blad- 
ders with  their  various  saccules,  pouches,  and  depen- 
dencies which  are  met  with  in  connection  with  advanced 
urethral  stricture  in  younger  adults  and  in  per.sons  of 
more  advanced  age  who  are  the  subjects  of  obstructive 
prostatic  disease.  In  many  of  these  the  bladder  is  no 
more  like  the  natural  organ  than  the  interior  of  a  glass 
bowl  resembles  the  section  of  a  coarse  bath  sponge. 
The  contents  of  the  latter  one  could  hardly  ever  hope 
to  w'ash  out  effectually,  though  one  might  succeed  in 
soaking  them  out.  For  washing  out  the  bladder  I 
almost  invariably  employ  the  hydrostatic  tank  which 
is  now  so  generally  used.  It  has,  I  believe,  many  ad- 
vantages over  syringes,  which  I  need  not  here  stop  to 
enumerate.  When  the  bladder  is  much  fasciculated 
washing  out  should  be  done  in  the  recumbent  position, 
with  the  object  of  opening  out  the  mucous  membrane 


as  completely  as  possible  without  causing  pain,  the  ob- 
ject being  to  reach  irregularities  on  the  surface  which 
otherwise  would  escape  contact  with  the  lotion.  When 
the  bladder  is  much  pouched  it  is  a  good  plan  after 
filling  it  and  before  removing  the  fluid  to  cause  the 
patient  to  agitate  his  body  from  side  to  side  so  as  to 
bring  any  dependencies  there  may  be  within  reach  of 
the  antiseptic.  In  various  ways  such  as  I  have  indi- 
cated the  process  of  washing  out  the  bladder  may  be 
rendered  more  searching. 

For  washing  out  in  ordinary  cases  of  bacterial  urine 
I  usually  prefer  boric  acid  or  the  boroglyceride. 
Condy's  fluid  or  iodoform  may  also  be  similarly  em- 
ployed. As  I  have  already  said,  a  solution  of  nitrate 
of  silver,  in  the  proportion  of  one-twelfth  of  a  grain 
to  the  ounce,  is  often  efficacious  in  rendering  turbid 
urine  clear  after  other  things  have  failed. 

The  sterilization  of  the  urine  by  internal  medicines 
is  an  important  adjunct  in  the  treatment  of  the  class 
of  cases  I  am  now  referring  to.  It  is  quite  unneces- 
sary to  draw  your  attention  to  the  many  obvious  ways 
in  which  the  urine  may  thus  be  influenced.  The  spe- 
cific gravity,  the  reaction,  and  the  composition  of  this 
secretion  may  to  a  large  extent  be  artificially  influ- 
enced, and  in  these  directions  the  course  of  suppura- 
tive diseases  of  the  urine  passages  may  be  most  im- 
portantly and  favorably  acted  upon. 

And  this  brings  me  to  speak  of  some  of  the  means 
at  our  disposal  for  rendering  the  urine  sterile,  so  far 
as  the  most  important  factors  in  suppurative  diseases 
are  concerned,  I  have  already  referred  to  the  steriliz- 
ing influence  that  certain  oils  and  essences,  such  as 
sandalwood  and  copaiba,  are  capable  of  exercising  in 
this  way.  No  less  marked  is  the  effect  that  boric 
acid  taken  internally  is  capable  of  effecting  in  con- 
trolling bacterial  life  in  the  urine.  Probably  no  bet- 
ter proof  of  this  exists  than  in  the  results  observed  in 
connection  with  operations  on  the  urethra,  such  as  the 
passing  of  catheters  and  in  internal  urethrotomy.  The 
late  Dr.  Palmer,  of  Louisville,  showed  many  years  ago 
that  by  the  use  of  boric  acid  beforehand  the  develop- 
ment of  urethral  rigors  and  fever  under  these  circum- 
stances was  rendered  highly  improbable,  and  this  has 
since  been  most  amply  proved  to  be  the  case.  Simi- 
larly the  use  of  quinine  as  a  prophylactic  against  urine 
fever  has  been  shown  to  be  most  efficacious:  salol  and 
other  like  drugs  are  also  well  recognized  as  urine 
sterilizers. 

Though  boric  acid,  in  doses  of  ten  or  fifteen  grains 
three  or  four  times  in  the  day,  is  probably  one  of  the 
most  reliable  sterilizers,  it  so  often  disagrees  and 
causes  dyspepsia  as  to  interfere  greatly  with  its  use 
for  this  purpose.  Some  3-ears  ago  my  atteiition  was 
called  to  a  preparation  called  boro-citrate  of  magne- 
sium, which  was  described  by  Dr.  Kockler,  of  Kosten' 
in  Germany,  as  a  solvent  for  uric-acid  calculi  and 
gravel.  In  the  communication  referred  to  it  is  stated 
that  it  is  prepared  by  dissohing  boracite  in  citric 
acid,  boracite  being  a  natural  borate  of  magnesium 
which  is  found  in  Strassfurt.  Whether  it  is  actually  a 
solvent  for  uric  acid  I  am  not  prepared  to  say.  While 
testing  it  for  this  purpose  I  found  that  it  frequently 
had  a  remarkable  eft"ect  in  sterilizing  and  clearing  up 
purulent  urine  and  in  favoring  the  expulsion  of  calculi 
and  gravel,  by  its  flushing  effects  on  the  urine  passages. 
For  the  latter  purpose  I  have  used  it  for  the  last  ten 
years  with  considerable  effect  in  conjunction  with 
other  means  for  preventing  urine  decomposition.  This 
is  a  si»cimen  as  prepared  by  Messrs.  Bell  &■  Co., 
which  I  am  in  the  habit  of  prescribing  in  teaspoonful 
doses  in  half  a  tumbler  or  so  of  either  warm  or  cold 
water  two  or  three  times  in  the  day.  It  is  extremely 
palatable  to  take  and  readily  dissolves. 

There  are  other  means  for  sterilizing  the  urine  by 
'  Herlin.  klin.  Wochen.,  Novembers,  1S70. 


Julys.  1S97] 


MEDICAL    RECORD. 


II 


the  mouth  which  I  will  mention,  as  one  method  or 
one  drug  is  not  universally  applicable.  There  is  a 
combination  of  the  salicylate  of  sodium  with  the  ben- 
zoate  of  sodium  which  often  possesses  this  power  in  a 
marked  degree.  I  have  frequently  found  urine  which 
has  been  rendered  opaque  by  the  presence  of  pus  and 
was  swarming  with  bacteria  to  be  rendered  clear  in  the 
course  of  a  few  days  by  this  preparation.  I  usually 
prescribe  fifteen  grains  of  both  of  these  salts  to  be 
taken  together  three  times  a  day  in  an  ounce  of  chlo- 
roform water.  The  hyposulphite  of  sodium  in  half- 
drachm  doses  has  also  in  some  instances  effected  the 
same  object. 

The  principle  of  urine  sterilization  may,  however, 
be  e.xtended  to  other  purulent  or  bacterial  conditions 
of  the  urinar)-  apparatus.  I  refer  more  particularly  to 
some  of  those  chronic  suppurations  resulting  from  the 
formation  of  abscesses  in  connection  with  the  prostate 
and  prostatic  urethra,  in  which  the  pus  was  originally 
discharged,  sometimes  against  gravity,  into  the  latter 
canal.  These  are  often  most  difficult  to  heal  by 
reason  of  the  absence  of  a  free  and  dependent  open- 
ing. Yet,  on  the  other  hand,  the  opening  of  the  peri- 
neum and  the  incising  of  the  prostate  to  secure  free 
drainage  of  the  discharge  is  a  proceeding  that  cannot 
always  be  undertaken  without  some  degree  of  risk  in 
elderly  subjects.  The  thorough  cleansing  of  these 
deep  parts  by  the  use  of  antiseptics  in  the  form 
of  auto-irrigation,  as  described  in  the  earlier  part  of 
this  paper,  will  be  found  efficacious  in  many  of  these 
cases  of  chronic  suppuration.  In  some  instances 
of  prostatic  suppuration  it  is  almost  impossible  to 
flush  a  sinus  connected  with  this  part  so  long  as  a 
catheter  of  any  kind  is  retained  in  the  bladder;  on 
the  other  hand  this  object  may  be  often  readily  effect- 
ed by  the  spontaneous  contraction  of  a  more  or  less 
distended  bladder.  In  the  sinuses  arising  out  of 
tuberculous  prostatitis  this  method  often  proves  very 
effectual. 

Again  I  have  resorted  to  this  method  of  flush- 
ing urinary  fistula  with  some  antiseptic  fluid  when 
the  primary  cause  of  them  has  been  removed,  as  by 
gradual  dilatation  or  after  internal  urethrotomy. 
Tortuous  routes  through  the  perineum  may,  by  flush- 
ing through  the  medium  of  the  bladder  two  or  three 
times  if  necessary  in  the  twenty-four  hours,  be  thus 
healed. 

A  few  months  ago  I  saw  a  middle-aged  man  with  a 
tight  stricture  in  the  deep  urethra  which  admitted  only 
a  No.  4  bougie.  In  addition  there  were  two  chronic 
perineal  fistulas,  one  opening  in  the  left  buttock  and 
the  other  by  the  side  of  the  scrotum,  through  which 
almost  the  whole  of  the  urine  was  passed  at  the  time 
of  micturition.  The  patient's  condition  was  an  ex- 
tremely distressing  one,  as  it  was  impossible  for  him 
to  pass  his  urine  with  any  degree  of  comfort  except 
upon  a  watercloset.  I  divided  the  stricture  from 
within  by  Maissoneuve's  urethrotome.  A  catheter  was 
then  tied  in  the  bladder  for  fortj'-eight  hours,  and  on 
its  removal  a  No.  12  silk  catheter  a  boitle  was  intro- 
duced morning  and  evening.  After  being  washed  out 
by  means  of  this  in  the  ordinary  way,  the  bladder  was 
filled  with  over  half  a  pint  of  warm  boric  lotion, 
which  the  patient  was  required  to  void  naturally  in 
the  standing  position  on  the  catheter  being  withdrawn. 
The  fluid  escaped  as  in  the  ordinary  act  of  micturition 
with  this  patient,  namely,  partly  by  the  urethra,  and 
partly  through  the  false  routes.  The  proportion  of 
the  fluid  coming  through  the  urethra  gradually  in- 
creased, while  that  passing  through  the  two  fistula; 
grew  less  daily,  and  in  the  course  of  ten  days  entirely 
ceased.  This  method  of  procedure  I  have  found  from 
repeated  trials  to  contribute  importantly  in  promoting 
the  sound  healing  of  these  fistula,  and  the  comfort  and 
cleanliness  of  the  patient. 


THE  TREATMENT  OF  FOLLICULAR  ABSCESS 
OF  THE  FOSSA  NAVICULARIS  WITH  AT- 
TENDANT FISTULA.' 

Bv    CHARLES    H.    CHETWOOD,    M.D., 


The  condition  described  in  the  title  of  this  paper 
is  not  an  infrequent  one,  and,  unless  my  own  experi- 
ence is  peculiar,  is  generally  obstinate  to  treatment, 
especially  when  the  accompanying  fistula  is  complete 
with  both  internal  and  external  openings. 

I  have  for  the  past  year  or  so  depended  upon  a 
method  of  procedure  in  the  treatment  of  these  cases 
which  has  of  late  developed  into  a  routine  so  success- 
ful in  its  results  as  to  warrant  a  detailed  description 
for  the  benefit  of  those  whose  experience  has  not 
taught  them  a  better  method. 

In  order  to  cover  all  the  cases  I  have  treated  which 
came  under  the  above  heading,  I  divide  them  into 
three  classes,  of  which  I  report  a  successful  case  rep- 
resenting each  class : 

I.  Follicular  abscess  with  blind  internal  opening. 

II.  Follicular  abscess  with  blind  external   opening. 

III.  Follicular  abscess  with  complete  fistula. 

The  etiology  of  all  of  these  varieties  is  the  same, 
there  being  an  extension  of  inflammation  during  an 


attack  of  acute  or  chronic  urethritis  resulting  in 
periurethral  abscess,  which  leaves  a  permanent  fistu- 
lous tract  of  one  of  the  above-named  varieties  connect- 
ing with  a  distended  follicular  sac  of  varying  dimen- 
sions. The  first  is  probably  the  most  frequently  met 
with,  and  consists  simply  of  a  small  pouch  behind  the 
meatus,  connected  with  the  urethra  by  a  dilated  follicle 
mouth.  The  second  is  when  the  natural  follicular 
opening  becomes  closed  and  the  abscess  finds  vent 
externally.  The  third  is  when  a  complete  urethral 
fistula  exists  with  both  e.\ternal  and  internal  opening, 
often  the  result  of  an  unwise  external  incision.  In- 
ternally the  mouth  of  more  than  one  follicle  may  con- 
nect with  the  sac  and  externally  the  abscess  may  open 
on  both  sides  of  the  frenum. 

The  symptoms  accompanying  these  conditions  are 
those  resulting  from  a  contracted  meatus.  There  is 
more  or  less  induration  at  the  site  of  the  fossa  navi- 
cularis  and  a  certain  amount  of  purulent  urethral  dis- 
charge from  the  meatus  when  there  is  an  internal 
opening,  or  alongside  of  the  frenum  when  an  external 
opening  exists,  notably  when  pressure  is  made  over 
the  swelling. 

As  regards  diagnosis,  the  existence  of  periurethral 
abscess  is  self-evident.  The  nature  of  the  fistula  is 
determined  by  the  injection  of  a  small  quantity  of 
peroxide  of  hydrogen  into  the  vent  of  the  abscess, 
which  will  find  its  way  to  the  end  of  the  tract,  and 
demonstrate  whether  it  be  a  blind  or  complete  fistula. 
For  examination  I  employ  a  simple  wire  urethral 
speculum,  as  shown  in  the  accompanying  illustration 
(Fig.  i).  The  position  of  the  speculum  introduced,  de- 
monstrated in  the  next  illustration,  is  particularly  use- 
ful, the  object  being  to  make  the  floor  of  the  urethra 
pass  over  the  end  of  the  speculum  beneath  the  index 
'  Read  before  the  New  York  County  Medical  Association. 


MEDICAL    RECORD. 


[July  3,  1897 


finger,  which  gives  a  much  tsetter  field  of  vision  than 
when  held  in  the  ordinary  manner,  and  is  utilized  in 
the  later  part  of  the  treatment  hereinafter  described 
{Fig.  2).  I  have  found  sunlight  entirely  efficient,  al- 
though reflected  and  artificial  light  may  be  employed 
if  preferred. 

In  regard  to  what  is  generally  held  to  be  the  prog- 
nosis in  these  cases,  I  quote  from  Morrow's  "  System  of 
Genito-Urinary  Diseases,"  which  states  "  they  are  fre- 
quently obstinate.  Some  of  the  smallest  resist  all 
those  means  of  treatment  so  long  as  only  the  trivial 
operations  of  stimulation  and  catheterization  are  re- 
sorted to" — implying  that  more  definite  surgical  in- 
terference is  recommended. 

Such  rational  treatment  of  these  cases  generally  re- 
ferred to  in  the  books  is  incision  of  the  swelling 
(externally  or  internally),  keeping  the  cavity  packed 
until  healed,  and,  when  a  complete  fistula  exists,  de- 
nudation of  the  whole  tract  by  dissection  or  scraping, 
followed  by  careful  suturing.  I  have  found,  however, 
and  others  have  found  the  same,  that  such  treatment 
is  not  always  practicable,  and  certainly  not  invariably 


the  means  of  effecting  a  cure.  If  the  incision  is  made 
internally,  it  is  difficult  subsequently  to  keep  the 
cavity  properly  packed  in  the  interior,  and  thus  a  fail- 
ure may  result;  and  if  an  external  incision  is  made 
the  danger  of  making  a  complete  fistula  is  presented. 
Fissures  which  are  demonstrated  to  have  an  inter- 
nal opening  only  are  the  most  favorable  for  this  mode 
of  treatment;  but  even  then  the  follicular  mouth 
within  the  urethra  may  be  only  temporarily  occluded, 
and  if  it  reopens  during  the  treatment  after  external 
incision  the  danger  of  complete  permanent  urethral 
fistula  is  again  threatened.  I  do  not  doubt  that  many 
successful  cases  under  various  other  means  of  treat- 
ment might  be  reported,  but  the  obstinacy  of  the 
generality  of  cases  remains;  hence  I  do  not  hesitate 
to  recommend  the  course  of  treatment  I  have  adopted 
in  all  cases  of  the  varieties  already  named,  and  at  my 
hands  it  has  never  yet  failed  of  a  cure. 

The  method  of  applying  this  treatment  is  as  follows: 
The  patient  is  placed  in  the  recumbent  position,  in  a 
good  light,  and  a  wire  speculum  is  introduced  into  the 
urethra,  as  the  treatment  is  always  applied  from  the 
interior  whether  or  not  there  be  an  external  opening. 
Prior  to  the  introduction  of  the  speculum,  a  small 
quantity  of  four-per-cent.  solution  of  cocaine  (or  eu- 
caine)  may  be  injected  into  the  urethra  and  retained 
three  minutes,  after  which  a  few  drops  of  the  same  solu- 
tion are  injected  through  a  liypodermic  needle  into  the 
several  parts  underlving  the  fossa  navicularis  and  thus 
absolute  local  anaesthesia  is  obtained.  Such  complete 
an.TESthesia  is  only  resorted  to  at  the  first  sitting,  when 
an  incision  is  generally  required  and  more  thorough 
inspection  of  the  interior  is  desired.  Proper  inspec- 
tion is  facilitated  by  conforming  to  the  position  above 
illustrated  (Fig.    2).     A   fistulous   orifice   is   readily 


recognized    when    brought   beneath    the    end    of    the 
speculum. 

The  subsequent  treatment  is  practically  the  same 
whether  the  fistula  be  complete  or  incomplete  and 
whether  the  opening  be  internal  or  external.  An  in- 
cision   is    first    made  interiorly   over  the   site  of  the 


periurethral  swelling,  unless  there  is  an  accumulation 
within  the  sac  and  there  already  exists  a  large  enough 
opening  to  admit  the  introduction  of  the  nozzle  of  a 
pipette.  The  urethra  is  now  packed  with  absorbent 
cotton  from  the  lower  end  of  the  speculum  up  to  the 
point  of  the  incision,  and  now  with  a  specially  con- 
structed pipette  (Figs.  3  and  4)  a  few  drops  of  the 
twenty-five-per-cent.  solution  of  peroxide  of  hydrogen 
are  injected  into  the  interior  of  the  sac,  which  requires 
the  adoption  of  the  second  position.  Effervesence  now 
takes  place  freely,  and  the  overflow  is  caught  in  the 
absorbent  cotton,  after  which  the  speculum  is  closed 
and  withdrawn  with  the  cotton  in  its  grasp.  This  com- 
pletes the  first  treatment  and  the  patient  is  told  to  re- 
turn in  two  or  three  days,  being  apprised  of  a  probable 
free  purulent  discharge  as  a  result  of  this  first  appli- 
cation, for  which  a  mild  injection  may  be  given. 

The  next  application  is  more  trivial  and  may  be 
performed  with  or  without  cocaine,  according  to  the 
sensitiveness  of  the  urethra.  A  small  quantity  of  the 
same  solution  is  introduced  in  the  manner  already 
described  and  subsequently  continued  applications 
are  repeated  at  about  the  same  inter\-als. 

The  effect  of  these  applications  is  to  cause  rapid 
contraction  of  the  sac  and  destruction  of  its  pyogenic 
properties.  When  the  stage  is  reached  where  the  dis- 
charge has  practically  ceased  and  a  small  blind 
internal  fistula  is  all  that  remains,  position  No.  1  is 
resorted  to,  and  the  solution  is  applied  to  the  fistulous 
opening  by  means  of  a  fine  glass  rod,  which  procedure 
should  in  a  short  time  eff^ect  a  complete  cure.  I  find  it 
advisable  toward  the  end  of  the  treatment  to  substitute 
the  five-per-cent.  for  the  twenty-five-per-cent.  solution 
when  a  less  destructive  action  is  necessary  than  in  the 
early  stage  and  there  is  adventitious  tissue  to  be  re- 
moved by  the  caustic  action  of  the  stronger  solution. 


The  length  of  time  necessary  to  keep  up  this  treatment 
varies  from  two  to  six  or  eight  weeks,  according  to  the 
severity  of  the  case.  The  intervals  between  the  treat- 
ments are  from  two  to  four  days,  according  to  the  irrita- 
tion produced.  The  most  obstinate  cases  are  those  in 
which  complete  fistula  exists  and  those  in  which  there 


July  3,  1897] 


MEDICAL    RECORD. 


13 


is  underlying  tuberculous  diathesis.  All  cases  should 
result  in  a  cure  when  the  treatment  is  properly  per- 
formed. 

The  preparation  employed  in  the  treatment  is  manu- 
factured under  the  proprietary  name  of  pyrozone,  and 
the  so-called  caustic  and  antiseptic  preparations  of 
this  substance  are  nothing  more  nor  less  than  twenty- 
five-per-cent.  and  five-per-cent.  ethereal  solutions  of 
peroxide  of  hydrogen,  and  are  referred  to  as  such  in 
this  article.  This  compound  was  formerly  kno^^■n  and 
manufactured  under  the  name  of  ozonic  ether  some 
twenty-five  years  ago.  It  is  unnecessary  to  mention 
here  the  facility  with  which  peroxide  of  hydrogen  co\  - 
ers  the  whole  surface  of  pus-forming  cavities,  exerting 
an  active  penetrating  antiseptic  influence.  The  per- 
oxide of  hydrogen  preparations  generally  sold  are 
aqueous  solutions  of  this  substance.  The  ethereal  are 
more  active  and  the  above  percentages  of  peroxide  of 
hydrogen  are  greater  than  those  contained  in  any  of 
the  aqueous  preparations  manufactured.  The  ether 
also  is  a  desirable  ingredient,  being  a  solvent  of  fatty 
matter,  which  may  readily  obstruct  the  proper  action 
of  any  antiseptic  application  on  diseased  surfaces. 

The  pipette  I  make  myself  out  of  an  ordinary  medi- 
cine dropper  with  a  long  nozzle,  which  is  shaped  in 
the  flame  of  a  Bunson  burner  so  as  to  turn  at  a  right 
angle  and  then  drawn  to  an  extremely  fine  point; 
othem-ise  the  solution,  being  ethereal,  cannot  be  re- 
tained. 

The  following  classified  cases  demonstrate  the  effec- 
tiveness of  this  mode  of  treatment: 

Case  I.  represents  Class  I.,  viz.,  follicular  abscess 

with  blind  internal  fistula.     June  g,  1894,  Mr.  C.  L 

had  had  four  attacks  of  acute  urethritis.  The  latter 
one,  of  overt^vo  weeks'  duration,  was  complicated  by  a 
phlegmon  commencing  behind  the  frenum,  which  had 
been  opened  by  the  physician  who  was  then  treating 
him.  When  he  was  first  seen  by  me,  there  was  an  inter- 
nal fistula  connecting  with  a  small  abscess,  which  was 
discharging  itself  into  the  urethra,  and  at  this  time  and 
for  several  days  later  the  danger  of  a  complete  fistula 
forming  was  threatened  by  spontaneous  external  open- 
ing. A  probe  introduced  from  within  could  be  felt 
just  beneath  the  mucous  lining  of  the  prepuce,  on  both 
sides  of  the  frenum,  which  was  so  thin  that  the  probe 
could  almost  be  seen.  After  one  week  of  the  above 
treatment  the  danger  of  external  opening  no  longer 
presented,  and  at  the  end  of  two  weeks  the  abscess  had 
stopped  discharging  and  the  fistula  closed  soon  after- 
ward. 

C.^SE  II.,  an  example  of  Class  II.,  follicular  abscess 

with  blind  external  fistula.     Mr.  J.  P had  an  acute 

urethritis  of  two  or  three  weeks'  duration,  some  time 
during  which  a  follicular  abscess  had  formed  at  the 
fossa  navicularis,  unnoticed  by  the  patient,  but  had 
opened  spontaneously  externally.  July  18,  1894,  an 
internal  incision  was  made  and  the  usual  treatment 
carried  out,  with  the  result  of  complete  recovery  in 
three  weeks. 

C.\SE  III.,   Mr.   H.   F.  G ,  was  one  in  which  a 

complete  fistula  was  formed.  The  patient  had  large 
swollen  glands  on  both  sides  of  the  neck,  was  anaemic 
and  had  an  e.xtremely  irritable  bladder,  very  obstinate 
to  treatment,  suggesting  the  possibility  of  a  tubercu- 
lous element.  There  was  an  indurated  sac  behind  the 
meatus,  an  external  opening  on  the  right  side  of  the 
frenum,  and  an  internal  one  on  the  floor  of  the  meatus, 
so  that  peroxide  of  hydrogen  injected  through  the 
e.xtemal  opening  would  effer\-esce  through  the  meatus. 
On  account  of  the  patient's  general  condition  and  the 
urgency  of  his  bladder  symptoms,  the  trouble  near  the 
meatus  was  not  immediately  treated,  except  to  wash  it 
out  occasionally  with  different  antiseptic  solutions, 
which  produced  no  curative  effect.  After  the  patient 
had  been  under  treatment  for  four  or  five  months,  his 


bladder  trouble  had  almost  entirely  subsided  and  his 
general  health  was  much  improved,  but  the  fistulous 
openings  near  the  meatus  persisted,  and  after  remain- 
ing away  two  or  three  months  longer  he  returned  to  be 
treated  for  this  condition.  January  21,  1896,1  en- 
larged the  internal  opening  and  followed  up  the  regu- 
lar course  of  treatment  as  if  no  external  opening 
existed.  The  patient  was  under  treatment  for  about 
seven  or  eight  weeks,  when  the  indiu-ated  area  had 
contracted  down  to  almost  nothing  and  both  fistulous 
openings  had  entirely  closed,  it  being  impossible  to 
press  out  any  discharge  internally  or  externally. 

In  conclusion,  I  would  state  I  have  seen  all  of  the 
above  cases  at  periods  of  from  three  mouths  to  a  year 
after  the  cessation  of  treatment,  and  in  none  was  there 
any  sign  to  indicate  that  the  recover)'  was  not  perma- 
nent. 


COWS    MILK   IX    INFANT    FEEDING.^ 
By   WALTER   G.    MURPHY,    M.D.. 

EAST  RARTFOED,   CONN, 

The  first  year  of  childhood,  often  for  purposes  of 
study  arbitrarily  named  the  first  nutrient  period,  pre- 
sents to  the  student  of  medicine  many  complex,  in- 
teresting, and  important  problems.  To  us  as  phy- 
sicians is  intrusted  the  important  office  of  guiding 
the  gro\\th  of  the  child  as  it  passes  through  its  de- 
velopmental stages,  that  in  its  growth  it  may  re- 
tain or  acquire  the  priceless  boon  given  mankind, 
namely,  good  health.  As  a  factor  in  the  growth  and 
general  well-being  of  the  child,  food  occupies  a  most 
important  position,  and  it  seems  appropriate  at  this 
time  to  present  for  your  consideration  the  subject  of 
cow's  milk  in  infant  feeding.  The  writer  cannot  hope 
to  present  an  exhaustive  treatise  on  such  an  extensive 
and  varied  topic,  but  rather  to  touch  up>on  a  few 
of  the  many  difficulties  with  which  we  have  to  con- 
tend. 

All  authors  agree  that  cow's  milk,  which  is  now 
universally  accepted  as  the  best  substitute  for  mater- 
nal milk,  must  be  modified  to  resemble  more  closely 
nature's  product.  A  comparison  of  the  analyses  of 
cow's  milk  and  woman's  milk  will  demonstrate  the 
difficulties  to  be  overcome  in  arranging  a  diet  of  cow's 
milk  for  a  young  child.  Leed's  analyses  give  4.01  fat 
and  2.06  albuminoids  in  woman's  milk,  and  3.75  fat 
and  3.42  albuminoids  in  cow's  milk.  Other  obser\ers 
give  even  a  higher  percentage  of  albuminoids  in  cow's 
milk. 

The  difficulty,  outside  of  the  laboratory,  is  to  dilute 
the  proteids  and  still  retain  the  fats  at  a  proper  stand- 
ard compared  with  woman's  milk.  The  acid  reaction 
of  cow's  milk  also  presents  difficulties.  AA'oman's 
milk  is  almost  uniformly  alkaline.  If  not,  it  should 
not  be  used  (Rotch).  Co\\''s  milk,  as  usually  received 
t«'enty-four  hours  after  milking,  is  quite  acid,  and  I 
believe  just  as  much  is  due  to  this  fact  as  to  the  pro- 
portion of  proteids  present.  Milk,  as  drawn  from  the 
breast  by  the  child,  is  sterile.  The  nicety  of  mecha- 
nism of  the  breast  in  performing  its  function  allows 
no  possibility  of  fermentation  before  the  milk  enters 
the  infant's  mouth,  and  as  the  gland  collapses  as  it  is 
gradually  emptied  a  vacuum  is  avoided.  If,  however, 
milk  is  exposed  to  the  air,  bacteria  multiply  very  rap- 
idly by  the  hundreds  and  thousands,  and  in  time, 
shorter  in  summer  than  in  winter,  increase  to  such 
proportions  that  fermentation  occurs,  lactic  and  buty- 
ric acids  are  formed,  and  the  milk  sours.  Milk  twenty- 
four  hours  old  is  an  entirely  different  substance  than 
when  perfectly  fresh.     Originally  not  harmful,  as  at- 

'  Read  at  the  semi-annual  meeting  of  the  Hartford  Count}- 
Medical  .Association,  Hartford.  Conn.,  April  21,  1397. 


H 


MEDICAL    RECORD. 


[July  3,  1897 


tested  in  some  countries  where  children  are  nursed  di- 
rectly from  the  cow,  milk  becomes  by  natural  changes, 
if  allowed  to  occur,  a  rank  poison. 

It  has  been  found  by  e.xperiment  that  if  milk,  imme- 
diately after  being  drawn  from  the  cow,  is  cooled  to 
40°  F.,  all  bacteria  growth  is  at  once  arrested  and  re- 
mains so  if  the  milk  be  kept  at  a  low  temperature. 
With  our  present  manner  of  handling  milk  in  the 
dairy,  unless  absolute  cleanliness  is  observed  about 
the  barn,  cow,  and  hands  and  clothing  of  the  milker, 
it  is  impossible  to  get  a  thoroughly  sterile  milk. 
Some  microbes  develop  very  rapidly,  doubling  in 
twenty  minutes,  while  others  require  a  longer  time. 
But  that  cooling  rapidly  is  effective  is  fully  proven  by 
an  experiment  at  the  Vale  Agricultural  Experiment 
Station.  Two  cultures  were  made  on  gelatin  plates — 
one  of  milk  cooled  to  40"  F.,  and  the  other  perfectly 
natural  milk,  with  all  its  gases  and  animal  heat  re- 
tained. The  first  plate,  after  sufficient  exposure,  gave 
only  twelve  colonies,  while  the  second  contained 
thousands. 

In  experiments  to  determine  the  size  of  the  curd  of 
cow's  milk  as  compared  with  the  curd  of  woman's 
milk,  it  is  noticed  that  the  precipitate  obtained  by  the 
addition  of  acid  to  cow's  milk  is  tough  and  hard,  while 
the  curd  of  woman's  milk  is  soft  and  flocculent  and  of 
smaller  size  than  cow's  milk.  I  believe  this  great 
difference  is  due  principally  to  the  fact  that  there  is  an 
acid  fermentation  in  cow's  milk,  due  to  the  presence 
of  bacteria  which  we  do  not  find  in  woman's  milk. 
The  curd  is  by  comparison  larger  in  cow's  milk  than  in 
woman's  milk,  but  it  does  not  seem  possible  that  in 
its  normal  state,  as  received  by  the  young  animal,  it 
would  precipitate  in  the  tough,  hard  mass  seen  when 
acid  is  added  in  a  test  tube. 

To  determine  this  fact,  I  undertook  a  series  of  ex- 
periments, and  in  every  case  it  was  noticed  that  the 
curd  was  smallest  when  the  milk  had  not  undergone 
an  acid  fermentation.  Hydrochloric  acid  was  added 
to  the  milk,  first  in  a  weak  solution  gradually,  and 
then  to  a  similar  specimen  of  milk  pure  acid  was 
added  quickly: 

Xo.  I. — Milk,  4  drams;  water,  8  drams — represent- 
ing the  quantity  for  a  child  two  or  three  weeks  old. 
Slightly  acid.  Heated  to  100°  F.  On  adding  acid 
the  curd  was  precipitated  in  fine  flakes. 

No.  2. — Whole  milk,  acid.  Treated  in  the  same 
manner,  precipitated  in  tough,  hard  masses,  as  when 
milk  has  soured  in  summer. 

No.  3. — Same  quantity  of  milk  and  water.  Treated 
with  a  weak  solution  of  hydrochloric  acid,  0.02  per 
cent.,  as  represented  in  normal  gastric  juice  (Schmidt). 
Acid  added  slowly  and  curd  fine,  as  in  No.  i. 

No.  4. — Whole  milk  with  weak  solution  of  acid 
added  slowly;  precipitated  in  small  particles  sus- 
pended in  the  milk.  On  separating  the  fluid  from  the 
curd  and  comparing  the  precipitates,  it  was  noticed 
that  while  No.  4  gave  more  in  quantity,  the  curd  was 
composed  of  soft,  easily  broken  bodies,  about  the  size 
of  those  obtained  in  No.  1. 

No.  5. — Pasteurized  milk,  diluted  one-quarter  and 
heated  to  100°  F.  Slightly  acid.  Diluted  and  tested 
with  strong  acid;  curd  finer  than  in  experiments  i,  2, 
3,  and  4. 

No.  6. — Whole  milk,  with  strong  acid,  required 
twice  the  quantity  of  acid  used  in  No.  2,  and  the  curd 
was  finer  than  in  experiments  i  and  2. 

No.  7. — Milk  diluted  one-quarter.  With  dilute 
acid  added  slowly,  the  curd  finest  of  all  specimens  so 
far  examined. 

No.  8. — Whole  milk  tested  with  dilute  acid.  Curd 
finer  than  in  experiments  i  and  2.  Pasteurized  milk, 
tested  with  strong  acid,  does  not  give  the  tough  curd 
noticed  in  whole  raw  milk.  The  curd  resembles  more 
that  obtained    in   diluting   ordinary   milk.      Aerated 


milk,  tested  eight  hours  after  being  received  from  de- 
livery wagon,  is  very  slightly  acid. 

No.  9. — Milk  diluted  one-quarter.  Temperature, 
100'^  F.  Tested  only  with  full-strength  acid.  Re- 
quired more  acid  to  cause  precipitate  than  any  diluted 
specimen  examined.  Curd  very  fine,  resembling  hu- 
man-milk curd. 

No.  10. — Whole  milk,  with  strong  acid,  precipitated 
a  curd  as  fine  as  any  diluted  specimen  except  No.  9. 
Required  four  times  the  quantity  of  acid  to  precipitate 
as  did  ordinary  morning's  milk  received  at  the  home 
about  the  same  time. 

Lehman  has  noticed  that  when  woman's  milk  is  tested 
after  standing  some  time  the  curd  is  heavier  and  more 
solid  than  when  precipitated  immediately  after  being 
drawn  from  the  breast.  Cow's  milk  twenty-four  hours 
old  will  react  to  less  acid  and  more  quickly  than  new 
milk.  Milk  curdles  more  quickly  and  the  curd  is 
heavier  when  acid  is  added  quickly  than  when  the 
same  quantity  of  acid  is  added  gradually. 

Applying  these  facts  to  the  action  of  the  gastric 
juice  in  a  child's  stomach,  I  think  we  are  justified  in 
believing  a  similar  precipitate  would  occur.  A  milk 
which  has  undergone  a  partial  acid  fermentation,  and 
is  of  a  decidedly  acid  reaction,  coming  in  contact 
with  the  acid  of  the  stomach,  we  should  expect  a  tough 
precipitate,  as  noticed  in  the  test  tube ;  whereas  a  per- 
fectly fresh  milk,  not  containing  an  excess  of  acid,  or 
a  diluted  milk  when  the  acid  is  also  diluted,  would 
precipitate  a  finer  and  softer  curd  than  would  experi- 
ment 2. 

While  we  cannot  compare  absolutely  a  chemical  ac- 
tion in  a  test  tube  with  the  action  of  the  normal  se- 
cretions in  the  stomach,  I  believe  it  is  evident  that  an 
excess  of  acid — that  is,  the  acid  of  the  milk  plus  the 
acid  secretions — would  produce  a  different  chemical 
action  than  if  the  gradually  secreted  gastric  juice  alone 
caused  the  precipitate  (Dalton). 

From  these  experiments,  then,  it  would  seem  that 
when  measures  have  been  employed  to  lessen  the  fer- 
mentation of  milk  the  curd  is  entirely  different  from 
that  of  ordinary  milk  as  obtained  from  the  cart,  and, 
further,  it  will  be  noticed  that  when  the  milk  has  been 
aerated  immediately  after  milking,  the  curd  is  finer 
than  that  of  Pasteurized  milk,  with  which  the  effort  is 
made  to  check  fermentation  after  it  has  already  begun. 

Babies,  as  a  rule,  are  able  to  digest  a  stronger  milk 
in  winter,  when  there  are  fewer  germs,  than  in  sum- 
mer, and  a  case  seen  during  the  past  season  illus- 
trates that  fact.  A  baby,  six  months  old,  was  taking 
cow's  milk  diluted  one-half.  It  was  the  custom  of  the 
mother  to  Pasteurize  a  fresh  supply  in  the  evening  for 
the  baby's  use  during  the  night.  The  baby  did  not 
nurse  more  than  twice.  The  milk  was  heated  in  sep- 
arate bottles,  submerged  in  hot  water  and  then  cooled, 
and  the  bottles  were  wrapped  in  a  light  woollen  blanket 
and  kept  at  the  foot  of  the  bed — a  most  convenient,  if 
not  entirely  scientific,  method  of  preser\-ing  milk. 
This  did  verv-  well  during  the  cold  months,  but  as  the 
weather  became  warmer  the  practice  had  to  be  discon- 
tinued and  the  milk  kept  on  ice  and  heated  as  re- 
quired. Almost  the  first  warm  night,  the  baby,  after 
drinking  his  milk  as  usual,  was  taken  sick  and  vomited 
thick,  hard  masses  of  sour  curd.  Exactly  the  same 
milk  was  used,  and  on  investigation  I  could  find  no 
reason,  either  in  the  cow  or  its  food,  and  so  was  satisfied 
to  ascribe  the  trouble  to  a  fermentation  which  had  oc- 
curred on  account  of  the  heat  in  the  room.  The  dilu- 
tion of  milk  with  lime  water  or  attenuants,  which  has 
for  years  been  generally  practised  with  good  results, 
undoubtedly  acts  by  neutralizing  the  acid  of  fermenta- 
tion, so  that  an  excess  of  acids  is  prevented. 

I  have  alluded  to  the  contamination  of  the  milk  in 
the  barn,  .ind  have  demonstrated  that  milk  may  be 
made  practically  sterile.     There  yet  remains  the  trans- 


July  3.  1897] 


MEDICAL    RECORD. 


porting  of  the  milk  to  the  consumer  and,  a  phase  of  the 
subject  not  often  alluded  to,  the  preservation  of  the 
milk  in  its  puritj-  in  the  home  where  it  is  to  be  used. 
Many  dairymen  now  employ  glass  bottles,  with  a  me- 
tallic or  ligneous  cap,  and  if  the  bottles  are  properly 
washed  before  the  milk  is  put  into  them  the  plan  is 
an  excellent  one  and  should  be  made  compulsory. 
Milk  properly  strained,  cooled,  and  bottled,  kept  at  a 
low  temperature  in  the  house,  and  exposed  no  more 
than  absolutely  necessary,  will  keep  sweet  twenty-four 
hours. 

Instead  of  this,  consider  for  a  moment  our  present 
methods.  The  milk  is  put  into  large  cans,  carted  about 
the  city  here,  there,  and  everywhere,  in  the  dust  and 
dirt  of  the  business  quarters,  and  the  hot,  close,  un- 
healthy atmosphere  of  the  tenement  districts,  uncov- 
ered and  exposed  at  each  stopping-place.  The  milk  is 
poured  into  a  can  or  pitcher,  possibly  not  over  clean, 
and  then  perhaps  left  on  the  doorstep  until  the  cook 
has  time  to  get  it,  or  kept  in  the  pantry  or  on  the 
windowsill  in  the  sun. 

Given  a  milk  declared  by  competent  authority  to  be 
germ  free  as  it  leaves  the  barn,  how  long  think  you 
will  it  remain  so?  If  we  could  have  at  hand  a  pure 
milk,  cooled,  bottled,  and  kept  cool,  I  believe  our  re- 
sults in  infant  feeding  would  be  better  than  they  now 
are.  The  fact  that  there  is  a  chemical  and  physical 
difference  between  human  and  cow's  milk  is  not  the 
only  difficulty.  A  child  may  to  a  certain  extent  adapt 
itself  to  a  slight  chemical  difference,  and  we  have  re- 
peatedly seen  a  child  do  well  on  its  mother's  milk 
when  that  milk  analyzed  would  fall  far  below  the  av- 
erage of  human  milk.  Adriance'  gives  analyses  of 
several  specimens  of  milk  which,  compared  with  the 
normal  standard,  would  be  considered  abnormal,  and 
yet  babies  fed  with  it  were  gaining  in  weight  and  ap- 
peared healthy. 

The  personal  idiosyncrasy  of  the  child  is  an  impor- 
tant factor,  and  when  a  child  thrives  on  a  milk  of 
unusual  percentages  of  fats  and  proteids  it  does  so 
because  the  milk  is  good  for  that  particular  infant.  I 
would  not  discourage  the  chemical  examination  of  milk 
in  arranging  a  diet  for  a  child,  but  I  would  emphasize 
the  importance  of  having  a  good  milk.  Of  what  use 
is  the  fact  that  we  have  the  proper  percentage  of  the 
several  constituents  of  breast  milk,  if  that  milk  is  also 
loaded  with  germs  of  fermentation?  We  cannot  al- 
ways be  sure  of  our  e.xact  chemical  relations:  we  can 
be  and  should  be  absolutely  certain  that  the  milk  is 
good  and  pure. 

The  particular  aerated  milk  employed  in  the  exper- 
iment was  delivered  in  bottles  early  in  the  morning. 
and  its  production  was  a  matter  of  thought  and  care 
in  every  detail.  Even  with  milk  produced  and  pre- 
ser\'ed  under  the  most  favorable  conditions,  dilution 
could  not  be  entirely  avoided;  the  natural  size  of  the 
particles  would  prevent  that;  but  the  milk  could  be 
given  stronger,  and  so  much  of  the  trouble  from  too 
little  fat  would  be  overcome.  Budin,  by  means  of 
sterilization  with  Soxhlet's  apparatus,  is  enabled  to 
give  whole  milk  to  even  very  young  children,  by  giving 
only  such  quantity  as  the  stomach  will  easily  tolerate. 
This,  although  sterilized  milk  is  now  no  longer  used  as 
a  continued  diet,  emphasizes  the  fact  that  many  of  the 
difficulties  in  infant  feeding  are  due  to  conditions 
favoring  an  acid  fermentation  of  the  milk  employed. 

That  milk  should  ferment  on  exposure  is  entirely 
consistent  with  our  present  knowledge  of  the  germ 
theory  of  suppuration  and  fermentation  in  wounds. 
Exactly  the  same  principles  apply  to  milk  as  to  any  tis- 
sue of  the  body.  To-day  a  surgeon  who  should  under- 
take an  operation  of  almost  any  grade  and  neglects  the 
principles  of  asepsis  or  antisepsis,  would  be  consid- 
ered behind  the  age,  if  not  criminally  liable.  The 
'  Archives  of  Paediatrics. 


inliuence  of  bacteria  on  healthy  tissue  is  now  under- 
stood and  appreciated,  and  it  is  only  necessary  to  w  it- 
ness  the  technique  of  a  modem  scientific  operation  to 
realize  that  no  detail  is  too  trivial  which  will  the  more 
effectually  prevent  infection  of  the  wound.  Surely 
we  cannot  plead  ignorance,  in  neglecting  this  impor- 
tant question,  of  the  proper  care  and  management  of 
milk,  especially  that  intended  for  infants  and  invalids. 

As  one  carefully  considers  this  subject  of  cow's 
milk  in  infant  feeding,  and  realizes  the  close  intimacy 
of  the  mortuary  statistics  with  the  milk  question,  the 
desire  for  good  milk  becomes  intensitied,  particularly 
when  we  contemplate  the  misery  and  sickness  directly 
traceable  to  poisoned  milk  and  are  confronted  with 
the  fact  that  artificial  feeding  is  on  the  increase. 
That  a  large  part  of  the  mortality  in  cities  is  traceable 
to  cow's  milk  is  proven  by  statistics.  Dr.  Coit,  in  a 
paper  on  the  "  Causation  of  Disease  by  Milk,"  says : 

■■  It  is  claimed  that  twenty  per  cent,  of  all  who  are 
born  to  man  in  large  centres  of  population  die  during 
the  so-called  nursing  period:  that  nearly  thirty  per 
cent,  of  all  deaths  in  many  large  cities  from  all  causes 
and  in  all  periods  of  life  are  infants  of  the  first  year, 
due  to  a  lack  of  physical  resistance  in  city  children, 
resulting  from  a  want  of  suitable  food:  that  it  has 
been  claimed  that  sixty  per  cent,  of  children,  hand 
fed  during  infancy,  perish  before  they  are  five  years 
of  age;  that  the  mortality  from  nutritional  disorders, 
directly  or  indirectly,  during  the  first  year,  comprises 
nearly  ninety  per  cent,  of  the  whole:  that  so-called 
cholera  infantum  and  the  summer  diarrhceas  among 
children  are  now  regarded  by  authorities  to  be  largely 
due  to  milk  infection." 

It  is  an  encouraging  sign  of  progress,  however,  that 
the  efforts  of  such  men  as  Coit,  Rotch,  Snow,  Yaughan, 
Leeds,  and  others  are  bearing  fruit,  as  evidenced 
by  the  number  of  certified  milk  farms  now  in  active 
and  successful  operation  in  various  cities  of  this  coun- 
try, under  the  direct  supervision  of  a  commission  of 
physicians,  chemist,  bacteriologist,  and  veterinan-  sur- 
geon. And  that  their  efforts  are  entirely  successful  is 
proven  by  a  case  reported  in  a  recent  article  received 
from  Dr.  Coit  in  answer  to  a  question  asked  by  the 
writer : 

"  A  Newark  physician  desired  to  have  a  baby  sup- 
plied with  fresh  milk  during  an  ocean  voyage.  Ac- 
cordingly, on  May  nth,  he  ordered  twelve  bottles 
delivered  on  board  a  steamer.  With  these  he  sent 
twelve  other  bottles,  asking  the  steward  to  keep  them 
on  ice  till  the  steamer  should  return  to  Xew  York. 
This  was  done,  and  on  May  31st  they  were  handed 
over  to  a  member  of  the  commission.  One  bottle  was 
opened  and  the  milk  found  to  be  sweet.  Other  bottles 
were  sent  to  the  chemist  and  bacteriologist,  and  found 
to  be  in  a  remarkable  state  of  preservation.  Three 
days  later,  when  the  milk  was  twent\--four  days  old,  it 
was  tasted  by  a  number  of  physicians  and  found  to  be 
perfectly  sweet.'' 

Such  results  cannot  be  passed  over  lightly.  They 
emphasize  the  importance  of  the  cleanliness  in  detail, 
exercised  at  a  certified  milk  farm,  in  the  production  of 
milk  for  infant  feeding.  I  would  that  such  farms 
were  more  general. 


Epsom  Salts. — The  stomach  will  not  reject  it  if 
prepared  in  this  way:  Put  a  tablespoonful  in  a  teacup 
and  add  tvvo  or  three  tablespoonfuls  of  boiling  water, 
stir  well,  decant,  and  reject  the  residuum.  Add  a  little 
lemon  juice,  let  the  mixture  cool,  and  give  to  the  pa- 
tient. If  in  the  country,  beyond  the  reach  of  lemons, 
vinegar  will  make  a  fourth-rate  substitute.  Repeat 
the  dose  every  four  hours  until  the  bowels  respond. 
The  quantity  of  water  may  be  varied  to  suit  the  ca- 
price of  the  patient. — Parcells. 


i6 


MEDICAL    RFXORD. 


[July  3,  1897 


©Utxical  department. 

TRIPLETS. 
Bv  ABRAHAM  GOLTMAN,  M.D.,  CM.,  L.R.C.I'.S.   En., 

Mr.s.   Mary  M- ,  aged  twenty-two,  pregnant  for  the 

third  timC;  came  to  me  on  March  ist,  stating  that  she 
was  in  her  last  month  and  "carrying  the  child  high." 
Her  history  showed  that  her  previous  labors  were  pre- 
cipitate. 

On  examination  the  abdomen  was  a  great  deal  larger 
than  could  be  accounted  for  at  the  ninth  month,  reach- 
ing up  to  nearthe  xiphoid  cartilage.  There  was  a  con- 
siderable amount  of  suprapubic  oedema.  The  abdo- 
men was  very  prominent  and  more  developed  in  its 
transverse  diameter.  There  was  present  slight  oedema 
of  the  lower  limbs.  Foetal  movements  could  be  made 
out  at  different  parts  of  the  abdomen. 

On  palpation  the  abdomen  was  hard  and  resisting, 
and  I  could  make  out  the  breech  of  one  foetus  at  the 
fundus  on  the  right  side,  and  the  head  of  another  on 
the  left  side.  On  further  palpation  I  made  out  on  the 
lower  and  right  portion  of  the  uterus  the  head  corre- 
sponding to  the  breech. 

On  auscultation  foetal  heart  sounds  could  be  made 
out  on  the  right  side  of  the  uterus  on  a  line  with  the 
navel,  synchronous  with  the  mother's  pulse.  After 
some  difliculty  I  made  out  foetal  heart  sounds  on  the 
left  side  on  a  line  running  from  the  middle  of  Poupart's 
ligament  to  the  navel.  The  heart  sounds,  at  these 
two  places,  were  not  synchronous  with  each  other,  but 
were  so  with  tlie  mother's  pulse. 

From  the  above  results  I  suspected  twins.  On 
March  igth  I  was  hurriedly  called  to  see  her,  at  10:30 
A.M.  She  stated  that  her  bag  of  waters  had  come  away 
that  morning  at  4:30,  and  that  she  was  now  in  pain. 
I  made  a  vaginal  examination  and  found  the  os  fully 
dilated  and  diagnosed  a  first  position.  Pains  were 
irregular  and  weak.  After  stimulating  the  uterus  to 
contract  with  hot-water  douches,  the  head  was  deliv- 
ered in  the  first  position,  and  very  rapidly  the  whole 
child  was  expelled  at  one  or  two  sharp  pains.  The  child 
was  very  cyanotic  and  phlethoric,  and  the  pulsations  of 
the  cord  were  feeble.  After  trying  artificial  respiration, 
with  the  aid  of  cold  and  hot  water  douches,  I  succeeded 
in  resuscitating  the  child.  On  returning  to  deliver 
the  placenta,  I  found  the  uterus  as  large  as  before  labor 
set  in.  I  examined  per  vaginam  and  felt  a  foot  pre- 
senting at  the  OS  through  the  membranes.  The  patient 
was  now  exhausted;  pains  had  entirely  ceased.  I  gave 
her  a  drachm  dose  of  fluid  extract  of  ergot  with  hot  va- 
ginal douches  and  waited  half  an  hour;  pains  did  not 
set  in.  I  repeated  the  dose  and  she  then  had  a  return 
of  pains.  The  membranes  were  ruptured,  and  witii  the 
flow  the  breech  of  a  second  infant  was  delivered  rapidly, 
tlie  head  remaining  grasped  by  the  vaginal  opening. 
After  strong  flexion  of  the  head  was  practised,  it  was 
delivered  without  any  difficulty.  After  the  cord  was  tied 
the  woman  complained  of  severe  pains  and  something 
"between  her  legs,"  which  I  found  was  a  bag  of  mem- 
branes protruding  at  the  vulva  and  containing  a  fwtus 
head  first,  which  also  was  delivered  rapidly,  the  pla- 
centa following  at  the  same  time.  Injections  of  strych- 
nine were  now  given,  tlie  uterus  became  well  contracted, 
and  a  drachm  of  ergot  was  repeated. 

The  last  fcttus  was  a  male,  and  appeared  to  be  pre- 
maturely born.  The  first  cried  but  little  and  was 
very  cyanotic.  The  other  two  were  of  natural  color. 
Each  f(etus  had  hardly  any  caput  succedaneum, 
and  none  was  fully  matured.  The  placenta  weighed 
twenty-five  ounces  and  contained  three  amniotic 
sacks,  each  having  separate  cords.      The  cord  corre- 


sponding to  the  first  foetus  was  shorter  than  the  other 
cords,  more  congested,  tortuous  and  thicker.  Where  it 
entered  the  placental  tissue,  that  portion  was  congested, 
dripped  blood,  and  tore  easily,  and  could  be  readily 
distinguished  from  the  remaining  placental  tissue. 

The  following  day  the  first  child  had  several  hemor- 
rhages (epistaxis),  and  died  twenty-four  hours  after. 
So  far  the  two  others  are  doing  well  and  nursing. 
The  mother  is  progressing  favorably.  The  children 
were  all  males. 

1612  Lexington  Avenve. 


HICCOUGHS   AND    THEIR   TREATMENT. 
Bv   LUKE   FLEMING,    M.D., 

TARR\TOWN,   N.   Y. 

In  view  of  the  serious  cases  of  hiccoughs  reported 
from  time  to  time,  I  am  led  to  give  the  history  of  the 
following  case  and  also  the  treatment  employed,  in  the 
hope  that  it  may  be  of  benefit  to  others. 

A.    M ,   female,    fourteen    years   of   age,  fairly 

healthy  and  of  good  family  history-,  was  attacked  on 
the  night  of  May  3d  with  hiccoughs,  the  attack  con- 
sisting of  three  or  four  paroxysms  of  half  an  hour's  du- 
ration each,  which  ceased  on  the  following  morning. 
Toward  the  afternoon  of  the  same  day  the  paroxysms 
reappeared,  increasing  in  severity  until  in  the  evening 
the  exhaustion  of  the  patient  frightened  the  parents 
and  I  was  called.  At  this  time  she  had  been  hiccough- 
ing continuously  for  two  hours  and  had  just  recovered 
from  an  attack  of  syncope.  During  the  faint  the  hic- 
coughs ceased,  but  returned  upon  her  regaining  con- 
sciousness. Her  temperature  was  normal ;  pulse  rap- 
id, feeble,  and  irregular:  and  her  general  appearance 
that  of  extreme  prostration. 

While  watching  her  I  remembered  her  as  a  patient 
whom  at  one  time  I  had  treated  for  malaria,  and  in 
whom  quinine  had  caused  a  most  unbearable  urticaria. 
It  occurred  to  me  now  that  if  I  should  again  prescribe 
quinine  and  induce  this  urticaria  I  might  so  dis- 
turb her  nervous  system  as  to  cure  the  hiccoughs. 
Acting  upon  this  thought,  I  gave  ten  grains  of  the  drug. 
During  the  ensuing  two  hours  her  hiccoughs  grew 
worse  and  her  condition  became  so  alarming  that  the 
parents  feared  death.  At  the  end  of  that  time,  how- 
ever, a  scarlet  rash  spread  over  her  body,  her  fingers 
and  face  pufted,  and  an  intense  itching  came  on.  At 
the  onset  of  this  rash  the  hiccoughs  promptly  ceased, 
and  altliough  but  one  dose  of  quinine  had  been  given 
and  the  rash  lasted  only  three  hours,  the  hiccoughs  did 
not  return. 

In  thinking  of  this  case  it  strikes  me  that  the  treat- 
ment of  hiccoughs  by  nerve  sedatives  is  unwise,  and 
that  a  more  rational  treatment  would  be  by  nerve  irri- 
tants. If  I  may  use  a  figure  of  speech,  we  might  com- 
pare the  nervous  system  of  a  patient  suft'ering  from 
hiccoughs  to  an  indolent  garrison  in  an  enemy's  coun- 
try allowing  a  crazy  gunner  to  exhaust  all  its  ammu- 
nition by  firing  salutes  to  the  sun.  By  throwing  a 
shell  into  its  midst  we  awaken  it  from  its  lethargy  and 
stop  this  foolish  pastime.  So,  in  a  case  of  hiccoughs, 
the  nervous  system  is  not  attending  properly  to  its 
duties  and  is  exhausting  its  vitality  in  a  harmful  di- 
rection. By  employing  some  means  that  will  give  it 
a  thorough  shaking  up,  we  awaken  it  to  its  danger  and 
restore  its  normal  action. 

In  the  above  case  this  result  was  obtained  by  the 
idiosvncrasy  of  the  jiatient  to  quinine.  In  other  cases 
we  might  seek  some  like  condition  and  utilize  it. 

Hospitals  for  Hagerstown.  —  The  authorities  of 
Salisbury  and  H.igerstown,  Md.,  contemplate  the 
building  of  hospitals  in  these  towns. 


July  3,  1897] 


MEDICAL    RECORD. 


17 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Stirgcry. 


GEORGE    F.    SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &  CO.,  43,  45,  &.  47  East  Tenth  Street. 


New  York,  July  3,  1897. 


DISINTERESTED    TESTIMONY    ON    THE 
DISPENSARY    QUESTION. 

The  Evening  Post  of  June  19th  contained  an  inter- 
esting account  of  a  visit  to  the  Vanderbilt  Clinic. 
The  reporter  seems  to  have  been  a  fair-minded  person, 
with  no  particular  theor}'  to  prove  but  with  only  a  de- 
sire for  facts.  He  introduced  himself  to  the  superin- 
tendent of  the  dispensary,  told  him  that  he  "  simply 
desired  to  observe  the  patients  as  they  entered  and 
left,  and  that  this  was  to  be  for  the  purpose  of  a  de- 
scription which  might  form  the  basis  of  some  judg- 
ment as  to  whether  the  assertion  concerning  the  char- 
acter of  many  persons  treated  at  the  clinic  were  true." 
The  superintendent  gave  him  a  note  to  the  clerk  of 
the  clinic  allowing  him  to  look  on,  but  restricting  him 
to  simple  observation  and  not  allowing  him  to  be  "ob- 
trusive," which,  however,  he  did  not  think  the  reporter 
de'sired  to  be.  The  latter  spent  two  hours  in  the  clinic, 
and  his  observations  may  be  presumed  to  be  a  fair 
statement  of  what  happens  in  this  particular  institu- 
tion from  day  to  day. 

He  estimates  the  number  of  applicants  during  his 
visit  to  have  been  about  four  hundred. 

"  Nobody  was  seen  to  arrive  in  a  carriage,  nor  was 
any  finely  dressed  man  or  sumptuously  attired  and 
adorned  woman  discerned  in  the  crowd.  But,  on  the 
other  hand,  those  whose  dress  and  appearance  de- 
noted an  extreme  degree  of  poverty  were  certainly  in 
a  very  large  minority.  It  is  difficult  to  resist  the  con- 
clusion that  not  more  than  one  in  twenty-five — the  pen 
is  tempted  to  write  one  in  fifty — of  the  applicants 
treated  at  the  Vanderbilt  Clinicon  the  afterno  on  of  ob- 
servation was  a  legitimate  patient.  Not  more  than  one 
in  fifty  was  at  all  shabbily  dressed.  A  large  majority 
were  fairly  well  dressed.  A  third  of  them,  it  will  be  safe 
to  say,  were  quite  presentably  dressed.  A  few — per- 
haps as  many  as  a  fifth — were  dressed  positively  well. 
Much  the  greater  number  of  the  patients  w-ere  women. 
Brightly  flowered  and  feathered  hats  abounded.  A 
silk  waist  or  a  silk  skirt  was  no  uncommon  sight. 
Many  of  the  women  carried  pocketbooks  in  their 
hands,  quite  as  women  do  when  they  go  shopping.  A 
good  many  of  them  also  carried  satchels,  not  a  few  of 
which  were  decent  enough  looking.  Umbrellas — most 
of  them  apparently  good,  sound  specimens,  and  some 
of  them  of  silk — were  seen  repeatedly.     Jewelry  was 


by  no  means  absent.  Breastpins,  earrings,  chains, 
bracelets — seemingly  of  gold — were  easily  to  be  seen. 
One  woman,  particularly  observed,  was  handsomely 
and  stylishly  dressed  in  black.  At  her  throat  was  a 
breastpin  that  looked  like  a  gold  one;  around  her 
neck  was  a  black  chain  ornamented  with  gold  or  the 
semblance  of  it;  about  her  wrist  was  a  heavy  coiled 
bracelet,  apparently  of  the  same  precious  metal.  Her 
hands  were  encased  in  black  kid  gloves,  her  hair  was 
carefully  and  modishly  arranged,  her  bonnet  harmo- 
nized with  her  dress,  and  her  whole  appearance  was 
that  of  a  person  in  thoroughly  comfortable  circum- 
stances. She  was  not  rejected.  She  received  advice 
and  a  prescription,  anc  waited  patiently  until  her  turn 
came  to  have  the  latter  filled,  when,  like  the  rest,  she 
laid  down  her  ten  cents  and  received  her  medicine. 

"A  considerable  number  of  children  was  present, 
either  as  patients  or  merely  accompanying  parents. 
The  most  of  these — or,  to  be  conservative,  at  least 
half  of  them — were,  to  all  appearance,  well  and  taste- 
fully dressed.  At  any  rate,  lace  and  ribbons  were 
frequent  adornments  of  their  caps  and  dresses,  and 
there  was  not  the  slightest  hint  about  them  of  dire 
poverty.  The  men,  on  the  whole,  seemed  less  well  off 
than  the  women,  yet  some  of  them  were  presentably 
clothed.  One  very  decently  attired  man  asked  the 
superintendent  of  the  building  to  expedite  his  turn  at 
the  pharmacy,  as  he  was  compelled  to  get  back  to  his 
work  on  a  street  car.  The  superintendent  obliged 
him.  A  colored  man  wearing  a  neat  bicycle  suit  with 
golf  stockings,  and  riding  an  almost  new-looking  1896 
bicycle  ($100  make)  (which,  at  the  suggestion  of  the 
superintendent,  he  brought  in  with  him,  and  put  in  a 
room  reserved  for  bicycles),  was  one  of  the  patients 
treated.  He  hung  around  for  a  longtime  after  getting 
his  medicine,  and,  when  questioned  by  the  superin- 
tendent as  to  why  he  lingered,  replied  that  he  was 
'  waiting  for  a  lady  who  had  accompanied  him.' 
.\nother  thing  noticed  was  that  the  change  returned  at 
the  window  of  the  pharmacy  not  seldom  included  bills 
as  well  as  coin.  In  short,  it  is  believed  that  few  im- 
partial spectators  could  have  resisted  a  feeling  of 
scepticism  concerning  the  absclate  inoDility  of  most 
of  these  people  to  employ  physicians  privately,  espe- 
cially as  it  is  the  almost  invariable  rule  of  practitioners 
to  take  into  consideration  the  circumstances  of  their 
patients  (as  the  rich  ones  know)." 

The  writer  of  this  article,  being  of  a  temperate 
mind,  does  not  claim  to  have  solved  the  problem  of 
dispensary  abuse,  and  shows  his  fairness  by  giving 
the  views  of  those  in  charge  of  two  of  the  dispensary 
services  of  the  city,  the  clinic  above  alluded  to  and 
the  Demilt  Dispensary.  The  great  inquiry  which  al- 
ways comes  up  in  discussions  on  this  subject  is,  w^hy 
not  employ  the  resources  of  the  Charity  Organization 
Society  in  an  effort  to  separate  the  worthy  from  the 
unworthy?  To  this  question,  in  the  present  case,  no 
conclusive  answer  was  given.  It  is  said  that  it  is 
"  more  feasible  to  get  along  without  the  society's  aid 
than  with  it."  Under  the  word  "feasible"  come  up 
the  questions  of  delay  in  reporting  upon  a  given  case 
and  the  expense  to  the  medical  institutions  of  carry- 
ing on  such  inquiries.      In  reply  to  this  it  may  be  said 


i8 


MEDICAL    RECORD. 


[July  3,  1897 


that  no  advocate  of  reform  in  this  matter  has  ever  ad- 
vised waiting  for  inquiry  to  be  made  in  cases  mani- 
festly needing  immediate  attention.  Such  attention 
should  be  given  at  once.  The  case  could  be  investi- 
gated later.  In  regard  to  expense,  of  course  it  would 
cost  something,  but  such  a  sifting  process  would  greatly 
lessen  the  number  of  cases  requiring  charitable  aid. 
The  managers  of  dispensaries  need  to  be  constantly 
reminded  that  the  true  object  of  dispensaries  is  to 
treat  those  who  are  sick  and  unable  otherwise  to 
obtain  proper  care,  not  to  see  how  man}'  cases  can 
possibly  be  gathered  in. 

The  most  discouraging  thing  of  all  is  the  absolute 
indifference  of  managerial  boards  to  this  burning 
question  of  the  hour.  They  do  not  seem  to  think  that 
it  is  of  sufficient  importance  to  call  for  consideration. 
They  do  not  care  about  it.  If  they  did,  they  would 
do  something.  In  these  days  when  social  questions 
are  receiving  such  careful  consideration  at  the  hands 
of  our  best  thinkers,  the  institution  manager,  with 
power  to  do  so  much  in  the  right  direction,  does  abso- 
lutely nothing  and  seems  unwilling  that  any  one  else 
should  further  the  progress  of  reform  along  this  line. 


SUSCEPTIBILITY   OF   INFANTS    TO    HOS- 
PITALISM. 

In  a  pamphlet  on  "  The  Babies'  Ward,  New  York 
Post-Graduate  Hospital,"  Dr.  H.  D.  Chapin  points  out 
the  dangers  to  which  infants  are  subjected  by  a  length- 
ened stay  in  a  hospital.  In  reference  to  admitting 
babies  to  these  institutions  under  any  circumstances, 
he  says:  ''  Entrance  to  a  hospital  should  be  limited  to 
acute  cases  of  illness,  and  discharge  should  take  place 
immediately  upon  recover}',  even  if  the  latter  is  only- 
partial.  A  speedy  or  satisfactory  convalescence  is 
impossible  for  an  infant  in  a  hospital.  The  earlier 
the  age,  the  greater  is  the  susceptibility  to  hospitalism 
and  the  quicker  it  ensues."  This  warning  is  well 
timed  and  one  to  be  seriously  regarded.  There  is  a 
too  great  tendency  on  the  part  of  parents  and  relatives 
to  place  infants  when  unwell  in  hospitals.  This  is 
often  done  to  evade  responsibility  and  trouble,  al- 
though of  course  in  many  instances  the  only  motive  is 
the  good  of  the  child.  On  account  of  the  great  sensi- 
tiveness of  a  child's  organism,  it  is  absolutely  essential 
that  the  young  should  live  in  the  most  healthful  con- 
ditions. Pure  air  is  of  more  importance  for  the  main- 
tenance of  health  in  children  than  in  grown-up  per- 
sons. To  quote  again  from  Dr.  Chapin:  "Outbreaks 
of  contagious  diseases  are  constant  dangers  in  hospi- 
tals for  infants  and  children,  and  can  be  guarded  against 
only  by  the  greatest  care.  Diphtheria,  measles,  and 
pertussis  are,  from  the  nature  of  these  diseases,  most 
liable  to  creep  in.  Visitors,  however,  are  often  re- 
sponsible for  the  bringing  of  contagion,  and  all  possi- 
ble safeguards  should  be  thrown  around  this  source  of 
danger,  and  children  should  be  refused  admittance  ab- 
solutely. The  hygienic  surroundings  must  be  of  the 
best,  the  nursing  of  a  ver}'  high  grade,  and  a  most 
scrupulous  and  painstaking  oversight  exercised.  One 
good  nurse  should  be  supplied  to  not  more  than  four 


or  five  sick  infants,  and  in  some  cases  one  nurse  may 
be  required  for  only  two  patients.  Finally  the  infants 
should  be  particularly  watched  for  the  first  sign  of 
hospitalism  and  promptly  discharged  before  the  mal- 
ady has  time  to  gain  any  hold  on  them."  The  extreme 
susceptibilit}'  of  children  to  contagion  when  congre- 
gated in  large  numbers  has  been  conclusively  proved 
time  after  time.  An  example  in  point  is  that  of 
I'Hopital  Trousseau  in  Paris.  This  hospital  for 
children  contains  upward  of  five  hundred  beds,  and  is 
located  in  the  heart  of  a  dense  working-class  popula- 
tion, so  that  its  wards  are  constantly  filled.  A  high 
municipal  official  some  time  ago,  referring  to  the  con- 
ditions prevailing  in  I'Hopital  Trousseau,  said:  "As 
to  the  hospital  Trousseau,  I  shall  use  my  strongest 
endeavors  to  have  it  abolished.  I  see  continually 
how  badly  the  system  works.  It  is  a  veritable  hotbed 
of  infection,  and  children  are  there  hospitalized  in 
the  most,  it  might  almost  be  said,  homicidal  manner." 
These  words  might  be  applied  with  equal  truth  to 
many  institutions  for  children  much  smaller  than  the 
hospital  Trousseau.  For  many  reasons  into  which 
there  is  no  space  to  enter  here,  it  is  always  undesirable 
to  have  young  children  living  together  in  large  num- 
bers. To  keep  the  rooms  which  they  inhabit  in  a 
sanitary  state  is  almost  an  impossibilit}'.  Hospitals 
for  children  on  a  large  scale  are  a  great  mistake. 
The  larger  the  hospital  the  greater  the  mistake. 


MEDICAL    EDUCATION    IN    AMERICA    AND 
GREAT  BRITAIN. 

But  a  few  years  ago,  and  it  would  have  been  absurd 
to  attempt  to  compare  medical  education  in  any 
part  of  America  with  that  in  England.  There  were 
then  no  points  of  comparison;  the  English  standard 
was  far  higher;  in  fact,  with  very  few  exceptions, 
the  standard  of  medical  education  here  was  so  low  as 
to  be  scarcely  worth  speaking  about.  The  strides 
made  in  late  years  in  many  of  the  States  have  been 
phenomenal.  So  much  so  has  this  been  the  case  that 
it  may  be  said  without  e.xaggeration  that  a  revolution 
in  the  training  of  medical  men  has  taken  place  in  these 
States.  New  York  is  well  to  the  front  in  this  matter, 
and  a  comparison  instituted  now  between  some  of  the 
British  schools  and  those  of  New  York  would  not  re- 
sult altogether  in  favor  of  the  former.  In  Great  Britain 
the  course  of  medical  education  is  controlled  by  an  act 
of  Parliament,  which  is  strictly  applied  to  the  whole 
countr}'.  In  .\merica  there  is  no  central  law  govern- 
ing the  practice  of  medicine.  Each  State  does  what 
it  pleases.  Medical  schools  have  been  multiplied 
without  reason,  the  profession  is  overcrowded,  and  as 
a  natural  result  many  of  those  with  licenses  to  prac- 
tise are  incompetent.  In  Great  Britain  there  is  a 
medical  school  to  about  2,300,000  of  the  population, 
while  in  this  country  there  is  one  to  440,000.  The 
medical  course  in  the  United  Kingdom  has  been 
lengthened  to  five  years — four  years'  attendance  at  a 
recognized  medical  school,  and  attendance  at  the  clin- 
ics of  a  hospital  or  private  practice  for  the  fifth  year, 
so  that  the   English  medical  training  is  longer  by  a 


July  3,  1897] 


MEDICAL    RECORD. 


19 


year  than  that  required  in  New  York  State,  although 
the  custom  of  serving  as  interne  in  some  hospital  for 
a  year  or  eighteen  months  after  graduation  makes  the 
course  here  practically  longer  than  in  Great  Britain. 
There  are  eleven  universities  in  Great  Britain  which 
have  the  privilege  to  grant  degrees  in  medicine, 
and,  in  addition  to  the  universities,  licenses  to  prac- 
tise are  granted  by  the  Royal  Colleges  of  Surgeons 
and  Physicians  in  each  count}-,  and  by  the  Societj- 
of  Apxjthecaries  of  London;  all  these  must  conform 
to  the  Medical  Council's  standard,  which  is  now  a 
high  one.  Each  degree,  however,  carries  with  it  a 
value  of  its  own;  this  fact,  although  not  appre- 
ciated by  the  general  public,  is  recognized  by  the 
profession  itself.  The  degree  of  doctor  of  medicine 
of  London  Universit}'  takes  the  highest  rank.  Of 
the  qualifications,  the  fellowship  of  the  Royal  Col- 
lege of  Surgeons,  England,  and  the  membership  of 
the  Royal  College  of  Physicians,  London,  stand 
first  The  joint  qualifications  of  the  membership  of 
the  Royal  College  of  Surgeons  and  the  licentiate 
of  the  Royal  College  of  Physicians  take  about  the 
same  rank  as  an  ordinar}'  universit}'  medical  de- 
gree, that  of  the  University  of  London  excepted.  Of 
the  various  schools  London  is  the  best  for  practical 
work,  and  Edinburgh  for  theoretical.  It  has  been 
suggested  that  the  plan  pursued  in  most  of  the  States 
of  the  Union,  of  compelling  a  man  before  he  is  al- 
lowed to  practise  to  pass  a  State  examination,  should 
be  adopted  in  England ;  but  for  many  reasons  the 
project  has  fallen  through.  In  America  more  at- 
tention is  paid  to  a  thorough  study  of  bacteriology 
than  in  England.  That  subject  has  been  greatly  neg- 
lected there,  although  now  the  great  practical  use  of  a 
knowledge  of  it  is  recognized  by  the  medical  schools 
throughout  the  country,  and  in  London  there  are  sev- 
eral well-equipped  bacteriological  laboratories  where 
it  is  possible  for  a  student  to  undergo  a  regular  course 
of  instruction.  Post-graduate  courses  have  also  been 
instituted. 

To  compare  the  teaching  in  the  medical  schools  of 
the  United  States  and  the  value  of  the  State  license  with 
those  of  Great  Britain  would  be  a  ver}-  difficult  task. 
In  the  United  Kingdom,  although  a  certain  standard 
fixed  by  the  Medical  Council  has  to  be  reached,  there 
is  not  the  uniformit}'  guaranteed  by  the  State  exami- 
nation, and  much  diversity  of  opinion  exists  as  to  which 
degree  after  that  of  London  L^niversit}'  is  the  best. 
The  course  here,  only  that  it  is  a  year  shorter,  is  much 
the  same  as  in  England;  the  other  difference  is  that  in 
most  of  the  United  States  the  final  examination  is 
conducted  under  the  auspices  of  the  State  itself,  where- 
as in  Great  Britain  it  is  in  the  hands  of  private  cor- 
porations. There  cannot  be  much  room  for  doubt  as 
to  which  is  the  better  plan. 


The  German  Gynaecological  Society. — The  sev- 
enth congress  of  the  German  Gynaecological  Societ}' 
was  held  this  year  at  Leipzig,  on  June  9th  and  two 
following  days,  under  the  presidency  of  Professor 
Zweifel.  Among  the  subjects  discussed  were  retro- 
flexion of  the  uterus  and  placenta  previa. 


Bcius  0f  the  Sxaccfe. 

The   International   Medical   Congress Dr.  A.  Ja- 

cobi  writes:  "A  letter  received  from  the  secretary- 
general  of  the  Twelfth  International  Medical  Congress 
conveys  the  following  information,  which  is  additional 
to  that  which  has  been  published  in  the  medical  jour- 
nals. As  it  is  too  late  to  send  tickets  to  the  Ameri- 
can congressists,  they  are  requested  to  send  to  the  sec- 
retary-general at  Moscow  their  addresses  in  London, 
or  Berlin,  or  Vienna,  or  Paris,  or  to  avail  themselves 
of  the  national  committees  in  those  cities  in  order  to 
receive  their  tickets  and  free  passes  over  Russian 
railroads.  The  free  passes  are  valid  from  July  13th 
to  September  13th,  over  the  following  routes:  Eydtku- 
nen  to  Moscow  and  back;  Moscow  to  St.  Peters- 
burgh,  or  Moscow  to  Graviza,  or  Moscow  to  Odes- 
sa, or  vice  versa;  Graviza  to  Warsaw  to  Moscow  and 
return  by  Moscow  to  St  Petersburgh  (or  Odessa,  or 
Eydtkunen,  or  L'ngheri,  or  Alexandrowo) ,  or  vice  versa. 
Different  lines,  going  and  returning,  may  be  chosen, 
and  stop  over  is  permitted.  The  trip  from  Eydtkunen 
to  St.  Petersburgh  is  excluded  from  the  free  list. 

A  New  Annex  to  St.  Vincent's  Hospital. — The 
sisters  of  charit}'  have  opened  at  Jar\-is  Lane,  Far 
Rockaway,  their  new  annex  to  St.  Vincent's  Hospital, 
New  York.  The  old  Jari-is  Homestead  has  been  trans- 
formed into  a  convenient  retreat,  more  particularly  for 
convalescents.  The  sanitar}'  arrangements  of  this 
countr}-  branch  are  perfect.  The  rooms  are  large  and 
cool,  and  afford  a  fine  view  of  the  ocean.  The 
grounds  are  spacious  and  well  shaded.  Although  only 
three  minutes'  walk  from  the  railroad  station,  this 
new  home  is  situated  in  a  secluded  spot.  The  sisters 
are  aided  by  a  staff  of  trained  nurses  in  the  care  of 
those  placed  under  their  charge. 

Navy  Department,  Bureau  of  Medicine  and 
Surger}-,  Washington,  D.  C.  Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
June  26,  1897.  June  24th. — Passed  Assistant  Surgeon 
G.  B.  Wilson  detached  from  the  Yantk,  ordered 
home,  and  granted  two  months'  leave. 

Medical  Society  of  New  Jersey — At  the  one 
hundred  and  thirt}--first  annual  meeting  of  the  Medi- 
cal Societ}-  of  New  Jersey,  held  at  Atlantic  Cit}-,  on 
June  22d  and  23d,  the  following  officers  were  elected 
for  the  ensuing  year:  President,  D.  C.  English,  of 
New  Brunswick;  First  Viee-President,  C.  R.  P.  Fisher, 
of  Bound  Brook;  Second  Vice-President,  Luther  M. 
Halsey,  of  Williamstown;  Third  Vice-President,  J.  H. 
H.  Love,  of  Montclair;  Corresponding  Secretary,  E.  L. 
B.  Godfrey,  of  Camden;  Recording  Secretary,  William 
Pierson,  of  Orange;  Treasurer,  .Archibald  Mercer,  of 
Newark. 

Colorado's  Contribution  to  the  Rush  Monument 

Fund Colorado  has  already  fulfilled  the  pledge  for 

a  $2,000  contribution  to  the  Rush  monument  fund, 
made  by  Dr.  Graham,  at  the  meeting  of  the  American 
Medical  .\ssociation  at  Philadelphia.  At  the  meeting 
of  the  State  Medical  Society,  June  15th,  the  full  sum 


20 


MEDICAL    RECORD. 


[July  3,  1897 


pledged  by  Dr.  Graham  was  immediately  raised  by 
'.ndividual  subscriptions  offered  most  generously  and 
with  great  enthusiasm. 

The  American  Institute   of  Homoeopathy  met  in 

annual  convention  in  Buffalo,  on  June  24th  and  fol- 
.'owing  days. 

Dr.  Charteris,  professor  of  materia  medica  in  Glas- 
gow University,  died  on  June  7th,  at  Comrie,  in 
Perthshire,  where  he  had  gone  to  recuperate  after  an 
attack  of  influenza. 

Dr.  Chancellor,  of  Baltimore,  lately  United  States 
consul  at  Havre,  has  returned  to  this  country. 

Dr.  T.  Mitchell  Prudden,  of  this  city,  received 
the  degree  of  LL.D.  from  Yale  Universit)'  on  June 
30th. 

Hospitals  for  Contagious  Diseases  in  London. — 

The  hospitals  of  the  metropolitan  asylums  board,  in 
London,  have  3,800  beds  set  apart  for  scarlet  fever, 
and  only  700  for  diphtheria. 

Dr.  Paul  L.  Post  has  been  appointed  fourth  as- 
sistant physician  to  the  New  Jersey  State  Hospital. 

The  Connecticut  State  Medical  Law,  which  went 
into  effect  on  the  first  of  this  month,  provides  that  no 
person  shall  receive  a  certificate  of  registration  until 
he  has  passed  a  satisfactory  examination  before  one  of 
the  three  examining  committees  appointed  for  that 
purpose.  These  committees  consist  of  five  members 
each.  The  examinations,  which  must  be  in  writing, 
will  be  required  in  anatomy,  physiology,  chemistry, 
materia  medica,  hygiene,  obstetrics,  and  medical  and 
surgical  patholog}',  diagnosis,  and  treatment.  The 
penalty  for  violation  of  this  law  is  a  fine  of  not  less 
than  $100  nor  more  than  $300  for  the  first  offence, 
and  for  each  subsequent  offence  not  less  than  $200 
nor  more  than  $500,  or  from  thirty  to  ninety  days  in 
the  county  jail.  One-half  of  the  fine  collected  goes 
to  the  person  or  persons  making  the  complaint  and  the 
other  half  to  the  State  board  of  health.  New  York 
doctors  have  been  diligent  in  securing  the  right  to 
practise  in  Connecticut  under  the  registration  law  of 
1893,  according  to  which  no  examination  was  neces- 
sary. This  explains  the  enormous  increase  in  medi- 
cal practitioners  with  which  Greenwich,  the  nearest 
town  to  New  York  City,  would  appear  to  have  been 
afflicted.  There  were  thirty-one  registrations  in  the 
entire  State  in  April,  of  which  twenty  were  in  Green- 
wich. 

A  Humane  Execution. — An  Italian  was  put  to  death 
at  Auburn  on  June  22d,  for  the  murder  of  a  fellow- 
countryman  eighteen  months  ago.  He  was  placed  in 
the  chair,  and  five  shocks  with  a  current  of  eighteen 
hundred  and  forty  volts,  each  of  about  one  minute 
duration,  were  made  at  intervals.  The  poor  creature 
was  not  pronounced  dead  until  eight  minutes  had 
elapsed  after  the  first  contact  was  made.  The  five 
shocks  were  necessary  because  of  the  imperfect  con- 
tact of  the  electrode  on  the  man's  leg.  The  smell  of 
burning  flesh  was  quite  distinct  in  the  chamber  after 
the  first  shock  had  been  given. 


The   Philadelphia   County  Medical   Society.— At 

the  final  stated  meeting  for  the  season  of  the  Phila- 
delphia County  Medical  Society,  Dr.  A.  G.  Thomsoa 
presented  the  report  of  a  case  of  complete  blindness 
due  to  acute  poisoning  from  overuse  of  Jamaica 
ginger,  followed  by  toxic  amblyopia  of  the  ordinary 
chronic  form.  Dr.  A.  A.  Eshner  read  a  paper  on 
"  Hysteria  in  Early  Life,"  in  which  he  detailed  the 
histories  of  a  small  group  of  cases  occurring  in  girls  at 
and  before  the  age  of  pubert}',  and  displaying  more  or 
less  characteristic  features  of  the  grand  neurosis.  Dr. 
Henr}-  Beates,  Jr.,  made  remarks  on  some  of  the  common 
causes  defeating  the  proper  progress  of  therapeutics. 

The  Health  Board  at  Dead  Man's  Curve. —  The 

grand  jury  and  the  district  attorney  having  been  una- 
ble to  stop  the  needless  sacrifice  of  life  at  the  various 
curves  of  the  cable  roads  in  this  city,  the  health  board 
has  taken  the  matter  in  hand.  At  a  meeting  held 
June  29th,  the  following  amendment  to  the  sanitary 
code  was  proposed  for  adoption :  "  No  conductor, 
driver,  or  gripman  of  any  railroad  car  or  other  vehi- 
cles running  on  tracks  in  the  city  of  New  York  shall 
allow  or  cause  the  same  to  be  pulled,  drawn,  or  pro- 
pelled on  or  around  any  cur\'es  on  any  public  street  or 
avenue  at  a  greater  rate  of  speed  than  two  miles  an 
hour.  And  no  director,  president,  superintendent,  or 
other  person  who  is  interested  in  or  who  owns  or  con- 
trols any  such  car  or  vehicle  shall  permit  it  to  be 
pulled,  drawn,  or  propelled.  This  section  of  the  san- 
itar)'  code  is  adopted  for  the  purpose  of  preventing  ac- 
cidents by  which  life  or  health  may  be  endangered." 
According  to  the  rules,  this  resolution  must  lie  over  a 
week  before  it  can  be  acted  upon. 

The  Late  Dr.  William  T.  Lusk The  faculty  of 

the  Bellevue  Hospital  Medical  College  have  the  pain- 
ful duty  of  directing  a  formal  record  in  their  minutes 
of  the  untimely  and  sudden  death  of  their  beloved  col- 
league and  president,  the  late  Prof.  William  Thomson 
Lusk,  on  June  12,  1897.  Dr.  Lusk  was  an  alumnus 
of  the  college,  class  of  1864,  and  class  valedicto- 
rian. He  became  one  of  the  instructors  in  the  sum- 
mer session  in  1870.  He  was  appointed  professor  of 
obstetrics  in  1871,  and  president  of  the  faculty  in 
1889.  His  great  ability  as  a  teacher  and  voluminous 
writer  commanded  the  respect  and  admiration  of  the 
profession  at  home  and  abroad.  His  public  services 
in  the  institutions  under  the  charge  of  the  commis- 
sioners of  public  charities  were  rewarded  by  the  ap- 
preciation and  gratitude  of  all  interested  in  medical 
charities.  His  devoted  work  in  behalf  of  medical 
education  connected  his  name  most  prominently  with 
the  teaching  of  medicine,  and  especially  with  the  Bel- 
levue Hospital  Medical  College.  But,  above  all,  his 
fearless  honesty  of  puqjose  and  his  exquisite  gentle- 
ness of  character  and  manner  so  endeared  him  to  his 
associates  in  the  college  that  we,  his  loving  colleagues 
and  friends,  feel  in  his  death  a  personal  bereavement 
which  words  fail  adequately  to  express.  In  common 
with  his  family,  the  profession,  and  his  many  devoted 
friends,  we  mourn  his  loss  and  deplore  the  premature 
end  of  a  most  useful  and  valuable  life. 

Austin   Flint,  Scrr,-ftirv. 


July  3.  1897] 


MEDICAL    RECORD. 


^aciety  glcports. 

CONGRESS    OF   AMERICAN    PHYSICIANS 
AND    SURGEONS. 

FOURTH    TRIENNIAL    SESSION. 

Held  in    Washington,  D.    C,   May  4,  j,  and  6,  iSgj. 

VViLLi.AM    H.  Welch,  M.D.,  of   Baltimore,    Presi- 
dent. 

(Concladed  from  Vol.  LI.,  page  916.) 

AMERICAN    ASSOCIATION  OF   GENITO-URI- 
NARY    SURGEONS. 

Second  Day —  Wednesday,  May  jth. 

Priapism. — Dr.  R.  W.  Taylor,  of  New  York,  read  a 
paper  with  this  title.  In  normal  conditions  erections 
last  a  short  time  only;  in  certain  morbid  conditions 
this  erection  is  much  prolonged  and  to  this  prolonged 
erection  the  term  priapism  is  applied.  It  may  Ije 
divided  into:  i.  Priapism  in  infants  and  children 
from  refle.v  causes.  2.  In  adults  symptomatic  of  stone 
in  the  bladder  or  urethra,  of  stricture  of  the  urethra,  or 
retention.  3.  SjTnptomatic  of  gonorrhoea.  4.  Due 
I        to  cantharides.     5.  Essential  priapism. 

The  tirst  four  are  not  the  subject  of  the  present 
paper,  but  the  fifth  form,  essential  priapism,  may  be 
divided  into  four  varieties  as  follows: 

1.  From  injur}'  to  spinal  cord  or  to  perineum. 

2.  Symptomatic  of  cerebral  or  descending  cord  dis- 
ease. 

3.  Occurring  after  alcoholic  and  sexual  excesses. 

4.  Cases  occurring  in  persons  of  general  good 
health,  with  no  apparent  adequate  cause,  but  now  by 
some  attributed  to  leuksemia. 

In  the  cases  resulting  from  spinal  injur}-  the  course 
depends  upon  the  extent  and  severity  of  the  injur}-.  In 
some  cases  recovery  occurs  and  the  priapism  ceases :  in 
others  death  occurs  without  relief  from  the  priapism. 
The  cases  of  priapism  from  cerebral  and  descending 
spinal  disease  are  rare  and  few  in  number,  and  in 
most  of  the  cases  reported  the  priapism  was  of  ver}- 
long  duration.  In  the  cases  from  alcoholic  and  sexual 
excess  the  mode  of  onset  is  variable,  in  some  cases 
sudden,  in  others  more  gradual;  but  in  all  the  con- 
dition is  persistent  and  temporarily  obstinate,  and  in 
many  of  them  ver}-  painful,  with  swelling  and  often  a 
nodular  condition  of  the  penis.  Often  there  are  marked 
tenderness  over  the  p>erineum  and  at  the  bulb,  and  spasm 
of  the  cremaster  muscle.  The  pain  also,  as  distuict 
from  the  tenderness,  is  often  very  severe,  and  there  will 
be  difficulty  in  passing  the  urine,  and  more  or  less  gen- 
eral systemic  depression  and  prostration.  Generally 
not  the  whole  organ  is  involved.  The  invasion  is 
usually  sudden  and  the  involution  usually  slow  and 
gradual,  with  many  relapses.  \\Tiile  the  etiolog}-  is 
not  yet  clearly  established,  it  would  seem  that  in 
most  if  not  in  all  cases  there  has  been  some  injury 
to  some  part  of  the  penis  itself,  or  marked  irritation 
of  the  sexual  centre,  or  of  the  ner\-i  erigentes,  or  of 
the  sympathetic. 

In  regard  to  the  class  of  cases  stated  as  pKjssibly 
due  to  leuksemia,  Dr.  Taylor  was  not  yet  fully  con- 
vinced of  the  certaint}-  of  the  relation  between  the 
two  conditions,  and  thought  that  possibly  they  might 
be  merely  coincident,  the  priapism  being  due  to  some 
other  cause  or  causes,  and  urged  more  careful  investi- 
gation of  the  previous  histor}-  of  these  cases. 

The  prognosis  was  always  somewhat  uncertain  and 
depended  upon  the  cause.  In  cases  due  to  injur}-  the 
treatment  by  incisions  would  usually  greatly  hasten 
recovery.     In  the  spinal  cases  the  prognosis  must  be 


ver}-  guarded.  In  the  neurasthenic  and  so-called 
leukaemic  cases  the  priapism  was  likely  to  be  very 
persistent,  and  liable  to  relapse. 

Treatment:  There  could  be  no  regular  routine  treat- 
ment. Chloroform,  ice,  electricit}-,  and  leeches,  as  a 
rule,  were  unsuccessful.  Dr.  Taylor's  preference  was 
for  early  moderate  incisions  into  the  most  turgid  part, 
or  parts  of  continuous  pain,  or  into  nodular  masses 
that  might  be  present  probably  as  a  result  of  trauma- 
tism. Bromides  and  other  sedatives  during  the  par- 
oxysms were  of  advantage.  Locally  hot  baths,  hot 
and  cold  spinal  douches,  sponging  with  hot  water  or 
anodyne  poultices  might  be  of  senice. 

Dr.  Lewis,  of  St.  Louis,  reported  a  case  of  priapism 
cured  by  ligation  of  the  dorsal  arteries  of  the  penis, 
and  Dr.  White,  of  Philadelphia,  suggested  the  use  of 
thyroid  extract,  disclaiming,  however,  any  experience 
with  it  in  this  condition. 

Chronic  Contraction  of  the  Prostatic  Fibres  En- 
circling the  Vesical  Neck — Dr.  Eugene  Fuller,  of 
New  York,  read  the  paper.  In  defining  the  condition. 
Dr.  Fuller  noted  the  distinction  between  spasm  of  the 
vesical  neck  and  the  true  contraction  (from  the  stand- 
point of  his  paper),  viz.,  that  spasm  is  but  a  momen- 
tary condition,  while  contraction  indicates  a  somewhat 
more  lasting  (sometimes  continuous)  tonicity,  and  both 
are  distinct  from  the  "  pain"  in  the  neck  of  the  blad- 
der, which  is  known  as  neuralgia  of  the  vesical  neck. 
Spasm  is  purely  functional  and  is  not  permanent,  and 
is  associated  with  no  pathological  change.  The  con- 
traction mentioned  in  the  title  of  the  paper  represents 
a  definite  pathological  condition,  but  bears  a  relation 
to  the  spasm,  in  that  long-continued  or  ver}-  frequently 
repeated  spasm  may  be  a  causative  factor  in  the  pro- 
duction of  the  contraction.  The  lesion  is  omparable 
to  that  in  the  stemo-cleido-mastoid  muscle  in  chronic 
torticollis.  If  perineal  section  is  made  under  full  anaes- 
thesia, a  hard  inelastic  ring-like  contraction  is  felt  by 
the  finger,  ver}-  different  from  the  feel  of  the  normal 
vesical  neck.  The  calibre  is  large  enough  readily  to 
admit  a  good-sized  sound,  and  therefore  cannot  be  de- 
termined by  examination  with  that  instrument.  One 
cannot  force  the  finger  into  the  bladder  without  tear- 
ing the  ring,  or  first  cutting  it,  preferably  through  the 
floor.  There  is  no  evidence  of  prostatic  enlargement, 
either  in  examination  by  rectum  or  through  such  a 
perineal  wound. 

Dr.  Fuller  has  had  no  opportunity  to  make  a  his- 
tological examination  of  the  lesion,  as  there  have  been 
no  deaths  among  the  observed  cases  this  far.  The 
principal  clinical  symptom  is  the  partial  or  complete 
inabilit}-  to  pass  urine,  which  inability  is  of  gradual 
and  intermittent  development,  beginning  with  hesi- 
tancy and  dribbling  and  finally  resulting  in  attacks  of 
complete  retention,  requiring  the  catheter  to  empty  the 
bladder;  and  later  the  constant  use  of  the  catheter 
becomes  necessary.  This  development  may  take  three 
or  four  years.  Diagnosis  must  be  made  from  the  clin- 
ical histor}-  and  by  exclusion  of  other  (-usually  acute 
inflammatory)  causes  of  obstruction  to  urination.  The 
only  positive  evidence,  however,  is  the  digital  exami- 
nation of  the  neck  of  the  bladder  through  a  perineal 
section,  at  which  time  also  the  disease  may  be  cor- 
rected by  thorough  incision  of  the  contracted  ring  of 
fibres.  In  many  cases  there  are  also  a  clinical  history 
and  evidence  of  trouble  with  the  seminal  vesicles,  or 
with  the  ureter  or  the  kidney  (c\g.,  chronic  pyelitis), 
or  possibly  of  the  rectum.  Most  cases  occur  in  pa- 
tients between  twent}--five  and  fifty  years  of  age.  The 
only  treatment  found  available  by  Dr.  Fuller  is  thor- 
ough divulsion  or  cutting  of  the  fibrous  ring  at  the 
neck  of  the  bladder,  putting  in  a  perineal  tube  for 
drainage  of  the  bladder  and  to  give  it  complete  rest 
for  a  p>eriod  varjing  according  to  the  case. 

Dr.  Fuller  said  he  had  found  no  literature  on  ex- 


MEDICAL    RECORD. 


[July  3,  1897 


actly  this  subject,  and,  comparing  his  cases  with  those 
reported  by  Belfield  and  Post,  pointed  out  the  differ- 
ences between  them  and  his  cases  as  reported. 

Dr.  Chismore  detailed  one  or  two  cases  of  similar 
character,  in  which  operation  had  not  effected  a  cure, 
and  felt  that  the  condition  was  to  a  large  extent  a 
neurotic  one. 

Dr.  Alex.'VNDEr  gave  it  as  his  judgment  that  the 
condition  was  due  not  to  contraction  of  the  fibres 
about  the  neck  alone,  but  to  a  hardening  or  contraction 
or  fibrous  condition  of  the  whole  substance  of  the 
prostate;  that  the  sudden  attacks  of  retention  were 
the  result  of  congestion,  and  that  the  operation  re- 
lieved the  condition  by  reducing  the  congestion.  He 
had  noticed  clinically  three  forms  or  conditions  of  the 
ring:  I  St.  When  it  was  still  soft  and  elastic,  but 
slightly  harder  than  normal.  2d.  When  it  presented 
some  resistance  at  first  to  the  entrance  of  the  finger,  and 
then  suddenly  gave  way,  splitting  in  a  stellate  manner. 
3d.  When  it  was  very  dense  and  hard,  and  would  not 
admit  the  finger  at  all.  In  the  first  and  second  con- 
ditions relief  was  obtained  by  dilatation;  in  the  third 
only  by  incision.  But  he  felt  that  the  complete  divi- 
sion of  the  ring  was  not  entirely  harmless,  as  he  had 
seen  a  condition  of  incontinence  following  it,  although 
in  these  latter  cases  the  patients  were  in  a  poor  and 
low  condition  of  general  health. 

Dr.  Brvson  spoke  of  the  unfortunate  lack  of  op- 
portunity to  get  at  the  e.xact  pathology  by  post- 
mortem examination.  He  reported  several  cases  simi- 
lar to  those  of  Dr.  Fuller,  and  spoke  of  one  of  them 
particularly,  in  which  with  almost  the  same  train  of 
■symptoms  he  had  found  a  very  much  hypertrophied 
veru  montanum.  He  suspected  tuberculosis  in  this 
case  and  later  found  a  descending  tuberculous  ureter- 
itis. In  connection  with  this  case  Dr.  Bryson  spoke  of 
the  relation  between  diseased  conditions  of  the  kidney 
and  ureters,  and  bladder  manifestations  resulting  from 
them,  and  gave  it  as  his  experience  and  opinion  that 
there  occurred  no  pain,  frequency,  or  tenesmus  (as  a 
result  of  disease  in  kidney  or  ureter)  unless  the  lower 
third  of  the  ureter  was  involved. 

Dr.  Bangs  said  that  he  found  cases,  such  as  Dr. 
Fuller  had  described,  not  at  all  uncommon.  He 
thought  that  the  etiology  was  traceable  to  some  ante- 
cedent trouble  of  an  inflammatory  character  in  the 
prostatic  urethra,  or  to  some  sexual  disturbance.  In 
the' case  of  retention  and  residual  urine,  the  bladder 
must  have  drainage  and  rest  for  a  sufficient  time  to 
restore  the  harmony  of  action  between  the  detrusor 
and  the  sphincter. 

Tuberculous  Necrosis  of  the  Prostate. — Dr.  Ful- 
ler read  a  second  paper  on  this  condition,  which  he 
•said  was  not  common,  most  of  the  cases  usually  classed 
as  such  being  a  tuberculous  condition  of  the  adjacent 
structures,  the  prostate  itself  not  being  involved.  The 
prostate  is  very  rarely  primarily  tuberculous.  Dr. 
Fuller  had  seen  two  cases  recently,  in  one  of  which 
■there  was  a  small  focus  of  necrosis  in  the  body  of  the 
prostate,  and  in  the  other  the  entire  prostate  was  in  a 
condition  of  necrosis.  Resolution  of  tuberculous  ne- 
crosis is  not  improbable,  either  by  the  area  affected 
becoming  encysted,  or  by  its  breaking  down  and  dis- 
charging freely  into  the  urethra  or  rectum. 

A  New  Method   of   Removing  Vesical  Polypi 

Dr.  George  Chismore,  of  San  Francisco,  read  a 
paper  with  this  title.  The  principle  involved  is 
suction,  by  means  of  an  aspirator  attached  to  an 
ordinary  litholapaxy  catheter,  the  aspirator  being  a 
strong,  thick,  rubber  hand  bulb.  The  bladder  is 
injected  with  three  or  four  ounces  of  boric-acid  solu- 
tion, with  cocaine,  four  per  cent.;  and  then  the  cathe- 
ter is  passed,  and  the  polyp  is  caught  by  suction  in 
the  eye  of  the  catheter;  when  it  is  caught,  the  catheter 
is  held  quiet  for  a  moment  to  get  a  firm  hold,  and  then 


by  a  slight  swaying  or  sawing  movement,  combined 
with  slight  traction,  the  growth  is  loosened  from  its 
attachment  to  the  bladder  wall  and  passes  through  the 
catheter  into  the  receptacle  attached  to  it  beUveen  the 
hand  bulb  and  the  proximal  end  of  the  catheter. 
When  a  polyp  is  caught,  the  "  feel"  is  different  from 
that  noted  when  the  eye  of  the  catheter  is  in  contact 
with  the  bladder  wall ;  in  the  latter  case  one  can  feel 
the  slight  thud  and  then  the  catheter  seems  firmly 
fixed,  and  at  the  same  time  there  is  a  cry  of  pain  from 
the  patient;  when  a  polyp  is  caught  there  is  no  pain, 
the  "thud"  is  absent,  and  the  catheter  is  not  firmly 
fixed,  but  usually  freely  movable,  especially  if  the 
growth  is  pedunculated.  The  polypus  usually  is  de- 
tached from  the  bladder  wall  very  easily,  with  very- 
little  traction  force.  After  the  removal  of  the  growths 
by  this  method,  the  hemorrhage  ceased  at  once  in 
the  two  cases  reported,  and  up  to  date  (three  years 
after  operation)  there  has  been  no  recurrence  of 
symptoms  indicating  the  presence  of  any  subsequent 
development  of  the  polypi. 

Dr.  Brvsox  remarked  that  he  had  never  yet  seen  a 
Papilloma  of  the  bladder  that  did  not  sooner  or  later 
degenerate  into  a  malignant  condition. 

Rapid  Formation   of  a   Vesical   Calculus Dr. 

William  Jidkixs,  of  Cincinnati,  Ohio,  reported  a 
case  of  vesical  calculus  in  a  child  about  five  years 
old.  A  stone  was  found  with  a  searcher  and  removed 
by  suprapubic  cystotomy.  While  the  bladder  was  open, 
very  careful  examination  was  made,  of  course,  for  evi- 
dence of  any  other  calculi,  and  none  was  found.  The 
one  removed  was  about  one  and  one-fourth  inches 
long,  three-fourths  inch  wide,  and  one-half  inch  thick; 
rounded  and  smooth,  and  absolutely  without  facets. 
During  the  convalescence  the  child  contracted  pneu- 
monia; the  abdominal  and  bladder  wound  sloughed 
and  opened  up,  and  there  was  a  small  omental  prolapse 
through  it.  The  child  finally  recovered,  and  the  ab- 
dominal wound  closed  and  was  sound  and  firm.  A 
short  time  afterward  symptoms  of  stone  again  ap- 
peared, and  upon  searching  another  one  was  found. 
This  time,  only  seven  months  after  the  first  operation, 
a  median  perineal  lithotomy  was  performed  and  a 
stone  extracted,  which  was  larger  than  the  one  formerly 
removed.  It  was  about  one  and  three-fourths  inches 
long;  somewhat  cylindrical  in  shape,  with  one  end 
rounded,  the  other  cut  off  square  and  blunt;  and  there 
was  a  moderate  hourglass-like  constriction  at  about 
the  middle.  It  was  rough  but  showed  no  facets,  and 
had  all  the  appearance  of  having  been  encysted.  The 
interesting  question  in  the  case  was  whether  a  stone 
of  the  size  of  the  second  found  could  have  formed  in 
the  short  time  between  the  first  and  second  operation : 
or  whether  it  was  present  at  the  time  of  the  first  oper- 
ation, and  if  so  where,  for  it  certainly  was  not  in  the 
bladder  at  that  time,  that  viscus  being  clear,  smooth, 
and  empty,  as  evidenced  by  the  careful  examination  of 
Dr.  Judkins  and  two  competent  assistants. 

Nephrectomy  for  Cystic  Adenoma  in  a  Preg- 
nant Woman.  —  Dr.  Charles  L.  Scipper,  of  Boston, 
reported  a  case  of  this  nature.  .At  the  time  of  the 
first  examination  the  patient  was  nineteen  years  of 
age,  and  gave  evidence  of  an  enlarged  and  movable 
left  kidney  with  the  usual  symptoms.  About  six 
months  later  she  was  married,  and  soon  after  became 
pregnant,  during  which  time  the  kidney  tumor  had 
grown  perceptibly  larger,  and  on  palpation  showed 
fluctuation.  A  portion  of  the  fluid  was  withdrawn  with 
an  aspirator,  and  showed  the  usual  constituents  of 
cystic  fluid,  with,  in  addition,  however,  the  rare  condi- 
tion of  the  presence  of  bile  in  it.  The  kidney  was 
removed  without  difficulty:  it  showed  no  connection 
by  adhesion  or  otherwise  with  the  liver  or  gall  bladder. 
The  recovery  was  uneventful;  the  pregnancy  went  on 
to  full  term,  with  delivery  of  a  healthy  child.     The 


Julys,  1897] 


MEDICAL    RECORD. 


23 


patient  had  been  well  and  strong  ever  since  then  (it  was 
now  three  years  since  operation),  and  had  had  a  second 
normal  pregnancy  and  delivery  since.  Seven  days  after 
the  removal  of  the  kidney  the  remaining  kidney  was 
secreting  a  normal  amount  of  urine  in  the  twenty-four 
hours.  The  urine  was  at  present  about  eighteen  hun- 
dred to  two  thousand  cubic  centimetres  in  quantity  in 
twenty-four  hours,  of  normal  specific  gravity;  the 
amount  of  urea  was  normal ;  there  were  at  times  a  very 
slight  trace  of  albumin  and  an  occasional  cast.  The 
interesting  points  of  the  case  were  the  presence  of 
bile  in  a  cyst  of  the  kidney,  the  fact  that  the  operation 
did  not  interfere  with  the  pregnancy,  and  the  time 
that  it  took  the  remaining  kidney  to  adjust  itself  to 
its  double  duty. 

Hernia  Testis. — Dr.  G.  W.  Allen,  of  Boston,  re- 
ported a  case  of  this  kind.  The  patient  had  a  long- 
continued  gleet,  but  had  never  had  syphilis  nor  any 
sign  of  tuberculosis.  He  had  epididymitis  for  three 
■weeks  at  time  of  examination.  A  little  later  there 
•was  a  swelling  over  the  testis,  resembling  a  tubercu- 
lous abscess  of  the  epididymis.  This  was  incised, 
and  the  incision  went  directly  into  the  testis.  There 
was  sloughing  of  the  skin  and  adjacent  tissues,  which 
persisted  for  some  time.  A  healing  process  finally  set 
in,  and  the  tunica  albuginea  was  filled  up  with  granu- 
lation tissue.  Several  attempts  were  made,  unsuccess- 
fully, to  cover  the  raw  area  with  skin.  The  patient  had 
at  present  a  small  area  of  open  granulation,  which 
was  slowly  closing  in.  Bacteriological  examination 
of  the  secretion  from  the  nodule  showed  staphy- 
lococci, but  no  streptococci,  or  gonococci,  or  tubercle 
bacilli.  There  was  very  little  suppuration.  Dr. 
Allen  thought  it  unusual  to  have  such  a  process 
•caused  by  the  staphylococcus. 


Third  Day—  Thursday,  May  6th. 

An  Aid  to  the  Discovery  of  Tubercle  Bacilli  in 
the  Urine. — Dr.  John  P.  Brvson,  of  St.  Louis,  read 
the  paper.  In  the  past  two  years  Dr.  Brvson  has 
noted  the  possibility  of  the  bladder  acting  as  a  reser- 
voir of  tubercle  bacilli  and  also  the  possibility  of  the 
bacilli  multiplying  there,  if  the  conditions  present 
furnish  them  a  good  culture  medium,  i.e.,  plenty 
of  mucus.  The  bacilli  are  not  killed  by  the  urine, 
but  for  a  long  time  remain  in  a  healthy  and  active  state 
in  the  mucus  usually  found  in  these  bladders.  The 
speaker's  method  of  demonstrating  these  microbes  in 
the  urine  consists  in  having  the  patient  pass  volun- 
tarily all  the  urine  that  he  can.  Then  he  passes  a 
sterile  catheter  and  draws  off  the  residual  urine.  This 
may  be  very  small  in  quantity,  perhaps  only  the  cath- 
eter full,  perhaps  only  a  few  drops,  but  by  some  pres- 
sure on  the  hypogastrium  one  can  almost  invariably 
get  enough  to  work  with.  This  is  caught  in  a  sterile 
test  tube,  the  catheter  being  squeezed  out  if  necessary 
or  flushed  with  sterile  water,  and  then  centrifugalized 
and  examined  by  the  usual  staining  methods.  Care 
must  of  course  be  taken  to  exclude  all  possibility  of 
contamination  from  outside  sources. 

Dr.  Bryson  detailed  a  number  of  instances  in  which 
the  method  had  proved  of  great  value,  and  presented 
a  number  of  photo-micrographs  showing  slides  from 
both  tidal  and  catheter  urine  from  the  same  patient,  in 
which  the  tidal  urine  gave  few  or  no  bacilli  and  the 
•catheter  urine  was  full  of  them. 

Oxaluria  and  Lithaemia. — Dr.  Bransford  Lewis, 
of  St.  Louis,  read  a  paper  on  "Urinary  Inflammations 
and  Disorders,  in  Connection  with  Oxaluria  and  Lilhoe- 
mia."  He  remarked  that  although  in  most  books  and 
monograms  on  genito-urinary  subjects,  the  general  in- 
fluence of  the  presence  of  oxalic  acid  and  uric  acid 
and  urates  in  abnormal  quantities  was  mentioned  in  a 
more  or  less  vague  way,  it  being  taken  for  granted  that 


the  condition  was  present,  he  knew  of  no  systematic 
literature  on  the  subject.  He  reported  in  detail  fif- 
teen cases  showing  the  apparent  influence  of  the  uric 
or  oxalic  acid  respectively.  In  some  of  the  cases 
almost  if  not  quite  all  of  the  symptoms  were  caused 
by  those  acids;  in  some  the  inflammatory  condition, 
caused  primarily  by  some  other  agent,  was  made  much 
worse  by  them.  He  had  seen  marked  frequency  of 
urination,  mucous  or  slightly  purulent  discharge,  even 
haematuria  and  pain  caused  by  the  presence  of  oxalate- 
of-calcium  crystals  in  the  urine,  all  of  which  symp- 
toms disappeared  upon  proper  treatment  of  the  "oxalic 
condition."  He  gave  as  a  summary  the  following 
conclusions : 

I  St.  Both  oxalic  and  uric  acids  may  appear  in  the 
urine  either  in  a  physiological  or  a  pathological  man- 
ner. 

2d.  When  pathological,  they  may  exert  certain  in- 
jurious effects  upon  the  genito-urinary  organs. 

3d.  These  effects  may  be  either  the  inciting  of  dis- 
ease where  there  has  been  previous  health,  or  they 
may  act  by  rendering  more  serious  and  resistant  to 
ordinary  methods  of  treatment  other  inflammations 
and  disorders  of  those  organs  which  are  already  pres- 
ent (e.g.,  gonorrhcea,  etc.). 

4th.  The  uric-acid  element  is  not  always  frankly 
evident  as  a  causal  or  complicating  factor  in  such 
cases,  and 

5th.  When  recognized  is  neither  more  nor  less  ea- 
sily controlled  than  when  its  disease  manifestations 
occur  in  other  organs  of  the  body. 

6th.  When  either  the  oxalic  or  uric  acid  element  is 
acting  injuriously  in  the  way  mentioned,  systemic 
treatment  (dietary,  hygienic,  and  medicinal)  is  de- 
manded, and  may  even  take  precedence  over  the  local 
measures  that  are  usually  considered  sufficient  in 
such  inflammations  and  disorders. 

For  medication  he  had  used  mostly  citrate  of  lith- 
ium and  the  salicylates  in  some  form.  The  diet  was 
carefully  regulated,  and  if  the  oxalates  were  present 
in  abundance  he  gave  plenty  of  meat  and  no  vege- 
tables; if  the  urates  or  uric  acid,  he  gave  vegetable 
diet  and  little  or  no  meat.  The  local  treatment  was 
that  usually  adopted  for  the  inflammatory  condition 
which  was  present,  according  to  its  cause  and  stage, 
etc. 

Dr.  White  said  that  he  had  been  in  the  habit  of 
regarding  these  disorders  as  always  associated  with 
neurotic  conditions.  He  related  one  case  in  which 
sexual  failure  had  been  connected  with  oxaluria,  and 
stated  that  with  relief  of  the  oxaluria  by  appropriate 
treatment  the  sexual  difliculty  had  disappeared.  He 
had  almost  altogether  given  up  the  use  of  the  salicylates 
directly,  but  was  in  the  habit  of  using  combinations  of 
caffeine,  phenacetin,  and  salol. 

Dr.  Bangs  spoke  of  the  important  relation  existing 
between  the  processes  of  animal  chemistry  within  the 
body  and  the  urinary  tract.  Systemic  and  hygienic 
treatment  he  did  not  believe  was  enough ;  he  thought 
that  in  many  if  not  all  cases  one  would  have  to  give 
considerable  local  treatment,  just  as  when  these  dia- 
thetic conditions  were  not  present. 

Dr.  Watson  referred  to  the  undoubted  existence 
of  cases  of  gouty  urethritis,  in  which  there  were 
large  quantities  of  uric  acid  and  urates,  with  bladder 
irritation  and  sometimes  a  purulent  discharge,  and 
mentioned  the  relation  between  these  conditions  and 
hematuria  occurring  before  the  formation  of  stone. 
In  the  cases  that  he  had  seen,  the  persistency  and  ob- 
stinacy of  the  condition  had  been  very  marked,  often 
resisting  for  long  periods  every  known  method  of 
treatment,  local  and  systemic. 

Dr.  Brvson  had  observed  often  that  the  uric  and 
oxalic  diatheses  had  increased  inflammatory  con- 
ditions already  existing,  but  thought  there   would  be 


24 


MEDICAL    RECORD. 


[July  3.  1897 


no  actual  purulent  discharge  without  some  other  in- 
fection being  present.  He  had  never  made  out  any 
satisfactory  relation  Ijetween  these  diatheses  and  se.x- 
ual  irregularities. 

Photographing  the  Interior  of  the  Bladder. —  Dr. 
William  K.  Otis,  of  New  York,  showed  an  instru- 
ment for  this  purpose.  It  was  a  Nitze  cystoscopic 
tube  with  a  small  circular  camera,  or  rather  plate- 
holder,  attached  to  the  pro.ximal  end.  There  was  a 
small  "finder"  attached  above  the  plateholder,  into 
which  the  image  was  thrown  by  right-angled  reflecting 
prisms.  The  best  exposure  time  with  ordinary  plates 
he  had  found  to  be  about  fifteen  or  twenty  seconds. 
By  rotation  of  the  circular  sensitive  plate  ten  pictures 
could  be  taken  without  changing  the  plate.  Dr.  Otis 
objected  to  and  criticised  the  circular  plate,  as  it  was 
difficult  to  cut  the  round  glass  plates  well,  and  incon- 
venient to  cut  out  the  individual  photographs  from  the 
printed  picture.  He  was  now  having  an  instrument 
made  that  would  take  a  square  plate,  which  he  thought 
would  be  much  easier  to  manage  in  many  w-ays.  He 
spoke  of  an  earlier  instrument  of  Fenwick's,  in  which 
the  effort  was  made  to  take  a  larger  picture  than  was 
practicable.  This  instrument,  which  he  presented, 
takes  the  picture  just  the  actual  size  of  the  calibre  of 
the  tube,  which  can  then  be  enlarged  from  the  original 
negative.      He  showed  no  pictures. 

The  association  then  adjourned  to  meet  ne.xt  at 
West  Point. 


AMERICAN    MEDICAL   ASSOCIATION. 

SECTION    ON   PRACTICE   OF    MEDICINE. 

J.  H.  MussER,  M.D.,  Philadelphia,  Chairman. 

Tuesday,  June  i. 

Address  of  Welcome. — Dk.  J.  H.  Musser,  chair- 
man, made  a  brief  address  of  welcome,  and  also  read 
a  paper  on  "The  Treatment  of  Dilatation  of  the 
Heart"  by  title.  Dr.  Musser  said:  "If  you  recall  the 
foundation  of  the  city  which  has  the  honor  of  enter- 
taining the  American  Medical  Association  this  week, 
the  city  of  justice  and  love;  if  you  remember  that  you 
are  in  the  city  of  the  minimum  of  tenements,  the  ma.xi- 
mum  of  homes,  exhaling  an  air  of  hospitality,  you  need 
not  We  reminded  that  its  citizens  vie  with  one  another 
in  extending  you  a  hearty  welcome.  Recall  the  fact 
that  in  this  community  labored  Rush,  Morton,  and 
other  distinguished  physicians;  that  here  the  first  hos- 
pital of  the  country,  the  first  medical  school,  the  first 
public  libraiy  were  founded;  that  here  the  first  acade- 
my of  natural  science,  the  first  medical  society  (tiie 
College  of  Physicians),  the  first  scientific  body  (the 
American  Physiological  Society),  were  organized,  and 
you  cannot  but  feel  that  in  this  city  of  brotherly  love 
you  are  thrice  welcome." 

The  Schott  Treatment  of  Cardiac  Disease — Dr. 
W.  R.  Carnac,  of  Baltimore,  read  the  paper.  The 
first  part  described  the  bath  and  exercise  systems  em- 
ployed by  Schott  at  Bad  Nauheim,  and  Schott"s  the- 
ory of  the  action  of  the  saline  baths.  The  author's 
principal  object  was  to  state  results  obtained  from  the 
same  system,  but  with  the  use  of  artificial  baths,  at  the 
Johns  Hopkins  Hospital,  Baltimore.  The  number  of 
cases  was  yet  limited,  ten — all  of  chronic  cardiac  dis- 
ease. The  principal  effects  noted  were:  (i)  Marked 
influence  upon  the  position  of  the  apex  beat,  bringing 
it  from  the  left  toward  the  median  line  and  its  normal 
position;  (2)  increase  in  the  amount  of  urine;  (3)  very 
marked  improvement  in  the  pulse,  even  in  cardiac 
dilatation  associated  with  arterio-sclerosis:  (4)  the  in- 
efficiency of  the  treatment  in  extreme  nephritis.  Of 
the  ten  patients,  four  died,  two  showed  no  improve- 


ment, one  showed  improvement  only  during  the  treat- 
ment, three  had  continued  to  improve.  It  was  remarked 
that  no  one  claimed  to  cure  chronic  cardiac  disease. 
In  one  fatal  case  (fatal  quite  independently  of  the 
treatment)  there  was  aortic  insufficiency,  in  two  there 
were  dilatation  and  arterio-sclerosis,  in  one  there  was 
chronic  nephritis,  in  one  mitral  stenosis.  The  author 
concluded  from  this  limited  experience  that  extensive 
nephritis  was  a  serious  obstacle  to  success  with  the 
baths  and  exercise,  though  if  it  was  not  too  grave  the 
patients  might  be  benefited.  Extensive  changes  in  the 
position  of  the  apex  beat  and  cardiac  outline  did  not 
necessarily  indicate  permanent  good  results.  Arterial 
sclerosis  did  not  necessarily  contraindicate  the  treat- 
ment. Among  drugs,  digitalis  was  freely  employed  in 
many  of  the  cases.  While  they  had  not  been  able  to 
effect  permanent  reduction  of  the  size  of  the  heart, 
they  had  found  in  every  case  slowing  and  strengthen- 
ing of  the  pulse  and  diminished  tension. 

Dr.  William  Osler  had  seen  some  patients  with 
whom  this  treatment  had  been  carried  out  at  Bad 
Nauheim  with  rather  extraordinary  results.  To  carry- 
it  out  in  either  hospital  or  private  practice  was  some- 
what irksome,  but  it  was  perfectly  feasible. 

Dr.  Stockton,  of  Buffalo,  referred  to  the  necessity 
for  conducting  the  exercises  with  care  lest  through 
overexercise  more  harm  than  good  be  done. 

Dr.  Foster,  of  Pennsylvania,  asked  the  author 
whether  control  experiments  had  been  made  with  sim- 
ple water  baths. 

Dr.  Herrick,  of  Cleveland,  thought  one  ought  to 
inquire  into  the  cause  of  the  heart  trouble  and  the 
habits  of  the  patient,  before  deciding  upon  any  course 
of  treatment. 

Dr.  Morrisy,  of  New  Vork,  spoke  of  the  value 
which  he  had  derived  from  massage  treatment  of 
chronic  heart  disease.  There  was  no  question  in  his 
mind  of  the  benefit  of  the  Schott  treatment. 

Dr.  Jones,  of  Buffalo,  understood  that  the  Schott 
brothers  also  directed  mountain  climbing  in  suitable 
cases. 

The  Prognosis  and  Therapeutic  Indications  in 
Heart  Disease.— Dr.  D.  L.  Rochester,  of  Buffalo, 
treated  this  subject  in  a  general  way,  then  gave  a  few 
illustrative  cases,  and  stated  these  general  conclu- 
sions: In  a  given  case  of  cardiac  disease  the  prognosis 
depends  chiefly  on  the  condition  of  the  heart  muscle 
and  the  walls  of  the  arteries,  especially  the  arterioles. 
The  chief  therapeutic  indications  were  rest,  removal 
of  obstruction  to  the  circulation,  massage,  baths,  regu- 
lated exercise,  stimulation  to  rhythmical  contraction  of 
the  muscular  fibres  of  heart  and  vessels.  Besides  car- 
rying out  these  indications  in  his  illustrative  case,  he 
induced  mild  catharsis  by  calomel  and  salines,  gave 
milk  and  kumyss,  and  induced  diuresis  by  diuretin. 
Ordinary  measures  failed  to  induce  diaphoresis  until 
he  combined  the  administration  of  pilocarpine  and  hot 
baths. 

Dr.  Herrick,  of  Chicago,  mentioned  three  cases  of 
cardiac  dilatation,  apparently  due  to  fibrous  myocar- 
ditis, the  patients  entering  the  hospital  with  extreme 
cyanosis,  a-dema,  etc.,  in  which  prompt  relief  followed 
venesection. 

Dr.  H.  O.  West,  of  Galveston,  called  attention  to 
two  factors  acting  in  the  production  of  cardiac  dilata- 
tion, viz.,  continued  hydrostatic  pressure,  the  column 
of  blood  acting  through  the  incompetent  aortic  valve 
upon  the  cavity  of  the  left  ventricle :  the  second  was 
disturbance  of  the  circulation  through  the  coronary 
artery  in  consequence  of  \-alvular  incompetency.  This 
interfered  with  the  nutrition  of  the  heart  muscle.  The 
abstraction  of  blood  was  strongly  indicated  in  some 
cases. 

Dr.  Marvin,  of  Louisville,  spoke  of  the  great  value 
of  str^'chnine    as  a  cardiac  tonic.     He    preferred  to 


July  3,  1897] 


MEDICAL    RECORD. 


25 


give  it  by  hypodermic  injection,  and  employed  increas- 
ing doses,  going  much  higher  than  one-twentieth  grain 
when  necessary. 

Dr.  J.  N.  Upshur,  of  Richmond,  had  found  mucli 
benefit  from  alternate  use  of  strychnine  and  nitrogly- 
cerin. 

Dr.  Cohn,  of  Philadelphia,  approved  of  venesection 
in  some  conditions  of  heart  disease. 

The  discussion  was  also  participated  in  by  Drs. 
Wai-N'wriiiht,  J.  F.  Jenkins,  McL'onnel,  Rochester. 

Reduplication  of  the  Heart  Sounds. — Dr.  C.  F. 
Hoover,  of  Cleveland,  read  the  paper. 

The  Use  of  Digitalin  with  Reference  to  Dose 

Dr.  Henry  Beates,  of  Philadelphia,  pointed  out  in 
the  first  part  of  this  paper  the  reasons  which  had  led 
him  to  abandon  the  use  of  the  crude  drug  digitalis. 
The  same  reasons,  complexity  of  composition  and  \a- 
riation  in  effect,  had  led  him  to  give  up  the  alkaloid 
in  favor  of  digitalin  (German,  pure).  This  prepara- 
tion was  a  derivative  from  digitalis,  uncontaminated 
by  other  principles,  possessed  unvarying  strength,  was 
free  from  that  property  which  produced  gastric  irrita- 
tion, was  a  powerful  stimulant  of  the  whole  cardiac 
apparatus,  was  a  reliable  and  pronounced  stimulant  of 
the  vasomotor  system,  did  not  develop  cumulative 
effects.  Dr.  Beates  gave  much  larger  doses  than  some 
had  recommended.  The  minimum  dose  with  him  was 
one-tenth  grain  ;  ma.ximum  dose,  one-third  to  one-half 
grain.  In  all  lesions  of  tlie  heart,  with  the  single  ex- 
ception of  mitral  regurgitation  complicated  by  dila- 
tation of  the  auricle,  this  drug  was  of  great  value. 

Dr.  Fowler  expressed  appreciation  of  the  practical 
value  of  Dr.  Beates'  paper. 

Dr.  Herrick,  of  Cleveland,  wished  to  know  whether 
the  author  would  use  digitalin  in  acute  inflammation 
of  the  heart.     If  so,  he  must  differ  from  him. 

Dr.  Beates  replied  that  he  would  not  give  digitalin 
in  simple  inflammation  of  the  heart,  but  it  was  valua- 
ble in  the  treatment  of  the  results  of  such  inflamma- 
tion. 

Tracheal  Tugging. — Dr.  Harry  Toulmin,  of  Phil- 
adelphia, read  a  paper  on  this  subject.  His  attention 
had  been  called  to  tracheal  tugging  clinically  under  Dr. 
Osier,  several  years  ago,  and  on  looking  up  the  litera- 
ture he  had  found  it  discussed  by  two  authors  and  men- 
tioned by  Dr.  Packard.  The  word  tugging  meant,  as 
stated  by  Dr.  Ross,  more  than  mere  movement;  or,  if 
the  latter  condition  were  included,  the  cases  might  be 
divided  into  four  groups:  ((z)  very  slight  up-and-down 
movement;  (/')  slight  movement ;  (;■)  distinct  tugging; 
{//}  marked  tugging.  Examination  of  seventy-five  pa- 
tients with  various  conditions  disclosed  distinct  tra- 
cheal tugging  in  only  seven.  The  heart  was  normal 
in  two  of  the  seven,  hypertrophied  in  four,  insufficient 
in  one,  possibly  aortic  stenosis  was  present  in  another, 
in  one  there  was  aneurism  of  the  ascending  aorta.  He 
said  he  should  expect  tugging  in  cases  of  dilata- 
tion of  the  aorta.  If  it  were  safe  to  draw  conclusions 
from  so  limited  a  number  of  cases  examined,  he  would 
say:  (i)  up-and-down  movement  of  the  trachea  occurs 
in  many  healthy  individuals,  and  accompanies  other 
diseases  as  well  as  aneurism;  (2)  in  such  cases  the 
movement  is  much  alfected  by  respiration,  in  the 
majority  of  cases  being  present  during  inspiration 
only;  (3)  in  a  very  small  percentage  of  cases  distinct 
tugging  of  the  trachea  may  be  present  w'ithout  in- 
volvement of  the  aorta  either  by  aneurism  or  simple 
dilatation. 

Thrombosis  of  the  Vessels  of  the  Neck. — Dr. 
Helen  Baldwin,  of  New  York,  read  the  history  of  a 
case  of  thrombosis  of  the  veins  of  the  neck,  and  gave 
a  resume  of  thirty-four  cases  found  in  literature.  Her 
case  was  that  of  a  girl  who  entered  the  infirmary  with 
a  history  of  having  had  three  attacks  of  rheumatism, 
the  last  one  seven  years  ago.     Five  days  before  enter- 


ing she  had  swelling  of  the  feet,  and  afterward  swell- 
ing in  the  neck  and  arm,  with  pain  and  such  symp- 
toms as  attend  venous  thrombosis.  The  swelling  in 
the  neck  was  on  the  left  side,  along  the  course  of  the 
jugular  vein,  which  was  hard,  tortuous,  and  tender, 
with  redness  of  the  overlying  skin.  There  were  dou- 
ble aortic  and  mitral  murmurs.  The  liver  was  en- 
larged; there  was  ascites;  albumin  and  casts  were 
found  in  the  urine.  The  temperature  was  persistently 
low  the  first  five  days,  from  94  to  96"  F.,  but  on 
taking  it  by  rectum  as  well  as  by  mouth  it  was  found 
higher  in  the  rectum,  102°  F.,  and  the  difference  of 
six  or  eight  degrees  persisted.  After  tliree  weeks 
double  pneumonia  developed,  the  patient  died,  and 
autopsy  showed  cardiac  disease,  with  great  dilatation 
of  the  right  ventricle.  The  veins  of  the  neck  were 
filled  with  firm  thrombi,  and  there  was  evidence  of  an 
endophlebitis  of  long  duration  in  the  subclavian  vein, 
which  evidently  had  been  the  seat  of  primary  forma- 
tion of  the  clot.  The  extension  of  the  clot  fonnation 
from  this  point  had  probably  been  favored  by  failing 
cardiac  compensation.  Lesions  were  present  in  the 
liver,  spleen,  stomach,  and  kidneys. 

As  to  causes,  in  eight  of  the  thirty-four  cases  found 
in  literature  there  was  pressure  on  die  veins,  causing 
stasis;  in  sixteen  there  was  grave  blood  dyscrasia;  in 
five  there  was  endophlebitis,  as  in  her  own  case. 
While  the  prognosis  of  venous  thrombosis  in  general 
was  not  so  grave,  in  cases  involving  the  jugular  veins 
it  had  seldom  been  seen  except  in  the  last  stages  of  a 
fatal  disease.  Only  four  of  the  thirty-four  subjects 
recovered. 


Wednesday,  June  2d — Morning  Session. 

Discussion  on  Orrhodiagnosis  of  Typhoid  Fever. 

— Dr.  Willia.m  H.  Welch,  of  Baltimore,  opened  the 
discussion  with  verbal  remarks  on  the  principles  un- 
derlying orrhodiagnosis.  There  could  be  no  question 
of  the  great  value  of  any  method  for  positive  diagnosis 
of  typhoid  fever.  While  a  clinical  study  of  the  case 
was  sufficient  in  many  instances,  yet  there  were  many 
cases  in  which  typhoid  presented  anomalous  symptoms, 
and  mistakes  in  diagnosis  were  not  uncommon.  In 
children  typhoid  often  ran  a  very  irregular  course,  and 
in  the  South  it  would  be  desirable  to  determine  how 
many  of  the  fevers  were  malarial  and  how  many  ty- 
phoid, or  whether  there  was  a  slow  climatic  fever  in 
the  Southern  States.  A  method  of  positive  diagnosis 
of  typhoid  fever  would  aid  us  greatly.  It  was  a  strik- 
ing fact  that  before  the  introduction  of  sero-diagnosis 
of  typhoid  fever  the  discovery  of  the  typhoid  bacillus 
had  led  to  few  practical  results,  being  in  contrast  with 
the  discovery  of  the  diphtheria  and  tubercle  bacilli. 
The  working  out  of  the  method  now'  known  as  Widal's 
grew  out  of  investigations  regarding  immunity,  which 
were  undertaken  for  scientific  interest  and  not  for 
practical  application. 

Having  passed  in  review  the  investigations  of 
Pfeiffer,  Gruber,  Widal,  etc.,  Dr.  Welch  briefly  de- 
scribed the  Widal  method.  The  serum  of  blood  of  a 
typhoid  patient  added  to  a  culture  of  typhoid  bacilli 
caused  the  latter  to  conglomerate  and  lose  their  motil- 
ity. This  reaction  probably  had  nothing  to  do  with 
immunity,  or  with  the  bactericidal  eftects  of  the 
blood.  Whether  the  phenomenon  was  a  histological 
one  or  a  physical  one  was  not  known.  It  (the  agglu- 
tination) occurred  also  with  dead  bacilli.  Blood 
dried  for  six  months,  possibly  longer,  retained  almost 
its  full  agglutinating  power  over  the  bacillus  cultures. 
It  was  not  affected  by  light,  but  was  destroyed  by  high 
temperature — 70'  to  75'  C.  The  agglutinating  prop- 
erty was  possessed  also  by  the  various  juices  of  the 
body  and  serous  exudates.  Whether  it  was  the  same 
substance  which  caused  both  the  immobilization  and 


26 


MEDICAL    RECORD. 


[July  3,  1897 


the  clumping  had  not  been  determined.  The  two  re- 
sults were  not  always  present  to  the  same  degree. 

Regarding  methods,  Dr.  Welch  thought  the  blood 
should  be  obtained  by  pricking  the  lobule  of  the  ear 
or  finger,  a  method  less  likely  to  beget  prejudice  than 
raising  a  blister  or  sticking  a  vein.  He  also  suggested 
as  a  point  for  discussion  whether  it  was  best  to  use 
serum  or  dried  blood.  It,had  been  claimed  as  an  ad- 
vantage for  serum  that  it  permitted  greater  accuracy 
in  dilution.  Perhaps  Dr.  Johnston,  who  had  brought 
forward  the  method  of  using  dried  blood,  could  tell 
how  to  make  a  correct  quantitative  estimate.  The 
microscopic  test  was  preferred  by  Dr.  Welch  to  the 
macroscopic  test. 

Should  one  lay  most  stress  upon  the  immobilization 
or  upon  the  clumping?  All  were  agreed  that  young 
cultures,  those  which  had  not  grown  more  than  twenty- 
four  hours,  should  be  used.  He  suggested  fifteen 
hours.  Some  preferred  agar,  some  bouillon  culture. 
As  to  the  time  limit,  he  would  suggest  two  hours  at 
the  temperature  of  the  thermostat.  As  to  dilution, 
Widal  held  that  one  in  ten  or  one  in  fifteen  was  best. 
But  in  doubtful  cases  a  larger  dilution,  say  one  in 
forty  or  fifty,  would  be  less  likely  to  show  the  reaction 
if  the  case  were  not  typhoid  than  if  it  were.  Indeed, 
no  case  not  typhoid  had  been  positively  known  to  give 
the  reaction  with  a  dilution  of  one  in  fifty,  while  a  good 
many  had  in  dilutions  of  one  in  ten  up  to  twenty  or 
twenty-five.  Another  point  of  possible  error  was  the 
presence  of  the  reaction  at  variable  periods  in  the  dis- 
ease ;  also  for  weeks  or  years  after  recovery,  even 
seven  or  ten  years. 

After  mentioning  practical  results  briefly,  the 
speaker  said  he  thought  the  test  was  extremely  valua- 
ble in  diagnosis,  and  local  and  State  health  boards 
ought  to  establish  laboratories  to  which  general  prac- 
titioners could  send  specimens  for  examination. 

Dr.  Wvatt  Johnston',  of  Montreal,  spoke  of  per- 
sonal observations  and  investigations  in  orrhodiag- 
nosis.  He  had  examined  somewhat  over  six  hundred 
samples  of  blood,  more  than  half  of  which  were  from 
typhoid  cases.  He  could  speak  strongly  of  the  diag- 
nostic value  of  the  method.  He  had  experimented 
by  using  the  clumping  of  the  typhoid  bacilli  as  a 
means  of  separating  them  from  others  in  a  liquid  cul- 
ture, filtering  this  through  sand.  The  colon  bacillus 
ran  through,  while  the  typhoid  remained  clumped. 
But  fiothing  practical  had  yet  come  of  the  method  as 
it  had  so  far  been  developed.  It  had  been  for  the 
purpose  of  making  the  test  useful  to  the  general  practi- 
tioners that  he  had  suggested  transmission  of  dried 
blood  for  examination,  for  Widal  had  already  shown 
that  drying  did  not  interfere  with  the  reaction.  In  this 
manner  samples  to  be  tested  were  sent  him  by  post 
from  long  distances.  The  hsmometer  enabled  him  to 
make  a  pretty  accurate  dilution  or  quantitative  test, 
but  he  did  not  advise  the  method  in  hospital  practice. 
The  clumping  took  place  in  a  slightly  alkaline  rather 
than  in  an  acid  culture  medium.  Dr.  Johnston  had 
found  the  reaction  absent  in  only  one  case  of  typhoid, 
and  in  that  instance  the  patient  was  not  seen  until  late 
in  tiie  disease. 

Dr.  R.  C.  C.\bot,  of  Boston,  read  a  clinical  report 
on  the  same  subject.  Of  cases  collected  in  which 
the  Widal  test  had  been  applied,  in  1,826  supposed 
to  be  typhoid  the  test  confirmed  the  diagnosis  in  1,740, 
or  95.2  per  cent.  Out  of  1,649  cases  known  to  be 
other  than  typhoid,  the  serum  reaction  was  nega- 
tive in  1,592,  or  96.5  per  cent.  Thus  in  a  total  of 
3,475  cases  the  results  of  the  serum  test  had  been 
borne  out  by  the  clinician.  Dr.  Cabot's  own  experi- 
ence related  to  a  little  over  400  samples,  all  tested  by 
himself,  from  patients  seen  by  him.  One  hundred  and 
one  of  these  were  supposed  to  be  typhoid,  and  he  got 
the  reaction  in  96;  failed  in  5.     In  301  known  to  be 


other  than  typhoid,  the  reaction  was  absent  in  300. 
In  I  it  was  positive — a  case  of  pernicious  anaemia  in 
a  negro.  In  17  cases  of  cerebro-spinal  meningitis  the 
reaction  was  not  present.  His  method  was  to  prick 
the  ear,  take  a  single  drop  of  blood  with  the  medicine 
dropper,  put  it  directly  into  a  small  tube  containing 
ten  drops  of  bouillon  culture,  and  wait  fifteen  to  thirty 
minutes  for  the  reaction.  Unless  there  were  both 
clumping  and  cessation  of  motion,  the  reaction  must 
be  regarded  as  doubtful. 

Dr.  W.  B.  Block,  of  Baltimore,  also  gave  a  clinical 
report  on  orrhodiagnosis,  based  on  work  in  the  Johns 
Hopkins  Hospital.  The  serum  and  dried  blood  tests 
had  given  about  the  same  results.  The  whole  num- 
ber of  tests  was  107.  Out  of  46  typhoid  cases  the 
percentage  of  failures  had  been  6.5.  The  method  was 
of  value  in  distinguishing  tj'phoid  from  some  cases  of 
tuberculosis  and  malaria.  In  these  diseases  without 
complicating  typhoid  the  reaction  had  been  present 
only  in  some  cases  with  coma:  why  it  was  present 
then,  he  was  unable  to  say.  He  had  used  a  dilution 
of  sixteen;  time  limit,  thirty  minutes. 

Dr.  H.  M.  Biggs,  of  New  York,  sent  a  paper  based 
on  the  work  of  the  board  of  health  of  New  York  City. 
The  board  at  first  provided  for  dried-blood  specimens 
to  be  sent  it  by  physicians :  later  it  expressed  a  pref- 
erence for  serum  obtained  by  fly  blister,  but  sometimes 
used  dried  blood.  Aside  from  this,  the  board  had 
seen  no  reason  to  change  the  method  originally  em- 
ployed— one  to  ten  bouillon,  fifteen  minutes.  Between 
three  hundred  and  four  hundred  samples  had  been 
tested.  While  the  serum  reaction  was  by  no  means 
specific,  yet  it  was  usually  reliable.  If  not  applied  in  a 
practical  way  it  was  liable  to  lead  to  false  conclusions. 
The  board  preferred  the  lower  dilution  to  the  higher,  be- 
cause more  errors  were  likely  to  arise  from  the  high  dilu- 
tions failing  to  reveal  typhoid  when  present  than  from 
low  dilutions  showing  the  reaction  when  typhoid  was 
absent.     But  both  could  be  employed  in  doubtful  cases. 

Dr.  S.  S.  Kne.\ss,  of  Philadelphia,  had  in  the  last 
six  months  made  103  blood  examinations:  45  were 
submitted  with  diagnosis  of  typhoid  fever,  and  43  of 
the  45  gave  the  complete  Widal  reaction  in  fifteen  or 
twenty  minutes.  Cases  not  typhoid  gave  uniformly 
negative  results. 

Drs.  J.  H.  MussER  and  John  M.  Swan,  of  Philadel- 
phia, presented  a  paper,  which  was  read  by  Dr.  Swan. 
One  hundred  samples  of  blood  had  been  examined:  35 
were  supposed  to  be  typhoid,  and  the  reaction  was  pres- 
ent in  34.  Twenty-four  were  from  patients  convales- 
cent from  typhoid.  In  iS  of  these  the  reaction  was  com- 
plete, in  4  imperfect,  in  3  absent.  In  part  of  7  cases 
of  prior  typhoid  the  reaction  was  present.  In  other 
diseases  than  typhoid  the  reaction  was  absent. 

Dr.  Mark  W.  Rtchardsox,  of  Boston,  gave  in  this 
paper  the  results  of  examinations  of  109  stools  from  49 
individuals,  by  the  Eisner  method  for  detecting  typhoid 
bacilli.  Thirteen  of  the  49  patients  were  known  to 
have  typhoid.  In  9  of  the  13  the  method  gave  posi- 
tive result — in  2  of  them  by  the  eleventh  day,  in  7  not 
later  than  the  twenty-sixth  day.  In  some  the  bacilli 
could  be  isolated  only  after  several  examinations. 
The  result  was  negative  in  3  cases.  In  all  13  the  se- 
rum reaction  was  present  at  least  two  days  before  the 
bacilli  could  be  found,  thus  showing  the  superiority 
of  this  method.  Yet  in  cases  in  which  the  serum  re- 
action was  negative  or  late,  it  would  seem  that  exami- 
nation of  the  stools  for  the  typhoid  bacillus  would  be 
of  value.  In  17  stools  of  non-typhoidal  cases  all  were 
negative.  Twentv-three  stools  of  13  patients  conva- 
lescing from  typhoid  were  examined,  with  i  positive 
result. 

Dr.  X.  S.  Davis,  Jr.,  said  the  results  of  the  Widal 
test  in  Chicago  corresponded  closely  with  those  given 
by  Dr.  Cabot— over  ninety  per  cent,  successful. 


July  3.  1897] 


MEDICAL    RECORD. 


27 


Dr.  H.  O.  West,  of  Galveston,  hoped  the  Widal 
test  would  soon  be  employed  more  generally  by  physi- 
cians in  the  South  in  cases  of  fever  diagnosticated  by 
some  as  malarial,  by  some  as  a  climatic  continued 
fever,  by  others  as  typhoid. 

Dr.  Herrick,  of  Chicago,  mentioned  two  cases  of 
negative  Widal  test,  in  which  post-mortem  showed  ty- 
phoid and  also  tuberculosis.  These  cases  raised  the 
question  of  the  influence  of  the  mixed  infection  on  the 
serum  test. 


Wednesday,  June  2d — A/fernoon  Session. 

Officers.- -The  nominating  committee  of  the  section 
reported  for  Chairman  for  the  ensuing  year.  Dr.  S.  A. 
Fisk,  of  Denver:  and  for  Secretary,  Dr.  Albert  Jones, 
of  Buffalo.     These  gentlemen  were  duly  elected. 

Observations  on  Two  Examples  of  Typhoid 
Meningeal  Infection — Dr.  A.  P.  Ohlmacher,  of 
Cleveland,  pointed  out  the  fact  in  this  paper  that  in 
very  few  cases  had  the  typhoid  bacillus  been  discov- 
ered as  the  cause  of  meningeal  inflammation,  and  it 
had  fallen  to  him  to  meet  with  three  cases  of  typhoid 
fever  in  which  meningitis  was  demonstrated.  In 
two  of  the  three,  examination  revealed  the  typhoid 
bacillus  as  the  infecting  organism  of  the  meninges. 
The  third  case  revealed  other  bacilli  as  well  as  the 
typhoidal  in  the  meninges,  and  was  therefore  reported 
separately  as  one  of  mixed  infection. 

Relapses  in  Typhoid  Fever Dr.  Willi.\m  Osler 

spoke  upon  this  subject.  The  doctor  was  often  erro- 
neously considered  responsible  for  these  relapses  by 
relatives  of  the  patient :  nor  was  the  diet  definitely 
responsible,  unless  in  a  limited  number  of  cases.  The 
term  relapse  should,  he  thought,  be  restricted  exclu- 
sively to  reinfection  after  a  distinct  and  definite  period 
of  apyrexia.  Intercurrent  relapses,  with  fall  of  tem- 
perature to  nearly  normal,  did  not  belong  to  the  same 
class  as  true  relapse.  The  sources  of  reinfection  were 
still  unknown.  The  typhoid  bacilli  might  be  present 
in  different  organs  as  well  as  in  the  intestine.  Out  of 
five  hundred  cases  of  typhoid  treated  in  his  wards  there 
had  been  relapse  in  forty,  which  was  about  the  percen- 
tage given  by  Liebermeister,  and  very  much  larger  than 
that  given  by  Murchison.  There  might  be  double, 
rarely  triple,  very  rarely  four  or  five  relapses.  In  one 
of  his  cases  the  disease  with  two  relapses  covered  a 
period  of  nearly  six  months.  The  Brand  treatment 
had  nothing  to  do  with  relapses. 

Perichondritis  of  the  Larynx  in  Typhoid  Fever. 
— Dr.  M.  H.  Fussell,  of  Philadelphia,  read  the  paper 
and  showed  photographs  of  a  case  of  perichondritis  of 
the  larynx  in  typhoid  fever.  The  patient  had  stenosis 
of  the  larynx  caused  by  the  perichondritis,  which  Dr. 
Fussell  diagnosticated,  but  refused  tracheotomy.  Au- 
topsy showed,  among  other  changes,  large  perichon- 
driac  abscess,  necrosis  of  cartilage.  Diagnosis  before 
stenosis  was  difficult  in  these  cases. 

The  Rational  Antiseptic  Treatment  of  Typhoid 
Fever — Dr.  H.  O.  \\'est,  of  Galveston,  Tex.,  read  the 
paper.  There  was  no  drug,  or  combination  of  drugs, 
which  had  received  general  acceptance  as  capable  of 
cutting  oft"  typhoid  fever.  The  author  gave  his  reasons 
for  scepticism  as  to  the  power  of  any  drug  to  cut  short 
this  disease.  It  was  of  infectious  nature,  and  drugs 
could  not  reach  all  of  the  micro-organisms  or  kill  the 
germs  without  killing  the  patient.  The  claims  for  so- 
called  specifics  in  this  disease  had  not  been  substanti- 
ated by  the  statistics  of  others  than  the  promoters  of 
the  methods.  A  rational  antiseptic  treatment  would 
include  liquid  diet  for  several  reasons,  among  them 
being  weakened  functional  activity  of  the  salivar}- 
glands,  of  muscles  of  mastication  and  deglutition,  and 
of  the  gastro-intestinal  tract,  more  particularly  of  the 
Stomach.      He  would  reiterate  and  emphasize  the  fact 


that  the  proper  adaptation  of  the  diet  to  the  conditions 
produced  by  the  disease  was  far  more  important  than 
the  use  of  any  drug  or  combination  of  drugs.  Intes- 
tinal antisepsis  could  be  promoted  by  free  use  of  water 
in  the  stomach,  which  tended  to  wash  the  organ  and  to 
aid  digestion.  It  also  stimulated  activity  of  the  skin, 
lungs,  and  kidneys.  For  similar  reasons  the  large  in- 
testine might  occasionally  be  washed  out.  Abnormal 
or  decomposing  intestinal  contents  should  occasionally 
be  swept  out  by  the  cautious  administration  of  a  mer- 
curial or  saline  cathartic.  In  his  opinion  the  persis- 
tent, continuous  use  of  purgatives  was  bad  practice. 
Before  prescribing  any  of  the  long  list  of  antiseptic 
drugs,  one  would  do  well  to  consider  the  effect  upon 
the  stomach.  If  they  favored  the  development  of  gases 
or  fermentation,  they  did  harm.  His  own  experience 
would  not  add  much  to  the  reputation  of  intestinal  an- 
tisepsis in  typhoid  fever.  Still,  he  could  recall  a  few 
cases  in  which  a  good  effect  seemed  to  have  been 
produced.  There  were  thymol,  bismuth,  turpentine, 
carbolic  acid — indeed,  the  very  fact  that  the  list 
was  so  long  was  pretty  conclusive  proof  that  none  had 
been  found  a  specific  in  typhoid.  The  hygiene  of  the 
room  required  especial  attention. 

The  Treatment  of  Typhoid  Fever.  —  Dr.  J.  N. 
L'psHi-R,  of  Richmond,  ^'a.,  was  the  author.  He 
thought  there  was  a  vagueness  of  conception  regarding 
the  treatment  of  typhoid  fever.  After  mentioning  pro- 
phylaxis by  disinfection  of  stools,  attention  to  milk 
and  water  supply,  etc.,  the  author  came  to  the  treat- 
ment of  a  case,  and  placed  special  emphasis  upon 
perfect  rest  and  quiet  in  a  well-ventilated  room  with 
all  precautions  against  spreading  infection.  The  pa- 
tient must  not  be  left  alone,  lest  in  a  state  of  melan- 
cholia he  commit  suicide.  Cool  water  should  be  given 
to  relieve  thirst;  the  diet  should  be  liquid,  easy  to  di- 
gest, nutritious,  milk  being  in  general  the  best  food, 
implicit  directions  should  be  given  as  to  time  and 
quantity  in  the  matter  of  feeding.  No  alcohol  for 
young,  vigorous  subjects;  a  moderate  amount  for  those 
accustomed  to  it.  ^lild  cases  required  practically  no 
treatment  further  than  rest  in  bed  and  observance  of 
the  points  already  mentioned,  and  the  use  of  enemata 
if  necessar)'  to  keep  the  bowel  open.  For  headache 
mention  was  made  of  cold  compress,  shutting  out  the 
light  from  the  eyes,  sodium  bromide;  for  nervous 
symptoms,  musk,  valerian,  ice  cap  for  a  short  period. 
Salol  might  be  indicated  for  intestinal  fermentation  j 
in  threatened  heart  failure,  strjchnine.  *  For  intestinal 
hemorrhage,  turpentine  stupe  over  the  abdomen,  ene- 
mata of  ice  water,  hypodermic  of  str)chnine  or  ergot, 
reduced  diet:  for  peritonitis,  opium  by  the  mouth. 
Attention  must  be  paid  to  the  bladder.  Regarding 
abortive  treatment,  many  claims  had  been  made  for 
this,  even  of  a  startling  nature  in  the  case  of  the 
Woodbridge  method.  Dr.  Upshur  had  never  tried  it, 
not  because  he  was  prejudiced  against  it,  but  because 
on  investigation  he  had  concluded  that  it  had  not 
been  supported  by  the  results.  He  thought  the  orig- 
inator of  the  method  must  have  drawn  erroneous  con- 
clusions from  cases  of  mistaken  diagnosis,  having  had 
no  death  in  twelve  years,  yet  having  imposed  no  re- 
striction upon  diet  or  exercise,  given  no  directions  as 
to  bathing.  In  fact,  a  cure  must  have  taken  place 
frequently  before  there  was  time  for  a  diagnosis.  The 
medicine  was  administered  so  often  as  to  leave  no 
time  for  sleep.  Was  it  strange,  therefore,  that  physi- 
cians in  the  great  hospitals  had  not  indorsed  or  com- 
mended this  treatment?  The  parasite  was  more  resis- 
tant to  antiseptic  treatment  than  was  the  host. 

One  Hundred  Cases  of  Typhoid  Fever.— Dr.  H. 
G.  McCORMicK,  of  Williamsport,  Pa.,  reported  on  124 
cases  of  t)-phoid  fever  which  he  had  treated  since 
1893,  the  last  100  cases  during  a  period  of  thirteen 
months.     The  first  24  he  treated  as  the  professors  and 


28 


MEDICAL    RECORD. 


[July  3,  1897 


the  text-books  generally  recommended,  and  3  of  the 
patients  died.  Of  the  last  100  cases  he  had  lost  only 
I.  The  one  patient  died  of  perforation  of  the  bowel. 
Of  the  100  cases  19  had  hemorrhage,  some  very  severe 
hemorrhage.  Principal  points  in  the  treatment  of  the 
hundred  cases  were:  Milk  and  animal-broth  diet, 
abandoning  anything  which  disagreed;  ventilation; 
cleanliness;  tepid  bath  twice  a  day  for  cleanliness; 
bowels  kept  thoroughly  open,  usually  by  calomel  given 
every  two  hours  until  from  four  to  eight  passages  had 
been  secured  in  the  twent)--four  hours;  an  occasional 
enema;  water  freely  by  the  mouth.  He  had  thus  ren- 
dered the  alimentar)-  canal  as  nearly  aseptic  as  possi- 
ble without  medicines.  He  gave  ever)-  two  hours  two 
drops  of  guaiacol  in  emulsion.  Guaiacol  remained 
as  such  within  the  intestine,  and  thus  reached  the 
point  at  which  it  was  intended  to  act  as  an  antiseptic. 
Another  point  emphasized  was  that  opium  ought  not 
to  be  given  in  case  of  hemorrhage.  This  was  against 
almost  universal  teaching,  but  his  objection  to  opium 
was  that  it  paralyzed  the  intestine,  tympanites  devel- 
oped, the  danger  of  perforation  was  greatly  enhanced. 
The  coal-tar  series  was  dangerous,  and  was  no  more 
effective  in  reducing  temperature  than  the  guaiacol. 
Strvxhnine  might  be  given  in  case  a  heart  stimulant 
were  required. 

Dr.  William  Osler  made  some  remarks  in  the 
general  discussion  of  the  several  papers.  Dr.  Ohl- 
macher's  case  of  meningitis  with  discovery  of  the  ty- 
phoid bacillus  as  the  cause  in  typhoid  fever  was  very 
interesting  and  very  rare.  He  had  known  meningitis 
to  be  diagnosticated  as  a  complication  of  typhoid  in 
many  cases,  whereas  autopsy  showed  no  evidence  of 
meningitis.  Regarding  Dr.  McCormick's  remarkable 
success  with  one  hundred  cases  of  typhoid  fever,  it 
was  very  interesting,  but  Dr.  McCormick  was  still  a 
young  man.  It  did  not  mean  a  great  deal  to  report 
a  number  of  cases  of  typhoid  without  a  death.  Dr. 
Osier  had  had  as  many  as  fifn-three  consecutive  cases 
without  a  single  death,  and  Dr.  Stewart,  in  Montreal, 
had  had  as  many  as  one  hundred  and  thirty  without 
a  death.  If  by  any  method  of  treatment  the  speaker 
should  have  intestinal  hemorrhage  in  nineteen  out  of 
one  hundred  cases,  he  would  want  to  change  his 
treatment  to  learn  if  there  was  not  some  method  which 
was  less  risky.  .\s  to  diarrhcta,  he  had  observed  that 
the  cases  which  had  given  the  least  mortality  were  the 
ones  in  which  there  was  diarrhoea.  Opium  was  indi- 
cated in  hemorrhage. 

Dr.  John  Cronvn,  of  Buffalo,  had  had  relapses  in 
four  out  of  sixty-five  cases  of  typhoid  the  past  winter. 
He  asked  whether  the  germ  which  caused  the  relapse 
was  in  the  spleen,  or  elsewhere,  and  redeveloped. 

Several  others  spoke,  and  Dr.  Andrews  upheld  Dr. 
McCormick,  expressing  the  opinion  that  if  a  mode  of 
treatment  saved  such  severe  cases  of  typhoid  that  in 
one  hundred  there  were  nineteen  with  intestinal  hem- 
orrhage, that  treatment  was  worthy  of  adoption. 

Dr.  J.  E.  WooDBRiDGE,  of  Cleveland,  regretted  that 
he  had  not  been  present  when  his  paper  on  typhoid 
fever  was  called  for.  He  had  been  accused  of  saying 
many  things  which  he  had  not  said.  He  had  never 
said  a  harsh  thing  about  any  member  of  the  medical 
profession.  He  was  receiving  letters  constantly  from 
many  physicians,  giving  most  flattering  results  from 
the  treatment  with  which  his  name  had  become  asso- 
ciated. Regarding  constipation,  this  was  frequently 
present,  and  sometimes  required  saline  laxatives  aside 
from  the  tablets. 

The  Clinical  Symptoms,  Bacteriologic  Findings, 
and  Post-Mortem  Appearances  in  Cases  of  Infec- 
tion of  Human  Beings  with  the  Bacillus  Pyocya- 
aeus. —  Dr.  L.  Karkkr,  of  Hahimore,  gave  the  results 
of  study  in  this  line  at  the  Johns  Hopkins  Hospital, 
where  it  was  the  custom  to  niake  bacteriologic  exam- 


ination in  all  cases  which  came  to  autopsy.  They  had 
found  the  bacillus  pyocyaneus  at  autopsy  in  various 
organs  of  the  body,  and  in  some  instances  also  during 
life  in  serous  collections,  etc.  The  symptoms  seemed 
to  be  due  less  to  the  local  action  of  the  bacillus  than 
to  systemic  poisoning  by  absorption  of  the  toxins. 
The  bacillus  had  been  found  in  inflammations  of  the 
various  serous  membranes,  also  of  the  mucous  mem- 
branes, in  gangrenous  conditions  of  the  skin,  etc. 
One  or  more  organs  might  be  infected  at  a  time.  Dur- 
ing life  the  diagnosis  of  the  presence  of  the  bacillus 
was  made  by  finding  it  in  the  urine,  by  tapping  the 
exudate,  by  the  sdor.  Less  was  known  about  it  in 
chronic  than  in  acute  infections.  The  prognosis  was 
apparently  grave,  for  only  fatal  cases  had  been  studied, 
but  the  writer  thought  infection  by  this  bacillus  was 
common  and  the  vast  majority  of  the  patients  recov- 
ered. Speaking  of  treatment,  there  was  already  a 
serum  awaiting  the  clinician's  use. 

Trichinosis  and  Trichina  Spiralis. — Dr.  F.  A. 
Packard,  of  Philadelphia,  read  the  histor)'  of  a  case 
of  trichinosis  in  a  man,  with  finding  of  the  tri- 
china spiralis  in  pieces  of  muscle  taken  from  each 
leg.  It  was  the  fourth  case  in  which  he  had  made 
the  diagnosis  of  trichinosis,  but  the  only  one  in 
which  he  had  had  opportunity'  to  confirm  it  by  seek- 
ing for  the  trichina  in  the  muscles.  His  patient  was 
still  living,  the  symptoms  having  largely  disappeared. 
They  had  in  the  first  place  come  on  rather  suddenly 
while  he  was  at  work  in  the  field,  not  having  been  ill 
previously.  There  were  one  chill,  some  vomiting,  no 
diarrhoea,  swollen  face,  cedema  of  eyelids  and  sur- 
rounding skin,  pain  in  thighs  and  calves,  especially 
on  pressure.  The  cedema  of  the  face  disappeared  in 
four  or  five  days.  Profuse  sweating  for  four  days; 
great  thirst.  Temperature  occasionally  was  104.4"  F-. 
and  on  several  occasions  it  fell  below  normal.  Elxces- 
sive  leucocytosis  was  not  found.  The  respiration  was 
rapid.  The  man  had  eaten  a  piece  of  bologna  sau- 
sage, but  it  was  doubted  whether  this  was  the  source 
of  the  trouble.  The  author  was  inclined  to  think  tri- 
chinosis was  not  infrequent,  was  mistaken  for  rheu- 
matic pains  in  the  muscles,  and  should  be  looked  for 
also  in  cases  of  quick  respiration  for  which  there  was 
no  other  explanation. 

Dr.  Stockton,  of  Buffalo,  could  on  looking  back 
over  his  clinical  experience  recall  cases  in  which  it  was 
likely  trichinosis  had  existed  and  he  had  not  recog- 
nized it.  It  was  probably  more  common  than  had  been 
supposed.  He  would  add  to  suspicious  symptoms 
those  of  cedema  and  sweating. 

Myxcedema,  with  Report  of  Two  Cases. — Dr.  J. 
M.  .\nders,  of  Philadelphia,  reported  the  cases.  The 
interest  in  one  case  was  the  fact  that  a  diagnosis  of 
chronic  nephritis  had  been  made,  and  urinary  phe- 
nomena of  that  disease  had  been  present  several  years, 
but  after  thyroid  extract  had  been  taken  for  six  weeks 
those  symptoms  disappeared  and  had  not  recurred. 
Photographs  were  shown  of  the  other  case,  which  was 
still  under  treatment.  One  patient  was  unable  to  take 
the  glycerin  extract  of  thyroid  without  suffering  from 
toxic  symptoms,  whereas  the  powdered  extract  caused 
no  symptoms. 

Treatment  of  Exophthalmic  Goitre  and  Other 
Vasomotor  Ataxias  with  Preparations  of  the  Thy- 
mus Gland  and  of  the  Adrenals.  —  Dr.  Solc>.mon 
SoLis-CoHEN,  of  I'hiladelphia,  presented  about  a 
dozen  patients,  and  in  his  remarks  referred  to  former 
papers  setting  forth  his  views  of  ataxias  of  the  vaso- 
motor system  and  the  etiological  bearing  of  heredity 
in  such  instabilities  of  the  nervous  system.  This 
hereditary  instabilit)-  could  not  be  wiped  out,  bat  con- 
tributing causes  to  such  phenomena  as  sensations  of 
heat,  cold,  sweating,  polyuria,  gastric  and  intestinal 
disturbances,  etc.,  could  be  largely  controlled  by  cer- 


July  3.  1897] 


MEDICAL    RECORD. 


29 


tain  modes  of  living  and  by  drugs.  Tlie  cases  pre- 
sented were  mostly  such  as  had  symptoms  pertaining 
to  goitre,  with  more  or  less  enlargement  of  tlie  thyroid 
body  and  more  or  less  exophthalmia.  In  these  cases 
he  had  administered  preparations  of  thymus  gland  or 
of  the  adrenals,  and  the  results  had  been,  in  many  in- 
stances at  least,  decided  reduction  in  size  of  the  thy- 
roid body  and  of  the  protrusion  of  the  eyes.  The 
adrenal  preparations  had  more  intluence  on  the  circu- 
latory symptoms,  not  so  much  on  the  eye  or  thyroid  as 
the  thymus  preparations,  but  the  best  results  had  come 
from  their  combined  administration. 

Plasmodium  of  Malaria,  Illustrated  by  Lantern 
Slides. — Dr.  J.  Dalaxd,  of  Philadelphia,  caused  to  be 
thrown  on  the  screen  photographic  and  some  diagram- 
matic pictures  of  the  plasmodium  malaria,  tertian 
t\-pe,  which  he  had  made  in  some  cases  under  his  ob- 
servation. They  showed  the  red  blood  cells  contain- 
ing the  Plasmodium  at  the  various  periods  of  its 
development  and  division,  and  the  changes  in  form 
undergone  by  the  cell:  also  a  few  of  the  bodies  in  the 
plasma  outside  the  cells. 


Thursday,  June  j(f — Morning  Session. 

Some  of  the  Clinical  Uses  of  the  X-Ray  in 
Medicine. — Dr.  F.  H.  Williams,  of  Boston,  read  the 
paper.  \Miile  he  had  used  the  .v-ray  also  in  surgery, 
he  limited  this  paper  to  its  uses  in  medicine,  more 
particularly  in  diseases  within  the  thorax.  During 
the  past  year  he  had  examined  the  chest  in  five  hun- 
dred cases,  and  could  say  that  the  method  was  decid- 
edly useful  to  the  doctor  who  would  take  the  trouble 
to  e.xamine  many  chests  in  both  health  and  disease. 
In  no  instance  had  he  seen  hann  result.  Having  be- 
come familiar  with  what  was  the  normal  brightness  of 
the  chest  under  the  fluoroscope,  one  would  find  the 
shadow  darker  in  spots  where  there  were  tuberculosis, 
infarctions,  pneimionic  consolidation,  aneurism,  new 
growths,  fluid  in  the  pericardial  sac  or  pleural  cavity, 
etc.  The  outlines  of  the  heart  could  be  determined, 
showing  presence  or  absence  of  hypertrophy,  etc.  A 
variation  from  the  normal  excursion  of  the  diaphragm 
was  present  in  pneumonia,  pericarditis,  and  various 
conditions,  and  was  an  important  element  in  diagnosis 
and  prognosis.  A  gradual  return  to  the  normal  ex- 
cursions of  the  diaphragm  took  place  in  pneumonia 
and  some  other  conditions.  In  emphysema  the  shadow 
was  lighter  than  in  the  normal  chest.  Dr.  Williams 
had  been  able  to  recognize  pneumonia  before  physical 
signs  could  be  elicited. 

(/"f  be  Continued.^ 


The  Use  of  Gauze  in  the  Treatment  of  Post- 
partum Hemorrhage. — Dr.  Schaefler  {Revue  Ohsti-t. 
Internat.,  December  i,  i8g6)  objects  to  gauze  as  a 
material  for  uterine  tampons  in  case  of  flooding. 
There  is  no  danger  of  sepsis,  if  impregnated  with 
iodoform  or  some  other  antiseptic.  If,  as  often  hap- 
pens, the  tampon  fails  to  stimulate  uterine  contractions, 
and  if,  when  the  bleeding  is  from  a  lacerated  cervix, 
the  plug  does  not  cause  the  torn  artery  to  close  by 
I  thrombosis,  the  gauze  increases  the  danger,  for  it  acts 
'  as  a  capillary  drain  and  takes  up  much  blood.  As 
the  tolerance  of  hemorrhage  is  very  irregular  indiffer- 
ent subjects,  and  an  apparently  triliing  loss  will  kill 
certain  women,  the  best  rule  in  flooding  is  not  to  allow 
one  drop  to  be  shed  that  can  be  saved.  Gauze,  above 
all  if  absorbent,  takes  up  many  drops  of  blood  at 
least.  Dr.  Schaeffer  uses  non -absorbent  gauze,  pre- 
pared by  impregnating  it  with  gutta  percha.  It  may 
be  mixed  with  iodoform  or  airol.  By  rolling  it  up 
into  a  small  ball,  it  can  be  passed  into  the  uterus, 
which  it  distends  without  absorbing  any  more  blood. 
The  gutta-percha  gauze  retains  its  elasticit)-,  and 
hence  Schaetter  finds  it  useful  in  inducing  abortion. 


Surgical  J>uggcstions. 

Tuberculosis  of  the  Superficial  Lymphatic  Glands. 

— Dr.  Willard  {An/mls  of  Surgery,  vol.  xxiv.,  No.  6) 
concludes  with  the  following  suggestions:  i.  Tuber- 
culous infection  of  superficial  glands  usually  occurs 
from  insigniticant  wounds,  and  is  most  common  in  the 
lymphatics  of  the  neck.  2.  Infected  glands  are  a  con- 
stant menace  to  the  system  and  should  be  removed. 

3.  Great  caution  is  necessary  in  operating  on  the 
deeper  structures,  to  prevent  injur}-  of  vessels  or  nerves. 

4.  Euxcision  should  be  thorough,  and  repeated  opera- 
tions, if  required,  are  advisable.  5.  Improved  hy- 
giene, air,  and  food  are  essential,  in  both  operative 
and  non-operative  cases. 

Ununited  Fractures:  Their  Cause  and  Treatment. 

— Dr.  Patton  {^77ie  Hospital,  January  2,  1897)  says  the 
causes  of  non-union  are  to  be  classified  as  general  and 
local.  Of  the  former  any  acute  or  wasting  diseases, 
such  as  syphilis,  scur\-y,  etc.,  have  been  held  respon- 
sible; but  it  is  doubtful  to  what  extent  they  act  and 
they  are  certainly  of  much  less  moment  than  the  local 
causes,  which  are  as  follows:  1.  Wide  separation  of 
the  fragments,  and  consequently  want  of  proper  ap- 
position ;  a  common  example  of  this  occurs  in  the 
ordinary  transverse  fracture  of  the  patella,  or  fracture 
of  the  olecranon,  which  always  unite  by  fibrous  tissue 
only;  (2)  interposition  of  some  foreign  bodv  between 
the  fragments,  such  as  a  piece  of  muscle  or  tendon, 
part  of  the  capsule  of  a  joint,  or,  in  fracture  of  tlie 
lower  jaw,  a  loosened  tooth,  etc.;  (3)  imperfect  treat- 
ment, when  sufficient  rest  is  not  obtained.  This  is 
well  seen  in  cases  in  which  fractures  have  occurred  far 
from  skilled  advice  and  treatment — for  example,  in 
sailors  at  sea.  It  may,  however,  occur  when  splints 
have  been  used  without  properly  fixing  the  fragments, 
by  including  the  joints  above  and  below  the  injury,  or 
possibly  the  circulation  may  have  been  interfered 
with  by  improper  bandaging,  but  this  seems  very  un- 
likely, without  producing  serious  damage  to  soft  parts 
as  well.  Imperfect  fixation  is  especially  likely  to 
occur  in  oblique  fractures  of  the  tibia,  the  obliquity 
not  only  permitting  but  also  aiding  in  a  sliding  move- 
ment of  one  fragment  on  the  other,  often  not  easy  to 
prevent;  (4)  lastly  may  be  grouped  together  such 
troubles  as  possible  injury  to  the  blood  or  nene  sup- 
ply of  the  bone  at  the  site  of  the  original  accident,  dis- 
ease of  the  broken  ends,  such  as  necrosis,  either  from 
constitutional  causes  or  the  severity  of  the  injury,  or  in 
a  compound  fracture  from  extensive  suppuration,  etc. 

Post-Partum  Hemorrhage — Dr.  Griff eth,  in  dis- 
cussing an  article  which  appeared  in  The  Hospital 
Nursing  Mirror,  November  28,  1896,  concerning  the 
advantages  of  compressing  the  aorta,  writes  as  follows: 
"  I  used  always  to  be  extremely  anxious  when  such  cases 
occurred,  or  when  I  was  called  to  them  occurring  in 
the  hands  of  others.  But  having  for  years  practised 
only  this  method  of  treatment  in  even  the  very  worst 
cases,  and  having  never,  even  in  one  instance,  had  it 
fail,  I  now  never  think  of  adopting  any  other  plan. 
It  may  be  practised  at  once  on  the  very  first  appear- 
ance of  loss  at  the  same  time  that  the  uterus  is  com- 
pressed. I  have  never  known  it  to  fail,  even  in  the  very- 
worst  instances,  and,  as  a  rule,  the  hemorrhage  is  im- 
mediately checked,  and  quite  stopped  in  fifteen  or 
twenty  minutes;  nor  have  I  ever  after  the  lapse  of 
half  an  hour  known  it  to  return,  though  continuous 
compression  had  not  been  kept  up  that  length  of 
time." 

Treatment   of  Retrodeviations  of  the  Uterus.— 

In  simple,  uncomplicated  retrodeviations,  producing 
symptoms,  pessaries  should  first  be  employed,  to  be  fol- 


30 


MEDICAL    RECORD. 


[Julys,  1897 


lowed,  in  the  event  of  failure,  by  Alexander's  operation. 
In  movable  retrodeviations  with  healthy  appendages 
but  complicated  by  mild  subinvolution  endometritis 
and  metritis,  Alexander's  operation,  preceded  by  cu- 
rettage, is  indicated  (curettage  and  pessaries  may 
cure  a  limited  number  of  this  class).  In  cases  com- 
plicated by  marked  subinvolution  endometritis  and 
metritis,  or  by  tubal  or  ovarian  disease,  or  by  adhe- 
sions, hysterorrhaphy  preceded  by  curettage  is  the  only 
method  permissible. —  Smith,  The  Jountal  oj  the 
American  Medical  Association. 

To  Fenestrate  a  Plaster  Splint. — My  method  is 
to  insert  a  chip  ointment  box  or  other  similar  article  a 
little  larger  than  the  ulcer  or  wound  directly  over  the 
affected  surface,  and  with  a  strip  of  bandage  encircle 
the  limb  and  box  so  that  the  ends  of  the  bandages  can 
overlap  and  be  pinned  over  the  box.  Having  applied 
the  flannel  roller  or  wadding,  I  apply  the  plaster-of- 
Paris  bandages  in  the  ordinary  way  to  the  limb,  fitting 
as  closely  as  possible  round  the  sides  of  the  box. 
When  the  plaster  has  hardened  I  take  the  pin  out  of 
the  piece  of  bandage  which  kept  the  box  in  position, 
undo  the  ends  and  lift  up  the  box,  and  the  ulcer  is  ex- 
posed ready  for  whatever  dressing  is  required.  The 
rest  of  the  limb  is  properly  encased. — Eslek,  British 
Medical  Journal. 

Excision  of  Testicle. — There  is  one  operation,  how- 
ever, in  which  I  sometimes  revert  to  the  old  Spence 
dressing,  viz.,  excision  of  the  testicle.  Professor 
Spence  treated  this  operation  wound  in  much  the  same 
way  as  an  amputation.  The  silk  ligatures,  which  were 
of  course  numerous,  were  brought  out  at  the  lower  end 
of  the  wound,  and  made  an  admirable  drain.  I  have 
often  seen  in  the  old  days  such  a  wound  healed  by 
first  intention,  all  but  the  point  at  which  the  ligatures 
were  hanging  out.  In  my  practice,  instead  of  the  silk 
ligatures,  I  have  a  strip  of  iodoform  gauze,  which  can 
be  removed  in  a  day  or  two. — Miller. 

Epithelioma  of  the  Face. — Dr.  du  Castel  has  for 
the  last  two  years  treated  systematically  at  a  hospital 
a  number  of  cases  of  epithelioma  according  to  Darier's 
method,  without  occasioning  any  inconvenience  to  the 
patients.  This  method  consists  in  applying  every 
third  day  a  solution  composed  of  methylene  violet, 
twenty  grains,  and  a  drachm  each  of  alcohol  and 
glyqerin  to  the  diseased  part,  and  after  this  treatment 
a  solution  of  chromic  acid  (1-5)  is  substituted  for 
a  few  days,  when  a  return  is  made  to  the  methylene 
violet.  The  treatment  yields  the  best  results  when 
the  disease  is  superficial.  When  the  parts  are  covered 
with  vegetations  the  latter  should  be  scraped  off  to  in- 
sure penetration  of  the  drug.  Collodion  is  painted  on 
after  each  application  of  the  drug. — Medical  J^ress  and 
Circular,  No.  3,003. 

Pelvic  Pain. — In  a  paper  on  dysmenorrhoea,  in  the 
Maritime  Medical  Neu's,  Dr.  Webster  says  the  follow- 
ing points  .should  be  remembered:  :.  The  pain  may 
be  directly  due  to  distinct  pelvic  lesions,  sufficient 
in  themselves  to  produce  this  symptom.  2.  Pain  may 
exist  with  minor  degrees  of  pelvic  trouble,  insufficient 
in  themselves  to  cause  more  than  a  small  amount  of 
suffering.  3.  Pain  may  be  a  pelvic  symptom  in  asso- 
ciation with  some  condition  which  in  itself  cannot 
directly  produce  this  symptom.  4.  It  may  be  a  promi- 
nent symptom  in  cases  in  which  no  local  changes  of 
any  kind  can  be  made  out. 

Traumatic  Haemarthrosis  of  the  Knee-joint.— Dr. 

O'Connor  [A'eio  Yorl;  Medical  Journal,  vol.  Ixiv.,  No. 
21)  thus  concludes  an  article  on  this  subject:  i.  In 
cases  of  effusion  into  the  knee-joint,  an  aspirating  nee- 
dle should  be  introduced  in  order  to  arrive  at  a  correct 
diagnosis.     2.  If  blood  is  present,  an  incision  should 


immediately  be  made  into  the  synovial  pouch,  and 
every  particle  of  blood  and  clot  removed ;  in  case  of 
fracture  into  the  joint,  the  fragments  should  be  exam- 
ined, and  if  necessary  reduced  and  fixed.  3.  A  gauze 
drain  should  be  inserted  for  a  few  days  in  order  to 
make  certain  that  no  further  reaccumulation  shall  take 
place,  and  when  it  is  evident  that  there  is  no  further 
danger  of  this  occurring  the  external  wound  should  be 
closed  by  "  waiting''  sutures.  When  union  is  suffi- 
ciently firm,  active  movement  should  be  encouraged, 
and  when  this  can  be  painlessly  executed,  then,  and 
then  only,  is  massage  a  most  useful  adjunct  in  restor- 
ing the  muscles  to  their  normal  condition. 

Operative  Treatment  of  Urinary  Fistula  in  the 
Female. — Dr.  S.  Broido  {Gazette des  Hbpitaux,  Septem- 
ber I,  1896)  bases  the  method  that  he  advocates  on 
the  two  following  principles:  i.  That  the  amount  of 
tissue  at  the  site  of  the  fistula  is  the  same  after  opera- 
tion as  before.  2.  That  the  denuded  surfaces  are  ap- 
proximated without  undue  tension  upon  the  edges,  and 
that  they  are  identical  anatomically.  The  method  is 
as  follows:  The  vaginal  tissue  is  elevated  at  one  point 
with  a  tenaculum  and  denuded  transversely.  Starting 
at  the  lower  border  of  the  incision,  the  mucous  mem- 
brane should  be  separated  along  the  entire  length  of 
the  vesico-vaginal  septum;  the  same  should  be  done 
at  the  upper  border  of  the  incision.  Sometimes  it  is 
better  to  construct  the  upper  portion  with  the  aid  of  a 
second  incision  perpendicular  to  the  first,  forming  two 
triangular  areas  with  the  superior  border  of  the  fistula 
to  the  division  of  the  septum.  These  areas  should  be 
sutured  longitudinally.  It  is  occasionally  preferable 
to  form  a  single  quadrilateral  denudation  superiorly 
by  two  ascending  incisions  which  pass  transversely. 
In  cases  complicated  by  prolapse  of  the  bladder,  if 
there  is  difficulty  in  bringing  the  edges  of  the  fistula 
together,  it  is  well  to -take  advantage  of  the  laxness  of 
the  bladder  walls  and  to  separate  the  vesical  tissue 
around  the  edges  of  the  fistulous  tract.  The  sutures 
are  divided  into  two  groups:  the  vesical,  which  should 
be  of  catgut  because  they  are  deep;  and  the  vaginal, 
which  should  be  of  silk  because  they  are  more  superfi- 
cial. After  the  sutures  are  tied,  the  bladder  should  be 
filled  with  some  fluid,  and  if  any  leak  is  detected  more 
sutures  should  be  put  in.  The  patient  is  not  to  be 
catheterized  after  the  operation. 

Antiseptic  Value  of  Iodoform. —  Dr.  Lonibry  {Gaz. 
He/'.,  No.  7)  gives  the  following  as  the  antiseptic  value 
of  iodoform,  i.  If  in  a  dog  or  rabbit  wounds  infected 
with  cultures  of  streptococci  or  staphylococci  are  pow- 
dered over  with  iodoform  they  present  a  better  aspect, 
secrete  less,  and  cicatrize  more  rapidly  than  similarly 
infected  wounds  left  without  dressing.  2.  The  anti- 
septic action  of  iodoform  is  manifest  on  condition  that 
the  experiments  are  made  with  culture  media  dissolv- 
ing iodoform.  3.  Iodoform  weakens  the  virulence  of 
staphylococci  and  streptococci.  It  neutralizes  or  de- 
stroys the  microbic  toxins,  but  without  the  neutraliza- 
tion of  them  or  of  the  bacteria  being  complete.  Instead 
of  having  an  injurious  influence  upon  the  movements 
and  phagocytic  properties  of  the  leucocytes,  it  seems 
to  excite  the  activity  of  the  latter. 

Heredity  in  Cancer. —  Manichon  {Journal  de  Mide- 
cinc)  discusses  this  question,  basing  his  remarks  upon 
his  observation  of  twenty-three  families,  in  which 
several  members  were  aflfected.  There  were  69  cases 
of  cancer  in  these  23  families,  distributed  as  follows: 
57  of  the  stomach,  4  of  the  uterus,  3  of  the  breast,  3  of 
the  rectum,  1  of  the  bladder,  i  of  the  liver.  Of  the  57 
instances  of  the  disease  occurring  in  the  stomach.  41 
were  in  males,  16  in  females.  In  11  families  the 
heredity  was  exclusively  in  the  male  line,  in  5  in  the 
female;  in  6  families  both  sexes  were  equally  affected. 


July  3,  1897] 


MEDICAL    RECORD. 


31 


Out  of  22  families  14  showed  cancer  in  the  stomach, 
and  of  these  the  males  were  affected  in  8.  According 
to  this  author,  heredity  in  cancer  is  no  longer  doubtful, 
and  he  also  points  out  that  the  special  form  of  cancer 
is  itself  hereditary. 

Prostatic  Disease. — Dr.  Dowd,  in  an  article  pub- 
lished in  the  Buffalo  Mcdkal  Journal,  February,  1897, 
says :  "  Prostatic  disease  in  old  men  is  readily  recog- 
nized on  account  of  the  interference  with  urination. 
On  the  other  hand,  when  occurring  in  young  or  mid- 
dle-aged, it  is,  in  my  opinion,  rarely  recognized,  and 
simply  because,  instead  of  abnormal  urination,  the 
symptoms  are  mostly  confined  to  the  sexual  function, 
urethral  discharge,  and  pronounced  neurasthenia.  The 
function  of  the  prostate,  as  you  all  know,  is  to  secrete 
a  fluid  for  dilution  of  the  semen,  it  also  helping  to  fill 
the  posterior  urethra,  thus  causing  contraction  of  the 
perineal  muscles,  aiding  in  its  ready  expulsion.  The 
secretion  is  slightly  acid  in  reaction.  There  is  one 
more  important  use  of  this  fluid,  which  brings  it  for- 
ward as  part  of  the  sexual  apparatus.  The  spermatozoa, 
until  they  become  mi.xed  with  the  prostatic  fluid,  are 
motionless.  This  has  been  demonstrated  by  Fiirbringer, 
and  I  have  proved  the  above  to  be  true  many  times.'' 

To  Prevent  Hemorrhage. — Dr.  Watson  Cheyne 
{LtiHirf),  having  read  Dr.  Wright's  papers  on  the  value 
of  chloride  of  calcium  in  increasing  the  coagulability 
of  the  blood  and  also  of  fibrin  ferment  as  a  styptic, 
invited  him  to  superintend  the  use  of  these  substances 
during  an  operation  that  promised  to  be  very  bloody. 
An  hour  before  the  operation  a  pint  of  water  contain- 
ing one-half  ounce  of  chloride  of  calcium  was  injected 
into  the  rectum,  and  during  the  operation  pledgets  of 
salicylic  wool,  soaked  in  Wright's  fibrin-ferment  solu- 
tion, were  applied  to  the  freshly  cut  surface.  Whether 
due  to  this  treatment  or  not,  the  fact  remains  that  not 
more  than  one  ounce  or  one  and  one-half  ounces  of 
b^ood  were  lost. 

Suppuration  of  Stitches. — Some  writers  explain 
the  suppuration  of  stitches  in  carefully  performed 
operations  by  the  presence  of  pathogenic  micro-organ- 
isms, normally  in  the  underlying  layers  of  the  derma, 
which  cause  suppuration  when  exposed  to  the  air. 
Remlinger  states  that  most  of  the  micro-organisms 
found  in  the  blood  drawn  from  the  fingers  come  from 
the  lower  layers  of  the  skin.  We  know  that  flora  of 
the  superficial  layers  is  extensive,  but  he  announces 
that  he  has  found  staphylococcus  albus  twenty-three 
times,  aureus  eleven  times,  and  citreus  fourteen  times, 
the  streptococcus  pyogenes  eight  times,  and  the  coli 
bacillus  five  times,  in  his  experiments  with  blood  taken 
with  a  sterilized  needle  from  the  deeper  layers  of  the 
skin  of  fifty  healthy  men.  To  avoid  error,  the  needle 
should  not  only  be  sterilized,  but  should  be  inserted 
while  red  hot.  Dr.  E.  Blondel  {Journal  de  Med.  de 
J\iris)  says  that  surgeons  might  make  their  incisions 
with  the  thermo-cautery,  but  the  same  effect  can  be  se- 
cured by  disinfecting  each  stitch  with  alcohol.  Dr. 
Blondel  has  revived  the  practice  taught  by  Theodoric 
and  Mondeville,  of  bathing  the  wound  with  wine,  and 
he  has  invariable  success.  In  total  perineorrhaphy, 
which  is  so  diflicult  to  perform  with  perfect  asepsis, 
he  has  secured  results  far  surpassing  any  previous 
achievement.  He  makes  as  few  stitches  as  possible  in 
the  deeper  layers,  and  wets  them  and  the  edges  of  the 
wound  with  ninety-per-cent.  alcohol,  and  sponges  the 
tissues  with  a  cotton  pad  dipped  in  it.  The  final  su- 
ture is  sponged  with  strong  alcohol  and  then  dusted 
with  iodoform  or  equal  parts  of  dermatol  and  aristol, 
repeated  every  second  day  after\vard.  Alcohol  dries 
the  surface  better  than  any  other  substance.  It  has  a 
coagulating  effect  on  the  serum,  and  thus  favors  cica- 
trization. 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

PARLIAMENT CARDIAC  THROMBUS — DISSECTING  ANEU- 
RISM OF  AORTA  LIGATURING  CAROTIDS  FOR  PHA- 
RYNGEAL     ABSCESS IRREDUCIBLE     HERNIA — DEATHS 

OF    PROFESSOR    CHARTERIS,    DR.    LAW,    DR.  COVER. 

London,  June  ii,  1897. 

The  report  of  the  departmental  committee  on  danger- 
ous trades  (anthrax,  etc.)  has  been  presented  to  both 
houses  of  Parliament. 

In  the  Commons  the  Scotch  public-health  bill  has 
been  reported,  with  amendments  by  the  law-  commit- 
tee. This  bill  has  excited  much  interest  in  conse- 
quence of  an  attempt  to  place  sanitary  inspectors  on 
a  level  with  medical  officers  of  health— a  proposal 
which  is  being  resisted  to  the  utmost. 

A  bill  to  provide  calf  lymph  under  government 
control  has  been  introduced. 

The  return  relating  to  experiments  on  living  ani- 
mals in  England  and  Scotland  has  been  circulated. 

At  the  last  Clinical  Society  meeting.  Dr.  W.  Ewart 
and  Dr.  H.  D.  RoUeston  gave  an  account  of  a  case  in 
which  a  large  ante-mortem  thrombus  was  attached  to 
the  fossa  ovalis  in  the  left  auricle,  passing  through  the 
mitral  valve,  which  was  not  contracted,  into  the  left 
ventricle.  The  patient,  a  woman  of  forty-three,  after 
some  acute  chest  trouble,  probably  pleuro-pneumonia, 
had  the  precise  symptoms  and  signs  of  mitral  stenosis 
with  failure  of  compensation.  She  ultimately  died 
rather  suddenly  with  symptoms  of  pulmonary  apo- 
plexy. At  the  post-mortem  the  viscera  showed  the 
usual  changes  met  with  in  cases  of  advanced  mitral 
disease,  beside  which  a  firm,  smooth,  dark,  hourglass- 
shaped  thrombus  was  found  firmly  attached  to  the  lower 
posterior  part  of  the  foramen  ovale,  passing  into  the 
left  ventricle,  with  a  constriction  at  the  mitral  orifice, 
which  was  otherwise  healthy.  There  were  no  adhe- 
sions between  the  flaps  of  the  valve  and  the  thrombus. 
Examination  of  the  thrombus  showed  that  it  was  old 
internally,  and  that  recent  clot  had  been  added  to  it 
lately;  there  was  no  actual  disease  of  the  mitral  cusps. 

Dr.  Kingston  Fowler  referred  to  a  very  similar  case 
formerly  under  his  care,  reported  by  Dr.  Voelcher  in 
the  Transactions  of  the  Pathological  Society,  1893. 
When  found  in  the  auricle  clots  usually  arise  between 
the  strands  of  the  musculi  pectinati;  in  the  ventricle, 
between  the  chordrc  tendineae.  In  the  early  stage  the 
central  part  probably  underwent  softening,  and  the 
cardiac  contractions  made  the  clots   project  as  polypi. 

Dr.  Bertram  Hunt  then  related  a  case  of  extensive 
dissecting  aneurisms  of  the  aorta  in  a  woman  aged 
forty-three.  While  under  observation  a  left-sided  he- 
mothorax developed,  and  thirty-three  ounces  of  blood 
were  removed  by  aspiration.  A  murmur  was  then 
heard  over  the  spine.  The  patient  remained  in  fair 
health  for  nine  months,  when  she  died  suddenly.  At 
the  post-mortem  a  large  dissecting  aneurism  was 
found,  which  commenced  by  an  orifice  in  the  inner 
coat  of  the  aorta  just  below  the  origin  of  the  left  sub- 
clavian artery  and  opened  again  into  the  left  common 
iliac  artery.  Death  was  due  to  leakage  into  the  right 
lung  and  pleural  cavity.  The  site  of  the  old  leak  into 
the  left  pleura  was  closed  by  adhesions. 

Dr.  De  Havilland  Hall  said  that  in  his  experience, 
when  a  large  aneurism  opened  into  a  serous  cavity, 
there  was  usually  a  large  sudden  escape  of  blood, 
whereas  when  the  aneurism  ruptured  on  to  a  mucous 
surface  the  opening  was  valvular  and  blood  escaped 
slowly. 

Dr.  Rolleston  referred  to  two  cases  of  hemorrhage 


32 


MEDICAL    RECORD. 


[July  3.  i! 


from  the  aorta  into  the  pericardium,  in  which  leakage 
occurred  slowly  in  one,  the  isericardium  was  distended 
with  signs  of  pericarditis,  and  there  was  a  leakage 
from  an  aortic  aneurism.  In  the  other  there  was  a 
very  minute  opening  into  the  pericardium,  which,  how- 
ever, contained  twenty-five  ounces  of  fluid.  He  re- 
membered one  case  in  which  Dr.  Dickinson  diagnosed 
a  dissecting  aneurism  during  life,  from  the  very  acute 
pain  which  radiated  along  the  arteries  in  both  arms 
and  legs. 

Dr.  Ewart  agreed  that  gradual  leakage  sometimes 
occurred  in  cases  of  rupture  of  an  intrapericardial 
aneurism. 

In  addition  to  his  paper  before  the  Medico-Chirurgi- 
cal  Society,  reported  in  my  last,  Mr.  Glutton  read  an  ac- 
count of  a  case  of  pharyngeal  abscess  followed  by  very 
severe  hemorrhage  from  an  abscess  in  the  roof  of  the 
pharyn.\  above  the  right  tonsil,  which  was  eventually 
successfully  arrested  by  the  ligature  of  the  common 
external  and  internal  carotid  arteries.  The  abscess 
cavity  was  at  first  plugged  with  cyanide  gauze,  as  it 
was  thought  the  bleeding  might  be  from  the  internal 
jugular  vein;  but  later  it  was  clearly  from  a  large 
artery,  probably  the  internal  carotid.  The  bifurcation 
of  the  common  carotid  on  the  right  side  was  exposed, 
and  a  goldbeater's  skin  ligature  applied  by  means  of 
a  "  stayknot"  to  the  common  carotid  and  its  two 
branches.  Considering  the  difficulties  in  determin- 
ing the  exact  source  of  hemorrhage  when  it  occurred 
from  a  pharyngeal  abscess,  Mr.  Glutton  believed  it 
to  be  the  safest  practice  to  tie  both  the  external  and 
internal  carotid  arteries,  as  well  as  the  common  car- 
otid, for  all  three  arteries  were  reached  through  the 
same  incision  at  the  bifurcation.  The  necessity  for 
tying  two  of  them  had  been  shown  by  Mr.  Pitts' 
paper  in  the  St.  Thomas'  Hospital  Reports,  vol.  xii., 
and  the  addition  of  the  third  scarcely  increased  the 
length  of  the  operation.  Mr.  Pitts  referred  to  a  case 
in  which  ligature  of  the  common  carotid  artery  was 
hastily  performed,  and  twenty-four  hours  later  profuse 
hemorrhage  recurred  and  proved  rapidly  fatal.  The 
source  of  hemorrhage  had  proved  to  be  the  internal 
carotid,  and  he  had  been  led  from  his  experience  in 
this  case  to  insist  on  the  ligature  of  at  least  the  com- 
mon and  external  carotid  arteries  in  such  a  case. 

Mr.  Harrison  Cripps  had  collected  si.xty-eight  cases 
of  ligature  of  the  common  carotid,  and  had  been 
struck  with  the  high  mortality,  largely  from  brain  symp- 
toms, occurring  immediately  or  in  a  few  days,  or  from 
secondary  hemorrhage;  so  that  ligature  of  the  common 
_  carotid  was  a  very  formidable  operation.  Out  of  all 
the  cases  there  was  clear  evidence  only  in  one  that 
the  internal  carotid  was  the  source  of  the  hemorrhage, 
and  when  that  occurred  death  would  probably  take 
place  at  once,  so  that  the  question  of  operation  did  not 
arise.  He  thought  that  in  most  cases  ligature  of  the 
external  arotid  would  suffice,  and  was  much  less  dan- 
gerous than  ligature  of  the  common  trunk. 

Mr.  Warrington  Haward  read  a  paper  on  "  Irredu- 
cible Hernia,"  based  upon  an  analysis  of  eighty-five 
cases  in  which  an  operation  was  performed  for  irredu- 
cible hernia.  His  conclusions  were :  i.  Irreducible 
hernia  is  a  condition  of  serious  danger,  the  gravity  of 
which  increases  with  its  duration  or  neglect.  2.  The 
application  of  a  truss  upon  an  irreducible  hernia  is 
not  only  useless  but  harmful.  3.  Irreducible  herniaj 
which  consist  wholly  or  in  part  of  bowel  are  very  apt 
to  become  strangulated.  4.  Hernix' consisting  wholly 
of  bowel,  upon  which  no  truss  has  been  worn,  may 
(even  when  of  large  size  and  of  considerable  duration) 
generally  be  returned  by  appropriate  treatment.  5. 
Of  the  cases  of  hernia  in  which  proper  treatment  fails 
to  obtain  reduction,  the  great  majority  are  irreducible 
because  of  adhesions  of  or  changes  in  the  protruded 
viscera — conditions  which  are  remediable  only  by  op- 


eration. 6.  The  most  common  cause  of  irreducibility 
is  the  presence  in  the  sac  of  adherent  omentum.  7. 
The  presence  of  irreducible  omentum  in  the  sac  of  a 
hernia  is  a  sourre  of  constant  danger,  which  can,  nev- 
ertheless, be  remedied  by  an  operation  of  extremely 
small  risk.  8.  Hernia  containing  irreducible  bowel 
are  more  dangerous  than  those  containing  only  omen- 
tum, and  as  the  danger  of  operation  increases  with  the 
magnitude  of  the  hernia  and  with  the  occurrence  of 
adhesions,  these  hernias  should  be  operated  upon  as 
soon  as  they  are  proved  by  the  failure  of  proper  treat- 
ment to  be  irreducible. 

Mr.  A.  E.  Barker  indorsed  all  the  conclusions  at 
which  Mr.  Haward  had  arrived;  but  Mr.  Macready 
made  light  of  the  pressure  of  a  truss  causing  adhe- 
sions; on  the  contrary,  he  held  that  it  favored  the  ab- 
sorption of  adhesions. 

Professor  Gharteris,  of  Glasgow,  died  on  Monday, 
atGomrie,  Perthshire.  He  had  gone  there  to  recuper- 
ate after  influenza.  His  health  had  been  failing  for 
some  time,  and  he  was  unable  to  give  his  course  on 
materia  medica  and  therapeutics  this  session.  His 
•'  Student's  Guide  to  the  Practice  of  Medicine"  is  prob- 
ably well  known  to  you.  His  contributions  included 
important  researches  on  the  salicylates  and  on  carbolic 
acid.  His  recommendation  of  chlorobrom  in  seasick- 
ness excited  a  good  deal  of  attention  some  three  years 
ago.  He  was  also  the  author  of  a  work  on  health  re- 
sorts, and  wrote  the  article  on  that  subject  in  Quain's 
Dictionary. 

Dr.  Joseph  Law,  consulting  physician  to  the  Sheffield 
Royal  Infirmary,  with  which  hospital  he  was  connected 
over  fifty  years,  died  on  the  ist  inst,  at  the  age  of 
ninety. 

Dr.  R.  M.  Cover,  late  Her  Majest)'s  inspector  of 
prisons,  died  on  the  5th.  He  retired  on  account  of 
failing  health  last  December.  He  was  a  valuable 
officer,  and  his  reports  contain  important  observations 
and  suggestions.  His  consideration  for  others  secured 
him  the  esteem  and  regard  of  the  staff  of  the  prisons. 


"CRIMINAL   ABORTION." 

To  THE  Editor  of  the  Medical  Record. 

Sir:  In  your  issue  of  May  2 2d,  Dr.  T.  F.  Connelly 
criticises  Dr.  H.  P.  Beirne's  article  on  "Criminal 
Abortion."  No  doubt  in  the  rural  districts  most 
women  are  lacking  in  the  knowledge  of  how  to  pro- 
cure an  abortion.  Unfortunately  it  is  too  true  that 
in  the  cities  abortions  are  performed  scientifically  by 
a  large  number  of  women  without  any  aid  from  a  phy- 
sician. Scores  of  women  are  able  to  find  the  "mouth 
of  the  womb"  with  greater  facility  than  a  recent  grad- 
uate, and  have  no  difficulty  in  passing  a  catheter  into 
the  uterus.  Most  American  wives  look  on  pregnancy 
as  a  domestic  calamity,  and  no  amount  of  advice  on 
the  enormity  of  the  sin  or  on  their  responsibility  to 
Almighty  God  will  deter  them  from  what  they  believe 
to  be  the  exercise  of  woman's  rights.  Why  is  it  that 
more  children  are  born  of  foreign-born  mothers  than  of 
American-born  women?  How  is  it  tliat  the  average 
American  family  consists  of  two  or  three  children? 
It  is  not  until  the  foreign-born  woman  is  initiated  into 
the  art  of  murdering  her  offspring  that  she  ceases  to 
populate  the  country.  I  know  one  woman  who  can 
procure  an  abortion  by  packing  her  vagina  with  warm, 
moist,  fine-cut  chewing  tobacco  and  squatting  over  a 
vessel  containing  hot  water.  There  is  no  crime  so 
base,  nor  any  which  so  cries  to  heaven  for  vengeance, 
as  the  murder  of  the  innocents.  It  is  possible  to  make 
atonement  for  other  crimes,  but  for  murder  restitution 
is  impossible.  E.  T.  Millig.\n,  M.D. 

Detroit,  Mich. 


July  3,  1897] 


MEDICAL    RECORD. 


To  THE  Editor  of  the  Medical  Record. 

Sir:  I  beg  leave  to  differ  from  Dr.  ConoUy,  who  takes 
the  position  in  your  issue  of  May  2 2d  that  women 
practically  never  produce  abortion  upon  themselves 
either  with  medicines  or  instruments,  for  the  simple 
reason  that  they  cannot.  My  e.xperience  teaches  me 
that  women  do  know  how  to  produce  abortions  upon 
themselves,  both  by  instruments  introduced  into  the 
uterus  and  by  taking  violent  medicines  internally; 
and  that  in  cases  too  numerous  to  mention  they  resort 
to  these  criminal  practices,  with  dire  results  many 
times.  Of  course  it  cannot  be  denied  that  most  pro- 
duced abortions  are  brought  about  by  unscrupulous 
people  who  have  had  some  medical  training;  still  we 
ought  not  to  be  blind  to  the  great  harm  done  by  wo- 
men upon  themselves,  and  one  woman  can  spoil  a 
good  many  others  in  her  vicinitv. 

\V'.  O.  Hexrv,  M.D., 

Omaha,  Xeb. 


"DON'T  TRUST  YOURSELF  IN   THE  HANDS 
OF   THOSE   COUNTRY    DOCTORS.' 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  A  few  months  ago  I  was  called  to  see  a  patient, 
thirty-eight  years  of  age,  who  was  nearly  bedridden  as 
the  result  of  spinal  neurasthenia  and  a  typical  retro- 
fle.xion  of  the  uterus.  The  patient  had  previously 
undergone  four  months'  treatment  in  a  sanatorium,  at 
a  cost  of  several  hundred  dollars.  The  only  thing 
that  had  been  done  for  her  was  to  subject  her  to  elec- 
trolysis according  to  Apostoli's  method,  and  return 
her  to  her  friends  with  the  assurance  that  her  case  was 
practically  cured,  and  that  a  few  weeks  would  suffice 
fully  to  restore  her  strength  and  convince  them  of  the 
great  value  of  the  treatment  to  which  she  had  been 
subjected. 

The  physician  who  had  charge  of  this  case  is  a 
gynaecologist  of  national  repute,  and  as  a  part  of  his 
final  advice  to  the  patient,  he  said:  "  Don't  trust  your- 
self in  the  hands  of  those  country  doctors.  If  you  do 
not  progress  satisfactorily,  write  me  and  I  will  advise 
what  course  to  pursue,"  etc. 

The  patient  and  friends  waited  very  patiently  for 
the  improvement  which  never  came,  and  after  a  few 
weeks  one  of  those  maligned  "country  doctors'  saw 
her  and  on  e.xamination  found  that  she  still  retained 
the  retrofie.xion  in  its  original  form  and  the  neuras- 
thenia was  worse,  if  anything,  than  before  she  had 
undergone  treatment.  Sequela;:  Eminent  specialist. 
richer  in  fees  but  with  the  loss  of  some  reputation, 
drops  out.  Patient,  rich  in  e.xperience  but  poorer  in 
purse,  at  the  instance  of  a  "  country  doctor"  submits 
to  operation  and  is  relieved  of  the  retrofle.xion  and 
under  rest  and  appropriate  treatment  is  slowly  regain- 
ing the  lost  ner\-e  tone. 

Instances  without  number  could  be  cited  to  show 
the  aggressive  tendencies  of  the  physicians  in  our 
cities  toward  "  the  ignorant  and  benighted  country' 
practitioner,"  as  the  urban  physician  is  prone  to  call 
his  country  brother;  but  the  one  given  will  suffice  as 
a  good  illustration  of  the  fallacy  of  the  position  which 
the  physicians  of  the  city  have  assumed  toward  their 
fellows  in  the  rural  districts.  That  the  attitude  of  the 
former  is  based  upon  a  fancied  rather  than  an  actual 
superiority,  is  apparent  to  those  members  of  our  pro- 
fession who  have  had  a  wide  experience  in  both  city 
and  country  practice,  and  who  in  consequence  of  such 
experience  are  best  qualified  to  pass  upon  the  merits 
of  the  two  classes  mentioned.  Such  judges  as  these 
invariably  tell  us  that  the  countr)-  physicians  have  as 
a  rule  better  professional  attainments  than  those  of  the 
city,  and  that  it  is  only  a  few  of  the  many  who  reside 
in  the  city  that  can  claim  with  any  show  of  justice 
their  right  to  superior  professional  attainment. 


The  country  physician  who  rode  several  miles  upon 
a  dark  night  to  a  patient  suffering  from  strangulated 
hernia,  which  he  relieved  by  cutting  with  the  meagre 
instruments  from  his  pocket  case,  and  saved  his  pa- 
tient, is  a  hero  when  compared  with  the  mediocre  city- 
physician  who  lost  a  similar  case  through  lack  of  skill 
and  promptness  of  action,  and  the  delay  occasioned  by 
the  calling  in  of  one  who  was  qualified  to  operate. 

The  country  physician  is  too  apt  to  entertain  invidi- 
ous feel-ngs  toward  his  fellow  competitor,  but  toward 
his  city  brother  he  evinces  feelings  of  respect  which 
too  many  times  is  very  poorly  reciprocated.  Neither 
is  the  country  physician  resentful,  as  much  as  he 
should  be,  of  the  aggressive  and  intrusive  tendencies 
on  the  part  of  his  urban  neighbor.  Too  often  the  lat- 
ter when  meeting  the  former  assumes  a  kind  of  dicta- 
torship in  affairs;  and  this  happens  many  times,  too, 
W'hen  the  true  situation  has  not  been  grasped  by  the 
would-be  dictator,  who  more  than  occasionally  fails  to 
discover  the  real  condition  of  the  patient,  notwith- 
standing his  self-assumed  and  erudite  air  of  superi- 
ority. 

.\gain  it  is  quite  a  common  practice  with  city  phy- 
sicians to  fill  their  clientele  who  spend  their  summers  in 
the  country  with  the  idea  embodied  in  the  above  title : 
■•  Don't  trust  yourself  in  the  hands  of  those  country 
doctors."  This  they  do  ostensibly  for  the  welfare  of 
those  under  their  charge,  but  in  reality  the  true  motive 
is  to  maintain  their  hold  upon  their  patrons  even  while 
absent  on  their  vacations.  How  to  overcome  the  dis- 
trust thus  created  in  a  patient  may  be  a  difficult  prob- 
lem. The  proper  way  is  for  the  countr)-  doctor  to 
maintain  his  dignity  and  self-possession,  and  to  act 
with  promptitude.  He  can  be  kind  yet  firm,  and  withal 
he  should  insist  upon  his  plan  of  treatment  being  faith- 
Tully  carried  out  w  ithout  undue  deference  to  the  notions 
that  the  patient  or  his  friends  may  have  respecting  the 
treatment.  If  the  family  doctor  from  the  city  is  called 
into  the  case,  meet  him  courteously  and  in  a  strictly 
ethical  way.  If  he  is  obtrusive  and  tries  to  create 
distrust  in  3-ou,  insist  upon  your  rights,  and  if  you 
cannot  obtain  them  withdraw  from  the  case.  If  the 
countr)'  doctor  would  follow  this  advice,  the  evil  com- 
plained of  would  soon  be  a  thing  of  the  past. 

There  is  no  good  reason  why  the  city  physician 
should  be  aggressively  inclined  tow-ard  his  fellow 
practitioner  in  the  country,  and  he  will  not  exhibit  his 
aggressive  tendencies  if  the  latter  exacts  a  respectful 
consideration  of  his  rights  and  privileges. 

In  conclusion  I  have  to  say,  let  it  be  known  that  in 
the  countr)-  many  "a  practitioner  of  the  old  school" 
still  lives  and  is  as  worthy  of  praise  and  honor  as  in 
days  of  yore,  and  respect  and  proper  recognition  will 
not  be  withheld  from  him  even  by  our  city  brethren. 
A.  Llewellyn  Hall,  M.D. 

Fair  Haves,  N.  V.,  June  5,  1897. 


MILK   CONTAMINATION. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  The  great  importance  of  a  pure  milk  supply  to  a 
great  city  like  this  needs  no  comment.  Much  has  been 
said  by  physicians  and  not  a  little  has  been  done 
by  the  authorities  toward  insuring  consumers  a  proper 
quality  of  milk.  Tuberculous  cows  are  now  pretty 
generally  discovered  and  destroyed.  I  wish  to  call 
attention  briefly  to  a  possible  source  of  tuberculous  as 
well  as  other  contamination  which  should  be  corrected. 
I  refer  to  the  danger  from  infected  milk  bottles.  Every 
physician  of  wide  experience  in  this  city  must  have 
had  it  happen  in  his  practice,  as  it  has  happened  in 
mine  many  times,  and  always  with  protest,  that  patients 
bring  urine,  pathological  specimens,  and  sputum  in 
milk  and  especially  in  cream  bottles.     The  order  given 


34 


MEDICAL    RECORD. 


[July  3,  1897 


to  procure  a  wide-mouthed  bottle  seems  to  suggest  at 
once  to  a  certain  class  of  patients  that  it  is  better  and 
cheaper  to  take  one  belonging  to  the  milkman  than 
to  buy  one  at  the  drugstore.  The  physician  can- 
not make  sure  that  the  bottle  is  destroyed,  there 
is  always  a  possibility  of  its  finding  its  way  back 
into  some  milk  dealer's  hands,  and  the  public  has 
no  assurance  that  his  methods  of  cleansing  and 
sterilization  are  perfect  and  reliable.     A  law  is  called 


for  to  prevent  the  use  of  beer,  wine,  or  milk  bottles 
which  can  by  any  possibility  be  used  again  for  food 
or  drink-holding  purposes  from  being  used  in  any 
such  way.  The  above  cut,  showing  a  fcetus  mummy 
in  the  bottom  of  a  cream  jar  recently  brought  to  my 
office,  illustrates  the  points  I  have  tried  to  make. 
Fancy  the  unappetizing  effect  of  consuming  milk  from 
such  a  bottle  as  this  and  finding  a  dried  foetus  as  a 
sediment.  Charles  W.  Allen,  M.D. 

126  East  Sixtieth  Street, 
May  27,  1897. 


^Txevjipetttic  pints. 

Roentgea  Rays  were  utilized  by  Dr.  Leopold 
Freund  to  destroy  a  hairy  naevus  occupying  the  neck, 
shoulders,  and  lateral  portions  of  the  thorax  in  a 
young  boy.  Kaposi  thought  that  when  the  nutrition 
disturbances  which  had  been  set  up  had  disappeared, 
the  hairs  might  grow  again. 

[In  all  instances  of  accidental  alopecia  caused  by 
the  x-rays  so  far  reported,  the  hair  has  shown  a  ten- 
dency to  grow  again,  and  for  this  reason  in  a  recent 
editorial  we  ventured  the  opinion  that  the  rays  could 
not  be  successfully  employed  for  purposes  of  epila- 
tion.— Ed.] 

Gargle  in  scarlet  fever,  measles,  etc.  The  follow- 
ing is  useful  in  the  subacute  inflammatory  affections 
occurring  during  the  course  of  the  exanthemata : 

I?  Acidi  acetici 3  ij- 

Glycerin! |  i. 

Aqua; ad  3  viij. 

Burow's  Liquid,  prepared  according  to  his  own 
formula,  calls  for: 

1    ^  I'lumbi  .icet.  cryst 100 

Aq.  distil 300 

2.  1?  Alum 66 

Sod.  sulphat 12 

.V'l.  dest 500 

Mi.x  the  two  solutions  cold,  and  let  stand  for  two  days 
at  a  temijerature  less  than  10^  C.  Filter  without 
washing  the  precipitate.  There  should  then  be  no 
trace  of  lead  in  the  solution,  which  can  be  applied  to 


extensive  raw  surfaces  without  the  danger  of  lead  poi- 
soning, which  is  not  the  case  when  the  solution  is  im- 
properly prepared. — Le  Scalpel. 

The  Treatment  of  Syphilis  by  Intravenous  In- 
jections of  Mercury Dr.  Ernest  Lane  {British  Med- 
ical Journal,  December  12,  1896)  summarizes  the  ad- 
vantages of  this  method  of  treatment  as  follows:  i. 
The  injections  are  absolutely  painless,  which  is  an 
advantage  over  the  intramuscular  method.  2.  The 
functions  of  the  digestive  tract  are  not  interfered  with. 
3.  The  doses  of  the  mercurial  salt,  being  small,  can 
be  easily  regulated  to  suit  the  varying  susceptibility  of 
different  individuals.  4.  With  ordinary  precautions 
the  treatment  is  perfectly  safe;  even  if  the  vein  is 
missed,  little  or  no  inconvenience  is  felt.  5.  The  re- 
sulting improvement  is  certain  and  rapid,  and  conse- 
quently the  method  seems  to  be  indicated  in  cases  of 
cerebral  syphilis.  Dr.  Lane  is  not  able  to  say  whether 
or  not  this  treatment  is  followed  by  relapse.  The  only 
real  difficulty  is  the  trouble  experienced  in  some  instan- 
ces of  bringing  the  veins  into  sufficient  prominence. 
This  is  an  insuperable  obstacle;  still  he  thinks  that  in 
intravenous  injections  we  have  a  valuable  addition 
to  our  means  of  applying  antisyphilitic  therapeutical 
agents,  though  one  he  cannot  recommend  as  a  routine 
practice. 

The  Administration  of  Quinine  to   Children. —  i. 

Quinine  pearls,  gelatine  capsules  containing  one  and 
one-half  grains,  are  taken  readily  by  children  over 
three  years  of  age,  while  younger  children  can  be 
taught  to  swallow  them.  2.  Quinine  chocolate,  each 
piece  containing  one  and  one-half  grains,  the  bitter 
taste  so  well  covered  that  infants  of  nine  months  take 
them,  and  they  do  not  produce  gastric  disturbance.  3. 
Suppositories  made  of  cacao  butter,  and  containing 
various  doses  up  to  seven  and  one-half  grains.  4.  A 
hypodermic  solution  of  one  part  of  hydrochlorate  of 
quinine  in  four  parts  of  water.  \\'ith  proper  precau- 
tions the  injections  are  not  followed  by  abscesses,  and 
are  found  valuable  in  cases  of  whooping-cough  in 
which  quinine  could  not  be  tolerated  by  the  mouth. 
5.  Quinine  maybe  given  in  enema;  the  quantity  of 
solution  used  should  not  exceed  one  ounce.  6.  Tan- 
nate  of  quinine,  which  in  powder  is  almost  tasteless, 
is  a  fairly  satisfactory  substitute  for  other  preparations, 
but  the  dose  given  must  be  double  that  of  the  sulphate, 
and  the  effect  is  not  produced  so  rapidly  nor  so  cer- 
tainly.— BiNZ,  Dent.  med.   JVocli. 

Treatment  of  Eclampsia. — Dr.  Charpentier  be- 
lieves he  is  authorized  to  submit  the  following  as  the 
conclusions  of  his  investigation  of  the  subject:  1. 
Every  pregnant  woman  with  albumin  in  her  urine 
being  exposed  to  attacks  of  eclampsia,  the  milk  diet 
giving  splendid  results  against  the  albuminuria,  and 
in  particular  that  met  with  in  pregnancy,  the  urine  of 
pregnant  women  should  be  examined  with  the  greatest 
care,  and,  if  albumin  is  found,  no  matter  how  small 
it  may  be  in  quantity,  an  absolute  and  exclusive  milk 
diet  should  be  instituted.  This  is  the  preventive 
treatment  par  excellence  of  eclampsia.  In  cases  in 
which  cedenia  is  present  without  albuminuria,  it  is 
well,  if  not  an  absolute  necessity,  to  prescribe  the 
milk  diet.  2.  Every  time  we  find  ourselves  in  pres- 
ence of  an  eclampsia,  begin,  if  the  patient  is  strong 
and  vigorous  and  if  cyanosis  is  present,  by  a  bleed- 
ing of  from  two  hundred  to  three  hundred  grams,  and 
then  give  cliloral :  give  milk  by  the  mouth  and,  if  nec- 
essary, through  a  sound.  3.  Combat  tlie  attacks  them- 
selves by  inhalations  of  chloroform  and  favor  diuresis 
by  subcutaneous  injections  of  artificial  serum.  4.  If 
the  woman  is  delicate,  the  cyanosis  is  not  very  marked, 
the  attacks  are  not  very  frequent,  chloral  should  alone 
be  given.     5.  Wait  until  the  labor  occurs  spontaneously 


July  3,  1897] 


MEDICAL    RECORD. 


35 


and  allow  it  to  end  without  inten-ention  whenever 
this  is  possible.  6.  If  labor  comes  on  spontane- 
ously, but  does  not  end,  because  the  uterine  contrac- 
tions are  too  feeble  or  too  slow,  end  the  labor  by  the 
application  of  the  forceps  or  a  version,  followed  by 
extraction,  if  the  child  is  living,  or  by  a  cephalo- 
tripsy,  basiatripsy,  or  cranioclasy,  if  the  child  is  dead. 
7.  Before  an  intervention  wait  until  there  is  complete 
dilatation,  or  at  least  a  dilatability  of  the  cervix,  in 
order  that  the  operation  may  be  done  without  violence, 
and  consequently  without  danger  for  the  mother.  S. 
Reserve  induced  labor  for  a  few  exceptional  cases.  9. 
Reject,  absolutely  reject  the  Cesarean  operation  and 
accouchement  forn  as  current  methods  in  the  treatment 
of  eclampsia. — Aunah  of  Gyiuec.  and  Pad.,  January, 
1897. 


^ei;j  Instntmnxts. 

A   NEW    ELECTRIC    HEATING    PAD. 

One  of  the  facts  early  noticed  in  electrical  experi- 
mentation was  the  heating  effect  produced  by  the  pas- 
sage of  a  current  through  a  wire.  This  manifestation 
has  since  been  utilized  in  many  practical  forms, 
among  the  most  familiar  of  which,  hailed  in  times 
past  as  most  useful  discoveries,  are  the  heating  to  in- 
candescence of  the  filament  in  the  incandescent  lamp, 
the  localization  and  control  of  the  required  temper- 
ature of  the  wire  in  the  cauterizer,  and  the  production 
of  useful  heating  apparatuses.  When  used  for  cook- 
ing tlie  extreme  effects  of  the  current  are  neither  ex- 
pected nor  required,  the  purpose  being  economically 
to  utilize  the  heating  effect  in  the  production  of 
temperatures  within  given  limits  and  always  under 
control.  The  modern  physician,  with  his  battery-  and 
electro-medical  cabinet,  undoubtedly  stands  nearest 
to  the  professed  electrician  in  his  knowledge  of  the 
behavior  and  effects  of  electricity.  It  is  not  surpris- 
ing, therefore,  that  he  should  be  among  the  first  to 
appreciate  the  improvements  being  made  from  time  to 
time  in  apparatuses  which  claim  his  interest  as  offering 
some  new  means  whereby  improved  results  may  be 
obtained  by  the  applications  of  simpler  methods. 
This  last  remark  is  made  with  more  especial  reference 
to  the  adoption  by  physicians  of  the  electric  heating 
pad,  which  promises  to  occupy  as  secure  a  position 
among  his  modern  appliances  as  the  cauterizer  or 
ozone  generator. 

The  electric  heating  pad  offers  advantages  and  ben- 
efits not  readily  obtainable  with  the  hot-water  bottle 
and  similar  means  for  making  local  applications  of 
heat.  The  proper  management  of  the  hot-water  bottle 
requires  a  watchful  care  and  frequent  renewals  to  ob- 
tain the  desired  eft'ect,  and  necessitates  repeated  agi- 
tation of  the  patient  and  periodical  extremes  of  tem- 
perature with  the  risk  of  exposure  incidental  to  the 
constant  changes;  or,  as  in  hospital  practice,  it  in- 
volves elaborate  and  bulky  circulating  apparatus,  both 
troublesome  and  expensive.  The  facilit)'  with  which 
connections  may  be  made  with  the  electric  current, 
and  the  simplicit}-  and  utilit}-  of  the  heating  pad  as  a 
practical  substitute  for  cruder  methods,  have  already 
led  to  its  adoption  in  various  institutions  and  in 
household  practice. 

Unlike  hot-water  applications,  which  cool  rapidly, 
the  electric  heating  pad  receives  a  constant  and  uni- 
form supply  of  heat;  and  by  simple  means  it  is  possi- 
ble to  maintain  or  regulate  the  temperature  as  may  be 
desired  without  unnecessary  disturbance  of  the  pa- 
tient. The  electrical  method  offers  a  further  advan- 
tage in  that  the  temperature  may  be  raised  gently  and 
the  patient  spared  the  discomfort  and  the  shock  of  the 


sudden  application  of  the  hot- water  bag  at  its  highest 
temperature.  The  gradually  increasing  temperature 
of  the  pad,  or  its  prolonged  application  at  a  fixed  tem- 
perature, also  assures  the  deeper  penetration  of  the 
heat  and  the  attainment  of  more  thorough  therapeutic 
effects.  In  pneumonia,  cramp,  rheumatism,  and  other 
cases  in  which  the  maintenance  of  a  suitable  tempera- 
ture may  be  of  vital  necessit}-,  it  is  apparent  that  any 
means,  which,  with  corresponding  advantages,  would 
prolong  a  given  temperature  indefinitely,  must  be  of 
the  highest  value.  In  the  treatment  of  inflammatory 
affections  of  the  pelvis,  both  acute  and  chronic,  in 
peritonitis,  and  in  ovarian  neuralgia,  the  heating  pad 
is  likely  to  prove  efficacious. 

The  weight  of  the  water  bottle  not  infrequently 
offers  objections  to  its  use  in  the  treatment  of  diseases 
of  the  stomach,  bowels,  and  other  organs,  when  the 
parts  are  sensitive  to  compression. 

The  construction  of  the  electric  heating  pad  is  illus- 
trated herewith.  The  conductor  forming  the  resist- 
ance or  heating  wire,  is  covered,  and  is  thus  thor- 
oughly insulated  and  protected  by  asbestos.  It  is  then 
woven  into  a  cloth  or  pad  about  eleven  by  fifteen 
inches,  and  one-fourth  of  an  inch  thick.  The  arrange- 
ment of  the  circuits  is  such  that  by  means  of  a  simple 


regulating  switch,  shown  in  the  lamp  cord,  three  de- 
grees of  heat  may  be  obtained  by  manipulating  the  key. 
The  cord  attached  to  the  pad  is  provided  at  its  end 
with  a  connecting  plug  for  attachment  to  the  ordinarj' 
incandescent  lamp  or  wall  socket.  The  full  amount 
of  electric  energy  required  to  heat  the  pad  is  the  same 
as  that  for  a  sixteen-candle-pow^er  lamp,  namely,, 
about  ^  of  an  ampere  on  a  no  volt  circuit.  The 
regulator  is  marked  with  the  four  positions  of  the  key, 
o,  I,  2,  3.  At  o  the  current  is  turned  off";  at  i  about 
yV  of  an  ampere  will  flow;  at  2,  ■^^\  and  at  3,  .j^  To 
heat  the  pad  quickly,  the  key  is  first  turned  to  3.  The 
pad  will  soon  attain  a  working  temperature,  and  its 
subsequent  behavior  may  be  readily  regulated  to  any 
degree  by  turning  the  key  in  the  switch  to  2,  to  i,  or 
to  o,  as  may  be  necessar)-,  or  by  the  judicious  arrange- 
ment of  coverings. 

The  eft'ect  of  the  latter  upon  the  rapidity  and  inten- 
sity of  the  heating  will  be  apparent.  The  pad  receives 
a  constant  supply  of  heat  from  the  electric  source.  If 
this  heat  be  permitted  to  escape  by  freely  exposing  the 
surfaces  of  the  pad  to  the  air,  no  great  effect  will  be 
apparent  in  the  pad  itself — in  other  words,  it  will  not 
get  hot.  If,  however,  the  pad  be  confined  between 
coverings  of  any  description,  whether  it  be  blankets  or 
the  human  body,  so  as  to  prevent  the  escape  of  the 
heat,  the  latter,  being  supplied  constantly,  will  accu- 
mulate until  a  temperature  is  attained  which  may  be 
excessive  for  therapeutic  purposes;  and,  were  it  not 
for  automatic  means  of  control  within  the  pad  itself, 
there  would  be  the  ultimate  risk  of  the  temperature 


36 


MEDICAL    RECORD. 


[July  3,  1897 


becoming  unnecessarily  severe  for  both  the  patient 
and  his  surroundings.  By  the  introduction,  however, 
of  the  thermostat  or  temperature  regulator,  shown  in 
the  shape  of  a  button  situated  in  the  centre  of  the  pad, 
any  such  danger  is  practically  obviated. 

When  applied  to  the  skin,  213"  F.  is  an  unendur- 
able temperature;  and  it  is  not  to  be  taken  for  granted 
that  in  the  form  of  a  heating  pad  such  a  temperature 
is  recommended  or  is  desirable  for  ordinary  applica- 
tions. But,  to  meet  average  conditions,  the  setting  of 
the  thermostat  at  such  a  limit — the  thermostat  is  to  be 
regarded  always  as  a  safety  valve— has  been  found  to 
furnish  temperatiu-es  suitable  and  convenient  for  the 
usual  applications.  The  e.xposure  of  the  heating  pad, 
whether  altogether  or  in  part,  is  so  influential  in  de- 
termining the  ultimate  temperature  under  a  given  set 
of  conditions,  that  if  the  thermostat  be  caused  to  work 
— that  is,  to  limit  the  heating,  say,  to  165°  F. — there 
is  an  immediate  complaint  from  the  average  user  that 
the  pad  does  not  get  hot  enough.  It  would  appear 
perfectly  practicable  to  construct  the  heating  pad  for 
special  conditions  and  to  render  it  of  the  greatest  value 
in  the  treatment  of  numerous  special  cases. 

The  interposition  of  coverings  between  the  body 
and  the  pad,  whether  they  be  used  as  a  poultice,  an 
embrocation,  or  shield,  can  modify  temperature  ac- 
cordingly. 


merticat  litems. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitar)'  Bureau,  Health  Department,  for  the 
week  ending  June  26,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. . . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox 


ISS 

16 

3 

6 

227 

S 

265 

-7 

9 

0 

13 

0 

At  Home. — The  Doctor — "Mrs.  Brown  has  sent  for 
me  to  go  and  see  her  boy,  and  I  must  go  at  once." 
His  Wife — "What  is  the  matter  with  the  boy?"  The 
Doctor — "  I  don't  know ;  but  Mrs.  Brown  has  a  book 
on  '  What  to  Do  Before  the  Doctor  Comes,'  and  I  must 
hurry  up  before  she  does  it." 

Thymic  Asthma. — The  diagnosis  of  this  disease 
is  usually  made  after  the  death  of  the  patient.  In  the 
case  of  a  child  described  recently,  who  suffered  from 
intense  dyspncea,  tracheotomy  was  performed  without 
result,  and  it  was  decided  that  the  cause  must  be  some 
compression  by  a  tumor  or  hypertrophied  thymus 
gland.  Extending  the  incision,  the  thymus  gland  was 
found  extremely  enlarged  and  was  removed.  At  once 
the  respiration  became  normal,  and  the  child  was  com- 
pletely cured.  Siegel,  who  reports  the  case,  suggests 
that  it  would  be  more  appropriate  to  designate  this 
trouble  as  thymic  stenosis  of  the  trachea  or  bronchi. 

Another  "Human  Ostrich." — A  Kansas  city  street 
fakir,  whose  special  means  of  entertaining  an  intelli- 
gent public  was  to  swallow  any  and  everything,  re- 
cently found  his  stomach  becoming  too  full,  and  was 
obliged  to  have  it  opened.  The  surgeon  who  per- 
formed the  operation  removed,  according  to  the  news- 
paper report,  the  following  articles:  One  four-bladed 
knife,  one  and  one-half  inches  long;  one  two-bladed 
Barlow  knife,  four  inches  long;  one  knife  blade,  three 
and  one-fourth  inches  long;  one  knife  blade,  three 
inches  long;    two  knife  blades,  each  two  inches  long; 


one  knife  blade,  one  inch  long:  thirty-two  eight  and 
ten  penny  fence  nails  and  spikes;  thirty-four  sixpenny 
wire  nails,  sharp  pointed;  twenty-six  shingle  nails, 
each  one  inch  long;  sixteen  carpet  tacks  and  small 
wire  nails,  one  horseshoe  nail,  three  large  screws,  one 
barbed-wire  staple,  and  three  ounces  of  fine  glass. 

Vital  Statistics  of  Philadelphia. — For  the  week 
ending  June  19th,  there  occurred  in  the  city  of  Phila- 
delphia 394  deaths — ii  more  than  during  the  preced- 
ing week,  and  20  less  than  during  the  corresponding 
week  of  the  previous  year.  Of  this  number,  162  oc- 
curred in  children  under  the  age  of  five  years.  The 
largest  individual  causes  of  death  were  as  follows: 
Pulmonary  tuberculosis,  45;  pneumonia,  31;  heart 
disease,  20;  diphtheria  and  carcinoma,  each  19. 
There  were  reported  during  the  week  119  cases  of 
diphtheria,  79  of  scarlet  fever,  and  39  of  typhoid 
fever,  as  compared  with  96  of  diphtheria,  124  of  scar 
let  fever,  and  74  of  t}'phoid  fever  during  the  previous 
week. 

The  Specialist  of  To-day  is  essentially  a  self-made 
man,  there  being  no  method  of  insuring  the  possession 
of  special  skill  nor  any  legal  or  professional  restric- 
tions upon  any  one  who  chooses  to  announce  himself 
as  a  specialist.  Thus,  so  far  as  a  specialtj-  is  con- 
cerned, the  physician  at  the  present  time  is  as  free 
from  college  or  society  supervision  and  as  innocent 
of  a  diploma  as  might  have  been  the  general  practi- 
tioner of  several  centuries  ago.  Under  these  circum- 
stances a  man  who  calls  himself  a  specialist  cannot 
be  considered  as  claiming  superiority  over  his  profes- 
sional brethren,  but  merely  as  one  who  seeks  to  limit 
his  practice  from  financial  motives  or  because  he  is 
conscious  of  certain  proclivities  and  interests. — Medi- 
cal and  Surgical  Reporter. 

Ricord  used  to  say,  concerning  the  preparations  of 
gold  that  certain  practitioners  had  substituted  for 
mercury  as  specifics  in  syphilitic  diseases,  that,  every- 
thing else  being  equal,  they  produced  better  results 
when  administered  by  the  patient  to  the  doctor  than 
by  the  physician  to  the  patient. 

Health  Reports. — The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  super\-ising  surgeon- 
general  of  the  United  States  Marine  Hospital  service, 
during  the  week  ending  June  26,  1897  : 

S.\i.\LL-Pox— L'mted  States. 

Cases.  Deaths. 

Memphis,  Tenn May  ist  to  31st 7 

:  i2th  to  t9th 

;  lath  CO  i9Ch 

:  12th  to  igth 

:  13th  to  ZQth 

:  i2th  to  igCh 

:  12th  to  19th 

Small-Pox — Foreign. 

London,  England May  30th  to  June  5th. . 

Gibraltar May  31st  to  June  6th 

St.  Petersburg,  Russia May  30th  to  June  sth  . . 

Odessa,  Russia May  jid  to  June  5th 

Moscow.  Russia May  15th  to  22d 

Riode  Janeiro,  Brazil May  8th  to  29th 

Havan.^,  Cuba    June  10th  to  17th 

Sagua  la  Grande,  Cuba June  5th  to  12th 

Warsaw,  Russia May  30th  to  June  5th. . 

Alexandria,  Eg>-pt May  14th  to  20th 

Cairo,  Eg\*pt May  14th  to  20th 

Bombav.  India May  iSth  to  25th 

Paris,  france May  3 1st  to  June  5th  . . 

Osaka  and  Hiogo.  Japan May  15th  to  22d 

Rio  Grande  do  Sul,  Brazil . . .  March  27th  to  May  1st . 

Yokohama,  Tapan May  1st  to  30th s 

Vera  Cruz,  ilcxico June  3d  to  loth o 

Madras.  India Jlay  8th  to  14th o 

Xagasaki.   Japan May  18th  to  25th at 

Calcutta,  India May  8th  to  15th o 

Choler.^. 


Pensacola,  Fla 

New  York,  N.  V 

Gloucester,  Mass 

Cambridge,  Mass 

Brooklyn,  N.  Y 


I  (varioloid). 


± 


I 


5th.. 


Bombay,  India May  iSth 

Calcutta,  India. May  8th  to  jsth 

Yellow  Fever. 

Rio  de  Janeiro,  Brazil. May  8th  to  auth 29 

Havana,  Cuba June  loth  to  i-th 351 

Sagua  la  Grande,  Cuba June  5th  to  12th .  24 

Cardenas,  Cuba June  5th  to  nth 3 

Plague. 
Bombay,  India  May  iSth  to  25th 


Medical  Record 

A  IVeekly    yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  2. 
Whole  No.  1392. 


New  York,   July    10,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riginal  Articles. 

THE    APPENDIX    IX    THE    IXTERVAL. 
XEW    METHOD    OE    STUDYIXG    IT. 

By    ROBERT   ABBE.    M.D.. 


When"  a  surgeon  has  removed  an  appendix  in  the  in- 
terval between  attacks,  he  usually  studies  it,  either  by 
immersing  it  in  alcohol  and  submitting  it  to  section 
after  davs  of  hardening,  or  he  makes  as  careful  an  ex- 
amination of  the  fresh  specimen  as  he  can  by  tning 
to  pass  a  probe  into  it  to  detect  stricture,  or  slicing  it 
from  end  to  end.  Either  method  gives  little  or  no  idea 
of  its  pathological  condition. 

During  the  past  few  months  I  have  adopted  another 
method,  which  has  revealed  a  most  unexpected  and  per- 
fect demonstration  of  the  exact  pathologv"  of  its  dis- 
eased structure  and  which  virtually  shows  the  causes  of 
appendicitis  in  its  several  varieties,  and  demonstrates 
to  the  eye  that  which  gives  an  explanation  of  the  clin- 
ical symptoms  of  chronic  cases. 

Within  a  few  hours  after  removal  the  appendix 
should  be  distended  with  ninet)--five-per-cent.  alcohol, 
through  a  conical  nozzle  of  a  small  syringe  tied 
tightly  into  its  cut  end  by  a  ligature,  which  is  tightened 
as  the  syringe  is  withdrawn  (Fig.  i).  The  distended 
organ  is  then  immersed  twent}--four  hours  or  mere  in 
alcohol  of  the  same  strength.  It  is  then  ready  for  sec- 
tion. If  it  is  sliced  centrally  from  end  to  end,  its 
interior  will  be  a  revelation  to  the  surgeon.  WTiereas 
the  outside  may  preser\-e  the  cylindrical  form  of  a 
normal  appendix,  and  may  give  little  or  no  evidence 
of  inflammation,  the  interior  (if  the  patient  has  had 
one  or  more  attacks)  will  show  one  or  several  of  the 
following  conditions.  These  are  illustrated  by  the 
annexed  cuts,  selected  from  a  considerable  number 
of  appendices  removed  by  me  during  the  past  four 
months : 

ist.  A  faecal  concretion   blocking  the  canal  i  Figs. 

2,3,  4)- 

2d.   Interior  ulcerations  (Figs.  5,  6,  7). 

3d.  Cicatricial  strictures,  often  of  pinhole  aperture 
only  (Figs.  8,  9,  10). 

4th.  Multiple  strictures  with  intermediate  p)ockets, 
containing  suppurating  and  catarrhal  products,  and 
confined  by  greatly  hypertrophied  muscular  and  mu- 
cous coats  (Fig.  11). 

5th.  Partial  obliterating  appendicitis  (Fig.  121, 

These  five  varieties  are  subject  to  infinite  variations. 
Indeed,  I  find  no  t\vo  alike. 

The  condition  resembles  very  much  cicatricial  stric- 
tures of  the  urethra  in  some  cases.  As  far  as  my  study 
goes,  I  am  led  to  assign  three  distinct  causes  which 
may  result  in  the  obstruction  which  leads  to  ultimate 
gangrene,  perforation,  or  rupture  following  distention  : 

First,  a  catarrhal  inflammation  alone  may  be  fol- 
lowed by  stricture,  as  in  the  urethra.  This  form  has 
been  distinctly  classified  by  Dr.  \V.  H.  Draper  as  co- 
incident with  or  a  sequel  of  an  attack  of  grippal  influ- 
enza. In  a  paper  read  by  him  two  years  since,  before 
the  Practitioners'  Society  of  Xew  York,  he  ventured 


the  explanation  of  a  lurking  remnant  of  influenza  in 
the  appendix,  as  a  reasonable  way  of  explaining  the 
increase  of  appendicitis  in  recent  years. 

Second,  a  natural  point  of  flexure  in  the  appendix 
(due  usually  to  an  abbreviated  point  in  its  mesentery) 
leads  to  an  arrest  of  its  faecal  contents,  which,  being 
inspissated,  grow  into  a  concretion.  In  Fig.  2  this 
is  well  shown,  and  opposite  to  it  a  sacculation  is  com- 
mencing, which  does  not  show  on  the  outside,  but 
which  was  ready  to  perforate  at  an  early  opportunit}-. 
This  patient  had  been  treated  for  a  year  for  ovarian 
inflammation,  the  symptoms  being  due  to  the  appen- 
dix, as  shown  by  her  normal  ovarv"  at  operation. 

Third,  an  otherwise  healthy  appendix  may  be  the 
subject  of  circular  ulceration,  from  no  apparent  cause 
other  than  probably  microbic  origin.  These  after 
healing  are  probably  the  cause  of  the  sharp  annular 
strictures  so  often  seen. 

Doubtless  many  of  the  cases  of  spontaneous  cure 
after  frequent  attacks  pass  into  the  stage  represented 
in  Fig.  II  (which  I  find  quite  common),  in  which  an 
extreme  proliferation  of  the  mucous  coat  ultimately 
obliterates  the  canal — as  in  Fig.  12.  But  the  patient 
runs  the  gantlet  of  many  attacks  in  which  distention 
of  the  intermediate  pockets  may  and  often  does  cause 
fatal  results. 

The  final  obliteration  of  the  canal,  moreover,  does 
not  always  rid  the  patient  of  pain.  The  lady  from 
whom  the  specimen  shown  in  Fig.  12  was  removed  had 
for  more  than  a  year  been  disabled  from  household 
duties  by  appendical  pain,  yet  I  found  merely  this  little 
atrophic  organ — which  evidently  in  its  cicatrization 
must  have  included  nerve  filaments  which  disturbed 
her  whole  system. 

In  another  case — that  of  a  child  aged  eleven,  whose 
appendLx  was  almost  the  counterpart  of  the  one  shown 
in  Fig.  II — only  one  distinct  attack  of  appendicitis 
had  ever  been  known,  and  that  occurred  two  weeks 
prior  to  operation;  but  it  was  evident  that  perhaps 
years  had  been  required  to  produce  the  chronic  changes 
shown — and  this  disturbing  organ,  unrecognized,  might 
well  have  been  the  cause  of  the  vet}-  puny,  ill-de- 
veloped condition  of  the  child,  who  scarcely  seemed 
larger  than  a  girl  of  seven  years. 

The  examination  of  the  concretions  is  of  much  in- 
terest. Microscopic  sfady  of  the  unstained  and 
stained  bits  taken  from  the  centres  of  many  of  them 
shows  that  they  are  uniformly  composed  of  the  inspis- 
sated remnants  of  the  contents  of  inflamed  appendices. 
The  pus  cells  make  up  the  greater  part;  exfoliated 
epithelium  cells  nearly  all  of  the  remaining  bulk; 
and,  added  to  these,  a  smaller  part  comjxised  of  minute 
bits  of  meat  fibre  (nearly  digested)  and  starch  cells, 
with  occasional  crystals  of  decomposition — all  welded 
together  by  a  great  variet}-  of  bacterial  debris.  In  the 
presence  of  the  latter  we  see  the  evidence  of  nature's 
effort  to  remove  the  incarcerated  residuum  of  decom- 
position and  inflammation,  and  it  is  possible  that  it 
might  be  accomplished  in  months  or  years  of  waiting. 

But  who  can  afford  to  wait  the  perilous  delay,  when 
the  surgery  of  the  day  offers  safe  and  speedy  relief.' 
It  is  now  possible  by  recently  perfected  methods  to  re 
move  these  dangerous  chronically  inflamed  organ* 
through  a  small  incision  (usually  one  inch  longj,  and 


38 


MEDICAL    RECORD. 


[July  lo,  1897 


Fu,.   5, 


July  lo,  1897] 


MEDICAL    RECORD. 


39 


leave  the  abdominal  wall  practically  normal   both  in 
appearance  and  function. 

The  foregoing  demonstration  of  the  interior  patho- 
logical appearance  of  the  appendices,  which,  when 
seen  at  operation,  often  present  little  or  no  gross  ap- 
pearance of  previous  inflammation  makes  it  the  im- 
perative duty  of  the  surgeon  at  operation  to  remove 
such  an  organ,  whenever  the  clinical  history  of  a  pre- 
vious attack  has  been  clear,  and  to  subject  it  to  this 
method  of  preparation  after  removal. 

In  Fig.  4  we  have  an  excellent  illustration  of  sev- 
eral phases  of  appendicitis.  The  specimen  was  re- 
moved from  a  boy  of  fourteen  years,  who  had  suffered 
four  grave  attacks  during  two  years.  The  operation 
was  done  during  an  interval.  A  concretion  of  the 
usual  type  was  found  incarcerated  in  a  sacculus  at  the 
end  of  the  organ.  The  alcohol  distending  the  speci- 
men passed  through  a  pinhole  opening  in  a  tough  stric- 
ture, and  it  was  thus  hardened  in  just  the  condition 
representing  the  inflammatory  distention  of  an  acute 
attack,  there  having  been  also  a 
stricture  at  the  point  where  the 
appendi.x  was  cut  off. 

One  may  read  the  past  and 
future  history  of  the  trouble  in 
the  pathological  picture  here 
presented.  Perhaps  at  the  next 
acute  congestion  of  this  organ 
the  stricture  would  become 
closed ;  the  sealed  cavity  at  the 
end  would  then  become  an  ab- 
scess, which  in  rupturing  would 
discharge  the  concretion. 

Regarding  these  so-called 
"concretions,"  it  is  not  well 
enough  understood  that,  though 
of  variable  degrees  of  hardness, 
they  are  not  limestones.  Con- 
cerning their  presence,  one  may 
repeat  the  remark  of  the  scientist 
lecturing  on  the  earth's  develop- 
ment, who  said :  "  There  are 
many  to  whom  it  is  still  a  mys- 
tery how  the  apple  came  to  get 
inside  the  dumpling."  The  pres- 
ence of  a  tight  stricture  prevents  the  epithelial 
scales  which  are  constantly  being  shed  by  the  lining 
membrane  from  being  discharged  into  the  colon. 
This  accumulation  is  by  no  means  a  slight  matter,  and 
as  the  laminated  deposit  increases  and  dries  out  it 
becomes  a  source  of  irritation,  which  adds  pus  cells 
to  the  deposit.  Thus  the  absence  of  food  products 
from  the  microscopic  examination  maybe  a  very  strik- 
ing feature  of  the  stone's  composition. 

The  development  of  the  diseased  appendix,  there- 
fore, may  be  said  to  pass  usually  through  these  stages: 

First,  a  catarrhal  inflammation  of  the  lining  mucous 
membrane. 

Second,  irregular  narrowing  of  the  calibre,  with 
hypertrophy  of  the  mucous  and  muscular  coats. 

Third,  strictures. 

Fourth,  imprisoned  food,  desquamated  epithelium, 
and  pus,  forming  concretions. 

Fifth,  obstruction  at  the  stricture,  distention,  perfo- 
ration, abscess. 

This  explanation  will,  I  believe,  be  found  to  include 
the  great  majority  of  cases,  but  does  not  excUtde 
appreciation  of  the  rarer  ones  resulting  from  simple 
flexion  of  the  organ,  or  those  resulting  from  internal 
ulceration. 


The  Latest  Application  of   the  Roentgen  Ray   is 

in  the  tracing  by  Kummel  of  the  course  of   a   Murphy 
button  through  the  intestine. 


TWO    CASES    OF    ERYTHROMELALGIA 
(MITCHELL).' 

Bv   D.    W.    PRENTISS,    M.D., 

WASHINGTON,    D.    C. 

Case  I. — Erythromelalgia    (red    neuralgia,  Mitchell). 

Mrs.  C ,  aged  fifty-eight  years,  neurotic  diathesis^ 

but  has  kept  up  and  worked  hard  in  household  duties 
keeping  a  summer  hotel.  Before  this  attack  she  was. 
"  run  down"  physically.  The  disease  first  began  in  Au- 
gust, 1895,  with  burning  pain  in  the  first  finger  of  the 
left  hand  at  the  angle  of  the  nail  next  the  thumb,  and 
continued  for  two  weeks  in  the  first  finger.  In  the 
F.utumn  of  1896  it  extended  to  the  second  and  third 
fingers,  then  to  the  fourth,  and  finally  to  the  thumb. 

A  large  tender  swelling  dexeloped  at  the  base  of  the 
thumb  and  this  winter  there  is  another  tender  spot  on 
the  back  of  the  hand  over  the  third  and  fourth  meta- 
carpal bones,  sometimes  over  the  abductor  minimi 
digiti  muscle.     The  pain  is  of  a  severe  burning  char- 


Fig.  I.— Shaded  : 


ow  location  of  pain. 


acter,  lasting  sometimes  for  days  together,  with  remis- 
sion, but  it  is  never  entirely  absent  during  the  attack. 

The  ulnar  artery  was  cut  at  the  wrist  several  years 
ago  by  a  broken  lamp  chimney,  and  was  tied.  The 
patient  thought  perhaps  the  nerve  was  injured  and  this 
caused  the  trouble.  This  is  hardly  likely,  however, 
as  the  pain  began  and  has  been  most  severe  on  the 
radial  side.  Stimulating  the  ulnar  nerve  at  the  elbow 
causes  twitching  of  the  third  and  fourth  fingers. 

The  character  of  the  pain  during  an  exacerbation  is 
of  a  severe  burning  nature  and  paroxysmal,  but  the 
parts  are  always  tender  until  the  attacks  pass  off;  then 
there  will  be  freedom  from  pain  until  the  next  attack. 
Previous  treatment  consisted  of  local  applications,  such 
as  chloroform,  tincture  of  iodine,  blistering,  etc.,  and 
general  treatment  in  the  form  of  tonics,  and  especially 
for  dyspepsia. 

Paroxysms  of  pain  were  in  recurring  attacks  from 
three  to  six  weeks  apart.  Pain  was  less  on  lying 
down.  Had  typhoid  fever  thirty  years  ago.  No  his- 
tory of  malaria  or  of  specific  disease. 

October  31,  1896,  she  came  under  my  care  suffer- 
ing from  the  symptoms  just  stated.  The  pain  was 
evidently  very  severe,  as  show-n  by  the  facies.  It  was 
felt  most  severely  in  the  thumb  and  first  and  second 
fingers  of  the  left  hand,  which  were  of  a  purplish  red 
hue  and  swollen. 

The  worst  pain  was  in  the  ball  of  the  left  thumb, 

'  Read  before  the  Association  of  .A.merican  Physicians,  May  4, 
1S97. 


40 


MEDICAL    RECORD. 


[July  lo,  1897 


-which  was  swollen  and  ver}-  tender.  The  general 
health  was  impaired;  heart's  action  weak,  but  other- 
wise normal.  She  was  very  nervous  and  slept  badly 
on  account  of  the  pain.  There  was  also  pain  up  the 
arm  to  the  back  of  the  neck,  described  as  a  drawing 
pain,  extending  also  to  the  ears,  jaws,  and  throat,  with 
a  dull  ache  of  the  head  and  blurring  before  the  eyes. 

No  dizziness,  but  occasional  difficulty  in  walking 
(ataxia).      Knee  jerk  normal. 

Dyspeptic  symptoms  very  marked,  and  aside  from 
the  pain  in  the  hand  the  ailment  which  called  espe- 
cially for  treatment. 

The  character  of  the  indigestion  was  that  common  in 
neurasthenia,  from  innervation,  not  from  organic  stom- 
ach disease.     For  relief  of  pain : 

^  Phenacetin - 

Caffeinae ^ 

In  ten  caps.     S.    Two  every  hour  until  relieved  or  until  six 
are  taken. 
Usually  one  dose  gave  partial  relief. 

She  was  given  nitroglycerin,  one  and  one-half  milli- 
grams, three  times  a  day,  with  tonics  and  bismuth  and 

carefully  regu- 
1  a  t  e  d  diet. 
After  two  weeks 
o  f  this  treat- 
m  e  n  t  without 
benefit,  galvan- 
ism was  applied 
from  the  hand 
to  the  back  of 
the  neck  daily, 
three  minutes  at 
a  time  at  first, 
the  length  of 
appl  i  c  at  ion 
being  gradually 
increased  until 
fifteen  minutes 
\v  a  s  reached. 
This  was  con- 
tinued with  the 
n  i  t  r  o  glycerin 
and  tonics  for 
a  month  with- 
o  u  t  apparent 
relief,  the  dull 
pain  still  con- 
tinuing. It  was  then  stopped  for  a  while,  but  the  pain 
became  worse,  and  galvanism  was  again  resorted  to. 
The  relief,  however,  was  nothing  to  boast  of,  though 
it  appeared  to  be  the  treatment  that  offered  the  best 
hope  of  good  result. 

The  nitroglycerin  was  to  strengthen  the  action  of 
the  weak  heart  and  stimulate  freer  passage  of  the 
blood  through  the  capillary  system  by  dilating  arteri- 
oles. The  constant  current,  with  the  positive  pole  in 
the  hand  and  the  negative  at  the  back  of  the  neck, 
should  relieve  pain  in  the  hand  and  rela.x  spasm. 

The  treatment  here  outlined  was  carried  out  for 
three  months  with  little  or  no  relief.  The  patient 
improved  somewhat  in  general  health,  however,  but 
there  was  no  improvement  of  the  pain  in  the  hand. 
It  fluctuated,  sometimes  better,  sometimes  worse,  until 
Februarj'  18th,  when  the  most  violent  attack  of  all 
occurred,  the  pain  being  of  an  intense  burning  char- 
acter, extending  to  the  whole  hand,  though  more  severe 
at  the  points  previously  indicated,  and  following  up 
the  arm  to  the  shoulder.  The  color  was  purplish-red, 
with  cedematous  swelling  of  parts  most  affected.  The 
last  joint  of  the  middle  finger  was  livid,  as  from  stran- 
gulation, and  appeared  as  though  gangrene  might 
follow. 

During  the  previous  night  she  had  taken  si.x  cap- 
sules of  phenacetin  and  caffeine  (of  the  former  1.20 


Fig.  3. — Erythromelalgia.    Mrs.  C. ,  showing  ch; 
ter  of  the  swelling.     (From  a  photograph. ) 


grams  in  all)  without  relief  of  pain,  but  with  profuse 
sweating.      Holding  up  the  hands  gave  relief. 

A  prescription  containing  extract  of  cannabis  in- 
dica,  0.03  ;  extract  of  belladonna,  o.oi ;  and  salicylate 
of  cinchonidine,  0.20.  to  the  dose,  to  be  taken  every 
three  hours,  was  ordered.  And  at  night  a  hypodermic 
injection  of  morphine  and  atropine  was  given,  which 
secured  relief  and  a  good  night's  rest.  The  pain  re- 
turned with  less  severity  the  following  day. 

The  hypodermic  was  repeated  the  next  night  in 
smaller  dose  with  the  same  good  effects,  and  then  was 
no  longer  needed. 

C.*SE   11.^  Mrs.    A ,   widow,   aged   thirty-seven 

years,  a  neurasthenic,  w  ith  severe  dyspeptic  symptoms. 
No  constitutional  taint,  as  far  as  known.  No  history 
of  malaria.  Pain  in  heels  began  three  or  four  years 
ago,  and  has  recurred  at  inter\-als  of  three  or  four 
months,  the  attacks  lasting  from  two  to  three  weeks. 
During  the  intervals  she  is  comparatively  free  from 
pain,  but  is  never  free  from  dull  aching  which  con- 
stantly reminds  her  of  something  wrong  about  the 
feet,  and  her  shoes  often  feel  too  tight. 

The  paroxysms  seem  to  be  brought  on  by  physical 
exhaustion  or  any  kind  of  strain  on  the  nervous  sys- 
tem, especially  if  she  is  obliged  to  stand  or  walk  more 
than  usual,  as  on  one  occasion  when  called  to  nurse 
her  mother  in  a  prolonged  illness. 

The  pain  begins  as  a  dull  ache  with  a  burning  sen- 
sation, at  first  with  a  feeling  as  of  p>ebbles  under 
the  heels.  As  the  attack  progresses,  the  burning  in- 
creases, and  e.xtends  to  the  soles  of  the  feet  and  up  the 
calves  of  the  legs.  When  the  pain  becomes  severe, 
the  heels  are  red  and  swollen,  and  shoes  cannot  be 
w'om.  As  the  attack  increases  in  severity,  a  peculiar 
sensation  extends  to  the  head,  with  restlessness  and 
hysterical  symptoms  and  a  disposition  to  scream. 
When  asked  as  to  severity  of  pain,  she  said  it  was  so 
bad  that  she  felt  that  she  "just  could  not  stand  it  an- 
other moment." 

Lying  down  relieved,  except  when  at  the  worst ;  then 
the  restlessness  forced  her  out  of  bed,  and  rubbing 
would  give  temporary  relief.  Cold  relieved.  Putting 
the  feet  out  from  under  the  cover  was  grateful.  At 
my  suggestion  cold  water  was  tried  with  benefit. 
.\ttacks  were  more  frequent  and  worse  in  summer  than 
in  winter,  and  also  when  the  feet  got  warm  in  bed. 

She  is  drowsy  and  dizzy  much  of  the  time  and  fre- 
quently shows  an  ataxic  gait. 

Treatment  has  been  directed  to  the  general  con- 
dition— the  dyspeptic  and  neurasthenic  symptoms. 
She  has  an  idiosyncrasy  against  strychnine,  the  latter 
causing  dizziness  and  vertigo.  No  disease  of  special 
organs  discoverable. 

This  disease  is  undoubtedly  a  rare  one,  and  fortu- 
nately so,  for,  as  Dr.  Mitchell  says,  treatment  is  almost 
unavailing,  though  patients  often  go  on  for  years  with- 
out becoming  worse.  It  occurs  almost  always  in  the 
feet.  Out  of  sixteen  cases  reported  by  Dr.  Weir  Mitch- 
ell '  in  only  one  was  it  in  the  hands  alone,  and  in  two 
the  feet  and  hands  were  both  affected.  In  all  of  the 
others  it  was  in  the  feet.  He  gives  as  the  character- 
istic symptoms  redness,  intense  burning  pain,  and  at 
the  beginning  rise  of  temperature,  but  later  fall  of 
temperature,  with  probably  inflammation  of  the  nerves 
affected.  It  usually  commences  in  die  ball  of  the 
foot,  or  the  heel,  or  the  great  toe,  and  extends  to  the 
sole  and  dorsum.  The  disease  is  more  common  in 
men  than  in  women.  Tweh'e  out  of  sixteen  cases,  re- 
ported by  Dr.  Mitchell,  were  in  men,  and  of  twenty- 
seven  cases  referred  to  by  Lannois  only  two  were  in 
women. 

Another  peculiarity  of  this  affection  is  that  it  is  ag- 
gravated by  heat  and  relieved  by  cold.     In  Dr.  Mitch- 

'  .American  lournal  of  the  Medical  .Sciences,  vol.  l.i.\vi.,  iSjS. 


July  lo.  1897] 


MEDICAL    RECORD. 


41 


ell's  cases  relief  came  from  lying  down,  although  in  a 
case  treated  by  prolonged  rest,  while  the  patient  was 
perfectly  comfortable  in  bed,  the  pain  returned  in  full 
force  when  she  got  up  and  walked. 

In  the  first  case  here  reported,  cold  does  not  relieve 
the  pain  and  but  little  relief  accompanies  the  recum- 
bent posture:  probably  because  it  is  in  the  hands  in- 
stead of  in  the  feet.  The  causes  of  the  disease  are 
obscure.  It  seems  to  follow  a  depressed  state  of  the 
nen'ous  system,  neglected  neurasthenia,  long  standing 
on  the  feet,  long  marches,  as  of  soldiers,  retie.x  irrita- 
tion, especially  of  the  male  urethra.  But  the  disease 
is  so  rare  and  these  reputed  causes  so  common  that 
such  reference  is  unsatisfactory. 

.\s  to  diagnosis  in  erythronielalgia,  according  to  Dr. 
Mitchell,  there  is  in  a  well  marked  case  no  other  dis- 
ease or  group  of  symptoms  with  which  it  can  be  con- 
founded. There  are  many  painful  affections  of  the 
feet  and  hands,  such  as  the  effects  of  gout,  rheumatism, 
sprain  from  flatfoot,  nodes  from  syphilis,  etc.,  but  none 
in  which  e.xists  the  train  of  symptoms  found  here:  and 
that  the  disease  is  rare  is  evident  from  the  small  num- 
ber of  reported  cases 

As  to  pathology,  it  is  obscure.  Some  of  Dr.  Mitch- 
ell's cases  ended  in  cerebro-spinal  disease. 

The  "red  neuralgia"  expresses  only  a  symptom. 

The  pathology  of  these  cases  is  involved  in  doubt. 
Erj-thromelalgia  is  classed  among  the  vasomotor  dis- 
eases. 

The  pain   either  precedes  or  is  simultaneous  with 

the  redness  and  swelling.     In  the  case  of  Mrs.  C 

they  came  on  at  the  same  time. 

In  the  second  case  pain  preceded  the  redness.  This 
would  seem  to  indicate  that  the  sensory  fibres  of  the 
ner\-es  were  first  affected,  the  vasomotor  becoming  in- 
volved secondarily  as  a  result. 

This  also  was  borne  out  by  the  severe  pain  on  pres- 
sure at  points  most  affected.  With  the  redness  and 
swelling,  however,  the  pain  is  greatly  aggravated. 

The  diseases  to  which  it  is  most  nearly  allied  are 
angio-neurotic  oedema  and  Raynaud's  disease. 

In  the  former  there  are  three  forms  described — the 
pale  form  (neuro-lymphangioma"),  due  to  dilatation  of 
the  lymphatics  and  of  paretic  origin :  the  red  form,  due 
to  angio-paralysis;  and  the  dark-red  purplish  form, 
caused,  according  to  Eskridge,'  by  spasm  of  the  arte- 
rioles, which  "  checks  the  7is  a  Urgo  of  the  arterial 
current  in  propelling  the  current  forward,  and  spasm 
of  the  small  veins,  which  may  force  the  blood  back- 
ward into  the  arterioles." 

Some  such  explanation  as  this  may  apply  to  er\- 
thromelalgia,  but  is  altogether  hypothetical. 

Angio-neurotic  oedema  is  supposed  to  be  a  form  of 
luticaria,  "the  greater  urticaria" — a  functional  ner- 
vous disease  caused  by  indigestion  or  transient  ner- 
vous excitement.  In  some  of  the  cases  which  I  have 
seen  it  has  been  attributed  to  spider  bite,  I  need  not 
say  without  cause.  The  element  of  pain  is  secondar}' 
in  angio-neurotic  ordema  and  not  important. 

This  disease  cannot  be  confounded  with  the  one 
under  consideration.  The  diagnosis  from  Raynaud's 
disease,  though  still  more  marked,  deser\-es  special 
notice,  since  many  of  the  cases  of  erA'thromelalgia  re- 
ported by  Mitchell  were  pronounced  by  high  authority 
to  be  cases  of  Raynaud's  disease."  The  two  diseases 
in  many  respects  are  the  opposite  of  each  other.  This 
is  perhaps  best  shown  in  the  comparison  in  parallel 
columns  given  by  Lannois.' 

This  comparative  statement  should  make  it  clear 
that  erj-thromelalgia  and  Raynaud's  disease  are  dis- 
tinctly separated. 

'  Wilson's  "  .Applied  Therapeutics,"  p.  9S1. 
■Osier's  "  Practice  of  Medicine,"  p.  962  (1892). 
'.\rticle,    "  Er)thromelalgia."    iSSo,    p.    71;    Weir   Mitchell, 
"Clinical  Lessons  on  Nervous  Diseases,"  1897,  p.  179. 


Local  asphyxia  (Raj.naud^.  Erytkromelalgia  (Mite  full). 

Se.x.  four-fifths  females.  In  twentj'-seven  cases  two  were 

females. 
Begins  with  ischemia.  Little  or  no  difference  in  color, 

until  foot  hangs  down  in  up- 
right  posture,    when  it   be- 
comes rose  red. 
.\ffected   part   becomes  blood-       Arteries   throb   and   parts   be- 
less  and   white.      In  certain  come  of  a  dusky  red  or  vio- 
cases     there     is    the    deep.  laceous  in  tint, 
dusky  congestion    of  a  cya- 
nosed  part,  with  or  without 
gangrene. 
Pain  may  be  absent  or  acute.       Pain    usually    present;    worse 
and  comes  and  goes;    has  no           when  part  hangs  down  or  is 
relation    to   position.      May           pressed  upon.      In  bad  cases 
precede  local  asphyxia.                     more  or  less  at  all  times. 
Unaffected    by    seasons.        In       Worse    in    summer  and    from 
many  cases  all  the  5)-mptoms          heat.     Eased  by  cold, 
can  be  brought  on  by  cold. 
.\naesthesia  to  touch.                         Sensation  of  all  kind  preser\ed. 
.\nalgesia.                                          Hyperalgesia. 
Temperature  much  lowered  and       Temperature      greatly     above 
unaltered  by  posture.                         normal.     Dependency  causes 
in   some   cases    increase    of 
heat,   in   others    lowering  of 
temperature. 
Gangrene    local    and    limited;       Xo  gangrene;  asymmetrical, 
likely  to  be  symmetrical. 

Two  Other  conditions  are  mentioned  as  belonging 
to  diseases  of  the  vasomotor  system,  namely  adiposis 
dolorosa  (Dercum's  disease)  and  acromegaly,  both  at- 
tended by  peculiar  changes  of  nutrition  and  without 
doubt  arising  from  disease  of  the  central  nenous 
system. 

In  acromegaly  "  there  were  found  enlarged  pituitarj' 
body  with  enlarged  sella  turcica,  persistence  of  the 
thymus  gland,  and  hypertrophy  of  the  fibres  and  glands 
of  the  vasomotor  system."  ' 

These  facts  are  mentioned  as  having  a  bearing  upon 
the  plausibilit}-  of  er)-thromelalgia  being  essentially 
a  central  disease. 

There  is  the  more  reason  for  this  hypothesis  in  the 
fact  that  a  number  of  the  cases  reported  developed 
into  well-marked  disease  of  the  cerebro-spinal  axis 
and  ran  their  course  to  a  fatal  result  (Mitchell).  Dr. 
Mitchell  was  disposed  at  first  to  this  opinion,  but  in 
his  recent  work  "  he  "  inclines  rather  to  some  form  of 
that  new  clinical  perple.xity,  peripheral  neuritis." 

The  action  of  ergot  (ergotism)  in  producing  gan- 
grene of  the  extremities  is  of  interest  as  bearing  upon 
the  general  question  of  causation  of  vasomotor  affec- 
tions by  central  disease.  Ergot  acts  upon  the  vaso- 
motor centres  in  small  doses  by  stimulating;  in  large 
doses  by  depressing.^  Dr.  H.  C.  Wood  mentions  a 
case'  of  fatal  ergot  poisoning  in  which  there  were  gas- 
tric irritation,  thirst,  diarrhoea,  burning  pain  in  the 
feet,  and  convulsions. 

The  principal  vasomotor  centre  is  in  the  medulla 
oblongata,  between  the  corpora  quadrigemina  and  cal- 
amus scriptorius.'  .\lso  in  the  spinal  cord,  are  second- 
ary centres  in  the  gray  matter  as  far  down  as  the 
liunbar  vertebrae.' 

Dr.  Schenk,  in  an  article  published  recently  in  the 
Medicinische  Fresse,  states  that  the  disease  is  no  doubt 
due  to  vasomotor  disturbance  consequent  on  an  ascend- 
ing degeneration  in  the  posterior  column  of  the  cord. 
Woodnut  has  also  described  a  case  of  errthromelalgia 
due  to  myelitis." 

Referring  again  to  Mitchell's  "  Clinical  Lessons,"  he 
says:  "At  the  time  I  wrote  (1878)  I  should,  if  driven 
to  be  positive  in  statement,  have  inclined  toward  con- 
sidering this  malady  as  due  to  some  form  of  spinal 
disorder.     But  at  present  the  reasonable  explanations 

'  "-American  Te.\t-book  of  Applied  Therapeutics."  Wilson, 
1S96,  p.  gSS. 

•  "Clinical  Lessons."  1397.  p.  i3o. 

'H.  C.  Wood's  "  Therapeutics."  *  Loc.  cit. 

°  Ludwig  and  Thiry.  Owsjannkow  and  Dittmar:  Erb's  "Dis- 
eases of  the  Medulla  Oblongata." 

•Goltz.  Vulpian.  1.  c.  'London  Lancet. 


42 


MEDICAL    RETORD. 


[July  lo,  1897 


incline  rather  toward  some  form  of  tliat  new  clinical 
perplexity,  peripheral  neuritis."  ' 

In  Case  LVIII.  (of  "  Clinical  Lessons,"  not  the  fifty- 
eighth  case  of  erythromelalgva)  the  disease  was  the 
result  of  an  injury,  a  stone  falling  on  the  foot.  This 
case  is  reported  in  great  detail  and  serves  to  strengthen 
the  theory  of  peripheral  neuritis,  from  the  fact  that  it 
was  caused  by  (or  followed)  a  local  injury.  Dr. 
Mitchell  further  goes  on  to  say:  "  I  use  the  word  neu- 
ritis, nerve-end  neuritis,  with  more  or  less  doubt. 
Some  such  distinct  affection  of  the  smaller  nerves 
does  seem  to  me  probable,  but  whether  it  is  conges- 
tion, neuritis,  or  some  other  of  the  undescribed  changes 
in  the  lesser  nerves  or  in  the  ultimate  nerve  plates, 
we  may  not  as  yet  describe  with  certainty." 

Again''  "neuritis  is  becoming  a  sad  puzzle.  We 
may  have  it  with  paresis  and  little  pain;  we  may  have 
it  without  notable  paresis  and  horrible  pain.  It  ex- 
ists with  or  without  notable  myositis. 

"Again,  it  may  give  rise  to  causalgia,  joint  trou- 
bles, and  alterations  of  nails  and  hair.  It  may  fail  to 
disturb  nutrition  or  greatly  to  alter  local  heat.  And 
lastly,  if  erythromelalgia  be  a  neuritis,  it  may  cause 
pain  and  flushing,  and  to  these,  increased  enormously 
by  dependency  of  the  part,  may  add  such  a  rise  of  tem- 
perature as  is  rarely  seen  in  acute  local  inflammation." 

Dr.  Mitchell  continues  to  discuss  the  possibility  of 
the  existence  of  neuritis  of  such  a  character  as  to  sin- 
gle out  individual  elements  in  a  nerve  containing 
fibres  of  sensation,  motion,  nutrition,  and  vasal  con- 
trol, affecting  some  and  not  others.  Such  a  hypothe- 
sis seems  untenable. 

In  Case  LVIII.,  previously  referred  to,  the  excised 
portions  of  the  musculo-cutaneous  and  internal  saphe- 
nous nerves  were  examined  microscopically  and  found 
"absolutely  normal." 

To  sum  up  the  pathology,  then,  we  have  the  choice 
between : 

1.  Disease  of  the  central  nervous  system. 

2.  Peripheral  neuritis  affecting  principally  or  only 
the  smaller  nerves  or  nerve  endings. 

If  the  former,  we  should  expect  the  disease  to  be 
located  in  the  medulla  oblongata  between  the  corpora 
quadrigemina  and  calamus  scriptorius,  or  in  the  pos- 
terior segment  of  the  spinal  cord  as  far  down  as  the 
lumbar  vertebrae. 

The  central  theory  seems  the  more  plausible,  but  at 
this  time  is  purely  hypothetical,  there  being  no  dis- 
sections to  support  it. 

The  opinion  of  peripheral  neuritis  of  a  peculiar 
character  is  given  a  show  of  plausibility  from  two 
cases,  reported  by  Dr.  Mitchell,  which  followed  local 
injury.  In  both  of  these  nerves  were  exsected,  and 
the  nerve  trunks  thus  removed  found  normal.  This 
fact  would  locate  the  neuritis  in  the  nerve  extremities. 

We  will  close  this  report  by  a  reference  to  treatment, 
which  unfortunately  can  be  shortly  disposed  of.  Thus 
far  curative  treatment  has  been  of  no  avail,  except  in 
one  case,  by  surgical  interference. 

The  treatment  divides  itself  into  three  indications: 

1.  That  of  the  general  health,  neurasthenia,  nervous 
dyspepsia,  and  hysteria  especially. 

2.  The  relief  of  pain.  For  this  purpose  phenace- 
tin  protected  by  caffeine  seems  of  first  value.  Can- 
nabis indica  and  belladonna  in  the  first  of  the  present 
cases  proved  useless,  as  did  also  the  phenacetin  in 
the  most  violent  paroxysms. 

During  the  latter,  subcutaneous  injection  of  mor- 
phine is  imperative,  but  the  objection  to  its  frequent 
use  is  obvious.  Rest  in  bed  and  cold  applications  are 
palliative.  Wendel  reports  a  case  cured  by  liquor 
acidi  arseniosi,  together  witli  general  treatment." 

3.  Surgical  treatment.     Exsection  or  stretching  of 

'  Loc.  cit.  p.  180.  -  Loc.  cit. 

'New  York  Meuicai.  Kkcord,  1S90,  vol.  x.xxviii.,  p.  545. 


the  ner\es  was  contemplated  in  the  first  case,  but  there 
being  no  precedent  for  it,  and  fearing  serious  nutri- 
tive changes,  it  was  not  determined  on.  This  was 
before  seeing  Dr.  Mitchell's  "  Clinical  Lessons,"  1897, 
in  which  he  reports  two  cases  thus  treated,  the  first 
one  with  success  in  relieving  and  curing  the  patient. 
In  the  second  case,  however,  gangrene,  resulting 
fatally,  followed.  The  operation,  the  first  of  its  kind 
in  this  disease,  I  quote  from  Dr.  Mitchell's  book:' 

"Dr.  Keen  operated  on  April  loth.  He  exsected 
two  and  one-half  inches  of  the  musculo-cutaneous 
nerve,  and  the  same  length  of  two  branches  of  the  in- 
ternal saphenous.  The  two  end  branches  (plantar)  of 
the  posterior  tibial  nerve  were  stretched  at  the  inter- 
nal malleolus  with  a  traction  of  fifteen  pounds  thrice 
used.  The  result  next  day  was  remarkable.  There 
was  almost  immediate  relief.  The  foot  could  be 
squeezed,  pinched,  or  pricked  without  pain.  Anaes- 
ih'jsia  was  not  so  extensive  as  we  were  led  to  expect  it 
might  be.  Temperature  the  day  following  the  opera- 
tion: right,  95*^^  F. :  left,  93.5^  F. ;  mouth,  99.5^  F. 
(It  was  the  right  foot  that  was  operated  upon.)     On 


show  location  of  pain. 


the  right  clonus  was  still  present  and  knee-jerk  was 
still  extensive.  The  wound  healed  in  a  few  days.  The 
4th  of  May  the  patient  was  able  to  walk  on  crutches. 
Clonus  had  disappeared  and  reflexes  were  no  longer  ex- 
aggerated. There  was  still  some  Hushing  when  the  foot 
was  pendent,  but  no  pain  or  hyperassthesia.  When 
discharged  May  6th,  he  could  walk  well,  but  was 
ordered  to  continue  the  use  of  crutches  as  a  measure 
of  precaution  and  had  also  a  bandage  applied  daily. 

"  Dr.  Kyle  reports  culture  of  blood  and  nerves  ob- 
tained at  the  operation  as  yielding   purely   negative 

results.   .  .  .  June   7th,   S is   reported   well   and 

walking  easily  without  crutches.  Six  months  later  he 
was  at  his  work  as  a  stone  mason  and  entirely  free 
from  pain." 

Thus  it  appears  that  at  least  one  was  cured  by  sur- 
gical procedure.  The  second  case  thus  treated "  was 
more  unfortunate.  I  will  only  mention  the  operation 
and  result. 

Operation,  April  12,  1894,  by  Dr.  T.  G.  Morton. 
Four  inches  of  the  musculo-cutaneous  nerve  and  five 
inches  of  the  internal  saphenous  excised.  The  pos- 
terior tibial  behind  the  internal  malleolus  stretched 
with  force  of  twenty-eight  pounds.  On  the  fifth  day 
gangrene  developed.  A  week  later  amputation  was 
performed,  with  death  on  the  operating-table.     Com- 

'  Loc.  cit..  p.  192. 

-Case  LIX.  of  "Clinical  Lessons." 


July  lo,  1897] 


MEDICAL    RECORD. 


43 


meriting  on  this  case,  Dr.  Mitchell  says:  "As  to  oper- 
ative relief  I  think  that  in  the  future  I  should  stretch 
all  the  nerves  and  leave  resection  of  their  trunks  to  be 
resorted  to  if  milder  means  gave  no  fortunate  results."  ' 
In  conclusion  I  append  titles  of  bibliography  of 
ervthromelalgia  taken  from  the  card  catalogue  of  the 
library  of  the  surgeon-general's  office.  These  titles 
do  not  appear  in  the  large  published  "  Index  Cata- 
logue." The  disease  had  not  been  differentiated  at 
the  time  the  volume  of  the  "  Index  Catalogue"  in 
which  they  would  have  appeared  was  compiled. 

BIBLIOGR.\PHY. 

Mitchell.  S.  W. :  Phila.  Med.  Times,  1872-73,  vol.  iii.,  pp. 
81  and  113.      Am.  Jour.  Med.  Sciences,  July,  1S7S. 

Fischer,  E.:  Ein  Fall  von  Erj-thromelalgie.  .St.  Petersb. 
raed.  Wchnschr.,  1895,  N.  F.,  xii.,  70. 

Senator,  H.;  Ueber  Er)-thromelalgie.  Svo.  Berlin,  1S92. 
Refr.  from  Berl.  klin.  Wchnschr.,  1S92,  No.  45. 

De  Sanctis,  G.:  Contribute  alia  casistica  dell'  eritromelalgia. 
Gli  Incurabili,  Napoli,   1S95,  .x. ,  144-156. 

Begnone,  A. :  Contributo  alio  studio  clinico  dell'  eritromelalgia. 
Gazz.  d.  Osp.,  Milano,  1894,  .xv.,   1.122-1,124. 

Nolen.  W.:  Erythromelalgie.  Nederl.  Tijdschrift  voorOenees- 
kunde,  1894,  2.  2.,  xxx.,  pt.   2,  521-529. 

Christiani,  A. :  Due  casi  di  eritromelalgia  (paralisi  vasomotrice 
deir  extremiti)  in  alienati  di  mente.  Riforma  Med.,  Napoli, 
1894.  X.,  pt.  4,  4-8. 

Charles.  M.:  Sur  un  cas  d'er)'thromelalgie.  Pratique  Med., 
Par.,  1892,  vi.,  207. 

Wendel,  .A.  V.;  Erythromelalgia.  Medical  Record,  N.  Y., 
1890,  xxxviii.,  545. 

Lombroso,  C,  and  Ottolenghi,  S. :  Eritromelalgia  in  una  truf- 
fatrice.     Arch    di  Psichiat.,  etc.,  Torino,  1SS8,  ix.,  593-596- 

Berbez;  Note  sur  un  cas  d'erythromelalgie.  Bull.  Soc.  Clin. 
de  Par.,  1S87-88,  xi. ,  1-4. 

Mitchell,  S.  W.  1  A  Case  of  Erythromelalgia.  Polyclinic, 
Phila.,  1884-85,  ii.,  no.  Jour.  Nerv.  and  Ment.  Dis. ,  N.  V.. 
1884,  N.  S..  ix.,  638-641. 

Auche  and  Lespinasse;  Sur  un  cas  d'erythromelalgie  ou  nevrose 
congestive  des  extremites.  Rev.  de  Med.  de  Par.,  1889,  ix., 
1,049-1,055. 

Eulenburg:  Ueber  Erythromelalgie.  Deutsche  med.  Wchnschr. , 
Leipz.  u.  Berl.,   1893,  xix.,  1.325-1,329. 

Staub,  A. :  Ueber  Erythromelalgie.  Monatsh.  f.  prakt.  Der- 
mal.,  Hamb.,   1894,  xix.,  10-14. 

Montschnit,  A.  •  Seuch.  Eritromelalgie.  Yuzhno-russk.  med. 
Gaz.,  Odessa,   1894,  iii.,  97-99. 

Lewin,  G.,  and  Benda,  T.:  Ueber  Erythromelalgie;  kritische 
Studie  auf  Grund  der  eigenen  und  der  von  den  Autoren  publicirten 
Falle.  Berl.  klin.  Wchnschr.,  1894,  xxxi.,  53-5'6,  87-90,  117- 
119,  144-146. 

Dunges:  Ein  Fall  von  Erythromelalgie.  Prakt.  Arzt,  Wetzlar, 
1893,  x.xxiv.,  217-219. 

Mitchell,  S.  \V. :  Erjthromelalgia;  Red  Neuralgia  of  the  Ex- 
tremities; Vasomotor  Paralysis  of  the  Extremities;  Terminal  Neu- 
ritis (?).      Medical  News,  Phila.,  1893,  Ixiii.,  197-202. 

Haslund.  Et.  Tilfselde  af  Erytromelagi.  Hosp.  Tid. , 
Vyxbent,  1893,  4.  2.,  i.,  649. 

Gerhard t,  C. :  Ueber  Erythromelalgie.  Berl.  klin.  Wchnschr., 
1892,  xxix.,   1,125. 

Senator,  H.:  Ueber  Erythromelalgie.  Berl.  klin.  Wchnschr. , 
1892,  xxix.,   1,127-1,129. 

Bernhardt,  M.:  Ein  Fall  von  Erythromelalgie.  Berl.  klin. 
Wchnschr.,   1892,  xxix..  1,129. 

Gerhardt,  C. :  Ueber  Erythromelalgie.  Deutsche  med. 
Wchnschr.,  Leipz.  u.  Berl..  1892,  xviii.,  865. 

Bernhardt,  M. :  Ein  Fall  von  Erj-thromelalgie.  Berl.  klin. 
Wchnschr.,  1892,  xxix.,  1,129. 

Staub:  Ueber  Erythromelalgie.  Verhandl.  d.  deutsch. 
Gesellsch.,  Wien  u.  Leipz.,  1894,  iv.,  429-434. 

Dehio,  K.:  Ueber  Erythromelalgie.  Berl.  klin.  Wchnschr., 
1896,  xxxiii.,  817-821. 

Pajor,  S.:  .■Kz  Erythromelalgarol.  Gyogyaszat,  Budapest, 
189;.  xxxv. ,  607-610. 

Dehio,  K. :  Ob  Eritromelalgii.  Russk.  Arct.  Patol.,  klin.  Med. 
i  Bakteriol.,  St.   Petersb..  l8g6.  i.,  145-157. 

Wendel,  M.  D.,  Newark,  N.  J.:  Medical  Record,  1S90, 
x.xxviii. ,  ';4i. 

Mitchell,  S.  W. .  Polyclinic,  Phila.,  1884-1885,9.  no.  Rec- 
ord of  case  (hospital)  as  kept  by  notes  at  time;  very  explicit  and 
instructive;   severe  case,  no  treatment  mentioned:  one  page. 

Mitchell,  S.  W.t  Jour.  Nerv.  and  Ment.  Dis.,  N.  V,,  1SS4. 
etc.     This  article  identical  with  the  above. 

Mitchell,  S.  W.:   Medical  News.  1893. 

Mitchell,  S.  W.  :  Clinical  Lessons  on  Nervous  Disease.  Lea 
Bros.  iN:  Co.,   1897. 

'  Loc.  cit.,  p.  204. 


A  STUDY  OF  DIET  AND  NUTRITION  IN 
RELATION  TO  CONTAGIOUS  DISEASES 
AND  TO  THOSE  DUE  TO  DISTURBED 
DIGESTION    AND    ASSIMILATION. 

By    E.    PALTER,    M.D., 

The  question  of  diet  dates  back  for  centuries.  Since 
man  acquired  the  power  of  thought  and  analysis,  die- 
tetics have  entered  a  great  deal  into  his  consideration. 
In  spite  of  this,  we  are  no  nearer  now  to  a  solution  of 
this  vital  question  than  we  were  centuries  ago,  the 
views  held  with  regard  to  it  being  in  certain  regards 
diametrically  opposed  to  each  other,  each  side  strenu- 
ously advocating  a  certain  regimen  in  health  and  in 
disease,  with  apparent  equal  show  of  logic  and  reason. 

It  is  quite  interesting  briefly  to  review  the  opinions 
e.xpressed  by  the  great  masters  of  the  human  mind  and 
thought  with  regard  to  the  kind  of  diet  most  suitable 
for  man.  The  Bible  lays  down  strict  rules  with  regard 
to  dietetics.  Though  it  does  not  forbid  animal  food, 
yet  it  eliminates  the  greatest  part,  and  allows  only  cer- 
tain ruminants  and  some  birds.  The  prohibition  of 
cooking  the  oft'spring  in  its  mother's  milk  is  probably 
more  on  account  of  cruelty  than  for  hygienic  reasons. 

Among  the  lay  writers  we  find  that  as  far  back  as 
570  B.C.  Pythagoras  was  against  flesh  eating.  Plato 
followed  in  his  footsteps  and  vvas  a  vegetarian,  or  at 
least  tried  to  be  as  strictly  vegetarian  as  circumstances 
would  allow.  Hippocrates,  in  his  writings  on  regimen, 
favored  a  vegetable  diet  as  the  one  conducive  to  good 
health,  and  so  did  Esculapius.  The  same  views  were 
held  by  Ovid  about  50  B.C.  Diogenes  and  Plutarch 
held  that  only  ferocious  animals  ate  flesh.  The  early 
Christians  taught  a  moderate  diet,  and  deprecated  the 
practice  of  flesh  eating.  Cheyne,  a  celebrated  English 
physician  in  1671,  maintained  that  it  was  possible  to 
avoid  and  to  cure  diseases  by  adhering  to  a  vegetable 
diet.  Pope  inclined  toward  a  vegetable  diet.  Linn^ 
said  that  this  species  of  food  was  the  most  suitable 
for  man.  Dr.  Lambe,  in  1765,  held  the  same  views. 
Buffon,  Lamartine,  Schopenhaur,  and  Rousseau  were 
against  flesh  eating.  Liebig  states  the  following: 
"  A  bear  was  peaceful  and  tame  as  long  as  it  was 
fed  on  bread,  and  a  hog  after  partaking  of  flesh  be- 
came ferocious  and  ready  to  attack  a  human  being." 
.A  German  philosopher  once  said:  ''Der  Mensch  ist 
was  er  isst."  And  this  probably  applies  to  other  ani- 
mals as  well  as  to  man. 

When  we  come  to  regimen  in  pathological  conditions 
opinions  differ  widely.  In  typhoid  fever  the  diet  is  a 
stumbling-block  to  therapeutists.  Bauer  recommends 
beef  tea  in  this  disease;  some  again  advise  milk. 
Dujardin-Beaumetz  advises  preparations  of  fruits  and 
farinacea.  He  also  recommends  a  vegetable  diet  in 
certain  forms  of  dyspepsia,  whereas  most  physicians 
find  that  starchy  food,  in  general,  is  not  well  borne  by 
dyspeptics. 

In  view  of  the  above-mentioned  array  of  great  names 
against  an  animal  diet  in  health,  and  the  conflicting 
views  of  modern  therapeutists  with  regard  to  the  die- 
tary in  disease,  the  question  arises:  "  Have  we  the  right 
to  slaughter  animals  and  be  guilty  of  a  wilful  and 
wanton  act  of  cruelty,  when  it  is  not  only  without  ben- 
efit, but  even  injurious  to  our  health  and  morality?" 

If  we  can  demonstrate  that  an  animal  diet  is  neces- 
sary for  man,  then  we  are  fully  justified  in  doing  so 
from  the  principles  of  self-preservation.  But,  unfor- 
tunately, modern  science  can  help  us  very  little  in  this 
regard.  Chemically  the  animal  and  vegetable  proteids 
do  not  differ.  Physiologically  they  also  seem  to  act 
alike.  Foster  has  the  following:  "  Vegetable  proteids 
appear  to  undergo  in  the  alimentary  canal  the  same 
changes  as  do  animal  proteids,  and  the  effect  seems 
to  be  the  same  on  the  body." 


44 


MEDICAL    RECORD. 


[July  lo,  1897 


W'e  must  therefore  consider  the  question  from  an 
etiological  standpoint,  and  see  what  influence  diet  has 
in  preventing  and  causing  diseases;  and  this  is  a 
most  difficult  problem,  since  such  complex  phenomena 
are  capable  of  different  interpretations. 

At  first  it  is  necessar}'  briefly  to  consider  the  food 
stuffs  and  their  ultimate  functions  in  the  economy  as 
far  as  they  can  be  ascertained  in  the  present  state  of 
physiology. 

The  food  stufts  are  as  follows:  Proteids,  carbo- 
hydrates, fats,  and  fruits. 

All  agree  that  all  of  the  above-named  food  stuffs 
must  enter  in  various  proportions  into  the  dietary  of 
man  to  maintain  health  and  life.  The  question  is 
only  as  to  whether  vegetable  proteids  alone  are  suffi- 
cient, or  there  must  be  also  animal  proteids. 

The  physiolog)-  of  digestion,  the  changes  which  the 
various  food  stuffs  undergo  in  the  various  parts  of  the 
alinientar)- canal  are,  with  the  exception  of  some  minor 
points,  prett}'  well  established. 

When  we  come,  however,  to  absorption  of  the  vari- 
ous food  stuffs  and  their  ultimate  functions  in  the 
economy,  we  are  groping  in  the  dark.  According  to 
Foster,  the  fats  are  absorbed  mainly  by  the  lacteals 
and  pass  through  the  thoracic  duct  into  the  venous  sys- 
tem. The  sugars  are  absorbed  mostly  by  the  capilla- 
ries of  the  villi,  through  the  intestinal  epithelium,  and 
thus  enter  into  the  portal  vein.  The  absorption  of  the 
proteids  or  peptones  is  less  understood  and  more  diffi- 
cult to  follow.  Foster  inclines  to  the  view  that  they 
are  absorbed  mostly  by  the  capillaries,  but  as  soon  as 
they  pass  into  the  blood  all  trace  of  them  is  lost.  The 
difficult}-  attending  this  subject  is  apparent. 

Some  claim  that  the  leucocytes  are  mostly  concerned 
in  the  absorption  of  fats  and  proteids.  Though  this 
view  is  discredited  by  physiologists,  yet  it  is  admitted 
that  the  leucocytes  do  ingest  in  themselves  particles 
of  food  stuffs  and  other  foreign  bodies  reaching  the 
system.  With  regard  to  the  ultimate  uses  made  by 
the  body  of  the  various  food  stuffs,  the  trend  of  opin- 
ion is  that  the  proteids  are  mainly  concerned  in  tissue 
metabolism,  and  are  excreted  by  the  kidneys  as  urea 
in  carnivorous  animals  and  mostly  as  uric  acid  in 
birds  and  reptiles. 

The  proteids,  however,  when  partaken  of  above  a 
certain  mark,  may  by  themselves  constitute  the  luxus 
consumption,  and  an  animal  may  gain  flesh.  The  fats 
and  carbohydrates  are  mainly  concerned  in  supplying 
the  body's  energ}'  in  its  various  forms.  They  are  also 
stored  up  as  adipose  tissue,  as  a  reserve  to  be  drawn 
on  whenever  necessar)'. 

This  is  a  brief  summary  of  the  food  stuffs  and  their 
destinations,  which  it  will  be  necessarj-  to  bear  in 
mind  in  the  further  discussion. 

It  would  seem,  then,  that  a  man  may  live  on  a  veg- 
etable diet  and  yet  continue  to  be  in  apparent  good 
health  and  capable  of  performing  prodigious  amounts 
of  labor,  as  is  proven  by  the  European,  especially  the 
Russian,  peasantr}-,  as  well  as  by  the  Asiatic  laborers, 
namely,  Japanese  and  Chinese,  who,  though  feeding 
almost  exclusively  on  vegetables,  yet  are  capable  of 
performing  continuous  fatiguing  labor;  and  this  is  the 
case  with  the  equine  race.  The  opinion  generally 
held  that  the  Esquimau  and  other  Northern  races  are 
stunted  in  growth  and  physically  weak  on  account  of 
their  animal  diet  is  lacking  of  proof,  for  there  are 
many  other  factors  obtaining  there,  so  that  it  is  hard 
to  say  what  pari  diet  plays  under  those  circum- 
stances. 

When,  however,  we  come  to  the  clinical  history  as 
well  as  the  morbid  changes  in  a  vast  number  of  dis- 
eases, there  seems  to  be  ver)-  little  difficult)'  in  tracing 
them  to  errors  in  diet,  and  the  animal  diet  seems  to 
exert  a  powerful  influence  on  the  economy  by  enabling 
it  to  resist  a  great  number  of  diseases.     There  are. 


however,  affections  which  can  be  traced  to  errors  of 
either  the  one  or  the  other  kind  of  diet,  as  I  will  trj- 
to  demonstrate. 

Gout  is  a  disease  par  excellence  which  is  due  to  an 
excess  of  concentrated  vegetable  principles  partaken  of 
by  man.  In  the  ancient  times  gout  was  prevalent 
mainly  in  the  upper  classes.  Since  the  introduction 
of  malted  liquors,  gout  is  quite  prevalent  among  the 
poorer  classes.  The  morbid  changes  in  gout  are  an  in- 
crease of  urates,  especially  that  of  sodium,  in  the  blood 
and  tissues.  Now,  uric  acid  in  the  forni  of  urates  is 
the  characteristic  in  the  urine  of  birds,  which  feed 
mo.stly  on  grain,  vegetable  proteids.  Foster  denies 
that  uric  acid  is  due  to  deficient  oxidation,  and  be- 
lieves that  it  is  an  independent  product,  as  urea.  And 
this  cause  of  gout  is  in  accord  with  the  clinical  expe- 
rience in  treatment.  Sydenham  and  others  thought 
that  farinaceous  food  was  suitable  in  gout)'  conditions, 
laboring  under  the  impression  that  it  is  due  to  an  ex- 
cess of  animal  food.  But  the  fact  is,  it  is  due  to  an 
excess  of  vegetable  principles,  and  this  is  in  accord 
with  Dr.  \\'illiam  H.  Draper's  experience,'  who  says 
that  albuminous  food  is  most  acceptable  to  gout)'  pa- 
tients, and  farinacea  should  be  excluded  as  much  as 
in  diabetes. 

Rheumatism  is  a  disease  which  is  generally  consid- 
ered as  being  more  or  less  allied  to  gout,  and  is  clas- 
sified with  the  latter.  There  is  sufficient  evidence  that 
it  is  a  disease  due  to  disturbance  of  nutrition,  such  a 
theor)'  having  been  advanced  already  by  some.  The 
microbic  theor)'  of  rheumatism  advanced  by  Heuters 
and  others  does  not  preclude  the  fact  that  the  main 
predisposing  cause  of  this  disease  is  a  disproportion- 
ate supply  and  demand  of  the  various  food  stuffs. 
Prout's  lactic-acid  theor)'  was  modified  by  the  sarco- 
lactic-acid  one;  but  both  acids  belong  chemically  to 
the  same  group,  and  both  are  derivatives  of  the  carbo- 
hydrates. The  carbohydrates,  according  to  Foster,  are 
mostly  made  use  of  by  the  muscles  for  kinetic  energ)-, 
and  are  given  off  as  C0„  by  them.  The  uric  metabo- 
lism is  but  slightly  increased  during  active  muscular 
exercise. - 

Xow  when  the  supply  of  the  carbohydrates  is  greater 
than  the  demand,  there  results  a  disturbance  of  nutri- 
tion which  manifests  itself  as  a  symptom  in  the  acids 
of  the  perspiration;  the  economy  is  thus  susceptible 
to  a  disease  which  is  brought  about  by  exciting  causes. 
Loomis  says:  "  Scrofula,  phthisis,  and  cancerous  affec- 
tions so  often  precede  rheumatism  that  a  connection 
between  them  cannot  be  denied.'' 

Phthisis  I  will  discuss  later,  and  propose  to  prove 
that  the  eft'ect  of  diet  on  it  is  admitted  by  most. 

A  remarkable  fact  about  rheumatism  is  that  suck- 
ling infants  are  almost  exempt  from  it.  Rauchfuss 
found  only  two  cases  of  it  among  fifteen  thousand  suck- 
ling infants,  and  such  is  the  experience  of  other  obser\'- 
ers.  If  we  take  into  consideration  that  the  sugar  of 
the  milk  is  proportionate  to  the  demands  of  the  infant, 
milk  being  its  natural  food,  the  exemption  of  infants 
from  rheumatism  is  explicable. 

Dr.  Percival,  in  1754,  wrote  about  the  benefits 
derived  from  cod-liver  oil  by  fishermen  suffering 
from  rheumatism.  Dr.  W.  H.  Thomson  recommends 
it  highly  in  this  affection,  though  from  another  stand- 
point, for  according  to  him  it  is  a  skin  disease.  But 
the  fact  remains  that  cod-liver  oil  is  beneficial  in 
many  cases  of  rheumatism,  and  this  helps  to  confirm 
the  view  that  it  is  a  disease  due  to  disturbance  of  nu- 
trition, and  the  disturbance  is  caused  by  the  dispro- 
portionate supply  of  the  food  stuffs. 

Hence  both  rheumatism  and  gout  are  diseases  caused 
mainly  by  an  excess  of  carbohydrates,  but  whereas  in 
the  latter  the  mischief  is  due  mainly  to  the  nitrogenous 

'  Pepper's  "  System  of  Medicine,"  vol.  ii..   "  Gout." 
•  Foster,  ^  530. 


July  lo,  1897] 


MEDICAL    RECORD. 


45 


elements,  in  the  former  it  is  due  to  the  non-nitroge- 
nous elements.' 

Diabetes  mellitus  is  a  disease  that  has  been  known 
for  centuries,  and  has  been  widely  investigated  of  late ; 
)-et  its  etiolog}-  and  patholog)'  have  not  been  satisfac- 
torily explained  so  far.  Aside  from  the  nervous  ori- 
gin of  diabetes,  which  was  established  by  older  ob- 
servers, recent  observers  have  laid  great  stress  on 
pancreatic  diabetes. 

Dr.  Kaufman,  in  an  e.xhaustive  article  on  this  sub- 
ject,^ tries  to  explain  the  relation  of  the  pancreas  to 
the  sugar  formation  of  the  blood.  He  inclines  to  the 
theory  that  the  pancreas  has,  per  sc,  aside  from  its  se- 
cretion, an  intrinsic  control  over  the  sugar  ferments  of 
the  blood,  and  that  when  this  intrinsic  power  is  gone 
there  is  an  excess  of  sugar  formation.  He  cannot  ex- 
plain, however,  what  this  power  is,  and  how  it  acts. 
Pathologically  we  find  a  hyperaemia  of  the  liver  in  di- 
abetes, and  sometimes  it  is  in  a  hypertrophic  and  cir- 
rhotic state.  Writers  try  to  explain  the  hyperemia  as 
being  due  to  affection  of  the  vasomotor  nerves  con- 
trolling the  liver.  Yet  competent  observers  have 
failed  to  demonstrate  any  nerve  lesions  in  many  cases 
of  diabetes.^  The  fact  is  that  though  hyperaemia  will 
follow  vasomotor  paralysis,  it  does  not  necessarily  fol- 
low that  the  cause  should  originate  in  the  nerves,  as 
many  local  irritants  will  cause  hyperaemia  as  well.  It 
is  highly  plausible  to  assume  that  diabetes  is  in  most 
cases  a  dietetic  disease,  and  it  is  akin  to  dyspepsia. 

Now,  what  is  dyspepsia.'  It  is  an  affection  charac- 
terized by  digestive  disturbances  of  one  or  several 
parts  of  the  alimentary  canal.  It  is  hardly  necessary 
to  say  that  unsuitable  diet  and  irregularity'  of  meals 
are  the  most  prolific  causes  of  dyspepsia.  It  may  also 
be  caused,  as  a  rule  temporarily,  disappearing  as  soon 
as  the  cause  is  removed,  by  worr)-,  anxiet)-,  fright,  etc. ; 
in  fact,  by  nervous  affections.  Digestive  disturbances 
may  be  gastric,  or  pancreatic  and  hepatic,  or  all  forms 
combined.  Gastric  disturbances  not  being  an  essen- 
tial part  of  the  subject  under  discussion,  I  will  not 
dwell  upon  it. 

Dyspeptics  are  variously  affected  by  the  several  ar- 
ticles of  diet.  A  great  many  cannot  easily  digest 
fats  and  carbohydrates.  In  such,  a  fatty  meal  causes 
pyrosis,  malaise,  and  semisolid  fatt}^  mucous  stools: 
carbohydrates  cause  excessive  fermentation  with  bor- 
borygmi.  Dyspeptics  also  generally  suffer  from  a  tor- 
pid liver,  with  its  concomitant,  piles.  Physiologically 
it  is  prett}'  well  established  that  fats  are  prepared  for 
absorption  by  the  pancreatic  secretion,  and  seconda- 
rily by  the  hepatic.  The  carbohydrates  undergo  amy- 
lolytic  changes  through  the  saliva,  and  to  a  greater  ex- 
tent through  the  pancreatic  juice,  whereby  they  are 
transformed  mostly  into  maltose,  which  is  absorbed 
by  the  liver  and  is  stored  up  as  glycogen,  having  un- 
dergone a  retrogressive  change.  Now,  since  owing  to 
dietetic  errors  the  fat- transforming  power  of  the  pan- 
creas and  the  liver  is  often  impaired,  there  is  no  rea- 
son why  the  same  should  not  happen  with  the  carbo- 
hydrates. It  is  a  general  law  that  when  the  function 
of  an  organ  is  impaired  it  should  not  be  overtaxed. 
But  dyspeptics,  as  a  rule,  and  also  diabetics,  seek  ad- 
vice very  late;  and  meanwhile  the  liver  and  the  pan- 
creas, having  undergone  excessive  strain  while  in  a 
weak  condition,  become  hvperaemic — which,  by  the 
way,  occurs  after  each  meal,  especially  a  mixed  diet, 
even  in  normal  conditions — and  this  hyperaemia  leads 
to  hypertrophy,  which  may  result  in  cell  proliferation 
and  cirrhosis. 

Clinically  it  is  a  fact  that  diabetic  patients  improve 

'  .\n  e.xcess  of  the  carbohydrates  and  the  fermented  and  malted 
liquors  is  probably  also  the  cause  of  delaying  the  metabolism 
and  elimination  of  the  animal  proteids,  which,  accumulating  in 
the  system,  help  to  bring  about  the  gouty  condition. 

*  Archives  de  physiologic  normale  et  pathologique,  1895,  serie  7. 

^Pepper's  "System  of  .Medicine,"  vol.  ii.,   "Diabetes." 


on  a  proteid  diet.  Some  glycosuria  will  still  appear, 
for  proteids  are  also  split  up  into  sugar.  Physiologi- 
cally the  pancreas,  as  I  have  said,  helps  the  saliva  to 
transform  the  carbohydrates  into  maltose,  and  this  is 
absorbed  by  the  liver  and  stored  up  as  glycogen. 
When,  however,  the  amylolytic  power  of  the  pancreas 
is  weakened,  at  the  same  time  the  absorbing  power  of 
the  liver  is  taxed  to  the  utmost,  for  it  has  to  absorb 
material  not  well  prepared;  the  pathological  changes 
of  diabetes  will  follow,  the  liver  becoming  altogether 
hors  de  combat,  and  all  the  glucose  formed  by  the  sali- 
va, and  which  is  probably  formed  by  fermentation  even 
in  normal  conditions  to  a  slight  extent  in  the  other 
parts  of  the  economy,  is  discharged  through  the  urine. 
The  amount  of  carbohydrates  consumed  by  an  indi- 
vidual is  not  a  criterion,  for  what  may  be  ver\-  small 
for  one  may  be  excessive  and  deleterious  to  another. 
The  digesting  and  absorbing  power,  as  well  as  the 
amount  utilized  for  kinetic  energy,  of  each  individual 
must  be  taken  into  consideration. 

According  to  Dickinson,  diabetes  is  more  prevalent 
in  the  agricultural  districts  of  England.  This  fact, 
if  true,  is  significant,  for  agriculturists  live  mostly  on 
fats  and  carbohydrates. 

In  short,  then,  diabetes  is  akin  to  fatt}-  dyspepsia. 
The  same  pathological  changes  in  the  pancreas  and 
liver  are  apt  to  occur  in  the  latter  after  a  time  as  in 
the  former. 

Tuberculosis  is  a  disease  which  greatly  occupies  the 
attention  of  the  medical  profession  at  present.  Since 
the  discover}'  by  Koch  of  the  tubercle  bacilli,  in  the 
last  decade,  the  trend  of  opinion  of  the  profession  is 
to  regard  it  of  microbic  origin  and  to  consider  it 
among  the  contagious  diseases. 

Now  there  are  remarkable  phenomena  with  regard 
to  the  microbic  diseases,  which  so  far  either  have  not 
been  explained  at  all,  or  are  explained  by  the  vague  term 
idiosyncrasy;  namely,  that  certain  ages  and  localities 
have  a  relatively  greater  immunit)'  than  others.  As  I 
intend  to  dwell  on  each  disease  separately,  I  shall  con- 
sider these  points  in  connection  w'ith  each. 

With  regard  to  tuberculosis,  we  find  that  infants 
under  one  year  and  the  aged  are  less  subject  to  it  than 
older  children  and  adults.  Dr.  A.  Jacobi,'  in  summa- 
rizing this  subject,  says :  "  Thus  tuberculosis  is  com- 
paratively rare  under  one  year,  undoubtedly  because 
of  the  comparatively  few  opportunities  for  infection." 
It  is.  however,  quite  incomprehensible  why  infants 
have  fewer  opportunities  for  infection  than  children 
and  adults.  Infants  under  one  year  are  comparatively 
under  worse  hygienic  conditions,  for  they  are  kept 
more  confined  and  enjoy  less  the  benefit  of  fresh  air. 
In  the  poor  districts  of  the  larger  cities,  infants  are 
kept  for  days  and  occasionally  for  weeks  without  get- 
ting an  airing,  confined  in  un ventilated,  overcrowded, 
unclean  rooms  of  tenement  houses,  which  are  gener- 
ally the  starting-points  of  all  contagious  diseases, 
as  is  well  known  to  ever)'  observer.  The  schoolhouse 
and  the  factory  are  certainly  under  more  favorable  hy- 
gienic conditions  than  is  the  tenement  house.  Infants 
of  tuberculous  parents,  or  in  a  family  in  which  there 
is  a  tuberculous  member,  are  thus  constantly  inhaling 
the  dried  tuberculous  sputum  under  conditions  most 
favorable  for  the  development  of  tuberculosis.  The 
period  of  incubation  of  tuberculosis  is  admitted  not  to 
extend  over  a  year,  but  is  counted  by  weeks,  so  that 
tuberculosis  should  be  at  least  as  prevalent  among 
infants,  if  not  more  so,  as  among  children  and  adults. 

When  we  come  to  old  age,  we  also  notice  tliat  tuber- 
culosis, as  well  as  most  contagious  diseases,  are  com- 
paratively rarer  then  than  at  the  other  periods  of  life.' 

'  Keating's  "  Cyclopiedia  of  Diseases  of  Children,  '  vol.  ii., 
p.  168, 

-Pepper's  "System  of  Medicine,"  vol.  iii..  "Tuberculosis, 
Phthisis." 


46 


MEDICAL    RECORD. 


[July  lo,  1897 


All  this  is  explained  by  the  obscure  term  of  "di- 
athesis."' Geographically  three  are  certain  places 
where  tuberculosis  is  ver)^  rare ;  such  are  the  Faroe 
Islands  and  Iceland.'  Ur.  S.  Kneeland,"  who  trav- 
elled in  those  islands,  says  about  the  inhabitants  that 
they  are  very  filthy,  seldom  taking  a  bath,  so  that  ver- 
min are  seen  crawling  on  their  bodies.  They  live  in 
crowded,  ill-smelling,  ill-ventilated  rooms,  huddled  up 
together.  This  description  is  in  accord  with  the  state- 
ments of  other  travellers. 

Now,  supposing  that  climate  exerts  a  favorable  in- 
fluence, it  ought  to  be  offset  by  the  unfavorable  hy- 
gienic surroundings,  so  that  tuberculosis  ought  to  be 
as  prevalent  there  as  in  other  places,  for  who  would 
think  of  sending  people  for  their  health  to  the  Adiron- 
dacks,  and  locate  them  in  overcrowded,  ill-ventilated 
quarters?  Would  not  the  Adirondacks  become  as  bad 
as  a  tenement  house?  It  is  also  stated  that  tuberculo- 
sis is  less  frequent  in  the  navy  and  more  prevalent  in 
the  army,  and  at  the  same  time  we  notice  that  witli 
regard  to  scurvy,  a  dietetic  disease  par  excellence,  the 
opposite  prevails.  Here,  then,  we  have  groups  of  in- 
dividuals who  are  little  susceptible  to  tuberculosis. 
There  is  one  characteristic  common  to  all  of  them,  and 
that  is  their  diet. 

Infants  feed  exclusively  on  animal  diet,  milk.  Old 
people,  being  unable  to  masticate  bulky  carbohydrates, 
live  largely  on  milk,  animal  proteids— the  latter,  on 
account  of  being  required  in  small  bulk,  are  most 
suitable  to  that  age — and  fats.  The  Faroese  and  the 
Icelanders,  because  of  the  aridit)'  of  their  land,  live 
mostly  on  animal  diet.  The  same  is  the  case  with 
sailors,  who  consume  little  of  the  vegetables  and  live 
on  preserved  flesh  and  fats,  and  hence  the  prevalence 
of  scurvy  among  them.  And  this  is  in  accord  with 
what  we  know  of  the  animal  kingdom.  We  find  that 
the  dog  and  the  cat  are  less  susceptible  to  this  disease 
than  other  animals.  With  regard  to  animals  kept  in 
confinement,  Mr.  Smith,  director  of  the  Central  Park 
Menagerie,  kindly  volunteered  to  me  the  statement 
that  the  carnivorous  animals  sutler  ver}'  little  from 
contagious  diseases,  but,  on  the  other  hand,  they  suffer 
and  die  from  intestinal  troubles,  are  subjected  to 
cramps,  and  convulsions,  and  kidney  troubles;  and 
this  is  precisely  what  happens  with  suckling  infants. 

Diphtheria  is  a  disease  of  childhood /<?/■  ^--vrt'/Avw, 
and  yet  infants  under  one  year  are  very  seldom  the 
subjectSjOf  it,  though  unquestionably  cases  are  occa- 
sionally met  with  at  that  age.  Oertel  says,"  with  re- 
gard to  diphtheria:  "In  the  first  half-year  the  infant 
organism  seems  to  be  not  at  all  susceptible  to  the  dis- 
ease." Jacobi''  explains  this  on  the  supposition  that 
the  abundant  acid  secretion  of  the  mouth  of  infants 
after  three  months  of  life  washes  away  the  diphtheritic 
infection,  and  does  not  give  it  a  chance  to  gain  a  foot- 
hold in  the  buccal  cavity. 

But  the  fact  is  that,  the  normal  buccal  secretion  be- 
ing alkaline,'  the  acid  secretion  shows  an  abnormal 
unhealthy  condition  of  the  mucosa  of  the  cavit}',  and 
is  generally  found  in  connection  with  the  various 
forms  of  stomatitis,  especially  the  parasitic  variety  due 
to  the  saccharomyces  albican.s. 

Now  it  is  quite  logical,  and  in  accord  with  what  we 
know  about  etiology  in  general,  to  expect  that  with  an 
acid  secretion,  when  the  mucous  membranes  are  more 
or  less  unsound,  diphtheria  should  set  in  sooner  than 
otherwise.  The  acid  secretion  is  certainly  valueless 
as  an  antiseptic,  for,  if  it  were  such,  how  would  the 
above-mentioned  parasites  thrive  in  it? 

'  Solis  Cohen:  Hare's  "  System  of  Therapeutics,"  "Tubercu- 
losis. "  '^  "  An  American  in  Iceland." 

'  Keating's  "  Cyclop.xdia  of  Diseases  of  Children,"  vol.  i., 
p.  595. 

■*  Pepper's  "  System  of  Medicine,"  vol.  i.,  "  Diphtheria.' 

'  Keating's  "  Cyclopa;dia  of  Diseases  of  Children."  vol.  ii., 
p.  959- 


r)ld  age  is  as  little  susceptible  to  diphtheria  as  in- 
fancy, and  finally  we  find  that  the  various  parasitic 
affections  of  the  buccal  and  nasal  cavities,  such  as 
glanders,  diphtheria,  and  scarlatinal  sore  throat,  are 
most  common  among  the  herbivorae  and  verj-  rare 
among  the  carnivorae.  We  find,  furthermore,  the  state- 
ment made'  that  diphtheria  is  more  fatal  in  the  rural 
than  in  the  urban  districts.  Now  reasonably  we 
should  expect  the  reverse,  since  even  the  poorest  of  the 
rural  inhabitants  are  under  better  hygienic  conditions, 
as  far  as  fresh  air,  spacious  quarters,  and  cleanliness 
go,  than  the  poorer  classes  of  the  tenement  districts  of 
cities.  We  cannot  ascribe  the  fatalit}-  to  lack  of 
skilled  physicians,  for  we  find  that  the  mortalit)' 
of  this  disease  is  less  among  the  Indians  than  the 
whites,  and  is  also  less  among  the  blacks— and  In- 
dians and  blacks,  as  a  rule,  care  ver)-  little  about  se- 
curing the  best  medical  skill;  yet  they  seem  to  be 
better  off. 

If  we  should  consider  diet  as  a  great  factor  in  this 
disease,  we  can  explain  the  above-mentioned  puzzling 
facts.  With  regard  to  Indians  and  blacks,  the  race 
influences  probably  play  also  important  parts,  besides 
diet. 

Measles  is  another  disease  remarkable  for  its  greater 
prevalence  at  certain  ages  and  in  certain  localities. 
Thus,  statistics  show  that  it  is  also  comparatively  rare 
under  one  year,  very  seldom  attacks  the  old,  and  is 
more  fatal  in  rural  districts." 

With  regard  to  small-pox  the  same  statement  is 
made,  though  we  should  expect  the  contrar}',  a  priori, 
since  infants  are  seldom  vaccinated  in  the  first  half- 
year  of  life,  so  that  small-pox  should  be  mo.st  preva- 
lent at  that  age. 

The  same  is  said  with  regard  to  t)phus,  typhoid, 
and  malarial  fevers.  Though  cases  of  each  undoubt- 
edly occur  in  infants,  yet  they  are  less  subject  to 
these  diseases  than  individuals  of  other  ages. 

Thus  we  find  a  number  of  diseases  to  which  groups 
of  individuals,  who  a  priori  we  might  suppose  should 
be  more  susceptible,  are  really  less  so,  and  vice  rersa. 
No  plausible  explanation  that  could  stand  a  moment's 
criticism  has  so  far  been  advanced.  Since  we  find, 
however,  that  in  those  groups  of  individuals  the  only 
marked  distinguishing  feature  to  their  advantage  or 
disadvantage  is  their  diet,  diet  then  must  be  the  great 
factor  responsible  for  greater  or  lesser  susceptibilit)' 
to  certain  diseases  in  certain  groups  of  individuals  of 
the  same  races.  I  say«of  the  same  races,  because,  race 
with  relation  to  diseases  being  a  subject  for  study  in 
itself,  I  do  not  wish  to  broach  it  here. 

With  regard  to  tuberculosis  and  diphtheria,  the  in- 
fluence of  diet  on  them  is  more  evident  than  with  re- 
gard to  the  other  contagious  diseases.  The  specific 
pathogenic  micro-organisms  of  these  two  diseases  have 
been  more  satisfactorily  established  than  those  of  the 
other  contagious  diseases,  and  the  advantages  of  the 
albuminates  and  fats  seem  to  consist  in  enabling  the 
system  to  overcome  the  pathogenic  micro-orsranisms. 
Physiologically  we  know  that  albuminates,  as  well  as 
all  the  proteids  in  general,  whether  animal  or  vegeta- 
ble— and  the  former  seem  the  more  so — hasten  tissue 
metalwlisni,  and  thus  cause  cell  stimulation,  /.<•.,  they 
hasten  the  disintegration  of  the  old  ones  and  cause 
their  withdrawal  from  the  economy,  and  these  are  re- 
placed by  new,  more  vigorous,  and  healthy  ones.  In 
addition  to  this,  the  albuminates  and  digestible  fats 
seem  to  be  the  most  suitable  nourishment  for  the  leu- 
cocytes. .\s  I  said  above,  some  claim  that  the  leuco- 
cytes are  responsible  for  the  absorption  of  the  fats  and 
proteids  from   the   alimentary  canal.     This   view  is 

'  Keating's  "  Cyclop.-vdia  of  Diseases  of  Children,"  vol.  i..  p. 
142. 

•  Keating's  "  Cyclop.x'dia  of  Diseases  of  Children,  vol.  i., 
"  Measles." 


July  lo,  1897] 


MEDICAL    RECORD. 


47 


discredited  by  Foster;  but  even  he  admits  that  the 
leucoc}tes  ingesc  within  themselves  great  quantities 
of  these  food  stuffs.  The  same  cannot  be  said  of  the 
carbohydrates;  no  observer  claims  that  they  are  ab- 
sorbed to  any  extent  by  the  leucoc}tes.  The  theor)-  of 
the  phagocjtic  properties  of  the  leucocytes  is  gaining 
more  and  more  ground.  They  seem  not  to  take  any 
important  part  in  the  constant  physiological  processes. 
and  are  placed  mainly  as  the  guardians  against  foreign 
intrusion.  A  great  excess  of  them  is  detrimental  to 
the  economy,  and  hence  the  disease  leukaemia.  To 
use  a  simile,  they  can  be  compared  to  a  standing  army 
of  a  commonwealth.  In  case  of  war  the  standing  army 
is  increased,  and  the  same  is  the  case  with  the  leuco- 
cj'tes,  which  increase  in  number  in  many  communica- 
ble diseases.  When,  however,  the  army  is  increased 
disproportionately  to  the  inhabitants  and  to  the  means 
of  the  commonwealth,  the  result  is  total  ruin  of  the 
latter  as  well  as  of  the  former. 

The  case  is  different  with  the  workers  and  producers 
of  a  communitj-.  A  general  increase  of  them  is  always 
beneficial.  So  with  the  tissues  performing  constant 
physiological  function,  a  general  increase  of  them  is 
beneficial.  There  is  no  disease  produced  by  an  in- 
crease of  red  blood  corpuscles.  The  slight  inconven- 
ience from  the  so-called  "  full-bloodedness"  can  easily 
be  overcome,  and  cannot  be  called  a  disease.  The 
same  with  general  muscular  and  nervous  development. 
The  adipose  tissue,  however,  being  kept  merely  as  a 
reserve,  and  being  called  upon  only  at  certain  times 
for  supplies,  is  injurious  by  its  e.xcessive  develop- 
ment. 

Pathologically  we  notice  that  in  most  contagious 
diseases  the  initial  lesion  is  found  somewhere  in  the 
lymphatic  system,  and  is  propagated  to  the  s)-stem 
dirough  the  lymphatics.  The  tubercle  of  tuberculosis 
consists,  according  to  Ziegler,'  principally  of  emi- 
grated leucocytes.  According  to  Virchow  and  U'ood- 
ward,  the  tubercle  always  takes  its  origin  in  a 
lymphatic  vessel.  In  diphtheria  the  membrane, 
according  to  most  authorities,  is  formed  by  the  migra- 
tion of  leucocytes,  together  with  the  fibrin  derived 
from  the  transuded  plasma."  There  being  prettj-  often 
a  glandular  enlargement  in  this  disease,  it  shows  that 
the  lymphatics  carry  the  contagion  to  the  body.  In 
typhoid  fever  we  find  the  characteristic  lesions  in  the 
intestinal  follicles  or  Peyer's  patches.  In  malarial 
fever  the  spleen  is  greatly  affected;  and  in  bubonic 
plague — a  disease,  by  the  way,  affecting  mostly  the 
Asiatics,  who  generally  live  on  carbohydrates— the 
glands  are  also  primarily  affected. 

How  do  we  explain  these  phenomena?  We  can 
easily  explain  them  by  the  fact  that  the  leucocytes, 
which  are  constantly  wandering  all  over  the  system,  as 
soon  as  they  meet  with  the  pathogenic  micro-organisms 
engage  in  a  deadly  struggle  with  them,  and  as  soon 
as  the  first  ranks  succumb  others  advance  to  take  their 
place  in  the  struggle,  and  the  outcome  of  this  struggle 
is  the  survival  of  the  fittest.  Since  the  leucocytes  are 
most  abundant  in  the  lymphatics,  they  are  apt  to  carr\- 
at  first  some  of  the  micro-organisms  over  there  sooner 
than  anywhere  else,  and  hence  the  lymphatics  suffer 
first  and  most.  To  use  again  the  above  simile,  in 
a  country  invaded  by  a  foreign  army  the  signs  of  bat- 
tle, whichever  side  wins,  are  mostly  seen  and  felt  in 
places  occupied  by  numerous  bodies  of  the  defending 
army. 

The  action  of  antitoxin  in  diphtheria  is  stated  by 
some'  to  be  due  to  cell  stimulation,  thus  enabling  the 
leucocytes  successfully  to  struggle  with  the  bacilli. 
This  view  seems  more  plausible  than  the  one  claiming 
it  to  be  a  chemical  antidote.     Thus  antitoxin  would 

'  Pepper's  "  System  of  Medicine."  vol.  iii.,  "  Tuberculosis." 
'A.  Jacobi:   "Diphtheria,"  in  Pepper's  "System."  vol.  i. 
'"Practical  Therapeutics,"  Foster,  "Antitoxin." 


be  considered  as  an  albuminoid,  and  act  simply  as  a 
food  for  strengthening  the  leucocytes. 

Modern  physiolog)-  teaches  that  the  peptones  are 
formed  by  a  process  of  fermentation  due  to  the  de- 
velopment of  micro-organisms.  Experiments  have 
shown'  that  the  gastric  and  pancreatic  juices  are  not 
germicides,  and  the  result  of  the  experiments  is  in 
accord  with  the  teachings  of  physiolog}- :  if  the  intes- 
tinal juices  were  germicidal,  digestion  could  not  go 
on,  for  there  could  be  no  fermentation  due  to  the  de- 
velopment of  micro-organisms.  It  would  also  seem 
reasonable  to  suppose  that  the  leucoc}tes  normally 
take  care  of  the  walls  of  the  stomach  and  intestine, 
destroying  the  micro-organisms  which  are  apt  to  adhere 
to  them.  The  peristaltic  movement  also  prevents  the 
food  normally  from  adhering  ver)-  long  to  the  walls,  so 
that  the  main  process  of  digestion  is  always  driven 
away  from  the  periphery-  toward  the  centre.  This  ex- 
planation seems  more  plausible  than  those  hitherto  ad- 
vanced as  to  why  the  walls  of  the  stomach  and  intestine 
do  not  digest  themselves.  The  explanation  that  the 
alkalinit}'  of  the  blood  neutralizes  the  acidit}-  of  the 
gastric  juice  does  not  hold  good  for  the  pancreatic  di- 
gestion, which  is  alkaline.      How"  is  this  neutralized? 

We  find  the  following  statement  made :  '  '"It  must 
not  be  forgotten  that  album  i  noses  are  produced  by 
microbes,  and  these  soluble  products  are  capable  when 
injected  into  an  animal  of  producing  immunity-  against 
certain  diseases."  I  must  add  that  the  same  author- 
it}"  considers  the  peptones  as  a  tox-albuminose.^ 

It  is  further  stated  that  "  Hankin  has  shown  that  an 
albuminose  is  capable  of  protecting  animals  against 
splenic  fever."'  '  This  brings  me  also  to  speak  of  the 
action  of  quinine  in  malarial  fever. 

The  therapeutic  action  of  quinine  in  malaria,  as 
well  in  fact  as  the  therapeutic  action  of  all  drugs  in 
all  diseases,  is  rather  empirical  and  obscure.  It  is 
claimed  by  some'  that  quinine  acts  per  se  as  a  germi- 
cide, destroying  the  plasmodia  in  the  blood.  But, 
since  the  plasmodia  are  endowed  with  amoeboid  move- 
ment, they  most  assuredly  penetrate  into  the  most  in- 
tricate recesses  of  the  system,  like  the  leucocytes,  and, 
admitting  that  the  germicidal  action  of  quinine  de- 
stroys the  Plasmodia,  the  whole  system  must  be  liter- 
ally saturated  with  it  in  a  sufficiently  strong  solution. 
Would  not  this  be  detrimental  to  the  economy?  Be- 
sides, if  quinine  acted  as  an  antiseptic,  other  antisep- 
tics should  also  be  more  or  less  efficient. 

It  would  seem  plausible  to  suppose  that  quinine  acts 
like  antitoxin  by  cell  stimulation.  We  find  ^  that 
quinine  increases  the  number  of  leucoc}tes.  We  find 
also"  that  in  malaria  the  leucoc}-tes  are  increased  in 
nimjber;  quinine  thus  helps  the  increase  of  the  leuco- 
cytes, to  overcome  the  swarms  of  plasmodia  which  in- 
vade the  system.  Quinine  has  been  administered 
empirically  in  all  z}-motic  diseases,  not  simply  as  an 
antipyretic,  but  with  the  vague  idea  that  it  somehow 
helps  along. 

Many  cases  of  chronic  malaria  do  not  yield  to  qui- 
nine, but  are  successfully  treated  bv  arsenic  and 
str}-chnine,  drugs  usually  administered  as  so-called 
tonics  and  not  as  germicides. 

In  addition  to  the  physiological  actions  of  animal 
diet,  the  fact  is  that  it  is  generally  submitted  to  high 
temperature  before  it  is  used,  and  is  rendered  more 
aseptic  than  vegetables,  which  are  eaten  either  raw  or 
cold.     It  is  yet  imdecided  '  whether  or  not  by  eating  the 

'  "  La  Cellule,"  1892. 

'  Landois  and  Stirling's  "  Physiology,"  §  g.  '  Ibid. ,  §  429. 

*  Feser's  experiments  on  rats  have  proven  that  those  fed  oa 
flesh  do  not  readily  contract  anthrax  by  inoculation,  while  those 
fed  on  vegetables  invariably  succumb. 

'Hare's  "System  of  Therapeutics,"  "Malaria." 

'  Landois  and  Stirling's  "  Physiology." 

'  Loomis'  "  Practice  of  Medicine,"  "Malaria." 

'See  Wilson's  "Elements of  Hygiene,"  "Diet." 


48 


MEDICAL    RECORD. 


[July  lo,  1897 


flesh  of  infected  animals  the  infection  will  be  carried 
to  the  system.  But  to  err  on  the  safe  side,  in  almost 
all  civilized  communities  animals  are  examined  by 
experts  before  being  used  for  human  food. 

The  foregoing  may  be  summed  up  as  follows:  Ani- 
mal diet  is  a  good  prophylaxis  against  the  microbic 
diseases.  Rheumatism,  gout,  dyspepsia,  and  diabetes 
are  less  apt  to  follow  an  animal  diet,  these  being  dis- 
eases par  excellence  due  to  vegetable  products.  On  the 
other  hand,  however,  animal  diet  is  a  prolific  cause  of 
acute  gastro-intestinal  trouble — witness  the  carnivo- 
rous animals  and  suckling  infants,  who  die  mostly  from 
intestinal  complaints;  it  is  also  a  cause  of  general 
convulsions  and  epilepsy.  Cases  of  ptomain  poison- 
ing due  to  an  animal  diet  are  reported.'  The  noxious 
effects  of  an  animal  diet,  when  partaken  of  injudi- 
ciously, are  thus  evident  and  palpable,  and  can  in  most 
cases  be  easily  traced  to  the  cause,  and  that  is  why  it 
is  looked  upon  by  many  people  with  such  suspicion. 

The  carbohydrates,  on  the  other  hand,  are  wolves  in 
sheep's  clothing.  Unlike  the  albuminates,  they  are 
more  apt  to  undergo  excessive  fermentation  than  pu- 
trefaction, and  thus  years  may  pass,  the  patient  feeling 
only  slight  discomfort  meanwhile,  till  its  noxious 
-effects  break  out.  It  is  not  surprising  then  that  the 
primary  cause  should  be  entirely  lost  sight  of,  and  the 
effects  attributed  to  intermediate  secondary  causes. 

I  have  traced,  as  far  as  it  is  possible  in  such  an  ar- 
ticle, the  good  and  the  evil  derived  under  certain  cir- 
cumstances from  each  regimen.  It  is  impossible  to 
lay  down  general  laws  as  to  regimen.  Each  individ- 
ual is  a  subject  for  separate  study,  and  the  best  advice 
that  can  be  given  in  this  matter  is :  '"  Man,  know  thy- 
self." 

854  Madison  Street. 


THE    CONDITION     OF     THE     GASTRIC     SE- 
CRETION   IN    MERYCISM. 

By   ANDREW   HALLIDAY,    M.B., 

SHl'BENACADIE,  NOVA    SCOTIA. 

In  the  Medicvl  Record  of  June  12th,  Dr.  Menassian, 
of  Iowa,  reports  a  case  of  merycism  which  is  very  in- 
teresting from  a  professional  standpoint,  but  is  doubly 
interesting  to  me  on  account  of  the  fact  that  I  myself 
have  the  power  of  regurgitating  and  ruminating. 

Since  my  boyhood  I  have  had  this  power  of  regur- 
gitating'and  remasticating  my  food  at  will.  Indeed, 
it  became  so  habitual  with  me  that  I  put  the  operation 
into  practice  after  almost  every  meal,  particularly  after 
dinner  or  when  I  had  taken  any  specially  solid  food 
and  which  I  had  not  thoroughly  masticated,  c.;:;.,  pieces 
of  meat,  hard-boiled  egg,  etc.  It  never  caused  me  the 
slightest  discomfort  to  go  through  the  process,  and  the 
food,  instead  of  being  in  any  way  disagreeable,  was 
rather  rendered  more  palatable,  this  being  accounted 
for,  no  doubt,  by  the  partial  conversion  of  the  starchy 
part  of  the  meal  into  sugar. 

When  about  eighteen  years  of  age  I  began  to  smoke, 
and  since  then  I  have  largely  given  up  the  regurgitat- 
ing habit,  simply  because  the  one  habit  has  supplanted 
the  other,  since  whereas  I  used  to  regurgitate  and  ru- 
minate after  a  meal,  I  now  smoke.  Nevertheless,  I 
often,  an  hour  or  two  after  a  meal,  almost  involuntarily 
regurgitate  a  mouthful  of  my  gastric  contents.  These 
contents,  however,  are  never  regurgitated  of  them- 
selves against  my  will.  I  have  perfect  control  of  tlie 
process,  and  although  I  may,  indeed,  do  it  involun- 
tarily, still  I  just  do  it  in  the  same  way  as  I  would, 
without  actually  thinking  of  what  I  was  doing,  go  and 
fill  and  start  to  smoke  my  pipe.  On  these  grounds, 
then,  I  am  led  to  consider  the  whole  thing  merely  a 

'  See  a  discussion  on  this  subject  in  Bulletin  de  I'.Acadi-mie  de 
M^decine,  1896,  Paris. 


matter  of  habit,  and  not  due  to  the  condition  of  the 
gastric  secretion.  Like  Dr.  Menassian's  patient, 
"nausea,  pyrosis,  pain,  or  distress  referable  to  the 
stomach"  are  subjective  symptoms  which  I  never  ex- 
perience; neither  have  I  epigastric  tenderness  nor  am 
I  neurasthenic.  The  only  thing  I  do  suffer  from  is 
migraine,  a  subject  which  I  have  discussed  in  this  re- 
lationship elsewhere. 

I  have  taken  Ewald's  test  breakfast  many  times, 
and  examination  of  the  gastric  contents  gives  the  fol- 
lowing results:  Reaction,  acid;  total  acidity  =  45 
to  55;  HCl  (Giinzburg's  test)  =  0.124  to  0.1604  per 
cent.:  acid  salts,  small  amount;  rennin  ferment,  active 
in  three  to  five  minutes  (Leo's  method) ;  proteolytic 
ferment,  active  for  fibrin  very  quickly. 

The  gastric  contents  were  usually  regurgitated  from 
forty -five  to  si.xty  minutes  after  taking  the  last  mouth- 
ful of  the  breakfast  (three  hundred  cubic  centimetres 
water  and  thirty-five  grams  bread).  After  one  hour  I 
was  not  able  to  regurgitate  enough  to  go  through  the 
various  tests,  but  between  forty-five  and  sixty  minutes 
I  could  always  get  more  than  enough. 

Dr.  Menassian  seems  to  think  that  this  indicates  too 
rapid  a  passage  through  the  stomach,  but  I  cannot 
quite  agree  to  this,  and  I  am  supported  in  my  opinion 
by  the  following:  "  As  the  result  of  eight  examinations 
on  healthy  subjects,  Boas  says  that  one  hour  after  tak- 
ing a  roll  and  three  hundred  cubic  centimetres  of 
water,  about  forty  cubic  centimetres  should  be  obtained 
by  expression  ;  the  amount  may  vary  fifteen  cubic  cen- 
timetres either  way;  otherwise  the  result  is  pathologi- 
cal."' '  According  to  the  above,  I  have  always  been 
within  the  normal  limits. 

In  conclusion,  then,  I  would  call  attention  to  the 
following  facts : 

(i)  The  whole  process  is  absolutely  under  control  of 
my  will  (although  it  may  occur  spontaneously,  as 
stated  above). 

(2)  HCl  is  never  absent,  a  point  Dr.  Minassian  lays 
great  emphasis  on:  and  although  I  have  examined 
very  frequently  I  have  never  found  it,  after  a  test 
breakfast,  below  0.124  per  cent.  We  therefore  agree 
as  to  a  diminution  below  the  normal  0.2  per  cent.,  but 
not  as  to  the  total  absence. 

Furthermore  I  have,  on  getting  up  in  the  morning, 
swallowed  one  ounce  or  so  of  water,  and  on  regurgi- 
tating part  of  it  in  about  two  minutes  it  even  then 
showed  distinctly  the  presence  of  HCl  on  applying 
Giinzburg's  test. 

It  seems  to  me  just  possible  that  the  regurgitating 
and  remasticating  of  the  food  may  in  the  first  instance 
have  been  an  attempt  on  the  part  of  nature  to  stimulate 
reflexly  the  secretion  of  gastric  juice,  considering  that 
it  is  usually  deficient  in  quality.  This,  however,  is 
merely  a  theory,  and  not,  I  fear,  susceptible  to  proof. 


Thyroid  Extract  as  a  Galactagogue. — Having  ob- 
served, in  conjunction  with  the  good  results  following 
the  employment  of  thyroid  extract  in  the  treatment  of 
sporadic  cretinism,  myxcedema,  and  some  cases  of 
mental  feebleness,  more  or  less  marked  increase  in  the 
activity  of  the  metabolic  processes  of  the  body,  Sta- 
well  {Intercolonial  Medical  Journal  of  Australasia, 
.'\pril  20,  1897)  was  led  to  believe  that  the  same  agsnt 
might  be  reasonably  expected  to  increase  the  metabol- 
ism of  the  mammarv  gland  in  suitable  cases.  Accord- 
ingly he  employed  thyroid  tablets  (presumably  each 
representing  one  grain  of  dried  gland),  given  from 
three  to  five  times  a  day,  in  nine  cases  of  nursing 
women,  and  in  seven  of  these  distinct  increase  in  the 
quantity  and  apparent  improvement  in  the  quality  of 
milk  secreted  followed. 

'  Ewald  :  "  Diseases  of  the  Stomach,"  Footnote,  p.  10. 


July  lo.  1897] 


MEDICAL    RECORD. 


49 


ON  DIGITAL  MANIPULATION  FOR  THE 
REMOVAL  OF  A  PIECE  OF  CATHETER 
OR  OTHER  INSTRUMENT  ACCIDENT- 
ALLY BROKEN  OFF.  AND  REMAINING 
IN   THE    DEEP  URETHRA  OF   THE   MALE. 

Bv    TOHN    H.    BRIXTON,    M.D., 


Three  times  it  has  happened  to  me  to  have  an  instru- 
ment part  or  break  during  manipulation  in  the  male 
urethra.  On  two  of  these  occasions  the  instrument 
was  a  flexible  English  catheter  of  small  size,  and  once 
it  was  a  filiform,  well  made  from  carefully  selected 
whalebone.  On  the  occurrence  of  such  an  accident 
one  must  act  at  once ;  the  remedy  to  be  efficient  must 
be  prompt.  Its  necessity  is  evident  not  only  to  the 
surgeon  but  to  every  bystander,  and  most  of  all  to  the 
patient.  I  can  never  forget  the  wistful  e.xpression  on 
the  face  of  the  patient  of  my  first  mishap,  years  ago. 
as  I  drew  from  his  meatus  the  anterior  fragment  of 
the  broken  English  catheter.  "  Yes,  doctor,  I  see  it 
has  broken  oft";  now  what  are  you  going  to  do  about 
the  other  piece?" 

.\nd  this  is  what  I  did:  Instinctively  I  placed  the 
fingers  of  my  left  hand  on  the  perineum  behind  the 
scrotum,  and  pressing  deeply  upward  and  backward, 
I  felt  the  urethra  in  front  of  the  bulb.  Within  its 
walls  I  could  readily  distinguish  the  broken  anterior 
end  of  the  fragment.  Grasping  both  tightly  between 
my  left  thumb  and  index  finger,  so  as  to  prevent 
the  catheter  from  slipping  toward  the  bladder,  I 
exerted  a  dragging  force  from  behind  forward  in  the 
course  of  the  urethra.  By  this  means  the  broken  end 
of  the  catheter  started  or  was  drawn  forward,  appar- 
ently half  an  inch.  Then,  with  the  thumb  and  index 
of  my  right  hand,  I  fixed  what  I  had  gained,  and,  mov- 
ing the  left  thumb  and  finger  backward,  I  took  a  fresh 
hold  and  renewed  the  manoeuvre  or  motion  from  be- 
hind forward,  with  effect  and  security.  Again  and 
again  I  repeated  this  process,  each  time  gaining  a  lit- 
tle until  the  ragged  upper  end  of  a  three-and-a-half 
inch  fragment  presented  at  the  meatus. 

In  a  recent  instance  of  a  filiform  broken  four  and 
a  half  inches  from  the  point  the  same  manipulation 
was  successful.  In  another  case  which  occurred  some 
years  since,  the  catheter  was  of  such  small  cali- 
bre and  had  broken  so  low  down  that  it  could 
scarcely  be  recognized  in  the  urethra  by  pressure 
from  without.  Here  I  introduced  my  right  fore-fin- 
ger into  the  rectum  and  then  readily  detected  the 
point  of  the  catheter  in  the  membranous  urethra.  I 
then  pressed  the  end  of  my  forefinger  firmly  up  and 
against  the  prostate,  so  that  the  catheter  fragment 
might  not  pass  further  bladderward.  Then,  with  my 
left  hand  resting  on  the  urethra  at  the  scrotal  junc- 
tion, I  gently  moved  my  right  forefinger  in  the  rectum 
forward  along  the  membranous  urethra.  The  frag- 
ment then  moved  forward,  and  so,  by  a  series  of  alter- 
nate motions  of  the  right  forefinger,  and  of  relaxation 
and  gripping  with  the  left  fingers,  the  fragment  ad- 
vanced until  its  progress  could  be  controlled  by  exter- 
nal manipulations  over  the  anterior  penile  urethra. 
whence  it  was  extracte'd  by  an  ordinary  thumb  for- 
ceps. 

I  have  been  lately  informed  by  Mr.  C.  B.  Stevenson, 
the  special  nurse  of  the  urinar\-  cases  at  the  Jefferson 
College  Hospital,  that  in  two  instances  he  has,  of  his 
own  origination,  in  the  same  manner  successfully  re- 
moved a  filiform  which  had  been  lost  in  the  urethra. 
In  both  these  cases  the  alternate  use  of  the  forefinger 
in  the  rectum  and  of  the  fingers  of  the  left  hand  ex- 
ternally over  the  urethra,  as  described,  brought  the 
errant  filiform  to  the  surface. 

I  may  also  add  that  I  have  satisfactorily  employed 


this  method  on  one  or  two  occasions,  in  which  a  pa- 
tient had  broken  his  catheter  in  self-catheterization. 
It  is  perhaps  worthy  of  note  that  I  have  observed 
clinically  that  the  tendency  of  a  flexible  fragment,  if 
left  to  itself,  is  to  work  toward  the  meatus.  This 
may  be  due  to  the  direction  of  the  urine  flow  or  pos- 
sibly to  the  action  of  the  contractile  fibres  of  the  ure- 
thra. It  is,  however,  contrary  to  the  generally  received 
opinion  that  the  course  of  a  foreign  body,  especially  if 
hard  and  smooth,  is  inward  toward  the  bladder. 

In  recapitulation  I  would  state,  from  my  own  experi- 
ence and  from  cases  of  which  I  have  knowledge,  that 
in  the  event  of  a  like  recent  accident,  or  in  the  attempt 
to  remedy  one  of  a  previous  date,  I  would  first  of  all 
insert  my  finger  into  the  rectum  and  press  against  the 
prostate  to  prevent  the  foreign  substance  from  passing 
deeper.  If  I  could  feel  it,  I  would  tr}-  and  work  it 
forward  by  the  alternate  movements  of  the  finger  of 
the  right  and  those  of  the  left  hand,  already  described. 
If  the  broken  portion  was  lodged  in  the  penile  ure- 
thra, anterior  to  the  scrotal  region,  the  digital  manip- 
ulation could  be  made  to  act  directly  upon  it,  without 
the  insertion  of  the  forefinger  into  the  rectum. 

The  process  I  have  thus  described  for  the  extraction 
of  a  retained  catheter  fragment  has,  it  may  be,  been 
used  by  others.  Even  if  not  novel,  it  is,  I  think,  not 
generally  practised,  and  I  am  sure  that  it  may  some- 
times be  resorted  to  with  good  effect.  It  has  at  least 
one  recommendation ;  it  requires  no  instruments  save 
those  which  the  surgeon  has  always  with  him — his 
faithful  fingers.  It  has  proved  of  ser^-ice  to  me,  has 
spared  me  some  anxiet)',  and  has  rendered  cutting  op- 
erations unnecesssary.  I  therefore  submit  it,  in  the 
hope  that  it  may  do  as  much  for  some  one  else. 

June  ii,  1897. 


Clinical  giepavtmcnt. 

EXSTROPHY  OF  THE  BLADDER  IN  A  GIRL 
OF  THIRTEEN  YEARS:  OPERATION;  RE- 
LIEF. 

By    F.    E.    T.\RVER,    M.  D., 

.\l-gl-sta.  ga. 

I  MAKE  no  apology  for  this  paper  except  the  rarity  of 
the  case,  it  being  somewhat  of  an  anatomical  curi- 
osity. 

About  twelve  years  ago  a  baby  was  born  in  Burke 
County.  It  soon  became  rumored  that  this  baby  was 
deformed.  I  took  occasion  to  call  and  asked  permis- 
sion to  examine  the  infant.  (I  had  at  one  time  prac- 
tised for  the  family.)  The  request  was  readily  grant- 
ed. In  conversation  with  the  mother  I  learned  that 
the  baby  was  a  girl,  and  was  unlike  any  she  had  ever 
seen.  At  this  time  the  infant  was  five  or  six  weeks 
old,  and  the  mother  then  had  four  or  five  children,  all 
of  whom  were  healthy  and  perfectly  formed. 

The  infant  was  exposed  for  examination,  and  I 
found  to  my  astonishment  the  following  condition  :  The 
vulva  was  very  large  and  very  much  protruded,  the  la- 
bia being  widely  separated  at  the  top,  with  a  cavity 
just  under  the  pubic  bone,  where  the  urethra  should 
have  been.  There  was  a  small  section  of  sphincter 
muscle,  but  no  sign  of  a  urethra;  there  was  an  oblong 
transverse  cavity  just  under  the  pubic  bone,  about  one 
and  one-fourth  inches  by  one-half  inch  wide.  The 
labia  minora  were  ver}'  prominent  and  thick;  the  labia 
majora  were  very  long  and  thin,  with  a  V-shaped  open- 
ing at  the  top,  extending  nearly  or  quite  through  the 
mons  veneris,  and  were  separated  from  three-fourths 
to  one  inch,  just  in  front  of  the  pubic  bone.  There 
was  a  small  strip  of  bladder  tissue  lying  on  top  of  the 
vagina  and  just  under  the  pubic  bone,  on  either  side 
of  which  the  ureters  emptied,  pouring  the  water  over 


50 


MEDICAL    RECORD. 


[July  lo,  1897 


the  vulva  and  limbs  of  the  child  in  an  almost  con- 
tinuous flow.  The  ureters  were  much  elongated. 
There  was  no  union  of  the  parts  from  the  sphincter 
of  the  urethra  up  through  the  urethra,  bladder,  both 
labia,  and  upper  section  of  the  vulva,  and  for  some 
little  distance  in  front  of  and  above  the  pubic  bone. 
The  vagina  and  pubic  bone  were  perfectly  formed. 
The  lower  part  of  the  vulva  was  normal.  Even  at  that 
age  there  was  decided  irritation  over  the  parts,  which 
the  urine  kept  continually  wet. 

The  mother  asked  my  opinion,  and  I  advised  an 
operation.  She  was  opposed  to  that,  and  called  a  sur- 
geon from  a  neighboring  town.  He  thought  best  to 
postpone  the  operation  until  the  child  grew  stronger. 

About  si.x  years  later  I  was  called  to  see  the  child. 
I  found  the  whole  of  the  inside  of  the  lower  limbs  ex- 
coriated, with  ulcers  in  and  around  the  vulva,  and  a 
chronic  irritation  in  and  around  the  oblong  cavity  be- 
fore mentioned.  Her  condition  was  virtually  the 
same,  e.xcept  that  it  was  greatly  exaggerated.  The 
labia  majora  were  much  longer,  thinner,  and  very  much 
more  separated  at  the  top;  the  labia  minora  were  im- 
mense, very  prominent,  and  lapping  together  so  as  al- 
most to  cover  the  oblong  cavity.  The  V-shaped  notch 
in  front  of  the  pubic  bone  was  much  wider  and  tilled 
with  mucous  membrane. 

The  child  was  in  an  awful  condition.  She  never 
wore  dry  clothes;  she  slept  in  a  wet  bed;  and,  as  a 
consequence,  was  debarred  from  nearly  all  the  social 
advantages  natural  to  a  child  of  her  age. 

I  again  advised  an  operation,  but  my  consultant  still 
thought  best  to  postpone.  At  the  age  of  eight  years 
matters  were  complicated  by  the  appearance  of  her 
menses,  which  were  regular  and  full,  but  she  did  not 
show  the  development  which  usually  accompanies  this 
period  in  a  girl's  life.  I  tried  every  form  of  urinal, 
with  not  only  no  benefit  but  often  with  positive  injury. 
I  had  several  made  from  original  designs,  but  with  no 
better  success. 

About  this  time  the  consulting  surgeon  died,  and  a 
short  time  afterward  I  moved  from  that  neighborhood. 
The  patient  then  was  nine  or  ten  years  old,  and  had 
begun  to  appreciate  her  condition.  Last  October  she 
was  brought  to  my  office.  Her  parents  had  consented, 
if  I  still  advised  an  operation,  to  have  it  performed  at 
once.  The  patient  was  willing.  She  was  then  so  an- 
noyed and  embarrassed  that  she  preferred  death  to 
long  life  of  this  torture.  She  was  now  thirteen  years 
old. 

I  made  a  thorough  examination  and  concluded  that 
her  chances  for  a  successful  operation  were  less  than 
when  she  was  last  seen,  but  there  was  still  some  hope 
of  benefit  if  not  of  a  cure. 

I  found  the  patient  thin,  pale,  poorly  nourished — 
ill  in  every  sense  of  the  term.  Her  condition  was 
very  distressing,  and  the  parents  were  very  apprehen- 
sive. I  again  advised  an  operation,  and  called  Dr. 
Thomas  R.  Wright  in  con.sultation.  After  a  careful 
examination  he  agreed  with  me. 

At  this  time  her  condition  was  an  extreme  exaggera- 
tion of  the  first,  and,  while  neither  of  us  was  very  san- 
guine in  regard  to  the  result,  we  thought  we  could  do 
little  harm  in  case  of  failure,  and  if  successful  she 
would  have  a  new  lease  on  life. 

Nothing  new  was  revealed  at  this  examination. 
There  was  only  a  small  section  of  the  sphincter  of  the 
urethra,  about  one-eighth  of  an  inch  long,  but  no  vestige 
of  the  urethra.  The  labia  minora  had  grown  larger, 
more  prominent,  and  were  honeycombed  in  every  direc- 
tion by  ulcers;  the  labia  majora  were  longer,  thinner, 
and  much  more  widely  separated  at  the  top  of  the  \ulva. 
The  intervening  space  was  filled  with  mucous  mem- 
brane. The  V-shaped  notch  that  extended  through  the 
mons  veneris  was  wider;  the  transverse  opening  just 
under  the  pubic  line  was  much  enlarged.     There  was  a 


small  strip  of  bladder  tissue  lying  just  above  the  \agina, 
on  either  side  of  which  the  ureters  emptied.  The 
whole  vulva  was  in  a  state  of  chronic  infiammation, 
with  ulcers  scattered  not  only  over  the  vuha  but  the 
whole  of  the  lower  limbs. 

W'e  could  find  but  few  cases  of  this  peculiar  defect; 
as  a  consequence  our  operation  must  be  to  a  certain 
extent  original.  Several  modes  were  discussed,  only 
to  be  discarded  as  soon  as  analyzed.  U  e  finally  de- 
cided on  the  following: 

.\fter  due  preparation  we  began  by  dissecting  a  two- 
thirds-circular  flap  out  of  the  mucous  membrane  in 
front  of  and  above  the  pubic  bone.  This  dissection 
was  two  inches  or  more  in  diameter,  and  was  from 
above  the  transverse  cavity,  continuing  down  on  either 
side,  and  wide  enough  to  form  the  urethra.  This  was 
continued  down  to  the  section  of  the  sphincter  muscle. 
The  dissected  flaps  were  brought  together  and  closed 
in  the  usual  way,  down  to  the  sphincter,  through  and 
around  which  we  inserted  one  or  more  circular  stitches. 
A  glass  tube  was  then  inserted  through  the  new-made 
urethra,  and  fastened  with  plaster,  etc.  Over  the  end 
of  the  glass  tube  was  inserted  a  rubber  tube  (one  yard 
in  length),  filled  with  water,  for  the  purpose  of  pro- 
ducing gentle  suction  on  the  fluids  that  would  accu- 
mulate in  the  new-formed  bladder.  This  tube  emptied 
into  a  vessel  by  the  side  of  the  bed,  and  succeeded 
nicely.  All  of  this  we  supported  by  various  forms  of 
bandages  and  pads.  This  step  in  the  operation  was 
successful. 

We  now  had  the  labia  to  close,  the  denuded  surface 
to  cover,  and  after  dissection  to  support  the  new-formed 
tissue.  This  was  done  by  carrying  the  dissection  a 
little  higher  up  in  the  V-shaped  notch,  paring  the 
edges  of  the  vulva,  trimming  the  labia  minora  to  nor- 
mal size,  and  bringing  the  whole  together  with  the 
usual  form  of  stitches,  except  that  we  inserted  one  or 
two  very  stout  sutures,  deep  and  wide,  to  support  the 
others.  The  parts  were  also  protected  with  the  usual 
form  of  pads  and  bandages.  This  step  was  also  suc- 
cessful. 

We  began  the  first  step  in  stretching  the  bladder  by 
removing  the  rubber  tube  and  using  a  cork  in  the  glass 
one,  which  was  removed  every  one  and  one-half  or 
two  hours  for  the  passage  of  urine,  and  then  replaced. 
During  the  whole  of  this  time  the  tube  had  been  duly 
removed,  cleansed,  and  the  bladder  thoroughly  irrigated 
with  boric  acid  to  prevent  the  accumulation  always  .^^o 
troublesome  in  tiiese  cases.  As  soon  as  union  was  com- 
plete, we  began  to  dilate  with  more  energy,  and  found 
this  the  most  difficult  if  not  the  most  serious  part  of 
the  procedure.  This  was  to  stretch  or  dilate  the  new- 
made  bladder,  which  by  this  time  was  very  much 
shrunken.  We  found  it  ven,'  difficult  to  get  a  support 
that  was  substantial  and  stationary.  After  trying  vari- 
ous plans  with  only  partial  success,  we  took  an  oblong 
cork,  cut  a  hole  in  the  end  of  it,  so  as  to  fit  the  bottle 
end  of  a  rubber  nipple,  which  was  tightly  corked  into 
the  hole.  The  cork  was  then  fashioned  to  fit  the  in- 
side of  the  vulva  and  put  proper  pressure  on  the  mouth 
of  the  urethra. 

.\fter  padding  with  gauze  an  ordinary  condom  was 
stretched  over  the  whole  and  tied  in  front  and  back. 
This  end  of  the  nipple  was  inserted  into  the  vagina 
and  the  cork  placed  between  the  labia.  We  tried  to 
support  this  with  an  ordinary  T-bandage,  but  found 
it  would  not  maintain  uniform  pressure.  We  then  had 
a  stout  belt  made,  supported  by  whalebone  to  prevent 
wrinkling  and  to  take  the  place  of  a  T-bandage.  To 
the  back  of  this  belt  was  fastened  a  four- inch  rubber 
bandage.  This  rubber  was  split  in  front  to  below  tlie 
vulva.  By  crossing  tiiese  two  ends  in  a  certain  man- 
ner, they  gave  support  to  both  t)ie  cork  and  the  out- 
side of  the  vulva  when  fastened  in  front.  When  nec- 
essary to  pass  water  she  could  <.letach  the  front  part 


July  lo,  1897] 


MEDICAL    RECORD. 


51 


of  the  bandage  and  replace  it  herself.  The  glass  tube 
was  dispensed  with,  of  course,  except  for  the  purpose 
of  washing  out  the  bladder  occasionally.  Within  the 
next  three  or  four  weeks  with  this  support  she  was 
able  to  hold  her  urine  from  one  and  one-half  to  two 
hours.  She  has  w-orn  this  support  for  about  tive 
months  intermittently,  and  is  able  to  hold  her  urine 
from  three  to  four  hours  without  it.  She  usually 
passes  water  from  two  to  four  times  at  night,  and  dur- 
ing the  day  about  every  four  hours. 

She  now  wears  dry  clothes  day  and  night.  But  this 
is  not  all.  She  has  undergone  the  most  remarkable 
change.  She  is  robust,  well  nourished,  and  is  rapidly 
acquiring  the  development,  both  physical  and  mental, 
so  long  delayed  with  her.  Not  only  are  her  parents 
delighted,  but  she  is  one  of  the  happiest  little  girls  in 
her  section. 

We  look  on  this  case  as  one  above  the  usual  inter- 
est, and  if  our  experience  shall  be  the  means  of  helping 
some  one  else  out  of  a  similar  bondage,  we  shall  feel 
amply  repaid. 


progress  of  Uledical  Jicicnce. 

Uraemic  Dyspnoea.  —  Five  forms  of  dyspnoea  have 
been  described  as  occurring  in  uraemia,  viz.:  i,  Con- 
tinuous; 2,  paroxysmal ;  3,  both  types  alternating;  4, 
laryngeal;  5,  Cheyne-Stokes  breathing.  The  pathol- 
ogy  of  uraemic  dyspnoea  has  been  variously  explained, 
e.g.,  I,  contraction  of  the  muscles  of  the  smaller 
bronchi;  2,  contraction  of  minute  arterial  twigs  be- 
longing to  the  coronary  arteries  or  to  the  pulmonary 
vessels;  3,  cedemaof  the  lung  or  accumulation  of  fluid 
in  the  pleural  sac;  4,  ana3mia;  5,  cardiac  debility  and 
dilatation;  6,  the  influence  of  uramic  blood  upon  the 
terminations  of  the  vagus  nerve,  or  irritation  of  the 
motor  fibres  which  supply  the  bronchial  muscles;  7, 
direct  irritation  of  the  respiratory  centre  in  the  me- 
dulla by  waste  products  in  the  blood. — Tir.\rd. 

A  Case  of  Congenital  Malaria — Dr.  Winslow 
(Boston  Medical  and  Surgical  Journal,  May  27,  1897) 
has  reported  the  case  of  a  male  child,  ten  weeks  old. 
apparently  healthy  and  weighing  seven  pounds  at 
birth,  that  did  not  flourish  on  its  mother's  milk  and 
suffered  from  colic  and  vomiting.  The  child  slept 
little,  cried  a  great_deal,  was  constantly  moving,  and 
had  cold  hands  and  feet.  It  had  become  emaciated, 
pallid,  and  weak.  Various  forms  of  artificial  food  had 
been  employed,  but  without  permanent  benefit.  The 
muscles  of  the  limbs  and  neck  were  rigid,  the  head 
was  slightly  retracted,  and  handling  induced  crying. 
While  under  observation  the  little  patient  had  a  severe 
convulsion  characterized  by  muscular  rigidity,  loss  of 
consciousness,  clonic  spasms,  and  strabismus,  followed 
by  a  period  of  muscular  relaxation  and  stupor.  It 
was  now  learned  that  similar  attacks  had  taken  place 
from  birth,  being  always  preceded  by  prolonged  try- 
ing. The  child  became  so  ill  that  the  prognosis  was 
for  a  time  doubtful.  The  question  of  malaria  was 
suggested  by  the  family,  but,  as  the  temperature  had 
been  normal  and  no  periodicity  of  the  symptoms  had 
been  observed,  the  matter  was  left  in  abeyance.  The 
mother  had  had  quotidian  malaria  of  a  severe  type  for 
two  weeks  preceding  the  birth  of  the  patient,  but  treat- 
ment had  been  withheld  on  account  of  the  existence  of 
pregnancy.  The  symptoms  disappeared  at  the  end  of 
labor.  Improvement  in  the  child's  condition  failing 
to  take  place  in  spite  of  varied  treatment,  examination 
of  the  blood  was  made,  with  the  result  of  disclosing 
the  presence  of  malarial  plasmodia  in  abundance. 
The  child  was  given  one  grain  of  quinine  by  enema 
twice  daily,  and  the  convulsions  at  once  ceased, 
although  the  muscular  rigidity,  the  sleeplessness,  the 


colic,  the  constipation,  and  the  restlessness  persisted. 
After  a  month  of  such  treatment  the  removal  of  the 
child  to  a  non-malarial  place  was  advised.  Improve- 
ment at  once  set  in,  and  after  a  week  the  quinine  was 
withdrawn  and  one-fifth-minim  doses  of  Fowler's  so- 
lution were  prescribed.  The  plasmodia  disappeared 
from  the  blood,  the  child  gained  in  weight,  and  in  a 
short  time  was  quite  restored  to  health.  The  opinion 
is  expressed  that  the  plasmodia  w^ere  probably  con- 
veyed directly  by  means  of  the  foetal  circulation,  al- 
though the  possibility  of  infection  through  the  mother's 
milk  is  not  to  be  excluded.  As  the  symptoms  were 
the  same  up  to  the  time  that  the  diagnosis  of  malaria 
was  made,  it  seems  evident  that  the  disease  existed 
from  birth. 

Successful  Removal  of  a  Cystic  Abdominal  Tu- 
mor from  a  Child  Aged  Seven  Months. — Dr.  Camp- 
bell {^British  Medical  Journal,  May  15,  1897)  has  re- 
ported the  case  of  a  female  child,  seven  months  old, 
born  with  ditficulty,  the  forceps  being  applied  high 
up.  The  infant  throve  well  and  was  apparently  healthy 
at  the  age  of  three  months,  but  about  a  month  later 
the  mother  noticed  swelling  of  the  abdomen,  which 
gradually  increased.  Periodic  attacks  of  violent  col- 
icky pain  also  occurred.  The  general  nutrition  was 
good.  The  respirations  were  shallow  and  embarrassed. 
The  abdomen  was  greatly  distended  by  a  lobulated 
tumor,  which  was  more  prominent  on  the  left  side,  and 
felt  hard  in  its  upper  half,  but  was  soft  and  fluctuating 
below.  There  was  dulness  on  percussion  all  over  the 
abdomen  except  in  the  right  hypochondriac  region, 
which  was  resonant.  Operation  was  decided  upon, 
and  under  chloroform  anaesthesia  a  median  incision 
was  made  from  midway  between  the  ensiform  cartilage 
and  the  navel  to  midway  between  the  naAel  and  the 
symphysis  pubis.  This  exposed  a  large  tumor  lying 
behind  the  posterior  parietal  peritoneum  and  pushing 
the  intestines  into  the  right  hypochondrium.  The 
cystic  portion  having  been  tapped,  the  whole  mass  was 
enucleated  from  the  subperitoneal  tissue.  No  bleed- 
ing of  consequence  occurred,  and  no  ligatures  were 
needed.  The  tumor  had  no  pedicle,  but  was  more 
firmly  attached  deep  in  the  left  side  of  the  pelvis  than 
elsewhere.  It  lay  in  front  of  the  left  kidney,  which 
was  situated  at  the  level  of  the  iliac  crest  and  was 
freely  movable.  The  peritoneal  covering  of  the  tiimoi 
was  attached  to  the  edges  of  the  lower  end  of  the  ab- 
dominal wound,  and  the  cavity  was  packed  with  gauze. 
The  upper  end  of  the  wound  was  closed  by  two  layers 
of  suture,  silk  being  used  for  the  peritoneum  and  silk- 
worm gut  for  the  skin  and  aponeurosis.  The  opera- 
tion was  well  borne,  except  for  a  few  seconds  during 
the  extraction  of  the  tumor,  when  the  pulse  became 
bad,  apparently  owing  to  pressure  on  the  cardiac  area 
of  the  diaphragm.  Two  hours  after  the  operation  the 
child  took  milk  and  barley  water,  and  was  thencefor- 
ward fed  every  two  hours.  Fifteen-minim  doses  of 
whiskey  were  given  every  half-hour  for  the  first  thiee 
hours.  The  child  slept  well  and  vomited  on  one 
occasion  only.  On  the  sixth  day  the  gauze  packing 
was  removed  and  the  bowels  acted  spontaneously.  On 
the  eleventh  day  the  silkworm-gut  stitches  were  re- 
moved. The  wound  was  then  healed  except  where  the 
drain  had  been.  At  the  end  of  a  fortnight  the  child 
went  home.  Three  months  later  the  silk  stitches  be- 
gan to  come  away.  Five  months  after  the  operation 
the  child  was  in  excellent  health,  though  all  of  the 
silk  had  not  separated.  The  tumor,  which  weighed 
three  pounds  when  fresh,  was  found  to  consist  of  a 
cyst  containing  about  ten  ounces  of  clear  yellow  fluid, 
and  of  a  solid  portion  in  which  a  mass  of  cartilage 
and  a  piece  of  bone  lay  embedded.  There  was  noth- 
ing to  indicate  the  organ  from  which  the  formation 
originated. 


52 


MEDICAL    RFXORD. 


[July  lo,  1897 


Medical  Record: 


A    Weekly  Jourjial  of  Medicine  and  Surgery. 


GEORGE   F.    SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth  Street. 


New  York,  July  10,  1897. 


THE     BIOLOGICAL    BASIS    OF     MENSTRUA- 
TION. 

Little  is  known  concerning  the  phenomena  of  sexual 
physiolog}'.  The  literature  on  it  is  ver)-  scant.  Up 
to  ten  or  fifteen  years  ago  the  universally  accepted 
belief  was  that  ovulation  was  the  cause  of  menstrua- 
tion, but  a  revolution  in  these  views  has  taken  place. 
Dr.  De  Sinety  in  188 1  cast  doubt  on  the  old  theor)-  and 
since  that  time  many  have  agreed  with  him,  although 
now  there  is  by  no  means  unanimity  of  opinion  among 
students  on  the  subject.  Various  theories  have  been 
introduced  as  to  the  causation  of  menstruation,  but  as 
yet  no  definite  conclusions  have  been  reached.  In  a 
paper  read  before  the  Montreal  Medico-Chirurgical 
Societ)-  and  before  the  New  York  Academy  of  Medi- 
cine, Dr.  Webster,  of  Montreal,  puts  forward  the  con- 
tradictory theories  of  different  authorities,  pointing 
out  where  he  thinks  they  are  wrong,  and  giving  the 
result  of  his  ow-n  observations.  To  Johnstone  in 
America  and  to  Heape  in  England  much  of  the  credit 
is  due  of  demonstrating  that  ovulation  is  not  the  cause 
of  menstruation.  In  this  connection  Heape  examined 
the  pelves  of  fort}'-two  monkeys  (Semnopithecus  entel- 
lus)  du'ring  their  menstrual  periods,  and  found  evi- 
dences of  ovulation  being  in  progress  in  only  two 
cases.  According  to  Lawson  Tait,  removal  of  the  Fal- 
lopian tubes,  the  ovaries  being  left  in  situ,  is  followed 
in  ninety-five  per  cent,  of  cases  by  cessation  of  men- 
struation. Bland  Sutton  says,  in  direct  contradiction 
of  this  statement,  that  "  the  Fallopian  tubes  exercise 
no  influence  on  menstruation,  and  in  order  to  produce 
artificial  amenorrhoea  both  ovaries  must  be  completely 
removed."  In  1887  Johnstone  disproved  the  long  held 
idea  that  each  menstruation  results  in  the  shedding  of 
the  entire  endometrium,  and  defines  the  process  of 
menstruation  as  a  shedding  of  the  superficial  layers  of 
the  endometrium  and  as  a  kindred  process  to  the 
moult  in  birds  and  the  shedding  of  the  horns  and  hair 
in  the  deer  tribe.  He  has  also  advanced  the  theorj-, 
in  which  he  is  supported  by  Tait,  that  tlie  menstrual 
act  is  a  special  function  related  to  a  distinct  nervous 
mechanism.  They  think  that  possibly  a  special  nerve 
trunk  running  in  the  upper  part  of  the  broad  ligament 
may  convey  the  regulating  currents.  Webster  is  in- 
clined to  regard  the  subject  from  a  body  metabolism 
and  biological  point  of  view,  and  thinks  that  the  theoiy 


advanced  by  Geddes  and  Thomson  in  their  "  Evolu- 
tion of  Sex"  is  worthy  of  great  consideration.  This 
theor)'  holds  that  the  menstrual  process  is  related  to 
the  balancing  of  anabolism  and  katabolism  in  the 
female.  If  the  female  sex  be  preponderatingly  anabo- 
lic, menstruation  is  one  of  the  functions  of  anabo- 
lism in  the  female  and  is  a  means  of  getting  rid  of  the 
anabolic  surplus.  Looked  at  from  a  biological  stand- 
point, the  argument  is  as  follows:  Throughout  the  ani- 
mal kingdom  the  distinctive  and  predominant  charac- 
teristic of  the  male  sex  is  katabolism  and  of  the  female 
anabolism.  The  same  distinction  is  also  found  in  the 
plant  world,  and  these  lines  of  inquir)-  are  suggested 
thereby:  1.  A  study  of  sexual  characteristics  in  the 
fully  developed  state  and  in  the  historj-  of  the  individ- 
ual. 2.  An  investigation  into  the  condition  of  the 
lowest  forms  of  animal  and  plant  life  in  which  sex  has 
its  beginning.  3.  Observation  of  normal  and  patho- 
logical changes  in  the  reproductive  apparatus.  4.  Ex- 
perimental inquir)-  into  the  nature  of  the  factors  which 
determine  sex. 

Doubtless  there  is  much  opportimity  for  original 
research  in  studying  this  question  from  a  biological 
standpoint,  and  it  is  possible  that  here  the  solution  of 
the  difficult  problem  will  be  found. 


HYGIENE   OF   THE    BARBER    SHOP. 

The  proposition  to  make  a  more  careful  man  of  the 
tonsorial  artist,  in  so  far  as  relates  to  the  transmission  of 
disease  from  his  infected  to  his  well  clients,  is  not  a  new 
one.  The  subject  has  been  written  upon  by  several 
earnest  men  before  Heinrich  Berger,  whose  "  Hygiene 
in  den  Barbierstuben"  recently  appeared  in  Leipzig. 
No  writer  has,  however,  seemed  to  go  so  deeply  into  the 
question  and  lay  down  such  strict  rules  for  the  knight 
of  the  shaving-knife.  We  are  told  that  he  must  be  a 
person  free  from  epilepsy  and  all  manner  of  seizures, 
drunkenness,  and  infectious  diseases. 

Being  free  from  these  aft'ections  himself  he  may 
give  professional  attention  to  all  persons,  including 
those  under  the  influence,  or  those  likely  to  have  a  fit 
in  the  chair,  provided  they  are  free  from  skin,  hair, 
and  sexual  diseases  of  an  infectious  nature.  Other- 
wise they  are  to  be  treated  at  home  with  tlieir  own  im- 
plements. The  author  gives  a  number  of  odier  rules 
which  are  in  themselves  and,  so  far  as  they  go,  good — 
if  barbers  could  be  prevailed  upon  to  follow  them — 
but  he  do^s  not  sufliciently  insist  upon  the  necessity 
of  boiling  to  the  point  of  sterilization  his  instru- 
ments, towels,  sponges,  and  especially  his  own  hands. 

There  are  many  things  besides  the  so-called  barber's 
itch  which  may  be  transmitted  in  uncleanly  shaving 
and  hair  dressing,  and  of  which  the  public  knows  little 
or  nothing.  Favus  is  decidedly  on  the  increase  in 
this  country,  and  the  number  of  children  turned  away 
from  the  cities'  schools  for  this  cause  since  the  in- 
spection innovation  went  into  effect  would  greatly 
surprise  tliose  who  think  of  favus  as  a  European  or 
foreign  aftection. 

Syphilis  is  undoubtedly  transmitted  now  and  then, 
through  the  medium  of  the  barber's  armamentarium. 


July  lo,  1897] 


MEDICAL    RECORD. 


53 


Attention  has  recently  been  called  by  a  member  of 
the  New  York  Dermatological  Society  {^Journal  of 
Cutaneous  and  Gensto-  Urinary  Diseases)  to  the  danger 
of  the  epilating  tweezers  used  in  barber  shops.  In- 
growing hairs  and  those  attended  by  suppurative  in- 
flammation, as  in  sycosis,  are  extracted,  and  the  next 
comer  is  operated  upon  without  adequate  and  usually 
without  any  cleansing  at  all  of  the  instrument.  In 
one  instance  reported,  a  chancre  of  the  cheek  was  at- 
tributed to  the  use  of  such  an  instrument,  which  had 
probably  not  been  cleaned  after  being  used  upon  a 
syphilitic  subject.  Certain  rules  should  be  adopted,  if 
possible,  by  barbers  in  general,  to  protect  their  patrons 
from  dangers  which  are  more  real  than  imaginary. 
Above  all,  they  should  remember  that  scrupulous 
cleanliness  of  implements  and  hands  is  the  first  requi- 
site, and  the  advice  now  being  given  to  surgeons  to 
"boil  their  hands"  applies  almost  equally  to  them. 
At  the  least  they  could  give  a  little  wash  between 
each  "  next,"  for  the  mere  sake  of  appearances  and  in 
the  interest  of  business  if  for  nothing  else. 


THE  EFFECT  OF  THE  DISPENSARY  SYSTEM 
IN    LONDON. 

In  reference  to  the  controversy  on  the  question  of  the 
abuses  of  dispensaries  now  in  progress  in  this  city,  it 
may  be  instructive  to  take  London  as  an  object  lesson 
and  to  sketch  briefly  the  effect  of  the  dispensar)  sys- 
tem there.  In  London  there  have  been  free  dispensa- 
ries for  more  than  one  hundred  years,  and  so  long  as 
the  system  was  restricted  to  free  dispensaries  and 
properly  super\'ised  it  was  of  great  benefit  to  the  poor. 
Since  the  introduction,  however,  of  self-supporting 
dispensaries,  some  twenty  years  ago,  this  happy  condi- 
tion has  been  totally  changed.  The  truth  is  now 
acknowledged  on  all  sides  that  the  self-supporting 
dispensary  system  has  been  a  prominent  factor  in  the 
reduction  of  medical  fees  throughout  the  kingdom. 
That  they  were  introduced  with  the  laudable  object  of 
helping  the  poor  and  of  fostering  in  them  a  spirit  of 
independence  is  probable,  but  unfortunately  the  result 
has  been  exactly  the  opposite.  From  their  inception 
abuses  crept  in,  and  have  continued  to  creep  in. 
Charity  was  the  object  of  the  old  free  dispensaries; 
money  making  appears  to  be  that  of  the  provident. 
The  principle  of  these  dispensaries  is  nothing  more 
in  too  many  cases  than  cheap  physic.  The  large  class 
for  which  they  were  designed,  that  between  the  pauper 
and  the  small  tradesman,  join  only  in  small  numbers; 
on  the  other  hand,  the  small  tradesman  and  respecta- 
ble mechanic,  who  can  afford  to  pay  a  small  medical 
bill,  are  supporters  of  the  dispensary,  and  both  the 
doctor  and  the  patient  are  sufferers — the  doctor  in  his 
pocket,  and  the  patient  in  his  self-respect. 

These  dispensaries  have  been  wholesale  propagators 
of  pauperism.  Through  their  means,  too,  in  London 
and  in  the  other  large  towns  in  Great  Britain,  the  cash 
practice  has  been  introduced,  with  the  consequent 
irremediable  reduction  of  medical  fees.  The  practi- 
tioners in  the  districts  in  which  provident  dispensa- 
ries were  introduced,  in  order  to  compete  with  them, 


were  compelled  in  sheer  self-defence  to  build  up  a 
clientele  by  somewhat  similar  means,  or  at  any  rate 
to  give  advice  and  medicine  at  an  equally  low 
rate.  John  Stuart  Mill  said:  "There  are  kinds  of 
labor  of  which  the  wages  are  fixed  by  custom  and  not 
by  competition.  Such  are  the  fees  or  charges  of  pro- 
fessional persons,  of  physicians,  surgeons,  barristers, 
and  attorne\'s.  These,  as  a  rule,  do  not  vary;  and 
although  competition  operates  upon  these  classes  as 
much  as  upon  any  others,  it  is  by  dividing  tlie  busi- 
ness and  not  by  diminishing  the  rate  at  which  it  is 
paid."  When  these  words  were  written  they  were  true, 
but  if  Mill  were  alive  now  what  a  change  he  would 
see,  when  there  is  as  much  cutting  among  medical  men 
as  among  tradesmen.  Forty  years  ago  in  England 
those  who  could  pay  for  medical  services  paid  a  fee 
of  about  a  dollar  and  a  half,  and  for  those  who  could 
not  afford  so  much  there  were  the  clubs  and  parish 
doctors.  Now  the  pleasing  spectacle  is  to  be  seen  of 
highly  educated  men,  graduates  of  Oxford  or  Cam- 
bridge, selling  their  skill  and  medicine  for  twenty-five 
cents,  and  others  underselling  them  at  t\velve  or  eight 
cents.  In  the  last  forty  years  a  lowering  of  the 
charges  for  medical  services  has  gone  ovi  pari  passu 
with  the  raising  of  the  standard  of  medical  education, 
so  that  at  this  moment  medical  men  in  England  are 
probably  the  best  educated  and  worst  paid  of  any  of 
the  professions. 

The  foregoing  is  a  true  account  of  the  manner  in 
which  the  development  of  the  dispensary  system  has 
acted  on  the  medical  profession  in  England.  The 
effect  on  the  general  public  is  just  as  disastrous;  the 
number  of  people  who  seek  the  aid  of  medical  charity 
in  London  is  simply  appalling. 


THE   SPITTING    NUISANCE. 

The  arrest  and  fine  of  an  influential  and  defiant 
spitter  in  one  of  the  street  cars  of  San  Francisco  is  a 
striking  means  of  educating  the  public  in  matters  of 
health  and  decency.  Considering  the  few  offenders 
who  are  punished,  and  the  vast  number  of  transgress- 
ors who  escape,  there  is  a  great  deal  of  missionary 
work  to  be  accomplished.  In  our  own  model  city, 
where  the  antispitting  boom  took  its  first  bound  into 
favor,  the  nuisance  of  promiscuous  spitting  is  almost 
as  bad  as  ever.  The  health-board  notices  do  no  good 
whatever.  If  more  arrests  were  made,  it  would  bring 
the  matter  of  violation  of  the  ordinance  most  directly 
and  most  forcibly  to  the  attention  of  the  people.  A 
good  way  to  start  an  efficient  crusade  against  the 
spitters  would  be  a  detail  of  policemen  in  citizen's 
clothes,  who  should  disperse  on  certain  car  lines  and 
should  immediately  arrest  ever)'  offender  caught  in 
the  act.  One  officer  in  one  car  of  each  of  the  different 
companies  could  make  a  record  which  would  astonish 
the  public  and  create  a  proper  sentiment  accordingly. 
There  is  no  reason  also,  for  the  convenience  of  such 
invalids  as  must  expectorate,  that  properly  disinfected 
cuspidors  should  not  be  provided  in  some  out-of-the- 
way  corner  of  the  conveyance,  or  in  the  larger  cars 
that  some  spitting  closet  should  not  be  set  apart  for 


54 


MEDICAL    RECORD. 


[July  lo,  1897 


the  spitters.  The  trouble  of  getting  up  to  expectorate 
would  oftentimes  as  effectually  settle  the  question  to 
spit  or  not  to  spit,  as  it  would  to  choose  or  not  the 
back  of  the  neck  of  a  standing  passenger  in  a  packed 
cable  car. 

THE    PATHOLOGY     OF    THE    UIARRHCEAL 
DISORDERS    OF    CHILDHOOD. 

From  an  extended  clinical  and  pathological  study  at 
the  Kaiser  and  Kaiserin  Friedrich  Kinderkrankenhaus 
in  Berlin,  Baginsky  (Archiv  fiir  Kinderheilkunde, 
Bd.  xxii.,  H.  3-6)  concludes  that  the  diarrhoeal 
disorders  of  childhood  arising  under  the  influence  of 
high  summer  temperature  are  at  first  only  functional 
in  character,  consisting  in  changes  in  the  motor  and 
secretory  functions  of  the  gastro-intestinal  tract,  with 
abnormal  digestive  chemism.  In  their  further  course 
profound  anatomical  alterations  take  place  in  the  walls 
of  the  stomach  and  bowels,  which  may  range  be- 
tween catarrh  and  necrosis  of  the  mucous  membrane. 
The  follicular  changes  are  processes  of  peculiar  char- 
acter and  independent  of  the  catarrhal,  with  which 
they  may  in  the  course  of  time  be  associated.  They 
lead  sometimes,  in  addition  to  superficial  changes, 
also  to  ulceration.  These  changes  are  attributable 
not  to  specific  bacteria,  but  to  the  ordinary  saprophytic 
micro-organisms  of  the  intestinal  tract  that  assume 
especial  virulence.  Under  peculiar  circumstances 
other  bacteria  not  ordinarily  found  in  the  intestinal 
tract  may  act  as  causes  of  diarrhceal  disorders.  These 
also  induce  profound  anatomical  changes  in  the  walls 
of  the  bowel.  The  invasion  of  other  organs  by  these 
bacteria  is  not  unusual,  but  is  rather  relatively  com- 
mon with  regard  to  the  kidneys.  Under  these  circum- 
stances the  bacteria  may  cause  profound  anatomical 
lesions,  even  to  the  extent  of  suppuration.  The  trans- 
mission does  not  usually  take  place  through  the  blood 
stream,  the  bacteria  being  but  rarely  found  in  the 
blood,  and  then  only  in  small  numbers.  The  most 
profound  disturbances  are  occasioned  by  the  fermenta- 
tive products  of  bacterial  activity,  toxic  or  non-toxic. 
These  are  either  of  the  nature  of  acids  or  products  of 
albuminous  degeneration,  down  to  ammonia  and  its 
combinations,  which  behave  as  active  irritants  and 
thus  cause  injury  to  the  walls  of  the  bowel.  Further, 
through  the  blood  current  and  the  lymph  stream  they 
exert  a  degenerative  influence  upon  other  organs, 
especially  those  possessed  of  excretory  functions,  such 
as  the  liver,  the  kidneys,  etc.  Under  the  influence  of 
this  intoxication  from  the  intestinal  tract  the  resist- 
ance of  the  whole  organism  to  the  invasion  of  other 
pathogenic  micro-organisms  is  diminished,  as  is 
manifested  by  numerous  complications. 


The  Medical  League,  whose  worthy  aim  is  to  sup- 
press the  glaring  abuse  of  dispensary  and  hospital 
charity,  is  growing.  It  has  recently  established  a 
branch  in  Brooklyn  and  gives  promise  of  keeping  up 
its  aggressive  warfare  until  the  enemy  is  routed,  and 
the  dispensing  of  charity  is  confined  within  proper 
and  decent  limits. 


Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
July  3,  1897.  July  ist. — Assistant  Surgeon  J.  F. 
Leys  detached  from  the  Fermonf,  July  6th,  and  ordered 
to  the  Helena,  July  7  th.  Assistant  Surgeon  C.  E. 
Riggs  ordered  to  the  Vertnont,  July  6th. 

The  Tri-State  Medical  Association  of  Western 
Maryland,  Western  Pennsylvania,  and  West  Virginia 
will  meet  at  Bedford  Springs  Hotel,  Bedford,  Pa.,  on 
Thursday,  July  15,  1897.  An  attractive  programme 
is  promised. 

A  Congress  of  Colored  Physicians  has  been  called 
to  meet  in  Washington  on  July  2ist-23d.  The  object 
of  the  promoters  of  the  meeting  is  to  form  a  National 
Medical  Association  of  Colored  Physicians.  But  "  it 
is  not  the  aim  of  the  association  to  conflict  with  white 
conventions  of  physicians,  nor  to  decrease  the  interest 
of  colored  physicians  in  those  white  organizations  to 
which  they  may  belong;  it  is  simply  wanted  for  a  pro- 
motion of  fraternal  interest  among  the  colored  profes- 
sional men."  It  is  estimated  that  there  are  about  two 
thousand  colored  physicians  in  regular  practice  in  the 
country.  Dr.  John  P.  Golden,  of  Allegheny,  Pa.,  is 
one  of  the  originators  of  the  movement. 

Paul  F.  Munde'  M.D.,  LL.D. — At  its  recent 
commencement,  it  being  also  the  centenary  of  the 
medical  school,  Dartmouth  College  conferred  the  hon- 
orary degree  of  LL.D.  on  Dr.  Paul  F.  Munde'. 

The  British  Medical  Temperance  Association. — 

At  the  recent  annual  meeting  of  this  association,  the 
president,  Dr.  Sims  Woodhead,  in  his  inaugural  ad- 
dress, pointed  out  how  medical  men  had  influenced  the 
temperance  movement.  He  referred  to  the  patho- 
logical degradation  observed  after  the  ingestion  of  re- 
peated moderate  quantities  of  alcohol,  and  commended 
the  work  of  the  Society  for  the  Study  of  Inebriety  and 
the  British  Medical  Temperance  Association  as  worthy 
the  support  of  the  members  of  the  profession.  The 
membership  of  the  association  is  now  four  hundred 
and  fifty-three. 

Prof.  W.  T.  Engelmann,  of  the  University  of 
Utrecht,  has  been  called  to  the  chair  of  physiology  at 
Berlin  rendered  vacant  by  the  death  of  Dubois-Rey- 
mond. 

Plague  (?)  in  Constantinople. — A  report  from  Sofia 
says  that  Bulgaria  has  established  a  two-weeks'  quar- 
antine against  travellers  from  Turkey,  because  of  an 
outbreak  of  the  plague  at  Constantinople. 

College   of  Physicians   of   Philadelphia. — At  the 

concluding  meeting  for  the  season  of  the  section  on 
general  medicine  of  the  College  of  Physicians  of 
Philadelphia,  on  June  14th,  Dr.  H.  A.  Hare  read  a 
communication  on  "The  Value  of  the  Various  Prepa- 
rations of  Digitalis,"  and  Dr.  J.  C.  Wilson  "A  Brief 
Statistical  Paper  on  Enteric  Fever  Based  upon  One 
Hundred  and  Fifty  Hospital  Cases." 


July  lo,  1897] 


MEDICAL    RECORD. 


55 


Dr.  Henry  C.  Coe  has  been  appointed  to  the  new 
chair  of  gynecology  at  Bellevue  Hospital  Medical 
College. 

"The  Pittsburg  Medical  Review,"  having  been 
made  the  official  organ  of  the  Medical  Society  of  the 
State  of  Pennsylvania,  has  become  The  Fennsylvania 
Medicaljouriial.  The  new  journal,  like  the  old,  will 
continue  to  be  published  in  Pittsburg.  The  greatest 
good  that  we  can  wish  the  journal  under  its  new  name 
is  that  it  will  be  the  equal  in  excellence  of  its  former 
self. 

A  Disastrous  Fire — Shortly  after  the  close  of  a 
brilliant  reception  given  some  time  ago  at  the  house 
of  Dr.  B.  Sherwood  Dunn,  in  Los  Angeles,  fire  broke 
out,  and  before  the  department  could  respond  and  get 
a  stream  upon  the  flames  the  entire  structure  was 
consumed,  together  with  its  contents,  including  many 
valuable  paintings,  bronzes,  and  tapestries  collected 
by  Dr.  Dunn  during  his  residence  in  Paris. 

International  Deaf-Mute  Congress. — A  convention 
of  educators  of  deaf-mutes  is  to  be  held  in  Glasgow 
on  July  28th-3ist,  and  will  be  immediately  followed 
by  an  international  congress  of  deaf-mutes  in  Lon- 
don, August  3d-9th. 

Tuberculin  in  France.— According  to  French  law 
the  sale  of  serums  is  authorized  only  after  the  Academy 
of  Medicine  has  given  its  approval  to  samples  and  in- 
spected the  laboratories  where  they  are  prepared. 
This  law  was  passed  to  prevent  all  sorts  of  serums  be- 
ing put  forward  by  druggists  without  any  guarantee  of 
asepsis  or  strength.  Very  few  laboratories  obtain  the 
necessary  certificate.  Koch's  tuberculin,  the  Paris 
correspondent  of  The  Lancet  writes,  to  have  the  right 
of  entry  in  France  for  sale,  has  had  to  undergo  the 
judgment  of  the  academy,  based  upon  the  report  of 
M.  Nocard,  the  assistant  director  of  the  Pasteur  In- 
stitute. The  report  commenced  by  saying  that  any 
French  product  produced  under  circumstances  pre- 
cluding the  academy  from  any  surveillance  as  regards 
the  conditions  of  its  manufacture  would  certainly  be 
refused.  The  sample  sent  in  amounted  to  one  cubic 
centimetre,  enough  for  only  one  experiment,  and  the 
liquid  was  turbid  and  full  of  bacteria  and  yeast  fungi. 
The  bacteria  were  very  possibly  not  pathogenic;  but 
their  presence  was  not  reassuring,  for  it  would  appear 
to  show  that  the  liquid  was  not  prepared  under  aseptic 
conditions,  and  even  if  the  organisms  did  no  harm  to 
the  patient  they  would  probably  weaken  the  power  of 
the  serum.  The  academy,  fearing  that  a  refusal  of 
the  authorization  would  be  attributed  to  national  jeal- 
ousy, has  authorized  the  introduction  of  the  lymph 
provisionally,  despite  the  report  of  M.  Nocard.  Many 
of  the  papers  have  published  articles  expressing  regret 
at  this  decision. 

Obituary  Notes — Dr.  Ira  B.  Read,  of  this  city, 
died  of  pulmonary  tuberculosis  on  July  4th.  He  was 
born  at  Norwalk,  Ohio,  and  was  a  graduate  of  the 
University  of  Michigan  in  1867,  and  of  the  Bellevue 
Hospital  Medical  College  in  1868.— Dr.  McD.  M. 
Powell,  of  Collinsville,  111.,  shot  himself  on  June 
20th.      He  was  thirty-four  years  old,  and  was  a  gradu- 


ate of  the  St.  Louis  Medical  College  in  1886. — Dr. 
James  Cavanaugh  died  at  Easton,  Pa.,  on  June  28th, 
at  the  age  of  sixty-seven  years.  He  was  graduated 
from  the  medical  department  of  the  University  of 
Pennsylvania,  in  1850,  and  was  at  the  time  of  his 
death  president  of  the  local  United  States  pension  ex- 
amining board.  He  was  for  many  years  physician  to  the 
Northampton  County  prison  and  surgeon  to  the  Cen- 
tral Railroad  of  New  Jersey. — Dr.  W.  H.  H.  Hutton, 
of  the  Marine  Hospital  service,  died  on  June  14th. 
He  was  born  in  York,  Ohio,  in  1838.  He  served  in 
the  union  army  during  the  civil  war.  He  attended 
his  first  course  of  medical  lectures  at  the  Alabama 
Medical  College,  at  Mobile,  and  on  March  16,  1875, 
was  graduated  from  the  Chicago  Medical  College, 
Chicago,  111.,  receiving  from  this  institution  the  first 
prize  of  the  faculty  for  the  best  graduating  thesis. 
He  was  appointed  assistant  surgeon  in  the  Marine 
Hospital  service,  in  1875,  ^""^  ^'^^  promoted  to  the 
grade  of  surgeon  the  following  year.  During  his  con- 
nection with  the  Marine  Hospital  service,  he  served 
as  commanding  officer  at  the  stations  of  New  York, 
Cincinnati,  New  Orleans,  Detroit,  Louisville,  Mobile, 
and  Baltimore.  In  addition  to  the  above  duties  he 
rendered  valuable  service  at  Brunswick  and  Way  Cross, 
Ga.,  and  Camp  Perry,  Fla.,  in  1888,  in  enforcing  the 
quarantine  and  other  measures  during  the  yellow-fever 
epidemic  of  that  year,  and  again  at  Brunswick,  Ga., 
during  the  yellow-fever  epidemic  in  1893.  At  Camp 
Perry  he  installed  and  was  in  command  of  the  first 
detention  camp,  which  proved  so  successful  in  the 
management  of  the  epidemic  at  that  time  raging  in 
Jacksonville.  He  was  also  in  charge  of  the  quaran- 
tine establishment  at  Sandy  Hook,  N.  J.,  during  the 
cholera  scare  in  1892,  and  later  in  the  same  year 
rendered  efficient  services  in  the  establishment  of  the 
quarantine  flotilla  at  Cape  Charles. — Dr.  Richard 
Smith  Bacon,  for  many  years  head  master  of  the 
Columbia  Grammar  School,  died  at  his  home  in  this 
city  on  July  6th.  He  was  a  graduate  of  the  College 
of  Physicians  and  Surgeons  in  this  city,  but  practised 
medicine  only  about  a  year. — Dr.  John  B.  Carpenter 
died  June  17,  1897,  at  Groveton,  N.  H.,  aged  thirty- 
five  years.  He  was  a  graduate  of  Buffalo  Medical 
College  in  the  class  of  1893.  He  practised  two  years 
in  Washington,  D.  C,  and  two  years  in  Groveton. 
He  was  a  member  of  the  Medical  Association  of  the 
District  of  Columbia,  and  also  a  member  of  the  New 
Hampshire  Medical  Society. 

Epidemic  Ophthalmia — It  is  reported  from  Ham- 
burg that  granular  ophthalmitis  prevails  there  to  an 
alarming  extent  among  the  school  children. 

Trouble  at  the  Collins  State  Hospital. — It  is  re- 
ported that  the  selection  of  Dr.  Daniel  H.  Arthur,  of 
Middletown,  as  superintendent  of  the  Collins  State 
HomcEopathic  Hospital  of  Erie  County,  by  the  board 
of  managers  of  that  institution,  to  succeed  Dr.  G. 
Allen,  will  not  be  recognized  by  the  State  lunacy 
commission  until  the  courts  have  passed  upon  the 
legality  of  the  action  taken  by  the  local  board  in  dis- 
missing Dr.  Allen.  The  matter  must  be  taken  to  the 
courts  very  soon,  as  the  Collins  Hospital   cannot  be 


56 


MEDICAL    RECORD. 


[July  lo,  1897 


run  without  money  obtained  through  the  lunacy  com- 
mission. Dr.  Allen  has  engaged  counsel  and  will 
contest  the  right  of  the  managers  to  remove  him. 
The  newly  appointed  superintendent  is  enjoying  a 
leave  of  absence  until  the  question  of  his  legal  exist- 
ence as  a  superintendent  is  determined. 

The  American  Medical  Temperance  Association 
held  a  meeting  on  July  5th,  at  Prohibition  Park, 
Staten  Island,  under  the  presidency  of  Dr.  T.  D. 
Crothers.  Most  of  the  speakers  held  that  the  use  of 
alcohol  in  medical  practice  is  not  only  unnecessary 
but  harmful.  One  of  them  was  reported,  we  trust  in- 
correctly, to  have  said  that  one  grain  of  wheat  con- 
tained more  nutrition  than  a  keg  of  beer.  It  is  re- 
grettable, for  the  sake  of  the  cause  which  they  advocate, 
that  so  many  temperance  orators  say,  or  are  reported 
to  say,  things  that  are  absurd  and  untrue. 

The  Late  Dr.  J.  Lewis  Smith. — It  is  with  sorrow 
that  we  record  in  the  minutes  of  the  faculty  of  the 
Bellevue  Hospital  Medical  College,  the  death  on  June 
9,  1897,  of  Dr.  J.  Lewis  Smith,  late  clinical  professor  of 
diseases  of  children.  Dr.  Smith  was  a  teacher  in  the 
college  for  thirty  years.  He  brought  to  his  instruc- 
tion a  ripe  experience  and  sound  judgment,  and  had 
attained  a  most  enviable  reputation,  not  only  as  a 
public  teacher  but  as  a  voluminous  writer  on  the  sub- 
jects of  his  special  studies.  His  loss  will  be  deeply 
felt,  not  only  by  the  profession  but  by  the  public  at 
large,  who  benefited  so  much  by  his  skill  and  devo- 
tion. Austin   Flint,  Secretary. 

Cheating  at  State  Medical  Examinations — From 
the  State  of  Pennsylvania  comes  the  report  that  in 
connection  with  the  recent  examinations  held  in  Phil- 
adelphia of  applicants  for  license  to  practise  medi- 
cine unsuccessful  attempts  were  made  to  secure  in 
advance  by  subterfuge  copies  of  the  questions  that 
were  to  be  put.  One  of  the  applicants  w^as  not  per- 
mitted to  conclude  his  examination  on  account  of  be- 
ing detected  in  the  possession  of  printed  questions 
which  had  been  secured  for  the  purpose  of  illegiti- 
mate aid. 

The  Dispensary  Abuse  in  Pennsylvania. — The 
medical  board  of  each  of  the  three  hospitals  of  Read- 
ing, Pa.,  has  appointed  a  committee  of  three  "for  the 
purpose  of  formulating  a  code  of  rules  under  which 
the  pecuniary  interests  of  the  medical  profession  can 
be  protected  without  prejudice  to  the  deserving  poor." 
Among  other  things  it  is  alleged  that  "  persons  in 
well-to-do  circumstances  are  in  the  habit  of  accepting 
medical  and  surgical  services  at  our  charitable  institu- 
tions free  of  charge." 

J.    M.   Da    Costa,    M.D.,  LL.D .\t   the  annual 

commencement  of  Harvard  University,  on  June  23d, 
the  honorary  degree  of  doctor  of  laws  was  conferred 
upon  Dr.  J.  M.  Da  Costa,  of  Philadelphia. 

Chautauqua  County  (N.  Y.)  Medical  Society 

The  annual  meeting  of  the  Chautauqua  County  Medi- 
cal Society  will  be  held  at  Chautauqua  Assembly, 
Tuesday,  July  13,  1897,  and  will  be  called  to  order 
at  II   o'clock  A.M.      The  annual  election  and  other 


routine  business  will  be  transacted,  including  the 
voting  upon  the  amendment  to  the  constitution  relative 
to  the  time  of  holding  the  semi-annual  meeting.  The 
president  is  Dr.  E.  S.  Rich,  of  Kennedy,  and  the  sec- 
retary Dr.  C.  A.  Ellis,  of  Sherman. 

Examinations  for  the  Army  Medical  Corps. — 
An  army  medical  board  will  be  in  session  at  Wash- 
ington City,  D.  C,  during  October,  1897,  for  the  ex- 
amination of  candidates  for  appointment  to  the  medi- 
cal corps  of  the  United  States  army,  to  fill  the  five 
existing  vacancies.  Persons  desiring  to  present  them- 
selves for  examination  by  the  board  will  make  ap- 
plication to  the  secretary  of  war,  before  September  i, 

1897,  for  the  necessary  invitation,  giving  the  date  and 
place  of  birth,  the  place  and  State  of  permanent  resi- 
dence, the  fact  of  American  citizenship,  the  name  of 
the  medical  college  from  which  they  were  graduated, 
and  a  record  of  service  in  hospital,  if  any,  from  the 
authorities  thereof.  The  application  should  be  ac- 
companied by  certificates  based  on  personal  acquaint- 
ance, from  at  least  two  reputable  persons,  as  to  his 
citizenship,  character,  and  .  habits.  The  candidate 
must  be  between  twenty-two  and  twenty-nine  years  of 
age,  and  a  graduate  from  a  regular  medical  college,  as 
evidence  of  which  his  diploma  must  be  submitted  to 
the  board.  Successful  candidates  at  the  coming  ex- 
amination will  be  given  a  course  of  instruction  at  the 
next  session  of  the  Army  Medical  School,  beginning 
November  i,  1897.  Further  information  regarding 
the  examinations  may  be  obtained  by  addressing  Dr. 
George  M.  Sternberg,  Surgeon-General,  United  States 
Army,  Washington,  D.  C. 

The  Senn  Surgical  Prize. — A  medal,  to  be  known 
as  the  Nicholas  Senn  prize  medal,  will  be  awarded 
at  the  annual  meeting  in  1898,  to  that  member  of  the 
American  Medical  Association  who  shall  present  the 
best  essay  upon  some  surgical  subject.  Two  other 
essays,  if  any  are  worthy,  will  receive  honorable  men- 
tion. The  conditions  of  the  competition  are  as  fol- 
lows: I.  The  name  of  the  author  of  each  competing 
essay  shall  be  inclosed  in  a  sealed  envelope  bearing 
a  suitable  motto  or  device,  the  essay  itself  bearing  the 
same  motto  or  device;  the  title  of  the  successful 
essay  and  the  motto  or  device  to  be  read  at  the  meet- 
ing at  which  the  award  is  made,  and  the  correspond- 
ing envelope  to  be  then  and  there  opened  and  the 
name  of  the  successful  author  announced.  2.  All 
successful  essays  become  the  property  of  the  associa- 
tion. 3.  The  competition  is  to  be  confined  to  those 
who  at  the  time  of  entering  the  competition,  as  well 
as  at  the  time  of  conferring  the  medal,  shall  be  mem- 
bers of  the  .\merican  Medical  Association.  4.  The 
competition  will  be  closed  three  months  before  the 
next  annual  meeting  of  the  American  Medical  Asso- 
ciation, and  no  essays  will  be  received  after  March  i, 

1898.  Competitors  will  address  their  essays  to  Dr.  J. 
McFadden  Gaston,  i  y^  Edgewood  Avenue,  Atlanta,  Ga. 

Some  Colored  Scalawags,  who  swindled  a  number 
of  medical  men  in  this  town  last  year  by  soliciting 
alms  for  the  support  of  an  alleged  school  in  Virginia, 
have  at  last  come  to  grief.     They  approached  a  num- 


July  lo,  1897] 


MEDICAL    RECORD. 


57 


ber  of  clergj^men,  who  are  more  conversant  with  wick- 
edness of  that  sort  than  the  innocent  and  guileless 
doctor,  with  the  result  of  falling  into  the  hands  of  the 
police. 

Mississippi    Department    of    Public    Health A 

bill  has  recently  passed  the  Mississippi  legislature 
providing  "  that  the  Mississippi  State  Medical  Asso- 
ciation and  all  other  State,  district,  and  count}'  medi- 
cal societies  and  associations  of  the  State  in  affiliation 
with  the  purposes  of  its  organization,  are  hereby  con- 
stituted the  '  Mississippi  Department  of  Public  Health  ' 
and  any  licensed  practitioner  of  medicine  in  the  State 
of  Mississippi,  who  is  a  graduate  of  an  approved  in- 
stitution of  medicine,  may  on  application  have  his 
name  enrolled  as  a  member  of  said  department." 
The  duties  of  this  department  are,  through  its  com- 
mittees, to  exercise  a  general  superintendence  over  the 
health  interests  of  the  State,  the  collection  of  vital 
statistics,  and  the  development  of  medical  literature: 
to  prescribe  rules  and  regulations,  with  a  specification 
of  duties,  for  the  conduct  and  reports  of  said  com- 
mittees; to  investigate  and  report  upon  the  hospitals, 
asylums,  and  other  like  institutions  in  the  State:  to 
take  cognizance  of  and  make  recommendations  for 
the  interest  of  health  and  life  among  the  people  gen- 
erally; to  investigate  the  causes,  means  of  prevention, 
and  treatment  of  endemic  and  epidemic  diseases;  to 
investigate  the  influences  of  localities  and  employ- 
ments upon  the  public  health ;  and  to  act  as  an  ad- 
visory board  to  the  State  in  all  hj-gienic  and  medical 
matters. 

A  Medical  Mayor. — Dr.  M.  Gibson  Porter,  a  grad- 
uate of  the  University  of  Mar}-land,  has  been  elected 
the  second  time  as  mayor  of  the  town  of  Lonaconing, 
Md. 

The  Superintendent  of  the  Molokai  Leper  Col- 
ony, Mr.  H.  R.  Meyer,  died  recently  of  heart  disease. 
He  was  a  resident  of  the  island  at  the  time  the  colony 
was  established,  and  was  its  superintendent  for  many 
years. 

The  Chalfont  Epileptic  Colony — Mr.  Bayard,  re- 
cently United  States  ambassador  at  the  Court  of  St. 
James,  laid  the  foundation  stone  of  the  new  Home  for 
Men,  presented  by  Mr.  Passmore  Edwards  to  the  Na- 
tional Society  for  the  Employment  of  Epileptics  at  the 
Colony  Chalfont,  St.  Peter,  Bucks,  on  Thursday,  May 
6th,  at  three  o'clock.  Mrs.  Bayard  opened  the  Home 
for  Women  at  the  colony,  also  the  gift  of  Mr.  Ed- 
wards, on  the  same  day. 

Jefferson   Medical   College A  scientific  meeting 

of  the  Philadelphia  Chapter  of  the  Alumni  Associa- 
tion of  the  Jefferson  Medical  College  was  held  in  the 
college  building  on  May  loth.  Dr.  John  Lindsay 
read  a  paper  on  "  The  Treatment  of  Acute  Anterior 
Urethritis  in  the  Male,"  in  the  discussion  of  which 
Drs.  J.  Chalmers  Da  Costa  and  On-ille  Horwitz  took 
part.  Dr.  Addinell  Hewson  was  elected  President; 
Dr.  J.  L.  Salinger,  Corresponding  Secretary  :  Dr.  W. 
M.  Sweet,  Recording  Secretary  ;  and  Dr.  J.  A.  Cantrell, 
Treasurer. 


Baltimore  County  Medical  Society.— The  physi- 
cians of  Baltimore  County,  Md.,  have  formed  a  County 
Medical  Society,  and  it  is  expected  that  such  socie- 
ties will  be  formed  in  the  other  counties  not  already 
having  them. 

An  Accusation  against  Harvard.—  Mr.  Moody, 
the  evangelist,  is  reported  by  the  daily  press  to  have 
asserted,  in  the  course  of  an  address  in  Boston,  that 
Har\ard  Universit)-,  the  Medical  Department  in  par- 
ticular, is  a  sink  of  moral  iniquit}-.  As  well  might 
one  say  that  the  Methodist  Church  is  a  hotbed  of  im- 
moralit}'  because  a  Methodist  minister  was  dismissed 
from  his  pastorate  a  few  days  ago  for  the  reason  that 
he  was  the  father  of  his  ser^-ant's  infant.  Mr.  Moody 
is  not  the  only  one  who  seems  to  think  the  cause  of 
religion  can  be  helped  by  intemperate  statements,  the 
exaggeration  in  which  borders  very  closely  on  the 
deliberately  spoken  untruth. 

A  Great  Man  Gone. — A  most  successful  maker  of 
quack  medicines  in  Berlin  recently  committed  suicide 
while  suffering  from  religious  mania.  His  income 
from  the  sale  of  his  remedies  was  estimated  at  over 
$50,000  a  year. 

Private  Hospitals  in  Berlin  are  threatened  in  their 
existence  by  the  new  regulations  issued  by  the  Prus- 
sian government.  According  to  these,  no  building 
used  in  whole  or  in  part  as  a  hospital  can  have  a 
courtyard  enclosed  on  all  four  sides:  the  corridors  in 
all  hospitals  must  be  at  least  1.8  metres  (five  feet  ten 
inches)  in  width,  the  staircase  must  be  of  a  certain 
width,  and  the  steps  of  a  certain  prescribed  height, 
and  no  room  with  none  but  north  windows  can  be  oc- 
cupied by  patients.  These  and  other  regulations,  if 
strictly  enforced,  will  make  it  impossible  to  use  any 
apartment  for  private  hospitals,  and  those  surgeons 
who  wish  to  maintain  those  they  now  have  will  be 
forced  to  erect  special  buildings — a  serious  matter  in 
Berlin,  where  land  is  very  expensive. 

English  Bacteriologists  are  apparently  held  in  as 
slight  esteem  by  the  government  of  Cape  Colony  as 
English  ophthalmologists  are  by  Queen  Victoria. 
Koch  was  hired  to  go  there  to  study  the  rinderpest, 
and  now  Kolle,  of  the  Berlin  Institute  for  Infectious 
Diseases,  has  received  a  year's  leave,  says  the  Medi- 
cal Times,  in  order  to  proceed  to  Cape  Colony,  where 
he  has  been  commissioned  by  the  Cape  Government 
to  cany  on  the  work  of  Professor  Koch.  He  will  con- 
tinue the  investigation  into  rinderpest  and  leprosy, 
and  organize  stations  for  the  study  of  those  diseases. 

The  Maryland  Homoeopathic  Hospital  in  Balti- 
more is  to  be  rebuilt  on  the  site  of  its  present  build- 
ing, which  is  much  too  small  to  accommodate  all  the 
applicants  for  admission.  The  proposed  building  is 
to  be  five  stories  high,  with  a  basement,  and  a  front- 
age of  one  hundred  and  fifty  feet  by  a  depth  of  sixty. 
The  cost  will  be  from  S8o,ooo  to  $100,000,  and  will 
be  raised  by  subscripion,  as  the  institution  is  wholly 
a  charitable  one.  During  the  past  year  there  were 
five  hundred  patients  treated  at  the  hospital,  and  four- 
teen thousand  prescriptions  were  put  up. 


58 


MEDICAL    RECORD. 


[July  lo,  1897 


J>ocietu  'Reports. 

AMERICAN   MEDICAL   ASSOCIATION. 

SECTION    OX   PRACTICE   OF   MEDICINE. 

J.  H.  MrssER,  M.D.,  Philadelphia,  Chairman. 

(Continued  from  page  29. j 

Thursday^  June  jii — Morning  Session. 

The  Application  of  the  Roentgen  Rays  to  Medi- 
cal Diagnosis. — Dr.  C.  L.  Leonard,  of  Philadelphia, 
was  the  author.  The  chief  advantage  of  the  radio- 
graphic method  over  previous  methods  was  in  the  fact 
that  it  formed  real  images,  whereas  only  mental  pictures 
existed  before;  it  eliminated  the  personal  equation  of 
the  observer  from  the  question  of  diagnosis.  The 
radiographs  could  be  retained  for  comparison  with 
others  of  similar  conditions.  The  application  in 
medicine  was  considerably  different  from  that  in 
surgery.  The  results  thus  far  had  not  been  so  bril- 
liant, but  the  field  promised  to  be  even  greater  than 
in  surgery.  The  author  showed  radiographs  of  cer- 
tain diseased  conditions  in  the  thorax,  abdomen,  and 
pelvis.  It  was  of  value  in  outlining  aneurism  of 
the  aorta.  In  one  case  it  showed  that  the  subcla- 
vian could  be  ligated  at  the  point  of  election  for  an 
existing  aneurism  without  involving  the  tumor.  In 
a  case  of  dilatation  of  the  heart  the  walls  were  so 
thin  that  the  light  penetrated  them  easily.  In  a 
case  of  dilatation  of  the  stomach  the  organ  was  washed 
out  and  a  solution  of  bismuth  salts  injected,  lining 
the  interior  of  the  cavitj';  the  shadow  cast  by  these 
salts  was  deeper  than  that  of  the  pelvic  walls,  thus 
enabling  an  observer  to  map  out  the  area  of  the  stom- 
ach. In  a  case  of  fluid  in  the  peritoneum,  this  was 
shown  b}'  deeper  shadow,  the  shadow  changing  its  po- 
sition with  the  movement  of  the  fluid.  In  the  same 
case  a  button  was  supposed  to  be  in  the  stomach,  but 
its  absence  was  proven. 

Tuberculosis  Antitoxin. — Dr.  E.  A.  de  Schweinitz, 
of  Washington,  gave  a  n'sumt' oi  experiments  made  in 
the  production  of  a  tuberculosis  antitoxin.  Briefly, 
such  a  substance  could  be  produced,  though  in  small 
amount,  w'hich  would  protect  an  animal  from  a  fatal 
dose  of  tuberculin  or  which  would  retard  a  fatal  issue 
from  th^  usual  time  of  three  or  four  weeks  to  ten  or 
twelve  weeks.  If  he  might  judge  from  his  own  results 
and  a  study  of  those  obtained  abroad,  it  was  possible 
that  an  antitoxin  could  be  produced  for  tuberculosis,  but 
treatment  by  this  method  was  still  in  the  experimental 
stage  and  would  probably  remain  so  until  it  became 
possible  to  protect  guinea-pigs  against  tuberculosis 
and  cure  them  when  infected,  as  was  done  in  the  case 
of  diphtheria  with  diphtheritic  antitoxin. 

Antituberculin. — Dr.  J.  McFarland,  of  Phila- 
delphia, said  his  paper  contained  the  results  of  exper- 
iments similar  to  those  of  the  last  reader,  only  he  had 
devoted  more  attention  to  antituberculin.  He  first 
gave  reasons  for  his  belief,  entertained  from  the  first, 
that  tuberculin  must  fail.  Among  these  was  the  path- 
ological fact  that  tuberculosis  was  an  inflammatory, 
not  a  toxic  condition.  Many  cases  progressed  to  the 
extent  of  producing  considerable  destruction  of  organs 
before  constitutional  conditions  manifested  themselves. 
Fin.illy,  when  the  tuberculous  nodes  began  to  disinte- 
grate, other  germs  appeared.  The  reader  disclaimed 
originality  in  the  use  of  antituberculin,  mentioning 
the  work  of  Paul  Paquin  and  others.  It  was  not  irra- 
tional to  suppose  that  it  might  add  to  the  resistance  of 
the  tissues,  or  prevent  breaking  down  of  those  in  which 
the  tubercle  bacilli  were  encapsulated,  thus  limiting 
their  spread  to  others.  In  doing  this  it  would  slow  the 
pulse,  stop  hectic,  etc.     The  animals  which  he  had  ex- 


perimented upon  had  not  recovered,  but  life  seemed  to 
have  been  prolonged.  Moreover,  guinea-pigs,  it  was  to 
be  remembered,  were  extremely  susceptible  to  tuber- 
culosis, and  because  an  agent  might  not  be  altogether 
successful  in  them  it  did  not  prove  that  it  would  not  be 
in  man.  The  guinea-pigs  on  which  he  had  practised 
immunization  longest  were  still  alive,  but  he  could 
not  say  that  they  had  not  tuberculosis,  since  there  were 
enlarged  glands.  He  had  found  the  tuberculin  harm- 
less in  both  healthy  and  tuberculous  guinea-pigs.  In 
man  the  remedy  had  been  applied  systematically  in 
about  twenty  cases.  He  thought  one  could  be  reported 
as  cured,  one  as  ver}-  encouraging,  one  as  distinctly 
better,  three  decidedly  improved,  five  improved  some- 
w-hat,  seven  not  definitely  changed,  two  worse;  three 
subjects  had  died,  but  not  because  of  the  treatment. 
Urticaria  was  almost  uniformly  present,  which  might 
be  accounted  for  by  the  fact  that  serum  of  the  ass  was 
used,  which  was  more  irritating  than  that  of  the  horse. 
There  was  some  pain  in  the  back  and  jaw. 

A  Report  on  Treatment  of  Tuberculosis. — Dr.  D. 
L.  Rochester,  of  Buffalo,  gave  some  experience  with 
different  methods  of  treatment  of  tuberculosis,  includ- 
ing the  use  of  Paquin's  tuberculous  antitoxin, Vaughan's 
nuclein,  and  Edson's  aseptolin.  When  criticised  for 
mentioning  the  latter  he  said  he  had  used  it  soon  after 
the  paper  describing  it  was  first  published  and  at  the 
request  of  the  patients  themselves.  The  number  of 
cases  treated  w ith  it  was  nine,  with  four  deaths,  one, 
he  thought,  as  a  result  of  the  agent  used.  In  no  case 
could  he  report  a  cure,  and  when  improvement  had 
taken  place  it  could  be  attributed  to  other  factors,  espe- 
cially that  of  living  out  of  doors.  Paul  Paquin's  tuber- 
culous antitoxin  was  of  no  value  when  phthisis  was 
at  all  advanced,  and  he  had  been  compelled  to  dis- 
continue it  by  the  patients  themselves,  because  of  der- 
matitis and  pain.  As  to  Vaughan's  nuclein,  it  had 
been  a  benefit  in  all  cases  but  one.  It  did  no  harm 
if  the  injections  were  not  too  rapidly  increased.  One 
patient  recovered,  although  there  was  a  cavit}-  at  the 
beginning  of  the  treatment  two  years  ago.  Yet  with- 
out exercise  and  fresh  air  all  efforts  must  count  for 
naught.  The  author  considered  treatment  of  special 
symptoms,  cough,  anaemia,  etc. 

A  Further  Report  on  the  Treatment  of  Tuber- 
culosis by  Iodoform  Inunctions. —  Dk.  L.  F.  Flick, 
of  Philadelphia,  referred  in  this  paper  to  one  which 
he  had  read  before  the  Philadelphia  County  Medical 
Society,  on  the  use  of  iodoform  inunctions  in  tubercu- 
losis, he  having  begun  its  use  about  eight  years  ago. 
The  conclusions  drawn  from  over  one  hundred  cases 
were  that  it  was  unsafe  to  form  an  opinion  of  a  treat- 
ment of  tuberculosis  within  a  short  time  after  its  com- 
mencement. Unless  the  case  had  stood  the  test  of  a 
cure  a  number  of  years  it  could  not  be  placed  among 
the  cures.  He  was  now  compelled  to  report  many  of 
his  patients  as  dead  whom  he  had  reported  cured  two 
or  four  years  ago.  Mere  increase  in  weight  and  im- 
provement in  symptoms  were  no  e\  idence  of  permanent 
cure  of  tuberculosis.  In  his  earlier  cases  he  must 
report  at  least  eighty  per  cent,  mortality  to-day. 

Dr.  S.  Solis  Cohex  discussed  the  several  papers. 
He  could  not  agree  with  the  last  reader  that  a  remedy 
could  not  be  said  to  have  cured  tuberculosis  should 
the  patient  die  years  afterward.  There  might  be  re- 
infection. Then  a  remedy  might  be  of  great  value  in 
causing  improvement,  prolonging  life,  and  checking 
the  active  process  of  the  disease. 


Thuisday,  Jiim-  jii — Aftfrnoon  Session. 

Curability  of   Pulmonary   Tuberculosis. — Dr.  E. 

B.  BoRLAMi,  of  Pittsburg,  read  a  paper  on  this  subject. 
Evidence  was  accumulating  which  went  to  show  that 
tuberculosis  was  not  only  a  universal  disease  but  the 


July  lo,  1897] 


MEDICAL    RECORD. 


59 


universal  disease.  Twenty-five  per  cent,  was  much 
too.  low  an  estimate  of  the  total  number  of  infections. 
The  author  quoted  autopsy  statistics  from  which  he 
concluded  that  fully  fifty  per  cent,  of  the  people  were 
infected  at  some  period  of  life,  two-thirds  of  them 
with  the  pulmonary  form.  Now,  since  the  total  death 
rate  gave  only  fourteen  per  cent,  as  due  to  tuberculo- 
sis, it  became  evident  that  the  disease  was  not  so  ver\- 
fatal.  There  must  be  many  spontaneous  cures.  Not 
a  single  antitoxin  having  been  discovered  to  cure  the 
ailection,  the  physician  would  do  well  to  make  the 
best  use  of  older  methods.  Tuberculosis  uncompli- 
cated by  sepsis  could  be  considered  a  curable  disease 
in  the  sense  of  being  held  in  abeyance,  provided  the 
vital  resistance  of  the  individual  were  kept  up  to  the 
normal  standard.  Nature  had  been  known  completely 
to  eradicate  tuberculosis  in  a  number  of  instances. 
Nothing  could  prevent  infection  when  three  conditions 
were  present — debility,  abrasions,  tubercle  bacilli. 

Dk.  Dexisox,  of  Denver,  approved  of  the  work  of 
de  Schweinitz,  McFarland,  Trudeau,  Klebs,  and  others 
in  searching  for  a  tuberculin  or  an  antituberculin. 
He  himself  had  been  accused  of  getting  results  during 
trials  with  some  of  these  which  it  was  claimed 
were  due  to  the  influence  of  climate.  Still  he  ap- 
proved of  such  researches. 

Dr.  Klebs,  of  Citronella,  thought  it  would  be  a 
dangerous  conclusion  to  infer  that  experiments  with 
tuberculin,  etc.,  made  in  laboratories  were  without 
value,  and  that  we  must  limit  ourselves  to  clinical  ob- 
ser\'ations,  for  it  would  stop  scientific  research.  Tu- 
berculosis was  so  various  in  its  manifestations  that 
long  obser\ations  in  experimental  research  were  neces 
sary  to  establish  the  value  of  a  remedy  against  it.  Dr. 
Klebs  thought  the  State  should  erect  institutions  for 
the  treatment  of  tuberculous  patients,  as  in  them  they 
could  best  be  taught  to  carry  out  hygienic  measures, 
proper  disposal  of  the  sputa,  etc. 

Dr.  Herrick,  of  Cleveland,  could  not  accept  fully 
the  idea  of  tuberculosis  being  due  to  infection,  but 
was  inclined  to  regard  it  rather  as  a  disease  due  to 
disturbances  of  the  blood-making  processes.  He 
should  never  look  for  a  specific  agent  against  tubercu- 
losis. We  must  go  back  to  the  physiological  principle 
in  treatment  and  prevention. 

Dr.  Sterxberg  expressed  his  surprise  at  hearing  a 
doctor  speak  to-day  with  doubt  regarding  the  infec- 
tiousness of  tuberculosis.  He  then  briefly  gave  the 
proofs  of  infection  by  tubercle  bacillus. 

Others  who  discussed  the  papers  on  tuberculosis 
were  Drs.  Altex,  of  Kansas  City,  Upshur,  of  Rich- 
mond, Tysox,  Paul  Paquix. 

Some  Deformities  of  the  Chest  in  the  Light  of 
Its  Ancestry  and  Development. — Dr.  Woods  Hutch- 
ixm)X,  of  Bufl'alo,  spoke  on  this  subject.  There  were 
two  forms  of  chest:  i,  the  quadrupedal,  in  which  there 
was  great  antero-posterior  development;  2,  the  chest 
in  which  the  lateral  expansion  seemed  to  have  gone 
on  at  the  expense  of  the  antero-posterior  development. 
The  former  existed  in  dogs  and  lower  animals  with  the 
exception  of  the  bat.  As  one  approached  man  the  lat- 
eral expansion  became  greater.  Dr.  Hutchinson  ex- 
plained the  development  of  the  chest  of  lateral  expan- 
sion by  man  and  his  nearer  ancestry  assuming  the 
upright  position  and  swinging  by  the  arms.  Taking 
100  as  tlie  basis,  the  following  index  was  given:  Pro- 
portion of  depth  to  breadth  of  chest  in  man,  71 ;  dog, 
125;  foetus,  103;  infant,  87;  tuberculous  chest,  77. 
The  index  for  length  was  also  given.  In  chests  show- 
ing a  tendency  to  become  diseased,  especially  with 
tuberculosis,  we  saw  a  narrow  chest,  one  showing  a 
tendency  toward  the  ancestral  type.  He  had  at  one 
time  accepted  without  investigation  the  notion  of  a 
flat  chest  in  tuberculous  patients,  but  on  investigation 
had   found  that  this   flatness  was   always,   or  nearly 


always,  only  seeming;  that  there  was  in  reality  less 
breadth  than  normal,  and  the  apparent  flatness  was 
due,  he  thought,  to  lack  of  flat  surface  on  which  the 
shoulders  could  rest,  these  rolling  forward  and  giving 
a  hollow  appearance  across  the  chest.  Reversion  to 
the  primitive  type  in  circumstances  not  suitable  to  it 
was  the  starting-point  for  disease.  The  explanation 
of  the  fact  that  the  lung  was  the  organ  most  frequently 
attacked  by  disease,  especially  by  tuberculosis,  was 
that  in  the  light  of  ancestral  development  it  was  the 
youngest  organ  of  the  body. 

Management  and  Treatment  of  Malignant  Types 
of  Croupous  Pneumonia. — Dr.  D.  S.  Campbell,  of 
Detroit,  discussed  in  a  general  w-ay  the  treatment  of 
croupous  pneimionia,  dividing  the  cases  into  two 
classes — the  mild  ones  which  required  little  treat- 
ment, and  the  severer  ones  in  which  there  was  high 
fever  with  tendency  to  heart  paralysis.  It  was  in  the 
latter  that  he  had  found  cold  the  most  valuable  heart 
stimulant  and  antipyretic.  Cold  applications  were 
usually  indicated,  but  in  very  obstinate  cases  the  cold 
bath  should  be  employed. 

Dr.  H.  O.  \\'est,  of  Galveston,  thought  the  author 
had  emphasized  too  strongly  the  purely  mechanical 
eft'ects  of  pneumonia  and  the  fever  element,  and  had 
overlooked  the  toxic  influence. 

The  Hot  Bath  in  the  Treatment  of  Pneumonia. 
— Dr.  T.  Eichberg,  of  Cincinnati,  read  a  paper  in 
which  he  praised  highly  the  effects  of  the  hot  bath 
used  systematically  in  the  treatment  of  pneumonia. 
At  first  he  had  used  it  as  an  antipyretic,  repeating  it 
only  when  the  temperature  rose  above  103'  F.,  but 
subsequently  repeated  it  every  three  hours,  regardless 
of  the  temperature.  It  had  a  marked  influence  on  the 
nervous  symptoms,  one  of  which  was  undefinable  un- 
rest, which  it  caused  to  disappear;  the  pulse  improved, 
delirium  subsided,  the  respirations  diminished;  the 
patient  was  enabled  to  sleep.  The  temperature  of  the 
bath  was  from  90"  to  110°  F.,  according  to  circum- 
stances;  it  was  continued  ten  minutes. 

Cheyne-Stokes  Respiration — Dr.  N.  S.  Davis,  Jr., 
of  Chicago,  read  a  paper  on  this  subject,  describing 
characteristic  Cheyne-Stokes  respiration,  mentioning 
errors  in  diagnosis,  then  referring  to  treatment.  He 
had  found  much  literature  on  the  subject,  principally 
theorization  regarding  the  cause,  and  little  as  to  treat- 
ment. In  chronic  cases  with  weariness  of  respiration 
this  was  important,  yet  his  own  success  seemed  not  to 
have  been  great,  and  he  had  tried  various  drugs,  such 
as  nitrites,  strychnine,  etc.  The  latter,  strychnine,  had 
given  him  very  little  result.  Cheyne-Stokes  respira- 
tion occurred  at  times  in  various  maladies,  but  most 
frequently  in  urasmia  and  cerebral  affections.  It  had 
also  been  produced  experimentally.  Its  exact  nature 
was  unknown.  Undoubtedly  the  best  treatment  was 
that  directed  against  the  maladies  causing  it. 

Multiple  Neuritis  Following  Influenza. — Dr.  H. 
B.  Allyx,  of  Philadelphia,  expressed  the  opinion  in 
this  paper  that  influenza  was  not  an  infrequent  cause 
of  neuritis,  sometimes  of  multiple  neuritis.  Person- 
ally he  had  seen  more  cases  of  neuritis  in  influenza 
the  past  year  than  in  the  previous  five  years,  and  more 
in  mild  cases  of  influenza  than  in  severe  ones.  It 
was  probable  that  some  cases  of  supposed  neuralgia 
were  cases  of  a  moderate  degree  of  neuritis. 

A  Case  of  Acute  Lymphatic  Leukaemia  with 
Streptococcus  Infection Dr.  J.  B.  Herrick,  of  Chi- 
cago, reported  the  case.  The  patient  was  a  saloon 
keeper,  twenty-seven  years  of  age,  who  had  been  quite 
well  a  few  weeks  before  Dr.  Herrick  saw  him;  he  was 
then  under  the  care  of  a  physician  who  stated  that  he 
first  had  a  sharp  attack  of  sore  throat,  with  recurrence 
after  a  week,  and  then  rapid  enlargement  of  the  glands 
of  the  neck,  axilla,  and  groin.  The  spleen  was  enlarged. 
He  was  under  Dr.   Herrick's  observation    only  three 


6o 


MEDICAL    RECORD. 


[July  lo,  1897 


days  before  death.  Besides  lymphatic  enlargements 
and  increase  in  the  size  of  the  spleen,  there  were 
numerous  retinal  hemorrhages,  pallor  of  skin  and  mu- 
cous membranes,  hemorrhagic  tendency  particularly 
marked  in  the  nose,  and  malaise.  The  blood  was  ex- 
amined once,  and  showed  great  increase  in  the  white 
cells  compared  with  the  red.  Streptococci  were  found, 
and  the  question  arose  whether  the  acute  leukaemia 
was  due  to  streptococcus  infection  in  the  throat.  It 
seemed  quite  certain  that  leukaemia  had  not  existed 
prior  to  the  throat  infection. 

Chronic  Inflammation  and  Ulceration  of  the 
Duodenum,  with  Resultant  Reflexes. — Dr.  J.  M. 
Alten,  of  Kansas  City,  Mo.,  related  in  this  paper 
clinical  and  pathological  observations  with  regard  to 
chronic  inflammation  and  ulceration  of  the  duodenum 
and  resultant  reflexes.  This  condition  of  the  duode- 
num was  very  frequent,  according  to  his  studies,  but 
had  received  very  little  attention  from  authors  of  text- 
books. He  thought  he  did  not  exaggerate  when  he 
stated  that  in  his  experience  as  many  as  tive  or  six 
hundred  cases  in  which  there  was  a  question  between 
duodenal  and_ gastric  trouble  had  come  to  autopsy  and 
a  decision  was  rendered  from  gross  and  microscopical 
appearances.  A  very  common  cause  of  various  reflex 
nervous  symptoms,  including  such  grav^e  conditions  as 
epilepsy,  melancholia,  and  insanity,  was  chronic  in- 
flammation and  ulceration  of  the  duodenum.  The 
most  common  origin  of  the  latter  was  in  typhoid  fever, 
and  it  was  seen  in  phthisis  pulmonalis,  chronic  dys- 
entery, acute  irritation,  etc.  He  had  investigated 
thirty  cases  of  diabetes  mellitus,  in  all  made  a  diag- 
nosis of  chronic  inflammation  of  the  duodenum,  and 
confirmed  it  by  autopsy  in  seven.  Was  the  relation 
between  the  two  direct,  through  interference  with  the 
digestive  function  in  the  duodenum,  or  was  it  indirect, 
through  reflex  interference  with  the  nervous  mechan- 
ism controlling  sugar  formation?  Treatment  included 
attention  to  gastric  and  rectal  feeding.  Epilepsy  of 
this  origin  could  be  cured  if  treatment  were  begun  be- 
fore the  second  year  of  its  existence. 

Dr.  Board.man  Reed  queried  whether  some  of  the 
cases  might  not  have  been  due  to  disturbances  of 
other  portions  of  the  gastro-intestinal  tract  and  the 
nervous  symptoms  caused  by  toxaemia,  instead  of  being 
reflex. 

Dr.  Alten  did  not  believe  that  there  could  be  ab- 
sorption of  toxins  in  the  gastro-intestinal  tract  with- 
out a  lesion  of  the  mucous  membrane.  It  was  against 
reason. 


Friday,  June  4.th — Moniiitg  Session. 

Discussion  on  Gout. — The  discussion  on  this  sub- 
ject was  opened  by  Dr.  Woods  Hutchinson,  of  Buf- 
falo, who  spoke  more  particularly  from  the  point  of 
view  of  ancestral  development.  Attention  was  first 
called  to  the  universality  of  gout,  not  only  in  man  but 
also  in  the  higher  species  of  animals.  As  Sydenham 
had  said,  gout  is  the  lord  of  disease  and  the  disease 
of  lords.  It  had  been  said  that  it  did  not  exist  much 
in  our  new  country,  but  this  was  an  erroneous  impres- 
sion, due  to  its  manifesting  itself  usually  in  forms  more 
or  less  dilTerent  from  that  in  the  classical  cases  of 
England.  Dr.  Hutchinson  mentioned  some  of  the 
lithamic  forms  of  gout  manifested  in  dyspepsia,  neu- 
ralgia, hay  asthma.  Rheumatism — well,  all  we  could 
say  about  -t  was  that  outside  the  acute  inflammatory 
variety  two-thirds  of  it  was  gout  and  the  other  third 
we  knew  nothing  about.  Gout  also  manifested  itself 
in  gynaecological  affections,  conditions  of  the  larynx, 
degeneration  of  the  arteries,  leading  to  Bright's  dis- 
ease of  the  kidneys,  etc.  What  was  lithrtmia?  It 
must  be  something  allied  very  closely  to  the  normal 
processes  of  the  body,  or  by  its  multitudinous  mani- 


festations it  would  soon  exterminate  the  individual. 
It  was  a  bad  habit,  a  kind  of  alcoholic  habit,  so  to 
speak,  which  the  tissues  had  of  falling  into.  It  was  a 
partial  reversion  to  the  avian  or  reptilian  type  in  the 
metabolism  of  the  cells.  The  same  elements  pro- 
duced by  the  ultimate  metabolism  of  our  bodies  caused 
in  us  gout,  while  in  birds  or  reptiles  it  was  in  harmony 
with  the  normal  health,  and  gout  in  them  was  the  result 
of  a  further  reversion.  The  same  law  could  be  traced 
even  to  plants.  Treatment  consisted  in  the  employ- 
ment of  any  means  to  keep  the  tissues  up  to  the  high- 
est possible  degree  of  metabolism  and  vigor.  Exer- 
cise, more  exercise,  more  exercise!  '"Live  on  a 
shilling  a  day  and  earn  it!'' 

The  Gastro-intestinal  and  Hepatic  Relations  and 
Manifestations  of  Gout. — Dr.  Charles  Stockton,  of 
Buffalo,  read  a  paper  on  this  subject.  In  his  conclu- 
sions he  stated  that  gout  was  a  disease  to  which  certain 
individuals  were  predisposed,  and  which  depended  for 
its  development  upon  causes  largely  unknown.  Lazi- 
ness, full  nitrogenous  diet,  and  the  use  of  fermented 
liquors  predisposed  to  the  disease.  So-called  lithae- 
mia,  as  the  term  was  commonly  applied,  was  not  gout, 
but  an  auto-intoxication  dependent  upon  gastro-intes- 
tinal derangement.  The  relation  of  the  food  to  gout 
should  be  carefully  ascertained  in  each  case. 

The  Ocular  Manifestations  of  Gout Dr.  Charles 

A.  Oliver,  of  Philadelphia,  stated  in  his  paper  that 
all  of  the  tissues  of  the  eye  might  manifest  gouty  in- 
flammatory conditions,  and  then  considered  these  in 
detail,  beginning  with  the  lids  and  conjunctiva  and 
proceeding  to  the  retina  and  optic  ner\e.  In  gouty 
inflammation  of  the  lids,  more  especially  of  the  upper 
lid,  there  was  swelling,  tumefaction  which  came  on 
quickly  and  passed  away  quickly.  For  this  condition 
he  would  say  use  heat,  heat,  and  more  heat.  He  found 
several  calcareous  infarcts  in  the  conjunctiva  near  the 
Meibomian  glands  of  one  man  who  refused  to  believe 
until  these  had  been  shown  him  that  he  was  gouty. 
Soon  afterward  he  had  gout)-  joints.  Gouty  manifes- 
tations in  the  eyes  often  caused  lancinating  pains, 
quickly  disappearing.  They  seldom  caused  ulcera- 
tion. Inflammation  in  the  back  of  the  eyeball  some- 
times extended  to  the  optic  ner\-e  itself,  even  as  far  as 
the  chiasm. 

The  Relation  of  the  Alloxur  Bodies  to  Gout,  or 
a  Uric-Acid  Diathesis,  with  Demonstration.— Dr. 
T.  B.  Ft'TCHER,  of  Baltimore,  read  a  paper  with  this 
title.  The  conclusion  from  his  experiments  was  that 
it  was  very  doubtful  whether  there  was  any  connection 
between  the  abundance  of  the  Neisser  granules  in  the 
blood  and  the  alloxur  bodies  in  the  urine,  and  the 
blood  of  persons  free  from  gout  contained  as  many  of 
the  granules  as  that  of  gouty  subjects. 

The  Relation  of  Uric  Acid  to  Neurasthenia. — 
Dr.  F.  S.  Pearce,  of  Philadelphia,  arrived  at  nine 
conclusions  of  considerable  length  in  this  paper, 
which,  so  far  as  the  relation  of  uric  acid  to  neurasthe- 
nia was  concerned,  admitted  such  relation  in  some 
cases  the  full  nature  of  which  we  did  not  understand. 
Diet  had  much  to  do  with  the  matter,  but  underlying 
it  all  in  many  instances  was  a  hereditarv-  instability  of 
the  neurons,  which  could  be  controlled  to  an  extent, 
but  not  eradicated.  Dietary  must  be  looked  to  in  the 
correction  of  the  faulty  metabolism,  also  rest  of  body 
and  mind,  suitable  diversion,  massage,  tonics,  etc. 

The  Treatment  of  Gout.  —  Dr.'h.  t  .  Wood,  of 
Philadelphia,  spoke  on  the  treatment  and  management 
of  gout.  He  hardly  knew  what  to  say,  for  he  was  ex- 
pected in  fifteen  minutes  to  epitomize  the  wisdom  of 
the  ages  with  regard  to  what  was  probably  the  most 
frequent  of  all  conditions  among  what  had  been 
called  the  better  class  of  the  human  race.  He  wished 
it  clearly  understood  in  the  first  place  that  all  our  sci- 
entific knowledge  of  gout  at  present  amounted  to  little 


July  lo,  1897] 


MEDICAL    RECORD. 


61 


more  than  a  mass  of  trundling  expectation  upon 
which  hereafter  was  to  be  built  some  true  knowledge. 
To  his  way  of  thinking  there  were  three  great  mani- 
festations of  the  same  thing  which  was  universally 
allied  to  itself.  They  were  rheumatoid  arthritis,  pod- 
agra or  true  gout,  and  articular  rheumatism.  We 
must  not  attempt  to  treat  gout,  but  treat  the  individual 
who  came  before  us.  Take  diet:  it  was  well  known 
that  Sydenham  believed  that  gout  was  made  worse  by 
red  meats.  Dr.  Wood  had  seen  gouty  patients  in 
whom  a  single  piece  of  roast  beef  would  precipitate  a 
furious  attack.  On  the  other  hand,  he  had  seen  many 
gouty  people  who  could  not  get  w^ell  unless  they  were 
put  up)on  red-meat  diet.  There  was  no  diet  for  the 
gouty,  but  there  was  a  diet  for  the  individual.  Nev- 
ertheless, in  the  large  majority  of  cases,  sugars  and 
starches  had  to  be  cut  off.  But  in  spare  gout}-  sub- 
jects farinacous  diet  might  be  essential.  Milk  prob- 
ably suited  the  largest  number  of  gouty  patients.  In 
the  matter  of  exercise,  we  must  give  the  right  measure 
to  the  individual  patient.  But  patients  who  could 
take  little  when  they  first  came  under  the  physician's 
control  could  gradually  be  led  up  to  the  point  of  tak- 
ing a  great  deal  of  e.xercise,  and  this  was  essential  for 
prevention  of  further  attacks.  Dr.  Wood  also  spoke 
of  the  best  way  to  give  salicylates  that  they  might  not 
disturb  the  stomach.  The  trouble  arose  usually  from 
the  fact  that  doctors  gave  the  salicylate  of  sodium. 
Strontium  salicylate  was  less  disturbing.  In  some 
instances  it  agreed  better  with  the  patient  when  com- 
bined with  digitalis  and  strychnine.  Medicines,  how- 
ever, would  not  eradicate  the  diathesis. 

The  Cardio- Vascular  and  Renal  Relations  and 
Manifestations  of  Gout. — Dr.  X.  S.  Davis,  Jr..  spoke 
upon  this  subject.  The  atheromatous  changes  which 
took  place  in  the  arterioles  throughout  the  body,  in- 
cluding those  of  the  kidney,  in  the  gouty  subject  were 
too  well  known,  he  said,  to  call  for  mention  in  detail. 
But  some  points  in  connection  therewith  had  been 
referred  to  only  in  a  broad  way  in  the  books,  and 
were  often  overlooked.  One  of  these  was  the  gradual 
progress  of  the  renal  disease,  the  organ  being  hit  in 
spots,  with  intermissions  in  the  degenerative  changes 
which  were  microscopical  in  size,  until  finally  large 
areas  were  involved.  In  these  cases  the  glomeruli 
and  the  tubules  were  attacked  in  a  way  at  times  to 
cause  scarcely  an  appreciable  symptomatology,  where- 
as the  same  changes  coming  on  suddenly,  as  in  cases 
of  a  different  etiology,  caused  striking  clinical  and 
urinary  manifestations.  The  arterial  changes  in  the 
nervous  system  led  to  various  neri'ous  disturbances  by 
interference  with  the  nutrition  of  nerve  centres.  Cer- 
ebral manifestations  might  arise  from  uraemia  or  from 
thrombosis  of  the  cerebral  arteries. 

Dr.  Tyson  said  that  Heberden's  nodosities  did  not 
mean  gout,  and  also  the  fact  that  in  the  treatment  or 
prevention  of  gout  continuous  use  of  alkaline  waters 
was  of  great  benefit,  espiecially  the  foreign  Vichy. 
Citrate  of  potassium  was  good. 

Rheumatoid  Arthritis Dr.  D.wid    Riesm.\n,  of 

Philadelphia,  read  the  paper.  He  preferred  the  term 
used  by  Virchow,  arthritis  deformans.  Heberden's 
nodes  were  manifestations  of  rheumatoid  arthritis 
rather  than  of  gout.  The  theories  which  had  been 
advanced  in  explanation  of  rheumatoid  arthritis,  or 
arthritis  deformans,  were:  1,  that  it  was  a  form  of 
chronic  rheumatism:  2,  that  it  was  a  mixture  of  in- 
herited rheumatism  and  gout;  3,  that  it  was  of  nervous 
origin;  4,  that  it  was  caused  by  a  specific  germ.  The 
author  thought  the  third  was  most  in  consonance  with 
the  symptomatology',  etc.  He  related  a  case  showing 
apparent  benefit  from  strontium  bromide.  It  had  re- 
lieved the  pain,  and  perhaps  had  eliminated  the  dis- 
ease. 

Discussion  on  Anaemia Dr.  Alfred  Stengel,  of 


Philadelphia,  was  lo  have  opened  the  discussion  on 
anamia,  but  in  his  absence  his  paper  on  "The  Nature 
and  Varieties  of  Anaemia"  was  read  by  Dr.  A.  E.  Tay- 
lor, of  Philadelphia.  The  studies  of  the  blood  by 
Virchow,  Cohnheim.  and  others  marked  an  advance  in 
our  knowledge  of  anamia.  One  point  emphasized  by 
the  author  was  that  it  would  be  an  error  to  consider 
the  blood  from  the  standpoint  of  the  corpuscular  ele- 
ment alone.  The  tendency  of  the  profession  to  regard 
the  corpuscular  element  as  the  criterion  from  which  to 
estimate  anaemia  needed  correction.  More  attention 
should  be  given  to  the  plasma.  The  author  con- 
sidered the  several  forms  of  anamia  or  conditions 
in  which  anaemia  was  manifest — chlorosis,  chorea, 
pernicious  anaemia,  etc.  The  term  splenic  disease 
ought  not  to  be  used — he  knew  of  no  disease  which 
should  be  dignified  by  that  title. 

The  Alterations  in  the  Blood,  and  Methods  of 
Determination. — Dr.  A.  E.  Taylor  then  read  his  own 
paper  on  this  subject  The  most  urgent  need  was  an 
instrument  to  take  the  place  of  the  hsemoglobinometer, 
as  this  instrument  was  very  unreliable.  The  o.xygen- 
carrying  power  of  the  blood  was  far  in  e.xcess  of  the 
needs  of  the  tissues,  and  the  evil  effects  in  aneemia 
were  obviously  not  due  to  disturbed  oxygenation. 
The  author  believed  that  the  chemical  study  of  the 
blood  would  henceforth  prove  far  more  important  than 
the  microscopical  study. 

The  Salivary  and  Gastric  Functions  in  Anaemia. 
— Drs.  S.  M.  Hamill  and  D.  L.  Edsall.  of  Philadel- 
phia, were  the  authors  of  this  paper.  Their  stud}', 
however,  seemed  to  have  been  limited  chiefly  to  the 
ferment  power  of  the  saliva  in  anamia.  After  speak- 
ing of  the  technique  of  collecting  the  saliva  and  the 
tests,  they  said  they  had  applied  those  tests  in  several 
cases,  including  leukamia,  chlorosis,  pernicious  an- 
amia,  etc.  The  conclusion  reached  was  that  anamia 
per  se  did  not  give  rise  to  noteworthy  changes  in  the 
ferment  activity  of  the  saliva. 

Optic  Symptoms  in  Anaemia. — Dr.  \\".  C.  Posey, 
of  Philadelphia,  read  a  paper  on  the  changes  in  the  fim- 
dus  of  the  eye  in  antemia.  ^^'hile  examination  of  the 
fundus  often  gave  indications  of  angemia,  it  did  not 
always  do  so,  especially  in  cases  of  anaemia  of  moderate 
degree.  In  chlorosis  ocular  manifestations  were  more 
frequent,  the  author  thought,  than  was  commonly  sup- 
posed, for  in  nearly  every  case  in  which  the  haemoglo- 
bin was  markedly  reduced  he  had  foimd  changes  in 
the  fundus.  The  most  common  change  was  a  dull, 
lustreless,  grayish  appearance  of  the  ner\e.  In  perni- 
cious aneemia  clinicians  had  obsen-ed  retinal  hemor- 
rhages, but  they  were  not  so  uniformly  present  as  some 
had  supposed.  As  a  rule  they  occurred  in  the  ad- 
vanced stage.  In  initial  anaemia  from  loss  of  quantity 
of  blood,  there  were  seldom  ocular  changes  unless 
some  other  factor  than  loss  of  blood  existed. 

A  Further  Report  on  Ischochjrmia  (Dilatation  of 
the  Stomach) — Dr.  Max  Einhorn,  of  New  York,  re- 
ferred in  this  paper  to  one  which  Senn  had  published 
in  the  Medical  Record,  189 i,  reporting  fifteen  cases 
of  stricture  of  the  pvlorus,  and  asserting  that  the  con- 
dition was  one  for  surgical  treatment:  also  to  a  paper 
which  Dr.  Einhom  had  read  before  the  German  Med- 
ical Society  in  New  York.  1894,  in  which  he  used  the 
name  "  ischochymia"  to  convey  the  idea  of  stagnation 
of  food  in  the  stomach  as  the  principal  symptom  of  the 
affection.  In  that  paper  he  recorded  four  cases  of 
stricture  of  the  pylorus  in  which  operation  had  been 
successfully  performed,  and  several  cases  of  malignant 
disease  of  the  pylorus  in  which  gastrostomy  had  proved 
of  temporar}-  benefit.  More  recently  he  had  read  a 
paper  on  ischochymia  before  the  German  Dispensary 
of  New  York,  and  to-day  it  was  his  intention  to  present 
a  summary  of  work  done  to  date.  He  divided  the 
cases  of    ischochvmia  into  two  classes:     i,  cases    in 


62 


MEDICAL    RECORD. 


[July  lo.  1897 


which  an  operation  was  indicated,  whether  the  stricture 
were  malignant  or  benign;  2,  cases  treated  by  pallia- 
tive measures.  The  cases  of  benign  stenosis  of  the 
pylorus  submitted  to  operation  numbered  ten.  In  all 
of  the  cases  operated  upon  the  diagnosis  was  com- 
pletely confirmed.  Of  the  ten  cases  eight  resulted  in 
cure ;  two  were  advanced,  and  the  shock  jf  the  opera- 
tion was  fatal.  In  the  cases  of  malignant  stricture  of 
the  pylorus,  diagnosis  based  on  the  lactic-acid  test  and 
presence  of  tumor,  the  majority  of  the  patients  who  sur- 
vived operation  gained  in  weight  and  were  made  more 
comfortable  than  by  any  other  measure.  The  salient 
point  in  the  diagnosis  of  ischochymia  was  the  presence 
of  food  in  the  stomach  from  a  meal  taken  the  previous 
day.  The  question  then  arose  whether  we  had  to  deal 
with  weakness  of  the  muscularis  or  with  stenosis  of  the 
pylorus.  The  symptoms  related  to  dilatation,  thicken- 
ing of  the  pylorus,  arrested  peristalsis,  fermentation 
products.  But  the  diagnosis  ought,  if  possible,  to  be 
made  before  the  occurrence  of  dilatation.  When  there 
was  tumor  and  ischochymia  had  existed  two  years,  one 
could  make  the  diagnosis  of  benign  stenosis.  In  his 
conclusions  Dr.  Einhorn  pointed  out  that  operative 
measures  were  usually  indicated  in  both  malignant 
and  benign  stenosis  of  the  pylorus  leading  to  ischo- 
chymia, the  operation  lying  between  excision,  gastro- 
enterostomy, and  plastic  procedures,  according  to  the 
extent  of  the  disease,  etc. 

Relation  of  Fat  Necrosis  and  the  Pancreas. — Dr. 
H.  U.  Williams,  of  Buffalo,  was  the  author.  The  pa- 
per dealt  more  particularly  with  that  form  of  fat  ne- 
crosis associated  with  disease  of  the  pancreas.  This 
fat  necrosis  appeared  in  the  fat  on  the  surface  of  the 
pancreas  and  vicinity;  similar  nodules  might  be  pres- 
ent in  the  fat  of  the  peritoneum  at  points  more  remote, 
denominated  disseminated  or  multiple  fat  necrosis. 
Peritonitis  was  not  usually  present.  Dr.  Williams 
had  studied  the  pancreas  in  eighty  dead  subjects,  and 
had  found  fat  necrosis  in  only  two.  He  had  also  ex- 
amined the  pancreas  of  one  hundred  hogs,  and  found 
fat  necrosis  in  the  interlobular  fat  in  two.  He  had 
also  met  with  what  appeared  to  be  the  same  change  in 
the  adipose  tissue  of  the  cat,  but  not  near  the  pancreas. 
In  some  instances  the  fat  nodules  had  been  found  ster- 
ile. The  bacillus  coli  communis  was  oftenest  present. 
The  author  had  published  in  \\-\&  Boston  Medical  and 
Surgical  Journal  results  of  his  experiments  with  tying 
the  nferve  plexus  of  the  pancreas  and  injuring  the  or- 
gan with  a  hook,  causing  fat  necrosis. 

Dr.  Blaisbrook,  of  Washington,  said  he  had  been 
interested  in  this  subject,  and  had  examined  the  pan- 
creas post  mortem  in  one  hundred  cases  for  fat  necro- 
sis, and  had  found  it  in  none.  The  only  disease 
which  he  had  found  was  carcinoma,  and  in  one  or  two 
of  these  the  gross  appearance  was  that  of  fat  necrosis, 
but  the  microscope  showed  cancer. 

The  Diagnosis  of  Abdominal  Effusions  and 
Growths. — Dr.  James  Tyson,  of  Philadelphia,  related 
a  recent  clinical  experience  which  seemed  to  him 
of  sufficient  interest  to  bring  to  the  attention  of  the 
section.  A  few  months  ago  there  was  a  woman  in  his 
wards  at  the  University  Hospital  with  ascites,  and 
some  physical  signs  of  that  condition,  notably  suc- 
cussion  tremor.  She  had,  however,  very  marked  tym- 
pany in  the  flanks,  so  marked  that  it  led  his  house 
physician  strongly  to  doubt  the  presence  of  fluid ;  but 
his  diagnosis  of  fluid  was  confirmed  by  drawing  off 
several  pints.  The  symptom  had  been  found,  but  in 
less  degree,  in  a  number  of  cases  of  ascites  in  the 
hospital  since  then,  and  his  colleague.  Dr.  Penrose, 
had  met  with  it  from  time  to  time.  Leube  had  men- 
tioned that  the  large  intestine,  which  went  as  far  for- 
ward as  the  midaxillary  line  and  was  shut  oft'  by  the 
peritoneum,  might  give  tympany  under  such  circum- 
stances. 


Drs.  Bavliss,  Rochester,  and  Allex  stated  that 
they  had  recently  met  with  cases  in  which  this  tym- 
pany had  caused  some  trouble  in  diagnosis. 

The  Treatment  of  Cancer  by  Zinc-Mercuric  Cata- 
phoresis. — Dr.  C.  B.  Mahsev,  of  Philadelphia,  de- 
scribed in  this  paper  a  use  of  metallic  electrodes  with 
high  milliampere,  up  to  one  thousand  or  more,  both 
electrodes  being  applied  within  the  cancerous  area  in 
a  manner  presumed  to  cause  diffusion  of  the  metal  into 
and  throughout  the  cancerous  tissue  by  cataphoresis. 
The  metal  thus  diffused  was  supposed  to  be  oxychloride 
of  mercury,  and  it  was  believed  to  reach  the  cancerous 
or  sarcomatous  elements  which  had  become  dissemi- 
nated into  the  surrounding  healthy  structures.  His 
review  of  eight  trial  cases  would  show  two  cured,  two 
apparently  cured,  two  benefited,  two  failures  perman- 
ently to  arrest  the  disease. 

Case  of  Primary  Renal  Tuberculosis. — Dr.  J.  D. 
Steele,  of  Philadelphia,  read  the  history  of  a  case  of 
presumable  primary  tuberculosis  of  one  kidney,  and 
called  attention  to  the  doubt  which  had  been  expressed 
by  some  authorities  as  to  the  occurrence  of  primary 
tuberculosis  of  the  kidney.  First  one  kidney  became 
diseased,  and  in  about  half  of  the  cases  the  other  be- 
came involved  before  death.  The  pelvis  of  the  kidney 
usually  escaped  until  late,  and  the  ureter  was  seldom 
implicated.  More  frequently  other  organs  were  also 
the  seat  of  tuberculosis. 

Experience  in  the  Treatment  of  Epilepsy  Accord- 
ing to  the  Method  Suggested  by  Niemeyer.  —  Dr. 
Matthew  Woods,  of  Philadelphia,  read  the  paper. 
His  reason  for  presenting  it  was  that  he  had  obtained 
better  results  from  this  treatment  of  epilepsy  than 
from  any  other.  The  many  varieties  into  which  epi- 
lepsy had  been  divided  was  simply  a  multiplication  of 
terms,  and  threw  no  light  on  the  causation  of  the  dis- 
ease. He  dwelt  upon  the  surgical  treatment — craniec- 
tomy, circumcision,  etc. — because  sometimes  it  was  an 
important  adjunct  to  drug  treatment,  and  because  he 
wished  to  show  that  too  much  importance  had  been 
attached  to  the  brain  as  the  seat  of  epilepsy  and  pres- 
sure on  the  brain  as  its  cause.  The  seat  of  epilepsy 
could  be  anywhere,  and  any  treatment  not  considering 
the  starting-point  must  fail.  One  case  he  had  cured 
by  operating  for  epispadias,  which  had  existed  prior  to 
the  development  of  epileptic  attacks.  One  woman 
burnt  her  hand,  whereupon  her  epilepsy  disappeared. 
The  chief  drug  used  by  the  author  was  bromide  of  po- 
tassium in  gradually  increasing  doses  taken  in  a  large 
quantity  of  water — ten  to  sixty  grains  from  one  to  four 
times  a  day,  the  treatment  to  be  continued  at  least  a 
year  after  cessation  of  the  convulsions.  In  his  sum- 
mary he  repeated  that  resort  should  be  had  occasion- 
ally to  surger)-,  to  relieve  constriction  of  the  prepuce, 
lacerated  cervix,  suspicious  cicatrices;  constipation 
should  not  be  allowed  to  exist;  digestion  should  be 
improved;  a  limited  amount  of  animal  food  once  a 
day;  outdoor  exercise;  bromide  of  potassium  in  the 
manner  stated. 

Medicine  as  an    Exact    Science Dr.   W.  J.    K. 

Klixe,  of  Washington,  read  a  paper  which  was  a  plea 
for  exact  science  in  the  teaching  and  clinical  applica- 
tion of  medicine,  so  far  as  this  science  had  been  de- 
veloped. 

The  Importance  of  the  Habit  of  Prognosis  in  the 
Development  of  the  Individual  Physician. — Dr.  L. 
1''.  lUsiiiii' ]-)rosente(.i  a  pa|X'r  t)n  tiiis  subject.  He  said 
it  was  the  physician's  duly  to  look  out  for  new  meth- 
ods which  tended  to  the  better  development  of  his  vork, 
as  well  as  to  keep  informed  and  his  mind  trained  by 
thought.  Habits  were  the  masters  of  lives  and  actions. 
These  were  as  potent  for  good  as  for  evil,  and  habits  of 
mind  and  thought  were  as  much  habits  as  those  of  the 
phvsiial  nature.  The  habit  of  prognosis  was  impor- 
tant as  not  only  looking  to  the  condition  of  the  pres- 


July  lo,  1897] 


MEDICAL    RECORD. 


63 


ent,  but  what  would  happen  if  certain  different  lines 
were  followed.  It  was  well  to  form  the  habit  of  a 
careful  prognosis,  and  by  study  and  comparison  this 
habit  could  be  made  more  accurate.  This  prognosis 
should  be  faithfully  promulgated  to  those  who  had  a 
right  to  know  it.  The  first  step  of  prognosis  was  not 
the  classifying  of  the  disease,  as  might  be  indicated  by 
the  inde-x  of  a  book,  but  the  placing  of  the  case  in  a 
particular  group  of  a  particular  variety  of  the  disease. 
Then  by  thorough  comparison  and  research  the  math- 
ematical theoiy  of  chances  and  possibilities  could  be 
brought  to  bear  and  the  conclusion  reached.  The 
insurance  companies  did  not  pretend  to  say  that  a  cer- 
tain man  would  live  to  a  certain  age,  but  by  observa- 
tion deduced  the  rule  that  the  average  age  would  be  a 
certain  one;  so  the  habit  of  prognosis  could  deduce 
the  conclusions  that  would  in  the  main  be  accurate. 
The  ideal  mode  of  study  of  prognosis  would  be  to 
compare  different  cases  of  the  same  disease  treated  by 
different  methods  with  untreated  cases,  but  such  op- 
portunities did  not  often  occur;  yet  by  careful  study 
of  the  cases  in  hand  and  a  summing  up  of  the  results, 
one  could  form  conclusions  that  would  aid  much  in 
the  habit  of  prognosis. 

Before  adjourning,  the  section  extended  a  vote  of 
thanks  to  the  chairman  and  the  secretary  of  the  sec- 
tion, Dr.  Musser  and  Dr.  Priestley. 

(^To  be  Continued,) 


NEW     YORK    COUNTY    MEDIC.\L    ASSOCIA- 
TION. 

Stated  Meeting,  April  ig,  iHg^. 

Joseph  E.  Janvrin,  M.D.,  President,  i.m  the  Chair. 

The  Treatment  of  Diphtheria  in  Private  Practice ; 
a  Comparison  of  Antitoxin  with  Other  Methods. — 

Dr.  James  J.  Concawo.n  read  the  first  paper. 
During  the  pre-antito.xin  period,  treatment  of  diph- 
theria had  been  very  variable,  and  it  was  so  to-day 
among  those  who  did  not  believe  in  antitoxin.  Many 
doctors  now  advised  parents  to  use  antitoxin;  others 
advised  them  to  let  it  alone.  Both  sides  were  honest, 
but  it  was  evident  that  many  lives  were  being  sacri- 
'ficed  during  the  solution  of  the  question  of  the  value 
of  this  treatment.  The  unsatisfactory  results  of  other 
treatment  were  pointed  out  and  were  well  known. 
The  claims  for  antitoxin  and  the  statistical  basis 
therefor  were  also  stated.  Nearly  all  of  the  doctors 
who  had  contributed  to  the  report  of  the  American 
Pediatric  Association  favored  the  remedy.  From  cer- 
tain of  the  statistics  quoted  it  was  shown  that  the 
mortality  was  only  five  per  cent,  when  the  serum  was 
administered  the  first  two  days. 

Dr.  Concannon  then  analyzed  thirty  cases  of  di])h- 
theria  which  he  had  (formerly)  treated  without  anti- 
toxin and  twenty-three  which  he  had  ti-eated  with  that 
remedy,  and  three  others  so  treated  seen  with  other 
physicians.  In  both  instances  he  divided  the  cases 
into  three  classes,  the  mild,  the  moderately  severe,  and 
the  severe.  The  mild,  the  moderately  severe,  and  the 
severe  cases  were  nearly  equal  in  the  two  instances. 
The  treatment  in  the  thirty  cases  varied,  and  seemed  to 
have  been  negative  in  effect.  The  internal  adminis- 
tration of  mercurials,  pilocarpine,  applications  of  nitric 
acid,  nitrate  of  silver,  etc.,  were  harmful  rather  than 
beneficial.  Insufflations  produced  little  or  no  result. 
Papoid  and  so-called  solvents  had  had  no  effect. 
Cleansing  solutions  had  a  place.  Iron  was  good  for 
the  anaemia.  In  the  twenty-six  cases  in  which  anti- 
toxin was  used  the  dose  varied  from  fifteen  hundred 
to  twenty-five  hundred  or  more  units.  There  was 
no  other  treatment  except  tincture  of  iron  in  three 
cases,  and  irrigation  with  sea  water  in  about  half. 
.^.s    to    results    of    the   two    methods,    eight   patients 


died  under  the  old  method,  only  three  under  the 
new.  Excluding  two  cases  already  moribund,  only 
one  death  could  be  placed  on  the  antitoxin  side. 
L'nder  the  old  method  there  were  nine  laryngeal 
cases,  five  of  which  were  intubated,  and  all  five  patients 
died  before  the  tube  was  removed.  Few  or  none  of  the 
laryngeal  cases  in  the  second  class  required  intubation 
after  use  of  antitoxin,  which  showed  that  antitoxin 
did  away  with  the  necessity  of  intubation.  Severe 
cases  under  the  old  treatment  required  attention  for 
weeks;  under  the  new  for  days.  Under  the  old  treat- 
ment we  never  dared  make  a  prognosis  nor  state  what 
a  remedy  would  accomplish;  under  the  new  we  could 
state  with  much  certainty  that  the  membrane  would 
disappear  in  forty-eight  hours,  the  patient  would  be 
much  improved  in  twenty-four  hours,  and  would  re- 
cover in  a  few  days.  The  author  had  seen  no  ill 
effects  from  antitoxin.  There  had  been  successful 
immunization  with  the  serum  in  several  families  ex- 
posed to  diphtheria. 

The  author  then  considered  charges  against  anti- 
toxin. Grant  that  some  sudden  deaths  had  occurred; 
they  had  also  occurred  without  the  use  of  the  serum. 
It  was  important  to  wait  before  making  the  injection 
for  the  air  to  rise  from  the  serum  drawn  up  into  the 
syringe.  The  author  was  disposed  to  regard  the  in- 
jection of  air  as  one  explanation  of  accidents  which 
might  have  occurred.  Theoretically  it  might  be  sup- 
posed the  antitoxin  would  be  useless  in  cases  of  mixed 
infection,  but  in  practice  cases  had  shown  improve- 
ment. The  objection  that  the  treatment  lessened  the 
number  of  the  doctor's  visits  held.  In  his  conclu- 
sions he  asserted  that  antitoxin  was  a  specific  for 
diphtheria  when  used  in  time;  that  it  was  the  only 
effective  treatment  known ;  that  it  was  effectual  as  a 
prophylactic. 

Results  of  Diphtheria  Antitoxin  in  Forty-Four 
Cases — Dr.  G.  B.  Philhower,  of  Nutley,  New  Jer- 
sey, opened  the  discussion.  In  this  country  to-day 
there  was  no  disease  which  so  struck  terror  into  a 
family  when  a  member  became  affected  as  diphtheria. 
In  view  of  its  great  fatality,  he  felt,  as  the  author  did, 
that  every  physician  should  be  compelled  to  use  anti- 
toxin. During  about  ten  years'  practice  before  he 
became  acquainted  with  the  use  of  antitoxin.  Dr. 
Philhower  treated  two  hundred  and  eighteen  cases  of 
diphtheria,  with  sixty-six  deaths,  a  mortality  of  thirty- 
one  per  cent.  He  felt  that  such  a  record  was  not  one 
to  be  proud  of;  that  it  left  too  many  vacant  places  in 
families;  that  he  ought  to  save  more  lives.  Besides, 
the  treatment  in  vogue,  the  swabbing,  the  spray,  etc., 
was  disgusting  to  him.  Therefore  when  a  new  remedy 
came  out  he  was  ever  ready  to  inquire  into  it.  Twenty- 
two  months  ago  he  began  the  use  of  antitoxin,  and  had 
since  treated  forty-four  cases  with  only  two  deaths. 
The  two  deaths  were  in  his  first  ten  cases.  One  of  the 
two  patients  died,  two  weeks  after  the  treatment  had 
cleared  up  the  throat,  of  broncho-pneumonia.  The 
average  age  was  eight  years,  period  of  injection  forty- 
eight  hours,  duration  of  sickness  about  four  days. 
The  only  symptom  on  the  increase  under  the  treatment 
was  laryngeal  paralysis,  but  analysis  of  the  cases 
showed  that  this  was  only  apparent,  due  to  patients 
recovering  who  formerly  would  have  died.  Laryngeal 
subjects  used  to  choke  to  death,  and  subjects  of  nasal 
diphtheria  died  of  infection.  Now  they  were  saved, 
but  some  of  them  had  paralysis.  It  was  not  due  to 
the  antitoxin.  He  had  seen  a  rash,  but  could  not  say 
that  it  was  due  to  the  antitoxin.  He  had  discouraged 
other  treatment  except  an  initial  dose  of  calomel,  sun- 
light, and  general  hygiene.  Of  course  it  was  possible 
that  during  the  period  he  had  used  antitoxin  he  had 
happened  to  run  across  cases  with  less  tendency  to 
fatal  issue  than  formerly,  but  there  was  no  reason  to 
think    this,  and    the  supposition  was  opposed  by  the 


64 


MEDICAL    RHCORD. 


[July  lo,  1897 


fact  that  other  physicians  in  his  village  who  had  not 
used  antitoxin  had  had  the  old  death  rate.  The  anti- 
toxin which  he  had  used  was  that  prepared  by  the 
Newark  board  of  health. 

Dr.  Adolph  Rupp  said  he  had  used  antitoxin  only 
in  one  case,  or  rather  he  had  advised  it  in  a  case 
in  which  the  father  was  anxious  to  have  it  tried,  for 
he  had  been  a  contributor  to  the  fund  early  collected 
to  supply  an  antitoxin  in  this  city.  Dr.  Rupp  saw  the 
patient  on  the  seventh  day  of  the  illness  and  the  in- 
jection of  antitoxin  was  made  by  the  board  of  health. 
The  pulse  went  up  immediately  after  the  injection; 
the  fever  rose,  the  membrane  continued  to  form,  the 
bacteria  did  not  cease  to  flourish.  He  doubted  whether 
the  optimism  of  the  first  speakers  was  well  based;  cer- 
tainly the  literature,  as  Dr.  Rupp  had  analyzed  it,  was 
not  so  favorable  as  it  had  been  represented,  not  so 
favorable  as  the  experience  related  to-night.  The 
average  mortality  for  diphtheria  in  Dr.  Rupp's  practice 
since  1881  had  been  less  than  fifteen  per  cent.  A 
writer  in  Breslau  had  reported  over  eight  hundred 
cases  treated  without  antitoxin  with  a  mortality  of  less 
than  five  per  cent.  The  nature  of  the  epidemic  had 
much  to  do  with  the  issue.  There  was  much  that  was 
contradictory  in  antitoxin  reports.  The  advocates  of 
the  method  made  too  little  of  objections.  It  was  easy 
to  say  that  the  patient  died  of  heart  failure.  It  ex- 
plained as  much  as  the  assertion  that  the  patient  died 
for  want  of  breath.  What  made  the  heart  fail.'  Not 
diphtheria  in  the  St.  Louis  child  which  received  an 
injection  simply  for  immunization  ;  nor  from  the  injec- 
tion of  air,  for  death  did  not  occur  until  forty  minutes 
after  the  treatment.  During  the  last  sixteen  months 
the  speaker  had  seen  sixteen  cases  of  diphtheria  in 
three  families,  and  none  had  proven  fatal.  Yet  he  did 
not  claim  to  have  any  specific  for  diphtheria. 

Dr.  August  Seibert  had  had  favorable  results  with 
antitoxin  treatment.  Papers  of  the  kind  read  this 
evening,  giving  excellent  results  from  this  treatment, 
had  been  published  by  the  dozen.  The  testimony 
had  been  from  men  of  such  high  standing  that  the  re- 
sults could  no  longer  be  questioned  by  any  sane  mind. 
It  was  simply  the  imperative  duty  of  all  physicians  to 
use  the  serum  early  in  every  case  of  diphtheria.  Dr. 
Seibert  pointed  out  the  apparent  reluctance  of  one  of 
the  daily  newspapers  originally  to  give  credit  to 
Behring  instead  of  Roux  for  the  cliscovery  of  this  treat- 
ment of  diphtheria,  and  also  mentioned  the  false 
prophecy  of  Dr.  Winters  with  regard  to  the  fate  of 
this  treatment  and  also  that  of  washing  out  the  stom- 
ach of  infants,  on  which  subject  Dr.  Seibert  had  written 
in  1888. 

Dr.  a.  Lambert  said  it  was  true  that  the  bacteria 
of  diphtheria  might  be  present  in  the  throat  without 
active  diphtheria,  but  the  board  of  health  was  com- 
pelled to  take  notice  of  such  cases  as  possible  sources 
of  infection.  He  thought  antitoxin  was  backed  by 
far  more  facts,  and  by  reasons  based  on  such  facts, 
than  was  true  of  the  vast  majority  of  our  remedies. 
Of  course  its  action  was  limited.  It  could  not  recu- 
perate cells,  but  it  would  prevent  their  death  by  action 
of  the  toxins  if  it  were  given  early  enough.  The 
amount  of  the  toxin  in  the  blood  was  unknown,  but  it 
had  been  found  by  experience  that  a  less  amount  of 
antitoxin  was  required  to  counteract  it  in  mild  cases  of 
diphtheria  than  in  severe  cases.  Hence  the  variable 
dose,  from  one  thousand  units  up  to  two  thousand  and 
more.  To  use  it  early  and  thoroughly  should  be  the 
rule  of  practice. 

Dr.  Louis  Fischer  mentioned  as  among  the  chief 
reasons  for  failure  with  antitoxin  the  employment  of  a 
poor  or  bad  quality ;  its  use  in  cases  already  moribund ; 
too  small  a  quantity.  He  had  known  physicians  to 
inject  only  fifteen  hundred  antitoxin  units  in  malignant 
•cases.     It  was  not  necessary  to  discard  other  treatment 


simply  because  antitoxin  was  used.  Some  people 
seemed  to  think  that  the  new  remedy  should  not  only 
cure  the  child,  but  also  take  the  place  of  food. 

Urethroscopic  Photographs Dr.  Ferd.  C.  Valen- 
tine demonstrated  on  the  screen  the  photographs, 
given  him  by  Kollmann,  of  Leipzig.  Drawings, 
afterward  colored,  had  been  made  by  different  writers, 
especially  by  Oberlaender  and  Guyon,  but  they  were 
not  so  reliable  as  photographs  which  were  entirely 
free  from  the  personal  equation.  Kollmann's  excellent 
pictures  had  been  taken  by  a  camera  devised  by  him 
for  the  purpose,  and  made  a  part  of  the  Oberlaender 
urethroscope.  Naturally  they  were  in  black  and  white. 
No  retouching  or  beautifying  pencil  had  spoiled  their 
original  strength  or  correctness.  True,  life  tints  were 
lacking. 

Dr.  Valentine  then  described  about  seven  photo- 
graphs representing  various  portions  of  the  pendulous 
and  anterior  urethra  in  the  normal  and  diseased  state, 
the  latter  including  strictures  and  papillomata.  The 
dark  mass  at  the  bottom  of  all  the  photographs  was 
the  much  foreshortened  light  carrier.  One  or  other 
side  of  the  urethra  preponderated  in  the  picture  when 
the  tube  was  directed  somewhat  to  one  side.  Radiat- 
ing folds  were  seen,  the  number  and  form  of  which 
depended  upon  the  size  of  tube  used.  They  repre- 
sented the  longitudinal  folds  of  the  urethra  and  pro- 
jected from  the  periphery  of  the  picture  to  the  funnel. 
Striation  of  the  urethra  became  more  evident  the  larger 
the  tube  used,  the  larger  tube  flattening  the  longitudinal 
folds.  The  third  picture  showed  the  mouth  of  a  Mor- 
gagni  pouch.  The  fifth  picture  showed  a  similar  pouch 
on  the  floor  behind  the  glans,  which  was  very  unusual. 
The  sixth  picture  showed  stricture,  Morgagni  pouch, 
and  Littre's  glands  opening  into  the  urethra.  The 
latge  craterlike  Morgagni  pouch  was  no  doubt  once 
the  site  of  inflammatory  process.  From  the  gaping 
mouth  it  would  be  possible  to  remove  secretion  w  ith 
Kollmann's  spatula  and  examine  for  gonococci. 

Dr.  Carl  Beck  felt  that  members  were  under  obli- 
gations to  Dr.  Valentine  for  this  demonstration,  which 
was  the  first  one  made  in  this  countrj'.  He  doubted 
whether  the  value  of  urethroscopy  and  urethroscopic 
photography  had  yet  been  grasped  by  the  profession. 
He  compared  them  to  laryngoscopy  and  ophthalmos-  • 
copy. 

Dr.  Thomas  Manlev  said  that  in  no  department  of 
surgery  had  there  been  greater  advance  the  past  few 
years  than  in  the  surgery  of  the  urinary  tract  and  or- 
gans. He  thought  urethroscopy  was  of  great  aid  in 
the  treatment  of  disease  of  this  tract,  but  that  urethro- 
scopic photography  was  likely  to  be  chiefly  of  value  in 
unusual  cases. 

Dr.  Rohert  New.man  presented  some  pictures  in 
color  of  the  urethra,  which  an  artist  had  made  under 
his  direction  .some  twenty-five  years  ago.  The  ure- 
throscopic pictures  had  first  been  made  by  hand  and 
afterward  photographed  and  published. 

New  Battery  Arrangements — Dr.  S.  F.  Brothers 
presented  with  Mr.  Hailev  some  new  battery  arrange- 
ments, consisting  of  a  water  motor  for  charging  a 
storage  battery  and  connections  for  running  a  small 
dynamo  by  the  storage  battery.  It  could  also  be  used 
for  generating  a  faradic  current. 

Reports  of  Special  Committees. — Several  special 
committees  made  their  reports.  Dr.  Stewart  read  that 
of  the  committee  appointed  to  wait  on  the  mayor  and 
urge  the  appointment  of  a  medical  man  to  fill  the 
vacancy  in  the  board  of  commissioners  of  charities. 
The  other  members  of  this  committee  were  the  president 
and  Dr.  George  T.  Harrison.  Dr.  Harrison  remarked 
after  the  report  had  been  read  that  the  mayor  certainly 
could  not  now  plead  ignorance  of  the  arguments  of  the 
other  side,  those  opposed  to  the  action  of  the  commis- 
sioners of  charities  in  their  sweeping  removal  of  physi- 


July  lo.  1897] 


MEDICAL    RFXORD. 


65 


cians  to  the  city  hospitals  and  placing  such  appoint- 
ments in  the  hands  of  a  narrow  medical  clique.  The 
committee  had  presented  the  matter  before  the  mayor 
verbally  and  in  writing,  and  showed  that  the  opposition 
to  a  medical  man  in  the  commission  came  only  from  the 
few  who  would  continue  the  control  of  the  hospital 
appointments  by  the  colleges.  The  greater  part  of  the 
work  of  the  charity  commissioners  could  be  under- 
stood and  discharged  only  by  men  having  a  medical 
education,  and  as  long  as  no  physician  was  on  the 
commission  its  members  had  to  depend  for  their  in- 
formation upon  the  statements  of  the  doctors  in  the 
clique  referred  to.  The  medical  profession  at  large  had 
no  representation.  The  so-called  fourth  division  of 
Bellevue  represented  itself  alone,  and  was  the  closest 
corporation  imaginable.  The  new  method  of  appoint- 
ment to  hospital  positions,  placing  the  appointments  in 
the  hands  of  the  colleges,  was  uncalled  for,  since  the 
colleges  already  had  far  more  facilities  for  hospital  in- 
struction than  they  made  use  of,  and  many  of  the  city 
hospitals  now  placed  under  their  control  were  inacces- 
sible for  teaching  purposes. 

The  report  was  accepted. 

Presidency  of  the  Board  of  Health,  etc — The 
special  committee,  composed  of  Drs.  McLeod,  Max- 
ley,  and  J.  Blake  White,  to  report  on  matters  relating 
to  the  board  of  health,  reported  in  opposition  to  the  com- 
pulsory reporting  of  cases  of  tuberculosis,  but  in  favor 
of  abrogating  that  provision  in  the  charter  which  pro- 
hibits the  appointment  of  a  physician  as  president 
of  the  board  of  health.  The  latter  part  of  the  report 
was  adopted.  The  part  relating  to  tuberculosis  led  to 
a  vote,  which  by  some  of  those  voting  meant  its  rejec- 
tion and  by  others  its  adoption  as  a  whole.  The  com- 
mittee was  continued,  and  no  doubt  the  sense  of  the 
association  on  this  question  will  be  made  clear  at 
another  meeting. 

The  Dispensary  Abuse. —  Dr.  McGaurax  read  the 
report  of  the  committee  on  this  subject.  It  had  acted 
with  the  Charity  Organization  Society  in  presenting 
a  bill  at  Albany,  which  bill  was  well  replaced  by  the 
following: 

"Section  i.  By  this  act  a  dispensary  is  defined  to 
be  any  institution,  agency  or  place,  society  or  associa- 
tion, whose  actual  or  alleged  purpose  it  is  to  furnish 
either  gratuitously,  or  at  a  merely  nominal  price,  to 
indigent,  needy,  or  other  persons  not  resident  therein. 
medical  or  surgical  relief,  advice  or  treatment,  medi- 
cine or  orthopaedic  or  other  like  appliances. 

"  Sec.  2.  On  or  after  the  first  day  of  October,  1897. 
it  shall  not  be  lawful  for  any  one  to  establish,  conduct, 
or  manage  at  any  place  in  this  State,  a  dispensary-  not 
duly  incorporated  as  such  under  the  laws  of  this  State, 
or  not  connected  with  another  incorporation  and  li- 
censed by  the  State  board  of  charities. 

"  Sec.  3.  In  no  case  shall  a  dispensarj'  be  estab- 
lished, carried  on,  or  conducted  in  any  place  in  this 
State  commonly  known  as  a  '  drug  store,'  nor  in  any 
place  or  building  in  the  State  defined  by  law  or  by  an 
ordinance  of  a  board  of  health  as  a  '  tenement  house.' 

"Sec.  4.  It  shall  not  be  lawful  for  any  person  or 
persons  to  display  the  word  '  dispensary,'  or  to  cause 
the  same  to  be  published  in  any  form  or  in  any  man- 
ner in  order  to  attract  any  indigent,  needy,  or  other 
person  to  any  dispensary  not  duly  incorporated  or 
licensed  as  provided  in  Section  2  of  this  act. 

"Sec.  5.  Any  person  who  shall  by  means  of  any 
wilful  false  representations  on  his  or  her  part,  obtain 
at  any  dispensary  medical  or  surgical  relief,  advice, 
or  treatment,  medicines  or  orthopaedic  or  other  appli- 
ances, or  any  person  who  shall  wilfully  violate  any 
of  the  provisions  of  this  act  shall  be  guilty  of  a  mis- 
demeanor, and  upon  conviction  shall  be  required  to 
pay  a  fine  of  not  less  than  fifty  nor  more  than  two 
hundred  and  fiftv  dollars. 


"  Sec.  6.  The  State  board  of  charities  is  hereby  em- 
powered to  make  rules  and  regulations  and  to  alter 
and  amend  the  same  when,  in  its  opinion,  necessary, 
in  accordance  with  which  indigent,  needy,  or  other 
persons  shall  be  given  medical  or  surgical  relief,  ad- 
vice or  treatment,  medicines  and  orthopaedic  or  other 
like  appliances  by  such  duly  incorporated  or  licensed 
dispensaries,  and  the  said  board  is  hereby  empowered, 
a  chance  for  a  hearing  having  been  given,  to  annul 
the  incorporation,  or  suspend  the  operations,  or  to  re- 
voke the  license  of  any  dispensary  for  wilful  neglect 
or  failure  on  the  part  of  its  managers,  trustees,  officers, 
or  employees  to  comply  with  the  rules  and  regulations 
so  established  by  said  board;  but  nothing  in  this  act 
contained  shall  be  construed  to  mean  that  said  board 
shall  have  power  to  determine  the  particular  school  of 
medicine  under  which  the  dispensary  shall  be  con- 
ducted. 

"Sec.  7.  All  acts  or  parts  of  acts  inconsistent  with 
the  provisions  of  this  act  are  hereby  repealed. 

"Sec.  8.  This  act  shall  take  effect  on  the  first  of 
October,  1897." 

Dr.  McGauran  said  this  bill  had  passed  the  senate 
and  assembly,  and  only  required  the  signature  of  the 
governor  to  become  law.  He  made  a  motion,  which 
was  carried,  urging  the  governor  to  sign  the  bill. 

On  motion  the  association  appropriated  Si 00  to  de- 
fray part  of  the  expenses  for  securing  this  legislation. 

Representation  in  the  State  Board  of  Medical 
Examiners  Demanded. — Dr.  Robert  Newman  offered 
the  following,  which  was  adopted  :  "  Resolved,  That  this 
association,  representing  over  one  thousand  physicians 
in  the  county  of  New  York,  considers  it  fair  that  the 
New  York  State  Medical  Association  should  have  a 
representative  on  the  medical  examining  board,  and, 
therefore,  is  in  favor  of  the  bill  introduced  into  the 
legislature  for  such  purpose." 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION   OX   OBSTETRICS   AND   GVN.tCOLOGY. 

Stated  Meeting,  April  22,  i8gj. 

S.  Marx,  M.D.,  Chairman. 

Specimens  of  Appendicitis,  of  Hydrosalpinx,  of 
Extra-Uterine  Pregnancy. — Dr.  Andrew  F.  Currier 
presented  a  vermiform  appendix  removed  with  success- 
ful result  early  in  the  disease  from  a  boy  sixteen  years 
old.  The  operation  verified  the  diagnosis  of  appendi- 
citis with  abscess.  He  also  presented  the  left  tube 
and  ovary  removed  for  hydrosalpinx  from  a  woman 
who  showed  some  symptoms  the  seventh  day  after  the 
operation,  and  it  was  found  that  there  were  stitch-hole 
abscesses,  a  rare  complication  in  modern  antiseptic  sur- 
gery. The  third  specimen  was  one  of  extra-uterine 
pregnancy  from  a  woman  who  had  had  some  ovarian 
symptoms  for  a  year,  with  pain.  The  day  before  Dr. 
Currier  saw  her  she  had  pain,  nausea,  and  vomiting, 
and  next  morning  collapsed  on  the  way  to  the  bath- 
room, and  was  picked  up  from  the  floor.  She  rallied, 
and  when  Dr.  Currier  saw  her  he  made  examination 
under  chloroform,  felt  a  tumor  on  the  right  side, 
operated,  found  blood  in  the  peritoneal  cavity,  and 
hemorrhage  going  on  from  the  site  of  a  ruptured  right 
tubal  pregnancy.  The  patient  did  perfectly  well. 
The  fourth  specimen  was  also  one  of  extra-uterine 
pregnancy  from  a  woman  who  gave  a  historj-  of  former 
gonorrhoea,  contracted  from  her  husband,  and  more 
recently  another  attack  with  symptoms  of  peritonitis. 
The  night  before  he  was  called  she  had  an  attack  of 
hemorrhage  during  coitus,  very  severe  pain,  and  next 
morning  when  he  saw  her  she  was  very  weak,  with  a 
pulse  of   150.      He  operated  and  found  ruptured  tubal 


66 


MEDICAL    RECORD. 


[July  lo,  1897 


pregnancy  with  fcEtus.  Four  days  later  lie  was  called 
by  her  physician,  and  on  arriving  she  was  dead.  The 
■cause  of  death  was  probably  heart  failure  and  not 
hemorrhage,  for  her  husband  said  she  had  before  had 
attacks  of  dyspncea.     An  autopsy  was  rejected. 

Dr.  Currier  said  that  in  both  of  these  cases  it  was 
the  right  tube  which  was  the  seat  of  the  extra-uterine 
pregnancy,  and  this  was  true  of  most  of  his  other 
cases.  The  last-named  case  was  one  of  bicornate 
uterus;  he  could  not  say  whether  that  fact  had  any 
etiological  bearing. 

Tumors  of  the  Uterus  in  Maiden  Women. — Dr. 
Robert  A.  Murray  presented  two  specimens  of  pa- 
pillomatous tumors  of  the  uterus,  and  made  them  the 
basis  of  some  remarks.  The  first  specimen  was  from 
a  maiden  woman,  aged  fifty-nine,  who  while  suffering 
from  an  attack  of  grippe  employed  a  nurse.  The  nurse 
learned  that  she  had  a  purulent  and  hemorrhagic  dis- 
charge from  the  vagina,  and  it  was  then  that  Dr.  Mur- 
ray was  called.  He  found  a  polypoid  tumor  projecting 
out  of  the  vagina  and  attached  to  the  cervi.x,  twisted  it 
off,  and  curetted  the  uterus  with  a  blunt  curette  and 
irrigated.  The  discharge  ceased.  The  second  speci- 
men was  similar,  and  was  from  the  widow  of  a  physician, 
sixty-two  years  of  age,  who  was  suffering  from  grippe 
and  pneumonia,  and  was  found  to  have  a  foul,  purulent, 
and  bloody  discharge  from  the  vagina.  Examination 
revealed  a  polypus  projecting  from  the  cervix.  He 
twisted  it  off,  washed  out  the  uterus,  curetted,  and  the 
patient  was  now  well. 

Dr.  Murray  dwelt  upon  the  necessity  for  respecting 
the  sense  of  delicacy  in  women,  especially  girls  and 
maiden  ladies,  who  were  apt  to  suffer  for  months  or 
years  with  pelvic  troubles  through  fear  of  exposure 
should  they  consult  a  physician.  Personally,  he  had 
never  been  refused  permission  to  make  such  an  exami- 
nation as  was  necessary  to  lead  to  a  correct  diagnosis 
and  to  carry  out  appropriate  treatment,  but  he  first  pro- 
posed a  rectal  examination  and  later  a  vaginal  one,  if 
the  former  proved  unsatisfactory.  The  hymen  was 
spared  whenever  it  was  possible  to  do  so.  The  use  of 
a  speculum  was  seldom  necessary  to  determine  the 
cause  of  flooding.  .An  unmarried  woman  might  have 
fibroid,  polypus,  endometritis,  displacement,  ovarian 
trouble,  but  she  rarely  had  cancer  at  the  menopause. 

The  chairman.  Dr.  Marx,  supposed  there  were 
members  who  disagreed  with  Dr.  Murray  regarding 
rectal  examination,  the  use  of  the  speculum,  the  use  of 
dilators.     These  questions  were  open  for  discussion. 

Dr.  H.  J.  BoLDT  said  that  when  it  was  necessary 
to  enlarge  the  cervical  canal  to  remove  the  tumor  he 
would  not  resort  to  dilators ;  it  was  safer  and  gave 
more  room  to  make  a  bilateral  incision  into  the  cervix. 
The  cut  would  heal  by  primary  union  after  introduc- 
tion of  a  suture. 

Dr.  A.  P.  Dudley  objected  to  speaking  of  women 
menstruating  after  the  menopause.  It  was  then  hemor- 
rhage, and  any  hemorrhage  after  the  menopause  was 
suspicious  and  should  lead  to  an  investigation.  A 
rectal  examination  would  nearly  always  have  to  be 
followed  by  a  vaginal  examination,  and  he  preferred 
to  begin  with  the  latter.  He  had  examined  many 
girls  with  the  little  finger  and  made  the  correct  diag- 
nosis. If  in  operating  it  was  necessary  to  enlarge  the 
cervix,  he  would  dilate  with  laminaria  tents  in  prefer- 
ence to  making  incisions,  as  recommended  by  Dr. 
Boldt.  In  girls  and  unmarried  women  it  was  more 
difficult  to  sew  up  the  incision  than  to  remove  the 
polyp.  In  fibroids  at  the  fundus  the  hvmen  could  not 
be  spared,  and  incision  of  the  cervix  enabled  one  to 
make  a  quicker  operation  than  bv  dilatation. 

Primary  Cancer  of  the  Fallopian  Tube. — Dr.  H. 
J.  Roi.nr  presented  a  tube  and  ovary  which  he  had  re- 
moved that  day  per  vaginani  after  having  ruptured  the 
tumor   during  examination.     Only  blood  was  found, 


and  the  appearance  of  the  ruptured  tube  on  gross 
examination  was  that  of  tubal  gestation,  but  the  patholo- 
gist, who  had  made  an  incomplete  examination  of 
the  specimen,  thought  it  was  cancer  of  the  tube,  in  all 
probability  primary'.  It  would  be  reported  upon 
further  at  a  future  meeting. 

Cancer  of  the  Cervix  with  Isolated  Involvement 
of  the  Fundus. — Dr.  Boldt  presented  a  second  speci- 
men  consisting  of  cancer  of  the  cer\  ix  with  isolated 
cancerous  spot  in  the  body  of  the  uterus.  It  was 
another  illustration  of  the  point  made  by  him  at  the 
meeting  of  the  American  Gynecological  Society  in 
Brooklyn  some  years  ago,  that  we  should  not  be  satis- 
fied with  supravaginal  amputation  of  the  cervix  for 
carcinoma  apparently  limited  to  the  cervix,  for  fre- 
quently there  co-existed  without  our  knowledge  cancer 
of  the  uterus  without  tumefaction  and  seemingly  inde- 
pendent of  the  disease  in  the  cer\'ix.  Dr.  John  Byrne 
deserved  great  credit  for  his  pioneer  work  with  the 
gahano-cautery,  but  Dr.  Boldt  thought  the  advantage 
over  the  knife  was  not  because  of  the  cautery  being 
electric,  and  personally  he  preferred  the  use  of  the 
Paquelin  cautery. 

Specimen  from  Early  Abortion — Dr.  Dudley  pre- 
sented the  products  of  an  early  criminal  abortion,  ap- 
parently a  double  uterine  pregnancy,  two  sacs.  The 
woman  visited  him  bleeding,  after  having  made  three 
visits  to  an  abortionist.  He  informed  her  husband  of 
the  circumstances  and  then  removed  the  loose  prod- 
ucts of  conception  from  the  uterus.  The  patient  re- 
covered. 

Result  of  Hysterorrhaphy.  —  Dr.  Dudley  pre- 
sented the  uterus  and  appendages  removed  for  pyosal- 
pinx  on  one  side  and  ovarian  tumor  on  the  other  in  a 
colored  woman  upon  whom  he  had  operated  four  years 
ago  for  retroverted  uterus,  suturing  the  uterus  to  the 
abdominal  wall  anteriorly.  This  was  an  operation 
which  he  had  some  time  ago  said  he  would  never  re- 
peat, and  the  present  case  gave  good  reason  for  that 
resolution.  On  opening  the  abdomen  at  the  recent 
operation  he  found  that  the  uterus  was  not  close  to 
the  abdominal  wall,  but  was  suspended  from  it  by  a 
pedicle  an  inch  and  a  half  long.  To  the  posterior 
wall  of  the  uterus  the  small  intestine  was  adherent 
and  knotted  into  a  mass  to  the  extent  of  a  foot.  In 
front  the  uterus  was  bound  to  the  bladder  and  it  was 
this  pathological  condition  which  had  given  rise  to 
her  most  severe  symptoms.  Separation  of  the  adhe- 
sions required  nearly  an  hour.  Subsequent  to  the 
operation  symptoms  of  intestinal  obstruction  developed, 
and  Dr.  Dudley  wished  to  reopen  the  abdomen,  to 
which  proposition  the  consultant  did  not  agree.  Au- 
topsy showed  twisting  of  the  gut  at  the  site  of  the 
former  adhesions.  He  repeated  that  hysterorrhaphy 
placed  the  uterus  in  an  unnatural  position,  and  he 
would  never  resort  to  it  again. 

The  Use  of  the  Curette  in  Puerperal  and  Chronic 
Endometritis.  —  Dr.  Rkuiux  Pf.i erscin,  of  C.rand 
Rapids,  Mich.,  read  the  paper.  In  the  introduc- 
tory he  said  he  did  not  object  to  the  general  practi- 
tioner using  the  uterine  curette,  but  he  should  do  it 
only  with  clear  ideas  of  what  he  wished  to  accomplisli, 
and  after  having  had  that  amount  of  experience  with 
surgical  work  which  had  developed  the  habit  of  secur- 
ing and  maintaining  strict  asepsis.  He  had  seen 
serious  results  from  curetting  practised  by  careless  or 
inexperienced  persons,  and  believed  that  such  in- 
stances were  too  common. 

Speaking  of  cases  of  abortion  before  the  fourth 
month,  the  treatment  applied  by  the  author,  he  said, 
consisted  in  thorough  emptying  of  the  uterus,  a  sharp 
curette  being  used,  since  the  dull  instrument  was  inef- 
ficient; then  irrigation  with  sterilized  water.  He  did 
not  use  antiseptic  fluids,  because  he  regarded  the  dan- 
ger of  some  passing  through  the  Fallopian  tubes  as 


July  lO,  1897] 


MEDICAL    RECORD. 


67 


real.  The  puerperal  uterus  should  never,  in  his  opin- 
ion, be  packed  tightly  with  gauze.  Nor  did  he  be- 
lieve in  using  the  fingernail  instead  of  the  curette,  as 
it  was  liable  to  convey  infection.  Perforation  of  the 
uterus  had  often  occurred,  and  to  avoid  this  accident 
the  operator  should  first  have  made  careful  measure- 
ments of  the  organ. 

Concerning  the  puerperal  septic  uterus,  the  author 
quoted  Bumm,  and  divided  the  cases  into  two  classes, 
those  in  which  the  infection  was  local  and  shut  off  by 
a  granulation  zone,  and  those  in  which  it  was  general. 
In  cases  of  saprasmia,  and,  indeed,  in  all  septic  puer- 
peral cases,  he  curetted  with  the  dull  curette,  avoiding 
the  sharp  curette  because  of  the  danger  of  opening 
up  new  channels  of  infection.  Retained  membranes 
should  be  removed;  then  should  follow  irrigation  with 
sterilized  water.  In  the  second  variety  of  cases  local 
symptoms  were  subordinate  to  general  symptoms,  and 
the  protecting  granulation  zone  could  hardly  be  said 
to  exist;  the  lochia  was  not  so  foul  as  in  the  saprremic 
cases.     Little  hope  was  offered  by  any  treatment. 

The  curette  was  useful  in  all  forms  of  non-puerperal 
chronic  endometritis.  The  sharp  instrument  was  re- 
quired; the  dull  one  had  been  inefficient  in  his  hands 
even  in  catarrhal  non-septic  cases.  Gonorrhceal  cases 
required  caustics  after  curettage,  although  some  had 
argued  that  they  were  contraindicated  as  interfering 
with  drainage.  There  should  be  free  exit  for  fluid; 
gauze  should  not  be  used  in  a  manner  to  interfere  with 
this,  if  it  were  used  at  all. 

Dr.  H.  T.  Hanks  opened  the  discussion.  In  speak- 
ing of  the  manner  of  packing,  it  is  not  wise,  he  said,  to 
pack  tightly.  Certainly  the  cervical  canal  will  not 
bear  tight  packing,  and  the  uterus  does  not  require  it 
excepting  after  the  removal  of  an  intra-uterine  tumor, 
and  generally  not  then.  But  he  believed  that  a  good 
iodoform  gauze  packing  can  remain,  and  is  beneficial 
if  it  remains  two  or  even  three  days  in  cases  of  endo- 
metritis of  some  weeks'  or  months'  standing.  The  only 
caution  which  he  would  give  to  friends  and  students 
is  that  after  the  thorough  curettage  the  gauze  should  be 
loosely  packed  in  all  parts  of  the  cavity,  and  not 
packed  at  all  at  the  internal  os;  only  the  small  strip 
of  gauze,  not  wider  than  one  inch,  should  simply  be 
left  straight  in  the  cervical  canal.  Such  a  packing 
never  causes  uterine  colic.  The  uterus  never  rebels. 
But  when  the  cervical  canal  at  the  internal  os  is  packed 
tightly,  there  is  less  opportunity  for  drainage,  and 
there  is  an  e.xciting  cause  for  uterine  colic  within  a  few 
hours.  One  does  have  pain  and  fever,  and  many  times 
the  surgeon  believes  that  he  has  a  case  of  iodoform 
poisoning  or  of  septic  inflammation,  when  nature  is  only 
trying  to  throw  off  the  offending  body  at  the  internal  os. 

Another  matter  of  great  importance  is  the  kind  of 
medicament  with  which  to  saturate  the  gauze.  He 
believed  that  good  iodoform  medicated  gauze  in  the 
uterine  cavity  is  better  than  sterilized  plain  gauze. 
He  further  believed  that  the  iodoform  in  the  gauze  has 
a  decidedly  beneficial  effect  in  chronic  endometritis 
and  metritis,  over  and  above  the  well-known  fact  of  its 
keeping  the  gauze  sweet  while  in  use,  for  two  or  three 
days. 

He  substituted  to-day  for  iodoform,  "  nosophen"  and 
its  component, '■  eudo.xin."  These  are  just  as  good 
medicaments,  and  they  are  far  less  offensive  than  iodo- 
form. He  had  used  constantly  for  more  than  a  year,  in 
all  his  private  practice,  eudoxin  or  nosophen  gauze. 
In  about  one-half  of  his  cases  of  uterine  packing 
in  the  Woman's  Hospital,  he  had  used  this  gauze  with 
most  satisfactory  results.  He  knew  the  effect  of  the 
nosophen  and  eudoxin  powders  on  the  raw  and  abraded 
surfaces,  like  those  following  burns,  etc.,  and  he  there- 
fore believed  it  has  a  direct  special  effect  on  congested 
abraded  surfaces  in  a  cavity,  other  than  the  mechani- 
cal effect. 


Nosophen  contains  over  fifty  per  cent,  of  iodine,  and 
has  no  odor,  and  therefore  a  one-per-cent.  or  a  two-per- 
cent, mixture  in  glycerin  certainly  ought  to  be  a  satis- 
factory medicament  for  saturating  gauze.  And  in  the 
author's  hands  it  has  been  altogether  most  satisfac- 
tory. 

Dr.  Currier  mentioned  a  case  to  emphasize  the 
fact  that  it  was  best  to  leave  the  operation  of  uterine 
curettage  to  those  in  whose  specialty  it  belonged. 
He  thought  the  author  had  not  given  sufficient  credit 
to  gauze  for  drainage.  The  precaution  should  be 
taken  in  introducing  it  pointed  out  by  Dr.  Hanks. 
Regarding  the  kind  of  curette,  many  cases  were  per- 
fectly amenable  to  the  dull  instrument.  No  doubt 
many  had  at  times  had  bad  results  from  employing 
methods  which  were  too  violent. 

Dr.  Dudley  used  the  sharp  curette  in  puerperal 
cases  before  the  third  month,  the  dull  one  later.  The 
best  instrument  was  the  irrigating  curette,  which  ren- 
dered the  parts  antiseptic  the  moment  it  was  used. 
The  forceps  sometimes  removed  material  better  than 
the  curette.  In  endometritis  he  painted  the  interior 
of  the  uterus  after  curettage  with  pure  or  ninety-five 
per-cent.  carbolic  acid.  P"or  packing  he  used  dry 
iodoform  gauze.  Glycerin  iodoform  gauze  favored 
absorption  of  the  iodoform  and  poisoning.  In  chronic 
endometritis  he  curetted  the  fundus  with  the  dull  in- 
strument, the  cerv'ix  with  the  sharp  one.  In  gonor- 
rhceal endometritis  he  used  nitrate  of  silver,  forty 
grains  to  the  ounce.  It  was  the  best  germicide  for 
the  gonococcus. 

Dr.  Boldt  always  washed  out  the  uterus  before 
curetting,  and  if  it  were  not  a  septic  case  no  harm 
would  be  likely  to  result  in  the  event  of  accidental 
perforation.  He  had  no  use  for  the  dull  curette  ex- 
cept just  after  delivery,  when  some  of  the  secundines 
had  been  retained,  but  in  most  of  such  cases  the  fin- 
gers would  do  better.  One  could  not  tell  how  much 
force  to  employ  with  the  dull  curette.  Gauze  did  not 
act  as  a  drain,  whether  packed  tightly  or  loosely.  It 
had  only  two  purposes:  to  cause  contraction  of  a  large 
uterus,  to  secure  hiemostasis.  Dr.  Dudley  had  said 
that  carbolic  acid,  when  used  pure,  was  not  absorbed 
because  it  formed  an  albuminate.  It  was  because  it 
formed  an  albuminate,  which  destroyed  its  penetrating 
germicidal  power,  that  Dr.  Boldt  did  not  employ  it 
pure,  but  diluted  one-half  with  glycerin. 

Dr.  R.  a.  Murray  mentioned  a  case  showing  that 
the  dull  curette  (used  by  another  physician)  had  no 
power  to  stop  the  septic  symptoms,  whereas  the  sharp 
curette  which  he  employed  when  called  to  the  case  set 
the  patient  at  once  on  the  road  to  recovery.  He  had 
no  use  for  the  dull  instrument.  He  introduced 
no  gauze,  made  no  applications  unless  of  iodine, 
which  seemed  to  contract  the  uterus  somewhat. 
Packing  was  indicated  only  for  bringing  about  con- 
traction. 

Dr.  Egbert  H.  Grandin  thought  the  paper  had 
been  a  protest  against  the  injudicious  use  of  the 
curette  and  in  favor  of  the  rational  use  of  gauze. 
In  so  far  he  agreed  with  the  author.  He  had  tried 
all  methods  of  treatment  in  non-septic  endometritis 
and  had  come  to  curettage  as  the  only  rational  one. 
But  it  must  be  used  with  discretion.  The  only  place 
for  the  dull  curette  was  for  removal  of  secundines 
which  were  not  infected,  but  here  the  fingers  would  do 
better.  He  resorted  to  the  sharp  curette  also  in  putrid 
infection  of  the  puerperal  state.  In  gonorrhoeal  en- 
dometritis he  used  the  nitrate  of  silver,  one  hundred 
and  twenty  grains  to  the  ounce.  If  he  introduced 
gauze  at  all,  it  was  only  plain  gauze  and  for  twenty- 
four  hours.  He  had  tried  all  jicinds  of  applications, 
carbolic  acid,  nitric  acid,  etc.,  and  had  given  them  up. 
He  now  mopped  out  the  uterus  with  alcohol ;  it  might 
be  of  some  value. 


68 


MEDICAL    RPXORD. 


[July  lo,  1897 


SECTION   ON    GENERAL   MEDICINE. 

Stated  Meeting,  April  20,  1897. 

Louis  F.  Bishop,  M.D.,  Chairman. 

The  Nomenclature  and  Mode  of  Production  of  Aus- 
cultatory Signs  in  Pulmonary  Diseases.  — Dr.  Eg- 
bert Le  Fevre  read  the  paiDcr.  All  teachers  of  phys- 
ical signs  relating  to  the  chest  must  have  noted  the 
difficulty  of  conveying  to  students  the  meaning  of  cer- 
tain terms  used  in  books  on  physical  diagnosis,  for 
under  the  same  terms  different  writers  had  described 
different  conditions  or  sounds.  In  confirmation  of 
this  statement  the  author  quoted  freely  from  several 
writers,  including  Musser,  Vierord,  Gibson  and  Rus- 
sell, Powell,  Page,  Loomis,  Flint,  Da  Costa.  These 
quotations  would  give  a  fair  conception  of  the  mode  of 
production  of  the  physical  signs  according  to  the  views 
of  the  several  authors.  It  was  evident  that  there  was 
an  attempt  to  adapt  the  definition  to  the  several  theo- 
ries of  production,  and  vice  versa.  The  three  prevail- 
ing theories  of  the  production  of  the  auscultatory 
sounds  were:  i,  That  the  vesicular  murmur  was  noth- 
ing more  than  the  sound  made  by  the  glottis  modified 
by  transmission  downward;  2,  that  it  was  produced 
entirely  in  the  alveoli;  3,  that  there  was  a  combina- 
tion of  the  two  sounds  from  the  glottis  and  from  the 
alveoli. 

The  reader  regarded  it  as  absolutely  necessary  to  a 
correct  interpretation  of  the  physical  signs  to  have  a 
true  conception  of  the  facts  which  went  to  make  up 
vesicular  or  respiratory  murmur.  He  offered  the  fol- 
lowing as  a  working  hypothesis :  There  was  no  doubt 
that  the  sounds  due  to  vibrations  in  the  laryn.x  were 
conducted  down  the  bronchial  tubes,  but  this  was 
not  the  only  basis  of  the  respiratory  murmur.  At  each 
inspiration  the  tidal  air,  equal  to  about  thirty  cubic 
inches,  was  carried  through  the  bronchi  and  alveoli. 
and  all  the  air  in  the  pulmonary  tract  was  set  in  mo- 
tion. The  sound  arising  from  the  air  passing  through 
the  glottis  was  transmitted  almost  unchanged  to  the 
division  of  the  trachea.  At  this  point  the  column  of 
air  was  broken  up  by  impinging  on  the  bronchi,  then 
another  sound  was  produced,  less  intense  than  the 
first  named;  at  the  next  division  there  arose  in  a  sim- 
ilar manner  another  vibration  and  sound,  and  so  on 
down  to  the  finest  bronchioles.  The  farther  the  col- 
umn of  air  proceeded  in  distance  and  in  subdivisions, 
the  less  intense  the  succeeding  sounds  became.  The 
first  sound  might  be  denominated  tracheal,  the  ne.xt 
one  a  combination  with  this  of  the  first  bronchial,  and 
so  on.  In  certain  physical  states  the  upper  tracheal 
and  bronchial  elements  were  more  predominant  than 
in  others.  In  view  of  the  fine  divisions  of  the  air  col- 
umn when  it  reached  the  terminal  bronchi  and  alveoli, 
and  its  slow  movement,  it  could  be  assumed  that  little 
sound  was  added  there.  The  intensity  of  the  sounds 
conveyed  to  the  ear  would  depend  upon  their  original 
character  modified  by  the  structures  through  which 
they  were  conducted — the  resiliency  of  the  lung  tissue, 
etc.  The  difference  in  tensity  of  the  lung  tissue  in 
inspiration  and  expiration  would  go  far  to  account  for 
the  greater  intensity  and  duration  of  the  respiratory 
murmur  on  inspiration. 

There  was  much  difference  of  opinion  regarding  the 
production  of  crepitant  rales.  Some  writers  claimed 
that  they  were  due  to  separation  of  the  adherent  walls 
of  the  alveoli  when  the  air  entered  the  lungs.  Others 
held  that  they  arose  in  the  pleura.  Regarding  the 
former  view.  Dr.  Le  Fevre  replied  that  the  alveoli 
were  rounded,  did  n^  become  completely  collapsed. 
so  that  there  could  not  be  a  separation  of  their  walls 
in  the  sense  spoken  of.  He  was  of  opinion  that  tiie 
sound  was  due  in  part  at  least  to  the  air  passing  fiuid 


exudate  on  entering  the  air  vesicles.     .Similar  sounds 
could  be  made  in  the  pleura. 

Ought  we  to  do  away  with  such  terms  as  rude  respi- 
ration, broncho-vesicular  respiration,  etc.,  and  limit 
ourselves  to  fixed  terms  indicating  the  characters  of 
sound — intensity,  duration,  and  quality?  Ought  pitch 
to  be  left  out  of  consideration,  as  had  been  done  in 
recent  text-books  ? 

Dr.  \V.  H.  Katzexbach  thought  the  author's  hy- 
pothesis regarding  the  normal  respiratory  murmur  was 
an  ingenious  one,  and  furnished  a  good  working  basis. 
He  had  himself  been  dissatisfied  with  the  term  vesic- 
ular breathing,  for  he  had  not  been  convinced  that  the 
normal  respiratory  murmur  was  produced  in  the  air 
cells.  He  had  been  rather  disappointed  that  the  au- 
thor had  not  referred  to  some  of  the  observations  of 
Dr.  Learning  on  the  production  of  the  respiratory 
murmur.  Dr.  Learning  had  held  that  there  was  no 
more  than  molecular  motion  in  the  air  cells,  which 
was  noiseless,  and  that  the  respiratory  murmur  was 
due  to  friction  of  the  air  passing  through  the  bronchial 
tubes,  this  sound  modifying  the  tubular  sound  coming 
from  the  glottis  and  trachea.  When  the  density  of  the 
lung  was  changed,  the  character  of  the  sound  became 
modified.  In  his  early  study  Dr.  Katzenbach  had 
been  associated  with  Dr.  Flint,  who  laid  stress  on  four 
elements  in  sound — namely,  duration,  intensity,  pitch, 
and  quality.  Regarding  the  origin  of  the  crepitant 
rale,  lie  believed  the  majority  of  those  with  whom  he 
had  conversed  rejected  the  view  that  it  was  produced 
in  the  air  cells  themselves.  Whether  it  was  produced 
in  the  terminal  bronchioles,  as  explained  by  Dr.  Le 
Fevre,  he  was  still  a  little  in  doubt.  He  had  for  a 
number  of  years  considered  it  a  crepitant  rale  from  the 
pleura. 

Dr.  Charles  E.  Quimby  said  the  views  of  the  pro- 
duction of  the  respiratory  murmur  and  on  the  use  of 
terms,  as  expressed  in  the  paper,  were  exactly  those 
which  he  had  been  teaching  students  for  seven  years. 
Five  years  ago  he  had  presented  half  a  dozen  patients 
before  this  section,  and  had  those  examining  thtm 
mark  on  a  piece  of  paper  what  they  heard  at  different 
localities  over  the  chest,  and  in  no  instance  did  any 
two  doctors  use  the  same  term  to  express  what  they 
heard.  Four  years  ago  he  published  a  paper  in  the 
Medical  Record,  which  he  had  read  before  the  Acad- 
emy of  Medicine,  expressing  the  views,  though  in  more 
technical  terms,  to  which  we  had  listened  to-night,  and 
it  gave  him  great  pleasure  to  know  that  he  was  not 
alone.  As  stated,  seven  years  ago  he  had  discarded 
the  use  of  such  terms  as  rude,  harsh,  or  bronchial 
breathing,  and  had  directed  the  attention  of  students 
to  the  intensity,  pitch,  duraticm,  and  quality  of  the 
sounds  heard.  When  it  came  to  known  physical  facts, 
no  man's  opinion  counted  for  anything.  The  laws 
governing  the  production  of  sound  had  been  demcn- 
strated  long  before  most  of  us  were  born.  The  only 
element  in  which  a  sound  lost  when  once  produced 
was  intensity.  The  tracheal  sound,  tor  instance,  re- 
tained precisely  the  quality  with  which  it  started  when 
heard  by  the  ear  placed  lower  over  the  lung.  There 
was  no  such  thing  as  pure  sound.  The  pitch  was  de- 
termined by  the  length  of  the  tube  set  in  vibraticn. 
being  lower  the  longer  the  tube:  hence  the  sounds 
from  the  larger  bronchi  were  lower  in  pitch  than  these 
arising  from  the  finer,  shorter  bronchi  set  in  motion 
by  the  air  impinging  upon  their  walls,  more  especially 
upon  the  angle  of  separation.  The  intensity  of  any 
sound  depended  first  upon  the  amplitude  of  the  primary 
vibrations.  When  the  angle  of  detlection  in  a  divid- 
ing bronchus  was  great,  the  ingoing  air  suffered  greater 
deflection,  which  caused  greater  vibration,  greater  in- 
tensity of  sound.  This  would  account  for  the  breath- 
ing at  the  right  apex  being  more  bronchial  than  at 
the  left,  for  the  bronchus  of  the  right   apex    made  a 


July  lo,  1897] 


MEDICAL    RECORD. 


69 


sharper  turn  on  dividing.  As  the  air  proceeded 
downward  it  produced  sounds  which  were  higher  in 
pitch  but  of  less  intensit)-.  According  to  the  case, 
the  larger  or  the  smaller  tube  sounds  would  predomi- 
nate. He  was  convinced  that  in  most  normal  cases 
the  small  tube  sounds  predominated,  hence  the  sound 
was  high-pitched.  But  high  and  low  were  only  rela- 
tive terras.  If  disease  cut  off  the  small  tube  sounds, 
we  had  left  only  the  large  tube  sounds,  or  low-pitch 
bronchial  breathing.  Regarding  greater  intensity  of 
sound  on  inspiration  than  on  e.xpiration,  unquestion- 
ably tensity  of  the  lung  had  to  do  with  it,  as  pointed 
out  by  the  author,  but  Dr.  Quimby  mentioned  two 
other  elements  which  he  regarded  as  important.  One 
of  these  was  the  direction  of  the  air,  being  toward  the 
ear  on  inspiration,  away  from  it  on  expiration.  The 
other  was  the  fact  that  on  expiration  the  vibrations 
were  caused  by  the  two  columns  of  air  impinging  upon 
each  other,  whereas  on  inspiration  they  were  caused 
bv  impact  upon  the  firm  bronchial  bifurcation.  On  ex- 
piration it  was  the  first  period  which  caused  most  of 
the  expirator)-  sound,  occurring  by  relaxation,  while 
the  further  outward  movement  of  the  air  was  slow  and 
not  strong  enough  to  cause  much  vibration  of  the 
tub3s.  He  agreed  v.ith  Dr.  Le  Fevre  with  regard  to 
the  production  of  rales. 

Dr.  Kxopf  expressed  pleasure  on  hearing  the 
younger  teachers  of  physical  diagnosis  making  the  at- 
tempt to  get  rid  of  too  many  terms  and  to  use  such  as 
would  be  clear  to  all  students.  Regarding  pitch,  he 
thought  a  prolonged  expirator)-  sound  and  change  of 
pitch  constituted  a  most  important  sign  of  beginning 
phthisis. 

Dr.  Le  Fevre  mentioned  as  proof  of  the  fact  that 
the  respiratory  sound  was  not  due  alone  to  the  vibra- 
tion of  the  air  as  it  passed  the  vocal  cords,  modified 
as  it  entered  the  lungs,  the  experiment  with  inflation 
of  the  lung  with  the  upper  part  of  the  trachea  cut  off; 
the  respiratory  sound  was  still  produced.  Regarding 
pitch,  his  ear  was  defective  in  appreciation  of  this  ele- 
ment of  sound,  especially  in  physical  diagnosis,  being 
unable  to  separate  it  from  the  other  elements,  and  it 
was  a  question  how  far  the  recent  text-books  were  right 
in  neglecting  it  and  speaking  only  of  intensity,  dura- 
tion, and  quality  of  the  sound.  He  was  unable  to  say 
how  many  students  were  capable  or  incapable  of  rec- 
ognizing the  pitch  of  the  respirator)-  sound. 

Dr.  Qui.mey  said  that  in  four  years'  teaching  medi- 
cal students  he  had  found  only  two  students  whom  he 
could  not  make  appreciate  the  element  of  pitch  in  half 
an  hour.  Theodore  Thomas  was  able  to  give  the  pitch 
of  any  sound  immediately  by  ear. 


Antiseptic      Street      Sprinkling The     Colorado 

Medical  Journal  says  that  there  are  hundreds  of  tuber- 
culous patients  promenading  the  streets  of  Denver 
daily,  and  expectorating  into  the  streets.  If  it  were 
not  for  the  constant  sunshine,  the  healthy  population 
would  have  no  show  against  the  invasion  of  these 
germs.  The  experience  of  several  Denver  physicians 
shows  that  tuberculosis  is  very  much  on  the  increase 
among  the  native  population,  and  it  is  necessary  to 
consider  every  practical  means  to  stop  its  advance. 
The  Journal  suggests  to  the  health  department  that 
corrosive  sublimate  be  added  to  the  water  in  the 
sprinkling  carts  of  the  city  in  sufficient  quantities  to 
be  effective  in  destroying  germs.  "  It  is  a  simple 
matter  to  make  this  solution  and  nothing  but  good  re- 
sults could  follow.  If  it  be  decided  that  corrosive 
sublimate  could  not  be  used  in  the  metallic  tanks,  let 
formaldehyde  be  used.  This  procedure  would  make 
the  dust  of  our  streets  less  harmful  and  help  to  lessen 
the  local  spread  of  tuberculosis.'' 


OUR   LONDON    LETTER. 


Ox 


■  Special  Correspondent. ) 


JUBILEE THE    PRIN'CE  S    FUND MEDIC.iL  JOURNALS  OF 

THE    REIGN ROYAL  SOCIETi" — COLLEGE  OF  SURGEONS 

MUSICAL    MURMURS — PARTURITION    DURING    PARA- 
PLEGIA. 

Lo.sDOX,  June  18,  1897. 

The  great  London  festival  to  come  off  on  Tuesday 
next,  and  inaccurately  called  the  Jubilee,  is  absorb- 
ing all  attention,  and  medical  affairs  occupy  a  back 
place  even  when  doctors  meet.  The  Graphic  has  pub- 
lished an  illustrated  programme  of  the  royal  proces- 
sion and  the  proceeds  of  the  sales  are  to  be  given  to 
the  Prince  of  Wales'  hospital  fund.  The  book  is 
worthy  of  the  artists  of  The  Graphic,  and  will  be  treas- 
ured as  a  beautiful  souvenir  of  the  great  pageant. 
The  progress  of  medicine  during  the  Queen's  sixty 
vears'  reign  is  in  itself  a  wonderful  story.  The  Lancet 
was  some  fourteen  years  old  when  Her  Majesty  as- 
cended the  throne,  and  is  still  the  leading  medical 
journal.  To-morrow's  number  will  be  the  thirt}--eight 
hundred  and  fift\-first.  The  ne.xt  oldest  is  the  Aledi- 
cal  Press  and  Circular,  Xo.  3,032  appearing  last  Wed- 
nesday. But  this  journal  was  for  many  years  the 
Dublin  Medical  Press  and  afterward  amalgamated  with 
a  much  younger  periodical.  The  Circular.  It  is  still, 
however,  the  organ  of  the  Irish  school  of  medicine 
and  may  be  regarded  as  the  Lancet  of  Ireland.  The 
British  Medical  Journal  for  this  week  will  be  No.  1.903, 
and  has  become  the  bulkiest  of  our  three  weeklies  on 
account  of  the  space  occupied  by  the  proceedings  of 
the  association  and  the  freedom  with  which  it  prints 
official  documents  instead  of  abstracting  or  condens- 
ing them.  All  these  journals  have  seen  others  started 
and  after  var}ing  success  discontinued.  Most  of  them 
have  done  good  service.  A  number  still  survive,  with 
which  you  are  acquainted  through  the  practical  nature 
of  their  contents. 

On  Wednesday  Lord  Lister  as  president  received 
the  guests  of  the  Royal  Society.  It  was  the  '"  ladies' 
night"  and  a  brilliant  exhibition.  Telegraphy  with- 
out wires  and  the  .v-rays  were  in  the  ascendant.  A 
series  of  argon  and  helium  tubes,  displaying  the  words 
"  Vivat  Victoria  Regina,"  arrested  the  visitors'  atten- 
tion on  entering. 

The  Society  of  Members  of  the  College  of  Surgeons 
have  asked  Lord  Lister  to  allow  himself  to  be  put 
forward  for  election  on  the  council  of  the  college. 
There  are  at  the  moment  five  vacancies  and  eleven 
candidates,  two  of  whom  seek  re-election. 

A  musical  murmur  is  sure  to  arrest  the  attention  of 
the  auscultator,  and  the  conditions  under  which  these 
sounds  are  produced  have  not  been  fully  worked  out. 
They  are  often  dismissed  as  phenomena  of  mitral  re- 
gurgitation, but  this  is  at  best  an  imperfect  explana- 
tion. Four  cases  of  such  murmurs  were  related  to  the 
Medico-Chirurgical  Society  by  the  president  (Dr.  Dick- 
enson) at  the  last  meeting,  all  of  which  were  associ- 
ated with  aortic  stenosis.  They  were  all  attributed 
during  life  to  mitral  regurgitation,  but  after  death 
aortic  obstruction  was  found  in  all.  In  three  out  of 
the  four  there  was  also  mitral  disease,  but  in  one  the 
valve  was  sound,  while  the  aortic  orifice  was  almost 
closed  by  recent  vegetations.  Dr.  Dickenson  sug- 
gested that  the  sound  was  due  to  the  overdistention 
of  the  ventricle  through  the  aortic  obstruction,  caus- 
ing leakage  at  the  mitral  orifice  from  the  abnormal 
pressure.  A  similar  explanation  was  offered  of  the 
other  cases,  in  which  hypertrophy  of  the  ventricle  and 
aortic  obstruction  were  associated  with  mitral  insuf- 


70 


MEDICAL    RECORD. 


[July  lo,  1897 


ficiency.  The  peculiar  tone  might  be  imparted  to 
regurgitation  in  small  volume  but  at  high  pressure. 

Dr.  N.  Moore  admitted  Dr.  Dickenson's  ingenious 
explanation  to  be  probably  the  correct  one,  though 
there  might  be  others  possible.  The  late  Dr.  .Andrew 
taught  that  a  systolic  ape.x  murmur  heard  at  the  angle 
of  the  scapula  was  due  to  mitral  regurgitation,  but  if 
not  heard  behind  it  might  be  aortic.  Information 
may  sometimes  be  obtained  by  listening  at  the  right 
suprascapular  fossa  as  well  as  at  the  angle.  A  mur- 
mur, loud  above  but  diminishing  on  passing  down- 
w-ard  and  lost  at  the  angle,  is  probably  due  to  aortic 
stenosis.  On  the  contrary,  a  murmur  becoming  clearer 
at  the  angle  is  probably  mitral  associated  with  aortic 
stenosis. 

Dr.  Amand  Routh  related  to  the  Obstetrical  Society 
an  interesting  case  of  parturition  in  the  course  of  para- 
plegia below  the  level  of  the  sixth  dorsal  vertebra, 
caused  by  an  accident  at  nearly  the  seventh  month  of 
pregnancy.  The  patient  was  admitted  to  the  surgical 
ward  and  remained  there  more  than  two  months,  was 
then  transferred  to  a  special  ward,  and  labor  came  on 
two  hundred  and  sixty-one  days  after  the  last  menstrua- 
tion, the  first  stage  lasting  ten  hours,  the  second  two 
and  one-quarter  hours.  The  placenta  followed  in  five 
minutes.  The  only  sensation  during  "  a  pain"  was  a 
"  tight  feeling"  at  the  epigastrium.  As  the  head  passed 
the  vulva  the  patient  cried  out,  though  she  had  no  pain- 
ful sensation;  so  it  seemed  only  a  reflex  act.  The 
"  pains"  were  not  so  well  defined  as  in  normal  cases, 
the  intermissions  being  often  incomplete — remittent 
rather  than  intermittent.  After  passing  in  review  re- 
corded cases,  Dr.  Routh  thought  we  might  conclude 
that  (a)  parturition  is  partly  automatic  and  partly  re- 
flex, these  acts  corresponding  mainly  with  the  first 
and  second  stages;  {/>)  direct  communication  with  the 
brain  is  not  essential  to  co-ordinate  uterine  action, 
though  the  brain  seems  to  regulate  the  pains;  (<•) 
direct  communication  between  the  uterus  and  the  lum- 
bar enlargement  of  the  cord  is  probably  essential  to 
the  regular  and  co-ordinate  contraction  and  retraction 
of  the  uterus  in  normal  labor ;  (d)  probably  the  uterus 
is  able  to  expel  its  contents  automatically  as  far  as 
the  relaxed  part  of  the  genital  canal,  even  when  de- 
prived of  spinal  influence,  but  in  the  absence  of  re- 
flexes the  process  of  labor  would  be  irregular  and 
probably  incomplete ;  (e)  lactation  does  not  depend 
on  nervous  influence  merely,  but  is  partly  due  to 
chemical  changes  in  the  blood,  and  these  are  in  turn 
due  to  the  metabolism  of  the  pregnant  uterus.  Dr. 
Mott  thought  that  the  cause  of  the  onset  of  labor  was 
certainly  bio-chemical,  and  suggested  that  the  physio- 
logical stimulus  is  an  increase  of  carbon  dioxide  in 
the  placental  circulation.  In  the  conversation  that 
followed  it  was  evident  that  this  point  was  of  much 
interest,  as  was  also  the  extent  of  reflex  action  in  the 
case  related. 


that  the  dispensary'  managers,  in  compliance  with  the 
State  law,  supply  a  safe  in  the  waiting-room,  accord- 
ing to  the  custom  in  hotels  and  bathing-pavilions, 
and  then  post  the  usual  notices  warning  people  that 
the  proprietors — or  rather  the  philanthropists — will 
not  consider  themselves  responsible  for  valuables  not 
placed  in  the  safe.  Louis  C.  Ager,  M.D. 

Bkooklvn,  N.  V. 


PROTECTION    OF   THE    DISPENSARY 
PATIENT. 

To  THK  Editok  of  thk  Meuical  Record. 

Sir:  I  have  just  read  with  great  regret  your  editorial 
comment  upon  a  recent  theft  in  a  free  dispensary. 
You  have  pointed  out  the  fact  of  contributory  negli- 
gence on  the  part  of  the  patient,  but  you  have  failed 
to  warn  the  philanthropists  who  devote  their  energies 
to  dispensary  benevolences  of  the  possible  source  of 
danger  to  them.  A  jury  would  be  likely  to  hold  them 
responsible  in  such  a  case  unless  they  could  prove 
that  they  had  exercised  due  care.  This  in  turn  migiit 
be  taken  advantage  of  by  the  occasional  dishonest 
dispensary  patient  as  an  opportunity  to  levy  blackmail. 
Bearing  these  facts  in  mind,  I  would   humbly  suggest 


THE    FERROCYANIC    TEST    FOR    ALBUMIN 
IN    THE   URINE. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  A  source  of  error  in  the  use  of  this  test,  not  here- 
tofore mentioned,  is  due  to  iron  in  mineral  water  taken 
by  the  patient.  In  a  case  recently  examined  by  the 
writer,  a  sample  of  urine,  which  gave  but  faint  traces 
of  albumin  with  Jolle's,  Spiegler's,  Tanret's,  Roberts', 
Esbach's,  and  the  heat  and  acid  tests,  yielded  an  abun- 
dant flocculent  precipitate  with  the  ferrocyanic  test 
after  standing  half  an  hour.  Sedimented  in  the  cen- 
trifugal machine,  the  bulk  percentage,  at  one  thousard 
revolutions  per  minute  for  five  minutes,  was  nearly 
seven,  reduced  to  two  and  one-half  at  seventeen  hun- 
dred revolutions  for  half  an  hour. 

Differentiation  from  albumin  can  be  made  by  ob- 
serving the  blue  color  of  the  precipitate  when  sedi- 
mented. The  mineral  water  in  question  was  that  of 
Pueblo,  Col.  Clifford  Mitchell,  M.D. 

Chicago. 


^exu  ^nstmmciitB. 

THE  HEMOSPAST. 
By   VERANUS   A.    MOORE.   M.D.. 

NhW    VORK   STATE    VETERINARY  COLLEGE,    CORNELL  UNI\'ERSITV,   ITHACA,  N.  V. 

The  extent  to  which  the  results  obtained  from  blood 
examinations  are  being  relied  upon  in  making  posi- 
tive diagnoses  renders  improvement  in  the  instruments 
for  drawing  even  the  little  blood  necessar)-  for  this 
purpose  a  matter  worthy  of  attention.  In  addition  to 
the  examination  of  the  blood  by  the  physician  for  im- 
mediate assistance,  it  is  being  investigated  more  and 
more  thoroughly  in  histological  laboratories,  and  in 
determining  the  nature  of  many  diseases  the  changes 
produced  in  the  blood  are  receiving  increased  consider- 
ation. By  any  of  the  methods  ordinarily  used  the  pro- 
curing of  fresh  blood  from  the  human  subject  for  mi- 
croscopic examination  is  somewhat  clumsy  and  often 
annoying  to  the  operator.  Usually  a  surgical  needle 
is  employed,  but  with  the  ana;mic  and  often  nervous 
individual  the  sight  of  this  simple  implement,  not  to 
mention  the  making  of  the  slight  incision,  causes  much 
apprehension.  This  is  especially  true  if  it  is  neces- 
sary, as  it  sometimes  is,  to  make  two  or  more  '"stabs" 
before  a  sufficient  flow  of  blood  is  obtained.  In  work- 
ing with  the  smaller  or  experimental  animals  the  task  is 
less  difficult,  but  even  here  the  incision  which  is  made 
with  a  scalpel,  bistoury,  or  scissors,  is  unnecessarily 
long  or  deep.  For  the  larger  animals  the  spring  fleam 
is  very  satisfactory,  but  it  is  not  applicable  for  the 
smaller  species  or  for  the  human  subject. 

The  introduction  of  the  hematocrit,  for  the  determi- 
nation of  the  number  of  red  blood  corpuscles,  ne- 
cessitates a  slightly  larger  quantity  of  blood  for  each 
examination  than  was  required  for  the  counting-appa- 
ratus, and  consequently  aggravates  the  difficulties,  by 
the  present  methods,  of  procuring  the  required  amount. 
The  desire  for  an  instrument  with  which  the  incision 
could  be  made  instantly,  and  the  depth  of  the  cut  ac- 
curntolv  regulated,  led  me  to  make  several  experiments 
in  the  construction  of  an  apparatus  possessed  of  these 


July  lo.  1897] 


MEDICAL    RECORD. 


71 


qualities.  The  outcome  was  a  spring  needle  lancet 
which  works  so  admirably  and  which  has  so  com- 
pletely removed  the  difficulties  attending  the  use  of 
the  surgical  needle  or  bistoury  that  it  seems  worthy  of 
a  brief  description. 

The  hemospast  '  consists  of  a  metal  tube  (I  have 
used  brass)  about  five  centimetres  long  and  one  centi- 
metre in  diameter,  with  the  upper  end  closed  and  the 
lower  one  covered  with  a  perforated  screw  cap  which 
has  a  terminal  regulator  in  the  form  of  a  smaller  per- 
forated cap.  A  narrow  slot,  three  centimetres  long,  is 
cut  in  one  side  of  the  tube,  beginning  one-half  centi- 
metre from  the  lower  end.  In  the  upper  part  of  the 
tube  is  a  piece  of  coiled  wire  spring  of  sufficient 
strength  to  give  the  necessarj'  force  to  a  cylindrical 
plunger,  carrying  the  needle,  which  is  placed  next  to 
it  in  the  lower  part  of  the  tube.  The  plunger  rests 
against  the  cap.  The  incision  is  made  with  a  trian- 
gular-pointed needle  constructed  with  a  shoulder,  for 
convenience  in  handling,  and  which  screws  into  the 
lower  end  of  the  plunger.  From  the  side  of  the 
plunger  projects  a  trigger  which  moves  in  the  slot 
and  with  which  the  plunger  is  pushed  up.  When  set 
the  trigger  is  easily  caught,  by  a  slight  twisting  move- 
ment, into  a  notch  near  the  upper  end  of  the  slot.  By 
means  of  the  regulator  the  length  of  the  projecting 
part  of  the  needle  can  easily  be  adjusted.  When  the 
spring  is  set  the  needle  is  hidden  entirely  from  sight, 
so  that  if  the  instrument  is  exposed  to  view  it  does 
not  suggest  an  implement  of  torture.  In  use  it  is  con- 
venient and  easily  handled.  After  the  finger,  or  other 
part  is  cleansed  and  the  incision  is  to  be  made,  the 
instrument  is  pressed  gently  to  the  part,  the  trigger 
touched,  and  the  incision  of  exactly  the  depth  desired 
is  instantly  made.  As  soon  as  sprung,  the  hemospast 
can  be  dropped  and  the  collection  of  the  blood  begun. 

This  instrument  is  equally  efficient  and  much  more 
convenient  in  procuring  small  quantities  of  blood 
from  experimental  and  other  animals  than  those  which 
I  have  heretofore  observed  in  the  hands  of  others  or 
employed  myself.  As  it  is  made  entirely  of  metal  it 
can  be  sterilized  in  any  of  the  germicides  used  in  dis- 
infecting surgical  instruments,  or  by  dry  heat.  If  de- 
sired, it  can  be  made  larger  and  stronger,  with  needles 
of  various  sizes,  and,  if  preferred,  with  a  cutting  edge 
of  a  millimetre  or  more  in  length.  It  is  available, 
therefore,  for  workers  in  laboratories  where  normal 
human  blood  or  that  of  healthy  or  diseased  animals  is 
being  studied,  as  well  as  for  the  practising  physician. 
Although  simple  in  its  design,  there  were  a  few  me- 
chanical difficulties  encountered,  for  the  overcoming  of 
which  I  am  indebted  to  Mr.  W.  C.  Barnard  for  timely 
suggestions. 

A  NEW  COMEDO  EXTRACTOR. 
By   CH.A.RLES  W.    .\LLEN,    M.D.. 

The  instrument  represented  in  the  accompanying  il- 
lustration has  the  advantage  over  others  in  use  for  the 
same  purpose  that  it  cannot  become  clogged;  that  the 


lesion  is  kept  in  unobstructed  view ;  that  lateral  pres- 
sure, massage,  and  gentle  squeezing  of  the  tissues  can 
be  carried  out  without  injurious  pressure,  being  pos- 
sible by  reason  of  a  guard  which  prevents  the  arms  of 

'  '■  Hemospast"  is  the  noun  from  the  Greek  combination  of 
which  the  adjective  form  hemospastic  (drawing  or  attracting 
hlood)  is  already  in  use. 


the  instrument  from  wholly  closing.  In  the  handle  a 
three-edged  lance-shaped  knife  and  sharp  spoon  are 
hidden.  The  former  is  sufficiently  sharp  for  scarifica- 
tion as  well  as  for  opening  pustules,  deep  nodes,  etc., 
or  for  pricking  the  opening  of  the  comedo  follicle  or 
incising  its  walls. 

With  the  st}iet  closed  the  instrument  can  be  carried 
in  the  pocket,  and  it  offers  the  further  advantage  of  a 
combination  of  all  the  instruments  necessary  in  the 
local  treatment  of  an  ordinary  case  of  acne  vulgaris,, 
or  comedones. 

It  is  made  by  Messrs.  Tiemann  &  Co.,  107  Park 
Row. 

SELF-RETAINING  ABDOMINAL  RETRACTOR, 
By   JOHN   N.    BELL,    M.D., 

DETROIT,   MICH., 


The  accompanying  illustration  represents  a  self -retain- 
ing abdominal  retractor  which  I  have  recently  devised. 
In  removing  pus-tubes,  small  fibromata,  and  multilocu- 
lar  cysts,  with  the  patient  in  Trendelenburg's  position, 
this  instrument 
i  s  especially 
useful ;  keep- 
ing, as  it  does, 
the  field  of  op- 
eration widely 
exposed  to 
view,  the  locat- 
ing and  ligat- 
ing  of  bleeding 
points  are 
greatly  facili- 
tated. 

The  shorter 
blades  are  en- 
tered through  the  abdominal  incision  and  retraction  of 
the  walls  made  to  any  extent  desired;  the  thumb- 
screw (which  should  point  toward  the  pubes)  is  then 
set. 

The  instrument  is  at  present  in  use  at  Harper  Hos- 
pital, and  gives  perfect  satisfaction. 


Uses  of  Bananas. — It  is  hardly  necessary  to  state 
that  well -matured  bananas  that  have  not  begun  to  de- 
cay are  a  very  wholesome  and  nutritious  food.  No 
more  than  that  the  biggest  apples  or  pears  always  are 
the  best,  are  the  biggest  bananas  the  finest  flavored ^ 
on  the  contrar}-,  the  larger  they  are  the  more  mealy 
they  taste.  The  cultivation  of  bananas,  although  it 
has  in  the  last  ten  years  assumed  gigantic  proportions, 
may  still  be  said  to  be  in  its  infancy.  Almost  every 
part  of  the  plant  can  be  used  for  some  useful  purpose ; 
the  stalk  forms  an  excellent  material  for  the  manufac- 
ture of  paper,  or  the  fibre  might  be  extracted ;  the  peel 
of  the  fruit  will  make  e.xcellent  indelible  ink;  the 
green  fruit  dried  can  be  converted  into  whole- 
some flour.  The  fruit,  when  ripe,  consists  of 
seventy-four  per  cent,  of  water;  of  the  remaining 
twenty-six  parts,  twenty  are  sugar  and  two  gluten 
or  flesh-forming  food.  Hence,  like  rice,  though 
exceedingly  nutritious,  it  requires  the  addition 
of  some  more  nitrogenous  material.  Green 
bananas,  boiled  tender,  if  given  to  the  hens,  will 
make  them  lay  more  eggs  than  any  other  food. 
Dried  bananas,  or  banana  figs  as  they  are  called, 
are  now  in  the  market,  and  will  undoubtedly  soon  be 
a  great  article  of  trade  as  soon  as  found  by  the 
schoolboy.  They  are  sweet,  wholesome,  and  nourish- 
ing.—  The  Sanitarian. 


72 


MEDICAL    RECORD. 


[July  lo,  1897 


^edicat  Stems. 

Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitarj'  Bureau,  Health  Department,  for  the 
week  ending  July  3,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever lb/  9 

Cerebro-spinal  meningitis o  6 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 

Chicken-pox 

Small-pox 

Egg  Albumen  as  a  Medicine. — When  the  patient 
is  hardly  able  to  pay  a  doctor's  bill,  to  say  nothing  of 
a  drug  bill,  a  cheap  and  handy  substitute  for  fancy  in- 
valid foods  is  desirable.  When  fever  is  present  and 
appetite  is  ;///,  and  when  we  want  an  aseptic  article  of 
diet.  Dr.  Boynton  says,  the  white  of  an  egg  raw  serves 
both  as  food  and  medicine.  The  way  to  give  it  is  to 
drain  off  the  albumin  from  an  opening  about  half  an 
inch  in  diameter  at  the  small  end  of  the  egg,  the  yelk 
remaining  inside  the  shell;  add  a  little  salt  to  this 
and  direct  the  patient  to  swallow  it.  Repeat  every 
hour  or  two.  In  typhoid  fever  this  mode  of  feeding 
materially  helps  us  in  carrying  out  an  antiseptic  and 
aseptic  plan  of  treatment.  Furthermore,  the  albumin 
to  a  certain  extent  may  antidote  the  toxins  of  the  dis- 
ease. Patients  may  at  first  rebel  at  the  idea  of  eating 
a  "raw'"  egg,  but  the  quickness  with  which  it  goes 
down  without  the  yelk  proves  it  to  be  less  disagreeable 
than  they  supposed. — Pacific  Medical  Journal. 

Tuberculosis — The  great  white  plague,  as  tubercu- 
losis has  been  aptly  termed,  is  the  greatest  disease 
scourge  of  the  human  race  at  the  present  day.  --Vc- 
cording  to  Vaughan,  one  person  in  every  sixty  in  this 
country  is  affected  with  the  malady  in  some  form. 
The  world  over,  ten  thousand  human  beings  "'■  cross 
the  range"  every  twenty-four  hours  from  this  cause 
alone.  The  ravages  of  war  and  famine  pale  into  in- 
significance when  compared  with  the  steady  march  of 
devastation  of  this  fell  enemy  of  mankind.  No  condi- 
tion of  life,  no  age  is  exempt.  The  infant  in  its  cra- 
dle, the  boy  and  girl  at  play,  the  young  man  at  his 
desk,  husband  and  wife,  father  and  mother,  the  white- 
haired  centenarian — all  succumb  to  the  invisible  but 
invincible  hordes. — Denver  Medical  Times. 

Nephew  of  George  Washington. — It  is  not  gener- 
ally known  that  a  nephew  of  the  first  president  of  the 
United  States  was  a  member  of  the  medical  profession. 
Dr.  Bitiley  Washington  entered  the  United  States 
navy  as  a  surgeon  in  1810.  He  died  .\ugust  5,  1854. 
He  was  the  surgeon  of  the  Enterprise  when  she  cap- 
tured the  Boxer  during  the  war  of  1812.  He  after- 
ward acted  with  great  efficiency  on  Lake  Ontario  under 
Commodore  Chauncey,  and  was  selected  by  him  as 
fleet  surgeon,  although  a  junior  officer  in  the  service. 
He  was  afterward  fleet  surgeon  under  Commodores 
Rogers,  Elliot,  and  Patterson  in  the  Mediterranean, 
and  closed  liis  active  sea  service  during  the  Mexican 
war.  .\t  the  time  of  his  death  he  was  consulting  and 
visiting  surgeon  of  the  navy  yard  and  marine  barracks 
in  Washington.  ^j'?/-///,f//  Medical  Journal. 

Hospital  Car.— It  is  reported  that  a  novelty  in  rail- 
way carriages  will  shortly  be  placed  on  the  Belgian 
lines.  This  is  a  wagon-lwpital,  fitted  up,  as  its  name 
implies,  for  invalids,  and  containing  twenty-four  beds 


upon  wire  springs,  and  various  surgical  and  medical 
appliances.  The  new  carriage  will  be  utilized  for 
the  first  time  by  the  pilgrims  to  Lourdes  next  month. 
An  unusual  feature  is  a  little  chapel  attached  to  the 
carriage,  where  by  special  permission  from  the  Pope 
mass  will  be  celebrated. — The  British  Medical  Journal. 

Health  Reports The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  supervising  surgeon- 
general  of  the  United  States  Marine  Hospital  service, 
during  the  week  ended  July  3,  1897  : 

Sm.\LL-PoX — U.MTED   StATE>, 

Cas*s.  r>caths. 

Memphis,  Tenn June  19th  to  26th 3 

Brooklyn,  N.  V June  19th  to  26th i  i 

Cambridge.  Mass June  19th  to  26lh o  1 

Chicago,  111 -May  1st  to  31st o  1 

Small-Pox— Foreign. 

Bombay.  India May  2sth  to  June  ist o  3 

Calcutta,  India May  8th  to  15th o  8 

Gibraltar June  6th  to  13th i  i 

Hong-Kong.  China April  24th  to  May  22d. . . .  o  33 

Madras.  India May  15th  to  28th o  I      ■ 

Madrid,  Spain May  2^h  to  June  9th o  5 

Xagasaki.  Japan -May  26th  to  June  2d 7  5 

Odessa,  Russia June  5th  to  12th 4  2 

Osaka  and  Hiogo,  Japan ftlay  29th  to  June  5tb  ....  3  c 

Matauzas,  Cuba June  gth  lo  i6th o  i 

Sagua  la  Grande,  Cuba June  12th  to  19th 45  2 

Trieste,  A  ustria Slay  22d  to  29th o  i 

Havana.  Cuba June  17th  to  24th o  3 

Chihuahua,  Mexico June  22d Reported. 

Ceara,  Brazil May  ist  to  31st o  2 

London,  England June  5th  to  12th o  z 

Glasgow,  Scotland June  sth  to  X2th o  i 

Cholera. 

Bombay,  India    May  25th  to  June  ist o  15 

Calcutta,  I  ndia May  Sth  to  i5lh o  59 


Matanzas.  Cuba. 

Sagua  la  Grande,  Cuba Ju 

Santiago  de  Cuba lu 

Havana,  Cuba Ju 


:9th  to  i6th... 
e  12th  to  lotb. . 
:  5th  to  19th... 
:  17th  to  24th. , 


Bombay,  India   May  25th  to  Ju 


The  Diagnosis  of  Uterine  Cancer  is  not  very  diffi- 
cult in  the  majority  of  cases,  says  Kessier  in  the  St. 
Petershurger  medicinische  Wochenschrijt.  The  text-books 
lead  us  to  believe  that  it  is  always  associated  with 
cachexia;  the  suffering  e.\pression  of  the  face,  very 
frequent  hemorrhages,  fcetid  discharges,  etc.,  are  not 
always  present.  But  a  serous  discharge  or  bleeding 
between  menstrual  periods,  and  particularly  a  hemor- 
rhage after  the  menopause,  should  make  one  very  sus- 
picious of  malignant  disease.  He  deprecates  the  prac- 
tice of  giving  ergot  or  styptics  in  uterine  hemorrhage 
when  one  suspects  carcinoma,  because  while  using 
these  drugs  the  disease  is  progressing  and  valuable 
time  is  lost. 


^ooka  ^eceivjcd. 

While  the  MEDICAL  RECORD  is  pleased  to  receive  all  new  pMbH- 
cations  which  may  he  sent  to  it,  and  an  acknowledgment  ■u-ill  l>e 
promptly  made  op  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not lie  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  Judgment  op  its  editor  will  not  be 
op  interest  to  its  readers. 

The  Menoi'AI'SE.  By  Pr.  .\ndrew  F.  Currier.  i2mo,  306 
pages.     D.  .\ppleton  &  Co.,  New  ^"o^k. 

Edinburgh  Medical  Joirnal.  Edited  by  Dr.  G.  .-\.  Gib- 
son. New  series,  \o\.  I.  Svo,  692  pages.  Illustrated. 
Young  J.  I'entland,  Edinburgh. 

Excretorv  Irrit.-vtion.  By  Dr.  David  Walsh.  l2rao.  (S 
pages.     Baillii-re,  Tindall  &  Cox,  London,     Price,  3s.  6d. 

Transactions  of  the  Sovthern  Sirgical  and  GvN.tcu- 
logial  .\ssociation,  1S96.     Vol.  IX.     Svo,  471  pages. 

-Vno.malies  and  CfRiosiTiES  OF  MEDICINE.  By  Dr.  George 
M.  Gould  and  Dr.  Walter  L.  Pyle.  Svo,  q6S  pages.  Illus- 
trated. W.  B.  Saunders,  Philadelphia,  Pa.  Price,  cloth,  $6.00; 
half  morocco,  $7.-oo. 


Medical  Record 


A  IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  3. 
Whole  No.  1393. 


New  York,  July   17,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©viginal  l^vticlcs. 


MORTALITY  AND  TREATMENT  OF  ACUTE 
INTUSSUSCEPTION— WITH  TABLE  OF  TWO 
HUNDRED    AND    THIRTY-NINE    CASES.' 

By   C.    L.    GIBSON,    M.D., 


In  the  course  of  a  systematic  study  of  the  recent  liter- 
ature of  intestinal  obstruction  the  writer's  interest  was 
particularly  attracted,  by  the  occurrence  of  several 
prominent  features,  to  that  variety  due  to  invagination 
of  the  various  segments  of  the  intestinal  tract.  These 
were  that  intussusception,  while  presenting  conditions 
allowing  of  easy  and  certain  diagnosis  much  oftener 
than  obser\-ed  in  other  forms  of  obstruction,  was  never- 
theless attended  with  no  lesser  mortality;  again,  that 
invagination  of  the  intestines,  unlike  other  varieties  of 
obstruction,  could  in  a  certain  proportion  of  cases  be 
relieved  by  mechanical  non-operative  measures,  and 
yet  remained  one  of  the  most  fatal. 

A  third  point  was  the  \ariance  exhibited  by  the 
statistics  collected  by  different  authors,  as  e.xampled 
by  Rydygier  in  1895,  giving  a  mortality  of  seventy- 
five  per  cent,  in  acute  cases,  and  Wiggins  in  i8g6. 
whose  statistics  in  recent  times  and  after  the  exclusion 
of  certain  conditions  gave  a  mortality  of  twenty-two 
per  cent.  The  conclusions  reached  by  the  latter  writer 
in  his  most  careful  paper  have  been  w  idely  quoted  and 
his  painstaking  work  has  received  most  favorable 
comment.  • 

To  the  writer  the  low  figure  (twenty-two  per  cent, 
mortality)  just  quoted  could  not  appeal,  and  it  seemed 
to  him  that  if  he  must  answer  his  own  query,  why  he 
was  attempting  to  add  to  an  already  congested  liter- 
ature, he  might  find  a  reply  in  the  effort  to  present  the 
subject  in  a  broader  light.  The  essential  reason,  how- 
ever, for  writing  this  paper  is  to  place  on  record  a 
more  extensive  literature  of  the  operative  relief  of 
acute  intussusception  than  has  ever  been  attempted 
before,  the  writer  believes,  in  English  or  any  other 
language.  Rydygier  in  1895  read  a  most  exhausti\e 
paper  before  the  German  Surgical  Congress,  based  on 
his  own  large  experience  and  the  cases  reported  in 
the  literature  for  the  previous  ten  years  (eighty-six 
cases),  taking  up  the  subject  where  Braun's  statistics 
had  paused  in  1885.  Braun's  table  contained  sixty- 
six  cases,  going  back  to  the  earliest  recorded  in  tiie 
seventeenth  century.  The  literature  of  the  subject 
then,  as  compiled  by  these  German  authors  in  1895. 
comprised  a  total  of  one  hundred  and  fifty-two  cases 
treated  by  abdominal  section,  in  which  all  cases— the 
chronic,  lasting  perhaps  for  years;  those  due  to  new 
growths,  and  therefore  attended  with  special  condi- 
tions; and  the  purely  acute  forms — were  all  included. 
But  very  slight  observation  convinced  the  writer  of 
the  necessity  of  a  very  definite  separation  of  these 
forms  for  the  purpose  of  studying  the  results  of  their 

'  Read  by  title  at  the  psediatric  section  of  the  American  Medi- 
cal .\ssociation.  June  3,  1897. 


treatment,  and  of  the  lack  of  a  single  exhaustive  collec- 
tion of  cases  of  the  acute  form  from  which  to  attempt 
to  derive  fair  conclusions. 

The  writer  has  collected  two  hundred  and  thirty-nine 
cases,  divided  into  t^vo  classes:  those  occurring  prior 
to  1888,  eighty-nine  cases,  and  those  occurring  since 
1887,  up  to  January  i,  1897,  one  hundred  and  fifty 
cases. 

The  division  of  time  is  somewhat  arbitrary,  repre- 
senting in  the  second  table  the  writer's  convenience 
as  to  a  part  of  his  studies  on  the  general  subject  of  in- 
testinal obstruction  since  1887.  These  later  years 
present  conditions  which  make  a  comparative  study 
of  intestinal  surgery  most  valuable.  Antisepsis  had 
already  become  quite  well  established  and  subse- 
quently was  reinforced  by  asepsis.  Union  of  divided 
or  non-adjacent  portions  of  the  intestine  by  mechanical 
aids  had  at  the  opening  of  this  period  been  shown  to  be 
of  great  value,  both  in  the  improvement  of  results  and 
in  the  encouragement  of  more  frequent  surgical  inter- 
ventions. The  increased  frequency  of  operations  fol- 
lowing familiarity  with  the  possibilities  of  artificial 
methods  of  anastomosis  led  to  eager  efforts  to  improve 
the  existing  means,  resulting  in  increased  and  better 
methods  of  suture  and  the  temporary  passing  of  the 
mechanical  devices.  In  the  latter  part  of  this  period, 
the  best  of  these  devices,  the  Murphy  button,  soon 
after  its  introduction  in  1892,  came  to  compete  with 
and,  to  a  great  e.xtent,  divert  attention  from  the  im- 
proved methods  of  suture. 

Then,  again,  many  of  the  operators  were  no  longer 
pioneers  in  the  branch  of  abdominal  surgery,  re- 
lying on  themselves  to  evolve  measures  of  certain 
value,  and  the  younger  generation  in  its  earlier  ef- 
forts was  now  guided  by  the  valuable  teaching  of  the 
riper  e.xperience  of  its  ptedecessors.  The  second  table 
will  therefore  be  used  exclusively  for  the  study  of  the 
conditions  from  which  a  fair  estimate  of  the  results  ob- 
tained may  be  derived.  Though  the  writer  can  claim 
an  honest  attempt  to  approach  the  subject  by  pains- 
taking efforts  of  research,  he  has  no  illusions  concern- 
ing its  completeness,  for  he  is  aware  of  the  existence 
of  a  number  of  observations  in  the  literature  of  the 
English,  French,  and  German  languages  that  were 
either  inaccessible  or  too  incomplete  to  utilize.  And, 
moreover,  he  has  little  doubt  that  he  has  overlooked 
some  cases,  for  which  no  reason  but  carelessness  can 
be  advanced.  The  records  of  the  first  series  prior  to 
1888  have  not  been  the  subject  of  the  same  care,  as 
their  smaller  value  on  the  whole  seemed  not  to  call  for 
a  like  amount  of  labor.  They  ha\e  only  exceptionally 
been  derived  from  their  original  source,  having  been 
obtained  almost  entirely  from  the  tables  of  Braun," 
IJarker,""  Rydygier,"  and  U'iggins."'  They  are  re- 
corded for  tlie  sake  of  completeness  and  for  their  pos- 
sible value  to  other  investigators. 

It  has  seemed  wisest  not  to  attempt  a  systematic  and 
equal  consideration  of  the  various  divisions  of  the  sub- 
ject of  intussusception  :  but  to  concentrate  the  obser\'a- 
tions  derived  from  the  recorded  cases  chielly  upon  a 
review  of  the  causes  and  elements  influencing  the  mor- 
tality attending  abdominal  section,  and,  guided  by  the 
results  thus  found,  to  attempt  the  outlining  of  a  definhe 


74 


MEDICAL    RECORD.  [July  17.   1897 

TABLE    I.  (Cases  Prior  to  1888).     Section  A— Died. 


Beck,  74*  . 
Beck,  74  . . 
Busch,  74  • 
Braun,  92  . 

Beck,  g2  . . 
Bell,  92    . . 


Corley,  74. 
Czemy,  92 . 


Carnes,  92 . 


ies-Coiiey,  52. 

Fischer,  92 

K.  Franks,  44  ... , 


Foxwell,  52. 


Godlee,  74. 
Godlee,  74. 
Hauff,  92  . 


Hirschsprung,   92. 


Hutchinson, 
Horsley,  74. , 
Horsley,  74. , 
Howard^  92. . 


Howse,  92 . 

Kiister,  ga. 


Jacobson,  52., 
Jaeger,  92... 


acobi,  74.... 

acobson,  74.. 

Little,  02 

Laroyenne,  92 
Marsh,  74 ... . 
Marsh,  92  ... . 
Mikulicz,  92  .. 
Morris,  92. . .. 


Miiller,  92. 

Owen,  74-  ■ 
Ohle,  92... 


41  Obalinski,  92  . 

42  Obalinski,  44 . 


Obalinski,  44. 

Pick,  74 

Page,  92 


Pollard,  92 . 

47' Robert,  92.. 


48  Rosenbach,  92 


49  Rydygier,  44  . 
SoRobson,  53  .. . 

51 'Sands,  74   

52  Symonds,  74 ., 
53jSymonds,   74.. 

54!  Stage,  74 

55|Smith,  74 

56  Stage,  74  ..... 

57  Strong,  40. . . , 


Thaden,  92. . . 
Van  Arsdale,  74  . 
Van  .Arsdale,  74  . 
Van  Arsdale,  74  . 

V.  Wahl.  44 

Winiwarter,  oa.. . 


Wells,  74 

Weinlcchner,  74  . 
Wcinlcchncr,  ya  . 


Walsham,  74.. 
Zielewicz,  13.. 


1873 
Before 


?  1863 
1817 
1880 


Duratioi 
Days. 


Anatomical 
Variety. 


Ileo-caccal. 
Sigmoid -colon. 


4   weeks;  Ileo-caecal. 

acute.         ' 
Some  days,  llleo-colic. 

8  Ileo-caecal. 


Ileo-caecal. 
Ileo-ca:cal. 

Colon. 
Ileo-csecal. 


Enteric. 

Colon-sigmoid 

Ileo-csecal. 

Enteric. 

Ileo-cxcal. 

Ileo-colic. 

Sigmoid  into 
descend- 
ing colon. 


Symptom 


Felt  in  rectum. 


Prolapsed. 
Blood    and 


Blood. 
Blood   and 


Ileo-caccal. 

Enteric. 

Ileo-cxcal. 


Enteric. 
Double  (r. 
verse)  coloi 
Colon. 


Ileum    a 
trans,    colon 
into  sigmoid 


Enemata. 


[Reduction  (?;. 


!Artiiicia]  anus. 

Enemata;  partial  Resection  8ocm.,E.-E.'t' 

reduction.         |    anastomosis,  suture. 
Enemata.  Irreducible. 

Enem  a  t  a  ,  a  i  rj  Irreducible,  art!  fi  c  i  a  1 
and  water, 

Irreducible,  arti  f 


duel 
day 

and  partial  re- 
duction second 
day;  enemata 
daily  till  oper- 
ation. 


Prolapseat  anus.|Manual    reposi- 


i  Enemata. 


Resecti< 


150  c 


Post   mortem,  i 
mosts  perfect 


Resection  47  cm.  ileum, 

E.-E.,  Czern^  suture. 

Irreducible,  artificial 


Incomplete  operation. 
Irreducible. 
Reduction  difficult. 
Artificial  anus. 


Reduction;  puncture  of| 
intestine.  : 

Gut  ruptured  in  reduc- 
tion; suture.  I 

Resection,  E.-E.  anas-' 
tomosis;  Lembert.        | 

Irreducible. 

Resection  80  cm.,  E.-E 
anastomosis,  Lembert 
ij^  hours. 

Reduction  difficult. 

Resection. 

Reduction. 

Irreducible. 

Artificial  anus. 

Reduction. 


rtifi 


Reduction,  suture  of 
colon,  threads  brought 
outside  belly. 

Resection  90  cm. 


Resection    ileo  ■ 


Reduced  with  ditliculty: 
necrotic  portion  treat- 
ed extraperitoneally. 


Reduction. 

Artificial  anus. 
Resection.     E.-E.. 

Czerny  suture. 
Reduction  difficult;  two 

tears  in  peritoneum. 


Ofwraiion  incomplete. 
Artificial  anus. 
Reduction. 
Irreducible,  arti  f  i  c  i  a 


Reduction  diftWult. 


Post  mortem,  benn- 
ning  gangrene,  une 
of  suture. 


Pyemia. 

Post  mortem,  supposed 
intussusception  felt 
in  rectum  was  a  clot 
of  blood. 

Post  mortem,  intussus- 
ception gangrenous. 


Peptic  peritonitis. 

Post    mortem,   pre-ex- 
isting peritonitis. 


Post  mortem,  operative 
condition  perfect. 


lonvulsions;  no  ab- 
dominal manifest»' 
tions  after  operation. 


Post   mortem,  necro 
and     perforation 
neck. 

Gangrene  of  iniuss. 


Pulmonan,'  <v^cn 


*  CorresDondine  number  of  bibliographical  inde.K 


+  End  to  End. 


July  17.  1897] 


MEDICAL,    RECORD. 

TABLE    I.     Section  B — Cured. 


75 


Open 


87 


Borch,  44  . 
Car\er.  54. 


76  Czemy,  92. . . 

77  Fucbsius,  92. 

78  Godiee,  74. . . 


Gay,  17 

Heald  and  Irish,  1 

Howse^  92 

Kieeberg,  92 

Marsh,  44. 

Nuck,  92 

Sands,  44 


Snowball,  44. 
Stelzner,  44. . 


89  Wilson,  92  183: 


Before 
1S83 
18S7 


1874 
1879 

1692 
1877 

1886 
Before 

1884 
Before 


0)30 


Dniadon. 
Days. 


Lateral   inva  g 
small  intest.  into 
sigmoid. 

Enteric. 


Sympto 


Fzcai  vomi 
blood;  felt 
rectum. 


Enemat  a 

and  wat 

Inflation. 


Reduction,  50  minutes. 


Resection  ileo  -  c  ae 
coil,  E.-E.,  Czeroy  su- 
ture, 95  minutes- 
Reduction  after  inci 
of  sheath,  purse-string 
suture  of  incision. 
Reduction  easy. 

Reduction. 

Reduction  difficolt. 

Reduction  easy. 
Reduction- 
Reduction  difficult. 

Reduction  easy. 
Reduction;  rupture  and 

suture  of  gut. 
Reduction. 

Reduction;    gnt    v  < 
suspicious. 


TABLE  11,     (Cases  Since  iSS;).     Section'  A — Successful  Abdominal  Section  for  Reducible  Intussusception. 


Annandale,  23' 
Alsberg,  43... 

Alsberg,  43 . . . 

Alsberg,  43. . . 
Ainsley,  65. . . 

Anderson,  77  . 


ter,  27. 

Barker,  27. 
Butler,  85  . 
Bogart.  37. 


Bush,  22 

B.  Clarke.  85. 
Cheyne.  55  . . . 
Crymes,  i  . . . . 


Delcroix,  j 
Eve.  33. . . 


Gould,  2 1   1891 


Godiee.  27 
Howitt,  6. 
'iti.6. 


Harris.  70 1    1890 

Hulke  ( ist.  op. ^,79 


27    Gould  (2d  op.),  79. 
el), 


28    HoUanderCls 

M- 
39   Johnson,  88  . 


iKelsey.  81 

I  Kammerer,  71 


32  Kopat,  82 

33  Koite,  44. 


Lund.  35  . 


Age.  I 

3 

> 

1" 

c 

1 

> 

3 

S 

'1889 
.89. 

.893 

II 

•895 

8 

18 

1895 

4 

.894 
1894 

4 
5 

■893 

7 

.889 

7 

1894 

5 

'"8^ 

5 

32 

.889 

5 

.890 
1892 

4 
6 

•• 

1889 

6 

". 

1895 

" 

,89. 

4 

1894 

4 
3 
7 

.. 

.890 
.890 

14 

1890 

^ 

71896 

16 

1890 

18 

.896 
.890 

3 
6 

■S95 

5 

Duration, 
Days. 


Hepatic  flex< 
Ueo-colic 


Caecum  a  n 

colon. 
Ileo-cz(3L 


Descen  d  1 1 

colon. 
Ileo-caecal. 


colon. 
Ileo-csecal. 
Enteric. 


Descen  din 

colon. 
Ileo-caecaL 


Ileo-caecaL 


Blood. 

Blood,  no  vomit. 

Blood,  vomit. 
Blood,  mucus;  felt 

rectum. 
Felt  in  rectam. 


Blood,  not  felt  i 

Blood,  mucus;  n* 

in  recttim. 
Felt  in  rectum. 

Blood,  vomit. 
Blood;  not  felt  i 
turn. 


Blood;  felt  in  rectum. 


Blood,  mucus;  felt 

rectum. 
Blood  and  vomit. 


Not  felt  m  rectum. 
Blood,  faecal  vomit. 
Blood. 


Blood;  felt  in  rectum. 
Blood  and  vomit. 


Previous  Treatment. 


Enema     under    anxs- 
thetic,  third  day. 
nema     (air)     second 
dav. 


Inflation  under  anaes- 
thetic. 
Attempt    to    reduce 
in\'agination "      (j 
aesthetic). 

No  enemata. 
nema   (anaesthetic) 
apparently       s  i 
cessfuL 

Enema. 


Hydrogen  inflation. 


Reduced  by  enema 
but  recurred;  sJ4 
hours. 

Enemata. 


Enema,  fir^t  day. 

Enema. 

Insufflation. 


Eoemata,  air  and 
ter,  under  anaesthetic 
at  4  hours. 


Enemata     for 
days. 


Operation. 


Reduction,   40 
Reduction. 


Reduction  easy. 
Reduction. 


Reduction  difficult. 
Reduction. 
Reduction,   30    min- 
utes. 
Reduction. 


Redaction;     rupture 
of  gut;  suture. 


Reduction,   30 

utes. 
Reduction. 


Reduction,  45 

utes. 
Reduction. 


Faecal  vomit. 


Had  pneumonia. 


Slight    invagination, 

not  entirely  reduc- 
ed by  < 


1  Same  patientj  re- 
curred  in  3 
months;  f  xcal 
fistula  which 
healed  in  2 
months. 


^ponding  number  of  tnbliographical  index 


76  MEDICAL    RECORD.  [July  17,  1897 

TABLE  II.     (Cases  Since  1887.)    Section  A — Successful  Abdominal  Section  for  Reducible  Intussusception. 


Operate 


Lindemann,  43* . . . 


Marsh  and  Savory, 

85- 
McBumey,  80 .... 

Meek,  75 

Macewen,  46 

Neuber,  44 

Obalinski,  44  .   . . . 
Ochsoer,  51 

Perceval,  53 

Pilgrim,  50 

Pollard,  64 

Roughton,  67 

Ridley  and    Beat- 
tey,  28. 


Renton,  47  . . . 
RentoQ,  35  . . . 

Renton,  35  . .  - 
Stretton,  66. . . 
Shepherd,  60. 

Swift,  19 

Thompson,  25 

niv.  C.  H.,  Lon- 
don, 74. 
Verrall,  26.... 

Warren,  21... 
Warren,  21 . .. 
Pollard,  61  a  . 


Anatomical 
Variety. 


Ileo-colic. 
Colon. 
Sigmoi 
rectal. 

Ileo-caecal. 


Colon  -  s  i  g 
Ileo-Ciecal. 


Ileo-ca£caI. 


Duration, 
Days. 


Symptoms. 


Blood ;  felt  in  rectum. 

Vomit;  not  felt  in  rcc 

turn. 
Blood. 


Vomit,  blood;     felt 

rectum. 
Vomit,  mucus;  felt 

rectum. 


Previous  Treatment. 


Redaction;  isolation' Artificial  anus  cured 


Enema  second  day. 


of  suspicious  gut; 
art.  anus  in  trans- 
verse colon  3  days 
later. 
Reduction. 


Blood,    vomit;    felt    ii 
Blood;  felt  in  rectum. 


Biood;  not  felt  i 


Blood  and  m: 

felt  inrectu 

Blood  and  mi 


Vomit;  not  felt  i 


coming  out  recurred. 
Insufflation  a  n  d  e  i 
anjesthetic;  reduc- 
tion;   faeces    passed; 


Inflation. 
Enemata,  air  and  ' 

ter;  kneading. 
Enema  ta. 


i^  n  e  m  a  second  day 
with  apparent  re- 
duction. 


Enema    under    anscs- 
ihetic  prior  to  oper- 


under   chloro- 


by  operation. 


TABLE    II.     Section  B— Unsuccessful  Abdominal  Section  for  Reducible  Intussussception. 


Alsberg,  43* 


Operator. 


Bennett,  89. 


Braun,  44  .... 

Curtis,  72 

B.  Clarke,  85. 


Crago,  12. . 
Cripps,  8s  . 


73iDesguin,  5  , 


Eve,  33- ■ 
Eve,  33  . 


Ueo-cxcal, 
Ileo-colic. 


Anatomical 
Variety. 


Duratic 
Days. 


:  (l6hrs.) 
:  (18  hrs.) 


Vomit,  blood;  felt 

in  rectum. 
Blood. 


Not  felt  in  rectum. 


Blood,  mucus;  felt 

by  rectum. 


Manipulation  fifth  day 


Enema  under  chloro- 
form; intussusception 
reduced;  recurrence 
next  day  of  signs 
and  symptoms. 

Inflation  end  of  fin 
hours  with  apparent 
reduction. 


Encmata  tnncc. 


Reduced  by  e  n  e  m  i 
under  chloroform  01 
si.xth  day;  recurred. 


Operation. 


Reduction  easy  ex- 
cept last  3  inches; 
incision  and  suture 
of  cascum;  begin- 
ning sloughing  of, 
colon  and  general 
peritonitis. 

Reduction. 


Reduction;     appear- 

pidous. 
Reduction. 


Reduction*     fixati 
of  suspicious  gut 
wound;  subsequent 
opening. 

Reduction. 


14  hours. 
5  hours. 
I  day. 


a  hours. 
5  da>-s. 


Ante  mortem,  t  c  m  - 
perat  u  re,  107.8*; 
post  mortem,  no  ul- 
ceration, no  slough- 
ing; srpsis  0)- 

Post  mortem,  perfo* 
ration  of  suspicions 
gut 

Shock. 

Past  mortem,  com- 
plete rcductioQ. 

Post  mortem,  4  inches 
intussu  s  c  e  p  t  i  o  o 
present. 

Post  mortem,  intes- 
tinal paral>*sis. 

Post  mortem,  broa- 
cho-pncumonia;  00 
peritonitis. 

I'omited  and  passed 
blood  after  opera- 
tion; no  post-mor- 


*  Corresponding  number  of  bibliographical  index. 


t  This  case  is  not  included  in  the  stadstical  deductions. 


July  17,  1897]  MEDICAL    RECORD. 

TABLE  II.     Section  B — Unsuccessful  Abdominal  Section  for  Reliable  Intussusception. 


77 


Operation. 


Horsley,  27 

JoUye.  58 

Korte,  44 

Lund,  35 

Lowenstein,  10  . . . 

Lauenstein,  44. . . . 


Lauenstem,  44. 

Marsh,  85 

Neuber,  44 

Nimier,  9 

Obalinslci,  44  . . 
Obalinski,  44  . . 


Obalinski,  44  . 


Power,  34  . . . . 
Rydygier,  44  . 


Roberts,  3 

Sick  (Schede),  44. 
Shepherd,  60  .  .    . 


Scott,  83 

Turner  and  Whip- 
ham,  90. 


Walsham,  85  . 
Weir,  96 


Ileo-cxcaL. 
Enteric. 


Into    open 
o  m  phali 
mesenteric 

duct. 
1 1  e  o  -cxcal 


)  o  u  *b 
colon. 


Ileo  -  caecal, 
desce  n  d  - 
ing  colon, 

Ileo -caecal. 


turn. 
Ileo-coiii 

Enteric  and 
2  volvuli 


Sympio 


Vomit,  blood, 
cus;  felt  in 
turn. 


PreWous  Treatment. 


;iEnemata  several  days 


Blood,  mucus 
rectum, 
lit,  blood. 


Felt  by  rectum. 
Vomit,  blood. 


Blood;  mucus;  felt 
by  rectum. 


Vomit,  blood;  felt 
by  rectum. 


Reduction; 
in   gut    to   relieve 


Reduction;     p 
ture  of  gut. 
Reduction. 


Reduction:, 
of  duct,  40  minutes. 


Reduction  difficult. 
Reduction. 
Reduction  easy;  du 
Reduction. 


Reduction,   25    min 

utes. 
Reduction. 


Reduction. 

Reduction 

twisting. 


Inflation   second    day; 
apparent  reduction. 


I  day. 


;  hour 
i  hour! 


I  day. 

I  day. 
6  hours. 
I  day. 
I  hour. 


Post  mortem,  second 
intussu  s  c  e  p  t  i  o  a 
found  (ileo-caecal). 


Post  mortem,  no  peri- 
Post  mortem,  general 
peritonitis. 

Post  mortem,  septic 
peritonitis. 

Post  mortem,  recur- 
rence; no  peritonitis. 

Post  mortem,  typhoid 
ulcer  in  intussus- 
ception. 

On  second  day  recur- 
rence and  reduc- 
tion; post  mortem, 
no  intussusception. 

Post  mortem,  intes- 
tinal paralysis. 

Post  mortem,  il  e  o  - 
csecal  intussuscep- 
tion not  pre\*iously 


I  day.    [Shock. 
I  day. 
3  hours. 


Post  mortem,  general 

peritonitis. 
Shock. 


I  day. 
I  day. 


Heart  failu 

Shock;    post  1 

bowel    almost   gan- 
grenous. 

Post  mortem,  small 
perforation  in  trans- 
verse colon. 

Exhaustion. 


TABLE    II.     Section  C— Slxcessful  Abdominal  Section  for  NOn-Reducible  Intussusception. 


Operat( 


Banks,  31  . 
Crippft,  36. 


Hollander  (Israel),  14. 

K<xher,  44 

Mikulicz,  44 


;o6lOderfeld,  38. 


107  Pick,  84  ... . 
loSlParona.  45. 


Anatomical 
Variety. 


Ileo-csecal. 
Enteric. 


F.    Ileo-caecal. 


Duration, 
Days. 


Visible  peristalsis. 


reducible;   entero  -  anas- 
tomosis. 
Resection,   18   inches  from 

valve;    E.-E.,      Murphy 

button. 
Artificial  anus;  later  latei 

anastomosis;  gangrene 

ileum    and     ascending 

colon.  I 

Resection      70  cm.,     E.-E.  Button  passed  sixth  day. 

anastomosis,  Murphy, 
Resection     141  cm.     small 


Button  passed,  19  days. 


Eight  days  later  9  inch 
slough  of  intussuscep- 
tion passed  by  artifical 


Irreducible;  ( i)  artificial  Fistula 
anus;  (2)  resection,  in-i  months, 
tussusception  6  weeks 
later;  (3)  and  (4)  for 
closure  of  fistula. 

Resection  of  invaginatum 
attempted;  resection  and 
E.-E.  anastomosis,  ile- 
um and  colon;  time,  3 
hours. 

Irreducible;    resection, 

Murphy  button:  time,  45 
minutes. 
Artificial  anus. 


[>ersisted     6 


Temporary  lislula. 


Button  passed  ninth  day. 


Fistula  closed  by  plastic 
operation. 


*  Correspond ini;  number  of  bibliographical  index 


78 


MEDICAL    RECORD. 


[July   17,  1897 


TABLE   II.     Section  D — Unsuccessful  Abdominal  Section  for  Non-Reducible  Intussusception. 


Cave,  29 

Cartledgc,  49. 

Dalton,  7 

Drobnik,  44  . . 
Erdman,  73. . . 


Reported   by   Ab- 
bott <?),  86. 


Bier(Esraarch),44 
Bayer,  82 


1893 


Gussenbauer,  44. 
Goode,  12 


Horsley,  27, 


Hofmokol,  95. 
Korte,  44 


Lockwood,  91. 

Makins,  24.. . , 

Meek,  75  .   ... 

Milton,  63..., 
Nelson,  15   . . . 


Obalinski, 
Obalinski, 


Obalinski,  44  . 
Obalinski,  44  . 


Rydygier,  44  . 
Rydygier,  44  . 


Sick  (Schede),  44 


Wyeth,  6[y 

Walshain,  85  , 


Anatomical 
Variety. 


Colon. 
Ileo-c£ecal. 


Ileo-colit 
Enteric. 


Enteric  (?). 

Enteric. 

lleo-ca:cal. 
Enteric. 


Dura- 
tion, 
Days. 


Blood,  vomit. 
Blood. 


Blood;     not 
by  rectum. 


Vomit. 


Operatic 


Gangrenous;  resection,  su- 
ture of  ends,  and  lateral 


Enema  u  n  d  e  i 
anxsthetic  be- 
fore operation, 


Vomit,  no  blood. 


felt  by  rectum. 


under  chloro 
form  first  day 
tumor  almosi 
disappeared. 

ether      i h  i  r 
and  fifth  day 


Gangrenous;  general  peri- 
tonitis; resection  8  in- 
ches, E.-E.,  Czerny. 

Ileum  gangrenous;  opera- 
tion incomplete. 

[gangrenous;     colo  t  o  m  y  , 

ascending  colon. 
Gangrenous;    res  e  c  t  i  o  n, 

E.-E.      anastomosis, 

Murphy  button. 
Gangrenous;  resection. 
Irreducible;  artificial  anus 

in  ileum. 


Gangrenous;  resectii 
E.-E.  anastomos 
Czerny -Lembert. 

Gangrenous,  rese  c  t  i  ^ 
arti6cial  anus. 

(Jangrenous;  artificial  a 
gangrenous    area  placed 
outside  belly. 

Artificial  anus  at  apex  of 
intussusception;  o  day 
later  recurrence  of^ symp- 
toms; resection  of  ileum; 
ends  sutured  and  lateral 
anastomosis  with  Senn's 
plates. 

A  rtificial  anus  in  central 
end;  2^  months  later, 
resection  and  lateral  an- 
astomosis, ileum  and 
descending  colon. 

Resection  of  invaginatum 
(Barker's  method),  2 
inches  of  gangrenous 
ileum  and  caecum. 

Irreducible;  resection  in- 
vaginatum (Barker's 
method). 

Resection;  artificial  anus. 

Incision  of  sheath;    reduc- 


I  day. 


Post   mortem,  con  d  t 

Post  mortem,  no  unioi 

between     divide) 

ends. 
Pre-existing  p  c  r  i  t  o 

nitis. 
Post  mortem,  v'lvulu 

of  colon. 

Shock. 


artificial 


ileu 


Gangrenous;  artificial  a 
gut  found  perforated  by 
injection  (4)3   feet    pres- 

Gangrenous;   general  peri- 


Irreducible;  exci  si  on 
cm.  ileum,  with  ends 
wound  for  artificial  an 

Irreducible:      resecti  o  n 
inches;    E.-E 
sis,  Murphy  button. 

Resection;  E.  -E.  anasto- 
mosis, Czcrny-Lembert. 

Gangrenous;  artificial  anus 
8  days  later,  resection : 
E.-E.  anastomosis  witli 
.Senn's  plates. 

Resection;    E.-E.    anasto- 

Gangrenous;    rcse  c  t  i  o  n  , 

E.-E.  anastomosis. 
Gangrenous;  artificial  anus. 
Resection,    E.-E.     anasto- 


Resectioi 

transverse    colon;    E.-E. 

anastomosis,    AI  u  r  p  h  y 

button. 
Gangrenous    and    general 

peritonitis;  resection.  j 
Resection;  artificial  anus.  1 
Gangrenous;  resection  j 

(Rydygier's  [?]  method). 
130  cm.    gut  gangrenous;' 

artificial  anus.  l 

Irreducible;  artificial  anus. 
Resection  5  inches  ileum, 

Lembert.  ! 

Resection. 
Gangrenous;    ope  ration' 

abandoned.  ! 

Artificial  anus.  1 


3  hours 

4  days. 
I  day. 


[  day. 
I  day. 


Diabetic  coma. 
Pre-existing  sepsis. 


Septic  peritonitis. 


Post  mortem,  perito- 
nitis; beginning  gan- 
grene of  gut. 

Post  mortem,  begin- 
ning peritonitis;  an- 
astomosis perfect. 

Shock. 


10  hours.  I 
8davs. 


1  day. 
5  days. 


3  days. 
3  days. 


3  hours, 
I  day. 


Croupous  pneumonia. 
Pre-existing     vwr  i  i  o  ■ 

nitis. 
Shock. 


Shock. 

No  post-mortem. 


■spouding  number  of  bibliographical  index. 


July  17,  1897] 


MEDICAL    RECORD. 


79 


plan  of  treatment  according  to  the  pathological  con- 
dition existing  in  any  given  case. 


One  symptom.. . . 
Two  symptoms  .. 
Three  symptoms. 
All  symptoms  one 


•Compiled  only  from  cases  contained  in  Table  II. 

As  regards  diagnosis,  little,  therefore,  need  be  said, 
as  nothing  new  or  important  has  been  evolved  from 
these  researches.  Attention  is  called  to  the  table  of 
symptoms  (unfortunately  quite  incomplete) ;  it  will  be 
seen  that  the  presence  of  a  bloody  discharge  from  the 
rectum  is  the  most  constant  symptom,  and  certainly, 
when  present  in  a  young  child  and  accompanied  by  the 
sudden  onset  of  abdominal  symptoms,  must  be  consid- 
ered pathognomonic.  Its  absence,  or  in  fact  the  ab- 
sence of  any  one  of  the  typical  symptoms,  does  not 
imply  that  intussusception  does  not  exist.  The  infre- 
quency  of  facal  vomiting  is  important  to  note,  as  some 
practitioners  obstinately  refuse  to  entertain  a  diag- 
nosis of  intestinal  obstruction  unless  this  symptom  is 
present. 

Notes  on  the  finding  of  a  tumor  by  abdominal  pal- 
pation have  intentionally  been  omitted,  lest  misleading 
deductions  be  drawn  from  them,  the  value  of  such  ob- 
servations depending  largely  on  our  knowledge  of  the 
observer's  individual  characteristics. 

It  may  be  stated,  though,  that  in  general  palpation 
of  the  abdomen  yields  definite  signs  of  greater  value 
and  more  frequently  than  in  other  forms  of  acute  in- 
testinal obstruction.  The  lesser  and  more  localized 
distention  usually  permits  us  to  palpate  the  outlines 
of  the  intussusception,  according  to  its  classical  de- 
scription, as  a  sausage-shaped  tumor.  Absence  of  a 
clearly  recognized  tumor  is  not,  however,  a  proof  that 
intussusception  does  not  exist. 

Predisposing  Causes. — The  writer  has  no  comment 
to  make  concerning  the  usual  causes  believed  gener- 
ally to  be  exciting  factors  in  the  development  of  intus- 
susception. The  greater  frequency  of  this  condition 
in  male  children  leads  him  to  speculate  whether  the 
.straining  due  to  a  tight  phimosis  or  to  a  contracted 
meatus  may  not  have  here  the  same  etiological  value 
as  is  ascribed  to  these  conditions  in  favoring  the  de- 
velopment of  hernia  and  prolapse  of  the  rectum.  He 
has  unfortunately  no  notes  relative  to  such  conditions. 
and  does  not  remember  to  have  seen  any  allusions  to 
the  possible  causal  relationship. 

Mortality. — The  mortality  as  collected  in  the  liter- 
ature is  by  no  means  thought  to  represent  that  of  ac- 
tual practice;  as  a  rule,  the  latter  is  usually  consider- 
ably higher.  It  is  believed  though  that  the  mortality 
given  in  these  tables  (fiftj'-three  per  cent.)  will  per- 
haps not  show  so  great  a  discrepancy  as  in  other  con- 
ditions. Operations  for  intussusception  are  not  so 
very  frequent,  and  the  great  interest  attached  to  them 
makes  it  probable  that  a  greater  number  of  the  cases 
is  put  on  record  irrespective  of  the  final  results.  The 
large  number  of  cases  of  purely  acute  intussusception 
here  recorded,  occurring  in  modern  times,  should  give 
a  fairer  estimate  than  previous  publications  based  on 
a  smaller  number  and  dealing  with  cases  operated  on 
before  the  development  of  abdominal  surgery.  More- 
over, these  cases  are  all  pure  forms  of  intussusception, 
not  due  to  the  presence  of  or  subject  to  the  complica- 
tions of  the  attending  new  growths. 

The  condition  of  acute  intussusception  is  one  of  in- 
testinal obstruction,  and  its  mortality,  like  that  of 
intestinal  obstruction,  is  due  essentiallv  to  the  duration 


and  cause  of  the  obstruction.  Also  to  be  considered 
are,  the  site  of  the  obstruction,  the  degree  of  the  path- 
ological changes  of  the  intestine,  the  age  (and  sex). 
Another  important  factor  having  a  particular  bearing 
on  the  condition  under  consideration  is  the  influence 
on  the  mortality  of  the  variet}-  of  treatment  employed, 
for  it  is  believed  that  in  no  other  form  of  intestinal 
obstruction  is  there  a  better  opportunity  for  the  exer- 
cise of  good  judgment  as  to  what  special  procedure  is 
indicated  in  any  given  case. 

Results  of  operations  alone  are  here  based  solely  on 
Table  II.  Table  I.  and  Table  II.  have  been  utilized 
in  such  observations  as  mortality  according  to  age  and 
sex,  and  site  of  obstruction. 

TABLE    IV. — Mortality  a.nd  Operations  Necessary  Ac- 
cording TO  Duration  of  Symptoms.* 


Day. 

Died. 
Cured. 

i 

Sft. 

•0 

(5 

1^ 

1 

0 

> 

9 
i8 

5 
3 

8 

13 
18 

4 

4 

4 
4 

1 

j8 
29 
■4 
14 

9 

S 
3 

3 

■4 

41 
39 
62 
72 

JX 

55 

24 
18 

6 
6 

5 
8 

3 
4 
3 
5 

6 
5 

3 

4 

It 

57 
57 

8^ 

Third 

Fourth 

Fifth 

SLsth 

Seventh 

Eighth..  

Eleventh 

Twelfth 

Fourteenth 

Third  week  .... 
Fourth  week  . . . 
No  date 

Total 

79 

70 

149 

53 

99 

" 

24 

4 

33 

*  In  these  tables  fractions  of  0.6  or  more  are  counted  as  a  unit. 

A  glance  at  Table  IV.  shows  that  the  total  mortalit)' 
for  one  hundred  and  forty-nine  cases  is  fifty-three  per 
cent.  The  first  and  second  days  show  a  mortality  rate 
inferior  to  the  general  mortalit)',  while  the  four  suc- 
ceeding days  show  a  steadily  increasing  mortality,  in 
each  instance  greater  than  the  average.  The  end  of 
the  week  shows  a  beginning  decrease  of  the  mortalit}', 
which  it  is  to  be  hoped  no  one  will  undertake  to  ex- 
plain by  showing  that  better  results  follow  delayed 
interference.  After  the  first  week  we  encounter  the 
class  of  cases  that  merge  from  the  acute  into  the  sub- 
acute variet}'  of  symptoms. 

The  statistician  working  to  prove  that  the  mortality 
is  in  reverse  ratio  to  the  duration,  would  prefer  that 
the  mortality  rate  of  the  first  and  second  days  could 
be  reversed;  but  on  sober  reflection  the  proportion 
can  only  appear  natural,  for  these  cases  occurring 
on  the  first  day  are  those  in  which  the  symptoms  and 
their  underlying  condition  may  be  properly  called 
hyperacute.  The  writer  found  the  same  ratio  of  mor- 
talit}- some  vears  ago  when  studying  the  fatalit}-  of 
appendicitis,  when  it  appeared  that  the  mortality  rate 
of  operation  performed  the  first  day  was  greater  than 
that  of  operations  performed  on  several  days  follow- 
ing. To  the  clinician  of  larger  experience  such  con- 
ditions are  well  known  and  appreciated  at  their  true 
value. 

TABLE   V. — Mortality  According  to  Condition  of  the 
Intussusception. 


Number 
of  Cases. 

Died. 

Mortality, 
Per  Cent. 

Reducible 

99 
9 

1 
IS 

38 

Irreducible 

^'L 

75! 

Total 

■49 

79 

53 

.\s  showing  the  acuteness  of  the  process,  it  may  be 
mentioned  that  in  the  nine  fatal  cases  occurring  on  the 
first  day,  two  died  with  symptoms  of  recurrence;    one 


8o 


MEDICAL    RECORD. 


[July  17,  1897 


died  on  the  first  day  in  collapse  (eigiit  months  oldj  ; 
two  died  on  the  first  day,  autopsy  showing  general 
peritonitis;  one  died  from  intestinal  paralysis;  one 
on  the  first  day  with  beginning  sloughing  of  the  gut 
and  general  peritonitis. 

The  mortality,  according  as  the  condition  was  found 
to  be  reducible  or  otherwise,  is  in  direct  proportion  to 
the  duration  of  symptoms.  Of  ninety-nine  reducible 
cases  thirty-eight  died,  mortality  of  thirty-eight  per 
cent.,  while  in  the  remaining  fifty  cases,  in  which  reduc- 
tion could  not  be  performed,  the  mortality  was  eighty- 
two  per  cent,  or  more  than  double.  As  Table  IV. 
shows  how  the  proportion  of  non-reducible  cases  rose 
steadily  after  the  first  day,  it  requires  no  further  dem- 
onstration that  an  early  inteixention  is  necessary  for 
reduction  and  cure  of  the  intussusception  by  virtue  of 
its  being  reducible. 

TABLE    VI. — Mortality    According    to    Procedure 
Employed. 


Number 
of  Cases. 

Died. 

Mortality, 
Per  Cent. 

99 
4 

38 
"9 
19 
3 

38 

«^t8= 

The  mortality,  according  to  procedures  employed,  is 
virtually  only  a  check  on  the  accuracy  of  the  last-men- 
tioned conditions,  showing  necessarily  the  same  mor- 
tality for  reduction — eighty-six  per  cent,  for  artificial 
anus,  and  seventy-nine  per  cent,  for  resection,  or  for 
both  procedures  eighty -two  per  cent.  The  signifi- 
cance of  these  figures  will  be  further  considered  in 
another  part  of  the  paper.  Under  the  heading  "Vari- 
ous" are  included  three  operations  that  were  either 
abandoned  or  hopelessly  incomplete,  and  one  entero- 
anastomosis  (cure). 


TABLE    VIL 


-Mortality    According    to   Anatomatical 
Variety. 


Variety. 

Died. 

Cured. 

Mortality, 
Per  Cent. 

Enteric 

45 
■3 

3' 

5 

64. 

11       cascal 

58 

J.           ]■ 

Colon 

50 

As  itegards  the  mortality  according  to  the  location, 
Table  VII.  shows  that  the  ileo-colic  variety  heads  the 
list  with  a  mortality  of  sevent)'-two  per  cent,  while  the 
colon  has  the  lowest — fifty  per  cent.  These  deductions, 
however,  the  writer  believes  to  have  only  a  relative 
value,  as  they  are  drawn  from  only  one  hundred  and 
fifty  cases  out  of  two  hundred  and  thirty-nine,  and  be- 
cau.se  doubts  must  in  many  instances  arise  as  to  the  cor- 
rectness of  the  classification,  owing  to  the  incomplete 
or  loosely  recorded  details.  'I"he  ileo-colic  and  enteric 
varieties  have  always  been   regarded  as  particularly 

TABLE    \' I IL— Mortality  According  to  Ace. 


Age. 

Died. 

Cured. 

Mortality, 
Per  Cent. 

14 
3' 
■7 
17 
6 

38 

3 
"7 

7 

5 

=3 

82 

64 

iS 

Five    years  or  under 

Ten         "           ••        

37 
63 

62 

Under    i  year,    65  per  cent,  mortality. 

"      15  years,  6i      '* 
.\dnlts,  62.     "  " 


fatal,  and  it  is  rather  remarkable  that  the  latter  does 
not  show  even  a  greater  mortality.  .Vn  explanation 
may  perhaps  be  found  in  the  considerable  number  of 
recent  cases  recorded,  for  in  this  class,  when  reduction 


cannot  be  effected,  the  improvement  in  the  technique 
of  reunion  of  the  intestine  after  resection  should  prove 
of  the  greatest  practical  value,  as  in  former  times  an 
artificial  anus  was  the  only  resource,  and  this  proce- 
dure, as  we  have  seen,  is  necessarily  attended  by  the 
highest  mortality. 

The  mortality,  according  to  the  age,  is  of  great  im- 
portance. The  observations  are  based  on  two  hundred 
and  eleven  cases,  their  relative  proportions  being  in- 
dicated in  the  accompanying  table.  The  latter  shows 
so  remarkable  a  distribution  of  the  mortality  that 
doubts  might  well  be  raised  against  the  value  of  such 
statistics,  were  they  not  derived  from  such  a  large 
number  of  cases.  Dividing  the  age  into  three  classes 
— infants  (one  year  or  under),  children  (fifteen  years 
or  under),  and  adults — we  find  only  four  per  cent,  dif- 
ference between  the  highest  and  the  lowest  death  rate. 
(It  must  be  borne  in  mind  that  the  mortalit\-  is  repre- 
sented by  the  sum  total  of  the  two  tables  and  not  by 
the  one  hundred  and  forn--nine  cases  since  1887). 
The  writer  believes  that  these  figures  have  a  value  in 
calling  attention  to  the  fact  that  the  mortality  in  intus- 
susception is  due  not  so  much  to  the  tender  age  of  the 
majorit)'  of  the  patients  but  to  the  condition;  also 
that  this  latter  circumstance  should  prevent  us  from 
being  sceptical  of  the  possibility  of  improving  our  re- 
sults, and  lead  us  to  discard  the  prevalent  belief  that 
we  are  dealing  mainly  with  a  class  of  patients  whose 
age  alone  necessarily  precludes  a  favorable  result. 
While  the  tables  certainly  emphasize  the  terrible  mor- 
tality in  \eiy  early  life,  the  improvement  of  eighteen 
per  cent,  in  the  second  quarter  of  the  first  year  is  cer- 
tainly gratifying  and  believed  in  all  fairness  to  be 
sufficiently  pronounced  to  justify  such  a  conclusion. 

TABLE    IX. — Mortality  According  to  Sex. 


Died. 

Cured. 

Mortality . 
Per  Cent. 

Male 

Female 

36 

•3 

73 

Mortality  According  to  Sex. — For  reasons  which 
are  in  general  sufficiently  accepted  and  fairly  constant, 
the  female  sex  is  supposed  to  show  a  larger  proportion 
of  recoveries  after  operations  in  general.  The  favor- 
ing elements  generally  ascribed  as  influencing  the  les- 
ser female  mortality  would  not  seem  to  apply  here, 
where  the  larger  proportion  of  the  cases  was  in  chil- 
dren. 

The  mortality  according  to  the  method  of  relief  tm- 
ployed  will  be  more  appropriately  discussed  under 
treatment. 

It  may  be  timely  here  to  contrast  the  mortality  of 
intussusception  with  that  of  intestinal  obstruction  in 
general.  The  writer  has  collected  nearly  six  hundred 
cases  of  acute  intestinal  obstruction  from  causes  other 
than  intussusception,  occurring  within  the  same  period 
of  time  (1888-1896^  as  the  table  of  one  hundred  and 
forty-nine  cases  here  recorded.  They  have  been  chosen 
with  the  same  care  relative  to  the  exclusion  of  cases 
due  to  new  growths,  etc.,  and  more  rigidly  as  regards 
duration,  none  being  included  in  which  the  time  is  not 
definitely  stated,  whereas,  for  the  sake  of  completeness 
in  these  tables,  a  few  cases,  believed  from  their  histo- 
ries to  be  acute,  have  been  included.  In  addition  to 
the  usual  etiological  causes  of  intra-abdominal  obstruc- 
tion, these  cases  include  a  large  number  of  operations 
for  gangrenous  hernia,  and  yet  tlie  mortality  in  these 
cases,  giving  rise  to  a  very  large  number  of  com- 
plicated and  extensive  operations,  is  only  42.01  per 
cent.,  while  intussusception  under  the  same  conditions 
shows  a  mortality  of  fifty-three  per  cent.  May  not 
these  figures,  contrasted  with  each  other,  be  taken  to 
show   that  either  we  are  dealing  with  a  more   serious 


July  17,  1897] 


MEDICAL    RECORD. 


form  of  intestinal  obstruction  or  tliat  our  methods  of 
dealing  with  intu:;susception  need  improvement?  The 
writer  is  strongly  impressed  with  the  reality  of  the 
latter  possibilit}'.  The  age  alone  of  the  subjects 
should  not  give  so  wide  a  variance  Moreover,  a  re- 
ducible intussusception  certainly  appears  to  offer  for 
speedy  and  simple  operation  conditions  that  do  not 
exist  in  the  majority  of  cases  of  intestinal  obstruc- 
tion. The  intussusception,  however,  is  not  always 
reducible,  hence  the  difference.  Our  figures  show  that 
the  mortality  of  the  reducible  intussusception  is  infe- 
rior to  that  of  other  forms  of  obstruction,  as  thirty-eight 
is  to  forty-two.  Therefore,  if  we  aim  to  reduce  the 
mortality  of  intussusception  to  the  level  of  or  below 
that  of  the  general  figures  of  intestinal  obstruction,  we 
must  operate  while  reduction  is  possible.  To  accom- 
plish tire  latter  purpose  we  must  operate  at  the  earliest 
possible  moment,  and  that  means  refraining  from  wast- 
ing precious  time  in  attempts  at  reduction  by  inflation 
per  rectum,  except  in  a  ver}-  limited  class  of  cases, 
and  such  an  attempt  to  be  made  only  with  the  deter- 
mination to  resort  to  abdominal  section  immediately, 
if  such  inflation  does  not  at  once  accomplish  its  pur- 
pose. 

Treatment  by  Inflation  of  the  Bowel  by  Ene- 
mata  of  Fluids  (or  Air). — It  is  probably  not  an  ex- 
aggeration to  say  that  if  all  cases  of  intussusception 
were  treated  at  the  onset,  or  say  within  fortj'-eight 
hours,  by  abdominal  section,  without  any  previous  at- 
tempts at  reduction,  the  mortality,  while  still  consider- 
able, would  in  all  probability  be  very  much  less  than 
the  present  figures.  The  writer  is  far  from  believing 
that  mechanical  distention  should  be  altogether  dis- 
carded, but  would  very  much  limit  its  application. 

The  vital  argument  against  treatment  by  enemata  of 
fluids  or  air  is  that  such  a  procedure,  should  it  not 
entirely  succeed,  delays  operative  measures.  Also 
that  it  is  uncertain,  in  that  it  may  give  rise  to  the  de- 
ceptive impression  that  the  invagination  has  been  en- 
tirely reduced,  while  an  unreduced  intussusception,  no 
matter  how  small,  is  still  an  obstruction  of  undimin- 
ished danger.  A  glance  at  the  general  tables  will 
show  how  many  instances  occurred  of  deceptive  suc- 
cesses following  inflation,  before  resort  was  finally 
had  to  abdominal  section.  The  records  of  such  cases 
show  that  recognition  of  the  success  of  the  reduction 
must  be  very  difficult  from  physical  signs  alone.  To 
allow  the  patient  to  recover  from  the  anaesthetic  and 
to  wait  for  symptoms  is  contrary  to  the  indications  of 
treatment  of  intestinal  obstruction,  which  should  con- 
sist in  immediate  and  certain  action. 

Enemata  are  distinctly  dangerous.  The  literature 
of  intussusception  in  general  is  full  of  reports  of  cases 
of  perforation  or  rupture  of  the  intestines  by  the  vari- 
ous agents  used  to  reduce  the  invagination.  Moreover 
these  accidents  are  not  invariably  the  result  of  what  is 
unmistakably  too  great  force  or  pressure.  A  striking 
instance  of  rupture  from  a  hydrostatic  pressure  of  only 
four  and  one-half  feet  is  Case  126,  Table  II.,  reported 
by  Harrington,  that  of  a  child  five  years  old.  The 
ileum  was  found  perforated  as  the  direct  result  of  a 
fluid  enema  administered  on  the  fifth  day.  Another 
typical  example  of  perforation  is  reported  by  Mr.  Fen- 
wick,''  where  an  intussusception  in  a  six-months  old 
child  was  apparently  successfully  reduced  on  the  sec- 
ond day  by  an  enema.  Death  occurring  almost  imme- 
diately afterward,  the  autopsy  showed  ulceration  and 
perforation  of  the  gut,  which  had  not  been  reduced. 
This  case  shows  plainly  that  the  danger  of  perforation 
is  not  limited  to  interference  in  those  cases  that  have 
lasted  for  a  considerable  period  of  time. 

.\nother  disadvantage  of  reduction  by  enemata  is  to 
be  found  in  the  tendency  of  the  intussusception  to 
recur:  a  number  of  such  instances  are  to  be  found 
in  the  tables.     Case  48,  Table  II.,  is  an  interesting 


example:  the  invagination  was  twice  reduced  and 
recurred  twice  before  abdominal  section  was  per- 
formed. While  it  may  be  rightly  advanced  that  such 
recurrences  are  sometimes  seen  after  abdominal  sec- 
tion, they  are  undoubtedly  rarer.  Moreover,  abdomi- 
nal section  permits  of  the  employment  of  prophylactic 
measures  against  such  recurrences,  many  surgeons  hav- 
ing rece^itly  recognized  the  necessity  of  "anchoring" 
a  newly  reduced  bowel,  and  in  all  probability  such  a 
procedure  will  become  the  rule  when  its  necessit}'  be- 
comes more  generally  recognized. 

Under  what  conditions  then,  if  any,  shall  we  make 
a  trial  of  high  injections  before  resorting  to  abdominal 
section  ?  It  seems  to  the  writer  that  to  attempt  to  re- 
ply to  this  question  dogmatically  would  be  a  confes- 
sion of  inability  to  appreciate  the  complexity  of  the 
circumstances  under  which  intussusception  may  be  en- 
countered. His  feeling  is  that  a  single  attempt  (in  a 
manner  to  be  described  elsewhere)  may  be  made  in 
the  first  twenty-four  hours.  If  the  condition  is  one  of 
very  great  intensity  of  symptoms,  it  will  perhaps  be 
wisest  to  refrain  from  making  such  an  attempt,  for  the 
reason  that  even  on  the  first  day  reduction  alone  will 
not  always  be  a  sufficiently  effective  treatment  of  ex- 
isting pathological  conditions.  A  study  of  the  anal- 
ysis of  the  mortalit}'  of  the  first  day  (see  above)  will 
show  that  in  at  least  three  of  the  cases  further  proce- 
dures were  called  for.  The  case  of  beginning  slough- 
ing of  the  colon  found  at  the  autopsy  is  a  sufficient 
proof  of  this  contention. 

In  the  second  twent)"-four  hours,  while  a  certain  pro- 
portion of  cases  will  in  all  probability  yield  to  me- 
chanical treatment,  its  usefulness  becomes  still  more 
restricted,  as  exampled  by  the  twent)'-eight  cases  oc- 
curring on  the  second  day  (Table  IV.),  when  in  four 
instances  other  procedures  than  reduction  were  found 
necessary. 

After  the  second  day  the  writer  believes  that  the 
possibility  of  relief  is  so  small  and  the  probability  of 
doing  harm  so  great  that  a  preliminary  trial  of  the 
enemata  should  be  omitted,  unless  there  are  some  spe- 
cially good  reasons  for  yielding  to  the  temptation  of 
resorting  to  them ;  for  the  tables  show  that  after  the 
third  day,  even  after  the  abdomen  was  opened,  a  non- 
reducible condition  was  found  in  proportions  varying 
from  fifty-seven  to  eighty  per  cent. 

A  small  percentage  of  cases,  which  may  be  called 
the  subacute  variety,  may  in  the  later  days,  say  in  the 
second  week,  offer  conditions  which  might  justify  a 
preliminary  trial  of  distention.  These  are  the  cases 
whose  symptoms  are  a  pretty  accurate  reflection  of  the 
lack  of  severity  of  the  general  or  local  condition, 
showing  neither  shock  nor  sepsis.  Such  cases,  however, 
would  from  their  excellent  condition  in  all  probability 
do  well  if  subjected  to  the  more  radical  and  certain 
operation  of  abdominal  section,  if  performed  under 
favorable  circumstances. 

The  pressure  which  can  be  used  with  safet\'  has 
been  shown  to  be  limited.  The  same  restriction  ap- 
plies to  the  amount.  Mr.  Pick"'  would  limit  the  amount 
in  a  child  under  one  year  to  a  pint  and  a  half,  and  the 
pressure  to  three  feet.  Parker  cites  a  case  in  which 
an  injection  of  one  pint  in  a  three-months-old  child 
caused  perforation,  the  autopsy  showing  a  small  rent 
in  the  lower  part  of  the  intussusception.  It  may  be 
said  that  such  fatalities  are  rare,  and  that  in  many  in- 
stances larger  amounts  and  greater  pressure  have  been 
successfully  employed  and  are  usually  necessary  for 
success,  'i'he  writer  would  reply  that  what  has  hap- 
pened can,  and  in  all  probability  will,  occur  again: 
likewise  that  dead-hou.se  experiments  on  non-morbid 
intestinal  tissues  are  so  little  in  relation  to  the  con- 
ditions one  meets  in  actual  practice  that  their  possi- 
ble value  cannot  be  discussed  here. 

The  writer  would  therefore  recommend  that  in  those 


82 


MEDICAL    RKCORD. 


cases  in  which  he  has  tried  to  show  the  justifiability  of 
a  preliminary  trial  of  inflation  the  attempt  shoulci 
be  made  as  a  stage  preparatory'  to  immediate  opening 
of  the  abdomen,  if  the  inflation  does  not  at  once  over- 
come the  obstruction.  All  preparations  for  operation 
having  been  made,  the  patient  should  be  anaesthetized 
and  the  outlines  of  the  intussusception  carefully  stud- 
ied. A  rectal  tube  should  be  pa.ssed,  care  being  taken 
that  it  does  not  double  up  oji  itself.  The  injected 
fluid  (preferably  warm  to  avoid  shock)  should  then  be 
allowed  to  run  in  by  gravit}-,  the  pressure  being  grad- 
ually raised.  It  is  probably  best  to  have  the  patient's 
pelvis  well  elevated.  The  operator  should  meanwhile 
keep  accurate  track  by  the  sense  of  touch  of  the  result- 
ing distention  and  its  influence,  if  any,  on  the  in- 
tussusception. His  perceptions  of  these  results  should 
guide  his  judgment  as  to  the  necessary  pressure,  rather 
than  actual  amount,  but  he  must  remember  that  after 
attaining  a  hydrostatic  pressure  of  four  feet,  and  even 
less  with  infants,  he  is  treading  on  dangerous  ground. 
Still,  even  here  the  conditions  pertaining  to  the  indi- 
vidual case  must  be  his  chief  guide. 

If,  as  a  result  of  the  enema,  the  operator  can  abso- 
lutely recognize  by  the  sense  of  touch  that  the  intus- 
susception has  entirely  disappeared,  the  operation  may 


h& postponed.  The  latter  term  is  used  advisedly,  for 
the  operator  should  take  the  attitude  that,  while  he  is 
certain  that  he  has  so  far  been  successful,  the  con- 
ditions are  likely  to  recur  within  the  next  few  hours 
or  days,^  and  all  preparations  must  be  kept  in  readi- 
ness. Should  the  intussusception  recur  after  success- 
ful reduction,  the  writer  believes  that  the  abdomen 
should  then  be  opened  at  once,  lest  by  further  delav 
the  "golden  moment"  be  allowed  to  pass. 

_(Braun"=  has  called  attention  to  a  frequent  source  of 
mistaken  belief  in  the  sucessful  performance  of  reduc- 
tion, in  that  the  wrinkling  and  stretching  of  the  sheath 
(Fig.  i)  allows  of  e,xtensive  variations  in  the  length  of 
the  intussusception;  for  instance,  one  may  have  the 
impression  that  the  intussusception  extends  only  three 
or  four  centimetres  into  the  sheath,  while  direct  ex- 
amination will  show  that  the  portion  of  the  sheath  in- 
volved measures  twenty-rtve  centimetres). 

The  writer  declines  to  discuss  means  of  inflation 
other  than  by  the  force  of  liquids  acting  under  gravity. 
Such  procedures,  while  attractive  by  reason  of  their 
ingenuity,  are  dangerous  and  less  suited  to  the  pur- 
poses of  accurate  observation  of  results. 

Can  a  comparison  be  drawn  between  the  relative 
value  of  treatment  by  enemata  alone,  by  enemata 
prior  to  laparotomy,  and  by  innnediate  laparotomy 
without  recourse  to  preliminary  measures.'  It  would 
seem  to  the  writer  as  impossible  to  obtain  fair  deduc- 
tions from  such  a  comparison  as  in  any  other  class  of 
diseases  which  present  varying  conditions,  calling  in 
some  instances  for  medical,  i.e.,  bloodless  procedures, 
in  others  for  surgical  or  operative  relief.  No  clinician 
of  wide  experience  would  to-day  attempt  to  show  such 
a  contrast  between  surgical  and  non-surgical  cases  of 


[July  17,   1897 

diphtheria,  cholelithiasis,  appendicitis,  etc.  Our  aim 
should  be  to  obtain  the  greatest  diminution  of  mortal- 
ity, and  It  would  seem  preferable  to  expose  one's  self 
to  the  reproach  of  having  done  a  needless  operation 
than  to  that  of  having  sacrificed  a  life  from  non-inter- 
vention. Therefore  it  would  .seem  preferable  to  yield 
to  an  excessive  desire  for  certainty,  as  illustrated  by 
Case6w7  (Table  II.),  in  which  the  surgeon,  not  feeling 
absolutely  certain  that  the  attempt  at  mechanical  re- 
duction had  been  perfectly  successful,  performed  ab- 
dominal section  only  to  find  that  the  intussusception 
was  already  reduced. 

Treatment    by   Abdominal    Section.— The   writer 
hopes  to  be  pardoned  if  he  takes  the  liberty  of  giving 
a  few  hints  as  to  the  preparations  for  operations  not 
conducted  in  an  institution.     A  sufficient  number  of 
assistants  should  be  obtained,  if  such  are  available,  and 
the   duties  of  each  one  clearly  defined.     The   house 
need  not  be  turned  topsy-turvy,  nor  carpets,  drapery, 
curtains,  etc.,  removed  except  for  direct  economy.     In 
fact,  it  is  better  not  to  do  anything  to  stir  up  a  dust  in 
the  room  where  the  operation  is  to  be  performed.     The 
best-lighted  room  should  be  chosen,  provided   it  can 
be  well  heated  if  the  weather  be  cool.      Sheets,  towels, 
etc.,  can  be  properly  sterilized  by  boiling  half  an  hour! 
It  IS  well  to  remember  that  in  an  emergency  even  five 
minutes'  boiling  gives  a  tolerably  high  degree  of  ster- 
ilization.    Among  other   methods   of    sterilizing    the 
patient's  skin   is    the    simple    one  of  scrubbing  with 
green   soap  and  washing  off    in  ninety-five  per-cent 
alcohol.      For  the  hands  *  a  simple  and  ven^  effectual 
method  is  scrubbing  with  hot  water  and  soap,  rinsing 
off,  and  then  rubbing  the  hands  and  arms  with  a  paste 
made  by  taking  in  the  palm  of  the  hand  a  teaspoonful 
of  washmg-soda,  adding  a  cr>-stal  of  chloride  of  lime 
about  half  the  size  of  the  terminal  phalanx  of  the  lit- 
tle finger,  and  adding  a  few  drops  of  water.     Rubbing 
this  mass  produces  a  paste,  which  becomes  smoother 
with  the  prolongation  of  the  rubbing.     The  nascent 
chlorine  thus  given   off  has  been   proven   one  of  the 
most  powerful   germicidal   agents  in  its   action  on  the 
skin  yet  discovered.      Some  boiled  water   should   be 
used  to  wash  off  the  paste  after  three  or  five  minutes' 
use.     The   instruments  should  be  boiled   for  half  an 
hour;  a  teaspoonful  of  washing-soda  added  to  the  water 
increases  the  efticacy  of  the  sterilizing  process  and 
keeps  the  metallic   instruments  from   rusting.     Once 
properly  rendered  aseptic,  neither  the  hands^^  nor  the  ' 
instruments  should  be  contaminated  by  touching  anv- 
thing  that  has  not  been   similarly  disinfected.^  The 
failure  to  observe  the   latter  rule   is  to-day  probably 
responsible   for  the  greater  part  of   the  fatal  results 
from  sepsis,  which  has  not  yet  been  eliminated  as  a 
source  of  death  as  a  sequel  to  operation. 

Every  preparation  requisite  for  the  possible  per- 
formance of  intestinal  resection  and  anastomosis 
should  be  in  readine.s.s,  all  intestinal  sutures  properly 
prepared  and  at  once  available  if  needed. 

Choice  of  Anaesthetic- The  writer  could  wish 
that  the  recorded  cases  might  have  furnished  some 
details  regarding  the  choice  of  the  ana-sthetic  em- 
ployed, but  only  few  records  could  be  found.  Even 
in  the  United  States,  where  ether  is  generally  given  the 
preference,  chloroform  is  very  largely  used  to  anaesthe- 
tize children,  and  will  probably  be  found  the  best  agent 
when  operating  for  intussusception  in  children.  The 
writer  believes  that  not  sufficient  attention  has  been 
given  to  the  temporary  stimulant  effect  following  sub- 
stitution of  ether  for  chloroform,  after  the  latter  has 
been  given  some  time.  Usually  such  a  change  is 
made  if  the  chhjroform  narcosis  is  not  satisfactory,  but 
the  writer  would  urge  a  trial  of  a  routine  mixed  anes- 
thesia, the  first  half  under  chloroform,  the  second  under 
ether. 

*For  fuller  det.niU  scr  article  by  R.  Y.  Weir  "on  this  subject 


July  17,  1897] 


MEDICAL    RECORD. 


83 


Operation. — The  incision  should  be  in  the  median 
line,  and  from  the  onset  should  be  generous,  and  ex- 
tended without  hesitation  if  sufficient  space  is  not  ob- 
tained for  ready  and  speedy  handling  of  the  intestines. 
If  no  point  of  definite  location'  of  the  invagination  is 
known,  and  the  first  comprehensive  sweep  of  the  fin- 
gers over  the  abdomen  reveals  nothing,  the  ileo-caecal 
valve  should  be  sought  for.  and  the  intestines  syste- 
matically examined  from  that  point  in  either  direction. 
If  the  caecum  is  collapsed  we  know  then  that  our 
search  must  be  directed  upward  in  the  small  intestine. 
The  intussusception  having  been  located,  it  should 
be  examined  by  direct  inspection  of  its  whole  extent. 
The  first  glance  may  show  that  reduction  is  impossible 
or  unwise.  Attempts  at  reduction  are  best  made  in 
the  direction  of  working  away  the  sheath  from  the  in- 
vagination rather  than  pulling  the  latter  out,  such 
a  procedure  often  causing  extensive  tears  of  the  gut 
at  some  adherent  point.  To  guard  against  extrav- 
asation of  fffices,  the  rest  of  the  intestines  and  the  ab- 
dominal cavity  should  be  protected  by  large  gauze 
pads.  If  the  intestine  has  been  successfully  reduced, 
a  close  examination  should  be  made  of  it  to  determine 
if  any  portion  is  so  injured  as  to  impair  its  vitalit}'. 
If  there  is  a  little  doubt  as  to  its  integrit}",  one  may 
employ  Hahn's  method  of  surrounding  that  portion  by 
a  gauze  packing,  over  which  the  sutures  of  the  abdom- 
inal wall  may  be  provisionally  tied.  By  such  a  pre- 
caution the  general  peritoneal  cavit}-  is  shut  off  from 
absorption  of  septic  material  from  possible  sloughing 
of  the  intestinal  walls,  and  if  perforation  takes  place 
it  does  so  under  the  conditions  of  an  extraperitoneal 
lesion.  Twent)'-four  hours'  observation  under  such 
conditions  will  usually  suffice  to  determine  the  ulti- 
mate fate  of  the  intestine,  whether  it  can  safely  be  re- 
turned into  the  belly  or  whether  further  procedures  are 
indicated.  The  writer  was  a  witness  of  this  treatment 
in  the  case  reported  by  Curtis,  Case  69,  Table  II., 
and  can  add  his  testimony  to  the  efficacy  of  the  pro- 
cedure. While  the  gut  was  so  isolated,  the  patient 
had  a  free  movement  of  the  bowels,  showing  that  the 
skilful  disposition  of  the  gauze,  while  accomplishing 
its  purpose,  had  formed  no  impediment  to  the  free  pas- 
sage of  intestinal  contents. 

Lindemann's  case  (No.  37,  Table  II.)  is  another 
example  of  the  wisdom  of  this  procedure. 

If  the  intestine  cannot  be  safely  or  effectively  re- 
duced, what  shall  be  our  attitude? 

The  first  point  to  decide  is  whether  the  irreducible 
intussusception  is  free  from  septic  conditions  or  slough- 
ing. Great  care,  experience,  and  judgment  are  re- 
quired to  be  able  to  answer  this  question  in  the  affir- 
mative. 

An  acute  intussusception  that  cannot  be  reduced  is 
in  all  probability  rarely  solely  an  irreducible  condi- 
tion— that  is  to  say,  it  is  usually  accompanied  by 
lesions  of  a  septic  nature,  which  endanger  life  both  by 
septic  infection  per  sc,  and  secondarily  by  permitting 
extravasation  of  the  faecal  contents.  If  the  conditions 
are  such  that  doubt  exists,  the  wisest  course  is  to  treat 
the  intussusception  as  of  the  gangrenous  variet)',  for 
which,  as  will  be  shown  later,  only  one  broad  line  of 
conduct  is  permissible. 

Having  determined  then  that  we  have  to  deal  with 
a  purely  irreducible  condition,  we  have  the  choice  of 
the  following  methods: 

1.  Artificial  anus. 

2.  Entero-anastomosis. 

3.  Partial  resection. 

4.  Typical  resection. 

(i)  A  purely  irreducible  intussusception  presents 
the  only  condition  in  which  a  primary  artificial  anus 
(as  a  sole  measure — see  below-,  combination  of  resec- 
tion and  artificial  anus)  is  ever  permissible.  Even 
here    its    use    must   necessarilv    be    limited.      In    all 


forms  of  intussusception  not  exclusively  limited  to 
the  large  intestine  (and  such  cases  are  infrequent) 
the  artificial  anus  is  necessarily  made  in  the  small 
intestine.  Except  for  the  lower  portion  of  the  ileum, 
an  artificial  anus  in  the  small  intestine  is  incom- 
patible with  the  preservation  of  life  except  for  a 
verj-  brief  period  of  time.  Even  in  the  lower  ileum 
nutrition  is  seriously  impaired  and  much  suffering  re- 
sults from  the  excoriating  character  of  the  fluid  intes- 
tinal contents.  The  procedure  should  therefore  be 
reserved  for  those  cases  whose  general  condition  is  so 
desperate  that  any  further  procedures  must  necessarily 
be  followed  by  death.  For  the  large  intestine  the  in- 
dications are  much  more  favorable,  and  in  some  cases 
will  constitute  the  most  judicious  form  of  treatment. 
A  decision  to  limit  one's  self  to  an  artificial  anus,  even 
under  these  circumstances,  must  be  undertaken  with 
the  full  appreciation  of  the  after-histor)-  of  these  cases. 
In  these  tables  only  three  cures  after  artificial  anus 
are  recorded,  and  all  three  required  more  or  less  ex- 
tensive operations  to  effect  such  a  cure.  Among  the 
fatal  cases  are  included  three  in  which  life  was  pro- 
longed for  a  variable 
period  of  time,  but  these 
patients  succumbing 
after  resection,  etc.,  of 
the  fistula,  they  are  pro- 
perly classed  among  the 
fatal  cases.  That  is,  in 
six  cases  of  artificial 
anus,  in  which  subse- 
quent operations  were 
found  advisable  or  nec- 
essar)',  the  mortal  it}- 
was  fifty  per  cent.,  and 
these  facts  should  be 
given  due  consideration 
by  the  operator  before 
his  decision  to  make 
an  artificial  anus  is 
reached. 

(2)  Entero-anasto- 
mosis. By  this  term 
we  mean  the  formation 
of  an  anastomotic  com- 
munication between 
the  segments  of  the  gut 
above  and  below  the 
intussusception,  thus 
side-tracking  the  affected  portion.  This  operation 
may  compete  with  the  next  two  to  be  described,  but 
not  with  artificial  anus,  the  latter  being  reserved  for 
the  desperate  cases. 

Entero-anastomosis  may  be  performed  by  means  of 
sutures  alone,  an  operation  requiring  for  its  proper 
and  speedy  performance  considerable  technical  skill, 
but  constituting  more  nearly  the  ideal  of  intestinal 
anastomosis,  or  by  means  of  some  mechanical  device. 
The  Murphy  button  will  here  give  a  very  speedy  and 
simple  means  of  reunion,  and  should  doubtless  be  pre- 
ferred when  time  is  a  very  important  element.  It  is 
to  be  borne  in  mind  that  anastomosis  by  any  mechani- 
cal device  that  must  eventually  perform  the  role  of  an 
intestinal  foreign  body  is  not  an  ideal  method. 

(3)  Partial  or  atj'pical  resection,  or  resection  of  the 
intussusception  through  an  incision  in  the  sheath. 

Various  procedures,  differing  chiefly  in  minor  or 
technical  details,  have  been  described,  and  to  them 
several  operators'  names  have  been  appended  (Jesset, 
Barker,  Rydygier). 

The  following  may  be  described  as  the  essential 
steps  of  the  operation  (Fig.  2)  :  Circular  running  su- 
ture securely  uniting  the  invaginated  gut  to  the  sheath 
at  the  neck;  longitudinal  incision  of  the  sheath; 
cross  section  of  the  invaginated  portion ;    sutures  of 


Fig.  2. — Sheath  Opened 
tion  Resected.     (After 


and   Invagina- 
Rydygier.) 


84 


MEDICAL    RECORD. 


[July  17,  1897 


varying  nature  and  extent  of  the  proximal  cut  edge, 
especially  of  the  mesenteric  portion  for  the  arrest  of 
hemorrhage;  extraction  of  the  (now)  free  portion  of 
the  resected  intestine  either  through  the  longitudinal 
incision,  or,  if  long  and  accessible,  by  the  rectum  from 
below ;  suture  of  the  incision  ;  closure  of  the  abdomen. 

For  the  successful  performance  of  this  operation, 
absence  of  firm  adhesions  within  the  sheath  is  desir- 
able. The  operation  under  favoring  conditions  is 
simple,  speedy,  and  sacrifices  less  intestine  than  a 
typical  resection,  as  the  sheath  is  preserved  intact. 
In  one  of  Mr.  Barker's"  cases  the  whole  duration  of 
the  operation  was  only  half  an  hour. 

(4)  Resection  of  the  entire  intussusception.  The 
performance  of  this  operation  for  irreducible  intus- 
susception will  probably  occur  less  frequently  with 
the  further  familiarity  with  the  last  described  proce- 
dure, the  latter  being  a  comparatively  recent  operation. 
Before  it  is  undertaken,  the  reasons  for  preferring  it 
to  the  last  two  operations  should  be  established. 
These  may  be  briefly  stated  to  be :  for  entero-anasto- 
mosis,  hesitation  at  leaving  a  considerable  portion  of 
the  gut  to  "take  care  of  itself,"  or  (rarely)  technical 
difficulties  in  performing  entero-anastomosis;  for  re- 
section of  the  invagination,  failure  to  separate  firm 
adhesions;  for  either  procedure,  if  there  is  any  sus- 
picion relative  to  the  intestine's  non-septic  condition. 

Treatment  of  Gangrenous  Intussusception. — The 
writer  believes  that  here  the  conditions  requiring  re- 
lief are  so  urgent  and  so  clearly  defined  that  there  can 
be  little  choice  in  the  methods  of  operating.  The 
patient  must  be  relieved  of  the  obstruction  and  of  the 
infection  attending  gangrene.  Remedying  the  first 
condition  without  remedying  the  second  is  equivalent 
to  doing  nothing  at  all.  To  make  an  artificial  anus 
under  such  conditions  is  simply  an  act  of  mercy  in- 
tended to  mitigate  the  sufferings  attending  dissolution. 
We  are  face  to  face  with  a  desperate  condition  and  one 
doubly  sad,  in  that  in  many  instances  the  responsibil- 
ity for  this  condition  is  on  the  shoulders  of  some  one 
who  ought  to  have  known  better.  To  operate  in  such 
a  manner  and  so  extensively  as  to  meet  the  require- 
ments of  the  condition  is  nearly  always  certain  to  be 
followed  by  death;  not  to  do  so  is  to  abandon  the  pa- 
tient to  his  fate.  It  may  be  objected  that  death  is 
inevitable  in  most  cases  from  the  existing  general 
peritonitis,  which  of  cour.se  no  amount  of  exsection  of 
the  intestine  can  deal  with.  To  this  objection  the 
writer  would  say  that  cases  of  diffuse  purulent  perito- 
nitis do  sometimes  end  in  recovery.  That  they  are  rari- 
ties is  freely  acknowledged,  and  tlie  writer's  scepticism 
about  many  alleged  cures  of  general  peritonitis  is  well 
pronounced,  as  many  such  cases  are  more  probably 
forms  of  extensive  localized  peritonitis.  Still,  if  by 
operating  even  only  one  in  a  hundred  lives  is  saved, 
shall  we  not  make  the  attempt?  The  chances  are  not 
so  desperate,  however,  as  the  question  might  lead  one 
to  judge.  The  present  methods  show  a  gain  in  saving 
of  life  that  could  not  have  been  conjectured  two  dec- 
ades ago.  In  1885  that  very  careful  observer,  Braun, 
could  find  no  record  of  cure  by  operation  of  non- 
reducible intussusception.  The  records  of  these  one 
hundred  and  forty-nine  cases  here  appended,  begin- 
ning in  1888,  show  that  nine  such  cases  have  been 
cured  by  the  improvements  of  modern  surgery,  whose 
progress  is  nowhere  more  marked  than  in  intestinal 
operations. 

While  the  experience  with  the  antistreptococcus 
serum  is  still  too  limited  t6  allow  of  more  than  a  hint 
as  to  its  possible  usefulness,  and  while  realizing  that 
any  unduly  enthusiastic  views  may  lead'  to  delusions 
which  so  easily  took  possession  of  the  profession  re- 
garding other  possibilities  in  the  line  of  antibacterial 
remedies,  the  writer  nevertheless  believes  that  we 
should  not  fail  to  make  use  of  this  or  any  similarly 


devised  principle  of  treatment  that  holds  out  hopes  of 
supplementar}'  aid  in  so  grave  a  condition  as  gan- 
grenous intussusception. 

As  regards  operative  treatment  the  writer  recom- 
mends only: 

1.  Resection  with  immediate  union  of  divided  in- 
testine; or, 

2.  Resection  with  utilization  of  divided  ends  for  a 
temporary  artificial  anus. 

(i)  It  is  thus  evident  that  any  method  that  does  not 
provide  for  removal  of  the  gangrenous  area  is  rejected. 
The  removal  should  not  be  niggardly,  the  healthy  area 
should  be  encroached  upon  to  a  sufficient  extent  to 
insure  radical  cure.  The  writer  has  collected  numer- 
ous instances  in  which  an  apparent  hesitation  to  follow 
the  above  recommendation  has  destroyed  the  chances 
of  what  would  otherwise  have  been  a  good  operation. 
An  example  of  necrosis  of  the  anastomotic  edges  is 
shown  in  No.  110,  Table  II.  Moreover,  resection  of 
a  large  portion  adds  comparatively  little  to  the  time 
or  difficulties  of  the  operation.  Astonishingly  large 
amounts  have  been  successfully  removed  with  little  or 
no  influence  on  the  general  health.  Cases  103  and 
104,  Table  II.,  are  instances  of  the  truth  of  this  as- 
sertion. Other  examples  are  to  be  found  in  the  fol- 
lowing: 

Kocci  and   Fantino^' 310  cm.,  ileum. 

Koberle 205     "  small  intestine. 

Hinterstossier" 186    *'  ileum. 

Kocher 160    "  small  intestine. 

Braun 137     *'  "            " 

.Schlange 135    "  "          " 

T.A.BLE  X. 

No.  of 
Results  of  Resection.  Cases.         Cured. 

End-to-end  suture 12  2 

Partial  resection 3  o 

End-to-end  anastomosis  (Murphy  button).  6  3 

Lateral  anastomosis  and  method  unknown.  3  o 

24  5 

Mortality.  79  per  cent. 

The  cases  are  too  few  to  venture  on  any  significant 
claims  for  the  advantages  of  any  one  method.  The 
proportion  of  recoveries  (fift}'  per  cent.)  with  the 
Murphy  button  is  encouraging,  and  should  certainly 
warrant  a  further  trial  of  this  method.  Undoubtedly 
the  time-saving  element  is  its  chief  advantage,  and  the 
operator  with  limited  experience  in  intestinal  work 
will  in  all  probability  often  get  the  best  results  with 
this  simple  device. 

A  record  of  Maunsell's  method  does  not  appear  in 
these  tables,  but  his  simple  device  can  well  compete 
with  the  Murphy  button.  It  takes  the  least  time  of 
any  of  the  methods  by  suture  alone,  and  is  free  from 
the  disadvantages  attending  the  u.se  of  any  mechanical 
aid. 

The  writer  is  compelled,  though  somewhat  regret- 
fidly,  to  refrain  from  a  further  prolongation  of  this 
paper  by  the  consideration  of  the  indications  for  the 
employment  of  the  several  methods  of  t}'pical  resec- 
tion. 

(2)  If  after  the  excision  of  the  gangrenous  area  we 
feel  that  the  patient's  failing  strength  will  not  permit 
further  measures,  we  can  bring  the  ends  of  the 
bowel  into  the  wound  (or  if  preferred  into  a  separate 
wound),  as  a  temporar)-  artificial  anus.  These  ends 
should  be  so  placed  witli  relation  to  the  external 
wound  and  to  each  other  as  to  permit  ultimately  of  the 
easiest  methods  of  repair. 

Before  closure  of  the  abdomen  the  operator  should 
convince  himself  that  no  second  intussusception  or 
other  form  of  obstruction  exist  Cases  79,  91,  and 
112,  Table  II.,  show  the  necessity  of  such  precaution- 
ary measures. 


July  17,  1897] 


MEDICAL    RECORD. 


85 


As  rapidity  of  operation  is  desirable,  the  following 
method  of  closure  of  the  abdominal  wound  is  given, 
as  this  part  of  the  operation  is  often  less  in  keeping 
with  the  desired  end  than  the  rest  of  the  operation. 
Transfix  all  the  layers  with  a  Peaslee  needle,  en- 
tering in  the  skin  on  one  side  (the  fascial  layer 
being  drawn  well  forward  by  the  assistant)  and  pass- 
ing through  the  peritoneum.  The  needle  then  trans- 
fixes the  opposite  side  in  reverse  order,  emerging  at 
the  skin.  A  piece  of  silkworm  gut  is  threaded  in  the 
eye  and  the  needle  withdrawn.  Should  the  condition 
allow  the  expenditure  of  more  time,  the  peritoneum 
may  be  sutured  separately  with  catgut,  and  not  in- 
cluded in  the  other  sutures.  Should  the  condition  be 
very  good,  the  fascial  layer  may  be  united  separately 
to  guard  against  hernia.  In  aseptic  cases,  interrupted 
buried  silkworm  sutures  have  given  the  writer  most 
gratifying  results,  both  immediate  and  remote. 

Shock — After-Treatment. — The  writer  does  not  be- 
lieve that  the  degree  of  shock  exhibited  by  children  is 
so  intense  as  usually  supposed.  We  must  differentiate 
between  the  shock  resulting  from  the  condition  neces- 
sitating operation  and  that  from  the  operation  proper. 
Children  bear  serious  operations  on  the  osseous  S)  s- 
tem  with  no  more  depression  than  is  exhibited  by 
adults,  on  condition  that  the  amount  of  hemorrhage  is 
small.  While  an  explanation  of  the  source  of  shock 
does  not  banish  the  condition  as  we  have  to  meet  it,  it 
emphasizes  the  importance  of  prophylaxis — not  to  let 
the  morbid  conditions  exist  or  progress  to  a  condition 
of  shock  which  per  se  is  hopeless. 

Much  can  be  done,  however,  to  tide  over  a  condition 
of  shock,  and  attention  to  minor  details  may  prove  the 
turning-point  in  obtaining  a  successful  result  after 
operation.  The  chief  stimulants  in  their  order  of  im- 
portance are  heat,  alcohol,  and  drugs.  Loss  of  heat 
at  any  stage  must  be  zealously  guarded  against,  and  in 
the  operation  contact  with  moist  cloths,  irrigating 
fluids,  etc.,  avoided,  owing  to  the  cooling  effects  of 
evaporation.  In  very  pronounced  shock  alcohol  should 
be  given  hypodermatically,  as  the  state  of  the  circula- 
tion will  probably  allow  but  little  absorption  by  the 
rectum.  Of  drugs,  strjxhnine  hypodermatically  is 
probably  the  most  efficient.  Camphor  dissolved  in 
olive  oil  is  a  most  valuable  subcutaneous  agent. 
Stimulation  by  drugs  requires  the  exercise  of  great 
judgment  and  accurate  observation  of  their  action. 
The  writer  feels  quite  sure  that  a  not  insignificant 
proportion  of  operative  cases  terminate  fatally  from  the 
injudicious  administration  of  dangerous  stimulants. 

The  injection  of  warm  saline  solutions  into  the 
circulation,  either  directly  into  a  vein  or  subcutane- 
ously,  is  no  longer  limited  to  the  treatment  of  shock 
dependent  on  hemorrhage.  While  never  having  had 
occasion  to  resort  to  it  in  children,  the  writer  would 
urge  that  a  trial  of  this  procedure  Ise  made  in  combat- 
ing the  shock  in  operations  for  intussusception  in 
children.  It  should  not  be  used  as  a  last  resort,  nor 
should  its  accomplishment  interfere  with  the  operator; 
to  some  competent  assistant  should,  if  possible,  be 
delegated  the  sole  duty  of  performing  it  whenever 
called  for.  In  the  first  few  hours  after  recovery  from 
the  anesthetic  the  pain  and  restlessness  may  compel 
one  to  give  some  form  of  opiate,  but  in  general  it  is 
best  withheld  in  order  not  to  confine  the  bowels.  The 
profession  is  now  very  nearly  a  unit  on  the  advisability 
of  obtaining  early  and  free  movements  of  the  bowels 
after  abdominal  operations,  and  the  treatment  is  of 
especial  value  if  there  is  any  suspicion  of  peritonitis. 
Dr.  A.  J.  McCosh,''  of  New  Vork  City,  is  so  convinced 
of  the  wisdom  of  the  above  that  he  has  adopted  a  radi- 
cally certain  method  of  obtaining  the  desired  result. 
Before  closing  the  abdomen  he  injects  an  ounce  or  so 
of  a  saturated  solution  of  Epsom  salts  directly  into 
the    intestine,  a    large   antitoxin   syringe  being  used. 


The  puncture  is  closed  with  a  Lembert  suture.  On 
recovering  from  the  anaesthetic  the  patient  is  further- 
more given  ten  grains  of  calomel. 

46  West  Thirtv-Third  Street. 

BIBLIOGRAPHY. 

1.  Alabama  Med.  and  Surg.  Age,  1S89,  478. 

2.  .\merican  Journal  Med.  Sciences,  v.  ciii. ,  664. 
2a.  Ibid.,  1S97  (May). 

3.  American  Practitioner  and  News,  v.  xviii.,  11. 

4.  .\nnal.  Soc.  Beige  de  Chir.,  1896,  185. 

5.  .Annal.  Soc.   Med.  d'Anvers,  1892-93,  189. 

6.  Annals  Gynaecol,  and  Pediatrics,  1894-95,  75. 

7.  Annals  of  Surgerj',  v.  ix. ,  92. 

8.  Ibid.,  V.  XX.,  41S. 

9.  Archiv.  de  Med.  et  Pharm.  Milit.,  1894,  141. 

10.  Archiv  f.  klin.  Chir.,  Bd.  49,  558. 

11.  Austral.  Med.  Gaz.,  v.  ix.,  33. 

12.  Ibid.,  V.  X.,  118,  1:9. 

13.  Berlin,  klin.  Wochensch. ,  1888,  292. 

14.  Ibid.,  1396,  765. 

15.  Bermingham  Med.  Review,  1893  (December). 

16.  Ibid.,  1893,  352. 

17.  Boston  City  Hospital  Reports,  1889. 

18.  Boston  Med.  and  Surg.  Jour.,  v.  cxiii.,  221. 

19.  Ibid.,  V.  c.xviii.,  246. 

20.  Ibid.,  V.  cxxi.,  485. 

21.  Ibid.,  1897,  No.  6. 

22.  Bristol  Med.  Chir.  Jour.,  1894,  6. 

23.  British  Med.  Jour.,  1889,  i. 

24.  Ibid.,  iSSg,  i.,  1,116. 

25.  Ibid..  1891.  ii.,  750. 
Ibid.,  1893,  ii.,  1,375. 
Ibid..  1894,  i.,  345. 
Ibid. ,  1894,  i.,  911. 
Ibid.,  1894,  ii.,  66. 
Ibid.,  1894,  ii.,  1,237. 
Ibid.,  1895,  i.,  410. 
Ibid.,  1895,  i.,  1,036. 
Ibid.,  1895,  ii.,  968. 
Ibid.,  1895,  ii.,  1,356. 
Ibid.,  1896,  ii.,  1,113. 
Ibid.,   1S97,  i.,  777. 
Brooklyn  Med.  Jour.,  1895,  529. 
Centralb.  f.  Chir.  ,1896,  542. 
Ibid..  1S96,  614. 

Chicago  Med.  Jour,  and  Examiner,  v.  Iviii.,  65. 
Deut.  med.  Wochensch.,  1892,  538. 
Ibid.,  1893,  373. 
Ibid.,  1S96,  515. 

Deut.  Zeitsch.  f.  Chir.,  1896,  Bd.  42  (i  and  2  Heft) 
Ibid.,  Bd.  39,  148. 
Gaz.  Med.  di  Lombard.,  1891,  145. 
Glasgow  Med.  Jour.,  i8g2,  276. 
Ibid. ,  V.  xliii. ,  302. 
Ibid.,  1S97,  28. 

Internation.   Med.  Mag.,  1895  (May). 
Indian  Med.  Gaz.,  1894,  297. 
Jour.  Amer.  Med.  Assoc,  v.  xxi. ,  156. 
Lancet  (London),  l888,  ii.,  20O,  262. 


26. 

27. 

28. 

29. 

30- 

31- 

32. 

33- 

34- 

35- 

36. 

37- 

38. 

39- 

40. 

41- 

42. 

43- 

44- 

44a. 

45- 

46. 

47- 

48. 

49. 

50. 

51- 

52. 

53- 

54- 

55- 

56. 

57- 

58. 

59- 

60. 

61. 

6la. 

62. 

63- 

64. 

65. 

66. 

67. 

68. 

69. 

70. 

71- 

72. 

73- 

74- 

75- 

76. 

77- 

78. 

79- 

80. 

81. 

82. 

83. 


Ibid., 
Ibid. 


Ibid 
Ibid 
Ibid. 
Ibid 
Ibid. 
Ibid 
Ibid 
Ibid 
Ibid. 


18S8,  ii.    . 

171. 

Ibid.,  1890,  ii.,  1,158. 
Ibid.,  l8gl,  i.,  1,312. 

i8g2  (January  9). 

1892,  ii..  714. 

1892,  ii.,  879. 

1892,  ii.,  1,155. 

i8g3,  i.  (June). 

I8g3,  ii.,  87g. 

i8g4,  i.,  345. 

i8g4,  i.,  468. 

1894,  i.,  473. 


Ibid.,  iS 


1.,  1,247. 


Ibid.,  1894,  ii. ,  797. 

Ibid.,   1895,  i.,  483. 

Ibid.,  i8g7,  i.,  427. 

Matthew's  Med.  Quart.,  1894,  73. 

Medical  News,  v.  Ivii.,  301. 

Medical  Record,  v.  x-xxvii. ,  113. 

Ibid.,  V.  xl.,  534. 

Ibid.,    1895,  i.,  457- 

Ibid.,  V.  xlix. ,  73. 

Ibid.,  V.  Ii.,  No.  11. 

Ibid.,  V.  Ii.,  469. 

Med.  Press  and  Circular,  1895  (June  I2> 

Ibid.,  1895,  ii.,  133- 

Middlesex  Hosp.  Reports,  1890,  97. 

New  York  Med.  Jour.,  v.  liii.,  434- 

Ibid.,  V.  l.xiii.,  387. 

Prag.  med.  Wochensch.,  1895,  199. 

Pittsburg  Med.  Re\-iew,  v.  v.,  161. 


I 


86 


MEDICAL    RECORD. 


[July  17,  1897 


Quart.  Med.  Jour.,  1896-97,  v.  107. 

St.  Bartholomew's  Hosp.  Reports,  v.  ,\.\viii. 

St.  Thomas'  Hosp.  Reports,  1892,  256. 

Schmidt's  Jahrb.,  1891. 

Southern  Med.  Record,  v.  .\xi. ,  281. 

Texas  Med.  News,  1696,  58. 

Trans.  Clin.  Soc,  London,  v.  xxiv. 

Ibid.,  V.  xxiv.,  too. 

Verhand.  deut.  Gesellsch.  f.  Chir.,  18 

Virginia  Med.  Monthly,  v.  xvi. ,  73. 

Wien.  klin.  Wochensch.,  1895,  98. 

Wien.  med.  Gesellschaft,  1891  (May). 

Unpublished. 


1895. 


HYSTERICAL   APHONIA. 


By   S.-^NGER   brown,    M.D., 


C.\GO, 


THE  NERVOUS  SYSTEM, 
-  MEDICAL  JUKISI'KUDE 
LEGE  ;  .\TTENDING  NEUROLOGIST,  ST.  EI.IZ.^BE 
NEUROLOGIST,  ST.  LUKE's  HOSPITAL  \  MEMBI 
SOCIETY,  LONDON,  ENG.;  NON-RESIDENT  I-El 
ACADEMY  OF  MEDICINE  ,'  FELLOW  OF  T 
CINE,    ETC. 


-GR.\DU.ATE  MEDICAL 
DENCE,  RUSH  IMEDICAL  COL- 
lBETH  hospital  ;  .ATTENDING 
IBER  OF  THE  neurological 
i-ELLOW  or  THE  NEW  YORK 
CHICAGO    ACADEMY     OF    MEDI- 


My  apology  for  calling  atention  to  a  mere  symptom  is 
that  hysteria  presents  such  an  endless  variety  of  symp- 
toms that  one  can  hardly  attempt  to  take  them  all  to- 
gether within  the  compass  of  one  short  paper.  I  in- 
vite attention  to  hysterical  aphonia  because,  while  it 
is  not  one  of  the  most  frequent  symptoms  of  hysteria, 
it  is  one  of  the  most  conspicuous  when  present,  and 
though  in  a  large  majority  of  the  cases  no  very  great 
difficulty  is  met  with  in  attempting  to  diagnose  it,  yet 
there  are  cases  which  have  baffled  the  general  practi- 
tioner successfully  for  a  number  of  years.  I  hope  I 
may  be  e.xcused  if  I  briefly  discuss  this  symptom 
somewhat  as  I  would  do  if  it  were  regarded  as  a  dis- 
ease, because  I  am  accustomed  to  discuss  medical 
topics  in  somewhat  of  a  stereotyped  way. 

Hysterical  aphonia  has  been  pretty  clearly  recog- 
nized and  described  for  a  century  at  least;  its  etiolog- 
ical conditions  are  practically  the  same,  of  course,  as 
are  those  of  the  disease  of  which  it  is  a  symptom, 
namely,  hysteria. 

In  quite  an  extensive  search  of  the  literature  of  the 
subject,  the  youngest  case  that  I  have  encountered  was 
one  occurring  in  a  girl  of  nine,  while  the  age  of  the 
oldest  was  that  of  a  woman  of  seventy-four  years. 

In  regard  to  the  symptomatology  and  etiology,  at 
least  two  fairly  distinct  types  are  found  ;  first  may  be 
considered  that  type  in  which  aphonia  is  merely  an 
accompaniment  of  many  other  pronounced  stigmata  of 
hysteria,  such  as  liysterical  pains,  hemiana>sthesia, 
vomiting,  etc.,  occurring  either  with  or  without  any 
apparent  exciting  cause.  In  such  cases  it  frequently 
happens  that  the  aphonia  is  not  entirely  pure;  that  is, 
for  hours  together,  when  the  other  symptoms  are  most 
complained  of,  the  patient  may  be  unable  to  raise  the 
voice  above  a  whisper,  but  in  the  intervals  may  be  able 
faintly  to  phonate  now  and  then  a  word  or  syllable. 
The  second  or  pure  form  of  aphonia,  however,  is  that 
in  which  this  symptom  occurs  suddenly  with  or  with- 
out an  e.xciting  cause,  continues  for  a  longer  or  shorter 
time,  and  constitutes  the  sole  evidence  of  hysteria. 

In  the  impure  type  the  aphonia  may  be  among  the 
first  symptoms  to  appear,  or  it  may  show  itself  only 
after  other  symptoms  have  been  present  for  weeks  or 
even  months.  It  may  commence  as  a  transient  hoarse- 
ness, worse  when  the  other  symptoms  are  worse,  or  as 
hoarseness  associated  with  an  ordinary  cold ;  finally, 
complete  or  almost  complete  aphonia  supervenes,  which 
may  last  from  several  days  to  several  weeks  or  even 
months. 

In  the  pure  type,  as  already  stated,  the  aphonia  usu- 
ally develops  suddenly,  with  or  without  exciting  cause. 
For  instance,  the  patient  conies  down  to  breakfast  in 
his  usual   health  and  spirits,  and   finds,  much  to  his 


surprise,  that  he  cannot  raise  his  voice  above  a  whis- 
per, or  very  rarely  he  may  be  entirely  mute;  or  the 
symptom  may  develop  suddenly  as  the  result  of  a  se- 
vere emotional  shock.  The  influence  of  an  emotional 
shock  will  vary  directly  with  the  susceptibility  of  the 
individual's  nervous  system  at  the  time  of  receiving 
the  shock.  This  point  is  of  the  utmost  importance  in 
estimating  the  influence  of  emotion  in  producing  dis- 
turbance of  any  function  of  the  nervous  system. 

Many  of  these  cases  recover  spontaneously  and  even 
suddenly  after  a  few  weeks  or  months,  with  or  w  ithout 
treatment;  others  remain  uninfluenced  by  treatment, 
the  symptom  persisting  steadily  for  years.  To  be 
sure  there  are  many  mixed  cases. 

A  great  many  methods  have  been  enthusiastically 
put  forward  .as  successful  in  the  treatment,  more 
especially  of  the  pure  types  above  referred  to,  but 
in  the  last  few  years  it  has  been  prett)'  clearly 
demonstrated  that  they  owed  their  success  entirely  to 
the  influence  of  the  suggestion  with  which  they  were 
accompanied;  and  in  my  opinion  any  method  depends 
for  its  success  upon  the  facility  which  it  affords  the 
patient  for  concentrating  his  efforts  upon  an  attempt 
to  phonate.  Hypnotism  has  been  successful  in  a 
number  of  instances,  but  not  more  so  than  the  various 
forms  of  electricity,  more  particularly  faradism,  ap- 
plied to  the  larynx,  sometimes  by  a  peculiarly  shaped 
electrode  applied  internally,  and  at  other  times  simply 
applied  externally 

A  method  advocated  by  Oliver  a  few  years  ago  at- 
tracted considerable  attention  and  became  known  as 
his  method,  and  has  given  excellent  results.  His  plan 
was  to  pinch  the  posterior  part  of  the  arytenoid  carti- 
lages between  the  thumb  and  index  finger,  and  thus 
produce  an  approximation  of  the  vocal  cords,  at  the 
same  time  vigorously  shaking  the  larj-nx  and  calling 
upon  the  patient  to  make  an  attempt  to  phonate,  assur- 
ing him  positively  of  his  ability  to  do  so.  At  first 
only  vowel  sounds  were  attempted,  and  gradually  the 
pressure  and  shaking  were  diminished,  until  the  patient 
was  able  to  phonate  without  assistance.  In  case  any 
particular  sound  was  not  satisfactorily  produced,  the 
pressure  and  shaking  were  reapplied. 

A  third  very  ingenious  and  successful  method  con- 
sists in  first  getting  the  patient  to  cough,  which  in 
nearly  every  case  can  be  accomplished;  having  done 
this,  then  have  him  cough  and  at  the  same  time  pro- 
nounce the  different  vowel  sounds,  and  thus  convince 
him  of  his  ability  to  phonate.  It  is  probable  that  in 
all  pure  cases  any  of  these  methods,  if  applied  with 
suitable  suggestion  on  the  part  of  the  operator,  would 
be  successful ;  but  in  the  cases  in  which  the  aphonia 
is  associated  with  other  marked  symptoms  of  hysteria, 
it  is  doubtful  if  complete  and  lasting  success  will  be 
attained  until  the  other  symptoms  have  in  a  great 
measure  subsided,  and  to  this  end  it  is  often  necessarj- 
to  improve  the  patient's  general  health. 

I  will  now  describe  some  cases  which  fairly  well 
illustrate  the  different  types  which  I  have  alluded  to 
above. 

As  representing  the  first  tyi>e,  I  will  quote  the  case 
of  a  policeman,  aged  forty,  of  good  habits,  robust  phy- 
sique; his  family  and  personal  history  are  good,  and 
he  could  not  fairly  be  regarded  as  a  man  of  ner\ous 
temperament.  Though  he  received  some  quite  severe 
flesh  wounds  in  the  Haymarket  riot,  in  the  main  his 
duties  have  not  been  severe,  neither  have  his  personal 
or  family  relations  been  of  such  a  nature  as  to  cause 
him  mucii  anxiety.  About  three  weeks  before  admis- 
sion to  the  hospital,  while  travelling  his  beat,  he  felt  a 
peculiar  sensation,  something  like  numbness  but  diffi- 
cult to  describe  to  his  satisfaction,  commence  in  the 
radial  side  of  the  hand,  extend  to  the  thumb  and  index 
finger,  and  thence  at  times  shoot  up  the  shoulder.  He 
continued  his  work  until  about  five  days  prior  to  ad- 


July  17,  1897] 


MEDICAL    RECORD. 


87 


mission,  when  he  suffered  frequent  paroxysms  of  severe 
pains  in  the  left  side  and  chest,  accompanied  by  nausea 
and  vomiting.  During  these  attacks  he  could  not 
speak  above  a  whisper,  and  during  the  intervals  he 
was  very  hoarse.  Finally,  when  admitted  he  was  pretty 
constantly  and  completely  aphonic,  though  occasion- 
ally a  syllable  would  be  faintly  phonated.  Movement 
of  the  legs  was  normal,  knee  jerks  were  very  lively 
indeed,  and  there  was  severe  general  jerk  of  the  body 
when  the  patellar  tendon  w-as  tapped;  vision  and  the 
visual  fields  were  normal,  but  there  was  complete 
absence  of  pain  reaction  to  pin  pricks  and  pinching 
over  the  entire  left  half  of  the  body,  including  the 
tongue,  gums,  and  inner  surface  of  the  cheeks,  while 
sensation  in  the  right  half  of  the  body  was  normal. 
Positively  assured  that  a  strong  current  of  faradism 
would  restore  his  voice  and  relieve  his  pain  and  vom- 
iting, after  the  first  application  he  phonated  clearly 
and  was  for  the  time  entirely  relieved  of  the  pains  in 
the  chest  and  nausea.  After  a  few  daily  applications 
he  said  he  felt  entirely  well,  with  the  e.xception  thai 
occasionally  he  had  slight  pain  through  the  chest  and 
still  a  little  numbness  in  the  radial  side  of  the  hand. 
He  returned  to  the  hospital  several  times  for  treatment 
after  resuming  his  duties,  but  in  the  course  of  two  or 
three  weeks  from  his  admission  he  had  entirely  recov- 
ered. This,  then,  was  a  case  of  an  impure  hysterical 
aphonia  occurring  in  connection  with  other  well- 
marked  symptoms  of  hysteria,  without  any  apparent 
e.xciting  cause. 

The  ne.\t  case  is  that  of  a  woman,  thirty-one  years 
of  age,  the  wife  of  a  professional  man.  She  has  had 
one  healthy  child,  has  correct  habits,  a  good  family 
history,  and  had  always  enjoyed  excellent  health  up  to 
two  years  ago,  when  a  railway  train  upon  which  she 
was  a  passenger  ran  into  a  culvert  while  going  at  a 
high  rate  of  speed,  and  was  stopped  so  suddenly  that 
all  the  seats  were  torn  loose  and  bunched  in  the  for- 
ward end  of  the  car.  The  patient  was  quite  severely 
bruised  on  the  posterior  aspect  of  the  left  hip  and 
thigh,  and  received  several  slighter  bruises  on  various 
parts  of  her  person.  No  one  was  killed,  or  in  fact 
more  severely  injured  than  herself,  so  the  mental  shock 
was  only  such  as  was  incident  to  the  sudden  confusion 
and  temporary  anxiety  for  the  welfare  of  her  child, 
who  was  with  her  but  sustained  no  injury.  Almost 
immediately  after  getting  out  of  the  car  she  felt  weak 
and  dizzy,  and  vomited.  The  accident  occurred  at 
about  I  P.M.,  and  a  few  hours  later  she  again  boarded 
a  train  without  assistance  and  rode  several  hours  till 
■she  reached  her  destination.  She  had  in  the  mean 
time  suffered  intense  and  increasing  pain  in  the  legs, 
and  had  been  able  to  walk  only  by  putting  forth  a 
great  effort.  She  slept  several  hours  after  a  full  dose 
of  morphine,  but  when  she  awoke  the  pain  in  her  legs 
Avas  as  severe  as  ever;  she  felt  greatly  prostrated,  was 
unable  to  stand  both  on  account  of  pain  and  weakness 
in  the  legs,  and  was  unable  to  speak  above  a  whisper. 
She  continued  in  this  condition  for  two  weeks,  when 
she  was  seized  with  severe  hysterical  convulsions  last- 
ing several  hours,  with  unconsciousness  and  opistliot- 
onos.  It  was  six  months  before  she  could  walk  with- 
out support,  and  about  six  weeks  before  she  spoke 
above  a  whisper.  Her  recovery  from  aphonia  was  not 
then  sudden  and  complete;  at  first  only  a  word  or  syl- 
lable was  phonated,  the  remainder  of  her  speech  being 
whispered;  then  she  gradually  improved  so  that  her 
voice  only  sank  to  a  partial  or  complete  whisper  when 
she  was  tired.  She  had  suffered  many  attacks  of 
complete  or  partial  aphonia,  always  associated  with 
pain  and  weakness  in  the  legs,  and  lasting  from  a  few 
days  to  a  few  weeks,  between  the  date  of  the  accident 
and  my  examination  several  months  ago.  .\t  that  time 
■she  hid  been  suffering  several  days  from  an  exacerba- 
tion of  symptoms  like  those  already  described,  which 


she  thought  had  been  brought  on  by  overwork  and 
taking  cold.  For  several  weeks  previous  to  this 
exacerbation  she  had  been  better  than  at  any  other 
time  since  the  accident,  was  comparatively  free  from 
pain,  could  walk  alone  in  the  street,  and  her  voice  was 
comparatively  clear  and  strong. 

\\'hen  examined  she  was  in  bed,  complaining  of  pain 
in  the  legs,  back,  and  head:  of  vertigo  and  nausea  on 
movement,  and  inability  to  walk.  She  conversed 
entirely  in  whispers  at  first,  but  later,  when  her  interest 
became  aroused,  now  and  then  a  word  or  two  were 
phonated  weakly  and  hoarsely.  She  said  she  felt  no 
pain,  and  showed  no  signs  of  feeling  any  when  pricked 
with  a  pin  ever  so  deeply  or  pinched  in  any  part  of 
her  body.  The  field  of  vision  for  white  was  reduced 
to  the  fixation  point.  The  knee  jerks  were  very  lively, 
and  when  the  tendon  was  tapped  the  whole  body  re- 
sponded with  a  violent  jerk.  The  body  was  well 
formed  and  well  nourished,  loss  of  appetite  and  nausea 
notwithstanding.  In  bed  the  arms  and  legs  could  be 
moved  voluntarily  in  any  direction,  though  she  declared 
she  was  entirely  unable  to  walk,  both  on  account  of 
pain  and  weakness.  I  saw  this  patient  only  once  and 
then  in  consultation,  and  cannot  say  anything  regard- 
ing the  results  of  treatment,  but  it  illustrates  a  type  in 
which  an  impure  form  of  aphonia  is  associated  with 
very  marked  symptoms  of  hysteria  developed  by  an  ex- 
citing cause. 

The  next  case  may  be  regarded  as  illustrating  the 
most  common  type  of  pure  hysterical  aphonia,  not 
associated  with  any  other  hysterical    stigmata.      Miss 

A.  A ,  aged  twenty-nine,  attendant  in  hospital  for 

insane;  nervous  temperament,  very  competent,  good 
general  health.  She  had  been  employed  several 
months  in  convalescent  ward,  and  was  not  under  a 
strain  of  any  kind,  when  on  rising  one  morning  after 
sleeping  well  and  feeling  in  her  usual  health,  she  found 
she  could  only  whisper.  She  declined  treatment  and 
the  attack  lasted  five  weeks  without  mitigation,  when 
it  suddenly  and  permanently  disappeared,  the  patient 
having  attended  to  her  work  as  usual  in  the  mean  time 
and  remained  in  her  good  general  health.  She  had 
previously  suffered  two  similar  attacks  at  intervals  of 
several  years,  from  which  she  had  recovered  spontane- 
ously, and  for  which  she  could  assign  no  cause. 

The  ne.xt  case  is  that  of  a  young  man,  aged  twenty, 
farmer's  son,  intelligent,  industrious,  of  correct  habits, 
fond  of  company,  and  not  notably  nervous.  His  family 
history  is  good,  and  he  has  always  enjoyed  excellent 
health,  rarely  having  even  a  cold.  When  he  was  eleven 
years  of  age  his  father  called  him  as  usual  one  morn- 
ing to  rise,  but  for  some  reason  he  went  to  sleep  again, 
so  that  his  father  called  him  a  second  time,  speaking 
somewhat  sharply.  From  that  moment  until  he  entered 
my  office,  nine  years  later,  according  to  his  own  testi- 
mony and  that  of  his  family  and  numerous  friends  and 
acquaintances,  he  had  never  uttered  a  sound  of  any 
kind:  in  fact,  had  been  absolutely  mute.  His  play- 
mates, when  he  was  still  a  child,  would  thrown  him 
down  and  tickle  him,  trying  to  make  him  laugh:  his 
face  on  such  occasions  would  undergo  the  usual  con- 
tortions, but  no  sound  was  emitted.  On  still  more 
careful  inquiry,  it  appears  that  occasionally  a  very 
slight  sound  had  been  emitted  when  he  was  in  the  act 
of  clearing  his  throat,  but  so  far  as  I  could  learn  he 
had  never  been  heard  to  cough  so  that  he  could  be 
heard  more  than  a  few  feet  distant,  and  some  members 
of  the  family  in  which  he  had  lived  for  years  were 
positive  that  they  never  heard  him  utter  a  sound  of 
any  kind;  his  communications  were  all  made  by  writ- 
ing. His  hearing  was  quite  acute.  Movement,  the 
reflexes,  the  visual  fields,  vision,  and  sensation  were 
all  entirely  normal. 

I  had  a  larj-ngoscopic  examination  made  by  my  dis- 
tinguished  colleague,  Prof.   E.   Fletcher   Ingals,  who 


88 


MEDICAL    RECORD. 


[July  17.  1897 


succeeded  in  getting  a  satisfactory  view  of  the  vocal 
cords  only  after  the  use  of  cocaine;  they  were  found 
to  be  normal  in  every  respect,  and  in  making  the 
manipulations  necessary  to  secure  a  satisfactory  exam- 
ination the  patient  coughed  slightly.  After  thoroughly 
arousing  his  interest  and  attention  by  a  rather  minute 
and  spirited  dissertation  upon  the  mechanism  of 
speech  (which  of  course  he  could  not  comprehend,  but 
which  convinced  him  none  the  less  of  my  great  skill), 
I  assured  him,  with  as  much  dramatic  force  as  I  was 
able  to  assume,  that  I  could  cure  him  entirely  by  the 
use  of  electricitj-,  and  very  speedily  too.  I  then  pro- 
ceeded to  apply  a  strong  faradic  current  to  the  larj-nx, 
only  for  a  few  moments,  by  placing  a  disc-shaped 
electrode,  about  one  and  one-half  inches  in  diameter, 
on  each  side  of  the  organ,  assuring  him  beforehand 
that  after  I  had  done  this  he  could  phonate  the  vowel 
sounds,  and  that  as  these  were  the  basis  of  articulate 
speech,  it  would  be  necessar)'  for  him  to  learn  to  pho- 
nate them  first  in  regaining  his  ability  to  speak.  Im- 
mediately after  this  procedure  he  was  able  to  phonate 
the  vowel  sound  "e"  after  me;  to  be  sure  it  was  very 
weak,  nevertheless  distinct:  whereupon  I  terminated 
th&siancf,  assuring  him  that  the  victory  had  been  won. 
After  this  I  gave  him  a  daily  treatment,  and  the  prog- 
ress was  ver}'  rapid.  He  was  soon  convinced  that  if 
he  said  "e"  he  could  say  "eat,"  and  if  he  said  "o" 
he  could  say  "go,"  and  so  on;  in  less  than  a  week  he 
could  carr)-  on  ordinar)'  conversation  in  rather  a  low 
tone  of  voice.  He  was  then  assured  that  in  the  course 
of  a  week  more  his  voice  would  gradually  strengthen 
until  it  would  finally  be  as  strong  as  that  of  the  ordi- 
nar)' individual,  and  this  he  found  to  be  the  case.  This 
was  six  months  ago,  and  he  has  continued  well  ever 
since. 

This  case  deser\'es  some  comment  on  account  of  the 
youth  and  sex,  perhaps,  of  the  individual  in  whom  it 
occurred,  but  more  particularly  on  account  of  nine 
years'  duration  of  unbroken  mutism.  He  had  seen  a 
great  many  practitioners,  none  of  whom,  so  far  as  I  can 
learn,  had  made  a  correct  diagnosis,  probably  because 
it  was  so  difficult  to  get  a  satisfactory  view  of  the  vocal 
cords,  and  after  the  case  had  lasted  two  or  three  years 
without  interruption  a  practitioner  might  naturally 
assume  that  it  was  not  one  of  hysterical  aphonia:  but 
really,  with  the  historj-  of  the  onset  that  I  was  able  to 
get,  the  excellent  state  of  general  health  ever  since, 
and  es'pecially  when  the  vocal  cords  were  found  to  be 
entirely  normal,  there  was  no  difficult}'  in  making  the 
diagnosis. 

A  somewhat  careful  examination  of  the  literature 
has  not  enabled  me  to  find  a  case  that  was  anything 
nearly  parallel  to  this  in  point  of  degree  or  duration.  I 
found  several  cases  of  hysterical  mutism  which  had 
lasted  for  several  weeks,  and  one — that  of  a  young 
woman  of  twent)' — which  had  begun  as  simple  aphonia 
and  continued  as  such  for  several  months,  when  it 
lapsed  into  a  condition  of  mutism  likewise  lasting 
several  months,  and  which  finally  recovered  by  sug- 
gestive treatment.  In  my  opinion  the  efficacy  of  the 
treatment  in  my  case  was  due  entirely  to  suggestion. 

The  pathology  of  the  disorder  is,  of  course,  the  same 
as  that  of  the  other  manifestations  of  hysteria.  It  is 
hypothetical,  but  most  pathologists  are  substantially 
agreed  upon  the  hypothesis,  which  is  this:  The  parts 
of  the  cerebral  cortex  which  normally  preside  over  the 
various  disordered  functions  become  inactive,  to  the 
extent  that  they  no  longer  respond  to  the  behests  of 
the  will  as  before;  accordingly  in  aphonia  the  cortical 
centres  from  which  in  health  the  motor  impulse  pro- 
ceeds to  the  muscles  concerned  in  phonation  are  no 
longer  excited  to  activity  by  the  volition  of  the  patient. 

Within  the  last  year  or  two  Lepine  and  Duval — each 
claims  priority  by  several  months — have  elaborated  a 
hypothesis  to  the  eflFect  that  neurons,  when  in  a  state 


of  functional  activity  or  potential  it)',  are  expanded  so 
as  to  be  in  physiological  contact  with  such  other  neu- 
rons as  properly  participate  in  any  particular  function. 
During  rational  sleep  or  hysterical  paralysis  they  are 
contracted,  and  physiological  contact  is  broken.  This 
theor)'  assumes  that  the  neurons,  which  are  in  fact 
protoplasmic  cells,  undergo  amceboid  movements,  and 
experiments  have  been  made  upon  frogs  which  appear 
to  demon.strate  the  possibility  of  such  movements  on 
the  part  of  neurons. 

The  eff'ect  of  suggestion  in  the  treatment  of  hysteria 
according  to  this  theory  might  be  rationally  accounted 
for  by  assuming  that  it  enabled  the  patient  to  e.xert  an 
extraordinary  amount  of  will  power,  resulting  in  the 
necessary  expansion  and  contact  of  the  neurons  con- 
cerned. 

-,4  Washington  Srr^n-:, 


progress  of  3j^edical  J'Clencc. 

Skiagraphing  the  Arteries.  —  At  a  recent  meeting 
of  the  Pathological  Society  of  Manchester,  Dr.  Raw- 
explained  to  the  society  a  method  he  had  adopted  for 
skiagraphing  the  arteries.  He  said  that,  when  trying 
to  examine  a  fracture  which  was  enveloped  in  a  thin 
layer  of  plaster  of  Paris,  he  found  it  quite  opaque  to 
A'- rays.  The  idea  then  occurred  to  him  that  the  ves- 
sels (arteries)  might  be  reproduced  in  the  skiagraph 
by  injecting  them  with  a  somewhat  similar  substance. 
Accordingly,  when  the  ne.xt  opportunity  occurred,  he 
injected  post  mortem  a  solution  of  calcium  sulphate 
and  carmine  into  the  femoral  arter)'  and  then  took 
skiagraphs  of  diff^erent  parts  of  the  body.  He  illus- 
trated his  remarks  by  exhibiting  several  pictures  show- 
ing the  arteries  perfectly,  even  to  the  most  minute 
anastomoses.  In  fact,  so  opaque  was  the  substance  that 
the  arteries  actually  showed  through  the  bones.  Dr. 
Raw  also  exhibited  a  twent)'-four  by  eighteen  inch 
bromide  print  of  a  child,  showing  all  the  arteries  of 
the  body  injected. 

Recovery  from  a  Large  Dose  of    Silver  Nitrate. 

— At  a  recent  meeting  of  the  Leeds  and  West  Riding 
Medico-Chirurgical  Society,  Drury  {^Lana-f,  May  15, 
1897)  related  that  while  pencilling  the  throat  with  a 
stick  of  silver  nitrate  in  the  course  of  an  attack  of  ton- 
sillitis, the  stick  became  detached  and  slipped  into  the 
oesophagus.  There  were  localized  pain  in  the  gastric 
region  and  a  strong  conviction  that  death  must  soon 
follow.  Immediately  a  frothy  foam  welled  up  in  large 
quantities,  forcing  its  way  through  the  mouth  and  nos- 
trils, staining  handkerchiefs  and  the  bed  linen.  There 
was  an  irresistible  feeling  that  the  pencil  was  lying 
impacted  in  the  gullet.  I'pon  the  urgent  request  of 
the  patient  a  probang  was  passed.  Mustard  was 
given  in  large  quantities  and  vomiting  induced. 
Some  time  aftenvard  common  salt  was  given.  Care- 
ful search  in  the  vomited  matter  failed  to  disclose  the 
presence  of  any  of  the  pencil  that  might  have  remained 
undissolved.  Collapse  and  great  exhaustion  fol- 
low'ed.  For  some  days  a  milk  diet  was  rigidly  ob 
served.  All  food,  especially  if  sweetened,  had  a  salty 
taste.  There  was  no  further  vomiting,  but  constipa- 
tion was  pronounced.  The  temperature  became  sub- 
normal and  the  earlier  symptoms  disappeared.  Dur- 
ing the  following  two  weeks  there  was  well-marked 
desquamation  over  the  whole  of  the  skin.  In  the  sub- 
sequent twelve  months  there  were  many  indications  of 
dyspepsia,  but  some  of  these  had  been  present  in  a 
milder  degree  previously.  The  pencil  was  composed 
of  four  per  cent,  of  potassium  nitrate  and  the  remain- 
der silver  nitrate,  'rhere  was  little  fluid  or  food  pres- 
ent in  the  stomach  at  the  time  of  the  accident. 


July  17,  1897] 


MEDICAL    RECORD. 


89 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Sttrgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 

WM.  WOOD  &  CO.,   43,  45,  &  47  East  Tenth  Street. 


New  York,  July  17,  1897. 


PTOMAIN    POISONING. 

The  recent  wholesale  poisoning  from  the  eating  of 
ham  sandwiches  at  a  picnic  in  Wappinger's  Falls 
calls  attention  to  a  source  of  danger  in  similar  gath- 
erings which  should  not  be  lightly  considered.  .Al- 
though it  is  currently  reported  that  the  cause  of  the 
trouble  was  the  creation  of  soluble  salts  of  copper,  due 
to  the  use  of  an  unclean  copper  vessel  in  which  the 
ham  had  been  cooked,  it  is  nevertheless  quite  evident 
that  ptomain  poisoning  was  at  the  bottom  of  the  trou- 
ble. It  may  sound  strangely  to  such  as  have  not  given 
the  subject  serious  attention  to  say  that  copper  uten- 
sils are  not  specially  dangerous  for  culinary  purposes, 
but  such  we  believe  to  be  the  fact.  For  ages  this  par- 
ticular metal  has  been  used  without  markedly  detri- 
mental results,  and  many  authorities  have  gone  so  far 
as  to  maintain  that  as  yet  no  well-authenticated  cases 
of  copper  poisoning  have  been  recorded.  "  It  is  a 
curious  fact,"  says  Professor  Brouardel,  of  Paris,  in 
his  interesting  and  instructive  book  on  Death  and 
Sudden  Death,"  '  "that  this  idea  of  poisoning  by  cop- 
per owes  its  origin  to  Jean  Jacques  Rousseau.  You 
know  how  fashionable  his  ideas  were  for  a  certain 
period ;  you  know  the  infatuation  they  created.  It  is 
not  very  wonderful,  therefore,  that  the  opinions  he 
professed  on  the  injuriousness  of  copper  should  have 
gained  acceptance.  Nevertheless,  it  has  not  been  for- 
gotten that  the  ancients  did  their  cooking  in  copper 
vessels.  The  tinning  of  copper  saucepans  was  only 
introduced,  into  the  west  of  Europe  at  any  rate,  by  the 
gypsies,  who  were  the  first  to  line  the  interior  of  cop- 
per vessels  with  tin  more  or  less  pure.  Lastly,  at  all 
times  and  even  to-day,  certain  culinary  preparations 
are  made  only  in  untinned  pans.  Such  is  the  case 
with  preser\'es,  which  have  never  poisoned  anybody 
yet,  and  yet  which  are  capable — for  example,  when 
preserves  of  currants  are  made — of  producing  soluble 
salts  of  copper.  We  know  now  that  copper  utensils 
are  quite  harmless,  so  long  as  they  are  kept  in  good 
order."  From  these  facts  we  are  led  to  infer  that  the 
alleged  cause  of  the  food  poisoning  in  the  Wappin- 
ger's Falls  outing  was  in  all  probability  founded  more 
on  popular  belief  than  on  scientific  fact. 

On  the  other  hand,  cases  of  ptomain  poisoning  from 

'  "  Death  and  Sudden   Death,"  by  P.    Brouardel.    New  York, 
Wm.  Wood  ic  Co.,  1S97. 


tainted  foud  ingredi^its  are  very  common.  The  nu- 
merous instances  of  severe  prostration,  vomiting,  and 
high  temperature  after  partaking  of  picnic  ice  cream 
are  instances  of  this  sort.  It  is  much  easier  to  under- 
stand that  the  ham,  either  before  or  after  it  had  been 
cooked,  might  have  become  partially  decomposed  dur- 
ing the  preparation  into  sandwiches,  than  that  the 
copper  kettle  should  have  been  the  leading  factor  in 
producing  the  results.  Then,  again,  it  is  not  positively 
stated  that  all  the  meat  was  cooked  in  the  same  vessel ; 
neither,  so  far  as  can  be  learned,  was  the  presence  of 
copper  salts  demonstrated  in  the  food  product  or  in 
the  vomited  materials  of  the  patients. 

It  is  well  known  that  under  certain  conditions  of 
high  temperature,  increased  humidity,  and  disturbed 
electrical  tension  albuminoid  foods  are  apt  to  take  on 
rapid  chemical  changes,  resulting  in  the  production  of 
numerous  well-demonstrated  cadaveric  alkaloids.  It 
is  not  necessary  that  disagreeable  odors  should  be 
evolved  in  all  cases  to  verify  the  existence  of  such 
changes,  neither  is  the  presence  of  the  latter  always 
manifested  by  the  sense  of  taste.  Another  fact  of  great 
importance  is  the  transitory  and  volatile  character  of 
different  ptomains  during  different  stages  of  decompo- 
sition. The  same  meat  which  may  poison  one  day 
may  be  relatively  harmless  the  next.  A  verj-  interest- 
ing verification  of  this  fact  is  given  by  the  same  au- 
thor, Brouardel:  "Two  pork  butchers  (in  Lille)  had 
purchased  a  pig,  but  whereas  the  customers  of  one  all 
fell  ill  after  eating  sausages  made  of  the  flesh  of  one- 
half  of  the  carcass,  the  customers  of  the  other  remained 
absolutely  free  from  anything  of  the  sort.  It  could 
not,  therefore,  be  the  previous  condition  of  the  pig 
that  was  to  blame;  the  shop,  the  stall,  and  the  work- 
shop of  the  butcher  were  clean  and  in  good  order.  It 
was  necessary  to  search  farther.  The  pig  had  been 
killed  on  a  Friday,  a  day  on  which  pork-butchers'  shops 
are  closed  in  Lille.  The  meat  had  been  exposed  for 
sale  on  Saturday,  May  19th,  and  Sunday,  May  20th, 
and  none  of  the  buyers  suffered  at  all.  Those,  how- 
ever, who  bought  sausages  on  Monday  and  Tuesday 
(May  2ist  and  2 2d)  were  all  taken  ill,  and  four  of 
them  died.  The  law  interfered  and  the  sausage  meat 
was  withdrawn  from  sale  on  the  Wednesday.  On  that 
day  and  the  day  following,  the  pork  butcher,  not  wish- 
ing to  lose  his  goods,  fed  himself  and  his  household 
on  the  remains  of  the  pork,  and  no  mishap  followed." 
Certainly  these  are  significant  facts  as  bearing  on  the 
probable  cause  of  poisoning  in  Wappinger's  Falls. 


CYCLING    FROM    THE     STANDPOINT    OF 
HEALTH. 

Another  note  of  warning  has  been  sounded  in  regard 
to  the  possible  evils  of  cycling.  Under  the  some- 
what ambiguous  title  of  "The  Hidden  Dangers  of  Cy- 
cling," an  alarmist  article  recently  appeared  in  the 
National  Revien\  pointing  out  some  of  the  risks  of  in- 
jury to  health  to  which  bicyclists  are  liable,  and  darkly 
hinting  at  others  likely  to  be  incurred.  The  chief 
novelt)'  of  the  article  lies,  however,  in  its  suggestion 
as  to  cause.     The  author.  Dr.  Shadwell,  has  written 


90 


MEDICAL   RECORD. 


[July  1  7,  1897 


on  the  subject  at  various  times,  so  that  his  views  carry 
a  certain  amount  of  weight.  To  him  also  belongs  the 
distinction  of  originating  the  term  "  bicycle  face," 
which  has  been  so  generally  adopted  to  express  the 
anxious,  strained  look  many  bicyclists  wear.  The 
hidden  dangers  of  the  exercise,  in  the  opinion  of  Dr. 
Shadwell,  threaten  women,  and  more  particularly 
young  women,  and  the  prediction  is  made  that  in  the 
course  of  a  year  or  two  quite  a  different  story  will  be 
heard  concerning  the  health-giving  properties  of  cy- 
cling. Dr.  Shadwell  says:  "Sufficient  time  has  not 
elapsed  since  it  became  a  general  practice  to  bring  the 
disadvantages  to  light — to  the  light,  that  is  to  say,  of 
public  recognition.  Medical  men  have  been  kept 
studiously  in  the  dark  on  the  subject.  They  always 
are  in  like  cases.  The  successes  are  blazoned  forth, 
the  failures  concealed.  So  with  bicycling.  The  for- 
tunate persons  who  have  derived  benefit  as  well  as 
pleasure  from  it  volubly  recount  their  experiences  to 
the  largest  audience  they  can  command,  and  the  chorus 
of  praise  waxes  louder  by  reiteration.  Those  who 
have  suffered  conceal  the  fact  as  far  as  possible,  and 
especially  from  the  doctor,  for  fear  of  being  forbidden 
their  beloved  '  bikes.'  That  is  noticeably  the  habit  of 
young  women,  who  are  the  chief  sufferers." 

A  few  cases  of  serious  breakdown  that  came  under 
the  author's  notice  are  cited,  one  of  a  girl  who  devel- 
oped exophthalmic  goitre  as  the  result  of  a  long  ride, 
and  which  became  chronic.  Appendicitis  and  internal 
inflammation  are  also  laid  to  the  charge  of  the  wheel. 
But  the  complaints  to  which  the  writer  in  the  JVatiofial 
Reiikw  chiefly  wishes  to  draw  attention  are  the  va- 
rious forms  of  ill-defined  nervous  effects  resulting  from 
even  a  moderate  use  of  the  bicycle.  The  contention 
is  made  that  the  harmfulness  of  the  exercise  does  not 
consist  so  much  in  excess  as  in  the  strain  on  the  ner- 
vous system.  The  proposition  is  laid  down  that  over- 
exertion is  quite  inadequate  to  explain  the  effects  from 
which  many  cyclists  suffer.  The  symptoms  are  essen- 
tially nervous,  and  point  to  a  cerebral  and  not  a  mus- 
cular origin.  The  theory  brought  forward  as  to  the 
cause  is  not  the  saddle,  the  vibration,  or  mechanical 
defects  of  the  machine,  but  its  instability  and  the  con- 
stant strain  required  to  keep  it  in  an  upright  position. 
Dr.  Shadwell  holds  that  this  incessant  tension  is  that 
which  tells  upon  the  nerves. 

The  arguments  introduced  in  this  article  are  not 
sufficiently  definite,  how'ever,  to  be  of  use  in  drawing 
any  conclusions.  Taking  into  consideration  the  im- 
mense number  of  persons  who  nowadays  ride  a  wheel, 
it  would  be  remarkable  if  among  the  number  there 
were  not  some  whom  cycling  did  not  suit  and  some 
to  whom  it  was  decidedly  harmful.  Unless  statistics 
can  be  given  clearly  showing  that  to  a  fair  proportion 
of  riders  the  exercise  is  pernicious,  a  vague  statement 
of  hidden  dangers  will  deter  but  few.  That  the  ner- 
vous system  is  affected  by  the  exercise  is  perfectly 
true,  but  here  again  the  question  of  constitution  and 
temperament  comes  in.  Some  can  ride  and  experi- 
ence no  ner\-e  trouble,  some  suffer  slightly,  while  there 
are  others  to  whom  continued  riding  means  a  complete 
shattering  of  the  nervous  system.  The  anticycling 
idiosyncrasy  does  exist,  but  those    with  whom   it   is 


present  must  be  aware  of  it,  and  if  wise  will  use  corre- 
sponding caution.  The  question  of  harm  resulting 
from  nervous  tension  has  been  greatly  exaggerated; 
cases  of  complete  or  even  partial  breakdown  from  this 
cause  are  comparatively  rare,  probably  fewer  than  in 
the  old  cycling  days.  In  bicycles  as  they  are  made 
now,  with  better  saddle  springs  and  the  pneumatic  tire, 
vibration  has  been  reduced  to  a  minimum  and  the 
tremulousness  that  used  to  exist  after  riding  one  of  the 
earlier  machines  has  practically  ceased  to  occur.  It 
should  not  be  forgotten  that  the  effect  of  bicycle  exer- 
cise on  health  has  already  been  ver}-  fairly  tested  as 
regards  men.  In  England  cycling  has  been  in  vogue 
for  twenty-five  years;  ten  years  ago  there  were  thou- 
sands of  riders  in  that  countrj-,  and  if  the  conse- 
quences had  been  as  disastrous  as  its  opponents  en- 
deavor to  prove  they  must  be,  the  truth  would  have 
been  brought  to  light  ere  this. 

Various  theories  have  been  advanced  to  account  for 
cycling  affecting  the  ner\-ous  system  in  the  way  it 
does,  but  none  of  these  explanations  is  quite  satisfac- 
tory. That  it  lies  wholly  in  the  action  of  balancing  is 
certainly  not  the  case.  Naturally  with  an  unpractised 
rider  the  effort  to  keep  in  an  upright  position  will 
produce  considerable  nerve  tension;  on  the  other 
hand,  to  the  expert  balancing  has  become  as  automatic 
an  action  as  walking  'or  running,  and  the  strain  will 
be  infinitesimal.  Riding  in  crowded  streets,  on  a 
rough  road,  down  a  steep  hill,  or  under  any  circum- 
stances when  the  senses  of  sight,  touch,  and  hearing 
must  be  continually  on  the  alert,  would  seem  more 
likely  to  have  a  harmful  eff'ect  than  the  act  of  keeping 
the  equilibrium  to  one  who  is  a  master  of  the  machine. 
Cycling  with  women  has  not  yet  received  the  test  it 
has  undergone  with  men,  but  the  time  has  been  long 
enough  to  prove  that  on  the  whole  the  exercise  is 
decidedly  good  for  them,  and  the  bogy  of  hidden  dan- 
gers need  spread  no  alarm  among  their  ranks.  A 
woman  organically  sound  can,  under  proper  conditions 
and  using  ordinarj'  precautions,  cycle  with  as  little 
dread  of  bad  results  as  a  man,  and  so  long  as  she 
keeps  strictly  within  the  limits  of  her  endurance,  for 
pleasure  and  health  and  not  for  emulation,  will  cer- 
tainly benefit.  Long  rides  and  centurj-  runs  can  do  no 
good  and  probably  may  do  harm.  Hill  climbing 
should  be  avoided  as  much  as  possible,  as  it  puts  too 
great  a  stress  on  the  large  abdominal  muscles,  and  a 
woman,  with  her  physiological  peculiarities,  should  not 
submit  herself  to  an  undue  strain.  In  the  case  of 
ancemic  girls  cycling  usually  acts  like  a  charm.  The 
general  tonic  etTect  of  an  outdoor  life  and  the  change 
of  thought  and  scene  have  an  invigorating  action  on 
the  entire  system,  and  all  the  organs  of  the  body  par- 
ticipate in  this  beneficial  result. 

The  fact  that  there  are  dangers  connected  with  cy- 
cling cannot  be  denied;  these,  however,  are  not  hid- 
den ones,  but  are  more  or  less  palpable  to  everj'  ob- 
server. It  may  be  said  that  there  is  danger  in  teach-  . 
ing  the  practice  to  the  quite  young.  Properly  cycling 
should  not  be  carried  on  to  any  extent  while  the  body 
is  undergoing  development.  .\nv  valvular  disease 
should  be  an  absolute  bar  to  cycling,  as  the  heart  is 
the  organ  principally  exercised.     Acute  inflammation 


July  17,  1897] 


MEDICAL   RECORD. 


91 


of  the  genital  organs  should  forbid  the  use  of  the  ma- 
chine to  women,  although  the  exercise  is  often  benefi- 
cial in  chronic  cases  of  uterine  disease.  The  question 
finally  resolves  itself  into  one  of  moderation  or  excess, 
and  the  personal  equation  in  this  respect  is  variable. 
A  healthy  man  may  be  able  to  do  one  hundred  or  one 
hundred  and  fifty  miles  without  exerting  himself, 
while  another  to  all  appearances  equally  healthy 
should  not  do  more  than  forty  or  fifty.  Cyclists  are 
too  apt  to  be  carried  away  by  the  spirit  of  emulation, 
and  when  they  do  so  with  riders  of  a  superior  capacity 
they  must  expect  to  suffer.  Each  cyclist  should  be  a 
judge  of  his  or  her  own  capacity. 


THE    DOCTORS    PUZZLED, 

No  headlines  to  a  column  in  the  daily  newspapers 
describing  a  rare  disease,  a  complicated  operation,  a 
girl  with  scleroderma,  or  a  boy  with  hiccough,  is 
complete  without  the  large-type  announcement  that 
the  doctors  were  perplexed  and  all  at  sea.  This 
must  delight  the  reader  or  the  reporter  would  not  put 
it  in.  He  knows  nine  times  out  of  ten  that  the  physi- 
cians understood  the  case  perfectly,  and  that  there  was 
nothing  very  puzzling  about  it.  Indeed  it  almost  al- 
ways happens  that  in  the  interview  with  the  chief 
physician,  which  comes  at  the  end  of  the  story,  it  is 
shown  that  he  has  frequently  seen  such  cases  and 
knows  all  about  them.  Now  it  is  not  pleasant  for  a 
physician  to  read  every  day  in  his  morning  journal 
that  his  colleagues  are  being  "  puzzled"  over  some- 
thing or  other.  It  is  a  reflection  which  he  mentally 
resents.  Lawyers  and  ministers  don't  get  puzzled. 
.\t  least  the  papers  never  say  they  do.  It  is  clearly 
the  duty  of  the  physician  interviewed,  in  the  interest 
of  the  profession  at  large,  to  make  it  a  sine  qua  turn 
that  if  his  views  are  published  there  shall  be  no  cap- 
tion indicating  that  he  himself  or  any  others  connected 
with  the  case  were  puzzled. 


A    CRAZY    WORLD. 

If  the  crazy  Diogenes  were  alive  to-day,  he  might  well 
light  his  lantern  and  set  out  in  quest,  not  of  an  honest 
man,  but  of  a  sane  one;  and  if  we  may  believe  all  who 
venture  to  pronounce  upon  the  subject,  his  search 
would  be  a  laborious  one  indeed.  We  all  know,  of 
course,  for  the  masters  have  told  us,  that  most  great 
geniuses  are  insane;  and  the  great  geniuses,  if  ques- 
tioned, would  not  hesitate  to  tell  us  that  the  inappre- 
ciative  vulgar  herd  is  mentally  incapable  of  compre- 
hending their  sublime  flights.  Nordau  has  proven 
beyond  question,  to  himself  at  least,  that  nearly  every 
one  of  any  rank  in  letters  or  art  is  a  degenerate,  and 
the  degenerates  have  answered  with  a  tu  quoque  argu- 
ment which  is  entirely  satisfactor}'  to  themselves. 
The  antivivisectionists  have  asserted  that  those  who 
experiment  upon  animals  are  really  sexual  perverts,  and 
a  writer  in  one  of  our  contemporaries  has  retorted  that 
these  intemperate  opponents  of  scientific  progress  are 
downright  insane.  The  learned,  we  dare  not  say  sane, 
editor  of  another  of  our  contemporaries  has  ventured  the 


opinion  that  a  writer  in  the  Medical  R.ecord  is  men- 
tally unsound  because  he  mildly  criticised  the  action  of 
the  Society  for  the  Diversion  of  Public  Funds  to  Pri- 
vate Uses  The  German  Emperor  has  been  called  in- 
sane because  he  pinches  the  legs  of  his  guests  or  trips 
them  up  with  his  sword.  The  Sultan  is  insane  be- 
cause he  has  a  harem  and  seems  to  favor  the  killing 
of  his  Armenian  subjects,  and  Gladstone  is  in  his  do- 
tage because  he  thinks  the  so-called  Christian  powers 
of  Europe  ought  not  to  approve  of  such  diversions. 
Bryan  is  insane  because  he  wants  a  silver  standard, 
and  the  majority  of  the  voting  population  in  the 
country  is  insane  because  it  doesn't  want  it.  And 
we  are  acquainted  personally  and  by  reputation  with 
a  great  many  people  who  do  not  think  as  we  do,  and 
are  necessarily  insane  for  that  reason.  We  are  get- 
ting discouraged,  for  what  can  we,  the  only  men- 
tally sound  in  this  vast  bedlam  of  degenerates  and 
maniacs,  do  to  prove  to  these  lunatics  that  we  are  the 
only  sane! 


Cems  of  tlxe 


Obituary  Notes.  —  Rev.  J.  B.  Macool,  M.D.,  of 
Elizabeth,  Pa.,  died  on  July  3d,  of  congestion  of  the 
brain.  He  was  a  graduate  of  the  Western  Pennsyl- 
vania Medical  College. — Dr.  William  C.  Wey,  of  El 
mira,  N.  Y.,  died  at  his  home  in  that  city  on  June  30th, 
at  the  age  of  sixty-eight  years.  He  was  a  graduate  of 
the  Albany  Medical  College  in  the  class  of  1849. 

"  The  New  Orleans  Medical  and  Surgical  Jour- 
nal "  announces  in  a  few  modest  words  the  completion 
of  the  first  half-century  of  its  existence.  The  journal 
was  established  in  1844,  but,  as  its  publication  was 
suspended  during  the  civil  war,  it  only  now  celebrates 
its  semicentennial.  We  congratulate  our  esteemed 
contemporary,  and  wish  it  many  more  jubilees. 

A  Scientific  Explanation  of  a  Lamentable  Occur- 
rence.— Probably  the  change  of  climate  from  the  sea- 
shore to  the  more  relaxing  and  debilitating  atmos- 
pheric conditions  at  Poughkeepsie  had  much,  though 
not  all,  to  do  with  the  collapse  of  the  Har\-ard  crew  in 
the  late  university  boat  race.  An  exposure  of  three 
weeks  to  such  a  change  is  either  too  long  or  not  long 
enough. — The  Boston  Medical  and  Surgical  Journal. 

The  New  Jersey  State  Board  of  Medical  Exam- 
iners  Drs.  G.  F.   Wilbur,   of  Asbury   Park;    .\.   K. 

Baldwin,  of  Newark;  and  Edwin  De  Baun,  of  Passaic, 
have  been  reappointed  members  of  the  State  board  of 
medical  examiners  of  New  Jersey  for  a  term  of  three 
years.  At  the  annual  meeting  of  the  board  the  follow- 
ing officers  were  elected  for  the  ensuing  year:  Presi- 
dent, Dr.  G.  F.  Wilbur,  of  Asburj'  Park ;  Secretary,  Dr. 
E.  L.  B.  Godfrey,  of  Camden ;  and  Treasurer,  Dr.  A. 
Ubelacker,  of  Morristown. 

Street  Cleaning  in  Rochester. — The  Pathological 
Society  of  Rochester,  N.  Y.,  has  taken  action  on  the 
condition  of  the  streets  in  that  city.  It  urges  the  pav- 
ing of  streets  with  brick,  stone,  or  asphalt,  laid  over 
cement   or  concrete  foundation.       In    the    matter   of 


92 


MEDICAL    RECORD. 


[July  17,  1897 


cleaning  it  has  adopted  a  resolution  that  the  method 
of  cleaning  by  constant  manual  sweeping  and  gather- 
ing of  accumulated  dirt  and  refuse  in  bags  is  the 
most  sanitary,  and  that  the  use  of  sweeping  machines 
which  raise  a  cloud  of  dust  should  be  discontinued. 
It  urgently  requests  the  city  officials  to  inforce  the  or- 
dinances against  the  littering  of  streets  with  ashes, 
garbage,  etc. 

The  Wisconsin  State    Medical  Board Governor 

Scofield,  of  Wisconsin,  has  appointed  the  following 
seven  physicians  to  compose  the  new  State  medical 
board  created  by  act  of  the  legislature  last  winter:  Drs. 
Walbridge,  of  Milwaukee;  Bell,  of  Beloit;  Ourrens, 
of  Two  Rivers;  Dale,  of  Oshkosh;  Forsbeck,  of  Mil- 
waukee; Ludwig,  of  Richland  Centre;  and  Quigg,  of 
Tomah. 

The  Southern  Empire  State  Medical  Association 
of  Georgia. — The  fourth  annual  meeting  of  this  flour- 
ishing association  of  colored  physicians  and  surgeons 
was  held  in  Macon  on  July  1st  and  2d.  The  follow- 
ing officers  were  elected  for  the  ensuing  year :  Presi- 
dent, Dr.  E,  E.  Green,  Macon,  Ga. ;  First  Vice-Presi- 
dent, Dr.  A.  L.  Falkner,  Macon ;  Second  Vice-President, 
Dr.  R.  E.  Grier,  Albany;  Treasurer,  Dr.  J.  R.  Porter, 
Atlanta;  Secretary,  Dr.  H.  R.  Butler,  Atlanta;  Board 
of  Censors,  Drs.  C.  McCarthy,  Macon,  A.  H.  Harris, 
Athens,  and  J.  T.  Shuften,  Macon;  Executive  Commit- 
tee, Drs.  G.  S.  Burrus,  Augusta,  W.  A.  J.  Mosley, 
Thomasville,  W.  H.  Harris,  Athens,  S.  P.  Loyd,  Sa- 
vannah, and  H.  R.  Butler,  Atlanta,  chairman.  The 
meeting  in  1898  will  be  held  at  Americus. 

Laryngological  Section  of  the  Moscow  Congress. 
— Dr.  J.  W.  Gleitsmann  writes  that  at  a  special  meet- 
ing of  the  Oto-Rhino-Laryngological  Society  of  Mos- 
cow, held  on  the  21st  day  of  June,  1897,  it  was  de- 
cided that  a  bureau  should  be  instituted  for  the  con- 
venience of  members  of  the  twelfth  section  of  the 
Twelfth  International  Medical  Congress  (otological 
and  rhino-laryngological  section).  The  object  of  this 
bureau  will  be  to  give  all  information  needed,  not  only 
as  to  matters  concerning  the  congress,  but  as  to  all 
other  matters  where  our  visitors  may  require  assistance 
or  information.  This  reference  bureau  will  be  open 
from  7  to  9  P.M.,  from  the  13th  to  the  19th  of  August, 
in  the  Doctors'  Club  (Bolshaya  Dmitroffka),  and  dur- 
ing the  meetings  in  the  room  of  the  twelfth  section  {b, 
laryngo-rhinology). 

The  Medical-Charity  Abuse  in  Iowa. — Drs.  E.  F. 
Clapp  and  C.  M.  Hobby,  of  Iowa  City,  have  issued  a 
circular  relative  to  an  appropriation  by  the  board  of 
regents  of  the  University  of  the  State  of  Iowa,  of 
nearly  $150,000,  for  the  construction  and  equipment 
of  a  hospital,  the  use  and  control  of  which  is  to  be 
restricted  to  members  of  the  faculty  of  the  medical 
department  of  the  State  University.  It  is  said  also 
that  any  persons  will  be  received  for  treatment  in  the 
hospital  provided  they  pay  their  board  and  reasonable 
fees  to  the  physician  or  surgeon  in  charge.  "  Thus," 
the  circular  reads,  "the  State,  in  behalf  of  a  few  indi- 
viduals connected  with  the  faculty  of  the  medical  de- 


partment of  the  university,  enters  into  competition 
with  every  general  practitioner  and  everj'  hospital  and 
sanatorium  in  the  State;  also  offering  to  furnish  a  set 
of  operating-rooms  and  all  special  appliances  to  the 
members  of  the  staff  without  e.xpense  to  them,  thereby 
giving  them  great  advantages  in  competition  with  the 
large  body  of  the  medical  profession  who  have  no  such 
extraneous  aid."  The  writers  ask  for  legislative 
enactment  forbidding  the  admission  of  any  patient 
who  is  able  to  pay  for  his  or  her  treatment  at  home  or 
in  a  private  institution;  and  also  providing  that  no 
member  of  the  hospital  staff  shall  receive  any  compen- 
sation for  his  services  or  receive  any  pay  or  gratuity 
from  any  patient  admitted  to  the  hospital. 

The  American  Association  of  Obstetricians  and 
Gynaecologists  will  hold  its  tenth  annual  meeting  at 
Niagara  Falls,  Tuesday,  Wednesday,  Thursday,  and 
Friday,  .August  17,  18,  19,  and  20,  1897,  under  the 
presidency  of  Dr.  James  F.  W.  Ross,  of  Toronto.  The 
scientific  work  of  the  association  will  begin  on  Tues- 
day morning  at  ten  o'clock,  and  end  Friday  at  one 
o'clock,  and  it  is  expected  so  to  arrange  the  programme 
as  to  afford  the  members  opportunity  to  visit  the  places 
of  interest  each  day  on  the  adjournment  of  the  after- 
noon session.  The  secretary  of  the  association  is  Dr. 
William  Warren  Potter,  of  Buffalo. 

A  Lost  Opportunity. — The  jubilee  exercises  proper 
on  the  third  day  might  have  been  worse  and  there  was 
abundant  room  to  have  made  them  better.  The  occa- 
sion afforded  ample  opportunity  for  hero  worshippers 
to  display  their  enthusiasm,  and  otherwise  it  was  a 
restful  break  in  the  routine.  Dr.  N.  S.  Davis  read  his 
address  in  good  voice  and  the  subject  matter  was  an 
interesting  bit  of  history.  The  opportunity  was  here 
afforded  to  invite  the  president  of  the  Medical  Society 
of  the  State  of  New  York  to  participate  in  the  proceed- 
ings, at  least  by  his  personal  presence ;  but  it  was  lost, 
more's  the  pity.  To  ignore  completely  a  great  medi- 
cal society,  that  was  founded  in  1806  and  was  the  first 
organized  body  to  give  direction  to  medical  education 
in  the  United  States,  in  which  also  the  .American 
Medical  Association  had  its  birth  and  after  which  its 
form  of  government  was  modelled,  was  in  our  view  an 
error,  if  not  a  misfortune.  These  jubilee  exercises 
were  distinct  and  apart  from  the  ordinary  work  of  the 
association,  and  during  their  conduct  it  would  have 
been  a  graceful  act  for  Dr.  Davis  to  have  welcomed 
the  president  of  that  society,  nor  would  it  have  dimin- 
ished the  renown  that  is  so  justly  accorded  to  the 
"father of  the  association"  had  he  displayed  a  mag- 
nanimity that  was  worthy  his  exalted  position  and  the 
occasion. — Buffalo  Medical  Journal. 

The  Statue  of  Charcot,  by  the  sculptor  Falguifere, 
is  nearly  finished,  and  will  soon  be  erected  at  the  Sal- 
petri^re. 

Government  Doctoring. — From  Queensland  comes 
a  proposition  that  the  principle  of  lodge  practice  be 
widened  out  so  as  to  be  made  a  State  institution.  The 
Medifal  Press  says  that  the  president  of  the  local 
branch  of  the  British  Medical  .Association  has  made 
the  startling  suggestion  that  the  medical  care  of  the 


July  17.  1897] 


MEDICAL    RECORD. 


93 


people  should  be  part  of  a  public-health  department, 
and  it  is  said  that  a  large  proportion  of  the  members 
of  the  branch  was  charmed  with  the  idea.  He  pro- 
poses that  the  whole  countn-  be  divided  into  districts, 
with  a  senior  and  two  junior  medical  officers  to  each, 
together  with  relieving  oificers  and  inspectors.  Every 
person  is  to  be  taxed  two  dollars  per  annum  to  pay  for 
his  or  her  doctoring.  This  is  a  distinct  improvement 
on  the  dollar-a-month  dispensaries  and  fifty-cent  hos- 
pitals. It  also  solves  the  dispensary-abuse  problem, 
by  extending  the  benefits  of  pauperism  to  the  entire 
community  without  any  property  qualification  what- 
ever. We  regret  we  are  unable  to  publish  the  name 
of  the  president  of  the  Queensland  branch  of  the  Brit- 
ish Medical  Association.     He  is  a  genius. 

The  Passing  of  the  Parrot. — If  the  parrot  in  his 
tropic  home  could  say  what  he  thinks,  he  would 
thank  his  stars  for  psittacosis,  that  form  of  broncho- 
pneumonia from  which  his  captive  brethren  sufter  in 
European  cages.  In  Genoa  fourteen  persons,  of  whom 
eight  have  died,  recently  contracted  the  disease  from 
two  parrots  brought  from  Brazil.  The  alarm  has 
spread  over  the  continent,  and  the  parrot  is  in  much 
less  request  than  formerly. 

The  Pedic  Society  of  New  York,  composed  of  the 
registered  chiropodists  of  the  State,  held  its  annual 
meeting  in  this  city  on  July  loth.  The  society  has 
one  hundred  and  seventy-one  members. 

An  Incredible  Accusation  and  its  Refutation. — 
One  of  the  most  unfortunate,  uncalled-for,  and  dis- 
gusting spectacles  which  men  sometimes  make  of  them- 
selves occurred  recently  in  St.  Louis,  at  the  close  of  a 
three-days'  session  of  an  auspicious  medical  society. 
A  so-called  "  smoker,'"  one  of  the  social  features  of 
the  occasion,  which  had  been  widely'  advertised  and 
to  which  men  of  prominence  had  been  invited,  de- 
generated from  a  pleasant  social  gathering  to  a  most 
disgusting,  vulgar,  and  vile  exchange  of  lewd  jokes 
and  foul,  reeking  stories,  at  which  even  the  untaught, 
unpractised,  barbarous  men  of  the  time  of  Moliere 
would  blush. —  TJu  Mediial  Fortnightly. 

A  medical  journal  which  claims  to  be  a  St.  Louis 
publication,  but  which  is  printed  and  mailed  at  St. 
Joseph,  Mo.,  and  edited  at  Jacksonville,  111.,  criticises 
the  "smoker"  given  the  Tri-State  Medical  Society  at 
its  recent  meeting  in  St.  Louis — probably  because  the 
leaders  in  the  entertainment  were  Drs.  James  Moores 
Ball  and  Emory  Lanphear,  each  generally  understood 
to  be  persona  non  grata  to  the  Jacksonville  editor. 
The  gentleman  wrote  the  criticism  upon  "general 
principles,"  quite  evidently,  for  he  was  not  present, 
and  none  of  the  frightful  things  pictured  by  his 
heated  imagination  actually  occurred.  —  American 
Journal  0/  Surgery  and  Gynecology. 

High  Potencies  Come  High.  —  An  American  was 
taken  down  with  pneumonia  last  winter  in  a  Paris  ho- 
tel, and  was  attended  by  the  hotel  physician.  The 
doctor  was  a  homoeopathist  and  treated  his  patient  on 
strictly  homoeopathic  principles,  but  did  not  furnish 
the  remedies.  These  were  obtained  on  his  prescrip- 
tion from  a  neighboring  pharmacy,  and  the  bill  for 


those  consumed  in  the  few  days  of  the  victim's  illness 
came  to  5150. 

The  Medical    Inspectors  of    Schools The    first 

quarterly  repon  since  the  appointment  of  medical  in- 
spectors of  schools  in  this  city  has  just  been  made  by 
Dr.  Blauvelt,  the  chief  medical  inspector.  The  report 
includes  a  table  showing  the  different  kinds  of  diseases 
for  which  children  were  excluded  from  the  schools. 
Parasitic  diseases  of  the  head  appear  to  have  been  the 
most  prevalent,  2,627  cases  having  been  discovered 
among  the  children  examined.  Contagious  diseases 
of  the  eye  come  ne.xt  on  the  list,  over  700  cases  being 
reported.  Skin  diseases  claimed  175  victims,  and 
diphtheria  91.  Measles  was  responsible  for  the  ex- 
clusion from  school  of  51  children,  and  20  cases  of 
genuine  scarlet  fever  were  discovered.  Croup  was  of 
comparatively  rare  occurrence,  but  26  scholars  were 
compelled  to  forego  school  attendance  for  a  short  time 
on  account  of  whooping-cough.  The  report  gives  the 
number  suffering  from  mumps  as  117,  and  from  chick- 
en-pox as  93. 

International  Association  of  Railway  Surgeons. 
— -At  the  session  in  Chicago  of  the  National  Associa- 
tion of  Railway  Surgeons,  out  of  compliment  to  the 
membership  in  Canada  and  Mexico,  the  name  of  the 
society  was  changed  to  the  International  Association 
of  Railway  Surgeons.  The  next  meeting  will  be  held 
in  Toronto,  in  May,  1898. 

Beds  for  Sick  Americans  in  London. — As  a  me- 
morial of  the  Queen's  diamond  jubilee  the  Ameri- 
cans residing  in  England  have  endowed  a  bed  in 
perpetuity  in  each  of  the  five  leading  London  hospi- 
tals, each  bed  being  endowed  with  the  sum  of  j£.\,ooo. 
The  beds  will  be  especially  for  the  use  of  Americans, 
but  other  patients  may  be  received  if  all  the  Ameri- 
cans are  well. 

Mississippi     Valley    Medical    Association The 

next  meeting  of  this  association  will  be  held  in  Louis- 
ville, on  October  5,  6,  7,  and  8,  1897.  The  railroads 
will  offer  reduced  rates.  The  president  is  Dr. 
Thomas  Hunt  Stucky,  and  the  chairman  of  the  com- 
mittee of  arrangements  Dr.  H.  Horace  Grant.  Titles 
of  papers  should  be  sent  to  the  secretary,  Dr.  H.  W. 
Loeb,  3559  Olive  Street,  St.  Louis. 

Pathological   Society  of  Philadelphia A  stated 

meeting  of  the  Pathological  Society  of  Philadelphia 
was  held  on  June  24th,  Dr.  Charles  W.  Burr  occupy- 
ing the  chair.  Dr.  John  M.  Swan  e.xhibited  an  aneu- 
rism of  the  aorta  at  the  junction  of  the  ascending  with 
the  transverse  portion  of  the  arch,  together  with  an 
enormously  enlarged  heart.  Dr.  William  G.  Spiller 
e.xhibited  microscopic  preparations  of  giant  cells  of 
the  cerebral  cortex.  Dr.  C.  W.  Biur  exhibited  a  sub- 
cortical neoplasm  of  the  precentral  lobe  of  the  left 
cerebral  hemisphere.  During  life  there  had  been  evi- 
dence of  suppurative  inflammation  of  the  middle  ear 
of  the  same  side,  and  the  ner\ous  phenomena  were 
attributed  to  abscess  of  the  brain.  The  mastoid  cells 
were  trephined  and  pus  was  afforded  exit,  but  no  im- 
provement in  the  ner\'ous  phenomena  followed. 


94 


MEDICAL    RECORD. 


[July  17,  1897 


Societij  Reports. 

AMERICAN    MEDICAL    ASSOCIATION". 

(Continued  from  page  63.) 

SECTION    ON    ANATOMY   AND   SURGERY. 

First  Day — Tuesday,  June  1st. 

President's  Address The    chairman,    Dr.    R.    H. 

Savre,  of  New  York,  in  his  opening  address,  recom- 
mended that  papers  be  fewer  in  number  and  well  pre- 
pared, in  order  to  allow  more  thorough  discussion, 
which  was  of  great  importance.  It  was  not  always 
easy  to  discuss  a  paper  on  the  spur  of  the  moment. 
He  thanked  the  section  very  heartily  for  the  honor 
conferred  upon  him  in  calling  him  to  act  as  its  presid- 
ing officer. 

Ligation  of  the  Carotid. —  "  (<?)  Ligation  of  the 
Common  Carotid  Artery  for  Trifacial  Neuralgia,  with 
E.\periments  and  Observations  on  Dogs,  {b)  Speci- 
mens and  Charts  pf  the  Arterial  and  Ner\-ous  Systems 
Illustrating  the  Paper."  Dr.  B.  Merrill  Ricketts, 
of  Cincinnati,  Ohio,  read  a  paper  with  this  title,  in 
which  he  stated  that  only  experimental  work  had 
been  done,  and  that  as  yet  but  few  conclusions  could 
be  drawn.  The  anatomy  of  a  dog  was  thought  to  be 
dififerent  from  that  of  a  human  being,  but  he  did  not 
concur  in  that  opinion.  Sir  Astley  Cooper  ligated 
the  vertebral  and  common  carotid  arteries  in  a  dog, 
but  the  object  of  the  operation  was  not  known.  In 
1866  Ehrman  ligated  the  common  carotid  for  trifacial 
neuralgia.  The  operation  had  also  been  done  by 
Gross  in  1883,  Hutchinson  in  1885,  and  Horsley  in 
1887.  The  cases  operated  upon  had  not  been  re- 
ported in  detail.  The  speaker  wished  to  mention  a 
case  operated  upon  one  year  ago.  The  patient  was 
ninety-si-x  years  of  age,  and  since  the  operation  he  had 
been  entirely  free  from  pain.  The  question  arose  as 
to  the  reason  for  this  relief.  It  was  supposed  that 
changes  took  place  in  the  Gasserian  ganglion,  but  the 
microscope  proved  that  such  was  not  the  case.  The 
experiments  extended  over  three  months;  twelve  dogs 
were  chosen,  their  common  carotids  were  ligated,  and 
the  dogs  were  killed  at  different  times  afterward. 
From  these  e.xperiments  he  concluded  that  pain  results 
from  one  of  two  conditions:  first,  anamia;  and  second, 
congestion.  He  referred  to  the  pain  of  local  meningi- 
tis. In  case  of  congestion,  ligation  of  tiie  common 
carotids  will  relieve  the  pressure  and  blood  tension. 
Specimens  were  shown  of  the  brains  of  dogs  killed  on 
different  days;  the  injection  material  used  was  com- 
posed of  starch,  carbolic  acid,  and  aniline. 

Dr.  J.  B.  Murphy,  of  Chicago,  asked  what  per- 
centage of  cases  of  ligation  showed  degenerative 
changes  in  the  hemispheres;  he  also  inquired  of  the 
author  what  his  theory  was  as  to  the  pathology  of  tri- 
facial neuralgia. 

Dr.  RicKErrs,  in  closing  the  discussion,  said  that 
there  were  no  changes  in  the  hemispheres,  so  far  as  he 
was  able  to  discover.  Congestion  seemed  to  be  a 
prominent  factor,  as  also  did  ana::mia.  The  speaker 
then  referred  briefly  to  Rose's  and  Langenbeck's  oper- 
ations for  the  cure  of  trifacial  neuralgia. 

The  Nerve  Element  in  Surgical  Pathology. — Dr. 
J.  McFadden  Gaston,  of  Atlanta,  Ga.,  read  a  paper 
with  the  above  title.  He  said  that  the  interlacing  of 
the  nerves  with  the  different  structures  of  the  body 
gives  energy  to  every  vital  organ  in  health,  and  aggra- 
vates their  disorder  in  disease. 

Neufalgia  in  all  its  protean  forms  is  not  a  mere 
functional  derangement  of  the  nerve  centres,  but  de- 
pends in  most  cases  upon  local  modifications  resulting 
from  inflammatory  action  in  the  neurilemma  or  paren- 


chymatous structure  of  the  affected  nerve.  It  may  also 
exist  in  a  spurious  form  connected  with  compression 
upon  the  trunk,  or  from  cicatricial  adhesions  after  op- 
erations. The  impression  that  contraction  of  the 
ner\'es  gives  rise  to  painful  development  has  led  to 
nerve  stretching,  but  little  advantage  has  attended  this 
procedure,  thus  showing  that  nen'e  shortening  is  not 
pathognomonic. 

Rheumatic  complications  involving  various  regions 
of  the  body  are  dependent  upon  the  nerve  supply  to 
the  part,  and  the  acute  sensibility  of  such  structures 
renders  anodynes  of  the  greatest  importance  in  the 
treatment  of  such  disorders.  Inflammatory  processes 
are  accompanied  by  pain  from  the  entrance  of  sen- 
sor)' branches  of  the  nerves  into  the  organs,  and  the 
means  adopted  for  the  relief  of  inflammation  must  in- 
clude the  control  of  the  neurotic  disturbances  by  com- 
bating pain.  It  is  fair  to  infer  that  all  agencies  for 
the  mitigation  of  pain  have  a  curative  effect  upon  the 
structures  involved  in  disease. 

The  reciprocal  influence  of  body  and  mind  in  the 
progress  of  most  physical  disorders  dep>ends  upon  their 
connection  through  the  nerv'ous  system. 

Our  deficient  knowledge  of  the  etiological  factor  in- 
volved in  shock  inclines  the  speaker  to  the  view  that 
a  continuous  baleful  influence  is  propagated  to  the 
ner\e  centres  from  the  disintegration  of  the  structure 
involved,  and  that  this  maybe  modified  by  amputation 
with  a  clean  incision  through  sound  tissues  above  the 
point  of  injury,  soon  after  such  violence  to  the  parts. 
The  injury  inflicted  upon  the  superficial  cutaneous 
ner\-e  fibrils  is  extended  to  the  internal  organs  by  the 
correlation  of  ner\es  and  capillaries  with  the  viscera. 
The  notable  effects  obser^-ed  from  cups,  sinapisms, 
and  blisters  upon  the  skin  are  due  to  the  sympathies 
established  through  this  channel  of  the  nerves.  The 
eruption  of  teeth  in  children  is  attended  by  neurotic 
disturbances  of  a  marked  character.  The  various 
manifestations  of  the  intimate  relations  of  the  nerves 
with  the  different  structures  of  the  body  open  the  way 
for  comprehending  the  role  of  the  ner\e  element  in 
surgical  patholog)'. 

The  development  of  traumatic  neuritis  is  the  most 
common  complication  of  surgical  cases,  and  there  is 
rarelv  any  e.xtensive  lesion  which  is  not  accompanied 
by  more  or  less  pain,  dependent  upon  inflammation 
of  the  nerve  or  its  neurilemma.  The  irritation  of  the 
peripheral  branch  of  a  nerve  may  set  up  a  train  of  dis- 
orders terminating  in  tetanus  or  lymphangitis,  and  the 
serious  consequences  of  these  affections  are  notorious. 
In  the  latter  condition  ganglions  as  well  as  lymphatics 
become  involved  in  the  inflammatory  process,  and  sup- 
puration is  set  up  in  the  course  of  the  lymphatics  with 
the  characteri.stic  features  of  pya?mia. 

The  subcutaneous  use  of  simple  distilled  water  has 
been  resorted  to  w  ith  apparent  cft'ect  upon  the  nervous 
svstem,  and  this  proves  a  delicate  response  of  the  ner\'es 
to  the  action  of  agents  introduced  hypodermically. 
The  transmission  of  cutaneous  modifications  to  the  in- 
ternal organs  becomes  in  numerous  instances  simply 
the  expression  or  delivery  of  a  dynamic  influence  which 
operates  through  the  nerves.  Instead  of  local  irrita- 
tion there  is  a  general  influence  upon  the  organism 
corresponding  to  the  special  property  of  the  agent  em- 
ployed, and  we  must  attribute  the  eftect  to  the  conduc- 
tion of  medicinal  powers  from  the  point  of  introduc- 
tion through  the  various  channels  of  communication 
with  the  dependent  structures. 

The  chief  features  in  the  relations  of  the  nen-ous 
system  to  other  structures  involved  in  surgery  lead  to 
the  following  deductions: 

I  St.  The  cutaneous  development  of  the  minute 
branches  of  the  cerebro-spinal  system  of  ner\es,  and 
the  ganglionic  ramifications  of  the  great  sympathetic, 
are  so  rel.Ued  to  the  capillaries  as  to  establish  a  recip- 


July  17,  1S97] 


MEDICAL    RECORD. 


95 


rocal  action  and  reaction  between  them  and  the  great 
ner\'e  centres. 

2d.  The  vasomotor  nerves  are  so  intimately  linked 
with  the  e.xcito-motor  and  excito-dynaniic  system  of 
nerves  that  impressions  made  through  the  superficial 
afferent  ner\es  are  conveyed  to  all  the  corporeal  struc- 
tures and  tissues,  so  as  to  produce  their  effects  upon  dif- 
ferent organs. 

3d.  Refle.x  phenomena  depend  upon  a  complex  in- 
terchange of  local  pathological  conditions  with  the 
nervous  ramifications  to  remote  parts  of  the  body. 

4th.  The  fountainhead  of  energy  for  all  the  func- 
tions lies  in  the  nerve  centres,  and  by  corrtrolling 
emanations  from  this  source  the  vital  forces  will  be 
propagated  with  regularity  and  uniformity  to  all  the 
remote  parts  of  the  physical  organization.  On  the  con- 
trary', a  hurtful  influence  disseminated  from  the  nerve 
centres  entails  disease  upon  the  different  organs. 

5th.  The  means  to  be  adopted  for  averting  injurious 
impressions  upon  the  ner\'e  centres,  and  the  measures  to 
be  used  for  the  correction  of  their  derangement,  make  up 
the  whole  prophylactic  agency  of  hygiene,  and  include 
all  the  therapeutic  appliances  in  the  treatment  of  dis- 
eases, as  well  as  the  application  of  surgical  measures. 

6th.  Close  observation  of  the  various  modifications 
of  the  ner\'e  element  on  the  physical  organism  should  re- 
veal its  direct  influence  in  surgical  pathology,  and  lead 
the  surgeon  to  the  adoption  of  proper  means  of  relief. 

Operative  Procedure  for  the  Relief  of  Occlusion 
of  the  Jaws. — Dr.  J.  Ewing  Mears,  of  Philadelphia, 
read  a  paper  on  this  subject.  With  regard  to  the 
procedures  which  have  been  used,  Mr.  Heath,  of  Lon- 
don, in  recording  a  case  in  which  he  had  operated, 
made  the  statement  that  English  text-books  contain 
very  little,  Drs,  Kocher  and  Valentine  Mott  both 
refer  to  a  case  of  a  sloughing  cheek  which  was  ac- 
companied by  closure  of  the  jaws.  The  most  complete 
account  of  this  condition  is  to  be  found  in  Gross'  "  Sur- 
gery," This  surgeon  had  opportunity  to  study  cases  in 
the  Southern  section  of  this  country,  where  this  condi- 
tion is  more  often  found.  He  recognizes  two  forms 
—  the  temporary  or  spasmodic,  and  the  permanent. 
Among  the  many  causes  of  the  temporary  or  spas- 
modic form,  the  speaker  mentioned  delayed  eruption 
of  the  molars,  alveolar  abscess  in  connection  with  the 
teeth,  and  tonsillitis.  The  treatment  of  this  form  de- 
pends entirely  upon  the  cause.  If  it  is  due  to  a  wis- 
dom tooth,  the  tooth  should  be  extracted.  In  regard 
to  the  permanent  form,  this  is  due  to  cicatricial  tissue 
or  to  osseous  bands  which  result  from  the  use  of  mer- 
cury. The  speaker  here  showed  a  cast  illustrating  the 
absence  of  development  of  the  lower  jaw.  Closure  of 
the  jaws  may  result  from  inflammation,  which  is  more 
often  rheumatic  in  character.  It  may  result  from 
blows  or  concussions,  but  is  most  frequently  due  to 
an  unrecognized  fracture  involving  the  neck  of  the 
condyle.  The  diagnosis  of  these  cases  may  offer 
great  difficulties.  A  complete  historj'  should  be  ob- 
tained. If  a  deviation  of  the  lower  jaw  to  the  affected 
side  exists,  it  will  aid  the  diagnosis.  The  prognosis 
is  favorable.  In  considering  the  treatment  the  speaker 
stated  that  cicatricial-tissue  deposits  tax  the  skill  of 
the  surgeon.  Different  operations  for  forming  false 
joints  have  been  advocated.  The  speaker  then  briefly 
described  his  method  of  treating  these  cases,  A  long 
cun-ed  needle,  armed  with  strong  silk,  is  introduced 
in  such  a  way  that  the  silk  encircles  the  cicatrix. 
The  ligature  is  then  drawn  backward  and  forward 
day  by  day,  and  thus  inflammation  is  set  up.  The 
jaws  are  separated  and  a  gag  is  placed  between  the 
teeth.  The  use  of  the  gag  is  kept  up  until  the  patient 
is  able  to  open  the  jaw  without  it.  The  speaker  then 
showed  photographs  of  patients  operated  upon. 

Dr.  McL.mx,  of  Detroit,  said  that  the  subject  of 
jaw  closure  was  \ery  interesting  and  important,  espe- 


cially because  of  its  rarity.  He  had  had  some  experi- 
ence with  this  trouble.  He  thought  it  was  difficult  to 
imagine  anything  more  annoying  than  an  ankylosis 
of  the  jaw.  He  referred  particularly  to  the  ankylosis 
following  scarlet  fever,  that  being  a  frequent  cause,  in 
his  opinion.  He  related  the  brief  history  of  the  case 
of  a  patient  who  was  entirely  unable  to  move  the  jaw- 
There  was  absolute  ankylosis  on  both  sides.  He  tried 
to  relieve  the  condition  by  what  he  thought  to  be  an 
original  operation.  He  dissected  off  part  of  the  mus- 
cles of  the  jaw  at  the  angle,  and  resected  a  V-shaped 
piece  from  each  side ;  he  kept  up  passi\e  movements 
until  false  joints  were  formed  on  both  sides. 

Dr.  Lewis  A.  Sayre,  of  Xew  York,  hoped  that  Dr. 
Mears  would  speak  of  the  operation  first  described  by 
Dr.  Schmidt,  of  Xew  York,  which  consisted  in  pr\'ing 
open  the  jaw  and  constant  use  of  the  joint. 

The  Chairman-  thought  that  each  case  must  be  dealt 
with  according  to  its  merits.  Bony  ankylosis  must  be 
treated  on  different  lines.  He  related  the  case  of  a 
patient,  six  years  of  age,  who  had  ankylosis  of  the 
jaw  for  several  years  before  his  parents  noticed  any 
trouble.  Treatment  consisted  in  prying  apart  the 
jaws  by  means  of  a  strong  wedge,  which  was  covered 
with  lead  to  engage  the  teeth. 

Improvement  of  Brain  Function  by  Surgical  In- 
terference.— Dr.  Ernest  Laplace,  of  Philadelphia, 
read  a  paper  with  this  title.  Sepsis  has  practically 
been  eliminated  from  brain  surgery.  Relief  depends 
upon  ability  to  remove  the  transient  cause,  which  is 
either  chemical,  psychical,  biological,  or  mechanical. 
He  thought  too  much  importance  had  been  placed 
upon  the  purely  functional  troubles  of  the  brain.  In 
brain  surgery  the  technique  must  be  perfect.  We 
should  guard  against  shock,  hemorrhage,  and  sepsis. 
Death  from  shock  is  due  usually  to  faulty  technique. 
The  treatment  of  this  condition  should  be  by  strj'ch- 
nine  hypodermically,  hot-water  bottles,  head  in  the 
dependent  position,  high  enemata  of  hot  water,  etc. 
The  most  frequent  indication  for  operation  is  concus- 
sion following  trauma.  The  sequela?  dreaded  are  in- 
sanity or  epilepsy.  If  consciousness  is  lost  we  must 
relieve  this  condition  by  blood-letting,  thus  reducing 
the  tension  of  the  parts  and  also  swelling,  which  may 
e.xert  pressure.  The  latter  condition  Dr,  Laplace 
relieves  by  transverse  craniectomy,  beginning  the 
operation  in  the  temporal  fossa  and  going  through 
the  thick  portion  of  the  skull.  One  sometimes  finds 
the  middle  meningeal  artery  running  through  the 
skull  and  not  through  a  groove.  He  showed  an  in- 
strument which  he  uses  to  separate  the  adhesions 
under  the  skull,  especially  over  the  longitudinal  sinus. 
This  instmment  is  no  larger  than  an  ordinary  wire, 
and  as  it  advances  does  not  tear  the  dura.  The 
knife  is  then  plunged  through  the  surface  of  the  dura ; 
the  brain  tissue  bulges  through  this  opening,  but  not 
enough  to  do  harm.  Then  he  proceeds  to  pack  the 
wound  with  gauze  fresh  from  the  sterilizer.  For  pur- 
poses of  packing  the  speaker  said  he  did  not  favor 
iodoform  or  other  gauzes,  but  only  gauze  taken  directly 
from  the  sterilizer  after  it  has  been  subjected  to  a 
heat  of  230°  to  260''  F,  He  packs  this  well  into  the 
groove  he  makes,  and  this  gives  support  to  the  brain. 
The  strip  is  left  eight  days  in  situ,  and  then  removed. 
In  this  operation  there  is  no  shock  or  loss  of  blood, 
and  there  is  no  vibration  through  the  brain.  He 
reported  twenty-two  cases  treated  after  this  method 
with  good  results.  In  acute  meningitis  this  method 
of  drainage  has  been  applied  with  advantage.  Fif- 
teen epileptic  patients  operated  upon  gave  evidence  of 
improved  mental  condition,  and  in  no  case  was  the 
patient  worse  after  operation.  In  idiocy  due  to  micro- 
cephalus — operation  at  the  coronal,  sagittal,  and  frontal 
sutures,  done  at  three  months'  intervals — some  cases 
showed  marked  improvement  both  physically  and  men- 


96 


MEDICAL    RECORD. 


[July  17,  1897 


tally,  and  here  again  no  case  was  worse  after  operation. 
The  speaker  then  referred  briefly  to  a  class  of  cases  of 
arrested  development  of  the  brain,  in  which  this 
operation  had  been  performed.  In  a  few  cases  the 
mental  condition  was  certainly  improved. 

Demonstration  on  the  Cadaver  of  a  New  Surgi- 
cal Engine. — Dr.  M.  H.  Cryf.r,  of  Philadelphia, 
read  a  paper  on  this  subject.  He  exhibited  a  modi- 
fied dental  engine,  which  differs  from  the  ordinary 
dental  engine  in  that  it  is  much  more  powerful  and 
can  make  more  revolutions  to  the  minute.  He  laid 
particular  stress  on  the  fact  that  the  parts  are  detach- 
able and  can  be  made  aseptic,  and  that  the  instrument 
can  be  used  in  all  bone  operations.  Another  advan- 
tage that  it  possesses  is  that  it  will  not  cut  the  flesh 
unless  the  flesh  comes  between  the  bone  and  the  burr. 
The  speaker  then  demonstrated  the  use  of  his  new- 
surgical  engine  on  the  head  of  a  cadaver. 

Dr.  Wyman,  of  Detroit,  believed  that  the  ideas  of 
Dr.  Laplace  were  with  us  to  stay.  Without  drainage 
the  majority  of  cases  terminated  in  death.  All  cases 
were  improved  by  surgical  interference.  In  regard  to 
the  apparatus  shown,  he  asked  how  it  worked  in  the 
living  subject.  Bloody  fluid,  bone  dust,  etc.,  choked 
up  the  burrs  of  the  saw  now  in  use,  and  he  asked  how 
this  new  machine  stood  the  test.  He  had  long  wished 
for  some  such  instrument. 

Dr.  De  Velbris,  of  Toledo,  spoke  in  regard  to  the 
removal  of  the  skull  bone,  as  demonstrated  by  Dr. 
Cryer.  He  thought  the  instrument  worked  admirably. 
The  great  difficulty  that  he  had  experienced  in  instru- 
ments that  he  had  used  was  that  he  could  not  cut  a 
circular  slit. 

Dr.  White,  of  Philadelphia,  said  that  he  was  not  so 
fortunate  in  his  cases  as  was  Dr.  Laplace.  He  was 
of  the  opinion  that  the  mortality  of  all  operations  of 
opening  the  cranium  was  considerably  above  two  per 
cent.  He  did  not  believe  that  the  whole  brain  could 
be  drained  through  an  opening  in  the  dura  mater. 
The  temporary  eft'ect  of  an  operation  should  be  con- 
sidered. He  reported  cases  in  which  operation  had 
been  performed  for  epilepsy.  Some  cases  apparently 
gave  something  to  guide  in  operation,  but  when  the 
part  was  cut  down  upon  nothing  was  found.  Occa- 
sionally the  opening  of  the  cranial  cavity  was  followed 
by  the  disappearance  of  the  so-called  organic  disease ; 
it  was  not  understood  why  this  was  so.  The  speaker 
thought  that  in  insanity  following  trauma  operation 
was  rational  and  justifiable. 

Dr.  Lewis  A.  Savre,  of  New  York,  spoke  of  tlie 
spiral  conical  trephine.  One  could  not  possibly  in- 
jure the  dura  mater  with  this  instrument,  and  he  w-as 
surprised  that  this  fact  had  not  been  mentioned.  The 
speaker  related  a  case  in  which  convulsions  and  other 
symptoms  led  him  to  believe  that  an  exostosis  was 
pressing  upon  the  brain.  An  operation  was  performed, 
but  nothing  was  found.  Since  the  operation,  which 
was  done  many  years  ago,  the  patient  had  not  had  a 
convulsion  and  was  perfectly  well. 

Hernia  of  the  Caecum. — Dr.  J.  H.  Gihrox,  of  Phil- 
adelphia, read  a  paper  with  this  title.  He  spoke  of 
acute  and  chronic  partial  intestinal-wall  herniiv,  giv- 
ing the  theory  of  the  manner  of  their  production,  symp- 
toms, diagnosis,  and  treatment.  The  usual  symptoms 
of  acute  hernia  might  be  present — inflammation,  gan- 
grene, and  perforation.  Littre's  hernia  was  a  hernia 
of  Meckel's  diverticulum.  The  object  of  the  paper  was 
to  prove  that  acute  partial  intestinal-wall  hernia  does 
occur,  and  also  that  acute  partial  enterocele  must  be 
differentiated. 


Sircnif  Day —  Wtubifsday,  June  2d. 

Two  Hundred  and    Fifty  Bassini  Operations  for 
the  Cure  of  Hernia,  without  Mortality.— Dr.  W.  15. 


De  Gar.mo,  of  New  York,  read  a  paper  with  the  above 
title,  it  being  largely  one  of  statistics  of  his  own  cases. 
Two  hundred  and  fifty  operations  had  been  done  on 
216  patients;  34  operations  had  been  done  on  both 
sides.  There  were  164  males  and  86  females;  55 
were  under  the  age  of  fourteen  years,  43  between  the 
ages  of  fourteen  and  twenty-five,  and  118  had  passed 
the  age  of  twenty-five  years;  8  were  between  the  ages 
of  sixty  and  seventy,  and  2  were  over  eighty.  The 
youngest  patient  was  five  months  old  and  was  operated 
upon  for  strangulated  scrotal  hernia;  he  recovered 
in  ten  days.  The  oldest  patients  got  well  apparently 
as  readily  as  the  youngest.  There  were  93  scrotal 
hernias,  55  irreducible,  and  16  strangulated.  The  larg- 
est hernia  was  about  two  feet  in  circumference,  com- 
posed of  large  and  small  intestines,  omentum,  and 
bladder.  In  4  cases  cysts  were  found  in  the  canal ; 
in  I  case  it  was  a  form  of  multiple  cyst;  207  cases 
healed  by  primary  union.  Suppurative  cases  started 
beneath  the  skin  in  all  cases,  and  one  was  from  gonor- 
rhoeal  infection.  In  only  one  instance  did  a  recur- 
rence take  place  in  a  suppurative  case.  All  double 
operations  were  done  at  the  same  time.  In  one 
case  there  was  a  direct  inguinal  hernia  on  the  left, 
side  and  a  femoral  hernia  on  the  right  side;  both  were 
operated  upon  at  the  same  time.  In  regard  to  suture 
material,  he  used  none  but  kangaroo  tendon.  He  had 
had  no  deaths.  The  permanence  of  cure  was  a  very 
important  thing  to  consider.  He  thought  that  ninety 
per  cent,  of  permanent  cures  was  too  low,  and  advanced 
his  percentage  to  ninety-five.  One  hundred  and  fifty 
of  his  cases  had  gone  over  one  year  without  recur- 
rences. He  had  had  only  three  actual  recurrences 
up  to  the  present  time.  The  real  cause  of  failure 
was  known  in  every  case  and  was  reported  by  the 
speaker. 

Dr.  Marcv,  of  Boston,  in  opening  the  discussion, 
thought  the  subject  too  large  to  be  treated  in  detail, 
but  wished  to  speak  of  one  or  two  points  which  he 
considered  to  be  essential.  He  demonstrated  by 
drawings  on  the  blackboard  the  causes  of  hernia. 
He  asked  why  all  were  not  subjects  of  hernia;  the 
opening  in  the  abdominal  wall  was  at  right  angles 
to  the  abdominal  pressure.  He  pointed  out  that  ana- 
tomical defects  caused  a  large  proportion  of  the  cases, 
such  as  pathological  conditions  and  lack  of  closure  at 
an  early  period  of  life.  In  treating  these  cases,  ques- 
tions arise  as  to  the  reconstruction  of  these  parts.  The 
speaker  then  briefly  related  a  history  of  his  researches 
and  publications  on  this  subject.  He  had  operated 
upon  subjects  of  three  months  and  upon  those  past 
eighty  years  of  age.  In  making  up  the  mortality  list 
he  did  not  think  that  strangulated  cases  should  be 
included  in  the  percentage;  ninety  per  cent,  had  re- 
mained cured.  He  used  no  truss  after  operation.  The 
young  should  be  operated  upon  as  well  as  the  older 
subjects.  All  persons  in  the  category  of  truss-bearing 
subjects  are  susceptible  of  certain  cure. 

Dr.  Ochsn'er,  of  Chicago,  wished  to  discuss  the  age 
limit.  It  was  apparent  to  all  those  who  saw  many  cases 
of  hernia  that  they  did  well  with  a  truss  until  they  got 
an  enlarged  prostate,  when  difficulty  began.  He  had 
done  castration  and  ligature  and  section  of  the  cord 
on  the  side  of  hernia.  As  a  result  urination  was  made 
easy  and  the  trouble  disappeared.  The  increased 
pressure  on  the  hernial  ring  was  diminished.  This 
was  a  principle  worthy  of  consideration.  He  had 
seen  several  hundred  children  suffering  from  hernia, 
and  had  found  that  in  many  cases  these  children  had 
a  phimosis,  and  as  a  consequence  strained  during  uri- 
nation. Circumcision,  followed  by  placing  the  patient 
in  bed  with  feet  elevated  to  an  angle  of  forty-five  de- 
grees for  four  or  five  or  six  weeks,  would  result  in  a 
cure.  He  did  not  think  it  justifiable  to  operate  in 
children  under  twelve  years  of  age.     His  experience 


July  17.  1897] 


MEDICAL    RECORD. 


97 


had  been  that  practically  all  children  recovered  with- 
out operation. 

Dr.  Ricketts,  of  Cincinnati,  asked  in  reference  to 
dealing  with  the  testicle,  if  any  operator  had  met  with 
a  hydrocele  accompanying  an  undescended  testicle. 

Dr.  De  G.\R-M0  closed  the  discussion.  He  stated 
that  to  Marcy,  of  Boston,  and  not  to  Bassini,  should 
the  credit  of  the  so-called  Bassini  method  be  given; 
that  Marcy  was  the  first  to  attempt  to  restore  the  canal 
to  its  normal  condition.  None  of  the  cases  Dr.  De  Gar- 
mo  operated  upon  had  enlarged  prostate.  Phimosis 
he  had  studied,  and  had  arrived  at  the  conclusion  that 
few  children  had  phimosis  so  marked  that  they  strain 
to  force  urine  through  the  urethra.  Examination  of 
children  in  Hebrew  institutions  showed  that  just  as 
many  hernias  occurred  there  as  elsewhere.  He  cer- 
tainly did  not  believe  in  elevating  the  bed,  as  advised 
by  Dr.  Ochsner,  but  preferred  to  operate.  In  regard 
to  hydrocele  occurring  with  an  undescended  testicle, 
he  had  seen  one  case,  in  which  the  tumor  was  as  large 
as  a  hen's  egg.  In  two  cases  of  undescended  testicle 
the  cord  was  so  short  that  he  could  not  bring  it  down. 
If  the  cord  was  long  enough,  he  believed  it  was  best 
to  bring  down  the  testicle.  He  looked  upon  the  aponeu- 
rosis of  the  external  oblique  muscle  as  tendon,  and  in 
his  operations  for  hernia  treated  it  as  such.  He  was 
perfectly  satisfied  with  kangaroo  tendon. 

Treatment  of  Abscess  of  the  Lung. — ^Dr.  Carl 
Beck,  of  New  York,  read  a  paper  with  this  title. 
Abscess  of  the  lung  is  not  a  rare  condition.  Its  at- 
tempted cure  should  be  by  purely  surgical  principles. 
The  diagnosis  is  much  easier  than  its  localization. 
The  absence  of  tuberculous  manifestations  and  explora- 
tory puncture  point  to  this  condition.  The  principles 
of  treatment  consist  of  thorough  evacuation  of  the  pus 
and  drainage.  Particular  care  should  be  employed  in 
rendering  the  skin  aseptic,  twenty-four  hours  being 
devoted  to  this  purpose.  The  speaker  then  described 
the  operation  for  entering  the  pleural  cavit}-.  If  no 
adhesions  exist  the  lung  may  collapse.  Palpation 
of  the  lung  area  and  the  introduction  of  the  needle 
into  the  lung  may  locate  the  pus  focus.  The  Paque- 
lin  cautery  thrust  into  the  suspected  portion  is  a  use- 
ful aid  in  diagnosis;  then  one  should  introduce  a  direc- 
tor and  watch  for  the  pus.  After  the  cavity  is  exposed, 
no  irrigation  is  necessary.  Iodoform  gauze  should  be 
packed  into  the  cavity.  The  speaker  advised  blowing 
with  the  mouth  frequently  to  increase  the  discharge. 
After  the  operation  small  doses  of  morphine  may  be 
given.  At  the  end  of  a  week  strophanthus  and  caffeine 
are  advised.  Anaesthesia  should  be  given  only  when 
the  patient  is  able  to  stand  it.  Even  cocaine  has  its 
dangers.  His  experience  was  obtained  from  four  cases, 
all  of  which  terminated  in  recover}-.  In  only  one  of 
these  cases  was  the  diagnosis  of  lung  abscess  made  be- 
fore operating.  The  history  of  this  one  case  was  given 
in  detail. 

Dr.  Man'ley,  of  New  York,  said  that  purulent  for- 
mations were  often  difficult  to  deal  with,  and  it  would 
seem  to  him  that  in  empyema  it  was  a  difficult  matter 
to  determine  whether  it  was  due  to  a  transformation  of 
a  serous  fluid  or  whether  it  was  an  interstitial  ab- 
scess. He  believed  that  it  was  impossible  to  decide 
whether  it  would  be  better  to  trust  to  the  exploratory 
needle  or  to  aspiration.  He  asked  Dr.  Beck  if,  in  the 
case  of  a  child,  it  would  not  be  better  to  spare  the  ribs 
as  much  as  possible. 

Dr.  Beck  said  that  if  pus  was  present  the  ribs 
should  usually  be  resected,  and  then  one  could  readily 
find  a  way  to  the  pus  cavity.  He  advised  the  employ- 
m;nt  of  the  .r-ray  in  all  cases  of  resection  of  the  rib. 

The  Diagnosis  of  Minor  Personal  Injuries  and 
their  Relation  to  Accident  and  Insurance  Associ- 
ations (With  Illustrations). — Dr.  Li-ton  H.  .Mo.n  j- 
GOMERY,  of  Chicago,  111.,  read  a  paper  on  the  above 


subject,  in  which  he  called  attention  to  declarations 
made  by  policy  holders  which  were  followed  bv  un- 
warranted legal  proceedings.  He  reported  several 
cases  showing  what  basis  claimants  had  for  de- 
manding damages.  He  referred  to  the  decisions  of 
courts  in  regard  to  certain  injuries  and  the  possible 
errors  of  judgment  which  may  occur.  He  brought  up 
the  question  of  the  liabilities  of  companies  in  septic 
infection. 

Anchoring  the  Kidney — Dr.  R.  Harvey  Reed, 
of  Columbus,  Ohio,  read  a  paper  on  this  subject.  He 
stated  that  hydronephrosis  and  pyonephrosis  are  of 
frequent  occurrence,  due  often  to  closure  of  the  ureters 
from  a  calculus  or  other  obstruction  which  prevents 
the  flow  of  urine.  Hydronephrosis  may  exist  for  from 
ten  to  fifteen  days  without  breaking  down  the  sub- 
stance of  the  kidney.  A  kidney  absent  from  its  natu- 
ral position,  may  be  replaced  sometimes  by  taxis,  but 
it  is  liable  to  return  to  its  former  position.  When 
this  does  occur  we  are  justified  in  doing  a  radical 
operation.  The  speaker  then  showed  by  diagram  the 
futility  of  attempting  to  replace  a  kidney  in  its  natu- 
ral position  and  hold  it  there  by  means  of  a  tight 
bandage.  The  bandage  could  not  be  made  tight 
enough  to  effect  this  object  without  interfering  with 
the  circulation ,  one  could  get  only  general  and  not 
local  pressure  by  this  means.  He  called  attention  to 
the  objections  made  to  the  radical  cure  of  floating 
kidney  and  showed  pictures  illustrating  his  method 
of  anchoring.  He  uses  the  abdominal  incision  over 
the  normal  position  of  the  kidney.  The  incision  is 
made  just  large  enough  to  introduce  the  fingers  into 
the  cavit)-  and  push  the  intestines  to  one  side,  so  as 
to  give  a  clear  field  for  obser\-ation.  A  long  curv-ed 
needle  with  a  strong  handle,  and  armed  with  one 
thread  of  silk,  kangaroo  tendon,  or  other  material,  is 
passed  through  the  upper  border  of  the  kidney  between 
the  eleventh  and  twelfth  ribs  and  on  through  the 
muscular  wall  out  to  the  back.  The  needle  is  un- 
threaded and  withdrawn.  The  other  end  is  threaded 
and  introduced  at  a  short  distance  from  the  point 
traversed  by  the  first;  the  threads  are  then  tied  over 
a  piece  of  gauze  in  a  manner  similar  to  the  fastening 
of  a  staple  stitch.  The  speaker  thought  that  in  going 
in  through  the  lumbar  region  one  would  experience 
greater  difficult)-  in  introducing  the  needle.  This 
was  a  radical  operation  rather  than  a  palliative  one. 
The  sutures  were  left  in  for  from  ten  to  fourteen  days. 
In  two  instances  it  was  his  good  fortune  to  be  called 
upon  to  operate  for  ovarian  trouble  in  patients  on 
whom  he  had  once  performed  this  operation.  One  of 
these  operations  was  performed  at  an  interval  of  six 
months  after  the  first  operation,  and  the  other  at  an 
inter\-al  of  one  and  a  half  years.  In  both  instances 
he  found  the  kidney  in  the  normal  position,  the  same 
as  the  one  on  the  other  side.  The  speaker  thought 
there  were  objections  to  the  lumbar  incision.  One 
does  not  always  find  the  kidney  where  it  ought  to  be 
and  is  sometimes  compelled  to  hunt  for  it.  By  the 
abdominal  route  a  greater  field  for  observation  is 
obtained. 

The  Comparative  Merits  of  Different  Operations 

for  Stone  in  the  Bladder Dr.    J.    B.    Deaver,   of 

Philadelphia,  read  a  paper  with  this  title,  in  which  he 
said  there  are  two  operations  which  are  quite  popu- 
lar: first,  suprapubic  lithotomy,  and  second,  lithola- 
pa.xy.  Litholapaxy  is  applicable  in  nearly  all  cases 
of  stone.  The  most  important  condition  which 
would  interfere  with  this  operation  is  stricture  in 
the  anterior  or  deep  urethra;  still,  with  Otis'  urethro- 
tome, this  difficult}-  can  be  obviated.  Stricture  of 
small  calibre  in  the  deep  urethra  is  no  contraindica- 
tion for  the  operation  of  litholapa.xy,  but  if  the  deep 
urethra  cannot  be  restored  the  operation  is  then  out 
of  the  question.     If  the  stone  is  large,  perineal   lithot- 


MEDICAL    RECORD. 


[July  17.  1897 


omy  is  the  operation.  In  speaking  of  enlargement  of 
the  prostate  gland,  the  reader  of  the  paper  said  that 
no  enlightened  surgeon  of  the  present  day  would  rec- 
ommend castration.  Cystitis  is  not  a  contraindica- 
tion in  litholapaxy;  it  is  essentially  present  in  stone 
in  the  bladder.  Almost  all  senile  cases  improve  under 
litholapaxy,  and  this  operation  does  not  seem  to  ag- 
gravate the  condition  of  senile  cystitis.  When  the 
stone  is  large,  litholapaxy  is  difficult,  because  to  crush 
a  large  stone  one  must  use  a  large  lithotrite.  In  these 
cases  it  is  better  to  do  a  suprapubic  lithotomy.  Ex- 
perience is  the  factor  which  must  decide  the  opera- 
tion. For  success  in  this  operation  it  is  essential  that 
it  be  done  at  one  sitting.  A  large  stone  with  an  irri- 
table bladder  makes  .litholapaxy  inadvisable.  If  one 
is  not  skilful  in  manipulation,  one  had  better  do  the 
cutting  operation.  Sometimes  the  stone  is  so  large  as 
to  necessitate  a  cutting  operation.  In  case  of  an  en- 
cysted stone  one  should  not  perform  a  litholapaxy.  If 
the  pelvis  of  the  kidney  is  diseased,  the  gravity  of 
the  operation  is  increased.  Litholopaxy  is  by  far 
the  safer  operation,  as  statistics  show.  Cutting  oper- 
ations must  be  made  whenever  indicated.  As  re- 
gards children  under  thirteen  years  of  age,  this  oper- 
ation should  not  be  done  on  account  of  the  high 
mortality,  and  again  the  urethra  is  rarely  so  large  as 
to  permit  the  passage  of  an  instrument;  cystitis  is 
frequently  set  up  by  the  operation.  A  great  advan- 
tage of  litholapaxy  is  that  the  patient  can  resume  work 
after  ten  or  fifteen  days.  In  operating  upon  a  child 
one  should  bear  in  mind  that  the  first  two  inches  is 
the  smallest  portion  of  the  urethra.  The  speaker  ad- 
vised the  use  of  a  lithotrite  which  does  not  become 
clogged;  a  fenestrated  lithotrite  is  the  better  instru- 
ment. Suprapubic  lithotomy  is  the  operation  that 
should  be  done  by  those  who  deal  with  stone  in  the 
bladder  but  occasionally.  For  old  men,  in  whom  stone 
is  associated  usually  with  enlarged  prostate,  supra- 
pubic lithotomy  is  the  operation.  One  should  remember 
that  in  pelvic  deformities,  ankylosis  of  the  hip-joint, 
etc.,  one  may  not  be  able  to  place  the  patient  in  the 
lithotomy  position.  The  great  advantage  in  the  oper- 
ation of  litholapaxy  is  that  it  lessens  the  sojourn  in 
bed,  and  the  sequela;  of  cutting  operations  are  not 
present. 

Demonstration  of  the  Technique  of  the  Roentgen 
Rays  with  the  Practical  Application  to  Surgery, 
Illustrated  by  Stereopticon  Views. — Drs.  Dk  For- 
rest WiLLARD  and  A.  W.  Good.speed,  of  Philadel- 
phia, presented  a  paper  on  this  subject. 

Dr.  Goodspeed  demonstrated  to  the  section  the  tech- 
nique of  the  Roentgen  rays. 

Dr.  De  Forrest  Willard  exhibited  upon  the  screen  a 
number  of  skiagraphs  taken  for  him  by  Professor 
Goodspeed,  illustrating  the  advantages  of  this  process 
in  fractures  of  the  bone,  especially  those  in  the  neigh- 
borhood of  the  joints,  as  regards  both  diagnosis  and 
treatment,  the  process  being  especially  valuable  when 
the  displacement  is  concealed  by  excessive  swelling. 
In  regard  to  deformities  following  fractures  and  cases 
of  non-union,  he  warned  surgeons  against  placing  too 
much  faith  in  delineation  ;  it  should  be  employed  only 
as  an  adjuvant  to  existing  clinical  symptoms.  Errors 
are  possible,  as  has  bsen  demonstrated  by  various  prac- 
tical workers.  The  benefit  of  the  skiagraph  in  dis- 
eases of  bones,  tuberculous  joints,  ankylosis,  exosto- 
sis, etc.,  is  beyond  qviestion.  In  distortion  of  the 
bones,  knockknees,  bowlegs,  etc.,  it  is  useful.  Foreign 
bodies  in  the  superficial  tissues,  oesopiiagus,  chest, 
abdomen,  and  even  pelvis  are  often  easily  demon- 
strable, but  the  exact  location  and  depth  cannot  be 
accurately  disclosed  except  by  various  processes  of 
angulation,  marking,  etc.  The  fluoroscope  is  very 
helpful.  The  wandering  habit  of  needles  makes  tiieir 
location  a  matter  of  considerable  difficulty.     Localiza- 


tion of  gall  stones,  stones  in  the  bladder,  stones  in  the 
kidney,  etc.,  while  still  somewhat  difficult,  is  a  matter 
that  will  be  easily  accomplished  as  the  method  and 
technique  of  the  process  advance  month  by  month. 
Manv  interesting  radiographs  were  shown  by  Dr. 
Willard. 


Third  Day — Thursday,  June  j,/. 

Some  Additional  Facts  Relating  to  Skin  Graft- 
ing, Technique,  etc — Dr.  Z.  J.  Lusk,  of  Warsaw, 
N.  Y.,  opened  the  day's  proceedings  with  a  paper  on 
this  subject.  He  referred  briefly  to  his  own  experi- 
ments and  writings,  and  the  results  he  had  obtained, 
relating  in  detail  five  cases.  He  emphasized  the  fact 
that  great  care  must  be  taken  in  separating  the  cuti- 
cle, and  that  it  should  be  kept  free  from  moisture.  He 
obtained  his  cuticle  from  blisters  produced  by  heat. 

Dr.  George  M.  Sternberg,  of  Washington,  D.  C. 
thought  it  remarkable  that  a  temperature  high  enough 
to  raise  a  blister  did  not  destroy  the  cuticle.  He 
thought  that  experiments  should  be  made  to  find  at 
what  temperature  the  cuticle  is  destroyed.  He  would 
advise  that  some  such  experiments  be  instituted. 

The  (Jhairman  said  that  he  had  been  surprised  to 
note  the  resistance  of  the  living  tissues  to  dry  hot  air. 
He  had  used  this  treatment  in  thronic  arthritis,  and 
exposed  joints  to  a  very  high  degree  of  heat.  .Skin 
will  endure  from  350°  to  400°  F.,  which  he  had 
thought  hardly  possible.  Some  can  stand  not  more 
than  180'^  or  220°  F.,  but  many  can  stand  much  higher 
than  400°  F.  He  had  noticed  that  after  a  few  days 
iiad  elapsed  ulcerated  spots,  etc.,  sometimes  appeared, 
which  ulceration  was  difficult  to  heal. 

Dr.  Manley,  of  New  York,  said  that  Dr.  Lusk's 
plan  was  not  true  skin  grafting,  but  was  epidermal 
grafting.  He  could  not  recommend  this  manner  of 
grafting  in  the  class  of  cases  described  by  Guernion- 
prez,  in  which  he  covers  in  a  large  surface,  as  of  the 
whole  limb.  He  thought  Thiersch's  method  a  ver}' 
good  one.  When  extensive  destruction  had  not  been 
done,  he  thought  the  reader's  plan  a  very  good  one, 
especially  when  motion  was  not  great. 

The  Traumatic  Fevers — Dr.  E.  W.  Holmes,  of 
Philadelphia,  read  a  paper  on  the  above  subject.  He 
classified  traumatic  fevers  into: 

{a)  Primary  fever. 

(/')  Secondary  fever:  i.  Suppurative  fever — acute, 
chronic;   2,  true  septicemia ;  3,  saprasmia;  4,  pya.-mia. 

((?")  Primary  fever :  Primary  or  aseptic  fibrin-ferment 
fever  appears  usually  within  forty-eight  hours  after  a 
traumatism  of  any  magnitude,  being  due  to  the  absorp- 
tion of  an  aseptic  fibrin-ferment  substance  from  the 
seat  of  injury.  It  follows  conditions  in  which  the 
aseptic  precautions  or  unbroken  skin  preclude  infec- 
tion, and  is  due  to  the  absorption  of  pyretogenic  sub- 
stances formed  from  the  products  of  the  aseptic  micro- 
biosis. 

(/')  Secondaiy  fever:  Secondary  fever,  which  comes 
on  after  the  fifth  day,  is  due  to  the  absorption  of  patho- 
genic genns,  either  the  pyogenic,  the  saprophytic,  or 
their  products.     I'nder  secondary  fever  he  considered: 

I.   Suppurative  fever,  which  may  be  acute  or  chronic. 

.\cute  suppurative  fever  follows  infection  with  the 
products  of  pvogenic  micro-organisms,  and  is  mani- 
fested by  chiil,  fever,  and  sweat,  usually  coincident 
with  the  formation  of  pus.  These  symptoms  usually 
disappear  wiien  the  pus  is  thoroughly  evacuated  and 
the  cavity  drained.  Acute  suppurative  fever  is  be- 
lieved to  be  due  to  the  products  of  the  pus  and  not  to 
the  actual  presence  of  the  pus  organisms  themselves: 
(i)  becau.se  the  actual  presence  of  the  pus  germs  has 
not  been  demonstrated  in  the  blood;  (2)  because  the 
symptoms  disappear  so  quickly  after  thorough  cleans- 
ing and  drainage. 


July  17.  1897] 


MEDICAL    RECORD. 


99 


The  chronic  form  of  suppurative  fever,  witli  charac- 
teristic rhythmic  temperature  chart,  '"  up  at  night  and 
down  in  the  morning,''  with  flush  of  cheek  and  wasting 
of  flesh,  is  called  hectic. 

3.  Septicfemia  (true  septicemia,  septic  infection)  is 
due  to  the  absorption  of  the  saprophytic  germs  or  micro- 
organisms of  putrefaction,  with  their  actual  presence 
in  the  blood  in  enormous  quantities.  The  symptoms 
are  an  initial  chill  (one  only),  a  continued  fever,  rapid 
pulse  and  respiration,  coma,  sordes  on  the  lips,  a  dry 
cracked  tongue,  mental  hebetude,  muttering  delirium, 
with  enlargement  of  the  spleen  and  of  the  superficial 
lymph  glands.  The  wound,  if  upon  the  surface,  will 
often  appear  gangrenous  and  emit  a  foul  odor.  Treat- 
ment consists  in  rigid  local  asepsis  and  the  most  vig- 
orous supportive  measures. 

3.  Saprcemia  (to.\asmia,  septic  into.xication,  ptoniain 
poisoning)  is  due  to  the  absorption  of  the  products  of 
micro-organisms  (ptomains)  from  the  seat  of  infection. 
It  is  evident  that  while  true  septicaemia  emphasizes 
the  actual  presence  of  bacteria  in  the  blood  itself,  sa- 
pr;T;mia  depends  largely  upon  their  limitation  to  the 
point  of  introduction  and  the  destruction  of  tissue 
there,  and  is  due  to  the  absorption  of  the  products 
from  the  original  point  of  infection.  Sapraemia  is 
often  ushered  in  with  a  single  chill,  followed  by  fever 
and  sweat,  tenderness  and  pain  at  the  infected  spot, 
or,  if  the  wound  be  under  observation,  it  will  appear 
swollen,  with  inflamed  edge  and  covered  by  unhealthv 
granulations.  The  skin  is  hot,  the  pulse  and  respira- 
tion are  rapid,  the  tongue  is  dry  and  thickly  coated, 
the  urine  scanty  and  highly  colored;  the  patient  is 
restless,  with  a  mild  delirium.  This  condition  lasts 
four  or  five  days,  and  the  symptoms  gradually  subside. 
It  is  in  obstetric  practice  that  this  form  of  disease  is 
too  often  found.  The  whole  course  of  sapra;mia 
emphasizes  the  local  element,  and  to  local  treatment 
we  must  look  for  its  removal.  The  constitutional 
treatment  consists  of  stimulating  and  supportive 
measures. 

4.  Pyiemia:  Few  terms  in  surgery  are  so  confusing 
as  pysmia.  It  seemed  to  the  speaker  that  we  can 
safely  restrict  the  term  to  a  distinct  disease  character- 
ized by  a  state  of  depression  common  to  all  typhoidal 
conditions,  but  distinguished  by  the  formation  of  pus 
cavities  in  different  and  widely  separated  parts  of  the 
body.  No  tissue  can  be  e.xempt.  There  is  here  surely 
a  double  infection,  the  micro-organisms  of  putrefac- 
tion and  of  pus  both  being  introduced  directly  into  the 
blood,  and  the  latter  proliferating  wherever  they  hap- 
pen to  lodge.  The  symptoms  appear  about  the  second 
week  after  the  injury.  They  are  repeated  chills  and 
colliquative  sweats,  the  temperature  rising  syncliro- 
nously  with  the  chill,  the  pulse  and  respiration  rapid 
and  weak,  with  icteroid  skin,  anorexia,  more  or  less 
diarrhoea,  great  prostration,  great  pain  at  the  imme- 
diate seat  of  the  abscess,  hyperaesthesia  of  the  cutane- 
ous surface,  and  erythematous  rashes  and  ecchymoses; 
the  mind  is  clear,  unless  metastatic  abscesses  lodge  in 
the  brain.  We  can  difl"erentiate  it  from  true  septicae- 
mia by  the  mental  clearness,  the  hyperassthesia,  the 
repeated  chill  (half  a  dozen  a  day)  and  excessive  ex- 
hausting sweat,  and  the  localized  abscess.  The  treat- 
ment is  supporting  and  stimulant,  with  early  evacua- 
tion of  the  abscesses  where  accessible. 

Arterial  pyaemia,  so-called,  is  an  entirely  different 
condition,  being  non-infective,  depending  upon  the 
lodgement  of  an  embolus  in  some  distant  organ,  de- 
tached from  a  fibrinous  white  thrombus  in  the  left 
ventricle.      The  term  should  be  abandoned. 

Cicatricial  Stenosis  and  Valve  Formation  as  a 
Cause  of  Pyloric  Obstruction,  with  a  Report  of 
Five  Cases  Relieved  by  Operation.  Dr.  VV.  ]. 
Mayo,  of  Rochester,  Minn.,  read  a  paper  on  this  sub- 
ject.     Non-malignant  forms  of  pyloric  obstruction  are 


not  infrequent,  and  have  been  confused  with  cancer- 
ous disease;  the  subjects  have  usually  been  left  ta 
die  without  surgical  intervention.  Stricture  of  the 
pylorus  following  upon  the  healing  of  gastric  ulcer  is 
the  most  common  form  of  non-malignant  obstruction, 
and  four  out  of  five  cases  upon  which  the  speaker 
has  operated  have  been  of  this  variety.  The  pro- 
duction of  valve  formation  at  the  pylorus  is  similar 
to  the  valve  formation  of  the  ureter  at  the  pelvis  of 
the  kidney  as  a  cause  of  hydronephrosis  and  pyone- 
phrosis, so  graphically  portrayed  by  Fenger.  Enterop- 
tosis  favors  such  obstruction.  A  few  cases  of  con- 
genital stricture  have  been  reported.  The  diagnosis 
of  marked  pyloric  obstruction  and  the  consequent  di- 
latation of  the  stomach  are  not  difficult.  The  gastro- 
scope  and  the  gastrodiaphanoscope  are  of  little  practi- 
cal value  to  the  surgeon.  The  differentiation  between 
malignant  and  non-malignant  forms  of  obstruction  is 
often  difficult,  and  maybe  impossible  without  explora- 
tory incision.  Examination  of  the  stomach  contents 
is  of  value.  When  the  meal  test  of  Ewald  and  Boas 
shows  the  absence  of  free  hydrochloric  acid  withGiins- 
burg's  test,  and  at  the  same  time  develops  lactic  acid 
by  Uftelmann's  method,  the  indications  are  for  cancer. 
After  all,  the  chief  factors  in  the  dift'erential  diagnosis 
will  be  obtained  from  a  careful  examination  in  con- 
nection with  the  personal  history  of  the  patient.  He 
called  attention  to  the  significance  of  enlarged  glands 
in  the  greater  and  lesser  omenta  as  evidences  of  malig- 
nancy. Bull  states  that  fifty  per  cent,  of  pyloric  can- 
cer cases  prove  fatal  before  glandular  infection  takes 
place. 

Operation:  The  median  abdominal  incision,  be- 
tween the  ensiform  cartilage  and  the  umbilicus,  has 
proved  to  him  the  most  satisfactory.  Pyloroplasty  is 
the  operation  of  choice.  The  incision  should  be  in 
healthy  tissue  rather  than  in  scar  tissue,  as  the  latter 
is  stiff  and  does  not  nicely  coapt,  and  atrophy  ne- 
crosis often  results  from  suture  pressure.  Out  of  five 
cases  he  was  able  to  do  pyloroplasty  in  but  two.  Py- 
lorectomy  will  be  seldom  done  for  non-malignant  stric- 
ture. 

Gastro-enterostomy  for  non-malignant  disease  is  an 
operation  of  expediency  and  not  of  choice.  Extensive 
contractures  of  the  pylorus,  the  presence  of  tissue  un- 
suitable for  the  security  of  suture  union,  and  inacces- 
sibility of  the  field  of  operation  by  reason  of  the  pres- 
ence of  dense  adhesions  to  important  structures, 
indicate  its  use.  Taking  all  facts  into  consideration, 
he  believes  the  suture  method  of  VVolfler  offers  the 
fewest  objections. 

The  speaker  then  gave  a  detailed  history  of  his  five 
cases. 

The  Present  Status  of  the  Injection  Treatment  of 
Hemorrhoids. — Dr.  L.  H.  Adler,  Jr.,  of  Philadel- 
phia, reviewed  briefly  the  injection  treatment  of  hem- 
orrhoids, quoting  largely  from  Agnew's  work  on  sur- 
gery. 

Transperitoneal  Ligation  of  the  Iliac  Artery, 
with  Report  of  Cases. — Dr.  T.  S.  K.  Morton,  of 
Philadelphia,  made  a  report  on  twenty-eight  cases 
operated  upon,  of  which  number  twenty-one  ended  in 
recovery.  Deaths  that  occurred  were  due  to  abdomi- 
nal complications. 

The  Etiology  and  Classification  of  Tumors — Dr. 
S.  H.  Friend,  of  Milwaukee,  Wis.,  read  a  deeply  sci- 
entific paper  on  this  subject. 

Serum  Therapy  in  Acute  Surgical  Infectious 
Diseases. — Dr.  Hi)w.\kii  LiLrENinAi.,  of  New  York, 
read  a  paper  on  this  subject. 

The  Differential  Diagnosis  of  Surgical  Lesions 
in  the  Right  Half  of  the  Abdomen  and  Pelvis,  with 
Especial  Reference  to  the  Diagnosis  of  Appendicitis. 
— Dr.  George  Rverson  Fowler,  of  Brooklyn,  N.  Y., 
read  a  paper  on  the  above  subject.     There  can  be  no 


MEDICAL    RECORD. 


[July  17,  I ! 


question  that  the  inflammatory  conditions  of  the 
vermifonn  appendix  constitute  the  most  important 
surgical  lesions  of  the  abdominal  cavity  in  both  sexes. 
The  difficulties  of  diagnosis  are  greatly  increased  in 
the  female,  owing  to  errors  arising  from  the  presence 
of  neighboring  organs  that  take  on  suppurative  in- 
flammation. All  conditions  which  may  be  mistaken 
for  appendicitis  in  the  male,  with  the  sole  and  rare 
exception  of  an  inflamed  right  undescended  testicle, 
occur  likewise  in  the  female.  Some  occur  with  greater 
frequency  in  women ;  such  are  cholelithiasis  and  im- 
paction of  gall  stones  and  resulting  dropsy  and  em- 
pyema of  the  gall  bladder,  etc.  Gall  stones  occur 
nearly  five  and  floating  kidney  six  times  more  often 
in  women  than  in  men.  One  should  bear  in  mind 
that  the  right  kidney  is  alifected  four  times  as  fre- 
quently as  the  left.  Appendical  affections  rank  first 
in  importance  among  the  surgical  affections  of  the  ab- 
dominal and  pelvic  cavities. 

Appendicitis  clinically  is  divided  into  acute,  sub- 
acute, and  chronic.  The  speaker  then  briefly  called 
attention  to  the  principal  points  to  be  borne  in  mind 
in  the  objective  and  subjective  symptoms  of  these 
clinical  forms. 

In  acute  appendicitis  points  to  be  noted  are:  (<?) 
Sudden  onset;  (/')  colicky  or  cramping  abdominal 
pains,  which  in  the  majority  of  cases  are  referred  to 
Ihe  region  immediately  above  the  umbilicus,  and  later 
become  diffused;  (i)  vomiting;  (J)  localized  pain 
and  tenderness — this  is  finally  referred  to  the  right 
iliac  region;  (<')  rigidity  of  the  right  rectus  muscle  at 
its  lower  part;  (/)  the  presence  of  a  tumor  in  the  ileo- 
cecal region,  which  makes  its  appearance  after  the 
first  or  second  day;  (^)  fever,  which  is  not  marked  at 
the  commencement,  and  some  acceleration  of  the  pulse. 
Variations  from  the  usual  and  typical  characteristics  of 
an  acute  attack  consist  in:  1st.  Occurrence  of  prima- 
ry general  abdominal  pain,  rather  than  the  localized 
pain.  2d.  .\bsence  of  vomiting,  due  to  the  fact  that 
the  stomach  is  quite  free  from  ingesta.  3d.  I-ocalized 
pain  usually  abated  and  right  iliac  tenderness  dimin- 
ished by  the  administration  of  opiates.  4th.  Opiates 
may  so  modify  respiratory  movements  as  to  render 
rigidity  of  the  right  rectus  muscle  of  no  service  in 
•diagnosis.  5th.  Tumor  is  not  usually  to  be  found 
until  after  twenty-four  hours;  it  is  often  delayed  until 
after  fortj'-eight  hours.  The  speaker  referred  to  the 
varfous  positions  in  which  the  tumor  may  be  found. 
•6th.  The  pulse  rate  may  be  but  slightly  affected  in  the 
beginning,  and  during  an  exceptionally  mild  attack 
ulcerative  perforation  of  the  organ  may  occur  at  any 
time  with  no  rise  of  temperature. 

In  subacute  appendicitis  the  onset  is  less  stormy, 
and  the  affection  is  often  regarded  as  indigestion  or 
intestinal  colic.  Tenderness  at  the  site  of  the  appen- 
dix can  generally  be  elicited,  but  usually  there  is  no 
tumor.  These  cases,  if  permitted  to  continue,  will 
<:ertainly  eventuate  in  an  acute  attack. 

Chronic  appendicitis  may  be  chronic  from  the  be- 
ginning. In  the  vast  majority  of  cases  it  either 
eventuates  from  rejjeated  subacute  attacks  or  follows  a 
well-defined  acute  attack.  The  characteristic  clinical 
picture  is  marked  by  tenderness  in  the  ileo-ca-cal 
region,  with  or  without  the  presence  of  tumor. 

The  differential  diagnosis  will  be  between  lesions  of 
gall-bladder  origin,  those  originating  in  the  intestine 
and  not  of  necessity  involving  the  appendix,  and  tubo- 
ovarian  disease.  The  passage  of  a  stone  along  the 
ductus  communis  choledochus  may  simulate  the  com- 
mencement of  an  acute  appendicitis.  A  gall  stone 
impacted  in  the  cystic  duct  and  followed  by  dropsy 
of  the  gall  bladder  may  give  rise  to  some  of  the  symp- 
toms of  chronic  appendicitis. 

.\n  acute  obstruction  or  a  perforation  of  the  bowel 
in  the   ileo-cacal   region  must  be  differentiated.     Of 


less  importance  are  the  chronic  obstructions  and 
neoplasms,  because  they  do  not  require  such  prompt 
diagnosis  and  celerit)-  of  action  as  do  cases  of  acute 
appendicitis. 

The  following  points  should  be  borne  in  mind: 
Frequency — males,  eighty  per  cent. ;  females,  twenty 
per  cent.  History  of  an  attack  is  usually  that  of  an 
acute  onset.  Pain  is  usually  acute  and  radiating.  In 
subacute  and  chronic  appendicitis  the  pain  may  be 
dull  and  localized.  Vomiting  is  exceedingly  conamon 
in  appendicitis.  Tenderness  in  the  great  majority  of 
cases  is  located  over  the  site  of  the  appendix.  Chill 
or  rigor  is  of  infrequent  occurrence  in  appendicitis. 
Fever  is  present  in  appendicitis,  although  its  grade 
does  not  indicate  the  severity  of  the  attack.  Muscular 
tension  is  almost  invariably  absent  in  adnexa  lesions. 
Tumor  is  rarely  present  before  the  third  day  in  appen- 
dicitis. It  is  rare  that  a  tumor  of  appendical  origin 
can  be  felt  by  the  vaginal  touch.  The  course  is  usually 
an  acute  one,  while  lesions  of  the  adnexa  are  usually 
subacute  or  chronic. 

The  speaker  called  attention  to  the  fact  that  one 
should  remember  that  great  diflSculties  may  present 
themselves  in  establishing  a  diagnosis  of  appendicitis 
in  the  male  sex  under  circumstances  of  a  long  appen- 
dix passing  deeply  into  the  lesser  pelvis. 


Fourth  Day — Friciay,  /line  4,  i8^J. 

U7 )  The  Treatment  of  Colles'  Fracture  ;  {h)  The 
Passing  of  Plaster. — Dr.  E.  A.  Tr.\cy,  of  Boston, 
Mass.,  discussed  the  above  subject.  In  1814  Colles 
published  his  obsen-ations ;  previous  to  this  time  he 
had  reported  a  case  of  this  condition  under  the  belief 
that  it  was  a  dislocation.  The  nearness  to  the  wrist- 
joint  and  the  absence  of  characteristic  signs  of  fracture 
sened  to  make  the  diagnosis  of  fracture  difficult.  The 
speaker  then  quoted  the  views  of  eminent  surgeons  in 
reference  to  the  treatment  of  Colles'  fracture.  The 
views  of  Sir  Astley  Cooper,  John  H.  Packer,  Swin- 
burne, Bright.  McClellan,  Agnew,  and  others  were 
mentioned.  The  stiffness  of  the  wrist  and  fingers  is 
due  to  a  fibrinous  exudate  about  the  tendon  sheaths. 
The  writer  believes  that  passive  motion  should  be  em- 
ployed about  the  fifth  day.  Fracture,  if  reduced,  has 
no  tendency  to  separate.  The  hand  is  placed  in  the 
semiprone  position,  and  a  splint  applied  which  needs 
only  moulding  and  no  padding.  In  the  treatment  of 
Colles'  fracture  we  must,  first,  reduce;  second,  protect: 
and  third,  employ  passive  motion  of  the  fingers  from 
the  first  day,  and  of  the  wrist  from  the  fifth  day.  Dr. 
Manley  some  time  ago  stated  that  plaster  of  Paris  is 
doomed.  The  speaker  thought  that  plaster  of  Paris 
will  be  soon  relegated  to  its  proper  position.  Plaster 
of  Paris  is  dangerous,  and  sometimes  deadlv.  It  does 
not  immobilize  the  inclosed  parts.  Passive  motion  is 
important  in  the  treatment  of  these  fractures,  and  im- 
mobilization is  not  indicated.  Splints  should  be  ap- 
plied daily  and  removed  daily,  so  that  the  surgeon 
may  know  the  condition  of  the  fracture.  He  related  a 
case  of  fracture  which  was  put  up  in  plaster-of  Paris 
splint;  after  the  removal  of  the  splint,  the  parts  were 
bathed  in  pus  and  the  bone  protruded.  He  wished 
to  call  the  attention  of  the  section  to  the  wood-fibre 
splint,  specimens  of  which  were  shown,  A  few  facts 
relative  to  wood  fibre  were  then  given.  This  material 
can  be  applied  to  a  fracture  of  any  limb.  No  cotton 
batting  is  used.  It  is  simply  letained  by  a  bandage. 
Swelling  does  not  interfere  with  the  keeping  of  the 
wood  fibre  in  position.  The  splint  can  be  readily 
removed,  in  order  to  conduct  passive  motion.  He  em- 
phasized the  fact  that  passive  motion  of  joints  should 
be  employed  at  the  earliest  possible  time.  The  mate- 
rial is  porous,  light  in  weight,  clean,  and  can  be  used 
for  months.     Wood-fibre  material  permits  of  the  intro- 


July  17.  iSg-] 


MEDICAL    RECORD. 


duction  of  antisepsis.  It  is  also  penious  to  the  -v-rays. 
Master)-  comes  to  any  one  who  possesses  ordinan-  me- 
chanical skill. 

Dr.  McFarlaxd,  of  Pittsburg,  said  that  he  thought 
sreat  abilitj-  was  necessary  in  applying  the  splint. 
He  could  not  coincide  with  the  reader  of  the  paper  in 
reference  to  the  baneful  influence  of  plaster  of  Paris. 
He  laid  great  stress  on  the  use  of  the  cotton  baiting. 
In  compound  fractures  it  is  possible  by  the  use  of  the 
fenestra  to  do  good  work  with  plaster  of  Paris.  One 
should  become  accustomed  to  its  use.  Plaster  of  Paris 
does  not  interfere  with  the  .v-rays.  It  is  now  a  well- 
recognized  procedure  to  treat  fractures  by  the  ambu- 
lator)' method — secure  the  limb  in  plaster  of  Paris  and 
allow  the  patient  to  walk  about — and  so  permit  a 
business  man  to  attend  to  his  duties. 

The  ChairM-\n  thought  that  a  great  deal  of  blame 
had  been  unjustly  placed  upon  plaster  of  Paris  by  the 
reader.  In  the  instance  reported  by  the  reader  of  the 
paper,  in  which  the  plaster  was  said  to  have  caused 
sloughing  of  a  limb,  he  thought  the  fault  was  with  the 
surgeon  who  applied  the  plaster  rather  than  with  the 
plaster  itself:  it  was  lack  of  intelligence  in  applying 
the  plaster  that  caused  the  slough.  Plaster  of  Paris 
did  immobilize  a  limb  if  placed  on  properly.  He 
thought  the  objection  to  the  splint  shown  was  the  lack 
of  good  application. 

Dr.  G.\.ston",  of  Atlanta,  Ga.,  said  that  in  the  resto- 
ration of  bone  we  must  have  inflammatory  action.  If 
there  is  no  inflammatory  action  bone  does  not  grow- 
together  well.  He  has  had  to  grind  ends  of  bone  to- 
gether in  order  to  get  enough  inflammatory  action,  and 
he  then  reapplied  the  plaster  of  Paris.  He  has  used 
pasteboard  splints  with  good  results. 

Dr.  Fowler,  of  Brooklyn,  stated  that  three-fourths 
of  all  malpractice  suits  against  practitioners  were 
brought  about  by  the  bad  results  following  fracture 
treatment.  He  had  used  plaster-of-Paris  material 
at  one  stage,  and  pasteboard  at  another  stage.  WoLff, 
of  Berlin,  attempted  to  make  a  spinal  jacket  of  silicate 
of  sodium  and  plaster  of  Paris  in  the  same  splint. 
This  device  could  be  applied  to  both  extremities.  The 
silicate  of  sodium  was  used  first,  then  dry  muslin,  and 
lastly  the  plaster  of  Paris  was  applied.  Later  the 
plaster  of  Paris  was  cut  away  and  the  silicate  of  so- 
dium was  left.  This  was  particularly  useful  for  weak 
women,  with  whom  the  light  silicate  could  be  used 
instead  of  the  heavy  plaster. 

Dr.  Tr.\cy  closed  the  discussion.  He  stated  that 
he  had  used  wood-hbre  splints  in  his  practice  for  many 
years.  He  also  stated  that  he  now  used  more  than 
ever  plaster  of  Paris  and  other  material.  He  had 
seen  bad  results  follow  the  use  of  wood  fibre  as  well 
as  that  of  plaster.  He  agreed  with  the  chairman  that 
the  fault  was  more  with  the  surgeon  than  with  the 
dressing. 

Oflftcers.  — •  The  following  officers  were  elected : 
Chairman,  Dr.  \\'.  Rodman,  of  Louisville.  Ky. :  Sicrc- 
iarv.  Dr.  H.  O.  Walker,  of  Detroit,  Mich. 


Appendicitis  and  Typhlitis Dr.  Storch  (Journal 

of  Practual  Meduim,  April)  concludes  as  follows;  i. 
The  term  typhlitis  as  applied  to  diseases  in  the 
region  of  the  iliac  fossa  is  erroneous,  misleading,  and 
dangerous.  2.  An  active  cathartic  assisted  by  enemas 
will  most  always  dispel  all  doubts  as  to  whether  we 
have  to  deal  with  a  case  of  strangulation  of  the  bowels 
or  with  appendicitis.  3.  Foreign  bodies  are  not  always 
the  sole  cause  of  appendicitis.  4.  The  pathogenic  in- 
testinal microbes  are  pus  producers  and  sole  agents  of 
ulceration  and  perforation,  and  as  such  play  the  active 
role  in  appendicitis.  5.  Surgical  interference  at  an 
early  period  is  the  only  rational  safe  procedure  in  ap- 
pendicitis. 


<f  urgical  J>ttggestions. 

Resection  of  Lung. — Resection  of  lung,  or  pneu- 
mectomy,  would  appear  at  first  glance  to  be  a  rational 
method  of  procedure  in  tuberculosis  of  the  pulmonarj- 
structure.  Surgeons  who  are  accustomed  to  practise 
resections  of  the  articular  e.xtremities  in  tuberculous 
osteoarthritis  and  extirpation  of  the  synovia  in  tuber- 
culous synovitis,  and  who  have  witnessed  the  gratify- 
ing results  following  these  operations,  are  at  once 
impressed  with  a  desire  to  institute  radical  operative 
methods  in  a  disease  which  counts  its  victims  by 
thousands  yearly.  The  pulmonar)-  structure,  however, 
differs  from  all  other  structures  in  the  body  in  its  sus- 
ceptibility to  infection  by  means  of  the  bacillus  tuber- 
culosis, and  its  anatomical  peculiarities  are  such  as  to 
favor  extension  of  infection  and  reinfection  of  parts 
whose  vital  resistance  has  been  lowered  by  disturb- 
ances of  nutrition  from  any  cause. — Dr.  George  R. 
Fowler.  Annals  of  Surgery,  November,  1896. 

Abdominal   Contusions  with  Visceral   Lesions. — 

Dr.  Gilliam  {^Columbus  MeJual  Journal,  March  i6th) 
says  that,  in  order  that  we  may  guard  against  such 
w-holesale  interference  and  still  include  as  many  as 
possible  of  the  cases  demanding  operation,  he  has 
formulated  the  following  rules.  Explorative  section 
should  be  made:  i.  When  blood  is  foimd  in  the 
ejecta  of  the  stomach  or  bowels  or  in  the  urine.  2. 
When  abdominal  rigidity,  t)-mpanites,  or  other  infer- 
ential signs  of  visceral  lesion  exists.  3.  When  the 
patient  complains  of  burning  pain  or  a  sense  of  grave 
internal  injur}-.  4.  When  there  is  profound,  remit- 
tent, or  recurrent  shock.  5.  \\'hen  from  the  nature 
of  the  injur)-  it  is  probable  that  visceral  lesion  has  re- 
sulted. And  finally  the  patient  in  all  cases  should  be 
watched  closely  for  fort}--eight  hours,  during  which 
time  any  imtoward  manifestation  should  be  the  signal 
for  exploration. 

Trephining — Dr.  Estes  states  that  his  experience 
leads  him  to  believe  that  one  should  never  use  the 
trephine  in  depressed  compound  comminuted  frac- 
tures. The  instruments  usually  necessary  are  a  knife, 
a  pair  of  blunt-pointed  scissors,  a  chisel,  a  good  sharp 
Hopkins  rongeur,  two  or  three  bone  forceps  with  dif- 
ferent ciu-ves.  an  elevatorium,  tsvo  thumb  forceps,  one 
"rat  toothed,""  a  half  dozen  hemostatic  forceps,  small 
and  medium-sized  curved  needles  and  a  good  needle 
holder,  small  and  medimn  silk,  silk  gut  and  catgut  for 
sutures  and  ligatiu-es.  The  small  needles  should  be 
previously  threaded  and  ready  for  instant  use. 

Acute  Osteomyelitis. — Deep,  rapidly  increasing 
pain  in  an  arm  or  leg.  accompanied  by  swelling  with- 
out redness  or  fluctuation,  together  with  high  fever  or 
chills,  is  the  t)-pical  picture  of  acute  osteomyelitis. 
The  disease  at  this  stage,  which  may  be  a  few  days  or 
only  a  few  hours  from  its  onset,  is  indeed  one  of  the 
emergencies  of  surger)'.  The  diagnosis  must  be  care- 
fully but  fearlessly  made  and  the  treatment  speedily 
instituted,  for  delay  may  mean  death  or  lifelong  de- 
formity. No  temporizing  should  be  permitted  once 
the  diagnosis  is  clear,  but  free  incision  to  the  bone, 
with  chiselling  into  its  marrow,  should  be  at  once  per- 
formed. Vou  will  not  find  pus,  as  ?  rule,  in  these  early 
cases,  but  a  periosteum  which  is  easily  peeled  from  the 
bone  and  a  cortex  which  bleeds  but  little.  Immediate 
relief  of  symptoms  will  show  that  you  have  not  struck 
amiss.  The  frequency  of  necrosis  of  bone  would  be 
greatlv  reduced  if  these  timely  operations  were  more 
common.  Unfortunately,  the  procrastinating  poultice 
or  the  ice  bag  too  often  has  its  day.  and  in  the  mean 
time  local  tissue  destruction  and  general  sepsis  may 


MEDICAL    RFXORD. 


[July  17.  1897 


•compromise  the  case.  Remember  that  any  bone  may 
be  the  seat  of  acute  osteomyelitis,  although  it  is  often- 
est  encountered  in  the  long  bones. — International  Jnur- 
iial  of  Surgery. 

Enlargement  of  the  Prostate. — In  the  ordinary 
•cases  of  prostatic  enlargement,  of  however  long  stand- 
ing, in  which  the  obstruction  is  not  great  and  the 
.power  of  the  bladder  is  fair,  in  which  there  is  not  an 
excessive  amount  of  residual  urine,  in  which  catheter- 
ism  is  easy  and  painless,  and  in  which  cystitis,  if  it 
exists,  is  not  severe  and  can  be  controlled  by  aseptic 
washings  and  regular  catheterism,  operative  treatment 
is  not  indicated. — Samuel  Alexander. 

Torticollis. — Dr.  Gillette  {Fcdiatrks)  reports  three 
cases  of  torticollis  due  to  adenoid  vegetations  and 
•chronic  hypertrophy  of  the  tonsils.  One  case  was 
.-cured  by  the  removal  of  the  local  trouble  and  the 
others  were  greatly  benefited. 

Massage   and   Movements  in  the  Treatment  of 

Practures Dr.  Davis  {^Annals  of  Surgery,  December, 

1896)  summarizes  his  views  as  follow  s :  "  It  is  my  be- 
lief that  massage  and  passive  motion  are  not  used  to 
the  extent  that  they  should  be  in  the  treatment  of  frac- 
tures; that  immobility  of  the  fractured  ends  favors 
.quick  union  with  little  deformity;  that  there  are  some 
cases  in  which,  owing  either  to  peculiarities  of  the 
•fracture  or  the  impaired  constitution  of  the  individual, 
ithe  tendency  to  the  formation  of  callus  is  marked. 
Motion  in  these  tends  to  the  formation  of  exuberant 
•callus  and  deformity.  There  are  others  in  which  bony 
union  is  unduly  delayed;  disturbance  of  the  fractured 
•ends  in  these  hinders  union.  It  is  wise  to  wait  until 
the  fractured  parts  are  glued  together,  usually  eight  or 
ten  days,  before  attempting  any  except  the  lightest 
massage,  and  any  extensive  passive  motion  after  that 
time  should  be  used  carefully  but  diligently.  Passive 
motion  and  massage,  when  first  attempted,  should  be 
of  the  most  gentle  character,  and  not  so  violent  as  to 
disturb  the  relation  of  the  broken  bones.  Any  marked 
pain  and  inflammatory  reaction  following  passive  mo- 
tion and  massage  are  evidence  that  they  have  been  too 
violent.  The  limb  should  receive  massage  and  manip- 
ulation at  each  inspection  or  change  of  dressing,  often 
•daily.  In  some  cases  it  is  advisable  to  administer 
such  massage  as  is  possible  without  removing  the 
splints.  Persistent  stiffness,  particularly  in  fractures 
or  injuries  of  the  wrist,  is  often  due  to  a  rheumatoid 
affection  locating  itself  in  the  injured  region.  Mas- 
sage is  valuable  in  the  treatment  of  such,  and  should 
be  given  to  that  part  of  a  limb  beyond  the  seat  of  frac- 
ture to  preserve  it  in  a  normal  condition.  Such  dress- 
ings and  methods  of  treatment  should  be  adopted  as 
will  allow  of  the  greatest  use  of  massage,  and  passive 
and  active  movements  consistent  with  proper  retention 
•of  the  fragments.'' 

The  Treatment  of  Injuries  to  the  Gall  Bladder 
and  Biliary  Ducts. — Drs.  Terrier  and  Auvray  i^Rev. 
de  C/iir.,  January,  1897)  recommend  operative  inter- 
ference in  doubtful  as  well  as  in  positive  cases  of  in- 
jury of  these  parts.  Laparotomy  should  be  performed 
even  though  the  question  may  arise  whether  a  wound 
of  the  abdominal  wall  be  a  penetrating  one  or  not, 
and  also  in  cases  of  contusion  when  one  suspects  a 
rupture  of  any  of  these  parts.  Peritonitis  caused  by 
the  effusion  of  bile  is  usually  restricted  and  of  a  mild 
character,  provided  the  fluid  be  aseptic:  still  there  can 
be  no  doubt  that  bile,  when  in  contact  with  the  peri- 
toneum, may  act  as  a  poison.  Loss  of  bile  resulting 
from  the  effusion  of  this  fluid  into  the  peritoneal  cav- 
ity leads  to  exhaustion  and  emaciation,  which  will 
sooner  or  later  threaten  the  life  of  the  patient.  There- 
fore in  a  case  of  abdominal  contusion  in  which  there 


is  the  least  doubt  as  to  the  existence  of  a  lesion  of  the 
biliary  passages  and  in  which  there  is  pain  localized 
in  the  epigastric  or  right  hypochondriac  regions,  one 
should  resort  to  prompt  exploratory  laparotomy.  This 
operation,  when  performed  with  strict  antiseptic  pre- 
cautions, is  quite  free  from  danger,  and  consists  in  a 
simple  incision  through  the  abdominal  wall  over  the 
region  in  which  the  presence  of  effused  bile  is  re- 
vealed by  dulness  and  in  the  evacuation  of  the  fluid. 
Caution  must  be  taken  not  to  wound  any  adherent  in- 
testine or  any  false  membrane  that  may  have  formed 
about  the  seat  of  rupture.  If  the  gall  bladder  be 
found  torn  through,  one  has  to  decide  between  chole- 
cystorrhaphy  and  cholecystectomy,  the  former  being 
practised  for  slight  wounds  and  the  latter  when  there 
has  been  much  laceration.  Rupture  of  the  cystic  duct 
should  be  treated  by  a  ligature  of  the  canal  at  its  pe- 
ripheral end  and  subsequent  cholecystectomy.  Rup- 
ture of  the  hepatic  duct  can  be  treated  only  by  evacu- 
ation and  temporary  plugging  and  drainage,  with  a 
view  of  preventing  further  effusion  into  the  abdominal 
cavity  and  the  formation  of  protective  adhesions.  In 
case  the  common  duct  be  opened  it  should  be  closed 
by  a  double  ligature,  and  then  a  communication  should 
be  established  between  the  gall  bladder  and  the  small 
intestines. 

Silver  as  an  Antiseptic   in   Surgical   Practice.— 

Dr.  Credc'  {dntralbl.  f  C/iirurg.,  No.  43,  1896)  advo- 
cates the  use  of  silver  and  silver  salts  as  safe  antisep- 
tic agents  in  the  treatment  of  wounds.  Gauze  impreg- 
nated with  finely  divided  silver  may  be  used  to  cover 
the  incision  made  in  a  surgical  operation.  If  this  is 
placed  over  ulcerated  or  freely  secreting  parts  the  sli- 
ver is  converted  into  the  lactate  of  silver  by  means 
of  the  products  of  decomposition;  this  substance  is 
very  irritating.  An  open  surface,  therefore,  is  first 
covered  by  powdered  citrate  of  silver  and  then  sil- 
ver gauze  is  placed  over  it  to  exclude  the  air.  Crede 
states  that  this  method  of  treatment  does  not  re- 
quire such  strict  precautions  as  other  methods  of  anti- 
septic treatment.  The  results  of  this  treatment  have 
been  very  good  and  he  regards  the  silver  dressings  as 
being  the  most  reliable  in  the  treatment  of  all  forms  of 
wounds. 

The  Best  Method  of   Suture   after   Laparotomy. 

— La  Torre  (International  Congress  in  Geneva)  says; 
A  good  abdominal  scar  depends  upon  three  main  fac- 
tors: the  location  of  the  incision,  the  suture  material, 
and  the  method  of  suturing.  Bantock :  Bacteria  take 
no  part  in  the  production  of  pus.  They  are  the  result 
and  not  the  cause  of  the  condition.  Suppuration  of  the 
abdominal  wound  or  the  suture  tract  does  not  originate 
from  the  introduction  of  germs  or  adult  bacilli  into  the 
wound,  but  is  the  sequence  of  necrosed  tissue  in  the 
wound  and  excessive  tension  of  the  sutures.  The  or- 
dinary interrupted  suture  suffices  in  most  cases,  but 
in  very  fat  subjects  it  is  advisable  to  close  the  peri- 
toneal cavity  with  continuous  sutures,  while  the  rest 
of  the  wound  is  united  by  two  layers  of  interrupted 
sutures.  Silk  is  the  best  material  for  interrupted 
sutures,  while  for  the  continuous,  catgut  (not  chromic- 
acid  gut)  is  preferred.  Byford :  Avoidance  of  wound 
infection  and  injury  to  the  tissue  during  operation  is 
of  prime  importance.  A  median  incision  is  advised. 
First  unite  the  peritoneum,  next  fascia  and  muscles, 
and  finally  the  skin.  Use  interrupted  sutures  of  silk- 
worm gut.  Edebohls:  The  resistance  of  the  abdomi- 
nal scar  depends  upon  a  broad  surface  of  contact. 
Divide  the  fibrous  covering  of  the  recti  and  in  the 
subsequent  closure  of  the  wound  the  peritoneum  is 
first  united,  next  the  two  recti  muscles  are  sutured  to- 
gether, and  the  suturing  of  the  fascia  and  skin  com- 
pletes the  operation.      Use  chromic-acid  catgut  for  all 


July  17,  1897] 


MEDICAL    RECORD. 


but  skin  sutures.  Wylie:  Hernia  in  the  linea  alba  is 
frequently  the  result  of  abscesses,  often  caused  by  an 
excessive  tension  of  the  sutures.  An  exact  suturing 
of  the  fascia  is  necessary;  this  should  never  be  done 
by  continuous  sutures  which  would  carry  infection 
throughout  the  whole  wound.  Pozzi  and  Engstroni 
also  lay  great  stress  upon  an  accurate  union  of  the 
same  anatomical  structures.  Coelho  considers  deep 
silk  sutures  the  best  method,  while  Latzko  demon- 
strates a  series  of  microscopical  sections  of  the  ab- 
dominal scar  which  show  that  deep  sutures  unite 
many  structures  not  anatomically  related  to  each 
other,  while  a  careful  suturing  of  fascia  to  fascia  and 
muscles  to  muscles,  etc.,  leaves  a  hardly  distinguish- 
able scar. — Indian  Medical  Gazette,  February,  1897. 

Pyloric  Obstruction  of  Hepatic  Origin. — This  rare 
sequel  of  cholelithiasis  has  been  mainly  acquired  by 
exploratory  operations.  MM.  Tuffier  and  Marchais 
record  two  cases  and  give  a  digest  of  those  recorded 
by  others.  The  calculous  origin  was  clearly  demon- 
strated in  the  whole  series,  except  when  the  obstruc- 
tion resulted  from  the  mechanical  pressure  of  an  he- 
patic ab.scess  or  of  a  biliary  cancer.  An  impaction 
of  a  calculus,  whether  in  the  bladder  or  in  the  ducts, 
may  be  followed  by  an  ascending  infection  resulting 
in  the  formation  of  adhesions,  with  cicatricial  contrac- 
tion following,  at  times  complicated  by  the  develop- 
ment of  fistulous  openings  between  the  gall  bladder 
and  the  pylorus  or  duodenum.  Symptoms  of  pyloric 
obstruction  develop  insidiously  and  may  not  appear 
until  a  long  time  has  elapsed  since  the  impaction  of 
gall  stones.  The  clinical  features  are  somewhat  the 
same  as  those  met  with  in  pyloric  obstruction  result- 
ing from  stricture  and  cancer.  The  vomited  matter  is 
very  abundant,  always  containing  free  hydrochloric 
acid,  and  there  may  be  a  large  amount  of  bile  and 
even  gall  stones.  In  a  small  number  of  cases  haema- 
temesis  is  present.  Dilatation  of  the  stomach  is  pro- 
nounced. As  the  stomach  gradually  dilates,  the  py- 
loric obstruction  may  become  complete  and  the  patient 
dies  of  inanition,  although  recovery  has  occasionallv 
followed  upon  the  vomiting  of  a  number  of  gall  stones. 
The  authors  recommend  washing  out  the  stomach  and 
other  measures  which  may  be  conveniently  described 
as  medical;  if  no  definite  improvement  follows,  an 
exploratory  operation  is  to  be  undertaken.  The  belly 
is  to  be  opened  in  the  median  line  rather  than  in  the 
area  of  possible  adhesions.  The  dilated  stomach  is 
to  be  displaced  upward,  which  allows  the  region  of 
the  pylorus,  the  duodenum,  and  gall  bladder  to  be  ex- 
plored; the  latter  may  be  found  small,  contracted,  and 
united  to  the  pylorus  by  adhesions,  or  there  may  be  an 
ill-defined  mass  formed  by  the  fusion  of  pylorus,  duo- 
denum, gall  bladder,  pancreas,  etc.,  so  firmly  matted 
together  that  it  is  dangerous  to  attempt  to  separate 
them  from  each  other;  but  if  it  is  possible  to  separate 
these  adhesions,  it  should  be  done  with  a  proper  sense 
of  the  risk  involved.  If,  however,  the  obstruction  at 
the  pylorus  is  not  relieved,  a  gastro-enterostomy,  which 
affords  the  best  means  of  relieving  the  symptoms,  is  to 
be  performed.  —  Fevier,  AV?'.  de  Chir.  dc  Paris,  1897. 

Moribund  Intestine. — Dr.  Power  {British  Medical 
Journal,  February  27,  1897),  in  an  article  on  "The 
Pathology  and  Surgery  of  Intussusception,"  writes  in  re- 
gard to  moribund  intestine  as  follows  :  "  When  the  sur- 
geon has  opened  the  abdomen  and  finds  that  the  intus- 
susception is  greatly  congested  and  has  lost  its  gloss 
he  must  not  too  hastily  assume  that  it  is  dead,  yet  it  is 
often  a  matter  of  no  slight  difficulty  to  decide  whether 
or  not  the  bowel  is  capable  of  recovery.  A  piece  of 
intestine  which  is  only  congested  will  bleed  if  it  be 
pricked,  even  though  it  has  lost  its  lustre,  and  if  it  be 
gently  stroked  until  its  vessels  are  emptied  the  blood 


will  be  seen  to  pass  along  the  vessels  again  as  soon  as 
the  pressure  is  taken  off  them.  A  piece  of  intestine 
in  such  a  condition  must  be  handled  very  tenderly. 
It  is  unnecessary  to  remove  it,  and  the  patient  is  often 
so  collapsed  as  to  render  any  prolonged  operation  im- 
possible, even  if  enterectomy  were  advisable.  The 
wisest  thing  to  do  in  such  cases  is  to  wrap  a  layer  or 
two  of  gauze  round  the  injured  intestine  as  soon  as 
the  invagination  has  been  released.  One  end  of  the 
gauze  is  left  hanging  out  of  the  abdominal  wound,  the 
intestine  is  laid  inside  the  peritoneal  cavity,  and  the 
incision  is  lightly  closed  with  temporary  silk  sutures. 
If  the  bowel  ruptures,  the  intestinal  contents  may  then 
find  their  way  out  of  the  abdominal  cavity,  while  if  it 
recovers  the  gauze  can  be  removed  and  the  wound 
will  close  by  granulations." 


OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 
JUBILEE     HONORS      FOR     DOCTORS — HOSPITAL      SUNDAY 
FUND — mercer's    HOSPITAL — HEALTH    OF    LONDON — 

COLLEGE  SURGEONS DEATH  OF    DR.    RAMSKILL THE 

HOSPITAL    FUNDS  —  FILARIA  LOA CHARCOT'S    DISEASE 

AND        RHEUMATOID        AFFECTIONS ANTITOXIN         IN 

DIPHTHERIA HEALTH    OF    LONDON    AND    DUBLIN. 


LONU 


N.    JU 


1897. 


Jubilee,  jubilee  all  the  week.  It  is  over  now  so  far 
as  London  is  concerned,  and  the  centre  of  its  interest 
is  the  naval  review. 

Doctors  have  not  been  altogether  omitted  from  the 
honors  conferred  on  the  occasion.  No  second  medical 
peerage  has  been  created,  but  some  baronetcies  and 
knighthoods  are  conferred  and  promotions  in  their 
orders  of  several  who  had  already  obtained  such  dis- 
tinctions. These  of  course  were  largely  represented 
by  our  military  and  naval  brethren.  The  presidents 
of  the  two  colleges  receive  baronetcies.  Dr.  Wilks,  of 
the  College  of  Physicians,  was  of  course  in  every  one's 
mouth  as  the  one  certainty,  and  we  are  all  glad  we 
were  right.  In  fact,  his  claims  could  not  be  exceeded. 
Sir  \Vm.  MacCormack  had  already  been  knighted  and 
less  could  not  be  offered.  The'  presidents  of  the  two 
Irish  colleges.  Dr.  Duffy  and  Mr.  Thomson,  receive 
knighthoods.  A  baronetcy  is  conferred  on  Mr.  T. 
Smith — Tom  Smith  of  Parts,  as  his  friends  have  so 
long  called  the  amiable  and  skilful  surgeon.  I 
wonder  if  they  will  drop  the  familiarity  now  he  is  Sir 
Thomas  Smith,  Bart.  Dr.  Cowers  is  knighted.  His 
work  has  been  worthy  of  even  higher  distinction.  Dr. 
F.  Semon  attains  the  same  honor.  This  is  the  sur- 
prise of  the  list,  as  he  is  a  German,  though  some  say 
that  is  the  reason.  He  holds  the  German  Red  Eagle 
Order  and  founded  a  German  periodical  devoted  to 
his  specialty. 

Among  those  promoted  and  admitted  to  orders  are 
Dr.  Thorne  Thorne,  C  B.,  who  naturally  receives  the 
K.C.B.  So  do  Inspector-General  Norbury  and  Sur- 
geon-General Gordon.  In  the  case  of  the  latter  the 
distinction  has  been  too  long  delayed.  Dr.  C.  A. 
Gordon  served  through  the  Indian  mutiny  and  in 
China  with  distinction  and  had  been  principal  medi- 
cal officer  of  Madras.  He  was  sent  to  Paris  with 
Surgeon-Major  Wyatt,  and  they  remained  through 
the  siege  and  felt  all  its  horrors.  The  ambassador 
did  not  remain,  but  fled  to  Lyons,  leaving  there 
two  surgeons  as  our  representatives.  The  wretched 
government  of  that  day  never  recognized  their  service 
— it  is  said  for  fear  of  reflecting  on  the  ambassador. 
.\X  length  the  present  government   repairs   the  neglect 


I04 


MEDICAL    RP:C'0RD. 


[July  17.  1897 


as  to  the  survivor,  and  Dr.  Gordon,  CB.,  becomes  Sir 
C,  A.  Gordon,  K.C.B.,  but  poor  Wyatt  has  long  been 
in  his  grave.  Mr.  Burdett  of  hospital  fame  and  Pro- 
fessor Crookes  also  get  K.C.B.,  and  as  their  work  is  so 
related  to  ours  they  may  be  included  in  our  congratu- 
lations. Dr.  Grimshaw,  registrar-general  for  Ireland; 
Dr.  Nicolson,  visitor  in  lunacy;  Major-General  Jame- 
son, director-general;  Sibthope,  Indian  medical  ser- 
vice: and  MacNalty,  army,  receive  the  C.B.  Among 
the  other  orders  the  medical  names  are  Mackie,  Egypt; 
Bushell,  Pekin;  Brown,  colonial  office;  Rowland, 
Lagos;  Hooker,  Kew;  Hooper  and  Cleghorn,  India; 
Husband,  Ajmere;  and  Inspector  of  Fleets  H.  C. 
Woods.  Dr.  Haffkine's  labors  in  India  are  recognized 
by  a  CLE. 

The  Hospital  Sunday  Fund  up  to  this  date  has 
amounted  to  only  half  as  much  as  in  the  corresponding 
week  last  year.  But  probably  the  suspension  of  busi- 
ness proceedings  through  the  jubilee  has  prevented 
the  remittance  of  the  collections  and  they  may  be 
larger  next  week. 

As  was  to  be  feared,  there  are  several  candidates 
for  Mercer's  Hospital,  who  are  ready  to  fill  the  va- 
cancies on  the  condition  of  being  equally  ready  to 
be  dismissed  whenever  the  non-medical  board  may 
plea.se.  Sad  to  say,  some  whose  assured  position 
should  make  them  equal  to  refusing  such  terms  are 
willing  to  "bow  the  knee''  to  the  gods  in  possession. 
Will  not  the  Irish  profession  boycott  them? 

The  health  of  London  just  now  is  a  source  of  con- 
gratulation. Last  week  the  mortality  rate  fell  to  13.4 
for  1,000.  The  previous  week  it  was  only  14.8.  We 
may  take  the  average  of  the  whole  country  as  about 
19,  though  in  many  places  it  is  only  16,  in  others  14, 
and  in  some  it  has  touched  12.  Our  present  figures 
have  been  well  contrasted  with  the  80  per  1,000  of 
Queen  F^lizabeth's  time. 

Lister  declines  the  projected  nomination  for  the 
Council  of  the  College  of  Surgeons. 

The  death  is  announced,  on  Jubilee  Day,  of  Dr. 
Jabez  S.  Ramskill,  many  years  physician  to  the  Lon- 
don Hospital,  a  member  of  the  College  of  Physicians 
from  1853,  and  from  some  strange  prejudice  never 
made  a  fellow.  He  was  long  physician  to  the  Hos- 
pital for  Paralysis  and  F^pilepsy,  and  contributed  many 
papers  on  nervous  diseases. 


The  Prince  of  Wales'  hospital  fund  has  done  well 
this  week.  Yesterday  checks  for  ^5,5 1  2  1 5,1'.  dd.  were 
received  from  the  Freemasons  of  England  as  the  result 
of  a  great  meeting  of  the  order  lately  held  at  the  Al- 
bert Hall,  under  the  presidency  of  the  prince  as  grand 
master  of  Freemasons  in  England.  These  contribu- 
tions from  the  grand  lodge  are  in  addition  to  many 
gifts  from  different  lodges  and  chapters,  as  well  as 
from  individual  Freemasons.  This  morning  it  is  also 
announced  that  the  annual  subscriptions  promised 
to  the  fund  amount  to  ^'2,449  io.c  yi ;  donations, 
;^i32,598  14^.  9(/.  Commuted  subscriptions,  to  be 
invested,  ^20,554  2f- 

The  Hospital  Sunday  fund  has  much  increased  dur- 
ing the  week,  but  still  lags  behind  the  amount  received 
in  the  same  period  last  year,  [t  is  hoped  that  this  is 
only  on  account  of  delay  in  remitting,  caused  by  the 
interruption  to  business  of  every  kind  during  the  jubi- 
lee week. 

F<'ilaria  Loa  is  rare  enough  to  excite  continuous  in- 
terest in  any  case.  Two  years  ago  Dr.  Argyll-Robert- 
son reported  one,  and  he  has  lately  related  to  the 
Ophthalmological  Society  its  subsequent  history.  Tlie 
patient  went  back  to  Old  Calabar,  and  forthwith  her 
symptoms  returned.  Itching  behind  the  eyes  and 
swellings  in  the  arms  were  prominent,  and  are  said  to 
be  almost  universal  in  the  Gaboon.     Once  the  patient 


felt  a  bite  in  the  night,  and  immediately  extracted  a 
portion  of  the  worm.  Movement  of  a  parasite  was  felt 
under  th;;  conjunctiva.  On  two  occasion.->  the  knuckles 
were  incised  in  search  for  one  felt  moving.  As  lately 
as  last  May  one  was  felt  near  the  umbilicus,  but  could 
not  be  secured.  When  the  parasites  are  felt  moving, 
headache,  nausea,  and  puffy  swellings  of  the  arms  are 
troublesome.  All  parts  of  the  body  seem  affected,  espe- 
cially the  scalp.  The  blood,  saliva,  nasal  mucus,  and 
excreta  have  been  searched  unsuccessfully  for  embryos. 
I  hear  that  two  cases  were  lately  under  Dr.  Manson's 
care.  The  life  history  of  this  parasite  has  yet  to  be 
made  out. 

The  relation  of  Charcot's  disease  to  chronic  rheu- 
matic arthritis  seems  still  uncertain — some  holding 
it  to  be  merely  a  variety,  others  regarding  it  as  in 
no  way  related.  The  question  was  lately  before  the 
Royal  Academy  of  Medicine  in  Ireland,  a  propos  of  a 
case  exhibited  by  Dr.  C'onolly  Norman,  with  skiagraphs 
showing  the  condition  of  the  bones.  He  thought  per- 
haps some  nervous  affection  is  in  such  cases  associated 
with  the  rheumatic  disease.  This  would  be  an  ap- 
proach to  the  view  of  those  who  look  upon  chronic 
arthritis  as  altogether  a  neurosis. 

Dr.  Norman  said  he  had  seen  only  one  case  of 
Charcot's  disease  in  Dublin,  but  had  examined  his 
specimens  at  the  London  congress.  He  thought  the 
destruction  of  bone  was  much  greater  than  in  rheu- 
matic arthritis,  but  nevertheless  the  disease  was  patho- 
logically the  same,  except  that  there  was  more  effusion 
in  rheumatism  in  these  islands,  but  he  said  this  was 
not  so  in  France,  as  shown  by  the  term  arthrite  s'nhe. 
I  fancy,  however,  this  term  onlv  belongs  to  one  stage 
of  the  disease,  for  great  variet)^  in  respect  to  effusion 
is  observed  in  different  cases,  and  the  majority  are 
characterized  by  a  diy  stage  at  some  period  of  their 
long  course.  Dr.  Finny  thought  Dr.  Norman's  case 
must  remain  at  present  in  an  unknown  category.  The 
degree  of  effusion  in  the  joints  and  the  backward 
movement  of  the  leg  differentiated  it  from  the  very 
few  cases  of  Charcot's  disease  he  had  seen.  It  was 
not  easy  to  test  the  knee  jerk,  and  the  mental  condi- 
tion was  against  tabes.  The  patient  was  not  affected 
in  the  upper  limbs,  but  they  might  become  involved 
later.  It  was  afterward  remarked  tiiat  the  onlv  symp- 
tom of  tabes  present  was  the  Argyll-Robertson  sign, 
and  there  was  much  ana;sthesia  of  the  legs,  which  is 
suggestive  of  alcoholic  neuritis.  Altogether  the  case 
is  interesting,  and,  considering  the  prevailing  confu- 
sion respecting  the  relation  of  various  diseases  to  the 
rheumatic  group,  well  worth  watching. 

In  the  Harben  lectures  at  Kings  College,  Dr.  Sims 
Woodhead  has  discussed  the  antitoxin  treatment  of 
diphtheria.  On  Wednesday  he  exhibited  specimens  of 
degeneration  of  tissues  produced  as  early  as  tlie  third 
and  fourth  day  of  the  disease,  and  observed  that  when 
such  changes  have  taken  place  we  cannot  expect  rapid 
restoration.  This  accounts  for  the  necessity  of  early 
treatment,  as  the  serum  decreases  in  power  with  every 
day  of  delay.  In  the  presence  of  both  toxin  and  anti- 
toxin, these  destructive  changes  do  not  occur.  He  held 
that  the  scrum  is  preventive  as  well  as  curative,  and 
would  recommend  its  use  as  a  prophylactic  to  persons 
exposed  to  infection.  He  enforced  the  necessity  of 
early  treatment  by  statistics  showing  great  differences 
in  mortality  according  to  the  day  on  which  it  was  begim. 
Even  in  cases  which  had  been  neglected  until  the  fifth 
day,  there  is  a  reduction  in  the  mortality  of  6.2  per 
cent.,  and  he  declared  that  those  who  oppose  the  use 
of  the  serum  "assume  a  tremendous  responsibility." 

London  is  maintaining  its  exceptionally  low  rate  of 
mortality.  The  health  of  Dublin  has  undergone  a 
remarkable  improvement.  It  is  not  long  since  I  men- 
tioned tlie  epidemics  there  and  the  terrible  moitality 
rate  of  42  per  1,000.      It  has  now  dropped  to  19.7. 


July  17,  1897] 


MEDICAL    RECORD. 


105 


OUR  BERLIN    LETTER. 


(Fr 


■  Special  Corresponde 


HOT   WATER    IN      DISEASES     OF     THE     SKIN — EXCESSIVE 

TREATMENT    IN    DISORDERS    OF     INFANTS HOSPITALS 

rOR  INFANTS NUTRITION  AND  PUTREFACTIVE  PROC- 
ESSES IN  THE  INTESTINES — A  UNIVERSAL  ANTI- 
SEPTIC     FOR      INFECTIOUS      DISEASES MEASUREMENT 

OF  PUS  IN  THE  URINE — TRAUMATIC  DISORDERS  OF 
THE    HEART. 

June,   .S97. 

A  FURTHER  proof  of  the  tendency  to  abandon  the 
purely  medicative  treatment  of  diseases  for  hygienic 
and  dietetic  methods  has  been  recently  furnished  to 
US  by  Rosenthal  in  a  paper  upon  "  The  Therapeutics 
of  Hot  Water,  Especially  in  Diseases  of  the  Skin," 
read  before  the  Verein  fur  innere  Medicin.  The 
physiological  effect  of  hot  water  upon  the  organism 
consists  principally  in  an  increase  of  the  waste  prod- 
ucts, brought  about  by  the  stimulation  of  the  circula- 
tion, an  increased  e.\change  of  the  gases,  etc.  Tliis 
effect  points  out  to  us  the  indications  for  its  employ- 
ment. Contraindications  are  heart  disease,  angina 
pectoris,  atheroma,  etc.  Good  examples  of  its  bene- 
ficial effects  are  seen  in  hot  forehead  baths  in  migraine 
and  hot  douches  in  uterine  hemorrhages.  Observing 
that  a  soft  chancre  in  feverish  patients  always  heals 
quickly,  Rosenthal  was  led  to  employ  hot  water  in  the 
treatment  of  this  affection.  Per  se,  it  will  not  heal, 
but  it  aids  the  healing  very  remarkably.  It  Has  been 
further  suggested  to  employ  hot  water  in  the  treatment 
of  gonorrhoea,  but  thus  far  no  reports  have  been 
handed  in.  The  bactericidal  working  of  hot  water  is 
especially  noticeable  in  favus  and  stinking  abscesses 
of  the  feet.  Of  great  benefit  is  its  employment  in 
.pruritus,  chronic  urticaria,  various  forms  of  eczema, 
and  notably  in  acne  vulgaris  and  acne  rosacea. 

Neumann,  the  well-known  paidiatrist,  has  come 
out  strongly  against  the  too  zealous  employment  of 
water  in  the  treatment  of  infants.  He  maintains  in 
his  article  upon  "  E.xcessive  Treatment  in  Disorders 
of  Infants"  that  the  early  removal  of  the  vernix  caseosa 
is  a  wrong  procedure,  because  it  is  aseptic.  The  first 
bath  should  therefore  be  given  after  the  navel  wound 
shall  have  healed.  Neumann  also  speaks  against  too 
active  cleansing  of  the  mouth,  too  much  rubbing  and 
scrubbing;  also  against  the  loosening  of  the  fra^num 
linguas,  which  is  so  often  unnecessarily  done.  He 
protests  especially  against  scarification  of  the  gums  in 
the  belief  that  dentition  is  the  cause  of  many  diseases. 
He  deserves  our  thanks  in  thus  combating  the  abuses 
in  infant  therapeutics,  and  in  thus  lending  weight  to 
the  maxims  "  Ne  nimis"  and  "Primum  nil  nocere." 

The  subjects  of  "  Infantile  Feeding"  and  "  Hospitals 
for  Infants"  have  been  recently  taken  up  by  Professor 
Huebner.  He  wanis  against  too  much  dilution  in 
artificial  milk  feeding,  as  the  infant  thereby  receives 
too  few  calories.  He  takes  stand  against  hospitals 
for  young  infants;  in  them  the  mortality  is  consider- 
ably higher  than  in  families.  He  found  the  cause  to 
be  an  infection  of  the  children  through  the  nurses, 
under  the  fingernails  of  whom  he  demonstrated  the 
presence  of  large  numbers  of  the  bacillus  coli  com- 
mvmis.  He  ordered  thereupon  that  those  nurses  who 
cleaned  the  children  should  not  feed  them,  with  the 
result  that  the  mortality  receded  from  eighty  per  cent, 
to  sixt}'-five  per  cent.  He  therefore  views  in  the  es- 
tablishment of  hospitals  for  suckling  infants  a  great 
danger;  but,  as  their  establishment  is  a  social  neces- 
sity, he  believes  the  dangers  may  be  minimized  by 
having  smaller  wards,  dividing  the  nursing-service, 
admitting  the  mothers,  etc.  In  the  discussion  to  which 
his  article  gave  rise  the  foremost  pardiatrists  of  Berlin 
participated,  and  all  conceded  the  justice  of  Huebner's 
stand  against  these    institutions.      Especial    attention 


was  called  to  the  large  mortality  among  the  ille- 
gitimate children  of  Berlin.  The  cause  is  to  be  found 
in  the  want  of  attention  and  the  lack  of  care  in  the 
preparation  of  the  food,  as  a  result  of  which  the  chil- 
dren fall  victims  to  intestinal  catarrh. 

Albu  has  recently  shown  in  a  paper  read  before  the 
Verein  fur  innere  Medicin,  entitled  "  Relationship 
of  Intestinal  Putrefaction  to  the  Nutrition,"  that 
in  disorders  of  this  nature  prophylaxis  is  the  chief 
thing.  Intestinal  antiseptics  and  intestinal  disinfec- 
tion, in  the  true  sense  of  the  word,  do  not  exist;  all 
attempts  to  prevent  intestinal  decomposition  ar.d 
putrefaction  by  means  of  internal  medication  have 
proven  futile.  This  applies  to  enemata  as  well. 
The  best  results  are  obtained  from  laxatives  which 
remove  decomposing  contents,  or  at  least  the  greater 
part.  .A.lbu  made  two  series  of  investigations:  first, 
the  influence  of  sterilized  food ;  secondly,  the  influence 
a  strict  milk  diet.  He  found  that  only  after  good 
previous  catharsis  would  the  intestinal  decomposition 
during  a  sterilized  diet  become  decreased  from  that 
resulting  from  an  ordinary  diet.  Of  course  this  is  not 
adapted  to  ordinary  living. '  The  decomposition  after 
a  milk  diet,  on  the  other  hand,  was  markedly  dimin- 
ished. A  variety  of  experiments  showed  that  this 
result  was  owing  to  the  sugar  of  milk  present  in  the 
milk,  working  either  as  a  laxative  or  as  a  specific 
intestinal  antiseptic.  This  antiseptic  action  finds  its 
explanation  when  we  consider  that  the  milk  sugar,  to- 
gether with  the  albumin  and  fat  of  the  milk,  is  brought 
into  intimate  contact  with  all  parts  of  the  intestines, 
and  splits  up  into  the  strongly  disinfecting  lactic  acid. 
Still  the  milk  sugar  cannot  prevent  the  intestinal  de- 
composition, as  the  latter  is  dependent  upon  a  great 
variety  of  circumstances  (quantity,  composition,  and 
quality  of  the  nutrition,  frequency  of  meals,  number  of 
stools,  etc.),  and  also  because  the  addition  of  other 
food  stuffs  interferes  with  the  working  of  the  milk 
sugar.  In  practice  we  must  therefore  refrain  from 
any  attempt  to  disinfect  the  intestines  through  medi- 
cation. 

Professor  Posner,  who  believes  it  necessary  to  make 
quantitative  tests  for  pus  in  the  urine,  has  devised  a 
method  for  this  purpose.  He  estimates  by  means  of 
the  transparency  of  the  urine.  The  urine  is  placed  in 
beakers,  each  beaker  being  placed  upon  or  before  a 
paper  w^ith  writing  or  printing  upon  it;  each  glass 
is  filled  with  the  urine  under  examination  until  the 
writing  or  printing  can  no  longer  be  read.  An  em- 
pirical scale  has  been  devised  and  is  used  as  a  stand- 
ard of  comparison.  As  a  second  method  of  estimat- 
ing pus,  Posner  employs  the  Thoma-Zeiss  apparatus 
for  counting  the  pus  cells. 

It  is  also  of  interest  to  note  a  case  reported  by  Lit- 
ten  which  illustrates  the  possibility  of  a  traumatic 
heart  disease.  A  soldier  in  active  service  received 
a  kick  from  a  horse  in  the  region  of  the  heart  and  was 
brought  into  the  hospital,  where  he  was  found  to 
have  an  acute  endocarditis.  He  convalesced.  Nine 
months  later  Litten  examined  him  and  found  an  in- 
crease in  size  of  the  right  and  left  sides  of  the  heart 
and  systolic  mitral  and  aortic  murmurs.  He  made  lhe 
diagnosis  of  mitral  regurgitation  and  endocarditis. 
Litten  has  no  hesitation  in  pronouncing  this  case  as 
one  of  indisputabe  traumatic  endocarditis.  -As  a  result 
of  the  kick  either  the  valves  were  torn  or  the  endocar- 
dium was  loosened,  and  thrombi  formed  at  the  place 
of  laceration;  these  last  organized  and  thus  produced 
the  vitiuni  cordis.  Of  course  the  patient  was  entirely 
well  prior  to  the  accident,  having  passed  the  militar}' 
examination. 


Kossmann  recommends  the  injection  of  a  drachm  of 
glycerin  within  the  cervix  to  induce  labor. 


io6 


MEDICAL    RECORD. 


[July  17,  1897 


MEDICAL    EDUCATION    IN    AMERICA    AND 
GREAT    BRITAIN. 


Sir  :  I  have  just  read  your  editorial  in  the  Medical 
Record  of  July  3d,  and  am  astonished  that  you  seem 
to  consider  New  York  the  sole  State  having  interest  in 
advanced  education.  You  evidently  have  forgotten 
the  battle  made  by  the  University  of  Pennsylvania  for 
this  high  standard,  and,  as  I  am  ver)-  familiar  with 
both  your  New  York  schools  and  those  of  Philadelphia, 
I  unhesitatingly  say  that,  should  any  be  singled  out 
for  conspicuous  leadership,  that  one  should  be  the 
University  of  Pennsylvania.  Your  article  is  most 
unfair  to  Pennsylvania  schools  in  general  and  to  the 
University  of  Pennsylvania  in  particular.  Having 
Ixau  opportunity  to  see  something  of  English  schools, 
too,  I  am  forced  to  conclude  that  it  is  not  of  inferior 
standard  compared  with  any  of  them. 

I  trust  you  will  see  your  way  clearly  to  present  your 
readers  these  proper  objections  to  your  editorial  posi- 
tion. S.  S.  KosER,  M.D. 

WlLLIAMSPORT,  Pa. 

[Our  correspondent  is  in  error  in  supposing  that  we 
intended  any  reflection  upon  the  University  of  Penn- 
sylvania. We  merely  stated  in  passing  that  New 
York  was  well  in  the  front  in  medical  education  re- 
form. We  made  no  invidious  comparisons,  and  are 
perfectly  willing  to  admit  the  good  work  of  the  univer- 
sity in  question,  and  also  of  the  Harvard  Medical 
School,  for  that  matter.  It  strikes  us  that  our  corre- 
spondent is  a  trifle  too  sensitive  to  be  reasonable. — 
Ed.] 

FORT'S    LINEAR    ELECTROLYSIS. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  .\t  a  meeting  of  the  New  York  County  Medical 
Association  on  March  15,  1897,  a  paper  was  read  by 
Dr.  Newman,  on  the  application  of  electrolysis  in  the 
treatment  of  stricture  of  the  urethra.  The  paper  in 
question  was  called  forth  by  what  occurred  during  my 
visit  to  the  United  States  toward  the  end  of  the  year 
189s,  when  in  the  clinical  practice  of  Dr.  R.  \\'.  Tay- 
lor, at  Bellevue  Hospital,  I  performed  a  number  of 
electrolytic  operations  for  urethral  strictures.  In  view 
of  the  success  attending  my  treatment,  Dr.  Taylor  pro- 
cured for  me  the  privilege  of  reading  a  paper  before 
the  New  York  Academy  of  Medicine,  the  members  of 
which  declared  themselves  distinctly  in  favor  of  the 
methods  adopted  by  me. 

It  is  with  the  statements  made  by  Dr.  Newman  in 
his  communication  above  referred  to  that  I  now  pur- 
pose to  deal. 

Dr.  Newman,  first  of  all,  contests  my  right  to  be 
considered  the  true  inventor  of  my  electrolytic  instru- 
ment, which  he  says  is  exactly  identical  with  that  of 
Dr.  Butler.  (It  is  described  in  the  American  Journal 
of  Elcitrology  and  Neurology,  vol.  i..  No.  2,  October, 
1879,  p.  95.)  Butler's  instrument  is  a  hollow  tube 
with  a  slot,  in  which  are  two  wires  that  may  be  brought 
together  by  means  of  a  screw,  or  separated  in  such  a 
manner  as  to  form  an  ellipse.  This  ellipse,  owing  to 
the  great  fle.xibility  of  the  wires,  adapts  itself  to  the 
shape  of  the  stricture. 

I  will  not  enter  into  further  details  of  Dr.  Butler's 
electrolyzer,  since  those  who  are  acquainted  with  mine 
will  see  from  the  above  tiiat  the  two  instruments  are 
altogether  different. 

Dr.  Newman  criticises  my  electrolyzer  adversely  on 
the  ground  that  it  i)ossesses  only  one  blade  for  ditfer- 
ent-sized  strictures.  This  is  a  serious  error,  for  I 
have  electrolyzers  of  different  sizes,  large  and  small. 
Furthermore,    1    will    add    that    my    own    exjjerience 


teaches  me  that  a  small  blade  may  be  used  to  dilate 
the  canal  just  as  well  as  a  large  one,  because  the  mus- 
cular fibres  of  the  urethra  contract  when  the  blade 
touches  them,  so  that  it  is  the  stricture  which  is  elec- 
trolyzed  on  the  blade  and  not  the  blade  which  acts 
upon  the  stricture. 

Dr.  Newman  does  not  consider  that  the  current  which 
I  use — ten  milliamperes — is  sufiicient  to  break  down 
the  stricture.  To  this  I  will  reply  by  using  the  argu- 
ment which  Dr.  Newman  himself  puts  forward  in  de- 
fence of  his  process:  "The  success  of  electrolysis  in 
urethral  strictures  is  so  well  established  that  simple 
negations  cannot  undo  affirmations.''  From  the  objec- 
tions made  by  Dr.  Newman,  it  is  evident  that  he  does 
not  under.stand  my  process  and  has  never  seen  it  ap- 
plied. 

In  regard  to  Dr.  Newman's  question  as  to  the  maxi- 
mum intensit)-  of  current  that  may  be  used,  I  will  say 
that  I  have  not  experimented  with  a  view  to  elucidat- 
ing this  point;  but  the  intensity  depends  upon  the 
patient's  power  of  resistance,  and  in  our  current  oper- 
ations I  have  seen  the  galvanometer  register  as  much 
as  forty  milliamperes,  and  this  without  ill  effects. 
The  operation  is  effected  just  the  same,  while  the  pain 
is  not  sensibly  increased. 

If  Dr.  Newman  understood  my  modus  operandi,  he 
would  not  accuse  me  of  practising  diviilsion;  for  I 
always  recommend  the  operator  not  to  force  or  push 
the  instrument,  but  simply  to  hold  it  steady.  If  divul- 
sion  occurred,  there  would  be  pain,  tearing,  and  hem- 
orrhage: but  there  is  neither  pain  nor  hemorrhage, 
and  consequently  no  tearing. 

"  Now,"  says  Dr.  Newman,  "  the  question  arises, 
Can  a  current  of  ten  milliamperes  for  thirty  seconds 
enlarge  a  stricture  eleven  numbers,  or  even  less,  by 
electrolysis;  or  is  the  enlargement  due  to  the  force, 
used,  thereby  being  a  divulsion?"  To  this  question 
I  will  simply  reply  that  I  enlarge  not  only  eleven 
numbers,  but  up  to  eighteen  or  nineteen,  and  without 
using  any  force.  I  have  a  considerable  body  of  notes 
relative  to  patients  with  almost  impassable  strictures, 
through  which,  after  the  operation,  I  was  able  to  pass 
a  No.  22  bougie,  and  even  a  No.  24,  French  scale. 

Dr.  Newman  claims  to  test  the  effects  of  my  process 
by  means  of  chemical  experiments,  but  I  will  not  enter 
into  the  discussion  thereof,  because  they  are  altogether 
negatived  by  the  facts.  In  my  work,  "  Traitenient 
des  Retrecissements  par  I'Electrolyse  Line'aire" 
("Treatment  of  Stricture  by  Linear  Electrolysis'"),  I 
have  published  a  large  number  of  observations  which 
effectually  silence  the  objections  made  by  Dr.  Newman 
against  my  modus  operandi. 

To  sum  up:  Dr.  Newman's  objections  to  my  opera- 
tive methods  have  no  value,  because  they  are  theoreti- 
cal and  in  complete  contradiction  of  facts,  and  also 
because  he  does  not  appear  ever  to  have  performed  my 
operation. 

In  its  action  my  instrument  resembles  to  some  ex- 
tent Maisonneuve's  urethrotome,  which  was  so  uni- 
versally recommended.  It  differs  from  this  latter  only 
in  that  it  does  not  cut  and  does  not  tend  to  produce 
any  of  the  accidents  so  frequent  after  urethrotomy. 

The  success  of  the  operation  depends  upon  the  form 
of  my  instrument,  which  acts  upon  one  single  line  and 
with  great  swiftness,  like  the  urethrotome  of  Maison- 
neuve.  But  the  tightest  strictures  may  be  operated 
upon,  provided  the  guide  bougie  can  pass  through. 

Any  soft  stricture  may  be  managed  with  a  current 
of  ten  milliamperes,  and  without  the  slightest  forcing. 
In  order  to  prevent  relapses,  it  is  necessary  to  pass  a 
bougie  along  the  canal  from  time  to  time,  t'p  to 
date  I  have  operated  upon  some  thirty-five  hundred 
patients,  and  my  record  cannot  be  affected  by  a  simple 
statement.  J.  A.  Fort,  M.D. 


July  17.  1897] 


MEDICAL    RECORD. 


107 


REPORT   ON    HYDROPHOBIA. 

To  THE  EdITOE  of  THE  MEDICAL  Record. 

Sir  :  Dr.  Charles  \V.  Dulles,  in  his  report  on  hydro- 
phobia, writes  to  your  journal  under  date  of  June  26, 
1897  :  "The  accumulation  of  these  cases  has  required 
a  great  deal  of  labor,  and  I  have  taken  pains  to  verify. 
as  far  as  possible,  the  facts,  and  to  correct  the  errors 
of  published  accounts  by  correspondence  with  the  phy- 
sicians who  have  had  the  care  of  the  cases."  Dr. 
Dulles  has  had  a  number  of  personal  inteniews  with 
the  writer  during  the  past  year,  and  yet  he  says,  in  his 
description  of  an  "interesting  case":  "The  opinion 
was  positively  given  by  the  bacteriologist  and  by  the 
coroner's  physician  that  the  dog  was  rabid  and  that  the 
child  was  in  great  danger.  The  father  was  advised  to 
send  the  child  to  New  York."  These  three  statements 
require  contradiction.  I  never  saw  the  dog,  never 
performed  any  experimental  inoculations,  and  never 
even  examined  the  child.  In  my  talk  with  the  father 
pending  a  consultation,  the  danger  was  minimized  and 
the  child  was  advised  to  go  not  to  the  Pasteur  Insti- 
tute at  New  York,  but  to  the  country  or  seashore. 
The  reader  will  readily  decide  between  the  high  pro- 
fessional standing  of  an  experienced  bacteriologist, 
such  as  Dr.  Bolton,  and  the  veterinan,-  surgeon  who 
says  the  dog  was  suffering  from  hydrophobia  and  the 
pound  keepers  who  say  the  dog  had  "fits." 

Henry  ^V.  C-^ttlll,  M.D. 

Phil-\dephl\. 


TREATMENT  OF  TIC  DOULOUREUX. 

To  THE  Editor  of  the  Medical  Record. 

Sfr  :  A  propos  of  the  letter  to  Dr.  Charles  L.  Dana 
published  in  the  issue  of  June  26th,  I  would  say  that 
I  have  used  large  doses  of  strjxhnine,  hypodermically 
and  by  the  mouth,  for  some  time,  with  gratifying  re- 
sults in  the  treatment  of  tic  douloureux.  It  may  be 
worth  recording  that  one  of  the  most  marked  cases  is 
in  an  old  lady,  at  present  under  treatment  for  the  sec- 
ond time  in  the  past  three  years.  She  is  seventy-nine 
years  of  age,  and  has  had  attacks  for  fifty  years  up  to 
the  institution  of  treatment.  She  had  been  free  up  to 
this  spring  for  the  past  two  years,  but  during  ray 
absence  for  post-graduate  work  her  attacks  recurred 
but  not  with  old-time  violence,  but  their  severity  was 
increasing.  Previously  I  had  never  exceeded  one- 
twentieth  grain  ter  dU,  but  owing  to  the  seeming 
urgency  I  gave  her  one-twentieth  grain  by  mouth 
morning  and  noon,  and  one-fifteenth  hypodermically 
in  the  afternoon.  This  was  followed  for  one  week 
without  any  toxic  symptoms  and  with  marked  decrease 
of  pain  after  the  second  day  and  entire  freedom  now 
for  four  days,  this  being  the  thirteenth  day  since 
my  return.  Previously  she  had  not  slept  for  weeks 
except  an  hour  or  t\vo  at  night.  In  her  old-time 
attacks  she  could  neither  eat  nor  speak,  the  muscular 
eflFort  bringing  on  the  spasm.  She  at  present  takes 
one-twentieth  grain  ter  die  by  mouth. 

The    interesting  points   are   the  advanced  age,  the 
heroic  doses,  the  absence  of  toxic  symptoms,  and,  most 
important,  the  almost  immediate  relief  from  pain. 
J.  H.  Greene,  M.D. 


Quinine  in  Suppositories. — Quinine,  ten  to  twenty 
grains,  in  suppositories  per  rectum,  gives  good  results 
without  the  production  of  the  nausea,  headache,  sing- 
ing in  the  ears,  etc.  It  should  be  given  in  this  man- 
ner in  all  cases  of  fever  in  which  quinine  is  indicated, 
and  especially  in  malaria  and  in  the  case  of  children. 
— T.  DiNB.\R  Brl'nton,  British  Medical  Journal. 


Hem  lustvumcnts. 

A  NEW  URETHRAL  SOUND. 

By   CHARLES   C.    F.    XIESCHANG, 
fokt  %va\-?»-e,  ixd. 

SEXU.A.L  neurasthenia,  atonic  impotence,  frequent 
emissions,  premature  ejaculations,  imperfect  erections 
and  erections  of  short  duration,  are  in  manv  cases 
caused  by  an  extremely  hyperasthetic  prostatic'urethra 
or  by  chronic  prostatitis.  Prostatorrhoea  has  a  bad 
effect  upon  the  mind  of  the  patient  believing  himself 
the  victim  of  spermatorrhoea.  The  most  frequent 
cause  for  this  condition  is  excessive  venery  or  pos- 
terior urethral  gonorrhcta. 

The  treatment  with  aphrodisiacs  and  sexual  stimu- 
lants    is     contraindicated 
and  in  many  cases  very  in- 
jurious. 

"  The  most  effective 
means  of  relieving  the 
irritability  of  the  prostatic 
urethra  is  the  systematic 
introduction  of  full-sized 
steel  sounds,"  Morrow's 
system,  which  overcome 
the  hyperesthesia  and  re- 
lieve congestion  by  disten- 
tion and  pressure  and 
contact  of  the  cold  sounds. 
Most  of  these  cases  are 
complicated  with  s  p  a  s  - 
modic  strictures,  either 
from  the  nervous  condition 
of  the  patient  or  from  re- 
flex irritations  of  the  ure- 
thra. The  passage  of  a 
cold  sound  will  in  a  great 
many  cases  bring  on  ure- 
thral spasm  resisting  the 
farther  introduction  of  the 
instrument,  whereas  a 
warm  sound  will  pass 
quite  easily.  I  have  ob- 
ser\ed  this  condition  often 
and  have  been  led  by  it 
to  devise  this  instrument. 
It  can  be  passed  warm 
and  then  be  immediately 
cooled. 

The  instrument  consists  of  four  hollow  soimds- 
Xos.  12,  14,  16,  and  18  French,  with  one  universal 
handle  with  two  small  tubes  projecting  for  connec- 
tion with  a  fountain  syringe  by  a  piece  of  rubber 
tubing. 

The  manner  of  using  the  sounds  is  obvious  and 
needs  little  explanation.  The  handle  is  attached  to  the 
sound  of  proper  size.  It  is  warmed  and  passed  into 
the  urethra:  a  fountain  syringe  filled  with  ice  water  is 
attached,  and  the  outflow  tubing  is  shut  off  until  the 
sound  is  full  of  water,  when  it  is  slightly  opened. 

I  have  had  unexpected  good  results  following  this 
treatment,  without  internal  medication  except  regulat- 
ing the  kidneys  and  alimentary-  tract,  with  hygienic 
and  dietetic  regulations. 

The  instrument  was  made  for  me  by  Messrs. 
Tiemann  &  Co.,  New  York. 

I  will  add  my  mode  of  lubrication.  The  usual 
way  is  to  apply  vaseline  or  some  bland  oil  to  the 
surface  of  the  urethral^  instruments.  Now  the  mea- 
tus, being  the  smallest  part  of  the  urethra,  it  rubs  oft' 
and  retains  the  lubricant,  and  beyond  the  orifice  the 
instrument  passes  comparatively  Ars.  Instead  of  oil- 
ing the  instrument,  I  take  an  ordinary  medicine  drop- 


io8 


MEDICAL    RECORD. 


[July  17,  1897 


per  and  draw  it  full  of  vaseline  oil,  slightly  warmed; 
inserting  its  point  into  the  meatus  and  holding  the 
organ  perpendicular,  I  press  the  oil  into  the  urethra. 


NEW  SUSPENSION  DEVICE  FOR  IRRIGATOR 
USED  IN  CONNECTION  WITH  THE  EDE- 
BOHLS  LEG  SUPPORTER. 

Bv    HEK.MAX   C.    BLEYLE,    M.D.. 


In  order  to  do  away  with 
the  inconvenience  so  often 
met   with    in  the  perfor- 
mance   of   gynecological 
work  at  the  homes  of  pa- 
tients, in  obtaining  suit- 
able means  of  suspension 
for     the     irrigator,     the 
writer  has  had  construct- 
ed  by    Messrs.    Tiemann 
&  Co.,  an  extension   rod, 
with  hook,  A,  which  when 
clamped    on    one    of    the 
upright      bars      of       the 
Edebohls    leg    supporter, 
-B,    very    effectively     an- 
swers   the    purpose   of 
furnishing     needed     sus- 
pension   facilities.     This 
device   allows  the  opera- 
tor to  place  the  table   in 
the   most  convenient  po- 
sition    as     regards    light 
and     his     own      comfort, 
and   relieves  him   of    the 
necessity     of    depending 
on      some      suspension 
point   inconveniently   sit- 
uated.      It    can    also    be 
utilized   in   many   of   the 
usual      surgical       opera- 
tions  in  which   an   ordi- 
nary   table    can   be    used 
and  constant  irrigation  is 
required.      The    mechanism 
plains  itself. 


gaecUcaX  Stems. 

Contagious   Diseases— Weekly    Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  July  10,  1897: 


Cases. 

Deaths. 

Tuberculosis 

164 

10 

107 

I 

150 

238 

10 

8 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. .  . 

7 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup). 

39 

Chicken-pox 

.Small-pox.  . . 

° 

Aqua  Tofana — Murrell  says  that  the  aqua  Tofana 
made  and  sold  by  the  iniquitous  Tofana  or  Tophiana, 
who  is  supposed  to  have  poisoned  with  it  more  than 
SIX  hundred  people,  including  two  popes,  Pius  III. 
and  Clement  IV.,  was  made  by  rubbing  white  arsenic 
mto  pork  and  collecting  the  liquid  which  drained  from 
It  durmg  decomposition.  It  is  probable  that  in  the 
process  a  ptomain  or  cadaveric  alkaloid  was  fonned, 


possessing  properties  of  the  highest  degree  of  toxicity 
Long  after  Tofana's  death  it  continued  to  be  made  ai 
Naples  and  to  be  distributed  secretly  throughout  Italy. 
It  was  used  by  Hieronyma  Spara,  an  old  fortune  teller^ 
who  was  presidentess  of  a  society  of  young  married 
women,  whose  diversion  it  was  to  poison  their  own 
and  other  women's  husbands.  Marie  de  Brinvillier's 
poison  contained  arsenic,  and  it  was  the  active  princi- 
ple of  the  poudrc  de  succession  or  inheritance  powder 
for  which  at  one  time  there  was  an  extensive  demand. 
— Medical  Brief. 

The  Thumb  and  the  Brain.— Dr.  Burton  Ward  de- 
clares there  is  one  infallible  symptom  indicating 
whether  one  is  sane  or  not.  Let  'a  person  speak  ever 
so  rationally  and  act  ever  so  sedately,  if  his  or  her 
thumbs  remain  inactive  there  is  no  doubt  of  insanity. 
Lunatics  seldom  make  use  of  their  thumbs  when  writ- 
ing, drawing,  or  saluting. 

The  Prognosis  of  Drug  Habits.  —  'Ihe  morphine 
habit  becomes  practically  incurable  in  five  years.  The 
user  of  alcoholic  spirits  may  continue  eight  or  ten 
years  before  he  reaches  the'  incurable  stage.  This 
will  depend  on  the  free  intervals  between  the  time  of 
using  spirits.  When  he  becomes  incurable  he  may 
abstain,  but  the  injured  brain  and  ner\-ous  system 
never  recover.— r//,^-  Quarterly  Journal  of  luehriety. 

To  Remove  Nitrate  of  Silver  Stains  from  Cloth- 
ing-— -^  solution  of  iodine  in  ammonia  water,  the  bo- 
called  colorless  tincture,  will  remove  nitrate-of-silver 
stains  from  the  hands,  clothing,  etc.,  but  owing  to  the 
danger  of  the  formation  of  nitrogen  iodide,  which  is  a 
powerful  explosive,  it  is  not  recommended.  A  solu- 
tion of  iodine  in  iodide  of  potassium  dissolved  in 
water  is  nearly  as  quick  and  quite  as  effective.  Dis- 
solve fifteen  parts  of  iodide  of  potassium  in  fiftv  parts 
of  water,  and  to  the  solution  add  ten  parts  of  iodine. 
U'hen  the  latter  is  dissolved  add  sufficient  water  to 
make  five  hundred  parts.  Keep  in  a  well-stoppered 
bottle.  Treat  the  spots  with  this,  and  after  a  few  min- 
utes with  a  ten-per-cent.  solution  of  caustic  soda, 
which  will  remove  the  silver  iodide  formed  bv  the  first 
treatment. — The  National  Druggist. 

Health  Reports — The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  superA-ising  surgeon- 
general  of  the  United  States  Marine  Hospital  service 
during  the  week  ended  July  10,  1897  : 

S.\nLL-Pox— United  Stated. 


^"^'>"-  ^ •  V Tune  26th  to  Tuly  3d , 

1  ueblo.  Col  .   June  26th  to  luly  sd •• 

( .loncester,  Mass    June  19th  to  "26th. t 

Sm.^li.-Pox-Fokeig.v. 

Montevideo May  29th  to  June  5th  ... .     i 

St.  Petersburg,  Russia June  5th  to  .oth ^ 

Moscow,  Russia >lav  29th  to  June  12th .  x 

Odessa,  Russia Mav  ,2th  to  19th 

Kanagawa,  Japan May  27th  to   lune  3d 2 

Sasrua  la  Grande,  Cuba June  19th  to  26th 60 

Calcutta.  India Mav  ijth  to  20th 

Bombay   India June  ist  to  8th '. 

Kuenos  .Ayres,  .■Vrsentina.  .  ..A,pril  2,d  to  30th 

Nagasaki,  Japan June  7th  to  14th ,. 

Montreal,  Canada July  ad  \ 

Aden,  .\rabia May  7>h'." ! .' "i.";.";.".";: 'i;  27 

Ale.vandria,  \  a May  2Sth  to   lune  3d ' 

Cairo   Kgjpt May  28th  to  June  3d 

Gibraltar.  ...       June  6th  to  13th..: , 

Hong-kong,  China April  24th  to  Jlav  aad   .. 

London,  Kn^land June  sth  to  12th ". 2 

Madrid,  Spain June  bth  to  16th 

Warsaw,  Russia Jun.  5th  to  ,2th 

iokohaina.  Japan ^Iay  20th  to  27th i 

Cardenas,  Cuba    June  22d  to  July  3d 

Cholkk.x. 

Calcutta,  India May  15th  to  29th 

Veli.o%v  Fever. 

Cardenas,  Cuba lune  i=lh  to  July  3d ,. 

Matanz^ui    Cuba..    J„„c  iSthtojjd..: 

Sagua  la  l.rande,  Cuba June  lyth  to  »«lh ,0 

Bombay,  India June  ist  to  8th  . . .       . 

.Brazil >Iay  2Qth  to  June  sth  . . . .  "  i 

....June  aoth  to  Inlv  i$t 


.Me.vii 


Honc-Kong,  China. 
Taiwan,  Formosa. . . 


•Tune  IS 
Mav  3, 


y  31st  III  June  Sth J3 


Medical  Record 

A  IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  4. 
Whole  No.  1394. 


New  York,   July  24,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©vigiual  Jirticlcs. 

JACKSONIAX  EPILEPSY:  ADEXOMA  OF 
LIVER:  ACUTE  ASCITES  WITH  TUBER- 
CLE BACILLI. 

Bv   A.    TACOBI,    M.D., 


A.  A •  was  born  August  7,  1885,  and  died  January 

16,  1897.  Her  father  was  always  in  good  health,  her 
mother  at  one  period  of  her  life  neurotic.  Father's 
family  was  without  any  morbid  taint;  mother's  ances- 
tors died  when  seventy-five,  eight)--five,  and  ninety 
years  old.  She  is  the  youngest  of  ten  boys  and  girls, 
none  of  whom  died  young.  One  sister  died  of  cere- 
bro-spinal  meningitis,  one  of  '"  fistula"  after  having 
been  insane,  one  brother  (the  oldest  in  the  family)  was 
an  army  officer  during  the  civil  war  and  died  insane. 
Of  the  seven  now  alive  one,  a  man  of  great  abstract 
learning  and  a  college  professor,  with  healthy  chil- 
dren, is  epileptic. 

A.  A weighed  eight  pounds  at  birth,   sixteen 

when  six  weeks,  twenty-eight  when  ten  months  old. 
Her  first  teeth  (lower  incisors)  appeared  at  six 
months ;  the  others,  both  temporary  and  permanent, 
came  in  due  order  and  without  any  trouble.  She 
walked  when  a  year  old.  She  was  wetnursed,  never 
perspired  on  the  head,  lost  no  hair,  had  no  thickened 
epiphyses,  her  limbs  were  straight.  The  only  symp- 
tom reminding  of  rickets  was  constipation,  which  ap- 
peared at  the  age  of  six  or  eight  weeks,  and  required 
enemata  until  she  was  five  years  old.  At  three  years 
of  age  she  had  whooping-cough ;  at  four,  measles :  no 
other  disease. 

In  September,  189 1,  she  fell  from  a  swing,  hurting 
the  left  side  of  her  head.  She  did  not  get  pale  or 
vomit;  she  cried,  and  appeared  uninjured.  In  Janu- 
ary or  February,  1892,  her  right  hand  was  noticed  to 
twitch  a  little.  In  November  she  began  to  take  music 
lessons;  the  twitching  became  stronger  and  more  fre- 
quent, and  the  lessons  were  discontinued.  On  No- 
vember I,  1893,  she  had  on  waking  in  the  morning  the 
first  hard  attack  of  convulsions,  probably  with  loss  of 
consciousness.  The  second  attack  of  the  kind  took 
place  on  the  i6th.  There  was  complete  loss  of  con- 
sciousness and  slow  recover)-.  Thick,  incoherent  talk: 
slight  paralysis  of  the  right  arm.  During  two  days 
previously  the  child,  who  was  remarkably  obsening 
and  intelligent,  had  noticed  fatigue  and  pain  in  her 
right  arm,  and  told  a  playmate  she  was  going  to  have 
an  attack.  On  November  24th  she  complained  of 
tiredness  and  numbness  in  both  arms,  more  so  in  the 
left.  She  slept  poorly  during  that  night,  and  expe- 
rienced Slight  twitchings  in  her  right  hand.  Feeling 
an  attack  coming  on  at  6:30  a.m.,  she  jumped  up  with 
the  idea  of  preventing  it.  It  was  slight,  with  no  loss 
of  consciousness.  Slight  stiffness  of  legs.  She  said 
she  had  to  hold  on  to  the  foot  of  her  bed,  as  she  was 
not  quite  steady.  .Afterward  she  felt  absolutely  well, 
and  played  all  day.  She  had  taken  bromides  two  days: 
they  were  continued  in  moderate  and  later  on  in 
larger  doses,  so  as  to  give  rise  to  bromism  repeatedly. 


Slight  twitchings  of  the  right  arm  in  the  night  of  Feb- 
ruary 1 8,  1894.  March  9th,  while  running,  she  tripped 
and  fell,  striking  her  right  arm  heavily.  She  com- 
plained at  once  of  twitchings,  which,  though  slight, 
continued  over  an  hour.  She  was  put  to  bed,  but  she 
complained  of  their  coming  more  frequently  while  she 
was  lying  down;  tying  a  cord  round  the  arm  above 
the  elbow  made  the  twitchings  stronger.  She  seemed 
very  nervous  and  worried  each  time  the  arm  twitched. 
When  she  was  read  to  the  shaking  stopped  instantly, 
and  she  was  well  all  day.  Evidently  this  attack  had  but 
partly  the  significance  of  the  former  ones.  The  right 
arm  shook  badly  on  waking  April  4th,  after  she  had 
been  playing,  skating,  and  falling  several  times  the 
previous  afternoon ;  again  on  April  13th  and  May  22d. 
During  two  days  previously  she  had  complained  of 
fatigue  and  pain  of  her  left  hand.  She  had  been  writ- 
ing a  good  deal,  however,  with  her  left  hand  pre- 
viously, having  been  taught  and  accustomed  to  use  her 
left  hand  in  place  of  the  right  when  the  local  convul- 
sions began.  Slight  attack  on  the  27th,  two  on  June 
2d. 

Most  of  the  attacks  would  come  on  in  the  morning 
on  waking  up:  they  lasted  mostly  a  few  minutes,  and 
were  but  rarely  attended  with  unconsciousness.  She 
would  often  laugh  and  joke  immediately  afterward. 
During  most  of  the  attacks,  and  often  days  before,  the 
child  was  pale;  sometimes  she  was  irritable  before  or 
after  them,  in  some  instances  for  days.  But  very  few 
times  she  had  more  severe  attacks  during  her  sleep, 
breathing  heavily  and  shaking  all  over  her  body. 
Before  she  was  taken  to  Europe  in  the  summer  of 
1894,  she  had,  however,  only  very  few  of  these  hard 
attacks.  L'p  to  this  time,  and  also  later,  she  enjoyed 
the  occasional  advice  of  Dr.  S.  Weir  Mitchell,  who 
saw  her  both  in  Philadelphia  and  in  New  York.  Drs. 
Gowers  and  Jackson  saw  her  in  London.  It  was  prin- 
cipally the  former  who  objected  strenuously  to  the 
jjerformance  of  an  operation,  the  advisability  of  which 
had  been  suggested. 

During  her  European  trip  she  was  not  changed. 
Slight  attacks  would  come,  mainly  when  she  was,  or 
had  been,  fatigued;  five  during  August,  1894.  .After 
three  slight  ones,  on  her  return,  she  had  a  fully  de- 
veloped epileptic  attack  in  her  sleep  on  October  26th. 
.After  a  few  slight  ones,  in  January,  1895,  the  attacks 
ceased  entirely  while  she  was  taking,  first  fifty,  after- 
ward sixty  grains  of  bromides  daily,  together  with  litlua 
and  valerianate  of  zinc.  The  bromides  having  disa- 
greeable effects  (as  heaviness,  drowsiness,  bloated 
face),  were  discontinued  June  8th,  and  valerianate  of 
zinc  only  administered.  .Attacks  returned — one  on 
the  25ih,  two  the  26th,  three  the  27th,  four  the  28th, 
six  the  29th,  four  the  30th  (wetted  the  bed  the  first 
time),  six  on  July  ist  (was  given  again  bromides,  60 
grains  daily:  zinc  valerian,  30  grains;  atropine,  jj-j- 
grain),  six  on  the  2d  and  on  the  3d,  nine  on  the  4th 
and  on  the  5th,  five  on  the  6th,  and  three  on  the  7th. 
The  bromides  again  showing  a  disagreeable  effect, 
they  were  diminished,  and  the  daily  medication  con- 
sisted of  30  grains  of  the  bromides,  15  grains  of  vale- 
rianate of  zinc,  10  grains  of  zinc  oxide,  and  -J^  grain 
of  atropine. 

No  attacks   until   December  21st  (slight)  and  22d 


MEDICAL    RECORD. 


[July  24,  1897 


(hard),  after  which  she  was  given  60-70  grains  of 
bromides  daily,  and  30  grains  of  valerianate  of  zinc, 
for  one  week.  They  were  then  stopped  a  while;  the 
attending  physician,  who  saw  her  often  every  day, 
changing  the  medication  as  circumstances  appeared 
to  demand. 

During  i8g6  the  case  changed  for  the  worse.  There 
was  a  severe  convulsion  on  January  2d;  it  began  in 
the  right  arm,  and  was  mostly  confined  to  the  right 
side.  Unconsciousness  lasted  but  a  few  minutes,  but 
there  was  great  weakness  and  numbness  of  the  right 
arm.  It  is  quite  important  to  remark  that  her  intel- 
lectual faculties  suffered  very  much  less  than  the  arm 
from  an  attack.  On  the  3d  there  was  a  severe  local 
convulsion  of  the  right  arm  without  any  unconscious- 
ness, and  one  slight  attack  each  on  the  15th,  i6th, 
i8th  (two  attacks),  and  the  20th.  On  the  previous 
night  her  pallor'was  excessive  and  her  pulse  feeble. 
In  February  she  had  twent}--one  attacks  of  shaking 
or  twitching  of  the  right  arm  (one  of  the  fingers  of  the 
right  hand  only)  on  ten  days  altogether.  During 
March,  1896,  the  attacks,  all  of  them  localized,  no 
general  convulsions,  became  both  more  numerous 
and  more  severe.  She  had  four  on  the  1  st,  five  on 
the  2d,  three  each  on  the  3d,  4th,  5th,  four  on  the  5th 
and  7th,  six  on  the  8th  and  9th,  seven  on  the  loth, 
eleven  on  the  nth,  fourteen  on  the  12th,  twenty-seven 
on  the  13th,  twenty-six  on  the  14th,  twenty-nine  on 
the  15th,  forty-nine  on  the  i6th,  twent}--five  in  the 
night  of  the  17th,  twenty-six  on  the  i8th  between  7 
A.M.  and  9  P.M.,  twenty-eight  on  the  19th  during  the 
same  hours,  and  nineteen  in  the  following  night.  The 
last  few  days  many  of  these  local  convulsions  were 
attended  with  heavy  breathing,  the  body  was  often 
drawn  to  the  left  while  the  right  arm  was  drawn  up 
or  shaking,  or  both,  and  on  the  19th  the  mouth  was 
noticed  to  be  drawn  to  the  left. 

It  was  on  that  day  that  Dr.  Charles  A.  Dana  saw  the 
patient.     To  his  kindness  is  due  the  following  report: 

"The  patient  was  seen  by  me,  March  19,  1896. 
She  was  a  well-grown  girl  for  her  years,  and  appar- 
ently well  nourished,  but  quite  ansemic.  Her  mind  was 
particularly  bright  and  mature.  She  had  a  slight  weak- 
ness of  the  right  arm,  but  no  paresis  of  the  facial  mus- 
cles or  of  the  legs.  The  knee  jerks  on  both  sides  were 
normal,  not  exaggerated  on  the  right  side.  The  right 
arm  showed  a  certain  amount  of  ataxia.  There  was 
an  inability  to  place  the  finger  easily  on  the  tip  of  the 
nose  with  the  eyes  closed,  or  perform  delicate  muscu- 
lar movements,  such  as  buttoning  the  clothes  or  pick- 
ing up  small  objects  from  the  table.  There  was  also 
a  slight  lack  of  localization  sense,  so  that  she  could 
not  determine  exactly  the  point  touched  by  the  hand 
or  arm.  There  was,  however,  absolutely  no  anaesthe- 
sia— no  loss  of  touch,  of  pain,  or  of  temperature  sense. 
The  elbow  jerk  was  present.  There  was  no  atrophy  or 
any  tremor  or  spasmodic  movement  in  the  arm.  The 
tongue  protruded  straight,  and  there  was  no  asymmetrj- 
of  the  facial  muscles.  The  patient  had  no  concentric 
limitation  of  the  visual  field  or  aural  field,  no  loss  of 
sense  of  smell  or  taste,  no  pharyngeal  annesthesia;  in 
fact,  absolutely  none  of  the  stigmata  of  hysteria. 
There  was  simply  the  weakness  of  the  arm,  with  ataxia 
and  defect  in  '  motor  touch,'  such  as  is  found  in  dis- 
ease of  the  motor  corte.v.  During  the  examination  she 
had  several  slight  convulsive  attacks;  the  arm  was 
extended,  the  forearm  pronated,  the  hand  flexed,  and 
the  whole  arm  separated  somewhat  from  the  side. 
The  head  was  drawn  over,  to  some  extent,  to  the  same 
side;  but  the  eyes  did  not  move.  There  was  some 
twitching  of  the  muscles  of  the  face  of  both  sides. 
There  was  no  biting  of  the  tongue,  and  had  not  been. 
The  attack  came  on  suddenly,  and  without  cry  or  dis- 
tinct aura;  the  patient  asserted  that  it  was  not  accom- 
panied by  loss  of  consciousness.     It  lasted  only  one 


or  two  minutes.  After  it  was  over  the  arm  was  for  a 
time  almost  paralyzed,  but  after  a  few  hours  gained 
considerable  strength.  She  would  have  a  number  of 
these  attacks  during  the  day.  Shortly  after  my  visits 
began  they  ceased,  however,  and  the  arm  grew  gradu- 
ally stronger,  less  clumsy,  and  eventually  she  could 
use  it  nearly  as  well  as  the  left,  though  never  quite 
the  same. 

"The  attacks  were  quite  typical  examples  of  a  Jack- 
sonian  epilepsy.  She  had  had  at  no  time  any  severe 
headaches,  no  vomiting,  and  had  no  optic  neuritis. 
The  diagnosis  at  the  time  was  Jacksonian  epilepsy, 
due  probably  to  some  slight  degenerative  changes  in 
a  limited  area  of  the  motor  cortex." 

Under  the  direction  of  Dr.  Dana  she  took,  on  March 
20th,  nitroglycerin,  ^t-^  grain;  and  urethan,  5  grains, 
every  two  hours ;  bromides,  50  grains,  through  the  day. 
She  had  thirteen  severe  attacks  through  the  day  (they 
had  since  becoming  so  numerous  been  more  frequent 
during  the  day),  and  nine  in  the  night;  on  the  21st 
forty-five  and  fifteen  (bromides,  45  grains;  urethan, 
45  grains;  nitroglycerin,  6  tablets  of  ^J.-j  grain);  on 
the  22d  thirteen  hard  attacks  and  thirty-three  slight 
twitchings  from  6  a.m.  to  10  p.m.;  six  times  the  right 
leg  shook  with  the  arm.  There  were  four  slight  at- 
tacks in  the  following  night.  Medication — bromides, 
35  grains:  urethan,  50  grains;  nitroglycerin,  7  tablets. 
On  the  23d  there  were  forty-nine  slight  twitchings  be- 
tween 8  :3o  A.M.  and  10  p.m.  ;  none  in  the  night.  Med- 
ication— bromides,  30  grains;  urethan,  55  grains; 
nitroglycerin,  3  tablets.  The  child  was  much  brighter 
and  stronger.  On  the  24th  there  were  twent)--one 
slight  twitchings  between  7:30  a.m.  and  9:30  p.m. 
Medication — bromides,  30  grains;  urethan,  60  grains. 
On  March  25th  and  the  following  days  the  same  medi- 
cation and  no  attack  whatsoever  at  any  time.  On 
April  ist  albuminuria  was  noticed,  and  urethan  was 
given  in  doses  of  45  grains;  on  the  3d  less  albumin 
— urethan,  30  grains.  This  dose  was  continued.  On 
the  6th  there  was  hardly  a  trace  of  albumin  and  the 
appetite  was  good.  At  the  same  time  daily  doses  of  30 
grains  of  bromide  were  given;  from  July  5th  to  July 
nth  she  took  25,  after  that  20  grains  daily. 

It  should  be  here  remarked  tliat  during  the  time  of 
the  greatest  number  and  severity  of  the  attacks  large 
doses  of  bromides,  up  to  100  or  even  120  grains,  were 
given  daily,  with  or  without  the  valerianate  of  zinc, 
and  had  often  to  be  discontinued  because  of  serious 
bromism.  The  only  time  in  which  the  attacks  ceased 
and  the  patient  felt  better  at  the  same  time  was  when 
she  took  urethan. 

She  continued  this  medication  while  in  the  Catskill 
Mountains  all  summer,  1896.  Her  general  condition 
did  not  improve;  she  lost  flesh  and  was  pale,  though 
in  fairly  good  spirits  most  of  the  time.  The  amount 
of  albumin  in  her  urine,  which  was  considerable  while 
she  was  having  her  attacks,  diminished.  But  while 
there  was  hardly  a  trace  and  sometimes  none  in  the 
middle  of  the  summer,  there  was  constantly  a  small 
quantity  of  bile  in  the  urine.  In  October  I  saw  her. 
She  was  in  bed,  pale  (she  never  was  icteric),  with 
anorexia,  and  a  frequent  pulse.  She  improved  some- 
what until  in  November  she  felt  better,  took  drives* 
and  with  slight  support  once  walked  ten  blocks.  Then 
her  general  condition,  however,  changed  for  the  worse, 
without  any  fever  or  other  tangible  symptoms.  I  saw 
her  with  Dr.  Dana  on  December  1st.  During  that 
month  she  grew  thinner  and  paler.  On  December 
28th  her  nurse  noticed  some  swelling  of  the  abdomen, 
whicli  had  been  rather  sunk  and  lean.  That  swelling 
was  observed  plainly  by  the  mother  and  by  Dr.  Dana 
on  January  2,  1897.  It  was  considered  to  be  due  to 
obstruction  of  the  bowels:  a  high  enema  brought  away 
a  peculiar  substance,  mixed  with  some  blood,  of  green- 
ish color  and  offensive  odor.     The  temperature  was 


July  24,  1897] 


MEDICAL    RECORD. 


but  slightly  raised,  and  there  was  no  pain.  Within 
one  or  two  days  tlie  abdominal  cavity  filled  up  with 
fluid,  the  diaphragm  was  somewhat  impeded  in  its 
motion,  respirations  increased  to  30  and  36.  Xo 
anasarca,  no  local  oedema  anywhere.  The  abdominal 
veins  were  verj-  numerous  and  dilated,  but  there  was 
no  caput  medusae. 

A  few  days  afterward  her  (moderate)  dyspnoea  be- 
came a  little  less  annoying:  the  abdomen  appeared  a 
little  less  tense,  and  the  veins  somewhat  smaller. 
Still  this  apparent  temporar)-  improvement  did  not 
last,  and  in  a  very  few  days  the  general  condition  sug- 
gested the  necessity  of  an  operation,  the  beginning  of 
which  was  to  be  a  laparotomy.  Dr.  McBurney  joined 
Dr.  Dana  and  me  in  a  consultation.  The  suddenness 
of  the  abdominal  effusion  suggested  the  presence  of  a 
thrombosis  of  the  portal  vein,  or  the  presence  of  a 
tumor  of  some  kind,  perhaps  tuberculous  lymph  bodies, 
compressing  the  portal  vein.  The  spleen  had  been 
made  out  to  be  large  the  previous  week;  the  liver  ap- 
peared somewhat  swollen.  Some  solid  or  semisolid 
masses  could  now  and  then  be  felt,  but  we  could  not 
be  certain  whether  we  had  to  deal  with  normal  or 
inflamed  and  adherent  intestines,  or  neoplastic  growths. 
or  peritonitic  exudations.  During  all  this  time  her 
strength  gave  way  slowly,  with  ven,-  poor  appetite  and 
a  urine  which,  after  having  been  copious,  had  become 
scanty  and  dark.  In  the  last  few  weeks  its  specific 
gravity  ranged  from  1.025  to  1.033,  '^^s  urea  about 
0.031  in  I  c.c.  It  contained  a  faint  trace  of  albumin. 
no  sugar,  little  oxalate  of  lime,  ver\'  little  bile,  a  large 
amount  of  urates  and  phosphates,  some  bladder  epi- 
thelium, and  some  little  pus  and  mucus. 

Laparotomy  was  performed  by  Dr.  McBumey  on 
the  loth.  There  was  a  gallon  or  more  of  a  thin  yel- 
lowish fluid  in  the  abdominal  cavit}-.  Its  specific 
gravity  was  i.oii ;  it  contained  but  little  albumin  and 
few  salts.  These  examinations  were  made  of  speci- 
mens of  fluid  which  were  removed  when  the  discharge 
was  about  half  finished.  The  spleen  was  found  to  be 
large,  the  liver  of  moderate  size ;  there  were  no  adhe- 
sions between  the  intestines,  or  between  them  and  the 
abdominal  wall  or  the  viscera.  No  large  neoplasms. 
The  omentum  was  in  good  condition,  the  mesenteric 
glands  were  not  swollen :  the  glands  surrounding  the 
portal  vein  were  felt  to  be  enlarged,  so  as  to  form  a 
thick  mass  encircling  and  pressing  on  the  vein. 

The  surface  of  the  liver  was  shining  and  covered 
with  very  numerous  yellowish-gray  bodies.  They 
were  of  different  sizes,  from  the  head  of  a  pin  to  a 
bean.  Those  of  the  latter  size  were  felt  reaching  far 
down  into  the  liver  tissue.  They  were  taken  to  be 
tuberculous. 

Many  specimens  of  the  abdominal  fluids  were  cen- 
trifuged  and  stained,  and  examined  for  tubercle  bacilli 
or  other  microbes.  One  in  six  such  specimens  yielded 
large  quantities  of  bacilli  tuberculosis  in  close  prox- 
imity to  each  other. 

The  general  condition  of  the  patient  did  not  improve 
after  the  operation.  Her  temperature  was  never  over 
100.8'  F.  in  the  axilla,  usually  100°  or  less,  down 
to  98.8"  F. ;  the  respiration  remained  between  30  and 
36;  her  pulse  rose  until  on  the  day  of  her  death. 
Januarj'  i6th,  it  reached  158,  but  little  influenced  by 
stimulant  subcutaneous  injections  which  were  con- 
tinued until  about  twelve  hours  before  she  died. 

The  autopsy  was  made  on  January  17.  1897,  twenty- 
four  hours  after  death,  by  Dr.  James  Ewing.  The 
following  report  is  mostly  from  his  pen.  By  his 
painstaking  investigations  extending  over  many  weeks 
he  has  placed  me  under  lasting  obligations. 

Report  of  Autopsy Body  that  of    a  moderately 

well-nourished,  distinctly  aneemic  child.  Rigor  mor- 
tis slight.     Xo  oedema  or  jaundice. 

Heart:   Pericardium  normal.     Right  chambers  mod- 


erately distended  with  clotted  blood.  Left  chambers 
contracted,  nearly  empty.  Valves,  muscle,  endocar- 
dium normal.     Xo  dilatation  or  h\-pertrophy. 

Lungs  show  considerable  venous  congestion  and 
oedema.  Bronchial  nodes  deeply  pigmented,  not  tu- 
berculous. Pleural  cavities  contain  a  few  drachms  of 
serous  fluid. 

Peritoneum:  Intestinal  walls  uniformly  anaemic; 
peritoneal  coat  is  slightly  dull  and  in  places  granular. 
In  pelvic  cavity,  about  drainage  tube,  are  a  few  drops 
of  pus,  and  a  light  purulent  coating  over  adjacent  coils 
of  intestine.  Parietal  peritoneum  shows  evidences  of 
intense  venous  congestion,  presenting  large  patches  of 
superficial  dark  and  bloody  infiltration.  No  miliary 
tubercles  are  anv-where  seen,  after  close  scrutiny. 

Liver:  Size  about  normal:  surface  and  section 
dotted  with  very  numerous  light  yellow  nodules,  from 
pinhead  to  pea  sized,  very  sharply  outlined  from  the 
surrounding  tissue.  Some  of  these  nodules  project 
slightly  above  the  peritoneal  surface.  They  are  not 
caseous,  but  otherwise  closely  resemble  miliars-  tuber- 
cles. There  are  many  less  on  the  surface  than  in  the 
interior.  The  hepatic  tissue  shows  ver}-  distinctly  the 
gross  appearances  of  chronic  congestion,  the  centres 
of  the  lobules  being  very  deep  red  and  depressed,  the 
peripheries  ver}-  light  colored,  but  no  blood  oozes 
from  the  sections. 

Gall  bladder:  Contents  and  mucosa  appear  normal. 

Spleen  considerably  enlarged,  four  to  five  inches 
long,  consistency  firm.  On  section  the  Malpighian 
bodies  appear  very  prominently  set  off  from  the  deeply 
congested  pulp  tissue. 

Kidneys  show  moderate  venous  congestion,  but  are 
otherwise  normal.  Adrenals  normal.  Pancreas  nor- 
mal. There  is  marked  superficial  congestion  of  ova- 
ries, otherwise  the  genital  organs  are  normal. 

Intestinal  mucous  membrane  appears  normal.  The 
solitary  follicles  are  only  faintly  visible.  The  stom- 
ach is  moderately  congested  and  coated  with  mucus. 

On  opening  the  peritoneal  cavitj'  attention  was  at 
once  directed  to  the  condition  of  the  portal  vein.  The 
gastro-hepatic  omentum  was  found  much  thickened 
and  ver}-  firm,  the  enlargement  proving  on  dissection 
to  be  due  to  swelling  of  the  periportal  lymph  nodes, 
four  or  five  of  which,  measuring  from  five  centimetres 
to  one  centimetre  in  diameter,  formed  a  nearly  con- 
tinuous mass  along  the  portal  vein,  f  ndoubtedly 
these  nodes  during  life  produced  considerable  narrow- 
ing of  the  lumen  of  the  vein.  On  removing  the  liver 
and  a  portion  of  the  diaphragm,  an  enlarged  lymph 
node,  measuring  one  centimetre  by  one  and  one-half 
centimetres,  was  found  lying  immediately  above  and 
adherent  to  the  hepatic  vein  at  its  junction  with  the 
vena  cava.  It  was  hard,  and  its  capsule  covered  with 
large  veins,  so  as  to  look  almost  angiomatous.  It  did 
not  seem  possible  that  the  hepatic  vein  could  have  es- 
caped partial  compression  by  this  considerable  mass 
of  tissue.  On  section  these  lymph  nodes  appeared 
deeply  congested,  but  were  not  tuberculous.  No 
thrombi  were  found  in  either  the  portal  or  hepatic  veins. 
The  mesenteric  nodes  were  not  enlarged. 

Brain  rather  large,  the  convolutions  not  flattened. 
Pia  mater  opaque,  whitish,  thickened,  and  rather 
hard  over  a  large  surface:  moderately  congested, 
mostly  so  over  the  region  of  the  motor  centres.  This 
change  was  more  perceptible  on  the  left  side  than  on 
the  right.  In  this  neighborhood  the  convolutions  are 
rather  separated  from  each  other  and  felt  hard.  This 
condition  was  suggestive  of  interstitial  swelling  in  the 
white  substance.  The  structure  of  the  brain  appeared 
normal  everywhere,  the  ventricles  were  empt\'.  the 
plexuses  normal. 

The  left  half  of  the  cranium  was  smaller  and  flatter 
than  t'le  right. 

Over  the  left  motor  centre  there  was  a  defect  in  the 


MEDICAL    RECORD. 


[July  24,  1897 


structure  of  the  bone,  one  and  one-fourth  centimetres 
wide  and  two  and  one-fourth  centimetres  long,  in  a 
forward  and  downward  direction.  The  bone  was 
transhicent,  its  outer  surface  quite  smooth  and  on  a 
ievel  with  the  rest  of  the  cranium,  its  inner  surface 
■depressed.  This  depression  was  quite  sharp,  as  in 
•  craniotabic  defects.  There  were  two  more  such  de- 
fects on  the  same  left  side,  in  a  forward  direction, 
quite  as  wide  but  shorter,  about  three  centimetres 
from  the  median  line.  One  more  such  spot  was  found 
over  the  left  brow;  another  was  located  over  the  left 
motor  centre,  one  and  one-half  centimetres  long  and 
one  and  one-half  centimetres  wide.  The  space  of  the 
large  fontanelle,  two  and  one-half  by  three  centime- 
tres, was  occupied  by  hard,  thick,  and  rather  irregular 
ibone,  which  was  surrounded  by  a  narrow  (about  three- 
fourth  centimetre)  semitransparent  area.  To  the  left 
of  this,  and  rather  forward  and  adjoining  the  coronal 
suture,  was  a  triangular  osseous  island,  also  flanked 
by  a  transparent  area. 

The  impressiones  digitatse  and  Pacchionian  depres- 
sions were  more  pronounced  on  the  left  side. 

On  the  occiput,  where  a  trauma  was  sustained  five 
years  previously,  no  abnormal  condition  was  observed. 


The  pia  was  moderately  congested,  and  over  the 
whole  convexity  was  considerably  thickened  and 
opaque.  The  brain  tissues  appeared  normal.  The 
thickness  of  the  parietal  bones  varied  greatly,  espe- 
cially along  the  sagittal  suture. 

Microscopical  Examination. — The  liver  shows  the 
usual  lesions  of  advanced  chronic  congestion,  with 
complete  atrophy  of  cells  at  the  centres  of  lobules,  and 
slight  fatty  degeneration  of  cells  at  the  peripheries  of 
lobules. 

'I'he  small  nodules  above  described  prove  to  be 
miliary  adenomata.  They  are  composed  of  thick  cords 
of  hypertrophic  liver  cells,  usually  containing  more 
than  one  nucleus,  and  at  some  points  showing  consid- 
erable fatty  infiltration.  The  larger  adenomata  are 
surrounded  by  a  distinct  fibrous  capsule,  within  which 
effects  of  chronic  congestion  have  not  been  felt,  as  the 
capillaries  of  the  adenomata  are  not  at  all  widened.' 
The  cords  of  liver  cells  surrounding  the  nodules  are 
much  compressed  for  a  considerable  distance  (see 
figure). 

The  lesions  in  the  lymph  nodes  include : 

I.  A  chronic    inflammatory   hyperplasia,   with   the 

'  In  this  respect  our  specimen  differs  from  the  majority  of  the 
few  cases  which  have  been  described.  In  them  the  liver-cells 
were  thoroughly  compressed  and  destroyed  by  copious  interstitial 
tissue,  and  new  cells  were  developed  through  a  compensatory 
process. 


production  of  new  connective  tissue,  extensive  exfolia- 
tion of  endothelial  cells,  and  atrophy  of  lymphoid 
cells. 

2.  An  extreme  dilatation  of  veins  and  capillaries, 
both  within  and  without  the  nodes. 

The  inflammatory  process  has  replaced  considera- 
ble portions  of  the  nodes  by  a  tissue  apparently  com- 
posed of  flattened  and  fusiform  endothelial  or  connec- 
tive cells,  and  entirely  lacking  in  lymphoid  cells.  In 
these  areas  the  capillaries  are  often  dilated  and  gorged 
with  blood.  The  lymph  nodules  are  all  quite  small, 
and  many  appear  to  have  been  replaced  by  the  above 
tissue.  There  is  a  slight  deposit  of  anthracotic  pig- 
ment in  the  fibrous  tissue.  The  large  neighboring 
veins  are  enormously  dilated,  and  possibly  increased 
in  number,  so  as  to  give  an  appearance  not  unlike  that 
of  a  cavernous  angioma.  The  venous  stasis  has  like- 
wise affected  the  vessels  within  the  nodes,  the  medul- 
lary lymph  cords  being  entirely  absent  and  replaced 
by  dilated  blood  spaces  or  fibrous  tissue.  The  condi- 
tion of  the  lypmh  nodes  indicates  a  process  of  older 
date  than  that  of  the  changes  in  the  liver. 

The  mesentery  shows  cedematous  infiltration,  and 
about  some  small  vessels  are  collections  of  mononu- 
clear and  polynuclear  cells. 

The  spleen  shows  the  effects  of  chronic  congestion 
equally  marked  with  those  of  the  liver.  The  sinuses 
are  much  dilated,  and  the  pulp  cells  contain  a  large 
deposit  of  blood  pigment. 

The  intestinal  wall  shows  a  light  coating  of  fibrin 
with  exfoliation  of  endothelial  cells. 

The  ovaries  and  Fallopian  tubes  show  venous  con- 
gestion, but  no  other  lesion. 

Hrain:  The  motor  cortex  of  both  sides  was  cut  in 
thin  slices  and  hardened  in  saturated  watery  solution 
of  corrosive  sublimate. 

Sections  stained  by  Nissl's  method  gave  very  un- 
satisfactory results,  owing  to  advanced  post-mortem 
changes.  As  nearly  as  could  be  judged,  the  motor 
areas  of  both  sides  were  identical  in  appearances,  in- 
cluding the  numbers  and  configuration  of  the  cells, 
and  the  character  of  chromatophilic  bodies  and  intra- 
cellular network.  The  pia  of  both  sides  was  consid- 
erably thickened,  that  over  the  left  motor  area  very 
much  so. 

Some  capillaries  were  found  containing  colonies  of 
cocci. 

The  ganglion  cells  of  the  cranial  nerve  nuclei  (XII., 
X.,  IX.  examined)  showed  no  unusual  appearances 
by  Nissl's  stain. 

Bacteriological  Examination A  portion  of  one  of 

the  superficial  adenomata,  including  a  section  of  the 
capsule  of  the  liver,  was  inserted  beneath  the  skin  of 
a  guinea-pig.  Seven  weeks  later  no  inflammatory 
changes  were  to  be  found  at  the  point  of  inoculation 
or  in  the  adjoining  lymph  nodes. 

A  similar  negative  result  followed  the  inoculation 
of  another  guinea-pig  with  a  swab  from  the  fluid  and 
pus  in  the  bottom  of  the  drainage  tube.  The  fluid  in 
the  drainage  tube,  smeared  on  cover  glasses,  showed 
the  presence  of  numerous  cocci  in  masses  and  short 
chains.  Pure  cultures  of  staphylococcus  pyogenes 
aureus  and  of  streptococcus  pyogenes,  of  marked  viru- 
lence, were  secured  bv  Dr.  t'harles  Norris  from  this 
same  fluid. 

The  fluid  from  the  drainage  tube  and  sections  of  the 
intestinal  wall,  niesenterv,  liver,  spleen,  and  lymph 
nodes  were  stained  for  tubercle  bacilli  with  a  negative 
result. 

I'he  serosa  of  the  inflamed  intestines  contained 
cocci  in  moderate  numbers. 

The  spleen  contained  large  numbers  of  minute  colo- 
nies of  cocci,  and  in  the  motor  cerebral  cortex  and  in 
a  lytnpii  node  single  colonies  of  cocci  were  observed. 

Diagnosis. — Chronic    inflammatory  hyperplasia  of 


July  24,  1897] 


MEDICAL    RECORD. 


113 


periportal  and  perihepatic  lymph  nodes,  of  undeter- 
mined origin.  Partial  compression  of  hepatic  and 
portal  veins.  Chronic  congestion  of  liver  and  portal 
viscera.  Multiple  miliary  adenomata  of  liver.  As- 
cites. Peritonitis.  Tubercle  bacilli  in  the  fluid. 
Septicaemia. 

Epicritical. — From  the  pathological  standpoint  the 
obscure  feature  of  the  case  is  the  relation  of  the  swell- 
ing of  the  perihepatic  lymph  nodes  and  the  condition 
of  the  liver.  In  the  absence  of  any  other  adequate 
cause  it  is  necessary  to  conclude  that  the  advanced 
chronic  congestion  of  the  liver  was  due  to  a  compres- 
sion of  the  hepatic  vein  from  the  enlarged  lymph  node 
lying  above  and  upon  this  vein.  It  then  becomes  nee 
essary  to  discover  a  cause  of  this  hyperplasia  of  the 
lymph  nodes,  which,  with  the  periportal  nodes,  were 
the  only  ones  in  the  body  thus  affected.  Several 
possibilities  may  be  suggested.  It  is  possible  that  the 
lymph  nodes  were  subjected  to  chronic  irritation  from 
intestinal  to.xsmia,  in  which  case  it  is  difficult  to  see 
how  the  mesenteric  nodes  could  have  escaped,  as  the\' 
did,  a  similar  irritation  and  hyperplasia.  The  prob- 
ability of  a  serious  retrograde  irritation  from  the  tho- 
racic chains  must  be  regarded  with  caution,  since  the 
thoracic  nodes  were  not  enlarged,  and  the  bronchial 
nodes  showed  only  moderate  pigmentation.  The  de- 
posit of  pigment  in  the  perihepatic  node  was  very- slight 
and  apparently  quite  insufficient  to  induce  the  lesion 
found  in  the  node.  Nevertheless  such  a  possibility 
may  be  entertained. 

Cholecystitis  could  have  affected  the  periportal 
nodes,  and  suppurative  lesions  in  this  viscus  com- 
monly do  so:  but  there  were  no  evidences,  either  gross 
or  microscopical,  of  any  disease  of  the  gall  bladder. 
The  considerable  size  of  some  of  the  adenomata  (one- 
half  centimetre  in  diameter)  suggests  that  these  may 
have  been  the  primary  lesions,  and  that  the  disor- 
dered condition  of  the  hepatic  circulation  and  func- 
tion led  to  the  hyperplasia  of  the  lymph  nodes  drain- 
ing the  organ.  While  there  is  no  positive  evidence  on 
which  to  deny  such  a  course  of  events,  many  recent 
studies  of  nodular  hyperplasia  of  the  liver  tend  to 
show  that  this  lesion  usually  represents  a  regenerative 
tendency,  well  marked  in  liver  cells,  to  replace  disor- 
dered or  destroyed  hepatic  tissue  by  way  of  compen- 
sation. No  other  cause  for  liver  congestion  can  be 
found  in  our  case  in  heart,  pleura,  or  lungs.  Some 
extensive  studies  of  this  character  have  been  contrib- 
uted, as  follows: 

Flock:  "  Ueber  Hypertrophic  und  Neubildung  der 
Lebersubstanz,"  Deiitscltes  Anhir  fiir  kUnische  Mediciii, 
1895,  Bd.  Iv. 

Marchand :  '"  Ueber  Ausgang  der  acuten  Leberatro- 
phie  in  multiple  knotige  Hyperplasie,"  Ziegler's 
Beit  rage,  1895,  Bd.  xvii.,  p.  206. 

Meder:  "  Ueber  acute  Leberatrophie  mit  besonderer 
Berucksichtigung  der  dabei  beobachteten  Regenera- 
tionserscheinungen,"  Ziegler's  .5(-//y(7;^<-,  1895,  Bd.  xvii., 

P-  143- 

Therese :  '"  Des  adenomes  du  foie,"  L' Union  Medi- 
cale,  1895,  No.  34. 

Babes  et  Manicatide:  '"  Les  proliferations  des  cel- 
lules h^patiques  dans  les  differents  affections  dufoie," 
Ref.  in  Centralhlatt  ficr  Pathologic,  etc.,   1896,  No.  23. 

The  very  general  distribution  of  the  nodules  in  tiu- 
present  case,  and  the  fact  that  they  represented  areas 
of  apparently  normal  liver  cells — in  the  diagram  the 
presence  and  absence  of  these  cells  in  adjoining  ter- 
ritory is  beautifully  represented — in  which  the  effects 
of  the  chronic  congestion  were  not  at  all  noticeable. 
seems  to  support  strongly  the  view  that  these  mili;iry 
adenomata  were  entirely  the  result  of  the  advanced 
chronic  congestion  and  atrophy  of  liver  cells  which 
affected  the  entire  organ. 

As  already  stated.  nioreo\'er,  the  lesion  in  the  lymph 


nodes  appears  to  have  been  probably  of  older  date 
than  the  adenomata  of  the  liver. 

Pressure  on  the  hepatic  vein  having  been  once  es- 
tablished, thereby  obstructing  the  venous  return  from 
the  nodes  themselves,  it  is  readily  seen  how  the  course 
of  events  should  lead  to  exactly  the  condition  found 
at  autopsy. 

The  peritonitis  and  septicaemia  which  terminated 
the  case  may  properly  be  regarded  as  the  natural  and 
very  frequent  result  of  the  sudden  relief  of  pressure 
from  the  abdominal  viscera,  especially  the  intestines, 
allowing  the  passage  of  intestinal  bacteria  into  the 
peritoneum,  and  apparently  also  into  the  general  cir- 
culation. The  intestinal  lumen  contained  a  very 
abundant  growth  of  cocci :  the  streptococcus  and  sta- 
phylococcus were  isolated  from  the  peritoneum,  and 
bacterial  thrombi  composed  of  cocci  were  found  in  the 
spleen  abundantly,  and  in  the  brain  and  hniph  nodes. 

This  consideration  affords  also  a  clew  to  the  pres- 
ence of  tubercle  bacilli  in  the  serum  contained  in  the 
abdominal  cavity.  They  are  transferred  through  the 
circulation,  either  of  the  blood  or  of  the  lymph.  The 
latter  would  start  from  lymph  nodes  which  were,  how- 
ever, nowhere  affected,  nor  was  there  any  organ  or 
tissue  infected  with  tuberculosis.  Therefore  the  pres- 
ence of  tubercle  bacill,  can  be  explained  by  transmis- 
sion through  the  blood  current  only.  Evidently  they 
were  only  a  complication,  an  incident.  When  the 
rapid  effusion  took  place  from  the  blood-vessels  of  the 
peritoneum  and  the  intestine,  where  the  bacilli  hap- 
pened to  be  located,  without  having  given  rise  to  local 
or  general  symptoms,  the  vessels  were  emptied  of  a 
thin  serum — of  i.oii  specific  gravity — with  all  its 
contents.  The  alkaline  fluid  in  the  abdominal  cavity 
proved  an  excellent  nutrient  and  a  preservative  for  the 
bacilli. 

The  presence  of  bacilli  in  the  ascitic  fluid,  in  the 
absence  as  well  of  tuberculous  deposits  or  degenera- 
tions anywhere  as  of  lesions  in  the  intestine  which 
could  be  charged  with  admitting  the  microbes  into  the 
circulation,  is  no  longer  an  improbability,  since  it 
iias  been  proven  that  surface  lesions  of  a  mucous  mem- 
brane are  not  required  to  admit  tuberculosis,  nor  hia- 
tuses in  the  epithelial  covering,  which,  for  instance, 
are  possessed  by  the  tonsils  (Stoehr)  in  their  normal 
state.  It  has  been  known  for  some  time  that  initial 
lesions  in  the  lungs,  for  instance,  need  not  correspond 
with  the  localities  of  original  affections,  for  pulmonary 
infiltrations  will  follow  the  subcutaneous  injections  of 
bacilli  in  distant  places.  Koch  proved  that  lymph 
bodies  may  become  diseased  without  affections  of  their 
roots.  Solid  particles  are  known  to  penetrate  the 
lungs.  The  spores  of  saprophytes  and  of  anthrax  are 
so  admitted.  Whether  this  happen"--  more  readily  in 
children,  whose  organs  are  less  changed  by  the  solid 
results  of  previous  morbid  processes,  remains  to  be 
seen.  Bollinger  and  Heller  demonstrated  that  tuber- 
cle virus  may  penetrate  through  intact  tissue,  and  that 
it  is  not  necessary  to  assume,  with  Babes,  that  cocci 
prepared  the  soil  for  absorption.  The  tubercle  ba- 
cilli in  the  ascites  of  our  case  would,  therefore,  be 
explained  in  one  of  two  ways.  They  were,  before  en- 
tering the  abdominal  cavity,  contained  either  in  the 
circulating  blood  or  in  the  intestinal  tract.  The  former 
is  very  improbable,  for  there  were  no  miliary  deposits 
anywhere.  The  presence  of  bacilli  in  the  intestinal 
tract  is  explained  by  the  facility  of  their  admission  in 
food.  It  is  probable  that  there  are  but  few  intestinal 
tracts  but  are  harboring  bacilli  now  and  then.  It  is 
under  favorable  circumstances  only  that  they  are  ab- 
sorbed instead  of  being  expelled.  Sucli  favorable 
circumstances  are  either  the  presence  of  local  lesions 
or  sudden  changes  of  osmosis.  The  latter  existed  in 
our  case. 

The  local  cranial  defects  remain  unexplained.      If 


114 


MEDICAL    RECORD. 


[July  24,  1897 


they  had  been  found  in  the  skull  of  a  baby  less  than 
six  or  ten  months  old,  they  would  certainly  have  been 
claimed  as  rachitical.  Craniotabes,  however,  when 
the  rachitis  has  disappeared,  never  leaves  behind  it 
these  attenuated  circumscribed  spots.  There  was  no 
symptom  of  rachitis  in  the  patient  when  an  infant, 
except  constipation.  There  was,  moreover,  no  tumor, 
no  thickening  inside  to  explain  a  local  absorption  of 
such  circumscribed  character.  I  prefer  to  point  to 
this  instance  of  defective  local  bone  development  on 
some  other  than  rachitical  basis. 

It  has  been  noticed  that  the  pia  and  the  surface  of 
the  brain  exhibited  marked  alterations  from  the  nor- 
mal, but  none  so  localized  as  to  explain  the  spas- 
modic symptoms  constituting  the  very  picture  of 
what  we  mean  by  the  term  Jacksonian  epilepsy.  The 
advisability  of  an  operation  undertaken  to  find  and 
remove  its  local  cause  was  often  considered  by  the 
medical  men  who  studied  the  case.  It  never  was  urged 
by  any  one,  it  was  advised  against  by  some.  Nothing 
that  is  positive  can  be  learned  by  this  feature  of  the 
case,  except  the  necessity  of  care  and  caution  and  pru- 
dence. 

A  therapeutical  remark  will  not  be  out  of  place.  It 
has  been  seen  that  the  bromides  would  sometimes  be 
required  in  such  quantities  as  to  interfere  seriously 
with  the  general  health  of  the  patient.  When  the 
doses  of  urethan,  recommended  by  Dr.  Dana,  were 
given  persistently,  the  convulsive  attacks  ceased  very 
soon,  never  to  return,  and  there  were  no  disagreeable 
symptoms  attributable  to  the  remedy. 


FELONS    AS    MEDICAL    PRACTITIONERS    IN 
NEW   YORK. 

By   W.    a.    PURRINGTON,   Esq., 


In  1887,  after  three  years  of  effort,  conflicting  views 
and  interests  were  sufficiently  harmonized  to  secure 
the  enactment  in  New  York  of  chapter  647  of  the 
laws  of  that  year,  which  is  substantially  the  present 
medical  law  of  this  State.'  Section  6  of  that  act  in- 
troduced this  new  provision  into  the  law  :  "  No  person 
shall  be  licensed  or  permitted  to  practise  physic  or 
surgery  in  this  State  who  has  been  convicted  of  a  fel- 
ony by  any  court  of  competent  jurisdiction ;  and  if 
any  person  who  is  or  hereafter  shall  be  duly  licensed 
to'  practise  physic  or  surgery  in  this  State,  shall  be 
convicted  of  a  felony,  as  aforesaid,  his  or  her  license 
to  so  practise,  if  any,  shall  be  revoked  by  the  fact  of 
such  conviction  having  been  had.  Any  person  .  .  . 
who,  after  conviction  of  a  felony,  as  aforesaid,  shall 
attempt  to  practise  physic  or  surgery  in  this  State, 
.  .  .  shall  be  deemed  guilty  of  a  misdemeanor,  and 
upon  conviction  thereof  shall  be  punished  by  a  fine  of 
not  less  than  $250,  or  imprisonment  for  six  months  for 
the  first  offence,  and  upon  conviction  of  a  subsequent 
offence,  by  a  fine  of  not  less  than  j;5oo  or  imprison- 
ment for  not  less  than  one  year,  or  by  both  fine  and 
imprisonment." 

Minimum  punishments  established  for  the  unlawful 
practice  of  medicine  by  others  than  felons  were  a  fine 
of  $50  for  the  first  olTence,  and  one  of  $100  or  impris- 
onment or  both  for  the  second;  tiie  maximum  fine  for 
either  offence  being  the  ordinary  maximum  in  cases 
of  misdemeanor,  viz.,  $500.  Thus  while  a  convicted 
felon  could  not  be  punished  by  a  greater  maximum 
fine  than  any  other  illegal  practitioner,  the  offences 
of  both  being  misdemeanors,  neither  could  he,  on  the 
other  hand,  receive  so  light  a  sentence  as  he  might 
except  for  such  previous  conviction. 

'  For  a  review  of  medical  legislation  in  the  State  of  New  York, 
prior  to  1887  see  the  Medical  Record  of  October  23,  1886, 
vol.  30,  No.  17. 


When  the  bill  came  before  the  governor  he  favored 
its  general  purpose,  but  suggested  that  this  new  provi- 
sion might  work  hardship  in  individual  cases;  in- 
stancing a  medical  practitioner  recently  pardoned  by 
himself — an  unfortunate  illustration,  as  the  event  has 
proved,  for  the  man  has  been  again  convicted  of 
felony. 

The  brief  then  submitted  in  behalf  of  the  State  and 
county  medical  societies,  in  arguing  the  constitutional- 
ity of  the  law,  cited  the  test-oath  cases  in  the  United 
States  supreme  court,  and  said:  "Both  the  prevailing 
and  dissenting  opinions  hold  that  any  proper  qualifi- 
cations may  be  required  of  professional  men,  that  do 
not  constitute  a  penalty  for  an  act  not  so  punishable 
when  committed."  And  in  enumerating  the  classes 
which  would  benefit  by  a  veto,  the  brief  mentioned  as 
one  of  them  '"  convicted  felons,  who,  as  in  the  case  of 
one  now  in  New  York,  may  serve  as  many  as  three 
terms  of  imprisonment  for  criminal  malpractice  and 
return  to  '  renew  business  at  the  old  stand.' " 

By  chapter  661  of  the  laws  of  1893  the  commission- 
ers of  statutory  revision,  one  of  whom  had  been  con- 
sulted upon  and  was  familiar  with  said  enactment, 
codified  the  laws  relating  to  public  health  into  chap- 
ter 25  of  the  general  laws,  which  re-enacted  the  provi- 
sion in  question,  by  these  words  in  section  140:  "Nor 
shall  any  person  practise  medicine  who  has  ever  been 
convicted  of  a  felony  by  any  court,"  and  these  words 
in  section  153:  "Any  person  .  .  .  who,  after  convic- 
tion of  a  felony,  shall  attempt  to  practise  medicine, 
.  .  .  shall  be  guilty  of  a  misdemeanor,  and  on  convic- 
tion thereof  shall  be  punished  by  a  fine  of  not  less 
than  $250,  or  imprisonment  for  six  months  for  the  first 
offence,  and  on  conviction  of  a  subsequent  offence,  by 
a  fine  of  not  less  than  $500,  or  imprisonment  for  not 
less  than  one  year,  or  by  both  fine  and  imprisonment." 

This  codification,  however,  while  forbidding  medi- 
cal practice  to  the  unlicensed  and  unregistered  citizen, 
provided  therefor  neither  fine  nor  imprisonment,  but 
only  a  civil  penalty.  Whether  this  omission,  specifi- 
cally to  infiict  the  fine  theretofore  imposed  by  the  laws 
codified,  removed  ordinar}'  illegal  practice  from  the 
class  of  misdemeanors,  was  a  question  on  which 
opinions  differed ;  but  it  was  never  submitted  to  the 
courts  nor  need  it  be  discussed  here,  for,  whether  it  did 
or  not,  the  convicted  felon  still  remained  liable  to  a 
greater  minimum  punishment  than  non-convicts  in 
pari  delictu. 

By  chapter  398  of  the  laws  of  1895,  section  153  of 
said  codification  was  so  amended  as  to  provide  that 
"any  person  who,  not  being  then  lawfully  authorized 
to  practise  medicine  within  this  State  and  so  registered 
according  to  law,  shall  practise  medicine  within  this 
State  without  lawful  registration  or  in  violation  of  any 
provision  of  this  article;  and  any  person  who,  .  .  . 
after  conviction  of  a  felony,  shall  attempt  to  practise 
medicine,  or  shall  so  practise,  .  .  .  shall  be  guilty  of 
a  misdemeanor,  and  on  conviction  thereof  shall  be 
punished  by  a  fine  of  not  more  than  two  hundred  and 
fifty  dollars,  or  imprisonment  for  six  months  for  the 
first  oftence,  and  on  convjction  of  any  subsequent  of- 
fence, by  a  fine  of  not  more  than  five  hundred  dollars, 
or  imprisonment  for  not  less  than  one  year,  or  by  both 
fine  and  imprisonment." 

Thus  this  amendment  of  1895,  which  is  the  existing 
law  as  to  penalties,  by  its  new  provisions  punishes  all 
illegal  practitioners  alike,  whether  felons  or  merely 
non-licentiates,  by  a  fine  which  cannot  exceed  for  the 
first  oftence  $250,  or  half  the  maximum  fine  imposed 
on  misdemeanants  by  the  penal  code  and  theretofore 
by  the  various  medical  laws  codified. 

Such  being  the  law  in  1896,  15enjamin  Hawker, 
alias  Perry,  alias  West,  was  tried  under  it  upon  an  in- 
dictment setting  forth,  as  reported,  only  two  facts:  (i) 
that  he  had  been  convicted  in  1878  of  the  crime  of 


July  24,  1897] 


MEDICAL    RECORD. 


abortion,  and  sentenced  to  ten  years  in  the  peniten- 
tiary; (2)  that  he  afterward  unlawfully  practised  med- 
icine in  the  city  of  New  York  upon  a  certain  woman 
on  the  22d  day  of  February,  i8g6,  against  the  form  of 
the  statute,  etc. 

To  this  indictment  defendant  demurred,  upon  the 
ground  that  these  facts  did  not  constitute  a  crime; 
contending  that  the  statute  was  only  prospective,  or, 
if  retrospective,  then,  as  to  him,  unconstitutional,  in 
that  his  conviction  of  felony,  having  been  had  prior 
to  its  taking  effect,  the  law  was  ex  post  facto,  as  creat- 
ing a  new  penalty  for  an  offence  for  which  he  had  been 
already  punished. 

The  demurrer  was  overruled  and  defendant  there- 
after convicted  and  sentenced  upon  his  admission 
of  the  truth  of  the  facts  pleaded.  On  appeal  the  ap- 
pellate division,  by  a  divided  court,  sustained  his  con- 
tention ;  the  prevailing  opinion  holding  that  the  law 
as  applied  to  the  case  of  a  physician  convicted  of  fel- 
ony before  it  took  effect  is  ex  post  Jacto,  and  therefore 
unconstitutional,  in  that  it  does  provide  a  new  penalty 
for  his  crime  by  depriving  him  of  his  license  to  prac- 
tise medicine,  which  is  in  the  nature  of  a  property 
right,  not  forfeited  by  a  conviction  of  felony  prior  to 
the  time  this  law  took  effect. 

The  opinions  of  the  court  '  are  noteworthy  e.xposi- 
tions  of  much  argued  topics,  and  deserve  quotation  at 
length. 

Upon  the  point  of  legislative  power  to  require  good 
moral  character  as  a  preliminary  qualification  for  ad- 
mission to  medical  practice,  the  prevailing  opinion 
laid  down  the  premise  that  such  a  test  must  relate  to 
present  status,  and  must  not  debar  a  wicked  man, 
turned  away  from  his  wickedness  committed  prior  to 
the  law's  enactment,  from  practising  medicine  in  a 
lawful  and  right  fashion.  .Said  the  court,^  the  ital- 
ics being  ours: 

"  Assuming  for  the  purposes  of  the  argument  that  the 
legislature  may  require,/;'/-  the  continuance  in  the  prac- 
tice oj  medicine,  that  the  practitioner  shall  possess  pro- 
fessional knowledge  and  skill  and  also  good  moral 
character,  it  is  obvious  that  such  requirement  must  relate 
to  a  present  status  or  condition  oJ  a  person  coming  within 
the  terms  of  the  act.  The  law  under  which  this  appel- 
lant was  indicted  does  not  deal  with  his  present  moral 
character.  It  seizes  upon  a  past  offence  and  makes 
that,  and  that  alone,  the  substantial  ingredient  of  a 
new  crime,  and  the  conviction  of  it  years  ago  the  con- 
clusive evidence  of  that  new  crime."  And  later:' 
"The  design  of  the  act  is,  therefore,  fully  apparent. 
No  matter  how  praiseworthy  the  motive  may  be,  it  is 
meant  to  deprive  one  class  oJ  persons,  otherwise  latifully 
engaged  in  the  exercise  oJ  a  right,  of  that  right  because 
of  past  occurrences,  ''many  of  7vhich  are  in  no  wise  asso- 
ciated with  their  professional  pursuits,'  for  this  act 
strikes  at  the  unfortunate  man  who  in  his  youth  may 
have  violated  the  law,  and,  without  real  evil  intent, 
have  committed  and  been  convicted  of  any  felony  and 
pardoned  the  very  day  of  his  conviction,  as  well  as  the 
hardened  criminal,  guilty  of  as  foul  an  offence  as  that 
of  which  this  appellant  was  convicted.  The  underly- 
ing purpose  of  the  act  may  be  to  purge  the  medical 
profession  of  members  unworthy  of  confidence,  but  the 
real  effect  is  to  accomplish  that  by  inflicting  an  addi- 
tional punishment  through  a  newly  created  offence  in- 
separably connected  with  the  anterior  crime,  and  thus 
bring  about  a  result  the  constitution  forbids,  no  matter 
in  what  form  the  statute  is  drawn.'" 

Upon  the  point  of  Hawker's  status  at  the  time  of 
his  conviction  of  felony  in  1878,  and  the  ineffective- 
ness of  that  conviction  to  deprive  him  of  his  "right ' 
to  practise  medicine,  the  court  said:' 

"  He  had  absolutely  the  right  to  practise  medicine  the 


'  Reported  in  14  App.  Div.  18 
*  At  p.  192. 


^  At  p.  190. 

*  At  pp.  190,  191. 


day  before  the  statute  was  passed.  His  fomter  convic- 
tion entailed  the  punishment  of  imprisonment  and 
disfranchisement  as  a  voter,  but  it  did  not  take  a7oay 
from  him  his  property  in  the  right  to  earn  his  living  on 
the  expiration  of  his  imprisonment  by  engaging  in  the 
profession  of  'which  he  rcas  and  is  a  member.  His  civil 
rights  were  not  e.xtinguished,  but  only  suspended,  dur- 
ing his  imprisonment  (2  R.  S.  701,  §  19;  Penal  code, 
§  710).  That  his  right  to  so  engage  in  that  profes- 
sion is  in  the  nature  of  a  property  right  cannot  be 
disputed.  It  is  not  a  mere  revocable  license.  As  is 
said  in  the  Dent  case  {supra),'  in  this  country  'all 
vocations  are  open  to  every  one  on  like  conditions. 
All  may  be  pursued  as  sources  of  livelihood,  some 
requiring  years  of  study  and  great  learning  for  their 
successful  prosecution.  The  interest,  or,  as  it  is  some- 
times termed,  the  estate  acquired  in  them,  that  is,  the 
right  to  continue  their  prosecution,  is  ojten  ;;/' great  value 
to  the  possessors  and  cannot  be  arbitrarily  taken  from 
them  any  mo?e  than  their  real  or  personal  property  can 
be  thus  taken.'  That  means  that  if  it  is  taken  away  it 
must  be  for  cause." 

Of  the  five  justices  sitting  at  the  argument,  three 
concurred  in  this  prevailing  opinion  and  judgment 
was  reversed. 

The  fifth  justice  dissented,  upon  the  ground  that  the 
exclusion  of  felons  from  practice  by  the  act  was  not 
the  infliction  of  a  new  penalty  for  an  old  offence,  but 
merely  the  establishment  of  a  test  of  moral  fitness  for 
the  practice  of  medicine,  not  in  itself  more  arbitrary 
than  the  test  of  general  qualification  to  practise  held 
constitutional  in  the  Dent  case,  viz.,  that  continuous 
medical  practice  within  the  State  for  ten  years  prior 
to  March  8,  1881,  should  be  equivalent  as  evidence  of 
qualification  to  a  diploma  or  certificate  of  successful 
examination  before  the  board  of  health. 

There  is,  however,  a  distinction  here  that  the  learned 
justice  did  not  comment  upon ;  for  while  it  is  quite 
true  that  to  accept  any  term  of  practice  within  the 
State  as  a  test  of  qualification  to  continue  so  to  prac- 
tise is  arbitrary,  and  conceivably  absurd,  yet  such 
continuous  practice  was  not  the  sole  test  under  the 
West  Virginia  statute,  which  permitted  any  one  to 
acquire  a  right  either  to  begin  or  continue  to  practise 
by  showing  his  qualifications  through  examination  or 
by  diploma;  while  under  our  health  law  the  felon  is 
absolutely  barred  from  practice. 

The  dissenting  justice  was  also  of  opinion  that  in 
pointing  out  the  hardship  conceivably  resulting  to  a 
convict  of  present  moral  life,  the  prevailing  opinion 
rather  criticised  the  propriety  of  the  legislative  test 
than  adduced  a  reason  for  declaring  it  unconstitution- 
al; and  he  might  w-ell  have  pointed  out  also  that  it  is 
not  more  severe  to  debar  a  person  from  practice  for  a 
past  felony  than  it  is  to  close  the  door  of  hope  and 
leave  no  locus  pa'iiitentiic  ior  future  offenders;  as  to 
whom  the  prevailing  opinion  admits  that  the  law  is 
constitutional. 

Finally,  the  dissenting  justice,  like  his  colleagues, 
also  assumes  that  Hawker  was  at  the  time  of  his  con- 
viction in  1878  a  licensed  physician,  and  therefore 
says,"  after  reciting  the  right  of  the  State  to  make  nec- 
essary health  regulations:  "I  do  not  understai-d  that 
they"  (such  regulations)  "are  necessarily  ex  post  facto, 
because  rights  of  the  individual  that  existed  prior  to 
the  passage  of  the  law  that  creates  the  restriction  are 
curtailed.  I  suppose  that  if  an  act  was  passed  requir- 
ing that  those  having  a  contagious  or  infectious  dis- 
ease should  be  isolated  so  as  to  avoid  communicating 

'  Dent  fj-.  West  Virginia,  129  U.  S.  114,  holding  constitutional 
a  statute  establishing,  as  one  test  of  fitness  to  practise,  the  fact 
that  the  licentiate  had  practised  medicine  within  the  State  of 
West  Virginia  "  continuously  for  the  period  of  ten  years  prior  to 
the  8th  day  of  March,  1881,"  and  affirming  the  conviction  of  one 
who  had  practised  in  the  State  for  only  five  years. 

•  At  p.  194. 


ir6 


MEDICAL    RECORD. 


[July  24,  i! 


the  disease,  the  fact  that  such  disease  existed  prior  to 
the  time  of  the  passage  of  the  act  would  not  make  the 
act  ^.v  post  facto,  and  so  unconstitutional,  nor  would 
such  isolation  or  control  over  a  person  who  has  such  a 
disease  be  a  punishment  for  having  the  disease;"  etc. 
To  which  the  answer  would  seem  to  be  that  a  man  is 
isolated  because  he  has  the  disease,  not  because  he 
has  had  it — the  argument  of  the  prevailing  opinion 
on  this  point  only  being  that  a  previous  conviction  of 
felony  is  not  more  conclusive  proof  of  a  present  im- 
moral character,  than  the  scar  of  small-pox  is  a  sure 
indication  of  a  present  contagion. 

Thus  it  appears  that  all  the  judges  of  the  appellate 
division  assumed,  and  were  entitled  upon  the  briefs  of 
counsel  to  assume,  in  their  premises,  as  a  fact  of  rec- 
ord, that  in  1878  Hawker  had  a  right  to  practise  med- 
icine, and  upon  that  assumption  their  reasoning  is 
based. 

And  their  conclusions  are,'  the  italics  being  their 
own:  " Fh-st,\h2X  the  provision  we  have  considered  of 
the  public  health  \-i.\s  is  constitutional  ^o  izx  as  it  op- 
erates prospectively  and  upon  persons  convicted  of 
felony  after  its  passage.  Second,  that  it  is  nnconstitii- 
tioiial  in  as  far  as  it  applies  by  its  terms  to  persons  so 
convicted  before  the  law  went  into  operation." 

But  the  court  of  appeals  has  now  reversed  the  appel- 
late division's  judgment  and  affirmed  the  judgment  of 
conviction,  upon  the  sole  point,  apparently,  that,  so  far 
as  the  reconl  sho-u's,  Hawker  never  was  a  physician, 
and  therefore  was  not  deprived  by  the  statute  of  a 
right  to  practise  medicine — a  point  that  does  not  ap- 
pear to  have  been  raised  at  all  by  the  briefs  of  counsel. 

The  prevailing  opinion  in  the  court  of  appeals," 
where  also  there  is  dissent,  holds  that  the  statute  is 
clearly  retrospective,  and  admits  that,  if  it  enhanced 
defendant's  punishment  for  his  felony  committed  prior 
to  its  enactment,  it  would  be  as  to  him  unconstitu- 
tional. 

But  it  goes  on  to  say,'  the  italics  again  being  ours: 
"  It  is  not  contended  that  the  law  in  question  makes  any 
change  with  reference  to  the  felony  of  which  the  de- 
fendant was  convicted,  or  that  there  has  been  any  ag- 
gravation or  change,  7vith  reference  to  the  punishment 
provided  therefor.  What  has  been  done  is  the  creation  of 
a  new  ojffense,  a  misdemeanor  after  a  felony  dependent 
upon  acts  thereafter  committed  in  violation  of  the  statute 
and  providing  a  punishment  for  such  misdemeanor. 
It  is  in  the  nature  of  providing  punishment  for  a  second 
or  an  additional  offense,  and  it  is  claimed,  with  refer- 
ence thereto,  that  it  operates  to  deprive  the  defendant 
of  his  rights  of  property,  of  his  right  to  earn  a  living 
by  the  practice  of  medicine,  and  that,  by  being  de- 
prived of  this  right,  the  effect  is  to  aggravate  his  pun- 
ishment for  the  felony.  The  difficulty,  however,  7C'ith 
this  contention  is,  that  it  does  not  appear  from  the  record 
in  this  case  that  he  ever  had  any  right  to  practise  the 
profession  of  medicine,  and  that  no  presumption  can  he 
indulged  in  to  that  effect.  ...  It  does  not  now  appear 
that  he  ever  studied  medicine  a  day  in  his  life;  that 
he  ever  received  a  diploma  from  any  medical  college 
or  university:  that  he  was  ever  registered  or  licensed 
to  pr?  :tise  medicine,  or  that  he  ever  did  practise  be- 
fore the  2 2d  day  of  February,  1896,  the  day  of  the 
charge  upon  which  the  indictment  in  this  case  was 
founded.  So  that  there  is  an  entire  absence  of  any 
evidence  showing,  or  tending  to  show,  that  he  was  de- 
prived of  any  rights  of  property,  or  of  means  of  earning 
a  livelihood,  that  he  theretofore  enjoyed  and  pos- 
sessed." 

And  after  asserting  the  legislative  power  to  require 
good  moral  character  as  a  test  of  fitness  to  practise 
medicine,  the  opinion  concludes  thus,  the  italics 
once  more  being  ours:'     "If,   therefore,  the  legisla- 


'  .\t  p.  193. 
■  At  p.  240. 


5  152  N.  Y.  234. 
*  .\t  p.  243- 


ture  may  impose  conditions  upon  which  persons  of 
good  moral  character  shall  engage  in  tfie  practice 
of  medicine,  and  may  im.pose  a  punishment  for  all 
persons  violating  the  conditions,  it  appears  to  us  that 
the  legislature  may  also  prohibit  from  practising  a 
person  who  has  been  convicted  of  a  felony,  whose 
character  is  presumed  to  be  bad,  tcho  has  nner  before 
studied  or  practised  medicine,  and  who  has  not  conformed 
to  a  single  condition  or  requirement  of  the  statute  under 
which  other  persons  are  licensed  to  practise.  The  defen- 
dant has  been  deprived  of  no  rights  secured  to  him 
either  by  the  United  States  or  State  constitutions.'' 

As  there  is  no  dispute  that  the  statute  can  and  does 
prohibit  from  practising  a  person  who  has  never  stud- 
ied medicine,  regardless  of  whether  he  is  a  felon  or  a 
Christian  gentleman,  this  opinion  would  be  clearer  if 
the  italicized  words  last  quoted  were  omitted.  They 
only  cloud,  if  they  do  not  evade,  the  question  sought 
to  be  raised,  the  statement  of  which  is  simple  enough. 
— Can  the  legislature,  under  its  admitted  power  to 
provide  a  test  of  the  moral  fitness  of  licentiates  in 
medicine,  exclude  by  a  general  law  all  convicted  fel- 
ons from  the  ranks  of  the  medical  profession? 

Only  two  out  of  the  seven  judges  of  the  court  of  ap- 
peals seem  to  have  concurred  in  the  reasoning  of  its 
opinion ;  for  two  concurred  '  "  /«  result  solely  on  the 
ground  that  the  record  contains  no  evidence  that  the  de- 
fendant at  the  time  of  his  conviction,  or  at  any  other  time, 
7C'as  a  physician  ;"  from  which  it  is  to  be  inferred  that 
they  approved  the  reasoning  of  the  prevailing  opinion 
of  the  appellate  division,  and  would  have  voted  to  sus- 
tain its  conclusion  had  Hawker  appeared  by  the  record 
to  have  been,  when  convicted  in  1878,  a  licensed  phy- 
sician. The  remaining  two  judges  dissented  and 
voted  to  affirm  the  judgment  appealed  from,  showing 
that  in  their  minds  the  conviction  could  not  be  sus- 
tained merely  because  of  the  record's  failure  to  show- 
that  the  defendant  was  ever  a  licensed  practitioner, 
but  must  depend  solely  upon  the  allegations  and  proof, 
viz.,  that  defendant  after  conviction  of  felony  in  1878 
practised  medicine  in  1896;  that  the  illegality  of  the 
practice  under  the  allegation  was  due  solely  to  the 
former  conviction  of  felony  and  not  to  the  failure  to 
prove  a  license  and  that  in  so  far  as  the  law  made 
such  previous  conviction  an  element  of  the  offence  it 
was,  in  their  opinion,  e.x  post  facto,  regardless  of  whether 
Hawker  was  a  physician  in  1878  or  not. 

The  conclusions  from  all  this  seem  to  be: 

(i)  The  final  judgment  against  Hawker  is  a  chance 
result  due  to  an  explicable  oversight  in  making  the 
record — an  oversight  scarcely  to  be  criticised  or  won- 
dered at,  since  it  seems  to  have  escaped  the  observa- 
tion of  all  the  able  counsel  in  the  case,  for  defendant 
as  well  as  for  the  prosecution,  of  the  careful  trial  judge 
as  well  as  of  the  learned  justices  of  the  appellate  divi- 
sion. The  point  upon  which  the  court  of  appeals  de- 
cides the  case  is,  as  already  said,  one  not  raised  by 
counsel;  nor  could  it  have  been  fairly  raised  by  the 
prosecution,  which  evinced  no  desire  to  take  any  ad- 
vantage of  it;  just  as  in  the  Dent  case  counsel  waived 
technical  defects  in  the  record  in  order  that  the  high- 
est court  might  pass  upon  the  substantial  question 
souglit  to  be  raised.  The  oversight,  as  already  indi- 
cated, is  this:  That  the  indictment  merely  alleges  two 
facts:  ((?)  The  conviction  of  Hawker,  in  1878;  and 
(/')  that  afterward  "  he  unlawfully  did  practise  medi- 
cine," etc.  The  intent  of  the  prosecution  was,  of 
course,  to  test  the  question  whether  any  person  con- 
victed of  felony  might  thereafter  practise  medicine. 
But  unfortunately  the  indictment's  allegation  that 
Hawker  unlawfully  practised  medicine  contrary  to  the 
form  of  the  statute,  has  been  held  to  be  a  good  plead- 
ing of  the  ordinary  misdemeanor  of  unlicensed  prac- 
tice, quite  apart  from  any  question  of  felony,  and  de- 
'  At  p.  243- 


July  24,  1897] 


MEDICAL    RECORD. 


117 


fendant  failed  to  prove  by  way  of  defence  to  this 
charge  the  fact  that  in  1884  he  registered  in  the 
county  of  New  York,  under  a  diploma  of  the  Eclectic 
College  of  that  city,  alleged  to  have  been  conferred 
upon  him  in  1876,  prior  to  his  said  conviction.  If 
he  had  proved  that  this  diploma  had  been  conferred 
upon  him,  the  reason  for  the  reversal  by  the  court  of 
appeals  would  not  and  the  facts  assumed  by  the  appel- 
late division  would  have  existed,  and  the  question 
whether  the  law  is  constitutional  in  so  far  as  it  debars 
from  continuance  in  practice  physicians  convicted  pri- 
or to  its  enactment  would  have  been  decided.  But  the 
question  would  still  have  remained,  whether  the  law 
is  constitutional  in  so  far  as  it  forbids  a  layman  con- 
victed of  felony  prior  to  its  passage  from  acquiring  a 
medical  license  under  the  same  conditions  imposed 
upon  other  laymen  not  so  convicted. 

(2)  The  question  sought  to  be  decided  would  seem 
to  be  still  open;  neither  opinion  of  the  appellate 
division  being,  in  the  view  of  the  court  of  appeals, 
a  strictly  binding  authority;  since  each  assumes  a 
state  of  facts  not  before  the  court. 

(3)  But  if,  technically  speaking,  no  absolute  and 
final  decision  has  been  rendered  upon  the  point  sought 
to  be  raised,  nevertheless  the  preponderance  of  judi- 
cial opinion,  both  in  the  appellate  division  and  in  the 
court  of  appeals,  is  that  the  medical  act  is  unconstitu- 
tional in  so  far  as  it  expelled  from  practice  licensed 
physicians  on  account  of  their  convictions  of  felony  be- 
fore it  took  effect.  On  this  point  the  judges  stand  four 
to  one  in  the  appellate  division,  and,  at  least,  four  t<5 
three  if  they  are  not  unanimous  in  the  court  of  ap- 
peals; so  that,  should  Hawker  again  be  arraigned,  he, 
probably,  would  make  a  successful  defence  if  he  could 
establish  the  validity  of  the  eclectic  college's  diploma. 
And  a  very  able  and  learned  judge,  sitting  in  oyer  and 
terminer  in  1884,  held  that  a  diploma  from  that  college 
was  a  defence  to  a  charge  of  unlicensed  practice,  even 
if  purchased  in  absentia  from  the  officers  empowered 
to  bestow  it,  and  that,  too,  although  two  signatures 
upon  it  were  proved  by  uncontradicted  testimony  to 
have  been  forged  or  procured  by  a  false  pretence;  a 
decision  from  which  the  prosecution  had  no  appeal. 

It  is  to  be  hoped,  therefore,  that  the  questions  in- 
volved may  be  brought  up  again  upon  a  record  ade- 
quate to  present  them  fully. 

So  far  as  the  previous  conviction  of  felony  is  an 
element  in  the  case,  the  dissenting  judges  of  the  court 
of  appeals  seem  to  hold  that  it  makes  no  difference 
whether  Hawker  when  first  convicted  was  a  physician 
or  a  layman.  If  the  law  is  unconstitutional  as  de- 
priving a  physician  of  his  "right"  or  "quasi  right"  to 
practise  medicine,  then  by  parity  of  reasoning  it  would 
seem  equally  unconstitutional  in  debarring  a  layman 
from  his  privilege  to  acquire  that  right  upon  the  same 
terms  with  others;  for  if  the  law  operates  only  on  pres- 
ent status,  speaking  from  the  time  of  its  enactment, 
and  if  prior  conviction  of  felony  does  not  establish 
that  status,  then  Hawker  or  any  one  in  pari  (Iclictu, 
even  assuming  that  he  had  not  the  right  to  practise 
medicine  in  1878,  had  at  least  the  right  to  acquire  it 
on  the  same  terms  with  others;  if  not,  then  his  pun- 
ishment for  felony  was  enhanced  quite  as  much  by  his 
prohibition  from  entering  the  ranks  of  physicians  as 
by  his  e.xpulsion  from  them.  Or  to  put  it  interroga- 
tively, can  the  Regents  to-day  refuse  a  license  to  A, 
otherwise  qualified,  solely  because  in  1886,  while  a 
layman  he  was  convicted  of  a  felony?  Again,  let  us 
suppose  the  case  of  one  convicted  of  felony  before  the 
act  of  1874  restored  the  jienalties  for  unlicensed  medi- 
cal practice,  which  had  been  abolished  by  the  act  "f 
1844,  and  therefore  at  a  time  when,  as  was  said  in  Bai- 
ley 7^.  Mogg,'  quackery  might  certainly  "boast  of  its 
triumphant  and  complete  establishment  by  law,"  and 
'  4  Denio  60. 


every  one  had  the  so-called  "  right"  to  practise  medi- 
cine— a  right  nov  created  but  only  regulated  by  statute.' 
Does  it  not  follow  logically,  from  the  reasoning  of  the 
majority  of  the  appellate  division  and  of  the  dissenting 
judges  of  the  court  of  appeals,  that  as  all  felons  at 
large  had  a  right  then  to  practise  medicine,  our  sup- 
posed convict  could  not  be  debarred  on  account  of  his 
past  crime  from  continuing  to  exercise  that  right,  if  in 
other  respects  he  could  show  statutory  qualifications? 
In  considering  these  questions  and  the  effect  upon  them 
of  the  prevailing  opinion  of  the  appellate  division,  we 
must  remember  that,  although  its  argument  proceeded 
upon  the  assumption  that  Hawker  was  a  physician 
when  first  convicted,  its  conclusion  above  quoted  is 
that  the  law  is  "  unconstitutional  in  so  far  as  it  applies 
by  its  terms  to  persons  so  convicted,"  etc.,  which 
strictly  means  all  persons — physicians  and  laymen. 

It  will  be  remembered,  too,  that  that  opinion,  fol- 
lowing the  Dent  case,  laid  much  stress  upon  the  fact 
that  convictions  of  felonies  "  in  no  zoise  associated  with 
their  professional  /pursuits"  would  serve  under  the 
statute  to  forfeit  licenses  of  physicians.  Are  we  to 
infer  that  if  the  provision  of  law  in  question  had 
affected  only  physicians  convicted  of  abortions  or  of 
manslaughter  by  reckless  administration  of  poison  to 
patients,  etc.,  it  would  be  constitutional  in  its  retroac- 
tive phase,  while  it  is  now  unconstitutional  because  it 
prohibits  medical  practice  to  one  convicted  of  burg- 
lary or  larceny  from  the  person  ? 

There  are  many  arguments  that  suggest  themselves 
in  the  premises,  which  there  is  here  no  space  even  to 
mention.  The  construction  of  laws  applying  the  po- 
lice powers  of  government  to  the  regulation  of  the 
various  professions  and  trades  is  one  of  the  most  diffi- 
cult functions  of  the  judiciary.  The  facts  are  kaleido- 
scopic. That  opinions  differ  is  not  surprising;  the 
opinions  of  the  same  judge  may  undergo  change  even 
upon  the  same  state  of  facts,  and  may  appear  to  change 
with  varying  facts.  What  is  needed  in  this,  as  in 
every  case,  is  an  authoritative  decision  upon  a  record 
adequately  presenting  the  facts.  Then,  and  then  only, 
we  may  know  accurately  where  we  stand  before  the 
law.  Meantime  we  may  profit  very  much  from  the 
very  able  and  learned  discussion  by  both  court  and 
counsel  of  a  puzzling  question  of  the  constitutional 
limits  of  the  police  power  in  regulating  the  licensing 
of  physicians. 


THE    MICROBE   OF    VELLOW    FEVER. 


By   GIUSEPPE    S.\XARELLI,    M.D., 


DIRECTOR    C\V    THE     ISSTITL-TE     OF 

Four  centuries  have  passed  since  a  terrible  disease, 
until  then  unknown,  attacked  the  daring  men  who  ac- 
companied Columbus  in  the  discovery  of  America. 
Two  centuries  scarcely  have  gone  by  since  the  same 
disease,  leaving  its  natural  habitat  in  the  Gulf  of 
Mexico  and  the  Antilles,  appeared  first  in  South  Amer- 
ica and  gave  the  Portuguese  physician,  Ferreira  da 
Rosa,  the  opportunity  to  describe  that  strange  morbid 
process  which  was  to  acquire  so  sad  a  .celebrity  under 
the  name  of  yellow  fever. 

While  other  infectious  diseases,  since  the  great  epi- 
demics noted  in  history,  whether  through  a  sort  of 
acquired   immunity,  transmitted  by  heredity  or  owing 

'  Wert  vs.  Clutter,  37  Ohio  .St.  34S. 

•  .\  translation  by  A.  C.  H.  Russell,  M.D.,  Surgeon,  U.  S. 
Xa^^•,  of  a  public  address  delivered  June  10,  1897,  in  the  Solis 
Theater,  Montevideo.  The  author's  description  of  the  symptoms 
and  morbid  anatomy  of  yellow  fever  in  man,  and  portions  of  his 
account  of  the  symptoms  and  post-mortem  examinations  in  ani- 
mals e.\perimented  upon,  have  been  omitied. 


ii8 


MEDICAL    RECORD. 


[July  24,  1897 


to  scientific  prophylaxis,  seem  to  have  diminished, 
little  by  little,  in  virulence,  or  at  least  tend  to  remain 
in  their  original  limits,  yellow  fever,  on  the  contrary, 
has  progressively  enlarged  its  domain,  and  is  far  from 
even  diminishing  its  virulence. 

From  the  point  of  view  of  the  anatomical  lesions, 
yellow  fever  may  be  considered  as  the  type  of  the  dis- 
eases (steatogenous)  that  cause  fatt)'  degeneration, 
since,  although  congestive  and  hemorrhagic  phenom- 
ena predominate  in  the  symptoms,  degenerative  lesions 
present  themselves  first  in  the  anatomical  changes. 

There  does  not  exist,  however,  any  lesion  truly 
pathognomonic  of  yellow  fever,  although  the  changes 
of  yellow  fever  in  their  entirety  constitute,  as  Jaccoud 
has  said,  '"an  anatomical  criterion  more  clear  and 
better  defined  than  that  of  the  majority  of  infectious 
diseases." 

I  procured  the  material  for  my  studies  partly  at  the 
Lazaretto  of  the  Island  of  Flores,  the  quarantine  sta- 
tion of  Montevideo,  where  a  small  laborator)-  was  set 
up  last  summer,  and  partly  in  the  hospital  of  San  Se- 
bastian at  Rio. 

When  I  thought  of  devoting  myself  to  the  study  of 
yellow  fever,  Sternberg  and  also  the  majorit}-  of  the 
medical  men  of  Brazil  thought  they  had  to  deal  prob- 
abl)"  with  a  local  infection,  seated  principally  in  the 
stomach.  In  that  organ,  according  to  them,  the  infec- 
tious agent,  as  yet  unknown,  elaborated  a  toxic  sub- 
stance, which,  absorbed  into  the  blood,  gave  rise  to  the 
general  symptoms  characteristic  of  yellow  fever. 

The  recognition  and  the  isolation  of  the  specific 
agent  of  yellow  fever  must  be  considered  as  the  most 
difficult  undertaking  yet  presented  to  the  patient  in- 
vestigation of  bacteriologists. 

The  cadavers  of  the  victims  of  yellow  fever  are 
either  sterile  or  they  are  found  to  be  invaded  through- 
out by  certain  species  of  microbes,  as  the  streptococcus, 
the  staphylococcus  pyogenes,  the  coli  bacillus,  the  pro- 
teus,  etc.,  which  cannot  be  considered  as  the  cause  of 
the  disease;  in  a  word,  they  show  a  mixture  of  mi- 
crobes, the  isolation  and  the  classification  of  which 
require  a  total  of  work  which  makes  systematic  and 
careful  investigation  impossible. 

I  owe  the  chance  of  the  discovery  of  the  microbe  of 
5-ellow  fever  to  the  second  case  of  the  disease  which 
presented  itself  to  me  at  the  Island  of  Flores.  This 
case,  though  it  showed  a  mixture  of  various  microbes, 
had,  i«  a  state  of  relative  purity,  the  specific  microbe, 
to  which  I  have  given  provisionally  the  name  of  "ba- 
cillus icteroides,"  because  yellow  fever  is  known  also 
under  the  name  of  typhus  icteroides. 

I  have  said,  "  in  a  state  of  relative  puritj,"  because 
yellow  fever  is  the  prototype  of  the  diseases  of  mixed 
infection.  I  have  never  found  the  ''  bacillus  icteroides" 
alone  in  the  autopsies  I  have  made.  It  has  been  as- 
sociated always  with  the  micro-organisms  previously 
referred  to  or  among  the  numerous  species  of  common 
microbes,  or  it  has  been  impossible  to  find  it  because 
the  other  microbes,  having  entered  the  organism  in  its 
train,  have  ended  by  impeding  its  evolution  and  have 
even  caused  it  to  disappear  entirely. 

The  "bacillus  icteroides"  must  be  sought  for  in  the 
blood  and  in  the  tissues,  and  not  in  the  gastro- 
intestinal tube,  in  which,  contrary  to  what  might  have 
been  supposed  a  priori,  I  have  never  encountered  it. 

In  reality,  in  yellow  fever,  as  in  typhoid  fever, 
there  takes  place  in  the  digestive  tube  an  extraordinary 
multiplication  of  the  coli  bacillus,  which  is  found 
there  in  a  state  of  almost  absolute  purity. 

Upon  the  result  of  my  investigations  I  will  say  that 
the  isolation  of  the  specific  microbe  of  yellow  fever 
is  possible   in   only  fift\--eight  per  cent,  of  the  cases. 

The  reasons  for  this  are  easy  to  understand.  Before 
all,  in  the  beginning  of  the  disease,  the  "bacillus  ic- 
teroides" multiplies  very  little  in  the  human  organism. 


a  very  small  quantity  of  its  toxin  being  sufficient  to 
provoke  in  man  the  worst  tj-pe  of  the  disease. 

In  the  second  place,  the  toxin,  whether  by  itself  or 
indirectly  through  the  profound  lesions  it  causes, 
especially  in  the  digestive  mucous  membrane  and  in 
the  liver,  facilitates  in  an  extraordinary  manner  ever)' 
sort  of  secondar}'  infection. 

According  to  my  investigations,  the  '"bacillus  icte- 
roides" is  found  in  the  circulating  blood  and  in  the 
tissues:  the  germ  of  yellow  fever  does  not  reside  in 
the  digestive  tube,  and  its  poison,  instead  of  being 
absorbed  through  the  intestinal  walls,  is  fabricated 
in  the  interior  of  the  organs  and  in  the  blood. 

Morphologically  this  bacillus  does  not  present  at 
first  sight  anything  characteristic.  It  is  a  little  rod, 
with  rounded  extremities,  united  at  best  by  pairs  in 
cultures  and  in  groups  in  the  tissues,  from  two  to 
four  micromillimetres  in  length,  and  generally  tno  or 
three  times  longer  than  it  is  broad.  It  is  sufficiently 
polymorphous. 

Investigating  it  in  the  tissues  does  not  give  good 
results,  unless  the  death  of  the  patient  occurs  without 
secondar)-  septicemia. 

Even  in  the  cases  that  give  the  best  results  from  the 
bacteriological  examination,  it  is  not  easy  to  place 
the  bacillus  in  evidence  in  sections  of  the  tissues,  on 
account  of  its  e.xtremely  small  number.  In  spite  of 
this,  by  using  the  utmost  care,  one  can  find  it  in  the 
organs,  united  usually  in  small  groups  and  situated 
always  in  the  minute  capillaries  of  the  liver,  the  kid- 
neys, etc. 

The  best  way  to  demonstrate  not  only  its  presence 
but  also  its  special  tendency  to  arrange  itself  in  small 
groups,  preferably  in  the  blood  capillaries,  consists  in 
placing  in  the  incubator,  at  37°  C.  for  twelve  hours, 
a  fragment  of  the  liver  taken  from  a  fresh  cadaver  in 
order  to  favor  the  multiplication  of  the  specific  mi- 
crobe. The  )-ellow-fever  bacillus  grows  suflScienily 
well  in  all  the  ordinar)'  culture  media.  In  common 
gelatin  it  forms  rounded  colonies,  transparent  and 
granular,  which  during  the  first  three  or  four  days 
present  an  aspect  analogous  to  that  of  leucocytes. 

The  granulation  of  the  colony  becomes  more  and 
more  pronounced,  appearing  ordinarily  as  a  nucleus, 
central  or  peripheral,  completely  opaque:  in  time  the 
whole  colony  grows  entirely  opaque.  It  never  lique- 
fies gelatin. 

In  beef  bouillon  the  bacillus  grows  quickly,  without 
forming  either  pellicles  or  deposits. 

On  blood  serum  solidified  it  grows  in  a  manner 
almost  imperceptible. 

Cultures  on  agar-agar  represent  for  the  "bacillus 
icteroides"  a  means  of  diagnosis  of  the  first  order:  but 
the  demonstration  by  this  means  of  diagnosis  is  effi- 
cacious only  under  certain  determined  conditions. 

When  the  colonies  grow  in  the  incubator,  they  pre- 
sent an  appearance  that  does  not  differ  from  that  of 
the  majority  of  the  other  species  of  microbes:  they 
are  rounded,  of  a  slightly  iridescent  gray  color,  trans- 
parent, even  in  surface,  and  regular  in  outline. 

If,  instead  of  causing  the  colonies  to  grow  in  the 
incubator  at  a  temperature  of  37"  C,  they  are  allowed 
to  evolve  at  a  temperature  of  from  2o"-i2'  C.  they 
appear  like  drops  of  milk,  opaque,  projecting,  and 
with  pearly  reflections:  that  is  to  say,  they  are  com- 
pletely distinct  from  those  grown  in  the  incubator. 

These  different  modes  of  evolution  can  be  used  for 
diagnosis  by  exposing  cultures,  first,  for  from  twelve 
to  sixteen  hours  to  the  temperature  of  the  incubator, 
and  aftenvard  for  other  twelve  to  sixteen  hours  to  the 
temperature  of  the  air. 

This  done,  the  colonies  show  themselves  to  be  con- 
structed with  a  flat  central  nucleus,  transparent  and 
azure,  having  a  peripheral  circle  prominent  and 
opaque.     This  peculiaritj-,  which  may  be  considered 


July  24.  1897] 


MEDICAL    RECORD. 


119 


specific,  may  be  made  evident  in  less  than  twenty- 
four  hours,  serving  thus  to  establish  the  bacteriological 
diagnosis  of  the  "  bacillus  icteroides." 

Apart  from  this  morphological  characteristic,  which 
suiBces  of  itself  to  differentiate  the  microbe  of  yellow 
fever  from  all  others  previously  known,  the  "bacillus 
icteroides"  is  endowed  with  some  interesting  biologi- 
cal qualities. 

It  is  a  facultative  anaerobe,  and  does  not  resist  the 
Gram  stain :  it  ferments  insensibly  lactose,  more  ac- 
tively glucose  and  saccharose,  but  is  unable  to  coagu- 
late milk;  it  does  not  produce  indol,  and  is  very 
resistant  to  drying;  it  dies  in  water  at  60°  C.  or  after 
being  exposed  for  seven  hours  to  the  solar  rays,  and 
lives  for  a  long  time  in  sea  water. 

The  microbe  of  yellow  fever  is  pathogenic  for  the 
greater  number  of  the  domestic  animals.  Few  mi- 
crobes have  a  pathological  dominion  so  extended  and 
so  varied.  Birds  are  completely  refractory-,  but  all 
the  mammiferous  animals  upon  which  I  have  ex- 
perimented have  shown  themselves  more  or  less  sus- 
ceptible. 

But  of  all  the  animals,  that  which  lends  itself  best 
to  showing  the  close  analogy,  anatomically  and  noso- 
logically,  between  experimental  yellow  fever  and 
human  yellow  fever,  is  the  dog. 

The  virus  should  be  injected  into  a  vein.  The 
morbid  process  that  results  manifests  itself  almost 
immediately,  with  a  violence  of  symptoms  and  an 
assemblage  of  lesions  which  recall  the  picture,  clini- 
cal and  anatomical,  of  human  yellow  fever. 

The  lesions  found  after  death  are  e.xtremely  inter- 
esting, as  the)-  are  almost  identical  with  those  observed 
in  the  human  cadaver. 

Attention  is  called  before  everything  to  the  intense 
fatty  degeneration  of  the  liver.  The  hepatic  cell, 
examined  in  a  fresh  state  with  a  little  osmic  acid,  ap- 
pears completely  turned  into  fat,  as  it  is  in  human 
victims  of  yellow  fever:  the  yellow-fever  toxin,  as  we 
shall  see  later,  is  a  true  specific  poison  to  the  hepatic 
cell,  as  are  phosphorus  and  arsenic.  A  complete  fatt}' 
degeneration  of  the  liver  may  be  effected  by  injecting 
directly  into  it,  through  the  abdominal  parietes,  a  fresh 
culture  of  the  specific  bacillus. 

The  kidney  shows  a  severe  fady  degeneration,  ac- 
companied by  lesions  of  acute  parenchymatous  ne- 
phritis, which  may  be  considered  the  direct  causes  of 
the  anuria  and  the  uraemic  intoxication. 

The  digestive  apparatus  shows  lesions  of  hemor- 
rhagic gastro-enteritis  as  intense  as  those  caused 
by  poisoning  with  cyanide  of  potassium.  They  are 
completely  analogous  to  those  in  man,  though  more 
grave. 

A  bacteriological  fact  of  great  interest  in  the  yel- 
low fever  of  the  dog  is  that  in  the  majorit)-  of  cases 
the  "  bacillus  icteroides"  is  found  in  the  blood  and  the 
organs  in  variable  quantity  and  in  a  state  of  absolute 
purity:  at  times,  it  is  found  associated,  as  in  man, 
with  the  coli  bacillus  and  the  streptococcus. 

As  the  tendency  to  secondary-  microbic  infections 
has  been  proved  even  in  the  yellow-fever  intoxication 
of  the  dog,  provoked  with  a  pure  culture,  filtered,  it 
must  be  concluded  that  the  yellow-fever  pwison. 
whether  by  itself  or  whether  through  the  alterations  it 
produces  in  the  different  viscera,  and  especially  in  the 
liver — which,  as  is  well  known,  should  be  considered 
the  organ  of  defence  against  microbes — favors  in  the 
dog  secondary  infections  "having  their  point  of  depar- 
ture in  the  intestinal  canal. 

This  is  an  important  point  of  resemblance  between 
the  yellow  fever  of  the  dog  and  that  of  man. 

From  the  results  of  the  first  part  of  the  investiga- 
tions relative  solely  to  the  comparative  morphology, 
biolog}',  and  patholog\"  of  the  "  bacillus  icteroides,"  we 
can  deduce  some  fundamental  conclusions  concerning 


the  etiolog)-  and  the  patholog}-  of  the  yellow  fever  or 
man. 

Yellow  fever  is,  then,  an  infectious  disease,  due  to 
an  organism  well  defined  and  susceptible  of  being 
cultivated  in  the  common  artificial  nutritive  media. 

This  micro-organism,  which  I  have  designated  pro- 
\isionally  with  the  name  of  "  bacillus  icteroides,''  can 
be  isolated,  not  only  from  the  cadaver,  but  also  during 
the  life  of  the  yellow-fever  patient. 

Its  isolation  presents  generally  difficulties,  some- 
times invincible,  due  in  part  to  the  constant  presence 
of  secondary  infections,  and  in  part  to  the  relative 
scarcity  of  the  organism  in  the  body. 

These  secondary  infections,  due  almost  always  to 
certain  species  of  microbes,  as  the  coli  bacillus,  the 
streptococcus,  the  staphylococcus,  the  proteus,  etc., 
may  appear  in  the  organism  long  before  the  death  of 
the  patient,  which  is  often  attributable  to  their  action 
rather  than  to  that  of  the  "  bacillus  icteroides." 

It  is  probable  that  the  protean  character  of  yellow- 
fever  in  man  may  be  due  to  the  nature  and  the  mode 
of  evolution  of  these  secondan,-  infections. 

Yellow  fever  progresses  in  cycles:  at  first  the  spe- 
cific microbe  is  very  scarce  in  the  organs,  and  it  is  only 
at  the  end  of  the  disease  cycle,  whose  duration  may 
be  established  as  between  seven  and  eight  days,  that 
the  microbe  multiplies  resolutely  and  suddenly  in- 
vades the  entire  organism,  accompanied  almost  al- 
ways by  other  microbes,  probably  of  intestinal  origin. 

The  "bacillus  icteroides,"'  once  in  the  organism,  not 
only  determines  a  general  intoxication,  but  also  pro- 
duces specific  alterations,  which  have  their  seat  of 
election,  above  all,  in  the  kidneys,  the  digestive  tube, 
and  the  liver. 

.\s  the  renal  lesion  is  one  of  the  first,  and  as 
the  anuria  it  provokes  establishes  itself  promptly,  to 
it  maybe  attributed  an  influence  not  to  be  despised  in 
the  evolution  and  termination  of  the  disease. 

The  patient  with  yellow  fever  is  in  reality  menaced 
by  three  imminent  dangers  at  the  same  time,  and 
the  bacteriological  examination  may  show,  with  suf- 
ficient exactness,  the  principal  cause  of  death : 

1.  It  may  be  attributed  chiefly  to  the  specific  infec- 
tion, when  the  bacillus  is  found  in  the  cadaver  in 
sufficient  quantity-  and  in  a  state  of  relative  purity-; 
this  is  seen  solely  in  those  cases  that  complete  their 
morbific  cycle. 

2.  It  may  be  considered  as  produced  by  the  secon- 
dary septicaemia,  supervening  in  the  course  of  the  dis- 
ease, when  the  cadaver  offers  cultures,  almost  pure,  of 
other  microbes. 

3.  It  may  be  attributed  in  great  part  to  the  renal 
insufficiency,  when  the  cadaver  is  almost  sterile  and 
when  the  quantity  of  urea  in  the  blood  is  very-  high 
and  death  comes  on  before  the  disease  has  terminated 
its  normal  cycle  of  evolution. 

It  is  difficult  to  pronounce  during  life  upon  the 
respective  importance  of  the  uraemic  and  of  the  spe- 
cific s\-mptoms.  The  frequency  of  the  complication  of 
renal  insufficiency  is,  without  doubt,  the  chief  cause 
which  prevents  the  adoption  of  a  specific  thermic  type 
for  yellow  fever. 

The  '■  black  vomit"'  is  due  to  the  action  of  the  gas- 
tric acid  upon  the  extravasated  blood  in  the  stomach. 
The  vomiting  itself  is  directly  provoked  by  the  spe- 
cific emetic  action  of  the  toxins  of  the  "bacillus  icte- 
roides'" circulating  in  the  blood. 

The  "bacillus  icteroides"  possesses  morphological 
characteristics  so  marked  that  it  can  be  distinguished 
with  much  ease  from  all  the  other  microbes  known  un- 
til now. 

Once  isolated,  whether  from  the  cadaver  or  from  the 
patient,  its  exact  bacteriological  diagnosis  does  not 
require  more  than  twenty-four  hours. 

The    disease    mav  be    transmitted    experimentally 


MEDICAL    RECORD. 


[July  24,  1897 


even  by  the  respiratory  tract  to  rabbits  and  guinea- 
pigs;  the  bacteriological  examination  of  these  cases 
shows,  at  least,  the  existence  of  a  toxic  process  identi- 
cal with  that  which  takes  place  in  man.  It  is  then 
possible  that  the  contagion  of  the  virus  of  yellow 
fever  may  be  effected  even  by  means  of  the  air,  which 
is  in  accord  with  the  dominant  opinions  in  this 
respect. 

The  virus  of  yellow  fever  possesses  three  chief 
pathogenic  properties,  which  join  to  give  it  a  peculiar 
physiognomy  that  may  be  considered  specific: 

1 .  The  steatogenous  property,  which  acts  with  greater 
intensity  the  higher  in  the  zoological  scale  the  animal 
experimented  upon  is.  The  jaundice,  which  appears 
in  general  when  the  illness  is  advanced,  is  due  in 
large  measure  to  the  anatomical  alterations  of  the 
liver,  which  constitute  a  mechanical  obstacle  to  the 
free  course  of  the  bile,  and  thus  favor  its  reabsorption 
by  the  lymphatics. 

2.  The  congestive  and  hemorrhage- producing  prop- 
erties which,  in  spite  of  being  common  to  other  varie- 
ties of  virus,  constitute  a  salient,  specific  characteris- 
tic, since  to  them  are  due  not  only  the  classic  black 
vomit  and  the  various  other  hemorrhages  from  the 
mucous  membranes,  but  also  the  vascular  conges- 
tions that  are  the  chief  cause  of  the  pathognomonic 
pains  of  yellow  fever — headache,  backache,  liverache. 

3.  The  emetic  properties  which,  even  Lf  they  are 
not  so  closely  connected  with  the  yellow-fever  virus 
as  are  the  preceding  manifestations,  impress,  however, 
upon  this  virus,  by  the  rapidity,  intensity,  and  fre- 
quency with  which  they  manifest  themselves  in  man 
and  the  superior  animals,  a  very  particular  pathogenic 
character  that  distinguishes  it  easily  from  all  others 
hitherto  known. 

On  account  of  the  numerical  scarcity  ordinarily  of 
the  "bacillus  icteroides"  in  the  human  organism,  and 
the  violence  of  the  symptoms  that  occur  immediately 
after  the  intravenous  injection  of  a  culture  relatively 
small,  we  must  suppose  the  existence  of  a  specific 
poison,  extremely  active.  We  will  occupy  ourselves, 
then,  with  this  poison,  which  is  obtained,  like  that  of 
diphtheria,  by  simply  filtering  cultures  in  broth  of  the 
*'  bacillus  icteroides,'"  twenty  to  twentj-five  days  old. 
The  yellow-fever  poison  tolerates  almost  with  impunity 
heating  to  a  temperature  of  70"  C,  but  the  heat  of 
ebullition  weakens  it  sensibly. 

If  the  sterilized  culture  with  ether  is  employed  in- 
stead of  the  filtered  culture,  the  toxic  power  is  sensibly 
augmented. 

In  the  dog  the  toxin  reproduced  the  same  symptoms 
and  the  same  lesions  we  have  described  in  speaking 
of  our  experiments  made  with  the  virus.  The  bacte- 
riological examination  showed  the  existence  of  mixed 
infections,  due,  as  always,  to  the  coli  bacillus,  or  the 
streptococcus,  or  the  staphylococcus. 

The  cat  is  the  most  resistant  animal  I  have  yet 
made  experiments  upon. 

In  the  goat  the  toxin  produced  exactly,  with  the  ex- 
ception of  the  vomiting,  the  same  lesions  that  have 
already  been  noted  in  the  dog  and  in  man. 

The  horse  is  very  sensitive  to  even  minute  quanti- 
ties of  the  toxin.  An  autopsy  upon  the  body  of  a 
horse  which  died  from  the  effects  of  the  toxin  showed 
great  swelling  of  the  spleen,  a  slight  degeneration  of 
the  liver,  nephritis,  albuminuria,  and  some  foci  of 
enteritis. 

These  are  the  experiments  the  most  imp)ortant  and 
the  most  convincing,  for  the  reason  that  they  fix  in  a 
definite  manner  the  specific  character  of  the  microbe 
I  have  discovered,  and  contribute  more  than  anything 
else  toward  a  revelation  of  the  secret  mechanism  of  its 
action  upon  man. 

Up  to  the  present  time  almost  every  sort  of  means 
has  been  tried  in  order  to  transmit  yellow  fever  experi- 


mentally. These  attempts  gave  no  results,  which 
explains  why  for  many  years  the  conviction  has  pre- 
vailed in  the  United  .States  that  this  terrible  malady 
was  not  contagious. 

A  perfect  explanation  of  the  surprising  failure  of 
these  experiments  is  to  be  found  in  the  fact  that  the 
black  vomit  was  commonly  believed  to  contain  the 
virus  of  yellow  fever,  and  this  was  consequently  used 
in  trying  to  communicate  the  disease. 

Now  we  have  seen  that  the  "  bacillus  icteroides"  not 
only  does  not  have  its  seat  in  the  stomach,  but  also, 
even  when  it  is  found  by  chance  in  that  organ,  it  is 
because  it  has  been  drawi?  along  by  the  blood,  and  is 
found  consequently  in  a  condition  of  extreme  dissolu- 
tion. 

My  experiments  upon  man  reach  the  number  of  five. 

For  reasons  easily  understood  I  have  not  used  living 
cultures,  but  simply  cultures  in  broth  from  fifteen  to 
twenty  days  old,  filtered  with  the  Chamberland  filter 
and  sterilized,  moreover,  with  the  greatest  caution  by 
a  few  drops  of  formic  aldehyde. 

In  two  of  the  individuals  I  tried  the  effect  of  sub- 
cutaneous injections  and  in  the  other  three  that  of 
intravenous  injections.  These  fortunate  experiments, 
though  few  in  number,  are  sufficient  to  illuminate  in 
a  manner  unhoped  for  all  the  pathogenic  mechanism, 
so  obscure  and  so  badly  interpreted  until  now,  of  yel- 
low fever. 

The  injection  of  the  filtered  culture  in  doses  rela- 
tively small  reproduces  in  man  typical  yellow  fever. 
The  fever,  the  congestions,  the  hemorrhages,  the 
vomit,  the  fatty  degeneration  of  the  liver,  the  head- 
ache, the  backache,  the  nephritis,  the  anuria,  the 
uraemia,  the  jaundice,  the  delirium,  the  collapse — 
in  fine,  all  that  conjunction  of  anatomical  and  symp- 
tomatic elements  which  constitute  by  their  combination 
the  indivisible  basis  of  the  diagnosis  of  yellow  fever, 
I  have  seen  unroll  before  my  eyes,  thanks  to  the  po- 
tent influence  of  the  yellow-fever  poison  made  in 
my  artificial  cultures.  This  fact  not  only  represents 
very'  valuable  evidence  in  favor  of  the  specific  nature 
of  the  '"bacillus  icteroides,"  but  it  establishes  new 
grounds  for  the  etiological  and  pathological  conception 
of  yellow  fever. 

Eliminating  thus  tlie  dominant  theory,  which  pre- 
sented the  digestive  canal,  and  above  all  the  stomach, 
as  the  focus  of  the  disease,  solely  because  the  gastro- 
intestinal phenomena  have  attracted  until  now  most 
vividly  the  attention  of  the  student  of  disease:  demon- 
strating thus  that  all  these  imposing  phenomena  are 
due  to  the  specific  poison,  fabricated  by  the  microbe 
which  circulates  in  the  blood,  yellow  fever  enters 
immediately  the  same  group  of  diseases  in  which  I 
have  for  some  time  placed  another  great  morbid  proc- 
ess, which,  previous  to  my  investigations,  had  always 
been  ill  understood.      I  refer  to  typhoid  fever. 

All  the  symptomatic  phenomena,  all  the  functional 
alterations,  all  the  anatomical  lesions  of  yellow  fever 
are  but  the  result  of  the  action,  eminently  steatogenic. 
emetic,  and  hemolytic,  of  the  substance  manufactured 
by  the  ""  bacillus  icteroides." 

It  is  justly  on  account  of  its  general  symptoms,  its 
characteristic  ataxo-adynamic  manifestations,  its  ten- 
dency to  hemorrhages,  its  jaundice,  etc.,  that  yellow 
fever  has  been  compared  to  the  poisoning  caused  by 
the  venom  of  certain  serpents. 

Another  point  of  contact  between  the  two  morbid 
processes  consists  in  the  ha;matogenic  gastro-enteritis, 
which  in  cases  of  poisoning  by  venom  is  attributed 
erroneously,  even  to-day.  to  a  species  of  '*  the  force  of 
elimination  of  the  organism." 

Xow  that  we  liave  eliminated  the  way  of  ingress  of 
the  specific  microbe  and  the  seat  of  election,  entirely 
arbitrary,  assigned  to  it  in  the  digestive  tube  accord- 
ing to  old-fashioned  ideas,  let  us  see  by  what  route 


July  24.  1897] 


MEDICAL    RECORD. 


this  microbe  penetrates  into  the  organism  in  order  to 
manufacture  its  poison,  and  let  us  say  at  once  that  it 
is  a  point  sufficiently  difficult  to  establish. 

In  countries  where  the  yellow  fever  exists,  no  evi- 
dence has  yet  been  collected  sufficiently  significant  to 
establish  the  transmission  by  water.  On  the  other 
hand  a  great  number  of  facts  exist  which  should  speak 
stronglv  in  favor  of  transmission  by  the  air. 

The  only  example  always  cited  by  authors,  referring 
to  the  diminution  of  the  yellow  fever  in  Vera  Cruz 
since  the  city  was  provided  with  good  drinking-water, 
can  have  only  a  relative  value,  as  have  all  the  affirma- 
tions of  this  kind. 

There  is  too  exclusive  a  tendency  to  attribute  to  the 
realization  of  a  single  hygienic  measure  the  sanitary 
improvement  of  a  city:  it  concerns  almost  always,  on 
the  contran,-,  a  series  of  hygienic  improvements  that 
have  of  a  necessity  preceded  or  accompanied  it. 

For  the  rest,  the  tenacious  resistance  to  desiccation 
and  to  water  I  have  found  in  the  "  bacillus  icteroides" 
authorize  me  to  admit  that  the  diffusion  of  the  \  irus 
of  yellow  fever  can  take  place  as  well  by  air  as  by 
water.  The  experiments  on  animals  show  that  infec- 
tion by  the  respiratory  tract  is  possible. 

With  respect  to  the  mechanism  of  infection  by  the 
way  of  fluids,  a  fact  beyond  doubt  is  that  when  the 
epithelium  of  the  digestive  tract  is  intact,  in  general 
it  does  not  permit  the  entrance  of  any  sort  of  patho- 
genic germ.  It  should  be  remembered,  notwithstand- 
ing, that,  in  countries  where  the  yellow  fever  exists,  the 
slightest  disorder  of  the  digestive  functions,  the  abuse 
of  alcoholic  and  iced  drinks,  and  of  fruits,  etc.,  above 
all  by  new-comers,  constitute,  as  all  of  them  causes  of 
general  depression,  just  so  many  factors  to  determine 
at  once  the  entrance  of  yellow  fever  upon  the  scene. 

The  marked  tendency  to  lesions  of  the  liver  in  hot 
countries  would  represent  then  not  only  one  of  the 
conditions  that  predispose  most  readily  to  yellow  fever, 
but,  when  this  has  once  been  established,  would  be  the 
chief  cause  of  those  secondary  infections  which  im- 
press at  times  a  physiognomy  so  complex  upon  the 
bacteriological  result  of  yellow  fever  and  which  con- 
tribute undoubtedly  in  a  notable  manner  to  the  in- 
crease of  the  mortality,  already  horrible,  of  this  dis- 
eas;. 

The  ■■  bacillus  icteroides,"  whether  by  the  effect  of 
its  specific  poison  or  whether  through  the  grave  he- 
patic lesions  which  are  its  most  immediate  conse- 
quence, favors  at  a  given  moment  the  entrance  into 
the  organism  of  septic  microbes,  which  not  only  end 
the  disease  much  before  the  specific  agent  could  do  it. 
but  are  also  prejudicial  to  the  latter,  invading  at  once 
its  domains,  suppressing  its  vegetative  faculty  and 
even  its  vitality. 

It  is  on  account  of  this  that  these  phenomena  of 
raicrobic  antagonism  between  the  yellow-fever  bacillus 
and  the  micro-organisms  of  septic  infections,  instead 
of  being  useful  to  the  patient,  tend  to  hasten  his  death. 

There  is  another  curious  bacteriological  phenome- 
non of  immense  value  in  the  epidemiology  of  yellow 
fever;  the  marine  propagation  of  this  disease  is  now 
completely  established,  the  cause  of  which  we  must 
seek,  guided  by  the  knowledge  we  have  acquired  con- 
cerning the  biology  of  its  specific  microbe. 

The  behavior  of  yellow  fever  on  ships  differs  singu- 
larly from  that  of  another  grave  epidemic  disease — the 
cholera.  The  latter,  once  introduced  on  board,  causes 
a  veritable  explosion,  attacking  rapidly,  one  may  al- 
most say,  all  it  ought  to  attack. 

The  gravity  of  this  explosion  varies  according  to  the 
quantity  and  the  energy  of  the  cholera  vibrios  and  the 
predisposition  of  the  subjects ;  but  this,  as  it  were,  act 
of  presence  once  accomplished,  the  cholera  vibrio  does 
not  seem  to  find  in  the  ordinary  nautical  conditions  a 
soil  ver\-  favorable  to  its  existence.      Failing  this  in- 


termediary between  man  and  the  cholera  agent,  above 
all  if  disinfection  is  well  carried  out,  the  disease  dies 
out. 

Yellow  fever  on  the  contrar)-,  once  established  on  a 
ship,  persists  long  and  tenaciously,  keeping  itself  es- 
pecially in  the  bilges,  holds,  storerooms,  and  finally  in 
every  narrow  and  confined  place.  It  is  generally  ad- 
mitted that  old  and  worn  ships  are  the  very  worst  for 
service  with  countries  in  which  yellow  fever  is  epi- 
demic. -\11  students  of  naval  hygiene  consider  as- 
types  of  "the  yellow-fever  ship"  those  ships  badly 
ventilated,  with  small  hatches  and  air  ports,  in  which 
vitiated  air  stagnates  above  and  fetid  moisture  below. 

Heat,  moisture,  darkness,  and  want  of  ventilation 
seem  to  be  the  best  coefficients  for  the  preser\-ation  o£ 
the  "bacillus  icteroides:"  but  we  know  in  the  present 
state  of  our  knowledge  it  is  not  possible  to  attribute 
any  specific  value  to  these  diverse  coefficients,  since 
on  the  whole  they  are  conditions  that  favor  all  mi- 
crobes in  general.  It  is  necessary  then  to  seek  in 
some  other  concomitant  element  the  cause  that  gives 
to  the  nautical  habitat  of  the  "bacillus  icteroides'"  a 
form  almost  specific. 

A  simple  phenomenon  which  attracted  my  attentioa 
under  various  circumstances  during  my  studies  ex- 
plained to  me  in  an  original  manner  the  probable 
cause  of  this  mysterious  longevity  and  resistance  of 
the  "bacillus  icteroides"  on  board  ships;  it  is  that  the 
common  moulds  of  the  atmosphere  constitute  the  great 
protectors  of  the  "bacillus  icteroides." 

The  microbe  of  yellow  fever,  though  endowed  with  a 
notable  power  of  resistance  to  the  natural  chemico- 
physical  agents,  cannot  be  indifferent  with  respect  to 
the  substances  necessar}-  for  its  nutrition. 

It  is  indubitable  that  during  its  saprophitic  existence 
outside  the  body,  as  for  example  in  the  hold  of  a  ship, 
it  cannot  make  use  of  nutritive  principles  of  much 
value,  and  this  is  so  certain  that  many  times  it  is  not 
capable  even  of  multiplying  on  a  layer  of  common 
gelatin.  If  notwithstanding  a  mould  begins  to  grow- 
in  its  vicinit}".  the  products  of  the  growth  of  this 
hyphomycete  or  the  changes  caused  by  it  in  the  sur- 
rounding media  are  sufficient  to  nourish,  vivify,  and 
multiply  the  '"bacillus  icteroides,"  which  otherwise 
would  have  been  left  to  die  sooner  or  later.  This 
favorable  property  of  mould  for  the  "  bacillus  icte- 
roides" can  be  demonstrated  experimentally  by  plac- 
ing the  spores  of  any  sort  of  mould  upon  a  layer  of 
gelatin  previously  sowed  with  microbes  of  yellow- 
fever,  which,  as  often  happens,  has  remained  sterile. 

Scarcely  has  the  mould  begun  to  grow  when  there 
appears  around  it  in  the  gelatin  a  crown  of  little 
punctiform  colonies  belonging  to  the  "bacillus  icte- 
roides." Commensurately  with  the  growth  of  the  mould 
these  colonies  become  more  numerous,  augmenting 
rapidly  their  zone  of  occupation  around  the  central 
stem  of  the  mould,  .\fter  a  few  days  the  plates  of 
gelatin  on  which  the  mould  has  grown  presents  an  ap- 
pearance extremely  curious:  around  each  piece  of 
mould  the  colonies  of  the  "bacillus  icteroides,"  which 
one  might  have  supposed  for  some  time  to  be  dead  or 
at  least  incapable  of  growing,  form,  as  it  were,  con- 
stellations, the  more  numerous  the  nearer  they  happen 
to  be  to  the  point  occupied  by  the  mould.  It  would 
seem  then  that  mould  possesses  a  species  of  radius  of 
influence,  within  which  only  is  the  evolution  of  colo- 
nies of  yellow-fever  bacilli  possible.  This  radius  of 
influence  is  more  or  less  extended  according  to  the 
variety  of  the  mould  and  the  space  it  occupies,  but  it 
is  always  perfectly  regular,  uniformly  distributed,  and 
equidistant  from  the  centre,  represented,  as  I  have  said 
before,  by  the  stalk  of  the  fungus.  Outside  of  this 
radius  of  influence,  which  is  always  clearly  limited,  the 
evolution  of  the  microbe  colonies  ceases  abruptly  and 
the  rest  of  the  gelatin  remains  sterile  unless  a  new 


MEDICAL    RECORD. 


[July  24,  1897 


spore  gives  rise  to  a  new  mycelium,  which  finds  itself 
promptly  surrounded  by  a  new  pullulation  of  icteroides 
colonies. 

It  is  very  probable  that  this  faculty  constitutes  a 
specific  characteristic  common  to  all  moulds  in  gen- 
eral, since  the  six  species  I  have  accidentally  isolated 
from  the  atmosphere  of  the  laboratory  have  all  shown 
themselves  capable,  though  in  different  degrees,  of 
favoring  the  revivification  and  multiplication  of  the 
icteroides  microbe,  which  without  this  condition  would 
not  have  been  able  to  unfold  itself. 

It  is  possible,  moreover,  that  there  exists  in  nature, 
above  all  in  localities  where  yellow  fever  takes  hold 
with  great  vigor,  some  mould  hitherto  unknown  and 
endowed  with  a  favoring  power  truly  specific  and  even 
much  more  notable. 

This  strange  phenomenon  of  parasitism,  which  could 
be  defined  as  the  loan  of  the  means  of  existence,  this 
rare  form  of  microbic  saprophytism  represents  prob- 
ably the  easy  acclimatization  of  yellow  fever  on  ships. 

It  is  in  reality  very  probable  that  in  the  holds  of 
badly  ventilated  ships  it  is  not  only  the  legendary 
moist  heat  considered  from  the  point  of  view  of  its 
chemico-physical  eff'ects  which  maintains  so  long  the 
vitality  of  the  yellow-fever  germs  accidentally  brought 
there.  In  the  holds  of  ships,  in  spite  of  the  moist  heat, 
other  pathogenic  microbes,  as  that  of  cholera  and  of 
typhus,  etc.,  do  not  prosper  and  remain  long  active. 
As  far  as  yellow  fever  is  concerned,  the  moist  heat  and 
insufficient  ventilation  should  be  considered  then  as 
indispensable  conditions  for  the  growth  of  the  moulds, 
and  therefore  as  indirectly  favorable  to  the  vitality  of 
the  "bacillus  icteroides." 

This  phenomenon  of  commensal  ism,  analogous  to 
that  Metchnikofi^  marked  out  some  time  ago  for  the 
cholera  vibrio,  is  in  accord  with  and  explains  many 
other  well-observed  practical  facts  which  form  part  of 
the  epidemiological  character  of  yellow  fever. 

We  must  consider  then  the  moulds  as  natural  pro- 
tectors of  the  specific  agent  of  yellow  fever,  as  it  is 
owing  to  their  intervention  that  the  latter  finds  the 
force  to  live  and  multiply  itself  until  a  point  is 
reached  at  which,  through  the  unsuitableness  of  the 
nutritive  medium  or  the  action  of  an  unfavorable  tem- 
perature, its  existence  would  be  rendered  impossible. 

The  intervention  of  this  factor,  so  insignificant  in 
appearance,  constitutes  notwithstanding  the  chief 
cause  of  the  acclimatization  of  yellow  fever  not  only 
on  ships  but  also  in  certain  localities  where  it  seems 
to  find  conditions  extraordinarily  favorable  for  its  sad 
dominion. 

We  know  in  truth  that  one  of  the  conditions  thought 
indispensable  for  the  evolution  of  yellow  fever,  moist- 
ure, represents,  joined  with  heat,  the  best  element  for 
the  formation  of  the  moulds.  Moreover  it  is  thought 
that  the  unhealthiness  of  Rio  Janeiro  is  due  chiefly  to 
the  want  of  ventilation  and  to  the  excessive  humidity 
of  the  atmosphere. 

It  is  probable  then  that  the  factor  of  humidity  on 
board  ship,  as  near  the  coast  and  in  the  interior  of 
countries,  represents  the  principal  coefficient  of  this 
biological  phenomenon. 

Moreover,  the  conspicuous  resistance  of  the  "bacil- 
lus icteroides"  to  desiccation,  which  is  the  chief  factor 
of  natural  disinfection,  and  its  longevity  in  sea  water, 
explain  sufficiently  the  easy  acclimatization  of  yellow- 
fever  and  its  tenacious  persistence  above  all  in  mari- 
time localities  afflicted  by  the  presence  of  its  specific 
agent. 

For  a  year,  by  work  often  interrupted,  I  have  had 
the  fortune  to  bring  to  this  point  our  knowledge  this 
terrible  infirmity,  which  represents  the  most  grave  and 
urgent  sanitary  problem  throughout  America.  The 
ground  covered  is  without  doubt  wide,  but  there  re- 
mains yet  much   to  go  over.     We  have   learned   to 


know  the  specific -agent  of  yellow  fever;  we  have  it  in 
our  power ;  we  have  studied  minutely  its  life,  its  habits, 
its  wants,  its  relations  to  external  agents  and  to  other 
small  organisms;  we  have  revealed  the  complicated 
mechanism  of  all  the  infinite  manifestations  which 
this  agent  determines  in  the  human  organism,  and  we 
have  finally  placed  this  disease,  which  a  few-  months 
ago  was  a  horrible  mystery,  on  the  same  level  as  that 
occupied  by  the  other  great  infectious  diseases. 

The  advantages  to  public  prophylaxis  and  to  clini- 
cal indications  which  will  rise  out  of  these  results 
need  not  be  indicated;  the  principal  base  of  social 
defence  against  diseases  is  the  exact  knowledge  of 
their  specific  causes. 

Asiatic  cholera,  typhoid  fever,  and  many  other  grave 
diseases  do  not  inspire  now  the  terror  of  former  days, 
because  science,  relying  upon  the  study  of  their  spe- 
cific agents,  can  guard  against  their  diffusion  and  ac- 
climatization by  adopting  wise  sanitary  measures  and 
effecting  various  hygienic  improvements — thanks  to 
the  good  results  of  which  certain  cities  have  been,  so 
to  speak,  almost  resuscitated. 

But  apart  from  the  prophylactic  ideal,  which  from 
the  hygienic  point  of  view  holds  the  greater  import- 
ance, because  it  is  always  better  and  easier  to  prevent 
diseases  than  to  cure  and  drive  them  out  when  they 
have  once  manifested  themselves,  there  exists  another 
ideal — the  therapeutic  ideal. 

Well,  then,  given  the  nature  of  the  process  we  have 
just  studied,  I  do  not  think  it  difficult  for  even  this 
ideal  to  be  realized  and  I  entertain  a  well-founded 
faith  that  it  will  soon  be  possible  to  apply  to  man  a 
specific  preventive  and  curative  treatment  of  yellow 
fever. 


THE  TECHNIQUE  OF  VAGINAL  SECTION, 
IRRESPECTIVE  OF  HYSTERECTOMY,  FOR 
DISEASED  APPENDAGES  AND  SMALL 
PELVIC    TUMORS.' 

By   AUGUSTIN   H.    GOELET,    M.D., 


GVN.ECOLOCV 


SCHOOL     OF     C1.I 


In  the  face  of  considerable  opposition  on  the  part  of 
some  surgeons  who  have  obtained  most  satisfactory  re- 
sults from  abdominal  section,  for  these  conditions  va- 
ginal section  has  continued  to  grow  in  favor  and  may 
be  regarded  as  the  accepted  method  of  procedure  in 
certain  cases.  As  one  of  those  who  at  first  opposed 
this  route  for  the  removal  of  diseased  pelvic  organs, 
I  feel  entitled  to  speak  upon  this  point  in  the  light  of 
recent  experience. 

My  excu.se,  if  one  be  needed  for  this  brief  paper,  is 
to  elucidate  the  technique  of  vaginal  section  and  the 
subsequent  management  of  these  cases,  and  thus  add 
my  quota  to  the  effort  to  brush  aside  the  prejudice 
which  still  exists  in  some  quarters  against  the  opera- 
tion. Anything  which  will  lessen  the  shock  in  opera- 
tion, reduce  the  mortality,  and  shorten  convalescence 
is  to  be  regarded  as  a  decided  advance  in  our  methods, 
and  this  may  be  said  of  the  vaginal  operation.  If  the 
surgeon  selects  his  cases  carefully  and  employs  this 
method  only  when  it  is  appropriate,  he  will  have  no 
dissatisfaction  with  the  results,  but  will  soon  learn 
infinitely  to  prefer  this  route  in  certain  conditions. 
There  will  still  remain  a  great  many  cases  in  which 
abdominal  section  can  be  done  to  better  advantage  and 
to  the  greater  safety  of  the  patient.  It  must  not  be 
thought,  then,  that  the  one  route  will  entirely  supersede 
the  other,  since  both  have  their  natural   limitations, 

'  Read  before  the  section  on  obstetrics  and  diseases  of  women 
of  the  American  Medical  -\ssociation,  1S97. 


July  24,  1897] 


MEDICAL    RECORD. 


based  upon  (i)  the  ease  with  which  the  operation  may 
be  completed,  (2)  the  complications  which  may  develop 
as  the  operation  proceeds,  (3)  the  danger  which  the 
operation  involves,  and  (4)  the  immediate  as  well  as 
the  remote  results,  including  the  necessity  for  drainage. 
The  advantages  of  this  method  aside  from  those 
already  mentioned  may  be  stated  as  follows,  viz. :  (i) 
The  patient  will  more  readily  consent  to  a  vaginal  sec- 
tion;  hence  hopelessly  diseased  organs  may  be  re- 
moved earlier  and  the  mortality  ther<-by  lessened  and 
suffering  relieved.  (2)  The  surgeon  wall  not  hesitate 
to  advise  vaginal  section  in  conditions  which  do  not 
seem  to  present  sufficient  gravity  to  warrant  the  risk 
of  abdominal  section.  (3)  As  a  method  of  explora- 
tion of  the  pelvis  necessan,-  to  clear  up  the  diagnosis 
when  the  diseased  condition  is  not  extensive  and 
when  adhesions  are  not  dense  or  numerous.  (4) 
If  subsequent  drainage  is  certain  to  be  required, 
it  is  more  prefectly  secured  through  a  vaginal  in- 
cision. 

•  The  operation  is  applicable  (1)  for  small  pelvic 
tumors  which  are  or  seem  to  be  solid  in  part  or  entire- 
ly so;  (2)  in  ovarian  cysts  of  considerable  size,  since 
the  fluid  can  be  evacuated  and  the  sac  withdrawn 
through  a  small  vaginal  incision  and  removed  quite 
as  readily,  and  many  times  more  readily  than  through 
an  abdominal  incision;  (3)  for  pyosalpinx,  hydro- 
salpinx, and  hematosalpinx;  (4)  for  cystic  or  other- 
wise enlarged  and  diseased  ovaries;  (5)  for  the  re- 
moval of  small  subperitoneal  fibroids  by  myomectomy; 
(6)  for  drainage  of  pus  accumulations  situated  low 
down  in  the  pelvis;  (7)  for  hematoma  and  ha-mato- 
cele;  (8)  for  pelvic  exudations  which  resist  other 
means  for  their  removal.  I  have  had  e.xcellent  results 
from  persistent  faradization  in  these  last-named  con- 
ditions; hence  I  believe  that  surgical  interference  is 
seldom  required  when  suppuration  has  not  occurred. 

Technique  of  Vaginal  Section.  —The  patient  is  as 
carefully  prepared  as  for  abdominal  section,  and  the 
abdomen  should  be  shaved  and  otherwise  rendered 
aseptic,  so  as  to  permit  an  immediate  section  there 
should  the  necessity  develop  during  the  course  of  the 
operation  through  the  vagina.  The  vagina  is  thorough- 
ly irrigated  the  evening  before  with  a  one-per-cent. 
solution  of  lysol  in  hot  water  and  packed  with  marka- 
sol  gauze.  This  is  preferred  because  it  is  certainly 
antiseptic  and  does  not  irritate  the  vaginal  surface. 
The  morning  of  the  operation  the  vulva  is  shaved  and 
washed  with  green  soap  and  a  one-per-cent.  solution 
of  lysol,  and  afterward  covered  with  a  pad  of  markasol 
gauze.  After  being  anesthetized  the  patient  is  placed 
upon  the  operating-table  in  the  exaggerated  lithotomy 
position,  with  buttocks  over  the  edge  of  the  table. 
The  vulva  and  the  vagina  ar^now  scrubbed  again  with 
green  soap  and  irrigated  with  a  one-per-cent.  solution 
of  lysol.  A  short  broad-bladed  hard-rubber  speculum 
is  inserted  and  the  perineum  retracted,  exposing  the 
cervix.  The  speculum  is  held  in  the  right  hand  by 
the  nurse,  who  sits  to  the  left  of  the  operator.  Tiie 
cervix  is  seized  with  the  angular  tenaculum  forceps, 
drawn  down,  and  the  cervical  canal  is  dilated;  the 
cavity  of  the  uterus  is  curetted  and  irrigated  with  a 
one-per-cent.  solution  of  lysol  and  packed  with  marka- 
sol gauze  to  the  external  os.  A  traction  ligature  is 
now  inserted  through  both  lips  of  the  cervix,  which  is 
held  by  the  nurse  with  her  left  hand,  who  draws  it 
down  and  up  against  the  pubis  if  the  section  is  to  be 
made  posterior  to  the  cervix.  The  cervico-vaginal 
fold  is  the  guide  for  the  line  of  incision.  With 
cur\-ed,  blunt-pointed  scissors  a  semicircular  incision 
is  made  through  the  vaginal  wall  along  the  fold  ex- 
tending about  half-way  around  the  cervix  on  either 
side.  After  the  vaginal  wall  has  been  penetrated,  the 
dissection  is  extended  farther  with  the  blunt  end  of 
the  scissors  closed  or  with  the  thumb  nail,  the  opera- 


tor hugging  the  posterior  wall  of  the  uterus  and  peel- 
ing the  tissues  away  from  it  until  the  peritoneal  fold 
of  Douglas'  pouch  is  exposed.  This  is  divided  with 
the  scissors  and  enlarged  to  the  extent  of  the  vaginal 
incision  on  either  side.  Up  to  this  point  there  may 
be  considerable  bleeding  from  small  vessels  which 
have  been  divided,  but  the  operation  need  not  be  de- 
layed by  any  effort  to  control  this  until  the  peritoneal 
cavity  is  opened. 

The  peritoneum  on  the  posterior  face  of  Douglas' 
pouch  is  now  drawn  down  with  a  tenaculum,  and  with 
a  continuous  catgut  suture  it  is  sewed  to  the  posterior 
edge  of  the  vaginal  incision  to  the  limit  on  either  side. 
This  very  effectually  controls  the  bleeding.  A  trac- 
tion ligature  of  silk  is  now  inserted  on  either  side  near 
the  angle  of  the  incision  in  the  vaginal  wall,  including 
the  peritoneum,  which  has  just  been  sewed  to  it.  We 
are  now  ready  for  exploration  of  the  pelvic  cavity. 
One  or  two  fingers  are  inserted,  and  when  adhesions 
are  encountered  they  are  separated;  the  diseased 
structure  is  brought  more  easily  within  reach  of  the 
examining  fingers  by  pressure  upon  the  abdomen 
above  with  the  disengaged  hand  and  by  removing  the 
perineal  retractor. 

If  a  distended  tube  is  discovered  or  any  cystic 
tumor,  care  is  necessarj-  to  avoid  rupture  and  soiling 
of  the  peritoneum.  The  adhesions  are  carefully  sepa- 
rated, and,  when  possible,  the  mass  is  delivered  through 
the  vaginal  incision,  the  pedicle  is  ligated,  and  it  is 
removed  intact.  But  should  it  prove  too  large  for  re- 
moval in  this  manner,  the  adhesions  are  separated  as 
far  as  it  is  possible  to  reach,  and  it  is  brought  down 
to  the  incision  and  held  firmly  there  by  pressure  upon 
the  abdomen  above,  while  it  is  seized  firmly  and  punc- 
tured, so  that  the  contents  will  be  discharged  along 
the  groove  of  the  speculum.  As  the  sac  collapses  it 
is  rapidly  drawn  through  the  incision  into  the  vagina. 
Adhesions  which  could  not  be  reached  before  can  now 
be  .separated.  If  the  tumor  is  a  large  ovarian  cyst,  it 
may  be  more  advantageous  to  employ  a  trocar,  but  I 
seldom  use  it.  If  the  tumor  proves  to  be  a  pus  ac- 
cumulation in  the  tube  or  ovary,  greater  care  must  be 
taken  to  avoid  soiling  or  infecting  the  peritoneal  cav- 
ity, and  free  irrigation  of  the  vagina  with  a  i  to  5,000 
solution  of  bichloride,  if  it  is  ruptured  during  removal, 
will  be  necessary.  As  a  rule,  irrigation  should  be 
avoided  when  possible,  and  I  seldom  use  anything 
except  normal  salt  solution. 

Prolapse  of  the  intestines  through  the  incision  is 
avoided  by  elevation  of  the  hips  and  by  inserting  a 
pad  of  sterilized  gauze,  with  string  attached  for  its  re- 
moval, through  the  incision  up  into  the  pelvic  cavity 
and  pushing  them  out  of  the  way.  This  is  done  of 
course  before  the  mass  is  brought  down  into  the  inci- 
sion. 

A  solid  or  semisolid  tumor  will  be  more  difficult  to 
remove  through  a  vaginal  incision,  though  I  have  re- 
moved dermoids  the  size  of  the  fist.  Solid  tumors 
attached  to  the  uterus  and  when  not  very  large  may 
be  removed  piecemeal,  though  I  prefer  abdominal  sec- 
tion in  these  cases. 

Small  subperitoneal  fibroids,  when  their  removal  is 
thought  best,  may  be  removed  likewise  by  a  myomec- 
tomy through  a  vaginal  incision,  the  pedicle  being 
enucleated  from  the  uterine  wall  and  the  wound 
closed  by  a  Lembert  suture  of  fine  catgut. 

When  the  location  of  the  mass  is  such  that  it  may 
be  reached  more  easily  by  an  incision  anterior  to  the 
uterus,  the  peritoneal  cavity  is  entered  by  a  similar 
incision  in  the  vaginal  wall  anterior  to  the  cervLx  and 
extending  up  between  the  uterus  and  b';adder.  It  will 
be  safer,  especially  when  there  is  any  prolapse  of  the 
anterior  vaginal  wall,  to  precede  the  operation  by  a 
thorough  exploration  of  the  bladder  by  means  of  a 
sound,  so  as  to  locate  its  position  relative  to  the  uterus. 


124 


MEDICAL    RECORD. 


[July  24.  1897 


Great  care  must  be  observed  in  the  dissection  be- 
tween the  uterus  and  bladder  not  to  wound  the  latter, 
.  and  it  must  be  remembered  that  the  dissection  must 
be  carried  much  farther  up  in  front  than  behind  before 
the  peritoneum  is  reached.  By  hugging  the  front  wall 
of  the  utterus  closely,  and  making  traction  upon  the 
cervix  downward  and  backward,  there  will  be  no  ex- 
cuse for  wounding  the  bladder.  When  the  peritoneum 
is  reached  and  the  ca\ity  opened,  the  edge  of  the  peri- 
toneum is  attached  to  the  edge  of  the  vaginal  incision 
by  suture,  and  we  are  ready  for  exploration  of  the  pel- 
vis and  the  removal  of  the  offending  structures.  This 
metiiod  of  procedure  is  the  same  as  when  the  incision 
is  made  into  the  posterior  cul-de-sac. 

The  after-dressing  of  these  wounds  in  the  \agina 
and  their  subsequent  management  will  depend  greatly 
upon  the  necessity  for  drainage  and  the  liability  to 
adhesions  of  the  intestines  to  the  returned  stump. 
\^'hen  the  character  of  the  work  done  is  of  such  a  na- 
ture that  drainage  is  not  required,  and  there  is  no  like- 
lihood that  adhesions  will  form,  the  vaginal  wound 
may  be  closed  by  suture,  though  this  is  not  absolutely 
necessary,  as  union  will  take  place  quickly  if  it  is 
left  unsutured.  It  is  not  even  necessary  to  remove 
the  catgut  suture  which  unites  the  peritoneum  to  the 
vaginal  wall,  since  the  two  surfaces  of  peritoneum  will 
fall  together  and  adhere,  and  the  absorption  of  the  cat- 
gut permits  the  other  tissues  to  come  into  coaptation 
subsequently.  (The  traction  ligatures  are,  of  course, 
removed.)  Yet  if  the  catgut  has  been  hardened  and 
we  are  not  certain  that  it  will  be  quickly  absorbed,  it 
should  be  removed. 

When  it  is  thought  best  to  close  the  vaginal  wound 
a  continuous  suture  of  ordinary  catgut  is  employed, 
and  care  is  taken  to  include  the  peritoneal  edges  in 
the  sutures.  Subsequently  the  vagina  is  packed  loose- 
ly with  markasol  or  plain  sterilized  gauze,  which  is  re- 
moved after  forty-eight  hours.  After  this  the  vagina 
is  irrigated  daily  if  required. 

When  drainage  is  necessary  or  adhesions  are  to  be 
avoided,  a  strip  of  plain  sterilized  gauze  is  carried 
through  the  incision  and  packed  around  the  returned 
stump  to  protect  it  from  contact  with  the  intestines. 
The  end  of  this  is  allowed  to  protrude  into  the  vagina, 
which  is  filled  loosely  with  the  same  gauze.  Forcon- 
yenience  of  removal,  the  strip  carried  up  through  the 
incision  should  be  continuous  with  that  in  the  vagina. 
This  gauze  is  permitted  to  remain  for  twenty-four 
hours,  when  that  in  the  vagina  should  be  removed, 
together  with  a  part  of  that  m  the  peritoneal  cavity! 
Some  fresh  gauze  is  placed  in  the  vagina,  and  after 
another  twenty-four  hours  the  whole  is  removed  by 
very  gentle  traction,  and  the  vaginal  wound  is  per- 
mitted to  close  if  there  is  no  longer  any  necessitv  for 
drainage. 

Union  will  usually  take  place  in  from  six  to  eight 
days,  even  when  the  gauze  drain  is  employed,  and  the 
patient  can  be  gotten  up  at  the  end  of  two  weeks  if 
nothing  occurs  to  pre\ent  it. 

It  is  the  exception  when  any  rise  of  temperature  fol- 
lows this  form  of  vaginal  section,  and  the  convalescence 
is,  as  a  rule,  rapid  and  uneventful. 

io3  West  Sevextv-Third  Street. 


Uterine  Sound — The  use  of  the  uterine  sound  to 
reduce  retrodisplacement  of  the  uterus,  although  rec- 
ommended by  some  text-books,  is  never  to  be  resorted 
to.  The  dangers  from  liability  to  perforate  the  organ, 
of  carrying  infection  into  its  cavity,  or  of  injuring  its 
mucous-membrane  lining  so  that  germs  that  are  already 
present  may  invade  the  tissues,  are  too  great  to  war- 
rant the  risk.  The  sound  should  never  be  used  for 
this  purpose. — Montoomerv. 


progress  of  ^Xctlical  J»cience. 

Poisoning  by  Quinine.— Gresswell  {Lancet,  May  i, 
1897)  has  reported  the  case  of  a  woman,  forty-seven 
years  old,  to  whom  he  was  called  because  it  was 
thought  she  had  fallen  into  a  fit.  He  found  her  pros- 
trated, unable  to  speak,  and  with  a  pallor  of  counte- 
nance like  that  of  impending  death.  On  inquiry  it 
was  learned  that  the  patient  had  taken  before  break- 
fast, about  two  teaspoonfuls  of  quinine  dissolved  in  acid 
after  which  she  vomited.  The  hands  and  face  were 
extremely  pale  and  the  pulse  was  quick  and  irregular 
—  almost  fluttering,  small,  thready,  and  feebie.  The 
heart  beats,  though  clear,  were  wanting  in  strength, 
and  were  of  a  dull,  subdued,  metallic  character. 
Hearing  was  entirely  lost  and  vision  was  greatly  im- 
paired. For  about  eight  hours  the  woman  remained 
speechless  and  quiescent,  though  not  quite  uncon- 
scious. At  the  end  of  this  time  she  began  to  speak, 
while  some  color  had  returned  to  the  cheeks  and  the 
action  of  the  heart  had  become  quieter  and  stronger. 
A  sedative  prescription  insured  a  comfortable  night 
and  on  the  following  day  the  patient  was  much  im- 
proved, although  still  deaf,  especially  in  the  right  ear. 
The  pupils  were  large  and  reacted  but  sluggishlv. 
Perfect  recovery  ensued  in  the  course  of  a  few  more 
days.  In  describing  the  onset  of  her  symptoms  the 
patient  stated  that  she  at  first  felt  faint,  then  dizzy, 
and  was  ne.\t  sick;  tingling  appeared  in  the  fingers 
and  all  over  the  body;  and  finally  unconsciousness 
developed  without  pain. 

The  Variability  in  Color  and  Amount  of  the  In- 
tracellular Biliary  Pigment  Deposits  in  the  Liver. 

—As  the  result  of  a  study  of  pathologic  changes  in 
liver  cells,  Krowicz  {Deutsche  iimiicuiische  UW/ieii- 
sc/irift,  June  3,  1897)  comes  to  the  conclusion  that  the 
beginnings  of  the  biliary  capillaries  are  to  be  found 
within  the  protoplasm  of  the  liver  cells  themselves, 
appearing  as  intraprotoplasmatic  biliary  passages  in 
direct  communication  with  the  intracellular  biliary 
passages.  The  so-called  secretion  vacuoles  of  Kupfe'r 
may  be  looked  upon  as  transverse  sections  of  intrapro- 
toplasmatic biliary  passages.  In  cases  of  pronounced 
intracellular  stasis  of  bile,  the  intraprotoplasmatic 
passages  may  furnish  the  basis  of  pathologic  vacuoli- 
zation of  the  liver  cells  of  varying  degree.  The  nucleus 
of  the  liver  cell  takes  an  active  part  in  the  secretion  of 
the  biliary  pigment.  The  deposition  of  such  pigment 
within  the  nuclei  of  liver  cells  under  pathologic  con- 
ditions is  not  indiscriminate  in  distribution  about  the 
reticulum,  but  takes  place  within  well-defined  rounded 
areas,  so  that  the  conclHsion  seems  justified  that  per- 
manent spaces  or  canals  are  present  in  the  resting 
nucleus,  which  become  distended  under  pathological 
conditions  and  afford  the  basis  for  pathologic  vacuo- 
lization of  the  nucleus.  Continued  investigation  upon 
the  same  lines  has  shown  that  within  the  chromatin 
ground  substance  of  the  nucleus  of  the  liver  cell  there 
exists  a  system  of  fine  spaces  or  canals  in  direct  com- 
munication with  the  intraprotoplasmatic  system  of 
canals,  and  this  in  turn  is  in  direct  communication 
with  the  intracellular  biliary  passages.  The  intranu- 
clear and  intraprotoplasmatic  system  of  canals  must 
be  considered  a  connected  system  of  secretorj-  canals, 
as  indicated  by  the  various  biliary  deposits  that  take 
place  in  them  under  pathologic  conditions.  The  be- 
ginnings of  the  biliary  passages  would  thus  have  to 
be  located  in  the  nucleus  of  the  liver  cell  itself. 
Pathologic  vacuolization  of  nuclei,  as  well  as  of  the 
protoplasm  found  in  association  with  pathologic  states 
of  the  liver  cells,  is  intimately  connected  with  the 
existence  of  an  intranuclear  and  intraprotoplasmatic 
secretory  canal  system. 


July  24,  1897] 


MEDICAL    RECORD. 


125 


Medical  Record: 


A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.    SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &  CO.,  43,  45,  &.  47  East  Tenth  Street. 


New  York,  July  24,  1897. 


THE  PATHOLOGY   OF    RECURRENT  APPEN- 
DICITIS. 

Whether  every  case  of  appendicitis  should  be  treated 
surgically  or  not,  even  when  the  most  approved  medi- 
cal measures  have  failed  to  eflect  speedy  relief,  and 
whether  or  not  the  diseased  appendi.x  should  be  re- 
moved invariably,  are  still  debatable  questions. 
There  can  be  no  doubt  that  in  many  instances  recov- 
er)-, from  the  immediate  attack  at  least,  ensues  without 
surgical  intervention,  and  it  is  even  probable  that 
some  attacks  pursue  a  favorable  course  without  so 
much  as  being  recognized,  though  less  commonly  at 
present  than  in  the  not  remote  past.  Death  from  peri- 
tonitis of  obscure  origin  also  is  less  common  now  than 
formerly. 

When,  however,  one  reflects  upon  the  frequency  with 
which  an  attack  of  appendicitis  is  followed  by  others 
when  the  diseased  organ  is  permitted  to  remain,  it  be- 
comes an  exceedingly  delicate  matter  to  decide  in  the 
individual  case  whether  it  is  better  to  undertake  a 
radical  operation  or  to  submit  to  the  uncertain  risks 
and  dangers  that  attend  a  lesion  of  undeterminable 
extent  and  degree.  While  the  mortality  from  the 
disease  may  not  be  greater  in  competent  medical  than 
in  equally  competent  surgical  hands,  the  future  of  the 
case  appears  assuredly  less  certain  under  the  former 
than  under  the  latter  conditions.  The  final  decision, 
however,  in  favor  of  the  one  or  the  other  course  of 
procedure  will  depend  ultimately  upon  a  thorough  ap- 
preciation of  the  pathology  and  the  natural  history  of 
the  morbid  process. 

It  is  for  this  reason  that  a  recent  report  by  Southam," 
of  the  pathological  conditions  found  in  twenty  cases 
of  recurrent  appendicitis  treated  by  operation,  will 
be  received  with  especial  interest.  Of  this  number 
seven  occurred  in  females  and  thirteen  in  males.  The 
youngest  patient  was  ten,  the  oldest  forty-four  years 
of  age.  In  fifteen  of  the  cases  the  patients  were  be- 
tween fifteen  and  thirty  years  of  age.  In  all  of  the 
specimens  examined  the  appendix  showed  evidences 
of  chronic  inflammatory  changes,  with  thickening  of 
its  coats.  In  some  cases  its  lumen  was  uniformly 
narrowed  and  almost  obliterated;  in  others  it  was 
partially  or  completely  occluded  at  some  point  and 
dilated  on  the  distal  side  of  the  obstruction,  occasion- 
'  The  Lancet,  June  5.  1897. 


ally  forming,  when  the  occlusion  was  complete,  a  cys- 
tic cavity  of  some  dimensions.  In  many  instances  the 
appendix  was  considerably  shortened;  it  was  fre- 
quently found  bent  upon  itself  and  bound  down  by 
adhesions,  in  one  case  the  tip  almost  touching  the 
caecal  end  of  the  process. 

The  contents  of  the  appendix  consisted  either  of 
clear  mucus  or  of  a  muco-purulent  fluid;  in  two  cases 
a  hard  fcecal  concretion  was  present  in  its  interior,  and 
in  another  a  concretion  which  had  ulcerated  through 
its  wall  was  found  in  an  abscess  cavity  external  to  it. 
In  most  cases  the  inflammatory  changes  were  not  con- 
fined to  the  appendix  itself,  for  evidences  of  appendic- 
ular peritonitis  were  generally  found  to  be  present, 
the  peritonitis  being  usually  of  the  adhesive  variety, 
the  inflammatory  exudation  that  had  been  poured  out 
round  the  appendix  having  undergone  organization 
and  forming  adhesions.  These  were  often  very  firm 
and  extensive,  surrounding  the  appendix  and  fixing  it 
to  the  parietal  peritoneum,  omentum,  caecum,  or  small 
intestine.  In  some  instances  they  were  present  after 
a  second  attack;  in  other  instances  they  were  absent 
after  many  attacks.  When  exceptionally  dense  and 
extensive,  complete  obstruction  of  the  bowel  may  be 
produced  from  inclusion  and  compression  of  a  small 
coil  of  small  intestine  in  the  adhesions,  and  if  the 
condition  is  incapable  of  relief  by  operation  the  result 
is  necessarily  fatal. 

In  some  instances  the  peritonitis  was  of  the  suppu- 
rative character,  pus  having  formed  in  the  neighbor- 
hood of  the  appendix.  This  complicatiion  was  en- 
countered in  eight  of  the  twenty  cases.  In  six  of 
these  the  suppuration  was  localized,  an  encysted  in- 
traperitoneal abscess  being  present.  In  two  cases  the 
suppuration  w-as  general,  there  being  well-marked  evi- 
dences of  diffuse  purulent  peritonitis.  When  suppu- 
ration takes  place  it  is  often  secondary  to  ulceration 
and  perforation  of  the  walls  of  the  appendix,  followed 
by  escape  of  its  contents.  In  one  case  the  appendix, 
though  not  actually  perforated,  was  extremely  thinned 
at  one  point,  which  was  found  to  correspond  with  an 
ulcer  involving  its  mucous  and  muscular  coats. 

Among  the  twenty  cases  the  duration  of  the  symp- 
toms ranged  from  four  months  to  six  years,  and  the 
number  of  attacks  from  two  to  ten  or  more.  If  cases 
of  recurrent  appendicitis  are  left  to  themselves  attacks 
may  recur  at  irregular  intervals  for  years,  and  ulti- 
mately a  cure  may  take  place  by  a  gradual  process  of 
obliteration  of  the  lumen  of  the  appendix  and  its  con- 
version into  a  fibrous  cord.  Suppuration  may,  how- 
ever, occur  at  any  time;  if  an  encysted  abscess  forms, 
the  appendix  should,  after  evacuation  of  its  contents, 
usually  shrivel  up,  becoming  obliterated  and  causing 
no  further  trouble.  On  the  other  hand,  if  the  suppu- 
ration is  diffuse — that  is,  if  there  is  general  purulent 
peritonitis — the  result  will  probably  be  fatal.  Another 
complication,  already  mentioned,  that  may  occur  is 
intestinal  obstruction  from  compression  of  a  coil  of 
bowel  by  adhesions. 

Of  the  various  theories  advanced  to  explain  the  oc- 
currence of  appendicitis,  the  most  plausible  is  that 
which  regards  the  appendix  as  a  diverticulum  tliat 
readily  allows  of  the  accumulation   and  stagnation  of 


126 


MEDICAL    RECORD. 


[July  24,  1897 


fecal  matter.  This,  mingling  with  the  secretion  from 
its  mucous  lining  and  undergoing  fermentative  or  pu- 
trefactive changes,  sets  up  a  catarrhal  inflammation, 
which  may  be  followed  by  ulceration  and  perforation, 
or  by  thickening  of  its  walls,  the  latter  condition  being 
that  which  is  most  commonly  encountered  in  the  re- 
current form  of  the  disease.  The  faecal  concretions 
found  in  the  interior  are  probably  the  consequence 
and  not  the  cause  of  the  inflammation,  being  due  to 
inspissation  of  its  contents;  but  once  formed,  they  no 
doubt  tend  to  excite  and  keep  up  the  recurrent  attacks. 


ENGLISH    AND    ITALIAN    EXCLUSIVENESS. 

English  medical  practitioners  in  Italy  are  bitterly 
complaining  of  an  attempt  that  is  being  made  by  the 
medical  profession  in  that  country  to  prohibit  by  law 
physicians  with  foreign  diplomas  from  practising 
there  without  having  first  obtained  an  Italian  qualifi- 
cation. Americans,  too,  are  interested  in  the  matter, 
and  they  probably  have  more  right  to  complain  of  this 
proposed  treatment  than  the  English.  The  Italians  in 
this  respect  are  but  following  in  the  footsteps  of  most 
of  the  other  nations  of  Europe,  and  perhaps  can  hard- 
ly be  blamed  for  endeavoring  to  protect  the  interests 
of  their  own  medical  men.  The  English  deny  that  a 
man  with  a  foreign  degree  is  not  allowed  to  practise 
in  England,  and  it  is  certainly  true  that  he  can  prac- 
tise there,  but  he  is  so  hampered  by  restrictions  that 
the  leave  to  do  so  is  of  no  use.  Unless  a  foreigner  is 
registered  he  cannot  recover  fees  by  legal  process,  or 
give  medical  evidence  in  courts  of  law,  or  hold  public 
offices,  and,  lastly,  he  may  not  sign  a  death  certificate ; 
so  that  in  reality  these  restrictions  act  as  a  bar  to  his 
practising  at  all. 

From  a  perusal  of  the  British  medical  act  of  1886, 
there  would  seem  to  be  no  especial  difficulty  in  regard 
to  the  registration  of  a  good  foreign  degree.  The 
paragraph  referring  to  foreign  registration  provides 
that  a  person  who  desires  to  be  registered  as  a  foreign 
practitioner  must  prove  to  the  registrar  that  he  holds 
a  recognized  foreign  diploma  granted  in  such  a  for- 
eign country,  and  also  that  he  is  not  a  British  subject, 
or  that  the  diploma  was  not  granted  while  he  was 
domiciled  in  the  United  Kingdom,  or  was  granted  in 
the  course  of  a  period  of  not  less  than  five  years  during 
which  he  was  resident  out  of  the  country,  or  that  he  was 
practising  in  the  United  Kingdom  on  the  said  date 
and  had  been  practising  there  or  elsewhere  for  not 
less  than  ten  years  immediately  preceding.  He  will 
then,  on  the  payment  of  a  fee  not  exceeding  $25,  be 
entitled  to  be  registered  without  further  examination. 
A  recognized  foreign  diploma  is  one  which  is  recog- 
nized for  the  time  being  by  the  General  Medical 
Council  as  furnishing  a  sufficient  guarantee  of  the  pos- 
session of  the  required  knowledge  and  skill  for  effi- 
cient practice.  Although  the  Privy  Council  has  power 
to  override  the  decision  of  the  General  Medical  Coun- 
cil, as  a  matter  of  fact,  the  recognition  of  equivalent 
qualifications  rests  with  the  Medical  Council.  Major 
(ireenwood,  M.D.,  in  an  article  published  in  the  Med- 
ical Magazine  oi  1894,  says  that  the  medici>l  profes- 


sion in  England  is  quite  in  accord  that  it  is  highly 
desirable  that  the  right  to  practise  medicine  there 
should  not  be  granted  to  those  who  possess  only  a  for- 
eign degree.  Foreign  degrees  are  practically  shut  out 
by  refusing  to  allow  them  to  be  registered,  and  this 
action  is  due  to  the  opposition  of  the  corporate  degree- 
granting  bodies.  In  Great  Britain  foreign  degrees  can 
be  registered  only  when  the  applicant  holds  an  Eng- 
lish qualification.  There  is  not  on  the  British  medi- 
cal register  the  name  of  one  man  who  holds  only  a 
foreign  degree.  There  are  few  medical  schools  grant- 
ing degrees  or  qualifications,  even  in  the  colonies  of 
Great  Britain,  which  are  recognized  as  granting  a  right 
to  practise  in  the  United  Kingdom.  Thus  it  would 
seem  that  to  all  intents  and  purposes  Italians  desirous 
of  practising  medicine  in  England  are  prohibited  to  as 
great  an  extent  as  Englishmen  will  be  in  Italy  if  the 
new  proposals  become  law.  The  United  States,  so  far 
as  the  regulations  ruling  the  practice  of  medicine  are 
concerned,  holds  a  different  position  in  regard  to 
Italy  than  England  does,  and  is  deser\'ing  of  better 
treatment  at  her  hands.  Even  in  the  States  in  which 
a  four-years'  course  is  compulsorj',  any  foreigner  pos- 
sessing an  equivalent  diploma  is  allowed  to  present 
himself  for  examination,  and  if  found  competent  is 
granted  a  license  to  practise. 

However,  after  all,  the  question  will  most  probably 
resolve  itself  into  one  of  money.  When  the  pecuniary 
situation  is  grasped  by  the  Italian  mind,  and  it  is 
perceived  that  to  drive  away  English  and  American 
doctors  would  be  to  drive  away  also  English  and 
American  residents  and  tourists,  the  matter  will  pre- 
sent itself  in  a  different  light.  When  the  interests  of 
the  country  at  large  are  seen  to  be  seriously  threatened, 
as  they  certainly  would  be  by  this  change,  more  pru- 
dent counsels  will  prevail  and  affairs  will  be  allowed 
to  remain  in  statu  quo.  The  Lancet,  in  a  short  article 
on  the  subject,  speaks  to  the  point:  "Italy  depends 
too  much  on  British,  American,  and  Anglo-colonial 
gold  to  thwart  the  requirement  of  its  distributors. 
About  one-third  of  her  annual  revenue  is  derived  from 
the  Anglo-American  sources  alone.  To  enact  a  law, 
therefore,  which  would  tend  to  diminish  her  English- 
speaking  population  (resident  or  migrator}')  w-ould  be 
little  short  of  suicidal.  If  it  ever  found  a  place  on 
the  statute  book,  the  government  would  forthwith  be 
besieged  by  the  combined  hotel-keeping  and  '  pension  ' 
interest  clamoring  for  its  immediate  repeal." 


VACCINATION    IN    AFGHANISTAN. 

A  NOTABLE  triumph  has  been  won  in  the  field  of  sci- 
entific progress,  and  this,  too,  by  a  woman.  The 
Ameer  of  Afghanistan,  ruler  of  one  of  the  most  savage 
of  races,  has,  through  the  influence  of  his  private  phy- 
sician. Miss  Hamilton,  M.D.,  become  a  convert  to  a 
belief  in  the  inoculation  theory.  Miss  Hamilton  vis- 
ited England  last  summer  with  the  Ameer's  son,  when 
she  obtained  a  model  for  a  stable  for  calves  which  are 
used  for  the  purpose  of  procuring  calf  lymph.  When 
she  returned  to  Cabul  she  initiated  the  Ameer  into  the 
mystery  of  vaccination.     The  Ameer,  who  has  on  many 


July  24,  1897] 


MEDICAL    RECORD. 


127 


occasions  showed  his  appreciation  of  the  improve- 
ments of  civilization  and  more  particularly  when  they 
have  seemed  likely  to  benefit  his  country,  was  much 
impressed  by  what  he  learned  of  vaccination  as  a  safe- 
guard against  small-pox.  As  Afghanistan  is  visited 
every  year  in  the  springtime  by  an  outbreak  of  small- 
pox in  virulent  form,  it  has  been  decided  to  establish 
vaccine  stations  and  to  endeavor  to  inculcate  in  the 
minds  of  the  warlike  but  uneducated  Afghans  the 
immense  protection  afforded  by  vaccination.  Miss 
Hamilton  is  the  only  European  physician  in  the  coun- 
try, so  that  the  task  of  introducing  vaccination  and 
of  educating  the  inhabitants  to  receive  it  will  be  a 
heavy  one.  If  Miss  Hamilton  succeeds  in  her  en- 
deavor, it  will  be  a  notable  triumph  for  her  individ- 
ually, and  will  also  reflect  credit  on  the  ever-increas- 
ing body  of  women  doctors.  It  is  to  be  hoped  that 
the  antivaccinationists  of  England,  who  are  very  rabid 
at  the  present  time,  when  they  hear  of  the  project  in 
Afghanistan,  will  not  forthwith  dispatch  some  of  their 
loquacious  disciples  to  Afghanistan  and  inaugurate  in 
that  country  a  crusade  against  this  life-presendng 
measure. 


Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
July  17,  1897.  July  12th. — Surgeon  C.  G.  Herndon 
ordered  to  special  duty  at  naval  rendezvous,  Duluth, 
Minn.,  July  19th.  July  i6th.  —  Assistant  Surgeon 
S.  B.  Palmer  detached  from  the  Texas,  and  ordered  to 
the  Annapolis,  July  20th;  Assistant  Surgeon  F.  L. 
Plead  well  detached  from  the  Constellation,  July  17  th, 
and  ordered  to  the  Texas,  }v\y  20th;  Passed  Assistant 
Surgeon  G.  B.  Wilson  ordered  to  the   Constellation. 

Dr.  Frederick  Holme  Wiggin  has  been  appointed  a 
delegate  from  the  New  York  State  Medical  Associa- 
tion to  the  Montreal  meeting  of  the  British  Medical 
Association. 

Obituary  Notes. — Dr.  James  A.  McLochlin,  of  this 
city,  died  at  his  summer  home  in  Saratoga  on  July 
1 6th,  of  renal  trouble.  He  was  forty-eight  years  old 
and  was  a  graduate  of  the  New  York  University  in 
1874.  He  was  a  member  of  both  the  County  Society 
and  the  County  Association.^ — Dr.  Robert  S.  Hub- 
bard, of  Bridgeport,  Conn.,  died  at  his  home  in  that 
city  on  July  i8th.  His  death  was  the  result  of  a  fall 
on  his  office  steps.  He  was  unconscious  when  picked 
up,  and  died  in  a  few  hours  without  recovering  his 
senses.  He  was  a  graduate  of  the  Yale  Medical 
School  in  1851. 

The   Missouri   Medical   League   of   St.  Louis  is 

the  name  of  a  newly  organized  society  of  medical 
practitioners  in  St.  Louis,  modelled  after  the  New 
York  Medical  League.  It  is  stated  in  the  Medical 
Review  that  the  organization  is  the  outcome  of  the 
recent  investigation  of  the  committee  on  clinics  and 
dispensaries  appointed  by  the  St.  Louis  Medical  So- 


ciety, and  has  for  its  object  the  elevation  of  the  medi- 
cal profession  by  influencing  legislation  to  require  a 
higher  standard  of  general  education  before  students 
can  matriculate  at  a  medical  college  and  a  higher 
standard  of  requirements  for  graduation  in  medicine. 
The  suppression  of  free-dispensary  and  clinic  abuses, 
et  id  genus  omne,  the  fostering  of  fraternity  between  the 
members  of  the  medical  profession,  and  the  support 
of  a  movement  to  secure  a  national  department  of 
public  health,  are  also  among  the  aims  of  the  society. 
The  first  meeting  of  the  new  organization  was  held 
on  July  I  St. 

The  Society  of  Neurologists  and  Psychologists  in 
Moscow  has  appointed  a  special  committee  to  report 
upon  the  present  state  of  inebriety  in  that  city,  and  to 
draw  up  a  plan  for  the  erection  of  a  hospital  for  in- 
ebriates. 

The  Health  of  Chicago. — For  the  week  ended  June 
27th,  the  Evening  Post  states,  the  mortality  rate  in 
Chicago  was  10.99,  said  to  be  the  lowest  ever  reported 
for  any  large  city. 

Inspecting  Water  Tanks The  inspectors  of  the 

New  York  City  health  department  have  been  examin- 
ing the  water  tanks  on  the  roofs  of  the  tenement 
houses,  and  have  found  many  of  them  in  a  filthy  con- 
dition. Wherever  they  were  found  to  be  dirty,  the 
owners  of  the  buildings  have  been  forced  to  have 
them  cleaned. 

Safety  at  "  Dead  Man's  Curve."— The  killing  or 
maiming  of  innocent  pedestrians  by  the  cable  cars  at 
Fourteenth  Street  in  this  city  has  now  been  abolished 
by  the  threat  of  the  board  of  health  to  hold  the  officers 
of  the  company  responsible  if  cars  were  run  on  the 
curves  at  a  greater  speed  than  two  miles  an  hour.  As 
soon  as  it  became  a  question  of  personal  safety  to 
themselves,  the  officers  of  the  company  suddenly  dis- 
covered a  grip  by  means  of  which  the  speed  of  the 
cars  could  be  easily  regulated.  Truly,  "  necessity  is 
the  mother  of  invention." 

Small-pox  in  Mexico. — A  dispatch  from  Pueblo  says 
that  black  small-pox  is  epidemic  there,  and  that  many 
deaths  have  occurred. 

A  Possible  Plague  Ship. — A  ship  recently  arrived 
at  San  Francisco  from  India  has  been  quarantined, 
awaiting  a  determination  of  the  nature  of  an  illness 
from  which  one  of  the  crew  had  died  and  two  others 
were  convalescent,  the  health  officers  fearing  from  the 
description  given  that  it  may  have  been  the  bubonic 
plague. 

Collapse  of  a  Nursing-Scheme  in  Canada. — The 
governor-general  of  Canada  and  Lady  Aberdeen  pro- 
posed recently  to  organize  a  "  Victorian  Order  of 
Nurses,"  whose  object  would  be  to  supply  trained 
nurses  to  care  for  the  poor.  The  governor-general, 
with  infinite  tact,  issued  a  pamphlet  in  favor  of  the 
scheme,  in  which  he  remarked  incidentally  that  "  Can- 
ada needed  more  Dr.  MacLures — men  who  were  not  in 
the  profession  for  the  sake  of  the  fees  alone."  Much 
to  the  author's  surprise  and  pain,  this  did  not  serve  to 


128 


MEDICAL    RECORD. 


[July  24,  1897 


recommend  the  project  to  the  men  in  the  profession 
who  were  dependent  for  their  living  upon  their  fees, 
and  they  have  expressed  themselves  so  forcibly  against 
such  a  method  of  commemorating  the  jubilee  that  its 
collapse  is  well-nigh  assured. 

A  Case  of  Misplaced  Confidence. — A  man  was  re- 
cently arrested  here  for  having  perpetrated  a  fraud 
upon  two  eclectic  practitioners  in  this  State.  Accord- 
ing to  The  Sun,  the  doctors  state  that  the  man  had 
some  preparation  which  he  said  would  remove  super- 
fluous hair  without  injury  to  the  skin.  They  believed 
in  his  representations  without  first  trying  the  prepara- 
tion on  hair,  and  got  a  paper  from  him  which  gave 
them  the  exclusive  right  to  sell  the  preparation  in 
their  county.  In  consideration  of  the  privilege,  they 
gave  him  $125  and  bought  a  lot  of  the  preparation. 
They  had  large  quantities  of  advertising  matter  sent 
out,  extolling  the  drug,  and  soon  began  to  treat  pa- 
tients. The  preparation  did  not  remove  hair,  and  they 
say  that  their  reputations  have  been  injured  and  that 
they  are  out  of  pocket. 

The  British  Medical  Association. — Over  two  hun- 
dred members  of  the  association  in  England  have  sig- 
nified their  intention  to  take  part  in  the  Montreal 
meeting. 

The  Right  to  Practise  Dentistry  in   Scotland — 

In  the  case  of  a  man  who  had  been  prosecuted  for  the 
illegal  practice  of  dentistry,  the  appeal  court  of  Scot- 
land has  decided  that  for  a  person  to  put  up  a  brass 
plate  with  the  inscriptions  "American  Dentistry,  A. 
Emslie"  and  "Dental  Office,"  is  not  an  offence 
against  the  dentists  act,  as  it  does  not  necessarily 
imply  that  A.  Emslie  is  qualified  and  registered.  The 
person,  whose  dentistry  may  really  be  as  bad  as  the 
worst  Scotch  instead  of  being  American,  as  his  sign 
would  imply,  has  the  right  therefore  to  continue  his 
practice  without  let  or  hindrance. 

Entertainments  for  the  Members  of  the  Moscow 
Congress. — A  number  of  entertainments  in  honor  of 
those  who  take  part  in  the  international  congress  will 
be  provided  for  after  the  sessions  have  closed.  One 
of  these  is  an  excursion  to  the  health  resorts  in  the 
Caucasus,  during  which  many  of  the  cities  in  south- 
ern Russia  will  be  visited.  The  entire  cost  of  the  trip 
of  ten  days'  or  two  weeks'  duration  will  be  only  about 
$30.  For  those  who  prefer  to  go  to  St.  Petersburg, 
there  will  be  several  receptions  arranged  for  by  the 
.  local  entertainment  committee  under  the  chairmanship 
of  Professor  Pashutin,  president  of  the  Russian  Medi- 
cal Council  and  director  of  the  Army  Medical  Acad- 
emy in  St.  Petersburg.  The  following  entertainments 
have  been  arranged:  On  August  28th  a  reception  by 
the  members  of  the  profession  and  medical  societies 
in  the  Salle  de  Noblesse.  On  the  29th  there  will  be 
an  excursion  to  Peterhof,  with  supper  in  the  park,  at 
the  summer  house  of  Monplaisir,  and,  on  the  same 
evening,  a  "rout"  given  by  the  Princess  of  Oldenburg. 
On  the  30th  the  new  anatomical  museum  in  memory 
of  Pirogof  is  to  be  formally  opened  in  the  morning, 
and  in  the  evening  there  will  be  a  "  rout"  given  by  the 
municipal  authorities.      August  31st  and  September 


ist  are  to  be  given  up  to  an  inspection  of  some  of  the 
medical  and  other  institutions  of  the  city.  A  ladies' 
committee  has  been  formed  in  connection  with  the 
congress,  under  the  presidency  of  Mme.  Sklififosofski, 
the  wife  of  the  president  of  the  organizing  committee. 
Members  who  expect  to  be  accompanied  by  ladies  are 
particularly  requested  to  communicate  the  fact  to  the 
general  secretary.  Professor  Roth. 

The  List  of  the  Scottish  Jubilee  Honors  is  as  long 
as  the  famous  chapter  on  snakes  in  Ireland,  and  those 
who  hoped  to  be  knighted  don't  know  what  to  make 
of  it.  The  British  Medical  Journal  tries  to  console 
the  Scots  by  telling  them  that  the  Queen  loves  them 
and  esteems  them,  and  that  she  will  doubtless  give 
them  at  some  other  time  the  plums  which  it  has  pleased 
her  in  her  wisdom  to  withhold  from  them  on  this 
glorious  occasion. 

Koch's  Report  on  the  Plague The  Berlin  corre- 
spondent of  The  Sun  states  that  Koch  has  made  a  re- 
port giving  the  result  of  his  investigations  into  the 
bubonic  plague  in  India.  He  says  that  the  bacillus 
possesses  but  little  vitality  outside  of  the  bodies  of 
men  and  animals,  and  adds  that  Hafifkine's  serum  pos- 
sesses undoubted  protective  qualities. 

A  Leper  Dead  in  Jersey  City. — A  man  supposed 
to  be  affected  with  leprosy,  whose  case  has  excited 
much  interest  here  and  across  the  river,  died  last  week 
at  his  home  in  Jersey  City.  He  was  a  motorman  on 
a  trolley  road,  and  first  noticed  the  skin  trouble,  which 
was  originally  thought  to  be  eczema,  about  two  years 
ago. 

Casualties  at  the  Jubilee  Celebration.  —  Many 
prophets  of  evil  foretold  a  great  loss  of  life  and  much 
painful  maiming  in  the  crush  of  people  assembled  in 
London  to  view  the  jubilee  procession,  but  their  prog- 
nostications proved  false.  In  spite  of  the  fact  that 
temporary  stands  were  erected  at  all  available  points 
along  the  entire  route,  and  of  the  more  important  fact 
that  they  were  all  filled  to  their  utmost  seating-capac- 
ity, not  one  collapsed.  No  one  of  those  standing 
along  the  line  was  crushed  to  death,  and  most  of  the 
cases  attended  to  by  the  medical  corps,  only  two  hun- 
dred and  one  in  all,  were  of  simple  fainting.  The 
number  of  accident  cases  treated  in  the  hospitals  was 
below  the  average  of  ordinary  days,  owing  doubtless  to 
the  fact  that  wagon  traffic  was  suspended  in  great  part. 

Injury  to  the  German  Emperor. — While  cruising 
on  his  yacht  one  Sunday  recently.  Emperor  William 
of  Germany  was  struck  on  the  head  with  some  swing- 
ing cordage.  The  cable  reports  that  one  of  his  eyes 
was  seriously  injured,  and  that  Duke  Charles  Theo- 
dore of  Bavaria,  an  ophthalmologist,  has  been  sum- 
moned to  Kiel  to  examine  him. 

Professor  von  Kdlliker,  of  Wiirzburg,  the  famous 
histologist,  celebrated,  on  July  6th,  the  completion  of 
his  eightieth  year  and  the  golden  jubilee  of  his  pro- 
fessorship. 

Sir  James  Reid,  physician-in-ordinary  to  Queen 
Victoria,  has  been  created  a  baronet  by  his  grateful 
patient. 


July  24. 


MEDICAL    RECORD. 


129 


Jiociettj  Reports. 

AMERICAX    MEDICAL    ASSOCIATION. 

'Continued  Ir-jm  page  101. > 

SECTION   OX   OBSTETRICS   AND   DISEASES   OF 
WOMEN. 

The  first  day's  session  was  called  to  order  by  the 
chairman.  Dr.  Milo  B.  Ward,  of  Topeka,  Kan.,  who 
delivered  the 

Annual  Address. — The  "healthy  mother"  is  one  of 
the  most  important  subjects  which  can  to-day  engage 
the  attention  of  physicians.  To  the  work  of  Sims  and 
Emmet,  as  pioneers  in  American  g)iiaecolog}-,  was  paid 
a  due  tribute,  and  the  histor}-  of  operations  upon  the 
female  pelvic  organs  in  America  was  passed  in  review 
from  the  earliest  days.  To  American  surgeons  is  due 
to  a  large  degree  the  position  now  held  by  these 
branches  of  medicine.  Gynacolog}"  as  a  specialty  can 
be  said  to  date  only  from  about  1869.  The  first  soci- 
et)-  was  formed  in  that  year  in  Boston.  To-day  ever} 
well-equipped  medical  college  has  a  full  professorship 
of  gynrecology.  Conservatism  should  always  e.xist. 
but  its  limitations  should  be  more  clearly  defined. 
Electricity  for  the  cure  of  fibroids  and  pelvic  e-xudates 
is  attended  by  so  much  harm  at  the  hands  of  tinkers 
and  unqualified  operators  that  it  has  perhaps  luijustly 
fallen  into  disrepute.  The  last  word  on  the  question 
has  not  yet  been  spoken,  but  only  those  fully  qualified 
should  attempt  its  use.  A  higher  standard  of  qualifi- 
cation in  those  who  attempt  operative  treatment  in 
general  of  pelvic  disease  is  called  for.  Many  compli- 
cations still  battle  the  most  expert  operators.  The  use 
of  clamps  instead  of  suture  in  vaginal  hysterectomy 
was  deprecated.  It  is  always  well  to  have  the  best 
clamps  at  hand,  but  it  is  best  not  to  use  them.  Ligat- 
ing  the  arteries  for  the  cure  of  uterine  fibroids  has  not 
yet  been  proven  a  successful  procedure.  A  tribute 
was  paid  to  the  work  of  Philadelphia  obstetricians 
and  g}-na?cologists. 

Uterine  Retroposition. — The  first  paper,  entitled  "  A 
Consideration  of  Some  of  the  Conditions  Influencing 
the  Results  of  the  Surgical  Treatment  of  Uterine  Re- 
troposition," was  read  by  Dr.  Augustus  P.  Clarke,  of 
Cambridge,  Mass.  The  fact  that  various  methods  of 
treatment  for  versions  and  flexions  have  been  devised 
is  suggestive  that  the  application  of  the  means  of  relief 
for  the  presence  of  such  pathological  conditions  has 
been  attended  with  more  or  less  difficult}-.  The  various 
ligaments  sometimes  become  inrtamed,  thickened,  and 
pulpy.  In  such  cases  the  connective  tissue  which 
penetrates  their  structure  becomes  vascular;  this  con- 
dition leads  undoubtedly  to  the  transformation  of  the 
parts.  In  other  instances  the  round  ligaments  under- 
go fatty  degeneration  and  atrophy,  and  become  inca- 
pable thereby  of  sustaining  the  organ  in  its  natur.i! 
position.  The  occurrence  of  these  changes  is  for  the 
most  part  secondary  to  inflammation  of  the  adjacent 
structures.  In  such  cases  the  fundus  will  in  all  prob- 
ability- be  found  firmly  adherent  posteriorly. 

.After  the  lacerated  tissues  of  the  cervix  and  peri- 
neum have  been  repaired,  an  operation  for  shortening 
the  round  ligaments  may  be  undertaken,  should  the 
displacement  backward  still  continue  to  give  rise  to 
marked  uncomfortable  symptoms.  If,  however,  the 
adhesions  cannot  be  overcome  and  there  are  thicken- 
ing of  the  fundus  and  induration  of  the  corporeal  struc- 
tures of  the  uterus,  due  to  metritis  and  peritoneal  in- 
flammation, the  operation  upon  the  ligaments  would 
be  contraindicated.  Sudden  and  severe  strain  put 
upon  the  ligaments,  such  as  may  take  place  in  lifting 
heavy  bodies,  is  alwavs  to  be  avoided  after  the  patient 
has  found  it  necessary-  to  submit  to  treatment  for  uter- 


ine displacement.  Restoration  of  the  perineum  can 
almost  always  be  safely  undertaken,  but,  in  order  to 
have  good  results  by  combining  with  it  the  operation 
of  narrowing  the  posterior  wall  of  the  vagina,  it  will 
be  essential  that  the  uterine  corpus  shall  be  brought 
into  as  nearly  a  normal  condition  as  is  possible. 

Recent  experiences  have  to  a  considerable  e.xtent 
dissipated  the  unfounded  fears  that  the  anteverted 
state  of  the  uterus  produced  by  the  shortening  of  the 
round  ligaments  would  interfere  with  subsequent 
pregnancy  and  parturient  processes.  The  Alexander 
operation  when  resorted  to  in  properly  selected  cases 
is  not  a  mutilation  :  by  it  is  removed  no  organ  nor  any 
structures  that  are  ever  regarded  as  essential  to  the 
normal  function  and  to  the  perfection  of  the  organism. 
The  operation  removes  only  tissue  that  has  become 
excessive  by  crtogenic  processes.  The  danger  that 
hernia  w ill  follow  the  operation  of  shortening  the  round 
ligaments  has  been  felt  to  be  an  objection  to  the  pro- 
cedure. Though  such  a  sequel  sometimes  ensues,  yet, 
if  proper  precaution  be  taken  to  effect  ablation  or  nar- 
rowing of  the  inguinal  canal,  the  risk  will  be  reduced 
to  the  minimum.  When  hernia  does  appear  after  the 
operation,  it  is,  according  to  the  author's  observation, 
mostly  in  those  cases  in  which  the  inguinal  canal  is 
abnormallv  large  and  in  which  the  muscular  element 
in  the  vicinity  has  previously  undergone  atrophy  and 
relaxation. 

Ventrosuspension.  hysterorrhaphy,  vaginal  fixation, 
cystopexy  of  the  uterus,  and  operations  upon  the  utero- 
recto-sacral  supports  are  liable  to  be  unfavorable  as  to 
their  subsequent  influence  on  pregnancy  and  parturi- 
tion. 

In  those  cases  of  retroposition  in  which  it  has  be- 
come necessan,'  to  remove  the  adnexa  on  account  of 
inflammation  or  other  morbid  conditions,  the  piedicles 
can  be  sutured  to  the  jjeritoneum  and  to  the  peritoneal 
fascia  on  each  side  of  the  incision.  Two  small  sutures 
may  then  be  passed  through  the  fundus  to  the  anterior 
wall  of  the  abdomen.  This  method  of  proceeding 
will  firmly  sustain  the  uterus,  and  will  in  most  instances 
prove  sufficient  without  the  necessity  of  resorting  to 
Alexander's  operation.  The  sutures  thus  taken  in 
such  cases  are  rather  compensatory  than  otherwise  for 
the  loss  of  uterine  suppons  resulting  from  the  removal 
of  the  adnexa.  There  is  a  rare  class  of  cases  in  which 
but  little  if  any  perimetric  adhesive  inflammation  oc- 
curs. In  cases  of  this  latter  variety,  as  in  all  others 
of  retroposition,  there  is  a  complication  of  more  or 
less  piolapse  of  the  organ.  Indeed,  it  is  hardly  to  be 
conceived  how  a  retrodisplacement  can  result  without 
the  previous  occurrence  of  some  degree  of  descent  of 
the  uterus. 

In  those  cases  in  which  the  patient  has  reached  the 
menopause  and  in  which  the  backward  displacement 
has  been  attended  with  complete  and  irreducible  pro- 
lapse, hysterectomy  will  prove  the  most  advisable  for 
insuring  permanent  relief. 

Dr.  Hall,  of  Missouri,  thought  too  many  hernias 
result  from  the  Alexander  operation.  The  future 
operation  for  retrodisplacement  is  fixing  the  uterus 
forward  through  the  vagina,  as  described  by  Vineberg. 
This  fixes  it  in  a  more  nearly  normal  position  without 
the  disadvantages  of  the  Alexander  operation. 

Dr.  Humistox,  of  Ohio,  failed  to  find  an  indication 
for  the  Alexander  operation.  A  radical  operation  is 
called  for  if  there  are  diseased  adnexa. 

Dr.  Mas.~ev.  of  Philadelphia,  did  not  believe  that 
inflammation  preceded  the  displacement,  as  a  rule,  but 
followed  it. 

Dr.  Kane  suggested  causing  patients  to  assume  the 
knee-chest  position,  with  calisthenic  exercises.  This 
is  the  next  best  thing  to  having  the  patient  walk  on 
all  fours. 

Dr.  N'ew.mann-,  of  Chicago,  did  not  think  the  round 


I30 


MEDICAL    RECORD. 


[July  24,  1897 


ligaments  have  any  supportive  power,  but  shortening 
them  will  do  something  if  sufficient  support  from 
below  is  furnished. 

'  Dr.  L.\wrence,  of  Columbus,  said  the  symptoms 
from  which  these  patients  suffer  are  not  dependent 
upon  the  displacement  but  upon  the  diseased  adnexa, 
endometritis,  etc. ;  and  here  the  Alexander  operation 
is  not  devoid  of  danger.  Peritonitis  may  follow. 
Ventral  fixation  cannot  be  expected  to  benefit  the  pa- 
tient if  it  is  true  that  anteversions  and  anteflexions  are 
about  as  bad  as  the  posterior.  The  broad  ligament  is 
the  true  supporter,  and  by  shortening  it  we  might  ac- 
complish our  purpose. 

Dr.  Clarke,  in  closing  the  discussion,  said  if  the 
parts  below  have  been  restored,  unless  the  round  liga- 
ments are  diseased,  they  will  be  adequate  to  hold  up 
the  uterus. 

Mechanism  and  Treatment  of  Perineal  Lacera- 
tions was  the  title  of  a  paper  by  Dr.  Joseph  Price,  of 
Philadelphia.  Many  men  say  they  have  never  ruptured 
a  perineum.  Such  a  statement  can  have  but  one  ex- 
planation. More  attention  should  be  directed  to  peri- 
neal lacerations,  and  the  functions  of  the  tissues 
involved  should  be  better  studied.  Attempts  at  repair 
should  be  undertaken  only  after  a  full  apprenticeship 
has  been  served  in  delicate  mechanics.  Nature  de- 
spises blundering  as  she  does  a  vacuum.  Complete- 
ness should  be  the  chief  aim  in  plastic  surgery  of  the 
perineum,  and  the  attempt  made  to  restore  the  parts  to 
as  near  the  normal  as  possible.  Every  perineal  tear 
begins  on  the  inside.  Outside  tears  without  internal 
laceration  are  of  extreme  rarity.  One  should  remember 
always  that  the  skin  may  not  be  lacerated  in  very  exten- 
sive tears.  Complete  tears  include  all  muscle  and  fas- 
cial tissues,  and  should  be  repaired  in  the  line  of  their 
anatomical  construction.  Flap-splitting  operations 
are  misleading  and  fallacious,  superficial  procedures, 
not  going  to  the  real  origin.  An  end-to-end  adapta- 
tion of  the  torn  muscle  must  be  substituted  for  them. 
The  Emmet  operation  is  the  foundation  for  all  opera- 
tions in  deep  tears,  either  with  or  without  involvement 
of  the  sphincter.  The  sphincter  is  a  distinct  anatom- 
ical unit.  When  the  sphincter  ani  is  ruptured,  the 
muscle  is  straightened,  the  depressions  on  either  side 
of  the  anus  being  caused  by  the  retraction  of  the  torn 
ends.  Short  strong  needles  and  good  silver  wire,  a 
needle-holder  without  lock,  a  shot  compressor  and  te- 
naculum are  all  that  is  required.  The  restoration  of 
the  pelvic  floor  is  the  ideal  operation  for  the  exagger- 
ated tears,  as  shown  in  Baker-Brown's  book. 

Dr.  Stone,  of  Washington,  thought  the  Emmet  oper- 
ation was  as  difficult  to  comprehend  as  anything  in 
surgery.  To  make  certain  points  clear  he  drew  dia- 
grams of  the  crown  suture,  as  applied  by  himself.  He 
thought  Emmet  was  seldom  followed  in  his  plan  of 
introducing  all  the  sutures  before  tying  any.  The 
crown  suture  is  applied  from  the  myrtiform  caruncles 
upward  and  inward,  emerging  at  a  corresponding  point 
on  the  opposite  side.     In  tying,  the  vagina  is  shortened. 

Dr.  Price  said  the  end  of  the  muscle  is  the  last  part 
to  be  denuded.  To  do  this  a  tenaculum  must  be 
buried  into  the  muscle  and  repeated  stitches  passed 
deeply.  All  secondary  operations  on  the  perineum 
should  be  obviated  by  immediate  operation  without 
ana-sthetics  at  the  time  the  tear  occurs.  There  is  no 
danger  and  no  difficulty  in  this.  All  operations  fol- 
lowing the  line  of  Emmet's  operation  must  of  necessity 
be  in  the  nature  of  modifications. 

Dr.  MacDonai.d,  of  Albany,  said  that  some  have  to 
continue  doing  a  flap-splitting  operation,  and  this,  too, 
with  satisfaction  to  the  patient.  Here  you  must  first 
undo  the  scar  effect,  following  the  lines  of  scar  and  sep- 
arating the  anterior  from  the  posterior  tissues.  Buried 
fine  catgut  or  Lembert  suture  enables  one  to  restore  the 
rectal  functions  with  resiliency  of  tissue. 


Dr.  East.m.\n  said  the  anal  sphincter  must  be  com- 
pletely dilated  and  put  at  rest  one  week  before  opera- 
tion. No  process  of  sterilization  is  capable  of  cleans- 
ing the  operator's  hands,  so  an  assistant  must  do  all 
dilating  at  the  time  of  operation. 

Dr.  S.  M.  Hay,  of  'J'oronto,  Canada,  being  intro- 
duced to  the  section,  said  he  regretted  there  bad  been 
any  differences  of  opinion  between  Canada  and  the 
United  States  in  regard  to  the  British  Medical  Asso- 
ciation meeting.  Political  difficulties  might  now  and 
then  arise,  but  the  professional  relations  should  always 
remain  pleasant. 

Dr.  Goldspohn,  of  Chicago,  said  that  perineorrha- 
phy proper  must  be  done  from  within  the  vagina; 
hence  the  Lawson  Tait  procedure  should  naturally  be 
condemned.  It  is  not  necessary  to  sacrifice  tissue. 
He  carried  out  Hap  splitting,  but  beginning  within 
the  hymen. 

Dr.  Fisher,  of  Philadelphia,  had  seen  many  flap- 
splitting  operations,  and  they  do  not  stand  the  test  of 
time.  Central  laceration  not  involving  the  sphincter 
does  not  occasion  prolapse.  In  lateral  lacerations  and 
those  involving  the  sphincter,  the  Emmet  operation  is 
required.  The  posterior  wall  is  here  held  up  against 
the  anterior.  The  crest  of  the  rectocele  is  that  point 
which  corresponds  w  ith  the  opening  of  the  urethra  an- 
teriorly. All  do  not  follow  this  rule,  which,  however, 
is  the  first  to  claim  attention. 

Dr.  Humiston  operates  without  general  anaesthesia, 
using  less  than  one  grain  of  cocaine  by  injection,  or 
forty  minims  of  a  two-per-cent.  solution. 

Dr.  Price,  in  closing,  said  silver  acts  as  a  splint  to 
the  tissues,  but  silkworm  suture  does  the  same  to  a 
lesser  degree.  Shouldered  and  shielded  silver  wire 
gives  the  most  valuable  suture.      It  comes  out  dry. 

The  Technique  of  Vaginal  Section,  Irrespective  of 
Hysterectomy,  for  Diseased  Appendages  and  Small 
Pelvic  Tumors  was  the  title  of  the  next  paper,  read 
by  Dr.  A.  Goelet,  of  New  York  (see  p.  122). 

In  the  discussion  Dr.  Howard  Kelly,  of  Baltimore, 
preferred  \aginal  section  in  instances  presenting  re- 
laxed vagina,  and  especially  Edebohls'  method  to 
secure  free  drainage.  Extra-uterine  pregnancy,  when 
pelvic  ha;matocele  is  present,  is  best  treated  by  this 
method.  In  extreme  bleeding  he  advises  proceeding 
with  abdominal  section. 

Dr.  Eastman,  of  Indianapolis,  said  he  would  not 
consent  to  operate  in  the  exaggerated  lithotomy  pos- 
ture, preferring  the  Sims  position  for  all  vaginal  oper- 
ations. 

Dr.  Goelet  said  some  conservative  work  can  be 
well  done  through  the  vagina,  and  infection  from  the 
cervix  is  more  imaginarv  than  real. 

Renal  Suppuration  and  the  Value  of  Micro-Dri- 
nalysis  as  an  Aid  to  Its  Definite  Diagnosis  was  dis- 
cussed in  a  paper  presented  by  Dk.  F.  H.  Manly,  of 
New  York. 

In  the  discussion  Dr.  Duning  said  pyonephrosis 
affecting  one  kidney  alone  is  a  curable  disease.  He 
considered  that  the  discovery  of  pus  coming  from  one 
or  the  other  side  before  it  reached  the  bladder  was  of 
importance.  He  spoke  of  a  case  of  multiple  abscess 
of  the  kidney  with  small  calculi  in  the  abscess  cavi- 
ties. In  one  instance  he  opened  and  drained,  with 
amelioration  of  all  symptoms.  Abscesses  developed 
in  other  points,  and  the  kidney  was  removed.  The 
value  of  bladder  exploration  with  the  cystoscope  and 
head  mirror  was  spoken  of.  The  ureter  can  be  cathe- 
terized,  and  in  this  way  the  side  affected  can  be  made 
out. 

Dr.  Noble,  of  Atlanta,  spoke  of  the  absolute  diag- 
nosis being  made  possible  by  the  catheter  introduced 
into  the  ureter  with  the  aid  of  cystoscopic  examination. 
This  is  of  more  importance  than  examination  of  the 
urine  for  pus. 


July  24,  1897] 


MEDICAL    RECORD. 


131 


Dk.  Manlv,  in  closing,  said  the  catheter  had  a  very 
limited  application  in  male  subjects,  especially  those 
■with  stricture. 

The  Destiny  of  Vaginal  Hysterectomy  for  Ma- 
lignant Disease  was  discussed  in  a  paper  by  Dr.  L. 
C.  H.ALL,  of  Kansas  City,  Mo.  The  discovery  of  can- 
cerous disease  is  often  made  only  after  the  cervix  has 
been  destroyed.  The  author  made  a  strong  plea  for 
early  and  frequent  examination,  so  that  these  cancers 
of  the  uterus  may  be  early  discovered  and  operated 
upon.  Most  cases  when  presented  are  inoperable, 
at  least  by  the  vaginal  route.  We  are  forced  to  admit 
that  the  latter  for  the  majority  of  cases  is  a  doubtful 
expedient.  The  danger  of  invasion  of  other  important 
structures  precludes  the  possibility  of  complete  re- 
moval. The  method  which  permits  of  inspection  must 
become  that  of  election.  The  author  thought  that 
Clark's  method  will  supersede  vaginal  hysterectomy. 

Dr.  f.AXVRiN,  of  New  York,  said  these  patients  usu- 
ally came  to  the  surgeon  so  late  that  vaginal  hysterec- 
tomy was  seldom  justified.  He  had  thus  operated  many 
times  for  cancer.  Women  ought  to  come  at  an  earlier 
stage,  in  which  the  cervix  alone  may  be  affected.  In 
the  majority  of  cases  operation  in  the  early  stage,  while 
the  patient  is  still  free  from  general  systemic  infection, 
offers  the  best  chances  of  cure,  and  in  all  such  an 
operation  can  be  successfully  carried  out.  He  had  re- 
ported statistics  last  year,  showing  that  thirty-three 
per  cent,  of  his  cases  were  still  living.  When  the 
glands  are  involved  in  a  late  stage,  the  disease  is  sure 
to  return. 

Dr.  East.man  advocated  operation  in  desperate  cases 
to  relieve  the  patient  from  the  disagreeable  features  of 
the  progressing  disease  and  to  prolong  life.  It  is  jus- 
tifiable to  operate  even  late  for  the  relief  afforded.  In 
cancer  of  the  fundus  perhaps  better  results  are  to  be 
expected  than  when  the  cervix  is  involved.  We  must 
go  wide  of  the  disease.  The  pedicle  can  be  well  fixed 
within  the  wound,  so  that  any  return  of  the  disease  can 
be  noted. 

Dr.  Dudley,  of  New  York,  said  the  destiny  of  vag- 
inal hysterectomy  for  malignant  disease  depends  sim- 
ply upon  diagnosis.  If  the  uterus  is  free,  vaginal 
hysterectomy  is  a  proper  operation.  If  any  portion 
of  the  vaginal  wall  or  broad  ligament  is  invoUed, 
another  operation  is  called  for — a  combined  method. 
No  one  can  tell  how  far  the  disease  has  gone  when  the 
broad  ligaments  are  involved. 

Dr.  Frederick,  of  Buffalo,  reported  a  case  bearing 
on  the  rapidity  with  which  cancer  progresses.  The 
patient  was  still  alive  and  in  fair  condition  after  seven 
years,  without  operation. 

Dr.  Kelly  thought  that  these  cancers  should  be 
taken  out  by  the  way  of  the  abdomen,  even  removing 
glands  lying  on  the  abdominal  aorta. 

Dr.  Janvri.v  asked  for  statistics. 

Dr.  Kelly  said  the  immediate  mortality  was  greater, 
but  the  ultimate  results  must  be  better.  Every  woman 
over  thirty  years  of  age  should  be  examined  three 
months  after  bearing  a  child,  and  the  condition  noted. 
In  this  way  many  cancers  can  be  discovered  early 
enough  to  give  good  chance  of  success. 

Dr.  Price  said,  in  reply  to  Dr.  Dudley  and  others, 
that  in  going  up  to  a  certain  point  in  operation  was 
good  theoretically,  but  difficult  to  carry  out.  He  pre- 
ferred the  vaginal  route  to  all  others,  excepting  in  the 
complications  on  the  part  of  the  tubes  and  ovaries 
referred  to  by  Dr.  Dudley.  Here  he  preferred  to 
attack  from  above.  Recurrences  in  the  bowels  and 
abdominal  organs  often  cause  horrible  death. 

Dr.  Thompson  spoke  of  the  importance  of  early  and 
e.xact  diagnosis,  not  only  in  cancer  of  the  uterus,  but 
of  the  breast. 

The  Treatment  of  Circumscribed  Pelvic  Hemor- 
rhage was  the  title   of   a   paper  next  read  by  Dk.  M. 


RosENWASSER,  of  Cleveland,  Ohio.  The  causes  are 
numerous;  many  instances  are  due  to  extra-uterine 
pregnancy.  Unless  there  is  absolute  indication  for 
immediate  operation,  rest  under  restriction,  in  hospital 
if  possible,  is  advised.  Instances  from  a  large  num- 
ber of  personal  cases  were  related.  \\'hen  watched, 
over  half  will  recover  if  put  upon  perfect  rest  for  six 
weeks.     The  con  lusions  reached  by  the  reader  were: 

1.  That  unless  they  require  immediate  operation  for 
cause  when  first  seen,  they  can  be  submitted  to  care- 
ful supervision  in  hospital  or  home  without  danger. 

2.  That  when  thus  watched,  more  than  one-half  will 
get  well  without  operation,  by  keeping  them  at  abso- 
lute rest  for  an  average  period  of  six  or  eight  weeks. 

3.  That  when  they  cannot  be  watched,  or  refuse  to 
rest,  early  operation  is  to  be  urgently  recommended. 

4.  That  operation  is  necessary  only  for  special  indi- 
cations, of  which  the  most  important  are  sepsis  with 
or  without  suppuration,  recurrent  hemorrhage,  growth 
of  tumor,  non-absorption  after  reasonable  time,  the 
compression  of   the  pelvic  viscera  (rectum  or  ureters). 

5.  Abdominal  section  is  to  be  preferred  to  vaginal 
incision  in  most  cases. 

Dr.  McMurtry,  of  Louisville,  said  that  as  our 
knowledge  has  increased,  the  matter  has  become  sim- 
plified. Many  terms  for  intrapelvic  hemorrhage 
should  be  dropped.  Almost  all  instances  are  due  to 
ruptured  tubal  pregnancy. 

Dr.  Goelet  could  not  believe  that  pregnancy  was 
nearly  so  often  the  cause  as  claimed.  The  thing  to 
do  is  to  remove  the  clot. 

Dr.  Noble  had  not  seen  hemorrhage  due  to  other 
cause  than  tubal  pregnancy.  He  operates  as  soon  as 
the  diagnosis  is  made,  and  has  lost  no  case  when 
tube  and  clot  were  removed. 

Dr.  Dunn  said  if  the  rupture  occurs  early  it  may 
not  be  necessary  to  remove  the  tube. 

Dr.  Dudley  thought  there  were  other  causes  than 
extra-uterine  pregnancy.  One  of  the  many  causes  is 
the  puncture  of  a  midwife  in  producing  abortion. 
Patients  come  into  the  hospital  septic  after  such  at- 
tempts. Ulceration  attended  with  hemorrhage  at  the 
extremity  of  a  tube  may  account  for  a  clot. 

Dr.  Duff,  of  Pittsburg,  thought  that  in  most  cases 
of  sudden  hemorrhage  it  was  due  to  extra-uterine 
pregnancy.  He  thought  the  danger  of  puncturing  the 
uterus  was  greater  than  is  usually  admitted.  He 
reported  an  instance  of  fatal  puncture. 

Dr.  Cordier  thought  this  paper  might  set  us  back 
ten  years.  He  agreed  as  to  the  cause  of  hemorrhage, 
but  he  was  unable  to  understand  how  the  diagnosis  is 
made  that  the  hemorrhage  is  circumscribed  or  will  re- 
main so.  Most  cases  develop  rupture  before  the  twelfth 
week.  Operation  should  be  done  by  the  abdominal 
route  at  the  time  of  sudden  hemorrhage. 

Dr  Kelly  said  that  when  circumscribed  and  held 
down  :he  patient  with  hemorrhage  could  be  safely  left 
under  rest  and  observation. 

Dr  RosENW.'iSSER  said  this  was  the  third  report  he 
had  made  on  the  subject.  He  had  no  hobby  to  ride, 
but  reported  cases  as  they  occurred.  If  the  truth  can 
"  set  back"  anything,  he  wished  it  set  back. 

Some  Reflex  Disturbances  Due  to  Pelvic  Disease, 
with  Report  of  Cases,  were  discussed  by  Dr.  J.  M. 
Duff,  of  Pittsburg.  The  following  cases  were  re- 
ported : 

Case  I. — Metritis  and  ovaritis,  iusanity.  Yaginal 
hysterectomy,  cure  of  insanity. 

Case  II. — Removal  of  tubes  and  ovaries  for  inflam- 
mation, followed  by  mania  (suicidal)  and  mental  dis- 
ease, lasting  one  year.     Final  recovery. 

Case  III. — Constant  vomiting,  reflex  from  cystic 
ovary.      Removal  of  ovary ;   prompt  cure. 

Case  IV. — Constant  vomiting;  patient  nourished 
for  eighteen  weeks  by  enemata.     Removal  of  pus  tubes, 


132 


MEDICAL    RECORD. 


[July  24,  1897 


followed  by  cessation   of   vomiting  and  cure   of   pa- 
tient. 

C.\SE  V. — Sciatica  of  two  years'  standing,  patient 
unable  to  walk.  Cured  promptly  by  removal  of  dis- 
eased tube  and  ovary  on  the  same  side. 

C.^sE  VI. — Epileptoid  seizures  continuing  for  eight 
years.  Insomnia  and  general  neurotic  condition, 
probably  cured  by  removal  of  the  uterus  and  appen- 
dages. Time  since  operation  too  short  to  draw  jrosi- 
tive  conclusions. 

Dr.  Kelly  said  the  paper  well  illustrated  the  fact 
that  in  treatment  the  pelvic  organs  cannot  be  separated 
from  the  whole  system. 

Dr.  Tuttle  said  we  must  establish  an  increased 
nutrition  of  the  nerve  centres  in  these  cases  by  rest, 
over-feeding  at  regular  intervals,  and  regulation  of  the 
functions,  with  increased  secretion. 

Dr.  Goi.dspohn  spoke  of  relieving  severe  sciatica 
by  removing  the  appendages. 

Dr.  Dukf  related  an  instance  of  epileptoid  seizure 
before  and  after  operation,  in  which  the  post-mortem 
revealed  cerebral  tumors,  explaining  the  failure  of  the 
pelvic  operation  to  gi\e  relief. 

The  Midwife  Question  in  America  was  discussed 
in  a  paper  by  Dr.  C.  S.  B.\con,  of  Chicago,  111. 

Dr.  Duff  thought  clandestine  midwives  should  be 
compelled  to  leave  the  field.  To  accomplish  this, 
legitimate  midwives  should  be  licensed,  and  they 
would  soon  drive  out  the  wrongdoers. 

Dr.  Baldwin,  of  Columbus,  thought  there  was  a 
place  in  this  country  for  the  educated  midwife.  The 
physician  could  not  afford  to  give  the  time  to  the  proper 
treatment  of  prolonged  obstetric  cases.  In  the  Co- 
lumbus school  an  attempt  had  been  made  to  establish 
a  midwifery  school,  but  it  had  not  succeeded.  We 
must  look  to  legislation  backed  by  public  sentiment. 

Dr.  Burxs  thought  that  in  large  cities  the  dispen- 
sary would  solve  the  problem  and  make  the  midwife 
soon  a  thing  of  the  past. 

Dr.  New.\l\nn  thought  Chicago  was  indebted  to  Dr. 
Bacon  for  the  work  he  has  done  in  this  line.  Many 
districts  are  not  reached  by  the  dispensary,  the  lady 
physician,  or  the  trained  nurse,  and  we  must  come  to 
depend  upon  the  midwife,  who  should  be  under  careful 
supervision.  Dr.  Bacon  thought  it  unwise  to  make 
paupers  of  the  class  who  now  employ  midwives.  There 
are  too  many  paupers  already.  Four-fifths  of  obstetric 
case,s  are  now  attended  by  midwives. 

New  Advances  in  the  Treatment  of  Fibroid 
Uteri,  a  paper  by  Dr.  How.^rd  .\.  Kellv,  of  Baltimore, 
was  next  read.  He  predicted  that  the  ne.xt  great  wave 
of  advance  would  be  in  the  line  of  conservatism.  He 
advocated  conservative  treatment  of  myomatous  uteri. 
He  would  excise  any  number  of  mvomata  and  sew  up 
the  incisions.  This  in  large  uteri  is  more  difficult 
than  to  remove  the  whole  uterus.  If  the  patient's 
condition  is  good,  and  an  operation  lasts  but  fifty  min- 
utes, and  the  patient  is  under  thirty-seven  years  of 
age,  myomectomy  should  be  done.  .\  free  incision  is 
made,  the  uterus  is  lifted  out,  and  the  tumors  are  then 
excised.  .\  uterus  thus  treated  is  somewhat  analogous 
to  a  Ca;sarean  uterus  with  multiple  wounds.  The 
speaker  said  he  had  made  as  many  as  nine  incisions. 
The  cavity  is  usually  not  opened,  but  he  has  opened  it 
from  end  to  end.  In  one  case  the  entire  anterior  wall 
of  the  uterus  was  removed,  leaving  only  the  mucous  sur- 
face of  the  posterior  wall.  This  operation  conserves  a 
natural  function  which  is  a  distinctive  attribute  of  sex. 
Vaginal  Section  in  Extra-Uterine  Pregnancy.  —  Dr. 
Lf.wis  SiiidOLKR,  of  Des  Moines.  Iowa,  read  the  paper. 
By  tills  is  meant  an  ample  enough  opening  for  the  ex- 
traction of  foetal  membranes.  To-day,  contrary  to  what 
was  taught  in  former  times,  the  diagnosis  of  extra- 
uterine pregnancy  can  be  made  with  accuracy.  The 
writer  did  not  believe  that  hernias  are  so  frequent  in 


the  vaginal  as  in  the  abdominal  method.  If  after  a 
lapse  of  time  the  vaginal  operation  is  found  to  relieve 
a  large  percentage  of  cases,  it  will  have  a  place; 
otherwise  it  will  become  a  forgotten  method. 

Dr.  Ro.senwasser  said  that,  while  free  to  operate,  he 
did  not  think,  as  Drs.  J.  and  M.  Price  did,  diat  every 
case  of  extra-uterine  pregnancy  should  be  operated 
upon.     Many  patients  get  well. 

Dr.  Duff  said  his  experience  justified  him  in  sav- 
ing that  every  case  should  be  operated  upon.  He  had 
seen  patients  perish  who  refused  operation.  We  can- 
not always  determine  which  are  the  safe  cases  to  leave. 
We  should  always  be  ready  to  do  transfusion  with  the 
normal  salt  solution  by  the  direct  method. 

Dr.  Schodler  said  few  cases  could  be  operated 
upon  successfully  through  the  vagina. 

Dr.  M.  Price  said  we  must  not  only  operate,  but 
operate  at  once  without  a  moment's  delay,  by  the  upper 
route  in  preference. 

Extra-Uterine  Pregnancy,  with  Report  of  Cases, 
was  a  paper  by  Dr.  M.  Price,  of  Philadelphia.  A 
series  of  cases  was  related,  showing  the  results  of 
operation.  The  urgent  indication  is  the  immediate 
stoppage  of  hemorrhage;  the  only  way  to  do  this  is  to 
open  the  abdomen  and  tie  the  vessels,  no  matter  in  what 
condition  the  woman  may  he,  so  long  as  she  is  not  dead. 

The  Vaginal  Route  in  Operation  for  Ruptured 
Tubal  Pregnancy  was  the  title  of  a  paper  by  Dr.  J. 
Wesley  Bi)vf;e.  of  Washington,  D.  C,  in  which  he 
stated  that  many  cases  of  rupured  tubal  pregnancy 
probably  escape  attention,  owing  to  the  slight  dis- 
comfort of  the  patient  or  to  improper  diagnosis 
being  made  and  procrastination  permitting  nature  to 
cure  the  condition.  This  class,  however,  he  thought 
is  a  ver)'  small  minority,  else  more  of  such  cases 
would  be  found  as  a  complication  when  abdominal 
section  is  made.  He  claimed  that  many  cases  that 
are  treated  are  slight  and  not  ver)-  dangerous  in  them- 
selves. These  cases  can  in  many  instances  be  treated 
by  operation  through  the  vagina,  and  to  substantiate 
his  claims  he  referred  to  the  work  of  Kelly,  Miller,  and 
others  and  reported  six  successful  cases  of  his  own 
treated  in  this  manner.  His  conclusions  were:  i,  that 
the  vaginal  route  is  preferable  for  operation  for  rup- 
tured tubal  pregnancy  when  the  hemorrhage  has  ceased 
or  is  slow,  when  the  escaped  blood  is  limited  to  the  pel- 
vic excavation,  and  especially  if  a  limiting  diaphragm 
has  formed  above  it :  2,  that  the  vaginal  route  is  freer  of 
shock,  is  less  liable  to  permit  infection,  and  furnishes 
better  drainage;  3,  that  there  is  less  liabilit)-  to  re- 
moval of  adnexa  than  when  the  abdomen  is  opened; 
4,  that  tiie  period  of  convalescence  is  shorter  and 
devoid  of  the  usual  complications  of  abdominal  section. 

Injuries  of  Parturition ;  the  Time,  Methods, 
and  Reason  for  Repair Dr.  .\.  H.  TrTTLE.  of  Cam- 
bridge, Mass.,  was  the  author.  The  paper  was  intro- 
duced with  the  report  of  a  case  of  severe  laceration 
repaired  one  week  after  the  accident.  The  writer 
pointed  out  the  fact  that  many  obstetricians  neglect 
to  make  a  careful  examination  of  their  patient  at  the 
close  of  labor,  and  that  unless  this  is  done  in  good 
light,  turning  the  vagina  out  and  inspecting  the  cervix 
and  deepest  portions  of  the  vagina,  it  is  impossible 
for  them  to  form  any  idea  whatever  of  the  extent  of  the 
injuries.  He  went  on  to  describe  the  various  lesions, 
and  pointed  out  with  emphasis  that  the  subperitoneal 
space  is  frequently  opened  by  a  tear  through  the  cer- 
vix that  passes  beyond  its  junction  with  the  vagina, 
and  also  by  a  direct  tear  of  the  vagina  in  its  deepest 
portions,  at  the  sides  and  vault,  entirely  distinct  from 
the  tears  extending  from  the  perineal  body  up  the 
lateral  sulci,  and  which  in  extreme  cases  extends  the 
full  length  of  the  vagina  along  the  sides,  parallel  to 
the  urethra  and  terminating  in  the  tissues  that  form 
the  prepuce  of  the  clitoris. 


July  24,  1897] 


MEDICAL    RFXORD. 


^33 


He  claimed  that  if  both  of  these  tears  are  not  sat- 
isfactorily repaired  at  the  time  of  injury,  healing  will 
occur  by  secondary  intention,  a' mild  or  severe  infec- 
tion follows,  and  the  patient  after  a  protracted  con- 
valescence is  left  with  a  uterus  fixed  high  and  the 
ovaries  bound  down  by  adhesions.  The  path  of  in- 
fection is  direct  and  not  by  the  way  of  or  neces- 
sarily involving  the  uterus.  He  recommended  the 
primary  repair  of  all  lesions  of  parturition,  this  to  be 
done  in  the  same  careful  manner  as  is  ordinarily  ex- 
ercised in  a  secondary  operation,  with  the  patient  on 
a  table,  plenty  of  assistance,  and  strict  antiseptic  and 
aseptic  measures.  If  the  accident  occurs  at  night  and 
assistance  is  not  at  hand,  the  patient  should  be  given 
ergot,  the  blood  squeezed  out  of  the  uterus,  and  an 
aseptic  pad  applied.  The  case  can  then  be  left  for  from 
ten  to  twent)'-four  hours  to  suit  the  convenience  of  the 
attendants.  He  claimed  that  repair  can  be  done  as 
easily  at  the  end  of  ten  hours  as  at  the  end  of  the  first, 
if  the  raw  surfaces  are  slightly  scraped  with  a  knife 
or -sharp  curette,  and  that  the  cervix,  owing  to  the  re- 
traction of  the  uterus,  can  be  treated  much  more  easily. 
He  employs  animal  sutures  in  the  repair  of  the  parts. 
The  lacerations  of  the  rectum,  skin,  and  mucous  mem- 
branes are  closed  with  buried  sutures,  a  fine  strand 
being  used  for  each,  and  the  torn  edges  of  the  muscles 
are  brought  back  into  exact  apposition  and  in  tlie  same 
position  they  occupied  before  the  accident  by  tigure- 
of -eight  suturing  and  a  number  of  superficial  layers. 
In  closing  the  rectal  and  vaginal  tears  the  necessity 
of  starting  the  suture  high  enough  to  close  tightly  the 
upper  angles  was  carefully  pointed  out. 

The  results  of  the  operations  were  almost  uniformly 
perfect.  In  one  case  the  stiches  gave  way,  but  the 
wound  was  opened  up,  cleaned,  and  repaired  again,  a 
few  days  after  the  first  operation,  and  healed  by  pri- 
mary union.  In  three  cases  stitch  abscess  formed, 
opened  outward  or  into  the  vagina,  and  healed  sponta- 
neously, leaving  a  very  satisfactory  perineum.  In  his 
conclusions  Dr.  Tuttle  said  that  in  the  lives  of  many 
women  there  is  no  time  more  opportune  for  the  repair 
of  the  parts  than  that  occupied  for  her  convalescence 
from  labor,  and  that  a  perfect  operation  will  shorten 
this  period;  that  the  public  should  be  instructed  in  tiie 
fact  that  injuries  during  parturition  are  unavoidable 
and  cast  a  reflection  on  the  obstetrician  only  when  their 
careful  repair  is  neglected ;  that  the  best  way  to  avoid 
a  suit  for  malpractice  for  these  injuries  is  to  call  in 
assistants  who  act  as  witnesses,  and  to  repair  or  offer 
to  repair  the  parts;  that  old  tears  may  be  repaired 
at  the  same  time ;  that  the  obstetrician  should  be 
better  educated  in  the  repair  of  these  injuries;  that 
a  satisfactory  repair  of  the  injuries  at  the  time  of 
their  occurrence  is  the  best  way  to  prevent  a  major- 
ity of  the  ills  of  women  which  arise  from  disease  of 
the  pelvic  organs. 

Dr.  Duff  said  lacerations  are  much  more  frequent 
than  is  usually  believed.  The  profession  is  blamed 
for  laceration  because  of  the  popular  and  occasional 
professional  ignorance  of  this  frequency;  some  look 
upon  the  intact  external  skin  as  an  evidence  that  there 
is  no  laceration.  No  one  thing  so  indicates  the  dif- 
erence  between  the  general  and  special  practitioner 
as  this  failure  to  discover  a  tear  in  the  presence  of 
intact  skin.  We  must  be  honest  with  one  another 
and  acknowledge  these  failures. 

Dk.  Hall  said  he  believed  in  making  repair  as 
soon  as  one  can  get  the  instruments  sterilized  and 
dressings  ready.  There  should  not  be  too  much  trim- 
ming of  tissues. 

Dr.  .Allen  preferred  to  wait  until  the  second  or 
fourth  day.  He  thought  there  was  no  more  danger  of 
sepsis  and  indeed  less. 

Dr.  FrsHER  believed  laceration  of  the  pelvic  floor 
extremely  frequent.     That  of  the  perineum  is  usually 


insignificant;  without  involvement  of  muscle,  it  is 
an  external  wound  easily  repaired.  He  prefers  the 
interruptured  suture,  and  operates  without  anaesthesia. 
As  an  antiseptic  eucaine  is  employed. 

Dk.  Da  Costa  said  that  tears  in  the  perineum 
proper  occur  in  thirty  per  cent,  of  cases;  many  do 
not  need  attention.  Physicians  fortunate  enough  to 
have  had  no  tears  to  report  may  be  incapable  of 
recognizing  them.  As  soon  as  the  placenta  is  de- 
livered, he  would  cleanse  and  approximate  at  once 
with  suture  without  trimming  the  parts;  the  latter  fall 
into  place  in  the  healing.  Failure  is  rare.  Serrefines 
will  answer  for  moderate  cases. 

Fibroid  Tumor  of  the  Vagina,  with  the  Report 
of  a  Case,  was  the  paper  by  Dr.  J.  M.  Em.mert,  of 
Atlantic,  Iowa.  The  paper  was  based  upon  an  inves- 
tigation of  the  subject  by  a  circular  letter  sent  out  to 
a  large  number  of  operators,  and  upon  the  author's 
personal  experience.  Twelve  published  and  twelve 
unpublished  cases  were  reported.  Out  of  sixteen  pa- 
tients, ten  were  over  thirty  and  under  forty  years  of 
age.  The  attachment  was  reported  as  being:  in  ten  in 
in  the  anterior,  in  five  in  the  posterior,  in  two  in  the 
lateral  walls.  The  history  and  subsequent  histologic 
examination  proved  the  author's  case  to  have  been  one 
of  fibroid.  The  tumor  was  enucleated  by  incising 
about  the  base  and  peeling  out  the  tumor.  In  the 
investigation  five  or  six  cases  were  excluded  from  the 
literature  as  doubtful. 

One  Hundred  Cases  of  Atresia  and  Stenosis 
Vaginalis  in  Labor,  with  Thirteen  Fatal  Cases,  was 
the  title  of  a  paper  by  Dr.  J.  J.  E.  Maker,  of  New 
York.  The  oldest  case  in  literature  is  that  observed 
by  Louis,  one  hundred  years  ago.  The  conclusions 
drawn  from  all  cases  and  especially  the  fatal  ones  are: 

1.  That  from  seventy  to  eighty  per  cent  of  all  these 
obstructions  being  found  in  the  middle  third  or  at  the 
orifice  of  the  vagina,  a  predisposing  condition  may  be 
discovered  in  an  increase  of  the  muscular  tonus  at 
these  points. 

2.  That  the  size  of  the  opening  does  not  necessarily 
jeopardize  the  result,  inasmuch  as  none  of  the  complete 
atresia  cases  proved  fatal,  and  among  the  fatal  cases 
four  had  openings  large  enough  for  the  finger  to  pass. 

3.  That  the  resistance  can  be  overcome  in  every 
case  is  evidenced  by  the  fact  that  only  two  of  the  ten 
cases  termed  cartilaginous  proved  fatal. 

4.  That  the  thickness,  which  in  fifteen  cases  was 
stated  as  varying  from  twenty  millimetres  to  that  of 
the  entire  length  of  the  vagina,  is  not  an  insuperable 
barrier,  for  only  two  of  such  dimensions  were  fatal. 
Of  the  other  two  mentioned  with  a  fatal  issue,  one 
gave  a  measurement  of  twelve  millimetres  and  the 
other  was  characterized  as  thin. 

5.  That  there  is  practically  no  difference  in  the 
character  of  the  stricture,  the  site,  location  of  open- 
ing, central  or  not,  resistance  or  thickness,  between 
the  congenital  or  post-partum  cases,  which  amounted 
to  eighty-seven  per  cent,  of  tlie  whole. 

6.  That  the  complication  should  not  necessarily 
have  been  fatal  except  possibly  in  two  cases,  one  of 
contracted  pelvis  with  shoulder  presentation,  and  one 
of  twin  pregnancy. 

7.  That  the  various  methods  of  treatment  applied 
both  to  the  obstruction  and  to  the  delivery  do  not  make 
a  bad  showing  when  it  is  remembered  that  many  of 
these  subjects  were  in  labor  for  days  before  inter- 
ference was  attempted  or  allowed. 

8.  A  grave  error  is  a  misconceived  idea  of  the 
powers  of  nature.  The  author  has  met  with  three 
cases  of  atresia  and  stenosis.  There  was  in  all  an  in- 
flammatory condition  of  the  vaginal  mucosa  behind 
the  barrier. 

Studies  in  Gynaecology  from  the  Service  of  the 
Woman's  Hospital  of  Philadelphia. — Dr.  Ax.na  M. 


134 


MEDICAL    RECORD. 


[July  24,  1897 


FuLLERTON,  of  Philadelphia,  read  the  paper.  She 
said  that  whenever  she  was  able  to  reach  a  woman's 
understanding  and  secure  her  co-operation  little  diffi- 
culty was  experienced  in  carrying  out  suitable  meas- 
ures. Education  in  physiological  laws  was  called 
for.  .\s  conservers  of  woman's  health  physicians 
should  influence  the  education  of  young  men.  Women 
should  be  taught  the  virtue  and  the  dignity  of  true 
wifehood  and  motherhood  as  controlled  by  physiologi- 
cal laws. 

Dr.  Kelly  said  that  doctors  are  too  apt  to  pass 
over  slight  symptoms  in  their  female  patients,  and 
neglect  leucorrhoeas  and  complaints  which  if  properly 
managed  would  not  result  in  more  serious  troubles. 
In  obstetrics  more  cleanly  attention  should  be  paid 
the  patient.  The  obstetric  binder  had  better  be 
thrown  aside.  Personal  cleanliness  is  emphasized 
by  the  physician  wearing  a  white  duck  suit  in  the 
lying-in  room.  The  scrubbing  brush  for  the  nails 
should  be  quite  stiff.  Less  liceose  should  be  given 
men  in  morality. 

The  Chair.man  asked  Dr.  Fullerton  her  opinion  of 
the  effect  of  the  bicycle. 

Dr.  Fullerton  answered  that  in  the  absence  of 
pelvic  disease  it  tends  to  increase  the  muscular  de- 
velopment and  does  good.  After  exercise  has  de- 
veloped the  muscles,  walking  can  be  indulged  in 
better  than  before.  There  are  no  bladder  troubles 
arising  from  the  use  of  the  wheel,  if  the  saddle  is  all 
right.  The  corset  should  not  be  worn  by  women  in 
riding. 

The  Technique  of  Abdominal  Hysterectomy  was 
the  subject  of  a  paper  read  by  Dr.  J.  F.  Baldwi.x,  of 
Columbus,  Ohio.  His  method  may  be  described  in 
brief  as  follows: 

Seizure  of  the  broad  ligament  with  a  long  clamp 
from  just  beyond  the  ovary  to  the  body  of  the  uterus, 
above  the  uterine  arterj-;  clamping  the  ovarian  ar- 
tery near  the  uterus;  severing  the  broad  ligament 
along  the  clamp  first  applied;  making  a  peritoneal 
flap  anteriorly  and  posteriorly  between  the  tips  of  the 
two  lateral  clamps;  separating  the  folds  of  the  broad 
ligament  between  the  point  of  the  clamp  and  the 
uterus,  and  seizing  the  uterine  arter}*;  removing  the 
body  of  the  uterus  at  or  below  the  internal  os,  making 
anterior  and  posterior  flaps.  The  uterine  artery  is  iso- 
lated from  surrounding  tissue  and  tied  as  far  back  as 
possible  with  fine  silk  or  kangaroo  tendon;  the  round 
ligament  caught  with  forceps  and  the  long  clamp  re- 
moved from  the  broad  ligament;  the  ovarian  arter}- 
brought  out  between  the  folds  of  the  broad  ligament 
and  ligated  with  fine  silk  or  catgut;  a  gauze  drain 
passed  through  the  cer\-ix  from  above  into  the  vagina, 
so  as  mechanically  to  clean  and  dilate  the  cervix: 
with  kangaroo  tendon  the  uterine  flaps  are  next 
brought  together,  the  round  ligament  on  each  side 
being  brought  down  and  sutured  between  the  flaps; 
the  peritoneal  layers  of  the  broad  ligament  are  next 
infolded  and  united  by  a  running  suture  of  kangaroo 
tendon,  which  passes  down  to  the  cervix,  uniting  the 
infolded  peritoneal  flaps  over  the  suture  already  in- 
serted in  the  cervical  tissue,  and  then  up  on  the  oppo- 
site side.  .As  thus  completed  the  pelvic  floor  is  en- 
tirely smooth,  with  no  projecting  points  of  raw  surface. 

The  points  of  novelty  claimed  for  this  technique  are 
in  the  bringing  in  of  the  round  ligaments  and  the 
snug  drawing  in  of  the  broad  ligaments  so  as  to  sup- 
port the  cer\^ical  plug,  which  thus  sustains  the  vault 
of  the  vagina.  The  advantages  of  this  method  of 
operating  are :  (1)  Such  a  shutting  off  of  the  vagina 
as  to  reduce  to  a  minimum  danger  of  infection  from 
that  source.  {z)  The  ligature  placed  around  the 
uterine  artery  is  entirely  outside  of  the  uterine  wound, 
and  being  buried  in  the  tissues  is  much  less  likely  to 
give   any  trouble.      (3)  The  snug  closing  of  the  cer- 


vical tissue  prevents  oozing.  (4)  The  smooth  perito- 
neum in  the  floor  of  the  pelvis,  having  no  projecting 
stumps  or  raw  surfaces,  reduces  to  an  absolute  mini- 
mum the  danger  of  intestinal  adhesions.  (5;  The  im- 
plantation of  the  round  ligaments  and  the  puckering  in 
of  the  broad  ligaments  prevent  prolapse  of  the  cervical 
stump  and  vagina.  (6)  The  use  of  the  clamps  on  the 
broad  ligaments  obviates  hemorrhage,  leaves  the  parts 
in  better  shape  for  the  subsequent  steps  of  the  opera- 
tion, and  saves  considerable  time. 

The  paper  was  based  on  a  study  of  ninety-five  opera- 
tions, with  a  mortality  of  5.26  per  cent. 

(Ttj  be  Continued.) 


MEDICAL    AND    CHIRURGICAL    FACULTY 
OF   THE   STATE   OF    MARYLAND. 

Niru'ty-JVint/i  Annual    Session,   Held   at    the    Hall  of 
the  Faculty,  April  27,  28,  29,  anil  JO,  iSgj. 

Tuesday,  April  2Jth — First  Day. 

President's  Addresss. — Dr.  William  Osler  de- 
livered the  president's  address  on  "  Functions  of  the 
State  Faculty.''  He  spoke  of  the  old  age  of  this 
society  and  the  fact  that  only  one  other  organization 
had  a  similar  name.  The  need  of  medical  societies  is 
very  evident  with  physicians,  as  a  rule  living  so 
much  to  themselves,  and  they  tend  to  rub  off  corners 
and  widen  personal  interest.  As  this  is  the  day  of 
consolidation,  the  speaker  suggested  that  it  would  be 
well  if  all  the  local  societies  would  consolidate  with 
the  State  Facult}-  as  sections,  just  as  has  been  done  in 
the  New  York  Academy  of  Medicine.  The  library  of 
the  faculty  is  growing  each  year  and  is  of  great  value 
to  the  members.  The  man  who  does  not  read  books 
and  journals  does  not  keep  up  with  the  times. 
Soon  the  Faculty  will  celebrate  its  one  hundredth 
anniversar}-,  and  on  this  occasion  opportunity  should 
be  taken  to  endow  the  faculty-  and  make  it  a  powerful 
body  in  the  State. 

The  Care  of  the  Dependent  Insane  in  Mary- 
land.— This  discussion  was  opened  by  Dr.  E.  N. 
Brush,  who  was  followed  by  Dr.  Henry  H.  Hurd. 
of  the  Johns  Hopkins  Hospital.  The  speakers  em- 
phasized the  fact  that  the  insane  were  the  children 
of  the  State  and  should  be  taken  care  of  by  the 
State.  The  insane  should  not  be  cared  for  in  alms- 
houses, where  the  number  of  attendants  is  small  and 
the  conditions  are  not  favorable  for  recover)',  but  in  a 
special  hospital  for  their  treatment.  The  lunacy 
commission  of  Maryland  does  the  ver}-  best  it  can. 
probably,  with  the  laws  which  are  on  the  statute  book, 
but  the  laws  are  very  defective  and  vague,  and 
throughout  the  smaller  towns  and  counties  of  the 
State  the  physicians  for  the  insane,  being  appointed 
politically,  take  very  little  interest  in  their  work.  The 
papers  of  commitment  are  often  faulty ;  the  statistics 
of  insanity  in  Maryland  also  are  not  reliable,  and  it 
is  not  likely  that  any  one  knows  how  many  insane 
persons  there  are.  Many  could  recover  under  proper 
treatment,  and  they  require  more  than  good  food  and 
clothing. 

In  answer  to  these  statements.  Dr.  William  Lee, 
the  secretary  of  the  lunacy  commission,  said  that  since 
the  organization  of  this  commission  in  1886  there  had 
been  a  gradual  improvement  in  the  care  of  the  depen- 
dent insane  and  that  this  had  gone  on  from  year  to 
year;  that  while  there  might  be  some  objections  as 
compared  with  States  much  wealthier  than  Maryland, 
and  the  insane  might  be  made  more  comfortable  under 
other  conditions,  still  the  commission  has  done  its 
very  best  under  the  e.xisting  laws. 


July  24.  1897] 


MEDICAL    RECORD. 


135 


Dr.  Rohe  also  spoke  on  the  same  general  subject, 
and  said  that  in  his  opinion  the  insane  were  better 
cared  for  than  they  were  formerly. 

Peritonitis This  was  a  special  subject  for  dis- 
cussion at  this  session.  Dr.  Simon  Flexxer  spoke 
of  the  pathology  and  etiolog}-.  This  is  a  very  large 
subject  and  the  manner  of  approaching  it  is  difficult. 
The  peritoneum  is  able  to  resist  a  great  deal  and  it 
can  dispose  of  foreign  substances  up  to  a  certain  limit. 
Xot  all  parts  of  it  earn,-  on  absorption,  but  only  a 
limited  portion,  that  near  the  central  tendon  of  the  dia- 
phragm. Stomata  between  the  endothelial  cells  do 
not  exist,  but  fluids  may  pass  through,  and  even  solids 
sometimes  escaf)e :  they  are  carried  through  by  cells. 
Some  substances  interfere  with  this  power  of  absorp- 
tion, but  quite  an  amount  can  be  absorbed,  and  even 
bacterial  organisms  can  be  destroyed  as  long  as 
the  peritoneum  is  intact.  At  the  Johns  Hopkins 
Hospital  he  had  records  of  one  hundred  and  ten  cases 
of  acute  peritonitis  in  man,  with  the  bacteriological 
examination,  and  these  cases  were  divided  into  certain 
groups.  We  must  admit,  first  of  all,  an  idiopathic  or 
primar)-  peritonitis.  Twelve  idiopathic  cases  were  in 
this  number.  In  all  these  cases  there  were  pre-exist- 
ing conditions  predisposing  to  this  peritonitis,  such  as 
chronic  heart  disease,  chronic  kidney  disease,  etc. 
Persons  subject  to  chronic  diseases  are  more  liable  to 
bacterial  infection.  In  several  cases  the  perito- 
neum was  one  of  several  serous  surfaces  involved  in 
the  body.  There  were  thirty-three  cases  of  exogenous 
peritonitis,  in  which  the  invasion  was  from  without,  and 
in  those  cases  laparotomy  had  been  performed  and  cer- 
tain other  operations  had  been  done.  Finally  there  is 
an  endogenous  form,  in  which  the  infection  is  from 
within;  it  is  an  intestinal  form.  Fifty  out  of  one 
hundred  and  ten  cases  which  he  found  recorded  were 
in  the  intestinal  tract,  from  a  perforated  appendix  or 
some  such  cause.  In  studying  the  bacteriology  of 
these  cases  it  is  interesting  to  note  that  in  the  first 
group  the  staphylococcus  aureus  and  the  streptococcus 
are  present  as  mono-infections.  In  the  second  group 
there  are  some  mono-infections  and  many  poly-infec- 
tions, such  as  by  the  staphylococcus,  the  streptococcus. 
and  the  colon  bacillus,  etc.  In  the  third  group  infection 
usually  comes  from  some  injury  to  the  intestines:  there 
is  a  poly-infection,  such  as  by  the  streptococcus  and  the 
colon  bacillus  together.  Septic  peritonitis  and  sup- 
purative peritonitis  are  terms  used  as  if  they  desig- 
nated distinct  conditions.  Peritonitis  in  the  absence 
of  the  micro-organism  is  ver)'  rare  indeed,  but  it  may 
occur.  The  fibrinopurulent  form  is  the  one  more  usu- 
ally met  with.  The  mycotic  form  is  one  in  which  the 
symptoms  run  such  a  rapid  course  that  there  is  little 
time  for  the  formation  of  bacteria  and  there  is  ver)- 
little  reaction  on  the  part  of  the  peritoneum.  This 
division,  however,  is  not  necessary. 

Dr.  S.  C.  Chew  said  that  the  diagnosis  of  perito- 
nitis was  sometimes  easy  and  sometimes  very  difficult. 
and  again  there  were  varying  shades  of  difference 
between  these  two  extremes ;  in  general  it  is  easy 
when  the  case  is  typical.  The  person's  history  in  the 
case  is  important.  He  instanced  conditions  that  may 
be  mistaken  for  peritonitis. 

Dr.  Ch.\rles  M.  Ellis,  of  Elkton,  said  it  is  not  easy 
to  draw  a  sharp  line  of  demarcation  between  medical 
and  surgical  peritonitis;  the  surgeon  is  not  so  success- 
ful. If  the  operation  is  done  after  the  tenth  day  the 
chances  are  good,  but  many  cases  recover  anyhow : 
still  after  ten  days  recoveries  are  more  frequent  than 
is  commonly  supposed.  Many  cases  belong  to  sur- 
gery from  the  beginning.  Nature  seems  to  understand 
the  treatment  by  fixing  the  parts.  Besides  this,  treat- 
ment should  be  supplemented  by  rest,  little  food  by 
the  mouth,  saline  cathartics  at  the  beginning,  and 
opiates. 


Wednesday,  April  28th — Second  Day. 

Rabies. — Dr.  John  Rvhrah  spoke  of  the  preven- 
tive treatment  of  rabies.  The  disease  is  very  common 
where  there  are  no  dog  laws,  but  where  there  are  a  high 
dog  tax  and  careful  supervision  there  are  few  cases  of 
hj'drophobia.  The  inoculation  period  is  about  ten 
weeks,  although  it  can  be  as  short  as  two  or  three.  The 
shortest  on  record  was  twenty-six  days,  while  in  one  case 
it  was  eighteen  months.  Deaths  in  three  weeks  are  rare. 
In  the  cases  which  were  reported,  about  forty-seven  per 
cent,  of  those  bitten  developed  the  disease.  Men  have 
a  greater  mortality  than  women,  and  children  the 
greatest  of  all.  Eight  per  cent,  of  suspected  cases  de- 
veloped. When  the  wound  was  immediately  cauter- 
ized the  mortality  reached  only  thirty-three  per  cent, 
of  the  forty-seven  per  cent,  mentioned  above,  while  in 
the  uncauterized  it  reached  eighty  per  cent.  In  the 
department  of  the  Seine  mortality  of  hydrophobia  was 
twenty-five  per  cent,  the  first  year  in  the  Pasteur  Insti- 
tute, and  sixteen  per  cent,  the  second  year.  The  virus 
affects  chiefly  the  central  ner\-ous  system.  In  prepar- 
ing virus  for  use  on  man  a  rabbit  is  inoculated  from 
a  rabid  dog.  Pasteur's  idea  was  to  make  a  modified 
form  of  the  disease. 

Dr.  William  H.  Welch  said  that  in  drawing  con- 
clusions it  is  well  to  remember  such  a  disease  as  hy- 
drophobia exists.  This  is  unquestionable.  Mistakes 
occur,  but  the  disease  has  characteristic  symptoms. 
Inoculation  in  animals  in  series  is  a  positive  patho- 
logical proof  of  the  existence  of  the  disease.  The 
state  of  mind  has  nothing  to  do  with  the  matter,  nor 
the  element  of  fear,  any  more  than  syphilophobia 
can  cause  syphilis.  The  method  of  treatment  rests  on 
a  complicated  experimental  basis,  which  is  just  as 
satisfactory  as  is  the  treatment  of  diphtheria.  The 
best  way  of  finding  its  value  is  by  the  statistical 
method  and  by  this  we  show  that  the  treatment  is  effi- 
cacious. It  is  not  a  sure  cure:  failures  occur,  but  are 
not  numerous. 

Microscopical  Examination  of  Milk. — Dr.  Wih- 
LiAM  Royal  Stokes,  bacteriologist  to  the  health 
board  of  Baltimore,  briefly  reviewed  the  methods  used 
in  the  municipal  laboratory  in  examining  milk.  When 
the  milk  examined  was  from  one  cow,  or  even  when  it 
was  a  mixed  milk  from  many  cows,  it  was  centrifugal- 
ized  for  some  minutes  and  then  the  sediment  was 
spread  out  on  a  glass  and  stained.  If  many  pus  cells 
were  found  the  specimen  was  rejected ;  but  if  there 
were  only  one  or  two  pus  cells  in  the  field  the  specimen 
was  passed. 

Food  Adulterations. — Dr.  J.  C.  Hemmeter  read  a 
paper  on  the  above  subject,  in  which  he  spoke  first  of 
beer  adulteration,  and  said  that  the  beer  made  in  Balti- 
more was  especially  free  from  adulterants,  while  the 
imported  beer  was  not  so  good,  on  account  of  the  sali- 
cylic acid  put  in  to  preserve  it  during  export.  The 
water  of  Baltimore  was  especially  good  and  contained 
very  few  organisms.  He  had  examined  a  great  many 
oysters  and  had  failed  to  find  any  t)-phoid  or  patho- 
genic bacteria.  He  thought  that  the  tidal  waves  of 
the  Chesapeake  Bay  and  lack  of  contaminated  water 
kept  the  oysters  free  from  disease. 


Thursday.  April  2gth— Third  Day. 

The  Early  History  of  Ophthalmology  and  Otology. 

— This  was  an  interesting  historical  sketch  by  Dr. 
Harry  Friedenwald,  who  said  that  as  early  as  1805 
reference  was  made  to  licenses  for  oculists  in  Balti- 
more. Dr.  Pierre  Chatard,  who  came  from  France  in 
his  early  life  to  Baltimore  in  1797,  was  a  prolific  writ- 
er, and  contributed  articles  on  diseases  of  the  eye. 
Other  writers,  as  Dr.  William  Gibson,  Dr.  George 
Frick,  Dr.  Cohen,  Dr.  Jameson,  and  Dr.  Harper,  show 


136 


MEDICAL    RECORD. 


[July  24,  1897 


that  the  diseases  of  the  eye  and  ear  received  very  early 
attention  in  Maryland.  In  fact,  Dr.  Frick's  book  was 
the  first  to  appear  in  English  on  the  subject  in  Balti- 
more and  the  third  in  the  English  language. 

Fracture  and  Dislocation  of  the  Vertebral  Col- 
umn.—  Dr.  K.  Percy  S.mith,  of  .Sunnybrook,  Md., 
exhibited  a  case  in  which  a  weight  of  five  hundred  and 
fifty  pounds  had  fallen  on  the  back  of  a  man,  and  had 
both  fractured  and  dislocated  his  vertebral  column  and 
injured  his  skull.  The  patient  is  able  to  go  about  and 
his  recovery  is  remarkable. 

Two  Cases  of  Gastrotomy  and  One  of  Gastro- 
Enterostomy — Dr.  Ruf.ert  W.  Johnson  exhibited 
one  of  his  patients  entirely  well.  She  was  a  young 
girl  who  had  severe  vomiting  before  the  operation  of 
gastrotomy,  and  after  the  operation  had  never  vomited; 
she  now  considered  herself  well.  In  one  case  he  re- 
covered a  long  bonnet  pin.  In  this  case  of  gastro- 
enterostomy the  patient  died. 

Dr.  Hem  MEIER  referred  to  the  cured  patient  as  one 
in  whom  he  had  used  the  electric  light  in  the  stomach, 
showing  the  dilated  condition  of  that  organ,  which 
extended  below  the  symphysis. 

Plaster  Jacket  versus  the  Steel  Brace  in  the  Treat- 
ment of  Pott's  Disease. — Dr.  R.  Tlxst.all  Taylor 
showed  five  children  who  were  undergoing  treatment 
for  Pott's  disease.  He  thought  that  the  plaster  jacket 
gave  good  support  when  the  curvature  was  below  the 
seventh  cervical  vertebra;  above  that  point  the  steel 
back  brace  was  best. 

Suppurative  Otitis  Media  with  Symptoms  of 
Sepsis  and  Intracranial  Disease  ;    Recovery  under 

Mastoid  Operation  and  Removal   of   Polypi This 

was  a  very  elaborate  paper  by  Dr.  HiR.\.\t  Woods,  Jr., 
showing  the  importance  of  attending  to  certain  run- 
ning diseases  of  the  ear  which  appear  harmless,  but 
which  in  reality  are  dangerous. 

Does  Medicine  Advance  ?  was  the  subject  of  the 
annual  address  by  Dr.  D.avid  W.  Cheever,  emeritus 
professor  of  surgery.  Harvard  University.  The 
speaker  took  up  the  various  departments  of  medical 
science  and  analyzed  the  changes  in  the  past  years, 
and  drew  conclusions  showing  that  medical  science 
had  advanced  all  along  the  line. 

After  the  address  a  banquet  was  ser\ed. 

Friday,  March  joi/i — Fourth  Day. 

Models  of  the  Original  Chamberlen  Midwifery 
Forceps — Dr.  J.  Whitridge  \Villi.\ms  showed  mod- 
els of  forceps  used  by  the  Chamberlens  at  the  end  of 
the  sixteenth  century.  He  had  obtained  these  models 
through  the  courtesy  of  the  Royal  Medico-C'hirurgical 
Society  of  London.  One  pair  showed  how  little 
change  had  been  made  in  the  forceps  in  all  these  vears. 
Some  of  the  blades  were  tied  together  by  tapes,  and 
some  had  mortise  locks. 

The  Common  Contagious  Diseases  of  the  Skin  in 
School  Children. — This  was  a  very  practical  paper  by 
Dr.  T.  C.  Gilchrist,  who  enumerated  ringworm, 
impetigo  contagiosa,  scabies,  and  pediculosis,  and 
gave  his  method  of  treatment  and  told  how  important 
it  was  to  quarantine  children  with  these  diseases.  He 
exhibited  a  case  of  alopecia  areata,  which  seemed 
to  be  of  myxtedeinic  origin,  and  which  had  improved 
under  thyroid  extract.  He  also  showed  a  case  of  pity- 
riasis rubra  in  a  man  otherwise  very  well. 

Dr.  MicHEAi-  said  that  some  cases  of  these  kinds 
mentioned  occurred  in  the  clean,  as  he  had  had  occa- 
sion to  notice,  and  they  were  very  obstinate  in  spite  of 
every  precaution  and  treatment  used. 

The  Spread  of  Tuberculosis  among  the  Russian 
Jews  of  the  City,  and  Its  Prevention.—  I'his  was  a 
paper  by  Dr.  J.  E.  Gichner,  who  as  physician  to  the 
Hebrew  Benevolent  Society  of  Baltimore  had  had  oc- 


casion to  observe  the  great  increase  of  pulmonary  tu- 
berculosis in  that  race,  and  spoke  of  the  crowded  con- 
dition of  the  people  and  other  causes,  and  outlined 
plans  for  its  prevention. 

This  was  discussed  by  Drs.  Canfield  and  Schaf- 

FER. 

Dr.  Charles  M.  Ellis  was  elected  President  for  the 
ensuing  year. 


XEW    YORK    ACADEMY    OF    MEDICINE. 

Stated  Meeting,  May  20,  iSgj. 

Edward  G.  Janewav,    M.D.,  President,  in  the 
Chair. 

Portrait  of   D.   B.  St.    John   Roosa,  Ex-President. 

— Dr.  David  Webster  presented,  on  behalf  of  about 
one  hundred  physicians,  an  oil  ponrait  of  Dr.  Roosa, 
late  president  of  the  academy.  Since  Dr.  Roosa  was 
still  with  us,  the  speaker  said,  perhaps  a  eulogium 
would  not  be  in  good  taste,  therefore  he  would  limit 
himself  chiefly  to  expression  of  high  personal  regard 
for  his  character  and  friendship  and  to  reading  a  few 
of  the  letters  accompanying  subscriptions,  all  of  which 
testified  to  marked  esteem  by  the  profession.  During 
his  presidential  term  the  academy  became  perpetually 
exempt  from  taxation,  and  the  cleansing  of  the  Croton 
watershed  was  brought  about.  He  established  a  pre- 
cedent which  possibly  would  be  ever  followed,  of  de- 
clining a  second  term.  In  accepting  the  handsome 
portrait  in  the  name  of  the  academy.  Dr.  Janewav 
expressed  again  the  desirability  of  adorning  the  acad- 
emy walls  with  portraits  of  Dr.  Austin  Flint  and  of 
Dr.  Alonzo  Clark. 

Report  of  Eight  Hundred  and  Five  Cases  of 
Sunstroke  in  New  York,  1896  ;  Treatment ;  Dis- 
cussion of  the  Pathology. — Du.  Alexander  Lam- 
bert read  the  paper,  the  latter  part  of  which  was 
a  discussion  of  the  pathology  of  sunstroke  by  Dr. 
Ira  Van  Gieson.  The  ten  days  from  August  4  to 
August  14,  1896,  would  alwa\s  be  remembered  as 
a  period  in  which  an  extraordinary  number  of  sun- 
strokes occurred  in  New  York  City.  The  week 
ending  August  isth  the  total  number  of  deaths 
in  the  city  was  one  thousand  eight  hundred  and 
ten,  the  largest  number  ever  known  since  the  bureau 
of  vital  statistics  was  established.  Of  this  number 
six  hundred  and  forty-eight  were  reported  as  due  to 
sunstroke.  The  heat  was  evidently  the  cause  of  this 
frightful  increase  in  deaths.  The  total  number  of 
deaths  from  sunstroke  for  August  was  seven  hundred 
and  twenty-five,  and  for  the  year  it  was  seven  hundred 
and  sixty-five. 

The  details  of  the  weather  for  the  ten  days  of  Au- 
gust 4th  to -August  14th  showed,  according  to  the  report 
of  Dr.  Daniel  Draper,  Central  Park  Observatory :  Mean 
hourly  humidity  for  the  whole  month  of  August,  73.17, 
100  being  saturation.  For  tlie  ten  days  referred  to  it 
was  below  this  mean  rather  than  above  it.  Therefore 
the  heat  was  the  main  factor,  which  in  the  shade  at  Cen- 
tral Park,  fifty-three  feet  above  the  street,  was  from  72^ 
to  97^  F.  .\ugust  7th  to  .\ugust  1 2th,  the  temperature 
ranged  from  So""  to  98°  except  for  about  three  hours. 
Of  course  it  was  hotter  down  in  the  city,  or  outside 
the  park.  The  temperature  in  the  sun  during  working 
hours  of  the  day  averaged  119"  F.,  and  ranged  from 
94°  to  137  F.  The  prevailing,  wind  was  a  land 
breeze,  from  the  north  and  west,  below  si.x  miles  an 
hour,  only  one-quarter  pound  pressure. 

To  sum  up,  there  was  excessive  prolonged  high  tem- 
perature, iiigh  humidity,  this  latter  being  usual  here, 
and  absence  of  cooling  breezes.  Experience  had 
shown   that  sunstroke   was   less  common  in   dry  hot 


July  24.  1897] 


MEDICAL    RECORD. 


137 


climates  than  in  moist,  for  evaporation  with  cooling  was 
more  rapid  in  drj-  air.  High  temperature  of  brief 
period  might  be  borne,  but  when  long  continued  caused 
numerous  sunstrokes.  The  eight  hundred  and  five 
cases  were  from  the  records  of  Bellevue,  Roosevelt, 
Presbyterian,  Xew  York,  Hudson  Street,  St.  Vincent's, 
and  the  Hood  Wright  hospitals,  and  for  the  statistics 
the  speaker  was  indebted  to  Drs.  Jackson,  Flint,  James, 
Thornley,  Loomis,  Connor,  O'Dwyer,  and  Knicker- 
bocker. Anything  which  lessened  the  resistance  of 
the  body  to  external  influences  might  be  said  to  pre- 
dispose to  sunstroke.  The  large  number  of  cases  in 
which  there  was  a  history  of  alcoholism  was  a  strik- 
ing feature.     The  great  majority  were  alcoholics. 

Clinically  the  cases  were  divided  thus:  i.  Heat 
prostration.  2.  The  asphy.xial  or  milder  form  of  sun- 
stroke. 3.  The  hyperpyrexial  form.  Of  the  first  clas^ 
there  were  two  hundred  and  forty-seven.  They  did  not 
lose  consciousness :  the  temperature  did  not  go  above 
105"  F. ;  in  some  it  was  subnormal.  All  recovered. 
Of  the  so-called  asphy.xial  or  mild  form  there  were 
thirt}'-eight  cases.  All  recovered.  They  lost  con- 
sciousness, but  the  temperature  did  not  rise  to  105'  F". 
There  was  often  a  marked  predominance  of  nervous 
symptoms.  Of  the  third  form,  hyperpyrexial  cases, 
there  were  five  hundred  and  twenty  cases,  with  one 
hundred  and  thirt}--two  deaths.  All  had  a  temperature 
of  105^  F.  or  over:  only  a  few  retained  consciousness. 
The  difference  between  the  three  classes  was  one  of 
degree,  not  of  kind.  The  majority  of  the  sunstrokes 
occurred  between  2  and  5  p.m.  and  between  7  and  10 
P.M.  The  nationalities  were  most  diverse.  There 
were  no  negroes.  The  occupations  were  also  diverse. 
Direct  exposure  to  the  sun's  rays  was  not  necessary, 
but  had  occurred  in  most  cases. 

The  author  then  considered  the  symptoms  in  the 
three  forms.  Among  prodromes  of  heat  prostration 
were  severe  headache,  dizziness,  pain  in  back  and  legs 
or  epigastrium,  sometimes  numbness  and  tingling  of 
hands  and  feet.  In  some  they  came  on  suddenly,  in 
some  they  were  present  from  one  to  three  days  before 
the  patient  came  to  the  hospital.  In  some  there  were 
diarrhoea  or  constipation,  nausea  and  vomiting,  and 
great  thirst.  The  tongue  was  more  often  moist  and 
heavily  coated.  In  a  few  the  temperature  was  sub- 
normal;  usually  there  was  a  rise  from  99'  to  104'  F. 
In  some  after  a  rest  from  five  to  twenty-four  hours  the 
temperature  gradually  returned  to  normal,  and  they 
went  out  feeling  well:  the  majority  continued  with 
slight  fever  from  two  to  five  days. 

The  second  or  asphyxial  form  was  by  far  the  least 
common.  The  prodromes  varied.  Sometimes  there 
were  none  and  the  patient  suddenly  lost  consciousness. 
Sometimes  this  was  immediately  preceded  by  dyspncea 
or  dizziness,  or  by  chromatopsia.  In  others  there  were 
chills,  sweating,  feeling  of  fever,  diarrhcea  or  consti- 
pation, vomiting.  In  some  there  were  sensations  of 
pins  and  needles  in  the  head,  or  headache.  There 
might  be  petechial  rash  on  the  body,  pupils  normal  or 
dilated.  Unconsciousness  lasted  until  after  a  bath,  or 
perhaps  twenty-four  hours.  The  pulse  varied  from 
normal  to  140.  Its  frequency  seemed  to  depend  more 
upon  the  condition  of  ner\ous  exhaustion  than  upon 
the  temperature.  The  respirations  were  usually 
slightly  increased,  24  to  28.  The  temperature  did 
not  go  above  105"  F.,  was  usually  lower,  sometimes  sub- 
normal. Of  this  class  in  Bellevue  thirty-three  were 
males,  five  females.  The  urinarj-  analyses  showed  no 
more  changes  than  were  usually  found  in  an  equal 
number  of  alcoholics  and  normal  persons. 

In  the  third  or  hyperpyrexial  class  the  prodromes 
when  present  were  often  more  prolonged,  lasting  from 
four  to  seven  days.  But  there  were  more  histories 
without  prodromal  symptoms.  .\mong  them  were 
physical  weakness,  anorexia,  great  irritability  and  rest- 


lessness, insomnia,  nausea,  diarrhoea  or  constipation. 
Just  before  consciousness  was  lost  sweating  ceased, 
and  there  was  a  feeling  of  intense  heat,  a  feeling  as  if 
the  head  would  burst  and  eyes  bulge  out,  chroma- 
topsia, blurred  vision.  Those  who  had  a  temperature 
above  108"  F.  often  had  no  prodromes.  In  several 
cases  the  patients  had  kept  at  work  long  after  noticing 
anything  or  answering  questions,  and  finally  were  taken 
to  the  hospital  unconscious.  In  even,'  case  in  which 
the  temperature  was  i  lo''  F.  or  over  coma  was  complete. 
Those  with  a  lower  temperature,  if  conscious,  com- 
plained of  intense  heat  and  headache.  The  uncon- 
scious patients  presented  a  striking  picture — skin 
drj-,  hot,  and  flushed,  or  cool,  pale,  and  livid,  or  cya- 
notic, with  clammy  perspiration  :  eyes  suffused,  or  half 
open,  staring,  and  filmy:  pupils  contracted,  normal,  or 
unevenly  dilated:  sometimes  the\-  would  react  to  light, 
sometimes  not :  mouth  often  open,  with  lower  jaw- 
twitching  convulsively;  respiration  in  short  gasps, 
with  piteous  moan  or  groan:  muscles  limp,  or  twitch- 
ing convulsively,  or  in  active  general  convulsion; 
often  wild  delirium,  struggling  furiously;  pulse  rapid, 
small,  thready,  or  full  and  strong  with  throbbing 
carotids,  or  pulseless.  In  many  cases  there  was  a 
petechial  rash  on  the  body  and  extremities.  There 
was  a  peculiar  disagreeable  odor,  distinct  from  the 
offensive  faces  and  urine,  which  often  passed  invol- 
untarily. Out  of  the  242  cases  with  a  temperature 
above  105"  F.  the  temperature  in  i  was  117°  F.,  with 
death:  115^  F.  in  i,  recover)';  in  27  it  was  above 
no'  F.      Of  these  242,  167  recovered. 

During  the  bath,  or  cold  pack,  or  within  an  hour 
afterward,  about  one-half  of  the  patients  became  con- 
scious, and  usually  remained  so.  Many  patients  did  not 
regain  consciousness  until  next  day,  or  until  from  three 
to  five  days,  one  not  for  ten  days.  Many  with  temper- 
ature above  108°  F.  did  not  regain  consciousness  at  all ; 
the  temperature  was  brought  down,  the  pulse  remained 
frequent,  dyspncea  and  cyanosis  were  often  marked,  and 
they  died.  These  patients  usually  died  within  twenty- 
four  hours  after  admission.  Several  patients  became 
conscious,  later  became  unconscious  again,  with  de- 
lirium, and  after  from  two  to  seven  days  recovered,  but 
a  few  died.  Patients  admitted  in  convulsion  usually 
continued  to  have  these  after  the  bath.  They  were 
usually  a  tonic  spasm,  with  intermittent  clonic  general 
convulsions.  Marked  rigidity  of  the  muscles  without 
convulsions  was  not  uncommon.  The  fall  in  temper- 
ature in  the  majority  of  cases  was  followed  by  one  or 
more  secondary  rises,  which  often  required  active 
interference. 

The  blood  showed  a  decided  leucocytosis,  red  cells 
distorted,  the  leucocytes  containing  pigment.  The 
haemoglobin  color  test  in  twelve  cases  gave  from  eight)- 
to  one  hundred  and  twent)--five  per  cent.,  averaging 
one  hundred  per  cent.,  which  was  far  above  the  normal 
and  was  due  to  the  free  hjcmoglobin  in  the  blocd  from 
destruction  of  the  red  cells.  There  was  subsequent 
anjemia  in  nearly  all  patients.  Some  patients  spat 
blood  in  the  bath :   a  few  had  bloody  stools. 

Retention  of  urine  was  not  uncommon.  The  urine 
in  the  first  twenty-four  hours  semed  lower  in  specific 
gravity  than  normal,  and  to  contain  a  lessened  amount 
of  urea.  Five  to  ten  days  later  it  seemed  of  higher 
specific  gravity.     Often  the  urine  was  normal. 

The  fatal  complications  observed  were  meningitis, 
pneumonia,  acute  exacerbation  of  chronic  kidney 
disease.  The  cause  of  death  iii  most  cases  was  fail- 
tire  of  respiratory  and  cardiac  centres.  In  some  cases 
a  sudden  rigidity  of  the  muscular  system  caused  suffo- 
cation. Immediate  sequelse  were  headache,  extreme 
weakness  and  malaise,  dizziness,  soreness,  numbness 
and  tingling  in  hands  and  feet,  extreme  ana-mia. 
Three  patients  became  insane  with  delusional  insanity. 
Two    developed    inco-ordination    of    the   extremities. 


138 


MEDICAL    RECORD. 


[July  24,  1897 


which  had  remained  until  now.  Dr.  Daly  had  traced 
seventy-three,  after  nine  months.  Of  these  forty-two 
had  no  sequels.  Three  had  become  insane;  twelve 
had  attacks  of  dizziness  and  were  more  sensitive  to 
heat;  five  had  severe  headache;  one,  chromatopsia ; 
one,  gastritis;  one,  changed  disposition.  Dr.  Van 
Gieson  had  reported  one  case  in  which  multiple  neu- 
ritis and  dementia  developed  two  months  after  sun- 
stroke. There  was  a  peculiar  asthenic  condition  in 
several  cases.  Usually  within  two  or  three  days  after 
the  sunstroke  the  skin  had  become  harsh  and  dry  and 
finally  peeled  off.  Bruises  were  common,  and  hypo- 
dermic injections  often  caused  ecchymoses. 

Treatment. — The  heat  prostrations  were  treated 
alike  in  the  dift'erent  hospitals.  The  patients  were  put 
to  bed,  and  if  necessary  given  a  cool  sponge  bath,  and 
phenacetin  or  some  such  drug  for  the  headache.  This 
with  rest  was  all  that  was  required.  Sometimes  an 
ice  cap  gave  great  relief. 

In  the  asphyxial  cases  tub  baths  were  given  at  60" 
F.,  or  sponge  baths,  or  if  their  coma  and  nervous  symp- 
toms demanded  it  they  were  put  for  a  few  minutes  into 
the  ice  bath  and  thoroughly  rubbed.  They  required 
little  more  than  quiet,  rest,  and  stimulation  of  a  cool 
bath. 

It  was  in  the  treatment  of  the  hyperpyrexia  cases 
that  the  test  came.  Hydrotherapy  in  some  form  was 
tried  in  all  cases.  It  differed  in  method  of  applica- 
tion and  temperature  of  the  water.  The  records  of 
mortality  in  the  different  hospitals  furnished  a  fair 
estimate  of  the  efficacy  of  the  methods  employed. 
The  mortality  among  the  patients  treated  with  ice 
baths,  and  the  bath  continued  until  the  temperature 
had  fallen  to  about  103'  or  102°  F.,  varied  in  the 
different  hospitals  from  18  to  27.5  per  cent.  When 
in  some  cases  the  ice  pack  was  used  instead  of  the 
ice  bath,  the  mortality  was  25.5  per  cent.  When  the 
ice  bath  was  given  for  ten  minutes,  irrespective  of 
the  point  to  which  the  temperature  fell  so  long  as  it 
remained  above  a  safe  limit,  the  mortality  was  forty 
per  cent.  Among  patients  treated  with  the  bath  at 
from  50°  to  75"  F.  the  mortality  was  one-third.  When 
the  baths  were  given  at  90"  to  no'  F.  and  reduced  in 
about  fifteen  or  twenty  minutes  to  72"  F.,  as  was  done  in 
the  Brooklyn  Homoeopathic  Hospital,  the  results  did 
not  seem  to  be  so  favorable  as  with  the  cold  baths. 
Among  the  patients  treated  w  ith  a  needle  spray  from  a 
hose  attached  to  the  cold-water  faucet,  the  mortality 
was  1 1.5  per  cent.  In  St.  ^'incent's  Hospital,  in 
which  the  treatment  was  cold  packs  followed  by  hot 
packs,  in  one  hundred  and  ninety-seven  pyrexial  cases 
the  death  rate  was  only  five  per  cent.,  or,  counting  eight 
patients  who  died  a  week  or  more  later,  the  mortality 
was  but  9.13  per  cent.  The  death  rate  of  sunstroke 
as  given  in  Quain's  '"  Dictionary  of  Medicine"  is  from 
forty-one  to  fifty  per  cent.  In  the  entire  number  of  hv- 
perpyrexia  cases,  as  recorded  in  this  paper,  five  hundred 
and  forty,  the  death  rate  was  25.38  per  cent.  There- 
fore the  treatment  employed  in  the  various  city  hos- 
pitals had  given  very  satisfactory  results. 

The  author  gave  in  greater  detail  the  bath  treat- 
ment, and  said  the  ice  bath  was  one  in  which  the 
patient  was  placed  in  a  tub  with  crushed  ice.  It  was 
emphasized  that  the  stay  in  the  bath  was  accompanied 
by  very  vigorous  rubbing  by  several  attendants.  The 
ice  pack  was  given  by  placing  the  patient  on  a  rub- 
ber sheet  and  putting  ice  along  the  legs  and  body, 
and  rubbing  with  ice.  The  author  did  not  think 
favorably  of  it.  The  needle  spray  was  given  in  the 
Flower  Surgical  Hospital,  patient  on  a  rubber  sheet, 
ice  cap  on  the  head,  three  streams  playing  over  him  from 
cold-water  faucets.  The  results  were  good.  In  St. 
Vincent's,  where  they  got  the  best  results,  the  method 
consisted  in  dashing  water  on  the  patient  from  pitchers 
at  a  distance,  the  patient  lying  on  a  cot,  rubber  under 


him,  wrapped  in  cotton  sheets.  Drugs  had  little  effect 
until  the  temperature  had  been  reduced.  Nitrite  of 
amyl,  one  or  two  drops  in  the  nose,  sometimes  re- 
la.\ed  muscular  spasm  and  convulsions. 

Briefly,  the  best  treatment  seemed  to  be  a  needle 
spray,  or  ice  bath,  or  cold  pack  till  the  temperature 
fell  to  103"  or  104"  F.,  followed  immediately  by  a  hot 
pack,  with  stimulants  and  sedatives  as  one's  judgment 
might  deem  necessary. 

Pathology. — The  gross  pathology  of  sunstroke  had 
always  been  conflicting,  and  the  changes  found  not 
characterized  by  any  definite  and  uniform  lesions, 
and  it  seemed  that  we  must  finally  turn  to  cellular 
pathology,  to  study  the  changes  in  the  cells  themselves, 
in  order,  if  possible,  to  discover  both  cause  and  effects. 
The  prodromal  symptoms  were  those  of  acute  func- 
tional disturbances,  and  the  serious  later  symptoms 
showed  that  there  were  grave  changes  in  the  blood  and 
in  all  the  nervous  centres,  especially  those  which  held 
in  a  state  of  equilibrium  the  heating  mechanism  of  the 
body.  Dr.  Ira  Van  Gieson  had  furnished  him  a  pre- 
liminary report  of  the  changes  in  the  nervous  system 
in  fifteen  cases  of  sunstroke. 

Sections  had  been  examined  from  the  spinal  cord, 
cerebellum,  and  various  portions  of  the  cerebrum.  All 
showed  more  or  less  changes  in  the  chromophilic 
plaques  of  the  ganglion  cells.  These  plaques  in  some 
cells  were  changed  in  shape  and  were  fewer  in  number; 
in  some  they  appeared  to  be  broken  up  or  to  have  entirely 
disappeared.  Since  the  chromophilic  plaques  showed 
the  potential  energy  stored  in  the  cells,  and  any 
changes  in  the  nucleus  might  be  said  to  be  directed 
against  the  life  of  the  cell,  it  would  readily  be  appre- 
ciated how  extensive  were  the  changes  which  had 
occurred.  Dr.  Van  Gieson's  deductions  were:  In 
three  cases  referred  to  there  was  universal  exhibition 
of  acute  parenchymatous  degeneration  of  the  neurons 
of  the  whole  neural  axis.  In  the  brain  cortex  and  in 
the  cerebellum  the  cells  showed  the  same  stages  of  de- 
generation. The  spinal-cord  cells  were  apparently 
not  so  extensively  involved.  There  seemed  to  be  no 
other  interpretation  open  as  to  the  significance  of  this 
degeneration  than  the  operation  of  a  toxic  substance 
upon  the  ganglion  cells.  There  was,  in  other  words, 
a  toxic  cytolysis  in  insolation,  or  cell  resolution  of  the 
neurons,  which  depended  upon  the  condition  of  the 
body  forces,  the  eliminative  capacit}-  of  the  body,  and 
the  duration  of  the  poison.  Depending  on  these  tliree 
factors,  the  neural  parenchymatous  degeneration  might 
result  in  restoration  or  destruction  of  the  neurons 
involved. 

This  theory  that  sunstroke  was  an  auto-intoxication 
with  heat  as  a  contributing  cause,  and  not  the  direct 
and  only  cause,  was  not  new.  The  blood  serum  from 
the  bleeding  of  some  patients  when  injected  in  doses 
of  only  five  cubic  centimetres  caused  death  in  rabbits 
within  an  hour.  The  urine  at  the  time  of  admission 
was  markedly  less  toxic  to  animals  than  twenty-four 
hours  later,  seeming  to  show  retention  of  the  toxic 
substances  in  the  body  at  the  time  of  the  sunstroke. 
But  these  experiments  had  been  few  in  number,  and 
it  could  not  be  claimed  that  the  auto-intoxication 
theory  had  yet  been  fully  proven.  Heat  alone,  how- 
ever, did  not  seem  sufficient  to  explain  all  of  the  clini- 
cal and  pathological  observations. 

Dr.  Ir.\  V.ax  Gieson  opened  the  discussion,  and 
further  elucidated  his  views  as  to  the  pathology  stated 
above,  and  spoke  of  the  experiments  on  animals. 
Regularly  a  certain  number  of  these  patients  made 
their  way  to  the  insane  asylums.  His  studies  in  one 
case  of  multiple  neuritis  and  dementia  had  been  men- 
tioned in  the  paper. 

Heavy  Clothing  and  Sunstroke. — Dr.  L.  A.  Con- 
nor gave  his  experience  in  one  of  the  hospitals.  He 
had  recognized  only  two  classes  of  cases  of  sunstroke  in 


July  24.  1897] 


MEDICAL    RECORD. 


139 


patients  who  entered  there:  i.  Heat  prostration,  some- 
times temporary  loss  of  consciousness,  temperature 
slightly  elevated,  sometimes  subnormal.  2.  Cases  of 
real  sunstroke,  though  varj-ing  still  in  degree.  He 
agreed  with  Dr.  Lambert,  that  vigorous  and  constant 
rubbing  should  be  used  during  the  bath.  At  his  hos- 
pital the  mortality  had  been  about  twenty-seven  per 
cent.  Dr.  Connor  dwelt  on  prophylaxis,  pointing  out 
the  great  proportion  of  cases  in  which  the  patient 
had  worn  heavy  clothing  in  spite  of  the  intense  heat. 
The  hat  was  usually  black  and  hea\y.  He  thought 
the  board  of  health  might  wisely  distribute  circulars  of 
information,  warning  against  too  heavy  clothing  in 
hot  weather.  The  reflection  from  the  sidewalks  daz- 
zled the  eyes,  and  it  might  be  well  to  wear  green  spec- 
tacles. 

Dr.  J.  P.  Thornley  said  that  at  the  Presbyterian 
Hospital  they  had  recognized  about  two  practical 
classes,  those  of  prostration  and  those  of  genuine  sun- 
stroke. The  treatment  had  been  the  tub  bath,  tem- 
perature of  40"  F.  The  results  had  been  fairly  good. 
With  one  e.xception  the  patients  who  recovered  recov- 
ered completely.      One  had  symptoms  of  meningitis. 

The  Heat  Regulating  Theory Dr.  L.  F.  Bishoi' 

presented  his  views  as  follows: 

•'  We  have  all  listened  with  pleasure  to  Dr.  Lam- 
bert's interesting  paper  and  the  instructive  remarks  of 
those  who  have  followed  him.  It  would  seem  that  there 
is  not  very  much  to  add  as  to  the  statistical  part  of  the 
subject,  nor  is  there  much  to  suggest  in  the  line  of 
therapeutics.  However,  the  experience  of  last  summer 
and  the  discussion  of  this  evening  have  given  rise  to 
some  thoughts  which,  though  perhaps  in  the  field  of 
medical  philosophy,  will  not  be  out  of  place. 

•■  Whatever  may  have  been  said  as  to  the  mecha- 
nism of  sunstroke,  it  would  seem  that  the  old  explana- 
tion would  still  be  most  worthy  of  belief — that  the 
body,  after  being  subjected  for  a  long  period  of  time 
to  a  high  temperature,  becomes  exhausted  as  to  its 
power  of  heat  regulation.  The  heat-producing  forces 
in  the  body  are  always  in  excess  of  the  requirements  of 
economy.  Now,  during  health  the  heat-controlling 
forces  keep  the  temperature  within  bounds,  but  when 
these  forces  have  been  put  on  the  strain  for  a  long 
period  of  time  they  may  at  some  particular  time  gi\e 
out,  and  the  temperature  of  the  body  rise  to  an  enor- 
mous degree,  as  in  sunstroke.  It  may,  of  course,  be 
true  that  the  heat-producing  forces  in  the  body  are 
very  much  increased  under  the  stimulus  of  external 
heat,  but  the  essential  element  in  the  production  of 
sunstroke  is  the  failure  of  the  heat-controlling  forces. 

"  There  is  another  point  suggested  by  the  study  of 
fever  in  general,  and  thermic  fever  in  particular,  and 
that  is  that  fever  is  not  a  positive  quantity  but  a  rela- 
tive quantity.  The  normal  temperature  of  the  body  is 
maintained  by  a  balance  between  the  heat-producing 
forces  and  the  heat-controlling  forces.  Now  it  is  very 
evident  that  in  certain  individuals  at  certain  times  the 
heat-producing  forces  may  be  very  low  and  the  heat- 
controlling  forces  correspondingly  inactive,  while  in 
others  at  other  times  the  heat-producing  forces  may  be 
very  active,  but  the  heat-controlling  forces  may  still  be 
adequate  to  maintain  the  normal  temperature.  In 
either  case  the  temperature  of  the  body  would  be  98.4° 
F.,  but  the  actual  conditions  presented  would  be  very 
different.  Hence  there  is  a  fallacy  in  believing  that 
we  can  estimate  the  thermic  condition  of  the  body  by 
the  measurement  of  a  thermometer.  Fever,  as  a  rule, 
indicates  weakness;  but  likewise  a  low  temperature 
may  indicate  weakness.  For  instance,  in  the  high 
temperature  of  pneumonia,  we  have  in  abeyance  the 
heat-controlling  forces,  allowing  the  temperature  to 
rise  under  the  stimulus  of  the  disease.  In  defer\-es- 
cence  with  collapse  in  the  course  of  pneumonia,  we 
may  have  a  failure  of  the  heat-producing  forces  simul- 


taneously with  the  re-establishraent  of  the  heat-con- 
trolling forces,  producing  a  condition  of  depression 
more  dangerous  than  the  high  temperature. 

"  I  had  not  intended  to  speak  of  therapeutics,  but 
there  is  one  point  in  connection  with  the  cold-water 
treatment  of  sunstroke  that  has  emphasized  what  has 
previously  seemed  to  be  true  with  the  cold-water  treat- 
ment of  typhoid  fever,  namely,  that  the  procedure  has 
a  value  beyond  that  of  the  actual  reduction  of  temper- 
ature. It  seems  to  have  the  power  of  re-habilitating 
the  heat  centres  and  giving  them  the  power  of  taking 
up  their  work  in  their  proper  way. 

■'  The  value  of  the  study  of  sunstroke  in  these  lati- 
tudes must  have  an  importance  of  its  own.  The  effect 
of  climate  upon  the  constitution  of  the  population  is 
such  that  we  cannot  draw  our  conclusions  from  the 
results  of  lower  latitudes.  People  living  in  the  south 
and  going  north  are  able  at  first  to  stand  low  temper- 
atures remarkably  well.  The  same  is  true  of  people 
going  from  the  north  south  as  to  high  temperature,  but 
after  a  time  each  must  adopt  the  customs  of  the  coun- 
try to  which  he  has  gone. 

"  In  conclusion,  we  would  like  to  emphasize  our  be- 
lief that  sunstroke  is  in  the  category  of  physiological 
rather  than  chemical  or  bacterial  disorders,  and  that 
whatever  substances  have  been  found  are  the  results  of 
the  high  temperature,  which  was  primarily  due  to  a 
functional  derangement  of  the  heat-controlling  and 
heat-producing  forces.  The  condition  of  sunstroke 
may  be  closely  imitated  by  hyperpyrexia  in  any  acute 
disease.  In  rheumatism,  or  even  in  typhoid,  there  is  a 
high  temperature  existing  from  internal  causes,  which 
may  bring  about  the  same  catastrophe  to  the  heat  cen- 
tres as  if  produced  by  external  heat  of  the  atmosphere. 
Sunstroke  is  a  disease  of  the  nervous  system. 

"The  lower  grades  of  thermic  fever  have  not  been 
considered  particularly,  because  the  subject,  sunstroke, 
has  hardly  suggested  their  study;  but  it  should  be 
borne  in  mind,  especially  as  to  young  children  in  the 
large  cities,  that  thermic  fever  may  resemble  very 
closely  cholera  infantum,  and  that  it  may  exist  en- 
tirely independent  of  any  primar}^  digestive  disturb- 
ance. In  these  cases,  of  course,  laboratory  milk  is 
not  a  panacea. 

"We  must  all  feel  indebted  to  Dr.  Lambert  for 
bringing  this  subject  before  us  at  this  time.  We  hope 
that  we  may  not  have  an  opportunity  this  summer  of 
putting  our  mature  knowledge  to  practical  use,  as  we 
had  last  summer."' 

The  Benefit  of  Mechanical  Irritation  of  the  Skin. 
— Dr.  Simon  B.\rlch  said  that  the  benefit  derived 
from  the  various  ways  of  using  water  was  not  due  so 
much  to  the  cold  as  it  was  to  the  mechanical  irritation 
of  the  cutaneous  nerves.  That  fact  should  be  borne 
in  mind  in  all  cases  of  application  of  cold  to  the  sur- 
face. All  hydrotherapists  advised  friction  of  the  skin 
in  combination  with  cold  water. 

Would  Hasten  the  Erection  of  Public  Baths. — 
Dr.  Baruch  offered  a  resolution,  urging  the  city  author- 
ities to  proceed  with  the  erection  of  city  baths  as  had 
been  provided  for  by  legislative  enactment.  The  res- 
olution was  laid  over,  under  the  rules,  until  the  next 
meeting. 


Tuberculosis.— For  the  cure  of  tuberculous  disease 
of  the  lungs,  as  we  ordinarily  meet  it,  we  need  a  spe- 
cific for  pyaemia  quite  as  much  as  one  for  tuberculosis, 
for  in  most  cases  there  is  mixed  infection,  and  when 
the  disease  is  well  advanced  the  pyaemia  is  as  marked 
as  the  tuberculosis.  Moreover,  while  the  human  sys- 
tem can  often  vigorously  resist  the  tubercle  bacillus, 
it  usually  fights  a  losing  battle  against  the  combined 
attack  of  it  and  pyogenic  organisms. — W.  S.  Davis, 
Medicine,  April,  1897. 


I40 


MEDICAL    RECORD. 


[July  24,  1897 


^Txcra^jexxtic  Hints. 

Atonic  Ulcers.— 

ii   lodol 2  parts. 

Vaseline. 

Lanolin    aa  10     " 

M.     Spread  thin  on  aseptic  lint  and  apply. 

— La  Presse  Medicixk. 
Cough  Mixture — 

I{  Ext.  pruni  virgin. . 3  i. 

Aq.  camphor 3  vij. 

Glycerin 3  i. 

M.     S.   Teaspoonful  ever)-  two  to  four  hours. 

— B.  F.  Sherman. 
Chronic  Rhino-Pharyngitis. — 

'B,  Menthol r 

Oil  of  sweet  almonds,  or 

Liquid  vaseline 10 

Apply  locally  with  a  brush. 

—  Ham  ON    DE    FOUGERAY. 

Intestinal  Antisepsis. — 

1}  Xaphthol  (alpha) gm.  iij. 

Chloroform gtt.  xv. 

Castor  oil gm.  c. 

Oil  of  peppermint gtt.  v. 

M.     S.   A  tablespoonful   in  port  wine,  beer,  or  black  coffee 
with  sugar,  for  adults,  and  a  teaspoonful  for  children. 

— J-  DE  Maximowitch. 

Cancer  of  the  Uterus 

'S,  Sodii  chlorat 3  v. 

Syr.  aurant.  flor §  i. 

Aq.  dest 1  iij . 

M.     S.   From  two  to  eight  teaspoonfuls  to  be  taken  daily. 

Locally : 

'S,  Sodii  chlorat. 

Bismuth  subnitrat aa    3  iiss. 

Iodoform 3  i- 

M.     S.   Apply  a  small  quantity  on  a  tampon  to  the  cenMx. 
E.    DUVRAE. 

Acute  Localized  Prostatitis. — 

R  Iodoform, 

Extract  of  hj-oscyamus aa  gr.  ss. 

Cacao  butter gr.  xlv. 

M.     S.    Use  as  a  suppository. 

— Journal  des  Praticiens. 
Lumbago. — 

'B,  Atropine gr.  iv. 

Oleic  acid 3  i. 

'    Castor  oil 3  i. 

Oil  of  lavender tUv. 

Rectified  spirit q.s.  ad   J  i. 

S.   For  local  application. 

— Martindale  and  Westcott. 
Chronic  Rheumatism. — 

"B,  Potassii  iodidi 3  i'j. 

Vini  colchici  sem., 

Tinct.  opii  camph aa  31]. 

Tinct.  stramonii 3  vi. 

Tinct.   cimicifug^ 3  iij. 

M.     S.   A  teaspoonful  thrice  daily. 

—St.  Luke's  Hospital,  N.  Y. 
Furuncles  of  the  Eyelid. — 

B,  Tincture  of  camphor. 

Precipitated  sulphur aa   gr.  xv. 

Lime  water, 

Rose  water aa  3  iiss. 

Gum  arable gr-  i' '  • 

— Landolt  and  Gigax. 
Tympanites. — 

B,  01.  terebinthiuEC 3  i. 

01.  amygdala;  dulc §  ss. 

Tr.  opii Z  ij. 

Mucil.  acaciie 3  v. 

.\q.  laurocerasi 3  ss. 

S.  A  teaspoonful  everj-  three  to  six  hours. 

— Medical  Press  and  Cireular. 


©orrjesjjoudence. 

OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.^ 

ROYAL    COLLEGE   OF    SURGEONS — COUNCIL     ELECTION — 
FELLOWSHIP    EXAMINATIONS — MEDICAL-AID   ASSOCIA- 

TION.S ANNUAL     MEETING     OF      FELLOWS MEMBERS* 

CLAIMS  REJECTED — MR.  ANDERSON'S  APPEAL — 
GARBAGE  AND  ELECTRIC  LIGHTING EPILEPTIC  COL- 
ONIES—  BIRMINGHAM        HOSPITAL       AND       ROYALTY 

HOSPITAL  REFOR.M — SIR  J.  REID — HEALTH  OF  LONDON. 

London,  July  9.  1897. 

The  election  to  the  council  of  the  College  of  Surgeons 
came  off  last  week.  Mr.  Howse  and  Dr.  Ward  Cous- 
ins were  re-elected  for  another  term,  and  the  three  new 
members  are  Messrs.  Edmund  Owen,  Rickman  Godlee. 
and  Watson  Cheyne.  The  election  was  not  more 
exciting  than  usual  since  voting-papers  came  into  use; 
forty-six  fellows  voted  in  person,  six  hundred  and 
nine  by  proxy,  four  votes  were  invalid,  and  four  were 
too  late.  It  is  to  be  feared  that  reformers  have  little 
reason  to  congratulate  themselves  on  the  result. 
The  new  members  are  not  particularly  liberal  in 
their  views,  so  far  as  their  public  statements  show, 
and  assuredly  all  three  cannot  compensate  the  cause 
of  progress  for  the  loss  of  the  late  Mr.  Rivington: 

As  to  other  college  matters,  the  examination  for  the 
fellowship  is  being  discussed  again,  and  no  wonder, 
for  it  is  the  most  uncertain  of  all  the  examinations. 
Neither  teachers  nor  candidates  can  form  any  opinion 
as  to  the  chances,  and  both  are  naturally  verj'  dissat- 
isfied. The  new  members  might  very  well  take  up 
this  question,  which  as  teachers  they  have  good  oppor- 
tunities of  understanding. 

Another  question  relates  to  the  powers  of  the  coun- 
cil to  censure  members.  The  bylaws  allow  the  coun- 
cil to  remove  from  the  list  any  fellow  or  member 
judged  by  the  council  to  be  guilty  of  disgraceful  con- 
duct in  a  professional  respect.  Some  are  anxious  this 
power  should  be  brought  to  bear  on  those  who  accept 
situations  under  the  medical-aid  associations.  The 
council  has  referred  this  question  to  its  legal  advisers, 
and  has  not  expressed  any  opinion  of  its  own  on  the 
matter  and  evidently  prefers  not  to  do  so.  It  will  not 
surprise  me  if  the  lawyers  advise  against  the  exercise 
of  the  power  of  expulsion,  as  it  is  quite  possible  such 
a  course  might  lead  to  litigation,  and  it  is  at  least 
doubtful  whether  the  judges  v.ould  uphold  such  a 
power  for  such  a  purpose  or  pronounce  it  as  '"  in  re- 
striction of  trade."  Perhaps  a  milder  course  would 
be  more  effectual.  The  council  might  surely  have  the 
courage  of  its  opinions,  and  let  every  one  know 
whether  it  considers  these  so-called  aid  associations 
injurious  to  the  profession,  and  accordingly  whether 
holding  office  under  them  is  discreditable  to  members 
of  the  college. 

The  annual  meeting  of  the  fellows  was  held  on 
Monday.  The  question  whether  members  should  be 
allowed  any  voice  in  their  college  was,  you  may  re- 
member, put  to  the  fellows  for  an  expression  of  opinion 
by  circular.  The  papers  have  been  returned,  and  two 
hundred  and  one  fellows  have  declared  for  this  meas- 
ure of  justice,  but  two  hundred  and  eighty-four  voted 
against  giving  up  any  share  of  their  exclusive  privi- 
leges ! 

Mr.  .Anderson's  case  came  before  the  meeting,  the 
council  having  declined  to  contribute  to  the  fund  for 
his  appeal  to  the  House  of  Lords.  Mr.  .Anderson 
pleaded  his  claim  to  assistance  on  the  ground  that  the 
college  undertakes  to  protect  fellows  and  members  in 
the  exercise  of  their  profession.  The  president.  Sir 
William  MacCormack,  replied  that  the  college  funds 


July  24,  1897] 


MEDICAL    RECORD. 


141 


were  a  trust  committed  to  them,  and  that  the  museum 
showed  how  well  the  trust  had  been  fullilled,  and  al- 
though sympathizing  with  Mr.  Anderson  and  willing 
as  individuals  to  subscribe  to  a  special  fund,  the  coun- 
cil did  not  feel  justified  in  using  the  corporate  money 
for  the  purpose. 

The  conclusion  seems  as  lame  as  the  premises,  for 
the  college  thus  refuses  to  maintain  the  rights  of  its 
fellows  and  members,  either  by  initiating  proceedings 
in  the  courts  or  subscribing  toward  law  costs.  'I'he 
feliow^s,  however,  indorsed  the  conclusion  by  twenty- 
five  to  four  votes,  though  a  number  of  them  did  not 
vote  at  all.  The  question  involved  is  a  most  impor- 
tant one,  and  the  Civil  Rights  Association  has  taken 
it  up  with  energy,  but  funds  are  needed  for  carrying 
on  the  contest.  Perhaps  no  greater  perversion  of  jus- 
tice has  been  brought  before  the  public.  Mr.  Ander- 
son's prosecution  was  at  the  hands  of  the  judges  in 
Tobago,  and  the  doctrine  that  the  judge  is  not  liable 
for  malicious  actions  done  in  the  capacity  of  judge 
must  be  set  aside  before  justice  can  be  done  to  Mr. 
Anderson.  Hence  the  question  at  issue  is  important 
to  every  citizen,  and  the  protection  of  civil  rights  a 
cause  worth  fighting  for. 

The  utilization  of  waste  products  has  a  natural 
charm  for  the  sanitary  reformer,  who  sees  in  the  proc- 
ess a  means  of  getting  rid  of  noxious  material  more 
effectual  than  its  removal  at  considerable  cost.  The 
"  dust  cart"'  has  long  been  a  source  of  vexation  to 
every  citizen,  but  there  is  a  promise  of  the  dawn  of 
better  days.  Shoreditch  vestry  leads  the  way,  and  last 
week  Lord  Kelvin  presided  at  the  opening  ceremony 
of  the  new  works  erected  for  that  part  of  the  metrop- 
olis. The  garbage  of  the  dust  carts  is  to  be  utilized 
as  fuel  for  the  engines  which  drive  the  dynamos  for 
electric  lighting.  If  not  the  first  attempt,  this  seems 
to  be  the  first  success  scored  in  this  line,  and  to  be 
partly  due  to  a  system  of  storing  the  heat  so  that  it 
can  be  used  by  night,  when  it  is  more  needed  than  by 
day.  Lord  Kelvin,  who  should  know,  said  the  plan 
was  an  example  of  the  amalgamation  of  scientific 
knowledge  and  forethought  with  mechanical  engineer- 
ing and  skill.  Perhaps  West  End  vestries  will  now 
follow  easterly  Shoreditch. 

The  committee  of  the  National  Society  for  the  Em- 
ployment of  Epileptics  is  appealing  for  funds  to  ena- 
ble it  to  carry  on  its  excellent  work.  It  has  in- 
deed money  in  hand  for  special  enlargements  and 
new  homes,  but  the  general  finances  are  ac  a  low  ebb. 
The  colony  has  passed  beyond  the  experimental 
stage;  it  would  be  a  calamity  to  discontinue  it.  The 
patients  are  taken  from  the  bad  hygienic  surroundings 
of  towns,  and  employed  in  gardens,  fields,  orchards, 
and  workshops  in  the  country,  where  they  ha\e  an 
abundant  simple  diet  without  alcohol.  A  marked 
improvement  is  generally  noticed  soon  after  admission. 
I  think  you  have  a  similar  system  in  working  order  in 
the  States,  and  you  will  be  glad  to  hear  that  it  is  suc- 
cessful here. 

On  Wednesday  the  Princess  Christian  with  her 
husband  and  daughter  went  to  Birmingham,  to  open 
the  new  buildings  of  the  General  Hospital  in  the 
name  of  her  mother,  the  Queen.  The  city  received 
the  royal  visitors  with  great  enthusiasm,  and  the  prin- 
cess expressed  gratification  at  the  success  which  had 
been  secured  to  the  hospital  and  her  own  great  inter- 
est in  the  sick  poor. 

The  Hospital  Reform  Association  carried  its  reso- 
lution at  Bristol,  although  there  were  not  wanting  some 
ditferences  of  opinion  as  to  the  method  of  removing 
admitted  abuses.  It  seems  an  excellent  plan  of  this 
vigorous  young  society  to  visit  the  several  towns  where 
there  are  large  hospitals,  and  get  the  local  members  of 
the  profession  to  discuss  the  subject. 

Sir  James  Reid,  K.C.B.,  resident  physician  of  the 


Queen,  receives  the  additional  honor  of  a  baronetcy, 
and  every  one  seems  pleased  that  his  services  are  thus 
recognized.  One  or  two  additional  honors  have  also 
reached  our  colonial  brethren,  and  also  given  satisfac- 
tion. On  the  other  hand,  there  is  some  grumbling  at 
home.  It  is  felt  that  the  profession  might  well  have 
received  further  distinctions  on  so  important  an  occa- 
sion. Why  should  Irish  presidents  get  knighthood, 
and  English  baronetcies.'  I  was  prepared  to  hear 
this  question,  for,  whatever  Ireland  gets,  she  asks  for 
more.  I  was,  however,  scarcely  prepared  for  the 
Scotch  grumble,  which  the  lay  press  has  indorsed. 
Scotland  has  generally  had  full  appreciation,  although 
the  Scottish  colleges  are  omitted.  After  all,  this 
talk  of  the  different  kingdoms  in  such  matters  par- 
takes of  the  parochial. 

The  phenomenal  health  of  the  metropolis  is  main- 
tained. In  the  last  week  the  mortality  returns  fell 
further  to  13.5  per  1,000.  The  last  four  weeks  the 
figures  have  been  13.8,  14.6,  14.6,  and  13.5,  showing 
an  average  for  the  month  of  14.1,  which  is  3.1  below 
the  average  for  the  decade,  corrected  for  increase  of 
population. 


OUR    BERLIN    LETTER. 

I  From  our  Special   Correspondent.) 

THE      FIFTEENTH      GERMAN      CONGRESS      OF       INTERNAL 
MEDICINE. 

I.ERLIN,  July    1,    1897. 

The  fifteenth  congress  of  internal  medicine,  which 
was  held  recently,  was  satisfactory  throughout.  The 
interest  taken  by  the  members  was  a  very  active  one, 
and  the  arrangement  introduced  of  having  demonstra- 
tions on  certain  days  only  was  an  eminently  practical 
one.  Provision  was  also  made  for  the  entertainment 
of  the  members  in  the  shape  of  a  festive  performance 
at  the  opera  house  and  a  festive  banquet  in  the  Zoolog- 
ical Garden. 

Professor  Leyden  was  absent  from  the  city  at  the 
time,  and  in  his  place  Professor  Schmidt,  of  Frank- 
fort, opened  the  congress  with  an  address  of  welcome. 
Following  this  Professor  Baumler  read  a  paper  on 
"  Chronic  Articular  Rheumatism  and  its  Treatment." 
He  dwelt  upon  the  history  of  the  term  rheumatism. 
Originally  employed  as  denoting  a  mucous  flow,  it 
later  became  a  general  term  for  all  "colds'"  and  their 
sequela.  An  especially  important  form  of  rheuma- 
tism is  "polyarthritis  deformans,"  in  the  study  of 
which  the  Roentgen  rays  have  proven  of  great  value. 
The  speaker  summed  up  as  follows:  Only  uncompli- 
cated cases  should  be  classed  as  "chronic  articular 
rheumatism;"'  bacteriological  researches  have  shown 
it  to  be  very  probable  that  it  is  of  bacterial  origin. 
It  is  to  be  remembered  that  in  its  course  various 
damaging  influences  are  working  upon  the  patient  at 
the  same  time. 

Dr.  Ott  spoke  upon  the  general  treatment  of  chronic 
rheumatism.  He  believed  the  best  results  are  to  be 
obtained  from  hygienic  methods;  the  careful  provision 
for  fresh  air,  good  and  proper  clothing  and  nutrition, 
and  suitable  bathing. 

In  the  discussion  the  main  interest  centred  itself 
about  the  question :  Is  or  is  not  articular  rheumatism 
an  infectious  disease?  The  first  to  speak  was  Pro- 
fessor Chvostek,  of  Vienna.  He  had  examined  the 
blood  and  joint  fluid  of  rheumatics,  and  had  made 
experiments  upon  animals,  but  all  with  negative  re- 
sults. He  therefore  regarded  articular  rheumatism  in 
no  sense  as  due  to  an  invasion  of  the  joint  by  bacteria. 
He  looked  upon  it  rather  as  a  toxic  process.  The 
swelling  of  the  joints  is  caused  by  a  toxin:  the  condi- 
tion of   the  joints  makes  it  easy  for  bacteria  to  lodge 


142 


MEDICAL    RECORD. 


[July  24.  1897 


and  propagate  there,  but  this  is  of  but  slight  import- 
ance— a  mere  side  issue. 

Dr.  Singer,  of  Vienna,  held  that  chronic  articular 
rheumatism  is  of  bacterial  origin.  He  based  his 
opinion  principally  upon  the  finding  of  the  staphylo- 
coccus in  the  joints.  He  believed  there  is  no  single 
germ,  but  a  number  of  various  germs  causing  the  dis- 
ease. 

Professor  v.  Noorden  had  investigated  the  popular 
"  lemon  cure"  of  the  lait}\  He  found  there  was  no 
alteration  in  the  metabolism  caused  thereby,  but  no 
patient  was  improved  by  it.  He  believed  that  a  reg- 
ular steady  reduction  in  weight  was  beneficial.  He 
had  found  the  Roentgen  rays  of  decided  advantage  in 
the  study  of  articular  rheumatism  and  similar  disor- 
ders. 

Baumler,  in  closing  the  discussion,  said  that  the 
bacteriological  question  was  the  one  toward  which 
special  attention  would  be  directed  in  future  studies 
of  chronic  articular  rheumatism. 

On  the  second  day  of  the  congress  Professor  Behr- 
ing,  the  discoverer  of  the  diphtheria  antitoxin,  ad- 
dressed the  assemblage,  by  special  request,  upon  '"  Eti- 
ological Therapeutics  as  Founded  upon  Experiment." 
Owing  to  improved  methods  in  the  preparation  of  the 
antitoxin,  it  is  now  possible  to  exclude  the  adventi- 
tious products  which  are  the  cause  of  the  injurious 
effect  of  antitoxin  preparation.  Antitoxin  in  itself  is 
harmless;  it  acts  exclusively  upon  the  specific  poison 
present  in  the  body.  It  has  not  been  possible  here- 
tofore to  produce  it  in  uncontaminated  form,  but  the 
speaker  did  not  think  this  necessar}-.  It  requires  the 
passage  of  the  toxin  through  an  animal  body  to  pro- 
duce the  antitoxin.  A  strong  tuberculosis  antitoxin 
has  been  recently  prepared  in  Marburg,  and  it  is  ex- 
pected that  practical  results  will  follow  its  use.  We 
have  thus  the  prospects  of  obtaining  a  good  working 
tuberculosis  antitoxin. 

Dr.  Boas,  of  Berlin,  presented  a  case  of  peristaltic 
restlessness  of  the  stomach  and  intestines.  These  or- 
gans were  in  constant  visible  motion,  and  yet  the  pa- 
tient felt  herself  otherwise  entirely  well. 

Prof,  .\lbert  Friinkel  discussed  the  surgical  treat- 
ment of  hydrops  pericardii.  He  pleaded  for  the  open- 
ing of  the  pericardium  through  an  incision,  and  con- 
demned simple  puncture  as  dangerous.  He  showed 
a  child  who  had  had  a  pericarditis,  and  had  been 
completely  cured  by  a  radical  operation. 

After  a  number  of  demonstrations  and  short  ad- 
dresses. Dr.  Magnus-Levy  read  a  paper  on  "  Myxoe- 
dema  and  Sporadic  Cretinism,"  two  closely  related 
diseases.  He  found  the  metabolism  in  them  dimin- 
ished, a  circumstance  in  striking  contrast  to  Graves' 
disease,  in  which  it  is  increased. 

Professor  Kronecker,  of  Bern,  reported  his  conclu- 
sions from  a  study  of  paralysis  of  the  heart  alleged  to 
follow  obstruction  within  the  coronary  arteries.  He 
held  that  such  a  paralysis  does  exist. 

Professor  Langerhans,  of  Berlin,  presented  the  or- 
gans of  a  young  man  who  had  been  treated  with 
Koch's  newest  tuberculin  and  who  subsequently  died. 
Autopsy  showed  a  general  miliary  tuberculosis;  the 
condition  reminded  one  strongly  of  that  found  after 
the  employment  of  Koch's  original  tuberculin. 

Professor  Rumpf,  of  Hamburg,  said  that,  in  spite  of 
extensive  employment  of  the  new  tuberculin,  he  had 
never  seen  any  disastrous  result. 

Professor  Liebreich,  by  special  reque.st  of  the  con- 
gress, next  spoke  at  length  of  the  "  Modern  Medicinal 
Therapy."  He  was  strongly  opposed  to  Behring's 
school  and  its  methods,  and  classed  himself  with  the 
old  school.  He  regarded  the  excitors  of  tuberculosis 
as  parasites,  which  thrive  and  ]iropagate  upon  any 
proper  soil.  He  was  opposed  to  the  recognition  of  a 
bacterium  as  the  cause  of  an  infectious  disease.     Es- 


pecially did  he  oppose  orrhotherapy.  He  recom- 
mended cantharidin  in  the  treatment  of  tuberculosis, 
claiming  for  it  that  it  increases  the  vitality  of  the  cells. 

After  the  applications  of  the  Roentgen  rays  in  in- 
ternal medicine  were  discussed,  the  question  of  lumbar 
puncture  was  taken  up.  This  procedure,  introduced 
by  Quincke,  was  discussed  by  that  authority  as  well  as 
by  Lenhartz  and  Fiirbringer,  these  three  being  best 
qualified  to  comment  upon  it.  A  diagnostic  value 
attaches  itself  to  the  method,  especially  in  tuberculous 
meningitis.  It  is  hardly  to  be  expected  that  it  will  be 
employed  in  regular  practice,  owing  to  the  difficult}- 
of  the  operation. 

Dr.  Goldscheider  read  a  paper  on  the  "  Eflect  of 
Irritations  in  the  Pathology  and  the  Therapy  of  the 
Ner\'ous  System  in  the  Light  of  the  Neuron  Theor)-." 
The  neuron  theory  opens  to  us  new  views  and  ideas  in 
the  teaching  of  psychology'  and  nervous  disease. 
Briefly  put,  it  regards  each  cell  with  its  axis  cylinder 
as  constituting  a  formative  and  nutritive  unity.  Irri- 
tations must  have  a  certain  degree  of  intensit}',  in  or- 
der that  they  may  pass  from  one  neuron  to  its  neigh- 
boring one.  All  neurons  are  associated,  yet  each  one 
has  its  own  irritability.  The  neuron  theory-  e.xplains 
the  symptoms  of  hysteria,  neuralgia,  hyperesthesia, 
tachycardia,  etc. 


ORRHOTHERAPY    OF   TUBERCULOSIS. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  Allow  me  to  reply  briefly  to  certain  strictures  of 
Dr.  Rochester  (Medical  Record,  p.  58)  on  the  use  of 
serum  in  tuberculosis.  Dr.  Rochester  used  the  serum 
in  cases  against  which  he  was  expressly  warned — 
cases  of  mixed  infection,  practically  moribund,  and 
acknowledged  by  himself  to  have  been  unsuitable. 
Dr.  Rochester  disregarded  instructions  in  the  use  of 
the  serum,  and  so  his  report  was  unscientific. 

Paul  Paquin,  M.D 

St.  Lous.  Mo. 


PAY    FOR    HOSPITAL   ATTENDANCE. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  I  have  read  with  interest  the  editorials  in  the 
Medical  Record  dealing  with  the  abuse  of  charit}" 
in  the  hospitals  and  dispensaries  of  this  city.  Rem- 
edy after  remedy  is  suggested,  but,  strangely  enough, 
the  only  effective  one  is  ignored.  Abuse,  varying  in 
degree,  is  heaped  upon  boards  of  managers,  and  phi- 
lanthropists are  scored  because  they  wink  at  the  misuse 
of  public  and  of  private  funds  which  go  to  the  support 
of  these  institutions.  The  chief  culprit,  however,  is 
overlooked,  and  this  culprit  is  the  doctor  himself. 
Take  any  one  of  these  institutions,  and  you  will  note 
that,  from  the  superintendent  to  the  scrubwoman,  all 
are  salaried.  The  prime  essential  agent  in  the  run- 
ning of  the  institution  secures  nothing  but  experience. 
Now  the  doctor  is  much  like  his  fellows  in  other  walks 
of  life:  he  cannot  feed  himself,  nor  wife  nor  children, 
on  experience:  and  vet,  dav  bv  day  and  year  by  year, 
we  see  him  giving  time  and  skill  without  pay  for  hu- 
manity's sake — true  enough,  but,  as  has  been  amply 
proven  and  as  will  be  more  fully  certified,  to  human 
beings  fifty  per  cent,  of  whom  are  able  to  pay.  Now 
the  remedy  is  so  plain  that  as  I  write  I  feel  that  1  am 
offering  an  insult  to  intelligence.  Let  the  profession 
decline  as  a  unit  to  sen-e  gratis  in  any  hospital  or  dis- 
pensarv  except  those  conducted  by  the  city  for  the 
care  of  the  paupers.  The  poor  would  then  be  cared 
for,  while  those  of  moderate  means  and  tlie  well-to-do 
would  ha\e  to  pay,  since  all  institutions  not  conducted 
in  the  spirit  of  proper  charity  would  have  to  close 
their  doors  for  lack  of  the  mainspring — the  doctor. 


July  24,  1897] 


MEDICAL    RECORD. 


143 


It  is  the  dut}'  of  the  city  to  care  for  its  indigent. 
The  city  should  establish  in  each  ward  a  hospital  and 
a  dispensary,  where  the  poor  of  the  ward  could  resort. 
One  or  more  salaried  agents  could  keep  track  of  the 
applicants,  even  as  the  registered  voters  are  traced. 
The  doctors  in  each  ward  would  gladly  treat  these 
paupers,  and  thus  gain  experience  without  robbing 
themselves  and  their  colleagues,  and  without,  as  under 
the  present  system,  teaching  the  rich  and  well-to-do 
how  to  pose  as  paupers  when  sickness  strikes  them. 
Egbert  H.  Grandin,  M.D. 


^e\v  Instinimcnts. 

A    METAL    DOUBLE-CURRENT    RECTAL    IR- 
RIGATOR. 

By    ROBERT   COLE.MAN    KEMP,   M.I>.. 


This  instrument  is  made  after  the  same  model  as  the 
hard-rubber  tube — a  central  tube  opening  at  its  apex 
and  two  lateral  openings  in  the  outer  tube.  It  is  five 
inches  long,  is  nickel  plated,  and  is  as  cheap  as  the 
rubber  instrument.  There  are  several  sizes  made,  No. 
-^  being  the  best.  The  cap  and  central  tube  unscrew 
in  a  single  piece.  The  tube  is  durable  and  can  be 
boiled.  In  using  high  temperatures  of  fluid,  a  small 
collar  of  soft-rubber  tubing  can  be  slipped  over  it,  to 
protect  the  sphincter  from  the  hot  metal.  The  instru- 
ment is  made  by  Reynders  &  Co.,  New  York. 

449  Park  Avbnle. 


A    NEW    DYNAMOMETER. 

Bv    T.    J.    McGILLICtrUDV,    M.D., 

NEW    VORK. 

In  chronic  abdominal  and  chest  disorders  the  use  of 
anthropometric  instruments  is  verj-  necessary,  to  show 


the  gradual  gain  in  flesh  and  strength  or  the  diminu- 
tion of  fat  that  takes  place  during  the  course  of  treat- 
ment. Regular  records  of  these  measurements  should 
be  carefully  kept.  The  ordinary  or  Mathieu  dyna- 
mometer, which  is  a  modification  of  the  Regnier,  has 
been  used,  not  only  for  measuring  the  strength  of  the 
hands,  but,  by  attaching  special  handles,  straps,  hold- 


ers, or  frames,  the  strength  of  other  portions  of  the 
body,  such  as  the 
chest,  back,  forearms, 
and  legs,  has  been 
obtained.  These 
holders  o  r  frames 
are  rather  compli- 
cated and  bother- 
some, and  look  as 
though  they  might 
readily  get  out  of 
order.  They  cost  as 
much  as  the  new  in- 
strument which  I 
have  devised.  Some 
years  ago  I  had  this 
circular  spring  dyna- 
mometer made  by 
Messrs.  Tiemann  & 
Co.,  and  to  it  I  have 
had  handles  attached, 
which  give  sufficient 
room  for  the  inser- 
tion of  the  foot  when 
testing  the  strength 
of  the.  side  of  the 
body,  as  in  Fig.  3. 
This  instrument  can 
also  be  used  to  test 
the  strength  of  the 
forearms,  chest,  and 
back.  The  illus- 
trations show  the  Fig.  2 
method  of  using  it  in 

testing  the   strength   of  certain    groups    of   muscles. 
Those  engaged  in  the  treatment  of   chronic   diseases 


will  find  this  dynamometer  of  practical  value  for  grad- 
ual strength  measurements.  It  combines  simplicity 
with  cheapness,  is  light  and  convenient,  and  is  made 
to  register  two  hundred  pounds  or  more.  Both  the 
English  and  metric  systems  can  be  used.  It  is  care- 
fully tested  and  is  absolutely  accurate. 

Long-Lived  Women. — Of  the  thirty-five  centenari- 
ans in  Massachusetts,  thirtv  are  women. 


144 


MEDICAL    RECORD. 


[July  24,  1897 


M^edical  perns. 

Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary-  Bureau,  Health  Department,  for  the 
week  ending  July  17,  1897: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. . . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 

Chicken-pox 

Small-pox 


The  Intelligent  Compositor. — Ours  is  a  marvel. 
We  wrote:  "'Is  there  no  balm  in  Gilead?"  Suppos- 
ing we  didn't  mean  it,  or  were  mistaken  in  the  town, 
our  compositor  slung  it  up  "Goliad."  But  that's  a 
small  matter.  Some  years  ago,  in  compiling  a  mor- 
tuary report  from  exchanges,  we  wrote :  "  Dr.  Jno.  B. 
Bailyhache,  aV.  74  years,  born  July  20,  1822,  and  died 
— .''  Imagine  our  consternation  on  finding  the  proof 
sheets  to  read:  '"Dr.  Jno.  Bellyache  eat  74  ears 
corn  July  20,  1822,  and  died  — ." — Texas  Medical 
Journal. 

The  Helpful  Hen. — In  China  the  hen  is  kept  con- 
stantly busy.  When  not  engaged  in  hatching  her  own 
brood  she  is  compelled  to  hatch  fish  eggs.  The 
spawn  of  fish  is  placed  in  an  eggshell,  which  is  her- 
metically sealed  and  placed  under  the  unsuspecting 
hen.  After  some  days  the  eggshell  is  removed  and 
carefully  broken,  and  the  spawn,  which  has  been 
warmed  into  life,  is  emptied  into  a  shallow  pool,  well 
warmed  by  the  sun.  Here  the  minnows  that  soon  de- 
velop are  nursed  until  strong  enough  to  be  turned 
into  a  lake  or  stream. — Medical  and  Surgical  Reporter. 

Beer  Drinking  and  Longevity. — Insurance  doctors 
are  much  against  beer  drinking.  Dr.  Rogers,  of  the 
New  York  Life,  in  reference  to  beer,  says:  "Recently 
I  had  occasion  to  make  some  study  of  what  happens 
among  persons  engaged  in  the  manufacture  of  beer. 
My  cases  included  not  only  the  workmen  engaged  in 
breweries,  but  also  the  proprietors  of  breweries.  It  is 
a  curious  fact  that  the  mortality  among  the  proprietors 
is  about  as  high  as  among  the  workmen,  showing  that 
they  are  all  given  to  copious  libations.  The  mortal- 
ity is  strikingly  low  among  brewers  in  early  years. 
Up  to  forty  or  thereabouts,  brewers  seem  to  be  about 
as  good  risks  as  pretty  much  anybody  else.  After 
forty  the  mortality  rises  very  high,  and  I  should  say 
that  at  fifty-five  or  si.xty  years  of  age  about  three  brew- 
ers may  be  e.xpected  to  die  where  one  average  person 
dies." 

Training  the  Nervous  System. — At  a  recent  meet- 
ing of  the  Naturalists'  Society  in  Dundee,  Dr.  Rorie 
read  a  paper  on  this  subject,  which  is  referred  to  in 
The  Laueel  a.s  follows:  "Can  the  functions  of  the  ner- 
vous system  be  raised  by  care  and  steady  diligence  to 
a  higher  standard  than  would  appear  at  present  to 
hold  ground?  In  other  words:  Could  the  present  men- 
tal and  moral  standard  of  the  human  subject  be  raised 
by  the  improvement  and  education  of  the  nerve  cell; 
and,  secondly,  would  mere  neglect  in  the  regular  e.x- 
ercise  of  the  various  nerve  centres — allowing  these  to 
sink  into  a  state  of  atrophy — result  in  moral  and  in- 
tellectual degeneration?  In  elaborating  his  theme, 
Dr.  Rorie   proceeded  to  give  a   lucid  e.xplanation  of 


recent  additions  to  the  knowledge  and  functions  of 
the  nerve  cells,  illustrating  his  remarks  by  means  of  a 
large  series  of  diagrams;  their  structure  and  develop- 
ment and  the  importance  of  a  healthy  nutrition  were 
fully  explained.  It  was  also  pointed  out  how  periods 
of  mental  depression  and  barrenness  and  states  of  ac- 
tivity and  fruition  were  in  their  turn  to  be  traced  to 
the  exhaustion  and  recuperation  of  the  nerve  cells  re- 
spectively. The  condition  of  the  nerve  cell  in  rela- 
tion to  the  development  of  insanity  and  its  bearing 
upon  the  elucidation  of  many  most  important  points- 
connected  with  criminal  anthropology  were  touched 
upon.  In  conclusion.  Dr.  Rorie  stated  that  the  latent 
capacities  of  individuals  were  in  the  majority  of  cases, 
if  not  in  all,  far  beyond  what  are  usually  reached,  and 
that  the  possibilities  of  increasing  and  developing 
these  to  their  full  extent  depended  on  raising  the  vi- 
tality of  the  ner\ous  system  to  its  highest  degree.  In 
every  individual  vast  numbers  of  cerebral  cells  prob-- 
ably  remained  undeveloped,  and  although  as  yet  no 
nerve  centres  had  been  found  corresponding  to  our 
knowledge  of  good  and  evil,  of  justice  and  benevo- 
lence, of  purity  and  veracity,  it  could  hardly  be  doubled 
that  these  had  correlative  neural  equivalents  equally 
with  the  mental  and  intellectual  faculties,  and  they 
were  therefore  as  much  worthy  of  careful  training." 

Health  Reports. — The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  supervising  surgeon- 
general  of  the  United  States  Marine  Hospital  service 
during  the  week  ended  July  17,  1897  : 


Memphis,  Tenn July  3d  to  lolh = 

New  York,  N.V July  3d  to  loth 

Toledo,  Ohio June  ist  to  30th 4 

Small-Pox — Foreign. 


Glasgow.  Scotland June  19th  to  26th 

Madrid,  Spain June  i6th  to  23d 

Pernambuco,  Brazil .-Vpril  25th  to  May  29lh . . . 

Sagua  la  Grande,  Cuba June  26th  to  Tulv  3d. 

Havana,  Cuba Ju 

Warsaw,  Russia Ju 


Ode 


Ru 


Zurich,  Switzerland  . 


19th  to  26th  . 
19th  to  26th. 
19th  to  26th . 


,.Ju 

:Manaos,  Brazil  Jui 

St.  Petersburg,  Russia Ju: 

Matanzas.  Cuba Jui 

Hong-Kong,  China May  22d 

<^saka  and  H  logo,  Japan.  ..June  5th  to  12th 

Montreal,  Canada June  25th  to  July  2d 


gth  to  26th 

23d  to  J  uly  7th  . 


Yellow  Fever. 


Santiago  de  Cuba Ju; 

Manzanillo,  Cuba Ju 

Cienfuegos,  Cuba Ju 

Rio  de  Janeiro,  Brazil Ju 

Sagua  la  (irande,  Cuba Ju 

na,  Cuba Ju 


Matanzas,  Cuba 


:  19th  to  July  3d.. 

£  8th  to  15th 

;  2oth  to  July  4th. 

:  5th  to  nth 

r  26th  to  July  3d  .. 

;  lit  to3oth.' 

;  23d  to  July  7th.. 
:  19th  to  July  3d... 


IFAi/e  the  Medical  Rfxord  is  fUased  to  receive  all  new  fuiH- 
cations  which  may  be  sent  to  it,  and  an  acknowledgment  will  lie 
promptly  made  0/  their  receipt  under  this  heading,  it  must  he  -,uith 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not he  considered  under  obligation  to  notice  or  review  any  puhHea- 
tion  received  by  it  which  in  the  judgment  of  its  editor  <fill  not  be 
of  interest  to  its  readers. 


By  Dr.  Theodore  H. 
William   Wood   and 


.V  Te.xt-Book  of  Mf.nt.\l  Dise.vses. 
Kellogg.  8vo,  776  pages.  Illustrated. 
Company,  New  York. 

Tr.\ns.\ctions  ok  thk  .Vmkkic.-vn  l*F.ni.\rRic  Society. 
1896.  Vol.  VIII.  Edited  by  Dr.  Floyd  .M.  Crandall.  Svo. 
243  pages.     Illustrated. 


d 


Bv  Dr.  Ambrose  L. 
The    K.     .\.    Davis 


Eye-Strain  in  Health  and  Disease. 
Ranney.  Svo,  321  pages.  Illustrated. 
Company,  New  York.     $2.00. 

Diseases  of  Women  and  Uterine  Therapei-  ncs.  Seventh 
Edition.  By  Dr.  MacNaughton- Jones.  i2mo.  90S  pages. 
Illustrated.      William  Wood  and  Company,  New  \'ork. 


Medical  Record 

A  IVeekly   "Joumal  of  Medicine  and  Surgery 


Vol.  52,  No.  5. 
Whole  No.  1395. 


New  York,  July  31,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rioinal  |trttclcs. 

THE     POSSIBLE     MORPHOLOGICAL     BASIS 
FOR    SOME    DISEASES    OF   THE   LUNG.' 

By    woods   HUTCHINSOX,    A.M..    M.D., 


PKOFESSOR     OF   CO.MP 


OF   BL'FFAL 


It  might  at  first  sight  appear  almost  inappropriate  to 
introduce  the  consideration  of  pathological  problems 
in  an  association  of  anatomists  pur  sang,  but  an  ex- 
planation of  the  real  meaning  of  my  title  will,  I  think, 
indicate  its  right  to  appear  upon  the  programme. 
The  aim  of  the  paper  is  not  to- inject  pathological 
considerations  into  anatomy,  but  if  possible  to  inject 
a  little  anatomical  spirit,  and  the  order  and  rationality 
that  go  with  it,  into  the  at  present  sadly  chaotic 
realm  of  pathology.  In  other  words,  it  will  be  a  per- 
haps presumptuous  endeavor  to  prove  that  we  have,  in 
some  cases  at  least,  a  valid  morphological  basis  for 
disease;  that  disease,  being  but  life  out  of  place,  vital 
energy  gone  wrong,  has  its  laws,  its  ancestry,  and  its 
principles  of  development  as  certainly  as  health  has. 
And  it  is  my  tirm  personal  conviction,  now  that  the 
wonderful  impulse  which  the  oil-immersion  lens 
and  the  bacteriological  world  opened  up  by  it  to 
our  view  have  given  to  pathology  has  apparently 
reached  its  flood,  and  even  shows  some  tendency  to 
subsidence,  that  the  chief  hope  of  advancing  and  sys- 
tematizing our  knowledge  of  disease  and  explaining 
some  of  its  deepest  problems  lies  in  the  anatomist  in 
general,  and  in  the  comparative  anatomist  in  particular, 
rather  than  in  the  bacteriologist  or  the  pure  patholo- 
gist. I  may  make  these  remarks  with  all  the  better 
grace  from  the  fact  that  I  can  hardly  claim  enrolment 
in  either  of  the  great  armies  that  have  been  men- 
tioned, and  can  only  venture  to  approach  the  subject 
from  the  standpoint  of  a  clinical  pathologist,  both 
human  and  comparative,  with  the  hope  that  the  le\\ 
fragmentary  connections  which  appear  to  suggest 
themselves  to  my  mind,  between  the  processes  of  de- 
velopment and  those  of  disease,  may  be  taken  up  and 
adequately  discussed  and  enriched  by  further  illustra- 
tion by  such  a  body  of  experts  as  this. 

The  suggestions  which  I  would  like  briefly  to  pre- 
sent for  your  discussion  will  be  along  the  following 
lines:  First,  as  to  the  vulnerability  of  the  organ  or 
organs  in  question,  as  contrasted  with  other  organs  of 
the  body;  second,  what  explanation  for  this  compara- 
tive vulnerability  or  immunity,  as  the  case  may  be. 
may  be  found  in  the  ancestry  of  the  organ  itself  ;  third, 
in  what  particular  region  of  the  organ,  if  any,  is  dis- 
ease most  likely  to  occur,  and  what  are  the  relations 
between  this  local  liability  and  the  development  of 
the  part;  and  fourth,  as  to  the  nature  of  some  special 
lesions  which  occur,  and  their  possible  relation  to  an- 
cestral tendencies.  The  first  thing  that  strikes  us,  at 
even  a  most  cursory  glance  at  vital  statistics  or  bills 
of  mortality,  is  the  "bad  eminence"  occupied  by  dis- 

'  Read  before  the  Association  of  Anatomists,  Congress  ■•( 
Physicians  and  Surgeons,  Washington,  May  ;,  1 897. 


eases  of  the  lungs  as  a  cause  of  death.  In  the  first 
place,  we  have  from  thirteen  to  nineteen  per  cent,  of 
the  entire  number  of  deaths  due  to  pulmonary  tuber- 
culosis; and  in  the  second  place,  the  next  most  prom- 
inent feature  in  the  list  will  be  found  to  be  the 
so-called  "  inflammatory"  diseases  of  the  organ,  as 
pneumonia,  bronchitis,  influenza,  etc.  In  fact,  by 
adding  together  the  various  forms  of  diseases  of  the 
lung,  which  appear  in  the  death  records,  in  the  human 
species,  it  will  be  found  that  they  are  responsible  foi 
at  least  twenty-five  per  cent.,  and,  according  to  some 
observers,  thirty  to  thirty-three  per  cent,  of  the  entire 
mortality.  I  do  not  quote  figures,  simply  because 
these  facts  are  matters  of  general  knowledge,  or  if  not 
can  be  verified  in  fifteen  minutes  by  any  who  will  take 
the  trouble  to  turn  to  the  mortality  records  of  any  of- 
our  large  cities  or  States.  Nor  is  this  state  of  affairs 
confined  to  the  human  kingdom.  Definite  statistics 
as  to  the  actual  morbility  from  any  cause  are  of  course 
practically  impossible  of  attainment  from  our  near 
cousins,  the  domesticated  animals,  for  the  reason  that, 
first,  no  systematic  record  of  deaths  is  kept,  and,  second, 
that  so  comparatively  few  of  them,  outside  of  horses, 
die  from  natural  causes ,  but  such  records  as  we  pos- 
sess seem  to  point  to  an  almost  precisely  similar  state 
of  afi^airs  in  them.  For  example,  such  diseases  as 
pleuro-pneumonia  in  cattle,  epizootic  in  horses,  tuber- 
culosis in  horned  cattle  and  in  birds,  and  one  of  the 
most  fatal  forms  of  hog  cholera,  are  all  of  them  of 
this  nature.  Of  tuberculosis  alone  we  possess  some 
sort  of  record,  and  it  ranges,  according  to  the  ob- 
server, from  an  average  of  fifteen  per  cent,  to  twenty- 
five  per  cent,  in  the  French  and  English  dairy  cattle, 
to  as  high  as  the  almost  incredible  proportion  of  sev- 
enty per  cent,  in  the  Holstein-Friesians.  That  is  to 
say,  of  cattle  used  in  the  dairy,  anywhere  from 
twenty-five  to  seventy  per  cent,  are  said  to  contract 
pulmonary  tuberculosis  at  some  time  during  their 
lives. 

As  to  the  undomesticated  animals,  in  a  state  of 
nature,  little  of  course  is  known,  partly  from  the  lack 
of  obsenation  and  partly  because  their  carcasses  are 
pounced  upon  by  some  one  of  a  dozen  scavengers, 
eagerly  anxious  for  a  meal.  But  the  records  of  those 
specimens  kept  in  captivity,  either  as  pets  or  for  sci- 
entific purposes,  support  this  position.  It  is  stated 
that  from  eighty  to  ninety  per  cent,  of  monkeys  die 
either  of  tuberculosis,  bronchitis,  or  pneumonia.  The 
canines  and  felines  in  spite  of  their  normal  immunity 
from  tuberculosis,  which  will  be  discussed  later,  fall 
under  the  same  ban  and  are  extremely  liable  to  die  of 
pneumonia  or  bronchitis.  Among  the  ungulates  gen- 
erally the  rule  does  not  hold  to  quite  the  same  degree, 
but  that  I  believe,  to  put  it  roughly  and  somewhat 
Hibernianly,  is  because  they  die  of  alimentary  dis- 
orders before  they  have  time  to  develop  the  slower 
and  more  chronic  lung  diseases  to  which  they  are  so 
specially  liable.  Nor  can  we  find  any  great  vital 
organ  or  even  system  which  can  be  compared  with  the 
lung  in  this  respect. 

There  are  at  least  nine  other  great  organs  or  sys- 
tems which  are  of  practically  equal  weight  and  vital 
importance  with  the  lung,  among  which  the  remaining 
mortalitv  is  to  be  divided  after  deducting  quite  a  con- 


146 


MEDICAL    RECORD. 


[July  31,  1897 


siderable  per  cent,  for  general  diseases,  accidents,  etc., 
which  are  not  to  be  classed  as  belonging  to  or  focaliz- 
ing in  any  particular  organ  or  system.  Diseases  of 
the  entire  alimentary  canal,  for  instance,  which  might 
justly  be  divided  into  three  separate  regions  of  the 
extent  and  importance  of  the  lung,  even  including 
typhoid  and  cholera,  are  responsible  for  barely  ten 
per  cent,  of  the  mortality  in  the  human  species.  In- 
deed I  really  ought  to  apologize  for  attempting  to  de- 
fend or  support  the  extraordinary  morbility  of  the 
lung  before  such  an  audience  as  this. 

Now,  let  us  look  for  a  moment  at  the  reasons  which 
have  been  advanced  for  this  high  grade  of  vulnerabil- 
ity. First  of  all  it  is  usually  urged  that  the  lung  is 
peculiarly  exposed,  especially  in  the  changeable  cli- 
mate of  the  temperate  zone,  and  more  readily  attacked 
by  changes  in  the  temperature,  moisture,  and  electric 
tension  of  the  air  which  must  be  breathed  into  it. 
But  we  think  this  exposure  theory  begins  to  reveal  its 
weakness,  when  we  discover  first  of  all  that  the  pro- 
portion of  fatal  lung  disease  in  any  given  race  or 
class,  particularly  of  tuberculosis  and  pneumonia,  is 
in  exactly  inverse  ratio  to  the  amount  of  exposure  to 
all  sorts  of  climatic  vicissitudes  to  which  its  mem- 
bers are  subjected.  Diseases  of  the  lung  are  emphati- 
cally diseases  of  city  dwellers,  or  of  such  classes  in 
"the  rural  population,  as,  for  instance,  farmers'  wives 
and  daughters,  who  suffer  from  too  little  fresh  air  and 
sunlight.  In  cattle  the  same  thing  is  even  more  strik- 
ingly illustrated.  Tuberculosis  in  particular,  and 
pleuro-pneumonia  in  a  less  degree,  are  emphatically 
diseases  of  stabled  cattle  or  cattle  of  limited  range, 
and  except  in  the  virulently  infectious  forms  of  the 
latter  are  comparatively  unknown  in  range  cattle. 
Besides,  when  we  come  to  look  at  the  wonderfully 
elaborate  and  effective  mechanisms  in  the  nostril 
sieve  and  turbinated  steam  coils  which  nature  has 
made  for  both  warming  and  moistening  the  inspired 
air,  so  that,  as  was  shown  by  Mackenzie,  air  at  even 
little  above  the  temperature  of  zero  is  raised  to  within 
two  or  three  degrees  of  the  body  temperature  by  the 
time  it  has  penetrated  to  the  nasopharv-nx,  we  shall, 
I  think,  be  able  to  see  on  anatomical  grounds  both  the 
weakness  of  this  exposure  theory  and  the  reason  why, 
in  its  purely  mechanical  form,  it  is  becoming  so  uni- 
versally discredited  in  clinical  etiology.  The  chill- 
ing effect  of  inspired  air  upon  either  nose,  trachea,  or 
bronchi  is  the  very  least  of  the  factors  which  result  in 
the' production  of  that  most  common  but  positively 
ludicrously  misnamed  pathologic  process,  a  "  cold," 
which  would  much  better  be  termed,  if  it  were  not  for 
possible  confusion  with  the  language  of  the  diamond, 
a  ""four' — though  even  this  confusion  is  not  so  much 
to  be  dreaded,  inasmuch  as  both  not  infrequently  re- 
sult in  the  verdict,  ''  and  out.'' 

But,  says  the  supporter  of  this  view,  this  may  be 
true  as  regards  mere  climatic  exposure  to  perfectly 
pure  air,  but  the  case  would  be  altogether  dift'erent 
with  the  air  which  very  many  of  these  city  dwellers 
are  compelled  to  breathe,  loaded  as  it  is  with  emana- 
tions from  the  bodies  and  lungs  of  others,  dust,  sewer 
gas,  and  impurities  of  all  sorts  and  descriptions.  This 
of  course  may  be  granted,  and  yet  we  must  remember 
that  the  wonderfully  efficient  barring-out  mechanism 
still  plays  an  important  part  even  here,  as  can  be  seen 
by  the  condition  of  the  nasal  mucus  after  a  day  spent 
in  a  particularly  dusty  atmosphere,  and  further  that 
this  same  course  of  reasoning  would  apply  with  ten- 
fold effect  to  the  stomach  under  these  circumstances. 
,\nd  when  we  remember  the  dietetic  errors  of  excess 
upon  the  one  hand  and  of  deficiency  and  poverty  upon 
the  othei,  the  nauseous  slops  and  messes,  the  greasy 
and  half-putrefying  dishes,  sauerkraut,  limburger,  soda 
biscuit,  "high"  game,  unleavened  bread,  and  gastric 
atrocities  of  all  sorts  and  descriptions,  to  say  nothing 


of  unfiltered  water,  stale  beer,  and  sour  milk,  I  think 
we  will  have  to  admit  that,  on  a-priori  grounds,  we 
would  expect  at  least  as  much  fatal  rebellion  on  the 
part  of  the  stomach  as  of  the  lungs.  Air  in  the  vilest 
den  is  never  quite  so  bad  as  the  food. 

The  next  explanation  advanced  is  that  of  complex- 
ity of  structure;  that  we  have  here  an  organ  of  verj- 
high  grade,  as  it  were,  of  vital  metabolism,  and  con- 
sequently, like  all  delicate  machinerj-,  peculiarly  liable 
to  get  out  of  order:  but  a  single  glance,  I  think,  will 
destroy  this  theory.  Important  as  the  function  is,  the 
actual  process  which  takes  place  in  the  lung  itself  Is 
one  of  the  simplest  and  most  purely  mechanical  that 
can  be  found  anywhere  in  the  body.  -■Ml  that  the 
epithelium  has  to  do,  so  to  speak,  is  to  keep  out  of 
the  way  of  the  wild  rush  of  the  imprisoned  carbon 
dioxid  toward  freedom  and  of  the  oxygen  toward  the 
hamoglobin.  Its  sole  function  is  to  keep  itself  alive 
and  keep  its  pores  open. 

Then  we  have  the  statement  made  that  the  lung  is 
almost  the  only  organ  in  the  body  which  never  rests 
and  is  obliged  to  remain  in  constant  activity  as  long 
as  life  lasts.  But  this  is,  we  think,  even  more  in- 
adequate, for  the  reason  that  upon  this  principle  the 
heart  ought  to  have  at  least  as  high  a  morbility  as  the 
lung,  instead  of  having  about  one-tenth  of  it;  and 
secondly,  that  the  real  active  work  of  respiration  is 
done  entirely  by  the  muscles  and  ner\es  of  the  chest, 
which  are  extremely  seldom  the  site  of  disease.  The 
lung  proper  is  as  passive  in  this  respirator)-  movement 
as  it  is  in  the  exchange  of  gases  through  its  epithelium. 

These  are  the  explanations  usually  advanced,  and  I 
think  you  will  agree  with  me  that  no  one  of  them 
alone,  or  all  taken  together,  are  in  any  real  sense  sat- 
isfactory explanations  of  the  extraordinarily  high 
degree  of  morbility  of  the  viscus.  As  in  other  prob- 
lems, when  existing  conditions  do  not  appear  to  ex- 
plain any  given  phenomenon  we  are  inclined  to  turn 
toward  the  light  of  history.  And  here  at  once  I  think 
we  come  upon  a  distinctive  and  unvarying  character- 
istic of  the  lung,  as  an  organ,  which  marks  it  off  from 
almost  all  other  organs  of  the  body  as  abruptly  and  as 
positively  as  does  its  marked  liability  to  the  attack  of 
disease,  and  that  is  its  extreme  recentness.  With  the 
exception  of  the  uterus  and  mammary  glands,  there  is 
no  organ  in  the  body  which  has  not  from  five  to  ten 
times  the  length  of  ancestral  historv'that  the  lung  has. 
Appearing  as  it  does  for  the  first  time,  and  in  a  mor- 
phological sense  de  no7v,  at  the  level  of  the  amphibia, 
with  no  invertebrate  history  whatever,  and  but  the 
merest  fragments  of  history  in  the  longest  and  largest 
fwrtion  of  our  vertebrate  family  tree,  it  is  a  thing  of 
yesterday,  morphologically  considered,  as  compared 
with  any  other  of  the  great  organs  of  the  body.  The 
stomach,  for  instance,  goes  back  to  the  hydria,  or  even 
in  an  impromptu  form  to  the  amceba  itself.  The  brain 
has  a  pretty  respectable  representation  from  the  time 
of  the  middle  citlenterates  and  certainly  of  the  worms. 
The  heart  goes  back  to  almost  the  same  point.  The 
kidneys  have  ancestors,  of  which  they  might  well  be 
proud,  in  that  illustrious  predecessor  of  ours  which  has 
been  degraded  to  the  base  use  of  concealing  fishhooks. 
The  liver  itself  bears  a  striking  family  likeness  to  its 
ancestor  in  Molluscan  times;  and  so  on  all  through 
the  list  of  our  body  organs.  In  short,  the  lung  repre- 
sents an  adjustment  of  the  body  mechanism  to  an  ex- 
tremely late  and  recent  factor  in  our  environment — 
the  direct  breathing  of  air.  Can  this  fact  of  recent- 
ness be  said  to  have  any  pathologic  bearing?  We 
think  that  it  can,  and  are  going  to  venture  to  formu- 
late a  law  upon  this  subject  for  your  discussion,  of 
which  this  particular  case  will  be  both  an  illustration 
and  a  support,  and  that  is  that  in  patholog)'  as  well  as 
in  biolog)'  the  ancestrally  old  is  the  individually  stable 
and  resisting,  and  conversely  the  ancestrally  recent  is 


July  31,  1897] 


MEDICAL    RECORD. 


147 


the  individually  unstable  and  vulnerable.  But  I  think 
some  one  will  say  at  once:  "Have  not  all  our  organs 
also  been  compelled  to  adjust  themselves  to  this  air- 
breathing  state  of  affairs  ?  U'eare  land  animals,  and  our 
entire  structure  has  been  modified  to  meet  that  change." 
To  which  I  will  venture  the  reply  that  not  only  is  this 
not  true  in  equal  degree  of  other  organs,  but,  strict!)- 
speaking,  no  other  organ  or  organs  in  the  body  have 
so  adjusted  themselves  except  in  the  most  superficial 
manner.  We  talk  about  our  body  republic  being  an 
air-breathing  and  land-living  organism,  but  as  a  mat- 
ter of  fact  all  of  our  citizen  cells  outside  of  the  lung 
are  still  absolutely  and  necessarily  aquatic  in  their 
habits,  and  marine  at  that:  cannot  live  except  when 
kept  continually  bathed  in  a  normal  saline  solution. 
First  of  all,  upon  a-priori  grounds,  I  think  we  should 
be  justified  in  the  conclusion  that  the  longer  a  given 
organ  has  performed  its  function  in  an  adequate  and 
satisfactory  manner  i  and  this  is  of  course  simply  what 
is  meant  by  the  remoteness  of  its  appearance  in  the 
family  tree)  the  more  likely  it  will  be  to  continue  to 
perform  that  function,  undisturbed  by  any  influences 
which  may  be  brought  to  bear  upon  it.  The  mere 
presence  and  history  of  such  an  organ,  for  instance,  as 
the  stomach,  are  a  standing  "  certificate  of  good  behav- 
ior" for  the  past  fifteen  or  sixteen  millions  of  years, 
and  like  all  other  such  "  characters"  would  be  entitled 
to  considerable  weight  in  calculating  its  probable  per- 
formances in  the  present  and  the  future.  And,  sec- 
ondly, I  think  it  will  be  quite  possible  to  show  that 
those  organs  or  functions  which  are  the  last  acquired 
are  the  first  to  fail  or  disappear,  either  in  the  normal 
history  of  the  body  or  under  the  stress  of  adverse  cir- 
cumstances. Take  for  instance  the  only  other  organs 
of  importance  which  are  more  recent  than  the  lung 
itself — the  mammary  gland  and  the  uterus.  Late  in 
their  appearance,  not  only  ancestrally  but  also  indi- 
vidually, as  to  the  establishment  of  their  functions, 
they  are  the  first  organs  of  the  entire  body  to  fail  and 
atrophy;  in  fact,  almost  the  only  ones  which  normally 
do  so  before  the  appearance  of  actual  senility  of  the 
general  system.  And  what  is  their  pathological  rec- 
ord? One  of  the  blackest  for  the  length  of  their 
existence  and  their  importance  to  the  individual  which 
is  to  be  found  in  the  entire  mechanism.  Nearly 
eighty  per  cent,  of  carcinoma  in  the  female  will  be 
found  to  have  its  site  in  these  organs,  while,  judg- 
ing from  the  number  and  clamorousness  of  our  gvna:-- 
cological  brethren,  one  would  almost  be  inclined  to 
think  that  the  normal  state  of  the  average  uterus  is 
one  of  disease,  and  it  would,  I  think,  be  a  conserva- 
tive estimate  to  say  that  one-third  of  all  women 
are,  more  or  less  chronically,  suflferers  from  some 
form  of  womb  trouble,  even  while  admitting  that 
much  of  this  may  be  reflex  or  but  a  cloak  for  our 
ignorance. 

.Another  case  in  point  is  that  of  the  higher  cerebral 
powers,  the  imagination,  the  creative  faculty,  the 
memor)-.  Appearing  for  the  first  time  in  the  higher 
mammals  and  at  a  comparatively  late  period  in  the 
individual,  they  are  among  the  first  to  fall  before  the 
onslaught  of  either  the  febrile  or  intestinal  toxarmias 
or  the  general  decadence  of  old  age.  The  same  may  be 
said  of  our  power  of  locomotion  in  the  erect  position. 
.\ppearing  elsewhere  only  in  our  double  first  cousins, 
the  gorilla  and  ourang-outang,  and  most  difficult  of  ac- 
quisition, in  our  own  anthropoid  stage  it  is  one  of  the 
first  things  to  disappear  under  the  disabling  touch  of 
serious  illness  or  in  the  development  of  the  tottering 
and  trembling  gait  of  threescore  years  and  ten.  The 
attitude  of  the  white-haired  grandsire,  tottering  along 
in  the  autumn  sunshine,  would  be  almost  absurdly 
anthropoid,  if  it  were  not  so  pathetic  in  its  helpless- 
ness: and  the  cane  with  which  his  feeble  balancing 
power   is   reinforced   is   a  civilized    imitation  of    the 


broken  bough  with  the  aid  of  which  the  gorilla  stalks 
through  his  native  forests. 

It  need  hardly  be  mentioned  that  in  the  realm  of 
morals  and  manners  this  law  is  already  accepted 
as  a  truism,  which  has  been  proved  time  and  again 
by,  for  instance,  the  awful  excess  of  mobs,  as 
during  the  French  revolution,  and  the  frightful  dis- 
regard for  the  rights  and  welfare  of  others,  to  say 
nothing  of  the  decencies  and  amenities  of  civilization, 
which  will  be  shown  under  the  pressure  of  panic,  hun- 
ger, or  pestilence.  The  whole  of  the  later  veneer  of 
civilization  scales  oflf  like  the  viper's  skin  at  the  slight- 
est touch  of  stress  or  danger,  and  this  rapid  blunting 
of  all  the  social  graces  and  matters  of  minor  con- 
science, which  are  the  last  things  acquired  in  the  de- 
.velopment  of  the  individual,  is  one  of  the  most  con- 
stant and  striking  symptoms  of  the  approach  of  chronic 
forms  of  insanity.  Last  to  bloom  and  first  to  fade  is 
as  true  of  the  faculties  and  even  of  organs  as  it  is  of 
flowers.  If  we  could  speak  of  the  body  republic  as 
composed  of  a  confederation  of  sister  states,  we  would 
say  that  the  lung  was  the  literal  Mexican  republic  of 
the  entire  system — a  thing  of  yesterday  by  contrast 
with  the  stomach  or  brain,  imperfectly  adjusted  to  its 
new  conditions,  varj-ing  constantly,  as  f  shall  attempt 
to  show  later,  and  liable  at  any  time  to  the  outbreak 
of  fatal  rebellion  or  serious  insurrection.  In  short, 
I  believe  that  nothing  less  fundamental  than  some 
such  factor  as  this  will  explain  the  extraordinarily 
disproportionate  morbility  and  mortalit}-  of  the  lung. 
Correlated  with  the  recentness  of  the  appearance  of 
the  organ  is  the  fact  to  which  we  have  already  briefly 
alluded,  that  it  is  the  farthest  departure  from  the  origi- 
nal water-loving  and  water-living  tjpe  of  the  primitive 
cell.  There  are  no  other  cells  in  the  body  which 
really  live  in  or  upon  air,  even  though  only  upon  one 
of  their  lateral  aspects.  All  the  superficial  epithelium 
of  the  skin-sheet,  so  long  as  it  retains  its  vitality,  re- 
tains its  moisture,  and  by  the  tmie  it  becomes  dry  it 
is  practically  dead  and  only  mechanically  adherent  to 
the  body,  ready  to  be  shed  at  any  moment.  It  is  per- 
fectly at  libert)-  to  protect  itself  through  either  oil  or 
keratin,  while  the  lung  cell  must  remain  readily  per- 
meable. 

In  short,  I  believe  that  we  have  a  fair  morphologic 
basis  for  regarding  the  lung  as  a  point  of  least  resist- 
ance in  the  entire  organism,  a  weak  spot  in  the  line 
of  defence  against  the  pestilence  that  walketh  in  dark- 
ness, and  this  I  think  will  be  seen  more  clearly  from 
the  pathologic  standpoint,  when  we  come  to  examine 
the  nature  of  the  majority  of  the  diseases  to  which  it 
is  subject.  Head  and  shoulders  above  all  other  proc- 
esses in  these  organs  stands  the  "great  white  plague 
of  the  North,"  as  the  lamented  Holmes  vividly  termed 
it — tuberculosis.  Tremendous  as  have  been  the  de- 
velopments of  this  disease  and  wide  as  the  difterences 
of  opinion  may  be  as  to  the  balance  of  its  two  factors 
in  its  etiolog}',  the  soil  and  the  seed,  all  observers  are 
agreed  that  its  most  powerful  predisposing  factor  is 
the  lowered  resistance  in  the  individual  or  organ  at- 
tacked. Of  all  the  deaths  which  are  ascribed  to  dis- 
eases of  the  lungs  in  the  mortality  reports,  pulmonary 
tuberculosis  claims  from  sixty  to  seventy-five  per  cent. 
Nor,  I  belie\e,  can  this  extraordinary  liability  on  the 
part  of  the  lung  be  accounted  for  solely  or  even  chiefly 
upon  the  grounds  of  entrj'  or  exposure,  for  the  tubercle 
bacillus  is  one  of  the  most  ubiquitous  organisms  which 
has  yet  been  demonstrated  in  the  human  tissues.  It  is 
to  my  mind  a  significant  fact  that  everywhere  that  it 
succeeds  in  effecting  a  lodgement  and  establishing  a 
breeding-station  is  the  point  at  which  there  are  tissue 
elements  of  a  low  degree  of  resistance,  either  frcm 
rapid  growth  and  the  presence  of  immature  cells  or 
from  the  opposite  process  of  atrophy  and  absorption. 
Its  commonest  sites  are  the   lymph  nodes,  where   the 


MEDICAL    RECORD. 


[July  31,  1897 


blood  is  in  process  of  manufacture;  the  growth  lines 
of  the  bones,  where  a  rapid  and  tumultuous  produc- 
tion is  constantly  going  on;  the  bodies  of  the  vertebra; 
and  intervertebral  discs,  where  the  notochord  is  even 
yet  in  process  of  absorption,  and  the  points  where  the 
notochord  longest  persists  are  the  regions  of  the  ver- 
tebral column  ^vhere  tuberculous  caries  is  most  likely 
to  occur.  I  cannot  but  regard  the  singular  fatality  of 
the  pulmonary  form  of  this  disease  as  due  not  so 
much  to  the  respirator}-  tract  being  the  most  common 
proof  entry  for  the  bacilli  or  their  spores,  but  to  the 
fact  that  here  and  here  alone  they  find  a  thoroughly  con- 
genial soil  in  a  vital  part.  Once  let  the  tubercle  bacil- 
lus get  the  organism  by  the  lungs,  and  he  can  pull  it 
•down  with  as  much  certainty  as  the  staghound  his  prey 
when  he  once  gets  it  by  the  throat.  Next  upon  the  role 
of  infamy  comes  the  dread  disease  pneumonia,  with 
nearly  twenty  per  cent,  of  the  entire  lung  mortality  to 
its  credit.  A  few  years  ago  we  should  have  found  no 
support  for,  but  in  fact  a  contradiction  of,  our  theory 
in  the  heavy  death  rate  of  this  process,  when  it  was 
regarded  as  an  inflammatory  and,  in  the  old  terminol- 
ogy, a  typical  "  sthenic"  disease.  Now,  however,  we 
simply  regard  it  as  due  to  a  lodgement  and  penetration 
into  a  vital  organ  of  a  germ  which  appears  not  infre- 
quently present  in  the  normal  saliva;  and  its  extraor- 
dinar}'  preference  for  the  lungs  is  probably  again 
due  to  their  character  as  a  point  of  least  resistance. 
Thus  we  have  from  eighty  to  ninety  per  cent,  of  the 
entire  lung  fatality  due  to  tvvo  great  diseases,  whose 
chief  determining  factor  is  a  lowered  vital  resistance. 
Now  let  us  look  for  a  moment  at  the  question  of  the 
favorite  site  or  sites  of  disease  in  the  lung.  Is  there 
any  one  part  or  region  of  the  lung  which  clinical  ex- 
perience has  shown  to  be  more  vulnerable  or  more 
frequently  the  starting-point  of  disease  than  any  other? 
For  the  purposes  of  this  inquiry  I  shall  confine  my- 
self to  the  most  frequent  and  important  of  the 
morbid  processes — tuberculosis — partly  because  the 
changes  in  this  have  been  more  carefully  and  accurately 
studied,  and  largely  also  on  account  of  the  much  more 
gradual  and  localized  development  of  its  symptoms. 
Pneumonia  is  as  hard  to  localize  as  a  prairie  fire.  In 
this  case  it  is  scarcely  necessary  to  ask  the  question  at 
the  head  of  this  paragraph.  One  of  the  commonest 
fundamental  pathologic  facts  in  our  knowledge  of 
tuberculosis  is  its  e.xtraordinarj'  fondness  for  the  apex 
of  the  lung.  The  proportions  vary  somewhat  among 
different  observers,  but  all  declare  that  from  fifty  to 
eighty  per  cent,  of  all  cases  of  pulmonary  tuberculosis 
begin  in  the  apex,  and  even  the  second-year  student 
would  instantly  concentrate  his  attention  chiefly  upon 
this  part  of  the  lung  in  examining  the  case  in  which 
there  was  any  suspicion  of  this  disease.  .-Vnd  the 
consensus  of  opinion  also  agrees  that  of  the  two  apices 
the  right  is  the  more  frequently  affected  in  the  propor- 
ton  of  about  three  to  two.  From  time  immemorial 
most  elaborate  explanations  have  been  advanced  to 
account  for  this  striking  and,  at  first  sight,  singular 
preference.  I  say  singular  because  the  apex  is,  in  the 
first  place,  the  smallest  and  most  definitely  limited 
region  of  the  whole  lung  substance,  and  presents  not  a 
twentieth  part  of  the  area  for  infection  which  is  offered 
by  the  base;  and  secondly,  because  if  the  disease  has 
any  connection  whatever  with  irritant  or  infectious 
materials,  introduced  in  the  inspired  air,  it  is  the  last 
place  in  the  world  where  we  would  expect,  upon  a- 
pnori  grounds,  that  a  lodgement  or  "settling"  of  these 
materials  would  be  likely  to  take  place.  Even  the 
bacilli  and  their  sixires  are  known  to  be  ponderable 
and  subject  to  the  law  of  gravit}-,  and  would  certainlv 
tend  to  collect  in  greatest  numbers  and  with  the  great- 
est facility  at  the  lowest  instead  of  the  highest  part 
of  the  organ.  The  same  of  course  is  true  as  regards 
the  course  of  congestion  or  stagnation  of  either  the 


blood  or  lymph  systems,  although  it  has  been  gravely 
declared  that  certain  peculiarities  in  the  arrangement 
of  the  pulmonary  veins  are  such  as  to  prevent  a 
proper  drainage  of  this  area  of  the  lung  and  cause  it 
to  be  a  point  of  deficient  circulation  and  consequently 
special  pathologic  liabilit}-.  And  this  in  the  face  of 
the  fact  that  all  hypostatic,  congestive,  or  purely  in- 
fiammator\-  processes  which  are  known  to  pathology 
invariably  begin  at  the  posterior  aspect  of  the  base. 
Another  explanation  which  is  offered  is  that  in  the 
apex  we  have  a  literal  cul-de-sac,  a  point  of  "  no  way 
out  here,"  for  both  blood  and  air.  The  statement 
must  be  admitted  as  perfectly  correct.  But  is  it  any 
more  true  of  this  region  than  it  would  be  of  any  part 
of  the  margin  of  the  lung,  whether  anterior,  posterior, 
or  inferior?  It  is  true  it  is  a  constricted  and  cone- 
shaped  projection,  but  it  is  not  one-half  so  compressed 
or  '"knife-edged''  as  any  portion  of  the  thin  leaf-like 
inferior  border,  or  the  irregularly  jagged  anterior  bor- 
der, particularly  on  the  left  side.  And  it  has  the  ad- 
vantage of  the  whole  influence  of  gravity  in  favor  of 
the  return  of  the  blood,  instead  of  against  it,  as  in 
these  other  localities.  Last,  and  most  weighty  of  all, 
we  have  the  theory  advanced  that  the  apex  is  a  point 
of  least  perfect  expansion,  and  the  air-cells,  in  conse- 
quence being  less  perfectly  extended,  are  more  liable 
to  collapse  or  become  filled  with  catarrhal  or  serous 
effusion.  As  to  this  purely  mechanical  version  of  the 
expansion  theor\-,  I  think  that  only  a  moment's  in- 
spection is  necessary  to  show  not  merely  its  inade- 
quacy, but  even  its  absurdity.  The  cells  of  the  lung 
are  filled  not  by  muscular  force  or  circulatory  energ}% 
but  simply  by  the  pressure  of  the  atmosphere :  and 
while,  if  we  were  dealing  with  a  fluid  which  had  to  be 
forced  under  pressure  into  every  part  of  the  cavity, 
we  might  naturally  expect  that  the  highest  portion  of 
the  cavity  would  be  the  one  most  likely  to  be  im- 
perfectly filled,  yet  when  we  remember  that  we  are 
dealing  with  a  gas,  and  a  heated  one  at  that,  the  prob- 
abilities are  absolutely  the  reverse.  Heated  air,  like 
any  other  gas,  tends  to  seek  and  accumulate  in  not 
the  lowest,  but  the  highest  point  of  its  chamber,  and, 
as  far  as  the  mechanical  distention  is  concerned,  the 
cells  in  the  upper  part  of  the  lung  in  the  neighborhood 
of  the  ape.x  would  be  more  abundantly  supplied  with 
air  than  those  in  the  middle  or  lower  parts  of  the 
organ;  and  this  is  actually  found  to  be  supported  by 
histologic  investigation,  which  has  shown  that  the  air 
cells  in  the  apex  are  larger  and  better  developed  than 
those  in  any  other  part  of  the  lung.  The  other  ver- 
sion, however,  of  this  expansion  theor)'  is  both  rational 
and  weighty,  and  that  is,  owing  both  to  the  constricted 
form  of  the  chest  at  this  point,  the  firmness  and  solid- 
ity of  its  bony  walls,  the  absence  of  cartilage  and 
limited  movement  of  the  first  rib,  and  the  pressure  of 
the  shoulder  girdles  and  its  great  muscles,  the  nor- 
mal respiratory  rhythm  in  this  region  is  decidedly 
limited,  and  especially  is  this  the  case  in  sedentary- 
occupations  or  in  some  forms  of  manual  labor,  such  as 
digging,  chopping,  ploughing,  etc.,  which  tend  to  drag 
the  shoulders  forward.  This  has  been  developed  by 
C'lough  into  the  so-called  "postural''  theorj-  of  the 
disease.  The  normal  expansive  movements  being  im- 
perfectly performed  results  in  a  lowering  of  the  gen- 
eral nutrition  and  the  production  of  a  sort  of  func- 
tional anemia,  which  of  course  predisposes  toward 
almost  any  kind  of  morbid  process.  I  would  scarcely 
dispute  that,  in  many  cases  at  least,  the  stagnation  in 
distention  which  this  theor\-  supposes  does  actually 
exist,  and  is  an  imjwrtant  factor  in  the  localization  of 
the  disease,  and  yet  I  am  inclined  to  doubt  whether 
the  actual  state  of  activity  of  the  apex  has  not  been 
very  much  underestimated.  It  is  perfectly  true,  of 
course,  that  the  bony  framework  of  this  jiart  of  the 
chest  is  both  limited  and  rigid,  as  compared  with  the 


July  31,  1897] 


MEDICAL    RECORD. 


149 


lower  regions.  But  when  we  remember  that  we  are 
dealing,  as  we  have  already  seen,  with  a  heated  gas 
and  not  with  a  fluid,  and  that  the  whole  elastic  resili- 
ency and  weight  of  the  entire  chest  wall  will,  at  each 
expiration,  expend  itself  not  only  upon  driving  the  air 
out  of  the  trachea,  but  also  to  some  degree  up  into  the 
apices ;  and  further,  that  while  this  portion  of  the  chest 
has  firm  lateral  boundaries,  it  has  no  definite  roof,  and 
that  the  pleural  cavity  actually  extends  from  three- 
fourths  of  an  inch  to  one  and  one-half  inches  above 
the  border  of  the  first  rib,  we  shall,  I  think,  be  justi- 
fied in  questioning  whether  the  immobility  of  this 
part  of  the  lung  has  not  been  unduly  insisted  upon. 
It  is  of  course  difficult  to  get  actual  obser\-ations  upon 
this  point,  for  the  reason  that  after  post-mortem  rigid- 
ity has  set  in  the  elastic  and  continual  changing  roof 
of  the  pleural  dome  becomes  as  rigid  and  unyielding 
as  its  bony  walls,  and  e\-en  articihal  respiration  is  but 
a  poor  substitute  ir  such  instances  as  this  for  the  nat- 
ural process.  I  happen,  however,  to  have  seen  per- 
sonally two  operations  in  the  surgical  clinic  for  the  re- 
moval of  huge  masses  of  (tuberculous)  cervical  glands. 
in  the  process  of  which  the  upper  aspect  of  the  pleural 
sac  was  freely  exposed,  and  the  way  in  which  it  plunged 
up  and  down  in  response  to  the  respiratory  rhythm 
was  little  short  of  appalling,  and  seriously  added  to 
the  risks  of  the  operation  and  the  possibility  of  an  ac- 
cidental puncture  by  the  surgeon's  knife.  In  one  case, 
in  a  child  of  about  seven,  the  membrane  appeared  to 
have  a  range  in  the  vertical  direction  of  at  least  an  inch 
if  not  an  inch  and  a  half,  although,  seen  at  the  bottom 
of  a  gaping  wound  in  the  neck  half  filled  with  blood, 
its  real  range  would  appear  distinctly  exaggerated,  lie 
this  as  it  may,  I  think  tiiat  I  am  justified  in  declar- 
ing that  neither  this  theory,  nor  any  other  which  has 
heretofore  been  proposed,  is  at  all  adequate  to  satis- 
factorily account  for  the  extraordinarily  high  morbid 
liability  of  this  region  of  the  lung.  When,  however, 
we  turn  to  morphology,  we  are  instantly  confronted 
with  the  striking  and  suggestive  fact  that  the  apex  im- 
precisely the  point  at  which  the  most  active  change 
in  the  area  of  the  lung  is  taking  place,  and  hence  is 
again  the  point  of  greatest  instability  and  lowered 
vital  resistancee.  It  is,  I  think,  generally  admitted 
that  while  the  respiratory  cavity  in  mammals  is  under- 
going progressive  limitation  at  both  its  cephalic  and 
caudal  extremities,  yet,  in  man  at  least,  these  changes 
are  most  active  at  the  cephalic  end.  This  is  shown. 
first,  in  the  not  infrequent  persistence  in  adult  life,  and 
constant  appearance  in  the  embryo,  of  cervical  ribs 
upon  one  or  both  sides ;  second,  in  the  not  infrequent 
atrophy  of  the  first  rib,  and,  in  the  internal  structure 
of  the  lung,  in  the  disappearance  of  the  eparterial  sys- 
tem of  bronchi.  Upon  the  left  side  this  disappearance 
is  complete,  but  upon  the  right  side  atrophic  traces 
of  the  system  still  linger,  in  the  shape  of  the  upper  or 
so-called  first  lobe,  and  it  is,  as  we  have  seen,  precisely 
in  this  lobe  that  sixty  or  seventy  per  cent,  of  cases  of 
apical  tubercle  have  their  origin.  In  other  words,  we 
have  the  disease  most  frequently  beginning  in  that 
part  of  the  lung  which  is  undergoing  the  greatest 
amount  of  ancestral  retrogression,  and  especially  fre- 
quent upon  that  side  in  which  there  is  still  an  atro- 
phied remnant  of  the  former  development.  In  fact, 
I  regard  tuberculosis  as  a  disease  preferring  not  only 
the  most  unstable  organ  in  the  body,  but  the  most  un- 
stable regions  of  that  organ,  and  of  those  regions  that 
side  of  the  median  line  in  which  retrogression  is  still 
going  on.  It  attacks  the  weakest  side  of  the  weakest 
part  of  the  weakest  organ  in  the  body. 

Of  course  I  am  aware  that  the  objection  w  ill  at  once 
be  raised  that  the  vestigeal  or  degenerate  nature  of  this 
lobe  is  by  no  means  satisfactorily  proved,  although  the 
preponderance  of  investigations  and  authority  appears 
to  point  decidedly   in  that  direction.     Abev,  for   in- 


stance, from  his  most  careful  and  elaborate  studies  of 
the  question,  has  come  most  decidedly  to  tlie  conclu- 
sion that  the  right  upper  lobe  has  no  remaining  coun- 
terpart upon  the  left  side,  and  although  Hasse's  fur- 
ther investigations  ha\e  rather  supported  the  view  that 
a  process  of  onward  growth  headward  has  been  taking 
place  in  the  human  lung,  of  which  the  right  upper  lobe 
is  the  first  result,  yet  Weber,  LeBouck,  and  Howes 
have  brought  forward  considerations  which  decidedly 
support  the  original  view  of  Abey.  Unfortunately  the 
ontogeny  of  man  throws  but  little  light  upon  the  ques- 
tion as  to  whether  a  symmetrically  tri-lobed  lung  with 
paired  eparterial  lobes  was  the  ancestral  condition  or 
not,  although  three  cases  of  a  pair  of  eparterial  lobes 
in  man  have  been  reported  by  Dalla  Rosa,  and  indeed 
the  arrangement  of  the  lungs,  as  to  symmetry,  through- 
out the  mammalian  kingdom  is  of  the  most  apparently 
arbitrary  and  uncertain  character.  In  a  few  species, 
for  instance,  Bradypus,  Equus,  Elephas,  and  Phoca, 
there  is  a  paired  eparterial  lobe.  But  these  can 
hardly  be  regarded  as  ancestral  or  specially  primitive 
forms ;  nor  does  there  seem  to  be  any  possible  relation 
between  the  phytogeny  or  the  environment  of  the 
various  forms  which  will  account  for  either  their  sym- 
metry or  lack  of  it.  In  Hystrix,  for  instance,  both  the 
eparterial  lobes  and  their  bronchi  disappear  com- 
pletely. Nor  does  our  premammalian  ancestry  throw 
any  further  light  upon  the  problem,  except  that  in 
their  very  earliest  appearance,  in  Dipnoi,  the  dividing 
of  the  lungs  begins  at  the  posterior  extremity,  the  an- 
terior extremities  remaining  united,  and  hence  the 
anterior  lobes  might  be  regarded  as  the  newest  part  of 
the  lung.  Almost  the  moment  that  we  land  among 
the  amphibia,  the  symmetry  which  is  originally  pres- 
ent begins  to  disappear,  sometimes  in  favor  of  the 
one  lung  and  sometimes  of  the  other,  though  in  the 
great  majority  of  cases  we  find  the  interesting  and 
possibly  suggestive  condition  that  the  left  lung  is  the 
one  which  begins  to  atrophy,  and  in  the  snakes  totally 
disappears.  It  would  of  course  be  a  very  far  cry  to 
say  that  this  ancestral  preponderance  of  the  right  lung 
had  any  bearing  upon  the  marked  mammalian  ten- 
dency for  the  supernumerary  lobe  to  be  retained  upon 
the  right  side,  which  of  course  is  the  condition  in  the 
vast  majority  of  cases.  The  great  name  of  Wieders- 
heim  must  also  be  added  to  the  support  of  the  "ves- 
tigeal" theory  of  the  right  cephalic  lobe,  and  the  im- 
pression is  strong  from  a  general  view  of  the  entire 
field  that  a  bilateral  symmetr}-  was  the  original  con- 
dition of  affairs,  and  that  where  that  symmetry  was 
disturbed  the  strong  tendency  is  for  this  to  occur  at 
the  expense  of  the  left  lung.  However,  as  I  have 
said,  tliis  is  still  a  disputed  question,  and  Hasse  and 
one  or  two  other  investigators  of  highest  standing  in 
Germany  are  decidedly  of  the  opinion  that  it  repre- 
sents a  new  growth,  and  I  have  been  informed  by  Dr. 
Huntington  in  private  conversation  that  his  own  stud- 
ies in  this  direction  have  led  him  rather  to  this  view 
of  the  case.  However,  for  the  purposes  of  this  dis- 
cussion, it  makes  but  little  difference  which  view  is 
accepted,  all  that  my  postulate  requires  being  that  the 
region  should  be  in  a  condition  of  marked  instability, 
which  of  course  would  be  true  in  either  case.  I  stated 
just  a  moment  ago  that  there  appeared  to  be  no  con- 
nection whatever  between  the  life  and  habits  of  any 
of  the  mammals  in  the  development  of  this  part  of  the 
lung,  and  so  far  as  balance  between  the  two  apices  is 
concerned  this  is  true,  but  not  as  to  the  proportion 
between  this  part  of  the  lung  and  the  base  in  some  of 
the  species.  Although  there  are  many  exceptions,  it 
may,  I  think,  be  laid  down  as  a  general  rule,  and  in- 
deed I  have  the  high  authority  of  Dr.  Huntington  for 
the  statement,  that  the  proportional  development  of  the 
cephalic  end  of  the  lung  is,  if  we  might  use  the  ex- 
pression, in  excess  of  the  normal  in  the  ungulates,  and 


ISO 


MEDICAL    RECORD. 


[July  31,  1897 


particularly  in  the  bovidae  and  cer\idae,  while,  gener- 
ally speaking,  it  is  below  the  average  in  the  carnivora. 
The  suggestion  has  made  itself  to  my  mind  that  prob- 
ably this  condition  may  be  due  in  the  graminivora  to 
the  constant  pressure  exerted  upon  the  base  of  the  lung 
by  the  enormously  distended  paunch,  which  pressure 
is  so  great  that  in  certain  forms  of  gastritis  (rumenitis), 
and  also  of  colitis  in  cattle  and  horses,  respiration  will 
be  so  seriously  interfered  with  as  to  produce  fatal  as- 
phyxia and  rupture  of  the  diaphragm  may  even  result. 
Be  this  as  it  may,  we  are  justified,  I  think,  in  stating 
that  the  posterior  or  caudal  extremity  of  the  lung  in 
ungulates  is  to  be  regarded  as  the  point  of  the  greatest 
tendency  to  recession.  And  here  again  we  have  what 
is  to  my  mind  a  most  interesting  and  suggestive  coin- 
cidence, and  that  is  that  in  domestic  cattle  the  point 
of  most  frequent  attack  and  the  initial  pulmonary  le- 
sion of  tuberculosis  is  in  the  dorso-caudal  lobe,  though 
not  quite  in  the  same  preponderance  as  in  the  apex  of 
the  human  lung.  However,  Friedberger  and  Frohner 
declare  that  between  sixty  and  seventy  per  cent,  of  all 
cases  of  pulmonar\-  tuberculosis  begin  upon  the  dorsal 
aspect  of  the  caudal  lobe.  It  would  be  interesting  to 
compare  the  morbility  of  the  different  extremities  of 
the  lung  in  the  carnivora  or  in  the  horse  with  his 
double  eparterial  lobe,  but  unfortunately  for  our  pur- 
poses both  of  these  are  largely  immune  to  tuberculo- 
sis. But  it  certainly  seems  a  singular  coincidence,  if 
nothing  more,  that  this  typical  disease  of  lowered  re- 
sistance should  attack  in  its  two  principal  victims  the 
human  and  bovine  families,  in  just  that  part  of  the 
lung  which  lies  at  a  disadvantage  either  ancestrally  or 
mechanically. 

There  is  one  other  disease  of  the  lung  which  it 
really  seems  we  might  almost  be  justified  in  regarding 
as  ancestral,  and  that  is  emphysema.  It  has  always 
been  something  of  a  puzzle  to  pathologists  w-hy,  when 
every  other  organ  in  the  body,  if  inflamed,  would 
undergo  either  actual  solidification  or  atrophic  or 
sclerotic  changes,  due  to  fibroid  degeneration  with 
shrinking  in  bulk,  the  lung,  on  the  other  hand,  dis- 
plays an  extraordinary  tendency,  under  almost  any 
form  of  chronic  irritation,  to  pursue  exactly  the  oppo- 
site course  and  become  lighter  and  more  expanded. 
The  usually  assigned  "back  pressure''  of  cough,  or  the 
gasping  respiration  of  asthma,  is  of  course  absolutely 
inadequate  by  itself,  but  when  we  remember  that  any 
or  all  of  these  causes  are  acting  upon  a  web  of  tissue 
which  has  gradually  grown  by  complex  folding  and 
refolding  and  meshing  from  a  simple  smooth-walled, 
distended,  epithelial  sac,  such  as  is  still  found  in  the 
frog  and  mudfish,  we  can,  I  think,  hardly  avoid  the 
belief  that  the  rarefaction  and  expansion  of  the  lung 
in  emphysema  is  simply,  as  is  the  case  with  so  many 
other  morbid  processes,  a  reversion  to  an  ancestral 
stage.  No  other  hollow  organ  in  tlie  body  tends  to 
become  lighter  and  more  expanded  under  the  influence 
of  chronic  inflammation,  and  no  other  organ  has  a 
similar  pedigree.  I  was  much  interested  in  talking 
with  a  professional  friend  a  few  weeks  ago  to  learn 
that  the  great  Fothergill  had  advanced  an  almost  sim- 
ilar suggestion,  stating  that  the  "barrel-chest"  of 
chronic  bronchitis  or  asthma  was  a  reproduction  of 
the  turtle  lung  with  its  e.xpanded  air-cells  and  rigid 
chest  wall;  and  while  the  suggestion  of  the  last  clause 
appears  at  first  sight  a  somewhat  whimsical  one,  yet 
we  have  grounds  for  believing,  as  I  hope  to  show  at 
some  future  time,  that  even  the  fixed  and  rigid  chest 
wall,  not  merely  of  the  asthmatic  but  also  of  the  con- 
sumptive, has  an  ancestral  basis. 


THE  TRE.ATMENT  OF  CANXER  BY  A  NEW 
METHOD,  VIZ.,  THE  ELECTRICAL  DIF- 
FUSION OF  NASCENT  OXYCHLORIDES  OF 
MERCURY   AND   ZINC. 

By   (J.    HETTO.V    MASSEV,    M.D., 


Tuberculosis  in  Cold-Blooded  Animals.— Professor 

Dub.ird,  of  Dijon,  shows  that  tuberculosis  occurs  in 
cold-blooded  animals  and  can  be  communicated  to  them 
experimentally.— /'/v'r/;w.W(//<-<r/<-,  May  15,  1S97, 


The  cancerous  affections,  carcinoma  and  sarcoma, 
have  been  successfully  treated  by  electricity  at  various 
times  in  the  past.  How  extensive  the  bibliography  of 
the  subject  is  was  admirably  shown  in  an  article  in  an 
English  magazine.  The  Contemporary  Review  for  March, 
1892,  compiled  by  Mrs.  Edith  Faithfull,  who  gave  as 
a  reason  for  her  interest  in  the  subject  that  she  herself 
was  a  sufferer  from  epithelial  cancer  and  had  been 
under  electro-surgical  treatment  after  two  failures  of 
the  knife  to  prevent  a  recurrence.  Some  months  had 
then  elapsed  since  an  apparently  successful  result. 

Granting  the  undoubted  occurrence  of  cures  by  this 
agent  in  the  many  isolated  cases  reported,  it  is  of  inter- 
est to  inquire  why  the  method  has  not  been  more 
generally  used,  in  view  of  the  reported  increase  of 
mortality  from  this  affection  under  the  recognized 
treatment.  This  reason  was  most  likely  of  a  threefold 
nature,  including  an  inadequacy  of  the  method  in  ad- 
vanced cases,  uncertainty  of  dosage  from  lack  of  ac- 
quaintance of  the  operators  with  means  for  measuring 
the  current,  and  the  general  dependence  of  the  pro- 
fession of  late  on  cutting  operations. 

To  Steavenson  and  Inglis- Parsons,  of  London,  is 
due  the  revival  of  the  remedy  under  modern  conditions 
of  electrical  knowledge,  the  latter  succeeding  in  curing 
a  number  of  mild  cases  by  massive  doses  of  the  cur- 
rent, flashed  and  reversed  through  the  growth  from 
needles  of  platinum  inserted  into  it  and  attached  to 
both  poles. 

It  was  with  these  encouraging  precedents  that  I  be- 
gan experimenting  with  carcinoma  of  the  cervix  uteri 
a  number  of  years  ago,  and  later  with  sarcoma  of  other 
portions  of  the  body,  and  after  several  preliminar\ 
publications  I  am  now  in  a  position  to  report  results 
which,  though  few  in  number  and  not  always  success- 
ful, are  yet  of  truly  momentous  importance  to  the  hu- 
man race.  For  as  a  result  of  these  experiments  I  can 
confidently  announce  that  a  real  cure  has  been  found 
for  sarcoma  in  accessible  locations,  and  a  probable 
cure  for  carcinoma  similarly  situated. 

The  principle  of  my  method  is  the  interstitial  difiFu- 
sion  and  impregnation  of  the  growth  with  nascent 
o.xychlorides  of  lethal  metals  by  electricity  in  massive 
doses.  The  destructive  effect  of  caustics  on  these 
neoplasms  is  well  known,  but  they  act  only  where 
placed,  exactly  as  the  knife  does.  By  my  method  a 
relatively  infinitesimal  portion  of  the  oxychloride  of 
mercury  acts  lethally  on  the  cancer  cells  because  of 
its  nascent  condition,  and  because  it  is  carried  by  the 
current  into  the  very  cells  themselves.  But  the  most 
important  point  is  that  by  the  method  we  may  cause 
the  medicinally  laden  current  to  seek  out  and  follow 
the  paths  of  proliferation  of  the  growth,  failure  to  de- 
stroy which  is  the  cause  of  its  reappearance  after  at- 
tempts at  extirpation  with  the  knife.  It  is  evident 
that  the  cancer  cell  has  less  resistance  to  this  intersti- 
tial attack  than  normal  tissue,  for  it  is  found  to  lose 
its  vitality  at  some  distance  from  the  electrode  without 
causing  necrosis  of  the  healthy  tissue,  though  all  tis- 
sues in  the  central  portion  of  the  mass  will  succumb  to 
the  method. 

The  metallic  substance  is  diffused  by  electrolytic 
cataphoresis — that  is,  it  is  produced  by  the  electrolytic 

'  Read  before  the  section  on  practice  of  medicine  of  the  .Ameri- 
can Medical  .Association  at  Thiladelphia,  June  4,  1897. 


July  31.  1897] 


MEDICAL    RECORD. 


151 


destruction  of  a  metal  placed  within  the  substance  of 
the  growth,  the  atoms  of  the  metal  uniting  with  the 
oxvgen  and  chlorine  and  also  with  the  albumin  of  the 
tissues,  and  this  compound,  together  with  still  nascent 
atoms  of  the  metal,  is  conveyed  physically  into  the 
tissues  by  what  is  called  cataphoresis,  following  the 
lines  of  least  resistance  toward  the  other  pole.  Con- 
siderable diffusion  occurs  in  all  directions  beneath 
this  active  pole,  since  the  lines  of  current  flow  spread 
out  in  a  widely  diverging  brush-like  form;  hence 
for  a  proper  saturation  it  is  necessary  to  bring  tlie 
metal  in  close  contact  with  all  portions  of  the  growth, 
or  else  employe  a  strong  current  to  convey  an  efficient 
density  to  the  desired  point. 

This  diffusion  of  a  metal  from  a  corrodible  elec- 
trode occurs  only  at  the  positive  pole,  it  is  therefore 
necessary  to  connect  the  active  electrode  to  this  pole 
of  the  battery.  Up  to  the  present  time  my  work  has 
been  conducted  with  active  electrodes  of  zinc,  heavily 
coated  with  mercury,  though  it  has  recently  occurred 
to  me  that  gold  and  mercury  would  be  a  better  com- 
bination. In  action  this  zinc  (or  gold)  becomes  smaller 
by  erosion,  but  the  greatest  loss  of  substance  occurs  in 
the  mercurial  coating,  which  must  be  renewed  before 
each  use  of  the  electrode.  The  e.xact  constitution  of 
the  metallic  o.^ychloride  thus  formed  has  not  yet  been 
determined,  but  it  is  most  probably  in  the  main  an 
oxychloride  of  mercury. 

The  cardinal  point  of  the  method  being  a  complete 
and  quick  saturation  of  the  growth  and  its  ramifica- 
tions, it  is  essentially  monopolar,  the  position  of  the 
negative  pole  being  so  arranged  that  the  whole  of  the 
possibly  diseased  area  shall  be  traversed  by  the  current 
on  its  way  from  the  positive  or  active  pole  to  the 
negative.  This  is  accomnlished  in  two  ways,  as 
follows : 

If  the  growth  be  small  the  active  electrode  is  placed 
within  it,  and  the  negative,  in  the  shape  of  a  large 
pad,  on  some  indifferent  surface  of  the  body.  Under 
this  arrangement  the  current  traverses  a  large  portion 
of  the  body,  and  on  account  of  the  diffusion  that  will 
occur  through  healthy  parts  I  have  never  employed 
more  than  five  hundred  milliamperes  in  this  way. 
Cocaine  anaesthesia,  simultaneouly  produced  by  cata- 
phoresis, is  sufficient  up  to  one  hundred  and  fifty  mil- 
liamperes, but  the  pain  developed  above  this  amperage 
makes  general  ana:sthesia  often  best.  At  the  lower 
current  strength  it  is  essential  that  the  application  be 
daily  or  thrice  weekly,  and  kept  up  until  the  whole  of 
the  morbid  area  has  been  either  destroyed  or  changed 
into  noniial  tissue  before  the  cavity-  thus  made  is  al- 
lowed to  heal.  Besides  small  and  recent  growths,  this 
method  is  also  applicable  to  inoperable  growths  of 
large  size,  in  which  the  situation  of  blood-vessels  or 
important  organs  renders  the  more  massive  and  imme- 
diate destruction  unwise. 

The  second  method,  in  which  an  operable  sarcoma 
or  carcinoma  is  destroyed  at  once,  is  applied  as  follows: 
The  patient  being  anaesthetized,  a  dozen  or  more  lancet- 
shaped  amalgamated  zinc  or  gold  electrodes  are  in- 
serted around  the  periphery  of  the  growth,  just  beyond 
the  area  of  infiltration,  each  electrode  being  attached 
to  one  of  a  leash  of  fine  wires  that  lead  to  the  positive 
pole  of  the  battery.  The  negative  pole,  a  disc  cov- 
ered with  absorbent  cotton  saturated  w-ith  a  solution 
of  potassic  arsenite,  iodide,  or  some  other  salt  with  a 
lethal  electro-negative  radicle,  is  placed  in  the  centre 
of  the  growth  itself.  It  will  be  necessary  to  make 
openings  in  the  skin  or  mucous  membrane  for  the 
zinc  lancets,  owing  to  their  brittleness  and  dulness. 
Everything  being  in  readiness,  a  current  of  about  a 
thousand  milliamperes  is  turned  on  through  a  controller 
and  reliable  meter  from  a  current  source  of  proper  volt- 
age. The  growth  will  blanch  and  shrink  at  once,  while 
areas   of   destruction   appear    about    each  blade    and 


probably  in  the  centre,  .\fter  a  duration  of  from  five 
to  fifteen  minutes,  according  to  the  size  of  the  growth, 
the  current  is  turned  off,  the  electrodes  are  removed, 
and  a  dry  dressing  or  acelanilid  ointment  is  applied. 

Such  is  a  brief  outline  of  the  methods  and  their 
technical  details,  but  it  should  be  understood  that 
these  details  are  subject  to  change  in  adapting  the 
method  to  individual  cases.  The  underlying  principle 
that  constitutes  the  novelty  is  that  there  is  a  virtue  in 
the  electric  diffusion  of  nascent  chemicals  throughout 
a  malignant  growth  which,  when  of  sufficient  density 
per  area,  will  cause  an  interstitial  death  and  ultimate 
absorption  of  the  malignant  cells  at  a  distance  from 
the  electrode,  without  destroying  the  connective  tissue 
surrounding  them,  and  that  this  intracellular  lethal 
action  is  independent  of  and  additional  to  the  ordi- 
nary destructive  action  of  a  strong  current  in  the  imme- 
diate neighborhood  of  the  electrodes.  With  this  im- 
portant fact  established,  the  cure  of  cancer  in  certain 
localities  becomes  a  mere  engineering  problem  in  this 
age  of  electric  power. 

I  am  happy  to  state  that  the  truth  of  these  proposi- 
tions has  been  corroborated  by  the  independently  con- 
ducted observations  of  Dr.  ]•  McFadden  Gaston,  of 
Atlanta,  Ga.,  who  reported  the  clinical  details  of  a 
successful  case  at  the  recent  meeting  of  the  American 
Surgical  Association  at  Washington. 

The  d"  covery  of  this  peculiar  action  of  nascent 
oxychloride  of  mercury  and  zinc  was  made  while  the 
writer  was  treating  a  case  of  inoperable  carcinoma  of 
the  groin  in  August,  1893,  by  means  of  a  carbon  elec- 
trode used  as  the  positive  pole.  The  rapid  disinte- 
gration of  the  carbon-ball  instrument  under  heavy 
currents  suggested  the  value  of  cataphoresis,  then 
already  in  use  in  endometritis  and  other  benign  con- 
ditions, and  the  mercury  was  first  employed  to  keep 
the  zinc  from  adhering  to  the  surface  of  the  wound- 
But  there  was  an  improvement  noted  in  the  growth  at 
some  distance  from  the  electrode  by  the  next  day,  and 
this,  coupled  with  the  facts  that  the  use  of  one  hundred 
milliamperes  each  time  required  that  the  mercury  be 
frequently  renewed  and  that  the  wound  became  rapidly 
aseptic,  showed  that  there  was  some  special  advantage 
in  the  mercury  thus  apparently  diffused.  This  case, 
in  which  the  carcinoma  was  about  three  inches  in  di- 
ameter and  adherent  to  the  great  vessels  of  the  thigh, 
became  much  better  under  prolonged  employment  of 
the  milder  method,  nearly  the  whole  of  the  diseased 
area  filling  in  with  healthy  granulations  and  the  gen- 
tleman regaining  the  power  to  walk,  but  it  was  unfor- 
tunately impossible  to  eradicate  the  cancerous  infiltra- 
tion of  the  femoral  artery  and  vein,  and  the  termination 
was  ultimately  fatal. 

Case  II. — The  second  case,  and  the  first  apparently 
complete  success,  was  a  recurrent  sarcoma  of  the  pal- 
ate which  had  been  partially  destroyed  by  the  writer 
by  ordinarv  electrolysis  in    1893.     This   man,  W.  H. 

L ,  aged  thirty-nine,  had  been  sent  to  me  by  Drs. 

Hemminger  and  Bixler,  of  Carlisle,  Pa.,  with  a  sar- 
coma of  the  left  palatal  arch  fully  the  size  of  a  goose 
egg,  which  he  had  declined  to  have  removed  at  the 
University  Hospital.  Respiration  and  deglutition 
were  greatly  interfered  with.  Nearly  complete  de- 
struction by  electrolysis  with  platinum  needles  gave 
him  comfort  for  a  year,  when  it  was  noticed  that  lumps 
were  re-developing  in  the  scar.  He  was  at  this  time 
(in  1894)  placed  on  the  mild  zinc-amalgam  method, 
which  was  kept  up  daily  for  six  weeks,  resulting  in  a 
disappearance  of  the  growth  after  some  additional 
treatment.  Three  years  have  since  elapsed,  and  late 
advices  report  no  sign  of  return. 

Case  III. — The  third  case  treated  by  the  metliod 

was  J.  B ,  a  farmer  of  Salem   County,  N.  J.,  aged 

fifty-five,  with  an  immense  epithelial  cancer  of  the 
face,  extending  from  the  external  angle  of  the  right  eye 


15: 


MI'DICAL    RECORD. 


[July  31,  1897 


to  the  under  border  of  the  lower  jaw,  the  functions  of 
the  corresponding  eye  and  ear  being  abolished  and 
the  right  ramus  of  the  lower  jaw  destroyed.  Before 
admission  to  the  Howard  Hospital  the  patient  was 
kindly  examined  by  Dr.  Duhring.  An  effort  was 
made  to  change  the  character  of  this  immense  surface 
by  tlie  milder  method  described,  tiie  current  not  ex- 
ceeding one  hundred  milliamperes,  and  the  treatment 
was  kept  up  for  some  months.  As  no  permanent 
change  of  sufficient  magnitude  was  produced,  he  was 
finally  sent  home  in  a  slightly  improved  condition. 
I  have  learned  since  that  he  died  about  a  year 
later. 

C.\SE  IV. — Mrs. ,  aged  fifty,  was  sent  to  me  by 

Dr.  Saylor  Brown,  formerly  of  Williamsport,  but  now 
a  resident  of  this  city,  on  October  8,  1895,  in  a  condi- 
tion of  profound  ana:-mia  and  cachexia  from  a  sigmoi- 
dal  ulceration  of  twelve  years'  standing.  She  suffered 
from  considerable  pain  in  the  right  groin,  and  had 
from  twenty  to  twenty-five  black  foul-smelling  stools 
a  day. 

Local  treatment  was  undertaken  with  a  new  hollow 
sigmoidal  electrode  devised  for  the  case,  with  an 
olive-shaped  active  surface  consisting  of  mercurialized 
zinc,  and  so  connected  with  a  syringe  that  its  insertion 
was  facilitated  by  a  cushion  of  albolene  dilating  the 
rectum  ahead  of  the  electrode  bulb.  A  stricture  was 
encountered  about  six  inches  from  the  anus,  which 
was  e.xtremely  sensitive.  From  forty  to  one  hundred 
milliamperes  were  employed  with  mercury  cataphore- 
sis.  After  several  applications  a  piece  of  tumor  tis- 
sue came  away,  about  the  size  of  the  last  joint  of  the 
little  finger,  and  was  sent  to  Dr.  Alfred  Stengel  for 
microscopic  examination,  who  pronounced  it  carcino- 
ma. A  large  number  of  such  pieces  came  away  subse- 
ciuently,  and  after  a  prolonged  treatment  she  was  sent 
hgme  considerably  improved  in  weight  and  general 
health,  and  having  not  more  than  two  or  three  stools 
per  day. 

Case  V.  — The  fifth  case,  Mrs.  H ,  aged  thirty- 
six,  of  Muncie,  Ind.,  came  under  my  care,  March  3, 
1896,  with  a  recurrent  sarcoma  of  the  left  pectoral 
muscles,  about  three  by  four  inches  in  superficial  ex- 
tent, and  apparently  pressing  upon  the  brachial  plexus 
and  axillary  vein,  for  the  left  arm  was  swollen  and  the 
seat  of  constant  pain.  Less  than  two  years  before,  in 
July,  1894,  the  left  breast  had  been  removed  by  Dr. 
Jos^eph  Eastman,  of  Indianapolis.  This  case  was  an 
excellent  one  for  the  stronger  method  described,  which 
had  not  yet  been  developed.  An  opening  was  made 
through  the  skin,  and  a  zinc-mercury  electrode  inserted 
daily  with  about  one  hundred  milliamperes,  under 
cocaine  cataphorically  applied.  After  a  number  of 
applications  the  swelling  and  pain  in  the  arm  disap- 
peared, and  later  a  piece  of  the  sarcomatous  tissue 
came  away,  about  two  and  one-half  by  four  inches  in 
size.  This  resembled  a  piece  of  sponge  filled  with 
cheesy  material,  and  after  its  removal  the  wound  was 
in  a  fair  way  to  heal.  Unfortunately  acute  mania  de- 
veloped at  this  time,  the  patient's  mental  condition 
having  been  suspiciously  exalted  for  some  time  be- 
fore admission,  compelling  her  husband  to  take  her 
home,  where  the  acute  mental  affection  speedily 
terminated  fatally. 

Case  VI. — Mrs.  A ,  aged   fifty-one,  of  Salem, 

N.  I.,  came  under  my  care  in  June,  1896,  suft'ering 
from  general  prostration.  In  searching  for  the  cause 
I  foimd  a  suspicious  ulceration  of  the  os  uteri,  the 
cervix  being  enlarged,  hard,  very  irregular  in  out- 
line, badly  ulcerated,  and  exuding  considerable  dis- 
ch.irge  with  characteristics  of  carcinoma.  Suspecting 
malignancy,  I  at  once  conferred  witii  her  husbantl  and 
suggested  the  new  treatment.  He,  however,  decided 
to  take  her  elsewhere  for  counsel.  A  week  later  he 
brought  his  wife  back  to  me,  saying  that  he  had  taken 


her  to  Prof.  '1  heophilus  Parvin,  who  concurred  in  sus- 
pecting carcinoma  and  advised  curettage,  to  be  fol- 
lowed later  by  removal  of  the  uterus.  Being  still  dis- 
satisfied, the  patient  was  taken  to  a  homceopathic 
physician,  who  after  examination  pronounced  the  affec- 
tion carcinoma,  but  proposed  that  she  come  under  his 
care  for  electrical  treatment.  This  latter  suggestion 
caused  the  gentleman  to  bring  his  wife  back  to  me, 
and  she  was  at  once  placed  on  mild  daily  applications 
of  the  mercurial  cataphoresis,  with  currents  varying 
from  fifty  to  one  hundred  milliamperes.  This  active 
treatment  did  not  continue  quite  six  weeks,  the  local 
conditions  improving  rapidly,  when  she  was  sent  hoine 
to  return  for  an  application  three  times  a  month. 
This  was  changed  later  to  once  a  month.  The  uterus 
is  now  normal,  the  diseased  area  being  completely 
healed  and  general  health  restored.  By  appointment 
I  took  the  patient  to  Dr.  Par\in,  May  28,  1897,  to  ver- 
ify her  present  condition. 

Case  VII. — Mrs.  P ,  aged  seventy,  is  now  under 

treatment  at  the  dispensary  of  Howard  Hospital  for 
carcinoma  of  the  cervix  of  the  scirrhus  variety.  The 
cervix  had  practically  disappeared  by  erosion  when 
the  treatment  was  begun  in  the  fall  of  1896,  and  the 
patient  suft'ered  from  frequent  hemorrhages,  continuous 
watery  discharges,  and  hypogastric  pain.  Under  mild 
applications  the  hemorrhage  ceased,  the  discharge 
lost  its  oft'ensive  nature  and  has  nearly  ceased,  together 
with  the  pain,  and  a  cachectic  condition  has  been  re- 
placed by  relative  health.  It  should  have  been  stated 
that  extensive  infiltration  of  the  pelvis  existed  at  the 
outset  of  treatment,  the  vagina  being  but  about  one 
inch  in  depth  and  surrounded  by  unyielding  walls. 
This  rigidity  of  the  shortened  and  narrowed  vagina 
continues,  but  the  whole  mass  can  now  be  slightly 
moved. 

Case    VIII. — Mrs.    E.    M ,    aged     forty-seven, 

came  under  my  care  at  the  Howard  Hospital  in  the 
autumn  of  1896,  and  hers  is  the  only  case  so  far  operated 
upon  by  the  stronger  method  described  in  this  paper. 
A  tumor  existed  in  the  scar  tissue  and  skin  at  the  site 
of  the  right  breast,  the  breast  having  been  removed  by 
Dr.  J.  William  \\'hite,  at  the  hospital  of  the  University 
of  Pennsylvania,  about  three  years  previously,  for  car- 
cinoma. The  tumor  was  about  the  size  of  a  half  of  an 
orange.  The  glands  of  the  axilla  had  not  been  re- 
moved at  the  operation  previously  performed,  and  were 
normal.  An  attempt  was  at  first  made  to  arrest  the 
growth  by  the  milder  method,  but,  tliis  appearing  too 
slow,  the  tumor  was  operated  upon  by  mercuric  cata- 
phoresis with  one  thousand  milliamperes,  at  the  hospi- 
tal, May  3d  last,  in  the  presence  of  Drs.  A.  E.  Roussel, 
E.  P.  Bernardy,  and  the  hospital  residents.  The  tu- 
mor at  this  time  had  increased  considerably  since  first 
seen,  measuring  three  and  one-half  by  three  and  three- 
fourths  inches.  An  immediate  blanching  and  shrinking 
of  the  growth  was  noticed,  with  the  production  of  small 
necroses  at  the  site  of  each  electrode  and  in  Uie  centre. 
At  the  end  of  thirteen  minutes  the  current  was  turned 
oft",  the  electrodes  were  withdrawn,  a  dry  dressing  was 
applied,  and  the  patient  put  to  bed.  The  necrosed 
portions  separated  painlessly  in  ten  days,  leaving  an 
apparently  healthy  granulating  surface;  but  before 
this  time  the  interesting  fact  was  noted  that  the  tissues 
between  the  electrodes,  which  hatl  been  hard,  swollen, 
vascular,  and  purplish  with  malignancy,  but  had  not 
become  necrosed,  were  now  level  with  the  surrounding 
surface,  soft,  and  possessed  of  a  healthy  pink  color, 
showing  that  an  influence  or  substance  passed  between 
the  electrodes  capable  of  destroying  the  cancer  cells 
that  was  unable  to  devitalize  the  normal  tissues  con- 
taining them.  All  evidences  of  malignancy  had  dis- 
appeared, except  at  one  spot  about  the  size  of  a  marble, 
which  may  require  additional  treatment. 

A  review  of  these  eight  experimental  cases  will  per- 


July  31,  1897] 


MEDICAL    RhXORD. 


153 


mit  a  provisional  classification  about  as  follows:  Two 
were  cured:  two  apparently  cured:  two  benefited,  of 
which  one  is  hopeful ;  and  two  were  failures  to  arrest 
the  disease.' 


INFLAMMATION     OF     JOINTS     IN     GONOR- 
RHCEAL    PATIENTS.^ 

By    EMANUEL   J.    SENN,    M.U., 


I>f  order  to  be  practical,  it  is  best  to  speak  with  Koe- 
nig  of  inflammation  of  joints  in  gonorrhceal  patients. 
As  a  matter  of  convenience  and  brevity,  it  is  well  to 
speak  of  gonorrhceal  arthritis,  because  that  term  implies 
etiological  and  pathological  specific  meaning.  It  is 
rather  the  exception  than  the  rule  to  find  the  specific 
organism  in  the  exudate  of  the  joint.  Nevertheless, 
the  pathological  conditions,  together  with  the  clinical 
histor}',  point  as  conclusively  to  the  gonorrhceal  origin 
as  heredit}'  and  pathological  conditions  of  a  tubercu- 
lous joint  point  to  its  specific  bacterial  origin;  al- 
though the  bacteriologist  often  fails  to  find  the  bacillus 
in  the  joint  contents.  Notwithstanding  that  the  joint 
affection  known  as  gonorrhceal  rheumatism  was  recog- 
nized for  centuries,  it  did  not  receive  the  attention  it 
deserved  until  the  discovery  of  the  gonococcus  by 
Neisser;  when  its  specific  nature,  like  other  forms  of 
metastasis  of  gonorrhceal  origin,  was  demonstrable  in 
enough  instances  at  least  to  establish  a  common  ori- 
gin. Petrus  Farestus,  in  1507,  was  the  first  author 
who  wrote  extensively  on  this  subject.  At  the  end  of 
the  last  centurj'  the  study  of  gonorrhceal  arthritis 
gained  credence  through  the  observations  of  Hunter 
and  Ricord;  latterly  of  Loraine  and  Rollet,  who  did 
much  to  make  the  affection  a  distinct  nosological 
entity.  Montiggia,  at  the  close  of  the  last  century, 
pointed  out  the  connection  between  gonorrhcea  and 
rheumatism,  and  proved  gonorrhceal  rheumatism  to  be 
a  distinct  form  of  rheumatic  disease.  Brandes,  in  1854, 
was  the  first  to  bring  it  before  the  public  as  it  is  known 
to-day.  Gonorrhceal  arthritis  is  not  a  very  prevalent 
disease,  occurring  in  about  two  per  cent,  of  all  cases  of 
gonorrhoea.  It  is  almost  impossible  to  get  a  correct 
ratio  of  the  joint  complications  accompanying  gonor- 
rhcea, for  the  reason  that  they  appear  during  the  later 
stages  of  the  acute  disease,  or  a  gleet;  and  when  a  care- 
ful clinical  histor}-  is  not  elicited  during  the  course  of 
such  a  complication  the  disease  is  not  apt  to  be  traced 
to  its  proper  source.  Patients  never  think  of  such  an 
association;  in  fact,  the  natural  tendency  is  to  shield 
the  guilt  of  gonorrhoea,  and  lay  stress  on  the  symptoms 
of  the  joint  complications.  It  is  needless  to  say  that  in 
an  enormous  number  of  these  cases  the  affection  is  er- 
roneously diagnosed  as  tuberculosis,  rheumatism,  or 
otherwise,  and  consequently  the  percentage  of  such 
complications  cited  in  literature  is  small.  Many 
theories  have  been  advanced  to  explain  the  etiology 
of  gonorrhceal  joint  complications.  We  must  first 
consider  whether  the  parent  disease  is  general  or 
local,  .\ndry  says  that  it  is  inconsistent  to  speak 
of  a  gonorrhcea  as  a  local  and  at  the  same  time  as 
a  general  disease.  It  must  always  or  never  be  a 
general  affection.  It  must  be  admitted  that  ordi- 
nary typical  gonorrhcea  in  its  evolution  presents 
no  general  manifestations  in  the  way  of  fever  or 
general  symptoms,  and  we  should  emphatically  con- 
sider it  a  local  disease.  It  is  only  under  certain  con- 
ditions  that    metastases  occur.      After  the  discover)- 

'  The  last  patient  mentioned  was  placed  under  a  second  cata- 
phoric operation  on  June  4th  before  invited  guests  from  the  as- 
sociation and  the  remaininjj  nodule  destroyed  by  a  monopolar 
application  of  five  hundred  milliamperes. 

''  Read  before  the  Tri-State  .Medical  Society,  St.  I.oiiis,  Mo.. 
April  C,  1S97. 


of  the  gonococcus  by  Neisser  in  1879,  gonarthri- 
tis  became  more  important  in  the  eyes  of  the  pathol- 
ogist, as  the  etiological  factor  opened  a  pathway  which 
was  formerly  shrouded  in  mystery.  Bacteriological 
examinations  of  joint  effusions  were  made,  and,  as  fail- 
ure often  attended  such  efforts,  other  theories  were  ad- 
vanced as  an  explanation  of  the  primal  cause.  Roso- 
limas  believed  that  the  gonorrhceal  poison  produced 
pathologic  conditions  at  a  distance  through  refiex 
action  on  the  vasomotor  nerves.  This  theory  is  also 
supported  by  Lewin.  Senator  explains  the  cause 
through  inriammatory  irritation  gradually  propagated 
from  the  urethra  to  the  sacral  plexus  and  spinal  cord, 
where  it  affects  the  trophic  ner\e  fibres.  Guyon  and 
Janet  have  the  opinion  that  gonorrhceal  metastasis  is 
the  result  of  toxa;mia  produced  by  the  ptomains  of 
gonococci  in  the  urethra.  Shuster  claims  that  the 
joint  affections  may  be  due  to  syphilis  and  gonorrhcea 
combined.  I^iday,  although  believing  in  the  specific 
infectious  character  of  gonorrhcea  as  the  exciting  cause, 
gives  clue  importance  to  a  rheumatic  diathesis  as  a 
cause  of  complications  of  the  disease,  such  as  cystitis, 
orchi-epididymitis,  iritis,  and  arthritis.  Thirj-  and 
Guyon  maintain  that  there  is  no  direct  connection  be- 
tween gonorrhcea  and  rheumatism,  but  surmise  that  the 
former  througli  the  depressing  effects  on  the  system 
favors  the  development  of  a  diathesis  which  has  up  to 
the  time  of  the  clisease,  that  is,  the  gonorrhcea,  been 
latent.  Peter  and  Bouillard  think  gonorrhceal  arthri- 
tis is  clue  to  rheumatism,  the  gonorrhcea  simply  provok- 
ing the  rheumatic  diathesis.  Duboc  is  of  the  opinion 
that  when  the  disease  occurs  in  later  life  it  is  due  to 
a  gouty  predisposition,  because  it  is  more  often  poly- 
articular on  account  of  the  awakening  of  the  gouty 
diathesis. 

Tammasoli  and  Hutchinson  consider  gonorrhceal 
arthritis  only  articular  rheumatism.  Garrod  thinks  it 
due  to  an  anaemia.  Loeb  does  not  attribute  the  cause  to 
the  action  of  the  gonococcus  directly,  but  supposes  that 
the  gonorrhceal  process  in  the  posterior  urethra  plays 
an  etiological  role  by  acting  as  an  infection  atrium  for 
pus  microbes  into  the  lymph  and  blood  streams,  and 
then  to  the  locus  minoris  resistentia;  in  the  joint. 
As  proof  he  mentions  the  observations  of  Traube, 
Koenig,  and  Lewin.  Andry  is  of  the  same  opinion. 
He  injected  gonorrhceal  pus  into  the  peritoneum  and 
also  into  the  auricular  vein  of  rabbits  without  positive 
results.  That  the  joint  affections  follow  gonorrhaa 
he  thinks  is  beyond  question,  but  claims  that  they 
can  also  follow  ordinary  catheterization.  Fournier 
regards  gonarthritis  to  be  due  to  injury  of  the 
urethra,  and  calls  it  urethral  rheumatism.  Panas 
offers  this  explanation  for  the  arthritis  which  follows 
catheterization :  "  There  is  erosion  of  the  mucous 
membrane  of  the  urethra,  which  acts  as  an  infection 
atrium  to  the  small  superficial  vessels.  Congestion 
of  the  kidneys  is  the  result,  not  by  reason  of  refiex 
action,  but  due  to  the  septicremia,  which  causes  itrarraia 
and  secondarily  articular  affections."  Ricord  and  R. 
Bergh  think  that  posterior  chronic  urethritis  is  a  neces- 
sary concomitant  for  gonorrhceal  arthritis.  Auvergniot 
assigns  the  cause  to  the  gonococcus,  although  there 
must  be  a  predisposition.  Kammerer  believes  that  as  in 
osteo-myelitis,  in  which  a  previous  injury  may  produce 
a  point  of  least  resistance  for  transient  pus  microbes, 
so  in  gonorrhceal  arthritis  a  previous  injury  may  be  a 
prominent  factor.  Bond  believes  the  joint  complica- 
tions are  caused  by  a  phlebitis  of  the  prostatic  veins 
rather  than  by  an  infiammation  of  the  lymphatics,  for  it 
is  common  for  the  lymphatics  to  be  affected  in  the  early 
stage  of  the  disease  and  it  is  not  followed  by  joint  com- 
plications. Guerin,  Loraine,  and  Les^gne  considered 
gonorrhcea  a  general  disease,  and  pointed  out  in  sup- 
port of  their  theory  the  fact  that  it  could  produce  remote 
complications.     They  ascribed    the    local    manifesta- 


^54 


MEDICAL    RECf)RD. 


[July  31,  1897 


tions  of   the  disease  as  a  period  of   incubation,  and 
insisted  that  no  remote  complications  would  ensue   if 
the  disease  could  be  stopped  during  this  period,  or  if  it 
did  not  extend  beyond  it.     That  inflammation  of  joints 
during  an  attack  of  gonorrhcea,  irrespecti\e  of  whether 
it  occurs  during  the  acute  stage  or  at  a  later  period, 
is  caused  solely  through  the   invasion   of  the  gono- 
coccus  per  se,   is    the  ftii-de-sin-k  opinion  of  to-day. 
Great  weight  was  given  to  this  etiological  basis  by  no 
less  an  authority  than    Fournier.     Not  only  did   the 
discovery  of  the  gonococcus  throw  light  on  its  migra- 
tory character,  but  the   possibility  of  cultivation   of 
the  diplococcus  was  the  basis  for  philosophical  de- 
ductions and  the  means  of  demonstrating  cause  and 
effect.      The    introduction    of  the   Wertheim   nutrient 
medium  (blood-serum  agar)  opened  a  new  field  for  the 
study  of  the  pathogenic  action  of  the  gonococcus  upon 
the  different  tissues.     Paltauf  and  Lang  were  the  first 
to  find  the  gonococcus  in  joint  effusions  and  to  confirm 
it  by  culti\'ation  on  nutrient  media.     Columbina  from 
a  joint  effusion  of  gonorrhceal  arthritis  was  unable  to 
obtain   any  pus  germs  whatever  upon  ordinary  media: 
but  upon  human  blood-serum  agar  obtained  abundant 
pure  cultures  of  the  gonococcus.     Petrone,  Kammerer, 
Sonnenburg,   and  Smirnoff  found   the  gonococcus   in 
joint  contents,  while  Leistikow,  Haslund,  Hofta,  Haab, 
and  Hornemann  were  unable  to  find  it,  but  cultivated 
upon  the  media  instead  the  staphylococcus  pyogenes. 
Kraske,  Brieger,  and  Ehrlich   in   numerous  e.xamina- 
tions  have  failed  to  find  the  specific  microbe.      Has- 
lund   examined   the    joint   exudate    in  four  cases    of 
gonorrh(tal   rheumatism  in   periods  varying  from  two 
to  seventeen  days  after  the  initiation  of  the  symptoms 
without  finding  the  gonococcus.      Pure  cultures  from 
cases  of  gonorrhceal   arthritis  have  been  obtained  by 
Hock,  Neisser.  and  Uffreduzzi,  the  observation  of  the 
last    named    being    conclusive,   as    the  cultures  were 
tested  with   positive   results  by   inoculation   into  the 
urethra.      Petrone  in  two  cases  of  gonorrhctal  rheuma- 
tism found  a  micrococcus  identical  with  that  described 
by  Neisser  in  the  pus  discharge  of  the  urethra,  in  the 
blood,  and  also  in  the  effusion  of  the  affected  joint. 
He  concludes  that  gonorrhceal  rheumatism  is  a  metas- 
tasis of  the  specific  cause,  being  transmitted  through 
the  medium  of  the  blood  to  the  tissue  having  a  dis- 
position for  rheumatic  affections.     Hewes  reports  two 
cases  of  gonorrhceal  rheumatism  in  which  the  specific 
bacterial  organism  was  found  in  the  blood.     In  one  case 
the  cultures  of  the  fourth  generation  were  inoculated 
upon  the  vaginal  mucous  membrane  of  a  dog;  thirty-six 
hours   later  a  thin  puriform  discharge  was  visible  at 
the  vaginal  orifice.     .\  bacteriological  examination  of 
this  discharge  revealed  the  presence  of  the  biscuit- 
shaped  diplococcus  both  within  and  without  the  pus 
cells.      Distinct  colonies  of  the  diplococcus  were  ob- 
tained by  culture  from  the  discharge.      Hall,  of  New 
York,  demonstrated  the  presence  of  gonococci   in  tlie 
knee-joint  in  the  fourth  case  on  record.     During  the 
later  stages  of  the  disease  he  was  unable  to  find  them. 
Kammerer  concludes  that  gonococci  do  not  thrive   in 
a   joint  fluid  more   than  a  few  days.     In  one  case  he 
found  gonococci  on  the  second  day,  but  was  unable  to 
find  them  later.      However,  the  gonococcus  was  found 
in  the  elbow-joint  on  the  twenty-sixth  day  by  W'ysche- 
minski,    in   the   hip-joint   on    the   fourteenth   day   by 
L()wenstein,  and    in   the    knee-joint    on    the    twentv- 
second  day  by  Bergmann. 

Joint  inflammation  can  appear  during  any  stage  of 
life,  but  is  most  prevalent  in  young  adults,  as  gonor- 
rhoea is  more  frequent  at  tha't  time.  Duboc  in  his 
able  thesis  comes  to  the  conclusion  that  gonarthri- 
tis  appears  most  often  before  twenty-four  years  of  age. 
This  form  of  arthritis  has  the  appearance  of  being  a 
primary  osteo-periostitis  of  the  epiphyseal  cartilage, 
which  is  in  a  state  of  great  physiological  activitv  dur- 


ing this  period.  According  to  the  same  authority,  it 
is  often  found  in  the  wrist-joint,  and  most  frequently 
in  that  of  the  right  hand,  because  it  is  used  the  more 
often. 

Gonorrhceal  microbes  may  cause  general  infection 
and  localize  in  joints  without  being  germinated  in  a 
specific  urethritis.  Deutschmann,  Panas,  von  Poncet, 
Galezowski,  Lucas,  Tundick,  Zatvornicke,  and  Wid- 
mark  observed  cases  following  blennorrhoea  neona- 
torum. In  quite  a  number  of  cases  the  gonococcus 
was  found  in  the  secretions  of  the  conjunctiva,  and 
also  in  the  eftusion  of  the  affected  joints.  Lucas  re- 
ports two  cases  following  purulent  ophthalmia  in  in- 
fants. In  one  case,  that  of  a  boy  eighteen  days 
old,  affecting  both  the  left  wrist  and  left  knee,  syphi- 
lis was  positively  excluded.  The  mother  suffered 
from  acute  gonorrhoea  at  the  time  of  birth.  There 
was  purulent  ophtiialmia  of  both  eyes.  The  other,  an 
infant  three  months  of  age,  had  an  arthritis,  impli- 
cating the  left  knee-joint.  The  child  had  ophthalmia 
four  days  after  birth,  but  inasmuch  as  it  concerned 
only  one  joint,  Lucas  thinks  that  the  arthritis  might 
have  been  due  to  accidental  causes.  Haushalter 
reports  a  case  of  gonarthritis  in  the  newborn,  the 
right  knee  and  left  wrist  being  involved.  Puru- 
lent ophthalmia  was  also  present.  The  effusion  in 
tile  knee-joint  contained  polynuclear  leucocytes  and 
gonococci.  In  the  newborn  the  affection  is  generally 
of  a  mild  type,  monarticular,  and  usually  involving 
the  knee-joint.  There  is  little  general  disturbance, 
and  cure  takes  place  usually  in  about  a  month! 
Gonorrhceal  complications  of  joints  are  not  so  likely 
to  occur  in  the  female  sex  as  in  the  male.  This  coin- 
cidence is  probably  due,  according  to  Foot,  to  the  fact 
that  the  vaginal  and  urethral  mucous  membrane  is 
thicker  and  tougjier  than  the  lining  of  the  male 
urethra. 

Davies-Colley  claims  that  the  disease  occurs  as 
often  in  women  as  in  men.  Auvergniot  reports  1 1 1 
cases  of  gonorrhceal  arthritis  in  women.  One  joint 
was  affected  in  88  instances,  in  the  remaining  the 
disease  was  polyarticular. 

Philpot  reports  a  case  affecting  the  metatarso-cunei- 
form  joint  in  a  girl  nine  years  of  age.  Hartley  re- 
ports 4  cases  occurring  in  the  female.  Of  252  cases 
collected  by  W.  P.  Northrup,  230  were  male  and  22 
female. 

While  the  disease  has  a  predilection  for  single 
joints,  in  many  instances  it  assumes  a  polyarticular 
aspect.  Julien  found  the  disease  polyarticular  in 
59  instances  and  monarticular  41  times.  Finger 
found  the  knee  affected  136  times:  tibio-tarsal.  :;9; 
wrist,  53;  fingers,  35;  elbow,  25;  shoulder,  24:  hip, 
18;  temporo-maxillary,  10:  metatarsal,;;  sacro-iliac, 
4:  sterno-clavicular,  4:  chondro-costal,  2:  and  inter- 
vertebral, 2  times.  Northrup  found  the  knee  affected 
91  times:  ankle.^;;  foot  (.small  joints),  40  :  wrist,  27; 
heel  and  toes.  21;  elbow,  18:  hip,  16;  shoulder,  16; 
hand  (small  joints),  n;  sterno-clavicular,  3:  and 
temporo-maxillary,  2  times. 

Hortelloup  reports  two  cases  of  gonorrhceal  ar- 
thritis of  the  sterno-clavicular  joint.  Loeb  savs  the 
knee-joint  is  nuxst  often  affected  and  the  wrist-joint 
very  seldom.  Davies-Colley  declares  that  the  disease 
can  occur  in  any  joint,  but  lie  found  it  most  fre- 
quently in  tile  elbow-joint.  In  those  predisposed  to 
gonorrheal  arthritis,  one  attack  does  not  furnish  a 
lease  of  immunity  to  subsequent  attacks.  When 
the  joint  lesion  is  due  to  a  specific  urethritis,  each 
catheterization  is  liable  to  cause  an  exacerbation  of 
the  joint  symptoms  or  to  produce  the  disease  in  other 
joints.  Later  attacks  of  gonorrha'a,  whether  due  to 
an  awakening  of  a  latent  process  or  to  an  additional 
infection,  are  followed  almost  without  exception  by 
joint  complications.      Hermet   reports   a  case,  in    the 


July  31,  1897] 


MEDICAL    RECORD. 


155 


service  of  Professor  Fournier,  of  a  man  thirty-five  years 
of  age,  of  apparent  good  health,  who  in  six  years  con- 
tracted gonorrhtta  five  different  times.  Each  attack 
was  followed  by  conjunctivitis  and  polyarticular 
arthritis.  Basset  obser\ed  a  patient  who  in  one  year 
had  gonorrhoea  five  limes,  presumably  an  auto-infec- 
tion, followed  each  time  by  painful  arthritis.  There 
was  a  typical  hydrarthrosis  of  the  knee  and  elbow. 
The  disease  also  attacked  the  smaller  joints,  not  the 
usual  seat  of  rheumatism,  such  as  the  temporo-ma.xil- 
lar)-,  sterno-clavicular,  metatarso-phalangeal,  and  the 
bursse  of  the  retro-  and  sub-calcanea.  After  each 
catheterization  for  cystitis  and  stricture,  there  were 
exacerbation  of  fever  and  pain  in  the  joints. 

The  gonococcus  does  not,  as  a  rule,  leave  its  habitat, 
the  mucous  membrane  of  the  urethra  or  conjunctiva, 
while  it  is  exerting  itself  in  acute  infiammation.  It 
is  only  when  the  acute  symptoms  have  subsided  that 
the  latent  microbe  finds  its  way,  through  some  second- 
ary cause  unknown  at  the  present  day,  into  the  general 
circulation  or  into  the  lymphatic  system,  and  subse- 
quently by  it  reaches  a  serous  membrane  at  a  distant 
seat.  Of  sixty-five  cases  of  gonorrhoeal  rheumatism, 
Brandes  in  fifty-one  found  gleet  as  its  precursor,  in 
seven  acute  gonorrhcea,  and  in  seven  it  was  impossible 
to  tell  whether  the  joint  lesions  originated  in  an  acute 
or  in  a  chronic  gonorrhcea.  The  gonococcus  on  mu- 
cous membranes  such  as  the  urethra  and  conjunctiva 
acts  as  a  pus  microbe;  but  in  its  migration  to  serous 
membranes  it  plays  an  inferior  role,  exciting  rather 
a  plastic  inflammation.  Bumstead  says  that  gonor- 
rhoeal rheumatism  is  essentially  a  hydrarthrosis  and 
suppuration  very  rarely  occurs.  Instances  of  sup- 
purative arthritis  have  been  observed  during  a  gonor- 
rhcea, although  such  is  rarely  the  case,  and  then  it  is 
in  all  probability  not  pus  due  to  the  action  of  gono- 
cocci,  but  is  the  result  of  a  mixed  infection,  the  same 
as  an  infective  arthritis  following  scarlet  or  typhoid 
fever.  On  mucous  membranes  the  gonococcus  has 
the  action  of  a  pyogenic  microbe;  the  pus  is  not 
the  direct  result  of  the  gonococcus  but  of  the  chemical 
substances  produced  by  it.  This  is  evident  from  the 
very  fact  that  pus  corpuscles  appear  before  the  specific 
agents  have  reached  the  vascular  layer  of  the  mem- 
brane. The  gonococcus  first  attacks  the  surface  of 
mucous  membranes  and  only  after  passageways  have 
been  formed  by  the  inflammatory  changes  do  the 
deeper  structures  become  implicated.  The  gonococcus 
has  a  special  predilection  for  mucous  membrane,  as 
is  well  shown  by  the  regularity  with  which  purulent 
ophthalmia  is  produced  by  the  infection  of  the  con- 
junctiva with  gonorrhoeal  pus.  The  real  seats  of  gon- 
orrhceal  infection  are  the  mucous  membranes  lined 
with  columnar  epithelium.  Andry  believes  that  the 
gonococcus,  when  in  course  of  emigration  to  predis- 
posed joints,  maintains  its  viability  in  the  blood 
through  the  oxygen  it  contains.  Again  its  possibility 
of  thriving  on  serous  membranes  speaks  in  favor  of 
cells  of  the  papillary  type  for  its  maintenance. 
Aubert  says  the  blennorrhagic  secretion  is  alkaline. 
The  gonococcus  thrives  better  on  membranes  with  an 
alkaline  reaction.  In  the  bladder  the  gonococcus  is 
not  so  persistent  as  in  the  urethra,  which  is  alka- 
line. It  is  well  known  that  the  life  of  the  gonococ- 
cus in  joint  cavities  is  short,  since  effusions  of 
gonorrhoeal  joints  have  been  examined  soon  after  the 
symptoms  presented  themselves,  with  positive  results 
as  regards  the  specific  cause,  while  subsequent  exami- 
nations proved  negative,  although  the  symptoms  pur- 
sued the  typical  cycle  after  the  disappearance  of  the 
primary  cause.  This  has  been  the  verdict  of  some  of 
the  most  expert  and  competent  pathologists,  including 
Kammerer,  and  for  this  reason  the  sjiecific  cause  from 
a  metastatic  standpoint  is  still  doubted  by  a  small 
minority  of  autliorities  on  this  subject.     Analogically 


speaking,  we  need  only  look  to  the  peritoneum, 
which  is  a  specialized  form  of  mesoblastic  tissue 
similar  to  the  synovial  membrane  of  joints.  Con- 
sider, as  pointed  out  by  Sinclair,  the  two  different 
pathologic  roles  played  by  the  same  microbe  on  tissues 
of  different  embryological  origin.  The  gonococcus, 
while  causing  purulent  infiammation  of  the  mucous 
membrane  of  the  Fallopian  tubes,  in  the  surrounding 
connective  tissues  is  not  prone  to  suppuration,  but 
manifests  an  intrinsic  vegetative  capacity  by  the  for- 
mation of  adhesions.  We  find  the  same  pathological 
condition  in  joints.  Of  two  hundred  and  seventy  one 
cases  observed  by  Bornemann,  only  three  were  of  a 
purulent  nature.  Of  eleven  cases  in  which  Haslund 
aspirated  gonorrhoto.'  joints,  he  found  the  contents 
in  ten  of  a  purulent  nature,  or  on  the  border  line 
of  being  pus,  the  so-called  catarrhal  pus  of  Volk- 
niann ;  but  he  was  not  able  to  find  the  specific 
cause.  In  the  other  case  the  contents  were  hemor- 
rhagic. The  patient  was  constitutionally  undermined, 
and  the  joint  was  massaged  for  a  long  time.  He 
compares  this  condition  to  the  analogue  of  an  in- 
cipient hemorrhagic  exudate  in  pleurisy,  the  result  of 
a  low  constitutional  condition.  The  ten  so-called 
purulent  cases  were  not  evidently  of  pyogenic  origin, 
but  simply  simulated  pus.  In  the  last  few  years, 
Koenig  has  done  more  than  any  one  else  in  the 
investigation  of  the  pathological  anatomy  of  gon- 
orrhoeal joints.  As  he  states,  the  mortality  of  this 
disease  is  so  small,  and  arthrotomy  is  so  seldom 
called  for,  and  the  opportunity  for  visual  inspection 
of  the  pathological  field  is  so  limited,  that  at  the 
present  time  the  true  pathology  is  in  need  of  en- 
lightenment. 

Koenig  gives  the  following  classification  : 
Gonorrhoeal  arthritis. 

1.  Hydrops  articularis. 

2.  Hydrops    articularis   sero-fibrinosus  et 

catarrhalis  (Volkmannj. 

3.  Empyema  of  joint. 

4.  Phlegmon  of  joint. 

The  simple  hydrops  is  the  mildest  form  and  has  a 
tendency  to  definitive  healing.  The  fluid  contents 
are  of  a  clear  synovial  type.  The  fibrinous  form  is 
characterized  by  a  hydrops  in  which  there  are  floc- 
culent  masses  and  which  has  a  great  tendency  to  cause 
ankylosis.  Empyema  of  a  joint  in  gonorrhoeal  pa- 
tients is  rare,  as  verified  by  statistics.  The  phlegmo- 
nous type  is  a  severe  form  of  inflammation,  in  which 
the  ravages  of  the  gonococcus  are  of  a  very  destructive 
character.  There  are  erosion  and  disintegration  of 
cartilages,  thickening  of  the  capsule  and  ligaments, 
and  a  phlegmon  of  surrounding  connective  tissues  often 
accompanied  by  inflammation  of  bursae  and  tendon 
sheaths.  In  the  severe  forms  of  joint  inflammations, 
even  with  little  external  swelling,  great  damage  can 
be  done.  Koenig  has  seen  a  marked  genu  valgum 
formed  and  a  backward  luxation  of  the  tibia  in  arthri- 
tis of  only  ten  or  twelve  days'  standing.  The  same 
authority  has  obsen,ed  absolute  bony  ankylosis,  in 
which  the  entire  joint  cavity  was  obliterated  without  a 
vestige  of  its  anatomical  identity  being  left,  in  three 
months'  time.  There  is  no  other  disease  with  such 
a  marked  tendency  to  ankylosis,  except  a  form  of 
arthritis  following  puerperal  fever,  which  also  mani- 
fests a  marked  tendency  to  ankylosis  and  which  prob- 
ably ultimately  is  of  gonorrhoeal  origin.  Bradford 
reports  a  case  of  ankylosis  of  the  vertebrK  following 
gonorrhoeal  rheumatism  and  extending  from  the 
seventh  cervical  vertebra  to  the  sacrum.  Fournier 
mentions  a  form  of  gonorrhoeal  arthritis  which  has  a 
predilection  for  the  small  joints  of  the  foot,  causing 
jjreat  deformity.  He  speaks  of  the  subject  under  the 
title  "Pied  blennorrhagique."  Amarel  wrote  an  ex- 
haustive thesis  on  this  form  of  arthritis.      He  called 


156 


MEDICAL    RECORD. 


[July  31,  1897 


it  "  Affection  polyarthrite  deformante  progressive 
pseudo-noueuse."  It  attacks  the  phalanges,  which  are 
deformed,  and  there  is  amj-otrophy  of  muscles.  He 
■observed  nine  cases  of  this  variety  in  Foumier's  clinic, 
and  concludes  that  it  is  probably  an  atrophy  of  reflex 
■origin.  According  to  Roustan,  when  there  is  a  gonor- 
rhceal  peri-arthritis  there  is  great  liability  to  muscular 
■contractures.  Dercum  reports  the  case  of  a  man  thirty- 
six  years  of  age  with  gonorrhceal  arthritis  of  the  right 
knee  and  right  elbow,  followed  by  inflammation  in 
other  joints.  Four  weeks  later  there  was  muscular 
wasting  of  the  upper  and  lower  e.xtremities.  Electrical 
examination  showed  no  qualitative  change  in  the 
muscles.  At  the  time  of  the  report  the  patient  was 
improving.  Myrtle  reports  the  case  of  a  man  thirty- 
two  years  of  age— gonorrheal  arthritis  of  the  right 
knee  and  wasting  of  muscles  of  both  sides  from  the 
hips  downward,  showing  the  origin  of  the  atrophy  to 
be  central  and  not  due  to  the  arthritis.  Souplet,  His, 
Leyden,  Councilman,  and  Wilms  observed  cases  of 
gonarthritis  complicated  by  endocarditis  and  myocar- 
ditis. 

The  clinical  history  of  gonorrhceal  patients  is 
variable.  There  is  a  complexus  of  symptoms  which 
are  characteristic  of  the  different  forms.  Gonorrhceal 
joint  complications  may  be  acute  or  chronic.  The 
rule  is  that  when  the  precursor  is  a  chronic  ure- 
thritis the  joint  invasion  is  initiated  by  acute  symp- 
toms. It  is  very  seldom  indeed  that  joints  are  in- 
fected during  the  acute  disease.  The  inflammation 
may  attack  one  joint  alone ;  but  often  it  may  first  be 
multiple.  Roustan  described  cases  in  which  the  pain 
was  not  localized.  About  three  weeks  after  the  incipi- 
ency  of  the  gonorrhcea,  there  was  slight  fever  with 
tenderness  in  the  neighborhood  of  certain  joints,  but 
without  marked  swelling  or  oedema  in  the  region  of  a 
particular  joint,  and  which  lasted  several  hours  or  days. 
The  same  symptoms  appeared  in  other  joints,  being  of 
a  fugitive  nature,  when  finally  the  disease  selected 
some  joint  in  particular  and  became  monarticular. 
He  is  of  the  opinion  that  this  peculiar  localization  of 
the  disease  needs  further  observation  and  investiga- 
tion. Acute  gonorrhceal  arthritis  usually  makes  its  ap- 
pearance from  four  to  six  weeks  after  the  primary  symp- 
toms of  the  gonorrhcea.  The  pain  is  intense.  There 
is  elevation  of  the  temperature  to  103°  F.,  or  even  105" 
F.,  and  a  corresponding  acceleration  of  the  pulse, 
often  ushered  in  by  a  chill.  The  pain  is  worse  at 
night  and  the  slightest  movement  causes  the  patient  to 
cry  with  pain.  The  whole  area  around  the  joint  is 
tender,  but  there  is  no  particular  spot  of  tenderness. 
There  is  flexion  of  the  joint  due  to  the  patient  assum- 
ing the  position  affording  the  greatest  degree  of  relief. 
According  to  Bond,  a  pathognomonic  sign  is  tenderness 
of  the  heels  in  walking.  The  swelling  of  the  knee- 
joint  is  peculiar  and  almost  diagnostic,  the  effusion 
being  most  marked  in  the  upper  part  of  the  joint 
under  the  vasti  muscles.  After  exudation  into  the 
joint,  digital  palpation  will  reveal  fluctuation.  When 
the  inflammatory  process  has  become  peri-articular, 
there  is  great  ttdema.  The  muscular  structures  above 
and  below  the  joint  become  atrophied.  The  discharge 
from  the  urethra  diminishes  or  ceases  to  flow  during 
the  height  of  the  joint  inflammation,  but  when  the 
acute  symptoms  begin  to  decline  it  again  appears. 
The  acute  form  can  gradually  become  subacute  and 
then  chronic.  During  the  course  of  a  gonorrhaa,  the 
chronic  form  of  arthritis  may  assert  itself,  coming  on 
insidiously  with  slight  symptoms.  There  is  a  gradual 
filling  of  the  joint  with  a  catarrhal  transudate.  These 
cases  present  almost  identical  symptoms  with  a  tuber- 
culous hydrops,  except  that  in  the  latter  there  is  often 
a  point  of  tenderness  in  the  epiphyseal  line,  denoting 
a  primary  osseous  tuberculosis  and  a  secondary  syno- 
vitis.    In  adults  the  diagnosis  is  difficult,  as  the  sy- 


novial tuberculosis  is  primary.  The  clinical  history 
and  macroscopical  and  microscopical  examination  of 
the  aspirated  joint  contents  will  throw  light  on  the 
diagnosis.  Koenig  believes  that  the  urethra  should  be 
investigated  in  every  case  of  acute  catarrhal  inflam- 
mation of  joints,  and  that  in  ninety-nine  out  of  every 
hundred  it  will  be  found  to  be  of  gonorrhceal  origin, 
provided  there  is  a  blennorrhagic  discharge.  This 
positive  opinion  of  such  an  eminent  authority  should 
have  great  weight,  as  doubtless  hundreds  of  cases  of 
gonorrhceal  hydrops  are  diagnosticated  and  treated  as 
tuberculous  affections.  Hutchinson's  contention  is 
that  in  patients  who  are  gouty  or  rheumatic,  any  urethral 
discharge,  specific  or  not,  may  give  rise  to  symptoms 
similar  to  those  of  gonorrhceal  rheumatism. 

The  disease  with  which  it  is  most  apt  to  be  con- 
founded is  polyarthritis  rheumatica.  The  fever  in 
gonarthritis  does  not  continue  long.  The  disease 
is  more  chronic,  continuing,  according  to  Nolens, 
two  months  or  more;  while,  according  to  Lebert.  in 
polyarthritis  rheumatica  the  average  duration  is 
only  forty-one  days.  Oonorrhteal  rheumatism  af- 
fects one  or  few  joints.  If  a  new  joint  is  attacked, 
the  one  previously  disturbed  does  not  become  free,  as 
is  the  case  in  acute  rheumatism.  The  joint  affection 
is  between  a  serous  and  a  suppurative  synovitis. 
Gonorrhceal  arthritis  is  more  often  complicated  with 
inflammation  of  tendon  sheaths  and  bursa;  than  artic- 
idar  rheumatism,  while  in  the  latter  endocarditis  is 
more  often  a  concomitant. 

The  prognosis  as  regards  the  mortality  is  favorable. 
Death  is  seldom  caused  by  this  disease,  except  when 
there  is  an  accompanying  gonorrhceal  endocarditis  or 
meningitis.  On  the  other  hand,  it  is  very  gra\-e  when 
considered  in  reference  to  functional  results.  Ac- 
cording to  Koenig,  when  the  joint  effusion  is  of  a 
distinctively  catarrhal  nature  (Volkmann),  the  prog- 
nosis is  relatively  good.  If  passive  motion  is  re- 
sorted to  early  enough,  the  patient  may  escape  even 
stiffness  of  the  joint,  much  more  ankylosis.  The 
rule  is,  however,  that,  in  spite  of  the  best  medical 
and  surgical  care,  there  is  apt  to  be  more  or  less  func- 
tional interference.  The  outlook  is  more  favorable  if 
the  ankylosis  be  of  a  fibrous  nature,  but  unfortunately 
it  is  more  often  osseous.  Auvergniot  reports  twentv- 
three  cases  affecting  the  wrist:  in  sixteen  there  were 
no  bad  after-effects,  in  the  rest  stiffness  and  ankylo- 
sis. In  thirteen  cases  involving  the  knee-joint,  only 
four  subjects  escaped  permanent  injur}'. 

The  treatment  rests  upon  the  etiological  basis.  In  the 
absence  of  more  convincing  evidence  we  must  assume 
a  predisposing  cause  in  conjunction  with  the  essential 
one,  the  gonococcus.  The  fact  that  joint  complica- 
tions appear  only  in  two  per  cent,  of  all  cases  of  gon- 
orrhtea  bespeaks  a  predisposition,  whether  anatomical, 
rheumatic,  or  gouty.  The  fact  that  salicylic  acid  and  its 
salts  have  a  favorable  action  on  the  disease,  although 
they  do  not  shorten  the  duration,  forces  us.  I  believe,  to 
assume  a  rheumatic  diathesis  as  a  prerequisite  at  the 
present  time.  Alkalies,  such  as  salicylates,  salol, 
carbonate  of  lithium,  and  citrate  of  potassium,  are 
antirheimiatic  and  antiblennorrhagic.  The  routine 
medical  treatment  of  these  cases  in  the  surgical  clinic 
of  Rush  Medical  t'ollege  is  the  iodide  of  potassium 
in  moderate  doses,  and  the  results  are  invariably  good, 
jullien  claims  that  the  oil  of  wintergreen  comes  near- 
est to  being  a  specific  of  any  of  the  remedies  used. 
R.  W.  Taylor  reports  favorable  results  from  in- 
ternal administration  of  this  drug  in  twelve  cases. 
Shuster  works  on  the  basis  that  joint  complications 
may  be  due  to  gonorrhcea  and  syphilis  together. 
Swellings  of  the  tuberosities  of  the  tibi.a,  the  sternal 
joints,  or  .sacrum  should  call  for  mercurial  treatment 
Jullien  treated  a  sixteen-year-old  girl,  suffering  with 
gonorrhieal  rheumatism,  with  subcutaneous  injections 


July  31.  1897] 


MEDICAL    RECORD. 


157 


of  corrosive  sublimate.  After  nine  injections  the 
disease  was  cured.  The  fever  was  combated  witii 
antipyrin  and  salicylates,  which  remedial  agents  were 
in  all  probability  the  true  cause  of  the  favorable  result. 
The  original  focus  should  not  be  lost  sight  of.  Lucas. 
in  a  case  of  purulent  gonorrhceal  ophthalmia  which 
was  the  primary  cause  of  the  general  dissemination, 
applied  strong  lotions  to  the  eyes  and  diminished  the 
discharge,  with  a  correspondingly  improved  arthritis, 
followed  later  on  by  a  complete  cure.  Ricord  and  R. 
Bei^h,  believing  that  posterior  urethritis  is  neces- 
sar\-  for  gonarthritis.  claim  to  have  prevented  it  bv 
means  of  abortive  injections,  thus  limiting  the  ure- 
thritis to  the  anterior  jwrtion  of  the  canal.  The 
urethra  should  receive  antiblennorrhagic  treatment; 
especially  strictures  should  call  for  proper  treatment, 
as  an  infection  atrium  is  liable  to  remain  jx)sterior  to 
such  an  obstruction.  The  joint  should  be  placed  at 
rest  on  a  splint  and  surrounded  by  hot  fomentations, 
followed  later  on  by  equable  pressure  by  means  of 
adhesive  strips.  Absorption  should  be  promoted  by 
pressure,  external  medication,  or  puncture,  as  occasion 
demands,  for  the  tendency  of  these  effusions  is  to 
remain  and  cause  ankylosis.  Jullien  recommends 
e.vternal  inunction  of  ichthyol  ointment  in  the  strength 
of  fifty  per  cent,  in  lanolin.  The  French  even  to- 
day resort  to  vesication  in  para-articular  processes. 
Koenig  believes  in  the  external  use  of  tincture  of 
iodine  in  phlegmonous  peri-arthritis.  He  lays  great 
stress  on  the  proper  application,  and  insists  on  not 
simply  applying  a  salve  but  thorough  medication  to 
the  point  of  blistering.  In  the  hydropic  form,  Koenig 
taps  the  joint,  injects  carbolic  acid,  and  also  resorts 
to  vesication  and  compression.  When  the  hydrops  is 
sero-fibrinous,  aspiration  and  injection  are  all  the 
more  necessary.  Fiitterer,  of  Chicago,  injected  one- 
half  drachm  of  the  oil  of  sandalwood  in  the  affected 
joint,  with  brilliant  results.  He  resorted  to  this  treat- 
ment in  four  cases.  During  the  first  fort)' -eight  hours 
after  injection  all  the  symptoms  were  exaggerated,  but 
a  gradual  permanent  amelioration  followed,  with  no 
functional  disturbance  remaining.  In  case  of  em- 
pyema of  the  joint,  immediate  incision  and  tubular 
drainage  are  indicated. 

Christen  is  very  radical  in  the  treatment  of  this 
disease.  He  advises  arthrotomy  in  all  cases  as  soon 
as  possible  after  the  onset.  If  the  disease  is  multiple, 
two  or  three  joints  should  be  opened  daily.  He 
claims  immediate  cessation  of  pain,  falling  of  temper- 
ature, and  no  ankylosis.  The  subsequent  treatment 
consists  of  immobilization  and  massage.  After  the 
acute  symptoms  have  abated,  absolute  rest  may  be 
maintained  by  a  plaster-of-Paris  cast,  but  this  should 
be  of  short  duration.  Vicious  position  should  be 
guarded  against  in  case  of  ankylosis.  If  there  is  an  ■ 
inclination  to  erosion  of  the  cartilages  or  bone  in  the 
joint,  traction  by  weight  and  pulley  is  of  great  import- 
ance to  remove  the  pressure  of  contiguous  structures. 
For  the  realization  of  the  best  ultimate  hopes,  too 
much  stress  cannot  be  laid  on  the  importance  of 
scientific  massage  and  active  and  passive  motion. 

100  StaTK   Sti:kei. 

I .  Brandes  :  De  rheumatismo  gonorrhoico  in  universum  et 
deforma  ejus  acuta.      Hannia-.  1548. 

2  Bergh,  R.  ■  Bidrarg  til  Kundskab  otn  Gonorre  has  Mand- 
folk.      Koebenhavn.  iStx).  p.  116. 

3.  Ricord,  Robert  Melchior  :  Kouveau  Traitement  des  Mala- 
dies veneriennes.      Paris,   1S61.  p.  246. 

4.  Bradford:  .\nkylosisof  the  Vertebrce  follo«4ng  Gonorrha>al 
Rheumatism.      Boston  Med.  and  Surg.  Journal.  iSyg,  p.  09=. 

5.  Haslund..\.;  Gonorreisk  Rheumatisme  og  Pyarthros  Goiior- 
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6.  Roustan  Lesions  peri-articnlaires  de  Nature  blennor- 
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7.  Fenger.  C.  and  Hinde,  \. :  The  Endoscope  in  the  Local 
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g.  Rosolimas :  Considerations  sur  la  Nature  de  la  Blennor- 
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Dermat.  et  de  Syph.,  Paris,  1SS3,  pp.  20-27. 

10.  Da\-ies-Colley  ;  On  Acute  Gonorrhoeal  Rheumatism.  Guv's. 
Hosp.  Reports,  London,  1S83,  xx^-i..  pp.  187—203. 

11.  Panas :  Les  Arthrites  blennorrhagiques.  Gaz.  d.  Hop., 
Paris,  1883,  p.  61S. 

12.  Petrone,  L.  >L :  Sulla  Natura  parasitaria  dell'  Artrite 
blennorragica.      Revista  Clinica  di  Bologna,  1S83. 

13.  Diday,  P. :   La  Blennorrhagie.      La  Semaine  Med.,  1883. 

14.  Hermet  :  Des  Alterations  de  I'Ouie  dans  le  Rheumatisme 
blennorrhagique.      Union  Med.,  Paris,  1SS4,  pp.  1,059-1,062. 

15.  Haslund  :  Beitrage  zur  Pathogenese  des  gonorrhoischen 
Rheumatismus.      Wien,  1SS4. 

16.  Hortelloup :  Arthrite  blennorrhagique.  Gaz.  d.  Hop., 
p.  1,004,  18S5. 

17.  Lucas  :  On  Gonorrhctal  Rheimiatism  in  Infants,  the  Re- 
sult of  Purulent  Ophthalmia.  Brit.  Med.  Jour.,  London,  1885, 
ii.,  pp.   57-59- 

18.  Loeb,  M.:  Die  Rheumatoiderkrankung  der  Gonorrhoiker. 
Deut.  Arch,  flir  klin.  Med..  Leipzig,  1885-86,  xxx™i.,  pp. 
156-1S5. 

19.  Basset  :  Rheumatisme  blennorrhagique.  Ann.  de  Der- 
mat. et  de  Syph.,  1886. 

20.  Hall.  R.  T.:  The  Gonococcus  in  a  Case  of  GonorrhceaL 
Arthritis.      N.  Y.  Med.  Jour.,  March  20,  1SS6. 

21.  Andr)-.  Chr. :  Du  Gonococcus  de  Neisser  et  de  ses  Rap- 
ports avec  quelques  Manifestations  parablennorrhagiques.  Ann. 
de  Dermat.  et  de  S\-ph.,  July.  1SS7. 

22.  Hartley,  F. :  Gonorrhceal  Rheumatism,  especially  in  the 
Female.      N.  Y.  Med.  Jour..  April,  1S87,  p.  376. 

23.  Taylor  :  Observations  on  the  Use  of  the  Oil  of  Winter- 
green  in  the  Treatment  of  Gonorrhoeal  Rheumatism.  N.  Y.  Med. 
Jour.,  June  4,  1S87. 

24.  Aubert,  P. :  Sur  le  Reaction  du  Pus  blennorrhagique. 
Lyon  Med.,  1SS7,  Nos.  19.  27,  25,  2g. 

25.  Philpot,  J.  H.:  Gonorrhceal  Rheumatism  Occurring  at  the 
-\ge  of  Nine  Years.      Lancet,  London,  1S8S.  ii.,  p.  675. 

26.  Dercum.  J.  H.:  A  Case  of  Arthritic  Muscular  Atrophy  of 
GonorrhcTeal  Origin.      Med.  News,  1888,  December  2g. 

27.  Sinclair:  Gcmorrhceal  Infection  in  Women,  London,   1S88. 

28.  Senn,  N.:  Surgical  Bacteriology,  1SS9. 

29.  Myrtle,  A.  S. :  Two  Cases  of  Gonorrhceal  Arthritis.  Brit. 
Med.  Jour.,  London,  1S89,  ii..  p.  243. 

30.  Shuster;  Rheumatismus  gonorrhoicus  oder  Syphilis? 
.\rchiv  f.  Dermat.  u.  S\-ph.,  Wien.  18S9,  xxi. ,  p.  353. 

31.  Bond,  T.:  Notes  on  Gonorrhoeal  Rhetmaatism.  West- 
minster Hosp.  Reports,  London,   iSSg.  v.,  163-16S. 

32.  .\uvergniot:  De  la  Monoarthrite  blennorrhagique  chez  la 
Femme.      These  de  Paris,  1890. 

33.  Mauriac :  Sur  un  Cas  Grave  d'Arthropathie  blennor- 
rhagique.    .Vnn.  de  Dermat.  et  de  S)-ph. ,  1S90,  p.  426. 

34.  Deutschmann,  R. :  Arthritis  Blennorrhoica.  Archiv  f. 
Ophthal..  Leipzig,  1S90,  xxx\-i.,  pp.  109-119. 

35.  .•\marel:  Contribution  a  I'Etude  du  Rheumatisme  blennor- 
rhagique. Arthropathies  graves  avec  Amyotrophic  ;  Diagnostic. 
Prognostic  et  Traitement.      Paris,  iSgi. 

36.  Beclere,  A.:  Le  Rheumatisme  blennorrhagique  chez 
I'Enfant.  Bull.  Soc.  Franc,  de  Dermat.  et  Syph.,  Paris,  i8g2, 
iii. .  pp.  215-21S. 

37.  Jacquet,  L.:  Recherches  de  Clinique  et  deBacteriologiesur 
le  Rheumatisme  blennorrhagique.  Bull.  Soc,  Fran9.  de  Der- 
mat. et  Syph.,  Paris,  1S92,  iii.,  pp.  2g3-299. 

38.  Jullien,  L.:  Traitement  du  Rheumatisme  blennorrhagique 
par  les  Injecrions  de  Sublime.     L' Union  Med..  i8g2,  Nos.  27-33. 

39.  Christen,  E.:  Considerations  sur  le  Rheumatisme  Blen- 
norrhagique et  de  son  Traitement  par  I'Arthrotomie.  These  de 
Paris,  1893. 

40  Guiteras:  Gonorrhoeal  Rheumatism  and  its  Treatment. 
N.  V.  Med.  Jour.,  1894.  lix..  pp.  355-358. 

41.  Therese,  L. :  Arthropathies  blennorrhagiques,  Gaz.  d. 
Hop.,  Paris,  1894,  Ixvii.,  pp.  345-349. 

42.  Hewes,  H.  F.:  Two  Cases  of  Gonorrhoeal  Rheumatism 
with  Specific  Bacterial  Organisms  in  the  Blood.  Boston  Med. 
and  Surg.  Jonr.,  1S94,  p.  515. 

43.  Northrup,  W.  B. :  Gonorrhceal  Arthritis,  Clinical  Observa- 
tions     Trans.  .\ss.  Amer.  Phy.,  Philadelphia,  lS95,x.,  141-158. 

44.  Koenig,  F. :  Ueber  gonorrhoische  Gelenkentzundung. 
Deut.  med.  Wochenschrift.  I8g6,  .v.xii.,  pp,  751-754. 

45.  Eisendrath,  D  N. :  Review  of  the  I.iterature  upon  the  In- 
ternal Localization  of  the  Gonococcus.  Chic.  Med.  Record, 
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46.  Koenig    Berlin,  klin.  Wochenschrift,  Januar)-  nth,  1897. 


Sarcinae  and  Torulae. — 

R  .'.cid.  sulphnrosi 3  i.-iss. 

Infus.  columbce 3  '^'j- 

M,     S.  Wineglassful  ten  minutes  before  meals. 

— Lawson, 


158  mp:dical  record 

A    STATISTICAL    STUDY    IX    EPILEPSY. 


[July  31,  1897 


3y    L.    pierce   CLARK,    M.D. 


■IKST       ASSISTAN 


In  a  careful  study  of  ninety-five  hundred  and  forty- 
five  seizures  which  occurred  in  one  hundred  and  fifty 
cases  of  epilepsy  admitted  to  the  Craig  Colony  during 
the  past  year,  considerable  attention  was  devoted  tow- 
ard ascertaining  whether  the  attacks  occurred  in  pe- 
riods; but  the  results  showed  that  there  was  no  peri- 
odic recurrence  of  seizures  which  could  be  at  all 
definitely  predicted  from  time  to  time.  These  obser- 
vations are  contrary  to  the  experience  of  some  inves- 
tigators in  epilepsy,  who  maintain  that  the  malady  is 
as  much  a  regularly  periodic  disease  as  it  is  a  convul- 
sive one. 

It  has  been  frequently  stated  by  neurologists  that 
the  generative  functions  are  in  close  connection  with 
the  higher  cerebral  centres,  and  in  most  mental  dis- 
eases, as  well  as  in  many  convulsive  ones,  the  organs 
of  generation  are  diseased,  which  disorder  is  very  often 
regarded  as  a  cause  of  the  nervous  disease  or  figures 
prominently  as  a  result  of  it.  During  the  year's 
study  upon  the  female  epileptics  at  the  Craig  Colony, 
it  was  noticed  that,  although  at  the  time  of  their  admis- 
sion many  patients  (and  very  frequently  their  friends) 
stated  that  the  seizures  appeared  regularly  at  the  men- 
strual period,  yet  this  was  not  borne  out  by  observation 
of  such  cases  after  admission.  For  several  months  the 
convulsions,  in  a  very  few  cases,  appeared  three  or 
four  days  before  and  after  the  menstruation  began,  but 
when  such  patients  had  become  thoroughly  accus- 
tomed to  colony  life  the  apparent  association  disap- 
peared. The  greater  number  of  the  female  patients 
were  remarkably  free  from  genito-urinary  disorders. 

When  we  take  into  account  the  fact  that  epilepsy  is 
a  disease  which  often  makes  its  first  appearance  dur- 
ing the  night,  and  may  exist  for  years  as  such,  we 
would  naturally  infer  that  the  greater  number  of 
attacks  would  occur  at  night;  but  the  records  kept  at 
the  colony  show  that  the  greater  number  of  attacks 
occur  during  the  day  rather  than  by  night,  being  in 
the  ratio  of  five  to  four.  This  may  be  accounted  for 
in  a  measure  by  the  fact  that  the  treatment  in  the 
majority  of  cases  was  a  bromide-chloral  one,  and 
chloral,  when  given  at  night,  is  a  well-known  remedy 
which  throws  nocturnal  seizures  into  diurnal  attacks. 
A  plausible  explanation  for  this  fact  rests  upon  the 
physiological  action  of  the  two  drugs.  The  ultimate 
effects  obtained  from  bromide  and  chloral  are  about 
the  same.  The  effects  of  bromide  are  much  longer  felt 
but  are  less  slowly  produced  when  compared  with  those 
of  chloral.  Both  drugs  probably  have  their  main  action 
upon  the  circulation.  Obviously,  for  rapid  effect, 
chloral  would  have  the  advantage  over  bromide.  As 
morning  approaches,  after  a  night  dose  of  chloral  the 
unstable  nervous  centres  approximate  the  condition  of 
a  fulminant,  but  receive  a  check  by  a  relatively  weaker 
drug  which  proves  impotent  to  prevent  the  explosion 
of  nervous  substance.  Consequently  a  seizure  which 
would  have  occurred  at  night  is,  with  chloral  treat- 
ment, tided  over  until  the  morning  or  the  following 
day. 

The  hour  of  the  day  (twenty-four  hours)  in  which 
the  greatest  number  of  epileptic  attacks  occur  has 
been  differently  stated  by  neurologists.  Some  have 
said  that  they  occur  with  greater  frequency  in  the 
early  morning  hours,  between  eight  and  ten  o'clock. 
F^r^  has  stated  that  practically  no  attacks  occur  be- 
tween the  hours  of  eleven  and  twelve  o'clock  in  the 
forenoon.'     In  a  study  of  nineteen  hundred  and  eighty- 

'  Dana's  "  Te.xt-Book  of  Nervous  Diseases,"  chapter  on 
Epilepsy. 


five  attacks,  he  found  but  three  occurring  at  this  hour. 
That  this  statement  is  not  in  accord  with  statistics  at 
the  Craig  Colony  may  readily  be  seen  by  reference  to 
the  appended  table  of  the  record  of  nearly  ten  thou- 
sand seizures,  which  have  been  tabulated  by  each  hour 
in  the  twenty-four  during  each  month  from  March, 
1896,  to  January  1,  1897 — a  period  of  ten  months. 
The  time  of  occurrence  of  each  attack  in  the  twenty- 
four  hours,  its  duration,  and  its  character  are  a  part  of 
the  permanent  record  of  each  case  at  the  colony.  This 
table  shows  that  three  hundred  and  seventy-eight 
attacks  occurred  between  eleven  and  twelve  o'clock, 
making  this  hour  rank  sixteenth  in  the  order  of  fre- 
quency of  the  whole  number  for  the  twenty-four  hours. 
It  will  be  seen  that  the  number  of  attacks  at  this  hour 
is  only  twenty  below  the  average.  The  greatest  num- 
ber of  attacks  have  been  found  to  occur  at  the  hour  of 
four  o'clock  in  the  morning;  the  least  number  at  seven 
o'clock  at  night. 

Table  showing  9,545  Epileptic  .Seizures,  .arranged  to 
show  the  number  of  attacks  which  occurred  in  each 
hoik  during  the  day  for  a  period  of  tex  months. 


353 

13 

411 

14 

433 

15 

537 

lb 

4S1 

17 

498 

18 

392 

19 

339 

20 

355 

21 

420 

22 

37H 

23 

435 

24 

412 

443 

424 

337 

341 

253 

224 

344 

455 

485 

39^ 

•_429 

'  lotal 9545 

The  diet  for  epileptics  has  been  so  arranged  that  the 
heaviest  meal  of  the  day  occurs  at  noon,  and  the  prog- 
ress of  stomachic  digestion  of  food  is  probably  com- 
plete in  two  hours.  Then  we  have  a  decided  remis- 
sion in  the  frequency  of  attacks,  that  continues  until 
the  nine  o'clock  hour,  when  they  once  more  occur  fre- 
quently. Nevertheless  we  should  be  guarded  in 
accepting  this  e.xplanation  as  an  adequate  one  to  settle 
the  question,  as  the  antithetical  idea  has  been  used  to 
explain  the  supposed  great  infrequency  of  attacks 
occurring  at  the  eleven-o'clock  hour,  which  we  have 
found  to  have  little  or  no  basis  in  fact. 

Aside  from  the  auto-intoxicant  theory  for  convulsive 
disorders,  which  has  been  and  is  still  being  so  assidu- 
ously urged  by  Haig  and  Bouchard,  the  epileptic  is 
still  known  to  be  a  person  incapable  of  receiving  any 
sudden  excessive  or  otherwise  abnormal  impression 
anywhere  throughout  the  whole  organism,  and  espe- 
cially in  the  alimentary  tract.  This  is  well  exempli- 
fied by  the  fact  that  nearly  one-half  of  the  patients 
admitted  to  Craig  Colony  suffer  from  more  or  less 
severe  constipation. 

The  reception  of  food  and  its  assimilation  are  one 
of  the  very  primitive  habits  of  life,  yet  any  abnor- 
mal departure  from  its  regular  and  methodical  proc- 
esses cannot  but  act  disastrously  to  the  whole  or- 
ganism. The  recognition  of  this  fact  has  led  to  the 
present  careful  consideration  of  the  dietary  for  epilep- 
tics. From  a  simple  methodical  principle,  any  abnor- 
mal departure  in  diet  would  act  as  a  fulminant  to  the 
unstable  nervous  centres  in  the  epileptic's  cerebral 
cortex. 

In  drawing  any  conclusion  in  regard  to  the  cause 
for  seizures  appearing  more  frequently  at  one  time 
than  at  another,  we  should  consider  the  metabolism  of 
the  whole  organism  and  its  influence  reflexly  upon  the 
nervous  system.  This  undoubtedly  is  the  first  and 
greatest  factor  which  should  be  studied  in  order  to 
solve  the  question  of  the  frequency  of  attacks  at  cer- 
tain hours  during  the  day.  As  for  the  greatest  num- 
ber of  attacks  occurring  at  4  a.m.,  two  reasons  may  be 


July  31,  1897] 


MEDICAL    RECORD. 


159 


given  to  explain  the  great  frequency  of  the  phenom- 
enon. It  is  one  of  the  sleeping  hours  when  the  epi- 
lepsy is  farthest  away  from  the  sedative  action  of  the 
chloral  and  bromide,  as  the  patient  generally  awakens 
some  time  during  the  eight-o'clock  hour.  Again,  the 
night  spent  in  sleep  is  well  known  to  be  a  time  when 
reflex  activity  runs  riot  in  the  organism.  All  the  vital 
forces  are  at  their  lowest  ebb  at  4  A.M.,  and,  above  all, 
the  ner\'ous  system  is  especially  defenceless  and  open 
to  the  reception  of  reflex  action. 

There  are  undoubtedly  many  other  factors  operative 
in  certain  cases  of  epilepsy  besides  reflex  and  diges- 
tive disturbances.  While  we  are  aware  that  such  a 
study  as  is  here  presented  in  this  article  is  not  at  all 
conclusive  and  final,  yet  we  do  believe  that  such  a 
tabulation  of  statistics  has  a  certain  value  and  interest. 
We  hope  in  time  to  see  such  studies,  by  means  of  such 
untiring  investigation  as  has  characterized  scientific 
research  in  other  more  tangible  diseases,  contribute 
their  share  toward  solving  the  mystery  of  the  causation 
of  epilepsy. 


Clint cnl  gcpai'tmcut. 

PROLOxVGED  PREGNANCY  AND  PREMATLRK 
OSSIFICATION  OF  THE  CRANIUM,  CAUS- 
ING   DYSTOCIA. 

By    H.    S.    BAKETEL,    M.D., 


E.'VRLV  in  March  I  was  engaged  to  confine  Mrs.  E , 

multipara,  aged  twenty-seven.  She  expected  her  ac- 
couchement March  27th.  I  heard  nothing  from  her 
until  the  morning  of  April  26th,  when  I  was  called  in 
by  the  husband  and  given  the  subsequent  facts.  She 
had  her  last  menstrual  flow  June  20,  1896.  Shortly 
after  its  cessation  she  went  away  on  a  visit  and  was 
absent  from  her  husband  nearly  two  months.  Her 
pregnancy  had  been  uneventful.  About  March  25th 
she  had  pains,  and,  thinking  the  labor  near  at  hand, 
sent  for  her  nurse.  These  pains  continued  several 
days  and  stopped  suddenly,  leaving  her  very  lame  in 
the  right  leg.  Thefcttus  at  once  became  more  active, 
but  there  had  been  no  further  signs  of  labor.  The 
woman  had  given  birth  to  three  children.  The  first, 
born  September  8,  1890,  came  at  full  term  and  lived 
twelve  days.  The  second,  bom  February  r,  1894, 
died  shortly  after  birth;  this  confinement  was  twenty- 
five  days  later  than  expected.  The  third  confinement 
came  November  24,  1895,  after  a  diflicult  labor,  last- 
ing seventy-eight  hours;   it  was  twenty-eight  days  late. 

On  examination  I  found  the  os  undilated  and  labor 
evidently  some  time  away. 

About  eleven  o'clock  on  the  night  of  April  28th  I 
■was  summoned,  and  found  the  os  dilated  three  fingers 
and  made  out  a  left  occipito-anterior  presentation. 
The  pains,  occurring  about  once  in  ten  minutes,  lasted 
on  an  average  seventy  seconds.  The  head  had  not 
engaged.  One  hour  later  examination  showed  no 
change,  except  that  the  os  had  fully  dilated,  and  in 
two  hours  the  conditions  were  the  same. 

Shortly  after  this  the  pains  decreased  in  severity, 
duration,  and  frequency,  and  on  April  29th  did  not 
occur  more  than  once  in  twenty  minutes.  That  night 
they  assumed  their  former  character,  but  repeated  ex- 
aminations showed  no  progress. 

Pains  continued  intermittently  April  30th  and  May 
ist.  Late  in  the  night  of  the  latter  day  I  called  in 
consultation  Dr.  David  S.  Clark  and  Dr.  Frederick 
Perkins.  It  was  decided  to  wait  until  daylight,  and 
then  remove  the  child  with  axis-traction  forceps  or  do 
a  craniotomy,  as  the  circumstances  warranted.  I  gave 
hypodermatically  one-half  grain  of  morphine  sulphate 


and  one-one-hundredth  grain  of  atropine  sulphate,  and 
ordered  repetition  in  two  hours  if  the  pains  did  not  de- 
sist. Notwithstanding  these  precautions,  there  had 
been  steady  pain,  and  at  eight  o'clock  the  next  morn- 
ing when  we  saw  the  patient  the  head  had  engaged, 
but  seemed  wedged  in  position. 

Under  chloroform  ana:sthesia  the  low  forceps  oper- 
ation was  done,  and  the  woman  delivered  of  a  male 
child  weighing  eleven  pounds  ten  ounces.  The  de- 
livery was  so  difficult  that  it  was  feared  craniotomy 
would  have  to  be  resorted  to,  but  perseverance  rendered 
this  step  unnecessary.  The  child  was  large  and  finely 
developed,  with  diameters  about  three-fourths  of  an 
inch  above  the  average.  There  was  complete  closure 
of  the  occipito-parietal  fontanelle,  while  the  fronto- 
parietal was  exceedingly  small.  The  sutures  were  very 
firm  and  could  not  be  felt.  The  occipito-mental  diam- 
eter was  six  and  one  eighth  inches,  the  biparietal  four 
and  one-fourth  inches,  the  fronto-mental  four  and  one- 
eighth  inches,  and  the  suboccipito-bregmatic  four  and 
seven-eighths  inches. 

This  woman,  who  is  unusually  strong,  was  in  hard 
labor  from  \N'ednesday  morning  until  Sunday  morning, 
or  ninety-four  hours.  She  ran  over  the  allotted  two 
hundred  and  eighty  days  a  period  of  thirty-six  days, 
making  her  pregnancy  continue  three  hundred  and 
sixteen  days.  I  am  fully  convinced  of  the  truth  of  the 
mother's  statement  as  to  the  last  menstrual  function 
and  absence  of  intercourse.  The  large  size  of  the 
child  and  his  strength  both  in  muscle  and  voice  show 
advanced  development. 

It  has  been  judicially  decided  in  the  United  States 
that  a  pregnancy  may  last  three  hundred  and  seventeen 
days.  Thompson'  reports  a  case  in  which  pregnancy 
lasted  three  hundred  and  seventeen  days  from  the  last 
menstruation,  and  three  hundred  and  one  days  from 
the  last  coition.  In  the  Boston  jMediial  and  Siir^iial 
Jdiinhil,  May,  1859,  a  pregnancy  of  three  hundred  and 
thirty  days  was  noted.  Dr.  \.  L.  Rodenstein"  reported 
four  cases,  in  which  pregnancy  was  prolonged  on  an 
average  two  months.  Maur^  had  a  pregnancy  continu- 
ing three  hundred  and  thirty-four  days.  Olshau- 
sen'  is  of  the  opinion  that  the  duration  of  pregnancy 
should  not  be  restricted  to  three  hundred  days,  but 
that  the  limit  be  e-xtended  to  three  hundred  and 
twenty-five.  Spiegelberg"  and  Winckel  also  believe 
that  pregnancies  can  be  prolonged  far  over  two  hun- 
dred and  eighty  days. 

Legally  the  authorities  of  this  country  differ.  In 
the  case  of  United  States  vs.  Collins,*  tried  in  the 
United  States  District  Court  for  the  District  of  Co- 
lumbia, in  which  the  defendant  was  on  trial  for  non- 
support  of  a  bastard  child,  the  presiding  justice  ruled 
that  a  living  child  could  be  born  after  a  gestation  of 
between  six  and  twelve  months ;  and  the  Supreme 
Court  of  Indiana,  in  the  case  of  The  State  r'.v.  Dill  ' 
for  bastardy,  allowed  that  pregnancy  could  continue 
three  hundred  and  thirteen  days. 

Medical  literature  comments  on  the  rarity  of  ossifi- 
cation of  the  cranium  and  prolonged  pregnancies; 
hence  this  report. 

BIBLIOGKAPHV. 

1.  London  Obstetrical  Society's  Transactions,  vol.  xxvii. 

2.  -American  Journal  of  Obstetrics,  June,  1882. 

3.  New  York  Medical  Journal,  May,  1S89. 

4.  Centralblatt  f.  Gynakol.,  i88g. 

5.  Theory  and  Practice  of  Midwifery. 

6.  Cranch's  Circuit  Court  Reports,  vol.  i.,  p.  592. 

7.  17th  Ind.,  210. 


Persistent  Furunculosis The  internal  use  of  ich- 

thyol  and  arsenic  sulphide,  giving  of  the  former  from 
three  to  ten  drops  in  capsules  thrice  daily,  while  the 
latter  may  be  advised  in  doses  of  from  one-hundredth 
to    one-twenty-fifth    of    a    grain    thrice   daily. — C.a.v- 

TRELL. 


i6o 


MEDICAL    RECORD. 


[July  31,  1897 


BILATERAL    CONGENITAL    AMAZIA. 

L!v    FKKI).    C.    ZArKFE,  M.H., 

Bv  referring  to  the  literature  on  this  subject  I  find  thai 
this  is  a  rather  rare  occurrence,  and  one  which,  accord- 
ing to  some  authors,  is  found  in  monstrosities  only. 
It  has  been  my  good  fortune  to  have  seen  a  case  of 
this  kind,  and  I  take  this  opportunity  of  putting  it  on 
record. 

Some  time  ago  I  was  called  to  see  a  lady,  who  had 
been  suddenly  attacked  by  a  violent  pain  over  the 
heart,  followed  by  unconsciousness.  Upon  examina- 
tion I  found  a  complete  absence  of  both  breasts.  The 
chest  was  well  formed,  but  theie  were  no  mamma;.  It 
was  not  a  case  of  micromazia,  as  I  at  first  suspected, 
but  a  total  absence.  The  ni]iples,  however,  were  large, 
like  a  normal  female  nipple,  and  had  a  pigmented 
areola  around  them. 

The  lady  is  thirty-two  years  of  age,  married  eight 
years,  has  had  five  miscarriages,  all  at  about  the  si.xth 
month,  and  has  given  birth  to  five  children,  two  of 
which  are  twins.  The  labors  were  all  normal.  She 
has  menstruated  only  once  since  her  first  pregnancy, 
and  is  now  again  four  months  pregnant.  She  gives  a 
history  of  having  never  been  sick,  and  claims  that  her 
breasts  were  at  no  time  larger  than  they  are  now.  She 
has  an  aortic  insufficiency  now.  The  history  shows 
that  this  is  not  a  case  of  atrophy,  either  primary  or 
secondary,  but  of  true  bilateral  congenital  amazia, 
without  a  concomitant  infantile  uterus. 


HYDRAULIC     DIL.VTATION     OF    THE    URE- 
THRA. 

By    I.    V.    RUMEK,    M.D.. 

The  following  is  a  short  description  of  my  method  of 
treating  retention  of  urine  caused  by  any  condition 
that  produces  a  lessening  of  the  calibre  of  tlie  urethra 
short  of  absolute  and  complete  closure.  I  have  been 
ad\  ising  this  long  enough  to  become  perfectly  satis- 
fied that  it  is  absolutely  harmless,  and  if  properly 
practised  by  an  intelligent  patient  is  of  inestimable 
viflue.  Instead  of  dilating  with  sounds  or  using  a 
catheter,  I  have  for  the  past  two  years  instructed  my 
patient  that  once  every  day,  when  getting  ready  to  pass 
water,  he  should  press  the  inde.v  finger  firmly  against 
the  meatus  so  as  completely  to  prevent  the  urine  from 
escaping,  and  slowly  and  carefully  exert  pressure  by 
contracting  the  muscular  coats  of  the  bladder.  Thus 
is  obtained  a  degree  of  water  pressure  that  is  consider- 
able, and  at  the  same  time  is  equally  distributed  along 
the  urethra,  in  such  a  manner  that  all  irritation,  such 
as  cannot  but  be  produced  on  the  surface  of  that  deli- 
cate lining  membrane  with  a  sound  or  catheter,  no 
matter  how'  skilfully  used,  is  avoided.  Pressure  is 
made,  and  thus  dilatation  is  effected  in  a  safe,  pleas- 
ant, and  efiicient  manner.  I  firmly  believe  that  there 
is  also  a  general  toning  up  of  the  muscular  parts  that 
are  concerned  in  the  act  of  micturition,  and  possibly 
of  the  seminal  parts  of  the  penis,  as  I  have  frequently 
had  men  impotent  tell  me  that  after  practising  this 
method  a  while  they  seemed  to  be  regaining  their  lost 
functions.  I  belie\e  it  strengthens  the  muscular  coats 
of  the  bladder,  gives  more  power  to  the  expulsive  effort, 
increases  the  size  of  the  stream,  and  makes  the  act  of 
micturition  in  this  class  a  natural  physiological  func- 
tion instead  of  a  pathological  experience.  Every 
physician  can  call  to  mind  patients  who  day  and  night 
every  two  or  three  hours  must  go  to  the  closet,  take  a  ca- 
theter, and  draw  a  few  drops  of  urine,  and  scarce  re- 


cover from  the  discomfort  of  the  act  before  it  must  be 
repeated. 

I  am  firmly  convinced  that,  if  this  method  of  treating 
these  cases  is  faithfully  followed,  very  much  suffering 
can  be  avoided. 


SPINAL      HVPER/EMIA      WITH      VICARIOUS 
MENSTRUATION. 

Bv    FREDERICK    D.    TVRkELE,    M.D., 


Tex  weeks  ago  I  was  called  in  to  attend    Miss  J , 

a  strong,  healthy,  plethoric  girl,  seventeen  years  of 
age,  for  "  paralysis."  It  had  been  her  habit  to  flow 
five  or  six  days  each  month,  and  during  her  last  pe- 
riod, the  night  being  warm,  she  placed  her  feet  through 
an  open  window  and  fell  asleep.  Toward  morning 
it  grew  very  chilly,  and  when  she  awakened  she  found 
that  her  menses  had  ceased.  She  complained  of  a 
"fire  in  her  backbone,"  pins  and  needles  in  the  feet, 
and  finally  complete  paraplegia  with  anaesthesia,  as 
shown  by  pricking  the  limbs  with  needles  and  apply- 
ing heat  and  cold.  I  made  a  diagnosis  of  spinal  con- 
gestion caused  by  the  suppression  of  the  menstrual 
discharge,  and  resorted  to  the  usual  treatment  of 
leeches,  ergot,  and  quinine,  with  gratifying  results. 

During  my  absence  she  complained  to  her  mother 
that  her  feet  felt  cold,  so  a  hot  flatiron  was  applied. 
In  some  manner  the  iron  worked  its  way  up  as  far  as 
the  calf  of  the  leg,  and  caused  an  ulcer  there  the  size 
of  a  silver  dollar,  which  I  dressed  daily. 

In  the  course  of  a  week  her  menstrual  flow  appeared 
and  continued  for  five  days.  Meanwhile,  the  sore  on 
her  leg  bled  profusely  and  ceased  only  when  the 
menses  had  stopped.  I  paid  no  attention  to  this  and 
continued  to  dress  it  regularly. 

The  next  month  when  her  menses  again  appeared, 
the  heretofore  comparati\ely  dry  wound  again  began 
to  bleed,  and,  as  before,  continued  throughout  the  pe- 
riod of  menstruation. 

The  patient  is  now  up  and  able  to  be  about,  and  the 
wound  is  entirely  healed. 


ICHTHVOL  IN  A  CASE  OF  CHRONIC  PUR- 
ULENT INFLAMMATION  OF  THE  MID- 
DLE   EAR. 

Kv    THFkHN"    \V.    KIE.MER.    .M.I>.. 


The  case  in  question  was  that  of  a  boy,  six  years  old, 
who  had  complained  of  frequent  attacks  of  intense  pain 
and  a  continuous  discharge  from  his  right  ear,  dating 
from  an  attack  of  scarlet  fever  seven  months  previous. 
LTpon  examination  I  found  a  moderate  amount  of  thick 
pus  and  crusts  lining  the  auditory  canal,  which  having 
been  cleansed,  the  drum  exhibited  the  following  ap- 
pearance: it  was  of  a  pale  color,  with  a  slight  perfora- 
tion in  the  posterior-inferior  quadrant.  Hearing  was  to 
some  extent  impaired.  After  thorough  cleansing  of  the 
parts  with  warm  water,  a  pledget  of  cotton  was  soaked 
with  a  three-per-ccnt.  solution  of  ichthyol,  and  placed 
close  up  against  the  eardrum.  A  second  piece  of  cot- 
ton was  loosely  placed  over  this  as  a  means  of  protec- 
tion. After  two  days  the  patient  again  visited  my 
office,  and  the  cotton  was  removed.  All  pain  had 
ceased,  the  discharge  was  less,  and  the  parts  appeared 
better  in  every  way.  The  ear  was  .igain  packed  as  be- 
fore, and  with  a  third  subsequent  treatment  the  dis- 
charge w  as  totally  stopped,  there  has  been  no  pain,  and 
the  hearing  is  a  very  little  improved. 


July  31,  1897] 


MEDICAL    RECORD. 


161 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Sitrgery. 


GEORGE    F.    SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &  CO.,   43,  45,  &  47  East  Tenth  Street. 


New  York,  July  31,  1897. 


gonorrhceal  endocarditis. 

For  a  long  time  it  was  supposed  that  rheumatism  was 
the  principal  cause  of  endocarditis,  with  its  consecu- 
tive valvular  defects,  but  evidence  has  been  gradually 
accumulating  that  these  complications  may  attend  any 
infectious  process,  and  possibly  also  any  toxic  process, 
under  suitable  conditions.  In  the  case  of  the  infec- 
tions it  may  be  assumed  that,  as  a  rule,  an  active, 
acute  inflammatory  process  is  set  up  as  a  result  of  the 
lodgment  of  infective  principles  (bacteria)  upon  and 
within  the  endocardium;  while  in  that  of  the  into.xi- 
cations  the  process  is  rather  a  slow,  chronic,  hyper- 
plastic, or  degenerative  one.  It  is  to  be  borne  in 
mind  that  under  the  former  conditions  a  state  of  in- 
toxication is  often  also  developed,  so  that  at  times 
both  sets  of  etiological  factors  are  operative  in  the 
same  case.  The  infectious  endocarditis  is  most  likely 
to  be  of  the  verrucose,  ulcerative,  or  malignant  variety ; 
the  toxic  of  sclerotic  or  indurative  type. 

That  gonorrhoea,  among  other  infections,  is  capable 
of  causing  endocarditis,  as  well  as  other  serious  com- 
plications, has  come  to  be  recognized  only  within  com- 
paratively recent  years.  Attention  had  been  called 
prior  to  1870  by  French  observers,  and  some  ten  years 
later  by  the  Germans,  to  the  occasional  clinical  asso- 
ciation of  the  two  disorders.  MacDonnell,  of  Mon- 
treal, in  189 1  insisted  upon  their  etiological  relation, 
and  Leyden,  before  the  Berlin  Society  for  Internal 
Medicine  in  1893,  seems  to  have  been  the  first  to  de- 
monstrate the  actual  dependence  of  the  endocardial  le- 
sion upon  the  activity  of  the  gonococcus,  which  Neis- 
ser  in  1889  had  shown  to  be  tiie  cause  of  the  urethritis. 
The  infectiveness  of  the  gonococcus  has  further  been 
shown  by  its  capability  of  inducing,  beside  urethri- 
tis, cystitis,  epididymitis,  orchitis,  etc.,  also  synovitis, 
arthritis,  abscess,  myelitis,  and  inflammation  of  serous 
membranes. 

A  considerable,  withal  not  large,  number  of  cases 
of  gonorrhceal  endocarditis  has  been  reported  since 
Leyden's  communication  upon  the  subject.  In  the 
majority,  although  the  gonococcus  could  be  found  on 
microscopical  examination,  culture  experiments  proved 
unsuccessful,  owing  to  the  sensitiveness  of  the  micro- 
organism to  external  influences.  An  additional  case  of 
this  kind  was  reported  by  Siegheim  (Deutsche  meilici- 
nische  Wochenschrift,  May  13,  1897),  at  a  recent  meet- 
ing of  the  Berlin  Society  for  Internal  Medicine. 


The  patient  was  a  woman  who  came  under  observa- 
tion on  account  of  chills,  followed  by  fever,  occurring 
daily  for  two  weeks  between  twelve  and  half-past 
twelve  noon.  Examination  disclosed  a  faint  systolic 
murmur  over  the  tricuspid  orifice,  with  a  pulse  fre- 
quency of  112,  but  no  elevation  of  temperature.  The 
appearance  of  the  patient,  however,  aroused  a  suspicion 
of  ulcerative  endocarditis,  and  this  was  strengthened 
when  it  was  learned  from  the  husband  that  he  was 
suffering  from  an  attack  of  gonorrhoea.  In  the  further 
progress  of  the  case  a  systolic  murmur  became  audible 
over  the  mitral,  and  later  a  loud  diastolic  murmur 
over  the  aortic  orifice.  The  pulse  increased  in  fre- 
quency, became  dicrotic,  irregular,  and  intermittent, 
and  finally  distressing  palpitation  and  great  dyspnoea 
set  in.  The  fever  pursued  for  a  time  a  typical  inter- 
mittent course,  subsequently  becoming  irregular.  The 
spleen  became  gradually  enlarged  and  appreciable  on 
palpation.  Vomiting  set  in,  and  finally  blood  and 
albumin  appeared  in  the  urine,  the  secretion  of  which 
further  became  notably  diminished.  Dyspnoea  and 
cough  became  aggravated,  until  death  resulted  amid 
symptoms  of  pulmonary  cedema. 

Post-mortem  examination  disclosed  the  existence  of 
proliferative  ulcerous  endocarditis  of  the  aortic  valve, 
with  myocarditis,  pulmonary  cedema,  nephritis,  paren- 
chymatous hepatitis,  endometritis,  and  purulent  cys- 
titis. During  life  inoculations  of  agar-agar  and  pep- 
tone-bouillon were  made  with  blood  obtained  by  punc- 
ture of  a  vein,  but  with  negative  results.  "Smear  pre- 
parations likewise  failed  to  disclose  the  presence  of 
micro-organisms.  Inoculations  with  blood  obtained 
from  the  heart  at  the  autopsy  also  yielded  negative 
results,  but  in  smear  preparations  and  in  sections 
made  from  the  endocardial  vegetations  and  examined 
under  the  microscope  diplococci  were  found  possessing 
all  the  characteristics  of  gonococci. 

The  failure  of  bacterial  colonies  to  develop  in  the 
inoculated  culture  media  in  this  case  is  considered 
sufficient  to  exclude  the  presence  of  the  ordinary  pyo- 
genic cocci.  The  gonococcus,  on  the  other  hand,  has 
been  shown  to  be  extremely  sensitive  to  thermal  varia- 
tions, developing  only  within  a  certain  narrow  range 
of  temperature.  As  the  autopsy  was  made  in  this  case 
twelve  hours  after  death,  the  negative  results  of  the 
inoculation-experiments  need  not  therefore  be  viewed 
with  surprise;  nor  can  they  be  considered  as  throwing 
doubt  upon  the  identity  of  the  organisms  observed 
under  the  microscope. 


"THE     IMMOR.\LITY     OF     THE     ANTIVIVI- 
SECTION    MOVEMENT." 

The  above  is  the  title  of  a  striking  article  in  The  Open 
Court,  written  by  Dr.  Paul  Carus.  In  it  the  antivivi- 
section  movement  is  stripped  of  its  sentimentalism 
and  the  subject  is  presented  in  a  common-sense  and 
practical  manner.  The  antivivisection  party  have 
always  posed  as  the  exponents  of  the  teaching  of  the 
Christian  religion,  and  have  insisted  that  Christianity 
and  vivisection  are  incompatible.  They  hold  that 
vivisection  is  immoral.  This  has  been  at  all  times 
their  strongest  argument.      Dr.  Paul   Carus  denounces 


l62 


MEDICAL    RECORD. 


[July  31,  1897 


this  proposition,  and  presents  the  case  in  a  quite  differ- 
ent light.  He  contends  that  the  immorality  rests  with 
the  antivivisectionists,  and  says:  "  The  antivivisection 
movement,  as  it  is  carried  on,  is  in  a  sense  guilty  of 
immorality,  and  we  deem  it  our  duty  to  state  our 
views  of  the  subject  openly  and  frankly.  The  two 
greatest  religious  leaders  of  mankind,  Buddha  and 
Christ,  have  taught  us  to  have  compassion,  but  neither 
the  one  nor  the  other  prescribed  to  avoid  once  and  for 
all  the  infliction  of  any  suffering.  On  the  contrary,  they 
taught  that  suffering  is  unavoidable.  Buddha  did  not 
say  that  salvation  is  obtained  by  yielding  unreserv- 
edly to  the  sentiment  of  compassion ;  he  taught  salva- 
tion by  enlightenment.  And  Christ's  mission  is 
mainly  a  lesson  of  sacrifice,  which  means  that  salva- 
tion is  obtained  through  suffering." 

And  again  he  says :  "  As  to  vivisection,  we  all  know 
that  it  is  not  a  pleasant  duty  of  the  physiologist,  but 
it  is  an  indispensable  task  that  must  be  done  for  the 
sake  of  investigation.  It  falls  within  the  same  cate- 
gory with  all  sacrifices.  Vivisection  may  truly  have, 
and  frequently  will  have,  the  tendency  of  blunting  the 
sentiments  of  the  vivisector;  but  so  does  dissection. 
Shall  we  surrender  dissection  as  an  obligatory  part 
of  medical  instruction,  lest  the  moral  sense  of  the  stu- 
dent be  shocked?"  The  article  concludes  with  these 
words:  "Vivisection,  if  strictly  kept  within  the  lim- 
its of  its  important  purpose,  is  a  moral  obligation ; 
and  he  who  would  hinder  the  physiologist  in  the  per- 
formance- of  his  duties  makes  himself  guilty  of  im- 
moral conduct;  but  any  cruelty  to  animals  —  viz., 
every  lack  of  respect  for  life,  every  thoughtless  or 
wilful  infliction  of  pain,  every  delight  taken  in  tortur- 
ing, injuring,  or  destroying  sentient  beings  —  is  a 
crime  that  should  be  denounced  and  reprimanded,  and, 
if  necessar}',  checked  by  the  power  of  law." 


THE   ETIOLOGY  OF    MULTIPLE  SCLEROSIS. 

Although  many  of  the  etiological  factors  of  this  in- 
teresting disease  have  been  determined  in  recent  years, 
the  true  cause  of  the  affection  has  not  yet  been  estab- 
lished, and  according  to  some  studies  of  Blumreich 
and  Jacoby  it  would  appear  that  a  variety  of  etiologi- 
cal moments  may  be  invoked.  The  account  of 
these  investigations,  based  upon  a  clinical  study  of 
twenty-nine  cases  observed  in  Gerhardt's  clinic  at  the 
University  of  Berlin,  is  published  in  the  Deutsche 
niedicinische  Wochcnschrift  of  July  8,  1897.  Of  the 
twenty-nine  cases  studied,  twenty-three  occurred  in 
males,  six  in  females.  Twenty-two  were  between  the 
ages  of  twenty  and  forty,  and  seven  between  forty  and 
sixty.  In  some  the  first  symptoms  were  noticed  early 
in  life.  A  number  of  the  patients  had  suffered  from 
infectious  diseases  during  childhood;  but  in  only  one 
of  all  of  the  cases  was  there  any  direct  relation  be- 
tween the  infection  and  the  nervous  disorder.  This 
case  occurred  in  a  man  of  twenty-five,  in  whom  the 
symptoms  of  multiple  sclerosis  developed  in  the 
sequence  of  an  attack  of  influenza.  In  only  one  of 
the  cases  could  a  history  of  syphilis  be  elicited  with 
certainty;  in  three  a  doubtful  history  of  this  kind  was 


obtained.  In  six  of  the  cases  there  existed  the  possi- 
bility of  intoxication  as  an  etiological  factor.  Two 
patients  were  addicted  to  alcoholic  excess,  but  in  both 
instances  other  causative  influences  might  have  been 
operative.  One  patient  had  suffered  from  carbon- 
monoxide  poisoning  nine  years  before  the  advent  of 
his  ner\'ous  symptoms.  Three  patients  had  been  ex- 
posed to  industrial  intoxications.  Two  of  these  were 
painters,  who  had,  however,  never  exhibited  other 
symptoms  of  plumbism.  In  one  there  had  been 
chronic  suppurative  disease  of  the  ear  from  childhood, 
together  with  eye  changes  suggestive  of  multiple  scle- 
rosis prior  to  exposure  to  lead.  In  the  other  the  first 
symptoms  of  nervous  disorder  followed  immediately 
upon  traumatism.  One  patient  was  occupied  in  ex- 
hausting glass  bulbs  employed  for  incandescent  elec- 
tric lighting,  and  had  suffered  from  mercurial  intoxi- 
cation. In  nine  cases  the  patients  attributed  their 
trouble  to  grief  and  overexertion,  but  in  five  of  these 
there  existed  the  possibility  of  other  etiological  influ- 
ences. In  all  of  the  cases  special  inquiry^  was  directed 
to  the  influence  of  traumatism  in  causing  the  ner%ous 
affection ;  and  in  eleven  cases  positive  evidence  of 
this  nature  was  secured.  In  the  remaining  five  the 
presence  of  other  etiological  possibilities  and  the 
length  of  time  between  the  two  events  caused  doubt  as 
to  the  relation  between  the  injury  and  the  disease  of 
the  brain  and  cord. 

This  study  shows  that  there  is  no  constant,  univer- 
sal cause  for  multiple  sclerosis.  In  some  cases  the 
mode  of  origin  escapes  recognition.  In  others  there 
are  three  main  groups  of  exciting  causes,  viz.,  acute 
infectious  diseases,  intoxications,  and  traumatism. 
These  may  operate  by  the  direct  action  of  the  injurious 
agencies  in  inducing  the  anatomic  changes  in  the  ner- 
vous system ;  by  rendering  apparent  previously  latent 
disease ;  and  by  acting  as  predisposing  influences  that 
favor  the  action  of  the  exciting  causes.  It  is  possible 
that  traumatism  may  not  really  play  any  part  in  the 
etiology,  being  perhaps  in  many  instances  an  accident 
due  to  the  vertigo  and  unsteadiness  symptomatic  of 
the  already  existing  neruous  disorder. 


COMPARATIVE     EFFECTS      OF     DIFFERENT 
ALCOHOLIC    DRINKS    ON    MAN. 

The  investigations  of  Lancereaux  concerning  the 
changes  taking  place  in  the  nervous  system  from  the 
abuse  of  various  alcoholic  drinks  are  of  much  interest 
The  following  are  some  of  his  conclusions  regarding 
the  effects  of  spirits,  wine,  beer,  and  absinthe :  '"  In 
excessive  use  of  alcoholic  drinks  of  high  percentage 
of  alcohol,  the  tactile  and  thermal  sensibilities  do  not 
seem  to  be  greatly  altered,  while  sensibility  to  pain 
seems  exaggerated.  In  tliose  who  use  absinthe  and 
similar  drinks  to  excess,  the  plantar  reflexes  are  in- 
creased, light  tickling  causing  movement,  while  slight 
stroking  of  the  knees,  legs,  or  abdomen  causes  pain 
severe  enough  to  make  the  patient  complain.  Similar 
results,  though  less  marked,  are  to  be  observed  in  the 
upper  extremities.  In  wine  drinkers  this  sensitiveness 
of  the  skin  is  much  less  in  the  lower  extremities,  above 


July  31,  1897] 


MEDICAL    RECORD. 


16: 


there  may  be  a  zone  of  hypersesthesia,  while  still  higher 
normal  skin  sensation  is  the  rule.  Psychical  symp- 
toms in  absinthe  drinkers  are  stated  to  be  fewer  than 
is  generally  supposed,  and,  as  is  taught  in  the  ordinary 
text-books,  wine  and  alcohol  drinkers  are  prone  to 
attacks  of  acute  delirium,  while  in  those  who  drink 
alcoholic  essences  forms  of  dementia  are  more  liable 
to  follow\" 


Scans  of  the  ^mcek 

The  Floating  Hospital  of  St.  John's  Guild  was 
struck  by  lightning  on  Friday  last,  and  a  baby  was 
killed  in  its  mother's  arms.  The  same  shock  caused 
the  premature  birth  of  another  child. 

Obituary    Notes Dr.    Charles    O.    B.\ker,    a 

prominent  surgeon  of  Auburn,  N.  Y.,  died  at  his  resi- 
dence, July  1 6th,  from  cerebral  hemorrhage.  He  was 
born  near  Auburn  in  1852,  and  was  graduated  from 
the  medical  department  of  the  Syracuse  University  in 
the  class  of  1873,  practised  general  medicine  in  and 
about  Auburn  until  1890-91,  when  he  visited  Europe, 
taking  a  special  course  of  operative  surgery^  under 
Lawson  Tait.  After  that  he  devoted  himself  almost 
exclusively  to  abdominal  surgery.  —  Dr.  William 
Thurmax  died  at  his  home  in  this  city  last  week, 
at  the  age  of  fifty-six  years.  He  was  a  graduate  of 
the  College  of  Physicians  and  Surgeons  in  this  city 
in  1864,  and  served  later  on  the  house  staff  of  the 
New  York  Hospital.  He  was  an  active  member  of  St. 
John's  Guild,  and  had  always  been  especially  inter- 
ested in  the  work  of  the  floating  hospital.  He  was 
also  a  school  physician,  having  been  appointed  by  the 
mayor  about  a  year  ago. — Dr.  Louis  F.  Kiefer  died 
in  this  city  on  July  23d,  at  the  age  of  forty-five  )ears. 
He  was  a  graduate  of  the  College  of  Physicians  and 
Surgeons  in  1886,  and  then  ser\-ed  as  interne  in  Roose- 
velt Hospital.  He  was  prominent  in  masonic  circles. 
— Dr.  Delos  a.  Crane  died  at  his  home  in  Holland 
Patent,  N.  Y.,  on  July  2 2d,  at  the  age  of  seventy-si.\ 
years.  He  was  a  graduate  of  Castleton  (Vt.)  Medical 
College  in  1844. — ^Dr.  Willia.m  H.  McNacghtox,  of 
Water vliet,  N.  Y.,  died  on  July  2 2d,  at  the  age  of 
thirty-four  years,  from  pulmonary  tuberculosis. 

A  Prize  for  the  Discovery  of  the  Bacillus  of 
Yellow  Fever. — It  is  announced  that  a  bill  has  been 
introduced  into  the  Brazilian  legislature,  offering  a 
prize  of  $220,000,  in  two  equal  parts — one  to  the  au- 
thor of  a  work  demonstrating  the  e.xistence  of  the  ba- 
cillus of  yellow  fever  and  the  surest  and  readiest  means 
of  its  recognition;  and  the  other  to  the  discoverer  of 
an  effective  treatment  of  the  disease.  The  decision 
upon  the  award  shall  be  made  by  the  Medical  Insti- 
tute of  Rio  Janeiro,  the  Hygienic  Institute  of  Berlin, 
and  the  Pasteur  Institute  of  Paris.  A  further  provi- 
sion of  the  bill  authorizes  the  reser\^ation  of  a  sum  of 
$110,000  for  the  founding  of  an  establishment  for  the 
preparation  of  a  curative  serum,  the  discoverer  of  the 
same  to  be  the  organizing  director  of  the  institute. 
The  first  of  these  prizes  will  doubtless  be  awarded  to 


Dr.  Sanarelli,  whose  paper  announcing  the  discovery 
was  published  in  the  Medical  Record  of  last  week, 
and  it  is  most  probable  that  the  second  will  also  fall 
to  him.  Such  substantial  rewards  for  medical  dis- 
coveries are  only  too  rare. 

Reports  of  the  State  Board  of  Charities.  —  The 
State  board  of  charities'  report  on  the  deaf  has  lately 
been  issued,  and  from  a  perusal  of  it  the  facts  are 
gathered  that  in  the  various  schools  in  the  State  there 
are  a  total  of  1,467  pupils,  817  of  whom  are  males  and 
650  females.  On  the  whole,  these  children  seem  to 
be  well  cared  for  both  in  mind  and  body,  but  the  in- 
spectors wish  to  call  the  attention  of  the  managers  of 
each  institution  to  the  differences  in  the  tables  con- 
taining the  standing  of  their  schools.  According  to 
the  report  of  the  committee  on  Craig  Colony,  it  is  in 
a  satisfactory  condition,  and  has,  since  its  opening  in 
January,  1896,  made  marked  progress.  In  the  case  of 
the  epileptics,  open-air  employment  has  been  found  to 
be  very  beneficial.  Commissioner  Bergen  reports  on 
Kings  County  Hospital  in  very  unfavorable  terms. 
He  states  that  the  overcrowding  is  excessive,  the  ac- 
commodation for  nurses  is  defective,  and  the  lighting 
is  bad.  He  characterizes  the  institution  as  improperly 
equipped  and  ill  constructed.  Commissioner  Man'in 
reports  on  the  various  institutions  in  the  third  judicial 
district,  and  says  that  he  finds  that  those  institutions 
under  the  management  of  sisterhoods  and  the  hospi- 
tals in  charge  of  trained  nurses  are  more  successful 
than  those  otherwise  controlled.  The  report  of  the 
State  commissioner  on  the  poorhouses  in  the  eighth 
judicial  district  is  in  most  respects  favorable.  There 
were  at  the  time  the  report  was  made  1,151  inmates  in 
the  eight  poorhouses  in  the  district.  The  commis- 
sioner passes  severe  strictures  on  the  management  of 
the  Erie  County  poorhouse,  but  the  seven  other  ones 
appear  to  be  in  a  good  condition.  The  report  of  the 
committee  on  the  institutions  in  this  State  for  idiots 
and  feeble-minded  states  that  all  these  establishments 
are  under  the  best  care  and  management.  Many 
structural  improvements  are  needed,  however,  at  the 
State  asylum  in  Rome,  the  dining-rooms  in  the  base- 
ment being  in  a  very  unsanitary  and  uncomfortable 
condition. 

The  Chautauqua  County  Medical  Society — The 
annual  meeting  of  this  society  was  held  at  Chautauqua, 
X.  Y.,  July  13,  1897,  under  the  presidency  of  Dr.  E. 
S.  Rich.  The  annual  election  of  officers  resulted  as 
follows:  President,  Dr.  Morris  N.  Bemus,  Jamestown, 
N.  Y. ;  Vice-President,  Dr.  V.  M.  Griswold,  Fredonia, 
N.  Y. ;  Secretary  and  Treasurer,  Dr.  Charles  A.  Ellis, 
Sherman,  N.  Y. ;  Censors,  Drs.  T.  D.  Strong,  Westfield, 
N.  Y. ;  W.  M.  Bemus,  Jamestown,  N.  Y. ;  J.  Murphy, 
Sherman,  N.  Y.  The  president's  address  was  "  Notes 
on  Puerperal  Eclampsia."  A  large  number  of  cases 
was  reported.  Dr.  \V.  \V.  Hotchkiss,  of  Jamestown, 
X.  Y.,  read  a  paper  on  "Tonsillitis."  Dr.  T.  D. 
Strong,  of  Westfield,  read  one  upon  "  Influenza."  Dr. 
Lucien  Howe,  of  Buffalo,  presented  a  case  of  "  Diph- 
theritic Membrane  of  the  Eyelid,"  which  had  existed 
many  months.  At  8  p.m.  Dr.  R.  R.  Ross,  superinten- 
dent of  the  Buffalo  General  Hospital,  lectured  upon 


164 


MEDICAL    RECORD. 


[July  31,  1897 


the  A--rays,  illustrating  with  the  apparatus  as  he  pro- 
ceeded, taking  a  photograph  of  a  fractured  femur  at 
the  close. 

The  Hamburg  Hospital. — Dr.  H.  Kiimmell,  surgi- 
cal director  of  the  New  General  Hospital  (Neues 
AUgemeines  Krankenhaus)  of  Hamburg,  in  the  name 
of  the  local  Hamburg  committee  and  also  in  that  of 
the  general  imperial  committees  of  the  Twelfth  Inter- 
national Congress,  invites  those  going  through  Ham- 
burg on  the  way  to  Moscow  to  inspect  the  hospital, 
and  particularly  the  new  hygienic  establishments  in 
that  city.  The  medical  men  will  be  at  the  hospital 
daily,  from  10  a.m.  to  2  p.m.  Still  they  request  that 
American  visitors  will  kindly  notify  them,  if  possible, 
of  the  day  of  their  visit. 

Appendicitis  and  the  Berry  Crop. — The  seed  the- 
ory of  appendicitis  has  become  so  widespread  among 
the  laity  that  it  is  said  to  have  interfered  very  seriously 
with  the  sale  of  small  fruits  this  season.  The  result 
is  that  the  unsuperstitious  and  the  "  appendicized"  are 
enjoying  an  abundance  of  the  healthful  berries,  to  the 
scandal  of  their  timid  neighbors. 

The  Independent  Medical  College,  of  Chicago, 
would  appear  to  be  an  institution  needing  investiga- 
tion by  the  postal  authorities.  It  is  advertising  in  the 
daily  papers  to  make  lawful  physicians  of  those  who 
pursue  a  "  home  course"  of  study. 

The   Prince   of    Wales'     Hospital    Fund. —The 

largest  contributor  to  this  fund  was  Mr.  W.  W.  Astor, 
who  has  promised  to  give  $5,000  annually,  the  ne,xt 
largest  annual  contribution  being  $1,250. 

The  Russian  Red  Cross  Society,  in  return  for  the 
action  of  the  New  York  society,  has  established  two 
beds,  one  at  St.  Petersburg  and  the  other  at  Odessa, 
for  the  care  and  comfort  of  patients  from  the  United 
States  navy. 

A  Grave  Charge  against  a  Surgeon. — The  charge 
has  been  made  that  two  Hindoo  girls  were  assaulted 
at  the  Khana  plague  inspection  camp  by  European 
officials.  A  surgeon,  police  sergeant,  and  a  hospital 
attendant  have  been  suspended  for  their  alleged  par- 
ticipation in  the  assaults,  and  the  governor  of  Bengal 
has  ordered  an  inquiry  to  be  made  concerning  the 
charge. 

A  Monument  to  the  Hunters. — At  a  recent  meet- 
ing called  in  Glasgow,  a  committee  was  appointed  to 
collect  subscriptions  for  a  monument  to  William  and 
John  Hunter.  It  is  hoped  to  raise  about  $20,000  for 
this  object. 

Mortality    among    Foundlings    in    Italy.  ^  The 

Roman  correspondent  of  y//;-  Lancet  called  attention  a 
short  time  ago  to  a  foundling  asylum  in  Naples,  in 
which  in  the  course  of  two  years  among  eight  hun- 
dred and  fifty-si.x  patients  admitted  only  three  had 
survived.  Among  other  causes  for  this  incredible 
mortality  was  the  nursing  of  three  or  four  infants  by 
one  wetnurse.  An  only  less  ghastly  exhibit  is  made 
by   the   foundling   hospitals   of    Venetia,   the  area  of 


which  is  twenty-four  thousand  square  kilometres,  and 
the  population  nearly  three  million  inhabitants,  and 
which  sends  annually  to  the  foundling  hospitals  a 
mean  of  one  hundred  and  forty  thousand  infants,  the 
vast  majority  of  which  are  illegitimate.  Among  this 
number  the  mortality  is  fifty-two  per  cent.,  as  a  result 
primarily  of  want  of  ncurishment,  and  secondly  of 
neglect  of  every  description.  The  administration  of 
the  several  hospitals  costs  annually  some  $3,000,000, 
derived  from  the  bequests  of  benefactors  and  the  con- 
tributions of  the  provinces  and  communes. 

Mississippi  Valley  Medical  Association. — At  the 
next  meeting  at  Louisville,  October  5,  6,  7,  8,  1897, 
the  address  on  surgery  will  be  delivered  by  Dr.  J.  B. 
Murphy,  of  Chicago,  and  that  on  medicine  by  Dr. 
John  V.  Shoemaker,  of  Philadelphia.  Title  of  papers 
should  be  sent  to  Dr.  H.  \V.  Loeb,  secretary,  St. 
Louis,  Mo. 

The    Italian  Society    of    Internal    Medicine   will 

hold  its  eighth  congress  at  Naples  in  October  next, 
under  the  presidency  of  Dr.  Guido  Baccelli.  In  con- 
nection with  the  congress  there  will  be  an  exhibition 
of  hydrology  and  climatology,  and  of  instruments  and 
appliances  used  in  medical  practice. 

Prosperous  Ophthalmic  Surgeons. —  The  Laruefs 
special  commissioner  on  hospital  abuse  says  that 
the  leading  ophthalmic  consultants  in  London  daily 
have  to  send  away  patients  who  pay  the  highest 
fees,  simply  because  there  is  no  time  to  see  them  all. 
This  is  probably  the  reason  why  the  Queen  sent  to 
Germany  for  an  oculist  to  examine  her  eyes,  the  Lon- 
don men  being  doubtless  too  busy  to  attend  to  her. 
The  same  writer  says  that  no  one  in  London  will  oper- 
ate on  a  poor  man  for  cataract  for  a  fee  of  $50,  unless 
he  is  moved  thereto  solely  by  a  feeling  of  charity. 

Grandmotherly  Legislation  in  the  United  States. 
— An  anticigarette  bill  has  passed  the  lower  house 
of  the  Tennessee  legislature  by  a  unanimous  vote, 
and  it  is  expected  that  it  will  also  pass  the  senate. 
The  bill  prohibits  absolutely  the  sale  of  cigarettes 
and  of  cigarette  papers  in  the  State.  The  law  is  to 
come  into  effect  on  May  i,  1897.  If  it  be  true  that 
every  people  has  the  government  which  it  deser\-es, 
the  good  folk  of  Tennessee  would  appear  to  be  of 
those  of  whom  it  was  said,  "Blessed  are  the  meek." 
— British  AleiUcal  Ji^unial. 

A  Monument  to  Duchenne  of  Boulogne On  Sun- 
day, June  27th,  a  monument  was  unveiled  in  the  square 
of  the  General  Infirmary  of  the  Salpetri^re  to  the 
memory  of  the  celebrated  Duchenne,  who  was  bom  at 
Boulogne  in  the  year  1S06,  and  is  universally  known 
by  the  title  of  Duchenne  of  Boulogne.  M.  Barthou, 
the  minister  of  the  interior,  presided  at  the  ceremony, 
and  Professor  Joffroy,  physician  to  the  Asylum  of  St. 
Anne  and  president  of  the  memorial  committee,  pro- 
nounced a  eulogium  on  Duchenne.  He  recalled  the 
two  great  names  of  Trousseau  and  Charcot — of  Trous- 
seau, who  made  generally  known  the  work  of  Du- 
chenne with  regard  to  locomotor  ataxia ;  and  of  Char- 
cot, who  was,  he  said,  the  great  worker  in  the  science 


July  31-  1897] 


MEDICAL    RECORD. 


165 


of  modern  neuro-pathology  and  one  who  had  rendered 
■the  greatest  possible  ser\ice  to  the  studj-  of  affections 
of  the  nervous  system.  On  the  pedestal  of  the  monu- 
ment is  the  following  simple  inscription  :  "  1806-1875. 
To  Duchenne  of  Boulogne.  Localized  electrization; 
Physiology  of  movement;  Neuro-pathology."  Profes- 
sor Raymond,  physician  to  the  Salpetriere,  charged 
himself  in  his  official  capacity  with  the  duty  of  demon- 
strating in  their  midst  the  innumerable  labors  of  Du- 
chenne. Dr.  LerbouUet,  of  the  Academy  of  Medicine, 
read  a  paper  by  Professor  Mathias-Duval  upon  the 
works  of  Duchenne,  and  after  an  address  by  Dr.  Mo- 
tet, of  the  Academy  of  Medicine,  who  spoke  in  the 
name  of  the  Medical  Society  of  Paris,  M.  Barthou  con- 
cluded the  series  of  speeches.  In  the  most  brilliant 
fashion  the  minister  of  the  interior  tendered  his  re- 
spectful homage '"to  the  mar^-ellous  unity  and  mod- 
esty of  the  great  savant  to  whom  they  that  day,  per- 
haps somewhat  tardily,  were  giving  his  well-deserved 
tribute  of  glory."  A  point  to  which  the  minister  did 
not  refer  at  this  official  ceremony,  at  which  the  faculty 
and  a  host  of  medical  officeholders  were  present,  was 
that  Duchenne  never  at  any  time  was  either  a  j^rofes- 
sor  or  a  hospital  physician.  He  worked  all  alone, 
going  round  the  wards  every  morning  examinmg  and 
questioning  the  sick  himself,  and  was  looked  upon  as 
a  madman  by  all  the  officials.  Only  by  the  worth  of 
his  works,  and  that  at  a  long  time  after  his  death,  has 
he  attained  his  right  position,  for  during  his  life  he 
met  with  nothing  but  scorn  from  the  official  scientific 
world. —  I'/ie  Lancet. 

International  Conference  on  Railway  and  Steam- 
ship Hygiene. — The  second  international  congress  of 
"  les  services  sanitaires  et  I'hygiene  des  chemins  de 
fer  et  de  la  navigation"  will  be  held  in  Brussels,  on 
September  6,  7,  and  8,  1897.  Those  desiring  to  take 
part  in  the  congress  are  requested  to  send  name  and 
titles,  with  address  and  five  francs,  to  .Monsieur  le 
Docteur  J.  de  Lantsheere,  Rue  de  1' Association,  56 
Bruxelles,  Belgium. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
July  24,  1897.  July  20th. — Passed  Assistant  Surgeon 
L.  W.  Spratling  detached  from  naral  hospital,  Nor- 
folk, and  ordered  to  naval  hospital,  Philadelphia,  July 
19th;  Passed  Assistant  Surgeon  R.  M.  Kennedy  de- 
tached from  naval  hospital,  Philadelphia,  July  igth, 
and  ordered  to  naval  hospital,  Norfolk;  Assistant 
Surgeon  J.  C.  Pry^or  detached  from  naval  laboratory. 
New  York,  and  ordered  to  the  naval  hospital.  Mare 
Island,  Cal. ;  Assistant  Surgeon  W.  M.  \\'heeltT  de- 
tached from  naval  hospital.  Mare  Island,  and  ordered  to 
the  Oregon  ;  Assistant  Surgeon  A.  Farenholt  detached  , 
from  the  Oregon,  ordered  to  Washington  with  insane 
patient,  then  to  the  Vermont :  Assistant  Surgeon  C.  E. 
Riggs  detached  from  the  Vermont  and  ordered  to  the 
New  York  na\-yyard.  July  2 2d. — Medical  Inspector 
.^.  F.  Price  detached  from  the  N'ew  York  navyyard, 
July  14th,  and  ordered  to  the  Olympia  as  fleet  sur- 
geon ;  Medical  Inspector  J.  .\.  Hawke  ordered  to  the 
New  York  navyyard.  August   14th:    Medical    Inspec- 


tor J.  G.  Ayers  detached  from  the  Olympia  as  fleet  sur- 
geon, ordered  home,  and  granted  t^vo  months'  leave. 
July  23d. — Surgeon  H.  E.  Ames  detached  from  the 
Cincinnati.,  July  25th,  and  ordered  to  the  naval  hospi- 
tal, Yokohama,  per  steamer  August  14th;  Surgeon  J. 
C.  Byrnes  detached  from  the  Norfolk  navyyard  and 
ordered  to  the  Cincinnati,  July  25th;  Surgeon  P.  Fitz- 
simons  detached  from  naval  hospital,  Yokohama,  on 
relief,  ordered  home,  and  placed  on  waiting  orders. 

Dr.  Donald  McLean,  of  San  Francisco,  dean  of  the 
California  Medical  College,  was  shot  on  Friday  last 
by  a  discharged  employee  of  the  college,  and  was  dan- 
gerously wounded.  His  assailant  killed  himself  when 
about  to  be  apprehended  by  the  police. 

Don  Juan  Creuz  y  Manso,  of  Madrid,  one  of  the 
most  progressive  and  best  known  of  Spanish  surgeons, 
has  recently  died.  He  was  the  translator  of  the 
greater  part  of  the  Spanish  edition  of  Ashhurst's 
"  Encyclopedia  of  Surger)-."  He  was  the  first  surgeon 
in  Spain  to  advocate  and  practise  antiseptic  surgery, 
and  was  also  the  first  in  that  country  to  perform  a 
successful  ovariotomy. 

Disease  in  India.  —  Reports  from  Bombay  state 
that  there  has  been  an  alarming  increase  in  the  num- 
ber of  deaths  from  cholera  in  the  presidency  since  the 
middle  of  July,  and  that  there  has  also  been  a  slight 
increase  in  the  number  of  cases  of  the  plague,  which 
had  been  regarded  as  practically  extinct.  The  natives 
of  India  seem  to  be  awakening  to  the  need  of  greater 
efforts  to  eradicate  the  endemic  diseases  of  the  coun- 
try, and  the  viceroy  has  announced  that  native  chiefs 
of  India  have  undertaken  to  found  an  institution  for 
the  scientific  investigation  of  Indian  diseases  in  com- 
memoration of  the  jubilee. 

Bellevue  Hospital  Medical   College.  —  Dr.   E.   G. 

Janeway  has  been  elected  president  of  the  faculty 
of  Bellevue  College,  to  fill  the  vacancy  occasioned  by 
the  death  of  Dr.  William  T.  Lusk. 

Foreign    Medical    Practitioners    in     Italy.  —  Dr. 

Santini,  a  member  of  the  Italian  chamber  of  deputies, 
the  author  of  the  attempt  to  drive  all  foreign  physi- 
cians out  of  Italy,  occupies  his  time  chiefly  in  inquir- 
ing of  the  government  how  soon  the  foreigners  are  to 
be  forced  to  give  up  attending  to  their  sick  compatriots. 
The  last  time  he  interpellated  the  government,  early 
this  month,  the  representative  of  the  latter  replied 
that  medical  practitioners  of  non-Italian  nationality 
would  be  allowed  to  practise  among  Italians  in  Italy 
if  Italian  medical  men  had  the  same  privilege  con- 
ceded them  by  the  other  nationalities  in  question. 
The  sanitar)'  laws,  still  in  force,  allow  foreign  medi- 
cal men  to  practise  among  their  compatriots  resident 
in  Italy  if  they  do  not  extend  their  clientele  to  Italians. 
The  abuse  of  this  privilege  will  be  carefully  guarded 
against  in  the  future,  as  it  has  been  in  the  past,  but 
the  Italian  government  is  probably  too  wise  to  risk 
driving  away  many  rich  and  money-spending  tourists 
in  an  attempt  to  throw  a  few  patients  in  the  way  of 
Dr.  Santini  and  his  fellow-practitioners. 


1 66 


MEDICAL    RECORD. 


[July  31,  1897 


gleuiews  and  ^oticea. 

Nevral  Terms,  Ixterxatioxal  and  National.  By 
BVRT  G.  Wilder,  M.D.,  Professor  of  Neurolog>',  etc., 
in  Cornell  University.  Reprinted  from  the  Journal  0/ 
Comparative  Xcurology,  \'I.,  December,  1896. 

Although  by  no  means  prepared  to  accept  in  toto  the 
principles  of  Dr.  Wilder's  nomenclature  or  its  application, 
nevertheless  we  heartily  recommend  this  opuscle  to  our  read- 
ers, neurologists  and  general  practitioners  alike.  The  care- 
ful painstaking  labor,  the  comprehensive  knowledge  of  his 
subject,  we  may  even  say  the  manly  fashion  in  which  the 
author  receives  the  contumely  and  attempt  at  ridicule  of 
those  whose  position  in  the  scientific  world  makes  such  con- 
duct particularly  unfitting — all  command  our  admiration. 
That  Dr.  Wilder  is  continually  receiving  converts  to  his 
mode  of  nomenclature  is  shown  by  the  fact  that  Van  Ge- 
huchten,  in  the  recent  edition  of  his  work  on  the  anatomy  of 
the  ner\'ous  system,  adopts  it  in  many  important  respects. 

DiSE.'VSES     OF     THE     EVE    AND    OPHTHALMOSCOPY.        .\ 

Handbook  for  Physicians  and  .Students.  By  Dr.  A.  Ei- 
GEN  FiCK,  University  of  Zurich.  Translated  by  Albert 
B.  Hale,  A.B.,  M.D.,  one  of  the  Ophthalmic  Surgeons 
to  the  United  Hebrew  Charities;  Consulting  Ophthalmic 
Surgeon  to  Charity  Hospital,  Chicago,  etc.  With  a  Glos- 
sary and  158  Illustrations,  many  of  which  are  printed  in 
colors.      Philadelphia:  P.  Blakiston,  Son  &  Co.      1896. 

This  work  forms  a  volume  of  four  hundred  and  eighty-eight 
pages,  is  of  convenient  size,  well  printed,  beautifully  and 
quite  fully  illustrated.  The  author  may  be  congratulated  on 
having  secured  such  an  admirable  translation  of  his  work ; 
all  the  points  of  the  original  are  retained  and  are  expressed 
in  excellent  English,  free  from  the  Germanisms  so  frequently 
met  with  in  translations  from  that  language.  The  plane  of 
the  work  is  high,  and  it  will  be  read  most  understandingly 
by  students  and  practitioners  who  have  already  obtained 
some  knowledge  of  physiological  optics  and  clinical  ophthal- 
mology. 

The  part  devoted  to  the  discussion  of  external  diseases  is 
undoubtedly  the  weakest  in  a  ver\'  strong  whole.  Omission 
of  the  discussion  of  some  of  the  rarer  diseases,  as  molluscum 
and  actinomycosis,  and  failure  to  mention  the  pneumococcus 
as  a  cause  of  one  form  of  acute  conjunctivitis,  are  noted. 
One  is  surprised  to  find  the  following:  "  There  is  no  doubt 
that  infection  with  the  gonococcus  of  Xeisser  and  with  the 
diphtheria  bacillus  of  Klebs-Loeffler  can  produce  a  conjunc- 
tival diphtheria."  The  omission  to  mention  the  method  of 
"  expression"  in  the  surgical  treatment  of  trachoma,  the  sug- 
gestion to  use  hot  compresses  of  camomile  tea  in-the  treat- 
ment of  corneal  ulcer,  and  the  statement  that  keratitis  striata  is 
probably  due  to  wrinkles  in  the  cornea,  do  not  comport  with 
a  work  supposed  to  be  up  to  date. 

Honest  criticism  of  the  work  would  compel  the  statement 
that  there  is  little  that  is  new  in  its  pages ;  indeed  some  of  the 
text  bears  marks  of  antiquity,  as  the  description  of  the  pa- 
thology of  retinitis  albuminurica;  however,  these  are  minor 
faults  and  few.  The  work  as  a  whole  is  well  written  and 
evidences  a  wide  knowledge  of  ophthalmolog)-  on  the  part  of 
the  author  and  of  the  translator.  The  parts  relating  to  physi- 
ological optics  are  excellent. 

A  New  Classification  of  the  Motor  .Anomalies 
OF  the  Eve,  Based  upon  Physiological  Prin- 
ciples, Together  with  their  Sy.mptoms,  Diagno- 
sis, AND  Trkat.ment.  The  Prize  Essay  of  the  Alumni 
Association  of  the  College  of  Physicians  and  Surgeons, 
New  York,  for  1896.  By  Ale.x.'v'nder  Dlane,  M.D., 
Assistant  Surgeon,  Ophthalmic  and  Aural  Institute,  New 
York.      New  York:  J.  H.  A'ail  &  Co.      1897. 

The  care  in  preparation,  exactness  in  statement,  and  beauty 
of  expression  which  have  always  characterized  the  writings 
of  this  author  are  not  wanting  in  this  brochure  of  one  hun- 
dred pages.  The  careful  study  of  the  action  of  the  extrinsic 
muscles  of  the  eye,  extending  over  a  long  period  of  time,  is 
presented  in  a  carefully  digested,  impartial  statement  of  the 
conditions  met  with,  given  in  the  light  of  a  full  knowledge  of 
the  work  of  others  in  physiological  optics  and  in  the  norma! 
and  abnormal  dynamics  of  the  eye.  A  complete  analysis  of 
the  movements  of  the  eye,  as  produced  by  the  individual  and 


combined  action  of  the  eye  muscles,  is  given,  and  this  is  fol- 
lowed by  a  verj-  ingenious  diagram  illustrating  these  move- 
ments in  a  graphic  manner.  The  discussion  is  sufficiently 
comprehensive  to  present  a  clear  exposition  of  the  subject': 
it  is  direct  and  free  from  verbosity.  The  laws  given  for  the 
determination  of  feeble  and  paretic  muscles,  the  discussion  of 
the  anomalies  of  individual  muscles  and  the  statements  re- 
garding contractures  subsequent  to  insufficiences  of  opposing 
miiscles,  paretic  or  otherwise,  are  all  excellent. 

Although  the  classification  advocated  is  somewhat  cum- 
bersome, it  is  based  on  facts,  and  the  terms  employed  are  ac- 
curate and  clearly  descriptive  of  the  conditions  to  which  they 
are  applied.  There  is  little  to  criticise  and  much  to  com- 
mend in  this  work.  It  should  be  read  by  all  who  are  in- 
terested in  the  .subject  of  the  anomalies  of  the  muscles  of  the 
eye. 

Injuries  and  Diseases  of  the  Ear.  Being  reprints 
of  papers  on  Otology.  By  Macleod  Yearslev, 
F.R.C.S.,  Fellow  of  the  British  Lar\-ngological,  Rhino- 
logical,  and  Otological  .Association ;  Surgeon  in  Charge  of 
the  Department  for  Diseases  of  the  Throat,  Nose,  and  Ear, 
The  Farrington  Dispensar\-,  etc.  London :  The  Rebman 
Publishing  Company,  Limited,   1897. 

As  stated  in  the  preface,  the  papers  have  appeared  before  in 
\arious  journals  and  have  been  collected  together  to  form 
this  little  volume.  There  are  six  papers,  making  a  volume 
of  forty  pag;es.  The  work  is  of  value  to  the  general  prac- 
titioner, as  it  contains  many  precepts  relating  to  the  most 
common  pathological  conditions  met  with,  in  a  readily  acces- 
sible form.  To  the  aurist  there  is  little  of  interest  e.xcept  the 
last  article,  which  treats  of  aural  reflexes.  There  are  no 
illu.strations. 

Retinoscopv  (Or  Shadow  Testi.  In  the  Determination  of 
Refraction  at  One  Metre  Distance,  with  the  Plane  Mir- 
ror. By  James  Thorington,  M.D.,  Adjunct  Professor 
of  Diseases  of  the  Eye  in  the  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine.  Twenty-four  Illustra- 
tions.     Philadelphia:  P.  Blakiston,  Son  &  Co.      1897. 

This  little  volume  of  sixty-three  pages  is  intended  for  the  use 
of  undergraduates  in  medicine  and  for  those  taking  post- 
graduate studies.  It  is  an  extremely  elementary  exposition 
of  retinoscopy,  good  so  far  as  it  goes,  with  the  e.xception, 
perhaps,  of  some  theories  regarding  the  oblique  position  of 
the  lens  in  certain  cases,  which  are  irrelevant  and  possibly  not 
correct.  A  practical  knowledge  of  retinoscopy  may  be 
gained  by  the  penisal  of  the  work.  The  pages  are  well 
illustrated. 

Clinical  Lectures  on  Mental  Diseases.  By  Thom- 
as S.  Clou.ston,  M.D.,  F.R.C.P.E.,  Lecturer  on 
Mental  Diseases  in  the  University-  of  Edinburgh.  Fourth 
Edition,  Thoroughly  Revised. 

Clouston's  treati.se  on  mental  diseases,  although  not  the 
most  scientific  of  British  treatises  on  insanity,  is  unquestion- 
ably the  most  satisfactory  to  students  and  10  physicians,  and 
in  ever)-  instance  a  safe,  reliable  guide  in  the  handling  of  the 
diseases  to  which  it  is  devoted.  One  rises  from  reading  a 
chapter  or  a  section  with  the  fullest  conviction  that  he  has 
been  listening  to  a  man  experienced  in  the  practice,  learned 
in  the  theory,  and  versed  in  the  literature  of  his  subject. 
The  more  the  volume  is  studied  the  more  convinced  does  the 
reader  become  of  this  fact.  The  book  has  its  serious  faults, 
from  the  viewpoint  of  the  American  psychiatrist,  but  some  of 
these  it  shares  with  all  other  .-Vnglican  text-books  on  the 
same  subject.  The  subject  of  paranoia  is  discussed  in  two 
pages.  This,  of  course,  is  a  decided  gain,  in  what  we  ven- 
ture to  believe  is  the  right  direction,  over  complete  ignoring 
of  the  subject,  the  rule  in  text-books  on  insanity  by  British 
••medical  men."  Nevertheless,  it  may  be  truthfully  said 
the  handling  of  the  subject  in  the  present  edition  scarcely  in- 
spires us  with  feelings  of  gratitude.  We  are  not  prepared  to 
admit  that  •  •  No  paranoiac  loves  his  wife,  or  his  brethren,  or 
his  friends  in  the  right  and  normal  way. "  The  question  of 
love  is  at  best  wholly  a  personal,  individualistic  possession, 
and  it  occurs  to  us  that  we  have  encountered  more  than  one 
paranoiac,  naturally  not  of  the  type  ••  paranoia  sexualis, "  who 
has  loved  his  wife  in  a  way  to  meet  the  approval  of  the  latter. 
In  referring  to  King  Louis  II.  of  Bavaria,  Clouston  says :  '•  In 
him  there  appeared  to  have  been  sexual  penersion  of  the  most 


July  31,  1897] 


MEDICAL    RECORD. 


167 


abominable  description.  In  this  country  we  rarely  sec  such 
cases  as  are  described  in  such  repulsive  detail  by  Krafft- 
Ebing  and  Schrenck-Xotzing,  and  I  think  it  is  better  we 
should  not  look  too  closely  for  them."  Better  said  :  "  This 
country  furnishes  the  daily  press,  yearly  or  oftener,  the  most 
abominable  and  sickening  details  of  such  per\-ersion  in  people 
of  all  grades  of  notoriety  up  to  royalty,  who,  for  the  weal  of 
the  community,  have  to  be  sent  to  prison  or  to  a  modern 
Van  Diemen's  land."  It  would  be  better  by  far  for  the 
good  of  humanity  if  they  were  looked  for  closely,  instead  of 
pushing  the  head  far  enough  into  the  sand  to  obscure  vision. 
We  have  quoted  the  designation  "medical  men"  above, 
havinginmind  Clouston's  XIX.  Chapter  "  Medico-Legal  and 
Medico-Social  Duties  of  Medical  Men,  etc."  Considering 
that  a  respectable  minority  of  the  asylum  physicians  in  this 
country  are  not  men.  may  we  not  reasonably  ask  the  author 
to  substitute  the  word  "physician"  in  future  editions,  at 
least  for  the  American  edition?  We  can  assure  him  that  the 
"  medical  men"  will  not  feel  aggrieved  and  the  medical 
women  will  be  touched  by  his  tacit  recognition  of  their 
existence. 

Twentieth  Century  Practice.  An  International  En- 
cyclopedia of  Modem  Medical  Science.  By  Leading  Au- 
thorities of  Europe  and  America.  Edited  by  TH0-Ma.s  L. 
Stedman,  M.D.  ,  Xew  York  City.  In  Twenty  Volumes. 
Volume  X. :  Diseases  of  the  Nervous  System.  Xew 
York :  ^\'illiam  Wood  and  Company.      1 897. 

The  contributors  to  the  volume  on  ner\-ous  diseases  of  this 
series  are  few  and  with  one  e.xception  all  are  American  prac- 
titioners. 

The  fifteen-page  index  would  indicate  that  the  field  has 
been  well  covered.  The  chapters  are  upon  diseases  of  the 
brain,  intracranial  hemorrhage,  tumors  of  the  brain,  diseases 
of  the  meninges,  hysteria,  epilepsy,  spasmodic  neuroses, 
neurasthenia,  disorders  of  speech,  and  disorders  of  sleep. 
All  of  these  authors  write  well  and  their  productions  make 
rather  more  fluent  reading  than  some  of  the  translations  from 
foreign  authorities.  The  two  contributions  from  the  pen  of 
Charles  Fere  on  hysteria  and  epilepsy  have,  however,  been 
marred  by  no  literal  rendering  of  idioms,  the  translation  pre- 
serving all  original  fluency  of  the  French.  The  first  two 
hundred  and  sixty  pages  are  covered  by  contributions  from 
Joseph  Collins,  of  Xew  York.  The  various  subjects  show- 
evidences  of  painstaking  care  in  their  preparation.  Fol- 
lowing this,  Charles  L.  Dana  has  an  extremely  well  written 
and  practical  article  on  apopleptic  conditions,  followed  by 
"Tumors  of  the  Brain"  from  the  pen  of  Bernard  Sachs,  also 
of  Xew  York,  who  has  treated  the  subject  in  a  masterly  way. 
Howell  Pershing,  of  Denver,  has  presented  a  chapter  on  the 
difficult  subject  of  disorders  of  speech,  covering  the  ground 
in  a  creditable  manner.  Sanger  Brown,  of  Chicago,  follows 
with  "The  Disorders  of  Sleep,"  the  chief  of  which  here 
treated  of  being  insomnia,  somnambulism,  and  nightmare. 
Dana  has  also  contributed  the  chapter  on  neurasthenia,  which 
is  short  and  to  the  point.  The  spasmodic  neuroses,  including 
chorea  and  the  various  tics,  are  well  described  by  Dr.  Fere. 

The  volume  is  a  worthy  and  valuable  addition  to  this  mas- 
terly series. 

The  Diseases  of  the  Stomach.  By  Dr.  C.  A.  Ewalu. 
Translated  and  Edited  by  Morris  Manges,  M.D.  Sec- 
ond Revised  Edition.  Xew  York:  D.  Appleton  &  Co. 
1897. 

This  excellent  book,  which  is  so  well  and  favorably  known, 
has  received  many  additions  from  the  author  as  well  as  from 
the  translator.  Full  mention  is  made  of  the  newer  litera- 
ture of  gastric  pathology.  Several  new  drawings  have  been 
added,  thus  the  gastrodiaphane  of  Einhorn,  the  re-current 
stomach  tube  of  Hemmeter,  and  a  few  drawings  from  Osier 
illustrating  dilatation  of  the  stomach.  There  is  no  doubt 
this  book  will  be  read  and  studied  by  the  American  profes- 
sion with  the  greatest  interest  and  much  profit. 

Experimentelle  Untersuchungen  uber  die  Wik- 
KUNG  rascher  Ver.\nderungen  des  Luftdrucki:;^ 
AUF  DEN  Organismus.  Von  Drs.  Richard  Heller, 
Wilhelm  Mager,  Hermann  von  Schroetter  in 
Wien.     Bonn.      1897. 

The  writers  of  this  work  arrive  at  the  following  conclusions : 
The  blood  of  the  organism  is  not  subjected  to  any  me- 
chanical changes  under  the  influence  of  compressed  ain 


After  a  rapid  liberation  from  the  compression,  free  gas 
may  be  shown  to  exist  in  the  blood-vessels.  This  gas  con- 
sists principally  of  nitrogen. 

If  the  stay  in  compressed  air  is  a  prolonged  one  and  the 
liberation  from  it  quite  rapid,  pathological  changes  arise 
which  act  either  upon  the  function  of  the  heart  and  lungs 
and  may  lead  to  death,  or  upon  the  nervous  system. 

All  these  pathological  changes  are  caused  by  the  presence 
of  free  gas  in  the  blood-vessels,  and  may  be  partly  subdued 
by  the  judicious  application  of  compressed  air. 

Practical  Pathology  for  Students  and  Physi- 
cians. By  Aldred  Sc(Jtt  Warthin,  Ph,D.,  M.D. 
Ann  .Arbor:  George  Wahr.      1897. 

This  work  may  be  considered  as  an  excellent  guide  for 
the  student  and  practitioner  in  all  laboratorj-  and  dissect- 
ing methods,  giving  them  as  practically  as  possible,  but  yet 
thoroughly  and  completely.  With  regard  to  the  differential 
diagnosis  of  tumors,  we  cite  the  following  from  page  100: 

' '  For  the  differential  diagnosis  of  sarcoma  or  carcinoma  in 
the  gross  specimen,  the  following  points  are  to  be  taken  into 
consideration :  Sarcomata  possess,  as  a  rule,  a  smooth 
homogeneous  surface,  from  which  no  cloudv  juice  rich  in 
cells  can  be  scraped.  An  uneven,  granulated  cut  surface, 
in  which  a  stroma  of  connective  tissue  may  be  made  out, 
containing  cell  masses  which  are  easily  scraped  away  with 
the  knife  as  '  cancer  juice, '  speaks  for  carcinoma.  Yet  for 
alveolar  sarcoma  this  distinction  cannot  be  made,  its  cut  sur- 
face resembling  in  all  points  that  of  carcinoma.  Squamous- 
cell  carcinoma  gives  a  dr\-  cut  surface,  from  which  the  gray- 
ish cell  masses  may  be  squeezed  out  like  comedones." 

Clinical  Lessons  on  Xervous  Diseases.  ByS.  Weir 
Mitchell,  M.D.  Philadelphia  and  New  York:  Lea 
Bros.  &  Co.      1897. 

This  little  volume,  from  the  pen  of  the  "  chief  ornament  of 
the  medical  profession  in  the  States,"  as  the  University  of 
Edinburgh  styled  him  on  the  occasion  of  his  enrolment 
among  her  favored  few  as  the  recipient  of  honorary  degrees, 
will  undoubtedly  find  a  large  and  appreciative  circle  of  read- 
ers both  at  home  and  abroad.  There  are  in  it  that  epitomiza- 
tion  of  years  of  bedside  experience,  that  evidence  of  clinical 
insight,  that  fund  and  wealth  of  resourcefulness  in  the  treat- 
ment of  obstinate  nervous  diseases — as  evidenced,  for  in- 
stance, in  the  chapter  on  sciatica — which  convince  that  it  is 
a  book  to  be  studied,  to  be  assimilated. 

It  is  commonplace  to  mention  Dr.  Mitchell's  literarj-  style, 
but  there  are  choice  bits  in  this  volume  that  the  talented  au- 
thor does  not  often  surpass  in  his  medical  writings.  To  se- 
lect one  sentence  taken  from  the  chapter  "  Some  Disorders 
of  Sleep  " : 

"  In  the  borderland  of  coming  slumber,  when  we  are  not 
yet  overwhelmed  by  its  full  power,  the  steadying  contradic- 
tions of  the  external  world  are,  in  a  measure,  by  degrees  cut 
off,  while  the  will  holds  a  slowly  lessening  rule. " 

The  physician  who  stri\'es  for  the  caresses  of  fame,  from  a 
literary  standpoint,  be  he  neurologist,  gj-na-cologist.  or  pro- 
fessor in  a  medical  college,  may  .see  in  these  delightful  and 
most  instructive  Lessons  an  unerring  signpost.  Devoid  of 
the  intricacies  with  which  even  attempt  at  completeness  causes 
the  customarj'  treatise  on  nervous  diseases  to  be  beset,  this 
collection  of  seventeen  lessons  must  be  a  welcome  accession 
to  the  readable  books  of  everv'  medical  practitioner. 

Dr.  Mitchell's  graciousness  in  preface  and  text  to  his  phy- 
sician assistants  is  a  notewonhy,  a  gratifying,  and  a  com- 
mendable feature. 

Manual  of  Static  Electriciiy  in  .V-Ray  and 
Therapeutic  Uses.  By  S.  H.  Monell,  M.D.  New 
York:  William  Beverley  Harison.      1897. 

This  interesting  book  contains  over  six  hundred  pages  de- 
voted to  the  value  of  the  static  current.  Beginning  with  a 
description  of  the  mechanism  and  modus  operandi  of  the  in- 
strument, the  author  treats  of  the  various  ways  of  applying  the 
currents,  and  gives  valuable  points  for  the  correction  of  vari- 
ous errors  in  the  management  of  the  same.  An  elaborate 
series  of  chapters  on  the  treatment  of  various  disorders, 
such  as  "Neuralgias"  and  "Rheumatism,"  "Hysteria," 
"  Headaches,"  "  Locomotor  .Ataxia,"  etc.,  follow.  It  is  al- 
most incredible  to  find  that  the  author  recommends  the  static 
current  for  the  treatment  of  gastro-intestinal  disorders  in  in- 
fants; in  fact,  he  describes  two  cases  of  infants,  one  a  child 


1 68 


mp:dical  record. 


[July  31,  1897 


seven  weeks  old.  in  which  he  used  the  current  with  excellent 
results.  This  was  (or  the  relief  of  diarrhoea,  but  he  says 
that  he  changed  the  diet  and  gave  some  internal  medication 
besides  the  static  current.  The  subject  of  .i-ray  photography 
is  given  in  an  excellent  manner.  This  is  the  best  part  of 
the  book.  To  those  desiring  infoimation  on  this  branch,  the 
author  gives  his  views  in  a  clear  and  masterh-  manner.  He 
has  had  abundant  experience  here  and  the  work  is  to  be 
commended  for  its  treatment  of  this  interesting  subject. 

Dk.^fh  -\.\d  Suddkx  Dk.vih.  I5y  P.  Bkouakdei,, 
Professor  of  Medical  Jurisprudence.  Dean  of  the  Faculty 
of  Medicine,  Paris.  Translated  by  F.  Lucas  Benham, 
M.D.,  B.S.  Lond.  New  York:  William  Wood  and 
Company.      1897. 

With  a  striking  title  and  still  more  striking  contents,  this 
book  is  destined  to  command  wide  attention  and  extensive 
reading.  Its  inherent  conception  is  novel  and  its  adaptabil- 
ity to  practical  needs  is  everything  that  could  be  desired. 
There  is  in  reality  no  work  with  which  we  are  acquainted 
that  so  effectually  covers  the  ground  as  does  this  one.  There 
are.  in  fact,  so  many  interesting  and  important  facts  men- 
tioned in  it  which  can  be  found  nowhere  else  in  such  a  con- 
venient compass  that  the  little  book  has  an  intrinsic  value.  It 
represents  a  course  of  lectures  on  forensic  medicine  delivered 
by  Brouardel  and  admirably  translated  by  the  English  editor. 
In  part  I.,  under  the  signs  of  death,  the  author  treats  of  the 
moment  of  death,  of  the  uncertainty  of  some  of  the  signs  of 
death,  and  of  the  absolute  proofs  of  the  actual  occurrence  of 
death.  The  dangers  of  premature  burial  in  cases  of  appar- 
ent death  are  fully  set  forth.  It  is  comforting  to  such  as  may 
have  exaggerated  notions  of  the  frequency  of  premature  burials 
to  know  that  the  chances  of  such  mishaps  are  reduced  to  the 
minimum,  in  fact  are  made  impossible  when  the  death  is 
scientifically  established.  In  estimating  the  relative  value  of 
the  signs,  that  of  cessation  of  heart  beat  ranks  first,  although 
the  reader  will  be  suqirised  to  learn  that  cardiac  action  can 
be  excited  after  a  cessation  of  three  hours  in  the  stillborn. 
The  reference  to  several  illustrative  cases  of  apparent  death 
for  hours  and  final  resuscitation  makes  very  interesting  and 
instructive  reading.  The  phenomena  of  decomposition  are 
ver>-  graphically  presented  and  many  instances  are  related  in 
which  the  cadaveric  ptoniains  have  in  medico-legal  cases 
been  mistaken  for  ingested  poisons.  Part  II.  treats  of  the 
causes  of  sudden  death  as  centred  in  the  different  vital  ap- 
paratus, and  many  instructive  instances  are  related  of  some 
curious  forms  of  sudden  death,  the  occurrence  of  which 
would  not  have  been  suspected  without  post-mortem  exami- 
nation. The  concluding  section  is  on  sudden  death  in  chil- 
dren, which  forms  a  distinctive  feature  in  a  work  which  is 
instructive  and  interesting  from  beginning  to  end.  We 
venture  to  say  that  no  physician  can  read  if  without  profit 
oriconsult  it  without  benefit. 

Contributions  TO  the  Physioluuv  and  Pathology 
OF  the  Nervous  System.     By  Isaac  Ott,  M.D. 

This  little  brochure  contains  essays  on  the  thermogenic  cen- 
tre in  the  tuber  cinereum ;  effect  of  section  of  the  vagi  upon 
temperature,  heat  production,  and  heat  dissipation ;  notes  on 
the  animal  extracts ;  the  rhythmic  action  of  the  bladder,  ef- 
fect of  certain  drugs  upon  it — the  original  publication  of 
which  materially  helped  to  establish  the  writer's  reputation 
as  a  physiologist. 

Illustrated  Skin  Diseases.  An  Atlas  and  Text- 
book. By  William  S.  GoTTHEiL,  M.D.  New  York: 
E.  B.  Treat,  1897. 

Part  IV.  treats  of  the  acute  "exanthemata,  morbilli.  ru- 
beola, scarlatina,"  etc.  These  are  treated  only  from  the 
point  of  view  of  the  skin  eruptions  that  characterize  them. 
\'aricella  and  variola  are  illustrated  from  typical  and  well- 
marked  cases.  The  picture  of  vaccinia  rash,  on  page  91, 
calls  attention  to  a  fairly  common  but  little  noticed  general 
eruption.  The  same  part  and  tlie  next  one  contain  the  sec- 
tion on  favus  and  ringworm,  and  are  appropriately  illustrated. 
Figs.  49  and  51  are  especially  good.  re|)resenting  ringworm 
and  pitiri.-isis  rosea.  Part  \'.  deals  also  with  the  parasitic 
skin  diseases  of  anim.il  origin  and  we  note  in  theni  some 
excellent  micro-photographs.  The  large  section  of  eczema 
concludes  Part  V.,  and  fills  the  first  pages  of  Part  \'l.  This 
important  subject  is  represented  in  a  number  of  photographs 


representing  all  its  various  stages  and  forms.  Pemphigus,  im- 
petigo, and  exfoliative  dermatitis  occupy  the  remainder  of  this 
part,  the  concluding  pages  being  devoted  to  psoriasis.  The 
color  plates  represent  ichthyosis,  keratosis,  and  zoster.  It  is 
interesting  to  note  that  almost  ever)-  picture  is  from  an  orig- 
inal photograph.  The  parts  are  filled  with  practical  informa- 
tion, and  give  very  valuable  prescriptions  for  the  managemeni 
of  the  various  disorders  treated.  These  three  parts  show  an 
expenditure  of  great  labor,  and  the  author  is  certainly  to  be 
complimented  on  the  successful  result.  The  t>-pe  is  verv 
clear,  and  the  illu.strations  are  large  and  distinct.  In  con- 
nection with  this  work  \\  e  may  say  that  it  is  a  matter  of 
wonder  to  us  where  the  publishers  of  the  numerous  atlases 
of  skin  diseases  issued  the  past  few  years  can  find  profit. 
Hardly  is  one  completed  than  another  is  begun.  There  are 
too  many  books  published. 

First  Aid  in  Ili.xk>s  and  Injury.  By  Ja.mk.-.  Pil- 
CHER,  .M.D.,  Ph.D.,  Captain  in  the  Medical  Department 
of  the  United  States  Army.  New  '^.ork:  Charles  Scrib- 
ner's  Sons.      1897. 

This  work  is  probably  the  best  of  its  kind  ever  brought  out. 
The  subject  matter  is  set  forth  in  clear  and  intelligible  lan- 
guage, and  the  use  of  technical  terms  is  avoided  as  much  as 
possible.  The  illustrations  are  copious  and  good,  and  alto- 
gether the  work  is  one  that  will  prove  useful  in  any  hou.se- 
hold. 

Diseases  of  the  Ear,  Nose,  and  Throat,  and 
their  Accessory  Cavities.  A  Condensed  Text- 
book. By  Seth  -Scott  Bishop,  M.D.,  LL.D..  Profes- 
sor in  the  Chicago  Post-Graduate  Medical  .School  and 
Hospital,  Surgeon  to  the  Illinois  Charitable  Eye  and  Ear 
Infirmar)-.  Philadelphia  and  New  York  ;  The  F.  A.  Da- 
vis Co. 

This  work,  which  is  comprised  in  four  hundred  and  ninety- 
six  pages,  is  excellently  printed  and  fully  illustrated.  It 
is  designed  to  be  of  use  to  a  large  number  of  medical  men, 
the  student,  the  practitioner,  and  the  specialist  in  his  early 
studies.  The  author  has  endeavored  to  bring  the  work 
fully  up  to  date,  and  much  prominence  is  given  to  the 
consideration  of  recent  advances  in  the  knowledge  of  diph- 
theria and  serum  therapy,  also  to  descriptions  of  recent  sur- 
gical appliances.  The  first  chapter  is  devoted  to  a  statisti- 
cal study  of  twenty-one  thousand  cases  of  diseases  of  the 
ear,  nose,  and  throat.  The  descriptions  of  the  conditions 
met  with  are  characteristic  of  the  author,  clear  and  not  too 
full.  The  specific  definite  manner  in  which  the  forms  of 
treatment  advocated  are  gpven  makes  the  information  valu- 
able to  the  student  and  practitioner,  and  the  number  of 
methods  and  remedies  mentioned  is  not  sufficiently  large 
to  be  confusing.  The  statement  regarding  the  introduc- 
tion of  sprays  and  medicated  vapors  into  the  ear  by  means 
of  ttibes  that  do  not  enter  the  nasal  cavities  beyond  the  ante- 
rior nares  would  with  the  hv-percritical  raise  the  question  as 
to  what  becomes  of  the  residual  air,  and  suggests  an  undue 
strain  on  the  law  of  the  diffusion  of  gases.  A  number  of 
extravagant  expressions  are  found.  The  style  in  parts  might, 
perhaps,  be  criticised.  Facetious  phrases  are  sometimes 
met  with.  These  features  ser\e  to  illustrate  the  well-known 
personal  peculiarities  of  the  author,  but  they  do  not  detract 
from  the  value  of  the  information  given. 

iNEBRiF.iY,  Its  Source,  Prevention,  and  Cure.  By 
Charles  Follen  Palmer.  Fleming  H.  Revell  Com- 
pany.     1 897. 

In  this  small  volume  the  author,  in  a  clear,  easy  style,  dis- 
cusses what  he  calls  the  ner\ous-mental  organization  in  its 
causal  relation  to  inebriety  and  allied  manifestations  of  an 
abnormal  nen-ous  system,  and  draws  the  following  conclu- 
sions:  ■•  .Alcoholic  inebriety  is  often  based  upon  and  de[v;n- 
dent  on  diseased  conditions  which  demand  proper  medical 
or  hygienic  treatment  for  their  removal.  The  inebriate  is  a 
dise.ised  person,  and  the  disease  has  either  preceded  the  in- 
ebriety or  is  dependent  upon  it.'"  He  believes  in  the  possi- 
bility of  altering  the  constitutional  temperament  by  suitable 
training  of  the  affected  individual,  preferably  from  earliest 
youth.  This  is  to  be  accomplished  by  the  choice  of  such 
physical,  mental,  and  moral  hygiene  and  exercise  as  tend  to 
make  a  hardy,  vigorous  organism,  and  especially  by  the  rig- 
orous and  systematic  strengthening  of  the  moral  will  power 
and  self-control.      He  deems  absolute  abstinence   from   all 


July  31.  1897] 


MEDICAL    RECORD. 


169 


stimulants  and  narcotics  an  essentia!  to  the  prevention  or 
cure  of  inebriety  in  the  disease  D,pe  of  iadhndual  under  dis- 
cussion. The  author  will  probably  be  deemed  oversanguine 
as  to  the  results  obtainable  in  the  maiorit\-  of  cases,  but  his 
book  contains  many  helpful  suggestions  for  the  treatment  of 
neurotics  in  general,  as  well  as  those  who  are  predisposed  to 
alcoholism. 

Hysteria  and  Certain  .Allied  Coxdition.s.-  Their 
Nature  and  Treatment,  with  special  Reference  to  the  Appli- 
cation of  the  Rest  Cure.  Massage.  Electro-therapy.  Hypno- 
tism, etc.  By  George  J.  Preston.  M.D.,  Professor  of 
Diseases  of  the  Xer\ous  System,  College  of  Physicians  and 
Surgeons.  Baltimore ;  \'isiting  Physician  to  the  City  Hos- 
pital, etc.  Illustrated.  Pp.  298.  Philadelphia:  P.  Bla- 
kiston.  Son  &  Co.      1897. 

This  is  an  e.xceedingly  attractive  little  book,  and.  although 
It  may  not  contain  much  that  is  new  to  the  specialist,  is  a 
valuable  contribution  to  the  voliuninous  literature  of  a  famil- 
iar subject.  It  will  be  especially  useful  to  the  general  prac- 
titioner, for  whom,  indeed,  it  is  intended.  The  introductorv 
historical  chapter  is  quite  interesting.  The  ne.xt  two  on  eti- 
ology and  pathologN'.  and  on  s\-mptomatolog\'.  are  admirably 
clear  and  succinct.  Chapters  IV.  to  \TII.  1  inclusive  1  deal 
wnth  motor  disturbances,  convulsive  attacks,  mental  condi- 
tions, and  visceral  and  vasomotor  disturbances,  and  are  well 
illustrated  by  plates  and  diagrams  from  Richer.  Charcot,  and 
de  la  Tourette.  Three  chapters  are  devoted  to  treatment,  in 
which  the  advantages  of  massage,  electro-therapy,  and  the 
rest  cure  are  thoroughly  discussed.  H)-pnotism  receives  due 
attention.  With  a  concluding  section  on  the  surgical  treat- 
ment of  hysteria  we  are  heartily  in  s\Tnpathy,  especiallv  the 
final  sentence,  viz.  :  ■  ■  The  rtde.  then,  that  should  be  adopted 
is  that  operations  should  not  be  performed  on  hysterical  wo- 
men for  the  relief  of  the  ner\ous  s\Tnptoms,  unless  some 
distinct  disease  of  the  reproductive  organs  can  be  detected." 

Lectures  on  the  Tre.\tment  of  Fibroid  Tumors  of 
the  Utervs,  Medical,  Electrical,  and  Surgical. 
By  Franklin  H.  Martin,  M.D.,  Professor  of  G\-nje- 
cology.  Post-Graduate  Medicai  School  of  Chicago,  etc. 
Pp.  1 74.     Chicago ;  The  \V.  T.  Keener  Company.     1 897. 

This  little  monograph  includes  a  series  of  ten  lectures, 
which  present  an  excellent  resume  of  the  most  recent  views 
on  the  subject  of  the  treatment  of  this  class  of  tumors.  The 
first  five  chapters  (sixty-five  pages  1  are  devoted  to  anatomy. 
pathology-,  and  non-surgical  treatment;  the  last  five  to  de- 
scriptions of  various  operations,  especially  hysterectomy. 
The  latter  are  excellent,  and  are  well  illustrated.  Chapter 
\\\.  deals  with  the  authors  operation  of  ligating  the  uterine 
aneries,  which  he  may  be  pardoned  for  making  rather  longer 
than  its  importance  would  seem  to  warrant  in  comparison 
with  other  more  radical  procedures.  The  style  is  clear  and 
pleasing,  and  the  little  book  will  well  repay  a  careful  read- 
ing, especially  by  the  general  practitioner. 

Organ  Diseases  of  Women,  Notably  Enlargements 

AND  DiSPL.VCEilENTS  OF  THE  UTEKUS  AND  STERILITY. 

Considered  as  Curable  by  Medicines.  By  J.  Comp- 
TON  Burnett,  M.D.  Pp.  156.  Philadelphia':  Boericke 
&  Tafel.      1897. 

1 F  It  were  not  for  the  fact  that  our  homoeopathic  friend  takes 
himself  so  seriously,  we  should  be  inclined  at  first  sight  to 
regard  this  little  book,  like  its  title,  as  a  medical  joke.  But 
the  author  is  certainly  an  original  character,  as  shown  bv  his 
epigrammatic  style  and  decided  opinions.  He  sets  his  face 
firmly  against  Malthusian  doctrines,  and  records  trium- 
phantly at  the  conclusion  of  most  of  his  cases  that  •  •  a  bonnie 
boy"  was  the  result  of  his  purely  medicinal  treatment.  It 
is  difficult  to  pass  judgment  on  views  from  which  we  differ 
so  esseatially,  but  even  from  a  purely  common-sense  stand- 
point one  is  forced  to  conclude  that  the  writer  ••  doth  profess 
too  much." 

Atlas  i-nd  Crundriss  der  Lehre  vom  Geburtsakt 
UND  der  operativen  Geburtshilfe.  Von  Dr.  Os- 
KAR  Schaeffer.  Privatdocent  an  der Universitat  Heidel- 
berg. IV.  Auflage.  Miinchen :  \'erlag  von  J.  F.  Leh- 
mann. 

The  fourth  edition  of  this  well-knowTi  work  has  been  thor- 
ojc^y  re\ised.  and  many  additions  have  been  made,  espe- 
cially in  the  section  devoted   to  operative  obstetrics.     We 


note  a  new  page  on  s>Tnph\-seoromy,  though  it  is  to  be  re- 
gretted that  there  are  no  accompanying  illustrations.  The 
same  comment  applies  to  the  new  subject  maner  on 
cucouchemeitt  forci\  a  procedure  which  has  assumed  consid- 
erable prominence  of  late. 

Of  course  the  most  valuable  part  of  the  book  is  the  picto- 
rial. The  plates  have  been  of  die  greatest  assistance  to  gen- 
erations of  medical  students  and  practitioners,  and  will  not 
easily  be  superseded.  The  graphic  representation  of  the 
more  common  obstetric  operations  (forceps  and  version)  are 
beyond  criticism.  We  are  happy  to  add  that  through  the 
enterprise  of  William  Wood  and  Company  this  work,  as  well 
as  the  companion.  •■  Essentials  of  Gynecology-."  have  been 
made  familiar  to  non-Gcnnan  readers. 

-Atlas  .\nd  Essenti.a.ls  of  GYN.tcoLOGY.  By  Dr.  Os- 
C.\R  SCH.A.EFFER,  Privatdocent  in  Obstetrics  and  Gynae- 
cology at  the  University  of  Heidelberg.  With  173'Col- 
ored  Plate  Illustrations  and  54  Moodcuts.  Pp.  288. 
New  York:  William  WckxI  and  Companv.      1897. 

To  say  that  the  publishers  of  this  translation  of  Schaefler's 
work  have  improved  on  the  original  in  their  colored  reproduc- 
tion of  the  plates  is  sufficient  commendation.  \\hen  we 
add  that  the  terse  condensed  style  of  the  author  has  been 
closely  followed  without  the  sacrifice  of  good  English,  we 
have  said  enough  to  con\ince  those  familiar  with  the  latest 
German  edition  that  .American  students  have  now  within 
their  reach  a  most  valuable  aid  in  their  practical  work  in 
gynjecology.  Though  praise  of  separate,  plates  would  be  in- 
vidious, we  are  especially  pleased  with  those  representing  the 
various  forms  of  malignant  disease  of  the  ponio  and  uterine 
displacements.  TTie  plate  facing  page  20.  and  those  show- 
ing different  varieties  of  fibroids,  are  also  worthy  of  com- 
mendation. 

The  work  of  the  translator  is  certainly  deser\ing  of  praise. 
The  reversal  of  the  original  order  (the  te.xt  being  first  in  the 
German),  and  the  tables  of  contents  and  of  illustrations,  are 
decided  improvements.  The  t\-pe,  binding,  and  tmit  aiscm- 
hle  of  the  American  edition  are  unusually  pleasing  to  the  eye. 

Sytiixgomy-elia  :  The  Alvarenga  Prize  Essay  of  the  Col- 
lege of  Physicians  of  Philadelphia  for  1895.  Bv  GUY' 
Hinsdale,' M.D.  Philadelphia:  P.  Blakiston,  Son  &  Co. 
1897. 

This  essay  has  already  appeared  in  the  columns  of  the  ///- 
tcrnafioniil Medical  Slagazim.  It  is  now  republished  with 
some  slight  additions,  a  dedication,  and  an  appendix. 

Dr.  Hinsdale  treats  his  subject  historically,  as  becomes  a 
prize  essay,  and  then  considers  the  causation,  symptoms, 
outcome,  etc. ;  but  it  cannot  be  said  that  he  has  done  so  ex- 
haustively. -Although  there  is  a  very  lengthy  bibliographical 
appendix,  the  te.xt  does  not  con\ince  one  that  the  wealth  of 
material  indicated  by  this  appendi-x  has  been  carefully  and 
comprehensively  digested.  The  discussion  of  the  pathogen- 
esis of  syringomyelia,  its  development,  and  even  its  morbid 
anatomy  are  by  no  means  w  hat  they  should  be  in  a  prize  es- 
say, particularly  when  it  is  borne  in  mind  that  the  author  has 
made  no  contribution  to  the  subject  save  two  verv-  brief  clin- 
ical histories.  .Although  the  monograph  bears  manv  evi- 
dences of  haste  and  loose  construction,  in  a  general  way  it 
gives  a  fairly  good  rc'suiiu  of  the  subject,  and  for  those  not 
familiar  with  German  literature  it  may  be  recommended  as 
the  most  lengthy  exposition  of  the  subject  in  English. 

The  .American  Ve.\r-Book  of  Medicine  and  Sur- 
gery. Being  a  Yearly  Digest  of  Scientific  Progress  and 
.Authoritative  Opinion,  draw-n  from  Journals,  Monographs, 
and  Text-Books  of  the  Leading  .American  and  Foreign 
.Aiuhors  and  Investigators,  under  the  General  Editorial 
Charge  of  George  M.  Gould,  M.D.  Philadelphia:  W. 
B.  Saunders,  1897. 

This  year-book,  like  several  others  of  a  similar  kind,  essays 
to  solve  the  extremely  hard  problem  of  how  to  present  a 
sufficient  and  critical  digest  of  contributions  to  every  branch 
of  medico-surgfical  literature  that  have  been  published  during 
the  preceding  year.  The  endeavor  to  cover  the  whole  range 
of  medical  science  within  the  limits  of  one  volume,  however 
bulky,  presents  in  many  ways  almost  insuperable  obstacles. 
So  far  as  the  particular  book  under  notice  goes,  it  is  well 
compiled,  but  its  scope  of  usefulness  and  that  of  all  year- 
books is  necessarily  a  restricted  one.  This  boiling-do»-n,  so 
to  speak,  of  the  medical  work  of  an  entire  year  is  attended 


I70 


MEDICAL    RECORD. 


[July  31,  1897 


with  many  drawbacks.  To  epitomize  properly  the  medical 
and  surgical  writings  of  so  long  a  period  is  nearly  impossi- 
ble. Dr.  Gould's  year-book  is  probably  as  successful  an  at- 
tempt as  has  been  made  in  this  direction.  To  criticise  the 
book  in  detail  would  be  to  attempt  a  task  beyond  the  powers 
of  any  one  individual,  so  that  no  decided  opinion  can  be 
given  as  to  whether  the  subjects  dealt  with  have  been  judi- 
ciously selected  or  appropriately  touched  upon.  Judging 
from  a  somewhat  cursory  perusal,  tlie  chosen  portions  appear 
to  provide  as  nourishing  literary  food  as  can  be  e.xpected. 

A  few  changes  have  been  made  in  the  names  of  those  in 
charge  of  some  of  the  departments,  but  on  the  whole  the 
editorial  staff  remains  the  same  as  that  of  the  issue  of  last 
year.  It  is  our  judgment  that  the  days  of  usefulness  of  all 
"year  books"  are  past,  and  that  their  continued  arrival  is 
in  the  nature  of  "pot  boilers,"  by  both  editors  and  publish- 
ers. No  wideawake  physician  needs  books  of  this  sort,  for 
he  keeps  himself  better  informed  by  means  of  his  weekly 
journals. 

Aphasia:  The  Cerebral  Speech  Mechanism.     By  Wii.ijam 
Elder,  M.D.,  F.R.C.P.     London:  H.  K.  Lewis.    1897. 

The  writer  of  this  treatise  is  known  to  the  readers  of  medical 
literature  from  a  remarkable  contribution  which  he  made  to 
the  subject  of  aphasia,  published  in  the  Edinburgh  Hospi- 
tal Reports  a  short  time  ago.  The  greater  part  of  the  pres- 
ent volume  is  the  author's  thesis  for  the  ALD.  degree  of  the 
Edinburgh  University. 

The  author  shovVs  his  familiarity  with  modern  literature, 
especially  that  of  the  school  of  Dcjerine,  from  the  writings  of 
which  he  has  evidently  got  much  inspiration.  The  burning 
questions  in  the  subject  of  aphasia  to-day  are,  first :  Is  there 
such  a  territory  as  the  speech  area?  second.  If  there  be,  are 
there  four  definite  centres,  one  for  articulate  speech  and  one 
for  written  speech,  constituting  the  motor  side  of  language, 
and  an  auditory  and  visual  centre  constituting  the  sensory, 
receptive  side  of  language?  It  is  well  known  that  this  was 
the  conception  of  Charcot  and  the  great  majority  of  writers 
since  the  former  gave  it  to  the  medical  world.  During  the 
past  decade,  however,  there  has  developed  a  school,  headed 
by  Dejerine,  which  refuses  to  follow  Charcot's  dictum  in  the 
face  of  absolutely  contradictory  evidence,  and  deny  the  exist- 
ence of  a  graphic  motor  centre,  while  affirming  the  existence 
of  one  receptive  speech  area,  injur)'  of  which  in  any  part  will 
invariably  entail  some  disorganization  of  internal  language. 
After  reading  Elder's  chapter  on  agraphia  and  the  ques- 
tion of  the  existence  of  a  graphic  centre,  it  seems  to  us  that 
he  denies  such  existence ;  yet  when  we  turn  to  page  55  we 
find  that  such  a  centre  is  beautifully  delineated  in  colors  oc- 
cupying the  area  to  which  Exner,  in  one  of  the  most  unscien- 
tific contributions  ever  made  to  medicine,  allotted  it,  and  on 
which  Charco,.  based  his  teaching  of  the  existence  of  this 
centre,  and  which  Bar  thought  he  corroborated  bv  the  publi- 
cation of  his  case. 

Space  prevents  us  from  an  analysis  of  this  very  mteresling 
book  of  Elder.  Its  most  serious  fault  seems  to  us  a  defi- 
ciency in  the  critical  faculty  and  evidences  of  too  close  study 
of  Wyllie's  recent  work,  which  we  regret  to  say  we  cannot 
believe  is  "  the  most  accurate  and  comprehensive  account  of 
the  whole  subject  that  has  yet  been  published,"  as  it  appears 
to  Elder.  Those  who  are  familiar  with  the  subject  of  apha- 
sia will  have  much  pleasure  and  profit  in  the  perusal  of  the 
book  before  us,  while  those  who  are  not  familiar  with  the 
subject  will  get  some  of  both. 


Diagnosis  of  Small  Ovarian  Tumors.— Dr.  Da- 
venport {Boston  Medical  and  Sur£;ical  Journal,  1896, 
No.  15)  concludes  his  article  with  the  following  pro- 
positions: I.  Small  intrapelvic  growths  give  rise  to 
marked  symptoms.  2.  Pain  is  usually  noted,  but  does 
not  bear  a  constant  relation  to  the  location  or  kind  of 
tumor.  3.  Menorrhagia  or  metrorrhagia  is  frequentlv 
present,  especially  in  cases  of  cystic  ovaries  adherent 
to  the  uterus.  4.  When  uterine  hemorrhage  exists  in 
connection  with  an  intrapelvic  tumor,  and  is  not 
affected  by  intra-uterine  treatment  (curettage  or  elec- 
tricity), the  tumor  is  probably  ovarian  rather  than 
uterine.  Refle.x  symptoms  are  rare  with  small  tiuuors, 
at  least  in  the  earlier  stage  of  their  development. 


Jiaciettj  gleports. 

NEW    VORK    ACADEMY    OF    MEDICINE. 

SECTION   ON    GENERAL   SUR(;EKV. 

Stated  Meeting,  May  10,  iSgy. 

W.   W.  Va.v  Arsdale,   M.D.,  C'hairma.v. 

Stab  Wound  of  Abdomen ;  Perforation  of  Intes- 
tine ;  Suture ;  Recovery. — Dr.  P.  R.  Bolton,  in 
presenting  the  patient,  said  that  one  point  which  the 
case  illustrated  was  the  usefulness  of  salt  solution  on 
the  peritoneum.  The  patient  was  a  man  of  twenty- 
six,  who  had  been  brought  to  the  Hudson  Street  Hos- 
pital last  September,  very  soon  after  ha\ing  received 
a  stab  of  the  abdomen.  "There  were  marked  shock  and 
a  wound  in  the  abdomen  about  four  inches  in  length  on 
the  left  side,  through  which  there  protruded  a  mass  of 
intestines  well  smeared  with  fa;ces.  The  wounds  of 
the  intestine  were  found  and  sutured,  and  salt  solution 
was  used  very  freely  both  before  and  after  reduction 
of  the  intestine.  The  usual  antiseptics  were  employed 
for  the  abdominal  wound,  and  this  was  closed.  It  was 
interesting  to  note  that  within  the  abdomen,  where 
only  salt  solution  was  used,  no  inflammation  or  trouble 
followed;  whereas  at  the  abdominal  wound,  where  bi- 
chloride, etc.,  were  used,  suppuration  took  place.  The 
patient  made  a  good  recovery,  with  some  weakness  of 
the  abdominal  wall,  over  which  he  now  wore  a  ban- 
dage. 

Nephrectomy,  Subsequent  Uretero-Lithotomy  on 
Opposite  Side. — Dr.  F.  Ka.mmerer  showed  a  patient, 
aged  thirty-one  years,  upon  whom  he  had,  in  the  sum- 
mer of  1895,  performed  nephrotomy  and  nephrectomy 
on  the  right  side  for  a  large  renal  calculus  and  degen- 
eration of  the  substance  of  the  kidney.  The  patient 
had  done  very  well  for  one  and  one-half  years  follow- 
ing these  operations,  and  had  gained  thirty  pounds  in 
weight.  Although  she  had  previously  suffered  for 
several  years  from  renal  colic  on  both  sides,  she  had 
never  had  any  pains  on  the  left  side  since  the  opera- 
tions in  1895.  In  February,  1897,  the  speaker  saw  her 
again,  and  she  gave  the  following  histor}-:  She  had 
had  severe  pains  on  the  left  side  for  the  past  two 
weeks;  very  little  urine  had  passed  during  the  last 
week.  She  was  nauseated  at  times  and  feverish.  On 
examination  the  left  kidney  was  rather  sensitive  to 
the  touch.  -She  was  watched  for  a  few  days,  but  when 
anuria  had  been  noted  for  thirty  consecutive  hours 
an  incision  was  made,  exposing  tlie  pelvis  of  the  left 
kidney  in  the  lumbar  region.  After  incising  the  ureter 
near  the  pelvis,  a  stone  the  size  of  a  bean  was  dis- 
covered, about  four  inches  from  the  junction  of  the 
ureter  with  the  pelvis,  which  was  after  some  e.xertion 
pushed  toward  the  incision  in  the  ureter  and  removed. 
The  pelvis  of  the  kidney  was  drained  through  an  in- 
cision in  the  kidney  substance  for  two  weeks,  and  tiie 
kidney  irrigated  with  normal  salt  solution.  The  inci- 
sion in  the  ureter  was  closed  on  the  fifth  day  with 
catgut  sutures.  In  about  two  months  the  entire  wound 
had  closed.  The  urine  still  contained  some  pus,  but 
no  renal  elements. 

Lithotomy,  Common  Bile  Duct.  -  Dr.  Kammerer 
also  presented  a  woman,  thirty  years  old,  who  had  al- 
ways been  healthy,  and  had  had  four  children.  Her 
first  illness  began  seven  months  ago,  when  she  had  a 
typical  biliary  colic.  Severe  attacks  had  occurred 
off  and  on  for  the  last  seven  months.  For  the  past 
si.x  months  she  had  had  increasing  jaundice;  urine 
dark,  stools  clay-colored.  Not  h;\ving  been  benefited 
by  any  internal  treatment,  she  was  referred  to  the 
hospital  for  surgical  interference.  She  h.ad  never 
passed  stones  to  her  knowledge     She  was  fairly  well 


July  31,  1897] 


MEDICAL    RECORD. 


171 


nourished;  icterus  was  intense  and  the  liver  was  en- 
larged. From  the  history  and  examinations  it  was  evi- 
dent that  some  obstruction  existed  in  the  common  bile 
duct,  but  excepting  the  enlarged  liver  palpation  proved 
negative.  The  transverse  incision  according  to  Cour- 
voisier,  parallel  and  about  one  inch  above  the  border 
of  the  liver,  was  made:  there  were  extensive  adhesions 
about  the  gall  bladder,  which  latter  was  finally  exposed 
by  separation  of  the  former.  The  attempt  to  separate 
the  pylorus  and  duodenum  from  the  cystic  duct,  in  order 
to  expose  the  latter,  proved  futile.  The  adhesions  be- 
tween the  organs  mentioned  were  so  dense  at  this  point 
that  the  somewhat  distended  cystic  duct  suddenly  gave 
way  during  manipulation,  and  a  large  quantity  of  bile 
was  discharged  through  the  rent  thus  produced.  A 
probe  passed  into  the  duct  was  arrested  at  a  distance 
of  two  and  one-half  inches  (in  the  common  ducti. 
Further  attempts  to  separate  the  pylorus  and  duodenum 
were  also  in  vain,  as  the  parts  were  so  densely  envel- 
oped in  adhesions  that  they  could  not  be  differentiated 
from  one  another  at  this  point.  The  stone,  on  the 
other  hand,  could  be  distinctly  felt  through  the  walls 
of  the  stomach.  All  attempts  to  dislodge  the  stone 
from  the  opening  in  the  cystic  duct  failed — forceps, 
spoons,  hooks,  etc.,  being  used.  After  a  great  deal  of 
manipulation  and  the  use  of  an  amount  of  force 
scarcely  warranted,  the  stone  was  finally  moved  by 
pressure  upon  the  walls  of  the  stomach  and  ultimately 
delivered  through  the  rent  after  the  latter  had  been 
considerably  enlarged.  It  was  of  about  the  size  of  a 
small  walnut.  The  opening  in  the  cystic  duct  was 
now  closed  with  catgut  sutures,  and  Murphy's  tube  in- 
troduced into  the  gall  bladder  for  drainage,  alongside 
of  which  a  tamix)n  was  pushed  to  the  point  at  which 
the  cystic  duct  was  sutured.  The  patient  made  a  slow 
but  uninterrupted  recover}',  complete  healing  being 
accomplished  in  about  six  weeks. 

The  interesting  point  in  this  case  was  the  dense 
adhesions  of  the  digestive  to  the  bile  tract.  The  time 
consumed  in  the  delivery  of  the  stone  was  almost  one 
hour,  and  the  speaker  thought  the  pressure  e.xerted  upon 
the  stone  through  the  wall  of  the  stomach  was  very 
great.  But  he  did  not  think  anyone  would  advise  in- 
cision of  the  stomach  to  get  at  the  common  bile  duct, 
which  otherwise  would  have  been  a  necessity  in  this 
case,  owing  to  the  changed  anatomical  relations 
of  the  parts,  although  the  procedure  by  incision 
had  been  eminently  successful  when  the  duodenum 
was  the  viscus  covering  the  common  bile  duct 
(Kocher). 

Drainage  of  the  Kidney  and  Pyrexia. — Dx.  Sam- 
uel T.  Alexander  remarked,  in  relation  to  the  fall 
of  the  temperature  in  Dr.  Kammerer's  case  after  re- 
moval of  the  drain  leading  to  the  kidney,  that  he  had  in 
several  cases  found  pyrexia  persisting  after  operations 
upon  the  kidney  until  the  drainage  tube  had  been 
withdrawn  from  the  kidney. 

The  Chairman  asked  whether  iodoform  gauze  had 
been  used  in  all  of  these  cases,  and  Dr.  Alexander 
replied  that  it  had  not  been  in  all. 

Dr.  Walker's  observation  had  confirmed  that  of 
Dr.  .\lexander. 

Dr.  Kammerer  thought  the  question  of  getting  the 
wound  leading  to  the  kidney  and  that  in  the  kidney  to 
close  would  depend  much  upon  the  condition  of  the 
kidney.  In  the  same  case,  one  kidney  the  seat  pre- 
senting stone  without  suppuration,  the  other  with  sup- 
puration, no  difficulty  might  be  encountered  in  secur- 
ing healing  on  the  one  side,  but  there  might  be  great 
difficulty  on  the  side  of  pyelitis. 

Dr.  .Alexander  had  recently  induced  healing  by 
the  use  of  one  of  the  ozone  solutions,  in  a  pus  pocket 
in  the  kidney,  which  had  been  found  to  be  the  cause 
of  persisting  sinus. 

Wound    Infection     by    the    Bacillus     Aerogenes 


Capsulatus. — The  paper  was  written  by  Drs.  Johk 
Erd.man  and  H.  R.  Brooks,  and  was  read  by  the 
former.  It  was  in  189 1  that  Dr.  William  Welch  pub- 
lished an  article  in  which  he  described  the  bacillus 
aerogenes  capsulatus  and  the  method  of  its  cultivation. 
Dr.  Welch  had  also  contributed  to  the  subject  subse- 
quently, and  twenty-three  cases,  not  all  of  them  surgi- 
cal, had  been  described  in  which  this  bacillus  was 
found.  Its  habitat  was  thought  to  be  the  soil,  and  Dr. 
Erdman  believed  it  was  often  present  in  the  intestine, 
from  whence  it  found  its  way  to  wounds.  The  infec- 
tion might  be  a  simple  or  a  mixed  one.  An  analysis  of 
the  cases  of  Welch,  Flexner,  and  Dunham  would  seem 
to  show  that  recoveries  had  been  confined  to  the  cases 
of  mixed  infection.  In  these,  pus  was  usually  present. 
The  infection  might  take  place  through  the  circulation 
or  through  instruments.  Among  the  symptoms  which 
arose  when  the  wound  became  infected  by  the  bacillus 
aerogenes  capsulatus  were  rapid  pulse,  rise  of  temper- 
ature, delirium,  discoloration  of  the  area  involved,  em- 
physema of  the  tissues,  and  rapid  distention  of  the  ab- 
domen when  the  peritoneal  cavity  was  involved.  The 
rapidly  developing  delirium,  stupor,  and  somnolence 
seemed  to  be  due  to  toxamia.  Incision  and  drainage, 
and  it  might  be  amputation,  were  indicated. 

The  authors  reported  one  case  which  had  come  un- 
der their  observation,  and  in  which  the  bacteriological 
report  was  made  by  Dr.  Dunham.  In  a  fall  the  pa- 
tient had  sustained  compound  fracture  of  the  right 
humerus,  contusion  of  the  shoulder,  and  slight  scalp 
wound.  The  infection  of  the  arm  wound  by  the  third 
day  by  the  bacillus  aerogenes  capsulatus  was  attended 
by  increased  pulse,  temperature,  and  respirations,  and 
delirium  soon  developed.  The  emphysematous  con- 
dition of  the  tissues  soon  extended  to  the  chest,  so 
that  amputation  of  the  arm  was  deemed  improper. 
The  patient  died  three  days  after  the  original  injury 
and  one  day  after  the  infection  alluded  to. 

A  summary  of  the  cases  of  Welch  and  Flexner 
which  had  a  surgical  bearing,  and  of  others,  including 
that  of  Dr.  Bryant,  brought  the  number  up  to  sixteen. 
Four  patients  recovered.  Two  cases  were  of  pure  in- 
fection, and  in  both  of  these  the  patients  died.  In  the 
others  the  best  results  were  obtained  when  amputation 
was  resorted  to.  The  most  frequent  mixed  infection 
was  with  the  streptococcus;  in  a  number  there  was 
the  bacillus  coli  communis.  In  their  conclusions  the 
authors  stated  that,  in  view  of  the  frequency  with 
which  the  bacillus  aerogenes  capsulatus  occurred  in 
the  peritoneal  cavity  and  its  association  with  the 
colon  bacillus,  they  were  justified  in  believing  that 
its  habitat  in  man  was  in  the  intestinal  tract.  When 
introduced  from  without  it  was  probably  from  the 
soil.  The  mixed  infection  was  not  so  grave.  This 
suggested  a  possible  treatment  by  an  antitoxin  serum 
or  germ  infection.  The  surgical  treatment  was  by  free 
incisions,  with  drainage  or  amputation.  Dr.  Halstead 
had  brought  out  a  treatment  by  immersion  in  a  bath, 
which  Dr.  Dunham  would  comment  upon. 

Dr.  E.  K.  Dunham  opened  the  discussion,  and 
confined  his  remarks  chiefly  to  points  suggested  by 
the  treatment  which  Dr.  Halstead  said  he  now  applied 
to  cases  of  infection,  placing  the  patients  in  a  full 
bath  of  warm  water — 96  to  98  F.  The  water  was 
renewed  at  intervals  of  about  two  hours.  He  claimed 
excellent  results  from  this  treatment  in  various  forms 
of  infection,  including  one  or  two  cases  of  infection 
from  the  bacillus  aerogenes  capsulatus.  He  was  una- 
ble to  give  Dr.  Dunham  a  good  explanation  of  how  the 
bath  acted,  but  it  seemed  at  least  to  promote  the  dis- 
charge of  the  poisons  from  the  wound.  In  view  of 
these  facts.  Dr.  Dunham  had  made  a  number  of  experi- 
ments with  the  bacillus  aerogenes  capsulatus.  The 
bacillus  was  a  strict  anaerobe,  or  incapable  of  growing 
in  free  oxygen.     It  had  occurred  to  him  that  one  might 


I  72 


MEDICAL    RECORD. 


Quiy  31,  1897 


take  advantage  of  this  fact  to  prevent  or  check  infec- 
tion by  exposure  to  oxygen.  In  certain  culture  tubes 
he  freed  the  bouillon  of  oxygen,  in  others  exposed  it 
to  oxygen.  The  bacilli  developed  in  the  former,  and 
little  or  not  at  all  in  the  latter.  When  they  did  get  a 
start,  the  evolution  of  gas  in  their  development  still 
further  favored  their  growth.  This  became  apparent 
in  experiments  with  pieces  of  the  liver  of  an  infected 
animal,  the  evolution  of  the  gas  within  the  tissue 
causing  it  to  rise  in  the  water  in  which  it  was  sub- 
merged. This  did  not  occur  with  pieces  of  the  kidney, 
which  would  seem  to  show  that  the  sugar  in  the  liver 
favored  this  gas  formation.  Perhaps  it  would  not  be 
so  in  life,  as  the  liver  might  then  possess  inhibiting 
influence  upon  the  bacilli.  Just  how  much  oxygen  the 
blood  might  carry  to  act  as  an  inhibiting  influence  on 
the  growth  of  the  bacilli  in  the  tissues  was  a  question. 
The  experiments  would  seem  to  point  to  the  wisdom 
of  getting  rid  of  the  dead  tissues  as  quickly  as  possi- 
ble, since  they  favored  the  development  of  these  ba- 
cilli, and  to  expose  them  as  soon  as  possible  to  oxygen. 
Regarding  Dr.  Erdman's  statement  that  the  cases  of 
mixed  infection  had  been  least  virulent,  it  was  not  yet 
safe  to  draw  the  conclusion  from  this  fact  that  the 
presence  of  the  other  germs  rendered  the  bacillus  aero- 
genes  capsulatus  less  virulent.  On  the  contrary,  the 
latter  was  known  to  possess  varying  degrees  of  viru- 
lence in  pure  culture,  and  when  the  conditions  were 
not  favorable  it  did  not  grow.  Now  necrotic  tissue 
with  the  presence  of  other  germs  might  cause  the 
less  virulent  germs  to  grow,  whereas  if  these  condi- 
tions were  absent  they  would  not  develop  at  all.  In 
Dr.  Erdman's  own  case,  this  bacillus  was  not  very 
virulent;  Dr.  Dunham  had  been  unable  to  kill  a 
guinea-pig  with  it. 

Kidney  Tumors  Derived  from  Suprarenal  Rests. 
— Dk.  P.  R.  Hoi.TON  read  the  paper  and  gave  the  his- 
tory of  a  case.  The  classification  of  these  tumors  was, 
he  thought,  in  a  state  of  chaos.  There  was  little 
American  literature  on  the  subject.  The  gross  and 
microscopic  appearances  of  the  tumor  in  his  case  were 
studied  by  Dr.  \\'arren  Coleman.  The  patient  was  an 
Englishman,  fifty-six  years  of  age;  family  history  neg- 
ative ;  he  had  had  African  fever  ten  years  ago.  He  had 
noticed  a  mass  in  his  left  side  for  a  year.  The  urine 
was  dark  red  and  contained  albumin,  many  blood  clots, 
and  a  few  casts.  Having  ascertained  that  the  other  kid 
neywas  sound.  Dr.  Bolton  removed  the  tumor,  which 
involved  the  kidney  and  capsule.  The  diameters  were 
fourteen,  eleven,  and  nine  and  one-half  centimetres. 
The  visible  surface  of  the  kidney  measured  five,  four 
and  one-half,  and  three  and  one-half  centimetres.  .\t 
one  point  of  section  there  was  distinct  connective- 
tissue  limitation  between  the  tumor  and  the  kidney. 
So  far  as  the  examination  had  proceeded  no  part  of  the 
kidney  was  involved  by  new  tissue,  but  the  kidney  was 
the  seat  of  chronic  diffuse  nephritis.  The  tumor  con- 
tained roundish,  yellowi.sh,  small  opaque  masses,  sur- 
rounded by  irjegular  fibrous  stroma  and  larger  and 
smaller  hemorrhages.  No  opinion  had  yet  been  formed 
of  the  nature  or  origin  of  tiie  tumor,  but  so  far  as  the 
examination  had  proceeded  it  was  independent  of  the 
kidney  proper.  Speaking  of  tumors  of  the  suprarenal 
capsule  in  general.  Dr.  Bolton  said  they  were  either 
benign  or  malignant,  but  even  in  cases  showing  dis- 
tinct characters  of  cancer  the  patient  might  live  sev- 
eral years.  Out  of  thirty-five  cases  tlie  male  sex  was 
affected  in  twenty-two,  the  female  sex  in  thirteen. 
The  age  had  varied  from  two  and  one-half  to  seventy- 
nine  years,  but  in  the  majority  of  cases  it  was  over 
forty.  The  right  and  left  kidney  had  been  affected 
about  equally.  Metastasis  had  occurred  into  various 
organs.  The  treatment,  when  possible,  was  nephrec- 
tomy. 

Dr.  Du.nham   said   he   had   met  with  onlv  one  case 


of  tumor  of  the  kidney  which  he  thought  had  its  origin 
from  the  adrenal  body.  It  was  of  very  small  size, 
and  attracted  attention  only  at  autopsy. 


SECTION    ON   GENERAL    MEDICINE. 

Stated  Meeting,  May  18,  iSgj. 

Louis  F.  Bishop,  M.D.,  Ch.-mr.man. 

The  Composition  of  Cream  and  a  Consideration 
of  the  Desirability  of   Establishing  a  Standard.— 

Dr.  J.  H.  HuDDLESTON  read  a  paper  on  this  subject. 
In  1896  the  city  consumed  about  nine  million  quarts 
of  cream.  It  came  from  within  a  distance  of  three 
hundred  miles.  .A.bout  half  of  it  was  consumed  by 
families,  the  other  half  by  ice-cream  factories,  baker- 
ies, etc.  The  former  usually  received  it  in  bottles, 
the  latter  in  cans.  The  bottle  method  was  best  if  the 
bottles  were  properly  cleansed ;  otherwise  it  was  the 
worst.  The  cream  was  called  gravity  cream  when 
collected  by  allowing  the  milk  to  stand  and  the  cream 
to  rise;  separator  cream  when  separated  from  the  milk 
by  some  one  of  the  centrifugal  machines.  The  latter 
method  was  the  quickest  way  of  collecting  the  cream, 
the  gravity  method  requiring  about  twent}-four  hours 
for  the  cream  to  rise  to  the  surface.  But  this  length 
of  time  seemed  to  be  of  little  consequence  in  the 
minds  of  the  dealers,  for  they  usually  retained  the 
cream  some  days,  even  a  week  or  longer,  as  age  added 
to  its  thickness  and  therefore  apparently  to  its  rich- 
ness. It  had  been  shown  that  this  thickening  from 
age  was  due  to  the  multiplication  and  action  of  bac- 
teria in  the  cream.  There  was  no  standard  richness 
of  cream.  Dealers  supplied  only  two  kinds,  what  they 
called  light  and  heavy  cream.  For  the  latter  they 
charged  considerably  more,  but  the  amount  of  fat 
which  either  kind  contained  was  variable.  This  was 
probably  due  to  the  fact  that  there  was  not  yet  a  well- 
considered  plan  as  to  cream  tested  by  fat  quantity. 
For  instance,  the  dealer  might  sell  a  can  containing  a 
certain  number  of  quarts,  .say  forty,  which  he  esti- 
mated would  produce  a  certain  number  of  pounds  of 
butter,  say  thirty-five,  but  when  this  had  been  tested 
the  amount  of  butter  obtained  had  not  corresponded 
with  the  estimated  amount  by  a  number  of  pounds. 
One  could  not  tell  the  composition  of  the  cream  by  its 
appearance,  for  the  same  cream  presented  a  different 
appearance  according  to  its  age,  etc.  The  effect  of 
sterilization  or  pasteurization  was  to  make  the  cream 
appear  thinner,  for  the  reason  that  germ  growth  was 
checked.  But  sterilization  made  it  unsuitable  for 
some  purposes,  and  pasteurization  as  usually  carried 
out  left  a  considerable  number  of  bacteria.  Still, 
such  cream  kept  longer  than  that  which  was  not  pas- 
teurized. If  the  temperatiue  were  carried  above  70"'  C 
the  cream  would  have  somewhat  a  cooked  taste.  The 
regulations  of  the  board  of  health  required  that  milk 
sold  in  the  city  should  confonn  to  certain  tests. 
Skimmed  milk  could  not  be  sold.  The  author  thought 
the  people  should  be  able  to  purchase  cream  of  a  cer- 
tain fat  test,  and  suggested  tlie  possibility'  of  a  plan 
to  supply  certified  cream  similar  to  the  plan  of  Dr. 
Coit  for  supplying  certified  milk  in  Newark.  Such 
cream  could  be  of  any  desired  fat  quantity  and  of 
known  age. 

Dr.  HfBBARD,  secretary,  read  a  letter  from  Dr. 
Henry  Coit,  of  Newark,  regretting  his  inability  to  be 
present,  and  suggesting  as  one  requirement  for  certi- 
fied cream  a  fat  percentage. 

Dr.  R.  G.  Free.man  thought  tliat  since  cream  was 
usually  valuable  in  proportion  to  the  amount  of  fat 
which  it  contained,  and  this  amount  varied  so  greatly 
in  substances  sold  under  the  name  cream,  there  ought 
to  be  some  standard.     Cream  which  was  collected  by 


July  31,  1897] 


MEDICAL    RECORD. 


17- 


the  uld  process  would  require  to  be  tested,  but  it  was 
likely  that  that  which  was  collected  by  centrifugal 
machines  would  usually  come  up  to  the  regulations, 
so  many  quarts  of  cream  to  so  many  quarts  of  milk,  al- 
lowing that  the  latter  conformed  to  the  requirements  of 
the  health  department.  He  understood  that  the  stand- 
ard for  milk  had  been  placed  so  high  in  Boston  that 
dealers  had  found  it  necessary  to  take  all  their  milk  to 
a  central  station  and  mix  it  to  avoid  any  portion  fall- 
ing below  that  standard.  Of  course  this  required 
manipulation.  The  less  manipulation  which  milk  re- 
ceived the  better  for  it.  The  ideal  method  was  to 
have  milk  properly  bottled  at  the  dairy  and  not  opened 
until  it  reached  the  consumer.  It  gave  less  chance 
for  contamination.  He  agreed  with  Dr.  Huddleston, 
that  skimmed  milk  had  a  certain  nutritive  value  for 
the  healthy  and  sick,  and  at  present  a  great  deal  was 
thrown  away  at  large  dairies  because  it  was  not  al- 
lowed to  be  sold  in  this  city.  He  thought  it  ought  to 
be  permitted  to  enter  the  city  and  sold  at  some  price 
as  skimmed  milk.  Regarding  pasteurization  of  milk 
in  large  plants,  he  thought  tjjat  had  injured  the  repu- 
tation of  pasteurization,  for  as  thus  carried  out,  in 
some  plants  at  least,  the  milk  was  raised  to  a  certain 
temperature  and  almost  immediately  cooled.  It  was 
far  more  effectual  to  keep  that  temperature  for  from 
fifteen  to  thirty  minutes.  A  temperature  of  68°  C.  for 
thirty  minutes  was  more  effectual  in  sterilizing  milk 
than  a  momentary  temperature  of  So'^  or  90  C,  and, 
of  course,  it  changed  the  taste  less. 

Ur.  L.  EMi[ET  Holt  felt  that  every  time  the  subject 
of  the  milk  and  cream  supply  was  brought  up,  new  im- 
pulse was  given  toward  securing  a  clean  and  reliable 
supply  of  these  nutritive  Huids.  At  present  there  cer- 
tainly was  the  greatest  possible  variation  with  regard 
to  the  cream,  and  he  supposed  it  was  because  there  had 
not  yet  been  sufficient  demand  for  a  cream  of  a  definite 
standard.  He  thought  it  did  not  make  so  much  difter- 
ence  just  what  figure  was  taken,  whether  fifteen  or 
twenty  per  cent.,  only  that  there  should  be  some  stand- 
ard. Perhaps  twenty  per  cent,  would  be  the  nearest 
for  our  supplv,  and  would  change  the  price  least. 
With  regard  to  skimmed  milk,  it  certainly  was  valuable 
in  certain  conditions.  He  had  been  experimenting 
witli  it  in  certain  intestinal  disorders  and  typhoid 
fever  in  children,  with  extremely  good  results,  espe- 
cially after  peptonizing  it. 

Dr.  W.  L.  Stowell  said  there  were  two  sides 
to  the  question,  the  one  the  commercial,  the  other 
the  scientific  or  food  value.  It  certainly  made  a  dif- 
ference to  a  person  from  the  point  of  view  of  nutri- 
tion whether  what  he  purchased  contained  twenty-five 
or  whether  it  contained  only  fifteen  per  cent,  of  fat. 
Heavy  cream  contained  forty  to  forty-two  per  cent. 
Light  cream  which  he  had  tested  contained  fifteen  to 
twenty  per  cent.  Most  cream  supplied  to  the  city  was 
centrifugal  cream.  It  ought  to  be  certified  as  to  the 
percentage  of  fat  and  the  purity  of  the  milk  from  w  hich 
it  came.  On  the  same  farm  the  surroundings  of  the 
horses  might  be  found  models  of  neatness,  while  those 
of  the  dairy  cows  were  dirty. 

Dr.  H.  G.  Piff.\kd  said  criticism  had  been  offered 
upon  the  double  standard  required  for  milk  sold  in  this 
cit)-,  that  of  the  fat  test  and  the  test  for  solids.  They 
did  not  correspond.  For  practical  purposes  he  thought 
the  fat  test  was  sufficient,  it  could  be  applied  more 
easily.  He  would  make  it  higher  than  that  required  at 
present,  for  the  average  milk  in  the  district  from  which 
New  York  received  its  supply  contained  3.75  per  cent. 
of  fat.  When  cows  failed  to  give  milk  of  that  stand- 
ard the  farmer  should  sell  them  to  the  butcher  and 
replace  them  by  those  which  gave  richer  milk.  He 
had  read  that  some  dairymen  in  the  West  would  not 
think  of  keeping  cows  which  gave  less  than  four  per 
cent.  fat.      Perhaps  dealers  would  do  as  they  did   in 


Boston,  pool  their  milk,  but  that  could  be  prevented  by 
occasional  tests  being  made  at  the  farms.  Dr.  Pifiard 
also  referred  to  the  value  of  skimmed  milk,  and  said 
that  much  of  it  was  thrown  away,  though  much  was  re- 
turned at  creameries  to  farmers  who  fed  it  to  their 
stock.  As  it  was  there  pooled,  he  had  in  a  paper 
called  attention  to  the  necessity  for  sterilizing  it  to 
prevent  spread  of  tuberculosis.  Regarding  cream,  Dr. 
Piffard  thought  there  should  be  legislation  prohibiting 
dealers  from  holding  it  back  or  selling  it  after  it  was 
a  certain  number  of  hours  old,  prohibiting  the  use  of 
preser\atives,  and  requiring  a  standard  for  butter 
strength. 

E.  Nelsox  Ehrh.art  spoke  upon  the  subject  of 
dairies  and  means  of  securing  pure  milk  in  general. 
He  had  been  engaged  to  analyze  the  milk  and  point 
out  necessary  changes  in  several  dairies,  and  was  con- 
vinced that  here  was  a  field  for  educated  and  practical 
men.  Some  such  system  of  preventing  contamination 
of  milk  as  that  employed  in  Copenhagen  was  desir- 
able. In  talking  with  Mr.  Martin,  of  the  board  of 
health,  he  had  been  infonred  that  the  sale  of  skimmed 
milk  had  not  been  allowe^  through  fear  dealers  would 
mix  it  with  other  milk.  It  would  seem,  however,  that 
licensed  dealers  ought  to  be  permitted  to  sell  it  as 
skimmed  milk,  for  it  possessed  food  value. 

Dr.  W.  L.  B.aner  had  tested  the  taste  of  gra\  ity  and 
centrifugal  milk,  and  his  preference  had  been  expressed 
for  the  former.  For  some  reason  the  taste  was  altered 
somewhat  by  centrifugal  separation. 

The  Methods  of  Infection  in  Malarial  Disease. 
— Dr.  J.  RiCH.ARD  Tavlor  read  this  paper.  The  first 
part  was  devoted  to  a  brief  statement  of  views  ex- 
pressed in  comparatively  recent  papers,  including 
Daily's,  R.  C.  Newton's,  Thayer  and  Hewetson's,  Man- 
son's,  Darlington's,  etc.  Sternberg  held  to  the  old 
view  of  inhalation  of  marsh  miasm .  Daily  advanced 
the  idea  that  infection  was  through  drinking-water; 
Manson  held  that  man  was  the  alternate  host,  frcm 
which  the  germs  must  escape  in  order  to  complete  their 
life  cycle,  and  this  was  by  agency  of  the  mosquito. 

House  Plants  and  Malaria.— Just  after  the  C  hrist- 
mas  holidays  Dr.  Taylor  was  called  at  Sag  Harbor  to 
a  woman  eighty-two  years  old,  who  had  some  paro.xysms 
of  fever  with  gastric  disturbance,  and  at  her  sugges- 
tion that  it  might  be  malaria  he  examined  the  blood 
and  found  the  Lavaran  plasmodium.  This  was  re- 
markable in  view  of  the  facts  that  the  ground  w  as  cov- 
ered deeply  with  snow,  the  patient  had  not  been  from 
home  for  four  years,  the  well  water  could  not  have  been 
contaminated,  all  ponds  were  frozen.  Soon  a  daughter 
had  similar  symptoms.  There  were  some  potted 
plants  in  the  house,  and  he  was  unable  to  make  any 
definite  impression  upon  the  disease  until  these  had 
been  removed.  At  the  same  season,  a  third  case  de- 
veloped in  another  house  in  which  a  trap  door  led  into 
a  cellar  whose  walls  were  covered  continuously  with 
mould.  In  still  another  house  some  weeks  later,  in  the 
same  town,  malaria  with  the  plasmodium  of  tertiary 
fever  developed  in  a  child,  and  no  apparent  cause 
could  be  found  except  the  potted  plants  in  the  room 
occupied  by  the  patient.  When  these  were  removed 
he  was  able  to  cure  the  disease.  He  then  went  to 
some  florists  in  localities  where  there  were  no  marshes, 
and  where  they  were  not  likely  to  be  infected  by  the 
water  supply,  and  inquired  their  historj-  and  made 
blood  examinations.  He  found  in  four  different 
localities  that  the  blood  of  these  people  contained  the 
malarial  plasmodium.  These  florists  were  not  ill,  but 
they  were  hardly  ever  quite  well,  complaining  of  di- 
gestive trouble,  headache,  and  indefinite  symptoms. 
They  could  be  straightened  up  temporarily  by  a  big 
dose  of  quinine. 

Dr.  T.avlor  then  gave  his  personal  experience  when 
in  Charleston.      He  took  precautions  about  the  drink- 


174 


MEDICAL    RECORD. 


[July  31,  1897 


ing-water  to  avoid  filaria  sanguinis  hominis,  and  when 
he  rode  out  he  took  the  precaution  to  return  early  be- 
fore tiie  mists  rose  from  the  marshes.  During  this 
time  he  kept  well,  but  later,  not  having  time  to  ride 
until  rather  late  in  the  evening,  he  contracted  per- 
nicious intermittent  fever.  He  could  then  find  the 
malarial  plasniodium  in  his  blood.  From  1879  ^'-' 
1883  he  resided  in  the  mountains  of  Colorado,  and 
saw  what  he  supposed  had  been  called  mountain  fever, 
but  all  the  cases  which  he  saw  were  tertian  intermit- 
tent fever.  A  German  writer  had  spoken  of  a  similar 
fever  developing  in  the  mountainous  regions  of  Rus- 
sia, at  the  time  of  the  melting  of  the  snow.  This 
was  in  harmony  with  what  he  had  seen  in  Colorado. 
But  at  Sag  Harbor  the  snow  was  not  melting  and  the 
region  was  not  mountainous.  There  was  no  bad  water 
to  explain  the  malaria  and  the  presence  of  the  malarial 
body  in  the  blood.  These  facts  would  seem  to  point 
to  something  emanating  from  the  plants,  or  rather  from 
the  earth  itself,  as  one  of  the  surest  means  of  infec- 
tion. Yet  the  water  theorj-  should  also  be  borne  in 
mind.  Some  observations  relating  to  the  water  sys- 
tem of  Sag  Harbor  during  one  period  pointed  in  this 
direction,  but  in  the  cases  related  above  the  water  was 
not  obtained  from  that  system. 

Dr.  H.  G.  Piffard  referred  to  the  sudden  develop- 
ment of  chills  in  tuberculosis  which  sometimes  simu- 
lated malaria,  but  the  changes  in  the  blood  were  dif- 
ferent. In  connection  with  treatment,  he  spoke  of  the 
value  of  .\lonzo  Clark's  combination  of  ten  grains  of 
quinine  and  si.x  of  capsicum;  also  of  boneset,  fluid 
extract  of  the  fresh  plant.  Regarding  the  plasmodia, 
which  were  supposed  to  take  twelve  or  twentj'-four 
hours  to  pass  through  their  stages,  he  could  not  har- 
monize this  view  with  the  occurrence  of  chills  within 
three  hours  after  exposure,  as  had  once  occurred  in  his 
own  person  and  often  in  sailors  visiting  tropical  coasts. 

Dr.  R.  C.  Newton  had  little  doubt  that  the 
potted  plants  were  the  cause  of  the  malarial  infection 
as  mentioned  in  the  paper.  He  could  give  some  ex- 
perience which  would  seem  to  confirm  that  view.  He 
had  a  friend  who  was  a  florist,  and  while  generally  in 
good  health  he  had  to  guard  against  exposure  on  ac- 
count of  taking  "colds,"'  which  he  could  cure  by 
quinine.  The  question  of  atmospheric  temperature  in 
relation  to  malaria  required  further  study.  Around 
New  York  malaria  was  most  common  during  seasons 
when  the  diurnal  variation  in  the  temperature  was 
greatest;  when  there  were  warm  days  and  cool  nights. 
There  were  not  wanting  microscopists  who  regarded 
the  Plasmodium  as  the  consequence,  not  the  cause  of 
malaria.  Nor  was  he  convinced  that  infection  could 
not  take  through  drinking-water. 

Dr.  T-  \V.  Krannan"  had  not  seen  in  literature 
potted  plants  referred  to  in  connection  with  the  etiol- 
ogy of  malaria.  It  might  be  that  there  was  more 
malaria  in  New  York  City  than  some  doctors  were 
disposed  to  admit,  and  in  potted  plants  might  be  an 
explanation. 

Dr.  R.  G.  Freeborn  said  there  was  a  good  deal  of 
malaria  which  originated  in  New  York  City.  It  was 
almost  invariably  associated  with  enlargement  of  the 
spleen,  and  usually  the  malarial  organism  could  be 
found.  Hut  in  his  opinion  malaria  and  enlargement 
of  the  spleen  existed  not  infrequently  when  ordinary 
examination  failed  to  reveal  the  malarial  organism. 
These  statements  were  based  on  what  he  had  seen  at 
the  Bellevue  and  Roosevelt  dispensaries  in  children 
not  from  out  of  town. 

Dr.  T.  S.  Suuthworth  had  almost  invariably  been 
able  to  find  a  histor\-  of  previous  residence  in  the 
country  in  cases  of  malaria  in  children  in  this  city. 
It  was  possible  malaria  might  develop  from  plants  in 
the  room  by  reason  of  soil  brought  from  New  Jersey 
or  Long  Island. 


Dr.  Taylor  said,  in  closing  the  discussion,  that  he 
had  been  surprised  during  a  visit  here  this  winter  to 
learn  that  in  the  German  Hospital  of  this  city  there 
were  nearly  equal  numbers  of  patients  with  pneumonia 
and  with  malaria  at  a  season  of  the  year  when  pneu- 
monia was  supposed  to  be  frequent  and  malaria  infre- 
quent. It  apjjeared  from  an  article  in  one  of  the 
journals  that  malaria  had  been  frequent  in  Philadel- 
phia the  past  winter,  as  well  as  in  New  York. 


©orriCBpondence. 


OUR    LONDON    LETTER. 


tKr 


r  Special  Correspondent. ) 


THE  NEW  HOSPITAL  FOR  INFECTIOUS  DISEASES — THE 
CAVENDISH  LECTURE — RELATION  OF  OVARIAN  DIS- 
EASE TO  PREGN.\NCY — ALCOHOLISM  AND  LEGISLATION 

INCUBATORS MEDICAL      EDUCATION      FOR     WOMEN 

VENEREAL     DISEASE   4N    THE    INDIAN    ARMY — MER- 
GER'S   HOSPITAL    DISPUTE. 

LoMJON,   July   16,    1697. 

The  Prince  of  \\'ales  is  doing  a  great  work  for  the 
hospitals  apart  from  the  fund  he  is  raising.  On  Mon- 
day, accompanied  by  the  Princess,  he  opened  the  new- 
Park  Hospital,  which  has  been  built  by  the  asylum's 
board  for  the  further  accommodation  of  cases  of  fever 
and  diphtheria.  For  two  years  about  eight  hundred 
workmen  have  been  engaged  on  these  buildings, 
which  are  situated  at  Hither  Green,  near  Lewisham, 
about  six  miles  from  London  Bridge,  in  grounds  of 
twent}'  acres.  In  1896  there  were  22,273  patients  ad- 
mitted into  the  board's  hospitals  for  fever,  but  these 
were  not  sufficient  for  the  metropolis,  swollen  to  some 
five  million  inhabitants.  Besides  the  small-pox  ac- 
commodation, the  board  has  nine  hospitals  for  infec- 
tious cases,  with  fort}'-two  hundred  and  fift)-four  beds. 
The  new  building  will  add  five  hundred  and  forty- 
eight  more.  It  is  provided  with  everything  of  the 
most  modern  type.  Another  hospital,  for  five  hundred 
and  twenty  beds,  is  in  course  of  construction  at  Toot- 
ing, and  it  is  proposed  to  build  wards  for  seven  hun- 
dred convalescents  at  Carshalton.  \\'hen  all  this  has 
been  accomplished,  there  will  be  provision  for  six 
thousand  patients  at  the  disposal  of  London,  which 
surely  ought  to  suffice.  The  burden  on  the  ratepayers 
is  heavv,  but  it  is  felt  that  in  the  end  thev  must  bene- 
fit. 

The  Cavendish  lecture  this  year  was  delivered  by 
Sir  John  \\"illiams,  who  devoted  it  to  the  consideration 
of  the  problems  involved  in  cases  of  ovarian  tumor  in 
pregnancy.  It  has  been  asserted  that  pregnancy  gives 
rise  to  these  growths,  but  there  seems  no  ground  for 
the  suggestion.  If  it  were  so,  such  tumors  must  surely 
be  much  more  common.  Taking  the  one  thousand 
cases  operated  on  by  Sir  Spencer  Wells,  and  dividing 
them  into  groups  according  to  age,  the  lecturer  found, 
from  t\venty  to  twenty-five,  ovarian  tumors  three  times 
as  frequent  in  the  single  as  in  the  married,  but  after 
thirty-five  the  proportions  were  reversed.  But  then 
there  is  the  great  change  in  the  relative  numbers  of  the 
married  and  single  with  advancing  age.  .\t  sixty-five 
single  women  have  these  tumors  in  the  proportion  of 
eight  to  one  married,  as  far  as  the  registrar-general's 
statistics  show.  By  similar  comparisons.  Sir  John 
Williams  concluded  that  these  tumors  were  less  fre- 
quent in  each  successive  pregnancy,  and  that  there  was 
no  ground  for  Leopold's  startling  suggestion,  based  on 
two  cases,  that  pregnancy  is  a  cause  of  cancer  of  the 
ovary.  It  is  surprising  that  such  a  notion  should 
have  been  based  on  a  couple  of  cases,  one  of  Leopold's 
own  and  one  of  Spiegelberg;  and  that  Wernich  should 
have  supported  it  on  two  others,  one  of  his  own  and 


July  31,  1897] 


MEDICAL    RECORD. 


one  of  Kursteiner.  But  strange  things  are  "made  in 
Germany.''  With  regard  to  the  conclusions  from  Sir 
S.  Wells  cases,  it  cannot  be  said  that  all  the  ovarian 
cases  passed  through  that  great  surgeon's  hands — a 
point  which  seems  to  me  considerably  to  affect  the 
statistics  put  for^vard,  and,  in  fact,  it  is  scarcely  pos- 
sible to  furnish  figures  which  statisticians  would  con- 
sider sufficient  to  build  upon.  The  lecturer  then  con- 
sidered the  effect  of  such  tumors  on  labor.  The 
mortality,  even  when  no  great  difficulty  in  delivery 
occurs,  is  '"appalling'' — and  for  explanation  of  this 
Sir  John  said  we  must  look  to  injury  done  to  the  tumor 
itself  and  the  parts  adjacent,  pelvic  or  abdominal. 
He  saw  but  two  ways  of  preventing  such  injur)-, 
either  removal  of  the  tumor  during  pregnancy  or  antici- 
pation of  labor  by  Cassarean  section.  Not  that  all 
cases  should  thus  be  met,  for  small  tumors  in  the  ab- 
domen or  those  which  could  be  raised  from  the  pelvis 
and  retained  in  the  abdomen  do  not  suffer  much  injury 
during  labor.  With  these  e.xceptions  he  advised  opera- 
tion in  all  cases.  Ovariotomy  during  the  pregnancy 
had  only  half  the  mortality  of  cases  left  to  natural 
labor.  When  this  was  impracticable,  from  adhesions 
or  otherwise,  he  would  have  recourse  to  Cesarean  sec- 
tion. 

Dr.  Pitcairn,  deputy  medical  officer  of  Holloway 
and  Newgate  prisons,  read  a  paper  on  Monday  on 
"  .\lcoholism  and  the  Penal  Laws  of  Europe  and 
United  States  of  America,"  before  the  Society  for  the 
Study  of  Inebriety.  He  awarded  the  distinction  of 
having  raised  tippling  to  a  fine  art  to  Germany,  where 
drinking  has  of  late  become,  as  it  were,  a  part  of  the 
nationality  of  the  people.  He  said  most  communities 
displayed  the  same  attitude  toward  the  public  drunk- 
ard, who  was  regarded  as  a  nuisance  which  it  was  at- 
tempted to  abate  by  fines  and  imprisonment.  The 
habitual  drunkard  has  been  too  long  ignored,  though 
found  everywhere.  This  he  thought  might  be  due  to 
the  worship  of  so-called  liberty,  and  is  perhaps  a  sur- 
vival of  the  time  when  no  disgrace  was  attached  to 
intoxication.  But  during  the  last  half-centur}-  there 
has  grown  up  a  conviction  among  psychologists  that 
inebriety  is  a  mental  disorder  requiring  seclusion. 
The  habitual  drunkard  has  assumed  a  national  instead 
of  individual  importance.  Austria  has  recognized  the 
necessity  of  grappling  with  the  problems  involved, 
and  public  opinion  is  ripe  for  reform  of  the  laws  of 
our  own  and  other  countries. 

At  the  Victorian  Era  Exhibition  there  has  been  a 
private  view  of  incubators.  The  "couveuse"  so  long 
adopted  in  France  for  rearing  premature  or  sickly 
infants  has  been  tried  in  some  of  our  maternity  hospi- 
tals with  success,  but  the  system  has  not  been  widely 
adopted  here.  In  the  exhibition  mentioned,  various 
improvements  in  the  incubators  are  exemplified,  espe- 
cially as  to  the  warming  (by  hot  water)  and  ventilation. 
Portability  has  also  been  attained  by  the  use  of  alu- 
minium in  their  construction. 

.\t  the  Woman's  Congress  on  Education,  held  here 
this  week,  the  idea  of  establishing  a  university  for 
women  alone  was  generally  repudiated.  Mrs.  Garrett 
Anderson,  M.I).,  was  among  the  leaders,  and  gave  some 
account  of  her  own  experience  in  the  sixties  in  obtain- 
ing medical  instruction.  She  delivered  an  address  on 
medical  education,  in  the  course  of  which  she  said 
that  with  the  six  universities  and  three  corporations 
now  open  to  women,  a  new  university  for  women  only 
would  not  attract  any  woman  to  enter  it.  Meantime, 
the  Women's  School  of  Medicine  is  making  great  prog- 
ress. The  number  of  students  increases,  and  the  school 
IS  more  than  self-supporting. 

The  Indian  government  has  taken  steps  to  have  a 
free  hand  in  dealing  with  the  prevention  of  venereal 
diseases  among  our  soldiers.  The  viceroy  and  the 
commander-in-chief   have    both    spoken    forcibly    in 


favor  of  the  measures  proposed.  Nothing  will  be 
done  that  can  be  represented  as  encouraging  vice,  and 
this  should  disarm  some  of  the  opposition  which  is 
threatened.  Already  Mrs.  Butler  and  Sir  J.  Stansfeld 
have  raised  their  voices,  and  it  is  quite  possible  that 
their  followers  may  give  rise  to  considerable  annoy- 
ance to  the  authorities,  but  they  have  no  longer  a 
chance  of  influencing  the  government,  and  public 
opinion  seems  to  be  against  their  views. 

The  Mercer's  Hospital  dispute  has  advanced  a  stage. 
Candidates  have  been  found  as  I  suggested  - —  yes, 
twenty  of  them — and  the  governors  have  made  their 
selection.  But  the  end  is  not  yet.  Protests  were 
handed  in,  and  I  am  assured  an  appeal  to  law  is  im- 
pending. But  that  law  is  slow  and  uncertain.  The 
lamentable  fact  remains  that  twenty  men  were  ready 
to  take  the  places  of  the  dismissed  staff — and  we  talk 
of  the  prestige  and  the  honor  of  the  profession ' 


OUR    VIENNA    LETTER. 


l.Kr 


■  Special  Correspondent.) 


PROF.  KARL  TOLDT,  THE  ANATOMIST,  ELECTED  RECTOR 
OF  THE  UN'IVERSITV — NEW  SURGICAL  AND  GYN.E- 
COLOGIC.^L  WARDS  FOR  THE  VIENN.\  GEN'ER.\L  HOS- 
PITAL  CARBONIC-.\CID    BATHS     FOR    HEART     DISEASE 

IN    VIENN.4 THE    MENINGOCOCCUS   INTRACELLULARIS 

AND    EPIDEMIC    SPIN.iL    MENINGITIS CANCER  OF  THE 

SINUS    PYRIFORMES    AND     SO-CALLED    BRANCHIOGENIC 
CANCER. 

Prof.  Karl  Toldt,  professor  of  anatomy,  has  just 
been  elected  rector  magnificus  of  the  University  of 
Vienna  for  the  scholastic  year  1897-98.  The  tenure 
of  office  is  but  a  year,  and  there  is  usually  a  rotation 
in  the  selection  of  candidates  from  the  different  facul- 
ties that  constitute  the  university.  Professor  Toldt 
succeeds  Professor  Reinisch,  a  jurist. 

It  has  at  last  been  definitely  decided  that  part  of  the 
old  Vienna  General  Hospital  must  go.  The  increased 
traffic,  with  the  incident  noise  and  dust  at  the  corner 
of  Alserstrasse  and  Spitalgasse,  made  the  wards  here 
almost  uninhabitable  for  patients.  Since  the  advent 
of  the  electric  tramway  this  state  of  affairs  has  been 
much  worse.  The  line  is  one  of  the  most  travelled  in 
Vienna,  and  is  becoming  more  so.  Its  cars  have  had 
to  be  increased  in  number,  and  this  will  constitute 
more  and  more  of  an  annoyance  as  time  goes  on.  The 
old  wards  in  the  hospital  have  become  a  constant 
source  of  complaint,  especially  for  the  surgeons  and 
gynecologists,  .\septic  surgery  and  aseptic  post- 
operative courses  are  extremely  difficult  to  secure  with 
the  limited  facilities  in  the  thoroughly  old-fashioned 
hospital  building.  .\  series  of  wards  on  the  pavilion 
plan  are  to  be  erected  on  the  grounds  of  the  Lower 
Austrian  National  Insane  Asylum  on  Lazareth  Gasse, 
which  are  to  provide  quarters  for  some  eighteen  hun- 
dred surgical  and  gynaecological  patients;  while  the 
buildings  at  the  corner  of  Alserstrasse  and  Spitalgasse 
are  to  be  replaced  by  a  large  apartment  house.  Such 
is  the  ministerial  decision,  but  as  to  when  the  plan 
will  be  accomplished,  WMth  the  proverbial  slowness  of 
the  .\ustrian  government,  especially  w  hen  merely  scien- 
tific matters  are  concerned,  it  is  extremely  hard  to  say. 

For  more  than  a  year  now  series  of  observations 
have  been  made  in  two  of  the  divisions  of  the  hospital 
with  carbonic-acid  baths  in  the  treatment  of  heart  dis- 
ease. The  Schott  or  Beneke  treatment  has  attracted  a 
good  deal  of  attention  in  America,  too,  so  that  the 
Vienna  opinion  of  it  will  be  of  interest.  They  are 
not  so  enthusiastic  over  its  success  here  as  Schott  him- 
self is  at  Nauheim.  It  is  not  a  novelty  in  therapeutics, 
however,  to  find  that  others  do  not  meet  with  the  same 
success  in  the  use  of  a  remedy  as  its  originator. 


176 


MEDICAL    RECORD. 


[July  31,  1897 


Of  course,  here  as  ever}'\vhere  else,  except  where 
there  are  abundant  natural  carbonic-acid  springs,  one 
labors  under  the  disadvantage  of  having  to  employ  arti- 
ficial solutions  of  carbonic  acid.  Despite  this,  it  has 
been  found  that  in  certain  cases  of  heart  disease, 
utterly  intractable  by  the  ordinary  methods  and 
remedies,  the  carbonic-acid  bath  is  of  great  bene- 
fit. It  has  been  found,  too,  that  when  the  ordinary 
heart  tonics  fail  to  produce  an  amelioration  of  symp- 
toms or  are  badly  borne  when  employed  only  in 
conjunction  veith  rest  in  bed,  they  regain  their  usual 
therapeutic  effect  after  a  course  of  carbonic-acid  bath- 
ing. When  used  alone  or  in  conjunction  with  the 
Swedish  movements  and  absolutely  without  drugs  of 
any  kind,  the  baths  often  give  excellent  results,  better 
than  could  be  hoped  for  with  ordinary  methods  of 
treatment.  There  are  certain  cases,  however,  in 
which  they  do  not  seem  to  produce  the  slightest  ef- 
fect. There  are  others  in  which,  apart  from  aneurism 
or  arterio-sclerosis,  which  are  considered  here  ab- 
solute contraindications,  they  produce  unfavorable 
effects.  They  increase  cardiac  arrhythmia,  and  some- 
times occasion  symptoms  of  collapse.  It  seems  im- 
possible to  tell  beforehand  the  cases  in  which  these 
unfavorable  effects  will  follow,  as  they  are  due  to 
personal  idiosyncrasy.  On  the  whole,  while  the  new 
treatment  is  a  welcome  adjuvant  to  the  limited  circle 
of  cardiac  therapeutic  measures,  it  is  by  no  means  a 
universal  panacea  for  heart  disease,  and  needs  care 
and  judgment  in  its  application. 

A  little  epidemic  of  cerebro-spinal  meningitis 
has  been  observed  in  Vienna  in  this  last  month. 
Several  cases  have  turned  up  at  the  Franz  Josef 
and  Rudolf  hospitals,  and  cases  of  meningitis  oc- 
curring without  easily  recognizable  etiology  are  sus- 
pected. For  purposes  of  disinfection  and  necessary 
burial  precautions,  the  post-mortem  diagnosis  is  im- 
portant, and  that  they  make  here  with  what  is  consid- 
ered ample  assurance  from  the  bacteriological  exami- 
nation of  the  purulent  exudate.  The  finding  of  the 
intracellular  meningococcus  decides  the  question  in 
favor  of  epidemic  cerebro-spinal  meningitis.  Weich- 
selbaum's  discovery  of  this  coccus,  its  constant  occur- 
rence, and  the  description  of  its  peculiarities  have 
been  confirmed  by  a  number  of  German  observers,  until 
now  its  specific  pathogeneity  is  considered  settled.  In  a 
recent  autopsy,  in  a  case  in  which  the  clinical  diagnosis 
had  been  meningitis  from  otitis  media,  and  in  which  the 
destructive  process  in  the  petrous  bone  was  very  slight, 
while  the  meningeal  suppurative  exudate  was  wide- 
spread over  the  base  and  in  the  cord,  the  anatomical 
differentiation  was  considered  to  be  assured  only 
when  the  bacteriological  examination  of  the  exudate 
gave  negative  results  as  regards  the  meningococcus 
and  showed  the  presence  in  large  numbers  of  other 
pus-producing  micro-organisms. 

A  case  of  recurring  squamous  epithelial  cancer  of 
the  cervical  glands,  in  which  the  patient  succumbed 
after  two  operations,  proved  of  special  interest  on  the 
autopsy  table  last  week.  The  most  careful  laryngo- 
scopic  examination  by  one  of  Vienna's  best- known 
laryngologists  had  failed  to  discover  any  suspicion  of 
neoplasm  in  the  larymx  or  its  neighborhood.  At  the 
autopsy  a  small  cancerous  nodule  was  found  deep  down 
in  the  right  sinus  pyriformis.  It  was  evidently  in- 
visible to  the  laryngoscope,  and  yet  undoubtedly  the 
original  seat  of  the  cancer,  which  had  given  metastases 
to  the  cervical  glands.  These  squamous  epithelial  can- 
cers of  the  cervical  region  are  often  spoken  of  as 
taking  their  origin  from  embryonal  vestigia  of  the 
branchial  clefts,  but  one  is  tempted  to  wonder  how 
often  the  simpler  explanation  of  their  metastatic  ori- 
gin from  small  cancerous  nodules  of  the  pharynx  and 
larynx  would  be  the  real  one.  Undoubtedly  this  is  the 
case  much  more  frequently  than  is  supposed. 


DO    ABNORMALITIES    TEND     TO    DIE    OUT 
IN    THE  COURSE  OF  TRANSMISSION? 


Sir:  In  Dr.  Park's  paper  upon  "The  Problems 
Which  Most  Perplex  the  Surgeon,"  published  in  the 
Medic.a^i,  Record  of  July  3d,  I  find  the  following 
paragraph  (page  3):  '' If  cancer  is  transmissible  by 
heredity  and  is  not  an  infection,  it  should  tend  to  die 
out  in  the  course  of  transmission,  as  do  all  abnormali- 
ties. Thus,  out  of  three  hundred  marriages  in  which 
both  husbands  and  wives  were  deaf  and  dumb,  in  only 
five  per  cent,  of  the  cases  were  the  offspring  similarly 
affected;  while  of  three  hundred  and  ten  deaf-mutes 
married  to  those  who  could  hear,  the  proportion  of 
affected  offspring  amounted  only  to  one  in  one  hun- 
dred and  thirty-five  (Buxton)." 

I  feel  a  great  deal  of  reluctance  in  challenging  Dr. 
Park's  statement;  but  my  study  of  heredity,  extending 
over  a  period  of  twenty  years,  leads  me  to  the  conclu- 
sion that  congenital  abnormalities  are  reproduced 
with  very  great  certainty,  and  that  it  is  extremely 
doubtful  whether  even  the  judicious  mating  of  the 
sexes  would  "breed  out"  such  pathological  variations 
as  epilepsy,  hemophilia,  idiocy,  and  deaf-mutism. 
My  opinion  that  congenitally  abnormal  persons  should 
not  marry,  because  they  are  likely  to  reproduce  their 
abnormalities  in  their  children,  is  supported  by  the 
views  of  such  authorities  as  the  late  Oliver  Wendell 
Holmes,  the  late  Benjamin  Richardson,  Paget,  Clous- 
ton,  and  Maudsley.  It  is  most  unfortunate  that  a  phy- 
sician of  Dr.  Park's  eminence  should  teach  that  '"all 
abnormalities  tend  to  die  out  in  the  course  of  trans- 
mission," since  it  will  encourage  the  physically  de- 
formed and  the  mentally  incapable  to  marry  without 
fear  of  the  consequences. 

Has  Dr.  Park  proved  that  deaf-mutism  "  tends  to 
die  out  in  the  course  of  transmission"?  I  trow  not. 
Mr.  Buxton  (David  Buxton,  of  Liverpool)  is  his  au- 
thority, not  mine,  and  the  following  quotation  was 
addressed  to  the  British  Association  in  1889  by  Sir 
William  Turner,  who  produced  a  mass  of  evidence, 
which  he  asserted  "proves  that  it  (deaf-mutism)  is 
often  hereditarily  transmitted"  :  ''  Mr.  Buxton,  who  has 
paid  great  attention  to  this  subject,  refers  to  several 
families  where  the  deaf-mutism  has  been  transmitted 
through  three  successive  generations,  tliough  in  some 
instances  the  affection  passes  over  one  generation,  to 
reappear  in  the  next.  He  also  relaies  a  case  of  a 
family  of  si.xteen  persons,  eight  of  whom  were  bom 
deaf  and  dumb,  and  one,  at  least,  of  the  members  of 
which  transmitted  the  affection  to  his  descendants  as 
far  as  the  third  generation"  {Liverpool  Mtdko-Chirnr- 
gical Joiinial,  July,  1857:  January,  1859). 

But  Mr.  Buxton's  evidence  possesses  a  limited 
value,  because  he  ignores  the  "  metamorphoses'"  of 
heredity,  and  he  pays  very  little  attention  to  atavism. 
Moreover,  he  does  not  appear  to  have  carefully  dis- 
tinguished between  congenital  and  acquired  deaf- 
mutism.  The  latter  form  of  the  disorder  consists 
chieriy  of  instances  in  which  deafness  has  followed 
some  injiury  to  the  auditory  apparatus  before  or 
shortly  after  the  power  of  speech  had  been  attained. 
This  class  (perhaps  forty  per  cent,  of  all  deaf-mutes) 
is  large  enough  to  infiuence  statistics,  and  its  existence 
partially  explains  the  figures  quoted  by  Dr.  Park. 
Acquired  deaf-mutism  is,  of  course,  no  more  heredi- 
tary than  accidental  blindness. 

Every  form  of  degeneration  is  liable  to  be  trans- 
muted in  tlie  course  of  generations.  What  is  passed 
on  from  parent  to  offspring  is  a  depraved  constitution, 
which  may  manifest  itself  in  half  a  dozen  different  dis- 
eases, such  as  hysteria,  imbecility,  idiocy,  etc.  Mo- 
reau  (of  Tours >,  in  his  "  Psychologie  Morbide,"  says: 
"  It  shows  an  incorrect  conception  of  tlie  l.iw  of  hered- 


July  31,  1897] 


MEDICAL    RECORD. 


177 


it>-  to  look  for  a  return  of  identical  phenomena  in  each 
new  generation."  Morel  ("Traite  des  Degene'res- 
cences")  writes:  "We  do  not  mean  exclusively  by 
heredity  the  very  complaint  of  the  parents  transmitted 
to  the  children,  with  the  identical  symptoms,  both 
physical  and  moral,  observed  in  the  progenitors.  By 
the  term  heredity  we  understand  the  transmission  of 
organic  dispositions  from  parents  to  children."  My 
quotation  from  Mr.  Boxton  shows  that  he  knew  of  this 
phenomenon  as  a  factor  in  the  heredit)'  of  deaf- 
mutism,  although  Dr.  Park's  quotation  seems  to  prove 
that  he  underestimated  its  statistical  value. 

Ribot,  in  his  work  upon  "  Heredity"  (page  42), 
writes :  "  We  would  remark  that  the  returns  of  the 
Deaf  and  Dumb  Institution  of  London,  from  its  foun- 
dation to  the  present  lime  (1875),  are  conclusive  in 
favor  of  heredity."  (Then  follow  statistics.)  "The 
deaf -muteness  of  ascendants  may,  in  their  descendants, 
be  transformed  into  an  infirmity  of  some  other  descrip- 
tion, such  as  obtuseness  of  the  mental  faculties  or  even 
idiocy.  Of  this  the  distinguished  anatomist  Menckel 
gives  many  instances." 

Dr.  Clouston,  in  "The  Neuroses  of  Development," 
says:  "Ordinary  deaf-mutism  is  closely  allied  to 
idiocy,  and  is  one  of  the  hereditary  neuroses.  To  me 
it  is  a  physiological  sin  that  marriages  between  such 
persons  should  be  legal." 

Congenital  deaf-mutism  is  not  mere  inability  to 
hear;  if  it  were,  I  should  not  trouble  you  with  this 
letter.  It  is  a  constitutional  affection  showing  a 
markedly  degenerate  state,  and  is  a  sign  that  the  fam- 
ily in  which  it  is  present  is  on  the  road  to  decay. 

'.■\ccording  to  Prof.  Graham  Bell,  idiocy  is  forty- 
three  times  as  common,  and  blindness  fourteen  and 
one-half  times  as  common,  among  deaf-mutes  as 
among  the  general  population.  I  assume  that  he  means 
congenital  blindness.  I  am  sure  that  Dr.  Park  will 
agree  with  me  that  an  idiot  parent  has  a  decided  ten- 
dency to  beget  idiot  children,  however  "normal,"  as  it 
is  called,  the  second  parent  may  be.  Professor  Bell, 
a  few  years  ago,  wrote  that  "philanthropy  is  doing 
ever)'thing  possible  to  encourage  marriage  among 
deaf-mutes.  Unless  this  system  is  changed,  we  shall 
certainly  have  a  deaf  variet)-  of  the  human  race."  Of 
this  I  see  no  danger,  for,  while  we  are  increasing  the 
supply  of  idiots,  of  lunatics,  of  deaf-mutes,  of  the  de- 
formed, et  hoc  genus  omiic,  the  tendency  is  for  degener- 
ated families  to  become  sterile  and  consequently  ex- 
tinct. 

The  marriage  of  a  deaf-mute  with  a  so-called  "  nor- 
mal" person  is  said  to  be  unproductive  of  deaf-mutism 
in  the  ne.xt  generation.  "  Normal"  in  this  instance 
appears  to  mean  that  the  individual  can  speak  and  can 
hear.  I  have  no  complete  statistics  of  the  results  of 
this  connubial  combination,  but  I  have  sufficient  evi- 
dence to  lead  me  to  suppose  that  it  is  productive  of 
abnormality,  not  necessarily  deaf-mutism,  of  course. 
The  following  case,  a  typical  case  of  atavism,  is 
vouched  for  by  the  Scotch  Lunacy  Commission: 


demonstrate  by  irrefutable  evidence  that  idiocy,  insan- 
ity (not  apparent  till  after  puberty),  epilepsy,  the  gouty 
diathesis,  hemophilia,  color  blindness,  and  the  tuber- 
culous diathesis — most  of  them  signs  of  racial  deteri- 
oration— are  almost  invariably  transmitted. 

Lawrence  Irwell,  M.A.,  B.C.L. 

FALO,    N.    v., 


With  great  respect,  I  submit  that  Dr.  Park  is  mis- 
taken in  thinking  that  "all  abnormalities  tend  to  die 
out  in  the  course  of  transmission."  L^pon  the  other 
hand,  I  feel  sure  that  many  pathological  variations, 
when  congenital,  have  a  decided  tendency  to  reappear 
in  the  next  or  some  future  generation.     I  believe  I  can 


THE   TREATMENT    OF    TYPHOID    FEVER. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  In  the  issue  of  the  Medical  Record  for  July 
3d  is  an  abstract  of  a  paper  in  which  my  name  was 
freely  used — and  also  a  synopsis  of  some  remarks  of 
my  own,  which  in  one  respect  does  me  too  much  and 
in  another  too  little  justice.  \<\\\  you  therefore  accord 
me  space  to  correct  an  erroneous  impression  which,  in 
the  Medical  Record,  will  have  too  large  a  circulation 
to  be  passed  uncriticised? 

Before  remarking  upon  Dr.  Upshur's  allusions  to 
■'  The  Woodbridge  Method"  it  is  proper  to  say  that  he 
has  my  most  hearty  thanks  for  the  polite  and  appar- 
entlv  sincere  compliments  he  pays  me,  but  when  he 
characterizes  the  verdict  rendered  upon  the  clinical 
reports  on  the  abortive  treatment  of  typhoid  fever  as 
"erroneous  conclusions  drawn  from  cases  of  mistaken 
diagnosis,"  he  is  disparaging  the  achievements  and 
discrediting  the  statements  of  a  very  large  and  very 
respectable  class  of  .American  physicians,  whose  state- 
ments upon  any  medical  question  are  quite  as  val- 
uable as  his  own,  and  upon  this  subject  much  more 
so,  since  their  remarks  are  the  rehearsal  of  facts  and 
the  expressions  of  opinions  that  have  been  founded 
upon  actual  experience  at  the  bedside,  while  his  own 
can  be  fully  characterized  in  no  other  way  than  as  the 
liberal  expressions  of  erroneous  conclusions,  the  result 
of  fault}'  reasoning  from  false  premises. 

Because  Dr.  Upshur  does  not  understan'd  the  abor- 
tive treatment  of  typhoid  fever,  and  because  the  exhi- 
bition of  certain  remedies  produce.'  results  which  he 
cannot  believe  to  be  possible,  "unless  the  day  of  mira- 
cles had  returned,"  he  attempts  to  discredit  it  on  the 
theor}'  that  "  it  had  not  been  supported  by  the  results" — 
a  theory  that  can  be  sustained  only  on  the  assump- 
tion that  the  many  hundreds  of  physicians  who  have 
aborted  typhoid  fever  and  have  reported  8,434  cases 
treated,  with  150  deaths  (death  rate  of  1.S8  per  cent.), 
have  made  errors  of  diagnosis.  Most  of  these  deaths 
occurred  in  cases  in  which  the  treatment  was  instituted 
late  in  the  course  of  the  disease,  or  when  the  method 
was  never  properly  applied,  and  yet  all  are  included  to 
silence  all  suspicion  that  the  statistics  have  been 
"doctored,"  though  they  unjustly  swell  the  death  rate. 

It  is  but  just  to  Dr.  Upshur  to  say  that  when  he 
read  his  paper  he  was  not  aware  of  tlie  enormous  pro- 
portions that  these  statistics  are  assuming,  but  if 
he  had  read  my  book  he  would  probably  have  found 
enough  there  to  prevent  him  from  putting  himself  in 
the  dilemma  from  which  he  will  find  it  difficult  to 
extricate  himself. 

Let  us  examine  the  data  contained  in  my  paper  read 
before  the  Ohio  State  Medical  Society,  which  con- 
sisted almost  entirely  of  brief  quotations  from  the  let- 
ters of  hundreds  of  physicians  from  all  parts  of  the 
country,  from  all  walks  of  professional  life,  frcm  the 
ablest  professors,  from  physicians  who  were  or  who 
had  been  at  the  head  of  some  of  the  largest  hospitals 
in  the  United  States,  from  the  equally  competent  pri- 
vate practitioner — all  of  whom  had  used  this  method 
so  successfully  that  many  declared  their  convictions 
that  death  is  a  wholly  unnecessary  consequence  of  ty- 
phoid fever.  Many  whose  ability  to  make  correct 
diagnoses  or  to  draw  exact  conclusions  no  man   would 


178 


MEDICAL    RECORD. 


Quly  31,  1897 


dare  to  question,  said  in  most  positive  language  that 
this  method  of  treatment  "aborts  typhoid  fever." 
Nearl)-  all  spoke  in  highest  commendation  of  it.  So 
far  as  I  know,  it  has  been  adversely  criticised  by  only 
twelve  physicians  who  spoke  from  bedside,  and  some 
of  these  from  an  experience  limited  to  the  treatment 
of  one,  two,  or  three  cases  each. 

This  report  dealt  with  the  data  of  5,449  cases  of 
typhoid  fever  treated  with  105  deaths  (every  death  of 
which  I  had  any  knowledge) — a  death  rate  of  1.92  per 
cent.,  and  an  average  duration  of  illness  in  the  3,129 
cases  in  which  it  was  given  of  12.7.  These  reports 
were  accompanied  by  a  large  number  of  clinical 
charts  or  histories,  and  present  conclusive  evidence 
that  they  were  the  outgrowth  of  the  most  patient  and 
painstaking  observations,  in  which  every  precaution 
had  been  taken  to  avoid  errors  of  diagnosis  or  judg- 
ment, and  they  show  that  the  conclusions  were  justified 
by  the  results. 

This  paper  was  read  on  May  2t,  1897,  and  since 
that  day  I  have  received  more  than  three  hundred  let- 
ters containing  the  reports  of  2,985  cases  treated,  with 
54  deaths  (a  death  rate  of  1.80  per  cent.,  which  slightly 
reduces  the  death  rate  from  that  of  the  previous  report), 
making  the  record  stand  now  at  8,434  cases  treated, 
with  159  deaths,  or  a  death  rate  of  1.88  per  cent., 
and  an  average  duration  of  illness  in  the  5,372  cases 
in  which  it  was  given  of  12.9  days. 

Besides  the  bare  statistics,  the  almost  universal 
verdict  of  this  host  of  observers  is  to  the  effect  that 
the  treatment  greatly  lessens  the  severity  of  the 
disease,  causing  it  to  run  a  mild  course  to  quick  re- 
coveiy.  Delirium  or  tympanites  rarely  develops  after 
the  treatment  is  instituted,  and  if  present  it  generally 
quickly  disappears,  the  tongue  remains  moist,  the 
temperature  runs  lower  or  quickly  drops  to  nearly  or 
quite  normal,  and  the  "  typhoid  state"  is  unknown. 

These  results  have  been  reported  in  thousands  of 
cases  in  which  the  treatment  was  instituted  after  there 
could  be  no  doubt  as  to  the  diagnosis,  and  it  is  to  be 
regretted  that  Dr.  Upshur  has  had  the  temerity  to  in- 
sult this  great  host  of  careful,  scientific,  self-sacrific- 
ing observers,  and  through  them  the  whole  medical 
profession,  by  stating  that  "  the  originator  of  the  method 
must  have  drawn  erroneous  conclusions  from  cases  of 
mistaken  diagnosis." 

The  correction  of  the  report  of  my  own  remarks  may 
be  very  brief  indeed.  "He  had  never  said  a  harsh 
thing  about  any  member  of  the  medical  profession." 
This  sounds  well  and  I  would  it  could  stand  unchal- 
lenged, but  when  I  first  declared  that  typhoid  fever 
could  be  aborted  the  announcement  was  met  by  such 
sharp  criticism,  sometimes  degenerating  into  personal 
abuse,  that  it  would  have  required  a  much  better  tem- 
per than  I  possess  to  have  enabled  me  to  withhold  all 
acrimonious  retorts.  The  above  quotation  requires  to 
complete  it  the  qualification — until  called  forth  and 
ju.stified  by  the  sharp  criticism  of  a  principle  which  can- 
not be  successfully  attacked.  I  was  in  a  very  apolo- 
getic mood  when  I  made  these  remarks,  which  was  due 
to  the  cordial  reception  which  had  been  accorded  me 
when  I  least  expected  it,  and  to  the  courteous  and 
friendly  letters  which  were  then  and  are  still  coming 
from  physicians  who  have  used  the  method  I  have 
advised  for  the  abortive  treatment  of  typhoid  fever  and 
commend  it.  John   Eliot  Woodhridge,  M.D. 

637  Pkosi'ECT  Street,  Cleveland,  Ohio. 


The  Austrian  Universities.— The  number  of  stu- 
dents at  the  Austrian  universities  last  semester  was: 
Vienna,  6,104;  Gratz,  1,667:  Prague,  1,391  German, 
2,787  f^ohemian:  Innsbruck,  1,004;  Lemberg,  1,556: 
Krakau,  1,296;  Czernowitz,  39  1 .  (If  the  total  num- 
ber, 4,728  were  medical  students. 


Tlcxv  Ixistvumcnts. 

A    FORMALDEHYDE    GENERATOR. 

The  investigations  of  the  last  few  years  have  shown 
that  formaldehyde  vapor  is  a  most  powerful  germicide 
and  antiseptic,  exceeding  in  promptness  and  efficacy 
most  of  the  disinfectants  usually  employed.  In  solu- 
tion it  is  likewise  a  powerful  antiseptic,  and  is  now 
largely  used  for  preser\'ing  anatomical  specimens. 
What  makes  it  so  valuable  as  an  air  or  room  disin- 
fectant is  its  lack  of  chemical  action  upon  metals,  col- 
ored fabrics,  etc.  A  room  may  practically  be  satu- 
rated with  it,  and  no  metallic  surfaces,  bronzes, 
paintings,  dresses,  or 
the  like  will  be  injured 
by  the  vapor. 

If  chlorine  or  sul- 
phurous-acid gas  are 
used,  articles  which 
are  liable  to  be  injured 
must  either  be  removed 
from  the  room,  o  r 
coated  with  varnish  or 
wax,  or  some  other  pro- 
tective. In  either  case 
there  is  a  chance  that 
some  of  the  germs  in- 
tended to  be  destroyed 
are  removed  from  the 
sphere  of  action  of  the 
disinfectant.  With 
formaldehyde  vapor  this  is  different.  Everything 
may  be  left  in  the  room,  uncovered  or  unprotected, 
and  the  apparatus  set  going.  The  accompanying 
illustration  represents  a  generator  for  the  diffusion 
of  formaldehyde  vapor.  It  is  produced  in  this  appa- 
ratus by  a  very  simple  application  of  the  best  method 
now  available,  viz.,  the  passage  of  a  mixture  of  the 
vapor  of  wood  alcohol  and  atmospheric  air  through 
platinum  gauze  in  a  state  of  red  heat,  thus  causing 
flameless  combustion  of  the  same.  In  less  than  one 
minute  the  process  can  be  brought  into  operation  and 
it  will  continue  without  further  effort  as  long  as  the 
supply  of  wood  alcohol  lasts.  The  apparatus  is  man- 
ufactured by  John  Reynders  &  Co.,  of  this  city. 


A    SIMPLE,    CONVENIENT,  AND    EFFICIENT 
CENTRIFUGE. 

Bv   A.    H.    STEWART,    M.D., 

I'HILADELPHIA,    PA. 

The  great  value  of  the  centrifuge  as  an  efficient  and 
speedy  aid  to  diagnosis  is  now  well  recognized  by  all. 
Having  had  occasion  during  the  past  five  years  to 
make  considerable  use  of  the  centrifugal  method,  I  be- 
came early  convinced  that  most  of  the  instruments 
were  unnecessarily  complex.  I  therefore  undertook 
the  task  of  designing  an  instrument  which  should  be 
at  once  adequate  to  the  purpose,  as  well  as  strong, 
and  at  the  same  time  simple  in  construction.  In  tliis 
work  I  have  been  aided  greatly  by  the  mechanical 
skill  and  ingenuity  of  Messrs.  U'illyoung  i\:  Co.,  of 
Philadelphia,  whose  facilities  were  very  kindly  placed 
at  my  disposal.  In  the  accompanying  figure  is  illus- 
trated the  instrument  which  I  have  designed.  There 
is  but  one  pair  of  gears,  viz.,  that  made  up  of  the  large 
circular  bevel  gear,  to  which  the  handle  is  affixed, 
and  a  smaller  beveled  pinion  at  the  base  of  the 
main  shaft.  The  bearings  are  of  polished,  hardened 
steel ;  that  of  the  large  gear  is  long  and  the  gear  wheel 


July  31.  1897] 


MEDICAL    RECORD. 


179 


itself  is  very  stiff,  so  that  no  twisting  or  binding  of 
the  gears  can  take  place.  The  main  casting  and  the 
clamp  casting  are  separate,  so  that  should  the  latter 
break  it  may  be  easily  replaced.  As  both  are  very 
strongly  ribbed,  however,  no  breakage  is  anticipated. 
The  clamp  has  considerable  area  and  is  so  designed 
that  it  is  impossible  for  the  instrument  to  twist  loose 
when  in  use.  The  thumb  nut  is 
above  instead  of  below,  so  that  at- 
taching or  removing  the  instrument 
is  easy.  The  urine  receptacles  are 
of  the  usual  conical  test-tube  shape, 
held  in  the  ordinarj-  aluminium 
guards ;  they  have  a  capacity  of  ten 
cubic  centimetres  and  one  of  them 
is  graduated  in  tenths  of  a  cubic 
centimetre. 

The  supporting  frame  merely 
slips  upon  the  shaft  and  engages 
with  the  ring  by  means  of  a  steady 
pin ;  no  bayonet  catch  or  screw 
action  is  found  necessary.  A  soft 
rubber  ring  acts  as  a  buffer  in  case 
the  tubes  drop  too  suddenly.  In 
practice,  however,  it  is  found  that 
this  ring  is  not  really  needed,  as  the  tubes  drop  slowly 
and  freely  into  the  vertical  without  any  tendency  to 
swing  inside  and  strike  the  frame.  A  metal  guard 
covers  the  gears  and  shaft,  and  makes  it  impossible 
for  fluid  to  be  thrown  into  them. 

Each  turn  of  the  handle  gives  twenty-three  revolu- 
tions of  the  main  shaft,  so  that  a  constant  speed  of 
from  one  thousand  five  hundred  to  two  thousand  five 
hundred  revolutions  is  provided  for;  this  lower  limit 
here  mentioned  has  been  found  amply  sufficient  for  all 
urinary,  water,  and  milk  analyses. 

252  North  Twelfth  Street. 


pCexXicaX  Stems. 

Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  July  24,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. .  . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 

Chicken-pox 

^mall-po.x 


180 

97 

13 

9 

S.3 

6 

2 

4 

14S 

5 

1 84 

22 

5 

2 

Study  of  the  American  Medicinal  Flora.— The 
Pan-.\merican  Medical  Congress,  at  its  meeting  held 
in  the  City  of  Mexico  in  November,  1896,  took  stejis 
to  institute  a  systematic  study  of  the  American  medi- 
cinal rtora,  through  the  medium  of  a  general  commis- 
sion and  of  special  subcommissions,  the  latter  to  be 
organized  in  the  several  countries.  The  subconnnis- 
sion  for  the  I'nited  States  has  been  formed,  and  cuii- 
sists  of  Dr.  Valery  Havard,  U.  S.  A.,  chairman;  Mr. 
Frederick  V.  Coville,  botanist  of  the  United  States 
department  of  agriculture;  Dr.  C.  F.  Millspaugh,  cu- 
rator of  the  botanical  department  of  the  Field  Colum- 
bian Museum,  Chicago;  Dr.  Charles  Mohr,  State  bot- 
anist of  Alabama;  Dr.  W.  P.  Wilson,  director  of  the 
Philadelphia  Commercial  Museums:  and  Prof.  H. 
H.  Rusby,  of  the  New  York  College  of  Pharmacy. 
This  subcommission  solicits  information  concerning 


the  medicinal  plants  of  the  United  States  from  every 
one  in  a  position  to  accord  it.  The  principal  points 
of  study  are  as  follows:  i.  Local  names.  2.  Local 
uses,  together  with  historical  facts.  3.  Geographical 
distribution  and  degree  of  abundance  in  the  wild  state. 

4.  Is  the  plant  collected  for  market,  and  if  so:  (<?)  At 
what  season  of  the  year  ?  (/')  To  how  great  an  extent  ? 
(c)  How  prepared  for  market?  (</)  What  is  the  elTect 
of  such  collection  upon  the  wild  supply?  (c)  What 
price  does   it  bring?      (/)  Is  the  industry  profitable? 

5.  Is  the  plant,  or  has  it  e\er  been,  cultivated?  If 
so  give  all  information  on  the  subject,  particularly  as 
to  whether  such  supplies  are  of  superior  quality  and 
whether  the  industry  has  proved  profitable.  6.  If  not 
cultivated,  present  facts  concerning  the  life  history  of 
the  plant  which  might  aid  in  determining  methods  of 
cultivation.  7.  Is  the  drug  subjected  to  substitution 
or  adulteration?  If  so  give  information  as  to  the 
plants  used  for  this  purpose.  While  it  is  not  expected 
that  many  persons  will  be  able  to  contribute  infoima- 
tion  on  all  these  points  concerning  any  plant,  it  is 
hoped  that  a  large  number  of  persons  will  be  willing 
to  commimicate  such  partial  knowledge  as  they  pos- 
sess. It  is  not  the  important  or  standard  drugs  alone 
concerning  which  information  is  sought.  The  sub- 
commission  desires  to  compile  a  complete  list  of  the 
plants  which  have  been  used  medicinally,  however 
trivial  such  use  may  be.  It  also  desires  to  collect  all 
obtainable  information  —  historical,  scientific,  and 
economic  —  concerning  our  native  and  naturalized 
plants  of  this  class,  and  to  this  end  invites  the  co- 
operation of  all  persons  interested.  Poisonous  plants 
of  all  kinds  come  within  the  scope  of  the  inquiry, 
whether  producing  dangerous  symptoms  in  man,  or 
simply  skin  inflammation,  or,  as  "  loco-weeds,"  being 
deleterious  to  horses,  cattle,  and  sheep.  In  this  respect, 
the  general  reputation  of  a  plant  is  not  so  much  de- 
sired as  the  particulars  of  cases  of  poisoning  actually 
seen  or  heard  from  reliable  observers.  It  is  believed 
that  much  interesting  knowledge  can  be  obtained 
from  Indians,  Mexicans,  and  halfbreeds,  and  that 
consequently  Indian  agencies  and  reservations  are 
particularly  favorable  fields  for  investigation.  Such 
knowledge  will  be  most  acceptable  when  based  upon 
known  facts  or  experiments.  In  order  to  assist  in  the 
study  of  the  habits,  properties,  and  uses  of  medicinal 
plants,  the  subcommission  undertakes  to  furnish  the 
name  of  any  plant  specimen  received,  together  with 
any  desired  information  available.  Owing  to  the  di- 
versity in  the  common  names  of  many  plants,  it  will 
be  necessary  for  reports,  when  not  furnished  by  bota- 
nists or  others  qualified  to  state  the  botanical  names 
with  certainty,  to  accompany  the  same  with  some  spec- 
imen of  the  plant  sufficient  for  its  identification. 
While  the  subcommission  will  endeavor  to  determine 
the  plant  from  any  portion  of  it  which  may  be  sent,  it 
should  be  appreciated  that  the  labor  of  identification 
is  very  greatly  decreased,  and  its  usefulness  increased, 
by  the  possession  of  complete  material  —  that  is,  leaf, 
flower,  and  fruit,  and  in  the  case  of  small  plants,  the 
imderground  portion  also.  It  is  best  to  dry  such  spec- 
imens thoroughly,  in  a  fiat  condition  under  pressure, 
before  mailing.  While  any  convenient  means  for  ac- 
complishing this  result  may  be  employed,  the  follow- 
ing procedure  is  recommended:  Select  a  flowering  or 
fruiting  branch,  as  the  case  may  be,  which  when 
pressed  shall  not  exceed  sixteen  inches  in  length  by 
ten  inches  in  width.  If  the  plant  be  an  herb  two  or 
three  feet  high,  it  may  be  doubled  to  bring  it  within 
these  measurements.  If  it  possess  root  leaves,  some 
of  these  should  be  included.  Lay  the  specimen  flat 
in  a  fold  of  newspaper,  and  place  this  in  a  pile  of 
newspapers,  carpet  felting,  or  some  other  form  of  paper 
which  readily  absorbs  moisture,  and  place  the  pile  in 
a  dry  place  under  a  pressure  of  about  twenty  or  thirty 


i8o 


MEDICAL    RECORD. 


[July  31,  1897 


pounds,  sufficient  to  keep  the  leaves  from  wrinkling 
as  they  dry.  If  several  specimens  are  pressed  at  the 
same  time,  each  is  to  be  separated  from  the  others 
by  three  or  four  folded  newspapers  or  an  equivalent  in 
other  kinds  of  paper.  In  from  twelve  to  twenty-four 
hours  these  papers  will  be  found  saturated  with  the  ab- 
sorbed moisture,  and  the  fold  containing  the  specimen 
should  be  transferred  to  dry  ones.  This  change  should 
be  repeated  for  from  two  to  five  days,  according  to  the 
state  of  the  weather,  the  place  where  the  drying  is 
done,  the  fleshiness  of  the  specimens,  etc.  The  best 
way  to  secure  the  required  pressure  is  by  means  of  a 
pair  of  strong  straps,  though  weights  will  do.  The 
best  place  for  drying  is  beside  a  hot  kitchen  range. 
When  dry  the  specimens  should  be  mailed  between 
cardboards  or  some  other  light  but  stiff  materials 
which  will  not  bend  in  transit.  It  is  a  most  impor- 
tant matter  that  the  name  and  address  of  the  sender 
should  be  attached  to  the  package,  and  that  the  speci- 
mens, if  more  than  one,  should  be  numbered,  the 
sender  retaining  also  specimens  bearing  the  same  num- 
ber, to  facilitate  any  correspondence  which  may  fol- 
low. The  subcommission  requests  that,  so  far  as 
practicable,  all  plants  sent  be  represented  by  at  least 
four  specimens.  .\11  packages  and  correspondence 
should  be  addressed  to  the  Smithsonian  Institution, 
Washington,  D.  C,  and  marked  on  the  outside,  "  Me- 
dicinal Plants,  for  the  United  States  National  Mu- 
seum." Franks  \*hich  will  carry  specimens,  when  of 
suitable  size,  together  with  descriptions  and  notes,  free 
of  postage  through  the  mails,  will  be  forwarded  upon 
application.  Should  an  object  be  too  large  for  trans- 
mission by  mail,  the  sender  is  requested,  before  ship- 
ping it,  to  notify  the  institution,  in  order  that  a  proper 
authorization  for  its  shipment  may  be  made  out. 

The  Founder  of  Guy's  Hospital. — Guy,  the  founder 
of  Guy's  Hospital  in  London,  was  as  parsimonious  in 
private  life  as  he  was  munificent  in  public.  A  good 
story  illustrative  of  this  is  told  of  him  in  connection 
with  John  Hopkins,  one  of  his  contemporaries  who 
was  nicknamed  Vulture  Hopkins,  on  account  of  his 
rapacious  mode  of  acquiring  his  immense  wealth. 
On  one  occasion  he  paid  a  visit  to  Guy,  who,  on  Hop- 
kins entering  his  room,  lighted  a  farthing  candle. 
Hopkins,  on  being  asked  the  reason  of  his  visit,  said: 
"  1  have  been  told  that  you,  sir,  are  better  versed  in  the 
prudent  and  necessary  art  of  saving  than  any  man 
living,  and  I  therefore  wait  on  you  for  a  lesson  in  fru- 
gality. I  have  always  regarded  myself  as  an  adept  in 
this  matter,  but  1  am  told  you  excel  me."  "  Oh,"  re- 
plied Guy,  "if  that  is  all  you  came  to  talk  about,  we 
can  discuss  the  matter  in  the  dark;"  and  thereupon  he 
blew  out  the  candle.  Struck  with  this  example  of 
ecoiioiny,  Hopkins  acknowledged  that  he  had  met  his 
superior  in  thrift. 

Treatment  of  the  Wounded  in  the  Graeco-Turkish 

War Dr.  Zavitziano  sends  to   Surgeon-General  Wy- 

man,  of  the  Marine  Hospital  service,  a  distressing 
picture  of  incompetence  and  cowardice  displayed  by 
the  surgeons  of  the  Greek  army  and  Red  Cross 
Society.  It  is  interesting  as  well  as  sad,  he  writes, 
to  note  that  the  Greeks,  who  as  individuals  are  so 
skilful  and  capable  of  doing  so  many  good  things, 
when  assembled  and  forming  a  government  are  incap- 
able of  doing  anything.  The  Greek  Red  Cross,  for 
instance,  was  not  of  any  assistance,  and  nearly  the 
same  may  be  said  of  the  sanitary  service  of  the  Greek 
army,  for  the  wounded,  as  well  as  the  refugees,  ha\e 
rather  suffered  from  them.  'l"he  wounded  and  the 
refugees  have  been  attended  with  efficiency  by  private 
physicians,  by  private  persons,  and  by  rich  (Jreeks, 
who  have  substituted  what  the  Greek  government,  the 
Greek  Red  Ooss,  and  the  sanitary  service  of  the  army 
have  not  been  able  to  do.      Before  the  beginning  of  the 


war  the  Greek  Red  Cross  had  established  five  hospitals 
for  wounded,  one  at  each  of  the  following  places: 
Volo,  Larissa,  Tyrnavo,  Carvassara,  and  Arta.  Each 
of  these  hospitals  was  fitted  for  fiftj-  beds.  The  hos- 
pital at  Larissa  was  complete,  and  it  was  made  the 
headquarters  of  the  Red  Cross.  All  the  Red  Cross 
material  had  been  accumulated  there,  and  according 
to  the  lowest  calculation  there  was  more  than  $20,000 
worth  of  material  included  in  the  armamentarium. 
The  wounded  of  the  Greek  army  have  been  deprived 
of  this  material,  as  the  hospitals  of  Larissa  and  Tyr- 
navo were  abandoned  to  the  Turks  by  the  physicians, 
who.  Dr.  Zavitziano  says,  had  no  sense  of  their  duty 
or  they  had  forgotten  it  at  that  moment.  The  sole 
excuse  they  could  offer  was  that  the  Turkish  army  had 
fired  on  the  Red  Cross  hospital  at  Ana.  As  a  conse- 
quence of  the  above-mentioned  cowardly  action  of  the 
physicians  of  the  Red  Cross,  as  well  as  of  the  army 
surgeons,  the  poor  wounded  were  left  without  any  aid ; 
but,  thanks  to  civilian  physicians,  ever\-thing  has  been 
re-established,  and  the  wounded,  as  well  as  the  refu- 
gees, have  been  attended  to  and  helped.  Greek  phy- 
sicians from  abroad  have  arrived  in  Greece  in  order  to 
serve  their  country,  and,  thanks  to  them,  the  wounded 
have  been  attended.  A  Greek  lady,  whose  example 
has  been  followed  by  others,  established  a  floating  hos- 
pital on  a  steamship,  by  which  the  wounded  were  car- 
ried from  the  seaports,  near  the  battlefields,  to  Athens, 
Piraeus,  Khalcis,  Patras,  Cephalonia,  and  Corfu,  where 
well-organized  hospitals  exist.  All  the  wounded,  ex- 
cept those  whose  condition  did  not  allow  them  to  be 
carried,  and  they  are  no  more  than  two  hundred,  have 
been  transported  to  the  above-mentioned  cities,  where 
the  populace  does  all  that  it  is  possible  to  do  in  order 
to  relieve  their  sufferings.  There  are  in  Athens  four 
large  hospitals  and  five  or  six  public  or  private  build- 
ings and  houses  transformed  into  hospitals.  The  lat- 
ter are  maintained  by  private  contribution.  There  are 
numerous  schools  as  well  as  large  private  houses  on 
which  a  Red  Cross  flag  is  hoisted,  where  the  victims 
of  the  war,  or  rather  of  the  Greek  government,  are 
attended.  It  has  been  observed  that  the  wounded 
Turks  are  constantly  visited  by  the  German  minister, 
who  visits  only  them. 

Health  Reports. — The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  supervising  surgeon- 
general  of  the  Lfnited  States  Marine  Hospital  .service 
during  the  week  ended  July  24,  1897  : 


Toledo,  Ohio Jum-  ist  lu  31st 

Brooklyn,  N.  V July  10th  to  17th  .  .. 

Memphis, 'I'cnn July  loth  to  i7ih.. . . 

New  Vork,  N.  V July  loth  to  i?th 

Pensacol.1,  Fla July  3^  ^^  >o*n 


Small-Pox — Foreign. 

Cakutt.i,  India Mav  29th  to  lunt'sth. 

Glasjjow,  Scotland June  j"6th  to ")    ' 

HonK-Kong,  China May  25th  to  ] 

Madras,  India May  29th  to  J 

^^ad^id,  Spain June  33d  to  30th 

Manaos,  Brazil June  12th  to  26th 

Sagiia  la  Crande.  Cuba. . .  .July  3d  to  loth 

Moscow,  Russia lunc  loth  tn  26th 

Nai,.'as;iki,  Japjin June  15th  to  226 

„,      -    „  ^V.  "*-     26th  to  Julys. ... 


sia  . . .  .July  id  l 

June  26th  to  July  3d. . 


Bombay,  India. 
Calcutta,  India.. 
Madras,  India.., 


Paiuima,  C  olombta June  2  jd  to  Julv  ;d 

Cardeniis,  Cuba lulv  31I  to  lolh . . . . 


Cienfnegos,  Cuba July  4th  to  nth.. 

SaKiui  la  Grande,  Cuba.. .  .July  3d  to  loth  . 


Formosa,  lapan tunc  oth  to  27th . . . 

Bombay.  India "June  8th  to  22d  . . . 


■  City,  X.  J., 


...July.Sth. 


Medical  Record 

A  IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  6. 
Whole  No.  1396. 


New  York,   August   7,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


Ovioiual  Articles. 

IS    PAIN    A   VALUABLE    SIGN     IX    THE    DI- 
AGNOSIS  OF   CANCER    OF   THE    BREAST? 

Bv    CHARLES    X.    DOWD,    M.D., 


There  is  still  a  prevalent  belief  that  cancer  of  the 
breast  is  painful  in  all  its  stages.  Physicians  as  well 
as  patients  continually  express  surprise  when  such 
cancers  have  reached  an  advanced  stage  without  pain ; 
and  even  in  one  of  our  most  recent  systems  of  surgery 
the  article  on  mammary  tumors  conveys  the  impres- 
sion that  we  may  e.xpect  a  woman  to  be  suffering  pain 
if  she  has  a  cancer  of  the  breast.  This  belief  is  prob- 
ably due  to  the  failure  to  discriminate  between  the 
early  and  late  symptoms  of  the  disease.  In  the  late 
stages,  after  surrounding  structures  are  pressed  upon 
or  ulceration  exists,  more  or  less  pain  is  generally  felt; 
but  in  the  early  stages  it  is  seldom  present. 

In  order  to  study  the  relationship  between  pain  and 
beginning  cancer,  and  to  draw  attention  anew  to  the 
fact  that  tumors  should  not  be  considered  bland  be- 
cause they  are  painless,  I  have  examined  the  histories 
of  the  patients  who  have  been  treated  in  the  New 
York  Cancer  Hospital  for  niammar)-  cancer  since  Jan- 
uary, 1889.  In  the  histor}'  blanks  there  is  a  space  for 
recording  the  presence  or  absence  of  pain  and  any 
other  pertinent  facts  concerning  this  symptom,  and 
this  has  usually  been  filled  in  with  care. 

The  total  number  of  cases  was  three  hundred  and 
thirty-one,  in  most  of  them  the  disease  was  far  ad- 
vanced. 

In  sixty-three  cases  pain  was  denied  in  an\-  slai;e 
of  the  disease. 

In  fifty-six  cases  pain  was  not  mentioned. 
In  one  hundred   and  ninety  cases  pain   came  in  the 
late  stages  of  the  disease  after  the  surrounding  struc- 
tures were  pressed  upon. 

In  twenty  cases  pain  was  present  in  the  early  stages 
of  the  disease. 

Hence  in  only  6.04  per  cent,  of  the  cases  is  there 
a  record  of  pain  at  the  time  when  the  diagnosis 
should  have  been  made  in  order  to  secure  the  best  re- 
sults from  operation.  Even  in  these  few  cases  the  pain 
was  of  such  a  character  as  to  give  little  alarm  to  the 
patients. 

In  five  instances  it  followed  bruises. 
In  one  instance  it  was  caused  by  what  was  supposed 
to  be  a  boil. 

In  seven  there  were  only  slight  shooting  or  acliing 
pains,  whicli  hardly  attracted  attention  at  the  time. 

In  six  there  were  severe  pains  at  the  beginning, 
which  intermitted  more  or  less  afterward. 

These  six  cases  represented  the  greatest  amount  of 
early  pain  which  was  recorded  in  the  entire  series  of 
three  hundred  and  thirty-one  patients.  Yet  the  aver- 
age duration  of  their  disease  had  been  twenty  months 
when  they  were  admitted  to  the  hospital — an  indication 
that  the  pain  had  not  been  verv  troublesome,  else  it 
would  ha\e  been   relieved  sooner.      People   will   not 


endure  severe  pain  for  twenty  months  when  it  can  be 
so  easily  relieved. 

Even  in  the  later  stages  of  the  disease  pain  was  not 
a  prominent  symptom.  Many  of  the  patients  who 
denied  pain  at  any  time  had  advanced  growths;  and 
in  the  group  of  one  hundred  and  ninety  patients  who 
had  pain  late  in  the  disease  there  was  seldom  much 
suffering  from  this  cause.  The  records  usually  say ; 
"  Occasional  shooting  pains,"  or  '"  Dull  pain  from  time 
to  time."  I  have  seen  severe  pain  accompanying  can- 
cer of  the  breast  only  when  there  was  abscess  or  phleg- 
mon in  addition  to  the  cancer,  or  when  axillary  pres- 
sure caused  oedema  of  the  arm. 

The  explanation  of  this  absence  of  pain  is  to  be 
found  in  the  peculiar  nature  of  the  growth.  As  the 
cancer  grows  it  replaces  the  neighboring  normal  struc- 
tures; it  does  not  distend  them,  as  acute  exudative  in- 
flammation does.  (Amcerous,  tuberculous,  and  syphi- 
litic inflammation  are  similar  in  this  respect,  and  all 
three  usually  progress  without  much  pain;  while 
inflammation  in  which  there  is  an  exudation  of  fluid 
under  high  pressure  is  very  painful. 

Abscess  of  the  breast,  acute  articular  rheumatism, 
and  a  '•  felon"  illustrate  this  point,  when  contrasted 
with  beginning  cancer  of  the  breast,  tuberculous  joint 
disease,  and  syphilitic  dactylitis.  The  first  three  are 
very  painful ;  the  last  three  seldom  give  pain,  except- 
ing when  motion  or  trauma  brings  pressure  on  nerve 
endings  which  are  still  sensitive. 

Growing  fibrous  tumors  in  the  breast  are  more 
likely  to  give  pain  than  is  growing  cancer.  There  were 
thirty-seven  such  treated  at  the  hospital  during  the 
time  mentioned,  and  nineteen  are  recorded  as  painful 
in  the  early  stages,  the  pain  being  usually  of  a  sharp 
shooting  character,  frequently  most  severe  at  or  about 
menstruation.  This,  indicates  that,  if  a  small  nodule 
is  painful,  it  is  more  likely  to  be  fibrous  than  cancer- 
ous. 

From  a  practical  standpoint  this  freedom  from  pain 
in  beginning  cancer  is  most  unfortunate,  as  people  are 
not  apt  to  seek  medical  or  surgical  advice  about  any- 
thing which  seems  so  unimportant.  We  may  well  be- 
lieve that  in  many  instances  they  do  not  themselves 
know  of  their  malady  until  it  has  existed  for  some 
time.  We  are,  however,  doing  our  best  in  the  matter 
if  we  endeavor  to  call  general  attention  to  the  real 
condition. 

Vaginal  Cystocele The  operation  for  tliis  con- 
dition, as  performed  by  Dr.  De  Marsi,  is  described  in 
the  Gazzctta  dcgli  Ospedali,  March,  1897,  as  follows; 
He  first  makes  a  longitudinal  median  incision  through 
the  mucous  and  submucous  tissues  of  the  anterior  vag- 
inal wall,  extending  from  the  fornix  to  the  subure- 
thral tuberculum,  if  necessary,  and  then  two  small 
transverse  incisions,  perpendicular  to  the  first  inci- 
sion, at  each  end  of  it,  and  raises  the  square  side  flaps 
thus  formed.  He  next  sutures  the  two  attached  edges 
of  these  square  side  flaps  together,  and  reduces  the 
prolapsus,  completing  the  operation  by  suturing  the 
free  edges  of  the  flaps.  By  this  means  a  solid  foun- 
dation for  the  vaginal  wall  is  secured  and  threatening 
prolapsus  uteri  averted.  The  same  process  could  be 
applied  to  rectocele,  with  slight  variations. 


l82 


MEDICAL    RECORD. 


[August  7.  1897 


PERSONAL  EXPERIENCES  IN  LAPAROTOMY. 

Bv    M.\KV    .\.    DIXON    JONES,    .M.I).. 

My  cases  come  within  the  period  1879  to  1889.  I 
will  now  give  my  work,  all  that  I  have  attempted  or 
performed.  My  first  case  was  that  of  a  patient  brought 
me  from  Maine  by  her  husband ;  the  tubes  and  ovaries 
were  wrapped  in  a  mass  of  disease.  At  the  time 
it  occurred  to  me  that  as  these  organs  were  incurable, 
and  could  be  of  no  possible  utility,  they  should  be 
removed.  This  was  the  thought  that  forced  itself 
upon  me.  I  had  not  then  heard  of  "  Tail's  opera- 
tion" or  of  "oophorectomy."  So  entirely  engrossed 
had  I  been  with  my  own  practice  that  my  medical 
journals  were  unopened,  nor  did  I  have  time  to  think 
of  the  advance  of  surgery  in  any  direction;  but  this 
procedure  seemed  .so  right,  so  self-evident,  that  I 
should  have  proposed  it,  had  not  attention,  as  I 
learned,  been  already  called  to  it. 

I  invited  Prof.  P..  F.  Dawson  to  see  this  patient 
with  me,  and  on  the  day  of  the  operation,  imagining 
she  might  have  a  better  chance  if  Professor  Dawson 
performed  it,  I  invited  him  to  do  so,  and  he  kindly 
complied.  So  now,  when  it  comes  to  the  arithmetic 
of  statistics,  I  cannot  put  this,  my  first  patient,  on  my 
list.  Dr.  Dawson  reported  the  case  to  the  New  York 
Obstetrical  Society'  and  before  his  class  in  the  New- 
York  Post-Graduate  School,  presenting  the  specimens 
on  each  occasion. 

My  first  laparotomy  was  performed  October  18, 
1884.  The  patient  was  brought  to  me  from  Connecti- 
cut by  her  parents,  in  June,  1884.  She  had  been  an 
invalid  seven  or  more  years — once  she  did  not  leave 
her  bed  for  a  period  of  eighteen  months.  After  e.\- 
amination  I  informed  the  parents  that  I  did  not  be- 
lieve any  amount  of  treatment  would  restore  the  organs 
to  health,  and  that  nothing  would  cure  or  relieve  the 
patient  but  the  removal  of  the  hopelessly  diseased 
structures.  Still  I  advised  treatment  to  see  if  an 
operation  could  not  be  avoided,  or  at  least  to  get  the 
patient  in  better  condition.  Careful  and  continuous 
treatment  I  gave  this  patient  for  four  months;  she  may 
have  improved  somewhat  in  general  condition,  but  I 
believe  the  organs  were  growing  worse  all  the  time, 
and  in  my  report  of  the  case  I  said  the  operation 
should  have  been  performed  years  before;  and  now  I 
say  of  her,  as  I  can  say  of  many  or  most  of  the  pa- 
tients in  this  list,  that  if  she  had  not  had  the  opera- 
tion, she  would  long  since  have  been  in  her  grave. 

My  second  case  of  laparotomy  was  for  bleeding 
myoma.  The  patient  came  from  Maine  to  see  me, 
March,  1885,  and  on  May  19th  I  removed  the  uterine 
appendages.  She  made  a  most  happy  recovery.  Sub- 
sequently with  the  microscope  I  studied  carefully  the 
tubes  and  ovaries  of  this  patient,  to  see  what  path- 
ological changes  might  have  taken  place.  In  the 
tubes  I  found  chronic  interstitial  salpingitis,  and  tiie 
ovaries  were  in  acute  and  subacute  inflammation.  It 
was  in  the  ovaries  of  this  patient  that  I  for  the  second 
time  recognized  diseased  ova.  In  other  cases  of  re- 
moval of  the  uterine  appendages  for  myoma,  I  have 
made  a  thorough  study  of  the  pathological  conditions 
of  tlie  appendages,  and  in  every  instance  ha\e  found 
in  them  profound  and  chronic  disease;  so  that  I  re- 
marked, in  an  article  in  the  M~!C'  York  Medical  Jour- 
nal of  September  i,  1888,  that  in  cases  of  fibroid  of 
the  uterus  the  tubes  and  ovaries  were  always  so  dis- 
eased that  on  that  account  their  removal  was  de- 
manded; and  that  probably  this  disease  of  the  appen- 
dages caused  the  development  of  the  myoma.  Of  this 
I  have,  from  subsequent  research,  become  more  con- 
vinced. 

'  M.iy  15,  1SS3.  American  Journal  of  Obstetrics,  iS^j,  p. 
1,192. 


My  third  case  of  laparotomy  was  also  for  a  helpless 
invalid,  who  for  fifteen  years  had  been  suffering  and 
had  been  refused  admission  into  two  hospitals,  having 
been  informed  at  one  institution  that  "the  hospital 
did  not  receive  incurables.''  I  admitted  the  patient 
into  my  jjrivate  hospital.  She  made  a  most  excellent 
recovery. 

Every  patient  in  the  following  list  of  laparotomies 
has  an  interesting  history.  The  cases  are  from  my 
private  practice,  from  two  dispensary  clinics,  and  six 
patients  were  sent  me  by  physicians.  One  of  the  dis- 
pensaries referred  to  had  from  eight  to  twenty  patients 
daily,  the  other  had  from  twenty  to  forty-five:  and, 
what  is  a  singular  circumstance,  in  the  first  dispensary 
I  seldom  found  a  case  of  "  pus  tubes,"  while  in  the 
second  I  had  them  every  day,  and  have  counted  in 
one  clinic  as  many  as  seventeen  patients  with  this 
disease.  We  could  not  possibly  operate  on  all  who 
needed  operation,  so  for  my  cases  I  selected  the 
patients  who  seemed  physically  to  be  in  the  most 
serious  or  dangerous  conditions,  and  thus  it  trans- 
pired that  I,  without  understanding  the  disease,  had 
many  cases  of  endothelioma  of  the  ovary — a  disease 
which  I  was  first  to  recognize,  and  which  at  the  time  I 
submitted  to  the  kindly  consideration  of  the  medical 
profession.  Few  diseases  make  such  serious  inroads 
upon  the  .system,  cause  more  pain,  or  have  more  pro- 
nounced symptoms.  There  are  marked  emaciation 
and,  in  advanced  cases,  almost  the  cadaveric  hue  of 
cancer  or  consumption,  and  a  general  cache.xy  of  the 
system.  The  first  patient  in  whom  I  recognized  this 
disease  was  one  on  whom  I  had  operated  on  June  25, 
188^.  Dr.  Charles  Heitzmann,  in  looking  at  the  long 
protoplasmic  masses  of  this  growth,  at  first  pronounced 
it  "sarcoma,"  and  subsequently  said:  "  \Ye  shall  have 
to  term  it  either  endothelioma  or  alveolar  sarcoma." 

The  ne.xt  case  in  which  I  found  this  disease  was  that 
of  a  patient  on  whom  I  operated  for  the  removal  of 
the  uterine  appendages,  May  10,  1887  (Case  No.  23). 
This  patient  was  so  emaciated,  so  cadaveric,  that  I 
at  first  thought  she  had  phthisis,  or,  more  likely,  can- 
cer of  the  liver.  I  presented  the  uterine  appendages 
before  the  New  York  Pathological  Society  the  same 
month,  and,  subsequently,  microscopical  slides  of  the 
growth.  .\lso.  Prof.  Mitchell  Prudden,  then  president 
of  the  society,  at  my  request  took  a  small  section  from 
each  of  the  ovaries  of  this  patient,  and  had  them 
mounted  in  his  laboratory.  He  wrote  me  it  was  "car- 
cinoma," al.so  sending  a  slide  so  labelled.  I  sent  a 
microscopical  slide  of  these  ovaries,  mounted  by  Dr. 
Louis  Heitzmann,  to  Professor  Waldeyer,  of  Berlin. 
He  replied,  Octolser  18,  1887,  that  "the  growth  is 
carcinoma:"  and  certainly,  in  studying  the  minute 
anatomy  of  this  growth  I  could  readily  believe  it  might 
be  some  foim  of  cancer.  I  am  still  more  impressed 
with  this  when  1  see  the  elTects  of  the  disease  upon 
the  system,  as  I  said  in  an  article  in  the  TVW.:'  York 
MiiUi-al  Joiinial,  September,  i88g:  "When  we  look 
at  this  rapidly  grow  ing  formation  and  the  great  masses 
of  granules,  the  impression  forces  itself  upon  us  that 
it  may  be  malignant.  Future  investigation  may  prove 
it  so.  The  cancer  epithelia  do  not  multiply  more  rap- 
idly, or  destroy  the  tissues  more  surely,  or  seem  more 
threatening  or  monstrous  in  their  appearance  and 
growth." 

While  in  this  list  I  have  included  all  my  case.s  of 
laparotomy,  whether  for  splenectomy,  hysterectomy,  or 
ovariotomy,  yet  most  of  the  operations  were  for  the 
removal  of  "diseased  uterine  appendages."  Some 
eminent  surgeons,  as  they  have  thought  proper,  have 
removed  the  uterine  appendages  for  "ovaralgia,"  "dys- 
menorriuta,"  and  various  nerve  conditions:  but  I 
never  could  accept  this  idea.  I  have  all  the  time  main- 
tained that  whatever  might  be  the  symptoms,  local  or 
constitutional,  the  tubes  and  ovaries  should  not  be  re- 


August  7,  1897] 


lEDICAL    RECORD. 


183 


moved  except  for  profound  disease  of  the  organs  them- 
selves, when  they  are  incapable  of  being  restored  to 
health,  and  when  their  remaining  becomes  a  positi\e 
injury  to  the  system.  I  said  in  1888,'  and  now  repeat: 
"  I  have  never  operated  on  a  case  but  I  had  full  and 
substantial  reasons  to  diagnose  incurable  disease  of 
the  appendages:'"  in  the  same  article  declaring:  ""1 
would  not  remove  the  uterine  appendages  for  menial 
or  neurotic  diseases  unless  I  believed  the  appendages 
were  diseased,"  and  the  disease  absolutely  demanded 
their  removal.  I  have  even  hesitated  in  some  instances 
to  remove  the  uterine  appendages  when  they  were  pro- 
foundly diseased,  and  when  there  were  indications 
even  apparently  necessitating  an  immediate  operation. 
A  patient,  twentj'-three  years  old,  entered  the  Woman's 
Hospital,  July  5,  1887.  One  ovary  was  enlarged  to 
the  size  of  a  small  orange  and  bound  in  on  all  sides 
by  adhesions;  the  tubes  gave  evidence  of  pyosalpin- 
gitis.  But  this  patient  had  had  a  child  thirteen 
months  before  I  If  these  organs  are  capable  of  these 
functions,  why  not  leave  them?  Any  one  might  have 
known  that  with  conditions  e.xisting  as  they  were  in  this 
woman  it  was  impossible  for  conception  to  take  place: 
but  I  wanted  to  give  her  the  millionth  part  of  a  chance, 
so  sincerely  do  I  congratulate  a  woman  who  has  chil- 
dren. The  patient  was  in  the  hospital  forty-si.x  days 
and  everj'thing  \\  as  done  to  improve  her  condition  :  she 
seemed  in  many  respects  much  better  and  compara- 
tively comfortable,  so  on  the  20th  of  August  I  dis- 
missed her  from  the  hospital  and  sent  her  home.  As 
soon  as  she  commenced  to  be  on  her  feet  and  go 
around,  she  realized  that  her  sufferings  were  just  the 
same,  and  just  as  intolerable.  She  returned  to  the 
hospital  three  days  afterward,  and  again  begged  that 
the  operation  might  be  performed.  In  due  time  it 
was  done.  This  is  Case  No.  t,^.  The  patient  was 
in  a  dangerous  condition,  and  should,  when  fir^t  in 
the  hospital,  have  been  operated  upon  without  delay. 
Not  only  was  there  destructive  disease  of  the  tubes, 
but  a  blood  cyst  in  the  left  ovary  was  in  immediate 
danger  of  rupturing,  with  possibly  fatal  results,  lie- 
sides,  to  show  still  more  plainly  how  futile  was  the 
delay,  every  ovum  in  both  of  her  ovaries  was  in  help- 
less ruin. 

Another  patient  to  \\hom  I  tried  in  the  same  way  to 
give  the  possibility  of  a  chance — subsequent  events 
proving  it  was  quite  as  useless — entered  the  \\"oman's 
Hospital  of  Brooklyn,  March  21,  1888.  Hoping  to 
save  the  tubes  and  ovaries,  I  gave  her  special  local 
and  constitutional  treatment.  She  improved,  and  we 
dismissed  her  April  17,  1888.  After  returning  home 
she  realized  that  her  trouble  was  still  there,  and  of 
her  own  accord  she  returned  to  the  hospital  in  four 
days,  and  again  requested  that  the  diseased  orgall^  be 
removed.  This  is  Case  No.  59.  In  this  instance 
also  I  realized  that  it  was  not  only  a  useless  but  a 
dangerous  delay. 

In    September,    1888,    Dr.    1! ,    of    Bridgeport, 

Conn.,  brought  a  young  woman,  twenty-six  years  old, 
married  three  years,  and  without  children,  in  my 
report  of  this  case,  in  the  Pittshiirg  Medical  A'<-7-inc'.' 
October,  1889,  I  said:  "It  seemed  so  extremely  sad 
for  one  so  young  and  so  lately  married  to  be  deprived 
of  all  chance  of   the  sacred  privilege  of  motherhood, 

that  I  suggested  to  Dr.  B that  the  patient  return 

home  and  have  the  cervix  dilated  and  the  anteflexion 
corrected,  and  thus  give  her,  if  possible,  a  ciiance." 
The   patient   at   once  objected   to   any  delay,  insisted 

I  upon  immediate  relief,  and  the  physician  added: 
"Treatment  has  been  tried."  This  is  Case  No.  69. 
There  was  immediate  demand  for  the  operation.  The 
pathological  conditions  showed  that  it  should  have 
I 


'  American  Journal  of  Obstetrics,   February.   iSSS.  p.   15'- 
'  Page  301 . 


been  done  without  delay,  even  before  the  time  the 
patient  visited  me. 

In  every  case  that  I  have  operated  on  I  have,  in 
studying  the  pathological  specimens  removed,  become 
more  impressed  that  not  only  was  there,  in  each  in- 
stance, a  necessity  for  the  operation,  but  in  each  one 
it  should  have  been  done  at  an  earlier  period  than  it 
was  performed.  The  great  danger  in  these  conditions 
is  delay;  and  this  delay  is  an  injustice  and  a  loss  to 
the  patient.  As  to  delaying  these  operations  for  a 
possible  conception,  in  every  one  of  these  patients,  as 
was  subsequently  demonstrated,  all  capability  of  any 
physiological  functions  of  the  tubes  and  ovaries  was 
destroyed  by  the  existing  disease ;  and  in  every  one 
this  complete  destruction  was  still  further  emphasized 
by  finding  in  the  ovaries  of  each,  as  far  as  examined, 
only  diseased  and  ruined  ova. 

In  some,  even  of  young  women,  I  found  complete 
destruction  of  these  important  structures,  not  one  egg 
in  either  ovary;  thus  giving  new  proof  of  and  new 
insight  into  what  I  said  in  1886,'  and  repeated  Sep- 
tember 28,  1889:'  "The  disease  that  caused  the 
suffering  has  also  produced  a  profound  sterility." 
.\fter  careful  study  into  the  pathology  of  every  speci- 
men I  have  removed,  I  again  repeat,  as  was  my  im- 
pression on  the  first  examination  of  the  various  pa- 
tients, that  not  only  was  there  a  necessity  for  the 
operation,  and  that  in  each  case  the  operation  should 
have  been  done  at  an  earlier  period,  but  in  every  in- 
stance, as  I  told  the  patient,  there  was  no  capability 
or  possibility  of  conception.  My  stereotyped  expres- 
sion, repeated  to  many,  was :  "  With  or  without  the 
operation,  you  can't  have  children."  The  operations 
were  done  to  save  life,  and  if  possible  to  restore  to 
health  and  active  usefulness. 

Of  all  the  cases,  there  were  of  pyosalpingitis  sev- 
enty-nine. Not  only  did  the  tubes  contain  pus,  but 
their  walls,  as  I  afterward  demonstrated,  were  more 
or  less  destroyed  by  suppurative  inflammation.  The 
ovaries  were  equally  diseased.  These  all  involved 
difficult  and  dangerous  operations. 

There  were  two  operations  for  cystoma,  or  ovarioto- 
my. Probably  these  were  the  least  difficult  of  all  the 
operations  in  the  list;  even  the  removal  of  a  cystoma 
that  contained  over  sixty  pounds  of  fluid  (Case  No.  89) 
was  in  no  way  a  difficult  operation  and  was  performed 
with  great  ease  and  celerity.  Yet  a  writer  uses  this 
expression:'  "I  have  long  entertained  the  opinion 
that  ovariotomy  is  the  most  difficult  operation  in  the 
whole  field  of  surgery."  I  must  dift'er  from  the  writer, 
for  I  have  long  maintained  the  belief  that  ovariotomy 
generally  is  one  of  the  least  difficult  operations  of 
abdominal  surgerj'.  Duncan  says:'  "It  cannot  be 
too  strongly  enforced  that  removal  of  the  appendages 
for  chronic  disease  is,  in  most  cases,  much  more  diffi- 
cult than  performing  ovariotomy."  Dr.  G.  Bantock 
says:'  "Difficulties  far  exceeding  those  of  nine  out 
of  ten  of  the  ordinary  run  of  ovariotomy."  Sir  Spen- 
cer Wells  on  the  same  occasion:  "It  is  more  difficult 
than  ordinary  ovariotomy."  Dr.  .\.  Martin,  of  Berlin: 
"The  operation  is  not  only  difficult,  but  dangerous." 
Lawson  Tait:  "  It  is  in  almost  all  instances  a  difficult 
operation,  sometimes  one  of  exceeding  difficult)."  Dr. 
L.  S.  McMurtry"  gives  his  testimony:  "To  remove  pus 
tubes  and  adherent  ovaries  is  among  the  most  severe 
tasks  of  operative  surgery."  And  Dr.  Thomas  Keith, 
nearly    thirty     years     before,    said :      "  There    is    no 

'  .Medical  Record,  August  21.  1SS6. 

'  New  York  Medical  Journal.  September  28,  iSSg. 

'A.  J.  C.  .Skene:  Proceedings  of  the  .Medical  Society  of  the 
County  of  Kings,  June,  1SS3,  p.  222.  "  Diseases  of  Women." 
p.  510,  18S8. 

*  British  ^[edical  Journal,  p.   104. 

'  Transactions  of  the  International  Congress.  i88i. 

*. Southern  Surgical  and  Gynaecological  Transactions,  1SS9,  p. 
202. 


MEDICAL    RECORD. 


[August  7.  1897 


mystery  in  ovariotomy;    it    is    not  a  difficult  opera- 
tion." 

But  certainly  there  is  often  great  difficulty,  and  mys- 
tery too,  in  leading  out  diseased  uterine  appendages 
from  a  complexity  of  dense  adhesions.  So  difficult  is 
this  that  Dr.  Thomas  Savage,  of  Birmingham,  said  ' 
that  in  five  of  his  forty  cases  he  was  unable  to  do  any- 
thing beyond  the  simple  abdominal  section,  on  ac- 
count of  the  strength  and  character  of  the  adhesions; 
adding:  "In  others  1  was  obliged  to  leave  behind  a 
part  of  one  ovary  at  least."  Dr.  C.  E.  Penrose,  in 
reporting  eleven  cases,  remarked:  "In  one  case  I 
found  it  impossible  to  remove  the  left  tube  and  ovary, 
they  were  so  firmly  adJierent."  A  similar  record  has 
been  made  by  many  great  surgeons. 

In  this  list  there  was  one  case  of  cancer.  No.  55, 
carcinoma  on  the  floor  of  the  pelvis,"  and  the  can- 
cerous material  had  infiltrated  the  tubes  and  ovaries. 
At  the  time  of  the  operation,  March  19,  1888,  so 
convinced  was  I  of  the  malignancy  of  the  disease  and 
the  hopelessness  of  the  case,  that  immediately  I  in- 
formed the  husband  that  ths  patient  probably  would 
not  live  three  days.  But  she  did  so  well  and  made  so 
good  a  recovery  that  I  dismissed  the  idea  of  malig- 
nancy until  the  following  December,  when,  in  due 
course,  studying  the  pathology  of  this  specimen,  I  found 
that  it  was  not  only  cancer,  but  cancer  of  the  most  ma- 
lignant type.  In  the  specimen  there  were  really  three 
forms  of  cancer — scirrhous,  adenoid,  and  medullar)'. 

Further,  in  studying  this  pathological  specimen,  it 
was  seen  for  the  first  time  and  clearly  demonstrated 
that  the  indifferent  or  medullar)'  corpuscles  were 
changing  to  large  polyhedral  epithelia,  and  forming 
cancer  nests.  This  change  of  inflammator)- corpuscles 
to  cancer  epithelia  had  never  before,  so  far  as  I  know, 
been  observed  or  mentioned.  It  was  a  startling 
thought. 

Also  in  this  sjjecimen  there  was  revealed  the  inter- 
esting fact  that  the  lymph  vessels  carry  the  cancer  epi- 
thelia. This  had  long  been  supposed  to  be  the  case, 
but  so  far  as  I  know  had  never  before  been  verified  or 
demonstrated.  Under  high  powers  of  the  microscope 
the  lymph  vessels  were  clearly  seen  to  be  largely  di- 
lated and  carrying  their  burden  of  cancer  epithelia. 
It  was  a  revelation  ! — marvellous! — to  see  these  vessels 
so  crowded  and  so  infinite  in  number! 

Another  fact  to  be  noted :  This  patient  had  suffered 
for  years  with  the  continued  distress  and  irritation  of 
diseased  uterine  appendages.  If,  ten  years  previously, 
these  organs — even  then  profoundly  diseased — had 
been  removed,  the  unfortunate  woman  might  have  been 
saved  not  only  the  infection  of  her  system  from  the 
diseased  tubes  and  ovaries,  but  the  subsequent  devel- 
opment of  cancer. 

Dermoid  cysts,  one  case  (No.  34).  This  was  one 
of  the  most  difficult  and  dangerous  of  the  whole  list 
of  operations.  The  case  was  reported  to  and  the  spec- 
imens were  presented  before  the  New  York  Pathologi- 
cal Society,  September  28,  1887.  Dr.  William  Goodell 
said:"  "In  my  experience  dermoid  cysts  are  very  apt 
to  have  firm  and  extensive  attachments,  which  make 
their  removal  far  from  easy."  Dr.  Thomas  Keith 
reports  a  dermoid  cyst;'  so  far  as  I  could  make  out 
the  conditions,  they  were  very  similar  in  every  respect 
to  those  in  my  case — ovaries  in  each  universally  ad- 
herent. The  operation  performed  by  Dr.  Keith  lasted 
three  and  one-half  liours,  and  the  patient  died  thirtv- 
six  hours  later.  In  my  case  of  dermoid  cyst  the  jia- 
tient  made  a  rapid  recovery,  and  subsequently  liad 
good  health. 

■|"he  number  of  cases  of  abscesses  of  or  connected 

'  liriiish  Medical  Journal,  October  19.  1S7S,  p.  fijo. 

'  Mi;i>K\i,   Rf.coru,  March  11,  1S93. 

''  Medical  News,  March  11,  1SS5,  p.  316. 

*  liri'ish  Medical  Journal,  October  19,  1S7S,  p.  591. 


with  the  ovaries  was  twenty-eight.  Dr.  La%\bon  Tait 
said:  "  In  a  majority  of  instances  probably  death  oc- 
curs from  the  rupture  of  the  abscess  into  the  perito- 
neum." He  reports'  one  case  before  the  British 
Gyna;cological  Society,  and  says:  "Operation  ex- 
tremely difficult,  and  hemorrhage  severe." 

Intraligamentous  cysts,  one  case  (No.  62).  Dr. 
Goodell  says:"  "  Intraligamentous  cysts  present  griev- 
ous complications,  which  tax  the  pluck  and  skill  of 
the  operator  to  the  utmost."  Dr.  Paul  F.  Munde  says:' 
"They  are  to  me  the  most  formidable  tumors  of  the 
uterine  appendages;  three  out  of  five  deaths  after  lapa- 
rotomy occurred  in  intraligamentous  cvsts."  My  pa- 
tient (No.  62J  made  a  rapid  recovery. 

Endothelioma,  twenty-two  cases.  This  is  a  more 
frequent  and  a  more  serious  disease  than  many  imag- 
ine, not  only  causing  much  suft'ering  but  being  destruc- 
tive to  health.  I  believe  an  untold  number  of  women 
have  died  from  this  disease  or  from  the  complications 
arising  therefrom. 

Of  haimatoma,  the  outcome  of  endothelioma,  there 
are  ten  cases.  Dr.  Howard  Kelly,  before  the  Obstetri- 
cal Society  of  Philadelphia,'  e.xhibited  a  specimen  of 
ha;matoma  of  the  ovarj'  with  adherent  Fallopian  tubes, 
remarking:  "The  hematoma  is  about  the  size  and 
shape  of  a  large  Spanish  chestnut.  The  indications 
for  operative  interference,  after  I  had  made  my  diag- 
nosis, were  greater  than  in  the  case  of  any  large  ova- 
rian cyst  I  have  ever  seen,  and  the  prospects  arn  re- 
sults of  any  form  of  palliation  were  futile.  Almost 
the  whole  of  this  large  ovary  is  filled  with  a  blootly 
cyst."  Dr.  A.  P.  Dudley  reported  to  the  New  Vork 
Pathological  Society"  a  hematoma  of  the  ovar)-,  occupy- 
ing nearly  the  entire  organ,  for  which  previous  to  its 
removal  he  had  "  for  a  year  adopted  ever)-  varietv  of 
general  internal  treatment,  with  external  applications, 
but  the  woman  was  not  in  the  least  relieved."  Dr. 
Boldt  has  reported  a  rupture  of  ha-matoma,  or  blood 
cyst,  and  states  that  but  for  immediate  operation  death 
would  have  ensued.  Dr.  R.  H.  Reed  says:'  "Early 
siygical  relief  is  the  only  safe  and  reliable  course  of 
treatment."  Dr.  R.  A.  Murray  reported  a  hematoma 
of  both  ovaries,"  saying:  "There  was  an  extreme 
amount  of  adhesions,  which  rendered  the  operation 
most  difficult,  prolonging  it  three  hours." 

Gyromatous  cysts,  eight  cases.  Gyroma  is  another 
disease  which  I  was  first  to  recognize.  These  cysts 
have  hard,  firm  walls,  sometimes  in  waxy  degenera- 
tion, or  in  intense  inflammation,  or  again  are  being 
reduced  to  firm  fibrous  connective  tissue —  in  anv  s-taie 
necessarily  compressing  delicate  nerve  fibre,  and  giv- 
ing rise  to  various  neuroses  and  reflex  irritations." 
As  I  said  in  the  AV?4'  I  c/X-  MedUal  Jonninl,  May 
10,  1890:  "The  irritation  of  these  hard,  firm  growths 
amid  the  delicate  tissues  of  the  ovary  not  only  causes 
pain,  but,  if  anything  would  produce  cancer  of  the 
ovary,  the  continued  irritation  of  these  nodular  masses 
would  seem  to  be  sufficient." 

Blood  cysts,  also  the  outcome  of  endothelioma, 
twelve  in  number.  From  their  nature,  growth,  and 
mode  of  development,  blood  cysts  are  most  serious 
conditions,  constantly  causing  great  pain  and  distress, 
and  ever  there  is  an  increasing  danger  of  their  ruptur- 
ing into  the  i:)eritoneal  cavity,  possibly  with  fatal  re- 
sults. 

In  every  case  of  blood  cyst  that  I  iiave  had.  1  have 
carefully  examined  with  the  microscope  all  other 
portions  of  the  ovary,  and  in  every  instance  have 
found  all  profoundly    diseased,  no  normal    tissue  in 

'  Hritish  Metlical  Journal.  May  S,  1SS6. 

■  Medical  Ne«-s.  Januar)-  29,  1SS7. 

■  .\nierican  Journal  of  (.ibstetrics.  lanuary,  iSSS. 

'■  Kebruarj-  4.  iSSd.  ■'  October  26,  1S87. 

'  Cincinnati  Lancet-Clinic.  January  28,  1S90.  p.  77;. 
'  M  KKICAL  KKa>RI).  January  iS,   1S89,  p.  79. 
'  .■\nicrican  Journal  of  Obstetrics,   Kebruan',  iSSS. 


August  ;,  1897] 


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MEDICAL    RECORD. 


191 


any  part;  and  invariably  I  JTave  found  destruction  of 
the  ova. 

Removal  of  the  uterine  appendages  for  internal 
myoma,  four  cases.  All  made  a  good  recovery.  Law- 
son  Tait  says'  that  the  cases  in  which  he  has  removed 
the  uterine  appendages  for  myoma  were  twenty-five  in 
number,  with  four  deaths;  and  one  death  in  an  in- 
complete operation,  making  in  all  five  deaths. 

Hysterectomy  for  myoma  of  the  uterus,  four  cases. 
The  first  total  hysterectomy  ever  perfonned  in  this 
country  for  myoma  was  Case  No.  52.-  The  tumor 
weighed  fourteen  pounds  after  its  removal.  The  pa- 
tient was  able  to  be  up  on  the  twelfth  or  thirteenth  day, 
and  she  sufifered  infinitely  less  than  if  the  pedicle  had 
been  treated  intraperitoneally  or  e.xtraperitonealh-. 
Dr.  T.  A.  Emmet  says;'  '"To  remove  the  uterus  when 
enormously  enlarged  by  a  fibroid  tumor  is  unquestion- 
ably one  of  the  most  formidable  operations  a  surgeon 
can  be  called  upon  to  undertake."  Dr.  Lawson  Tait 
says:'  ■'  Hysterectomy  for  fibroid  is  the  most  ghastly, 
serious,  and  difficult  operation  in  the  whole  realm  of 
abdominal  surgery."  Dr.  C.  D.  Palmer  says  :°  '"  There 
are  no  operations  within  the  domain  of  surgery  more 
grave;"  "the  dangers  to  be  encountered  are  the  great- 
est within  the  range  of  pelvic  surgery." 

By  entire  hysterectomy  the  operation  is  relieved  of 
many  of  its  difficulties,  and  especially  is  free  from  the 
many  dangers  of  the  pedicle  treated  intra  or  extra 
peritoneal  ly. 

In  this  list  there  were  adhesions  in  eighty  cases. 
Dr.  Joseph  Price  says:"  "Adhesions  constitute  the 
surgeon's  greatest  difficulty."  Sir  Spencer  Wells 
said,  January  4,  1862,  that  he  looked  upon  pelvic  adhe- 
sions as  one  of  the  most  serious  indications  against 
ovariotomy.  Dr.  Peaslee  said:'  "Adhesions  com- 
promise the  result  of  ovariotomy."  Krichsen  said:' 
"  They  undoubtedly  are  a  serious  obstacle  to  the  suc- 
cess of  an  operation." 

In  a  few  of  my  patients  hernia  developed  subse- 
quently to  the  operation,  but  in  everj-  instance  this 
was  in  hard-working  women,  who  after  leaving  the 
hospital  commenced  at  once  their  heavy  labors.  One, 
No.  24,  did  the  household  work  and  washing  for  a 
family  of  eight  persons,  and  sometimes  took  in  the 
w-ashing  for  a  boat's  crew.  If  these  women  had  taken 
one-tenth  of  the  care  and  precaution  that  a  certain 
physician  did  after  undergoing  laparotomy  for  appen- 
dicitis they  would  have  been  in  no  danger  of  hernia. 

Dr.  Bantock  says:'  "Cases  of  hernia  after  o\ari- 
otomy  are  by  no  means  rare."  Joseph  Price  says:'" 
"Hernias  cannot  always  be  avoided,  and  they  are  not 
among  the  avoidable  sequelae." 

Many  or  most  of  the  operations  mentioned  in  tiiis 
list  were  so  dangerous  that  I  often  marvelled  that 
the  patients  did  so  well  or  made  so  rapid  a  recov- 
ery. At  the  same  time  I  am  infinitely  grieved  that 
any  patient  under  my  care  died  subsequently  to  oper- 
ation;  but  in  every  instance  of  a  fatal  termination 
there  were  indications  that  even  without  the  operation 
there  would  soon  have  been  the  same  result.  Some  of 
the  cases  were  undertaken  as  a  forlorn  hope.  Case 
No.  49  was  one  of  a  large  pelvic  abscess  and  abscesses 
all  through  the  peritoneum  ;   the  case  was  fatal  before  it 

'  New  Kngland  Medical  Monthly,  May  18,  1S82,  p.  336. 

''  Annals  of  (lynx-cology  and  Pajdiatry,  June,  1S95,  p.  573. 
Monatschrift  fUr  Geburtshilfe  und  Gynak.  New  York  Academy 
of  Medicine,  section  for  gyna;cology  and  obstetrics,  March  2S, 
1895. 

'  "  Diseases  of  Women." 

■*  American  Journal  of  Obstetrics,  May,  1886,  p.  .486. 

'  Transactions  of  American  Gynaecological  Society.  1880,  p. 
361. 

'  Annals  of  Gyn<Teco!ogy.  August.  l83S. 

'  Peaslee,  p.  346. 

"Lancet,  January.   1S65. 

'  British  Medical  Journal.  July  12,  l38o. 

'"  Medical  News,  May  31,  iSqo. 


was  touched,  as  was  also  the  case  of  the  colored  woman 
(No.  12),'  who  was  brought  to  the  hospital  with  septic 
peritonitis.  Equally  fatal  beforehand  was  the  case  of 
splenectomy  (No.  46).  Dr.  Charles  Heitzmann  said, 
before  the  operation,  from  his  examination  of  the 
urine,  that  "there  is  an  abscess  in  one  kidney, 
which  abscess  opens  into  the  descending  colon."  Be- 
sides, the  spleen  gave  evidence  of  malignancy.  It 
was  foully  diseased  in  ever)-  part.  Even  under 
the  most  favorable  circumstances  removing  the  spleen 
is  a  very  dangerous  operation.  In  1886  there  had 
been  in  Great  Britain  twelve  splenectomies,  and  they 
were  all  fatal;  T.  Bryant,  of  Guy's  Hospital,  had  two 
subjects,  both  of  whom  died  from  the  operation;  and 
Billroth,  in  Vienna,  had  performed  the  operation 
thrice,  each  time  with  a  fatal  result.  The  first  suc- 
cessful case  in  Great  Britain  was  that  of  J.  Knowsley 
Thornton."  The  patient  was  a  girl,  nineteen  years 
old;  the  spleen  weighed  one  pound  eleven  ounces — so 
small  that  Dr.  Thornton  supposed  it  was  the  left  kid- 
ney. The  spleen  of  my  patient  weighed  nearly  eigh- 
teen pounds,  and  enlarged  the  abdomen  to  enormous 
proportions.  There  was  not  the  least  chance  for  the 
patient;  but  she  begged  to  have  the  operation  per- 
formed, hoping  that  in  this  last  resort  she  might  find 
relief.  As  Dr.  John  Homans"  says:  "A  surgeon  is 
bound  at  times  to  operate  in  cases  in  which  he  can 
give  but  little  hope  of  a  favorable  result." 

All  three  of  these  ca,ses  might  be  called  "  exploratory 
incisions."  Now,  if  I  should,  as  some  have  done,  give 
only  my  "completed  operations,"  this  would  take  off 

Mrs.  Bates,  Mrs.  E ,  and  Mrs.  Bruggeman,  and  my 

mortality  would  thereby  be  reduced  to  about  2.5  or  3 
per  cent.  Then,  on  the  same  principle  I  could  exclude 
one  or  two  cases  that  died  in  consequence  of  specific 
constitutional  disease,  which  is  foreign  to  the  opera- 
tion and  is  far  more  formidable  than  acute  sepsis. 
Acute  sepsis  may  be  relieved  by  full  action  of  the 
bowels,  but  the  freest  evacuations  have  no  effect  upon 
this  chronic  mysterious  poison.  I  believe  this  specific 
constitutional  disease,  syphilis,  has  been  the  hidden 
enemy  that  has  increased  the  death  rate  of  many  a  sur- 
geon. 

In  Case  No.  86  the  patient  had  a  blood  cyst,  but  it 
was  not  so  dangerous  or  so  complicated  as  were  the 
blood  cysts  of  patients  Nos.  10,  90,  and  94;  nor  was 
this  patient  in  .so  weak,  dangerous,  or  precarious  a 
condition  as  were  manv  patients  in  this  list;  and  in  no 
respect  was  it  half  so  difficult,  half  so  .serious  or  dan- 
gerous an  operation  as  were  Nos.  29,  34,  52,  and 
many  others,  or  even  Nos.  83,  84,  and  85,  who  hap- 
pened to  be  in  the  hospital  the  same  time.  All  these 
patients  made  a  good  recovery,  and  had  subsequently 
excellent  health:  but  No.  86  had  the  specific  con- 
stitutional disease,  and  though  everything  was  done, 
every  care  and  precaution  known  to  the  best  surgeons 
in  this  country  or  in  Europe  were  taken,  and  though  her 
physicians  were  with  her  night  and  day,  studying  and 
doing  everything  for  her  recovery,  yet  she  succumbed 
— died  on  the  sixth  day  of  some  kind  of  blood  poison- 
ing. I  do  not  believe  any  propo.sed  preparation  or 
procedure  could  have  saved  her.  Her  death  was,  I 
belie\e,  entirely  due  to  this  mysterious  blood  poison, 
this  specific  constitutional  taint  of  syphilis. 

Though  there  were  losses,  yet  by  the  various  opera- 

'  This  case  was  very  similar  to  the  one  presented  by  Prof.  W. 
T.  Lusk  before  the  New  York  Obstetrical  Society,  October  21, 
1879 — general  peritonitis,  oophoritis,  abscesses.  Dr.  Lusk  did 
not  do  an  operation,  but  tlie  patient  died  just  the  same.  As  Dr. 
Noeggerath  wisely  said  :  "The  primary  disease  was  a  double  sal- 
pingitis." So  the  primary  disease  in  my  case  was  a  double  sal- 
pingitis. 

-  Medico-Chirurgical  Transactions.  1SS6,  page  408.  Transac- 
tions of  Royal  Medico-Chirurgical  Society,  new  series,  vols.  i. 
and  ii.,  p.   103. 

^  Boston  Medical  and  Surgical  Journal.  January  20,  1881,  p. 
50. 


192 


MEDICAL    RECORD. 


[August  7,  1897 


tions  in  this  list  many  valuable  lives  were  saved; 
many  patients  were  restored  to  health  who  would 
otherwise  have  been  hopelessly  lost.  Dr.  L.  S.  Pilcher 
wrote  in  1892  a  paper  on  "The  Ultimate  Results  of 
Operations  for  Removal  of  the  Uterine  Appendages," 
referring  to  the  possible  "persistence  of  pain,"  the 
possible  development  of  "hernia,"  of  "faecal  and 
urinary  fistula,"  and  the  possible  sequelae  of  "  mental 
disturbances." 

None  of  these  sequela;  need  follow.  In  cases  in 
which  the  conditions  demand  an  operation,  there  is 
usually  an  entire  relief  of  the  pain  ;  and  in  no  instance 
have  I  seen  an  operation  followed  by  mental  disturb- 
ances, when  similar  mental  disturbances  or  abnormal 
mental  conditions  did  not  previously  exist,  and  in  a 
more  exaggerated  form  or  degree.  So  in  proper  cases 
I  am  prepared  to  assert  that  "the  ultimate  results  of 
the  removal  of  the  uterine  appendages"  are:  Many 
Jives  are  saved  ami  counticss  iiinnlicrs  arc  redeemed 
from  lieipless  invaiidisv!.  Many  who  do  not  recover 
would  probably  soon  die  from  existing  causes.  Prof. 
William  T.  Lusk  said:'  "The  operation  of  remov- 
ing the  uterine  appendages  has  been  the  means  of 
liberating  many  women  from  persistent  suffering,  and 
has  perhaps  saved  many  others  from  death."  Dr. 
Joseph  Eastman  says:'  "Some  argue  that  the  opera- 
tion is  being  done  too  often.  My  limited  experience 
induces  me  to  believe  that  where  the  uterine  appen- 
dages have  been  unnecessarily  removed  once,  ten 
women  have  gone  down  to  the  grave  whose  lives  could 
have  been  saved  by  timely  removal  of  the  uterine 
appendages." 


DIAGNOSIS    AND    TREATMENT    OF    AFFEC- 
TIONS   OF   THE   FRONTAL    SINUSES.' 

By    F.    FEHLEISEN,    M.D., 

SAN    FRANCISCO,    CAI..    (LATK    OT'    I'.r-:KI.1N). 

The  diseases  of  the  frontal  sinuses  offer  us  an  inter- 
esting and  many-sided  picture,  and  only  to  outline  the 
same  and  merely  to  mention  the  many  mistakes  in 
diagnosis  made  by  physicians  familiar  with  the  sub- 
ject would  force  me  far  beyond  the  limits  of  this 
paper.  Therefore  I  shall  only  briefly  name  the  chief 
kinds  of  sinus  affections,  dwelling  somewhat  more  at 
length  on  a  diagnostic  point  of  considerable  import- 
ance, and  finally  discuss  the  great  advances  made  in 
the  treatment  during  the  last  few  years. 

In  the  large  majority  of  cases  frontal-sinus  affec- 
tions are  caused  by  infection.  The  inflammation  fre- 
quently spreads  from  the  nose  to  the  frontal  sinus. 
However,  primary  inflammations  (usually  acute)  of 
the  frontal  sinus  may  occur  with,  or  more  rarely  with- 
out, simultaneous  disease  of  the  nasal  cavities.  The 
former  is  the  case  with  simple  coryza,  the  latter  with 
certain  infectious  diseases,  especially  with  measles, 
scarlet  fever,  diphtheria,  typhoid,  pneumonia,  influ- 
enza, etc.  Also  .syphilis  of  the  nasal  cavities  can  ex- 
tend to  the  frontal  sinus. 

One  differentiates  according  to  the  kind  of  infection 
the  following  forms:  sinusitis  catarrhalis,  blennorrho- 
ica,  and  pyorrhoica,  and  an  encapsulated  empyema  of 
the  frontal  sinus.  No  strict  line  can  be  drawn  between 
these  different  forms,  as  generally  a  mixture  of  mucus 
and  pus  and  often  blood  also  is  found.  Frequentlv 
thickened  crumb-like  masses  occur.  The  difference  in 
the  clinical  pictures  is  chiefly  influenced  by  the  more 
acute  or  chronic  course  of  the  disease.  The  more  acute 
cases  begin  with  high  fever,  sometimes  even  a  chill, 
followed    by    severe    constitutional    symptoms.     The 

'  New  York  Academy  of  Medicine,  March  6,  1S90.       -'  Ibid. 
^  Read  before  the  Society  of  German  I'hysicians,  .San  Francisco, 
Cal.,  .September  2,  1896. 


sensorium  is  not  clear.  Soon  perforation  occurs,  as  a 
rule  in  the  anterior  and  inferior  wall,  and  an  eyelid 
or  orbital  phlegmon  results.  Very  rarely  it  opens 
posteriorly  toward  the  cranial  cavity.  The  mucous 
membrane  of  the  sinus  is  in  such  cases  frequently 
colored  black  and  is  gangrenous,  and  the  exudate 
ichorus  or  purulent.  Between  these  very  acute  cases 
and  the  chronic  ones,  some  of  which  have  lasted  for 
years  and  whose  actual  beginning  cannot  be  deter- 
mined, there  are  many  intermediate  forms.  The  most 
frequent  are  the  chronic  forms,  the  purely  chronic  as 
well  as  those  whose  course  is  interrupted  by  subacute 
attacks.  There  are  suppurative  cases  which  show  no 
other  symptoms  except  a  flow  of  pus  on  one  side  of 
the  nose,  lasting  for  years,  and  sometimes  an  occlu- 
sion of  the  nose  accompanied  by  frequent  headaches 
with  more  or  less  dizziness.  In  encapsulated  empy- 
ema, which  can  also  de\elop  slowly,  the  flow  of  pus  is 
of  course  absent,  but  the  headaches  are  more  pro- 
nounced. Often  such  patients  first  come  under  obser- 
vation when  in  connection  with  a  common  coryza  an 
exacerbation  has  set  in,  and  the  process  suddenly  as- 
sumes a  more  or  less  acute  character.  Other  common 
forms  have  a  inore  acute  beginning.  In  connection 
with  a  coryza  a  mild  sinusitis  catarrhalis  with  slight 
symptoins  develops.  With  the  disappearance  of  the 
swelling  in  the  nose,  the  swollen  ductus  nasofrontalis 
opens  again,  the  secretions  flow  off,  and  the  patient 
feels  well.  But  every  new  catarrh  is  followed  by  an- 
other attack  of  acute  or  subacute  inflammation  of  the 
frontal  sinus.  After  a  time  the  inflammation  no  longer 
wholly  disappears  and  chronic  disease  of  the  sinus  re- 
sults. This  terminates  in  one  of  two  ways.  Either 
the  attacks  become  more  severe  and  the  complaints 
greater,  even  between  two  exacerbations,  and  in  time  a 
pyorrhcea  or  an  encapsulated  empyema  occurs,  accord- 
ing to  whether  the  outlet  becomes  pervious  between 
the  attacks  or  not;  or  it  may  happen  that  when  the 
outlet  is  permanently  closed  the  attacks  become  less 
and  less  severe  and  finally  cease.  In  this  case  the 
patient  believes  himself  cured,  until  at  some  future 
period  a  swelling  near  the  root  of  the  nose,  toward  the 
orbit  of  the  eye,  is  noticed,  or  disturbances  of  vision 
send  him  to  the  oculist.  The  sinusitis  catarrhalis  be- 
comes a  mucocele,  which,  unlike  the  empyema,  gives 
no  discomfort  to  the  patient,  until  either  the  in- 
creasing bulging  of  the  forehead  near  the  sinuses  or 
disturbances  of  \  ision  call  his  attention  to  the  trouble.' 

The  second  etiological  factor  of  sinus  diseases  is 
traumatism.  A  number  of  reliable  cases  have  been 
observed  in  which  either  a  mucocele  or  an  empyema  has 
followed  trauma.  A  blow,  with  or  without  fracture  of 
the  bone,  can  cause  a  liow  of  blood  into  the  sinus,  and 
a  clot  is  formed  which  inflames  the  mucous  membrane 
by  irritation.  Then,  either  a  sinusitis  catarrhalis  with 
closure  of  the  ductus  nasofrontalis,  followed  by  the 
formation  of  a  mucocele,  occurs,  or  a  sinusitis  pyor- 
rhoica or  encapsulated  empyema  results,  according  to 
whether  the  outlet  remains  open  or  not.  A  third 
group  of  sinus  diseases,  caused  by  tumors,  parasites, 
and  foreign  bodies,  is  simply  mentioned  because  of 
their  rarity. 

The  diagnosis  of  the  acute  cases  is,  as  a  rule,  easy. 
Chronic  cases  on  the  other  hand  are  often  mistaken 
for  supra  orbital  neuralgia,  migraine,  etc.  Many  cases 
have  been  published  which  were  misunderstood  for 
years,  and  which  Anally  astonished  patient  as  well  as 
physician  by  perforation  taking  place  through  the 
forehead  or  orbit.  This  is  chiefly  true  of  those  remit- 
tent cases  in  which  at  intervals  of  weeks  or  even  months 
short  acute  or  subacute  attacks  occur,  giving  us  an 

'  An  exhaustive  treatise  by  II.  Kiihnt.  entitled  "  Die  entzttnd- 
lichen  Erkrankungen  der  Stirnhohlen  und  ihre  FolgezustSnde." 
^ives  a  detailed  account  of  the  various  and  interesting  eye  com- 
plications. 


August  7.  1897] 


MEDICAL    RECORD. 


193 


exact  picture  of  neuralgia.  Of  course  the  easiest  to 
recognize  are  those  cases  in  which  there  is  either  «i 
continual  flow  of  pus,  or  in  which  the  acute  attacks  stop 
with  the  empt}-ing  of  the  sinus. 

Pus  flowing  from  one  side  of  the  nose  should  arouse 
suspicion  of  disease  of  one  of  the  cavities  opening 
into  the  nose.  If  on  closer  inspection  one  sees  the  pus 
coming  from  the  anterior  end  of  the  thickened  middle 
turbinated  bone,  it  points  to  frontal-sinus  disease. 
The  diagnosis  can  be  made  sure  by  putting  a  sound 
into  the  ductus  nasofrontalis  and  allowing  the  secre- 
tion to  escape.  In  cases  of  encapsulated  empyema 
this  symptom  is  of  course  absent,  and  the  diagnosis 
would  become  very  difficult  were  it  not  for  one  symp- 
tom which  I  consider  of  great  importance,  namely,  tlie 
tenderness  of  the  bone  on  pressure.  That  the  bone  in 
acute  cases  is  painful,  botli  spontaneously  and  on 
pressure,  is  clear,  but  in  chronic  cases  also  pressure 
with  a  thick  sound  or  pencil,  percussion  with  a  plexim- 
eter,  etc.,  will  cause  pain.  Many  physicians  could 
by  these  means  draw  the  limits  of  the  sinuses  on  the 
forehead  and  later  at  the  operation  assure  themselves 
of  their  accuracy.  Much  more  important  than  this 
well-known  tenderness  on  pressure  of  the  forehead  is 
the  same  sign  elicited  at  the  floor  of  the  sinus,  that  is, 
the  upper  wall  of  the  orbit,  and  that  is  a  point  to 
which,  as  far  as  I  know,  our  attention  has  only  lately 
been  called  with  sufficient  emphasis  by  Kuhnt.  To 
understand  this,  one  must  know  how  the  bones  are 
affected  in  these  diseases,  the  process  being  different 
according  to  whether  a  mucocele  or  an  inflammatory 
condition  is  present.  In  the  former  {i.e.,  the  mucocele 
or  hydrops)  a  simple  pressure  atrophy  and  distention 
of  the  bone  follow.  It  becomes  thin  and  blown  out 
like  a  bubble,  especially  the  anterior  and  perhaps  still 
more  so  the  inferior  wall.  The  sinus  can  contain  in 
this  way  as  much  as  si.x  ounces  or  more  of  fluid.  The 
ethmoid  and  sphenoid  may  be  pressed  downward  and 
the  whole  orbit  pushed  out  of  place.  Of  inflammator}- 
changes  there  are  no  signs.  So  also  in  the  cases  of 
traumatic  hydrops  generally  and  those  of  cystoid  hy- 
drops or  mucocele,  in  the  great  majority  there  is  no 
pain.  At  all  events  the  subjective  symptoms  are  much 
less  than  in  the  purulent  process. 

Often  the  first  symptom  of  the  mucocele  is  the  bulg- 
ing of  the  bone  which  usually  occurs  in  the  upper  and 
inner  corner  of  the  orbit.  Why  just  there  I  shall 
explain  later. 

In  purulent  inflammation  of  the  sinus  the  bone  is 
altogether  differently  affected.  Here  we  have  to  deal 
not  with  a  pressure  atrophy  of  the  bone  but  with  an 
extension  of  the  inflammation  from  the  mucous  mem- 
brane to  the  surrounding  bones.  As  elsewhere,  in  the 
immediate  vicinity  of  the  inflamed  point,  a  rarefying 
ostitis  sets  in,  the  bone  becomes  soft,  and  at  length, 
this  process  continuing,  is  perforated.  Of  course  I 
cannot  deny  that  pressure  may  also  develop  in  the  pus 
sac,  but  this  does  not  cause  a  slow  bulging  of  the 
bone,  but  rather  an  acute  attack  with  severe  frontal 
headache,  higli  fever,  and  a  comatose  condition  as  chief 
symptoms.  These  do  not  subside  until  either  the 
pressure  diminishes,  or  the  pus  escapes  through 
the  ductus  nasofrontalis,  or  perforation  of  the  bone 
takes  place.  In  chronic  purulent  processes  the  per- 
foration occurs  slowly  and  there  is  no  distention  of 
the  bone.  .\  small  opening  is  formed,  just  as  in 
chronic  necrosis  of  a  long  bone;  a  so-called  cloaca 
results,  due  to  purulent  dissolution  of  the  bone. 

I  would  not  give  so  much  space  to  this  had  ii  not 
repeatedl}-  happened  that  one  of  my  colleagues  wished 
to  question  my  diagnosis  with  the  remark  that  no  dis- 
tention was  present.  Likewise  in  the  literature  of  the 
last  few  years  I  find  in  discussions  on  empyema  that 
absence  of  elevation  is  mentioned  as  a  peculiarity. 
This  elevation  is  one  of  the  symptoms  of  hydrops,  but 


not  of  empyema,  in  which  it  is  generally  wholly  ab- 
sent, except  when  a  case  of  purulent  mucocele  is  in 
question. 

This  perforation  ver}- rarely  occurs  inwardly  toward 
the  brain,  less  rarely  toward  the  forehead,  and  gener- 
ally downward  through  the  orbital  wall,  not  only  be- 
cause this  is  thin,  but  also,  as  Kuhnt  has  endeavored  to 
prove,  because  it  is  not  so  well  nourished.'  Now  there 
are  two  places  in  the  orbital  wall  where  the  perforation 
usually  takes  place.  One  is  in  the  inner  and  upper 
corner  of  the  orbit,  immediately  behind  and  under  the 
fovea  trochlearis :  the  other  somewhat  behind  the  in- 
cisura  supra-orbitalis.  At  both  of  these  points  the 
bone  is  pierced  by  veins  which  run  from  the  mucous 
membrane  of  the  sinus  to  the  \ena  ophthalmica  and 
supra-orbitalis.  Along  these  vessels  the  inflammation 
travels  and  starts  the  resorption  of  the  bone.  Conse- 
quently, if  in  doubtful  cases  one  wishes  to  make  the 
tenderness  of  the  bone  on  pressure  of  diagnostic  value,. 
one  must  not  confine  the  examination  to  the  frontal 
wall  of  the  sinus,  but  must  introduce  the  little  finger 
into  the  upper  and  inner  corner  of  the  orbit;  then  the 
patient  is  told  to  look  downward  and  an  attempt  is  made 
to  enter  behind  the  incisura  supra-orbitalis.  Here  the 
bone  is  sometimes  thin  and  giving,  as  the  cover  of  a 
tin  box,  or  there  may  be  an  inflammatory  thickening 
of  the  periosteum,  but  almost  without  exception  pres- 
sure will  be  found  to  be  painful.  If  the  examination 
is  conducted  in  this  way,  the  tenderness  on  pressure 
will  hardly  ever  fail  to  aid  in  the  diagnosis  of  chronic 
disease  of  the  frontal  sinus.  Commonly  the  tender- 
ness is  very  pronounced,  at  times  intense. 

The  illumination  of  the  frontal  sinus,  advocated 
chiefly  by  Vohsen,  has  not  fulfilled  expectations. 
The  picture  of  the  normal  illuminated  sinus  is 
too  variegated  and  often  different  on  the  two  sides,  so 
that  small  differences  in  the  transparency  of  the  two 
sides  prove  nothing.  In  very  pronounced  empyema 
the  diseased  side  appears  darker,  but  in  chronic  pyor- 
rhoea both  sides  may  seem  equally  light;  therefore  the 
negative  result  of  the  examination  proves  nothing, 
though  the  positive  is  of  some  value. 

Regarding  the  therapy,  the  first  attempt  to  get  at 
frontal-sinus  disease  in  a  bloodless  way  through  the 
nose  was  made  by  A.  Hartmann.' 

There  are  patients  who  with  every  severe  cold  they 
contract  become  at  the  same  time  affected  with  sinusitis 
frontalis  catarrhalis  and  closure  of  the  canalis  naso- 
frontalis. This,  according  to  Hartmann,  causes  con- 
ditions of  the  frontal  sinus  similar  to  that  found  in 
the  middle  ear  in  closure  of  the  Eustachian  tube. 
Having  this  in  mind,  Hartmann  endeavored  to  force 
air  through  the  canalis  frontalis,  just  as  by  Politzer's 
method  the  Eustachian  tube  is  opened.  Although  this 
method  is  said  to  have  been  of  value  in  some  of  these 
cases,  it  has  not  to  my  knowledge  had  many  followers. 
However,  the  attention  of  the  specialist  was  drawn  to 
this  route,  and  already  in  the  next  decade  Jurasz  was 
able  to  pass  a  sound  from  the  nose  through  the  ductus 
nasofrontalis.  In  this  way  he  not  only  let  the  secre- 
tions escape,  but  also  by  means  of  syringing  and  wash- 
ing out  could  treat  the  mucous  membrane  of  the  sinus. 
It  is  true  that  the  passing  of  a  sound  is  not  possible 
in  all  cases,  but  by  this  method  of  Jurasz  a  large 
number  of  early  ca.ses  of  sinus  catarrh  and  suppurative 
processes  can  be  cured.  For  acute  and  phlegmonous 
cases  this  method  is  of  no  use,  as  more  energetic 
treatment  is  necessary.  Likewise  it  is  not  sufficient 
for  obstinate  cases  of  chronic  suppuration  and  empy- 
ema, as  in  these  such  changes  in  the  mucous  mem- 
brane have  usually  occurred  that  it  can  no  longer 
return  to  its  normal  state.     And  here  I  must  say  that, 

'  The  anterior  wall  is  the  strongest;  about  the  same  or  slightly 
less  so  is  the  posterior  wall,"an<l  the  inferior  wall  is  the  thinnest. 
-  Deutsche  medicinische  Wochenschrift,  1877. 


194 


MEDICAL    RECORD. 


[August  7,  1897 


generally  speaking,  the  importance  of  the  obstruction 
of  the  ductus  nasofrontalis  in  chronic  purulent  proc- 
esses of  the  frontal  sinus  is  to  this  day  greatly  over- 
rated. It  is  difficult  to  give  statistics  about  this,  as 
many  authors  impart  no  or  insufficient  information  on 
the  subject.  There  are,  however,  many  reliable  cases 
published  in  which  the  disease,  in  spite  of  free  dis- 
charge of  the  pus  through  the  nose,  has  lasted  for 
years,  and  has,  even  in  spite  of  syringing  and  flushing, 
grown  worse.  I  remember  a  case  in  which  an  orbital 
fistula  was  present,  injected  fluid  running  out  through 
the  no.se.  The  case  was  not  cured,  although  many 
different  agents  were  used.  The  fistula  closed  several 
times  but  always  reopened.  Permission  to  operate 
was  refused.  From  what  has  been  said  it  is  clear 
that  a  radical  surgical  procedure  from  the  forehead  is 
indicated  in  a  number  of  cases,  as  encapsulated  em- 
pyema, mucoceles,  or  hydrops,  and  those  chronic  sup- 
purations in  which  the  mucous  membranes  have  been 
greatly  altered,  as  well  as  the  severe  acute  phlegmo- 
nous inflammations.  Now  trephining  of  the  frontal  si- 
nus is  an  old  operation,  but  in  its  original  form  it  was 
not  satisfactory.  The  simple  opening  allowed  an  exit 
for  the  inflammatorj-  products  and  placed  the  patient 
out  of  danger.  But  the  wound  remained  open  as  a 
fistula  for  a  long  time,  and  even  if  it  closed  one  could 
not  be  sure  that  it  would  not  reopen.  With  a  sinusitis 
it  is  not  a  question  of  a  bone  abscess,  which  after 
being  emptied  heals,  but  of  a  cavit}^  lined  with  dis- 
eased mucous  membrane.  And  the  same  is  true  of 
this  mucous  membrane,  as,  for  instance,  of  the  dis- 
eased uterine  membrane,  the  membrane  lining  the 
lacrymal  duct,  etc.  They  are  all  incapable  of  re- 
turning to  a  normal  state  by  means  of  medical  treat- 
ment, if  they  have  undergone  certain  great  changes. 
It  is  perhaps  curious  that  the  idea  not  only  to  chisel 
open  the  sinus,  but  at  the  same  time  to  take  away  the 
diseased  mucous  membrane,  has  not  occurred  sooner. 
This  was  done  occasionally  formerly.  Thus  Kuhnt 
mentions  a  case  of  Runge's  of  the  last  century  in  which 
the  membrane  was  destroyed  by  chemical  agents. 
More  recently  Spencer  Watson  has  recommended  strong 
solutions  of  iodine  and  Richet  aqua  juglandis  spirit- 
uosa  for  the  destruction  of  the  secreting  membranes. 
But  it  was  only  in  1890  that  Nebinger  recommended 
extirpation  of  the  pituitary  membrane  after  opening 
the  frontal  sinus  with  a  chisel. 

Nebinger  opened  the  sinus  widely  from  the  front, 
while  Jansen  three  years  later  proceeded  from  below 
through  the  orbit.  Jansen  did  this  more  especially 
to  secure  the  best  cosmetic  effect.  Both  methods  are 
rational,  as  they  fully  remove  the  seat  of  disease  and 
surely  effect  a  cure.  However,  in  the  Jansen  method 
a  considerable  cavity  is  formed  in  the  bone,  which 
takes  a  long  time  to  heal.  Jansen  exjDected  that  the 
fatty  tissues  of  the  orbit  would  fill  the  empty  sinus, 
but  we  cannot  count  on  that  with  certainty,  and  as  a 
matter  of  fact  his  cases  need  half  a  year  and  longer  for 
healing.  I  can  see  no  advantage  in  Jansen's  method  as 
compared  with  that  of  Nebinger,  as  the  cavity  cannot 
be  inspected  as  well  if  opened  from  below  as  when 
opened  widely  in  front.  Jansen  actually  had  to  make 
several  secondary  oj^erations  to  remove  portions  of 
mucous  membrane  that  had  been  left.  I  strongly  rec- 
ommend a  modification  of  Nebinger's  melliod  as  de- 
scribed by  Kuhnt.  This  consists  chiefly  in  that  not 
only  is  the  sinus  opened  widely,  but  also  the  whole 
front  wall  and  sometimes  part  of  the  lower  wall 
are  removed.  The  bony  edges  are  bevelled  as  much 
as  possible,  so  that  no  bony  cavity  but  as  shallow  a 
depression  as  possible  results,  to  which  the  soft  parts 
can  be  pressed  by  a  bandage.  This  cannot  always  be 
done  jx-rfectly,  but  the  cavity  of  the  wound  can  always 
be  reduced  considerably,  especially  as  compared 
with   Jansen's   operation.     In    this   way  the  time  of 


treating  is  very  greatly  reduced  and  the  cosmetic  effects 
are  bettered.  I  followed  Kuhnt's  advice  in  two  cases, 
the  one  of  empyema,  the  other  of  sinusitis  pyorrhoica 
chronica,  in  both  of  which  rapid  recovery  took  place. 
Both  patients  were  dismissed  from  treatment  at  the 
end  of  the  first  month,  while  my  former  cases  of  sinus 
trephining  always  took  several  months,  and  sometimes 
would  be  discharged  having  a  fistula. 

In  regard  to  one  thing  only  do  I  disagree  with 
Kuhnt  and  that  is  the  indications.  Kuhnt  first 
opens  the  sinus;  then  after  inspecting  the  mucous 
membrane  decides  whether  to  remove  it  or  to  drain  in 
the  old  way.  This  last  is  no  longer  considered  by 
me,  after  having  seen  the  more  rapid  and  better  re- 
sults of  the  radical  operation.  I  deem  it  self-evident 
that  in  early  cases  it  will  always  be  tried  to  open  the 
ductus  nasofrontalis  by  means  of  a  sound.  Even  if 
this  is  not  accomplished  the  first  time,  the  rhinologist 
can  still  attain  his  object  by  obtaining  a  reduction  of 
the  swelling  of  the  mucous  membrane  near  the  open- 
ing of  the  caiialis  nasofrontalis,  either  by  removing 
the  anterior  thickened  part  of-  the  middle  turbinated 
or  by  other  procedures  which  alone  have  caused  early 
cases  to  heal. 

Xo  patient  will  submit  to  an  operation  after  the  first 
or  second  slight  attack  of  sinusitis  catarrhalis.  When 
he  finally  agrees  to  it  the  mucous  membrane  has 
undergone  changes  which,  if  one  desires  to  save  it, 
will  lengthen  the  duration  of  treatment  and  delay  the 
closure  of  the  wound.  The  greatest  disadvantage, 
however,  is  the  danger  of  return.  On  the  other  hand, 
if  we  obliterate  the  sinus  by  extirpation  of  the  mucous 
membrane,  then  the  result  is  not  only  sure  but  quicker. 
Against  this  it  is  of  no  moment,  in  my  opinion,  that 
the  operation  may  last  from  ten  to  twenty  minutes 
longer,  or  that  the  scar  may  be  slightly  larger,  for  dis- 
figurement is  little  dependent  on  the  length  of  the  in- 
cision. The  more  radical  the  operation  the  sooner 
the  cure  and  the  more  linear  will  be  the  scar.  I  wish 
now  briefly  to  describe  the  technique  of  the  operation, 
in  the  main  points  of  which  I  agree  with  Nebinger 
and  Kuhnt. 

As  regards  the  point  of  chiselling,  most  operators 
recommend  a  place  corresponding  to  the  inner  end  of 
the  eyebrow.  It  is  at  the  intersection  of  two  lines, 
one  of  which  connects  the  two  incisura;  supra-orbitales, 
the  other  being  drawn  perpendicular  to  the  first  from 
the  crista  lacrymalis  anterior.  Tlie  point  lies  at  the 
margo  supra-orbitalis  perpendicularly  over  the  liga- 
mentum  palpebra.  Nebinger  advises  to  begin  chisel- 
ling at  the  OS  nasa;.  I  must  confess  that  the  fear  which 
many  have  of  opening  the  skull  gives  me  little  worry. 
In  general  the  frontal  bone  consists  of  a  tabula  exter- 
na and  a  tabula  interna,  with  spong}-  bone  between. 
The  anterior  sinus  wall  consists  solely  of  tabula  ex- 
terna; so  if  one  chisels  carefully  one  can  hardly  enter 
the  cranial  cavity,  as  one  will  see  the  spongy  bone 
and  be  warned.  Having  chiselled  through  the  sinus 
wall,  the  mucous  membrane  will  appear  as  a  dark  red 
or  perhaps  tliscolored  yellowish  or  black  cyst,  pro- 
vided that  it  has  not  been  destroyed  by  gangrene. 

Not  infrequently  the  sinus  contents  pulsate,  which 
in  no  way  points  to  a  defective  posterior  wall  of  the 
sinus,  but,  as  Boeckel  showed,  is  always  present  when 
a  bony-walled  cavity  is  opened  in  which  there  are  tis- 
sues containing  many  vessels.  Such  pulsations  have 
been  noted  also  in  the  antrum  of  Highmore  and  in 
the  marrow  canals  of  bones.  After  opening  the  sinus 
one  determines  tiie  size  of  the  cavity  by  means  of  a 
sound,  and  then  removes  the  anterior  and  possibly 
part  of  the  inferior  wall.  The  sharp  edges  of  the 
bone  are  bevelled  off  and  one  tries  to  make  instead  of 
an  irregular  cavity  as  flat  a  surface  as  possible.  The 
more  clo.sely  the  skin  is  adapted  to  the  subjacent 
bone,  strictly  avoiding  the  formation  of  a  pouch,  the 


August  7,  1897] 


MEDICAL    RECORD. 


195 


more  rapidly  will  the  healing  occur.  The  mucous 
membrane  is  thoroughly  removed,  the  upper  part  of 
the  ductus  nasolacrymalis  being  also  robbed  of  its 
mucous  membrane.  If  this  is  closed  it  is  unneces- 
sary, nay,  even  harmful,  to  open  it.  Formerly  when 
one  did  not  primarily  remove  the  mucous  membrane, 
it  was  of  course  necessary  to  establish  a  communica- 
tion with  the  nose,  either  by  passing  a  sound  through 
the  ductus  nasofrontalis  or  by  breaking  into  the  nose, 
in  order  to  give  the  secretions  an  outlet. 

If  one  obliterates  the  cavity  in  the  above-described 
manner,  however,  the  ductus  nasofrontalis  not  only 
becomes  superfluous  but  its  artificial  opening  may  do 
harm  by  allowing  inflammatory  products  from  the  nose 
to  come  in  contact  with  the  wound.  The  after-treat- 
ment is  to  be  in  accordance  with  the  ordinary  rules  of 
surgen,-.  Even  when  one  has  operated  in  strongly  in- 
flamed tissues  and  cannot  sew,  there  results  at  worst 
after  this  operation  a  small  abscess  cavity,  the  absolute 
healing  of  which  is  but  the  question  of   a  short  time. 


MOTHER  AND  CHILD. 
Bv    F.    W.    EPLEY,    M.D., 

NEW    RICHMOND,    WIS. 

Of  all  the  suffering  to  which  human  flesh  is  heir, 
none  perhaps  is  more  acutely  painful  and  distressing 
than  that  caused  by  sore  nipples  in  the  act  of  nursing. 
How  often  do  we  see  the  young  mother  writhing  with 
pain  and  the  big  tears  streaming  down  her  cheeks  in 
her  heroic  attempts  to  nourish  her  offspring — this 
crowning  act  of  motherhood,  this  clima.x  of  maternal 
affection  turned  into  tortures  akin  to  those  of  the  In- 
quisition. If  we  look  for  the  cause  we  shall  not  have 
to  search  long.  Improper  habits  of  dress  have 
cramped  the  glands  and  embedded  the  nipples  within 
them,  or  if  begun  early  enough  have  prevented  the 
development  of  the  nipple,  so  that  if  any  have  grown 
they  are  distorted  and  retracted  out  of  all  semblance 
to  the  proper  shape  and  figure.  This  in  turn  has 
cramped  and  distorted  the  larger  milk  tubes  leading 
to  the  nipple,  until  \.hen  lactation  takes  place  it  is 
nearly  or  quite  impossible  for  the  infant  to  get  hold 
of  it,  and  if  it  does  the  result  is  that  the  folds  of  in- 
verted skin  are  drawn  out,  the  accumulations  of  skin 
cells  are  easily  displaced,  lea\ing  only  the  most  deli- 
cate layer  of  true  skin  to  withstand  the  irritation  and 
violence  of  the  nursing  act.  This  it  is  wholly  unable 
to  do,  and  the  result  is  that  in  the  drawing  out  of  the 
nipple  the  skin  is  fissured.  The  crack  becomes  deeper 
and  deeper,  nursing  more  and  more  painful,  until  the 
poor  mother  gives  up  in  despair.  By  this  time  infec- 
tion has  taken  place,  or  by  reason  of  the  distorted  milk 
ducts  the  proper  discharge  of  the  lacteal  fluid  has  been 
impossible,  and  mastitis  and  abscess  with  all  their 
painful  sequela.-  supervene. 

The  remedy  is  just  simple,  plain  common  sense, 
but  this  must  be  applied  before  confinement;  it  is  too 
late  after  lactation  has  actually  begun.  Let  us  see 
what  we  have  two  months  before  the  end  of  gestation : 
a  small,  stunted,  deformed,  retracted,  very  tender 
nipple — exactly  what  we  do  not  want  in  any  par- 
ticular. We  want  for  baby's  use  a  large,  long — I  never 
saw  one  too  long — well  formed,  protruding,  tough- 
skinned  nipple.  Can  we  make  it.'  VVe  can,  by  ex- 
actly the  same  process  by  which  any  part  of  the  body 
may  be  developed  and  toughened,  namely,  by  fre- 
quent regular  exposure,  use,  and  irritation.  At  the 
end  of  the  seventh  month  the  nipples  should  both  be 
subjected  to  a  systematic  course  of  massage,  pull- 
ing, rubbing,  rolling  and  stripping,  and  especially  the 
latter.  This  cannot  be  done  too  often  or  too  thor- 
oughly.    The   result   will    be    most   gratifying.     The 


otherwise  whollv  useless  and  worse  than  useless  organ 
will  be  prepared  for  its  work:  lactation  will  be  free 
and  painless.  The  glands  will  be  well  and  easily 
emptied ;  the  nightmare  of  fissures,  mastitis,  and  ab- 
scess will  disappear  never  to  return,  and  the  young 
mother  can  hug  her  baby  to  her  breast  and  say  how 
sweet  is  maternity. 

In  my  early  years  of  practice  I  have  experienced  all 
the  evils  of  neglect  and  mismanagement  of  the 
maternal  font,  until,  driven  to  desperation  almost  by 
my  repeated  failures  to  relieve  this  most  distressing 
condition,  it  occurred  to  me  to  put  into  practice  this 
simple  common-sense  plan  of  preparation,  and  I  have 
had  the  extreme  gratification  of  seeing  all  my  patients 
so  treated  go  through  lactation  with  only  sensations  of 
pleasure. 

My  only  defence  for  the  principles  embodied  in  this 
paper  is  that  they  are  based  on  observation  in  an 
active  practice  of  general  medicine,  extending  over  a 
period  of  twenty  years,  and  the  rearing  of  a  family  of 
five  children,  who  are  almost  never  ill. 

When  a  baby  presents  himself  for  admittance  into 
the  family  circle  he  should  receive  a  warm  welcome. 
The  temperature  of  the  welcome  should  be  maintained 
until  the  little  fellow  is  able  to  kick  and  jump  with 
sufficient  vigor  to  maintain  a  healthy  circulation.  If 
he  is  strong  and  vigorous  he  should  have  one  good 
general  bath,  after  that  he  should  be  kept  simply 
clean.  The  common  practice  of  giving  the  poor  little 
creature  a  daily  scrub  all  over  with  soap  and  water  is 
to  be  discouraged.  Soiled  or  wet  linens  should  never 
be  allowed  to  remain  in  contact  w  ith  the  delicate  skin, 
and  when  changed  should  be  replaced  with  warm,  soft, 
clean  ones.  The  eyes  should  be  kept  clean,  but  never 
washed  with  the  same  cloth  used  for  the  general  bath. 
For  this  purpose,  a  clean  cloth,  clean  water,  and  no 
soap  should  be  used.  Feed  regularly,  but  not  oftener 
than  once  in  two  hours.  I  do  not  lay  this  down  as  an 
arbitrary  rule  never  to  be  broken,  but  it  is  an  impor- 
tant point;  the  little  stomach  needs  rest,  and  much 
can  be  done  toward  the  fostering  of  the  digestive  and 
assimilative  powers  by  an  intelligent  obser\-ation  of 
this  principle.  Teach  the  baby  to  drink  early.  Wash 
his  mouth,  gums,  tongue,  and  cheeks  regularly.  If 
the  mother  is  weak,  sick,  thin  in  flesh,  or  while  nurs- 
ing loses  flesh  to  any  marked  degree,  if  the  baby  does 
not  seem  to  thrive,  or  the  mother's  milk  is  not  suffi- 
cient and  has  to  be  supplemented  by  other  food  after 
she  has  resumed  her  accustomed  place  in  the  house- 
hold, wean  the  baby.  A  good  healthy  cow  is  far  pref- 
erable as  a  commissary  department  for  baby  than  a 
mother's  breast  which  is  wanting  in  any  essential 
quality.  I  did  not  read  this  in  a  book  or  hear  it  in  a 
lecture  room.  In  the  selection  of  a  cow  great  care 
should  be  taken  to  get  one  free  from  disease.  .She 
should  be  tested  by  a  veterinary  for  tuberculosis :  kept 
in  clean,  dry  quarters,  fed  regularly  on  clean  hay  and 
bran,  and  in  winter  given  water  slightly  warmed  to 
drink.  If  she  becomes  heated,  worried,  or  excited  in 
any  way  unduly,  the  milk  should  be  suspended  and 
some  preparation  containing  milk  as  a  basis  should  be 
used  until  the  cow  regains  her  normal  condition.  L'se 
simple  nipples  pulled  over  the  mouth  of  the  bottle. 
Teach  baby  to  drink  as  soon  as  possible  and  discard 
the  bottle  altogether.  For  the  first  year  only  soft 
woollen  fabric  should  come  in  contact  with  the  skin, 
and  there  should  be  plenty  of  outer  clothing  to  keep 
the  body  warm.  It  is  true  infants  have  great  powers 
of  resistance,  but  it  is  a  fact  that  many  a  baby  has  been 
buried  because  the  mother  has  been  overzealous  to 
have  her  baby  look  prettier  than  her  neighbor's:  has 
changed  the  wool  fabrics  for  light  white  goods.  She 
has  not  realized  the  chilly  air  as  evening  approached, 
has  put  the  little  one  to  bed  in  its  cotton  underclothes 
or  nightdress;  the  baby  during  the  night  has  become 


196 


MEDICAL    RFXr)RD. 


[August  7,  1897 


chilled  and  a  fatal  cholera  infantum  or  enterocolitis 
has  been  set  up.  Xo  matter  how  warm  the  night  the 
bowels  should  be  covered  with  flannels.  At  home  is 
the  place  for  the  baby  under  all  circumstances  and 
conditions.  There  is  no  exception  to  this  rule,  espe- 
cially during  the  heated  summer  months;  new  faces, 
strange  surroundings,  and  the  fatigue  of  travel  are 
prolific  sources  of  indigestion  and  its  natural  train  of 
evils.  It  is  these  and  the  natural  strain  upon  the 
delicate  nervous  system  incident  to  them,  and  not  the 
change  of  food,  which  make  baby  sick. 


that  upon  tile  mind  prepared  by  some  such  rough 
illustration  a  demonstration  upon  the  cadaver  makes 
lasting  impression.  Properly  prepared  and  preserved, 
dissections  can  be  made  almost  as  useful  as  models, 
the  several  structures  being  brought  out  by  coloring. 
Of  every  region  there  should  be  several  dissections, 
each  showing  a  separate  layer — thus  relations  can  be 
clearly  obser\'ed.  Viscera  can  be  hardened  carefully, 
cut  in  pieces  (so  that  every  part  of  the  interior  may  be 
demonstrated;,  the  necessary  coloring  done,  and  each 
piece  varnished.     The  result  is  highly  satisfactor)-. 


SOMK    THOUGHTS    ON    TEACHING 
ANATOMY. 


^H-oi]irc6!3  of  ijtXcdiCcXl  J'ciencc. 


By   J.    W.    HENSUN,    M.D., 

PROFESSOR   OF   AXATOMV    IN     THE    I'MVEBSITV     COLI.ECK    OF    MEDICINE,    RICH- 

The  times  demand  that  graduates  in  medicine 
should  be  better  prepared.  ■  Requiring  a  high  percent- 
age upon  examination  is  a  good  thing.  It  is  one 
means  to  gain  the  end,  but  it  is  insufficient.  To  pass 
creditably  a  pretty  rigid  examination  is  not  always  a 
proof  of  proficiency.  What  then  ?  It  behooves  us  as 
teachers  to  make  our  course  of  instruction  more  thor- 
ough and  attractive.  I  use  the  latter  word  advisedly, 
for,  unless  made  attractive,  teaching  can  scarcely  be 
thorough.  How  shall  we  accomplish  this  in  anatomy? 
Every  one  will  subscribe  to  the  statement  that  impres- 
sions made  upon  the  brain  through  the  medium  of 
sight  are  far  more  lasting  than  others. 

What  is  told  us  we  forget,  however  exciting  the  nar- 
rative may  be.  What  we  see  our  memory  retains 
almost  inclefinitely,  even  the  details.  Anatomists  be- 
lieve this,  as  shown  by  the  importance  attached  to 
dissecting.  If  this  same  principle,  viz.,  appealing  to 
the  sense  of  sight,  be  applied  to  our  preparation  of 
men  for  dissecting,  our  teaching  will  be  both  attrac- 
tive and  thorough.  So  much  is  expected  of  the  dis- 
secting-hall  that  students  art  not  properly  prepared  to 
enter  it,  and  as  a  result  do  poor  dissecting  and,  worse 
still,  learn  not  half  so  much  from  what  is  seen  there 
as  they  should.  Therefore  let  us  make  more  use  of 
diagrams,  preserved  dissections,  and  models,  models  of 
viscera  and  regions,  each  made  to  take  apart  and  show 
the  interior  of  a  viscus  or  the  relations  of  all  the 
structures  of  a  region.  Often  after  the  use  of  the 
roughest  diagram  students  will  report  that  the  point 
is  for  the  first  time  made  clear.  Accentuation  is  the 
secret  of  this  success.  The  same  thing  obtains  in 
the  use  of  models.  The  parts  in  a  dissection  may 
seem  all  confusion  to  the  mind  of  a  beginner,  while 
the  clear  outlines,  the  veiy  boldness  of  a  model  will 
appeal  to  the  mind  of  the  dullest.  The  study  of  rela- 
tions is  greatly  facilitated,  not  only  by  this  same 
accentuation,  but  by  the  ability  to  remove  the  parts 
layer  by  layer  or  piece  by  piece  and  replace  at  will. 
Upon  one  occasion  a  class  was  for  the  first  time  listen- 
ing to  a  general  description  of  the  cerebrum — the  sur- 
faces of  the  hemispheres,  longitudinal  fissure,  etc. 
Several  brains  just  taken  from  cadavers  and  in  good 
condition  were  distributed.  In  spite  of  this  a  blank 
expression,  almost  universal,  greeted  the  remarks.  In 
desperation,  the  cerebrum  was  compared  to  the  half  of 
the  kernel  of  a  walnut.  Instantly  the  light  of  compre- 
hension appeared  upon  the  faces  of  the  men  and  the 
description  was  then  easy.  This  occurrence  only  illus- 
trates a  constant  experience  which  pro\cs  the  follow- 
ing: Kirst,  that  the  mind  of  a  beginner  is  usually  slow 
to  understand  well  a  demonstration  upon  some  part  of 
the  human  subject.  Secondly,  that  the  same  facts  are 
quickly  and  clearly  comprehended  when  some  simple 
but  homely  imitation  is  used  to  illustrate.     Thirdly, 


Rupture  of  Interstitial  Tubal  Pregnancy ;  Su- 
ture ;  Recovery. — A  case  is  reported  by  Tytler  in 
the  Brilisli  Medical  Journal,  June  12,  1897,  of  a 
woman,  thirty-one  years  old,  who  had  borne  seven 
children,  and  came  under  observation  in  a  state  of 
collapse  from  internal  hemorrhage.  Menstruation  had 
been  absent  for  six  weeks,  and  the  woman  had  been 
seized  with  severe  pain  at  the  bottom  of  the  abdomen, 
although  after  a  few  hours  she  arose  and  resumed  her 
work.  The  menstrual  flow  returned  after  this,  but  the 
discharge  was  dark  and  scanty.  Five  days  after  the 
onset  of  the  acute  attack  noted,  while  washing  clothes 
the  woman  was  again  suddenly  seized  with  great  pain 
in  the  stomach  and  became  as  cold  as  death.  She  was 
put  to  bed,  and  remained  in  a  state  of  great  collapse 
for  five  days.  .At  this  time  she  presented  marked  pal- 
lor, coldness  of  the  surface,  feeble  pulse,  eto.  On 
physical  examination  of  the  abdomen  a  rounded  mass 
was  found,  softish  and  smooth,  low  down  and  to  the 
right  of  the  middle  line.  Impulse  applied  to  the  cer- 
vix was  communicated  to  the  tumor.  There  were  mu- 
cus and  blood  in  the  vagina.  The  cervix  uteri  was 
deeply  torn  on  the  left  side.  The  thoracic  and  other 
organs  were  normal.  Percussion  over  the  lower  part 
of  the  abdomen  was  clear,  and  nothing  could  be  found 
in  Doulgas'  cul-de-sac.  For  a  day  or  two  the  patient 
appeared  to  rally,  but  at  the  end  of  this  time  she  be- 
gan to  vomit  and  grew  much  worse.  A  small  explora- 
tory incision  was  now  made  between  the  pubes  and 
the  umbilicus,  with  a  view  of  verifying  the  diagnosis 
of  ruptured  tubal  pregnancy.  On  opening  the  perito- 
neum the  abdomen  was  found  to  be  full  of  black 
clotted  blood.  The  incision  was  at  once  enlarged  and 
a  hand  introduced  to  compress  the  right  broad  liga- 
ment, to  pre\ent  renewed  bleeding.  There  was.  how- 
ever, no  sign  of  recurrence  or  of  recent  bleeding.  A 
rent,  nearly  two  inches  long,  was  found  in  the  uterus 
on  the  right  side,  extending  from  the  middle  to  the 
origin  of  the  right  oviduct.  The  right  side  of  the 
fundus  was  twice  the  breadth  of  the  left.  The  rent 
opened  into  a  spherical  cavity  filled  with  fibrin,  which 
was  removed,  without  disclosing,  however,  any  trace 
of  cyst  wall  or  ovum.  After  clearing  the  peritoneal 
cavity,  the  right  tube  and  ovary  were  removed.  Then 
after  carefully  washing  out  the  fundus  of  the  uterus, 
the  rent  was  closed  w  ith  four  catgut  sutures,  the  edges 
being  inverted  slightly,  .\fter  again  carefully  clear- 
ing out  and  inspecting  the  peritoneal  cavity,  a  drain- 
age tube  was  introduced  and  the  abdomen  closed  in 
the  ordinary  way.  The  patient  made  a  good  recovery 
and  was  discharged  some  six  weeks  after  the  operation, 
with  a  small  sinus  at  the  lower  end  of  the  wound  at 
the  site  of  the  drainage  tube.  This  sinus  remained 
open  for  some  months,  discharging  a  suture  now  and 
again  until  it  healed.  .-Vbout  eight  months  later  the 
patient  had  a  severe  attack  of  dysentery,  following 
which  there  was  more  or  less  diarrho-a  at  each  men- 
strual period. 


August  7,  1897] 


MEDICAL    RECORD. 


197 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth  Street. 


New  York,  August  7,  1897. 

CLINICAL    EXPERIENCES  WITH  TR  TUB?:R- 
CULIN. 

The  editor  of  the  Deutsche  medicinische  Wochenschrift 
has  undertaken  to  secure  from  various  clinical  sources 
reports  of  the  results  obtained  from  the  employment 
of  Koch's  modified  tuberculin  in  the  treatment  of  dif- 
ferent forms  of  tuberculosis,  and  presents  in  the  issue 
of  that  journal  for  July  8th  two  communications  upon 
this  subject.  The  authors  of  these  papers  are  ex- 
tremely cautious  and  conservative  in  their  statements 
and  disclaim  any  suggestion  of  committing  themselves 
to  final  conclusions  in  the  matter,  which  it  is  pointed 
out  can  be  reached  only  after  an  experience  of  months 
and  even  of  years. 

Bussenius  reports  the  results  in  nineteen  cases  ob- 
served during  three  months  at  the  clinic  of  Professor 
Fraenkel  at  the  Charite  for  the  treatment  of  diseases 
of  the  nose  and  throat.  Of  these  cases  twelve  were 
examples  of  laryngeal  tuberculosis,  four  instances  of 
lupus,  tW'O  e.xamples  of  pulmonary  tuberculosis  solely, 
and  one  was  an  example  of  asthmatic  attacks.  Of  the 
whole  number  the  treatment  was  completed  in  fifteen, 
in  one  it  was  intermitted,  and  in  the  remainder  it  was 
still  in  course  of  application.  The  fifteen  cases  re- 
ceived in  all  three  hundred  and  fourteen  injections, 
the  remainder  twenty.  The  largest  number  of  injec- 
tions received  by  a  single  patient  was  twenty-five. 
The  largest  single  injection  consisted  of  four  cubic 
centimetres.  The  longest  period  during  which  the 
treatment  was  continued  was  sixty-five  days,  the 
shortest  twenty-nine. 

The  fifteen  cases  in  which  the  treatment  was  car- 
ried out  to  its  conclusion  yielded  no  reaction  to 
Koch's  old  tuberculin.  Only  four  of  the  cases 
yielded  no  reaction  whatever,  local  or  general,  to 
the  injections.  The  greatest  elevation  of  tempera- 
ture in  a  previously  non-febrile  case  following  an 
injection  was  2.7°  C.  The  reaction  and  its  quality 
differed  with  the  specimen  of  tuberculin  employed. 
One  preparation  was  capable  of  inducing  a  reac- 
tion in  the  same  person  in  whom  a  larger  dose  of 
another  preparation  at  a  previous  time  had  induced 
none.  The  frequency  of  pulse  and  respiration  corre- 
sponded as  a  rule  with  the  height  of  the  temperature. 
Elevation  of  temperature  was  attended  with  evidences 
of  ner\'ous  disturbance,  such  as  headache,  languor, 
twitching,  palpitation  of  the  heart,  which  sometimes 


occurred  also  independently  of  such  elevation.  Two 
patients  complained  regularly  of  oppression  of  the 
heart  and  profuse  perspiration.  In  a  series  of  ex- 
aminations of  the  blood  no  noteworthy  alteration  in 
the  number  of  colorless  corpuscles  was  found.  In 
two  of  the  cases  reported  enlargement  of  the  spleen 
was  made  out. 

Of  the  fifteen  cases  in  which  the  treatment  was  con- 
tinued until  its  completion  there  was  gain  in  weight 
in  seven,  loss  of  weight  in  five.  Such  loss  as  took 
place  occurred  principally  in  connection  with  the  ad- 
ministration of  large  doses  and  violent  reaction.  In 
no  instance  did  an  abscess  form  at  the  site  of  injec- 
tion, but  in  ten  of  the  nineteen  painful  infiltration  of 
the  subcutaneous  tissues  took  place.  In  two  cases  the 
local  lymphatic  glands  became  slightly  enlarged.  In 
the  cases  of  pulmonary  tuberculosis  the  results  were 
not  considered  conclusive,  but  in  t^vo  in  which  tuber- 
culosis and  syphilis  were  associated  the  employment 
of  TR  after  the  cure  of  the  syphilis  was  followed  by 
the  disappearance  of  cough  and  expectoration,  together 
w^ith  tubercle  bacilli.  Tuberculosis  of  the  pharynx 
and  larynx  showed  no  greater  improvement  than  is 
usual  with  ordinary  topical  treatment.  Three  cases  of 
lupus,  however,  were  quite  cured. 

At  the  medical  clinic  of  the  University  of  Bonn 
Schultze  treated  nine  cases  of  tuberculosis  with  TR. 
In  none  was  any  such  aggravation  observed  as  fol- 
lowed injections  of  the  original  tuberculin.  In  one 
case  tuberculosis  of  the  larynx  developed  during  the 
progress  of  the  treatment,  with  loss  of  weight,  and  the 
patient  declined  to  submit  to  further  treatment.  In 
another  the  treatment  was  discontinued  on  account  of 
the  development  of  diarrhoea,  probably  of  tuberculous 
origin.  In  this  case  there  was  at  first  gain,  but  later 
there  was  loss  of  weight.  In  four  other  cases  there 
was  no  noteworthy  change.  In  still  another  improve- 
ment took  place  in  a  dry  pleurisy  and  also  in  the  gen- 
eral condition.  In  the  remaining  two  improvement 
took  place,  and  in  one  of  these  pronounced  perichon- 
dritis of  the  arytenoid  cartilage  was  cured. 


VACCINATION    IN    ENGLAND. 

In  many  districts  of  England  there  exists  the  strongest 
possible  prejudice  against  vaccination.  Nothing  can 
shake  the  belief  of  the  rabid  anti vaccinationist  that 
the  operation  is  distinctly  harmful;  he  is  not  satisfied 
with  disallowing  its  efficacy.  To  statistics  and  proofs 
of  every  kind  he  turns  a  deaf  ear  or  explains  them 
away  to  his  own  satisfaction.  He  is  an  enthusiast  in 
the  support  of  his  cause,  and  will  pay  fines  time  after 
time  and  even  go  to  prison  rather  than  allow  his  chil- 
dren to  be  vaccinated.  The  causes  for  this  decided 
stand  against  vaccination  are  not  altogether  easy  to 
explain.  One  reason  may  be  that  the  present  strict 
enforcement  of  the  law  of  compulsory  vaccination  is 
looked  upon  as  an  infringement  on  the  liberty  of  the 
subject ;  ignorance  is  doubtless  another ;  and  lastly  the 
carelessness  of  many  of  the  public  vaccinators  is  an 
important  factor  in  the  case.  The  report  of  the  royal 
commission  on  vaccination  in  England  and  particu- 


198 


MEDICAL    RECORD. 


[August  7,  1897 


larly  in  regard  to  the  late  small-pox  epidemic  in  Glou- 
cester has  just  been  published,  and  should  tend  to 
convince  disbelievers  of  the  efficacy  of  Jenner's  dis- 
covery. The  commissioners,  one  and  all,  after  a  care- 
ful and  unprejudiced  consideration  of  the  subject, 
commit  themselves  to  the  opinion:  i.  That  vaccina- 
tion diminishes  the  liability  to  be  attacked  by  the 
disease.  2.  That  it  modifies  the  character  of  the  dis- 
ease. 3.  That  the  protection  it  affords  against  attacks 
of  the  disease  is  greatest  in  the  years  immediately 
succeeding  vaccination  (say  for  nine  or  ten  years). 
4.  That  after  the  lapse  of  this  period  the  efficacy  of 
vaccination  rapidly  diminishes,  but  that  it  is  still 
considerable  in  the  next  quinquennium  and  probably 
never  altogether  ceases.  5.  That  its  power  to  modify 
the  character  of  the  disease  does  not  diminish  so 
rapidly  as  its  power  to  prevent  attack.  6.  That  re- 
vaccination  restores  the  protection  which  lapse  of 
time  has  diminished.  7.  That  the  beneficial  effects 
of  vaccination  are  most  experienced  by  those  in  whose 
case  it  has  been  most  thorough.  In  Gloucester  at  the 
time  of  the  outbreak  vaccination  had  been  practically 
abandoned,  and  figures  show  that  the  disease  and  mor- 
tality were  nearly  wholly  confined  to  the  un vaccinated. 
The  epidemic  was  soon  exterminated  when  the  vacci- 
nation machinery  had  been  effectively  organized.  It 
is  a  remarkable  fact  that  there  was  not  a  single  case 
of  small-pox  among  the  nurses  or  workers,  all  of  whom 
had  been  revaccinated.  Estimates  which  can  be  re- 
lied upon  put  the  yearly  death  rate  from  small  pox  in 
England  during  the  latter  half  of  the  eighteenth  cen- 
tury at  the  proportion  of  three  thousand  to  every  one 
million  of  the  population;  with  the  present  number  of 
inhabitants  this  would  mean  one  hundred  thousand 
cases  a  year.  In  1890  there  were  in  England  only  six- 
teen deaths  from  small-pox,  but  since  then  there  has 
been  a  most  alarming  increase.  This  increase  is  with- 
out a  doubt  due  to  the  antivaccinationist  movement. 

The  existing  laws  are  very  unpopular  and  possibly 
an  amendment  of  them  might  be  beneficial,  but  the 
demand  of  the  opponents  of  vaccination  that  they 
should  be  totally  repealed  would  be  nothing  less  than 
a  national  calamity. 


THE    DISUSE   OF    ERGOT   IN    PRESENT-DAY 
MIDWIFERY    PRACTICE. 

The  abuse  of  ergot  has  led  to  so  radical  a  change  in 
the  views  of  medical  men  as  to  the  useful  qualities  of 
that  drug  in  obstetric  practice  that  the  other  extreme 
has  been  reached,  and  it  is  now  scarcely  ever  used. 
The  great  majority  of  obstetricians  nowadays  seem  to 
have  arrived  at  the  opinion  that  the  use  of  ergot  is 
not  indicated  in  any  stage  of  labor,  but  that  after  the 
uterus  is  completely  emptied  of  its  contents  it  may 
prove  valuable  in  the  prevention  of  post-partuni  hem- 
orrhage. Dr.  T.  More  Madden,  of  Dublin,  joins  issue 
with  these  conclusions,  and  holds  to  the  view  that 
under  many  conditions  of  labor  the  use  of  ergot  is 
most  beneficial.  Dr.  Madden's  experience  has  been 
so  extensive  that  his  opinion  must  carry  weight.  He 
says  that,  as  regards   the  circumstances  under  which 


ergot  may  be  employed  in  midwifery  practice,  "  judg- 
ing from  the  recent  literature  of  this  subject,  it 
may  not  be  superfluous  to  premise  that  to  use  ergot 
or  any  of  its  preparations  safely  and  effectively 
during  parturition  the  presentation  should  as  a 
rule  be  cranial ;  that  there  should  be  no  dispro- 
portion between  the  foetus  and  maternal  parts,  nor  any 
obstacle  to  a  deliverance  in  the  genital  tract;  that 
the  OS  uteri,  if  not  previously  fully  dilated,  should  at 
least  be  sufficiently  dilatable  to  allow  speedy  deliv- 
ery by  the  forceps  whenever  that  may  become  neces- 
sary; and  that  a  preparation  of  ergot  should  be  se- 
lected and  a  dose  given  calculated  to  produce  the 
required  ecbolic  effect.  Under  such  conditions  ergot 
may  be  given  with  utility  when  required  either  before, 
during,  or  after  ihe  second  stage  of  labor,  viz. :  ist.  In 
some  instances :  (a)  of  delay  from  inertia  of  the  uterus 
before  full  dilatation  of  the  dilatable  os  and  in  which 
there  is  any  evident  danger  to  either  mother  or  child 
from  protraction  of  labor.  2d.  It  may  be  adminis- 
tered during  the  second  stage ;  (6)  in  nearly  every 
case  of  long  delay  from  inertia  wherein  the  presenta- 
tion is  natural  and  the  delivery  not  otherwise  impeded, 
or  in  which  (<)  there  is  then  reason  to  apprehend  either 
the  probability  of  subsequent  hemorrhage  or  any 
such  complication  as  may  call  for  its  use.  3d.  Dur- 
ing the  last  stage  of  labor  this  ecbolic  may  be  em- 
ployed (if)  to  hasten  the  expulsion  of  the  placenta 
when  delayed  by  inertia,  or  (e)  for  the  arrest  of  hem- 
orrhage. 4th.  After  labor  ergot  may  be  resorted  to 
either  immediately  (/)  to  prevent  or  check  flooding, 
or  subsequently  (g)  to  produce  such  tonic  or  perma- 
nent contraction  as  will  effectually  seal  up  the  uterine 
vessels  and  so  lessen  the  liability  to  subsequent  septic 
invasion ;  or  (//)  to  effect  the  expulsion  of  clots  and  so 
arrest  afterpains.  5th  and  lastly,  (/)  to  stimulate  such 
contraction  as  may  quicken  or  secure  the  process  of 
involution  after  parturition."  Dr.  Madden  believes 
in  bold,  full,  and  effective  dosages  of  ergot,  and  uses 
the  fresh  liquid  extract  of  the  British  Pharmacopoeia. 
The  dose  he  gives  is  two  or  three  drachms  by  the 
mouth  and  a  drachm  by  deep  hypodermic  injection  in 
the  gluteal  region  at  the  same  time.  The  abstract  of 
one  hundred  and  fifty  cases  in  which  ergot  was  used 
in  all  stages  of  labor  as  well  as  after  the  birth  of  the 
child  are  given.  In  one  hundred  and  forty-eight  cases 
the  result  was  favorable  to  the  mother.  The  paper 
concludes  with  these  words:  "  My  experience  on  this 
subject  points  to  the  conclusion  that  the  dangers 
which  are  now  so  commonly  ascribed  to  the  use  of 
ergot  in  obstetrics  are  probably  largely  attributable 
to  its  misuse,  or  administration  in  unsuitable  cases, 
or  in  insufficient  doses,  and  therefore  furnish  no  argu- 
ment whatever  against  its  judicious  and  proper  em- 
ployment." 


En  Route  to  Moscow. — The  Normannia,  which 
was  prevented  from  sailing  on  July  29th  through  the 
discovery  of  a  crack  in  one  of  her  crank-shaft  jour- 
nals, had  on  board  thirty  physicians  from  Mexico  who 
were  bound  for  Moscow.  They  sailed  two  days  later 
on  another  vessel. 


August  7,  1897] 


MEDICAL    RECORD. 


199 


Dr.  Charles  G.  Duncan,  of  Socorro,  X.  Mex.,  has 
been  appointed  delegate  from  the  New  Mexico  Medi- 
cal Society  to  the  Montreal  meeting  of  the  British 
Medical  Association. 

Medical  Schools  in  Denver. — The  supreme  court 
of  the  State  of  Colorado  has  forbidden  the  University 
of  Colorado  from  carrjing  on  any  part  of  its  medical 
department  in  Denver,  because  the  constitution  locates 
the  university  itself  at  Boulder.  In  consequence  of 
this  the  members  of  the  faculty  resident  in  Denver 
have  resigned,  and  most  of  them  have  united  with 
the  medical  department  of  the  University  of  Denver. 
Among  those  who  have  thus  strengthened  the  Denver 
Medical  School  are  Dr.  H.  T.  Pershing  in  diseases  of 
the  mind  and  nervous  system,  Drs.  S.  G.  Bonney 
and  H.  B.  Whitney  in .  medicine.  Dr.  Charles  A. 
Powers  in  Surger}',  Dr.  Walter  A.  Jayne  in  gyna;- 
cology,  Dr.  George  B.  Packard  in  orthopeedics,  Drs.  L. 
E.  Lemen  and  J.  W.  O'Connor  in  clinical  surger}-,  Dr. 
T.  E.  Taylor  in  clinical  obstetrics,  and  Dr.  John 
Chase  in  clinical  ophthalmology.  The  faculty  of  the 
school  has  been  further  enlarged  by  the  election  of 
Dr.  P.  V.  Carlin  in  obstetrics,  Drs.  W.  H.  Bergtold 
and  W.  B.  Fenn  in  patholog)',  and  Dr.  Carroll  E. 
Edson  in  therapeutics. 

The  Results  of  the  Pennsylvania  State  Medical 
Examinations Of  four  hundred  and  forty-five  appli- 
cants for  license  to  practise  medicine  examined  by 
the  Pennsylvania  State  board  in  June  of  this  year 
eighty-three  failed  to  pass  a  percentage  of  18.56.  The 
whole  number  included  twenty  women,  of  whom  seven 
failed  to  pass.  The  examina'ions  were  said  to  have 
been  a  little  more  rigorous  than  in  previous  years.  In 
a  spirit  of  equity  the  papers  of  those  that  failed  were 
examined  a  second  time  by  the  board. 

A  Hospital  without  a  Site. — The  governor  of 
Pennsylvania  has  felt  constrained  to  veto  an  appro- 
priation for  $10,000  for  the  American  Hospital  Asso- 
ciation of  Mahanoy  Township,  Schuylkill  County,  for 
maintenance  for  the  fiscal  year  beginning  June  i, 
1898,  because  the  association  is  yet  without  a  hospital 
building  and  without  a  site  for  the  erection  of  one. 

Lehigh   Valley  (Pa.)  Medical  Association The 

seventeenth  annual  meeting  of  the  Lehigh  Valley 
Medical  Association  was  held  at  Water  Gap,  Pa.,  on 
July  28th  and  29th.  Dr.  L.  Duncan  Bulkley,  of  New 
York,  delivered  an  address  on  "The  Importance  of 
Little  Things  in  Dermatolog}-."  Dr.  Mary  Green- 
wald,  of  Stroudsburg,  was  elected  President;  Drs. 
Howell,  of  Wilkesbarre, Wilson,  of  Bethlehem,  Mensch, 
of  Montgomery  County,  and  W.  C.  Albertson,  of 
Belvidere,  Vice-Presidents ;  Dr.  Charles  Mclntire,  of 
Easton,  Secretary;  Dr.  W.  S.  Stewart,  of  Wilkes- 
barre, Assistant  Secretary;  Dr.  A.  Stout,  of  Beth- 
lehem,  Treasurer. 

The  Indian  Territory  Medical  Association.— At 
the  regular  semiannual  meeting  of  this  association, 
held  at  South  McAlester,  I.  T.,  June  29  and  30,  1897, 


the  following  officers  were  elected  for  the  ensuing 
year:  President,  Dr.  E.  N.  Allen,  South  McAlester, 
I.  T. ;  First  Vice-President,  Dr.  G.  W.  \\est,  Eufala,  I. 
T. ;  Second  Vice-President,  Dr.  J.  B.  Roleter,  Oklohoma 
City,  O.  T. ;  Secretary,  Dr.  LeRoy  Long,  Caddo,  I.  T. 
The  next  meeting  of  the  association  will  be  held  at 
Muskogee,  I.  T.,  December  7  and  8,  1897. 

An  Alumni  Association  of  the  German  Hospital 
in  this  city  has  been  organized  with  the  following 
officers:  /V<fJw!?«/,  William  K.  Kubin;  Vice-President, 
Franz  Torek;  Treasurer,  Alexis  V.  Moschcowitz;  Re- 
cording Secretary,  Selian  Neuhof;  Corresponding  Sec- 
retary, Gustav  G.  Fischlowitz.  The  association  will 
hold  semiannual  meetings  in  April  and  November  of 
each  year. 

The  International  Congress.— Drs.  Danilevski,  of 
Kharkov,  and  Fre'de'ricq,  of  Lie'ge,  will  not  deliver 
addresses  at  the  general  meetings.  In  place  of  them 
Dr.  Metschnikoff  will  deliver  an  address  on  "The 
Plague,"  and  Dr.  Lannelongue  one  on  "  The  General 
Treatment  of  Surgical  Tuberculosis."  There  is  some 
complaint,  apparently  well  founded,  of  dilatoriness  on 
the  part  of  the  management  of  the  congress.  No  in- 
formation concerning  hotel  accommodation,  transpor- 
tation, etc.,  was  given  out  until  it  was  too  late  for 
many  living  at  a  distance  from  Moscow  to  profit  by  it. 
The  oflFer  of  free  railway  tickets  in  Russia  is  very  lib- 
eral, but  as  it  applies  only  to  those  who  have  cards  of 
membership,  several  from  this  countrj-  who  have  sent 
their  subscription  but  received  neither  membership 
card  nor  receipt  are  unable  to  avail  themselves  of  the 
offer. 

Substantial  Recognition  of  Dr.  Sanarelli's  Ser- 
vices.— The  L'ruguay  legislature  has  conferred  honor- 
arj-  citizenship  upon  the  discoverer  of  the  yellow-fever 
microbe,  and  has  also  voted  him  a  donation  of  ten 
thousand  dollars,  at  the  same  time  recording  its  regret 
that  "the  unhappy  condition  of  the  country  does  not 
admit  of  its  doing  more  to  evince  its  gratitude  to  a 
physician  and  naturalist  who  has  already  laid  those 
regions  under  so  many  obligations." 

News  for  New  Yorkers. — The  heat-«ave  that  has 
recently  rolled  over  the  L'nited  States  now  happily 
shows  signs  of  abatement.  Since  the  first  of  this 
month,  however,  about  two  thousand  cases  of  severe 
prostration  and  three  hundred  and  fifty  deaths  due  to 
the  excessive  heat  have  been  reported  in  New  York 
alone.  The  deathrate  in  other  parts  of  the  States 
has  registered  a  corresponding  increase.  It  looks  as 
if  the  elements  have  chosen  that  part  of  North  Amer- 
ica as  their  special  arena  when  they  want  to  "run 
amuck." — Medical  Press  and  Circular,  July  14,  1897. 

Burned  by  Roentgen  Rays — The  daily  papers 
report  a  case  of  extensive  burning  by  .r-rays  in  the 
person  of  a  young  woman  who  was  skiagraphed  in 
order  to  determine  the  nature  of  a  supposed  aflfection 
of  the  antrum  of  Highmore.  It  is  stated  that  all  the 
hair  has  fallen  from  one  side  of  her  head  and  that  the 
skin  of  the  face  and  neck  was  also  blistered  over  a 
large  siuiace. 


MEDICAL    RFXORD. 


[Aug-ust  7,  1897 


A  Hospital  Quarrel Owing  to  differences  which 

have  arisen  between  the  medical  board  and  one  of  the 
consulting  surgeons  of  the  Bayonne  Hospital,  it  is  re- 
ported that  the  board  of  managers  has  removed  the 
entire  consulting  staff.  It  is  understood,  however,  that 
all  will  be  reappointed  with  the  exception  of  the  one 
member  whose  action  in  a  certain  case  was  the  cause 
of  the  dissension. 

Malaria  Following  Flood. — It  is  reported  that 
malaria  prevails  to  an  unusual  degree  along  the  Mis- 
sissippi lowlands  which  were  flooded  by  the  high 
water  last  spring.  When  the  flood  receded  many 
lakes  and  pools  of  stagnant  water  remained,  and  to  the 
presence  of  these  is  attributed  the  increase  in  the 
prevalence  and  mortality  of  the  disease. 

An  Unpleasant  Interruption  to  an  Excursion — 
Twenty-seven  American  tourists  are  on  board  of  the 
steamer  Passport  in  Toronto  Bay  in  quarantine.  They 
arrived  there  from  Montreal  on  August  ist  and  in- 
tended to  leave  by  train  for  their  homes  the  same  day, 
but  the  medical  health  officer  at  Toronto  met  the 
steamer  with  a  tug  and  informed  the  captain  that  there 
was  a  small-pox  case  on  board  and  that  the  passengers 
and  crew  would  have  to  remain  in  quarantine  twelve 
days.  The  man  who  was  the  cause  of  the  detention 
had  been  under  observation  at  Belleville,  but  escaped 
and  boarded  the  steamer  when  she  touched  there. 

The  Water  Supply  of  Boston The  State  of  Mas- 
sachusetts has  undertaken  to  supply  the  metropolitan 
water  district,  including  Boston  and  twenty-seven  other 
towns  and  cities,  with  pure  water  from  an  immense 
lake,  nine  miles  in  length,  covering  forty-one  hundred 
and  ninety-five  acres,  three  hundred  and  eighty-five 
feet  above  high-water  mark,  and  with  an  average 
depth  of  forty-six  feet.  It  is  to  take  the  place  of  what 
is  now  a  busy  manufacturing  district  in  the  valley  of 
the  upper  Nashua  River.  The  greater  part  of  two 
towns  and  five  villages,  including  churches,  schools, 
the  houses  of  seventeen  hundred  and  eleven  people, 
two  large  mills,  and  hundreds  of  small  farms  will  be 
wiped  out  of  existence  to  provide  for  this  enormous 
reservoir.  Its  construction  made  necessary  the  pas- 
sage of  a  law,  said  to  be  without  a  precedent  in  this 
country,  which  provides  that  the  State  shall  pay  to 
such  employees  of  the  mills  at  the  time  of  the  confis- 
cation of  the  property  a  sum  equal  to  six  months' 
wages.  The  State  also  treats  liberally  people  with 
established  businesses,  the  value  of  which  the  seizure 
of  land  for  reser\'oir  uses  completely  destroyed,  by  a 
liberal  allowance  for  accumulative  or  prospective 
damages.  When  all  this  is  done,  the  people  of  Mas- 
sachusetts will  have  a  bill  variously  estimated  at  from 
$30,000,000  to  $50,000,000  to  pay. —  The  Sanitary 
Era. 

Suicide  a  la  Parisienne — Four  seamstresses  in 
Paris  recently  decided  that  life  was  not  worth  while, 
and  perhaps  they  had  cause  to  be  tired  of  it,  for  the 
husband  of  the  eldest,  who  was  but  twenty-five  years 
old,  was  insane,  another  had  been  deserted  by  her 
husband,  the  third  had  been  jilted  by  her  lover,  while 
the  youngest,  aged  seventeen  years,  joined  the  others 


out  of  sympathy.  They  dined  together  one  day  and 
then  passed  a  jolly  evening,  drinking  cherry  brandy. 
When  the  bottle  was  empty  they  signed  a  statement 
to  the  effect  that  they  died  with  pleasure,  closed  the 
door  and  windows  tightly,  and  then  lighted  a  charcoal 
fire,  the  fumes  of  which  killed  them.  One  of  the 
women  was  the  great-grandniece  of  a  former  arch- 
bishop of  Paris,  who  was  executed  during  the  reign  of 
terror. 

Obituary  Notes Dr.  John    Joseph   Curran,  of 

this  city,  died  two  weeks  ago  of  heart  disease.  He 
was  thirty-seven  years  old  and  was  bom  in  Newport, 
R.  I.  After  graduation  from  St  Francis  Xavier's 
College,  he  studied  medicine  at  the  College  of  Physi- 
cians and  Surgeons,  where  he  received  his  degree  of 
M.D.  in  1888.— Dr.  E.  M.  Ike,  of  Altoona,  Pa.,  died 
on  July  29th  as  a  result  of  a  laceration  of  the  hand  by 
a  broken  bottle.  He  was  bom  March  21,  1867,  and 
was  graduated  from  Jefferson  Medical  College  in 
1888. 

Results  of  a  Tank  Inspection. — The  special  in- 
spection of  water  tanks  in  tenement  houses  ordered  by 
the  board  of  health  last  month  has  resulted  in  the 
discovery  that  1,343  out  of  6,060  tanks  examined  were 
in  an  improper  condition.  The  board  has  ordered  the 
owners  of  the  buildings  in  which  the  unhealthy  tanks 
were  found  to  cleanse  them  forthwith. 

The  St.  Louis  "  Smoker." — In  a  recent  issue  we 
published  a  charge  made  by  the  Medical  Fortnightly 
that  a  '■  smoker"  held  recently  at  St.  Louis  degener- 
ated into  such  disgusting  story  telling  that  several  of 
the  invited  guests  were  compelled  to  leave  the  room. 
As  a  matter  of  fair  play  we  also  inserted  a  refutation 
of  the  charge,  glad  of  the  opportunity  to  do  so  without 
any  expression  of  opinion  on  our  part.  Since  then  we 
have  received  a  letter  from  Dj.  Norbury,  editor  of  the 
Fortnightly,  reiterating  the  charges,  and  from  his  stand- 
point substantiating  them  on  the  testimony  of  several 
gentlemen  who  were  present.  We  mention  these  facts 
in  order  to  say  that  we  hardly  think  it  worth  while  to 
discuss  the  subject  further,  being  willing  to  give  any 
benefit  of  doubt  on  the  side  of  a  charitable  con- 
struction of  the  difference  of  opinion,  thus  impliedly 
holding  up  tlie  decency  and  dignity  of  the  profession 
as  a  whole.  We  cannot  see  that  anything  more  can 
come  of  this  by  further  discussion  of  the  pros  and  cons. 

The  Rocky  Mountain  Interstate  Medical  Associ- 
ation.— This  is  an  organization  of  the  regular  medical 
profession  of  Colorado,  Utah,  Montana,  Idaho,  Wyo- 
ming, New  Mexico,  and  Arizona.  The  idea  of  this 
society  was  formulated  by  Drs.  C.  K.  Fleming,  J.  W. 
Hull,  Leonard  Freeman,  and  Robert  Levy,  of  Denver, 
Col.,  in  the  summer  of  1896.  A  circular  letter  was 
sent  by  them  to  prominent  physicians  inviting  their 
opinion  as  to  the  desirability  of  such  a  society  and 
their  co-operation  in  its  organization.  The  plan  re- 
ceived the  hearty  and  almost  universal  approval  of  in- 
dividual physicians  as  well  as  the  indorsement  of  the 
Colorado,  Utah,  and  Montana  State  medical  societies. 
Accordingly  a  committee  of  three,  from  each  of  these 
seven  States,  was  appointed  to  draft  a  constitution  and 


August  7,  1897] 


MEDICAL    RECORD. 


bylaws  and  to  organize  the  society.  This  committee 
met  at  the  Knutsford  Hotel  in  Salt  Lake  City,  July 
24,  1897,  with  the  following  members  present,  viz.: 
Colorado:  Drs.  C.  K.  Fleming,  Clayton  Parkhill,  and 
D.  H.  Coover,  of  Denver.  Utah :  Drs.  C.  P.  Hough, 
C.  G.  Plummer,  and  A.  S.  Bower,  of  Salt  Lake  City. 
Montana:  Drs.  C.  K.  Cole,  of  Helena;  Henr)-  Chap- 
pie, of  Billing,  and  T.  J.  Murray,  of  Butte  City. 
Wyoming:  Dr.  E.  Stuver,  of  Rawlins.  The  com- 
mittee organized  by  electing  C.  P.  Hough  president, 
and  E.  Stuver  secretary,  and  at  once  proceeded  to  the 
consideration  and  adoption  of  a  constitution  and  by- 
laws. The  code  of  ethics  of  the  American  Medical 
Association  was  adopted.  The  following  officers  were 
elected  for  the  ensuing  year,  viz. :  Charles  P.  Hough, 
President,  Salt  Lake  City:  C.  K.  Qo\t,  First  I'ice- 
President,  Helena,  Mont.;  Cla)-ton  Parkhill,  Second 
Vice-President,  Denver,  Col. ;  E.  Stuver,  Secretary  and 
Treasurer,  Rawlins,  Wyo.  It  was  decided  to  hold  the 
first  annual  meeting  in  Denver,  in  June,  1898,  during 
the  meeting  of  the  American  Medical  Association. 

Death  and  Honorary  Distinction — ^L  Capiat,  di- 
rector of  the  Departmental  Asylum  of  Nanterre,  in 
France,  who  received  the  cross  of  the  Legion  of 
Honor  on  the  occasion  of  a  visit  paid  to  that  place  by 
President  Faure,  died  the  following  day  from  e.xcessive 
joy.  A  knighthood  of  the  same  order  also  proved 
fatal  to  an  architect  of  the  Assistance  Publique. 

Inflammable  Hair  Wash. — A  woman  in  London 
died  recently  from  burns  received  through  the  ignition 
of  a  petroleum  hairwash  which  was  being  applied  to 
her  head  by  a  hairdresser.  There  was  no  open  tlame 
near  her  at  the  time,  and  the  explanation  given  of  the 
accident  is  that  the  inflammable  material  was  set  lire 
to  by  an  electric  spark  produced  by  the  friction  of  the 
barber's  hand  on  the  hair. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
ger\-,  Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  na\y  for  the  week  ending 
July  21,  1897.  July  27th. — Passed  Assistant  Surgeon 
-S.  S.  V.'hite  ordered  to  report  on  the  Concord  imme- 
diately. July  28th. — Surgeon  J.  D.  Gatewood  ordered 
to  Brussels,  Belgium,  and  Berlin,  Germany,  as  dele- 
gate, then  to  return.  July  29th. — .\ssistant  Surgeon  J. 
C.  Thompson  ordered  to  the  naval  laboratory,  .New 
York.  Surgeon  H.  E.  Ames,  when  detached  from  the 
Cincinnati,  ordered  home  and  granted  two  months' 
leave.  Surgeon  J.  E.  Gardner  detached  from  the  Arn- 
phitrite  and  ordered  to  the  Dolphin.  Surgeon  F. 
.\nderson  detached  from  the  Dolphin  and  ordered  to 
the  hospital,  Yokohama,  per  steamer  of  August  1 4th. 
.Surgeon  H.  G.  Beyer  detached  from  Museum  of  Hy- 
giene and  ordered  to  the  Amphitrite.  July  30th. — 
Passed  Assistant  Surgeon  T.  B.  Bailey  detached  from 
the  AJachias  and  ordered  to  the  Yorktown.  Passed 
.\ssistant  Surgeon  J.  S.  Page  detached  from  the  York- 
toii'n  and  ordered  to  the  Olympia.  Passed  .Assistant 
Surgeon  G.  Rotliganger  detached  from  the  J'inta  and 
ordered  to  the  IVheelin;^  .Vugust  loth.  Passed  .Assist- 
ant Surgeon  M.  R.  Pigott  detached  from  the  Olympia 
and  ordered  to  the  Macliias. 


©bitttJir^. 

JOHN    J.  H.  LOVE,  M.D. 

MONTCLAIR,    N.  J. 

Dr.  Johx  J.  H.  Love  died  suddenly  on  the  morning 
of  July  30th,  while  at  the  bedside  of  a  patient.  L'p 
to  the  moment  that  he  was  stricken  he  had  apparently 
been  in  tlie  enjoyment  of  perfect  health. 

Dr.  Love  \\as  bom  in  Harmony  Township,  N.  J., 
on  April  3,  1833.  He  was  educated  at  Lafayette  Col- 
lege, subsequently  taking  his  medical  course  at  the 
New  York  L^niversitv-  Medical  School,  where  he  ob- 
tained his  degree  of  M.D.  in  1855.  ^^  ^^  once 
began  practice  in  Montclair.  At  the  breaking  out  of 
the  civil  war  he  enlisted,  serving  as  surgeon  to  the 
thirteenth  New  Jersey  volunteers,  and  later  in  the 
twelfth  corps  of  the  army  of  the  Potomac.  At  the 
close  of  the  year  1864  he  received  an  honorable  dis- 
charge and  returned  to  Montclair,  where  he  resided 
continuously  up  to  the  time  of  his  death.  He  was 
always  prominently  identified  with  the  interests  of 
Montclair,  which  was  but  a  comparatively  small  vil- 
lage \vhen  he  first  went  there  to  live,  although  he 
never  held  any  public  office  except  that  of  school  com- 
missioner. It  was  in  great  measure  to  his  labors  that 
the  present  public-school  system  of  Montclair  owed 
its  existence,  and  he  was  always  occupied  in  some 
capacit)-  with  its  ntanagement,  first  as  trustee  and 
later,  under  the  changed  system,  as  commissioner. 
He  was  one  of  the  organizers  of  Trinit}-  Church  in 
Montclair  and  was  on  its  board  of  trustees.  He  was 
also  active  in  the  establishment  of  the  Young  Men's 
Christian  Association  and  in  the  foundation  of  a  pub- 
lic library-.  He  was  a  founder  of  the  Montclair  Club 
and  of  the  Bank  of  Montclair,  was  a  member  of  the 
Loyal  Legion,  of  the  Grand  Army  of  the  Republic, 
and  of  many  medical  societies. 

On  Tuesday,  April  16,  1895,  a  banquet  was  given 
to  Dr.  Love  in  the  Montclair  clubhouse,  on  the  for- 
tieth anniversar}-  of  his  coming  to  the  town  to  prac- 
tise, in  recognition  of  his  ser\-ices  to  the  community. 
Over  two  hundred  guests,  laymen  and  physicians  of 
Montclair  and  neighboring  places,  were  present. 
Congratulatory  addresses  were  made  by  Mr.  John  H. 
Wilson,  who  presided,  and  by  Messrs.  Philip  Dore- 
mus,  Edwin  B.  Goodell,  John  R.  Howard,  Starr  J, 
Murphy,  Dr.  George  F.  Shrady,  Hon.  Franklin  Mur- 
phy, and  the  Rev.  Dr.  A.  H.  Bradford. 

Dr.  Love  was  a  man  who  did  his  dutj'  and  more 
than  his  dnX\  in  every  station  in  which  he  was  placed, 
whether  as  a  soldier,  a  public-spirited  citizen,  a  man 
of  family,  or  a  physician.  His  many  acts  of  kindness 
and  of  unostentatious  charitj-  endeared  him  to  all  his 
patients,  and  his  sterling  qualities  as  a  man  and  a 
citizen  raised  up  for  him  a  host  of  friends  and  ad- 
mirers such  as  it  is  given  to  few  men  to  possess. 

The  funeral  services  were  held  on  Mondaj-  after- 
noon, not  in  the  church  which  he  attended,  but  in  the 
Congregational  Church,  that  being  selected  because  it 
was  the  largest  in  the  town,  yet  numbers  \\ere  unable 
to  gain  admission.  The  services  were  conducted  by 
the  Rev.  Orville  Reed,  pastor  of  Trinit}-  Church. 
.\mong  the  pallbearers  were  Joseph  Van  V leek,  John 
R.  Howard,  Philip  Doremus,  John  R.  Livermore,  and 
the  medical  staff  of  the  Mountainside  Hospital,  Drs, 
Whitehome,  Brown,  Halsey,  Case,  Francis,  and  New- 
ton. Delegations  were  present  in  the  church  from  the 
veterans  of  the  thirteenth  New  Jersey  volunteers,  the 
Loyal  Legion,  the  Grand  Army  of  the  Republic,  and 
from  the  various  business,  social,  and  medical  associa- 
tions with  which  Dr.  Love  was  identified.  Dr.  Love's 
wife,  son,  and  two  daughters  survive  him. 


202 


MEDICAL    RECORD. 


[August  7,  1897 


O^Unical  gepavtmcut. 

A    CASK    OF    MIGRATORY     PNEUMONIA     IN 
A  PARTURIENT  WOMAN. 

r,\    U.    P.    RITCHIE,    M.l)., 


The  following  is  a  brief  report  of  a  case  of  lobar  pneu- 
monia, which  is  of  exceptional  interest  because  of  its 
unusual  course,  extreme  severity,  and  happy  termina- 
tion. 

Mrs.  B ,  aged  thirty,  seamstress,  family  and  per- 
sonal health  record  negative,  was  delivered  by  me,  on 
September  19,  1896,  of  her  fourth  child,  after  a  per- 
fectly normal  labor,  from  which  she  made  a  rapid  and 
uneventful  recovery. 

On  October  i  itli  she  first  ventured  from  the  house, 
and  some  hours  after  her  return  was  seized  with  a  pro- 
nounced chill  and  severe  pain  in  the  right  lower  tho- 
rax. The  onset  was  marked  and  sudden,  she  being 
engaged  at  that  time  in  her  ordinary  household  duties 
and  having  no  premonition  of  the  attack.  Five  hours 
after  the  onset  her  temperature  was  103''  F. ;  pulse, 
no;  respiration,  28,  accompanied  by  severe  pain. 
The  classical  signs  of  consolidation  soon  manifested 
themselves  in  the  right  lower  lobe,  and  the  case  ap- 
peared to  be  on 2  of  frank  lobar  pneumonia. 

When  she  was  seen  on  the  third  day  a  friction  mur- 
mur was  present  over  the  extreme  right  base,  and  with 
a  small  area  of  movable  flatness  determining  the  pres- 
ence of  a  complicating  pleurisy  with  a  small  effusion. 

During  the  night  of  the  16th  the  crisis  occurred, 
and  when  she  was  seen  on  the  morning  of  the  17th 
her  temperature  was  98.4°  F. ;  pulse,  96 ;  respiration 
easy,  and  patient  comfortable.  Strict  instructions  as 
to  rest  in  bed  were  given  and  wholly  disregarded  by 
the  patient,  and  on  the  evening  of  the  same  day  I  was 
called  to  find  the  patient  just  recovering  from  a  severe 
chill,  with  dyspncea,  pain  in  both  apices,  temperature 
of  103°  F.,  and  pulse  of  140. 

The  next  day  Dr.  Charles  L.  Greene  kindly  saw  the 
case  with  me,  and  involvement  of  both  apices  was  sus- 
pected and  later  confirmed  by  unmistakable  signs  of 
consolidation.  The  middle  lobe,  however,  remained 
free  from  consolidation,  although  the  breath  sounds 
were  much  exaggerated.  The  percussion  note,  how- 
ever, was  hyperresonant,  and  the  changes  in  the  pitch 
in  the  descent  from  tlie  dull  note  of  the  apex  to  the 
hyperresonance  of  the  middle  lobe,  and  thence  to  the 
duller  note  of  the  consolidated  but  resolving  lower 
right  lobe  anteriorly,  and  to  the  fiat  note  over  the  fluid 
in  the  back,  were  very  marked.  Thus  at  this  time  the 
act  of  respiration  was  carried  by  the  right  middle  and 
left  lower  lobes. 

On  October  20th  there  was  increased  expectoration; 
large  rales  appeared  anteriorly  in  the  right  lower  lobe, 
while  the  note  posteriorly  was  obtained  over  a  smaller 
area.  Both  apices  presented  most  pronounced  and 
typical  signs  of  consolidation:  accentuation  of  pul- 
monary second  sound  remained  well  marked. 

On  (October  21st,  right  lobe  resolving,  no  change  in 
apices.  Temperature,  102°  F.;  respiration,  35  ;  pulse, 
118.  Widal's  test  for  typhoid  fever  was  tried,  with 
negative  results. 

Phis  condition  continued  until  October  25th,  when 
the  temperature  dropped  to  100.4°  F. ;  with  respira- 
tion, 26;  pulse,  96  and  strong.  Breathing  was  easy 
and  there  was  profu.se  expectoration  of  rusty  sputum. 
Rales  of  resolution  had  appeared  over  the  upper  lobes, 
and  the  patient  was  very  comfortable.  'Plie  tempera- 
ture, however,  continued  to  run  irregularly  from  100 
to  102°  F.  for  several  days. 

On  October  29th,  the  eighteenth  day  of  her  illness, 


I  was  again  called,  to  find  the  patient  in  chill  and 
complaining  of  intense  pain  in  the  left  lower  lobe. 
Dyspnoea  was  extreme  and  cyanosis  marked. 

On  the  morning  of  the  30th  Dr.  Greene  was  again 
consulted,  and  consolidation  of  the  left  lower  lobe  was 
determined.  Temperature  mounted  to  104"  F. :  pulse, 
146;  panting.  The  pulmonary  second  sound  was 
for  the  first  time  very  weak,  the  closure  of  the  valve 
imperfect,  and  the  patient  seemed  to  be  almost  in  ar- 
tliiilo  mortis.  Fortunately  the  right  lower  lobe  was  in 
its  twelfth  day  of  resolution  and  the  apices  were  in 
their  fourth  day,  but  at  the  best  there  must  have  been 
but  little  function.  \et  the  laboring  heart  responded 
grandly  to  stimulation,  and  upon  November  2d,  the 
third  day,  the  temperature  fell  to  loi  '  F.,  with  pulse  of 
107,  and  respiration  of  28,  deeper  and  easier.  The 
fever  ran  from  100°  to  102"  F.  during  the  next  week, 
but  gradually  came  to  normal,  and  at  the  end  of  the 
next  four  weeks  the  lungs  had  practically  cleared  up. 

On  November  i  2th  signs  of  inflammation  of  the  right 
saphenous  vein  occurred,  which  condition  progressed 
to  a  pronounced  phlebitis,  which  kept  the  patient  in 
bed  for  six  weeks. 

Until  Januar}-  2d  I  heard  nothing  further  of  the  case. 
Then  I  was  called,  to  find  her  in  a  semiconscious 
condition,  with  a  partial  paralysis  of  the  left  side. 
This  condition  persisted  for  several  hours  and  passed 
away,  leaving  only  a  slight  impairment  of  sensation, 
which  returned,  however,  in  a  short  time. 

Mv  patient,  therefore,  suffered  from  three  distinct 
and  successive  attacks  of  lobar  pneumonia,  involving 
in  turn  the  right  lower  lobe,  both  apices,  and  the  left 
lower  lobe,  with  an  accompanying  pleurisy  with  small 
effusion  on  the  right  side,  and  had  as  sequela;  phlebi- 
tis and  a  transitory  paralysis,  probably  due  to  em- 
bolus. 

The  unusual  clinical  features  make  the  case  one  of 
exceptional  interest. 


A    CASE    OF   DOUBLE    PULMONIC   MURMUR, 
WITH   DIASTOLIC  THRILL. 


Bv     T.    N.    H.ALL,    M.U., 


Well-m.\rked  disease  of  the  pulmonarj-  valves  in 
adult  life  is  sufficiently  infrequent  to  make  the  follow- 
ing case  worthy  of  record: 

Mrs.  R.  M ,  twenty-four  years  of  age,  with  no 

family  history  of  importance  in  this  connection,  pre- 
sented herself  at  the  medical  clinic  of  the  University 
of  Colorado  six  months  ago.  She  had  one  healthy 
child,  twelve  months  of  age;  no  other  labors.  Al- 
though subject  to  severe  attacks  of  bronchitis  for  some 
years,  especially  in  winter,  her  babyhood  and  child- 
jiood,  with  the  exception  of  whooping-cough,  were 
apparently  free  from  serious  disease.  'I'here  was  no 
history  of  rheumatism. 

She  complained  of  cough,  expectoration,  and  dysp- 
naa,  and  presented  high  temperature  and  rapid  pulse, 
with  moderate  dulness  and  moist  rales  in  both  bases, 
especially  behind.  I  examined  the  lieart,  with  nega- 
tive result.  Phe  patient  was  sent  to  her  home  and 
treated  by  Miss  C.  L.  Moore,  a  senior  student,  she  re- 
porting to  me  upon  the  progress  of  the  case,  which  I 
did  not  see  again.  Although  the  dy.spnoea  was  very 
marked,  recovery  ensued  after  a  febrile  course  of  about 
ten  days.  The  case,  although  not  typical,  was  regarded 
as  one  of  pneumonia.  Miss  Moore  examined  the  en- 
tire chest  frequently  during  tiie  illness,  without  noting 
anything  unusual  in  the  heart's  action. 

One  month  ago  the  patient  applied  for  treatment  for 


August  7,  1897] 


MEDICAL    RECORD. 


203 


a  severe  bronchitis,  sonorous  and  sibilant  rales  being 
heard  through  the  clothing  with  the  unaided  ear  by 
the  student  detailed  to  the  case.  In  verifying  the  stu- 
dent's report,  I  heard,  in  addition  to  the  rales  men- 
tioned, a  very  loud  and  unusual  murmur  over  the  heart. 
The  chest  having  been  stripped  to  complete  the  exam- 
ination, the  following  conditions  were  noted: 

The  patient  was  well  developed,  of  natural  color, 
with  the  exception  of  slight  anamia,  and  presented  no 
oedema,  lividity,  or  clubbing  of  the  fingers.  Weight, 
one  hundred  and  thirty-five  pounds.  Temperature, 
normal;  pulse,  100;  respiration,  34  in  a  state  of  rest, 
but  increasing  in  frequency  upon  slight  exertion. 
Abundant  rough,  sonorous,  and  sibilant  rales  through- 
out the  chest,  without  perceptible  dulness.  Cardiac 
dulness  increased  moderately  upward  and  to  the  right, 
and  nearly  to  the  nipple  line  to  the  left.  Apex  beat 
just  within  this  line  in  the  fifth  space.  Valvular 
sounds  of  heart  normal,  excepting  over  the  pulmonic 
region. 

Here  there  was  heard  a  very  loud,  whizzing,  hum- 
ming murmur,  continuous,  but  accentuated  at  the  be- 
ginning of  systole,  and  changing  in  timbre  at  the  time 
of  occurrence  of  the  normal  second  sound,  which 
sound,  however,  could  not  be  made  out  over  the  pul- 
monic area.  The  murmur,  after  the  change  of  timbre 
noted,  continued,  louder  than  before,  until  the  next 
systole.'  There  was  not  the  perfectly  distinct  inter- 
mission between  the  two  parts  of  this  murmur  heard 
in  double  murmurs  at  the  aortic  and  the  mitral  valves. 
The  systolic  portion  of  this  murmur  was  transmitted 
much  less  distinctl}-,  especially  downward,  over  the 
precordial  area,  than  the  diastolic,  but  was  heard  with 
great  distinctness  between  the  left  scapula  and  the  spi- 
nal column,  where  the  diastolic  murmur  was  inaudible. 
The  diastolic  portion  of  the  murmur  was  transmitted 
most  strongly  downward,  especially  toward  the  apex, 
but  was  heard  quite  distinctly  over  the  entire  precor- 
dia.  Over  the  second  interspace,  covering  an  area  of 
about  the  size  of  a  silver  dollar,  was  a  purring  thrill, 
very  distinctly  diastolic  and  occupying  the  entire 
diastole. 

The  bronchitis  disappeared  after  about  two  weeks, 
and  the  patient  was  exhibited  at  the  meeting  of  the  Den- 
ver and  Arapahoe  Medical  Society,  March  23,  1897. 
She  was  examined  by  many  members  of  the  society, 
and  there  was  no  dissent  as  to  the  presence  of  the 
signs  described,  although  some  discussion  occurred  as 
to  their  interpretation. 

My  own  theory  as  to  the  origin  of  the  disease  and 
the  interpretation  of  the  signs  is  as  follows,  viz. :  that 
she  suffered  for  years  previously,  possibly  from  birth, 
from  some  defect  in  the  pulmonary  valve  not  giving 
rise  to  distinct  physical  signs.  The  frequent  and  se- 
vere attacks  of  bronchitis  furnish  ground  for  such  a 
suspicion.  The  attack  of  pneumonia,  a  disease  which 
is  prone,  as  we  know,  to  light  up  an  endocarditis,  may 
well  have  caused  a  sudden  increase  in  such  a  valvular 
trouble  if  of  endocarditic  nature,  or  may  have  origi- 
nated an  endocarditis  </<•  >io7'i)  upon  a  congenitallv  de- 
formed valve.  At  least,  the  rapid  development  of  the 
physical  signs  since  the  pneumonia  would  certainly 
lead  one  to  connect  this  disease  with  the  valvular 
trouble. 

The  systolic  portion  of  the  murmur,  rough  and 
transmitted  into  the  back,  leads  me  to  infer  a  narrow- 
ing of  the  pulmonic  orifice,  while  the  diastolic  portion, 
with  distinct  thrill,  leaves  no  room  for  doubt,  I  be- 
lieve, as  to  the  existence  of  pulmonic  insufficiency. 

The  only  case  comparable  to  this  one  which  has 
come  under  my  observation  I  saw  but  once,  the  woman 
suffering  at  the  time  from  an  attack  of  colic.  She  was 
thirty  years  of  age,  and  had  experienced,  ten  years 
previously,  a  very  severe  attack  of  measles.  Three 
months  before  she  had  nearlv  died  from  an  attack  of 


puerperal  fever  following  an  instrumental  labor;  and 
she  also  gave  a  history  of  a  mild  attack  of  acute  rheu- 
matism. So  far  as  the  organs  within  the  chest  were 
concerned,  she  complained  only  of  palpitation  and 
dyspnoea  upon  exertion. 

The  area  of  cardiac  dulness  was  slightly  enlarged, 
and  she  presented  the  following  murmurs,  without 
thrill,  viz. : 

(a)  An  apical  systolic  murmur,  transmitted  into  the 
axilla,  having  the  usual  characteristics  of  the  murmur 
of  mitral  regurgitation. 

(1*)  A  diastolic  murmur,  heard  most  distinctly  over 
the  aortic  area,  transmitted  toward  the  lower  end  of 
the  stemimi  and  slightly  to  the  left,  prolonged,  and 
rather  rough  in  character. 

(<■)  A  diastolic  murmur,  soft  and  blowing,  most  dis- 
tinct at  the  second  left  interspace,  of  different  timbre 
from  the  one  to  the  right  of  the  sternum,  transmitted 
directly  downward  to  the  fourth  rib. 

Between  the  locations  of  the  two  last-described  mur- 
murs was  a  space  where  neither  could  be  heard  dis- 
tinctly. I  do  not  feel,  however,  in  the  absence  of 
thrill,  in  the  presence  of  well-defined  aortic  regurgita- 
tion, and  especially  in  view  of  the  known  rarity  of  the 
affection,  that  one  could  speak  positively  of  pulmonic 
regurgitation  in  this  case,  although  I  believe  it  existed. 
I  considered  it  possibly  of  septic  origin. 

In  the  first  case.  Dr.  Charles  Denison  suggested  the 
possibility  of  pressure  upon  the  pulmonar)^  artery  by 
tuberculous  deposit  in  the  lung,  or  by  tuberculous 
glands.  In  a  careful  examination  since  the  recovery 
from  the  bronchitis,  I  was  unable  to  find  any  evidence, 
rational  or  physical,  of  such  a  condition. 


VAGINAL  HYSTERO-SALPIXGO-OOPHOREC- 
TOMY  BY  EXL'CLEATION,  WITH  THE  IN- 
DIVIDUAL LIGATION  OF  VESSELS  ONLY, 
FOR  PUERPERAL  METRITIS,  INTRAMU- 
RAL  ABSCESS,    ETC. 

By  J.    COPLIX    STINSON,    M.D.. 


The  following  case  is  reported  rather  fully,  as  it  pre- 
sented several  points  of  interest : 

Mrs.  M.  L ,  aged  thirty-three  years;  three  chil- 
dren living;  always  enjoyed  fairly  good  health;  had 
two  miscarriages;  from  the  second  she  made  a  slow 
recover}-,  being  confined  to  her  bed  for  three  months. 

The  patient  was  first  seen  by  me  March  19,  1897, 
in  consultation  with  Dr.  X".  Selling.  For  six  weeks 
previous  to  the  time  Dr.  Selling  was  called  to  the  case, 
the  patient  had  a  persistent  flow,  due  probably  to  a 
partly  detached  placenta.  The  physician  who  previ- 
ously had  charge  of  the  case  had  for  some  weeks  en- 
deavored by  rest,  vaginal  packings,  etc.,  to  carrj-  the 
patient  through  her  period  of  gestation.  When  she 
was  first  seen  by  Dr.  Selling,  her  general  condition 
was  very  poor.  She  was  in  a  fainting  condition  bor- 
dering on  collapse,  exceedingly  anarmic,  and  had  vomit- 
ing, headache,  and  intense  thirst;  rhythmical  uterine 
pains  were  accompanied  by  alarming  gushes  of  blood. 
Pulse  was  140;  temperature,  loi''  F.  (mouth);  ab- 
domen tender;  fundus  at  about  the  height  of  six  months' 
pregnancy;  os  dilated,  admitting  a  finger,  which  de- 
tected, after  removing  a  large  quantity  of  clots,  a  por- 
tion of  detached  placenta  above  the  internal  os. 

I  saw  the  case  with  Dr.  Selling  three  hours  later, 
and  on  account  of  the  urgent  condition  I  delivered 
that  same  afternoon  as  soon  as  preparations  could  be 
made.  She  was  placed  in  the  lithotomy  position,  the  os 
was  manually  dilated,  the  membranes  were  ruptured,  a 
foot  was  grasped,  the  foetus  delivered,  and  placenta  re- 
moved.    There  was  a  very  foul  odor  from  the  fcetus,  etc., 


204 


MEDKAL    RECORD. 


[August  "],  1897 


during  extraction.  Tlie  uterus  was  liglnly  curetted  and 
irrigated  witii  bichloride  solution,  followed  witli  boiled 
water.  The  patient  was  in  such  iwjor  condition  that 
no  ana;sthetic  could  be  administered.  She  vomiteti 
the  stimulants  given  her  during  the  operation.  .She 
was  given  saline  and  stimulating  enemata,  and  rectal 
feeding  was  also  resorted  to  for  several  days.  The 
uterus  was  subsequently  irrigated  twice  daily.  She 
was  given  stimulants,  tonics,  and  later  some  solid 
food,  as  soon  as  her  stomach  could  retain  it.  The  tem- 
perature gradually  rose  from  loi''  F.  (one-half  a  de- 
gree each  day)  till  it  reached  103  F.,  when  the  uterus 
was  curetted,  irrigated,  and  carbolic  acid  applied. 
The  temperature  gradually  dropped  to  10 1"^  F.,  when 
she  had  a  chill  and  the  temperature  rose  to  104  F. 
She  now  complained  of  pain  and  tenderness  in  the  left 
inguinal  region.  She  was  again  curetted  and  irri- 
gated with  bichloride  and  pero.xide  solutions.  The 
temperature  dropped  by  lysis  to  100'  F.,  and  in  a  few 
days  to  98.8  F.,  where  it  remained  for  several  days. 
Pulse  varied  now  from  100  to  105.  On  the  afternoon 
of  April  I  ithshe  had  a  slight  chill  followed  by  a  rise  of 
temperature  to  102°  F.,  and  complained  of  pain  on  the 
left  side  above  the  pubes.  Examination  showed  thick- 
ening and  tenderness  of  the  left  tube  and  ovary,  also 
some  tenderness  on  the  right  side.  The  temperature 
ran  along  between  10 1'  and  102  F.  for  several  days, 
but  on  the  evening  of  April  16th  it  reached  103.2  F. 
Her  general  condition  was  now  poor.  Thinking  that 
the  woman  might  be  saved  by  radical  measures,  pre- 
parations were  made  for  operation,  which  I  performed 
the  following  morning  at  eight  o'clock.  The  morning 
temperature  was  loi  F. ;  pulse,  i  10.  Chloroform  was 
administered  by  the  drop  method.  The  patient  was 
placed  in  the  lithotomy  position,  with  the  pelvis 
slightly  elevated  ( Eldebohls'  table).  The  uterus,  tubes, 
and  ovaries  were  removed  per  vaginam  by  enucleation, 
with  the  individual  ligation  of  vessels  only.  The 
enucleation,  which  was  somewhat  difficult  on  account 
of  the  size  and  friability  of  the  uterus,  was  facilitated 
by  using  "  long  forceps  as  temporary  haemostatics, 
levers,  and  tractors" — what  I  call  "an  addition  to  the 
enucleation  method."  Long  forceps  were  clamped 
successively  on  the  broad  ligaments  close  to  the  uterus, 
wliile  the  latter  was  from  time  to  time  separated  from 
the  former  by  blunt  dissection  aided  at  times  by  cuts 
from  the  scalpel,  keeping  very  close  to  the  uterus. 
By  mak'ing  slight  traction  on  the  severed  portions  of 
the  broad  ligaments,  using  the  forceps  as  levers  and 
tractors,  the  cut  edges  could  be  brought  well  into  view 
so  as  to  inspect  the  stumps  for  open  mouths  of  vessels, 
which  were  clamped  with  .small  forceps  and  ligated 
with  fine  catgut.  Then  the  long  clamps  were  re- 
moved, but  small  forceps  were  first  applied  at  the 
upper  angles  of  the  pedicles,  to  control  them  so  that 
the  stumps  could  be  again  inspected  Ijefore  the  gauze 
packing  was  introduced,  when  the  forceps  were  re- 
moved. Under  such  circiunstances  the  clamps  are  an 
addition  to  the  enucleation  method,  acting  temporarily 
as  levers  and  tractors,  and  as  prophylactics  against  hem- 
orrhage, while  the  severed  portions  of  the  broad  liga- 
ments are  inspected  and  the  vessels  located  and  ligated. 
Three  arteries  were  ligated  during  the  operation. 
After  the  removal  of  the  uterus  and  appendages,  a 
portion  of  the  intestines,  which  presented  evidence  of 
diminishing  peritonitis,  was  freely  irrigated  with  hot 
saline  solution  and  then  dried  with  sponges.  The 
pelvis,  the  cut  edges  of  the  broad  ligaments,  and 
vagina  were  lightly  but  systematically  packed  with 
wide  strips  of  bichloride  gauze  (moist).  Finallv  an 
occlusion  pad  of  the  same  gauze  and  a  T-binder  were 
applied. 

D;3cription  of  Specimen  Removed.— The  speci- 
UK'n  was  al)out  the  si/e  of  a  uterus  between  the  third 
and    fourtii  months  of  ijestation,  showing  that   it   had 


undergone  a  considerable  degree  of  involution.  The 
walls  were  markedly  friable,  there  was  an  abscess  in 
the  left  wall  near  the  fundus,  the  left  tube  (which  was 
severed  during  the  operation,  allowing  the  escape  of 
pus)  contained  pus.  On  pressure  pus  exuded  from 
the  left  cornu  of  the  uterus  (a  tubo-uterine  abscess). 
The  left  ovary  was  of  the  size  of  a  hen's  egg,  solid,  and 
contained  a  small  abscess  on  its  surface  where  it  had 
been  connected  with  the  tube ;  the  right  tube  and 
ovary  were  injected  but  not  enlarged. 

Treatment  and  After-Treatment — She  was  freely 
stimulated  with  hypodermics  of  whiskey  and  strjxh- 
nine  and  subcutaneous  injections  of  hot  saline  solu- 
tion. The  temperature  gradually  rose  to  103.4  F.,and 
she  died  eighteen  hours  after  the  operation. 

Autopsy  Ten  Hours  after  Death  (by  Drs.  Selling 
and  Stinson). — The  abdomen  was  opened.  The  peri- 
toneal cavity  contained  a  couple  of  drachms  of  serous 
fluid.  The  bladder  contained  about  two  ounces  of 
urine.  The  intestines  occupying  the  lower  part  of 
the  abdomen  showed  peritonitis.  The  gauze  in  the 
pelvis  was  moderately  wet  and  only  slightly  blood 
stained.     There  was  no  evidence  of  bleeding. 

This  is,  I  believe,  the  first  case  wherein  vaginal 
hysterectomy  has  been  performed  by  enucleation  w  ith 
ligation  of  vessels  only,  for  puerperal  metritis,  tubo- 
uterine  abscess,  etc.  For  this  reason  and  because 
vaginal  hysterectomy  for  puerperal  metritis  is  of  suffi- 
ciently rare  occurrence,  I  report  the  case.  I  am  sure 
that  in  this  case,  had  the  uterus  and  appendages  been 
removed  in  the  incipiency  of  the  second  attack  of  in- 
flammation, /.J-.,  before  the  peritoneum  was  involved, 
I  could  have  reported  a  recovery.  In  operating  I 
avoided  serial  ligation  and  the  clamp  operations.  Both 
of  these  procedures  are  open  to  serious  objections,  as 
vital  tissues  are  unnecessarily  constricted,  with  com- 
plete interference  with  drainage  from  the  broad  liga- 
ments, which  is  of  great  import  .nee  in  those  cases  in 
which  the  broad  ligaments  are  involved  in  the  inflam- 
mation. Hemorrhage  from  the  broad  ligaments,  etc., 
can  be  prevented  by  simply  clamping  and  tying  the 
individual  vessels.  By  enucleation  (with  ligation  of 
vessels  only),  aided  when  necessary  by  forceps  used 
temporarily  as  levers,  tractors,  and  prophylactics, 
while  the  vessels  are  ligated,  you  do  away  witli  mass 
ligatures,  mass  clamping,  the  cautery,  sloughing,  pain- 
ful and  sloughing  stumps,  septic  discharges,  pelvic 
exudates,  wandering  and  dead  ligatures,  adhesions, 
etc. 

lilBLIOGRAPHV. 

Stinson  .  On  a  Combined  A'agino-Abdominal  .Method  of  Enu- 
cleation with  Ligation  of  Vessels  Only.  New  York  Mkdic.xl 
Record,  July  20,  1S95. 

Stinson  :  On  the  Treatment  of  Retroposed  Uteri.  Therapeu- 
tic (laiette,  May,  1890. 

Stinson  :  On  the  Removal  of  a  Tubo-Ovarian  Abscess,  Ova- 
rian Cyst,  and  Tube  fay  Enucleation  without  Ligature,  Clamp,  or 
Cautery.  Transactions  of  the  San  Francisco  County  Medical 
Society,  December  S,  1896.  New  York  .MEr)IC.\l. '  Rkcord, 
I'ebruary  13,  1S97. 

Stinson :  On  Ectopic  Gestation  ;  Points  in  Technique,  etc. 
Therapeutic  Gazette,  .March  15,  1S07. 


Soft  Soap  is  preferable  to  vaseline  for  anointing 
the  fingers  before  making  vagina!  examination  and 
for  lubricating  the  vaginal  speculum.  It  is  prepared 
by  dissolving  castile-soap  shavings  in  warm  water. 
If  the  vessel  containing  the  soft  soap  be  surrounded 
by  hot  water  for  a  few  minutes  before  it  is  used,  the 
contents  will  be  of  thin  consistence,  resembling  olive 
oil.  The  advantages  of  using  this  emollient  are  that 
it  helps  to  clean  the  vaginal  mucous  membrane  and 
readily  washes  off  when  it  is  desired  to  medicate. — 

T.M.l.EV. 


August  7,  ib97j 


MEDICAL    RECORD. 


205 


LICHEN    PLANUS    PRESENTING    LESIONS 
WITH    A    CIRCULAR     FORM. 

By   J.    ABBOTT   CANTRELL,    M.D., 

PROFESSOR  OF  DISEASES  OF  THE  SICIN  IN  THE  PHILADELPHIA  POLVCLINIe 
AND  COLLEGE  FOR  GRADUATES  IN  MEDICINE  ;  DERMATOLOGIST  TO  THE 
PHILADELPHIA  AND   FREDERICK   DOUGLASS    MEMORIAL    HOSPITALS,   PHILA- 

Although  in  the  majority  of  cases  of  lichen  planus 
which  are  encountered  during  the  practice  of  a  phy- 
sician a  characteristic  formation  is  shown,  there  are 
nevertheless  many  which  present  a  configuration 
diametrically  opposite.  There  are  many  cases  of  this 
cutaneous  disease  which  may  assume  irregularities  of 
distribution,  and,  while  these  arrangements  may  pre- 
sent in  variously  aggregated  patches,  others  are  ob- 
served in  which  they  may  resemble  the  appearances  of 
other  dermal  affections.  As  usually  seen,  these  cases 
present  lesions  which  may  be  discrete  in  some  in- 
stances, while  in  others  two,  three,  or  a  much  greater 
number  of  papules  may  aggregate  themselves  into 
groups,  accepting  no  particular  formation,  but  either 
being  rounded  or  becoming  more  irregularly  placed. 
Cases  have  also  been  recorded  in  which  these  papules 
have  been  observed  presenting  a  linear  arrangement, 
either  when  a  few  have  congregated  themselves  into 
such  a  streak  or  when  an  innumerable  quantity  has 
stretched  this  line  over  a  considerable  area.  At 
times  the  figurations  have  formed  into  circles,  while 
single  lesions  have  shown  a  tendency  to  clearing  in 
the  centre. 

I  present  the  case  in  this  record  because  of  the  pe- 
culiar tendency  of  two  patches  situated  upon  the  fore- 
arm to  accept  a  circular  form  with  a  clearance  in  the 
centre,  thus  presenting  some  of  the  characteristics  of 
an  ordinary  tinea  circinata;  and  so  much  so  that, 
were  it  not  for  other  lesions  in  the  vicinity,  it  would 
have  created  the  necessity  of  recourse  to  the  micro- 
scope for  a  positive  diagnosis. 

Harry    R ,   aged    twenty-four    years,    presented 

himself  for  treatment  through  the  kindness  of  Dr.  \V. 
().  Xander,  of  Philadelphia,  on  March  28th  last.  His 
occupation  was  that  of  lead  glazier,  and  he  had  been  a 
sufferer  from  the  present  eruption  for  three  months 
previous  to  this  visit.  His  health  h'ad  always  been  of 
the  best,  and  never  had  there  been  an  eruption  of  any 
character  other  than  that  from  which  he  was  now  a 
sufferer.  No  similar  disease  had  ever  been  witnessed 
in  any  member  of  his  family,  as  far  as  he  was  able  to 
state.  Born  in  Frederick,  Md.,  he  had  remained  in 
that  vicinity  until  his  fourteenth  year,  when  he  moved 
to  Philadelphia  and  began  learning  his  trade,  at  which 
he  has  always  been  occupied. 

The  eruption  for  which  he  sought  advice  was  obser\  ed 
on  the  chest  and  He.xor  surface  of  the  right  forearm. 
The  lesions  upon  the  chest  occupied  the  greater  por- 
tion of  the  region,  constituting  almost  a  universal  con- 
dition, but  showing  areas  of  healthy  skin  at  infrequent 
inten'als.  The  lesions  were  of  the  small  type,  but,  as 
usual  in  the  affection,  were  closely  aggregated,  although 
showing  no  tendency  to  coalescence.  Upon  the  fle.xor 
surface  of  the  right  forearm  was  found  the  peculiar 
condition  occasioning  this  paper,  owing  to  the  unu- 
sual configuration  mentioned  in  the  foregoing  re- 
marks. The  lesions  in  tiiis  locality  were  rather  larger 
than  those  observed  upon  the  chest,  although  they  were 
still  of  a  small  size,  being  of  the  diameter  of  a  large 
pinhead  in  the  majority  of  instances  and  in  others 
of  the  size  of  a  half-pea  or  half-bean.  One  group  of 
lesions  was  observed  directly  over  the  He-xor  surface 
of  the  wrist  and  had  a  diameter  of  one-fourth  inch, 
being  made  up  of  probably  eight  lesions,  all  of  which 
showed  the  rounded  or  irregular  outline  with  a  ten- 
dency to  clearance  in  the  centre. 

The  lesion  whicii  showed  the  greatest  similarity  to 
the  ordinary  tinea  circinata  was  observed  about  two 


inches  above  the  wrist  on  the  flexor  surface  of  the 
forearm,  it  being  composed  of  twenty  or  more  small 
papules.  They  were  arranged  in  u  ring  or  circle 
having  a  diameter  of  one  and  one-nalt  inches,  and 
upon  close  examination  could  be  discerned  to  be 
closely  aggregated  but  having  a  depression  between 
each,  thus  showing  their  individuality.  Within  the 
circle  there  was  no  inflammation  whatsoever,  nor  was 
there  any  tendency  to  redness  surrounding  the  collec- 
tion of  lesions.  Upon  the  summit  of  all  of  these 
small  papules  slight  scales  could  be  observed,  thus 
drawing  one's  mind  more  closely  to  the  superficial 
ringworm.  This  ring  was  rather  a  continuation  of 
one  lesion  after  the  other,  and  had,  as  far  as  this  man's 
knowledge  went,  been  just  the  same  throughout  the 
existence  of  the  manifestation. 

Elsewhere  than  upon  the  region  mentioned  there  were 
a  number  of  discrete  lesions,  and  we  saw  still  other 
spots  where  two  or  three  had  aggregated  themselves 
together.  They  all  showed  the  characteristic  appear- 
ances of  the  affection  under  consideration,  and  the 
diagnosis  was  made  with  little  difficulty. 

The  treatment  adopted  in  this  case  was  large  doses 
of  arsenic  in  the  form  of  arsenious  acid,  the  man  being 
given  at  first  a  dosage'  of  one-eighteenth  of  a  grain 
thrice  daily,  which  afterward  was  increased  to  one- 
fourth  of  a  grain  thrice  daily.  Locally  he  was  ordered 
the  liquor  carbonis  detergens  in  one-quarter  strength. 
In  about  five  weeks  the  affection  had  entirely  dis- 
appeared, leaving  some  slight  pigmentations  over  the 
site  of  the  former  lesions. 

The  uniqueness  of  this  appearance  seemed  to  me 
worthy  of  record,  simply  because  of  its  resemblance 
to  ringworm,  and  I  have  described  it  with  the  hope 
that  it  will  pro\e  of  some  assistance  to  those  who 
may  read  this  paper. 

315  SofTH  Eighteenth  Stkef.i. 


A    CASE    OF    STRVCHNINE    POISONING. 

By    .\1.FRK1)    S.    WAUK.    M.D.. 

I  w.-^s  recently  called  to  attend  a  man  v,ho  had  delib- 
erately weighed  out  and  taken  one  grain  of  strychnine 
sulphate.  He  was  forty  years  of  age,  powerfully  built, 
and  weighed  two  hundred  and  twenty-five  pounds.  He 
was  just  recovering  from  the  effects  of  a  spree  and  took 
the  drug  with  whiskey.  After  taking  the  poison  he 
lay  down  on  the  bed  in  his  room,  and,  not  feeling  any 
effects  from  the  experiment,  took  up  a  book  to  read, 
but,  he  says,  was  unable  to  see  the  print  clearly 
enough  to  read.  He  lay  there  for  nearly  an  hour, 
when  he  was  called  from  downstairs  by  his  sister  to 
supper.  On  attempting  to  rise  he  was  at  once  taken 
with  spasms  of  the  legs,  arms,  and  muscles  of  the 
trunk.  He  called  out  to  his  sister  to  send  for  a 
doctor  at  once,  that  he  had  taken  strychnine.  Havmg 
some  knowledge  of  medicine,  he  had  his  sister  give 
him  a  teaspoonful  of  sulphate  of  zinc  dissolved  in 
water.  He  swallowed  this  with  much  difficulty,  as 
he  felt  a  "tightness"  of  the  muscles  of  the  throat; 
he  followed  this  by  a  draught  of  warm  water,  which 
failed  to  produce  emesis.  \\'hen  I  arrived,  a  few  min- 
utes later,  I  found  my  patient  suffering  intense  agony 
from  frequent  spasms  of  the  whole  body.  His  body 
was  bathed  in  perspiration,  his  face  was  swollen,  and 
his  eyes  were  protruding. 

I  immediately  injected  one-tenth  of  a  grain  of  apo- 
morphine  hydrochlorate  hypodermically  and  gave  him 
by  the  mouth  one  drachm  each  of  chloral  hydrate  and 
potassium  bromide.  In  a  few  minutes  he  began  to 
vomit  freelv,  but  at  each  attempt  at  emesis  was  seiztd 
with  violent  convulsions.     After  the  vomiting  ceased 


2o6 


MEDICAL    RECORD. 


[August  7,  1897 


I  gave  him  a  second  dose  of  chloral  and  potassium 
bromide,  one  drachm  each,  which  I  again  repeated 
in  one  hour.  Gradually  the  spasms  left  him,  but  the 
slightest  noise — the  opening  of  a  door,  and  in  one 
case  just  speaking  to  him — brought  on  the  attacks  in  a 
minor  degree.  In  three  hours  from  the  time  of  my 
arrival  all  spasms  had  disappeared,  with  the  exception 
of  a  twitching  of  the  muscles  of  the  face.  His  only 
complaint  the  next  day  was  a  "soreness"  of  the  mus- 
cles all  over  his  bodv. 


MECHANICAL    RESTRAINT    OF    MASTURBA- 
TION IN  A  YOUNG  GIRL. 

Bv   C.    D.    W.    COLBY,    M.l)., 

JACKSON,    .MICH. 

A  GIRL,  aged  seven  years,  slight  build,  swarthy  com- 
plexion, black  curly  hair,  light  blue  eyes,  unusual  1\' 
precocious. 

She  had  been  taught  the  habit  by  vicious  children 
at  a  "  county  house,"  from  which  she  was  adopted  in 
the  summer  of  1895. 

I  learned  from  the  fostermother  that  on  the  advice 
of  physicians  she  had  given  her  worm  remedies,  they 
thinking  that,  perhaps,  the  irritation  was  due  to  the 
migration  of  "pinworms."  The  parts  had  been  kept 
thoroughly  cleansed;  she  had  been  made  to  sleep  in 
sheepskin  pants  and  jacket 
made  into  one  garment, 
with  her  hands  tied  to  a 
collar  about  her  neck:  her 
feet  were  tied  to  the  fool- 
board  and  by  a  strap  about 
her  waist  she  was  fastened 
to  the  headboard,  so  that  she 
couldn't  slide  down  in  bed 
and  use  her  heels;  she  hat! 
been  reasoned  with,  scolded, 
and  whipped,  and  in  spite  of 
it  .dl  she  managed  to  keep 
up  the  habit. 

( »n  making  an  examina- 
tiiiii  I  found  an  adherent 
clitoris,  retained  smegma, 
and  a  redundant  prepuce. 
I  broke  up  the  adhesions, 
cleansed  the  parts  thorough- 
ly, and  removed  the  redun- 
dant preputial  tissue,  think- 
ing this  would  remove  the 
irritation  and  stop  the  habit. 
She  was  not  made  to  wear 
her  jacket  after  the  operation  (the  fosterparents  ob- 
jected to  a  clitoridectomy),  and  the  first  niglit  she 
tore  off  the  dressings  and  opened  the  wound  with  her 
fingers,  starting  up  quite  a  iiemorrhage.  From  that  on 
she  was  watched  till  the  wound  healed  and  then  sent 
home  (fifteen  miles)  to  wait  two  weeks,  while  I  could 
devise  some  scheme  to  break  her  of  the  habit. 

The  result,  which  is  shown  in  the  sketch  appended, 
is  built  of  No.  8  coppered  iron  wire,  the  legs  and  arm- 
pits are  protected  with  sheep's  wool,  and  over  the  whole 
thing  is  fitted  a  stout  canvas  jacket.  At  bedtime  the 
child  is  slid  into  the  "harness"  from  the  top  and  the 
canvas  jacket  is  laced  up  the  back  and  strapped  over 
the  shoulders. 

It  succeeded  in  breaking  the  habit  for  a  year,  when 
she  was  returned  for  a  new  one,  having  outgrown  the 
old  one).  She  had  gained  six  inches  in  height  and 
nearly  twenty  pounds  in  weight.  The  habit  was  resumed 
as  soon  as  the  "  harness"  was  left  off  at  night.  I  built 
a  new  and  larger  "  harness"  the  first  of  February  and 
so  far  it  seems  to  have  worked  as  well  as  the  first. 

208  South  Jackson  Strkkt. 


A  NOTE  OX  THE  USE  OF  THE  PEGLEG 
AS  A  PROTECTIVE  APPARATUS  IN  THE 
TREATMENT  OF  DISEASE  OF  THE  ANKLE 
OR    TARSUS.' 

Bv   JOHN    C.    SCHAPP.S.    M.lJ., 

PUEBLO,   COL., 
LATR  I  HIEF  0|-    ORI'ARTMKNT   OF  ORTHOPAEDIC    Sl-kf;ERV,  ST.    MAItvV   HOSPITAL, 


Lx  examining  recently  a  case  of  tarsal  disease,  I  was 
impressed  by  the  patient's  ingenuity  in  securing  the 
protection  afforded  by  a  pegleg.  The  man's  name  is 
Michael  Sobbi.  He  was 
thus  able  to  perform,  with- 
out injury  to  his  foot,  the 
hard  work  of  a  fireman. 
The  apparatus,  as  shown  in 
the  cut,  requires  no  skill  in 
construction  or  application, 
and  accomplishes  efficiently 
the  following  purposes:  i. 
Protection  against  pressure 
of  weight.  2.  Relaxation 
of  calf  muscles.  Thus  the 
foot  can  be  kept  at  or  nearly 
at  a  right  angle  with  tlie  leg 
without  thereby  causing  in- 
terosseous pressure.  3.  Di- 
minution of  the  ill  effects  of  pendency.  It  permits 
the  application  of  plaster  of  Paris  or  other  means  of 
fixation.  It  renders  unnecessary  the  use  of  crutches. 
The  pegleg  consists  of  two  slats  of  wood,  attached 
below  to  a  conical  block,  upon  whose  upturned  and 
padded  base  the  patient's  weight  is  received.  The 
block  ends  in  a  peg,  which  should  be  ferruled.  If  the 
patient  has  to  walk  upon  soft  ground,  the  lower  end 
of  the  peg  should  be  made  broad.  The  outer  strip 
extends  nearly  to  the  crest  of  the  ilium,  the  inner  to  a 
point  a  few  inches  above  the  condyle.  The  whole 
may  be  cut  from  a  single  piece  of  hard  wood,  from 
two  to  two  and  one-half  inches  thick.  It  is  secured 
by  straps,  as  shown. 

Kraske's  Operation  for  Carcinoma  of  the  Rectum. 

— The  operation  by  cutting  through  the  sacrum  has 
not  yet  obtained  that  position  in  the  estimation  of 
the  profession  which  its  advantages  entitle  it  to  pos- 
sess. The  idea  of  cutting  through  the  sacrum  in  order 
to  get  at  the  rectum  appears  to  many  as  such  a  for- 
midable procedure  that  they  hesitate  to  recommend  it 
in  the  early  stage  of  disease  when  it  can  be  carried 
out  most  satisfactorily,  and  perhaps  give  it  a  trial 
only  when  the  patient  himself  demands  it  because 
his  sufferings  are  becoming  more  than  he  can  bear. 
Heidenhain  considers  that  "the  only  local  contrain- 
dication to  the  operation  is  the  extension  of  the 
growth  to  the  prostate,  bladder,  or  ureter.'"  There 
can  be  no  doubt,  however,  that  if  the  loose  connective 
tissue  about  the  rectum  is  involved  the  case  is  very- 
unfavorable,  as  it  also  is  if  the  retroperitoneal  glands 
are  affected.  Dr.  .Vllison  states  that  "the  reported 
cases  of  excision  of  the  rectum  after  Kraske's  method 
for  cancer  show  a  mortality  of  thirty  per  cent.,  with  a 
recurrence  in  forty  per  cent,  of  the  recoveries.  This 
includes,  however,  many  inoperable  cases,  as  is  proved 
by  a  mortality  of  eight  per  cent,  in  the  hands  of  some 
surgeons  in  properly  selected  cases.'"  Senn  writes 
that  "  the  surgeon  w  ho  removes  the  cancer  of  the  rec- 
tum by  excision  will  liave  a  great  mortality,  while  the 
one  who  follows  the  loose  connective-tissue  spaces, 
resorts  to  blunt  instruments,  and  carefully  guards 
against  hemorrhage,  will  show  the  best  results." — 
The  LiVhd,  March  1-,  1897. 

'  Keail  .It  tlie  .iniuial  meeting  of  the  .\merican  Orthop.vdic  .As- 
sociation, Washington,  P.  C,  May  6,  1S97. 


August  7,  1897] 


MEDICAL    RECORD. 


207 


J>uvoicHl  J»viggcstious. 

Black  Eye. — To  prevent  ecchymosis  of  the  e\elid 
after  injuries,  paint  the  part  with  the  foUon  ing,  avoid- 
ing any  broken  surface : 

Ti  Mucil.  acacia; 3  >-. 

Tr.  capsici Z  i  • 

Glycerini ad   3  i . 

—Da   Costa. 

Toxin  Treatment  of  Malignant  Growths.-  In 
Czerny's  clinic  (Heidelberg)  27  cases  were  treated 
according  to  the  method  of  Coley.  Of  these  27  cases 
10  were  carcinomata,  and  17  sarcomata  (7  round-cell, 
3  spindle-cell,  3  lympho-,  2  angio-,  i  osteo-,  and  i 
melano-.  The  following  deductions  were  drawn  :  i.  In 
carcinomata  the  results  were  completely  valueless.  2. 
In  sarcomata,  only  very  e.xceptional  cases  showed  an\ 
result.  3.  This  questionable  advantage  was  equalized 
by  the  dangers  of  poisoning  as  well  as  by  the  increase 
of  the  tumors  in  other  cases. —  A'A'/'.  German  Su/x/ra/ 
Cojign'ss. 

The  Treatment  of  Furuncles. — Dr.  Louis  Dumoni 
{Aniiaks  tfc  Dirmatologic  it  Jr  Syphiligraphie,  tome  vii., 
No.  II,  1896)  employs  the  method  of  linear  scarifica- 
tion used  in  ulcers  and  some  of  the  chronic  skin  dis- 
eases, and,  according  to  the  author,  who  has  used  this 
method  for  some  years  in  military  service,  the  results 
are  very  satisfactory.  The  skin  over  the  beginning 
pustule  or  boil  is  first  cleaned  with  a  brush  and  an 
antiseptic  solution  (i  to  1,000  bichloride;  i  to  50 
carbolic);  several  parallel  incisions  are  made,  a  milli- 
metre apart,  through  the  dermis;  a  similar  scries  is 
made  at  right  angles  to  the  first;  a  wet  antiseptic 
dressing  is  then  applied.  When  this  treatment  is  in- 
stituted early  in  the  disease,  the  pain,  redness,  and 
swelling  will  usually  disappear  within  the  first  twenty- 
four  hours.  The  advantages  of  this  procedure  are 
that  bleeding  is  more  free,  the  access  of  the  antiseptic 
is  made  more  easy,  cure  is  more  speedy,  and  scarring 
is  practically  absent. 

Urethral  Stricture. —  i.  Strictures  of  large  calibre, 
that  is,  of  more  than  fifteen  French,  situated  at  or  be- 
hind the  bulbo-membranous  urethra,  are  to  be  treated 
by  gradual  dilatation.  2.  Strictures  of  large  calibre, 
occupying  the  pendulous  urethra,  are  to  be  treated  by 
gradual  dilatation  when  very  recent  or  soft,  and  by 
internal  uretlirotomy  when  of  longer  standing  and  dis- 
tinctly fibrous.  3.  Strictures  of  the  meatus  and  of  tlie 
neighborhood  of  the  fossa  navicularis  should  be  di- 
vided upon  the  floor  of  the  urethra  whenever  there  are 
real  pathological  conditions.  4.  Strictures  of  small 
calibre,  less  than  fifteen  French,  situated  in  advance 
of  the  bulbo-membranous  junction,  usually  call  for 
internal  urethrotomy,  preferably  with  a  dilating  ure- 
throtome under  strictest  antiseptic  precautions.  5. 
Strictures  of  small  calibre  situated  at  or  deeper  than 
the  bulbo-membranous  junction  should  be  treated 
whenever  possible  by  gradual  dilatation  ;  in  cases  of 
resilient  or  irritable  stricture,  which  is  not  dilatable, 
by  e.xternal  perineal  urethrotomy.  6.  Impassable 
stricture  of  the  deep  urethra  always  requires  the  per- 
formance of  perineal  section. — Dr.  Sanders,  JSew 
England  Medical  Gazttte. 

Dislocations  of  the  Hip-Joint.  —  Dr.  D.  H.  .\llis 
{Diing/ison's  ColUge  and  C/inira/  Record,  Marcli,  1897), 
in  discussing  the  inward  dislocations,  summarizes  as 
follows :  "  The  patient  lying  supine,  the  surgeon  kneels 
by  his  side,  and  if  the  right  femur  is  dislocated  he 
seizes  the  ankle  with  his  right  hand  and  places  the 
bent  elbow  of  his  left  arm  beneath  the  popliteal  space: 
(i )  he  now  turns  the  bent  leg  outward  by  means  of  the 


ankle  and  lifts  upward  (skyward)  ;  (2)  then  turns  the 
bent  leg  inward  and  brings  the  femur  down  in  exten- 
sion. Should  this  method  fail,  the  method  by  trac- 
tion should  be  adopted.  The  obstacles  to  reduction 
are:  i.  Lack  of  skill  in  the  operator  or  lack  of  facili- 
ties. 2.  Obstacles  that  prevent  the  head  from  enter- 
ing the  socket.  3.  Obstacles  pushed  into  the  socket 
by  the  head.  4.  The  sciatic  nerve  hooked  over  the 
neck  of  the  femur. 

Primary  or  Subjective  Causes  of  Stricture  of 
the  Male  Urethra. — Dr.  Strittmatter  {Diuiglison's  Col- 
lege and  Clinical  Record,  March,  1897)  felt  war- 
ranted in  offering  the  following  conclusions  taken 
from  personal  obser\'ations:  i.  The  condition  known 
as  urethral  spasm,  between  the  bulb  and  the  meatus 
urinarius,  is  not  due  to  contraction  of  the  circular 
muscle  fibres,  but  to  either  a  folding  over  of  the  re- 
laxed mucous  membrane  or  the  sudden  contraction  of 
the  cut-off  and  accelerator  urinjF  muscle,  causing  a 
sudden  engorgement  of  the  part  subjected  to  irrita- 
tion. 2.  Post-gonorrhceal  stricture  is  frequently  but 
an  augmentation  or  an  infection  of  a  pre-existing  con- 
dition of  stricture.  3.  Gonorrhoea,  while  capable  of 
inducing  stricture,  very  rarely  does  so  without  an  ele- 
ment of  decided  traumatism,  or  without  conditions  in- 
terfering with  free  urethral  drainage.  4.  Chronic 
prostatitis  in  the  aged  is  always  preceded  and  associ- 
ated with  either  an  old  gonorrhoeal  urethritis  or  with 
conditions  interfering  with  the  proper  drainage  and 
healthy  condition  of  the  urethra.  5.  Masturbation, 
when  prolonged,  may  induce  sufficient  irritation  to  in- 
augurate a  stricture,  but  more  frequently  the  intract- 
able habit  is  the  result  rather  than  the  cause  of  stric- 
ture. 

Cocaine  for  Fistula. — The  Medical  Bulletin,  No- 
vember 25,  i8g6,  reported  a  case  of  salivary  fistula 
cured  by  painting  with  cocaine;  the  issue  of  December 
2d  describes  a  similar  success  obtained  with  it  in 
the  case  of  a  fistula  of  the  parotid  gland,  treated  pre- 
viously with  nitrate  of  silver  and  chloride  of  zinc  with- 
out effect.  The  solution  of  cocaine  used  was  five  to 
fifty  grams  each  of  water  and  glycerin.  The  skin 
alone  was  painted  twice  a  week.  No  result  was  per- 
ceptible at  first,  but  at  the  end  of  the  second  week  the 
improvement  was  evident  and  the  cure  progressed  to 
completion. 

Appendicitis. — Dr.  J.  VV.  White  writes  as  follows: 
'■  Immediate  operation  is  indicated  whenever  the  onset 
of  appendicitis  is  marked  by  both  suddenness  and  se- 
verity; whenever,  during  even  a  mild  attack,  the  symp- 
toms at  the  end  of  forty-eight  hours  are  unrelieved  or 
are  growing  wor.se ;  whenever,  in  cases  seen  later,  a 
firm,  slowly  forming,  well-defined  mass  is  to  be  felt  in 
the  right  iliac  fossa;  whenever  at  any  time  a  sudden 
increase  in  the  acuteness  of  the  pain  and  a  rapid  diffu- 
sion of  tenderness  occur;  whenever  there  is  good  rea- 
son to  believe  the  appendix  infection  to  be  tuberculous 
in  character;  whenever  attacks  of  any  type  have  been 
numerous,  or  are  increasing  in  number  or  gravity,  or 
have  unfitted  the  patient  for  work  or  activity,  or  have 
caused  local  symptoms  which  are  permanent  or  persis- 
tent, or  have  at  any  time  put  the  patient's  life  in  dan- 
ger." 

Perityphlitis.— Dr.  .\.  Marmaduke  Sheild,  in  the 
Clinical  Record,  January  20,  1897,  writes  that  that  the 
bacillus  coli,  associated  with  other  microbes,  exten- 
sively infects  the  cellular  tissue  around  the  appendix, 
producing  an  abscess  of  varying  size  filled  with  pecu- 
liarly fcetid  pus  and  gas,  which  is  situated  in  the  right 
iliac  fossa,  and  usually  slowly  and  painfully  works  its 
way  toward  the  skin.  It  may  burst  just  above  Pou- 
part's  ligament,  or  into  the   intestine,  bladder,  or  rec- 


208 


MEDICAL    RECORD. 


[August  7,  1897 


turn,  and  in  females  it  has  been  known  to  )5oiin  and 
burst  into  the  vagina.  In  other  cases  the  abscess, 
which  may  be  very  small  in  size,  transgresses  its  feeble 
barriers,  and  the  pus  extravasates  into  the  peritoneal 
cavity.  So  the  affections  of  the  appendix  may  be  di- 
vided into  two  classes — one  class  in  which  the  part 
gets  thickened  and  glued  down  ;  and  a  second  in  whicii 
an  abscess  forms  and  l)ursts,  or  is  opened  by  tiie  sur- 
geon. 

The  Curette  and  Morbus  Cordis.  — Dr.  Resnikoff 
{Monats.  f.  Gcbiiitsh.  11.  Gyinik.,  January,  1897 )  warns 
against  scraping  the  endometrium  for  menorrhagia  or 
metrorrhagia  until  the  patient's  heart  has  been  exam- 
ined. When  organic  disease  of  the  heart  exists,  the 
use  of  the  curette  is  often  followed  by  an  increase  in- 
stead of  a  diminution  of  the  hemorrhage. 

Carcinoma  of  the  Uterus. — Dr.  W.  W.  Russell 
concludes  a  paper  upon  the '' Operative  Significance 
of  Metastasis  and  Post-Operative  Recurrences  in  Car- 
cinoma of  the  Uterus"  with  the  following  proposi- 
tions: I  Cancers  of  the  vaginal  portion  of  the  cervix 
tend  to  advance  out  on  to  the  vaginal  walls,  either  su- 
perficially or  beneath  the  mucous  membrane,  and  if 
the  case  is  suitable  for  operative  treatment  a  wide  re- 
moval of  the  vagina  is  indicated.  2.  These  growths 
are  usually  epitheliomata  and  have  little  tendency  to 
metastasis.  If  the  local  extirpation  is  complete  the 
prognosis  is  good.  3.  Growths  of  the  cervix  are  usu- 
ally adeno-carcinomata,  and  from  their  situation  are 
to  be  considered  the  most  malignant  of  uterine  cancers. 
The  parametrium  and  bladder  are  the  critical  points, 
and  the  former  should  always  be  removed  as  com- 
pletely as  possible.  4.  Adeno-carcinoniata  of  the  body 
are  the  most  accessible  to  operative  procedure  and  give 
the  most  favorable  prognosis. 


NEW    YORK     COUNTV     MEDICAL     ASSOCIA- 
TION. 

Stated  Meeting,  May  17,  i8g-. 

JosKPH  E.  Janvrin,  M.D.,  President,  i.\  the 
Chair. 

The  Treatment  of  Pertussis. — Dr.  Lotis  Fischer 
read  the  first  paper.  We  must  individualize,  not  gen- 
eralize the  treatment.  Each  case  must  be  studied 
separately,  somewhat  as  follows :  How  many  paro.xysms 
had  the  patient  had  in  an  hour  or  a  day?  Had  he 
vomited,  and  how  often  ?  Of  what  did  the  vomit 
consist?  Were  the  paroxysms  most  violent  at  niglit 
or  during  the  day?  Had  there  been  any  hemor- 
rhages? The  temperature?  How  much  food  was 
retained  and  digested  as  shown  by  the  faces?  Was 
the  child  emaciating  in-  increasing  in  weight?  What 
was  the  condition  of  the  heart?  What  complications 
existed?  In  the  first  or  catarrhal  stage,  expectorants 
and  general  hygienic  rules,  plus  concentrated  nutrition, 
cod-liver  oil,  malt  extract,  and  other  restoratives,  would 
relieve  and  aid  in  recovery.  Hut  if  cough  persisted,  or 
if  we  were  called  in  the  second  or  convulsive  stage, 
we  must  resort  to  heroic  measures.  The  following 
headings  appeared  under  treatment  :  (i)  Isolation,  (2) 
clothing,  (3)  fresh  air,  (4)  the  room,  (5)  medicinal 
treatment.  Isolation  was  necessary  to  prevent  spread- 
ing of  the  disease.  The  clotiiing  should  be  warm, 
and  flannel  underwear  should  be  worn  both  winter  and 
summer.  It  was  Dr.  iMscher's  belief  that  more  ciiil- 
dren  were  lost  by  injudicious  exposure  and  careless 
dress  than  by  any  other  means,  for  usually  those  found 
in   a   hopeless   condition    were     suffering    less    from 


whooping-cough  than  from  some  complication  or  se- 
quel. Eresh  air  was  one  of  the  most  valuable  means 
of  relieving  and  modifying  the  cough.  To  keep  the 
window  open  was  the  cheapest  and  handiest  way  to 
secure  oxygen  and  ozone.  If  the  child's  condition 
permitted,  it  should  be  in  a  park  all  day.  The  tem- 
perature of  the  room  should  be  kept  at  from  68  to  72^ 
V.  Sweeping  the  floor  or  in  other  ways  raising  dust 
must  be  prohibited.  Let  the  floor  be  washed  instead 
of  swept.  Tobacco  smoke,  cooking  of  onions,  etc., 
must  be  prohibited.  Handkerchiefs  should  be  placed 
in  an  antiseptic  as  soon  as  soiled.  Expectoration 
should  be  into  a  cuspidor  containing  one-f)er-cent.  car- 
bolic solution.  In  medicinal  treatment  almost  every 
drug  in  the  pjiarmacopceia  had  been  mentioned.  The 
tendency  in  all  instances  was  toward  antizymotic 
agents,  local  antisepsis,  and  anodynes.  Inhalations 
of  steam,  or  steam  impregnated  with  carbolic,  thymol, 
or  eucalyptol,  was  recommended  bv  some.  The  author 
had  tried  hot  poultices,  ice  bags,  and  ice  cream,  but 
without  benefit.  In  the  Medical  Record,  September 
6,  1890,  would  be  found  an  elaborate  paper  by  him  on 
the  treatment  of  pertussis  with  bromoform,  based  on 
fifty-one  cases.  Since  then  he  had  used  it  with  many 
successes,  and  also  with  poor  results  in  some  in- 
stances. A  pure  preparation  must  be  used,  given  not 
in  solution,  but  only  in  drop  doses  from  a  spoon.  It 
was  very  volatile,  and  should  be  kept  in  a  well-stop- 
pered bottle,  protected  from  the  light.  The  dose  for 
children  was  from  three  to  eight  drops,  three  times  a 
day,  according  to  the  age.  He  Juid  one  case  of  poi- 
soning to  report  from  taking  too  much  by  mistake,  but 
the  child  recovered.  Chloroform  or  ether  was  called 
for  only  in  urgent  cases  to  relieve  the  violence  of  the 
paroxysm  when  there  was  hemorrhage  or  to  prevent 
rectal  prolapse.  Belladonna  had  been  an  utter  failure 
in  his  hands.  The  same  was  true  of  atropine.  He 
had  discarded  antipyrin,  and  the  coal-tar  series  in 
general  was  contraindicated  on  account  of  the  heart. 
He  had  tried  morphine  and  opium  with  trepidation. 
.Steam  inhalations  impregnated  with  ichthyol,  a  tea- 
spoonful  to  two  ounces  of  water,  had  given  him  good 
results  in  children  wlio  could  inhale  properly.  'I'his 
was  also  true  of  one-per-cent.  formalin  iniialations  or 
impregnating  the  air  of  the  room  with  it.  Menthol 
seemed  best  for  controlling  vomiting,  about  one  grain 
three  times  a  day.  Bichloride  of  mercury,  one-one- 
hundredth  grain,  combined  with  fi\e  drops  of  ichthyol, 
three  times  a  day,  had  gi\en  good  results  in  some 
cases  in  which  bromoform  had  failed.  Vaccination 
with  cow  lymph  seemed  to  have  been  of  benefit,  but  only 
in  children  not  previously  vaccinated.  Bromides  and 
chloral  relieved  cough  only  for  the  time  being.  Anti- 
streptococcus  serum  was  injected  in  one  case,  without 
apparent  benefit.  In  some  cases  of  irritable  pharynx, 
rectal  feeding  was  indicated. 

Dr.  S.  Henrv  Dessau  opened  the  discussion.  He 
fully  agreed  with  the  author  that  fresh  air  was  one  of 
the  most  necessary  things  in  the  management  of  per- 
tussis. The  sleepingapaitnients  should  be  well  ven- 
tilated in  winter  as  well  as  in  summer.  Eresh  air  and 
the  ozone  which  it  contained  was  the  best  antiseptic. 
He  was  in  the  habit  of  directing  the  nurse  to  take  the 
patient  to  the  gasworks  of  the  city,  and  sit  an  hour  in 
the  room  when  they  opened  the  purification  boxes. 
The  asphalt  works  could  be  visited  for  the  same  pur- 
pose. He  also  resorted  to  suljihur  fumigation  of  the 
rooms,  followed  bv  thorough  ventilation  of  them,  after 
which  the  child  was  retunied.  The  renewed  air  was 
supposed  to  be  then  quite  pure  and  germ  free.  Many 
mothers  had  the  notion  th.it  whooping-cough  did  not 
amount  to  much,  yet  it  was  not  long  ago  when  it  ranked 
third  as  the  cause  of  death,  directly  or  indirectly.  In 
looking  for  some  rational  treatment,  one  could  not  but 
consider  the  cause  of  the  disease  as  some  germ,  known 


August  7,  1897] 


MEDICAL    RECORD. 


209 


or  unknown.  Therefore  benefit  should  come  from 
remedies  having  both  an  antiseptic  and  a  sedative 
effect,  such  as  antipyrin  and  phenacetin.  He  disa- 
greed with  the  author  in  his  comments  upon  the  coal- 
tar  series,  for  he  had  limited  himself  almost  entirely 
to  their  use  in  whooping-cough  for  some  seven  years. 
We  ought  not  to  give  disagreeable  mi.xtures  to  chil- 
dren, and  for  this  reason  he  had  discontinued  bronio- 
form.  Patients  for  whom  it  was  piescribed  at  the  dis- 
pensary were  not  brought  back.  For  the  same  reabon 
he  had  given  up  bromide  and  chloral.  Enlargement 
of  the  bronchial  glands  at  the  root  of  the  lung  was 
frequent,  especially  in  children  with  a  phthisical  ten- 
dencv,  and  when  this  came  on  there  were  likely  to  be 
paroxysms  of  coughing  which  led  mothers  to  say  that 
there  was  recurrence  of  the  whooping-cough.  In  these 
cases  he  had  found  nothing  to  act  as  well  as  iodide 
of  potassium.  In  patients  with  chronic  intestinal 
indigestion,  alum  was  useful. 

Dr.  Qrixi,.AX  said  a  child  had  recently  been  brought 
to  his  clinic  with  the  statement  that  it  had  had  whoop- 
ing-cough, that  during  a  paroxysm  epistaxis  had  come 
on.  Its  nose  was  plugged  with  cotton  containing  alum, 
etc.  On  examination  he  found  the  tonsils  much  en- 
larged, and  on  excising  them  the  epistaxis  and  whoop- 
ing-cough ceased. 

Dr.  Fischer  thought  the  benefit  from  a  visit  to  the 
ga.shoiise  was  probably  due  to  the  outing.  The  case 
related  by  Dr.  Quinlan  was  one  of  pseudo-pertussis. 
Pure  bromoform  was  not  disagreeable.  It  was  im- 
portant to  keep  up  the  nutrition  of  patients  with 
whooping-cough. 

Atrophic  Rhinitis. — Dr.  H.  Beaman  Doiglass 
read  this  paper.  Atrophic  rhinitis  presented  a  loath- 
some picture,  and  there  was  no  easy  escape  from  that 
loathsomeness  when  once  it  became  established.  The 
scabbing,  the  horrible  stink,  the  hawking,  the  difficulty 
of  breathing,  the  repulsiveness  to  friends,  often  made 
a  recluse  of  the  patient,  perhaps  caused  melancholia 
and  suicide.  The  remedies  which  had  been  suggested 
for  its  relief  included  nearly  all  new  and  old  agents, 
and  pointed  to  the  rebelliousness  of  the  disease  if  not 
to  ignorance  of  its  etiology.  Regarding  the  latter, 
search  had  been  made  of  recent  years  for  some  special 
germ  as  the  cause,  possibly  w-ith  success.  The  author 
said  that  vitiated  air,  close  rooms,  dry  heat,  and 
crowding  undoubtedly  contributed  to  its  development. 
Debility,  especially  inherited  weakness,  favored  it. 
It  was  often  seen  in  persons  with  abnormally  flat, 
wide  nose,  and  at  the  dispensary  they  not  infrequently 
made  a  diagnosis  of  atrophic  rhinitis  at  sight  when  a 
person  with  a  nose  of  that  form  entered  the  room. 
In  only  a  few  cases  was  atrophic  rhinitis  found  in  an 
aquiline  nose  with  small  nares,  and  then  as  a  result 
of  degeneracy  or  ana;mia.  More  frequently  complete 
obstruction  would  cause  atrophic  rhinitis  of  the  oppo- 
site side.  The  free  side  tried  to  do  double  work,  suc- 
ceeded for  a  time,  but  finally  gave  up  the  struggle,  and 
the  structures  became  atrophic.  Destructive  operative 
work  had  in  many  cases  been  the  cause  of  atrophic 
rhinitis.  This  included  work  with  the  cautery  and 
caustics.  It  had  been  by  this  expensive  lesson  that 
rhinologists  had  learned  the  exceeding  importance  of 
sparing  gland  and  vascular  tissue.  Among  the  symp- 
toms were  headache,  both  frontal  and  occipital :  cough. 
nosebleed,  dead  feeling  along  the  nose,  hot  and  dry 
feeling,  tenderness  on  touch  along  hard  and  soft  palates, 
jjersistent  feeling  of  nasal  obstruction,  foetid  odor, 
scabbing,  with  feeling  of  necessity  to  free  the  nose. 
The  most  frequent  place  for  scabs  was  about  the  pha- 
ryngeal opening  of  the  Eustachian  tubes.  Unless  it 
were  remembered  that  all  parts  of  the  lining  mem- 
brane of  the  nose  might  be  affected,  the  treatment  was 
likely  to  be  unsuccessful.  The  treatment  related  to 
alleviation   of  the  symptoms,  cleanliness,  antisepsis, 


and  to  the  cure  of  the  disease.  For  practical  purposes 
this  division  was  made:  i.  Treatment  of  earlv  cases; 
2,  treatment  of  unilateral  cases;  3,  treatment  of  ulcer- 
ative cases :  4,  treatment  of  obstruction  in  superior  or 
middle  meatus;  5,  treatment  of  the  general  condition. 
Complete  removal  of  the  scabs  was  necessary.  The 
physician  should  see  the  patient  every  other  day  or 
every  day.  When  the  patient  was  told  to  use  the 
douche  in  the  interim,  he  must  be  cautioned  not  to 
overdouche.  The  doctor  could  remove  the  scabs  with 
a  probe  wrapped  with  cotton,  wet  with  some  fluid. 
An  antiseptic  and  deodorizing  solution  must  be  used 
twice  a  day,  to  be  followed  by  a  medicament  if  the 
doctor  so  directed.  Dr.  Douglass  had  douched  with 
light  antiseptic,  i  to  100,000  bichloride,  and  i  to 
1 0,000  zinc.  The  electric  cautery  might  be  necessary 
to  induce  healing  of  ulcerated  surface.  Any  obstruc- 
tion must  be  removed.  I'he  general  condition  required 
treatment,  including  exercise  in  the  open  air.  As  to 
climate,  a  dry  air  was  best:  temperature  made  less 
difference.  Finally,  he  knew  no  specific.  Faithful 
carrying  out  of  treatment  must  be  insisted  upon.  The 
earlier  it  was  begun,  the  better  for  the  patient  and  the 
more  satisfactory  to  the  physician. 

Dr.  V.  J.  QrixLAX  opened  the  discussion.  In  the 
course  of  his  remarks  he  said  atrophic  rhinitis  was  the 
terminal  stage  of  fietid  rhinitis  or  oza-na.  The  phar- 
ynx and  larynx  participated  in  the  process.  As  the 
author  had  said,  the  mutilation  of  soft  parts  in  treat- 
ment must  be  avoided  as  far  as  possible  in  the  earlier 
stage.  -A  fact  not  mentioned  in  the  paper  was  that 
young  women,  at  least  according  to  Dr.  Quinlan's 
experience,  were  oftenest  aft'ected.  The  odor  seemed 
more  marked  during  menstruation.  One  author  had 
likened  the  condition  to  that  of  foetid  odor  from  the 
axilla,  or  decomposing  smegma.  Deafness  was  a 
s}Tnptom  not  mentioned  in  the  paper.  There  was 
contraction  of  tissue  at  the  entrance  to  the  Eustachian 
tubes,  perhaps  extension  of  disease  to  the  middle  ear. 
There  was  a  marked  kinship  between  the.se  cases  and 
disease  of  the  accessory  cavities  of  the  nose.  He 
thought  the  nasal  douche,  as  well  as  acids  and  caus- 
tics, had  been  a  cause  in  many  cases. 

Dr.  U'.  F.  Chappel  remarked  that  the  speakers  had 
confined  their  remarks  chietiy  to  one  form  of  atrophic 
rhinitis.  In  his  opinion  there  were  four  or  five  forms, 
some  of  them  not  so  serious.  There  was  the  rheumatic 
and  gouty  form,  in  which  local  treatment  was  not  so 
important,  and  relief  followed  remedies  directed 
against  the  gout  or  rheumatism.  .Another  form  ac- 
companied anaemia,  and  treatment  of  this  relieved  the 
ana;mic,  drawn,  dry  state  of  the  nasal  mucous  mem- 
brane. Then  there  was  traumatic  atrophic  rhinitis, 
seen  in  stonecutters,  millers,  and  persons  working  in 
overheated  air.  A  fourth  form  was  that  which  had 
been  referred  to  chiefly  to-night.  In  this  form  he 
thought  more  emphasis  should  be  put  upon  the  consti- 
tutional influence  and  the  necessity  for  constitutional 
treatment  against  the  scrofulous  state,  etc.  He  thought 
oz£Ena  was  nearly  always  of  specific  origin.  It  might 
be  a  hereditary-syphilis  manifestation.  Dr.  Douglass, 
he  said,  had  not  expressed  much  faith  in  oily  prepa- 
rations, but  the  speaker  thought  they  were  of  value, 
after  removing  scabs,  in  preventing  their  reformation. 
In  ordinarv  atrophic  rhinitis  he  had  found  nothing 
equal  to  iodine.  Plenty  of  cod-liver  oil  and  outdoor 
exercise  should  be  given. 

Dr.  T.  J.  Harris  said  he  would  confine  his  remarks 
to  atrophic  fetid  rhinitis.  According  to  the  com- 
mon definition,  there  were  three  characteristic  symp- 
toms which  were  constant,  namely,  atrophy  of  the 
mucous  membrane,  discharge,  odor.  The  speaker 
thought  only  one  of  these  was  constant,  namely,  dis- 
charge. There  might  be  atrophy  here,  hypertrophy 
there,  and  odor  might  be  entirely  absent,  but  discharge 


MEDICAL    RECORD. 


[August  7,  1897 


which  consuntly  recurred  was  never  missing.  I-ow- 
enberg  claimed  about  two  years  ago  to  have  found  the 
bacillus,  but  was  unable  to  get  a  culture  which  would 
produce  the  disease.  Later  it  it  had  been  claimed 
that  the  true  bacillus  resembled  the  pneumococcus  of 
Fraenkel  but  with  differences,  and  it  had  been  asserted 
that  oza;na  could  be  produced  by  introduction  into  the 
human  nose.  Other  observers  in  Italy  and  France 
had  found  the  same  bacillus.  The  other  theory  was 
the  old  one  of  Michel  that  oza;na  always  came  from 
a  purulent  condition  of  the  frontal  sinus.  Later 
Grunwald  had  modified  this  by  saying  that  there  was 
always  a  purulent  condition  of  one  or  other  of  the 
accessory  sinuses,  and,  bearing  this  fact  in  mind,  he 
claimed  to  cure  his  cases.  Dr.  Harris  thought  re- 
searches into  the  etiology  should  be  continued,  but 
we  ought  not  to  disregard  the  factor  of  disease  in  the 
accessory  sinuses. 

Dr.  Concanon  had  treated  fourteen  cases,  in  every 
one  of  which  there  was  a  purulent  condition  of  the 
ethmoid  cells.  Five  had  been  cured.  Treatment 
included  washing  out  the  ethmoid  cells,  and  use  of 
iodoform-gauze  pack,  saturated  with  ichthyol,  in 
the  upper  part,  lea\ing  room  below  for  breathing. 

Locomotor  Ataxia  (?)  and  Hodgkin's  Disease. 
Dr.  Abrams  presented  a  man,  thirty-five  years  old, 
single;  history  negative  until  two  years  ago  symptoms 
of  locomotor  ataxia  began  to  manifest  themselves, 
consisting  in  shooting  pains  in  the  lower  extremities, 
absent  patellar  reflexes,  slight  swaying  with  eyes  closed 
and  feet  together.  About  a  year  ago  he  noticed  a  mass 
on  the  back  of  the  head  and  neck,  and  to-day  swelling 
of  the  glands  constituted  tumors  in  the  neck  beneath 
the  jaw,  in  the  back  of  the  neck ;  the  glands  in  the 
axilla  were  enlarged;  the  mamma;  were  also  enlarged. 
It  was  clear  that  the  man  had  Hodgkin's  disease;  had 
he  also  tabes  dorsalis?  A  friend  had  suggested  alco- 
holic neuritis,  but  the  patient  drank  only  occasionally. 
The  interest  in  the  case  was  the  combination  of  the 
two  diseases. 

Amendment  of  Bylaws. — The  following  amend- 
ment to  article  v.,  section  7,  of  the  bylaws  was 
adopted:  "Whenever  an  investigation  of  charges 
against  a  member  is  undertaken  by  the  executive  com- 
mittee, in  regular  order,  it  shall  be  within  its  power  to 
cite  before  it  as  many  of  the  members  concerned  as 
the  committee  may  consider  necessary  for  an  equitable 
adjustment  of  the  matter.  Should  any  member  so 
summoned  fail  to  comply,  without  valid  excuse,  he 
shall  be  judged  in  contempt,  and  it  will  be  the  duty 
of  the  executive  committee  to  recommend  his  censure 
or  expulsion  from  the  association." 


MEDICAL    SOCIETY    OF   THE    COUNTY    OF 
NEW  YORK. 

StaUif  Meeting,  May  24.  1897. 

L.  C.  Gray.   M.D.,    I'resident,  in  the  Chair. 

Resection  of  Pylorus  for  Cancer. — Dr.  Carl  Beck 
presented  a  man  whose  pylorus  he  had  resected  for 
cancer.  The  points  made  were:  Early  diagnosis  and 
early  operation  gave  promise  of  cure;  formalin  catgut 
was  used,  one  row  of  suture,  which  contributed  to  the 
good  result,  for  the  patient  was  able  to  be  up  by  the 
ninth  day  and  to  be  presented  on  the  twelfth  day  after 
the  operation. 

Report  of  Committee  on  Legislation. — Dr.  Frank 
\'ax  I''i,i;i;i-  read  the  report  of  the  conunittee.  The 
committee  had  been  appointed  to  act  with  that  of  the 
State  Medical  Society  to  oppose  undesirable  bills 
affecting  the  medical  profession  brought  before  the 
legislature,  and  to  advocate  others.  It  had  very  prop- 
erly and  successfully  opposed  the  opticians'  bill,  which 


had  again  been  brought  before  the  legislature  at  its 
recent  session.  It  had  sought  to  have  the  charter  of 
the  Pedic  Society  repealed,  but  had  not  been  disap- 
pointed in  failure.  The  amended  bill  affecting  dis- 
pensaries had  passed  the  legislature.  The  committee 
had  started  out  to  do  a  certain  work,  and  this  it  had 
accomplished.  On  motion  of  Dr.  Van  Fleet  the  mem- 
bers of  the  legislature  who  had  acted  with  the  commit- 
tee receixcd  a  \ote  of  thanks. 

Report  of  the  Committee  on  the  Abuse  of  Med- 
ical Charity. — Dr.  J.  H.  Blrtenshaw,  chairman  of 
the  committee,  read  the  report.  The  first  step  taken 
was  to  ascertain  the  sentiment  of  the  governing  boards 
of  the  different  dispensaries,  and  to  communicate  with 
the  Charity  Organization  Society  with  the  object  of 
ascertaining  what  system  could  be  instituted  for  the 
investigation  of  the  worthiness  of  applicants  for  free 
medical  treatment.  A  circular  was  sent  to  the  officials 
of  the  ninety-five  dispensaries  in  the  city,  with  three 
interrogatories,  briefly  as  follows:  1.  Did  the  govern- 
ing board  of  the  dispensary  approve  of  the  movement 
to  abolish  or  regulate  the  abuse  of  medical  charity? 
2.  Would  the  governing  board  co-operate  with  the 
County  Medical  Society  in  this  matter?  3.  Would  it 
post  a  placard  in  a  conspicuous  place  in  the  dispensary, 
stating  that  the  ability  of  applicants  for  free  medical 
treatment  to  pay  would  be  investigated?  Replies  were 
received  from  seventy-six.  Of  the  other  nineteen,  five 
were  homceopathic,  two  were  under  the  supervision  of 
the  department  of  charities,  most  or  all  of  the  others 
had  a  local  or  limited  patronage.  The  replies  were 
favorable  or  conditional,  with  the  exception  of  that  from 
St.  Marv's  Free  Hospital  for  Children,  which  treated 
over  seven  thousand  yearly,  and  the  New  York  Hospital 
dispensary,  which  treated  over  nine  thousand  yearly. 
The  committee  co-operated  with  one  from  the  New 
York  County  .Medical  Association  and  one  or  more 
others,  and  had  aided  in  having  the  amended  Sullivan 
bill  passed  in  the  legislature  for  the  control  of  charity 
abuse.  The  profession  throughout  the  State  seemed 
to  be  practically  unanimous  in  favor  of  that  bill.  The 
committee  had  every  reason  to  suppose  that  the  bill 
would  receive  the  signature  of  the  governor,  and  had 
been  greatly  disappointed  that  he  had  not  yet  signed  it, 
as  the  thirtieth  day  since  tfie  adjournment  of  the  legis- 
lature would  expire  at  midnight.  The  committee  and 
the  entire  medical  profession  fully  recognized  the  fact 
that  there  was  no  charity  more  beneficent  than  free 
medical  attendance  on  the  poor,  but  it  had  been  con- 
clusively demonstrated  that  the  abuse  of  this  had  at- 
tained such  great  proportions  as  to  make  it  imperative 
to  adopt  measures  to  check  it  at  once. 
It  was  moved  to  accept  the  report. 
The  Sullivan  Bill  too  Effective  ?— Dr.  D.  H.  St. 
John  Roosa  said  he  supposed  he  was  not  in  accord 
with  the  majority  of  the  societj-,  but  he  thought  he 
would  be  if  they  would  Ix;  kind  enough  to  hear  him. 
He  thought  the  question  of  the  abuse  of  medical  char- 
ity had  been  much  exaggerated.  He  was  connected 
with  two  large  institutions,  both  of  which  he  had 
helped  to  found,  and  he  wished  to  state  that,  whatever 
the  medical  press  might  say  to  the  contrary,  they  were 
not  working  primarily  for  the  glorification  of  the  doc- 
tors connected  with  them,  but  for  the  benefit  of  the 
sick  poor.  Secondarily  they  hoped  to  achieve  for 
themselves  an  honorable  reputation.  If  there  was  any 
treason  in  that,  then  they  were  guilty  of  it.  They  took 
the  greatest  pains  to  exclude  those  unworthy  of  charity. 
He  "thought  it  would  be  found  that  the  reason  why  the 
governor  hatl  not  signed  the  present  bill  was  not  that 
he  had  not  had  time  to  consider  it,  but  that  he  had 
considered  it.  The  fatal  error  in  the  original  bill  was 
that  it  undertook  to  give  the  control  of  chartered  insti- 
tutions into  the  hands  of  a  self-constituted  society, 
which  had  not  been  born  long  enough  for  most  members 


Au 


crust 


1897] 


MEDICAL    RECORD. 


to  know  anything  about  it.  The  amended  bill  gave 
the  State  board  of  charities  power  to  annul  charters, 
and  to  this  he  was  opposed.  That  power  should  lie 
elsewhere  when  it  was  proven  that  the  provisions  of 
a  charter  had  been  violated. 

A  point  of  order  having  been  raised,  The  President 
ruled  that  Dr.  Roosa  was  not  in  order,  but  said  he 
would  entertain  a  motion  which  would  allow  the  dis- 
cussion to  continue. 

The  motion  to  accept  the  report  was  carried. 

Dr.  Sturgis  then  moved  to  continue  the  committee, 
and  accepted  an  amendment  by  Dr.  Grandin  to  allow 
$2oo  to  pay  for  past  e.xpenses  of  the  committee.  The 
work  of  the  committee  had  been  great,  much  greater 
than  would  appear  from  so  brief  a  report. 

Dr.  Egbert  H.  Graxdix  spoke  for  the  adoption  of 
the  resolution.  It  was  seldom  that  the  society  had 
opportunity  to  hear  so  valuable  a  report  as  this  one 
on  an  evil  which  threatened  the  medical  profession  of 
the  city.  He  was  not  connected  with  any  institution, 
and  could  speak  from  a  somewhat  different  standpoint 
from  the  gentleman  who  had  upheld  two  institutions 
with  which  he  was  connected,  but  which  nevertheless 
had  helped  defraud  the  medical  profession.  He  was 
being  brought  in  daily  contact  with  the  general  practi- 
tioners of  the  cit}'.  who  told  him  of  their  patients  who 
were  able  to  pay  an  adequate  fee  going  to  hospitals 
and  dispensaries  where  they  paid  nothing,  unless  it 
was  ten  cents  for  a  prescription  or '"a  dollar  a  month." 
He  contended  that  it  was  just  as  unethical  for  a  hos- 
pital or  dispensarj-  to  rob  him  of  a  patient  who  was 
able  to  pay  him  a  fee,  as  it  was  for  his  ne.xt-door 
neighbor  to  do  so.  If  there  was  a  body  of  men  in  this 
city  who  should  take  hold  of  this  question  it  was  the 
Count)'  Societ}'.  We  had  been  speaking  and  writing 
editorials  on  the  subject  for  years:  boards  of  mana- 
gers had  been  shown  that  the  charit}'  which  they  were 
carr)'ing  out  was  not  of  the  kind  the  good  book  spoke 
of.  -\t  last  an  appeal  had  been  made  to  the  legisla- 
ture and  a  bill  had  been  passed,  but  as  it  promised 
something  effectual  the  rich  managers  of  hospitals  and 
dispensaries  had  killed  it.  But  a  drop  of  water  would 
in  the  end  wear  out  a  stone,  and  perhaps  some  day 
there  would  be  a  governor  in  Albany  who  would  recog- 
nize the  voice  of  the  medical  society  of  this  county. 
Within  a  brief  period  three  of  his  patients,  able  to 
pay  him  a  fee,  had  been  taken  from  him  by  institutions 
which  charged  Si 5  a  week  board.  Hereafter  let  the 
members  keep  track  of  all  such  cases,  and  let  the  a.\e 
be  laid  at  the  root  of  the  evil.  The  doctors  connected 
with  such  institutions  would  learn  that  it  did  concern 
them  ;  that  they  also  must  investigate  cases  coming  for 
free  treatment,  whatevei  the  managers  might  do. 

Dr.  F.  R.  Sti'rgis  said  members  had  been  told  to- 
night that  there  had  been  a  great  deal  of  unnecessary- 
talk  with  regard  to  the  abuse  of  medical  charity.  Pick 
up  the  reports  of  any  of  the  dispensaries  and  charity  in- 
stitutions in  this  city,  and  one  could  not  but  be  con- 
vinced that  in  each  of  them  abuse  of  medical  charity 
was  practised  to  an  enormous  extent.  Dr.  Sturgis 
thought  the  most  effectual  method  of  entering  com- 
plaint under  existing  conditions  was  not  that  suggested 
by  Dr.  Grandin,  but  that  each  known  case  of  abuse  of 
medical  charity  should  be  reported  to  the  State  board 
of  medical  charities,  and  that  when  one  knew  of  a  new 
institution  about  to  be  founded  he  should  present  facts 
to  that  board  showing  there  was  no  necessity  for  it. 

-After  several  other  members  had  spoken,  the  presi- 
dent called  upon  Dr.  Jaxvrix,  president  of  the  County 
Medical  .Association,  and  Dr.  Haddex,  who  had  just 
returned  from  .\lbany,  where  they  had  visited  the  gov- 
ernor, urging  him  to  sign  the  Sullivan  bill  relating  to 
the  regulation  of  dispensaries.  They  had  had  an 
audience  of  only  about  ten  minutes,  but  were  able  in 
this  short  time  to  present  their  points  briefly.     They 


pointed  out  that  at  present  there  was  no  way  of  regulat- 
ing the  dispensary  abuse;  that  physicians  had  no  con- 
trol in  the  matter:  that  every  dispensar}-  in  New  Vork 
was  a  law  unto  itself.  More,  the  different  dispensa- 
ries would  not  co-operate  with  one  another  in  trying 
to  rectify  abuses.  The  whole  medical  profession  felt 
the  injustice  of  the  present  want  of  system,  and  was 
practically  unanimous  in  supporting  the  bill  awaiting 
the  governor's  signature.  It  was  anxious  to  leave 
to  the  State  board  of  charities  the  arbitration  of  the 
whole  matter.  If  any  dispensaries  were  opposed  to 
this  method,  it  was  known  that  they  did  not  wish  the 
abuses  rectified.  The  State  board  of  charities  at  pres- 
ent had  simply  general  supen'ision,  but  it  had  no  power 
to  regulate  the  abuses.  The  governor  did  not  give 
them  any  assurance  of  signing  the  bill,  but  expressed 
the  wish  that  he  had  heard  from  them  sooner.  What 
that  meant,  Dr.  Hadden  remarked,  he  did  not  know. 

.\  member  asked  if  it  was  known  who  had  opposed 
the  signing  of  the  bill,  and  Dr.  Hadden  said  it  was 
rumored  that  two  men  whom  he  named  had  done  so, 
one  of  them  a  doctor. 

Dr.  Sturgis'  motion  was  adopted,  with  few  voices 
in  opposition. 

Blood  in  the  Urine  :  How  to  Verify  its  Presence 
and  Determine  its  Source,  together  with  Some 
General  Considerations  as  to  its  Causes. — Dr. 
William  K.  Otis  read  a  paper  with  this  title.  The 
question  of  blood  in  the  urine  interested  both  special- 
ist and  general  practitioner.  It  interested  the  general 
practitioner  because  the  patient,  greatly  alarmed,  al- 
ways came  to  him  first.  The  presence  of  blood  in  the 
urine  might  be  due  to  a  condition  or  a  lesion  of  com- 
parative insignificance,  or  it  might  indicate  one  which 
must  inevitably  prove  fatal. 

When  the  urine  contained  blood  its  color  first 
attracted  attention.  The  amount  of  blood  varied  from 
a  quantity  only  sufficient  to  cause  slight  smokiness  to 
that  which  caused  a  cherr\-red  appearance.  One  part 
of  blood  in  fifteen  thousand  of  urine  was  enough  to 
cause  smokiness,  one  in  five  hundred  to  cause  a  bright 
red.  The  color  was  due  to  hemoglobin,  and  when  this 
became  changed  the  color  might  become  dark  brown. 
It  was  a  mistake,  however,  to  suppose  that  when  the 
color  of  the  urine  was  dark  brown  the  source  of  the  hem- 
orrhage was  necessarily  in  the  kidney,  not  below  that 
point.  The  use  of  certain  drugs  and  the  presence  of 
bile  pigments  might  impart  a  color  closely  resem- 
bling haematuria.  The  chemical  tests  by  which  to  dis- 
tinguish between  this  and  blood,  when  microscopical 
examination  was  not  sufficient,  as  it  usually  was,  were 
given.  The  presence  of  blood  in  the  urine  could 
also  be  determined  by  the  spectroscope. 

The  next  question  was  to  determine  in  what  part 
of  the  urinary  tract  the  blood  originated:  Was  it  from 
the  anterior  urethra  in  front  of  the  compressor  urethrae; 
was  it  between  the  latter  point  and  the  bladder:  was 
it  in  the  bladder;  was  it  in  the  ureter  or  kidney?  If 
anterior  to  the  compressor  urethrae,  the  blood  would 
exude  from  the  meatus,  or  could  be  stripped  out.  The 
urine  first  passed  alone  contained  blood.  The  ure- 
throscope could  also  be  used.  If  the  hemorrhage  was 
from  the  posterior  urethra  the  blood  would  not  exude 
from  the  meatus,  but  would  back  into  the  bladder  if  of 
sufficient  quantity.  If  the  hemorrhage  was  small  the 
blood  would  appear  onlv  with  the  beginning  or  at  the 
end  of  micturition,  the  rest  of  the  lu-ine  being  clear; 
or  the  urine  at  both  beginning  and  end  of  micturition 
might  be  tainted,  the  intermediate  portion  being  free. 
.•\t  times  a  clot  might  escape.  When  the  hemorrhage 
was  from  the  bladder  the  entire  urine  was  mi.xed  with 
the  blood.  Microscopic  examination  might  show  evi- 
dence of  a  new  growth  in  the  bladder.  Let  the  ex- 
aminer wash  out  the  bladder  with  solution  of  borax 
until  the  water  came  awav  clear,  then  throw  in  two 


MEDICAL    REC:ORD. 


[August  7,  1897 


or  three  ounces,  wait  a  few  minutes,  and  withdraw 
it;  if  it  contained  blood  it  was  probable  the  hemor- 
rhage was  vesical.  A  further  test  was  the  fact  that 
the  bladder  lining  membrane  absorbed  very  slowly 
except  when  through  disease  some  portion  of  it  was 
deprived  of  its  protective  epithelium.  Let  the  ex- 
aminer, having  cleansed  the  bladder,  throw  in  a 
small  amount  of  iodide  of  potassium  in  solution,  ten  or 
fifteen  grain.s,  wait  fifteen  minutes,  collect  the  saliva, 
and  test  it  for  iodine  by  the  starcli  method.  If  the 
saliva  contained  iodine  that  fact  would  point  conclu- 
sively to  some  lesion  of  the  bladder — assuming  that 
the  patient  had  not  been  taking  iodine  internally.  He 
had  got  this  idea  from  Dr.  Mcliride,  but  on  visiting 
Germany  found  it  in  use  there.  In  case  of  a  new 
growth  in  the  bladder  it  could  sometimes  be  felt  by 
rectal  examination.  The  value  of  an  examination  by 
the  electrocystoscope  could  hardly  be  overestimated. 
It  often  revealed  the  nature  of  the  lesion  as  well  as 
its  seat.  In  locating  hemorrhage  in  the  kidney  or 
ureter,  the  history  was  usually  of  value,  for  the  pres- 
ence of  stone  or  passage  of  gravel  was  apt  to  give  a 
history  of  pain.  Occasionally,  however,  hemorrhage 
from  above  the  bladder  came  on  without  the  slightest 
warning.  The  amount  of  blood  passed  varied  greatly. 
Intermittency  might  be  caused  by  blood  clot  obstruct- 
ing the  ureter.  Dr.  Alexander  had  presented  a  clot 
which  had  beeiT  passed,  and  which  was  a  complete 
cast  of  the  pelvis  of  the  kidney.  The  pain  might  be 
positive,  or  only  an  uneasy  feeling.  Pain  over  the 
region  of  the  kidney  might  be  elicited  with  the  finger 
when  it  could  not  with  the  whole  hand.  If  the  bladder 
seemed  to  be  the  source  of  hemorrhage  which,  how- 
ever, could  not  be  definitely  located,  suprapubic 
exploratory  incision  was  justifiable. 

Dr.  L.  Bolton  Bancs  opened  the  discussion. 
There  was  little  to  add  except  liy  way  of  confirmation. 
It  had  been  well  stated  that  the  presence  of  blood  in 
the  urine  was  only  a  symptom.  The  important  thing 
was  its  cause  and  where  situated.  The  color  of  the 
urine  was  no  indication  of  its  source.  He  had  seen 
urine  of  bright  red  color  when  the  source  of  the  hem- 
orrhage was  the_  kidney,  not  the  bladder.  The  cysto- 
scope  might  fail  to  reveal  the  lesion  when  this  was  in 
the  bladder  because  of  discoloration  of  the  injected 
fluid  by  active  hemorrhage,  but  this  fact  itself  pointed 
to  the  bladder  as  the  source  of  the  hemorrhage  in  op- 
position to  the  kidney.  The  iodide-of-potassium  test 
had  failed  several  times  in  his  hands  when  the  lesion 
was  in  the  bladder.  He  had  had  a  case  of  profuse 
hemorrhage  whose  source  was  doubtful :  he  made  an 
exloratory  suprapubic  cystotomy;  the  cause  was  found 
to  be  tuberculosis,  and  the  hemorrhage  ceased,  but 
recurred  when  the  drainage  opening  closed.  Hygienic 
measures  were  emploved,  and  there  had  been  no 
hemorrhage  in  two  years. 

Dr.  F.  R.  SrfRGis  had  found  the  determination  of 
the  source  of  the  hemorrhage  in  the  bladder  with  the 
cystoscope  difficult  even  after  irrigation  when  the 
hemorrhage  was  considerable.  'i"he  iodine  test  had 
not  been  of  much  value  in  his  ca.ses.  The  author,  he 
said,  had  limited  his  paper  almost  exclusively  to 
hemorrhage  in  surgical  cases.  But  there  were  many 
other  causes  of  hematuria,  among  them  certain  drugs, 
supplementary  ha-maturia  in  menstruation,  in  bleed- 
ing hemorrhoids;  hematuria  caused  by  mental  emo- 
tions, by  parasites,  especially  in  hot  countries;  by 
transfusion  of  blood,  in  the  case  of  animals,  etc. 

Dr.  SAMfEi,  Alexander  thought  the  best  test  as  to 
the  presence  of  blood  was  microscopic  examination. 
The  other  tests,  although  useful,  were  rather  a  refine- 
ment. He  had  found  tliat  a  good  test  of  wliether  the 
bleeding  was  due  to  calculus  was  to  have  the  patient 
ride  on  a  Fifth  Avenue  .stage  and  immediately  after- 
ward examine  the  urine  for  blood.      He  regarded  the 


Fifth  Avenue  stage  as  a  part  of  his  clinical  armamen- 
tarium I  As  a  rule  the  shape  and  size  and  solidity  of 
the  clot  gave  little  information,  but  in  his  case  alluded 
to  in  the  paper  the  clot  was  a  distinct  fibrinous  mould 
of  the  pelvis  of  the  kidney  and  its  calyces.  Subse- 
quently a  renal  calculus  was  removed  by  oiseration. 


therapeutic  pints. 

Tic  Douloureux.  —  Ewart  (British  Aledical  Jour- 
nal) states  that  in  the  etiolog)"  of  this  disease  the 
importance  of  gout  in  the  larvate  forms  is  often 
overlooked.  It  may  be  recognized  by  the  following 
indications:  i.  It  occurs  often  in  the  healthy  with 
ruddy  complexion,  which  is  common  in  sthenic  gout. 
2.  Presence  of  Heberden's  nodules,  or  of  tophi  in  the 
ears.  3.  History  of  gravel  or  stone.  4.  Ner\-ous, 
gastric,  intestinal,  and  hepatic  disturbances  of  long 
duration.  5.  Strength  of  pulse  and  endurance  of  pa- 
tient after  prolonged  pain  and  insomnia.  6.  Adverse 
influence  of  alcohol  and  certain  diet.  7.  Presence  of 
uric  acid  in  the  urine.  The  nature  of  the  etiological 
action  of  gout  is  not  explained,  though  it  is  thought 
to  act  by  producing  an  irritability  of  the  nervous  sys- 
tem. His  treatment  consists  of  sedative,  restorative, 
alterative,  and  tonic  measures.  As  sedatives  he  rec- 
ommends morphine  and  choral ;  as  restorative  agents, 
rest  and  a  non-nitrogenous  diet;  as  alteratives,  salts 
of  iodine,  mercury,  guaiacum,  and  for  tonics  the  vege- 
table tonics,  massage,  and  salt  baths.  The  results 
which  he  obtained  by  mercury  and  the  salts  of  iodine 
in  cases  which  were  not  specific  are  most  satisfactory. 
He  gives  the  histories  of  several  patients  about  to  sub- 
mit to  an  operation,  who  recovered  under  this  line  o£ 
treatment. 

The  Treatment  of   Graves'  Disease. — Dr.  Hector 

Mackenzie  KAmcrican  Journal  of  the  Medical  Scianes, 
February,  1897)  speaks  as  follows  in  regard  to  the 
treatment  of  Graves'  disease  by  means  of  thymus 
gland:  "I  am  of  opinion  that  the  dose,  to  be  of  any 
use,  should  be  at  least  one  or  two  drachms  a  day,  of 
the  fresh  gland  or  its  equivalent  in  the  form  of  ex- 
tract or  powder.  The  conclusion  at  which  I  have  ar- 
rived is  that  tlie  thymus  gland  possesses  no  specific 
action  in  Graves'  disease.  I  have  found  it  in  most 
cases  to  have  no  effect  either  on  the  heart,  on  the 
goitre,  or  on  the  exophthalmos.  At  the  same  time  it 
appears  to  be  a  remedy  of  some  value,  improving  the 
general  condition,  and,  in  this  way,  may  assist  toward 
the  recovery  of  the  patient.  I  should,  at  present,  place 
it  in  the  same  class  of  remedies  as  cod-liver  oil." 

The  Treatment  of  Chronic  Bronchitis.  — Dr.  .Ar- 
thur Davies  recently  read  a  paper  on  this  subject 
before  the  Hunterian  Society.  He  alluded  to  the 
many  drugs  which  had  been  employed  in  the  treatment 
of  this  disease,  but  he  now  emphasized  the  value  of 
the  spray  method.  This  was  carried  out  by  frequent 
administrations  of  ipecacuanha  wine  three  or  four 
times  a  day.  At  each  sitting  one-half  or  one  drachm  of 
the  drug  was  used,  but  the  patients  were  directed  not 
to  swallow  the  wine.  Cases  were  cited  which  showed 
relief  from  difficulty  of  breathing  and  lessening  of  the 
expectoration.  The  disadvantages  of  the  inhalations 
were  that  sometimes  vomiting  followed,  and  if  the  drug 
were  used  pure  spasmodic  dyspncta  would  sometimes 
come  on,  and  it  was  not  suited  for  cases  of  asthma. 
Dr.  Davies  had  tried  a  spray  of  potassium  iodide  with 
encouraging  results.  The  class  of  cases  suitable  for 
treatment  with  the  i])ecacuanha  spray  was  early  cases 
with  much  dyspnaa  and  tenacious  sputa.  He  had  also 
had  much  help  from  the  administration  of  trinitrin, 
the  dyspncra    especially  being   relieved.     When   tlie 


August  7-  1 897]                           MEDICAL  RECORD.                                                   213 

dyspncea  was  moderate,  tar  in  various  forms  was  found 

useful.     Terebene    also    fell    in    the   same   category.  (CoVCrSpOUdCUCe. 
\Vhen  ftctid  bronchitis  and  bronchiectasis  were  pres- 
ent, inhalations  of   creosote  have  been  found  eflfica-  OUR    LONDON    LETTER, 
c'ous.  „            -     .  ,  ^            J      ^ 

( t  rom  our  bpecial  Correspondent.) 

For  Greenish  Dejections.-  ^^^  ^    ^^^j^,  ^^  ^^^  ^^^^^  ^^^^^  ^^  ^^^  heart- 

^  Sodii  bromid 4  PROFESSOR    FRASER   ON    SERPENT  POISON,  A  FIRTHER 

Tinct'''opii'°"mph aa      S  COMMUNICATION— ROYAL     COLLEGE    OF    SURGEONS— 

Aqu.-e  anisi ad  60  NURSING-HOMES  —  HOSPITAL    SUNDAY    FUND. 

M.      S.   One  tablespoonful  even  two  to  four  hours. 

London.  July  23,  111^7. 

^  srmpkTymp '.     '. '. '. '. '. '. .... '-  '■  • ' '.  '■  ■  ■  ■  -  • .  ■■.■  '■  '■  '■  9S  The  mechanism  by  which  the  first  sound  of  the  heart 

Lemon  juice q-s.  ;s  produced  is  again  under  discussion.      Sir  Richard 

M.     S.  One  teaspoonful  ever}-  three  hours.  Quain,   notwithstanding    recent    illness   and    his   ad- 

— Hatfield,  "  Z>/seasis  of  Chihiroi."  vanced  age,  has  submitted  a  paper  to   the  Royal  Soci- 
ety on  this  subject.      He   attributes   the  sound  to  the 

Whooping-Cough.— Since  Michael  suggested  nasal  jn^p^ct  of  the  blood  driven  forcibly  against  the  column 

insufflations  of  antiseptic  powders,  Moizard  has  also  ^f  ^j^g   ^^^^g    A^^j^l    ;„  ^i^^  vessels    (supported  by  the 

employed  them  with  great  benefit.     He  recommends:  ^^ives),  which  is  in  a  condition  of  momentary  repose. 

K  IJenzoin  (pulv. ) lu  Vou  may  be  inclined  to  say  you  have  heard  this  view 

Salicylate  of  bismuth 10  before,  and  certainly  it  closely  resembles   if  it  is  not 

(Quinine  isulphate) 2  precisely  the   same  as  that  advocated  by  the   late  Dr. 

The   insufflations    are   made  five  times  a  day.      In   a  Arthur  Leared  in  his  thesis,  "On  the  Sounds  Caused 

week  or  less  the  accesses  of  coughing  are  reduced   in  by  the   Circulation  of   the  Blood,"  published  in  1861. 

number  and   intensity,  and  the  cure  is  rapid. — Joiini.  \)x.  Leared  even  went  further,  and  held  a  similar  view 

dc  Med.  it  de  Cliir.  Fiat.  of  the  production  of   murmurs.      If  thf   stream  meets 

with  sufficient  resistance  in  the  blood  pressure  in  the 

Trismus  Neonatorum. —  ^^orta  and  pulmonary  artery,  what  about  the  valves  and 

1^  Ext.  gelseniii tn  viij.-.wi.  ventricular  walls?      Surely  they  also  ofier  resistance, 

Syr.  simplicis ^  i-  ^^^  Some  would  say  more  resistance  than  the  colimin 

M.'^^S.'Half-teaspoonfulever^- two  ,0  four  hours.  in  the  vessels.      Be' that  as   it  may,  the   cause  of  the 
Bartholow  '^'^^'^  sound  has  always  been  in  dispute,  and  the  vener- 
able baronet,  who  has  always  made  the  heart  a  special 

"B,  Tinct.  opii gtt.  v.  study,  may  be  congratulated  on  his  attempt  to  settle  a 

Tinct.  asafoetidse ^  iss.  ,        Jl              ..• 

Svr.simp Iv.  knotty  question.                                                         ,      ^        , 

Aq  ad  :  XV.  Professor   Eraser  has  communicated  to    the  Royal 

M.    S.  Half  teaspoonful  every  hour.  .Societ}'  of  Edinburgh  further  experiments  w'ith  serpent 

—  Eberle.  poison.     He  has  found  that  the  bile  of  all  animals  is 

Purulent  Conjunctivitis  in  Infants—  antivenomous,  but  that  of  venomous  serpents  is  most 

•          1  J,  potent,  e.g.,  o.\  bile   is   onlv    about   one-seventieth  as 

\cid"bodc.,'"  potent  as  the   bile  of  the  'most    venomous    serpents. 

Sodii  bibora't aa  gr.  v.  Serpents'  venom  does  not  seem  to  be  destroyed  in  the 

Tinct.  opii  deed 3  ss.  stomach,  and  yet  it  fails  to  poison ;   so  it  is  also  clear 

-•\qu.e  dest 31  that  it  is  not  absorbed  from  the   stomach.      It  is  then 

Mix  .-ind  hlter.  ^  .^.  ,  probable,  from  Professor  Eraser's  experiments,  that 
Several  bad  cases  were  all  cured  within  two  weeks  ^^^  ^.^^^^  .^  destroved  bv  the  bile,  and  we  mav  con- 
It  should  be  injected  under  the  lids  ev-ery  hour,  and  ^^^^  ^^^^  ^^^^  ^^  ^f^^  ^^^^  ^^  ^^^^  secretion  is  to  ren- 
the  eyes  still  more  often  cleansed  with  tepid  water,  ^^^  ^^^^  ^  ;^  ;^^^^  .^^^^  .^j^^  antivenomous 
and  vaseline  applied  to  the  edges  of  the  lids  e^•er^■  ^^^^^^^^^  ^f  bile  does  not  seem  to  be  soluble  in  alco- 
night.  -Scott,  Am.  Jour.  Oph.  ^^^^   ^^^  -^^    Eraser  has    separated   a   watery  extract 

Chapped  Hands  and  Face  or  Fissured  Nipple.-  which  displays  considerable  potency,  and  thinks  that 

„  "       ,  from    bile    an     antidote    for    snake     poison    mav   be 

.IIcom'"!"'".™"'^:::;:::::::::::. ■.:.:::.  "ij"'  produced  equal    to    the  most    powerful    anth-enin   or 

Aqua;  ros* 3  ss.  antivenomous  serum  that  has  yet  been   obtained  from 

Glycerin I  i.  the  blood  of    immunized   animals.      As   bile   may  per- 

M.     s.  Apply  to  chapped  surfaces  at  night,  after  washing  j^^pg  j^g  equally  destructive  to  Other  toxic  agents,  it 

with  soap  and  water  and  carefully  drjing.  ,,  ^u    I  •  r  »u     £      ^v\ ..  .-.f  fi,^  k;1o 

'               Th     T>          ■  would  seem  that  our  views  of  the  functions  of  the  bile 

^2 he  I rachtwmr.  should  be  enlarged  and  that  we  may  be  prepared  to 

Mumps.  learn    that    it    constitutes    a    most  valuable    barrier 

'B,  Ichthyol,  against  various  toxins  formed  in  the  bodv  or  entering 

Plunihi  lodidi .la  gr.  xlv.  ,°            .  , 

.\mmon.chl |r.  x.xx.  from  Without.                                                           ,         ^          ,, 

Adipis ;  i.  Sir  W  lUiam  MacCormack  has  been  re-elected  to  the 

M.     S.    I'o  be  applied  to  the  swollen  parts  three  times  daily.  presidency  of  the  College  of   Surgeons.      The  council 

Sometimes  vaseline  may  be  used  in  place  of  lard  and  belladonna  ^^f  ^j^g  college  has  followed  the  example  of   the   Phvsi- 

may  be  added  w.th  advantage.                         —Tranchet.  ^'^"^'  <^^ollege  in  the  maUer  of  the  medical-aid  associ- 

Nervine  Tonic. ations. 

The  Morning  Post  has  admitted  a  number  of  corre- 

^  Add7art^niosi '.■.■.'.'.■.'.■.!'.■.'.".■.'.■.■.'.'.'.'.;'.■.'.'..'  gr'.ss.  spondents'    complaints    about    the     management     of 

Strychnina-  sulph  . .    . . . . . . !...!.!.!! . . '. ..  gr.  ss.  nurses'  homes.     One  further  charges  doctors'  secreta- 

Ext.  sumbul 3  iss.  ries  with  frauds  which  if  perpetrated  would  speedily 

Kerri  subcarb 3  ij.  brjng  them  within  the  clutches  of  the  law.      It  is  rather 

M.''mX  :iTrs- No.- •24V    -S.-  One  capsule  a^'er  each  hard   to    publish    such    anonymous    charges,  ^^ithout  a 

meal.  tittle  of    evidence,   against    a  whole    class   ot   men — 

— Browx,   Fa.  Med.  Semi-Moiitltly.  charges,  too,  on  the  face  of  them  most  improbable. 


214 


MF.DICAL    RECORD. 


[August    7,  1897 


The  Hospital  Sunday  fund  still  lags  behind,  and  no 
wonder,  for  the  distribution  committee  still  indorses 
the  clique  which  is  endeavoring  to  destroy  the  smaller 
and  special  hospitals,  though  they  have  given  up 
their  separate  collectings  toward  the  fund. 

Dr.  \V.  H.  Robertson,  F.R.C.P.,  of  Buxton,  died  on 
the  isth  inst.,  aged  eighty-six.  He  had  been  a  promi- 
nent figure  for  more  than  half  a  century  in  Buxton;  in 
fact,  he  settled  there  in  May,  1836,  after  he  had  prac- 
tised for  about  five  years  in  Chesterfield.  He  became 
physician  to  the  hospital  and  took  a  leading  part  in 
all  the  public  movements  of  the  town,  to  the  growth 
of  which  he  so  largely  contributed  that  he  was  some- 
times said  to  have  "made  Buxton."  There  is  no 
doubt  that  his  influence  did  much  to  extend  the  repu- 
tation of  the  important  mineral  waters  and  to  foster 
the  rapid  growth  of  this  bracing  spa.  He  was  buried 
on  Tuesday,  full  of  honors  as  fall  of  years,  all  the 
town  seeming  to  follow  him  to  the  grave.  He  had 
been  so  long  associated  witli  Buxton  that  many 
thought  he  must  be  much  older,  and  I  have  often  heard 
it  said  that  he  must  be  ninety,  but  I  hear  now  that  he 
was  only  eighty-six.  He  enjoyed  the  esteem  of  all  his 
local  brethren,  as  well  as  of  a  very  wide  circle  of  the 
profession  in  London.  Of  course  he  had  practically 
retired  for  some  years,  but  he  retained  all  his  facul- 
ties to  the  last,  firesided  at  the  meeting  of  the  hospital 
committee,  in  which  he  took  the  keenest  interest,  as 
well  as  those  of  the  I'ublic  Gardens  C'ompany.  He 
now  and  again  saw  patients,  and  I  hear  that  he  did  so 
on  the  day  of  his  death,  whicli  took  place  rather  sud- 
denly that  night  from  heart  failure.  Buxton  is  one  of 
our  most  important  inland  health  resorts.  It  is  situ- 
ated in  the  beautiful  peak  district  of  Derbyshire,  fa- 
miliar to  you  from  Scott's  "Peveril  of  the  Peak," 
though  I  believe  the  "Wizard  of  the  North"  never  ac- 
tually visited  the  locality.  The  town  is  nearly  one 
tliousand  feet  above  the  sea  level,  and  there  are  higher 
hills  round  about,  but  they  cannot  be  said  to  protect 
it  from  winds.  In  sunnv  weather  it  is  hot  enough,  but 
on  dull  days  there  is  always  a  keen  breeze,  and  out 
of  the  short  summer  season  it  must  be  very  cold  com- 
pared with  London.  I  have  been  there  often  enough 
to  experience  its  varying  moods.  The  mineral  waters 
belong  to  the  indifferent  class;  in  fact,  "  mineral" 
is  a  misnomer,  for  the  water  contains  none  and  ap- 
proaches distilled  water,  unless  account  be  taken  of 
the  free  nitrogen  present.  The  temperature  of  this 
water  is  82'  F.,  and  the  natural  baths  are  considered 
the  most  valuable,  although  there  are  hot  baths  for 
those  who  cannot  take  the  natural  one.  The  place  has 
from  a  remote  period  been  celebrated  for  rheumatism 
and  gout,  and  in  the  season  is  crowded  with  sufferers 
from  these  diseases.  Rheumatoid  arthritis  is  often 
relieved  by  a  course  at  Buxton,  which  maintains  its 
repute  as  our  best  resort  for  these  chronic  invalids, 
many  of  whom  spend  three  or  four  weeks  there  every 
summer. 


OUR    BERLIN    LETTER. 

(From  our  Special  Correspondent.) 

THK.    NEW    TUBERCULIN PA-STOR  KNEIPP — CANCER  AND 

TRAUMA  —KLACK-W..\TER    FKVER. 

v.KKUS.  July  IS,   .8g7. 

'{"he  festivities  of  the  Congress  for  Internal  Medicine, 
which  were  reported  in  detail  in  niv  last  letter,  are 
all  over;  members  and  guests  coming  from  all  places 
in  Germany  have  departed  for  their  individual  homes, 
well  satisfied  with  the  work  done.  F.ach  one  pursues 
in  silence  his  further  labors  and  researches,  perhaps  to 
bless  mankind  soon  or  in  after-years  with  some  valu- 
able discovery.  In  spite  of  tlie  distressing  heat  of  the 
dog  days,  scientific  Berlin  works  on  untiringly. 


The  fiist  professional  opinion  upon  the  new  tuber, 
culin  was  expressed  lately  before  the  Dermatological 
Society  of  Berlin.  As  may  have  been  expected,  judging 
by  the  shortness  of  time  in  which  this  remedy  has 
been  before  us,  there  are  considerable  caution  and  con- 
servatism indicated  in  the  opinion,  which  is  by  no 
means  unfavorable.  Of  course  it  covers  only  the 
treatment  of  lupus  (skin  tuberculosis).  Professor 
Lassar  showed  five  patients  who  had  been  receiving  the 
injections  for  three  months,  beginning  with  one-five- 
hundredth  milligram  and  gradually  increasing.  He 
(Lassar)  could  not  sfseak  of  a  real  curative  effect,  but 
there  certainly  was  an  improvement  without  any  gen- 
eral disturbance  of  the  system.  One  surprising  feature 
of  this  treatment  is  its  expensiveness,  the  daily  cost 
for  the  five  patients  being  seventeen  marks  ($4).  The 
other  dermatologists  present  who  participated  in  the 
discussion  all  expressed  themsehes  very  cautiously; 
some  even  took  an  opposing  stand  upon  the  question. 
Before  forming  a  definite  opinion,  it  would  be  best 
therefore  to  await  the  results  of  further  careful  inves- 
tigation. If  not,  there  might  occur  the  same  wild 
scenes  of  seven  years  ago,  when  the  first  tuberculin 
made  its  appearance. 

As  we  see  the  adherents  of  the  medical  schools 
achieving  success  after  success  through  orrhotherapy, 
so  we  note  cries  of  woe  and  lamentation  within  the 
camp  of  their  opponents,  the  antimedical  crowd,  at  the 
loss  of  their  leader  and  master,  the  world-renowned 
Pastor  Kneipp.  The  death  of  this  man  in  Worisho- 
fen,  after  a  lingering  illness,  on  June  17th,  is  an 
event  which  even  a  medical  journal  must  chronicle. 
Even  though  we  must  regard  his  working,  from  a  med- 
ical standpoint,  as  harmful,  yet  we  must  not  class  this 
man  with  the  ordinary  run  of  quacks,  for  he  labored 
not  for  personal  benefit,  but  was  actuated  by  love  of 
the  human  race  and  a  faith  in  his  own  teachings.  He 
certainly  achieved  some  good  through  his  warnings  to 
lead  a  temperate  and  rational  life.  While  we  cannot 
attack  the  personal  character  of  the  man.  yet  there  re- 
mains, on  the  other  hand,  the  fact  that  his  activity  was 
a  most  unwholesome  one,  for  the  number  of  the  duped 
patients  at  Worishofen  is  an  enormously  large  one,  as 
every  practising  physician  of  Munich  can  relate.  He 
did  much  to  introduce  and  widen  the  use  of  cold  water 
among  the  populace,  but  in  no  wise  did  he  advance 
scientific  hydrotherapy.  Following  its  originator, 
the  so-called  Kneipp  system  will  disappear  from  the 
scene. 

It  is  a  certain  satisfaction  to  observe  in  these  times, 
when  there  is  a  tendency  to  ascribe  as  the  cause  of 
most  diseases  some  form  of  microscopic  organism, 
that  some  investigators  recognize  other  factors,  which 
are  not  of  a  parasitical  nature,  as  playing  an  impor- 
tant etiological  role  in  disease,  especially  as  regards 
malignant  tumors.  This  is  shown  by  a  paper  read  by 
Dr.  I.  Boas,  at  the  Verein  fiir  innere  Medicin,  upon 
"Traumatic  Intestinal  Carcinoma,  with  Especial  Ref- 
erence to  .Vccident  Insurance."  This  question  is  of 
vast  interest  to  us  Germans,  because  the  law  grants  a 
yearly  stipend  to  a  workman  sutTering  from  carcinoma 
(or  to  his  heirs  in  the  event  of  his  death),  if  it  can  be 
shown  that  there  was  a  trauma  preceding  shortly  the 
appearance  of  the  carcinoma.  In  sixt)-two  cases  ob- 
served by  him  during  the  past  few  years.  Boas  ob- 
tained'a  history  of  nine  of  them.  Of  these,  two  were 
ci'sophageal  cancers,  six  stomach,  and  one  liver.  Ac- 
cording to  his  statistics.  Boas  finds  that  Iieredity  plays 
a  minor  role:  three  times  was  there  cancer  in  the  as- 
cendants, and  seven  times  among  the  brothers  and  sis- 
ters. The  trauma  which  entered  into  the  etiology  of 
these  cases  was  received  from  a  few  years  to  a  few- 
months  previous  to  the  appearance  of  the  first  symp- 
toms. The  speaker  is  of  the  opinion  that  a  carcinoma 
may  remain  latent  for  years  until   an    accidental    cir- 


August  7,  1897] 


MEDICAL    RECORD. 


215 


cumstance  (among  others  a  trauma)  may  call  forth  an 
active  cell  proliferation.  He  also  believes  that  a  cancer 
may  retrograde,  for  at  autopsies  cancers  of  the  stom- 
ach have  been  casually  observed  in  persons  who  dur- 
ing life  never  had  stomach  disturbances.  From  per- 
sonal observations  and  deductions  arrived  at  from 
general  considerations,  Boas  draws  the  important  prac- 
tical conclusion  that  in  accident  insurance  traumatism 
must  be  accepted  as  a  cause  of  cancer.  The  law  does 
not  ask  for  positive  evidence  of  the  relation  between 
trauma  and  cancer,  but  merely  a  strong  probability. 
The  verdict  of  the  past  few  years  in  accident-insurance 
cases  has  sustained  this  opinion. 

At  the  Berliner  medicinische  Gesellschaft,  Dr.  Be- 
low reported  some  interesting  facts  about  the  so-called 
"black-water  fever."  Long  years  of  personal  experi- 
ence in  Me.xico  and  the  reports  of  others  in  New 
(uiinea  have  brought  him  to  conclude  that  this  disor- 
der is  more  closely  related  to  yellow  fever  than  to 
malaria.  He  is  certain  that  the  melanuria  occurs  only 
after  the  administration  of  large  doses  of  quinine  :  that 
it  is,  therefore,  not  a  symptom  of  the  disease,  but  a 
result  of  the  quinine  therapy. 

The  researches  of  Dr.  Giirber,  of  Wiirzburg,  cast  a 
new  light  upon  the  mooted  question  of  the  function  of 
the  suprarenal  bodies.  He  first  verified  the  known 
fact  that  watery  extracts  of  the  suprarenal  bodies 
cause  an  increase  of  blood  pressure  in  animals:  he 
furthermore  succeeded  in  obtaining  a  substance  from 
the  e.xtract  which  exercises  a  direct  contrary  physio- 
logical effect,  viz.,  diminishes  blood  pressure.  Evap- 
orating the  watery  extract  at  100"  C.  (212'  F.)  to  dr}- 
ness,  he  obtained  this  new  factor  each  time  readily. 
It  is  much  more  poisonous  than  the  substance  which 
raises  blood  pressure,  for  after  injections  of  apparently 
minute  quantities  into  animals,  death  ensued  very  soon, 
with  symptoms  of  cardiac  paralysis.  Giirber  is  of  the 
opinion  that  this  blood  depressor  exists  ready  formed 
in  the  suprarenal  bodies,  but  has  remained  unknown 
heretofore  because  its  activity  was  masked  or  neutra- 
lized by  its  antagonist,  and  only  after  the  latter  has 
been  destroyed  does  it  become  eftective.  These  two 
substances  in  the  suprarenal  bodies  really  appear  to 
antagonize  each  other.  It  has  not  been  possible  to 
isolate  them,  each  for  itself.  Giirber's  disco\'er)'  is  a 
great  advance  in  the  study  of  the  rather  obscure  func- 
tions of  the  suprarenals.  VVe  hope  that  even  this 
problem  will  soon  be  solved. 


LINEAR    ELECTROLYSIS. 


Dr.  Fort  insists  that  I  do  not  understand  his  modus 
operandi.  Perhaps  I  do  not,  but  I  demonstrated  by 
experiment  before  the  New  York  County  Medical  As- 
sociation that  the  chemical  electrolysis  which  took 
place  by  using  ten  milliamperes  for  thirty  seconds  was 
so  slight  as  to  be  hardly  perceptible,  which  statement 
is  verified  by  the  annexed  letter  of  Mr.  Livingston: 

"July  26,  1896. 
"The  experiments  of  electrolysis  referred  to  in  Dr. 
Newman's  paper,  published  in  the  New  York  Medical 
Record  of  March  27,  1897,  were  conducted  by  the 
undersigned  in  the  presence  of  the  physicians  attend- 
ing the  meeting,  and  the  results  stated  and  demon- 
strated to  the  society  as  obtained  are  absolutely  correct 
in  every  particular.  T.   F.  Livingston." 

I  have  operated  twice  according  to  Dr.  Fort's  rules, 
and  in  both  cases  caused  pain  and  hemorrhage,  with 
a  result  very  unsatisfactory.  A  chemical  experiment 
demonstrating  a  result  is  a  fact,  and  can  be  met  only 
by  ocular  demonstration  showing  an  opposite  result. 
It  cannot  be  "  silenced"  by  observations. 

Lastly,  Dr.  Fort,  in  his  paper,  admits  that  his 
method  does  not  cure  but  only  alleviates  strictures^ 
when  he  says:  "  In  order  to  prevent  relapses  it  is  nec- 
essary to  pass  a  bougie  along  the  canal  from  time  to 
time."  When  a  stricture  is  properly  treated  by  elec- 
trolysis, the  stricture  is  so  completely  absorbed  that 
the  urethra  is  restored  to  its  normal  condition  and 
thereafter  it  is  wholly  unnecessary  to  pass  any  instru- 
ment through  the  canal  for  any  purpose.  This  result 
I  have  produced  in  several  thousand  cases,  some  of 
which  are  of  twenty  years'  standing,  without  relapses, 
and  many  of  which  have  been  investigated  by  a  med- 
ical board,  and  by  said  board  found  to  be  as  I  stated. 

I  therefore  still  contend  that  Dr.  Fort's  method  of 
practice  is  not  true  electrolysis.  My  purpose  in  my 
former  paper  was  not  to  criticise  any  method  of  treat- 
ment, but  to  compare  the  various  methods  of  treatment 
of  strictures  of  the  urethra,  and  to  prevent  misrepre- 
sentation of  the  method  which  I  have  advocated.  I 
claim  that  such  does  not  cause  any  pain:  the  patient 
is  not  detained  from  his  business;  no  tissues  are  burned 
or  destroyed,  but  stricture  only  absorbed  by  chemical 
action  ;  no  relapses  have  occurred  after  a  cure  has  been 
made:  and  afterward  there  has  been  no  occasion  for 
the  introduction  of  a  sound  or  catheter.  Such  cures, 
have  been  accomplished  in  an  average  of  two  months,, 
having  required  a  seance  once  a  week. 

Robert  New.m.an,  M.D. 

New  York,  July  ^o,  1807. 


Sir:  In  your  issue  of  July  17,  1897,  is  a  letter  from 
Dr.  J.  A.  Fort,  criticising  my  paper  entitled  "Re- 
sults of  Chemical  Electrolysis  versus  Divulsion  or 
Cutting  in  Treatment  of  Urethral  Strictures."  I  no- 
where in  my  paper  undertook  to  determine  who  was 
the  true  inventor  of  the  instrument  called  by  Dr.  Fort 
his  "  electrolyzer."  On  the  contrary,  after  exhibiting 
models  of  Dr.  Fort's  and  Dr.  Butler's  instruments,  I 
pointed  out  the  difference  between  the  two  instru- 
ments, and  left  the  question  of  priority  entirely  to  the 
consideration  of  my  auditors.  Instead,  as  Dr.  Fort 
presumes,  of  assuming  that  there  was  but  one  size  of 
his  electrolyzer,  I  suggested  that  difficulties  regarding 
the  size  of  the  instrument  could  be  overcome  by  hav- 
ing various-sized   instruments. 

The  next  point  made  by  Dr.  Fort  is  that  sometimes 
as  high  a  current  as  forty  milliamperes  is  used.  So 
high  a  current  would  almost  certainly  pass  the  instru- 
ment through  the  stricture,  but  in  almost  every  in- 
stance destroy  the  mucous  lining  of  the  urethra :  the 
passage  would  be  obtained  ratherLy  cauterization  than 
electrolysis. 


DEFERRED    CREDITORS. 

To    THE    E0ITOK    OF   THE    MeDJCAI,   RecoRU. 

Sir  :  I  recently  took  occasion  to  dun  a  patient  whom 
I  have  treated  for  the  past  twenty-three  years  and 
never  received  one  cent  in  payment — not  even  a  load 
of  hay  or  a  bushel  of  oats  for  my  nag.  He  said : 
"  Doc,  I'm  liable  to  pay  you  most  any  time.  I 
haven't  got  down  to  you  yet." 

This  reminds  me  of  what  Samuel  Foot  said  one- 
hundred  and  fifty  years  ago,  in  "The  Lame  Lover": 

"  Sir  Luke. — A  pox  o'  your  law.  You  make  me 
lose  sight  of  my  story." 

One  morning  a  \Velsh  coachmaker  came  with  his 
bill  to  my  lord,  whose  name  was  unluckily  Lloyd.  My 
lord  had  the  man  up. 

"You  are  called,  I  think,  Mr.  Lloyd.'" 

"  At  your  lordship's  service,  my  lord." 

"What,  Lloyd  with  an  L.'" 

"  It  was  with  an  L  indeed,  my  lord." 

"  Because  in  your  part  of  the  world  I  have  heard 
that  Lloyd  and  Floyd  were  synonymous — the  very- 
same  names." 


2l6 


MEDICAL    RECORD 


[August  7,  1897 


"Verj'  often  indeed,  my  lord." 

"But  you  always  spell  yours  with  an  L?  ' 

"  Always." 

"That,  Mr.  Lloyd,  is  a  little  unlucky;  for  you 
must  know  1  am  now  paying  my  debts  alphabetically, 
and  in  four  or  five  years  you  might  have  come  in  with 
an  F,  but  I'm  afraid  I  can  give  you  no  hopes  for  your 
L.     Ha,  ha,  ha!"    ' 

I'm  afraid  my  man  will  never  get  down  to  P. 

H.  R.  Porter,  M.D. 

BISMAKCK,    X.   J>. 


medical  yicms. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitan-  Bureau,  Health  Department,  for  the 
week  ending  July  31,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. . . . 

Measles 

Diphtheria 

Lar)-ngeal  diphtheria  (croup). 
Chicken-pox 


211 
26 
71 
o 
135 
147 
4 


The  Prevention  of  Tuberculosis. — A  writer  in  a 
recent  number  of  the  British  Medical  Journal,  in  dis- 
cussing this  question,  states  that  since  Koch's  discov- 
er}' it  has  been  manifest  that  phthisical  sputum  fur- 
nishes the  infective  material  of  tuberculosis.  Schill 
and  Fischer  showed  that  dry  phthisical  sputum  re- 
mained infectious  for  a  long  time.  Dr.  Cornet  con- 
ducted experiments  with  the  dust  of  rooms  and  hospi- 
tal wards  in  which  phthisical  persons  were  being 
treated,  and  found  that  when  no  particular  care  had 
been  exercised  in  removing  infectious  discharges  this 
dust  contained  sufficient  infective  material  to  cause  the 
disease  when  injected  into  a  guinea-pig.  Dr.  James 
Niven  read  a  paper  before  the  Kpidemiological  Soci- 
ety, Nfarch  19th,  in  which  he  said  that  the  registrar- 
general's  returns  showed  an  enormous  reduction  in  the 
mortality  from  tuberculosis  during  the  last  fifty  years; 
this  might  be  partially  due  to  better  diagnosis  and 
changes  of  nomenclature,  but  it  was  also  partly  due  to 
sanitary  progress.  Congenital  tuberculosis  must  be 
extremely  rare.  Boltz,  in  twenty-five  hundred  and 
seventy-six  necropsies  on  children  under  fifteen  years 
of  age,  failed  to  find  the  least  trace  of  tubercle  in  any 
under  one  month;  of  those  between  three  and  si.v 
months,  8.6  per  cent,  were  tuberculous,  and  as  the  age 
advanced  the  percentage  of  the  tuberculous  cases  in- 
creased. Heredity,  in  the  strict  meaning  of  the  term, 
was  improbable,  though  the  children  of  consumptives, 
like  all  persons  with  narrow  chests  and  enfeebled  con- 
stitutions, were  more  susceptilile  to  infection.  The 
British  Mtiiual Journal  mentions,  as  a  reason  why  tu- 
berculosis has  not  been  brought  under  control,  that 
there  is  a  marked  disinclination  on  the  part  of  manv 
practitioners  toward  any  interference  by  sanitary  au- 
thorities with  their  treatment  of  tuberculous  patients. 
Dr.  N'iven  advises  that  spittoons  should  alwavs  be  used 
in  the  sick-room,  and  provided  in  workshops,  lodging- 
houses,  railway  carriages,  etc.  He  urges  the  control  of 
dairies,  and  says  that  tuberculous  milk  should  not  be 
given  unboi'ed  even  to  pigs.  Dr.  Willoughby,  in  dis- 
cussing Dr.  Xiven's  paper,  said  he  believed  that  the 
prevalence  of  consumption  among  the  native  population 
of  health  resorts,  and  the  way  in  which  each  was  in 
turn  discarded  in  favor  of  some  other,  was  a  result  of 
their   becoming  Stiturated  with    infection.     There  was 


no  doubt  that  there  should  be  special  regulations  in 
these  resorts  for  the  prevention  of  the  dissemination  of 
tuberculosis.  Dr.  Xocard  has  called  attention  to  the 
great  faculty  of  spreading  which  tuberculosis  ]X)ssesses 
when  it  is  once  introduced  into  a  herd.  He  shows  how 
easy  it  is  by  proper  and  simple  means  of  isolation  to 
save  sound  animals.  It  would  be  an  advantage  to 
have  an  intercommunication  of  ideas  betwen  scientific 
observers  and  agriculturists  on  the  preventive  measures 
which  may  be  usefully  and  economically  taken.  The 
pathologist  and  physician  would  be  stimulated  to 
appreciate  and  overcome  the  difiiculties  which  beset 
the  breeder  and  cow  keeper,  and  the  owners  would  real- 
ize the  advantages  which  would  accrue  from  rational 
precautions.  Meat  from  tuberculous  cattle  should  also 
be  condemned. 

An  Expensive  Testimonial. — .\  \eteran  living  in 
the  interior  of  Massachusetts  recently  gave  a  testimo- 
nial to  a  patent-medicine  manufacturer,  stating  that 
he  had  been  entirely  cured  by  the  nostrum.  It  seems 
that  he  was  receiving  a  pension  for  the  ills  of  which 
the  medicine  cured  him,  and  that  when  the  authorities 
learned  of  his  recovery  his  pension  was  cut  off.  Is 
he  likely  to  sulTer  relapse?  and  if  he  does  will  he  get 
back  his  pension .' — Boston  Mt-dical  and  Surgical 
Journal. 

Effects  of  Absinthe — Dr.  Pauly,  in  La  Alidecine 
Modcrnc,  relates  his  observations  on  a  man,  thirty 
years  of  age,  who,  wishing  to  commit  suicide,  took 
three-fourths  of  a  litre  of  absinthe.  Three  hours  later 
he  had  not  vomited  nor  had  he  regained  consciousness. 
Injections  of  ether,  artificial  respiration,  and  lavage 
of  the  stomach  were  resorted  to.  A  stomach  pump  was 
introduced,  and  part  of  the  absinthe  flowed  off  almost 
pure.  Forty  litres  of  water,  at  a  temperature  of  35  C, 
were  then  passed  through  the  stomach.  Respiration 
returned,  and  the  heart  became  regular,  but  there  were 
complete  coma  and  abolition  of  refle.xes.  The  follow- 
ing day  the  patient  died.  .\t  the  autopsy  they  found 
an  acute  desquamative  gastritis,  nephritis,  with  diflu^o 
renal  hemorrhages,  .\lcohol  was  present  in  all  the 
organs,  but  was  especially  abundant  in  the  brain.  Dr. 
Pauly  attributed  the  symptoms  more  especially  to  alco- 
hol, the  characteristic  effect  of  absinthe  being  the  pro- 
duction of  epileptiform  coma.  Dr.  Lepine  did  not 
entirely  concur  in  this  opinion.  .Absinthe  is  not  only 
an  epileptogenic  poison,  but  has  also  a  stupefying  prin- 
ciple which  would  add  its  action  to  that  of  the  alcohol. 

Health  Reports. — The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  sujjervising  surgeon- 
general  of  the  United  States  Marine  Hospital  service 
during  the  week  ended  July  31,  1897  : 


.  Tuly  ijlh  to  i^ih  . 
July  ijih 


h  to  24th  . 
Small-Pox— Foreign. 
h  to  10th. . . 


.  fth. 


Rio  dc  Janeiro.  Hrazil lunc  ij 

Sinj^porc.  India Niay  isi 

Madnd,  Spain July  ist 

Odessa.  Russia July  3d 

St.  Petersburg,  Russia July  3d  to  loth  . 

Calcutta.  India June  5th  tu  it^th 

Bomhay,  India June  izd  to  .29th 

Montreal.  Canada Julv  2d  to  36th.. 

AVan>aw,  Russia July  3d  t..  loih.. 


Calcutta.  India .    

I'ombav,  India |ui 

Tokio  Ku.  lapan lui 

Fukuoka  Ken.  Japan Jui 

HioKo  Ken.  Ja[>an   |ui 

Oyama  Ken.  japan .J 

( >saka  Fn,  Japan.. . 


June  fth  to  iQth. 


.Ma 


;  2Sth  to  lulv  6th     3 

r  jSth  to  lulv6th i 

-.  j8th  to  lulv  6th I 

r  .'Sth  to   |ul\-6th i 


Riode  Jancir...  liraiil lunc  wth  to  iqth. 

Cicnfueiros.  Cuba July  nth  to  18th. 

Matanzas,  Cuba July  7th  to  iist.    .. 


Iriunbay.  India Ju 

'I'aiwan  <  Ft.»nnos;i>,  Japan. . .  Ju 


:  ,;  id  to  2Qth 

:  j8ih  to  July  fth 13 


Medical  Record 

A  JVeekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  7. 
Whole  No.  1397. 


New  York,  August   14,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rigiual  J^rticle•s. 

PERSISTENT    TACHYCARDIA   WITH    DIGES- 
TIVE  AND    NERVOUS    DISORDERS.' 

By    \V.    H.    THOMSON,    M.D.,    LI..I)., 


My  attention  has  been  drawn  for  some  years  to  cases 
occurring  in  my  private  practice  of  persistent  non- 
febrile  tachycardia  which  could  not  be  accounted  for 
by  any  inflammatory  or  structural  disease  of  the 
heart,  nor  by  any  concomitant  affection  of  the  kidneys, 
nor  of  the  brain  or  spinal  cord.  Of  course  also  they 
were  not  cases  of  paro.xysmal  tachycardia,  as  the  rapid 
action  of  the  heart  was  continuous  for  prolonged  pe- 
riods, and  when  recovered  from  the  subsidence  was  in 
each  case  very  gradual.  Moreover,  in  no  instance  was 
the  tachycardia  the  only  affection  present,  for  without 
exception  this  seemed  part  of  a  general  derangement, 
of  which  the  most  pronounced  accompaniments  were 
digestive  and  nutritive  disorders,  coupled  with  serious 
nervous  symptoms,  both  sensor)-  and  motor.  While  I 
could  cite  also  similar  cases  from  the  wards  of  my 
ser\'ice  in  the  Bellevue  and  the  Roosevelt  hospitals, 
I  prefer  to  quote  from  my  records  of  private  patients, 
because  naturally  they  were  followed  up  for  much 
longer  periods  than  could  be  possible  with  hospital 
cases. 

Case  I. — Mrs.    C.    H ,  widow,  aged    si.\ty-five. 

Seen  first,  April  ii,  1896.  Patient  stated  that  she 
had  been  quite  healthy  until  some  two  and  one-half 
years  ago,  when  she  began  to  suffer  from  constantly 
recurring  attacks  of  nausea  on  rising  in  the  morning. 
.\t  first  these  would  pass  off  after  breakfast,  but  after 
some  months  they  recurred  often  during  the  day,  and 
for  the  past  year  the  sense  of  nausea  had  been  almost 
constant.  During  the  past  year  especially  she  felt 
that  she  was  losing  ground  and  was  growing  very 
weak,  all  of  which  she  attributed  to  the  state  of  her 
stomach.  But  on  November  i,  1895,  she  developed  a 
series  of  severe  and  anomalous  symptoms,  consisting 
of  violent  paro.xysmal  pains  over  the  head  and  scalp, 
with  excessive  tenderness  of  the  external  ears,  which 
became  very  red,  particularly  the  left.  She  described 
the  severest  pain  as  radiating  from  the  left  ear  to  the 
neck,  so  that  she  could  not  lie  on  the  left  side.  She 
then  had  violent  neuralgic  paro.xysms  in  the  jaws,  ac- 
companied by  stiffness  of  the  tongue,  so  that  she 
could  not  protrude  it.  She  also  had  intense  pains 
in  the  palms  of  both  hands,  and  finally  in  the  legs. 
especially  about  the  hips  and  knees,  but  all  her  pains 
had  more  or  less  tendency  to  shift.  When  they  oc- 
curred, however,  whether  in  the  neck  or  in  the  upper 
or  lower  extremities,  the  muscles  of  the  affected  part 
became  stiff  and  painful  on  movement.  Latterly  she 
began  to  have  alarming  attacks  of  vertigo,  accom- 
panied by  a  sense  of  impending  death  and  ending  in 
free  vomiting.  She  could  not  turn  in  bed,  especially 
to  the  left,  without  inducing  dizziness.  During  the 
vertigo  she  had  sensations  of  falling  rather  than  of 

'  Read  before  Ihe  New  York  .Vcademv  of  Medicine,  June  3, 
1897. 


turning,  or  else  while  in  bed  the  whole  room  seemed 
to  turn  round.  She  had  no  tinnitus,  but  I  found  that 
she  could  hear  my  watch  tick  only  for  one  inch  from 
the  left  ear  and  for  twelve  inches  from  the  right.  At 
times  she  had  temporary  diplopia,  but  I  could  find  no 
evidence  of  paralysis  in  any  of  the  ocular  movements. 
Occasionally  also  she  had  transient  but  distinct  at- 
tacks of  aphasia,  but  more  commonly  of  paraphasia. 

On  examination  I  found  the  patient  much  emaci- 
ated, and  her  family  stated  that  she  had  been  losing 
flesh  markedly  since  her  pains  began.  The  tempera- 
ture was  normal,  and  remained  so  or  slightly  sub- 
normal throughout  her  illness.  The  pulse  was  156, 
regular  but  small,  weak  and  very  compressible.  No 
cardiac  murmurs.  Cardiac  percussion  area  of  dul- 
ness  normal.  No  tremor  in  muscles  of  the  face,  of 
the  tongue,  or  of  the  hands.  Knee  reflexes  normal. 
No  pulmonary  affection  whatever,  no  enlargement  of 
the  thyroid  and  no  exophthalmos.  Liver  and  spleen 
normal.  As  to  the  alimentary  canal,  the  tongue  was 
small,  pointed,  glazed,  very  red,  and  sore;  in  a  few 
days  aphthae  developed  in  the  mouth  and  pharynx, 
as  in  a  patient  in  the  terminal  stage  of  phthisis, 
making  deglutition  very  painful;  the  stomach  was 
dilated  and  t}'mpanitic.  There  was  no  epigastric  ten- 
derness, no  rigidit}',  and  no  evidence  of  tumor  or 
thickening.  Bowels  habitually  constipated.  Urine 
amber  colored:  specific  gravity,  1.025;  "^^  albumin  or 
casts,  no  sugar. 

The  diagnosis  of  cerebral  tumor  had  been  made  by 
her  previous  medical  attendant,  which  was  apparently 
justified  by  her  attacks  of  vertigo,  vomiting,  aphasia, 
diplopia,  cephalic  pains  radiating  to  the  neck  and  ex- 
tremities, and  her  continuous  wasting.  The  fact,  how- 
ever, that  her  firsi:  symptoms  were  gastric  and  had  so 
continued  unchanged  for  over  two  years;  that  her  pains 
were  too  shifting  in  character  and  were  so  widely  dis- 
tributed over  such  symmetrical  regions  as  both  palms, 
both  hips,  and  both  knees,  as  well  as  implicating  the 
jaw  and  tongue;  and  that  it  was  difficult  to  reconcile 
those  about  the  head  with  the  progressive  irritation  or 
pressure  of  an  intracranial  growth  which  would  affect 
both  ears,  jaws,  and  tongue,  with  occasional  aphasia 
and  ocular  symptoms,  and  yet  without  a  sign  of  motor 
paralysis  anywhere,  or  of  any  localized  anaesthesia, 
and  with  normal  refle.xes- — all  made  me  doubt  the 
presence  of  such  a  lesion.  I  once  had,  however,  a  pa- 
tient who  had  similar  attacks  of  vertigo  and  of  occip- 
ital headache  supenening  upon  a  chronic  purulent 
otitis,  with  a  long  history  of  progressive  wasting  end- 
ing in  death.  At  the  autopsy  general  chronic  pachy- 
meningitis was  found,  which  had  been  set  up  by  ex- 
tension frorii  the  old  ear  disease.  But  in  that  case 
there  were  no  tachycardia,  no  pronounced  gastric 
symptoms,  and  no  pains  in  any  way  resembling  this 
patient's.  On  reviewing  the  totality  of  the  symptoms 
of  this  case,  therefore,  my  conclusion  was  that  the 
tachycardia,  with  the  nutritive  and  nervous  disorders 
of  the  patient,  was  not  due  to  any  inflammatory  or  or- 
ganic mischief,  and  the  event  proved  that  this  surmise 
was  correct. 

A  condensed  abstract  of  the  subsequent  history  of 
the  case  under  my  care  is  as  follows :  First,  the  pains 
of  the  patient  v,ere  markedly  and  rather  unexpectedly 


2l8 


MEDICAL    RECORD. 


[August  14,  1897 


relieved  by  fifteen-grain  doses  of  strontium  salicylate 
three  times  a  day.  This  at  first  sight  would  seem  to 
indicate  their  rheumatic  character,  but  the  peculiarity 
was  that  no  other  salicylate,  such  as  the  sodium  sali- 
cylate, salol,  or  salicin  itself,  appeared  to  approach 
the  strontium  salt  in  efficacy.  Antipyrin,  phenacetin, 
and  acetanilid  had  no  analgesic  effect  whatever.  I 
have  repeatedly  tried  the  strontium  preparation  in 
other  cases,  but  without  any  such  unmistakable  relief 
as  with  this  patient,  except  in  one  case  to  be  soon 
mentioned.  The  pains  were  by  no  means  wholly  re- 
moved, but  were  so  plainly  benefited  that  she  contin- 
ued to  take  from  forty-five  to  sixty  grains  a  day  of  the 
strontium  salt  uninterruptedly  for  eight  months.  On 
the  other  hand,  an  examination  of  the  painful  parts 
showed  no  correspondence  to  the  signs  of  a  rheumatic 
inflammation;  there  was  no  tenderness  on  pressure  of 
any  joint,  no  swelling  anywhere,  and  no  redness  ex- 
cept of  the  ears.  The  tenderness  on  pressure  was 
limited  to  the  tendons  and  to  the  fascia  of  the  mus- 
cles. There  was  nothing  like  peripheral  neuritis,  or 
true  myositis,  for  the  pains,  which  curiously  stiffened 
the  muscles  and  made  them  very  painful  on  mo\e- 
ment,  in  a  few  hours  would  shift  elsewhere,  always  ex- 
cepting the  left  side  of  the  neck.  Unlike  rheumatic 
pains  also,  they  were  not  aftected  by  changes  of  the 
weather,  nor  were  they  worse  at  night.  The  patient 
always  felt  worse  in  every  way  on  waking  in  the  morn 
ing.  Besides  the  persistent  pain  and  rigidity  of  the 
muscles  on  the  left  side  of  the  neck,  she  had  for  a 
long  time  contraction  of  the  fingers  with  rigidity  of 
the  tendons  in  the  palms  of  the  hands,  closely  resem- 
bling the  familiar  palmar  tenositis  of  gout.  But  she 
showed  absolutely  no  other  symptoms  of  gout,  and  the 
pulse  was  always  weak  and  ver)-  compressible. 

She  was  ordered  to  have  a  mercurial  purge  once  a 
week,  to  avoid  all  meat  and  meat  e.xtracts,  and  to  live 
principally  on  matzoon,  kumyss,  or  peptonized  milk, 
and  take  fish,  poultry,  rice,  potatoes,  and  most  vegeta- 
bles, excepting  asparagus  and  celery.  Medicinally, 
besides  the  .strontitmi  salicylate,  she  took  in  capsules 
ten  grains  each  of  phenol  bismuth  and  sodium  benzo- 
ate,  three  times  a  day,  varied  occasionally  with  the 
addition  of  ichthyol.  At  one  time,  when  the  phenol 
bismuth  was  increased  to  forty  grains  per  diem,  the 
urine  became  dark  and  showed  traces  of  albumin,  so 
that  it  had  to  be  decreased  to  thirty  grains  daily,  which 
quantity  she  continued  to  take  without  cessation  from 
April,  1896,  to  March  i,  1897 — or  a  period  of  nearly 
eleven  months. 

The  first  effect  of  this  treatment  was  to  reduce  the 
pulse  from  an  average  of  150-160  down  to  1  lo-i  20. 
But  in  other  respects  she  seemed  for  a  long  time  to 
grow  worse  instead  of  better.  The  tongue  became 
still  more  sore,  and  from  April  iith  to  May  iith  my 
notes  show  that  her  nausea  was  almost  constant.  She 
could  now  lie  only  on  her  right  side,  for  if  she 
turned  on  her  back,  still  more  on  her  left  side,  the 
dreaded  vertigo  would  soon  come  on.  During  the 
second  month,  from  May  iith  to  June  nth,  the  sto- 
matitis became  very  troublesome  and  the  aphtha.-  in- 
creased in  the  mouth  and  pharynx,  rendering  degluti- 
tion veiy  painful.  I  may  mention  that  every  ordinarv 
pre.scription  for  stomatitis  was  tried  witiiout  eft'ect, 
but  finally  she  seemed  to  be  most  benefited  by  infusion 
of  rhus  glabrum  rhizoma,  or  sumach.  Tlie  nausea 
also  persisted  as  well  as  the  dizziness;  the  patient  con- 
tinued to  emaciate  until  she  had  to  be  padded  with 
cotton  batting  to  prevent  bedsores.  After  nearly  sixty 
days'  treatment  the  attacks  of  diplopia  seemed  to  be- 
come more  frequent,  her  speech  was  often  hesitating 
or  paraphasic,  and  she  was  sometimes  delirious  at 
night.  In  fact,  her  condition  appeared  so  serious  that 
a  fatal  issue  could  not  have  been  surprising.  I  could 
not  see,  however,  any  valid  reasons  for  changing  my 


first  opinion  of  the  case,  and  the  treatment  was  ordered 
to  be  kept  up  without  change. 

About  June  7th  the  pulse  had  dropped  to  106  and 
was  stronger.  The  stomatitis  was  slowly  improving. 
Blistering  of  the  left  mastoid  seemed  to  act  favorably 
on  the  vertigo.  The  emaciation,  however,  continued, 
and  the  patient  had  great  repugnance  to  food,  owing 
to  her  fear  of  increasing  her  nausea,  which  was  never 
absent. 

After  June  i  ith  the  nausea  began  to  be  much  better. 
Both  the  pulse  and  the  nausea,  it  had  been  frequently 
noted,  improved  for  twentj-four  hours  after  she  had 
taken  one  and  one-half  grains  of  calomel  in  six  frac- 
tional doses,  one  every  fifteen  minutes  till  the  six  were 
taken,  which  dosage  was  generally  followed  by  a  loose 
movement  in  about  four  hours.  She  always  com- 
plained that  the  calomel  made  her  feel  prostrated  at 
the  time  of  action,  but  the  next  day  the  pulse  almost 
always  was  reduced  by  ten  or  more  beats  and  the 
stomach  felt  easier,  and  then  in  about  three  days  more 
this  improvement  would  seem  to  pass  off. 

On  June  2  2d  the  excessive  heat  of  that  week  affected 
her  unfavorably,  and  the  stomatitis  returned,  as  bad  as 
ever. 

On  June  27th  she  had  an  attack  of  total  aphasia, 
now  plainly  motor,  though  before  I  had  regarded  it  as 
of  the  auditor}'  variety.  It  seemed  induced  by  a  bad 
dream,  but  I  found  no  signs  of  muscular  paralysis  ac- 
companying it  on  the  right  side.  Before  night  she 
fully  regained  her  speech.  During  this  month,  how- 
ever, the  dizziness  was  slowly  improving,  and  one  day 
she  told  me  that  she  had  read  some  in  a  magazine,  for 
the  first  time  in  a  year,  as  before  that  reading  always 
brought  on  a  sense  of  distress  in  the  head. 

During  the  fourth  month,  from  July  nth  to  August 
I  ith,  the  great  heat  of  the  season  again  had  bad  effects, 
though  the  stomatitis  continued  to  improve  and  the 
nausea  became  less  constant.  One  most  annoying 
complication  then  occurred  in  phlebitis  of  the  right 
saphena  vein,  with  much  cedema  of  the  leg.  As  the 
weather  improved,  however,  she  began  to  gain  mark- 
edly. 

About  September  1  st  the  nausea  disappeared  en- 
tirely, never  to  return.  She  began  to  relish  food,  and 
after  a  calomel  action  on  September  i8th  the  pulse 
came  down  to  92,  for  the  first  time  below  100.  She 
now  began  to  gain  in  flesh,  color,  and  strength,  and 
by  the  end  of  the  sixth  month  of  treatment  she  was 
able  to  walk  down  stairs. 

A  month  later,  in  October,  she  went  out  driving,  and 
the  improvement  in  November  and  December  was 
slow  but  progressive,  the  chief  symptoms  complained 
of  being  rheumatoid  pains  in  her  knees  and  some  dis- 
comfort still  in  tiie  head  if  she  lay  on  her  left  side. 
Through  the  past  winter  she  has  gone  about  the  city 
witli  but  little  inconvenience.  Her  appearance  as  to 
flesh  and  color  is  excellent. 

The  note  on  March  31,  1897,  is  that  her  tongue  is 
perfectly  natural ;  that  her  stomach  gives  her  no 
trouble  whatever,  after  more  than  two  years  of  distress 
there;  pulse,  S6,  regular  and  of  fair  strength,  even 
after  quite  a  long  walk  to  my  office;  the  only  symp- 
toms now  complained  of  being  occasional  pains  in  the 
back  and  legs,  for  which  she  insists  on  taking  the 
strontium  salt  until  they  are  relieved.  She  also  has 
some  numbness  in  her  toes  and  some  twitching  of  the 
fingers. 

The  last  entry  is  April  28,  1897.  The  patient  can 
now  lie  on  either  side  at  night,  and  considers  herself 
quite  well.  Her  hearing  is  perfect  in  both  ears. 
Her  remark  was  that  whenever  she  feels  mean  she 
takes  a  dose  of  calomel,  which  makes  her  feel  meaner 
yet  for  a  while,  but  the  next  day  she  is  all  right. 

On  thus  reviewing  the  chief  clinical  details  of  this 
case,  the  question  seems  pertinent:  What  disease  did 


August  14,  1897] 


MEDICAL    RECORD. 


219 


this  patient  have?  That  it  was  a  dangerous  disease 
for  a  time,  no  experienced  physician  could  doubt.  In 
fact,  a  reall)-  long-persistent  tachycardia  like  hers, 
verging  upon  160,  could  be  no  trifling  matter,  whatever 
the  other  conditions  were.  But  in  trying  to  come  to 
a  conclusion  about  the  nature  of  the  malady  itself,  a 
diagnosis  by  exclusion  may  possibly  be  hazarded. 
Following  the  safe  clinical  rule  to  begin  with  the  be- 
ginning and  then  keep  hold  of  the  first  important 
symptom  which  maintains  throughout  a  prominent  re- 
lation to  the  complaint,  we  must  admit  that  pronounced 
gastric  derangement  preceded  for  nearly  two  years 
every  other  symptom :  also  that  it  afterward  accom- 
panied all  other  developments,  until  they  in  turn  dis- 
appeared with  the  disappearance  of  the  gastric  trouble. 
That  she  never  had  any  serious  inflammatory  cerebral 
mischief  is  evident  from  the  fact  that  she  never  had 
any  febrile  temperature,  while  it  is  equally  patent  that 
her  numerous  cerebral  symptoms  were  not  due  to  any 
tumor  or  abscess  by  her  getting  well  of  evervthing 
when  her  stomach  improved.  That  she  had  neither 
rheumatism  nor  gout  is  plain  from  the  consideration 
that  neither  of  these  diseases  is  preceded  by  nausea 
for  two  years,  nor  do  they  give  rise  to  diplopia,  re- 
peated vertigo,  or  aphasia,  nor  do  they  occasion  ex- 
treme emaciation  with  aphthous  stomatitis,  or  purely 
functional  continuous  tachycardia  for  months  to- 
gether. That  she  did  not  have  Graves'  disease,  if  by 
that  is  meant  exophthalmic  goitre,  was  plain  by  the 
fact  that  in  her  emaciated  throat  the  thyroid  seemed 
atrophied  if  anything,  nor  was  there  the  least  protru- 
sion of  the  eyes  or  weakness  of  the  eyelids,  and  cer- 
tainly she  had  no  my.xcedema.  My  surmise  at  my  first 
visit  was  that  she  was  suff'ering  from  a  grave  form  of 
toxaemia  of  gastro-intestinal  origin,  and  the  treatment 
was  perseveringly  followed  according  to  that  supposi- 
tion. My  reasons  for  maintaining  that  view  were  that 
though  an  extreme,  yet  hers  was  not  an  isolated  ex- 
ample in  my  experience  of  what  I  now  consider  a 
definite  disease,  with  characters  as  special  as  those 
of  any  other  affection  which  has  a  name,  the  leading 
manifestations  of  which  are  a  persistent  rapid  action  of 
the  heart,  conjoined  with  greatly  varied  and  yet  char- 
acteristic functional  nervous  disorders,  and  apparently 
accompanied  by  certain  digestive  derangements  as 
regularly  as  diabetes  mellitus  is  accompanied  by  sac- 
charine polyuria.  So  definitely  associated  are  these 
symptoms  in  these  cases  that  now,  whenever  I  am 
consulted  about  certain  nervous  troubles,  I  early  take 
note  of  the  pulse,  and  if  tachycardia  be  present  which 
proves  to  be  persistent  and  not  simply  from  excite- 
ment, and  is  not  to  be  accounted  for  by  the  other  well- 
known  causes  of  cardiac  overaction,  I  then  suspect 
that  the  nen-ous  derangement  is  due  to  this  particular 
malady,  and  recommend  special  treatment  accordingly. 

Case  II.  —  Mr.  G ,  lawj-er,  a  light-complexioned, 

fairly  well-nourished  man,  aged  forty-two,  first  con- 
sulted me  on  October  28,  1895.  He  said  that  eigh- 
teen months  before,  without  any  antecedent  gastric  or 
other  trouble,  he  was  taken  quite  suddenly  one  day 
with  nausea  and  distress  in  the  stomach,  which  have 
continued  ever  since  in  spite  of  treatment  by  a  num- 
ber of  physicians  and  consultants.  He  has  never  felt 
any  real  relief  except  for  brief  intervals  while  on  out- 
ings. His  s\Tnptoms  are  nausea  and  an  ill-defined 
sense  of  distress  referred  to  the  stomach,  which  is  not 
aggravated  by  eating  or  worse  when  the  stomach  is 
empty.  There  is  no  spontaneous  pain  there,  nor  is 
any  induced  by  pressure.  He  generally  feels  worse 
on  waking  in  the  morning  and  best  in  the  evening. 
He  can  lie  on  his  left  side  as  well  as  on  the  right. 

Inspection  showed  pupils  normal  in  their  reactions, 
knee  jerks  normal,  no  shooting  pains,  no  ataxia.  Ex- 
amination for  movable  kidney  negative.  Epigastrium 
very  prominent,  and  this  proved  to  be  due  to  a  decid- 


ed enlargement  of  the  left  lobe  of  the  liver,  whose 
lower  border  was  nearly  two  inches  below  the  lower 
limit  of  the  right  lobe.  There  was  no  enlargement  of 
the  spleen,  but  the  stomach  was  dilated,  its  tympanitic 
resonance  extending  from  the  sixth  interspace  to  near 
the  umbilical  line.  Though  there  was  epigastric  mus- 
cle resistance,  yet  there  were  no  other  signs  of  gastri- 
tis; he  stated  that  he  had  had  his  stomach  washed 
out  verj'  often,  but  with  nothing  excepting  clear  water 
being  brought  up.  He  says  that  after  every  movement 
of  the  bowels,  even  when  of  natural  consistency,  he 
has  a  sense  of  having  had  diarrhoea,  which  sensation 
lasts  for  some  time  afterward.  The  urine  has  been 
repeatedly  examined  and  always  found  normal.  His 
tongue  was  covered  with  a  thick  brown  fur,  and  he 
said  that  a  year  ago  it  was  quite  black.  He  did  not 
use  tobacco.  I  found,  after  a  number  of  countings, 
that  his  pulse  averaged  130,  and  was  not  at  all  affected 
by  movement.  There  was  no  cardiac  enlargement  or 
murmur.  But  besides  his  dyspeptic  symptoms,  his 
chief  complaints  were  of  recurrent  attacks  of  nervous 
prostration,  most  pronounced  on  waking  in  the  morn- 
ing, which  made  him  feel  wholly  unfit  to  attend  to 
business.  These  might  pass  oft'  in  a  few  hours  and 
he  would  then  go  to  his  office,  but  diey  were  often 
accompanied  by  a  sense  of  weakness  and  sometimes 
by  severe  aching  in  his  legs.  These  sensations  in  his 
legs  sometimes  came  on  quite  independently  of  his 
gastro-intestinal  symptoms.  He  never  had  any  pain 
or  aching  in  the  back,  and  only  occasional  headache. 
When  this  did  occur  it  was  occipital.  He  showed  no 
signs  of  muscular  tremor,  no  enlargement  of  the  thy- 
roid ;  the  expression  of  the  eyes  was  natural. 

This  patient  attended  very  regularly  for  a  year,  and 
for  a  number  of  months  his  troubles  proved  verj-  te- 
dious and  intractable,  being  further  complicated  after 
a  time  with  obstinate  morning  diarrhoea.  At  first  I 
tried  a  great  variety  of  remedies  for  dyspepsia,  with 
no  better  success  than  my  numerous  predecessors 
had.  I  then  learned  from  him  that  while  living  at 
College  Point,  Long  Island,  about  fifteen  years  ago, 
he  had  prolonged  chills  and  fever  for  some  three  years, 
which  he  got  rid  of  only  by  going  abroad.  He  then 
had  a  chill  on  the  third  day  after  getting  back,  but 
none  since.  Accordingly,  on  the  supposition  that  his 
present  troubles  might  be  due  to  latent  malarial  infec- 
tion, he  was  treated  with  full  doses  of  quinine,  War- 
burg capsules,  arsenic,  and  ergot,  with  counter-irrita- 
tion over  the  enlarged  lobe  of  the  liver,  but  without 
benefit.  Meantime  his  pulse  kept  up  between  104  and 
135.  His  temperature  was  never  noted  above  normal. 
Neither  digitalis  nor  strophanthus  had  any  effect  upwn 
the  pulse,  and  they  had  to  be  given  up  on  account  of 
e.xciting  nausea. 

Finally,  on  February  7,  1896,  after  a  bad  week,  I 
determined  on  a  change  of  treatment,  letting  his  car- 
diac and  gastric  symptoms  alone  so  far  as  medicines 
directed  to  them  were  concerned,  and  put  him  on  an 
exclusive  diet  of  peptonized  milk  with  phenol  bis- 
muth and  sodium  benzoate,  of  each  forty  grains  a  da)'. 
In  a  week  his  diarrhoea  was  checked  and  his  pulse 
dropped  to  108. 

A  month  later,  on  March  14th,  the  record  is  that  he 
has  been  much  better,  has  had  only  one  loose  move- 
ment the  past  week;  pulse,  102;  he  says  that  he  has 
counted  it  down  to  90. 

After  another  month,  April  20th,  he  reports  that  his 
diarrhoea  has  entirely  ceased,  and  that  his  nervous 
symptoms  have  so  much  improved  that  he  has  not 
missed  a  day  from  business,  although  he  occasionally 
has  some  nausea. 

As  his  pulse  still  was  at  no,  I  ordered  three-grain 
doses  each  of  ichthyol  and  salol  to  be  added  to  the 
phenol  bismuth,  t.i.d. 

June  2d,  he  has  been  improving  steadily:   has  had 


MEDICAL    RECORD. 


[August  14,  1897 


none  of  his  old  nenous  symptoms,  no  gastric  uneasi- 
ness, no  diarrhcea;  liver  dulness  diminished,  but  left 
lobe  still  larger  than  normal.  Pulse,  98.  To  con- 
tinue treatment. 

October  19th,  just  short  of  one  year  since  beginning 
treatment,  he  reported  that  he  kept  up  the  peptonized 
milk  and  the  medicines  until  September  20th.  Since 
then  he  has  been  on  ordinary  diet  and  feels  quite  well : 
pulse,  86. 

In  this  case  the  clinical  peculiarit)-  in  the  history 
is  the  sudden  beginning  of  the  gastro-intestinal  symp- 
toms on  a  definite  day,  without  any  error  of  diet  or 
other  reason  to  account  for  them.  But  to  the  patient 
a  serious  element  was  the  disabling  nature  of  his  ner- 
vous symptoms,  which  were  both  mental  and  sensory, 
and  which  when  present  made  him  incapable  of  men- 
tal effort.  The  effect  was  as  specific  and  often  as 
temporary  as  if  he  had  taken  a  single  dose  of  some 
paralyzing  narcotic  poison.  It  was  the  regular  onset 
of  this  condition  on  his  waking  in  the  morning  which 
first  excited  my  suspicions  that  he  had  this  particular 
malady,  whatever  we  may  call  it,  for  I  have  always 
found  that  these  oatients  feel  worse  in  the  morning, 
whatever  their  general  s)'mptoms  be. 

Case  III.— Miss  L.  VV ,  aged  forty-two.  Pa- 
tient of  unusually  equable  temperament,  without  the 
slightest  indication  of  hysteria.  She  had  commonly 
enjoyed  excellent  health.  She  first  consulted  me  April 
20,  1895,  f*""  ^  sudden  access  of  pain  in  her  left  ear 
and  left  arm,  and  also  an  aching  under  the  right  scap- 
ula. As  her  eyeballs  looked  rather  yellowish,  she 
was  first  treated  with  a  calomel  laxative  for  hepatic 
disorder.  These  symptoms,  however,  continued,  ir- 
regularly recurring,  for  more  than  a  month,  and  as  they 
were  ascribed  to  malaria  she  took  quinine  from  time 
to  time,  without  further  advice,  for  a  number  of 
months. 

Nearly  a  year  afterward,  April  6,  1896,  after  having 
suffered  from  her  symptoms  for  some  time,  accom- 
panied by  some  gastric  uneasiness,  she  again  consulted 
me  for  pain  in  the  left  side  of  her  head.  She  said 
that  headaches  were  very  unusual  with  her,  but  that 
this  pain  often  centred  in  her  left  ear,  which  became 
very  sensitive  to  the  touch.  This  symptom,  in  fact, 
was  precisely  similar  to  the  curious  ear  sensitiveness 
detailed  in  the  histor)'  of  Case  I.  In  addition,  she 
had  frequent  attacks  of  pain  on  the  middle  of  the  right 
clavicle,  to  which  she  attached  a  good  deal  of  signifi- 
cance, which  I  did  not  understand  at  the  time,  but 
which  she  afterward  explained.  She  also  had  pains 
in  her  hands  and  tips  of  the  fingers,  especially  on  the 
fingernails,  as  she  described  them.  Pains  were  com- 
plained of  also  in  her  shoulders  and  in  the  middle  of 
the  back.      Pulse,  126. 

She  was  ordered  fifteen  grains  of  the  strontium  sali- 
cylate, three  times  a  day,  and  was  as  much  relieved 
by  it  as  Case  I.  was.  Her  other  symptoms,  however, 
continued,  and  more  than  a  month  later,  May  30th, 
she  complained  of  an  additional  ache,  rather  than  pain, 
in  her  throat.      Pulse,  120. 

Patient  then  went  to  the  country  for  the  summer,  so 
that  I  did  not  see  her  again  till  September  14,  1896. 
She  stated  that  she  had  been  feeling  badly  all  summer. 
Pain  was  still  frequent  in  left  ear.  Pulse,  120.  But  a 
new  symptom  was  sudden  attacks  of  total  blindness  in 
her  right  eye,  lasting  some  five  minutes.  The  sight 
then  returned  all  right,  but  was  followed  by  pain  in  the 
eyeball  for  some  time.  During  these  attacks  the  sight 
of  the  left  eye  was  wholly  unatTected.  She  had  no  di- 
plopia, no  hemiopia,  no  contraction  of  the  field  of 
vision  during  these  attacks  (she  had  been  directed 
to  observe  for  herself,  being  a  very  intelligent  woman ). 
She  had  no  tremor  except  in  the  tongue;  this  was  not 
fibrillar. 

I  may  here   remark  that  this  affection  of  the   eve- 


sight  is  interesting  on  account  of  its  resemblance  to 
the  ocular  derangements  of  migraine.  But  this  pa- 
tient had  never  had  migraine  before,  while  this  partic- 
ular symptom  occurred  in  her  about  the  time  of  life 
when  migrainous  headaches  begin  to  decline.  I  have 
long  held  that  migraine  is  of  toxic  origin,  and  this 
disturbance  of  sight  in  the  present  patient  would  seem 
to  confirm  the  supposition  that  her  affection  is  also 
toxic. 

On  November  10,  1896,  there  is  a  record  of  pro- 
nounced weakness  in  the  knees;  also  pains  about  the 
heart,  radiating  to  the  inner  siu^ace  of  the  left  upper 
arm;  also  much  pain  in  the  tip  of  the  second  left 
finger.  Pulse,  124.  No  cardiac  murmur,  no  arrhyth- 
mia. No  enlargement  of  the  thyroid,  no  exophthal- 
mos, no  tremor  of  the  eyelids  when  closed.  The  pa- 
tient stated  that  she  had  been  feeling  much  better  under 
the  treatment  ordered  September  14th — exclusive  milk 
diet  and  intestinal  antiseptics,  with  tincture  of  stro- 
phanthus — until  she  took  dinner  at  a  friend's,  where 
she  ate  both  meat  and  lobster,  the  cardiac  pain  re- 
turning on  the  next  day.  On  resuming  treatment, 
she  again  improved  in  lier  neuralgic  symptoms,  except 
that  during  an  attack  of  influenza,  April  12,  1897,  she 
had  a  severe  neuralgic  pain  referred  to  the  left  mas- 
toid and  to  that  ear.  The  patient  is  still  under  treat- 
ment, and  the  pulse  continues  to  range  between  no 
and  120,  but  her  pains  are  much  relieved  as  long  as 
she  keeps  to  the  milk  diet,  which,  however,  is  a  serious 
infliction  to  her. 

Now  in  this  patient,  as  in  Case  I.,  we  have  very 
similar  nervous  symptoms,  without,  however,  tlie  se- 
rious nutritive  disorders  which  that  patient  had.  It  is 
interesting  also  to  note  the  control  of  the  pains  about 
the  joints,  when  they  occur,  by  the  strontium  sali- 
cylate; but  the  other  localized  neuralgias  are  not 
affected  by  it,  nor,  as  in  Case  I.,  are  they  relieved  at 
all  by  bromides  or  antipyrin  or  phenacetin. 

Case  IV. — In  my  experience  this  variety  of  pains 
which  the  histories  of  both  Case  I.  and  Case  III. 
illustrate  is  peculiar  to  this  class  of  patients,  and 
therefore  might  be  very  puzzling  to  account  for  if  the 
nature  of  the  complaint  itself  were  not  recognized. 
This  is  shown  in  the  story  of  Case  IV.,  a  Miss  G. 
H — — ,  schoolteacher,  who  was  brought  to  me  recently, 
May  15,  1897,  by  Dr.  H.  ^\■.  Kice,  of  Port  Oram, 
N.  J.,  and  which  I  here  include  on  account  of  the 
difficulty  in  diagnosis  which  her  physician  had  in 
accounting  for  the  pains  which  the  patient  complained 
of.     I  append  his  history  of  the  case  as  follows: 

"The  patient  first  complained  four  years  ago  of  a 
feverish  condition,  especially  at  nighttime,  when  she 
would  be  very  thirsty.  This  condition  lasted  for  about 
two  months,  being  sometimes  better  and  sometimes 
worse,  though  she  all  the  time  continued  about  her 
work.  Following  this  trouble  she  complained  of 
pain  in  the  heels,  particularly  in  the  right^ — a  sensa- 
tion as  if  the  skin  was  rubbed  off.  She  says  that 
before  any  of  the  above  symptoms  were  obser\ed,  for 
a  year  or  two  she  suffered  from  cramps  in  the  feet  and 
calves  of  both  limbs,  the  right  generally  being  the 
worse;  the  cramps  sometimes  lasted  a  few  minutes, 
at  other  times  an  hour,  and  occasionally  all  night. 
-Aiter  the  pain  in  the  heel  had  lasted  for  about  three 
weeks,  it  went  into  tiie  entire  foot,  dien  both  feet; 
then  the  feet  became  numb,  as  if  asleep,  the  arms 
experiencing  the  same  feeling.  The  patient's  atten- 
tion was  attracted  to  the  condition  of  the  hands  when 
she  tried  to  pick  up  a  pin  or  needle  from  the  floor,  or 
anything  that  required  the  hands  to  be  down:  in  fact, 
simply  hanging  the  hands  down  caused  pain  in  the 
tips  of  the  fingers.  The  hands  got  very  red  on  hang- 
ing down.  In  walking,  the  legs  from  the  knees  down 
felt  like  sticks  of  wood— stiff.  They  at  first  had  a 
sensation  as  if  in   ice  water,  when  suddenlv  thev  felt 


August  14,  1897] 


MEDICAL    RECORD. 


hot,  the  sensation  passing  from  one  extreme  to  the 
other.  The  head  symptoms  were  very  noticeable :  the 
first  attracting  attention  was  a  feeling  as  if  the  entire 
head  was  in  a  tight  rubber  cap.  She  would  also  at 
times  experience  a  sensation  of  vertigo,  or  as  if  the 
ground  were  coming  up  to  meet  her.  Several  times  on 
rising  in  the  morning  the  patient  felt  pain  in  the  stom- 
ach, very  severe,  running  tlirough  to  the  spine.  This 
pain  would  last  for  an  hour  or  two,  and  would  subside 
without  treatment.  These  pains  were  always  more 
noticeable  in  the  morning. 

"I  was  called  at  midnight  four  years  ago  in  Octo- 
ber to  relieve  her  of  a  severe  gastralgia,  at  which  time 
I  took  the  case  in  charge.  The  patient  lost  eighteen 
pounds  in  two  years,  from  one  hundred  and  eight 
she  was  reduced  to  ninety.  Under  treatment  she  re- 
gained the  lost  flesh,  gaining  twenty  pounds.  The 
general  condition  has  improved,  so  that  the  patient 
now  weighs,  after  four  years,  one  hundred  and  eight 
pounds,  which  was  her  normal  weight.  But  she  has 
failed  to  find  relief  from  the  other  symptoms  described 
above.  Her  condition  at  present  is  about  the  same. 
She  finds  it  almost  impossible  to  do  any  amount  of 
reading  without  feeling  the  fulness  in  the  head. 
There  is  also  a  constant  desire  to  .close  the  eyes — not 
for  sleep,  but  for  contentment.  A  sensation  of  sore- 
ness along  the  spine,  as  if  having  been  pounded,  is 
complained  of  in  the  morning;  also  a  nauseous  feel- 
ing, which  soon  passes  off  after  rising.  There  is 
tendon  reflex.  The  pupils  react  to  the  light.  There 
is  a  slight  swaying  of  the  body  when  the  eyes  are 
closed  or  arms  extended.  There  are  no  lightning 
pains. 

"The  above  history  of  the  case  was  taken  last  au- 
tumn. The  symptoms  have  continued  since,  not  con- 
stant, but  var\-ing:  sometimes  a  few  symptoms  only 
annoy  the  patient,  at  others  there  would  be  much 
suffering.  In  April  last  I  saw  her  for  a  severe  gas- 
tralgia. The  pain  was  severe  in  the  right  side. 
Pain  has  been  most  constant  in  the  left  side  for  the 
last  two  months.  The  bowels  are  constipated.  The 
patient  is  troubled  with  insomnia;  she  passes  perhaps 
one  night  a  week  without  sleep.  Heart  action  rapid, 
120  per  minute." 

Examination  :  Patient  pale  and  emaciated,  with  an 
anxious  expression.  She  said  that  besides  her  other 
pains  she  had  lately  had  a  severe  pain  in  her  right 
ear.  The  character  of  the  pains  showed  that  they 
were  not  due  to  peripheral  neuritis.  Knee  jerks  and 
other  reflexes  were  nonnal.  Pulse,  130.  Her  physi- 
cian said  that  he  had  never  counted  it  below  120  for 
four  years.  There  was  no  enlargement  of  the  thyroid, 
but  patient  said  she  often  had  a  sense  of  tightness 
there.  There  was  no  exophthalmos,  but  the  palpebral 
fissure  was  widened  and  the  lids  were  very  tremulous 
on  closing,  especially  the  left. 

In  other  cases  the  gastro-intestinal  symptoms  are 
the  chief  manifestations  for  which  the  patients  seek  ad- 
vice, as  in  Case  II.,  and  here  again,  so  long  as  the  nature 
of  the  malady  is  not  recognized,  the  treatment  is  nat- 
urally directed  toward  remedying  the  supposed  diges- 
tive derangements,  but  with  most  disappointing  results 
as  regards  both  stomach  and  bowel  troubles.  I  have 
been  struck  with  the  total  failure  of  all  the  reputed 
remedies  for  derangements  of  the  stomach,  including 
lavage,  which  in  these  patients  have  proved  useless, 
when  faithfully  tried  either  by  myself  or  by  others  be- 
fore me.  This  disappointment  is  still  more  likely  in 
the  treatment  of  the  diarrhoea,  when  that  is  present.  In 
these  patients  it  is  a  painless  watery  flux,  coming  on 
in  the  morning,  but  the  frequent  sense  of  uneasiness  in 
the  bowels  is  always  accompanied  by  bad  feelings 
in  the  head  and  a  sensation  of  general  depression. 
Astringents  only  increase  this  discomfort,  and  they 
control  the  looseness  but  temporarily.     Of  course  the 


continued  absence  of  a  febrile  temperature  with  the 
tachycardia  must  be  carefully  noted,  in  order  to  ex- 
clude the  presumption  of  tuberculosis.  Another  mis- 
take in  such  cases  is  to  rest  content  with  the  adoption 
of  that  equivocal  term,  "neurasthenia."  All  the 
symptoms  of  ner\-ous  weakness  may  be  present  in  these 
cases,  and  I  have  found  that  every  antineurasthenic 
remedy  has  been  tried,  from  strychnine  to  hydropathy, 
or  I  have  tried  them  myself,  without  any  permanent 
benefit,  as  the  record  of  the  following  shows : 

Case  V. — Mr.  J.  C ,  cashier,  aged  forty,  con- 
sulted me  first,  June  13,  1894.  This  gentleman  has  a 
sister,  whom  I  treated  for  epilepsy  of  seven  years'  du- 
ration in  1 88 1,  and  from  which  she  quite  recovered, 
so  that  I  was  not  consulted  again  by  her  for  fifteen 
years,  when  she  came  with  symptoms  of  Graves'  dis- 
ease, from  which  in  the  course   of   about  a  year  and  a 

half  she  also  recovered.      Mr.  C consulted  me,  as 

above,  for  persistent  gastric  and  intestinal  uneasiness, 
accompanied  by  almost  constant  occipital  headaches 
and  spinal  achings ;  he  slept  badly,  awoke  unref reshed, 
and  always  felt  worse  in  the  mornings.  What  he  also 
especially  complained  of  was  tremor  of  the  right  hand, 
interfering  with  his  signing  checks.  Pulse,  104.  As 
he  seemed  a  very  nersous  subject  and  a  chronic  dys- 
peptic, he  was  treated  accordingly  throughout  1894, 
but  with  very  varying  results.  In  1895  my  notes 
show  him  still  complaining  of  frequent  sense  of  pros- 
tration, constant  feeling  of  pressure  in  the  head  and 
pains  in  the  eyes,  pulse  not  falling  below  100,  and 
with  frequent  attacks  of  palpitation  and  continued 
tremor  of  the  hand.  He  had  often  taken  quinine  on 
the  hypothesis  of  malaria,  but  if  anything  felt  the 
worse  for  it.  Headaches  were  most  relieved  by  ten- 
grain  doses  of  antipyrin  and  twenty-grain  doses  of  am- 
monium bromide,  repeated  in  two  hours  and  always 
taken  in  the  morning.  Throughout  July,  1895,  he  had 
morning  diarrhoea,  with  much  increased  tremor  in  the 
right  arm.  The  rest  of  the  story  of  1895  is  that  of 
ups  and  downs,  the  patient  feeling  best  when  giving  up 
all  business  and  going  on  a  long  vacation  in  the  country, 
the  morning  diarrhoea  then  ceasing  of  its  own  accord. 
He  relapsed,  however,  on  returning  to  the  city,  and 
Januar)-  i,  1896,  he  complained  of  aching  in  the  right 
shoulder  and  neck  and  upper  part  of  the  right  leg, 
with  a  feeling  of  general  nervousness.  He  had  been 
taking  cod-liver  oil  and  various  tonics.  For  a  time  he 
seemed  to  improve  imder  arsenic  and  ichthyol,  with 
sodium  benzoate  at  night,  but  my  notes  in  April  and 
May  and  June,  1896,  record  frequent  returns  of  his 
morning  diarrhoea,  which  was  always  painless;  also 
early  waking  with  feelings  of  gastric  distress,  severe 
neuralgic  pains  in  the  back  of  the  head  and  neck,  for 
all  which  he  again  tried  the  country  cure.  He  was 
not  benefited,  however,  and  returned  August  loth,  with 
severe  morning  headaches,  prostration,  verj-  trouble- 
some palpitation,  tinnitus,  tremor  of  hand,  and  pains 
in  the  eyes.  I  should  mention  that  I  sent  him  on  this 
account  to  Dr.  Carl  Roller,  who  reported  that  nothing 
in  the  condition  of  his  eyes  accounted  either  for  the 
pain  in  them  or  for  the  headaches.  He  was  accord- 
ingly put  upon  the  treatment  for  persistent  tachycardia 
with  digestive  disturbance  and  nervous  symptoms — 
namely,  abstinence  from  meat,  matzoon  diet  exclu- 
sively, with  sparing  use  of  vegetables,  on  account  of 
his  diarrhoea,  and  a  blue  pill  once  a  week,  with  phenol 
bismuth  and  sodium  benzoate. 

The  notes  that  I  may  cite  are,  first  month,  Septem- 
ber i  jth,  diarrhoea  stopped:  still  has  headaches,  but 
lessening  in  severit)'. 

October  7th,  feels  generally  better;  treatment  con- 
tinued. 

March  7,  1897,  has  not  reported  all  winter  because 
he  felt  so  much  better;  has  been  continuing  treatment 
faithfully.     Pulse,  80. 


MEDICAL    RECORD. 


[August  14,  1897 


As  this  patient  recovered  from  his  tachycardia,  the 
tremor  of  his  right  hand  improved  so  that  he  could  use 
it  again.  But  the  tendency  to  headaches  and  morning 
depression  returned  again,  April  27th,  and  still  con- 
tinues at  the  last  date,  May  31st,  though  the  pulse  is 
only  76.  He  avers,  however,  that  nothing  makes  him 
feel  so  well  as  the  blue  pill,  as  the  next  day  after  taking 
it  is  the  best  in  the  week.  Such  relapses  must  be  ex- 
pected in  chronic  digestive  troubles  of  whatever  kind, 
but  the  improvement  during  the  past  winter  is  so 
evident  that  the  patient  is  well  content  to  persevere. 

I  have  had  several  patients  with  this  form  of  persis- 
tent tachycardia,  who  complained  much  of  pain  in  the 
eyes,  generally,  however,  along  with  headaches  similar 
to  those  experienced  in  this  case. 

Thus  Miss  B first  consulted  me,  February  8, 

1894,  for  daily  severe  headaches  with  pain  in  the  eyes, 
always  worse  in  the  morning  on  waking,  suggesting, 
therefore,  that  use  of  the  eyes  did  not  cause  or  at  least 
did  not  aggravate  the  headaches.  Dr.  Roller  also 
examined  her  eyes,  and  reported  that  there  was  noth- 
ing in  them  to  account  either  for  the  pain  or  for  the 
headaches.  Her  pulse,  counted  at  repeated  visits,  ran 
from  130  to  140.  Under  treatment,  outlined  as  above, 
her  symptoms  all  improved  in  about  two  months. 

Ca.se    VI. —  Miss    C.    B ,    aged    thirty,    music 

teacher,  first  consulted  me  for  this  condition,  October 
21,  1896.  This  patient's  trouble  could  easily  be  mis- 
taken for  a  case  of  hysteria,  as  she  was  very  nervous 
and  emotional  and  had  so  many  troubles  to  complain 
of — as  insomnia,  constant  headaches,  pains  in  the 
eyes,  pulsation  felt  in  the  head  and,  as  she  averred,  in 
the  neck  also,  with  pains  at  the  last  cervical  vertebra 
and  coccygodynia.  .She,  moreover,  especially  dreaded 
her  fits  of  mental  depression.  She  was  also  much 
disfigured  with  pustular  acne.  Her  appetite  was 
poor,  and  she  complained  of  great  gastric  discom- 
fort, without,  however,  symptoms  of  gastritis.  At  re- 
peated visits  from  October,  1896,  to  May,  1897,  the 
pulse  ran  generally  above  120,  but  at  the  last  visit 
it  was  94.  I  mention  this  case  more  for  tiie  pur- 
pose of  directing  attention  to  the  symptoms  of  men- 
tal depression,  which,  I  think,  in  this  class  of  pa- 
tients is  very  frequently  misinterpreted  as  hysterical. 
I  have  for  many  years,  when  the  question  of  this 
protean  disorder  of  iiysteria  has  arisen,  been  accus- 
tomed'to  rely  on  certain,  to  me,  distinctive  mental 
accompaniments,  the  undoubted  presence  or  absence 
of  which  has  determined  my  diagnosis  accordingly. 
Of  course  this  element,  in  this  cerebral  complaint, 
cannot  be  described  in  a  word;  but  to  say  that  hys- 
teria must  somehow  be  spectacular  perhaps  comes 
nearest  to  my  meaning,  as  it  implies  that  mental  dis- 
position illustrated  in  the  anecdote  of  the  Frenchman, 
who  was  complimented  on  the  emotion  which  he  dis- 
played at  the  funeral  of  a  friend.  "  Ah,  but  you 
should  have  seen  me  at  the  grave!"  was  his  replv. 
There  is  something  dramatic  about  the  hysterical  pa- 
tient, even  when  siie  is  dumb,  whicii  is  distinctive. 
Now  in  this  patient,  and  in  others  with  this  form  of 
tachycardia,  there  is  often  much  nervousness  present, 
but  it  is  not  in  the  least  six-ctacular,  any  more  than 
the  approaching  delirium  of  fever  is;  and  observation 
of  the  action  of  the  heart  soon  proves  that  its  rapid 
action  cannot  be  due  to  emotion.  The  presence  of 
true  tachycardia  must  be  based  upon  repeated  careful 
examinations  of  the  pulse,  for  nothing  is  more  com- 
mon than  mere  emotional  quickening  in  weak  or  ner- 
vous patients.  When  due  to  excitement  it  will  invari- 
ably be  formd  to  vary  on  the  second  or  third  counting 
at  the  same  sitting,  upon  the  jiatienls  becoming  accus- 
tomed to  the  proceeding,  and  very  likely  not  to  be 
present  at  all  at  the  next  visit. 

In  this  patient  the  last  note.  May  7.  1897,  was: 
"Feeling  much  better;  pulse,  94;   headaches  greatlv 


improved.  Finds  great  help  from  ten-drop  doses  of 
strophanthus  tincture,  especially  against  nocturnal 
palpitation." 

I  may  mention  that  I  have  found  the  action  of  this 
drug  very  variable  with  these  patients,  some  finding 
it  beneficial,  and  others  not,  especially  if  it  disagreed 
with  the'  stomach. 

It  will  readily  be  inferred  from  the  prolonged  his- 
tory of  most  of  the  foregoing  cases  that  their  treatment 
may  tax  to  the  utmost  the  patience  of  both  patient  and 
physician.  I  do  not  wonder,  therefore,  that  some 
cases  which  I  have  seen  in  consultation  with  other 
physicians  have  illustrated  the  pathology  of  the  affec- 
tion more  than  its  therapeutics. 

Thus  Mr.  J.   N.  S ,  sent  to  me  by  Dr.  Charles 

S.  Kerley,  of  this  city,  November  12,  1894,  a  fairly 
healthy-looking  young  man,  aged  twenty-four,  came 
with  a  story  of  constant  diarrhcea  for  six  months,  com- 
ing on  when  he  rises  in  the  morning  and  very  watery 
in  character,  and  which  lasts  till  10  a.m.  His  chief 
complaint,  however,  is  of  sudden  attacks  of  great 
prostration,  which  may  occur  anywhere  in  the  street, 
when  he  feels  as  if  he  were  going  to  drop  and  lose 
consciousness.  This  state  may  last  two  or  three  hours. 
I  found  his  pulse  no.  Dr.  Kerley  stated  that  he  had 
suffered  from  these  attacks  of  prostration  for  three 
years,  following,  according  to  the  patient,  an  attack  of 
the  grippe,  since  which  he  had  never  felt  well,  and  that 
from  the  beginning  he  had  rapid  heart  action,  though 
the  diarrhcea  was,  as  stated,  of  but  six  months'  dura- 
tion. This  patient  afterward  returned  to  England, 
and  the  change  seemed  to  do  him  the  most  good. 

Another  patient,  Mr.  A.  J.  C ,  aged  thirty,  lit- 
erary man  and  artist,  was  referred  to  me  by  Dr.  W.  R. 
Chichester,  of  this  city,  February  3,  1897.  His  mother 
had  lifelong  migraine,  as  he  described  it,  in  one  eye. 
He  suffers  from  peculiar  headaches,  which  are  pre- 
ceded or  accompanied  by  a  sense  of  great  distress  in 
the  bowels,  described  variously  as  pain,  nausea,  and 
great  general  nervousness.  They  often  set  in  as  sud- 
denly as  a  fit.  No  ocular  symptoms.  No  albumin  or 
sugar  in  the  urine.  The  pulse  is  very  rapid  and 
irregular,  but  as  I  saw  him  only  once  I  cannot  state 
how  persistent  the  tachycardia  is.  Dr.  Chichester, 
under  date  of  May  26,  1897,  writes:  ''  For  a  time  Mr. 

C seemed  to  improve  under  the  administration  of 

the  antiseptics  you  prescribed,  with  the  weekly  dose 
of  blue  pill.  Later  on  he  began  to  lose  flesh  and 
strength,  and  was  drifting  into  a  state  of  mental  de- 
pression. These  phenomena  would  appear  to  come 
on  when  he  could  not  get  his  matzoon  and  partook  of 
red  meats  (beef).  About  a  month  ago  his  condition 
was  most  deplorable,  and  at  that  time  I  stopped  his 
medicine  and  fell  back  on  the  old  pil.  asafcetida,  as 
his  nervous  condition  at  times  became  one  of  frenzy. 
The  increased  heart  beat  and  the  intestinal  pain 
seemed  to  be  coincident.  His  diet  during  the  last 
month  comprised  everything  except  red  meats,  although 
he  has  confined  himself  to  matzoon  in  the  main.'" 

As  to  the  pathology  of  this  affection,  it  appears  to 
me  that  some  insight  into  the  problem  is  gained  by  a 
study  of  the  peculiar  pains  and  their  accompaniments 
which  have  been  described  in  the  histories  detailed. 
.\s  a  class  they  appear  characteristically  to  differ  from 
the  other  varieties  of  pain  which  we  usually  meet.  In 
tiie  first  place,  they  certainly  are  not  inllammatory,  for 
they  jiresent  no  signs  of  local  exudation  or  infiltration 
or  swelling,  and  they  are  more  shifting  in  character 
than  true  inflammatory  pains.  Though  apparently  de- 
veloping often  in  the  fascia  of  muscles  and  their  ten- 
dons, vet  they  are  rarely  aflected,  as  all  inflammations 
of  fibrous  tissues  are,  by  alterations  in  the  weight  of 
the  atmosphere,  such  as  presage  the  advent  of  a  storm. 
.\lso,  though  sometimes  resembling  peripheral  neuri- 
tis, vet  they  produce   no  changes   in   the    normal   re- 


August  14,  1897] 


MEDICAL    RECORD. 


flexes,  as,  for  example,  in  the  lower  extremities,  no 
matter  how  long  they  have  been  complained  of  there. 
They  are  not  accompanied  either  by  any  more  muscu- 
lar wasting  than  comports  with  the  general  emaciation 
present.  The  same  may  be  said  of  the  accompanying 
numbness  or  paraesthesia,  as  in  Dr.  Kice's  case,  in 
which  the  patellar  reflexes  were  just  normal,  neither 
increased  nor  diminished.  Just  as  certainly  they  are 
not  degenerative  pains,  for  I  have  never  found  local- 
ized ana;sthesiae,  whether  of  pain,  touch,  or  tempera- 
ture. They  differ  also  from  pure  neuralgias  in  being 
accompanied  by  distinct  local  arterial  hypera-mia,  and 
by  producing  a  peculiar  stiffness  of  the  muscles,  with 
pain  on  movement.  But  this  stiffness,  totally  unlike 
the  tetanic  reflex  contraction  of  the  periarticular  mus- 
cles of  an  inflamed  joint,  was  also  unlike  the  inflam- 
matory stiffness  of  muscular  rheumatism,  for  example. 
because  it  changes  rapidly,  sometimes  by  simply  alter- 
ing the  position  of  the  limb,  as  if  the  arterioles  of  the 
part  had  lost  their  tone  and  the  blood  in  them  was 
affected  by  gravity,  giving  rise,  moreover,  to  that  sub- 
jective sensation  of  inward  pulsation  all  over  the  body, 
which  these  patients  often  complain  of  when  standing. 
Moreover  the  tremor,  so  frequent  in  these  patients, 
never  had  the  characters  of  a  clonus  or  of  any  analo- 
gous reflex  phenomenon.  A  closer  examination  into 
these  symptoms  seems  to  connect  them,  instead,  with 
a  state  of  general  arteriole  dilatation;  the  condition 
of  the  ear  in  Case  I.  being  precisely  similar  to  that  of 
the  ear  of  a  rabbit  in  whom  the  sympathetic  in  the  neck 
on  that  side  has  been  severed.  It  might  be  surmised, 
therefore,  that  paralytic  arterial  distention,  particularly 
in  the  vasa  nervorum,  is  the  proximate  cause  of  many 
of  the  pains,  especially  those  felt  in  the  abundant 
plexus  of  the  tips  of  the  fingers  and  in  the  toes.  On 
the  same  hypothesis  I  would  account  for  the  pains  in 
the  eyes  and  ears  and  the  accompanying  interference 
with  their  special  functions. 

I  may  add  that  a  patient  of  this  kind  under  my  treat- 
ment once  lost  the  sense  of  smell  for  several  months, 
following  upon  a  headache  which  was  relieved  by  an 
attack  of  epistaxis.  The  relief  which  blistering  of  the 
mastoid  afforded  to  the  pain  and  deafness  in  the  left 
ear  in  Case  I.,  with  improvement  of  the  vertigo,  does 
not  invalidate  the  inference  that  the  aural  trouble  was 
not  inflammatory,  for  the  blister  may  have  relieved  the 
arterial  hyperemia  of  the  part  simply  by  the  well- 
known  effect  of  the  vasomotor  stimulation  which  is 
produced  by  counter- irritation. 

Lastly,  it  may  well  be  asked:  What  morbid  process 
of  an  organic  kind,  whether  inflammatory  or  degenera- 
tive, can  involve  such  symmetrical  areas  as  hands  and 
feet,  knees  and  hips,  both  ears  and  both  eyes,  besides 
the  motor  branches  of  the  fifth  and  the  hypoglossal 
nerve,  and  likewise  cause  aphasia — all  of  which  phe- 
nomena were  present  in  Case  I. .'  In  fact,  we  may  say 
that  not  a  sign  is  wanting  in  these  patients  of  a  state 
of  the  vascular  system  which  is  summed  up  in  the 
term  vasomotor  paralysis,  and  that  the  distribution  of 
the  symptoms  is  such  that  it  cannot  correspond  to  any 
systemic  affection  of  vasomotor  tracts  or  centres,  but 
must  be  brought  about  by  an  agency  operative  through 
the  circulation  itself — all  of  which  is  equivalent  to 
saying  that  that  agency  must  be  toxic  in  its  nature. 
On  this  theory  we  might  infer  that  the  tachycardia 
also  is  not  a  local  affection,  but  due  largely  to  the  gen- 
eral loss  of  arterial  tone,  though  this  does  not  exclude 
a  direct  effect  as  well  of  the  toxajmia  upon  the  heart 
itself. 

The  next  question  is:  In  what  direction  are  we  to 
look  for  the  origin  of  the  toxcemia?  The  clinical  evi- 
dence, it  appears  to  me,  points  strongly  to  the  alimen- 
tary canal  as  the  primary  seat  of  the  mischief,  owing, 
in  the  first  place,  to  the  fact  that  in  the  history  of 
these  patients  distinct  digestive  disturbances  precede. 


often  for  months  or  even  years,  both  the  tachycardia 
and  the  nervous  derangements.  If  the  gastro-intes- 
tinal  symptoms  dated  only  from  the  time  that  the  other 
derangements  were  first  noted,  still  more  if  they  devel- 
oped subsequently  to  the  tachycardia,  this  presumption 
would  not  be  so  strong.  Instead  of  that,  I  have  not 
failed,  on  careful  inquiry  into  the  pre\ious  history  of 
every  one  of  my  patients,  to  find  that  they  had  been 
long  subject  to  digestive  disorders,  very  often  of  quite 
a  characteristic  kind.  Thus  both  the  gastric  and  the 
intestinal  derangements  in  these  patients  rarely  ha\e 
presented  the  signs  of  catarrhal  inflannnation.  The 
stomach  troubles,  instead,  are  more  like  those  which 
migrainous  patients  complain  of,  while  the  intestinal 
disorders  comprise  habitual  constipation  or  simple 
watery  diarrhcea,  accompanied  by  a  sense  of  uneasiness 
in  the  bowels  and  of  depression  rather  than  of  pain. 

In  the  second  place,  when  improvement  in  the  ac- 
tion of  the  heart  and  in  the  nervous  symptoms  takes 
place,  the  improvement  invariably  has  been  preceded 
by  improvement  or  cessation  of  the  digestive  disorders. 
About  this  clinical  fact  there  can  be  no  mistake,  and 
hence  it  is  difficult  to  resist  the  conclusion  that  the 
relation  of  the  gastro-intestinal  derangements  to  the 
others  must  be  causative,  when  we  find  that  the  latter 
neither  begin  nor  end  without  the  former  have  first  be- 
gun or  ended. 

We  must  await  the  progress  of  chemistry  to  demon- 
strate what  the  supposed  poison  or  poisons  are  which, 
generated  in  the  alimentary  canal  in  this  affection,  are 
then  by  absorption  productive  of  the  specific  symp- 
toms. Here  again  clinical  experience  seems  to  indi- 
cate that  it  is  in  the  digestion  of  certain  highly  nitro- 
genous articles  of  food  that  the  occasion  of  the  trouble 
arises.  Repeatedly  I  have  found  all  the  symptoms  of 
the  patients  as  distinctly  aggravated  by  indulgence  in 
red  meats  as  indulgence  in  starchy  food  aggravates  the 
symptoms  of  diabetics.  In  one  patient  even  the  flesh 
of  fowls  caused  derangement,  though,  with  most,  poul- 
try in  moderation  is  allowable.  A  milk  diet,  however, 
when  made  digestible  by  artificial  fermentation  or  by 
peptonizing  it,  is  by  all  odds  the  most  conducive  to 
restoration,  and  in  many  cases  so  distinctively  cura- 
tive in  its  effects  that  it  affords  of  itself  a  strong  pre- 
sumption of  the  digestive  origin  of  the  complaint. 

As  to  diagnosis,  the  presence  of  the  specific  tachy- 
cardia is  the  leading  element.  It  would  be  difficult 
to  cite  an  aft'ection  who.se  symptoms  might  be  more 
obscure  or  baffling  than  this  one,  whether  in  the  re- 
bellious dyspepsia  or  bowel  disorder,  or  in  the  curious 
and  protean  character  of  the  nervous  symptoms,  until 
the  clew  is  furnished  by  the  concomitant  rapid  action 
of  the  heart.  Failing  to  note  the  presence  or  to  ap- 
preciate the  significance  of  this  functional  cardiac 
derangement,  we  may  vainly  try  for  months  to  treat 
the  alimentary  canal  or  the  nerves  with  our  measures 
with  as  little  success  as  if  we  gave  tonics  to  a  diabetic 
for  his  weakness  or  stimulants  for  his  nervousness. 
On  the  other  hand,  digestive  disorders,  however  well 
treated,  always  require  patience  and  perseverance,  and 
in  this  complaint  this  principle  is  particularly  appli- 
cable. If  the  patient  will  agree  to  follow  a  systematic 
course  only  for  a  month  or  so,  no  cure  should  be 
promised. 

Finally,  we  may  ask:  Is  there  any  disease  which  is 
at  all  comparable  in  its  symptoms  and  nature  to  the 
affection  which  we  have  been  illustrating  by  these 
clinical  examples.''  The  answer  is  that  undoubtedly 
Graves'  disease  does  so  in  every  respect,  except  in  the 
addition  of  two  symptoms,  neither  of  which  was  pres- 
ent in  the  cases  which  I  have  detailed,  but  which  two 
symptoms,  on  account  of  their  obtrusiveness  when 
present,  have  given  it  its  most  common  name,  exoph- 
thalmic goitre — most  unfortunately,  as  I  think.  In 
Graves'   disease  we   have   digestive  disturbance,    cul- 


!24 


MEDICAL    RECORD. 


[August  14,  1897 


initiating  in  severe  cases  in  marked  emaciation  with- 
out fever,  and  in  a  large  number  witii  a  tendency  to 
])ersistent  diarrhcta.  In  a  large  proportion  these  di- 
gestive disorders  are  specifically  associated  with  a 
variety  of  sensory  and  motor  symptoms  in  different 
parts  of  the  body,  such  as  neuralgic  pains,  disturbance 
of  the  special  senses,  local  paralyses,  muscular  tremor, 
vasomotor  derangements,  etc.  Lastly,  there  is  the 
same  rapid  action  of  the  heart.  But  because  the  thy- 
roid enlarges  and  the  eyes  protrude,  that  disease  ha.s 
been  regarded  as  a  purely  thyroid  affection,  when  it 
might  as  well  be  called  an  eye  affection,  for  some- 
times goitre  occurs  without  exophthalmos  and  exoph- 
thalmos without  goitre.  In  many  cases  also  the  pa- 
tients suffer  severely  with  the  general  symptoms  of  the 
complaint  for  months  or  even  years,  before  any  en- 
largement of  the  thyroid  or  exophthalmos  appears,  and 
then  when  these  do  appear  they  vary  in  degree  from 
time  to  time  up  to  complete  disappearance  and  then 
recurrence.  The  mischief  of  naming  diseases  after 
inconstant  symptoms  is  twofold,  in  that  the  disease 
may  not  be  recognized  when  actually  present  because 
these  particular  symptoms  are  not  developed,  or  it  may 
lead  to  erroneous  views  of  pathology  by  inconstant 
symptoms  being  interpreted  as  causative,  which  they 
never  can  be  if  they  are  inconstant.  A  real  cause  can 
never  be  absent  from  its  effect. 

In  this  list  which  I  have  detailed  this  evening,  not 
one  of  these  patients  had  either  goitre  or  exophthalmos. 
Two  of  them  have  this  feature  connected  with  them 
— the  gentleman,  Case  V.,  who  has  a  sister  who  once 
had  exophthalmic  goitre;  and  the  lady.  Case  III.,  who 
also  has  a  sister  five  years  older  than  herself,  whose 
history  I  published  in  my  second  communication  on 
Graves'  disease  in  the  Ncju  York  Medical  Joititm/. 
October  10,  1896.  In  this  patient,  Case  II.  of  that 
paper,  the  first  complaint  was  pain  on  the  anterior  as- 
pect of  both  thighs  at  night,  then  distracting  throbbing 
in  the  left  ear,  then  tremor  of  the  right  arm  preventing 
writing  in  the  morning  but  not  in  the  evening,  with 
other  characteristic  and,  some  of  them,  very  distressing 
symptoms,  along  with  a  pulse  of  130,  but  no  goitre 
from  1893  to  1896,  when  it  suddenly  developed,  curi- 
ously enough,  just  as  all  her  other  symptoms  were 
markedly  improving.  Meanwhile  up  to  this  week,  as 
I  saw  her  on  June  ist,  instead  of  the  goitre  increasing 
her  troubles,  these  have  wellnigh  disappeared,  and  the 
thyroid'enlargement  comes  and  goes  irregularly  with- 
out much  discomfort  so  that  the  patient  cares  nothing 
about  it.  Therefore  if  she  had  not,  after  three  years 
of  her  trouble,  finally  shown  enlargement  of  the  thy- 
roid, I  should  now  have  included  her  story  along  with 
that  of  her  sister's.  The  fact  is  that  one  sister  has 
exophthalmic  goitre  and  the  other  has  not,  but  iiotii 
have  Graves'  di.sease.  On  one  subject,  however,  botli 
sisters,  who  are  exceptionally  intelligent  ladies,  ex- 
press deep  regret — namely,  they  are  convinced  from 
their  own  experience  that  their  mother  died  of 
the  same  disease.  She  was  sixty-four  years  of  age 
when  she  died  from  exhaustion  after  an  illness  of  four 
years,  during  which  she  was  attended  by  .several  of 
the  most  eminent  physicians  of  this  city,  none  of 
whom  ventured  to  give  a  positive  diagnosis  of  her 
complaint.  .-Vccording  to  their  statement  she  had 
first  for  three  years  a  great  deal  of  gastric  trouble  with 
frequent  vomiting.  She  suffered  from  much  palpita- 
tion and  had  sudden  attacks  apparently  of  heart  fail- 
ure. One  physician  said  that  she  would  die  from 
heart  disease,  but  that  it  was  not  valvular.  She  had 
a  great  deal  of  vertigo;  then  severe  pains  in  the  toes 
and  then  in  tiie  fingers;  then  recurrent  phlebitis  oc- 
curring twice  in  both  legs,  but  from  which  she  recov- 
ered. She  had  attacks  also  of  transient  blindness, 
and  finally  a  severe  pain  in  the  right  clavicle  with 
some   swelling  there,  which  a  distinguished  surgeon 


said  was  in  her  condition  an  inoperable  tumor,  but 
which  would  grow  till  she  succumbed  to  it.  From 
the  description  I  judge  that  it  may  have  been  sup- 
posed to  be  a  subclavian  aneurism,  but  the  surgeon 
had  to  change  his  mind  afterward,  as  both  the  tumor 
and  the  pain  in  the  clavicle  disappeared.  I  give  this 
account  for  what  it  is  worth;  but  the  lady  who  fur- 
nishes it  is  fearful  that  the  pain  which  she  has  had 
herself  in  the  right  clavicle  and  the  attacks  of  blind- 
ness in  the  right  eye,  above  described  in  the  historj-  of 
her  case,  ominously  remind  her  of  her  mother's  expe- 
rience. I  may  mention  that  the  statement  of  the  phle- 
bitis naturally  interested  me,  on  account  of  its  super- 
vention in  Case  I.  of  this  paper. 

If,  however,  the  pathology  of  the  cases  now  reported 
by  me  is  that  of  toxamia  of  gastro-intestinal  origin, 
the  same  I  hold  to  be  true  of  Graves'  disease  itself. 
The  enlargement  of  the  thyroid  then  may  be  regarded 
as  due  to  overstimulation  of  the  thyroid  cells  by  the 
presence  of  a  toxic  irritant  in  the  blood.  It  is  not  an 
improbable  theory,  in  fact,  that  one  of  the  functions  of 
this  gland  is  to  neutralize  by  its  secretion  poisonous 
materials  constantly  absorbed  from  the  alimentary 
tract,  and  that  it  is  only  their  excessive  quantit}'  in 
Graves'  disease  which  causes  it  to  become  relatively 
insufficient  to  its  task.  We  can  only  refer  here  to  the 
experimental  researches  of  Breisacher,  Ewald,  Rosen- 
blatt, and  Benissovitch,  who  agree  in  reporting  the 
rapidly  poisonous  effect  of  a  meat  diet  on  thyroidecto- 
mized  dogs,  while  the  number  and  intensity  of  the 
symptoms  are  diminished  on  a  milk  diet,  indicating 
that  a  normal  function  of  this  gland  is  to  prevent  in- 
jury from  products  of  the  normal  digestion  of  what  is 
a  natural  food  with  these  animals.  On  the  other  hand, 
the  many  curious  effects  of  the  blood  condition,  in 
producing  both  motor  and  paralytic  affections  in  ner- 
vous tracts,  may  also  be  the  cause  of  the  exophthalmos. 
Exophthalmos,  and  sometimes  enlargement  of  the  thy- 
roid, have  been  reported  by  Filehne  as  the  result  of  the 
division  of  the  restiform  bodies  in  rabbits,  which  phe- 
nomena therefore  would  seem  to  be  induced  by  a  par- 
alytic impression  on  medullary  centres,  a  deduction 
which  is  further  borne  out  by  the  paretic  symptoms  in 
Graves'  disease  of  the  Stellwag  and  von  Graefe  signs. 


THE     PHYSICLW,     HIS      PERSONNEL.    AND 
HOW    IT    AFFECTS    HIS    SUCCESS.' 

Hy   t.    J.    HILI.IS,    M.n., 

The  Physician. — Of  all  the  pursuits  and  occupations 
engaging  the  attention  of  civilized  man,  there  is  none 
so  trj'ing  and  so  grinding  on  the  nervous  system  as  the 
practice  of  medicine.  Men  engaged  in  other  walks 
of  life,  and  the  people  at  large,  have  as  a  rule  regular 
hours  in  which  to  transact  business,  appointed  hours 
for  meals,  a  time  for  rest  and  amusement.  The  day 
laborer,  the  lawyer,  the  artist  has  regular  hours  for 
repose.  Tiiese  periods  are  dedicated  to  sleep,  a 
heritage  to  be  maintained,  an  institution  to  be  perpet- 
uated. No  ringing  at  their  doorbells  at  unseasonable 
hours,  no  jumping  out  of  bed  half-awake  at  a  moment's 
notice,  no  running  out  into  the  darkness  half-dressed, 
no  solitary  walk  through  miles  of  street  under  angry 
and  unpropitious  skies;  for  the  doctor  no  holiday,  no 
Sunday,  but  weary  years  of  toil;  no  church  bell  to 
summon  him  to  devotion,  no  process  server  to  remind 
him  he  is  a  citizen.  Occasionally,  in  the  monotony 
of  tumult,  he  receives  a  sudden  jar  when  the  bailiff 
comes  to  eject  him  for  non-payment  of  rent ;  however, 

'  Read  at  the  thirteenth  annual  meeting  of  the  Fifth  District 
Branch  of  the  New  York  State  Medical  .\ssociation.  May  35, 


August  14,   1897] 


MEDICAL    RECORD. 


225 


happily  this  is  of  infrequent  occurrence.  He  is  ex- 
empt from  some  obligations,  only  to  be  a  shne  to 
others.  His  vocation  is  to  be  ever  \vaiting  and  always 
read}' — a  bondman  ilc  facto,  while  a  citizen  dc  Jinc. 
He  would  be  discomfited  and  destroyed  by  these  ac- 
cumulated woes,  were  he  not  buoyed  up  by  the  con- 
sciousness of  doing  good.  Here  the  poison  and  the 
antidote  are  companions  of  a  journey. 

Dwelling  in  the  midst  of  alarms  and  a  witness  of 
so  many  tragic  scenes,  no  matter  how  steeled  his 
heart,  the  effect  is  felt  and  the  image  reflected;  tiiere 
the  negative  or  shadow  finds  an  abiding-place,  and  the 
development  will  come  slowly  or  may  suddenly  be 
precipitated  by  a  favorable  condition.  Excitements 
will  begin  to  tell  at  fifty-five  on  the  floor  of  the  heart, 
roughening  its  naturally  smooth  surface  and  binding 
down  its  longitudinal  fibres,  rendering  the  doors  or 
valves  leading  to  the  main  arteries  leaky  and  ineffi- 
cient. The  circular  fibres  of  the  arteries  supplying 
this  floor,  the  vasa  vasorum,  contract  too,  narrowing 
the  lumen  of  the  vessels  and  destroying  their  function, 
when  atheromatous  or  calcareous  degeneration  ensues. 
Now  the  condition  known  as  endocarditis  e.xists,  and 
few  physicians  at  si.xty-five  are  free  from  this  patho- 
logical sequence. 

After  sixty  there  is  a  sort  of  chronic  inrtammaliun, 
progressive  and  increasing,  according  to  the  labor  or 
excitement  to  which  the  physician  is  exposed.  There 
is  no  temf)erature  range  of  any  consequence  attached  to 
this  contraction  and  thickening;  in  fact,  the  tempera- 
ture may  often  be  subnormal.  This  might  on  general 
principles  be  designated  as  dry  rot.  Old  trees  are 
subject  to  this  disease,  too.  The  old  tree  rots  at  the 
heart,  as  the  saying  goes,  while  the  young  tree  dies  at 
the  root.  The  old  man's  ner\ous  system  is  not  so 
impressionable  as  that  of  the  young.  It  has  not  the 
elasticity  to  rebound  or  the  potential  energy  to  sum- 
mon quick  reinforcements.  The  old  man's  heart  is  a 
storm  gauge.  It  receives  the  blows  and  they  are 
registered  on  the  endocardium.  He  may  be  uncon- 
scious of  the  manner  of  reckoning,  and  indeed  even  of 
the  blows,  but  excitements  after  sixty  will  ha\e  a  cu- 
mulative and  finally  a  disastrous  effect,  and  tlie  sav- 
ing will  go  around:  "  He  died  of  a  broken  heart;  that 
news  he  heard  yesterday  killed  him.'' 

Not  Interested  about  Himself It  is  a  well-known 

fact  that  the  physician  is  careless  about  himself,  some- 
times to  a  degree  of  fatuit}'.  \\'hi]e  interested  in  his 
patient's  heart  murmur  and  the  pallor  of  his  patient's 
cheek,  he  thinks  not  at  all  of  his  own.  He  will  ex- 
amine with  great  minuteness  a  blood  disc  from  his 
patient's  artery,  to  determine  its  ratio  to  the  standard 
of  health,  and  investigate  the  source  and  quality  of 
a  murmur  with  care;  while  his  own  heart  is  weak,  its 
valves  are  faulty,  with  murmurs  long  and  loud,  heartl 
everywhere  over  the  areas  of  exploration.  He  trusts 
himself  to  the  mercy  of  the  elements,  chance,  and  per- 
ennial hope,  while  he  builds  a  wall  of  protection 
around  his  patient  and  formulates  a  treatment  that 
will  withstand  a  vigorous  bombardment  from  disease. 

When  He  Will  be  Reminded  that  there  is  a  Limit 
to  His  Endurance — .\t  sixty-five  the  surgeon  should 
hand  his  scalpel  to  a  worthy  brother,  younger  than  he. 
Many  reputations  have  been  ruined  by  not  knowing 
when  to  quit.  He  should  not  imitate  the  pugilist  anil 
wait  for  a  knock-out  blow  before  retiring,  .\fter  that 
age  he  will  have  a  tremor  in  his  hand,  and  the  eye  will 
grow  dim  in  spite  of  glasses;  even  though  the  mind 
is  as  clear  as  running  water,  and  its  reasoning  per- 
fect, it  cannot  control  that  tremor  of  the  hand.  Then 
let  him  retire  gracefully  when  he  feels  that  the  touch 
of  time  is  upon  him,  for  none  should  know  better  than 
he  that  nature  is  inexorable  and  will  not  be  trifled  wiiii. 
If  he  further  persists  from  habit  or  vanitv  in  the  \  i\  i- 
section  of  his  fellow-beings,  he  is  ver}'  likely  to  he  the 


subject  of  some  good-natured  ridicule  in  the  operating- 
room  by  the  younger  men  around,  and  even  by  the  neat 
and  keen-visaged  nurse  at  his  elbow.  Each  day 
brings  poorer  results.  There  is  nothing  to  be  hoped 
for  but  retrogression  in  his  methods.  There  is  no  time 
here.  He  is  looking  backward.  He  wants  to  grasp 
again  the  triumphs  that  younger  and  brighter  days  had 
brought  him,  to  prop  him  up  in  this,  the  hour  of  his 
sore  distress.  Through  the  dim  vista  of  the  past  he 
discerns  the  phantom  flying  and  sees  the  lurid  flame 
— forbear,  good  doctor^ — 

To  tempt  tlie  dangerous  gioom." 

He  takes  the  step  heedless  of  the  warning,  and  disap- 
pears from  the  scene. 

The  physician  at  seventy  should  take  in  his  sign 
and  seek  a  quiet  retreat  in  the  corner  of  a  consulta- 
tion-room. He  is  now  admirably  adapted  for  giving 
advice.  The  stored-up  experiences  of  years  have  an 
inestimable  value  here.  If  he  further  persists  in  ac- 
tive labor  and  launches  again  on  the  stormy  deep,  his 
hulk  will  founder,  since  it  is  leaky,  shrunken,  warped, 
eaten  by  the  resistless  furj-  of  the  elements  and 
weighed  down  by  the  incrustations  of  tiine,  a  prey  to 
the  conditions  that  are  the  offspring  of  age  and  com- 
plements of  senility  and  decay. 

His  Discipline.  —  The  well-disciplined  physician 
will  not  worry  too  much  if  things  do  not  go  to  his  lik- 
ing in  the  sick-room,  or  take  it  to  heart  if  he  loses  a 
patient  suddenly  and  unexpectedly.  If  he  does,  the 
sooner  for  his  peace  of  mind  and  health  he  enters 
another  pursuit  the  better  for  him.  The  constant 
fretting  will  wear  his  mind  and  consume  his  body, 
and  while  yet  young  he  shall  be  gathered  to  his  fathers 
and  join  the  majority  beyond. 

The  wise  physician  will  forget  the  pains  and  tribu- 
lations of  the  sick-room  after  the  door  is  clo.sed 
behind  him.  In  that  room  let  him  think  and  use  his 
skill  and  judgment  well,  give  his  instructions  in  an 
easy  yet  emphatic  manner,  not  recapitulate  except  on 
special  occasions.  Often  for  this  cause  good  doctors 
have  been  accounted  bores,  and  patients  have  disap- 
peared from  their  lists  without  their  knowing  why. 

The  physician  must  not  be  too  sympathetic  in  the 
sick-room,  or  carried  away  by  the  tears  and  sad  faces 
he  sees  around  him.  He  must  be  like  the  sturcly  oak 
in  the  forest — bend  to  the  blast,  while  not  being 
affected  by  it.  He  must  always  keep  himself  well  in 
hand,  never  lose  his  temper  or  presence  of  mind;  if 
he  is  master  of  himself,  he  will  seldom  have  difficulty 
in  being  master  of  the  sick-room.  He  must  be  ever 
conscious  of  the  fact  that  the  family  did  not  send  for 
him  for  the  purpose  of  sympathizing  with  them;  their 
friends  and  spiritual  adxiser  are  abundantly  able  to 
do  this,  and  more  too,  for  it  will  be  found  that  the 
former,  and  unfortunately  often  the  latter,  indulge  in 
criticisms  not  overfavorable  to  the  physician.  His 
method  of  treatment  will  be  measured  by  his  degree  of 
success,  and,  if  failure  perches  on  his  banner,  a  cute 
and  knowing  friend  in  the  background  comes  to  the 
front  to  whisper  into  the  ear  of  the  distressed  relative; 
'■  I  told  you  so;  I  said  all  along  he  did  not  under- 
-stand  the  case.'' 

The  nature  and  character  of  the  disease  play  no 
part  with  these  people.  It  is  always  a  question  of 
the  degree  of  ability  of  the  physician. 

His  Trials. — It  cannot  be  too  forcibly  emphasized 
or  too  often  repeated  that  humiliation  has  come  to  the 
physician  because  of  his  kindness  of  heart  and  ever- 
ready  sympathy.  He  is  doing  excellent  professional 
work  to  save  his  patient,  and  has  hope  he  can  pull  him 
over  the  crisis.  He  neglects  other  patients  whose 
money  is  sure,  for  this  one  whose  money  is  not  sure, 
but  whose  promises  are  inflated  and  extravagant:  he 
has  taken  a  special  interest  in  this  case,  is  in  the  sick- 


2  26 


MEDICAL    RECORD. 


[August  14,  1897 


room  early  and  late,  watches  all  the  symptoms,  and 
combats  every  unfavorable  turn. 

At  the  crisis,  and  while  he  is  preparing  to  see  this 
patient,  who  is  the  first  on  his  morning  list,  his  door- 
bell rings  violently,  a  small  boy  hands  in  a  note  di- 
rected "To  the  Doctor.  ' 

On  the  previous  e\ening  a  patient  promised  to  send 
the  doctor  a  fee  that  was  long  overdue.  His  heart  was 
full  of  glee  and  words  of  thankfulness  were  on  his 
lips  as  he  was  about  to  break  the  seal.  He  felt  he  w  as 
rather  hasty  on  the  previous  evening,  when  he  sent  a 
tart  note  requesting  the  money,  and  when  the  word 
was  returned  that  it  would  come  in  the  morning  he 
felt  that  human  nature  was  not  quite  so  bad  as  he 
thought — and  he  is  now  about  to  be  in  possession  of 
that  fee!  The  doctor  tears  the  envelope  with  confi- 
dence and  hope.  He  opens  the  letter.  There  is  no 
money  in  it!  He  is  disappointed.  He  is  further  dis- 
appointed, surprised,  and  disgusted  when  he  reads : 

"Dr.  Kindheart:  A  friend  of  ours,  a  lady,  Mrs. 
Lightbody,  from  across  town,  called  this  morning  to 
see  your  patient.  She  is  not  satisfied  with  your  treat- 
ment and  thinks  that  Marguerite  is  growing  weaker: 
consequently  she  summoned  her  own  physician,  who 
is  now  in  the  house.  Please  do  not  call  again  until 
we  send  for  you. 

•■  \'ery  respectfully, 

'■  Mrs.   Lighthe.\d.'' 

A  physician  was  called  out  of  bed  in  the  night  to 
see  a  child  suffering  from  croupous  lar}ngitis.  The 
physician  was  not  young,  nor  was  his  health  vigorous. 
The  night  was  bitterly  cold,  and  the  sick-room  to  which 
he  was  called  was  anything  but  comfortable  and  con- 
genial. He  went  home  for  his  case  of  instruments, 
returned  to  the  sick-room,  performed  a  delicate  opera- 
tion, and  remained  through  the  night,  lest  an  emer- 
gency should  arise  demanding  his  immediate  presence 
there.  His  treatment  gave  instant  relief  and  promise 
of  final  success.  Tired  and  worn  out  by  the  labors  of 
the  night,  the  physician  turned  his  thoughts  on  home. 
After  giving  directions  as  to  the  course  to  be  pursued 
in  his  absence  and  until  his  return  in  the  morning, 
he  left  the  house,  enveloped  in  an  atmosphere  of 
prayers  and  praise  by  the  good  people  of  the  family 
that  his  days  might  be  long  in  the  land  and  pros- 
perity always  lend  him  her  smile;  they  would  never 
forget  his  skill  and  kindness  as  long  as  they  lived, 
and  would  without  fail  pay  him  for  his  night's  services 
when  he  returned  in  the  morning — just  then  they  weie 
so  overcome  lay  their  feelings  of  gratitude  and  emo- 
tion that  money  was  of  small  consideration  and  of 
minor  importance.  He  came  according  to  promise 
in  the  morning;  as  he  entered  the  apartments  he 
met  a  member  of  the  family,  and  in  reply  to  the 
query,  "How  is  your  brother?"  he  was  told:  "Do- 
ing well  now,  but  two  hours  after  you  left  this  morn- 
ing he  had  a  change  for  the  worse,  and  we  thought  it 
wise  to  summon  another  physician,  who  has  left  posi- 
tive orders  that  no  person  be  allowed  to  see  the  patient 
but  my  mother,  who  is  in  attendance  until  his  return. 
We  would  have  sent  you  word  not  to  call,  hut  were 
too  exhausted  after  the  fatigue  of  the  night  to  pay  anv 
attention  to  a  tiling  of  sucli  small  importance." 

Recognizing  the  Situation — .\n  experience  or  two 
of  this  sort  every  week  will  bring  the  piiysician  to  his 
senses,  and  after  a  while  he  will  get  it  through  his 
cranium  that  people  do  not  send  for  him  to  prescribe 
for  them  because  they  like  him,  or  because  they  enter- 
tain a  regard  for  him  above  or  beyond  other  members 
of  his  profession.  They  call  him  in  because  they  be- 
lieve he  can  do  the  best  possible  for  the  sick  one. 

Ingratitude — When  they  are  convinced  or  imagine 
some  one  else  can  do  better,  they  throw  him  down  like 
a  dishrag.     Thev  have,  as  it  can  be  seen,  no  regard 


for  his  feelings  or  gratitude  for  what  he  has  accom- 
plished. They  will  trample  him  in  the  dust  in  their 
haste  to  bring  some  one  else,  not  so  competent  as  he, 
to  carry  on  the  work  he  so  auspiciously  began.  The 
homely  saying,  "  Don't  swap  horses  crossing  a  stream,'" 
has  no  weight  here,  for  these  people  do  a  great  deal  of 
swapping — the  further  down  in  the  social  scale  the 
more  so — and  during  this  swapping  there  is  swamping, 
for  the  new  horse  often  throws  his  rider,  not  being  so 
surefooted  as  the  old  one.  This  will  account  for  the 
awful  mortality  in  crowded  tenement  districts  in  times 
of  sickness  or  epidemic.  They  play  with  doctors  as  a 
child  plays  with  toys,  and  change  their  doctors  oftener 
than  they  do  their  underclothes,  with  the  result  that 
"  too  many  cooks  spoil  the  broth."  It  is  hardly  nec- 
essary to  say  the  cooks  don't  get  paid.  It  is  the  com- 
mon lot  of  all  physicians  to  have  such  experiences 
some  time  or  other  during  their  professional  career, 
and  those  with  quick  perceptions  and  fine  nervous 
organizations  suffer  the  most  from  the  base  and 
cowardly  ingratitude  and  often  atrocious  conduct  of 
these  miscreants,  calling  themselves  human  beings 
and  claiming  a  common  humanity  with  us. 

"  \\'lio  knows  thee  well,  must  quit  thee  with  disgust, 
Oegratleti  mass  of  animated  dust." 

It  takes  about  ten  years'  observation  to  know  and 
understand  the  dear  public,  for  whom  and  among 
whom  we  labor,  and  about  twenty  years  to  have  a  fair 
knowledge  of  human  nature,  as  it  presents  itself  inside 
and  outside  the  sick-room. 

His  Charity. — There  is  no  profession  so  charitable 
or  so  ready  to  give  its  services  away.  The  physician, 
if  properly  approached,  will  never  say  "  No"  any- 
where and  everywhere  that  his  services  are  needed. 
In  an  emergency  he  is  there,  binding  up  the  wounds 
of  the  injured  or  ministering  to  the  wants  of  the 
sick;  in  that  hour  of  peril  he  is  as  brave  as  a  lion, 
prodigal  of  his  labor  and  skill,  and  as  kind  as  a  sister 
of  charity.  This  professional  gentleman  is  ever  alive  to 
the  appeal  of  the  needy,  and  always  ready  to  relieve  a 
fellow-l)eing's  pain.  If  he  is  apparently  deaf  to  en- 
treaty and  slow  to  respond  to  a  so-called  emergency 
call,  he  has  just  cause  for  his  action,  and  will  in 
every  case  be  able  to  show  that  the  seeker  after  his 
services  is  worthless  and  undeserving  of  consideration, 
and,  after  all,  not  really  in  need  of  his  services  at  all. 
He  has  broken  faith  with  this  physician  many  times 
before,  and  is  prepared  to  do  it  again  when  the  occa- 
sion presents  itself.  If  the  people  kept  faith  with  the 
physician  as  the  physician  does  w  ith  them,  there  would 
be  little  need  of  that  institution  known  as  the  dispen- 
sary, and  that  other  colossal  concern,  the  hospital, 
would  shrink  to  its  normal  proportions.  Then  would 
the  board  of  governors  cease  to  play  the  role  of  man- 
darins, the  superintendent  that  of  Turkish  pacha;  then 
would  the  physicians  and  surgeons  attached  to  those 
establishments  be  emancipated  from  serfdom,  and  the 
hospital  itself  cease  to  be  an  engine  of  oppression. 

His  Habits. — There  is  a  saying  among  the  people 
that  "all  good  doctors  drink:"  that  if  a  patient  is 
fortunate  enough  to  catch  the  doctor  sober,  his  case 
will  be  speedily  diagnosed  and  recovery  rapid. 

It  is  not  an  unusual  proceeding  for  several  sick  peo- 
ple to  be  on  the  lookout  for  the  doctor,  as  at  this  pe- 
riod the  mind  is  in  a  formative  state,  and,  like  the 
elements,  in  a  nascent  condition,  eager  to  form  new 
combinations  and  liberate  latent  force.  .\t  this  trans- 
ition stage  his  touch  has  a  healing  infiuence,  and  the 
words  that  fall  from  his  lips  are  charged  witli  potency 
and  promise. 

Physicians  not  overburdened  with  pr.actice,  having 
in  mind  tiiis  popular  delusion,  often  rapidly  spring 
into  favor  by  sinudating  intoxication.  Before  he  was 
commonplace  an<.l  little  noticed.      Xow  attention   has 


August  14,  1897] 


MEDICAL    RECORD. 


227 


been  directed  to  hini;  he  has  exploited  himself  at  op- 
portune moments ;  the  people  in  the  marketplace  and 
on  the  thoroughfare  recognize  that  the  mental  processes 
and  nervous  energies  of  this  physician  are  rapid,  in- 
terchanging, and  extremely  exhausting,  and  that  after 
all  he  is  only  paying  the  debt  he  owes  to  genius.  He 
must  have  a  stimulant  to  restore  his  nervous  equilib- 
rium, and  what  is  so  rapid  in  effect  and  so  easily  as- 
similated as  alcohol  ?  He  cries  for  it  and  appropriates 
it  with  celerity  and  gusto.  In  time  the  mist  will  have 
cleared  away  and  the  popular  illusion  will  have  van- 
ished, but  often  not  before  the  physician  retires  with  a 
competency. 

His  Triumphs. — 'I'lie  triumph  of  the  physician  is 
complete  when  after  his  patient  is  dead  the  family 
speak  of  him  with  respect  and  esteem.  Death  drew 
them  closer  together,  and  now  binds  them,  as  it  were, 
with  hooks  of  steel.  Their  loved  one  was  too  good  to 
linger  long  here  below.  He  was  called  away  to  fill  a 
measure  of  usefulness  beyond  the  vision  of  our  gross- 
ness,  but  only  to  realize  the  fruition  of  our  hope. 
Happy  is  the  physician  who  can  multiply  these  expe- 
riences, for  his  voke  is  made  easv  and  his  burden 
light. 

The  Status  of  the  Giants  of  the  Profession.  —  It 
will  be  observed  that  the  giants  of  the  profession,  the 
college  professors  and  great  practitioners  of  the  day, 
are  not,  as  a  rule,  the  medical  advisers  of  the  four 
hundred.  Their  profession  with  them  is  the  serious 
business  of  life.  There  are  too  much  intensity  and 
force  of  character  in  them  to  allow  them  to  be  obse- 
quious and  over-obliging.  In  their  effort  after  knowl- 
edge they  forget  to  cultivate  the  art  of  pleasing  and 
the  subtle  ways  that  hypnotize  and  control — no  polite 
aphorisms  in  the  drawing-room,  that  leave  behind  fra- 
grant memories  and  make  the  ladies'  breasts  thrill 
with  emotion  as  they  anticipate  new  and  repeated 
sea/uvs .'  These  men  have  no  tricks,  no  sly  ways,  no 
cards  up  their  sleeves,  no  surprises  to  spring,  no  pleas- 
antries to  relate.  Their  appearance  will  bear  evidence 
of  this;  features  rugged  as  the  granite  hills,  strong  to 
resist  the  force  that  is  in  them,  the  r/j  a  tergo  of  the 
mind — faces  always  impressive,  often  implacable,  ter- 
rible when  confronting  stupid  opposition  or  condemn- 
ing imposture  and  hypocrisy.  These  homely  faces 
reflect  thought  and  pent-up  force.  Men  with  faces 
like  these  make  history,  revolutionize  society,  and  re- 
arrange the  maps  of  states  and  countries. 

The  rubicund  and  unctuous  belongings  of  the  pres- 
tidigitator and  Don  Ca;sar  de  Bazan  of  the  fashiona- 
ble sick-room  are  all  absent  here.  Plain  and  direct, 
life  has  an  object  and  time  a  value  to  him.  He  is 
businesslike  and  brief  in  the  sick-room.  He  came 
there  for  a  purpose;  that  purpose  accomplished  he  re- 
tires without  ostentation;  in  fact,  these  great  men 
carry  the  odor  of  the  counting-room  and  the  directness 
of  the  bailiff  into  the  sick-room  so  conspicuously  that 
their  presence  is  seldom  welcome  there.  For  tliis 
reason  they  are  seen  in  the  portals  of  swelldom  only 
when  the  angel  of  death  is  hovering  over  the  house 
and  Gil  Bias  is  fearful  that  he  will  not  be  able  to  bear 
the  burden  of  disaster  alone. 

His  Personnel. — The  personal  qualities  of  the  phy- 
sician are  always  to  be  reckoned  with  on  the  balance- 
sheet  of  success  or  failure:  his  magnetism,  his  abil- 
ity to  attract  or  repel — in  short,  all  the  details,  items, 
and  attributes  that  make  up  his  personnel.  This  will 
not  consist  of  a  strained  and  awkward  effort  to  please, 
or  of  any  effort  on  his  part.  It  will  be  a  qualit)-  or 
condition  peculiar  to  himself,  and  of  which  he  may  be 
wholly  unconscious;  however,  it  contains  the  elements 
of  success,  the  force  to  impel  him  along. 

The  versatile  and  dashing  physician  has  neither  the 
time  nor  the  disposition  to  pour  over  cumbersome  tomes 
and  consult  authorities  on  medical  topics.      He  has  an 


assistant  to  do  that  for  him ;  to  tell  the  truth,  he  has 
no  great  liking  for  these  same  authorities,  for  are  they 
not  too  prosy,  too  dreary,  and  altogether  unsatisfactory 
as  to  conditions  and  final  conclusions?  Who  can 
blame  him  for  wanting  none  of  them?  It  will  be  seen 
later  he  is  a  law  unto  himself,  and  a  higher  law.  To 
his  mind  they  are  well-meaning  but  honest  fools,  toil- 
ing and  bearing  the  burden  in  the  heat  of  the  day, 
while  he  is  regaling  himself  at  the  opera  or  admiring 
the  scenes  from  art  or  nature  from  his  dogcart  in  the 
park  or  driveway. 

"  While  the  author  is  wrestling  with  the  problem  of  disease. 
His  forte,  to  wheedle,  manipulate,  and  please. 

He  has  the  genius  or  inspiration  to  distinguish  be- 
tween conditions,  and  determine  beforehand  and  an- 
ticipate the  quality  of  fatality.  In  the  drawing-room 
his  smile  is  expansive  and  illuminated;  his  features 
are  mobile,  impressionable,  and  pleasing,  .\fter  cast- 
ing an  auspicious  horoscope  for  the  young  lady  at 
the  piano,  and  assuring  her  mother  that  youth  yet 
lingers  with  herself,  that  it  is  not  difficult  to  discern 
whence  her  daughter's  ready  wit  and  beauty  came,  he 
talks  of  the  opera,  what  constitutes  a  dancing  set, 
which  is  the  best  French  play,  criticises  the  latest 
novel,  and  anticipates  the  fashions  for  the  season;  he 
also  says  a  word  about  golf,  and  incidentally  mentions 
Newport  and  Lake  George.  These  varied  topics  form 
an  uninterrupted  chain:  the  subjects  blend  into  each 
other  like  the  coloring  in  a  landscape,  and  please  the 
eye  while  amusing  the  fancy. 

In  the  sick-chamber  upstairs  he  drops  his  light  and 
airy  fairy  ways.  His  face  is  a  picture  now  (a  verita- 
ble Jekyll-Hyde  transformation) — features  contracted, 
cold,  and  thoughtful;  language  measured  and  slow; 
manner  severe  and  aggressive.  He  is  diagnosing  the 
case.  His  ponderous  mind  is  like  a  sea  swept  by  the 
fury  of  the  gale.  The  intensity  and  concentration  of 
thought  are  terrible.  His  mental  perceptions  have 
grasped  and  solved  the  problem  ,  the  diagnosis  is  com- 
plete. He  apprehends  disaster,  though  there  is  no 
danger  signal  flying,  no  high  temperature,  no  rapid  or 
irregular  pulse,  no  respiratory  sigh  flashing  like  sheet 
lightning  with  ominous  torpedo-like  explosion,  and, 
with  gravit}-  mingled  with  emotion,  he  informs  the 
friends  of  the  patient  that  pneumonia  is  about  to  de- 
velop, but  he  thinks  it  can  be  aborted  or  diverted,  or, 
as  the  electricians  say  of  the  current,  '"grounded:"  so 
he  furnishes  the  conductor,  a  lightning-rod,  in  the 
shape  of  a  placebo,  gives  some  details  to  his  nurse, 
says  he  will  send  his  assistant  to  the  house  immedi- 
ately and  that  he  will  call  himself  in  the  evening, 
jumps  into  his  brougham,  and  is  driven  to  the  matinee. 
On  his  return  from  the  matinee  he  visits  a  flower  show 
at  the  grounds  of  the  Horticultural  Society.  At  home 
he  instructs  his  assistant  in  some  minor  details  and 
dispatches  him  again  to  the  sick-room.  This  assistant 
is  often  a  clever  fellow,  and  understands  his  business 
well.  He  is  ever  mindful  that  his  first  and  only  duty 
is  to  please  his  master.  To  this  end  he  is  diplomatic 
and  craft)';  nothing  to  affect  his  reputation,  nothing  to 
detract  from,  nothing  to  compromise  his  employer  ever 
falls  from  his  lips.  He  is  as  silent  as  a  sphinx, 
thoughtful  as  a  philosopher,  and  companionable  as  an 
owl. 

How  It  Affects  His  Success.  —  The  master  is 
drowned  on  a  yachting-cruise,  and  the  mantle  of  suc- 
cess falls  on  this  scholarly  hack.  He  puts  it  on,  but 
it  is  a  hideous  misfit.  He  would  like  to  wear  it,  but  it 
makes  him  look  so  ridiculous.  It  is  so  altogether  out 
of  proportion  that  he  is  not  certain  where  to  begin  in 
order  to  remedy  the  inequalities  and  restore  its  sym- 
metry. At  a  conclave  of  his  friends  it  is  decided  that 
a  change  in  construction  would  ruin  the  mantle. 
There  is  now  nothing  left  for  the  hack  but  to  wear  it 


228 


MEDICAL    RECORD. 


[August  14,  1897 


himself  or  give  it  away — but  it  will  fit  none  of  his 
friends;  a  spirit  of  loyalty  to  his  departed  leader, 
however,  prevents  him  from  pursuing  the  latter  course, 
and  he  dons  it  himself.  He  suddenly  recovers  his 
voice  and  grows  quite  loquacious.  He  is  called  pro- 
fessionally to  a  house,  not  unknown  to  him,  but  one 
that  his  lamented  predecessor  knew  so  well.  In  the 
drawing-room  he  talks  of  the  physical  aspects  of  the 
moon,  the  solar  spectrum,  and  tlie  belts  of  Jupiter,  drops 
a  few  words  in  commendation  of  Milton's  "  Paradise 
Lost''  and  Gibbon's  "Decline  and  Fall  of  the  Roman 
Empire,"  and  concludes  with  a  reference  to  Mun- 
kacsy's  "Christ  before  Pilate."  Upstairs  in  the  sick- 
room he  is  simplicity  itself,  and  readily  takes  the 
family  into  his  confidence.  He  declares  that  at  pres- 
ent there  is  no  danger,  that  it  will  be  four  or  five  days 
before  symptoms  are  sufficiently  developed  to  permit  a 
positive  diagnosis.  In  treatment  he  speaks  about  di- 
gestive ferments  and  assimilants;  he  also  speaks  like 
one  having  authority  on  leucoc\tosis  and  bacteriology. 
He  departs  with  quiet  dignity.  His  last  words  are : 
"  If  a  change  should  come  for  the  worse,  be  patient 
and  hopeful,  and  immediately  notify  me."  He  hails  a 
street  car,  and  alights  at  the  rooms  of  the  Historical 
Society. 

The  drawing-room  below  has  a  frosty  atmosphere 
from  his  presence  there.  His  dissertations  and  ad- 
monitions upstairs  fell  on  unsympathetic  ears.  He  is 
now  standing  alone,  no  shadow  of  greatness  to  hide 
him  from  the  fierce  criticism  that  beats  with  relentless 
fury  on  his  head.  The  shafts  of  slander  that  are 
hurled  at  him  from  feminine  tongues  strike  in  vital 
parts.  His  enemies  are  numerous  and  still  increasing. 
His  patients  are  one  by  one,  like  autumn  leaves,  fall- 
ing from  his  daybook;  they  drift  with  the  tide  of  suc- 
cess, while  he  is  left  high  and  dry  on  the  shore  of  dis- 
appointment and  despair,  to  ruminate  on  the  fact  that 
ability  and  skill  in  his  profession  are  only  a  small  part 
of  the  armamentarium  of  a  successful  physician,  and 
that,  though  he  may  masquerade  in  his  master's  clothes 
for  a  while,  he  will  in  time  be  discovered,  and  in  the 
end  his  defeat  and  humiliation  will  be  more  complete. 

Some  physicians  fail  who  are  thoroughly  equipped. 
They  possess  all  the  elements  of  success,  but,  unable 
to  control  or  to  utilize  the  force  that  is  in  them,  they 
are  overwhelmed  and  destroyed. 

"  \'ie\ved  his  own  pinion  on  the  fatal  dart, 
j.\nd  winged  the  shaft  that  quivered  in  his  heart." 

Others  fail  because  they  had  ideas  and  expectations 
of  easily  and  suddenly  acquired  wealth.  i'he  medical 
schools  are  to  a  great  extent  responsible  for  this  sort 
of  failure.  They  hold  out  great  expectations  to  the 
aspiring  medico,  and  often  fill  their  catalogues  with 
glittering  generalities,  which  speedily  evaporate  into 
thin  air.  The  student  is  charged  and  primed  in  the 
lecture  and  class  rooms  with  this  elusive  philosophy, 
and  longs  to  pluck  the  golden  fruit  that  he  sees  dang- 
ling in  the  orchard  of  popular  favor.  Rut  alas!  a 
rapidly  flowing  torrent  separates  him  from  the  reali- 
zation of  this  dream.  He  cannot  hear  the  roaring 
waters  as  they  are  precipitated  over  the  cataract,  or  see 
the  gulch  below;  but  the  rapid  pace  he  is  running 
will  bring  him  face  to  face  with  it  soon,  and  his  im- 
petus will  fling  him  into  the  whirling  eddv,  where  too 
often  these  troubled  waters  hide  him  and  his  blasted 
hopes.  He  perished  because  his  alma  mater  did  not 
sufficiently  instruct  him,  and  impress  the  fact  on  his 
mind  that  the  road  leading  to  success  is  hard  and 
rocky,  circuitous  and  full  of  inequalities,  abounding 
in  pitfalls  and  canons:  and  further,  that  eternal  vigi- 
lance is  not  only  the  price  of  liberty,  but  of  success 
as  well.  In  his  haste  to  acquire  wealth  and  fame  he 
failed  to  acquaint  himself  with  the  difficulties  to  be 
encountered  in  pursuit  of  these  objects. 


Success  in  the  practice  of  physic,  then,  depends  not 
on  the  knowledge  one  possesses  on  that  subject,  but 
on  the  nice  adjustment  of  the  various  mechanisms  that 
enter  into  a  perfect  whole.  The  mental  faculties  must 
be  rounded  out  by  a  keen  appreciation  of  human  na- 
ture, and  of  the  fact  that  while  this  human  nature  is  an 
element  to  be  considered  in  any  social  equation,  it  is 
especially  conspicuous  and  prominent  in  the  practice 
of  medicine. 

51    CHAKLT..S    StKEET. 

SOME  IMPORTANT  POINTS  FOR  CONSID- 
ERATION IN  THE  TREATMENT  OF  ACUTE 
LOBAR  PNEUMONI.\.' 

Hv    I.OLIS    F.AUGERES    HISIIOP.    .\.M.,    .M.D., 


CHAIK.\1AN  OF  THE  SECTION  ON 
MBDICINE;  MBMDEB  OF  T] 
PITAL,  NEUROLOGICAL  SOCIE 


^NERAL  MEDICINE,  NEW  VOKK  ACADEHY  or 
:  SOCIETY'  OF  ALUH.NI  OF  ST.  LUKH*S  HO»- 
r,    ETC. 


The  proceedings  of  our  medical  societies  are  some- 
times criticised  by  superficial  observers,  and  by  those 
who  do  not  take  an  earnest  part  in  the  work,  for  the 
frequent  recurrence  of  old  topics  and  the  absence  of 
novelty  and  originality.  Such  persons  mistake  the 
office  of  the  scientific  medical  society  and  the  motives 
of  those  workers  who  can  always  be  counted  upon  to 
express  freely,  honestly,  and  with  humility  what  they 
know  or  to  acknow  ledge  their  ignorance  of  any  subject 
that  may  be  brought  forward.  The  object  of  the  work 
is  more  to  crystallize  truth  than  to  disseminate  what  is 
new.  Such  novel  information  has  a  spreading  power 
in  itself  that  easily  carries  it  to  the  whole  profession. 
In  the  medical  societv'  men  gather  to  compare,  correct, 
and  fill  out  their  experience.  Here  the  immature 
views  of  young  men  germinate  and  develop,  while 
even  the  oldest  has  his  established  beliefs  pruned  into 
better  form  by  free  discussion. 

The  introduction  of  the  subject  of  pneumonia  with- 
out the  excuse  of  any  original  observations,  without 
any  new  statistics,  or  any  favorite  plan  of  manage- 
ment, requires  only  the  e.xcuse  that  we  are  still  seek- 
ing the  best  plan  of  treatment.  Every  physician  has 
some  mode  of  procedure  that  he  has  acquired  from  his 
preceptor  or  has  carried  from  his  hospital.  That  any 
one  shall  approach  the  treatment  of  a  case  of  acute 
lobar  pneumonia  with  confidence  of  a  successful  out- 
come is  impossible,  so  long  as  the  present  death  rate 
remains.  ,\  mortality  approaching  twenty-five  per 
cent.,  which  has  not  been  materially  diminished  in 
modem  times,  is  certainly  sufficient  excuse  for  free 
and  frequent  discussion. 

There  are  two  ways  in  which  the  treatment  of  dis- 
ease may  be  improved:  By  a  gradual  improvement  in 
the  details  of  treatment,  with  a  better  appreciation  of 
the  disease  and  an  improved  technique:  or  some  spe- 
cific treatment  may  be  discovered  suddenly  to  suf>- 
plant  all  previous  plans  and  inuned lately  reduce  mor- 
tality. The  improvement  in  the  treatment  of  typhoid 
fever  is  an  illustration  of  the  first;  diphtheria  is  an 
instance  of  the  second.  .\  number  of  specific  treat- 
ments of  pneumonia  are  claimed  each  year,  but  im- 
provement is  still  confined  to  the  elaboration  of  a  bet- 
ter technique. 

I  will  touch  upon  four  points — feeding,  the  preven- 
tion of  delirium,  hydrotherapy,  and  stimulation. 

.\s  to  diet.  In  acute  lobar  pneumonia  it  has  always 
seemed  to  me  that  the  tendency  was  rather  to  overfeed. 
It  is  questionable  whether,  in  the  acute  stages  of 
the  disease,  with  the  undoubted  accompanying  con- 
gestion of  the  abdominal  organs,  harm  is  not  often 
done  by  stuffing  the  stomach  with  milk  to  the  produc- 
tion of  large  quantities  of  gas  and  upward  pressure  on 

'  Read  l)efore  the  .New  Jersey  ,'^tate  Medical  Society  at  .Atlantic 
City,  June  22,  1S97. 


August  14,  1897] 


MEDICAL    RECORD. 


229 


the  diaphragm.  Now  and  again  a  feeble  voice  is 
raised  against  overfeeding  in  pneumonia.  The  lesson 
of  feeding  in  other  febrile  diseases  has  been  so  ^ell 
learned  that  the  shortness  of  the  course  of  pneumonia 
is  not  enough  considered.  There  are  undoubted  bene- 
fits in  restricted  diet  in  a  disease  so  acute.  Overfeed- 
ing means  a  consumption  of  physiological  force  in  the 
digestion  and  assimilation  of  food.  It  means  the  di- 
version of  so  much  energy  from  the  reparatorj-  forces 
of  the  body  to  the  digestive  forces.  It  means  throw- 
ing into  the  circulation  a  quantity  of  crude  food  prod- 
ucts that  must  be  taken  care  of.  It  means  the  pres- 
ence in  the  intestinal  canal  of  the  waste  matter  of  the 
food  that  must  be  gotten  rid  of.  The  patient  dying  in 
acute  pneumonia  does  not  die  from  a  lack  of  reserve 
force,  such  as  might  be  produced  by  a  system  of  stuffed 
feeding,  but  rather  from  the  failure  of  the  develop- 
ment when  needed  of  the  latent  force  already  existing. 
If  by  a  system  of  overfeeding,  such  as  would  produce 
this  more  remote  force,  part  of  our  stock  of  immedi- 
ately available  energy  is  used  up,  more  injur)-  than 
good  is  done.  It  is  just  as  if  the  captain  of  a  ship 
with  an  important  and  pressing  commission  should 
stop  to  replenish  the  coal  supply  on  the  wharf  when 
he  should  be  on  his  journey,  burning  the  supply  in  his 
well-filled  bunkers.  Diet  should  be  bland  and  moder- 
ate in  quantity.  It  would  seem  that  only  a  miscon- 
ception of  the  conditions  of  pneumonia  leads  to 
stuffing. 

There  is  no  disease  in  which  it  is  more  important 
to  discount  future  events.  An  acute  delirium  in  an 
alcoholic  patient,  when  fully  developed,  frequently 
means  a  fatal  termination.  The  feeble  power  of  drugs 
to  control  this  delirium,  short  of  paralyzing  the  patient 
with  dangerous  doses,  is  only  too  well  known.  If  at 
the  outset  of  pneumonia  in  an  alcoholic  case  we  fore- 
see that  the  day  of  delirium  is  bound  to  come,  we  can 
by  the  free  use  of  safe  sedatives  avoid  or  at  least  limit 
the  delirium  of  the  later  days. 

The  bromides  are  not  sufficiently  appreciated  for 
their  good  qualities  in  acute  disease.  Their  harmless- 
ness  has  been  so  impressed  upon  me  by  the  experience 
of  treating  a  large  number  of  epileptics,  who  took  con- 
tinually enormous  quantities,  that  it  has  seemed  desir- 
able to  consider  their  usefulness  in  other  conditions. 
The  reason  that  the  bromides  have  so  little  reputa- 
tion in  emergencies  compared  with  morphine,  chloral, 
hyoscine,  and  the  hypnotics,  is  that  they  have  been 
given  in  too  small  amounts.  Other  drugs  get  more  fair 
treatment.  We  push  them  until  we  accomplish  the  re- 
sult aimed  at,  or  until  the  appearance  of  some  danger 
symptom.  With  bromide,  single  doses  of  from  five  to 
thirty  grains  are  too  often  given,  and  then  resort  is 
had  to  some  other  expedient.  A  solution  of  bromide 
well  diluted  is  not  irritating  to  the  stomach.  It  re- 
sembles very  closely  in  its  chemical  and  physical 
properties  the  saline  salt  solutions  that  we  do  not  hes- 
itate to  put  directly  into  the  veins.  It  is  not  poi- 
sonous in  any  dose  that  any  one  would  possibly  ap- 
ply. Its  most  glaring  defects  are  the  size  of  the 
dose  and  the  slowness  of  the  results.  The  fear  of 
bromism  that  is  constantly  before  the  mind  rests  upon 
a  foundation  chiefly  of  tradition.  It  occurs  in  patients 
who  have  been  taking  large  quantities  for  a  long  time. 
«nd  is  the  result  not  simply  of  the  drug  itself,  but  of 
mixed  causes,  such  as  gastric  irritation  and  deficient 
elimination. 

If  the  alcoholic  pneumonia  patient  is  brought  from 
the  beginning  of  the  disease  under  the  influence  of 
bromide  in  efficient  quantities,  the  use  of  the  more 
powerful  and  dangerous  sedatives  at  a  later  period 
may  be  avoided.  After  delirium  is  once  thoroughly 
established  in  pneumonia,  bromide  is  a  drug  too  mild 
to  be  efficacious.  It  should  be  begun  in  the  very  be- 
ginning of  the  disease  in  alcoholics  and  given  freely, 


so  that  the  patient  stiall  get  from  one-half  ounce  to 
one  ounce  in  the  twenty-four  hours.  Lives  seem  to 
have  been  saved  in  alcoholic  cases  by  the  free  use  of 
bromides  from  the  beginning. 

The  third  point  in  the  treatment  of  pneumonia  that 
can  well  be  discussed  is  the  value  of  hydrotherapy. 
In  going  over  the  recent  literature  of  pneumonia  as 
found  in  the  later  te.xt-books  and  systems  of  medicine, 
a  restlessness  and  reaching  out  for  new  methods  is 
perceived  that  is  not  found  in  the  older  ones.  While 
we  do  not  find  among  the  conservative  men  who  are 
usually  selected  as  the  authors  of  these  books  one  who 
definitely  recommends  the  exclusive  use  of  hydrother- 
apy, still  nearly  all  point  to  it  as  a  possible  or  even 
probable  improvement,  and  quote  some  other  man  in 
support. 

The  great  problem  that  confronts  us  in  this  disease 
is  the  maintenance  of  the  circulation  in  spite  of  the 
obstruction  of  the  consolidated  lung.  To  get  the  best 
results  of  management,  we  must  regard  the  circulation 
as  a  whole,  not  concentrating  our  attention  entirely 
upon  the  heart  or  the  pulmonary  circulation  or  the 
systemic  circulation,  but  always  remembering  that 
what  benefits  one  part  of  the  circuit  cannot  but  affect 
favorably  the  other.  The  stimulation  of  the  heart  and 
the  use  of  vasodilators  to  relieve  its  burden  are  im- 
fwrtant,  but  hydrotherapy  is  not  frequently  enough  em- 
ploj^ed  in  combating  prostration  and  blood  stasis. 
The  difficulties  and  prejudices  to  be  overcome  before 
it  can  be  generally  adopted  in  pneumonia  are  so  great 
that  it  is  with  some  diffidence  that  one  undertakes  to 
break  ground.  Hydrotherapy  has  been  so  much  the 
property  of  men  who  have  prostituted  medical  science 
to  the  ends  of  mere  personal  profit  that  much  of  value 
has  been  lost  to  more  conservative  practitioners.  No 
one  who  has  once  witnessed  the  splendid  results  of 
systematic  cold  bathing  in  typhoid  fever  would 
be  willing  to  cut  off  from  this  resource  in  a  severe 
case.  In  the  same  way  in  pneumonia  the  effect  of  hy- 
drotherapy properly  adapted  to  the  condition  of  the 
patient  would  reduce  mortality  as  much  as  in  the  case 
of  typhoid  fever.  It  can  never  be  emphasized  enough 
that  the  value  of  hydrotherapy  extends  far  beyond  the 
limits  of  the  mere  reduction  of  temi>erature.  The 
effect  is  a  general  tonic  to  the  ners'ous  system,  rehabil- 
itating the  heat-controlling  forces  of  the  body  and 
restoring  the  tone  of  the  circulation.  To  accomplish 
these  results,  the  temperature  and  duration  of  the  bath 
must  be  properly  adapted  to  the  case  and  the  condi- 
tions present,  but  there  is  one  element  in  the  applica- 
tion of  bathing  that  is  of  so  much  importance  that 
one  is  almost  tempted  to  speak  of  the  treatment  as  tub 
rubbing  instead  of  tub  bathing.  While  in  the  bath 
the  patient  must  be  properly  rubbed  in  every  part  of 
his  body  by  a  sufficient  number  of  properly  trained 
attendants.  Without  the  rubbing  properly  carried  out, 
the  tub  bathing  in  an  acute  disease  is  indeed  the  fear- 
fully dangerous  procedure  that  it  is  often  supposed  to 
be  by  those  who  have  not  given  the  subject  mature 
consideration. 

The  Brand  method  of  treating  typhoid  fever  gives  a 
standard — the  bath  of  65'  F.,  the  rubbing  by  strong 
attendants  during  the  whole  time  of  immersion,  the 
immediate  removal  to  a  dry  bed,  the  precautions  that  a 
patient  should  never  be  bathed  when  the  feet  are  cold, 
and  that  cold  feet  after  a  bath  should  be  treated  by 
application  of  warmth. 

Every  man,  before  undertaking  the  treatment  of  dis- 
ease by  the  application  of  cold  water,  would  do  well 
to  follow  a  few  cases  of  typhoid  treated  by  this  method. 
Then  he  would  be  in  a  position  intelligently  to  depart 
from  the  set  system,  according  to  the  demands  of  each 
case.  Thus  the  bath  may  be  advantageously  modified 
by  only  half  covering  the  patient,  and  trusting  to  the 
attendants  to  apply  water  to  the  part  of  the  body  not 


230 


MEDICAL    RECORD. 


[August  14,  1897 


covered.  A  very  suggestive  paper  by  Dr.  P.  Gun- 
drum,  of  California,  in  the  Therapeutic  Gazette  of  last 
year,  emphasizes  the  importance  of  hydrotherapy  in 
pneumonia.  He  found  that  by  placing  a  blanket  in  the 
bath  under  the  patient  the  treatment  was  rendered  less 
objectionable.  He  states  that  in  his  experience  packs 
were  found  a  useful  adjunct  when  for  any  reason  fre- 
(luent  baths  were  difficult  to  give,  but  whenever  the 
temperature  went  above  103"  F.  he  resorted  to  the 
baths.  With  all  other  writers,  he  emphasizes  the  fact 
that  equal  in  value  with  the  reduction  of  temperature  is 
the  general  nervous  stimulus  of  the  cold  water  and  the 
rubbing.  The  effect  of  cold  water  in  health,  as  a  re- 
freshing and  stimulating  agent,  needs  to  be  remem- 
bered. 

Without  detriment  to  the  treatment  the  baths  may  be 
commenced  at  a  temperature  of  80'  or  90  "  F-.  and 
then  while  the  patient  is  being  thoroughly  rubbed  the 
temperature  may  be  reduced  by  the  addition  of  cold 
water.  This  lessens  the  shock  somewhat  with  sensi- 
tive persons. 

In  the  discussion  of  the  hydrotherapy  of  pneumo- 
nia, curiously  enough  we  come  once  more  upon  the 
old  question  of  heat  or  cold  in  the  treatment  of  dis- 
ease, emphasizing  once  again  the  only  possible  an- 
swer to  this  dispute  of  two  thousand  years'  standing— 
that  there  is  good  in  both.  The  ground  for  belief  is 
strong  in  the  experience  of  every  one  of  you  that  in 
pneumonia  heat  applied  to  the  chest  by  poultices,  hot- 
water  coils,  or  other  means,  has  a  beneficial  effect 
upon  the  morbid  processes  within  the  chest.  It  cer- 
tainly benefits  commencing  oedema  from  whatever 
cause,  and  is  said  to  hasten  the  cycle  of  the  pneumonic 
processes.  That  heat  is  good  I  firmly  believe;  on 
the  other  hand,  there  is  good  authority  from  some  of 
the  best  observers  in  the  world  that  cold  applied  to 
the  chest  in  pneumonia  has  also  the  power  of  influ- 
encing for  good  the  course  of  the  disease,  cutting 
short  the  processes  and  hastening  recovery.  Thus 
between  heat  and  cold  we  cannot  decide  absolutely, 
saying  one  is  good  and  the  other  bad.  It  is  even  pos- 
sible that  there  are  times  when  the  very  hot  bath  might 
benefit  a  desperate  case. 

In  the  Maternity  Hospital  I  have  frequently  stud- 
ied the  effect  of  such  immersion  in  new-born  children, 
in  whom  vitality  was  at  a  dangerously  low  ebb. 

The  effect  of  a  properly  adapted  bath  was  beauti- 
fully shown  in  the  case  of  a  child  of  seven.  The  child 
had  pneumonia  with  a  very  high  temperature  and  rapid 
pulse.  There  was  much  venous  stasis,  and  eve.rything 
seemed  to  be  going  wrong.  This  child  was  put  into 
a  bath  at  a  temperature  of  90°  F.,  and  thoroughly 
rubbed  for  a  period  of  about  fifteen  minutes.  When 
the  child  was  taken  out  of  the  tub  and  put  back  to  bed 
the  temperature  had  fallen,  the  breathing  was  quiet, 
the  pulse  improved,  and  the  whole  picture  had 
changed.  The  bathing  without  the  rubbing  would  not 
have  accomplished  any  such  result. 

In  a  discussion  in  the  section  on  general  medicine  in 
the  New  York  Academy  on  the  treatment  of  typhoid 
fever  by  cold  bathing,  the  influence  of  the  baths  as  a 
respiratory  stimulant  was  dwelt  upon  by  Dr.  A.  H. 
JJall.  It  would  seem  that  in  pneumonia  this  action 
should  be  advantageous.  Its  wonderful  tonic  effect 
upon  the  nervous  system,  equalizing  the  circulation  and 
bringing  about  piiysical  rest,  has  astonished  every  one 
who  has  had  the  opportunity  of  studying  fever  cases  so 
treated.  Increase  in  the  secretion  of  urine,  such  as  is 
a  constant  observation  in  fever  patients  who  are  taking 
baths,  would  suggest  improved  elimination  of  toxins. 
The  reports  of  the  treatment  of  pneumonia  in  which 
bathing  was  used  as  a  tonic  and  supportive  measure,  as 
opposed  to  merely  antipyretic  baths,  are  very  meagre. 
Professor  liozzolo  says:  "After  a  considerable  num- 
ber of  observations:   (i)  Such  baths  are  well  borne  in 


severe  cases;  they  never  produce  collapse.  {2)  They 
lower  temperature  rapidly  and  notably,  and  keep  it 
down  for  a  considerable  length  of  time;  they  may  be 
repeated  every  three  hours.  (3)  The  mortality  per 
cent,  among  patients  treated  thus  with  cold  bath  is 
among  the  lowe.st  recorded  under  any  form  of  treat- 
ment." ' 

The  fourth  and  last  point  in  pneumonia  is  the  circu- 
lation.    Every  thoughtful  physician  has  a  philosophy 
of  his  own  that  guides  him  in  the  choice   of  means  of 
stimulation.     The  direct  care  of  the  heart  is  equal   in 
importance  to  the  attention  to  delirium  and  the  destruc- 
tive forces  of  high  temperature.      Every  one  who  has 
watched  a  patient  with  pneumonia  from   the  onset  of 
the  disease  to  a  termination  has  felt  that  the  heart  was 
the  organ   upon   which   the   brunt  of   the  battle  had 
fallen.     There  is  no  question  of  equal  general  import- 
ance or  greater  difficulty  than  that  of   heart  stimula- 
tion.    It  is  a  problem  to  be   approached  with  the  ut- 
most humilitv,  because  there  are  many   points  upon 
which  it  must  honestly  be  confessed  that  definite  facts 
are  not  known.     The  mechanism  of  the  heart  and  cir- 
culation are  admirably  adapted  to  fulfil  their  functions. 
The  heart   has   its  wonderful  nerve   supply,  both  from 
the  central  nervous  system  and  from  the  ganglia  within 
itself.     The  blood-vessels  are  governed  by  the  marvel- 
lous vasomotor  system,  with  its  millions  of  constrictors 
acting  as  a  system  of  regulators  whose  perfection  sur- 
passes the  comprehension    of  man.     The    automatic 
action  of  the  respiratory  and  cardiac  nervous  centres 
also  elude  our  complete  understanding.      In  health  the 
slightest  mental  or  physical  exertion  is  followed  by  an 
increased  effort  on  the  part  of  the  heart  and  a  corre- 
sponding deepening  of    respiration.     When  anything 
happens  to  cause  obstruction  to  the  breathing  or  circu- 
lation, the  heart  immediately  responds   with  a  large 
increase  of  labor  to  overcome  the  obstruction,  and  the 
lungs  increase  their  activity  to  an  even  greater  degree. 
Now,  nature  having  provided  this  wonderful   plan  of 
increased  activity  to  meet  emergencies,  the  question 
of  stimulation  resolves  into  an  inquiry  as  to  whether 
we  can  by  artificial  stimulants  supplement  with  advan- 
tao-e  the  natural  stimulus  that  comes  from  the  nervous 
system.     We  come  face  to  face  with  the  possibility  of 
injudicious  stimulation,  or  stimulation  at  the  wrong 
time,  which  may  exhaust  the  natural  resources  so  that 
they  will  not  respond  at  a  more  critical  period.     On 
the  other  hand,  leaving  stimulation,  pure  and  simple, 
out  of  the  question,  can  we  not  control   the  action  of 
the  heart  and  conserve  its  forces  to  calm  the  excessive 
stimulation  of  an  excited  nervous  system,  and  in  this 
way  reserve  the  force  required  to  tide  over  a  critical 
period?      In  addition   to   stimulation   and  control,  it 
would  seem  that  nutrition  of  the  heart  was  of  great 
importance.     Particular  drugs  cannot  be  discussed  at 
much  length.      The  best  general  plan  of  management 
of  the  heart  in   pneumonia  is  to  conserve  its  forces 
early  in  the  disease  by  the  control  of  delirium  by  the 
use  of  a  proper  antipyretic  but  at  the  same  time  tonic 
system  of  bathing,  and  by  the  use  of  such   drugs  as 
will  relax   the  general  circulation  and  diminish  the 
hyperactivity  of  the  iieart.     Undoubtedly  with  all   its 
disadvantages  the  aconite  group  of  drugs  affords  very 
valuable  properties. 

The  importance  of  the  philosophical  consideration 
that  it  is  the  right  side  of  the  heart  instead  of  the  left 
which  is  chielly  in  danger  of  exhaustion  seems  to  im- 
press itself  with  difficulty  upon  the  profession.  Dr. 
Andrew  H.  Smith  has  for  a  long  time  advocated  the 
study  of  the  pulmonic  second  sound  as  a  guide  to 
prognosis.  Still  it  is  not  perfectly  clear  that  we  have 
any"  means  at  hand  by  whicii  we  can  stimulate  one 
part  rather  than  another,  nor,  indeed,  with  all  that  has 
been  studied  and  written,  is  the  mechanism  of  the 
'  l_;a//<.-Ua  Medica  Italiaua,  luly  2.  iSSi. 


August  14,  1897] 


MEDICAL    RECORD. 


231 


circulation  so  well  understood  that  we  can  proceed  to 
a  very  great  degree  in  the  treatment  of  particular  parts 
of  it  with  confidence.  After  all  is  said,  when  we  re- 
call to  mind  the  impression  made  upon  us  by  a  critical 
case  of  pneumonia  at  the  critical  period,  it  is  of  an 
elTort  to  apply  cardiac  and  pulmonary  stimulants  with 
the  object  of  tiding  our  patient  over.  Before  my  mind 
is  a  patient  surrounded  by  the  paraphernalia  of  the 
sick-room  and  the  an.xious  attendants,  but  more  dis- 
tinctly there  stands  out  in  my  imagination  a  picture  of 
a  struggling  heart  and  certain  alkaloids,  notably 
strychnine,  atropine,  digitalin,  and  cocaine,  that  must 
be  applied  hour  by  hour  to  keep  this  heart  from  fail- 
ing in  its  task.  After  one  has  cared  for  a  case  like 
this,  it  is  often  difficult  afterward  to  describe  just  what 
doses  were  given,  as  each  was  administered  according 
to  immediate  indications.  In  Wood  and  Fitz's  new 
text-book  on  practice,  we  find  the  following  recom- 
mendation that  appeals  to  our  judgment  of  stimulation 
in  a  severe  case,  the  drug  to  be  given  hypodermically 
if  not  well  borne  by  the  mouth:  Strychnine,  one-twen- 
tieth grain,  every  four  hours,  and  cocaine,  one-sixth 
grain,  every  four  hours,  alternating  so  that  one  or  the 
other  is  given  every  two  hours.  The  strychnine  may 
be  slowly  increased  to  one-fourteenth  grain  and  the 
cocaine  to  one-half  grain.  Dr.  Wood  thinks  he  has 
seen  life  saved  by  even  larger  doses.  Certainly  a 
well-thought-out  and  courageously  applied  plan  of 
stimulation  offers  the  only  hope  for  critical  cases. 

Time  compels  the  omission  of  the  discussion  of  the 
place  of  alcohol,  belladonna,  nitroglycerin,  and  digi- 
talis in  pneumonia.  Nor  can  the  place  of  bleeding  be 
touched  upon,  but  these  will  doubtless  be  taken  up  in 
the  discussion. 

Faith  in  the  value  of  hydrotherapy  in  pneumonia  is 
more  the  gradual  growth  of  time  and  thought  than  a 
belief  founded  upon  any  special  line  of  experiment  or 
the  teaching  of  any  single  person.  The  literature, 
though  curiously  meagre  considering  its  importance, 
is  entirely  favorable  to  the  views  expressed  above. 
Many  occasions  arise  in  the  course  of  pneumonia 
when  a  tub  bath  of  moderate  temperature,  carried  out 
with  skilful  rubbing,  would  benefit  the  patient  more 
than  a  great  deal  of  drug  stimulation.  To  carry  on 
such  a  method  requires  courage,  apparatus,  and  skill. 
In  advocating  it  at  this  time  we  can  only  hope  to 
stimulate  thought,  with  the  desire  that  means  may  be 
found  to  adopt  this  important  measure  in  practical 
medicine.  \Vhen  reason  is  con\inced,  no  valuable 
addition  to  therapeutics  must  be  discarded  on  account 
of  apparent  difficulty  or  pre-existing  prejudice.  It  was 
my  privilege  to  witness  the  introduction  of  the  cold- 
bath  treatment  of  typhoid  fever  into  a  large  hospital, 
and  I  have  listened  to  all  the  objections  that  will  be 
raised  again  in  the  application  of  hydrotherapeutics  to 
pneumonia,  and  yet  we  have  all  seen  this  method  ac- 
cepted by  every  one  who  has  had  the  opportunity  of 
observing  cases  under  treatment. 

Until  an  antitoxin  is  discovered,  the  treatment  of 
pneumonia  must  be  in  its  final  analysis  expectant,  and, 
valuable  though  it  may  have  been  to  review  the  \a- 
rious  means  by  which  the  patient  is  protected  from 
mortal  injury  by  the  disease  and  supported  to  resist  it, 
still  in  the  application  of  each  and  every  one  of  these 
measures  the  judgment  of  the  individual  physician  at 
the  particular  time  must  have  influence  greater  than 
the  voice  of  any  authority.  It  is  this  quality  of  judg- 
ment that  is  found  in  its  most  excellent  development 
in  the  general  practitioner  occupying  the  field  a  little 
removed  from  the  atmosphere  of  theoretical  teaching 
and  extreme  specialism.  To  such  men  it  is  a  privi- 
lege and  an  advantage  to  bring  the  results  of  thought, 
study,  and  research,  and  from  them  I  trust  my  conclu- 
sions may  be  reflected  back  with  the  additional  light 
of  well-digested  experience. 


IN  THE  TREATMENT  OF  APPENDICITIS,  IS 
THE  FREE  USE  OF  THE  KNIFE  NECES- 
SARY? ' 

By   G.    H,    BALLERAV,    M.D.. 


FORMERLY  SURGEON  TO  THE  WOMAN  S  HOSPITAL,  NEWARK,  N.  J. J  GVN.fi- 
COLOGIST  TO  THE  GENERAL  HOSPITAL  AND  TO  ST.  JOSEPH'S  HOSPIT.^L, 
OBSTETRICIAN  TO  THE  MATERNITY  HOSPITAL,  PATERSON,  N.  J.;  FELLOW 
OF  THE   BRITISH   GVN.tCOLOGICAL   SOCIETY'. 

Mr.  President  and  Gentlemen:  Some  years  ago  1 
would  have  entered  upon  this  discussion  with  a  good 
deal  of  self-confidence;  to-day  1  approach  it  with  a 
great  deal  of  self-mistrust,  for  I  cannot  help  feeling 
that  the  more  I  see  of  appendicitis  the  less  I  know- 
about  it.  I  shall  endeavor  to  confine  my  remarks  to 
answering  the  question  propounded  by  your  commit- 
tee, viz. :  "  In  the  treatment  of  appendicitis,  is  the 
present  free  use  of  the  knife  necessary?" 

The  question  cannot  be  answered  offhand  for  the 
reason  that  every  case  of  appendicitis  is  a  law  unto 
itself;  and  while  in  one  class  of  cases  the  free  and 
early  use  of  the  knife  is  absolutely  necessary,  in  the 
other  class  the  use  of  the  knife  is  unnecessary  and 
therefore  unjustifiable.  At  the  outset  it  is  important 
to  bear  in  mind  the  difl^erent  varieties  of  appendicitis 
actually  met  with  in  practice. 

Appendicitis  presents  itself  under  five  dift'erent 
forms,  as  follows:  ist.  Acute  perforative  appendicitis 
with  ditTuse  general  peritonitis.  2d.  Acute  simple, 
catarrhal,  or  interstitial  appendicitis  with  circum- 
scribed fibrinous  peritonitis.  3d.  Acute  perforative 
appendicitis  with  localized  purulent  peritonitis.  4th. 
Relapsing  appendicitis.     5th.   Recurrent  appendicitis. 

Of  these  the  first,  third,  and  fourth  varieties  are  the 
most  dangerous  to  life.  Recurrent  appendicitis  is 
probably  the  chronic  form  of  what  was  originally  an 
attack  of  acute  or  subacute  appendicitis  with  circum- 
scribed plastic  peritonitis.  This  at  least  is  the  con- 
clusion at  which  I  have  arrived  from  the  observation 
of  the  cases  occurring  in  my  own  practice  as  well  as 
those  occurring  in  the  practice  of  my  hospital  col- 
leagues whose  operations  I  have  witnessed.  In  most 
cases  of  recurrent  appendicitis  it  will  be  found  that 
the  original  attack  was  not  very  severe.  It  lacked  the 
profound  abdominal  shock,  pinched  countenance,  li- 
vidity  of  surface,  retracted  abdomen,  and  early  and 
persistent  vomiting  of  acute  perforative  appendicitis 
with  diffuse  general  peritonitis;  it  also  lacked  the 
high  temperature  and  frequent  but  comparatively  full 
pulse  of  acute  perforative  appendicitis  with  circum- 
scribed purulent  peritonitis.  It  was  in  fact  a  moder- 
ately acute  or  subacute  appendicitis,  catarrhal  or 
interstitial,  with  localized  fibrinous  peritonitis. 

.\fter  the  subsidence  of  the  acute  symptoms  the  ex- 
udation is  generally  in  great  measure  absorbed,  leav- 
ing only  a  small,  elongated,  indurated  mass  in  the 
region  of  the  appendix,  which  can  be  easily  felt  for 
several  weeks  after  the  patient  is  convalescent. 

The  appendix  as  a  rule  remains  adherent  to  what- 
ever organ  or  structure  it  was  in  contact  with  at  the 
time  of  the  invasion.  It  is  often  bent  upon  itself;  its 
walls  are  generally  thickened  and  indurated,  and  its 
cavity  is  sometimes  dilated,  sometimes  sacculated,  and 
contains  a  thick  mucus  or  caseous-like  substance. 
Stercoral  concretions  are  rarely  found  in  the  appendix 
in  recurrent  appendicitis,  whereas  I  believe  that  they 
are  almost  a  sine  ijiia  mvi  of  relapsing  appendicitis. 
To  my  mind  recurrent  appendicitis  is  the  analogue  of 
catarrhal  or  interstitial  salpingitis  with  limited  pelvic 
peritonitis.  The  pathological  changes  are  the  same  in 
both;  the  symptoms  sometimes  so  closely  resemble 
each  other  that  right-sided  salpingitis  is  sometimes 
mistaken  for  appendicitis  and  vice  versa.      But  owing 

'  Read  at  the  annual  meeting  of  the  New  Jersey  State  Medical 
Society,  June  23,  1897. 


MEDICAL    RECORD. 


[August  14,  1897 


to  the  reflex  intestinal  disturbances  set  up  by  a  dis- 
eased and  adherent  appendix,  its  removal  may  be 
necessary  for  pathological  changes  which  would  hardly 
justify  a  resort  to  salpingotomy.  The  limits  of  this 
discussion  will  not  permit  me  to  enter  in  detail  upon 
the  pathological  changes  which  occur  in  the  various 
forms  of  appendicitis.  But  as  a  proper  understanding 
of  the  clinical  differences  which  present  themselves  to 
the  observation  of  the  intelligent  practitioner  can  be 
obtained  only  through  a  clear  idea  of  the  pathological 
changes  taking  place  in  the  appendix  and  adjacent 
structures,  I  shall  briefly  pass  in  review  the  morbid 
processes  peculiar  to  each  of  the  varieties  above  enu- 
merated. 

Our  knowledge  of  the  pathology  of  appendicitis  has 
been  derived  rather  from  the  obser\'ations  of  practical 
surgeons  in  the  operating-room  than  from  those  of 
pathologists  on  the  post-mortem  table.  To  .American 
surgeons  is  due  the  credit  of  having  evolved  the  true 
pathology  of  the  appendix.  Their  operations,  often 
undertaken  within  a  few  hours  after  the  manifestation 
of  symptoms,  enabled  them  to  appreciate  the  structural 
changes  which  characterized  the  early  stages  of  appen- 
dicitis, whereas  the  older  writers  could  describe  only 
the  advanced  and  complicated  morbid  processes  ob- 
served after  death.  American  physicians  have  also 
contributed  largely  to  our  knowledge  of  this  subject; 
and  prominent  among  these  is  Reginald  Fitz,  of  Eos- 
ton.  It  must  not  be  forgotten,  however,  that  to  Melier, 
of  France,  we  owe  all  that  we  know  of  the  disease 
under  consideration ;  for  it  was  he  who  first  brought 
order  out  of  chaos  and  taught  that  the  diseases  previ- 
ously described  as  typhlitis  and  perityphlitis  were  in 
reality  appendicitis,  as  the  morbid  process  always  orig- 
inated in  the  appendix.  Before  the  publication  of 
Melier's  observations  the  appendix  vermiformis  was 
credited  w^ith  being  an  organ  of  little  or  no  import- 
ance, the  lesions  of  w^hich  often  passed  unnoticed  in 
the  autopsy  room.  Therefore,  all  honor  to  the  bril- 
liant Frenchman  to  whom  the  medical  profession  and 
suffering  humanity  owe  a  debt  of  gratitude  which  can 
never  be  paid. 

Whatever  may  be  the  results  of  perforative  appen- 
dicitis, its  cause  is  alwavs  the  same,  viz. :  the  penetra- 
tion into,  and  impaction  within,  the  cavity  of  the 
appendix  of  a  foreign  body — generally  a  stercoral  con- 
cretion.j  Many  foreign  bodies  have  been  found  in  the 
appendix;  but  all  foreign  bodies  other  than  ster- 
coral concretions  are  found  in  only  a  comparatively 
small  number  of  cases  of  perforative  appendicitis. 
When  a  hard  foreign  body  of  irregular  shape  pene- 
trates into  the  cavity  of  the  appendix  it  produces  a 
condition  of  irritabi lit)'  of  the  gastro-intesiinal  tract 
which  is  accompanied  by  colicky  abdominal  pains  and 
sometimes  vomiting,  'i'liis  condition  is  exactly  anal- 
ogous to  that  which  is  produced  by  the  impaction  of  a 
gall  stone  in  tlie  common  bile  duct  or  of  a  renal  cal- 
culus in  the  ureter.  .\nd  as  those  conditions  are 
spoken  of  as  biliary  and  renal  colic,  so  this  condition 
may  properly  be  called  appendicular  colic.  The  signs 
and  symptoms  which  characterize  appendicular  colic 
are  abdominal  pain,  sometimes  vomiting,  tenderness 
over  McBurney's  point,  and  rigidity  of  the  right  rectus 
abdominis  muscle.  Under  the  influence  of  the  con- 
tractions of  the  walls  of  the  appendix  the  foreign  body 
may  be  forced  back  into  the  cai'cum  and  the  symptoms 
may  disappear  as  ijromptly  as  those  of  renal  colic  after 
the  passage  of  the  obstructing  calculus  into  the  blad- 
der. But  if  the  concretion  remains  tightly  wedged 
between  the  opposing  walls  of  the  appendix,  what 
happens?  Well,  two  things  happen:  first,  we  have 
an  obliteration  of  the  orifice  of  communication  between 
the  appendix  and  ca*cum;  second,  there  results  a  com- 
pression of  the  walls  of  the  appendix  and  consequentlv 
an  interference  with  tiie  circulation  in  the  vessels  con- 


tained in  those  walls.  The  obliteration  of  the  orifice 
results  in  the  accumulation  of  the  products  of  the 
glandular  secretion  of  the  mucous  lining  of  the  appen- 
dix and  distention  of  its  cavit)-,  while  from  the  com- 
pression of  the  vessels  results  a  diminution  of  the 
vitality  of  the  organ.  But  the  obstruction  and  com- 
pression are  not  sufficient  in  themselves  to  accomplish 
the  process  of  ulceration  and  perforation ;  the  inter- 
vention of  a  third  factor  is  necessary  to  bring  about 
destruction  of  the  anatomical  elements  of  the  walls  of 
the  appendix.  This  third  factor  is  found  in  the  pres- 
ence of  large  numbers  of  bacteria,  which  invade  the 
tissues  already  weakened  and  devitalized  by  the  inter- 
ference with  the  blood  supply,  and  complete  the  work 
of  destruction. 

When  the  process  of  ulceration  and  perforation  is  so 
rapid  that  nature  has  no  time  to  throw  up  protective 
barriers  of  lymph  around  the  appendix — between  it 
and  the  general  peritoneal  cavity — the  disease  presents 
itself  in  its  most  deadly  aspect.  This  variety  of  ap- 
pendicitis is  known  as  acute  perforative  appendicitis, 
and  is  always  followed  immediately  by  diffuse  general 
septic  peritonitis.  In  cases  in  which  the  process  of 
ulceration  goes  on  more  slowly,  an  effusion  of  plastic 
lymph  occurs  which  binds  the  appendix  to  contiguous 
structures  and  thus  protects  the  general  pertioneal  cav- 
ity from  the  sudden  extravasation  of  the  contents  of 
the  diseased  appendix.  This  effusion  of  lymph  is  the 
result  of  a  circumscribed  plastic  peritonitis.  As  the 
destructive  process  in  the  walls  of  the  appendix  goes 
on,  a  focus  of  suppuration  develops.  The  collection 
of  pus  surrounds  the  appendix,  which  occasionally 
forms  a  portion  of  the  abscess  wall.  At  times  when 
the  abscess  is  opened,  the  appendix  is  found  lying 
loose  in  its  cavity,  having  been  entirely  separated 
from  the  ca;cum  in  the  form  of  a  slough.  Cases  are 
occasionally  met  with  in  which  after  the  existence  of 
well-marked  evidences  of  appendicitis  the  symptoms 
gradually  subside,  to  recur  after  an  indefinite  period 
of  time.  The  second  or  third  attack  may  result  in  the 
formation  of  an  abscess  which  contains  a  stercoral 
concretion,  and  occasionally  the  de'bris  of  the  sphace- 
lated appendix.  These  are  the  cases  which  I  would 
classify  under  the  head  of  relapsing  appendicitis.  It 
would  seem  probable  that  in  these  cases  the  stercoral 
concretion — which  is  the  real  thorn  in  the  flesh — ex- 
cites the  morbid  process,  which  proceeds  to  a  certain 
point  and  then  Ijecomes  quiescent.  Later,  without 
any  appreciable  cause,  the  fire  becomes  rekindled  and 
the  disease  goes  on  until  gangrene  and  destruction  of 
the  appendix  and  abscess  result.  In  the  early  stage 
of  this  class  of  cases  there  has  been  an  effusion  of 
plastic  lymph  which  protects  the  general  peritoneal 
cavity  so  long  as  the  walls  of  the  abscess  do  not  give 
way  and  allow  its  contents  to  escape  into  the  cavity  of 
the  peritoneum.  \\'hen  suppuration  occurs,  the  loca- 
tion of  the  abscess  will  depend  upon  the  position  of 
the  appendix  at  the  moment  of  the  attack.  The  nor- 
mal position  of  the  appendix  varies  in  different  indi- 
viduals. While  its  upper  portion  is  attached  to  the 
posterior  and  inner  border  of  the  caput  coli,  its  free 
extremity  seems  to  enjoy  a  considerable  degree  of  lib- 
erty, and  consequently  cannot  be  expected  to  be  found 
always  in  the  same  place.  The  result  of  a  large  num- 
ber of  autopsies  shows  that  in  a  very  large  proportion 
of  cases  the  appendix  is  in  contact  witii  the  posterior 
surface  of  the  caecum  and  the  cellular  tissue  of  the 
iliac  fossa.  If  perforation  occurs  in  a  case  of  this 
sort,  the  resultiJig  abscess  will  be  in  the  subperitoneal 
cellular  tissue  of  the  iliac  region,  and  the  collection 
of  pus  most  easily  reached  at  the  outer  margin  of  the 
Cfecum.  The  appendix,  if  long,  may  dip  down  into 
the  pelvis  and  may  be  adherent  to  the  rectum,  or,  in 
the  female,  to  the  ovary.  Fallopian  tube,  or  broad  liga- 
ment.     It  is  sometimes  found  adherent  to  several  loops 


August  14,  1897] 


MEDICAL    RECORn. 


233 


of  small  intestine  high  up  in  the  abdomen.  Should 
perforation  and  suppuration  occur  under  such  circum- 
stances, the  practitioner  might  easily  be  deceived  as 
to  the  nature  and  origin  of  the  resulting  abscess.  In 
acute  catarrhal  or  interstitial  appendicitis  with  limited 
plastic  peritonitis  the  changes  in  the  appendi.x  consist 
in  turgescence  and  thickening  of  its  walls,  and  dilata- 
tion of  its  cavit}'  with  a  viscid  mucous  or  semi-piuTi- 
lent  fluid.  The  contiguous  coils  of  intestine  are  ad- 
herent to  it  and  to  each  other.  When  of  recent  date 
these  adhesions  are  easily  broken  down  with  the  fin- 
ger. This  form  of  appendicitis  usually  terminates  by 
resolution,  the  plastic  effusion  being  gradually  ab- 
sorbed. But  if  the  disease  in  the  walls  of  the  appen- 
dix is  verj'  extensive,  subsequent  attacks  are  likely  to 
occur,  constituting  tj^pical  recurrent  appendicitis.  In 
acute  perforative  appendicitis  the  process  of  gangrene 
and  ulceration  of  the  appendix  may  go  on  so  insidi- 
ously that  no  marked  symptoms  occur  until  perforation 
has  actually  taken  place.  This  is  most  likely  to  occur 
in  cases  in  which  a  stercoral  concretion  becomes  im- 
pacted in  the  cavit)-  of  an  appendix  previously  the 
seat  of  interstitial  inflammation,  resulting  in  a  loss  of 
sensibility  of  the  organ. 

Symptoms — The  symptoms  of  appendicitis  var}' 
with  the  t)'pe  of  the  disease.  In  its  most  acute  form 
perforative  appendicitis  presents  the  following  symp- 
toms: sudden  acute  abdominal  pain,  beginning  per- 
haps in  the  right  iliac  fossa  but  rapidly  spreading  over 
the  whole  abdomen;  the  countenance  is  pinched;  the 
surface  cool  and  sometimes  livid;  the  abdomen  is  re- 
tracted and  the  right  rectus  muscle  rigid.  Vomiting 
is  an  early  and  persistent  symptom  and  is  sometimes 
accompanied  by  singultus.  The  character  of  the  vom- 
iting differs  from  that  accompanying  the  other  forms 
of  appendicitis.  It  is  more  frequent  and  persistent, 
and  often  resembles  the  vomiting  due  to  intestinal  ob- 
struction. An  obstinate  constipation  is  often  present. 
The  pulse  becomes  frequent  early  in  the  attack.  It 
may  vary  from  120  to  130,  140,  or  150,  and  as  a  rule 
it  is  a  pulse  of  low  tension.  The  expression  of  the 
face,  when  not  altered  by  the  injudicious  administra- 
tion of  opium,  is  indicative  of  abdominal  shock.  The 
facies,  the  pulse,  and  the  vomiting  are  the  three  symp- 
toms which  enable  us  to  recognize  early  this  h)"per- 
acute  form  of  perforative  appendicitis.  Tenderness 
on  pressure  over  McBurney's  point  is  as  a  rule  much 
more  marked  than  at  any  other  point  of  the  abdomen. 
The  temperature  may  not  be  above  normal  in  the  early 
stage;  at  times  it  is  subnormal,  but  when  the  perito- 
nitis has  become  general  it  may  rise  to  102''  or  103' 
F.,  although  it  generally  keeps  below  102^  F.  As  the 
disease  progresses,  the  abdomen  becomes  distended; 
the  vomiting  becomes  almost  incessant;  the  pulse 
more  and  more  frequent,  and  finally  imperceptible, 
and  the  patient  sinks  and  dies  from  exhaustion  and 
sepsis. 

In  perforative  appendicitis  with  encysted  piu'ulent 
peritonitis  the  pulse  may  reach  120  or  more  at  an 
early  stage,  and  the  temperature  in  the  evening  may 
exceed  104'  F.,  especially  in  young  subjects.  There 
may  be  vomiting,  but  it  is  not  persistent,  and  as  a  rule 
yields  readily  to  intelligent  medication  and  alimenta- 
tion. Constipation  if  present  yields  to  gentle  laxa- 
tives or  carefully  administered  enemata.  The  absence 
of  persistent  vomiting,  obstinate  constipation,  frequent 
adynamic  pulse,  and  pinched  anxious  countenance 
will  serve  to  distinguish  this  from  the  hyperacute  form 
of  perforative  appendicitis  in  the  early  stage.  Tender- 
ness over  the  region  of  the  appendix  and  rigidit)'  of 
the  right  rectus  muscle  are  common  to  this  and  the 
other  forms  of  appendicitis.  As  the  disease  pro- 
gresses, a  well-marked  tumefaction  develops  in  the 
neighborhood  of  the  appendix.  This  tumefaction  is 
due  to  the  presence  of  pus,  and  may  continue  to  in- 


crease until  the  abscess  bursts  into  the  peritoneal  cav- 
ity or  elsewhere,  unless  the  surgeon  intervenes. 

In  catarrhal  or  interstitial  appendicitis  with  limited 
plastic  peritonitis  the  pulse  is  never  verj-  frequent  and 
the  temperature  rarely  goes  above  102^  F.  The  morn- 
ing temperature  is  generally  below  100^  F.  The  pulse 
rarely  reaches  no.  The  expression  of  the  counte- 
nance is  good.  There  may  be  tenderness  over  the  ap- 
pendix, and  there  generally  is  more  or  less  abdominal 
pain;  but  the  pain  is  rarely  very  severe.  Rigidit}-  of 
the  right  rectus  is  generally  present.  After  a  few 
days  a  greater  or  less  tumefaction  in  the  region  of  the 
appendix  develops,  due  to  the  agglutination  of  coils  of 
small  intestine  to  the  appendix  by  fibrinous  exudation. 

Treatment. — The  first  indication  in  the  treatment 
of  appendicitis  is  rest  The  patient  should  be  put  in 
bed  and  closely  watched  in  order  to  determine  early 
the  true  nature  of  the  case.  No  food,  except  some 
form  of  animal  broth,  should  be  given.  Anodynes 
should  not  be  administered,  as  they  tend  to  mask  the 
sj-mptoms  and  create  doubt  in  the  mind  of  the  prac- 
titioner as  to  the  form  of  disease  that  he  is  dealing 
with.  It  is  of  vital  importance  that  the  t}"pe  of  the 
disease  should  be  recognized  at  the  earliest  possible 
moment,  for  upon  a  correct  appreciation  of  the  nature 
of  the  case  the  success  of  the  treatment  depends.  If 
the  case  prove  to  be  one  of  acute  perforative  appendi- 
citis with  incipient  diffuse  general  peritonitis,  the  ab- 
domen should  be  opened  immediately  in  the"  median 
line,  the  appendix  excised,  the  abdominal  cavit}'  thor- 
oughly flushed  with  hot  saline  solution,  a  glass  drain- 
age tube  inserted,  and  the  wound  closed.  Drainage  is 
absolutely  necessary  in  these  cases,  as  the  peritonitis 
is  always  septic.  In  perforative  appendicitis  with 
encysted  purulent  peritonitis,  suppuration  rarely  oc- 
curs before  the  fifth  day.  and  rupture  of  the  resultant 
abscess  into  the  peritoneum  seldom  takes  place  before 
the  ninth  day.  The  rapidit}"  of  the  suppuration  proc- 
ess bears  a  direct  relation  to  the  severity  of  the  gen- 
eral symptoms — the  more  severe  the  general  symptoms 
the  earlier  the  formation  of  pus.  If  the  temperature 
reaches  104^  F.  every  evening  for  several  successive 
days  and  does  not  fall  below  102"  F.  in  the  morning, 
while  the  pulse  keeps  at  about  120  and  there  is  some 
tumefaction  in  the  region  of  the  appendix,  suppuration 
as  early  as  the  fifth  day  is  probable,  and  operation 
should  not  be  deferred  beyond  the  morning  of  the  sev- 
enth day.  If  the  evening  temperature  does  not  exceed 
103"  F.,  and  the  morning  temperature  loi'  F.,  the 
pulse  var}-ing  from  104  to  116  and  the  local  swelling 
not  increasing,  operation  may  be  safely  deferred  until 
the  ninth  day.  Exceptions  to  this  rule  will  be  rare. 
If  from  the  sLxth  to  the  ninth  day  there  is  some  im- 
provement in  the  general  symptoms  but  no  improve- 
ment in  the  local  signs,  or,  on  the  contrary-,  an  increase 
in  the  local  swelling,  the  surgeon  should  not  be  de- 
ceived by  the  apparent  improvement;  he  should  pro- 
ceed to  operate  without  delay. 

Acute  Catarrhal  Appendicitis Cases  of  acute  ca- 
tarrhal or  interstitial  appendicitis  with  circumscribed 
plastic  peritonitis  do  not  call  for  operative  interfer- 
ence. Such  cases  are  fatal  only  through  the  officious- 
ness  of  the  doctor.  They  probably  constitute  fort}- 
per  cent,  of  all  the  cases  of  appendicitis  met  with  in 
practice. 

Recurrent  appendicitis  is  sometimes  associated  with 
a  chronic  catarrhal  inflammation  of  the  lower  bowel, 
which  is  as  often  the  cause  of  the  patient's  discomfort 
or  suffering  as  is  the  diseased  appendix.  This  con- 
dition calls  for  intelligent  medical  treatment  But 
when  the  recurrent  attacks  are  plainly  traceable  to  the 
diseased  condition  of  the  appendix,  its  removal  is  not 
only  justifiable  but  imperative.  In  conclusion  I  would 
state  that  the  treatment  of  appendicitis  does  not  belong 
exclusively  to  either  the  physician  or  surgeon.     The 


234 


MEDICAL    RECORD. 


[August  14,  1897 


lormer  is  too  prone  to  procrastinate  and  his  procrasti- 
nation may  be  paid  for  by  the  patient  with  his  life. 
The  latter  has  too  great  a  tendency  to  resort  immedi- 
ately to  his  knife,  which  is  often  unnecessar)'.  Let  the 
physician  call  the  surgeon  early  and  place  upon  him 
the  responsibility  of  deciding  when  to  operate,  but  let 
the  surgeon  appreciate  the  fact  that  he  is  not  called 
merely  as  an  operator,  that  it  is  to  his  judgment,  not 
to  his  scalpel,  that  the  physician  appeals. 


progress  0t  I^aedical  Science. 

Carcinoma  of  the  Breast  in  a  Child.— Dr.  Blodgett 
[Boston  Medical  and  Surgical  Journal,  June  17,  1897) 
has  reported  the  case  of  a  youth,  born  of  healthy  pa- 
rents free  from  all  suspicion  of  malignant  heredity. 
The  father  had  been  at  times  grossly  intemperate. 
Up  to  the  age  of  twelve  years  the  boy  presented  no  ap- 
pearance of  glandular  or  other  disease,  but  soon  after 
this  time  a  swelling  was  noticed  in  the  left  breast, 
beneath  and  attached  to  the  nipple,  which  was  slightly 
reddened  and  harder  than  its  fellow.  The  swelling 
and  induration  gradually  increased  in  size  during  the 
succeeding  months,  and  the  skin  became  more  exten- 
sively adherent.  Surgical  removal  of  the  breast  was 
advised,  assented  to,  and  effected.  The  growth  pre- 
sented on  microscopical  examination  the  typical  struc- 
ture of  carcinoma,  and  had  invaded  all  visible  glandu- 
lar tissue  of  the  breast.  The  wound  healed  by  first 
intention,  and  there  had  been  no  recurrence  or  metas- 
tasis at  tlie  end  of  five  years. 
Chronic    Diarrhoea    Due   to   Senile  Degeneration 

of  the  Intestinal  Walls Duprey  {The  Lancet,  May  i, 

1897)  reports  a  case  of  chronic  diarrhoea  in  a  wo- 
man, fifty-six  years  old,  in  which  he  believed  there 
existed  degeneration  of  the  intestinal  walls,  in  conse- 
quence of  senile  changes.  During  a  period  of  nine 
months  the  patient  had  suffered  from  four  attacks  of 
diarrhcea,  each  of  which  was  more  severe  than  the 
preceding  one.  In  the  last  of  these  the  temperature 
reached  101.2°  F.  and  the  pulse  84.  The  area  of  cardiac 
percussion  dulness  was  unchanged;  the  heart  sounds 
were  feeble,  but  the  rhythm  was  not  disturbed.  Vi- 
sion was  impaired  and  there  was  well-marked  arcus 
senilis  in  each  eye.  The  tongue  was  slightly  furred 
and  the  p^itient  retched  often  and  occasionally  vom- 
ited. She  also  complained  of  pain  in  the  abdomen, 
which  was  tender  on  pressure.  Fluid  evacuations 
were  passed  from  the  bowels  at  intervals  of  twenty 
minutes  or  half  an  hour.  Ptomain  poisoning  being  sus- 
pected, brandy  and  milk  with  soda  water  were  directed, 
in  conjunction  with  a  mixture  containing  bismuth  sub- 
carbonate  and  nepenthe.  During  the  ne.xt  twenty-four 
hours  the  diarrhoea  was  less  frequent,  but  symptoms  of 
cardiac  failure  made  their  appearance,  and  death  ap- 
peared imminent.  Repeated  attacks  of  fainting  oc- 
curred, the  skin  became  icy  cold,  the  lips  livid,  and 
the  pulse  at  the  wrist  scarcely  perceptible.  It  was 
now  learned  that  fainting  fits  had  occurred  also  in  the 
previous  attacks.  In  view  of  the  marked  degeneration 
of  the  cornea,  the  dimness  of  vision,  the  failure  of  cir- 
culation, and  the  chronic  diarrhoea,  the  intestinal 
symptoms  were  attributed  to  degeneration  resulting 
from  senile  changes.  The  treatment  consisted  further 
in  the  application  of  artificial  warmth  and  the  admin- 
istration of  five  drops  of  tincture  of  digitalis  and 
twenty  drops  of  spirit  of  nitrous  ether  every  four  hours. 
Improvement  at  once  set  in  and  progressed  to  eventual 
recovery. 

Meningitis  and  Typhoid  Fever. — According  to 
Dr.  Kuehnan  the  disproportion  between  the  cerebral 
symptoms  in  typhoid  fever  and  the  morbid  lesions 
found    in    the   nervous   system    have  long   attracted 


attention,  and  these  pseudomeningeal  symptoms  are 
well  known  to  experienced  observers.  Purulent  men- 
ingitis has  occasionally  been  seen  in  enteric  fever. 
It  has  been  put  down  as  a  mi.xed  infection  due  to  pyo- 
genic micro-organisms,  but  it  has  been  shown  that  the 
typhoid  bacillus  has  pyogenic  properties,  and  can  pro- 
duce this  purulent  meningitis.  The  author  relates  a 
severe  case  of  enteric  fever  in  a  man,  aged  thirty-two, 
accompanied  by  hemorrhage  and  complicated  by  pur- 
ulent meningitis.  A  bacteriological  examination  of 
the  blood  during  life  showed  colonies  of  the  typhoid 
bacillus.  The  cerebral  symptoms  did  not  appear 
until  the  thirty-second  or  thirt}'-third  day  of  the  dis- 
ease. The  patient  rapidly  became  somnolent,  the 
pulse  irregular,  and  the  urine  and  faeces  were  passed 
unconsciously.  The  pupils  were  equal,  but  reacted 
sluggishly.  There  was  slight  retraction  of  the  head, 
but  no  optic  neuritis.  Death  occurred  on  the  thirty- 
sixth  day  in  profound  coma.  The  t}'phoid  ulcers  were 
nearly  all  in  process  of  healing.  Numerous  typhoid 
bacilli  were  still  present  in  Peyer's  patches.  There 
were  slight  m.icroscopic  changes  in  the  renal  epithe- 
lium. After  the  removal  of  the  dura  mater  the  convo- 
lutions were  seen  to  be  covered  with  purulent  exuda- 
tion. The  pus  was  intimately  connected  with  the  pia 
mater.  The  presence  of  the  typhoid  bacillus  in  the 
mesenteric  glands,  spleen,  and  exudation  over  the 
convexity  as  well  as  at  the  base  of  the  brain  was 
proved  bacteriologically.  Here  the  purulent  menin- 
gitis was  a  metastasis  of  the  typhoid  bacillus.  The 
bacillus  had  penetrated  into  the  blood,  as  shown  by 
the  bacteriological  examination  made  during  life,  and 
had  settled  down  by  predilection  in  the  membranes  of 
the  brain. — Berliner  klinische  Wochenschrift. 

Extra-Uterine  Pregnancy From  a  study  on  this 

subject  by  Dr.  Chaput  the  following  conclusions  are 
announced:  (i)  the  differential  diagnosis  between 
hematocele  and  pyosalpinx  is  usually  difficult;  (2) 
non-ruptured  extra-uterine  pregnancy  before  the  fifth 
month  can  only  be  suspected;  (3)  in  extra-uterine 
pregnancy  complicated  by  non-encysted  hemorrhage 
surgeons  are  unanimous  as  to  the  proper  treatment 
being  immediate  laparotomy;  (4)  in  encysted  hsema- 
tocele  or  effusion  the  choice  lies  between  (a)  laparot- 
omy and  (/')  vaginal  incision.  The  latter  is  far  from 
being  free  from  danger,  and  the  author  always  per- 
formed laparotomy  if  hematocele  resisted  ordinary 
medical  treatment.  Even  if  it  is  first  discovered  on 
making  a  vaginal  hysterectomy  or  puncture  he  would 
perform  laparotomy,  which  makes  it  possible  to  take 
away  the  ovum  and  placenta  and  stop  bleeding.  In 
discussing  these  propositions  Dr.  Bouilly  thought  that 
in  any  case  of  extra-uterine  pregnancy  one  had  to  do 
with  an  abdominal  tumor  which  indicated  laparotomy. 
Laparotomy  is  also  indicated  when  sudden  alarming 
symptoms  make  one  suspect  rupture  of  extra-uterine 
pregnancy.  The  symptoms  of  hematocele  from  rup- 
ture of  extra-uterine  pregnancy  usually  make  the  diag- 
nosis easy;  suppression  of  menses,  suddenness  of 
onset  of  symptoms,  more  or  less  peritonitis,  and  de- 
velopment of  tumor  in  Douglas'  pouch.  Incision 
through  the  posterior  cul-de-sac  is  the  best  treatment. 
Bouilly  had  operated  in  thirteen  cases  with  the  best 
results.  Dr.  Tuffier  thought  the  diagnosis  of  rupture 
by  no  means  easy.  Out  of  four  cases  seen  by  him  he 
mistook  the  first  for  acute  peritonitis  from  perforation; 
in  the  second  no  diagnosis  was  made.  He  agreed 
with  Bouilly  that  incision  through  the  posterior  cul- 
de-sac  was  the  best  treatment  of  simple  or  suppurating 
hematocele.  Reynier  and  Terrier,  however,  would 
limit  vaginal  incision  to  septic  cases,  performing  lapa- 
rotomy in  all  recent  ones,  which  allows  the  operator 
to  see  what  he  is  doing,  and  to  remove  diseased  ap- 
pendages if  necessary. — La  Semaitie  MidicaU. 


August  14,  1897] 


MEDICAL'  RECORD. 


235 


Medical  Record: 

A   Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
vVM.  WOOD  &.  CO.,  43.  45,  &  47  East  Tenth  Street. 


New  York,  August  14,  1897. 


THE  EFFECT  OF  CHLOROFORM  UPON  THE 
VITAL    FUNCTIONS. 

The  action  of  anesthetics  has  ever  been  a  favorite 
field  of  investigation  by  physiologists,  and  of  late 
years  many  laudable  attempts  have  been  made  to  clear 
up  the  doubtful  points  involved.  Notwithstanding 
these  attempts,  the  question  as  to  whether  in  cases  of 
death  by  chloroform  the  respiration  or  the  heart  stops 
first  is  still  an  open  one.  The  two  Hyderabad  commis- 
sions both  came  to  the  decision  that  in  every  case  in 
which  chloroform  was  pushed  respiration  stopped  be- 
fore the  heart  did.  The  Lancet  special  commission  to 
investigate  the  matter  from  a  clinical  standpoint 
found,  out  of  five  hundred  and  six  fatal  cases,  that  the 
heart  failed  first  in  one  hundred  and  forty-three,  res- 
piration first  in  fifty-nine,  both  together  in  forty-six; 
no  note  in  two  hundred  and  eleven.  Therefore  the 
conclusion  arrived  at  bears  out  the  view  that  in  a 
large  majority  of  cases  death  is  due  to  syncope,  so  far 
as  the  clinical  evidence  can  decide  one  way  or  the 
other.  Dr.  Hobart  A.  Hare  {Gaillard's  Medical  Jour- 
nal, June,  1897)  is  inclined  to  adhere  to  the  belief 
held  years  ago,  that  both  the  respiration  and  the  pulse 
need  watching.  He  says:  "As  with  other  discus- 
sions in  medicine,  the  truth  of  the  question  as  to 
whether  chloroform  causes  death  by  respiratory  fail- 
ure or  by  cardiac  failure  lies,  as  it  were,  half  between 
the  two  antagonistic  forces;  and,  further  than  this, 
the  somewhat  startling  statement  may  be  made  that 
it  is  not  directly  due  in  the  majority  of  cases  to 
either  of  these  causes.  On  the  contrary,  the  cause 
of  death  from  chloroform  is  usually  vasomotor  de- 
pression. My  conclusions,  therefore,  are  that  while 
chloroform  in  its  general  depressing  power  depresses 
all  vital  functions,  it  is  the  question  of  blood  pressure 
which  is  most  important."  Mr.  Leonard  Hill  says 
{Treatment,  May  27,  1897)  :  "The  cause  of  chloroform 
collapse  is,  in  all  cases,  a  primary  failure  of  the  cir- 
culatory mechanism.  It  is  secondarily  that  respira- 
tion fails,  on  account  of  the  anemia  of  the  bulbar 
centres.  That  the  cause  of  chloroform  collapse  is  pri- 
marily due  to  failure  of  the  circulation  is  contrary  to 
the  conclusions  arrived  at  by  the  Hyderabad  commis- 
sion. Examining  all  the  tracings  taken  by  this  com- 
mission, I  have  found  that  in  them,  although  it  is  not 
so  interpreted  by  the  experimenters,  the  same  typical 
fall  of  arterial  pressure  is  recorded  actually  occurring 


before  the  cessation  of  respiration.  Thus  their  own 
experimental  evidence  contradicts  the  conclusions 
arrived  at  by  the  workers  on  the  commission." 

There  can  be  no  doubt  that,  whatever  may  be  the 
outcome  of  the  discussion,  it  has  already  been  clearly 
demonstrated  that  respiration  is  of  the  greatest  import- 
ance in  chloroform  giving.  In  regard  to  the  safety 
of  different  anaesthetics,  the  fact  cannot  be  too  strongly 
urged  that  the  chief  cause  of  danger  rests  with  the 
administrator.  The  safest  anesthetic  is  dangerous  in 
the  hands  of  a  careless  administrator,  whereas  the 
most  dangerous,  when  used  by  a  skilful  and  competent 
man,  is,  considering  all  things,  marvellously  safe. 


IS    INSANITY    INCREASING? 

Public  opinion  has  decided  that  this  is  a  neurotic  age 
and  that  insanity  is  ever  on  the  increase.  This  gen- 
eral impression,  however,  appears  to  be  erroneous,  and 
the  trouble  is  probably  more  relative  than  actual.  Yet 
that  there  is  an  increase  can  hardly  be  denied.  A 
hot  and  bitter  discussion  has  been  prevailing  on  the 
subject  for  many  years  in  Great  Britain,  and  still  con- 
tinues with  undiminished  vigor.  The  lunacy  depart- 
ments there  hold  that  the  increase  is  only  apparent, 
while  those  taking  the  opposite  view  contend  that  the 
increase  is  only  too  real.  Regarding  the  question 
from  a  statistical  point  of  view  alone,  the  conclusion 
arrived  at  by  most  persons  would  be  that  the  latter  are 
right,  but,  as  an  old-time  Glasgow  professor  was  in  the 
habit  of  telling  his  class,  "  Statistics  are  like  sausages. 
It  all  depends  on  the  old  wom-an  who  makes  them." 
In  the  Westminster  Review  for  May  is  a  slashing  arti- 
cle attacking  the  arguments  of  the  lunacy  commission- 
ers which  they  bring  forward  in  support  of  their  con- 
tention th^at  the  increase  is  only  apparent  The  writer 
of  this  article  says  that  there  is  a  real  substantial  and 
progressive  increase,  and  backs  up  his  words  with  fig- 
ures. In  1862  in  England  there  were  2.02  lunatics  in 
every  10,000  of  population;  in  1895  there  were  3.15. 
In  1862  where  there  were  1.36  in  every  10,000  of  the 
population;  in  1895  there  were  3.96.  In  1862  in  Scot- 
land there  were  2.01  lunatics  in  every  10,000  of  the 
population;  in  1895  there  were 3.39.  Figures  so  star- 
tling as  these  will  take  a  great  deal  of  explaining  away, 
but  to  a  large  extent  they  are  misleading.  Statistics  in 
lunacy  must  be  dealt  with  very  broadly  and  cautiously. 
One  reason  for  the  great  increase  in  the  population 
of  hospitals  for  the  insane  is  the  fact  that  lunatics 
are  looked  upon  with  different  eyes  than  formerly. 
In  the  early  part  of  the  century  insanity  was  re- 
garded with  horror  or  scorn,  and  with  little  feeling 
of  pity  or  sympathy.  The  truth  that  it  was  a  disease 
possible  to  cure  had  not  entered  men's  minds.  An 
asylum  was  a  prison,  the  inmates  of  which  were  treated 
more  harshly  than  criminals ;  now  that  asylums  are  rec- 
ognized as  hospitals,  they  contain  inmates  who  former- 
ly were  not  counted  as  lunatics.  The  advance  in  Eng- 
land in  the  number  of  the  insane  has  been  almost 
wholly  in  the  pauper  class,  and  is  doubtless  due  to  the 
improved  accommodation  and  treatment  and  the  con- 
sequent enhanced  appreciation  of  the  benefits  of  being 


236 


MEDICAL    RECORD. 


[August  14,  1897 


an  inmate  of  a  hospital.  This  state  of  affairs  applies 
also  to  this  countn-.  The  accumulation  of  chronic 
cases  is  another  fruitful  cause  of  increase,  and  it  must 
not  be  overlooked  that  the  accumulation  of  chronic 
cases  is  inevitable  at  a  hospital  for  the  insane  as  dif- 
fering from  a  general  hospital,  because  at  any  insane 
asylum  all  the  incurables,  O!  nearly  all,  have  to  be 
kept  as  permanent  patients.  Under  the  modern  sys- 
tem, too,  the  rate  of  mortality  is  very  much  less. 
When  all  that  is  to  be  said  has  been  said  to  minimize 
as  much  as  possible  this  increase,  it  is  useless  to 
pretend  that  there  has  been  no  real  increase  whatever. 
It  is  certainly  not  so  great  as  statistics  without  neces- 
sary explanations  and  the  alarmists  would  lead  us  to 
suppose;  still  the  fact  that  there  is  some  increase  is 
more  or  less  self-evident. 


THE   NEED    OF    A    HOME    FOR    CONVALES- 
CENTS. 

The  charity  which  would  commend  itself  with  great- 
est force  to  physicians  and  intelligent  laymen  is  an 
institution  which  would  provide  a  shelter  for  conva- 
lescents, and  for  persons  not  ill  enough  to  secure  hos- 
pital care  yet  not  well  enough  to  compete  with  the 
hard  conditions  of  life  in  a  large  city. 

There  is  not  a  physician  in  New  York  who  has  not 
met  with  poor  persons  too  ill  to  look  after  themselves, 
and  yet  not  proper  hospital  cases.  With  a  few  weeks' 
rest  under  proper  super\'ision  these  unfortunates  could 
be  restored  to  a  life  of  usefulness.  In  the  same  way 
discharged  hospital  patients,  freed  from  disease  but 
yet  too  weak  to  take  up  their  usual  burdens,  could  be 
rehabilitated. 

We  commend  this  idea  to  the  thoughtful  and  prac- 
tical philanthropist.  No  institution  adequate  for  the 
real  necessities  of  the  situation  is  now  in  e.xistence  in 
this  city,  but  the  value  of  such  a  one  would  be  immense. 
It  would /fill  the  great  gaps  beyond  the  reach  of  the 
hospitals.  It  would  materially  lessen  pauperism,  and 
bring  back  to  independence  and  vigor  thousands  who 
now  drift  annually  into  helplessness. 


Russian  Congress  of  Syphilography. — A  congress 
to  arrest  the  spread  of  syphilis  in  Russia,  recently 
summoned  by  the  government,  was  attended  by  over 
five  hundred  persons,  including  physicians,  teachers, 
professors,  heads  of  penal  and  other  institutions,  in- 
spectors of  factories,  and  military  and  naval  officers. 
Among  the  measures  proposed  were  stricter  supervi- 
sion of  the  morals  of  the  young  and  cultivation  of  out- 
door sports;  education  of  the  public  to  the  dangers  of 
syphilis  by  popular  illustrated  lectures,  pamphlets, 
etc. ;  the  adoption  of  a  uniform  blank  for  recording  all 
cases,  and  for  annual  reports  to  a  central  bureau: 
physical  examination  of  prostitutes  by  female  physi- 
cians, and  also  the  examination  of  the  men  who  visit 
them.  Special  measures  for  preventing  the  spread  of 
syphilis  among  the  innocent,  w-hich,  as  shown  by 
Bulklcy  in  his  work  on  "  Syphilis  Insontium,''  is  so 
common  in  Russia,  were  also  recommended. 


The  Cumberland  County  (N.  J.)  Medical  Society 
convened  at  the  Hotel  Cumberland,  July  13,  1897, 
with  the  president.  Dr.  H.  W.  Elmer,  in  the  chair. 
Dr.  Rulon  Dare,  of  Deerfield,  read  a  paper  on  "  Serum 
Therapy,"  and  Dr.  D.  H.  Oliver  reported  on  the  ad- 
vance in  medicine.  The  society  adjourned  to  meet 
the  second  Tuesday  in  October. 

Dr.  Joseph  J.  Kinyoun,  of  the  Marine  Hospital 
service,  has  been  designated  by  the  secretarj'  of  the 
treasury  to  represent  this  government  at  the  interna- 
tional exposition  on  hygienic  and  sanitary  service  on 
shipboard,  to  be  held  in  Brussels  in  September.  He 
has  also  been  appointed  a  delegate  to  the  interna- 
tional leprosy  conference,  to  be  held  in  Berlin  in  Oc- 
tober. While  in  Europe  he  will  visit  the  several  bac- 
teriological laboratories  on  the  continent,  for  the 
purpose  of  obtaining  information  for  the  use  of  the 
Marine  Hospital  service  as  to  recent  advances  in  the 
investigation  of  contagious  diseases. 

Collision   with    an    Ambulance An   ambulance 

from  the  Harlem  Hospital  was  run  into  at  Lexington 
Avenue  and  One  Hundred  and  Twentieth  Street  on 
Tuesday  last  by  an  electric  car.  The  ambulance  sur- 
geon received  a  scalp  wound,  and  the  driver  was  in 

jured  about  the  body. 

The  New  Morgue.— The  sinking  fund  commis- 
sioners have  authorized  the  dock  board  to  extend  the 
pier  at  the  foot  of  East  Twenty-sixth  Street  to  give  ad- 
ditional space  to  the  new  morgue  building.  A  resolu- 
tion to  the  same  effect  was  passed  several  months  ago, 
but  it  was  lost  in  the  mayor's  office  and  was  not  acted 
upon. 

Mr.  Christopher  Heath,  ex-president  of  the  Royal 
College  of  Surgeons,  is  to  deliver  the  second  course  of 
Lane  lectures  at  San  Francisco  this  year.  There  will 
be  ten  lectures  on  the  following  subjects:  Two  lec- 
tures on  congenital  malformations,  two  on  diseases  of 
the  rectum,  two  on  diseases  of  the  jaws,  one  on  dis- 
eases of  the  tongue,  one  on  diseases  of  the  joints,  one 
on  aneurism,  and  a  concluding  lecture  entitled  "  A 
Century  of  Surgery."  For  accepting  the  invitation  to 
deliver  these  lectures,  Mr.  Heath  was  bitterly  assailed 
by  some  of  his  amiable  colleagues  in  the  Royal  Col- 
lege, the  charge  being  made  that  he  had  lowered  the 
dignity  of  his  profession  by  accepting  the  honorarium 
offered,  although  the  latter  will  barely  cover  the  ex- 
penses of  the  long  journey. 

The  American  Association  for  the  Advancement 

of  Science. — Tlie  forty-ninth  .innual  meeting  of  this 
association  was  opened  on  Monday  in  Detroit  by  Vice- 
President  McGee,  of  Washington,  and  continued  in 
daily  sessions  until  Friday. 

To  Keep  Away  Mosquitoes. — A  resident  of  New- 
Jersey,  who  has  tried  the  prophylactic  with  signal  suc- 
cess, writes  that  a  mixture  of  one  part  of  oil  of  sassa- 
fras in  five  parts  of  alcohol  applied  to  the  hands,  neck, 
and  other  exposed  parts,  will  effectually  keep  away  the 


August  14.  1897] 


MEDICAL    RECORD. 


237 


most  ferocious  of  mosquitoes.     It  is  necessary  to  re- 
neiv  the  application  ever)'  two  or  three  hours. 

A  Case  of  Supposed  Superfoetation. — It  was  reported 
recently  in  Cleveland  that  a  woman  of  that  town  had 
given  birth  to  two  children,  one  three  months  earlier 
than  the  other.  At  the  time  the  first  child  was  sup- 
posed to  have  been  bom,  the  woman  was  visiting  in 
Connecticut.  She  returned  with  a  girl  baby  which  she 
declared  'i  be  her  own.  Three  months  later  she  gave 
birth  to  a  boy.  The  husband  and  the  attending  phy- 
sicians accepted  the  woman's  story,  and  looked  upon 
the  case  as  particularly  remarkable.  On  inquiry, 
however,  it  was  found  that  the  woman,  who  is  out  of 
her  mind,  had  given  birth  to  no  child  while  in  Con- 
necticut, and  it  is  now  supposed  that  she  stole  the  baby 
she  brought  home  with  her. 

Bicycle  Accidents. — During  July,  during  abouc  half 
of  which  it  was  raining  and  consequently  few  wheels 
were  out,  the  newspapers  reported  forty-eight  more  or 
less  serious  accidents  from  bicycling.  Most  of  the 
sufferers  were  those  riding  the  wheel,  but  there  were 
also  many  children  run  down  while  playing  in  the 
street.  It  is  a  favorite  sport  of  these  innocents  to 
stand  directly  in  the  path  of  a  wheelman  and  make 
faces  at  him,  so  that  it  is  almost  impossible  at  times 
to  avoid  an  accident. 

The  American  Jubilee  Fund,  which  was  started 
for  the  purpose  of  raising  money  to  establish  beds  in 
perpetuity  in  the  chief  London  hospitals,  has  been 
closed.     The  subscriptions  exceed  $21,500. 

The  Moscow  Congress. — The  preparations  for  the 
meeting  in  Moscow  are  proceeding  with  a  slowness 
comparable  to  that  of  the  railway  trains  and  many 
other  things  in  Russia.  The  preliminary  programme, 
issued  the  latter  part  of  July,  announces  that  there 
will  be  but  three  general  meetings,  instead  of  five  as 
first  proposed.  The  Tsar  will  receive  one  member 
from  each  country,  in  order  to  fulfil  his  role  of  patron 
of  the  congress,  but  this  reception  will  be  held  in  St. 
Petersburg  two  days  before  the  opening  of  the  con- 
gress. The  selection  of  the  one  person  to  be  thus 
honored  will  be  left  with  the  national  committee,  in- 
stead of  with  the  ambassador  of  each  country,  as  was 
first  announced.  This  will  reduce  the  number  of  those 
taking  part  in  the  ceremony,  for  there  will  be  time  to 
appoint  representatives  from  European  countries  only. 
The  town  council  of  Moscow  was  asked  to  entertain 
the  members  of  the  congress,  but  instead  of  doing  so 
decided  to  establish  a  triennial  prize  for  the  best  essay 
upon  some  subject  connected  with  public  health  or 
epidemiology.  Some  twenty  members  will  be  put  up 
at  the  Maison  des  Cavaliers,  one  of  the  official  resi- 
dences in  the  Kremlin,  as  guests  of  the  Tsar,  but  it  is 
not  stated  how  these  lucky  twenty  will  be  selected. 
The  preliminary  programme  contains  the  titles  of 
nearly  one  thousand  papers  which  it  is  proposed  to 
inflict  upon  the  members  of  the  various  sections. 

Professor  Max  Joseph  Oertel,  of  Munich,  died  on 
July  13th.  He  was  born  in  Dillingen.  Bavaria. 
March  20,  1835.     Early  in  his  medical  life  he  turned 


his  attention  to  respiratory  diseases,  and  was  apt- 
pointed  to  the  chair  of  laryngology  in  Munich  in  1867. 
He  was  especially  occupied  for  a  time  with  the  studv 
of  diphtheria,  upon  which  he  wrote  an  article  in 
Ziemssen's"Cyclopsdia,"  and  always  claimed  that  he 
was  the  first  to  discover  the  bacillus  of  Klebs-Loeffler. 
His  classical  work  on  the  pathogenesis  of  diphtheria 
was  published  in  1887.  About  1870  he  began  to  suf- 
fer from  heart  trouble,  accompanied  by  albuminuria, 
marked  circulatory  disturbances,  oedema,  and  obesity. 
After  several  years  of  orthodox  but  unsuccessful  treat- 
ment, he  restored  himself  to  a  state  of  practical  health 
by  means  of  a  special  diet  and  graduated  exercises, 
which  he  afterward  developed  irfto  a  system  followed 
in  the  various  "  Terrain-Curorte"  which  he  established 
in  Germany  and  Austria.  This  system  he  described 
luUy  in  his  articles  on  the  treatment  of  circulatory 
disorders  in  Ziemssen's  "  Handbook  of  Therapeutics," 
on  the  milk  cure  in  circulatory  disturbances  in  the 
"  Festschrift"  in  honor  of  Pettenkofer's  jubilee  in 
1893,  and  on  obesity  in  the  "Twentieth  Century  Prac- 
tice of  Medicine" — the  latter  being  his  last  contribu- 
tion of  importance  to  medical  literature.  He  was  an 
honorary  member  of  many  learned  societies  in  Ger- 
many and  other  countries,  and  was  the  bearer  of  six 
decorations  conferred  upon  him  by  the  Emperor  of 
Austria  and  various  German  rulers. 

Philadelphia  Hears  of  a  Great  Discovery,  and 
at  once  puts  it  to  practical  use.  "  Philadelphi.a, 
August  9th. — At  the  Polyclinic  Hospital  this  after- 
noon the  -v-rays  were  used  to  locate  a  pin  which  was 
swallowed  yesterday  afternoon  by  Kate  Kellie,  five 
years  of  age.  The  child  was  playing  with  a  spool 
containing  four  pins,  and  in  pulling  one  out  with  her 
teeth  it  slipped  down  her  throat." — Special  Telegram 
to  The  Sun. 

Obituary  Notes. ^Dr.  Eugene  Franxis  Sanger, 
of  Bangor,  Me.,  died  at  his  home  in  that  city  on  July 
24th,  after  an  illness  of  several  months.  He  was  born 
in  Water\'ille,  Me.,  October  i8,  1829.  He  was  a 
graduate  of  Dartmouth  College  in  the  class  of  1849, 
and  then  studied  medicine  in  Philadelphia,  receiving 
his  M.D.  degree  from  the  JetTerson  Medical  College  in 
1853.  After  ser\^ing  in  the  Marine  Hospital  at  Chel- 
sea and  later  on  the  staff  of  the  Charity  Hospital  in 
this  city,  he  went  to  Europe,  studying  in  the  hospitals 
in  Edinburgh,  London,  and  Paris.  Upon  returning 
to  this  country  he  began  practice  in  Ellsworth,  but 
soon  established  himself  in  Bangor.  Immediately 
upon  the  breaking  out  of  the  civil  war  he  joined  the 
medical  staff  and  served  with  distinction  during  the 
entire  war,  filling  many  important  places  of  trust,  and 
upon  being  mustered  out  at  its  close  he  was  brevetted 
lieutenant-colonel  for  meritorious  service.  Returning 
home  to  Bangor,  he  commenced  the  practice  of  his 
profession  in  October,  1865,  and  continued  there  to 
the  time  of  his  death.  In  1868  he  was  made  examin- 
ing surgeon  of  the  pension  bureau.  He  was  made 
surgeon -general  of  Maine  by  Governor  Chamberlain, 
and  sen-ed  seven  years  as  surgeon  to  the  State  militia. 
He  was  president  of  the  Maine  Medical  Association 


238 


MEDICAL    RECORD. 


[August  14,  1897 


in  1876.  He  was  an  honorary  member  of  the  Detroit 
Academy  of  Medicine  and  of  the  Baltimore  Medical 
and  Surgical  Society;  a  member  of  the  county  and 
State  medical  societies,  and  of  the  American  Medical 
Association ;  a  member  of  the  G.  A.  R.  and  the  Loyal 
Legion.— Dr.  Edwin  SPRENKLEdied  at  Hanover,  Pa., 
on  August  4th,  at  the  age  of  thirty-nine  years,  as  a  re- 
sult of  injuries  received  in  being  dragged  and  tram- 
pled on  by  his  runaway  horse.  He  was  a  graduate  of 
Franklin  and  Marshall,  and  of  the  Jefferson  Medical 
College  in  the  class  of  1884. — Dr.  Albert  F.  E. 
Krog  died  suddenly  at  his  home  in  this  city  on  Au- 
gust loth.  He  was  a  graduate  of  the  New  York  Uni- 
versity Medical  School  in  the  class  of  1881. 

Inspection  of  Chinese  Laundries —  The  health 
commissioner  of  St.  Louis  has  issued  an  order  for  the 
inspection  of  all  the  Chinese  laundries  in  that  city. 
He  says  that  many  of  the  Chinamen  are  tuberculous, 
and  that  they  carry  tubercle  bacilli  in  their  mouths 
and  squirt  them  on  the  clothes  they  are  ironing,  the 
latter  thereby  becoming  carriers  of  contagion. 

The  Plague  in  China.  —  It  is  reported  that  the 
plague  prevails  in  Canton,  and  the  English  residents 
in  Hong-Kong  are  alarmed  lest  it  break  out  in  that 
city.  Nothing  has  been  done  to  put  the  Chinese  quar- 
ter of  Hong-Kong  in  a  good  sanitary  condition,  and  it 
is  feared  if  the  plague  once  gains  admission  its  rav- 
ages will  be  fearful. 

Surgeons  in  Ordinary  to  the  Prince  of  Wales — 
Sir  William  MacCormac,  president  of  the  Royal  Col- 
lege of  Surgeons,  and  Alfred  Downing  Fripp,  assis- 
tant surgeon  to  Guy's  Hospital,  have  been  appointed 
surgeons  in  ordinary  to  His  Royal  Highness.  Mr. 
Fripp  obtained  his  licentiate  in  the  Royal  College  of 
Surgeons  only  eight  years  ago  and  was  but  recently 
appointed  assistant  surgeon  to  Guy's  Hospital,  and 
there  is  some  grumbling  that  the  Prince,  now  himself 
a  fellow  of  the  college,  should  not  have  selected  one 
of  his  more  aged  colleagues. 

An  International  Jenner  Society.— It  is  proposed 
to  organize  among  the  members  of  the  Moscow  con- 
gress an  International  Jenner  Society,  the  object  of 
which  will  be  the  encouragement  of  vaccination  and 
the  collection  and  publication  of  facts  and  statistics  in 
connection  with  smallpox  and  vaccination.  Dr. 
Hubert,  the  secretary  of  the  Russian  Public  Health 
Society,  who  has  the  matter  of  organization  in  charge, 
proposes  the  name  Jennerianum  for  the  new  society. 

Censure  of  Hospital  Surgeons A  boy  shot  him- 
self accidentally  last  month  through  the  palm  of  his 
left  hand  with  a  revolver.  He  was  taken  to  one  of  the 
city  hospitals,  where  the  hand  was  dressed.  The 
wound  did  not  heal,  however,  and  a  few  days  later  the 
boy  was  seized  with  convulsions.  A  private  physi- 
cian was  then  called  and  extracted  a  piece  of  wadding 
from  the  palm  of  the  hand.  The  boy  died  from  tet- 
anus. An  inquest  was  held,  and  the  coroner  charged 
the  jury  that  the  case  was  clearly  one  of  criminal  neg- 
lect on  the  part  of  the  hospital  authorities  in  not 
giving  proper  treatment  to  the  boy.  The  jury  returned 
a  verdict  that  the  boy  came  to  his  death  by  tetanus 


following  a  wound  made  by  the  wadding  of  a  blank 
pistol  cartridge,  and  they  censured  the  surgeons  at  the 
hospital  for  failing  to  discover  the  wadding  in  probing 
the  wound  and  for  failing  to  remove  the  powder  also 
contained  in  the  wound. 

Medical  Society  of  the  Missouri  Valley — The 
annual  meeting  of  the  society  will  be  held  at  Council 
Bluffs,  Iowa,  Thursday,  September  16,  1897.  Titles 
of  papers  to  be  read  should  be  sent  to  the  secretary, 
Dr.  Donald  Macrae,  Jr.,  not  later  than  August  26th. 

Antitoxin  of  Tetanus A  case  of  tetanus  in  a  col- 
ored man,  resulting  from  a  nail  wound  of  the  foot,  has 
been  placed  under  treatment  at  the  Emergency  Hospi- 
tal at  Washington,  D.  C,  with  antitoxin  prepared  in 
the  United  States  army  medical  laboratory. 

The  Boston  Medical  Library  has  received  the  med- 
ical libraries  of  the  late  Drs.  Edward  Wigglesworth, 
of  Boston,  and  William  G.  Wheeler,  of  Chelsea.  The 
former  is  composed  almost  entirely  of  books  and  peri- 
odicals on  dermatology,  and  contains  nearly  everything 
published  on  this  subject  up  to  a  short  time  before  the 
owner's  death.  The  latter  consists  of  books  by  early 
American  writers,  standard  medical  works,  files  of 
valuable  periodicals,  and  a  large  collection  of  books 
and  monographs  on  obstetrics  and  gy-naecology. 

Hot  Weather  in  Italy. — The  weather  in  all  parts 
of  Italy  during  July  has  been  extremely  hot,  and  to 
aggravate  the  sufferings  of  the  inhabitants  there  is  an 
ice  famine,  the  price  of  this  necessit)'  having  risen  to 
$1.20  a  hundredweight. 

Beriberi  has  been  discovered  on  board  a  Norwegian 
vessel  recently  arrived  at  Cork  harbor  from  the  west 
coast  of  Africa.  Six  of  the  crew  were  suffering  from 
the  disease  and  one  had  died  on  the  voyage. 

The  Right  to  Practise  Medicine  in  France. — The 

Paris  correspondent  of  The  Lancet  writes  that  the 
French  government  has  been  asked  to  annul  the  by- 
law of  two  years'  standing,  under  which  foreign  stu- 
dents desiring  to  study  medicine  in  France  were  sent 
to  the  provincial  universities.  Previously  to  this  by- 
law the  foreign  student  was  in  a  better  position  than 
the  French  student,  because  he  was  not  compelled  to 
serve  three  years  in  the  army  or  to  pass  a  matricula- 
tion examination  of  equal  severity.  As  a  set-off  to 
this  great  advantage,  foreign  students  were  therefore 
drafted  to  the  provincial  centres  instead  of  being  per- 
mitted to  work  at  the  Faculte  de  Paris.  But  more  re- 
cently a  rule  has  come  into  force  whereby  the  degree 
of  doctor  of  medicine  shall  give  the  right  of  prac- 
tice in  France  or  French  possessions  only  to  such  stu- 
dents as  shall  have  passed  the  usual  French  prelimi- 
nary examinations  and  have  served  three  years  in  the 
army.  Native  talent  is  considered  by  the  municipal 
council  to  be  sufficiently  protected  now,  and  the  pre- 
fect of  the  Seine  has  promised  to  communicate  this 
view  to  the  government.  The  commencement  of  the 
next  November  session  will  therefore  probably  see 
foreign  students  again  inscribing  their  names  at  the 
Faculte  de  Paris,  but  the  degree  which  they  expect 
will  not  give  them  the  right  to  practise  in  France  un- 
less they  conform  to  the  new  regulations. 


August  14,  1897] 


MEDICAL    RECORD. 


239 


©linicat  §svnvtm&nt. 

STRANGULATED       UMBILICAL      HERNIA 
OPERATION    AND    RECOVERY. 

By   WILLI.\M    B.    COLEV,    M.D., 


CRIPPLED  ;    AT- 


Inasmuch  as  successful  operations  for  strangulated 
umbilical  hernia  are  comparatively  rare,  the  following 
clinical  case  may  be  of  interest: 

Mrs.    S ,  aged   fifty-two,  married,    had   had   an 

umbilical  hernia  for  twenty-two  years,  since  the  birth 
of  her  last  child.  The  hernia  had  remained  reduci- 
ble until  two  years  ago;  since  then  it  had  slowly 
increased  in  size  and  had  at  times  given  rise  to  symp- 
toms of  incarceration.  These  attacks  were  accom- 
panied by  severe  pain,  with  constipation,  nausea,  and 
vomiting,  which  sometimes  obliged  her  to  remain  in 
bed  for  two  or  three  days.  The  present  attack  began 
on  April  21,  1897.  There  had  been  some  pain  at  the 
site  of  the  hernia  the  preceding  day.  The  symptoms, 
however,  became  greatly  intensified  on  the  morning  of 
the  2 1  St,  while  she  was  attending  to  her  household 
duties;  vomiting  soon  began,  became  severe  and  fre- 
quent, and  during  the  latter  part  of  the  day  was  green- 
ish in  color.  She  had  one  movement  of  the  bowels  in 
the  morning.  The  pain  greatl)'  increased  in  severity, 
and  at  about  four  o'clock  in  the  afternoon  she  was 
seen  by  Dr.  George  Peace,  of  Dover  Plains,  N.  Y., 
who  made  the  diagnosis  o£  strangulated  hernia.  The 
tumor  was  about  the  size  of  a  closed  fist;  the  skin 
over  the  sac  was  discolored  and  very  thin.  The  tumor 
on  light  percussion  was  dull;  on  heavy  percussion 
showed  an  indistinct  tympanitic  note,  which  suggested 
bowel  masked  by  omentum  or  liquid. 

I  first  saw  the  patient  on  the  train  at  Pauling, 
N.  Y.  At  that  time  her  pulse  was  84;  temperature, 
99.5°  F.  She  rode  on  the  train  eighty  miles,  during 
which  time  there  was  no  vomiting,  but  considerable 
pain  and  much  nausea.  The  tumor  was  exceedingly 
tender  on  pressure. 

She  was  admitted  to  the  Post-Graduate  Hospital 
at  9  P.M.,  and  immediately  prepared  for  operation. 

Operation  was  performed  at  9 140  p.m.,  about  ten 
hours  after  the  beginning  of  strangulation,  with  ether 
as  the  anajsthetic.  An  incision  through  the  skin  and 
Ihin  sac  showed  only  a  mass  of  discolored  omentum 
which  was  adherent  to  the  sac  throughout,  though  most 
of  the  adhesions,  especially  those  in  tiie  fundus  of  the 
sac,  were  of  recent  origin.  There  was  little  fluid  pres- 
ent. On  separating  the  omentum  there  appeared  a 
knuckle  of  small  intestine,  about  eight  inches  in 
length,  badly  congested,  but  which  had  not  lost  its 
glossy  appearance.  The  bowel  was  completely  envel- 
oped in  this  mass  of  omentum,  which  really  formed  a 
second  sac  and  could  not  be  seen  until  an  opening  had 
been  made  in  the  omentum ;  on  account  of  the  thick 
layer  of  fat  in  the  abdominal  wall  the  ring  was  deeply 
seated,  and,  moreover,  very  narrow,  making  a  very 
tight  constriction.  After  the  constricting  ring  had 
been  cut,  the  bowel  soon  regained  its  color,  and  it  was 
thought  safe  to  replace  it  in  the  abdominal  cavity. 
The  entire  mass  of  adherent  omentum  was  then  ligated 
in  small  sections  with  catgut  and  removed;  the  sac 
and  skin  pouch  were  likewise  e.xcised,  and  the  wound 
was  closed  with  three  layers  without  drainage  ;  kanga- 
roo tendon  was  employed  for  the  fascia.  The  time  of 
operation  was  forty  minutes.  The  pulse  at  the  close 
ofthe  operation  was  78  and  of  excellent  quality. 

The  subsequent  liistory  of  the  patient  contained 
nothing  worthy  of  note;  recovery  was  absolutely  unin- 
terrupted;  the  wound  healed  by  perfect  primary  union. 


The  mortality  in  strangulated  umbilical  hernia  is 
still  very  high,  varying  between  fifty  and  eighty  per 
cent.  The  reason  for  this  mortality  lies,  I  think,  in 
the  fact  that  the  patients  are  usually  very  stout  women 
and  very  poor  subjects  for  any  serious  operation.  In 
addition,  the  hernia  is  usually  complicated  with  a 
large  mass  of  irreducible  adherent  omentum,  the  re- 
moval of  which  materially  delays  an  operation  which 
for  its  success  is  largely  dependent  on  rapidity  of  ex- 
ecution. 

HVDATIDIFORM    MOLE. 
By    C.   C.    CRONKHITE,    M.D., 

On   February  16,  1897,  I   was  called  to  attend  Mrs. 

D ,  primipara,  twenty-two  years   of   age,  in  what 

she  supposed  was  confinement.  On  arrival  I  found 
her  having  pain  and  apparently  in  the  first  stage  of 
labor.  There  was  a  slight  discharge  tinged  with  blood 
from  the  parturient  canal.  On  palpation  I  found  a 
large  and  doughy  abdomen,  quite  firm  at  the  lower 
portion  of  the  womb.  An  outline  of  the  child  could 
not  be  made.  Digital  examination  showed  the  cervi- 
cal canal  dilated  to  the  size  of  a  silver  twenty-five-cent 
piece.  The  pains  were  increasing  in  severity.  At  1 1 
P.M.  I  was  hastily  called.  The  patient  informed  me 
that  something  had  just  passed  during  a  severe  pain. 
I  found  a  large  mass  (at  least  half  a  gallon)  and  small 
particles  continued  to  pass  for  three  days.  On  the 
third  day  the  patient  was  quite  tympanitic.  I  used 
vaginal  douches  of  hot  carbolized  water  and  placed 
turpentine  stupes  over  the  abdomen.  After  this  there 
was  a  gradual  and  uninterrupted  recovery.  The  pa- 
tient thought  herself  at  full  time  and  believed  that  she 
had  felt  movement  for  several  months.  In  September, 
1896,  she  had  a  slight  How  resembling  menstruation. 
In  October,  1896,  she  had  pain  in  the  womb  and  a 
small  mass  resembling  a  blood  clot  was  expelled. 


A  TYPICAL  CASE  OF   SCURVY   IN   A   COUN- 
TRY-BRED   INFANT. 

By   CHARLES    B.    W.VRNER,    M.D., 

rOKT   HENRV,    N.    V. 

The  following  case  is  of  interest,  as  scurvy  is  such  an 
extremely  infrequent  affection  in  this  country.  It 
also  demonstrates  unmistakably  the  danger  of  elimi- 
nating fresh  milk  from  the  dietary  of  tender  infants. 
According  to  Dr.  Northrup,  in  Starr's  "  American 
Text-Book  of  Diseases  of  Children,"  there  have  been 
in  American  practice  only  fifteen  recently  published 
cases  of  scurvy  in  children. 

The  subject  of  this  report  was  born  in  May,  1894. 
Parents  healthy  and  well-to-do;  history  of  rachitis  in 
maternal  grandmother  and  two  great-aunts.  The  child 
was  weaned  at  twenty-two  months,  having  been  fed 
nothing  besides  mother's  milk,  except  a  well-known 
proprietary  food  prepared  with  a  small  quantity  of 
cow's  milk.  This  food  was  also  the  exclusive  diet  for 
eight  months  after  weaning.  For  the  next  two  months 
animal  broths  constituted  the  principal  part  of  her 
bill  of  fare,  not  a  drop  of  milk  being  given. 

I  was  called  to  see  her  and  found  her  suffering  with 
lameness  in  the  left  leg.  This  condition  increased 
rapidly.  In  a  few  days  she  was  quite  unable  to  walk, 
and  carrying  her  or  moving  the  limb  caused  intense 
pain.  At  night  the  pain  in  both  legs  was  so  great 
that  she  was  deprived  of  sleep. 

The  legs  were  kept  flexed,  any  attempt  to  straighten 
them  causing  her  to  cry  out.  The  left  tibia  became  a 
good  deal  enlarged  in  the  lower  third.  A  few  days 
later  the  gums  became  sore  and  continued  to  grow 
worse  until  thev  became   verv  much    swollen,   dark, 


240 


MEDICAL    RFCORD. 


[August  14,  1897 


spong)-,  and  bleeding.  They  could  be  separated  from 
the  teeth  down  to  the  alveolar  process.  The  patient 
was  fairly  well  nourished,  but  very  petulant:  the 
bowels  were  in  good  condition;  the  temperature  was 
slightly  elevated  at  times. 

I'he  treatment  was  antirheumatic  for  a  few  days,  the 
true  condition  not  being  recognized  immediately,  fol- 
lowed by  syrup  of  lactophosphate  of  lime,  syrup  of 
iodide  of  iron,  solution  of  arsenite  of  potassium,  qui- 
nine sulphate,  bitter  tonics  with  iron,  and  cod-liver 
oil  inunctions — but  to  no  avail. 

.A  change  of  regimen  was  advised  early  in  the  case, 
fruit  and  milk  being  prescribed,  but  as  the  child  dis- 
liked both  they  were  not  given.  The  proprietary  food 
prepared  with  a  small  quantity  of  milk  and  animal 
broths  constituted  its  menti. 

On  May  3d,  the  infant  having  been  sick  about  three 
months,  the  situation  was  very  clearly  explained  to 
the  little  girl's  mother,  and  a  radical  change  of  diet 
was  insisted  upon,  potatoes,  fresh  cow's  milk,  and 
orange  juice  being  again  prescribed.  The  juice  of 
one  orange  was  given  each  day  and  more  milk  was 
added  to  the  food.  Potatoes  were  not  given.  The 
effect  was  little  less  than  magical.  In  three  days  the 
gums  were  wonderfully  improved,  and  in  five  days 
were  well.  The  improvement  in  the  legs  was  almost 
as  rapid,  she  being  practically  well  in  two  weeks  after 
commencing  the  orange  juice. 

To  those  unfamiliar  with  scurvy,  it  will  seem  either 
incredible  or  almost  miraculous  that  a  child  could  be 
restored  from  a  constitutional  disturbance  so  grave  that 
death  often  results  to  perfect  health,  by  the  juice  of 
five  oranges. 

SYMPHYSEOTOMY      WITH      AN       UNUSUAL 
COMPLICATION. 

By   EDWIN    B.    CRAGIX,    M.D. 


The  interest  in  the  following  case  lies  not  so  much 
in  the  operation  as  in  the  complication  which  inter- 
rupted the  convalescence. 

On  February  25,  1895,  the  writer  was  called  by  Dr. 

H.  S.   Houghton,  of  this  cit\-,  to  see  Mrs.  Y who 

had  been  in  labor  eighteen  hours.  Forceps  had  been 
tried,  but  their  application  proving  very  difficult  they 
were  abandoned. 

Examination  showed  a  narrow  conjugate,  a  large 
caput,  and  no  advance  under  powerful  uterine  contrac- 
tions. This  was  her  second  labor.  Her  first  occurred 
in  1893,  and  lasted  forty-eight  hours.  After  repeated 
applications  of  the  forceps  this  first  child  had  been 
delivered,  but  the  head  had  been  injured  and  the  child 
lived  but  three  days.  The  present  condition  seemed 
to  indicate  symphyseotomy,  and  as  soon  as  prepara- 
tions could  be  made  this  was  performed  with  the  able 
assistance  of  Drs.  Houghton  and  Lyle.  A  male  child 
weighing  seven  and  a  quarter  pounds  was  then  easily 
delivered  with  forceps. 

The  case  progressed  favorably.  I  saw  the  woman 
on  March  17th,  and  told  her  she  could  sit  up  on  the 
following  day.  That  evening  the  husband,  who  was 
acting  the  part  of  nurse,  gave  her  an  enema.  This 
was  accompanied  and  followed  by  severe  pain  and  the 
next  day  I  was  summoned  in  haste.  I  found  a  tem- 
perature of  103.5  !'■'  pulse  of  120,  and  abdomen  dis- 
tended, with  dulness  over  the  left  inguinal  region. 
Examination  disclosed  the  fact  that  the  husband  in 
giving  the  enema  had  perforated  the  rectal  wall  and 
deposited  the  soapsuds  in  the  retroperitoneal  tissue. 
The  finger  passed  easily  along  the  false  passage 
through  and  outside  the  rectum.  I  expected  suppura- 
tion, but  instead  of  that  the  soapsuds  infusion  was 
absorbed  and  in  a  week,  /.<•..  four  weeks  from  the  time 
of  operation,  the  woman  was  able  to  sit  up. 


On  April  25th  I  found  the  patient  on  the  street, 
walking  without  difficult)'  and  carrying  her  child. 

May  2oth  I  found  her  doing  her  washing.  She 
could  hop  on  either  foot  without  difficulty  and  said 
she  felt  well  and  strong.  The  symphysis  showed  firm 
fibrous  union  with  little  if  any  motion.  The  true  in- 
ternal conjugate  measured  three  and  a  fourth  inches. 

62  West  Fiftieth  Street. 


A   CASE   OF    PTOMAIN    POISONING. 
By   J.    \.    ONEILL.    M.D., 

NEW   VORtC. 

I  CALLED  recently  at  a  large  machine  shop  to  attend  a 
workman  who  was  said  to  be  dying.  I  foimd  him 
semiconscious,  his  face  pale,  lips  and  fingernails 
blue,  pupils  contracted,  and  pulse  hardly  perceptible. 
His  respirations  were  sighing  and  occurred  at  alarm- 
ingly long  intervals,  yellow  froth  coming  from  his 
mouth  with  each  expiration ;  involuntary  defecation 
had  also  taken  place. 

I  suspected  opium  poisoning  but  thought  the  patient 
too  greatly  depressed  to  stand  an  emetic,  so  I  gave  him 
a  hypodermic  injection  of  strj-chnine  with  a  generous 
amount  of  brandy.  Partly  aroused  by  this  he  was 
soon  able  to  drink  some  strong  hot  coffee  and  to  an- 
swer questions.  He  said  he  had  had  a  diarrhoea  the 
night  before  but  had  taken  no  medicine  or  drug  of 
any  kind.  He  had  eaten  no  breakfast  but  had  drunk 
some  milk  from  a  tin  canteen. 

Knowing  that  in  the  early  stages  of  putrefaction  of 
nitrogenous  bodies  poisonous  ptomains  are  produced, 
I  changed  my  diagnosis  from  opium  to  tyrotoxicon 
poisoning.  Ptomain  poisoning  frequently  resembles 
that  of  the  vegetable  alkaloids,  such  as  morphine,  co- 
deine, veratrine,  etc. 

A  mention  of  this  case  seems  timely  during  the 
present  hot  weather,  and  may  aid  some  fellow  prac- 
titioner to  a  diagnosis  when  confronted  by  similar 
ambiguous  symptoms. 

iiS  West  EiCHT%--FaiRTH  Sikeet. 


MENSTRU.ATION    AND    EPILEPSY. 
By   D.   T.    MARSHALL,  M.D., 

NEW    VORK. 

The  following  table  was  compiled  from  the  histories 
of  ten  epileptic  girls,  to  see  whether  the  epileptic  at- 
tacks were  in  any  way  influenced  by  the  occurrence  of 
the  menstrual  flow.  The  figures  in  the  table  are  the 
totals  for  the  months  during  which  the  obser\'ations 
were  made,  and  do  not  indicate  whether  the  attacks 
were  more  numerous  immediately  before  or  after  the 
periods.  Examination  of  the  histories,  however,  would 
show  that  the  attacks  were  about  evenly  distributed 
throughout  the  months,  the  periods  apparently  having 
no  influence.  Of  thirty  girls  under  obser\ation  but 
four  gave  any  history  of  an  aura.  Of  these  one  says 
she  feels  faint  for  a  second  before  the  attack.  An- 
other says  she  feels  as  though  she  were  going  to  fall 
into  a  pit  of  fire. 


Case  Number. 

Age. 

Time  under 

Observation, 

Months. 

Total 
Number  of 
Attacks. 

.Attacks  dur- 

inc'  Menstruml 

Period. 

1 

24 
I^ 
16 
14 
18 
16 
14 

«7 
18 
14 

6 
S 
6 
S 
4 
4 
4 
5 
•3 
3 

16 

118 
49 
49 

27 
74 
28 
326 
149 
186 

3 

8 
4 

S 

8 

6         

IS 

4 

S 

46 

23 

13 

August  14.  1897] 


MEDICAL    RECORD. 


241 


J»ocTCtr(  Reports. 

THE  NEW    YORK    ACADEMY   OF   MEDICINE. 

Stated  Meeting,  June  j,  iSgj. 

Edward    G.    Janew.w,    M.D.,    President,    ix    ihe 
Chair. 

Public  Baths After  a  brief  discussion  the  resolution 

offered  at  ttie  last  meeting  to  appoint  a  committee  to 
urge  on  the  city  authorities  the  erection  of  public 
baths  was  adopted,  and  Drs.  Simon  Baruch,  George 
Fowler,  and  Richard  Yan  Santvoord  were  appointed 
on  the  committee. 

Persistent  Tachycardia  with  Digestive  and  Ner- 
vous Disorders. — Dr.  William  Thomson  read  the 
paper  upon  this  subject  (see  page  217). 

Dr.  C.  L.  Dana  said  he  had  looked  over  his  cases 
and  found  that  he  had  a  record  of  twenty-six  with  per- 
sistent tachycardia  due  to  organic  disease  of  the  lieart, 
eight  to  neurasthenia,  four  to  melancholia,  eight  to 
Graves'  disease,  two  to  typhoid  fever,  two  to  paralysis 
agitans,  and  two  to  locomotor  ata.xia.  Some  of  these 
cases  gave  a  good  many  of  the  symptoms  described  in 
the  paper,  but  he  had  found  no  case  which  he  could 
not  explain  on  some  other  ground  than  that  presented 
by  the  writer.  In  some  neurasthenic  cases  he  thought 
the  heart  was  small  and  weak,  perhaps  congenilally  so, 
and  the  nerve  force  was  small.  Another  class  of  cases 
was  those  of  women  nearing  the  menopause.  The 
tachycardia  in  the  melancholic  cases  was  of  psychical 
origin.  Grippe  sometimes  left  taclrycardia  that  was 
very  persistent,  but  he  thought  that  was  due  to  injury 
to  the  vagus  nerve  or  to  the  ganglia  of  the  heart.  He 
could  not  understand  how  the  alimentary  tract,  which 
is  not  a  secreting  gland,  could  be  constantly  throwing 
to.\ins  into  the  system  and  thus  causing  persistent 
tachycardia. 

Dr.  Richard  Yan  Santvoord  said  that  the  inter- 
pretation of  the  cases  seemed  to  him  in  the  main  cor- 
rect It  seemed  that  Graves'  disease  was  somewhat 
analogous,  probably  due  to  a  poison  from  the  thyroid 
gland.  He  had  been  able  to  explain  his  cases  on 
ground  other  than  that  of  the  writer.  He  had  one 
case  of  tachycardia  in  which  there  were  mild  attacks 
of  to-^caemia  for  four  years,  but  the  tachycardia  could 
be  e.xplained  as  neuralgic. 

Dr.  Janewav  said  he  thought  the  ground  had  been 
about  covared.  It  was  a  question  whether  these  cases 
should  be  considered  as  arising  from  toxeemia  or  from 
disturbance  of  nervous  tone.  He  had  had  two  cases 
which  interested  him  especially,  one  in  a  lawyer,  the 
other  in  a  physician.  Both  had  a  very  large  output  of 
urea  and  he  thought  the  tachycardia  might  be  due  to 
that.  He  was  not  ready  yet  to  express  a  positive 
opinion  on  the  theory  of  toxa;mia  from  the  digestive 
tract. 

Dr.  Tho.mson  said  in  conclusion  that  his. subject 
disposed  of  the  argument  of  Dr.  Dana.  He  knew 
there  were  many  cases  of  tachycardia  due  to  the 
causes  mentioned,  but  the  paper  dealt  with  tachy- 
cardia with  pronounced  gastric  symptoms  and  not  the 
ones  referred  to  by  Dr.  Dana.  It  was  possible  by  hav- 
ing patients  eat  bread  and  meat  to  prove  that  cases 
such  as  those  mentioned  could  be  due  to  auto-infec- 
tion. The  tachycardia  could  be  induced  by  changing 
diet  and  reduced  by  returning  to  milk  diet.  He  would 
also  say  that  in  many  cases  melancholia  came  from  the 
alimentarj-  tract 

No  Smallpox  in  New  York.— The  last  case  of 
smallpox  in  this  city  was  reported  on  July  14th,  and  the 
Board  of  Health  announces  that  the  epidemic  is  over. 


MEDICAL    SOCIETY    OF   NEW    JERSEY. 

One  Hundred  and  Thirty-First  Annual  Meeting,  Held 
at  Atlantic  City,  June  22  and  2j,  ^Sgy. 

T.  J.   Smith,  M.D.,  of  Bridgeton,  President. 

The  session  was  opened  with  prayer  by  Rev.  W.  M. 
White.  The  secretary,  Dr.  William  Pierson,  called 
the  roll.  The  mayor  of  the  city,  Hon.  F.  P.  Story, 
then  made  a  brief  address,  welcoming  the  society  again 
to  .\tlantic  City,  where  its  meetings  had  been  held 
several  times,  the  last  time  five  years  ago.  He  was 
followed  by  Dr.  Boardman  Reed,  chairman  of  the 
committee  of  arrangements,  who  announced  an  excur- 
sion, reception,  and  entertainments.  Dr.  H.  R. 
Baldwin  read  the  report  of  the  committee  on  business, 
by  which  it  appeared  that  under  the  new  bylaws  sev- 
eral of  the  papers  were  to  be  in  the  nature  of  a  resume 
of  therapeutics  in  different  departments  of  medicine 
for  the  year,  prepared  by  members  of  the  standing 
committee.  Dr.  Reading  announced  that  the  pho- 
tographer awaited  the  pleasure  of  the  society,  and  1  )r. 
Pierson  hoped  he  would  have  to  wait  until  he  became 
as  tired  as  the  society  had  in  the  past.  A  number  of 
gentlemen  were  invited  to  sit  as  corresponding  mem- 
bers. Dr.  H.  W.  Elmer  reported  that  the  committee 
on  ethics  had  not  come  to  a  decision  in  one  case,  but 
later  reported  for  the  committee,  dismissing  the  charges. 
The  report  of  the  treasurer,  Dr.  Alfred  Mercer, 
showed  a  deficiency  of  assessment  to  meet  running 
expenses,  and  United  States  bonds  had  been  deposited 
to  secure  a  loan.  Later  a  motion  to  sell  one  of  the 
society's  four  $1,000  bonds  to  meet  expenses  in  prefer- 
ence to  borrowing  was  voted  down,  as  a  dangerous 
precedent  in  invading  the  permanent  fund.  The  as- 
sessment for  the  coming  year  was  made  $2.  Dr.  E. 
L.  B.  Godfrey  read  his  report  as  corresponding  sec- 
retary, which  showed  considerable  correspondence  in 
relation  to  appropriation  for  State  laboratory,  vivisec- 
tion in  the  District  of  Columbia,  with  district  societies, 
etc.  The  President  appointed  on  the  auditing  com- 
mittee Drs.  Baldwin,  Hollister,  and  Blake,  who  found 
the  treasurer's  account  correct.  Dr.  H.  G.  Taylor 
reported  that  the  committee  on  honorary  membership 
had  had  no  name  submitted  to  it,  whereupon  Dr. 
Pierson  nominated  Dr.  Pennington,  of  Newark,  for 
honorary  membership,  his  name  to  go  to  the  commit- 
tee for  report  next  year. 

Bovine  Tuberculosis.  —  Dr.  J.  W.  Stickler,  of 
Orange,  chairman  of  the  committee  on  legislative  ac- 
tion on  bovine  tuberculosis,  stated  in  his  report  that 
the  committee  thought  it  could  do  something  toward 
securing  a  more  effective  legislative  measure  for  the 
eradication  of  bovine  tuberculosis  in  the  State  if  it 
were  authorized  to  act  with  certain  other  bodies,  in- 
cluding the  State  board  of  health  and  the  dairy  com- 
mission. On  motion  the  committee  was  continued 
and  authorized  to  act  in  conjunction  with  the  bodies 
named. 

State  Laboratory  at  Princeton. — Dr.  D.  M.  Skin- 
ner, chairman  of  a  committee  which  had  been  ap- 
pointed last  year  to  go  before  the  legislature  to  urge 
the  passage  of  the  bill  appropriating  money  to  the 
laboratory  of  bacteriology  at  I'rinceton,  reported  that 
the  committee  had  been  successful  in  its  mission,  and 
$3,000  had  been  appropriated. 

Report  of  Standing  Committee.— Dr.  H.  W.  Elmer 
read  the  report,  which  was  supplemented  later  by  re- 
views of  the  progress  of  medicine  in  its  different 
branches  by  the  other  members  of  the  committee.  It 
appeared  by  Dr.  Elmer's  report  that  a  local  societ)"  ex- 
isted in  Atlantic  City,  called  the  Atlantic  City  Academy 
of  Medicine.  Most  of  the  county  societies  held  only 
two  meetings  during  the  year,  one  in  the  spring  and 
one   in   the  autumn.      In  some  portions  of  the   State 


242 


MEDICAL    RECORD. 


[August  14,  1897 


there  had  been  a  good  deal  of  typhoid  fever.  The  gen- 
eral death  rate  per  thousand  in  Atlantic  City  had  been 
only  6.5  per  cent.,  which  was  extraordinarily  low. 

.Expert  Testimony Dr.  William   H.   Iszard,  in 

the  last  part  of  a  paper  reviewing  the  subject  of  ex- 
pert testimony,  pointed  out  the  desirability  of  a  change 
in  the  law,  which  seemed  likely  to  take  place  in  New 
York  and  some  other  States,  making  the  medico-legal 
expert  an  officer  of  the  court  rather  than  an  tx-/>a>ie 
witness  for  the  side  of  the  prosecution  or  defendant. 

Surgery. — Dr.  Charles  Young,  in  a  review  of  the 
surgery  of  the  year,  referred  to  Murphy's  report  of 
two  cases  of  end-to-end  suture  after  resection  of  large 
blood-vessels  injured  in  continuity;'  to  a  new  mode 
of  ligaturing  which  permitted  removal  of  the  ligature 
without  cutting  and  which  had  been  employed  in  the 
Woman's  Hospital;  to  .Stimson,  on  the  use  of  saline 
injections  in  extreme  shock ;  to  Wyeth,  on  local  anaes- 
thesia by  cocaine ;  to  the  report  in  27ie  Lancet  of  a 
case  of  tetanus  which  recovered  under  mercuric  bin- 
iodide;  to  the  use  of  anti.streptococcus  serum;  to  arti- 
cles on  gunshot  wounds  of  the  head,  wounds  of  the 
air  passages,  injuries  of  the  liver  in  which  exploratory 
laparotomy  was  recommended,  blunt  needle  for  liga- 
tion of  liver  vessels,  use  of  catgut  ligature.  Articles 
on  perforating  gastric  ulcer  pointed  out  the  necessity 
for  operation.  One  operator  had  reported  five  cases, 
with  four  recoveries.  One  patient,  operated  upon  fifty 
hours  after  perforation,  had  recovered.  Surgery  had 
been  shown  to  be  the  only  rational  treatment  of  ty- 
phoid ulcer  with  perforation.  The  rules  laid  down 
by  Shrady  for  operation  in  appendicitis  were  read. 
In  the  treatment  of  fractures  Woolsey  considered  the 
ambulatory  plan  as  ideal. 

State  Medicine  and  Hygiene.  —  Dr.  Henry 
Mitchell,  of  Asbury  Park,  stated  in  his  review  of  this 
department  that  many  new  facts  were  continuing  to  be 
brought  out  which  had  important  bearing  upon  hygiene 
and  State  medicine.  In  laboratory  work  the  depart- 
ment of  bacteriology  had  been  most  rewarded.  Alen- 
tion  was  made  of  Koch's  discovery  in  prevention  of 
the  rinderpest,  of  diphtheria  antito.xin,  of  sero-diagno- 
sis  of  typhoid  fever,  of  the  po.ssibility  of  oysters  con- 
veying infectious  germs,  of  the  increasing  use  of  for- 
maldehyde in  disinfection,  of  the  aseptic-tank  system 
of  treating  sewage,  of  the  pasteurization  or  steriliza- 
tion of  milk,  of  the  appointment  of  medical  school  in- 
spectors, which  he  hoped  would  come  to  be  done  in 
New  Jersey. 

Diseases    of    Nose    and    Throat Dr.   FAVErrK 

treated  of  this  topic.  He  spoke  of  advantages  of  the 
forehead  electric  lamp  over  the  head  mirror,  and  of 
the  fact  that  autoscopy  seemed  to  be  viewed  with 
greater  favor  by  some  than  was  laryngoscopy.  The 
-v-ray  gave  promise  of  some  utility  in  diagnosis  of  the 
upper  air  passages.  Dr.  French  had  been  prosecuting 
laryngeal  photograpliy  with  success.  The  treatment 
of  goitre  with  thyroid  had  shown  good  results  in  youth, 
but  the  likelihood  of  recovery  from  any  mode  of  treat- 
ment was  slight  in  adults.  Relapses  were  the  rule. 
The  relation  of  ear  disease  to  postnasal  adenoids  had 
received  considerable  attention.  The  indications  for 
operation  depended  upon  the  mischief  produced  by 
the  adenoids  rather  than  upon  their  quantity.  Men- 
tion was  also  made  of  the  relation  of  the  uric-acid  dia- 
thesis to  hay  fever.  A  constantly  increasing  volume 
of  testimony  had  been  recorded  in  favor  of  the  exist- 
ence of  this  diathesis. 

Eye  and  Ear. — Dr.  Cham  hers,  of  Jersey  City, 
presented  a  review  of  this  department.  He  spoke  of 
the  use  of  formaldehyde  as  a  disinfectant;  of  one  au- 
thor's observation  of  blennorrha'ic  ojihthalmia  in  spite 
of  the  use  of  the  Crede  method;  of  the  Roentgen  ravs 
in  disclosing  small  pieces  of  metal  in  the  lens;  of 
'  Medical  Recorii,  January  16,  1897. 


the  treatment  of  prolapse  of  the  iris  by  excision  if  seen 
at  once,  tentatively  if  seen  after  a  few  days;  of  tinnitus 
aurium  in  ear  affections;  of  surgery  of  the  ear,  of  the 
sinuses,  or  of  the  brain  in  cases  of  abscess,  etc. ;  of 
Tiffany's  preference  for  chloroform  anaesthesia  in  brain 
surgery.  Buck  he  said  had  called  attention  to  the  con- 
nection of  gout  with  diseases  of  the  ear,  and  various 
other  things. 

President's  Address. —  Dr.  T.  J.  Smith,  of  Bridge- 
ton,  chose  for  the  subject  of  his  address,  "The  Prob- 
lem of  Dependency.''  As  a  director  in  the  New  Jer- 
sey training-school  for  feeble-minded  children,  he 
had  given  a  good  deal  of  thought  to  this  subject,  and 
it  had  again  been  strongly  forced  upon  his  attention 
by  the  failure  of  the  governor  to  approve  the  bill  pro- 
viding for  an  epileptic  colony.  The  law  of  the  sur- 
vival of  the  fittest  did  not  release  us  from  our  obliga- 
tions to  the  dependent.  Compassion,  charity,  and  love 
were  above  natural  law  in  the  restricted  sense.  Com- 
passion was  not  natural ;  it  was  supernatural.  Besides, 
these  people  who  required  charity  were  the  fruit  of 
our  civilization,  which  made  it  but  just  that  those 
endowed  with  strength  and  wisdom  should  help  the 
weak.  Yet  the  problem  of  dependency,  with  the  proper 
conception  of  its  varied  causes  and  results,  had  been 
a  perplexing  one  since  the  inquiry,  "  Am  I  my  broth- 
er's keeper?''  was  first  propounded.  The  failing  ranks 
of  the  human  race  were  ever  to  be  replaced  with  a 
certain  proportion  of  the  degenerate,  the  inefficient, 
and  the  vicious.  Shall  the  stringent  process  of  law 
or  the  gentler  influence  of  benevolence  prove  to  be 
more  successful  agency  in  dealing  with  such  per- 
sons? Social  reforms  moved  slowly.  It  was  much 
easier  to  walk  in  the  old  ways  than  to  search  out  new. 
True  reform  was  accomplished  by  persistent  effort 
wisely  directed.  We  could  not  discharge  our  duty  to 
those  in  want  by  simply  flinging  them  a  gift  in  pass- 
ing. When  the  law  of  benevolence  supplanted  that  of 
mere  friendship,  it  had  marked  the  transition  from  a 
pagan  to  a  Christian  civilization.  The  president  then 
took  up  the  subject  of  the  care  of  epileptic  depen- 
dents, and  advocated  the  adoption  of  a  method  which 
had  prevailed  for  years  in  France  and  Germany  of 
caring  for  them  in  colonies,  a  method  which  had  re- 
ently  been  put  to  a  practical  test  in  New  York,  at  the 
Craig  Epileptic  Colony.  It  was  shown  that  epilep- 
tics improved,  that  some  of  them  were  permanently 
cured  at  these  colonies,  that  they  became  useful  and 
contented  in  their  several  occupations  and  largelv  self- 
supporting.  At  present  in  New  Jersey  they  crowded 
the  asylums  for  the  insane  and  the  poorhouses,  and 
created  much  alarm  among  other  inmates  when  their 
paroxysms  occurred.  At  the  laboratory  the  pathology 
of  the  disease,  about  which  we  now  knew  little,  could 
be  studied.  It  was  estimated  that  in  New  Jersey  there 
were  from  two  to  three  thousand  epileptics,  and  in  the 
United  States  one  hundreil  and  thirty-five  thousand. 
The  legislature  had  made  a  small  appropriation  for 
the  starting  of  an  epileptic  colony,  but  the  governor 
had  vetoed  the  bill.  It  was  necessary,  therefore,  that 
the  society  should  continue  its  educational  work. 

Dr.  Marsh  moved  that  a  committee  of  five  be  ap- 
pointed to  present  the  subject  of  establishing  an  epi- 
leptic colony  before  the  legislature,  if  it  thought  best. 
The  motion  was  adopted,  hut  Dr.  Marsh  declined  an 
appointment  on  the  committee,  because  he  had  no 
positive  views  on  the  subject. 

Some  Important  Points  in  the  Treatment  of 
Pneumonia.  1)r.  I,.  I-.  I'.isndf  read  the  paper  (see 
page  2j8). 

Foreign  Bodies  Found  in  the  Stomach  of  an  In- 
sane Man.  Dk.  !'..  D.  K\  ans  exiiibitod  half  a  dozen 
spoons,  over  a  dozen  stones  of  various  sizes,  and 
as  many  otiier  hard  objects,  which  were  found  in  the 
stomach  of  a  man  who  had  died  recentlv  of  chronic 


August  14.  1897] 


MEDICAL    RECORD. 


243 


insanit)-  in  the  asylum  at  Morris  Plains.  About  four 
months  before  his  death  he  had  been  detected  swal- 
lowing the  handle  of  a  spoon,  and  then  confessed 
having  swallowed  various  objects  with  the  intention  of 
committing  suicide,  for  he  had  been  placed  under 
guard  for  other  attempts  upon  his  life.  There  had 
been  nothing  to  direct  attention  to  his  stomach  until 
he  was  seen  to  swallow  the  spoon  handle.  Hard  ob- 
jects could  be  felt  on  palpation,  but  no  operation  was 
undertaken.  It  was  only  when  i  losely  questioned 
that  he  had  admitted  having  a  gnawing  sensation 
in  the  stomach.  A  number  of  stones  had  passed  by 
the  anus.  He  died  of  dementia,  and  autopsy  showed 
nimierous  stones,  spoons,  etc.,  in  the  stomach  and  in- 
testine. 

A  Criticism  of  Modified  Milk  of  Present  Dairy 
Methods. — Dr.  Richard  C  Xewtun,  of  Montclair. 
read  the  paper.  When  we  considered  the  fact  that  the 
science  of  ractology,  if  he  might  be  allowed  to  coin  a 
term,  was  only  about  a  dozen  years  old,  it  gave  prom- 
ise of  great  things.  It  was  likely  that  milk  would 
come  more  and  more  into  demand  as  a  food  product 
as  time  went  on.  The  advance  made  in  the  subject 
of  lactology  the  last  few  years  had  been  remarkable, 
and,  with  discoveries  likely  soon  to  be  made  in  bacte- 
riological lines,  promised  to  revolutionize  many  meth- 
ods now  in  use  in  dairies.  It  must  be  admitted,  how- 
ever, that  at  present  we  could  not  base  the  feeding  of 
infants  upon  our  knowledge  of  the  chemistry  and  bac- 
teriology of  milk.  Often  trial  alone  would  determine 
whether  the  milk  of  a  given  animal  would  agree  with 
an  infant,  or  how  it  required  to  be  modified.  He  had 
come  to  the  conclusion  some  years  ago,  and  e.xperience 
had  confirmed  him  in  the  opinion,  that  the  sooner  milk 
was  fed  to  the  infant  after  being  taken  from  the  udder 
the  better,  and  the  less  it  was  shaken  the  better.  Clin- 
ical illustrations  were  given.  The  author  considered 
the  various  subjects  of  sterilization,  pasteurization, 
alkalinity  or  acidity  of  milk,  danger  of  infection,  com- 
parative value  of  milk  from  different  animals  for  in- 
fants, etc. 

In  the  Treatment  of  Appendicitis,  is  the  Free 
Use  of  the  Knife  Necessary? — This  was  the  subject 
for  discussion  decided  upon  at  the  last  annual  meeting. 
The  discussion  was  opened  by  Dr.  G.  H.  Bai.i.er.av, 
of  Paterson  (see  page  231). 

Dr.  H.  R.  Baldwin  related  clinical  experience 
which  led  him  to  think  that  many  cases  of  appendi- 
citis recovered  without  operation.  His  treatment  had 
been  to  move  the  bowels  and  to  poultice  outside  and 
inside — flaxseed  outside  and  Indian  meal  inside. 

Dr.  I.  N.  QviMP.v  said  that  while  he  was  fond  of 
operating  he  really  thought  the  physician  should  be 
first  to  take  charge  of  cases  of  appendicitis.  There 
was  some  disposition  to  substitute  the  knife  for  thera- 
peutics, which  he  thought  was  a  great  mistake. 

Dr.  M.  Lampsox,  of  Jersey  City,  said  the  burning 
question  to-day  was  when  to  operate,  if  at  all.  On 
the  one  hand  there  were  surgeons,  he  believed,  who 
recommended  operation  in  every  instance — if  not  at 
the  moment  yet  at  some  time,  perhaps  between  attacks. 
Then  there  were  physicians  who  were  too  conser\-ative 
and  too  slow  to  permit  operation.  It  had  been  shown 
in  the  discussion  that  forty  per  cent,  of  all  cases  of 
appendicitis  would  recover  even  spontaneously,  and 
some  had  claimed  that  as  many  as  ninety  per  cent, 
would  recover  without  operation.  That  suggested  the 
question:  Would  the  loss  of  life  be  greater  if  no 
operations  were  done?  His  own  experience  witli  op- 
erative interference  had  been  rather  unfortunate,  he 
having  lost  three  out  of  four  cases  last  year. 

Dr.  p.  a.  Harris,  of  Paterson,  recalled  the  teach- 
ing of  .\lonzo  Clark  with  regard  to  peritonitis  and  its 
treatment  by  opium,  and  was  inclined  to  think  that 
many  patients  with  appendicitis  or  conditions  so  diag- 


nosticated would  be  better  off  with  that  treatment.  If 
this  treatment  were  not  carried  out  the  cases  were 
more  likely  to  require  operation. 

Dr.  Newton  defended  two  Xew  York  surgeons 
against  the  charge  that  they  used  the  knife  in  all 
cases. 

Dr.  a.  W.  Sulliv.\n  was  disposed  to  find  the  mush- 
and-poultice  treatment  applicable  in  most  cases. 

Dk.  Barton,  of  Philadelphia,  expressed  his  views 
at  some  length  in  favor  of  surgery,  which  he  found  in- 
dicated in  many  cases. 

Dr.  Ill  believed  that  he  operated  in  not  more  than 
one  of  half  a  dozen  cases  of  appendicitis  seen.  He 
regretted  very  much  that  Dr.  Harris  had  commended 
the  opium  treatment.  It  locked  the  bowel,  masked 
the  symptoms,  and  did  nothing  but  mischief. 

Dr.  Reillv  gave  some  personal  experience. 

Dr.  Boardman  Reed  said  they  once  called  all  cases 
typhlitis  and  perityphlitis,  and  later  appendicitis. 
At  one  time  he  believed  in  operating  in  nearly  all 
cases,  but  further  experience  had  brought  him  to  me- 
dium ground. 

The  discussion  was  continued  by  Dr.  Rhx;  and 
closed  by  Dr.  Ballerav. 

The  following  committee  was  appointed  on  the 
President's  address  on  the  founding  of  an  epileptic 
colony:  Drs.  Barker,  J.  T.  Smith,  John  W.  Ward.  B. 
1).  Kvans.  and  .Shepherd. 

Headaches,  Auto-Intoxication  a  Factor. — Dr.  Lu- 
ther M.  Halsev,  of  Willijunstown,  chose  this  as  the 
subject  of  his  address  as  third  vice-president.  The 
investigations  of  Bouchard,  Ratchford,  Haig,  Stem- 
berg,  and  others  were  reviewed,  a  few  clinical  cases 
were  read,  and  the  conclusion  was  arrived  at  that  auto- 
infection  had  not  a  little  to  do  with  certain  disturb- 
ances of  the  system,  particularly  nersous  disturbances 
and  headache.  There  could  be  no  doubt  that  the  au- 
thors named  were  working  along  lines  where  they  were 
likely  to  discover  important  causes  of  disease. 

A  Successful  Prize  Essay. — The  Fellows'  Prize 
of  Si 00  was  awarded  to  Dr.  George  Bayles,  of  Orange, 
for  an  essay  on  antitoxin.  An  essay  by  Dr.  Floyd  Ewen 
received  favorable  mention. 

Scarlet  Fever  Reproduced  by  Inoculation,  and 
Some  Important  Facts  Deduced  Therefrom.-  Dr. 
I.  W.  Stickler  presented  a  brief  statement  of  some 
experiments  which  he  had  been  carrying  out  the 
past  six  years.  He  began  with  the  view  of  develop- 
ing an  immunizing  serum  for  scarlet  fever.  Instead 
of  succeeding  in  this  he  had  proven  another  fact  of 
importance.  The  secretions  were  taken  from  the 
throat  of  a  man  ill  with  scarlet  fever,  the  eruption 
having  been  present  two  days.  As  stated,  the  object 
was  to  discover  an  immunizing  serum.  The  secretions 
were  diluted  with  water,  and  also  a  part  with  car- 
bolic acid,  1-600.  Ten  persons  were  inoculated,  six 
of  them  infants,  at  one  time,  the  needle  being  intro- 
duced only  just  under  the  cuticle,  not  into  subcu- 
taneous tissue.  All  developed  typical  scarlet  fever. 
Fortunately  all  recovered.  The  average  period  of 
incubation  was  thirty-two  hours;  average  time  before 
vomiting,  twelve  hours:  average  temperature  range, 
99.22"  F. :  shortest  time  for  desquamation,  three  days; 
longest,  nine  days.  The  experiments  established  these 
facts:  I.  That  the  mucus  of  the  throat  and  mouth 
contained  with  absolute  certainty  the  contagium  of 
scarlet  fever.  2.  That  the  early  eruptive  stage  was 
exceedingly  infective  because  of  the  discharges  from 
the  mouth  and  throat.  The  remaining  conclusions 
referred  to  preventing  the  spread  of  the  contagium, 
especially  from  the  mouth  and  nose. 

The  Present  Status  of  the  Serum  Treatment  of 
Diphtheria. — Dr.  Ale.\.\nder  McAllister,  in  pre- 
senting the  present  status  of  the  serum,  especially  the 
antitoxin,  treatment  of  diphtheria,  pointed  out  that  its 


244 


MEDICAL    RECORD. 


[August  14,  1897 


position  was  becoming  constantly  less  assailable,  and 
that  antitoxin  ought  to  be  used  in  ever>'  case  of  diph- 
theria. In  the  pharyngeal  type  one  should  use  one 
thousand  units  immediately  on  making  the  diagnosis; 
if  the  case  was  seen  later  or  was  of  the  croupous  va- 
riety, he  should  give  two  thousand  units.  If  the 
symptoms  were  not  relieved,  the  dose  should  be  re- 
peated. 

Four  Types  of  Infantile  Diarrhoea,  and  Indica- 
tions for  Treatment Dr.  W.  Edg.ar  D.arn'ell  read 

the  paper.  In  a  concluding  remark  on  treatment  he 
said  it  was  necessarj'  to  eliminate  from  the  bowel  the 
causes  of  the  disturbance  as  far  as  possible,  and  adopt 
measures  which  would  aid  in  restoring  normal  func- 
tions. 

Rush  Monument  Committee. — The  following  com- 
mittee was  appointed  on  raising  money  for  the  Rush 
monument  fund:  Urs.  William  Elmer,  E.  L.  K.  God- 
frey, W.  J.  Chandler,  and  Day. 

Officers President,  D.  C.  English:  First  Vice- 
President,  C.  R.  P.  Fisher;  Second  Vice-President, 
Luther  M.  Halsey ;  Third  Vice-President,  John  J.  H. 
Love,  of  Montclair;  Corresponding  Secretary,  E.  L.  B. 
Godfrey;  Recording  Secretar\,\<l\\\\-!iXaY\e.TSOTi.-,  Treas- 
urer, Alfred  Mercer;  Standing  Committee,  Stephen 
Pierson,  Morris  Iszard. 

Place  of  next  annual  meeting,  Asbury  Park.  June 
28,  29,  30,  1898. 

THE  NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  December  g,  iSg6. 

John  Sl.^de  Ely,  M.D.,  President. 

The  Formation  of  Giant  Cells Dr.  Ann.a  W.  Wil 

LIAMS  exhibited  under  the  microscope  a  number  of 
sections  from  the  lung  of  a  child.  As  these  were  ob- 
tained from  a  laboratory  jar,  labelled  "miliary  tuber- 
culosis in  a  child,"  no  history  bearing  on  the  condi- 
tion was  available.  There  were  two  pieces  of  lung — 
one  from  the  neighborhood  of  the  hilus,  showing  con- 
solidation on  gross  examination  ;  and  the  other,  taken 
from  the  apex,  showing  a  few  scattered  miliary  tuber- 
cles. The  sections  exhibited  were  from  the  first  por- 
tion. From  the  appearance  of  some  of  the  giant  cells, 
the  speaker  said  she  had  been  led  to  conclude  that 
their  mgde  of  formation  was  more  complicated  than 
was  generally  supposed  The  sections  had  been 
stained  for  tubercle  bacilli,  with  positive  results,  and 
serial  sections  had  been  stained  with  hfematoxylon  and 
eosin.  Under  a  low  power  a  large  number  of  giant 
cells  are  to  be  seen,  many  of  them  circular  or  oval. 
having  an  unusually  regular  outline,  suggesting  a 
wall,  and  the  nuclei  arranged  more  or  less  regularlv 
about  the  periphery  within  this  wall.  Other  cells  are 
more  irregular  and  less  well  defined.  These  cells 
are  generally  the  centre  of  a  smaller  group  of  epitheli- 
oid cells.  Under  a  high  power  the  "wall"  is  found 
to  be  composed  of  elongated  cells,  with  oval  nuclei 
such  as  one  sees  in  cross  sections  of  small  bloo<l- 
vessels  or  lymph  vessels.  Within  this  wall  are  more 
oval  nuclei  and  some  spheroidal  cells.  The  centre 
shows  a  granular  and  more  or  less  homogeneous  mass. 
The  serial  sections  show  that  many  of  these  giant 
cells  are  much  elongated  and  branched.  The  branches 
are  narrow  and  oblong,  bounded  by  elongated  nuclei, 
giving  the  appearance  of  a  small  vessel.  The  blood- 
vessels in  these  sections  show  little  change  except  that 
the  smaller  ones  in  the  vicinity  of  the  tubercles  have 
their  walls  infiltrated  with  small  spheroidal  cells. 
The  bronchi  show  the  changes  of  simple  exudative 
inflammation.  From  these  specimens  it  would  seem 
reasonable  to  conclude  that  the  principal  infection 
occurs  through  the  lymph  channels,  that,  the  lympho- 
cyte taking  up  the  tubercle  bacilli  and  becoming  ag- 


glutinated and  degenerated,  small  particles  of  these 
degenerated  masses  pass  to  the  smaller  lymphatics, 
plugging  them  and  causing  a  thrombus.  The  lympho- 
cytes collect  about  the  periphery  of  the  vessel  at  this 
point,  the  endothelial  cells  increase,  and  necrosis  ex- 
tends from  the  centre.  The  observations  made  by 
Borrel  on  the  formation  of  the  giant  cell  in  tuberculo- 
sis, as  published  in  his  article,  "Tuberculose  Pulmo- 
naire  Experimentale,"  '  were  interesting  in  this  con- 
nection. He  inoculated  a  pure  culture  of  tubercle 
bacilli  into  the  ear  vein  of  rabbits,  killing  an  animal 
immediately  after  the  inoculation,  and  others  every  ten 
minutes,  thirty  minutes,  three  hours,  fourteen  hours, 
and  then  every  twent}-four  hours.  Section  of  the 
hardened  lungs  were  studied.  He  found  that  imme- 
diately after  the  inoculation  there  developed  an  in- 
tense polynuclear  leucocytosis,  most  of  the  leucocytes 
containing  bacilli.  After  a  day  this  general  polj'nu- 
clear  leucocytosis  disappeared,  and  only  a  varying 
number  of  groups  of  these  leucocytes  containing  bacilli 
remained  in  the  blood-vessels.  The  evident  decrease 
in  the  number  of  leucocytes  was  due  to  the  fact  that 
the  blood  stream  carried  some  of  them  to  other  parts 
of  the  body,  while  others  passed  through  the  vessel 
wall  into  the  alveoli  of  the  lungs.  On  the  third  day 
the  leucocytes  containing  bacilli  in  the  blood-vessels 
showed  degenerative  changes,  gradually  breaking  up 
and  setting  the  bacilli  free.  As  this  last  change  was 
going  on,  a  number  of  large  mononuclear  leucocytes 
formed  about  the  periphery  of  the  vessel  at  the  place 
where  the  degenerated  polynuclear  leucocytes  were 
grouped,  inclosing  the  degenerated  elements.  Through 
the  fusion  of  these  mononuclear  leucocytes  with  the 
central  detritus,  giant  cells  were  formed.  These  Bor- 
rel called  the  intravascular  giant  cells.  He  did  not 
say  that  he  observed  an  increase  in  the  connective- 
tissue  cells  of  the  blood-vessel  wall,  but  that  this  takes 
place  was  veiy  probable,  especially  when  there  are  few 
bacilli,  or  when  they  are  less  virulent,  or  the  individ- 
ual predisposition  to  tuberculous  infection  was  not 
great.  In  the  present  case  only  a  few  tubercle  bacilli 
were  found,  and  these  were  at  the  periphery  of  the 
more  degenerated  giant  cells. 

Dr.  Henry  Power  said  that  he  thought  some  of 
the  appearances  would  lead  to  the  conclusion  stated 
by  Dr.  Williams  regarding  the  formation  of  the  giant 
cells.  Such  a  conclusion  could  not  be  made  posi- 
tively, ho\ve\er,  without  more  prolonged  study  of  the 
specimens. 

The  President  said  that  the  specimens  certainly 
indicated  that  some  of  the  giant  cells  were  formed  in 
the  manner  claimed.  In  the  cross  sections  many  of 
the  giant  cells  could  be  followed  for  a  considerable 
distance,  and  with  that  regularit)-  which  would  be  ob- 
served if  they  had  been  formed  in  a  channel.  He 
saw  no  reason  why  giant  cells  should  not  be  formed  in 
this  way. 

Dr.  Power  asked  what  prevented  the  larger  lym- 
phatics from  taking  part  in  the  same  change. 

The  President  replied  that  to  get  such  a  formation 
the  lymphatic  to  be  occluded  must  be  rather  small. 
If  a  small  bit  of  cheesy  matter  .should  happen  to  gain 
lodgement,  the  arrangement  would  be  eccentric.  One 
would  hardl)-  expect  that  a  large  particle  would  be 
carried  along  in  this  way. 

Constitutio  Lymphatica.-  Dr.  J.^mes  Ewing  pre- 
sented sijecimens  hardened  in  alcohol  from  a  case  in 
which  death  occurred  from  chloroform  narcosis.  In 
connection  with  lhi.>  case,  he  made  some  remarks  on 
the  subject  of  the  "Constitutio  Lymphatica." 

Dr.  Power  recalled  an  autopsy  in  a  case  of  Base- 
dow's disease,  in  which  the  thymus  gland  was  consid- 
erably enlarged.  The  subject  was  a  woman,  twenty-one 
years  of  age.      The  uterus  and  ovaries  were  undevel- 

'  .Vnnales  de  I'lnstitut  I'.-isteur,  1S93. 


August  14,  1897] 


MEDICAL    RECORD. 


245 


oped,  and  the  kidneys  were  lobulated.  No  other  en- 
larged glands  were  found.  He  did  not  think  that  as 
yet  we  were  justified  in  placing  either  the  thyroid  or 
the  thymus  glands  among  the  lymphatic  glands. 

Dr.  Ewing  said  he  was  not  able  to  say  just  where 
the  thymus  and  thyroid  glands  were  to  be  classed. 
He  thought  a  word  ought  to  be  said  on  the  negative 
side  of  this  subject.  The  lymphatic  constitution  did 
not  seem  to  him  as  yet  an  established  fact.  Many 
victims  of  sudden  death  under  chloroform  had  been 
previously  subjected  to  severe  tests  of  vitality,  and 
had  not  succumbed.  A  fact  in  connection  with 
reports  from  Germany  which  was  of  some  import- 
ance, was  the  freedom  with  which  chloroform  is  ad- 
ministered in  that  country.  The  diagnosis  of  consti- 
tutio  lymphatica  was  accepted  without  comment  in 
Vienna  at  the  present  day,  and  hence  the  condition 
should  receive  more  attention  here. 

Foetal  Endocarditis.  —  Dr.  Martha  Wollsteix  ore- 
sented  a  heart  taken  from  a  baby,  six  weeks  old,  who 
had  been  admitted  to  the  Babies'  Hospital.  On  ad- 
mission there  was  a  loud  systolic  cardiac  murmur, 
heard  with  greatest  intensity  at  a  point  just  below  the 
left  nipple,  but  audible  all  over  the  chest.  Cyanosis 
was  present  only  just  before  death.  The  autopsy 
showed  the  heart  to  be  enlarged,  the  left  ventricle  de- 
cidedly hypertrophied,  the  aortic  orifice  stenosed  to 
about  half  its  normal  size,  and  the  semilunar  valves  so 
agglutinated  that  there  were  only  two  flaps  instead  of 
three.     All  the  other  valves  were  normal. 

The  Diplococcus  Intracellularis  Meningitidis. — 
Dr.  Wollstein  also  presented  a  brain  from  a  boy  who 
had  been  admitted  to  the  hospital  when  five  months 
old,  after  an  illness  of  seven  weeks.  According  to 
the  history  the  child  had  been  perfectly  well  up  to  the 
beginning  of  this  last  illness.  The  onset  was  sudden, 
and  was  marked  by  crying,  vomiting,  and  the  classical 
symptoms  of  meningitis.  Three  days  before  this  the 
child  had  fallen  out  of  bed  on  to  the  floor.  On  ad- 
mission the  child,  although  five  months  old,  weighed 
only  eight  pounds  eleven  ounces.  There  was  marked 
opisthotonos;  the  left  patellar  refle-x  was  exaggerated; 
there  was  a  spastic  condition  of  all  the  muscles;  the 
child  was  entirely  blind;  the  pulse  was  200  and  irreg- 
ular; there  were  no  rales  anywhere  in  the  chest.  The 
tenperature  just  before  death  reached  105.4^  F. 
There  had  not  been  any  true  convulsions,  although 
there  had  been  twitciungs.  The  day  before  his  death 
there  was  a  hemorrhagic  discharge  from  one  ear.  The 
autopsy  revealed  a  thin,  purulent  exudate  over  the 
entire  surface  of  the  brain,  most  marked  on  the  con- 
vexity. While  removing  the  brain  an  abscess  was 
opened  into  on  the  inferior  surface  of  the  cerebellum. 
It  was  about  the  size  of  a  hazelnut.  The  pus  was 
greenish  and  very  viscid,  and  the  convolutions  were 
visibly  flattened.  Both  lateral  ventricles  were  filled 
with  this  same  viscid  pus.  The  third  and  fourth  ven- 
tricles and  their  communication  were  also  distended. 
Permission  could  not  be  obtained  to  remove  the  spinal 
cord,  but  the  membranes,  detached  through  the  fora- 
men magnum,  were  infiltrated.  The  lungs  were  not 
consolidated  an)-where.  but  they  were  very  hyperajmic 
and  somewhat  (Edematous.  A  small  infarction  was 
found  in  the  upper  border  of  the  left  lower  lobe.  The 
liver  was  iatty.  There  were  no  other  lesions.  The 
petrous  portions  of  both  temporal  bones  were  exam- 
ined, and  found  to  be  normal.  On  making  cover-glass 
smears  from  the  pus  and  staining  by  Baumgarten's 
method,  verj-  few  organisms  were  found,  and  these  were 
all  diplococci.  They  did  not  resemble  the  pneumo- 
coccus.  They  were  not  decolorized  by  Gram's  stain. 
Cultures  on  glycerin  agar  from  the  ventricles  and 
cerebellar  abscess  showed  in  twenty-four  hours  a  gray- 
ish growth,  which  was  much  more  abundant  dian 
would  have  been  obtained  from   a  pneumococcus  cul- 


ture at  this  time.  On  the  second  day  there  were 
larger  colonies  than  would  have  been  present  from  a 
pneumococcus  culture.  In  neutral  bouillon  the  growth 
was  more  luxuriant  than  a  pneumococcus  growth.  A 
white  mouse  was  given  a  subcutaneous  injection  of  a 
pure  bouillon  culture.  It  remained  well.  After 
seven  days  it  was  killed,  and  the  blood  was  found  to 
be  perfectly  sterile.  Dr.  Wollstein  concluded,  there- 
fore, that  the  organism  in  this  case  was  the  diplococcus 
intracellularis  meningitidis  described  in  1887  by 
Weichselbaum.  This  organism  was  found  by  Jaeger 
to  be  longer  lived  than  the  diplococcus,  and  where 
chains  were  formed  there  were  longitudinal  lines  of 
division.  Weichselbaum  described  the  diplococcus 
as  decolorized  by  Gram's  stain,  but  Jaeger  had  stated 
that  the  smears  remained  stained,  although  the  sec- 
tions were  decolorized.  It  was  very  difiicult  to  de- 
monstrate the  organism  in  sections,  .\nilin  oil  and 
gentian  violet,  followed  by  acetic  acid  and  alcohol, 
constituted  the  best  stain  for  the  sections. 

A  Chondro-Epithelioma  i?).— Dr.  Henry  Power 
presented  a  microscopical  section  of  a  tumor  found  in 
the  subcutaneous  tissue  in  front  of  the  angle  of  the 
jaw  in  a  girl  of  eighteen.  The  tumor  had  been  there 
for  some  time,  but  had  grown  rapidly  during  the  last 
two  months.  It  was  encapsulated  and  had  a  distinct 
hiluni.  It  was  easily  removed.  On  section  it  was 
quite  dense.  There  was  a  considerable  quantity  of 
cartilage  in  the  tumor,  both  normal  and  degenerated, 
and  scattered  through  this  was  a  deposit  resembling 
in  some  respects  carcinoma.  He  presented  the  speci- 
men for  a  diagnosis. 

Dr.  Ewing  said  that  he  had  seen  a  tumor  from  the 
supraclavicular  region  which  had  presented  an  almost 
identical  structure.  The  specimen  presented  sug- 
gested, of  course,  the  possibility  of  its  being  an  endo- 
thelioma. 

The  President  also  looked  upon  the  specimen  as 
probably  an  endothelioma. 

Globular  Thrombus  in  the  Heart. — Dr.  Harlow 
Brooks  presented  a  tumor  removed  from  the  right 
auricle  of  the  heart  of  a  boy.  When,  eight  years  old 
the  child  had  had  an  attack  of  scarlatina.  About  tivo 
weeks  ago  there  was  found  to  be  considerable  adema, 
and  he  was  brought  to  the  hospital.  Examination  of 
the  urine  showed  evidence  of  acute  nephritis.  Physi- 
cal examination  of  the  chest  showed  mitral  stenosis 
and  a  double  aortic  lesion.  It  was  found  necessary 
to  tap  the  abdomen  twice,  and  to  drain  the  fluid  from 
the  lower  extremities.  Bacteriological  examination  of 
the  urine  and  of  the  fluid  taken  from  the  abdomen  was 
negative.  At  the  autopsy  the  remarkable  feature  was 
the  heart,  which  was  ver)-  much  dilated  on  the  right 
side,  while  the  left  side  was  contracted  and  the  aortic 
segments  were  much  thickened.  The  mitral  valves 
were  very-  indistinct,  and  the  papillary  muscle  had 
also  become  fused  by  an  endocarditis.  The  right 
auricle  contained  the  specimen  presented — a  mass 
which  appeared  to  be  a  globular  thrombus.  It  lay  in 
the  auricle  perfectly  free.  In  the  fresh  state  its  sur- 
face had  presented  a  slightly  papular  appearance. 
A  hasty  reference  to  the  literature  seemed  to  indicate 
that  this  was  a  very  rare  condition.  He  found  it  diffi- 
cult to  understand  how  such  a  body  could  exist  in  the 
auricle  during  life  without  having  been  detected  by 
physical  examination.  There  were  many  areas  of 
hemorrhagic  infarctions  in  the  lungs. 

The  President  said  that  he  had  never  seen  just 
such  a  thrombus,  although  he  recalled  having  seen  a 
pedunculated  thrombus  presented  to  this  society  some 
years  ago.  The  explanation  of  these  cases,  as  oftered 
by  Dr.  Osier,  was  that  there  was  originally  a  thrombus 
with  a  slender  pedicle,  and  that  this  had  been  broken 
ofif. 

The  societ}'  then  went  into  executive  session. 


246 


MEDICAL    RECORD. 


[August  14,  1897 


Stated  Meeting,  December  23,  j8g6. 
John  Slade  Ely,  M.D.,  President. 

A  Pancreatic  Cyst Dr.  Warren  Coleman  pre- 
sented a  pancreatic  c)'st  removed  from  a  woman,  sixt)- 
years  of  age,  who  died  of  pulmonary  tuberculosis  in 
Bellevue  Hospital,  in  the  ser\-ice  of  Dr.  \V.  Oilman 
Thompson,  through  whose  kindness  he  was  permitted 
to  report  the  case.  Aside  from  the  condition  of  the 
pancreas,  the  details  of  the  autopsy  were  uninteresting 
in  this  connection.  While  removing  the  intestine  a 
distinct  prominence  was  noted  in  the  pancreatic  region 
between  the  stomach  and  transverse  colon.  It  was 
found  to  be  a  cyst  with  fluid  contents.  The  cyst,  with 
the  adjacent  structures,  including  a  portion  of  the 
duodenum,  was  removed.  It  was  bilocular,  consisting 
of  a  large  and  a  smaller  division,  communicating  by  a 
large  opening.  A  dense  band  of  fibrous  tissue  e.x- 
tended  across  this  opening.  The  cyst  contained,  but 
was  not  entirely  filled  by,  a  yellowish-brown,  turbid 
liquid,  in  which  were  numerous  small,  shining,  flat 
yellow  crystals.  The  wall  of  the  cyst  consisted  of 
dense  fibrous  tissue,  with  circumscribed  thickenings 
on  its  inner  surface.  The  total  length  of  the  cyst  was 
1 1.5  cm.,  the  larger  division  measuring  8x10,  and  the 
smaller  3x6  cm.  The  thickness  of  the  wall  was  2.5 
cm.  On  the  inner  side  of  the  wall  of  the  cyst  toward 
the  duodenum  was  a  distinct  papilla  with  a  central 
opening,  which  admitted  a  filiform  bougie.  The  bou- 
gie passed  out  into  the  duodenum,  through  the  biliary 
papilla.  The  ductus  communis  choledochus  joined 
the  pancreatic  duct  in  the  wall  of  the  duodenum.  At 
first  it  appeared  that  all  of  the  pancreatic  tissue  had 
disappeared,  but  on  careful  dissection  it  was  found 
that  several  small  masses  were  still  present  between 
the  cyst  and  duodenum,  and  that  there  was  a  small, 
single  mass  at  the  extreme  tip  of  the  smaller  division 
of  the  cyst.  Sections  taken  from  the  wall  of  the 
larger  and  smaller  divisions  of  the  cyst  show  that 
there  was  no  definite  lining  membrane.  The  wall  was 
composed  of  dense  fibrous  tissue,  which  toward  the 
cavity  of  the  cyst,  however,  formed  a  more  or  less 
open  meshwork,  in  which  were  chiefly  small-round 
cells  and  a  few  larger,  round,  flattened  cells.  Young 
connective-tissue  cells  were  also  to  be  seen. 

From  these  appearances  it  would  seem  that  the  cyst 
wall  was  adding  to  its  thickness  from  within.  The 
circumscribed  thickenings  on  the  inner  surface  of  the 
larger  division  possessed  essentially  the  same  struc- 
ture. They  contained,  however,  numerous  pigmented 
cells  and  a  few  giant  cells,  and  were  plentifully  sup- 
plied with  blood.  The  pigment,  when  tested  with 
potassium  ferrocyanide  and  dilute  hydrochloric  acid, 
failed  to  give  the  reaction  for  iron. 

Albumin  and  mucus  were  present  in  abundance  in 
the  cyst  contents.  No  sugar  was  found  by  Fehling's 
test,  nor  did  Gmelin's  test  reveal  the  presence  of  any 
bile  pigments.  The  crystals  already  mentioned  were 
cholesterin.  In  addition,  numerous  small  acicular 
crystals  were  present.  A  small  number  of  round,  flat- 
tened epithelioid  cells  were  found.  A  moderate  num- 
ber of  white  and  red  blood  cells  were  found,  but  they 
were  supposed  to  have  gained  entrance  on  the  knife 
and  scissors  used  to  open  the  cyst. 

Experiments  were  undertaken  to  determine  the  physi- 
ological properties  of  the  liquid.  Three  test  tubes 
were  filled  with  a  dilute  .solution  of  boiled  starch,  and 
varying  amounts  of  the  cyst  contents  were  added  to 
them.  They  were  put  into  an  incubator  for  twenty- 
four  hours,  after  which  they  were  examined.  The 
tube  containing  the  greatest  amount  of  cyst  contents 
.showed  complete  conversion  of  the  starch  into  sugar, 
while  the  other  two  contained  in  addition  to  sugar 
some  unaltered  starch  and  erythrodc.\trin.  The  tests 
used  were   Fehling's  solution  and   iodine.     Unfortu- 


nately lack  of  time  prevented  examination  for  the 
presence  of  trypsin.  The  emulsifying  terment  was 
not  present.  Fitz  ("American  Te.xt-Book  of  Medi- 
cine'') states,  however,  that  in  cysts  of  long  standing 
one  or  more  of  the  ferments  may  be  absent,  and,  on 
the  contrary.  Boas  and  Jaksch  believe  that  liquids  pos- 
sessing these  physiological  properties  are  not  neces- 
sarily derived  from  the  pancreas,  since  other  pathologi- 
cal liquid  accumulations  might  possess  one  or  all  of 
them. 

Fitz  also  divides  cysts  of  the  pancreas  into  three 
classes,  viz. :  the  retention  cyst,  the  cystoma  resembing 
cystomata  of  the  ovary,  and  a  form  which  appears  to  be 
on  the  border  line  between  these  two.  Both  of  the 
former  varieties  might  be  multilocular.  This  author 
says  that  "  in  typical  cases  from  dilatation  the  duct 
(of  Wirsung)  may  be  traced  from  the  duodenum  into  the 
cavity  of  the  cyst,  and  from  the  tail  into  the  same  cav- 
ity. At  times  the  duodenal  end  of  the  duct  is  obliter- 
ated in  the  immediate  vicinity  of  the  cyst  wall." 

The  speaker  said  that  it  was  somewhat  difficult  to 
assign  the  cyst  under  consideration  definitely  to  any 
one  of  the  three  classes.  No  evidence  had  been  left 
of  any  cause  of  retention,  and  moreover  in  sections 
from  the  remaining  portions  of  the  pancreas  there  was 
no  retention-dilatation  of  the  ducts.  Neither  could 
the  cyst  be  classed  with  the  cystomata,  because  of  the 
absence  of  a  lining  membrane.  It  was  probable, 
therefore,  that  the  cyst  did  not  belong  to  any  of  the 
above  varieties. 

Referring  to  the  etiology,  he  said  that  the  cyst  was 
evidently  of  long  duration  from  the  thickness  and 
density  of  its  wall.  In  the  absence  of  definite  evi- 
dence the  question  of  the  origin  of  the  cyst  must  be  a 
matter  of  conjecture.  The  most  probable  theory  was 
that  the  cyst  was  of  traumatic  origin,  though  cysts 
arising  in  this  region  from  traumatism  were  no^ 
strictly  speaking,  pancreatic  (Fitz),  as  a  rule.  The 
fact,  however,  that  the  remains  of  the  pancreas  were 
so  widely  separated,  portions  being  at  either  end  of 
the  cyst,  and  the  fact  that  the  cyst  cavity  communi- 
cated with  the  duodenum  through  the  usual  channel 
would  seem  to  show  that  originally  the  pancreas  was 
of  normal  size  and  position.  The  retention  theory 
was  not  tenable  because  of  the  absence  of  a  calculus 
or  a  constriction  in  the  duct  between  the  cyst  and 
duodenum. 

The  case  was  interesting  also  from  another  stand- 
point. The  urine  did  not  contain  sugar,  thus  furnish- 
ing clinical  confirmation  of  the  fact  established  ex- 
perimentally by  von  Mering,  Minkowski,  Hedon,  and 
others,  that  if  a  small  portion  of  the  pancreas  remain, 
whether  in  its  normal  relations  or  grafted  under  the 
skin,  glycosuria  did  not  occur.  And  this  confirmation 
was  all  the  more  remarkable  from  the  fact  that  sec- 
tions from  the  remaining  pancreatic  tissue  showed 
extensive  degeneration.  It  was  unfortunate  that  such 
symptoms  of  pancreatic  disease  as  probably  had  been 
present  could  not  have  been  noted.  But  the  woman 
had  been  in  the  hospital  only  a  day  or  two,  and  the 
pulmonary  affection  demanded  the  chief  attention. 

The  President  said  that  a  short  time  ago  he  had 
examined  the  contents  of  one  of  these  cysts  chemi- 
cally, and  had  found  neither  the  aniylolytic  or  the 
proteolytic  ferment  present,  and  he  had  not  detected 
any  change  in  the  starch  after  it  had  stood  over  night. 
He  believed  that  the  presence  of  the  ferment  was  not 
at  all  constant  in  the  contents  of  such  cysts.  It  had 
just  occurred  to  him  that  the  cyst  under  consideration 
might  possibly  have  been  the  result  of  a  necrosis  of 
the  pancreas — as  a  secondary  degeneration.  He  did 
not  see  why  a  cyst  should  not  form  in  this  way  as  well 
in  the  other  ways  already  referred  to.  Such  a  change 
was  occasionally  seen  in  infarctions.  Another  possi- 
bilitv  was  an  abscess  formation. 


August  14,  1897] 


MEDICAL    RECORD. 


247 


Dr.  Coleman  replied  that  the  objection  to  this  the- 
ory was  that  there  was  an  increase  in  the  size  of  the 
cyst  without  any  obstruction  to  the  outflow  of  the  con- 
tents. He  had  thought  first  that  it  might  be  of  con- 
genital origin,  but  had  abandoned  this  idea  because 
of  the  wide  division  between  the  parts,  making  it  seem 
that  the  pancreas  had  originally  been  of  normal  size. 

The  society  then  adjourned. 


Stated  Meeting,  February  10,  iSgj. 
John  Slade  Ely,  M.D.,  President. 

A  New  Microtome. — Dr.  Sidney  Yankauer  exhib- 
ited a  new  microtome,  constructed  on  a  novel  plan, 
for  which  he  claimed  several  advantages  (see  p.  250). 

Dr.  F.  S.  Mandelbaum  said  that  he  had  used  this 
microtome  before  it  had  been  perfected,  and  had  suc- 
ceeded even  then  in  making  ver>'  good  sections  with 
it.  With  any  new  microtome  one  felt  rather  awkward 
at  first.  So  far  as  he  knew,  the  principles  of  its  con- 
struction were  entirely  novel.  The  instrument  was 
not  quite  so  compact  as  some  others.  It  had  one  draw- 
back, i.e.,  when  one  desires  to  use  paraffin  serial  sec- 
tions are  usually  wanted,  and  these  could  not  be  cut 
with  this  instrument. 

The  President  said  that  as  he  had  watched  the 
action  of  the  instrument  it  had  seemed  to  him  that  it 
was  not  sufficiently  rigid,  and  that  it  would  be  apt  on 
this  account  to  ride  over  the  specimen  at  times.  But 
even  as  at  present  constructed  it  apparently  did  verj- 
good  work. 

Dr.  Yankauer  said  that  this  defect  had  been  no- 
ticed in  the  original  model,  which  had  been  made  of 
wood.  It  was  his  intention  in  future  instruments  to 
have  the  bars  made  heavier. 

A  New  Ganglion-Cell  Stain. — Dr.  E.  S.  Steese, 
present  by  inxitation,  exhibited  several  specimens  un- 
der the  microscope  to  illustrate  a  new  combination 
ganglion-cell  stain.  The  stain,  he  said,  was  essen- 
tially a  modification  of  the  Nissl  stain,  but  consisted 
of  two  fluids  instead  of  one.  The  method  of  its  appli- 
cation was  like  that  of  the  Nissl  stain.  The  tissues 
should  be  cut  into  small  pieces,  and  should  be  fixed, 
hardened,  embedded,  and  cut  in  the  usual  manner. 
Corrosive  sublimate  and  formalin,  two  per  cent.,  and 
absolute  alcohol  seemed  to  be  the  best  of  the  fixing 
solutions.  If  formalin  were  used,  the  specimen 
should  be  left  in  contact  with  it  for  at  least  forty-eight 
hours.  The  staining  solution  consists  of  two  parts  of 
a  one-per-cent.  aqueous  solution  of  methyl  blue  and 
six  parts  of  a  saturated  aqueous  solution  of  fuchsin. 
After  combining  these  two  solutions,  the  mode  of  pro- 
cedure is  the  same  as  with  the  Nissl  stain.  Only  a 
few  sections  should  be  placed  in  a  watchglass,  two- 
thirds  full  of  the  fluid.  This  should  be  heated  until 
vapor  is  noticed  to  come  from  the  surface.  It  should 
then  be  set  aside  for  not  more  than  one  minute  to  cool. 
The  sections  should  next  be  immediately  transferred 
to  ninety-five-per-cent.  alcohol.  The  differentiation 
and  dehydration  take  place  ver\'  rapidly.  The  speci- 
mens would  become  very  white,  generally  in  one  or 
two  minutes.  When  that  is  the  case,  they  should  be 
immediately  transferred  to  some  clearing  solution, 
preferably  oil  of  bergamot  or  oil  of  origanum.  The 
latter  he  preferred.  The  mounting  solution  he  had 
used  was  balsam,  but  damar  also  answered  very  well. 
The  only  advantage  over  the  Nissl  stain  was  that  it 
seemed  to  give  more  character  to  the  Nissl  bodies, 
making  them  stain  a  deep  purple  instead  of  a  greenish- 
blue.  The  neura.xons  take  a  ver)'  pale  violet,  but  they 
can  be  readily  traced  for  a  considerable  distance,  and 
within  them  the  Nissl's  bodies  can  be  easily  seen. 
The  nuclei  stain  a  pale  violet.  The  nucleoli  stain 
usually  a   rather  brilliant  red;  the  pigment  granules 


also  stain  red.  The  surrounding  sustentacular  tissue 
remains  absolutely  colorless.  The  round  cells,  for 
the  most  part,  stain  red,  although  occasionally  blue. 
The  stain  is  also  a  very  good  one  for  cellular  .vork, 
contrasting  ver}^  well  with  eosin.  Certain  accidental 
observations  had  led  him  to  think  that  it  was  possible 
that  by  proper  dehydration  the  neuraxons  could  be 
stained  a  decided  red. 

Dr.  Larkin  asked  if  this  were  a  combination  of  the 
two  methods  described  by  Nissl- — the  fuchsin  and  the 
methyl-blue  method. 

Dr.  Steese  replied  that  it  might  be  called  so,  but 
Nissl  used  these  two  stains  separately. 

Dr.  Larkin  remarked  that  in  clearing  up  the  Nissl 
stain  the  oil  of  origanum  did  not  work  very  well. 

Thrombosis  of  the  Pulmonary  Artery ;  Advan- 
tages of  Formalin  as  a  Preservative  of  Gross  Ana- 
tomical Specimens.  —  Dr.  Larkin  said  that  in  preserv- 
ing specimens  in  the  gross  for  cabinet  purposes,  it  was 
very-  desirable  to  keep  the  natural  color,  as  far  as  pos- 
sible. Alcohol,  the  time-honored  preservative  fluid, 
bleached  the  tissues,  so  that,  for  instance,  a  thrombus 
would  turn  white,  and  after  a  considerable  time  would 
be  for  the  most  part  destroyed.  If  fresh  specimens 
were  dried  in  the  air  for  an  hour  or  two,  and  were  then 
immersed  in  a  two  to  five  per  cent,  solution  of  forma- 
lin, and  left  in  that  for  any  convenient  time  less  than 
a  week,  it  would  be  found  that  they  could  be  perma- 
nently preserved  in  ninety-five-per-cent.  alcohol,  and 
that  the  normal  color  of  the  structure  of  the  organs 
and  of  the  blood  would  be  preserved.  For  microscop- 
ical use  it  was  better  to  use  a  mixture  of  Miiller's 
fluid  and  formalin.  To  illustrate  the  advantages  of 
this  method,  Dr.  Larkin  exhibited  a  specimen  showing 
thrombosis  of  the  pulmonary  artery.  The  color  of  the 
thrombus  had  been  preserved  quite  well,  and  the  en- 
dothelial lining  of  the  pulmonary  artery  and  the  color 
of  the  lung  had  also  been  preserved. 

Dr.  Larkin  then  exhibited  the  dura  mater  from  a 
case  of 

Chronic  Hemorrhagic  Pachymeningitis — The  pa- 
tient was  a  German,  who,  for  three  weeks  prior  to  ad- 
mission to  the  hospital,  had  suffered  continuously  from 
headache  and  insomnia.  For  the  last  two  days  he  had 
been  semicomatose.  On  the  afternoon  of  the  day  of 
admission  he  became  comatose.  He  had  previously- 
complained  of  the  sensation  of  a  hea\y  weight  on  the 
head.  After  ten  days  of  this  coma  he  died.  On 
opening  the  cranium  tiie  dura  mater  appeared  very 
dark,  and  on  removing  it,  it  was  found  that  there  was 
a  chronic  pachymeningitis.  The  blood-vessels  un- 
derneath the  dura  were  very  full  of  blood. 

Dr.  Larkin  next  presented  specimens  from  a  case  of 

Chronic  Pachymeningitis,  removed  from  a  man, 
forty  years  old,  who  had  been  sick  for  five  months  pre- 
vious to  admission.  One  week  before  coming  to  the 
hospital  he  had  had  five  fits.  .-Vfter  entering  the  hos- 
pital he  became  semicomatose,  and  remained  in  that 
condition  for  about  a  week.  He  then  had  ten  convul- 
sions within  twent\--four  hours,  after  which  he  passed 
into  coma  and  died  at  the  end  of  six  hours.  -A.t  the 
autopsy  the  greater  portion  of  the  brain  was  found  to 
be  covered  with  a  large  effusion  of  blood.  At  the 
right  temporo-sphenoidal  lobe  was  a  large  depression, 
and  just  above  this  and  near  the  occipital  lobe  a 
second  depression.  The  corresponding  dura  mater  on 
that  side  presented  a  large  clot,  which  fitted  accurately 
into  the  depression  on  the  brain  surface.  The  speaker 
remarked  that  a  more  careful  clinical  record  of  this 
case,  made  by  a  competent  neurologist,  would  have 
probably  added  to  our  scanty  knowledge  of  the  func- 
tions of  the  temporo-sphenoidal  lobe.  The  man  was 
a  syphilitic,  and  had  well-marked  endarteritis  at  the 
base  of  the  brain  and  in  the  coronary  arteries. 

Dr.  Larkin  then  presented  specimens  from  a  case  of 


248 


MEDICAL    REf^ORD. 


[August  14,  1897 


Rupture  of  the  Liver. — The  patient,  a  young  man 
of  twenty-two,  had  been  injured  by  being  struck  by  a 
heavy  box  and  thrown  into  an  area.  A  depressed 
fracture  of  the  skull  caused  his  death  a  few  hours 
later.  In  addition  to  the  injuries  to  the  skull,  the 
autopsy  revealed  several  quarts  of  fluid  blood  in  the 
abdominal  cavity,  with  some  clots,  and  further  exam- 
ination showed  a  large  rupture  of  the  liver.  There 
was  no  fracture  of  the  ribs  or  of  the  vertebra. 

Discussion. — Dr  M.\xDELB.A.t'M  said  that  after  try- 
ing various  methods  for  preserving  anatomical  speci- 
mens for  museum  purposes,  he  had  recently  adopted 
and  could  now  recommend  the  following  method :  Fresh 
specimens  should  be  subjected  to  fomialin  vapor  for 
twenty-four  hours ;  then,  without  coming  in  contact  with 
water,  they  should  be  placed  in  ninety-five-per-cent. 
alcohol  for  twenty-four  or  forty-eight  hours.  They 
could  then  be  transferred  to  a  strong  solution  of  acetate 
of  potassium  in  equal  parts  of  glycerin  and  water,  and 
kept  indefinitely  in  that  solution.  P'or  exposing  the 
specimens  to  the  formalin  vapor,  it  was  convenient  to 
use  a  large  museum  jar,  in  which  was  placed  some 
absorbent  cotton  moistened  with  a  forty-per-cent.  so- 
lution of  formalin.  The  alcohol  could  be  used  sev- 
eral times.  The  formalin  at  first  bleaches  the  speci- 
men slightly,  but  the  alcohol  restores  the  color  and 
brings  out  the  blood  perfectly.  After  this  the  speci- 
men does  not  undergo  any  further  change.  He  had 
succeeded  in  preser\-ing  some  sisecimens,  which  were 
in  all  respects  as  good  as  when  perfectly  fresh.  An- 
other plan  was  to  place  the  specimen  first  in  a  solution 
of  formalin,  instead  of  exposing  it  to  the  vapor,  but, 
according  to  his  experience,  this  method  was  much 
inferior  to  the  one  first  described. 

Dr.  J.  S.  Ely  said  that  about  a  year  ago  a  few 
specimens  of  intestine  had  been  treated  by  this  method 
— although  he  did  not  recall  whether  formalin  solu- 
tion or  vapor  had  been  used — and  while  the  results 
obtained  with  it  at  the  laboratory  of  the  College  of 
Physicians  and  Surgeons  had  been  at  first  very  satis- 
factory, the  specimens  had  been  noticed  to  deteriorate 
in  the  glycerin.  Glycerin  was  always  an  objectiona- 
ble fluid,  for  the  reason  that  it  made  the  specimens  so 
transparent.  He  was  also  sceptical  regarding  the 
method  just  advocated  by  Dr.  Larkin.  Although  the 
specimen  presented  looked  well  now,  he  felt  pretty 
sure  th^t  in  the  course  of  six  months  a  great  deal  of 
the  color  would  have  left  the  clot,  and  in  a  year  or 
two  the  color  would  have  almost  entirely  gone.  He 
had  preserved  quite  a  number  of  specimens  by  placing 
them  first  in  formalin,  and  then  in  strong  alcohol. 
He  had  been  delighted  with  the  results  at  first,  but  the 
color  had  faded  within  two  years.  He  had  tried  the 
plan  of  drying  the  surface  before  immersing  the  sjjeci- 
men  in  alcohol,  and  for  a  year  or  more  the  color  had 
been  well  preserved,  but  it  was  now  fading  from  the 
specimens  so  treated. 

Dr.  L.^rkin  said  tiiat  lie  had  noticed  that  the  po- 
tassium acetate  also  seemed  to  make  the  specimens 
very  brittle,  so  that  they  could  be  handled  with  diffi- 
culty. The  color  of  the  specimen  ju.st  exhibited  by 
him  had  not  faded  perceptibly  in  two  months. 

The  society  then  went  into  executive  session. 


Dyspepsia  and  Constipation  in  Children. — 

^  Sod.  bicarb. . 

Magnes.  calcin aa  0.25  cgm. 

Pulv.  nuc.  vom o.oi 

S.   To  take  in  a  spoonful  of  sugar  and  water  morning  and 
night  for  ten  days  of  each  month. 

The  dose  of  nux  vomica   should  not  surpass  half   a 
centigram  per  day  for  each  year  of  the  child's  age. — 

COMBY. 


©otrrespondeuce. 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.  > 

THE     PRINCE      OF     WALES      A      DOCTOR PARLIAMENT 

BERIBERI — AR.MY       MEDICAL       STAFF DEATH       FROM 

INFLAM.MABLE    HAIR    WASH — BRITISH    MEDICAL    ASSO- 
CIATION—  HARROGATE    NEW     BATHS — THE     LATE     DR. 
CHANCE,  SIR  J.  C.   BUCKNILL,  AND   DR.   H.  THOMPSON. 
Lo.vDO.v,  July  30,  1807. 

The  Prince  of  Wales  has  accepted  the  honorary 
fellowship  of  the  Royal  College  of  Physicians,  and 
so  may  be  added  to  the  short  list  of  royal  doctors. 
There  are  very  few  precedents  for  the  honorary  fellow- 
ship. As  His  Royal  Highness  will  only  be  an  orna- 
mental fellow,  the  newspapers  generally  congratulate 
the  venerable  college  on  enrolling  him. 

There  has  been  a  further  outbreak  of  beriberi  at 
the  Richmond  Asylum,  Dublin.  In  June  there  were 
ten  patients  still  suffering  from  symptoms  and  the  num- 
ber rapidly  increased  to  one  hundred  and  twenty-four, 
though  the  type  is  said  to  be  mild.  A  temporary  hos- 
pital is  to  be  erected.  A  new  fully  equipped  asylimi 
for  twelve  hundred  patients  is  in  course  of  erection, 
and  it  is  expected  a  portion  will  be  opened  in  about  a 
year.  It  was  stated  in  Parliament  that  the  temporary 
buildings  are  being  constructed  to  the  satisfaction  of 
the  inspectors  and  with  every  care  as  to  sanitation. 
No  doubt  the  disease  is  fostered  by  the  overcrowding 
which  has  for  some  time  prevailed  in  the  asylum. 

The  under  secretary  for  war  has  given  a  rather  eva- 
sive answer  to  a  question  as  to  whether  it  had  been 
proposed  to  utilize  students  for  ambulance  work  in  the 
Soudan.  He  has  also  said  that  there  are  twenty-seven 
candidates  for  the  army  medical  examination  which 
is  held  to-day.  How  many  will  pass  for  the  thirty 
vacancies?  It  is  rumored  that  the  twenty-seven  will 
not  turn  up.  Even  if  they  do,  the  service  will  still  be 
shamefully  incomplete  and  the  existing  staff  over- 
worked. 

A  sad  death  from  an  inflammable  hair  wash  gave 
rise  to  another  question,  to  which  the  home  secretary 
replied  that  the  law  as  to  petroleum  was  unsatisfac- 
tory, but  he  made  no  promise  to  attempt  amendment. 

This  is  the  British  Medical  week,  and  the  business 
part  has  been  transacted  in  London  as  well'  as  an  ex- 
traordinary meeting  to  discuss  resolutions  as  to  de- 
fence, etc.  The  first  was  to  require  the  council  to 
obey  the  mandates  of  general  meetings.  An  amend- 
ment was  carried  by  sixty-two  to  forty-one,  that  as  a 
report  of  a  committee  on  the  constitution  is  about  to 
be  issued  it  is  premature  and  inexpedient  to  discuss 
the  matter.  Put  as  a  substantive  motion,  the  carried 
amendment  was  affirmed  by  seventy -one  to  fifty-five. 

Another  resolution  to  force  the  council  to  take  up 
medical  defence  was  proposed  by  Dr.  Woods,  who  said 
the  council  liad  followed  the  e.xample  of  the  '"heathen 
Chinee,"  referring  the  matter  to  the  branches  in  the 
expectation  they  would  negative  the  proposal.  An 
amendment  by  Dr.  Welsford,  instructing  the  council 
to  carr)-  out  the  decision  of  the  meeting  of  1896.  was 
carried  bv  sixtv-five  to  sixty-four.  A  division  was 
demanded  and  resulted  in  a  vote  of  eighty-nine  for  and 
eighty-eight  against  this.  Later  a  resolution  proposed 
by  Dr.  Myrtle  requesting  the  council  to  take  a  plebi- 
scite by  reply  cards  was  adopted  by  forty-eight  to 
twenty-five. 

On  the  balance  sheet  Mr.  Lawson  Tait  made  some 
good  play  about  the  costs  in  Kingsbury  7-.  Hart,  which 
were  concealed  among  association  expenses.  Further, 
Mr.  Tait  exposed  the  practices  of  the  editor  and  jour- 
nal committee,  and  said  the  reference  committee  ap- 
pointed by  the  council  was  improper  and  illegal. 


August  14.  1897] 


MEDICAL    RECORD. 


249 


Gold  medals  were  presented  to  Sir  \V.  Foster  and 
Mr.  Wheelhouse  for  their  services  to  the  association. 
The  Stewart  prize  went  to  Dr.  Sims  Woodhead  and 
the  Middlemore  prize  to  Dr.  Hill  Griffith. 

Two  members  were  expelled  for  their  action  in  tak- 
ing office  at  the  Adelaide  Hospital  under  circumstances 
of  which  you  are  aware. 

The  report  of  tlie  constitution  committee  mentioned 
above  was  referred  back  to  the  council,  with  a  request 
that  it  consult  the  branches  and  reappoint  the  commit- 
tee. So  the  matter  is  staved  off  once  more.  Next  year 
we  meet  at  lidinburgh  and  Sir  T.  Grainger  Stewart  was 
appointed  president-elect.  Various  votes  of  thanks 
and  other  formal  business  being  over,  we  adjoiumed 
for  the  scientific  work  to  Montreal. 

On  Saturday  the  Duke  of  Cambridge  went  to  Harro- 
gate and  opened  the  new  royal  baths.  These  have  been 
erected  at  a  cost  of  some  ;£^i2o,ooo,  and  bring  Harro- 
gate to  the  front  as  a  balneological  centre,  for  she  now 
offers  the  most  sumptuous  establishment  of  the  kind  in 
the  country.  .\  nimaber  of  medical  men  from  London 
went  to  the  ceremony  and  still  larger  numbers  from 
the  surrounding  district.  Dr.  Myrtle,  whose  name  is 
closely  associated  with  the  spa,  where  he  has  lived 
long  (I  remember  him  between  thirty'  and  fort}- 
years)  gave  a  magnificent  reception  in  the  winter  gar- 
den to  some  eight  hundred  guests,  to  say  nothing  of 
his  house  party,  where  his  hospital  it}-  was  profuse. 
Nor  were  the  other  doctors  behind  in  welcoming 
friends  and  visitors,  though  the  doyen  of  the  place  na- 
turally filled  the  most  arduous  part:  but  he  is  well 
qualified  for  the  task.  There  can  be  little  doubt  that 
the  new  buildings  will  add  to  the  fame  of  our  great 
sulphur  spa.  An  excellent  feature  of  these  splendid 
baths  is  that  a  patient  can  be  wheeled  into  the  dress- 
ing-rooms in  a  bath  chair. 

Frank  Chance,  M.B.  Cantab..  R.F.C.P.,  who  died 
lately  at  Nice,  aged  seventy-one  years,  was  a  scholar 
as  well  as  a  doctor.  He  gained  the  Tyrwhitt  Hebrew 
scholarship  at  Cambridge.  His  edition  of  Bernard's 
commentary  on  Job  and  new  translation  appeared  in 
1864,  and  was  reissued  with  an  appendix  in  1884. 
His  translation  of  Virchow's  "Cellular  Pathology'' 
was  published  four  years  earlier.  He  was  a  member 
of  the  Old  Testament  revision  committee,  on  which 
his  scholarship  was  highly  valued.  He  had  retired 
from  practice  for  several  years. 

Sir  J.  C.  Bucknill,  who  died  on  the'  20th,  aged 
seventy-nine  years,  was  a  man  of  literary  as  well  as 
scientific  reputation.  As  early  as  1857  his  Sugden- 
prize  essay  appeared.  The  subject  was  "  Unsoundness 
of  Mind  in  Relation  to  Criminal  Acts."  From  that 
time  he  was  recognized  as  an  authority.  In  conjunc- 
tion with  Dr.  H.  Tuke  he  wrote  the  well-known  "  Man- 
ual of  Psychological  Medicine."  You  will,  no  doubt 
remember  his  "  Notes  on  American  Asylums,"  and  his 
essays  on  the  medical  knowledge  of  Shakespeare  and 
the  mad  persons  depicted  by  the  bard  are  of  general 
interest.  The  Asylum  Journal,  which  became  X^it:  Jour- 
nal of  Mental  Science,  was  founded  and  for  a  long  time 
edited  by  Dr.  Bucknill,  and  he  contributed  much  to 
its  pages.  He  was  appointed  lord  chancellor's  visi- 
tor in  lunacy  in  1862.  He  was  called  the  father  of 
the  volunteers,  for  in  1852  he  obtained  permission  of 
the  government  and  enrolled  the  first  regiment  of  rifle 
volunteers,  and  it  was  in  recognition  of  this  senuce 
as  well  as  of  his  medical  position  that  his  knighthood 
was  given  him;  but  this  token  of  approval  was  not 
offered  until  1S94,  about  twenty  years  after  he  had 
retired  from  official  work  and  practice.  Our  govern- 
ments are  never  in  a  hurry  to  recognize  scientific 
men's  work,  even  when  they  have  contributed  to  the 
welfare  of  the  country  in  other  departments. 

The  death  of  another  retired  physician  occurred  last 
week,   viz.,   H.   Thompson,   M.D.  Cantab.,  1853,  con- 


sulting physician  to  the  Middlesex  Hospital,  to  which 
of  course  he  had  filled  the  staff  appointment  and  where 
his  chief  life  work  was  done.  He  was  senior  fellow 
of  St.  John's  College,  Cambridge,  where  he  took  his 
M..\.  in  1841.  He  published  some  "Clinical  Lec- 
tures and  Cases  with  Commentaries'"  in  1880. 


DECINORMAL    S.\LT    SOLUTION. 

To  THE    EpiTOR    OF  THE    MeDICAL    ReCORD. 

Sir:  The  term  "normal"  salt  solution  is  almost  imi- 
versally  employed  in  medical  literature  to  designate 
a  solution  of  sodium  chloride  of  six  parts  to  the  thou- 
sand. I  desire  to  call  attention  to  the  fact  that  this 
use  of  the  term,  strictly  speaking,  is  erroneous,  and 
that  the  designation  "decinormal"  is  the  proper  one 
for  a  solution  of  salt  of  this  strength. 

In  volumetric  chemistn,-  the  term  normal,  as  applied 
to  solutions  of  reagents,  has  a  ver}-  accurate  and 
mathematically  precise  signification.  A  normal  solu- 
tion is  "  one  containing  in  one  thousand  cubic  centi- 
metres an  amount  of  the  active  constituent  just  suffi- 
cient to  combine  with  or  replace  one  gram  of  hydrogen'" 
(Billings).  For  monobasic  acids  and  their  salts  (such 
as  sodiiun  chloride)  a  normal  solution  is  one  in  which 
the  number  of  grams  in  the  litre  is  equal  to  the  molec- 
ular weight  of  the  reagent.  The  molecular  weight  of 
sodium  chloride  is  58.37  :  a  normal  solution  of  sodium 
chloride  is  one  containing  58.37  grams  to  the  litre  of 
water.  A  solution  of  one-tenth  this  strength,  contain- 
ing 5.837  grams  to  the  litre,  is  a  decinormal  solution 
(see  United  States  Pharmacopceia,  1890,  and  Sutton's 
"Volmnetric  .Analysis"). 

The  highest  usefulness  of  the  term  "  normal,"  as 
used  in  chemistry,  can  be  secured  only  by  its  emplov- 
ment  in  its  strict  mathematical  sense.  To  apply  it  to 
a  solution  of  one-tenth  normal  strength  is  misleading, 
incorrect,  and  a  violation  of  scientific  precision. 

W.^.m.NGTO.s-,  D.  C.  ^■    B.    NlCHOL.<=.  M.D. 


HYDRAULIC     DILATATION     OF    THE     URE- 
THRA. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  I  desire  to  add  my  testimony  of  approval  of  the 
hydraulic  method  of  dilating  the  urethra,  which  was 
given  in  the  issue  of  July  31st,  by  Dr.  Rumer,  of  Da- 
vison, Mich. 

The  method  is  a  good  one,  and  has  been  practised 
by  me  for  some  time,  being  first  suggested  by  a  pa- 
tient of  mine.  It  is  very  efficient  in  many  of  the  di- 
latable constrictions,  and  is,  when  it  will  answer, 
much  to  be  preferred  to  the  common  method  of  using 
rubber  or  metallic  sounds. 

If  projaerly  practised  it  is  surprising  how  much  force 
can  thus  be  e.xerted  and  to  what  capacity  the  urethra 
can  thus  be  distended. 

It  is  of  great  utility  in  washing  out  the  bladder 
and  urethra  in  gonorrhaa  and  other  affections.  In 
the  treatment  of  gonorrhcea  it  has  been  my  custom  to 
have  my  patient  thus  distend  the  urethra  and  refill 
through  a  soft  catheter,  if  convenient,  attached  to  the 
faucet  of  a  w  ater  pijse,  when  considerable  external  force 
or  counterpressure  can  be  exerted,  care  being  taken 
to  cut  off  the  current  when  the  bladder  is  full.  Repeat 
the  process  of  distending  the  urethra  by  forcing  out 
the  water  as  before,  thereby  thoroughly  cleansing  the 
bladder  and  urethra.  Lastly,  refill  the  bladder  and  fol- 
low w  ith  injections  of  w  hatever  medicines  it  is  intend- 
ed to  use.  Let  the  water  remain  as  long  as  desired, 
and  force  out  as  before.  This  leaves  the  bladder  and 
urethra  in  a  perfectly  clean  and  aseptic  condition. 

In  treating  strictures,  hydraulic  counterpressure  is 
obtained  bv  attaching  to  the  ordinary  bath-tub  faucet 


MEDICAL    RECORD. 


[August  14,  1897 


a  large-sized  catheter,  with  central  fenestra,  introduced 
within  the  meatus  and  held  firmly,  and  using  long- 
continued  pressure  in  the  intractable  cases. 

By  these  two  methods  I  have  had  most  gratifying 
results.  J.  B.  Taulbee,  M.D. 

Mt.  Sterling,  Kv, 


^eiu  instvnmcnte. 

A    NEW    MICROTOME.' 
By   SIDNEY    YANK.AUf:K.    M.D., 

I  DESIRE  to  exhibit  to  the  society  my  new  microtome, 
which  is  not  a  modification  of  any  old  in.strument,  but 
is  constructed  on  principles  which,  so  far  as  I  know, 


are  novel  in  microtomes.  In  the  Thoma  instrument 
the  knife  moves  in  a  slide,  and  the  edge  of  the  knife, 
considered  as  a  line,  describes  in  successive  cuts  the 
same  plane.  The  specimen  is  moved  up  through  this 
plane  a  distance  represented  by  the  thickness  of  the 
section  to  be  cut.  In  my  instrument  the  specimen 
remains  stationar}-,  but  the  plane  in  which  the  knife 
moves  is  continually  lowered.  The  instrument  con- 
sists of  two  parts — a  stand  and  a  sliding  piece.  The 
stand  consists  of  a  triangular  piece  of  metal,  across 
the  base  of  which  a  plate  of  glass  is  fixed.  Near  this 
is  a  perforation  containing  a  vertical  rod.  On  top  of 
the  latter  is  the  ordinary  clamp  for  holding  the  speci- 
men. At  the  ape.x  of  the  triangle  is  a  small  elevation, 
<?,  and  at  the  top  of  this  elevation  a  hole,  one-eighth 
of  an  inch  in  diameter  and  one-eighth  of  an  inch  deep. 
This  hole  is  made  hemispherical  at  the  bottom,  and 
is  so  placed  that  the  bottom  of  the  hole  is  in  the  same 
plane  as  the  surface  of  the  glass,  so  that  if  the  surface 
of  the  glass  were  prolonged  into  a  plane  this  would 
just  touch  the  bottom  of  the  hole.  The  sliding  piece 
is  made  of  a  piece  of  metal,  ^,/,  g,  bent  at  a  right  an- 
gle, and  having  at  its  angle  and  at  either  end  a  perfo- 
ration through  which  passes  a  screw. 
These  three  screws  have  the  same 
sized  screw  threads,  are  pointed  at  the 
ends,  and  capped  by  small  spheres, 
one-eighth  of  an  inch  in  diametei. 
The  screw  at  the  end  of  the  long  arm 
of  the  sliding  piece  carries  a  plate 
on  its  upper  end,  which  is  divided 
into  one  hundred  parts.  This  screw 
corresponds  to  the  micrometer  screw 
of  the  ordinary  microtome.  On  this 
long  arm  of  the  sliding  piece  is  the 
screw,  /,  by  means  of  wiiich  the  knife 
(//,  Fig.  i)  is  fastened  in  such  a  posi- 
tion that  it  is  parallel  to  the  short  arm  of  the  sliding 
piece.  As  the  screws  are  of  the  same  lengtii,  the  edge 
of  the  knife  must  be  parallel  to  a  line  joining  the 
points  of  the  two  screws  on  the  short  arm.     The  small 

'  Read  before  the  New  York  Tathological  .'^ociety.  February  10, 
i8q7. 


sphere  at  the  end  of  the  micrometer  .screw  fits  into  a 
little  hole  on  the  top  of  the  elevation,  and  the  two 
other  spheres  rest  on  the  glass  plate.  By  sliding  the 
piece  along  the  glass  plate,  the  knife  moves  across  the 
specimen.  After  being  moved  back  again,  the  micro- 
meter screw  is  rotated  to  the  left.  This  lowers  the  end 
of  the  long  arm  of  the  sliding  piece,  and  in  so  doing 
lowers  the  knife  a  certain  distance.  Then  another 
cut  is  made,  and  the  knife,  being  now  in  a  lower  posi- 
tion, must  cut  through  the  specimen  at  a  lower  point. 
An  important  practical  question  in  connection  with 
this  instrument  is  whether  the  sections  have  parallel 
surfaces  or  are  wedge  shaped.  The  demonstration 
of  the  parallelisiTi  of  the  sections  is  as  follows:  Im- 
agine a  plane  passing  through  the  three  points  of  the 
instrument,  and  call  that  plane  the  plane  of  the  screw- 
points.  The  edge  of  the  knife  is  so  situated  that  it 
is  parallel  to  a  line  joining  the  upper  two  screw- 
points  (y,  g.  Fig.  i).  Being  a  line 
parallel  to  a  line  in  a  plane,  it  is 
parallel  to  the  plane  itself,  and  there- 
fore the  edge  of  the  knife  is  parallel 
to  the  plane  of  the  screw  points.  It 
is  immaterial  in  w-hat  position  the 
micrometer  screw  is,  for  whether 
lowered  or  raised  the  edge  of  the 
knife  is  always  parallel  to  the  line 
joining  the  points  of  the  screws  on 
the  short  arm.  If  the  sliding  piece 
be  placed  upon  the  stand,  the  three 
points  rest  in  the  plane  of  the  glass, 
because  the  bottom  of  the  hole  is  in  the 
plane  of  the  glass;  hence  the  plane  of  the  screw 
points  and  the  plane  of  the  glass  must  coincide,  and 
whatever  is  true  of  the  plane  of  the  screw  points  is 
true  of  the  plane  of  the  glass.  Inasmuch  as  the  edge 
of  the  knife  is  parallel  to  the  plane  of  the  screw- 
points,  it  is  parallel  to  the  plane  of  the  glass.  In 
inaking  tiie  sliding  motion  along  the  glass  plate,  the 
edge  of  the  knife  remains  at  a  constant  distance  from 
the  plane  of  the  glass;  for  its  distance  from  the  plane 
of  the  screw  points  is  fixed  by  the  micrometer  screw. 
The  edge  of  the  knife,  considered  as  a  line  moving 
over  a  plane  to  which  it  is  parallel,  and  from  which  it 
remains  a  constant  distance,  must  describe  a  plane 
parallel  to  the  plane  of  the  glass.  Now,  when  the 
micrometer  screw  is  turned  so  as  to  lower  the  long  end 
of  the  sliding  piece,  and  in  that  way  lower  the  knife, 
the  parallelism  of  the  edge  of  the  knife  to  the  plane 
of  the  screw  points  is  not  altered,  but  the  edge  is 
nearer  the  plane  of  the  screw  points,  and  therefore 
nearer  the  plane  of  the  glass  than  before.  Having 
fixed  the  knife  in  this  new  position,  the  same  condi- 
tions must  be  true  as  previously — that  is,  the  edge  of 
the  knife  must  describe  a  second   plane,  parallel  toi 


the  plane  of  the  glass.  As  two  planes  parallel  to  a 
third  plane  are  parallel  to  each  other,  the  sectioi> 
which  is  included  between  the,se  two  planes  must  be 
bounded  by  parallel  surfaces.  True,  tiie  surface  of 
the  knife  does  not  remain  at  the  same  angle  to  the 
plane  of  the  glass;  but  as  it  is  not  the  surface  of  the 


August  14,  1897] 


MEDICAL    RECORD. 


251 


knife  but  the  edge  of  the  knife  that  determines  the 
cutting,  the  difference  in  tlie  angle  between  any  two 
positions  of  the  knife  for  a  section  of  ten  microns  in 
thickness,  which  amounts  to  one-one-hundredth  of  a 
degree,  should  not  make  any  dift'erence  in  the  cutting 
of  a  section.  For  specimens  larger  than  one-half  inch 
the  position  of  the  knife  can  be  altered  by  a  joint  in 
the  long  bar,  n. 

For  cutting  paraffin  the  knife  must  be  placed  at 
right  angles  to  the  line  of  motion.  For  this  purpose 
a  smaller  knife  {k.  Fig.  2),  fitting  into  the  same  place 
as  the  larger  one,  is  used,  but  with  its  edge  standing 
in  the  other  direction.  As  the  two  screws  which  are 
parallel  to  the  edge  of  the  knife  must  remain  fixed, 
the  micrometer  screw  and  one  of  the  other  screws  {g) 
must  be  made  to  change  places.  Owing  to  the  prin- 
ciple upon  which  the  instrument  is  constructed — /.<•., 
that  the  measurement  is  made  at  the  end  of  the  long 
bar,  the  knife  being  situated  at  the  upper 
end — any  possible  error  in  the  construc- 
tion of  the  instrument  will  be  divided 
by  five  at  the  knife.  Mechanically  it  is 
just  as  easy — indeed,  more  easy — to  con- 
struct a  screw  having  ten  threads  to  the 
inch  as  one  having  fifty  threads  to  the 
inch. 

The  measurements  are  made  as  follows : 
The  long  arm  of  the  sliding  piece  meas- 
ures twelve  and  one-half  inches;  the 
knife  is  situated  at  a  distance  from 
the  short  bar  equal  to  one-fifth  of  the  entire  length  of 
the  long  bar;  the  screws  have  ten  turns  to  the  inch, 
so  that  a  complete  revolution  of  the  micrometer  screw- 
lowers  the  long  end  of  the  sliding  piece  one-tenth  of 
an  inch.  Inasmuch  as  the  knife  is  situated  at  one- 
fifth  of  the  distance  from  the  point  of  rotation,  the 
knife  must  be  lowered  one-fifth  as  much  as  the  end  of 
the  long  arm — in  other  words,  for  every  complete  ro- 
tation of  the  micrometer  screw  the  knife  must  be  low- 
ered one-fiftieth  of  an  inch.  But  there  are  one  hun- 
dred divisions  on  the  head  of  the  micrometer  screw; 
hence  for  every  one  of  these  divisions  the  knife  is 
lowered  one-five-thousandth  of  an  inch,  or  five  mi- 
crons. 

The  theoretical  advantages  of  the  instrument  are: 
(i)  That  inasmuch  as  the  specimen  remains  absolutely 
fi.Ked,  the  entire  motion  being  limited  to  three  points 
and  one  screw,  the  possible  errors  are  diminished: 
and  (2)  that  the  errors  in  the  knife  are  only  one-fifth  as 
great  as  any  possible  errors  in  the  micrometer  screw. 
It  is  important  in  this  instrument,  however,  that  the 
plane  of  the  glass  should  coincide  exactly  with  the 
bottom  of  the  hole,  and  that  the  edge  of  the  knife 
should  be  parallel  to  the  plane  of  the  screw  points. 
The  accuracy  of  the  former  can  be  easily  determined 
by  placing  a  ruler  on  the  glass  plate,  and  noticing 
where  the  ruler  strikes  the  small  projection  at  the  apex 
of  the  stand.  To  determine  whether  or  not  the  edge 
of  the  knife  is  parallel  to  the  plane  of  the  screw 
points,  the  ruler  should  be  placed  across  the  two 
screw  points.  On  holding  the  ruler  against  the  light, 
one  obtains  a  reflex  across  the  knife,  and  when  the 
light  is  almost  entirely  cut  off  any  lack  of  parallelism 
will  be  shown  by  an  irregularity  in  the  thickness  of 
the  band  of  light.  If  not  parallel,  the  parts  can  be 
very  easily  readjusted. 

The  instrument  is  made  by  Tiemann  lV  Co.,  of  New- 
York. 

An  Ephemeral  Society. — .\  number  of  unmarried 
women  in  New  York  are  reported  to  have  formed  a 
society  for  the  prevention  of  hereditary  diseases. 
They  have  registered  a  solemn  vow  not  to  many  any 
man  whose  family  is  tainted  with  consumption,  insan- 
it\-,  alcoholism,  or  other  heritable  disease. 


THE     PERINEAL     HORN— A     NEW     INSTRU- 
MENT. 

By    EDWIN    DE    BAUN,    M.I)., 

1A5S.MC,     N.    J. 

This  instrument,  which  I  have  called  the  perineal  horn, 
is  intended  to  support  the  perineum  during  childbirth, 
and  is  to  be  used  instead  of  the  hand  for  bringing 
pressure  to  bear  on  the  infant's  head  or  presenting 
part  and  prevent  the  child  from  descending  too  sud- 
denly, and  also  to  assist  in  gradual  dilatation  of  the 
perineal  body. 

Disadvantages  of  the  Present  Method (i)  Pres- 
sure of  the  hand  on  the  descending  head  or  presenting 
part  is  rather  difificult,  as  the  surface  is  small,  smooth, 
slippery,  and  therefore  uncertain. 

(2)  Pressure  on  the  perineum  for  any  length  of  time 
produces    more    or    less    contusion    with    consequent 


oedema,  which  renders  the  perineum  very  friable  and 
therefore  easily  ruptured. 

Advantages  of  and  Directions  for  Using  the  Peri- 
neal Horn. — When  the  head  impinges  upon  the  peri- 
neum, place  the  concave  surface  of  the  horn  against 
the  infant's  head  or  the  presenting  part,  and  between 
it  and  the  perineum ;  then  by  grasping  the  handle  or 
placing  the  ball  of  the  thumb  in  the  concavity  of  the 
handle  (there  are  two  instruments,  the  only  difference 
being  in  the  shape  of  the  handles)  you  ha\-e  by  alter- 
nate relaxation  and  pressure  full  control  of  the  case. 

The  presenting  part  should  be  allowed  to  descend 
during  each  pain  as  far  as  advisable,  gradually  dis- 
tending the  perineum,  and  finally,  when  the  perineum 
is  sufficiently  dilated  to  meet  the  demands  of  the  indi- 
vidual case,  the  presenting  part  may  be  pressed  well 
up  in  the  space  beneath  the  arch  of  the  symphysis 
pubis,  thus  applying  the  force  or  pressure  not  to  the 
perineum  but  to  the  presenting  part. 

With  the  perineal  horn  the  perineum  may  be  sup- 
ported by  one  hand,  while  with  the  other  hand  the 
forceps  may,  if  necessary,  be  used  with  greater  advan- 
tage than  under  the  old  method. 

Should  the  perineum  become  partially  ruptured,  the 
extent  of  the  lesion  can  be  lessened  by  the  use  of  this 
instrument. 

I  have  used  the  perineal  horn  for  about  two  years 
with  very  good  results.  The  instrument  is  small, 
weighs  onlv  a  few  ounces,  and  can  be  conveniently 
carried  in  the  pocket  or  obstetric  case. 

Messrs.  George  Tiemann  &  Co.,  of  New  York  Cit)-, 
have  very  carefully  carried  out  my  ideas  in  making 
the  instrument. 

Serum  Experiments.  —  Dr.  Weisbecker  (  Gazette 
Medicate  tie  Liege,  June  24,  1897)  has  investigated  the 
question  as  to  whether  the  serum  of  convalescents  has 
any  action  in  an  affection  similar  to  that  from  which  it 
was  derived.  To  obtain  his  information  he  injected 
in  two  cases  of  typhus,  five  of  pneumonia,  and  five 
of  scarlatina  serum  from  convalescents  from  the 
same  diseases.  He  observed  no  modification,  or  local 
inflammation,  or  rise  of  temperature.  Moreover,  in  all 
these  cases  the  general  state  and  the  subjective  state 
were  ameliorated  for  some  minutes  after  the  injection. 


252 


MEDICAL    RECORD. 


[August  14,  1897 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitarj'  Bureau,  Health  Department,  for  the 
week  ending  August  7,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. .  . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox 


268 

36 

70 

I 

s- 

150 


Orrhodiagnosis The  committee  appointed  by  the 

chairman  of  the  section  on  practice  of  medicine  of  the 
American  Medical  Association  at  the  Philadelphia 
meeting  made  the  following  report:  i.  In  selecting 
the  material  used  in  making  the  test  the  choice  be- 
tween ((7)  serum,  {b)  dried  blood,  (r)  fluid  blood,  and 
{d)  blister  fluid,  will  depend  largely  upon  whether  the 
object  be  scientific  research,  clinical  diagnosis  in  hos- 
pital or  private  practice,  or  public  laboratory  diagno- 
sis when  the  samples  have  to  be  sent  some  distance. 
2.  In  spite  of  considerable  variation  in  technique, 
there  has  been  a  remarkable  uniformity  in  the  results 
obtained  by  those  taking  part  in  the  discussion,  and 
their  average  of  about  ninety-five  per  cent,  of  suc- 
cesses agrees  with  the  general  average  of  the  cases, 
nearly  four  thousand,  thus  far  recorded  in  medical 
literature.  3.  Each  of  several  methods  of  technique 
advocated  may  thus  give  good  results  in  the  hands  of 
those  thoroughly  familiar  with  the  details  found  nec- 
essary in  each  case  and  the  sources  of  error  to  be 
avoided,  success  depending  rather  on  being  perfectly 
familiar  with  one  method  than  on  the  particular  one 
selected.  4.  For  routine  diagnostic  work  even  the 
very  simplest  methods  may  give  good  practical  re- 
sults, but  for  recording  scientific  observations  those 
methods  which  are  accurately  quantitative  should  be 
selected.  This  is  especially  necessary  in  reporting 
exceptional  cases  at  variance  with  the  general  results 
recorded  or  when  the  obser\'ations  are  made  the  basis 
of  generalizations.  5.  A  complete  reaction  should 
comprise  both  characteristic  clumping  and  total  arrest 
of  motion  occurring  within  a  definite  time  limit.  For 
practical  diagnostic  work  a  dilution  of  i  to  lo,  with  a 
fifteen-minute  time  limit,  is  convenient.  In  any  doubt- 
ful case  the  dilution  should  be  carried  as  far  as  i  to 
50,  or  perhaps  i  to  60.  and  a  reaction  not  obtainable 
at  that  point  should  not  be  regarded  as  perfectly  con- 
clusive. For  these  higher  dilutions  the  time  limit 
should  be  e.xtended  to  two  hours.  6.  Intensity  of  re- 
action in  a  given  serum  should  be  estimated  by  deter- 
mining the  degree  to  which  it  may  be  diluted  without 
losing  its  power  of  giving  a  decided  reaction,  as  both  to 
agglutination  and  loss  of  motion.  7.  The  intensity 
of  reaction  shown  by  the  same  serum  is  influenced  bv 
the  age,  condition,  and  virulence  of  the  test  culture, 
and  by  the  composition  and  reaction  of  the  culture 
medium.  F'or  purposes  of  comparison  the  sensiti\e- 
nese  of  the  test  culture  should  be  taken  into  consider- 
ation. 8.  The  evidence  so  far  recorded  establishes 
that  the  reaction  may  be  delayed  or  occasionally  may 
not  be  obtained  in  cases  of  genuine  typhoid  infection; 
and  also  that  it  may  be  exceptionally  present  in  non- 
typhoid  cases,  though  not  in  an  intense  degree.  9.  In 
investigating  e.xceptional  and  contradictory  results  the 
following  circumstances  have  to  be  considered:  (<m 
The  uncertainty  of  clinical  diagnosis;   (A)  the  absence 


of  bacteriological  or  other  confirmatory  methods  of  di- 
agnosis during  life,  giving  decisive  negative  results; 
{c)  the  possibility  of  overlooking  typhoid  infection 
even  post  mortem,  in  the  absence  of  characteristic  in- 
testinal lesions  when  a  very  thorough  bacteriological 
examination  has  not  been  carried  out.  10.  The  mod- 
ifying influences  mentioned  above  suffice  to  explain 
the  divergencies  existing  in  the  reports  of  different 
observers.  Without  being  absolutely  infallible  the 
typhoid  reaction  appears  to  aft'ord  as  accurate  diagnos- 
tic results  as  can  be  obtained  by  any  of  the  bacterio- 
logical methods  at  our  disposal  for  the  diagnosis  of 
other  diseases.  It  must  certainly  be  regarded  as  the 
most  constant  and  reliable  sign  of  typhoid  fever,  if 
not  an  absolute  test.  The  committee  stated,  however, 
that  this  summary,  while  expressing  the  general  con- 
sensus of  opinion  brought  out  during  the  discussion 
on  serum  diagnosis  before  the  section  on  practice  of 
medicine  of  the  American  Medical  Association,  did 
not  claim  to  represent  exactly  the  individual  views  of 
any  one  of  those  who  took  part. 

Blood  Stains. — The  statement  has  been  lately  pub- 
lished that  a  warm  solution  of  tartaric  acid  is  most 
efficient  in  removing  blood  stains  from  towels,  aprons, 
etc.  Acetic  acid  has  long  been  in  use  for  this  pur- 
pose, and  either  acid  will  probablv  answer  equallv 
well. 

The  Stabbing  of  a  Foetus. — The  A'urshig  Record 
published  recently  a  case  of  a  woman  who,  when  six 
months  pregnant,  was  stabbed  twice  in  the  abdomen. 
Both  wounds  penetrated  the  abdominal  cavity,  and,  as 
there  were  signs  of  internal  hemorrhage,  the  abdomen 
was  immediately  opened.  The  uterus  was  found  to 
have  been  perforated  in  two  places  by  the  knife.  The 
hemorrhage  was  checked  by  stitching  the  wounds  of 
the  uterine  wall.  The  patient  progressed  very  well 
until  the  third  day,  when  pains  came  on,  and  on  the 
next  day  an  abortion  took  place.  i'he  fcetus  was 
dead,  and  examination  showed  that  the  knife  had  pen- 
etrated the  left  side  of  the  chest,  and  had  also  wounded 
the  small  intestine  in  two  places,  purulent  peritonitis 
having  resulted.  The  case  was  regarded  as  especially 
noteworthy  because  of  the  peritonitis  set  up  by  an  in- 
testinal wound  in  a  fcetus  of  that  age,  but  it  might 
have  been  caused  equally  by  the  introduction  of  septic 
matter  from  without  on  the  point  of  the  knife. 

Health  Reports. — The  following  statistics  concern- 
ing sniall-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  super\-ising  surgeon- 
general  of  the  United  States  Marine  Hospital  ser\Mce 
during  the  week  ended  .August  7,  1897  : 

Small-Pox — Foreign.  Cases.       Deaths. 

Glasgow,  Scotland July  lolh  to  i7lh 3 

Madras,  India June  i2lh  to  Inly  2d 3 

Rio  de  Janeiro June  loth  to  ])uly  3d 6 

Calcutta,  India June  19th  to  26th 3 

Bombay.-India June  31st  to  July  6th 4 

Montreal,  Canada July  2d  10  26th 5  3 

Singapore,  India May  ist  to  31st 4 

Pemambuco,  I'razil May  29th  to  June  36th 13 

Warsaw,  Russia July  3d  10  17th s 

Sagua  la  Grande,  Cuba July  lolh  to  34th 113 

Cienluegos,  Cuba luly  iSlh  to  3sth 13 

f)dessa,  Russia July  loth  to  i7lh 1 

St.  Petersburg,  Russia JtJly  loth  to  17th C 

Para,  Brazil July  3d  to  17th 40  2 

Athens,  Greece June  ist  lo  30th 14  i 

Gibraltar July  nth  to  i8th i 


Cholera. 


Madras,  India 
Calcutta,  Indi: 
Hombav,  Indii 


■  i3th  to  July  3... 

;  loth  10  36tn 

:  31st  to  J  uly  6th  . 


Rio  de  Janeiro.  Brazil 

Santiago  de  Cub.i July  17th  to  34th.. 


lune  iqth  to  July  3d. 


Panama,  U.  S.  of  Colombia. July  13th  to  23d 5 

Sagua  la  Grande,  Cuba July  loth  to  34th 74 

Manzanillo,  Cuba July  ist  to  tsth 

I'ara.  Brazil July  %A  tu  irlh 


Homb.iv.  India 


PLAGfE. 

:  31st  to  July  6th  . 


Medical  Record 

A  IVeekly  Journal  of  Medicine  and  Surgery 


Vol.  52,  No.  8. 
Whole  No.  1398. 


New  York,   August   21,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©nginal  Articles. 

CASE    EXAMINATION    IN    EPILEPSY. 
By    L.    pierce   CLARK,    M.D., 

FIRST      ASSISTANT      l-HVSICIAN      AT      THE      CRAIG      COLONY      FOR       EHILEPTILS, 
SONVEA,    N.    Y. 

The  desirability  and  necessity  of  having  some  syste- 
matic method  of  examining  cases  of  epilepsy  is  but 
little  recognized  until  one  is  called  upon  to  examine 
many  cases,  either  in  private  practice  or  in  an  institu- 
tion especially  devoted  to  the  treatment  of  this  disease. 
There  are  evidently  many  things  which  are  necessary 
for  the  physician  to  know  in  regard  to  each  particular 
case,  aside  from  those  included  vnider  the  headings 
which  are  upon  the  symptom  chart  here  submitted.  For 
instance,  it  is  desirable  to  inquire  into  the  details  of  the 
alleged  causes  of  the  patient's  epilepsy  and  all  the  pos- 
sible or  probable  effects  which  any  particular  cause 
may  have  had  upon  the  special  caseunderexamination. 
At  the  same  time,  when  we  have  a  chart  upon  which 
the  principal  general  questions  have  been  stated,  we 
can  very  easily  diverge  at  any  point  from  the  beaten 
path  of  routine  examination. 

The  chart  which  is  presented  with  this  article  was 
especially  designed  for  purposes  of  examination  of 
epileptics  admitted  to  the  Craig  Colony.  The  man- 
ner in  which  this  information  is  to  be  secured  makes 
it  easy  to  obtain  it  from  the  patient  himself,  or  from 
the  relative  or  friend  who  may  accompany  him. 
When  considerable  mental  impairment  has  taken 
place  in  the  patient's  condition,  it  is  almost  impossi- 
ble to  obtain  such  information  from  the  patient  him- 
self, even  if  he  may  be  disposed  to  give  it.  In  such 
cases  admitted  to  the  Craig  Colony,  this  scheme  for 
examination  is  supplemented  by  a  blank  form  covering 
all  unanswered  questions,  which  is  sent  to  relatives  to 
be  filled  out.  Obviously  even  all  these  efforts  prove 
fruitless  when  the  relatives  and  friends  of  the  patient 
give  vague  answers  to  wrongly  interpreted  questions. 
The  examination  of  epilepsy  seems  even  more  difficult 
to  conduct  than  that  of  many  other  nervous  diseases 
in  which  the  mentality  of  the  patient  is  materiallv  at 
fault. 

The  writer  desires  to  call  attention  to  the  necessity 
of  making  careful  inquirj'  upon  each  particular  head- 
ing in  this  chart,  and  he  would  also  urge  that  a  sys- 
tematic and  orderly  manner  of  case  taking  is  very  es- 
sential in  order  to  secure  data  of  scientific  value  from 
a  number  of  recorded  cases. 

Case  Examination  in  Epilepsy. — Number.  Name. 
Age.  Religion.  Social  status,  .\ddress  of  nearest 
relative. 

Family  history  (phthisis,  rheumatism,  inebriety, 
consanguinity,  feeble-mindedness,  rachitis,  insanity, 
epilepsy,  or  other  convulsive  diseases).  Number  of 
brothers  and  sisters.  Number  of  deaths  in  family  and 
their  cause.      Habits  of  parents  and  relatives. 

Personal  history  (prenatal  causes  if  any,  injury  at 
birth,  convulsions  at  birth,  convulsions  at  dentition, 
diseases  of  childhood,  scarlet  fever,  measles,  typhoid 
fever). 


Cause  of  epilepsy  (syphilis,  masturbation,  sexual 
excesses,  headaches,  epistaxis,  trauma). 

Disorders  of  sleep  in  family  or  patient  (night  ter- 
rors).     Paralysis  in  infancy. 

Kind  and  quality  of  work  while  at  school.  Degree 
of  education.      Occupation  and  regularity  of  work. 

First  seizure.  Character  of  disorder  in  conscious- 
ness. Aura.  Subsequent  stupor.  Subsequent  men- 
tal state.  Subsequent  paresis  or  aphasia.  Character 
and  duration  of  subsequent  seizures.  Time  of  day 
when  attacks  occur  most  frequently. 

Manifestations  of  hysteria.  Automatism.  Hallu- 
cinations.     Pallor.      Flushing. 

Primary  movements.  Order  of  invasion  and  side 
most  affected.  Sphincters.  Conditions  which  cause 
or  arrest  attacks.  Mental  state  in  interim.  Memory. 
Disposition.  Frequency  of  attacks  at  present.  Date 
of  last  attack. 

Habits  of  patient  (diet,  appetite,  digestion,  sleep, 
alcohol,  tobacco,  narcotics). 

Heart.  Pulse.  Circulation.  Lungs.  Respiration. 
Bodily  condition.  Hearing.  Sight.  Pupils.  Speech. 
Skin.  Bowels.  Tongue.  Superficial  refle.xes.  Deep 
reflexes.  Motion  and  co-ordination.  Dynamometer: 
right,  left.     Stigmata  of  degeneration. 

For  women,  menstruation  (first  occurrence,  charac- 
ter, length  of  time  present,  regularity,  relationship  of 
seizures  to  menstruation  or  pregnancy,  anomalies  of 
menstruation  at  present  if  any). 

In  the  beginning,  as  regards  family  history,  although 
phthisis  has  been  excluded  by  Gowers'  as  having  no 
etiological  significance  in  epilepsy,  yet  as  epilepsy 
must  primarily  be  regarded  as  a  nervous  disease  of 
degeneration,  we  must  take  into  account  all  hereditary 
characteristics  which  point  to  a  degenerative  condition 
of  the  family.  Many  German  and  F^rench  authors  lay 
considerable  stress  upon  phthisis  as  an  hereditary 
factor  in  producing  epilepsy. 

Although  the  presence  of  neoplasms  in  family  his- 
tory has  no  direct  etiological  significance  upon  epi- 
lepsy, yet  they,  too,  portray  a  certain  element  of  family 
degeneracy  in  the  organized  tissues,  which  renders 
them  an  object  of  consideration  in  the  study  of  the 
causes  of  any  disease,  especially  in  diseases  which 
have  such  elusive  and  intangible  dependencies  as  has 
epilepsy.  The  great  influence  of  rheumatism  and  the 
gouty  diathesis  in  the  etiology  of  epilepsy  has  come 
to  be  recognized  by  most  authorities.  Although  Gow- 
ers considers  it  of  slight  importance,  rheumatism  and 
gouty  diathesis  are  diseases  closely  dependent  upon 
disordered  blood  states,  and  especially  upon  abnormal 
metabolism,  which,  in  turn,  is  closely  associated  with 
insufficient  elimination  of  urea  and  its  allied  products. 
This  latter  principle  has  been  carefully  worked  out  bj' 
Haig,  Bouchard,  and  others. 

Inebriety:  It  has  been  estimated  by  competent  au- 
thorities that  nearly  one-third  of  all  epileptics  have 
had  intemperate  progenitors,  who  were  intemperate 
either  before  the  birth  of  the  patient  or  just  at  the 
time  of  conception. 

Consanguinity  has  long  since  been  recognized  as 
an  essential  factor  in  considering  family  degeneracy. 
This  condition  is  probably  of  more  frequent  occur- 
'  "  Te.\t-book  of  Nervous  Diseases,"  vol.  ii.,  p.  731. 


254 


MEDICAL    RFXORD. 


[August  21,  1897 


rence  in  Europe  than  in  America.  In  but  one  case 
has  this  factor  been  found  to  play  an  important  part 
in  examination  of  over  two  hundred  cases  admitted 
to  the  Craig  Colony. 

Gowers  has  stated  that  rachitis  is  a  most  potent 
factor  in  the  production  of  epilepsy  in  infancy. 

Epilepsy  connected  with  dentition  he  would  ascribe 
to  rachitis  primarily,  the  latter  condition  being  based 
upon  defective  feeding.  However  true  this  may  be  in 
England,  based  upon  this  author's  most  extensive  ex- 
perience, the  writer  has  not  been  able  to  elicit  evi- 
dence to  substantiate  the  fact  that  rachitis  and  defec- 
tive feeding  were  the  primary  dilflculty  in  epilepsy 
following  convulsions  at  dentition. 

Insanity  again  brings  us  to  a  point  about  which 
there  are  many  mooted  questions  at  present.  It  is 
questionable  whether  insanity  predisposes  any  one  to 
epilepsy,  or  gives  even  a  basis  for  suggesting  a  hered- 
itai7  characteristic  which  is  transmissible  in  the  form 
of  epilepsy.  When  insanity  is  present  in  the  family 
it  certainly  does  predispose  tlie  individual  epileptic  to 
rapid  and  marked  mental  deterioration. 

The  significance  of  epilepsy  in  the  family  history 
should  not  be  given  so  much  importance  as  it  has 
received  in  the  past  from  the  profession  at  large.  The 
disease  itself  is  not  so  certain  of  transmission,  and, 
even  if  so,  is  not  certain  of  direct  transmission.  Gow- 
ers states  that  the  presence  of  epilepsy  in  an  individual 
does  not  necessarily  preclude  his  marriage,  or  if  he 
does  marry  he  is  not  certain  to  inflict  the  disease  upon 
his  immediate  offspring.  The  author  makes  such 
careless  statements  in  regard  to  this  factor  in  produc- 
ing epilepsy  that  the  writer  thinks  it  would  bear  much 
more  consideration  than  he  gives  it.' 

The  presence  or  absence  of  other  convulsive  dis- 
eases, such  as  chorea,  tic  convulsif,  habit  spasm,  occu- 
pation neurosis,  etc.,  is  desirable  to  ascertain,  although 
too  much  emphasis  should  not  be  laid  upon  such  in- 
formation if  they  are  found  to  exist. 

The  writer  desires  to  call  special  attention  to  the 
scheme  under  personal  history.  It  is  extremely  diffi- 
cult to  obtain  valuable  and  accurate  information  bear- 
ing upon  prenatal  causes  of  the  disease  or  any  abnor- 
malities existing  at  the  labor  period:  for  this  reason 
alone,  such  information  has  relatively  but  little  value. 
Convulsions  at  birth  and  at  dentition  should  always 
be  inquired  into,  as  many  persons  are  of  the  opinion 
that  "  spasms"  at  birth  or  at  dentition  are  perfectly 
physiological  and  that  they  have  no  special  signifi- 
cance in  the  child's  growth  or  the  after-development 
of  the  nervous  system. 

In  about  eighty  per  cent,  of  all  cases  of  epilepsy  ad- 
mitted to  the  Craig  Colony  in  which  the  convulsions 
began  in  early  infancy  they  were  found  to  be  closely  as- 
sociated with  dentition.  Any  abnormality  of  develop- 
ment in  this  epoch  probably  has  more  etiological 
significance  than  the  mere  process  of  dentition  itself 
"  In  considering  the  infectious  diseases  of  childhood, 
we  would  say  that  scarlet  fever,  measles,  and  typhoid 
fever  represent,  in  the  order  named,  the  manner  in 
which  they  have  been  the  causation  of  epilepsy. 
Occasionally  pertussis  has  been  given  as  a  cause,  but 
in  such  cases  it  seems  purely  incidental.  Measles  is 
rarely  found  to  cause  epilepsy,  while  scarlet  fever  has 
been  found  in  the  examination  of  cases  at  the  Craig 
Colony  to  be  a  more  frequent  and  certain  factor  than 
have  all  the  other  infectious  diseases  combined.     This 

'  The  writer  deems  this  subject  of  so  much  importance  that 
further  comment  .seems  necessary.  In  some  twelve  cases  of  epi- 
leptics admitted  to  the  Craig  Colony  eight  were  married  after 
their  epilepsy  had  begun.  Three  were  married  after  consultation 
with  a  physician,  and  in  all  cases  a  decided  change  for  the  worse 
was  noticeable  after  marriage.  Fortunately  but  few  had  offspring, 
and  in  most  of  these  cases  the  children  died  in  early  infancy.  In 
but  one  case  have  amicable  relations  been  maintained  between 
husband  and  wife. 


statement  is  quite  in  accord  with  former  statistics 
upon  the  subject. 

Under  the  heading  of  causation  of  epilepsy,  we 
would  say  that  it  is  very  difficult  for  one  to  elicit  the 
proper  information  which  has  much  or  any  bearing 
upon  the  real  etiology  of  the  disease.  Whenever 
syphilis  is  present  it  is  usually  very  easy  to  detect 
it,  and  seizures  following  syphilis  of  the  brain 
are  very  easy  of  diagnosis  by  a  careful  observer. 
They  should  never  be  classed  with  true  epilepsy,  as 
they  belong  properly  in  that  class  known  as  epilepti- 
form. Occasionally  cases  are  seen  following  syphilis, 
in  which  the  ravages  of  syphilis  have  been  eradicated 
and  yet  convulsions  continue;  such  resemble  true 
idiopathic  epilepsy,  and  have  then  probably  become 
such  to  all  intents  and  purposes. 

Masturbation  and  sexual  excesses  have  both  been 
very  much  overestimated  in  the  past,  and  are  properly 
receiving  at  present  but  little  attention  as  regards  the 
causation  of  the  disease,  although  when  present  such 
habits  undoubtedly  prolong  and  aggravate  the  malady. 

The  association  which  periodic  attacks  of  headache 
and  epistaxis  have  with  disorders  of  the  nervous  sys- 
tem, as  seen  in  epileptics,  is  very  difficult  of  exact 
explanation,  but  that  they  do  have  some  relationship  to 
the  disease  is  clearly  proven  in  the  case  of  six  patients 
who  were  admitted  to  the  Craig  Colony,  and  in  whom 
there  was  a  record  of  periodic  attacks  of  headache  and 
epistaxis  covering  a  period  of  four  or  five  years  prior 
to  the  occurrence  of  any  seizure.  Headache  of  this 
character  must  be  differentiated  from  that  following  a 
slight  petit-mal  attack,  which  is  frequently  observed. 
Probably  the  conditions  underlying  both  are  analogous. 
Epistaxis  frequently  disappears  as  soon  as  the  seizures 
become  at  all  frequent.  The  exact  explanation  of 
the  presence  of  both  of  these  symptoms  when  they 
precede  the  development  of  true  epilepsy  it  would  be 
of  great  interest  to  ascertain  by  future  study. 

The  disorders  of  sleep,  night  terrors,  and  nightmare, 
as  found  in  the  family  and  patient's  history,  are  of 
considerable  interest  and  give  us  some  clew  as  to  the 
sensibility  of  the  cerebral  cortex;  or,  in  other  words, 
they  give  us  an  idea  of  the  manner  in  which  the  higher 
cerebral  centres  influence  the  motor  areas,  which 
points  to  the  instability  of  the  motor  area  of  the  brain 
in  epilepsy.  It  is  not  an  infrequent  observation  to  see 
those  epileptics  who  have  had  some  disorder  of  sleep, 
either  in  their  family  history  and  in  their  own  per- 
sonal history,  show  themselves  particularly  liable  to 
automatism  following  petit-mal  attacks.  It  is  hardly 
necessary  for  the  writer  to  say  that  any  paralysis  from 
which  the  patient  may  have  suffered  in  early  infancy, 
if  slight  in  character  and  transitory  in  duration,  will 
manifest  itself  but  little  in  later  life.  Infantile  cere- 
bral palsies  are  particularly  difficult  to  detect.  About 
eighty  per  cent,  of  all  such  cases  become  epileptics  in 
later  life.  Only  by  close  examination  of  the  reflexes, 
dynamographic  examination,  and  comparison  of  the 
extremities  as  to  size,  muscular  rigidity,  and  tonus, 
can  one  detect  the  presence  of  a  slight  lesion  of  infan- 
tile paralysis. 

The  kind  of  education  and  the  manner  of  obtaining 
the  same  are  very  necessary  to  a  proper  conception  of 
the  degree  of  mental  force  which  the  patient  possessed 
in  early  life.  The  occupation  and  regularity  of  work 
which  the  patient  has  performed  in  the  past  also  give 
one  some  idea  of  the  capacity  of  the  individual  and 
the  effects  the  epilepsy  may  have  had  upon  the  organ- 
ism in  causing  it  to  depart  from  the  normal  social 
status  of  conduct. 

Careful  inquiry  into  the  details  of  the  first -seizure 
shall  be  made  before  we  can  form  a  definite  idea  as 
to  how  severe  the  etiological  factor  may  have  been 
in  the  production  of  the  patient's  epilepsy.  Quite 
frequently  the  alleged    cause  for   the  first  attack   is 


August   21,    1897] 


MEDICAL    RECORD. 


255 


only  an  excitant  acting  upon  an  intierited  or  ac- 
quired unstable  organism.  The  kind,  degree,  and 
form  of  disorder  in  consciousness  which  occurred 
at  the  first  seizure  should  be  carefully  studied.  Just 
what  change  occurs  in  the  material  substratum  under- 
lying a  disordered  consciousness  is  still  unknown;  it 
is  questionable  whether  this  ever  will  be  known,  but 
in  the  mean  time  we  should  study  all  disordered 
states  of  consciousness,  and  ascertain  as  far  as  pos- 
sible the  influence  which  they  have  over  the  mental 
processes  of  the  individual  epileptic. 

The  great  significance  of  the  epileptic  aura  makes 
it  a  very  important  factor  in  the  consideration  of  the 
epilepsy,  as  the  aura  generally  indicates  the  part  of 
the  brain  beginning  the  nervous  discharge.  It  often 
is  well  marked  at  first,  but  dies  out  as  the  discharge 
gradually  becomes  more  general  or  diffuse.  The 
mental  state  subsequent  to  the  paroxysm  and  pres- 
ence or  absence  of  aphasia  or  paresis  following  the 
seizure  are  all  of  great  value  in  the  study  of  the  case. 
The  manner  in  which  all  of  the  above-mentioned 
symptoms,  connected  with  the  first  seizure,  may  under- 
go modifications  in  subsequent  attacks  should  also  be 
investigated,  to  aid  in  forming  an  opinion  of  the  prog- 
ress of  the  disease  and  what  factors  indicate  a  favora- 
ble or  unfavorable  prognosis. 

There  is  a  frequent  association  of  hysteria  in  its 
many  forms  with  epilepsy,  especially  in  women  and 
occasionally  in  men — which  latter  association,  b\-  the 
way,  is  much  more  frequent  than  is  stated  by  text- 
books upon  epilepsy.  This  heading  in  the  scheme  is 
a  most  important  one  for  careful  study,  both  at  the 
primary  examination  and  many  times  for  months  after. 
Many  text-books  state  that  the  differential  diagnosis 
between  hysteria  and  epilepsy  is  very  easy  to  make  to 
one  who  is  at  all  familiar  with  both  diseases.  The 
anomalous  forms  in  which  both  diseases  may  be  asso- 
ciated in  the  same  case  renders  it  practically  impossi- 
ble for  the  clinician  to  state  that  one  disease  is  more 
pronounced  than  the  other,  which  gives  us  the  name 
of  hystero-epilepsy. 

The  automatic  state  that  usually  follows  petit-mal 
and  psychic  attacks,  and  occasionally  after  grand  mal, 
is  a  desirable  subject  to  investigate  from  the  mental 
side  of  epilepsy.  Frequently  sane  epileptics  have  hal- 
lucinations either  of  sight  or  hearing,  without  having 
any  particular  mental  disturbances  accompanying 
them.  This  fact  has  not  always  received  as  much  at- 
tention as  it  merits.  There  seems  to  be  no  doubt 
that  in  many  cases  of  epilepsy  in  which  vivid  hallu- 
cinations of  sight  and  hearing  were  prominent,  and 
also  in  which  later  in  life  epileptic  seizures  were 
common  and  frequent,  these  early  hallucinations  had 
some  connection  with  the  disturbed  mental  condition 
which  finally  culminated  in  the  epilepsy.  This 
statement  well  illustrates  the  place  which  epilepsy 
takes  midway  between  a  mental  and  true  nervous 
disease. 

The  association  which  vasomotor  disturbances  have 
in  connection  with  epilepsy  has  been  a  subject  of  con- 
siderable study,  although  but  little  definite  information 
has  been  obtained  concerning  their  interdependence. 
That  pallor  and  flushing  have  some  connection  with 
the  epileptic  paroxysm  is  generally  an  acknowledged 
fact,  although  Gowers  states  that  even  though  the  face 
may  be  flushed  it  is  no  evidence  that  the  brain  is  in  a 
corresponding  condition.  Any  one  who  has  had  per- 
sonal experience  with  flushing  and  pallor  of  the  normal 
state  must  be  conscious  of  the  close  relationship  be- 
tween the  vasomotor  apparatus  of  the  surface  of  the 
face  and  certain  cerebral  states,  as  illustrated  by  close 
study,  intense  application,  or  any  kind  of  mental  excite- 
ment. 

Considerable  attention  should  be  devoted  to  the 
onset  of  the  seizure,  as  to  what  muscles  are  first  in- 


volved, and  thus  we  will  be  able  to  reason  a  posteriori 
as  to  what  portions  of  the  motor  cortex  were  first 
affected  in  the  convulsive  discharge.  It  is  desirable 
that  we  should  also  know  the  muscles  successively 
affected  and  the  muscles  which  are  most  affected. 
For  many  reasons  it  is  desirable  that  we  should  make 
careful  inquiry  as  regards  the  action  of  the  sphincters 
during  the  attack.  Gowers  states  that  these  symptoms 
are  produced  in  some  other  manner  aside  from  the 
mental  enfeeblement  or  loss  of  consciousness  which  is 
present  in  epilepsy,  as  some  subjects  always  lose  con- 
trol of  the  sphincters  in  their  attacks  and  others  never 
lose  control,  although  they  may  have  epilepsy  for 
years.  Future  study  should  enable  us  to  clear  up  this 
matter,  but  at  present  it  would  be  purely  conjectural 
for  us  to  formulate  explanations  for  the  presence  of 
this  disagreeable  symptom.  Some  of  the  reasons  put 
forward  are  that  excessive  muscular  contraction  forces 
the  contents  by  a  naturally  unwilling  sphincter:  an- 
other is  that  the  control  of  the  higher  cerebral  centre 
is  lost  over  the  spinal-reflex  centre;  still  another  is 
gi\en  that  the  sphincters  receive  the  initial  shock  of 
the  cerebral  discharge  and  are  relaxed  thereby. 

Special  attention  should  be  given  the  examination 
bearing  upon  any  particular  excitant  which  causes  an 
attack.  Equal  attention  should  be  given  to  anything 
which  arrests  an  attack,  not  only  from  a  therapeutic 
standpoint,  but  because  it  enables  us  to  know  whether 
the  patient  has  any  hysterical  symptoms  attending  the 
epilepsy.  As  the  disorders  of  consciousness  of  epilep- 
tic seizures  are  almost  invariably  followed  by  a  certain 
degree  of  mental  impairment,  we  should  know  as  much 
as  possible  about  the  mental  state  in  the  interim. 
Then,  too,  the  memory  in  epilepsy  is  almost  always 
impaired.  This  seems  to  be  due,  in  a  great  measure, 
to  the  often  reported  disorders  of  consciousness. 

We  should  know  about  the  frequency  of  the  early 
attacks  and  their  frequency  at  present,  in  order  that 
we  may  form  a  definite  idea  as  to  the  prognosis  and 
the  kind  and  manner  of  medical  treatment  which 
should  be  given.  The  diet  should  be  carefully  in- 
quired into  from  all  points.  Quite  frequently  after 
patient  examination  of  a  case,  both  through  friends 
and  the  patient  himself,  one  may  elicit  no  information 
upon  this  point — when,  almost  by  accident,  the  exam- 
iner will  stumble  upon  some  ver}'  important  unhygienic 
condition  which  the  patient  and  his  friends  thought 
was  perfectly  harmless.  It  is  really  the  minutix-  of  the 
daily  life  of  the  epileptic  which  give  us  a  true  insight 
into  the  malady  and  its  treatment. 

Appetite,  digestion,  sleep,  use  of  alcoholics,  tobacco, 
and  other  narcotics,  are  all  obviously  of  great  import- 
ance. The  writer  would  warn  any  examiner  from 
being  led  astray  in  obtaining  information  regarding 
disorders  of  digestion,  as  the  epileptic  is  notoriously  a 
hypochondriac. 

In  the  physical  examination  it  is  unnecessary  for 
me  to  emphasize  the  great  importance  of  a  careful 
study  of  the  case  from  this  point,  as  this  not  infre- 
quently gives  us  a  decided  clew  as  to  the  true  etiolog)- 
of  the  disease.  However  the  fact  may  be  interpreted, 
it  does  seem  that  in  the  majority  of  epileptics  heart 
diseases  are  much  more  frequent  than  many  other 
organic  lesions.  The  valvular  lesion  most  frequently 
found  is  mitral  regurgitation.  One  of  the  principal 
reasons  for  this  condition  is  alleged  by  many  writers 
to  be  due  to  an  abnormal  blood  pressure,  caused  by 
the  muscular  contracture  in  the  seizure. 

Some  writers  have  stated  that  the  pupils  of  epilep- 
tics are  unusually  large  and  responsi\e  to  stimulation. 
.\lthough  the  writer  thinks  that  this  statement  will  not 
be  borne  out  by  persistent  and  thorough  examination 
in  a  great  number  of  cases,  yet  some  amount  of  atten- 
tion should  be  paid  to  the  pupillary  reflexes  in  epilep- 
sy, and  these  undergo  various  modifications  before,  at 


256 


MEDICAL    RECORD. 


[August  2  1,  1897 


the  time  of,  and  after  seizures.  It  is  doubtful  whether 
there  is  much  if  any  dependence  to  be  placed  upon  the 
examination  of  the  so-called  deep  refle.xes,  especially 
when  they  indicate  a  slight  diminution.  Not  infre- 
quently the  condition  of  the  reflexes  of  one  side,  as 
compared  with  the  other,  will  show  marked  exaggera- 
tion. This  should  always  be  a  sufficient  indication  for 
us  to  look  for  temporary  exhaustion  paralysis  follow- 
ing the  seizures;  occasionally  it  is  the  one  symptom 
jpresent  indicative  of  such  a  post-paroxysmal  disorder. 
Jn  almost  all  cases  in  which  epilepsy  has  been  existent 
for  many  years,  a  certain  degree  of  disordered  motion 
and  co-ordination  will  be  observed.  Hughlings-Jack- 
son  has  formulated  a  theory  for  this  condition,  in 
•which  he  states  that  it  is  due  to  a  gradual  loss  of 
memory  impressions  of  motor  acts  in  the  brain,  and 
that  in  each  seizure  there  are  lost  successively  less 
complex  muscular  movements  which  are  never  entirely 
regained.  Notwithstanding'  that  such  a  statement  is 
verj-  difficult  of  proof,  it  gains  more  credence  the  more 
carefully  it  is  investigated. 

Often  an  examination  by  dynamometer  gives  one 
the  first  clew  to  the  presence  of  the  effects  of  infantile 
paralysis,  which,  as  mentioned  before,  is  always  very 
difficult  to  discover  if  the  paralysis  has  occurred  in 
very  early  life  and  the  patient  has  been  thereafter  in 
strong  and  robust  physical  health.  Again,  it  may  give 
one  a  clew  to  a  marked  incapacity  of  one  side  of  the 
body  as  compared  with  the  other,  without  there  being 
any  cerebral  or  spinal  disease  underlying  it.  It  may 
be  a  congenital  defect,  a  real  physical  stigma  of  de- 
generation, closely  allied  to  the  well-known  stigmata 
of  asymmetries  of  the  body. 

In  making  a  record  of  the  stigmata  of  degeneration 
in  epilepsy,  w-e  are  forcibly  reminded  that  this  disease 
presents  probably  more  stigmata  of  degeneration  tlian 
all  other  nervous  diseases  combined.  Sufficient 
explanation  for  this  condition  is  still  wanting.  Slight 
errors  of  development  which  might  be  known  as  stig- 
mata should  not  be  given  too  serious  attention,  espe- 
cially as  regards  the  prognosis  of  the  epilepsy.  In 
the  order  of  their  most  frequent  occurrence,  and  prob- 
ably in  the  order  of  their  greatest  significance,  they 
are  as  follows:  Palate,  ear,  asymmetry  of  cranium  and 
face,  general  physical  development.  Although  the 
presence  of  marked  stigmata  gives  us  some  clew  as  to 
the  probable  deficient  development  of  the  cerebral 
centres,'  yet  it  should  not  influence  us  too  much  in  de- 
claring a  particular  case  as  without  hope  of  recover)'. 
Frequently  in  those  cases  in  which  stigmata  of  degen- 
eration are  most  prominent,  the  least  difficulty  of 
ameliorating  the  severity  of  their  epileptic  seizures  is 
noticed. 

A  word  of  warning  should  be  given  here  against  the 
possibility  of  mistaking  stigmata  of  degeneration  for 
the  results  of  falls  or  injuries  received  by  the  epileptic, 
either  before  his  seizures  begin  or  after  they  are  grand 
mal  in  character.  Such  injuries  frequently  resemble 
closely  the  various  stigmata  of  degeneration  found  in 
the  face  and  ears.  In  a  measure  this  indicates  why 
the  deformit)'  of  the  palate  is  most  to  be  relied  upon 
in  making  a  just  estimate  of  the  influence  the  stigmata 
of  degeneration  have  upon  the  patient. 

Any  abnormality  found  in  the  first  menstruation 
(whether  it  be  delayed  or  premature)  is  an  essential 
factor  in  the  examinations  of  female  epileptics.  It  is 
essential  to  ascertain  if  any  irregularity  of  menstrua- 
tion is  associated  with  the  occurrence  of  a  great  number 
of  epileptic  seizures.  The  relationship  which  true 
epilepsy  has  to  seizures  which  occasionally  occur  dur- 
ing the  labor  period  is  of  considerable  interest.  Of- 
tentimes a  history  of  such  as.sociation  will  be  given  to 
the  physician  by  patient  and  friends  when  close  ob- 
servation will  prove  none  to  exist. 

Although  Gowers  states  that  convulsions  following 


the  puerperal  eclampsia  rarely  if  ever  lead  to  true 
epileptic  seizures,  at  times  it  is  very  difficult  to  differ- 
entiate the  convulsions  of  puerperal  eclampsia  from 
those  of  epileptic  seizures  which  follow. 


A    CASE   OF    EUSTRONGYLUS    GIGAS. 
By   JOHN    TRUMBULL,   M.D., 

Concerning  this  large  nematoid  worm,  which  inhabits 
the  pelvis  of  the  kidney  in  certain  carnivora  and  other 
mammals,  Fagge  says  that  it  is  "excessively  rare  in 
man."  He,  too,  is  authority  for  the  statement  that  of 
the  fourteen  cases  cited  by  Kiichenmeister  only  four 
seem  to  be  authentic,  viz.,  those  of  Grotius  in  1595.  of 
Ruysch,  of  Blasius,  and  a  more  recent  one  of  Moublet. 
The  rarity  of  the  disease  is  therefore  sufficient  warrant 
for  immediate  publication. 

Being  accosted  on  the  street  by  a  friend,  who  com- 
plained of  a  tightness  across  the  chest,  with  pain  which 
radiated  down  the  right  ann,  and  which,  though  coming 
on  suddenly  the  night  before  with  a  sense  of  impend- 
ing dissolution,  had  persisted  till  then,  I  insisted  on 
having  a  specimen  of  his  water,  and  promised  to  call 
round  to  examine  his  heart  early  the  next  morning. 
As  the  pain  continued,  he  came  to  my  office  with  a 
bottle  of  urine,  and  an  appointment  was  made  to  see 
him  in  bed  that  evening. 

The  urine  was  clear  and  acid:  specific  gravity,  1.018; 
it  gave  a  slight  cloudiness  in  the  upper  half  of  the 
test  tube  when  boiled  after  the  addition  of  acetic  acid. 

My  patient,  Mr.  E ,  a  former  sea  captain^  seventy- 
three  years  of  age,  who  has  resided  in  Valparaiso  for 
over  twenty-two  years  in  daily  active  employment, 
gave  the  following  history  :  The  night  previous  he  had 
retired  feeling  perfectly  well,  but  about  midnight  was 
awakened  by  severe  pain  across  the  lower  portion  of 
the  chest,  shooting  down  into  the  right  arm.  No  short- 
ness of  breath,  no  pain  on  breathing,  no  palpitation 
or  irregularity  of  heart  action.  The  anguish  disap- 
peared, but  the  pain  persisted.  Questioning  elicited 
the  fact  that  for  three  or  four  years  he  has  had  to  rise 
some  four  or  five  times  during  the  night:  and  he  has 
noticed  that  often,  almost  immediately  after  emptying 
the  bladder,  he  feels  impelled  to  rise  again.  The 
quantity  of  urine  he  admits  to  have  been  above  the 
normal — "would  half  fill  the  vessel  during  the  night.'' 
Now  and  then,  after  an  attack  of  diarrhcea  or  cold,  he 
remembers  that  the  urine  has  been  scanty  and  dark. 
He  has  never  passed  blood ;  never  has  had  cedema 
of  the  feet,  or  puffiness  of  the  lids,  or  morning  head- 
ache; no  pain  in  lumbar  region:  never  conscious,  he 
says,  of  having  kidneys,  lungs,  liver,  or  heart.  Three 
months  ago,  though  regular  in  habit,  he  had  a  sudden 
desire  one  day  to  empty  his  bowel,  and  to  his  surprise 
passed  about  a  quart  of  pure  blood.  Bleeding,  though 
in  much  diminished  quantity,  recurred  off  and  on  for  a 
month  or  six  weeks.  He  had  never  suffered  from 
piles. 

Physical  examination  was  purely  negative,  aside 
from  a  slight  enlargement  of  the  heart  unaccompanied 
by  increased  arterial  tension,  and  signs  of  arterio- 
sclerosis. 

While  convinced  that  his  attack  had  been  one  of 
angina  pectoris,  due  probably  to  disease  of  the  coronary 
arteries,  I  expected  that  the  microscopic  examination 
of  the  urine  would  confirm  the  existence  of  an  intersti- 
tial nephritis.  In  going  over  a  slide,  twenty-four 
hours  after  the  voiding  of  the  urine,  I  had  found  three 
or  four  hvaline  casts,  when  mv  attention  was  aroused 
by  the  appearance  wiiiiin  the  field  of  vision  of  a  worm 
which  was  in  active  motion.  It  stretched  clear  across 
the  field,  and  with  slow  motion  curved  anterior  and 


August    2  1,    1897] 


MEDICAL    RECORD. 


25- 


posterior  extremities  in  opposite  directions,  until  it 
assumed  the  outline  of  a  figure-of-eight:  when  it 
slowly  unfolded,  to  bend  back  again,  or  move  the  buc- 
cal end  from  side  to  side.  It  had  the  appearance  of  a 
diminutive  angle-worm,  tapering  to  a  point  at  the 
posterior  end:  while  at  the  head  there  was  a  much 
slighter  narrowing,  which  ended  in  a  circular  opening. 
From  this  opening  a  fine  thread-like  process  was  seen 
to  protrude  now  and  then.  Both  ends  were  light  in 
color,  and  of  a  faint  bluish  tint,  though  a  dark  line 
could  be  traced  running  from  the  mouth  into  the  body. 
.\t  the  junction  of  the  more  transparent  anterior  por- 
tion with  the  more  opaque  portion  of  the  body,  which 
took  place  a  little  more  than  one-fifth  of  the  distance 
toward  the  distal  e.xtreraity,  there  were  two  dark  spots 
which,  in  a  couple  of  specimens  found  later  on,  had  a 
ver)'  faint,  distinctly  pinkish  tint.  The  rest  of  tlie 
body  was  of  a  dark,  granular  aspect,  sharply  defined, 
running  the  whole  length  of  the  worm  to  near  the  pos- 
terior end,  and  had  on  either  side  of  the  dark  line 
which  limited  the  granular  portion  a  lighter  trans- 
parent band  between  it  and  the  cleanly  cut  outline  of 
the  worm. 

I  called  my  friend,  Dr.  Talavera,  to  see  the  worm : 
and  from  Rafael  Blanchard's  article  on  ''Animal  Par- 
asites," in  Salagar  and  Newman's  "  E.xamen  Quimico 
y  Bacteriologico  de  las  .Aquas  Potables,"  was  able  to 
identify  the  worm  as  belonging  to  the  nematoid  group, 
and  as  being  the  strongylus  gigas. 

Valparaiso  draws  its  main  water  supply  from  a  river 
which  flows  bottom  side  up,  so  to  speak,  for  the  water 
is  pumped  from  wells  sunk  in  the  Salto  Valley,  where 
there  is  an  underground  river  e.xcept  during  the  rainy 
season.  The  hill  on  which  my  patient  resides  has, 
however,  for  years  been  supplied  with  water  from  the 
Quebrada  Verde — surface  water.  The  possibility  of  a 
stray  strongylus  gigas  having  got  in,  from  the  water 
used  to  rinse  out  an  empty  medicine  bottle,  was  pres- 
ent in  my  mind;  but  a  second  slide  examined  that 
evening  dispelled  such  a  suppositiouj  for  in  it  I  found 
five  worms,  two  of  which  were  living,  and  nine  or  ten 
^SS^-  Tlie  eggs  were  ellipsoidal  in  shape,  and  sharp- 
ened at  the  poles:  with  small,  scattered,  bright  points, 
surrounded  by  a  dark  border,  which,  while  not  so  per- 
fect as  the  illustrations  of  the  ovum  in  Blanchard's 
article,  yet  hinted  at  the  small  openings  in  the  fragile 
enveloping  coat  which  allow  of  the  nutrition  of  the 
developing  worm  by  interchanges  with  the  fluid  in 
which  it  lies.  The  third  slide  gave  me  three  worms 
and  several  ova;  while  in  the  fourth  I  counted  thirteen 
worms  of  different  sizes,  and  since  then  every  slide 
has  contained  four  or  five. 

As  the  patient  passed  the  urine  directly  into  the  bot- 
tle, the  large  number  of  ova  and  growing  worms  found 
could  scarcely  have  come  from  a  few  drops  of  water 
used  for  rinsing.  On  the  other  hand,  the  fact  that 
these  worms  in  macroscopic  structure,  so  to  speak, 
correspond  perfectly  with  the  strongylus  gigas,  which 
has  its  habitat  in  the  pelvis  of  the  kidney,  makes  it 
impossible  for  them  to  have  come  other  than  from  the 
urine. 

In  the  short  article  to  which  I  have  referred,  the 
passage  of  ova  only  is  mentioned,  and  not  that  of  liv- 
ing worms.  Here,  however,  we  have  a  man  advanced 
in  years,  with  enlarged  prostate,  no  doubt,  who  never 
succeeds  in  thoroughly  emptying  his  bladder.  In  its 
albuminous  fluid  (is  Bright's  disease  an  essential  fac- 
tor in  the  development  of  this  worm?)  tlie  ova  receive 
ample  nutrition,  are  kept  at  a  uniform  temperature, 
and  hatch  out.  Thus  it  is  that  living  specimens  are 
voided,  together  with  eggs  more  recently  cast  off  by  the 
inhabitant  in  the  peh  is  of  the  kidney.  The  hair-like 
process  from  the  mouth,  seen  in  the  first  living  speci- 
men, is  doubtless  the  perforating  tooth  by  which  it 
makes  its  way  through  the  intestinal  wall  to  the  blood- 


vessels, and  thence  is  swept  to  the  kidneys,  where  nu- 
triment is  to  be  found,  indirectly,  by  going  first  through 
the  veins  to  the  heart.  But  for  the  fact  that  in  the 
bladder  there  is  an  abundant  supply  of  albuminous 
fluid  ready  at  hand,  there  is  no  reason  why  the  young 
worms  might  not  pierce  its  mucous  surface  and  thus 
themselves  reach  the  kidney. 

Since  the  above  was  written  I  have  had  two  other 
samples  of  urine.  With  the  first,  which  w^as  only  an 
ounce,  eighteen  or  twenty  slides  failed  to  give  me  a 
single  worm,  though  the  sediment  gave  ample  evidence 
as  to  the  existence  of  a  prolific  breeder,  it  being  lodged 
somewhere  in  the  urinary  tract.  In  the  second  speci- 
men, just  examined,  I  found  several  dead  worms  and 
pieces  of  worms  (Fig.  i).  In  all  of  these  the  granules 
of  the  central  portion  were  replaced  by  larger  refracting 
masses,  due  to  the  products  of  decomposition,  and  with 
the  slightest  pressure  of  the  cover  glass  these  were 
expelled,  so  that  the  worm  remained  more  translucent 
and  homogeneous  looking.  Among  the  slides  exam- 
ined with  this  sediment  I  found  the  bodies  shown 
in  the  accompanying  illustration  (Fig.  2).     A  was  un- 


FlG.  I. — Young  Wo 


Fig.  2.— Ova  and  Debris  of  Shells. 

doubted ly  the  vitellin  membrane  of  an  empty  egg, 
whose  pole  had  been  ruptured  for  the  escape  of  the 
embryo.  It  looked  like  a  thin  eggshell  with  the 
top  cut  off;  and  the  upper  lighter  circle  was  clearly 
on  a  lower  level,  and  formed,  with  the  more  sharply 
defined  anterior  edge,  the  rim  of  a  cup-shaped  hollow. 
The  difference  in  thickness  between  the  single  integu- 
ment in  the  circle  and  that  of  the  rest  of  the  mass, 
where  the  light  came  through  two  membranes,  was 
clear  and  distinct.  B  was  another  ring  of  a  per- 
forated pole,  with  only  a  piece  of  the  rest  of  the 
membrane  attached.  C  and  /?  are  one  and  the  same 
mass  looked  at  in  different  positions  as  it  tumbled 
about  responsive  to  the  impulse  of  expired  air  in 
breathing.  These,  and  others  figured  in  the  lower 
right-hand  corner,  I  take  to  be  t/H'ris  of  broken-up 
eggshells. 


2S8 


MEDICAL    RECORD. 


[August  21,  1897 


The  following  gentlemen  have  seen  my  specimens, 
as  I  have  been  finding  them,  and  have  authorized  me 
to  cite  them  as  to  the  genuineness  of  the  case,  and  as 
to  the  accuracy  of  ray  representation  of  what  was  seen 
under  a  lens  magnifying  five  hundred  diameters: 
Dr.  Olof  Page,  of  the  Universit)-  of  Pennsylvania;  Dr. 
Luis  Asta-Huruaga,  of  the  College  of  Physicians  and 
Surgeons,  New  York,  and  ex-interne  of  Roosevelt  Hos- 
pital ;  Dr.  Roberto  Montt,  of  the  University  of  Chile, 
who  studied  under  Giinther  of  Berlin  and  Levy  of 
Strasbourg;  Mr.  Thomas  Griffiths,  associate  of  the 
Pharmaceutical  Society  of  London.  Dr.  Luis  Mour- 
gues,  of  Paiis,  and  Senor  Carlos  E.  Porter,  of  the 
Municipal  Laboratory,  have  already  photographed  one 
of  the  specimens  under  a  high-power  lens,  but  are  wait- 
ing for  a  more  favorable  opportunity  to  secure  better 
plates.  They  have  been  able  to  distinguish  three 
small  papillae  or  nodules  on  the  edge  of  the  flattened 
mouth,  and  infer  that  the  characteristic  six  will  be 
found  in  a  more  perfect  specimen.  My  representa- 
tions of  ova  correspond  with  those  shown  in  works  be- 
longing to  the  enthusiastic  naturalist,  Senor  Carlos  E. 
Porter. 

The  case  merits  study  and  a  more  detailed  report, 
which  will  be  forthcoming  as  soon  as  possible. 


THE   NERVOUS    SYSTEM    IN    DISEASE. 
Bv   JO.SEPH    F.    ED\V.\RDS.    .\.M.,    M.l)., 

ATLANTIC   CITV.    N.    J., 

FELLOW  OF  THE  COLLEGE  OF  PHYSICIANS  OK  PHILADELPHIA ;  ^X-MEMBER. 
STATE  BOARD  OF  HEALTH  OF  PENNSYLVANIA  ;  FOREIGN  ASSOCIATE  MEM- 
BER,  FRENCH  SOCIETY  OF   HYGIENE,  ETC. 

Some  five  years  ago  a  girl  of  fourteen  (a  mem- 
ber of  my  own  family),  who  had  all  through  her  life 
presented  every  appearance  of  robust  health,  after  a 
period  of  close  application  to  study  commenced  to 
present  evidences  of  some  little  loss  of  her  previously 
vigorous  health;  and  one  day  said  to  me,  laughingly: 
"I  am  getting  paralyzed;  I  have  no  feeling  in  my 
fingers.  You  could  cut  them  off  and  I  would  not  feel 
it."  For  two  weeks  at  intervals  she  would  repeat  this 
remark,  then  run  off  to  her  books  or  play,  and  no  at- 
tention was  given  to  these  supposedly  insignificant 
and  meaningless  complaints.  It  should  be  particu- 
larly noted  that  the  outward,  obvious  evidences  of 
departure  from  vigorous  health  were  so  insignificant 
as  not  to  attract  attention,  and  only  to  be  remembered 
and  recalled  in  the  light  of  subsequent  events.  This 
young  girl  retired  one  night  in  her  usual  health.  In 
the  morning  she  was  the  sickest-looking  child  I  have 
ever  seen ;  she  presented  symptoms  of  perihepatitis, 
pleurisy,  and  subsequently  double  pneumonia,  with 
death  from  heart  failure  at  the  end  of  two  weeks. 

In  the  very  beginning  of  the  illness  I  inquired  into 
the  condition  of  the  different  organs,  to  ascertain 
whether  they  would  be  likely  to  carrj'  her  through  the 
contest.  In  the  course  of  this  examination,  made  at 
the  onset  of  the  disease,  I  was  struck  at  finding  in  the 
urine  an  enormous  deposit  of  the  earthy  and  alkaline 
phosphates.  Owing  to  personal  reasons  this  case 
made  a  deep  and  lasting  impression  upon  me,  and 
this  enormous  phosphatic  deposit  was  constantly  in 
my  mind,  until,  so  to  speak,  unconsciously  the  ques- 
tion evolved  itself,  whether  a  broken-down  nervous 
system  had  not  preceded  and  made  possible  the  devel- 
opment of  the  disease;  whether  we  are  not  puttin<T 
"  the  cart  before  the  horse"  when  we  teach  that  pros- 
trated nervous  systems  are  the  results  of  disease; 
whether  prostrated  nervous  systems  are  not  always  a 
necessary  prerequisite  of  disease;  whether  that  which 
we  call  the  result  is  not,  in  truth,  the  cause. 

Then  I  commenced  to  examine  the  urine  of  every 


patient  that  came  before  me,  with  the  invariable  result 
of  finding  a  very  great  deposit  of  phosphates  in  all 
conditions  of  weakness  or  prostration,  and  an  ex- 
tremely slight  deposit  in  disorders  not  attended  by 
prostration.  Then  I  began  adding  to  my  routine  treat- 
ment for  the  particular  disease  under  consideration 
ner\-e  tonics  or  nerve  sedatives,  as  I  would  find  an 
excess  or  deficiency  of  phosphatic  deposit.  My  results 
were  good ;  so  very  good  that  I  found  myself  securing 
the  reputation  of  a  "  specialist  in  nervous  diseases" 
among  my  patients. 

Then  I  commenced  to  look  for  a  theory  that  would 
fit  into  my  observation  and  experience,  and  I  elabor- 
ated the  following  doctrine,  a  brief  outline  of  which  I 
now  submit  to  my  professional  brethren. 

I  have  come  to  regard  the  various  organs  and  parts 
of  the  body  merely  as  agencies  for  the  manifestation 
of  a  force  that  is  generated  in  the  ner%'ous  system. 
The  functions  of  digestion,  assimilation,  excretion, 
circulation,  calorification,  respiration,  and  so  on 
throughout  the  whole  list  of  vital  functions,  I  have 
come  to  regard  as  manifestations  of  a  force  generated 
in  the  nervous  system.  Just  as  one  central  dynamo 
may  furnish  heat,  light,  motion,  or  sound,  in  accord- 
ance with  the  construction  of  the  agency  through 
which  the  force  generated  in  and  by  the  dynamo  is 
made  manifest — so  the  stomach  will  digest,  the  kid- 
neys will  excrete,  etc.,  not  because  of  any  power  resi- 
dent within  or  generated  within  themselves,  but  be- 
cause of  a  latent  resident  power  incited  to  activity  by 
the  force  generated  in  the  nervous  system.  In  other 
words,  my  idea  is  that,  while  capable  of  function,  no 
organ  can  originate  within  itself  the  force  necessarj- 
for  its  function.  The  carbon  points  are  necessarj-  for 
the  manifestation  of  the  electric  light;  the  car  is  nec- 
essary for  the  manifestation  of  the  electric  force  gen- 
erated for  motor  purposes;  but  neither  the  carbon 
points  nor  the  car  are  capable  of  generating  this  force 
within  themselves.  The  stomach,  liver,  spleen,  kid- 
neys, lungs,  heart,  etc.,  are  all  necessar}-  for  the  man- 
ifestation of  vital  force  familiar  to  us  as  life,  but  not 
one  of  these  organs  can  originate  within  itself  this 
force. 

According  to  this  doctrine,  we  would  be  compelled 
logically  to  regard  the  nervous  system  as  the  vivifying, 
regulating,  controlling  portion  of  the  body,  and  so  I 
took  it  to  be ;  I  did  not,  and  do  not,  think  that  I  am 
advancing  any  new  physiological  doctrines,  but  sim- 
ply that  I  am  suggesting  a  wider  and  more  universal 
application  of  those  already  taught.  So  I  thought, 
until  I  was  staggered  by  the  replies  received  by  me 
from  the  professor  of  physiology  in  one  of  our -leading 
medical  colleges,  to  some  queries  bearing  upon  this 
question. 

1.  Is  not  the  nervous  system  the  only  portion  of  the 
body  capable  of  originating  force?  To  this  query  our 
professor  replies.  No. 

2.  Can  any  organ  perform  its  function  because  of  a 
force  or  power  originated  within  itself,  independently 
of  the  nervous  system?  To  this  query  he  replies.  Yes. 

3.  Would  functional  activity  be  possible  without 
the  force  originating  in  and  transmitted  from  the  ner- 
vous system?     To  this  he  replies,  Yes. 

Now,  while  these  replies  may  be  in  accord  with 
physiological  teaching,  are  tliey  correct? 

The  affirmative  reply  to  querj-  No.  2  would  seem  to 
imply  that  each  individual  organ  of  the  body  consti- 
tutes in  itself  an  entity  capable  of  independent  exis- 
tence.    Is  this  correct? 

Does  not  an  affirmative  reply  to  query  No.  3  imply 
that  the  voluntary  muscles  possess  in  themselves  the 
power  of  contraction  and  relaxation  independently  of 
the  nervous  system,  and,  if  this  be  true,  why  does  par- 
alysis of  certain  muscles  follow  a  remote  injun.-  that 
interferes  with  the  transmission  of  force  from  the  ner- 


August  2  1,  1897] 


MEDICAL    RECORD. 


!59 


vous  system  to  these  muscles?  If  the  bladder  can 
perform  its  function  independently  of  the  nervous  sys- 
tem, why  does  paralysis  thereof  result  from  injury  to 
the  cord?  If  the  heart  is  a  complete  entity,  capable  of 
independent  function,  why  will  destruction  of  the 
cerebellum  arrest  its  action? 

These  queries  have  arisen  in  connection  with  my 
doctrine  that  a  disordered  nervous  system  is  a  pre- 
requisite to  the  existence  of  disease. 

It  seems  to  me  that  we  can  make  two  grand  divi- 
sions of  all  diseased  or  disordered  conditions: 

[.  Functional  derangements,  in  which  there  is  no 
alteration  of  structure;  simply  a  defect  in  quality  or 
quantity  of  vital  force. 

2.  Nutritional  or  organic,  for  in  all  organic  dis- 
eases not  mechanical  the  fundamental  lesion  is  an 
alteration  in  the  structure  of  the  diseased  part;  lience 
it  is  a  nutritional  change. 

If,  then,  the  nervous  system  originates  the  force  or 
power  necessary  for  function;  if  nutrition  is  a  func- 
tion: if  a  normal  ner\-ous  system  will  originate  nor- 
mal, and  an  abnormal  nervous  system  abnormal  force 
— does  it  not  logically  follow  that  an  abnormal  ner- 
vous system  must  precede  an  abnormal  functional  or 
nutritional  derangement  of  any  organ  or  part,  that  is 
not  mechanical  or  produced  by  a  mechanically  acting 
cause?  Let  it  be  understood  that  when  I  speak  of 
the  ''nervous  system,"'  I  am  not  confining  my  reference 
to  the  brain  and  spinal  cord,  but  that  I  include,  of 
course,  nerve  tissue  wherever  it  may  be  found.  With 
this  understanding,  is  it  not  true  that  the  ner\-ous  sys- 
tem is  the  only  portion  of  the  body  capable  of  origi- 
nating force;  that  a  normal  nervous  system  is  abso- 
lutely inimical  to  an  abnormal  condition  of  any 
remote  organ;  and  that,  in  seeking  to  locate  the  seat 
of  original  departure  from  health,  must  we  not  look 
for  it  in  some  abnormal  condition  of  the  nervous  sys- 
tem? If  my  contentions  are  correct,  will  it  not  logi- 
cally follow  that,  with  organic  disease  in  which  some 
organ  is  so  damaged  structurally  as  to  be  incapable 
of  perfect  function,  the  measure  of  function  to  be 
derived  therefrom  will  depend  upon  the  quantity  and 
quality  of  vital  or  ner\-ous  force  with  which  it  is 
supplied,  and  that  the  quantit)-  and  quality  of  this 
force  will  depend  upon  the  degree  of  integrity  of  the 
ner\-ous  system  that  originates  it?  Hence  are  we  not 
compelled  to  fall  back  upon  the  nervous  system  as  the 
ultimate  element  in  etiology,  and  to  start  with  it  as 
the  primal  element  in  therapeutics? 


A  PLEA  FOR  THE  MORE  GENERAL  U.SE 
OF  THE  ENDOSCOPE  IN  CHRONIC  URE- 
THRITIS. 

Bv   .\LBERT   A.    BERG,    M.D. 


There  is  probably  no  one  affection  of  the  many  that 
present  themselves  daily  to  the  general  practitioner 
that  deserves  more  careful  consideration  or  demands 
more  serious  thought  on  his  part  than  does  the  treat- 
ment of  chronic  urethritis,  yet,  in  spite  of  the  great 
frequency  of  this  condition  and  its  obstinacy  in  yielding 
to  the  usual  methods  of  treatment,  the  general  prac- 
titioner still  clings  to  the  long  obsolete  measures  of 
internal  medication  or  injections  of  one  of  the  too 
numerous  astringent  solutions.  The  success  of  this 
plan  of  treatment  we  know  only  too  well,  for  the 
numerous  cases  of  gleet  and  stricture  that  are  con- 
stantly presenting  themselves  to  the  specialist  are  only 
too  forcible  reminders  of  its  inefficacy. 

A   short   resume   of   the  local  conditions    found   in 
most  cases  of  chronic  gonorrhoeal   urethritis  will  at 


once  make  clear  the  reason  for  the  failure  of  these 
therapeutic  methods. 

Lesions  of   Chronic  Urethritis An  acute  gonor- 

rhttal  urethritis  follows  one  of  two  types:  {a)  Either 
it  is  a  mild  inflammation  with  simply  a  swelling  of 
the  mucous  membrane  and  desquamation  of  the  super- 
ficial epithelial  cells;  or  {b)  A  more  severe  inflam- 
matorv'  process  with  erosion  and  ulceration  of  the 
mucous  membrane  in  addition. 

It  is  quite  evident  that  the  first  class  of  cases,  which 
fortunately  is  the  more  frequent,  will  tend  to  heal 
spontaneously.  The  inflammation  subsides  in  about 
ten  days,  there  is  a  complete  regeneration  of  the  epi- 
thelium, and  the  urethral  canal  returns  to  its  normal 
state. 

It  is  hardly  necessary  to  do  anything  for  this  class 
of  patients  beyond  relieving  the  burning  on  urination, 
restricting  their  diet  and  drink,  and  keeping  their 
urine  slightly  acid.  Injections,  if  used  at  all,  serve 
only  to  remove  the  products  of  e.xudation  and  inflam- 
mation from  the  urethral  canal;  hence  they  should  be 
as  mild  as  it  is  possible  to  have  them. 

In  the  more  severe  cases  the  lesions  produced  by 
the  inflammator)-  process  render  a  complete  regenera- 
tion of  epithelium  an  impossibility,  because  the  epi- 
thelial layer  of  the  canal  at  the  site  of  these  ulcera- 
tions has  been  destroyed.  When  the  ulceration  heals, 
it  does  so  by  the  process  of  granulation,  and  so  the 
epithelium  is  replaced  by  connective-tissue  cells  and 
stroma.  This  can  easily  be  demonstrated  by  viewing 
a  urethral  mucous  membrane  w  hich  is  the  seat  of  such 
an  inflammatory  process,  several  days  after  its  onset, 
by  means  of  the  electro-endoscope.  We  find  the  mu- 
cous membrane  swollen  and  congested,  and  in  iso- 
lated spots  ulcerated  and  eroded.  Viewed  at  a  little 
later  stage,  the  site  of  these  ulcerations  is  seen  to  be 
covered  by  granulations  which  appear  as  small,  rounded, 
reddened  masses.  Microscopical  examination  of  such 
a  granulating  area  shows  it  to  be  made  up  of  round 
cells  and  numerous  blood-vessels;  the  surrounding 
tissue  is  thickened  and  infiltrated  with  similar  cells, 
and  the  surrounding  epithelium  has  changed  to  the 
pavement  variety.  This  pathological  condition  of  the 
mucous  membrane  of  the  urethra  has  been  termed 
granular  urethritis. 

Now  let  us  see  what  the  results  of  such  granulating 
areas  in  the  urethra  are.  (a)  When  the  granulations 
become  exuberant  they  more  or  less  completely  block 
up  the  urethral  canal,  lead  to  stagnation  of  urine  be- 
hind the  obstruction,  and  so  produce  secondary  changes 
in  the  otherwise  healthy  mucous  membrane.  (/')  The 
longer  these  granulations  persist,  the  larger  they  will 
become,  and  the  more  marked  will  the  infiltration  of 
the  surrounding  tissues  be,  for  the  constant  passage  of 
urine  over  these  raw  surfaces  tends  to  irritate  them 
and  so  stimulate  the  growth  of  granulations,  (c)  The 
result  of  this  infiltration  is  a  thickening  of  the  mu- 
cous membrane  and  consequent  narrowing  of  the 
canal. 

These  three  factors  lay  the  foundation  of  all  the 
cases  of  chronic  gleet  and  stricture,  results  that  could 
possibly  have  been  avoided  if  the  existing  conditions 
had  been  met  in  the  right  way  from  the  very  onset  of 
the  trouble. 

Bumstead  in  his  ■'^'enereal  Diseases,"  '  says:  "Be- 
sides the  discharge  which  comes  from  the  presence  of 
granulation  tissue  the  narrowing  of  the  canal,  due  to 
the  thickening  of  the  mucous  membrane,  has  been  de- 
monstrated as  capable  of  causing  an  indefinite  continu- 
ance of  a  urethral  discharge." 

Therapeutics — It  becomes  then  a  matter  of  con- 
siderable importance  to  be  able  to  recognize  and  treat 
these  granulating  areas  at  as  earlv  a  stage  as  is  pos- 
sible. Then  when  are  we  to  commence  the  treatment; 
'Page  341. 


26o 


MEDICAL    RECORD. 


[August  2  1.  1897 


and  how  are  we  to  treat  these   granulations    in    the 
proper  and  rational  method? 

It  is  well  known  that  during  the  first  or  acute 
stage  of  an  inflammation  the  less  the  active  treatment 
the  better  for  the  inflammation,  because  the  process 
which  has  been  inaugurated  cannot  be  aborted,  and 
because  any  irritation  of  the  inflamed  part  increases 
the  severity  of  the  process.  Hence  during  the  first 
ten  days  of  any  acute  urethral  inflammation  we  follow 
merely  the  symptomatic  method  of  treatment.  If  the 
process  is  a  mild  one  it  tends  to  heal  spontaneously 
and  needs  no  interference  on  our  part.  If  the  process 
is  a  more  severe  one  we  wait  until  the  acute  stage  has 
subsided,  which  is  about  the  tenth  day,  and  then  pro- 
ceed to  aid  in  the  healing  of  the  ulcerations,  which 
are  the  cause  of  the  chronicit}'  of  the  dis- 
charge and  the  subsequent  malconditions 
in  the  urethra. 

In  considering  the  therapeutic  measures 
to  be  applied  to  the  conditions  as  outlined 
above,  we  will  be  most  successful  if  we 
follow  those  lines  of  procedure  which  have 
proven  most  beneficial  in  similar  con- 
ditions on  the  external  surface  of  the 
body.  When  we  deal  with  granulating 
areas  here,  we  direct  our  efforts  (i)  to 
protecting  the  granulations  from  irritation; 
and  (2)  to  preventing  these  granulations 
from  becoming  exuberant,  for  this  inter- 
feres with  their  healing. 

Botii  of  these  conditions  are  met  by 
the  use  of  nitrate  of  silver,  for  this  pro- 
duces when  applied  to  a  granulating  area  a  protective 
film  of  the  albuminate  of  silver,  beneath  which  heal- 
ing may  occur,  and,  secondly,  prevents  the  granula- 
tions from  becoming  exuberant.  Moreover,  and 
verj-  important  in  the  consideration  of  lesions  in 
the  urethral  canal,  the  silver  nitrate  tends  to  soften 
the  infiltrated  area,  and  so  favor  its  removal  by 
absorption.  This  then  would  appear  to  be  the  ideal 
method  of  treatment  of  a  granulating  area,  and  the 
question  now  arises:  How  should  we  apply  the 
silver?  Two  methods  are  available:  (i)  Flushing 
the  urethra  with  solutions  of  silver  nitrate;  (2)  Direct 
local  application  of  silver  nitrate  to  the  granulating 
spots. 

Let  \}S  consider  the  advantages  and  disadvantages  of 
these  two  methods.  In  favor  of  the  former  we  can 
only  say  that  it  requires  very  little  knowledge  to  carry 
it  out,  and  is  easily  and  quickly  done.  But  it  has 
many  disadvantages: 

(a)  It  is  hardly  to  be  expected  that  we  can  reach 
deep-seated  lesions  by  an  anterior  injection,  and  if 
deep  injections  are  made  there  is  the  danger  of  forcing 
the  fluid  down  through  the  seminal  ducts  into  the  epi- 
didymides and  testes. 

(fi)  The  healthy  urethra  is,  moreover,  subjected  to 
the  same  treatment  as  the  diseased  areas,  and  it  is  to 
be  expected  that  from  the  constant  irritation  of  these 
caustic  solutions  it  soon  takes  on  a  reactive  inflam- 
mation. 

In  favor  of  direct  local  application  we  can  say  that 
we  deal  directly  and  solely  with  the  diseased  areas. 
There  is  no  danger  of  epididymitis  or  orchitis,  and 
with  a  few  trials  the  application  becomes  just  as  easv 
as  irrigation. 

Direct  local  treatment  of  the  urethra  is  made  possi- 
ble by  the  use  of  the  endoscope.  With  the  aid  of  the 
Otis  electric-light  attachment,  a  complete  view  of  the 
urethral  canal  is  afforded.  A  positive  diagnosis  of 
urethral  affections  can  thus  easily  be  made,  and  treat- 
ment easily  carried  out. 

The  requisites  for  such  examination  and  treatment 
are:  (i)  A  set  of  short  and  long  endoscopic  tul>es: 
(i)   a  constant  battery ;   (3)  an  Otis  electric  attachment. 


1.  The  endoscopic  tubes  are  made  in  two  lengths, 
depending  on  whether  they  are  to  be  used  in  the  an- 
terior or  deeper  urethra.  They  varj"  in  calibre,  a  set 
of  three  being  sufficient — 10  F.,  20  F.,  and  25  F. 

They  are  usually  made  of  coin  silver,  but  may  be 
made  of  hard  rubber.  If  made  of  silver,  it  is  best  to 
have  their,  interiors  blackened  so  that  the  shining  sur- 
face of  the  silver  may  not  interfere  by  its  reflection 
of  the  iight. 

2.  The  batter)'  should  be  a  constant  one.  One  or 
two  Daniell  cells  are  sufficient.  It  should  be  strong 
enough  to  supply  the  lamp  in  the  electric  attachment, 
without  consuming  the  film  too  rapidly. 

3.  The  light:  The  best  form  of  illumination  is 
the  electric  light,  which  can  be  attached  to  the  endo- 


scopic tube,  as  shown  in  the  sketch.  The  Otis  light 
is  a  ver}-  good  form.  After  a  little  practice  the  sun's 
light  reflected  into  the  tube  by  means  of  a  head  mir- 
ror will  ser\e  the  purpose  verj-  well.  The  technique 
of  the  procedure  is  as  follows: 

The  patient  is  placed  upon  his  back.  The  urethra 
is  first  thoroughly  cleansed  by  irrigating  it  with  hot 
saline  solution  or  a  mild  antiseptic  solution,  e.^.,  cor- 
rosive sublimate  1-10,000.  The  endoscopic  tube  with 
its  obturator,  the  latter  serving  only  to  facilitate  the 
introduction  of  the  tube,  is  introduced  to  its  full 
length,  and  the  obturator  withdrawn.  As  large  a  tube 
as  the  urethra  can  comfortably  accommodate  is  se- 
lected. The  light  is  now  thrown  into  the  tube  and  a 
systematic  examination  of  the  mucous  membrane  is 
made,  the  endoscope  being  slowly  withdrawn  so  as  to 
bring  the  entire  mucous  membrane  successivelj'  into 
view.  Each  ulceration  is  nt)ted  and  located.  Hav- 
ing thus  made  an  accurate  diagnosis  of  the  condi- 
tion of  the  urethra,  we  are  ready  to  proceed  to  its 
treatment.  The  endoscope  is  again  introduced,  the 
obturator  withdrawn,  and  the  deepest  granulation  (for 
it  is  best  to  commence  with  the  deepest  lesions)  is 
brought  into  view.  An  ordinary-  applicator,  carr}-ing 
a  piece  of  absorbent  cotton  firmly  wrapped  around  its 
end,  is  dipped  into  a  twenty-per-cent.  solution  of  sil- 
ver nitrate,  and  introduced  through  the  tube,  touching 
the  granulating  area.  Two  or  three  such  spots  are 
treated  at  any  one  sitting.  The  patient  is  to  lie  quiet 
for  fifteen  or  twenty  minutes  after  such  treatment,  for 
the  smarting  is  at  times  considerable.  He  is  also  to 
be  told  that  the  discharge  will  increase  on  the  day  fol- 
lowing, but  will  then  subside.  Such  applications  are 
to  be  m.ade  twice  a  week,  and  in  the  interim  the  pa- 
tient washes  out  the  urethra  with  a  mild  solution,  so 
as  to  keep  the  canal  clear  of  pus  and  detritus.  F.ach 
granulating  spot  is  treated  in  this  manner,  and  gener- 
ally in  about  three  weeks  a  complete  healing  has  taken 
place. 

It  is  to  be  borne  in  mind,  however,  that  if  a  stric- 
ture has  fonned  in  the  urethra  the  presence  of  this 
alone  is  sufficient  to  keep  up  a  gleety  discharge :  hence 
the  subsequent  treatment  of  the  sti'icture  by  dilatation 


August  2  1,    1897] 


MEDICAL    RECORD. 


261 


is  important  if  a  gleet)-  discharge  persists  after  the 
mucous  membrane  has  entirely  healed. 

What  is  especially  to  be  remarked  about  the  direct 
local  treatment  of  ulcerations  in  the  urethra  is  that  the 
healing  when  brought  about  is  of  a  peraianent  charac- 
ter, not  to  be  compared  to  the  healing  which  has  oc- 
curred in  so  many  patients  discharged  as  cured,  but 
who  after  a  slight  e.xcess  in  ventre  et  Bacclio  have  a  re- 
turn of  their  old  trouble. 

I  have  selected  this  one  pathological  state  of  the 
urethra  for  treatment  by  use  of  the  endoscope  merely 
because  it  is  the  most  common,  but  the  use  of  the 
endoscope  in  the  urethra  is  by  no  means  limited  to 
this  field.  A  wider  and  more  systematic  use  of  the 
endoscope  in  all  urethral  affections,  from  the  simplest 
to  the  most  complicated  lesions,  will  lead  us  on  the 
one  hand  to  a  more  accurate  diagnosis,  and  on  the 
other  to  a  more  rational  method  of  treatment. 

A  few  cases  will  serve  to  illustrate  the  advantage  of 
direct  local  treatment  in  urethral  affections. 

CjVSE  I. —  E.  A ,  aged  nineteen  years,  had  several 

attacks  of  gonorrhceal  urethritis.  The  attack  from 
which  he  was  still  suffering  commenced  about  eight 
months  ago.  He  went  through  the  regular  course  of 
internal  medication  and  injections,  but  the  discharge 
continued.  About  this  time  his  physician  injected 
into  his  urethra  a  twent)--per-cent.  solution  of  nitrate 
of  silver,  with  the  effect  of  increasing  the  discharge 
and  causing  the  patient  considerable  pain.  UTien  he 
came  under  my  treatment  he  had  in  the  scroto-penile 
urethra  four  granulating  areas.  He  was  at  once  sub- 
jected to  direct  local  treatment  with  silver,  and  ad- 
vised to  flush  the  urethra  three  times  a  day  with  one 
per  cent,  of  sulphocarbolate  of  zinc.  In  three  weeks 
the  granulations  had  entirely  healed,  but  the  presence 
of  a  stricture  kept  up  a  slight  discharge,  which  dis- 
appeared as  the  stricture  was  dilated. 

Case  II. — M.  T ,  aged  nineteen  years,  had  one 

previous  attack  of  gonorrhoea.  The  present  attack 
was  of  two  weeks'  standing.  The  discharge  was 
gleet)",  and  there  were  some  pains  and  tenderness  in 
the  anterior  urethra.  Examination  with  the  endoscope 
revealed  the  presence  of  several  granulation  areas  in 
the  anterior  urethra,  and  at  one  point  considerable 
perifolliculitis.  The  granulations  and  folliculitis 
were  subjected  to  the  direct  local  use  of  silver,  and 
rapid  healing  with  complete  cure  resulted. 

Case  III. — A.  S ,  aged  twent\--four  years,  had 

several  previous  attacks  of  gonorrhoea,  this  last  attack 
of  several  weeks'  duration.  He  had  used  injections 
faithfully,  but  his  discharge  continued.  Endoscopic 
examination  showed  the  presence  of  several  granulat- 
ing areas  in  the  penile  urethra.  These  healed  rapidly 
under  local  applications  of  silver,  with  a  complete 
cessation  of  the  discharge. 


MEDICAL    SELECTION    FOR    LIFE    IXSUR- 
AXCE.' 


Bv   BR.\XDRETH   SY.MOXDS,    A.M.,    M.D., 


NiOR   EX.\MIN-ING  PHYSICIAN  OF 


NCE    COMPANY 


Pes  Cavus. — The  treatment  consists  in  division  of 
the  plantar  fascia,  after  which  extension  should  not 
be  made  for  three  or  four  weeks,  as  cicatricial  thick- 
ening and  pain  are  thereby  avoided.  The  best  appa- 
ratus for  after-use  is  a  tin  shoe  with  a  divided  sole 
plate,  so  arranged  that  the  front  part  of  the  foot  may 
be  uplifted  and  brought  into  the  same  horizontal  plane 
as  the  heel.  The  raising  of  the  front  part  should  be 
done  gradually,  as  some  pain  incidental  to  the  rapid 
method  is  thereby  avoided.  If  there  remain  much 
rigidity  of  the  tissues  afterward,  a  second  operation 
is  advisable;  or  considerable  relaxation  of  the  fascia 
may  be  obtained  by  soaking  the  foot  in  hot  water  con- 
taining bicarbonate  of  sodium,  afterward  manipulat- 
ing it  freely  and  stretching  the  sole.  The  relief 
afforded  by  this  simple  operation  of  section  of  the 
plantar  fascia  is  very  considerable  indeed. — Dr.  Tub- 
by, The  Clinical  Journal,  April  28th. 


It  has  often  been  stated  that  no  selection  is  necessary 
for  life  insurance,  and  the  argument  is  something  like 
this:  All  men  have  to  die.  Why  not  therefore  calcu- 
late uf)on  the  mortality  of  the  whole  population  and 
admit  them  all  to  life  insurance?  Some  expense,  that 
of  medical  investigation  and  some  others,  are  thereby 
saved  and  at  the  same  time  the  opportunity  is  given  to 
everybody  to  partake  of  the  blessings  of  insurance. 
Something  of  this  kind  is  now  under  trial  in  Germany. 
It  is  a  stupendous  scheme  of  insurance  against  invalid- 
it)'  and  old  age  but  does  not  contemplate  life  insurance. 
Nearly  all  wage  earners  over  sixteen,  whose  average 
annual  earnings  do  not  e.xceed  about  5500,  are  com- 
pelled to  participate.  A  most  elaborate  system  of  reg- 
istration and  espionage  has  been  devised,  so  that  no 
person  of  the  twelve  millions  or  more  entitled  to  its 
benefits  may  escape  the  blessings  thus  thrust  upon 
him.  This  plan  has  not  yet  been  tried  long  enough  to 
determine  its  stability ;  but  we  could  draw  no  infer- 
ence even  from  its  success.  It  is  a  scheme  forced  by 
an  almost  autocratic  government  upon  a  submissive 
people,  at  least  more  submissive  than  we  are.  How 
would  it  succeed  if  applied  to  our  life-insurance  meth- 
ods? A  life-insurance  association  or  company  of  to- 
day is,  with  us,  a  voluntar)-  aggregation  of  individuals. 
If  there  were  no  way  by  which  those  who  are  below 
the  present  standard  of  prospective  longevity  could  be 
excluded  from  its  advantages,  it  would  be  composed 
exclusively  of  such  inferior  specimens.  Consequently 
the  mortalit)-  rate  would  be  vastly  higher  than  that  of 
the  average  population.  Xo  soimd  person  would  join 
who  could  obtain  insurance  in  a  company  that  adopted 
a  higher  standard.  Man  is  indeed  becoming  more  al- 
truistic, and  the  growth  of  life  insurance  itself  would 
indicate  this.  But  his  altruism  is  yet  far  below  the 
level  which  would  cause  him  to  make  personal  sacri- 
fice of  strength,  time,  and  money  for  the  benefit  of 
some  unknown  stranger,  perhaps  thousands  of  miles 
away.  He  is  eager  to  make  such  an  offering  upon  the 
altar  of  his  home,  when  he  can  thereby  save  his  wife 
and  children  from  want,  perhaps  shame  and  dishonor. 
But  he  would  make  no  such  effort  for  the  unknown 
weaklings  who  as  a  class  will  surely  die  before  their 
time.  He  wants  to  associate  himself  with  those  who 
are  as  strong  as  he  is,  and  whose  expectation  of  life 
is  as  great.  Therefore  the  interests  of  the  policy 
holders  who  are  already  in  a  company  demand  that 
none  be  admitted  unless  they  be  up  to  the  standard 
already  adopted.  On  this  account  the  best  medical 
skill  is  employed  to  watch  that  the  maimed  and  halt 
are  kept  out. 

Selection  of  risks  for  life  insurance  is  not  neces- 
sarily riedical.  For  example,  in  some  associations 
only  total  abstainers  are  admitted,  and  this  precedent 
must  be  regarded  as  a  form  of  selection.  Again  it  is 
found  that  those  risks  who  take  the  higher-priced  poli- 
cies compare  more  favorably  with  the  average  than 
those  who  take  the  cheaper  ones.  This  form  of  nat- 
ural selection  is  of  decided  consequence  to  the  com- 
pany, but  is  in  no  sense  medical. 

The  points  which  enter  into  the  medical  judgment 
of  a  risk  may  be  grouped  under  four  heads:  (<7)  Pres- 
ent physical  condition  :  (/')  Previous  personal  history 
as  regards  disease,  habits,  etc. :  (<)  Family  record  as 
regards  disease  and  longevity :  (d)  Material  environ- 
ment, including  occupation,  climate,  etc. 

(<7)  Comparatively  few  of  us  are  in  a  perfect  phys- 

'  Read  before  the  .Xmerican  Social  Science  .Association,  I.)epart- 
ment  of  Health,  September  2,  iSg6. 


262 


MEDICAL    RECORD. 


[August  21,  1897 


ical  condition,  and  in  many  cases  mucii  judgment  is 
exercised  in  determining  what  variation  from  the 
norm  is  sufficient  to  disqualify  an  applicant.  Any  ab- 
normality which  causes  a  shortened  class  longevity 
among  those  who  are  afflicted  with  it  must  be  regarded 
as  a  sufficient  disqualification.  In  some  cases  tempo- 
rary ailments  should  cause  a  postponement  until  the 
restoration  to  health.  It  is  hardly  proper  to  pass  any 
acute  disease  as  trivial.  An  attack  of  apparently  acute 
bronchitis  may  be  the  forerunner  of  some  serious  mis- 
chief in  the  lungs :  a  simple  diarrhoea  may  be  the  pre- 
monition of  typhoid  fever.  On  the  other  hand  some 
chronic  abnormalities,  though  pathological,  do  not 
warrant  us  in  excluding  a  case.  Such  a  condition  as 
a  few  bilateral  pleuritic  adhesions  at  the  base  of  the 
lungs,  if  it  can  be  detennined  that  they  are  old,  ought 
not  singly  to  be  a  cause  for  rejection.  But  chronic 
pulmonary  or  pleuritic  conditions  are  rarely  presented 
to  a  life-insurance  examiner,  simply  because  most 
people  know  that  such  diseases  are  almost  invariably 
bars  to  insurance. 

Xot  infrequently  a  person  has  no  idea  that  he  has 
any  trouble  with  his  heart  until  he  is  rejected  by  some 
insurance  examiner.  It  may  seem  hard  at  times  to 
refuse  some  of  these  cases,  the  damage  is  so  slight  and 
the  compensation  is  so  perfect;  but  all  organic  lesions 
of  the  heart  ought  to  be  rigidly  excluded.  It  is  fortu- 
nately true  that  some  of  them  live  for  many  years  and 
finally  die  of  intercurrent  disease,  but  unfortunately 
we  can  rarely  pick  these  cases  out  of  the  mass.  The 
same  rule  applies  to  some  of  the  so-called  functional 
diseases  of  the  heart,  such  as  angina  pectoris,  and  that 
symptom  complex  known  as  exophthalmic  goitre,  in 
which  the  frequent  heart  action  is  a  marked  feature, 
although  the  disease  is  not  often  regarded  as  essen- 
tially one  of  the  thyroid  gland.  On  the  other  hand  a 
mild  acceleration  of  the  pulse  is  usually  found  in 
those  who  are  being  examined.  I  have  frequently 
found  a  pulse  rate  of  eighty  or  more  in  my  examina- 
tions. Xow  that  is  above  the  average  even  in  these 
days  of  hurly-burly  and  must  be  regarded  as  the  evi- 
dence of  slight  nervousness  of  which  the  applicant  is 
unconscious,  or  at  least  says  he  is.  Recognizing  this, 
we  do  not  hesitate  to  accept  pulse  rates  up  to  ninetv'. 
When  it  remains  persistently  above  this  point,  it  be- 
comes a  factor  of  more  consequence,  as  it  ma)-  be  the 
only  evidence  we  have  of  beginning  renal,  pulmonary, 
or  ner\ous  disease.  Or  it  may  indicate  a  diminished 
vitality,'  impaired  by  overwork,  dissipation,  etc.,  not 
in  itself  alarming,  but  a  serious  complication  of  any 
acute  disease  which  might  happen  along.  But  there 
are  a  few  cases  in  which  the  acceleration  of  the  pulse 
has  lasted  over  many  years  of  continuous  good  health, 
and  these  may  be  regarded  as  cases  of  personal  idio- 
syncrasy and  not  necessarily  unfit  for  insurance.  The 
evidence,  however,  must  be  very  convincing.  Similar 
considerations  influence  the  disposal  of  cases  of  other 
alterations  of  the  pulse  rhythm,  such  as  too  infrequent 
a  pulse  and  intermittent  or  irregular  pulses.  As  long 
as  these  conditions  are  present  they  are  bars  to  insur- 
ance usually,  and  the  exceptions  to  this  rule  must  be 
ver)'  rare. 

Comparatively  few  suspect  any  pathological  condi- 
tion of  the  urine  until  examination  reveals  it.  They 
feel  in  good  health,  are  vigorous  and  active,  and  they 
resent,  as  a  personal  insult  in  some  cases,  the  state- 
ment that  the  condition  of  the  urine  revealed  by  the 
examination  is  unsatisfactor)-,  and  that  they  cannot 
obtain  insurance  on  account  of  it.  I  know  of  nothing 
more  trying  to  the  tact,  temper,  and  patience  of  the 
medical  examiner  than  the  endeavor  to  smooth  some 
of  these  ruffled  dignities.  I  have  had  men  who  knew 
better  tell  me  that  they  ought  to  be  accepted  for  insur- 
ance because,  forsootli,  they  felt  themselves  to  be  per- 
fectlv  well,  and  knew  that  thev  did  not  have  anv  dis- 


ease, although  they  had  been  told  that  the  urine  con- 
tained albumin  or  sugar.  If  such  were  the  standard 
for  life  insurance,  our  duties  would  be  very  much  sim- 
plified. 

Let  us  consider  this  topic  more  in  detail.  I  am 
convinced  that  the  presence  of  genuine  albumin  in  the 
urine  is  always  pathological.'  It  may  be  due  to  pus  or 
blood,  the  sources  of  which  may  be  various,  but  in  the 
great  majority  of  cases  the  albumin  is  of  renal  ori- 
gin. In  these  cases  it  may  be  temporary  or  perma- 
nent. If  permanent,  it  is  due  to  some  organic  change 
in  the  kidneys,  which  may  or  may  not  be  progressive. 
If  temporary,  it  is  due  to  some  inflammator}-  or  degen- 
erative or  vascular  disturbance  of  the  kidney,  which 
sooner  or  later  passes  away  entirely,  leaving  no  trace 
behind.  In  many  of  these  cases  the  individuals  are 
below  par  generally  while  the  albimiinuria  lasts.  In 
some,  dietetic  errors,  muscular  exercise,  and  other 
causes  play  a  part.  Some  are  convalescing  from  a 
febrile  disturbance,  such  as  a  cold  or  a  diarrhoea. 
During  the  epidemics  of  influenza  albuminuria  isver)- 
often  found  among  those  who  have  this  disease  even 
mildly.  A  favorite  time  for  its  occurrence  is  between 
the  ages  of  fifteen  and  twents-five.  In  a  fair  propor- 
tion of  cases  no  cause  whatever  can  be  assigned.  But, 
whatever  the  cause,  the  presence  of  genuine  serum 
albumin  in  the  urine  must  be  a  bar  to  insurance  until 
it  has  completely  and  permanently  passed  away.  I 
say  genuine  serum  albumin,  for  undoubtedly  many  mis- 
takes have  arisen  from  confounding  other  substances, 
notably  nucleo-albumin,  with  this.  Investigators  in 
this  line  have  endeavored  to  seek  out  delicate  tests 
at  the  cost  of  accuracy.  Many  of  these  tests  respond 
to  the  presence  of  even  ver}'  small  amounts  of  serum 
albumin,  but  unfortunately  they  react  well  with  some 
other  substances,  notably  nucleo-albumin.  This  state- 
ment applies  certainly  to  all  tests  in  which  organic 
acids,  particularly  acetic  acid,  are  used.  I  feel  there- 
fore, that  injustice  has  been  done  heretofore  to  a  large 
class  of  applicants  whose  urine  on  more  particular 
examination  would  now  be  regarded  as  healthy. 

Similar  considerations  confront  us  when  we  detect 
the  presence  of  sugar  in  the  urine.  Nearly  all  the 
tests  for  sugar  are  simply  reduction  tests,  upon  which 
other  reducing  substances  besides  sugar  may  act. 
Some  reducing  substances,  such  as  creatinin,  are  al- 
ways present  in  the  urine,  but  normally  in  too  small 
quantities  to  give  a  reaction.  Many  drugs,  such  as 
rhubarb  and  chloral,  when  excreted,  act  as  reducing 
agents.  At  times  some  abnormal  ingredients,  such 
as  glycosuric  acid,  cause  the  same  difficulty.  Now 
merely  because  the  urine  happens  to  be  concentrated 
and  the  creatinin,  etc.,  are  in  sufficient  quantities  to 
have  a  reducing  power,  or  because  the  man  ate  a  big 
dinner  and  took  a  rhubarb  pill  after  it,  or  because  he 
had  headache  and  took  a  does  of  chloral  the  night  be- 
fore examination,  and  as  the  result  of  any  or  all  of 
these  our  ordinary  sugar  tests  show  a  reaction,  it  is 
certainly  not  right  to  refuse  that  man  insurance  on  ac- 
count of  glycosuria.  The  usual  tests  are  prompt,  con- 
venient, and  sufficiently  delicate,  and  are  therefore  all 
that  we  need  for  negative  results.  But  if  we  obtain 
a  positive  reaction,  we  should  in  all  cases  seek  to  con- 
firm it  by  a  further  accurate  test,  such  as  the  phenyl- 
hydrazin  test  or  the  fermentation  test. 

Of  course  permanent  glycosuria  acts  as  a  bar  to 
insurance,  but  what  importance  shall  we  attach  to 
transient  glycosuria?  This  temi  should  be  applied 
to  cases  in  which  the  absence  of  sugar  is  not  brought 
about  by  changes  in  the  diet,  for  we  all  know  that  in 
some  cases  of  diabetes  the  sugar  can  be  made  to  dis- 
appear entirely  for  some  time  from  the  urine  simply 
by  the  thorough  elimination  of  starches  and  sugars 

'  This,  of  course,  does  not  include  the  albuminuria  due  to  men- 
strual blood,  ordinarj-  vulvo-vaginal  secretions,  possibly  semen. 


August  2  1,  1897] 


MEDICAL    RECORD. 


26: 


from  the  dietan\  Xo  one,  however,  regards  such  an 
aglycosuria  as  healthy,  and  when  sugar  is  found  every 
time  that  a  man  relaxes  from  a  rigid  diet  the  case 
must  be  deemed  from  a  life-insurance  point  of  view  as 
hopeless  as  if  the  glycosuria  were  permanent.  But  real 
cases  of  transient  glycosuria  do  occur,  though  they  are 
much  rarer  than  those  of  transient  albuminuria.  These 
persons  are  more  often  quite  stout,  sometimes  very 
fat,  and  their  obesity  is  apt  to  run  to  large  and  pen- 
dulous abdomens.  It  is  possible  that  the  dragging 
on  the  liver  by  the  falling  abdominal  wall,  with  the 
consequent  disturbance  of  the  hepatic  circulation, 
may  act  to  produce  glycosuria,  for  in  some  cases  this 
is  entirely  removed  by  the  use  of  a  snug  supporting 
abdominal  belt.  Most  of  these  cases  are  non-insura- 
ble  on  other  grounds  than  the  presence  of  glycosuria, 
but  occasionally  that  is  the  only  bar.  In  such  cases, 
when  the  sugar  has  disappeared  from  the  urine,  it  must 
be  determined  by  repeated  examinations  that  it  stays 
away  and  that  this  absence  is  not  due  to  any  change 
in  the  diet.  We  should  also  seek  for  some  cause  for 
the  temporary  glycosuria,  such  as  the  ingestion  of 
sweet  wine,  of  candy,  or  of  fruit  in  excess.  Nearly 
all  these  cases  should  be  postponed  for  some  months, 
but  ultimately  after  careful  investigation  a  few  may 
be  accepted. 

(/')  When  an  applicant  states  that  he  has  had  any 
sickness,  the  questions  that  arise  are:  Has  it  left  any 
permanent  disability?  Has  it  a  tendency  to  recur? 
Is  it  the  symptom  of  a  serious  disease? 

A  permanent  disability  would  usually  be  found  on 
e.xamination,  but  not  infrequently  our  methods  of  phys- 
ical exploration  will  fail  to  reveal  the  latent  sequel 
of  a  disease,  especially  if  it  involves  the  abdominal 
or  pelvic  organs.  There  may  also  be  some  doubt  in 
regard  to  the  technical  skill  of  our  examination.  For 
these  reasons  a  risk  is  usually  postponed  after  a  severe 
illness  until  such  time  as  would  make  the  latent  se- 
quels manifest  if  there  were  any  such. 

Some  diseases  have  a  tendency  to  recurrence,  and 
this  must  be  guarded  against  by  postponing  consider- 
ation of  the  risk  until  reasonable  danger  from  this 
cause  has  passed.  Each  of  such  diseases  must  be  con- 
sidered separately,  for  the  same  rule  will  not  apply 
equally  to  gout  and  appendicitis,  to  rheumatism  and 
gall  stones.  In  cases  in  which  the  disease  has  recurred 
repeatedly,  insurance  should  be  withheld  either  per- 
manently or  until  many  years  after  the  last  attack. 

Certain  conditions,  inconsequential  in  themselves, 
are  of  importance  as  being  the  manifest  symptoms  of 
deeper  and  more  serious  trouble.  The  loss  of  two  or 
three  drachms  of  blood  is  a  matter  of  no  consequence, 
per  St\  but  if  it  comes  from  the  lungs  it  is  of  the  great- 
est significance  and  must  be  regarded  as  very  serious. 
In  Dr.  Marsh's  report  on  the  mortuary  statistics  of  the 
Mutual  Life  Insurance  Company  of  New  York,  he 
says:  "The  general  ratio  of  the  consumption  mortal- 
ity was  19.74  per  cent.,  while  in  these  cases  [thosie  in 
which  a  history  of  haemoptysis  was  given]  it  is  34.92 
per  cent.,  or  nearly  double.  ...  In  less  than  half  the 
cases  the  supposed  source  or  cause  of  the  hemorrhage 
is  given,  and  in  the  majority  of  these  it  was  reported  as 
slight,  as  coming  from  the  throat  and  nose,  or  as  the 
result  of  an  injur)-  or  excessive  exertion.  These  ex- 
planations are  mostly  given  in  the  consumptive  cases, 
and  our  experience  shows  that  statements  indicating 
the  cause  of  the  hemorrhage  are  usually  untrustworthy, 
as  patients  always,  and  physicians  sometimes,  are  apt 
to  delude  themselves  with  the  most  hopeful  views." 

((-)  When  we  come  to  look  at  the  family  history  of 
an  applicant,  we  are  confronted  with  a  great  difficult)-, 
the  lack  of  accurate  knowledge  on  many  points  that 
are  essential.  For  instance,  very  few  can  give  the 
full  names  of  all  their  four  grandparents.  Ignorance 
on  a  point  considered  by  most  people  so  essential  as 


this  indicates  even  greater  lack  of  knowledge  about 
the  duration  of  their  lives  and  the  cause  of  their  deaths. 
We  have  to  pierce  through  this  haze  of  misinforma- 
tion and  imperfect  knowledge  as  best  we  can.  Fortu- 
nately, as  a  rule,  the  applicant  for  life  insurance  gives 
the  most  favorable  presentation  that  he  knows  or  does 
not  know.  He  not  infrequently  states  that  his  parents 
died  of  "  natural  causes,"  or  still  better,  of  "  nothing 
serious."  Of  course  he  means  to  imply  that  the  cause 
of  death  was  not  one  of  those  diseases  which  are  usu- 
ally regarded  as  hereditary.  It  follows  naturally  that 
we  put  the  worst  possible  interpretation  on  all  equiv- 
ocal answers  in  the  family  history.  This  feeling  of 
distrust  is  justified  by  certain  facts.  Thus  Manley  in- 
vestigated certain  cases  in  which  there  was  a  family 
history  of  consumption.'  To  offset  this  family  history- 
policies  were  issued  only  when  such  applicants  were 
physically  above  the  standard.  In  spite  of  this  supe- 
rior physique,  the  mortality  proved  to  be  above  the  av- 
erage. Where  only  the  father  was  consumptive,  the 
actual  mortality  was  twenty-four  per  cent,  in  excess 
of  the  expected :  where  only  the  mother  was  consump- 
tive, the  actual  mortality-  was  twenty-five  per  cent,  in 
excess.  But  now  note  this:  where  the  father  did  not 
die  of  consumption  and  the  mother's  death  was  ascribed 
to  childbirth,  the  actual  mortality  was  twenty-eight 
per  cent,  in  excess  of  the  expected.  In  other  words 
the  death  of  the  mother  from  childbirth  had  as  unfa- 
vorable an  influence  upon  the  longevity  of  her  offspring 
as  her  death  from  consumption.  The  most  plausible 
and  the  most  probable  explanation  of  this  is  that  these 
applicants  made  a  mistake  when  they  stated  the  cause 
of  the  mother's  death.  The  idea  of  consumption  is  so 
dreaded,  by  the  laity  especially,  that  a  case  of  it  in  the 
family  is  forgotten  as  soon  as  possible,  or  some  fable 
about  it  is  gradually  invented,  amplified,  and  polished, 
until  finally  it  passes  as  the  truth. 

On  the  other  hand,  we  tend  to  give  less  and  less 
credit  to  hereditan,-  influences  in  the  development  of 
certain  diseases.  Tuberculosis  is  now  recognized  to 
be  a  germ  disease  and  distinctly  contagious.  If  the 
dose  of  the  tuberculous  poison  is  sufficiently  large, 
any  man  will  die  from  it,  no  matter  how  great  his 
strength  and  vitality-.  If  the  husband  develops  con- 
sumption, and  the  wife,  in  her  tender,  loving  care,  be- 
comes infected  by  him  and  both  die  of  it,  surely  it  is 
not  right  to  credit  the  children  of  these  with  a  double 
inheritance  of  this  disease.  The  inability  to  resist 
such  a  destructive  process  is  almost  the  only  part  that 
is  inherited,  and  this  can  largely  be  determined  by 
itself  from  the  physical  examination  and  the  previous 
personal  history  of  the  individual.  Necessarily  much 
precaution  must  be  taken  in  selecting  such  cases,  and 
only  those  which  are  distinctly  above  the  average  in 
both  these  respects  should  be  admitted  to  life  insur- 
ance on  terms  of  equality  with  others.  The  possibil- 
ity of  any  present  family  contagion  should  be  carefully 
guarded  against.  A  person  who  is  living  with  a  tu- 
berculous relative  is  in  much  greater  danger  tlian  one 
who  has  lost  several  relations  eight  or  ten  years  previ- 
ously. 

A  strong,  although  as  yet  unsuccessful,  effort  is 
making  to  prove  that  cancer  is  also  caused  by  a  para- 
site. Xx.  any  rate  the  trend  of  professional  opinion 
questions  the  capacit)-  of  hereditary  transmission 
which  was  once  ascribed  to  it.  Here  the  pathological 
ignorance  of  the  laity  works  to  their  detriment,  for 
any  fatal  tumor  is  apt  to  be  called  by  them  a  cancer. 

((/)  We  stand  on  much  firmer  ground  when  we  come 
to  the  occupation  of  an  applicant,  as  this  can  seldom 
be  disguised  or  concealed.  Some  occupations  are  so 
hazardous  that  no  company  will  insure  the  participants 

'  '  \n  .\ttempt  to  Measure  the  Extra  Risk  Arising  from  a  Con- 
sumptive Family  Historj-. "     Journal  of  the  Institute  of  Actuaries, 

vol.   XX.X. 


264 


MEDICAL    RECORD. 


[August  2  1,  1897 


in  it  at  the  regular  rates.  Good  companies  rigidly 
exclude  such  persons  as  brakemen,  aeronauts,  barten- 
ders, etc.,  simply  because  the  risk  in  them  is  too  great. 
The  mortality  in  these  classes  is  so  great  that  it  would 
be  unfair  to  the  other  members  of  the  company.  Among 
occupations  which  stand  highest  in  point  of  longevity 
are  those  of  farmers  and  ministers.  Physicians,  I  re- 
gret to  state,  have  not  a  longevity  above  the  average. 
Modesty  forbids  me  to  mention  the  altruistic  qualities 
which  cause  this  sacrifice.  Another  factor  in  the 
material  environment  is  the  place  where  the  applicant 
lives.  Some  countries  are  so  lawless  that  life  insur- 
ance and  they  are  incompatible.  One  can  hardly  im- 
agine for  instance  any  life-insurance  company  doing 
business  in  Crete  or  .Armenia  or  Upper  Egypt.  Again, 
some  countries  are  so  unhealthy  that  the  mortality  far 
exceeds  what  we  regard  as  proper.  In  such  countries 
insurance  at  the  regular  rates  would  be  preposterous 
and  is  not  attempted.  In  some  of  them  an  actuar\- 
can  determine  the  premiums  suitable  to  this  increased 
mortality.  Insurance  can  then  be  effected  without 
detriment  to  the  other  members  of  the  company. 


THE  CORNEA  AND  THE  CAUTERY— THE 
USE  OF  THE  G.\LVANO  -  CAUTERY  IN 
ULCER    OF    THE   CORNE.A.. 

Bv   C.    S.    RODMAN,   M.D., 

WATERBURV.   CONN.. 
OPHTHALMIC  SURGEON  TO  THE  WATERBVRV  HOSPITAL, 

In  August,  1895,  The  Hospital,  a  well-known  English 
medical  journal,  after  quoting  from  the  address  of  Sir 
William  Broadbent  before  the  annual  congress  of  the 
British  Medical  .\ssociation,  to  the  eftect  that  new 
remedies  are  added  every  day  for  the  benefit  chiefly  of 
those  who  do  not  know  how  to  employ  the  old  ones, 
observed  that  the  story  of  King  David's  sling  and 
stone  has  a  priceless  application  in  medicine. 

Whenever  in  any  important  respect  the  treatment  of 
a  disease  may  be  believed  to  have  been  brought  to 
perfection,  the  evolution  of  the  method  and  its  tech- 
nique are  worthy  of  record,  until  universally  adopted 
the  lack  of  novelty  does  not  render  the  matter  too  trite 
for  our  consideration.  To  such  perfection  do  I  be- 
lieve tFie  management  of  corneal  ulceration  has  been 
brought.  Of  necessit)%  a  subject  so  selected — namely, 
one  disease,  one  remedy — is  restricted,  it  is  anotlier 
application  of  "King  David's  sling." 

Twenty-five  years  ago,  October  28,  1872,  at  the 
meeting  of  the  San  Francisco  Medical  Society,  Dr. 
Martinache  exhibited  two  patients,  a  child  and  a 
woman,  whom  he  had  cured  of  corneal  ulcers  by  the 
application  of  the  actual  cauterj-,  an  iron  probe  at 
white  heat.  The  Pacific  Medical  Journal,  which  re- 
ported the  society's  proceedings,  questioned  not  the 
success  of  the  treatment,  but  Martinache's  claim  to 
priority,  stating  that  the  cautery  had  hitherto  been 
extensively  used  and  certainly  so  in  the  treatment  of 
pannus.  Dr.  J.  H.  Claiborne,  before  the  New  York 
Academy  of  Medicine,  .\pril  20,  1891,  in  an  address 
upon  the  use  of  the  actual  cautery  in  infected  ulcers 
of  the  cornea,  gives  the  bibliography  of  the  cautery  in 
diseases  of  the  eye  from  the  time  of  Hipocrates,  who 
is  credited  with  using  it  to  destroy  growths  on  the 
inner  surface  of  the  lid.  Dr.  Martinache,  however, 
appears  to  be  entitled  to  the  credit  of  first  directing 
attention  to  the  value  of  the  cauterj-  in  affections  of 
the  cornea.  Perhaps  the  application  in  other  condi- 
tions, in  trachoma,  in  fistula  of  the  tear  sac,  etc.,  a 
revival  of  ancient  methods  of  no  particular  utility, 
served  to  divert  the  attention  of  the  profession  from 
the  specific  value  of  the  cauter)-  in  ulceration  of  the 
cornea.      Claiborne  stated  that  Martinache's  discovery 


was  adopted  in  Europe  more  generally  than  in  Amer- 
ica, and  that  the  advocates  of  his  method  (in  189 1) 
were  comparatively  rare  in  this  country.  The  state- 
ment hardly  holds  good  to-day.  Claiborne  advocated 
Martinache's  method  in  infected  ulcers,  which  he  de- 
fined as  the  "  serpent  ulcer,"'  the  deep-seated,  perforat- 
ing ulcer  which  may  discharge  pus  into  the  anterior 
chamber,  and  the  rodent  or  superficial  wandering  ulcer 
which  destroys  the  epithelium  of  the  cornea.'  We 
find  advocated  at  this  time  the  crude  device  of  Mar- 
tinache, platinum  being  substituted  for  iron,  but  the 
probe  was  heated  in  tlie  spirit  lamp  and  quickly,  no 
doubt  deftly,  carried  at  a  glowing  heat  to  the  ulcer.  It 
was  a  question  whether  the  probe  should  be  held  there 
until  cold — a  question  determined  in  the  negative  by 
Claiborne,  who  deprecated  the  galvano-cauter}-  on  ac- 
count of  the  increased  radiation  of  heat  and  the  dis- 
tance of  the  glowing  point  from  the  surgeon's  hands, 
thereby  making  accurate  application  more  difficult. 
All  this  is  referred  to  as  to  the  great  credit  of  Dr. 
Claiborne,  who  fully  realized  the  utility  of  Marti- 
nache's method  and  practised  it  in  those  cases  of 
corneal  ulceration  which  were  least  manageable,  albeit 
with  appliances  very  crude  and  terrifying  to  the  patient 
as  compared  with  the  means  to-day  at  the  command  of 
the  surgeon. 

With  an  ophthalmic  practice  by  no  means  large 
enough  to  provide  many  cases  annually  of  diseases 
less  common,  with  glaucoma,  iritis,  or  even  strabismus 
matters  of  anything  but  daily  recurrence,  it  is  my  for- 
tune to  see  a  large  number  of  corneal  ulcers.  The 
limitation  of  the  hour  would  render  impossible  a  reci- 
tal of  all  seen  during  the  past  year,  and  I  will  briefiy 
refer  to  only  two  or  three  recently  treated  at  the  Wa- 
terbury  Hospital,  as  illustrating  the  efficacy  of  the 
cautery.  For  the  purpose  of  such  illustration,  they 
are  the  better  because  long  neglected,  attended  by  de- 
struction of  almost  the  entire  pupillar)-  area,  and  by 
extension  to  the  deeper  tissues  of  the  eye. 

.\pril  12,  1897,  G.  M— — ,  three  years  of  age,  was 
referred  to  me  by  Dr.  .\xtelle,  under  whose  obser\-a- 
tion,  not  treatment,  the  boy  came.  The  historv'  was 
of  severe  inflammation,  photophobia,  and  neglect  for  a 
year.  The  condition  on  examination  was  ulceration 
involving  the  entire  pupillarv-  region,  extending  about 
half  through  the  cornea,  iris  implicated,  contracted, 
and  glued  to  the  lens.  The  boy  was  chloroformed  on 
that  same  day,  and  the  ulcerated  tissue  burned  away 
with  a  delicate  platinum  point  and  without  perforation 
of  the  cornea.  His  recovery  has  been  immediate, 
rapid,  and  continuous.  Slight  opacity  and  a  slight 
facet  remain.  Notwithstanding  the  iritic  adhesions 
which  formed  during  the  long  period  of  untreated  in- 
liammation,  the  eye  will  be  a  useful  one,  although  it 
is  as  yet  too  soon  to  determine  what  degree  of  visual 
power  will  be  preserved.  This,  however,  does  in  no 
way  militate  against  the  fact  of  a  rapid  recover}-, 
which  began  as  soon  as  the  ulcer  was  converted  into  a 
corneal  burn. 

.\pril   14,  1897,  Mrs.  L.  L ,  fifty-three  years  of 

age,  of  Southbury,  was  sent  to  me  by  Dr.  Shepard. 
She  had  suffered  for  many  months  with  violent  pain, 
relieved  only  by  narcotics.  The  treatment  of  the  eye 
had  been  wholly  neglected.  The  pupillar)'  area  was 
occupied  by  a  deep-seated  ulcer,  involving  almpst  the 
entire  thickness  of  the  cornea,  obscuring  the  border  of 
the  discolored,  contracted  iris,  and  pus  was  collecting 
in  the  anterior  chamber.  .Vny  result  that  should  re- 
lieve from  further  suftering  and  enable  her  to  resume 
her  occupation  as  a  nurse  was  felt  to  be  a  good  one, 
and  this  without  hope  of  vision  in  the  eye,  so  long 
and  so  extensively  ravaged.  Under  cocaine  the  ulcer 
was  thoroughly  burned  down  with  the  galvano-cautery ; 
at  the  edges  first,  on  account  of  its  depth;  then  in  the 

'  New  York  MeJical  Journal,  May  30,  1^91. 


August  2\,    1897] 


MEDICAL    RECORD. 


265 


centre,  until  a  spurt  of  aqueous  humor  indicated  that 
the  cornea  was  perforated.  The  operation  was  pain- 
less until  the  tension  was  reduced  by  escape  of  fluid 
from  the  anterior  chamber.  A  pressure  bandage  was 
applied,  and  she  was  put  to  bed  for  a  few  hours.  Pain 
soon  ceased,  and  the  subsequent  progress  and  improve- 
ment were  as  rapid  as  though  it  had  been  a  healthy 
eye  instead  of  one  ulcerated  for  months  that  had  been 
cauterized.  In  ten  days  the  patient  was  sent  home, 
eye  nearly  free  from  irritation,  pus  absorbed  from  the 
anterior  chamber,  with  moderate  opacity  and  a  slight 
facet.  The  iris  is  moderately  dilated  under  atropine, 
irregular  in  fonii,  permanent  adhesions  having  formed 
during  the  neglected  progress  of  the  disease.  How- 
ever slight  may  be  the  visual  power  regained  in  this 
case,  the  incalculable  advantage  derived  by  the  substi- 
tution of  a  corneal  burn  for  the  chronic  spreading  dis- 
secting ulcer  could  not  be  denied. 

A  third  case  may  sufficiently  illustrate  the  utility  of 
cauterization  of  the  cornea.  December  27,  1896,  an 
infant  of  twenr\-two  months  was  referred  to  me  with 
a  letter  from   Dr.  St.  John,  of  Hartford,  from  which  I 

quote :  "■  R.  F ,  whom  you  saw  a  year  ago,  has  been 

brought  to  me,  and  I  find-  right  eye,  corneal  abscess 
central :  left  eye,  keratitis  involving  whole  cornea  and 
rather  superficial.  Xo  atropine  has  been  used  up  to 
now,  though  I  learn  that  you  gave  atropine  ointment 
a  year  ago,  but  it  was  used  only  three  or  four  times. 
I  have  given  a  very  bad  prognosis  for  right  eye,  and  a 
fair  one  for  left  eye,  provided  the  child  is  cared  for." 
It  appeared  upon  inquiry  that  I  had  seen  the  child  once 
about  a  year  before,  while  it  was  suffering  from  phlyc- 
tenular conjunctivitis:  immediate  recover}- not  ensu- 
ing, the  treatment  advised  was  omitted  after  a  day  or 
two,  and  the  case  practically  neglected  for  a  year,  dur- 
ing which  time  irreparable  damage  to  the  right  cornea 
occurred.  After  cauterization  improvement  was  im- 
mediate, and  the  case  was  discharged  in  two  weeks 
from  the  hospital,  where  it  was  sent  from  distrust  of 
home  treatment.  The  resultant  opacity  has  been  far 
less  than  was  anticipated.  On  May  7,  1897,  four 
months  later,  the  child  came  to  me  again,  with  a  verj' 
threatening  ulcer  of  the  cornea  of  the  left  eye.  The 
mother  very  gladly  saw  me  destroy  this  with  the  cau- 
tery, and  expressed  herself  as  willing  to  take  the  child 
again  to  the  hospital,  which  indicates  the  educating 
effect  of  experience.  To-day  the  eye  appears  to  be 
doing  well,  under  the  care  which  the  mother  has 
learned  to  give  it. 

Less  severe  instances  of  corneal  ulceration,  in  which 
recovery  has  occurred  entirely  without  opacity,  can  be 
cited  in  any  number,  but  it  appears  that  the  three  re- 
ported, all  long  neglected,  and  in  which  useless  un- 
sightly eyes  were  to  be  looked  for  by  reason  of  the 
unfavorable  conditions,  make  most  apparent  the  spe- 
cific value  of  the  cauter}-.  I  am  sorry  not  to  have 
these  three  cases  here  for  you  to  examine.  The  hour 
and  the  place  are  somewhat  unsuitable  for  very  young 
subjects,  but  the  woman  from  Southbur}-  has  consented 
to  come  here,  and  perhaps  one  will  answer  as  well  as 
all.  That  the  opacity  of  the  cornea  is  greatest  in  this 
case  is  not  to  be  wondered  at,  when  we  reflect  upon 
the  rapid  absorption  often  observed  in  verj-  young 
subjects. 

To  illustrate  the  tolerance  of  the  cornea,  I  will  ask 
you  to  examine  that  of  a  dog,  whose  right  eye  I  punc- 
tured a  week  ago.  carrying  the  redhot  platinum  point 
into  the  anterior  chamber.  Dr  Bland,  to  whom  I  am 
indebted  for  our  subject,  which  he  ana;sthetized  for 
this  purpose,  states  that  the  animal  appeared  to  suffer 
no  subsequent  inconvenience.  You  will  see  that  the 
restoration  is  complete.  A  faint  opacity  only  remains, 
which  will  evidently  wholly  disappear. 

The  perfected  apparatus  for  cauterization  of  the 
cornea  is  before  you.     The  platinum  point  or  electrode 


IS  about  one-half  inch  in  length  from  its  attachment  to 
the  handle.  It  is  of  wire,  Xo.  12  or  Xo.  14  gauge,  /.(., 
is  somewhat  over  one-one-hundredth  inch  in  diameter. 
It  is  retained  at  any  desired  heat  by  regulation  of  the 
current  at  the  rheostat ;  radiation  of  heat  is  reduced  to  a 
minimimi,  and  is  far  less  than  from  a  probe  sufficiently 
large  to  retain  the  requisite  heat  during  transferrence 
from  the  flame  to  the  cornea.  The  hard-rubber  handle 
is  two  and  one-half  inches  long,  and  weighs  one-fourth 
of  an  ounce ;  it  is  more  lightly  held  in  the  fingers  than 
a  penholder;  it  is  made  without  a  spring  or  current 
interrupter,  because  the  requisite  pressure  deflects  the 
aim  of  the  operator  and  makes  more  difficult  the  ap- 
plication of  the  platinum  point  at  the  exact  spot  de- 
sired. The  connection  is  therefore  made  by  pressing 
a  spring,  on  which  the  foot  rests.  The  cautery  handle 
was  made  to  my  order  about  five  years  ago.  The 
rheostat  is  a  Gish  rheostat;  by  it  the  degree  of  incan- 
descence desired  is  previously  fixed.  The  platinum 
point  can  be  placed  while  cold  against  the  ulcer,  and 
instantly  heated  to  the  previously  determined  degree 
upon  completing  the  circuit.  The  electric  current  is 
the  Edison  current  of  one  hundred  and  ten  volts. 

My  conclusions  may  be  smnmarized : 

To  cure  quickly  and  surely,  cauterize. 

Unless  inevitable  from  previous  destructions  of  tis- 
sue, opacities  do  not  result. 

Heat  radiation  is  minimized  by  the  galvano-cauterj- 
and  the  rheostat. 

Cocaine  ansesthesia  is  perfect  and  applicable  except 
for  young  children. 

With  the  electrode  in  contact  with  the  cocainized 
cornea  before  the  electric  current  is  completed,  cau- 
terization can  be  effected  without  the  knowledge  of 
the  patient. 


THE  BIPARIETAL  DIAMETER  AS  A  SYMP- 
TOM AXD  DIAGNOSTIC  CRITERION  OF 
TUBERCULOSIS." 

Bv    MARK    I.    KNAPP.    M.D., 


Theory  led  me  to  the  very  interesting  and  highly  im- 
portant obsen-ation  of  the  peculiar  formation  of  the 
head  in  tuberculosis,  which  is  either  flat  from  side  to 
side,  or  of  a  somewhat  triangular  form  with  the  base 
corresponding  to  the  occipital  bones.  However,  it 
must  not  be  understood  that  tuberculosis  modifies  the 
contour  of  the  head  which  has  previously  been  of  a 
different  shape.  Speaking  thus  of  what  appears  to  be 
a  pathological  condition,  the  question  arises:  ^^■hich 
is  the  normal  head?  The  word  normal  has  a  rekuive 
value,  and  what  is  normal  in  one  case  may  be  abnor- 
mal in  the  other.  While  the  aquiline  nose  is  normal 
to  the  Roman,  the  Greek  one  is  typified  as  straight. 
My  technical  subdivision  of  the  shape  of  the  head  is 
into  three  classes :  The  globular,  the  convexo-parietal 
(wide  biparietal),  and  the  piano-parietal  (narrow  bi- 
parietal). 

These  three  conditions  may  be  recognized  either  by 
the  touch  or  by  vision,  and,  best  of  all,  by  the  ordi- 
nary hatter's  conformator.  The  first  class  I  shall  omit 
in  this  paper.  In  running  our  palms  along  the  parie- 
tal bones  of  any  person  from  before  backward,  we  per- 
ceive in  the  convexo-parietal  (wide  biparietal)  (Fig. 
4)  abrupt  eminences,  corresponding  to  the  parietal 
eminences,  which  perception  is  absent  in  the  piano- 
parietal  (narrow  biparietal)  head.  These  abrupt  emi- 
nences may  be  present  only  on  one  side  or  on  both 
sides,  in  which  latter  case  they  may  be  developed 
either  equally  on  both  sides  or  unequally.  In  the 
piano-parietal  (narrow  biparietal)  head  the  examining 

'  Read  before  the  New  York  County  .Medical  .Association.  June 
21,  1S97. 


2  66 


MEDICAL    RECORD. 


[August  2  1,  1897 


palm  perceives  either  no  irregularities  at  all — the  con- 
tour of  the  head  (Hg.  1)  running  smoothly,  uninter- 
ruptedly, almost  in  a  straight  line  from  before  back- 
ward— or  it  may  perceive  apparent  eminences  (Figs. 
2  and  3).  These  eminences,  however,  are  only  appar- 
ent, and  on  further  examination  they  will  resolve 
themselves  into  well-developed  sutures  of  the  contigu- 
ous bones;  they  are  not  abrupt,  as  are  the  eminences 
in  the  convexo-parietal  head.  These  latter  cases  give 
the  triangular-shaped  head  (Fig.  2).  The  conformator 
shows  this  best. 

The  statements  just  cited  are  substantiated  by  a 
few  hundred  cases,  of  which  four  hundred  and  seventy- 
seven  were  collected  at  the  following  hospitals  of  this 
city:  St.  Joseph's  Hospital,  Montefiore  Home,  Metro- 
politan Hospital,  and  City  Hospital,  in  which  hospi- 
tals I  have  taken  only  those  cases  where  a  diagnosis 
had  been  positively  made.  I  have  taken  them  as  they 
came,  from  bed  to  bed,  without  selection.  In  all  those 
cases  I  have  found  only  seven  exceptions.  Neither 
are  there  included  in  this  number  about  fifty  or  sixty 
consumptive  women  also  seen  at  the  hospitals,  all  of 
whom  had  the  characteristic  piano-parietal  head,  but 
whose  shape  I  did  not  care  to  take,  owing  to  the  in- 
terfering hair. 


the  soil.  Jiut  pertinent  reasoning  refutes  this  by 
the  very  observations  and  statements  of  the  same  au- 
thorities. The  floors,  the  ceilings,  the  walls,  the  mats, 
the  draperies,  the  very  air,  our  investigators  say, 
swarm  with  that  deadly  bacillus,  and  yet  we  find  peo- 
ple undisturbedly  occupying  the  same  apartments  for 
weeks,  months,  nay,  for  years,  during  which  time  tons 
of  bacilli  must  have  been  inhaled.  As  to  that  highly 
ductile  expression  of  '"  favorable  soil,'"  are  there  not 
abundant  examples  of  cured  diseases  in  the  midst  of 
tuberculous  surroundings?  Of  course,  the  deductions 
above  are  alluded  to  only  as  possibilities;  they  need 
further  proofs.  The  further  inference  to  be  drawn 
from  the  piano-parietal  head  is  that  the  foundation  for 
tuberculosis  is  prepared  for  the  individual  either  in 
ittero  or  in  earl}-  life. 

The  several  hundred  almost  exceptionless  cases  have 
satisfactorily  proven  to  me  that  not  only  is  the  asso- 
ciation of  a  piano-parietal  head  in  a  disease  important 
for  diagnostic  purposes,  but  that  such  an  association 
is  a  most  trustworthy  symptom  of  tuberculosis,  not 
only  of  the  lungs  but  in  tjeneral,  no  matter  of  what 
organ.  Pathological  symptoms,  refer  they  to  the 
respiratory  organs  or  to  the  urinary  apparatus,  refer 
they  to   some  derangement   in   the  brain   or  to   some 


X 


Now,  taking  for  granted  that  in  all  cases  of  tuber- 
culosis the  biparietal  diameter  is  narrow  (piano-parie- 
tal head),  what  does  it  signify  ? 

We  are  confronted  with  two  facts,  which  certainly 
allow  of  a  deduction  that  involuntarily  forces  itself 
upon  us.  On  one  hand  we  have  the  constant  or  almost 
constant  association  of  pulmonary  tuberculosis  with  a 
piano-parietal  head,  and  on  the  other  the  piano-parie- 
tal head  which  is  the  product  of  physiological  chem- 
istry. Borrowing  from  algebra,  we  find  that  if  a  equals 
h  and  /'  equals  r,  the  deduction  therefrom  is  that  a 
must  equal  c.  May  we  not  draw  like  conclusions  in 
medicine?  If  tuberculosis  is  associated  with  a 
piano-parietal  head  (narrow  biparietal  diameter),  and 
if  the  respective  size  of  the  biparietal  diameter  be 
caused  by  physiological  chemistry,  could  we  not,  as 
in  mathematics,  conclude  that  tuberculosis  and  the 
piano-parietal  head  are  dependent  upon,  caused  by 
the  same  chemical  agents?  Such  conclusion  seems 
reasonable.  And  again,  if  tuberculosis  be  caused  only 
by  chemical  products  and  if  it  be  found  only  in  a  cer- 
tain class  of  persons- -viz.,  the  plano-parietals — could 
we  not  furthermore  conclude  tiiat  tuberculosis  could 
hardly  be  communicable  or  infectious?  Why  should 
the  tubercle  bacillus  have  selected  just  tiie  plano- 
parietals?  This  is  contrary  to  all  scientific  reason- 
ing. Differing  only  in  the  dose,  morphine  kills  all; 
neither  do  arseniuretted  hydrogen  and  hydrocyanic  acid 
know  of  exceptions  as  regards  the  biparietal  diame- 
ters— both  are  fata! ;  a  little  more  for  one,  a  little  less 
for  the  other — there  is  no  immunity  in  any  of  these 
cases.  Why  should  not  its  analogue  hold  good  with 
regard  to  the  tiny  tubercle  bacillus?  .\s  an  answer, 
we  are  given  the  inefficiency  of  either  the  quantity  or 


hidden  lesion  of  the  tibia,  if  the  individual  have 
a  piano-parietal  head  and  there  be  no  excess  of 
urates  in  the  urine,  the  lesion  is  a  tuberculous  one, 
whether  the  tubercle  bacillus  be  present  or  not. 
Syphilis,  which  I  have  not  yet  studied  in  this  relation, 
may  possibly  claim  exception.  Thus,  not  only  must 
bronchitis  associated  with  a  piano-parietal  head  be 
looked  upon  as  such,  but  as  the  possible  precursor  of 
phthisis. 

Four  cases,  three  at  the  City  Hospital  and  one  in 
my  own  practice,  strikingly  illustrate  this  assertion. 

Case  I.— John  G ,  forty  years  of  age,  came  to 

the  hospital,  and  the  diagnosis  then  was  chronic 
bronchitis;  now  phthisis  is  found. 

Cask  II.— Coyle,  thirty-eight  years  of  age,  came 
primarily  with  nephritis,  but  when  the  shape  of  head 
was  taken  there  were  positive  symptoms  of  phthisis. 

Case  III. — Dennis  S ,  forty  years  of  age.     His 

left  foot  was  amputated  some  years  ago.  At  the  time 
of  my  measurements  he  was  at  the  hospital  for  pul- 
monary phthisis. 

In  all  these  three  instances  the  heads  were  of  the 
piano-parietal  type.  (I  have  not  yet  gone  into  the 
previous  histories  of  consumptives;  these  histories 
were  volunteered  by  the  patients.) 

The  fourth  case  was  in  my  own  practice.  Mr.  Max 
K ,  twenty-four  years  of  age,  came  to  me  to  be  ex- 
amined for  admission  into  a  society.  His  piano- 
parietal  head  caused  me  to  subject  him  to  a  rigorous 
physical  examination  of  his  chest,  which  substantiated 
mv  suspicion.  I  rejected  him  and  told  him  the  reason. 
This  caused  that  young  man  to  consult  other  physi- 
cians, who  seemingly  corroborated  my  diagnosis,  as 
Ihev  also  told  the  jiatient,  after  very  careful  examina- 


August   2  1,    1897] 


^lEDICAL    RECORD. 


26: 


tion,  that  his  lung  was  affected,  not  yet,  however,  ad- 
mitting tuberculosis  without  bacteriological  proof, 
much  to  the  surprise  of  the  patient,  who  claimed  never 
to  have  had  anything  which  should  call  his  attention 
to  the  lungs.  After  having  heard  the  opinion  of  these 
physicians,  he  came  back  to  me  for  treatment,  when, 
questioning  him  about  his  habits,  he  told  me  that  for 
the  last  three  years  he  had  been  having  daily  two  or 
three  watery,  odorless  movements  of  the  bowels.  Now 
in  the  absence  of  symptoms  of  ner\-ous  troubles  and 
in  the  positive  absence  of  syphilis,  which  the  subse- 
quent treatment  also  proved,  and  with  the  presence  of 
consolidated  spots  in  the  lungs,  was  not  that  chronic 
diarrhcea  tuberculous  in  character  or  at  least  strongly 
suspicious  of  tuberculosis? 

As  a  symptom,  the  respective  development  of  the 
parietal  eminences  has  proven  of  very  high  value  in 
my  researches  and  observations;  it  is  the  ever-ready 
and  unconcealable  betrayer  of  men's  constitution.  In 
my  own  practice  it  not  only  affords  evidence  of  tuber- 
culosis, but  gives  the  key  to  the  entire  nature  of  the 
patient,  the  key  to  his  likes  and  dislikes,  to  his  predi- 
lections, and  chiefly  to  his  diet. 

Now,  does  the  fact  that  a  man  has  a  piano-parietal 
head  mean  that  such  a  man  either  already  has  or  that 
he  of  necessity  is  doomed  to  tuberculosis.'  No,  de- 
cidedly not.  The  piano-parietal  head,  the  narrow  bi- 
parietal  diameter,  as  a  diagnostic  criterion  of  tubercu- 
losis, is  of  importance  only  when  a  pathological  con- 
dition makes  itself  evident — no  matter  of  what  organ 
— and  this  is  not  associated  with  e.xcess  of  urates  in 
the  urine.  In  fact,  the  centenarians  and  the  athletes 
recruit  themselves,  so  far  as  I  ha\e  studied  them,  from 
the  plano-parietals. 

To  sum  up,  my  researches  lead  me  to  the  follow- 
ing conclusions:  The  piano-parietal  head  is  a  very 
valuable  symptom  of  tuberculosis  without  regard  to  the 
presence  of  the  tubercle  bacillus,  if  e.xcess  of  urates 
does  not  accompany  the  disease;  secondly  it  is  found 
only  in  a  certain  class  of  persons,  not  in  all,  and  that 
consequently  tuberculosis  can  be  neither  infectious 
nor  communicable;  and  thirdly,  and  most  important 
of  all,  it  proves  that  the  foundation  for  tuberculo- 
sis is  laid  in  very  early  life,  and  that  therefore  we 
must  direct  all  our  efforts  to  watching  and  guiding  the 
infant  life  if  we  want  to  save  the  adult  from  tuberculo- 
sis. 

In  conclusion,  I  wish  to  thank  all  the  gentlemen 
connected  with  the  several  hospitals,  and  especially 
Dr.  C.  M.  Cauldwell  and  Dr.  George  T.  Stewart. 

280  Bkou.me  Street. 


Is  it  Ever  Impossible  to  Pass  a  Catheter  through 
the  Urethra  into  the  Bladder  ?— Dr.  Buckston 
lirowne  discussed  this  question  before  the  Harveian 
Society  at  a  meeting  held  April  ist.  He  thought  that 
it  was  never  impossible  to  pass  an  instrument,  even- in 
the  worst  cases  of  stricture  of  the  urethra,  unless  the 
urethra  had  in  some  part  of  its  course  actually  ceased 
to  exist.  If  an  instrument  was  once  passed,  the  case 
■could  be  brought  to  a  successful  issue  without  any 
perineal  incision,  and,  that  being  so,  the  patient  was 
saved  all  the  risks  of  hemorrhage,  and  of  that  terrible 
misfortune  a  perineal  fistula.  In  the  most  severe 
cases  of  prostatic  enlargement  the  urethra  was  simply 
tortuous.  The  difficulties  were  fully  described,  and 
instruments  were  shown  by  which  they  could  all  be 
overcome.  In  no  prostatic  case  was  it  allowed  that 
the  urethra  was  impassable  by  instruments,  and  there- 
fore there  was  rarely  any  real  need  for  any  form  of 
prostatectomy  or  for  castration.  All  the  other  forms 
of  urethral  obstruction  were  discussed,  and  the  ques- 
tion which  formed  the  title  of  the  paper  was  answered 
emphatically  in  the  negative. 


SUNSTROKE,  OR  THERMAL  FEVER,  AND 
HEAT  EXHAUSTION;  THEIR  TREATMENT 
THROUGH  THE  NERVE  CENTRf:S  AND 
THE   LUNGS. 

i;v    BEVERLEV    OLIVER    KINNE.\K,    .M.U., 


If  any  measure  acting  as  a  preventive  of  heat  e.xhaus- 
tion  and  sunstroke,  which  is  also  rapidh-  ameliorative 
and  curative  at  the  time  of  the  attacks,  can  be  dis- 
covered, the  medical  profession  and  the  public  will 
have  a  double  control  of  these  diseased  conditions,  by 
the  ability  to  ward  them  off  as  well  as  to  restore  the 
patient  to  health  speedil)-,  and  thus  put  a  check  to 
those  trying  and  weakening  effects  so  often  visible  for 
months  and  years  after  an  attack  of  sunstroke  or 
thermal  fever  in  particular.  It  is  with  the  full  belief 
that  I  possess  the  secret  of  such  a  treatment  that  I  now- 
lay  the  subject  before  the  profession. 

Heat  Exhaustion. — Nearly  every  one  who  has  been 
compelled  to  remain  in  large  cities  during  hot 
summers  is  perfectly  familiar  with  "heat  exhaustion." 
The  sense  of  prostration,  both  mental  and  physical, 
the  cool  or  cold  surface  of  the  body  bathed  in  cold 
perspiration,  the  nausea  or  actual  vomiting,  the  rest- 
lessness accompanying  the  symptoms,  the  pale  face, 
the  feeble  pulse,  and  the  tendency  to  faint,  are  prob- 
ably known  to  all  those  who  have  endured  great  heat 
while  in  active  professional  or  business  labor. 

It  has  been  the  writer's  own  experience  many  times 
during  the  past  sixteen  years,  after  a  hard  day's  work 
in  the  heat,  to  arrive  home  suffering  in  just  this  way: 
but  during  the  period  mentioned,  by  the  application  of 
the  measures  about  to  be  considered,  he  has  invariably, 
when  so  seized,  been  enabled  within  an  hour  to  feel 
as  comfortable  and  refreshed  as  if  he  had  not  suc- 
cumbed to  the  heat  in  consequence  of  his  active 
mental  and  bodily  labor  in  it. 

.\nd  not  only  this,  but  by  the  use  of  the  same  means 
he  has  been  enabled  to  obtain  refreshing  sleep  during 
the  hottest  summer  nights,  and  thus  be  ready  for  the 
work  of  the  next  day.  Again,  very  many  patients  have 
expressed  to  him  the  relief  obtained  by  its  use,  and 
particularly  the  sense  of  refreshment  and  rest  when  it 
has  been  applied  during  heated  terms.  This  treat- 
ment is  the  application  of  cold  over  the  spine;  and 
by  it  we  can  dry  up  the  cold  perspiration,  warm  the 
whole  surface  of  the  body,  quiet  the  muscular  restless- 
ness, stop  the  nausea,  strengthen  the  pulse,  reacquire 
mental  and  muscular  vigor,  and  thus  recover  from  the 
prostration  and  faintness. 

By  the  local  action  of  the  cold  on  the  nerve  centres 
the  excess  of  blood  is  expelled  from  them,  and  the 
symptoms  which  are  due  to  this  excessive  circulation 
in  the  nerve  centres  disappear;  while  the  action  of  the 
cold  locally  upon  those  nerv-e  centres,  causing  contrac- 
tion of  the  arteries,  expels  the  blood  from  them,  and 
the  arteries  throughout  the  body  dilate,  causing  the 
pulse  to  recover  its  strength  and  the  system  its  vigor, 
in  consequence  of  the  restored  normal  distribution  of 
the  blood. 

The  effect  is  delightful  to  the  person  treated,  who 
in  a  short  time  experiences  a  renewed  sense  of  vital- 
ity. I  have  induced  these  effects  in  cases  of  heat  ex- 
haustion hundreds  of  times,  by  this  application,  and 
am  convinced  that  if  business  and  professional  men 
would  supply  tliemselves  with  a  bag  of  the  right  kind 
and  use  it  once  or  twice  a  day  in  hot  weather,  they 
would  find  themselves,  if  not  impervious  to  the  effects 
of  heat,  yet  enabled  to  do  their  work  with  more  vigor 
and  with  greatly  lessened  danger  from  either  heat 
exhaustion  or  sunstroke. 

For  the  average  person  the  bag  should  not  be  more 
than  twenty-two  inches  long,  and  four  and  one-quarter 


268 


mf:dical  rp:cord. 


[August   2  1,    1 1 


inches  wide,  because  a  wider  bag  will  chill  the  body, 
and  a  longer  one  will  pass  below  the  portion  of  the 
spinal  cord  in  which  central  nerve  cells  are  placed. 
These  bags  are  made  of  rubber,  and  are  fastened  with 
a  clamp  at  the  top.  They  are  divided  into  three  com- 
partments, for  two  reasons:  in  order  that  the  ice 
placed  within  them  may  not  all  float  to  the  top,  when 
the  bag  is  applied  over  the  spine,  and  thus  make  a 
greater  degree  of  cold  over  one  section  than  another: 
and  also  that  one,  two,  or  three  of  the  compartments 
may  be  used,  as  may  be  necessary  in  the  treatment  of 
the  case  at  hand. 

I  am  of  the  opinion  that  excessive  heat  of  the  at- 
mosphere, especially  moist  heat,  which  prevents  the 
natural  evaporation  from  the  skin,  draws  the  blood  in 
excess  into  the  nerve  centres;  and  in  heat  exhaustion, 
those  centres  in  particular  which  preside  over  the 
vasomotor  functions.  In  consequence  of  the  hyper- 
emia of  these  centres,  the  blood  leaves  the  surface  of 
the  body  and  goes  to  tlie  internal  organs,  including 
the  nerve  centres  in  the  spinal  cord,  giving  rise  to  the 
muscular  restlessness,  the  cold  perspiration,  the  nausea, 
and  the  faintness.  If  this  be  so,  it  can  be  easily  un- 
derstood how  cold  applied  locally  over  the  spinal  cord 
and  the  knots  of  nerve  tissue  upon  each  side  of  the 
spine,  known  as  the  .sympathetic  ganglia,  will  act  to 
overcome  the  condition  by  expelling  the  blood  from 
the  nerve  centres,  preventing  them  thereby  from  exer- 
cising their  function  abnormally.  That  the  treatment 
does  so  there  is  a  great  mass  of  evidence  from  its 
use  in  a  large  variety  of  diseased  conditions.  The 
temperature  of  the  body  falls  very  low  in  severe  cases 
of  heat  exhaustion,  and  the  usual  treatment  now 
adopted  by  the  regular  profession  is  the  use  of  ex- 
ternal heat  by  hot-water  baths,  the  hypodermic  injec- 
tion of  atropine,  strychnine,  and  digitalis,  in  order  to 
stimulate  the  heart  and  start  the  general  circulation  ; 
but  these  remedies  are  often  insufficient  either  to 
ameliorate  or  to  cure  in  serious  attacks;  while  the 
cold  over  the  spine  will  always  act,  and  act  promptly, 
and  it  can  be  aided  in  its  action  by  applying  hot-water 
bottles  to  the  surface  of  the  body  until  the  circulation 
has  recovered  its  full  strength  and  the  patient  his 
normal  tone.  Besides  this,  it  is  much  more  easy  of 
application  than  hot  baths  in  cases  of  prostration,  and 
it  is  not  at  all  distressing,  but  at  once  refreshing  to 
the  sufferer. 

In  tilling  the  ice  bag  with  finely  chopped  ice,  the 
lower  compartment  should  be  first  filled  to  the  bottom 
of  the  second,  then  the  second  one  to  the  bottom  of  the 
first,  and  lastly  the  top  one  to  the  line  of  the  thick 
piece  of  rubber  across  which  the  clamp  is  placed. 
The  clamp  should  then  be  screwed  tightly  on  and 
the  bag  held  in  the  warm  hands  for  a  few  moments, 
to  expel  the  latent  air  that  is  held  in  the  ice,  and 
directly  the  air  bulges  out  the  bag  the  clamp  should 
be  unscrewed  sufficiently  to  enable  it  to  escape  en- 
tirely, and  when  this  is  done  the  appliance  is  ready 
for  use,  and  may  be  placed  directly  along  the  centre 
of  the  spine,  from  the  line  of  the  shirt  collar  to  the 
full  extent  it  will  fall  down  the  spine.  It  may  be 
kept  on— being  refilled  every  two  hours — until  the  cir- 
culation is  fully  re-established  and  the  sutTerer  has 
recovered  a  good  modicum  of  strength ;  it  may  then 
be  removed,  and  used  one  hour  in  every  four,  until 
the  patient  feels  as  well  as  usual.  During  the  rest  of 
the  hot  season,  and  to  prevent  further  attacks,  it  would 
be  well  to  use  a  bag  once  a  day  for  an  hour  until  the 
cool  weather  sets  in;  taking  care  that  during  the  use 
of  the  treatment  the  bowels  are  kept  freely  moving 
and  well  cleared  from  all  fecal  matter  by  the  biweekly 
use  of  large  enemas  of  soap  and  liot  water. 

Meat,  except  upon  cool  summer  days,  is  hurtful  to 
everyin)dy,  and  an  unirritating  and  farin;\ceous  diet 
shoukl  be  enjoined. 


Sunstroke,  or  thermal  fever,  is  a  condition  induced 
by  heat  which  is  just  the  opposite  of  heat  exhaustion, 
as  it  is  accompanied  by  ver)'  high  temperature,  appar- 
ent expansion  of  the  arteries  throughout  the  system, 
flushed  face,  eyes  injected  with  blood,  and  congestion 
of  the  brain,  with  either  total  unconsciousness,  de- 
lirium, or  mental  confusion.  There  may  be  convul- 
sions, there  is  often  vomiting,  and  frequently  there  are 
diarrhoea  and  intense  muscular  restlessness. 

The  direct  action  of  the  sun  is  not  necessary  to  in- 
duce these  symptoms,  but  simple  exposure  to  long- 
continued  and  great  heat.  The  worst  attacks  fre- 
quently take  place  at  night,  and  we  believe  that  one 
of  the  causes  of  this  is  that  the  patient  goes  to  bed 
with  an  already  congested  brain,  and,  the  prone  posi- 
tion enabling  the  excited  heart  to  send  more  blood  to 
the  brain  with  less  eiifort  than  in  the  erect  posture,  the 
arteries  in  the  brain  expand  still  more  widely  than  they 
have  expanded  in  the  daytime,  and  the  so-called  sun- 
stroke may  be  then  more  likely  to  result. 

The  breathing  is  apt  to  be  irregular  and  labored, 
and  at  times  stertorous,  denoting  to  our  obser\-ation 
excitement  of  nerve  centres,  and  some  hyperaemia  of 
the  lungs. 

The  sequela;  of  this  disease  denote  that  there  is  left 
behind  a  condition  of  cerebral  hyperaemia,  which  may 
become  chronic  and  interfere  for  the  rest  of  the  pa- 
tient's life  with  his  work  and  his  enjoyment.  These 
after-effects  consist  of  pain  in  the  head,  feebleness  of 
memory,  heat  of  the  head  when  exposed  to  any  un- 
usual heat  in  winter  as  well  as  in  summer,  stiffness  of 
the  muscles  of  the  back  of  the  neck ;  and  in  recovery 
in  very  bad  cases  there  may  be  symptoms  of  chronic 
cerebral  inflammation,  also  a  tendency  to  convulsions. 

The  object  of  treatment  is  of  course  to  lower  the 
temperature  as  quickly  as  possible,  and  the  chief 
measures  now  adopted  are  the  cold  bath,  rubbing  with 
ice,  perhaps  blistering,  shaving  the  head,  and  the  in- 
ternal use  of  antipyrin. 

There  is  no  doubt  that  in  tliermal  fever  the  brain 
is  intensely  congested  and  the  circulation  at  the  same 
time  is  very  active;  thus  the  ice  to  the  head,  which  is 
also  always  used,  is  an  excellent  measure.  Hut  all  of 
these  together  cannot  compare,  in  my  estimation  and 
in  my  experience,  with  heat  applied  over  the  last  four 
cervical  and  first  four  dorsal  sympathetic  ganglia,  to 
overcome  the  congestion  in  the  head  and  brain  by 
contracting  the  dilated  arteries  in  these  regions. 

The  effect  of  heat  so  placed  in  a  double-columned 
hot-water  bag  is  at  once  to  begin  to  lower  the  tem- 
perature, cause  profuse  perspiration,  slow  the  rapid 
action  of  the  pulse,  and  restore  the  patient  to  con- 
sciousness, if  in  a  state  of  stupor ;  or  to  his  senses,  if 
delirious. 

One  case  in  New  York,  under  my  own  care,  I 
treated  by  this  application  with  immediate  success. 
The  patient  was  suffering  from  pronounced  sun- 
stroke; his  temperature  was  105°  F. ;  the  pulse  was 
full  and  bounding  at  the  wrist  and  in  the  temporal 
arteries;  the  head  was  very  hot,  the  face  was  flushed, 
the  eyes  were  injected,  and  the  man  was  in  a  condition 
of  semistupor.  Heat  was  applied  over  the  lower  cervi- 
cal and  upper  dorsal  vertebra-,  with  the  effect  that  in 
three  hours  the  temperature  had  fallen  almost  to  nor- 
mal, the  pulse  was  quiet,  the  man  was  quite  rational, 
and  had  enjoyed  some  sleep.  The  application  was 
used  for  half  an  hour  every  third  hour  through  the 
night,  and  at  mv  morning  visit  I  found  the  attack 
quite  conquered. 

In  a  second  case,  treated  by  correspondence,  in  Kliz- 
abeth,  N.  J.,  the  patient,  a  physician,  after  treatment 
for  several  days,  found  that  he  was  going  down  hill, 
with  the  fever  unsubdued  and  the  head  syminoms 
growing  worse.  His  wife,  a  very  intelligent  woman, 
treated  him  with  the  double-columned  hot-water  bag. 


AuGfUSt   2T,    1897] 


MEDICAL    RECORD. 


269 


and  in  half  an  hour  the  temperature  began  to  fall  and 
he  broke  out  into  a  profuse  perspiration.  Twent)- 
four  hours'  use  of  the  bag,  at  stated  intervals,  sufficed 
to  relieve  him  completely. 

A  third  patient  was  the  managing  editor  of  one  of 
the  large  New  York  religious  papers,  and  his  case  is 
an  e.xceedingly  interesting  one,  because,  although  it 
was  chronic,  it  yielded  readily  to  treatment  by  the 
double-columned  hot-water  bag.  Having  been  over- 
come by  the  heat  several  years  ago,  and  laid  up  for 
some  time  in  consequence,  he  apparently  fully  recov- 
ered, but  during  the  following  summer,  directly  the 
very  hot  weather  set  in,  he  was  obliged  to  rest  sev- 
eral days  by  reason  of  congestion  of  the  brain,  and 
toward  the  end  of  the  season  another  attack  followed. 
These  attacks  took  place  each  season,  until,  in  1892, 
during  one  of  them  he  put  himself  under  my  care. 
He  was  in  a  semiconscious  state  when  first  visited, 
with  a  very  red  face  and  injected  conjunctiv.'e,  and 
could  be  aroused  to  talk  only  for  a  few  minutes  at  a 
time,  when  he  would  relapse  into  a  state  of  partial 
stupor;  there  was  no  rise  of  temperature,  but  the  con- 
dition was  evidently  dangerous. 

The  double-columned  hot-water  bag  was  at  once  ap- 
plied over  the  proper  segment  of  the  spine,  and  before 
half  an  hour  had  elapsed,  the  face  had  lost  its  flush, 
the  mind  became  more  active,  and  the  redness  of  the 
eyes  disappeared. 

In  twenty-four  hours  the  patient  resumed  work,  and 
he  has  had  only  one  return  of  the  trouble  since,  when 
the  prompt  application  of  the  hot-water  bag  speedily 
relieved  him. 

It  is  the  writer's  opinion  that  if  every  hospital  sur- 
geon in  the  large  cities  would  supply  himself  with  a 
number  of  double-columned  rubber  hot-water  bags, 
eight  inches  long  and  four  and  a  quarter  inches  wide, 
for  prompt  use  in  cases  of  thermal  fever,  he  would 
have  much  less  trouble  in  treatment,  and  much  more 
speedy  recovery  from  such  seizures;  and  the  unpleas- 
ant sequelffi  of  the  attacks  would  be  to  a  large  extent 
prevented. 

It  is  my  conviction  that  the  cause  of  the  high  tem- 
perature in  thermal  fever  is  intense  hyperaemia  of  the 
brain  and  the  spinal  nerve  centres,  but  particularly  of 
the  brain,  overcoming  in  this  organ  almost  completely 
the  normal  contracting  power  of  the  sympathetic  gan- 
glia; therefore  the  most  energetic  and  efficient  treat- 
ment is  to  stimulate  the  cervico-dorsal  sympathetic 
centres,  by  means  of  heat,  to  such  powerful  action  as 
to  overcome  the  abnormal  action  of  the  cerebro-spinal 
vasodilator  centres,  thus  contracting  the  arteries  in 
the  congested  areas,  distributing  the  blood  in  normal 
quantity  throughout  the  body,  and  so  not  only  quickly 
subduing  the  dangerous  symptoms,  but  also  restoring 
the  natural  vigor  of  the  patient. 

As  the  sequela;  invariably  denote  hypereemia  of  the 
brain  and  upper  body,  I  advise  the  use  of  the  spinal 
ice  bag,  filled  in  the  two  upper  compartments  and 
applied  from  the  line  of  the  shoulder  blades  down  the 
spine  to  the  line  of  the  waist.  This  treatment  will 
dilate  the  arteries  in  the  lower  body  and  induce 
healthy  metabolic  action  in  the  digestive  and  secret- 
ing organs,  give  vigor  to  the  muscular  system,  and  at 
the  same  time  withdraw  the  excess  of  blood  from  the 
brain  and  upper  body,  and  allow  the  unduly  expanded 
arteries  in  these  regions  to  contract  to  normal.  The 
hot-water  bag  may  also  be  used  once  or  twice  a  week 
over  the  cervico-dorsal  region  so  as  to  assist  in  the 
contraction  of  the  arteries  required  to  accomplish 
complete  recovery. 

By  these  measures  the  after-results  of  sunstroke, 
such  as  the  inability  to  bear  heat  without  cerebral 
discomfort  or  pain,  the  headache,  the  failure  in  gen- 
eral strength,  the  stiffness  of  the  muscles  of  the  neck 
which  sometimes  results,  the  vertigo,  loss  of  memory, 


inability  to  concentrate  thought,  and  the  nervous  irri- 
tability, may  be  readily  and  speedily  overcome;  and 
the  patient  will  be  able  to  resume  work,  and  enjoy  life 
as  formerly. 

There  is  another  remedy  which  we  find  most  efficient 
in  preventing  and,  if  they  are  present,  rapidly  check- 
ing the  disagreeable  symptoms  induced  by  heat,  and 
that  is  the  inhalation  of  oxygen.  It  will  almost  in- 
stantly remove  the  fulness  of  the  head  or  the  headache 
induced  by  heat;  it  will  dry  up  at  once  the  moist  per- 
spiration, warm  the  body,  and  invigorate  the  muscles; 
and  the  sense  of  glow  from  its  use,  witii  the  increased 
feeling  of  vitality,  is  most  agreeable  and  refreshing; 
it  deepens  the  natural  respiration  for  some  hours  after 
its  use,  and  it  makes  the  pulse  full  and  incompres- 
sible.    I  speak  here  from  personal  experience. 

I  would  also  strongly  advise  its  use  to  overcome  the 
after-eft'ects  of  thermal  fever;  to  relieve  the  headache, 
strengthen  the  digestion,  stimulate  the  heart,  and  in- 
crease nutritive  processes  in  general;  and,  if  it  were 
used  daily  by  those  who  have  a  tendency  to  "  blood  to 
the  head"  in  hot  weather,  I  have  no  doubt  that  rapid 
and  continual  relief  will  be  obtained. 

O.xygen  to  be  efficient  must  be  pure,  and  it  must  be 
combined  with  a  gas  of  lighter  specific  gravity  also, 
in  order  to  obtain  successful  results  from  its  use,  as 
pure  oxygen  alone  is  too  dense  in  its  specific  gravity 
for  absorption  by  the  pulmonary  capillaries,  and  gives 
rise  to  too  great  local  oxidation,  if  the  mucous  mem- 
brane of  the  bronchial  tubes  is  at  all  irritable.  The 
gas  which  has  been  found  most  efficient  for  the  dilu- 
tion of  the  o.xygen  is  nitrous  monoxide;  and  the  for- 
mula used  by  the  London  O.xygen  Hospital  is  consid- 
ered by  all  authorities  upon  oxygen  as  the  best.  It 
consists  of  two  parts  of  pure  o.xygen,  one  of  nitrous 
monoxide,  and  one  per  cent,  of  electrified  oxygen,  or 
ozone,  to  keep  it  fresh. 

In  hot  weather  it  is  best  for  all  men  to  live  on  a 
light  and  unstimulating  diet;  to  avoid  in  every  way 
either  great  mental  or  bodily  fatigue,  as  well  as  un- 
usual excitement  from  any  cause,  and  all  excesses 
in  any  form  whatever. 

Followins;  such  rules  m  summer  time  is  in  itself  a 
great  preventive  of  attacks  of  either  heat  exhaustion 
or  sunstroke ;  therefore  the  person  who  is  temperate 
in  all  things  during  the  hot  season  has  the  best  chance 
of  escape. 

In  conclusion  I  would  recapitulate  as  to  the  chief 
causes  of  thermal  fever  and  heat  exhaustion.  The 
causes  of  the  latter  I  believe  to  be  hyperemia  of  ner- 
vous centres,  but  especially  of  the  sympathetic  ganglia; 
as  only  by  excessive  function  of  these  special  knots  of 
nerve  tissue  can  the  arteries  become  contracted  through- 
out the  body  and  the  temperature  fall  below  the 
normal. 

In  sunstroke  we  have  excessive  circulation  in  and 
increased  function  of  nerve  centres,  but  so  great  is  the 
stimulation  of  the  vasodilator  centres  that  the  function 
of  the  vaso-constrictorsor  .sympathetic  ganglia  is  almost 
completely  overcome,  especially  those  controlling  the 
circulation  in  the  upper  body,  head,  and  brain;  so 
that  there  are  both  an  active  circulation  in  these  parts, 
in  most  cases,  and  excessively  dilated  arteries,  induc- 
ing excitement  of  the  brain  and  confusion  of  thought, 
but  if  of  more  serious  form  causing  stupor  or  coma. 

The  best  treatment  for  sunstroke  is  to  overcome  the 
cerebro-spinal  excitement  by  contracting  the  arteries, 
through  the  agency  of  the  sympathetic;  and  for  heat 
exhaustion,  to  expel  the  excess  of  blood  from  the 
spine  and  sympathetic  ganglia,  by  means  of  the  spinal 
ice  bag,  thus  restoring  the  general  circulation  and 
relieving  the  excited  centres  of  their  congestion. 

The  temperature  of  the  water  used  in  the  spinal  hot- 
water  bag  should  not  exceed  120°  F. 

202  West  One  Hundred  and  Sixth  Street. 


270 


MEDICAL    RECORD. 


[August  21,  1897 


SOME  PRELIMINARY  OBSERVATIONS  ON 
THE  APPLICATION  OF  THE  KASHIDA- 
OGATA  MEDIUM  TO  THE  EXAMINATION 
OF    DRINKING-WATER. 

By   ARTHUR   J.    WOLFF,    M.D., 

AND 

JOHN    B.    McCOOK,    M.D., 

HARTFORD,   CONN. 

The  recently  published  observations  of  Dr.  K.  Kashi- 
da,'  under  the  direction  of  Professor  Ogata,  at  the 
Royal  University  of  Tokio,  Japan,  on  a  new  and  orig- 
inal medium  for  the  differentiation  of  the  bacillus  coli 
from  the  typhoid  bacillus,  attracted  our  attention  to  its 
probable  usefulness  for  the  detection  of  these  organ- 
isms in  drinking-water.  The  very  distinct  reactions 
which  can  be  produced  by  the  medium,  and  the  rapid- 
ity with  which  the  necessary  operations  can  be  carried 
on,  render  it  a  promising  field  for  investigation. 

Preparation  of  the  Medium.  —  Production  of  the 
litmus  solution:  Twenty  grams  of  common  litmus  are 
completely  exhausted  with  water;  this  liquid  is  care- 
fully filtered;  the  resulting  filtrate  is  now  evaporated 
on  the  water  bath  to  an  extract,  the  latter  being  neu- 
tralized with  acetic  acid.  The  evaporation  is  now  car- 
ried on  until  all  the  acid  is  driven  off,  and  the  result- 
ing extract  is  then  exhausted  with  a  large  quantity  of 
ninety-five-per-cent.  alcohol.  The  alcohol  removes  all 
the  acetate  of  potassium  formed  and  at  the  same  time 
the  red  coloring  matter  of  the  litmus.  When  the  alco- 
hol comes  through  the  filter  devoid  of  red  color,  the 
blue  residue  left  on  the  filter  is  allowed  to  dry,  and 
then  distilled  water  is  poured  upon  the  filter  in  such 
amounts  as  to  produce  a  saturated  solution  of  blue- 
litmus  extract.  This  is  preserved  in  flasks  properly 
plugged  with  cotton  and  carefully  sterilized.  A  one- 
and-one-half -per-cent.  solution  of  agar  in  neutral  bouil- 
lon is  now  prepared,  and  to  this  are  added  two  per  cent. 
of  milk  sugar,  one  per  cent,  of  chemically  pure  urea, 
and  when  these  are  completely  dissolved,  thirty  per 
cent,  of  the  above  litmus  solution;  the  mixture  is  now 
carefully  filtered  and  sterilized.  This  completes  the 
Kashida  medium.  Before  the  addition  of  the  litmus 
the  reaction  of  the  material  is  to  be  carefully  tested 
and  properly  corrected,  as  upon  this  depends  to  some 
extent  the  accuracy  of  the  results.  With  the  medium 
as  above  prepared,  one  can  very  readily  confirm  the 
conclusions  of  Kashida  in  the  article  mentioned. 

Experiments  with  our  Hartford  water  supply  have 
been  productive  of  surprising  and  satisfactory  results, 
which  point  to  this  medium  as  a  possibly  valuable  ad- 
dition to  our  methods  of  examination. 

Cultures  were  first  made  with  the  tap  water  upon 
Petri  plates,  and  tiiese  incubated  at  the  body  tempera- 
ture, no  change  being  observed  in  the  color  of  the  me- 
dium, except  that  a  colony  was  discovered  which  pro- 
duced a  deeper  blue  than  that  of  the  surrounding 
medium.  An  examination  of  this  colony  showed  it  to 
be  a  pure  culture  of  a  bacillus  which  at  the  present 
time  is  being  completely  investigated. 

Definite  quantities  of  the  tap  water  were  contami- 
nated with  coli  and  typhoid  bacilli,  both  alone  and  in 
mixture.  The  following  are  some  few  of  the  results 
obtained :  One-half  cubic  centimetre  of  tap  water  was 
contaminated  with  a  loop  from  an  agar  culture  of  tv- 
phoid  bacilli  and  a  loop  from  a  similar  culture  of  ba- 
cillus coli  communis;  this  mixture  was  plated  with 
about  ten  cubic  centimetres  of  the  Kashida  medium 
and  incubated.  K.\amined  after  the  lapse  of  twenty- 
four  hours,  the  medium  exhibited  a  distinct  acid  reac- 

'  "  Differenzierunjj  der  Typhusbacillen  vom  Bacterium  coli 
commune  durcli  die  Ammoniareaction.  Aus  dem  hygienischen  In- 
stitute der  Kaiserlichen  Universitat  zu  Tokio,''  etc.,  von  Dr. 
K.  Kashida.  Centralblatt  fvlr  Bakteriologie,  etc.,  Bd.  xxi,.  No. 
30-21,  June  24,  1897. 


tion  and  a  profuse  gas  formation,  as  shown  by  a  diffuse 
mottling  of  the  medium  with  bubbles.  After  seventy- 
two  hours  the  medium  commenced  to  change  to  a  blue 
color,  due  to  the  formation  of  ammonia  during  the  de- 
composition of  the  contained  urea.  This  change  did 
not  occur  until  after  seventy-two  hours,  and  at  the 
same  time  the  bubbles  commenced  to  diminish  in  num- 
ber and  size. 

A  mixture  was  made  containing  one  loop  each  of 
coli  and  typhoid  from  agar,  these  being  placed  in  one 
cubic  centimetre  of  tap  water  and  plated  with  ten  cubic 
centimetres  of  the  medium.  In  twenty-four  hours  this 
showed  a  marked  acid  reaction  and  the  production  of 
gas.  After  the  lapse  of  fifty-four  hours  no  change  in 
color  was  observed,  but  decided  diminution  in  the 
number  of  gas  bubbles.  In  seventy-two  hours  a  begin- 
ning alteration  of  color  to  blue  was  marked,  and  dur- 
ing the  next  twenty-four  hours  the  change  to  deep  blue 
was  complete. 

Ten  cubic  centimetres  of  the  Kashida  medium  were 
inoculated  with  one-half  cubic  centimetre  of  the  fol- 
lowing mixture:  Tap  water,  fifty  cubic  centimetres; 
one  loop  from  agar  culture  of  typhoid ;  one  loop  from 
agar  culture  of  coli  bacilli.  One  loop  of  this  mi.xture 
was  placed  into  ten  cubic  centimetres  of  tap  water  and 
plated.  In  fifty-four  hours  this  plate  showed  a  marked 
acid  reaction,  with  profuse  gas  production.  In  this 
there  were  colonies,  some  appearing  white,  while  oth- 
ers showed  a  distinct  blue  color.  (Bouillon  cultures 
of  both  were  made.)  After  seventy -two  hours  the  blue 
color  had  replaced  the  red,  the  former  being  much 
deeper  than  in  the  original  medium. 

Two  specimens  were  prepared  in  the  following  man- 
ner :  One-half  cubic  centimetre  of  tap  water  was  mixed 
with  ten  cubic  centimetres  of  the  medium  and  plated. 
At  the  end  of  fifteen  hours  these  plates  showed  very- 
slight  mottling  of  red  here  and  there,  but  when  exam- 
ined on  a  white  surface  this  red  coloring  was  very  in- 
distinct. There  was  a  very  profuse  growth  of  bacteria 
on  the  plates,  but  no  formation  of  gas  bubbles  whatever 
in  any  of  them.  After  thirty-nine  hours  they  had  not 
perceptibly  changed;  no  gas  was  to  be  discovered  in 
either.  At  the  end  of  seventy-two  hours  one  of  these 
plates  showed  a  loss  of  the  red  tint  and  the  production 
of  a  yellowish-white  appearance  in  certain  zones  of 
the  plate.  Another  specimen  showed  a  .still  deeper 
shade  of  red,  but  which  by  transmitted  light  mostly 
appeared  of  a  blue  color  with  some  few  yellowish-white 
areas. 

Other  specimens  of  tap-water  were  examined  in  tubes 
filled  with  the  medium,  the  results  being  in  no  mate- 
rial manner  different  from  those  already  described. 
Specimens  of  water  which  were  known  to  have  been 
contaminated  with  sewage  were  next  employed,  and 
in  each  case  the  results  would  seem  to  correspond 
with  the  degree  of  contamination  of  the  water. 

Comparing  our  results  with  those  obtained  with 
other  media,  we  are  led  to  feel  encouraged  in  the  be- 
lief that  Kashida's  medium  may  have  an  important 
future  in  water  examinations.  Certain  questions, 
however,  have  already  forced  themselves  upon  us: 
May  there  not  be  other  bacteria  than  the  coli  bacillus, 
existing  in  water,  which  produce  the  same  changes  of 
color  and  similar  gas  formation  ?  Our  obser\-ations, 
however,  thus  far  show  that  in  any  case  in  which  an 
atypical  reaction  occurs,  the  microscope  clears  up  the 
doubt  in  a  few  minutes  without  any  tedious  technical 
process  of  isolation. 

Bactbriological  Laboratory  of  the  Board  of  Hkalth, 
Hartford,  Conn.,  Au^sc  5, 1897. 


The  Sightless  Ones. — It  is  stated  that  there  are 
1,000,000  blind  people  in  the  world,  or  one  to  every 
I, coo  inhabitants. 


August  21,  1897] 


MEDICAL    RECORD. 


271 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE    F.    SHRADY,  A.M.,  M.D.,   Editor. 

Publishers 
WM.  WOOD  &  CO.,  43,  45.  &  47  East  Tenth  Street. 


New  York,  August  21,  1897. 

THE  ELIMINATION  OF  LEPROSY-BACILLI 
FROM  THE  BODIES  OF  LEPROUS  SUB- 
JECTS. 

While  formerly  the  view  was  almost  universally  held 
that  leprosy  is  transmitted  by  inheritance,  it  had  long 
been  suspected  that  the  disease  is  contagious.  It  was 
not,  however,  until  the  discovery  of  the  leprosy-bacil- 
lus by  Hansen,  in  1880,  that  this  suspicion  became 
susceptible  of  scientific  confirmation.  The  rapidity 
of  extension  of  the  disease  in  those  localities  in 
which  it  was  introduced  was  sufficient  to  exclude  he- 
reditary transmission  as  the  sole  agency  in  its  spread. 
On  the  other  hand,  the  results  of  inoculation-experi- 
ments have  been  variable  and  in  most  instances  of 
negative  character,  but  "the  single  positive  result  in 
the  case  of  the  Hawaiian  convict  condemned  to  death 
is  sufficient  to  establish  the  infectiousness  of  leprosy. 
Some  authorities  have  taken  an  intermediate  position, 
maintaining  that  leprosy  is,  like  syphilis,  transmissi- 
ble by  both  contagion  and  inheritance. 

In  order  to  prove  the  contagiousness  of  leprosy  it 
would  be  necessary  to  demonstrate  the  presence  of  the 
specific  bacterium  in  all  cases,  its  mode  of  elimina- 
tion from  the  body  of  infected  subjects,  and  its  trans- 
fer to  another  and  the  development  of  leprosy  in  the 
latter.  The  organism  is,  however,  difficult  of  cultiva- 
tion, and  definite  knowledge  has  been  wanting  as  to 
its  usual  mode  of  elimination.  To  clear  up  some  of 
the  doubtful  points  surrounding  the  channels  through 
which  conveyance  of  leprosy  takes  place,  Weber 
{^Deutsche!  Archiv  fur  klinische  Medicin,  B.  Iviii.,  H. 
4,  5)  undertook  a  careful  study  of  a  case  that  chanced 
to  come  under  obser\-ation.  The  patient  was  a  cigar- 
maker,  forty-three  years  old,  in  whose  family  history 
there  was  no  suggestion  of  leprosy,  and  who  had  spent 
some  ten  years  in  the  Dutch  East  India  Islands,  in 
the  course  of  which  he  had  come  in  contact  for  two 
weeks  with  a  native  officer  suffering  from  leprosy. 
After  an  interval  of  nineteen  months  following  this 
exposure,  lesions  of  leprosy  made  their  appearance, 
the  patient  meanwhile  suffering  from  loss  of  appetite, 
which  was  attributed  to  the  quality  of  the  food;  from 
weakness  and  sweating,  which  were  ascribed  to  the 
great  heat;  and  from  occasional  bleeding  from  the 
nose,  which  had  been  present  from  boyhood.  The 
skin  was  in  various  situations  thickened  and  infiltrated, 
in  places  the  seat  of  hyperemia,  macules,  and  pigmen- 


tation; there  was  some  glandular  enlargement,  and 
in  places  there  were  analgesia  and  thermanasthesia. 
In  order  to  determine  the  presence  and  the  mode  of 
elimination  of  the  bacilli,  a  systematic  bacteriological 
study  was  made  of  all  the  secretions  and  excretions, 
the  blood  and  the  fluids  of  the  tissues,  the  skin,  the 
scales,  the  hair.  The  Ziehl-Neelsen  method  of  stain- 
ing with  carbol-fuchsin  proved  to  be  the  best,  and 
positive  results  were  obtained  with  blood  from  a  dis- 
eased area — that  is,  bacteria  were  found  in  the  con- 
tents of  a  blister  induced  by  the  thermo-cautery  in  the 
skin  and  in  the  scales  thrown  off,  in  the  hair,  in  the 
sweat,  in  the  seminal  fluid;  while  bacilli  were  not 
found  in  blood  obtained  from  a  healthy  area,  in  the 
saliva,  or  in  the  urine. 

From  these  observations  it  is  obvious  that  there  are 
numerous  channels  through  which  the  bacilli  may  be 
eliminated,  and  that  the  transmission  may  take  place 
by  mediate  or  more  or  less  immediate  contact.  That 
infection  is  not  thus  more  commonly  conveyed  than  it 
actually  is  may  be  due  to  the  fact  that  the  bacteria 
thrown  off  through  the  channels  indicated  may  be  de- 
ficient in  virulence  or  that  certain  peculiarities  must 
first  be  complied  with  on  the  part  of  the  exposed  indi- 
vidual. Under  any  circumstances  it  may  be  safely 
maintained  that  leprosy  is  a  specific,  infectious  dis- 
ease, capable  of  transmission  by  more  or  less  direct 
association  of  sick  and  well.  It  is  not  known  that 
any  form  of  medicinal  treatment  is  capable  of  e.xer- 
cising  a  directly  curative  elTect,  but  the  spread  of  the 
disease  can  be  prevented  by  the  adoption  of  the  broad 
principles  of  prophylaxis  applicable  to  all  of  the  in- 
fectious diseases,  namely,  isolation  of  the  sick  and 
disinfection  of  the  materials  in  and  with  which  the 
causative  micro-organisms  are  eliminated  from  the 
body. 


TRAUM.\TIC    HYSTERIA. 

Ix  this  age  of  railway  travel,  when  so  many  persons 
spend  an  appreciable  portion  of  each  day  on  a  train, 
the  fact  that  a  new  group  of  symptoms  has  been  devel- 
oped in  connection  with  railway  injuries  is  only  in 
the  common  order  of  things.  The  close  relationship 
of  distant  parts  of  the  body  through  the  agency  of  the 
nen'ous  system  makes  it  unavoidable  that  prolonged 
physical  pain  should  cause  mental  an.xiety  and  de- 
rangement of  general  health,  but  a  trifling  injury  to 
the  periphery  may  tend  in  time  to  considerable  mental 
disturbance,  while  psychical  shock  acting  on  the  cere- 
bral cortex  may  bring  about  grave  impairment  of 
health.  To  this  class  of  complaints  the  name  of 
traumatic  neuroses  is  most  commonly  applied.  In 
the  July  number  of  Aledicine,  Dr.  Augustus  A.  Eshner 
writes  instructively  on  this  subject.  He  says:  "The 
symptoms  of  this  disorder  do  not  differ  essentially 
from  those  of  hysteria  of  any  other  origin,  but  I  have 
used  the  term  in  order  to  express  disapproval  of  it." 
And  again:  "Concerning  the  intimate  nature  of  hys- 
teria, we  can  as  yet  but  theorize.  To  designate  the 
disorder  a  neurosis  adds  nothing  to  our  knowledge, 
and  to  burden  this  designation  with  such  qualifica- 


272 


MEDICAL    RECORD. 


[August  21,  1897 


tions  as  functional  or  reflex  or  idiopathic  or  traumatic, 
in  no  wise  tends  to  clarify  our  notions  upon  the  sub- 
ject of  its  pathology.  In  hysteria  we  have  to  deal 
essentially  with  a  defect  in  the  nen,'ous  co-ordination, 
an  adequate  cause  for  which  can  be  conceived  to  reside 
in  the  metabolic  alteration  in  the  ultimate  nervous 
elements  resulting  from  modifications  in  cellular  nu- 
trition. Such  a  conception  is  not  in  conflict  with  the 
alluring  theory  of  the  motility  of  the  neuron  so  ably 
advocated  by  Dercum  and  others,  as  it  is  probable 
that  the  metabolic  processes  taking  place  in  all  of  the 
tissues  are  attended  with  cellular  movement."  Char- 
cot pointed  out  that  in  the  vast  majority  of  cases  of 
traumatic  hysteria  the  patient  at  first  thinks  he  has 
escaped  without  injury,  because  he  has  felt  no  imme- 
diate ill  effects.  There  would  seem,  therefore,  to  be 
a  period  of  incubation,  and  in  many  cases  the  patient 
may  not  develop  symptoms  for  some  weeks.  The  fact 
is  now  universally  recognized  that  it  is  a  mistake  to 
regard  these  symptoms  always  as  imaginary  or  feigned, 
and  if  such  a  course  be  followed  the  treatment  is  at 
times  likely  to  be  unsuccessful. 


THE   ABUSE   OF    HOSPITAL   CHARITY. 

The  abuse  of  hospital  charity  appears  to  be  an  almost 
universal  evil.  From  all  the  large  cities  of  the  civi- 
lized world  comes  the  wail  of  the  general  practitioner 
that  the  hospitals  and  dispensaries  are  taking  from 
him  the  means  of  gaining  a  livelihood.  He  cannot 
compete  with  them  on  equal  terms.  According  to  the 
Journal de  Midecine  it  has  been  computed  that  there  are 
in  Paris  twent)'-five  hundred  medical  men  battling  with 
starvation  from  precisely  the  same  causes  as  in  the 
United  States  and  Great  Britain.  It  is  in  London,  how- 
ever, that  the  abuse  of  hospital  charit)'  has  risen  to  its 
highest  pitch.  Statistics  show  that  yearly  more  than 
one-fpurth  of  its  population  are  recipients  of  medical 
relief.  Dr.  D.  Campbell  Black,  of  Glasgow,  in  an 
address  on  hospital  management  in  Great  Britain  in 
general,  and  in  London  and  Glasgow  in  particular, 
referring  to  London,  says  that  "  the  hospital  system 
there  has  reached  its  apogee  of  iniquit}-,"  and  adds 
"that  the  system  in  the  virtuous  citj'  of  Glasgow  is  in 
an  equally  rotten  state."  It  is  to  be  hoped  that  Dr. 
Black  is  somewhat  carried  away  by  his  feelings  and  is 
inclined  to  exaggerate  matters,  but  that  there  would 
seem  to  be  much  truth  in  his  statements  cannot  be  de- 
nied. A  special  commissioner  of  The  Lancet,  who  is 
investigating  the  subject,  reports  that  abuses  do  exist 
to  a  ver)'  large  e.\tent,  and  says  that  the  special  hos- 
pitals are  the  greatest  sinners.  The  fact,  too,  that  the 
"  Prince  of  Wales'  hospital  fund"  has  been  a  partial 
failure  is  a  proof  that  there  is  an  uneasy  feeling  in  the 
public  mind  in  regard  to  the  conduct  of  these  institu- 
tions; there  are  a  great  many  rich  persons  both  will- 
ing and  ready  to  give  freely,  provided  that  they  are 
satisfied  that  the  money  will  be  judiciously  expended. 
Indiscriminate  charit)-  does  more  harm  in  the  long 
nui  than  good,  and  the  manner  in  which  London 
hospitals    have    been    conducted    has    given    rise   to 


the  suspicion  that  there  must  be  something  radi- 
cally wrong  in  their  management.  The  conduct  of 
the  out-patients'  department  has  been  characterized 
by  a  high  English  authoritj'  as  often  a  complete 
farce,  demoralizing  to  the  people  and  unjust  to  the 
medical  profession.  For  this  state  of  affairs  tiie  gen- 
eral public  is  not  wholly  to  blame.  On  the  medical 
profession  itself,  as  has  so  often  been  shown,  a  large 
share  of  the  responsibilit}-  rests.  Dr.  Black  insists 
that  in  Great  Britain  the  medical  men  connected 
with  the  hospitals  are  responsible  for  all  the  trouble. 
He  makes  the  sweeping  assertion  that  "the  medical 
profession  is  the  most  masterly  of  all  callings  in  its 
hypocritical  devices  to  catch  the  public  eye,  and  to 
accomplish  this  it  finds  in  the  hospital  system  the 
most  convenient  and  popular  medium,  falsely  based 
as  it  is  on  the  best  attributes  of  our  common  humanity, 
viz.,  benevolence  and  compassion."  There  can  be  no 
doubt  that  it  is  invariably  the  object  of  young  and 
ambitious  men  to  obtain  a  position  on  the  staff  of  a 
hospital,  and  they  are  sometimes  willing  for  the  sake 
of  the  advertisement,  with  the  hope  of  ultimate  gain,  to 
abase  themselves  before  the  public  and  to  shut  their 
eyes  to  all  abuses.  In  London  various  schemes,  for  the 
most  part  more  or  less  visionar}',  have  been  suggested  as 
a  remedy,  but  nothing  practical  has  as  yet  been  put  for- 
ward. The  position  is  a  most  difficult  one,  owing  to 
the  many  interests  involved,  and  the  only  remedy  lies, 
in  the  opinion  of  The  Lancet,  "  in  the  organization  of 
the  medical  profession  and  the  simultaneous  action  of 
the  hospitals." 

WHERE  QUACKS  ARE  NOT  WANTED. 

The  Kentucky  State  board  of  health  has  recently 
gained  a  notable  victory  over  quackery  by  securing  the 
conviction  and  fine  of  a  professor  of  osteopathy  who 
plied  his  trade  for  a  time  in  Louisville.  The  osteo- 
paths there,  as  elsewhere,  seek  to  evade  the  medical- 
practice  law  by  setting  forth  the  claim  that  they  do 
not  "practise  medicine,"  that  is  to  say,  they  do  not 
prescribe  drugs,  perform  surgical  operations,  or  set 
fractures,  but  simply  manipulate  the  muscles  with  the 
hands.  This  was  the  plea  advanced  by  an  osteopath 
in  Louisville  who  was  charged  with  practising  medi- 
cine without  a  license,  in  that  he  twisted  and  pulled 
and  flexed  the  leg  and  thigh  of  a  poor  little  martyr 
with  hip  disease,  or,  in  the  words  of  the  opinion  of 
Judge  Thompson,  in  that  "  in  his  ignorance  of  the 
fundamental  principles  of  his  profession  he  subjected 
the  child,  which  was  laboring  under  a  tuberculous 
disease  of  the  hip,  to  cruel  and  unnecessary  torture, 
affecting  its  health  and  necessitating  the  employment 
of  a  physician  to  treat  it  for  fever  resulting  from  his 
inaptitude." 

The  ruling  of  the  court,  which  will  doubtless  serve 
as  a  precedent  in  future  cases  of  the  sort,  was  that 
"  any  person  who,  for  compensation,  professes  to 
apply  any  science  which  relates  to  the  prevention, 
cure,  or  alleviation  of  the  diseases  of  the  human  body, 
is  practising  medicine  within  the  meaning  of  the 
statute."     On  the  evidence,  the  judge  found  the  defen- 


August  2  1,  1897] 


MEDICAL    RECORD. 


27: 


dant  guilty  as  charged,  and  a  fine  of  fifty  dollars  was 
assessed  against  him. 

The  osteopaths  were  well  provided  with  money  and 
were  ably  defended  in  this  case,  but,  in  the  face  of 
the  evidence  brought  fomard,  the  conviction  of  the 
man  was  inevitable. 

Kentucky  has  many  things  of  which  its  sons  are 
justly  proud.  They  claim  that  it  has  the  handsomest 
women,  the  finest  horses,  and  the  best  whiskey  in  the 
wide  world,  and  now,  last  but  by  no  means  least,  it  has 
a  lot  of  real  doctors,  men  whose  right  to  practise  was 
honestly  come  by.  To  quote  from  a  letter  of  Dr.  J. 
X.  McCormack,  secretarj-  of  the  State  board  of 
health :  "  Our  law  has  now  been  in  operation  nearly 
four  years.  It  has  been  tested  upon  every  point  and 
so  far  we  have  not  failed  to  secure  a  conviction  in 
each  case  tried.  We  convicted  the  Copeland  people, 
the  '  K  and  K's,'  and  all  other  concerns  of  that  kind 
doing  business  here,  and  are  able  to  report  that  there 
is  not  now  an  itinerant  or  advertising  doctor  within 
the  limits  of  this  State."  Would  that  the  same  could 
be  said  of  everv  State  in  the  Union ! 


^atjs  of  the  ^meeh. 

A  State  Veterinary  College  has  been  established 
at  Cornell  University  in  which  free  instruction  in 
veterinary  medicine  and  surgery  will  be  given  to  citi- 
zens of  New  York  State.  In  addition  to  this  the 
authorities  of  the  college  will  conduct  investigations 
as  to  the  nature,  prevention,  and  cure  of  animal  dis- 
eases; investigate  the  economic  questions  which  con- 
cern the  more  profitable  breeding,  rearing,  and  utili- 
zation of  animals;  and  produce  reliable  standard 
preparations  of  antitoxins  and  other  products  to  be 
used  in  the  diagnosis,  prevention,  and  cure  of  diseases 
in  animals.  Cornell  University  will  administer  the 
veterinary  college,  appoint  investigators,  teachers,  and 
other  officers,  lay  out  lines  of  investigation,  and  pre- 
scribe the  requirements  for  admission  and  the  course 
of  study.  The  university-  is  to  receive  no  compensa- 
tion for  this. 

Moscow  Delegates  Received  by  the  Tsar. — On 
Tuesday  of  this  week  the  Tsar  received  at  the  Peterhof 
Palace  in  St.  Petersburg  a  number  of  physicians  who 
were  on  the  way  to  Moscow  to  attend  the  International 
Congress. 

Low   Mortality  in  New  York  City The  lowest 

death  rate  for  a  week  in  this  city  for  the  past  twenty- 
five  years  was  that  for  the  seven  days  ending  last  Sat- 
urday. It  was  20.09  PC  i^ooo-  The  first  week  in  Au- 
gust also  had  a  very  low  death  rate,  20.78.  This  favor- 
able showing  is  due  in  large  measure  to  a  remarkable 
decrease  in  the  number  of  deaths  among  children. 
There  has  never  been  a  year  when  there  was  so  little 
cholera  infantum.  The  figures  for  the  five  weeks  end- 
ing July  31st  are  2,457  for  1897,  and  2,566  for  iSg6. 
The  reason  for  the  lessened  mortality  among  chil- 
dren under  five  years  of  age  is  to  be  found  in  the  im- 
proved sanitary  condition  of  the  streets,  in  the  rigid 


inspection  of  milk  and  the  supervision  of  the  dealers 
by  the  board  of  health,  and  in  the  absence  of  any 
prolonged  season  of  excessive  heat. 

Medical  Schools  in  Denver. — As  we  noted  in  a 
recent  issue,  by  a  decision  of  the  supreme  court  the 
Medical  Department  of  the  University  of  Colorado 
will  no  longer  be  permitted  to  conduct  a  course  of  in- 
struction in  Denver:  consequently  the  regular  course 
of  medical  instruction  will  be  given  in  Boulder  for  the 
present,  but,  as  soon  as  the  charter  is  amended,  the 
medical  department  will  be  reorganized  in  Denver. 
Many  of  the  former  faculty  of  the  University  of  Colo- 
rado have  united  with  the  (iross  Medical  College  of 
Denver,  among  them  being  Drs.  Clayton  Parkhill, 
Josiah  N  Hall,.  G.  Melville  Black,  and  James  M. 
Blaine.  To  the  faculty  of  the  Gross  Medical  College 
have  also  been  elected  Drs.  William  N.  Beggs,  of  St. 
Louis;  Lincoln  Mussey,  of  Cincinnati;  George  Ed- 
ward Tyler,  of  Washington,  D.  C;  Louis  H.  Kemble, 
of  Denver;  Charles  Byron  Nichols,  of  Boston:  David 
H.  Coover  and  David  D.  Thornton,  of  Chicago. 

Dr.  Paul  F.  Munde,  of  New  York,  has  been 
elected  an  honorary  fellow  of  the  Edinburgh  Obstet- 
rical Society. 

Pennsylvania  and  Maryland  Union  Medical  As- 
sociation.— The  twentieth  annual  reunion  of  this 
society  will  be  held  at  Highland  Park,  York,  Pa.,  on 
Thursday,  August  26,  1897.  The  officers  of  the  as- 
sociation are;  Fresideiit,  Dr.  Joseph  Price,  Philadel- 
phia, Pa.;  Vice-Presidents,  Dr.  C.  A.  Rahter,  Harris- 
burg,  Pa.,  and  Dr.  Chas.  G.  Hill,  Baltimore,  Md.;. 
Secretary,  Dr.  Roland  Jessop,  York,  Pa. 

A  Proving  of  the  Bacillus  Icteroides. — A  physi- 
cian in  L'ruguay,  Dr.  Antonio  Quesada,  has  offered  to 
subject  himself  to  inoculation  with  the  bacillus 
icteroides  in  order  to  prove  the  correctness  of  Sana- 
relli's  assumption  that  it  is  the  pathogenic  agent  of 
yellow  fever.  All  attempts  to  turn  Dr.  Quesada  from 
his  purpose  by  pointing  out  its  dangers  have  been 
unavailing,  so  that  with  every  precaution  the  experi- 
ment will  be  conducted  in  the  presence  of  a  few 
selected  physicians,  who  will  carefully  note  the  prog- 
ress of  the  case.  Dr.  Quesada  is  a  robust  man.  forty- 
two  years  of  age,  who  was  formerly  a  surgeon  in  the 
Spanish  army,  ser\ing  in  the  Philippines  and  in  Cuba. 
He  made  a  deep  study  of  yellow  fever  while  in  Cuba, 
but  asserts  that  he  has  never  had  the  disease.  He 
professes  absolute  confidence  that  the  experiment  will 
prove  the  value  of  Sanarelli's  researches. 

Canadian  Medical  Association The  thirtieth  an- 
nual meeting  of  this  society  will  be  held  on  Monday 
and  Tuesday,  August  30  and  31,  1897,  in  Synod  Hall, 
Montreal,  under  the  presidency  of  Dr.  Y.  H.  Moore, 
Brockville,  Ont. 

Disinfection  of  Sleeping-Cars. — The  Louisiana 
State  board  of  health  has  decided  to  disinfect  all 
sleeping-cars  coming  to  New  Orleans.  .A.11  such  cars 
entering  the  city  immediately  upon  their  arrival  will 
be  cleaned  thoroughly  and  disinfected  under  the  sur- 
veillance of   the  sanitary  inspectors   of  the  board  of 


2  74 


MEDICAL    RECORD. 


[August  2  1,  1897 


health.  The  towels  and  bedclothes  will  be  sterilized 
by  steam.  The  system  of  disinfection  will  also  be 
extended  to  all  steamships  arriving  at  that  port. 

Medical  Society  of  New  Jersey — Dr.  D.  C.  Eng- 
lish, president  of  the  Medical  Society  of  New  Jersey, 
has  appointed  Dr.  William  Pierson,  of  Orange,  third 
vice-president  of  the  society,  to  fill  the  vacancy 
occasioned  by  the  death  of  Dr.  John  J.  H.  Love,  of 
Montclair.  He  has  also  appointed  Dr.  William  J. 
Chandler,  of  South  Orange,  recording  secretary  in 
place  of  Dr.  Wm.  Pierson,  resigned. 

Quarantine  Regulations  in  Costa   Rica. — Dr.    T. 

M.  Calnek,  of  San  Jost,  Costa  Rica,  member  of  the 
international  executive  commission  of  the  Pan-Ameri- 
can Medical  Congress,  in  a  recent  communication  to 
the  secretary,  Dr.  Chas.  H.  Reed,  of  Cincinnati,  states 
that  it  is  the  intention  of  the  government  of  that  country 
to  establish  a  fully  equipped  quarantine  station  with 
all  necessary  disinfecting  appliances.  The  necessit}- 
for  this  course  is  found  in  the  infected  condition  of 
practically  all  of  the  tropical  ports  of  the  Pacific.  An 
efficient  inspection  service  is  now  maintained  at  Port 
Limon  under  the  supervision  of  Dr.  Varela. 

A  Microbic  Cure  for  Typhoid  Fever. ^ — Dr.  Han- 
kin  has  reported  to  the  Indian  government  the  discov- 
ery by  a  young  Parsee  medical  man,  Dr.  Ghadialli,  of 
a  micro-organism  to  which  is  ascribed  the  power  of 
destroying  the  tv'phoid  bacillus.  This  discovery  was 
suggested  by  the  fact  that,  in  samples  of  water  sent  for 
examination  containing  this  microbe,  the  bacillus  typhi 
abdominal  is  was  never  found.  Hankin  has  named 
the  microbe  after  its  discoverer,  the  "micrococcus 
Ghudiallii."  In  pure  cultures  it  is  harmless  to  man 
when  swallowed  by  the  mouth,  and  produces  no  ill 
effects  when  injected  into  the  peritoneal  cavity  of  rab- 
bits and  guinea-pigs.  It  is  already  suggested  that 
cultures  of  this  micro-organism  might  be  used  as  a 
remedy  in  typhoid  fever,  as  a  disinfectant  of  typhoid 
stools,  and  as  a  purifier  of  infected  drinking-water. 

Syphilis  and  Colds  in  the  Head. — Dr.  C.  IJ.  Tay- 
lor, an  erratic  physician  of  Nottingham,  has  been 
speaking  and  writing  at  length  against  the  measures 
that  are  to  be  again  put  in  force  to  reduce  the  morbid- 
ity of  venereal  diseases  among  the  British  troops  in 
India.  Among  other  up-to-date  views  enunciated  by 
this  exponent  of  scientific  medicine  are  that  gonor- 
rhoea is  an  affection  of  little  or  no  gravity;  that  a 
common  cold  is  more  dangerous  than  syphilis,  since 
it  "  causes  one  hundred  and  twenty  thousand  deaths 
every  year,  while  syphilis  is  probably  the  least  fatal 
of  all  serious  diseases;"  that  it  is  a  very  rare  event  for 
a  syphilitic  parent  to  transmit  the  disease  to  the  off- 
spring; and  that  in  the  great  majority  of  cases  svphi- 
lis,  the  "only  serious  form  of  venereal  disease,"  either 
spontaneously  disappears  or  is  readily  and  perma- 
nently cured. 

Medical  Saints. — The  rewards  of  medicine  are  few 
indeed  in  this  world,  or  even  in  the  next,  if  we  may 
judge  by  the  small  number  of  practitioners  who  have 
been  placed  upon  the  calendar  of  saints.  We  there- 
fore have  cause  to  rejoice  that  one  more  was  added  to 


the  list  by  the  Pope  in  the  solemn  canonization  on 
-Ascension  Day.  The  new  saint  is  Dr.  Antonio  Maria 
Zacaria,  who  was  born  at  Cremona  in  1503,  and  stud- 
ied medicine  in  the  University  of  Pavia.  He  prac- 
tised chiefly  among  the  poor,  and  died  in  Cremona  in 
1563- 

The  Effect  of  Civil-Service  Examinations It  is 

stated  that  eighteen  women  who  were  recently  exam- 
ined under  Governor  Black's  new  civil-ser\-ice  scheme 
have  suffered  from  nervous  prostration  as  a  result 
of  the  excitement  attending  the  examination.  The 
Boston  Medical  and  Surgical  Journal  thinks  that, 
"  if  such  is  to  be  the  general  result  of  the  new  sys- 
tem, there  can  be  no  question  that  the  scheme  must 
be  regarded  a  failure.  It  is,  to  say  the  least,  unfor- 
tunate that  any  new  source  of  nervous  breakdown, 
which  is  not  absolutely  necessary,  should  be  forced 
upon  our  public  servants."  It  would  seem  rather  that 
a  woman  whose  health  is  so  precarious  that  it  can  be 
broken  down  by  the  strain  of  an  examination  is  not 
in  a  physical  condition  to  perform  satisfactorily  the 
duties  of  the  place  to  which  she  aspires.  We  sympa- 
thize with  the  ladies  who  have  had  this  trying  expe- 
rience, but  the  hard  fact  remains  that  the  public  ser- 
vice is  no  place  for  invalids. 

The  British  Association. — The  si.xty-seventh  an- 
nual meeting  of  the  British  Association  for  the  Ad- 
vancement of  Science  began  in  Toronto  on  August 
i8th,  and  will  continue  in  session  till  the  25th. 
.\bout  five  hundred  delegates  were  registered  the  first 
day,  and  it  is  thought  that  the  total  attendance  will  be 
nearly  one  thousand.  On  Thursday  a  reception  was 
given  to  the  members  by  the  Governor-General  and 
Lady  Aberdeen  in  the  Parliament  buildings. 

Dr.  L.  F.  Warner  has  been  appointed  special 
medical  e.xaminer  for  the  municipal  civil  service 
board  of  New  York. 

A  Peculiar  Accident. — A  three-year  old  child  in 
Newark,  N.  J.,  recently  picked  up  something,  which 
is  assumed  from  its  effect  to  have  been  dynamite,  and 
began  to  chew  on  it.  Shortly  afterward  there  was  a 
terrific  explosion,  and  the  head  of  the  boy  was  blown 
from  his  body  and  parts  of  it  were  hurled  for  a  con- 
siderable distance. 

Professor  Virchow  has  been  elected  a  foreign  asso- 
ciate of  the  French  .Academic  des  Sciences.  There 
are  six  other  foreign  associates  of  tlie  academy,  three 
of  whom  are  Englishmen. 

The  Sign  Language  for  Deaf-Mutes. — It  is  pro- 
posed toestablibh  in  England  a  college  for  deaf-mutes, 
modelled  after  that  established  in  Washington  by  Dr. 
E.  M.  Gallaudet. 

The  Coming  of  the  Plague.— .According  to  a 
newspaper  paragraph,  which  we  have  been  unable  to 
trace  to  its  source,  if  it  has  any  authentic  one,  Yersin 
declares  his  conviction  that  the  plague  which  has  pre- 
vailed in  southern  China  since  1894,  and  in  British 
India  since  1896,  is  the  genuine  black  death  of  the 
Middle  Ages,  and  that  it  will  in  all  probability  reach 
Europe  in  a  year  or  two. 


August    2  1,    1897] 


MEDICAL    RECORD. 


275 


Ol^Iiuical  gcpitvtnicut. 

A   CASE    OF    NEUROTIC    ALOPECIA. 

ISv    AVILLIAM    S.    GOTTIIEII.,    M.])., 


Falling  of  the  hair  may  be  complete  or  partial, 
and  either  variety  may  be  local  or  general;  and  par- 
tial local  alopecia  may  not  affect  the  entire  area  that 
is  diseased,  but  may  occur  in  circumscribed  patches 
surrounded  by  an  otherwise  normal  pilous  growth. 
Leaving  out  of  account  the  cases  in  which  the  hair 
bulbs  have  been  destroyed  by  inflammatory  and  ulcer- 
ative processes,  as  by  lupus  erythematosus  or  vulgaris, 
folliculitis,  syphilis,  etc.,  as  also  by  the  parasitic  dis- 
eases, ringworm  and  favus,  we  may  classify  the  vari- 
ous kinds  of  alopecia  as  follows: 

1.  Congenital  alopecia,  a  rare  general  form,  in 
which  the  hair  follicles  are  few  in  number  or  absent, 
and  which  is  usually  associated  with  defects  of  the 
nails  and  teeth. 

2.  Symptomatic  alopecia,  in  which  the  hair  falls  out 
all  over  the  body  from  constitutional  causes.  The 
loss  of  hair  is  rarely  complete ;  it  is  seen  after  severe 
illnesses,  as  after  fever  following  major  operations, 
and  in  the  cachexias,  as  phthisis,  diabetes,  syphilis, 
and  leprosy.  It  is  a  diffuse  thinning  of  the  hair  rather 
than  a  distinct  alopecia,  and,  while  sometimes  very 
e.Ktensive,  is  rarely  complete.  The  prognosis  is  al- 
most always  good;  the  hair  bulbs  remain  and  growth 
begins  again  as  soon  as  their  nutrition  is  improved. 

3.  Alopecia  areata,  where  from  a  trophoneurotic  or 
a  parasitic  cause  (it  is  yet  undecided  which)  the  hair 
falls  out  over  localized  areas  usually  circular  in 
shape.  The  bald  spots  appear  anywhere  upon  the 
body,  but  most  commonly  upon  the  head.  They  may 
coalesce,  and  in  bad  cases  almost  all  the  hair  of  the 
body  falls  out,  but  the  history  of  its  appearance  in 
spreading  spots  is  very  definite;  the  skin  of  each  area 
is  completely  denuded  of  hair,  but  otherwise  normal; 
and  at  the  margins  of  the  coalesced  patches  a  ridge 
of  hair  or  a  few  stragglers  are  usually  left. 

4.  Neurotic  alopecia,  a  rare  affection,  of  which  two 
distinct  varieties  are  to  be  noted.  The  partial  neurotic 
alopecia  that  occurs  in  the  area  of  distribution  of  a 
nerve  after  an  injury  of  that  structure  is  occasionally 
seen.  General  and  complete  alopecia  from  neurotic 
causes  is  even  less  common.  Cases  have  been  re- 
ported by  Tyson,  Duckworth,  Cooper,  and  others.  In 
almost  every  case  a  severe  nervous  shock  preceded  the 
falling  of  the  hair.  One  case  was  that  of  a  captain 
whose  ship  was  struck  by  lightning;  another  that  of 
a  boy  who  fell  from  a  great  height  from  a  tree.  The 
progress  of  the  alopecia  is  usually  very  rapid  in  one 
case  it  took  only  ten  days;  and  in  some  of  them  the 
finger  and  the  toe  nails  were  also  shed.  It  fs  never, 
however,  absolute;  a  few  straggling  hairs  are  left  be- 
hind. The  prognosis  in  these  cases  is  usually  bad; 
for  some  reason  of  which  I  am  unaware  the  hair  does 
not  grow  again  in  its  former  luxuriance,  and  some- 
times it  does  not  reappear  at  all.  The  following  is 
the  history  of  a  striking  case  of  the  kind  which  re- 
cently appeared  at  my  clinic. 

T.  Q ,  thirty-four  years  of  age,  hostler,  widower, 

had  never  had  sickness  of  any  kind  save  a  pneumonia 
five  years  ago.  As  he  put  it,  he  had  never  had  occa- 
sion to  take  five  cents'  worth  of  salts.  He  is  a  man 
of  steady  habits,  a  total  abstainer,  and  he  lives  with 
his  mother  and  sister,  to  whom  he  is  much  attached. 
He  has  always  had  a  remarkably  heavy  head  of  hair 
and  a  very  thick  and  bristly  moustache  and  beard ;  his 
chest  and  back  were  covered  with  long  and  tangled 


hair,  so  that  he  was  ashamed  of  himself  when  he  was 
exposed  while  bathing;  and  his  arms  and  legs  were 
equally  hirsute.  The  color  of  his  hair  is  a  vivid  red, 
and,  judging  by  what  remains  of  it,  it  is  of  exceptional 
calibre  and  stift'ness.  His  history  was  that  at  Christ- 
mas of  last  year  he  lost  his  job  and  was  out  of  work 
for  the  first  time  in  six  years.  He  worried  a  good 
deal  about  it,  since  his  family  was  dependent  upon 
him.  In  February  he  began  to  have  insomnia  and 
lose  his  appetite,  and  he  has  decreased  in  weight  from 
one  hundred  and  seventy-four  to  one  hundred  and  fifty 
pounds  since  January  1st  of  this  year.  During  the 
last  month  his  hair  has  been  falling  out. 

When  he  first  presented  himself  on  March    12th  of 
this  year  his  appearance  was  a  striking  one.      He  was 


a  sturdy,  healthy- looking  man,  somewhat  below  middle 
height,  with  firm  muscles,  a  clear,  florid  complexion, 
and  seemed  fairly  well  nourished.  His  head  looked 
"moth  eaten,"  there  being  a  general  diffuse  falling  of 
the  hair  over  the  entire  scalp.  What  hair  he  had  was 
long,  but  it  came  out  in  bunches  at  the  slightest  pull. 
His  eyebrows  were  represented  by  about  six  hairs  on 
each  side;  the  eyelashes  were  entirely  gone.  All  that 
remained  of  his  moustache  was  a  few  stray  but  very 
long  red  hairs  at  each  angle  of  the  mouth.  He  had  not 
shaved  for  a  week,  and  on  his  cheeks  and  chin  were  ir- 
regularly scattered  hairs,  not  one-sixth  of  the  normal 
amount,  according  to  his  statement.  Chest  and  back, 
arms,  hands,  and  legs  showed  only  a  few  scattered  but 
long  red  hairs.  The  axilla;  were  almost  hairless,  and 
on  the  pubis  was  a  sparse  tuft. 

He  was  carefully  examined  for  any  signs  of  syphi- 
lis, past  or  present,  as  well  as  regarding  the  presence 
of  any  disease  of  the  internal  organs,  but  no  sign  of 
anything  of  the  kind  was  discovered;  and  the  only 
conclusion  that  it  was  possible  to  come  to  was  that  the 
case  was  one  of  true  neurotic  alopecia  caused  by  men- 
tal anxiety.  The  treatment  consisted  of  general  tonics, 
arsenic  with  nux,  and  the  mineral  acids,  together  with 
the  local  use  of  a  bichloride  and  adeps  lana;  ointment 
(1-1,000)  for  the  scalp. 

During  the  two  months  that  he  was  under  treatment 
the  alopecia  steadily  progressed.  A  few  scattered 
hairs  only  remain  on  the  scalp  and  face;  the  mous- 
tache and  eyebrows  are  entirely  gone,  and  the  body  is 
quite  free  from  hair  save  a  few  stray  ones  upon  the 
pubis.  He  has  slept  and  eaten  better,  and  is  not  so 
worried;  but  the  falling  of  the  hair  continues. 

As  I  mentioned  above,  the  prognosis  as  to  a  renewed 
growth  of  the  hair  is  not  good.     Why  this  should  be 


2  76 


MEDICAL    RI^CORD. 


[August  21,  1897 


so  it  is  liard  to  imagine,  for  tiie  depressed  state  of 
nutrition  wiiich  the  skin  siiares  with  the  other  organs 
of  the  body  in  conditions  such  as  his  can  hardly  be 
severe  or  prolonged  enough  to  lead  to  a  permanent 
atrophy  of  the  hair  bulbs.  It  is  possible  that  some 
good  may  be  gotten  by  the  systematic  use  of  the  faradic 
brush,  or  from  chrysarobin,  or  from  the  hypodermatic 
injection  of  small  doses  of  pilocarpine.  But  the  rec- 
ords of  these  cases  usually  show  a  result  tiiat  is  very 
unsatisfactorv. 


HYSTERECTtXMV.' 
By    B.    F.    KIXG.SLEV,  M.I)., 

SAN    ANTON-IO,    TEXAS. 

Whk.v  an  operation  becomes  so  common  and  has  been 
given  so  much  careful  thought  as  hysterectomy,  it 
ceases  to  have  that  interest  to  the  average  physician 
that  it  did  as  an  innovation  in  surgery,  unless  there 
should  attach  to  the  case  some  unusual  history — some- 
thing of  uncommon  interest  in  the  operation  or  its  re- 
sults. Believing  that  I  have  a  few  such  cases,  I  am 
prompted  to  place  on  record  the  following- 

Case  I. — Miss  K ,  aged  eighteen,  aborted  Sep- 
tember 3,  1894,  between  third  and  fourth  months,  two 
or  three  weeks  after  the  criminal  induction  thereof. 
I  saw  her  first  on  September  9th,  and  found  her  with 
a  temperature  of  105'^  F.,  pulse  quick  and  full,  and 
great  pain  and  tenderness  over  the  lower  abdomen. 
She  was  curetted,  washed,  and  packed  twice  in  the  next 
week,  with  the  effect  to  cause  a  slight  reduction  in 
fever.  These  symptoms  continued  without  incident 
until  September  29th,  when  an  abdominal  section  was 
made.  Extensive  adhesions  were  found  in  and  around 
both  tubes.  The  ovary  and  tube  on  the  left  side  were 
successfully  removed,  but  the  one  on  the  right  contained 
an  abscess,  partly  within  the  wall  of  the  uterus  and  part- 
ly in  the  tube,  the  walls  of  which  would  not  hold  a  lig- 
ature; cutting  through  left  a  large  hole  in  the  uterus 
through  which  pus  ran  freely.  The  womb  was  large 
and  soft,  and  infiltrated  with  pus.  This  predicament 
left  us  no  alternative  but  hysterectomy,  which  was  ac- 
complished without  trouble,  and  the  patient  made  a 
prompt  and  complete  recovery,  and  is  now  able  to  ride 
a  bicycle  and  work  as  before,  and  looks  better.  This 
operation  was  done  at  the  patient's  home,  amid  very 
unsafe  surroundings. 

Case      II. — Mrs.     G ,     aged     thirty-nine,     was 

brought  to  my  private  hospital,  January  14,  189:;,  from 
an  adjoining  town.  She  was  the  most  perfect  pic- 
ture of  a  living  skeleton  I  think  I  ever  saw; 
her  pulse  was  barely  perceptible  and  very  irreg- 
ular, and  she  had  occasional  attacks  of  dyspncea. 
I  learned  that  she  had  come  to  Texas  from  Mis- 
souri four  years  before  for  lung  trouble,  having 
had  repeated  hemorrhages.  She  had  had  only  one 
in  Texas.  Physical  examination  of  her  chest  revealed 
a  dry  cavity  in  the  apex  of  the  right  lung.  She 
had  been  confined  on  November  2,  1894,  with 
her  tenth  child,  and  the  confinement  was  fol- 
lowed by  fever  which  continued  till  I  saw  her. 
Eight  years  previously  she  liad  been  confined  to  her 
bed  three  months  following  a  confinement,  from  which 
she  dated  her  pelvic  trouble.  I  found  a  deep  bilateral 
laceration  of  the  cervix,  and  it  was  filled  with  polypoid 
growths.  There  was  a  copious  muco-purulent  dis- 
charge, great  tenderness  in  the  vault,  especially 
to  the  left,  and  the  womb  was  fixed.  There  was  a 
large  tumor  on  the  left  side,  the  outlines  of  which 
could  be  distinctly  seen  extending  from  the  pubis 
to  nearly  the  border  of  the  ribs,  and  it  was  ex- 
quisitely tender.     After  five  days'  meditation,  an  oper- 

'  Read  before  the  gynxcological  section  of  the  Te.xas  Slate 
Medical  .Vssociation,  at  Paras,  Tex.,  .\pril  2-.  1S97. 


ation  was  decided  upon.  The  abdomen  was  opened 
on  January  19th.'  The  appendages  were  found  free 
on  the  right  side  and  removed,  the  uterine  artery 
was  tied,  an  opening  made  into  the  vagina  in  front 
and  behind,  and  the  reverse  course  pursued  on  the  left 
side,  according  to  the  method  suggested  by  Prof.  How- 
ard Kelly.  On  the  left  the  womb  was  tied  off  from 
below  upward,  and  the  adherent  and  .suppurating 
masses,  from  which  streamed  quantities  of  pus,  were 
left  intact,  after  being  washed  carefully  with  hot  deci- 
normal  salt  solution,  and  the  surface  and  interstices 
so  far  as  possible  covered  with  iodoform  gauze  pro- 
jecting into  the  vagina  and  out  of  the  abdominal 
wound.  She  began  to  improve  at  once,  and  soon  the 
attacks  of  dyspnoea,  which  occurred  several  times 
daily  and  for  which  digitalis  and  large  doses  of  strych- 
nine were  given,  became  less;  her  convalescence  was 
rapid,  and  six  months  later  she  paid  me  a  visit  on  her 
way  North,  the  picture  of  health.  At  last  accounts 
she  was  well. 

Case    III. — Mrs.    V ,  aged  forty-one,   has   one 

child,  a  boy  aged  fourteen ;  labor  was  prolonged  and 
instrumental,  and  since  then  she  has  had  headaches 
increasingly  violent,  for  which  finally  she  travelled 
and  was  treated  more  or  less  constantly.  Some  eight 
or  ten  years  after  her  confinement  a  deep  bilateral 
laceration  of  the  cervix  was  discovered  and  repaired, 
giving  her  temporary  relief.  A  few  months  after  this 
operation  she  had  a  pelvic  inflammation,  which  re- 
sulted in  a  pelvic  abscess,  which  was  opened  in  the 
posterior  cul-de-sac.  This  abscess  cavity  and  sinus 
refused  to  heal,  and  she  was  treated  at  home  and  in 
the  Woman's  Hospital,  New  York,  and  elsewhere  a 
year  before  it  closed;  her  headaches  continued  to  in- 
crease, although  she  no  longer  suffered  from  an\- 
pelvic  trouble  that  she  was  conscious  of.  She  be- 
catne  finally  a  complete  invalid  by  reason  of  these 
headaches,  was  confined  to  her  room  and  bed  most 
of  the  time,  and  was  compelled  to  use  morphine, 
whiskey,  and  other  drugs  more  or  less  constantly 
to  get  any  relief.  She  finally  came  under  my  sys- 
tematic care.  In  January,  1895,  I  found  the  womb 
perfectly  fixed  and  some  tenderness  on  deep  pressure; 
she  was  a  short,  thick-set  woman,  with  thick  tense  ab- 
dominal walls.  This  was  all  I  could  make  out,  but 
this  was  enough  to  establish  the  fact  to  my  mind  that 
this  was  a  probable  cause  of  her  reflex  pains.  Care- 
ful examination  enabled  me  to  exclude  other  organs, 
except  possibly  the  brain.  I  did  not,  therefore,  hesi- 
tate to  advance  the  opinion  that  the  headaches  were 
of  pelvic  origin,  and  that  nothing  short  of  a  hysterec- 
tomy would  relieve  them.  In  order  to  be  more  certain 
of  my  ground,  I  obtained  the  opinion  of  several  of  the 
ablest  gyna;cologists  in  the  country,  all  of  whom  except 
two  agreed  with  me.  Accordingly,  on  March  25th.  the 
abdomen  was  opened;  the  right  tube  and  ovary  were 
dug  up  —  if  I  may  use  this  expression — with  great  diffi- 
culty and  removed.  The  tube  was  at  least  one  inch  in 
diameter,  and  filled  with  pus;  the  left  but  little  smaller, 
but  containing  no  pus.  This  also  was  removed,  and 
the  womb,  not  \erv  much  enlarged  hut  very  hard,  fol- 
lowed. Time,  two  and  one-half  hours.  From  the 
moment  she  became  conscious  after  the  operation  she 
said  her  headaches  were  gone,  and  for  two  weeks  until 
she  was  nearly  ready  to  sit  up  she  never  ceased  to 
wonder  at  her  great  relief.  At  this  time  the  nurse 
heard  her  moaning  in  the  night,  and  upon  going  to  her 
found  her  right  side  paralyzed;  she  was  completely 
aphasic,  but  could  understand  what  was  said  to  her. 
In  the  course  of  twelve  hours  she  became  unconscious, 
and  the  paralysis,  both  motor  and  sensory,  was  com- 
plete; there  was  partial  ptosis  of  the  left  eyelid,  and 
an  ophthalmic  examination  showed  the  disc  in  the  left 
eve  somewhat  cloudy.  It  was  determined  to  open  the 
skull  on  the  left  side,  which  was  done  by  Dr.  Robert 


August  2  I,  1897] 


MEDICAL    RECORD. 


^11 


E.  Moss.  There  was  no  pulsation  o£  the  dura,  which 
was  incised,  nor  was  anything  discovered  to  account 
for  her  condition.  The  wound  was  closed,  with 
the  confession  tliat  we  were  baffled.  She  died  on  April 
19th,  one  week  after  the  last  oiDeration  and  over  three 
weeks  after  the  h\-sterectoniy.  An  autopsy  revealed  a 
perfect  condition  in  tlie  pelvis;  the  vaginal  vault  was 
closed  as  perfectly  and  smoothly  as  though  there  had 
never  been  any  womb  there;  the  intestine  lying  over 
it  was  attached  by  a  small  segment.  On  removing  the 
skull  cap  a  diffuse  blood  clot  was  seen  covering  the 
entire  right  hemisphere,  quite  thick  and  dense,  poste- 
riorly. There  was  no  necessity  for  searching  farther 
for  an  explanation  of  the  situation.  The  araclnioid 
was  adherent  at  two  or  three  small  points  along  the 
border  of  the  great  longitudinal  sinus.  It  is  interest- 
ing to  speculate  on  what  connection  if  any  the  first 
operation  had  to  the  cerebral  hemorrhage;  second,  that 
the  hemorrhage  was  on  the  side  of  the  paralysis,  which 
rather  goes  to  disprove  some  of  our  theories  of  cereliral 
localization. 

Case  IV.  —  Miss  R ,  aged  twenty,  had  suffered 

from  dysmenorrhoea  for  several  months,  the  e.xcessive 
flow  lasting  for  weeks,  but  there  was  never  any  pain 
e.xcept  near  the  menstrual  period.  For  this  condition 
she  was  in  the  course  of  three  years  curetted  and  packed 
several  times,  which  checked  the  hemorrhage  only  for 
the  time.  In  the  latter  part  of  April,  1896,  a  distinct 
tumor  was  discovered  on  the  left  side,  which  had  made 
its  appearance  and  grown  rapidly  long  after  she  had 
had  any  treatment.  She  was  now  having  a  light 
fever  continuously,  was  profoundly  anajmic  and  \ery 
weak.  An  operation  was  advised  and  done.  May  2, 
1896.  The  right  tube  and  ovary  were  free  and  nor- 
mal in  size  and  appearance,  but  wedged  against  the 
pelvic  wall  by  pressure  of  the  tumor  from  the  opposite 
side;  on  the  left  was  a  tumor  filling  the  pelvic  and 
abdominal  cavities,  and  extending  nearly  to  the 
border  of  the  ribs,  to  which  the  intestines  were  ad- 
herent. The  tumor  was  so  dense  and  vascular  as 
to  remind  one  of  a  soft  myoma,  which  I  thouglit  it 
was  until  the  womb  was  removed.  I  found  it  im- 
possible to  free  the  tumor  from  its  bed  from  above; 
so  I  removed  tlie  adnexa  on  the  right,  divided  the 
broad  ligament  between  sutures,  opened  the  vault  be- 
fore and  behind  and  as  on  two  or  three  former  occa- 
sions reversed  the  order,  working  from  below  upward 
on  the  left.  When  I  came  to  the  tube  its  wall  rup- 
tured, letting  a  few  drops  of  pus  escape.  It  was  now 
for  the  first  time  that  the  true  nature  of  the  tumor  be- 
came apparent;  the  rent  was  seized  with  forceps  to 
prevent  further  escape  of  pus,  and  the  tumor  dissected 
out  carefully  en  masse.  Great  care  was  necessary  to 
avoid  the  ureter,  as  the  mass  layover  its  entire  course. 
An  iodoform  gauze  tampon  was  used  for  drainage,  and 
the  abdominal  wound  was  closed.  E.xamination  of  the 
tumor  showed  its  walls  to  be  about  one-fourth  of  an  inch 
thick  and  very  vascular  externally.  Some  five  days 
after  the  operation  a  copious  watery  discharge  from 
the  vagina  began.  This  kept  up  until  the  middle  of 
September,  with  only  an  interval  of  two  or  three  days. 
The  amount  of  the  discharge  was  enormous;  it  was 
neutral  in  reaction,  with  a  specific  gravity  of  1.005,  and 
odorless  until  after  standing  a  number  of  hours,  when  a 
slight  urinous  odor  developed.  The  quantity  of  urine 
passed  from  the  bladder  was  normal  in  quantity  and 
quality.  About  the  middle  of  September  it  ceased  al- 
together, and  thereafter  for  three  or  four  months  violent 
paroxysms  of  pain  over  the  right  kidney  occurred  at 
about  the  regular  menstrual  periods,  accompanied  by 
fever  and  purulent  urine.  This  condition  was  reme- 
died by  the  administration  of  morphine,  salol,  and 
hyoscyamus.  For  the  last  five  months  she  has  been 
entirely  free  from  any  trouble,  .steadily  gaining  in  color, 
flesh,  and  strength,  and   is  now  feeling  better  than  for 


several  years.  Interesting  points  in  this  case  were  the 
freedom  from  pain  throughout  the  sickness  before  and 
after  the  operation,  except  at  the  menstrual  period, 
and  the  fact  that  there  was  no  vaginal  or  abdominal 
tenderness;  the  rapid  development  of  an  enormous 
pyosalpinx;  the  copious  vaginal  discharge  continuing 
for  months,  which  could  come  only  from  a  wounded 
ureter,  and  its  final  spontaneous  closure. 

F'rom  a  study  of  these  cases  the  following  conclu- 
sions seem  to  be  justified:  First,  in  pus  cases  we  may 
find  the  womb  normal  and  the  pus  confined  to  one  side, 
the  other  remaining  also  normal,  or  we  may  have  both 
tubes  and  womb  completely  septic;  and  we  must  there- 
fore not  enter  the  abdomen  with  a  preconceived  deter- 
mination to  do  a  certain  operation,  but  with  a  view  of 
doing  what  circumstances  demand.  If  we  have  a 
young  woman  or  married  woman  without  children,  it 
may  be  advisable  to  undertake  to  save  one  tube  and 
ovary  if  possible,  even  at  the  expense  of  a  second 
operation  later.  Second,  in  all  pus  cases  we  are 
bound  to  have  displacement  and  adhesions,  and  the 
tissues  involved  are  irreparably  damaged.  Hence  it  is 
absurd  to  do  these  operations  per  vaginam,  because 
the  womb  is  fixed  and  the  relations  of  the  parts  are 
changed,  necessitating  blind  surgerv  and  leaving  be- 
hind diseased  tissues  certain  to  give  rise  to  future 
trouble.  Third,  strange  and  incomprehensible  re- 
flex complications  often  accompany  and  follow  pelvic 
disease.  Fourth,  in  cases  of  sepsis  following  abortion 
or  occurring  in  the  puerperium,  the  safest  time  to  op- 
erate is  after  a  few  weeks  rather  than  immediately.  I 
wish  to  acknowledge  the  great  assistance  given  me  in 
these  cases  by  Drs.  F.  Paschal.  F.  M.  Hicks,  R.  Yl. 
Moss,  and  my  sister,  Dr.  Josephine  Kingsley. 


A    MALINGERER  (.'). 

Hv    EDG.\R    1.    srR.\.TI.IXG,    M.U. 


In  the  winter  of  1891-92  a  beggar  who  pretended 
to  be  horribly  deformed  with  rheumatism  was  refused 
alms  by  a  rabbi  who  had  been  warned  against  him  as 
a  fraud;  for  this  refusal  the  beggar  shot  him.  A  con- 
viction followed;  in  prison  he  would  obey  no  orders, 
was  filthy,  noisy,  and  violent.  He  was  given  the 
benefit  of  any  doubt  that  might  exist  and  committed 
10  the  hospital  for  insane  criminals.  There  he  at 
once  began  to  find  fault  with  everything,  and  declared 
that  he  was  beaten,  poisoned,  and  in  man}'  ways  perse- 
cuted, none  of  which  complaints  were  based  on  fact. 
He  soon  began  to  break  furniture,  yell,  and  make  as- 
saults on  those  about  him.  For  these  acts,  frequently 
repeated,  he  was  placed  in  a  separate  room  with 
screened  windows,  whereupon  he  pretended  to  become 
physically  insensible  and  paraplegic,  could  not  or 
would  not  take  food  or  control  the  sphincters.  He  was 
then  fed  by  means  of  a  tube  and  received  an  infant's 
care.  This  condition  lasted  during  the  two  following 
years,  examinations  being  made  from  time  to  time,  each 
apparently  giving  akinesia  and  analgesia  of  the  lower 
half  of  the  body.  He  resisted  every  examination  and 
for  a  day  or  two  afterward  would  pour  out  a  stream  of 
complaints  in  a  whining  tone,  of  heat,  cold,  bad  odors, 
repulsive  sights,  annoying  sounds,  etc.,  all  of  which 
were  baseless  materially.  At  times  he  would  show 
blood  on  his  bedding,  "declaring  that  he  had  had  a 
pulmonary  hemorrhage,  but  under  guarded  observation 
it  was  found  to  come  from  self-inflicted  injuries  of  the 
gums;  and  one  night  while  under  observation  he  was 
seen  to  climb  up  the  window  to  get  and  eat  a  piece  of 
cheese  put  there  by  another  patient.  The  next  day  in 
spite  of  his  resistance  a  Sayre's  apparatus  and  a  fara- 


278 


mp:dical  record. 


[August  21,  1897 


die  current  were  used.  A  few  days  of  this  treatment 
and  he  began  to  walk,  though  in  a  halting  manner, 
and  the  sphincter  paralysis  disappeared,  but  he  would 
immediately  relapse  into  his  former  state  of  pseudo- 
paralysis whenever  the  apparatus  and  battery  were 
taken  from  the  ward.  He  was  kept  up  and  made  to 
go  to  the  dining-room  and  exercise  court,  much  against 
his  will,  till  February,  1897,  when  he  passed  a  small 
amount  of  blood  by  the  rectum.  Kxamination  simply 
confirmed  many  previous  ones,  giving  an  enlarged 
spleen  and  small  liver,  but  no  reason  for  a  sudden 
collapse  and  resumption  of  the  old  state  in  all  its  de- 
tails. But  two  days  later  anasarca  of  the  feet  and 
scrotum  was  noticed,  followed  rapidly  by  ascites. 
After  only  five  days  tapping  gave  nearly  two  gallons 
of  fluid,  and  on  ever}-  second  or  third  day  thereafter  a 
like  amount  was  withdrawn.  He  generally  appeared 
insensible  or  pleaded  paralysis,  but  at  rare  inter\'als 
would  walk  about  the  ward  at  will. 

In  May  he  died.  The  post-mortem  gave  old  excori- 
ations of  the  leg  centres  and  two  inches  backward  on 
both  hemispheres.  No  other  pathological  or  develop- 
mental peculiarity  of  the  brain  or  nerves  could  be 
found.  Liver  hobnailed  and  about  one-third  size; 
spleen  about  four  times  increased:  heart,  lungs,  kid- 
neys, and  intestines  normal. 

The  patient  was  syphilitic.  Absolutely  nothing  of 
his  past  could  be  learned,  but  he  was  supposed  to  have 
been  born  an  Algerian  Mohammedan  and  to  have  led 
a  haphazard  existence  from  childhood.  The  proba- 
bilities are  that  he  had  had  syphilitic  paralysis  at 
some  time  in  the  past  and  that  locomotion  was  diffi- 
cult and  painful  and  his  delusions  and  hallucinations 
were  genuine,  but  that  all  mental  and  nervous  troubles 
were  many  times  multiplied  for  a  malingering  purpose. 
This  belief  is  strengthened  by  the  fact  that  he  never 
did  complain  of  the  real  physical  disease  of  which  he 
died — cirrhosis  of  the  liver. 


Jiociety  Reports. 

NEW    YORK    COUNTY     MEDICAL    ASSOCIA- 
TION. 

Stated  Meeting,  June  21,  iSgj. 

Jo.'^EPH  E.  Janvrin-,  M.D.,  President,  ix  the  Chmr. 

The  Biparietal  Diameter  as  a  Symptom  and  Diag- 
nostic Criterion  of  Tuberculosis. — Dr.  Mai;vc  I. 
Knapp  read  the  paj^er  (see  page  265). 

In  discussing  Dr.  Knapp's  paper  Dr.  C.  E.  Qlimby 
said  this  seemed  a  new  line  of  research.  The  author 
might  well  have  discussed  the  narrowness  of  the  bipa- 
rietal diameter  in  those  who  did  not  have  tuberculosis, 
for  it  would  be  interesting  to  know  if  non-tuberculous 
individuals  had  wide  biparietal  diameters.  If  the  nar- 
row biparietal  existed  in  other  than  tuberculous  pa- 
tients, how  could  the  argument  that  the  two  were  due  to 
the  same  cause  be  deduced?  The  line  of  investiga- 
tion might  be  an  interesting  one,  but  he  still  felt  that 
he  would  prefer  to  rely  upon  the  methods  now  followed, 
viz.,  physical  examination  of  the  patient,  with  the  evi- 
dences found  by  inspection,  palpation,  percussion,  and 
auscultation,  than  to  rely  upon  the  mere  fact  that 
the  individual  had  a  narrow  biparietal  diameter.  It 
was  evidently  more  beneficial  to  the  practitioner  and 
doubtless  more  satisfactor\  to  the  patient. 

Dr.  Kxapp  said  the  diameter  varied  in  different  in- 
dividuals, but  the  whole  head  had  to  be  taken  into 
consideration  and  the  fact  of  a  wide  or  narrow  biparie- 
tal diameter  be  determined  by  comparison  with  other 
diameters.     He  had  a  theorv  as  to  certain  anatomical 


abnormalities  in  connection  with  other  diseases,  which 
he  hoped  to  be  able  to  present  at  some  future  time. 

The  Genital  Phenomena  of  Renal  Calculi — Dr. 
R.  Abrahams  read  the  paper  upon  this  subject.  He 
proceeded  to  give  the  history  of  several  cases  in  which 
the  genital  phenomena  were  the  only  indications  of 
the  existence  of  the  affection  and  the  approach  of  its 
most  painful  manifestations,  colic. 

The  first  case  was  that  of  a  man,  single,  aged  twenty- 
two,  healthy.  He  was  seized  with  pain  in  the  right 
testicle  and  taken  home  bordering  on  collapse.  He 
vomited  once  or  twice  during  the  evening  and  had 
nausea  in  the  intervals.  The  abdomen  was  normal ; 
the  right  testicle  was  very  tender  and  the  seat  of  ex- 
cruciating pain,  accompanied  by  swelling  and  tume- 
faction. The  epididymis  was  hard  and  painful.  The 
urine  gave  no  aid  to  diagnosis.  There  was  no  history 
of  gonorrhoea,  but  the  affection  was  diagnosed  as  acute 
epididymitis  of  gonorrhceal  origin,  which  was  distaste- 
ful to  the  young  man,  as  he  was  on  the  eve  of  matri- 
mony. The  treatment  was  such  as  is  usual  in  epididy- 
mitis. After  four  days'  attack  of  violent  pain  in  the 
region  of  the  right  kidney,  radiating  down  the  pelvis 
and  thigh,  the  patient  passed  a  large  quantity  of  urine 
mixed  with  blood,  gravel,  and  large  and  small  frag- 
ments of  broken  calculi.  Simultaneously  with  the  dis- 
charge of  debris  the  testicle  began  to  improve  and  two 
days  later  the  patient  was  out  of  bed,  hale  and  heart}', 
the  pain  and  swelling  gone. 

The  second  case  was  that  of  a  man  and  was  similar 
to  the  first.  The  third  case  cited  was  that  of  a  woman, 
married,  aged  thirty-three,  who  was  healthy  until  De- 
cember, 1895.  Her  physician  said  she  then  had  an 
attack  of  acute  ovaritis.  This  attack  kept  her  in  bed 
a  week,  with  ice  on  the  pelvis  and  morphine  supposi- 
tories in  the  rectum.  The  recovery  was  complete. 
Just  a  year  later  she  had  a  similar  attack.  In  the  ab- 
sence of  the  family  physician  the  writer  was  called. 
She  had  frequent  vomiting,  coated  tongue,  was  consti- 
pated: pulse  feeble  and  rapid;  temperature,  loi  F. ; 
extremities  cold;  face  pale  and  covered  with  sweat. 
The  left  ovary  was  enlarged  and  exquisitely  tender. 
At  the  end  of  a  week,  after  a  large  warm  injection,  the 
woman  passed  a  good  quantity  of  water  mixed  with 
gravel  and  particles  of  broken  calculi.  Relief  in  the 
ovarian  region  was  immediate,  and  a  few  days  later 
the  previously  enlarged  and  tender  ovary  could  hardly 
be  felt. 

The  writer  would  not  have  any  one  infer  that  everj' 
instance  of  sudden  onset  of  pain  and  swelling  of  the 
testicle  or  ovary  attended  by  no  history  of  sepsis  or 
traumatism  was  a  bona-Jiile  expression  of  stone  in  the 
kidney,  yet  he  would  beg  every-  one  to  remember  the 
possibility  of  the  occurrence  of  such  a  state  of  things. 
The  literature  dealing  with  the  possibility  of  such  a 
cause  in  ovarian  troubles  was  \ery  scanty.  There  was 
more  literature  on  the  subject  of  the  affection  of  the 
testicle  in  cases  of  renal  calculi.  Dr.  Abrahams  also 
cited  the  case  of  a  boy  two  years  old,  in  which  or- 
chitis was  due  to  a  stone.  The  child  had  several  at- 
tacks, each  one  leaving  the  testicle  more  tender,  until 
it  had  to  be  supported  and  was  sensitive  all  the  time. 
On  one  occasion  the  child  was  brought  with  the  history 
of  retention  of  urine.  The  bladder  was  distended,  the 
testicle  swollen  and  tender,  and  the  penis  somewhat 
cedematous.  .\  stone  was  found  embedded  in  the  bul- 
bous portion  of  the  urethra,  and  after  its  removal  "the 
child  was  at  once  relieved  and  has  had  no  attack  of 
orchitis  since,  now  two  years.  The  significance  of 
the  genital  phenomena  as  indicating  renal  calculi,  if 
rightly  interpreted,  might  be  of  great  aid  in  preventing 
an  attack  of  renal  colic. 

In  discussing  Dr.  Abrahams'  paper.  Dr.  Robert 
Newmax  said  one  would  think  it  easy  to  diagnose 
renal  calculi,  but  at  tiie  bedside  it  was  not  so  easy. 


August   2  1,    1897] 


MEDICAL    RECORD. 


279 


The  writer  had  given  a  valuable  point,  but  even'  that 
would  not  remove  all  the  difficulties.  There  were 
to  be  considered  the  many  affections  to  which  the 
genital  organs  were  liable,  as  orchitis,  etc.  Then 
gout,  pvelitis,  etc.,  often  made  the  diagnosis  of  renal 
calculi  difficult.  Catheterization  of  the  ureter  aided 
somewhat,  but  even  that  did  not  always  settle  the  mat- 
ter. He  cited  a  case  in  which  the  patient  had  a  large 
renal  calculus  necessitating  removal  of  the  kidney. 
The  patient  recovered,  but  the  ne.xt  year  she  had  a 
large  calculus  in  the  remaining  kidney.  Dr.  Campbell 
succeeded  in  removing  this  from  the  kidney  and  the 
patient  recovered. 

Ur.  Thomas  Manlev  said  the  purpose  of  the  paper 
was  in  the  right  direction,  as  it  treated  of  symptoms, 
and  symptoms  led  to  diagnosis.  He  thought  there 
was  not  much  difficulty  at  the  present  time  in  diagnos- 
ing renal  calculi,  and  if  the  urine  were  e.xamined  it 
would  be  likely  to  reveal  the  difficulty.  He  had  not 
met  any  cases  similar  to  the  ones  referred  to  by  the 
writer  of  the  paper. 

Dr.  L.  B.  Bangs  said  he  had  not  hitherto  had  his 
attention  called  to  the  subject  as  presented  by  the 
writer,  and  he  thought  the  suggestions  were  quite  in- 
teresting. Renal  calculi  did  not  prove  so  ver}-  diffi- 
cult of  diagnosis,  but  the  suggestions  made  might  be 
of  importance.  He  recalled  a  hospital  case  in  which 
the  patient  had  what  was  supposed  to  be  tuberculosis 
of  the  testicle,  but  after  a  time  he  passed  a  stone  and 
the  case  cleared  up. 

Drs.  McCleop,  White,  and  Xewmax  were  appointed 
a  committee  to  arrange  for  appropriate  exercises  at 
the  next  meeting  of  the  association,  in  memory  of  Drs. 
Smith  and  Lusk. 

A  motion  to  appoint  a  committee  to  revise  the  by- 
laws and  constitution  was  carried. 


TH?:  \E\V  YORK   PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  February  24,  i8gj. 

JOHX  Slade  Ely.  M.D..  President. 

Total  Thrombosis  of  the  Left  Pulmonary  Artery. — 
Dr.  James  Ewing  presented  a  specimen  which  had 
been  taken  from  a  woman,  thirty-eight  years  of  age, 
a  laundress  by  occupation.  The  previous  history 
was  negative  except  that  there  was  an  absence  of 
rheumatism.  She  had  not  been  verj'  ill  until  about 
six  months  before  her  death,  which  had  occurred 
on  February  18,  1897.  On  her  admission  to  the 
hospital  there  were  the  physical  signs  of  advanced 
mitral  stenosis.  During  the  two  or  three  months  she 
was  in  the  hospital,  the  course  of  the  disease  was  that 
of  a  severe  mitral  stenosis.  The  principal  symptoms 
were  referable  to  the  pulse,  which  was  irregular,  small, 
and  at  times  ver)"  intermittent.  At  one  time  there  was 
a  ver)-  severe  attack  of  tachycardia  in  which  the  pulse 
ran  up  to  180.  There  was  one  attack  of  severe  heema- 
temesis.  The  pain  in  the  precordium  was  severe 
throughout  the  illness,  but  there  was  no  history  of  an 
acute  exacerbation  of  this  symptom.  There  was  con* 
siderable  oedema  at  the  time  of  admission,  and  this 
increased  steadily  up  to  the  time  of  her  death.  The 
urine  contained  albumin  and  numerous  casts.  The 
manner  of  death  was  of  interest.  She  became  deliri- 
ous about  five  days  before  death,  but  at  no  time  showed 
any  severe  acute  exacerbation  of  the  symptoms,  such 
as  would  indicate  the  occurrence  of  the  thrombus  or 
an  occlusion  by  an  embolus.  She  was  comatose  for 
two  days  before  death.  There  was  practically  no 
fever  during  her  stay  in  the  hospital.  During  the  last 
two  weeks  the  temperature  did  not  rise  above  99"  F., 
and  there  were  no  evidences  of  pneumonia.     At  the 


autopsy  it  was  noted  that  there  were  moderate  anasarca 
and  jaundice,  and  on  opening  the  thoracic  cavity  the 
right  lung  was  found  to  be  consolidated.  There  was 
about  one  litre  of  slightly  blood-stained  serum  in  the 
left  pleural  cavity.  The  left  lung  appeared  to  be  some- 
what diminished  in  size.  It  was  apparently  the  seat 
of  the  ordinary  consolidation  that  occurs  in  advanced 
heart  disease,  but  on  section  the  lung  was  found  to 
represent  a  complete  infarct,  the  whole  tissue  being 
studded  wi>h  rather  large  infarcts.  The  pleural  sur- 
faces of  the  lower  lobe  had  become  adherent,  and  when 
torn  apart  showed  a  large  cavity  in  the  lower  lobe 
which  had  evidently  arisen  from  softening  of  an  in- 
farct. In  the  upper  lobes  were  two  areas  of  softening. 
Around  all  the  infarcts  were  areas  of  lighter  color, 
representing  the  zones  of  hyperarmia.  The  other  lung 
showed  two  infarcts.  The  heart  was  of  moderate  size, 
and  presented  a  uniformly  narrowed  mitral  valve,  ad- 
mitting the  tip  of  the  little  finger.  All  the  chambers 
of  the  heart  were  dilated.  There  was  hypertrophy  of 
the  left  auricle  only.  The  left  auricular  appendix  con- 
tained an  old  and  partly  organized  thrombus.  There 
was  some  freshly  clotted  blood  in  the  right  side  of  the 
heart,  but  there  were  no  old  parietal  thrombi  or  points 
of  origin  here  for  a  thrombus.  The  liver  showed  ad- 
vanced chronic  congestion,  and  the  kidneys  chronic 
congestion  with  nephritis.  The  spleen  was  much  en- 
larged and  congested.  It  was  evident  from  an  exami- 
nation of  the  specimen  that  the  lung  had  been  con- 
verted into  a  single  large  infarct.  The  large  cavity 
in  the  lower  lobe  was  surrounded  by  fibrin  where  it 
had  been  adherent  to  the  parietal  pleura,  and  evidently 
antedated  the  one  in  the  upper  lobe.  It  was  interest- 
ing that  no  date  could  be  fixed  for  the  beginning  of 
this  extensive  lesion,  and  that,  notwithstanding  its  ex- 
istence, the  patient  was  able  to  breathe  fairly  well. 
This  history  was  in  marked  contrast  to  that  of  the  case 
in  which  sudden  death  occurred  after  confinement, 
being  caused  by  the  occlusion  of  one  branch  of  the  pul- 
nionar)-  artery  by  a  thrombus. 

From  a  pathological  standpoint  the  etiolog)-  was 
also  of  interest.  It  might  be  supposed  that  the  lung 
had  first  been  the  seat  of  a  pneumonia,  and  afterward 
of  a  thrombosis  which  finally  reached  the  pulmonary 
arter)-.  On  section,  however,  aside  from  the  lesions 
of  chronic  congestion,  there  was  no  inflammatoiy  exu- 
date found  except  in  the  zones  around  the  infarctions; 
hence  such  an  origin  could  be  excluded.  Another 
possible  origin  was  an  endarteritis  of  the  pulmonary 
vessels  leading  to  a  parietal  thrombus,  beginning  per- 
haps in  the  lower  lobe  and  causing  the  gangrenous 
cavity;  but  on  section  none  of  the  lesions  of  endar- 
teritis was  found.  A  third  possible  mode  of  origin 
was  the  ordinary  marantic  thrombus,  but  one  would 
naturally  look  for  some  other  exciting  cause,  as,  for 
instance,  a  small  area  of  inspiration  pneumonia  lead- 
ing to  thrombosis  of  a  vessel  which,  owing  to  the  fail- 
ing circulation,  had  increased  until  the  entire  pul- 
monar)-  arter)-  had  been  occluded.  None  of  these 
explanations  seemed  to  the  speaker  entirely  satisfac- 
tory. It  was  worthy  of  note  that  the  trombosis  could 
not  have  arisen  from  the  heart,  as  there  was  nothing 
in  the  right  side  of  the  heart  to  give  color  to  such  a 
view. 

Haemato-Myelopore — A  New  Spinal-Cord  Disease. 
— Dr.  Ira  ^^vN  Gieson  said  that  since  1S86  he  had 
been  engaged  in  a  study  of  the  origin,  nature,  and 
distribution  of  certain  slender  columns  or  canals  in 
the  spinal  cord,  which  had  been  hitherto  unexplained. 
He  believed  they  were  expressive  of  a  disease  of  the 
spinal  cord  of  a  distinctive  individuality,  deserving  a 
special  name,  and  he  had  therefore  given  to  it  the  name 
"  haemato-myelopore."'  The  word  is  from  the  Greek, 
and  signifies  an  aqueduct  or  canal  in  the  spinal  cord 
arising  from  a  hemorrhasre. 


28o 


MEDICAL    RECORD. 


[August  2  1,  1897 


The  speaker  said  that  he  had  first  met  w  ith  this  le- 
sion of  the  spinal  cord  in  1886  at  the  St.  Catharine's 
Hospital  in  Brookl3n.  The  patient  was  a  middle-aged 
man  who,  in  falling  from  an  ice  wagon,  had  injured 
his  back.  He  developed  a  severe  paraplegia,  but  lived 
for  nine  months.  The  autops}'  showed  an  old  fracture 
of  the  spinal  cord  at  about  the  twelfth  dorsal  segment. 
The  spinal  cord  at  this  point  was  reduced  to  a  small 
band.  Extending  upward  through  the  whole  dorsal 
region  was  a  narrow,  slender,  partly  tubular  canal, 
which  contained  necrotic  elements  of  the  cord  sub- 
stance. Dr.  Van  Gieson  here  exhibited  drawings  of 
the  lesion  found  in  this  case.  He  said  at  the  time 
the  condition  had  been  mistaken  for  syringomyelia. 
The  specimens  were  taken  to  the  pathological  labora- 
tory at  Heidelberg,  where  the  opinion  was  also  ex- 
pressed that  the  case  was  one  of  syringomyelia.  -Some 
time  afterward  Dr.  Dana  had  secured  an  autopsy  on  a 
woman  who  had  been  suddenly  seized  with  an  acute 
transverse  myelitis,  occurring  without  traumatism. 
This  case  also  showed  a  long  narrow  tubular  canal  in 
the  spinal  cord.  The  focus  of  the  myelitis  was  found 
in  the  mid-dorsal  region.  Dr.  Dana  published  the 
case  in  1889  under  the  title  "A  Case  of  .\cute  Mye- 
litis with  Central  Perforating  Necrosis  of  the  Spinal 
Cord."  In  1891  the  speaker  published  the  case  first 
referred  to  under  the  title  "  Traumatic  Myelitis;  De- 
struction of  the  Twelfth  Dorsal  Segment,  with  a  Col- 
umn of  Necrosis  E.xtending  into  the  Dorsal  Region." 
More  recently  he  had  met  with  three  or  four  cases  of 
traumatic  hamatomyelia.  The  mechanics  of  the 
spinal  cord  showed  why  it  was  necessary  for  blood  es- 
caping into  the  cord  to  assume  the  form  of  slender  col- 
umns. The  distribution  and  topography  of  these  hem- 
orrhages so  closely  simulated  that  of  the  canals  already 
referred  to  that  he  was  led  to  look  upon  these  hemor- 
rhages as  the  true  explanation  of  the  "  perforating  ne- 
crosis." Blood  passes  through  the  gray  matter  and 
disintegrates  it.  After  a  time  this  may  be  absorbed, 
leaving  a  clean-cut  hole  in  the  spinal  cord.  Up  to  the 
last  few  months  he  had  been  unable  to  find  the  inter- 
mediate stage  between  the  columns  of  hemorrhage  and 
the  perforating  necrosis,  but  through  the  courtesy  of 
Dr.  Fraenkel  he  had  been  able  to  study  a  case  in  which 
this  intermediate  stage  was  present.  There  is  a  dis- 
position after  a  time  to  the  formation  of  new  neuroglia 
tissues  about  these  long  slender  canals,  and  it  was  for 
this  reason  that  the  condition  had  been  mistaken  for 
syringomyelia.  The  symptoms  of  haemato-myelopore 
are  entirely  distinct  from  those  of  syringomyelia,  al- 
though resembling  them  in  some  particulars.  The 
structural  resemblance  between  the  two  diseases  is  due 
to  the  inflammation  which  tries  to  replace  the  tubular 
gap  in  the  spinal  cord  in  hamato-myelopore.  Dr. 
Van  Gieson  said  that  he  had  artificially  injected  the 
spinal  cord  with  colored  gelatin,  and  had  found  that 
these  injections  look  the  form  of  the  columns  observed 
as  a  result  of  hemorrhage. 

Dr.  Ewinc,  said  that  the  society  should  be  congrat- 
ulated on  being  the  first  to  hear  the  presentation  of 
this  important  subject.  The  speaker  had  stated  that 
the  course  of  the  blood  was  determined  by  the  limita- 
tion afforded  by  the  pia  mater.  It  would  seem  to  him 
that  the  b-lood  should  be  able  to  travel  in  anv  direc- 
tion within  the  limits  of  the  pia  mater;  hence  he  could 
not  understand  this  slender  columnar  distribution. 
The  charts  exhibited  would  seem  to  indicate  that  near 
the  source  of  the  hemorrhage  several  such  columns 
were  sometimes  present. 

Dr.  V,\.v  Giksox  replied  that  if  the  spinal  cord 
were  injected  with  colored  fluids  it  would  be  found 
that  more  resistance  was  met  with  in  passing  trans- 
versely than  in  passing  vertically  through  the  cord. 
The  two  crescents  of  gray  matter  are  softer  and  more 
spongy  than    the    nerve  fibres,  and    hence  offer    less 


resistance.  There  are  interstices  between  the  nerve 
fibres  which  constitute  slender  canals — indeed,  the 
whole  spinal  cord  would  appear  to  be  constructed  as 
if  it  were  itself  a  columnar  or  tubular  formation. 

JJr.  Van  (iieson  then  announced  the  publication  of 
a  more  detailed  presentation  of  the  subject  in  the 
State  Hospital's  Bulletin  and  a  final  presentation  of 
the  disease  for  the  congress  at  Moscow  during  the 
coming  summer. 


Stated  Meeting;,  Man/i  10,  iHgj. 
Jmhx   Si.ade   Ki.v,   M.D.,   Presipext. 

The    Results   of    Experimental   Nephrectomy  in 
Dogs  as  Bearing  upon  the  Uraemic  State. — Dr    C. 

A.  Herter  presented  a  report  on  the  results  of  his 
study  of  this  subject,  chiefly  with  a  view  to  indicating 
that  the  blood,  after  ligation  of  the  vessels,  or  removal 
of  the  kidney,  underwent  a  change  in  its  to.xicit}-.  The 
paper  was  based  on  fourteen  obser\-ations,  all  of  which 
were  upon  the  dog,  with  one  e.xception.  In  that  case 
the  pig  was  the  animal  experimented  upon.  In  one 
animal  death  followed  the  remo\al  of  one  kidnev,  and 
this  was  explained  by  the  fact  that  after  death  the 
other  kidney  was  found  to  be  the  seat  of  an  extensive 
hydronephrosis.  Both  kidneys  were  extirpated  in  six 
dogs,  and  in  the  pig.  The  average  duration  of  life 
was  two  and  a  half  days,  the  shortest  being  twenty-four 
hours,  and  the  longest  four  and  a  half  days.  Immedi- 
ately after  the  operation,  there  is  usually  considerable 
prostration ;  in  the  case  of  the  pig  there  was,  however, 
marked  restlessness.  The  first  striking  symptom  is 
vomiting,  which  usually  begins  about  the  end  of  the 
first  twenty-four  hours.  It  is  usually  repeated  a  num- 
ber of  times  and  then  ceases.  The  vomited  matter  is 
ordinarily  bile  stained,  and  sometimes  contains  blood. 
In  four  of  the  dogs  diarrhoea  was  associated  with  the 
vomiting,  more  or  less  blood  being  commonly  present 
in  the  diarrhceal  discharges.  Food  was  refused  by 
all  the  animals  except  the  pig.  At  the  time  of  the 
vomiting  there  was  usually  much  prostration,  and 
the  respirations  became  much  slower  and  deeper, 
being  reduced  from  50-80  a  minute,  to  25  a  minute 
at  the  end  of  forty-eight  hours.  In  some  instances, 
the  rate  fell  as  low  as  14  to  the  minute.  At  first 
the  heart  action  was  nonnal,  but  it  usually  became 
slower  after  a  while,  the  reduction  being  from  150  to 
80  a  minute.  This  was  associated  with  a  distinct  in- 
crease in  the  force  of  the  heart's  action,  and  usually  in 
the  fulness  and  tension  of  the  pulse.  After  forty-eight 
hours  the  nephrectomized  animal  was  apt  to  become 
drowsy  and  remain  in  this  state  until  death.  In  some  of 
the  dogs,  living  more  than  fifty  hours,  there  was  fibril- 
lary twitching  of  the  muscles.  In  only  one  case  was 
there  a  true  convulsive  seizure.  This  occurred  in  a 
dog  living  eighty-two  hours  after  the  removal  of  both 
kidneys.  It  was  preceded  by  pronounced  fibrillary 
contractions,  and  consisted  of  clonic  spasms  of  several 
minutes'  duration.  It  terminated  fatally.  Such  sei- 
zures, the  speaker  said,  appeared  to  be  quite  rare  in 
cases  of  experimental  ura-mia.  He  had  not  been  able 
ft)  satisfy  himself  tiiat  blindness  ever  occurred  in  these 
dogs.  During  the  last  hours  of  life  the  respirations 
were  even  slower  than  during  the  middle  period,  but 
they  were  more  shallow.  In  some  instances  there  was 
pronounced  irregularity  of  breathing,  sometimes  sug- 
gestive of  Cheyne-Slokes  respiration.  These  symp- 
toms justified  the  belief  that  they  were  dependent  upon 
paralysis  of  the  respiratory  mechanism.  Death,  how- 
ever, invariably  occurred  from  respirator}-  failure.  On 
the  other  hand,  the  heart,  even  in  the  terminal  stage, 
continued  to  act  forcibly,  and  maintained  a  nearly  nor- 
mal arterial  pressure  to  the  end.  On  division  of  the 
vagus  nerves  at  this  time,  the  pulse  rate  was  increased. 


August  2  1,  1897] 


MEDICAL    RECORD. 


•81 


The  cardiac  symptoms  were  evidently  the  result,  in 
part  at  least,  of  vagus  inhibition.  In  several  nephrec- 
tomized  dogs  there  was  a  striking  increase  in  the  ful- 
ness and  tension  of  the  femoral  pulse,  in  comparison 
with  that  found  before  operation.  Xo  doubt  such  a 
pulse  in  a  nephritic  patient  would  be  called  a  high- 
tension  pulse.  At  times,  the  heart  sounds  were  mucii 
increased  in  intensit)-  on  the  second  or  third  day  after 
nephrectomy,  and  the  aortic  second  sound  was  espe- 
cially loud  and  valvular.  In  these  animals  the  tem- 
perature was  never  increased  above  the  normal,  except 
as  a  result  of  sepsis ;  on  the  contrary,  the  temperature 
was  one  to  three  degrees  Fahrenheit  below  the  normal 
for  the  greater  part  of  the  period  of  obser\'ation.  The 
symptoms  were  practically  the  same  in  all  the  ani- 
mals, whether  the  kidneys  were  removed  or  the  ureters 
were  simply  tied — a  matter  of  much  importance,  as  it 
showed  that  Brown-Se'quard's  theor)-  of  urtemia  was 
hardly  sustained. 

A  most  important  feature  of  these  cases  was  that 
the  blood  serum  was  found  to  be  increased  in  toxicity 
if  taken  twenty-four  hours  or  more  after  operation. 
The  degree  was  roughly  related  to  the  duration  of  the 
experiment.  This  toxicity  was  either  much  reduced, 
or  quite  lost,  by  exposing  the  serum  for  a  few  minutes 
to  a  temperature  between  60  and  67  C.  The  change 
in  toxicit}-  was  associated  with  a  darkening  of  the  se- 
rum and  the  development  of  a  peculiar  odor.  Dr.  Her- 
ter  said  that  he  had  not  yet  been  able  to  determine  the 
point  at  which  this  change  in  toxicity  first  took  place. 
It  was  sometimes  noticeable  that  this  loss  of  toxicity 
was  not  so  complete  with  an  exposure  for  tsvo  minutes 
to  a  temperature  of  67'  C.  as  with  an  exposure  of  five 
minutes.  At  times  there  was  a  slight  separation  of  a 
reddish  gelatinous  material  at  this  temperature,  but 
without  distinct  coagulation.  It  was  possible  that  the 
substance  whose  activity  was  destroyed  was  a  globulin. 
but  all  attempts  to  determine  its  nature  had  hitherto 
failed.  It  was  important  to  note  that  the  normal  se- 
rum of  the  dog  was  toxic  to  rabbits.  Former  observers, 
the  speaker  said,  had  not  noted  that  in  the  case  of 
dogs  the  normal  serum  underwent  a  striking  reduction 
in  its  toxicity  when  it  was  heated  in  the  manner  just 
described  in  connection  with  the  foregoing  experi- 
ments. The  increase  in  the  toxicity  of  the  serum  va- 
ried ;  sometimes  it  was  not  more  than  one-third  more 
toxic  than  the  normal  serum,  but  in  other  cases  it  was 
from  two  to  six  times  more  toxic  than  the  normal. 

It  was  important  to  emphasize  the  fact  that  the  re- 
sults obtained  by  this  experimental  study  were  of  the 
most  definite  character,  and  that  the  results  had  been 
concordant  in  all  the  cases  in  which  the  serum  of  ne- 
phrectomized  animals  had  been  tested.  In  these  ex- 
perimental studies  the  rate  of  making  the  injection  was 
of  importance.  For  instance,  if  made  too  rapidly, 
more  serum  would  be  injected  than  was  required  to 
c.uise  the  symptoms  or  produce  death.  He  had  found 
that  the  rate  should  be  from  two  to  five  cubic  centi- 
metres per  minute.  It  was  important  to  distinguish 
between  the  results  obtained  in  studying  the  toxic- 
ity of  urine  and  those  from  a  study  of  the  toxicity 
of  the  blood  serum.  In  the  case  of  the  urine,  the  po- 
tassium salts  form  an  exceedingly  important  element, 
as  from  sixty  to  eighty  per  cent,  of  the  toxicity  of  the 
urine  is  due  to  the  presence  of  these  salts — in  other 
words,  only  a  comparatively  small  proportion  was  due 
to  the  organic  ingredients,  such  as  urea,  extractives,  etc. 
Unless,  therefore,  we  knew  just  how  much  potassium 
salts  were  present,  particularly  the  chloride,  we  could 
not  say  just  how  much  of  the  toxicity  was  due  to  the 
salts.  In  the  blood  serum  there  would  be  found 
\ery  little  potassium  salts.  The  diminution  in  toxic- 
ity in  the  experiments  could  not  be  ascribed  to  the 
destruction  of  the  extractives  and  urea,  because  a  far 
higher  temperature  was   necessary  for  their   destruc- 


tion. The  diminution  of  toxicity  appeared  to  be  due 
to  a  substance  similar  in  its  properties  to  that  found 
in  the  urine  of  some  cases  of  human  ura;mia.  In  both 
cases,  the  toxicity  was  destroyed  or  reduced  by  the  ap- 
plication of  heat,  and  the  color  and  odor  underwent 
similar,  if  not  identical,  changes. 

The  muscles  and  the  liver  were  extracted  with  a  two- 
per-cent.  salt  solution  at  the  room  temperature,  and 
the  clear  extracts  were  injected  into  rabbits.  It  was 
found  in  this  way  that  the  liver  did  not  store  the  ther- 
mo-sensitive  substance,  and  that  it  did  not  give  posi- 
tive toxic  results.  We  must  look  to  the  skeletal  mus- 
cles for  information  regarding  the  thenno-sensitive 
substance  which  was  responsible  for  the  change  in  the 
toxicity  of  the  blood.  Occasionally,  massage  had 
been  found  hannful  in  patients  with  chronic  nephritis 
on  the  verge  of  urajmia,  resulting  sometimes  in  aggra- 
vating the  dyspncea  and  general  discomfort.  An  ex- 
tract of  the  muscles  of  the  normal  dog  when  injected 
into  rabbits  was  found  also  to  be  toxic,  but  in  a  rather 
different  way,  the  animals  dying  apparently  of  suffoca- 
tion and  without  the  development  of  convulsions.  The 
significance  of  this  observation  was  not  yet  known. 
As  was  well  known,  the  urea  of  the  blood  in  the  ne- 
phrectomized  dogs  was  increased  from  two  to  ten  times 
the  normal  amount,  varying  with  the  time  the  animal 
lived  after  the  nephrectomy.  In  the  nephrectomized 
dogs,  changes  in  the  color  of  the  retina  had  been  ob- 
served. Marked  congestion  of  the  intestine  was  quite 
frequently  found  in  these  animals.  A  marked  conges- 
tion of  the  mucous  membrane  of  the  small  intestine,  of 
uneven  distribution,  was  commonly  found  after  forty- 
eight  hours.  The  mucous  membrane  of  the  stomach 
was  often  moderately  congested,  as  was  also  that  of 
the  lower  colon  and  rectum.  A  similar  congestion 
might  be  produced  by  large  intravenous  injections  of 
urea,  but  the  congestion  was  apparently  not  due  to 
urea  in  the  experiments  under  consideration,  as  com- 
paratively small  quantities  of  urea  were  found  in  the 
intestine.  .A  similar  congestion  was  produced  by  in- 
jecting into  dogs  the  serum  from  uremic  patients. 

Dr.  Herter  said  that  he  had  analyzed  forty-one  ap- 
parently reliable  cases  in  which  anuria  in  the  human 
subject  had  lasted  more  than  four  days.  Of  the  twenty 
one  autopsies  in  these  cases,  the  ureter  or  pelvis  was 
obstructed  by  calculus  in  fourteen,  and  in  three  growths 
obstructed  the  ureters.  Of  thirty-six  cases  in  which 
there  was  absolute  or  nearly  total  anuria,  in  eleven 
the  anuria  lasted  more  than  four  days,  and  in  seven 
more  than  fourteen  days.  In  seven  of  the  forty-one 
cases  no  urjemic  sypmtoms  occurred,  although  the  dura- 
tion of  the  anuria  was  from  five  to  eleven  days,  and 
caused  death  in  at  least  three  of  the  cases.  In  a  num- 
ber of  the  cases  more  than  a  week  elapsed  before  the 
indications  of  uraemia  began:  in  most  cases  it  was 
from  the  seventh  to  the  ninth  day.  In  twelve  of  the 
forty  cases,  vomiting  was  present  at  some  period.  Diar- 
rhoea was  noted  in  only  six  cases.  Insomnia  and  rest- 
lessness were  observed  early  in  a  number  of  the  cases. 
Pronounced  delirium  and  general  convulsions  were 
rare.  Muscular  twitchings  were  observed  in  about  one- 
fourth  of  the  cases.  The  mental  faculties  were  often 
but  little  impaired.  Death  was  usually  preceded  by 
drowsiness,  if  death  were  deferred  more  than  a  week. 
Motor  paralysis  was  not  noted  in  one  of  the  forty-one 
cases.  In  four  cases  there  was  a  urinous  odor  in  the 
breath.  Contraction  of  the  pupils  was  a  common  and 
characteristic  symptom.  The  temperature  was  elevat- 
ed in  only  one  of  these  cases.  In  the  last  days  of  life 
the  temperature  was  apt  to  be  subnormal.  On  com- 
paring the  symptoms  of  human  obstructive  and  experi- 
mental obstructive  ura-mia,  it  would  be  found  that 
vomiting  was  an  early  synipotm  :  that  marked  muscular 
prostration  was  usually  present  in  both:  that  delirium 
and  paralysis  were  absent  in   both:    and  that  in  the 


282 


MEDICAL    RECORD. 


[August  2  1,  1897 


terminal  stage  fibrillary  twitchings  were  common  in 
both  and  general  convulsions  were  exceptional.  The 
most  important  clinical  resumblance  was  that  the  tem- 
perature was  normal  or  slightly  subnormal.  A  patient 
with  both  ureters  blocked  might  live  two  weeks,  yet  a 
dog  with  both  ureters  tied  did  not  live  more  than  one 
week.  This  difference  could  hardly  be  ascribed  to 
-the  shock  of  the  operation.  The  pupils  were  much 
more  apt  to  be  contracted  in  man  than  in  dogs.  When 
the  urea  in  the  blood  of  a  dog  accumulated  beyond  a 
certain  point  (five  per  cent.),  it  was  excreted  by  the  in- 
testine. It  would  seem  probable  that  the  pathological 
conditions  in  nephrectomized  dogs  were  essentially 
those  which  were  responsible  for  the  symptoms  of  ob- 
structive urajmia  in  human  beings.  Unfortunately  we 
had  no  definite  knowledge  of  the  condition  of  the 
bio  o  in  cases  of  obstructive  urasmia  in  the  human 
subject.  It  should  be  remembered  that  ursemia  was  not 
a  specific  intoxication,  but  is  due  to  the  accumulation 
of  several  classes  of  toxic  substances  in  the  blood 
when  the  kidneys  were  unable  to  do  their  work 
properly. 

Dr.  James  Ewing  asked  if  in  the  liver  of  the  dog 
any  condition  resembling  that  found  in  cases  of 
eclampsia  had  been  observed — in  other  words,  was 
there  any  indication  of  a  hemorrhagic  hepatitis? 

Dr.  Herter  replied  that  he  had  observed  this  con- 
dition of  the  liver  in  some  cases  of  puerperal  eclamp- 
sia and  a  somewhat  similar  condition  in  some  of  these 
dogs,  but  he  did  not  feel  sure  that  the  two  conditions 
were  identical. 

Dr.  Ira  y.\y  Gieson  expressed  his  high  apprecia- 
tion of  work  of  the  class  represented  by  this  paper. 
He  said  that  he  had  induced  ursmia  in  some  animals 
by  injecting  the  serum  from  urasmic  patients,  but  his 
observations  had  been  too  few  to  be  of  much  value  at 
the  present  time.  He  predicted  that  bleeding  would 
come  into  favor  again  as  a  therapeuic  measure,  simply 
because  of  its  removing  to.xic  substances  from  the 
blood.  The  examination  of  the  cells  of  the  cerebel- 
lum in  three  ura;mic  cases  that  he  had  studied 
showed,  in  slight  degree,  the  mark  of  toxic  degenera- 
tion— a  resolution  of  the  cytoplasmic  elements  of  the 
cell.  Four  rabbits  were  injected  with  the  serum  of 
urremic  cases,  in  small  amounts  and  cumulatively.  He 
preferred  to  introduce  a  time  element  rather  than  to 
give  the  serum  continuously  up  to  a  fatal  result ;  he  pre- 
ferred to  have  from  six  to  forty-eight  hours  elapse  be- 
fore death,  as  this  offered  a  better  standard  of  com- 
parison. The  animals  showed  an  cedemaof  the  upper 
extremities  and  died  with  oedema  of  the  lungs.  The 
pleural  cavities  contained  over  an  ounce  of  transuded 
material — a  condition  that  he  had  never  seen  in  any 
other  experiments  on  rabbits.  The  temperature  dropped 
from  103'  to  99^  F.,  and  remained  so  for  some  time  after 
the  injection.  .\n  increase  of  temperature  in  a  rabbit 
was  very  easily  produced,  but  a  decrease  in  the  tem- 
perature was  a  matter  of  much  greater  significance. 

Dr.  Herter,  in  closing,  said  that  he  was  inclined 
to  agree  with  the  last  speaker  regarding  the  time  ele- 
ment in  these  experiments.  It  probably  enabled  one 
to  delect  with  accuracy  smaller  differences  of  toxicitv, 
but  by  the  method  that  he  had  employed  the  differ- 
ences had  been  sufficiently  striking  to  lead  him  to  con- 
tinue it  in  order  that  he  might  make  fair  comparisons 
with  the  earlier  case.  He  was  veiy  strongly  disposed 
to  accept  the  statement  that  bleeding  would  become 
in  the  future  a  much  more  frequent  therapeutic  meas- 
ure, yet  it  should  be  remembered  that  these  conditions 
were  often  very  complex^  The  most  favorable  condi- 
tions for  bleeding  were:  a  good  heart  action  and  a 
high-tension  pulse,  moderate  anjemia  only,  and  intense 
dyspn<ea.  The  relief  to  the  dyspnica  was  most  strik- 
ing, even  when  the  administration  of  arterial  dilators 
gave  little  or  only  very  temporary  relief. 


Aortic  Valve  with  Only  Two  Segments ;  Adult 
Heart ;  Congenital  Origin. — Dr.  F.  P.  Shelby,  Jr., 
presented  a  specimen  that  had  been  removed  from  a 
man,  forty  years  of  age,  admitted  to  Bellevue  Hospital 
on  December  12,  1896.  He  gave  a  history  of  having 
suffered  since  infancy  from  shortness  of  breath  and 
nervousness.  He  did  not  remember  having  had  rheu- 
matism or  chorea,  or  any  of  the  infectious  diseases  of 
childhood.  The  only  serious  illness  that  he  had  ever 
had  was  an  attack  of  pneumonia,  which  had  occurred 
in  his  twenty-fifth  year.  He  had  been  a  steady  drinker 
of  whiskey  and  had  used  tobacco  to  e.xcess.  He  had 
never  had  any  venereal  disease.  Two  weeks  before 
coming  to  the  hospital  he  had  caught  cold  and  had 
become  feverish,  had  felt  a  soreness  in  the  chest,  and 
had  begun  to  cough.  After  a  few  days  he  had  noticed 
small  dark  clots  of  blood  in  his  sputum.  Then  he 
had  become  very  short  of  breath  and  his  feet  had  be- 
gun to  swell.  On  admission  he  was  slightly  cyanosed, 
and  was  suffering  greatly  from  dyspnoea.  The  respi- 
rations were  rapid  and  shallow.  On  account  of  the 
loud  rapid  breathing  phvsical  examination  was  unsat- 
isfactory, but  an  obstructive  murmur  at  the  mitral  valve 
was  discovered,  and  moist  rales  were  heard  over  both 
lungs.  On  the  eighth  day  after  admission,  he  became 
delirious,  but  remained  in  this  state  only  a  few  hours. 
At  this  time  there  was  cyanosis  more  marked.  The 
respirations  were  regular,  but  rapid  and  shallow.  The 
apical  impulse  was  in  the  si.xth  interspace  in  the  nip- 
ple line,  and  was  irregular  in  force  and  rhythm.  A 
well-marked  purring  thrill  was  felt.  The  area  of  car- 
diac dulness  was  continuous  with  dulness  over  the 
lower  lobe  of  the  left  lung.  There  was  a  presystolic 
mumiur,  with  maximum  intensity  at  the  apex.  The 
sounds  at  the  other  valves  were  normal.  The  respira- 
tory murmur  was  absent  over  the  lower  part  of  the  left 
lung,  and  there  was  distinctly  tubular  breathing.  Pleu- 
ritic friction  sounds  were  heard  over  the  right  lung,  and 
here  and  there  were  a  few  fine  moist  rales.  The  pa- 
tient died  in  a  few  hours  from  the  time  of  this  examin- 
ation. 

The  autopsy  was  made  forty-eight  hours  after  death. 
The  body  was  well  developed  and  of  medium  size, 
but  poorly  nourished.  The  brain  was  normal.  The 
left  pleural  cavity  was  obliterated  by  firm  old  adhe- 
sions There  was  a  slight  excess  of  fluid  in  the  right 
pleural  cavity,  but  there  were  no  adhesions.  The  peri- 
cardium was  tense,  and  was  slightly  displaced  down- 
ward and  to  the  left  by  the  adherent  lung.  There  was  a 
normal  amount  of  serous  fluid  in  tlie  pericardium. 
There  was  a  thrombus  in  the  left  pulmonarj-  arterj-,  just 
below  the  point  at  which  the  first  large  branch  is  given 
off.  .\bout  half  of  the  lower  lobe  of  this  lung  was 
consolidated,  and  on  section  presented  the  appearance 
of  an  infarction.  There  were  congestion  and  rtdema 
in  the  upper  lobe.  The  right  lung  showed  two  small 
circumscribed  areas  of  fibrinous  pleurisy  which  cor- 
responded to  two  small  infarctions.  In  the  other  parts 
of  this  lung  there  were  marked  congestion  and  oedema. 
The  liver  weighed  three  pounds  six  ounces,  was  firm, 
dark  red  in  color,  and  on  section  showed  the  nutmeg 
appearance  of  passive  hpyera^niia.  The  spleen  weighed 
six  ounces,  was  soft,  pale  blue  in  color,  and  in  its 
anterior  border  presented  a  deep,  congenital  fissure  in 
which  was  att.iched  a  part  of  the  omentum.  The  kid- 
neys weighed  seven  ounces  each ;  the  capsule  was  not 
adherent,  and  left  a  smooth  surface  on  removal.  The 
markings  were  distinct,  the  cortex  was  slightly  swollen, 
and  the  pyramids  were  congested.  The  stomach  and 
intestines  were  congested.  All  the  cavities  of  the  heart 
were  distended  with  dark,  partially  clotted  blood,  but 
no  firm  clots  were  found.  There  were  great  dilatation 
of  the  left  auricle  and  slight  dilatation  of  all  the  other 
cavities.  The  walls  were  pale  and  rather  soft.  The 
tricuspid  and  pulmonarj'  valves  were  normal.      The 


August   2  1,    1897] 


MEDICAL    RECORD. 


mitral  valve  would  admit  only  the  end  of  one  finger; 
its  cusps  were  greatly  thickened  and  there  were  ad- 
hesions in  the  angles  between  the  cusps.  In  one 
angle  there  was  a  calcareous  deposit.  The  aortic 
valve  had  only  two  segments,  an  anterior  and  a  pos- 
terior, both  of  which  were  verj-  thick.  The  segments 
were  of  nearly  equal  size,  the  anterior  being  slightly 
longer.  About  the  middle  of  the  base  of  the  anterior 
segment  was  a  small  constriction,  which  caused  a  slight 
puckering,  but  which  did  not  involve  the  free  border. 
At  a  point  in  the  aorta  which  corresponded  to  the  cen- 
tre of  this  segment  there  was  a  distinct  ridge,  which 
seemed  to  mark  the  place  where  a  third  segment  should 
have  been  attached.  There  was  a  calcareous  plaque 
near  the  left  end  of  the  posterior  segment,  which  did 
not  e,xtend  to  the  free  border  or  the  aortic  attachment. 
The  sinuses  of  Valsalva  were  pouched  out.  Both  cor- 
onary arteries  were  given  off  from  the  anterior  sinus. 
There  were  a  few  atheromatous  patches  in  the  aorta  at 
the  upper  margin  of  the  sinuses.  The  valve  was  quite 
competent.  When  freed  from  blood,  the  heart  weighed 
fourteen  ounces. 

The  histor)-  and  the  appearance  of  the  specimen, 
Dr.  Shelby  said,  seemed  to  warrant  tlie  conclusion 
that  this  was  a  congenital  affection,  probably  due  to 
disease  during  intra-uterine  life;  and  that  the  absence 
of  one  of  the  segments  was  caused  by  the  coalescence 
of  two  segments  at  the  time  of  their  formation.  The 
specimen  illustrated  the  fact  that  a  valve  of  this  type 
might  be  entirely  competent  andyet  have  only  two  seg- 
ments. It  seemed  clear  that  the  lesion  at  the  mitral 
orifice  caused  all  the  symptoms.  The  nearly  equal 
size  of  the  segments  showed  the  wonderful  adaptabil- 
it}-  of  these  segments  to  each  other.  After  two  small 
segments  had  united  to  form  this  large  anterior  seg- 
ment, the  posterior  segment  appeared  to  have  under- 
gone extra  development  to  meet  the  requirements  of 
its  fellow.  The  unusual  thickness  of  both  aortic  and 
mitral  valves,  and  the  calcareous  deposits  in  them, 
would  indicate  that  there  had  been  during  extra-uterine 
life  a  chronic  endocarditis,  but  he  thought  there  could 
be  no  doubt  that  the  primary  lesion  had  started  in 
iitcro. 

Adeno-Carcinoma  of  the  Kidney ;  Total  Throm- 
bosis of  the  Vena  Cava. — Dr.  James  Ewing  present- 
ed a  kidney  which  had  been  removed  from  a  German, 
forty-eight  years  of  age.  The  patient  gave  a  phthisical 
family  history,  and  a  personal  historj'  of  excessive  in- 
dulgence in  alcohol  and  of  syphilitic  infection  in  his 
youth.  Ten  months  before  his  death  he  had  noticed 
a  swelling  of  the  legs  and  feet,  associated  with  head- 
ache and  vomiting.  Urination  was  then  normal.  The 
symptoms  disappeared  after  a  short  time  but  returned 
four  months  later,  and  then  the  urine  was  at  times 
scanty  and  bloody,  and  he  had  severe  pain  in  the  kid- 
ney and  on  urinating.  After  three  weeks  these  sub- 
sided. Six  weeks  before  his  admission  to  the  hospital 
they  reappeared,  and  in  addition  the  abdomen  begaji  to 
swell.  The  stools  were  light  colored ;  tlie  superficial 
abdominal  veins  were  considerably  distended.  There 
was  no  abdominal  pain;  very  slight  ascites.  The 
urine  was  alkaline,  had  a  specific  gravity  of  1.024,  3-nd 
contained  five  per  cent,  of  albumin  and  a  few  blood 
cells,  but  no  sugar.  Physical  examination  showed  a 
slight  quantity  of  fluid  in  the  chest,  with  oedema  of  the 
lungs;  the  heart  was  normal;  the  spleen  was  not  pal- 
pable. While  he  was  in  hospital  there  were  no  urinary 
symptoms,  but  he  developed  symptoms  of  obstruction 
to  the  portal  circulation  and  to  the  venous  return  from 
the  lower  limbs.  The  distention  of  the  abdominal 
wall  was  the  chief  feature  clinically.  It  was  thought 
that  there  was  probably  a  thrombosis  of  the  portal  or 
mesenteric  vein.  He  was  tapped,  but  this  was  followed 
by  peritonitis  and  death  in  forty-eight  hours.  At  the 
autopsy,  the  chamber  of  the  right  auricle  showed  at  the 


opening  of  the  inferior  vena  cava  a  round  whitish 
mass,  looking  like  a  blood  clot.  There  was  no  endo- 
carditis. There  was  also  a  partially  necrotic  mass  in 
the  region  of  the  vena  cava,  behind  the  liver.  The 
vena  cava  was  distended  to  the  diameter  of  nearly 
three  inches  at  this  point,  and  was  entirely  occluded 
by  a  large  mass  of  tumor  tissue,  which  proved  to  have 
been  derived  from  the  original  tumor  in  the  kidney. 
The  right  kidney  showed  the  appearances  of  carcino- 
matous or  adenomatous  growth  arising  in  the  cortex, 
projecting  into  the  pelvis  and  infiltrating  the  tissue 
around  the  renal,  and  passing  up  the  renal  veins  to  the 
vena  cava,  where  it  had  grow  n  rapidly.  A  completely 
organized  thrombus  was  found  in  the  vena  cava  below 
the  kidney,  reaching  into  the  iliac  veins  and  extend- 
ing below  Poupart's  ligament.  Another  interesting 
feature  was  the  apparent  reconstruction  of  the  circula- 
tion through  the  intestines,  spleen,  and  left  kidney,  as 
these  organs  showed  very  little  venous  congestion. 
The  hepatic  vein  and  its  smaller  branches  were  oc- 
cluded by  freshly  clotted  blood.  The  liver,  of  course, 
was  extremely  congested,  but  the  other  abdominal  or- 
gans were  only  very  moderately  so.  Another  point  of 
interest  was  the  fact  that  the  patient  had  survived  a 
total  thrombosis  of  the  vena  cava,  this  thrombosis 
having  apparently  existed  for  five  weeks. 

Haemato-Myelopore.— Dk.  \k\  V.\x  Giesox  pre- 
sented a  specimen  from  one  of  the  cases  of  haemato- 
myelopore  described  by  him  at  the  last  meeting,  and 
demonstrated  the  columnar  lesion  found  in  the  spinal 
cord. 

The  societv  then  went  into  executive  session. 


Suppurating  Wounds. — 

R  Iodoform, 
Salol, 

Bismuth  subnitrate, 
Charcoal, 
Cinchona, 
Benzoin aa  p.  re . 

— ^CRViKfCTZ,  Journal  de  Aiakciiie  de  Paris,  May  2d. 

Radical  Cure  of  Congenital  Hydrocele. — M.  Men- 
ciere  (Arch.  Clin.  d<-  Bordeaux^  Xo.  6,  p.  283,  1897) 
publishes  his  observations  on  two  patients  affected 
with  congenital  hydrocele,  upon  whom  M.  Demons 
employed  an  operative  procedure  which  has  given 
satisfaction.  The  operation  consists  in  making  a  long 
incision  following  the  greater  axis  of  the  tumor;  that 
is  to  sa)-,  from  above  downward,  the  incision  reaching 
to  the  inguinal  ring.  When  he  comes  to  the  serous 
portion  he  incises  it  freely  according  to  the  method  of 
Volkmann,  then  he  destroys  the  peritoneo-vaginal  sac, 
cutting  it  transversely  with  the  aid  of  scissors.  The 
edges  of  the  serous  sac  thus  formed  are  brought  to- 
gether and  sutured  with  catgut,  in  such  a  way  that  the 
testicle  is  contained  in  a  reconstructed  vaginalis,  less 
extended  than  the  former.  From  below  this  new  vagi- 
nalis he  excises  the  serous  coat  to  a  certain  height,  so 
that  the  peritoneo-vaginal  canal  is  incontestably  de- 
stroyed. Then,  considering  the  superior  part  of  this 
canal  as  a  hernial  sac,  he  precedes  with  a  truly  radi- 
cal cure  of  hernia.  Thus  the  inguinal  ring  is  closed, 
the  portion  of  the  peritoneo-vaginal  canal  situated  im- 
mediately beneath  is  excised,  and  the  testicle  is  con- 
tained in  a  new  vaginal  cavity  having  no  communica- 
tion with  the  abdominal  cavity.  This  method  differs 
from  that  described  by  Faure,  in  which  the  operator  is 
content  to  open  the  vaginalis  and  trust  to  an  adhesive 
inflammation  to  obliterate  the  peritoneo-vaginal  canal. 
Here  the  surgeon  not  only  obliterates  the  canal,  but 
closes  the  inguinal  ring.     Instead  of  leaving  the  vagi- 


284 


MEDICAL    RECORD. 


[August  21,  1897 


nalis  to  mend  itself,  some  sutures  of  fine  catgut  recon- 
struct it  immediately.  The  operator  can  reconstruct 
the  vaginalis  and  afterward  close  the  inguinal  ring. 
In  cases  of  congenital  hydrocele,  it  is  preferable  first 
to  close  the  inguinal  ring  and  then  proceed  with  the 
repair  of  the  vaginal  cavity. 

Treatment  of  Injuries  of  the  Liver — In  penetrat- 
ing wounds  the  existing  wound  can  be  enlarged  and 
converted  as  far  as  possible  into  the  incisions  about  to 
be  described.  If  the  site  of  injury  is  in  the  left  lobe, 
or  is  undetermined,  a  median  incision  should  be 
made;  in  wounds  of  the  right  lobe  a  curved  incision 
along  the  lower  border  of  the  costal  cartilages  and  to 
the  right  of  the  rectus  muscle  is  to  be  preferred.  In 
some  cases  these  may  be  combined,  thus  forming  an 
angular  incision.  Since  by  far  the  greater  number  of 
wounds  of  the  liver  are  located  on  the  ventral  or  later- 
al aspects  of  the  viscus,  these  two  plans  of  attack  will 
nearly  always  suffice.  In  wounds  situated  posteriorly, 
the  lumbar  incision  is  hardly  to  be  recommended  on 
account  of  the  thickness  of  the  muscular  walls,  and 
the  fact  should  be  borne  in  mind  that,  as  reported  by 
Lannelongue,  the  thoracic  wall  can  be  resected  along 
the  anterior  portions  of  the  eighth,  ninth,  tenth,  and 
eleventh  costal  cartilages,  for  the  pleura  does  not  ex- 
tend down  to  this  part  of  the  che^t  wall.  The  method 
of  Lannelongue  consists  in  an  incision  parallel  with 
the  thoracic  border  and  two  centimetres  above  the 
same,  beginning  three  centimetres  from  the  border  of 
the  sternum  and  ending  at  the  junction  of  the  tenth  rib 
with  the  costal  cartilage.  The  retraction  of  the  divided 
muscles  e.xposes  the  costal  cartilages  to  be  resected; 
they  are  carefully  freed  from  their  attachments  and 
cut  through  with  cartilage  scissors.  Then,  if  the 
ends  of  the  ribs  are  retracted  and  pressed  apart,  nearly 
the  entire  e.xtent  of  the  convexity  of  the  liver  can  be 
made  accessible. — Schlatter. 

Capital  Operations  without  Anaesthesia. —  i.  Pa- 
tients with  limbs  so  crushed  as  to  require  amputation, 
who  are  in  good  general  condition,  should  be  operated 
on  at  once.  2.  Those  who  present  evidences  of  severe 
shock  and  great  loss  of  blood,  should  be  treated  by 
external  heat  and  stimulants,  including  the  hypoder- 
matic use  of  whiskey,  digitalin,  stiychnine,  and  nitro- 
glycerin, and  the  rectal  injection  of  whiskey,  strong 
coffee,  and  hot  water.  The  crushed  limb  should  be 
disinfected  as  completely  as  possible,  and  6  to  1,000 
saline  solution  of  not  less  than  two  quarts  for  an  adult 
be  allowed  to  flow  into  a  vein,  this  infusion  to  be  re- 
peated, if  necessary,  at  intervals  of  a  few  hours,  ac- 
cording to  the  effect  produced.  3.  If  by  these  efforts 
complete  reaction  should  be  established,  anesthesia 
and  amputation  should  be  proceeded  with  as  in  ordi- 
nary cases.  4.  If,  however,  a  moderate  or  doubtful  re- 
action only  should  occur,  the  propriety  of  a  rapid 
amputation  without  anaesthesia  should  be  seriouslv 
considered,  if  the  consent  of  the  patient  be  gained.  5. 
The  comjilete  disinfection  of  crushed,  lacerated,  dirty, 
and   infected   limbs  usually  cannot  be  accomplished. 

6.  The  sooner  such  limbs  are  removed,  the  better, 
provided  the  patient's  life  be  not  lost  in  the  operation. 

7.  If,  notwithstanding  the  vigorous  treatment  just 
mentioned,  an  amputation,  either  with  or  without  an- 
asstliesia,  be  fraught  with  great  risk,  it  is  far  better  to 
disinfect  as  thoroughly  as  possible,  drain  well,  pack 
all  open  spaces,  and  take  the  chance  of  infection,  which 
in  most  doubtful  cases  is  probably  less  than  the  risk 
of  death  from  shock  following  operation. — Buchanan. 

Treatment  of  Tuberculous  Cavities Equal  parts 

of  iodoform  and  calomel  form  a  harmless  and  powerful 
antiseptic  dressing  for  the  caxities  left  after  operating 
for  tuberculosis  of  the  bones,  joints,  tracheotomies,  etc. 
It  promotes  the  formation  of  a  thin  eschar,  thus  pre- 


venting the  sticking  of  the  dressings  to  the  tissues. 
After  ha.-mostasis  i.'j  secured,  the  powder  is  sprinkled 
over  the  walls  of  the  cavit}'  with  a  small  pointed 
spoon  and  rubbed  in  with  a  gauze  pad  held  in  the 
forceps.  As  much  as  four  and  one-half  grams  can 
thus  be  applied  without  inconvenience.  The  wound 
is  afterward  kept  open  with  a  tampon. — Sprengel,  Chi. 
/.  Cliir.,  February  6th. 

Remote  Effects  of  Bone  Trauma. — The  practical 
propositions  involved  in  this  paper  are  based  on  in- 
flammation or  irritation  in  bone  following  injury  and 
the  sequel  resulting  therefrom.  i.  Resolution,  in- 
cluding a  complete  restoration  of  the  bone  to  its  nor- 
mal condition,  occurs  in  the  vast  majority  of  cases.  2. 
Resulting  in  rarefying  ostitis.  Condensing  ostitis,  or 
a  combined  rarefying  and  condensing  ostitis,  which 
may  remain  as  a  more  or  less  permanent  condition  :  if 
slight  in  degree,  giving  rise  to  no  well-marked  subjec- 
tive or  objective  signs  after  the  process  becomes  ar- 
rested. 3.  If  the  process  continues  for  a  period  be- 
yond a  few  months,  well-marked  and  unmistakable 
changes  in  the  physical  condition  and  appearance  of 
the  bone  will  become  manifest.'  4.  A  persistent  acute 
or  chronic  osteomyelitis  will  also  give  rise  to  unmis- 
takable physical  changes  in  the  bone.  5.  A  persistent 
chronic  osteo-periostitis  will  give  rise  to  thickening  of 
both  periosteum  and  bone  of  a  character  that  will  be 
readily  recognized  if  the  bone  is  so  situated  as  to  ad- 
mit of  easy  surface  examination.  6.  If  the  products 
of  inflammation  in  cases  of  rarefying  ostitis  or  in  os- 
teomyelitis become  infected  with  pus-forming  mi- 
crobes, the  suppurative  process  will  become  plainly 
evident,  except  in  cases  in  which  the  process  is  verj- 
limited,  giving  rise  to  a  small  abscess  in  the  bone 
which  may  be  indicated  only  by  subjective  symptoms. 
7.  The  injury  and  irritation  following  may  establish  a 
locus  minoris  rcsisfoifite,  which  may  become  the  seat  of 
tuberculous  infection  with  certain  definite  results.  The 
length  of  time  after  a  trauma  during  which  this  influ- 
ence may  exist  cannot  be  definitely  determined,  but  it 
may  be  assumed  in  the  light  of  critical  practical  expe- 
rience and  pathological  research  that  the  special  predis- 
position will  cease  to  exist  as  soon  as  the  effused 
blood  is  absorbed,  and  the  protoplasmic  elements — 
the  products  of  irritation  or  inflammation — have  been 
resolved  into  new  bone  or  have  undergone  degenera- 
tion and  absorption,  /.(•.,  as  soon  as  the  normal  nutri- 
tion balance  is  restored.  I  do  not  believe  there  is  any 
scientific  evidence  or  any  practical  facts  that  will  bear 
criticism,  which  will  support  the  assumption  that  the 
/ociis  miiioris  rcsistcnfiip  may  continue  for  months  or 
years  after  all  signs  of  the  injur}-  and  its  immediate 
results  have  disappeared.  S.  There  is  no  evidence  to 
show  that  a  carcinoma  or  sarcoma  may  develop  as  the 
result  of  an  injury  after  the  immature  bone  elements 
have  become  transformed  into  tissue  of  a  normal  re- 
sisting physiological  type. —  Ur.  I).  S.  pAiRCHirn, 
Joiirihjl  of  the  American  Mciiical  Association,  July  loth. 

Irreducible  Hernia. — From  the  facts  and  argu- 
ments adduced  tlie  following  conclusions  were  drawn  : 
1.  That  irreducible  iiernia  is  a  condition  of  serious 
danger,  the  gravity  of  which  increases  with  its  dura- 
tion or  neglect.  2.  That  tlie  application  of  a  truss 
upon  an  irreducible  hernia  is  not  only  useless,  but 
harmful.  3.  That  irreducible  hernia;  which  consist 
wholly  or  in  part  of  bowel  are  very  apt  to  become 
strangulated.  4.  That  hernia?  consisting  wlioliy  of 
bowel,  upon  which  no  truss  lias  been  worn,  may  (even 
when  of  large  size  and  of  considerable  duration)  gen- 
erally be  returned  by  appropriate  treatment.  5.  That 
of  the  cases  of  hernia  in  which  proper  treatment  fails 
to  obtain  reckiction,  the  great  majority  are  irreducible 
because  of  adhesions  of,  or  changes  in,  tlie  protruded 


August  31,  1897] 


MEDICAL    RECORD. 


-'05 


viscera— conditions  which  are  remediable  only  by  op- 
eration. 6.  That  the  most  common  cause  of  irreduci- 
bility  is  the  presence  in  the  sac  of  adherent  omentum. 
7.  That  the  presence  of  irreducible  omentum  in  the 
sac  of  a  hernia  is  a  source  of  constant  danger,  which 
can,  nevertheless,  be  remedied  by  an  operation  of  ex- 
tremely small  risk.  8.  That  hernise  containing  irre- 
ducible bowel  are  more  dangerous  than  those  contain- 
ing only  omentum,  and  that  as  the  danger  of  operation 
increases  with  the  magnitude  of  the  hernia  and  with 
the  occurrence  of  adhesions,  these  hernice  should 
be  operated  upon  as  soon  as  they  are  proved  by  the 
failure  of  proper  treatment  to  be  irreducible. —  Dr. 
Warrington  Howard,  meeting  of  the  Royal  Medical 
and  Chirurgical  Society,  May  26th. 

Naevi.  —  Mi.xed  navi  and  venous  nasvi,  unless  they 
are  adapted  for  e.xcision,  are  best  treated  by  electro- 
lysis; and  this  electrolysis  should  be  done  veiy  pa- 
tiently, a  little  at  a  time,  with  a  long  interval  between 
each  use  of  the  needles,  to  get  the  full  effect  of  the 
shrinking  of  the  growth;  it  is  impossible  to  hurry  the 
process,  and  in  the  end  one  gets  the  best  results  by 
working  slowly.  Capillary  naevi,  if  they  ulcerate,  are 
generally  to  be  left  to  themselves;  this  natural  cure 
of  them  will  probably  give  as  good  a  scar  as  we  should 
get  by  the  use  of  caustics. — Dr.  Paget,  The  Clinical 
Journal,  April  28th. 


OUR    LONDON"    LETTER. 

(  From  our  Special   Correspondent.) 

parliament:  university  bill,  army    medical    ser- 
vice,   RABIES,    etc. — college     OF     PHYSICIANS     AND 

HOSPITAL       ABUSE THE         REFORM         ASSOCIATION 

BRITISH    .MEDICAL  ASSOCI.\TION EXPULSION  OF  MEM- 
BERS  SUNDAY     FUND MORTUARIES — THE     GLASGOW 

CHAIR    OF    M.4TERIA    MEDICA. 

Lo.NDON,  August  C,  li'97. 

Both  houses  of  Parliament  met  this  morning  to  close 
the  session,  and  members  are  now  released  for  their 
holidays.  There  has  not  been  much  done  during  the 
week.  The  London  Universities  bill  has  been  slaugh- 
tered with  other  innocents,  but  the  government  pro- 
poses to  introduce  it  ne.xt  session.  If  it  means  to 
pass  it  they  must  bring  it  forward  earlier  and  submit 
it  to  further  discussion  than  is  possible  at  a  late 
period.  The  army  medical  service  has  given  rise  to 
several  questions  in  the  Commons.  •  It  was  admitted 
that  thirty-six  vacancies  were  declared  and  only 
twenty-eight  candidates  applied,  two  of  whom  were 
medically  unfit,  three  did  not  appear,  and  one  was 
otherwise  disqualified.  Further  questions  elicited  that 
for  the  Indian  medical  service  there  were  eighteen 
vacancies  for  which  thirty-eight  candidates  applied, 
but  five  of  these  were  physically  unfit.  The  contrast 
be  ween  these  two  sets  of  figures  should  surely  open 
the  eyes  of  the  government  to  its  folly  in  supporting 
the  prejudices  of  the  "  military  advisers"  in  wrecking 
the  service;  if  not  the  country  will  soon  be  demand- 
ing a  change  in  unmistakable  terms.  The  difficulty  of 
obtaining  leave  to  which  medical  officers  are  entitled 
by  the  regulations  was  also  brought  forward  and  ex- 
cuses were  made  on  account  of  the  home  establish- 
ment being  under  strength — but  whose  fault  is  it  that 
the  service  is  undermanned?  Rabies,  muzzling  dogs, 
glanders,  and  the  late  water  famine  in  East  London 
were  also  subjects  of  questions. 

The  Royal  College  of  Physicians,  as  1  have  already 


informed  you,  has  expressed  its  inability  to  undertake 
a  thorough  examination  of  the  question  of  hospital 
abuse.  But  the  Reform  Association  is  not  discouraged. 
Rather  is  it  determined  to  continue  to  agitate  the 
question.  At  the  dinner  of  the  association  last  week 
Mr.  Timothy  Holmes  was  present.  He  worked  at 
this  question  when  it  was  agitated  in  1871,  but  I  can- 
not see  any  change  for  the  better  since  then ;  in  fact, 
the  evil  has  extended  and  is  a  blight  on  the  profes- 
sion. The  Hospital  Sunday  Fund  has  had  no  good 
influence  in  this  direction.  Rather  has  its  tendency 
been  in  the  contrary  direction  and  its  management 
must  be  reformed.  Its  rule  as  to  the  relation  of  main- 
tenance and' administration  is  calculated  to  stimulate 
reckless  expenditure,  and  its  officials  assume  an  infal- 
libilit)-  and  assert  their  views  in  terms  discourteous 
and  offensive.     A  change  is  urgently  called  for. 

The  Mercers'  Hospital  dispute  seems  to  be  extend- 
ing its  area.  The  governors  hold  that  they  removed 
Mr.  O'Grady  from  the  surgeoncy  by  their  resolution 
dismissing  the  whole  staff.  But  Mr.  O'Grady  denies 
their  authoritj-  and  is  prepared  to  appeal  to  the  courts. 
Meantime,  being  himself  a  governor,  he  could  not  be 
prevented  from  visiting  the  hospital  and  holding  him- 
self out  as  surgion  to  it.  The  next  move  was  a 
motion  "that  the  board  dispense  with  the  services  of 
Mr.  O'Grady  as  governor."  Whether  governors  can 
thus  remove  one  of  their  number  who  demands  reforms 
opens  a  still  wider  question. 

The  expulsion  of  the  two  members  of  the  British 
Medical  Association  for  accepting  posts  in  the  Ade- 
laide Hospital  is  causing  some  searchings  of  hearts. 
It  is  true  the  membership  confers  no  advantage  beyond 
receiving  the  journal  and  admission  to  the  meetings, 
and  the  members  expelled  may  therefore  afford  to 
laugh  at  the  solemnity  assumed  by  the  ruling  clique. 
There  is,  however,  another  aspect  of  the  matter.  If 
the  stigma  of  expulsion  is  to  be  placed  on  women  for 
taking  posts  in  the  colonies  vacated  by  others  in  de- 
fence of  the  honor  of  the  profession,  how  about  the 
men  in  London  who  have  eagerly  grasped  appoint- 
ments in  precisely  similar  circumstances?  Are  they 
too  numerous  to  attack?  Is  it  not  notorious  that  the 
Journal  has  basely  deserted  the  men  fighting  in  such 
a  case  and  even  supported  their  supplanters?  Per- 
haps after  the  criticism  on  the  editor's  conduct  at  the 
meeting  here  such  scandals  may  not  be  repeated. 
But  to  return  to  the  expulsion.  If  this  is  to  be  a  pre- 
cedent, it  would  be  interesting  to  learn  whether  any  of 
the  new  staff  of  Mercers'  Hospital  are  members  of  the 
Association,  and  further  whether  any  of  the  numerous 
candidates  for  those  appointments  are  also  members. 
And  further,  if  so,  are  they  to  be  arraigned  and  if  not 
why  not  ? 

We  have  it  now  on  the  authority  of  the  chairman  of 
the  county  council  that  arrangements  have  been  made 
which  will  obviate  the  necessity  of  holding  inquests 
in  public  houses,  good  mortuary  accommodation  hav- 
ing teen  provided  in  nearly  all  the  London  districts. 
Such  mortuaries  are  increasingly  used  for  the  recep- 
tion of  corpses  awaiting  interment  in  other  than  in- 
quest cases.  The  public  is  recognizing  the  advan- 
tage of  removing  corpses  from  crowded  houses  to 
properly  arranged  mortuaries  in  which  sentiment  is 
respected  and  sanitation  satisfied.  The  extension  of 
the  mortuar)-  system  is  therefore  a  fact  on  which  Lon- 
don and  its  authorities  are  to  be  congratulated. 

An  exhibition  was  held  last  week  of  medical  and 
hygienic  articles.  It  seems  to  have  been  designed  to 
take  the  place  of  the  museum  of  the  British  Medical 
Association,  and  the  exhibits  were  much  the  same  as 
those  annually  shown  at  the  meetings. 

Dr.  Stockman  succeeds  the  late  Dr.  Charteris  as 
professor  of  materia  medica  and  therapeutics  at  the 
University  ot  Glasgow. 


286 


MEDICAL    RECORD. 


[August  21,  1897 


OUR    VIENNA   LETTER. 


(Fr 


■  Special  Correspondent.; 


VACATION    COURSES   DURING   SEPTEMBER — KOCH  S     NEW 

TUBERCULIN REPORTS      AS       TO      ITS       THERAPEUTIC 

VALUE    NOT     ENCOURAGING— THE     AUSTRIAN     BOARD 

OF    HEALTH   AND    MEASURES    AGAINST   THE  PLAGUE 

MOSCOW  AND  ACCOM  MOD.-VTIONS  FOR  ME.MBERS  OF 
THE  CONGRESS — SO.ME  DISSATISFACTION  WITH  PRICES 
DE.MANDED    FOR    RESERVED    ROOMS. 

Vienna,  July  30,  1897. 

The  vacation  courses  open  here  on  Monday  .\ugust 
2d,  the  programme  for  them  having  been  out  for  some 
time.  The  giving  of  a  series  of  regular  courses  dur- 
ing the  vacations  was  tried  more  or  less  as  an  experi- 
ment last  year.  The  result  was  so  satisfactory  that 
now  these  courses  are  to  be  made  a  special  feature 
of  the  medical  work  here.  The  announcements  for 
September  especially  show  that  an  effort  is  to  be  made 
to  rival  in  Vienna  the  Berlin  vacation  courses,  which  for 
years  now  have  attracted  a  large  international  attend- 
ance. American  visitors  to  the  international  congress 
at  Moscow  will  have  an  opportunity  on  their  way  home 
to  see  the  methods  of  the  Vienna  school  and  get  an 
idea  of  medical  life  here  notwithstanding  that  it  is 
vacation  time. 

Professor  Koch's  new  serum  was  not  received  very 
enthusiastically  by  the  profession  here,  and  observa- 
tions made  with  it  do  not  seem  to  confirm  even  the 
limited  claims  that  its  inventor  now  makes  for  it. 
The  Vienna  school  has  always  been  much  more  inter- 
ested in  pathology  than  in  therapeutics,  and  new 
remedies  generally  are  received  very  coolly  and  tried 
in  a  conservative  scientific  way  that  usually  reduces 
considerably  the  enthusiastic  claims  of  the  dis- 
coverer. Even  when  Koch's  tuberculin  first  came  out 
and  the  whole  medical  world  became  so  completely 
wrapped  up  in  the  demonstration  of  the  effectiveness 
of  tlie  new  remedy,  Vienna  went  on  in  the  even  tenor 
of  its  way  and  calmly  awaited  developments.  That 
from  various  sources  there  should  come  unfavorable 
reports  as  to  the  action  of  the  tuberculin,  even  when 
supplied  directly  by  the  commercial  house  to  which 
Koch  has  intrusted  its  preparation,  is  not  surprising, 
for  most  observations  made  with  it  even  in  Germany 
have  not  been  distinctly  favorable;  while  from  other 
countries  the  reports  would  seem  to  be  distinctly  un- 
favorable. 

From  a  series  of  cases  reported  here  it  is  clear  that 
gradually  an  immunity  against  the  action  of  the  tuber- 
culin itself  is  acquired,  and  that  large  doses  of  it  may 
then  be  borne  without  any  consequent  febrile  reaction. 
This  does  not  include  protection  against  the  tubercle 
bacillus  itself,  however,  or  its  products.  Even  when 
the  patient  under  treatment  fails  to  react  to  the  tuber- 
culin, bacilli  may  be  found  in  his  sputum  and  the 
area  of  dulness  in  his  lungs  may  be  demonstrated  to 
be  increasing  in  size.  In  some  cases  during  the  treat- 
ment bacilli  have  disappeared  from  the  sputum,  ijut  in 
no  case  in  which  an  area  of  dulness  iti  the  lungs  could 
be  demonstrated  has  that  been  found  to  diminish  in  size. 
On  the  other  hand,  patients  who  had  been  gaining  in 
weight  before  they  began  the  treatment,  /.<■.,  with  only 
the  ordinary  constitutional  hygienic  and  dietetic 
measures,  have  been  known  to  lose  in  weight  after  the 
injections  were  commenced.  This  opinion  as  to  the 
lloubtful  value  of  the  new  tuberculin  seems  to  be 
shared  l^y  most  of  the  clinicians  here  who  have  tried 
the  new  remedy,  and  they  are  not  few  in  number.  That 
it  will  be  of  certain  usefulness  in  the  earlv  diagnosis 
of  doubtful  ca.ses  seems  to  be  generally  admitted,  but 
therapeutically  it  is  more  than  likely  to  share  the  fate 
of  its  predecessor  in  the  same  field  and  after  e.xploita- 
tion  for  a  time  be  allowed  to  drop  out  of  use. 


One  of  the  surprising  reports  about  it,  considering 
the  well-known  thoroughness  of  its  inventor  in  such 
matters,  is  that  the  preparation  is  not  always  sterile. 
A  number  of  slight  abscesses  and  interstitial  exuda- 
tions that  were  sore  for  some  days  having  followed  its 
use,  cultures  were  taken  from  a  number  of  samples 
and  pus  micro-organisms  were  sometimes  found  to  be 
present.  This  is  probably  due  to  the  fact  that  the 
preparation  is  put  up  in  wooden-stoppered  bottles,  for 
continental  use  at  least ;  that  these  become  soaked  with 
moisture  from  the  underlying  serum,  and  so  form  an 
excellent  culture  ground  for  micro-organisms.  It  is  a 
bit  of  mechanical  imperfection,  an  oversight  that  one 
would  scarcely  expect  under  the  circumstances,  how- 
ever, and  that  will  often  prove  annoying  in  its  conse- 
quences to  the  practitioner. 

Though  the  Austrian  plague  commission's  official 
report  declared  that  the  plague  was  not  under  ordinary- 
circumstances  very  contagious  and  that  the  infection 
was  not  liable  to  be  carried  in  fomites,  the  Austrian 
health  authorities  consider  it  advisable  to  take  cer- 
tain special  precautions  against  its  possible  introduc- 
tion. Professor  Weichselbaum  has  been  asked  in  his 
official  capacity  as  state  medical  counsellor  to  furnish 
the  government  physicians  with  the  data  and  the  ma- 
terial necessary  to  insure  the  prompt  bacteriological 
recognition  of  the  disease  should  suspicious  cases  oc- 
cur. He  has  been  asked  too  to  open  a  course  at  the 
Pathological  Institute  in  which  the  characteristics  of 
the  bacillus  will  be  minutely  described  and  specimens 
and  cultures  of  it  shown,  so  that  its  obsen-ation  may 
be  a  matter  of  practical  experience. 

Austria  has  at  best  but  a  limited  seacoast,  though 
that  of  course  is  in  dangerous  communication  with  the 
East  through  the  Mediterranean.  The  additional  pre- 
cautions seemingly  are  taken  not  so  much  because 
there  seems  from  a  scientific  standpoint  any  liability 
of  the  introduction  of  the  plague  as  because  public 
opinion  demands  some  practical  application  of  the 
governmental  investigation  of  the  disease.  Money  for 
purely  scientific  purposes  is  not  usually  voted  willing- 
ly and  some  return  must  be  shown  for  the  expense  in- 
curred. The  .\ustrian  commission's  report  as  to  the 
non-contagion  through  fomites  has  been  formally 
confirmed  by  the  German  commission  with  Koch  at 
its  head,  which  finds  that  the  bacillus  is  incapable  o'' 
growing  after  it  has  been  eight  days  outside  the  body. 
As  has  been  often  pointed  out  before,  the  only  real 
danger  that  may  exist  is  in  the  possibility  of  rats  on 
shipboard,  the  animals  being  very  liable  to  the  disease 
and  being  probably  the  great  infection  carriers  in  the 
epidemics  that  occur. 

The  tickets  for  members  of  the  congress  at  Moscow^ 
together  with  the  railroad  tickets  that  are  to  carr\-  them 
free  from  the  Russian  border  to  Moscow  and  back,  are 
at  la.st  reaching  their  destinations.  The  doctors  are 
to  travel  practically  as  government  officials  and  the 
privileges  accorded  are  ample.  Notifications  of  the 
reservation  of  rooms  for  those  who  wrote  to  the  secre- 
tary for  that  purpose  are  also  at  hand.  These  are  not 
so  satisfactory  as  the  railroad  tickets,  and  a  good  many 
in  Vienna  seem  to  be  of  the  opinion  that  there  will  be 
some  exploitation  of  visitors  by  hotel  people — that  in 
fact  there  will  be  a  repetition  of  .some  of  the  unpleas- 
antness experienced  at  Rome  during  the  last  Interna- 
tional Medical  Congress.  Moscow  is  of  course  much 
larger  than  Rome;  the  last  Russian  census  taken  last 
year  gives  it  about  goo,ooo  population,  and  one  might 
reasonably  conclude  that  7,000  visitors  (that  is  the 
number  of  free  railroad  tickets  issued")  would  easily 
find  accommodations  without  the  possibility  of  crowd- 
ing. Moscow's  lloating  population,  however,  is  verj" 
small:  in  the  matter  of  hotels  she  is  decidedly  provin- 
cial, and  so  her  capacity  for  the  reception  of  visitors 
is  probably  to  be  tested  to  its  utmost  limit.     It  is  to 


August   2  I,    1897] 


MEDICAL    RECORD. 


287 


be  hoped  that  some  of  the  presentiments  in  the  matter 
of  discomfort  and  expense  that  are  now  rather  freely 
expressed  may  not  be  realized.  The  committee  of  ar- 
rangements has  shown  so  far  its  thorough  ability  to 
cope  with  the  various  and  at  times  vexing  problems 
that  arose,  and  it  may  be  confidently  depended  on 
to  put  the  finishing  touches  to  its  work  in  arranging 
for  the  convenience  of  its  guests. 


Beiu  instruments. 

URIN.\TING-TUBE  FOR  USE  WITH    WOUNDS 
OF    THE    PERINEUM. 

By   J-    G.    CROSS,    .M.S.,    M.D., 

ROCHESTER,   MINN". 

The  instrument  herewith  presented  to  the  profession 
was  devised  for  use  with  female  patients  with  surgical 
or  traumatic  wounds  of  the  perineum  not  yet  healed, 
neccessitating  urination  while  in  the  recumbent  posi- 
tion. It  consists  simply  of  a  conducting  tube  of  an- 
nealed glass,  so  fashioned  that  its  upper  end  fits  the 


parts  about  the  meatus  urinarius  without  pressing  upon 
the  urethra,  and  by  a  suitable  curve  avoids  contact 
with  the  perineum,  but  carries  the  urine  into  the  recep- 
tacle below.  The  illustration  makes  further  descrip- 
tion unnecessary. 

The  advantages  of  this  tube  over  the  catheter  in  tht- 
class  of  cases  mentioned  are  readily  seen.  It  is  easil}' 
rendered  sterile,  being  entirely  of  smooth  glass,  an- 
nealed to  withstand  heat.  Its  use  gives  the  patient  no 
discomfort,  and  requires  no  especial  skill  in  the  atten- 
dant. The  urine  is  kept  entirely  away  from  the  wound, 
even  the  drop  that  usually  follows  the  withdrawal  of  a 
catheter  from  the  urethra.  With  simple  directions  as 
to  cleanliness,  it  can  be  safely  left  in  hands  to  which 
the  physician  would  hesitate  to  intrust  the  care  and 
use  of  a  catheter. 

The  urinating-tubes  are  made  b\'  Tiemann  &  Co., 
of  New  York. 


The  Future  of  Greek  and  Turk. — In  the  preface 
to  his  '■  Impressions  of  Turkey  during  Twelve  Years' 
Wanderings,"  recently  published  by  the  Putnams. 
Prof.  W.  M.  Ramsay  says  that  he  was  strongly  im- 
pressed with  one  great  contrast  between  the  average 
Turkish  and  Greek  villages.  In  Turkish  villages  the 
women,  so  far  as  he  could  judge  from  sight  and  re- 
port, are  feebler  and  poorer  in  both  physique  and 
mind  (owing  to  their  hard  lot  in  childhood);  whereas 
the  Greek  women  struck  him  as  being  better  and  mor- 
ally higher  than  the  men,  physically  good,  and  intel- 
lectually well  developed.  Therein  he  believes  lies  the 
future  of  the  two  races.  In  the  one  case  there  is  a 
rich  soil  from  which  future  generations  acquire  strengtli 
and  moral  vigor;  in  the  other  a  stunted  and  impover- 
ished motherhood  produces  a  poor  and  diminishing 
people.  '■  In  the  condition  of  the  Turkish  women  lies 
the  reason  for  the  steady  degeneration  of  the  Turkish 
people." 


S^edical  Stems. 

Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitarj-  Bureau,  Health  Department,  for  the 
week  ending  August  14,  1897  : 


Tuberculosis 155  105 

Typhoid  fever 52  9 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 

Chicken-pox 


The   Healing  of   Wounds  in  the  Negro  Races. — 

Dr.  Plehn  [Di-iitschc  mcd.  JJW/i.,  34,  1896)  says  that 
infected  wounds  are  rare  among  the  negro  races  in 
.\frica,  and  that  severe  wounds  heal  sooner  than  do 
like  wounds  in  Europeans.  He  is  of  the  opinion  that 
specific  pus  organisms  are  not  common  in  Kamerun  or 
that  the  tissues  of  the  negro  are  resistant. 

Gluttony  has  its  victims,  hardly  less  numerous  than 
other  vices.  To  overeat  is  to  overburden  the  digestive 
organs  to  such  an  extent  that  it  will  be  impossible  for 
them  to  perform  their  duties  properly,  deleterious 
products  are  created,  and  health  is  finally  destroyed. 
No  man  can  overeat  and  live  out  his  expectancy.  It 
is  as  important  to  inquire  into  the  habits  of  a  man 
proposed  for  insurance  in  this  respect  as  in  drinking. 
Men  have  been  known  to  kill  themselves  in  this  man- 
ner. A  prominent  judge  in  New  Jersey  used  to  say 
such  men  dig  their  graves  with  their  teeth — and  it  is 
so.  —  T/w  Medical  Examlnfr. 

Water  Purification —  Dr.  Thomas  B.  Carpenter 
concludes  an  article  on  this  subject  {Albany  Medical 
Annals,  April,  1897)  as  follows:  1.  Purification  of 
water  should  be  municipal,  not  domestic,  because  do- 
mestic filtration  cannot  be  relied  upon.  2.  Domestic 
purification  can  be  best  obtained  by  heating  to  80°  C. 
for  twenty  minutes.  3.  .All  evidence  available  at  the 
present  time  favors  the  superiority  of  "natural"  filtra- 
tion for  purification  on  a  large  scale.  4.  With  few  ex- 
ceptions, all  American  cities  furnish  their  inhabitants 
a  water  that  is  at  least  suspicious,  and  in  most  cases 
polluted.  5.  A  continued  typhoid  mortality  of  over 
twenty  per  one  hundred  thousand  means  a  polluted 
water  and  a  preventable  sacrifice  of  human  life. 

"  Charaka-Samhita."  — Part  sixteen  of  the  transla- 
tion of  this  curious  Hindu  medical  classic  closes  the 
section  on  the  pathogenesis  of  disease  and  on  timely 
and  untimely  death,  and  takes  up  that  on  diagnosis. 
The  three  especial  means  for  ascertaining  the  nature 
of  disease  are  the  following  of  the  instructions  of  the 
inspired,  obser\'ation,  and  inference.  The  matters 
about  which  the  inspired  lay  down  instructions,  the 
matters  which  are  apprehended  by  observation,  and 
tlie  matters  which  are  to  be  ascertained  by  inference, 
and  the  manner  in  which  they  are  to  be  known,  are 
here  fully  expounded  in  this  lesson.  The  closing 
section  treats  of  the  several  ducts  of  the  body,  their 
contents,  and  the  symptoms  pointing  to  disease  of 
them. 

Vital  Statistics  of  Philadelphia. — For  the  week 
ending  Jul}-  31st  there  were  reported  to  the  Philadel- 
phia board  of  health  396  deaths,  79  less  than  during 
the  preceding  week  and  137  less  than  during  the  cor- 
responding week  of  the  previous  year.     Of  the  whole 


MEDICAL    RECORD. 


[August  21,  1897 


number  175  occurred  in  children  under  tlie  age  of  live 
years.  The  principal  causes  of  death  were  as  follows : 
('holcra  infantum,  60;  pulmonary  tuberculosis,  36; 
marasmus,  19;  pneumonia,  17;  diphtheria,  16;  in- 
anition, 13;  carcinoma,  heart  disease,  intlammation 
of  the  brain,  each  12  ;  apoplexy,  convulsions,  each  12. 
There  were  reported  during  the  week  84  cases  of 
diphtheria,  63  of  typhoid  fever,  and  50  of  scarlet 
fever. 

The  Cause  of  the  Heart  Beat.— As  the  result  of 
an  experimental  investigation,  Porter  (Journal  of  Ex- 
ftcrimaital  Mcdkiiic,  July,  1S97)  arrives  at  the  conclu- 
sion that  the  cause  of  the  rhythmic  contraction  of  the 
ventricle  lies  within  the  ventricle  itself.  It  is  not 
dependent  upon  a  single  localized  co-ordination  cen- 
tre, the  co-ordinati\e  mechanism,  whatever  it  may  be, 
is  present  in  all  parts  of  the  ventricle.  The  ape.x  of 
the  mammalian  heart  possesses  spontaneous  rhythmic 
contractility.  Assuming  that  the  general  belief  in  the 
absence  of  nerve  cells  from  the  apical  part  of  the  ven- 
tricle is  correct,  this  investigation  indicates  that  ner\'e 
cells  are  not  essential  to  spontaneous,  long-continued 
co-ordinated  contractions  of  the  heart  muscle. 

A  Pen  Sketch  of  Pasteur. — In  a  recent  number  of 
Good  Words,  Mrs.  Percy  Frankland  quotes  the  follow- 
ing description  of  the  great  French  chemist  and  man 
of  science,  as  he  appeared  a  short  time  before  his 
death:  "Weary,  traversed  with  deep  lines,  his  face 
and  beard  both  white,  his  hair  still  thick  and  nearly 
always  covered  with  a  black  cap,  the  grand  forehead 
wrinkled,  seamed  with  the  scars  of  genius,  the  mouth 
slightly  drawn  by  paralysis,  but  full  of  kindness,  as 
expressive  in  pity  for  the  sufferings  of  others,  as  in- 
different to  personal  pain,  and  above  all  the  living 
thought  which  still  flashes  from  the  eyes  beneath  the 
deep  shadow  of  the  brow — this  is  Pasteur." 

The  Birthplace  of  the  American  Medical  Asso- 
ciation.—  The  Philadelphia  meeting  was  called  the 
semicentennial,  but  really  to  New  York  belongs  the 
honor  of  being  the  birthplace  of  the  American  Medical 
.\ssociation.  The  meeting  of  physicians  held  in  this 
city  in  May,  1846,  was  properly  the  first  meeting  of 
the  association,  although  it  was  then  without  name  or 
oilier  evidences  of  a  formal  organization.  Put  it  was 
borrv  tlien  and  here — and  not  one  year  later  in  Phila- 
delphia. A  baby  has  no  name  and  not  much  of  a 
constitution  the  day  he  is  born,  but  he's  a  baby  for  all 
that,  and  when  he  has  grown  to  manhood,  he  counts 
back  his  vears  to  the  day  he  came  into  the  world,  and 
not  to  the  time  he  received  a  name  or  first  encased  his 
nether  limbs  in  knickerbockers. — Pediatrics. 

What  Next? — The  latest  association  formed,  ac- 
cording to  Nature,  is  for  the  "  Harmonious  Develop- 
ment of  Faculties,"  an  object  which  certainly  is 
deserving  of  sympathy.  We  may  expect  soon  to  hear 
of  the  amalgamated  societies  for  the  promotion  of 
idiocy.  The  "  association"  business  is  being  very 
much  overdone  these  days,  apparently. — Medieal  Age. 

The  Value  of  Sterilized  Milk. — Dr.  Parton  draws 
the  following  conclusions  from  a  careful  study  of  this 
subject:  i.  Completely  .sterilized  milk,  if  administered 
without  any  fresh  food,  will  undoubtedly  sooner  or 
later  jjioduce  scurvy.  2.  Milk  tliat  is  raised  to  the 
boiling-point,  or,  better,  to  within  two  degrees  of  the 
boiling-point,  and  maintained  there  from  five  to  ten 
minutes,  is  "comparatively"'  sterilized,  and  will  never 
produce  scurvy,  and  is  almost  free  from  pathogenic 
organisms.  3.  Completely  sterilized  milk,  if  adminis- 
tered at  once  in  perfectly  clean  bottles,  spoons,  or 
cups,  can  be  relied  upon  as  being  free  from  anv  patho- 
genic micro-organisms.      4.    The  liealingof   milk  alters 


very  little,  if  at  all,  its  nourishing  qualities.  5.  All 
kinds  of  sterilized  milk,  if  free  from  added  chemicals, 
can  become  foul  as  quickly,  if  not  more  quickly, 
than  ordinary  fresh  milk.  6.  All  sterilized  milk  that 
is  put  into  hermetically  sealed  vessels,  and  which  cjin 
keep  fresh  in  them  for  many  days,  will  produce 
scurvy  unless  some  fresh  food  is  administerd  daily. 
7.  Milk  that  is  boiled  directly  over  a  fire  will  un- 
doubtedly cause  constipation.  If  the  milk  be  placed 
in  a  vessel  which  stands  in  another  vessel  contain- 
ing water,  and  the  water  be  brought  to  the  boiling- 
point,  its  antiscorbutic  properties  are  not  lost  and  it 
does  not  cause  constipation. — British  Medical  Journal. 

Health  Reports. — The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  supenising  surgeon- 
general  of  the  United  States  Marine  Hospital  service 
during  the  week  ended  August  14,  1897  : 

S.\i.M.L-Pux — United  St.\tes. 

Cases.     Deaths. 
Kirminijham, -Ala May  8th  to  Aug.  lath 9* 

S-MALL-Pox — Foreign. 

Cardenas,  Cuba July  24th  to  31SI 1 

Glasgow,  Scotland July  17th  to  24th" 3 

Hongkong.  China June  12th  to  19th 2 

Nagasaki.  Japan July  3d  to  10th 10  1 

Osaka  and  Hiogo,  Japan. . .  .June  27th  to  July  loth 3 

Ptrnambuco,  lirazil May  29th  to  June  26th 12 

Rio  dc  Janeiro,  Brazil July  3d  to  loth 3 

Warsaw,  Russia July  J7th  to  24th 5 

Calcutta,  India June  19th  to  26lh 3 

Harcelona,  Spain ^[ay  1st  to  31st 16 

Vokohama,   lapan June  24th  to  July  i 1  i 

Moscow,  Russia July  loth  to  17th i 

.M.ldras,  India July  3d  to  9th 3  i 

Odessa,  Russia Tulv  17th  to  24th I  t 

Madrid,  S|>ain July  26th i 

St.  Petersburg,  Russia July  17th  to  24th 9  2 


Osaka  and  Hioco,  Japan Tunc  27th  to  July  _ 

Calcutta,  India June  19th  to  July  3d 

liombav,  India [une  30th  to  July  6th 

Tokyo,'  Japan July  7th 

Fukuoka  Ken,  Japan Julv  7th 

•■       •  .July 


Ih. 


15th  . 
■  7th  to  15th  . 


:igawa  Ken,  Japan. 

Yellow  Feveh. 

Cardenas.  Cuba Inly  24th  to  31st 

Cienfuegos,  Cuba July  iSth  to  25th 

Rio  dc  Janeiro.  Brazil July3dto»oth 2 

Matanzas,  Cuba    July  21st  to  28th 

Cienfucgos,  Cuba July  28th  to  .August  ist 

Panama,  U .  S.  of  Colombia..  I  uly  27th  to  .August  3d J  J 

Santiago  de  Cuba July  24th  to  31st 

Pl..\GL-E 

nombay,  India lune  30th  to  July  6th 

Kanagawa  Ken,  Japan..    ..  July  7th  to  15th i 

Formosa,  Japan July  7*b  *o  15th 8 


While  the  Medical  Kecokd  is  fUascd  to  receive  all ne:v publi- 
cations u'liici  may  be  sent  to  it,  and  an  ackno-jjUdgment  -,iAll  he 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  n-ith 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  rn-iew  any  puiHca- 
tion  received  by  it  which  in  the  judgment  of  its  editor  it-ill  not  he 
of  interest  to  its  readers. 

Crime  and  Cki.mi.nai.s,  Ky  Dr.  J.  S.  ihristison.  121110. 
117  pages.  Illustrated.  The'W.  I".  Keener  Company.  Chi- 
cago.     Price,  $1.00. 

The  Pocket  TiiERArisT.  By  Dr.  T.  S.  l>owse.  iMiio. 
192  pages.     John  Wright  A:  Co.,  Hristol.      Price.  5/. 

Urinai.vsis.  By  Dr.  Heinrich  Stern,  l2mo.  fil  pages.  Il- 
lustrated.    IC.  K.  Pelton,  New  York. 

Retrospect  OF  Medicine.  Vol.  iij.  Hy  Dr.  J.  liraiih- 
waite  and  Dr.  K.  I".  Trevelyan.  i2mo,  416  pages.  Simpkin, 
Marshall,   Hamilton.  Kent  &  Co. .  London. 

PR.AfriCAl.  HlsTOLOcv.  Second  Kdition.  liy  Dr.  K.  .\. 
Schafer.  i2nio,  2gS  pages.  Illustrated.  I.ca  Hrothers  A:  Co., 
Phil.adelphia. 

.\  System  (ik  Practkai.  Medicine.  Uy  Dr.  .-K.  L.  I.oi  mis 
anil  Dr.  W.  G.  Thompson.  \o\.  2.  Svo,  .141  pages.  Illus- 
trated,    l.ea  Brothers  &  Co.,  Philadelphia. 

TWESTIEIII  CENTIRV  PkACrKE  OF  Medktne.  Vol.  XI. 
Diseases  of  the  Nervous  System.  Kdited  by  Dr.  Thos.  1..  Sled- 
man.     Svo.  (/>2  pages.      \Villi.-im  Wood  iV:  Co.,  New  York. 


Medical  Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  9. 
Whole  No.  1399. 


New  York,   August  28,    1897. 


$5.00  Per  Annum. 
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©riginal  Articles. 

CLASSIFICATION    AND    SURGICAL    TREAT- 
MENT   OF   ACUTE    PERITONITIS.' 

X.   SEXX,   .M.D.,    rn.l).,    1.I..D.. 


An  intelligent  and  systematic  discussion  of  the  treat- 
ment of  acute  peritonitis  must  necessarily  be  based 
on  a  rational  classification.  A  great  deal  that  lias 
been  said  and  written  on  this  subject  is  worthless, 
owing  to  a  lack  of  a  proper  classification.  The  classi- 
fication should  include  the  anatomy,  pathology,  and 
etiology  of  the  disease.  It  is  especially  important  in 
the  discussion  of  the  surgical  treatment  of  peritonitis, 
before  an  audience  composed  of  physicians  and  sur- 
geons, to  make  a  clear  distinction  between  the  differ- 
ent clinical  forms  with  a  view  of  pointing  out  the 
limitation  of  purely  medical  treatment  and  the  legiti- 
mate scope  of  surgical  intervention.  The  clinical 
classification  which  I  here  suggest  appears  to  coxer 
the  ground  fairly  well,  but  would  be  incomplete  with- 
out an  exemplification  from  other  standpoints,  and  for 
this  reason  I  have  prepared  the  following: 

Syllabus  of  Classification  of  Acute  Peritonitis — 
Ainitomical. — Ectoperitonitis,  endoperitonitis,  parie- 
tal peritonitis,  and  visceral  peritonitis,  viz.,  mesen- 
teritis,  epiploitis,  perigastritis,  peri-enteritis,  peri 
typhlitis,  peri-appendicitis,  pericolitis,  perihepatitis, 
perisplenitis,  pericystitis  (urinary  and  gall  bladder >, 
perimetritis,  perisalpingitis,  peri-oophoritis,  pelvic 
[>eritonitis,  diaphragmatic  peritonitis. 

Etioloi^itiil. — Traumatic  peritonitis,  idiopathic  peri- 
tonitis, perforative  peritonitis,  metastatic  peritonitis, 
puerperal  peritonitis,  peritonitis  infantum,  foetal  and 
intra-uterine  peritonitis,  peritonitis  neonatorum. 

Pathologiuil. — Diffuse  septic  peritonitis,  putrid, 
hemorrhagic,  .suppurative,  serous,  and  fibrino-ijlastic 
peritonitis. 

Baeteriologkal.  —  Streptococcus  infection,  staph vlc- 
coccus,  pneumococcus,  bacillus  coli  commune,  gono- 
coccus,  and  tuberculous  infection. 

Clinical.  —  Ectoperitonitis,  general  septic  jierito- 
nitis,  perforative,  circumscribed,  ha;matogenous.  vis- 
ceral fsee  under  anatomical),  pelvic,  puerperal,  and 
subdiaphragmatic  ]3eritonitis. 

I.  Ectoperitonitis An  inflammation  of  the  at- 
tached side  of  the  peritoneum  is  called  ectoperito- 
nitis. As  compared  with  inflammation  of  the  serous 
surface,  this  form  is  characterized  clinically  and 
pathologically  by  intrinsic  tendencies  to  limitation  of 
the  inflammatory  process.  The  mechanical  and  ana- 
tomical conditions  for  diffusion  of  the  infection  are 
less  favorable  than  when  the  free  surface  of  the  mem- 
brane is  affected.  It  may  become  quite  diffuse,  how- 
ever, when  the  cavum  Retzii  or  the  retroperitoneal 
space  on  either  side  of  the  spinal  column  is  the  seat 
of  a  suppurative  inflammation.  In  infected  wounds 
of  any  part  of  the  abdominal  wall  in  which  the  peri- 
toneum is  exposed,  but  not  perforated,  the  primary 
ectoperitonitis  is  occasionally  followed  by  the  exten- 

'  .Abstract  of  an  address  delivered  before  the  Twelfth  Interna- 
tional Medical  Congress,  held  in  Moscow,  August  19-26,  1S97. 


sion  of  the  infection  to  the  serous  surfaces  through  the 
lymphatics,  or  the  direct  extension  of  the  infective 
process  through  the  tissues  until  it  reaches  the  endo- 
thelial lining.  Peritonitis  of  visceral  origin  is  alwavs 
preceded  by  ectoiJeritonitis. 

The  surgical  treatment  of  an  ectoperitonitic  sup- 
purating focus  is  curative  and  prophylactic.  The 
prophylaxis  consists  in  the  prevention  of  rupture  of 
the  contents  of  the  abscess  into  the  free  peritoneal 
cavity,  by  means  of  an  extraperitoneal  incision  and 
drainage. 

Suppurative  inflammation  of  the  loose  connective 
tissue  in  the  cavum  Retzii  often  leads  to  extensive 
ectoperitonitis,  occasionally  to  perforation  into  the 
peritoneal  cavity,  septic  peritonitis,  and  death. 
Leusser  found  that  the  loose  connective  tissue  between 
the  peritoneum  and  the  abdominal  muscles  is  divided 
into  two  layers  by  a  plane  of  fascia  which  is  inserted 
into  the  upper  border  of  the  symphysis.  An  abscess 
in  this  region  may  therefore  be  submuscular  or  pre- 
vesical ;  the  former  occupies  the  space  between  the 
fascia  and  the  muscles,  and  assumes  an  o\  ate  outline 
with  the  pointed  extremity  of  the  swelling  directed 
downward;  an  abscess  behind  the  fascia,  a  true  pre- 
vesical abscess,  resembles  in  outline  the  distended 
bladder.  The  indications  for  prompt  surgical  inter- 
ference are  particularly  urgent  when  the  abscess  is 
subperitoneal,  as  it  is  in  such  cases  that  the  perito- 
neum is  extensively  involved,  and  the  danger  is  great- 
est of  extensive  burrowing  of  the  pus  and  perforation 
into  the  peritoneal  cavity  most  frequently  takes  place. 
The  proper  treatment  of  an  abscess  in  the  cavum 
Retzii  is  an  early  and  free  incision  made  in  the  same 
manner  and  with  the  same  care  as  in  operations  for 
stone  in  the  bladder  by  the  suprapubic  route. 

2.  General  Septic  Peritonitis.— I  understand  by  a 
general  septic  peritonitis  an  inflammation  of  the  en- 
tire peritoneal  sac,  the  result  of  most  virulent  infec- 
tion, the  patients  dying  not  so  much  from  the  effects 
of  the  inflammation  as  from  the  rapid  introduction  into 
the  general  circulation  of  septic  material  from  the  peri- 
toneal cavity.  In  suppurative  peritonitis  the  primar}' 
microbic  cause  is  less  in  quantity  or  virulence,  and  a 
sufficient  length  of  time  intervenes  between  the  begin- 
ning of  the  attack  and  the  operation  or  death  for  the 
formation  of  pus  and  other  inflammator}'  products. 
Every  acute  peritonitis  is  septic  in  so  far  that  phlo- 
gistic substances  reach  the  general  circulation  from  the 
inflammatory  lesion,  but  the  term  septic  should  be 
limited  to  those  cases  of  diffuse  septic  peritonitis  in 
which,  as  a  rule,  death  occurs  in  a  few  days  and  be- 
fore any  gross  pathological  conditions  have  had  time 
to  develop.  It  is  a  disease  that  is  almost  uniformly 
fatal  with  or  without  operation.  The  claim  of  opera- 
tors to  have  cured  such  cases  by  laparotomy  must  be 
accepted  with  a  good  deal  of  allowance.  Acute  gen- 
eral septic  peritonitis  is  essentiall)'  a  streptococcus 
disease.  The  disease  is  observed  most  frequently 
after  perforation  into  the  free  peritoneal  cavity  of  an 
abscess  containing  septic  pus,  rupture  or  perforation 
of  any  of  the  abdominal  or  pelvic  viscera  containing 
septic  material,  gunshot  or  stab  wounds  of  the  abdo- 
men with  injury  of  the  gastro-intestinal  canal,  and 
occasionally  as  the   result  of   infection    during   l«pa- 


290 


MEDICAL    RECORD. 


[August  28,  1897 


rotomy.  The  gravest  form  of  puerperal  sepsis  is  a 
diffuse  septic  peritonitis. 

The  subjects  of  this  variety  of  peritonitis  die  so 
soon  after  the  beginning  of  the  disease  that  at  the 
post-mortem  or,  if  the  abdomen  is  opened  during  life, 
at  the  operation  no  gross  tissue  changes  are  discov- 
ered. Beside  a  lightly  increased  vascularity,  nothing 
is  found  to  indicate  the  existence  of  peritonitis.  The 
septic  material  formed  in  large  quantities  and  of  in- 
tense virulence  is  rapidly  absorbed  by  the  stomata  of 
the  under  surface  of  the  diaphragm,  discovered  and 
described  by  von  Recklinghausen.  In  putrid  perito- 
nitis the  streptococcus  infection  is  complicated  by  the 
presence  of  putrescible  substances  which  serve  as  a 
nutrient  medium  for  saprophytic  bacteria  which  modify 
the  character  of  the  inHammatory  product.  It  occurs 
iiicst  frequently  in  connection  with  grave  forms  of 
puerperal  metritis.  Surgery  has  done  much  toward  its 
prevention,  but  very  little  toward  saving  life  after  the 
disease  is  once  fully  developed.  Careful  analysis  of 
tlie  cases  which  yielded  to  laparotomy  would  un- 
doubtedly disclose  the  fact  that  most  of  them  were  not 
genuine  cases  of  general  .septic  peritonitis,  but  cases 
of  more  or  less  localized  inflammation  of  the  perito- 
neum with  or  without  suppuration. 

I  have  opened,  drained,  and  washed  out  the  perito- 
neal cavity  in  many  cases  of  diffuse  septic  peritonitis, 
and  I  am  free  to  confess  without  a  single  successful 
result.  All  of  my  patients  died  in  from  a  few  hours 
to  a  day  or  two  after  the  operation,  of  sepsis,  in  spite 
of  heroic  stimulation  and  in  some  cases  of  frequently 
repeated  irrigation  with  sterilized  water,  decinormal 
salt  solution,  or  mild  antiseptic  solutions.  On  the 
other  hand,  some  surgeons  report  a  fair  percentage  of 
recoveries  after  laparotomy  for  what  they  call  general 
septic  peritonitis.  Krecke  has  collected  one  hundred 
and  nineteen  cases  of  laparotomy  in  general  perito- 
nitis, in  which  there  were  fifty-one  recoveries  and 
sixty-eight  deaths.  .\.  J.  McCosh  operated  between 
1888  and  1895  inclusive  in  forty-three  cases  of  general 
septic  peritonitis.  Of  these  thirty-seven  died  and  six 
recovered,  a  mortality  rate  of  about  eighty-six  per  cent. 
A  free  abdominal  incision  was  made  in  all,  and  with 
few  exceptions  irrigation  was  employed. 

It  is  not  easy,  or  always  possible,  to  ascertain  the 
extent  of  inflammation  in  Tiro  by  opening  the  perito- 
neal, cavity,  and  a  strong  suspicion  remains  that  at 
least  in  some  of  the  cases  which  recovered  the  peri- 
tonitis was  not  general,  or  that  the  operation  was  per- 
formed before  the  entire  serous  surface  was  involved. 

.-V  general  discussion  of  the  mcilical  iioitmint  of 
peritonitis  is  out  of  place  here,  but  a  few  words  in  ref- 
erence to  what  the  surgeon  should  do  and  what  he 
should  not  do  in  the  way  of  medical  treatment  when 
he  assumes  charge  of  a  case  of  peritonitis  are  perti- 
nent to  my  subject.  Stomach  treatment  must  be  limited 
to  the  administration  of  liquid  food  and  stimulants. 
If,  as  is  so  frequently  the  case,  nausea  and  vomiting 
are  prominent  symptoms,  rectal  enemata  are  of  the 
greatest  value.  The  distressing  thirst  can  often  be 
effectually  relieved  by  high  rectal  enemata  of  warm 
water,  and  if  these  are  not  tolerated  by  hypodermic 
infusion.  Some  authorities  favor  cathartics,  others 
condemn  them  and  rely  on  opium.  Mr.  Tait  taught 
us  years  ago  the  value  of  saline  cathartics  in  the  pre- 
vention of  peritonitis  and  in  its  treatment  during  the 
incipient  stage,  and  his  teachings  and  practice  are  not 
only  supported  by  clinical  observation,  but  have  been 
substantiated  by  experimental  investigations.  He  has 
found  the  most  efficient  treatment  for  septic  conditions 
following  abdominal  section  to  be  thirty  or  forty  grains 
of  sulphate  of  magnesium,  repeated  every  hour  or  every 
other  hour  until  the  bowels  move  freely.  I  have  seen 
many  cases  of  threatened  peritonitis  after  abdominal 
section  aborted  by  the  timely  administration  of  saline 


cathartics.  If  the  stomach  is  intolerant,  calomel  in 
small  doses,  repeated  hourly,  and  saline  enemata  are 
indicated.  One  of  the  great  dangers  in  peritonitis  is 
rapid  distention  and  paresis  of  the  intestines,  condi- 
tions which  are  provoked  by  opium  and  which  can  be 
most  effectually  averted  by  early  and  free  catharsis. 

The  use  of  cathartics  is,  of  course,  absolutely  contra- 
indicated  in  all  cases  of  peritonitis  caused  by  perfo- 
ration. 

In  such  cases  the  use  of  opium  is  legitimate  and 
useful,  as  it  diminishes  shock,  and  lessens  the  extra- 
vasation of  septic  material  and  its  rapid  diffusion  over 
the  peritoneal  surface.  Shock,  general  debility,  and, 
as  Fritsch  has  shown,  a  weak  heart  increase  the  danger 
from  sepsis.  Strychnine,  camphor,  and  alcoholic 
stimulants  should  be  employed  early  and  at  short  inter- 
vals in  all  cases  of  grave  peritonitis.  The  application 
of  ice  or  the  cold  coil  over  the  abdomen  frequently 
succeeds  in  diminishing  tympanites  and  should  be 
employed  to  prevent  overdistention  and  paresis  of  the 
intestines  when  this  condition  appears,  and  the  state 
of  the  peripheral  circulation  is  good.  If  the  heart's 
action  is  weak  and  the  capillary  circulation  sluggish, 
hot  applications  are  more  agreeable  to  the  patient  and 
a  better  stimulant  for  the  feeble  peripheral  circulation. 

There  can  be  no  difference  of  opinion  in  reference 
to  the  advisability  of  early  opimtire  tieatmait  in  the 
management  of  genera!  diffuse  septic  peritonitis. 
Without  operation  death  is  certain.  An  early  opera- 
tion may  succeed  in  arresting  further  extension  of  in- 
fection in  cases  in  which  the  disease  would  become 
diffuse,  and  in  dift'use  cases  may  occasionally  be  the 
means  of  saving  a  life  which  without  it  would  be 
surely  lost.  An  early  diagnosis  and  prompt  operative 
interference  are  the  conditions  sine  qua  noti  of  success. 
The  patient  should  be  properly  prepared  for  the  oper- 
ation, not  only  with  a  view  of  securing  absolute  asepsis 
for  the  field  of  operation  and  everything  that  is  to  be 
brought  in  contact  with  the  wound,  but  the  necessary 
precautions  should  also  be  carried  into  effect  to  sus- 
tain the  heart's  action  and  stimulate  tlie  capillary  cir- 
culation during  and  immediately  after  the  operation. 
I  am  partial  to  the  use  of  sulphuric  ether  as  an  anes- 
thetic in  performing  laparotomy  for  this  indication,  as 
it  has  a  less  injurious  effect  upon  the  already  enfeebled 
circulation  than  chloroform.  The  body  must  be  care- 
fully protected  against  loss  of  heat,  by  warm  flannel 
blankets  and  by  bottles  or  rubber  bags  containing  hot 
water.  The  solutions  which  are  to  be  used  for  irriga- 
tion must  be  kept  at  a  temperature  of  iio"  to  120"^  F. 

Laparotomy,  as  a  therapeutic  resource  in  the  treat- 
ment of  peritonitis,  is  of  recent  date.  J.  Ewing  Mears 
as  early  as  1875  operated  by  abdominal  section  in  a 
case  of  circumscribed  suppurative  peritonitis  follow- 
ing childbirth.  He  advocated  at  that  time  surgical 
intervention  in  all  cases  of  suppurati\e  peritonitis. 
Treves  rejiorted  a  case  of  acute  peritonitis  treated  by 
abdominal  section  in  1885,  which  terminated  in  re- 
covery, and  he  recommended  the  operation  in  similar 
cases.  During  the  same  year  I'e'an  advocated  in  the 
treatment  of  septic  peritonitis  incision,  toilette,  and 
drainage  of  the  abdominal  cavity,  .^bout  the  same 
time  Oberst  urged  energetic  surgical  treatment  in  cases 
of  acute  peritonitis.  In  1886  Law  son  Tait  reported 
two  cases  of  acute  peritonitis  treated  by  abdominal 
section,  of  which  one  recovered.  He  advised  lapa- 
rotomy in  all  cases  of  peritonitis  if  an  effusion  can  be 
demonstrated  and  the  existence  of  fever  indicates  the 
pyogenic  nature  of  the  inflammatory  product.  In  1889 
successful  laparotomies  for  septic  peritonitis  were  re- 
ported by  Demons,  Houilly,  Dernuce,  Brun,  Labbe, 
and  Routier.  It  is  evident  that  in  most  of  these  cases 
the  operation  was  performed  for  circumscribed  sup- 
purative, and  not  for  diffuse  septic  peritonitis. 

The  treatment  of  peritonitis  by  laparotomy  received 


August  28,  1897] 


MEDICAL    RECORD. 


291 


a  new  impulse  when  about  nine  years  ago  it  was  found 
that  the  disease  is  so  often  produced  by  primary  sup- 
purative and  perforative  lesions  of  the  appendix  ver- 
miformis. 

Incision. — Authorities  are  as  yet  not  agreed  as  to  the 
size,  location,  and  number  of  incisions.  In  circum- 
scribed peritonitis  the  rule  is  usually  followed  to  open 
and  drain  by  the  shortest  and  most  direct  route.  In 
perforation  of  any  organ  other  than  the  appendix  ver- 
miformis,  resulting  in  diffuse  peritonitis,  the  first  in- 
cision should  always  be  made  at  or  near  the  median 
line.  The  incision  is  made  above  the  umbilicus  if 
the  gall  bladder,  stomach,  or  duodenum  is  the  seat  of 
perforation,  below  the  umbilicus  in  perforation  of  any 
other  portion  of  the  small  intestines. 

Mikulicz  makes  a  sharp  distinction  in  the  treatment 
of  diffuse  septic  and  progressive  fibro-purulent  perito- 
nitis. In  the  former  the  abdominal  incision  should 
be  large,  the  perforation  closed,  and  the  abdominal 
cavity  disinfected  and  drained.  In  the  latter  the  ad- 
hesions should  be  carefully  preserved  and  the  differ- 
ent pus  accumulations  opened  and  evacuated  sepa- 
rately. Some  surgeons  prefer  to  open  the  abdomen 
some  distance  from  the  linea  alba.  Ramsay  gives 
cogent  reasons  why  the  incision  should  be  made 
through  the  centre  of  either  rectus  muscle,  where  the 
abdominal  wall  is  thickest  and  strongest  and  where 
the  different  layers  can  be  sutured  separately  with  the 
greatest  ease,  and  where  for  these  reasons  ventral 
hernia  is  least  likely  to  follow.  Prolonged  drainage 
is  always  an  important  etiological  element  in  the  oc- 
currence of  postoperative  ventral  hernia,  and  this 
complication  is  certainly  less  likely  to  follow  if  the 
incision  is  made  through  the  muscular  portion  of  the 
abdominal  wall  than  through  the  thin  fibrous  linea 
alba. 

In  the  treatment  of  dift'use  septic  peritonitis  the  in- 
cision should  be  at  least  large  enough  to  insert  the 
hand  for  the  purpose  of  making  a  careful  intra- 
abdominal exploration.  Mr.  Bowlby  is  of  the  belief 
that  an  incision  below  the  umbilicus  does  not  neces- 
sarily empty  the  peritoneal  cavity.  In  cases  of  peri- 
tonitis resulting  from  perforation  of  a  gastric  or  duo- 
denal ulcer  he  advises  two  incisions  (one  above  and 
one  below  the  umbilicus)  to  insure  complete  flushing. 
In  diffuse  peritonitis  incisions  should  be  made  at  a 
number  of  points  with  a  view  to  facilitate  irrigation 
and  insure  free  drainage.  The  best  points  will  be 
above  the  pubes,  above  the  umbilicus,  and  posteriorly 
through  the  lumbar  region  on  each  side.  In  woman 
free  drainage  into  the  vagina  by  incising  Douglas' 
cul-de-sac  will  answer  an  excellent  purpose. 

McBurney  has  devised  an  incision  for  operations 
upon  the  appendix  that  reduces  to  a  minimum  the 
risks  of  a  subsequent  formation  of  a  ventral  hernia. 
"The  skin  incision  is  oblique,  about  four  inches  in 
length,  crossing  at  a  right  angle  a  line  drawn  from  the 
spine  of  the  ilium  to  the  umbilicus  and  about  an  inch 
from  the  spine.  This  incision  is  a  little  to  the  outer 
side  of  the  normal  situation  of  the  appendix.  The 
fibres  of  the  external  oblique  and  its  aponeurosis  are 
not  cut,  but  are  separated  with  great  care  in  the  direc- 
tion in  which  they  run.  When  the  edges  of  the  wound 
of  the  external  oblique  are  separated  with  retractors,  a 
considerable  expanse  of  internal  oblique  muscle  is 
seen,  the  fibres  of  which  cross  somewhat  obliquely 
the  opening  formed  by  the  retractors.  With  a  blunt 
instrument  the  fibres  of  the  internal  oblique  and 
transversalis  muscle  can  be  separated,  without  cutting 
more  than  an  occasional  fibre,  in  a  line  parallel  with 
their  course,  that  is,  nearly  at  right  angles  to  the  in- 
cision in  the  external  aponeurosis.  Blunt  retractors 
are  now  introduced,  and  these  expose  the  transver- 
salis fascia,  which  is  then  divided  in  the  same  line: 
last  of  all  the  peritoneum  is  divided.''     This  incision 


is  an  ideal  one  for  the  removal  of  a  diseased  appendix 
not  complicated  by  suppurative  peri-appendicitis.  In 
the  latter  event  the  incision  must  be  large  enough  to 
enable  the  surgeon  to  see  what  he  is  doing  in  order  to 
avoid  injuring  important  neighboring  organs. 

Eventration. — A  number  of  surgeons  favor  eventra- 
tion, after  incising  the  peritoneal  cavity  freely,  in  order 
to  obtain  more  thorough  disinfection.  In  septic  peri- 
tonitis the  serous  coat  of  the  intestines  is  always 
damaged  and  frequently  the  muscular  coat  is  paretic. 
These  conditions  render  them  liable  to  be  injured  and 
even  ruptured  when  extensive  eventration  is  made,  to 
say  nothing  of  the  shock  which  always  attends  such  a 
procedure. 

I  have  seen  the  dangers  of  extensive  eventration 
many  a  time  in  the  operative  treatment  of  intesti- 
nal obstruction,  and  wherever  possible  I  am  only  too 
anxious  to  reach  without  it  the  object  for  which  oper- 
ation is  performed. 

Irrigation. — Some  surgeons  invariably  irrigate; 
others  believe  that  irrigation  does  more  harm  than 
good  and  are  content  to  remove  the  inflammatory  prod- 
ucts by  means  of  sponges.  It  is  generally  conceded 
that  in  diffuse  peritonitis  it  is  impossible,  by  any 
known  methods  of  irrigation,  to  remove  all  of  the  in- 
fectious material  from  the  peritoneal  cavity,  yet  the 
surgeon  resorts  to  irrigation  almost  instinctively  to  di- 
minish the  danger  from  this  source.  The  use  of  strong 
antiseptic  solutions  has  been  abandoned,  and  sterilized 
water,  decinormal  salt  solution,  solutions  of  boric 
acid  or  acetate  of  aluminium,  and  Thiersch's  solution 
are  now  most  frequently  used.  Whatever  solution  is 
employed  it  should  be  used  at  a  temperature  of  110° 
to  115°  F.,  and  the  stream  should  be  sufficiently  large 
and  strong  to  wash  out  the  most  remote  corners  of  the 
peritoneal  cavity  in  the  direction  of  the  drainage  open- 
ing or  openings. 

Reichel's  attempts  to  treat  septic  peritonitis,  artifi- 
cially produced  in  animals,  were  almost  entirely  a 
failure.  Irrigation  of  the  peritoneal  cavity  with  sub- 
limate, chloroborate  of  sodium,  salicylic  acid,  etc., 
were  useless;  the  animals  quickly  perished.  Some- 
what better  results  were  obtained  by  sponging  gently 
the  peritoneal  surfaces  with  gauze  sponges  and  em- 
ploying the  Mikulicz  gauze  drain.  In  nine  experi- 
mental cases  in  dogs,  two  recoveries  were  obtained  by 
this  method.  Reichel  believes  successful  operative 
treatment  is  applicable  only  in  cases  of  circumscribed 
empyema-like  pus  accumulations.  Delvet  speaks  more 
favorably  of  the  results  of  irrigation  of  the  peritoneal 
cavity.  He  advocates  the  use  of  salt  solution  in  oper- 
ations upon  the  abdominal  cavity,  when  contamination 
takes  place  during  the  operation,  and  in  the  operative 
treatment  of  septic  peritonitis.  Barker  has  found  by 
experience  that  a  very  convenient  method  of  flushing 
the  abdominal  cavity  is  to  use  a  can  with  three  taps 
to  which  tubes  of  large  calibre  are  attached,  and  thus 
the  peritoneal  cavity  can  be  flushed  from  several  points 
at  once,  the  fluid  flowing  out  through  the  original  in- 
cisions. Wiggin  believes  that  the  use  of  peroxide  of 
hydrogen,  followed  by  plenty  of  decinormal  salt  solu- 
tion, is  most  beneficial  in  disinfecting  the  peritoneal 
cavity  and  in  preventing  adhesions. 

Continuous  irrigation,  which  is  useful  in  the  treat- 
ment of  septic  wounds  in  other  localities,  has  been 
suggested  in  the  treatment  of  general  peritonitis. 

The  propriety  of  tearing  up  adhesions  for  the  pur- 
pose of  making  the  irrigation  more  thorough  is  very 
questionable  and  as  a  rule  should  be  avoided.  The 
so-called  toilette  by  using  sponges  must  be  done  with 
the  utmost  gentleness,  if  resorted  to  at  all,  as  all 
mechanical  insults  inflicted  upon  the  endothelial  sur- 
face are  sure  to  aggravate  the  existing  conditions.  If 
it  is  intended  to  remove  the  fluid  from  the  peritoneal 
cavity,  it  is  better  to  do  so  by  placing  the  patient  on 


292 


MEDICAL    RECORD. 


[August  28,  I J 


the  side  so  as  to  pour  it  out  instead  of  removing  it  by 
mopping. 

Incision  of  Overdisteiuied  Intestine. — One  of  the 
most  unfavorable  conditions  in  peritonitis  is  over- 
distention  of  the  intestines  with  gas  and  septic  fluid 
material.  A  paretic  inflamed  intestine  is  permeable 
to  pathogenic  microbes,  thus  adding  another  fruitful 
source  of  infection  to  the  existing  septic  inJiammation. 
It  is  natural  that  surgeons  should  have  made  attempts 
to  relieve  the  distention  and  unload  the  intestines  of 
septic  material  by  tapping  or  by  making  one  or  more 
incisions.  Mixter  recommends  incision  of  the  coils 
of  the  paretic  intestines  at  as  many  points  as  may  be 
necessary  to  evacuate  them.  The  intestines  should  be 
drawn  out  of  the  wound,  lield  over  a  basin,  incised  in 
from  one  to  four  places,  and  thoroughly  emptied,  after 
which  the  coils  should  be  quickly  washed  ofif  with  a 
hot  saline  solution,  the  visceral  wounds  sutured,  the 
intestine  returned,  and  the  abdominal  incision  closed. 
I  have  made  visceral  incisions  in  a  number  of  cases 
in  which  the  intestine  had  become  paretic,  and,  al- 
though but  one  of  the  patients  recovered,  I  am  firmly 
convinced  that  it  is  almost  essential  to  success  in  such 
desperate  cases.  I  place  the  patient  on  the  side, 
bring  the  most  distended  part  of  the  intestine  well 
forward  into  the  wound,  and  make  a  transverse  in- 
cision about  an  inch  in  length  opposite  the  mesenteric 
attachment.  As  the  intestinal  wall  does  not  contract, 
evacuation  should  be  secured  by  pouring  out  the  con- 
tents from  above  and  below  the  incision  by  grasping  the 
intestine  at  some  distance  away  and  bringing  it  above 
the  level  of  the  incision.  By  this  method  several 
feet  of  intestine  can  be  evacuated  through  one  incision. 
After  thorough  cleansing  of  the  exposed  intestinal 
surface  with  warm  salt  solution  the  wound  is  sutured 
in  the  usual  manner  and  the  intestine  is  returned. 

Drainage. — -Drainage  of  the  abdominal  cavit)'  after 
operations  for  peritonitis  is  an  admission  of  the  pres- 
ent imperfect  state  of  surgery;  it  is  an  acknowledg- 
ment on  the  part  of  the  surgeon  that  he  has  only  in 
part  fulfilled  the  indications  for  which  the  operation 
was  performed,  it  is  a  confession  that  he  was  not  able 
to  accomplish  what  was  so  much  needed  and  what  he 
so  earnestly  desired^complete  asepsis  of  the  entire 
peritoneal  cavity. 

Ih  1870,  during  the  Franco-Prussian  war,  Marion 
Sims  made  a  special  study  of  the  cause  of  death  in 
cases  of  gunshot  wounds  of  the  abdomen.  He  found 
that  with  few  e.xceptions,  if  the  bullet  entered  above 
the  pelvis  the  case  proved  fatal,  while  similar  wounds 
of  the  pelvic  portion  of  the  abdominal  cavity  ended  in 
recovery.  He  ascribed  this  difference  in  the  mortality 
to  the  circumstance  that  high  wounds  resulted  in  ex- 
travasation of  the  intestinal  contents  which  accumu- 
lated in  the  pelvic  cavity,  while  in  pelvic  wounds  the 
track  made  by  the  bullet  ser\-ed  as  a  drainage  canal. 
In  1872  he  recommended  that  in  all  penetrating 
■wounds  of  the  abdomen  and  in  operations  on  any  of 
its  contents  drainage  should  be  established.  Very 
few  surgeons  at  the  present  day  would  feel  justified  in 
opening  tlie  abdominal  cavity  for  peritonitis  and  dis- 
pensing with  drainage.  Voices  have,  however,  been 
raised  against  too  frequent  resort  to  drainage,  among 
them  Olshausen,  w'ho  says:  "Drainage  of  the  perito- 
neal cavity  is  an  illusion.  Drainage  to  be  of  serA-ice 
must  be  limited  to  the  evacuation  of  preformed  patho- 
logical spaces."  In  perforating  wounds  he  recom- 
mends a  careful  cleansing  and  complete  hamostasis, 
avoiding  drainage  in  all  recent  cases. 

Barker  relies  mainly  on  thorough  flushing  and 
sutures  the  abdominal  incision.  He  resorts  to  drain- 
age only  in  the  treatment  of  putrid  abscesses  cau.sed 
by  appendicitis.  If  a  drain  is  used  in  exceptional 
cases  of  peritonitis  he  advises  its  removal  at  the  ex- 
piration of  twenty-four  hours. 


At  present  there  are  three  methods  of  drainage  in 
general  use:  i.  Tubular  drainage;  2.  Capillary^ drain- 
age; 3.  .-V  combination  of  tubular  and  capillary 
drainage. 

Tubular  drainage  is  especially  indicated  in  cases  in 
which  the  abdominal  cavity  contains  pus.  The  tubes 
employed  are  made  of  either  glass  or  soft  rubber. 
Keith's  glass  drains  answer  an  excellent  purpose  in 
draining  the  lowest  pwrtion  of  the  abdominal  cavity. 
They  should  be  slightly  curved  at  the  abdominal  end 
so  as  to  reach  the  floor  of  the  pelvic  cavity  without 
making  harmful  pressure  against  the  bladder.  Fre- 
quent aspiration  of  the  contents  of  the  drain  is  neces- 
sary for  the  purpose  of  removing  the  fluid  inflamma- 
tory product  as  soon  as  it  is  formed.  The  rubber 
drain  answers  the  same  purpose,  but  is  justly  accused 
of  causing  more  mechanical  irritation  than  the  smooth 
glass  tube.  Prolonged  tubular  drainage  has  not  infre- 
quently caused  intestinal  fistula  by  pressure.  It  is  for 
this  reason  that  I  now  almost  invariably  surround  the 
rubber  or  glass  tube  with  a  few  layers  of  iodoform 
gauze  seciu-ely  fastened  to  the  tube.  In  draining  the 
pelvic  porton  of  the  abdominal  cavity  I  frequently  use 
two  drains  of  the  size  of  a  little  finger,  one  on  each 
side,  brought  out  through  the  same  opening  in  the 
lower  angle  of  the  wound.  In  draining  in  the  lumbar 
regions  and  through  the  vagina  rubber  drains  should 
be  employed. 

Capillary  drains  are  frequently  employed  as  substi- 
tutes for  the  tubular  drain  and  in  addition  must  often 
be  relied  upon  as  an  important  haemostatic  resource  in 
arresting  parenchymatous  oozing.  The  name  of 
Mikulicz  is  connected  with  a  special  method  of  gauze 
drainage  of  his  own  device,  which  has  proved  of  great 
value  in  the  surgical  treatment  of  peritonitis.  The 
typical  Mikulicz  tampon  is  made  by  taking  a  piece  of 
iodoform  gauze  the  size  of  a  large  handkerchief,  to  the 
centre  of  which  a  strong  piece  of  aseptic  silk  tluead 
is  stitched.  When  used  it  is  arranged  as  a  pouch  and 
is  carried  by  means  of  curved  forceps  to  the  bottom  of 
the  jjelvis  and  is  filled  with  strips  of  iodoform  gauze, 
the  free  end  of  the  silk  thread  issuing  frcm  the  mouth 
of  the  pouch.  When  it  is  desired  to  remove  the  drain 
the  gauze  strips  are  drawn  out  and  the  pouch  is  re- 
moved by  making  traction  u])on  the  string.  In  deal- 
ing with  large  cavities  requiring  an  enormous  amount 
of  gauze  I  have  learned  to  fear  iodoform  gauze,  l)e- 
cause  the  cases  are  by  no  means  isolated  in  which  a 
drain  composed  e.xclusively  of  iodoform  gauze  became 
the  immediate  cause  of  death  from  iodoform  into.vica- 
tion.  This  is  particularly  liable  to  occur  in  cases  in 
which  the  patient's  kidneys  are  not  functionating 
properly.  I  should,  therefore,  limit  the  iodofonn 
gauze  to  an  outer  layer  or  two  and  pack  the  jx>uch 
with  ordinary  sterilized  gauze. 

Drainage  by  sterilized  wicking  has  been  popular  in 
Germany  for  a  number  of  years  and  in  many  cases  has 
answered  an  excellent  purpose.  It  has  never  found 
its  way  to  any  e.xtent  into  America,  where  gauze  is 
employed  in  preference.  R.  T.  Morris  reconuuends 
wicks  whicli  he  employs  in  a  peculiar  way.  The 
simplest  wick  consists  of  a  little  roll  of  bichloride 
gauze,  around  which  is  wrapped  a  couple  of  thick- 
nesses of  Lister's  protecti\  e  silk.  I'he  gauze  protrudes 
a  little  from  each  end  of  the  cylinder,  and  a  few  small 
fenestra-  in  the  protective  silk  allow  the  serum  to 
reach  the  gauze  elsewhere.  When  a  large  gauze  pack- 
ing for  the  pelvis  or  abdomen  is  needed,  an  apron  of 
the  silk  can  expand  over  the  gauze  and  protect  against 
intestinal  adhesions.  This  method  possesses  great 
advantages  over  ordinary  tubular  and  capillary  drain- 
age, and  recommends  itself  more  especially  in  the 
surgical  treatment  of  ditTuse  septic  peritonitis.  The 
prolonged  cont;ict  of  gauze  with  a  serous  surface  is 
very  prone  to  give  rise  to  permanent    adhesions,  as 


August  28.  1897] 


MEDICAL    RECORD. 


293 


ever}-  clinician  knows.  In  employing  gauze  in  drain- 
ing the  peritoneal  cavity  it  is  necessary  to  use  long 
strips  which  should  be  inserted  in  different  direc- 
tions and  brought  out  at  the  same  place  and  fast- 
ened together  with  a  safety  pin.  Van  Hook  has 
shown  that  the  gauze  drains  more  freely  if  the  ex- 
ternal ends  are  left  long  and  placed  on  the  side  of  the 
pelvis  below  the  level  of  tlie  wound.  Drainage  must 
be  dispensed  with  as  soon  as  possible,  in  order  to  pre- 
vent adhesions  and  to  enable  the  surgeon  to  close  the 
incision  by  secondar}-  suturing,  an  important  precau- 
tion against  the  formation  of  a  ventral  hernia.  The 
strips  should  be  shortened,  and  one  after  the  other 
removed  as  the  indications  for  drainage  disappear. 

The  simultaneous  use  of  tubular  and  capillar\- 
drainage  is  an  excellent  method.  It  is  effected  bv 
packing  loosely  a  glass  drain  of  proper  length  and 
size  with  strips  of  gauze  or  aseptic  wicking.  This  is 
especially  useful  when  the  inflammatory  product  is 
serum  instead  of  pus. 

Intra- Intestinal  Saline  Injections.  —  The  value  of 
saline  cathartics  in  the  treatment  of  incipient  peri- 
tonitis not  caused  by  perforation  is  now  generally  rec- 
ognized. One  of  the  difficulties  encountered  in  the 
treatment  of  such  cases  is  the  intolerance  of  the  stom- 
ach to  food  and  medicines.  A.  J.  McCosh  has  suc- 
ceeded in  securing  free  catharsis  and  in  overcoming 
the  intestinal  paresis  after  operations  for  peritonitis  by 
injecting  into  the  small  intestine,  at  a  point  in  the 
jejunum  or  in  the  ileum,  as  high  up  as  possible,  a 
saturated  solution  containing  between  one  and  two 
ounces  of  sulphate  of  magnesium. 

After-Treatmcnt. — In  all  cases  the  most  attenti\f 
and  careful  after-treatment  is  essential  to  success. 
The  patients  are  prostrated  by  the  disease  and  the 
operation,  and  require  a  stimulating  treatment.  Ex- 
ternal dry  heat  is  an  important  element  in  counteract- 
ing the  shock  and  in  restoring  the  peripheral  circula- 
tion. The  thirst  is  quenched  most  effectually  by 
subcutaneous  infusion  or  rectal  enemata  of  water. 
Strychnine  and  alcoholic  stimulants  are  best  calcu- 
lated to  increase  the  force  of  the  heart's  action  and 
the  tone  of  the  arterial  circulation.  Partial  inversion 
of  the  body  by  raising  the  foot  of  the  bed  and  also 
autotransfusion  are  potent  means  of  inducing  cardiac 
stimulation.  .\  well-fitting  abdominal  bandage  ap- 
plied firmly  exerts  a  favorable  influence  in  preventing 
and  diminishing  abdominal  distention.  Saline  ca- 
thartics should  be  administered  as  soon  as  the  stom- 
ach is  in  a  condition  to  absorb  them.  Meteorism  can 
often  be  relieved  by  high  turpentine  enemata  and  the 
use  of  the  elastic  rectal  tube. 

As  no  operation  ever  secures  completely  aseptic  con- 
dition of  the  peritoneal  cavity  in  cases  of  general  peri- 
tonitis, Marmorek's  streptococcus  antitoxin  may  prove 
a  useful  adjunct  to  the  after-treatment.  A  number  of 
cases  have  recently  been  reported  in  which  the  serum 
appears  to  have  been  of  great  value  in  the  treatment 
of  septic  conditions  in  the  peritoneal  cavity  and  else- 
where. It  is  not  probable  that  it  will  ever  displace 
the  knife  in  the  treatment  of  dift'use  general  septic 
peritonitis,  but  it  is  more  than  probable  that  it  will 
prove  to  be  an  important  therapeutic  agent  in  the 
treatment  of  peritonitis  before  and  after  operation. 
Opium  should  be  used  with  great  caution.  The 
external  dressing  should  be  changed  as  soon  as  it  has 
become  saturated.  If  continuous  irrigation  is  decided 
upon  a  decinormal  salt  solution  at  a  temperature  of 
\o'^°  F.  is  the  one  usually  employed.  The  current 
should  be  small  and  without  much  force.  The  outflow 
from  the  peritoneal  cavit)-  should  be  received  upon  a 
rubber  blanket  and  conducted  into  a  receptacle  near 
the  bed.  This  method  of  irrigation  recommends  itself 
particularly  in  cases  of  diffuse  septic  peritonitis.  In 
suppurative  diffuse  peritonitis  periodical  flushings,  at 


internals  of  two  or  three  hours,  will  prove  of  value  ir» 
removing  from  the  peritoneal  cavity  the  fluid  products 
of  the  inflammatory  process.  The  solutions  best 
adapted  for  this  puprose  are  a  saturated  solution  of 
the  acetate  of  aluminium,  a  three  to  five  per  cent,  solu- 
tion of  boric  acid,  or  Thiersch's  solution.  Drainage 
when  once  established  should  be  suspended  gradually 
and  not  suddenly.  As  soon  as  the  peritoneal  cavity 
and  the  drain  canals  are  aseptic  the  external  wound 
should  be  sutured,  to  prevent  as  far  as  possible  the 
subsequent  formation  of  a  ventral  hernia. 

3.  Perforative  Peritonitis. —Perforative  peritonitis 
invariably  occurs  as  a  secondary  affection,  usually  in 
connection  with  an  ulcerative  or  gangrenous  lesion  of 
some  part  of  the  gastro-intestinal  canal.  Penetrating 
wounds  of  the  abdomen  with  injury  of  the  gastro- 
intestinal canal  must  be  regarded  in  the  same  light  as 
perforative  lesions  of  the  abdominal  organs  in  the 
causation  of  peritonitis.  Perforative  peritonitis  is 
manifested  by  the  sudden  onset  of  diffuse  pain  and 
tenderness,  rigid  abdominal  walls,  fever,  vomiting, 
and  the  presence  of  gas  in  the  free  peritoneal  cavity. 
According  to  my  observation,  peritoneal  meteorism 
in  perforative  peritonitis  caused  by  appendicitis  is 
rare,  while  I  have  seldom  found  it  absent  after  perfo- 
ration of  any  other  portion  of  the  gastro-intestinal 
canal.  .According  to  the  number  and  virulence  of  the 
microbes  which  find  their  way  into  the  peritoneal 
cavity  with  the  e.xtravasation,  the  resulting  peritonitis 
is  either  diffuse  or  more  or  less  circumscribed.  The 
colon  bacillus  is  invariably  present  in  the  inflamma- 
tory product,  but  others,  according  to  the  nature  of  the 
primary  affection,  may  also  be  found.  Perforative 
peritonitis  must  be  treated  as  a  strictly  surgical  dis- 
ease. The  perforation  should  be  found  and  properly 
treated  before  a  general  septic  peritonitis  has  had  time 
to  develop.  There  are  exceptions  to  this  rule  in 
cases  in  which  the  perforation  is  small  and  the  extra- 
vasation has  produced  a  limited  peritonitis  in  a  local- 
it)'  where  it  is  safe  to  wait  for  abscess  formation,  as 
is  often  the  case  in  the  region  of  the  gall  bladder  and 
appendix  vermiformis.  Penetrating  wounds  of  the  ab- 
domen with  visceral  lesions  of  sufficient  extent  to  give 
rise  to  extravasation  call  for  immediate  laparotomy. 

Perforating  Gastric  Ulcer. — Perforating  ulcer  of  the 
stomach  is  found  most  frequently  on  the  anterior  wall 
near  the  small  cunature.  Perforation  in  this  locality 
is  followed  more  constantly  by  dift'use  peritonitis  than 
is  that  through  the  posterior  wall.  The  onset  of  the 
disease  is  always  sudden,  no  matter  what  the  ante- 
cedent SNTiiptoms  may  have  been.  Shock  is  present  in 
greater  or  less  degree.  A"omiting,  though  frequent,  is 
not  constant.  .Abdominal  pain  and  tenderness,  in- 
creased by  pressure,  are  nearly  always  present;  ab- 
dominal rigidity  in  the  early  stage,  and  distention 
later  on,  are  frequently  noted.  The  duration  of  the 
cases  varies  from  a  few  hours  to  five  days,  most  of  them 
terminating  in  death  in  less  than  twenty-four  hours. 

Mikulicz  performed  the  first  operation  for  this  con- 
dition in  1883.  The  first  successful  case  was  reported 
by  Kriege,  of  Berlin.  The  incision  should  be  made  in 
the  median  line  from  the  ensiform  cartilage  to  the 
umbilicus,  and  enlarged  if  necessary.  If  the  posterior 
wall  is  perforated  and  the  perforation  cannot  be 
reached  in  the  usual  manner,  the  anterior  wall  is  in- 
cised and  the  perforation  closed  through  this  incision. 
Before  the  perforation  is  sutured  the  stomach  should  be 
emptied  through  a  stomach  tube,  or  through  the  open- 
ing. It  is  not  necessar)-  to  excise  the  margins  of  the 
ulcer,  as  these  can  be  inverted  in  tying  the  Lembert 
sutures.  Should  the  wall  of  the  stomach  in  the  imme- 
diate vicinity  present  an  unfavorable  condition  for 
successful  suturing,  an  omental  flap  or  graft  or  re- 
quisite size  should  be  sewed  with  catgut  over  the  line 
of  suture. 


294 


MEDICAL    RECORD. 


[August  28,  1897 


rcrforatiiig  Ulcer  of  the  Duodenum. — This  occurs 
suddenly  and  frequently  without  any  marked  premoni- 
tory symptoms  indicative  of  the  existence  of  the 
primary  disease.  It  is  only  recently  that  peritonitis 
resulting  from  this  cause  has  been  subjected  to  opera- 
tive treatment.  The  ulcer  is  usually  in  the  iirst  part, 
but  may  be  in  either  of  the  other  two  portions.  The 
ulcer  is  simply  inverted,  excision  being  imnecessary. 
J)rainage  must  also  be  provided  for. 

Per/orating  Typhoid  Ulcer. — Perforation  of  a  ty- 
phoid ulcer,  large  enough  for  extravasation  to  take 
place  into  the  free  peritoneal  cvaity,  is  a  fatal  acci- 
dent, death  ensuing  in  the  course  of  a  day  or  two. 
Perforation,  however,  does  not  always  terminate  in 
that  way.  Extravasation  is  often  prevented  by  the 
affected  part  of  the  intestinal  wall  becoming  attached 
to  an  adjacent  serous  surface,  thus  protecting  the  peri- 
toneal cavity  against  infection.  I  have  seen  several 
cases  of  typhoid  fever  in  which,  about  the  time  that 
perforation  is  most  likely  to  occur,  circumscribed  peri- 
tonitis set  in  which  could  have  been  caused  only  by  a 
perforating  ulcer  under  such  favorable  conditions, 
and  from  which  the  patients  recovered  without  opera- 
tive intervention. 

Kussmaul,  in  October,  1885,  was  tlie  first  to  excise 
and  suture  a  perforating  typhoid  ulcer.  Lueck  per- 
formed laparotomv  for  the  same  indication  on  October 
22,  1885. 

VViggin  collected  twenty-four  cases  of  perforating 
typhoid  ulcer  subjected  to  laparotomy  with  six  recov- 
eries. If  those  cases  are  rejected  in  which  the  diag- 
nosis is  somewhat  doubtful,  there  are  seventeen 
patients  with  three  recoveries.  The  first  successful 
result  was  obtained  by  Van  Hook,  the  second  by  Net- 
schajans,  the  third  by  Abbe.  J.  Price  has  recently 
reported  three  consecutive  operations  with  as  many 
recoveries,  a  surgical  feat  which  it  will  be  difficult  to 
duplicate.  The  writer  has  performed  the  operation 
three  times  with  one  recovery.  The  feasibility  and 
justifiability  of  abdominal  section  for  perforating  ty- 
phoid ulcer  have  been  established  in  view  of  the  fact 
that  all  of  the  patients  who  have  been  operated  upon 
would  have  died  without  the  operation.  The  opera- 
tion should  be  performed  as  soon  as  possible  after  the 
accident  has  occurred.  The  mortality  will  always 
remain  great,  owing  to  the  debilitated  condition  of  the 
patients  and  the  existence  of  multiple  ulcers. 

4.'  Circumscribed  Peritonitis. — This  is  an  inflam- 
mation of  the  peritoneum  during  which  a  greater  or 
lesser  part  of  the  peritoneal  cavity  becomes  excluded 
from  the  original  source  of  infection  by  the  formation 
of  plastic  visceral,  parietal,  or  visceral  and  parietal 
adhesions.  The  symptoms  appear  suddenly,  or  are 
preceded  by  those  incident  to  the  jirimary  disease. 
The  intensity  of  the  general  symptoms  is  determined 
more  by  the  nature  and  virulence  of  the  microbic 
cause  than  the  area  of  the  peritoneal  surface  involved. 
The  clinical  course  and  termination  are  determined 
largely  by  the  nature  of  the  bacterial  cause,  the 
abdominal  location  of  the  primary  starting-point,  and 
nature  of  the  environment.  Localized  peritonitis  is 
most  likely  to  occur  outside  of  the  limits  of  the  small- 
intestine  area.  It  may  be  confined  to  the  lesser 
omental  cavity,  particularly  in  cases  of  perforating 
ulcers  of  the  stomach  and  duodenum.  More  frequently 
it  is  caused  by  appendicitis  and  ca-citis.  A  very  fre- 
quent cause  of  circumscribed  peritonitis  is  inflamma- 
tion about  the  gall  bladder,  uterus.  Fallopian  tubes,  or 
ovaries.  Localized  peritonitis  can  usually  be  detected 
only  if  a  demonstrable  swelling  forms  at  the  seat  of 
inflammation.  The  mildest  form  of  infection  gives 
rise  to  fibrino-plastic  peritonitis,  which  leaves  tem- 
porary or  permanent  adhesions  but  terminates  without 
suppuration.  Circumscribed  suppurative  inflamma- 
tion is  always  attended   by  fibrino-plastic  peritonitis, 


the  products  of  which  and  the  viscera  which  it  involves 
form  the  abscess  wall.  In  fibrino-plastic  peritonitis 
surgical  interference  becomes  necessary  only  when 
intestinal  obstruction  is  caused  by  adhesions.  In  cir- 
cumscribed suppurative  peritonitis  the  pus  should  be 
evacuated  as  soon  as  the  disease  is  recognized  and  if 
possible  by  an  extraperitoneal  route. 

Acute  Tuberculous  J'eriionitis. — 'iuberculous  perito- 
nitis, usually  circumscribed,  occasionally  presents 
itself  as  a  widely  diffused  acute  affection.  According 
to  the  intensity  of  the  infection  or  the  degree  of  sus- 
ceptibility of  the  patient  to  the  action  of  the  tubercle 
bacillus,  the  disease  assumes  one  of  the  following 
forms:  (1)  Tuberculous  ascites;  {2)  fibrino-plastic 
peritonitis;  {3)  adhesive  peritonitis.  Suppuration 
takes  place  only  when  the  tuberculous  product  becomes 
the  seat  of  a  secondary  mixed  infection  with  pus 
microbes.  Laparotomy  is  now  a  well-established 
operation  in  tuberculous  peritonitis,  but  the  exact 
manner  in  which  the  operation  exerts  its  therapeutic 
influence  is  not  well  understood.  1  have  obtained 
very  satisfacory  results,  in  cases  which  resisted  lapa- 
rotomy and  drainage,  by  repeated  tappings  and  injec- 
tions of  two  to  four  drachms  of  a  ten-per-cent.  iodo- 
form-glycerin  emulsion. 

Suppurathe  Peritonitis. — Suppurative  peritonitis  is 
always  more  or  less  circumscribed.  It  is  generally 
associated  with  fibrino-plastic  exudation.  The  accu- 
mulation of  pus  may  be  so  large  that  upon  opening  the 
abdomen  it  mav  appear  as  though  the  entire  peritoneal 
cavity  and  all  of  the  organs  contained  within  were 
implicated,  but  a  careful  examination  will  almost 
always  reveal  the  fact  that  a  large  part  of  the  peri- 
toneal cavity  and  many  of  the  organs  are  shut  out 
from  the  inflammatory  process  by  plastic  adhesions. 
The  appearance  and  character  of  the  pus  are  often 
greatly  modified  by  the  admixture  of  an  extravasated 
material.  If  the  pus  is  thin  and  serous,  we  speak  of 
a  sero-purulent  peritonitis.  It  is  a  serous  peritonitis 
with  the  formation  of  pus  in  sufficient  quantity  to 
render  the  serum  more  or  less  turbid.  This  sub- 
variety  of  suppurative  peritonitis  is  without  exception 
accompanied  by  fibrinous  exudations  which  tend  to 
limit  the  extension  of  the  infective  process.  Sedimen- 
tation of  the  solid  constituents  takes  place,  so  that  the 
fluid  contains  more  of  the  solid  matter  in  the  most 
dependent  portion  of  the  affected  district. 

J-'i/>riiio-J'l<istic  J'critonitis. — This  is  a  very  frequent 
form  of  circumscribed  peritonitis.  It  is  usually 
secondary  to  an  affection  of  one  of  the  abdominal  or 
pelvic  organs.  The  exudation  is  often  so  copious  that 
it  has  been  mistaken  for  malignant  disease.  The 
exudation  in  the  course  of  time  contracts  and  results 
in  strong  bands  of  adhesion  which  frequently  flex  and 
distort  the  organs  to  which  they  are  attached;  this  has 
given  rise  to  the  icrm,  peritonitis  deformans. 

The  surgical  treatment  of  circumscribed  peritonitis 
by  abdominal  section  has  yielded  very  encouraging  re- 
sults. The  extraperitoneal  route  is  the  one  of  choice 
in  all  ca.ses  in  which  the  abscess  cavity  can  be 
safely  reached  and  efficiently  drained.  In  circum- 
scribed accumulations  of  pus  in  the  peritoneal  cavity 
in  which  the  seat  of  the  disease  must  be  reached 
through  the  free  abdominal  cavity,  the  safest  course 
to  ])ursue  is  to  perform  the  operation  in  two  stages. 
The  first  operation  then  consists  in  suturing  the 
parietal  peritoneum  to  the  wall  of  tlie  abscess  cavity, 
suturing  the  abdominal  incision  with  the  exception  of 
a  space  large  enough  to  incise  and  drain  the  abscess 
cavity  later.  This  space  is  packed  with  iodoform 
gauze  and  two  or  three  days  later  the  abscess  is  incised 
and  drained.  If  the  symptoms  are  urgent  and  the 
operation  must  be  completed,  the  contents  of  the 
abscess  cavity  should  first  be  removed  by  aspiration. 
In  fibrino-plastic  peritonitis  without   suppuration  no 


August  28,  1897] 


MEDICAL    RFXORD. 


295 


attempt  should  be  made  to  tear  the  adhesions  unless 
they  have  caused  intestinal  obstruction.  Some  sur- 
geons, however,  aim  to  remove  the  fibrinous  exudate 
with  the  pus.  Demona  had  under  his  care  a  woman 
suffering  from  suppurative  peritonitis  following  sup- 
puration of  an  ovarian  cyst.  Her  condition  at  the 
time  of  operation  was  critical.  He  opened  the  ab- 
domen, evacuated  the  pus,  removed  the  cyst,  and.  with 
a  rough  sponge  and  blade  of  a  knife,  scraped  the 
entire  surface  of  the  intestine;  a  most  satisfactory 
recovery  followed.  There  are  few  surgeons  who  would 
follow  his  example  to-day.  Adhesions  tend  to  limit 
the  infective  process  and  should  be  interfered  with  as 
little  as  possible. 

5.  Haematogenous  Peritonitis — Idiopathic  perito- 
nitis, so-called,  or  ha;matogenous  peritonitis  ma_\- 
occur,  but  is  much  more  rare  than  a  similar  affection 
of  the  pleura  and  pericardium.  As  peritonitis  is 
always  caused  by  bacteria  of  some  kind,  a  peritonitis 
that  develops  independently  of  a  local  cause  is  the 
result  of  an  infection  through  the  blood  and  should 
be  called  hrematogenous  or  metastatic  peritonitis.  It 
has  been  observed  in  connection  with  nephritis, 
pyaemia,  rheumatic  arthritis,  and  acute  e.xanthematous 
diseases.  In  the  absence  of  even  a  distant  focus  of 
infection  it  is  plausible  to  assume  that  peritonitis  in 
very  rare  cases  is  caused  by  the  localization  of  pus 
microbes  from  the  blood  in  some  part  of  the  perito- 
neum prepared  for  their  reception  and  growth  by  some 
antecedent  injury  or  disease. 

The  surgical  treatment  must  be  guided  by  the  loca- 
tion and  the  extent  of  the  disease,  the  existence  or 
absence  of  complications,  and  the  pathological  type  the 
disease  presents  at  the  time  of  operation. 

6.  Visceral  Peritonitis. — The  intlammatory  process 
is  seldom  limited  to  a  single  organ,  as  during  the 
course  of  the  disease  adjacent  organs  or  the  parietal 
peritoneum  will  surely  become  involved.  In  inflam- 
matory and  rheumatic  affections  of  the  abdominal 
walls  and  the  abdominal  and  pelvic  viscera,  plastic 
inflammation  of  the  omentum  frequently  constitutes 
the  safeguard  against  infection  of  the  general  perito- 
neal cavity  by  the  omentum  becoming  firmly  attached 
over  a  threatened  perforation  or  visceral  or  parietal 
wound.  The  surgeon  often  imitates  nature's  process 
and  makes  use  of  the  omentum  in  covering  denuded 
surfaces  or  those  where  perforation  threatens.  The 
surgical  treatment  of  appendicitis  and  its  various 
complications  is  not  well  settled  at  the  present  time. 
Some  surgeons  adxise  operation  in  all  cases  in  whicii 
a  diagnosis  of  appendicitis  can  be  made,  regardless 
of  the  nature  of  the  disease  and  the  character  of  its 
complications.  The  more  conservative  element  of  the 
profession  limits  the  use  of  the  knife  to  cases  in  which 
there  are  positive  indications  for  surgical  interference. 
For  my  own  part  I  resort  to  operation  in  all  cases  dur- 
ing a  first  attack,  when  the  symptoms  point  to  perfora- 
tion or  gangrene  of  the  appendix.  The  sooner  the 
operation  is  undertaken  under  such  circumstances  the 
better  the  results.  The  appendix  should  be  sought 
for  and  removed  only  if  pus  is  found  in  the  iliac  fossa, 
and  when  it  can  be  done  without  a  material  increase 
in  the  immediate  risks  of  the  operation :  otherwise  the 
treatment  by  incision  and  drainage  will  yield  the  best 
results.  In  mild  cases  of  appendicitis  from  eighty  to 
ninety  per  cent,  recover  under  appropriate  medical 
treatment  and  in  a  fair  percentage  of  cases  the  disease 
does  not  return.  The  gravest  cases  are  those  in  whicli 
the  affection  of  the  appendix  is  followed  by  diffuse 
peritonitis.  In  the  treatment  of  this  class  of  cases 
nearly  all  surgeons  are  fully  in  accord  with  the  rules 
laid  down  by  McBurney  in  an  article  in  The  Medical 
Record,  March  30,  1895.  In  relapsing  appendicitis 
an  operation  is  indicated,  particularly  in  cases  in 
which  the  attacks  set  in  at  short  intervals  and  with 


gradually  increasing  intenbity.  In  peritonitis  result- 
ing from  infective  lesions  of  the  uterus,  ovaries,  or 
Fallopian  tubes,  the  organ  primarily  affected  and  the 
resulting  intraperitoneal  abscess  can  often  be  reached 
more  safely  by  a  vaginal  than  by  an  abdominal  opera- 
tion. Occasionally  the  combined  operation  will  be 
better. 

7.  Pelvic  Peritonitis. — Pelvic  peritonitis  is  seldom 
met  with  in  the  male.  It  is  a  form  of  peritonitis  in 
which  the  female  pelvic  organs  are  the  primary  start- 
ing-point of  infection  with  extension  to  the  perito- 
neum, through  either  the  Fallopian  tubes  or  the  lym- 
phatics of  the  uterus  or  of  its  adnexa.  It  is  caused 
most  frequently  by  gonorrhaal  or  puerperal  infection, 
or  develops  after  instrumental  examination  of  the  in- 
terior of  the  uterus  or  operation  upon  that  organ.  In 
pyogenic  infection  the  inflammation  may  become  dif- 
fuse, and  if  circumscribed  usually  leads  to  the  forma- 
tion of  parametritic  or  intraperitoneal  abscesses,  or 
pus  formation  takes  place  in  both  of  these  localities. 
In  the  peritoneal  cavity  the  gonococcus  produces  a 
plastic  peritonitis,  and  sometimes  localized  suppura- 
tion. Salpingo-peritonitis  and  more  diffuse  pelvic 
peritonitis  are  most  frequently  caused  by  gonococcus 
infection.  Abdominal  section  is  seldom  performed 
for  gonorrhttal  peritonitis  during  the  acute  stage.  An 
early  incision  through  the  vaginal  roof  into  the  cul- 
de-sac  of  Douglas,  so  strongly  urged  by  Henrotin,  is  a 
rational  procedure  and  frequently  succeeds  in  prevent- 
ing the  extension  of  the  infection  and  the  occurrence 
of  serious  remote  complications.  I  have  in  several 
instances  incised  and  drained  the  Fallopian  tube 
through  such  an  incision,  and  in  this  way  prevented 
further  leakage  from  the  tube  into  the  peritoneal 
cavity,  and  thus  directly  cut  oft"  additional  supply  of 
infectious  material.  The  treatment  of  large  parame- 
tritic abscesses  by  an  extraperitoneal  incision  is  pref- 
erable to  a  transperitoneal  operation  in  all  cases  in 
which  the  abscess  can  be  reached  by  this  route. 

We  shall  hear  less  of  intestinal,  vesical,  and  rectal 
fistula  as  the  remote  result  of  pehic  peritonitis  or  para- 
metritic abscesses  as  soon  as  the  profession  recognizes 
fully  the  necessit)  of  timely  operative  interference. 

8.  Puerperal  Peritonitis By  this  term  is  under- 
stood a  progressive  inflammation  of  the  peritoneum, 
occurring  in  consequence  of  an  extension  of  an  infec- 
tion from  any  part  of  the  genital  tract  in  puerperal 
women  after  delivery  or  abortion.  The  infection 
usually  takes  place  through  the  lymphatics,  and  in  the 
majority  of  cases  terminates  in  diffuse  septic  perito- 
nitis. In  some  instances  the  disease  remains  limited 
to  the  pelvic  organs  and  their  serous  investment;  then 
al)scess  formation,  intra-  and  extra- peritoneal,  is  \erv 
likely  to  occur. 

The  treatment  of  the  localized  form  of  puerperal 
peritonitis  is  the  same  as  that  advised  in  circum- 
scribed peritonitis  resulting  from  other  causes.  The 
foudroyant  form  of  puerperal  sepsis  proves  fatal  in 
spite  of  the  most  energetic  medical  and  surgical  treat- 
ment. The  use  of  the  streptococcus  antitoxin  may 
prove  of  great  value  and  should  receive  an  early  and 
fair  trial.  It  has  been  suggested  that  early  removal 
of  the  infected  uterus  would  prevent  the  extension  of 
the  disease  to  the  peritoneum  and  death  from  sepsis, 
but  the  results  have  not  been  encouraging.  It  is  ex- 
ceedingly difficult,  and  in  many  cases  absolutely  im- 
possible, to  make  a  sufficiently  early  and  positive 
diagnosis  to  warrant  such  a  grave  and  mutilating 
operation  as  a  timely  and  life-saving  measure.  If 
the  uterus  is  removed  after  general  septic  peritonitis 
has  developed,  the  operation  is  performed  too  late  and 
death  from  shock  and  sepsis  is  the  rule. 

9.  Subdiaphragmatic  Peritonitis. — This  is  a  peri- 
tonitis limited  to  the  under  surface  of  the  diaphragm 
and  adjacent  surfaces  of  the  abdominal   organs.      If 


296 


MEDICAL    RECORD. 


[August  28,  1897 


the  inriammation  remains  limited  and  life  is  suffi- 
ciently prolonged,  it  usually  terminates  in  the  forma- 
tion of  a  subdiaphragmatic  or  subphrenic  abscess. 
Perforating  ulcer  of  the  stomach  and  duodenum,  ab- 
.scess  of  the  spleen  and  liver  are  the  most  frequent 
aflfections  which  precede  subdiaphragmatic  peritonitis. 
Subphrenic  abscess  often  ruptures  into  the  pleural 
cavity,  and  in  cases  of  empyema  the  possible  existence 
of  a  subphrenic  abscess  must  be  kept  in  mind. 

Accurate  location  of  the  abscess  and  the  positive 
diagnosis  are  made  by  exploratorj-  puncture.  As  per- 
forating ulcer  of  the  stomach  is  the  most  frequent 
cause,  subphrenic  abscesses  are  more  frequently 
located  on  the  left  than  on  the  right  side.  Occa- 
sionally a  spontaneous  cure  occurs  by  perforation  of 
the  abscess  into  a  hollow  adjacent  organ.  The  satis- 
factory results  of  operation  in  these  cases  furnish  the 
most  conclusive  proof  regarding  its  necessity  and 
life-savinsr  value. 


ON  THE  RELATION  OK  PHYSIOLOGY, 
PHARMACOLOGY,  PATHOLOGY,  AND 
PRACTICAL  MEDICINE.' 

By  T.  L.JiUDER    BRUNTOK,   M.D..  D.Sc.  Edin..   LL.D. 
Hon.   ,\bf.rd.,   F.R.C.I'.,   F.R..S.. 


The  desire  for  knowledge  which  is  common  to  the 
lower  animals  and  man,  savage  or  civilized,  and  has 
induced  members  of  this  congress  to  come  from  the 
ends  of  the  earth  in  order  to  gain  information,  must 
have  led  primitive  man  from  the  earliest  times  to 
study  the  great  problems  of  physiology,  the  nature 
of  life,  of  growth,  of  reproduction,  and  of  death,  as 
well  as  to  notice  the  connection  of  the  latter  with 
mechanical  injuries,  such  as  the  wounds  inflicted  by 
clubs  and  spears  or  by  the  teeth  and  claws  of  wild 
beasts. 

Next  to  the  problems  of  physiology  come  those  of 
pharmacology,  by  which  I  mean  the  poisonous  or 
remedial  action  of  various  substances  mineral,  vege- 
table, or  animal.  A  knowledge  of  this  subject  is 
found  even  among  the  lowest  savages,  and  is  of  the 
greatest  use  to  them,  for  it  enables  them,  on  the  one 
haivd,  to  avoid  eating  things  which  may  cause  discom- 
fort, pain,  or  death,  and,  on  the  other,  to  obtain  food 
by  poisoning  waters  and  thus  catching  fish,  or  by 
poisoning  their  arrows  to  kill  game  which  would 
otherwise  escape.  Closely  associated  with  the  knowl- 
edge of  the  poisonous  is  that  of  the  curative  powers  of 
herbs,  and  it  is  possessed  by  animals  as  well  as  man, 
for  cows  avoid  noxious  plants,  and  dogs  will  every 
now  and  again  eat  grass  apparently  as  medicine. 
Primitive  peoples  use  various  substances  as  remedies 
in  disease,  witli  more  or  less  success,  and  one  of  the 
most  extraordinary  points  in  their  practice  is  that  they 
seem  to  some  extent  to  have  forestalled  the  newest  re- 
searches on  venins,  antivenins,  and  organotherapy, 
for  in  .\frica  tlie  liushmen  are  accustomed  to  drink 
tlie  poison  of  venomous  snakes  as  a  prophvlactic 
against  their  bite,  and  the  Hausas  prevent  hydropho- 
bia by  killing  the  mad  dog  and  making  the  man  it 
has  bitten  eat  its  liver. 

The  occurrence  of  death  from  wounds  or  poison  is 
intelligible  even  to  a  savage,  but  when  illness  and 
death  occur  independently  of  these,  men  naturally 
attribute  tiiem  to  invisible  powers.  Thus  the  Dyaks 
of  Borneo  ascribe  sickness  to  wounds  from  invisible 
spears  wielded  by  invisible  spirits,  and  during  an 
epidemic  of  disease  in  the  Middle  .Ages  the  cry  often 
arose  that  the  wells  had  heeii  pi)isoned.  These  crude 
ideas   contain   germs  of  truth,  and  when   we   look  at 

'  An  address  delivered  before  tlie  Twelfth  International  Medi- 
cal Congress,  held  in  Moscow,  August  ig-26,  iSqy. 


Professor  Met.schnikoff's  drawings  of  a  Daphnia  at- 
tacked by  a  Monospora  we  seem  to  recognize  the  in- 
visible darts  of  the  Dyaks,  while  during  an  epidemic 
of  typhoid  fever  we  have  often  to  acknowledge  that 
our  w'ells  have  been  poisoned  by  bacilli. 

It  is  impossible  to  trace  the  steps  by  which  the 
crude  ideas  of  savage  peoples  regarding  physiolog}-, 
pharmacology,  and  pathology  have  grown  into  defi- 
nite sciences,  or  even  to  indicate  the  most  impor- 
tant landmarks,  though  we  naturally  think  of  the 
names  of  Alkmaon,  Galen,  and  Harvey  in  physiologj-; 
of  Xicander,  Magendie,  and  Bernard  in  pharmacology; 
and  of  Morgagni,  Virchow,  and  Pasteur  in  pathology. 
During  this  century  these  three  sciences  have  devel- 
oped with  almost  incredible  rapidity,  a  complete 
knowledge  of  them  is  enough  to  tax  severely  the  most 
retentive  memory,  and  it  is  almost  impossible  for  any 
individual  to  keep  up  with  the  advance  of  all  three  of 
them. 

But  just  as  the  whole  subject  of  astronomy  became 
.suddenly  simplified  by  a  change  of  standpoint  at  the 
verj'  time  when  cycles  and  epicycles  became  most 
bewildering,  so  at  the  very  time  when  these  three 
sciences  are  becoming  most  complex  and  diverse  they 
appear  to  be  tending  to  unification  and  simplification. 
Pathology,  for  example,  is  now  becoming  to  a  great 
extent  a  branch  of  pharmacolog)-,  for  while  a  few  years 
ago  its  chief  object  was  to  discover,  examine,  and 
classify  the  microbes  which  give  rise  to  disease,  it  is 
now  striving  rather  to  discover  the  nature  and  actions 
of  the  ferments  and  poisons  which  they  form,  and  by 
which  they  are  able  to  cause  disease  and  death  in  the 
animals  they  attack.  Pharmacological  investigation, 
instead  of  being  confined  to  the  alkaloids  and  other 
poisons  formed  by  higher  plants,  has  now  extended  to 
those  formed  by  microscopic  plants  or  microbes,  and 
thus  conies  to  include  a  great  part  of  pathology. 

In  the  same  way,  though  pharmacology  is  a  branch 
of  physiology,  inasmuch  as  it  deals  with  the  phe- 
nomena of  life  as  modified  by  drugs,  yet  physiology 
may,  to  a  certain  extent,  be  regarded  as  a  branch  of 
pharmacolog}-,  because  some  of  the  latest  researches 
regarding  the  processes  of  life  have  been  made  by 
pharmacological  methods,  using  the  products  of  ani- 
mal life  instead  of  vegetable  poi-sons.  Among  the 
pioneers  in  this  line  I  may  mention  my  two  masters, 
Kiihne  and  Ludwig;  the  former  of  whom  by  his 
chemical  investigations  has  enabled  us  to  differentiate 
the  various  products  of  albuminous  decomposition, 
while  the  latter,  with  his  pupils,  Schmidt-Miihlheim 
and  W'ooldridge,  discovered  the  poisonous  action  of 
albumoses  and  peptones,  and  of  the  juices  of  various 
tissues  when  injected  directly  into  the  blood. 

Before  the  proteid  constituents  of  our  food  can  be 
absorbed  they  must  be  split  up  during  digestion  into 
albumoses  and  peptones :  vet  these  researches  show 
that  the  very  sub.stances  which  are  necessary  to  repair 
waste  and  are  indispensable  for  the  continuance  of  life 
prove  fatal  when  introduced  into  the  body  in  a  wrong 
way  or  in  too  great  quantity.  But  the  products  of  the 
digestion  of  albumin  do  not  normally  enter  the  circu- 
lation as  albumoses  and  peptones.  During  absorption 
they  undergo  changes  of  a  synthetic  nature  in  the 
walls  of  the  intestine,  and  probably  to  a  certain  extent 
also  in  the  liver,  so  that  they  again  form  harmless 
substances,  and  their  poisonous  properties  are  de- 
.stroyed  before  thev  enter  the  general  blood  stream. 

But  how  is  it  that  the  ferments  which  decompose 
albuminous  food  and  form  poisons  from  it  in  the  in- 
testine do  not  pass  into  the  blood  and  kill  the  animal 
by  digesting  the  tissues  and  forming  poisons  from 
them  ?  Of  course  iiejisin  cannot  do  so,  as  it  acts  only  in 
an  acid  medium,  but  there  is  no  such  hindrance  to  the 
action  of  trypsin,  and  yet  it  does  not  destroy  the  tis- 
sues composing  the  body   itself.      In   all   probability 


August  28,  1897] 


MEDICAL    RECORD. 


297 


the  reason  why  digestive  ferments  do  not  digest  the 
tissues  is  not  that  they  are  destroyed  in  the  digestive 
canal,  nor  yet  that  they  are  not  absorbed,  but  that  they 
are  altered  from  active  enzymes  into  inert  zymogens 
which  can  be  stored  up  without  risk,  and  can  again 
liberate  active  enzymes  when  these  are  required  to  di- 
gest a  subsequent  meal.  In  tliis  respect  they  may  be 
compared  to  the  knives  used  by  wandering  peoples  to 
cut  up  their  meat,  and  which  are  not  thrown  a\va\- 
after  each  meal,  but  are  simply  put  into  sheaths  which 
cover  their  edges  and  deprive  them  for  a  time  of  their 
cutting  power. 

But  it  is  not  in  the  intestine  only  that  enzymes  are 
found;  they  are  also  poured  into  the  blood  by  the  pan- 
creas and  probably  by  the  thyroid  and  other  glands. 
As  our  acquaintance  with  the  processes  of  cell  life  in- 
creases it  seems  more  and  more  likely  that  the  tissue 
change  on  which  functional  activity  depends  is  effected 
by  enzymes,  and  the  truer  do  the  speculations  of  Van 
Helmont  appear — that  life  is  a  process  of  fermentation. 

There  can  be  little  doubt  that  if  enzymes  in  a  free 
state  were  to  circulate  through  the  body  they  would  do 
much  harm,  and  indeed  we  may  regard  this  as  well- 
nigh  proved  in  regard  to  the  enzyme  of  tetanus. 

But  their  action  is  limited  either  by  their  conversion 
into  zymogens  or  their  localization  to  the  cells  or  tis- 
sues where  their  action  is  required.  This  is  more 
readily  seen  in  plants  than  in  animals,  and  one  of  the 
best  examples  of  it  is  that  in  germinating  wheat.. 

In  the  ordinary  state  of  the  grain  the  diastatic  fer- 
ment is  kept  apart  from  the  starch  by  a  small  layer  of 
cellulose,  through  which  the  diastase  cannot  pass,  but 
during  germination  another  ferment  appears  which 
has  the  power  of  dissolving  cellulose,  and  by  breaking 
down  this  dividing  membrane  it  allows  the  diastatic 
ferment  to  act  upon  the  starch,  and  renders  it  avail- 
able for  the  needs  of  the  growing  plant. 

Enzymes  appear  to  differ  among  themselves  nearly 
as  much  as  albumin,  albumoses,  and  peptones.  Some 
are  easily  separated  from  the  cells  in  which  they  e.xist, 
while  others  are  so  closely  united  to  the  protoplasm 
that  their  separate  existence  apart  from  it  has  been 
denied.  The  yeast  plant,  for  example,  yields  an  in- 
vert enzyme  which  can  be  extracted  with  comparati\e 
ease,  but  the  enzyme  which  splits  up  sugar  into  alcohol 
and  carbonic  acid  is  so  firmly  attached  to  the  proto- 
plasm of  the  cell  that  it  is  only  within  the  last  few 
months  that  it  has  been  isolated  by  Buchner  by  the 
application  of  enormous  pressure.  It  is  probable  that 
the  enzymes  contained  in  the  cells  of  animal  tissues 
differ  in  like  manner,  and  that  by  the  use  of  similar 
methods  we  may  obtain  a.  number  of  enzvmes  with 
which  we  are  at  present  unacquainted. 

But  it  is  not  merely  the  products  formed  in  the 
digestive  canal,  or  in  the  organs  of  ar.imals  during 
life,  nor  even  the  alkaloids  that  are  formed  bv  the 
higher  plants,  that  act  as  poisons.  The  processes  of 
life  are  much  the  same  in  the  lowest  microbes  as  in 
animils,  or  in  the  higher  plants,  and  these  microbes, 
by  forming  ferments  and  poisons,  give  rise  to  disturb- 
ance of  function  or  death  in  animals.  When  grown 
in  suitable  media  outside  the  body  they  produce  en- 
zymes and  poisons,  albumoses  and  alkaloids,  and 
many  of  them  continue  to  do  .so  after  their  introduc- 
tion into  the  body. 

One  of  the  most  curious  points,  in  the  chemistr)' 
of  both  the  higher  plants  and  of  microbes,  is  that  they 
tend  to  form  at  the  same  time  a  poison  and  its  anti- 
dote. In  Calabar  bean,  for  example,  we  find  there  are 
two  poisons — physostigmine  and  calabarine,  the  former 
tending  to  paralyze  the  spinal  cord  and  the  latter  to 
stimulate  it,  so  that  each  poison  to  a  certain  extent 
antagonizes  the  other.  The  same  condition  is  found 
even  more  markedly  in  jaborandi,  of  which  the  two 
alkaloids,  pilocarpine    and    jaborine,  antagonize    one 


another's  action,  so  that,  although  pilocarpine  generally 
greatly  predominates,  it  might  be  possible  to  get  a 
specimen  of  the  leaf  having  no  action  at  all  although 
it  contained  a  quantity  of  alkaloids. 

When  injected  into  animals  the  toxins  formed  by 
microbes  and  the  venins  of  serpents  cause  the  produc- 
tion of  antitoxins  and  antivenins  which  neutralize 
their  action  apparently  by  chemical  combination  in 
somewhat  the  same  way  as  an  acid  and  alkali,  each 
poisonous  by  itself,  combine  to  form  a  comparatively 
inert  salt.  But  the  two  components  here,  like  an  or- 
ganic acid  and  a  mineral  base,  are  unequally  affected 
by  destructive  agencies,  and  the  antivenin  may  be  de- 
stroved,  so  that  the  \enin  again  regains  its  activitv. 

The  conversion  of  zymogens  into  enzymes  mav  be 
compared  to  the  freeing  of  veniris  from  their  com- 
pounds, while  the  conversion  of  active  venins  into  in- 
ert bodies  by  combination  with  antivenins  suggests 
that  a  similar  process  may  occur  in  the  case  of  active 
enzymes,  by  which  they  may  be  converted  into  inactive 
zymogens. 

Perhaps  the  hypothesis  I  mentioned  eight  years  ago 
to  my  pupil  and  friend,  Mr.  Hankin,  that  the  germi- 
cidal power  of  organisms  is  ]3roportional  to  their  power 
to  produce  enzymes,  may  not  be  altogether  unfounded, 
and  possibly  we  may  discover  also  that  immunity,  nat- 
ural or  acquired,  is  nothing  more  than  an  extension 
to  the  cells  of  the  tissues  generally  of  a  power  which 
is  constantly  exercised  during  digestion  by  those  of 
the  intestine  and  liver. 

This  problem  is  one  which  pertains  to  all  three 
sciences,  and  has  a  most  important  bearing  on  practi- 
cal medicine. 

Practical  medicine,  except  when  empirical,  de- 
pends for  its  advance  on  physiology,  pharmacology, 
and  pathology.  A  knowledge  of  the  physiolog)-  of 
digestion  has  led  to  the  satisfactory  treatment  of  dys- 
pepsia by  the  administration  of  digestive  enzymes, 
and  pharmacological  research  has  enabled  us  to  treat 
diseases  of  the  circulation  with  a  success  previously 
undreamt  of,  by  teaching  us  not  only  how  to  use 
aright  old  remedies,  such  as  digitalis,  but  also  how  to 
apply  new  ones,  such  as  strophanthus  and  amyl  nitrite, 
and  even  to  manufacture  others,  such  as  nitro-ervthrol, 
which  possess  the  special  actions  we  desire,  but  are 
lacking  in  the  drugs  we  already  have.  Indeed  new 
remedies,  which  shall  alter  tissue  change,  lower  tem- 
perature, relieve  pain,  and  procure  sleep,  are  now  be- 
ing made  in  such  numbers  that  it  is  hard  to  keep  count 
of  them. 

But  among  all  the  new  gains  of  practical  medicine 
none  are  so  remarkable  as  those  which  we  owe  to 
pathology.  Time  would  fail  me  to  speak  of  the  pre- 
vention and  cure  of  zymotic  diseases,  but  no  less  as- 
tonishing is  the  discovery  that  myxcedema  depends  on 
inactivity  or  absence  of  the  thyroid  gland,  and  can  be 
cured  by  the  administration  of  its  extract,  which  seems 
to  act  as  an  enzyme  on  living  tissues,  so  that  the  lieavy, 
shapeless  features  of  the  patient  resume  their  natural 
expression  and  the  sluggish  mental  processes  become 
quickened.  An  exhaustive  study  of  enzymes  and  their 
products  appears  to  be  the  most  promising  way  of  ad- 
vancing our  knowledge  of  both  the  nature  and  treat- 
ment of  disease.  Probably  more  is  to  be  hoped  for 
from  an  investigation  into  the  nature  and  properties 
of  those  enzymes  which  are  intimately  associated 
with  the  protoplasm  of  the  cells  in  the  various  tissues 
and  organs  than  even  of  those  which  are  poured  into 
the  blood  by  glands  having  an  internal  secretion,  such 
as  the  thyroid.  For  all  organs,  even  those  which,  like 
muscles  and  nerves,  are  not  glandular,  have  an  action 
on  the  blood  comparable  to  that  of  the  yeast  plant, 
which  modifies  the  fluid  in  which  it  lives  by  the  sub- 
stances which  it  removes  from  or  adds  to  it.  It  is  to 
a  knowledge  of  the  processes  which  occur  in  the  pro- 


MEDICAL    RKCORD. 


[August  28,  1897 


toplasm  of  the  cells  in  the  intestinal  wall  and  liver, 
and  of  the  enzymes  by  which  these  processes  are  in  all 
probability  carried  out,  that  we  must  look  for  an  ex- 
planation of  the  conversion  of  the  poisonous  albumoses 
formed  during  digestion  into  innocuous  albumins,  and 
of  dangerous  enzymes  into  harmless  zymogens. 

Moreover,  it  seems  to  me  that  it  is  by  researches 
into  the  nature  and  action  of  the  enzymes,  not  only  of 
microbes,  but  in  the  various  tissues  of  the  body  in 
higher  animals,  that  we  shall  learn  how  the  microbes, 
like  the  enzymes  of  the  intestinal  canal,  produce 
poisonous  albumoses,  and  how  the  tissues,  like  the 
cells  of  the  intestinal  walls  or  liver,  convert  them  into 
harmless  or  even  protective  substances.  In  this  way 
we  may  hope  to  obtain  an  explanation  of  toxins  and 
antitoxins,  of  pathogenesis  and  immunity,  as  well  as 
of  the  nature  of  diseases  unconnected  with  the  pres- 
ence of  microbes,  such  as  diabetes.  Twent3'-three 
years  ago  I  attempted  to  obtain  a  glycolytic  enzyme 
from  muscle,  in  order  to  enable  diabetic  patients  to 
utilize  the  sugar  in  their  blood.  My  attempt  was  un- 
successful, but  we  may  still  hope  that  by  other  methods 
we  may  obtain  from  animal  organs  various  enzymes, 
the  administration  of  which  may  prove  as  useful  in 
other  diseases  as  the  thyroid  in  myxcedema. 

Practical  medicine  depends  on  physiolog)%  pharma- 
cology, and  pathology,  but  all  three  are  tending  to 
become  more  and  more  subdivisions  of  the  wider  and 
all-embracing  science  of  chemistry.  It  is  to  a  chem- 
ist, Pasteur,  that  we  owe  the  wonderful  development  of 
pathology  within  the  last  quarter  of  a  centur)-,  and  we 
may  fairly  regard  his  fellow-countryman,  Lavoisier,  as 
the  founder  of  this  science.  Men  from  all  countries, 
and  especially  from  Germany,  have  aided  its  develop- 
ment; but  it  seems  fitting  that  at  this  congress,  in 
acknowledging  our  obligations  to  this  science,  we 
should  not  omit  to  mention  that  at  its  head  now  stands 
a  Russian,  Mendeleef,  whose  marvellous  prescience 
enabled  him  to  predict  the  existence  of  elements 
\\hich  were  then  unknown^,  and  even  to  describe  their 
properties  more  correctly  than  those  who  first  verified 
his  predictions  by  obtaining  the  substances  them- 
selves. When  we  consider  that  little  more  than  a 
hundred  years  have  elapsed  since  the  time  of  Lavoi- 
sier, and  contemplate  the  vast  benefits  which  medicine 
and  its  allied  sciences  have  derived  from  chemistry 
during  this  time,  our  hopes  cannot  be  otherwise  than 
great  for  the  centuries  to  come. 


MUSHROOM    POISONINC;. 
liv  GUIDO    E.  CA(JL1?.RI.   M.O.. 

SAS   FRANCISCO.   CAl.. 

Last  February  I  was  called  in  consultation  to  see  a 
family  of  six  persons  who  had  partaken  of  poison- 
ous mushrooms,  which  resulted  in  the  death  of  three 
of  the  children.  I  consider  it  interesting  to  report 
these  cases  from  the  fact  that  the  symptomatology  was 
unlike  that  of  the  usual  cases  of  reported  poisoning,  and 
furthermore  for  the  reason  that  poisoning  by  toadstools 
should  be  more  carefully  studied  by  physicians  and 
reported,  so  that,  in  view  of  the  uncertainty  which  ex- 
ists in  the  literature  on  this  subject,  we  may  gather 
more  extensive  data  from  wliich  to  draw  our  deduc- 
tions. 

The  special  mushroom  whicli  produced  death  in  these 
cases  was  pronounced  by  botanists  to  be  the  Agaricus 
muscaria,  but  I  suspect  there  was  more  than  one 
variety  among  those  eaten  ;  therefore  not  too  much  im- 
portance must  be  attached  to  the  above  classification. 

Case  I. — Hoy,  aged  eight:  robust;  he  ate  a  little  over 
one-half  of  a  medium-sized  fungus  about  six  o'clock 
on  the  evening  of  February  2  4.th  ;  he  slept  well  alt  night 


and  awoke  next  morning  with  little  disposition  to 
play  with  his  brothers  before  getting  up,  as  was  his 
custom  each  morning.  When  he  arose  from  bed  he 
had  a  loose  passage  but  complained  of  no  pain.  The 
father  noticed  that  his  eyes  had  not  their  usual  bright- 
ness. When  dressed  he  complained  of  being  short  of 
breath  and  wanted  to  stay  in  the  open  air.  The 
bowels  again  moved,  with  more  pain.  The  father,  sus- 
pecting the  mushrooms,  then  administered  castor  oil 
to  all  the  family,  which  was  vomited  by  them.  After 
this  the  diarrhcea  increased  and  likewise  the  griping, 
but  no  further  vomiting  followed  the  administration  of 
the  oil.  At  three  o'clock  the  boy  was  feeling  fairly 
well,  but  quite  weak;  in  the  mean  time  the  father  had 
consulted  a  physician,  who  gave  him  some  chlorodyne 
for  the  boy.  During  the  early  part  of  the  evening  he 
was  taken  with  convulsions  which  increased  in  inten- 
sitj',  and  at  eleven  o'clock  he  expired  in  one  of  these 
attacks.  I  did  not  see  this  patient,  being  called  in 
consultation  the  next  morning. 

C.\.SE  II. — Boy,  aged  five;  robust;  he  ate  the  same 
quantity  as  the  former,  and  likewise  slept  well  during 
the  entire  night,  looking  dull  in  the  morning;  after 
dressing  he  went  into  the  yard  to  get  some  fresh  air, 
complaining  of  dyspnota  as  his  brother  had  done.  After 
he  was  given  the  oil  he  vomited,  which  was  soon  fol- 
lowed by  diarrhoea, but  he  did  not  complain  particularly 
of  pain  ;  during  the  evening  he  stated  that  he  felt  well, 
although  the  father  says  he  had  the  same  dull  look 
that  was  present  during  the  day.  After  the  death  of 
the  first  patient  he  was  put  to  bed,  and  slept  ap- 
parently soundly  during  the  night,  being  awakened 
only  for  his  medicine.  Following  the  death  of  the 
first  child,  another  physician  was  called  in,  who  ad- 
vised the  administration  of  two  drops  of  tincture  of 
belladonna  every  hour;  this  was  given  to  all  the 
patients  during  the  rest  of  the  night.  The  follow- 
ing morning  the  boy  on  awaking  asked  for  his  coffee, 
which  was  at  once  ejected  by  the  stomach,  followed 
by  general  convulsions.  It  was  at  this  time  that  I 
was  sent  for  and  found  the  boy  in  the  dorsal  decubitus, 
breathing  heavily  and  quickly  with  slightly  livid  face. 
The  pulse  was  very  rapid,  empty,  easily  compressed 
but  regular.  It  was  impossible  to  arouse  him;  the 
pupils  were  contracted  and  did  not  react  to  light; 
toward  the  end  they  dilated  widely.  The  body  was 
dry  with  the  e.xception  of  the  face  and  neck,  which 
were  slightly  moistened  with  perspiration.  It  was 
quite  evident  that  the  patient  was  moribund  and  after 
several  hours  of  convulsions  he  died. 

C.\SE  III. — Boy,  aged  ten;  robust;  ate  about  one- 
sixth  of  a  mushroom.  During  the  same  evening  he  slept 
well,  and  next  morning  with  the  exception  of  the  sick- 
ness produced  by  the  oil  felt  well  enough  to  attend 
school,  where  he  had  a  slight  attack  of  vomiting  at  ten 
o'clock.  During  the  rest  of  the  day  no  particular  ill- 
ness was  complained  of,  with  the  exception  of  a  feel- 
ing of  lassitude  and  restlessness.  I  saw  this  patient 
in  the  morning,  thirty-six  hours  after  the  ingestion  of 
the  mushrooms;  at  this  time  there  was  an  expression 
of  extreme  fear  on  his  countenance.  The  pupils  were 
contracted;  the  head  and  neck  were  covered  with  per- 
spiration; the  respirations  were  rapid  and  full:  the 
pulse  was  rapid,  full,  and  regular.  There  was  no 
vomiting,  diarrhcea,  or  colic.  The  intelligence  was 
considerably  blunted.  After  a  few  hours  I  again 
saw  him  and  he  was  then  comatose,  although  whtn 
shaken  violently  and  asked  if  he  wished  to  drink  he 
would  answer  in  the  affirmative.  The  pulse  at  this 
time  was  slower  and  the  pupils  were  more  dilated, 
but  as  he  was  now  being  subjected  to  injections 
of  atropine  this  change  was  probably  due  to  the 
drug.  His  condition  for  the  next  fifteen  or  twenty 
hours  remained  the  same;  there  were  occasional  at- 
tempts at  vomiting,  and  there  seemed  to  be  a  suppres- 


August  28,  1897] 


MEDICAL    RECORD. 


299 


sion  of  urine,  which  ceased  after  the  application  of  hot 
poultices  to  the  loins.  The  evening  of  the  third  day 
after  eating  the  fungi  the  boy  grew  worse;  his  stupor 
became  more  profound,  the  pupils  more  dilated,  the 
pulse  more  quickened,  more  compressible  and  irregu- 
lar, the  breathing  acquiring  the  characters  of  Cheyne- 
Stokes  respiration,  and  lastly  a  hiccough  developed. 
At  three  o'clock  the  next  morning  there  was  a  spasm 
of  the  lower  jaw,  which  lasted  but  a  few  minutes,  and 
then  death  super\-ened,  the  pulse  becoming  rapidly 
feebler  and  irregular  just  before  the  end.  Death  oc- 
curred in  this  case  eight}'  hours  after  the  boy  had 
eaten  the  mushrooms. 

Case  IV. — -The  father,  a  man  of  about  thirty-eight, 
strong,  robust,  and  of  unusual  intelligence,  ate 
by  far  the  most  of  the  mushrooms,  having  consumed 
at  his  dinner  nearly  two  mushrooms.  That  night  he 
felt  a  little  dull  and  the  next  morning  on  awaking 
felt  more  so.  However,  he  overcame  this  feeling  and 
went  out  in  the  morning  to  get  the  castor  oil,  which 
he,  like  the  others,  vomited.  He  again  vomited  at 
eleven  o'clock  in  the  morning.  During  the  day  he 
was  stupid,  but  still  felt  anxious  regarding  the  chil- 
dren. He  continued  in  this  state  until  after  the  death 
of  the  first  boy,  when  he  felt  so  ill  that  he  was  obliged 
to  go  to  bed,  attributing  his  illness  to  grief  at  the 
death  of  his  son.  He  could  not  sleep,  but  yet  had 
a  feeling  of  satisfaction:  he  realized  that  his  son 
was  dead  yet  did  not  care.  During  the  early  hours 
of  the  morning  he  attempted  to  arise  but  found  he 
could  not  move  excejrt  after  great  effort.  His  feel- 
ing of  apathy  then  gave  way  to  one  of  great  fear 
for  the  safety  of  the  children.  In  the  mean  while 
the  gastro-intestinal  symptoms  were  becoming  more 
marked,  and  he  was  taken  with  frequent  desire  to  go 
to  stool  and  slight  vomiting.  I  saw  him  at  this  time 
and  found  him  in  a  stupwr;  he  was  easily  aroused  and 
was  then  able  to  answer  questions  fairl)-  intelligently. 
The  skin  was  moist  with  perspiration;  the  pulse  small 
and  rapid  but  regular:  the  breathing  quick,  shallow, 
and  noisy;  the  pupils  were  slightly  contracted.  This 
condition  continued  for  a  period  of  twent}-four  hours 
or  more,  and  then  gradually  improved,  so  that  in  a  few 
days  he  was  entirely  well  with  the  exception  of  an 
urticaria  which  developed  over  the  body  generally. 

Case  V. — The  mother,  aged  about  thirt)--five,  robust 
and  healthy.  N'ervous  temperament.  She  showed 
few  signs  of  intoxication  with  the  exception  of  slight 
diarrhcea  and  vomiting,  with  some  mental  e.xcitement. 
.\fter  the  death  of  the  third  son  she  had  an  attack  of 
hysteria,  which  soon  passed  and  there  was  no  further 
trouble.  She  ate  only  one-sixth  of  a  mushroom,  which 
accounted  for  the  mildness  of  the  case. 

Case  VI. — Little  girl,  aged  four:  ate  about  one- 
si.xth  of  a  mushroom ;  her  symptoms  were  the  mildest 
of  all :  she  had  only  a  little  vomiting  on  the  second  day 
and  practically  no  other  signs.  The  treatment  was 
mainly  prophylactic  in  her  case. 

This  is  a  resume  of  the  cases  which  it  was  my  lot 
to  have  to  treat.  I  presume  my  readers  will  be 
struck,  as  I  was,  with  the  difference  in  time  it  took  the 
mushrooms  to  prove  fatal.  The  second  son,  who  ate 
about  one-half  of  a  mushroom,  died  in  about  thirty 
hours,  whereas  the  younger  brother  died  after  eating 
the  same  quantit)-  twenty  hours  later.  The  eldest  son, 
who  ate  the  same  quantity  as  the  little  girl  and  mother, 
succumbed  after  eighty  hours,  whereas  his  sister 
and  mother  were  but  slightly  disturbed.  Lastly  the 
father,  who  ate  nearly  two  entire  mushrooms,  was  ren- 
dered quite  sick,  but  recovered  after  eating  nearly  four 
times  the  quantity  that  proved  fatal  in  thirt}-  hours  in 
a  boy  of  eight  years. 

It  would  be  impossible  to  draw  any  conclusions 
from  the  above  figures  except  what  seems  to  me  to  be 
most  likely — that  there  was  only  one  poisonous  mush- 


room in  the  small  lot  that  was  cooked  and  that  this 
was  divided  among  the  boys,  the  others  suffering  from 
the  edible  fungi  being  impregnated  with  poisonous 
principles  in  the  process  of  cooking.  The  study  of 
poisonous  fungi  and  the  nature  of  the  poison  is  one 
of  the  most  difficult  in  toxicologj'.  Cases  of  poison- 
ing by  mushrooms  are  fairly  common,  especially  in 
winter  and  spring,  but  fortunately  many  terminate 
favorably  even  after  severe  manifestations  of  toxic 
action.  I  consider  it  unnecessary  in  this  paper  to 
describe  the  criteria  for  distinguishing  the  poisonous 
from  the  non-{X)isonous  varieties,  for  this  is  necessary 
only  for  those  interested  in  the  gathering,  selling,  and 
cooking  of  this  dangerous  article  of  food.  Moreover.  I 
think  that  if  I  were  to  do  so  I  would  have  a  difficult  task 
on  my  hands,  if  I  am  to  be  guided  by  what  I  read  in  this 
regard.  Dr.  R.  T.  Foster,  in  an  article  in  The  Boston 
Medical  and  Surgical  Journal,  says  that  the  signs  of 
differentiation  between  the  two  varieties  are  not  well 
marked:  while  on  the  other  hand  Dr.  Charles  Mcll- 
vaine,  in  an  article  in  The  Therapeutic  Gazette,  stales 
that  it  is  verj-  easy  indeed  to  recognize  the  edible 
from  the  non-edible  fungi.  Lastly,  many  of  the  Ger- 
man authorities  claim  that  all  fungi  are  poisonous,  a 
statement  which  I  consider  exaggerated. 

However,  be  this  as  it  may,  the  facts  remain  that 
when  we  are  called  to  treat  people  who  have  been 
suddenly  taken  ill  and  give  a  historj-  of  having 
feasted  on  mushrooms,  it  is  our  duty  to  act  and  act 
quickly,  without  delaying  to  inquire  as  to  the  nature  of 
the  mushroom  partaken  of.  The  poisoning  due  to 
mushrooms  manifests  itself  in  t^vo  ways:  the  one  with 
marked  gastro-intestinal  s\Tnptoms  coming  on  soon 
after  the  ingestion  of  the  fungi  and  rarely  fatal  in 
adults,  the  other  with  similar  symptoms  soon  super- 
seded by  a  narcotic  condition  frequently  ending  fatallv. 

The  former  cases  explain  why  some  consider  all 
forms  of  fungi  as  poisonous.  Their  opinion  is  based 
on  the  fact  that  many  forms  of  edible  fungi  have  at 
times  caused  dangerous  s\-mptoms  in  those  who  have 
partaken  of  them,  ignoring  whether  the  mushrooms  con- 
tained some  alkaloid  proper  to  the  plant  or  whether 
the  sickness  was  not  induced  by  some  other  acci- 
dental conditions  developed  in  them.  Mushrooms 
are  substances  rich  in  water,  nitrogen,  and  vegetable 
albumin,  which  in  the  presence  of  heat  and  air  furnish 
capital  conditions  for  putrefactive  changes  giving  rise 
to  noxious  ptomains  which  are  violent  irritants  to  the 
alimentar}'  tract  in  exactly  the  same  manner  that 
meats,  cheese,  and  other  articles  of  food  are  when 
spoiled.  It  is  likely  also  that  variations  in  the  soil 
may  affect  the  nature  of  edible  mushrooms,  for  it  is 
probable  that  these  have  an  influence  on  the  products 
elaborated  by  the  vital  activit}-  of  the  plant,  in  the 
same  way  that  certain  bacteria  become  pathogenic 
only  when  cultivated  in  certain  special  culture  media. 

The  treatment  to  be  instituted  in  poisoning  by  this 
non-muscarine-containing  mushroom  consists  only  in 
allaying  the  pain,  nausea,  and  diarrhoea,  and  stimulat- 
ing the  heart  with  mild  cardiac  e.xcitants.  The  form 
of  poisoning  which  occurred  in  the  cases  I  have  re- 
ported was  not  of  this  type,  but  was  due  to  the  deadly 
Amanita  muscaria.  The  poisonous  principle  is  gener- 
ally conceded  to  be  muscarine,  first  isolated  by  Schmie- 
deberg.  Apoigier  has  prepared  from  the  amanita  a 
crystallizable  acid  principle,  soluble  in  ether.  Leteil- 
lier  separated  an  amorphous  tasteless  substance  that  he 
named  amanitine.  Ponchet,  in  an  article  which  re- 
cently appeared  in  Le  Progris  Mifdical,  denies  that  the 
active  toxic  principle  of  toadstools  is  muscarine,  and 
claims  it  to  be  an  albuminous  compound  similar  to 
the  toxins  found  in  putrid  organic  matter,  which  has 
when  injected  into  frogs  a  physiological  action  in  no 
way  similar  to  that  of  muscarine.  Muscarine,  accord- 
ing to  the  description  of  Schmiedeberg,  is  a  colorless, 


300 


MEDICAL    RECORD. 


[August  28,  1897 


syrupy  mass,  lacking  odor  or  taste,  easily  soluble  in 
water,  especially  if  slightly  acidulated,  and  in  absolute 
alcohol;  it  forms  salts  with  acids  and  has  an  alkaline 
reaction.  Muscarine  is  present  in  the  dry  fungus  to 
the  amount  of  about  one-fifth  per  cent.  The  symp- 
toms produced  by  muscarine  poisoning  are  similar  to 
those  produced  by  amanita.  I  have  been  unable  to  find 
a  case  of  muscarine  poisoning  reported,  but  from  its 
administration  in  animals  we  see  symptoms  quite  simi- 
lar to  those  found  in  cases  in  which  poisonous  fungi 
have  been  eaten. 

Rademaker,  in  an  article  on  the  to.xic  action  of  mus- 
carine, in  The  American  J'ractitio)ier  a/ul  Nezos,  says,  in 
speaking  of  the  physiological  action  of  this  drug, 
that  "after  the  administration  of  ten  grains  of  sul- 
phate of  muscarine  to  a  dog  weighing  thirty  pounds 
the  symptoms  manifested  were  as  follows:  Half  an 
hour  after  eating  the  food  containing  the  muscarine, 
vomiting  was  produced,  followed  almost  immediately 
by  evacuations  from  the  bowels  and  the  passage  of 
urine.  The  pupils  became  contracted  and  the  heart's 
action  irregular.  The  lacrymal  secretion  and  flow 
of  saliva  were  increased:  at  the  same  time  the  dog 
had  general  tremors.  The  dog  completely  recovered. 
The  next  day  the  same  dog  was  given  the  same  dose 
again,  with  the  same  symptoms  following  and  complete 
recovery  in  eight  hours.  These  e.\:periments  prove 
that  muscarine  cannot  be  considered  a  very  powerful 
poison,  but  it  demonstrates  the  fact  that  its  action 
is  almost  immediate,  even  when  taken  with  a  full 
meal." 

I  cannot  agree  with  Rademaker  when  he  says  that 
muscarine  is  not  a  powerful  poison.  He  doubtless 
forgot  that  much  of  the  ingested  poison  was  eliminated 
with  the  vomited  matter.  Schmiedeberg  found  that 
one-thirteenth  of  a  grain  of  muscarine  in  the  human 
subject  caused  myosis,  loss  of  focalizing  power,  abun- 
dant secretion  of  saliva,  flushing  of  the  face,  perspira- 
tion of  the  whole  body,  griping  and  rumbling  in  the 
bowels  and  a  feeling  of  weight  in  tlie  head.  Moreover, 
Avhen  we  consider  that  the  quantity  of  muscarine  in  the 
amanita  in  the  dry  state  is  one-fifth  per  cent,  and  that 
the  quantit)'  of  mushrooms  eaten  by  the  eldest  of  the 
three  boys  that  died  was  so  small  (only  one-si,\th  of  a 
small  mushroom  which  was  rich  in  water)  was  suffi- 
cient to  produce  death  in  eighty  hours,  I  consider  it 
indeed  a  very  powerful  poison  or  else  there  must  be 
present  in  the  mushrooms  secondary  poisons  of  which 
we  have  no  knowledge. 

The  treatment  of  these  cases  is,  as  in  all  cases  of 
poisoning,  to  empty  the  stomach  if  we  think  that  any 
food  remains  in  this  organ  and  to  administer  a 
good  purge:  ne.\t  to  support  the  strength  of  the  heart 
by  the  injection  of  stimulants.  The  drug  pur  ixce/- 
Jeiue  which  is  to  be  used  for  this  is  atropine.  This 
is  a  real  antidote  to  muscarine,  having  in  every  respect 
a  physiological  action  exactly  opposite  to  that  of  mus- 
carine. The  treatment  followed  in  my  cases  was  that 
pursued  and  recommended  by  all  toxicologists.  Ow- 
ing to  the  fact  that  I  saw  the  patients  as  late  as  thirty- 
six  hours  after  they  had  eaten  the  mushrooms,  1  consid- 
ered it  useless  to  administer  an  emetic,  and  furthermore 
it  was  evident  from  the  condition  of  the  patients  that 
the  poison  had  to  be  combated  in  the  circulation. 
The  patients  were  immediately  given  injections  of 
one-fiftieth  of  a  grain  of  sulphate  of  atropine  and  one- 
sixtieth  of  a  grain  of  strychnine  alternately  every  hour. 
The  children  were  given  less  strychnine  in  proportion 
than  the  adults,  but  were  given  the  same  quantity  of 
atropine,  with  the  exception  of  the  little  girl,  who, 
owing  to  the  mildness  of  her  .symptoms,  did  not  re- 
cpiire  ver}'  active  treatment.  After  the  injections,  the 
pupils  dilated  widely  and  the  heart  and  breathing  im- 
proved, but  the  coma  remained  unchanged.  The 
patients    were    given    in    addition    cracked    ice    with 


cognac  and  seltzer  by  the  inouth.  Authorities  all 
agree  that  fluids  by  the  mouth  are  injurious,  owing  to 
the  fact  that  they  favor  the  absorption  of  the  muscar- 
ine, which  is  very  soluble  in  water.  This  objection, 
though,  is  not  to  be  considered  in  my  cases,  for  the 
muscarine  had  undoubtedly  all  been  absorbed  and  the 
administration  of  water  could  only  do  good  by  favor- 
ing the  flow  of  urine  and  in  this  way  accelerating  the 
elimination  of  the  poison  from  the  system. 

Atropine  is  unquestionably  the  most  reliable  anti- 
dote that  v.e  possess  for  mushroom  poisoning.  Com- 
paring the  action  of  muscarine  and  atropine  in  the 
animal  body,  we  find  an  almost  complete  physio- 
logical antagonism.  Why,  then,  you  may  ask,  were 
we  not  more  successful  in  our  cases?  The  reasons  are 
several. 

(i)  The  time  which  elapsed  from  the  fatal  meal 
to  the  beginning  of  the  manifestations  of  toxic  symp- 
toms was  so  great  that  the  poison  was  undoubtedly 
all  absorbed,  and  hence  emetics,  purges,  etc.,  were 
useless. 

(2)  The  period  which  elapsed  from  this  time  to  the 
injections  of  atropine  brings  up  the  total  to  about 
thirty-six  hours  before  the  patients  received  the  treat- 
ment which  might  have  saved  their  lives. 

(3)  The  injections  of  atropine  should  have  been 
made  more  frequently  and  in  smaller  quantities. 

(4)  The  slow  elimination  of  the  poison  from  the 
body  owing  to  the  suppression  of  urine. 

This  suppression  of  urine  is  common  in  cases  of 
poisoning  from  many  other  substances,  and  I  have  no 
doubt  is  caused  by  the  great  lowering  of  blood  pressure 
due  to  the  vasomotor  paralysis.  That  there  is  a 
paralysis  of  the  vasomotor  system  and  of  the  sym- 
pathetic in  muscarine  and  many  other  forms  of  poison- 
ing, is  shown  by  the  livid  face,  congestion  of  the  con- 
junctiva, oral  and  nasal  mucous  membrane  (more 
marked  in  other  cases  I  have  read  of  j,  headaches  and 
delirium,  contracted  pupils,  increased  flow  of  saliva 
and  of  perspiration. 

The  ideal  method  of  treating  any  case  of  poisoning 
in  which  the  toxic  substances  have  already  entered 
the  blood  would  be,  first,  to  stimulate  the  heart  only 
to  that  point  necessary  to  overcome  the  decreasing 
action  of  the  poisonous  drug :  second,  to  hasten  the 
elimination  of  the  poison  as  much  as  possible;  third, 
to  dilute  the  poison  as  much  as  possible  within  the 
body.  Regarding  the  use  of  cardiac  excitants  in 
poisoning-cases,  I  consider  that  the  greatest  discretion 
is  necessary,  for  at  this  time  the  heart  is  laboring 
under  the  greatest  disadvantages  and  the  slightest 
overstimulation  mav  cost  the  patient  his  life.  It 
is  for  this  reason  I  would  suggest  a  change  in  the 
method  of  administration  of  stimulants  in  these 
cases.  We  are  called  to  see  a  case  similar  to  those 
I  have  described  and  we  find  the  heart  badly  af- 
fected; we  at  once  inject  a  fair  dose  of  some  cardiac 
stimulant  and  the  heart  in  a  few  minutes  picks  up  its 
strength  so  as  to  beat  e\  en  more  strongly  than  normal, 
then  in  a  brief  period  it  again  begins  to  fail:  but  we 
do  not  always  dare  to  gi\e  another  injection  at  once 
for  fear  of  substituting  ()ne  poison  for  another.  In 
this  way  the  iieart  is  alternately  overstimulated  and 
then  allowed  to  beat  on  in  a  weakened  condition. 
The  obvious  way  to  correct  this  would  be  to  furnish 
the  antidote  in  small  doses,  but  to  inject  it  continu- 
ously. The  way  in  whicii  I  propose  to  do  this  would 
not  only  fulfil  this  condition  but  would  also  raise  the 
blood  pressure  in  the  arteries  and  dilute  the  poison. 
I  would  suggest  injecting  subcutaneously  a  large 
quantitv  of  fluid,  sav  six  or  eight  ounces  every  hour, 
in  which  a  small  triturate  of  the  sjjecial  stimulant  used 
is  dissolved.  I  would  precede  this  by  at  least  one  in- 
jection in  the  ordinarj-  way  and  then  resort  to  the 
method  1  have  described. 


August  28,  1897] 


MEDICAL    RECORD. 


301 


I  have  as  yet  had  no  experimental  or  clinical  ex- 
perience with  this  method,  but  I  hope  that  some  may 
see  enough  in  the  suggestion  to  try  it  at  the  first  op- 
portunity that  presents  itself  and  report  with  what 
success. 

:23   MONTGOMER>-    StkEET. 


KOLLMANN'S    NEW    URETHRAL    DILATOR. 
Bv   FEKD.    C.    VALENTINE,    M.I)., 


All  cases  of  urethritis,  acute  or  chronic,  simple  or  spe- 
cific, are  curable.     This  assertion  is  likely  to  provoke 


very  frequent  disproportion  between  the  meatus  and 
sounds,  especially  those  over  30  F.,  and  the  exceed- 
ingly disagreeable  sensations  produced  by  their  inser- 
tion, led  my  thoughts  primarily  to  a  dilator.  I 
worked  for  a  number  of  years  with  a  spring  dilator  of 
insufficient  strength ;  accident  then  brought  Otis'  in- 
strument into  my  hands.  In  the  course  of  time  I 
gradually  developed  from  it  a  number  of  instruments 
suitable  for  each  zone  of  the  urethra.  ...  In  1888, 
about  a  year  after  the  publication  of  my  instruments, 
von  Planer,  of  Graz,  also  made  known  dilators  based 
upon  the  same  principle.  He  now  (1894)  uses  my  in- 
struments." 

Shortly  before  Oberlaender  published  his  first  paper 
on  dilatation  in  chronic  urethritis,  James  P.  Tuttle,  of 
New  York,  independently  took   up   the  method,  with. 


criticism  from  those  who  hold  opposite  views,  or  who 
deem  "  life  too  short  to  waste  it  on  chronic  clap.' 

Yet  those  who,  guided  by  the  urethroscope,  follow 
methodical  dilatations  as  developed  by  Oberlaender 
and  irrigations  as  popularized  by  Janet  have  every 
reason  to  controvert  both  the  above  opinions.  Cases 
recover  more  rapidly  than  by  either  of  the  plans  of 
the  eminent  men  cited,  and  during  the  treatment  none 
of  the  concomitants  occur  as  they  do  in  using  each 
method  alone. 

Irrigations,  urethral  and  intravesical,  without  a  ca- 
theter,   were  not    accorded    the   popularity  due  them 


until  about  eighteen  months  ago.  Indeed  it  required 
the  persistence  of  a  Janet,  a  Goldberg,  a  Brewer,  a 
Swinburne,  to  persist  in  the  then  uncleanly  treatment 
due  to  faulty  apparatus.  I'o-day  even  a  tyro  can  irri- 
gate the  bladder  without  a  call>eter,  and  not  spill  a 
drop  of  the  fluid  used.  I  lay  stress  upon  this  fact,  in 
the  hope  of  inducing  all  exclusive  specialists  to  em- 
l)loy  the  method  which  has  such  splendid  scientific 
indorsement  as  of  the  eminent  gentlemen  mentioned. 
Piut  my  purpose  now  is  to  take  advantage  of  the  pres- 
ent high  privilege  accorded  me  of  demonstrating  a 
new  dilator,  which,  you  will  agree,  is  the  most  inge- 
nious, as  well  as  the  best  in.strument  thus 
far  devised  for  the  purpose. 

\   few  words  on   the  e\olution    of    the 
dilator  may  not  be  amiss   in    this  connec- 
tion.     Oberlaender,"  to  whom  the  credit  of 
working  out  the  dilatation  treatment  is  due, 
says :    "  The  purpose  of  instrumental  treat- 
ment is  to  stretch  or  break  hard  or  soft  infiltrates,  either 
with  superficial  or  submucous  injury  to  them.'     Noth- 
ing  else   can  be  accomplished   by  the  introduction  of 
metallic  instruments  of  small  or  large  calibre.     The 

'  KeatI  before  tlie  f;enito-urinary  section  of  the  .\cailemy  nf 
Medicine,  on  February  q,  1S97. 

■'  ■'  Klinisches  Handbuch  der  Harn-  und  Sexualorgane,"  Leip- 
zig. 1894. 

'  Tuttle.  in  an  exquisite  paper  on  "  Extreme  Local  Dilatation  in 
the  Treatment  of  Urethral  Stricture  and  its  ,\llied  Conditions" 
(New  York  Medical  Journal,  .A.pril  13,  1S95),  says;  "  The  cure 
of  stricture  by  gradual  dilatation  is  based  upon  the  assumption 
that  a  retrograde  metamorphosis  is  set  up  in  the  connective  tissue, 
which  causes  its  atrophy  or  absorption,  and  the  coarctation  is 
thus  removed." 


however,  not  entirely  the  same  purpose  in  view.  He 
writes  me:  "  My  dilator  was  made  for  me  in  Decem- 
ber or  January,  1886-87.  ^  used  it  first  as  an  adjuvant 
to  internal  urethrotomy,  afterward  taking  up  extreme 
dilatation,  as  I  became  more  and  more  convinced  that 
it  was  this  which  cured.  The  first  description  I  ever 
saw  of  Oberlaender's  instruments  was  published  more 
than  two  years  after  I  had  been  using  mine.  I  do  not 
know  how  much  earlier  it  had  been  published  in 
German.  I  did  not  publish  my  instrument  until 
I  had  sufficient  experience  to  recommend  its  use 
and  the  cases  to  show."  He  first  described  his  di- 
lator in  the  J\^eic'  York  Medical  Journal  for 
October  3,  i8gi.  The  illustration  show-s 
that  it  differs  in  some  essential  points  from 
the  instruments  devised  by  Oberlaender  and 
Kollmann.  Tuttle's  dilator  is  best  described 
in  the  inventor's  words :  "  The  special 
points  of  interest  in  the  instrument  are  its  parallel 
separation  over  a  limited  space,  its  powerful  mechan- 
ism, its  applicability  to  all  portions  of  the  urethra, 
and  its  protecting  rubber  cap." 

To  attempt  to  belittle  the  modest  claims  of  the  in- 
genious inventor  would  be  to  earn  just  condemnation. 
An  honest  difference  of  opinion,  however,  may  lead 
to  discussion  which  must  be  of  the  desired  benefit. 
()n  this  score  I  beg  to  submit  to  Professor  Tuttle  the 
following  thoughts  on  his  dilator.  If  the  urethra  were 
a  rigid  tube,  giving  firm  support  to  the  shaft  of  the 
instrument,  the  dilating  blade    would    exercise    that 


equal  pressure,  in  at  least  two  directions,  which  is  the 
purpose  in  view.  The  branches  of  the  Oberlaender 
and  Kollmann  dilator  separate  equally  from  an  imag- 
inary central  line,  accomplishing  the  end  sought  more 
efficaciously  than  could  be  done  by  the  Tuttle  instru- 
ment. The  advantage  of  separation  over  a  limited 
space  is  not  evident  to  me.  .4s  die  beneficial  effects 
of  dilatation  are  exerted  upon  the  points  of  greatest 
resistance,  the  unaffected  parts  are  spared  compression. 
Assuming  that  every  operator  has  the  skill  to  locate 
exactly  the  diseased  points,  it  seems  to  me  that  limit- 
ing the  dilatation  to  them  implies  a  greater  frequency 
of  and  more  prolonged  treatment  than  if  an  instru- 
ment able  to  dilate  the  entire  urethra   is  employed. 


302 


MEDICAL    RECORD. 


[August  28,  i! 


The  powerful  mechanism  of  the  Tuttle  dilator  is  glad- 
ly conceded  and  indeed  seems  to  me  the  most  impor- 
tant feature  of  the  instrument.  Its  applicability  to  all 
portions  of  the  urethra  is  not  so  patent.  It  is  readily 
seen  that  the  Tuttle  dilator  can  well  be  applied  to  all 


(. — Oberlaender'i 

parts  of  the  pendulous  urethra,  when  the  cur\ed  tip 
would  prove  rather  an  impediment.  But,  if  used  even 
at  the  first  portion  of  the  pars  Jixa,  it  cannot  disturb 
the  relations  of  the  region  ;  certainly  not  an  advantage 
in  treatment  directed  primarily  to  increasing  the  lu- 
men. These  criticisms,  made  in  that  same  cordial 
spirit  with  which  Professor  Tuttle  favors  those  whose 
work  he  discusses,  suf- 
fer much  in  force  when 
his  brilliant  results  with 
this  instrument  are  ex- 
amined. 

Discussion  of  the  Tut- 
tle dilator  saves  repeti- 
tion and  makes  unneces- 
sary a  detailed  description 

of  the  other  dilators  in  use  to-day,  as  far  as  my  knowl- 
edge extends. 

Oberlaender's  almost  straight  dilator  for  the  anterior 
urethra  was  his  first  instrument  on  this  plan.  Its  re- 
semblance to  the  one  devised  by  Otis  is  at  once  evi- 
dent. 

Oberlaender's  cuned  dilator,  intended  mainly  for 
dilatation  of  the  bulbous  portion,  certainly  makes  a 


Kollmann's  genius  produced  his  four-bladed  dilator 
with  the  Guyon  curve,  for  the  posterior  and  part  9f 
the  anterior  urethra. 

This  instrument,  which   I  now  have  the  honor  of 
being  the  first  to  show  in  America,  has  been   in  daily 
use     for     about    three  months.       Ex- 
perience,   covering     about     two    hun- 
dred    and     fift)-    dilatations    during 
this  period,  has    made   me   an   enthu- 
siast  for   it.        The   mechanism    is    so 
self-evident    that    I     need    only    add 
praise   for  the   ease  with   which   it   is 
inserted,  for  the  exquisite  gentleness 
yet  efficacy   of  its   dilatations,  for  the 
markedly   rapid   results   it  yields,  and   its  surprising 
painlessness  to  patients. 

The  therapeutic  value  of  dilatations,  the  indications 
for  each  instrument,  the  technique  of  their  employ- 
ment, have  been  fully  discussed  in  a  paper  on  "  The 
Treatment  of  Chronic  Urethritis,''  prepared  by  me  for 
the  Second  Pan-American  Medical   Congress,  held  at 


Mexico  in  November,  1896.  I  am  more  than  pleased 
that  opportunity  still  remains  to  add  the  description  of 
this  instrument  to  that  paper  before  its  publication. 

242  West  Fortv-Thiru  Stkeet. 


Strangulated  Hernia. —  The  treatment  of  cases  of 


Fir..  6.— Kollmann's  Fnur-bladcd  Dilator  for  Posterior  Ircthr 


decided  advance  over  its  predecessor,  in   urethra!   in- 
strumentation. 

Oberlaender's  dilator  with  the  Be'nique  curve,  as  its 
shape  shows,  is  intended  for  dilatation  of  the  posterior 
urethra  exclusively.  The  straight  blades  of  the  in- 
strument, lying  in  the  anterior  urethra,  do  not  expand 
at  all,  thus  sparing  this  region  unnecessar)-  dilatation. 

While  the  immense  therapeutic  advance  made  by 
these  intruments  is  undeniable,  they  have  their  limita- 
tions in  the  fact  that 
they  are  two-bladed. 
With  a  view  to  hasten- 
ing the  results  in  the 
chronic  diseases  of  the 
urethra,  KoUmann  de- 
vised    his     four-bladed 

dilators.  His  first  in- 
strument for  that  purpose,  as  its  form  shows,  is  in- 
tended for  the  anterior  urethra.  This  was  followed, 
after  two  years  of  close  study  and  experiment,  by 
Kollmann's  four-bladed  dilator  for  the  posterior 
urethra.  Hut  after  use  of  this  instrument  for  some 
time,  it  proved  to  be  somewhat  clumsy  and  pain- 
ful to  the  patients;  at  least,  so  it  acted  in  my 
hands.  This  led  me  to  essay  designing  a  better  four- 
bladed  instrument  for  the  posterior  urethral  curve. 
But  before  I  could  even  properly  formulate  my  thoughts, 


strangulated  hernia  after  the  operation  is  almost  as 
important  as  the  operation  itself.  This  patient,  almost 
immediately  after  the  operation,  was  given  something 
by  the  mouth  every  hour ;  only  a  few  teaspoonf uls  of 
stimulant  or  of  fluid  food,  but  still  something.  These 
patients  suffering  from  what  we  may  call  the  asthenic 
form  of  strangulated  hernia  must  not  be  starved  after 
the  operation.  They  are  advanced  in  age,  feeble, 
pulled  down  by  hard  work,  drink,  or  chronic  organic 


Foxir-hladed  Antero-postf 


disease,  ill  nourished,  and  now  still  further  e.xhausted 
by  pain,  vomiting,  loss  of  sleep,  and  fear  of  death. 
Often  they  come  to  the  hospital  in  the  middle  of  the 
night,  and  at  once  they  are  subjected  to  the  further 
shock  of  the  anasthetic  and  the  operation.  Such  pa- 
tients must  not  be  starved,  or  fed  only  by  the  rectum: 
it  is  absolutely  necessary  that  we  should  begin,  even  a 
few  hours  after  the  operation,  to  give  them  small 
quantities  of  stimulant  and  of  fluid  food  bv  the  mouth, 
— Dr.  P.\r.Er,  TJk  Clinual Joiinuil,  .April  ;8th. 


August  28,  1897] 


MEDICAL    RFXORD. 


CHROXIC-  FOLLICULAR    TONSILLITIS/ 
By  W.   SCOTT  RENNER.   M.D., 

BUFFALO,  N.  v., 

LLOW  OF  THE  AMERICAN*  LAB^'NGOLOGICAL,  RHINOLOGIC.\L,  AND  ^iTOLOGI- 
CAL  SOCIETS';  PROFESSOR  OF  L.ARYNGOLOGY,  MEDICAL  DEPARTMENT, 
NIAGARA  CNIVERSITY';  St'RGEON  IN  CHARGE  OF  THROAT  DEPARTMENT, 
Bl'FFALO  EVE  AND  EAR  INFIRMARY;  LARY'NGOLOGIST  TO  THE  ERIE 
COfNTY-  HOSPITAL;  LARY'NGOLOGIST  TO  THE  SISTERS  OF  CHAKITi'  Ho^ 
PITAL;  LARVNGOLOGIST  TO  THE   CHILDREN'S    HOSPITAL,  ETC. 


The  conditions  which  I  am  about  to  describe  are 
not  correctly  defined  by  the  above  title;  they  are  more 
correctly  although  not  fully  described  by  the  term 
chronic  lacunar  tonsillit-is.  Therefore,  if  you  will 
pardon  me,  I  will  tr\-  to  tell  you  in  as  few  words  as 
possible  just  what  are  the  classes  of  cases  which  I 
wish  to  include  under  the  above  title.  The  conditions 
are  simple  and  well  known  to  ever}-  one,  but  the 
sjTnptoms  vary  greatly  in  individual  cases,  and  the 
reflex  manifestations  produced  by  them  are  so  varied 
that  I  hope  I  shall  be  excused  for  calling  your  atten- 
tion at  this  time  to  so  simple  a  condition.  I  wish 
merely  to  excite  discussion  and  the  citation  of  cases 
illustrating  some  of  the  peculiar  phenomena. 

Chronic  follicular  tonsillitis  is  characterized  by  the 
formation  of  plugs  of  secretion  in  the  crj-pts  of  the 
chronically  inflamed  tonsils.  These  plugs  resemble 
ver}-  much  the  contents  of  comedones ;  are  usually 
about  the  size  of  a  rice  kernel,  but  var)-  very  greatly 
in  size;  they  are  white  or  yellowish-white  in  color 
and  have  a  verj-  offensive  odor,  which  is  brought  out 
by  crushing  them.  They  are  frequently  the  source  of 
offensive  breath:  when  crushed,  they  are  found  to  be 
of  a  soft  cheesy  consistence ;  they  consist  of  the  ma- 
terial discharged  from  the  tonsillar  crypts,  and  are 
made  up  of  leucocytes,  epithelium,  chalk,  mucus,  and 
the  various  bacteria,  etc.,  which  infest  the  mouth, 
among  which  leptothrix  frequently  pla3-s  an  important 
part.  The  only  chronic  condition  with  which,  as  you 
know,  this  can  be  confounded  is  mycosis  of  the  tonsil, 
in  which  the  plugs  are  of  a  more  dense  consistence 
and  project  from  the  crypts  beyond  the  surface  of  the 
tonsil  like  small  cockspurs.  These  spurs  are  removed 
vith  greater  difficulty  than  the  simple  plugs,  and  are 
found  when  examined  under  the  microscope  to  be 
made  up  entirely  of  leptothrix  or  some  other  form  of 
mycotic  growth  which  develops  very  rapidly,  the 
spurs  replacing  themselves  ven,-  quickly  if  removed. 
The  tonsils  themselves  in  which  the  chronic  follicular 
trouble  occurs  are  often  more  or  less  hypertrophied. 
but  some  of  them  are  considerably  atrophied:  in  fact, 
some  are  so  small  that  they  cannot  be  seen  on  making 
a  pharyngeal  examination  until  the  anterior  palatine 
fold  is  pulled  forward  and  to  one  side  with  a  probe, 
when  frequently  one  or  two  crypts  are  exposed  filled 
with  ver}-  large  plugs  of  secretion ;  these  crypts 
have  very  little  tonsillar  tissue  about  them,  and  often 
in  tonsils  of  much  larger  size  the  offending  cn,-pt  is 
not  found  until  the  palatine  fold  is  pulled  aside  to 
exfKDse  it.  The  number  of  crypts  which  are  inflamed 
or  obstructed  varies  greatly:  in  large  ragged  tonsils 
the  gland  is  often  filled  with  numerous  plugs;  small 
tonsils  may  have  but  one  or  two  obstructed  cr}pts. 
The  large  tonsils  with  numerous  crypts  do  not  often 
produce  so  unpleasant  or  so  marked  symptoms  as 
those  with  less  secretion,  especially  if  the  cr}-pts  which 
are  giving  trouble  are  so  located  that  the  secretion  is 
not  easily  expressed  from  its  bed  by  the  ordinary 
movements  of  the  throat  muscles.  The  larger  tonsils 
when  filled  with  the  secretion,  unless  during  an  acute 
exacerbation,  produce  only  a  sensation  of  fulness  in 
the  throat:  the  patients  who  have  more  obstruction  to 
the  free  discharge  of  the  contents  of  the  lacuna;  com- 
plain of  pain  in  the  throat,  pain  extending  to  the  ear 

'  Read  May  4,  iSgy,  at  the  third  annual  meeting  of  the  .\mer- 
can  I.arY-ngological,  Rhinological,  and  Otological  Society.  heM  at 
■Washington,  D.  C. 


or  chest,  pain  externally  in  the  cervical  region,  on  one 
or  both  sides,  fatigue  of  the  muscles  of  the  neck,  and 
some  complain  of  severe  neuralgia  and  various  other 
indefinite  reflex  phenomena.  The  plugs  do  not  pro- 
duce symptoms  while  they  are  small,  and  when  they 
are  once  expressed  from  the  crypts  the  symptoms  usu- 
ally disappear  until  another  crop  has  had  time  to  form. 
As  the  masses  increase  in  size,  they  often  cause  a 
swelling  at  the  orifices  of  or  about  the  middle  of  the 
duct  just  external  to  the  offending  secretion:  this  is 
especially  apt  to  take  place  after  exposure  to  cold, 
after  the  ingestion  of  hot  food,  and  a  sudden  increase 
of  the  virulence  of  the  streptococci  contained  in  the 
secretion  may  set  up  an  acute  inflammation;  such 
acute  attacks  may  last  for  a  day  or  two,  or  may  end  in 
a  regular  acute  follicular  tonsillitis  involving  a  part 
or  the  whole  of  the  tonsil,  or  both  tonsils,  and  this  may 
be  accompanied  by  more  or  less  fever,  according  to 
the  virulence  of  the  bacteria  contained  in  the  inflamed 
tonsil.  Should  the  tonsil  at  the  same  time  contain 
some  of  the  Klebs-Loeffler  bacilli  such  a  case  would 
be  classed  by  our  boards  of  health  as  one  of  true 
diphtheria.  Patients  who  are  subject  to  frequent  at- 
tacks of  quinsy  are  usually  subject  also  to  chronic  fol- 
licular tonsillitis,  and  destruction  of  the  chronic  ton- 
sillar disease  will  do  much  to  prevent  the  annual  return 
of  these  unpleasant  attacks. 

The  upper  angle  of  the  tonsil,  which  is  often  hidden 
from  view  between  the  anterior  and  posterior  palatine 
folds  where  they  approach  each  other  to  unite  in  the 
soft  palate,  often  contains  one  cr}-pt,  sometimes  two 
cr}pts,  with  their  external  openings  pointing  upward. 
.Such  a  cavit}-  is  not  so  easily  emptied  as  one  which  is 
directed  downward,  and  the  secretion  remains  in  the 
follicle  for  a  long  time.  When  you  examine  a  tonsil 
in  which  this  portion  is  producing  the  svmptoms,  the 
patient  will  exclaim,  when  this  portion  of  the  tonsil 
is  touched  with  a  probe,  "That  is  the  place,"'  and  if 
in  such  a  case  you  separate  the  sides  of  the  crypt 
located  here  the  pearl-like  pellet  of  secretion  will 
visually  pop  out  or  can  be  easily  pressed  out  of  its 
bed.  Such  patients,  besides  complaining  of  some 
dysphagia,  will  complain  of  otalgia,  or  a  tickling  in 
the  external  auditor}-  canal  of  the  corresponding  side. 
If  this  portion  of  the  tonsil  is  touched  with  a  hot  elec- 
trode, either  when  the  tonsil  is  normal  or  when  it  is  dis- 
eased, the  patient  will  complain  of  pain  in  the  ear.  This 
is  a  reflex  through  the  auricular  branch  of  the  vagus. 
I  have  frequently  located  the  cause  of  an  otalgia  in  an 
obstructed  lacuna  In  the  upper  part  of  the  correspond- 
ing tonsil.  This  symptom  is  usually  accompanied  by 
some  dysphagia.  Such  cases  were  especially  instruc- 
tive when  the  patients  happened  to  be  suffering  at  the 
same  time  from  chronic  deafness,  and  when  both  they 
and  their  physicians  considered  that  the  otalgia  and 
the  deafness  were  due  to  the  same  cause.  This  pain 
in  the  ear  is  more  familiar  in  cases  of  severe  acute 
inflammation  in  this  region  of  the  throat,  such  as  a 
jDeritonsillar  abscess  or  quinsy.  Only  the  other  day  I 
saw  a  case  with  severe  pruritus  in  the  external  audi- 
tory canal,  which  was  relieved  by  applying  cocaine  to 
the  upper  portion  of  the  tonsil.  In  a  climate  such 
as  is  found  in  the  region  of  the  great  lakes,  where  all 
parts  of  the  upper  air  passages  may  manifest  some 
evidence  of  catarrhal  inflammation,  it  often  becomes 
difficult  to  locate  exactly  the  cause  of  some  obscure 
throat  symptoms.  It  is  often  ver}-  diflacult  to  say 
whether  the  symptoms  are  due  to  an  obstructed  nose, 
a  granular  phar}-ngitis,  or  to  some  condition  of  the 
phar}-ngeal,  lingual,  or  faucial  tonsils. 

The  following  history  of  a  case  illustrates  such  a 
difficulty,  which  occurred  to  me  a  few  months  ago, 
when  the  trouble  proved  to  be  due  to  an  unsuspected 
condition  of  one  of  the  faucial  tonsils.  A  general 
practitioner,  a  friend  of  mine,  wrote  me  as   follows: 


304 


MEDICAL    RI-XORD. 


[August  28,  1897 


"  May  I  encroach  upon  your  kindness  and  ask  your 
aid  in  an  obscure  case  of  mine.  The  patient,  a 
married  lady  of  twenty-five,  lias  had  a  great  deal 
of  trouble  with  her  throat:  she  was  in  a  church 
choir  a  long  time,  and  suddenly  her  voice  began 
troubling  her  in  sustaining  tones,  and  any  exertion 
of  singing,  or  even  talking  for  any  length  of  time, 
caused  her  to  have  a  constant  ache  and  acute  burn- 
ing sensation  in  iier  throat,  which,  in  fact,  is  the 
condition  of  the  patient  at  the  present  writing. 
I  have  examined  her  carefully  from  time  to  lime, 
and  beyond  a  condition  of  relaxation  and  general 
congestion  I  can  detect  nothing  patliological.  I  have 
thought  it  was  rheumatism,  but  rheumatic  pains 
elsewhere  have  entirely  disappeared,  while  this  re- 
mains, and  both  she  and  I  are  discouraged.  It  has 
been  a  year  since  it  began,  and  I  have  exhausted  my 
remedies  without  result;  what  about  electricity?  I 
would  take  it  very  kindly  should  you  help  me  out." 
There  was,  of  course,  nothing  in  this  history  wiiich 
should  make  me  suspect  the  tonsil  of  being  the  cause 
of  the  trouble.  I  therefore  concluded  that  she  prob- 
ably was  not  using  her  voice  properly,  etc.,  and  sug- 
gested that  she  had  probably  been  improperly  trained 
in  the  use  of  her  voice,  and  that  she  had  some  nasal 
obstruction  which  he  might  have  overlooked,  which 
would  increase  the  fatigue  of  using  her  voice,  espe- 
cially if  used  in  an  improper  manner.  I  advised  him  to 
use  the  electricity  as  he  had  sugge.sted,  together  with 
iron  and  strychnine,  and  to  enjoin  rest  of  the  vocal 
organs  until  he  had  treated  her  nose  if  necessary,  and 
until  she  could  procure  a  better  vocal  instructor. 
This  treatment,  of  course,  did  not  help  her:  no  one 
could  make  a  diagnosis  without  seeing  the  patient. 
Ill  a  few  weeks  she  came  to  ISuffalo  to  see  me.  At  first 
I  could  find  nothing  in  the  throat  which  seemed  suffi- 
cient to  cause  her  symptoms,  for  besides  the  loss  of 
her  singing  voice  she  complained  bitterly  of  intense 
pain,  neuralgic  in  character,  in  the  right  half  of  her 
neck.  Besides  this,  she  had  a  feeling  of  great  fatigue 
in  the  muscles  of  the  throat,  especially  after  using  the 
voice.  I  was  much  puzzled  for  a  cause  of  the  symp- 
toms. I  found  her  throat  about  as  her  physician  had 
described  it.  She  had  some  granular  pharyngitis,  and 
I  commenced  to  cauterize  the  patches  on  the  posterior 
wall  of  the  pharynx,  and  was  engaged  in  the  third 
Si'iiihv  of  the  treatment,  when  her  right  tonsil,  which 
was  small  and  iserfectly  smooth,  attracted  my  atten- 
tion. I  noticed  a  much  distended  crypt  on  the  upper 
surface.  I  at  once  plunged  my  electrode  into  this 
opening.  The  tonsil  proved  to  be  simply  a  small 
crypt-like  organ  distended  with  inspissated  secretion, 
and  I  opened  it  with  the  electrode  and  destroyed  it. 
.After  thorough  destruction  of  all  traces  of  the  tonsil, 
which  was  accomplished  with  the  galvano-ca\itery  in 
two  or  three  sittings,  all  the  symptoms  of  pain  and 
fatigue  disappeared:  her  voice  improved  under  proper 
vocal  instructions  and  tonic  treatment. 

This  is  only  one  of  the  many  cases  which  might 
be  cited  of  small  diseased  tonsils  which  have  been 
the  unsuspected  cause  of  distressing  symptoms.  .V 
paroxysmal  cough  is  frequently  caused  by  some  dis- 
eased condition  of  the  faucial  tonsils.  In  children 
the  cough  is  frequently  due  to  very  large  faucial 
tonsils,  which  by  touching  other  parts  of  the  throat 
set  up  an  irritation,  resulting  in  distressing  and 
prolonged  coughing.  When  in  children  the  faucial 
tonsils  are  not  enlarged,  the  cau.se  of  the  cough  can 
often  be  found  in  the  presence  of  a  large  amouiu  of 
aden()id  tissue  in  the  vault  of  the  pharynx,  but  en- 
larged tonsils  aie  not  the  only  tonsils  which  are  pro- 
ductive of  cough.  It  frequently  has  its  origin  in  an 
old  follicular  inflammation,  sometimes  in  tonsils 
which  are  very  much  atrophied.  I  once  sought  for  a 
loni;  time  for  the  cause  of  a  verv  irritatinij  cou>rh  which 


had  persisted  for  eighteen  years.  This  occurred  in 
a  patient  over  fifty  years  of  age.  I  found  the  cause 
in  an  obstructed  crypt  on  the  posterior  surface  of  the 
right  tonsil:  the  lacuna  was  prevented  from  easily 
discharging  its  contents  by  a  partial  adhesion  between 
the  tonsil  and  the  posterior  palatine  fold. 

Treatment. — .\  paper  has  already  been  presented  at 
this  meeting  on  "Surgery  of  the  Faucial  Tonsils," 
therefore  it  will  be  superfi-ious  for  me  to  enter  into  a 
detailed  discussion  of  the  treatment  of  these  cases.  I 
shall  merely  outline  tlie  principal  indications  for 
treatment.  I'he  first  indication  is  to  open  and  destroy 
every  pocket  or  crypt  which  may  form  a  lodging-place 
for  secretion  or  particles  of  food,  and  secondly,  if  we 
accept  the  teaching  that  the  tonsil  is  simply  a  diseased 
mass,  especially  in  adult  life,  the  only  indication  for 
treatment  is  to  remove  or  destroy  all  of  the  diseased 
mass,  to  eradicate  as  far  as  possible  every  trace  of 
tonsillar  tissue:  these  two  objects  may  be  accom- 
plished in  various  ways,  and  the  individual  case 
will  suggest  to  the  experienced  operator  the  best  way 
to  attain  his  object,  the  destruction  of  the  tonsil. 
The  conditions  of  which  I  have  spoken  are  usually 
found  in  adult  life;  the  principal  trouble  caused  by 
hypertrophied  tonsils  in  children  is  due  to  the  ob- 
struction which  they  cause  to  respiration,  and  this 
usually  is  due  more  to  the  accompanying  adenoids 
than  to  the  tonsils,  unless  the  tonsils  are  e.xtremeh' 
large.  Tonsillotomy  has  many  opponents  among  the 
laity,  by  whom  \arious  reasons  are  given  for  their  be- 
lief that  it  does  harm  or  no  good.  Most  of  die  reasons 
which  they  give  are  not  the  real  ones  for  the  failure 
of  the  operation  to  benefit  the  patient.  The  first 
reason  for  the  unsatisfactory  result  is  that  the  tonsils 
have  been  removed,  while  the  adenoids,  the  chief  cause 
of  the  obstructed  breathing,  have  been  left,  a  mistake 
which  is  often  made  by  the  general  surgeon  in  treating 
these  cases.  The  second  reason  for  failure  is  that  the 
tonsils  have  not  been  thoroughly  enough  removed  to 
destroy  all  the  diseased  crypts,  and  consequently  the 
patient  will  still  be  subject  to  repeated  attacks  of 
acute  follicular  and  supurative  tonsillitis:  in  these 
cases  great  masses  of  lymphoid  tissue  are  left  attached 
to  the  palatine  folds,  while  only  the  parts  of  the  ton- 
sils have  been  removed  which  projected  beyond  the 
folds  into  the  isthmus  of  the  fauces.  This  demon- 
strates that  all  adhesions  between  the  palatine  folds 
and  the  tonsils  should  be  broken  down  before  an  at- 
tempt is  made  to  remove  them  by  any  method.  It  is 
also  important  that  the  tonsils  of  children  should  be 
more  thoroughly  removed  than  they  often  are,  for 
thereby  all  diseases  of  the  tonsil  which  might  occur 
in  adult  life  may  be  prevented. 

I  formerly  always  used  the  tonsillotome  in  removing 
the  glands  from  children's  throats,  but  lately  I  have 
found  that  a  much  more  thorough  operation  could  often 
be  done  with  a  cold  snare  in  many  cases,  because  the 
loop  of  the  snare  could  be  passed  well  in  between  the 
palatine  folds  and  almo.st  every  vestige  of  the  tonsil 
removed.  In  adults,  when  the  offending  tonsil  is 
large  enough  to  grasp  with  the  snare,  I  use  it  to  re- 
move the  organ,  and  the  ordinary  polypus  snare  is 
usually  sufficient  for  ordinary  hypertrophied  tonsils, 
such  as  those  I  have  described.  When  the  tonsils 
are  fibroid  in  character  an  ecra.seur  or  the  galvano- 
cautery  snare  might  be  necessary:  for  very  Hat  tonsils, 
which  cannot  be  grasped  with  the  tonsillotome  or 
snare,  some  other  method  must  be  followed.  I  usu- 
ally either  lay  open  the  crypts  with  a  long  sharp 
bistoury  and  remove  the  intervening  jiortions  of  ton- 
sillar tissue  with  the  cold  snare  or  a  pair  of  cutting 
forceps,  or  destroy  tliem  by  means  of  tlie  galvano- 
cautery.  The  cases  which  give  the  most  trouble  are 
those  in  which  large  crypts  are  situated  in  the  side 
wall  i)f  the  pharynx  with   scarcely  any  tonsillar  tissue 


Auorust   28,    1897] 


MEDICAL    RFXORD. 


305 


about  them :  here  the  only  thing  that  can  be  done  is 
to  change  the  whole  affair  into  cicatricial  tissue  b)^ 
means  of  the  galvano-cautery.  The  danger  of  hemor- 
rhage after  the  removal  of  tonsils  occurs  most  fre- 
quently in  hyperplasia  of  the  tonsil,  the  fibrous  tonsils, 
a  class  of  cases  which  it  has  not  been  my  intention  to 
speak  of  in  this  paper. 

361  Peak..  Stkkki. 


WHAT  ARE  THE  FUNCTIONS  OF  THE 
RODS  AND  CONES  AND  THE  PIGMENT 
EPITHELIUM  LAYER  OF  THE  HUMAN 
RETINA? 

r.v    FRANK    I'.    PRATT,     M.D., 

The  human  eye  has  long  engaged  the  attention  of  stu- 
dents and  specialists.  Exhaustive  research  has  been 
made  in  the  field  of  anatomy,  histology,  and  pathologv 
of  the  different  ocular  tissues  in  man  and  in  the  lower 
orders  of  vertebrates;  yet  there  are  many  problems, 
around  which  the  searchlight  of  scholarly  minds  is 
being  thrown,  which  have  not  been  satisfactorily  e.\- 
plained. 

The  phenomenon  of  vision  is  one  of  these;  particu- 
larly so  when  we  consider  the  part  played  by  the  ret- 
ina, or  rather  the  epithelial  pigmentary  layer  and  the 
layer  of  rods  and  cones,  in  this  complex  act. 

The  generally  accepted  theory  is  that  both  the  rods 
and  cones  are  the  terminal  cells  of  the  optic  nerve ; 
that  the  image  of  external  objects  is  focussed  upon  this 
layer,  and  that  here  light  vibrations  are  changed  into 
another  kind  of  motion,  namely,  nerve  stimuli;  that 
certain  mechanical  and  perhaps  chemical  changes  take 
place  in  the  epithelial  pigment  layer,  and  that  a  pecu- 
liarly intimate  relation  exists  between  this  layer  and 
the  layer  of  rods  and  cones. 

Fuchs  says  that  the  place  in  which  the  conversion  of 
luminous  vibrations  into  nerve  exitation  occurs  is  the 
rods  and  cones.  I  wish  to  present  the  following 
hypotheses : 

ist.  That  the  cones  alone  are  the  terminal  cells  of 
the  optic  fibres  in  the  human  retina. 

2d.  That  the  rods  are  supporting  tissue  to  the 
cones,  their  outer  segments  practically  forming  a  part 
of  the  pigment  epithelial  layer. 

3d.  That  the  tenth  or  pigment  layer  is  that  in 
which  light  vibrations  are  changed  into  nerve  stimuli. 

A  full  consideration  of  the  microscopical  anatomy 
of  the  retina  would  be  impossible  here,  on  account  of 
limited  space:  reference,  therefore,  must  be  made  to 
the  text-books  of  anatomy  and  histology.  Piersol's 
article  on  "  Microscopical  Anatomy  of  the  Retina,"' 
and  May's  on  "  Photo-Chemistry  of  the  Retina,"  in 
Norris  and  Oliver's  work,  cover  the  field  very  fully. 

Assuming,  then,  that  this  histological  knowledge  is 
in  mind,  we  will  review  only  such  salient  points  as 
are  necessary  to  make  clear  the  foundation  for  tlie 
propositions  above  presented. 

The  retina  of  the  old  school  comprised  the  nine  in- 
nermost layers  only,  or  that  part  which  includes  the 
fibres  and  terminal  cells  of  the  optic  nerve,  ttigethei' 
with  the  internal  limiting  membrane.  Later  research 
has  demonstrated  that  the  epithelial  pigment  layer  also 
belongs  to  the  retina,  and  constitutes  its  tenth  stratum. 
This  layer  is  in  intimate  relation  with  the  ninth,  and, 
together  with  the  seventh  and  eighth  layers,  has  no 
blood-vessels  of  its  own,  but  receives  its  nourishment 
from  the  same  source — the  choroid  vessels.  The 
rods  and  cones  alike  pass  through  the  cribriform  ex- 
ternal limiting  membrane,  the  rods  extending  to  the 
"base"  of  the  epithelial  cells,  where  they  terminate  in 
irregular  "  gnawed-off"  ends ;  the  epithelial  cells  send- 
ing down   protoplasmic   processes  between   the  rods 


and  cones  to  \arious  depths;  or  this  epithelial  '"base" 
maybe  considered  as  a  "  disc,"  which  is  perforated 
with  cylindrical  channels  for  the  reception  of  the  ex- 
ternal segments  of  the  rods.  Thus  the  outer  rod  cell 
is  plunged  deeply  in  the  pigmented  portion  of  the 
epithelial  cells.  This  relation  of  rods  and  epithelial 
processes  is  maintained  uninfluenced  by  the  light 
stimulus. 

The  cones  also  pass  outward  and  terminate  in  gently 
rounding  ends,  which  reach  little  more  than  half-way 
to  the  "base"  of  the  epithelial  cell.  The  cone  is  not 
a  fixed  cell,  but  under  the  influence  of  its  normal 
.stimulus  retracts,  so  that  the  whole  cell  is  nearer  the 
external  limiting  membrane.  When  this  stimulus  is 
removed  the  whole  cell  again  advances.  This  is  an 
important  difference,  and  should  be  given  its  proper 
weight  in  a  consideration  of  the  functions  of  the  rods 
and  cones. 

Authorities  differ  as  to  whether  the  terminal  cell  is 
connected  to  the  nerve  fibre  by  continuity,  or  simply 
by  contiguity  or  approximation.  Hosch,  however, 
claims  that  he  "finds  in  the  Golgi  silver  preparations 
evidence  of  direct  anatomical  continuity  between  the 
fibrils  proceeding  from  the  base  of  the  cone  cell  and 
the  processes  of  the  nerve  cell."  No  such  continuity 
has  been  demonstrated  or  claimed  for  the  rod. 

What  proofs,  then,  ha\e  we  that  the  cones  alone  are 
the  terminal  cells  of  the  optic  nerve  in  the  human  ret- 
ina?    Consider  in  this  light  the  following  facts: 

I  St.  That  the  cones  alone  have  been  demonstrated 
to  be  connected  directly  with  the  filaments  of  the  optic 
nerve. 

2d.  That  no  such  claim  is  made  for  the  rod;  in  fact, 
the  base  of  the  rod  is  known  to  terminate  in  a  bulb, 
and  approximation  is  its  only  relation  to  the  nerve  fil- 
aments. 

3d.  That  the  cone  is  mechanically  irritated  by 
converted  light  stimulus,  as  shown  by  its  power  of 
contraction  and  extension  under  that  stimulus. 

4th.  That  converted  light  stimulus  has  no  mechani- 
cal effect  upon  the  rod;  that  its  close  relation  to  the 
base  of  the  epithelial  cell  remains  unchanged  under 
its  influence. 

5th.  That  the  only  change  noted  in  the  rod  cell  is 
that  which  occurs  in  the  bleaching  and  reproduction 
of  the  so-called  visual  purple,  which  has  its  exclusive 
seat  in  the  outer  segment  of  the  rod  cell,  and  this 
bleaching  appears  to  be  effected  by  the  action  of  the 
luminous  vibrations  themselves,  and  not  by  the  proper 
nerve  stimulus.  Light  vibrations  as  such  are  not  ex- 
citors  to  the  terminal  cells  of  the  optic  nerve. 

6th.  That  the  cones  alone  occupy  the  position  of 
most  acute  vision. 

7th.  That  the  rods  are  not  necessary  to  acute  and 
perfect  vision. 

8th.  Because  in  central  scotoma  the  disease  involves 
only  that  portion  of  the  retina  which  has  to  do  with 
acute  \ision,  namely,  the  macular  region;  yet  a  cross- 
section  of  the  optic  nerve,  where  it  enters  the  bulb, 
shows  an  accompanying  atrophy  of  nerve  filaments, 
which  occupy  a  sector-shaped  space,  with  base  out 
and  apex  toward  the  centre,  and  make  up  nearly  or 
quite  one-third  of  the  total  nerve  filaments  (F'uchs). 
When  we  consider  what  a  small  part  of  the  retinal 
surface  the  macular  region  occupies  and  how  insig- 
nificant numerically  the  cones  of  this  region  are  com- 
pared with  the  combined  rods  and  cones  of  the  extra- 
macular  region,  it  not  only  adds  weight  to  the  belief 
that  each  cone  in  this  region  has  an  individual  nerve 
fibre,  but  also  to  the  fact  that  each  cell  element  of  the 
extra-macular  region  cannot  have  an  individual  nerve 
fibre;  nor  one  fibre  for  seven  cells,  as  estimated  by 
Selzer  and  Krause.  These  authorities  estimate  the 
cones  at  7,000,000.  Becker  estimates  13,000  in  the 
macula  lutea.     The  rods   are  much  more  numerous, 


3o6 


MEDICAL    RECORD. 


[August  28,  1897 


being  estimated  as  high  as  130,000,000  by  Krause. 
Selzer  and  Krause  estimate  the  number  of  measur- 
able fibres  of  the  optic  nerve  at  425,000.  Now,  taking- 
out  the  13,000  fibres  distributed  to  the  macular  cells, 
there  remain  412,000  fibres,  to  be  distributed  to  137,- 
000,000  extra-macular  cells.  If  these  were  distributed 
to  both  the  rods  and  cones,  there  would  be  i  fibre  to 
332  cell  elements;  if  to  the  rods  alone,  i  to 301 ;  if  to 
the  cones  alone,  i  to  about  17.  These  estimates  fur- 
nish additional  evidence  that  the  cone  cells  alone 
receive  filaments  of  the  nerve. 

9th.  That  the  normal  position  of  the  cone  is  at  right 
angles  to  the  external  limiting  membrane  and  the  pig- 
ment epithelial  layer. 

That  this  position  can  be  thus  maintained,  outside 
of  the  macular  region,  only  by  appropriate  supporting 
tissue. 

In  the  macular  region  each  cone  is  a  support  to  its 
neighbor;  therefore  no  rods  are  necessary.  In  the 
extra-macular  region  the  cones  become  farther  and  far- 
ther apart  toward  the  peripheral  portions  of  the  retina; 
they  can  no  longer  support  each  other ;  therefore  rods 
appear,  and,  with  the  protoplasmic  processes  of  the 
epithelial  layer  and  the  modified  lymph,  fill  in  the  in- 
tervening spaces.  The  rods,  which  in  the  macular 
region  form  a  single  layer  around  each  cone,  gradually 
increase  in  number,  until,  in  the  region  of  the  ora 
serrata,  each  cone  is  surrounded  by  three  or  more  lay- 
ers of  rods.  The  outer  segment  of  the  supporting  rod, 
as  it  dips  deeply  into  the  pigment  processes  of  the 
epithelial  layer,  thus  becomes  practically  a  part  of 
that  layer. 

loth.  That  in  proportion  as  the  cones  increase  in 
number  over  a  given  area,  vision  increases,  and  '('ice 
versa.  Thus  the  cones  within  the  macula  lutea  are 
many  times  more  numerous  than  in  any  other  equal 
space  on  the  retina.  Therefore,  more  terminal  fila- 
ments being  irritated,  sight  is  more  acute. 

The  third  general  proposition  is  that  the  tenth  retinal 
layer  in  that  is  which  light  vibrations  are  changed 
into  nerve  stimuli. 

Briefly  stated,  the  tenth  layer  is  composed  of  a  sin- 
gle stratum  of  hexagonal  cells,  a  view  of  the  inner 
surface  of  which  shows  a  beautiful  mosaic  arrange- 
ment, deeply  pigmented,  except  in  the  region  of  the 
nucleus.  A  vertical  section  shows  the  cell  to  be  di- 
vided into  three  parts  or  zones — the  outermost  con- 
taining the  nucleus,  and  being  unpigmented;  a  middle 
zone  deeply  pigmented,  sometimes  known  as  the 
"  base"  of  the  cell ;  and  an  irregular  zone  of  "  indefi- 
nite protoplasmic  processes,"  extending  between  the 
outer  segments  of  the  rods  and  cones.  This  pigment 
is  special  and  peculiar  to  this  layer;  it  differs  from 
the  stroma  pigment  of  the  choroid  in  being  crystal- 
line and  rod-shaped  instead  of  granular.  Under  the 
influence  of  light  these  pigment  crystals  advance 
within  the  protoplasmic  extensions  of  the  "base"  of 
the  cell,  between  the  rods,  the  migration  not  being 
accompanied  by  the  protraction  and  retraction  of  the 
processes  them.selves. 

I  present  the  following  reasons  for  believing  the 
third  general  proposition  to  be  true: 

I  St.  The  pigment  epithelial  cells  increase  in  size 
from  the  region  of  the  fovea,  where  they  are  the  small- 
est, to  the  region  of  the  ora  serrata,  where  they  reach 
tlieir  maximum  size,  thus  coinciding  with  the  decreas- 
ing number  of  cones  from  centre  to  circumference;  so 
that  it  is  probable  that  when  the  ninth  and  tenth  layers 
are  in  their  normal  position  each  cone  points  to  the 
centre  or  nucleus  of  each  epithelial  cell. 

2d.  The  peculiar  yet  significant  associated  action 
of  the  epithelial  pigment  and  the  cone  cell,  under  the 
influence  of  light  stimulus:  as  the  pigment  advances 
within  the  epithelial  processes,  the  cone  retracts,  and 
vice  versa,  their' relative  positions  being  little  changed. 


3d.  The  position  of  the  cone  is  strong  evidence  that 
the  image  is  not  formed  upon  this  layer.  Nature  is  a 
conser\a.or  of  forces;  then  why  does  she  not  turn  the 
cones  toward  the  source  of  light,  if  this  layer  is  the 
necessary  surface  upon  which  the  image  is  cast,  in- 
stead of  turning  them  in  the  opposite  direction.'  In 
the  one  position  the  image  would  fall  directly  upon  the 
percipient  surface;  in  the  other  the  light  rays  pass 
through  the  nine  different  retinal  layers  to  accomplish 
the  same  purpose,  if  the  accepted  theory  is  true. 

Nature  has  made  no  mistake.  The  cones  are  turned 
toward  the  source  of  their  normal  stimuli,  but  this 
stimulus  is  not  light  vibration,  as  such,  and  therefore 
does  not  come  from  the  object  itself;  it  is  another 
form  of  energ)'.  "This  is,  with  at  doubt,  simply  an- 
other sort  of  motion,  of  such  a  .mature  as  to  be  trans- 
mitted within  the  nerve  fibres  to  the  brain — a  property 
which  is  not  possessed  by  the  vibrations  of  luminous 
ether"  (Fuchs). 

Thus  it  would  seem  that  "vibrations  of  luminous 
ether"  must  pass  unobstructed  through  the  various  ret- 
inal layers,  including  the  cones,  until  they  are  focussed 
upon  the  tenth  layer,  which  point  is  a  "  murky  veil'" 
at  the  focal  point  of  the  normal  eye,  fixed  between  the 
delicate  terminal  cells  of  the  optic  nerve  and  the  cho- 
roid coat.  It  is  the  ground-glass  plate  of  our  living 
camera,  upon  which  the  images  in  our  visual  field  are 
spread  in  all  their  various  colors,  and  in  which,  in  a 
manner  not  yet  fully  understood,  light  vibrations  are 
transferred  into  nerve  stimuli,  and  from  which  comes 
the  normal  stimulus  of  the  ocular  fibres. 

It  is  well  known  that  the  anatomical  and  histologi- 
cal arrangements  of  tissues  are  not  the  same  in  different 
vertebrates — thus,  in  the  frog  rods  ma)'  predominate 
in  the  region  of  most  acute  vision;  or  that  rods  alone, 
or  perhaps  modified  cones,  may  alone  be  present  in 
others;  or  that  a  complete  decussation  of  the  optic- 
nerve  fibres  takes  place  in  some  of  the  lower  animals. 
Yet  this  does  not  warrant  us  in  assuming  that  the 
above  facts  do  not  hold  true  in  man. 

In  the  words  of  Fuchs,  in  speaking  of  the  decussa- 
tion of  ocular  fibres:  "The  only  mistake  that  has 
been  made  is  in  assuming  the  same  condition  to  hold 
good  for  the  higher  vertebrates  also.'" 

It  is  not  claimed  here  that  pigment  is  necessarily 
present  in  order  that  this  change  from  light  vibrations  to 
nerve  stimuli  may  take  place;  for  in  albinos,  in  which 
pigment  is  absent,  the  visual  act  is  accomplished,  yet 
always  imperfectly.  It  is  therefore  probable  that  in 
exceptional  cases  some  modification  in  the  pigment 
substance  takes  place,  yet  always  at  the  expense  of 
perfect  vision. 

Much  has  been  said  about  the  visual  purple  or  rho- 
dopsin  of  Boll.  Yet  when  all  is  said,  little  or  nothing 
is  known  of  its  real  utility.  \\"e  know  that  it  exists 
exclusively  in  the  outer  segment  of  the  rod ;  tliat 
even  in  the  cone  cell  of  the  e.xtra-macular  region  it  is 
not  present.  That  it  is  not  essential  to  perfect  vision 
is  evidenced  by  tiie  fact  that  it  is  absent  in  the  region 
of  the  fovea.  "Animals  that  have  been  deprived  of 
visual  purple  do  not  act  differently  from  those  which 
possess  it.  Frogs,  without  this  visual  purple,  search 
for  their  favorite  color,  green'"  (May).  In  fact,  it  may 
act,  owing  to  its  position,  in  common  with  the  elements 
of  the  pigment  layer  in  absorbing  and  transforming 
luminous  ether  vibrations  into  normal  nerx'e  stimulus. 


Ulcer  Grafting.  -Skin  grafting  will  not  succeed 
upon  an  unhcahhy  surface.  Cleanse  the  surface  well 
for  a  few  days  with  boric  fomentations,  slightly  abrade 
the  granulations,  enough  to  cause  oozing,  and  then 
apply  the  grafts  to  the  abraded  surface,  where  they 
are  iield  in  place  by  green  protective. — Gill. 


August  28,  1897] 


MEDICAL    RFXORD. 


Medical  Record: 

A    Weekly  Journal  of  Aledicine  and  Surgery. 

GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 

WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth  Street. 


New  York,  August  28,  1897. 


THE   MOSCOW    CONGRESS. 

The  Twelfth  International  Medical  Congress,  of  which 
we  publish  in  this  issue  the  first  part  of  our  special 
cabled  report,  was  successful  far  beyond  the  expecta- 
tions of  those  who  had  watched  the  course  of  prepara- 
tion for  it  during  the  past  two  years.  The  committee 
on  organization  had  much  more  to  contend  with  than 
any  similar  committee  of  an  international  congress, 
most  of  its  trials  being  due  to  the  peculiarly  paternal 
character  of  the  government  under  which  its  members 
lived.  When  it  was  first  announced  in  Rome  that  the 
next  congress  would  be  held  in  Russia  it  was  stated 
that  the  committee  was  not  authorized  to  announce 
the  place  of  meeting,  for  the  designation  of  the  city 
to  be  thus  honored  must  be  left  to  the  Tsar.  When 
the  preliminaries  of  the  plan  of  organization  were 
published,  the  English-speaking  world  was  antago- 
nized by  the  dropping  o£  English  from  the  list  of  offi- 
cial languages.  This  drew  forth  a  vote  of  protest 
from  the  American  Medical  Association,  and  may 
have  been  the  reason  why  the  British  Medical  Associ- 
ation decided  to  meet  this  year  in  another  part  of  the 
world,  as  far  as  possible  from  Moscow.  No  sooner 
had  this  error  been  recognized  and  corrected  than  the 
news  c^une  that  the  efficient  and  popular  secretary- 
general  of  the  committee,  Professor  Erismann,  had 
for  political  reasons  been  expelled  from  Russia.  At 
the  same  time  Hebrew  physicians  began  to  inquire 
how  they  would  be  treated  if  they  attempted  to  go  to 
the  congress,  and  it  was  intimated  that  they  would  be 
turned  back  at  the  frontier.  After  more  or  less  dis- 
cussion and  protest  it  was  finally  announced  that  on 
this  occasion  no  discrimination  would  be  made  against 
any  physician  desiring  to  take  part  in  the  proceedings 
of  the  congress,  because  of  his  race  or  religious  belief. 
These  difficulties  and  many  others  which  could  not 
have  come  up  elsewhere,  and  which  would  seem  to 
have  been  enough  to  chill  the  ardor  of  the  most  enthu- 
siastic committeeman,  were  all  met  and  overcome. 
And  the  Moscow  congress,  in  its  externals  at  least, 
for  we  cannot  judge  of  its  scientific  rank  until  the 
reports  of  the  section  work  have  been  received  and 
studied,  has  passed  into  historj'  as  one  of  the  most 
successful  of  the  twelve. 

The  general  addresses  were  all  of  a  creditable  char- 
acter, although  no  new  facts  of  serious  import  were 
brought  forward — nothing,  indeed,  of  the  startling  and 


sensational  character  of  Koch's  memorable  address 
in  Berlin  seven  years  ago.  This  is  perhaps  just  as 
well,  for  true  science  needs  no  theatrical  setting,  and 
it  would  have  been  much  better  if  the  German  inves- 
tigator had  not  been  forced  by  his  government  superior 
to  make  a  premature  announcement  of  his  discover}-  in 
order  to  add  eclat  to  the  tenth  congress.  The  orators 
in  Moscow,  at  least  those  who  did  not  deal  chiefly  with 
orrhotherapy,  as  a  rule  contented  themselves  with  restat- 
ing old  facts,  some,  as  Virchow,  reiterating  the  beliefs 
to  which,  in  somewhat  modified  form,  they  still  clung 
despite  the  assaults  of  the  neopathologists.  Vir- 
chow's  was  a  touching  figure  at  the  congress — this 
wonderful  old  man  and  indefatigable  worker  in  many 
fields,  a  physicist,  a  publicist,  a  linguist,  and  a  pathol- 
ogist, equal  to  the  first  in  each  of  his  chosen  spheres 
of  activit}'.  All  the  world  will  add  with  one  voice  its 
fer\-ent  J^'o  to  those  with  which  the  congressists  met 
his  suggestion  that  this  was  perhaps  the  last  congress 
at  whose  deliberations  he  would  be  able  to  assist. 
The  young  man  of  seventy-six  summers  was  well  in- 
spired when  he  chose  as  his  theme  "  The  Continuity  of 
Life,"  and  his  hearers  did  well  to  remind  him  that  he 
was  wandering  too  far  from  his  subject. 

The  entertainments  provided  for  the  visitors  were 
on  a  most  lavish  scale,  and  are  even  yet  not  at  an  end. 
While  one  party  has  been  taken  to  see  the  beautiful 
scenery  of  the  Caucasus,  another  has  gone  to  the  Cri- 
mea, and  still  another  is  enjoying  a  series  of  fetes 
organized  in  honor  of  their  guests  by  the  hospitable 
citizens  of  the  northern  capital.  The  method  adopted 
by  the  municipality  of  Moscow  for  showing  its  appre- 
ciation of  the  honor  of  harboring  the  congress  was 
unique.  Instead  of  opening  a  public  building  for  a 
reception  and  spending  a  large  sum  foi  decorations, 
and  for  eatables  and  drinkables,  the  memory  of  which 
would  pass  away  almost  as  quickly  as  the  headaches 
they  had  occasioned,  the  council  determined  to  estab- 
lish a  prize  for  medical  work,  to  be  awarded  at  each 
recurring  congress.  The  sum  set  aside  for  this  pur- 
pose was  about  16,000  rubles,  and  the  value  of  the 
triennial  prize  will  be  $1,000.  Thus  will  the  memory 
of  these  sober  city  fathers  ever  be  kept  green. 

The  announcement  that  the  next  congress  will  be 
held  in  Paris  at  the  time  of  the  international  exposi- 
tion is  only  what  was  anticipated.  The  French  have 
long  contended  for  the  honor  of  entertaining  the  con- 
gress and  it  is  fitting  that  they  should  do  so  during 
their  year  of  jubilation. 

From  the  report  of  the  proceedings  of  the  principal 
sections  which  our  special  representative  has  secured 
for  us,  and  which  will  be  published  in  future  issues, 
the  readers  of  the  Medical  Record  will  learn  of  the 
work  of  the  congress  and  will  be  able  to  judge  whether 
it  was  such  as  will  contribute  to  the  onward  progress 
of  scientific  medicine. 


RECIPROCITY   IN    MEDICAL    PRACTICE. 

The  action  of  some  physicians  of  New  York  and  other 
large  cities  who  visit  the  summer  resorts  of  New 
England  and  elsewhere  and  there  follow  their  profes- 
sion is  always  severely  criticised  and  gives  rise  to  much 


3o8 


MKDTCAL    RF.r-ORD. 


[August  28,  1897 


/leart-burning  among  the  resident  medical  men.  They 
contend  that  these  city  doctors  have  no  right  thus  to 
combine  business  with  pleasure  and  take  the  bread  out 
of  their  mouths.  We  find  in  the  Atlantic  Medical  Weekly 
of  July  17th  some  correspondence  and  editorial  com- 
ments on  this  subject,  in  which  the  case  is  presented 
very  fairly.  It  would  appear  that  the  fault  lies  chiefly  in 
the  laxity  of  the  State  laws,  and  that  so  long  as  a  visit- 
ing physician  conforms  to  the  law  no  valid  objection 
can  be  made  to  his  practising,  but  that  if  he  does  not 
fulfil  the  necessary  regulations  then  the  authorities, 
if  notified,  must  act.  As  to  the  hardships  resulting 
to  the  local  practitioners  from  the  lack  of  reciprocity 
our  contemporary  says :  "  Granting  all  the  premises 
regarding  the  raison  d'/tre  of  the  law,  it  is  notably  un- 
fair that  one  State  should  admit  to  all  the  rights  of  the 
profession  while  barred  from  gaining  an  equivalent 
for  its  own  citizens,  unfair  that  New  York  men  may 
come  to  New  England  and  replenish  their  purses  while 
recuperating  their  health,  while  New  England  men  who 
may  spend  a  few  months  in  the  metropolis  attending 
perhaps  post-graduate  studies  are  denied  the  privilege 
of  practising."  All  this  is  very  true,  but  surely  at  least 
to  a  certain  extent  the  remedy  is  in  the  hands  of  the 
resident  practitioners.  Why  should  not  the  doctors  of 
New  England  follow  the  example  set  them  by  the  native 
medical  men  in  Italy  in  their  present  crusade  against 
foreign  physicians,  and  induce  their  legislatures  to  de- 
bar others  from  practising  medicine  in  their  States  un- 
less they  can  be  allowed  the  same  facilities  in  New  York 
or  in  the  other  cities  from  which  the  visiting  doctors 
may  come .''  Of  course  the  inequality  in  the  standards  in 
the  different  States  is  the  chief  obstacle  in  the  way  of 
reciprocity,  and  until  a  uniform  course  and  a  uniform 
method  of  conducting  examinations  are  introduced,  it 
would  seem  that  the  difficulties  are  almost  insuperable. 
However,  after  all  the  solution  of  the  problem  lies  in 
State  legislation,  and  that  is  where  the  remedy  should 
be  sought. 


BICYCLE  RIDING  A  REMEDY  FOR  ASTHMA. 

Dr.  Marcet,  of  London,  is  strongly  of  the  opinion  that 
bicycle  riding  is  very  beneficial  in  cases  of  asthma, 
he  even  goes  further  and  says  that  it  may  act  as  a  cure. 
If  this  opinion  should  receive  practical  verification, 
the  already  popular  exercise  will  gain  yet  another 
impetus. 

Dr.  Marcet  says:  "  If  asthma  is  a  form  of  mountain 
sickness,  and  if  that  distressing  affection  of  high  alti- 
tudes can  be  cured  by  training  for  the  exercise  of 
climbing,  why  should  not  asthma  also  yield  to  the 
training  of  the  respiration  carried  out  by  practising 
the  respiratory  movements  wanted  to  carry  the  tidal 
air  through  the  lungs?  Of  all  means  of  training  res- 
piration I  think  cycling  is  the  best.  When  a  person 
first  takes  to  cycling  exercise  it  will  be  found,  espe- 
cially on  going  uphill,  that  the  breath  is  wanting,  the 
heart  beats  uncomfortably,  and  the  legs  tire;  but  after 
some  training  these  discomforts  all  disappear;  nothing 
will  be  thought  of  hills  to  ascend,  the  heart  has  become 
perfectly    comfortable,   all   breathlessness  has  disap- 


peared, and  the  legs  will  no  longer  feel  any  fatigue. 
Cycling  exercise  first  of  all  increases  the  depth  of 
breathing,  and  that  without  fatigue,  as  the  respiratory 
movements  are  automatic;  at  the  same  time  it  will  ac- 
custom the  rider  instinctively  to  take  in  at  each  re- 
spiration the  volume  of  air  required  to  aerate  the  blood 
and  to  eliminate  a  fixed  proportion  of  C0„,  leaving 
in  the  circulation  the  precise  balance  of  CO,  compat- 
ible with  health.  Persons  who  do  not  care  for  cycling 
out  of  doors  can  take  the  same  kind  of  exercise  at 
home  by  means  of  a  dummy  cycle  consisting  of  an  iron 
wheel  driven  by  pedals,  the  resistance  of  the  wheel 
being  so  contrived  as  to  simulate  bicycle  riding.  A 
strap  carried  partly  round  the  rim  of  the  wheel  can  be 
tightened  at  will  by  the  rider,  thus  increasing  the  labor 
and  recalling  the  effort  of  riding  uphill.  My  experi- 
ence of  the  results  of  this  treatment  is  unfortunately 
limited  to  only  one  person;  in  this  case  it  has  proved 
eminently  successful.  This  person  took  to  bicycle  rid- 
ing about  three  years  ago  for  pleasure,  and  in  very 
great  moderation  for  the  first  two  years.  He  obser\  ed 
last  summer  that  the  attacks  of  asthma  to  which  he 
was  subject  had  become  very  much  fewer.  The  tight- 
ness and  wheezing  which  occurred  every  night  have 
now  entirely  disappeared." 


VERMINOUS    PERSONS    IN    ENGLAND. 

In  England  it  is  proposed  to  deal  by  the  strong  hand 
of  the  law  with  those  who  are  troubled  with  parasites. 
The //('jy>//'(7/ for  July  17th  has  an  article  under  the 
rather  repellent  title  of  "Verminous  Persons."  It 
would  appear  that  a  bill  has  lately  been  introduced 
into  the  British  House  of  Commons  Tor  the  relief  of 
verminous  persons,  and  that  in  order  to  avoid  discus- 
sion of  the  female-suffrage  bill,  which  was  the  next 
on  the  list,  a  flood  of  small  wit  was  let  loose  upon  the 
bill  for  the  relief  of  verminous  persons,  merely  to  kill 
time  and  prevent  discussion  of  the  other  bill.  The 
Hospital  gravely  rebukes  the  House  of  Commons  for 
its  unbecoming  levity  on  the  subject,  and  if  the  ac- 
counts given  in  the  Hospital  are  true  the  matter  is  cer- 
tainly past  a  joke.  According  to  our  contemporary,  the 
"  verminous  persons'  bill"  is  a  most  necessary  measure, 
and  one  that  would  add  greatly  to  the  comfort  of  the 
poorer  classes  in  the  metropolis  and  in  other  large 
towns  in  Great  Britain.  It  is  said  that  the  tenements 
inhabited  by  these  classes  are  infested  with  vermin  to 
such  an  extent  that  it  is  almost  impossible  to  obtain 
in  them  a  satisfactory  night's  rest,  and  inconsequence 
hundreds  of  men  may  be  seen  sleeping  on  warm  days 
in  the  parks  for  the  reason  that  they  are  unable  to 
sleep  in  their  lodgings  on  account  of  the  lively  pulex 
and  the  bloodthirsty  ciniex.  It  is  difficult  to  say 
whether  the  pest  of  mosquitoes  from  which  so  many 
people  in  places  outside  of  New  York  City  suffer  is 
worse  than  the  vermin  pest  of  the  English  cities.  The 
mosquitoes  while  they  stay  are  perhaps  more  venomous 
and  their  favors  are  more  impartially  distributed,  but 
by  way  of  comjjensation  their  season  is  limited,  where- 
as in  Great  Britain  the  "verminous  persons"  are  vermi- 
nous the  year  round. 


August  28.  1897] 


MEDICAL    RECORD. 


309 


^eius  ot  the  ^Blcek. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, U'ashington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
August  21,  1897.  August  14th. — Assistant  Surgeon 
F.  L.  Pleadwell  detached  from  the  7>.V(?j  August  17th 
and  ordered  to  the  iVi/j/zrvy/t' August  19th;  Assistant 
Surgeon  \\.  M.  Wheeler  detached  from  the  Oregon 
August  23d  and  ordered  to  the  Mare  Island  navy 
yard  for  duty  in  connection  with  the  Marietta.  Au- 
gust 20th.  —  Assistant  Surgeon  D.  H.  Morgan  de- 
tached from  the  Moiioiigahcla  and  ordered  to  the  Chi- 
cinnati;  Surgeon  A.  G.  Cabell  detached  from  the 
Monongahela  and  ordered  home  to  be  ready  for  sea. 

The  Risks  of  Travel  in  Far  Countries. — Tlie 
accident-insurance  companies  in  England  do  not  per- 
mit their  policy  holders  to  run  off  when  they  will  to 
wander  in  the  wilds  of  New  York  or  Montreal.  The 
British  Medical  Journal  announces  the  fact,  which  it 
thinks  may  be  of  interest  to  the  members  of  the  asso- 
ciation who  intend  to  be  present  at  the  meeting  in 
Montreal,  that  though  life-insurance  companies  permit 
policy  holders  to  travel  in  Canada  and  the  United 
States,  an  extra  premium  is  charged  by  accident-in- 
surance companies.  The  impression  seems  to  be  that 
we  shoot  only  to  uing  and  not  to  kill. 

The  Fourth  Congress  for  the  Study  of  Tubercu- 
losis will  take  place  in  Paris  during  the  week  begin- 
ning July  25,  1898,  under  the  presidency  of  M.  No- 
card,  of  the  Alfort  Veterinary  School.  The  following 
questions  will  be  discussed;  The  value  of  sanatoria 
as  prophylactics  and  as  a  means  of  treating  tuber- 
culosis; serum  and  toxins  in  treating  tuberculosis; 
use  of  x-rays  in  diagnosing  tuberculosis;  the  -v- 
rays  in  treating  tuberculosis;  the  success  of  pro- 
phylactic measures  in  combating  animal  tuberculosis. 

The  Plague  is  reported  to  be  increasing  again  in 
the  district  of  Poonah  and  in  the  city  of  Bombay. 

Typhoid  Fever  is  reported  to  be  epidemic  in 
Milan. 

Trouble  in  Oklahoma. — The  new  goverpor  of 
Oklahoma  Territory  has  appointed  a  homcEopathic 
physician  president  of  the  territorial  board  of  health. 
This  action  has  naturally  aroused  the  regular  practi- 
tioners of  the  Territory,  and  they  are  endeavoring  to 
have  the  appointment  revoked. 

Homoeopathy  at  the  University  of  California. — 
The  directors  of  the  Halmemann  Hospital  College  in 
San  Francisco  have  petitioned  for  affiliation  with  the 
University  of  California,  and  a  counterpetition  has 
been  presented  to  the  regents  by  the  regular  faculty  of 
the  medical  department  of  the  university.  At  a  meet- 
ing of  the  regents  of  the  university  held  Augu.st  loth 
both  petitions  were  heard,  but  the  final  vote  will  not 
be  taken  till  the  ne.xt  meeting,  on  September  7th.  The 
main  argument  cf  the  homoeopathic  school  is  that  not 
to  allow  it  to  come  into  the  State  University  would  be 
taxation  without  representation.  The  members  of  the 
regular  facultj'  were  supported  at  the  hearing  by  sev- 


eral good  speakers,  including  a  delegation  from  the 
Medical  Society  of  the  City  and  County  of  San  Fran- 
cisco, by  petitions  from  the  surgeons  of  the  army  and 
navy  stations  in  San  Francisco,  the  local  medical  so- 
cieties, and  the  medical  societies  of  Sacramento  and 
of  Los  Angeles,  and  by  vigorous  letters  from  Dr. 
Donald  McLean,  of  Detroit,  formerly  professor  of 
surger)'  in  Ann  Arbor,  and  from  Dr.  C.  L.  Bard,  pres- 
ident of  the  California  State  Medical  Society. 

The  International  Congress  of  Neurology,  Psy- 
chiatry, Medical  Electricity,  and  Hypnology. — 
The  first  session  of  this  congress  will  be  held  at 
Brussels  from  September  14th  to  19th,  under  the  presi- 
dentship of  Professor  Verriest,  of  Louvain.  The  gen- 
eral secretar}-  is  Dr.  Crocq,  of  the  Molenbeek  Hospi- 
tal, Brussels.  Among  the  subjects  for  discussion  will 
be  the  surgical  treatment  of  epilepsy;  the  pathogeny 
and  treatment  of  exophthalmic  goitre;  refle.xes,  mus- 
cular rigidity,  and  contracture  :  general  paralysis;  psy- 
chosis and  dreams;  the  semeiological  value  of  electri- 
cal reactions  of  muscles  and  ner\es;  the  therapeutical 
value  of  high-frequency  currents:  the  therapeutical 
value  of  hypnotism  and  suggestion  ;  and  the  question 
of  criminal  suggestions,  their  origin  and  actual  state. 

Obituary  Notes. — Dr.  Georcie  R.  K_auffmax  died 
at  Chambersburg,  Pa.,  on  August  13th,  at  the  age  of 
fifty-six  years,  in  the  sequence  of  an  attack  of  hemi- 
plegia.— Dr.  George  Y.  Lehr  died  at  Philadelphia 
on  August  1 8th  from  carcinoma  of  the  stomach.  A 
surgical  operation  was  performed  for  the  removal  of 
the  growth  a  year  ago,  but  recurrence  took  place.  Dr. 
Lehr  was  born  at  Gratz,  Dauphin  County,  Pa.,  May  13, 
1842,  and  was  graduated  from  Jefferson  Medical  Col- 
lege in  1863.  He  has  lived  in  Philadelphia  for  thir- 
teen years. — Dr.  Edward  W.  Kitchel,  of  Newark, 
N.  J.,  died  at  the  Roosevelt  Hospital  in  this  city  on 
August  25tli,  in  consequence,  it  is  said,  of  injuries  re- 
ceived in  a  railway  accident.  Dr.  Kitchel  was  twenty- 
seven  years  of  age.  He  was  assistant  instructor  in 
normal  histology  at  the  College  of  Physicians  and 
Surgeons,  New  York. 

The  Late  Dr.  John  J.  H.  Love. —  The  following 
minute  was  adopted  at  a  meeting  of  the  visiting  staff 
of  the  Mountain  Side  Hospital,  .\ugust  16,  1897: 

"  No  words  can  express. the  loss  which  the  Moun- 
tain Side  Hospital  has  sustained  in  the  death  of  Dr. 
Love,  nor  is  it  possible  so  to  construe  language  as  to 
give  the  measure  of  our  personal  loss  in  the  death  of 
our  beloved  leader. 

"  Filled  with  the  courage  and  self-sacrifice  that  are 
boni  of  high  purpose  and  unselfish  broadmindedness, 
and  always  willing  to  prefer  the  wellbeing  of  others 
to  his  own,  he  gave  freely  of  his  time  and  substance 
to  the  hospital. 

"  Its  good  name  was  as  dear  to  him  as  his  personal 
honor,  and  from  his  clear  and  comprehensive  mind 
came  most  of  the  suggestions  by  the  adoption  of 
which  the  enterprise  has  been  successfully  carried  on. 
Without  Dr.  Love  it  would  have  failed;  with  him,  it 
has  achieved  an  enviable  measure  of  success  and  use- 
fulness. 


3IO 


MEDICAL    RECORD. 


[August  28,  1897 


"  We  can  no  longer  enjoy  his  friendship,  his  guid- 
ance, his  counsel,  or  his  sympathy,  but  we  have  the 
brilliant  example  of  his  noble  life  and  of  his  devotion 
to  the  best  interests  of  this  hospital. 

"  Richard  C.   Xewton, 

"  E.  M.  Ward, 

"  H.  B.  Whitehorne, 

"  Committee." 

Colored  Woman  Physicians — Dr.  Cornelia  Kahn, 
of  Cleveland  Springs,  N.  C,  referring  to  a  statement 
that  Dr.  Emma  Wakefield,  of  Louisiana,  was  the  first 
colored  woman  to  graduate  in  medicine,  says  that  the 
Woman's  Medical  College  of  Pennsylvania  has  been 
graduating  colored  women  for  years.  "  One,  the  wife 
of  a  minister  in  Philadelphia,  has  been  practising 
with  success  for  at  least  fifteen  years.  This  spring, 
a  colored  woman  physician.  Dr.  Brown,  passed  the 
State  e.xamination  with  more  credit  than  her  dark 
brothers,  and  better  than  some  of  the  white  candidates. 
She  is  now  serving  as  resident  in  the  hospital  for  col- 
ored people  in  Charleston,  where  they  have  also 
started  a  training-school  for  nurses." 

The    Adelaide    Hospital     Trouble Drs.    Leith 

Napier  and  Ramsay  Smith,  formerly  of  London,  who 
sold  their  services  to  the  lay  managers  of  the  Ade- 
laide (South  Australia)  Hospital  to  take  the  places 
left  vacant  by  the  former  medical  board,  are  doubtless 
rather  sorry  now'  that  they  did  not  remain  at  home. 
They  have  not  been  recognized  by  their  colleagues 
since  their  arrival  in  Adelaide  and  now  they  have 
been  cast  out  at  home  through  a  sentence  of  expulsion  ' 
from  the  British  Medical  Association.  While  one 
may  be  permitted  to  look  with  equanimity  upon  the 
infliction  of  punishment  for  dishonorable  actions,  it  is 
yet  difficult  to  see  how  the  culprits  in  this  case  h;ue 
committed  an  actual  crime  or  have  done  anything 
legally  "  infamous."  The  scramble  for  hospital  ap- 
pointrtients  which  have  been  vacated  by  colleagues 
under  pressure  from  their  lay  masters  is  not  regarded 
with  pleasure  by  disinterested  onlookers,  but  if  every 
man  who  had  gleefully  taken  a  brother's  place  were 
expelled  from  his  medical  society  there  would  be  a 
sad  thinning  out  indeed. 

German  University  Students. — The  number  of 
matriculated  students  in  twenty-one  German  universi- 
ties during  the  summer  semester  of  1897  was  30,932, 
and  of  hearers  1,519,  of  whom  207  were  women;  stu- 
dents of  theology,  4,326;  of  law,  8,368;  of  medicine, 
8,232;  of  philosophy,  10,006.  There  was  a  marked  de- 
crease in  the  number  of  students  of  theology  and  med- 
icine, and  an  increase  in  that  of  students  in  the  phil- 
osophical department,  especially  in  philology  and 
natural  science. 

A  Department  of  Public  Health  in  Great  Britain. 

— The  announcement  has  been  made  that  when  Par- 
liament rea.ssembles  it  will  be  moved  in  the  House 
of  Commons  "That  in  the  opinion  of  the  house  it  is 
desirable  that  a  department  of  public  health  be  con- 
stituted, and  that  the  same  be  under  the  charge  of  a 
responsible  minister  having  a  seat  in  Parliament.'' 


Secretary  of  the  Interior  Ulloa  of   Costa  Rica. — 

The  present  secretar}'  of  the  interior  of  Costa  Rica  is 
Dr.  Juan  J.  Ullda,  who  studied  medicine  in  this  city 
and  served  upon  the  house  staff  of  St.  Vincent's  Hos- 
pital. As  a  member  of  the  international  executive 
commission  of  the  first  Pan-.\merican  Medical  Con- 
gress, he  was  the  author  of  the  resolution  creating  the 
sub-commission  on  Pan-American  quarantine.  He  is 
not  only  a  leading  medical  practitioner  of  that  country 
but  one  of  its  most  potent  political  factors. 

"A  Cheerful  Fact  for  New  York  City."— Under 
this  heading  an  esteemed  but  somewhat  east-winded 
contemporary  remarks  that  "  a  statistician  catering 
for  the  good-will  of  the  Greater  New  York  says  that 
for  the  six  deaths  every  fifteen  minutes  there  are  seven 
births.  Unfortunately,  however,  the  births  are  largely 
from  that  class  in  the  community  which  is  of  least 
benefit  to  the  city."  And  so,  we  would  apologetically 
add,  are  the  deaths. 

Dr.  Max  Einhorn  has  been  requested  by  the  fac- 
ulty of  the  Post-Graduate  School  to  give  special 
courses  next  autumn  and  spring  on  the  newer  methods 
of  diagnosis  and  treatment  of  diseases  of  the  stomach. 

A  Town  Without  a  Doctor. — The  wonderful  dis- 
covery has  been  made  that  only  a  short  distance  from 
New  York  City  exists  a  town  which  has  no  resident 
physician.  This  town  is  North  Bergen  in  New  Jer- 
sey. The  township  authorities  had  been  notified  by 
the  State  board  of  health  to  appoint  a  town  physician, 
and  when  they  set  about  doing  so  they  found  there 
was  no  medical  man,  except  a  veterinarj'  surgeon,  liv- 
ing in  the  place.  The  salary  attached  to  this  impor- 
tant office  is  $50  per  annum. 

Hospital  Enterprise — A  hospital  in  Omaha  is  dis- 
tributing broadcast  a  catchy  circular,  which  reads  in 
part  as  follows:  "  Accident  insurance  is  a  good  thing. 
Insurance  against  ordinary  sickness  is  a  better  thing. 
Both  in  one  is  the  best  thing.  Do  not  wait  until  sick- 
ness or  accidents  come  to  you  before  taking  out  a 
membership  certificate  entitling  you  to  free  admission, 
bed,  bqard,  nursing,  medical  and  surgical  care  in  case 
of  accident  or  sickness  in  the  Methodist  Hospital  of 
the  Omaha  Hospital  and  Deaconess  Home  Association 
of  the  Methodist  Episcopal  Church.  A  two-edged 
sword  cuts  both  ways,  and  accomplishes  its  mission  in 
either  direction.  So  does  your  membership  fee.  If 
you  have  occasion  to  use  the  hospital  as  a  member, 
you  have  the  first  right  to  accommodations,  above  any 
other  class  of  patients,  and  you  will  he  mo.st  tenderly 
cared  for.  If  the  Lord  .spares  you  in  perfect  health, 
your  money  will  assist  the  institution  in  caring  for 
some  one  else  not  able  to  pay.  It  thus  becomes  a 
sweet  charity  whose  fragrant  memory  will  follow  you 
all  your  life."  The  cost  of  membership  is  $10  a  year 
in  advance.  The  payment  of  S250  in  advance  makes 
one  a  life  member  entitled  to  continuous  free  treat- 
ment for  himself  or,  "if  the  Lord  spares  him  in  per- 
fect health."  for  some  one  else  of  whom  Providence  is 
not  so  careful. 


August  28,  1897] 


MEDICAL    RECORD. 


G^Unical  Scpavtmcnt. 

EIGHT  INTESTINAL  PERFORATIONS  FROM 
PISTOL  BULLET;  OPERATION:  RECOV- 
ERY. 

By  I.   F.   B.\LD\VIN',  A.M.,  M.D.. 


The  following  case  is  worthy  of  report,  since  few 
■cases  of  more  e.xtensive  injur\-  to  the  intestines  with 
recover}-  have  been  recorded : 

April  25,  1897,  T.  \V.,  aged  twenty-one,  a  student 
at  Delaware  College,  accidentally  shot  himself  in  the 
abdomen  with  his  revolver.  The  bullet,  of  thirt)' -two 
calibre,  entered  the  abdomen  four  inches  below  the 
umbilicus  and  two  inches  to  the  right  of  the  median 
line.  As  nearly  as  he  could  tell,  the  bullet  entered 
at  right  angles  to  the  surface.  The  accident  occurred 
at  five  o'clock  in  the  afternoon,  and  he  was  seen  within 
a  few  minutes  by  two  physicians.  At  this  time  he 
was  suffering  from  the  effects  of  a  good  deal  of  shock. 
He  was  at  once  given  a  hypodermic  injection  of  one- 
quarter  grain  of  morphine  with  atropine,  and  whiskey 
was  given  internally.  At  eight  o'clock  the  injection 
of  morphine  was  repeated.  I  saw  him  at  1 1  p.m.,  in 
conjunction  with  his  physicians,  Drs.  Seamans, 
Murray,  and  Vogt.  .\t  this  time  his  general  condi- 
tion was  excellent.  His  pulse  was  somewhat  acceler- 
ated, varying  from  84  to  108  per  minute,  but  of  good 
strength  and  volume.  He  was  free  from  pain  and 
expressed  himself  as  feeling  entirely  well. 

Notwithstanding  his  excellent  condition,  I  took  the 
ground  at  the  consultation  which  followed  the  ex- 
amination that  from  the  direction  apparently  taken  by 
the  bullet  we  could  scarcely  imagine  the  bowels  to 
have  escaped  injury.  Even  if  there  were  no  injury  to 
the  intestine,  an  exploratory  incision  would  not  ma- 
terially increase  the  risk,  while  if  a  perforation  ex- 
isted it  would  almost  certainly  prove  fatal  if  left  alone. 
The  other  physicians  present  concurred  in  this  opinion, 
and  when  our  view  was  explained  to  the  patient  he 
promptly  acquiesced.  The  young  man  was  the  son  of 
a  surgeon.  Dr.  J.  L.  Wylie,  of  Ripley,  Ohio,  and  had 
himself  studied  medicine  one  year. 

With  the  aid  of  my  assistant,  Dr.  Chapman,  and 
the  physicians  above  mentioned,  the  operation  was 
commenced  as  soon  as  the  preparations  could  be  com- 
pleted. The  incision  was  made  so  as  to  include  the 
wound.  The  first  loop  of  bowel  noticed  was  brought 
up  into  the  incision  and  passed  through  the  fingers 
until  a  perforation  was  found.  This  was  carefully 
closed  with  a  double  row  of  Czerny-Lembert  sutures, 
fine  iron-dyed  silk  being  used.  The  surrounding  area 
was  carefully  cleansed  and  the  bowel  returned,  while 
more  was  brought  into  view.  In  this  way  eight  per- 
forations of  the  small  intestines  were  found  and 
closed,  and  three  perforations  of  the  mesenter}-. 
There  had  been  no  hemorrhage  of  any  moment.  The 
perforations  were  all  within  about  three  feet  of  the 
ileo-cacal  valve,  the  last  being  about  an  inch  and  a 
half  above  the  colon.  The  peritoneal  cavity'  was 
carefully  cleaned  and  the  incision  closed  except  at  a 
point  where  a  gauze  drain  was  inserted,  so  as  to  give 
drainage  in  case  an  opening  had  been  overlooked  or 
a  leak  should  occur  at  any  point.  The  operation 
was  completed  at  2  a.m.,  and  the  patient  put  to  bed  in 
good  condition. 

The  after-treatment  of  the  case  was  attended  to  by 
Drs.  Murray  and  Seamans  until  the  arrival  of  Dr. 
Wylie,  twelve  hours  after  the  completion  of  the  opera- 
tion Thirty-six  hours  after  the  operation  I  changed 
the  gauze  drain  for  a  small  piece  inserted  just  through 


the  incision ;  this  was  allowed  to  remain  forty-eight 
hours  longer,  when  it  was  removed  and  the  opening 
closed.  The  bowels  were  opened  by  cathartics  on  the 
fourth  day.  Convalescence  was  absolutely  uninter- 
rupted, the  highest  pulse  rate  being  88  and  tempera- 
ture 100'  F.  At  the  end  of  three  weeks  the  patient 
resumed  his  college  work,  and  a  week  later  called 
on  me  at  Columbus. 

No  attempt  was  made  to  find  the  bullet,  which  was 
doubtless  lodged  somewhere  in  the  muscles  of  the 
back.  In  case  its  presence  should  ever  make  trouble, 
it  can  be  located  by  the  .v-rays  and  easily  removed. 

The  presence  of  the  drain  necessarily  left  a  some- 
what weak  place  in  the  abdominal  wall,  but  if  a 
hernial  protrusion  should  occur  at  this  point  a  second- 
ary operation  would  be  a  very  simple  matter. 

The  case  is  of  interest  as  emphasizing  the  import- 
ance of  making  exploratory^  incision  in  cases  of  ab- 
dominal injur)-  from  gunshot  wounds,  without  waiting 
for  symptoms  of  hemorrhage  or  of  peritonitis  to  de- 
velop. It  also  shows  that  with  care  in  the  technique 
even  most  extensive  injuries  of  the  intestines  may 
be  recovered  from. 


SUBMAXILLARY    ADENITIS    WITH     APPAR- 
ENT   INCIPIENT    LYMPHADENOMA.' 

Bv    EDWIN    R.    M.WSOX,    .\.M..    M.D.,    I.1..D., 

Adenitis,  or  inflammation  of  a  gland,  with  or  without 
suppuration  or  caseation  in  scrofulous  subjects,  has 
long  been  fairly  well  understood.  But  lymphadenoma, 
which  consists  in  its  first  stage  of  "  a  mere  hyper- 
plasia," and  "subsequently  of  fibroid  induration" 
(Gowers),  when  not  arrested  in  its  incipiency,  though 
described  by  many,  from  Malpighi  (1669)  to  Murchi- 
son  (1870)  and  later,  appears  even  now  to  be  but  im- 
perfectly understood.  .\nd  a  complication  of  the  two 
conditions,  as  apparently  occurred  in  a  case  that  re- 
cently fell  under  my  care,  must,  I  think,  be  very  rare. 
I  have  seen  only  two  other  cases,  and  they  were  not 
apparently  complicated  with  submaxillary  adenitis; 
in  neither  case  did  the  patient  live  long  enough  for 
the  process  to  pass  on  to  induration,  suppuration,  or 
caseation. 

The  subject  in  this  case  is  a  man,  si.vty-two  years  of 
age,  farmer,  who  in  childhood  had  some  sort  of  ab- 
scess or  swelling  about  the  face  or  neck,  left  side, 
leaving  no  visible  scar  that  I  could  discover.  Two  or 
three  near  relatives  are  said  to  have  died  from  wasting 
abscesses.  He  chewed  and  smoked  tobacco,  but 
was  otherwise  temperate  .After  a  slight  attack  of 
grippe,  lasting  about  a  week,  during  which  he  was 
seen  by  two  physicians,  neither  of  whom  appeared  to 
have  defined  his  disease,  there  appeared  an  almost 
painless  swelling  which  commenced  with  slight  ten- 
derness in  the  left  submaxillary  gland;  this  swelling 
rapidly  extended  to  the  sublingual  and  lymphatic 
glands,  and  all  the  structures  and  tissues  of  the  left 
side  of  the  face  and  the  entire  neck  from  ear  to  ear, 
so  as  to  produce  an  enormous  distention  devoid  of 
noticeable  pain  or  tenderness.  It  was  at  this  stage, 
after  one  week  of  illness,  that  I  was  called  to  attend 
him,  the  swelling  having  increased,  I  was  assured,  one- 
half  during  the  preceding  twenty-four  hours,  almost 
obstructing  respiration,  deglutition,  and  speech,  thus 
presenting  the  gravest  possible  symptoms,  with  the 
fearful  prospect  of  speedy  dissolution,  but  attended 
by  little  or  no  pain  or  tenderness. 

Called  at  such  a  crisis,  my  first  inquiry  was  as  to 
the  possibility  of  any  poison  having  been  taken  into 

'  Read  before  the   Syracuse  .\cademv  of   Medicine,  lune  22. 

1S97. 


MEDICAL    RECORD. 


[August  28,  1897 


the  mouth  that  might  have  irritated  the  left  submaxil- 
hiry  gland,  which  was  slightly  tender  from  the  first,  I 
learned.  But  this  elicited  only  the  fact  that  tobacco 
had  been  used  quite  freely,  by  chewing  and  smok- 
ing; and  this  fact,  together  with  the  evidence  of  a 
liglit  attack  of  influenza  attended  by  a  loss  of  ap- 
petite, coated  tongue,  a  bounding  pulse,  such  as  I 
have  rarely  if  ever  witnessed  before,  led  me  to  the 
conclusion,  in  the  absence  of  other  causes,  that  nico- 
tine had  poisoned  the  left  subma.villary  gland  and 
irrit.ited  the  adjacent  lymphatic  glands  and  tissues, 
and  together  with  the  poison  of  the  grippe  had  led  to 
the  apparent  incipient  lymphadenoma,  which  was 
threatening  a  rapidly  fatal  termination  by  apnoea  from 
pressure  upon  the  larynx,  trachea,  or  respiratory  pas- 
sages. 

The  prominent  symiHoms  in  this  case  were  the 
enormous  distention  from  ear  to  ear,  under  the  jaws, 
in  front  of  the  neck,  and  of  the  left  side  of  the  face, 
witii  difficult  respiration,  a  bounding  pulse,  difficult 
speech,  an  an.xious  expression  of  countenance,  and 
slight  tenderness  of  the  left  submaxillary  gland  on 
pressure  under  the  lower  jaw.  The  remaining  symp- 
toms, catarrhal,  coated  tongue,  loss  of  appetite,  lame 
neck,  and  slight  cephalalgia,  were  apparently  from  the 
grippe,  as  I  viewed  the  case. 

From  erysipelas  it  differed  in  not  being  attended 
by  redness;  from  an  ordinary  inflammation,  in  the 
absence  of  pain  and  tenderness,  which  were  slight  and 
manifest  only  in  the  left  submaxillary  gland  under  the 
jaw,  and  from  all  other  conditions,  except  perhaps 
sn.ike  or  septic  poisoning,  in  the  rapid  extension  and 
development  of  the  swelling. 

From  all  the  facts  connected  with  this  case,  it  was 
my  opinion  that  the  grippe  predisposed  to  the  hyper- 
plasia which  followed,  the  submaxillary  gland  being 
poisoned,  inflamed,  and  narcotized  by  nicotine,  so  as 
to  deaden  the  pain,  as  it  passed  on  to  inflammation 
and  suppuration  without  pain,  all  the  tissues  being 
thus  relaxed,  accounting  for  this  supervening  apparent 
incipient  lymphadenoma  witii  the  attendant  threatened 
suspension  of  respiration,  deglutition,  etc.  For  while 
under  the  treatment  which  I  adopted  and  followed 
out,  no  more  distention  or  swelling  occurred,  at  one 
time,  the  tenth  day  of  my  treatment,  while  the  respira- 
tion and  speech  appeared  impro\ed,  the  patient  de- 
clare'd  himself  imable  to  swallow  for  about  twenty 
hours,  the  sublingual  glands  became  tense,  and  the 
surface  assumed  from  the  chin  to  the  sternum  an  ery- 
sipelatous appearance.  This  I  attributed  to  the  pas- 
,sage  of  pus  from  the  submaxillary  toward  the  surface. 
And  this  was  probably  the  case,  for  two  days  later,  the 
twelfth  day  of  my  treatment,  the  pus  made  for  itselt  a 
painless  opening  nearly  opposite  the  middle  of  the 
lower  jaw  of  the  left  side.  The  pus  came  out  in  a 
stream,  materially  lessening  the  swelling  and  disten- 
tion of  the  parts.  The  pus  was  thick,  yellowish,  and 
had  a  slight  odor,  as  might  liave  been  anticipated  in 
such  a  case. 

The  prognosis  in  simple  uncomplicated  adenitis, 
attended  or  not  by  caseation  or  suppuration,  may 
not  be  very  unfavorable  when  properly  treated,  though 
liable  to  be  of  protracted  duration.  l!ut  when  com- 
plicated with  incipient  lympiiadenoma,  as  it  appeared 
to  be  in  this  case,  tiie  danger  is  very  great  at  best,  and 
especially  if  not  attended  to  in  season.  In  all  cases 
(if  lymphadenoma,  even  in  the  incipiency  if  involving 
the  neck,  and  later,  if  passing  on  to  induration,  involv- 
ing the  spleen,  attended  or  not  by  caseation,  or  pos- 
sil)ly  in  scrofulous  .subjects  suppuration,  a  fatal  ter- 
mination is  to  be  feared.  Strangely  enough  the  two 
cases  that  I  had  seen  in  consultation  before  this, 
already  referred  to,  both  of  which  terminated  fatally 
very  soon,  were  clearly  produced  by  ;iicotine,  as  was 
verified  by  the  jihysicians  attending  them. 


The  treatment  I  pursued  in  this  case  was  general 
and  local,  the  general  consisting  of  sulphide  of  cal- 
cium, two  grains,  morning  and  evening,  to  lessen  pus 
formation  ;  one  or  two  cathartic  pills  daily  to  clean  the 
tongue;  sulphocarbolate  of  sodium,  a  grain  and  a  half, 
with  three  drops  of  tincture  of  nux  vomica  every  six 
hours;  and  alternating  with  this  a  grain  and  a  half  of 
cinchonidine  for  the  antiseptic  and  tonic  effect,  with 
such  liquid  nourishment  as  could  be  swallowed,  and  a 
warm  foot  bath  at  evening  to  favor  perspiration. 

Locally,  removing  a  cold  bread-and-milk  poultice,  I 
had  a  clean  white  flannel  broughr  under  the  swelling 
and  up  over  the  sides  of  the  face  so  as  to  cover  it,  tied 
with  tapes  over  the  head  so  as  to  make  pressure  on  the 
swollen  parts.  Under  this  I  had  applied  everj-  six 
hours  a  strong  solution  of  chloride  of  ammonium 
(tepidj,  except  over  the  region  of  the  submaxillary 
gland,  where  I  substituted  ichthyol,  one  part  to  about 
three  of  glycerin.  .\nd  this  was  continued  till  the 
erysipelatous  appearance  occurred  under  the  chin, 
when  a  folded  linen,  wet  in  a  tepid  solution  of  sul- 
phate of  iron,  about  an  ounce  to  a  pint  of  water,  was 
kept  on  that  part  under  the  flannel  and  a  solution  of 
iodide  of  potassium  over  the  gland,  about  two  drachms 
to  the  ounce  of  water,  till  the  pus  discharged  two  days 
later,  the  fourteenth  day  of  my  treatment  and  twenty- 
first  of  the  disease.  Then  the  ichthyol  was  again  ap- 
plied over  the  region  of  the  gland  about  the  opening, 
and  a  poultice  of  bread  and  milk  was  applied  and  re- 
newed every  six  hours. 

While  it  is  claimed  that  of  "  two-thirds  of  the  cases 
of  lymphadenoma  no  cause  can  be  traced"  (Gowers), 
it  is  said  that  it  may  commence  with  an  "  irritation  in 
the  submaxillary  gland."  as  in  this  case,  and,  e.xtend- 
ing,  may  "encircle  the  neck  beneath  the  lower  jaw." 
But  I  do  not  find  a  parallel  to  this  case  in  the  pain- 
less suppuration  of  a  submaxillar}^  gland  attended  by 
a  rapid  hyperplasia,  filling  the  neck  from  ear  to  ear, 
devoid  of  both  pain  and  tenderness.  .\nd  yet  this 
case,  with  almost  painless  submaxillary  adenitis,  with 
suppuration,  was  apparently  one  of  hyperplasia,  con- 
stituting the  incipient  stage  of  lymphadenoma,  while 
the  two  fatal  cases  referred  to  were  without  submaxil- 
lary adenitis,  as  appeared. 

Finally  it  remains  to  be  seen  whether  this  case  of 
apparent  incipient  lymphadenoma  complicated  with 
submaxillary  adenitis  must  necessarily  pass  on  from 
the  hyperplasia  to  tiie  formation  in  the  lymphatics  of 
"tissues  similar  to  those  observed  in  the  glands,"  en- 
largement, induration,  etc.  (Roberts),  or  if  the  sub- 
maxillary adenitis  with  the  drainage  of  suppuration, 
early  treatment,  and  no  very  strong  predisposition  may 
not  perhaps  temporarily  and  possibly  permanently  stay 
or  avert  the  con.sequences  of  this  semimalignant  dis- 
ease. The  abscess  healed  in  about  a  week,  and  the 
fulness  and  induration  have  diminished  up  to  the 
present,  it  being  now  the  eighth  week. 

,Sl8  M.MJISON  Stkeet,  June  32.  .8,7- 


Cholelithiasis. — In  considering  the  question  when 
to  operate  Dr.  Carl  Beck  (AtVi'  Vor/^-  Mcilical JoHrna!. 
May  8th)  says :  "  In  summing  up,  I  would  therefore  ad- 
vise the  operation  as  follows:  i.  Whenever  the  diag- 
nosis of  acute  cholecystitis  is  made,  cholecystotoni} 
should  be  performed  w  ithout  delay.  2.  Cholecystotomy 
should  also  be  performed  in  chronic  hydrops  of  the 
gall  bladder.  3.  Whenever  acute  colicky  attacks  in 
the  region  of  the  gall  bladder,  combined  with  fever, 
return  for  a  second  or  tiiird  time.  4.  Whenever  jaun- 
dice is  present  for  more  than  f()ur  weeks.  5.  In  gall- 
stone ileus.  6.  Ii\  all  obscure  cases  when  inflamma- 
tory symptoms  resembling  peritonitis  turn  up  in  the 
region  of  the  gall  bladder,  exploraton,'  laparatomy  is 
indicated." 


August  28,  1897] 


MEDICAL    RECORD. 


113 


THE    TREATMENT    OF    TAPE\VOR^[,    WITH 
REPORT   OF    CASES. 

Hv    ]■:.    C.    CHAMBERLIN,    M.D., 

Any  one  wno  is  privileged  to  examine  and  prescribe 
for  a  large  number  of  people  daily  will  not  infre- 
quently meet  with  a  case  of  tapeworm.  This  dis- 
tressing affection  seems  to  be  almost  entirely  confined 
to  womankind.  In  fact  I  have  not  seen  a  single  case 
of  tajnia  saginata  or  solium  in  a  man  and  my  histories 
are  all  furnished  by  women.  This  is  not  strange,  when 
the  report  of  the  military  surgeons  of  the  French  army 
for  ten  years  showed  only  one  case  in  every  thirty-six 
thousand  men.  I  will  not  attempt  to  discuss  the  nat- 
ural history  of  taenia  or  describe  the  familiar  ribbon- 
like shape  of  the  worm. 

The  diagnosis  is  often  made  by  the  patient  before  she 
presents  herself;  and  again  cases  exist  which  have 
been  treated  for  dyspepsia,  anamia,  and  many  other 
disorders  for  a  long  time. 

The  symptoms  ate  not  well  defined,  though  intesti- 
nal disorders,  with  or  without  pain,  salivation,  ver- 
tigo, loss  of  llesh  with  great  increase  of  appetite,  are 
the  most  common  ones.  The  imagination  in  woman 
may  var}-  the  symptoms  in  many  ways  after  once  the 
presence  of  the  worm  is  known. 

The  treatment  pursued  in  the  following  cases  I  have 
found  to  give  much  satisfaction.  It  contains  nothing 
new  except  in  the  combination. 

Case  I. — Miss  A had  complained  of  pains   in 

abdomen  with  attacks  of  nausea  and  vomiting  for  the 
past  two  months.  Emaciation  and  loss  of  strength  had 
been  rapid.  She  had  been  taking  iron  for  her  blood. 
After  a  brisk  cathartic  several  links  of  taenia  were 
found  in  the  stools.  Strict  orders  as  to  diet  were  then 
given.  For  one  and  a  half  days  she  was  allowed 
only  two  cups  of  tea  with  toast.  .\t  the  end  of  her 
fast  she  received  a  half-ounce  of  magnesium  sulphate 
with  two  glasses  of  water:  early  the  ne.\t  day  half  an 
ounce  of  castor  oil ;  about  two  hours  later,  after  numer- 
ous stools,  she  took  the  first  dose  of  the  following 
mixture,  followed  by  another  an  hour  later,  until  all 
had  been  taken : 

H  Spir.  chlorofoniii Z  ']■ 

01.  terebinthin;t, 

Oleoresince  aspidii aa  3  i. 

Glycerini q.s.  ad  r  \. 

M.      .S.   Z  ij.  q.  h. 

The  stools  after  the  administration  of  the  castor  oil 
contained  several  links  of  the  worm,  but  not  until  the 
above  mixture  had  blinded  him  did  he  let  go  of  the 
lining  of  the  intestine  with  his  suckers,  when  the  head 
and  twelve  feet  of  the  worm  were  captured.  This  was 
no  doubt  a  teenia  solium. 

Case  H. — Mrs.  B had  had  dull   pains  in  the 

abdomen,  constipation,  and  diarrhoea  at  intervals  for 
the  past  si.x  months,  with  increased  appetite.  She  imag- 
ined all  sorts  of  things  after  the  discovery  of  her  tape- 
worm, which  she  made  herself,  .\fter  the  same  treat- 
ment as  outlined  in  Case  I.  she  passed  a  worm  exactly 
twenty-one  feet  in  length.  There  had  been  no  return 
of  her  trouble  for  over  a  year. 

Case  III. — Baby,  two  years  old.  The  mother  said 
that  when  the  child  was  one  year  old  it  passed  several 
feet  of  a  worm.  When  I  saw  the  child  at  its  home  in 
March,  1896,  I  gave  it  castor  oil.  Latter  it  passed  ten 
feet  of  worm  connected.      In  the  morning  I  gave: 

Q  01.  terebinthina-, 

Spir.  chloroformi, 

Aspidii aa  ;  -^. 

Glycerini    ;  s^ 

Sig.   :  i.  q.  h. 

In  the  evening  the  child  passed  eleven  feet  more,  as 
was  ascertained  bv  careful  measurement.     If  the  child 


had  not  been  a  strong  one  the  above  dose  might  be 
considered  large.  Again  I  anticipated  that  much 
would  be  vomited  up,  which  was  the  case.  There  has 
been  no  return  of  trouble  as  yet. 

Case  IV. — Miss  G ,  December,  1896,     For  the 

past  three  months  she  had  had  nausea  and  vomiting  at 
times.  A  physician  had  washed  out  her  stomach,  which 
gave  temporary  relief.  She  had  vertigo,  much  ner- 
vousness, lumbar  pains,  frequent  urination,  and  many 
other  reflex  symptoms.  She  was  very  fond  of  rare 
meat  and  had  for  some  time  past  eaten  a  good  deal 
of  it.  When  first  seen  she  said  she  had  worms 
and  that  they  were  always  dropping  from  the  rectum. 
These  worms  proved  to  be  the  joints  of  the  tarnia.  I 
gave  fifteen  minims  of  oleoresin  aspidium  every  two 
hours,  with  the  result  that  a  large  number  of  segments 
were  passed.  Two  weeks  later  after  another  dose  of 
aspidium  she  passed  one  worm  exactly  5.3  metres 
(or  i6j:^  feet).  Three  months  later  she  applied  again 
for  treatment.  This  time  I  used  the  mixture  as  pre- 
scribed in  Case  I.,  with  the  satisfaction  of  recovering 
the  entire  worm.  By  careful  measurement  it  was 
found  to  be  8.2  metres  (26 '-2  feet)  in  length  and 
almost  intact.  There  h'as  been  no  return  of  trouble 
for  past  seven  months. 

In  the  preparation  of  the  patient  there  are  certain 
things,  as  described  in  Case  I.,  which  must  not  be 
overlooked,  for  on  these  depends  the  success  of  the 
medicine.  In  order  to  find  the  head  and  smaller  por- 
tions, a  good  deal  of  care  must  be  exercised  in  the 
manner  in  which  the  stools  are  received  and  examined. 
.\  good  routine  practice  is  to  have  ready  several  pieces 
of  cheesecloth,  one  of  which  is  to  be  stretched  over 
a  receptacle.  .A.s  soon  as  one  evacuation  has  taken 
place,  put  another  cloth  in  its  place,  spreading  these 
cloths  with  contents  on  sheets  of  newpapers  for  ex- 
amination. It  is  only  thus  with  great  care  that  all 
parts  may  be  washed  and  saved,  and  the  head  may 
then  often  be  discovered. 


A  CASE  OF    HODGKIX'S    DISEASE   COMPLI- 
CATED   BY   PULMONARY    TUBERCULOSIS. 

liv   CHARLES    U.    LEWIS,   M.D., 

.NEW    YORK, 
VISITING    l'HVSICI.\X   TO  COLl'MBUS  HOSPITAL. 

The  disease  of  many  names,  but  perhaps  best  known 
to-day,  in  English-speaking  countries  at  least,  as 
Hodgkin's  disease,  was  first  systematically  described 
by  Richard  Hodgkins'  in  1832.  His  data  were  drawn 
from  seven  cases,  extending  over  a  period  of  nearly  six 
years.  Three  or  perhaps  four  of  these  cases  in  clini- 
cal history  and  autopsy  closely  resemble  tuberculous 
adenitis;  in  two  there  seems  no  doubt  that  tuberculo- 
sis was  the  etiological  factor. 

A  quarter  of  a  century  later  Samuel  Wilks'  de- 
scribed five  cases  with  the  characteristic  appearance 
of  glands  and  spleen.  Two  of  these  cases  presented 
such  marked  evidence  of  pulmonary  tuberculosis  at 
autopsy,  that  the  diagnosis  admits  of  considerable 
doubt.  He  classed  the  five,  however,  in  the  same  cat- 
egor\'  with  Hodgkin's  cases,  and  christened  them  all 
with  Hodgkin's  name.  Wunderlich,  Billroth,  and 
Trousseau  later  described  the  morbid  conditions,  and 
each  dubbed  the  disease  differently — all  appellations, 
however,  being  more  or  less  descriptive  of  the  domi- 
nant lesions.  The  course  of  the  disease  since  its 
recognition  in  1832  has  run  suspiciously  close  to  tu- 
berculosis, and  the  lines  of  differential  diagnosis  in 
many  cases  have  been  invisible  to  the  naked  eye  of 
any  but  the  reporter.      Leukaemia   is  excluded  by  the 

'  Medico-Chirurg.  Transac. ,  London,  1832. 

-  Guy's  Hospital  Reports,  .Series  3,  vols.  ii.  and  i.\. 


3H 


MEDICAL    RECORD. 


[August  28,  1897 


microscope,  and  to  that  instrument  it  seems  to  me  we 
must  occasionally  appeal  in  order  to  exclude  a  tuber- 
culous gland  infection. 

In  1892  Professor  Duplay'  presented  a  case  of 
Hodgkin's  disease,  complicated  or  associated  with  tu- 
berculous adenitis.  So  far  as  I  am  aware  this  is  the 
only  case  recorded  as  combining  both  diseases,  al- 
though some  histories  might  justify  a  diagnosis  of  either 
or  both,  according  to  the  predilection  of  the  reporter. 
The  following  case  appears  worthy  of  record,  mainly 
on  the  ground  of  differential  diagnosis. 

L.  V ,  female,  married,  of  Italian  birth,  was  ad- 
mitted to  Columbus  Hospital,  August  20,  1896.  She 
had  been  in  this  country  si.xteen  years.  Family  his- 
tory irrelevant,  except  that  a  brother  is  said  to  have 
died  of  •"bronchitis."  The  previous  history  discloses 
no  syphilitic,  tuberculous,  or  malignant  tendency,  and 
is  otherwise  immaterial  up  to  si.v  months  prior  to  ad- 
mission, at  which  time,  while  pregnant,  the  patient 
noticed  "some  swellings  in  the  neck."  These  swell- 
ings appeared  .soon  after  moving  into  a  new  house,  the 
walls  and  floors  of  which  were  quite  damp.  Later  she 
suffered  some  abdominal  and  back  pains.  Two  or 
three  months  subsequent  to  the  neck  swellings  similar 
swellings  appeared  in  the  axillary  and  inguinal  re- 
gions. About  this  time  she  gave  birth  to  a  seven- 
months'  child.  After  her  confinement  the  swellings 
took  on  a  very  rapid  growth,  the  back  and  abdominal 
pains  increased;  she  says  she  became  very  pale  and 
lost  Hesh  and  strength.  .\  persistent  and  exhausting 
cough  appeared  about  three  weeks  before  admission; 
expectoration  was  scanty  and  from  description  without 
significance. 

On  admission  the  patient  was  weak,  emaciated, 
rather  ancemic,  and  complained  chiefly  of  abdominal 
pains  with  more  or  less  general  tenderness.  The  cer- 
vical glands  in  front  and  behind,  while  not  greatly 
swollen,  on  account  of  the  emaciated  condition  stood 
out  prominently.  They  were  quite  uniformly  enlarged, 
about  the  size  of  a  chestnut,  symmetrically  arranged, 
and  extended  along  the  sterno-cleido  muscles  from  the 
lower  jaw  to  the  clavicles.  The  parotid  and  submax- 
illary glands  partook  of  the  general  enlargement. 
The  suboccipital  glands,  somewhat  smaller,  ran  from 
the  scalp  to  the  ribs  behind.  Some  of  these  glands 
were  rather  soft,  but  by  far  the  greater  number  had  a 
hard,  smooth  feel ;  they  were  not  adherent  to  the  skin 
or  toeach  other;  none  seemed  cheesy  and  none  con- 
tained pus. 

The  axillary,  epitrochlear,  inguinal,  and  apparently 
the  mesenteric  glands  adhered  to  this  general  descrip- 
tion, except  that  all  appeared  of  hard  consistence. 
None  was  sensitive. 

The  spleen  was  enlarged,  not  painful. 

The  heart  appeared  healthy,  rather  rapid  in  action. 

Lungs :  Prolonged  expiration  over  left  apex :  no  rales 
or  other  abnormal  physical  signs  were  detected.  Tem- 
perature, 102.4°  V.\  pulse,  120.  Urine  turbid;  spe- 
cific gravity,  1.012;  acid;  albumin  one  per  cent,  by 
volume;  quantity  normal.  Microscopical  examina- 
tion negative.  Blood  count  showed  some  diminution 
of  red  corpuscles  and  no  leucocytosis;  hamoglobin, 
eighty  per  cent.  Sputum  scanty,  muco-purulent ;  no 
tubercle  bacilli  found. 

I  ordered  arsenious  acid,  one-thirtieth  grain,  t.i.d., 
to  be  gradually  increased. 

Repeated  examinations  of  sputum  were  negative 
until  August  28th,  when  tubercle  bacilli  were  detected. 
At  this  time  more  of  the  neck  glands  had  a  softer  feel 
— some  almost  chee.sy,  and  one  Huctuated.  The  other 
glands  were  apparently  unchanged.  Legs  adema- 
tous;  abdomen  distended,  somewhat  tympanitic,  and 
containing  a  moderate  amount  of  fluid. 

September  ist,  general  condition  progressively  fail- 
'  La  I'rance  .Med.,  1S92,  p.   .1, 


ing.  An  epitrochlear  gland  removed  for  examin- 
ation. 

September  9th,  still  more  of  the  cervical  glands 
had  rapidly  softened  and  apjjeared  tuberculous.  Ba- 
cilli in  sputum.  The  epitrochlear  gland  removed  on 
the  ist  inst.  showed  no  bacilli  or  tuberculous  structure, 
but  proliferation  of  lymph  cells  with  increase  of  con- 
nective tissue.     No  marked  leucocytosis. 

On  September  loth  death  took  place  by  gradual 
exhaustion. 

Temperature  ranged  from  100'  to  120"  F.  during 
stay  at  hospital. 

Autopsy  by  Dr.  Farquhar  Ferguson,  twenty-four 
hours  after  death  ;  Rigor  mortis  not  marked.  Poorly 
nourished.  Oidema  of  lower  extremities.  Thorax: 
No  adhesions;  one  ounce  of  dark-colored  fluid  in  right 
pleural  cavity.  Heart  shows  cloudy  swelling.  The 
left  lung  is  oedematous;  has  a  small  tuberculous  no- 
dule at  apex;  localized  pleurisy  in  lower  lobe  due  to 
a  small  infarction.  Right  lung  cedematous,  otherwise 
normal.  Bronchial  glands  enlarged  and  cheesy. 
Liver,  nutmeg.  Spleen  greatly  enlarged.  The  gas- 
tric, hepatic,  retroperitoneal,  and  mesenteric  glands 
are  all  enlarged,  from  the  size  of  a  pea  to  a  horse- 
chestnut,  and  of  hard  consistence.  The  mesenteric 
glands  alone  are  fused  together  and  form  irregular 
masses,  varying  in  size  from  a  hen's  egg  to  a  large 
orange.  A  large  mass  of  agglutinated  glands  partially 
covers  the  intestines  in  front.  Right  kidney  shows 
cloudy  swelling  Left  kidney  has  capsule  somewhat 
adherent,  is  contracted,  and  contains  bands  of  connec- 
tive tissue  with  evidences  of  chronic  diffuse  nephritis. 

Microscopical  examination  of  the  lymph  nodes 
shows  proliferation  of  round  cells.  No  invasion  of 
other  tissues.  The  cells  seem  to  be  crowded  out  by 
redundant  new  connective  tissue,  thus  agreeing  with 
Snow's'  description.  Spleen  shows  same  condition. 
Kidneys  present  clusters  of  round  cells  throughout 
cortical  portion. 

I  have  recorded  the  autopsy  notes  rather  literally 
and  included  all  points  in  them  which  seem  to  bear 
directly  or  indirectly  upon  the  disease.  I  have  done 
this  because  cases  of  Hodgkin's  disease  are  not  fre- 
quently met  with  and  autopsies  still  less.  According 
to  the  reports  for  the  past  year  of  eighteen  hospitals 
in  this  city,  out  of  over  seventeen  thousand  cases 
strictly  medical  there  were  but  six  cases  of  Hodgkin's 
disease.  Of  these  six  cases  three  were  discharged 
"  improved,"  one  "  unimproved,"  one  has  no  record,  and 
one,  reported  above,  died.  Stephen  Mackenzie'  has 
reported  two  cases  with  autopsy. 

In  the  clinical  history  exposure  to  a  damp  atmos- 
phere is  the  only  apparent  etiologial  factor.  The  dis- 
ease seemed  to  receive  fresh  impetus  after  the  confine- 
ment, thus  resembling  a  case  mentioned  by  Gowers,' 
where  the  malady  lay  dormant  during  a  pregnancy, 
but  advanced  with  redoubled  speed  after  delivery. 
The  association  of  Hodgkin's  di.sease  with  the  tuber- 
culous infection  is  chietlv  interesting  as  duplicating 
Duplay's  case,  which,  so  far  as  I  know,  is  unique  in 
the  literature  of  the  subject.  It  is  to  be  regretted  that 
the  cer\'ical  glands,  which  in  their  later  manifesta- 
tions, to  the  eye  at  lea.st,  certainly  resembled  tubercu- 
lous structures,  were  not  examined  for  bacilli.  The 
tuberculous  nodule  in  the  lung,  however,  with  the  ba- 
cillary  infection  of  the  sputum,  makes  the  tuberculous 
element  of  the  case  positive.  The  other  symptoms 
with  the  autopsy  findings  clinch  the  diagnosis  of 
Hodgkin's  disease. 

.Arsenic  in  increasing  doses  seems  to  be  the  only 
remedy  available.     Karenski'  reports  four  cases,  with 

'  Uiitisli  Meilical  Journal,  iSg6,  p.  133. 
'  The  Lancet,  January  4,  lSg6. 
'  Reynolds'  "  System  of  Medicine." 
'' Berlin,  klin.  Wochensch..  1SS4. 


August  28,  1897] 


MEDICAL    RECORD. 


315 


three  recoveries:  one  of  the  latter  subsequently  died 
of  phthisis,  a  fact  which  may  throw  doubt  upon  the 
diagnosis.  Rosenberg'  followed  a  case  si.x  years 
without  finding  any  curative  eiTect  in  arsenic.  Dresh- 
field  -■  reports  two  incipient  cases  cured  by  arsenic. 
Mackenzie's  cases  were  uninfluenced  by  arsenic  and 
suprarenal  extract.  In  the  case  reported  not  the  slight- 
est temporar)-  benefit  from  the  arsenic  was  noted. 

38  West  Si.\tv-Fikst  Stkeet. 


TWELFTH    INTERNATIONAL    MEDICAL 
CONGRESS. 

I/c-M  ill  Moscoii',  August  ig.  20,  21,  22.  2j,  24.  2j.  and 
26.  1897. 

(.Special  Repiirt  by  Uirect  U.  S,  Cable  to  the  -Medical  Recoku.^ 

GENERAL    SESSIONS. 

First  Day — Thursday,  August  TQt/i. 

The  opening  session  of  the  congress  was  not  held  in 
the  Grand  Theatre,  as  was  originally  intended,  since 
it  was  feared  that  the  hall  would  be  too  small  to  ac- 
commodate the  immense  assemblage,  and  accordingly 
the  meeting  was  called  together  in  the  Military  Ma- 
noeuvre Hall,  a  large  armory,  over  five  hundred  feet  in 
length,  which  serves  excellently  for  the  reunions.  All 
the  various  bureaus  of  the  congress  have  also  been  es- 
tablished in  the  same  building.  The  Chamber  of 
Commerce,  an  almost  equally  large  building,  is  to  be 
utilized  for  all  the  public  functions  of  a  strictly  social 
character,  and  is  admirably  adapted  to  this  purpose. 
Moscow  is  crowded  with  physicians  and  their  fami- 
lies, conservative  estimates  placing  the  entire  number 
of  visitors,  physicians  with  their  wives  and  daughters, 
at  fully  ten  thousand.  The  fears  which  had  been 
entertained  and  freely  expressed  that  the  railroads 
would  be  unable  to  transport  the  great  crowds  con- 
verging to  Moscow  from  all  points  on  the  frontier 
were  found  to  be  groundless,  for  the  accommodations 
were  ample.  The  customs  regulations  were  found  to 
be  no  more  vexatious  than  they  are  everywhere:  the 
officials  on  the  frontier  and  everywhere  on  the  route 
were  most  obliging,  and  the  passport  formalities  caused 
no  trouble  to  any  one.  Indeed,  there  is  no  word  but 
of  praise  for  Russian  courtesy  and  Russian  hospital- 
ity. Shortly  after  one  o'clock  the  Grand  Duke  Ser- 
gius  stepped  forward,  and  in  a  few  formal  words 
declared  the  Twelfth  International  Medical  Congress 
opened. 

Address  of  Welcome. — After  the  applause  follow- 
ing this  announcement  had  died  away,  Hospodin  Dv- 
LIANOV,  the  minister  of  public  instruction,  delivered  a 
brief  address  of  welcome,  couched  in  what  Virchow 
and  others  of  his  hearers,  who  were  competent  to 
judge,  pronounced  most  cla.ssical  and  finished  Latin. 
He  spoke  of  the  great  obligation  of  all  the  members 
of  the  congress,  the  Russians  especially,  to  the  Tsar, 
whose  unbounded  liberality  alone  had  made  it  possi- 
ble to  bring  together  this  great  assemblage  in  the 
heart  of  Russia,  for  without  not  only  his  consent,  but 
his  active  and  personal  support  and  aid,  this  congress 
could  not  have  been  held  in  this  place.  He  bade  all 
his  hearers  welcome  to  Moscow  and  to  Russia,  and 
expressed  the  earnest  hope  not  onlv  that  tiie  scientific 
labors  of  the  meeting  would  be  productive  of  great 
good  to  humanit}-  and  of  added  renown  to  the  distin- 
guished men  who  assisted  at  the  congress,  but  that  all 

'  Berlin,  klin.  Wochensch.,  1S95. 
-Med.  Chron.,  1895-96,  vol.  iv. 


here  assembled  would  enjoy  to  the  utmost  the  mo- 
ments of  relaxation  between  the  meetings:  if  they  did 
not,  it  w^ould,  he  was  sure,  not  be  the  fault  of  the  citi- 
zens of  Moscow  and  of  Russia,  lay  and  medical. 

President's  Address. — Professor  Sklifosovsky, 
ihe  president  of  the  committee  of  organization,  then 
spoke.  Moscow,  he  said,  greeted  joyfully  this  bril- 
liant assembly  of  most  eminent  medical  authorities 
who  had  gathered  there  from  all  parts  of  the  civilized 
world,  even  from  Eastern  Asia  and  from  distant  Amer- 
ica, North  and  South.  There  was  no  longer,  he  con- 
tinued, a  wall  between  Russia  and  the  rest  of  Europe, 
but  the  former  was  as  open  as  the  plains  which  his 
hearers  had  seen  after  crossing  the  frontier.  To-day 
Europe  is  united  as  it  never  was  before:  the  east  and 
the  west  are  drawing  together  and  becoming  as  one  in 
the  bonds  of  a  common  civilization.  It  is  only  now 
that  Europe  is  beginning  to  recognize  its  debt  of  obli- 
gation to  Russia  for  protecting  it  from  the  incursions 
of  the  barbarians.  For  ages  the  Slavs  stood  on  the 
outskirts  of  civilization  with  their  faces  turned  to  the 
hordes  pouring  toward  the  west  and  threatening  the 
very  existence  not  only  of  the  Slavs  themselves  but  of 
the  peoples  of  the  western  lands  as  well.  In  this 
long  conflict  Russia,  in  order  to  face  the  foe,  stood 
with  her  back  to  the  rest  of  Europe,  and  so  the  latter 
came  to  regard  her  as  a  race  apart  and  not  as  of  the 
family  of  nations.  In  consequence  of  her  isolation 
and  of  the  necessity  she  was  under  of  first  re- 
deeming her  land  from  the  Tartars  and  then  reuniting 
its  severed  parts,  Russia  had  long  remained  behind 
the  rest  of  Europe  in  culture  and  the  arts  of  peace, 
but  she  was  now  hastening  with  giant  strides  to  take 
her  place  in  the  front  ranks,  shoulder  to  shoulder  with 
the  other  nations  of  Europe  and  America.  With  the 
strength  of  an  unexhausted  race  she  had  been  able  to 
accomplish  in  a  portion  of  a  century  what  it  had  taken 
other  nations  three  centuries  to  perform.  This  was 
not  said  in  a  spirit  of  boastfulness  but  in  one  of  con- 
fidence and  of  dignified  assertion.  The  medical  men 
of  Russia  were  now  ready  to  co-operate  with  those  of 
all  the  world  in  furthering  the  uplifting  of  their  be- 
loved science. 

An  International  Language. — Continuing,  Profes- 
sor Sklifosovsky  said  that  the  one  great  obstacle  to 
medical  progress  was  the  want  of  a  common  medium 
of  communication  between  the  men  of  science  of  dif- 
ferent nationalities.  Nowhere  was  this  almost  fatal 
lack  so  fully  realized  as  in  Russia.  The  great  mass 
of  Russian  medical  literature  was  a  sealed  book  to 
western  peoples,  and  few  outside  of  the  country  had 
any  conception  of  the  enormous  amount  of  scientific 
work  that  was  being  done  there.  Russians  recognized 
that  their  language  was  too  difificult  ever  to  become 
universally  known  to  westerners,  and  they  were  there- 
fore the  more  keenly  alive  to  the  necessit}-  of  the 
adoption  of  some  international  speech.  He  hoped 
that  this  would  be  one  of  the  useful  works  of  the  pres- 
ent congress.  He  would  suggest  the  appointment  of 
a  committee  to  draft  a  preliminar}'  agreement  which 
should  be  laid  before  the  next  congress  for  considera- 
tion. 

Report  of  the  Secretary-General. — Prof.  W.  K. 
Roth,  of  Moscow,  the  secretarj'-general  of  the  execu- 
tive committee  of  the  congress,  then  presented  his 
report.  His  first  and  most  pleasing  duty,  he  said, 
was  to  thank  in  the  name  of  the  congress.  His  Im- 
perial Majesty,  the  Tsar  of  Russia,  the  "  High  Pro- 
tector" of  the  congress.  Without  his  magnificent 
liberality  the  meeting  would  have  been  impossible. 
The  Russian  members  of  the  congress,  he  continued, 
have  withdrawn,  wherever  necessar\',  to  yield  their 
places  on  the  programme  of  the  sections  to  the  for- 
eigners. In  the  name  of  the  committee  he  would 
crave  the  indulgent  pardon  of  all  for  the  delay  there 


3i6 


mp:dical  record. 


[August  28,  1897 


liad  been  in  the  distribution  of  railway  tickets  and 
in  publishing  details  concerning  matters  of  interest 
to  intending  visitors.  Their  only  excuse  was  that  they 
feared  to  promise  too  much  and  were  therefore  obliged 
to  wait  for  the  necessar)-  authorization,  and,  as  every- 
body knew,  the  unwinding  of  red  tape  is  a  slow  proc- 
ess. He  was  able  to  report  the  attendance  of  7,300 
members  in  Moscow.  Of  this  number  more  than 
3,500  were  from  Russia,  800  from  Germany,  as  many 
from  Austria,  400  from  France,  300  from  Italy,  300 
from  England,  120  from  the  United  States,  30  from 
Mtjxico,  10  from  Japan,  4  from  China,  and  the  rest 
from  the  less  populous  countries  of  Europe,  South 
.\merica,  and  the  East. 

The  Moscow  International  Prize — Prince  G.\llit- 
zi.v,  the  mayor  of  Moscow,  then  greeted  the  members 
of  the  congress  on  behalf  of  the  great  municipality 
which  it  was  his  honor  to  represent.  He  announced 
that  the  city  of  Moscow  had  desired  to  express  in  some 
appropriate  manner  its  appreciation  of  the  great  honor 
that  had  been  bestowed  upon  it  by  its  selection  as  the 
place  of  meeting  of  this  greatest  of  congresses,  and  it 
had  decided  to  establish  a  prize  of  5,000  francs,  to  be 
awarded  at  each  international  congress,  for  all  time  to 
come,  to  the  person  who  in  the  interval  since  the  pre- 
ceding congress  shall  have  done  that  medical  work 
which  shall  be  deemed  of  the  greatest  benefit  to 
humanity. 

Addresses  from  National  Delegates. — Short  ad- 
dresses were  then  delivered  by  delegates  from  the  va- 
rious countries  represented  at  the  congress.  General 
Kohler,  surgeon  in  the  Cierman  amiy,  said  he  brought 
greetings  from  his  gracious  master,  the  German  em- 
peror. Peace  was  the  watchword  of  the  times,  peace 
in  order  that  mankind,  under  the  leadership  of  the 
medical  profession,  might  wage  war  against  the  com- 
mon enemy,  disease.  The  enormous  strides  that  med- 
icine has  made  in  recent  times  is  shown  by  the  fact 
tliat  morbidity  and  mortality  from  disease  are  now 
less  than  one-half  what  they  were  only  two  decades 
ago.  This  address  had  something  of  a  political  turn, 
and  whenever  the  names  of  the  two  emperors  were 
mentioned  the  speaker  was  interrupted  by  the  cheers 
which  he  evidently  expected.  He  concluded  with 
''God  bless  the  Tsar/'  and  his  words  brought  the  audi- 
ence to  their  feet  with  a  thunder  of  cheers.  Other 
representatives  who  spoke  were  von  Ziemssen  for  Bava- 
ria, Gussenbauer  for  Austria,  Sir  William  MacCormac 
for  Great  Britain,  Thayer  of  the  Johns  Hopkins'  Uni- 
•versity  for  the  I'nited  States,  Dujardin-Beaumetz  for 
France,  Hlawa  for  Bohemia,  Kocher  for  Switzerland, 
and  Haga  for  Japan.  The  latter  said  that  he  had 
been  authorized  to  invite  the  next  congress  to  a.sseni- 
ble  in  Tokio,  and  he  could  assure  his  hearers  that 
they  would  meet  with  a  warm  welcome  should  they 
consent  to  honor  Japanese  medicine  by  an  acceptance 
of  the  invitation  which  it  was  his  pleasure  to  extend 
to  them.  Professor  Hlawa,  of  Prague,  spoke  in  Bohe- 
mian and  was  loudly  and  enthusiastically  cheered  by 
all  those  present  of  Slavic  stock.  Dr.  Dujardin-Beau- 
metz, medical  inspector  of  the  French  army  and  direc- 
tor of  the  sanitary  service  under  the  minister  of  war, 
received  the  greatest  ovation  from  the  Russians  pres- 
ent, exceeding  that  given  the  German  representative, 
in  recognition  doubtless  of  the  popularity  of  the  Franco- 
Russian  alliance.  Hearty  cheers  also  greeted  Profes- 
sor Ivocher,  of  Heme,  but  this  was  of  course  devoid  of 
political  signiticance  and  was  an  evidence  siniplv  of 
his  personal  popularilv. 

Invitation  to  St.  Petersburg.-  I'hk  Mayor  of  St. 
Petersburg  then  spoke  briefly,  saying  that  he  had  come 
from  his  own  city  to  Moscow  expresslv  to  invite  all 
the  members  of  the  congress  to  visit  the  northern  cap- 
ital after  the  labors  of  the  meeting  were  over.  .Mos- 
cow   was,    indeed,   the   heart   of    Russia,  hut    Russian 


hospitality  could  not  be  confined  to  the  heart  alone; 
it  extended  to  the  head  as  well.  If  his  hearers  would 
come  they  should  come  as  guests  of  the  government 
and  of  the  municipality.  The  railway  transportation 
would  be  free  of  all  charge,  and  many  fetes  in  honor 
of  the  congress  had  been  arranged  for. 

Honorary  Presidents. — The  announcement  v.as  then 
made  of  the  honorary  presidents  of  the  congress.  These 
were:  Germany — Virchow,  Leyden,  Ziemssen,  and 
Waldeyer;  Austria — Gussenbauer,  Hlawa,  and  Kudi- 
ger;  Great  Britain — Stokes,  MacCormac,  and  Simp- 
son; United  States — Senn  and  Thayer  (Billings,  it 
was  announced,  would  have  been  one  of  this  number 
had  he  not  been  absent);  Spain^ Robert;  France- — 
Lannelongue,  Le  Dentu,  Grasset,  and  Pinard:  Italy 
— D' Anton  a,  Bottini,  and  Lombroso.  The  name  of  the 
latter  was  greeted  with  prolonged  cheers.  A  recess  of 
five  minutes  was  then  taken  before  the  beginning  of 
the  scientific  work  of  the  congress. 

The  Continuity  of  Life. — PRot.  Rvl>olph  Vir- 
chow-, of  Berlin,  delivered  the  opening  address,  tak- 
ing for  his  subject  the  continuity  of  living  matter. 
Life,  he  said,  has  no  other  origin  than  from  life  itself, 
and  this  is  one  of  the  truths  which  the  labors  of  pa- 
thologists and  biologists  of  the  present  century  have 
established  beyond  the  possibility  of  doubt.  For  long 
many  men  of  acumen  and  true  scientific  minds  were 
inclined  to  doubt  the  unbroken  continuity  cf  life  and 
to  regard  spontaneous  generation  as  possible  if  not 
actually  probable.  This  theory  is,  however,  dead,  and 
dead  beyond  the  possibility  of  resurrection- — a  result 
which  we  owe  to  the  labors  of  many  earnest  investiga- 
tors, conspicuous  among  whom  stands  the  grand  figure 
of  Louis  Pasteur.  The  role  of  chemical  action  in  the 
processes  of  life  or  of  its  continuity  has  also  been 
found  to  be  less  important  than  it  was  at  one  time 
supposed  to  be.  Life  is  in  the  cell.  He  who  speaks 
of  serum  as  a  vital  force  apart  from  cells  is  wrong. 
The  grand  truth  of  cellular  succession  may  be  assailed 
in  the  future  as  it  has  been  in  the  past,  but  it  will 
never  be  thrown  to  earth:  it  will  shine  through  all  the 
long  years  of  the  twentieth  centur)'.  few  if  any  of  which, 
the  venerable  speaker  said  in  a  half-regretful  \oicc,  it 
would  be  his  privilege  to  see.  This  might  be  his  last 
congress  (cries  of  "  Xo.  no!"i.  but  whether  it  was  or 
not,  his  earnest  hoi>;  was  that  the  final  mystery  of  life 
might  be  solved  and  its  .solution  proclaimed  at  some 
future  congress.  If  it  ever  is  to  be  solved,  solved  it 
will  be  by  the  united  labors  of  the  biologist  and  the 
pathologist:  it  is  in  their  laboratory  that  the  key  will 
be  forged  whicli  shall  unlock  the  door  that  .still  holds 
us  back  from  a  full  knowledge  uf  the  processes  of  life. 

The  Sclerogenic  Treatment  of  Surgical  Tubercu- 
losis.— PROFES.SOR  L.\NNELOXGfE,  of  Paris,  delivered 
the  .second  general  address,  in  which  he  developed  at 
length  the  method  for  some  time  advocated  by  him  ior 
the  cure  of  local  tuberculosis.  Resection  of  tubercu- 
lous joints  was,  he  said,  a  measure  of  much  utility 
and  for  a  long  time  was  the  best  we  had  for  the  arrest 
of  this  destructive  process,  but  at  best  it  was  a  make- 
shift. It  was  a  mutilation  and  in  so  far  a  confession 
of  defeat  by  the  surgeon.  Furthermore,  it  was  not 
alwavs  possible  to  embrace  all  the  diseased  tissue  in 
the  area  operated  uix)n,  and  then  relapses  were  almost 
sure  to  take  place.  Injections  of  antiseptic  substances 
had  been  suggested  and  had  been  actively  urged  by 
some  enthusiasts,  but  practical  and  e.xtensive  trials 
had  demonstrated  their  inefficiency.  Theoretically 
they  ought  to  destroy  the  tubercle  bacilli  and  put  an 
end  to  the  disease,  but  practically  they  did  no  such 
thing.  He  had  conceived  the  idea  of  building  a  wall 
within  the  tissues,  enclosing  on  everj-  side  the  distr..std 
part,  and  so  shutting  otT  the  pathological  focus  from 
any  communication  with  the  healthy  structures  in  the 
neighborhood.      \'ery   numerous   clinical    and  experi- 


August  28,  1897] 


MEDICAL    RECORD. 


mental  facts  had  been  gathered  to  demonstrate  the 
value  of  this  method.  By  injecting  irritating  sub- 
stances deeply  into  the  parts  surrounding  the  diseased 
centre  on  every  side  he  was  able  to  cause  the  produc- 
tion of  an  envelope  of  fibrous  tissue  enclosing  the 
tuberculous  focus.  These  irritating  injections,  be- 
sides leading  to  the  production  of  fibrous  tissue,  ex- 
cited an  afflux  of  leucocytes  to  the  part,  whose  phago- 
cytic action  contributed  powertully  to  the  destruction 
of  the  pathogenic  agents  of  the  disease.  The  speaker 
referred  to  the  careful  and  convincing  experiments  of 
Nocard,  who  had  demonstrated  by  them  that  the  tuber- 
cle bacilli,  when  enclosed  by  this  artificially  produced 
sclerotic  zone,  were  all  killed  in  froni  six  to  eight 
weeks. 

Relationship  of  Physiology,  Pharmacology,  Pa- 
thology, and  Practical  Medicine. — Dr.  T.  Laider 
BRUN'roN',  of  London,  delivered  an  address  with  this 
title  (see  page  296). 

Reception  to  the  Congress. — In  the  evening  a  re- 
ception was  given  to  the  members  of  the  congress  and 
their  ladies  by  the  medical  men  of  the  city.  It  was 
held  in  the  Chamber  of  Commerce,  the  immense  gal- 
leries of  which  were  thronged  by  a  concourse  of  more 
tiian  ten  thousand  people. 


Second  Day — Sunday,  August  2 2d. 

The  second  general  session  was  opened  at  2  p.m.  on 
Sunday. 

The  Next  Congress The  announcement  was  made 

tliat  the  next  international  congress  would  be  held  in 
Paris  in  the  summer  of  1900.  Professor  Lannelongue 
was  appointed  president  of  the  organization  commit- 
tee, and  Dr.  Chauffard.  professeur  agre'gtf  in  the  Fac- 
ult}-  of  Paris,  honorary  secretary-general.  This  an- 
nouncement was  received  with  prolonged  cheers. 

Etiology  of  Progressive  General  Paralysis. — Prof. 
v.  Ivraffi-Ki'.im;,  of  Vienna,  then  delivered  an  ad- 
dress, taking  as  his  subject  a  consideration  of  certain 
of  the  etiological  factors  of  general  paresis  of  the  in- 
sane. In  order  to  obtain  a  clear  understanding  of 
these  factors,  he  said,  it  would  be  necessary-to  review 
the  conditions  of  life  in  the  latter  iialf  of  the  century 
which  is  now  so  rapidly  drawing  to  a  close.  Unless 
we  pause  a  minute  in  our  onward  rush  and  look  back 
fifty  or  a  hundred  years,  we  cannot  realize  the  change 
that  has  occurred.  Tlie  struggle  for  existence  has  be- 
come mucli  more  severe  than  it  was;  competition  is 
becoming  more  and  more  active,  and  this  competition 
is  not  only  between  the  individuals  in  one  community, 
one  country,  or  one  continent,  but  all  the  world  is  en- 
gaged in  the  struggle.  The  steamship,  the  railwaj-, 
the  telegraph,  have  brought  distant  countries  in  con- 
tact with  each  other  and  made  them  rivals  in  the  fight 
for  existence.  One  result  of  this  is  that  people  arc 
being  driven  more  and  more  from  the  country  into  the 
crowded  centres  of  population,  individual  effort  is  vain, 
and  success  comes  only  by  means  of  combinations  of 
capital  and  of  labor.  The  vital  tension  has  become 
extreme,  and  the  mass  of  mankind  is  struggling  now. 
not  for  ease  and  comfort,  but  for  ver)-  existence.  This 
strain  has  become  so  exhausting  in  its  effects  that  men 
are  driven  to  artificial  means  of  relief,  to  nerve  stimu- 
lants such  as  alcohol,  tea,  cofifee,  and  tobacco.  The 
result  of  all  this  overwork  and  worry  and  stimulation 
is  seen  in  the  nervous  heredity  witli  which  so  many  of 
our  time  are  cursed.  General  paralysis  is  an  end-of- 
the-century  disease,  the  predisposing  cause  of  whicli 
is  this  nervous  overtension,  the  exciting  cause  of  which 
is  syphilis. 

The  undoubted  etiological  role  played  by  this  dis- 
ease is  shown  by  many  facts.  In  the  first  place  we 
see  that  the  proportion  between  the  sexes  is  the  same 


for  sufferers  from  syphilis  as  it  is  for  general  para- 
lytics, namely  four  men  to  one  woman.  General  pare- 
sis is  more  common  among  men  of  the  upper  classes, 
such  as  army  officers,  well-to-do  merchants,  bankers, 
and  the  like,  who  are  among  the  least  circumspect  in 
their  sexual  relations,  while  it  is  very  rare  among  the 
clergy  and  among  women  of  the  upper  classes.  The 
principal  objection  thus  far  urged  against  this  theory 
has  been  that  it  is  not  possible  always  to  obtain  a  his- 
tory of  syphilis  in  cases  of  general  paralysis.  But  the 
rich  statistics  of  the  Vienna  General  Hospital  show  a 
still  greater  proportion  of  patients  with  unmistakable 
tertiary  lesions  from  whom  absolutely  no  history  of 
syphilis  could  be  obtained  than  of  general  paralytics 
from  whom  no  syphilitic  history  could  be  obtained. 
Nine  general  paralytics  in  Vienna,  who  were  without 
any  syphilitic  history,  were  recently  inoculated  with 
syphilitic  virus,  and  although  they  were  under  daily 
observation  for  a  period  of  six  months  not  one  pre- 
sented the  slightest  syphilitic  manifestation.  It  is 
highly  improbable,  if  not  actually  impossible,  that 
these  nine  persons  would  have  shown  themselves  re- 
fractory to  the  action  of  the  syphilitic  virus  had  they 
not  acquired  an  immunity  through  a  previous  attack. 
The  modern  struggle  for  existence  contributes  to  the 
frequency  of  general  paralysis  not  only  by  predispos- 
ing the  nervous  centres,  but  also  by  making  syphilis 
a  more  common  disease.  The  necessities  of  modem 
life  cause  late  marriages,  and  this  enforced  celibacy 
of  the  younger  generation  leads  to  an  increase  in  pros- 
titution. Indeed,  civilization  and  syphilization  have 
come  to  be  correlative  terms.  The  remedy  for  this 
deplorable  condition  is  to  be  found  in  education, 
moral  as  well  as  mental.  Young  people  must  be 
warned  in  season,  and  their  teachers  must  not  be  con- 
tent with  preaching  abstract  morality — it  is  the  con- 
crete that  appeals  to  youth.  The  young  must  be  told 
of  tlie  clangers,  proximate  and  remote,  of  an  unbridled 
indulgence  of  their  appetites ;  they  must  be  counselled 
to  moderation  in  work,  to  the  avoidance  of  worry,  and 
the  consumption  of  alcohol  should  be  limited  as  far 
as  practicable.  Especially  during  the  growing  period 
our  boys  and  our  girls  should  be  watched  over  and 
trained  up  to  lives  of  sobriety — it  is  at  this  time  that 
the  foundation  of  a  sound  constitution,  bodily  and 
ment.il,  must  be  laid. 

Classification  and  Surgical  Treatment  of  Acute 
Peritonitis. — Dr.  X.  Sexx,  of  Chicago,  then  deliv- 
ered an  address  witii  this  title  (see  p.  289). 

The  Plague. — Dr.  Metchnikoff,  of  Paris,  had 
selected  this  as  a  timely  subject  for  discussion  at  the 
present  time.  He  described  Yersin's  plague  bacil- 
lus, and  said  that  the  existence  of  spores  could  not  be 
doubted,  for  an  explanation  of  the  many  ciises  of  in- 
fection through  clothes  and  other  fomites  after 
months  of  desiccation  was  otherwise  impossible.  The 
bacillus  itself  is  extremely  delicate  and  is  most  easily 
destroyed.  The  speaker  then  described  the  metliod  of 
antitoxin  manufacture  as  employed  by  Roux  at  the 
Pasteur  Institute  in  Paris,  and  explained  why  this 
serum  when  practically  tried  in  India  had  proved  in- 
efficacious. Because  of  the  fear  of  causing  a  spread 
of  the  disease  in  Europe,  tlie  thirty  horses  inoculated 
in  Paris  in  order  to  procure  antitoxic  serum  for  use  in 
India  were  inoculated  with  dead  cultures.  That  this 
was  the  true  reason  for  the  failure  of  Yersin's  tests 
was  shown  by  the  fact  that  the  serum  employed  in 
China,  which  w'as  obtained  after  inoculation  with 
living  cultures,  was  curative.  Thus  the  mortality  of 
the  Chinese  cases  in  which  the  serum  was  employed 
was  only  seven  per  cent.,  while  that  of  the  Indian 
cases  was  forty-nine  per  cent,  .\fter  Yersin  arrived 
in  India  he  made  use  of  living  cultures  in  the  manu- 
facture of  antitoxin,  but  his  ill  luck  pursued  him,  for 
no  sooner  had  he  got  everything  well  started,  and  had 


3-8 


MEDICAL    RECORD. 


[August  28,  1897 


gone  away  again,  than  the  chief  veterinarian  of  the 
laboratory  died  of  pernicious  malaria,  and  those  who 
were  left  in  charge  did  not  conduct  all  the  stages  of 
the  manufacture  properly.  Nevertheless,  the  serum, 
poor  as  it  was,  was  better  than  nothing.  The  mortal- 
ity of  plague  when  untreated  is  eighty  per  cent.,  so 
that  its  reduction  to  forty-nine  per  cent,  was  a  de- 
cided gain  even  if  not  a  perfect  result  and  not  what 
■was  anticipated.  There  is  now  being  made,  however, 
an  antitoxic  seruiji  of  great  strength  from  living  cul- 
tures which  is  undoubtedly  efficacious  in  conferring 
immunity  and  in  curing  the  disease  in  its  early 
stages.  Recent  reports  from  India  declare  that  the 
protective  immunizing  power  of  this  serum  is  now 
greater  than  is  that  of  the  serum  prepared  after  Haff- 
kine's  method.  Inoculations  with  this  serum  are  de- 
void of  all  danger,  and  produce  absolutely  no  reaction, 
and  the  protective  influence  of  the  antitoxin  is  fully  as 
lasting  as  is  that  of  Haffkine's  serum.  This,  the 
speaker  continued,  is  an  undoubted  triumph  of  orrho- 
therapy,  and  establishes  the  principle  of  preventive  in- 
oculation on  a  foundation  which  can  never  be  shaken. 
That  at  least  some  specific  diseases  can  be  prevented 
and  cured  is  a  fact  that  cannot  be  gainsaid  at  the  pres- 
ent day  by  any  but  the  most  blindly  sceptical.  A 
general  employment  of  this  protective  serum  would 
guarantee  the  civilized  world  against  an  invasion  of 
the  plague.  It  would  be  too  much  to  hope  for  the 
stamping  out  of  the  disease  among  the  millions  in 
Asia,  where  the  pest  has  its  habitat,  but  it  would  be 
feasible  to  inoculate  every  one  coming  from  infected 
regions  to  Europe  and  other  parts  of  the  world  and  so 
prevent  the  spread  of  the  disease. 

The  speaker  closed  with  an  eloquent  peroration,  re- 
counting the  obligations  of  the  peoples  of  all  lands  to 
men  of  science.  The  contentions  of  scientists,  one 
with  another,  sometimes  excited  the  scorn  and  con- 
tempt of  the  ignorant,  but  there  is  going  on  here  as 
everywhere  a  struggle  for  existence,  and  the  law  of  the 
survival  of  the  fittest  is  as  inexorable  in  its  action  here 
as  elsewhere  throughout  the  universe.  Medical  selec- 
tion, indeed,  exerts  a  most  powerful  influence  over 
natural  selection.  It  is  through  rivalry,  through  crit- 
icism, perhaps  even  through  the  aspersions  of  the  jeal- 
ous and  the  envious,  that  truth  is  brought  to  light  and 
firmly  established.  The  discoveries  of  recent  years  in 
medicine  have  increased  the  span  of  life,  and  the  ther- 
apeutic secrets  which  have  been  wrested  from  nature 
herself  are  now  finding  wider  and  wider  employment 
to  the  advantage  of  all,  of  the  poor  as  well  as  of  the 
rich,  of  the  millions  in  distant  India  and  China,  as 
well  as  of  the  more  cultured  inhabitants  in  Europe 
and  America.  This  science  of  the  closing  years  of 
the  nineteenth  century  is  greater  in  its  humanitarian 
aims  than  was  dreamed  of  by  its  early  votaries,  and 
who  can  tell  what  the  twentieth  century  will  reveal? 
The  one  desire  of  the  speaker,  his  earnest  hope, 
was  that  this  work  for  humanity  would  continue  and 
would  prosper,  as  it  must  in  these  times  of  union  and 
mutual  encouragement  of  medical  men  and  scientists 
in  all  the  countries  of  the  world. 

The  Mutual  Relations  of  Pathology  and  Thera- 
peutics.—  Dr.  Roiuiur,  of  Harcelona,  delivered  the 
next  address.  The  cell,  he  said,  is  the  unit  of  being. 
Every  function  is  dependent  upon  the  integrity  of  the 
cell,  upon  its  condition  of  nutrition,  and  upon  its 
power  of  reaction  against  external  influences.  Pa- 
thology consists  in  the  study  of  disturbed  cellular  life, 
of  the  disturbed  relations  between  the  nucleus  and 
the  protopl.ism  of  the  cell  body.  The  more  we  study 
•cellular  pathology  and  the  greater  reliance  we  place 
upon  its  teachings,  the  more  certain  is  our  progress 
toward  the  goal  of  a  rational  and  effective  therapy. 
The  treatment  of  disease  must  have  for  its  object  a 
rearrangement  and  a  rectification  of  the  disturbed  re- 


lations between   the  cells  and  between  the  difi'erent 
parts  of  each  cell. 

Man,  however,  is  more  than  a  mere  cellular  con- 
geries; he  is  a  being  endowed  with  certain  powers  of 
resistance  against  influences  which  threaten  his  well- 
being  or  his  very  existence.  Disease  is  not  dependent 
so  directly  upon  the  action  of  any  specific  micro-organ- 
ism as  it  is  upon  an  increased  organic  susceptibility. 
The  mystery  of  disease  is  still  a  mystery,  and  it  has 
not  been  solved  as  yet  by  any  of  the  facts  of  bacteri- 
ology or  pathology.  One  man  is  affected  by  disease, 
another  exposed  to  the  same  influences  escapes  un- 
scathed. A  neoplasm  which  is  to-day  benign  in  its 
appearances  may  to-morrow  assume  an  entirely  differ- 
ent aspect  and  take  on  all  the  characters  of  malig- 
nancy. Why  is  this?  We  cannot  yet  answer.  The 
human  organism  reacts  as  a  whole  to  the  assaults  of 
disease,  and  not  by  the  isolated  action  of  any  individ- 
ual cell  or  group  of  cells.  A  specific  infectious  dis- 
ease is  warded  off  or  overcome,  not  by  phagocytosis 
alone  and  not  by  the  special  chemical  properties  of 
the  blood  serum  alone,  but  it  is  conquered  by  the 
organism  considered  as  an  entity. 

Our  therapeutic  efforts  must  be  directed  in  a  way  to 
furnish  aid  to  the  entire  organism  in  its  struggle 
against  disease,  to  strengthen  its  innate  pow-ers  of 
resistance,  and  not  merely  to  fortify  one  of  the  ap- 
proaches, leaving  the  others  unguarded.  The  indica- 
tions of  a  rational  treatment  of  disease  are  to  combat 
the  influences  which  have  weakened  the  body  and  so 
have  predisposed  it  to  yield  to  the  assaults  of  the 
morbific  agents;  to  support  and  increase  the  cellular 
energies;  to  strengthen  and  stimulate  the  function  of 
those  organs  whose  office  it  is  to  preside  over  metab- 
olism and  furnish  a  suitable  pabulum  to  the  rest  of 
the  body;  and  to  protect  the  sensitive  nervous  system, 
upon  whose  integrity  so  much  depends,  against  injury. 

The  so-called  causal  treatment  of  disease  is  not 
always  effective  and  its  advantages  are  often  illusory. 
In  our  well-meant  efforts  to  repress  and  expel  the 
causes  of  disease,  we  may  easily  go  too  far  and  injure 
the  already  weakened  organism  in  its  resistant  powers. 
It  will  be  of  little  avail  to  annihilate  the  greater  part 
of  the  attacking  force  if  we  thereby  so  weaken  the  de- 
fence that  it  is  unable  to  resist  the  small  remnant  of 
the  enemy  which  has  escaped  the  action  of  our  de- 
structive agents. 

We  must  rather  imitate  nature  in  her  therapeutic 
efforts,  which,  after  all,  are  so  often  effective.  The 
modern  treatment  of  diphtheria  by  means  of  injections 
of  a  specially  prepared  antitoxic  serum  is  an  imitation 
of  nature  and  is  a  brilliant  exemplification,  the  orator 
maintained,  of  the  wisdom  of  this  course.  The  tri- 
umphs of  orrhotherapy  in  the  management  of  diphtheria 
have  been  great  and  indisputable. 

In  health  as  in  disease  all  the  organs  work  together, 
and  it  is  in  a  disregard  of  this  great  truth  that  the 
chief  danger  of  specialism  exists.  The  specialist  is 
too  wont  to  consider  the  needs  of  one  system  or  of  one 
organ  in  a  system,  .separating  it  from  the  body  as  a 
whole.  This  danger  is  an  imminent  one  at  the  pres- 
ent day,  and  it  is  one  against  which  the  true  scientific 
physician  must  never  be  weary  of  protesting.  The 
therapist  must  be  a  man  of  broad  views,  and,  however 
small  and  apparently  circumscribed  is  the  lesion  he 
is  called  upon  to  treat,  he  must  keep  ever  before  him 
the  sufferings  of  the  entire  organism,  and  must  recog- 
nize and  act  upon  the  unquestionable  fact  that  man  is 
a  unit  and  that  we  cannot  hope  to  treat  with  success  a 
part  while  ignoring  the  whole. 

Finally,  the  speaker  said,  the  nervous  system  must 
be  strengthened  and  enabled  to  act  its  part  in  the 
struggle  against  disease.  This  most  vital  part  of 
the  human  organism  is  not  influenced  by  medication 
alone,  but  there  is  here  room  for  tliat   imponderable 


August  28,  1897] 


MEDICAL    RECORD. 


119 


therapeutic  agent  which  is  personal  to  each  physician 
and  which  finds  expression  in  his  moral  influence  over 
the  patient.  To  fulfil  in  the  highest  degree  his  divine 
mission  the  true  therapeutist  must  be  a  physician  of 
the  mind  as  well  as  of  the  body,  he  must  be  able  to 
inspire  in  his  patient  that  confidence  in  himself  and 
that  hope  in  the  efficacy  of  his  remedies  without  which 
his  best  directed  efforts  will  scarcely  avail. 

The    second    general    session    was    then    declared 
adjourned. 

(  7<J  be  Continued,') 


THE  NEW   YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  March  24,  i8gj. 

Warren   Cole.man,  M.D.,  Vice-President,  in    the 
Chair. 

Dr.  E.  p.  Shelby,  Jr.,  presented  a  sjsecimen  of 

Rupture  of  the  Heart. — The  lesion  occurred  in  a 
woman,  sixty-six  years  of  age,  who  had  been  treated 
for  heart  disease  ten  years  before.  She  was  confined 
in  an  insane  asylum  for  some  time,  but  was  discharged 
as  harmless  three  years  ago.  During  the  past  few 
months  she  had  lived  in  constant  fear  of  being  poi- 
soned, and  had  refused  every  article  of  diet  except 
eggs.  Three  days  before  death  she  began  to  suffer 
f.om  diarrhcea  and  nausea.  These  symptoms  grew 
worse  until  the  third  day,  when  she  died  suddenly  after 
a  violent  paroxysm  of  vomiting.  An  autopsy  was  held 
forty-eight  hours  after  death,  by  Dr.  E.  J.  Donlin,  who 
had  kindly  sent  him  the  specimen  and  the  history  of 
the  case.  The  body  was  greatly  emaciated.  The 
brain  was  ana;mic,  but  showed  no  other  gross  change. 
The  left  pleural  cavity  was  filled  with  clotted  blood. 
The  right  pleural  cavity  was  normal.  Both  lungs  were 
aniemic.  There  was  a  distinct  tear  in  the  left  side  of 
the  pericardium,  and  the  sac  contained  several  ounces 
of  blood.  The  heart  was  covered  with  blood,  and  on 
its  posterior  surface  presented  a  rupture  in  the  wall  of 
the  left  ventricle,  about  one-half  inch  long,  running 
p.irallel  to  and  one-half  inch  from  the  ventricular  sep- 
tum, about  midway  between  the  apex  and  base. 
Around  the  point  of  rupture  there  was  an  extravasation 
of  blood  under  the  pericardium.  On  the  inner  surface 
of  the  ventricle  was  an  L-shaped  tear,  whose  long  side 
ran  from  above  downward,  and  measured  one  and  one- 
half  inches.  The  short  side  extended  three-fourths  of 
an  inch  to  the  left.  The  heart  wall  at  the  point  of 
rupture  was  rather  thin,  and  somewhat  paler  and  softer 
than  normal,  but  there  was  no  indication  of  ulceration. 
Minute  examination  revealed  a  thrombus  in  the  right 
coronary  artery,  which  had  started  in  a  calcareous  area 
about  one  inch  from  the  aortic  orifice.  There  were 
also  two  calcareous  patches  in  the  left  coronary  artery, 
which  greatly  diminished  its  lumen.  As  the  throm- 
bosed vessel  was  the  one  which  nourished  that  part  of 
the  wall  in  which  the  rupture  occurred,  it  was  proba- 
bly the  predisposing  cause.  The  heart  weighed  thir- 
teen ounces.  There  was  no  valvular  change  except  a 
slight  thickening  of  the  mitral  valve.  The  stomach 
contained  a  small  quantity  of  yellowish  mucus  and 
several  pieces  of  hard-boiled  egg.  The  mucous  mem- 
brane was  congested.  The  small  intestine  showed 
marked  congestion  in  places.  The  kidneys,  liver, 
and  spleen  were  anaemic,  but  no  pathological  changes 
were  noted.  The  violent  effort  at  \omiting,  which 
was  probably  due  to  the  irritation  of  the  hard-boiled 
eggs,  seemed  to  have  caused  the  rupture  in  the  heart 
wall;  and  the  fact  that  the  pericardial  sac  was  also 
ruptured  would  indicate  that  the  heart  had  continued 
to  contract  after  the  initial  rupture  had  occurred. 

Dr.  Warre.m.  Coi-EMan  said  that  it  was  the  first 
case  of  rupture  of  the  heart  that  had  ever  come  within 
his   observation,   and   it   was  exceedingly   interesting 


from  the  fact  that  from  the  gross  examination  there 
was  no  evidence  of  any  change  in  the  heart  at  the  lo- 
cation of  the  rupture.  But  in  these  cases  of  rupture  of 
the  heart  there  was  almost  always  some  lesion  which 
appeared  to  have  impaired  the  integrity  of  the  wall. 

Pertussis ;  Punctate  Hemorrhages  in  the  Brain. 
—  Dr.  Rowland  G.  Freema.x  presented  a  brain  which 
was  the  seat  of  punctate  hemorrhages  following 
whooping-cough.  The  specimen  had  been  removed 
from  a  colored  child,  two  and  one-half  years  old,  who 
had  been  admitted  to  the  Foundling  Hospital  in  a 
moribund  condition.  It  had  had,  at  the  time,  a  tem- 
perature of  101.5'  F.  and  a  pulse  of  180.  There  were 
general  convulsions,  with  attacks  of  coughing,  and 
these  attacks  were  followed  by  some  strabismus.  The 
child  died  twenty-four  hours  after  admission,  and  the 
autopsy  was  made  forty -eight  hours  after  death.  There 
was  no  rigor  mortis.  There  was  one  ounce  of  serum  in 
the  right  pleural  cavity  together  with  a  small  amount  of 
fibrinous  exudate.  The  right  lower  and  middle  lobes 
of  the  lung,  and  the  posterior  fourth  of  the  upper  lobe, 
showed  marked  lobular  pneumonia.  In  the  left  pleu- 
ral cavity  were  four  ounces  of  serum.  The  pericar- 
dium contained  one  ounce  of  serum.  The  right  auri- 
cle was  distended  with  a  firm  clot,  which  passed  into 
the  right  ventricle  and  up  into  the  pulmonary  artery. 
The  liver  was  considerably  enlarged.  The  spleen 
was  enlarged  below  the  free  border  of  the  ribs.  The 
stomach  was  distended  with  gas.  The  brain  showed 
punctate  hemorrhages  throughout  the  cerebrum,  but 
none  in  the  cerebellum  or  in  the  pons.  These  hemor- 
rhages were,confined  to  the  white  matter. 

The  speaker  said  that  in  cases  of  pertussis,  hemor- 
rhages were  common  in  many  places,  but  were  noticed 
most  often,  perhaps,  in  the  conjunctiva.  Epistaxis, 
haimoptysis,  hemorrhage  from  the  ears,  and  purpuric 
eruptions  were  also  not  infrequent.  Trousseau  had 
reported  a  case  in  which  a  child  was  said  to  have  cried 
"  tears  of  blood."  The  occurrence  of  cerebral  hemor- 
rhage in  connection  with  pertussis  had  been  reported 
by  Marshall,  in  1885. 

Dr.  Freeman  also  presented  specimens  from  two 
cases  of 

Large  Waxy  Liver  in  Children. — The  first  was 
that  of  a  child  of  six  years,  who  died  at  the  Foundling 
Hospital,  on  March  2  ist.  It  had  been  under  observa- 
tion in  the  hospital  for  a  number  of  years.  In  July, 
1896,  it  was  noted  that  the  child  had  an  upper  lumbar 
and  a  lower  dorsal  kyphosis,  with  a  sinus  draining 
below  the  right  hip.  In  September  the  child  had  gas- 
tro-enteritis,  with  a  temperature  of  103°  F.  In  Octo- 
ber an  abscess  developed  in  the  lumbar  region  and 
the  old  sinus  reopened.  In  November  the  liver  was 
first  noticed  to  be  enlarged.  There  was  no  cough  nor 
were  there  any  signs  in  the  chest.  Examination  on 
March  i,  1897,  showed  the  liver  to  be  very  large  and 
firm,  and  the  spleen  also  increased  in  size.  The 
urine  contained  twenty-five  per  cent,  of  albumin.  On 
March  loth  there  was  fluid  in  the  abdomen,  the  ex- 
tremities were  swollen,  there  were  signs  of  fluid  in 
both  sides  of  the  chest,  and  the  liver  extended  to  the 
umbilicus.  On  March  j  ist  the  child  died.  The  au- 
topsy was  made  twelve  hours  after  death.  There  was 
no  rigor  mortis.  The  body  was  very  markedly  emaci- 
ated. The  peritoneal  cavity  contained  twenty-five 
hundred  cubic  centimetres  of  clear  serum.  The  lungs 
and  large  bronchi  contained  some  mucus.  The  bron- 
chial lymph  nodes  were  enlarged,  and  one  contained 
some  fibrous  tissue,  looking  somewhat  like  an  old 
phthisical  process;  there  was,  however,  no  active  tu- 
berculosis found  in  these  nodes.  The  diaphragm  was 
at  the  fourth  space  on  both  sides.  The  liver  extended 
from  the  fourth  space  to  the  level  of  the  umbilicus; 
it  was  very  hard  and  waxy.  The  spleen  extended  be- 
low the  free  border  of  tlie  ribs   and  was  also   waxv. 


320 


MEDICAL    RECORD. 


[August  28,  1897 


The  pancreas  was  large.  The  adrenals  were  enlarged, 
and  apparently  both  were  tuberculous.  The  kidneys 
were  pale  and  waxy.  The  mesenteric  lymph  nodes 
were  enlarged.  There  was  a  bone  abscess  connecting 
with  the  spine. 

Dr.  Freeman  said  that  this  was  the  first  case  of 
waxy  liver  that  he  had  ever  seen  at  the  Foundling 
Hospital,  an  institution  in  which,  for  the  most  part, 
the  children  are  under  five  years  of  age. 

The  second  case  of  waxy  liver  occurred  in  a  child 
of  ten  years.  This  child  had  had  a  persistent  and 
progressive  antemia  for  very  nearly  a  year.  In  Sep- 
tember the  ha;moglobin  was  only  27.5  per  cent.,  but 
there  was  no  leucocytosis.  The  cause  of  the  trouble 
was  not  suspected.  At  the  autopsy  the  examination 
of  the  lungs  and  heart  was  negative.  The  liver  ex- 
tended from  the  fourth  space  to  the  umbilicus,  and  was 
hard  and  waxy.  The  spleen  extended  to  a  line  drawn 
fiom  the  umbilicus  to  the  left  anterior  superior  spine 
of  the  ilium.  The  left  kidney  was  the  seat  of  a  very 
large  abscess,  and  the  capsule  was  hard  and  thick. 
The  right  kidney  was  pale  and  waxy.  In  this  case 
the  right  adrenal,  or  the  one  on  the  side  opposite  to 
the  kidney  lesion,  was  tuberculous.  There  were  also 
two  tuberculous  mesenteric  lymph  nodes.  No  other 
tuberculous  lesions  were  found,  i'he  speaker  remarked 
that,  .so  far  as  he  had  been  able  to  ascertain,  tubercu- 
losis of  the  adrenals  is  very  rare  in  children.  There 
was  10  pigmentation  of  the  skin  or  other  evidence  of 
Addison's  disease. 

Dr.  Coi,EMA>f  said  that  he  had  carefully  examined 
the  suprarenals  in  all  autopsies  that  he  had  made  dur- 
ing the  past  five  years,  yet  he  had  found  them  in- 
fected in  only  three  cases — all  adults.  From  some  ex- 
periments that  he  had  made  on  animals  he  had  been 
led  to  believe  that  there  was  something  about  the  su- 
prarenals that  tended  to  protect  them  in  large  measure 
from  infection. 

Dk.  Shelry  asked  if  tubercle  bacilli  had  been 
found  in  the  pus  from  the  abscess  in  the  kidney. 

Dr.  Free.vian  replied  that,  owing  to  a  misunder- 
standing, such  an  examination  had  not  been  made. 
The  appearance  was  that  of  a  tuberculous  abscess,  but 
microscopical  examination  of  the  wall  did  not  give 
evidence  of  any  tuberculous  process. 

Dr.  D.-win  ISov.MRn  said  that  the  second  child  had 
coni,e  under  his  care  first  for  a  tuberculous  process  of 
the  spine,  and  had  been  treated  with  a  brace.  After 
a  year  a  psoas  abscess  developed,  and  after  a  while  this 
ruptured.  The  discharge  continued  for  some  time, 
and  then  the  sinus  closed.  Following  that,  a  lumbar 
abscess  appeared  and  .steadily  increased  in  size.  The 
enlargement  of  the  liver  and  spleen  was  apparently 
secondary  to  the  lumbar  ab.scess.  It  was  interesting 
to  note  that,  although  the  disease  in  the  vertebral 
canal  was  apparently  in  process  of  healing,  the  lumbar 
absce.ss  developed. 

The  society  then  adjourned. 

Stated  Mcctins:,  April  14,  iHgj. 

Warren   Coleman,   M.I).,  \'icK-PRK.sn)KNT,  in    the 
Chair. 

Dr.  John  II.  I.arkin  presented  an 

Aneurism  of  the  Thoracic  and  Abdominal  Aorta, 

which  had  been  taken  from  a  man,  forty-five  years  of 
age,  who  had  a  pronounced  syphilitic  history.  For  a 
number  of  years  a  pulsating  tumor  had  been  noticed 
in  the  epigastric  region,  but  it  iiad  never  caused  any 
distress.  He  entered  the  hospital  about  one  year  ago, 
and  after  remaining  there  for  one  and  one-half  montlis 
went  out  again.  About  two  months  ago  he  was  read- 
mitted for  a  severe  pain  in  the  back.  It  was  found 
that  the  pulsation  was  much  more  marked  than  on  his 
first  entrance  to  the  hospital;  he  suffered  much  from 


dyspnoea,  and  the  heart  was  displaced  laterally.  The 
breath  sounds  were  very  indistinct  in  the  left  chest. 
One  night  while  in  the  hospital  he  got  up  and  walked 
across  the  ward,  and  then  fell  down  dead.  It  was 
found  that  the  aneurism  had  ruptured  posterior  to  the 
peritoneum  and  had  discharged  dowTiward  toward  the 
kidney.  The  case  was  interesting  on  account  of  the 
large  size  of  the  aneurism  and  the  comparative  ab- 
sence of  urgent  symptoms.  The  seventh  and  eighth 
and  ninth  vertebra:  were  eroded. 

Aneurism  at  Apex  of  Heart.^Dr.  Larkin  then 
presented  a  rather  large  heart,  removed  from  a  woman, 
eighty-six  years  of  age.  She  had  never  complained 
of  any  cardiac  trouble,  and  death  resulted  from  apo- 
plexy. The  autopsy  showed  a  small  aneurism  at  the 
apex  of  the  heart,  with  complete  absence  of  cardiac 
muscle  at  the  apex  of  the  left  ventricle.  There  was 
a  replacement  fibrosis  at  this  point.  Some  parts  were 
quite  calcareous,  and  there  was  also  slight  interstitial 
myocarditis.  The  coronary  artery  was  the  seat  of 
atheroma. 

Aneurism  of  the  Sinus  of  Valsalva Dr.  Larkin 

presented  still  another  heart.  It  had  been  taken  from 
a  man,  thirty-five  years  of  age,  who  died  from  chronic 
Bright's  disease.  There  was  a  history  of  marked 
syphilitic  disease.  At  the  autopsy,  in  addition  to 
marked  chronic  diffuse  nephritis,  there  was  a  large 
aneurism  of  the  sinus  of  Valsalva.  The  posterior 
coronary  artery  was  found  only  with  some  difficulty, 
and  it  was  markedly  atheromatous.  It  could  be 
traced  up  to  the  aneurism,  but  the  opening  into  the 
aneurism  could  not  be  detected.  The  coronary  artery 
contained  a  little  semifluid  blood. 

Dr.  Larkin  said  that  Sibbs  had  made  a  collection 
of  860  cases  of  aneurism.  Of  this  number  87  were  at 
the  sinus  of  Valsalva,  480  were  of  the  whole  arch,  140 
of  the  ascending  portion,  120  of  the  transverse  por- 
tion of  the  arch,  1 1  2  of  the  ascending  and  transverse 
portions  together,  72  of  the  descending  portion,  20  of 
the  transverse  and  descending  portions  of  the  arch. 
There  were  71  aneurisms  of  the  thoracic  aorta,  i^i  of 
the  abdominal  aorta  with  the  cceliac  axis,  and  26  of 
the  lower  portion  of  the  abdominal  aorta. 

Dr.  Shelby  asked  if  in  the  case  of  aneurism  of  the 
sinus  of  Valvsalva,  examination  had  been  made  of  the 
muscular  fibre;  and,  if  so,  if  any  fatty  degeneration 
had  been  found  in  the  region  which  should  have  been 
supplied  by  the  coronary  artery. 

Dr.  Larkin  replied  that  the  heart  muscle  was  not 
fatty.  If  the  coronary  artery  really  had  been  occlud- 
ed, there  should  have  been  an  important  lesion  of  the 
heart  muscle  itself.  In  this  case  there  had  been  no 
.symptoms  at  all  referable  to  the  heart. 

Dr.  Colemax  said,  regarding  the  question  of  the 
occlusion  of  the  coronary  artery,  that  in  this  connec- 
tion the  researches  of  Porter,  of  the  Har\ard  Medical 
School,  were  of  special  interest.  His  experiments  on 
the  heart  of  the  dog  showed  that  the  coronary  arteries 
were  terminal,  and  if  one  portion  were  occluded  the 
part  supplied  by  it  became  infarcted.  Even  though 
there  were  an  anastomosis,  there  was  no  passage  ol 
blood  from  one  coronary  artery  to  the  other  by  reason 
of  the  difl'ercnce  in  pressure.  If  these  e.vperiments 
were  correct,  then  we  must  assume  that  this  coronary 
was  open;  otherwise  there  would  have  been  a  degener- 
ation of  at  least  a  large  part  of  the  heart  wall  supplied 
by  this  artery. 

Dr.  Larkin  said  that  a  number  of  French  patholo- 
gists had  gone  over  this  ground  experimentally,  and 
had  come  to  practically  the  same  conclusions.  He 
now  had  in  his  possession  a  specimen  from  a  case  in 
which  vegetations  from  the  valve  had  gotten  into  the 
coronary  arteiy  and  completely  occluded  it.  In  this 
heart  there  was  a  distinct  softening  of  the  heart  mus- 
cle, and  also  a  globular  thrombus. 


August  28,  1897] 


MEDICAL    RECORD. 


321 


Peruvian  Heads  —  Savage   War  Trophies.— Dr. 

Oscar  A.  Holder  exhibited  one  of  the  l^eruvian  heads 
or  trophies  so  highly  prized  by  certain  tribes  near  the 
head  waters  of  the  Amazon.  He  said  that  these  tribes 
were  ahiiost  constantly  at  warfare  with  one  another, 
and  instead  of  scalping  a  victim  it  was  their  cus- 
tom to  decapitate  him  and  put  the  head  through  some 
secret  process  by  which  the  features  were  wonderfully 
well  preserved,  appearing  like  a  diminutive  of  the 
original.  Fine  metallic  crystals  could  be  discerned 
in  some  portions  of  the  specimen. 

Dr.  Shelby  said  that  he  had  just  been  speaking 
with  a  man  who  travels  extensively  in  Brazil,  and  who 
had  brought  one  of  these  heads  to  the  Metropolitan 
Museum  within  the  last  few  days.  This  gentleman 
had  told  him  that  the  process  consisted  in  skinning 
the  head  and  packing  the  integumental  covering  with 
the  bark  of  a  certain  tree.  It  was  then  hung  up  and 
smoked,  after  which  it  was  dried  in  the  sun. 

Thrombosis  of  the  Pulmonary  Artery. — Dr.  War- 
ren Coleman'  presented  a  specimen  of  thrombosis  of 
the  pulmonary  artery,  removed  from  a  woman,  twenty- 
seven  years  of  age,  who  about  a  month  previous  to  her 
death  had  given  birth  to  a  child  at  full  term  in  the 
emergency  department  of  Bellevue  Hospital.  She  was 
discharged  at  the  usual  time,  the  ninth  day.  About 
two  weeks  later  she  entered  the  general  hospital  with 
a  moderate  temperature,  complaining  of  slight  pain  in 
the  infra-axillary  region  on  the  right  side.  The  pres- 
ence of  pus  was  suspected  in  the  pleural  cavity,  since 
the  uterus  was  free  from  sepsis.  The  patient  was 
confined  to  bed.  During  the  three  or  four  days  imme- 
diately preceding  her  death  she  suffered  from  slight 
shortness  of  breath,  and  the  night  nurse  reported  thai 
after  twelve  o'clock  on  the  night  she  died  she  had 
been  very  restless,  tossing  from  one  side  of  the  bed 
to  the  other.  A  little  before  six  o'clock  that  morning 
she  had  sat  up  in  bed  to  bathe  her  face,  and  a  feu 
minutes  later,  while  taking  a  cup  of  coffee,  fell  back 
upon  the  pillow.  The  house  physician,  Dr.  R.  E. 
lirown,  was  called,  and  he  found  the  patient  cyanotic 
and  gasping  for  breath.  The  pulse  was  rapid,  small, 
feeble,  irregular,  intermittent,  and  at  last  impercepti- 
ble. Stimulants  were  administered,  but  without 
avail,  and  the  patient  died  in  a  few  minutes. 

The  autopsy  was  not  made  until  four  days  after 
death,  but  the  body  had  been  kept  on  ice  and  was  in 
good  condition.  The  pericardium,  endocardium,  and 
valves  were  normal.  The  right  ventricle  was  markedly 
dilated  and  contained  a  large  amount  of  dark,  imper- 
fectly coagulated  blood.  The  walls  of  the  heart  were 
soft  and  light  colored,  presenting  evidences  of  paren- 
chymatovis  changes.  The  weight  of  the  heart  after 
the  blood  had  been  washed  out  was  thirteen  ounces. 
Part  of  this  hypertrophy,  at  least,  might  be  accounted 
for  by  the  recent  pregnancy.  Both  pleural  caAities 
contained  a  moderate  amount  of  liquid,  though  there 
was  no  pleurisy.  The  cut  surfaces  of  the  lungs  w^ere 
congested  and  cedematous.  The  lower  first  divisions 
of  the  pulmonary  artery  to  both  lower  lobes  contained 
thrombi  which  were  intimately  adherent  to  the  walls  of 
the  vessels.  This  union  did  not  extend  entirel\ 
around  the  lumina  of  the  vessels,  and  elsewhere  tlie 
clots  were  simply  in  contact  with  the  endothelimn. 
When  the  thrombi  were  forcibly  torn  from  their  attach- 
ments, a  rough,  ragged  suiface  was  left,  leading  to  the 
opinion  that  the  arterial  walls  had  suffered  actual 
change  at  these  points.  This  opinion  was  subse- 
quently confirmed  by  microscopic  examination.  From 
the  sections  presented  it  was  evident  that  the  thrombi 
were  at  first  parietal  and  partial,  and  that  the  vessels 
were  subsequently  occluded  by  further  coagulation 
within  their  lumina.  The  arterial  wall  and  clot 
merged  into  each  other  at  the  point  of  adherence,  so 
that  it  was  difficult  to  determine  their  respective  lim- 


its. From  the  presence  of  cell  elements,  some  of  them 
fusiform,  in  the  outer  margin  of  the  clot,  it  was  be- 
lieved that  organization  of  this  first-formed  portion  of 
the  thrombus  had  begun.  Evidences  of  infarctions 
were  carefully  sought  for  in  both  lungs,  but  without 
success.  The  pulmonary  arteries  beyond  the  thrombi 
were  dissected  as  far  as  could  be  done  with  small  scis- 
sors, without  finding  an  embolus.  The  uterus  was 
subinvoluted.  The  walls  were  thickened  and  the  cav- 
ity was  enlarged.  The  length  of  the  uterus  was  six- 
teen centimetres;  the  breadth  at  the  fundus  was  ten 
centimetres;  the  depth  of  the  cavit}'  from  the  internal 
OS  to  the  fundus  was  eight  centimetres.  The  cavity  of 
the  uterus  contained  a  small  amount  of  dark  brownish 
material,  which  did  not  appear  or  smell  septic.  The 
spleen  was  enlarged  and  dark.  The  kidneys  were 
swollen,  pale,  and  moderately  congested.  Sections 
.showed  moderate  acute  parenchymatous  changes. 
Smear  preparations  of  the  clot  contained  numerous 
large  bacilli,  a  few  small  bacilli,  and  a  very  few  or- 
ganisms apparently  encapsulated  and  resembling  the 
diplococcus  lanceolatus.  Cultures  from  the  clot  (un- 
avoidably delayed  for  twenty-four  hours)  gave  nothing 
but  a  large,  rapidly  spreading,  foul-smelling,  putrefac- 
tive bacillus.  The  incompleteness  of  the  bacteriolog- 
ical examination  was,  of  course,  to  be  regretted. 

Dr.  Coleman  said  that  the  chief  interest  in  this  case 
centred  around  the  etiology  of  the  thrombosis.  The 
occurrence  of  pulmonary  thrombosis  had  been  ex- 
plained, he  said,  upon  two  theories- — primar)-  coagula- 
tion through  changes  in  the  constituents  of  the  blood 
(Barker  and  Playfair),  or  as  the  result  of  embolism 
from  the  heart  or  a  peripheral  thrombus.  There  was 
no  thrombosis  of  the  iliac,  femoral,  or  ovarian  veins 
from  which  an  embolus  might  have  been  dislodged, 
and  the  right  heart  contained  only  imperfectly  coagu- 
lated blood,  so  that  the  dislodgement  of  an  embolus 
large  enough  to  have  been  arrested  at  the  site  of  the 
thrombosis  might  be  excluded.  The  theor)-  of  pri- 
mary coagulation  from  changes  in  the  constituents  of 
the  blood  was  scarcely  tenable  in  the  light  of  existing 
knowledge  as  to  the  causes  of  thrombosis.  The 
changes  which  had  been  noted  as  present  in  the  wall 
of  the  pulmonary  artery  rendered  it  probable  that 
.some  injury  was  infiicted  to  the  endothelial  lining  and 
that  upon  this  site  coagulation  began.  How  this 
injury  was  inflicted  would  be  merely  a  matter  of  spec- 
ulation ;  he  would  suggest,  however,  that  it  was  in  some 
manner  connected  with  a  septic  condition  of  the  woman. 
In  phlegmasia  alba  dolens  coagulation  sometimes 
takes  place  from  causes  within  the  vessel  without  a 
pre-existing  phlebitis,  and  the  inflammation  after- 
ward extends  to  the  vessel  wall  and  perivascular  struc- 
tures. From  the  researches  of  Prudden  upon  the  local- 
ization of  inflammatorj'  processes  after  the  intravenous 
inoculation  of  pyogenic  organisms,  it  was  known  that 
such  localization  was  determined  by  a  lowering  of  lo- 
cal resistance,  as  by  traumatism.  That  the  trauma- 
tism might  at  times  lie  slight,  was  shown  by  the  occur- 
rence of  endocarditis  during  a  septic  puerperium,  in 
which  the  only  cause  of  injury  which  could  be  as- 
sumed was  the  normal  closing  of  the  valves  or  the 
impact  of  an  embolus  against  them.  In  the  present 
case,  though  no  thrombus  was  found  in  the  larger  pe- 
ripheral veins,  it  seemed»not  unlikely  that  an  embolus 
was  detached  from  a  thrombus  in  a  smaller  vessel, 
which  was  not  discovered,  and,  striking  the  wall  of 
the  pulmonary  artery,  determined  the  occurrence  and 
location  of  the  thrombosis.  The  shortness  of  breath 
which  preceded  death  for  several  days  might  be  ex- 
plained by  the  gradual  formation  of  the  thrombus. 

Dr.  Larkin  said  that  the  shortness  of  breath  for 
several  days  before  death  was  an  unusual  symptom  in 
these  cases  of  pulmonary  thrombosis,  and  would  apper.r 
to  indicate  that  the  obstruction  had  formed  slowlv. 


322 


MEDICAL    RECORD. 


[August  28,  1897 


Dr.  Coleman  said  that  he  believed  the  coagulation 
had  first  occurred  at  the  side  of  the  vessel,  and  that 
the  lumen  had  been  gradually  encroached  upon  and 
finally  completely  occluded.  In  another  case,  in  which 
death  had  occurred  in  five  minutes,  a  large  embolus 
had  been  dislodged  from  a  thrombus  in  the  right  ven- 
tricle and  had  immediately  closed  one  of  the  large 
branches  of  the  pulmonary  artery,  causing  almost  in- 
stant death. 

Dr.  Larkix  said  that  some  months  ago  he  had  pre- 
sented a  specimen  of  thrombosis  of  the  pulmonary 
artery.  In  this  case  a  woman  had  done  well  for  eight 
or  ten  days  after  confinement,  and  had  then  suddenly 
dropped  dead.  Here  he  had  been  unable  to  find  any 
change  in  the  endothelial  lining  which  would  account 
for  the  thrombosis.  Unquestionably  the  specimen 
just  exhibited  under  the  microscope  showed  that  the 
primary  changes  in  this  instance  had  occurred  in  the 
endothelium. 

The  society  then  adjourned. 


®otrrcsvandctice. 

OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE  HOSPITAL  FUNDS:  THE  AMERICAN,  THE  PRINCE's, 
THE  SUNDAY — THE  SPECIAL  HOSPITAL  GRIEVANCE  AS 
TO  THE  SUNDAY  FUND — INCREASE  OF  DIPHTHERIA; 
HOSPITALS  CROWDED — EXPERT  ASSESSORS A  MUNI- 
FICENT   POOR-LAW    SALARY. 

London,  August  13,  1897. 

The  .\merican  jubilee  fund  for  endowing  beds  in 
our  hospitals  amounts  to  above  ^"4,300.  The  surplus 
will  be  given  to  the  Prince  of  Wales'  fund.  This 
latter  it  was  yesterday  announced  amounts  to  over 
;^i8o,ooo. 

The  Sunday  fund  this  year  reached  ;^4o,ooo,  being 
less  than  last  year  by  ^2,124,  but  this  deficiency  is 
less  than  might  have  been  expected  considering  the 
large  amounts  which  ha\e  been  collected  for  analogous 
purposes  in  celebration  of  the  Queen's  reign  of  sixty 
)'ears'.  The  distribution  committee's  report  has  passed 
the  council  and  above  .^39,700  is  in  course  of  being 
distributed  to  one  hundred  and  thirty-two  hospitals 
and  fifty-six  dispensaries.  Some  _£"2,ooo  of  this  goes 
toward  the  purchase  of  surgical  appliances  in  monthly 
proportions.  .\ny  further  sums  that  may  come  in  will 
be  credited  to  next  j'ear's  account. 

The  committee  plumes  itself  on  ha\ing  received 
thirty  deputations  for  conference  or  explanations,  but 
this  work  is  not  so  important  as  it  seems  to  imagine; 
for  nothing  could  surpass  the  partiality  displayed  at 
these  conferences  and  the  absurd  adherence  to  certain 
fixed  rules.  As  to  the  latter  it  is  remarkable  that  St. 
Thomas'  Hospital  gets  nothing  because  its  accounts 
are  not  in  the  stereotyped  form  adopted  by  the  commit- 
tee. .\s  to  the  former  the  chairman  and  others  have 
always  been  hostile  to  special  hospitals  and  sometimes 
discourteous  to  their  representatives.  Taking  his  cue 
from  this,  the  secretary  has  "gone  one  better"  and,  as 
some  one  said,  "made  a  hole  in  his  manners."  He 
told  one  person  that  his  hospital  had  no  right  to  ex- 
ist— although  it  was  older  than  the  fund  and  had  given 
up  its  separate  collections  for  the  general  one,  and 
therefore  in  common  honesty  was  entitled  to  some 
share.  He  returned  the  accounts  of  a  hospital  duly 
audited  by  a  chartered  accountant  on  the  system  of  the 
fund  because  the  secretary  had  not  added  up  for  him 
thi  pages  of  contributions  by  subscribers.  Manv  de- 
clare that  there  are  only  two  courses  for  the  special 
institutions  to  adopt.     They  must  either  unite  and  ap- 


peal to  the  public  on  the  unfairness  and  prejudice,  or 
else  resume  separate  collections  in  the  churches  of 
their  localities.  Either  course  might  do  more  harm 
to  the  general  fund  than  good  to  the  specialists — and 
it  is  to  be  hoped  the  managers  of  the  fund  will  reform 
their  proceedings  and  the  secretary  be  told  that  his 
office  does  not  give  him  libert)'  to  pronounce  in  the 
name  of  the  distribution  committee  his  private  and 
ill-informed  opinions.  Ihe  Lancet  has  done  such 
splendid  work  for  the  fund  and  is  so  interested  in  it 
that  little  help  can  be  expected  from  your  contempo- 
rary in  case  of  an  appeal  to  the  public  against  the  com- 
mittee; apart  from  that  I  should  deprecate  such  an 
appeal  even  from  the  united  special  institutions,  which, 
in  spite  of  opposition,  are  still  flourishing. 

Although  the  general  health  of  London  has  been 
very  good  of  late,  diphtheria  has  continued  to  spread 
and  there  is  some  difficulty  in  accounting  for  this  dis- 
quieting fact.  .\s  I  have  reported,  there  will  shortly 
be  five  hundred  and  forty-eight  additional  beds  at  the 
new  Park  Hospital,  but  in  the  mean  time  the  pressure 
on  the  hospitals  of  the  asylums  board  is  so  great  that 
more  beds  have  been  crowded  into  the  wards  than 
were  intended.  This  reduction  of  the  air  space  cal- 
culated for  the  patients  is  recognized  as  an  evil  and  to 
be  tolerated  only  during  a  temporary  emergency.  Nor 
is  overcrowding  confined  to  the  board's  hospitals. 
The  outbreak  of  beriberi  in  the  Richmond  Asylum, 
Dublin,  has  brought  to  the  public's  knowledge  a  con- 
dition of  overcrowding  there  which  has  again  and 
again  been  impressed  on  the  authorities.  A  similar 
state  has  just  been  reported  at  Brookwood  Asylum, 
where  1,085  ^'^  ijiQo  patients  occupy  the  accommoda- 
tion provided  for  1,050.  The  Surrey  Count)-  Council 
seems  to  receive  patients  from  the  London  Council, 
which  is  said  to  be  in  a  still  worse  condition. 

Mr.  Justice  Williams  at  a  recent  trial  advocated  the 
employment  of  medical  experts  as  assessors,  to  be 
selected  for  their  acquirements  and  not  to  be  ad- 
vocates for  either  plaintiffs  or  defendants.  The  plan 
has  often  been  recommended  by  medical  and  scientific 
authorities,  but  hitherto  our  legal  luminaries  have  been 
opposed  to  it.  Now  that  a  judge  has  spoken  in  its 
favor  there  is  more  hope  of  a  reform. 

The  Hampstead  board  of  guardians  proposed  to 
appoint  a  medical  officer  to  the  workhouse  and  infir- 
mary at  the  princely  salary  of  ^?4o  per  annum  with 
rooms  and  rations.  He  was  to  have  the  double  quali- 
fication, and  in  addition  to  his  medical  work  was  to  do 
all  the  dispensing.  The  local  government  board  has 
pronounced  the  salar)-  inadequate  and  yesterday  in- 
formed the  local  gentlemen  that  it  must  be  at  least 
^60,  or  if  dispensing  be  included  ^80. 


OUR    BERLIN'    LETTER. 

t  From  our  Special   Correspondent.) 

MIDSUMMER    DULNESS — THE    TWELFTH     INTERNATIONAL 

MEDICAL       CONGRESS ABSENCE       OF       UTERUS       AND 

OVARIES — COITUS     PER      uReTHRAM CEREBRAL     DIS- 
EASE   IN    THE    NEW-BORN  —  LEUK^EMIC     APOPLEXY — A 

TOOTH      IN      THE      NASAL      FOSSA THE      GONOCOCCUS 

TOXIN. 

Berlin,  August  i?,  1807. 

When  at  the  end  of  July  the  university  closes  its 
doors  and  the  professors  with  their  families  go  off  to 
the  various  resorts,  then  the  medical  societies  also 
lapse  into  quiet,  and  their  members  have  time  to  gain 
from  their  rest  renewed  strength  for  their  labors  in  the 
autumn. 

The  coming  events  of  the  medical  congress  are  cast- 
ing their  siiadows  before,  even  as  far  as  Berlin.  There 
will  be  a  very  large  representation  from  this  city,  and 
as  nearly  all  will  start  at  the  same  time  it  is  easy  to 


August  28,   1897] 


MEDICAL    RECORD. 


see  that  the  railways,  especially  those  in  Russia,  will 
be  taxed  to  their  utmost  to  provide  transportation.  It 
will  evidently  be  impossible  to  provide  for  all  without 
the  putting  on  of  extra  trains,  for,  in  addition  to  our 
own  contingent,  almost  all  the  congress  members  from 
northern  Europe  and  America  will  pass  through  Berlin 
en  route.  All  the  available  sleeping-car  accommoda- 
tions have  already  been  engaged,  and  the  prospect  for 
the  majority  is  that  they  will  be  shipped  to  Moscow- 
like  a  ton  of  herring,  and  arrive  there  half  suffocated 
after  a  thirty-hour  car  ride.  The  Russian  express 
trains  creep  along  at  a  delightfully  easy  jog  at  just 
about  half  the  speed  of  an  ordinary  accommodation 
train  in  America.  We,  of  course,  have  reason  to  be 
grateful  to  the  Russian  government  for  the  gift  of  free 
railway  tickets;  but  the  Russian  is  not  so  stupid  or  so 
generous  as  he  might  seem  to  be.  In  the  first  place 
the  price  of  railroad  transportation  in  Russia  is  very- 
low,  and  in  the  next  place  the  offer  of  anything  free 
will  attract  a  very  much  greater  concourse  and  all  of 
these  "guests"  will  leave  a  goodly  amount  of  gold  in 
holy  Russia.  The  Prussian  railway  officials  are  also 
wise  in  their  own  way.  While  almost  all  the  other 
European  railways  and  steamship  companies  have 
made  very  substantial  reductions  in  the  price  of  tick- 
ets to  members  of  the  congress,  the  Prussian  minister 
of  railways  says  simply:  "  iVcw  possiimiis;  the  great 
congress  is  our  sponge,  let  us  squeeze  it.''  In  this 
action  he  is  in  direct  opposition  to  his  colleague,  the 
minister  of  instruction,  for  in  few  countries  is  so  much 
done  for  science  as  in  Prussia  with  her  numerous  uni- 
versities. 

At  the  session  of  the  Gesellschaft  fiir  Psychiatric 
und  Nervenkrankheiten  held  just  before  the  vacation 
season.  Dr.  Grauck  presented  a  patient  in  whom  the 
vagina  consisted  of  nothing  but  a  shallow-  cul-de-sac, 
and  no  trace  of  uterus  or  ovaries  could  be  discovered. 
The  appearance  of  the  patient  was  thoroughly  femi- 
nine, but  she  had  never  menstruated.  She  suffered 
much  from  hysterical  attacks,  the  first  of  -svhich  ap- 
peared soon  after  her  marriage,  and  were  perhaps  ex- 
cited by  the  attempts  at  coitus,  which  were  always 
painful  and  the  occasion  of  great  e.xcitement.  The 
urethra  was  widely  dilated  and  it  was  doubtless  in 
this  direction  that  penetration  took  place  during  the 
sexual  act.  At  the  same  meeting  Dr.  Koppen  read  a 
paper  on  diseases  of  the  brain  in  very  young  children. 
These  affections  have  been  hitherto  but  little  studied; 
the  brain  has  been  examined  macroscopically  only, 
and  in  consequence  of  some  superficial  resemblances 
to  that  of  an  animal  the  various  departures  from  the 
normal  in  conformation  have  been  ascribed  to  atavism. 
In  two  cases  examined  carefully  by  the  author,  he  was 
able  to  demonstrate  that  the  changes  were  not  at  all 
due  to  an  arrest  of  development,  but  rather  to  a  true 
pathological  process.  Dr.  Benda  reported  the  case  of 
a  patient  suffering  from  leukaemia  who  died  with  the 
symptoms  of  apoplexy.  .\  careful  examination  of 
many  sections  of  the  central  nenous  system  showed 
no  lymphomatous  disease  anywhere  except  in  the 
region  where  the  apople.xy  had  taken  place.  One 
ought  always  to  bear  the  possibiliU'  of  such  a  compli- 
cation in  mind  when  in  the  presence  of  a  sufferer  from 
leulaemia. 

At  the  last  meeting  of  the  Berlin  Medical  Society, 
Dr.  Frankel  showed  a  patient  having  an  inverted  tooth 
in  the  left  nasal  fossa.  The  patient,  a  child,  suffered 
from  hereditary  syphilis  with  resulting  caries  and  ne- 
crosis of  various  portions  of  the  nasal  bones.  During 
the  attempt  to  extract  the  sequestra  the  operator  came 
across  a  bony  projection  which  it  was  impossible  to 
remove,  even  with  the  saw-.  Closer  examination 
showed  that  it  was  a  tooth  which  apparently  had  been 
reversed,  its  crown  projecting  from  the  floor  of  the 
left  nasal  fossa.     Dr.  Wassem-iann  then  read  a  paper 


on  the  gonococcus  toxin.  He  had  made  many  experi- 
ments to  discover  a  culture  medium  for  gonococci 
which  could  be  made  use  of  in  general  practice.  Up 
to  the  present  time  it  had  been  possible  to  conduct 
culture  experiments,  which  called  for  the  use  of  sterile 
human  serum-albumin,  only  in  institutions  where  such 
a  fluid  could  be  readily  obtained.  The  speaker  had 
found  that  hog's  serum  was  an  efficient  substitute  for 
that  of  man,  and  he  had  succeeded  in  cultivating  the 
gonococcus  in  a  medium  composed  of  hog's  serum, 
casein-sodium  phosphate,  and  peptone-bouillon.  From 
such  cultures  he  had  been  able  to  obtain  a  very  potent 
toxin  which  caused  fever  and  swelling  of  the  glands, 
joints,  and  muscles.  He  had  been  unable  to  produce 
any  immunity  against  the  action  of  this  toxin.  These 
e.xperiments  offered  a  ready  explanation  of  the  occur- 
rence of  rheumatism  after  gonorrhoeal  infection.  The 
gonococci  die  speedily  indeed,  in  the  inflammatory- 
exudate,  when  deprived  of  oxygen,  but  this  only  the 
more  readily  sets  free  the  inflammation-exciting, 
poison,  so  that  the  destruction  of  the  gonococci  leads 
to  no  improvement  in  the  disease,  since  there  is  no- 
free  discharge  of  the  toxins.  Dr.  Wassermann  ad- 
vised, therefore,  that  all  foci  of  inflammation  due  X.o 
the  presence  of  the  gonococcus-toxin  should  be  opened 
up  widely  in  order  to  give  exit  to  it,  for  he  maintained 
that  there  is  no  remedy  which  can  oppose  the  action 
of  this  poison,  and  the  only  hope  of  relief  is  in  get- 
ting rid  of  it. 


^euT  lustntmcixts. 

AX    IMPROVED    HYPODERMIC    SVRIXGE. 

The  accompanying  illustration  shows  the  newest  im- 
provements in  hypodermic  syringes.  This  instrument 
is  unique  from  the  fact  that  it  embodies  very  desira- 
ble features  in  both  syringe  and  case.  It  is  the  out- 
come of  many  years  of  experience  in  this  line  of  work. 
The  case  is  made  of  aluminium  and  is  curbed  to  fit  the 
body  when  carried   in  the  vest  pocket.     It  permits  of 


sterilization  by  boiling.  The  piston  packing  is  made  of 
improved  vulcanized  rubber.  This  is  so  disposed  that 
by  simply  turning  the  piston  head  to  the  right  the 
packing  is  adjusted  at  any  point  in  the  barrel.  No 
lubricant  is  needed,  the  fluid  to  be  injected  furnish- 
ing all  that  is  necessary.  The  packing  does  not 
shred,  as  is  the  case  with  asbestos,  nor  become  hard 
and  unyielding,  as  does  leather.  On  the  other  hand, 
when  it  is  found  necessary  to  renew-  the  packing  it  is 
not  necessary  to  send  the  syringe  to  the  manufacturer, 
since  the  physician  can  insert  a  new-  washer  by  follow- 
ing the  written  directions.  The  syringe  was  designed 
by  the  H.  K.  Mulford  Company,  of  Philadelphia. 


324 


MEDICAL    RHCORD. 


[August  28,  1897 


pc^etlical  items. 


Contagious  Diseases— Weekly  Statement.— Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  August  21,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. .  . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox 


Long  Survival  with  Incised  Wound  of  the  Heart. — 

It  is  reported  that  a  Hungarian,  stabbed  during  a  quar- 
rel at  Easton,  Pa.,  on  August  3d,  survived  for  twenty- 
si.x  hours  an  incised  wound  of  the  heart,  found  upon 
post-mortem  examination  to  be  three-eighths  of  an 
inch  long. 

A  Novel  Method  of  Arresting  Hemorrhage  in  a 
Case  of  Haemophilia.— Dr.  Bienwald  describes,  in  the 
Semainc  Medicalc,  an  ingenious  method  employed  by 
him  to  control  the  bleeding  from  a  small  wound  of  the 
face  in  a  case  of  hamophilia  in  a  child  two  years  old. 
Having  failed  to  arrest  the  hemorrhage  by  the  applica- 
tion of  ferric  chloride,  some  blood  was  obtained  by 
aspiration  from  a  healthy  subject  and  deposited  upon 
the  wound.  In  a  few  minutes  coagulation  took  place 
and  the  hemorrhage  at  once  ceased. 

Bicquerel  Rays. — The  rays  of  Becquerel,  observed 
also  independently  by  Prof.  Silvanus  Thompson,  have 
been  further  experimented  with,  and  the  observations 
carried  forward  by  Dr.  Russell.  It  is  found  that  not 
only  uranium  but  many  ordinary  substances  emit  radi- 
ations, which  although  invisible  to  the  human  eye  can 
penetrate  opaque  bodies.  Such  various  substances 
as,  e.g.,  the  section  of  a  young  larch  tree,  printers'  ink, 
cardboard,  lead,  and  tin,  when  placed  for  a  certain 
length  of  time  near  a  sensitive  plate  in  a  dark  room, 
leave  a  distinct  impression  on  the  plate.  It  is  stated, 
however,  that  while  the  radiations  from  the  uranium 
compounds  pass  readily  through  glass,  the  latter  com- 
pletely stops  the  radiations  from  the  substances  in 
question.  Whatever  be  the  "mysterious  force"  ema- 
nating from  such  bodies,  it  is  certain  that  increased 
temperature  of  the  body  which  emits  it  greatly  in- 
creases its  activity,  and  also  that  aqueous  vapor  does 
not  assist  its  action.  According  to  Mr.  Lewis  Wright, 
Hicquerel  rays  are  "invisible  light  rays  of  an  ex- 
tremely ultraviolet  character,  i.e.,  transverse  vibrations 
in  the  ether,  of  extremely  short  period  and  wave 
length."  And  he  continues:  "It  is  now  generally 
held  that  the  Roentgen  rays  are  ether  waves  of  the 
same  character,  but  still  higher  frequency;  certainly 
not  less  and  possibly  much  more  than  a  hundred  times 
that  of  green  light.  The  ab.sence  of  sensible  refrac- 
tion, polarization,  and  regular  reflection  is  exactly 
what  would  then  occur.  The  waves  are  probably  sim- 
ply too  small  to  be  reflected  from  any  polish  at  pres- 
ent attainable,  or  polarized  by  any  ordinary  structure 
in  a  sensible  degree. —  Treatment. 

A  Moving  Tale. — The  Chicago  mind  is  as  fertile 
of  imagination  as  ("hicago  water  of  typhoid  bacilli. 
The  Inter  Oee,iii  of  that  city  recently  described  a  won- 
derful invention,  which  it  justly  remarks  cannot  fail 
to  be  of  great  value  in  the  study  of  diseases.  "  .\  mi- 
cromotoscope  has  been  invented  which  is  a  kinetoscope 


for  photographing  cell  life  in  motion  as  seen  in  the 
microscopic  field.  The  pictures  are  taken  by  the  gel- 
atin film  at  from  five  thousand  to  fifteen  thousand 
magnifications,  and  at  the  rate  of  sixteen  hundred  to 
twenty-five  hundred  per  minute.  Ihe  images  being 
magnified  thousands  of  times  when  projected  upon  a 
screen,  the  views  of  some  of  the  families  of  microbes 
are  very  realistic.  It  has  been  learned  that  some  of 
them  possess  great  intelligence.  The  photographs  of 
blood  in  circulation  in  the  thinnest  part  of  the  ears 
and  webs  of  the  fingers,  showing  its  capillary  or  arte- 
rial motion  and  the  changes  going  on  in  the  white 
cells,  are  of  great  interest.  They  indicate  something 
of  the  nature  of  life  and  disease.  The  stream  of  cir- 
culating human  blood  is  so  swift  that  the  eye  cannot 
keep  pace  with  it,  and  the  changes  in  the  white  blood 
cells  are  correspondingly  rapid.  Some  of  the  pictures 
show  a  white  cell  on  the  fast-moving  stream,  like  a 
white  cap  on  the  sea,  constantly  changing  its  shape. 
It  throws  out  or  takes  in  its  arms  like  an  octopus,  seiz- 
ing the  microbes  in  its  path.  In  disease  this  move- 
ment of  the  arms  takes  place  with  much  less  energy 
than  in  health.'"  We  have  long  believed  in  the  supe- 
rior intelligence  of  many  of  the  schizomycetes,  and 
we  are  glad  to  find  our  suspicions  confirmed  by  the 
revelations  of  the  micromotoscope. 

A  Quarantine  against  Consumption. — Califomians 

are  rebelling  against  the  use  of  their  State  as  a  sana- 
torium for  consumptives.  There  was  a  time  when  the 
salubrity  of  the  climate  and  the  consequent  advan- 
tages to  people  of  weak  lungs  were  held  out  as  an  in- 
ducement to  immigration.  But  too  many  have  accepted 
the  invitation,  and  there  is  a  feeling  now  among  the 
unafilicted  that  the  incursion  is  dangerous  to  them. 
Just  what  they  can  do  about  the  matter,  however,  is  a 
puzzling  question.  Directors  of  the  State  board  of 
trade  have  decided  that  some  measures  should  be 
taken,  and  they  have  in  mind  a  quarantine  against 
the  health  seekers.  Lawyers  tell  them  that  this  may 
not  be  feasible,  although  no  great  difference  would 
seem  to  exist  between  the  right  to  isolate  people  ill 
with  a  contagious  disease  and  the  right  to  prevent  the 
entrance  of  such  people  into  the  State. 

Health  Reports. — The  following  statistics  concern- 
ing yellow  fever,  cholera,  small-pox,  and  plague  have 
been  received  in  the  ofiice  of  the  L'nited  States  Marine 
Hospital  service  during  the  week  ended  August  21, 
1897: 


r.irmingham,  Ala May  Sth  to  .Kw^.  14th 91'' 

MontgonH-ry,  Ala jVugust  7th  id  13th 28 

Small-Pox — Foreign. 

Nagasaki,  lapan, July  I3tb  to  20tb »o 

Cardenas,  Cuba July  31st  to  .August  7lh 

Singapore,  India   June  1st  to  30th 

London,  Kngland July  24th  to  .A.ugusl  7U1 a 

Glasgow,  Scotland July  24th  to  31st 3 

Sagua  laCrande,  Cuba luly  24th  to  .August  7th 7° 

Montreal,  Canada luly  2d  to  26th 14 

Rotterdam,  Holl.lnil August  ist  to  7th i 

St.  Petersburg,  Russia July  24lh  to  July  31st 6 

Cholera. 

Bombay,  India July  i3lh  to  20th 

Singapore,  India June  1st  to  30th 

Ki.ito  Fu,  lapan July  i6th  to  25th « 

Osaka  I- u, "lapan July  i6th  to  25lh 2 

Tokio  I'll,  Japan July  16th  10  25th 8 

Kukuioka  Ken,  Japan July  16th  to  25th 2 

Kanagawa  Ken,  Japan July  16th  to  25th 4 

Saitam  Ken,  Jap.in July  i6th  10  25th 1 

Calcutta,  India July  3d  to  loth 

Colombo,  Ceylon July  3d  to  lolh 3 

Yellow  Fever. 

Cienfuegas.  Cuba.    August  1st  to  Sth 

Cardenas,  Cuba July  31st  to  7th 

Malanzas.  Cuba July  28th  to  .\ugust  4th 

S.igiuila(;randc,  Cuba .\ugust  1st  to  7lh f'5 

Man/Aiiillo   CuKi July  i;th  to  31SI 

Kingston,  Jamaica July  17th  10  24lh i 

Placib. 

Kanagawa  Ken,  Japan July  i6th  to  25th ' 

Konnosa,  lapan July  16th  to  25lh 4 

BomUiv,  India July  13th  to  ictii 


Cases.     r>eaths. 


Medical  Record 

A  JVeekly  youmal  of  Medicine  and  Surgery 


Vol.  52,  No.  10. 
Whole  No.  1400. 


New  York,   September  4,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riginal  JirticlcB. 

BiaXISH  MEDICAL  ASSOCIATION— ADDRESS 
OF   THE   PRESIDENT.' 

By   T.    G.    RODDICK,    M.D.,   M.P., 


You  have  been  welcomed  to  the  Dominion  of  Can- 
ada by  the  noble  earl  who  is  the  worthy  representa- 
tive of  our  beloved  Queen ;  you  have  been  welcomed 
to  the  Province  of  Quebec,  to  which  this  city  belongs, 
by  our  eloquent  and  justly  esteemed  lieutenant  gov- 
ernor; the  chief  magistrate  of  our  city  has  given  you 
'■'■  CtuJ  milk  failke"  in  a  manner  in  which  only  an 
Irishman  with  such  a  great  sympathetic  heart  as  he 
possesses  can  give ;  and  now  I  rise  to  welcome  you  on 
behalf  of  the  medical  profession  in  Canada,  and  to 
thank  you  for  the  honor  conferred  on  this  city  and 
country  by  \'our  presence  here  to-day.  Would  that  I 
could  find  suitable  language  in  which  to  thank  you 
also  for  the  high  honor  you  have  done  me  in  electing 
me  to  preside  at  this  great  meeting  of  the  British 
Medical  Association,  an  honor  which  is  appreciated 
none  the  less  by  the  consciousness  that  it  is  not 
a  personal  matter  but  a  compliment  to  Canadian 
medicine. 

■  This  meeting  of  the  British  Medical  Association  in 
Canada  is  an  event  which  will  serve  still  more  to  im- 
press upon  the  memory  of  our  people  the  year  1897, 
tlie  year  of  the  diamond  jubilee  of  our  beloved  sov- 
ereign, Queen  Victoria.  In  no  part  of  her  vast  em- 
pire did  her  subjects  celebrate  the  great  event  with 
more  enthusiastic  loyalty  and  devotion  than  in  Can- 
ada, especially  in  this  province,  the  home  of  the 
French-Canadians.  We  Canadians  of  both  tongues 
love  and  honor  our  Queen.  Long  may  she  live! 
Deeply,  too,  have  we  appreciated  here  the  splendid 
reception  accorded  in  the  old  home  to  our  premier, 
the  Right  Hon.  Sir  Wilfred  Laurier,  whose  distin- 
guished bearing  and  grace  of  manner  eminently  fitted 
him  for  the  important  part  it  was  his  peculiar  privil- 
ege to  play  in  the  magnificent  ceremonies  of  the  ju- 
bilee. A  French-Canadian,  Sir  Wilfred's  presence  in 
En  ;land  as  the  chosen  representative  of  the  dominion 
wa:,  an  object  lesson  to  the  empire  and  to  the  world 
in  the  harmony  existing^  between  the  two  nationalities 
which  comprise  the  Canadian  people. 

And  here  let  me  express  on  behalf  of  every  repre- 
sentative from  the  British  Isles,  and  on  behalf  of 
every  Canadian  present,  the  genuine  pleasure  we  feci 
in  having  among  us  on  this  memorable  occasion  so 
many  of  our  brethren  from  the  United  States.  Thi> 
only  proves  the  cosmopolitan  character  of  our  profes- 
sion; this  is  only  another  recognition  of  the  unity  of 
medicine.  Legislators  may  squabble,  the  air  may  be 
filled  with  wild  alarms,  and  war  mav  appear  imminent 
day  by  day,  but  our  relations  are  not  disturbed  in  tiic 
slightest  degree;  our  interests  are  common — we  are 
kinsmen  in  science;  we  go  forward  hand-in-hand,  ir- 
respective of   race  or  creed  or  color,  having  one   in- 

'  Delivered  at  Montreal,  Aujjust  31,   1897. 


tent  only:  the  advancement  of  our  noble  profession, 
and  through  that  the  amelioration  of  the  ills  of  man- 
kind. 

It  is  my  privilege  also  to  welcome  the  representa- 
tive of  another  republic.  La  Belle  France,  to  whose 
gifted  men  of  science  our  profession  is  so  greatly  in- 
debted. This  gentleman,  who  bears  the  credentials 
of  his  government  and  olficially  represents  the  great 
nation  of  which  he  is  so  bright  an  ornament,  is  known 
far  and  wide  as  the  professor  of  physiology  in  the 
University  of  France.  Dr.  Charles  Richet.  In  coming 
to  Canada  it  cannot  be  said,  nor  will  he  feel,  that  he 
comes  to  a  foreign  country,  for  in  the  Province  of 
Quebec  he  will  find  another  France,  with  a  delightful 
mingling  of  the  old  and  the  new :  his  own  beautiful 
language  spoken  with  all  the  grace  and  purity  of  the 
old  regime. 

But  we  are  further  honored  by  the  presence  among 
us  to-day  of  the  most  illustrious  surgeon  of  our  gener- 
ation. Lord  Lister,  who  stands  for  the  rise  and  zenith 
of  modern  surgery.  It  has  been  well  and  truly  said 
that  as  long  as  surgery  is  scientifically  discussed  Lord 
Lister's  name  cannot  fail  to  be  mentioned.  We  have 
only  to  compare  the  surgery  of  the  time  before  1873 
with  the  surgery  as  practised  to-day  to  appreciate  all 
that  he  has  done  for  the  science.  Can  it  be  for  a  mo- 
ment questioned  that  Lord  Lister  has  made  operative 
proceedings  possible  which  only  twenty-five  years  ago 
would  have  been  considered  criminal?  Undoubtedly 
the  most  powerful  agency  in  the  development  of  sur- 
gery in  this  century  has  been  the  introduction  of  the 
antiseptic  and  aseptic  methods  of  wound  treatment 
which  he  initiated.  It  is  due  to  his  efforts  that  sur- 
gical wards  have  been  freed  from  pyaemia,  and  the 
mortality  of  lying-in  hospitals  reduced  to  the  limits 
of  normal  parturition.  For  the  past  twenty  years  hon- 
ors many  and  great  have  been  showered  upon  him. 
Oxford,  Cambridge,  Edinburgh,  Glasgow,  Dublin, 
Toronto,  and  now  McGill,  have  vied  with  one  an- 
other in  hastening  to  do  him  homage.  Our  sovereign 
in  conferring  upon  him  the  richly  deserved  distinc- 
tions which  he  bears  with  such  gracious  dignity  only 
gives  expression  to  the  general  feeling  of  his  country- 
men throughout  the  empire  and  his  admirers  the 
world  over.  We  are  glad,  I  say,  to  have  him  with  us 
to-day:  his  presence  is  an  intellectual  stimulus  and 
an  energizing  force  in  our  deliberations. 

It  is,  I  understand,  an  unwritten  law  of  the  associa- 
tion that  the  president  shall  not  in  his  address  en- 
croach upon  the  topics  which  belong  by  right  and 
usage  to  the  readers  of  the  main  addresses  and  to  the 
presidents  of  the  various  sections.  I  have  observed 
that  the  majority  of  my  predecessors  have  contented 
themselves  with  discoursing  on  objects  and  circum- 
stances of  local  interest:  they  describe  the  town  or 
city  in  which  the  meeting  is  held,  or  perhaps  they  dis- 
cuss questions  of  a  public  character.  In  the  absence 
of  an  address  on  public  medicine,  others  have  taken 
that  for  their  theiue.  It  has  been  my  unhappy  lot  to 
select  and  consider  subjects  only  to  find  in  quick  suc- 
cession that  they  had  already  been  appropriated,  either 
by  the  association  Journal,  in  describing  so  fully 
Montreal  and  its  Mirroundings,  or  by  the  editors  of 
the  official  guide  or  souvenir,  who  have  given  a  \ery 


!26 


MEDICAL    RKCORD. 


[September  4,  1897 


comprehensive  description  of  Canada,  or  by  some  of 
tlie  gentlemen  wlio  preside  over  the  sections,  who,  I 
have  been  led  to  understand,  purpose  discussing  ques- 
tions of  medical  education.  I  fear  therefore  that  what 
I  have  to  say  this  afternoon  will  fall  far  short  of  the 
brilliant  presidential  addresses  which  members  of  this 
association  have  been  accustomed  to  in  other  years. 
Indeed  when  I  look  at  the  long  roll  of  eminent  men 
who  have  been  my  predecessors  in  this  high  office — 
men  oftentimes  distinguished  for  their  literary  gifts 
as  well  as  for  their  exalted  position  in  the  medical 
world — I  confess  that  I  marvel  at  my  temerity  in  ac- 
cepting so  great  a  responsibility.  In  speaking  of  my 
predecessors  allow  me  specially  to  refer  to  the  retiring 
president,  Dr.  Henry  Barnes,  w^hose  courteous  and 
kindly  manners,  together  with  his  sterling  ability, 
makes  us  all  glad  to  know  that  his  election  as  a  vice- 
president  for  life  insures  his  continued  official  and 
active  connection  with  the  association.  Here  might 
I  also  be  pemiitted  to  say  how  greatly  I  appreciated 
the  many  kindnesses  and  courtesies  extended  to  me 
by  the  president  (Dr.  Saundby)  and  members  of  the 
council  when  in  London  last  winter,  making  the  ini- 
tial arrangements  for  this  meeting. 

With  respect  to  the  other  addresses  which  it  is  cus- 
tomary to  deliver  on  these  occasions,  medicine  will 
be  dealt  with  by  one  whose  reputation  is  now  world- 
wide— by  our  Osier — whose  professional  education 
was  in  great  part  received  in  this  city,  and  who,  I 
am  happy  to  say,  is  still  a  Canadian.  How  he  has 
been  able  to  escape  the  alien  law  is  a  puzzle  to  many; 
but  he  has  really  only  been  borrowed  for  a  time;  he 
is  merely  passing  through  the  United  States  in  bond. 
We  are  only  waiting  until  we  can  find  a  place  large 
enough  to  hold  him,  when  we  shall  coa.x  him  back. 
Sorry  am  I  that  his  old  colleagues  in  his  own  depart- 
ment of  medicine,  Howard  and  Ross  and  Macdonnell, 
are  not  here  to  share  with  us  the  genuine  pleasure  we 
experience  in  finding  him  in  the  position  which  he  oc- 
cupies to-day.  One  of  these,  the  late  lamented  How- 
ard, had  much  to  do  with  moulding  his  career  and 
setting  him  to  the  task  which  he  has  so  ably  accom- 
plished. 

You  will  hear  addresses  in  surgerv  and  pulilic 
medicine,  delivered  by  gentlemen  who  have  devoted 
their  lives  to  their  special  subjects. 

Before  proceeding  farther,  however,  allow  me,  for 
the  benefit  of  those  who  may  not  be  ac"  .ited  with 
the  work  of  the  British  Medical  Assoc,  il  ,  to  give 
in  as  few  words  as  possible  a  genernl  idea  of  its  or- 
ganization. 

The  British  Medical  Association. — V\'hen,  in  1832, 
Sir  Charles  Hastings,  of  Worcester,  comn;unicated  to 
a  few  of  his  personal  friends  the  idea  he  had  con- 
ceiveil  of  a  medical  association  which  should  bring 
the  whole  piovincial  profession  of  England  into  a 
common  brotherhood;  it  may  be  safely  affirmed  that 
he  did  not  dream  that  he  was  laying  the  foundation  of 
an  association  which  would  ultimately  not  only  em- 
brace the  whole  of  the  British  Isles,  but  extend  to  that 
(Ireater  Britain  beyond  the  seas,  and  become  an  asso- 
ciation of  imperial  magnitude  and  of  imperial  impor- 
tance and  significance.  I  ha\e  no  hesitation  in 
expressing  my  belief  that  the  British  Medical  As.socia- 
tion  will  be  an  important  factor  in  bringing  to  a  suc- 
cessful issue  that  great  scheme  of  imperial  federation 
which  now  exercises  the  minds,  and,  let  mo  add,  the 
hearts,  of  the  leading  statesTnen  of  the  empire.  Sir 
Charles  Hastings'  aim  was  to  bring  town  into  profes- 
sional union  with  town,  county  with  county:  now  it 
has  become  the  aim  of  the  society  he  called  into  being 
to  ad<I  State  to  State  -  and  may  I  not  say  continent  to 
coiuineut? — until  all  the  nations  and  peoples  who  live 
under  the  British  Hag  are  brought  within  the  benefi- 
cent intiuence  of  the  Association. 


With  resjject  to  the  objects  of  the  association,  as  set 
forth  on  its  foundation,  they  may  briefly  be  stated  to 
be: 

1st.  The  collection  of  speculative  and  practical  in- 
formation through  essays,  hospital  reports,  infirmaries, 
dispensaries,  or  private  practice. 

2d.  Increase  of  knowledge  of  the  medical  topog- 
raphy of  England  through  statistical,  meteorological, 
geological,  and  botanical  inquiries;  the  investigation 
of  the  modification  of  endemic  and  epidemic  diseases 
in  different  situations  and  at  various  periods,  so  as  to 
trace,  as  far  as  the  recent  state  of  the  art  would  per- 
mit, their  connection  with  peculiarities  of  soil  and 
climate  or  with  the  localities,  habits,  and  occupations 
of  the  people. 

4th.  The  advancement  of  medico-legal  science 
through  succinct  reports  of  cases  occurring  in  courts 
of  judicature. 

5th.  The  maintenance  of  the  honor  and  respecta- 
bility of  the  profession  generally  in  the  provinces  by 
promoting  friendly  intercourse  and  free  communica- 
tion of  its  members,  and  by  establishing  among  them 
the  harmony  and  good  feeling  which  ought  ever  to 
characterize  a  liberal  profession. 

During  its  earliest  years  the  movements  and  pro- 
ceedings of  the  association  were  quiet  and  unostenta- 
tious, the  meetings  simple  in  their  arrangements:  but 
it  was  not  long  before  medical  societies  began  to  join 
the  newer  body,  and  towns  in  all  parts  of  the  king- 
dom soon  came  to  regard  it  as  an  honor  to  entertain 
the  association.  Graduallv  the  best  men  of  each  dis- 
trict enrolled  their  names,  and  the  membership  in- 
creased so  greatly  that  subdivisions  into  branches 
became  a  necessity.  Each  branch,  with  its  own  ordi- 
nary and  annual  meetings,  was  practically  a  replica 
of  the  parent  society,  possessing  its  own  president, 
vice-president,  secretary,  treasurer,  council,  and  by- 
laws, subject  to  the  approval  of  the  council  of  the 
association,  to  which,  besides,  each  branch  sent  rep- 
resentatives according  to  its  numerical  strength.  In 
1837,  five  years  after  the  foundation  of  the  associa- 
tion, there  were  three  of  these  branches  formed,  namely, 
the  East  Anglian,  the  Bath  and  Bristol,  and  the  Lan- 
cashire and  Cheshire.  By  the  end  of  1878  the  asso- 
ciation had  SP'c.id  over  the  whole  I'nited  Kingdom, 
the  total  number  of  branches  at  that  date  being  thirty — 
one  of  the  thirty,  it  is  interesting  to  note,  being  Jamaica, 
the  first  colonial  branch  to  be  formed.  It  was  orga- 
nized in  1878.  Two  years  later  we  find  that  Australia 
appears  for  the  first  time,  contributing  three  branches 
to  the  a.ssociation.  Since  then  thirt}-six  more 
branches  have  been  added,  making  a  grand  total  of 
sixty-five,  with  a  collective  membership  of  nearly 
seventeen  thousand.  Of  the  branches  twenty-seven 
are  Indian  and  colonial.  Doubtless  before  long 
those  portions  of  Africa  which  are  now  becoming 
rapidly  civilized  will  also  add  their  quota,  so  that 
it  is  possible  that  within  the  lifetime  of  all  present 
the  British  Medical  Association  will  be  represented 
wherever  the  British  tiag  tlies.  As  Xova  Scotia  is 
always  to  the  fore  in  matters  intellectual,  it  is  not 
surprising  that  the  first  Canadian  branch  of  the  asso- 
ciation should  have  been  formed  in  Halifax.  It  was 
started  in  1887,  four  years  ahead  of  Montreal,  To- 
ronto, Manitoba,  and  British  Columbia.  Canada  has 
now  se\  en  branches,  the  Ottawa  and  (Quebec  branches 
having  been  formed  within  the  last  year.  The  forma- 
tion of  the  Manitol)a,  Toronto,  antl  Montreal  branches 
was  the  immediate  result  of  the  visit  to  this  country  of 
Mr.  Ernest  Hart.  In  1S91.  Mr.  Hart,  who  has  been 
editor  of  the  British  Mdlical  Journal  since  1867,  and 
who  has  been  well  and  truly  described  as  the  jjivol  on 
which  the  machinery  of  the  whole  association  re- 
volves, passed  througl;  Canada  in  that  year  and  ad- 
dressed (•//  rouk  the  nien\bers  of  the   profession    in 


September  4,  1897] 


MEDICAL    RECORD. 


327 


Winnipeg,  Toronto,  and  Montreal.  Of  the  Manitoba 
branch,  which  began  with  tvventy-five  members,  Dr. 
Ferguson  was  nominated  as  president  and  Drs. 
Thornton  and  Lamont  as  vice-presidents.  In  Toronto 
the  branch  also  began  with  twent\-five  members, 
Dr.  Macallum  being  nominated  president  and  Dr. 
Thistle  honorary  secretary.  In  Montreal  the  meet- 
ing was  largely  representative  in  spite  of  the  short 
notice  given,  and  twenty-six  members  of  the  profes- 
sion at  once  signed  applications  for  membership. 
The  officers  nominated  were:  President,  Dr.  (now 
.Sir  William)  Kingston:  first  vice-president,  the  late 
Dr.  George  Ross;  second  vice-president.  Dr.  James 
Perrigo.  The  members  of  the  council  were:  Drs. 
Roddick,  F.  \V.  Campbell,  and  George  Wilkins.  In 
the  course  of  a  very  happy  speech  made  on  this  occa- 
sion by  Mr.  Hart  he  remarked  that  he  looked  for- 
ward to  the  time  when  the  Canadian  membershi]:) 
would  be  large  enough  to  invite  the  association  to 
hold  a  meeting  in  Canada;  and  he  hoped  that  the  first 
meeting  held  outside  the  limits  of  the  British  Isles 
might  be  held  in  this  country.  Little  did  we  think 
at  the  time  that  Mr.  Hart's  hopes  would  be  so  quickh' 
realized.  But  the  idea  has  ever  been  present  with  us. 
and  those  who  subsequently  attended  meetings  of  the 
British  Medical  Association  in  England  have  lost  no 
opportunity  of  advocating  the  claims  of  Canada,  and 
especially  of  this  the  metropolitan  city  of  Canada,  as 
a  place  of  meeting  for  the  association. 

One  of  the  secrets  of  success  of  the  British  Medical 
Association  is  that  it  makes  no  distinction  in  the 
treatment  of  its  members.  Colonial  members  have  all 
the  privileges  of  the  British  members,  and  are  always 
warmly  welcomed  at  the  headquarters  in  the  Strand 
and  at  the  annual  meetings.  The  association  has  a 
large  reserve  fund  of  £40,000  sterling,  which  is  the 
joint  property  of  the  members,  to  be  used  for  public 
and  professional  purposes,  and  any  suitable  appli- 
cations for  grants  for  medical  research,  whether 
from  British  or  colonial  members,  always  recei\e 
attention. 

A  gentleman  to  whom  the  association  is  greatly  in- 
debted is  Mr.  Francis  Fowke,  who  was  appointed  sec- 
retary and  general  manager  in  1872.  At  that  time 
the  association  was  in  rather  a  precarious  condition 
financially,  owing  to  its  deficient  organization;  but 
shortly  after  Mr.  Fowke  took  up  the  reins  of  office 
matters  were  found  steadily  to  improve.  About  the 
time  he  was  appointed  the  sub.scriptions  amounted  to 
£■4.677.  Ten  years  later  they  had  nearly  doubled, 
the  amount  being  £9,147;  and  in  1891  they  had 
reached  the  very  respectable  sum  of  ^14,759.  It  is 
interesting  to  note  how  closely  the  advertisements  in 
the  Journal  kept  pace  with  the  increase  in  niembt-r- 
ship.  In  1876  the  amount  received  for  advertise- 
ments was  ^/"i,992;  in  1881,  _y'6,o89;  and  in  1891, 
^14,568.  The  head  office,  which  had  been  in  Bir- 
mingham, was  moved  to  London  in  1872,  where,  after 
two  removals,  the  present  commodious  premises  in  the 
Strand  were  taken.  In  1879  the  association  began 
the  printing  as  well  as  the  publishing  of  its  Journal. 
The  library,  which  now  contains  ten  thousand  volumes, 
and  which  includes  nearly  ever\'  modem  medical  work 
of  note,  and  many  valuable  books  of  reference,  has  de- 
veloped in  that  time.  That  the  British  Medical  As- 
sociation is  the  largest  and  most  influential  guild  in 
the  world  cannot  be  questioned.  Moreo^  er,  the  good 
it  accomplishes  increa.ses  from  year  to  year,  and  more 
than  keeps  pace  with  the  expansion  of  the  association. 
Imagine  the  mighty  power  of  the  collective  action  of 
seventeen  thousand  earnest  men  pitted  against  false 
dogmas  and  ever  battling  for  the  trutii  I  It  is  not,  how- 
ever, by  the  greatness  of  numbers  that  the  association 
w>ll  be  judged — it  is  by  the  diversit)' and  quality  of  re- 
sults.     It  is  impossible  to  imagine  any  combination  of 


circumstances  which  would  render  this  great  association 
any  less  necessary  or  useful  than  it  is  to-day.  It  will 
undoubtedly  continue  to  grow  in  numbers,  to  increase 
in  importance,  and  to  be  ever  more  and  more  an  in- 
fluence making  for  the  amelioration  and  elevation  of 
mankind. 

The  Canadian  people,  and  especially  the  citizens  of 
Montreal,  are  highly  flattered  and  gratified  that  Can- 
ada should  be  the  first  country  without  the  United 
Kingdom  to  be  honored  by  a  meeting  of  the  British 
Medical  Association;  and,  while  they  hope  that  it  will 
not  be  long  before  the  honor  is  repeated,  our  people 
are  not  insensible  to  the  claims  of  other  portions  of 
the  empire,  more  especially  the  great  island  continent 
of  the  antipodes,  .\ustralia.  Either  Sydney  or  Mel- 
bourne would  be  a  fit  meeting-place  for  such  an  im- 
perial organization  as  this,  and  should  the  next  meet- 
ing which  is  held  outside  the  British  Isles  be  held 
under  the  Southern  Cross  our  hospitable  .Australian 
kinsmen  may  count  on  a  large  contingent  from  the 
Dominion  of  Canada. 

Climatic  Conditions. — As  it  may  be  presumed  that 
to  the  majority  of  those  present  here  to-day  Canada  is 
almost  an  unknown  countrj",  I  have  thought  that 
among  one  or  two  other  subjects  a  few  remarks  on  the 
atmospheric  conditions  and  health  resorts  of  the  Do- 
minion would  not  be  \vithout  interest. 

The  best  way  to  understand  the  atmospheric  condi- 
tions of  a  countr}'  is  first  to  understand  its  physical 
features.  The  physical  features  of  Canada  are  very 
remarkable.  Broadly  speaking,  the  countrj-  is  sepa- 
rable by  climatic  and  physical  conditions  into  three 
great  regions,  the  eastern,  central,  and  western  re- 
gions, which  approximately  run  north  and  south  in 
the  general  trend  of  the  continent.  The  eastern  re- 
gion, which  includes  the  older  provinces  of  the  do- 
minion— Ontario,  Quebec,  Nova  Scotia,  New  Bruns- 
wick, and  Prince  Edward  Island — besides  the  great 
fur  territor)^  stretching  far  to  the  east  and  northeast 
of  James  Bay,  extends  from  the  Atlantic  to  Lake  Su- 
perior and  the  chain  of  great  lakes  running  in  a 
northerly  direction  from  Lake  Superior  to  the  Arctic 
Ocean.  Between  this  great  chain  of  lakes  and  the 
eastern  base  of  the  Rocky  Mountains  is  the  immense 
interior  continental  plain  which  constitutes  the  cen- 
tral region  of  Canada,  its  southern  part  consisting  of 
open  prairie,  its  northern  part  of  forest  lands.  The 
third  part  of  the  division,  the  western  region,  is  nat- 
urally very  well  defined,  consisting  of  the  wide  and 
wild  mountainous  border  of  the  continent  on  the  Pa- 
cific side — the  Rocky,  Selkirk,  and  Gold  ranges, 
which  form  the  great  Cordilleran  belt,  whose  average 
width  in  Canada  is  four  hundred  miles. 

Eastern  Canada,  our  first  and  largest  region,  is  geo- 
logically of  very  ancient  origin.  Here  geologists  have 
placed  the  nucleus  of  the  continent  — the  broad  belt  of 
crystalline  rock  of  great  antiquity  called  the  Lauren- 
tian  plateau.  This  region  is  remarkable  for  its  im- 
mense number  of  lakes  large  and  small,  and  for  its 
irregular  and  winding  rivers  with  numerous  rapids 
and  falls.  Between  the  Laiirentian  plateau  on  the 
north  and  the  Appalachian  mountain  system  on  the 
south,  lies  the  great  Valley  of  the  River  St.  Lawrence. 
The  basin  of  this  majestic  river  covers  530,000  square 
miles,  of  which  460,000  are  in  Canada.  .Above  the 
city  of  Quebec,  the  base  of  the  Laurentian  highlands 
and  the  ridges  of  the  .Appalachian  system  diverge, 
and  the  mighty  river  flows  through  an  extensive  low 
country  of  notable  fertility,  in  earlier  days  the  great 
granary  of  Canada. 

It  may  be  added,  < «  passattt,  that  Mount  Royal,  which 
gives  such  distinction  and  character  to  our  city,  repre- 
sents the  basal  remnants  of  a  volcanic  vent  of  great 
antiquity.  From  its  picturesque  summit  may  be  seen 
similar  abrupt  elevations  far  off  toward  the  east  and 


328 


MEDICAL    RECORD. 


[September  4,   1897 


south — Montarville,  Beloeil  or  St.  Hilaire,  Mt.  Rouge- 
mont,  with  Mt.  Yamaska  behind  it,  Mt.  Shefford,  and 
the  conical  Mt.  Johnson  or  Monnoir.  The  Adiron- 
dacks  are  visible  in  the  distance  to  the  southwest,  and 
the  Green  Mountains  to  the  southeast. 

Included  in  the  eastern  region  is  one  of  the  most 
remarkable  geographical  features  of  Canada — the  great 
fresh-water  lakes  or  inland  seas,  Superior,  Huron, 
Erie,  and  Ontario,  which  form  the  perennial  reser- 
voirs of  the  St.  Lawrence.  Together  with  Lake  Mich- 
igan, which  is  wholly  in  the  United  States,  they  have 
■an  aggregate  area  of  94,750  square  miles,  an  area 
larger  than  that  of  Great  Britain.  They  stand  at  four 
distinct  levels  above  the  sea — Ontario,  247  feet;  Erie, 
573;  Huron,  581;  and  Superior,  602.  The  Niagara 
Falls,  the  greatest  and  most  impressive  of  the  natural 
wonders  of  our  continent,  are  the  direct  result  of  the 
great  height  of  Lake  Erie  above  Lake  Ontario,  the 
river  connecting  the  lakes  being  only  a  few  miles 
long.  Besides  the  St.  Lawrence,  eastern  Canada  has 
several  other  great  rivers,  notably  the  Ottawa,  which 
has  a  course  of  1,800  miles  and  a  basin  of  nearly 
1,000,000  square  miles;  the  St.  Maurice,  the  Sague- 
nay,  and  the  St.  John,  the  glory  of  New  Brunswick, 
•which,  together  wiih  the  Atlantic  slope,  has  a  basin 
of  50,214  square  miles.  The  central  and  western 
regions  also  have  their  abundant  share  of  large  and 
small  lakes  and  great  rivers,  an  account  of  which 
would  fill  reams  of  paper.  It  should  be  noted  that 
the  Canadian  rivers  and  lakes  collectively  cover  an 
area  of  130,000  square  miles,  and  contain  one-half 
the  fresh  water  on  the  globe. 

I  draw  special  attention  to  this  series  of  vast  lakes 
and  rivers  because  it  e.xerts  an  immense  and  benefi- 
cent influence  on  the  climate  of  Canada.  It  presen-es 
llie  mean  temperature  while  the  land  e.xperiences  the 
extremes.  In  summer  the  water  is  cooler  and  in  win- 
ter warmer  than  the  land  conditions,  which  tends  to 
modify  the  differences  and  to  favor  uniformity  of 
climate.  Without  these  waters,  too,  we  should  have 
vast  regions  of  comparatively  little  value,  as  in  Af- 
rica. Asia,  and  in  the  United  States  west  of  the  Mis- 
sissippi River,  where  large  tracts  of  land  far  from 
water  are  nothing  more  than  arid  wastes.  Our  cli- 
mate is  more  uniform  than  that  of  Europe;  the  me- 
terorological  differences  are  produced  by  position 
alone,  but  Europe  has  a  higher  mean  temperature,  and 
the  extremes  there  are  not  so  marked  or  so  wide  apart 
as  in  Canada.  Owing  to  the  great  area  of  Canada, 
extending  over  twenty  degrees  latitude,  or  from  the 
latitude  of  Constantinople  to  that  of  North  Cape  in 
Norway,  the  range  of  temperature  is  naturally  very 
•wide.  The  southern  boundary  stretches  over  fully 
four  thousand  miles,  along  which  line  we  find  that 
southern  Ontario  has  the  latitude  of  Central  Italy, 
Nova  Scotia  that  of  Northern  Italy,  Manitoba  and 
Vancouver  that  of  central  Germany.  Speaking  gener- 
ally, the  Canadian  summer  may  be  stated  at  60^  F.  to 
70°  F. 

From  its  vast  and  varied  extent,  Canada  may  be 
said  to  be  the  possessor  of  several  climates.  Taking 
Solly's  classification  as  to  position,  we  have  in  Can- 
ada all  the  three  land  climates,  the  low,  the  medium, 
and  the  high.  The  first  has  an  elevation  up  to  2,500 
feet,  the  second  up  to  4,500,  and  the  third  from  4,500 
upward.  As  to  temperature  and  huniiditv,  Canada 
comes  under  the  category  of  "cold,  moderate,  and 
dry." 

Health  Resorts.— In  the  eastern  region  of  tlie 
dominion  there  are  at  least  two  localities  which  have 
been  proved  to  possess  many  of  the  qualities  which 
constitute  a  climate  for  convalescents  from  fevers  and 
other  depressing  diseases,  and  also  for  consumption 
in  the  incipient  stage.  I  refer  to  the  region  in  the 
Province  of  Quebec  among  the  Laurentians  north  of 


this  city,  of  which  the  village  of  Ste.  Agathe  is  the 
centre,  the  other  being  the  Muskoka  district  in  On- 
tario. 

The  first  has  been  called  the  Adirondacks  of  Can- 
ada, having  many  of  the  features,  physical  and  cli- 
matic, of  that  new  celebrated  plateau  situated  in  the 
northeastern  part  of  New  York  State,  and  stretching 
from  the  Mohawk  Valley  in  the  south  one  hundred 
and  fifty  miles  north,  almost  to  the  frontier  line. 
The  average  elevation  of  the  two  regions  is  about 
the  same,  being  from  sixteen  hundred  to  eighteen 
hundred  feet.  The  immense  pine  forests,  together 
with  the  moderate  temperature,  constitute  the  chief 
characteristics  of  the  Canadian  district,  from  the  med- 
ical point  of  view.  No  very  systematic  meteorologi- 
cal observations  have  yet  been  taken  of  the  Ste.  Agathe 
region,  but  the  indications  will  probably  prove  to  be 
very  similar  to  tliose  of  the  American  resort.  It  is  in 
contemplation  to  erect  a  sanatorium  on  Trembling 
Mountain,  overlooking  the  village  of  Ste.  Agathe, 
which  will  doubtless  in  time  rival  the  Adirondack 
Cottage  Sanatorium  near  Saranac  Lake  Village,  which 
has  proved  such  a  marked  success  under  the  able  man- 
agement of  Dr.  E.  L.  Trudeau.  The  elevation  of  the 
sanatorium  will  be  twenty-five  hundred  feet,  thus  hav- 
ing an  altitude  of  nearly  seven  hundred  feet  greater 
than  the  establishment  at  Saranac.  It  is  the  inten- 
tion of  the  Quebec  government  to  set  apart  a  sufficient 
portion  of  the  crown  lands  to  form  a  natural  park  in 
that  part  of  the  province.  It  will  be  called  the 
Trembling  Mountain  Park,  and  will  cover  an  area  of 
one  hundred  thousand  acres  of  land,  in  which  arc 
several  beautiful  lakes.  Within  the  boundaries  of 
this  park  the  sanatorium  will  be  constructed.  There 
is  therefore  no  reason  to  doubt  that  we  will  shortly 
have  within  our  own  lines  a  health  resort  possess- 
ing all  the  advantages  of  the  Adirondacks  region, 
and  capable  of  affecting  for  good  the  same  class  of 
patients  now  so  decidedlv  benefited  bv  a  residence  in 
those  mountains. 

One  hundred  miles  north  of  Toronto,  in  the  high- 
lands of  Ontario,  is  the  Muskoka  Lake  region,  an  area 
of  about  ten  thousand  square  miles,  perhaps  the  most 
picturesque  portion  of  the  whole  province.  Within 
this  district,  which  has  a  mean  altitude  above  the 
sea  of  about  eight  hundred  feet  (two  hundred  feet 
above  Lake  Huron),  there  are  nearly  a  thousand 
lakes  and  ponds,  connected  by  innumerable  streams. 
The  chief  lakes  are  Muskoka,  Rosseau,  and  Joseph. 
These  contain  about  four  hundred  islands.  It  is 
a  region  abounding  in  pine  forests;  the  climate  is 
dry,  and  the  air  pure  and  invigorating.  The  Mus- 
koka region  has  been  found  undoubtedly  to  possess 
remarkable  climatic  advantages  for  those  with 
phthisical  tendencies.  The  death  rate  from  phthisis 
in  this  section  of  Ontario  is  proved  to  be  less  than 
one-tenth  the  rate  which  obtains  in  otlier  parts  of  the 
province.  At  Gravenhurst  the  Muskoka  Cottage  San- 
atorium for  the  cure  of  incipient  phthisis  has  recently 
been  founded,  under  the  best  auspices,  with  accommo- 
dation for  forty  patients.  The  present  sanatorium  con- 
sists of  a  large  and  well-planned  main  building,  sur- 
rounded within  ea.sy  distance  by  a  number  of  small 
cottages.  The  grounds,  which  embrace  seventy-five 
acres,  are  situated  on  Lake  Muskoka.  Pine  forests 
and  rocky  ridges  protect  the  buildings  on  the  north 
and  west  sides,  whence  come  the  colder  winds  in 
winter.  Like  the  Adirondacks  sanatorium,  the  inten- 
tion is  to  occupy  it  all  the  year  round.  The  progress 
of  this  institution,  at  present  in  the  experimental 
stage,  will  be  watched  with  much  interest. 

In  the  central  region  of  Canada,  that  section  of 
the  Northwest  Territories  known  as  southern  Alberta 
— the  home  of  the  cowboy — has  much  to  recommend 
it  as  a  health  resort.     This  strip  of  prairie  and  hill 


September  4.  1897] 


MEDICAL    RFXORD. 


329 


country  is  bounded  on  the  north  by  the  Canadian  Pa- 
cific Railway,  and  on  the  south  by  the  international 
boundary  line ;  its  eastern  boundary  extends  as  far  as 
Medicine  Hat;  its  western  boundarj'  to  the  summit 
line  of  the  Rockies  and  British  Columbia,  comprising 
in  all  an  area  of  about  twenty  thousand  square  miles. 
The  plain  here  has  an  elevation  above  sea  level  of 
twenty-seven  hundred  feet,  which  gradually  increases 
up  to  the  entrance  of  the  Crow's  Nest  Pass,  where  the 
elevation  is  forty-five  hundred  feet.  Calgary,  the 
capital  of  Alberta,  is  itself  thirty-five  hundred  feet 
above  sea  level.  With  this  gradual  incline  from  a 
lo'.v  to  a  high  level  altitude  the  patient  can  choose 
the  locality  which  suits  his  particular  case.  In  a  long 
experience  Kennedy  knew  of  only  two  cases  of  phthisis 
originating  in  that  country — one  of  acute  tubercu- 
losis with  a  strong  hereditary  taint,  which  proved 
fatal;  the  other,  of  the  ordinary  type,  recovered  without 
leaving  the  place.  He  claims  for  the  climate  of  south- 
ern Alberta  a  dry  aseptic  atmosphere  and  a  dry  soil, 
the  greatest  possible  number  of  sunshiny  days  (ninety 
per  cent.),  with  cool  nights.  Patients  can  live  there  all 
the  year  round,  and  with  the  exception  of  an  occ  a- 
sional  snowstorm,  which  may  cover  the  prairie  to  a 
varying  depth,  nothing  need  interfere  with  their  prac- 
tically living  in  the  saddle.  The  so-called  chinook 
wind  has  a  remarkable  influence  over  all  this  western 
section  of  Canada.  It  is  a  warm  wind  which  blows 
with  varying  intensity  from  west  to  southwest.  Mc- 
Caul,  who  describes  it  very  graphically,  speaks  of  its 
approach  being  heralded  by  the  massing  of  dark 
clouds  above  the  mountain  tops,  and  a  distinct  wail- 
ing and  rumbling  from  the  passes  and  gorges.  Its 
effect  in  winter  is  little  short  of  miraculous.  When 
the  real  chinook  blows  the  temperature  often  rises  in 
a  few  hours  from  20'  below  to  40^  above  zero.  The 
snow,  which  in  the  morning  may  have  been  a  foot  deep, 
disappears,  and  before  night  everything  is  dripping. 
Rut  in  the  space  of  a  single  day  all  the  water  is  lapped 
up  by  the  thirsty  wind,  and  the  prairie  is  so  dry  that  a 
horse's  hoof  hardly  makes  an  impression. 

The  cases  which  have  been  most  especially  bene- 
fited by  Alberta's  climate  are  pulmonary  tuberculosis 
in  the  earliest  stage,  although  neurasthenics  and  ana- 
mic  women  are  likewise  favorably  affected  to  a  marked 
degree.  It  is  well  known  that  delicate  lads  sent  from 
the  British  Isles  to  this  section  of  the  Northwest  to 
work  on  the  cattle  ranches  become  in  a  year  or  two 
healthy  and  vigorous  men,  and  are  scarcely  recognized 
on  their  return. 

Still  farther  west,  and  nearly  midway  between  Cal- 
gary and  the  Pacific  coast,  is  the  beautiful  Valley  of 
K.imloops,  another  all-the-year-round  resort  which 
has  much  to  commend  it  to  those  suffering  from  many 
forms  of  tuberculous  disease.  This  picturesque  valley, 
which  lies  between  the  Rocky  Mountains  and  the  Cas- 
cade Range,  has  a  low  altitude  climate  of  eleven  hun- 
dred feet,  but  is  exceedingly  dry,  showing  an  annual 
rainfall  of  only  1 1.05  inches,  with  an  average  of  about 
seventy-five  rainy  days  in  the  year.  The  rain  soon  dis- 
appears, the  soil  being  light  and  gravelly.  In  this 
region  we  have  an  illustration  of  the  local  variabilit}- 
of  climate  recently  pointed  out  by  Rrj'ce,  who,  in  re- 
ferring to  the  two  not  very  distant  localities  of  Van- 
ci)  iver  and  Kamloops.  showed  that,  whereas  the  former 
his  an  annual  rainfall  of  thirty-five  inches,  the  latter 
records  but  eleven  inches  and  a  decimal.  The  mean 
annual  temperature  of  the  Valley  of  Kamloops  is  46.03 
I''.,  the  annual  range  being  only  22.8  .  The  tuberculous 
patients  who  appear  to  be  most  benefited  by  a  residence 
in  Kamloops  are  those  in  whom  there  is  a  tendency 
to  chronic  congestion.  Cases  of  bronchitis  are  likewise 
said  to  do  well  there.  The  climate  can  also  be  rec- 
ommended for  consumptives  in  whom  cardiac  disease 
exists  as  a  complication.     That  Canada  is  an  excep- 


tionally healthful  country  is  the  general  testimony  of 
the  army  and  navy  surgeons  who  have  been  stationed 
in  Canada  with  the  different  regiments  from  the  time 
of  the  conquest  to  the  present  day.  Crawford,  who 
was  attached  to  one  of  the  regiments  stationed  in  Mon- 
treal many  years  ago,  and  who  subsequently  left  the 
army  and  practised  in  this  city,  published  elaborate 
and  carefully  collected  statistics  to  prove  that  few 
portions  of  the  British  Empire  have  a  climate  equal 
to  that  of  Canada.  In  fact  his  statistics  prove  con- 
clusively that,  out  of  ever)'  one  thousand  of  the  troops 
stationed  at  the  various  garrisons  throughout  the 
empire,  the  percentage  constantly  ineffective  from 
sickness  was  smaller  in  this  country  by  seven  per  cent. 
than  at  Gibraltar,  which  was  then  taken  as  the  type. 
I  think  it  can  be  satisfactorily  proved  that  Canada  is 
expressly  fitted  to  develop  a  hardy  race  capable  of 
great  endurance.  The  races  of  the  British  Isles  and 
the  French  race  have  certainly  not  degenerated  here. 
Hingston  proved  this  very  conclusively  some  years 
ago  by  obser\-ations  made  upon  the  medical  students 
attending  the  various  schools  in  this  cit)-.  He  found 
that  the  lumbar  strength  of  the  British  Canadian  of 
the  third  generation  exceeded  by  twenty  pounds  that  of 
the  recently  arrived  English  and  Scotch  students.  But 
the  French  Canadian  of  the  tenth  generation  did  better 
than  all  by  nearly  thirty  pounds.  Not  only  has  the 
French  Canadian  increased  in  strength  but  also  in 
height  and  weight  over  the  original  Normandy  stock. 

Has  the  intellectual  improvement  in  our  people 
kept  pace  with  the  physical?  We  are  a  modest  peo- 
ple, but  I  think  we  can  say  with  truth  it  has.  We 
have  a  very  respectable  literature  of  our  own,  but  the 
best  intellect  of  the  country  is  as  yet  absorbed  in  the 
practical  affairs  of  life,  and  has  too  seldom  found  ex- 
pression in  art  and  literature.  It  is  not  very  long 
since  a  distinguished  American  litterateur,  Charles 
Dudley  Warner,  gravely  attributed  what  he  called  the 
literary  inactivity  of  Canada  to  the  coldness  of  the 
climate.  He  said,  in  short,  that  the  cold  benumbed 
our  intellectual  faculties,  and  we  had  to  spend  so 
much  of  our  energy  in  trying  to  keep  warm  that  none 
was  left  for  any  other  purpose.  It  must  be  admitted 
that  if  we  measure  the  intellectual  capacity  of  our 
people  by  the  number  of  books  produced  in  Canada 
the  result  is  not  all  we  might  desire;  but  the  climate  is 
not  to  blame.  Especially  is  it  not  the  cold,  for  the 
winter  is  the  season  devoted  pre-eminently  to  intellec- 
tual effort  and  intellectual  amusements.  If  Mr.  War- 
ner had  said  that  the  heat  of  our  summer  was  an  un- 
favorable factor  in  our  intellectual  life  he  would  not 
have  shot  quite  so  wide  of  the  mark;  he  would  not 
have  been  right,  but  tie  would  not  have  been  quite  so 
wTong.  The  very  vicissitudes  of  our  climate,  by  train- 
ing the  system  to  endure  severe  physical  conditions, 
must  react  favorably  upon  the  mental  attitude. 

Canadian  Spas. — We  have  in  Canada  several  min- 
eral springs  of  undoubted  therapeutic  value,  and  they 
are  pretty  generally  distributed  all  over  the  domin- 
ion, although  differing  materially  in  temperature 
and  composition.  The  best  known  Canadian  spas 
are  the  Caledonia,  the  St.  Leon,  and  the  Plantagenet 
Springs,  in  the  Province  of  Quebec,  and  the  Banff 
Springs  in  Alberta.  Other  springs  in  the  Province 
of  Quebec  are  the  .\benakis  and  the  Ca.xton.  Besides 
these  there  are  at  least  three  or  four  artesian  wells 
or  springs.  Of  these  the  chief  are  the  Laurentian 
Spring,  in  the  east  end  of  this  city  (a  mild  alkaline 
water  with  sodium  bicarbonate  as  its  predominat- 
ing ingredient),  and  the  Radnor,  a  well  of  some 
considerable  repute  situated  in  the  county  of  Cham- 
plain.  This  was  discovered  a  very  few  years  ago 
when  boring  for  water  to  supply  the  workpeople 
engaged  at  the  well-known  Radnor  Forges.  The 
well  is  over  four  hundred  feet  in  depth.     In  the  Prov- 


330 


MEDICAL    RECORD. 


[September  4,  1897 


ince  of  Ontario  the  chief  springs  are  the  Winchester 
and  the  Preston,  and  those  in  the  town  of  St.  Catha- 
rines, near  Niagara  Falls.  The  best  known  and  the 
most  popular  are  the  Caledonia  Springs,  situated  on 
the  line  of  the  Canadian  Pacific  Railway  about  mid- 
way between  .Montreal  and  Ottawa,  and  about  nine 
miles  from  the  Ottawa  River.  They  consi.st  of  four 
springs — the  gas,  the  saline,  the  white  sulphur,  and 
the  intermitting  or  Duncan  spring.  The  first  three 
are  situated  within  a  distance  of  three  or  four  rods  of 
each  other,  and  the  mouths  of  the  latter  two  are  not 
more  than  four  feet  apart.  The  intermitting  spring  is 
situated  about  two  miles  from  the  others.  This  is  so 
named  because  the  discharge  of  gas  is  not  regular, 
some  minutes  elapsing  between  the  periods  of  quies- 
cence and  disturbance.  The  average  temperature  of 
these  springs  is  about  46'  ¥.  The  intermitting  spring 
has  the  largest  percentage  of  chloride  of  sodium,  and 
differs  from  all  the  others  in  possessing  a  greater  por- 
tion of  chlorides  of  calcium  and  magnesium.  It  has 
also  nearly  twice  the  proportion  of  carbonate  of  mag- 
nesium that  the  others  contain.  It  has  been  found 
that  taken  judiciously  and  under  advice  these  waters 
have  a  remarkable  effect  in  subacute  and  chronic 
rheumatic  conditions.  People  suft'ering  thus  are  found 
flocking  to  Caledonia  from  all  parts  of  this  continent 
and  even  South  America,  especially  during  the  months 
of  July  and  August.  Gouty  conditions  depending  upon 
liver  disturbances  also  yield  ver)'  readily  to  these  wa- 
ters. The  waters  of  St.  Leon  and  Plantagenet  are  simi- 
lar in  many  respects  to  those  just  described,  and  as  a 
rule  suit  the  same  class  of  patients. 

All  the  springs  so  far  mentioned  yield  cold  waters, 
but  Canada  also  possesses  the  most  famous  thermal 
springs  on  this  continent. 

Banff,  now  a  picturesque  town  magnificently  situ- 
ated in  the  heart  of  the  Rocky  Mountains,  yet  within 
the  limits  of  that  division  of  the  Northwest  Territories 
known  as  Alberta,  has  become  one  of  our  noted  health 
resorts,  although  frequented  more  on  account  of  its 
remarkable  thermal  springs  than  for  its  climatic  ad- 
vantages. The  town  is  built  on  the  banks  of  the  Bow 
and  Spray  rivers,  two  large  glacier  streams,  and  is 
surrounded  by  mountains  towering  many  thousands  of 
feet  above  the  level  of  the  sea.  The  winter  is  short, 
beginning  in  December  and  ending  in  February,  and 
is  much  milder  than  in  Ontario.  Very  little  rain  falls, 
and  the  days  as  a  rule  are  bright  and  cloudless.  Pro- 
longed periods  of  warm  weather  are  e.xperienced  dur- 
ing winter.  March  and  April  are  variable:  May  is 
warm  and  bright;  June  is  the  month  in  which  the 
greatest  rainfall  occurs;  July,  August,  September,  and 
October  are  very  warm  and  verj^  dry,  with  cold  nights. 
At  all  seasons  with  the  exceptions  perhaps  of  June  the 
air  is  dry  and  notably  aseptic.  It  is  positively  stated 
that  no  case  of  malaria  or  tuberculosis  has  ever  been 
known  to  originate  at  Banff.  Independently  of  the 
springs,  then,  Banff  has  much  to  recomiiiend  it  from 
a  climatological  standpoint. 

The  far-famed  Thermal  Springs  of  Banff  were 
discovered  some  fifteen  years  ago  during  the  construc- 
tion of  the  Canadian  Pacific  Railway.  At  its  source 
in  the  mountain  side  it  has  a  temperature  of  127'^  F. 
and  the  air  is  charged  for  some  distance  around  with 
the  steam  emitted  from  the  pool  to  which  the  water 
flow's.  The  most  recent  analysis  .shows  it  to  contain 
the  following  ingredients: 

Calcium  sulphate 3<J.S5 

Nf agnesium  sulphate 12.39 

Calcium  carbonate 3.29 

Sodium  sulphate 15. 60 

Sodium  carbonate 35-73 

Silica traces. 

Organic  matter traces. 

The  waters  of  Banff  have  been  used  with  great  ben- 


efit in  rheumatism,  gout,  sciatica,  and  glandular  affec- 
tions, in  certain  forms  of  skin  disease,  and  especially, 
it  is  thought,  in  tuberculous  affections  of  the  skin  and 
mucous  membrane.  Aided  by  the  admirable  climatic 
conditions  the  waters  have  also  been  found  to  benefit 
in  a  marked  manner  functional  diseases  of  the  liver, 
stomach,  and  kidneys,  and  tuberculous  joint  affections. 
In  debilitated  constitutions  from  any  cause  the  activ- 
ity of  the  skin  is  noticed  to  be  increased,  the  heart 
and  vascular  system  are  strengthened,  and  the  muscular 
and  nervous  .systems  much  improved  in  tone.  Ra- 
chitic and  delicate  children  are  much  benefited  by  the 
Thermal  Springs.  This  seems  a  larger  order;  but  the 
therapeutic  effects  of  these  springs  have  been  carefully 
-Studied  by  competent  medical  men  who  have  been  sta- 
tioned there  for  some  years.  The  climate  doubtless 
assists  materially  the  action  of  the  waters  in  very  many 
cases. 

I  doubt  if  the  Canadian  profession  sets  a  suffi- 
ciently high  value  on  the  therapeutic  properties  of 
our  own  mineral  springs.  When  visiting  the  Spas  of 
Great  Britain  and  Europe,  one  is  impressed  by  the 
caution  exercised  by  patients  in  the  method  of  using 
the  waters  which  have  been  prescribed.  There,  com- 
petent local  medical  men  are  always  to  be  found  who 
can  give  the  proper  advice  regarding  the  water  to  be 
taken  for  the  ailment  from  which  the  patient  suffers 
and  the  judicious  use  of  baths.  Here,  unfortunately, 
in  many  places  no  professional  advice  is  available, 
and  the  patient  consequently  does  very  much  as  he 
pleases,  or  as  the  hotel  proprietor  may  advise,  and  in 
consequence  more  harm  than  good  constantly  follows 
the  use  of  the  waters. 

Medical  Education  in  Canada The  general  ques- 
tion of  medical  education  is  one  of  great  importance 
and  of  unceasing  interest,  nor  is  this  interest  con- 
fined to  the  profession  ;  it  is  becoming  universal.  The 
needs  of  medical  education  are  fortunately  being  more 
fully  realized  by  those  who  on  accouunt  of  their  wealth 
and  influence  are  in  a  position  to  render  that  substan- 
tial assistance  which  is  so  requisite.  The  time  was 
when  every  medical  school  was  a  purely  proprietan. 
concern  '"  run  "  for  the  money  that  was  in  it.  We  feel 
in  Canada,  and  I  think  I  can  speak  for  the  profession 
in  the  neighboring  republic,  that  this  day  is  passed, 
that  high-minded  philanthropists  like  the  Right  Hon. 
Lord  Strathcona  and  Mount  Royal,  the  late  John 
Henrv"  Molson,  the  McDonalds,  the  Drakes,  and  others 
with  us,  and  the  Johns  Hopkins,  the  Stanfords,  the 
Vanderbilts.  the  Rockefellers,  the  Miss  Garretts,  and 
others  with  them  are  beginning  to  realize  that  unen- 
dowed instruction  in  medicine  must  lead  to  imperfect 
results,  and  that  private  endowment,  in  the  absence  of 
State  aid,  has  become  an  absolute  necessity  to  a  proper 
medical  training.  I  am  not  an  advocate  for  State  aid 
to  universities,  and  I  rejoice  that  the  university  to 
which  I  have  the  honor  to  belong  is  not  so  dependent, 
as  it  might  thus  be  deprived  of  those  gifts  of  private 
munificence  to  which  I  have  just  referred.  All  honor 
to  those  far-seeing,  open-handed  men  and  women  who 
are  giving  of  their  abundance  in  order  to  elevate  the 
standard  of  medical  education  and  by  so  doing  benefit 
their  kind.  As  Gould  very  tersely  puts  it  in  one  of 
his  clever  articles:  "1  think  our  reliance  must  be 
upon  private  bequests,  and  the.se  can  be  secured  only 
as  we  interest  the  rich.  \\"e  must  never  wear}'  in 
showing  the  neglect  of  the  greatest,  most  palpable, 
most  certain  means  of  doing  good.  There  is  a  strange 
fatalit)-  in  men,  an  unaccountable  inability  of  seeing 
the  need  that  lies  nearest  the  good  that  is  dearest. 
There  is  more  money  to-day  devoted  to  astronomy 
than  to  the  prevention  of  disease.  It  is  positively 
wonderful  to  think  that  men  should  be  more  interested 
in  stars  and  constellations  than  in  their  bodies  and 
their  physiological  life." 


September  4,  1897] 


MEDICAL    RFXORD. 


331 


A  question  which  is  nowadays  agitating  the  minds 
of  those  especially  interested  in  medical  education  is 
the  kind  of  groundwork  which  is  likely  to  bear  the 
most  direct  relation  to  the  future  studies  of  the  medi- 
cal student.  I  think  it  is  now  conceded  by  all  that 
he  is  placed  at  a  greater  advantage  who  first  passes 
through  an  arts  or  a  science  course.  I  am  happy  to 
be  able  to  report  that  from  fifteen  to  twenty  per  cent. 
of  those  who  are  studying  medicine  in  this  country  to- 
day have  had  a  collegiate  training  in  either  arts  f)r 
science.  Which  of  the  Vko  should  the  parent  or 
guardian  choose?  Had  I  a  son  whose  instincts  were 
in  the  direction  of  medicine  I  think  I  should  choose 
for  him  the  science  course.  The  late  Professor  Hux- 
ley thought  it  was  a  most  self-evident  proposition  that 
the  educational  training  for  persons  who  proposed  to 
enter  the  medical  profession  should  be  largely  scien- 
tific; not  merely  or  even  principally  because  an  ac- 
quaintance with  the  elements  of  physical  and  biologi- 
cal science  is  absolutely  essential  to  the  comprehension 
of  human  physiology  and  pathology;  but  still  more  be- 
cause of  the  value  of  the  discipline  afforded  by  prac- 
tical work  in  these  departments  in  the  process  of  ob- 
ser\ation  and  experiment,  in  inductive  reasoning  and 
in  manipulation. 

The  subjects  in  the  science  curriculum  might  be 
specially  selected  for  the  future  medical  student.  Of 
course  it  may  be  said  in  favor  of  the  arts  course  that 
many  of  the  subjects,  such  as  physics  and  chemistry, 
constitute  part  of  the  curriculum;  but  then  calculate 
the  loss  to  the  future  surgeon  of  that  training  of  the 
hand  and  eve  which  would  lead  him  up  to  be  a  skilled 
operator;  or  to  the  scientific  physician  whose  compli- 
cated instruments  of  precision  employed  in  the  diag- 
nosis of  disease  need  some  mechanical  knowledge  for 
both  their  use  and  repair — besides  the  number  of 
those  has  been,  increasing  in  number  and  complexity 
with  the  increase  of  scientific  know-ledge. 

But  can  we  not  make  a  new  departure,  can  we  not 
urge  that  a  special  scientific  education  be  arranged  by 
the  universities  for  those  who  desire  to  enter  the  med- 
ical profession  ?  Such  a  course  would  embrace  ele- 
mentary Latin  and  Greek,  French  and  German, 
physics,  chemistry,  biology,  psychology,  elementary 
mechanics,  a  practical  laboratory  course  on  electri- 
city and  drawing.  After  two  years'  study  this  might 
entitle  the  successful  candidate  to  the  degree  of  li- 
centiate in  science. 

Something  of  this  kind  has  been  recently  attempted 
in  the  University  of  McGill.  By  a  special  arrange- 
ment with  the  faculty  of  arts  it  is  now  possible  for 
students  to  obtain  the  degree  of  B.A.  along  with 
M.D.,  CM.,  after  only  six  years  of  study.  It  has 
been  decided  to  allow  the  primary  subjects  (anatomy, 
physiology,  and  chemistry)  in  medicine  to  count  as 
subjects  of  the  third  and  fourth  years  in  arts.  It  fol- 
lows, then,  that  at  the  end  of  four  years'  study  a  stu- 
dent may  obtain  his  B.A.  degree  and  have  two  years 
of  his  medical  course  completed.  The  last  two  years 
of  study  are  of  course  devoted  to  the  third  and  fourth 
year  subjects  in  medicine.  A  certificate  of  licentiate 
in  arts  will  be  given  along  with  the  professional  de- 
gree in  medicine  to  those  who  previous  to  entrance 
upon  their  professional  studies  proper  have  completed 
two  years  in  the  faculty  of  arts,  and  have  fully  passed 
the  prescribed  examinations  therein.  By  this  plan 
also  during  the  first  two  years  of  the  arts  course  the 
medical  student  practically  completes  his  studies  in 
physics,  chemistry,  botany,  and  elementary  psychology. 
This  scheme  is  still  in  the  experimental  stage,  Ijut 
there  is  every  reason  to  believe  that  it  will  result  sat- 
isfactorily. What  deters  so  many  from  taking  a  full 
course  in  arts  or  science  before  entering  medicine  is 
the  length  of  time  consumed  before  the  doctorate  de- 
gree  is  reached,  although   I   hope  the  time  is  not  far 


distant  when  every  graduate  in  medicine  in  Canada 
shall  of  necessity  be  also  a  graduate  in  arts  or  science. 
I  might  state  that  the  standard  for  the  ordinary  matric- 
ulation examination  for  entrance  to  medicine  exacted 
by  all  universities  and  licensing  boards  in  this  coun- 
try is,  with  one  or  two  exceptions,  very-  high.  I  doubt 
if  the  requirements  in  this  way  of  the  Medii  al  Coun- 
cil of  Great  Britain  are  any  higher. 

Now  as  to  the  purely  professional  portion  of  medi- 
cine, I  might  state  that  we  have  in  the  Dominion  of 
Canada  no  fewer  than  eleven  medical  schools,  includ- 
ing one  for  women  only,  all  having  the  power  of  grant- 
ing degrees  and  all  connected  directly  or  by  affiliation 
with  university  bodies.  To  enumerate  them;  Begin- 
ning with  the  Atlantic  provinces,  we  have  in  Halifax 
the  medical  school  attached  to  Dalhousie  L'niversity, 
the  only  medical  school  in  the  Maritime  Provinces; 
in  this  province  there  are  four  schools,  La\al  in  Que- 
bec, Laval  in  Montreal,  Mc(iill  and  Bishop's  in  Mon- 
treal; in  Ontario,  four  schools,  namely,  the  Royal 
College  of  Physicians  and  Surgeons,  Kingston;  the 
University  of  Toronto  Medical  Faculty,  Trinity  Med- 
ical College,  and  the  Ontario  Women's  Medical  Col- 
lege, in  Toronto;  in  London,  Ontario,  the  Western 
University  Medical  Faculty;  and  lastly,  in  Winnipeg, 
the  Manitoba  University  Faculty  of  Medicine.  All 
told,  we  had  in  Canada,  during  the  last  winter  session, 
two  hundred  and  eighty-six  teachers,  including  profes- 
sors, lecturers,  and  demonstrators,  and  seventeen 
hundred  and  thirty-six  students.  The  tendency  for 
the  past  two  years  has  been  to  increase  the  teach- 
ing staff  quite  out  of  proportion  to  the  increased  num- 
ber of  students.  Taking  McCiill,  we  find  that  there 
are  in  the  present  year  fifty-three  teachers  for  three 
hundred  and  eighty-eight  students,  being  a  proportion 
of  nearly  one  to  eight.  Laval,  in  Montreal,  has  thirty- 
six  teachers  and  one  hundred  and  ninety-seven  stu- 
dents, a  still  greater  proportion.  The  Toronto  School 
of  Medicine  had  during  the  past  year  forty-one  teach- 
ers and  two  hundred  and  ninety-three  students. 
We  find  that  this  proportion  compares  well  with  the 
larger  schools  in  the  United  States;  thus,  in  1893, 
there  were  in  Harvard  Medical  School  seventy-one 
teachers  to  look  after  four  hundred  and  seventy-one 
students;  at  the  Columbia  Medical  College  in  New- 
York  with  six  hundred  and  sixty-one  students  there 
were  one  hundred  and  five  teachers  (one  to  six)  ;  in  the 
Universit)-  of  Penn.sylvania  the  teaching  staff  in  the 
same  year  comprised  only  eighty-four  members  with 
eight  hundred  and  twenty-five  students,  being  a  little 
over  one  to  ten.  What  does  this  mean  ?  Ten  years 
ago,  when  McGill  had  two  hundred  and  thirty-seven 
students,  a  staff'  of  twenty-three  professors  and  demon- 
strators was  considered  sufficient.  Why  are  so  many 
more  thought  necessary  nowadays?  The  number  of 
subjects  taught  has  not  increased  very  much.  The 
answer  is  that  the  subjects  are  differently  taught;  the 
old-fashioned  daily  didactic  lectures  are  now-  given 
two  or  three  times  a  week  only;  although  I  should  be 
sorry  to  see  them  further  reduced  in  nimiber,  I  believe 
that  so  many  are  absolutely  necessary.  It  is  in  the 
dissecting-room,  the  chemical,  physiological,  thera- 
peutical, and  pathological  laboratories,  that  we  see  the 
change.  These  which  before  were  for  the  most  part 
only  "  side  shows  "  are  now  made  to  hum  with  the  prac- 
tical work  which  is  done  within  them,  while  demon- 
strators are  moving  about  busily  engaged  in  examin- 
ing and  instructing. 

In  clinical  teaching  also  we  have  made  marked  ad- 
vances. A  creation  of  the  last  few  years  is  the  clini- 
cal demonstrator,  who  takes  small  classes  of  students 
into  the  wards  or  the  out-door  departments  of  our  hos- 
pitals and  gives  them  that  "  bedside  instruction " 
which  is  so  essential,  leaving  the  clinical  professor 
to  deal  with  the  full  classes  in  the  lecture  or  operating 


3^2 


MEDICAL    RECORD. 


[September  4,  1897 


room.  Thus  each  student  is  enabled  personally  to  ex- 
amine the  case,  to  study  the  physiognomy  of  disease, 
and  to  make  deliberate,  thorough,  and  systematic  ex- 
aminations. He  thus  learns  to  use  his  special  senses 
and  gets  into  careful  habits  of  observation,  which,  once 
thoroughly  acquired,  will  be  found  to  contribute  large- 
ly to  future  success.  Wnh  this  in  view  we  encourage 
students  to  attend  the  out-patient  department  of  the 
hospitals  as  early  as  the  second  year. 

In  order  to  make  the  clinical  instruction  more  com- 
plete and  more  thorough,  chemical  and  bacteriological 
laboratories  have  been  added  to  the  pathological  de- 
partments of  our  hospitals.  Thus  it  will  be  seen  that 
laboratory  methods  everywhere  prevail,  all  with  the 
idea  of  developing  the  scientific  spirit  in  students  and 
of  cultivating  methods  of  thought  with  obser\-ation. 

The  question  sometimes  arises,  however:  May  the 
student  not  be  getting  too  much  of  a  good  thing?  Is 
it  not  possible  that  laboratory  teaching  may  be  over- 
djne? — because,  as  Welsh  very  truly  says:  "'The  stu- 
dent whose  knowledge  of  a  subject  is  derived  exclu- 
sively from  laboratory  courses  is  likely  to  lo.se  his 
perspective  in  details,  to  acquire  only  a  fragmentary 
knowledge  of  the  subject,  to  fail  to  comprehend  the 
general  bearing  of  observed  facts;  and  not  to  acquire 
the  general  principles  and  systematic  conceptions 
which  are  essential.  Laboratory  work  should  be  ac- 
companied and  supplemented  by  the  reading  of  text- 
books and  by  lectures."  I  am  convinced  that  with 
us  in  Canada  laboratory  work  is  not  overdone,  but,  on 
the  contrary,  in  some  departments  needs  and  deserves 
further  encouragement.  I  hope  every  laboratory  teacher 
in  the  country  realizes  that  the  object  of  a  college  is 
to  give  a  good  general  education,  and  not  to  make  ex- 
perts in  various  branches.  I  have  long  felt  myself, 
however,  that  the  didactic  lectures  were  being  unfairly  ' 
dealt  with.  There  is  a  feeling  abroad  that  they  should 
be  practically  elbowed  out  of  sight.  I  think  the  di- 
dactic lecture  has  its  place  in  the  medical  course; 
and  while  I  quite  feel  that  the  old  plan  of  compelling 
students  to  listen  to  five  didactic  lectures  a  week  in 
all  of  the  great  subjects  was  a  mistake,  I  still  feel  that 
a  good  lecturer  can  teach  in  this  way  a  certain  some- 
thing which  cannot  be  imparted  by  practical  instruc- 
tion or  by  recitations.  The  personal  influence  of  a 
good  lecturer  very  often  makes  an  impression  which 
nothing  else  can  make;  and  if  such  lectures  are  made 
also  demonstrative,  as  by  the  u,se  of  diagrams,  the  lan- 
tern, experiments,  etc.,  they  must  of  necessity  fill  a 
very  important  place  in  the  medical  course. 

Hygiene  is  at  last  receiving  in  this  country  the  at- 
tention which  its  importance  demands:  all  medical 
schools  in  Canada  have  facilities  for  teaching  it.  In 
McGill  University  the  scope  of  the  teaching  of  hy- 
giene has  been  vastly  extended,  thanks  to  the  gener- 
ous endowment  of  that  department  recently  by  the 
chancellor,  the  Right  Hon.  Lord  Strathcona  and 
Mount  Royal.  The  subject  can  now  be  taught  in  a 
scientific  and,  at  the  same  time,  eminently  practical 
manner.  There  will  he  three  teachers  associated  with 
the  professor  himself,  viz.,  the  heads  of  the  depart- 
ments of  practical  chemistry,  of  pathologv,  and  of 
bacteriology. 

Tills  is  following  very  much  the  German  system, 
also  adopted  by  the  University  of  Pennsylvania,  the 
chemical  and  bacteriological  aspects  of  the  subject 
being  regarded  as  really  the  most  important.  An  ex- 
tensive working  museum,  witii  sanitary  apparatus  of 
every  kind,  forms  part  of  the  scheme,  and  will  doubt- 
less add  greatly  to  the  efficiency  of  the  course  when 
it  is  completed.  Should  the  experiment  succeed  you 
will  be  rejoiced  to  hoar  at  no  distant  date  that  the 
other  schools  in  (^anatla  have  followed  the  lead  of 
their  elder  sister. 

I   fear   I   have  given  you  a  very  imperfect  idea  of 


medical  education  in  Canada;  and  it  may  be  charged 
against  me  that  I  have  been  partial  in  my  description 
to  my  own  university:  but  I  assure  you  that  such  was 
farthest  from  my  thoughts.  The  medical  faculty  of 
McGill  University  has  the  right  of  seniority  and 
might  fairly,  I  think,  be  taken  as  a  type  of  Canadian 
medical  schools.  Be  assured  there  is  no  mean  spirit 
of  rivalry'  abroad.  We  are  all  working  with  one  ob- 
ject only,  the  advancement  of  medicine  in  Canada. 
The  teaching  facilities  of  some  medical  schools  in  this 
country  may  be,  and  are  actually  greater  than  others, 
owing  to  the  munificence  of  citizens,  and  the  school  at- 
tached to  McGill  is,  I  am  happy  to  say,  in  that  posi- 
tion ;  but,  although  assistance  has  been  rendered  in 
a  general  way,  with  two  exceptions  the  chairs  are  still 
unendowed.  Yet  we  have  great  expectations  which  we 
hope  will  be  realized  in  the  near  future.  Let  us  hope 
that  our  sister  universities  throughout  Canada  will  be 
equally  fortunate  ;  so  that  before  long  we  shall  be  able 
to  report  that  we  are  all  marching  abreast  equally 
equipped. 

The  facilities  for  clinical  teaching  in  the  larger 
cities  of  Canada  are  admirable.  Speaking  for  the  city 
of  Montreal,  we  have  in  the  five  general  hospitals,  the 
Hotel  Dieu,  Montreal  General,  Notre  Dame,  Royal 
Victoria,  and  Western  Hospitals  nearly  eight  Iiundred 
beds.  The  number  of  students  attending  the  three 
medical  schools  was,  last  session,  six  hundred  and 
forty-six;  and  considering  that  only  about  half — those 
of  the  third  and  fourth  years — have  access  to  the  wards, 
there  will  be  at  least  two  beds  for  each  student.  The 
number  of  outdoor  patients  attending  the  five  hospitals 
daily  would  aggregate  at  least  three  hundred,  so  that 
there  could  be  no  possible  cause  for  complaint  regard- 
ing both  the  quantity  and  quality  of  clinical  material 
availaiile  in  this  city. 

While  on  the  subject  of  hospitals,  I  would  take  this 
opportunity  of  saying  that  the  training-schools  at- 
tached to  the  larger  English  hospitals  are  in  a  very- 
flourishing  condition  and  are  found  to  contribute  not 
a  little  toward  the  thoroughness  of  the  practical  teach- 
ing. It  was  my  intention  to  have  referred  at  some 
length  to  the  whole  question  of  nurses  and  nursing, 
but  the  limits  of  this  address  forbid.  I  might  say, 
however,  while  as  a  profession  we  feel  the  absolute 
necessity  for  the  training-school,  and  thoroughly  ap- 
preciate the  services  of  the  well-trained  nurse,  both 
in  hospital  and  in  private  practice,  there  is  the  fear 
that  the  supply  may  soon  exceed  the  demand.  A  pro- 
ject is  on  foot  now,  however,  whicii  may  delay,  if  not 
actually  prevent,  such  a  result.  I  refer  to  the  recent 
establishment  by  that  most  estimable  and  charitable 
woman,  the  Countess  of  .\berdeen,  of  the  Victorian 
Order  of  Nurses — another  outcome  of  the  jubilee  of 
our  beloved  (lueen.  Her  Excellency's  idea  in  estab- 
lishing this  order  is  to  supply  the  sparsely  settled 
parts  of  our  great  Northwest,  the  outlying  districts  of 
Canada  generally,  and  the  poor  in  towns  and  cities 
with  nursing  aid.  In  this  great  work  hundreds  of 
nurses  will  in  time  be  employed.  The  rcheme,  which 
is  purely  non-sectarian,  and  appeals  to  all.  irrespec- 
tive of  nationality,  when  thoroughly  worked  cut  and 
more  generally  understood  will  become  one  of  our  na- 
tional institutions.      Let  us  wish  it  every  success. 

Medical  Legislation  in  Canada. —  Time  will  not  per- 
mit of  my  discussing  the  subject  of  medical  legislation 
in  Canada  at  any  length;  and  besides  you  will  find  it 
very  fully  treated  in  the  excellent  official  guide  oi 
souvenir,  prepared  for  you  by  the  executive  committee. 
In  addition  I  might  explain,  however,  that  when  the 
British  American  jirovincos  became  confederated  in 
1867,  under  the  British  Xorih  America  act,  the  gov- 
ernance of  educational  matters  was  taken  awaj-  from 
the  federal  authorities  and  handed  over  to  the  prov- 
inces, each  to  look  after  them  in  its  own  way.    In  con- 


September  4,  1897] 


MEDICAL    RECORD. 


333 


sequence  we  ha\e  since  had  a  curious  complexity  of 
medical  legislation,  there  being  practically  no  uni- 
formity among  the  provinces  in  regard  to  standard 
of  study  or  qualification  for  practice.  Each  province 
has  its  own  medical  board  or  medical  council,  as  the 
case  may  be,  which  has  the  power  to  grant  license  to 
practise  either  after  examination  or  on  simply  present- 
ing the  diploma  of  certain  recognized  uni\ersities.  In 
the  provinces  of  Ontario  and  Kritish  Columbia  an  ex- 
amination is  exacted;  in  the  others  the  license  is  given 
under  certain  restrictions  on  presentation  of  the  de- 
gree, although  in  the  Maritime  Provinces  an  examin- 
ing-board  is  now  about  to  be  established.  In  this  wa\. 
as  can  readily  be  seen,  a  Chinese  wall  is  built  round 
each  province,  and  the  frontier  is  carefully  guarded,  su 
that  it  is  unsafe  for  a  medical  man  to  pass  from  one 
to  the  other  unarmed  with  a  license,  because  of  the 
risk  of  fine  or  even  imprisonment.  Such  a  condition 
of  affairs  is  hardly  credible  and  probably  exists  no- 
where else  to  the  same  extent.  What  is  the  remedy.' 
Two  remedies  have  been  suggested — either  the  estalj- 
lishment  of  a  central  examining-board  in  each  prov- 
ince, with  a  uniform  standard  of  matriculation  and  a 
uniformly  high  standard  of  curriculum,  which  siiall  in 
time  lead  up  to  a  general  scheme  of  reciprocity;  or, 
secondly,  a  dominion  examining-board.  'I'he  first 
scheme  is  at  present  under  serious  consideration,  al- 
though there  are  many  difficulties  in  the  way  of  its 
accomplishment,  none  of  which  is  insuperable,  how- 
ever, providing  a  spirit  of  conciliation  prevails.  'Jlie 
second  alternative  (a  dominion  e.xamining-board) 
would  in  many  respects  be  more  desirable,  because 
not  only  could  the  licentiate  practise  in  any  part  of 
the  dominion,  but  he  could  register  in  Great  Britain, 
and  thus  receive  recognition  all  over  the  empire.  As 
you  are  doubtless  aware,  we,  as  a  profession,  suffer  in 
this  country  from  being  inhabitants  of  provinces  which 
are  confederated.  In  an  enactment,  now  of  some 
twelve  years'  standing,  the  British  Medical  Council 
decided,  in  effect,  to  recognize  the  degrees  of  univer- 
sities situated  in  autonomous  provinces  only.  As  a 
consequence,  Australians  obtain  privileges  which  are 
denied  to  us,  they  being  permitted  to  register  in  Great 
Britain  without  examination.  We  are  being  punished 
for  belonging  to  a  colony  whose  form  of  government 
is  recognized  to  be  in  advance  of  theirs  and  likely  to 
be  imitated  by  them.  Let  me  give  our  Australian  breth- 
ren a  hint:  if  the  confederation  of  your  provinces  be 
in  contemplation,  see  to  it  that  all  matters  of  profes- 
sional education  are  left  in  the  hands  of  the  central 
government,  at  least  as  far  as  qualification  for  regis- 
tration is  concerned.  By  so  doing  you  will  avoid  the 
almost  inextricable  tangle  in  which  we  in  Canada  find 
ourselves.  Let  common-school  education  go  to  the 
various  pro\inces  if  you  will,  but  for  the  profession 
of  medicine  (and  doubtless  law  also)  there  should  be 
a  uniform  .standard  of  matriculation,  a  uniform  cur- 
riculum of  medical  studies,  and  one  central  examining 
and  registering  board,  composed  of  the  best  men  from 
all  the  universities.  We  hope  in  Canada  to  reach 
that  ideal  at  no  distant  date:  in  fact  1  have  the  very 
best  authority  for  stating  that  it  is  not  impossible  of 
accomplishment.  Some  scheme  of  reciprocity  first  ar- 
ranged would  doubtless  make  the  task  less  difficult, 
but,  failing  that,  our  duty  is  to  arrange  for  some  legis- 
lation which  sh4ll  give  our  better  and  more  ambitious 
students  an  opportunity  of  passing  a  dominion  licens- 
ing-board  (or  whatever  it  maybe  called)  which  shall 
give  the  privilege  of  practising  their  profession  not 
only  in  any  part  of  their  native  country,  but  in  any 
part  of  the  world  over  which  the  British  Hag  flies. 
Such  a  scheme  need  not  interfere  in  any  way  with  tiu- 
autonomy  of  the  provinces.  Each  may  still  retain  its 
provincial  board  for  the  purpose  of  examining  and  is- 
suing licenses  to  those  candidates  who  are  satisfied  x<.i 


practise  their  profession  in  the  limited  sphere  of  their 
own  provinces.  I  think  the  legislators  of  this  country 
will  some  day  (and  not  far  distant  either)  be  induced 
to  see  that  the  system  which  at  present  obtains  is  un- 
worthy of  a  great  and  growing  country. 

In  conclusion,  allow  me  to  express  the  hope  that 
the  arrangements  made  by  the  executive  committee  for 
the  entertainment  of  our  guests  may  meet  with  appre- 
ciation and  approval,  and  that  the  memories  of  the 
brief  sojourn  here  may  be  all  that  is  bright  and  happy. 
The  loyalty  and  unanimity  with  which  the  profession 
throughout  the  dominion  has  co-operated  with  us  in 
Montreal  to  make  this  meeting  of  the  British  Medical 
Association  a  success  from  every  point  of  view,  deserve 
and  receive  our  heartiest  thanks.  We  are  also  greatly 
indebted  for  the  kind  and  ready  assistance  of  the  do- 
minion government,  the  Quebec  government,  and 
the  civic  government  of  Montreal.  Our  hands  have 
been  strengthened  and  the  cause  we  have  so  much  at 
heart  has  been  furthered  by  the  active  good  will  of  the 
country's  official  representatives. 

One  word  more :  It  is  a  good  thing  to  be  here  to- 
day, in  the  midst  of  this  great  gathering  so  full  of 
power  and  vigor.  The  fruits  of  such  a  gathering 
should  be  tangible,  enduring,  not  ephemeral,  not  for 
to-day,  but  for  all  time.  To  our  kinsmen  from  beyond 
the  great  seas  let  me  express  the  earnest  hope  that  in 
the  future  our  kinsiiip  will  be  a  more  real  and  living 
thing  than  in  the  past.  We  are  members  of  one  great 
family,  members  one  of  another,  in  a  peculiar  and  very 
real  sense.  Let  that  once  be  recognized,  and  the 
statesman's  task  will  be  an  easy  one.  In  more  than 
words  has  Canada  shown  henself  worthy  of  her  high 
heritage,  worthy  of  a  part  in  the  empire,  worthy  to 
share  in  its  trials  and  its  triumphs.  We,  who  know 
her  history,  can  say  with  well-founded  confidence: 

"  So  in  the  long  hereafter  this  Canada  shall  he 
The  worthy  heir  of  British  power  and  British  liberty; 
Spreading  the  blessings  of  her  sway  to  her  remotest  bounds, 
While  with  the  fame  of  her  fair  name  a  continent  resounds. 
True  to  her  high  traditions,  to  Britain's  ancient  glory, 
Of  patient  saint  and  martyr,  alive  in  deathless  story; 
Strong  in  their  liberty  and  truth  to  shed  from  shore  to  shore 
.\  light  among  the  nations  till  nations  are  no  more." 


BRITISH    MEDICINE    IN    GREATER 
BRITAIN.' 

By   WILLIAM    O.SLEK,    M.IX,    F.K.C.K. 


The  Making  of  Greater  Britain.— To  trace  success- 
fully the  evolution  of  an\-  one  of  the  learned  profes- 
sions would  require  the  hand  of  a  inaster,  of  one  who, 
like  Darwin,  could  combine  the  capacity  for  patient 
observation  with  philosophic  vision.  In  the  case  of 
medicine  the  difficulties  are  enormously  increased  by 
the  extraordinary  development  which  belongs  to  the 
history  of  the  present  century.  The  rate  of  progress 
has  been  too  rapid  for  us  to  appreciate,  and  we  stand 
bewildered,  and,  as  it  were,  in  a  state  of  intellectual 
giddiness,  when  we  attempt  to  obtain  a  broad,  compre- 
hensive view  of  the  subject.  In  a  safer  "middle 
flight"  it  is  my  purpose  to  dwell  on  certain  of  the  fac- 
tors which  have  moulded  the  profession  in  English- 
speaking  lands  beyond  the  narrow  seas — of  British 
medicine  in  Greater  Britain.  Even  for  this  lesser 
task  (though  my  affiliations  are  wide  and  my  sympa* 
thies  deep)  I  recognize  the  limitations  of  my  fitness, 
and  am  not  unaware  that  in  my  ignorance  I  shall 
overlook  much  which  might  have  rendered  less  sketchy 
a  sketch  necessarily  imperfect. 

'  The  address  in  medicine  delivered  at  the  annual  meeting  of 
the  British  Medical  Association,  .Montreal,  September  i,  1897. 


334 


MEDICAL    RI>:CORD. 


[September  4,  1897 


Kvolution  advances  by  such  slow  and  imperceptible 
degrees  that  to  those  who  are  part  of  it  the  linger  of 
time  scarcely  seems  to  move.  Kven  the  great  epochs 
are  seldom  apparent  to  the  participators.  During  the 
last  century  neither  the  colonists  nor  the  mother  coun- 
try appreciated  the  thrilling  interest  of  the  long-fought 
duel  for  the  possession  of  this  continent.  ["he  acts 
and  scenes  of  the  drama,  to  them  detached,  isolated, 
and  independent,  now  glide  like  dissolving  views  into 
each  other,  and  in  the  vitascope  of  history  we  can  see 
the  true  sequence  of  events.  That  we  can  meet  here 
to-day,  Britons  on  British  soil  in  a  P'rench  province, 
is  one  of  the  far-off  results  of  that  struggle.  This  was 
but  a  prelude  to  the  otiier  great  event  of  the  eighteenth 
century,  the  revolt  of  the  colonies  and  the  founding  of 
a  second  great  English-speaking  nation—  in  the  words 
of  Bishop  Berkeley's  prophecy,  "  Time's  noblest  ofif- 
spring." 

Surely  a  unique  spectacle,  that  a  centur}^  later  de- 
scendants of  the  actors  of  these  two  great  dramas 
should  meet  in  an  English  city  in  New  France.  Here 
the  American  may  forget  V'orktown  in  Louisberg,  the 
Englishman  Bunker  Hill  in  Quebec,  and  the  French- 
man both  Louisberg  and  Quebec  in  Chataquay ;  while 
we  Canadians,  English  and  French,  in  a  forgiving 
spirit,  overlooking  your  unseemly  quarrels,  are  only 
too  happy  to  welcome  you  to  our  country,  this  land  on 
which,  and  for  which,  you  have  so  often  fought.  Once 
and  onlv  once  before  in  the  history  of  the  world  could 
such  a  gatliering  as  this  have  taken  place.  Divided 
though  the  f Greeks  were,  a  Hellenic  sentiment  of  ex- 
traordinary strength  united  them  in  certain  assemblies 
and  festivals.  No  great  flight  of  imagination  is  re- 
quired to  picture  a  notable  representation  of  our  pro- 
fession in  the  fifth  century  r..c.  meeting  in  such  a 
colonial  town  as  Agrigentum  under  the  presidency  of 
Empedocles.  Delegates  from  the  mother  cities,  bril- 
liant predecessors  of  Hippocrates  of  the  stamp  of 
Damocedes  and  Herodicus,  delegates  from  the  sister 
colonies  of  Syracuse  and  other  Sicilian  towns,  from 
neighboring  Italy,  from  far  distant  Massilia,  and  from 
still  more  distant  Pauticapreum  and  Istria.  And  in 
such  an  assemblage  tiiere  would  have  been  men  ca- 
pable of  discussing  problems  of  life  and  mind  more 
brilliantly  than  in  many  subsequent  periods,  in  pro- 
portion as  the  pre-Hippocratic  philosophers  in  things 
medical  had  thought  more  deeply  than  many  of  those 
who  came  after  them. 

We  English  are  the  modern  Greeks,  and  we  alone 
have  colonized  as  they  did,  as  free  people.  There 
have  been  other  great  colonial  empires,  Phoenician, 
Roman,  Spanish,  Dutch,  and  French,  but  in  civil  lib- 
erty and  in  intellectual  freedom  Magna  Gra;cia  and 
Greater  Britain  stand  alone.  The  parallel  so  often 
drawn  between  them  is  of  particular  interest  with 
reference  to  the  similarity  between  the  Greek  settle- 
ments in  Sicily  and  the  English  plantations  on  the 
Atlantic  coast.  Indeed,  Freeman  says,  "  I  can  never 
think  of  America  without  something  suggesting  Sicily, 
or  of  Sicily  without  something  suggesting  America." 
I  wish  to  use  the  parallel  only  to  emphasize  two 
points,  one  of  difference  and  one  of  resemblance. 
Tlie  Greek  colonist  took  Greece  with  him.  Hellas 
had  no  geographical  bounds.  "Massilia  and  Obia 
were  cities  of  Hellas  in  as  full  a  sense  as  Atliens  or 
Sparta."  While  the  emigrant  Britons  changed  their 
sk)',  not  their  character,  in  crossing  the  great  sea,  yet 
the  home  stayers  had  never  the  same  feelings  toward 
the  plantations  as  the  Greeks  had  toward  the  colonial 
cities  of  Magna  Gracia.  If.  as  has  been  shrewdly  sur- 
mised, Professor  Seely  was  Herodotus  reincarnate,  how 
grieved  the  spirit  of  the  "  Father  of  Historv"  must 
have  been  to  say  of  Englishmen,  "  N'or  have  we  even 
now  ceased  to  think  of  ourselves  as  simply  a  race  in- 
habiting an  island  off  the  northern  coast  of  the  conti- 


nent of  Europe."  The  assumption  of  gracious  supe- 
riority which,  unless  carefully  cloaked,  smacks  just  a 
little  of  our  national  arrogance,  is  apt  to  jar  on  sensi- 
tive colonial  nerves.  With  the  expansion  of  the  em- 
pire, and  the  supplanting  of  a  national  by  an  imperial 
spirit,  this  will  become  impossible.  That  this  senti- 
ment never  prevailed  in  Hellas,  as  it  did  later  in  the 
Roman  empire,  was  due  largely  to  the  fact  that  in 
literature,  in  science,  and  in  art  the  colonial  cities  of 
Greece  early  overshadowed  the  mother  cities.  It  may 
be  because  the  settlements  of  Greater  Britain  were 
things  of  slower  growth  that  it  took  several  genera- 
tions and  several  bitter  trials  to  teach  a  lesson  the 
Greeks  never  had  to  learn. 

The  Greek  spirit  was  the  leaven  of  the  old  world, 
the  workings  of  which  no  nationality  could  resist. 
Thrice  it  saved  Western  civilization,  for  it  had  the 
magic  power  of  leading  captivit)-  captive,  and  making 
even  captive  conquerors  the  missionaries  of  culture. 
What  modern  medicine  owes  to  it  will  appear  later. 
■■  The  love  of  science,  the  love  of  art,  the  love  of  free- 
dom, vitally  correlated  to  each  other  and  brought  into 
organic  union,"  were  the  essential  attributes  of.  the 
Greek  genius  (Butcher).  While  we  cannot  claim  for 
the  Anglo-Saxon  race  all  of  these  distinctions,  it 
has  in  a  high  degree  that  one  which  in  practical  life 
is  the  most  valuable,  and  which  has  been  the  most 
precious  gift  of  the  race  to  the  world — the  love  of 
freedom — 

"of  freedom  in  her  reg.'il  ^eat 
Of  P'.njrland." 

It  would  carry  one  too  far  afield  to  discuss  the  dif- 
ference between  the  native  Briton  and  his  children 
scattered  so  widely  up  and  down  the  earth.  In  Can- 
ada, South  Africa,  Australia,  and  New  Zealand  tj'pes 
of  the  .\nglo-Saxon  race  are  developing  which  will 
differ  as  much  from  each  other  and  from  the  English 
as  the  American  does  to-day  from  the  original  stock; 
but  amid  these  differences  can  everywhere  be  seen 
those  race  qualities  which  have  made  us  what  we  are 
—  "courage,  national  integrity,  steady  good  sense,  and 
energy  in  work."  At  a  future  meeting  of  the  associa- 
tion, perhaps  in  Australia,  a  professional  Sir  Charles 
Dilke,  with  a  firm  grasp  on  the  subject,  may  deal  with 
the  medical  problems  of  Greater  Britain  in  a  manner 
worthy  of  the  address  in  medicine.  My  task,  as  I 
mentioned  at  the  outset,  is  much  less  ambitious. 

The  Influence  of  Greece  on  Britain Could  some 

one  with  full  knowledge  patiently  analyze  the  charac- 
teristics of  British  medicine  he  would  find  certain 
national  traits,  sufficiently  distinct  for  recognition. 
Three  centuries  cannot  do  very  much — and  that  pe- 
riod has  only  just  passed  since  the  revival  of  medicine 
in  England — but  the  local  conditions  of  isolation, 
which  iiave  been  singularly  favorable  to  the  develof>- 
ment  of  special  peculiarities  in  the  national  character, 
have  not  been  without  effect  on  the  medical  profes- 
sion. I  cannot  do  more  than  touch  upon  a  few  fea- 
tures, not  distincti\e  but  illustrative — features  which 
will  be  useful  as  indicating  the  sources  of  infiuence 
upon  (Greater  Britain  in  the  past,  and  which  may,  per- 
haps, be  suggestive  as  to  lines  of  progress  in  the  future. 

Above  the  fireplace  in  Sir  Henry  ,\cland's  study  are 
three  panelled  portraits  of  Linacre,  Sydenham,  and 
Harvey:  the  scroll  upon  them  reads:  '' j.ifi-m.  J'r,j.xis, 
SiirnOi!."  To  this  great  triumvirate^  as  to  the  foun- 
tainhead>.  we  may  trace  the  streams  of  inspiration 
which  have  made  British  medicine  what  it  is  to-day. 

Linacre,  the  type  of  the  literarj'  physician,  must 
ever  hold  a  unique  place  in  the  annals  of  our  profes- 
sion. To  him  was  due  in  great  measure  the  revival 
of  Greek  thought  in  the  sixteenth  century  in  England, 
and  in  the  la.st  Haneian  oration  Dr.  Payne  has  pointed 
out  his  importance  as  a  forerunner  of  Harvey.  He 
made  Greek  methods  available;    through  him  the  art 


September  4.  1^97] 


MEDICAL    RPXORD. 


335 


of  Hippocrates  and  the  science  of  Galen  became  once 
more  the  subject  of  careful,  first-hand  study.  Linacre, 
as  Dr.  Payne  remarks,  •"was  possessed  from  his  youth 
till  his  death  by  the  enthusiasm  of  learning.  He  was 
an  idealist,  devoted  to  objects  which  the  world  thought 
of  little  use."  Painstaking,  accurate,  critical,  hyper- 
critical, perhaps,  he  remains  to-day  the  chief  literary 
representative  of  British  medicine.  Neither  in  Brit- 
ain nor  in  Greater  Britain  have  we  maintained  the 
place  in  the  world  of  letters  created  for  us  by  Lina- 
cre's  noble  start.  It  is  true  that  in  no  generation 
since  has  the  profession  lacked  a  man  who  might  stand 
unabashed  in  the  temple  at  Delos:  but,  judged  by  the 
fruits  of  learning,  scholars  of  his  type  have  been  more 
common  in  France  and  Germany.  Nor  is  it  to  our 
credit  that  so  little  provision  is  made  for  the  encour- 
agement of  the.se  studies.  For  years  the  reputation  of 
Great  Britain  in  this  matter  was  sustained  almost  alone 
by  the  great  Deeside  scholar,  the  surgeon  of  Banchorj-, 
Francis  Adams,  the  interpreter  of  Hippocrates  to  Eng- 
lish students.  In  this  century  he  and  Greenhill  have 
well  maintained  the  traditions  of  Linacre.  Their 
work,  and  that  of  a  few  of  our  contemporaries,  among 
whom  Ogle  must  be  specially  mentioned,  has  kept  us 
in  touch  with  the  ancients.  But  by  the  neglect  of  the 
study  of  the  humanities,  which  has  been  far  too  gen- 
eral, the  profession  loses  a  very  precious  quality. 

While  in  critical  scholarship  and  in  accurate  his- 
torical studies  British  medicine  must  take  a  second 
place,  the  influence  of  Linacre,  e.xerted  through  the 
Royal  College  of  Physicians  and  the  old  universities, 
has  given  to  the  humanities  an  important  part  in  edu- 
cation, so  that  they  have  moulded  a  larger  section  of 
the  profession  than  in  any  other  country.  A  phy- 
sician may  possess  the  .science  of  Harvey  and  the  art 
of  Sydenham,  and  yet  there  may  be  lacking  in  him 
those  finer  qualities  of  heart  and  head  which  count  for 
so  much  in  life.  Pasture  is  not  everything,  and  that 
indefinable,  though  well  understood,  something  which 
we  know  as  breeding  is  not  always  an  accompaniment 
of  great  professional  skill.  Medicine  is  seen  at  its 
best  in  men  whose  faculties  have  had  the  highest  and 
most  harmonious  culture.  The  Lathams,  the  Watsons, 
the  Pagets,  the  Jenners,  and  the  Gairdners  have  influ- 
enced the  profession  less  by  their  special  work  than 
by  exemplifying  those  graces  of  life  and  refinements 
of  heart  which  make  up  character.  And  the  men  of 
this  stamp  in  Greater  Britain  have  left  the  most  en- 
during mark :  Beaumont,  Bovell,  and  Hodder  in  To- 
ronto; Holmes,  Campbell,  and  Howard  in  this  city; 
the  Warrens,  the  Jacksons,  the  Bigelows.  the  Bow- 
ditches,  and  the  Shattucks  in  Boston ;  Bard,  Hossack, 
Francis,  Clark,  and  Flint  in  New  York;  Morgan. 
Shippen,  Redman,  Rush,  Coxe,  the  elder  Wood,  the 
elder  Pepper,  and  the  elder  Mitchell  in  Philadelphia 
—Brahmins  all,  in  the  language  of  the  greatest  Brah- 
min among  them- — Oliver  Wendell  Holmes — these. 
and  men  like  unto  them,  have  been  the  leaven  which 
has  raised  our  profession  above  the  dead  level  of  a 
business.  The  /i/rnr ////nitj/it/oris.  represented  by  Lin- 
acre, revived  Greek  methods,  but  the  faculty  at  the 
end  of  the  sixteenth  and  the  beginning  of  the  seven- 
teenth centuries  was  in  a  slough  of  ignorance  and  self- 
conceit,  and  not  to  be  aroused  even  by  Moses  and  the 
prophets  in  the  form  of  Hippocrates  and  the  fathers 
of  medicine. 

In  the  pictures  referred  to  Sydenham  is  placed  be- 
tween Linacre  and  Harvey,  but  science  preceded  prac- 
tice, and  Har\ey's  great  Lunileian  lectures  were  de- 
livered before  Sydenham  was  born.  Linacre  has  been 
well  called  by  Payne  Har\-ey's  intellectual  grand- 
father. "  The  discovery  of  the  circulation  of  the  blood 
was  the  climax  of  that  movement  which  began  a  cen- 
tury and  a  half  before  with  the  revival  of  Greek  medi- 
cal classics  and  especially  of  Galen"   (Payne).     Har- 


vey returned  to  Greek  methods  and  became  the  founder 
of  modern  experimental  physiology  and  the  great  glory 
of  British  scientific  medicine.  The  demonstration  of 
the  circulation  of  the  blood  remains  in  every  detail  a 
model  research.  I  shall  not  repeat  the  ofttold  tale 
of  Har\-ey's  great  and  enduring  influence,  but  I  must 
refer  to  one  feature  which,  until  lately,  has  been  also 
a  special  characteristic  of  his  direct  successors  in 
Great  Britain.  Harvey  was  a  practitioner  and  a  hos- 
pital physician.  There  are  gossiping  statements  by 
Aubrey  to  the  effect  that  "he  fell  mightily  in  his 
practice"  after  the  publication  of  the  "  De  Motu  Cor- 
dis," and  that  his  "  therapeutic  way"  was  not  admired; 
but  to  these  his  practical  success  is  the  best  answer. 
It  is  remarkable  that  a  large  proportion  of  all  the 
physiological  work  of  Great  Britain  has  been  done  by 
men  who  have  become  successful  hospital  physicians 
and  surgeons.  1  was  much  impressed  by  a  conversa- 
tion with  Professor  Ludwig  in  1884.  Speaking  of 
the  state  of  English  physiology,  he  lamented  the  lapse 
of  a  favorite  English  pupil  from  science  to  practice; 
but  he  added,  "while  sorry  for  him,  I  am  glad  for  the 
profession  in  England."  He  held  that  the  clinical 
physicians  of  that  country  had  received  a  very  positive 
impress  from  the  work  of  their  early  years  in  physiol- 
ogy and  the  natural  sciences.  I  was  surprised  at  the 
list  of  names  which  he  cited — among  them  I  remem- 
ber Bowman.  Paget,  Savory,  and  Lister.  Ludwig  at- 
tributed this  feature  in  part  to  the  independent  char- 
acter of  the  schools  in  England,  to  the  absence  of  the 
university  element,  so  important  in  medical  life  in 
Germany,  but.  above  all,  to  the  practical  character  of 
the  English  mind,  the  better  men  preferring  an  active 
life  in  practice  to  a  secluded  laboratory  career. 

Thucydides  it  was  who  said  of  the  Greeks  that  they 
possessed  "the  power  of  thinking  before  they  acted 
and  of  acting  too."  The  same  is  true  in  a  high  de- 
gree of  the  English  race.  To  know  first  w'hat  has  to 
be  done,  then  to  do  it,  comprises  the  whole  philosophy 
of  practical  life.  Sydenham  (Aiig/he  liiiru-ti,  as  he  has 
been  well  called )  is  the  model  practical  physician  of 
modern  times.  Linacre  led  Har\-ey  back  to  Galen, 
Sydenham  to  Hippocrates.  The  one  took  Greek  sci- 
ence, the  other  not  so  much  Greek  medicine  as  Greek 
methods,  particularly  intellectual  fearlessness,  and  a 
certain  knack  of  looking  at  things.  Sydenham  broke 
with  authority  and  went  to  nature.  It  is  an  extraordi- 
nary fact  that  he  could  have  been  so  emancipated  from 
dogmas  and  theories  of  all  sorts.  He  laid  down  the 
fundamental  proposition,  and  acted  upon  it,  that  "all 
diseases  should  be  described  as  objects  of  natural  his- 
tory." To  do  him  justice  we  must  remember,  as  Dr. 
John  Brown  says,  "  in  the  midst  of  what  a  mass  of 
errors  and  prejudices,  of  theories  actively  mischie- 
vous, he  was  placed,  at  a  time  when  the  mania  of 
hypothesis  was  at  its  height,  and  when  the  practical 
part  of  his  art  was  overrun  and  stultified  by  vile  and 
silly  nostrums.'" 

Sydenham  led  us  back  to  Hippocrates;  I  would 
that  we  could  be  led  oftener  to  Sydenham.  How  nec- 
essary to  bear  in  mind  what  he  says  about  the  method 
of  the  study  of  medicine.  "  In  writing,  therefore,  such 
a  natural  history  of  diseases,  ever}-  merely  philosophi- 
cal hypothesis  should  be  set  aside,  and  the  manifest 
and  natural  phenomena,  however  minute,  should  be 
noted  with  the  utmost  exactness.  The  usefulenss  of 
this  procedure  cannot  be  easily  overrated  as  com- 
pared with  the  subtle  inquiries  and  trifling  notions  of 
modern  writers,  nor  can  there  be  a  shorter,  or,  indeed, 
any  other  way  of  coming  at  the  morbific  causes,  or  of 
discovering  the  curative  indications,  than  by  a  certain 
perception  of  the  peculiar  symptoms?  By  these  steps 
and  helps  it  was  that  the  father  of  physic,  the  great 
Hippocrates,  came  to  excel,  his  theory  being  no  more 
than  an  exact  description  or  view  of  nature.      He  found 


336 


MliDICAL    REf:ORD. 


[September  4,  1897 


that  nature  alone  terminates  diseases,  and  works  a  cure 
with  a  few  simple  medicines,  and  often  enough  with 
no  medicine  at  all."  Well,  indeed,  has  a  recent  writer 
remarked :  '"  Sydenham  is  unlike  every  previous  teacher 
of  the  principles  and  practice  of  medicine  in  the  mod- 
ern world." 

Sydenham — not  Linacre  or  Harvey — is  the  model 
British  physician,  in  whom  were  concentrated  all 
these  practical  instincts  upon  which  we  lay  such  stress 
in  the  Anglo-Sa.xon  character.  The  Greek  facult}' 
which  we  possess  of  thinking  and  acting  has  enabled 
us,  in  spite  of  many  disadvantages,  to  take  the  lion's 
share  in  the  great  practical  advances  in  medicine. 
The  three  greatest  scientific  movements  of  the  cen- 
tury have  come  from  Germany  and  France.  Bichat, 
Laennec,  and  Louis  laid  the  foundation  of  modern 
clinical  medicine;  Virchow  and  his  pupils  of  scien- 
tific patholog)';  while  Pasteur  and  Koch  have  revolu- 
tionized the  study  of  the  causes  of  disease;  and  yet 
the  modern  history  of  the  art  of  medicine  could  almost 
be  written  in  its  fulness  from  the  records  of  the  Anglo- 
Saxon  race.  We  can  claim  almost  every  practical  ad- 
vance of  the  very  first  rank — vaccination,  anaesthesia, 
preventive  medicine,  and  antiseptic  surgery — the  "  cap- 
tain jewels  in  the  carcanet"  of  the  profession,  beside 
which  can  be  placed  no  others  of  equal  lustre. 

The  Influence  of  Authority  in  Medicine. — One 
other  lesson  of  Sydenham's  life  needs  careful  conning. 
The  English  Hippocrates,  as  I  said,  broke  with  au- 
thority.    His  motto  was: 

"  Thou,  Nature,  art  my  goddess;   to  thy  law 
My  ser\'ices  are  bound.  " 

Undue  reverence  for  authority  as  such,  a  serene  satis- 
faction with  the  status  quo,  and  a  fatuous  objection  to 
change,  have  often  retarded  the  progress  of  medicine. 
In  every  generation,  in  everv'  country,  there  had  been, 
and  ever  will  be,  lauuatores  tctnporis  aiti,  in  the  bad 
sense  of  that  phrase,  not  a  few  of  them  men  in  high 
places,  who  have  lent  the  weight  of  a  complacent  con- 
ser\-atism  to  bolster  up  an  ineffectual  attempt  to  stay 
the  progress  of  new  ideas.  Every  innovator  from 
Harvey  to  Lister  has  been  made  to  feel  its  force. 
The  recently  issued  life  of  Thomas  Wakley  is  a  run- 
ning commentary  on  this  spirit,  against  the  pricks  of 
which  he  kicked  so  hard  and  so  effectually.  But  there 
are  signs  of  a  great  change.  The  old  universities  and 
the  colleges,  once  the  chief  offenders,  have  been  eman- 
cipated, and  remain  no  longer,  as  Gibbon  found  them, 
isteeped  in  port  and  prejudice.  The  value  of  authority 
per  si  has  lessened  enormously,  and  we  of  Greater 
Britain  have  perhaps  suffered  as  the  pendulum  has 
swung  to  the  other  extreme.  Practice  loves  authority, 
as  announced  in  "the  general  and  perpetual  voice  of 
men"  (Hooker").  Science  must  ever  hold  with  Epi- 
charmus  that  a  judicious  distrust  and  a  wise  scepti- 
cism are  the  sinews  of  the  understanding.  And  yet 
the  very  foundations  of  belief  in  almost  everything 
relating  to  our  art  rest  upon  authorit}'.  The  prac- 
titioner cannot  always  be  the  judge,  the  responsibility 
must  often  rest  with  the  teachers  and  investigators, 
who  can  learn  only  in  the  lessons  of  history  the  terri- 
ble significance  of  the  word. 

In  the  treatment  of  fever  the  fetters  of  a  thousand 
years  were  shattered  by  Sydenham — shattered  only  to 
be  riveted  anew.  How  hard  was  the  battle  in  this 
century  against  tlie  entrenched  and  stubborn  foe!  Lis- 
ten to  the  eloquent  pleadings  of  Stokes,  pleading,  as 
did  Sydenham,  against  authority,  and  against  the 
bleedings,  the  purgings,  and  sweatings  of  fifty  years 
ago.  "Though  his  hair  be  gray,  and  his  authority 
high,  he  is  but  a  child  in  knowledge  and  iiis  reputa- 
tion an  error.  On  a  level  with  a  child,  s-o  far  as  cor- 
rect appreciation  of  the  great  truths  of  medicine  is 
concerned,  he  is  very  different  in  other  respects,  his 


powers  of  doing  mischief  are  greater;  he  is  far  more 
dangerous.  Oh !  that  men  would  stoop  to  learn,  or  at 
least  cease  to  destroy."  The  potency  of  human  au- 
thority among  "  the  powers  that  be"  was  never  better 
drawn  than  by  the  judicious  Hooker  in  his  section  on 
this  subject:  "And  this  not  only  with  the  'simpler 
sort,'  but  the  learneder  and  wiser  we  are,  the  more 
such  arguments  in  some  cases  prevail  with  us.  The 
reason  why  the  simpler  sort  are  moved  with  authority 
is  the  conscience  of  their  own  ignorance;  whereby  it 
cometh  to  pass  that,  having  learned  men  in  admira- 
tion, they  rather  fear  to  dislike  them  than  know  where- 
fore they  should  allow  and  follow  their  judgments. 
Contrariwise  with  them  that  are  skilful,  authority  is 
much  more  strong  and  forcible;  because  they  only  are 
able  to  discern  how  just  cause  there  is  why  to  some 
men's  authority  so  much  should  be  attributed.  For 
which  cause  the  name  of  Hippocrates  (no  doubt)  were 
more  effectual  to  persuade  even  such  men  as  Galen 
himself  than  to  move  a  silly  empiric."  ' 

Sydenham  was  called  "  a  man  of  many  doubts,"  and 
therein  lay  the  secret  of  his  great  strength. 

Medicine  in  America  to  1820. — Turning  now  to 
the  main  question  of  the  development  of  this  British 
medicine  in  Greater  Britain,  I  must  at  once  acknowl- 
edge the  impossibility  of  doing  justice  to  it.  I  can 
indicate  only  a  few  points  of  importance,  and  I  must 
confine  my  remarks  chiefly  to  the  American  part  of 
Greater  Britain. 

We  may  recognize  three  periods,  corresponding  to 
three  distinct  waves  of  influence:  the  first  from  the 
early  migrations  to  about  1820;  the  second  from 
about  1820  to  i860;  and  the  third  from  about  i860 
to  the  present  time. 

The  colonial  settlements  were  contemporaneous 
with  the  revival  of  medicine  in  England.  Fellow- 
students  of  Harvey  at  Cambridge  might  have  sailed 
in  the  Alavflower  and  the  Arbella.  The  more  carefully 
planned  expeditions  usually  enlisted  the  services  of  a 
well-trained  physician,  and  the  early  records,  particu- 
larly of  the  New  England  colonies,  contain  many  in- 
teresting references  to  these  college-bred  men.  Giles 
Firman,  who  settled  in  Boston  in  1632,  a  Cambridge 
man,  seems  to  have  been  tiie  first  to  give  instruction 
in  medicine  in  the  new  world.  'I'he  parsons  of  that 
day  had  often  a  smattering  of  physic,  and  illustrated 
what  Cotton  Mather  called  an  '"  angelical  conjunc- 
tion." He  says:  "Ever  since  the  days  of  Luke,  the 
Evangelist,  skill  in  physic  has  been  frequently  pro- 
fessed and  practised  by  persons  whose  more  declared 
business  was  the  study  of  divinity."  Firman  himself 
finding  physic  "  but  a  meane  helpe,"  took  orders. 
These  English  physicians  in  the  New  England  colo- 
nies w-ere  scholarly,  able  men.  Roger  Chillingworth, 
in  Hawthorne's  "Scarlet  Letter,"  has  depicted  tliem 
in  a  sketch  of  his  own  life:  "Made  up  of  earnest, 
studious,  Uioughtful,  quiet  years,  bestowed  faithfully 
for  the  increase  of  knowledge;  faithfully,  too,  for  the 
advancement  of  human  welfare;  men  thoughtful  for 
others,  caring  little  for  themselves,  kind,  just,  true,  and 
of  constant  if  not  warm  affections"^  a  singularly 
truthful  picture  of  the  old  colonial  physician. 

Until  the  establishment  of  medical  schools — Uni- 
versity of  Pennsylvania,  1763;  King's  College  (after- 
wards Columbia),  1767  ;  and  Harvard,  1782 — the  sup- 
ply of  physicians  for  the  colonies  came  from  Great 
iiritain,  supplemented  by  men  trained  under  the  olil 
apprentice  system,  and  of  colonists  who  went  to  Edin- 
burgh, Leyden,  and  London  for  their  medical  educa- 
tion. This  latter  group  had  a  most  powerful  effect  in 
moulding  professional  life  in  the  prerevolutionary 
period.  They  were  men  who  had  enjoyed  not  alone 
the  instruction,  but  often  the  intimate  friendship  of 
the  great  English  and  European  physicians.  Morgan, 
'  "Ecclesiastical  Politv,"  Bk.  ii..  vii.,  2. 


September  4,  1897] 


MEDICAL    RECORD. 


i2>T 


Rush,  Shipper!,  Bard,  VVistar,  Hossack,  and  others  had 
received  an  education  comprising  all  that  was  best  in 
the  period,  and  had  acquired  the  added  culture  which 
can  come  only  from  travel  and  wide  acquaintance  with 
the  world.  Morgan,  the  founder  of  the  medical  school 
of  the  Universit}'  of  Pennsylvania,  was  away  seven 
years,  and  before  returning  had  taken  his  seat  as  a 
corresponding  member  of  the  French  Academy  of  Sur- 
gery, besides  having  been  elected  a  fellow  of  the  Royal 
Society.  The  war  of  independence  interrupted  tempo- 
rarily the  stream  of  students,  but  not  the  friendshi]> 
which  existed  between  CuUen  and  Fothergill  and  their 
old  pupils  in  America.  The  correspondence  of  these 
two  warm  friends  of  the  colonies  testifies  to  the  strong 
professional  intimacy  which  existed  at  the  time  be- 
tween the  leaders  of  the  profession  in  the  old  and  new 
worlds.  But  neither  Boerhaave,  Cullen,  nor  Fother- 
gill stamped  colonial  medicine  as  did  the  great  Scotch- 
man, John  Hunter.  Long  weary  centuries  separated 
Harvey  from  Galen;  not  a  century  elapsed  from  the 
death  of  the  great  physiologist  to  the  advent  of  the 
man  in  whose  phenomenal  personality  may  be  seen  all 
the  distinctive  traits  of  modern  medicine,  and  the  range 
of  whose  mighty  intellect  has  had  few,  if  any,  equals 
since  .\ristotle.  Hunter's  influence  on  the  profession 
of  this  continent,  so  deep  and  enduring,  was  exerted 
in  three  ways.  In  the  first  place,  his  career  as  an 
army  surgeon,  and  his  writings  on  subjects  of  special 
interest  to  military  men,  carried  his  work  and  ways 
into  innumerable  campaigns  in  the  long  French  wars 
and  the  war  of  independence.  Hunter's  works  were 
reprinted  in  America  as  early  as  179 1  and  1793.  In 
the  second  place,  Hunter  had  a  number  of  most  dis- 
tinguished students  from  the  colonies,  among  whom 
were  two  who  became  teachers  of  wide  reputation. 
William  Shippen,  the  first  professor  of  anatomy  in  the 
University  of  Pennsylvania,  lived  with  Hunter  on  terms 
of  the  greatest  intimacy.  He  brought  back  his  meth- 
ods of  teaching,  and  some  measure  of  his  spirit.  With 
the  exception  of  Hewson  and  Home,  Hunter  had  no 
more  distinguished  pupil  than  Philip  Syng  Physick, 
who  was  his  house  surgeon  at  St.  George's  Hospital 
and  his  devoted  friend.  For  more  than  a  generation 
Pliysick  had  no  surgical  compeer  in  America,  and  en- 
joyed a  reputation  equalled  by  no  one  save  Rush.  He 
taught  Hunterian  methods  in  the  largest  medical  school 
in  the  country,  and  the  work  of  his  nephew  (Dorseyi 
on  surgery  is  very  largely  Hunter  modified  by  Physick. 
Rut  in  a  third  and  much  more  potent  way  the  great 
master  influenced  the  profession  of  this  continent. 
Hunter  was  a  naturalist  to  whom  pathological  proc- 
esses were  only  a  small  part  of  a  stupendous  whole, 
governed  by  law,  but  which  could  never  be  understood 
until  the  facts  had  been  accumulated,  tabulated,  and 
systematized.  By  his  example,  by  his  prodigious  in- 
dustry, and  by  his  suggestive  experiments  he  led  men 
again  into  the  old  paths  of  Aristotle,  Galen,  and  Har- 
vey. He  made  all  thinking  physicians  naturalists;  he 
lent  a  dignity  to  the  study  of  organic  life,  and  re- 
established a  close  union  between  medicine  and  the 
natural  sciences.  Both  in  Britain  and  Greater  Britain 
he  laid  the  foundation  of  the  great  collections  and 
museums,  particularly  those  connected  with  the  medi- 
cal schools.  The  Wistar-Horner  and  the  Warren  Mu- 
seums originated  with  men  who  had  been  greatlv 
influenced  by  Hunter.  He  was,  moreover,  the  intel- 
lectual fatiier  of  that  interesting  group  of  men  on  this 
side  of  the  .Atlantic,  who,  while  practising  as  phy- 
sicians, devoted  much  time  and  labor  to  the  study  ot 
natural  history.  In  the  latter  part  of  the  last  century, 
and  during  the  first  thirty  years  of  this,  the  successful 
practitioner  was  very  often  a  naturallist. 

I  wish  that  time  permitted  me  to  do  justice  to  the 
long  list  of  men  who  have  been  devoted  naturalists, 
and   who    have    made   contributions  of   great    value. 


Benjamin  Smith  Barton,  David  Hossack,  Jacob  Bige- 
low,  Richard  Harland,  John  D.  Godman,  Samuel 
George  Morton,  John  Collins  Warren,  Samuel  L. 
Mitchell,  J.  .\iken  Meigs,  and  many  others  have  left 
the  records  of  their  industry  in  their  valuable  works 
and  in  the  transactions  of  the  various  societies  and 
academies.  In  Canada  many  of  our  best  naturalists 
have  been  physicians,  and  collections  in  this  city  tes- 
tify to  the  industry  of  Holmes  and  McCullough.  I 
was  regretting  the  humanities  a  few  minutes  ago,  and 
now  I  have  to  mourn  the  almost  complete  severance 
of  medicine  from  the  old  natural  history.  To  a  man 
the  most  delightful  recollections  of  whose  studentship 
are  the  Saturdays  spent  with  a  preceptor  who  had  a 
Hunterian  appetite  for  specimens — anything  from  a 
trilobite  to  an  acarus — to  such  a  one  across  the  pres- 
ent brilliant  outlook  comes  the  shadow  of  the  thought 
that  the  conditions  of  progress  will  make  impossible 
again  such  careers  as  those  of  William  Kitchen  Parker 
and  William  Carmichael  Mcintosh. 

Until  about  1820  the  English  profession  of  this 
continent  knew  little  else  than  British  medicine. 
.\fter  this  date  in  the  United  States  the  ties  of  profes- 
sional union  with  the  old  country  became  relaxed, 
owing  in  great  part  to  the  increase  in  the  number  of 
home  schools,  and  in  part  to  the  development  of  an 
.\merican  literature.  To  1820,  one  hundred  and  four- 
teen native  medical  books  of  all  kinds  had  been  issued 
from  the  press,  and  one  hundred  and  thirty-one  re- 
prints and  translations,  the  former  English,  the  latter 
almost  e.xclusively  French  (Billings).  Turning  for  a 
few  minutes  to  the  conditions  of  the  profession  in 
Canada  during  this  period,  I  regret  that  I  cannot 
speak  of  the  many  interesting  questions  relating  to 
the  French  colonies.  I  may  mention,  however,  that 
with  the  earliest  settlers  physicians  had  come,  and 
among  the  Jesuits,  in  their  devoted  missions,  there 
are  records  of  domics  (laymen  attached  to  the  ser\'ice) 
who  were  members  of  the  profession.  One  of  these, 
Rene  Goupil,  suffered  mart)"rdom  at  the  hands  of  the 
Iroquois.' 

Between  the  fall  of  Quebec  in  1759  and  1820,  the 
English  population  had  been  increased  by  the  settle- 
ment of  Upper  Canada,  chiefly  by  X-nited  Empire 
Loyalists  from  the  United  States,  and  after  the  war  of 
1812  by  settlers  from  the  old  country.  The  phy- 
sicians in  the  sparsely  settled  districts  were  either 
young  men  who  sought  their  fortunes  in  the  new  col- 
ony, or  were  army  surgeons  who  had  remained  after 
the  revolutionary  war  or  the  war  of  18 12.  The  mili- 
tary clement  gave  for  some  years  a  very  distinctive 
stamp  to  the  profession.  These  surgeons  were  men  of 
energy  and  ability,  who  had  seen  much  serv'ice  and 
were  accustomed  to  order,  discipline,  and  regulations. 
Sabine,  in  his  "  History  of  the  Loyalists,"  refers  to 
the  Tor>'  proclivities  of  the  doctors,  and  says  that  they 
were  not  so  much  disturbed  as  the  lawyers  and  clergy- 
men. Still  a  good  many  of  them  left  their  homes 
■'for  conscience  sake;"  and  Canniff,  in  his  ''History 
of  the  Profession  in  Upper  Canada,"  gives  a  list  of 
those  known  to  have  been  among  the  United  Empire 
Loj'alists.  The  character  of  the  men  who  controlled 
the  profession  of  the  new  colony  is  well  shown  by  the 
proceedings  of  the  medical  board,  which  was  orga- 
nized in  1819.  Drs.  Macaulay  and  Widmer,  both 
army  surgeons,  were  the  chief  members.  The  latter, 
who  has  well  been  termed  the  father  of  the  profession 
in  Upper  Canada,  a  man  of  the  very  highest  ciiaracter, 
did  more  than  any  one  else  to  promote  the  progress  of 
the  profession,  and  throughout  his  long  career  his 
efforts  were  always  directed  in  the  proper  channels. 
In  looking  through  Canniff's  most  valuable  work  one 
is  much  impressed  by  the  sterling  worth  and  mettle  of 
the  old  army  surgeons,  who  in  these  early  days  formed 
'  Parkman:  "Jesuits  in  North  .\inerica." 


338 


MEDICAL    RECORD. 


[September  4,  1897 


the  larger  part  of  the  profession.  The  minutes  of  the 
medical  board  indicate  with  what  military  discipline 
the  candidates  were  examined,  and  the  percentage  of 
rejections  has  probably  never  been  higher  in  the  his- 
tory of  the  province  than  it  was  in  the  first  twenty 
years  of  the  existence  of  the  board. 

One  picture  on  the  canvas  of  tho.se  early  days  lin- 
gers in  the  memory,  illu.strating  many  of  the  most 
attractive  features  of  a  race  which  has  done  much  to 
make  this  countrj'  what  it  is  to-day.  Widmer  was  the 
type  of  the  dignified  old  army  surgeon,  scrupulously 
punctilious,  and  in  every  detail  regardful  of  the  pro- 
prieties of  life.  "Tiger"  Dunlop  may  be  taken  as 
the  very  incarnation  of  that  restless,  roving  spirit 
which  has  driven  the  Scotch  broadcast  upon  the  world. 
After  fighting  with  the  Connaught  Rangers  in  the  war 
of  1812,  campaigning  in  India,  clearing  the  Sangur  of 
tigers — hence  his  sobriquet  "Tiger"- — lecturing  on 
medical  jurisprudence  in  Edinburgh,  writing  for 
Blackri'ooil,  editing  the  British  Press  and  the  Telcscopt, 
introducing  Beck's  "  Medical  Jurisprudence"  to  Eng- 
lish readers,  and  figuring  as  director  and  promotor  of 
various  companies,  this  extraordinary  character  ap- 
pears in  the  young  colony  as  "Warden  of  the  lilack 
Forest"  in  the  employ  of  the  Canada  Company.  His 
life  in  the  backwoods  at  Gairbraid,  his  "  Noctes  Am- 
brosiana;  Canadenses, "  his  famous  "  Twelve  Apostles," 
as  he  called  his  mahogany  liquor  stand  (each  bottle  a 
full  quart),  his  active  political  life,  his  remarkable 
household,  his  many  eccentricities — are  they  not  all 
portrayed  to  the  life  in  the  recently  issued  "  In  the 
Days  of  the  Canada  Company"? 

America:  1820 — 1860.— Turning  now  to  the  sec- 
ond period,  we  may  remark  in  passing  that  the  nine- 
teenth century  did  not  open  very  auspiciously  for  Brit- 
ish medicine.  Hunter  had  left  no  successor,  and, 
powerful  as  had  been  his  influence,  it  was  too  weak  to 
stem  the  tide  of  abstract  speculation  with  which  Cul- 
len.  Brown,  and  others  flooded  the  profession.  No 
more  sterile  period  exists  than  the  early  decades  of 
this  century.  W'illan,  a  great  naturalist  in  skin  dis- 
eases, with  a  few  others,  save  it  from  utter  oblivion. 
The  methods  of  Hippocrates,  of  Sydenham,  and  of 
Hunter  had  not  yet  been  made  available  in  every-dav 
work.  The  awakening  came  in  France,  and  such  an 
awakening!  It  can  be  compared  with  nothing  but 
the  renaissance  in  the  sixteenth  and  seventeenth  cen- 
turies, which  gave  us  Vesalius  and  Harvey.  "Citi- 
zen" Bichat  and  Broussais  led  the  way,  but  Laennec 
really  created  clinical  medicine  as  we  know  it  to-day. 
The  discovery  of  auscultation  was  only  an  accident — 
of  vast  moment  it  is  true — in  a  systematic  study  of  the 
correlation  of  symptoms  with  anatomical  changes. 
Louis,  Andral,  and  Chomel  extended  tiie  reputation 
of  the  French  school,  which  was  maintained  to  the 
full  until  the  sixth  decade,  when  the  brilliant  Trous- 
seau ended  a  long  line  of  Paris  teachers,  whose  audi- 
ence had  been  worldwide. 

The  revival  of  medicine  in  (ireat  Britain  was  di- 
rectly due  to  the  French.  15right  and  .Addison,  (iraves 
and  Stokes,  Forbes  and  Marshall  Hall,  Latham  and 
Bennett  were  profoundly  affected  by  the  new  move- 
ment. In  the  United  States,  Anglican  influence  did 
not  wane  until  after  1820.  Translations  of  tlie  works 
of  Bichat  appeared  as  early  as  1802,  and  there  were 
reprints  in  subsequent  years,  but  it  was  not  until 
1823  that  the  Hrst  translation  of  Laennec — a  reprint 
of  Forbes'  edition — was  issued.  Broussais'  works 
became  very  popular  in  translations  after  1830,  and  in 
the  journals  from  this  time  on  the  change  of  alle- 
giance became  very  evident.  But  men  rather  than 
books  diverted  tiie  trend  of  jirofessional  thought. 

After  1825  American  students  no  longer  went  to 
Edinburgh  and  London,  but  to  Paris,  and  one  can  say 
that  between  1830  and  i860  every  teacher  and  writer 


of  note  passed  under  the  Gallic  yoke.  The  transla- 
tions of  Louis'  works  and  the  extraordinary  success 
of  his  American  pupils — a  band  of  the  ablest  young 
men  the  country  has  ever  seen — added  force  to  the 
movement.  And  yet  this  was  a  period  in  which 
American  medical  literature  was  made  up  largely  of 
pirated  English  books,  and  the  systems,  encyclope- 
dias, and  libraries,  chiefly  reprints,  testify  to  the  zeal 
of  the  publishers.  Stokes,  Graves,  Watson,  Todd, 
Bennett,  and  Williams  furnished  Anglican  pap  to  the 
sucklings,  as  well  as  strong  meat  to  the  full  grown. 
In  spite  of  the  powerful  French  influence  the  text- 
books of  the  schools  were  almost  exclusively  English. 

In  Canada  the  period  from  1820  to  i860  saw  the 
establishment  of  the  English  universities  and  medi- 
cal schools.  In  Montreal  the  agencies  at  work  were 
wholly  Scotch.  The  McGill  Medical  School  was  or- 
ganized by  Scotchmen,  and  from  its  inception  has 
followed  closely  Edinburgh  methods.  The  Paris  in- 
fluence, less  personal,  was  exerted  chiefly  through 
English  and  Scotch  channels.  The  LTpper  Canada 
schools  were  organized  by  men  with  English  affilia- 
tions and  the  traditions  of  Guy's.  St  Bartholomew's, 
St.  Thomas',  St.  George's,  and  of  the  London  Hos- 
pital, rather  than  those  of  Edinburgh,  have  prevailed 
in  Toronto  and  Kingston. 

The  local  French  influence  on  British  medicine  in 
Canada  has  been  very  slight.  In  the  early  decades  of 
the  century,  when  the  cities  were  smaller,  and  the  inter- 
course between  the  French  and  English  was  somewhat 
closer,  the  reciprocal  action  was  more  marked.  At 
that  period  English  methods  became  somewhat  the 
vogue  among  the  French;  several  very  prominent 
French  Canadians  were  Edinburgh  graduates.  At- 
tempts were  made  in  the  medical  journals  to  have 
communications  in  both  languages,  but  the  fusion  of 
the  two  sections  of  the  profession  was  no  more  feasible 
than  the  fusion  of  the  two  nationalities,  and  the  de- 
velopment has  progressed  along  separate  lines. 

America:  i860 -1897. — The  third  period  dates 
from  about  i860,  when  the  influence  of  German  med- 
icine began  to  be  felt.  The  rise  of  the  Vienna  school 
was  for  a  long  time  the  onlv  visible  result  in  Germany 
of  the  French  renaissance.  Skoda,  the  German  Laen- 
nec, and  Rokitansky,  the  German  Morgagni,  influ- 
enced English  and  American  thought  between  1840 
and  i860,  but  it  was  not  until  after  the  last  date  that 
Teutonic  medicine  began  to  be  felt  as  a  vitalizing 
power,  chiefl\"  through  the  energv  of  Virchow.  After 
the  translation  of  the  "Ct-llular  Pathology"  by  Chance 
(i860)  the  way  lay  clear  and  open  to  every  young  stu- 
dent who  desired  inspiration.  There  had  been  great 
men  in  Berlin  before  ^'irchow,  but  he  made  the  town 
on  the  Spree  a  Mecca  for  the  faithful  of  all  lands. 
From  this  period  we  can  date  the  rise  of  German  in- 
fluence in  the  profession  of  this  continent.  It  came 
partly  through  the  study  of  pathological  histology 
under  the  stimulus  given  by  \'irchow,  and  partly 
through  the  development  of  the  specialties,  particu- 
larly diseases  of  the  eye,  of  the  skin,  and  of  the  larynx. 
The  singularly  attractive  courses  of  Hebra,  the  or- 
ganization on  a  large  scale  in  ^'ienna  of  a  system  of 
graduate  teaching  designed  especially  for  foreigners, 
the  remarkable  expansion  of  the  German  laboratories, 
combined  to  divert  the  stream  of  students  from  France. 
The  change  of  allegiance  was  a  deserved  tribute  to  the 
splendid  organization  of  the  German  universities,  to 
the  untiring  zeal  and  energy  of  their  professors,  and 
to  their  single-minded  de\otion  to  science  for  its  own 
sake. 

Medicine  in  Australasia.  — In  certain  aspects  the 
.Vustr.ilasian  setllemenls  jiresent  the  most  interesting 
problems  of  Cireater  Britain.  More  liomogeneous,  thor- 
oughly British,  isolated,  distant,  they  must  work  out 
their  destiny  with  a  less  stringent  environment  than, 


September  4,  1897] 


MEDICAL    RECORD. 


339 


for  example,  surrounds  the  English  in  Canada.  The 
traditions  are  more  uniform,  and,  of  whatever  char- 
acter, have  filtered  through  British  channels.  'I'he 
professional  population  of  native-trained  men  is  as 
yet  small,  and  the  proportion  of  graduates  and  licen- 
tiates from  the  English.,  Scotch,  and  Irish  colleges 
and  boards  guarantees  the  dominance  of  old-country 
ideas.  What  the  maturity  will  show  cannot  be  pre- 
dicted, but  the  vigorous  infancy  is  full  of  "crescent 
promise."  On  looking  over  the  files  of  Australian 
and  New  Zealand  journals  one  is  impressed  with  the 
monotonous  similarity  of  the  diseases  in  the  antipo- 
des to  those  of  Great  Britain  and  of  this  continent. 
Except  in  the  matter  of  parasitic  affections  and  snake 
bites,  the  nosology  presents  few  distinctive  qualities. 
The  proceedings  of  the  four  intercolonial  congresses 
indicate  a  high  level  of  professional  thought.  In  two 
points  Australia  has  not  progressed  as  other  parts  of 
Greater  Britain.  The  satisfactory  regulation  of  prac- 
tice, so  early  settled  in  Canada,  has  been  beset  with 
many  difficulties.  Both  in  the  L-nited  States  and  in 
Australia  the  absence  of  the  militar}'  element,  which 
was  so  strong  in  Canada,  may,  in  part  at  least,  ac- 
count for  the  great  difference  which  has  prevailed  in 
this  matter  of  the  State  license.  The  other  relates  to 
the  question  of  ethics,  to  which  one  really  does  not 
care  to' refer,  were  it  not  absolutely  forced  upon  the 
attention  in  reading  the  journals.  Elsewhere  profes- 
sional squabbles,  always  so  unseemly  and  distressing, 
are  happily  becoming  very  rare,  and  in  Great  Britain 
and  on  this  side  of  the  water  we  try  at  any  rate  to 
wash  our  dirty  linen  at  home.  In  the  large  Australian 
cities  differences  and  dissensions  seem  lamentably  com- 
mon. Surely  they  must  be  fermented  by  the  atrocious 
system  of  election  to  the  hospitals,  which  plunges  the 
entire  profession  every  third  or  fourth  year  into  the 
throes  of  a  contest  in  which  the  candidates  have  to 
solicit  the  suffrages  of  from  two  thousand  to  four 
thousand  voters.  Well  indeed  might  Dr.  Batchelor, 
in  his  address  to  the  fourth  intercolonial  congress, 
say:  "It  is  a  scandal  that  in  any  British  community, 
much  less  in  a  community  which  takes  pride  in  a 
progressive  spirit,  such  a  pernicious  system  should 
survive  for  an  hour." 

Medicine  in  Hindustan. — Of  India,  of  "  Vishnu- 
land,"  what  can  one  say  in  a  few  minutes?  'I'iiree 
thoughts  at  once  claim  recognition.  Here,  in  the  dim 
dawn  of  historv,  with  the  great  Aryan  people,  was  the 
intellectual  cradle  of  the  world.  To  the  Hindus  we 
owe  a  debt  which  we  can  at  any  rate  acknowledge; 
and  even  in  medicine  many  of  our  traditions  and  prac- 
tices may  be  traced  to  them,  as  may  be  gathered  from 
that  most  interesting  "  History  of  Aryan  Aitdical  Sci- 
ence," by  the  Thakore  Sahib  of  (}ondal. 

Then  there  arises  the  memory  of  the  men  who  have 
done  so  much  for  British  medicine  in  this  great  em- 
pire. Far  from  their  homes,  far  from  congenial  sur- 
roundings, and  far  from  the  stimulus  of  scientitic 
influences,  Annesley  and  Ballingall,  Twining.  More- 
head,  Waring,  Parkes,  Cunningham,  Lewis,  X'andyke 
Carter,  and  many  others  have  nobly  upheld  the  tra- 
ditions of  Harvey  and  of  Sydenham.  On  the  great 
epidemic  diseases  how  impoverished  would  our  litera- 
ture be  in  the  absence  of  their  contributions!  But 
then  there  comes  the  thought  of  "the  little  done,  the 
undone  vast"  when  one  considers  the  remarkable 
opportunities  for  .study  which  India  has  presented. 
Where  else  in  the  world  is  there  such  a  field  for  oli- 
servation  in  cholera,  leprosy,  dysentery,  the  plague, 
typhoid  fever,  malaria,  and  in  a  host  of  other  less  im- 
portant maladies?  And  what  has  the  British  govern- 
ment done  toward  the  scientific  investigation  of  thr 
diseases  of  India?  I'ntil  recently  little  or  nothing, 
nnd  the  proposal  to  found  an  institute  for  the  scien- 
tific studv  of  disease  has  actuallv  come  from  the  natix'e 


chiefs.  The  work  of  Dr.  Hankin  and  of  Professor 
Hahkine,  and  the  not  unmixed  evil  of  the  brisk  epi- 
demic of  plague  in  Bambay,  may  arouse  the  officials 
to  a  consciousness  of  their  shortcomings.  While  san- 
itary progress  has  been  great,  as  shown  in  a  reduction 
of  the  mortality  from  sixty-nine  per  mille  before  1857 
to  fifteen  per  mille  at  present,  many  problems  are  still 
urgent,  as  may  be  gathered  from  Dr.  Harvey's  presi- 
dential address  in  the  "Proceedings  of  the  Indian 
Medical  Congress."  That  typhoid  fever  can  be  called 
the  "  scourge  of  India,"  and  that  the  incidence  of  the 
disease  should  remain  so  high  among  the  troops,  point 
to  serious  sanitary  defects  as  yet  unremedied.  As  to 
the  prevalence  of  venereal  disease  among  the  soldiers, 
an  admission  of  nearly  fi\e  hundred  per  mille  tells  its 
own  tale.  On  reading  the  journals  and  discussions 
one  gets  the  impression  that  things  are  not  as  they 
should  be  in  India.  There  seems  to  be  an  absence 
of  proper  standards  of  authority.  Had  there  been  in 
each  presidency  during  the  past  twenty  years  well- 
equipped  government  laboratories  in  charge  of  able 
men,  well  trained  in  modern  methods,  the  contribu- 
tions to  our  knowledge  of  epidemic  diseases  might 
have  been  epoch  making,  and,  at  any  rate,  we  should 
have  been  spared  the  crudeness  which  is  evident  in 
some  of  the  work  (particularly  in  that  upon  malaria) 
of  zealous  but  badly  trained  imn. 

The  Future  of  Medicine  in  Greater  Britain. — In 
estimating  the  progress  of  medicine  in  the  countries 
comprising  Greater  Britain,  the  future  rather  than  the 
present  should  be  in  our  minds.  The  strides  which 
have  been  taken  during  the  past  twenty  years  are  a 
strong  warrant  that  we  have  entered  upon  a  period  of 
exceptional  development.  When  I  see  what  has  been 
accomplished  in  this  city  in  the  short  space  of  time 
since  I  left  I  can  scarcely  credit  my  eyes.  The  reality 
exceeds  the  utmost  desires  of  my  dreams.  The  awak- 
ening of  the  profession  in  the  United  States  to  a  con- 
sciousness of  their  responsibilities  and  opportunities 
has  caused  unparalleled  changes,  which  have  given  an 
impetus  to  medical  work  which  has  already  borne  a 
rich  han'est.  Within  two  hundred  years  who  can  say 
where  the  intellectual  centre  of  the  Anglo-Saxon  race 
will  be  ?  The  mother  country  herself  has  become  an  in- 
tellectual nation  of  the  first  rank  only  within  a  period 
altogether  too  short  to  justify  a  prediction  that  she  has 
reached  the  zenith.  .She  will  probably  reverse  the 
history  of  Hellas,  in  which  the  mental  superiority  was 
at  first  with  the  colonies.  At  the  end  of  the  next  cen- 
tury ardent  old-world  students  may  come  to  this  side, 
"  as  o'er  a  brook,"  seeking  inspiration  from  great  mas- 
ters, perhaps  in  this  verv  city;  or  the  current  may  turn 
toward  the  schools  of  the  great  nations  of  the  South, 
ll^nder  new  and  previously  unknown  conditions  the 
.\fricander,  the  .\ustralian,  or  the  New  Zealander  may 
reach  a  development  before  which  even  the  "glory 
that  was  Greece"  may  pale.  Visionary  as  this  may 
appear,  it  is  not  one  whit  more  improbable  to-day 
than  would  have  been  a  prophecy  made  in  1797  that 
such  a  gathering  as  the  present  would  be  possible 
within  a  century  on  the  banks  of  the  St.  Lawrence. 

Meanwhile,  to  the  throbbing  vitality  of  modern  med- 
icine the  two  great  meetings  held  this  month,  in  lands 
so  widely  di.stant,  bear  eloquent  testimony.  Free, 
cosmopolitan,  no  longer  hampered  by  the  dogmas  of 
schools,  we  may  feel  a  just  pride  in  a  profession 
almost  totally  emancipated  from  the  bondage  of  error 
and  prejudice.  Distinction  of  race,  nationality,  color, 
and  creed  are  unknown  within  the  portals  of  the  tem- 
])le  of  .-F'sculapius.  Dare  we  dream  that  this  harmony 
and  cohesion  so  rapidly  developing  in  medicine,  oblit- 
erating the  strongest  lines  of  division,  knowing  no  tie 
of  loyalty  but  loyalty  to  truth — dare  we  hope,  I  say, 
that  in  the  wider  range  of  human  affairs  a  similar 
solidaritv  mav  ultimatelv  be  reached  ?      \\'ho  can   say 


340 


MEDICAL    RHCORD. 


[September  4,  189; 


that  the  forges  of  time  will  weld  no  links  between  man 
and  man  stronger  than  those  of  religion  or  of  country? 
Sjine  son  of  Beor,  touched  with  a  prophetic  vision, 
piercing  the  clouds  which  now  veil  the  eternal  sun- 
shine of  the  mountain  top,  some  spectator  of  all  time 
and  all  existence  (to  use  Plato's  expression)  might  see 
in  this  gathering  of  men  of  one  blood  and  one  tongue 
a  gleam  of  hope  for  the  future,  of  hope,  at  any  rate, 
that  the  great  race,  so  dominant  on  the  earth  to-day. 
may  progress  in  the  bonds  of  peace — a  faint  glimmer, 
perhaps,  of  the  larger  hope  of  humanity  of  the  day 
when  "the  common  sense  of  most  shall  hold  a  fretful 
world  in  awe."  But  these,  I  fear,  are  the  dreams  of 
the  closet  student  who  knows  not  the  world  nor  its 
ways.  There  remains  for  us,  Greater  Britons,  of  what- 
soever land,  the  bounden  duty  to  cherish  the  best  tra- 
ditions of  our  fathers,  and  particularly  of  the  men  who 
gave  to  British  medicine  its  most  distinctive  features: 
of  the  men,  too,  who  found  for  us  the  light  and  lib- 
erty of  Greek  thought— Linacre,  Harvey,  and  Syden- 
ham— those  "  ancient  founts  of  inspiration,'"  and  mod- 
els for  all  time  in  literature,  science,  and  practice. 


ADDRESS    IN    SURGERY.' 
By    W.    MITCHELL   BANK.S,    M.D.   Edin. 


The  Surgeon  of  Old  in  War. —  I  am  indeed  greatly 
honored  by  having  to  deliver  to  you  to-day  an  address 
in  surgery.  Fortunately  for  me  the  title  is  a  wide  one, 
and  I  shall  take  advantage  of  that  fact  to  di\erge  from 
the  strict  consideration  of  surgical  disease,  and  shall 
offer  you  instead  a  brief  sketch  of  some  of  the  most 
notable  work  done  of  old  by  a  body  of  members  of  our 
profession  who  have  never  received  their  due  reward 
— those,  namely,  who  have  devoted  their  lives  to  the 
succor  of  the  sick  and  the  wounded  in  war. 

Military  Surgeons  in  the  Roman  Army. — Twelve 
months  ago  my  friend.  Dr.  Barnes,  of  Carlisle,  ex- 
president  of  this  association,  made  me  acquainted  with 
a  remarkable  paper  by  the  late  Sir  James  Simpson, 
entitled  "Was  the  Roman  Army  Provided  with  Medi- 
cal Officers?'' — a  papjer  e.\hibiting  such  profound 
learning,  so  charmingly  written,  and  so  little  known 
that  I  need  not  make  any  apolog)'  for  acquainting  you 
with  some  of  its  chief  points  of  interest. 

The  most  careful  investigations  have  failed  to  make 
out  from  their  writings  whether  the  Romans  regularly 
appointed  physicians  and  surgeons  to  their  armies  or 
not,  although  nearly  every  other  question  relating  to 
their  military  organization  has  been  treated  of,  some- 
times very  fully.  Curiously  enough,  what  little  infor- 
mation we  possess  on  the  subject  comes  mainly  from 
mortuary  or  from  votive  tablets.  Borcovicus,  in 
Northumberland"  now  called  Housesteads — was  one 
of  the  principal  stations  on  the  line  of  Hadr'an's  wall. 
Here,  about  seventy  years  ago,  was  found  a  monumen- 
tal tablet,  now  in  the  Newcastle  Museum.  On  it  is 
the  following  inscription  : 

11    M  I'(IIS)     M(A.MKI-i) 

ANICIO  ANICIO 


INGF.NUO 
MF.lilCO 

OKI)  con 

I    TIINGR 
MX    AN    XXV 


INGENUo 

M  Kill  CO 

'RI>(IXARIo)    COH(OKT1S 

PKIM.-E  TUNOR(ilRi:.M) 

Vlx(n)     AN(NOS)    XXV 


The  first  Tungrian  cohort  is  known  to  have  been 
present  at  the  battle  of  the  Mons  Grampius,  and  to 
have  served  at  Castlec.iry,  at  Cramond  near  Edin- 
burgh, in  Cumberland,  and  at  Housesteads.      The  tab- 

'  Delivered  at  the  .inmi.il  ineetiii};  of  the  British  Meilic.il  .\sso- 
L-iation  at  Montreal,  September  2,  if>97 


let  is  highlv  ornamented,  and  antiquarians  hold  that  a 
rabbit  and  round  bucklers  carved  in  the  upper  p)art, 
which  are  emblems  of  Spain,  show  that  the  young  mil- 
itary doctor  was  probably  a  native  of  that  country. 
From  various  works  treating  of  Roman  inscriptions 
Simpson  was  enabled  to  find  that  four  more  tablets, 
in  which  surgeons  f)f  cohorts  are  mentioned,  existed. 
They  were  found  at  Rome.  One  of  them  is  a  votive 
tablet,  the  inscription  upon  which  intimates  that  it 
was  dedicated  by  Sextus  Titius  Alexander  to  .Alscula- 
pius  and  to  the  safety  of  his  fellow-soldiers.  It  was 
cut  in  the  year  of  the  consulship  of  F.  Flavius  Sabi- 
nus,  which  is  known  to  have  been  a.i>.  83.  As  the 
Roman  legion  consisted  of  ten  cohorts,  it  is  interest- 
ing to  know  that  not  only  were  medical  officers  at- 
tached to  each  cohort,  but  also  one  was  attached  to  the 
legion — a  sort  of  surgeon-colonel,  as  we  should  call 
him  nowadays.  Three  tablets  have  been  discovered 
in  which  the  miilinis  lcf;ionis  is  mentioned.  One  found 
at  Verona  was  a  tablet  raised  by  Scribonia  Paustina 
to  her  dearest  husband,  J.  Caelius  Arrianus,  medical 
officer  to  the  second  Italian  legion,  who  died  at  the 
age  of  forty-nine  years  and  seven  months.  Further- 
more, Simpson  routed  out  of  Mommsen's  Latin  in- 
.scriptions  of  Naples  a  tablet,  now  in  the  Dresden 
collection,  which  was  found  in  the  Elysian  fields  near 
Baiae,  close  to  the  I'ortus  Julius,  which  was 'the  sta- 
tion of  a  division  of  the  imperial  tleet.  The  inscrip- 
tion'tells  that  M.  Satrius  Longinus,  mctlicus  dtiplica- 
torius  to  the  trireme  Ciipiil,  and  the  heirs  of  those 
freed  bv  Julia  Veneria  erected  the  tablet  to  tlie  manes 
of  that  deserving  lady.  The  term  liiipiicatorius  means 
that  by  reason  of  long  or  meritorius  service  he  was 
entitled  to  double  pay  and  rewards.  These  little 
gleanings  from  Simpson's  paper  show  what  an  inter- 
esting one  it  is,  and  one  is  astonished  at  the  labor 
that  must  have  been  expended  in  digging  up  the  in- 
formation contained  in  it. 

Ambroise  Pare.  —  Hundreds  of  years  went  past  be- 
fore there  came  upon  the  scene  any  military  surgeon  of 
note,  but  when  he  did  appear  he  was  a  man  of  trans- 
cendent merit — the  illustrious  .Ambroise  Pare.  From 
1517  to  1590,  for  seventy-three  years,  he  lived  a  long 
and  incessantly  active  life,  the  contemporary  of  Vesa- 
lius,  the  immediate  predecessor  of  Harvey.  We  have 
only  time  to  glance  at  the  soldier-surgeon  side  of 
Pare's  life.  For  over  thirty  years  he  followed  the 
wars  under  four  kings  of  France — Henry  the  Second, 
Francis  the  Second,  Charles  the  Ninth,  and  Henry  the 
Third,  with  intervals  of  a  few  years  at  home  in  Paris. 
Perpignan,  Metz,  X'erdun,  Rheims,  Hesdin  (where  he 
was  taken  prisoner  and  had  to  write  to  his  wife  for  his 
ransom\  St.  Quentin,  La  Fere,  .Amiens,  the  taking  of 
Rouen,  Dreux,  Moncontour— these  are  but  some  of  tlie 
bloody  battles  and  sieges  at  which  he  was  present 
Through  them  all  liis  humanity,  his  love  of  his  profes- 
sion, his  independent  character,  and  his  jovial,  frank 
disposition  carried  him  safe,  and  niade  for  the  son  of 
the  poor  country  joiner  warm  friends  among  the  great- 
est and  noblest  warriors  of  France.  Even  that  miser- 
able monster,  Charles  the  Ninth,  loved  the  Huguenot 
surgeon,  and  when  the  awful  day  of  St.  Bartholomew 
came  Pare  was  spared  to  tend  his  wretched  master 
through  the  brief  term  of  agonized  and  remorseful  life 
that  was  given  him.  The  description  in  Dumas' 
novel,  the  "Two  Dianas,"  of  the  wound  cf  the  famous 
warrior,  Duke  of  Guise,  where  the  lance  entered  above 
the  right  eye  and  came  out  between  the  nucha  and  the 
left  ear,  breaking  short  olT,  and  how  Tare  lugged  it 
out,  with  the  chance  that  when  it  did  come,  one  terri- 
ble gush  of  blood  would  tinish  his  illustrious  patient's 
life  and  his  own  career  at  the  s;ime  moment — the  pic- 
ture of  all  this  is  real  history. 

.\niid  all  the  splendid  work,  both  anatomical  and 
surgical,  which  Pare  did,  the  application  of  the  prin- 


September  4,  1897] 


MEDICAL    RECORD. 


341 


ciple  of  the  ligature  to  bleeding  arteries  is  of  course 
that  with  which  his  name  will  be  forever  associated. 
In  this  day  of  grace  it  is  impossible  for  us  to  imagine 
the  horrors  that  awaited  a  wretched  man  so  soon  as 
his  limb  was  cut  off  and  the  process  of  stopping  the 
bleeding  began.  Think  of  the  raw  and  exquisitely 
sensitive  stump  exposed  to  the  red-hot  cauterj-  or 
plunged  into  boiling  pitch!  For  this  frightful  treat- 
ment Pare  substituted  the  ligature,  which  in  our  own 
day,  employed  in  the  form  of  an  aspetic  animal  mate- 
rial which  the  tissues  quietly  absorb,  has  practically 
reached  the  pitch  of  perfection.  In  his  time,  too, 
there  was  a  fixed  belief  that  the  danger  from  gunshot 
wounds  arose  from  the  poison  of  the  gunpowder  con- 
veyed on  the  bullet.  To  destroy  this  poison  the  treat- 
ment was  to  pour  into  the  wound  boiling  oil  in  which 
elderwood  bark  had  been  stewed.  On  one  occasion, 
not  having  this  infernal  concoction  at  hand,  Pare  used 
a  cold  mixture  of  yolk  of  egg,  oil  of  roses,  and  turpen- 
tine to  his  wounded  soldiers.  He  passed  a  sleepless 
night  from  dread  that  this  would  injure  those  to  whom 
it  had  been  applied,  and  his  delight  next  day  was 
proportionately  great  when  he  found  that  they  had 
had  but  little  pain,  while  their  wounds  were  free  from 
inflammation  and  swelling.  This  was  his  panacea  for 
wounds  ever  afterward.  There  are  of  course  persons 
who  wish  to  make  out  that  he  was  not  original  in  the 
matter  of  the  ligature.  He  himself  says  this  about  it: 
■'  Taught  me  as  I  interpret  it  by  the  suggestion  of  some 
good  angel,  for  I  neither  learnt  it  of  my  masters  nor 
of  any  other  man.  And  thus  I  wish  all  chirurgions  to 
doe.  For  it  is  not  in  our  art,  as  it  is  in  civill  affaires, 
that  prescription,  law,  or  authority  should  prevail  over 
right  reason."  But  these  cavillers  have  doubtless 
never  heard  of  an  ancient  proverb  which  says  that 
there  is  nothing  new  under  the  sun.  In  spite  of  them 
the  world  will  ever  believe  in  a  glorious  trio — Pare, 
the  Frenchman,  who  invented  the  ligature ;  Morton, 
the  American,  who  discovered  anaesthetics ;  and  Lis- 
ter, the  Englishman,  who  introduced  antiseptics.  In 
the  fulness  of  years,  possessed  of  alliuence  and  sur- 
rounded by  friends,  died  Pare,  the  whilom  poor  bar- 
ber-chirurgeon,  now  a  councillor  of  state  and  surgeon- 
in-chief  to  the  king.  One  final  touch  will  perhaps 
reveal  a  sentiment  that  permeated  and  guided  his 
every  labor.  On  one  occasion,  after  the  successful 
treatment  of  a  wounded  officer,  he  made  this  wise  and 
reverent  remark,  afterward  adopted  as  his  motto :  "  Je 
!e  pansay  ;  Dieu  h  giiarist" — "  I  treated  him  ;  God 
cured  him." 

Robert  Clowes. — Coming  to  England,  a  surgeon 
who  saw  no  little  fighting  was  Robert  Clowes,  who 
was  born  somewhere  about  1540  and  died  in  1604. 
He  served  in  France  in  the  army  commanded  by  the 
Earl  of  Surrey,  and  was  afterward  for  several  years  in 
the  navy.  He  then  began  practice  in  London,  and 
was  made  surgeon  to  St.  Bartholomew's  and  Christ's 
Hospitals.  But,  after  being  about  fourteen  years  in 
civil  practice,  he  was  despatched  by  Queen  Elizabeth's 
orders  into  the  Low  Countries  to  attend  upon  the  Earl 
of  Leicester,  commander  of  Her  Majesty's  forces.  He 
was  at  Zutphen  when  Sir  Philip  Sydney  was  killed. 
His  last  piece  of  service  was  a  glorious  one,  he  being 
with  our  fleet  that  defeated  the  Spanish  armada.  It 
is  told  of  him  that  he  always  kept  beside  him  his  mil- 
itary surgical  chest  with  the  bear  and  ragged  staff  of 
his  old  chief  Leicester  on  the  lid.  He  finally  settled 
down  once  more  in  London,  where  he  was  ver\"  suc- 
cessful in  practice,  and  was  made  surgeon  to  the 
queen.  He  wrote  several  works  in  English,  of  which 
the  most  important  is  entitled  "  A  profitable  and  nec- 
essarie  Booke  of  Observations  for  all  those  that  are 
burned  with  the  flame  of  gunpowder,  &c.,  and  also  for 
curing  of  wounds  made  with  musket  and  caliver  shot, 
and  other  weapons  of  war  commonlv  used  at  this  day 


both  by  sea  and  land."  A  good  half  of  this  treatise 
is  occupied  with  a  record  of  surgical  cases  of  note 
which  he  had  treated,  and  this  renders  the  work  very 
entertaining,  inasmuch  as  we  get  an  accurate  and  pos- 
itive knowledge  of  everything  that  was  done  for  a 
wounded  man  in  those  days,  while  there  are  numerous 
little  side  touches  very  characteristic  of  life  at  the 
time  it  was  .written.  He  tells  us,  for  instance,  of 
■■  The  cure  of  one  Master  Andrew  Fones,  a  merchant 
of  London,  which,  being  in  a  ship  at  the  sea  was  set 
upon  by  the  Flushingers,  in  which  fight  he  was  very 
dangerously  wounded  with  gunshot."  There  is  "The 
Cure  of  one  Henry  Rhodes,  one  of  the  waiters  at  the 
Custom  House,  he  being  upo  the  river  of  Thames  a 
skirmishing  with  his  peece,  and  by  reason  the  peece 
had  certain  flaws  in  it,  did  breake  into  many  peeces, 
and  made  a  great  wound  upon  his  chin,  and  carried 
away  a  good  part  of  the  manduble  and  the  teeth  with- 
all;  moreover,  it  did  rend  his  hand  greatly :  all  which 
I  cured  without  maime  or  deformitie."  There  is  "An 
observation  for  the  cure  of  the  master  of  a  Hoy  that 
had  both  his  legs  fractured  and  broken  into  many 
peeces  with  an  iron  bullet,  shot  out  of  a  great  basse 
or  harquebusse  of  crocke  at  the  sea  by  a  Pyrat  or  sea 
rover."  These  few  titles  will  give  you  an  idea  of 
Clowes'  clinical  cases.  The  importance  which  at- 
taches to  them,  and  the  reason  why  they  constitute  a 
distinct  advance  in  the  science  of  surgery  is  that  the 
author  gives  his  actual  experiences  and  tells  us  what 
he  did  to  his  patients,  whereas  at  that  period  the  ten- 
dency was  to  write  endless  commentaries  on  ancient 
writers,  to  whose  every  dictum  the  blindest  and  most 
unreasoning  respect  was  paid. 

Peter  Lowe. — Contemporarj-  with  Clowes  was  a 
most  interesting  character — Maister  Peter  Lowe — w ho 
was  born  in  Scotland  about  1550,  and  lived  some  sixty 
or  sLxt)'-five  years,  reaching  well  into  the  seventeenth 
century.  Like  many  of  his  countrymen,  he  went  to 
France  when  very  young,  where  he  lived,  for  some  say 
ten,  some  twenty  years.  Then  he  returned  to  Glasgow, 
where  he  lived  and  died  a  citizen  of  much  renown, 
having  obtained  in  1599  from  King  James  the  Sixth  a 
charter  for  the  Faculty  of  Physicians  and  Surgeons  of 
Glasgow,  which  he  thus  founded.  A  few  years  ago 
Dr.  Finlayson  published  a  most  charming  account  of 
Maister  Peter. 

His  most  important  work  is  termed  "  A  Discourse 
of  the  whole  art  of  chirurgery,  compiled  by  Peter 
Lowe,  Scottishman,  Doctor  in  the  Faculty  of  Chirur- 
gerie  at  Paris,  and  ordinarj'  Chyrurgion  to  the  French 
King  and  Navarre."  The  first  edition  dated  from 
1597,  and  is  one  of  the  earliest,  if  not  the  ver)'  earli- 
est, work  embracing  the  whole  art  of  surger}'  published 
in  English.  It  is  clear  that  Lowe  must  have  seen  a 
good  deal  of  military  service  abroad,  being  '"Chirur- 
gion  Major  to  the  Spanish  regiments  two  years  at 
Paris,  and  since  that  time  following  the  king  of  France 
my  maister  in  the  warrs."  In  his  day,  as  we  have 
seen,  the  surgical  world  was  still  greatly  exercised 
about  gunshot  wounds  and  burning  by  gunpowder,  as 
it  was  believed  that  they  were  injuries  of  quite  a  pecu- 
liar and  ver)'  poisonous  character.  Lowe,  however, 
treats  of  them  with  great  good  sense.  Thus:  "Of 
Wounds  done  by  Gun-shot. — These  wounds  come  in- 
differently to  all  parts  of  our  body  whereof  there  are 
divers  opinions;  some  think  that  there  is  a  venenosily 
in  the  powder,  and  burning  in  the  bullet,  which  is 
false,  for  the  things  whereof  the  powder  is  ordinarily 
made,  as  Brimstone,  Saltiseter,  coales  of  divers  sorts 
of  trees.  Water,  Wine  and  Aquavitce,  have  no  venenos- 
ity  in  them;  likewise  there  is  no  burning  in  the  bul- 
let, for  if  the  bullet  of  lead  being  shot  a  great  way, 
should  burne,  through  heat  would  be  melted  itself.  I 
have  cured  divers  within  these  thirty  yeares  of  divers 
nations  which  have  followed  the  warres  in   Fraunce 


342 


MEDICAL    RKf^OKD. 


[September  4,  1897 


and  other  cuntries,  in  the  which  I  have  found  no  more 
difficulty  than  in  any  other  contused  wounds."  Here, 
again,  we  have  a  most  important  advance  made  by  a 
military  surgeon,  for  only  those  who  are  acquainted 
with  the  medical  literature  of  Lowe's  time  can  under- 
stand the  ridiculous  views  then  held  about  gunshot 
wounds,  and  the  dreadful  consequences  to  the  patients 
which  followed  from  them. 

We  have  seen  that  Pare  lived  between  15 17  and 
1590,  and  that  Peter  Lowe  was  in  France  between 
1570  and  1580;  consequently,  he  probably  learned  all 
about  the  ligature  for  the  arrest  of  hemorrhage.  When 
treating  of  amputations  he  describes  the  whole  process 
of  the  operation  up  to  the  removal  of  the  limb.  Then 
he  says:  "One  of  the  Assisters  shall  put  the  extream- 
ities  of  his  fingers  on  the  great  vains  and  arteries  to 
stay  them  from  bleeding  till  the  Chyrurgion  either 
knit  or  cauterize  them  one  after  another.  Where  there 
is  putrefaction  we  stay  the  flux  of  blood  by  Cauters 
actuals,  and  where  there  is  no  putrefaction,  malignilie 
nor  humour  venomous  we  use  the  legator."  He  nar- 
rates the  case  of  a  certain  valiant  Captain  Boyle  of 
the  Spanish  troops,  whom  he,  in  the  capacit}'  of  chy- 
rurgion-major  to  the  regiment,  was  summoned  to  treat 
for  an  "aneurisme  on  the  right  side  of  liis  cragge." 
Lowe  ordered  it  to  te  let  alone,  "  but  the  captain  sent 
for  an  ignorant  Barbor  who  did  open  the  swelling  with 
a  Launcet,  which  being  done,  the  spirit  and  bloud 
came  forth  with  such  violence  that  the  Captain  died 
in  fewe  howers  after."  Having  duly  castigated  the 
Ignorants  who  do  such  things,  Lowe  observes  that  his 
treatment  for  such  cases  is  first  to  draw  blood  in  both 
arms,  and  then  to  apply  on  the  tumor  "  Rec,  Pul- 
veris  subtilissimi  boli  arminici,  sanguis  draconis, 
myrtilorum,  lapidis  calaminaris  in  aceto  extincti,  ab- 
sinthii  ad  unc.  cum  cerato  refrigerantis  Galeni  quan- 
tum suflicit,  fiat  unguentuni.''  Curious  to  note  how. 
even  in  men  of  distinct  ability  like  Lowe,  a  complete 
ignorance  of  patholog}'  dragged  them  into  the  perpe- 
tration of  tlie  silliest  empiricism. 

Woodall's  "Viaticum." — In  1628  appeared  the 
first  work  in  F^ngland  specially  devoted  to  military 
and  naval  surgery.  Some  eleven  years  later  a  second 
edition  apjaeared,  and  this  is  its  title — "  Viaticum,  be- 
ing the  Pathway  to  the  Surgeon's  Chest,  containing 
chirurgical  instructions  for  the  younger  sort  of  sur- 
geons imployed  in  the  service  of  his  Majestic  or  for 
the  Common-Weahli  upon  any  occasion  whatsoever 
intended  for  the  better  curing  of  wounds  made  by 
Gunshot,"  by  John  Woodall.  A  ]x;rusal  of  the  "Viat- 
icum" shows  that  Woodall  was  a  very  practical  sur- 
geon and  an  eminently  religious  man,  and  the  way  in 
which  he  mixes  up  jiills  and  piety  is  sometimes  ver)' 
diverting.  After  some  excellent  general  advice  to  the 
surgeon's  mate,  including  a  warning  against  "being 
given  and  dedicated  to  the  I'ot  and  Tobacco-pipe  in 
an  unreasonable  measure,"  he  enumerates  the  instru- 
ments for  the  surgeon's  chest,  including  among  others 
Catlings,  Rasours,  Trapans,  Trafine,  Lavatories,  Caut- 
erising Irons.  Storks' bills.  Ravens'  bills,  Crowes'  bills, 
Terebellum,  Probes  or  fiamules.  Glister  Sirings  and 
(what  would  have  utterly  damned  his  book  in  the  pres- 
ent day)  "one  bundle  of  small  German  instruments." 
Then  comes  a  list  of  medicines  under  the  heading  Cn- 
guentum,  Aqua,  Sol,  Oleum,  Chemicall  Oyles,  Syrups, 
Conserva,  F.lectuaria-,  and  so  on,  winding  up  with  a 
list  of  the  Simples,  and  of  the  Herbs  and  Roots  most 
fit  to  be  carried.  A  long  and  careful  description  of 
the  uses  of  the  instruments  and  drugs  follows,  and 
then  come  chapters  on  wounds,  apostumes,  fractures, 
dislocations,  amputation,  scurvy,  the  plague,  gangrene, 
and  other  topics.  He  olxserves  that  the  cauterizing 
irons  had  gone  somewhat  out  of  fashion,  and  lie  did 
not  use  them  much  himself  "because  of  the  feare  they 
put  the  Patient  into  and  for  speech  of  people  who  are 


ready  to  scandalise  an  Artist  upon  each  light  occa- 
sion." In  amputation,  moreover,  they  are  "now 
wholly  forborne  for  reasons  aforesaid,  and  for  that  a 
more  pleasant  course  is  known  better  for  the  patient 
and  the  Artist  by  making  a  ligature  upon  the  veine, 
wound  or  artery,  which  is  the  binding  of  each  end 
thereof,  being  first  caught  and  holden  with  some  fit 
instrument,  and  tied  with  a  sure  and  strong  thread." 

Woodall  advances  the  cure  of  wounds  a  distinct 
step,  once  more  putting  us  under  an  obligation  to  the 
soldier-surgeon.  This  he  does  by  sharply  attacking 
all  through  his  works  the  inordinate  and  meddlesome 
use  of  strong  caustics.  He  says  that  he  had  seen  men 
lamed  by  the  needless  use  of  caustic  medicines,  even 
in  slight  wounds,  to  which  if  an  old  wife  had  only  ap- 
plied her  one  salve  for  all .  sores,  no  such  thing  had 
happened.  "They  will  not  see  a  wound  incarne  and 
red  and  good  flesh  to  grow,  but  straight  they  slander 
it  of  pride,  and  call  it  proud  flesh,  like  their  owne: 
and  then  must  at  the  fairest  Precipitate  or  Vitriale 
burnt  goe  to  work,  yea  though  the  Patient  be  lame  for 
it,  or  at  the  least  the  griefe  put  back  again." 

Richard  Wiseman.— I  wish  I  had  time  to  give  you 
a  proper  account  of  the  adventurous  life  of  Richard 
Wiseman,  who  has  been  termed  the  father  of  English 
surgery,  and  that  not  without  reason.  Born  in  1620, 
dying  in  1676,  he  lived  in  the  time  of  Charles  the 
First,  of  the  commonwealth,  and  of  Charles  the  Sec- 
ond. He  was  a  naval  surgeon  to  begin  with,  serx'ing 
in  the  early  part  of  his  life  in  the  Dutch  navy.  Being, 
however,  a  devoted  Royalist,  he  served  with  the  armies 
of  Charles  the  First,  and  after  his  death  went  into  ex- 
ile with  his  son  in  France.  He  was  present  at  the 
battle  of  Worcester,  where  he  was  taken  prisoner,  and 
afterward  confined  in  Lambeth  House  for  a  while. 
During  the  coninionwealth  he  was  naturally  under  a 
cloud,  and  even  went  ofif  for  three  \ears  to  serve  in 
the  Spanish  navy.  At  the  restoration  the  King  did 
not  forget  his  old  surgeon,  who  had  done  and  suflered 
so  much  in  his  service,  but  appointed  him  his  surgeon- 
in-ordinary,  and  afterward  sergeant-surgeon.  The  first 
edition  of  his  work,  printed  in  1672,  is  quite  a  small 
book,  and  is  entitled  "A  Treatise  of  Wounds,"  but  it 
afterwards  expanded  into  a  very  large  volume. 

Nothing  reveals  a  man  like  his  own  words,  and  so 
in  tr)-ing  to  give  you  an  idea  of  these  old  worthies  I 
have  let  them  tell  their  own  stories.  Wiseman  be- 
lieved in  the  need  for  giving  stimulants  to  a  man  who 
was  in  the  habit  of  taking  them,  if  that  man  was  in  a 
dire  strait.  After  describing  the  parlous  case  of  a 
certain  patient,  it  seems  that  the  "man  swooned  and 
complained  that  he  could  not  li\e  without  wine.  1 
complied  with  his  desire;  he  drank  again  as  he 
pleased,  his  sickness  went  oft,  his  wound  digested,  and 
he  cured.  This  I  have  often  seen  in  some  of  our 
Dunkirkers  at  sea,  who  drank  extraordinarily,  and 
were  full  of  drink  in  our  sea  fights.  I  could  scarce 
ever  cure  them  without  allowing  them  wine,"  and 
thereby  their  spirits  were  kept  up,  and  I  had  the  lib- 
ert}'  to  bleed  them  as  I  thought  fit."  From  this  it  is 
clear  that  the  old  saying  about  Dutch  courage  has  a 
distinct  origin  in  fact.  But  if  the  unhappy  Batavians 
were  liable  to  be  bled  at  once  by  the  lance  of  the 
enemy  and  the  lancet  of  the  surgeon,  one  can  hardly 
wonder  at  their  taking  something  to  keep  their  spirits 
up. 

When  speaking  of  gunshot  wounds,  he  insists  upon 
the  bullet  being  searched  for  and  extracted  at  once. 
"The  part  is  at  first  dressing,  with  what  diligence  you 
can,  to  be  cleared  of  all  such  Foreign  Bodies  as  have 
made  violent  Intrusion  into  it,  while  the  patient  is 
warm  w  ith  the  heat  of  liattel,  and  the  wound  fresh  and 
very  little  altered  by  either  .\ir  or  Accidents,  so  that 
less  pain  must  necessarily  follow  upon  the  extraction. 
In  the  .\rmada  Naval  de  Dunquerque,  where  we  Chi- 


September  4.  1897] 


MEDICAL    RECORD. 


343 


Turgeons  were  oft  employed  in  this  Seivice,  we  after 
every  fight  went  together  visiting  one  another's 
wounded  men.  Amongst  us  it  was  thought  a  great 
shame  if  any  of  this  work  of  Extraction  was  there  to 
be  done.  It  hath  been  the  cause  of  the  death  of  many 
a  brave  Souldier,  and  every  Battel  produces  instances 
of  it,  to  the  discredit  of  our  profession."  This  is  good 
surgery  and  straight  talk.  I  think  it  must  have  been 
a  fine  spectacle  to  have  seen  these  rough  old  surgeons, 
with  their  limited  knowledge  and  their  miserable 
means  of  treatment,  walking  round  to  see  each  other's 
patients  and  learning  how  best  to  mend  their  mistakes. 

He  has  a  chapter  entirely  devoted  to  a  great  case  of 
a  fracture  made  by  a  splinter.  The  patient  had  his 
arm  badly  smashed  above  the  elbow,  and  ought  to 
have  had  it  amputated ;  but  a  sudden  cry  of  fire  stopped 
this.  "  I  hastily  clapt  a  dressing  upon  his  wound  and 
rouled  it  up,  leaving  his  arm  in  his  other  hand  to  sup- 
port it,  and  endeavoured  to  get  up  out  of  the  hold  as 
the  others  did,  I  verily  believing  I  should  never  dress 
him  or  any  of  them  more.  But  our  men  bravely 
quitted  themseltes  of  the  Fire-ship  by  cutting  the 
Sprizil  Tackle  off  with  their  Hatchets  (which  they 
wore  during  fight  sticking  in  their  Shashes);  we  were 
freed  of  the  fire,  and  by  our  hoisting  up  the  top  sails 
got  free  of  our  Enemy.  Now,  I  was  at  a  loss  what  to 
do  with  this  man,  who  lay  not  far  off  complaining  of 
his  arm.  I  would  have  cut  off  his  arm  presently  with 
a  Razor  (the  Bone  being  shattered  there  needed  no 
Saw) ;  but  this  man  would  not  suffer  me  to  dress  his 
arm;  he  cryed  '  it  was  already  drest.'  The  Fight  over, 
we  got  into  the  next  Port;  I  caused  presently  the  Mar- 
iner's Bed  to  be  set  up  (which  was  four  pieces  of  wood 
nailed  together  and  corded,  and  a  Bear's  skin  laid  upon 
it);  this  was  fastened  between  two 'Guns  to  the  Car- 
riages." Wiseman  then  set  hard  to  work  to  save  this 
unfortunate  mariner's  arm ;  but  "  when  it  came  to  my 
turn  to  be  visited  by  my  brother  Chirurgeons  of  our 
Squadron,  they  did  not  dislike  the  wound  nor  my  way 
of  dressing  (for  we,  being  used  to  see  one  another's 
Patients,  had  all  much  one  way  of  dressing)  ;  but  they 
laught  at  the  e.xcuse  I  made  for  not  cutting  of  his  arm, 
and  doubted  I  should  yet  be  forced  to  do  it.  But  at 
the  end  of  two  months  there  was  in  this  Patient  a 
strong  callus,  filling  up  the  void  place  of  the  lost  Bone 
at  least  two  inches,  with  little  or  no  shortening  of  the 
arm."     Well  done,  \\iseman! 

Baron  Larrey.  — Up  till  the  time  of  the  French 
Revolution  it  is  clear  that  military  surgeons  were  not 
men  of  much  importance,  and  probably  had  very  little 
influence,  if  any,  in  the  conduct  of  campaigns.  Hut 
in  the  latter  part  of  the  last  century  war  was  nvade  on 
a  scale  which  was  never  known  before,  and  was  made* 
also  with  a  rapidity  and  a  precision  quite  unprece- 
dented. Moreover,  the  science  and  art  of  surgery  had 
been  rescued  from  quackery,  and  surgeons  in  actual 
practice  were  able  to  be  of  great  and  real  service  to 
the  wounded.  As  a  result  of  the  vast  masses  of  men 
that  were  hurled  against  each  other,  the  number  of 
wounded  after  a  big  battle  amounted  to  thousands, 
and  civilization  had  so  far  advanced  that  it  was  im- 
perative that  immediate  help  should  be  given  to  them. 
So  that  about  this  time  the  military  surgeon  really  be- 
came an  important  officer  in  warfare,  and  began  to 
have  his  rank  and  pay  well  defined,  and  his  merits 
(up  to  a  certain  point)  recognized. 

In  1776,  near  the  Pyrenees,  was  born  Jean  Domi- 
nique Larrey,  the  chirurgien-en-chef  de  la  grande 
armde,  the  friend  and  body  surgeon  of  Napoleon,  the 
greatest  military  surgeon  that  ever  lived.  He  studied 
at  the  medical  school  of  Toulouse,  and  in  1792  joined 
the  headquarters  of  the  Republican  army  of  the  Rhine 
under  Custine.  Now,  the  ambulances  of  these  days 
were  obliged  to  remain  about  a  league  from  the  army, 
and  the  wounded  were  picked  up  only  after  the  fight- 


ing was  done.  General  Custine  was  a  man  who  moved 
his  troops  very  rapidly,  which  made  matters  worse  for 
the  wounded.  This  greatly  affected  Larrey,  who  set 
to  work  and  devised  a  new  ambulance  hung  on  springs, 
and  combining  great  strength  with  lightness.  Such 
carriages  were  termed  ambulaiues  volanks.  They 
could  keep  up  with  the  advanced  guard  of  the  army 
with  the  speed  of  flying  artillery,  and  they  carried  off 
the  w^ounded  almost  as  they  fell.  Larrey  had  early 
perceived  the  enormous  advantage  a  wounded  man  got 
by  having  his  fracture  set  or  his  bleeding  stopped  as 
rapidly  as  possible,  and  by  then  getting  a  roof  over  his 
head  before  night  set  in.  General  Beauharnais,  in  a 
dispatch  to  the  Convention,  made  special  mention  of 
"  Surgeon-Major  Larrey  and  his  comrades  with  flying 
ambulances,  whose  indefatigable  care  in  the  healing 
of  the  wounded  has  diminished  those  afflicting  results 
to  humanity  which  have  generally  been  inseparable 
from  days  of  victory,  and  has  essentially  served  the 
cause  of  humanity  itself  in  preserving  the  brave  de- 
fenders of  our  country.'"  The  staff  of  a  flying  ambu- 
lance was  about  three  hundred  and  forty  in  number. 
For  each  division  there  were  four  heavy  carriages  and 
twelve  light  ones.  Some  had  two  and  others  four 
wheels,  and  they  were  furnished  with  mattresses.  In 
Napoleon's  Italian  campaigns  they  came  greatly  to  the 
fore,  and  the  great  man  displayed  a  lively  interest  in 
them,  reviewing  them  and  causing  them  to  manoeuvre 
before  him  just  as  if  they  were  on  a  battlefield. 
After  one  of  these  inspections  he  said  to  Larrey : 
"  Your  work  is  one  of  the  most  happy  conceptions  of 
our  age.     It  will  suffice  for  your  reputation." 

When  Napoleon  undertook  his  Egyptian  campaign 
Larrey  proceeded  to  Toulon  to  organize  the  medical 
staff'.  So  readily  did  professional  men  respond  to  the 
call  made  by  him  that  he  soon  was  able  to  reckon  on 
eight  hundred  well-qualified  surgeons,  of  whom  many 
had  served  in  the  army  of  Italy,  and  these  were  in  ad- 
dition to  the  medical  officers  actually  attached  to  regi- 
ments. This,  I  think,  shows  the  value  that  the  king 
of  commanders  set  upon  the  health  of  his  troops,  and 
the  trouble  and  expense  which  he  was  prepared  to  face 
in  order  to  maintain  it — a  great  contrast  to  the  miser- 
able way  of  dealing  with  this  subject  which  has  too 
long  been  the  fashion  with  our  military  rulers.  Not 
long  after  the  landing  at  .Alexandria  a  certain  General 
Figuieres  was  severely  wounded,  liy  able  treatment 
he  recovered,  and  in  gratitude  for  the  preservation  of 
his  life  he  asked  Napoleon  to  accept  a  valuable  Da- 
mascus sword.  "  Yes,"  said  the  latter,  "  I  accept  it  in 
order  to  make  a  present  of  it  to  the  surgeon-in-chief,  by 
whose  exertions  your  life  has  been  spared."  Upon  the 
sword  jvere  engraved  the  words  "  .Aboukir"  and  "  Lar- 
rey," and  the  surgeon  had  it  till  the  fatal  day  of  Water- 
loo, when  the  Prussians  robbed  him  of  it.  Some 
months  after  the  occupation  of  Egypt  a  terrible  revolt 
took  place  in  Cairo  by  fanatical  Turks.  Utterly  re- 
gardless of  anything  except  how  to  get  at  Frenchmen 
to  murder  them,  they  attacked  the  hospital,  which  was 
crowded  with  sick  and  wounded  soldiers,  but  the  doc- 
tors valiantly  defended  their  patients,  and  two  staff- 
surgeons,  Roussel  and  Monjin,  were  killed,  while 
Larrey  nearly  shared  the  same  fate. 

At  one  period  there  was  a  total  dearth  of  meat,  and 
Larrey  had  nothing  wherewith  to  make  even  a  drop  of 
bouillon  for  his  patients.  He  ordered  camels'  meat 
to  be  used  for  this  purpose,  and,  when  that  fell  short, 
he  used  up  the  horses.  Years  afterward,  in  the  sec- 
ond campaign  against  .Austria,  the  imperial  guard 
and  several  other  corps  were  crowded  together  in  the 
island  of  Lobau  in  the  midst  of  the  Danube,  which 
Napleon  was  endeavoring  to  cross.  The  days  were 
roasting  and  the  nights  icy  cold,  and  provisions  be- 
came so  sarce  that  Larrey's  patients  were  in  danger 
of  starvation.     Without  more  ado  he  impounded  cer- 


344 


MEDICAL    RECORD. 


[September  4,  1897 


tain  officers'  horses  and  had  them  slaughtered  and 
employed  as  food.  As  there  was  a  lack  of  kettles,  he 
employed  the  cuirasses  of  those  who  had  been  killed, 
and  made  his  horse-flesh  soup  and  stews  in  them. 
Certain  generals  made  bitter  complaint  to  the  emperor 
of  Larrey's  proceedings,  who  summoned  the  surgeon - 
in-chief,  and  in  the  presence  of  his  staff  demanded  an 
explanation  with  a  severe  expression  of  countenance. 
"What,"  he  said,  "have  you  on  your  own  responsi- 
bility disposed  of  the  horses  of  the  othcers  in  order  to 
give  soup  to  your  wounded?""  "Yes,"  answered  Lar- 
rey.  He  added  no  more,  but  soon  afterward  he  heard 
of  his  promotion  to  the  rank  of  baron  of  the  empire. 

One  of  the  most  appalling  retreats,  next  to  that  from 
Moscow,  was  Napoleon's  retreat  from  the  invincible 
walls  of  St.  lean  d'Acre  through  Jaffa.  There  is  no 
doubt  that  at  that  place  considerable  numbers  of 
patients  sick  of  the  plague  were  quietly  put  out  of 
their  misery  by  opium.  Alison  says  si.xty:  Sir  Rob- 
ert Wilson  says  five  hundred  and  eighty.  The  retreat 
had  to  go  on,  the  Turks  were  only  an  hour's  march 
behind,  and  nothing  but  a  cruel  death  awaited  these 
unfortunates,  so  that  whether  this  were  a  justifiable 
deed  or  not  maV  well  give  ground  for  argument.  But, 
as  .\lison  says:  "  History  must  record  with  admiration 
the  answer  of  the  French  chief  of  the  medical  staff 
when  the  proposal  was  made  by  Napoleon  to  him: 
'  My  vocation  is  to  prolong  life,  and  not  to  extinguish 
it.'" 

In  those  days  means  of  transport  were  so  inferior, 
and  the  necessity  for  removing  hopelessly  damaged 
limbs  as  soon  as  possible  after  the  injury  so  impera- 
tive, that  amputations  were  performed  on  the  field  of 
battle,  while  it  was  still  raging,  and  amid  showers  of 
bullets.  During  the  battle  produced  by  the  landing 
of  the  English  in  .\boukir  Bay,  General  Silly  had  his 
knee  crushed  by  a  bullet.  Larrey  saw  that  imless  the 
leg  were  promptly  amputated  the  case  would  prove 
fatal,  and,  the  general  giving  his  consent,  the  opera- 
tion vvas  performed  in  the  space  of  three  minutes  under 
the  enemy's  fire.  Just  then  the  English  cavalry  came 
upon  them.  "  I  had  scarcely  time,"  said  Larrey,  "  to 
place  the  wounded  officer  on  my  shoulders  and  to  carry 
him  rapidly  away  toward  our  army,  which  was  in  full 
retreat.  I  spied  a  series  of  ditches,  some  of  them 
hedged  with  caper  bushes,  across  which  I  passed, 
while  the  enemy,  owing  to  the  ground  being  so  cut  up. 
had  t'o  go  by  a  more  circuitous  route.  Thus  I  had  the 
happiness  to  reach  the  rear  guard  of  our  army  before 
this  corps  of  dragoons,  .^t  length  I  arrived  at  Alex- 
andria with  this  honorably  wounded  officer,  where  I 
completed  his  cure."  We  must  all  agree  that  these 
were  a  pair  of  heroes.  , 

As  may  be  imagined,  the  awful  retreat  from  Mos- 
cow called  into  play  all  Larrey's  resources,  and  many 
an  interesting  story  could  be  told  of  his  efforts.  Think 
of  the  awful  battle  of  the  Borodino,  where  under  Lar- 
rey's own  direction  two  hundred  amputations  were 
performed,  where  there  were  neither  couches  nor 
blankets  nor  covering  of  any  kind,  and  where  the  food 
consisted  of  horseflesh,  cabbage  stalks,  and  a  few  po- 
tatoes. Think  of  cold  so  intense  that  the  instruments 
requisite  for  the  operations  too  often  tumbled  from  the 
powerless  hands  of  the  French  surgeons.  Think  of 
the  savage  Cossacks,  hovering  about  all  the  while, 
and  waiting  their  chance  to  kill  the  surgeon  and  the 
wounded  men  equally  with  the  combatant.  Then  came 
tlie  passage  of  the  ]5eresina.  Take  an  incident  of  it. 
Among  the  wounded  was  General  Zayonchek,  who  was 
over  sixty  years  of  age.  His  knee  was  crushed,  and 
without  amputation  the  saving  of  his  life  was  impos- 
sible, it  was  performed  under  the  enemy's  fire,  and 
amid  thick-falling  snow.  There  was  no  shelter  except 
a  cloak,  which  two  officers  held  over  him  while  the 
operation  was  being  performed;    but  the  surgeons  did 


their  work  with  such  coolness  and  dexterity  that  the 
old  general  survived,  and  died  fourteen  years  after- 
ward viceroy  of  Poland.  Larrey  succeeded  in  getting 
over  the  Beresina  with  the  imperial  guard,  but  dis- 
covered that  the  requisites  for  the  sick  and  wounded 
had  been  left  on  the  other  side.  At  once  he  recrossed 
the  river,  only  to  find  himself  in  the  midst  of  a  furi- 
ous struggling  crowd.  He  was  on  the  point  of  being 
crushed  to  death  when  providentially  the  soldiers  rec- 
ognized him.  No  .sooner  did  they  do  so  than  they 
carried  him  across  the  river  in  their  arms,  with  the 
cry,  "  Let  us  save  him  who  saved  us!"  and  forgot  their 
own  safety  in  their  desire  to  preserve  the  man  whose 
tender  kindness  they  had  so  often  experienced. 

Following  his  adored  master  through  victory  and 
defeat,  Larrey  at  last  stood  at  night  on  the  field  of 
Waterloo,  alone  except  for  some  medical  officers  and 
the  wounded  who  lay  groaning  around  them.  Down 
upon  them  came  a  squadron  of  Prussian  lancers.  Elx- 
pecting  no  quarter,  he  fired  his  pistols  at  them  and 
galloped  away.  They  shot  his  horse  and  sabred  him 
as  he  lay  on  the  ground.  Leaving -him  apparently 
dead,  they  went  off.  But  he  recovered  his  senses,  and 
tried  to  crawl  by  crossroads  into  France.  Again  he 
was  seized  by  another  detachment  of  Prussian  cav- 
alry. They  robbed  him  promptly  of  all  he  possessed, 
and  took  him  before  a  superior  officer,  who  ordered 
him  to  be  shot.  What  a  reward  from  a  soldier  to  one 
whose  life  had  been  passed  in  succoring  soldiers! 
About  a  quarter  of  an  hour  before  the  sentence  was  to 
be  carried  out,  a  surgeon-major  recognized  Larrey. 
He  had  attended  with  deep  intere.st  a  course  of  lec- 
tures which  Larrey  had  delivered  in  Berlin  six  years 
previously.  The  prisoner  was  brought  before  Bulow, 
and  finally  presented  to  Bliicher,  whose  son  in  the 
.\ustrian  campaign  had  been  badly  wounded  and  cap- 
tured by  the  French,  and  who  owed  his  life  to  Larrey's 
exertions. 

Larrey's  honorable  and  glorious  life  terminated  in 
1842.  Napoleon,  when  he  made  his  will  at  St.  He- 
lena, wrote  in  it:  "I  bequeath  to  the  surgeon-in-chief 
of  the  French  army,  Larrey,  100,000  francs.  He  is 
the  most  virtuous  man  I  have  e\er  known."  From 
Napoleon's  lips  the  words  of  free,  spontaneous,  un- 
grudging praise  such  as  tliis  rarely  fell. 

Pestilence  More  Deadly  than  the  Sword. — In  the 
middle  of  the  last  century,  while  surgery  had  distinctly 
impro\ed,  the  gross  neglect  of  the  government  and  the 
pig-headed  obstinacy  of  the  generals  were  such  that  our 
unfortunate  soldiers  and  sailors  were  hardly  any  better 
off  than  they  were  in  the  days  of  Pare.  It  has  been 
maintained  that  Smollett,  in  the  appalling  picture  of 
naval  life  as  witnessed  in  the  miserable  expedition  to 
Carthagena  which  he  drew  in  "  Roderick  Random,'"  and 
which  is  known  to  have  been  the  record  of  his  own 
experience  as  surgeon's  mate,  grossly  exaggerated  the 
evils  thereof.  I  do  not  believe  this.  Look  at  the 
awful  and  unsuccessful  expedition  to  Porto  Bello  in 
1726,  when  nearly  tlie  whole  of  tlie  crews  of  the  ships 
were  destroyed  by  fever  three  times  over;  where  2 
admirals,  10  captains,  50  lieutenants,  and  about  3.000 
to  4,000  inferior  officers  and  men  perished  without 
striking  a  blow.  Look  at  the  taking  of  Havana  in 
1762.  The  Earl  of  Albemarle  look  with  him  in  the 
lleet  11,000  soldiers.  Between  June  and  the  middle 
of  October,  when  Cuba  was  ours,  we  had  lost  560  men 
by  wounds,  and  4,708  by  sickness.  At  the  end  of  the 
seven  years'  war  a  statement  was  drawn  up  in  the 
"Annual  Register"'  for  1763,  from  which  it  appeared 
that  in  all  the  naval  battles  of  that  war  there  were  but 
1,512  sailors  and  marines  killed,  while  133,738  had 
died  of  disease  or  were  "  missing."  Look  even  at  the 
end  of  last  century,  and  consider  the  wretched  and 
disgraceful  Walcheren  campaign.  Never  did  our  poor 
soldiers  fight  with  more  gallantrv  than  in  that  cam- 


September  4,  1897] 


MEDICAL    RFXORU. 


345 


paign,  onlv  to  perish  beside  Dutch  ditches  and  canals 
from  fever  and  ague  and  dysentery. 

Military  Courage. — As  we  have  just  seen,  Baron 
Larrey's  whole  life  shows  that,  while  absolutely  de- 
voted to  the  work  of  his  profession,  he  displayed  a 
cool  courage  on  the  field  of  battle  not  less  heroic  than 
the  more  dazzling  deeds  of  his  fellow  combatant  offi- 
cers. Not  less  does  it  mark  the  military  surgeon  of 
the  present  day.  Have  you  ever  heard  of  Surgeon 
Thomson,  who,  during  the  Crimean  war,  when  the 
armv  marched  off  after  the  battle  of  the  Alma,  volun- 
teered with  his  ser\'ant,  John  McGrath,  to  remain  be- 
hind on  the  open  field  with  five  hundred  terribly 
wounded  Russians,  and  passed  three  awful  days  and 
nights — these  two  Englishmen  alone — among  foreign 
foes,  some  dead,  some  dying,  and  none  able  to  raise  a 
hand  to  help  themselves?  Have  you  ever  heard  of 
Assistant  Surgeon  Wolseley,  of  the  twentieth  regi- 
ment, who,  at  the  battle  of  Inkerman,  had  quietly  es- 
tablished his  field  hospital  in  that  awful  place,  the 
Sandbag  Battery?  When  the  one  hundred  and  fifty 
men,  who  were  all  that  remained  of  its  defenders,  were 
forced  to  desert  it,  about  one  hundred  of  them  fell  back 
in  one  direction,  and  in  that  they  found,  at  thirty  paces 
from  them,  a  Russian  battalion  blocking  their  path. 
There  was  not  a  combatant  officer  left,  so  the  assistant 
surgeon  took  command.  He  had  not  even  a  sword 
with  him,  but,  laying  hold  of  a  firelock  with  a  fi.xed 
bayonet  on  it,  he  spoke  a  few  words  to  the  men  within 
range  of  his  voice,  and  told  them  that  what  they  now 
had  to  fight  for  was  not  victory  but  life.  Then  he 
gave  them  the  word  of  command :  '"  Fix  bayonets, 
charge,  and  keep  up  the  hill."  The  soldiers  answered 
him  with  a  burst  of  hurrahs,  sprang  forward  to  the 
charge,  and  the  next  instant  were  tearing  through  the 
thickest  of  the  Russians.  One-half  of  these  reached 
the  other  side  alive.  Have  you  ever  hard  of  Surgeon 
Landon,  who  was  shot  through  the  spine  while  attend- 
ing to  the  wounded  on  Majuba  Hil'  ?  His  legs  were 
paralyzed,  but  he  caused  himself  m  be  propped  up, 
and  continued  his  merciful  work  till  his  strength 
ebbed  away.  When  unable  for  more  he  quietly  said : 
"I  am  dying;  do  what  you  can  for  the  wounded." 
Have  you  ever  heard  of  Surgeon-Captain  Whitchurch, 
who  gained  the  Victor  a  Cross  at  the  beleaguering  of 
Chitral  for  the  most  determined  courage  in  endeavor- 
ing to  save  the  life  of  Major  Baird?  Yes,  you  have, 
for  last  year  at  Carlisle  you  gave  him  the  gold  medal 
of  the  association,  the  highest  honor  which  our  asso- 
ciation can  give  to  its  members.  There  died  the 
other  day  a  certain  Surgeon-General  Reade,  C.B., 
V.C.  During  the  siege  of  Delhi,  while  attending  to 
the  wounded  at  the  end  of  one  of  the  streets  of  the 
city,  a  party  of  rebels  advanced  from  the  direction  of 
the  bank,  and,  having  established  themselves  in  the 
houses  in  the  street,  commenced  firing  from  the  roofs. 
The  wounded  were  thus  in  very  great  danger,  and 
•would  have  fallen  into  the  hands  of  the  enemy  had 
not  Surgeon  Reade  drawn  his  sword  and,  calling  upon 
a  few  soldiers  who  were  near  to  follow,  succeeded 
under  a  very  iieavy  fire  in  dislodging  the  rebels  from 
their  position.  Surgeon  Reade's  party  consisted  of 
about  ten  in  all,  of  whom  two  were  killed  and  five  or 
six  wounded.  Ladies  and  gentlemen,  Surgeon  Reade 
was  a  ("anadian,  and  the  son  of  a  colonel  of  the  Cana- 
dian militia.  Of  the  one  hundred  and  eighteen  wear- 
ers of  the  Victoria  cross  fourteen  are  surgeons,  nearly 
twelve  per  cent,  of  the  whole  number.  They  stand  in 
the  proportion  of  9.5  per  cent,  of  ali  the  officers  of  the 
army,  so  at  all  events  they  have  contributed  not  less 
than  their  fair  share  of  the  deeds  of  valor  which  alone 
can  win  that  glorious  distinction. 

The  Army  Medical  Service  To-day.— Ladies  and 
Gentlemen:  I  have  diverged  from  the  beaten  track 
common  to  the  givers  of  addresses  such  as  this  to  tell 


you  what  splendid  men  have  been  the  military  and 
naval  surgeons  of  old,  who  not  merely  did  their  duty 
nobly  and  courageously  as  such,  but  who  have  in  their 
day  enormously  contributed  to  the  advance  of  the  art 
of  surgery.  I  have  done  it  with  a  purpose;  with  the 
hope  of  attracting  more  strongly  than  ever  the  sympa- 
thy and  help  of  this  great  association  to  their  military 
brethren  in  a  critical  juncture  of  their  history.  To- 
day Her  Majesty's  government  cannot  induce  candi- 
dates to  come  forward  for  the  medical  service  of  the 
Queen's  anny.  And  why?  Because  it  has  persis- 
tently treated  the  army  medical  department  meanly  and 
shabbily.  To-day  the  government  of  India  can  secure 
the  ser\-ices  of  the  pick  of  our  newly  fledged  doctors 
for  its  army.  And  why?  Because  it  has  always 
treated  the  Indian  medical  service  liberally  and  gen- 
erously. I  am  not  going  to  enter  into  the  reasons  for 
this ;  I  desire  merely  to  emphasize  one  point,  namely, 
that  money  is  not  at  the  bottom  of  this  difficulty.  The 
soldier  surgeons  of  to-day  are  the  same  men  now  that 
they  "\vere  in  the  days  of  William  Clowes,  who  winds 
up  his  book,  as  I  shall  my  address,  with  these  verses : 

"  When  valiant  Mars,  with  brave  and  warlike  band. 
In  foughten  field  with  sword  and  shield  doth  stand, 
May  there  be  mist  a  surgeon  that  is  good. 
To  salve  your  wounds  and  eke  to  stay  your  bloud. 

"  To  cure  you  sure  he  will  have  watchful  eie, 
And  with  such  wights  he  means  to  live  and  die. 
So  that  againe  you  must  augment  his  store, 
.\nd  ha\-ing  this  he  will  request  no  more." 


THE    PROGRESS    AND    RESULTS    OF    PATH- 
OLOGICAL  WORK.' 

Bv    W.    W.\T.sOX    CHEVNE,    M.}!.,     F.R.C.S.,    F.R.S.. 

LONDON,    ENGLAND, 
rROFE<:?OR   OF  Sl'RGERV,   KING'S  COLLEGE,   LONDON,  ETC. 

Gentlemen  :  On  such  an  occasion  as  this  one  is  natu- 
rally tempted  to  look  back  on  the  history  of  pathology 
during  the  last  sixty  years,  but  I  hope  that  you  will  not 
expect  me  to  follow  the  fashion  in  this  respect.  To 
trace  the  history  of  pathology  during  the  last  sixty" 
years  would  be  to  follow  the  science  practically  from 
its  commencement  and  go  back  to  a  state  of  matters 
which  it  is  almost  impossible  for  us  now  to  realize. 
Even  going  back  to  the  time  when  I  was  first  intro- 
duced to  the  study  of  pathology,  some  twenty-five  years 
ago,  the  changes  which  have  taken  place  are  enormous. 
At  that  time  the  lectures  on  pathology  consisted  prac- 
tically entirely  of  morbid  anatomy — long  descriptions, 
for  the  most  part  very  accurate  and  not  materially  dif- 
ferent from  those  of  the  present  day,  were  given  of  the 
naked-eye  appearances  of  the  diseased  parts,  but  as  to 
how  or  why  these  changes  were  brought  about  hardly 
any  reference  was  made.  Indeed,  very  little  was  known, 
and  when  an  explanation  was  attempted  it  was  gener- 
ally of  a  mechanical  or  physical  character.  At  the 
present  time,  while,  of  course,  the  changes  which  take 
place  in  disease  must  be  known,  the  study  of  pathology- 
is  especially  directed  to  the  discovery  of  the  mode  in 
which  these  changes  occur  and  the  reasons  why  they 
appear.  To-day  it  is  the  etiological  side  of  pathol- 
ogy, so  to  speak,  which  occupies  our  attention,  and 
deservedly  so,  for,  so  far  as  practical  results  in  the 
treatment  of  disease  are  concerned,  the  knowledge  of 
the  changes  produced  is  of  comparatively  minor  im- 
portance as  compared  with  that  of  the  reason  why  they 
are  set  up  and  how  they  take  place.  The  more  accu- 
rately we  can  trace  the  etiological  factors  in  disease 
and  the  subsequent  course  of  events,  the  more  likely 
are  we  to  arrive  at  a  rational  method  of  treatment. 

'  An  address  delivered  at  the  opening  of  the  section  of  pathol- 
<igy,  at  the  annual  meeting  of  the  British  .Medical  Association,  at 
.Montreal,  September  i,  1897. 


346 


>fF,I>IC.\L    RKCr)KI). 


[September  4.  1897 


The  most  striking  and  important  advance  lias  Ijcen 
the  growth  of  the  great  science  of  bacteriology,  a  sci- 
ence which  has  not  only  led  to  most  important  practi- 
cal results,  but  has  also  thrown  a  flood  of  light  on  the 
processes  which  go  on  in  the  body  as  a  whole,  and  has 
stimulated  research  in  other  directions  not  immediately 
associated  with  it.  Twenty-five  years  ago  bacteriol- 
ogy as  a  science  was  nonexistent.  So  far  as  I  re- 
member bacteria  were  not  even  alluded  to  in  our  course 
of  pathology,  and  it  was  only  from  Lord  Lister  that 
we  heard  the  real  facts  so  far  as  they  were  known,  or 
gained  any  idea  of  the  importance  of  their  study;  but 
even  at  that  time,  although  his  methods  of  treatment 
were  already  yielding  brilliant  results  and  saving 
many  lives,  and  although  he  had  deduced  from  clinical 
facts  many  points  in  the  life  history  of  bacteria  and 
their  relations  to  the  living  body,  which  were  only 
confirmed  by  experiment  subsequently,  still  the  num- 
ber of  actual  proved  facts  was  e.xtreniely  few. 

It  is  difficult  for  those  who  have  taken  up  the  subject 
of  bacteriology  only  comparatively  recently  to  real- 
ize the  absolute  blank  which  it  presented  even  twenty 
years  ago.  When  I  became  house  surgeon  to  Lord 
Lister  in  1876  objections  of  all  kinds  were  urged 
against  the  theory  on  which  Listerism  was  based,  some 
denying  the  existence  of  bacteria  at  all,  others  main- 
taining the  theory  of  spontaneous  generation:  some 
asserting  that  organisms  were  always  present  in  the 
healthy  tissues,  others  denying  that  they  had  anything 
to  do  with  disease,  or  that  the  success  of  the  antiseptic 
principle  depended  in  any  wav  on  the  exclusion  of  mi- 
cro-organisms from  wounds.  It  was  these  objections 
which  led  me  to  take  up  bacteriologj-,  for  it  seemed  to 
nie  of  great  importance  to  ascertain  whether  or  not,  as 
the  result  of  antiseptic  treatment,  organisms  were  ab- 
sent from  the  discharges  from  the  wounds.  Although 
at  the  present  time  such  an  investigation  would  be  one 
of  the  simplest,  yet  when  I  came  to  carry  it  out  I  was 
met  with  the  greatest  difficulties.  Practically  nothing 
of  the  kind  had  been  done  before,  and  all  the  means 
of  investigation  had  to  be  devised.  Methods  of  stain- 
ing bacteria  had  not  been  introduced,  we  had  no  oil- 
immersion  lenses,  and  I  very  soon  found  that  by  look- 
ing at  discharges  from  wounds  containing  leucocytes, 
granular  matter,  and  ilebris  with  dry  or  water  immer- 
sion lenses,  and  w  ithout  substage  condensers,  no  sat- 
isfactory result  could  be  arrived  at.  Hence  I  came  to 
the  conclusion  that  attempts  must  be  made  to  see 
whether  organisms  grew  in  suitable  fluids  inoculated 
from  the  discharges.  Here  again  everything  had  to  be 
devised.  A  suitable  pabulum,  methods  of  steriliza- 
tion, of  inoculation,  and  of  incubation  had  to  be 
worked  out.  .\  large  amount  of  time  was  spent  in 
getting  over  the  preliminary  difficulties,  and  after  a 
satisfactory  method  had  been  found  much  labor  had 
to  be  devoted  to  preliminary  questions,  such  as  spon- 
taneous generation,  morphological  characters  of  bac- 
teria, their  presence  or  absence  in  the  living  body, 
conditions  of  growth,  and  so  on. 

A  great  advance  which  followed  soon  afterward  was 
the  remarkable  research  by  Lord  Lister  on  the  bacte- 
rium lactis,  in  which  he  devised  a  method  of  separat- 
ing bacteria  by  fractional  cultivation,  which  resulted 
in  the  separation  of  the  bacterium  which  causes  lactic 
fermentation  from  other  organisms.  By  this  research, 
apart  from  the  method,  a  great  step  was  gained  in  the 
proof  of  the  specificit}-  of  a  particular  bacterium,  both 
as  regards  morphological  characters  and  chemical  ac- 
tion. 

Then  came  Koch's  work  on  infective  diseases  of 
wounds,  and  the  publication  of  his  methods  of  stain- 
ing and  examining  bacteria  and  of  cultivating  them 
on  solid  media,  and  this  work  is  at  the  foundation  of 
all  modern  bacteriological  research.  From  this  period 
the  investigations  have  branched  off  in  two  directions. 


In  the  first  place,  almost  all  the  infective  diseases 
have  been  investigated  for  parasitic  organisms,  and  in 
a  large  number  the  causal  agents  have  been  identified. 
.Vnd,  in  the  .second  place,  researches  have  been  carried 
on  in  the  direction  of  tracing  out  the  life  history  and 
functional  activity  of  bacteria,  and  of  ascertaining 
what  occurs  in  the  body  when  organisms  or  their  pro- 
ducts are  introduced. 

From  the  latter  point  of  view  we  come  to  another 
great  landmark  in  the  study  of  bacteriology,  namely, 
Metchnikoff's  work  on  phagocytosis,  a  theory  which  is 
not  only  very  fascinating  in  itself,  but  which  has 
proved  a  most  suggestive  working  hypothesis  leading 
to  many  of  the  researches  which  have  given  bacteriol- 
ogy its  present  position.  What  a  remarkable  series  of 
views  have  been  opened  up  in  this  direction;  ques- 
tions of  the  relation  of  the  cells  of  the  body  to  the 
parasite,  the  differentiation  of  cells,  alterations  in  se- 
rum, chemiotaxis,  the  development  of  the  protective 
agencies  and  of  antibacteric  substances,  antitoxins, 
immunity,  and  so  forth.  And  yet  we  are  clearly  only 
on  the  threshold:  the  very  simplicity  of  many  of  the 
explanations  is,  to  my  mind,  sufficient  to  show  that 
they  are  incomplete,  for  the  workings  of  the  living 
body  are  far  too  intricate  to  be  summed  up  in  a  simple 
formula. 

In  spite,  however,  of  all  that  has  been  done,  many 
problems  still  remain  unsolved.  In  the  case  of  tuber- 
culosis, why  is  it  that  in  one  part  of  the  body  we  have 
a  slow-growing  lupus  disease,  and  in  another  part, 
perhaps,  of  the  same  body  a  rapidly  developing  tuber- 
culosis? None  of  the  explanations  usually  given, 
such  as  difference.-,  in  the  structure  or  resisting  pwwer 
of  the  tissues  affected  or  of  the  individual,  differences 
in  the  virulence  or  activity  of  the  organism,  etc., 
seems  to  furnish  sufficient  explanation.  And  the  same 
problem  is  apparently  presented  with  regard  to  the  ba- 
cilli of  diphtheria,  in  that  we  may  have  in  one  case  a 
true  diphtheria,  in  another  a  membranous  rhinitis, 
while  in  the  third,  although  the  bacilli  are  present  in 
the  throat,  the  individual  may  be  apparently  healthy. 

.\nother  very  remarkable  problem  is  presented  by 
the  results  which  follow  free  incisions  into  tuberculous 
tissue.  An  incision  is  made  into  the  abdominal  cav- 
ity, masses  of  tuberculous  tissue  and  tubercle  ar« 
found  scattered  over  the  peritoneum ;  nothing  whateyer 
is  done,  the  wound  is  stitched  up,  and  yet  in  many 
cases  the  patient,  who  up  to  that  time  has  been  going 
steadily  down  hill,  begins  to  pick  up,  and  the  disease 
may  come  entirely  to  a  standstill.  This  phenomenon 
is  not  limited  to  peritoneal  tuberculosis.  When  1  was 
a  student  the  tuberculous  nature  of  what  are  now  rec- 
ognized as  tuberculous  diseases  of  bones  and  joints 
was  then  only  suspected,  and  was  not  generally  ac- 
cepted by  the  medical  profession.  At  that  time  Lord 
Lister,  under  the  impression  that  these  diseases  were 
of  a  simple  inflammatory  nature,  and  having  observed 
the  improvement  which  often  followed  free  incisions 
into  chronically  inflamed  tissues,  began  as  an  ordinary 
line  of  practice  to  make  free  incisions  through  the 
thickened  synovial  membrane  of  tuberculous  joints 
with  the  view  of  relieving  tension,  which  he  looked  on 
as  the  chief  cause  of  the  continuance  of  the  trouble. 
Nothing  else  was  done,  the  joint  was  not  even  washed 
out,  nothing  was  taken  away,  and  yet  in  a  considera- 
ble number  of  cases  so  treated  improvement  began 
from  the  time  that  the  incisions  were  made,  the  pa- 
tients lost  their  pain,  the  wounds  gradually  healed  up, 
and-the  disease  subsided.  F.ven  in  cases  in  which  the 
results  were  not  so  satisfactory  it  could  as  a  rule  be 
noted  that,  although  the  swelling  continued  in  other 
parts  of  tile  joint,  and  although  the  disease  began 
again  after  a  few  weeks  as  vigorously  as  before,  yet 
for  a  time  at  least  the  thickening  disappeared  in  the 
neighborhood  of  the  scars,  showing  that  there  at  any 


September  4,  1897] 


MEDICAL    RECORD. 


347 


rate  temporary  benefit  had  occurred.  What  possible 
explanation  can  we  give  of  such  a  result  ?  The  older 
surgeons  used  to  speak  of  "setting  up  a  healthy  action 
in  the  part,"  and  were  quite  satisfied  with  that  state- 
ment. Such  a  view  is  too  vague  for  us  nowadays,  but 
may  there  not  be  here  a  possible  working  hypothesis 
which  if  followed  out  might  throw  light  on  this  mat- 
ter? May  not  the  occurrence  of  healing  processes  at 
one  part  influence  in  some  way  or  other  morliid  proc- 
esses in  the  vicinity? 

Again,  what  is  the  meaning  of  a  chronic  abscess? 
How  is  it  that  the  tubercle  bacilli  at  one  time  pro- 
duce a  quantit}'  of  tuberculous  tissue,  at  another  a 
cheesy  mass,  and  at  another  a  chronic  abscess?  I  do 
not  for  one  moment  accept  the  view  that  we  have  in 
the  latter  case  to  do  with  a  mixed  infection,  and  thai 
the  pyogenic  organisms  have  died  out  before  the  ab- 
scess was  opened. 

In  connection  with  the  pyogenic  organisms  also  wc 
have  many  problems.  How  is  it,  for  example,  that 
after  an  abscess;  is  opened  antiseptically  suppuration 
at  once  ceases?  If  instead  of  opening  the  abscess  an- 
tiseptically a  poultice  be  applied,  suppuration  goes  on 
and  may  be  verj-  profuse.  But  if  it  be  opened  at  a 
time  when  there  is  free  fluctuation  and  when  it  is  be- 
ginning to  point,  and  if  the  necessary  antiseptic  pre- 
cautions be  taken  and  proper  drainage  provided  no 
more  pus  forms,  and  vet  when  the  abscess  is  opened  it 
is  found  to  contain  livmg  pyogenic  organisms.  We 
can  easily  understand  that  the  subsidence  of  the  fever 
and  general  disturbance  is  due  to  diminished  absorp- 
tion of  toxic  products.  But  why  do  not  these  living 
pyogenic  organisms  keep  up  the  suppuration  ?  and  why 
is  it  that  after  two  or  three  days  one  may  fail  to  ob- 
tain any  cultivations  from  the  serum  which  escapes 
from  the  wound?  If  the  inllamed  part  be  opened  up 
antiseptically,  however,  at  an  early  period,  just  when 
pus  is  beginning  to  form,  there  is  not  always  the  same 
complete  absence  of  suppuration,  although  it  seldom 
goes  on  to  any  considerable  extent. 

.■\gain,  an  operation  wound  becomes  septic  and  one 
naturally  opens  it  up  freely  and  establishes  drainage: 
but  here  suppuration  does  not  cease  at  once  in  the 
same  typical  manner  as  in  the  case  of  an  abscess 
which  has  existed  for  some  days.  The  old  surgeons 
used  to  speak  of  an  abscess  being  "ripe,"  and  they  al- 
lowed it  to  remain  unopened  for  some  days  till  it  was 
pointing.  They  found  that  if  they  opened  a  deep  ab- 
scess early,  suppuration  went  on  and  was  apt  to  extend. 
No  doubt  a  variety  of  causes  led  to  this  dictum  :  they 
did  not  provide  proper  drainage;  they  introduced 
other  and  more  vigorous  organisms  at  the  time  of 
operation  and  afterward,  etc. :  but  do  not  the  facts 
seem  to  indicate  that,  as  regards  the  cessation  of  sup- 
puration, there  is  some  ground  for  this  idea  of  riix,-- 
ness?  Is  it  possible  that  when  the  abscess  has  at- 
tained a  considerable  size  and  the  tension  of  the  pus 
in  it  is  great  the  sudden  release  of  the  pent-up  fluid 
may  lead  to  such  a  pouring  out  of  serum  containing 
antitoxic  substances  as  absolutely  to  destroy  the  organ- 
isms present,  w^hile,  the  case  being  treated  antisepti- 
cally, no  fresh  organisms  can  come  in  to  take  their 
place?  And  yet  I  can  hardly  think  that  that  is  the 
whole  explanation. 

Although  it  is  in  the  department  of  bacteriology 
that  the  most  striking  advance  has  been  made,  great 
progress  has  also  gone  on  in  patholog)'  generally,  in  a 
considerable  number  of  cases  no  doubt  stimulated  by 
the  results  of  bacteriological  research,  and  more  espe- 
cially by  MetchnikofF's  work.  The  subject  of  inflam- 
mation has  had  much  attention  paid  to  it  as  the  result 
of  these  studies,  although  I  cannot  say  that  to  my  mind 
it  has  been  made  any  clearer.  The  tendency  now  ap- 
pears to  be  to  regard  inflammation  as  the  natural  etTort 
at  repair  after  injury.      At  one  time  this  was  the  view 


held  by  surgeons,  and  the  doctrine  was  that  inflamma- 
tion was  essential  to  healing,  and  in  the  description  of 
healing  by  first  intention  it  was  stated  that  a  red  blush 
occurred  around  the  wound,  not  so  severe,  however,  as 
where  suppuration  takes  place,  and  that  without  this 
red  blush  the  edges  did  not  adhere.  When  antiseptic 
treatment  was  introduced  it  became  evident  that  no 
inflammatory  blush  or  other  sign  of  inflammation  was 
necessar}-  for  healing  by  first  intention;  in  fact,  it  was 
found  that  wounds  healed  best  when  no  visible  sign  of 
inflammation  was  present.  I  have,  therefore,  always 
taught  that  inflammation  and  healing  are  two  differ- 
ent and,  indeed,  to  some  extent  antagonistic  processes, 
and  that  although  in  every  wound  the  tissues  in  resent- 
ing the  injur}-  show  the  early  stage  of  inflammation, 
yet  if  no  organisms  be  admitted  the  inflammatory  phe- 
nomena soon  pass  olT,  and  where  there  is  destruction 
of  tissue  a  second  process,  namely,  that  of  repair,  be- 
gins. As  I  have  said,  in  recent  writings  the  tendency 
apjjears  to  be  to  look  on  inflammation  and  healing  as 
parts  of  the  same  process;  but  in  spite  of  the  verv 
able  arguments  adduced  in  favor  of  this  view  I  am 
still  unconvinced.  I  still  look  on  inflammation  as  the 
mechanism  which  gets  rid  of  rioxious  agents  or  neu- 
tralizes their  eftects,  and  on  the  healing  process  as 
that  which  repairs  defects,  whether  they  are  caused  by 
injury  and  associated  with  inflammation  or  not.  In 
fact,  inflammation  must  be  followed  by  repair  if  recov- 
ery is  to  take  place,  but  repair  need  not  be  preceded 
by  inflammation.  The  difficult}'  arises  from  the  close 
association  of  the  two  processes,  both  of  which  have 
to  do  with  the  growth  of  cells,  and  from  the  fact  that 
repair  follows  as  soon  as  the  inflammation  begins  to 
subside.  Hence  under  the  microscope,  except  in  cases 
of  acute  suppurative  inflammation,  one  sees  the  two 
processes  at  work  side  by  side,  and  it  is  not  a  matter 
of  surprise  that  they  should  be  confounded.  As  a 
matter  of  fact,  the  more  the  cellular  processes  are  in- 
vestigated the  more  it  becomes  evident  that  there  is  a 
marked  differentiation  of  cells  as  regards  function. 

When  Cohnheim  first  published  his  observations  on 
the  emigration  of  corpuscles  it  was  thought  by  many 
that  the  leucoc}'te  was  everything  and  did  everything, 
but  it  was  soon  evident  that  other  cells  of  different 
origin  must  be  taken  into  consideration.  When  Metch- 
nikoft's  theor}-  of  phagocytosis  first  came  out,  some 
of  those  who  adopted  it  assumed  that  all  wandering 
cells  were  phagocytes:  but  here,  again,  further  inves- 
tigation has  shown  that  cells  difter  greatly  as  regards 
their  phagocytic  action.  I  think  that  a  good  deal  of 
the  confusion  of  these  processes  arises  from  the  fact 
that  expressions  involving  a  teleological  argument  are 
becoming  very  common,  more  especially  with  regard 
to  the  protective  arrangements  of  the  body.  On  the 
idea  of  an  acting  intelligence  on  the  part  of  the  cells, 
the  two  processes  would  naturally  go  together;  but, 
looked  on  as  the  simple  effect  of  an  injury,  they 
should,  I  believe,  be  regarded  as  independent,  and 
the  less  and  the  shorter  the  inflammation  the  better 
and  quicker  the  healing  process. 

A  ver}-  remarkable  thing  in  connection  with  these 
advances,  especially  in  experimental  patholog}-,  is  the 
enormous  direct  practical  benefit  which  has  already 
resulted  to  the  human  race;  and  it  is  sufficient  answer 
to  the  antivivisectionists  who  oppose  the  use  of  intel- 
ligence and  observation  and  experiment,  to  point  to 
the  saving  of  human  life  and  the  relief  of  suft'ering 
which  has  taken  place  in  the  last  few  years.  Since 
Pasteur's  experiments  on  spontaneous  generation  were 
published,  only  thirty-six  years  have  elapsed,  and  dur- 
ing that  time  remarkable  results  ha\e  been  attained  in 
treatment  as  the  result  of  experimental  patholog}-. 

Scientific  eft'ort  to  arrive  at  the  truth  as  regards  the 
workings  of  nature  are  necessarily  slow,  and  must  be 
carried  on  without   anv   regard   to   possible  ultimate 


348 


MEDICAL    RECORD. 


[September  4,  1897 


practical  results.  When  the  earlier  investigators  stud- 
ied the  phenomena  of  electrical  action,  I  doubt  if  it 
ever  occurred  to  them  that  the  result  of  their  study 
would  be  of  any  practical  value;  certainly  they  could 
have  had  no  idea  of  the  revolution  which  the  study  of 
electricity  would  effect  in  the  history  of  the  world. 
When  Pasteur  resolved  to  test  the  theory  of  spontane- 
ous generation,  it  did  not  seem  likely  to  lead  to  any 
beneficial  result;  indeed,  his  friends  tried  to  dissuade 
him  from  entering  into  what  was  apparently  a  useless 
investigation,  and  yet  what  numbers  of  human  lives 
have  been  saved  as  the  result  of  that  work,  and  what 
incalculable  benefit  has  accrued!  It  is  greatly  the 
fashion  with  the  opponents  of  e.xperimental  research 
to  demand  a  single  instance  in  which  an  experiment 
has  led  to  the  discovery  of  a  means  of  cure;  but  in  no 
department  of  science  has  a  single  e-xperiment  of  itself 
alone  led  to  the  practical  result;  the  final  observation 
which  led  to  the  practical  result  has  been  built  up  on 
numerous  and'laborious  preliminary  investigations  and 
observations.  .4nd  similarly,  in  regard  to  the  cure  or 
prevention  of  disease,  the  final  trials  on  man  have  been 
led  up  to  by  numerous  preceding  observations  and  ex- 
periments. If  these  deluded  people  had  their  way,  the 
result  would  be  that  experiments  would  be  limited  to 
man,  and  every  one  to  whom  a  new  idea  occurred  would 
apply  it  wdthout  any  previous  investigation — surely  an 
appalling  prospect,  whether  for  physician  or  patient. 

The  practical  results  already  obtained  affect  diag- 
nosis, prophylaxis,  and  treatment.  The  diagnosis  of 
many  parasitic  diseases  has  now  been  rendered  certain 
and  easy  by  searching  for  the  causal  organism,  and  I 
need  only  instance  such  diseases  as  diphtheria,  tuber- 
culosis, malaria,  anthrax,  gonorrhcta,  etc.  And  it  is 
not  only  by  the  discovery  of  the  parasite  that  diag- 
nosis is  assisted,  but  also  by  other  effects  of  the  or- 
ganism, such  as  the  sort  of  changes  set  up  in  the  tissue, 
the  reaction  to  products  of  the  organism,  for  instance 
tuberculin  and  mallein,  etc.,  and  we  shall  hear  a  good 
deal  about  one  of  these  diagnostic  advances  in  the 
course  of  the  meeting,  namely,  the  action  of  the  serum 
of  typhoid  patients  on  motile  typhoid  bacilli.  If  no 
other  practical  advance  had  resulted  from  bacterio- 
logical work,  the  possibility  of  establishing  a  definite 
diagnosis  in  obscure  cases  is  surely  a  gain  of  the  ut- 
most importance,  for  it  enables  a  rational  prophylaxis 
and  treatment  to  be  instituted. 

The  greatest  of  all  the  advances,  because  so  wide- 
reaching,  has  been  in  the  prophylaxis  of  disease,  espe- 
cially in  the  prevention  of  septic  disease  after  opera- 
tions, as  brought  about  by  the  discoveries  of  Lord 
Lister.  By  these  discoveries  the  occurrence  of  sepsis 
in  wounds  made  through  unbroken  skin  is  prevented, 
and  the  chances  of  general  sepsis  in  septic  wounds 
are  much  diminished,  and  numerous  lives  are  saved, 
not  only  in  this  way,  but  also  by  tlie  fact  that  the  Lis- 
terian  treatment  permits  the  performance  of  many  life- 
saving  operations  which  could  not  otherwise  be  at- 
tempted. In  other  cases  also,  prophylaxis  is  of  great 
value,  as  in  diphtheria,  and  in  Pasteur's  treatment  of 
rabies,  which  may  properly  be  grouped  as  a  prophy- 
lactic rather  dian  a  curative  treatment. 

Lastly,  I  may  refer  to  advances  in  the  cure  of  dis- 
ease. In  the  case  of  diphtheria  there  can  be  no  ques- 
tion that  the  antitoxin  is  a  most  potent  curative  agent, 
and  that,  used  in  the  early  stages,  it  is  almost  certain 
to  cut  short  the  disease.  .\s  regards  tetanus,  the  evi- 
dence in  tlie  case  of  animals  is  absolutely  convincing, 
but  in  patients  suffering  from  the  disease  the  effect  is 
not  certain,  probably  because  we  have  to  do  with  an 
acute  illness,  which  runs  its  course  before  the  serum 
has  had  time  to  act.  The  same  may  also  be  the  case 
with  the  antistreptococcic  serum,  although  I  have  great 
doubts  of  its  value  as  a  curative  agent.  In  other  in- 
stances, such  as  plague  and  snakebite,  we  may  appar- 


ently look  forward  to  a  cure;  while  researches  are 
being  carried  on  with  regard  to  pneumonia  which  may 
lead  to  valuable  results;  nor  must  I  forget  to  mention 
Pasteur's  system  of  inoculating  cattle  against  anthrax. 
What  are  we  to  say  about  the  new  tuberculin?  We 
all  know  how  careful  an  observer  Koch  is,  and  the 
fact  that  he  looks  on  it  as  a  valuable  remedy  is  to  my 
mind  sufficient  to  make  it  necessary  to  give  it  a  care- 
ful and  hopeful  trial.  I  must  say  that  I  have  always 
been  favorably  inclined  to  the  old  tuberculin,  and 
have  regarded  it  in  relation  to  phthisis  like  iodide  of 
potassium  in  relation  to  syphilis,  and,  had  I  been  a 
physician,  I  do  not  think  I  should  have  abandoned  it 
in  the  hurried  manner  in  which  it  was  thrown  aside. 

But  it  is  not  only  in  the  direction  of  bacteriology 
that  advantage  has  resulted  from  pathological  re- 
search. Look  at  the  advances  in  treatment  from  the 
use  of  organic  fluids.  As  the  result  of  observations 
on  man  and  researches  on  animals  as  to  the  effects  of 
excision  of  the  thyroid  gland  attempts  were  made  to 
transplant  the  healthy  thyroid  gland  into  animals  and 
patients  in  whom  it  was  absent,  and  following  these  at- 
tempts the  use  of  thyroid  extract  has  ultimately  come 
to  be  a  recognized  method  of  treatment.  There  is, 
perhaps,  nothing  more  striking  in  medical  treatment 
than  the  rapid  and  remarkable  improvement  in  cases 
of  myxcedema  from  the  use  of  thyroid  extract. 

I  might  enumerate  many  other  instances  of  direct 
benefit  from  pathological  research,  such  as  the  ad- 
vances in  the  treatment  of  tuberculous  diseases  of 
bones  and  joints  as  the  result  of  better  knowledge  of 
the  nature  and  distribution  of  the  disease,  the  treat- 
ment of  appendicitis,  and  the  investigations  on  peri- 
tonitis and  diseases  of  the  appendix,  the  more  com- 
plete operations  for  cancer  following  fuller  study  of 
the  mode  of  spread  of  the  disease,  and  so  on ;  but  1 
have  said  enough  to  show  the  great  importance  and 
value  of  pathological  research.  Such  results  must  en- 
courage us  to  go  on  working  with  all  our  might  and 
without  ceasing,  bearing  in  mind  that  many  are  suffer- 
ing and  dying  every  day  who  might  be  saved  if  only 
we  had  just  a  little  more  knowledge  of  the  workings 
of  the  body  and  the  processes  of  disease. 

But  while  pathologists  are  thus  working  out  prob- 
lems which  affect  the  general  well-being  of  mankind, 
and  the  solution  of  which  can  be  of  no  personal  gain 
to  themselves,  is  it  too  much  to  ask  mankind  to  fur- 
nish the  means  for  such  research?  The  English  are 
looked  on  as  a  thoroughly  practical  people,  and  yet  it 
is  a  very  remarkable  thing  that  England  is  almost  the 
only  country  which  does  not  realize  the  importance  of 
scientific  research,  and  the  result  is  that  in  England, 
with  very  few  exceptions,  men  who  might  otherwise 
have  thrown  much  light  on  these  matters  are  com- 
pelled to  turn  their  attention  to  practice  in  order  to 
make  a  living.  Unless  work  of  this  kind  is  done  hovr 
can  we  hope  to  advance  with  any  rapidity  in  the  treat- 
ment and  cure  of  disease?  The  surgeon  or  physician 
must  wait  till  the  information  of  which  he  is  urgently 
in  need  has  been  acquired  for  him  by  the  pathologist. 
Such  apathy  can  surely  be  the  result  only  of  igno- 
rance. A  rich  man  aftected  with  an  obscure  or  incur- 
able malady  cannot  understand  how  it  is  that  he  fails 
to  obtain  the  definite  opinion  or  the  relief  which  he  so 
earnestly  desires,  and  for  which  he  is  prepared  to  pay 
any  price.  Surely  if  he  understood  the  meaning  and 
importance  of  pathological  research,  and  that  tlie  prac- 
tising physician  can  apply  and  carry  out  only  what  is 
taught  by  the  pathologist,  he  would  bestir  himself  to 
aid  researcii  in  order  to  gather  information  which 
might  be  of  much  use  to  him  and  to  others. 


Torpid  Ulcers,  oven  when  painful  and  due  to  vari- 
cose veins,  may  be  made  to  cicatrize  convfortably  if 
dusted  daily  with  antipyrin. — Schreiber. 


September  4,  1897] 


MEDICAL    RECORD. 


349 


^trogrcas  jof  l^cdical  Science. 

Bilateral  Optic  Neuritis  Complicating  Enteric 
Fever. — Braine  -  Hartnell  {British  Medical  Journal, 
May  29,  1897)  has  reported  the  case  of  a  boy,  eleven 
years  old,  of  weak  intellectual  development,  who 
"ailed"  for  a  few  days,  without  presenting  any  defi- 
nite symptoms.  On  the  third  day  the  temperature  was 
103.4'^  F.,  and  his  bowels  were  moved  five  times.  For 
the  ne.\t  four  days  the  bowels  were  moved  twice  daily. 
The  child  was  restless  and  noisy,  and  could  with  diffi- 
culty be  kept  in  bed.  Photophobia  and  signs  of  cere- 
bral irritation  developed.  The  face  was  pale,  the  pu- 
pils were  equal,  the  tongue  was  dry,  and  sordes  formed 
on  the  lips.  The  bowels  were  not  loose  from  the 
seventh  day  until  death  took  place,  upon  the  eighteenth 
day  of  the  illness,  but  formed  stools  were  constantly 
passed.  The  abdomen  w^as  if  anj-thing  somewhat  re- 
tracted. There  were  no  spots;  the  spleen  could  not 
be  felt,  nor  could  an  enlarged  area  of  percussion 
dulness  be  made  out.  The  temperature  fell  on  the 
tenth  day  to  normal,  but  rose  again  on  the  fifteenth, 
and  on  the  eighteenth  day,  just  before  death,  it  reached 
105.2^  F.  The  pulse  rate  varied  from  120  to  160. 
The  left  knee  jerk  could  not  be  elicited;  the  right 
was  present.  Plantar,  cremasteric,  and  abdominal 
reflexes  all  were  present.  There  was  no  impairment 
of  sensation  and  no  retention  of  urine.  There  was 
never  any  strabismus  and  no  convulsions  were  noted. 
Two  days  before  death  there  were  slight  inequality  of 
the  pupils  and  well-marked  bilateral  optic  neuritis, 
more  pronounced  upon  the  right  side.  There  was  no 
nasal  or  aural  discharge,  and  no  pulmonary  abnormal- 
ity could  be  detected.  The  post-mortem  examination 
revealed  distinct  inflammation  of  Peyer's  patches,  with 
decided  enlargement  of  the  mesenteric  glands  and 
solitary  follicles.  Nothing  was  found  in  the  brain  to 
give  rise  to  the  optic  neuritis. 

Disinfection  of  Typhoid  Excreta. — Dr.  W.  Oilman 
Thompson  {Albany  Alcdical  Annals,  April,  1897)  con- 
cludes as  follows:  I.  The  best  disinfectants  of  typhoid 
stools  for  practical  use  are :  (a)  i  to  500  acidulated 
solution  of  corrosive  sublimate;  (U)  i  to  10  crude 
carbolic-acid  solution;  {/)  chlorinated  lime.  2.  Ow- 
ing to  the  possibility  of  injury  to  plumbing,  the  car- 
bolic-acid solution  is  preferable  wherever  plumbing  is 
concerned.  The  lime  is  best  for  country  use  in  privies 
and  trenches.  3.  The  disinfectant  should  be  thor- 
oughly mixed  with  the  stool  and  left  in  contact  vith 
it  for  fully  two  hours.  Enough  of  the  disinfectant 
must  be  added  to  cover  completely  the  stool  witii  tlie 
.solution.  4.  The  bed  pan  should  be  kept  ready  fillet! 
at  all  times  with  at  least  a  pint  of  the  disinfectant, 
into  which  the  stool  is  at  once  discharged,  and  should 
be  cleaned  with  scalding  water  and  one  of  the  disin 
fecting  solutions.  5.  Rectal  thermometers,  syringes, 
tubes,  and  all  utensils  coming  in  contact  with  any  of 
the  fsecal  matter  must  be  disinfected  with  the  corro- 
sive-sublimate or  carbolic-acid  solution.  6.  .After 
each  stool  the  patient's  perineum  and  adjacent  parts 
should  be  washed  and  sponged  with  a  i  to  2,000 
corrosive-sublimate  solution.  7.  Nurses  and  atten- 
dants should  be  cautioned  to  wash  their  own  hands 
thoroughly  and  immerse  them  in  a  i  to  1,000  corro- 
sive-sublimate solution,  after  handling  the  bedpan, 
thermometer,  syringe,  or  patient,  or  giving  sponge  or 
tub  baths.  8.  All  linen  and  bedclothing  used  by  the 
patient  should  be  soaked  in  a  i  to  20  carbolic-acid 
solution  and  subsequently  boiled  for  fully  two  hours. 
9.  Disinfection  of  the  stools  should  be  begun  as  soon 
as  the  diagnosis  of  enteric  fever  is  established,  and 
should  be  continued  for  ten  days  after  the  tempera- 
ture has  remained  at  the  normal.      10.   In   localities 


where  a  proper  drainage  system  is  lacking,  the  stools 
should  either  be  mixed  with  sawdust  and  cremated, 
or  buried  in  a  trench  four  feet  deep  after  being  cov- 
ered with  chloride  of  lime. 

Eucalyptus  Globulus  in  Strychnine  Poisoning. — 

Dr.  Monfrida  Musmecin  has  found  that  a  decoction  of 
the  leaves  of  eucalyptus  globulus  and  a  solution  of  a 
salt  of  strychnine  formed  a  flocculent  precipitate  of  a 
clear  color,  a  solution  of  citron-yellow  tint  remaining 
above  and  the  strychnine  losing  its  bitter  taste.  This 
raised  the  question  as  to  whether  eucalyptus  was  an 
antidote  for  strychnine.  The  author  carried  out  a 
number  of  experiments  upon  animals,  to  ascertain 
what  effects  would  be  produced  by  giving  these  two 
drugs  together,  and  what  antidotal  power  eucalyptus 
would  exert  after  the  development  of  the  symptoms  of 
strychnine  poisoning.  He  found  that  when  these  drugs 
were  given  simultaneously  the  animal  sur\'ived,  while 
if  the  same  amount  of  strychnine  were  given  alone  to 
an  animal  of  the  same  kind  and  size,  death  would 
ensue.  In  another  set  of  experiments  the  eucalyptus 
was  given  after  convulsions  had  appeared,  and  then 
these  became  much  less  marked  and  even  disappeared. 
From  these  experiments  the  writer  believes  that  eu- 
calyptus has  a  real  antidotal  action,  and  that  a  practi- 
cal application  of  it  should  be  made  by  employing  a 
decoction  for  washing  out  the  .stomach  in  such  cases. 
—  British  MfJicalJoiiriiah 

Sudden  Death  in  the  Puerperium. — Dr.  Goltman 

{Alemphis  Mediuil  Monthly,  April,  1897),  in  an  article 
on  this  subject,  formulates  the  following  deductions: 
I.  Pulmonary  embolism  is  the  cau%e  of  death  in  most 
of  these  cases.  2.  It  is  rare,  but  so  shocks  a  com- 
munit}-  when  it  occurs  that  it  is  advisable  to  take 
every  precaution  to  guard  against  it.  3.  Phlebitis, 
varicose  veins,  prolonged  labor,  hemorrhage,  anremia, 
sepsis,  cancer,  syphilis,  etc.,  predispose  to  its  produc- 
tion. 4.  In  the  presence  of  peripheral  thrombosis, 
etc.,  absolute  rest  must  be  enjoined,  especially  be- 
tween the  second  and  third  weeks  of  the  puerperium, 
as  this  is  the  disintegrating  period  of  the  clots.  The 
danger  should  also  be  explicitly  pointed  out  to  both 
patient  and  attendants,  thus  insuring,  to  an  extent,  a 
healthy  co-operation.  5.  The  extreme  changes  in  the 
blood  usually  ascribed  to  pregnancy  and  the  puerpe- 
rium are  erroneous,  and  not  corroborated  by  modern 
investigation.  6.  Sudden  death  from  air  embolism  in 
the  puerperium  is  doubtful  from  physiological,  patho- 
logical, and  rational  standpoints.  7.  Shock  is  both  a 
direct  and  indirect  cause  of  death  in  the  puerperium, 
and  should  be  guarded  against.  8.  Organic  heart 
affections,  kidney  trouble,  etc.,  are  capable  of  produc- 
ing death  at  any  time,  and  should  not  be  overlooked  in 
the  puerperium. 

Puerperal  Biliary  Colic. — According  to  Dr.  Eier- 
mann,  cases  of  biliary  colic  occurring  after  labor  are 
rare.  He  relates  one  occurring  in  a  primipara,  aged 
twenty-nine,  who  sutTered  from  albuminuria  during 
pregnancy;  Delivery  was  difficult,  and  a  rupture  of 
the  perineum  almost  into  the  rectum  occurred.  In 
five  days  the  oedema  of  the  legs  disappeared,  but  then 
the  patient  was  seized  with  shivering  and  severe  pain 
in  the  upper  part  of  the  abdomen.  On  the  next  day 
there  was  distinct  jaundice,  which  disappeared  in  two 
or  three  days.  There  had  been  no  previous  history  of 
gall  stones.  Eiermann  attributed  the  colic  to  the  sud- 
denly altered  pressure  relations  in  the  abdomen  after 
labor.  Gottschalk  has  seen  nine  or  ten  cases  of  gall 
stones  in  women  in  the  puerperal  state.  In  one  the 
colic  reappeared  after  a  subsequent  pregnancy,  the  pa- 
tient having  been  free  from  it  in  the  interval.  The 
diagnosis  may  be  difficult  if  there  is  no  jaundice. — 
Miinchcncr  inedicinische  Wochcnschrijt. 


350 


MEDICAL    RECORD. 


[September  4,  1897 


Medical  Record: 

A    Weekly  Journal  of  Medkine  and  Surgery. 


GEORGE   F.    SHRADY,  A.M.,  M.O.,  Editor. 

PfBLISHEKb 

WM.  WOOD  &.  CO.,  43,  45.  &.  47  East  Tenth  Street. 


New  York,  September  4,  1897. 

THE    MONTREAL    MEETING   OF    THE 
ISH    MEDICAL   ASSOCIATION. 


In  the  president-elect,  Sir  Thomas  Grainger  Stew- 
art, of  Edinburgh,  the  association  will  have  a  presid- 
ing officer  whose  fame  is  world  wide.  Edinburgh  was 
selected  as  the  next  place  of  meeting,  and  the  scien- 
tific position  of  the  city,  to  say  nothing  of  its  prover- 
bial Scottish  hospitality,  indicates  the  wisdom  of  the 
selection. 

.\lthough  the  constitution  of  the  association  pre- 
vents any  but  British  subjects  from  enjoying  the  privi- 
leges of  membership,  the  American  profession  was 
well  represented  among  the  guests,  and  those  who  were 
thus  honored  expressed  themselves  as  well  pleased 
with  the  reception  they  received. 


BRIT-      THE    ANTITOXIN      TREATMENT     OF     DIPH- 
THERIA. 


The  sixty-fifth  annual  meeting  of  the  British  Medical 
Association,  at  Montreal,  during  the  present  week,  a 
special  report  of  the  first  part  of  which  will  be  found 
in  another  column,  was  an  event  in  the  medical  history 
of  Canada  which  will  be  long  and  pleasantly  remem- 
bered by  our  neighbors  across  the  border.  The  fact 
that  it  was  the  first  time  in  the  Iiistory  of  the  associa- 
tion that  the  annual  meeting  was  held  outside  the  Brit- 
ish Isles  gave  rise  to  some  forebodings  as  to  its  success. 
While  the  number  of  members  registered  was,  as 
might  naturally  be  expected,  smaller  than  is  usual, 
those  who  proposed  bringing  the  association  to  this 
side  of  the  Atlantic  have  reason  to  be  highly  gratified. 
The  visitors  from  abroad  will  return  home  with  en- 
larged ideas  of  the  Greater  Britain  to  which  many  of 
them  were  previously  strangers.  Montreal  is  one  of 
the  most  beautifully  situated  cities  of  the  British  em- 
pire, and  has  from  its  foundation  in  1642  been  devoted 
to  medicine.  Paul  de  Chomedey,  Sieur  de  Maison- 
neuve,  brought  in  his  company  the  devoted  Jeanne 
Mance,  head  of  the  little  community  of  nuns  nominated 
by  the  founders  of  the  colony  to  nurse  the  sick.  She 
founded  the  Hotel  Dieu,  the  oldest  hospital  in  America, 
which  remains  to  this  day  the  greatest  Catholic  hos- 
pital in  Canada. 

The  opening  ceremonies,  which  were  preceded  by  a 
service  and  sermon  in  the  English  cathedral,  were 
highly  interesting,  and  demonstrated  the  fact  that  a 
hearty  welcome  greeted  the  association,  as  Lord  Aber- 
deen, the  governor-general,  expressed  it,  from  every 
citizen  of  the  dominion.  The  addresses  of  the  presi- 
dent. Dr.  T.  G.  Roddick,  of  Montreal,  Dr.  William 
Osier,  of  Baltimore,  and  Mr.  T.  Mitchell.  Banks,  of 
Liverpool,  which  we  are  enabled,  through  the  courtesy 
of  the  British  Medical  Journal,  to  present  in  full  to  our 
readers,  were  worthy  of  the  authors  and  of  the  occasion. 

Everything  possible  was  done  to  make  the  meeting 
memorable.  All  the  most  interesting  features  of  the 
city  with  its  crowning  glory.  Mount  Royal,  were  made 
attractive  to  the  visitors.  The  thoroughness  and  care 
which  marked  all  the  arrangements  for  the  conven- 
ience and  comfort  of  the  members  were  a  pleasing  and 
notable  feature  of  the  gathering.  The  extensive  li.st 
of  entertainments  left  nothing  to  be  desired  from  a 
social  point  of  view. 


The  claims  that  have  been  put  forward  as  to  the  effi- 
cacy of  the  antitoxin  in  the  treatment  of  diphtheria 
have  not  been  successfully  assailed  from  any  quarter, 
and  the  affirmative  evidence  afforded  by  statistics  on 
the  largest  scale  and  from  the  most  diverse  sources 
has  not  been  in  the  slightest  degree  shaken.  On  the 
contrary,  the  evidence  has  steadily  increased  and  the 
claims  have  been  fortified.  In  the  face  of  the  facts 
it  is  difficult  to  understand  the  mental  attitude  of  the 
small  minority  who  are  yet  willing  to  antagonize  a 
method  of  treatment  that,  according  to  almost  univer- 
sal testimony,  has  now  proved  its  worth  for  more  than 
three  years,  and  whose  employment  has  resulted  in 
the  saving  of  many  lives  and  the  sparing  of  many  days 
of  illness.  To  the  wholly  unprejudiced  and  imper- 
sonal reports  of  the  two  collective  investigations  insti- 
tuted by  the  American  Pediatric  Society  and  the  ear- 
lier report  of  the  collective  investigation  of  the  Berlin 
Society  for  Internal  Medicine,  may  now  be  added  the 
report  of  one  of  the  most  exhaustive  and  elaborate 
statistical  studies  of  the  treatment  of  diphtheria  with 
the  antitoxin,  recently  issued  by  the  medical  superin- 
tendents of  the  hospitals  of  the  London  Metropolitan 
Asylums  Board  (Lanuf,  June  5,  1897). 

According  to  this  report,  the  total  number  of  cases 
treated  in  the  several  hospitals  under  the  control  of  the 
board  during  the  year  1S96  was  4.175,  with  87  i  deaths, 
or  a  mortality  of  20.8  per  cent.  Of  the  whole  number 
received  in  1896,  2,764  (71.3  per  cent.)  were  treated 
with  the  antitoxin,  with  717  deaths — a  mortality  of 
25.9  per  cent.  In  the  year  1894,  before  the  employ- 
ment of  the  antitoxin  had  been  in.stituted,  there  oc- 
curred among  3,042  cases  902  deaths  (^29.8  per  cent.) 
— a  saving  thus  of  8.8  j,>er  cent.,  or  365  lives.  The 
antitoxin  treatment  was  not  resorted  to  in  moribund 
or  hopeless  cases,  or  in  those  of  doubtful  nature,  or 
so  mild  in  character  as  to  seem  not  to  require  any 
specific  treatment.  The  best  results  of  the  treatment 
were  obtained  when  it  was  instituted  early,  and  tlie 
value  of  these  results  is  strengthened  by  the  fact  that 
the  proportion  of  the  very  young  was  much  greater 
among  those  treated  with  the  antitoxin  than  among 
those  not  so  treated.  Another  evidence  of  the  greater 
comparative  severity  of  the  cases  in  the  antitoxin  series 
is  to  be  found  in  the  fact  that  in  this  group  tlie  per- 


September  4-  1897] 


MEDICAL    RECORD. 


centage  of  larj'ngeal  cases  was  17.6  per  cent.,  as  com- 
pared with  1.9  per  cent,  in  the  non-antitoxin  series.  A 
comparison  between  the  age  incidence  and  mortality  of 
all  cases  of  diphtheria  treated  in  1896  (whether  by  the 
antitoxin  or  not)  and  those  of  the  cases  treated  by  the 
board  in  1894,  not  only  shows  that  the  total  mortality 
was  less  by  8.8  per  cent,  in  the  year  tirst  named,  but 
the  difference  is  the  more  accentuated  in  accordance 
with  the  eaiiiness  of  the  period  at  which  the  cases 
came  imder  observ-ation. 

It  is  interesting  to  note  that  clinical  rather  than 
bacteriological  evidence  was  taken  as  the  criterion  in 
arriving  at  a  diagnosis,  and  also  that  in  only  4.5  per 
cent,  did  the  latter  fail  to  confirm  the  former.  One 
of  the  most  striking  eitects  of  the  use  of  the  antitoxin 
was  observ-ed  in  the  diminution  of  severity  induced 
in  cases  in  which  the  larynx  was  involved.  In  1894 
the  mortality  in  the  hospitals  of  the  Asylums  Board  was 
in  larv'ngeal  cases,  62  per  cent.;  in  1896  it  was  29.6 
per  cent.  In  1894  the  mortality  after  tracheotomy 
was  70.4  per  cent.;  in  1896  it  was  41  per  cent.,  al- 
though in  the  latter  year  the  proportion  of  laryngeal 
cases  submitted  to  tracheotomy  was  56,  as  compared 
with  41  in  1894.  The  proportion  of  cases  in  which 
albuminuria  and  paralysis  respectively  occurred  was 
greater  in  1896  than  in  1894,  but  this  discrepancy  is 
to  be  explained  by  the  increased  attention  paid  to  the 
detection  of  albuminuria,  while  the  greater  proportion 
of  cases  of  paralysis  is  viewed  as  confirmatory  evi- 
dence of  the  larger  proportion  of  sur\'ivals  from  the 
initial  dangers  of  the  diphtheria  virus. 

The  average  dose  of  the  antitoxin  employed  was 
two  thousand  units  per  injection,  and  the  average 
number  of  injections  2.3  for  each  patient.  Often  this 
dose  was  considerably  exceeded,  and  some  cases  re- 
ceived many  injections.  Untoward  effects  incidental 
to  the  injections  were  noted  in  only  a  small  propor- 
tion of  cases.  Thus  a  rash  was  observed  in  35.2  per 
cent.,  joint-pains  in  6.5  per  cent.,  pyrexia  in  19.8  per 
cent.,  abscess  in  1.2  per  cent. 

In  a  summing  up  of  the  results  yielded  by  the  clini- 
cal and  .statistical  observations  made  in  connection 
with  this  study,  the  advantages  achieved  in  the  cases 
of  diphtheria  treated  during  the  year  1896  are  stated 
to  be:  I,  .\  great  reduction  in  the  mortality  of  cases 
brought  under  treatment  on  the  first  three  days  of  ill- 
ness; 2,  the  lowering  of  the  combined  general  mortal- 
ity to  a  point  below  that  of  any  former  year;  3,  the 
still  more  remarkable  reduction  in  the  mortality  of 
the  laryngeal  cases;  4,  the  uniform  improvement  in 
the  results  of  tracheotomy;  and  5,  the  beneficial  effect 
produced  on  the  clinical  course  of  the  disease. 


IHF. 


REL.\TION    BETWEEN     VACCINATION 
AND    TUBERCULOSIS. 


According  to  the  Berlin  correspondent  of  the  British 
Medical  Journal,  July  3,  1897,  the  scientific  committee 
for  all  matters  relating  to  medicine  and  public  hygiene 
has  replied  in  the  negative  to  the  question  asked  by 
the  medical  department  of  the  Prussian  ministry  of 
education — whether  it  is  possible  for  vaccination  to 


cause  a  tendency  to  tuberculosis  and  scrofula,  and,  if 
so,  under  what  conditions.  The  committee  takes  the 
ground  that  since  the  discovery  of  the  tubercfe-bacil- 
lus  as  the  cause  of  tuberculosis  vaccination  cannot  be 
held  responsible  as  a  cause  of  that  disease. 

As  to  the  allegation  frequently  made  that  vaccination 
produces  a  disposition  to  tuberculosis,  it  is  often  as- 
sumed that  certain  diseases,  e.g.,  diabetes,  measles, 
whooping-cough,  and  debilitating  diseases  generally, 
cause  such  a  predisposition.  The  question  arises:  Can 
the  short,  feverish  attrck  produced  by  vaccination  be 
included  among  these.'  It  is  to  be  remembered  that 
tuberculosis  is  the  most  widespread  disease  known,  so 
that  of  course  a  number  of  vaccinated  persons  must 
become  its  victims.  There  is,  however,  no  evidence 
that  would  permit  recognition  and  proof  that  in  any 
case  of  tuberculosis  or  scrofula  developing  after  vac- 
cination the  disease  is  a  consequence  of  the  prophy- 
lactic procedure,  or  that  would  go  to  show  that  an 
individual  after  vaccination  is  more  predisposed  to 
scrofula  and  tuberculosis  than  are  unvaccinated  per- 
sons. 

Mortality  statistics  on  a  large  scale  also  go  to 
show  that  vaccination  is  not  even  indirectly  a  cause 
of  tuberculosis.  Tuberculosis  is  the  most  frequent 
cause  of  death,  and  if  really  increased  by  compulsory- 
vaccination  the  mortality  should  have  increased  since 
the  introduction  of  the  latter.  The  reverse,  however, 
is  the  case.  In  spite  of  strictly  enforced  revaccina- 
tion,  the  mortality  from  tuberculosis  in  the  Prussian 
army  has  diminished.  It  is  possible  that  untoward 
complications  of  vaccination,  such  as  erysipelas,  may 
weaken  the  organism  and  lower  its  resisting  power  to 
the  invasion  of  the  tubercle-bacillus.  Neither  is  it  to 
be  denied  that  when  tubercle-bacilli  have  already 
found  their  way  into  the  organism  vaccination  may  be 
followed  by  their  increase  or  spread. 


A  Useful  Medical  Society. — The  McKean  County 
(Pa.)  Medical  Association  is  a  live  organization, 
which  is  awake  to  the  interests  of  tha  community  and 
does  all  possible  to  protect  it  against  injury  by  quacks. 
The  society  has  recently  had  three  advertising  itiner- 
ants, who  unwarily  attempted  to  ply  their  trade  in 
Bradford,  arrested  and  driven  from  the  place.  This 
is  an  example  worthy  of  imitation  by  other  county  so- 
cieties in  all  States  where  an  efficient  medical-practice 
law  exists. 

Anthrax  in  Pennsylvania. — As  the  result  of  an 
investigation  undertaken  at  the  instance  of  the  Penn- 
sylvania State  board  of  health.  Dr.  Leonard  Pearson, 
State  veterinarian,  reports  that  the  death  of  the  foiur 
men  in  Jefferson  County  under  dubious  circumstances 
was  due  to  anthrax,  derived,  it  is  believed,  from  the 
handling  of  infected  hides  imported  from  Asia.  A 
number  of  cattle  also  have  been  affected.  The  hides 
in  question  had  been  treated  with  arsenic  and  they 
had  been  washed  in  a  neighboring  creek,  and  it  was 
thought  that  the  trouble  might  have  been  due  to  drink- 
ing the  polluted  water. 


352 


MEDICAL    RKCORD. 


[September  4,  1897 


^etus  of  the  ^lecfe. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
ger)',  Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
August  28,  1897.  August  25th. — Assistant  Surgeon 
VV.  M.  Wheeler  detached  from  the  Marietta  and  or- 
dered to  the  IVkee/ing,  September  2d ;  Passed  Assis- 
tant Surgeon  G.  Rothganger  detached  from  the  Wheel- 
ing and  ordered  to  the  Mari,-tt(i,  September  2d. 

Italian  Society  of  Laryngology,  Otology,  and 
Rhinology. — The  third  biennial  meeting  of  this  so- 
ciety will  be  held  in  Rome,  commencing  on  October 
28th.  The  subjects  for  the  set  discussions  are:  The 
value  of  autoscopy  in  the  diagnosis  and  treatment  of 
laryngeal  affections;  adenoid  vegetations  in  Italy; 
physiology  of  the  middle  ear.  The  president  of  the 
association  is  Dr.  V.  Grazzi,  and  the  secretary  Dr.  A. 
Fasano,  of  Naples. 

A  Tiny  Midget. — From  St.  Louis  comes  the  report 
of  the  birth  of  a  child  weighing  one  pound  and  meas- 
uring eight  inches  in  length. 

The  Milk  Supply  of  New  York.  —  According  to 
the  report  of  the  board  of  health  for  1896,  the  number 
of  cows  which  furnish  milk  for  this  city  is  115,570. 
There  are  seven  thousand  places  in  the  city  where 
milk  is  sold  both  wholesale  and  retail.  The  system 
of  granting  permits  to  venders  of  milk,  which  went 
into  effect  at  the  commencement  of  the  year  1896,  has 
been  found  to  be  of  great  value.  As  a  result  of  this, 
together  with  the  application  of  the  tuberculin  test  to 
raflch  cows,  there  is  now  a  system  of  milk  inspection 
which  is  as  perfect  as  is  possible  at  the  present  day 
and  with  the  present  force.  The  milk  permits  are  in 
force  during  the  pleasure  of  the  board  of  health,  which 
revokes  them  on  the  second  trial  and  conviction  for 
the  sale  of  "adulterated  milk,"  that  phrase  meaning 
milk  containing  more  than  eighty-eight  per  cent,  of 
water  or  fluid  and  less  than  four  per  cent,  of  milk  sol- 
ids, or  less  than  three  per  cent,  of  fat,  milk  drawn 
from  animals  fed  on  distillery  waste,  milk  from  which 
any  part  of  the  cream  has  been  removed,  and  milk 
from  cows  kept  in  crowded  or  unhealthy  places.  In 
1895,  *"  ^^^  samples  of  milk  which  were  tested,  three 
hundred  and  ninety-three  cases  of  adulteration  were 
discovered,  while  last  year  the  inspection  and  test 
showed  only  two  hundred  and  thirty-three.  The  num- 
ber of  arrests  in  1895  for  selling  adulterated  milk  was 
four  hundred  and  eight;  in  1896  there  were  only  two 
hundred  and  twenty. 

Efforts  to  Abate  the  Spitting-Nuisance  in  Jersey 
City. — The  Jersey  City  board  of  health  has  passed  an 
ordinance,  making  expectoration  on  the  floors  or  plat- 
forms of  trolley  or  horse  cars  or  public  conveyances 
of  any  kind  punishable  by  the  imposition  of  a  $10 
fine.  The  ordinance  was  recommended  by  the  health 
inspector,  and  its  passage  was  urged  by  many  women, 
who  complained  that  the  filthy  habit  had  frequently 
caused  the  destruction  of  their  dresses. 


Obituary  Notes — Dr.  Benjamin  R.  Whitaker,  of 
Phenixville,  Pa.,  died  at  Philadelphia  on  August  18th, 
at  the  age  of  fifty-three  years.  He  was  a  graduate  of 
the  medical  department  of  the  University  of  Pennsyl- 
vania, and  ser\'ed  during  the  war  of  the  rebellion  as 
surgeon  to  the  one  hundred  and  fourth  regiment,  Penn- 
sylvania volunteers,  and  during  the  riots  of  1877  as 
surgeon  to  the  Pennsylvania  national  guard.  —  Dr. 
De  Wrrr  Clintox  Hough,  of  Rahway,  N.  J.,  died  on 
August  25th,  of  paralysis.  He  was  bom  in  1827  at 
Point  Pleasant,  Bucks  County,  Pa.  He  graduated  at 
Jefferson  Medical  College  in  the  class  of  1847,  ^t^*^ 
went  to  Rahway  in  1857.  He  was  for  three  years  the 
chief  surgeon  in  the  seventh  New  Jersey  volunteers, 
ranking  as  major.  Dr.  Hough  was  mayor  of  Rahway 
in  1867  and  1868,  and  also  served  in  the  legislature 
for  three  terms. — Dr.  Johx  R.  Cabell,  of  Danville, 
Va.,  was  assassinated  on  August  26th  by  one  of  his 
tenants,  whom  he  had  notified  to  give  up  the  farm  on 
which  he  lived  on  the  ground  of  some  irregular  trans- 
actions. Dr.  Cabell  was  a  graduate  of  the  medical 
department  of  the  Universit)-  of  Virginia  in  1850. — 
Dr.  Walter  McKexzie,  of  Nanuet,  N.  Y.,  committed 
suicide  by  taking  morphine  on  August  26th.  He  was 
thirty-seven  years  of  age,  and  was  a  graduate  of  Belle- 
vue  Hospital  Medical  College  in  this  city. 

International  Congress  of  Legal  Medicine.— The 
meeting  of  the  International  Congress  of  Legal  Medi- 
cine, held  at  Brussels  from  August  2d  to  7th,  was  a 
great  success.  The  French  go\ernment  was  repre- 
sented by  Professor  Brouardel,  dean  of  the  Paris  Med- 
ical Faculty,  and  by  Drs.  G.  Pouchet,  Motet,  Mosny. 
Thoinot,  Descoust,  Vibert,  Ogier,  and  Socquet;  that 
of  Sweden  by  Dr.  Johan-Mauriti;  Aspelin,  of  Stock- 
holm; the  Swiss  State  council  by  Professor  Gosse,  of 
Geneva;  the  Spanish  government  by  Dr.  Enrique 
Simancas;  and  the  Russian  government  by  Prof.  De- 
metrius von  Kossorotoft',  of  St.  Petersburg.  The  New 
York  Society  of  Legal  Medicine  sent  Dr.  Valentine  as 
a  delegate.  The  meetings  of  the  congress  were  at- 
tended by  a  large  number  of  prominent  members  of 
the  legal  and  medical  professions  and  of  the  magis- 
tracy. Important  discussions  took  place  on  criminal 
lunatics  and  public  asylums,  poisoning  by  carbonic 
oxide,  professional  secrecy  in  relation  to  the  law,  the 
medico-legal  value  of  subserous  ecchymoses,  the  gly- 
cogenic function  of  the  liver  in  relation  to  medical 
evidence,  cadaveric  spasm,  the  internal  factors  of  ca- 
daveric decomposition,  the  lung  test  of  life  after  birth, 
poisoning  by  sulphuretted  hydrogen,  the  place  and 
duty  of  the  medical  expert  in  relation  to  poisoning  by 
meat,  hypnotism  in  its  relation  to  crime,  and  responsi- 
bilit)' — particularly  partial  responsibility.  The  next 
meeting  of  the  congress  will  be  held  in  Paris  in  1900. 
—British  Mciii-iiljoiinuil. 

An  Old  Swindle  Revived. — Some  man  is  working 
a  verv  successful  swindle  in  the  suburbs  of  tliis  city, 
by  means  of  a  new  application  of  an  old  trick.  He 
pretends  to  be  a  physician  from  some  odier  place,  who 
has  a  sick  servant  needing  hospital  care.  He  calls 
on  one  of  the  attending  staff  of  the  hospital  and  gets 


I 


September  4,  1897] 


MEDICAL    RECORD. 


3s: 


a  letter  of  introduction  to  the  matron.  .•Vrmed  with 
this  he  goes  to  the  hospital  and  makes  arrangements 
for  the  reception  of  the  patient,  paying  in  advance 
with  a  check  which  is  larger  than  the  amount  required. 
The  matron  gives  the  change  in  money,  and  finds  a 
few  days  later  that  the  check  is  worthless. 

The  Sanitary  Institute  of  Great  Britain,  the 
twenty-first  anniversary  of  the  formation  of  which 
was  recently  commemorated  by  a  dinner  in  London, 
now  numbers  twenty-one  hundred  members  and  asso- 
ciates, and  its  annual  income  is  more  than  ^'6,000. 

Cholera  is  spreading  in  Bombay,  many  of  the  Eng- 
lish troops  stationed  there  having  been  attacked.  In 
spite  of  the  warning  of  the  plague,  the  sanitary  condi- 
tion of  the  city  is  said  to  be  most  unsatisfactory. 

The  Medical  Society  of  the  County  of  Queens — 
The  midsummer  quarterly  meeting  of  this  society 
was  held  at  Long  Beach,  Long  Island,  on  Tuesday 
afternoon  of  this  week.  The  main  subject  for  discus- 
sion was  "  The  Diagnosis  and  Treatment  of  Fractures 
and  Dislocations."  Many  medical  men  not  members 
of  the  society  were  present,  and  the  meeting  was  re- 
garded as  a  very  successful  affair. 

Texas  Fever  is  reported  to  be  spreading  among  the 
cattle  in  southwestern  Iowa.  The  cattlemen  have  be- 
come greatly  alarmed  and  have  appealed  for  assistance 
to  the  State  authorities. 

Quarantine  against  Montreal. — The  telegraph  re- 
ports that  tlie  health  board  of  Ottawa  has  established 
a  quarantine  against  trains  from  Montreal,  because  of 
the  small-pox  in  the  latter  city. 

A  Confidence  Game  which  has  been  successfully 
played  upon  the  ambitious  physicians  of  a  city  in 
Nebraska  is  so  simple  and  withal  so  certain  in  its 
results  that  we  can  commend  it  warmly  to  the  God- 
fearing managers  of  all  the  hospitals  in  the  country. 
The  hospital  was  one  of  several  in  the  city,  and,  the 
number  of  inhabitants  not  being  unlimited,  it  suffered 
somewhat  from  the  competition  of  unscrupulous  rivals 
who  underbid  it  and  secured  most  of  the  wealthy  sick. 
-Vfter  three  or  four  years  of  ups  and  downs  the  hospi- 
tal was  reorganized  and  a  new  medical  staff  was  ap- 
pointed. As  soon  as  the  new  doctors  were  comforta- 
bly settled  in  their  places  and  had  become  accustomed 
to  their  new  titles,  the  members  of  the  board  of  trustees 
called  upon  them  personally,  told  them  of  the  finan- 
cial straits  of  their  beloved  institution,  and  intim<lted 
that  it  would  have  to  close  its  doors  unless  more 
money  was  forthcoming.  To  avert  such  a  calamity, 
which  would  fall  so  heavily  on  the  suffering  poor. 
each  member  of  the  new  medical  board  drew  his  check 
for  an  amount  which  he  thought  would  be  sufficient  to 
make  him  secure  in  his  new  place,  and  so  the  hospital 
expenses  were  met,  and  the  trustees  were  encouraged 
to  remodel  one  of  the  buildings.  The  first  of  this 
year  a  number  of  these  guileless  medical  men,  consti- 
tuting a  majority  of  the  attending  staff,  received 
notices  from  the  board  of  trustees  that  their  services 
were  no  longer  required,  a  new  staff  having  been  ap- 
pointed.     The  checks  of  the  new  appointees  will  soon 


be  called  for,  and  we  would  suggest  to  them  that,  if 
they  desire  to  continue  their  charitable  labors  longer 
than  a  twelvemonth,  they  had  better  signify  their  in- 
tention of  making  an  annual  contribution  to  the  good 
cause. 

Punishment  of  a  Clerical  Medical  Practitioner. 
— -The  right  of  a  clergyman  to  attempt  to  heal  by 
prayer  and  the  laying  on  of  hands  has  been  questioned 
in  New  Orleans,  where  a  Catholic  priest  has  been 
prosecuted  for  a  violation  of  the  State  medical-practice 
law  and  of  a  city  ordinance  relative  to  clairvoyants, 
unlicensed  practitioners,  and  the  like.  The  clergy- 
man, while  willing  to  pray  over  those  who  desired  his 
services,  did  not  pretend  to  be  able  to  cure  disease 
and  did  not  demand  any  payment  for  his  services, 
although  accepting  such  small  sums  as  his  callers 
chose  to  give  him.  The  charge  of  violating  the  State 
law  was  dismissed,  but  a  fine  of  twenty-five  dollars 
was  imposed  for  violation  of  the  city  ordinance. 

A  New  Narcotic — It  is  reported  that  the  physi- 
cians in  the  Me.xico  insane  asylum  have  discovered 
that  the  seeds  of  the  sapodilla  furnish  a  reliable  nar- 
cotic which  produces  a  quiet  sleep  followed  by  no 
unpleasant  after-effects. 

The  Canadian  Medical  Association. — The  thirtieth 
annual  meeting  of  this  society  was  held  in  Montreal 
on  Monday,  .\ugust  30th.  On  account  of  the  meeting 
of  the  British  Medical  Association  the  following  day, 
it  had  been  decided  that  no  scientific  papers  would  be 
read,  and  the  meeting  was  held  only  for  the  transac- 
tion of  the  necessary  executive  business.  The  presi- 
dent of  the  association.  Dr.  V.  H.  Moore,  of  Brock- 
ville,  delivered  the  annual  address.  After  thanking 
the  members  of  the  societ\'  for  the  honor  of  an  election 
to  the  highest  office  in  their  gift,  he  addressed  a  few 
words  of  greeting  to  the  members  of  the  British  Medi- 
cal Association  who  had  come  into  the  meeting,  and 
also  to  the  numerous  American  physicians  who  were 
present.  Medical  men  in  the  United  States,  he  said, 
"  are  industrious,  persevering,  and  energetic,  quick  to 
see,  ready  to  adopt,  and  eager  to  carry  out  any  and  all 
improvements  and  discoveries  to  a  successful  or  final 
issue;  hence  it  is  not  surprising  that  they  have  made 
such  progress."  He  then  took  up  the  main  portion  of 
the  address,  which  was  devoted  to  the  condition  of 
medical  and  other  branches  of  education  in  Canada  at 
the  present  day.  In  closing  he  again  welcomed  the 
members  of  the  British  Medical  Association  on  behalf 
of  the  medical  profession  of  Canada,  and  he  said  that 
the  citizens  of  Montreal,  who  are  so  noted  for  their 
hospitality,  and  indeed  all  Canadians,  would  do  their 
utmost  to  make  the  stay  of  their  brethren  in  the  coun- 
try as  pleasant  and  as  profitable  as  possible.  The 
election  of  officers  resulted  in  the  choice  of  the  follow- 
ing: rrcsidciit.  Dr.  J.  M.  Beausoleil,  Quebec;  Viu-- 
Presidents — Drs.  A.  McPhedraw,  Toronto;  C.  S.  Parke, 
Quebec;  R.  A.  McKean,  Glace  Bay;  P.  R.  Tuch,  St 
John,  R.  McNeil,  Stanley  Bridge,  J.  R.  Jones,  Winni- 
peg; F.  C.  McWheen,  Lethbridge;  and  J.  Tunstall, 
Vancouver;  General  Sarettiry,  Dr.  F.  N.  G.  Starr. 
Toronto;    Treasuiir,  I>r.  H.  B.  Small,  Ottawa. 


354 


MEDICAL    RECORD. 


[September  4,  1897 


M>0cut'Q  Reports. 

twelfth  international  medical  con- 
grp:ss. 

I/e/d  in  Mos<ro7tf,  Angus/  ig,  JO,  21,  22,  23,  24,  2j,  and 
26,  1^97- 

(Special  Report  by  Direct  U.  S.  Cable  to  the  Mkdical  Rkcokd.) 

GENERAL    SESSIONS. 
(Continued  from  page  319.) 

Tliird  Day — Thursday,  August  26th. 

The  third  and  closing  general  session  of  the  Moscow 
congress  was  held  on  Thursday  afternoon,  under  the 
presidency  of  Sir  William  MacCormac,  of  London. 
The  attendance,  as  is  usual  in  gatherings  of  this  kind, 
was  much  smaller  at  this  session  than  at  the  opening 
one,  though  larger  than  at  the  intermediate  .session  on 
Sunday  afternoon. 

The  Cell  Nucleus. — Prokk.ssor  Lukianov,  of  St. 
Petersburg,  was  the  first  orator  of  the  day.  His  ad- 
dress was  devoted  to  a  consideration  of  the  effect  of 
inanition  upon  the  nucleus  of  the  cell  and  to  the  con- 
clusions derived  from  the  results  of  this  .study  as  to 
the  functions  and  importance  of  the  nucleus.  Cellu- 
lar morphology,  he  claimed,  is  the  most  important  of 
biological  studies,  surpassing  all  other  studies  as  re- 
gards the  information  which  it  gives  us  concerning  the 
processes  of  life.  This  is  true  even  as  regards  uni- 
cellular organisms,  but  more  especially  so  when  we 
study  the  morphology  of  the  cell  in  multicellular  be- 
ings. In  many  respects  bacteria  are  analogous  to  cell 
nuclei,  especially  as  concerns  the  changes  which  they 
undergo  as  a  result  of  inanition.  In  the  course  of  a 
long  series  of  experiments  conducted  in  the  orator's 
laboratory,  it  had  been  discovered  that  bacteria  lose 
fifty-one  per  cent,  of  their  substance  during  the  first 
six  days  that  they  are  deprived  of  necessaiy  sustenance, 
but  then  attain  an  equilibrium  which  is  maintained 
practically  unchanged  during  from  forty  to  eighty 
days  of  furtlier  culture.  In  the  same  way  it  has  been 
found  that,  wlien  an  animal  is  suffering  from  inani- 
tion, the  nuclei  of  its  cells  lose  more  than  one-half  of 
their  substance  without  undergoing  degeneration.  In 
rabbits  which  had  been  starred  for  a  certain  period, 
the  I6ss  in  weight  was  thirty-five  per  cent.,  the  size  of 
the  pancreas  was  reduced  three  per  cent.,  the  cells 
were  diminished  in  size  about  thirteen  per  cent.,  but 
there  was  no  change  visible  in  the  structure  of  the  nu- 
clei. From  this  the  speaker  concluded  that  the  nuclei 
are  independent  of  the  cell  body.  If,  however,  the 
nucleus  is  autonomous,  it  must  necessarily  have  a 
composite  structure.  That  it  has  a  selective  action  of 
its  own  has  been  proved  by  a  number  of  experiments 
in  feeding  animals  with  dilTerent  substances.  Ani- 
mals were  fed  exclusively  on  lard,  or  sugar,  or  pep- 
tone, or  albumin,  or  hay,  and  it  was  found  that  the 
nuclei  varied  in  size  according  to  the  kind  of  nutri- 
ment employed.  The  nuclei  also  multiply  differently 
according  to  the  nature  and  amount  of  the  nutritive 
material  supplied  to  them.  But  this  multiplication  or 
reproduction  of  the  cell  nucleus  occurs  entirely  inde- 
pendently of  the  cell  body.  The  cell  is  therefore  not 
an  elementary  body.  Thi.s,  Professor  Lukianov  ven- 
tured to  believe,  is  a  new  truth,  an  end-of-the-century 
discovery  which  will  serve  as  a  basis  for  the  working 
out  of  many  biological  problems  during  the  years  of 
the  twentieth  century  which  is  about  to  dawn,  and 
which  we  have  every  justification  for  believing  will  be 
so  productive  of  knowledge  and  of  advance  in  every 
department  of  science. 

The  Present  Modes  of  Treating  Consumptives  and 
their    State  Control.— Priiff.ss()r  e.  v.   Lkvukn,  of 


Berlin,  said  that  he  had  no  apology  to  offer  for  se- 
lecting such  a  well-worn  subject,  for  the  miser}-  in  the 
world  caused  by  pulmonary  tuberculosis  is  so  great 
that  until  we  have  solved  the  problem  we  can  never  tire 
of  discussing  the  means  of  its  prevention.  He  pro- 
posed to  discuss  especially  the  institutional  treatment 
of  consumption  and  see  in  what  way  its  benefits  may 
he  extended  to  the  poor,  who  at  present  are  almost 
wholly  debarred  from  participation  in  them. 

The  ancient  belief  in  the  incurability  of  pulmonary 
tuberculosis  was  thrown  down  by  Brehmer  in  1855, 
when  he  established  his  famous  sanatorium  in  Gor- 
bersdorf  and  began  to  restore  to  societ)'  pulmonarj- 
invalids  who  had  been  condemned  to  death  by  physi- 
cians and  friends.  The  elements  of  this  method  of 
cure  are :  the  choice  of  a  healthful  climate,  abundant 
nourishment,  fresh  air,  hardening  of  the  body  and  syste- 
matic exercises,  re.st  and  passive  movements,  psycho- 
therapy and  discipline  of  the  patient,  and  lastly  the 
use  of  drugs  in  certain  cases. 

But  before  considering  these  points  in  detail  the 
speaker  would  dwell  briefly  on  the  prophylaxis  of  tu- 
berculosis. Assuming  as  proven  that  tuberculosis  is 
a  contagious  disease  and  that  the  agent  of  infection  is 
Koch's  bacillus,  he  said  that  contagion  may  be  direct, 
indirect,  or  from  animals.  Direct  contagion  is  usually 
easily  followed,  but  the  path  of  indirect  contagion  by 
means  of  dust,  infected  vessels,  clothing,  or  other  ob- 
jects of  various  kinds,  is  often  most  obscure.  Infec- 
tion from  animals  through  milk,  butter,  and  meat  is, 
he  held,  much  more  frequent  than  physicians  and  the 
public  are  apt  to  believe.  He  laid  but  little  stress  on 
heredity,  for  he  believed  that  in  most  cases  the  disease 
was  transmitted  to  children  by  contagion  from  their 
parents,  and  not  by  inheritance.  Our  preventive  meas- 
ures are  conducted  along  two  lines:  the  prevention  of 
infection,  and  the  strengthening  of  the  body  to  resist 
the  attacks  of  the  pathogenic  agent.  The  latter  can 
be  effected  by  bringing  up  children  with  Spartan  se- 
verity and  by  shunning  every  approach  to  coddling. 
It  is  along  this  path  that  we  may  hope  for  success, 
for  the  attempt  to  avoid  the  agent  of  contagion  must 
necessarily  fail  and  will  result  only  in  causing  a  ba- 
cillophobia  that  is  unworthy  of  a  rational  people. 
The  public  is  justly  suspicious  of  attempts  of  the  sani- 
tary authorities  to  suppress  this  disease.  Certain  pre- 
cautionary measures,  such  as  the  destruction  of  sputa 
and  the  avoidance  of  intimate  association  of  the  sick 
with  the  well,  are  of  course  necessar)-,  but  they  should 
be  carried  out  otherwise  than  by  the  power  of  the  po- 
lice. In  this  connection  the  speaker  took  up  the  ques- 
tion of  the  alleged  danger  of  sanatoria  for  consumptives, 
and  denied  with  emphasis  that  anv  such  existed  in  a 
properly  conducted  institution. 

The  medicinal  treatment,  he  said,  may  be  consid- 
ered under  three  heads,  viz.,  pharmacological  prod- 
ucts, opotherapy,  and  orrhotherapy.  While  admitting 
the  efficacy  of  certain  drugs  of  the  creosote  order,  he 
denied  that  they  had  any  specific  action.  Opotherapy 
with  "pulmonin"  he  dismissed  with  a  word  of  con- 
tempt. He  then  took  up  the  history  of  tuberculin  and 
other  serum  products,  and  said  that  they  are  all  as  yet 
only  on  trial  and  their  actual  therapeutic  value  remains 
to  be  proven.  There  is,  however,  a  verv'  present  dan- 
ger that,  in  looking  forward  to  ultimate  .success  by  this 
means,  we  come  to  value  less  highlv  the  verv'  eflficacious 
means  we  have  at  hand  in  the  institutional  treatment 
of  consumption,  that  is,  the  hygienic  and  dietetic  ther- 
apy of  the  disease. 

Taking  up  the  several  points  in  this  treatment,  he 
spoke  first  of  climate,  (ireat  faith  has  for  a  long  time 
been  placed  upon  a  change  of  climate  for  the  phthis- 
ical, especially  a  change  to  an  elevated  region  where 
consumption  is  seldom  encountered  among  the  na- 
tives.    While  valuing  highly  the  climatic  advantages 


September  4,  1897] 


MEDICAL    RECORD. 


355 


of  high  altitudes,  the  speaker  warned  his  hearers  that 
there  is  no  actual  immunity  against  tuberculosis  in 
these  regions,  and  we  cannot  depend  upon  any  climate 
as  in  itself  directly  curative  of  this  disease.  Neither 
are  the  hills  the  only  regions  where  benefit  may  be 
obtained,  for  the  .seashore  and  southern  climates  are 
equally  efficacious  in  many  cases.  The  chief  disad- 
vantage of  a  warm  climate  is  that  it  unfits  the  sufferer 
for  a  life  in  his  northern  home  after  the  cure  of  his 
tuberculosis.  The  speaker  quoted  Dr.  Knopf,  of  New 
York,  who  disbelieves  in  tiie  specific  action  of  any 
particular  climate  and  recommends  that  sanatoria  be 
established  within  eas)-  distance  of  the  large  centres 
of  population. 

The  assumed  specific  action  of  fresh  air  in  tubercu- 
losis is  also  one  of  the  myths  of  medicine.  It  has  no 
such  action,  but  its  value  is  a  purely  hygienic  one, 
since  it  aids  greatly  in  strengthening  the  organism  and 
rendering  it  more  resistant  to  the  attacks  of  the  patho- 
genic organisms.  The  air  should  be  pure,  as  free  as 
possible  from  dust,  not  liable  to  great  and  sudden 
changes  of  temperature,  and  the  place  should  be  free 
from  violent  storms. 

Of  great  importance  is  the  nourishment  of  the 
phthisical.  The  time  has  long  passed  when  men 
treated  consumption  as  they  did  other  pyretic  affec- 
tions, by  a  low  diet.  Experience  has  shown  that  the 
more  food  the  consumptive  takes  and  digests  the  bet- 
ter are  his  chances  of  recovery.  Formerly  great  stress 
was  laid  upon  the  consumption  of  large  quantities  of 
fats,  cod-liver  oil,  cream,  and  the  like,  and  also  upon 
the  taking  of  a  plentiful  supply  of  alcohol.  The  lat- 
ter is  now  given  in  much  mailer  quantity,  for  it  is 
neither  a  suitable  food  nor  a  destroyer  of  the  patho- 
genic germ.  It  is  useful  to  cheer  the  patient  and  to 
stimulate  his  appetite,  but  in  no  other  way,  and  it 
may  be  harmful  by  favoring  ha:;moptysis.  We  do  not 
even  place  as  much  reliance  on  fats  and  milk  as  in 
former  times,  but  we  accommodate  the  diet  to  the 
needs  and  the  taste  of  the  patient,  taking  care  only  to 
see  that  it  is  so  composed  as  to  furnish  calories  enough 
to  more  than  compensate  for  the  daily  loss. 

The  value  of  psychotherapy  in  tuberculosis  must 
not  be  underestimated.  The  patient  should  be  en- 
couraged to  hope  for  a  cure  and  should  be  taken  into 
the  physician's  confidence  to  the  e.\tent  that  he  may 
understand  the  object  of  each  of  the  measures  adopted, 
so  that  he  may  be  able  to  further  their  good  eft'ect  by 
his  own  co-operation  and  may  be  inspired  with  confi- 
dence in  the  methods  employed.  The  discipline  of 
the  institution,  however,  should  not  be  too  strict,  but 
the  patients  should  be  allowed  all  liberty  that  is  con- 
sistent with  the  proper  execution  of  the  hygienic  and 
dietetic  rules. 

Finally,  v.  Leyden  said,  we  have  to  consider  the 
hardening  process,  and  he  had  reserved  the  discussion 
of  this  for  the  last  in  order  emphasize  its  importance. 
This  is  the  point  in  the  hygienic  and  dietetic  method 
which  in  a  measure  marks  its  superiority  over  the 
specific  treatment.  The  latter  combats  the  pathogenic 
agents  and  its  success  is  assured  only  when  it  has  com- 
pletely and  permanently  destroyed  the  tubercle  bacilli 
so  as  to  secure  a  lasting  immunity  for  the  organ- 
ism. The  hardening  process,  however,  so  strengthens 
the  diseased  body  that  it  acquires  sufficient  resisting 
power  not  only  to  tolerate  the  disease  but  to  over- 
power it,  and  so  gain  a  complete  and  enduring  victory 
over  it.  Among  the  measures  by  which  this  is  effected 
(ire  a  life  in  the  open  air,  living  in  airy  apartments, 
and  sleeping  with  open  windows.  Hydrotherapy  is 
another  powerful  agent  in  this  process,  and  consists 
in  cold  sponging,  showers,  and  short  cold  plunges. 
Further  exercises  in  the  open  air  are  necessary,  such 
as  methodically  prescribed  hill  climbing,  similar  to 
Oertel's  "  Terraincur,"  .md  various  sports — riding,  row- 


ing, golf,  and  the  like.  Overheating  is,  however,  to 
be  avoided,  as  it  may  cause  bronchitis  or  even  ha;mop- 
tysis.  The  rest  cure  is  suitable  only  for  very  weak 
patients,  whom  we  should  endeavor  to  strengthen  as 
rapidly  as  possible  and  then  subject  them  to  a  gradu- 
ated hardening  process. 

It  has  been  asked  whether  similar  results  cannot  be 
obtained  by  following  out  all  the  prescriptions  of  diet, 
exercise,  etc.,  outside  of  an  institution,  and  in  reply 
the  speaker  said  they  could,  though  \\  ith  much  greater 
difficulty.  In  some  cases  the  patient  has  such  a  re- 
pugnance to  institution  life  that  it  is  necessary  to 
give  him  outside  treatment.  Sometimes,  however,  this 
repugnance  can  be  overcome  by  firmness  on  the  part 
of  the  physician,  and  once  the  patient  has  made  a  trial 
of  the  sanatorium  he  is  generally  satisfied  to  remain. 

Naturally,  however,  the  benefits  of  this  treatment 
can  be  enjoyed  by  only  a  few  whose  means  will  per- 
mit, and  the  thousands  and  thousands  of  the  poor  are 
debarred  from  the  privileges ;  but  if  the  combat 
against  tuberculosis  is  to  become  general  we  must 
bring  the  benefits  of  the  institution  treatment  within 
reach  of  the  poorest  by  the  establishment  of  special 
sanatoria  for  the  people. 

Much  interest  has  of  late  been  aroused  in  Germany 
in  what  has  been  called  the  "sanatorium  movement.'' 
This  movement  dates  from  about  ten  years  back,  being 
stimulated  by  the  discussion  of  the  question  of  the 
isolation  of  consumptives.  The  idea  of  forcible  segre- 
gation of  the  tuberculous  was  happily  abandoned  as 
being  only  apparently  humane  and  really  inhuman  in 
its  consequences,  but  it  resulted  in  the  determination 
to  establish  public  sanatoria  where  the  poor  could  re- 
ceive the  same  care  as  the  well-to-do  in  private  insti- 
tutions. At  present  there  are  in  (Germany  twenty  san- 
atoria in  course  of  construction  or  already  in  working 
order.  Almost  all  of  the  old-established  sanatoria 
now  have  annexes  of  more  modest  character,  where 
those  of  small  means  can  be  treated,  and  many  of  the 
large  cities  of  Germany  have  undertaken  the  estab- 
lishment of  hospitals  for  consumptives. 

The  speaker  tlien  referred  to  wliat  had  been  done  in 
this  direction  in  other  lands,  notably  in  England, 
where  the  Royal  Hospital  for  Diseases  of  the  Chest 
was  established  in  18 14  and  the  Brompton  Hospital 
in  1841.  He  mentioned  also  various  sanatoria  in  the 
United  States,  France,  Austria,  and  Russia,  where 
much  is  being  done.  v.  Leyden  himself  had  devoted 
much  time  and  labor  to  the  extension  of  this  sana- 
torium movement.  In  1894  he  delivered  a  public  ad- 
dress, before  the  International  Hygienic  Congress  at 
Budapest,  on  "The  Care  of  the  Tuberculous  by  the 
Large  Cities,"  and  a  year  later  read  a  paper  on  "  The 
Necessity  of  the  Establishment  of  Public  .Sanatoria 
for  Sufferers  from  Pulmonary  Disease  "  at  a  meeting 
of  the  National  Public  Health  Association.  After 
detailing  the  plans  or  the  Berlin-Brandenburger  Heil- 
statten-Verein,  established  for  the  purpose  of  erecting 
free  sanatoria  for  consumptives,  which  has  already 
made  satisfactory  progress,  the  speaker  closed  with 
the  hope  that  soon  all  the  countries  of  the  civilized 
world  would  be  dotted  with  hospitals  for  consump- 
tives which  might  ser^'e  as  worthy  monuments  to  the 
memory  of  the  philanthropists  of  the  nineteenth  cen- 
tury. 

New  Horizons  in  Psychiatry Prof.  Cesare  Lom- 

BRoso,  of  Turin,  was  the  last  orator.  When  he 
stepped  forward  on  the  platform  he  was  received  with 
long-continued  and  repeated  rounds  of  applause,  just 
as  his  name  was  cheered  to  the  echo  when  it  was  read, 
on  the  first  day  of  the  congress,  among  those  of  the 
national  presidents.  The  doctrine  of  criminal  an- 
thropolog}-,  of  which  the  Turin  professor  is  the  most 
distinguished  apostle,  numbers  many  of  its  most  en- 
thusiastic and  active  supporters  among  Russian  men 


is6 


MEDICAL    RECORD. 


[September  4,  1897 


of  science.  In  Uie  introduction  to  his  subject  the 
s]x;ak.er  said  that  by  the  term  '"  new  horizons'  he 
meant  new  applications  of  the  science  of  psychiatry, 
namely,  the  application  of  the  facts  of  this  branch  of 
learning  to  a  study  of  abnormal  man,  of  the  criminal 
and  degenerate.  All  new  sciences  meet  with  great 
opposition  at  first,  and  it  is  best  that  they  should. 
This  new  science  had  not  escaped  the  usual  fate;  it 
had  even  been  denied  the  distinction  of  being  a  sci- 
ence. But  there  is,  the  speaker  maintained,  much 
true,  earnest,  scientific  work  being  done  in  it.  The 
tendency  of  the  science  is  not  to  undermine  the  penal 
code,  as  some  legislators  have  imagined,  but  its  aim 
is  solely  to  protect  diseased  humanity;  it  is  to  turn 
society  from  its  cherished  system  of  vengeance  for 
wrongs  done  to  it  by  irresponsible  beings,  to  a  pcjlicy 
of  correction  and  of  prevention  of  crime.  In  fortu- 
nately, and  this  is  a  fact  which  has  been  used  by  oppo- 
nents to  discredit  the  science  of  criminal  anthropology, 
pathology  is  of  little  or  no  help  in  the  study.  But 
there  is  the  same  drawback  in  the  study  of  many  ner- 
vous disea.ses,  for  in  perhaps  the  majority  of  them, 
the  so-called  functional  nen-ous  diseases,  there  are  no 
definite  lesions  discoverable  with  the  aids  at  our  com- 
mand. There  is  hope,  however,  for  the  future  in  the 
new  theorj'  of  the  neuron.  In  this  theory  of  indepen- 
dent movements  of  the  neurons  we  find  a  very  satisfac- 
tory explanation  of  the  phenomena  of  sleep,  of  hypno- 
tism, and  of  memory.  I'he  fact  that  in  dealing  with 
supposed  psychical  states  we  are  dealing  with  pure 
hypotheses  is  one  that  tends  to  discourage  observation, 
but  it  should  not.  We  ought  to  study  carefully  all 
modifications  of  the  psychical  state,  for  the  discoveries 
which  this  may  lead  us  to  are  incalculable  in  their  im- 
portance. An  explanation  of  telepathy  or  mental  in- 
fluence acting  at  a  distance  is  possibly  to  be  found  in 
a  polarization  of  the  molecular  elements  of  the  brain 
substance.  This  science,  this  study  of  psychiatry, 
which  has  been  but  begun  in  the  nineteenth  century, 
will  be  handed  down  as  a  legacy  to  the  twentieth,  and 
the  development  which  it  may  attain  and  the  benefits 
to  the  human  race  which  may  flow  from  its  discoveries 
are  beyond  our  powers  to  foresee — indeed,  beyond  t-xen 
the  powers  of  imagination. 

First  Award  of  the  Moscow  Prize. — 1'kokessor 
V'iRCHow  then  jiroposed,  amid  universal  expressions 
of  approbation,  that  the  first  Moscow  prize,  established 
by  the  municipality  of  Moscow  and  to  be  awarded  at 
e.ich  recurring  international  congress,  be  bestowed 
upon  Henri  Dunant,  the  founder  of  the  Red  Cross  So- 
ciety, in  recognition  of  his  inestimable  services  to  hu- 
manity. This  proposal  was  accepted  with  acclamation 
and  prolonged  cheers. 

A  telegram  was  then  sent  to  the  Tsar,  informing 
him  of  the  close  of  tiie  twelfth  international  congress, 
and  thanking  him  for  his  liberality  which  had  made 
this  meeting  possible. 

Professor  Virchow  then  rose  again,  and  in  eloquent 
words  thanked  Professor  Sklifosovskyijn  behalf  of  the 
members  of  the  congress  for  the  cordial  reception 
which  had  been  accorded  them,  and  he  assured  the 
president  and  all  his  colleagues,  to  whose  untiring 
elTorts  the  success  of  the  meeting  was  due,  that  never 
would  the  foreign  congressists  forget  that  Russian 
hospitality,  of  which  they  had  so  often  heard  and 
which  now  they  had  had  the  opportunitv  to  exix'rience 
in  their  own  persons. 

Processor  Ski.ii-osovskv  replied  with  tears  in  his 
eyes,  and  tlien  turning  to  his  brethren  on  the  commit- 
tee, addressed  them  in  Russian,  saying  that  it  was  to 
them  the  thanks  were  due.  His  part  had  been  a  fee- 
ble one,  though  he  had  performed  it  to  the  best  of  his 
power.s.  l?ut  the  main  part  of  the  labor  had  been 
theirs,  and  if  any  praise  were  due  for  what  had  been 
done  it  was  to  them  that  it  must  be  accorded. 


Sir  Wii.lia.m  M.'VcCormac  followed  with  a  brief  ad- 
dress of  thanks  on  behalf  of  his  English-speaking 
colleagues. 

Professor  Sklifosovsky  then  declared  the  congress 
adjourned,  and  wished  all  present  au  revoir  a  Paris  I 

<  To  be  Continutd.  j 


BRITISH    MEDICAL    ASSOCIATION. 

Sixty-I'ifth     Annual     jMceting,     Held     at     Montreal, 
Canada,  August  jl,  September  j,  2,  j,  l8gj. 

(Special  Report  fur  the  Mkdicai.  Record.) 
GENERAL   SESSIONS. 

J'irst  Day—  Tuesday,  August  jist. 

Dk.  T.  G.  Roddick,  M.P.,  president  of  the  associa- 
tion, was  called  to  the  chair  at  3  p.m. 

Addresses  of  Welcome. — Mr.  Wilson  S.mith,  mayor 
of  the  city  of  Montreal,  expressed  a  hearty  welcome  in 
tlie  name  of  the  metropolitan  city  of  Canada  to  the 
members  and  guests  of  the  liritish  Medical  Associa- 
tion. He  alluded  to  the  pleasure  the  citizens  felt  when 
Montreal  had  been  selected  as  the  meeting-place.  It 
seemed  to  him  peculiarly  appropriate  that  in  this  great 
year,  when  the  jubilee  of  Queen  Victoria's  reign  had 
been  so  enthusiastically  honored  by  the  colonies  of 
Great  Britain,  such  an  opportunity  should  be  afforded 
the  members  of  the  medical  profession  to  become  ac- 
quainted with  the  Greater  Britain.  He  trusted  the 
members  of  the  association  would,  by  visiting  the  differ- 
ent parts  of  Canada,  become  much  and  favorably  im- 
pressed with  the  resources  of  the  dominion,  in  order 
that  they  might  carry  back  to  the  people  unto  whom  it 
was  their  pleasure  to  minister  a  true  and  intelligent 
account  of  the  magnitude  of  this  part  of  the  British 
empire.  He  wished  them  to  know  for  themselves  that 
this  was  not  a  land  of  ice  and  snow,  but  a  dominion  (if 
great  natural  resources  and  with  a  climate  second  to 
none  in  the  world. 

His  Honor,  the  lieutenant  governor  of  the  Province 
of  Quebec,  Sir  Adolphe  Ch.\pl1!1.\u,  said  he  was  a 
Britisher  at  heart,  and  on  behalf  of  the  province  he 
cordially  welcomed  the  association  to  Quebec.  The 
legislative  grant  toward  defraying  some  of  tlie  e.xpenses 
of  the  meeting  was  only  an  outcome  of  the  hospitality 
which  was  a  distinguishing  characteristic  of  the  two 
great  races  which  occupied  the  province.  In  this  aus- 
picious jubilee  year,  the  meeting  being  held  outside  the 
J5ritish  Isles  was  a  great  and  good  omen  of  the  coming 
closer  union  between  the  motherland  and  her  colonies. 
He  eloquentlv  reviewed  the  history  of  the  association, 
and  paid  a  eulogistic  tribute  to  the  scientific  work  it  had 
accomplished.  In  conclusion,  he  assured  the  mem- 
bers of  the  association  that  while  they  sojourned  with- 
in the  borders  of  the  province  thev  were  to  be  partakers 
in  that  freedom  wiiich  was  the  great  cornerstone  on 
which  the  hopes  and  aspirations  of  true  Canadians 
rested. 

The  Karl  ok  AiiEKi>EK.\,  governor-general  of  Can- 
ada, said  his  was  the  third  speech,  so  the  association 
might  consider  itself  thrice  welcome.  He  indorsed 
all  that  had  previously  been  expressed  in  welcoming 
tlie  members  and  guests  of  the  association  to  Canada. 

Dk.  I.  G.  -Vdami,  of  Montreal,  then  introduced  the 
accredited  delegates  to  the  a.ssociation. 

President's  Address. —  Dr.  T.  G.  Roddick  then  de- 
livered the  presidents  address  (see  page  325). 

Lord  Lister  moved  a  vote  of  thanks  to  Dr.  Rod- 
dick for  his  valuable  and  eloquent  address. 

Sir  James  GRA.\r,  of  Ottawa,  in  seconding  the  res- 
olution, expressed  the  pride  and  gratification  which 
all  Canadians  felt  at  the  visit  of  the  association  to  the 
dominion.     They  were  also  pleased  to  see  the  visitors 


September  4.  1897] 


MEDICAL    RECORD. 


557 


from  the  other  side  of  the  line.  They  were  one  people, 
the  only  difference  being  that  the  progenitors  of  their 
American  friends  landed  on  Plymouth  Rock,  while  tlie 
progenitors  of  the  Canadians  paddled  up  the  St.  Law- 
rence in  order  that  they  might  enjoy  under  the  British 
flag  the  principles  of  civil  and  religious  liberty.  He 
made  a  graceful  allusion  to  tlie  presence  of  Professor 
Richet,  and  congratulated  Dr.  Roddick  on  his  ad- 
dress. With  respect  to  the  question  of  interprovincial 
registration,  or  a  central  examining  board,  he  was  sure 
the  time  was  not  far  distant  when  an  agreement  would 
be  arrived  at. 

Dr.  S.\un'dby  briefly  expressed  the  obligations  of 
the  association  to  the  governor-general,  Lieutenant- 
Governor  Chapleau,  and  the  mayor  for  their  presence. 

The  meeting  then  adjourned. 

In  the  evening  a  soire'e  was  held  at  Laval  Univer- 
sity, 

The  Work  of  Pasteur  and  the  Modern  Conception 
of  Medicine. — Prof.  Charles  Richet,  of  Paris,  the 
delegate  of  the  French  government  and  of  the  Faculty 
of  Aledicine  of  Paris  to  the  association,  addressed  the 
company  on  this  subject.  He  first  gave  a  sketch  of 
the  life  of  Pasteur,  and  then  reviewed  briefly  his  work 
and  its  influence  on  the  doctrines  of  the  microbic  the- 
ory of  disease,  of  antiseptic  surger}%  and  of  orrhother- 
apy. 

At  the  conclusion  of  this  address  there  followed  a 
reception  by  the  Earl  of  Aberdeen,  the  governor-general 
of  the  dominion. 


Second  Day —  Wedrusday,  September  ist. 

The  chair  was  taken  at  3  p.m.  by  the  president,  Dr. 
T.  G.  Roddick,  M.P. 

The  address  in  medicine  was  delivered  by  Dr. 
^VILLI.'v.^r  OsLER,  of  Baltimore  (see  page  ZZZ)- 

Dr.  Stephen  Mackenzie,  of  London,  moved,  and 
Or.  a.  Jacobi,  of  New  York,  seconded  a  vote  of  thanks 
to  Dr.  Osier. 

At  the  conclusion  of  the  address  a  special  session 
of  convocation  of  McGill  University  was  held,  tht- 
chancellor,  the  Right  Honorable  Lord  Strathcona  and 
Mount  Royal  presiding.  The  honorary  degree  of 
LL.D.  was  conferred  in  due  form  upon  the  following 
distinguished  members  of  the  profession  now  in  at- 
tendance at  the  association  meeting:  Lord  Lister,  Sir 
W.  Turner,  and  Messrs.  Broadbent,  Gaskill,  >rcAllister. 
Watson  Cheyne,  Henry  Barnes,  and  A.  G.  Wheel- 
house. 

The  meeting  adjourned  after  formal  announcements 
had  been  made. 

A  reception  was  tendered  to  the  members  and  guests 
of  the  association  on  Wednesday  evening  by  Lord 
Strathcona  and  Mount  Roval. 


SKCTION    IX   .SfKGKRV. 
Fir^t  Day —  IVrd/i.-s./ay,  Se/>feml>tr  isf. 

The  Teaching  of  Surgery. — ^Mr.  Christopher 
Heath,  F.R.(J.S.,  of  London,  chairman  of  the  section, 
delivered  the  annual  address.  After  a  brief  intro- 
duction, he  referred  to  the  two  subjects  which  were 
to  be  discussed  at  this  meeting,  viz.,  (i)  Appendicitis 
ani  its  surgical  treatment,  and  (2)  the  treatment  of 
cancer  of  the  rectum,  with  special  reference  to  the 
high  operation,  and  then  continued: 

"  Nothing,  I  venture  to  think,  is  more  remarkable 
than  the  recent  progress  of  abdominal  surgery. 
Twelve  years  ago  I  was  engaged  in  editing  a  '  Dic- 
tionary of  Practical  Surgery,'  and  neither  appendici- 
tis nor  the  operation  for  removal  of  the  rectum,  with 
which  Kraske's  name  is  connected,  was  mentioned  in 
it.  although  I  had  the  assistance  of  the  leading  Lon- 
don hospital   surgeons.       Kraske's   original  paper,  I 


may  mention,  was  published  in  1885,  and  is  referred 
to  in  Ball's  work  on  the  rectum,  published  in  1887, 
and  in  most  surgical  works  since  tiiat  date.  The  sub- 
ject of  appendicitis,  so  far  as  British  surgerj-  goes, 
dates  from  a  paper  read  before  the  Royal  Medical  and 
Chirurgical  Society  in  February,  1888,  b)-  Mr.  Fred- 
erick Treves,  though  the  title  of  it  was  Relapsing 
Typhlitis  treated  by  Operation.'  In  August  of  the 
same  year  Mr.  Treves  opened  a  discussion  en  '  Surgi- 
cal Treatment  of  Typhlitis,'  at  the  meeting  of  the  Brit- 
ish Medical  Association  at  Leeds,  and  subsequently 
published  his  address  with  additions  and  alterations 
in  the  form  of  a  monograph,  entitled  '  The  Surgical 
Treatment  of  Perityphlitis.'  I  do  not  know  to  whom 
we  are  indebted  for  the  hybrid  term  '  appendicitis,' 
but  it  did  not  appear  in  the  index  to  the  British  Med- 
iial  Journalheioxe.  1891. 

"  But  it  is  not  merely  in  these  two  departments  that 
]3rogress  has  been  made.  The  surgery  of  the  kidney 
and  of  the  liver  has  advanced  pari  passu  with  that  of 
the  hollow-  viscera,  and  the  labors  of  Morris  and  Rob- 
son  in  England,  and  of  Keen  and  others  on  this  side 
of  the  Atlantic,  have  done  much  for  the  relief  of 
suffering  and  the  prolongation  of  life. 

"  Looking  back  over  fort)'  years  of  professional  life, 
nothing  surprises  me  more  than  the  change  which  has 
come  over  the  treatment  of  calculus.  In  my  student 
days,  to  see  Fergusson  cut  for  stone  by  the  lateral 
method  was  to  witness  an  operation  as  near  perfection 
as  was  conceivable,  and  the  dexterity  and  rapidity 
with  which  the  calculus  was  extracted  were  marred 
only  by  the  frequency  with  which  death  from  septic 
causes  spoiled  the  skill  of  the  surgeon.  To  have  one's 
first  lithotomy  was  an  event  in  the  life  of  the  young 
surgeon,  and  every  now  and  then  a  reputation  was 
spoiled  by  some  contretemps  in  the  public  performance 
of  the  operation.  Later,  I  was  the  frequent  witness  of 
my  colleague  Henrj'  Thompson's  skill  in  using  the 
lithotrite  to  break  up  the  calculus  in  a  series  of  '  sit- 
tings.' Then  came  '  litholapaxy,'  oi  rapid  lithotrity, 
which  we  owe  to  Bigelow,  the  great  American  sur- 
geon :  and,  lastly,  that  recurrence  to  the  old  high  or 
suprapubic  operation  which  was  due  to  the  Scandina- 
vian surgeon  Petersen.  Hence  the  student  of  to-day 
rarely  if  ever  sees  a  perineal  lithotomy,  and  as  a  con- 
sequence his  interest  in  the  anatomy  of  the  parts  con- 
cerned in  the  operation  has  greatly  diminished.  Pos- 
sibly the  surgeons  of  the  last  generation  laid  too  much 
stress  upon  anatomical  details,  but  it  is  somewhat  re- 
markable to  find  how  little  anatomy  seems  to  serve  for 
practice  in  the  present  day. 

"  I  am  told  by  those  who  are  teaching  anatomy  now 
that  it  is  diffirult  to  get  the  student  to  take  the  trouble 
to  make  a  neat  dissection,  because  he  can  find  in  the 
various  museums,  and  notably  at  the  College  of  Sur- 
geons of  England,  such  beautiful  preparations  in  spirit 
that  he  prefers  to  study  from  them  or  from  pictures 
rather  than  labor  to  get  out  the  details  for  himself. 
If  this  is  so  I  can  only  regret  that  the  present  race  of 
students  is  so  short-sighted,  for  without  a  working 
knowledge  of  human  anatomy  I  can  conceive  of  no 
progress  in  surger}-. 

"  But  I  regret  to  find  that,  in  (Jreat  P.ritain  at  least, 
the  teaching  of  anatomy  is  gradually  getting  more  and 
more  into  the  hands  of  professors  who  are  anatomists 
but  not  surgeons,  and  that  their  tendency  is  to  lay 
stress  upon  transcendental  details  rather  than  surgical 
relations.  When  these  gentlemen  happen  to  become 
examiners  this  tendency  to  specialize  becomes  very 
marked,  and,  as  this  applies  equally  to  the  teachers  of 
physiology  and  chemistry,  the  unfortunate  medical 
student  becomes  the  victim  of  science  (falsely  so 
called),  and  sometimes  develops  into  that  man-ellous 
being,  a  London  B.Sc. 

■■  But  seriously,  are  we  not   overdoing  the   scientitic 


358 


MEDICAL    RECORD. 


[September  4,  1897 


teaching  of  the  man  who  has  after  all  to  get  his  living 
as  a  practitioner  of  medicine,  surgery,  and  midwifery? 
When  the  medical  curriculum  was  lengthened  by  a 
year,  it  was  hoped  that  the  additional  time  would  be 
devoted  to  clinical  work;  but  I  fear  that  this  is  by  no 
means  always  the  case,  for  it  is  not  uncommon  for  the 
student  to  take  three  years  in  passing  his  primary  ex- 
aminations, with  the  result  that  but  two  remain  for  the 
study  of  medicine  and  surgery.  When  I  became  a 
student  of  medicine  I  took  to  heart  the  advice  of  my 
teacher  of  physiology,  William  Bowman,  and  never 
allowed  a  day  to  pass  without  visiting  the  hospital; 
and  though  as  a  lad  of  sixteen  I  failed  of  course  to 
appreciate  the  importance  of  all  that  I  saw,  yet  I  saw 
it,  and  I  can  carry  my  mind  back  now  to  cases  seen 
and  lessons  learned  in  the  early  fifties  which  are  of 
service  to  me  at  the  present  time.  But  the  student  is 
practically  forbidden  to  enter  the  wards  now  until  he 
has  satisfied  the  examiners  in  anatomy  and  physiology, 
which  he  may  or  may  not  do  in  two  years,  and  then 
there  are  but  three  years  left  for  him  to  study  totam 
rem  incdicam. 

''Far  be  it  from  me  to  decry  the  modern  methods  of 
teaching  medicine  in  the  wards  of  our  hospitals.  I 
believe  that  the  care  taken  to  induct  every  student  into 
the  mysteries  of  auscultation  and  percussion  are  be- 
yond praise;  and  if  with  some  teachers  treatment  is 
regarded  as  of  secondary  importance,  at  least  the  stu- 
dent has  the  opportunity  of  studying  the  vis  im-d'uatrix 
iidfi/ne  untrammelled  under  one  teacher,  and  of  watch- 
ing the  effects  of  every  new  drug  upon  the  human  sys- 
tem under  another.  15ut  all  this  takes  time,  and  so 
also  the  elaborate  manipulations  of  the  gyna;cological 
department,  the  researches  of  the  pathological  profes- 
sor, and  all  the  other  teachings  of  the  third  and  fourth 
years.  And  where,  then,  does  surger)^  come  in  ?  Why, 
I  consider  myself  fortunate  if  I  can  secure  the  regular 
attendance  of  candidates  for  a  surgical  diploma  for 
the  last  three  months,  when  their  names  are  put  on 
my  list,  and  I  subject  them  to  rigid  surgical  cross- 
examination.  But  if  I  venture  to  refer  to  an  illustra- 
tive case  of  last  year,  I  find  that  no  one  present  saw 
it  or  even  heard  of  it,  though  at  the  time  the  whole 
surgical  staff  may  have  been  in  consultation  upon  it. 
How,  I  ask,  is  it  possible  for  the  student  to  see  the 
serious  surgical  ailments  which  are  not  very  common, 
sue);  as  aneurism,  tumors  of  bone,  tetanus,  etc.,  if  his 
attendance  in  the  surgical  wards  is  limited  to  a  few 
months? 

".\nd  yet  there  has  never  been  a  time  of  greater 
activity  in  operative  surgery,  not  only  among  hospital 
surgeons,  but  among  general  practitioners,  who,  thanks 
to  anaesthetics  and  antiseptics,  undertake  operations 
of  a  magnitude  which  the  hospital  surgeon  of  the  last 
generation  would  have  hardly  attempted.  How  are 
we  to  explain  the  apparent  contradiction?  In  the  first 
place,  I  am  afraid  we  must  allow  that  a  great  many 
mistakes  in  diagnosis  are  made,  or,  rather,  that  too 
often  no  attempt  at  diagnosis  is  made,  but  that  an  op- 
eration is  undertaken  to  '  clear  up  the  case.'  That  it 
generally  does  no  doubt,  but  not  always  to  the  benefit 
of  the  patient.  Then  we  must  allow  that,  w  iih  unlim- 
ited time  for  the  anasthelic,  the  least  skilful  surgeon 
may  hope  to  bring  an  operation  to  a  conclusion  more 
or  less  satisfactory  to  himself,  and,  if  he  operates  un- 
der fairly  favorable  circumstances,  for  his  patient  also. 
Lastly  comes  the  enormously  increased  opportunity 
for  the  publication  of  a  success  at  one  of  the  numerous 
mutual  admiration  societies  and  in  one  of  the  medical 
journals  of  the  day.  Can  we  wonder,  then,  that  young 
surgeons  whose  stock  in  trade  of  professional  knowl- 
edge is  of  the  smallest,  blossom  rapidly  into  operat- 
ing surgeons  in  some  special  department,  and  trv  not 
unsuccessfuHy  to  prox-e  that  all  is  fish  whicli  conios  to 
their  net? 


"  Still,  gentlemen,  the  great  foundations  of  the  art 
and  science  of  surgery  remain  undisturbed.  Without 
a  knowledge  of  anatomy,  of  pathology,  and  histology 
progress  in  surgery  is  impossible,  and  it  is  for  those 
who  hold  the  important  positions  of  teachers  in  our 
great  medical  schools  to  insist  upon  a  foundation  of 
scientific  and  practical  training  being  given  to  our 
students  if  they  are  to  become  the  successful  practi- 
tioners of  the  future.  The  growing  tendency  of  the 
non-medical  teachers  of  collateral  science  to  regard 
their  particular  subject  as  the  one  most  essential  for 
the  medical  student  must  be  restrained,  and  the  pre- 
liminary period  of  medical  study  must  be  cleared  of 
many  obstructions  if  the  student  is  to  have  the  neces- 
sary time  to  devote  to  the  thorough  study  of  these 
strictly  medical  subjects  which  will  fit  him  to  be  a 
sound,  practical  and  at  the  same  time  scientific  phy- 
sician and  surgeon." 

Discussion  on  Appendicitis.  —  A  discussion  then 
followed  on  appendicitis,  led  by  Dr.  G.  E.  Arm- 
strong, of  Montreal.  It  consisted  of  the  report  of 
517  cases  seen  in  the  leading  Montreal  hospitals.  It 
was  fo'ind  to  be  most  common  between  the  ages  of 
twenty  and  thirty,  and  occurred  twice  as  often  in 
males  as  in  females.  Discussing  the  etiology  of  the 
question,  the  speaker  said  he  could  throw  little  light 
upon  it,  but  he  thought  anything  that  removed  the 
epithelial  lining  from  the  mucous  membrane  of  the 
appendix,  allowing  germs  to  get  in  and  do  the  work, 
was  the  starting-point  in  most  cases.  A  stercoral  ul- 
cer might  form,  the  healing  of  which  caused  contrac- 
tion of  the  appendix  and  tended  to  prevent  egress  of 
material  from  it,  and  thus  endangered  the  patient's 
life.  The  doctor  handed  around  specimens  of  con- 
strictured  appendices  for  examination.  In  the  total 
number  of  cases  reported,  the  average  mortality  was 
12.8  per  cent. ;  but  from  1853  to  1890,  before  opera- 
tion was  done — that  is,  in  pre-operative  days — the 
mortality  was  23.8  per  cent.  Of  the  517  cases,  389 
were  operated  on  and  128  treated  without  operation. 
In  this  latter  list  the  mortalit)'  was  3.12.  Of  319,  81 
were  interval  cases,  in  which  there  was  not  one  death. 
Of  305  operated  on  in  the  acute  stage,  63  died.  The 
great  point  in  treatment  was  to  anticipate  the  severer 
forms  resulting  in  septic  peritonitis.  This,  the  essay- 
ist held,  was  accomplished  by  early  surgical  interfer- 
ence. Even  fulminating  attacks  were  preceded  by 
mild  attacks,  in  which  the  operation  would  be  suc- 
cessful. The  question  w  hen  to  operate  was  of  great 
importance.  There  w  ere  two  groups  of  cases :  one, 
very  mild,  where  the  question  scarcely  arises;  and  the 
other,  where  there  was  a  difference  of  opinion,  and  it 
was  in  this  latter  class  that  the  judgment  and  experi- 
ence of  tlie  surgeon  were  called  into  play  to  the  fullest 
extent.  Operation  in  the  interval  was  safe.  During 
the  acute  attack  symptoms  were  unreliable.  One 
must  consider  them  all  carefully,  but  the  time  did  arise 
when  only  a  bold  surgeon  would  dare  to  wait  and  a 
cautious  surgeon  would  dare  to  operate.  The  essayist 
said  he  had  seen  rapidly  fatal  cases  follow  too  soon 
getting  up,  too  early  moving  around  after  a  mild  attack, 
and  he  had  seen  one  case  of  rupture  follow  a  dose  of 
castor  oil.  His  rule  was  to  advise  operation  at  the 
end  of  twenty-four  or  thirt)--six  hours  if  the  patient 
was  not  improving.  In  ca.ses  of  general  septic  peri- 
tonitis, in  which  there  was  paresis  of  the  walls  of  the  in- 
testine, he  was  in  the  habit  of  turning  the  wliole  intes- 
tine out  of  the  cavity  before  returning  any.  In 
draining  these  cases  he  used  three  tubes — one  in  the 
pelvis  and  one  in  each  loin.  In  treating  the  disease 
in  the  abscess  stage,  most  experienced  operators  were 
opposed  to  breaking  down  adhesions  and  removing  the 
appendix.  The  wisdom  of  that  course  might  be  ques- 
tioned. He  had  got  better  results  by  removing  the 
whole  abscess  as  far  as  possible.     If  this  was  not  done. 


September  4.  1897] 


MEDICAL    RECORD. 


359 


a  secondary  abscess  might  go  undiscovered  and  lead 
to  the  loss  of  the  patient's  life.  Thorough  removal, 
too,  of  all  pus,  and  breaking  down  material,  lessened 
the  chances  of  septic  infections  through  the  mesenteric 
veins  and  liver.  In  such  cases  he  believed  in  sur- 
rounding the  sides  of  the  abscess  ver\'  thoroughly 
with  gauzes,  sponges,  etc. 

Dr.  Ward  Cousins,  of  Southsea,  England,  in  dis- 
cussing Dr.  Armstrong's  paper  on  appendicitis,  re- 
ferred to  it  in  ver)-  complimentary  terms.  He  said 
very  great  care  should  be  exercised  as  to  the  time 
of  operation.  The  great  question  was  when  to  oper- 
ate. He  did  not  rely  on  statistics,  as  each  case  must 
be  treated  individually.  If  symptoms  are  quiescent  or 
subsiding,  one  should  not  operate.  In  such  case  the 
pain  would  be  less  severe,  the  temperature  falls,  the  ab- 
dominal distention  subsided,  and  the  tenderness  les- 
sened. If  the  symptoms  were  increasing  and  ver\-  se- 
vere, operation  was  called  for.  Rapid  pulse,  anxious 
face,  great  distention,  and  induration  or  fluctuation 
would  certainly  indicate  the  necessitj-  of  operation. 
The  induration  did  not,  in  his  opinion,  indicate  the  di- 
rection in  which  the  appendi.x  lies.  Fulminating  cases 
usually  present  all  the  symptoms  of  general  peritonitis, 
but  the  disease  is  usually  localized  to  the  cacum.  In 
operating  he  preferred  an  oblique  incision,  as  it  gives 
a  better  view  of  the  abdominal  cavity  and  is  closer  to 
disease.  He  uses  an  electric  light  to  enable  him  the 
better  to  examine  the  abscess,  and  never  uses  metal 
retractors.  He  prefers  instead  a  couple  of  ligatures  in 
either  wall  of  the  incision.  When  he  reaches  the 
abscess  he  drains  out  what  pus  will  flow,  and  then 
wipes  out  the  cavitj".  He  never  irrigates,  and  consid- 
ers it  imperative  to  be  as  gentle  as  possible  in  all 
manipulations.  If  the  bowel  is  in  the  way,  he  wraps  it 
carefully  around  with  sponges  and  moves  it  aside.  He 
does  not  use  drainage  tubes  except  when  absolutely 
necessary,  as  he  is  afraid  of  them,  and  then  usually 
only  one  large  one  in  the  groin.  The  surgeons  of  Great 
Britain  were  verj-  chary  of  the  surgical  treatment  of 
appendicitis.  He  felt  that  the  American  surgeons  had 
stimulated  them  to  earlier  operation,  and  had  helped 
them  to  overcome  their  tendency  to  procrastination. 

Dr.  Ball,  of  Dublin,  said  the  number  of  cases  of 
appendicitis  in  which  he  had  operated  could  be  ex- 
pressed in  two  figures;  that  he  had  not  operated  so 
often  as  he  might  have  done.  Cases  of  this  disease 
divided  themselves  into  four  classes.  About  three  of 
them  there  was  little  difficulty.  The  first  was  where 
peritonitis  suddenly  occurred ;  the  second  embraced 
those  in  which  abscess  had  definitely  formed;  and 
the  third  sort  was  where  the  patient  led  a  miser- 
able life  by  reason  of  repeated  attacks,  where  opera- 
tion in  the  internal  was  so  safe.  But  it  was  in  those 
cases  of  first  attack,  in  which  the  symptoms  did  not  ena- 
ble us  to  form  any  accurate  opinion  as  to  what  extent 
the  disease  had  spread,  that  difficult)-  was  met  with. 
If  a  patient  was  not  improving  by  the  third  day  it  was 
his  rule  to  operate. 

Dr.  Jordax,  of  Birmingham,  said  that  real  appen- 
dicitis, strictly  speaking,  was  a  disease  confined  to  the 
appendix,  and  when  this  was  the  case  there  were 
two  sorts:  First,  those  simple  cases  which  got  well; 
and  second,  those  in  which  the  appendix  slowly  dis- 
tended with  irritating  fluid  charged  with  organisms, 
which  fluid  made  its  way  through  into  the  peritoneal 
cavity  and  gave  rise  to  other  forms  of  the  disease  with 
complications.  In  such  cases  the  physicians  and  sur- 
geons should  see  the  case  together.  Too  much  stress, 
he  thought,  had  been  laid  on  McBurney's  point. 
Early  diagnosis  was  very  important. 

Dr.  V.^xder  Veer,  of  Albany,  X.  Y.,  in  discussing 
this  question,  said  bethought  that  possibly  the  British 
surgeons  might  think  the  American  surgeons  were 
rather  too  eager  to  operate. 


Dr.  W.  H.  HiNXKsox,  of  Montreal,  said  that  statis- 
tics could  not  be  depended  upon.  He  thought  in  no 
case  should  one  operate  to  establish  a  diagnosis.  The 
question  of  appendicitis  was  one  that  concerned  the 
physician  as  well  as  the  surgeon.  They  should  go 
hand  in  hand  in  the  studj'of  the  case.  As  far  as  pos- 
sible he  liked  to  get  along  without  operation.  He 
could  call  to  mind  at  least  twent\--seven  cases  in  which 
he  had  recommended  against  operation,  and  all  the 
subjects  got  well.  He  did  not  operate  in  more  than 
one  in  ten,  and  he  did  not  regret  not  having  operated 
in  the  other  nine.  In  one  case  referred  to  him,  in 
which  there  had  been  three  or  four  attacks  induced 
apparently  by  overindulgence  in  cabbage,  he  recom- 
mended the  patient  to  stop  eating  cabbage  rather  than 
submit  to  an  operation.  It  was  claimed  that  the  op- 
eration was  without  danger.  That  was  not  the  case. 
He  had  known  instances  of  death  to  occur  by  reason 
of  operation. 

Ventral  and  Umbilical  Hernia  in  the  Same  Patient 
was  the  title  of  a  paper  by  Dr.  .\.  E.  Garrow  of  Mon- 
treal. He  said  cases  of  umbilical  and  epigastric 
hernia,  having  separate  sacs  but  common  coverings, 
for  which  radical  cure  was  successfully  carried  out, 
are  evidently  rare,  or  at  least  not  frequently  recognized 
and  reported.  After  carefully  looking  over  the  litera- 
ture at  his  disposal  he  had  found  but  one  case  reported 
within  the  last  twelve  years,  namely,  one  by  Ochner, 
of  Chicago,  in  which  radical  cure  was  performed  for  a 
small  supra-umbilical  and  a  large  imibilical  hernia. 
Double  umbilical  hernia;,  with  separate  sacs,  and  mul- 
tiple ventral  hemise,  the  result  of  repeated  laparoto- 
mies, are  not  uncommon  at  the  present  day.  Marcy 
in  his  work  on  the  "  Anatomy  and  Surgical  Treatment 
of  Hernia"  says  of  supra-umbilical  hernia:  "It 
is  not  rare  to  iind  examples  of  ventral  hernia,  in  the 
middle  line  above  the  umbilicus;  these,  so  far  as  I 
have  had  the  means  of  obser\-ation,  are  small  in  size, 
oftentimes  giving  little  or  no  discomfort ;  occasionally 
they  interfere  with  the  process  of  digestion,  causing 
nausea,  flatulency,  and  pain."  In  the  case  under  con- 
sideration, the  contents  of  the  supra-umbilical  protru- 
sion consisted  of  large  and  small  intestine,  cacum 
with  appendix,  and  omentum,  the  latter  being  spread 
out  so  as  to  form  a  more  or  less  complete  sac;  it  was 
adherent,  and  could  be  reduced  only  with  difficult)". 
The  umbilical  hernia,  on  the  other  hand,  was  small, 
sausage  shaped,  and  contained  but  a  single  loop  of 
small  intestine,  which  was  not  adherent  and  was  very 
readily  reduced. 

This  case  at  least  clearly  supports  the  view  that 
large  irreducible  hernia;  may  escape  elsewhere  than 
through  the  umbilical  opening.  Within  the  last  two 
months  I  have  had  an  opportunity-  of  examining  two 
cases  of  hemise  occurring  in  women  past  middle  age 
in  which  the  neck  lay  some  distance  above  the  um- 
bilicus. The  explanation  of  the  few  cases  reported 
may  be  due  to  the  impossibilitv-  of  diagnosing  such  a 
condition  previous  to  operation,  and  that  sirrgeons  are 
comparatively  seldom  called  upon  to  give  radical  re- 
lief for  hernia  in  this  situation  unless  strangulation 
has  occurred,  because  the  subjects  of  such  hemiEe  are 
usually  well  advanced  in  years,  obese,  frequently 
suffering  from  bronchial,  renal,  or  cardiac  disease;  in 
short,  poor  patients  for  any  operative  interference,  par- 
ticularly a  prolonged  laparotomy.  Besides,  many  of 
them  are  made  comfortable  by  wearing  some  form  of 
abdominal  support.  The  danger  in  suitable  cases  in 
opterating  for  such  hernia;  would  not  seem  to  be  much 
greater  than  that  entailed  in  a  modem  laparotomy, 
and  the  important  lesson  learned  by  the  writer  is  that, 
since  in  such  cases  it  is  impossible  to  recognize  the 
double  protrusion  before  incision,  after  opening 
the  main  sac  and  replacing  the  contents  within  the 
abdominal  cavitv  a  careful   search  from  within  should 


;6o 


MEDICAL    RECORD. 


[September  4,  1897 


be  made,  to  ascertain  whether  any  other  hernia  exists 
before  proceeding  to  remove  the  adipose  tissue  mapped 
out  at  the  beginning  of  the  operation. 

W.  J ,  a  colored  female,  aged  forty-five,  entered 

the  Royal  Victoria  Hospital  December  10,  1896,  com- 
plaining of  an  abdominal  tumor  and  asking  for  radical 
relief.  Patient  wasmarriel  twenty-one  years  ago; 
within  three  years  she  had  born  three  children.  Some 
months  after  the  birth  of  the  third  child  a  small  lump 
made  its  appearance  about  one  inch  above  the  um- 
bilicus; this  lump  gradually  increased  in  size  until 
three  years  ago,  when  it  was  about  one-half  its  present 
dimensions,  but  since  then  it  had  grown  rapidly.  Ex- 
cepting transient  attacks  of  abdominal  pain  which  she 
attributed  to  wind  in  the  bowels,  and  some  dragging- 
down  pains,  relieved  bj'  assuming  the  recumbent  posi- 
tion, she  had  suffered  but  little  until  the  last  year. 
During  the  last  twelve  months,  however,  disturbances 
of  digestion  had  been  persistent;  besides,  the  ab- 
dominal pains  and  dragging-down  sensations  already 
referred  to  had  become  much  aggravated,  and  though 
benefited  by  rest  in  bed  had  never  been  entirely  ab- 
sent. Various  abdominal  pads  and  trusses  were  tried 
in  turn,  but  utterly  failed  to  give  relief,  in  fact  aggra- 
vated her  symptom.  Patient  has  had  repeated  attacks 
of  what  she  called  low  fever  at  her  home  in  Jamaica, 
also  muscular  rheumatism  and  sciatica.  Examination 
showed  a  large  tumor  projecting  from  the  mid- 
abdominal  region,  irregularly  hemispherical,  freely 
movable,  soft  and  doughy  in  some  parts  but  tense  and 
elastic  in  others,  irreducible,  distinctly  lobulated, 
somewhat  tender  to  palpation,  which  elicited  gurgling 
sounds.  The  note  was  tympanitic  in  some  places,  in 
others  dull.  The  navel  was  at  the  lower  left-hand  side 
partially  concealed  by  the  overhanging  mass,  and  the 
skin  immediately  surrounding  it  was  superficially 
ulcerated,  evidently  from  the  friction  of  her  clothes. 
The  tissue  above  this  part  are  ver\-  thin,  so  that  the 
outline  of  the  contents  could  be  readily  made  out. 
Umbilical  hernia  was  diagnosed  because  the  neck 
of  the  protrusion  seemed  to  occupy  the  umbilical 
opening. 

The  essayist  then  proceeded  to  describe  the  opera- 
tion, which  was  performed  on  December  14,  1896. 
The  incision  was  elliptical  and  was  made  over  the 
most  prominent  part  of  the  tumor.  Much  difficulty 
■n-as  experienced  in  separating  the  entangled  structures 
contained  in  the  tumors  and  its  coats,  and  on  raising 
the  mass,  which  had  been  ligatured  preparatory  to  re- 
moving it  with  the  knife,  a  gurgling  sound  was  heard, 
which  led  the  operator  to  dissect  toward  the  middle 
line  with  the  result  of  finding  that  the  mass  consisted 
of  two  sacs.  The  peritoneum  was  found  in  both  her- 
nia; adherent  to  the  surrounding  fibrous  rings  and  was 
dissected  away  from  the  margin  a  full  inch.  Each 
opening  was  then  sutured  in  turn  and  separately,  the 
skin  wound  closed,  and  the  ordinarj-  antiseptic  dress- 
ing applied.  The  patient  made  a  good  recovery  from 
the  operation.  She  was  kept  in  bed  for  .seven  weeks, 
all  precautions  being  taken  to  keep  the  openings 
closed  by  strips  of  adhesive  plaster  drawing  the  skin 
from  the  opposite  side  of  the  abdomen.  I'hotographs 
were  then  distributed  showing  the  result  six  months 
later. 

Traumatic  Aneurism  of  the  Internal  Maxillar 
Treated  by  Ligature  of  the  Common  Carotid. — Dr. 
H.  T.AXGi.EY  Rrowxf.  read  a  paper  on  this  subject. 
James  Pearsall,  aged  thirty-two,  married,  boatman 
by  occupation,  was  admitted  to  the  hospital  at  West 
Bromwich.  Marcii  12,  1897,  sufl'ering  from  a  lacerated 
wound  of  the  scalp,  punctured  wound  of  the  right  cheek, 
and  concussion  of  the  brain,  his  injuries  arising  from 
a  kick  of  a  horse.  The  patient  was  semi-conscious  on 
.admission  and  suffering  from  shock.  He  was  bleeding 
profusely  from  the  cheek,  ear,  nose,  and  scalp.     The 


right  side  of  the  face  was  much  swollen,  the  right  eye 
was  completely  closed,  and  the  swelling  extended 
about  half-way  down  the  neck. 

On  examination  the  lower  jaw  was  found  fractured 
on  the  left  side  close  to  the  symphysis,  and  on  the 
right  side  through  the  neck  of  the  jaw.  Crepitus  was 
al.so  detected  over  the  right  malar  bone.  The  temper- 
ature rose  to  100.2°  F.  next  evening,  but  then  fell  to 
normal,  at  which  it  remained  till  the  20th,  when  it 
registered  101.8°  F.  in  the  evening.  The  evening 
temperature  continued  to  rise  till  on  the  25th  it  stood 
at  104.6'  F.  The  patient  then  took  thirty  minims  of 
Warburg's  tincture,  and  the  temperature  fell  to  98.2°  F. 

During  the  next  seven  days  the  swelling  slightly  de- 
creased, and  on  April  5th  the  temperature  again  rose 
to  101.2°  F.,  and  on  the  9th  fluctuation  was  detected 
in  the  neck.  An  incision  was  made  in  the  neck  and 
six  ounces  of  pus  evacuated.  The  patient  was  much 
relieved,  the  swelling  did  not  quite  subside,  and  on 
the  13th  a  copious  hemorrhage  from  the  incision  in 
the  neck  took  place.  This  was  controlled  and  the 
wound  stuffed  with  iodoform  gauze.  The  swelling 
now  increased,  and  on  the  15th  distinct  pulsation  was 
felt  over  the  right  cheek.  On  examining  the  mouth 
the  soft  palate  was  found  greatly  depressed  on  the  right 
side  and  congested,  and  pulsation  was  easily  felt. 

On  the  24th  he  had  a  slight  hemorrhage  from  the 
mouth,  and  again  on  the  26th  a  copious  hemorrhage 
took  place  from  the  mouth,  and  Dr.  Browne  then  de- 
cided to  ligate  the  carotid.  This  was  done  on  the 
26th,  and  the  patient  was  easy  and  restful.  On  the 
29th  he  passed  faices  involuntarily,  but  since  that  time 
he  has  had  perfect  control.  He  was  discharged  cured 
on  May  24th,  and  has  since  reported  himself  weekly 
at  the  hospital. 

Intussusception  of  the  Vermiform  Appendix  and 
Caecum  was  the  title  of  a  paper  by  Theodore  A.  Mc- 
(Jraw,  of  Detroit,  Mich.  The  speaker  reported  the 
case  of  a  boy,  seven  years  old,  who  suffered  from  a 
form  of  intussusception  which  the  speaker  believed 
was  unique  and  threw  a  light  on  the  pathology  of  the 
affection.  The  salient  points  of  the  history,  which  up 
to  the  time  of  operation  co\ered  upward  of  four 
months,  were  as  follows:  An  attack  of  cholera  morbus 
was  followed  by  only  partial  recovery,  and  for  a  pe- 
riod of  some  weeks  attacks  of  diarrhoea  and  very  se- 
vere pain  occurring  in  paroxysms  were  the  prominent 
symptoms.  There  was  no  fever  during  this  period, 
and  for  a  few  days  at  a  time  the  boy  appeared  to  en- 
joy fair  health.  There  was  occasionally  some  traces 
of  blood  in  the  stools.  The  attacks  of  pain  became 
more  frequent  and  severe  as  time  went  on,  until  it  was 
deemed  advisable  to  make  an  exploratory'  incision. 
No  tumor  could  be  felt  in  the  rectum  nor  in  the  iliac 
fossa.  He  referred  his  pain  to  the  epigastric  region. 
There  was  but  little  tenderness  and  no  tympanitis. 
His  tongue  was  clean  and  his  appetite  good.  The 
day  before  the  operation  the  temperature  rose  to  100.2" 
F.  An  exact  diagnosis  was  impossible.  Immediately 
on  opening  the  peritoneal  cavity  the  transverse  colon 
presented  itself  intensely  red,  highly  inflamed,  and 
coated  with  lymph.  The  ascending  colon  had  a  meso- 
colon of  such  length  that  he  was  able  to  draw  it  and 
the  caecum  with  ease  through  the  opening  made  above 
the  navel.  The  ca'cum  and  appendix  were  invagi- 
nated  and  made  a  tumor  within  the  gut,  which  could 
be  felt  through  the  walls  of  the  colon,  about  the  size 
of  a  walnut.  The  ileum  was  not  invaginated.  The 
speaker  then  continued  that  he  thought  it  better  sur- 
gery to  remove  the  invaginated  portion  rather  than 
merolv  to  replace  it,  as  he  felt  the  affected  part 
would  most  likely  return  to  the  old  condition ;  in  other 
words,  that  the  affection  would  be  almost  sure  to  recur. 
He  therefore  removed  the  diseased  part  completely 
and  united  carefully  the  cut  edges  with  c.-itgut  sutures. 


September  4,  1897] 


MEDICAL    RECORD. 


361 


one  for  the  mucous  and  one  for  the  serous  surfaces. 
The  child  made  a  splendid  recovery.  He  had  no  more 
attacks  of  pain  and  gained  in  health. 

The  peculiar  point  of  tlie  case  was  the  occurrence 
of  the  invagination  at  the  extreme  end  of  the  cacum, 
and  not  in  its  continuity  or  at  the  ileo-caacal  valve. 
In  all  other  cases  which  had  been  reported  the  ileo- 
cecal valve  formed  the  apex  of  the  tumor  in  the  caecum. 

An  Analysis  of  One  Thousand  Cases  of  Lateral 
Curvature  of  the  Spine  Treated  by  Posture  and 
Exercise  Exclusively  (without  Mechanical  Sup- 
ports.— Dr.  Bernard  Roth,  Brighton,  Eng.,  pre- 
sented a  paper  on  this  subject.  This  paper  relates 
to  1,000  consecutive  cases  of  scoliosis  which  have 
been  under  the  author's  treatment  in  private  practice 
from  June  27, 1885,  to  November  24,  1892,  and  are  sub- 
sequent to  a  series  of  200  cases  reported  at  the  annual 
meeting  of  the  British  Medical  Association  in  1S85. 
The  whole  of  these  1,000  cases  have  been  treated  by  the 
methods  described  in  the  author's  book,  "The  Treat- 
ment of  Lateral  Curvature  of  the  Spine,"  1889.  The 
author  hopes  by  the  publication  of  this  series  to  con- 
vince a  larger  proportion  of  the  medical  profession  of 
the  superiority  of,  and  the  much  more  rapid  results  ob- 
tained by,  his  method  at  all  stages  and  at  all  ages  than 
by  the  old  treatment  of  lateral  curvature  by  spinal  sup- 
ports or  other  mechanical  means. 

Sex:  The  1,000  cases  consisted  of  122  males  and 
878  females.  Messrs.  Bradford  and  Lovett  in  their 
"Orthopaedic  Surgerj',"  1890,  have  collected  2,340 
cases,  of  which  363  were  males  and  1,979  females; 
that  is,  a  percentage  of  15.5  males  to  84.5  females, 
which  is  to  be  compared  with  the  author's  percen- 
tages of   12.2  males  to  87.8  females. 

Age  when  brought  to  the  author  and  age  when  the 
deformity  of  the  spine  was  first  noticed :  The  average 
age  of  the  1,000  cases  is  12.32  years  for  the  commence- 
meni  of  the  deformity,  and  15.65  years  for  the  age  at 
which  they  came  under  treatment;  897  cases  (i.e.,  89.7 
per  cent.)  commenced  to  develop  lateral  curvature  be- 
tween the  ages  of  five  and  seventeen  years,  and  more 
than  half  by  594  between  the  ages  of  ten  and  fifteen 
years. 

Causes  of  lateral  curvature  of  the  spine:  In  231 
cases  no  assignable  cause  of  the  defonnity  could  be 
found,  while  of  the  remaining  769  cases  297  were 
hereditary;  203  were  due  to  rapid  growth;  176  were 
described  as  delicate;  59  followed  acute  specific 
fevers,  scarlet  fever,  whooping-cough,  measles,  typhoid 
fever,  etc.;  41  were  attributed  to  lung  diseases:  27 
were  born  in  tropics;  24  had  a  neurotic  origin;  14 
were  attributed  to  overstudy,  violin  playing,  etc.;  11 
were  attributed  to  premature  birth;  10  were  attributed 
to  eye  affections;  8  were  twins;  5  were  children  of 
elderly  parents;  11  were  attributed  to  miscellaneous 
causes  (as  being  very  tall,  above  6  feet,  3  cases;  to 
rickets,  2  cases,  etc.). 

The  very  small  percentage  of  cases  which  were  attri- 
buted to  rickets  is  due  to  the  fact  that  almost  invari- 
ably patients  came  from  the  middle  and  wealthy 
classes  and  included  no  hospital  patients. 

Description  of  the  different  forms  of  the  lateral  cur- 
vature of  the  spine:  The  1,000  cases  divide  readily 
in  six  classes: 

(a)  With  whole  convexity  to  left — 523,  or  52.3  per 
cent. 

(l>)  With  dorsal  (upper)  convexity  to  the  right  and 
lumbar  (lower)  convexity  to  the  left — 329,  or  32.9  per 
cent 

{c)  With  whole  convexity  to  right — 72,  or  7.2  per 
cent. 

(cf)  With  dorsal  (upper)  convexity  to  the  left  and 
lumbar  (lower)  convexity  to  the  right — 45  or  4.5  per 
cent. 

(f)  With  triple  curvature,  highest  and  lowest  c.irvr,. 


being  convex,  to  the  left  and  middle  curve  convex  to 
the  right — 28,  or  2.8  per  cent. 

{/)  With  triple  curvature,  highest  and  lowest  curves 
being  convex  to  the  right  and  middle  curve  convex  to 
the  left — 3,  or  0.3  per  cent. 

Amount  of  osseous  or  incurable  deformity  of  the 
ribs  and  vertebra;:  If  osseous  deformity  is  present,  to 
that  extent  the  case  is  incurable  and  no  patient  has 
ever  been  exhibited  at  any  recognized  medical  society 
with  slight  or  severe  osseous  deformit)'  before  treat- 
ment and  shown  again  after  treatment  with  this  osseous 
deformity  corrected.  The  method  of  scoliosiometry 
which  the  author  has  employed  for  many  years  and 
which  he  first  published  in  the  British  Medical  Journal 
of  October  27,  1888,  is  still  the  simplest  and  most 
rapid  method  of  recording  the  degree  of  osseous  de- 
formitj'  in  lateral  cur\-ature.  The  amount  or  degree 
of  osseous  deformity  is  classified  as  extreme,  severe, 
moderate,  and  a  trace.  If  the  ribs  posteriorly  and  the 
erectores  spina  are  perfectly  symmetrical  when  the 
trunk  is  well  flexed,  absence  of  osseous  deformitj-  is 
diagnosed.  Of  the  523  cases  of  deformity  {a)  117 
cases  had  only  moderate  deformity  of  the  lumbar  ver- 
tebras and  76  cases  had  a  trace  of  osseous  deformity 
of  the  left  ribs  posteriorly  and  moderate  osseous  de- 
formity of  the  lumbar  vertebras.  Of  the  329  cases  of 
defonnity  (b)  67  had  moderate  deformity  of  the  right 
ribs  posteriorly  and  of  tlie  lumbar  vertebrae  with  con- 
vexity to  the  left.  The  72  cases  of  deformity  (i)  had 
14  with  moderate  osseous  deformation  of  the  right  ribs 
posteriorly  and  of  the  lumbar  vertebra.  The  45  cases 
of  deformity  (d)  had  10  with  moderate  osseous  defor- 
mity of  the  lumbar  vertebra;- ;  while  the  28  cases  of  de- 
formity {e)  and  3  cases  of  deformity  (/)  all  had  more 
or  less  osseous  deformation  of  the  ribs  posteriorly  and 
of  the  lumbar  vertebra:  of  course  when  osseous  de- 
formity of  the  ribs  posteriorly  is  indicated,  osseous 
deformit)'  of  the  dorsal  vertebra;  is  implied.  Only  79 
cases  out  of  the  whole  1,000  were  without  definite 
osseous  deformity. 

Pain  or  backache;  476  cases,  viz.  47.6  per  cent., 
had  more  or  less  backache,  including  1 1  with  extreme 
pain,  230  with  severe  pain,  87  with  moderate  pain,  and 
148  with  slight  pain. 

Flatfoot:  The  author  was  one  of  the  first  surgeons 
to  point  out  the  extremely  frequent  association  of  flat- 
foot  with  lateral  curvature  of  the  spine  (see  British 
Medical  Journal  oilslzy  IT,,  1882).  Out  of  these  1,000 
cases,  565,  viz.,  56.5  per  cent.,  had  more  or  less  well 
marked  flatfoot,  and  256  cases  in  addition  had  a  trace 
of  flatfoot  which  perhaps  .some  surgeons  would  not 
accept  as  such. 

Previous,  i.e.,  unsuccessful,  treatment  of  the  1,000 
cases:  Omitting  treatment  by  ordinary  or  special 
g\-mnastics,  suspension  by  the  head  and  the  innu- 
merable forms  of  shoulderstraps,  etc.,  202  cases  had 
been  treated  by  means  of  spinal  supports,  including 
1 04  cases  by  steel  supports  and  98  by  other  forms  of 
spinal  supports.  Of  these  many  Jiad  worn  supports  for 
several  years;  thus  24  had  worn  them  for  1  year,  25 
for  2  years,  19  for  3  years,  and  so  on,  including  cases 
in  which  spinal  supports  had  been  worn  for  10,  11,  12, 
16,  20,  25,  and  even  40  years. 

Duration  of  the  author's  personal  treatment:  The 
average  course  consisted  of  three  months'  daily  treat- 
ment or  72  visits;  634  cases  underwent  that  amount. 
Early  cases  of  lateral  curvature  with  little  or  no  os- 
seous deformity  of  the  vertebra  to  the  number  of  265 
made  each  from  24  to  48  daily  visits;  28  adult  male 
cases  have  been  treated  on  36  alternate  days  or  by 
weekly  visits.  The  remaining  73  cases,  with  6  to  18 
daily  visits,  and  with  81  to  216  daily  visits,  have  been 
exceptional  patients,  in  whose  cases  the  treatment  has 
either  been  interrupted  too  soon  or  from  intercurrent 
illness  unduly  prolonged. 


362 


MEDICAL    RECORD. 


[September  4,  1897 


Result  of  author's  treatment :  As  osseous  deformity 
of  the  vertebra;  even  to  the  slightest  extent  is  to  that 
extent  incurable,  the  author  has  not  ventured  to  label 
any  case  as  "  cured,"  although  probably  most  surgeons 
would  have  employed  that  term  instead  of  "  much  im- 
proved." By  "  much  improved"'  the  author  describes 
the  best  possible  result  that  he  was  able  to  prognosti- 
cate when  the  patient  was  first  examined;  that  is,  a 
.strong  and  much  straighter  spine  where  the  most  im- 
proved posture  possible  has  become  a  more  or  less 
habitual  one,  with  disappearance  of  backache,  with 
improvement  in  the  general  health  where  this  has 
been  failing,  and  finally  with  arrest  of  further  increase 
of  the  osseous,  /.(•.,  incurable  deformity  of  the  ribs  and 
vertebra;.  There  were  869  cases  much  improved,  and 
75  cases  improved.  By  "  improved"  the  author  dis- 
tinguishes those  cases  in  which  arrest  of  the  further  in- 
crease of  the  osseous  deformity  has  been  effected,  but  in 
which  pain  has  still  persisted  more  or  less  or  in  which 
the  patients  have  not  held  themselves  so  well  as  they 
ought  to  have  done.  Fifty-six  cases  were  more  or  less 
failures,  including  47  which  were  apparently  success- 
ful at  first  but  then  relapsed,  and  9  which  were  not 
improved  from  the  very  first.  Most  of  these  5.6  per 
cent,  failures  have  been  due  to  want  of  intelligence  or 
perseverance  in  the  several  patients.  The  most  suc- 
cessful of  the  author's  cases  and  those  which  gave 
least  trouble  were  young  men  anxious  to  become  offi- 
cers in  the  army  and  who  ran  some  risk  of  being  re- 
jected as  physically  unfit,  and  young  women  engaged 
to  be  married.  Of  the  "much  improved"  and  "  im- 
proved" cases,  207  were  confirmed  by  e.xaniination 
during  the  first  three  years  following  the  completion 
of  their  treatment  under  the  author's  personal  care. 
Some  were  reported  as  continuing  straight  and  well 
ten  years  after. 

Four  hundred  and  twenty-nine  cases  were  sent  direct 
to  the  author  by  two  hundred  and  two  medical  men,  to 
whom  he  conveys  his  thanks. 

C  To  hi  Conthiiied.^ 


THE  NKW  YORK  P.A.THOLOGK'AL   SOCIETY. 

StaUd  Mi-rfing,   April  28,   l8g/. 

John  Slade  Ely,  M.D.,  Presideni. 

Disease  of  the  Coronary  Arteries  with  Red  In- 
farction of  Myocardium. — Dr.  John  H.  I.arkin  pre- 
sented specimens  taken  from  a  woman,  forty  years  of 
age,  a  chronic  alcoholic,  who  had  had  several  attacks 
of  acute  rheumatism.  Four  months  ago  she  became 
lame  and  the  ankles  were  much  swollen,  the  breath 
was  short,  and  there  was  slight  and  gradually  increas- 
ing cough.  She  also  complained  of  weakness,  head- 
ache, and  some  gastric  pain.  Later  there  was  a  good 
deal  of  blood-tinged  expectoration.  Five  weeks  ago 
she  entered  the  hospital.  The  heart  was  enlarged, 
and  there  was  a  systolic  murmur  at  the  apex  and  one 
at  the  base,  with  a  systolic  thrill.  There  were  cough 
and  profuse  frothy  expectoration.  No  tubercle  bacilli 
were  found  in  it.  There  was  occasional  vomiting  for 
a  week  or  two  before  death,  but  no  elevation  of  tem- 
perature. The  urine  had  a  specific  gravity  of  between 
1.020  and  1.030,  and  contained  a  trace  of  albumin 
but  no  casts.  At  the  autopsy  the  lungs  showed  brown 
induration,  with  multiple  hemorrhagic  infarcts.  The 
liver  was  "nutmeg."  The  spleen  contained  fresh  and 
old  infarcts.  Tlie  kidneys  showed  tlie  lesions  of 
chronic  diffuse  nephritis  and  also  old  infarcts.  The 
coronary  artery  was  occluded  by  an  embolism.  On 
tlie  inner  surface  of  the  endocardium,  both  on  tlie 
papillary  muscle  and  on  the  mitral  valve,  were  numer- 
ous vegetations,  .some  of  which  could  be  seen  lianging 
by  tliread-like  processes.     One  of   these  vegetations 


was  removed  from  the  mitral  valve,  and  also  a  small 
white  thrombus  from  the  coronar)'  artery.  Microscop- 
ical examination  proved  these  to  be  identical  in  struc- 
ture, .-^t  the  apex  of  the  right  ventricle  was  a  large 
globular  tiirombus  filled  with  a  milky  fluid.  Dr.  Nor- 
ris  had  made  cultures  from  the  thrombi,  and  also  from 
the  heart  muscle,  with  negative  result,  even  after  sev- 
eral weeks.  In  the  region  supplied  by  the  anterior 
coronary  artery — the  tip  of  the  left  ventricle  and  a  por- 
tion of  the  right  ventricle — was  a  distinct  area  of  soft- 
ening in  the  cardiac  muscle.  There  was  no  intersti- 
tial myocarditis.  The  heart  was  otherwise  fairly 
normal,  except  for  the  increase  in  size,  due  rather  to 
dilatation  of  the  left  ventricle  than  to  hypertrophy  with 
dilatation.  -Sections  of  the  cardiac  muscle  were  ex- 
hibited under  the  microscope.  They  showed  very  well 
the  large  effusion  of  blood  into  the  heart  muscle,  dis- 
placing the  muscular  fibres  of  the  heart.  There  was 
also  some  compression  atrophy  of  the  heart  muscle 
fibres  in  the  immediate  vicinity  of  the  hemorrhage. 

Atrophy  of  the  Pancreas  with  Replacement  by 
Fat. —  Dr.  Larkin  then  presented  sections  of  the  pan- 
creas from  a  woman,  fifty  years  of  age,  who  had  been 
admitted  to  Bellevue  Hospital  in  November,  1896. 
She  was  addicted  to  the  use  of  beer,  tobacco,  and  mor- 
phine. She  said  that  she  had  been  well  up  to  one 
month  previous.  Then  she  had  chills  and  headache, 
followed  by  fever,  thirst,  and  weakness.  On  admis- 
sion there  was  slight  cough,  with  dyspncea  on  exertion. 
She  passed  large  quantities  of  urine.  The  bowels 
were  constipated  and  the  appetite  was  fair.  Thirst  was 
marked,  the  mouth  was  dry,  and  the  tongue  cracked. 
The  temperature  was  103  F. ;  pulse,  112;  respi- 
rations, 36.  Physical  examination  showed  the  chest  to 
be  barrel  shaped  ;  there  was  diminished  and  prolonged 
low-pitched  expiration,  and  a  few  subcrepitant  rales 
were  heard  over  the  back.  The  size  of  the  heart  was 
normal,  but  its  action  was  very  irregular  in  force  and 
frequency.  No  murmur  could  be  heard.  The  liver 
was  not  palpable.  The  spleen  was  nonnal.  The 
urine  had  a  specific  gravity  of  1.012,  and  contained  a 
trace  of  albumin  and  some  granular  casts.  One  drop 
of  the  urine  gave  a  pronounced  reaction  with  Fehling's 
test  at  one  time,  but  not  on  other  examinations.  At 
the  autopsy  the  brain  was  "wet,"  there  was  moderate 
atheroma  of  the  arteries  of  the  base,  the  anterior  por- 
tion of  the  pia  mater  was  lustreless.  The  heart  was 
very  pale  and  exceedingly  fatty;  there  were  no  valvu- 
lar lesions.  The  lungs  were  emphysematous  and 
adematous  posteriorly  at  the  base.  The  spleen  was 
hard,  large,  and  congested.  Tiiere  was  a  large  nutmeg 
liver.  The  kidneys  were  of  normal  size,  the  cortex  was 
pale,  and  the  markings  were  fairly  distinct.  Con- 
nected with  the  left  kidney  was  a  tumor,  the  size  of  a 
small  orange,  containing  a  viscid  fluid.  At  the  edge 
of  this  tumor  was  a  blood-vessel  apparently  connected 
with  the  renal  artery.  Cultures  made  from  the  viscid 
contents  of  the  tumor  proved  negative  as  regards  tu- 
bercle bacilli,  etc.  The  pancreas  measured  trans- 
versely about  two  centimetres.  It  was  much  dimin- 
ished in  size,  the  greater  portion  of  the  pancreatic 
tissue  being  replaced  h\  fat,  whicli  appeared  as  large 
yellowish  areas  shutting  otT  little  islands  of  pancreatic 
tissue.     The  small  tumor  was  a  telangiectatic  sarcoma. 

The  Presipen  I' said  that  Dr.  l.arkin,  in  speaking 
of  the  structure  of  the  tiirombus  in  the  coronary  artery 
being  identical  with  that  of  the  vegetation  on  the  mi- 
tral valve,  had  expressed  the  ojiinion  that  the  occlud- 
ing mass  was  an  embolus.  To  this  he  could  hardly 
.agree,  as  it  seemed  to  him  the  mechanical  difficulties 
would  be  enormous,  owing  to  the  course  of  the  blood 
current  and  the  peculiar  manner  in  which  the  coronary 
arteries  are  given  oft"  behind  the  mitral  valve  and  at 
right  angles  to  the  course  of  the  lilood  in  the  aorta. 
On  (?-//-/((/7  grounds  merely  it  seemed  to  him  that  em- 


September  4,  1897] 


MEDICAL    RECORD. 


holism  of  the  coronary  artery  should  be  extremely  rare. 
As  to  the  occurrence  of  sudden  death  in  disease  and 
occlusion  of  the  coronary  artery,  in  his  opinion  it 
would  make  a  very  great  difference  which  coronary- 
artery  was  occluded  as  to  whether  or  not  sudden  death 
occurred.  Why  should  the  heart  suddenly  stop  heat- 
ing simply  because  one  of  the  branches  of  the  coronary 
artery  going  to  the  apex  had  become  occluded?  An 
occlusion  of  the  branch  running  upon  the  heart  in  the 
auriculo-ventricular  ring  might  cause  sudden  death, 
because  that  is  the  situation  of  the  intrinsic  cardiac 
ganglia.  It  seemed,  therefore,  that  for  absolute  and 
sudden  stoppage  of  the  heart,  the  determining  factor, 
when  there  is  no  rupture,  must  be  the  degeneration, 
impairment,  or  cessation  of  the  function  of  these  in- 
trinsic cardiac  ganglia.  Experiments  apparently  con- 
firming this  view  had  been  published.  On  the  other 
hand,  if  the  circulation  of  the  horizontal  branch  were 
left  intact,  stoppage  of  the  branch  going  to  the  apex 
might  occur  without  seriously  affecting  the  intrinsic 
cardiac  ganglia. 

Dr.  James  Ewixg  said  that  last  summer  a  man,  forty 
or  fifty  years  of  age,  had  come  under  observation,  who 
was  addicted  to  the  use  of  enormous  amounts  of  mor- 
phine hypodermically.  Shortly  ai'ter  one  excessively 
large  injection  he  died.  The  autopsy  showed  a  well- 
developed  adipose  layer  all  over  the  body,  and  a  large 
amount  of  perirenal  and  retroperitoneal  fat.  With 
some  difficulty  the  pancreas  was  found  in  this  mass  of 
fat.  On  section  it  was  found  that  the  organ  was  the 
seat  of  fatty  replacement.  The  remaining  islands  of 
pancreatic  tissue  were  apparently  normal. 

The  society  then  adjoumed. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitaiy  Bureau,  Health  Department,  for  the 
week  ending  August  28,  1897  : 


137 

6S 

26 

12 

6S 

3 

I 

I 

42 

4 

124 

IS 

3 

2 

Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. .  . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 

Chicken-pox 

Pertussis 


The  Baths  at  Harrogate. — At  this  well-known 
spa,  in  Yorkshire,  England,  probably  the  most  magnifi- 
cent baths  in  the  world  have  just  been  completed. 
These  erections  cost  $600,000,  and  were  opened  to 
the  public  on  July  21st.  In  addition  to  an  immense 
pump  room,  ladies  and  gentlemen's  baths,  winter  gar- 
den, Turkish  and  Russian  baths,  is  an  inhalation  room, 
containing  a  sulphur-water  fountain,  giving  off  a  fine 
spray  which  is  inhaled  by  the  occupants  of  the  apart- 
ment; there  is  also  a  "pulverization  room,"  where 
medicated  water  can  he  applied  to  the  throat,  eyes. 
etc.  Among  the  other  varieties  of  haths  may  be  men- 
tioned several  kind  of  douche,  slipper,  and  needle 
baths. 

Microbe  Ragout.  —  Parisians  have  been  greatly 
alarmed  by  learning  through  the  daily  press  that  a  rob- 
bery had  taken  place  at  the  Auhervilliers  Hospital, 
which  is  specially  devoted  to  contagious  diseases. 
.\  number  of  rabbits  inoculated  for  some  researches 
of  M.  Roger  have  been  stolen,  and  they  had  been  in- 
oculated with  diphtheria,  i-rt.mus,  typhus,  chr'era,  etc. 


As  it  is  probable  that  the  thieves  sold  the  rabbits  to 
dealers,  every  one  who  supped  off  rabbit  that  evening 
is  consumed  with  a  horrible  fear  of  having  caught 
some  infection.  Interviews  with  Dr.  Roux  and  other 
authorities  have  been  published  and  instructions  have 
been  given  to  the  octroi  officials  to  stop  the  entry  of 
such  rabbits,  their  carcasses  being  easily  recognized  by 
having  been  shaved  for  the  purpose  of  inoculation. 

The  Dangers  of  Chlorate  of  Potassium. — A  no- 
tion is  prevalent  among  the  public  that  chlorate  of  po- 
tassium is  a  remedy  which  may  be  safely  indulged  in 
to  an  unlimited  extent,  but  it  is  high  time  that  this 
dangerous  error  should  be  exposed.  Therapeutists 
are  well  aware  that  even  in  comparatively  moderate 
doses  chlorate  of  potassium  is  a  very  active  drug,  pro- 
ducing a  marked  effect  upon  the  blood,  which  it  turns 
brown,  and  leading  in  large  doses  to  cardiac  paralysis, 
albuminuria,  and  death.  Instances  of  this  sort  are 
not  very  rare,  and  but  a  few  days  ago  a  young  man  at 
Morpeth  died  from  sucking  pellets  of  the  drug  with 
the  object  of  preparing  himself  to  sing.  He  absorbed 
altogether  two-thirds  of  an  ounce,  causing  death  from 
syncope.  Even  in  what  are  considered  safe  doses 
chlorate  of  potassium  often  gives  rise  to  great  mental 
and  physical  depression,  insomnia,  and  various  other 
disturbances  of  the  human  economy. — Alcdical  Press 
and  Circular. 

Reichmann's  Syndrome. — In  a  critical  review  of 
recent  works  upon  continued  hydrochloric  hypersecre- 
tion, Dr.  Jean  Ch.  Roux  [^Gazette  <ics  Hppitaux,  May 
29,  1897),  after  describing  the  morbid  symptoms  fre- 
quently observed  in  dyspeptics,  concludes;  i.  It  is 
better  to  speak  of  the  syndrome  of  Reichmann  than  of 
the  disease  of  Reichmann.  2.  It  is  an  exaggeration 
to  look  upon  the  syndrome  as  being  alw  ays  the  clinical 
e.xpression  of  motor  insufficiency  of  the  stomach 
(Schreiber),  due  almost  exclusively  to  an  incomplete 
organic  stenosis,  pyloric  or  subpyloric  (Hayem).  3. 
In  most  instances  we  should  admit  an  exaggerated  se- 
cretory excitability  of  the  stomach's  mucous  membrane, 
the  patients  being  hyj^erchlorhydrics  before  the  ap- 
pearance of  Reichmann's  syndrome.  4.  The  syn- 
drome should  he  admitted  as  existing  only  when,  in 
the  course  of  a  test  meal  carried  out  after  washing  out 
the  stomach,  a  quantity  of  hydrochloric  acid,  free  or 
combined,  is  discovered  in  much  larger  quantities  than 
normal.  The  examination  of  the  fluid  obtained  in  the 
morning  while  fasting  is  not,  in  the  author's  opinion, 
sufficient  to  characterize  Reichmann's  syndrome.  5. 
The  syndrome  is  encountered  in  gastric  dilatation  of 
passing  or  lasting  nature,  according  as  there  exist  or 
not  material  lesions  of  the  stomach,  and  particularly 
in  the  pyloric  region  (these  lesions  may  be  ulcer  in 
condition  of  activity,  chronic  ulcer,  cicatrized  ulcer,  or 
cancer).  It  thus  results  that  Reichmann's  syndrome 
may  be  itself  of  short  or  permanent  duration.  6. 
There  are  intermediar)' forms  from  simple  to  continued 
hyperchlorhydria.  7.  At  all  events,  we  must  admit 
that  stasis  plays  an  important  role  in  the  chain  of 
symptoms,  if  it  does  not  in  itself  suffice  to  create  the 
syndrome.  It  is  certain  that  it  suffices  to  make  it  dis- 
•ippear  in  order  to  bring  about  a  considerable  amelio- 
ration and  even  complete  cure.  We  have  here  an  indi- 
cation of  the  first  order  for  our  medical  and  surgical 
therapy. 

Dispensary  Abuse. — ^Ue  are  glad  to  note  that  the 
failure  of  tiie  governor  to  sign  the  bill  regulating  dis- 
pensary practice,  and  doing  away  with  many^  of  its 
present  evils,  has  not  thrown  cold  water  upon  the 
efforts  of  the  advocates  of  the  hill.  On  the  contrary, 
it  has  acted  as  a  decided  stimulant  to  the  fight  against 
dispensary  abuse.  Medical  societies  are  e.xerting 
.heir  power  against  it;    medical  periodicals  have  dis- 


3^4 


MEDICAL    RECORD. 


[September  4,  1897 


cussed  it  pro  and  con  and  from  every  conceivable 
standpoint.  We  are  pleased  to  see  that  the  crusade 
has  become  so  general  and  strong,  and  that  this 
strength  presages  the  ultimate  doing  away  with,  to  a 
degree  at  least,  of  a  practice  which  is  not  only  sap- 
ping the  profession  of  its  income  but  its  dignity. — 
Albany  Medical  Annals. 

The  Seat  of  Lumbago. — Mr.  Jonathan  Hutchinson, 
in  the  April  number  of  Archkcs  of  Surgery,  says  con- 
cerning lumbago:  "It  may  perhaps  seem  to  savor 
of  the  love  of  contradiction  if  I  assert  that  the  pain  in 
lumbago  is  not  in  the  lumbar  muscles  nor  indeed  in 
the  loins  at  all.  Yet  I  feel  sure  that  such  is  the  case. 
I  have  asked  hundreds  of  its  subjects  to  put  the  hand 
over  the  exact  site  of  the  pain,  and  with  the  invariable 
result  that  the  sacral  region  is  the  part  indicated.  If 
we  wish  to  use  this  word  with  precision  we  should 
understand  it  to  denote  a  liability  to  pain  on  move- 
ment across  the  sacrum  or  in  the  sacro-iliac  synchon- 
droses." 

Violent  Remedies. — Professor  Brouardel,  in  a  re- 
cent lecture,  related  the  following  case:  A  m;ui  had 
a  pharyngeal  abscess,  so  deeply  seated  that  his  medi- 
cal attendant  was  afraid  to  meddle  with  it.  One 
night  a  burglar  broke  into  the  house,  and  on  the  sick 
man  calling  for  help  tried  to  throttle  him.  The  ab- 
scess burst,  deluging  th  burglar  with  pus  and  causing 
him  to  beat  a  rapid  retreat  His  intended  victim  e.Y- 
perienced  instant  relief  and  made  a  rapid  recovery. 

A  Serum  Jag  Cure. — A  physician  on  the  Pacific 
coast  claims  to  have  discovered  a  cure  for  drunken- 
ness by  inoculation  of  horse  blood.  The  substance 
which  he  gains  by  injecting  alcohol  into  the  blood  of 
a  horse  he  calls  equisin.  Alcohol  is  introduced  into 
the  horse  and  the  blood  drawn  off  into  a  sterilized  ves- 
sel, in  which  it  is  mixed  with  chloral  to  influence  the 
clot.  After  settling  for  twenty-four  hours  it  is  sub- 
jected to  a  freezing  process,  and  then  shaken  for  half 
an  hour.     The  result  is  a  thin,  somewhat  sticky  fluid. 

A  Celebrated  Quack.— A  writer  in  the  Illustrated 
London  Neu's  narrates  some  very  curious  incidents  in 
connection  with  the  practice  of  medicine  in  England. 
Some  si.xty  years  ago  Mr.  St.  John  Long  was,  although 
unyualified,  practising  in  Harley  Street,  and  had  made 
for  himself  a  great  reputation,  particularly  for  his 
treatment  of  consumption.  His  method,  shortlv 
stated,  was  in  cases  of  internal  disease  to  cure  the 
malady  by  causing  an  external  wound.  The  eftects 
«f  this  treatment  were  always  painful  and  often  shock- 
ing to  behold.  A  Dublin  lady  came  up  to  London  to 
consult  him  concerning  the  health  of  her  two  daugh- 
ters. The  vounger  was  far  gone  in  consumption;  the 
elder  perfectly  well.  What  had  happened  to  her  sis- 
ter naturally  alarmed  her,  however,  and  Long  under- 
took to  prevent  her  falling  a  victim  to  the  same  dis- 
ease. He  applied  his  remedies,  which  gave  her 
intense  agony  and  made  her  very  ill,  and  on  the  tenth 
day  Prodie  was  called  in,  but  too  late,  for  the  patient 
died.  The  body  of  llie  jjoor  girl  was  exhmned  and 
examined  by  a  committee  of  doctors.  It  was  shown 
that  there  was  nothing  the  matter  with  her  save  a 
wound  in  the  back,  apparently  produced  by  fire, 
though  the  mode  of  inflicting  it  could  not  be  discov-. 
ered.  Tliat  was  Mr.  Long's  secret.  At  tlie  incpiest 
medical  testimony  was  unanimous  against  him,  but  he 
had  a  cloud  of  witnesses,  male  and  female,  most  of 
them  his  patients,  who  gave  evidence  in  his  favor.  In 
the  end  the  coroner's  jury  returned  a  verdict  of  man- 
slaughter, which  was  received  in  a  crowded  court  with 
cries  of  "Shame!  shame!"  On  his  trial  at  the  Old 
Pailey  he  was  found  guilty,  but  escaped  on  ixwing  a 
fine   of    .f250    to   tlie  king.      Long   was    subsequenllv 


tried  a  second  tune  for  pursuing  the  same  treatment 
with  fatal  results,  but  was  acquitted.  He  acknowl- 
edged an  income  of  ^/"i2,ooo  a  year.  There  is  a 
monument  to  him  in  Kensal  Green  cemetery,  erected 
by  his  former  patients. 

The  Plague  in  India — In  India,  coexistent  with 
and  indeed  tracing  its  source  from  the  plague,  there 
has  been  an  ominous  and  increasing  feeling  of  unrest 
among  a  portion  of  the  native  population.  The  Hin- 
doos above  all  else  are  sensitive  to  any  slur  or  seem- 
ing slur  on  their  religion;  their  caste  prejudices  are 
unconquerable,  and  unfortunately  some  of  the  sanitarv 
measures  necessary  for  checking  the  inroads  of  the 
pestilence  have  clashed  with  religious  and  political 
sentiments.  'The  Lancet  of  July  24th,  in  an  article  on 
the  plague  and  its  literature,  does  not  see  in  the  late 
riots  and  murders  at  Foonah  much  cause  for  uneasiness, 
although  admitting  that  there  is  considerable  local 
disaffection.  At  anj'  rate  the  measures  taken  for  the 
suppression  of  the  plague,  however  obnoxious  they 
may  have  been  to  the  Hindoos,  have  attained  their 
object  w  ith  great  success,  and  from  all  accounts  the 
worst  appears  to  be  over.  Among  the  many  official 
and  medical  reports  and  the  vast  mass  of  literature 
bearing  on  the  plague  in  all  its  phases,  the  results  of 
the  commission  under  Professor  Koch,  which  have 
just  been  published,  will  probably  be  of  the  widest 
general  interest.  T/te  Lancet  says  that  Koch  has 
found  that  the  plague  bacillus,  outside  the  human 
body  or  those  of  certain  animals,  has  very  brief  vital- 
ity. The  duration  of  the  life  of  the  bacillus  was  found 
to  be  from  eight  to  ten  days  at  most.  The  bacilli  do 
not  develop  without  the  influence  of  oxygen.  Experi- 
ments on  animals  showed  various  results.  Rats  were 
found  to  be  in  the  highest  degree  susceptible,  and  to 
be  the  chief  medium  for  spreading  the  plague  germs 
and  communicating  them  to  human  beings.  The 
commission  observed  only  isolated  cases  of  illness 
among  people  camping  in  the  open,  while  among 
those  who  had  remained  indoors  the  epidemic  con- 
tinued its  ravages  without  abatement.  Haffkine's  sys- 
tem of  inoculation,  which  was  applied  to  fourteen  hun- 
dred patients,  showed  undoubted  protective  results, 
although  a  number  of  patients  were,  it  is  stated,  made 
seriously  ill  by  the  inoculations.  From  this  and  other 
reports  we  may  believe  that  under  proper  sanitary  ar- 
rangements the  plague  will  soon  lose  its  hold.  This 
is  plainly  shown  by  the  fact  that  those  who  camped 
in  the  open  were  comparatively  free  from  the  scourge. 
This  disease  can  exist  and  flourish  only  in  dirty  and 
unsanitary  surroundings. 


IVkilt  thi  Medical  Record  is pleastd  to  receive  aUnewjmiH- 
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promptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  ceut- 
not  be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  judgment  cf  its  editor  will  not  he 
of  interest  to  its  readers. 

Tr.\nsactio.ns  of  the  Medical  Societv  ok  the  Stape 
OF  New  York.     1S97.     Svo,  5 S4  pages,     Illustraied. 

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tano's,  New  Vork.      IVicc,  $1.50. 

Tra.nsactio.nsok  THE  Associ.vTioN  OF  .\MJiRicAN  Physicians. 
Twelfth  Session.     Vol.  XII.     Svo,  510  pages.     Illustrated. 

The  Oi"iiTH.\LMOSCOrE.  Third  Edition.  15y  Gustavus  llart- 
ridge.  i2mo,  isgpages.  Illustrated.  P.  Blakiston,  Son  &  Co, , 
I'hiladelphia,   Pa.      Price,  $1.50. 

Convergent  Straiusmis  ami  us  Treatment,  By  Kdwia 
llolthouse.  l2mo.  177  pages.  1'.  Hlakiston,  Son  &  Co.,  Phila 
delpliia,  Pa.      Price,  $2. 10. 


Medical  Record 

A  IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  II. 
Whole  No.  1401. 


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ORK,    September    ii 


1897. 


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®riginal  Articles. 

A  CASE  OF  PHLEGMONOUS  GASTRITIS  FOL- 
LOWING ULCLS  CARCINOMATOSUM  OF 
THE  PYLORUS— DILATATION,  PERFORA- 
TION, AND  PERITONITIS— A  CLINICAL 
HISTORY  OF  FOURTEEN  MONTHS  WITH 
CHEMICAL,  BACTERIOLOGICAL,  AND  HIS- 
TOPATHOLOGICAL  STUDY. 

Bv   JOHN    C.    HEMMETER,    M.B..    Ph.D.,  M.D., 


PROFESSOR 


DELANO    AMES,    A.B.,    M.D., 


CATHOLOGV,    ETC., 


IMORE    MEDICVL 


A  DISEASE  which  is  so  rarely  obser\-ed  that  there  are 
but  fifty-six  cases  reported  in  the  medical  literature  of 
the  world  is  always  interesting,  especially  when  the  pa- 
tient has  been  studied  at  intervals  for  fourteen  months, 
has  been  under  the  almost  constant  observation  of  the 
authors  for  the  last  t^vo  months  of  his  illness,  and  upon 
whom  a  satisfactory  autopsy  has  been  held. 

In  December,  1895,  our  associate.  Dr.  Edward  L. 
Whitney,  demonstrator  of  clinical  patholog)-  in  the 
Baltimore  Medical  College,  treated  the  patient  during 
a  ts'pical  attack  of  gastric  ulcer.  The  following  note 
of  the  case,  made  by  Dr.  Whitney  at  the  time,  is  a 
concise  history  of  the  attack,  giving  an  account  of  the 
hxmatemesis,  dorsal  and  epigastric  pain  spots,  great 
«.xcess  of  hydrochloric  acid,  and  recover}-  after  treat- 
ment by  rest,  rectal  alimentation,  nitrate  of  silver,  bis- 
muth subnitrate,  and  alkalies. 

Dr.  Edward  L.  Whitney's  Notes  of  the  Case. — In 
December,  1895,  I  was  asked  to  see  the  colored  pa- 
tient, George  \\illiains,  in  consultation,  and  made  the 
following  notes  of  the  case:  The  patient  is  a  fairly 
well-nourished  colored  man,  giving  a  historv'  of  pain 
in  the  stomach  near  the  pylorus  for  several  weeks,  in- 
tensified by  eating.  F"or  a  few  days  he  had  had  occa- 
■lional  attacks  of  vomiting,  the  vomited  matter  con- 
taining fresh  red  blood.  Physical  examination  showed 
no  dilatation,  no  palpable  tumor,  exquisite  tenderness 
over  the  pylorus  and  over  the  eleventh  dorsal  vertebra, 
e.Ktending  slightly  to  the  left.  While  no  palpable 
tumor  could  be  made  out,  there  was  slightly  increased 
resistance  over  the  pylorus. 

After  the  double  test  meal  employed  at  the  Mary- 
land General  Hospital,  the  amount  was  found  to  be 
about  one  hundred  cubic  centimetres.  -It  was  clear, 
contained  no  blood,  was  of  normal  odor,  showed  no 
lactic  acid,  but  the  reaction  for  erythrode.xtrin  was  pro- 
nounced. The  contents  showed  no  proteids,  but  a 
large  amount  of  starchy  matter  from  both  test  ineals. 
The  total  acidity- was  110.  There  was  an  excess  of 
hydrochloric  acid  by  the  Boas  test. 

The  patient  was  at  once  put  on  the  usual  treatment 
for  gastric  ulcer:  absoluterest  and  rectal  feeding  (milk, 
«gg,  whiskey,  and  boiled  starch).  Small  doses  of  the 
nitrate  of  silver  were  given  in  the  morning,  dosage 
with  alkalies  after  meals  was  kept  up,  and  moderate 
doses  of  bismuth  subnitrate  were  given.  In  two  weeks 
the  patient  began  to  improve  and  in  about  four  weeks 


was  completely  relieved  of  all  pain  as  well  as  of  other 
symptoms,  and  was  able  to  resume  his  accustomed 
work.  After  this  he  passed  from  obser\-ation  until 
he  entered  the  Maryland  General  Hospital.' 

On  December  \.  1896,  the  negro  George  Uilliams 
was  admitted  to  the  Maryland  General  Hospital  and 
gave  the  following  history:  .-Vge,  forty-nine  years; 
married;  family  historj-  good.  No  hereditary  facts 
of  importance.  Is  the  father  of  nine  children,  all  in 
good  health.  Worked  in  the  coal-oil  business  for 
fourteen  years,  but  for  the  past  six  years  has  followed 
the  calling  of  a  cooper. 

The  anamnesis  :  Has  alwavs  been  strong  and  healthy 
up  to  four  years  ago  when  he  had  an  attack  of  influ- 
enza lasting  about  four  weeks.  This  he  asserts  left 
him  permanently  weak. 

In  June,  1895,  he  was  taken  with  an  attack  of  vom- 
iting associated  with  violent  pains  radiating  from  the 
epigastrium  to  the  umbilicus.  The  vomited  matter 
"made  his  teeth  stand  on  edge."  He  recovered  from 
this  illness  without  treatment. 

In  December,  1895,  he  had  a  second  illness  during 
which  he  vomited  regularly  after  he  had  taken  food. 
At  this  time  the  pains  were  localized  in  the  epigas- 
trium, occasionally  shooting  back  to  the  shoulder 
blades.  The  vomit  is  described  as  having  been  very 
bitter  and  acid.  Sometimes  he  brought  up  verj-  clear 
irritating  fluid  containing  no  food.  At  other  times  he 
vomited  blood.  He  was  continually  constipated. 
(This  is  probably  the  attack  during  which  Dr.  Whit- 
ney treated  him.) 

After  a  treatment  of  four  weeks  he  recovered  and 
worked  at  his  trade  for  the  next  seven  weeks. 

About  the  middle  of  February.  1896.  a  third  attack 
was  experienced,  in  all  respects  identical  with  the  two 
previous  ones  except  that  there  was  more  vomiting, 
particularly  of  blood,  more  pain,  and  a  loss  of  fifteen 
pounds  in  weight  in  two  weeks.  He  claims  to  have 
been  jaundiced,  but  little  importance  can  be  attributed 
to  this  assertion,  as  the  conjunctiva  are  said  to  have 
been  always  pigmented  and  the  skin  of  the  negro  per- 
mits of  no  judgment  being  formed  on  this  question. 

He  improved  once  more  and  resimied  work,  but  on 
November  i,  1896,  the  vomiting  of  food  and  blood 
and  the  pain  returned.  He  requested  admission  to 
the  hospital,  November  30,  1896. 

On  December  1,  1896,  he  was  given  the  Manland 
General  Hospital  double  test  meal  as  follows: 

At  8  A.M.,  one  small  piece  of  beef,  scraped  and 
boiled,  80  grams;  one  soft-boiled  egg;  boiled  rice,  30 
grams;  milk,  250  c.c. ;  bread.  50  grams. 

At  1  P.M.,  an  Ewald  test  meal. 

The  advantage  of  this  double  test  meal  has  been 
set  forth  in  Hemmeter's  work  on  "  Diseases  of  the 
Stomach,"  p.  88. 

The  first  meal  was  vomited  about  forty-five  minutes 
after  it  had  been  eaten.  The  results  of  titration  by 
Toepfer's  method  were  as  follows:  Total  acidity,  94: 
free  hydrochloric  acid,  34:  combined  hydrochloric 
acid,  24;  acid  salts  and  organic  acids,  46:  lactic 
acid  absent  by  Boas'  test:  erythrodextrin  present. 
No  blood,  bile,  or  tissue  fragments.     Small  amount  of 

'On  one  occasion  ( December  4.  1805),  his  total  acidity  was 
124  and  some  blood  was  contained  in  the  tar-colored  stool. 


366 


MEDICAL    RECORD. 


[September  ii,  il 


mucus.  When  this  test  meal  was  given  there  had 
been  no  haematemesis  for  ten  days. 

Physical  cxaminatii'ii :  Heart  and  lungs  normal. 
The  tongue  is  red  at  edges.  Urine  cloudy;  specitic 
gravity,  1,024;  amount  in  twenty-four  hours  var}-ing 
from  320  c.c.  to  600  c.c.  It  contains  a  great  e.xcess  of 
indican  and  urophen  but  no  albumin,  casts,  or  sugar, 
and  a  high  ratio  of  ethereal  to  preformed  sulphates. 

Several  tables  of  detailed  analyses  by  Dr.  Whitney 
are  appended. 

December  2d. — On  moderate  distention  with  carbon 


was  exhibited  to  the  clinic,  and  the  Einhorn  electric 
diaphane  was  introduced.  The  light  did  not  shine 
through  the  abdonunal  wall  of  the  colored  man  as  well 
as  it  did  on  an  equally  emaciated  white  patient;  still 
it  could  be  plainly  seen  and  reached  down  to  a  point 
half-way  between  the  symphysis  pubis  and  the  um- 
bilicus. 

The  capacity  of  the  stomach  by  Hemmeter's  method  ' 
was  twenty-three  hundred  cubic  centimetres.  As  this 
method  was  originally  devised  to  obtain  graphic  rec- 
ords of  the  motor  function'  a  gastrogram  was  taken, 


Fig.  I  A. 


^€?; 


\ 


•:>•■' -i 


^.s-«-^-/^ 


l-'invKE  I  -/. — A  section  through  the  w.lll  of  tlie  stomach,  showiiijj  the  edge  and  a  portion  of  the  base  of  tlie  ulcer.  Objective,  two-thirds;  eyepiece,  twii 
inches.    Stained  with  ha:tnato\ylon  and  eosin.     The  drawing  is  built  up  from  a  series  of  microscopic  fields.     Magnification,  about  15  diameters. 

Exi'LANATinN. — (/,  Mucous  membrane;  /«,  muscularis  mucosa:;  j.  submucosa;  <i,  base  of  the  ulcer;  7//  w,  muscle  coiit  of  stomach;  nt .-,  jjroups  of  cancer  cells 
between  the  bundles  of  mu.scle  fibres;  d  c^  >jroups  of  cancer  cells  in  the  edye  of  the  ulcer  in  the  mucous  membrane;  sCy  >;n>ups  of  cancer  cells  in  the  submucosa; 
(»,  necrotic  membrane  lining  the  base  of  the  ulcer. 

B. — A  small  nodule  from  the  serous  coat  of  the  stomach  over  the  base  of  the  ulcer.  Objective,  two-thirds;  eyepiece,  two  inches.  Stained  with 
hajmatoxylon  and  eosin.     Magnification,  about  15  diameters. 

KxPLANATlON. — This  figurc  gives  a  good  idea  of  one  of  the  nodules  in  the  serosa.  It  is  composed  entirely  of  a  collection  of  giuups  and  masses  of  closely 
packed  cancer  cells,  so  closely  packed  that  the  outlines  of  the  individual  cells  cannot  I>e  made  out.  F.xeept  for  these  nv^dular  thickenings  the  serosa  was  n.'t 
altered,    f  f,  Cancer  masses  in  peritoneal  coat. 


dioxide  a  gastrectasia  could  be  distinctly  made  out  by 
simple  inspection.  The  greater  curvature  was  two 
inches  below  the  umbilicus.  A  nodular  thickening 
about  two  to  three  inches  long,  quite  hard  to  the  touch, 
could  be  felt  at  the  pylorus  through  the  emaciated  ab- 
dominal walls.  The  liver  was  normal  to  percussion 
and  paljiatioii.  There  was  no  evidence  of  movable 
kidney.  The  patient  was  now  fed  by  rectum,  his 
stomach  washed  out  with  sodium  bicarbonate,  and  he 
was  sub.sequently  treated  by  bismuth  irrigations,  ac- 
cording to  Kleiner's  method.  His  temperature  was  97 
F. ;  pulse,  80;  respiration.s,  24.  He  had  no  natural 
stool  for  a  period  of  eight  days.  \  daily  cleansing 
enema  precedes  the  rectal  feeding. 

.\s  the  patient   improved  until   December  luh,  he 


showing  tiiat  the  peristalsis  was  not  seriously  impaired, 
and  the  food  retention  was  most  probahlv  due  to  an 
insurmountable  obstruction  at  the  pvlorus.  In  view  of 
the  clinical  history  of  ulcer  and  the  abnormal  capacity 
with  increased  amount  of  hydrochloric  acid,  absence  of 
lactic  acid,  the  diagnosis  of  gastrectasia  depending 
upon  cicatricial  stenosis  of  the  pylorus  was  made  very 
probable. 

A  striking  symptom  in  this  case  was  that  for  two 
months  his  temperature  did  not  rise  above  98^  V. 
During  a  very  evident  perforation  peritonitis  with 
disappearance  of  liver  dulness,  tlie  temperature  was 
subnormal,  standing  at  97"  F.      .\t  one  time  it  sank  to 

'  I.oc.  cit.,  p.  7(1. 

'  >iee  New  York  Mkuicm.  RK.coKt>,  liine  >7,  iScjj. 


I 


September  ii,  1897] 


MEDICAL    RECORD. 


367 


93'  F.  This  is  of  interest  in  view  of  the  fact  that  the 
autopsy  revealed  a  diffuse  phlegmonous  gastritis,  a 
prominent  symptom  of  which  is  higli  fever. 

Resorption  from  the  stomach  was  tested  by  Pen- 
zoldt's  and  Hemmeter's  methods,  and  found  to  be 
almost  entirely  lost.  Bacterial  cultures  from  the  voniii 
resulted  in  prolific  growths  of  streptococci  and,  what 
was  significant,  of  the  Oppler-Boas  bacillus.  There 
were  also  many  other  varieties  of  organisms,  but  these 
were  the  most  important. 

The  vomit  showed  at  times  the  presence  of  pus  in 
traces.     This  was  confirmed  microscopically. 

On  account  of  the  great  irritability  of  the  stomacii, 
rectal  feeding  was  almost  exclusively  depended  upon 
for  nourishment.  The  stagnation  was  partially  pre- 
vented by  careful  lavage  every  other  day.  We  con- 
sidered the  advisability  of  lavage  in  a  case  of  this 
kind  and  concluded  that  the  remote  dangers  of  its  use 


(ij  The  long  time  that  the  patient  was  under  ob- 
servation, from  December,  1895  (Dr.  Whitney),  to 
February,  1897,  but  with  distinct  history  of  gastric 
ulcer  as  early  as  1895. 

(2)  The  continued  presence  of  normal  or  super- 
normal amounts  of  hydrochloric  acid  in  the  stomach 
contents  to  the  end. 

(3)  Owing  to  this  no  lactic  acid,  altliough  there 
was  a  large  gastrectasia. 

(4)  Probable  development  of  a  carcinoma  from  the 
ulcer.  Tumor,  progressive  cache,\ia,  and  the  presence 
of  the  Oppler-Boas  bacillus. 

(5)  The  presence  of  blood,  pus,  and  of  the  pyogenic 
cocci  in  the  stomach  contents. 

(6)  The  continued  sabnormal  temperature,  particu- 
larly after  the 

(7)  Perforation. 

The  perforation  had  occurred,  as  will  be  seen  later. 


opening  and  the  duode 


'lion  of  a  photograph  of  tiic  upened  stomach,  showing  the  nearly  i 
.lised  condition  of  the  ulcer  walls  is  well  shown,  as  is  also  the  normal,  wrinkled  ci.iulHi.n  i  il,.  ,  :m,  n 
s  a  dark  spot,  to  the  right  and  a  little  above  the  centre  of  the  ulcer.  The  stenosed  condition  of  the  pylori 
m  have  been  laid  widely  open.     It  can  be  seen,  however,  that  the  ulcer  does  not  involve  the  duodenum. 


h  edge 

^.  The  point  where  per- 
not  shown,  as  the  pyloric 
:  one  place  a  small  cube  o( 


were  not  so  grave  as  those  of  persLstent  vomiting  and 
auto-intoxication.  Operation,  or  at  least  an  e.xplora- 
tory  laparotomy,  was  suggested,  but  permission  was 
refused. 

On  January  i8,  1897,  the  patient's  temperature  sud- 
denly fell  from  98.8°  to  94  "  F.,  the  pulse  became  feebU- 
and  fluctuated  between  60  and  64  per  minute,  respira- 
tions ranging  between  14  and  20.  There  was  occa- 
ional  vomiting,  or  rather  retching.  His  abdominal 
muscles  became  \ery  hard  and  rigid.  On  percussion 
the  normal  liver  dulness  could  not  l)e  made  out. 
These  symptoms  and  signs  became  more  marked  dur- 
ing the  following  days.  .\11  gastric  alimentation  and 
treatment  were  stopped.  With  these  unmistakable  signs 
of  perforation,  oedema  of  the  lower  e.xtremities  and  un- 
controllable hiccough  de\'eloped.  The  patient  died 
on  February  i,  1897,  having  been  in  the  hospital  just 
two  months. 

The  main  features  of  the  clinical  history  are  as 
follows : 


in  the  floor  of  the  ulcer,  in  the  base  and  walls  of  which 
a  carcinoma  had  developed.  The  stenosis  of  the  py- 
lorus was  not  absolute,  a  small  passage,  permitting 
with  difficulty  the  entrance  of  a  small  lead  pencil,  still 
existing. 

The  Necropsy. — Section  No.  124  was  made  twenty- 
four  hours  after  death  on  February  2,  1897,  by  Dr. 
Delano  Ames,  assisted  by  Dr.  A.  A.  Huntley,  and  the 
following  notes  were  dictated  at  the  time.  The  body 
is  that  of  a  negro,  five  feet  eleven  inches  in  height, 
and  apparently  fifty  years  old. 

Muscular  development  is  fairly  good,  but  nutrition 
has  been  niucli  impaired.  Rigor  mortis  is  we!! 
marked. 

The  usual  post-mortem  lividity  is  found  in  those 
dependent  parts  that  were  not  in  contact  with  the  bed, 
and  is  more  noticeable  than  usual  in  the  negro,  be- 
cause of  the  light  color  of  the  subject. 

There  is  a  slight,  dark,  fluid  discharge  from  the 
mouth.     The  tissues  of  the  right  hand  and  of  the  chest 


368 


MEDICAL    RKCORD. 


[September  ii,  1897 


are  quite   redematous,  but  other  than  tiiis  there  are  no 
external  signs  of  note. 

Abdomen :  Upon  making  the  usual  primary  incision 
the  muscles  of  the  thorax  and  abdomen  are  seen  to  be 
of  the  normal  color.  The  subcutaneous  fat  is  almost 
entirely  absent.  On  opening  the  abdomen  the  follow- 
ing conditions  are  found  :  The  transverse  and  descend- 


e-.-ii.\th; 
on  betw 


nch. 


Figure  3. — .\  portion  of  the  mucous  coat  near  the  ulcer.  Objective,  ui 
Ivlagnification,  about  320  diameters.     Stained  with  hxmatoxylon  and  orange  < 

Explanation. — This  plate  shows  very  well  the  small-round-ceil  infiltrat 
■of  the  gastric  tubules,  with  here  and  there  the  cells  very  much  crowded  (A). 

The  exfoliation  of  the  cells  lining  some  of  the  glandular  acini  is  also  shown  in  places  (jff). 

At  one  or  Iwo  places  the  proliferation  of  the  epithelial  cells  that  line  the  glands,  with  breaking  of  the; 
jflandular  structures  and  the  escape  of  some  of  the  cells  into  the  surrounding  tissue,  is  seen  (C). 

The  entire  obliteration  of  some  of  the  glandular  structures  by  masses  of  cancer  cells  (/>),  which  i 
■many  places  are  strung  out  for  some  distance  (£"),  and  in  a  few  others  take  on  the  pseudoglandul,^ 
■arrangement  (/•'),  is  also  well  shown. 

ing  colons  are  much  distended  with  gas  and  bulge 
through  the  opening  as  it  is  made,  while  the  stomach 
lies  lower  in  the  abdominal  cavity  than  normal,  its 
■greater  curvature  being  about  one  finger's  breadth  above 
the  umbilicus.  But  for  this  the  abdominal  contents 
■occupy  their  normal  positions. 

There  is  a  small  amount  of  sero-purulent  fluid  in 
the  deepest  portion  of  the  abdominal  cavity  in  which 
iioat  numerous  flakes  of  fibrin. 

The  peritoneum  everywhere  presents  the  following 
■changes:  Its  vessels  are  engorged  with  blood,  giving 
it  a  pinkish  color  and  a  slightly  roughened  surface. 
In  places  it  is  distinctly  thickened,  and  in  addition  it 
has  lost  its  normal  lustre  and  is  covered  nearly  every- 
where with  a  thin  film  of  soft  whitish  material,  fibrin, 
that  can  be  easily  .scraped  off  with  the  finger  nail. 
Owing  to  the  presence  of  this  fibrinous  e.vudate  tlie 
various  coils  of  the  small  intestine  are  glued  together 
and  the  peritoneum  covering  them  presents  the  same 
appearances  as  does  that  lining  the  abdominal  cavitv. 

The  mesentery  likewise  presents  the  same  appear- 
ance, is  thickened  and  bathed  by  a  sero-purulent  Huid, 
and  more  or  less  covered  with  fibrin.  The  position  of 
the  diaphragm  on  the  two  sides  is  normal. 

Thorax  :  The  ribs  and  costal  cartilages  present  no 
•changes.  On  removing  the  sternum  the  thoracic  or- 
gans are  seen  to  occupy  their  normal  positions.  The 
lungs  lie  free  in  the  pleural  cavities,  e.xcept  for  one 
small  adhesion  that  binds  the  lower  lobe  of  the  right 
Jung  to  the  diaphragm.     In  both  pleural  cavities  there 


are  about  si.x  ounces  of  clear  serous  fluid.     The  pleurae 
present  no  changes. 

The  pericardium  is  apparently  healthy  and  contains 
a  small  amount  of  a  straw-yellow  fluid. 

T/te  Heart :  The  heart  is  somewhat  smaller  than 
normal  and  weighs  approximately  eleven  to  twelve 
ounces.  Its  position  is  normal.  Its  surface  presents 
no  changes.  The  coronary  veins 
are  partly  filled  with  dark  fluid 
blood  and  the  coronary  arteries  are 
soft  and  apparently  healthy.  All 
of  the  cavities  of  the  heart  are 
empty.  There  is  no  fluid  or  clotted 
blood  in  any  of  them.  The  aorta 
measures  one  and  one-fourth  inches 
in  diameter;  its  walls  are  not  thick- 
ened, and  its  intima  is  healthy. 
The  same  holds  good  for  the  pul- 
monary artery,  which  measures 
three-fourths  of  an  inch  in  diameter. 
The  closure  of  the  aortic  and  pul- 
monary valves  is  perfect.  The 
heart  muscle  is  somewhat  darker 
in  color  than  normal.  All  of  the 
valvular  orifices  are  normal  in  size 
and  the  valve  segments  healthy. 
The  thickness  of  the  ventricle  walls 
is  likewise  normal. 

Lungs :  In  color,  size,  w  eight, 
and  general  appearance  the  lungs 
are  normal.  On  section  there  is 
a  small  firm  nodule,  about  the  size 
of  a  hickory  nut,  in  the  apex  of  the 
right  lung,  which  is  probably  a  heal- 
ing area  of  tuberculous  disease. 
In  the  same  location,  in  the  left 
lung,  there  are  a  number  of  smaller 
nodules,  each  containing  a  cheesy 
material  inclosed  by  a  distinct 
capsule  of  dense,  pearly-gray  tissue, 
a  fraction  of  a  millimetre  in  thick- 
ness. Aside  from  these  changes, 
the  lung  parenchyma  is  apparently 
healthy.  A  considerable  amount 
of  frothy  pinkish  fluid  escapes  from 
the  left  lung  when  it  is  cut  and  compressed.  The 
Ijronchi  are  not  altered. 

T//e  Liver :  In  size,  weight,  color,  and  general  ap- 
pearance the  liver  apjiears  normal.  In  consistency  it 
is  softer  than  normal  and  is  somewhat  flabby.  On 
.section  its  color  is  darker  than  normal.  The  dia- 
phragm is  adherent  in  one  spot  to  the  upper  surface 
of  its  left  lobe.  In  all  other  respects  this  organ  ap- 
pears to  be  unaltered. 

The  gall  bladder  contains  a  moderate  amount  of 
greenish-brown  bile,  rather  thick  and  sticky  in  con- 
sistency.    There  are  no  concretions. 

The  Spleen :  This  organ  weighs  four  and  a  half 
ounces.  Its  capsule  is  smooth,  and  in  color,  consist- 
ency, and  general  appearance  it  seems  to  be  normal. 

The  Jntestincs :  riie  serous  coat  of  the  intestines, 
as  already  described,  shows  all  the  signs  of  an  acute 
inflammation.  The  intestinal  contents  consist  of  a 
semifluid  material  and  ctmsiderable  gas.  Upon 
opening  the  intestines  the  mucous  membrane  is  seen 
to  be  very  mucii  discolored  and  in  the  upper  portion, 
especially,  to  be  bile  stained.  The  glandular  struc- 
tures are  unaltered,  and  the  appendix,  which  is  three 
and  a  half  inches  long,  is  healthy. 

The  Stonituh :  As  already  stated,  the  stomach  is 
displaced  downward,  its  greater  curvature  lying  one 
finger's  breadth  above  the  umbilicus.  Its  serous  coat 
is  involved  in  the  same  general  inflammatory  process 
that  involves  the  peritoneum  and  mesentery.  Its  ves- 
sels are  all  engorged,  while  its  surface  is  roughened  and 


1 


I 


September  ii.  1897] 


MEDICAL    RFXORD. 


369 


Anatomical  diagnosis :  Acute  general  peritoniris 
due  to  perforation  of  the  stomach  and  escape  of  stom- 
ach contents.  Healed  ulcer  of  the  stomach  with  ste- 
nosis of  the  pylorus.  Perforation  of  the  stomach  by 
a  fresh  ulcerative  process  engrafted  on  the  old  one. 
Probable  cancerous  infiltration  of  the  walls  and  base 
of  the  old  ulcer.  Gastrectasia.  Healed  and  healing 
pulmonarj-  tuberculosis  in  both  apices.  Remains  of  a 
former,  slight,  localized  pleurisy  of  the  lower  right 
lobe. 

Microscopic  Appearances  of  the  Stomach  Wall.' 
— Portions  of  the  stomach  wall  were  fixed  in  a  four- 
per-cent.  solution  of  formol,  hardened  in  alcohol,  em- 
Ijedded  in  both  paraffin  and  celloidin,  and  stained  both 
for  a  study  of  the  histopathological  changes  and  for 
any  micro-organisms  that  might  be  present.  The  fol- 
lowing appearances  were  noted : 

T/ie  mucous  coat:  In  the  mucous  coat  the  greatest 
changes  were  found  in  the  immediate  vicinity  of  the 
ulceration,  and  these  gradually  disappeared  in  the 
surrounding  tissue.  One  of  the  most  striking  changes 
was  the  presence  of  enormous  numbers  of  small 
round  cells  (Fig.  3).  These  were  diffusely  scat- 
tered throughout  the  entire  thickness  of  the  mucosa, 
being  most  numerous  in  its  deeper  layers,  where  in 
many  instances  they  passed  over  and  infiltrated  the 
muscularis  mucosa;  and  submucous  layers.  In  many 
places  these  cells  were  grouped  together  into  minute 
clumps,  resembling  in  appearance  early  abscess  for- 
mation.    The  farther  one  passed  from  the  immediate 


covered  with  a  film  of  fibrin.  Careful  study  of  the 
stomach  discloses  the  cause  of  tlie  general  peritonitis, 
for  on  its  anterior  aspect,  not  far  from  the  pylorus  and 
a  short  distance  from  the  lesser  cur\'ature,  there  is  a 
very  small  opening  measuring  from  one  and  a  half  to 
two  millimetres  in  diameter,  through  which  there  es- 
capes a  dark-colored  riuid — the  contents  of  the  stomach. 

Close  inspection  of  the  outer  coat  of  the  stomach  in 
the  neighborhood  of  this  perforation  shows,  in  addition 
to  the  general  signs  of  inilammation  already  mentioned, 
many  ver}-  slight,  rounded  elevations,  the  largest  not 
so  big  as  the  head  of  a  small  pin,  and  many  so  small 
•  that  they  are  only  seen  clearly  with  a  magnifying 
glass.  Palpation  of  the  organ  discloses  considerable 
thickening  and  induration  of  its  walls  in  the  region  of 
the  pylorus,  except  just  about  the  perforation,  where 
the  tissue  seems  to  be  verj-  thin,  this  portion  ending 
sharply  in  tissue  that  is  unusually  thick  and  firm. 

Section:  On  opening  the  stomach  it  is  found  to 
contain  about  four  ounces  of  a  dark  coffee-colored, 
mushy  material  which  u]X)n  careful  examination  is 
seen  to  contain  no  blood.  The  mucous  membrane  ap- 
pears to  be  quite  normal  and  is  thrown  into  prominent 
folds  (see  Fig.  2).  If  altered  at  all  it  is  slightly 
thickened  and  swollen. 

Near  the  pylorus  there  is  a  large,  prominent  ulcer, 
nearly  circular  in  outline  and  measuring  five  centi- 
metres in  diameter.  This  has  completely  healed  ex- 
cept in  one  place  where  perforation  has  taken  place. 
The  ulcer  is  evidently  an  old  one.  Its  borders  are 
elevated,  thickened,  slightly  ir- 
regular, and  but  little  under- 
mined. Its  base  is  comparatively 
smooth,  there  being  but  a  few 
rounded  elevations  here  and 
there.  The  portion  of  the  stom- 
ach, which  when  examined  from 
without  gave  the  impression  of 
being  thin  walled,  is  that  which 
forms  the  base  of  the  ulcer,  just 
about  the  perforation,  all  the 
surrounding  tissue  being  thick- 
ened and  quite  firm  to  the  touch. 
Up  to  the  edge  of  the  ulcer  the 
mucous  membrane  i  s  intact. 
The  pyloric  opening  has  been 
involved  in  the  ulcerative  proc- 
ess and  the  contraction  conse- 
quent to  healing  has  resulted  in 
an  extreme  grade  of  stenosis,  so 
much  so  that  the  pyloric  opening 
now  admits  only  the  end  of  a 
small  lead  pencil.  Beyond  this 
the  duodenum  appears  to  be 
health}-  and  does  not  share  in 
the  process  of  ulceration.  The 
induration,  which  is  most  marked 
in  the  edges  of  the  ulcer,  is 
confined  to  its  immediate  neigh- 
borhood and  rapidly  fades  away 
into  the  surrounding  tissue. 

The  pancreas  is  adherent  to  the 
stomal  h  in  one  or  two  places.  It 
is  of  normal  consistence  and  size, 
but  is  almost  pure  white  in  color. 

-7./  r-*J  T"!-  •     !_..    1    ■  J         wuitu  uicrc  area        ^  >     ,  ,  . 

1  lie    KianeXS  :      1  he  right    kid-    cells  (O,  a  few  of  which  show  the  attempt  at  pseudo-slandular  fonnation  (Z>V 

ney  is  smalle'r  than   normal  but  '•""n^'-'' >■<  ^»'"p'-'--^'>'''-- "'■"'"'"•""^^'•''ly  ^  porti, 
healthy  in  appearance.     Its  cap- 
sule  strips   off  easily.      On   section   the  cortex    and 
medulla  are  of  relatively  normal  dimensions  and  un- 
altered in  appearance.     The  pelvis  is  normal. 

The  left  kidney  is  considerably  larger  than  the 
right  but  is  of  about  normal  size.  In  all  respects  it 
seems  to  be  healthy.  The  pelvic  viscera,  brain,  and 
spinal  cord  were  not  removed  or  examined. 


:'A^: 


-._p 


.^i:; 


ti 


eyepiece 


KlcrRE  4. — Section  of  a  portion  of  the   muscular  coat  of  the  stomach.     Objective,  oi 
le  inch.     Stained  with  h;ematoxylon  and  orange  G,     Magnification,  about  320  diameters. 

Explanation. — Cros^sections  of  bundles  of  inuscle  fibres  from  the  muscular  coat  are  shown  M),  between 
hich  there  are  a  large  number  of  small-round  cells  (5)  in  places,  and  here  and  there  lar^e  clumps  <  " 


es  arranging 


vicinity  of  the  ulcer,  the  fewer  became  these  cells  until 
finally  they  were  not  found  at  all.  These  small  round 
cells  were  mostly  of  the  character  of  the  polymorpho- 
nuclear leucocyte  of  the  blood,  having  lobulated  and 

'The  illustrations  are  taken  from  Hemmeter's  "Diseases  of 
the  Stomach,"  P.  Blakiston,  Son  &  Co.,  Phila.,  iSyr.  and  were 
made  under  the  direction  of  Dr.  .\mes. 


370 


MEDICAL    RF.CORD. 


[September  ii,  1897 


irregularly  shaped  nuclei  which  in  some  instances  ap- 
peared to  be  composed  of  two  or  three  separate  parts, 
which  upon  close  inspection  were  seen  to  be  connected 
b)'  slender  threads  of  nuclear  substance.  A  few  of 
these  cells  resembled  the  small  mononuclear  leuco- 
cytes. 

A  further  important  change  noticed  in  tliis  layer  of 
the  stomach  was  the  presence  of   larger  and   smaller 


Figure  5.— A  portion  of  an  area  in  the  submucosa  largely  composed  of  groups  of  cancer  cells.  Ob- 
jective,  one-sixth;  eyepiece,  one  inch.  Stained  with  hsematoxylon  and  orange  G.  Magnification, 
about  320  diameters. 

>N.— The   fibrous   tissue  of    the   submucosa    is    infiltrated    with  many  small  round  cells, 
me   places  are  very  numerous  (.■!).      I'he    most   prominent  change  appears  in  the  numerous 

ncer  cells,  almost  all  of   which  He  in  open  spaces  in  the   tissue  (B).     These  clumps  are   like  r  j       •  1.        • 

the  other  coats  of  the   stomach,   but  the  attempt  at  glandular  formation  is  more   marked      Changes       AVere      fOUnd       in      the    IHl- 
any_  other  locality  .(C).     In  the.upper  part. of  .h=  pla,e>.  see„_the  lower  portion  of  the  muscu-      niediate  neighborhood    of    the    ulcCf 


which 


the  clumps  of  epithelial  cells  were  found,  one  occa- 
sionally found  an  acinus  the  cells  of  which  seemed  to 
be  in  a  state  of  reproduction.  In  these  cases  the 
lumen  of  the  gland  would  be  partly  filled  with  new 
cells;  about  its  margins  there  would  occasionally  be 
seen  a  double  row  of  cells,  and  once  in  a  while  an 
acinus  was  found  which  had  apparently  broken  and 
allowed  the  newly  formed  cells  to  escape  into  the 
inter.stices  of  the  surrounding  tis- 
sue, where  they  soon  took  on  the 
character  of  the  cells  already  de- 
scribed as  forming  the  groups  and 
clumps  so  numerous  near  the  mar-, 
gins  of  the  ulcer  (Fig.  3  and  Fig.  i 
A).  Whether  or  not  this  is  a  proc- 
ess of  atypical  cell  reproduction 
which  has  given  rise  to  all  the 
extraneous  cells  of  epithelial  type 
seen  in  the  tissue  is  a  question. 
While  glandular  acini,  such  as  we 
have  just  described,  are  not  fre- 
quently found,  it  is  possible  that 
the  epithelial  cells  so  formed  have 
continued  to  reproduce,  as  we  know 
to  be  their  custom  in  similar  cases, 
and  have  so  given  rise  to  all  of  the 
new  cells  found.  The  supposition 
is  at  least  plausible  and  would  cor- 
respond closely  to  what  Hauser  and 
others  have  described  as  taking 
place  in  similar  cases. 

There  did  not  seem  to  be  any 
formation  of  new  fibrous  tissue  in 
this  layer  of  the  stomach,  and  a 
study  of  the  proper  secreting  cells 
of  the  gastric  glands  did  not  dis- 
close any  important  changes  in 
them. 

7'/ie  muscuiaris  mucosie :  While 
in  general  this  layer  of  the  stom- 
ach wall  showed  but  little  change, 
other  than  a  moderate  amount  of 
small-cell      infiltration,     important 


those  S" 
here  th; 


:  (7^),  infiltrated  with  many  s 


nd  cells, 


clumps  of  quite  large  cells,  each  of  which  contained  a 
clearly  vesicular  nucleus  surrounded  by  considerable 
protoplasm.  So  closely  were  these  cells  packed  in 
the  clumps  referred  to,  that  only  occasionally  could 
the  outline  of  the  cell  be  made  out.  The  clunips  on 
casual  observation  seemed  to  be  made  up  only  of 
masses  of  nuclei  and  cell  protoplasm;  the  outlines  of 
individual  cells  not  being  visible  (Fig.  3).  In 
many  instances  the  cells  formed  clumps  of  consid- 
erable size,  that  gradually  tapered  out  into  single 
rows  of  cells  that  lay  between  the  cross-sections  of 
the  gastric  tubules  (Fig.  3).  CJroups  and  rows  of 
these  cells  were  most  numerous  in  the  very  edge  of 
the  ulcer  and  were  much  scarcer  a  little  distance  from 
it.  Occasionally  these  cells  were  arranged,  as  it  were, 
in  the  form  of  a  glandular  acinus.  This  arrange- 
ment, however,  was  much  more  common  in  the  sub- 
mucosa, where  the  same  cells  were  found  in  abund- 
ance (Fig.  5).  These  were  apparently  epithelial  in 
character,  and  where  they  were  most  numerous  the  gas- 
tric tubules  were  completely  destroved,  wiiile  about 
these  areas  the  tubules  were  found  to  be  \ery  much 
altered  (Fig.  3).  (llandular  acini  were  found  from 
the  walls  of  which  the  gland  cells  had  been  exfoli- 
ated ;  others  to  whose  basement  membrane  a  few 
cells  were  still  attached,  while  within  their  lumina 
lay  the  degenerating  bodies  of  those  that  had  alrcadv 
been  shed.  While  liiis  process  of  exfoliation  and 
cell  death  was  most  common   in   the  areas  in  which 


the  lower  portion  of  the 
d  containing  a  few  of  the  masses  of  cane 

in  a  number  of  places.  In  the 
areas  referred  to,  the  muscuiaris  mucosa  was  found  to 
be  very  much  thickened  and  its  fibres  widely  sepa- 
rated by  a  most  intense  grade  of  infiltration  with  small 
round  cells.  Here  in  numerous  places  they  were  ac- 
cumulated into  small  masses  of  about  the  head  of  a  pin 
in  size  and  lay  one  after  another  in  a  regular  row.  Be- 
tween them  the  collection  of  cells  was  but  little  less 
pronounced.  We  evidently  here  had  a  collection  of 
miliary  abscesses,  all  the  signs  being  those  of  an 
acute  process  (Fig.  6).  It  is  to  be  remarked  that  al- 
though microscopic  examination  showed  the  muscu- 
iaris mucosK  to  be  filled  with  numbers  of  these  small 
abscesses,  no  pus  could  be  expressed  from  the  tissue 
at  autopsy.  In  the  neighborhood  of  these  abscesses 
the  accumulation  of  small  cells  had  passed  over  and  in- 
volved the  deeper  portions  of  the  mucosa  and  to  a  less 
extent  had  spread  also  into  the  submucous  coat  for  a 
short  distance.  So  widely  had  the  fibres  of  the  muscu- 
iaris been  separated  that  it  was  difficult,  with  the 
small  cells  obscuring  the  image,  to  determine  exactly 
what  its  boundaries  were. 

Only  a  very  few  of  the  cells  of  epithelial  type,  so 
numerous  in  the  mucosa,  were  found  in  this  layer.  In 
a  few  places  they  were  seen,  and  occasionally  a  small 
vessel  was  found  plugged  with  them  (Fig.  6,  O. 

7"//6'  si/l'miiiVSii :  About  tlie  base  of  the  ulcer,  and  es- 
pecially about  the  angle  made  where  it  turned  upward 
toward  the  surface,  the  submucosa  consisted  of  very 
dense,  firm  fibrous  tissue,  iwor  in  blood-vessels.     But 


September  1 1,  1897] 


MEDICAL    RECORD. 


little  of  the  infiltration  with  small  cells,  so  marked  in 
the  upper  two  layers,  was  fomid.  Just  beneath  the 
muscularis  mucosa;  in  a  number  of  places  there  were 
groups  of  cell  clumps  similar  in  all  respects  to  those 
found  in  the  mucous  membrane.  It  was  in  this  layer 
of  the  stomach  wall  that  these  cells  were  most  fre- 
quently found  to  arrange  themselves  in  the  pseudo- 
glandular  manner  already  described,  which  is  well 
shown  in  Fig.  5,  C,  which  represents  an  area  of  these 
cells  found  just  under  the  muscularis  mucosa;.  Just 
under  the  base  of  the  ulcer  where  it  lies  in  the  sul)- 
mucosa  there  were  also  a  number  of  areas  composed  of 
groups  and  clumps  of  the  same  cells,  and  here  too  tlie 
pseudo-glandular  arrangement  was  well  shown. 

JVte  muscular  hiytr :  The  chief  point  of  interest  in 
the  muscular  coat  of  the  stomach  was  the  presence  of 
groups  and  masses  of  the  epithelial-like  cells  between 
the  bundles  of  muscle  fibres  in  the  neighborhood  of  the 
ulcer.  In  all  respects  these  clumps  and  the  cells  thai 
composed  them  were  like  Those  already  described. 
They  were  not  so  numerous  and  the  gland-like  ar- 
rangement was  not  so  frequently  seen.  The  small-cell 
infiltration    was    also   verv   much    less    marked    (Fig. 

4,  !>)■ 

The  Si-rous  layer:  In  describing  the  naked-eye  ap- 
pearance of  the  surface  of  the  stomach  it  was  stated 
that  the  serous  surface  in  the  neighborhood  of  the 
pylorus  showed  upon  very  close  inspection,  especially 
with  a  magnifying  glass,  minute  elevated  points  vary- 
ing in  size  from  that  of  a  pinhead  to  very  much 
smaller.  Upon  microscopic  examination  these  slightly 
elevated  points  were  seen  to  be  composed  almost  en- 
tirely of  masses  of  cancer  cells,  like  those  already 
described.  Instead  of  being  dif- 
fusely scattered  all  through  the 
serosa    they  were   aggregated    into  CL, 

small   areas,     each     composed     of  J^ 

numerous  epithelial-cell  clumps. 
The  only  points  of  difference  noted 
were  that  the  clumps  themselves 
were  considerably  smaller  than 
those  in  the  other  layers  of  the  stom- 
ach wall,  and  that  the  individual 
cells  were  likewise  smaller.  No 
pseudo-glandular  formations  were 
found.  One  of  these  nodules  in  the 
serosa  is  admirably  represented  in 
Fig.  I  B.  The  serous  coat  in  other 
places  did  not  appear  to  be  at  all 
thickened. 

Bacteriological  Examination. — 
Sections  were  stained  by  Gram's 
method  with  both  fuchsin  and 
methyl  violet  for  micro-organisms, 
with  the  following  re.sults:  In  the 
necrotic  tissue  lining  the  floor  of 
the  ulcer,  the  following  organisms 
were  found,  all  of  which  stained 
well,  especially  with  methyl  violet. 

A  bacillus.  This  appeared 
either  as  single,  moderately  long 
rods,  sometimes  staining  solidly, 
sometimes  showing  clear  open  spa- 
ces   in    the   protoplasm    about    the   ""^f^y  *'"'"s  "p,"''  "'"* 

centre     of     the     rod,   while     the     ends  scesses,  between  which  Ihcy  are  but  little  le; 

.     ■-    J    J       -1  T  •         ^u  J  widely  separated  by  these  cells.     Few  cancer  cells  J 

.Stained  deeply.        In    size  these  rods  place  (O  they  are   found  plugging  completely  a  sm 

closely     resembled     anthrax     bacilli  of  the  cancer  cells  can  aUo  be  seen  (Z>). 

and  when  they  contained  the  open 
spaces  just  mentioned  looked  very  much  like  anthrax 
rods  with  spores.  In  many  instances  this  organism 
appeared  swollen  at  one  end,  resembling  in  shape  a 
baseball  bat,  and  at  other  times  one-half  of  the  rod 
would  be  somewhat  broader  than  the  remaining  jialf. 
the  change  in  size  being  quite  abrupt.  Not  infre- 
quently what  appeared  to  be  the  same  organism  was 


found  in  chains  of  from  two  to  eight  segments,  some 
segments  staining  solidly  while  others  showed  the 
same  open  spaces  found  in  the  single  rods.  Even  in 
the  chain  formation  the  peculiar  morphology  already 
mentioned  was  noted.  By  far  the  greater  number  of 
these  organisms  was  found  in  the  necrotic  membrane 
on  the  floor  of  the  ulcer,  in  both  its  superficial  and 
deeper  portions,  but  a  few  were  also  found  in-  the  liv- 
ing tissue  beneath  the  ulcer,  in  the  submucosa.  In  all 
respects  this  bacillus  corresponded  to  one  that  was 
cultivated  from  the  stomach  washings  and  from  the 
vomit,  and  it  agrees  with  the  description  of  a  bacillus 
frequently  associated  with  gastric  carcinoma  given  by 
Oppler  and  Boas  and  by  Kaufmann,  and  known  as  the 
"  Oppler-Boas  lactic-acid"  bacillus.  It  is  of  peculiar 
interest  in  this  case  because  of  its  association  with 
the  carcinoma  engrafted  on  the  old  ulcer,  as  already 
mentioned. 

Beside  this  organism  the  sections  also  showed,  both 
in  the  necrotic  base  of  the  ulcer  and  in  the  living  tis- 
sue below  it,  a  few  micrococci  arranged  in  clumps  and 
occurring  singly,  but  never  found  in  chains.  While 
these  were  found  in  the  location  just  mentioned,  it  is 
to  be  noted  that  a  most  careful  search  failed  to  reveal 
any  micro-organisms  whatever  in  connection  with  the 
numerous  small  abscesses  found  chiefly  in  the  muscu- 
laris mucosa;  and  mucosa  in  the  neighborhood  of  the 
ulcer. 

A  third  organism  was  also  found  which,  however, 
we  have  not  as  yet  been  able  to  classify  exactly.  In 
shape  and  general  appearance  it  resembled  \ery  closely 
an  ordinary  yeast  cell  but  was  very  much  smaller,  since 
when  studied  with  a  one-twelfth  oil-immersion  objec- 


FlGlRE  6.— 

glands,  the  muse 
sixth;  eyepiece, 


howing  the  lower  part  of  the  mucou-  coat  w  th  the 
icosze,  and  a  small  portion  of  the  upper  part  of  the  S' 
Stained  with  haematoxylon  and  orange  G.  Magnifi' 
1  all  the  other  sections,  the  small-round-cell  infiltrat* 
cularis  mucosae  and  invading  tht 
s  are  aggregated  into  a  number 

■    ■    ■  The  fibres 

o  be  seen  in 
essel.     in  thi 


so  1  e  of  the  gastric 

)sa.     Objective,  one- 

about  320  diameters. 

,'ell  marked,  the  cells 

portion  of  the  mucous  coat.     In  the  raus- 

Tcular,  dense  masses  (ZT),  miliary  ab- 

of  the  muscularis  mucosae  have  been 

lis  portion  of  the  tissue,  but  in  one 

uppt-r  part  of  rhe  submucosa  a  few 


tive  it  appeared  even  smaller  than  a  yeast  cell  would 
when  viewed  with  a  one-sixth  dry  lens.  The  usual 
shape  of  these  organisms  was  either  circular  or  oval, 
and  they  often  appeared  as  though  in  the  act  of  budding, 
a  small  knob-like  projection  being  found  on  one  side, 
usually  about  one-fourth  the  size  of  the  parent  cell. 
Sometimes  the  organism  appeared  as  a  double  cell, 


3/2 


MEDICAL    RECORD. 


[September  ii,  1897 


the  two  parts  being  of  about  the  same  size.  In  no  in- 
stances were  more  than  two  such  cells  found  together, 
and  in  this  it  differed  from  yeast,  which  often  occurs 
in  chains  of  several  budding  cells.  The  protoplasm 
of  these  cells  stained  a  bluish-violet  color  and  the 
capsule  a  somewhat  darker  tint.  Within  the  proto- 
plasm there  was  usuallj-  a  number  of  darker-staining 
granules  which  were  sometimes  so  numerous  as  to  give 
the  cell  a  coarsely  granular  look.  In  many  respects 
these  organisms  resembled  protozoa,  to  which  class 
they  probably  belong.  Their  presence  was  probably 
purely  accidental. 

-■V  good  representation  of  the  three  organisms  found  in 
the  tissue  in  this  case  is  given  in  Fig.  i,  A,  B,  and  C. 

The  changes  therefore  /ound  in  the  walls  of  the 
stomach  point  to  three  different  morbid  processes.  In 
the  first  place,  the  ulceration.  This  was  of  long  stand- 
ing, as  was  evidenced  by  the  fact  that  it  had  healed 
and  in  the  healing  had  produced  a  gradually  increas- 
ing pyloric  stenosis.  The  fibrous  tissue  about  the 
base  and  margins  of  the  ulceration  was  firm,  dense, 
and  poor  in  blood-vessels.  In  one  place  the  ulcera- 
tion had  progressed  or  a  new  ulcerative  process  had 
been  re-established  in  the  seat  of  the  former  and  per- 
foration had  taken  place,  allowing  an  escape  of  stom- 
ach contents  and  the  consequent  production  of  an  acute 
general  peritonitis.  This  new  area  of  ulceration  was 
very  limited  in  e.xtent  and  the  resulting  perforation 
very  small. 

In  the  second  place,  within  the  tissue  immediately 
surrounding  the  ulceration,  that  is,  in  the  walls  and 
base  of  the  ulcer,  there  had  developed  a  diffuse  can- 
cerous growth;  atypical  epithelial-cell  reproduction 
had  taken  place,  probably  originating  in  tubules  of  the 
gastric  glands,  in  some  way  affected  by  the  process  of 
ulceration  and  by  the  later  process  of  cicatrization. 
The  ulcerative  process,  it  is  conceivable,  as  pointed 
out  by  Hauser,  reduces  the  natural  tissue  resistance, 
while  the  cicatrix  formation  produces  a  constant  low- 
grade  irritation ;  the  result  of  these  two  being  the 
stimulation  of  the  glandular  tissue  to  reproduce,  the 
new  cells  being  allowed  to  grow  and  develop  in  the 
spaces  of  a  tissue  less  resistant  than  nomial.  That 
these  cells  may  find  their  way  into  the  lymphatics  and 
blood-vessels  is  shown  in  Fig.  6,  C,  and  in  this  way 
they  may  ultimately  find  their  way  into  more  distant 
parts.  The  peculiar  tendency  of  these  atypical  gland- 
ular cells  to  reproduce  the  t}pe  of  gland  from  which 
they  originated  by  lining  lymph  spaces  and  spaces  in 
the  surrounding  tissue  is  well  shown  in  some  of  the 
sections.  Had  the  patient  lived  long  enough  the  new- 
growth  would  probably  have  spread  beyond  the  confines 
of  the  stomach  wall  and  involved  distant  tissue,  not 
only  by  successive  invasions  of  contiguous  tissue  but 
also  by  being  transported  through  the  lymph  and  blood 
currents. 

In  the  third  place,  a  study  of  the  tissue  in  the  im- 
mediate vicinity  of  the  ulcer  showed  an  interesting 
condition  that  is  not  often  seen.  The  lower  layers  of 
the  mucous  membrane  and  the  muscularis  mucosa- 
were  the  seats  of  a  diffuse  phlegmonous  intlammation. 
Numerous  very  minute  abscesses  were  found  in  the 
muscularis  mucosa,*  and  the  signs  of  acute  suppurative 
inflammation  spead  over  and  involved  the  under  part 
of  the  mucosa  as  w-ell.  Owing  to  the  presence  of  these 
small  abscesses  the  muscularis  mucosas  was  greatly 
thickened  and  its  fibres  were  widely  separated  by  the 
large  number  of  small  cells  present  in  the  tissue. 
This  particular  morbid  change  is  of  iiUerest.  since  it 
is  so  rarely  found  and  especially  because  of  its  asso- 
ciation with  the  ulcus  carcinomatosum. 

Let  us  resume  once  more  the  clinical  aspect  of  this 
rare  case.  Pus  is  occasionally  observed  in  gastric  car- 
cinoma,' and  V.  Leube  mentions  a  case  of  simple  gastri- 

•  Boas:   ■' Diagnostik  und  Therapie  d.  Magenkrankh. ."  p.  3. 


tis  wiili  abundant  purulent  secretion,  but  does  not 
classify  this  with  phlegmonous  gastritis.  The  discov- 
ery of  the  Oppler-Boas  bacillus  in  the  vomit  was  suffi- 
cient to  induce  us  to  refrain  from  an  e.xact  diagnosis  of 
the  cause  of  the  stenosis.  Oppler  and  Boas'  first  called 
attention  to  these  characteristic  large  bacilli  in  gastric 
contents  from  cases  of  carcinoma.  In  unstained  prep- 
arations they  can  be  recognized  by  their  considerable 
size,  imraotility,  and  form.  Most  of  them  have  the 
shape  of  a  baseball  bat,  gradually  becoming  thicker 
at  one  end.  .\ccording  to  Kaufmann  they  possess  the 
property  of  forming  lactic  acid  abundantly  from  vari- 
ous kinds  of  sugar.  In  twenty  cases  of  carcinoma 
Kaufmann  succeeded  in  demonstrating  their  presence 
nineteen  times.  In  only  one  case  were  they  not  found 
and  in  this  lactic  acid  was  also  absent.  There  was 
a  constant  parallelism  between  the  enormous  occur- 
rence of  these  bacilli  and  large  amounts  of  lactic  acid, 
and  Kaufmann  suggests^that  if  this  fact  can  be  con- 
firmed, the  complicated  analysis  of  lactic  acid  might 
be  replaced  by  the  simple  investigation  of  a  drop  of 
the  stomach  contents  or  vomit  under  the  microscope. 

According  to  Schlesinger  and  Kaufmann,'-  who  first 
succeeded  in  obtaining  this  form  of  lactic-acid  bacillus 
in  pure  culture,  the  presence  of  numerous  large  bacilli 
of  this  kind  speaks  with  great  probability  for  gastric 
carcinoma.  The  negative  result  of  searching  for  these 
bacilli  is  as  valid  a  proof  as  the  absence  of  lactic  acid 
itself.  If  a  pyloric  stenosis  is  evident,  they  argue 
that  the  absence  of  the  Oppler-Boas  bacilli  speaks 
against  its  origin  from  carcinoma.  Although  these 
organisms  are  not  pathognomonic  of  cancer  of  the 
stomach,  and  although  there  are  many  other  bacteria 
that  can  form  lactic  acid,  they  are  nevertheless  very- 
significant  and  important  for  the  diagnosis  of  carci- 
noma. F.  Riegel  '  confirms  the  occurrence  of  this 
bacterium  in  enormous  numbers  in  cases  of  gastric 
cancer  and  regards  them  as  significant  (■' bedeutungs- 
voU"). 

The  remarkable  facts  about  this  case  were  that  it 
had  undoubtedly  originated  in  a  gastric  ulcer  and 
conclusions  were  justifiable  that  gastrectasia  was  due 
to  cicatricial  stenosis.  There  were  two  signs  that 
made  us  hesitate  in  making  a  definite  diagnosis,  and 
these  were  the  constant  presence  of  the  Oppler-Boas 
bacillus  and  a  pronounced  progressive  cachexia. 

It  will  be  evident  from  the  appended  analyses  that 
lactic  acid  was  found  only  once  and  that  hydrochloric 
acid  was  present  at  every  analysis,  the  smallest  amount 
found  being  equal  to  12  decinonnal  NaOH.  From 
the  work  of  Oppler,  Kaufmann,  and  Schlesinger  re- 
ferred to,  one  may  conclude  that  lactic  acid  is  an  un- 
avoidable accompaniment  of  the  Oppler-lSoas  bacilli, 
and  that  they  rarely  or  never  occur  when  hydrochloric 
acid  is  present  in  normal  amount.  Here  was  a  case 
in  which  these  characteristic  bacilli  were  repeatedly 
found  by  Dr.  Whitney  and  Professor  Henimeter  in 
the  stomach  contents  before  death,  and  which  were 
found,  as  alreadv  shown,  bv  Dr.  .\mes  in  the  walls  of 
the  stomach  at  autopsy,  and  in  which  there  was  nor- 
mal and  sometimes  hvperacidity  with  an  absence  of 
lactic  acid. 

The  absence  of  lactic  acid  we  might  e.\plain  by  the 
fact  that  the  man  had  for  two  weeks  at  a  time  been 
fed  almost  exclusively  by  the  rectum,  and  when  he 
really  did  receive  nourishment  by  the  stomach  it  con- 
tained mainly  proteid  diet,  such  as  whipped  egg,  meat 
pulp,  albmnen  water,  and  brandy.  It  is  true  that 
F.wald  test  meals  were  repeatedly  analyzed,  but  then 
the  w-ork  of  Ferdin,  Langguth,'  and  of  Feiertag'  makes 

''•7..  Kenntniss  d.  Mageninhalts  b.  C'arcinonie."  etc. 
Heutscli.  med.  Woch.,  1S95,  No.  5. 

*  Wien.  klin.  Rundschau,  :So5.  No.  15. 

'  "  Die  Erkrankungen  d.  Magens."  p.  174. 

*  .-Kroliiv  f .  Verdauungskrankh.  von  Boas.  B.  i.,  S.  355. 
'  Inaug.  Dissert.,  Dorpat.  iSoi. 


September  ii,  1897] 


MEDICAL    RECORD. 


373 


it  clear  that  \cry  little  lactic  acid  is  contained  in  the 
test  breakfast,  many  times  none  at  all.  One  essential 
condition  for  the  production  of  lactic  acid  is  the  sup- 
pression of  the  secretion  of  hydrochloric  acid;  in  this 
case  there  was  some  stagnation  but  normal  amounts  of 
hydrochloric  acid,  and  at  times  some  hyperacidity,  so 
that  the  absence  of  lactic  acid  in  the  gastric  contents 
is  traceable  to  the  absence,  or  nearly  absence,  of  car- 
bohydrate ingesta  and  to  the  presence  of  hydrochloric 
acid  at  all  times. 

According  to  the  obser\ations  of  Rokitansky  and 
of  Dittrich,  and  later  of  Hauser,'  there  can  be  no 
doubt  that  atypical  cell  proliferations,  which  may  en- 
tirely possess  the  character  of  gastric  carcinoma,  may 
arise  on  the  basis  of  a  benign  ulceration.  Such  a 
metamorphosis  is,  however,  infrequent.  In  189 1 
Kollmann"  collected  fourteen  cases  and  in  1895  Hoas 
could  add  but  eight  more,"  so  that  although  the  phleg- 
monous suppura-  _ 
tive  gastritis 
which  was  found 
at  autopsy  is  a 
rare  disease,  well 
authentica  ted 
cases  of  carcinoma 
arising  from  gas- 
tric ulcer  are 
equally  rare,  thus 
making  this  report 
doubly  interesting. 

In  from  five  to 
six  per  cent,  of 
gastric  ulcers  a 
carcinoma  devel- 
ops in  the  mar- 
gins.* The  diag- 
nosis is  based 
upon  the  presence 
of  progressive  ca- 
chexia with  tumor, 
and  normal 
supernormal  se- 
cretion of  hydro- 
chloric acid.'  In 
spite  of  absence 
of 


have  been  described  in  which  the  only  symptoms  were 
those  of  ulcer  with  cachexia,  no  tumor  mass  at  the 
pylorus  being  palpable,  and  whicli  yet  at  autopsy 
showed  an  ulcus  carcinomatosum. 

We  had  no  hesitation  in  establishing  a  diagnosis  of 
carcinoma  in  our  own  case,  based  upon  the  progressive 
cachexia,  the  tumor  mass  at  the  pylorus,  and  the  pres- 
ence of  the  Oppler-Boas  bacillus,  and  as  there  was  no 
doubt  about  the  previous  existence  and  probable  per- 
sistence of  an  ulcer  the  diagnosis  of  ulcus  carcinoma- 
tosum was  made  very  probable. 

The  diffuse  suppurative  (phlegmonous)  gastritis 
which  was  found  at  the  autopsy  in  the  form  of  numer- 
ous miliary  abscesses  in  tiie  mucosa  and  in  the  mus- 
cularis  mucosa;,  in  the  floor,  and  in  the  margins  of 
the  neoplastic  ulcer,  was  not  diagnosed  ante  mortem, 
for  although  micrococci  and  pus  were  observed  in 
the  gastric  contents,  these  are  not  infrequently  noted 
r  in  connection  with 

^      r  y^  carcinoma,  and   as 

the  temperature 
was  almost  contin- 
ually normal  or 
subnormal,  the 
possibility  of 
phlegmonous  in- 
flammation of  the 
stomach  did  not 
enter  our  minds, 
and  finding  it  in 
the  sections  was  a 
great  surprise. 
The  method  of 
hardening,  s  e  c  - 
tioning,  staining, 
etc.,  has  already 
been  described  by 
Dr.  Ames,  who 
made  the  autopsy 
and  studied  the 
tissue  with  the  as- 
sistance of  Dr.  A. 
A.  Huntley,  his 
assistant  in  the 
pathological  lab- 
oratory in  the 
Ealtimore  Medical 
College. 

In  many  partic- 
ulars our  case  re- 
sembles    one     of 


r  ba>t-  I'f  iht  ulcer,  shoivin^  micro-organisms. 
.-ith    methyl    violet,  anilin-oil    solution,    by  C 


ethod. 


r  baseball-bat 
and  the  other 
:here  are  clear 


I  the  necrotic 


Figure  7.— Section  of  tis 
twelfth;  eyepiece,  one   inch.     Stained 
Magnification,  1,060  diameters. 

ExPL-\N.\TioN. — a.  The  Oppler-Boas  bacillus,  singly  and  in  chains.  Tl 
shape  is  shown  in  some  cases,  while  in  others  it  is  seen  that  one  end  of  the  rod 
broad,  the  change  in  size  being  sudden.     Some  of  the  rods  stain  solidly,  while  in 

6,  A  micrococcus  which  occurs  singly  .'»nd   in  clumps,  but  never  in  chain: 

hvHrrirhlnrir  the  Oppler-Boas  bacillus  and  the  next  organism  to  be  described  were  found  both 

11)  ui  UI.U1U1 11.  ^^.^^  jjj^  ,^^^  ^f  j^_.  ^^,^^_.  ^^j  .^  j^^  healthy  tissue  below  the  same, 
acid,      however,       a  «:.  X  peculiar  yeast-llke  ttrganism,  that  is  probably  some  protozoon.     It  is  much  smaller  than  a 

.  yeast  cell.     Budding  forms  are  seen,  and  the  granular  protoplasm  in  some,  and  the  few  large,  deeply 

carcinoma  may  staining  dots  in  others,  are  well  represented. 

ne\"ertheleSS      ha\'e  .       This  section  should  have  been  in  colors  ;   owing  to  its  complex  reproduction  it  was  impossible  to 

.     .  insert  it   except  in  black,  and  in  consequence  the  organisms  only  arc  shown  in  their  e.\act  positions, 

originated  from  an  the  tissue  in  which  they  lay  nut  being  represented. 

ulcer.  The  diag- 
nosis is  supported  by  the  previous  characteristic  his- 
tory of  ulcer  and  the  course  of  the  disease.  An  ulcer 
does  not  suddenly  strike  into  the  existence  of  an  in- 
dividual as  carcinoma  does,  and  ulcus  carcinomatosum 
occurs  in  individuals  who,  as  a  rule,  have  suffered 
for  years  with  gastric  pain.  If  hjtmatemesis  and 
bloody  stools  are  recorded  in  the  anamnesis,  the  diag- 
nosis acquires  some  certaint). 

The  diagnosis  between  gastric  carcinoma  ^.v  iihcrc 
and  tumor-like  induration  of  a  simple  ulcer  is  difficult. 
Boas  holds  that  in  some  cases  the  secondary  metasta- 
sis in  the  liver  or  other  organs,  and  such  other  signs 
as  ascites,  peritoneal  carcinosis,  etc.,  may  give  the  de- 
ciding clew.  Such  aids,  however,  are  very  rarely 
obtained.  Among  other  conditions  hypertrophic  ste- 
nosis of  the  pylorus  may  have  to  be  eliminated.     Cases 


1  "  Das  chronischt  Magengeschwiir."  Leipzig.  1SS3. 

'  KoUmann:  "  Zur  Differentialdiagnose  z%vischen  Magen- 
geschwQru.  .Magenkrebs."  IJerlin.  klin.  Wochen.,  iScji,  Nos.  5 
and  6. 

^  "  Diagnostik  u.  Therapie  d.  Magenkrankh.,"  Leipzig,  1S9;, 
P    189.  ■*  Hauser,  1.  c. 

'Rosenheim:  "Zur  Kenntniss  des  mit '  Krebs  complicirten 
runden  MagengeschwUrs."  Zeitschr.  f.  klin.  Med.,  B.  x^ni.,  S. 
116. 


phlegmonous  gastritis  follow  ing  gastric  cancer  reported 
by  S.  Mintz,'  who  at  that  time  collected  forty -one  cases. 
In  a  new  compilation  we  give  all  the  cases  of  phleg- 
monous gastritis  referred  to  in  the  literature,  amount- 
ing in  all  to  ninety-five  references,  as  well  as  a  list  of 
all  works  referring  to  the  subject.  These  are  mainly 
from  the  reports  of  Mintz."  the  text-books  of  Ewald, 
Boas,  Rosenheim,  and  Riegel;  the  fourth  volume  of 
the  Edinburgh  Hospital  Reports:  an  article  by  R.  F. 
C.  Leith,  pp.  51-114;  from  Debove  and  R^mond,' 
and  from  the  various  journals  quoted.  It  is  appended 
under  the  bibliography  at  the  end  of  this  article,  to- 
gether with  the  bibliography  of  ulcus  carcinomatosum. 

Analysis  of  Stomach  Contents  of  George  Wil- 
liams.— March  4,  1896,  Maryland  General  Hospital. 
Meal  at  1 1  130  .\.m.  Ewald  meal  at  3  130.  Contents 
of  stomach  examined  at  4:40. 

Macroscopic  examination  :  Amount,  180  c.c.  Clear. 
Acid  odor.  Xo  apparent  fermentation.  Normal 
amount  of  mucus.  Rice.  Small  pieces  of  meat  prob- 
ably indigestible.     Xo  blood.     Small  amount  of  bile. 


'  Deutsch.  .\rchiv  f.  klin.  Med..    Bd.  .\li.\., 

=  L.  c. 

*  "  .Maladies  de  I'Estomac,"  p.  200. 


p.  4S 


374 


MEDICAL    RECORD. 


[September  ii,  1897 


Chemical  examination:  Reaction  acid  to  litmus, 
Congo  paper,  and  Boas  reagent.  Negative  to  Uffel- 
mann's  test.  Total  acidity:  5  c.c.  filtered  contents 
treated  required  5.4  c.c.  alkali  to  neutralize.  Total 
acidity,  108. 

Dr.  Whitney's  conclusions  at  this  lime  were  as  fol- 
lows: Marked  hyperacidity.  Some  atony.  Probably 
gastric  ulcer  with  pyloric  obstruction. 

The  patient  was  put  upon  rest,  milk  diet,  bismuth, 
Carlsbad  water,  Blaud's  pill  with  arsenic  for  a  time, 
lime  water,  and  bicarbonate  of  sodium.  Local  treat- 
ment for  pains. 

Result:   Cure.      Patient  discharged  May  i,  1896. 

Second  Examination:  Stomach  contents  drawn  at  8 
A.i\F.     No  food  since  the  previous  day. 

Macroscopic  examination  :  Amount,  goo  c.c.  Color 
brownish.  Large  amount  of  grumous  disintegrating 
blood.  Traces  of  pus.  No  other  solid  particles. 
Odor  normal.     No  bile.     No  excess  of  mucus. 

Chemical  examination:  Acid  to  litmus.  Acid  to 
congo  paper.  .\cid  to  dimethyl.  Free  HCl  present. 
Lactic  acid  absent.  Sugar,  verj-  faint  trace.  Ery- 
throdextrin  absent.  Peptone  present.  Acidity:  free 
HCl,  33  per  cent.  Organic  acids  and  acid  salts,  29 
per  cent.  Combined  HCl,  i  per  cent.  Total  acid- 
ity, 62  per  cent. 

December  6,  1896.  Maryland  General  Hospital 
meal  at  8  a.m.  Ewald  meal  at  12  m.  Contents  drawn 
at  I  P.M. 

Macroscopical  examination:  Contents  large,  1,200 
c.c.  Odor  slightly  offensive.  Small  bits  of  bread 
from  Ewald  meal.  Egg  yellow  present  from  Maryland 
General  Hospital  meal.  Small  bits  of  tissue,  appar- 
entlv  meat.  Small  amount  of  mucus.  No  blood.  No 
bile." 

Microscopical  examination  :  In  addition  to  food  the 
small  bits  of  tissue  showed  numerous  flat  epithelial 
cells.  No  sarcina'.  Sections  will  he  made  of  the 
tissue. 

Chemical  e.xamination :  x\cid  to  litmus.  Acid  to 
Congo.  Acid  to  dimethyl-amido-azo-benzol.  Free 
HCl  present.  Lactic  acid  absent  by  Boas  test. 
Acetic  acid  (?).  Erythrodextrin  absent.  Sugar  pres- 
ent. Peptone  present.  Free  HCl,  14  degrees. 
Combined  HCl,  24  degrees.  Acid  salts  and  organic 
acids,  46  degrees.     Total  acidity,  84  degrees. 

December  7,  1896.  —  Maryland  General  Hospital 
meat  at  8  a.m.  Ewald  meal  at  12  m.  Contents  drawn 
at  I  P.M.  The  stomach  was  washed  thoroughly  at  7  130 
A.M.  and  all  drugs  were  stopped. 

Macroscopic  examination:  Contents  large,  about 
350  c.c.  Filtrate  faintly  cloudy,  300  c.c.  No  blood, 
bile,  or  excess  of  mucus.  Odor  faintly  sour  and 
slightly  unpleasant.  No  meat  or  milk  left  from  Mary- 
land General  Hospital  meal.  Small  bits  of  egg  yel- 
low and  bread.      No  bits  of  mucosa  to  be  found. 

Chemical  examination:  Acid  to  litmus,  congo,  and 
dimethyl.  Free  HCl  present.  Lactic  acid  absent. 
Acetic  acid  (?).  Sugar  present.  Erythrodextrin 
absent.  Peptone  present.  Total  acidity,  70  degrees. 
Free  HCl,  12  degrees.  Combined  HCl,  24  degrees. 
Acid  salts,  etc.,  34  degrees. 

December  17,  1896. — Last  food  gi\en  the  evening 
of  December  i6th.  Contents  were  drawn  about  8:30 
.\.M.,  December  17th. 

Macroscopic  examination:  .Vmount  about  500  c.c. 
Odor  faintly  unpleasant.  No  food  contents  recogniz- 
able. Sinall  particles  of  bismuth  from  former  days. 
No  blood,  bile,  or  excess  of  mucus.  Pus  present. 
Filtered  readily.  Filtrate  clear.  Slightly  brownish 
tinge. 

Chemical  examination:  .\cid  to  litmus,  congo,  and 
dimethyl.  Free  HCl  present.  Lactic  acid  absent. 
Butyric  acid  absent.  Acetic  acid  absent.  Erythro- 
dextrin    absent.     Sugar    present.     Peptone    present. 


Total  acidity,  84  degrees.  Free  HCl,  20  degrees. 
Acid  salts  and  organic  acids,  57  degrees.  Combined 
HCl,  7  degrees. 

January  8,  1897.  —  Stomach  washed  out  in  the  morn- 
ing and  then  Maryland  General  Hospital  meal  at 
8:10.  Ewald  meal  at  12:10.  Contents  drawn  at 
I  :io. 

Macroscopic  examination:  Amount,  1,100  c.c. 
Odor  offensive.  Small  amount  of  blood  shown  in  the 
filtrate.  Slight  excess  of  mucus,  no  bile.  Bread, 
meat,  egg,  rice,  present  in  contents.  Filters  slowly. 
Filtrate  brownish,  clear. 

Chemical  examination:  Acid  to  litmus,  congo,  di- 
methyl. P'ree  HCl  present.  Lactic  acid  absent. 
Peptone  present.  Er}'throdextrin  present  in  small 
amount.  Sugar  present,  nearly  normal.  Free  HCl, 
27  degrees.  Combined  HCl,  7  degrees.  Organic 
acids  and  acid  salts,  53  degrees.  Total  acidity,  87 
degrees. 

Ferments :  Pepsin  and  rennet  present  in  about  nor- 
mal power. 

Synopsis  of  the  Urine  Examinations  of  George 
Williams. — The  amount  varied  from  470  to  680  c.c. 
in  the  twenty-four  hours.  The  reaction  was  in  every 
instance  but  one  alkaline.  The  odor  was  as  a  usual 
thing  normal.  The  specific  gravity  varied  from  1.02 1 
to  1.032.  Albumin  was  never  detected.  Sugar  was 
never  detected.  Globulin  was  never  detected.  Indi- 
can  was  always  in  excess.  Urophen  was  norma)  in 
three  examinations  and  in  e.xcess  in  two.  Urea  varied 
from  12.22  to  20.06.  Uric  acid  varied  between  0.3326 
and  0.4737.  Chlorides  varied  from  0.658  to  i.  53  gni.as 
NaCl.  Phosphates  varied  from  0.7884  to  1.3  86  gm.  as 
P.O..  Bile  pigments  were  always  absent.  Acetone 
was  absent  in  all  but  one  examination,  when  it  was 
marked.  Bile  salts  were  always  nonnal.  Blood  was 
always  absent.  Ha-moglobin  was  always  absent.  Di- 
acetic  acid  was  always  absent.  Creatinin  was  always 
in  excess.  Uroerj-thane  was  present  but  once.  The 
microscopic  examination  showed  epithelial  cells,  some 
pus,  triple  phosphates,  mucus,  and  amorphous  urates. 

BIBI.IO<;K.\riIY     OF     PHLEGMONOUS     GASTRITIS. 

Andral,  (;. :  Clinique  Medicale.  Maladies  de  r.\bdomen, 
1839,  tome  ii; 

Auvrav:  Etude  siir  la  (lastrite  phlegmoneuse.  These  de 
Paris,  i860. 

Asverus:  Ein  Fall  von  Gastritis  phlegmonosa.  Jenaische 
Zeitschr.   f.  med.  Xatur.,  Jena,  1S66,  Bd.  ii.,  S.  476-4S2. 

Ackermann:  Ein  Pall  von  phlegmonoser  Gastritis  mit  Throm- 
bose  zalilreiclier  .Magenvenen  und  embolischen  Heerden  in  der 
Leber  und  in  den   I.ungen.      Virchow's   Archiv,  i86g,  Bd.  .tIv. , 

S.  39- 

Albers:  Rheinisch-W  estph.  med.  Correspondenzblatt,  1S44, 
No.  5.  Reported  by  Tillmanns.  Arch.  f.  klin.  Chir. ,  Berlin, 
1SS2,  P.d.  xxvii.,  S.  i;;. 

Beckler:  Ein  Fall  von  idiopathischer  phlegmonbser  Gastritis. 
Aerztl.  Int.  Bl.,  MUnchen,  jSSo,  Bd.  .x.wii.,  No.  37,  S.    403. 

Brinton:   Diseases  of  the  Stomach. 

Bonetus;  Sepulchretum  sive  -Vnatomia  practica.  Lib.  iii., 
Geneva,  1700. 

Bamberger:  Henoch's  Klinik  der  Unterleibskrankhciten. 
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September  ii.  1897] 


MEDICAL    RFXORD. 


375 


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1887. 


THE    SC.'IENTIFIC    TREATMENT    OF    TUJiKR- 
CULOSIS.' 

By   JOSHUA    LINDLEV    BARTON,    M.D 


ATTENDi.NC  rUVSlClAN 
throat),  [JELI.EVU1 
OF  THE    SEW    YORK 


I  THE   DEPARTMENT  OF  OUT-DOOR   POOR  (NOSE  AND 
HYSICIAN  TO  THE    LUNG    DEPARTMENT 
AND   NOSE   HOSPITAL, 


The  discovery  of  the  tubercle  bacillus  by  Dr.  Koch 
in  i88i  marked  an  epoch  in  the  history  of  tuberculous 
disease;  first,  because  up  to  that  time  the  etiology  of 
the  disease  was  obscure ;  and  secondly,  the  treat- 
ment, being  largely  symptomatic,  was  defective. 

"The  great  desideratum  in  nomenclature,  as  applied 
to  disease,  is  that  the  name  of  each  disease  shall  e.K- 
press  the  morbid  condition  involved."  Not  only  is 
the  proper  nomenclature  of  this  disease,  however,  in 
doubt,  but  also  the  e.xact  pathological  conditions  in- 
tended to  be  described  by  the  synonyms  used.  We 
find  it  mentioned  by  medical  writers  as  consumption, 
tuberculosis,  and  phthisis.  These  terms  are  applied 
to  a  number  of  inflammatory  conditions  which  may  be 
either  acute  or  chronic,  incipient  or  far  advanced,  pneu- 
monic, tuberculous,  or  fibroid.  Granting  that  in  nearly 
if  not  quite  all  of  these  cases  the  tubercle  bacillus  is 
the  cause  of  the  disease,  it  still  remains  true  that  clin- 
ically much  perplexity  exists  because  of  a  failure  suf- 
ficiently to  appreciate  the  fact  that  '"  tuberculosis  and 
phthisis  are  distinct  and  different  conditions,"  while 
the  term  consumption  may  be  applied  to  an  entirely 
different  form  of  disease. 

The  practice  of  medicine  is  both  a  science  and  an 
art ;  liut  "  Science  is  knowledge  reduced  to  principles ;" 
"Art  is  knowledge  reduce  to  practice."  U'e  can, 
therefore,  hardly  wonder  that  our  art  so  often  fails  to 
master  this  disease,  when  we  ignore  the  first  princi- 
ples of  sound  practice  and  treat  the  disease  by  name, 
regardless  of  the  pathological  conditions. 

Since  1881  tuberculosis  has  severely  taxed  the  in- 
genuity of  the  profession.  The  etiology  of  the  disease 
being  so  simple  and  due  to  one  cause,  the  conclusion 
has  been  natural  that  if  we  can  remove  the  cause 
we  shall  cure  the  disease.  We  have,  therefore,  been 
too  apt  to  ignore  the  patient,  considering  him  simply 
as  a  culture  medium  for  the  disease  germs,  and  have 
paid  our  respects  almost  wholly  to  the  tubercle  bacilli. 

Tubercle  bacilli  are  minute  vegetable  bodies,  about 
one-three-thousandth  of  an  inch  in  length.  They  are 
ubiquitous,  omnipresent — in  the  water  we  drink,  in 
the  air  we  breathe,  and  in  the  food  we  eat.  Thev 
seem  to  have  neither  beginning  of  days  nor  end  of 
years.  High  and  low,  rich  and  poor  alike,  are  liable 
to  their  visitations.  It  is,  therefore,  of  much  interest 
to  inquire  why  it  is  that  some  individuals  are  attacked 
while  others  escape. 

The  consensus  of  clinical  experience  and  scientific 
opinion  seems  to  be  that  malnutrition,  hereditv,  and 
irritation  of  the  respirator)-  mucous  membrane,  from 
whatever  cause,  are  all-powerful  factors  predisposing 
to  the  disease;  and  that  when  the  tubercle  bacilli 
gain  entrance  to  soil  prepared  by  one  or  all  of  these 
agencies  they  take  root,  and  shortly  the  sufferer  pre- 
sents himself  with  the  clinical  phenomena  of  pulmo- 
nary tuberculosis. 

Curability  of   the   Disease.— Medical  authorities' 

'  Read  before  the  Medico-Surgical  Society.  April  5,  1S97. 
'  Prof.    Hughes  Bennett,  Prof.   A.  L.  Loomis,   Prof.    V'rancis 
Delafield,  Dr.    Richard  Quain,  Dr.  James  I'ollock,  Prof.  \V.  H. 


are  quite  unanimously  of  the  opinion  that  a  large  per- 
centage of  the  incipient  cases  can  be  cured  by  appro- 
priate treatment,  while  in  the  more  advanced  and 
chronic  forms  the  disease  may  be  greatly  delayed  and 
life  rendered  fairly  comfortable.  But  it  should  not 
be  forgotten  that  altcnim  altcriiis  niixilio  cgei  is  a  con- 
ilitio  sine  (jua  iioii  to  success. 

Prophylaxis. — The  old  adage  that  an  "ounce  of 
prevention  is  worth  a  pound  of  cure"  is  eminently  true 
in  connection  with  pulmonarj'  tuberculosis.  But  pro- 
phylaxis should  embrace  not  only  a  prohibition  of  ex- 
pectoration in  public  places  and  an  additional  hos- 
pital for  the  proper  care  of  a  few  of  those  who  are  ill; 
it  should  also  provide  for  the  destruction  of  all  in- 
fected animals  and  for  our  tenement-house  population 
large,  airy  living-rooms  into  which  the  glorious  sun- 
shine may  come. 

Plan  of  Treatment — The  plan  of  treatment  should 
take  into  consideration,  first  of  all,  the  pathological 
condition,  i.e.,  whether  the  case  is  one  of  simple  tuber- 
culosis or  of  phthisis;  whether  the  disease  is  quies- 
cent or  progressive ;  and  whether  the  conditions  of 
cure  are  present  or  absent;  i.e.,  whether  the  patient  has 
the  vitality  or  recuperative  power  to  respond  to  the 
treatment. 

Hygienic  Management. — The  general  health  of  all 
persons  suffering  from  this  disease  should  be  carefully 
promoted.  Their  sleeping-apartments  should  be  large 
and  well  ventilated ;  they  should  spend  several  hours 
each  day  in  the  open  air ;  their  nervous  systems  should 
be  stimulated  to  healthy  action;  physiological  errors 
in  digestion  and  assimilation  should  be  corrected; 
the  blood  should  be  improved  in  quality,  so  that  it 
may  furnish  to  the  individual  cells  those  elements 
which  will  build  up  and  impro\e  the  tissues. 

Mechanical  Treatment — No  mechanical  device 
yet  suggested  exceeds  in  value  the  "  pneumatic  cabi- 
net," as  a  therapeutic  agent  in  the  treatment  of  pul- 
monary diseases.  "The  mastery  of  its  physics,  a 
thorough  knowledge  of  physiolog}-,  and  a  correct  ap- 
preciation of  the  pathological  condition  in  each  par- 
ticular case  are  of  course  indispensable."  '  Some  of 
the  most  important  results  obtained  by  a  judicious  use 
of  this  instrument  are  as  follows,  viz. :  the  muscles  of 
respiration  are  developed;  the  lungs  are  made  to  ex- 
pand; portions  of  lung  tissue  which  have  been  com- 
paratively idle  are  made  to  perform  their  physiological 
function;  "  infiammmatory  stasis  is  prevented;  septic 
products  and  mechanical  obstruction  to  circulation  and 
respiration  are  removed ;  lymphatic  absorption  is  in- 
creased, and  the  nutritive  supplv  is  augmented."  ' 

Topical  Treatment A   recent  writer  upon  "The 

Surgical  Treatment  of  Tuberculosis"  makes  the  asser- 
tion that  "  tuberculosis  is  amenable  to  treatment  in 
direct  ratio  to  our  ability  to  attack  it  locally."  If 
this  is  true  of  tuberculosis  of  the  skin,  bones,  joints, 
kidneys,  and  pleura,  it  is  also  true  of  tuberculosis  of 
the  lungs. 

The  late  Dr.  Horace  Green,  of  this  city,  as  long  ago 
as  1838,  taught  that  pulmonary  tuberculosis  could  he 
treated  locally  by  means  of  injections  into  the  trachea 
and  bronchi  tiirough  the  mouth  and  larynx.  In  1840 
he  brought  the  subject  before  the  New  York  Medical 
and  Surgical  Society,  and  reported  fifteen  cases  of  se- 
vere laryngeal  and  bronchial  disease  whicli  had  been 
cured  by  this  means.  Between  f  )ctober.  1 854,  and  Feb- 
ruary. 1856,  he  had  treated  one  hundred  and  six  cases. 
Of  these,  seventy-one  were  classed  as  cases  of  tubercu- 
losis. Of  these  tuberculosis  cases,  thirty-two  were 
considered  as  cases  of  advanced  tuberculosis, /.<?.,  cases 

Thompson,  Dr.  James  Henry  Bennett,  Dr.  C.  K,  Quimby,  Dr. 
lames  R.  Le.tming. 

•  Dr.  \'on  Ruck. 

'  Dr.  C.  E.  (Juimby,  in  a  paper  read  before  the  Ameriaen 
Climatological  Association,  June,  1S92. 


September  1 1,  1897] 


MEDICAL.    RECORD. 


m 


in  which  tuberculous  cavities  were  recognized:  and 
thirty-nine  as  cases  of  early  tuberculosis.  Of  the  sub- 
jects of  advanced  tuberculosis,  twenty-five  were  more 
or  less  improved  — their  lives  being  apparently  pro- 
longed by  this  means  of  medication.  Of  the  thirty- 
nine  cases  of  incipient  tuberculosis,  twelve  had  appar- 
ently recovered  at  the  time  the  report  was  written,  and 
five  more  were  nearly  well.  Of  the  remaining  rwenty- 
two  cases,  seventeen  were  greatly  improved,  three  were 
moderately  benefited,  and  three  failed  to  receive  an\- 
benefit  whatever.  Of  the  twenty-eight  cases  of  bron- 
chitis, sixteen  were  cured,  and  all  of  the  others  greatly 
benefited.  In  si.v  cases  of  asthma  treated  by  this 
means — in  all  except  one — the  disease  was  entirely 
removed.  Four  years  later  in  a  paper  read  before  the 
Medico-Chirurgical  College,  he  adds  :  ""  Such  lias  been 
the  amount  of  success  which  has  continued  to  attend 
this  plan  of  treatment  that  I  am  now  ready  to  affirm, 
after  an  experience  of  many  years  in  a  field  of  obser- 
vation unusually  large,  that,  if  I  were  required  to  re- 
linquish all  other  known  therapeutic  measures  or  top- 
ical medication  in  the  treatment  of  thoracic  diseases. 
I  should  choose  the  latter  with  hygienic  means  alone, 
in  preference  to  the  entire  class  of  remedies  ordinarih 
employed  in  the  treatment  of  these  diseases."  ' 

The  technique  is  simple.  An  ordinarv-  aspirating 
syringe  with  an  endo-laryngeal  tube,  a  head  mirror,  a 
laryngeal  mirror,  a  Mackenzie  condenser,  and  a  cocaine 
spray  constitute  the  necessary  apparatus;  while  a 
steady  hand,  a  cool  head,  and  some  knowledge  of  laryn- 
golog)^  will  enable  any  physician  to  treat  the  disease 
topically  by  means  of  intrabronchial  injection. 

"This  method  of  medication  has  several  advanta- 
s;es,  viz. : 

■■  I.  The  remedy  is  a|)plied  directly  to  the  irritated 
mucous  surface. 

■■  2.  It  immediately  alleviates  the  most  distressing 
symptoms,  adding  at  once  to  the  comfort  of  the  patient. 

■■  3.  In  a  certain  number  of  cases  the  antiseptic  effect 
of  the  medicine  is  ver)-  pronounced,  as  shown  by  tht- 
longer  interval  between  febrile  attacks,  and  bv  tlieir 
lessened  intensitv  when  they  do  occur. 

■■  4.  The  tracheal  and  bronchial  mucous  membrane 
rapidly  absorbs  the  medication,  so  that  we  mav  expect 
a  general  as  well  as  a  local  eftect. 

■■5.  We  avoid  disturbing  the  patient's  stomach  with 
nauseating  doses,  and  the  shattering  of  his  ner\ous 
system  with  opiates. 

"6.  This  method  of  alleviating  the  most  distressing 
and  annoying  symptoms  does  not  interfere  in  the 
slightest  degree  with  any  other  line  of  general  treat- 
ment which  may  be  deemed  advisable. 

■■  7.  In  cases  characterized  by  an  atrophic  condition 
of  the  tracheal  mucous  membrane,  or  of  pulmonary 
disease  with  cavitation  leading  to  retention  and  de- 
composition of  the  secretions,  intrabronchial  injec- 
tion will  remove  the  disgusting  fetor  of  the  breath 
consequent  upon  this  condition."  " 

Local  applications  to  diseased  areas,  in  phthisis, 
may  also  be  made  by  means  of  intrapulmonary  injec- 
tion. An  exhaustive  review  of  the  history  of  thi> 
procedure  will  be  found  in  an  excellent  paper  written 
by  Dr.  Beverley  Robinson  and  published  in  the  Med- 
ical  Rfxord,  of  January  lo,  1885. 

The  technique  is  fully  described  in  an  admiralile 
paper  by  Dr.  J.  Blake  White  and  published  in  the 
Medical  Record  of  November  13,  1886.  The  results 
oljtained  by  means  of  topical  medication  in  pulmonary 
diseases  should  inspire  us  with  confidence  that  a  ver)- 
large  number  of  cases  may  be  amenable  to  scientific 
treatment  which  were  formerly  considered  hopeless. 

'  B.  P.,  125;  B.  P..  vol.  52. 

■'  Dr.  Joshua  L.  Barton,  in  a  paper  read  before  the  laryngo- 
logical  section  of  the  New  York  .\cademy  of  Nfedicine,  .March 
2j,  i3g6. 


Medicinal  Treatment — A  long  list  of  remedies 
has  been  suggested  for  administration  in  tuljerculosis; 
but  with  the  exception  of  those  which  promote  nutri- 
tion there  is  little  to  encourage  their  use.  When 
the  fact  is  clearly  recognized  that  a  restoration  of 
normal  nutrition  is  of  greater  value  in  the  treatment 
of  tuberculous  disease  than  the  whole  class  of  so-called 
antiseptics,  and  that,  owing  to  the  physiological  and 
pathological  complications,  a  specific  remedy  is  out  of 
the  question,  a  brighter  day  will  ha\e  dawned  for  botli 
patient  and  physician. 

There  are  two  remedies,  however,  in  addition  to 
those  commonly  prescribed,  to  which  I  wish  especially 
to  call  attention.  First,  the  chloride  of  gold  and  so- 
dium with  the  iodide  of  manganese,  brought  promi- 
nently before  the  profession  as  a  therapeutic  agent  in 
tuberculosis  by  our  honored  president,  Dr.  J.  Blake 
\^'hite,  is  a  most  valuable  remedy  as  well  as  a  power- 
ful nutritive  stimulant,  and  is  deserving  of  a  much 
more  extended  trial  than  it  has  yet  received.  Sec- 
ondly, the  tuberculin  of  Koch,  "regarded  for  a  short 
time  as  a  specific  in  tuberculosis,"  is  a  remedy  of  the 
greatest  value  when  used  in  small  doses,  as  suggested 
by  Dr.  ^'on  Ruck,  .\fter  an  experience  of  some  years 
his  testimony  is  that  •'  its  effects  are  as  reliable  and 
uniform  as  we  can  expect  them  to  be  when  we  take  inta 
consideration  individual  idiosyncrasy,  the  stage  of  the 
disease,  and  the  pathological  complications  which  are 
usually  present."  Doctors  Trudeau,  Muir,  Berming- 
ham,  and  many  others  bear  testimony  to  its  therapeutic 
worth,  and  I  may  venture  to  add  that  my  own  experi- 
ence with  this  remedy  has  been  of  the  most  satisfac- 
tor)-  character. 

The  initial  dose  should  never  exceed  one-twen- 
tieth of  a  milligram  and  should  be  increased  onlv 
after  tolerance  has  been  established,  the  rule  being 
never  to  give  a  dose  large  enough  to  cause  a  febrile 
reaction.  The  second  week  the  dose  may  be  in- 
creased to  one-tenth  of  a  milligram,  and  the  third 
week  to  one-fifth  of  a  milligram,  and  so  on,  until 
the  maximum  dose  which  a  patient  can  take  has  been 
reached.  Should  a  reaction  occur  the  remedy  should 
be  discontinued  for  a  time  and  then  resumed,  the 
minimum  dose  being  given  as  in  the  first  instance. 

It  is  best  administered  in  a  one-half-per-cent.  car- 
bolic solution,  so  prepared  that  five  minims  of  the 
solution  will  contain  one-twentieth  of  a  milligram 
of  the  tuberculin.  This  may  be  injected  with  a  hypo- 
dermic needle  into  any  convenient  part  of  the  body, 

"  Whenever  a  point  is  reached  w  here  the  improve- 
ment is  radical  and  the  active  symptoms  have  entirely 
subsided,  the  remedy  should  be  discontinued  and  the 
patient  kept  under  observation  for  some  weeks.  If 
the  cure  seems  to  be  permanent  the  patient  may  then 
be  discharged;  otherwise  a  rejietition  of  the  treatment 
is  necessary."  ' 

Change  of  Climate. — The  theory  that  tuberculosis 
can  be  speedily  eradicated  or  more  successfully  treated 
by  establishing  hospitals  and  sanatoriums  in  certain 
localities  is  fallacious  in  the  extreme.  Back  of  tu- 
bercle bacilli  are  causes  which  are  operating  to  pro- 
duce malnutrition  and  a  lowered  vitality.  The  people 
need  to  be  taught  how  to  live  rightly.  Instead  of  more 
sanatoria,  let  us  have  schools  of  physiolog)'  and  hygi- 
ene, and  instead  of  introducing  militar)-  drill  let  the 
public  schools  teach  cooking  and  dietetics. 

Climate  undoubtedly  exerts  some  influence  over  the 
processes  of  nutrition,  but  it  has  been  greatly  overrated 
as  a  curative  agent  in  pulmonary  tuberculosis. 

Modern  methods  of  scientific  treatment,  combined 
xvith  a  liberal  diet  of  good  nourishing  food  and  sev- 
eral hours  spent  each  day  in  the  ojjen  air,  are  worth 
far  more  than  any  change  of  climate  can  possibly  be 
to  the  vast  majorit)'  of  sufferers  from  this  disease. 
'  Dr.  Von  Ruck. 


378 


MEDICAL    RECORD. 


[September  ii,  1897 


Length  of  Time  during  which  Treatment  Should 
be  Continued. — If  eternal  vigilance  is  the  price  of 
liberty,  eternal  patience  and  perseverance  upon  the 
part  of  both  physician  and  patient  are  the  price  of 
success  and  of  cure  in  connection  with  pulmonary 
tuberculosis.  The  treatment  must  be  continued,  not 
only  until  the  tubercle  bacilli  have  disappeared,  but 
until  the  general  condition  and  nutrition  of  the  patient 
have  been  restored. 

A  plan  of  treamient  which  combines  the  hygienic, 
the  mechanical,  the  topical,  and  the  medicinal  is  full 
of  hope  for  those  who  suffer  from  this  disease.  The 
day  is  not  far  distant— indeed  it  has  already  come — 
when  a  large  class  of  patients  may  be  led  to  hope 
not  only  for  a  temporary  improvement  in  their  condi- 
tion, but  for  a  radical  cure  for  their  disease. 

I  have  treated  during  the  past  year  twelve  cases  of 
tuberculosis;  six  of  these  were  cases  of  early  tubercu- 
losis and  six  cases  of  advanced  tuberculosis,  /.<-.,  cases 
in  which  either  consolidation  or  cavities  were  recog- 
nized. Of  the  early  cases,  two  have  apparently  recov- 
ered and  three  more  are  nearly  well,  while  all  of  the 
others  have  been  greatly  benefited. 

Report  of  Twelve  Cases. — Case  I. — Mr.  B ,  aged 

twenty-eight,  works  in  tobacco  factory.  This  patient 
presented  himself  at  my  clinic  at  the  department  of 
out-door  poor,  Bellevue  Hospital,  in  March,  1894. 
He  complained  of  cough,  night  sweats,  loss  of  flesh, 
and  profuse  expectoration.  He  had  been  taking  cod- 
liver  oil  and  creosote  for  six  months  with  no  apparent 
benefit.  Examination  revealed  prolonged  expiration 
with  fine  rales  over  tlie  whole  upper  lobe  of  the  right 
lung.  The  sputum  showed  tubercle  bacilli.  In  this 
case  the  cod-liver  oil  and  creosote  were  continued  and 
the  patient  was  given  one-twentieth  of  a  milligram  of 
tuberculin  three  times  a  week  by  hypodennic  injec- 
tion. This  treatment  was  continued  for  five  months. 
The  patient  improved  steadily,  the  cough  gradually 
became  less,  the  expectoration  ceased,  the  appetite  im- 
proved, the  night  sweats  stopped,  and  there  was  a 
marked  increase  in  weight.  The  treatment  was  dis- 
continued for  two  months  and  then  resumed,  intrabron- 
chial  injections  three  times  a  week  being  added. 

This  treatment  was  continued  for  six  months  longer, 
when,  all  the  active  symptoms  having  disappeared  to- 
gether with  the  tubercle  bacilli,  the  patient  declaring 
that  he  felt  perfectly  well,  he  was  discharged  cured.- 
This  patient  has  since  been  kept  under  observation 
and  is  to  all  appearances  in  perfect  health. 

Case  II. — Mr.  P ,  merchant,   aged  thirty,  had 

measles  in  April,  1896,  from  which  time  his  general 
health  has  been  much  impaired.  He  began  to  cough 
about  July,  1896.  At  the  time  when  he  came  under 
observation  he  was  expyectorating  about  two  ounces 
daily,  temperature  ranging  from  99  to  1  o  i .  6  F.  Ex- 
amination revealed  pro-longed  expiration  over  the  apex 
of  the  left  lung,  with  slight  roughness  of  the  breathing 
sounds.  The  sputum  contained  tubercle  bacilli. 
This  patient  was  treated  by  intrabronchial  injection, 
hypodermics  of  tuberculin,  and  the  pneumatic  cabinet. 
The  treatment  was  continued  daily  and  the  patient 
steadily  imjiroved  until  Xovcmber  27th,  when  he  sud- 
denly developed  pneumonia  after  an  exposure  to  cold. 
For  three  weeks  the  treatment  was  discontinued  with 
the  exception  of  the  intrabronchial  injections,  which 
were  repeated  two  or  three  times  a  week.  .At  the  end 
of  the  third  week  the  full  treatment  was  resumed  and 
continued  daily,  and  tiie  patient  improved  all  of  the 
time  until  February  i8th.  An  examination  of  the  spu- 
tum upon  that  date  showed  that  the  tubercle  bacilli 
had  disapi^eared.  Treatment  by  intrabronchial  in- 
jection and  the  pneumatic  cabinet  was  continued,  how- 
ever, until  March  17th,  when,  the  active  symptoms 
having  all  disappeared,  the  patient  was  discharged 
apparently  cured. 


Case  III. — Mr.  b ,  pilot,  aged  thirty-four.     This 

patient  came  under  observation  in  the  lung  department 
of  the  New  York  Throat  and  Nose  Hospital,  August 
28,  1896.  No  definite  history  of  his  previous  condi- 
tion was  obtained.  He  complained  of  cough,  expec- 
torated freely,  was  losing  riesh,  and  the  sputum  con- 
tained tubercle  bacilli.  The  trouble  was  located  in 
the  apex  of  the  right  lung.  This  patient  was  treated 
three  times  a  week  by  intrabronchial  injection,  hypo- 
dermics of  tuberculin,  and  the  pneumatic  cabinet. 
This  was  continued  until  December  26th,  when,  the  ac- 
tive symptoms  having  disappeared  together  with  the 
tubercle  bacilli,  the  treatment  was  discontinued. 
With  the  e.xception  of  a  slight  cold,  this  patient  has 
continued  to  improve  and  is  now  to  all  appearances  in 
perfect  health. 

C.'VSE  IV. — Mr.   B had   pleurisy   in   the   right 

side  in  September,  1895,  and  had  not  been  well  since. 
He  complained  of  cough,  rise  of  temperature,  and  ex- 
pectoration. Examination  revealed  consolidation  of  the 
middle  lobe  of  the  right  lung  and  the  sputum  contained 
tubercle  bacilli.  Preatment  has  been  by  intrabron- 
chial injection,  the  pneumatic  cabinet,  and  hypoder- 
mics of  tuberculin,  repseated  daily  since  November 30th. 
There  is  a  marked  subsidence  of  all  of  the  active 
symptoms.  Respiration  is  much  better  and  the  gen- 
eral condition  and  nutrition  of  this  patient  are  greatly 
improved.      He  is  still  under  treatment. 

C.\SE  V. — Mr.  H ,  aged  twenty-nine,  plumber, 

some  years  ago  strained  his  left  side,  after  which  he 
spat  up  blood.  He  has  had  six  hemorrhages,  has  cough, 
and  expectorates  quite  freely.  Examination  revealed 
prolonged  expiration  over  the  left  ape.x,  with  subcrepi- 
tant  rales  at  the  level  of  the  second  rib,  near  its  junc- 
tion with  the  sternum.  The  sputum  contained  tubercle 
bacilli.  'Phe  treatment  in  this  case  has  been  by  intra- 
bronchial injections,  the  pneumatic  cabinet,  and  hv- 
podermics  of  tuberculin  repeated  daily.  The  cough 
and  expectoration  have  been  much  diminished  and  he 
has  increased  in  weight.  His  general  health  has  been 
much  improved.      He  is  still  under  treatment. 

Case  VI. — Miss  \\' ,  aged  fourteen,  came  under 

observation  December  29,  1896,  complaining  of  cough, 
loss  of  appetite,  night  sweats,  and  vomiting  after 
meals.  Examination  revealed  prolonged  expiration 
over  the  upper  lobes  of  both  lungs.  The  sputum 
showed  tubercle  bacilli.  The  temperature  ranged 
from  normal  to  i  o  i '  F.  The  treatment  in  this  case  has 
been  by  intrabronchial  injection,  pneumatic  cabinet, 
and  hypodermics  of  tuberculin  repeated  three  times  a 
week,  with  an  occasional  dose  of  sulphate  of  atropine 
for  the  night  sweats.  Her  general  health  has  greatly 
improved.  The  night  sweats  have  ceased.  She  eats 
well  and  has  gained  fourteen  pounds  in  weight.  She 
is- still  under  treatment. 

Case  VII. — Mr.  C ,  bookkeeper,  aged  twenty- 
four.  Family  histor)^  not  ver)'  good.  Cough  for  three 
months.  Expectorates  freely.  Has  night  sweats. 
Whole  upper  lobe  of  right  lung  involved.  The  sputum 
does  not  contain  tuliercle  bacilli.  This  patient  has 
been  treated  by  the  pneumatic  cabinet,  intrabronchial 
injections,  and  hypodermics  of  tubercalin  repeated 
three  times  weeklv  since  January  9th.  There  has 
been  a  marked  improvement  in  his  general  condi- 
tion; cough  is  less  and  the  expectoration  diminished. 
The  night  sweats,  however,  continue.  He  is  still  under 
treatment. 

Cases  Reported  by  Dr.  Carpenter. — Case  VIII. — 

Mr.   ■ ,   aged  thirty-five  years,   German  bartender. 

Cavity  at  left  apex,  both  lungs  diseased  throughout, 
night  sweats  very  profuse,  bloody  expectoration,  breath- 
ing verv  shallow,  had  lost  over  thirty  pounds  in  last 
year,  bacilli  numerous.  This  man  had  been  taking 
creosote  tin  ;e  months,  with  slight  improvement,  before 
I  used  the  intrabronchial   injections.      He  has  been 


I 


September  ii,  1897] 


MEDICAL    RECORD. 


379 


steadily  improving  in  every  way  since  and  at  the 
present  time  is  working  regularly:  he  coughs  ver)-  sel- 
dom, has  no  expectoration ;  night  sweats  have  stopped 
entirely;  he  has  a  ravenous  appetite  and  has  gained 
thirteen  pounds  in  weight.  Intrabronchial  injections 
began  lane  6,  1896.  For  the  past  month  examination 
has  failed  to  disclose  any  bacilli. 

C.\SE  IX. — Mr.   M ,  aged    twenty-eight    years, 

German  salesman.  For  one  year  previous  to  treat- 
ment by  intrabronchial  injection  he  had  a  slight 
cough,  and,  although  he  had  been  under  constant  treat- 
ment, had  lost  twelve  pounds  and  his  condition  had 
not  improved.  Both  lungs  were  affected,  and  he  had 
night  sweats  two  or  three  times  a  week.  On  Septem- 
ber 3d  this  patient  received  the  first  intrabronchial 
injection  which  I  repeated  three  times  a  week.  Night 
sweats  have  entirely  disappeared;  he  coughs  \erj-  lit- 
tle, principally  in  the  morning  after  getting  up;  the 
expectoration  is  ver)-  slight  and  his  appetite  is  much 
improved.  The  patient  looks  much  better  and  shows 
improvement  in  even,-  way.  October  7,  1896,  says  he 
has  gained  four  and  one-half  pounds  in  the  past  month. 
5till  under  treatment. 

Case   X. — Mrs.    M ,    aged  twenty -seven  years, 

married  three  years,  had  a  cough  for  over  one  year. 
Slight  expectoration :  occasional  night  sweats,  not  very- 
severe;  bacilli  found  in  expectoration  not  very  numer- 
ous: slight  dulness  found  over  apices  of  both  lungs: 
has  tuberculous  laningitis.  Intrabronchial  injections 
began  August  15,  1896,  and  were  repeated  three  times 
a  week.  Throat  symptoms  began  to  improve  from  the 
beginning;  cough  is  much  relieved:  appetite  has  re- 
turned. October  7,  1896,  has  not  had  a  night  sweat 
in  over  two  weeks:  her  breathing  is  much  freer.  Still 
under  treatment. 

Case  XI. — Mr.   S ,  aged  thirt)-  years.      Marked 

consolidation  at  the  apex  of  the  left  lung;  nodules 
throughout  both  lungs.  He  also  has  tuberculous  lar- 
yngitis. Numerous  bacilli  were  found.  First  intra- 
bronchial injection  June  i6th;  these  were  continued 
•daily,  beginning  with  one-half  drachm  and  increasing  to 
t\vo  drachms;  creosote  internally,  beginning  with  three 
<lrops  and  increasing  to  ten  drops  three  times  a  day. 
June  23d,  cough  softer  and  easier:  expectoration  more 
free;  throat  feels  much  better;  night  sweats  diminished. 
September  28th,  cough  much  improved:  expectorates 
very  little:  has  not  had  a  night  sweat  in  six  weeks: 
throat  does  not  bother  him  at  all;  has  gained  five  and 
one-half  pounds  in  weight;  about  half  the  previous 
number  of  bacilli  found  in  sputum. 

Case  XII. — Mr.  S ,  aged  thirty  years,  salesman, 

had  been  sick  six  months.  Severe  cough  and  night 
sweats,  profuse  expectoration,  gradual  emaciation. 
Took  aseptolin  without  any  improvement  whatever. 
First  intrabronchial  injection  June  ist,  repeated  daily 
until  July  ist,  then  discontinued  because  he  was  feel- 
ing so  well,  .\tthe  first  e.xamination  bacilli  were  quite 
plentiful.  June  25th,  bacilli  were  verj-  few.  .Aiter 
the  injections  had  been  discontinued  for  two  weeks 
bacilli  became  more  numerous  again  and  he  dropped 
back  into  his  old  condition.  He  went  to  the  country 
July  15th,  and  I  have  not  seen  him  since.  I  believe 
in  this  case  that  if  patient  had  continued  treatment  a 
good  result  would  have  been  secured. 


lodoformism,  after  wounds  and  operations,  and 
•especially  bums  due  to  a  localized  or  generalized  re- 
flex polyneuro-dermatitis,  has  been  studied  by  Tussau. 
After  a  period  of  toleration  in  which  the  wound  does 
well  an  inllammator)-  area  develops  at  the  periphery 
of  the  wound  and  a  lymphangitis  may  develop  in  a 
limb,  followed  by  necrosis  which  may  threaten  loss  of 
limb  if  not  of  life.  lodoformic  herpes  is  only  the 
first  stage  of  this  reflex  polyneuritis. — Dublin  Medual 
Journal. 


A  DISCUSSION  OF  THE  COMPOSITION  OF 
CREAM  AND  A  CONSIDERATION  OF  THE 
DESIRABILITY  OF  ESTABLISHING  A 
STANDARD." 

Bv  J.    H.    HUDDLESTOX,    .\..M.,     M.D., 

■■  Modified  milk'"  has  become  such  a  routine  pre- 
scription for  bottle-fed  children  that  all  of  its  com- 
f)onents  desene  the  most  careful  study,  and  one  of 
them,  cream,  has  apparently  as  yet  had  less  than  its 
share.  For  those  cases  in  which  the  condition  of  the 
stomach  demands  more  than  ordinarj-  care  the  milk 
laborator}-  has  demonstrated  its  usefulness,  even  per- 
haps its  necessity;  but  laboratory  milk  is  expensive 
and  its  use  is  therefore  practically  limited.  Dift'erent 
podiatrists  have  taught  us  how  the  materials  for  home 
modification  may  be  supplied  by  letting  the  milk 
stand  a  sufficient  number  of  hours  and  then  skimming 
it  for  the  cream ;  by  this  means  a  cream  of  sufficiently 
nearlv  constant  composition  can  be  obtained,  but  this 
method  delays  the  preparation  of  the  bottles  of  milk 
to  a  somewhat  late  hour  in  the  day,  and  there  seems 
to  be  no  reason  why  the  cream  required  should  not  be 
obtained  directly  from  the  dair}-,  just  as  the  milk  is 
obtained.  There  is  also  sufficient  economic  reason 
for  an  inquiry  into  the  amount  and  character  of  a  food 
material  received  daily  by  an  immense  number.  Led 
by  those  considerations,  I  have  tried  to  find  out  some- 
thing of  the  present  condition  of  the  cream  supply  in 
this  cit}-,  and,  as  published  matter  on  cream  is  rare  in 
medical  literature,  I  have  turned  to  the  reports  of  the 
dair}'  division  of  the  United  States  department  of 
agriculttire  and  to  the  reports  of  various  agricultural 
e.xperiment  stations.  This  information  has  been  sup- 
plemented by  much  most  valuable  advice  from  Dr.  E. 
J.  Lederle  and  also  from  Chemist  Martin,  of  the  city- 
health  department:  from  Mr.  E.  N.  Ehrhart,  sani- 
tar\-  engineer;  Mr.  J.  A.  Howell,  of  the  Howell  Con- 
densed Milk  and  Cream  Company :  Mr.  L.  B.  Halsey, 
of  the  Sheffield  Famis  Company,  and  others. 

The  Milk  Reporter,  the  official  journal  of  the  milk 
trade,  states  that  during  1896  there  were  received  in 
New  York  City  practically  nine  million  quarts  of 
cream,  a  daily  average  of  nearly  twenty-five  thousand 
quarts,  and  three  hundred  and  twenty  million  quarts 
of  milk.  The  district  which  supplies  this  immense 
amoimt  is  shown  by  the  statement  that  about  two 
million  cans  came  over  the  D.,  L.,  &  W.  R.  R.,  one 
and  a  half  millions  over  the  Erie,  the  same  over  the 
Ontario,  and  the  rest  in  smaller  amounts  over  nine  or 
ten  other  roads.  Orange,  Dutchess,  Chenango,  and 
Delaware  counties  supply  over  one-half  of  the  total 
amoimt  sent.  The  farthest  point  from  which  milk  is 
shipped  to  New  York  is  over  three  hundred  and 
twenty-five  miles  away,  and  the  journey  to  the  cit}- 
occupies  about  twenty-four  hours.  Much  the  greater 
part,  however,  is  brought  in  less  than  ten  hours. 

Cream  comes  to  the  city  either  in  fort\-quart  tin 
cans  or  in  glass  bottles :  cans  are  most  used  on  ac- 
count of  their  smaller  freight  charges  (twenty-eight 
cents  for  fort)-  quarts  in  a  can,  forty  cents  for  the 
same  amount  in  bottles).  According  to  its  method  of 
manufacture  it  is  divided  into  two  classes:  gravity, 
/.(•.,  hand-skimmed,  or  Cooley  cream,  and  machine  or 
separator  cream.  The  proportion  of  machine  cream 
to  the  gravity  is  said  to  be  about  ten  to  one.  About 
half  of  the  cream  supply  of  New  York  is  sold  to 
families,  the  other  half  is  sold  to  ice-cream  factories, 
bakers,  and  confectioners.  The  immense  amount  used 
in  these  trades  is  shown  by  the  fact  that  during  the 
four  summer  months  of  May,  June,  July,  and  .Yugust, 
1896,  there  was  received  a  total  of  about  four  million 

*  Read  before  the  section  on  general  medicine  of  the  .\cademy 
of  Medicine.  May  iS,  1697. 


38o 


MEDICAL    RECORD. 


[September  ii,  1897 


six  hundred  thousand  quarts  of  cream,  /./•.,  more  than 
in  tlie  other  eight  months  put  together. 

The  gravity  cream,  which  is  almost  entirely  taken" 
by  the  ice-cream  makers,  restaurants,  and  hotels,  varies 
in  fat  content,  although  the  great  bulk  of  it  ranges 
from  twelve  to  sixteen  per  cent.  It  is  usually  raised 
by  gravit}-  in  "  Cooley"  cans,  which  have  a  faucet  at 
the  bottom  by  which  the  lower  part  of  the  contents 
can  be  drawn  off  without  disturbing  the  upper;  these 
are  submerged  in  cold  water  for  about  twenty-four 
hours  and  then  skimmed  by  drawing  off  the  milk  be- 
low the  cream.  The  cream  thus  collected  does  not 
keep  well  and  there  is  said  to  be  frequently  added, 
therefore,  a  composition  of  borax  and  salicylic  acid, 
called  "  Preservitas." 

The  machine  cream  is  separated  from  the  milk  by 
the  use  of  some  one  of  the  several  centrifugal  separa- 
tors. It  can  be  made  very  quickly,  and  therefore  does 
not  need  the  twenty-four  hours  practically  necessary 
for  gravity  cream.  It  can  usually  be  delivered  in 
from  twenty-four  to  thirty-six  hours  from  the  cow,  but, 
as  it  keeps  well,  it  is  frequently  not  shipped,  in  winter 
at  least,  for  ten  days  or  two  weeks,  and  sometimes  for 
even  longer.  Most  cream  delivered  in  New  York  is 
at  least  seventy-two  hours  old  before  it  reaches  the 
city.  If  there  happens  to  be  a  surplus,  the  extra  cream 
is  kept  buried  in  ice  for  days.  Nearly  all  tlie  cream 
furnished  to  private  families  is  separator  cream,  and, 
though  brought  to  the  city  in  forty-quart  cans,  is  put 
into  half-pint,  pint,  and  quart  bottles  before  delivery. 
Bottling  in  the  city  is  now  under  the  regulation  of  the 
health  department,  and  must  be  done  in  such  a  man- 
ner as  to  prevent  "contamination  by  dust  from  the 
streets  or  by  other  impurities."  Moreover  there  are 
certain  regulations  as  to  cleansing  and  caring  for  the 
bottles.  Certain  dairies,  however,  send  their  cream 
to  the  cit\'  in  bottles  filled  and  sealed  while  the  cream 
is  fresh.  Milk  bottles  are  prepared  in  the  same  way, 
and  if  the.se  are  carefully  carried  much  less  time  is 
required  for  the  cream  to  reach  the  top  after  delivery 
than  when  the  bottles  are  filled  just  previous  to  de- 
livery. The  practice  of  supplying  milk  and  cream  in 
bottles  is  now  about  twenty  years  old,  and  in  that 
time  the  methods  have  been  immensely  im])roved. 
When  the  bottling  is  done  in  a  properly  equipped 
laborator)-  under  sanitary  regulations  there  is  no  doubt 
that  the  bottles  form  the  best  and  safest  means  of  de- 
livering the  milk,  but  when  the  bottling  is  done  in  an 
unsuitable  place,  with  improperly  cleansed  and  un- 
sterilized  material,  there  is  also  no  doubt  that  the 
bottling  system  is  one  of  the  most  objectionable.  In 
i8g6  less  than  five  million  quarts,  i.e.,  less  than  one- 
sixtieth  of  the  whole  amount,  came  to  the  city  in 
bottles,  but  as  there  are  about  1.700,000  bottles  in 
daily  use  in  the  city  the  immense  importance  of 
supervision  of  these  possible  infection  carriers  is 
evident.  Clubs,  hotels,  restaurants,  and  ice-cream 
factories  also  get  the  machine  cream,  but  usually  have 
it  supplied  in  cans.  The  great  bulk  of  this  variety 
is  JO  to  30  pound  cream,  but  there  are  prepared  and 
shipped  with  greater  or  less  regularity  15,  18,  20,  25, 
30,  35,  40,  50,  and  even  55  pound  cream.  This  means 
that  the  number  of  pounds  specified  of  butter  can  be 
made  from  a  forty-quart  can  of  the  cream.  That  this 
classification,  however,  is  a  commercial  one  of  the 
roughest  character  may  be  seen  from  the  accompany- 
ing analyses  which  have  been  made  of  ten  samples  of 
each  class: 

Ckk.\m. 

.pound.     20-poimd.     2S-pound.     50-pound.     35-pound.     40-pound 

c    "r  T-»   er»  tt   ^r  «r   ^ft  oft  o?  lA  n- 


i8-p<junti. 

2<j-pound. 

:j5-pound. 

3^IM,un.i. 

^^-pcund. 

40-pouQd, 

14.38 
16.90 
15.50 

'7-53 

16.35 
15.23 
19-03 
16.95 

35-40 
32.15 
35-2S 
33-83 

29.93 
26.95 

26.S8 

37-40 
40.93 
-12-3; 
38.93 

38.23 
38.25 

42.99 
41.62 

.Vveraj;e.  14.62 

17-83 

3I-77 

32. 86 

37-59 

41.08 

15.75 

17.50 

23-95 

35-98 

38.25 

46.05 

15.50 

20.70 

29.00 

30.50 

34-50 

40.35 

ri.25 

13.50 

35.70 

38.90 

37-20 

4l.7<> 

11.75 

18.00 

29.90 

36.5c 

36.40 

42. SS 

13.25 

17-93 

28. 95 

36.75 

34.02 

41.54 

M-35 

23.05 

33-55 

33-33 

35-93 

37.23 

As  will  be  observed,  some  20-pound  cream  has  less 
fat  than  some  18-pound  cream,  and  other  20-pound 
cream  has  nearly  as  much  fat  as  some  2 5 -pound 
cream ;  moreover,  the  25  and  30  pound  creams  dift'er  in 
their  average  fat  content  by  only  about  one  per  cent. 
The  inexactness  of  this  classification,  however,  is 
probably  due  to  the  fact  that  there  is  yet  no  consider- 
able well-formulated  demand  for  a  cream  of  a  known 
fat  content.  The  Walker-Gordon  milk  laboratorj-, 
which  furnishes  two  classes  of  cream,  one  containing 
sixteen  per  cent,  of  fat  and  the  other  thirty-two  per 
cent,  of  fat,  has  a  patronage  which  is  almost  the  only 
e.xception.  Even  the  rough  division  sjjecified  is  used 
almost  exclusively  by  the  wholesale  dealers,  and  the 
usual  reply  of  the  retail  dairy  or  milk  men,  when  asked 
for  information  about  the  cream,  is  either  that  they 
have  but  one  grade  and  that  that  is  '"  a  good  cream, 
good  enough  for  anybody,"  or,  in  the  case  of  some 
special  dairies,  that  they  have  two  grades,  a  "light" 
and  a  "heavy"  cream.  The  exact  composition  of  the 
particular  cream  or  creams  is  usually  unknown  to 
them.  Ever)'  dealer  knows  practically  how  good  a 
cream  must  be  in  appearance,  that  is,  to  sell  in  his 
neighborhood:  and  he  secures  from  the  wholesale- 
dealer  a  cream  having  about  that  appearance.  What- 
ever the  character  of  the  cream,  the  retail  price  at  an\ 
of  the  fifty-five  hundred  milk  stores  in  New  York  is 
nearly  the  same,  about  five  times  as  much  as  milk, 
/.(•.,  it  is  approximately  forty  cents  a  quart  through 
much  of  the  city,  though  seventy-five  cents  and  ten 
cents  per  quart  have  been  noted  as  extremes.  The 
wholesale  rates  for  ordinary  cream  vary  with  the  price 
of  milk  from  S4.50  to  56.00  for  a  forty-quart  can. 
Heavy  (40-pound)  cream  varies  from  $1 1.00  to  $13.00 
per  can.  Dr.  Yan  Slyke,  chemist  of  the  New  York 
Agricultural  Experiment  Station,  has  pointed  out  that 
everywhere  in  the  State  "  the  sale  of  cream  is  abso- 
lutely without  control  or  supervision,  except  that  the 
agricultural  law  defines  pure  cream  as  cream  taken 
from  unadulterated  milk.  Anything  passes  as  cream 
which  the  consumer  is  willing  to  accept,  whether  it 
contains  ten,  fifteen,  twent\\  or  twentv-five  per  cent,  of 
fat.'" 

Such  is  the  present  state  of  the  cream  supply,  but 
not  a  necessary  state.  Any  grade  of  cream  required 
may  be  easily  furnished  with  a  centrifugal  machine, 
simply  by  supplying  the  milk  to  the  separator  at  a 
greater  or  less  rate  of  speed.  The  amount  of  fat  in 
the  milk  used  for  the  cream  must  l^e  known.  For  ex- 
ample, if  the  milk  contains  four  per  cent,  of  fat  and  a 
twenty-pound  cream  is  desired,  as  many  quarts  of  the 
four  per  cent,  milk  must  be  used  in  the  separator  as 
four  is  contained  in  twenty — that  is,  five.  Fourteen 
cans  of  average  milk  are  necessar)-  to  make  one  can 
of  fifty-pound  cream,  twelve  cans  of  milk  to  make  one 
of  forty-pound  cream,  and  so  on. 

I  cannot  forbear  saying  a  word  here  of  the  by-prod- 
uct in  the  production  of  cream,  the  skimmed  milk. 
This  has  the  following  average  comixjsition :  Water. 
90.34;  fat,  0.15:  sugar,  3. 98:  casein.  4.80;  salts, 
0.7S.  -At  present  it  is  used  largclv  in  the  manufacture 
of  skim-milk  cheese,  and  also  to  some  extent  in  feed- 
ing calves  and  pigs,  and  is  sold  to  farmers  at  ten  cents 
for  a  forty-quart  can.  .\n  immense  amount  of  this 
nutritious  and  readily  digestible  food  could  probably 
be  sold  in  New  York  at  .i  price  which  would  make  it 
one  of  the  cheapest  of  good  foods  were  it  not  for  the 
clause  in  the  sanitary  code  which  says  that  "  no  milk 
which  has  been  .  .  .  changed  in  any  respect  ...  by 


September  ii,  1897] 


MEDICAL    RFXORD. 


the  removal  of  cream  shall  be  brought  into.  held, 
kept,  or  offered  for  sale  at  any  place  in  the  city  of 
Xew  York."  This  evidently  forbids  the  use  of  milk 
freed  from  fat  by  a  milk  laboratorx'.  That  skimmed 
milk  may  be  sold  by  unscrupulous  dealers  as  whole 
milk  hardly  constitutes  sufficient  reason  for  prohibit- 
ing its  sale  for  what  it  is. 

The  factors  necessarj-  for  the  production  of  cream  of 
definite  fat  contents  are  a  skilled  dairyman,  an  effi- 
cient separator,  milk  of  uniform  composition  (to  obtain 
this  the  day's  milk  supply  must  be  put  in  a  vat,  thor- 
oughly mi.xed,  and  its  composition  tested),  and  a  Bab- 
cock  tester  for  the  rapid  determination  of  the  amount 
of  fat.  This  last  instrument  is  in  brief  a  centrifugal 
apparatus  containing  a  bottle  in  which  the  cream  to 
be  tested  in  placed  together  with  sufficient  sulphuric 
acid  to  set  free  the  entire  fat  content.  In  less  than 
ten  minutes  the  fat  can  be  all  brought  into  the  long 
neck  of  the  bottle  and  its  total  amount  read  on  an  at- 
tached scale.  At  my  suggestion  the  Sheffield  Farms 
Uair}-  Company  kindly  undertook  to  produce  for  a 
week  a  cream  which  should  contain  uniformly  forty 
per  cent,  of  fat.  This  cream  was  made  daily:  a  speci- 
men was  analyzed  the  following  day  by  Dr.  Lederle 
and  the  following  list  of  percentages  resulted:  41.20. 
38.50,  40.50,  39.00,  40.80,  38.50,  41.00,  40.00.  No 
specimen  was  more  than  one  and  one  half  per  cent, 
from  the  prescribed  forty  per  cent.,  and  an  error  of 
that  size  in  cream  of  that  grade  may  be  safely 
neglected. 

Accepting  then  this  as  a  demoiistration  that  cream 
of  a  uniform  composition  can  be  produced,  and  noting 
the  statement  of  Mr.  Halsey,  the  president  of  the 
company,  that  it  can  be  produced  without  greatly  in- 
creased cost,  it  remains  to  be  obser\-ed  that  cream  of 
one  composition  does  not  always  have  the  same  ap- 
pearance. Cream  thickens  with  age,  and  it  is  there- 
fore a  very  frequent  practice,  especially  in  cold 
weather,  to  hold  back  cream  from  delivery  for  several 
days  that  it  may  appear  richer.  This  increase  in 
thickness  of  the  cream  is  due  to  bacterial  growth. 
Russell  reports  that,  in  seven  samples  of  cream  taken 
when  the  cream  was  from  six  to  eighteen  hours  old. 
the  average  content  was  a  little  over  a  million  bacteria 
per  cubic  centimetre :  and  that  in  fifteen  samples 
taken  when  the  cream  was  from  thirty  to  forty-two 
hours  old,  the  average  content  was  somewhat  over  nine 
million  bacteria  per  cubic  centimetre.  Still  it  should 
be  added  that  the  work  of  the  last  few  years  has  em- 
phasized the  fact  that  the  number  of  bacteria  present 
in  milk  is  of  very  little  significance.  The  widest  pos- 
sible variations  in  the  numbers  seem  to  be  found 
under  almost  identical  conditions.  The  difficulties  in 
the  way  of  obtaining  from  the  cow  milk  without  bac- 
terial contamination  are  e.xtremely  great  and  practi- 
cally insurmountable.  The  milk  even  when  first  drawn 
from  the  cow  usually  contains  bacteria,  probably  on 
account  of  the  ease  with  which  the  milk  is  contami- 
nated in  the  milk  duct.  On  the  other  hand  the  variety 
even  of  non-pathogenic  bacteria  is  all-important. 
Considerably  over  two  hundred  distinct  tvpes  of  or- 
dinar)-  milk  bacteria  have  been  described  in  literature 
up  to  the  present  time.  It  has  been  shown,  for  ex- 
ample, that  it  is  to  the  growth  of  a  few  well-studied 
species  that  the  aroma  and  flavor  desirable  in  cream 
and  butter  are  due,  and  it  is  not  less  true  that  the  dis- 
agreeable flavor  and  odor  occasionallv  noted  in  cream 
are  due  to  other  bacteria.  Conn's  bacillus  No.  41  has 
been  shown  to  give  butter  the  flavor  which  is  known 
among  e.xperts  as  that  of  "June  butter.''  The  etTect 
of  sterilization  or  pasteurization  is  to  make  a  cream 
which  is  thinner  in  appearance  than  unsterilized  or 
unpasteurized  cream.  This  effect  has  been  regarded 
as  a  detriment,  and  at  the  Wisconsin  .Agricultural 
Station  it  has  been  shown  that  cream  can  be  artificiallv 


thickened  by  adding  a  solution  of  cane  sugar  in  lime 
water,  that  is  a  sucrate  of  lime,  "viscogen"  so-called, 
with,  it  is  said,  no  injurious  results  to  the  cream. 

The  physical  action  of  separation  is  of  value  in 
diminishing  the  number  of  bacteria  in  cream,  for  a 
varying  proportion  is  caught  in  the  slime  of  the  sepa- 
rator. Many  other  bacteria,  however,  are  carried  over 
into  the  skimmed  milk,  and,  according  to  Ur.  Moore, 
especially  into  the  cream.  For  example,  e.xamination 
of  milk  artificially  infected  with  bacilli  of  tubercu- 
losis, and  then  separated,  showing  that  in  16  per  cent, 
of  the  preparations  of  the  skimmed  milk,  and  in  all 
of  those  of  the  cream,  tubercle  bacilli  were  found. 
They  were  also  more  numerous  in  the  preparations 
made  from  the  cream  than  in  those  made  from  the 
milk,  and  this  result  was  always  the  same,  without 
regard  to  the  rapidit}-  of  revolutions  of  the  separator. 
It  has  been  shown  too  along  the  same  lines  that  butter 
mav  ser\-e  to  carry  typhoid  fever,  tuberculosis,  and  cer- 
tain other  germ  diseases.  Separation,  therefore,  is 
not  an  adequate  means  of  obtaining  a  sterile  cream. 

That,  in  the  absence  of  the  few  desirable  bacteria, 
it  is  a  distinct  advantage  to  have  cream  as  nearly 
sterile  as  is  possible  without  any  alteration  in  its 
physical  characteristics,  hardly  needs  argumenc 
Sterilization  by  any  method  now  in  use  is  known  to 
change  the  character  of  cream  so  as  to  make  it  un- 
suitable for  many  purposes,  notably  for  use  in  infant 
feeding.  That  pasteurization  probably  modifies  the 
milk  somewhat  is  shown  by  the  fact  that  the  coagulum 
produced  by  hydrochloric  acid  is  different  in  character 
in  pasteurized  milk  from  that  in  fresh  milk.  There 
should,  however,  in  pasteurized  milk  be  no  "  cooked" 
taste.  The  temperature  at  which  this  taste  appears  is 
not  a  definite  and  distinct  point,  however,  but  varies 
somewhat  with  the  treatment  given  to  the  fluid:  more- 
over a  marked  cooked  taste  may  be  perceptible  imme- 
diately after  heating,  and  then  disappear  when  the 
milk  is  cooled.  Nevertheless,  milk  heated  above  70 
C.  usually  has  a  slight  cooked  taste.  That  pasteuriza- 
tion as  usually  performed  leaves  a  considerable  num- 
ber of  bacteria  is  shown  by  Russell,  who  found  as  an 
average  of  fiftv'-eight  samples  of  unpasteurized  twenty- 
five-per-cent.  cream  8,700,000  bacteria  per  cubic  cen- 
timetre, and  in  the  same  pasteurized  an  average  of 
24,250  bacteria  per  cubic  centimetre:  he  has  isolated 
fifteen  species  of  bacteria  from  pasteurized  milk  and 
cream,  numerous  enough  to  make  it  certain  that  they 
were  derived  from  the  milk.  Of  these  only  si.x  pre- 
dominated; and  by  a  study  of  these  he  came  to  the 
conclusion  that  to  a  large  extent  the  lactic-acid  bac- 
teria are  destroyed  by  pasteurization,  that  half  of  the 
ordinary  forms  present  seem  to  have  no  effect  on  the 
physical  character  of  the  culture  medium,  and  that  the 
bulk  of  the  remainder  belong  to  the  rennet-forming 
bacteria.  Bacteriological  study  of  pasteurized  cream 
has  shown  that  old  cream,  which  is  more  apt  to  have 
spHDre-bearing  germs,  is  not  at  all  well  suited  for  pas- 
teurization. It  has  sometimes  happened,  for  instance, 
that  cream  pasteurized  on  Monday  has  failed  to  keep 
as  long  as  that  pasteurized  on  the  Saturday  previous. 
This  was  due  of  course  to  the  large  number  of  spores 
present  in  the  older  cream.  The  cost  of  pasteurizing 
milk  on  a  large  scale  is  less  than  that  of  sterilizing 
the  milk :  and,  as  the  result  of  a  careful  study  of  the 
subject  at  the  Wisconsin  Agricultural  Station,  Russell 
says  that  the  actual  cost  of  pasteurizing  cream  is 
merely  nominal,  although  it  varies  somewhat  under 
different  conditions.  Where  a  business  of  anv  mag- 
nitude is  carried  on,  the  cost  of  operating  the  plant 
could  not,  under  ordinary  conditions,  be  more  at  most 
than  a  very  few  cents  a  gallon. 

To  the  energ)-  and  interest  of  Dr.  H.  L.  Coit,  of 
Newark,  is  due  the  supply  to  that  cit}'  of  what  is  called 
"certified  milk;"    a  committee   of  physicians  stated 


382 


MEDICAL    RECORD. 


[September  1 1 ,   1897 


formally  certain  conditions,  on  the  acceptance  and 
the  proper  carrj'ing  out  of  which  by  a  milk  dealer  under 
inspection  they  were  willing  to  allow  him  to  mark  the 
milk  "  certified,"  and  to  furnish  a  certificate,  signed  by 
this  committee,  as  to  the  character  of  the  milk. 
Would  it  not  be  possible  here  in  New  York  to  estab- 
lish a  similar  process  of  certification  for  cream;  that 
is,  might  not  a  committee  of  physicians  lay  down  cer- 
tain conditions  of  production,  of  analysis,  and  of  care, 
under  which  they  would  permit  the  use  of  the  name 
"certified  cream"?  Collier  in  a  comparative  study  of 
the  profits  derived  from  selling  milk,  butter,  cheese, 
and  cream  finds  that  selling  cream  is  by  far  the  most 
profitable ;  and  points  out  that  the  reason  is  that  the 
consumption  of  cream  is  comparatively  small,  con- 
sumers regarding  it  as  a  great  luxur)-,  and  that  they 
are  not  aware  of  the  fact  that  it  would  often  be  more 
economical  to  purchase  milk  and  raise  their  own 
cream.  It  may  be  mentioned  that  the  milk  e.xperts 
have  for  some  time  advocated  the  sale  of  both  milk 
and  cream  on  the  basis  of  the  fat  content :  then  a  three- 
per-cent.  milk,  for  e.xample,  would  have  a  certain  price, 
a  three  and  one-half  per  cent,  a  higher  price,  a  four- 
per-cent.  still  higher:  while  there  might  well  be  grades 
of  milk  fortified  by  addition  of  cream  which  should 
be  six  per  cent.,  seven  per  cent.,  and  so  on.  Then 
every  person  selling  milk  at  retail  should  be  compelled 
by  law  to  place  in  conspicuous  figures  on  each  can  or 
vessel,  in  or  from  which  milk  is  sold,  the  percentage 
of  fat  in  the  milk:  he  should  be  required  to  guarantee 
this,  and  be  prosecuted  if  an  e.xamination  showed  the 
milk  to  be  below  the  guarantee.  Purchase  of  milk 
and  cream  on  this  basis  of  fat  content  is  actually 
carried  out  at  ths  present  time  in  many  cheese  fac- 
tories and  creameries. 

The  main  propositions  of  this  paper  are,  in  brief : 

1.  Cream  in  this  city  is  at  present  milk  containing 
an  amount  of  fat  greater  than  five  or  six  per  cent. 

2.  Cream  containing  any  desired  percentage  of  fat 
could  be  regularly  furnished  without  material  increase 
in  cost. 

3.  Cream  is  now  usually  old  when  it  reaches  the 
consumer. 

4.  Cream  as  fresh  as  milk  could  be  furnished  to  the 
consumer. 

5.  Cream  is  now  usually  so  laden  with  spore-bear- 
ing ■germs  at  delivery  that  pasteurization  is  to  a  great 
extent  ineffectual. 

6.  Cream  could  be  pasteurized  while  fresh  at  the 
dairy  at  little  cost. 

7.  An  eas>  means  of  securing  a  supply  of  cream  of 
known  composition,  age,  and  bacterial  condition  would 
be  certification  by  a  responsible  body. 

REFERE^"CES. 

The  Milk  Reporter,  Januan-,  iSq7,  Deckertomi.  X.  J. 

Habcock  and  Russell:  Univ.  of  Wis.  Agric.  Exp.  Station 
Bull..  No.  54- 

Russell:   Univ.  of  Wis.  Agric.  Exi.  Station  Bull.,  Xo.  44. 

Russell,  Farrington:  Thirteenth  Annual  Report,  Univ.  of 
Wis.  Agric.  Exp.  Station. 

Farrington:   Univ.  of  111.  Agric.  E.\p.  Station  Bull.,  Xo.  32. 

Lintield:   Utah  Agric.  Coll.  Exp.  Station  Bull..  Xo.  42. 

Van  Slyke:  X^ew  York  Agric.  Exp.  Station  Bull.,  No.  70. 

Collier:  New  York  Agric.  Exp.  Station  Bull.,  No.  8g. 

Wing:  Cornell  Univ.  Agric.  Exp.  Station  Bull.,  Xo.  85. 

Wing:   Cornell  Univ.  Agric.  E.\p.  Station  Bull..  Xo.  105. 

Cavanaugh:  Cornell  Univ.  Agric.  E.xp.  Station  Bull.,  No.  iiS. 

Hayward  .ind  McDonnell:  Penn.  State  Coll.  Agric.  Exp. 
Station  Bull.,  No.  33. 

Allen:   U.  S.  Dept.  of  .\gric.  Farmers'  Bull..  No.  29. 

Pearson:   U.  S.  Dept.  of  Agric.  F'armers'  Bull..  No.  42, 

.Mvord:  U.  S.  Dept.  of  -Vgric,  Bureau  of  Animal  Industrv 
Bull.,  No.  II. 

DeSchweinitz:   U.  S.  Dept.  of  Agric.  Yearbook  for  1804. 

.Moore:   U.  S.  Dept.  of  Agric.  Yearbook  for  1S95. 

Conn:  Centralbl.  fiir  Bakt.  u.  Parasit.,  May  15.  1S95. 

Conn:  Centralbl.  fiir  Bakt.  u.  Parasit.,  July  if,  iSqO. 

Snyder:  Chemistn,-  of  Dairj'ing.  Chemical  Pub.  Co. 

Freeman:  X.  ^'.  .\Ikd.  Rec,  June,  1S93. 


THE  c:repitant  rale  a.v  intrapleural 

SOL'ND. 


By   F.  a.  BURRALL.  M.D., 


ATTESDTN'C    PltV^ICIAN 


PRE<iB\-rERI.* 


Ix  the  Medical  Record,  of  June  5th,  ult.,  is  a 
clear  and  instructive  article  by  Dr.  Louis  H.  Jones,  of 
Atlanta,  on  the  seat  of  the  crepitant  or  vesicular  rale, 
which  is  worthy  of  careful  reading. 

I  think  this  is  especially  true,  because,  notwithstand- 
ing all  that  has  been  said  and  written  concerning  this 
rale,  the  method  of  its  production  still  remains  some- 
what unsettled.  Not  very  long  since,  at  a  meeting  of 
the  Academy  of  Medicine,  one  of  the  speakers  referred 
to  the  crepitant  rale  as  diagnostic  of  pneumonia,  which 
showed  that  this  view  is  still  existent.  The  older 
teachings  were  that  the  crepitant  rale  was  pathogno- 
monic o£  pneumonia,  but  it  seems  to  me  that  an  im- 
partial examiner  of  Dr.  Leaming's  writings  on  this 
subject  must  arrive  at  an  entirely  opposite  conclu- 
sion. My  friend.  Dr.  J.  H.  .\nderson,  first  called  my 
attention,  several  years  ago,  to  Dr.  Leaming's  views. 
They  were  the  result  of  careful  and  continuous  study, 
and  have  been  of  the  greatest  ser\'ice  to  me  in  my 
practice.  About  the  time  when  I  first  heard  of  them 
I  had  been  treating  a  class  of  cases  in  which  the 
febrile  reaction  and  constitutional  disturbance  were 
not  very  marked,  in  which  the  crepitant  rale  was  pres- 
ent, yet  they  were  not  pneumonia  and  would  run  their 
course  in  about  ten  days. 

I  thought  them,  yet  in  an  unsatisfied  way,  to  be 
subacute  a;demas  of  the  lungs,  but  when  in  the  light 
of  Leaming's  teachings  I  discovered  plastic  exudation 
with  intrapleuritic  rales  the  diagnosis  cleared  up. 
Since  that  time  I  have  seen  fewer  cases  of  pneumonia, 
and  can  conceive  one  reason  why  this  should  be  so, 
with  a  more  satisfactory  knowledge  of  the  mechanism 
of  the  crepitant  rale.  I  cannot  but  think  also  that 
one  reason  why  I  found  so  few  of  my  cases  of  in- 
fluenza complicated  with  pneumonia  must  be  that  the 
teachings  of  Leaming  led  me  to  place  the  vesicular 
rale  of  "acute  epidemic  bronchial  catarrh,"  or  in- 
fluenza, within  the  pleural  cavity  instead  of  in  the 
lung.  My  own  experience,  which,  like  that  of  most 
general  practitioners,  has  embraced  many  cases  of  the 
grippe  during  recent  vears,  leads  me  to  believe  that 
if  the  elements  of  rest,  with  early  and  steady  support, 
as  well  as  careful  avoidance  of  hepatic  obstruction  (a 
term  used  for  want  of  a  better),  be  avoided,  the  grippe 
is  not  very  likely  to  run  into  pneumonia. 

Dr.  Leaming  was  ver)-  confident  of  the  correctness 
of  his  views  and  I  have  often  talked  with  him  upon 
the  subject. 

With  regard  to  the  diagnosis  of  this  rale  and  its 
situation.  Dr.  Jones  writes  that  this  sound  "lacks  the 
element  of  distance.  While  not  a  loud  sound,  yet  the 
ear  placed  in  contact  with  the  naked  chest  wall  will 
recognize  that  it  hears  a  sound  which  is  immediately 
beneath  the  surface  and  not  produced  deep  down  in 
the  lung  tissue." 

I  would  suggest  that  additional  aids  in  the  study  of 
the  vesicular  rale  are  found  in  the  phenomena  of 
superficial  dulne.ss  with  light  percussion  over  an  area 
in  which  the  rale  is  audible  and  deep  resonance  with 
harder  percussion  over  the  same  area.  A  reasonable 
explanation  is  that  the  superficial  dulness  proceeds 
from  percussion  over  the  layer  of  pl.istic  exudation, 
while  harder  percussion  over  a  lung  not  engorged  de- 
velops a  resonant  sound. 

It  is  ver)' desirable  that,  with  our  present  knowledge 
on  this  subject  and  our  improved  methods  of  investi- 
gation, the  mechanism  of  the  crepitant  or  vesicular 
rSle  should  be  fuUv  and  clearlv  imder>tood. 


September  ii,  1897] 


MEDICAL    RECORD. 


583 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 

WM.   WOOD  &.  CO  ,   43,  45,  &  47  East  Tenth  Street. 


New  York,  September  11,  1897. 


THE    REGULATION    OF    MARRIAGE. 

Dr.  E.  T.  Rulison  read  a  paper  on  this  subject  before 
the  Academy  of  Medicine  of  Buffalo,  last  winter," 
in  which  he  gave  a  brief  history  of  marriage  and 
called  attention  to  the  Jewish  canonical  laws  on 
the  subject  of  the  marriage  contract.  He  showed 
that  to  the  care  exercised  in  marriage  is  due  the  con- 
stant and  wonderful  progress  that  this  race  has  made 
and  its  prominence  commercially,  politically,  and  in- 
tellectually. The  Greeks  selected  their  wives  with  a 
view  to  the  health  and  vigor  of  their  children.  Par- 
entage is  too  serious  a  question  to  be  left  to  chance, 
as  is  now,  at  least  in  this  country,  usually  the  case. 
Any  one  who  is  in  doubt  as  to  the  influence  of  hered- 
ity should  read  Ribot's  work  on  this  subject.  Darwin 
says:  "Man  scans  with  scrupulous  care  the  character 
and  pedigree  of  his  horses,  cattle,  and  dogs  before 
mating  them,  but  when  it  comes  to  his  own  marriage 
he  rarely  or  never  takes  any  such  care."  Both  sexes 
ought  to  refrain  from  marriage  if  they  are  in  any 
marked  degree  inferior  in  mind  or  body;  but  such 
hopes  are  Utopian  and  will  never  be  realized  until  the 
laws  of  heredity  are  understood. 

The  low,  diseased,  and  vicious  marry  early  and  be- 
get a  numerous  progeny,  while  the  thrifty  usually  marry 
later  and  have  fewer  children.  With  savages  the  weak 
in  mind  and  body  are  soon  eliminated,  but  we  do  all 
in  our  power  to  prevent  this  elimination  by  building 
asylums  and  hospitals,  and  using  every  effort  to  pro- 
long their  lives.  Dr.  Rulison  gives  alarming  statistics 
as  to  the  increase  of  the  criminal,  insane,  and  defec- 
tive classes,  and  shows  the  great  expense  of  their 
maintenance.  Simply  to  name  inebriety,  tuberculo- 
sis, syphilis,  idiocy,  and  epilepsy  is  to  remind  us  of 
the  fact  that  the  burden  we  are  carrj'ing  is  almost  over- 
whelming. "  You  who  were  fortunately  born  must  be 
the  keeper  of  your  dangerous  though  perhaps  unfortu- 
nate brother  man,  or  he  will  overpower  and  ruin  you." 
It  should  be  the  first  duty  of  the  State  or  nation  to  pro- 
tect the  lives  of  future  generations,  as  well  as  the  lives 
and  property  of  those  now  living.  The  law  protects 
us  against  scarlet  fever,  diphtheria,  and  small-pox; 
why  not,  he  asks,  against  ill-advised  marriages,  the  rt- 
sults  of  which  are  almost  as  serious?  Education  has 
done  nothing  for  us  in  this  direction  so  far.  Weallli 
and  social  position  are  important  factors  in  making 
up  the  sum  of  human  happiness,  but  how  insignificant 


when  compared  with  health !  "  If  we  are  to  be  left  per- 
fectly free  to  follow  our  own  impulses,  or  ambitious 
promptings  to  attain  wealth  or  social  position  through 
matrimony,  regardless  of  physical  consequences,  then 
I  can  see  no  relief  for  the  great  majority  of  our  people, 
but  perpetual  ill-health  and  misery."  Our  schools, 
pulpits,  and  periodicals  might  enlighten  our  boys  and 
girls,  might  teach  them  that  parentage  is  the  prime 
object  of  marriage,  and  prepare  them  to  assume  the 
responsibility. 

In  Brazil,  it  is  said,  there  is  a  self-imposed  law 
among  the  higher  classes  in  relation  to  marriage.  The 
man  about  to  marry  is  compelled  to  furnish  a  certifi- 
cate from  one  or  more  physicians  to  the  effect  that  he 
is  free  from  diseases  of  a  certain  character  and  from 
signs  of  diseases  that  could  be  transmitted  to  offspring. 
The  physician  consulted  must  testify  that,  as  far  as 
he  can  learn,  the  union  is  in  accord  with  the  laws  of 
sanitation.  At  a  recent  woman's  congress  held  in 
Paris  resolutions  were  adopted  to  the  effect  that  all 
families  must  secure  certificates  of  health  from  in- 
tending sons-in-law  in  order  to  guard  the  daughters  of 
the  Republic  from  risk  and  to  prevent  hereditarj'  mal- 
adies in  the  fathers  of  a  later  generation. 

"As  society  is  at  present  constituted  and  controlled, 
the  unhealthy  and  vicious  class  is  increasing  more 
rapidly  than  the  desirable  one.  In  the  days  of  Mal- 
thus  the  danger  lay  in  the  population  increasing  more 
rapidly  than  the  means  of  subsistence.  This  danger 
no  longer  threatens,  but  a  more  serious  one  in  the  sur- 
vival and  overwhelming  increase  of  imperfect  physical 
and  mental  beings." 

Dr.  Rulison  suggests  that  a  medical  staff  be  ap- 
pointed to  examine  all  boys  and  girls  from  twelve  to 
fifteen  years  of  age,  relative  to  their  physical  condi- 
tion and  family  history  and  that  records  be  kept.  He 
suggests  three  classes:  {a)  Those  being  physically 
and  mentally  sound,  of  good  habits,  and  having  no 
history  of  hereditary  disease  for  at  least  three  preced- 
ing generations.  {/>)  Those  having  the  same  qualifi- 
cations but  with  a  family  history  extending  to  the 
grandparents  only,  {r)  All  those  not  included  in  clas- 
ses a  and  (/').  No  one  should  be  allowed  to  marry 
outside  of  the  class  to  which  he  or  she  belongs.  This 
would  tend  to  make  classes  {a)  and  {b)  continually 
stronger  and  better.  Class  {e)  would  at  first  predomi- 
nate, but,  if  those  included  in  it  were  not  permitted  to 
marry  outside  of  their  class,  nature  in  a  few  genera- 
tions would  solve  the  problem  by  eliminating  them. 

Perhaps  the  time  will  come,  in  the  course  of  the 
evolution  of  the  human  race,  when  methods  such  as 
those  suggested  by  the  author  can  be  put  in  practice. 
But  by  the  time  mankind  is  ready  to  adopt  this  mar- 
riage regulation,  disease  will  doubtless  have  been  ban- 
ished by  other  means,  so  that  the  course  of  true  lo\e 
will  continue  after  the  present  fashion,  uninterrupted 
bv  committees  of  unromantic  and  meddlesome  doctors. 


The  Sale  of  Cocaine,  except  upon  the  written  pre- 
scription of  a  legally  qualified  physician  or  dentist, 
has  been  forbidden  by  an  act  of  the  Colorado  legisla- 
ture. 


384 


MEDICAL    RECORD. 


[September  11,  T897 


UNUSUAL    MODES    OF    POISONING   WITH 
LEAD. 

In  view  of  the  manifold  and  obscure  channels 
through  which  lead  may  enter  the  system,  as  well  as 
the  difficulty  oftentimes  of  referring  the  symptoms  of 
intoxication  to  their  proper  cause,  especially  when  a 
knowledge  of  contact  with  the  metal  is  to  be  acquired 
only  by  direct  and  searching  inquiry,  the  report  by 
Pel,  of  Amsterdam  {Ce/itra/b/att  fiir  innere  Median, 
June  12,  :897),  of  three  uncommon  modes  of  poison- 
ing with  lead  is  not  without  interest  and  importance, 
'['he  first  case  occcurred  in  a  shoemaker,  nineteen  years 
old,  who  suffered  from  pain  in  the  testicles,  which  was 
increased  by  walking.  The  pain  was  constant,  though 
marked  by  exacerbations.  In  the  course  of  three 
months  pain  appeared  also  in  the  right  shoulder,  with 
corresponding  amelioration  of  that  in  the  testicles. 
For  several  days  there  had  also  been  pain  in  the  hypo- 
gastrium.  The  bowels  were  constipated ;  the  appetite 
was  impaired.  The  patient  was  emaciated  and  sallow. 
Examination  of  the  gums  disclosed  the  presence  of  a 
blue  line.  There  was  at  times  difficulty  of  micturi- 
tion; the  urine  contained  urobilin  and  haematopor- 
phyrin.  Under  treatment  with  opium,  purgatives,  and 
potassium  iodide,  improvement  soon  followed.  On 
inquiry  it  was  learned  that  the  patient  had  been  em- 
ployed in  the  manufacture  of  shoes  for  the  govern- 
ment, using  tinned  nails,  in  the  preparation  of  which 
lead  entered.  For  convenience'  sake,  the  man  held 
the  nails  in  his  mouth,  from  which  he  removed  them 
one  by  one  as  required.  It  was  not  known  that  other 
men  employed  in  the  same  factory  exhibited  symp- 
toms of  lead-poisoning.  The  neuralgic  pains  were 
considered  to  be  of  toxic  nature. 

The  second  case  occurred  in  a  cigarmaker,  forty- 
four  years  old,  who  for  fifteen  months  had  suffered 
from  rheumatic  pains  in  the  arms,  legs,  back  and 
hypogastrium,  and  from  headache.  The  man  was 
nervous  and  sleepless  and  constantly  languid  and  tired. 
The  bowels  were  torpid,  the  appetite  was  poor,  the 
complexion  sallow,  and  the  nutrition  impaired.  There 
was  a  blue  line  at  the  margin  of  the  gums  and  the 
urine  contained  urobilin  and  hamatoporphyrin.  In 
this  case  it  was  learned  that  the  patient  in  the  process 
of  making  the  cigars  rolled  them  upon  a  board  covered 
with  a  tin  plate,  in  the  composition  of  which  lead 
entered.  Upon  this  plate  also  the  cigars  were  cut 
with  a  knife  which  the  man  was  in  the  habit  of  hold- 
ing in  his  mouth. 

The  third  case  occurred  in  a  man,  twenty-nine  years 
old,  who  had  been  employed  for  fifteen  years  in  em- 
bedding diamonds  in  a  warmed  lead  mass,  manipulat- 
ing this  with  the  fingers  moistened  with  saliva.  On 
account  of  impaired  eyesight  the  man  was  compelled 
to  give  up  this  work  and  seek  employment  elsewhere, 
becoming  a  clerk  in  a  bakery.  In  the  course  of  five 
months  symptoms  of  acute  lead  poisoning  made  their 
appearance — nausea,  vomiting,  colic,  constipation, 
increased  arterial  tension,  typical  urinary  phenomena, 
and  a  blue  line  on  the  gums.  Cases  of  similar  kind 
have  been  previously  observed  in  Holland,  though 
rarely. 


These  cases  serve  to  illustrate  some  of  the  less 
common  modes  of  poisoning  with  lead,  and  their 
recital  should  stimulate  the  clinician  always  to  the 
most  searching  inquiry  in  the  determination  of  the 
origin  and  nature  of  apparently  simple  and  uncom- 
plicated cases,  as  well  as  those  of  greater  complexity 
and  obscurity. 


THE    POPE    ON    WHAT    TO  EAT. 

The  Pope  in  his  extreme  old  age  has  been  giving  some 
sound  advice  in  the  matter  of  food.  Although  the 
dietary  set  before  us  1  y  the  Pope  is  not  an  especially 
luxurious  one,  still  there  are  many  persons  who  would 
be  only  too  glad  to  be  able  to  follow  his  advice.  In 
fact  it  will  strike  most  persons  who  read  it  that  the 
Pope  is  not  a  bad  judge  of  what  is  good  for  him,  and 
is  himself  a  proof  of  the  efficiency  of  his  maxims.  He 
writes:  "  Pay  attention  before  all  to  cleanliness,  that 
the  table  appointments  are  spotless,  glass  bright,  na- 
pery  immaculate,  that  from  the  cellar  comes  the  purest 
wine  of  the  Albanian  Hills,  which  exhilarates  the 
spirit  and  drives  away  trouble:  but  do  not  trust  Bac- 
chus, so  do  not  be  sparing  in  diluting  wine  with  water; 
obtain  from  healthy  grain  well  cooked  bread,  eat  spar- 
ingly of  chicken,  lamb,  and  beef  which  are  most  nour- 
ishing to  the  body ;  meat  should  be  tender  without 
abundant  sauces  or  root  vegetables,  which  spoil  it:  fresh 
fruits  are  excellent  whether  raw  or  slightly  cooked : 
an  abundant  quantity  of  foaming  milk,  it  nourishes 
infants  and  assists  old  age;  also  honey,  celestial  gift, 
but  this  Ibleo  nectar  [from  Mount  Ibla  in  Sicil}-]  use 
frugally ;  add  to  this  the  sweet  herbs  and  fresh  vege- 
tables that  the  garden  supplies;  add  ripe  fruit  accord- 
ing to  the  season,  and  especially  tender  apples,  which 
with  their  pink  tints  brighten  the  banquet;  lastly 
comes  the  drink,  which  in  hard  seeds  fertile  Moka 
sends  you,  softly  sipping  the  black  liquor  that  com- 
forts the  heart."  From  the  foregoing  it  would  appear 
that  Leo  is  a  disciple  of  Horace.  Certainly  the  menu 
has  quite  an  Horatian  flavor. 


A  Proposed  College  for  Medical   Missionaries. — 

The  guild  of  St.  Luke,  in  London,  has  under  consid- 
eration a  proposal  to  establish  a  college  of  St.  Luke 
for  men  training  as  medical  missionaries  in  connection 
with  the  Church  of  England.  The  British  Alt-dical 
y(;///7/(7/ says  that  it  is  proposed  that  the  institution 
should  be  purely  residential.  Its  principal  would  be 
a  medical  man,  and  it  would  have  a  chaplain,  while 
the  students  would  receive  their  medical  education  at 
the  London  medical  schools.  Those  who  intended  to 
become  medical  missionaries  after  qualification  would 
be  supported  by  the  guild  or  other  society,  entirely  or 
in  part,  but  other  students  would  also  be  received. 
-At  a  recent  meeting  a  discussion  took  place  on  the 
subject,  and  tiie  hope  was  expressed  that  such  a  resi- 
dential college  would  be  the  means  of  providing  suit- 
able men  for  many  medical  posts  in  connection  with 
mission  stations  which  it  had  hitherto  been  difficult 
to  fill. 


September  ii,  1897] 


MEDICAL    RECORD. 


385 


^cws  of  tttc  ISJecfe. 

The  Surgeon-General   of   the  Navy The   term   of 

service  of  Surgeon-General  Tryon  has  expired,  and  it 
is  expected  that  the  announcement  of  the  appointment 
of  his  successor  by  the  President  will  soon  be  made. 
Dr.  Tryon  has  been  thirty-five  years  in  the  medical 
department  of  the  navy,  and  has  an  enviable  record  for 
efficient  service  at  sea  and  on  shore.  It  is  to  be  hoped 
that  the  President  will  see  his  way  to  reappointing  Dr. 
Tryon  to  the  post  which  he  has  filled  with  such  credit 
to  himself  and  benefit  to  the  service. 

Yellow  Fever  on  the  Gulf  Coast.— A  fever  which 
has  been  prevailing  for  some  weeks  at  Ocean  .Springs, 
Miss.,  on  the  Bay  of  Biloxi,  and  which  was  thought  to 
be  dengue,  has  been  pronounced  yellow  fever.  About 
two  weeks  ago  the  health  authorities  made  an  investi- 
gation. There  had  been  several  hundred  cases  then, 
but  very  few  deaths,  and  a  board  of  experts  declared 
the  disease  dengue  fever.  The  death  rate  increased, 
however,  and  the  symptoms  looked  more  like  tliose  of 
yellow  fever;  the  alarm  now  became  so  great  that  the 
health  authorities  again  convened,  and,  after  a  search- 
ing investigation,  pronounced  the  disease  yellow  fever. 
It  seems  probable  that  there  was  first  an  epidemic  of 
dengue  and  that  the  yellow  fever  was  brought  in  later, 
but  passed  unobserved  for  a  time  in  the  midst  of  the 
cases  of  the  prevailing  fever.  The  Marine  Hospital 
service  has  sent  several  surgeons  to  the  place  to  ex- 
amine the  cases  and  to  take  the  necessar}'  precautions 
if  the  diagnosis  of  the  State  health  authorities  should 
be  confirmed. 

The  Tri-State  Medical  Society  of  Alabama, 
Georgia,  and  Tennessee. — The  ninth  annual  meeting 
of  this  society  will  be  held  in  the  senate  chamber  of 
the  State  Capitol,  Nashville,  Tenn.,  Tuesday,  Wed- 
nesday, and  Thursday,  October  12,  13,  and  14,  1897. 
The  secretary  of  the  society  is  Dr.  Frank  Tre.ster 
Smith,  of  Chattanooga,  Tenn. ;  the  president.  Dr.  W. 
F.  Westmoreland,  of  Atlanta,  Ga. ;  and  the  chairman 
of  the  committee  of  arrangements.  Dr.  W.  1).  Hag- 
gard, Jr.,  of  Nasiiville,  Tenn. 

A  Collective  Investigation  of  Infantile  Scorbutus. 
— The  .American  Pediatric  Society  is  making  a  collec- 
tive investigation  of  infantile  scurvy  as  occurring  in 
North  -America,  and  earnestly  requests  the  co-operation 
of  physicians,  through  their  sending  of  reports  of 
cases,  whether  these  have  already  been  published  or 
not.  No  case  will  be  used  in  such  a  way  as  to  inter- 
fere with  its  subsequent  publication  by  the  observer. 
Blanks  containing  questions  to  be  filled  out  will  be 
furnished  on  application  to  any  one  of  the  committee. 
A  final  printed  report  of  the  investigation  will  be  sent 
to  those  furnishing  cases.  The  committee  is  com- 
posed of  Drs.  J.  P.  Crozer  Griffith,  chairman,  123  South 
Eighteenth  Street,  Philadelphia;  William  D.  Booker, 
853  Park  Avenue,  Baltimore;  Charles  G.  Jennings, 
457  Jeflferson  Avenue,  Detroit;  Augustus  Caillc,  753 
Madison  Avenue,  New  York;  and  J.  Lovett  Morse, 
317  Marlboro  .Street,  Boston. 


The  Fate  of  the  Idiot.— The  Journal  of  the  Ameri- 
can Medical  Association  has  in  a  recent  issue  a  long  and 
unconvincing  argument  in  support  of  its  proposition 
to  kill  all  idiots.  This  is,  of  course,  a  verj^  easy  so- 
lution of  the  problem  of  what  to  do  with  these  poor 
creatures,  and  the  same  remedy  would  be  extremely 
efficacious  in  the  case  of  the  incurably  insane,  the 
crippled,  sufferers  from  cancer,  the  blind,  the  aged, 
and  all  who  are  more  or  less  of  a  trouble  for  society 
to  take  care  of.  We  trust,  however,  this  is  not  to  be 
regarded  as  an  opinion  stamped  with  the  approval  of 
the  trustees  or  any  other  officers  of  the  .American  Med- 
ical Association. 

The  British  Medical  Association At  the  closing 

session,  on  Friday  of  last  week.  Dr.  Saundby,  presi- 
dent of  the  British  Medical  Council,  introduced  a 
motion  recommending  the  election  of  the  Governor- 
General  of  Canada,  and  Lord  Strathcona  and  Mount 
Royal,  to  honorary  membership  in  the  association. 
Dr.  Roddick,  the  retiring  president,  introduced  a 
resolution  indorsing  the  scheme  for  the  organization 
of  a  system  of  district  nursing  in  the  isolated  por- 
tions of  Canada.  He  remarked  that  many  people 
refused  to  emigrate  to  Canada  on  account  of  the 
great  distance  they  would  be,  particularly  in  the 
Northwest,  from  nursing  and  medical  assistance.  It 
was  contemplated  to  establish  an  order  of  nurses 
which  would  work  throughout  the  dominion,  and  the 
name  Victorian  Order  of  Nurses  had  been  .suggested 
by  the  Countess  of  Aberdeen,  with  whom  the  scheme 
originated.  On  Saturday  the  members  of  the  associ- 
ation went  on  an  excursion  to  Ottawa,  where  they 
were  entertained  by  the  local  medical  profession,  and 
after  a  luncheon  were  shown  through  the  Parliament 
buildings  and  taken  about  the  city  on  electric  cars. 

Tuberculosis   at    an    Agricultural    College.— The 

board  of  regents  of  the  Kansas  State  Agricultural  Col- 
lege at  Manhattan  has  discovered  that  many  of  the 
cattle,  sheep,  and  hogs  kept  on  the  college  farm  are 
infected  with  tuberculosis.  Several  of  the  attendants 
who  have  been  employed  at  the  stables  are  seriously 
ill,  and  one  who  has  had  more  direct  charge  of  the 
cattle  is  not  expected  to  live,  having  been  suffering 
with  the  disease  for  several  months.  Others  connected 
with  the  college,  but  who  have  not  been  brought  into 
direct  contact  with  the  diseased  cattle,  are  also  tuber- 
culous, and  it  is  thought  that  they  may  have  become 
infected  through  drinking  the  milk  of  diseased  cows. 

Dr.  Lays,  of  Paris,  died  recently  at  the  age  of  sixty- 
seven  years.  He  was  an  extreme  believer  in  the  won- 
ders of  hypnotism,  believing  that  he  could  narcotize 
I^eople  by  holding  near  the  brain  a  closed  vial  contain- 
ing morphine.  Some  years  ago  these  cases  were  in- 
vestigated by  Mr.  Ernest  Hart,  and  it  was  shown  that 
the  subjects  wilfully  deceived  the  too  credulous  experi- 
menter. 

A  Woman's  Medical  Society  in    Europe There 

are  between  thirty-five  .uul  forty  medical  women  in 
Switzerland,  and  a  number  of  them  recently  got  to- 
gether and  founded  a  club  of  female  physicians,  nhich 
is  said  to  be  the  first  of  its  kind  in  Europe. 


386 


MEDICAL    RFXORD. 


[September  ii,  1897 


DiarrhcEa  in  London. — The  prevalence  of  and  mor- 
tality from  diarrhtea  in  London  among  children  under 
f:ve  years  of  age  are  exciting  much  comment.  The 
death  rate  from  this  cause  is  higher  than  it  has  been 
for  very  many  years.  By  many  people  it  is  thought  to 
be  due  in  the  poorer  portions  of  the  great  city  to  de- 
fective drainage,  as  in  children  so  young  the  cause  can 
hardly  be  the  one  usually  given — the  consumption  of 
unripe  fruit.  It  really  seems  that  something  must  be 
wrong  in  the  sanitary  conditions  of  London,  for,  in 
addition  to  diarrhcca,  diphtheria  is  more  rampant  than 
for  some  time. 

The  Johns  Hopkins  University  has  recently  been 
beaten  in  a  suit  against  the  receivers  of  the  Baltimore 
and  Ohio  Railroad,  by  which  it  endeavored  to  estab- 
lish its  claim  to  be  a  preferred  creditor.  The  court 
has  decided  that  such  a  claim  is  untenable,  and  the 
university  will  suffer  in  consequence  a  considerable 
reduction  in  its  income. 

Honors  for  Professor  v.  KoUiker. — The  Imperial 
Leopold-Carolina  Academy  of  German  Scientists  of 
Halle  has  awarded  the  gold  Comenius  medal  to  Pro- 
fessor von  Kolliker,  of  Wiirzburg,  who  recently  cele- 
brated the  completion  of  his  eightieth  year  and  the 
jubilee  of  his  appointment  as  professor. 

The  American   Academy  of   Railway  Surgeons. 

. — The  ne.xt  annual   meeting  of  this  society  will   be 
held  in  Chicago,  Octo!)er  6,  7,  and  8,  1897. 

American  Electro-Therapeutic  Association. — The 
next  annual  meeting  of  this  association  will  be  held 
at  Harrisburg,  Pa.,  September  21,  22,  and  23,  1897. 
The  preliminary  programme  contains  a  list  of  nine- 
teen papers  on  a  wide  variety  of  subjects. 

Typhoid  Fever  is  prevailing  to  an  alarming  extent 
in  several  places  in  Germany.  In  many  of  the  small 
epidemics  the  milk  supply  has  been  incriminated,  and 
the  Berlin  health  authorities  have  issued  a  special  warn- 
ing to  the  public  against  the  use  of  unboiled  milk. 

Cruelty  to  Convicts. — An  investigation  into  the 
condition  of  the  convicts  in  Georgia  has  revealed  the 
.existence  of  many  shocking  abuses,  both  of  cruelty 
and  flagrant  disregard  of  sanitary  provisions,  occur- 
iring  in  private  camps,  where  misdemeanor  convicts 
were  leased  to  individuals  in  violation  of  law.  Of 
seventeen  hundred  and  ninety-two  misdemeanor  con- 
victs, about  four  hundred  are  thus  hired.  The  rate  of 
mortality  in  private  camps  is  about  double  that  in  the 
public  camps.  In  the  private  camps  the  law  requiring 
a  daily  record  of  the  conduct  of  each  convict  as  a  basis 
for  the  good-conduct  allowance  of  four  days  a  month 
is  ignored.  In  one  camp  thirty  negroes  and  one  white 
convict  slept  chained  together  in  a  close  unventilated 
room,  only  fifteen  by  seventeen  feet,  with  the  window 
nailed  up.  In  another  camp,  at  his  first  visit  the  in- 
spector found  forty-six  negroes  and  fifteen  whites 
sleeping  in  a  room  nineteen  feet  square  and  less  than 
eight  feet  high.  It  is  said  that  the  governor  of  the 
State  contemplates  pardoning  all  of  the  convicts  in 
private  camps,  as  the  only  way  in  which  he  can  rescue 
iheni  before  the  expiration  of  their  terms. 


Failure  of  Koch's  Rinderpest  Remedy.  —  The 
government  of  the  Cape  of  Good  Hope  is  now  regret- 
ting the  money  spent  in  securing  Koch  to  elaborate 
a  protective  serum  for  use  against  the  rinderpest.  The 
undertaking  has  ended  in  absolute  failure,  for  the  in- 
oculation treatment  has  had  no  eflfect  in  preventing  the 
cattle  from  dying  of  the  disease.  It  is  said  that  Koch 
is  about  to  return  to  South  Africa  to  renew  his  experi- 
ments and  try  once  more  to  make  an  effective  serum. 
The  Medical  Press  says  that  the  Cape  government, 
"  has  not  foimd  that  its  introduction  of  a  German  pro- 
fessor into  the  colony  has  had  any  other  effect  than 
that  of  costing  it  a  large  sum  of  money.  Perhaps, 
upon  the  next  occasion  that  some  official  bacteriolog- 
ical investigations  are  required,  it  will  bear  in  mind 
that  science  made  in  Germany  is  no  better  than  science 
made  elsewhere,"  and,  our  contemporar}-  might  have 
added,  it  has  of  late  acquired  a  decidedly  commercial 
character. 

The  Study  of  Apparent  Death. — A  committee  has 
been  formed  in  Naples  for  the  study  of  the  question  of 
apparent  death.  The  president  is  Dr.  Oscar  Giacchi. 
and  the  members  are  Drs.  G.  Albertolli,  F.  Bonelli, 
E.  Chiaisio,  S.  Lanza,  F.  Conti,  L.  Lombar,  and  P. 
Vandoni,  and  Miss  Elizabeth  Berkeley- Barter.  The 
secretaries  of  the  committee  are  Dr.  F.  Bonelli  and 
Signor  C.  Gallo. 

The  Fatal  Bargain  Counter. — A  woman  was  killed 
recently  in  London  in  the  crush  at  a  bargain  sale. 
The  crowd  of  women  was  so  large  and  so  disorderly 
that  it  required  the  services  of  twenty-two  policemen 
to  hold  it  in  check.  The  verdict  of  the  coroner's  jury 
was  that  the  woman  '"died  from  syncope  caused  by  the 
exertion  and  excitement  of  getting  into  a  bargain  sale, 
and  that  such  death  was  due  to  natural  causes."' 

Murders  by  the  Brute  Creation  in  India. — Dur- 
ing the  year  1896,  according  to  the  official  statistics 
just  published,  1,133  persons  in  India  died  from  the 
effects  of  serpent  bites,  and  291  were  killed  by  tigers 
and  other  wild  animals.  The  figures  are  much  below 
those  for  the  preceding  years. 

Obituary  Notes. — Dk.  Georgk  \V.  Voc.ler,  of 
I'hiladelijhia,  tlied  at  Kste's  Park,  Col.,  on  August 
26th,  in  his  forty-second  year.  He  was  graduated 
from  the  medical  department  of  the  University  of 
Pennsylvania  in  1876,  and  was  subsequently  resident 
physician  in  the  German  and  Philadelphia  hospitals. 
Later  he  became  consulting  physician  to  the  German 
Hospital,  and  was  chief  of  the  out-patient  department 
for  diseases  of  women. — Dr.  William  Brodie  died 
suddenly  at  Forest  Grove,  Pa.,  on  September  3d.  of 
nephritis,  at  the  age  of  forty-two  years.  He  was  born 
in  Philadelphia,  and  was  graduated  from  the  medical 
department  of  the  University  of  Pennsylvania.  After 
a  year's  practice  in  Philadelphia  he  removed  to  Pine- 
ville,  and  subsequently  to  Forest  Grove. — Dr.  H.  R. 
O'CoNNER,  of  Pittsburg,  Pa.,  died  at  Charles  River, 
Mass.,  on  .August  3 1  St.  He  had  been  engaged  in  prac- 
tice for  more  than  twenty-five  years,  and  was  one  of 
the  physicians  to  the  Southside  Hospital  and  also  a 
pension  examiner. 


September  ii,  1897] 


MEDICAL    RECORD. 


387 


BRITISH    MEDICAL    ASSOCIATION. 

Sixty -Fifth  Annual  Meeting,  Held  at  Montreal,  Canada, 
August  ji,  September  i,  2,  j,  iSgj. 

I  Special  Report  for  the  Medical  Recokd.  ) 
GENERAL    SESSIONS. 

(Continued  from  page  362.) 

Third  Day — Thursday,  September  2it. 

The  Presidext  called  the  meeting  to  order  at  3  p.m. 

The  Surgeon  of  Old  in  War.  —  The  address  in 
surgerj'  was  delivered  by  Mr.  T.  Mitchell  Banks, 
of  Liverpool  (see  page  340). 

At  the  conclusion  of  the  address  a  heart)'  vote  of 
thanks  was  tendered  Mr.  Banks  for  his  instructive  dis- 
course. 

The  meeting  then  adjourned,  a  large  number  of 
members  visiting  the  General  Hospital,  where  the 
cornerstone  of  the  new  Nurse's  Home  was  laid  by 
Lord  Lister  at  4:30  p.m.  The  annual  banquet  of  the 
British  Medical  Association  was  held  in  the  evening. 


Fourth  Day — Friday,  September  jd. 

The  meeting  was  called  to  order  by  the  president 
at  the  usual  hour. 

Preventive    Medicine  in  the  City  of  New  York. 

— Dr.  Hermann  M.  Biggs,  of  New  York,  then  deliv- 
ered the  address  in  public  medicine.  The  speaker 
acknowledged  his  appreciation  of  the  honor  conferred 
upon  him  by  the  invitation  to  deliver  the  address  on 
public  medicine,  but  he  interpreted  that  invitation  as 
a  tribute  to  the  work  of  the  health  department  of  New 
York  City,  with  which  he  had  been  so  long  connected, 
and  regarded  it  as  a  command  from  the  council  to  se- 
lect for  the  subject  of  his  address  the  discussion  of 
some  of  the  measures  which  have  more  particularly 
distinguished  the  work  of  the  New  N'ork  health  de- 
partment, rather  than  the  consideration  of  any  general 
topic  of  public  medicine.  It  has  been  the  custom  of 
sanitarians  of  all  nations  to  look  to  England  for  guid- 
ance and  direction  in  matters  connected  with  public 
health,  and  the  low  mortality  statistics,  especially 
from  zymotic  diseases,  in  England  testify  in  no  uncer- 
tain language  to  the  value  of  English  sanitar)-  methods 
and  the  efficiency  of  their  execution.  The  advances  in 
sanitation  in  Great  Britain  have  preceded  those  in 
every  other  country. 

In  the  United  States  there  is  no  national  board  of 
health,  each  State  having  its  own  health  board  and 
sanitary-  laws,  and  consequently  there  is  no  uniformity 
in  regulations  and  methods.  Speaking  broadly,  in 
the  rural  districts  and  in  the  smaller  towns  the  sani- 
tary methods  are  crude,  while  in  many  of  the  large 
cities  there  is  an  enlightened  and  progressive  policy 
to  be  found,  equal  to  that  in  any  of  the  great  cities  of 
the  world.  New  York  may  be  taken  as  a  type  of  the 
best  conditions  and  methods  of  sanitary  work  to  be 
found  among  the  greater  cities  of  the  United  States, 
and  the  speaker  said  that  he  would  confine  himself, 
therefore,  to  the  discussion  of  the  sanitary  work  in 
New  York  City. 

The  health  department  of  New  York  City  is  an  en- 
tirely independent  sanitary  organization,  not  being 
subject  even  to  the  jurisdiction  of  the  State  board  of 
health.  The  jurisdiction  of  the  board  extends  over 
the  whole  city,  containing  at  present  about  two  million 
population;  and  in  1898  a  similar  board,  increased  to 
five  members,  will  have  jurisdiction  over  Greater  New- 
York,  with  a  population  of  three  million  two  hundred 
and  fifty  thousand.     Ordinarily  the  duties  of  sanitary 


authorities  relating  to  the  infectious  diseases  are  lim- 
ited to  the  inspection  of  reported  casss  of  only  a  few 
of  the  infectious  diseases,  the  removal  of  patients  to 
hospitals  w'hen  required,  and  the  subsequent  disinfec- 
tion of  the  premises.  In  New  York  City,  however,  all 
matters  connected  with  the  scientific  investigation, 
diagnosis,  care,  or  sanitary  super\-ision  in  every  way 
of  the  infectious  diseases  are  regarded  by  the  board  of 
health  as  properly  coming  within  its  province. 

The  Bacteriological  Laboratory. — The  first  impor- 
tant departure  in  New  York  City  from  the  older  meth- 
ods was  made  in  1892.  by  the  establishment  of  a 
bacteriological  laboratory,  this  being  the  first  bacterio- 
logical laboratory  ever  established  under  municipal 
control.  Ordinarily  designed  to  afford  facilities  for 
the  bacteriological  diagnosis  of  Asiatic  cholera  and 
for  the  investigation  of  questions  relating  to  disinfec- 
tion, the  scope  of  its  work  was  soon  extended  to  in- 
clude the  bacteriological  diagnosis  of  diphtheria.  The 
investigations  of  the  New  York  City  health  depart- 
ment relating  to  diphtheria  laid  the  foundation  of  mu- 
nicipal bacteriological  laboratories  and  made  them 
necessary  to  the  proper  conduct  of  sanitary  work.  In 
October,  1894,  investigations  in  connection  with  the 
production  of  diphtheria  antitoxin  were  begun,  and  in 
December  of  that  year  a  special  annual  appropriation 
(antitoxin  fundj  of  S30.500  was  made  by  the  city  au- 
thorities for  the  prosecution  of  this  work.  The  spe- 
cial antitoxin  fund  made  possible  the  establishment  of 
a  research  bacteriological  laboratory  devoted  to  the 
production  of  diphtheria  antitoxin  and  other  bacterio- 
logical products,  and  to  general  experimental  investi- 
gations in  relation  to  the  infectious  diseases.  In  1896 
arrangements  were  completed  for  placing  at  the  com- 
mand of  the  physicians  of  New  York  City  Widal's  test 
for  the  diagnosis  of  typhoid  fever,  and  recently  ar- 
rangements have  also  been  made  for  the  administra- 
tion of  Pasteur's  treatment  for  the  prevention  of  rabies. 
.V  special  laboratory  and  stable  are  devoted  to  the  pro- 
duction of  bovine  vaccine  virus,  and  this  is  freely  dis- 
tributed and  vaccination  is  performed  free  of  charge 
by  the  medical  officers  of  the  department. 

Every  case  of  contagious  disease  reported  to  the 
department  is  inspected  by  the  medical  inspectors  of 
the  district  in  which  it  occurs,  and  when  necessarj' 
such  cases  are  removed  to  the  department  hospitals. 
Disinfection  is  then  performed  and  is  compulsory  in 
every  case,  all  infected  materials  being  taken  to  the 
disinfection  station  for  destruction  or  disinfection  by 
steam.  The  work  of  inspection  is  carried  on  by  a 
number  of  different  corps  of  inspectors.  These  in- 
clude the  district  medical  inspectors,  the  district  and 
special  vaccinators,  the  inspectors  for  the  administra- 
tion of  diphtheria  antitoxin,  the  diagnosticians,  the 
summer  corps  of  inspectors,  the  medical  inspectors 
of  schools,  etc.  There  are  also  a  number  of  sanitary 
and  food  inspectors,  who  are  not  necessarily  medical 
men,  such  as  the  inspectors  of  plumbing  and  ventila- 
tion, the  sanitary  police,  the  inspectors  of  offensive 
trades,  the  inspectors  of  meat,  fish,  milk,  etc.,  and  the 
inspectors  of  mercantile  establishments — these  last 
having  under  their  charge  the  regulations  as  to  the 
emplojTnent  of  women  and  children  in  such  establish- 
ments. Besides  these,  there  are  veterinary  inspectors, 
who  have  the  supervision  of  the  application  of  the 
tuberculin  test  for  the  diagnosis  of  tuberculosis  in  cat-' 
tie  and  the  diagnosis  of  other  infectious  diseases  in 
cattle  and  horses. 

Dr.  Biggs  then  described  in  detail  the  method  of 
procedure  followed  by  the  officers  of  the  health  de- 
partment when  the  existence  of  a  case  of  diphtheria 
comes  to  their  knowledge. 

The  Prevention  of  Tuberculosis.  —  The  speaker 
then  explained  the  attitude  assumed  bv  the  health  de- 
partment of  New  ^'ork  City  toward  pulmonary  tuber- 


388 


mp:dical  record. 


[September  ii,  1897 


culosis,  and  recounted  the  measures  adopted  for  its 
prevention.  Tlie  health  board  lirst  began  an  educa- 
tional campaign  in  relation  to  the  causation  and  pre- 
vention of  tuberculosis  in  1S89,  and  leaflets  based  on 
a  communication  on  this  subject,  giving  the  essential 
facts  as  to  the  nature  of  this  disease,  were  widely  dis- 
tributed. In  1893  it  was  determined  to  institute  more 
comprehensive  measures  tor  the  prevention  of  this 
disease.  The  measures  then  adopted  required  notifi- 
cation of  all  cases  of  pulmonarj' tuberculosis  occurring 
in  public  institutions,  and  requested  reports  of  cases 
occurring  in  the  practice  of  private  ph)-sicians :  they 
also  included  arrangements  for  the  bacteriological 
examination  of  sputum;  the  inspection  of  all  reported 
cases  in  tenement  houses,  lodging-houses,  hotels,  and 
boarding-houses,  and  the  instruction  of  the  patients 
and  their  families  as  to  the  nature  of  the  disease  and 
the  means  to  be  taken  for  its  prevention :  the  inspec- 
tion of  the  premises  in  all  instances  where  deaths  were 
reported  as  due  to  tuberculosis,  and  the  issuing  of 
orders,  where  it  was  deemed  necessary,  upon  the  own- 
ers of  apartments  which  had  been  occupied  by  con- 
sumptives and  vacated  by  death  or  removal,  requiring 
that  such  apartments  be  thoroughly  renovated  by 
painting,  papering,  or  kalsomining,  before  they  were 
again  occupied;  and  the  education  of  the  public,  by 
wider  and  more  comprehensive  methods,  as  to  the  na- 
ture of  tuberculosis.  In  1894,  4,166  cases  of  tubercu- 
losis were  reported;  in  1895,  5,818;  and  in  1896, 
8,334.  .All  cases  reported,  so  far  as  possible,  except 
those  in  private  hou.ses,  were  visited  or  the  premises 
where  they  occurred  were  inspected,  and,  in  addition,  the 
premises  occupied  by  persons  dying  from  tuberculosis 
(numbering  each  year  nearly  6,000)  were  inspected 
and  such  action  was  taken  as  was  considered  possible 
and  desirable.  In  the  beginning  of  1897,  on  the  recom- 
mendation of  Drs.  Biggs  and  Prudden,  the  health 
board  of  New  York  City  finally  declared  pulmonary 
tuberculosis  to  be  "  an  infectious  and  communicable 
disease,  dangerous  to  public  health,"  and  required  the 
notification  of  all  cases  occurring  in  the  city,  in  the 
same  way  as  is  required  of  cases  of  small-pox,  scarlet 
fever,  diphtheria,  etc.  The  healtli  department  has 
also  elaborated  with  great  care  methods  for  protecting 
the  public,  as  far  as  possible,  from  infection  by  the 
meat  and  milk  of  tuberculous  animals.  Since  1895  no 
mjlk  is  allowed  to  be  sold  within  the  city  without  a 
permit  from  the  health  department,  and  before  these 
permits  are  issued  information  must  be  furnished  as 
to  the  source  from  which  the  milk  is  obtained,  the 
number  of  animals,  the  character  of  the  food  supply, 
and  the  sanitary  conditions  surrounding  the  dairy. 
There  are  also  special  regulations  controlling  the  sale 
of  milk,  and  the  permits  may  be  revoked  if  these  regu- 
lations are  not  complied  with.  .Vll  milch  cows  in  the 
city  are  subjected  to  the  tuberculin  test,  and  animals 
found  to  be  diseased  are  killed.  There  also  exists  a 
careful  inspection  of  animals  slaughtered  for  food  and 
of  all  meat  sent  into  the  city,  and  the  carcasses  of  those 
found  to  be  tul>ercuious  are  destroyed.  Most  benefi- 
cial effects,  the  speaker  said,  have  already  resulted 
from  the  various  measures  instituted  for  the  preven- 
tion of  tuberculosis.  Not  only  has  there  been  a  very 
material  decline  in  the  number  of  deaths  occurring 
from  this  disease,  but  there  has  been  a  most  gratifying 
increase  of  knowledge  and  intelligence  among  the 
poorest  class  of  the  population  as  to  its  nature.  This 
increase  of  intelligence,  and  the  precautions  re.sulting 
from  it,  afford  the  greatest  promise  in  the  future  of  a 
persistent  and  still  more  rapid  decline  in  the  frightful 
mortality  caused  bv  the  tuberculous  di.seases. 

School  Inspection. — Early  in  1897,  under  the  au- 
thority of  a  special  resolution  of  the  board  of  esti- 
mate, one  hundred  and  fifty  medical  school  inspectors 
were  appointed  and  a  system  of   medical  school    in- 


spection was  begun.  During  three  months,  si.xty-five 
school  days,  in  which  this  system  was  in  operation, 
there  were  examined  63.812  children,  and  4,183  were 
excluded  from  school  for  the  following  diseases: 
Measles,  diphtheria,  scarlet  fever,  croup,  whooping- 
cough,  mumps,  contagious  eye  diseases,  parasitic  dis- 
eases of  the  head  and  body,  chicken-pox,  and  skin  dis- 
eases. This  system  of  school  inspection  has  thus  far 
given  most  satisfactorj-  results  and  promises  still  more 
for  the  future. 

The  Educational  Work  of  the  Health  Depart- 
ment constitutes  a  ver\-  important  feature  of  its  useful- 
ness. It  has  been  the  custom  of  the  department  for 
some  years  past  to  issue  from  time  to  time  circulars  of 
information  on  various  topics,  and  especially  those 
connected  with  infectious  diseases — their  diagnosis, 
treatment,  or  management.  Some  of  these  circulars 
are  popular  in  character,  very  large  editions  being 
published,  fifty  thousand  or  more  at  a  time,  and  are 
designed  for  general  distribution,  particularly  among 
the  tenement-house  population.  These  circulars  are 
also  published  by  the  various  medical  journals  and 
by  the  daily  papers  in  New  York  City,  and  thus  gain 
a  very  wide  circulation.  They  are  also  sent  by  mail 
or  delivered  by  messenger  to  the  physicians  of  the  city. 
Numerous  scientific  bulletins  have  also  been  issued 
from  the  bacteriological  laboratories,  detailing  the 
results  of  original  investigations  in  connection  with 
infectious  diseases,  and  these  bulletins  are  widely  dis- 
tributed among  the  profession  of  New  York  City.  The 
value  of  this  educational  work  in  disseminating  infor- 
mation in  regard  to  the  results  of  the  latest  studies  in 
infectious  diseases  is  incalculable,  and  there  have 
been  constantly  e.xhibited  in  New  York  the  most  grat- 
ifying indications  of  the  influence  of  the  information 
thus  distributed,  on  both  the  general  public  and  the 
medical  profession.  The  criticism  has  often  been 
made,  particularly  in  Europe,  and  in  the  earlier  work 
of  the  New  York  City  health  department,  that  the 
methods  proposed  are  impracticable.  The  results  have 
shown  that  they  are  not  impracticable.  What  has  been 
described  is  not  something  that  it  is  purposed  to  do. 
but  it  is  a  statement  of  what  has  been  done,  and  the 
work,  as  briefly  outlined  in  some  of  its  phases,  is  to 
be  considered  as  only  introductory.  It  is  the  purpose 
of  the  health  board  to  establish  a  super\-ision  of  all 
infectious  diseases  along  the  lines  which  have  been 
thus  far  developed,  in  relation  to  tuberculosis  and 
diphtheria,  as  rapidly  as  the  scientific  knowledge  at 
command  will  make  sucii  a  course  possible. 

Reduced  Death  Rate  in  New  York  City.— The 
final  test  of  the  etViciency  of  any  scheme  of  sanitary 
control,  Dr.  Biggs  continued,  is  found  in  the  mortal- 
ity statistics.  Various  factors  and  conditions,  how- 
ever, mav  influence  these,  such  as  densitv  of  popula- 
tion, nationality  of  the  inhabitants,  and  physical 
conformation  of  the  country.  The  conditions  in  New- 
York  City  are  in  many  respects  very  unfaxorable.  The 
average  density  of  population  of  the  larger  part  of 
New  York — that  is,  on  .Manhattan  Island— is  greater 
than  that  of  any  other  great  city  of  the  world.  Sani- 
tary district  A  of  ward  1 1 ,  New  York  City,  has  a  pop- 
ulation of  more  than  Soo  to  the  acre;  ward  10,  over 
640  to  the  acre ;  ward  13,  540;  ward  17,  430.  The 
only  localities  approaching  these  wards  in  density  of 
population  is  a  small  area  in  Paris,  where  the  popula- 
tion is  430  to  the  acre;  one  district  in  Prague,  with 
4S5  to  the  acre:  and  the  W'hitechapel  district  in  Lon- 
don, which  has  a  population  of  about  300  to  the  acre 
in  Spitalfields,  Mile  End,  and  Newtown,  and  365  in 
Bethnal  Green.  The  density  and  cosmopolitan  char- 
acter of  the  population  of  New  York  also  render  the 
sanitar)'  problems  presented  extremely  difficult  of  so- 
lution. Then,  too.  the  physical  conformation  of  Man- 
hattan Island,  which  is  long  and  very  narrow,  produces 


September  ii,  1897] 


MEDICAL    RECORD. 


389 


overciowding,  fully  three-fourths  of  the  population 
living  in  tenement-houses,  which  are  five,  six,  or  more 
stories  high,  and  contain  from  two  to  four  or  more 
families  on  each  floor. 

A  comparison  of  the  mean  death  rate  for  decennial 
jjeriods  in  Xew  York  City  since  1834  shows  that  there 
was  an  increase  during  the  first  three  periods  ending 
in  1863,  and  that  since  that  date  there  has  been  a 
continuous  and  marked  decline  in  the  rate,  especially 
in  recent  years.  The  mortality  in  New  York  rose  to 
such  a  point  that  the  inhabitants  became  alarmed,  and 
in  1866  the  health  department  as  now  constituted  was 
organized.  In  the  decennial  period  ending  in  1843 
the  mean  death  rate  was  28.03;  ^o''  the  period  ending 
1853  it  had  risen  to  33.81  ;  the  ne.xt  period,  ending  in 
1863,  it  was  33.94.  Since  that  time  it  has  declined 
to  31.11  for  the  decennial  period  ending  in  1873;  to 
26.87  ^or  the  period  ending  in  1883;  to  25.78  for  the 
IDeriod  ending  in  1893;  while  in  the  year  1894  it  was 
22.76;  in  1895,  23.10;  in  1896,21.54;  and  for  the 
first  half  of  1897,  19.60.  The  population  meanwhile 
has  increased  from  312,000  in  1840  to  an  estimated 
population  of  1,990,000  on  July  1,  1897.  The  mor- 
tality rate  is  normally  higher  for  the  first  half  of  the 
year  than  the  second  half,  and  it  is  therefore  probable 
that  the  rate  for  1897  will  be  a  fraction  over  19,  or  a 
diminution  of  twenty-fi\e  per  cent,  on  the  death  rate 
for  the  decennial  period  ending  in  1893.  The  largest 
reduction  has  been  in  the  zymotic  death  rate,  includ- 
ing diarrhceal  diseases  of  children  under  five  years, 
and  there  has  been  also  a  steady  decline  in  the  death 
rate  from  tuberculosis  since  1886.  A  reduction  in 
the  mortality  from  diphtheria  and  croup,  amounting  to 
nearly  forty  per  cent.,  has  occurred  since  the  introduc- 
tion of  diphtheria  antitoxin  with  the  beginning  of 
1895.  This  reduction  has  taken  place  in  spite  of  an 
increase  in  the  number  of  reported  cases  of  the  dis- 
ease. Up  to  the  beginning  of  1895  there  had  been  a 
steady  increase  for  some  years  in  the  mortalitv  from 
diphtheria  and  croup,  and  for  the  year  1894  the  death 
rate  was  higher  than  that  from  any  other  single  dis- 
ease, excepting  tuberculosis  and  pneumonia — pneumo- 
nia really  including  a  number  of  different  affections. 
The  combined  death  rate  from  measles,  scarlet  fever, 
diphtheria,  croup,  small-pox,  and  typhoid  fever  has 
been  reduced  exactly  one-half  within  ten  years — the 
rate  for  1896  for  these  diseases  being  1.64  per  i.ooo 
population,  as  contrasted  with  3.26  for  1887;  for  1897 
it  will  apparently  be  still  lower. 

The  government  of  the  United  States  is  democratic, 
but  the  sanitar)- measures  adopted  are  sometimes  auto- 
cratic, and  the  functions  performed  bv  sanitar}- 
a  ithorities  paternal  in  character.  We  are  prepared 
when  necessary  to  introduce  and  inforce,  and  the  peo- 
ple are  ready  to  accept,  measures  which  might  seem 
radical  and  arbitrary  if  they  were  not  plainly  designed 
for  the  public  good  and  evidently  beneficent  in  their 
effects.  Even  among  the  most  ignorant  of  our  foreign- 
bom  population,  few  or  no  indications  of  opposition 
or  resentment  are  exhibited  to  the  exercise  of  arbitrary 
power  in  sanitar}-  matters.  The  public  press  will  ap- 
prove, th3  people  are  prepared  to  support,  and  the 
coiirtij'  sustain  any  intelligent  procedures  which  are 
evidently  directed  to  the  preservation  of  the  public 
health.  The  belief  is  never  aroused  in  any  class  of 
the  population,  however  ignorant,  that  the  institution 
or  inforcement  of  any  sanitary  measure  is  primarily 
designed  for  the  restriction  of  the  individual  freedom. 
There  is  nowhere  to  be  found  any  jealousy  or  distrust 
of  law  and  government,  as  such.  It  is  therefore  pos- 
sible to  adopt  measures  more  arbitrary  in  many  re- 
spects than  could  be  adopted  in  most  other  countries, 
simply  because  our  government  is  democratic.  This 
gives  the  keynote  to  the  attitude  of  the  sanitary  au- 
thorities of  S^ew  York. 


In  concluding.  Dr.  Biggs  said  that  there  is  no  great 
city  in  the  world  to-day  which,  in  the  broad  sense,  is 
cleaner  and  healthier  than  Xew  Y^ork.  By  "  clean"  is 
meant  purity  of  the  atmosphere,  cleanliness  of  the 
streets,  abundance  and  purity  of  the  water  supply,  and 
efficiency  of  the  sewerage  system.  Nowhere  can  there 
be  foimd  a  fuller  recognition  than  in  the  I'nited 
States  of  England's  high  standard  of  excellence  in 
public  medicine,  or  a  more  sincere  appreciation  of  her 
\ast  contributions  to  the  progress  of  sanitary  science. 
Hut  she  must  look  well  to  her  laurels  if  her  cities  are 
to  be  kept  cleaner  than  the  great  cities  of  the  United 
States,  or  her  urban  population  is  to  be  healthier  and 
happier  than  the  same  class  on  this  side  of  the  Atlan- 
tic. 


SECTluX    IX   MEDICINE. 

First  Day —  Wednesday,  September  ist. 

On  the  Influences  that  have  Determined  the 
Progress  of  Medicine  during  the  Preceding  Two 
and  a  Half  Centuries. — Dr.  Stephen  M.ackexzie,  of 
London,  deli\ered  the  address  of  the  chairman,  taking 
this  as  his  subject.  These  influences  were  varied,  the 
first  place  in  point  of  time  and  one  of  great  importance 
being  yielded  to  anatomy.  Of  any  one  influence,  how- 
ever, that  has  helped  the  advance  of  scientific  study 
and  the  progress  of  medicine,  probably  the  increasing 
perfection  of  the  microscope  has  been  the  greatest. 
With  each  new  development  of  this  instrument  a 
greater  range  has  been  given  to  our  researches,  and, 
with  the  assistance  of  chemistry,  it  is  continuing  to  re- 
veal to  us  fresh  facts  that  have  created  new  branches 
of  science.  The  thermometer,  again,  has  been  of  in- 
valuable aid  in  the  studv  of  diseases,  allowing  us  to 
measure  and  record  the  degree  of  fever,  and  to 
watch  its  progress  with  such  a  degree  of  accuracy 
as  to  furnish  us  with  evidence  of  the  greatest  value  in 
the  diagnosis,  prognosis,  and  treatment  of  disease. 
Electricity,  by  the  laborious  and  complete  investiga- 
tions of  Dubois-Reymond,  has  revealed  to  us  the 
mode  of  action  of  nerve  and  muscle,  that  would  have 
been  impossible  to  obtain  in  any  other  way.  Though 
the  hopes  at  first  entertained  of  its  value  in  the  treat- 
ment of  diseases  have  not  been  altogether  fulfilled,  it 
is  still  of  much  service  in  this  respect,  and  perhaps 
still  more  valuable  as  an  aid  in  diagnosis.  The  oph- 
thalmoscope, introduced  by  Helmholtz,  has  enabled 
us  to  understand  diseases  of  the  interior  of  the  eye, 
which  without  its  assistance  was  impossible.  It  has 
allowed  the  exact  examination  of  refraction,  and  has 
revealed  changes  in  the  termination  of  the  optic 
nerve,  in  the  retina,  and  choroid,  not  only  valuable 
in  themselves,  but  so  important  in  the  light  they  throw 
on  pathological  changes  occurring  in  the  ner\ous  sys- 
tem and  in  the  body  generally  that  the  use  of  this  in- 
.strument  has  become  a  necessity  of  practical  medicine. 
The  laryngoscope,  perfected  by  Czermak,  has  given 
precision  not  otherwise  attainable  to  the  diagnosis 
and  treatment  of  diseases  of  the  throat,  and  has  im- 
portant bearings  on  general  medicine  in  the  recogni- 
tion of  paralysis  of  the  muscles  that  move  the  vocal 
cords,  in  aneurism,  and  in  disease  of  the  central  ner- 
vous system.  The  sphygmograph,  the  cardiograph, 
the  arteriometer,  and,  the  latest  invention  of  this  class, 
the  sphygmometer,  have  enabled  us  to  ascertain  the 
exact  condition  of  the  circulatory  system,  and  are  of  the 
greatest  service  not  only  in  studying  the  problems  of 
normal  and  abnormal  physiolog}',  but  in  the  recogni- 
tion of  disease  and  its  tendencies  and  in  the  influence 
of  remedies.  Nothing  from  the  time  of  Harvey  gave 
svich  an  impetus  to  the  study  of  exact  medicine  as  the 
introduction  or  discovery  of  auscultation  by  Laennec 
in  1816;  and,   indeed,  Har\ev's  great  discovery  had 


390 


MEDICAL    RECORD. 


[September  ii,  1897 


little  practical  application  in  clinical  medicine  until 
its  introduction.  Auenbrugger  had  introduced  percus- 
sion in  1761.  Laennec  had  adopted  it,  and  his  dis- 
covery of  auscultation,  with  his  zeal  as  a  morbid  anat- 
omist, enabled  him  to  work  out  most  of  the  great 
problems  of  diseases  of  the  thorax.  The  knowledge 
thus  begun  has,  by  the  labors  of  many  workers,  in- 
creased in  range  and  accuracy  down  to  the  present 
time,  and  the  diagnosis  of  diseases  of  the  chest  has 
reached  a  degree  of  precision  unequalled  in  any  other 
department  of  practical  medicine.  We  are  now  able 
not  only  to  recognize  disease  of  each  of  the  valves  of 
the  heart,  but  to  estimate  its  degree  and  the  influence 
of  the  lesion  on  the  greater  and  lesser  circulations, 
and  to  trace  the  course  and  effects  of  emboli  carried 
along  the  blood  stream.  Our  knowledge  of  diseases 
of  the  lungs  is  nearly  as  complete  as  that  of  the  circu- 
latory system.  The  speaker  then  reviewed  the  progress 
that  had  been  reached  in  clinical  medicine,  dwelling 
especially  on  fevers,  renal  diseases,  diseases  of  the 
nervous  system,  Addison's  disease,  and  myxctdema. 

The  Symptoms  and  Diagnosis  of  Cholelithiasis. — 
Dr.  J.  K.  Gr.aham,  of  Toronto,  read  a  paper  with 
this  title.  He  said  that  for  the  success  of  surgical 
interference  in  gall-stone  disease  it  is  incumbent 
upon  the  physician  to  make  an  early  diagnosis  so 
that  calculi  may  be  removed  before  a  serious  damage 
is  done  by  their  presence  either  in  the  gall  blad- 
der or  in  the  large  bile  ducts,  and  before  the  sys- 
tem is  irreparably  injured  by  obstructive  jaundice. 
Cases  of  gall-stone  disease  are  often  divided  into  two 
classes:  those  without,  and  those  with  jaundice.  This 
is  at  best  an  artificial  classification,  since  bile  pig- 
ment may  be  found  in  the  urine  when  calculi  are 
situated  in  any  part  of  the  gall  bladder  or  bile  ducts, 
although  its  presence  is  much  more  marked  when  they 
are  arrested  in  the  hepatic  or  common  bile  duct. 
The  symptoms  are  influenced  very  much  by  the 
length  of  time  required  for  the  formation  of  the  cal- 
culi. It  is  generally  thought  that  they  grow  very 
slowly,  but  Naunyn  is  of  the  opinion  that  ordinary 
gall  stones  of  the  soft  variety  may  form  in  a  few  days, 
even  in  a  few  hours.  Biliary  concretions  may  exist  in 
the  gall  bladder  a  number  of  years  without  producing 
any  symptom.s,  at  least  any  sufficient  to  lead  the  pa- 
tient to  consult  a  physician.  They  have  been  found 
in  one-tenth  of  all  post-mortem  examinations  and  in 
one-fourth  of  all  in  whicli  the  subjects  were  elderly 
women.  Frequently  indefinite  symptoms  have  been 
noticed,  such  as  bilious  headache,  bilious  attacks 
without  headache,  and  a  feeling  of  pressure  over  the 
stomach  after  certain  articles  of  food.  If  a  frequent 
and  careful  examination  of  the  urine  were  made,  bile 
would  be  found  in  many  of  these  cases,  especially 
when  cholecystitis  exists.  This  latter  condition  in 
the  chronic  form  may  end  in  contraction  and  atrophy 
of  the  gall  bladder,  (,'ourvoisier  has  collected  sixty- 
three  such  cases,  in  .seven  of  which  the  biliary  passages 
were  not  obstructed.  The  speaker  had  for  a  number 
of  years  a  patient  under  observation  who  had  xantho- 
mata  of  the  eyelids  and  who  suffered  from  frequent 
attacks  of  biliousness  but  with  no  local  sign.  She 
died  of  intestinal  hemorrhage  and  the  gall  bladder 
was  found  filled  with  calculi.  Fremitus  has  been 
noticed  and  stones  have  been  detected  by  sounding. 
This  is  not  a  safe  procedure  if  cholecystitis  be  pres- 
ent. When  in  addition  to  calculi  there  is  an  inva- 
sion of  pyogenic  organisms,  very  grave  symptoms 
rapidly  supervene.  Pain  and  tenderness  over  the 
region  of  the  gall  bladder  often  set  in  suddenly. 
The  pain  is  not  of  the  nature  of  colic,  unless  the  cys- 
tic duct  has  been  entered.  Symptoms  of  localized 
peritonitis  and  irregular  high  temperature,  anorexia, 
nausea,  and  vomiting  come  on. 

The   speaker  saw  a  very  interesting  case  of    this 


kind.  The  patient,  a  man  of  full  habit,  was  in  ordi- 
nary health,  when,  while  walking,  he  felt  a  pain  in 
the  right  hypochondrium,  accompanied  by  much  ten- 
derness in  the  hepatic  region  and  tension  of  the  right 
rectus.  Irregular  fever  followed,  with  occasional  rigor, 
and  death  took  place  in  about  six  weeks.  The  au- 
topsy showed  the  gall  bladder  filled  with  calculi,  the 
mucous  surface  separated  by  ulceration,  and  pysemic 
abscesses  in  the  liver  and  kidneys. 

Eberth's  bacillus  is  the  infective  agent  in  some 
cases  of  cholecystitis.  The  amount  of  ectasis  of  gall 
bladder  varies  in  different  cases,  and  when  occlusion 
of  the  cystic  duct  exists  the  distention  may  be  very- 
great.  Biliar)-  calculi  sometimes  escape  into  the 
peritoneal  cavity,  connective  tissue,  or  liver:  such  es- 
cape into  the  back  peritoneal  cavity  may  occur  during 
a  paroxysm.  In  one  case  the  bile  flowed  into  the  peri- 
toneal cavity,  was  removed  by  successive  tappings,  and 
the  patient  recovered.  In  the  great  majority  of  ca.ses  of 
rupture,  previous  ulceration  of  the  bladder  wall  has 
existed,  and  the  calculi  enter  the  surrounding  connec- 
tive tissue.  When  calculi  pass  into  the  cystic  duct  the 
well-known  symptoms  of  colic  supervene.  This  colic 
occurs  in  less  than  one-half  of  all  gall-stone  cases. 
An  attack  may  be  brought  on  by  error  in  diet,  emo- 
tional disturbances,  active  movements  of  the  bod}', 
menstruation,  confinement,  or  after  removal  of  abdomi- 
nal tumors,  etc.  Hagen  has  collected  eighteen  cases 
occurring  during  the  course  of  typhoid  fever.  The 
.seat  of  pain  is  usually  in  the  gall-bladder  region,  but 
also  in  the  epigastrium,  left  hypochondrium,  right 
shoulder,  and  right  inguinal — simulating  appendicitis. 
The  severity  of  pain  depends  more  on  the  shape  than 
on  the  size  of  the  stone.  Death  has  occurred  during 
an  attack.  Potain  believes  acute  dilatation  of  the 
right  ventricle  may  take  place,  as  evidenced  by  bruit 
lie  galop  or  pulsation  in  the  epigastrium.  This  he 
thinks  is  due  to  a  spasmodic  contraction  of  the  pul- 
monary capillaries  and  consequent  obstruction  of  the 
circulation. 

The  diagnosis  of  biliary  colic  without  jaundice  is 
often  not  easily  made;  especially  is  it  difficult  to  sepa- 
rate from  spasmodic  closure  of  the  pylorus  with  pain- 
ful distention  of  the  stomach.  If  seen  during  an  attack 
the  gastric  distention  may  be  evident.  Excess  of  free 
hydrochloric  acid  in  the  gastric  juice  points  to  the  stom- 
ach as  the  seat.  Rigors  with  fever  and  perspirations, 
especially  referred  to  by  Osier,  have  occasionally  been 
observed.  This  condition  resembles  urethral  fever, 
and  probably  results  from  toxin  poisoning  and  does 
not  necessarily  indicate  suppuration.  Jaundice  occurs 
in  one-half  of  the  cases  of  calculi,  but  the  presence  of 
bile  in  the  urine  is  a  valuable  sign.  The  breaking 
down  of  calculi  does  not  often  occur,  \\hen  a  stone  is 
arrested  in  the  cystic  duct  the  completeness  of  obstruc- 
tion may  depend  on  the  axis  of  the  stone,  and  a  change 
of  its  direction  may  materially  change  the  symptoms. 
There  is  no  proof  that  calculi  have  origin  in  the  cys- 
tic duct.  \\'hen  the  calculus  becomes  lodged  in  the 
cystic  duct  the  gall  bladder  becomes  distended.  If 
obstruction  is  complete  the  viscus  becomes  distended 
with  mucus.  In  some  cases  the  calculi  form  a  ball 
valve,  allowing  the  entrance  but  not  the  exit  of  bile. 
.Vs  much  as  ten  pints  of  fluid  has  been  removed  from 
the  gall  bladder. 

The  diagnosis  between  a  distended  gall  bladder 
and  a  displaced  right  kidney  is  often  a  matter  of  diffi- 
culty. The  differential  points  are:  1.  History  of  bili- 
ary colic.  2.  Movement  of  tumor  with  respiration. 
3.  The  lower  extremity  is  movable,  whereas  die  upper 
is  fixed.  4.  The  kidney  may  be  felt  behind  the  tumor. 
5.  The  colon  lies  in  front  of  the  kidney  and  behind 
the  gall  bladder.  6.  In  pyonephrosis  the  urine  may 
contain  pus,  and  in  distended  gall  bladder  bile  pig- 
nient  may  be  present. 


September  ii,  1897] 


•MEDICAL    RECORD. 


391 


The  two  following  cases  illustrate  this  dithculty  of 
differentiation : 

Case  I. — The  patient,  a  married  woman,  fifty-two 
years  old,  had  suffered  during  the  summer  from  occa- 
sional attacks  of  pain,  together  with  general  malaise. 
In  October  a  tumor  was  discovered  below  the  liver, 
e.xtending  downward  nearly  to  the  crest  of  the  ilium. 
It  was  large,  smooth,  elastic,  and  tender.  The  right 
kidney  was  displaced,  as  shown  by  the  absence  of  kid- 
ney dulness.  Under  chloroform  the  kidney  could  not 
be  found  separate  from  the  tumor.  The  latter  did  not 
move  with  respiration,  nor  was  the  lower  e.vtremit}- 
any  more  movable  than  the  upper.  The  urine  was 
free  from  pus,  but  contained  a  small  amount  of  bile 
pigment.  Symptoms  of  suppurative  fever  were  pres- 
ent. Dr.  Temple  operated,  and  found  a  distended, 
suppurative  gall  bladder  and  a  stone  in  the  cystic  duct. 
The  patient  made  a  good  recovery. 

C.\SE  II. — A  female  patient  complained  of  severe 
pain  in  the  gall-bladder  region,  which  was  accompa- 
nied by  swelling  below  the  margin  of  the  ninth  and 
tenth  ribs.  The  pain  occurred  irregularly  at  intervals 
of  weeks  or  months,  and  was  nearly  always  relieved 
by  pressure  over  this  region.  The  tumor,  which  was 
thought  to  be  a  distended  gall  bladder,  was  found  to 
be  a  distended  cystic  kidney.  The  urine  was  negative. 
The  length  of  time,  eight  years,  during  which  the  pa- 
tient .suffered  from  the  pains  should  have  decided 
against  a  distended  gall  bladder.  The  operation  was 
followed  by  recovery. 

When  the  calculus  has  passed  through  the  cystic 
duct,  it  usually  finds  its  way  without  difficulty  until 
obstructed  by  the  narrow  duodenal  outlet.  In  many 
cases,  however,  it  is  found  in  different  parts  of  the 
ca.ial,  but  near  the  outlet  in  thirt)'-five  per  cent,  of 
cases.  The  symptoms  of  passage  of  calculi  through 
the  common  bile  duct  are  similar  to  those  already  de- 
scribed in  connection  with  the  cystic  duct.  Obstruc- 
tive jaundice  is  the  marked  differential  sign  between 
the  two  conditions.  Many  calculi  pass  through  the 
natural  channels  without  producing  any  symptoms. 
When  there  is  complete  obstruction  the  bile  finds  its 
way  into  the  blood-vessels  through  the  lymphatics. 
Cholelithiasis  is  now  given  as  one  of  the  causes  of 
cirrhosis.  The  pressure  of  bile  in  the  distended  ducts, 
as  well  as  irritation  due  to  calculi  in  the  e.\trahepatic 
and  intrahepatic  ducts,  together  with  microbes  and 
their  products,  are  probably  the  principal  agents.  In 
all  cases  of  biliary  obstruction  from  calculi  there  is  a 
danger  of  the  introduction  and  growth  of  bacteria, 
leading  to  suppurative  cholangitis  and  cholec}stitis. 
The  pain  in  this  condition  is  usually  not  se\ere,  and 
although  an  abscess  may  form  it  is  not  large  and  may 
contain  hepatic  calculi.  The  abscesses  vary  in  size 
and  number.  The  bacteria  usually  found  are  bacillus 
coli  communis,  streptococcus,  staphylococcus  aureus, 
and  the  diplococcus  pneumonia?. 

The  diagnosis  of  calculous  abscesses  of  the  liver  is 
always  difficult.  Naunyn  gives  the  following  points 
in  distinguishing  the  jaundice  of  chronic  lithiasisfrom 
that  due  to  other  forms  of  obstruction  :  i.  The  contin- 
uous or  occasional  presence  of  bile  in  the  faeces.  2. 
Distinct  remissions  in  the   intensity  of  the  jaundice. 

3.  Normal  size  or  only  sligjit  enlargement  of  the  liver. 

4.  .\bsence  of  distention  of  the  gall  bladder.  5. 
Presence  of  febrile  disturbances.  6.  Duration  of 
jaundice  for  more  than  a  year. 

In  acute  yellow  atrophy  there  is  a  decreased  area  of 
hepatic  dulness.  Fever  is  sometimes  present  in  car- 
cinoma of  the  liver.  Calculi  in  the  gall  bladder  and 
biliary  canals  are  often  the  cause  of  carcinoma.  Per- 
nicious anaemia  has  followed  biliary  obstruction.  Cal- 
culi sometimes  pass  through  the  ducts  into  the  intes- 
tines and  there  increase  in  size  and  produce  acute 
obstruction,  which   usually   occurs   at   the    ileo-cacal 


valve.  A  calculus  may  ulcerate  through  the  gall 
bladder  from  a  fistula,  which  may  extend  upward 
through  the  diaphragm  into  the  pleural  cavity  or  lung, 
forming  a  broncho-biliary  fistula.  A  case  has  been 
recorded  of  perforation  into  the  left  pleura,  into  the 
mediastinum,  and  then  into  the  pericardium.  Perfo- 
ration may  also  take  place  into  the  stomach,  pelvis  of 
kidney,  or  portal  vein.  When  the  perforation  is  into 
the  abdominal  wall  the  fistula  is  usually  tortuous. 

The  Dietetic  Treatment  of  Diabetes. — Dr.  Robert 
Saundby,  of  Birmingham,  England,  opened  the  dis- 
cussion on  this  subject.  When  the  diagnosis  of  dia- 
betes mellitus  has  been  established,  he  said,  some- 
times when  only  the  presence  of  sugar  in  the  urine 
has  been  detected,  it  is  the  very  general  practice  to 
place  the  patient  upon  a  so-called  ''  diabetic  diet." 
That  is  to  say,  he  is  furnished  with  a  list  of  permitted 
and  forbidden  articles  of  food  and  drink  arranged 
upon  the  principle  that  all  carbohydrates  are  injurious, 
and  he  is  told  that  he  must  keep  to  this  diet  until  the 
sugar  has  disappeared  from  his  urine.  But  carbohy- 
drate food  is  not  the  only  source  of  sugar.  In  severe 
diabetes  glycosuria  continues,  although  much  reduced 
in  amount,  when  the  patient  is  placed  on  a  flesh  diet, 
and  this  is  explained  by  the  discovery  that  a  carbohy- 
drate molecule  is  formed  in  the  process  of  converting 
albumin  into  urea,  in  the  proportion  of  fort)'-five  per 
cent.  This  fact,  duly  appreciated,  must  convince 
every  one  of  the  futility  of  persisting  in  w  ithholding 
carbohydrates  in  the  hope  of  removing  the  glycosuria. 
If  it  is  conceded  that  the  disputed  data  of  physiologists 
do  not  afford  a  sound  basis  for  our  treatment  of  dia- 
betes, but  that  we  must  look  to  clinical  results  before 
we  say  that  a  means  is  good  or  bad,  then  the  old  rou- 
tine method  is  doomed.  Instead  of  ordering  a  stereo- 
typed diet  in  every  case,  we  must  try  experimentally 
in  each  individual  how  much  carbohydrate,  or  rather 
what  combination  of  proteid,  fat,  and  carbohydrate 
gives  the  best  result.  This  was  the  method  which  the 
speaker  would  advocate,  and  it  had  been  adopted 
solely  upon  the  basis  of  clinical  experience.  The 
method,  he  said,  does  not  involve  a  great  sacrifice  of 
time  on  the  part  of  the  doctor;  in  fact,  all  the  most 
important  observations  can  be  made  and  a  register 
kept  by  the  patient  himself.  The  only  thing  he  can- 
not do  is  the  analysis  of  the  urine.  The  patient 
should  once  weekly  get  weighed,  and  collect  and 
measure  the  whole  of  his  urine  for  twenty-four  hours; 
a  specimen  of  the  urine  should  be  sent  to  the  doctor, 
who  should  determine  the  total  amount  of  sugar.  Of 
these  observations,  the  body  weight  is  the  most  im- 
portant, for  if  it  continues  to  be  stationary  or  tending 
upward,  we  have  the  best  proof  that  the  diet  is  prop- 
erly regulated,  even  though  the  sugar  shows  a  moder- 
ate increase.  In  order  to  determine  the  diet  most 
suitable  to  each  patient  we  must  proceed  experimen- 
tally, and  this  is  better  done  by  gradually  increasing 
the  amounts  of  saccharine  and  starchy  food.  Many 
patients  suffer  from  polyuria  and  great  thirst,  and 
these  symptoms  can  best  be  checked  by  strict  diet  for 
a  limited  time,  combined,  if  necessary,  with  the  ad- 
ministration of  a  grain  or  two  of  extract  of  opium 
every  night.  Further,  the  result  of  strict  diet  affords 
valuable  information  for  prognosis,  as  it  is  only  in 
the  milder  cases  that  the  sugar  disappears  under  its 
influence.  The  patient  should,  if  possible,  make  one 
meal — for  example,  breakfast — of  fat  bacon  or  eggs 
and  bacon,  with  which  he  may  eat  cabbage  and  starch- 
less,  not  gluten,  bread  or  biscuits.  He  is,  of  course, 
allowed  other  green  vegetables,  any  animal  food,  tea 
or  coffee  with  cream,  and,  if  he  desires  it,  two  to  three 
ounces  of  sugar-free  alcohol,  with  mineral  water. 
When  after  a  week  of  this  diet  the  sugar  is  found  to 
have  disappeared  entirely,  or  almost  entirely,  six 
ounces  of  baked  potatoes  and  one  and  one-half  pints 


392 


MEDICAL    RECORD. 


[September  ii,  1897 


of  milk,  containing  between  them  the  equivalent  of 
about  eleven  hundred  grains  of  sugar,  may  be  added. 
If  this  causes  no  glycosuria,  four  and  one-half  ounces 
of  dry  toast,  of  which  about  eight  hundred  grains  are 
starch,  may  be  given,  as  also  a  bottle  of  light  wine 
containing  very  little  sugar,  such  as  ordinary  Bor- 
deaux or  Moselle,  or  in  some  cases  a  pint  of  bitter 
Burton  ale.  If  such  a  diet  causes  no  return  of  symp- 
toms, the  doctor  may  be  satisfied  and  the  patient  is 
generally  contented,  and  if  sugar  continues  to  be  ab- 
sent the  quantity  of  toast  or  bread  may  be  gradually 
increased  to  double  the  amount.  Such  cases  are, 
however,  e.xceptional.  As  a  rule,  the  sugar,  though 
diminis.hed,  persists.  In  such  a  case  we  may  give 
first  the  milk  and  then  the  potatoes,  and  if  there  is  no 
return  of  distressing  symptoms  we  should  not  retrace 
our  steps  because  there  is  some  moderate  increase  of 
sugar,  but  watch  the  body  weight.  If  that  shows  no 
loss,  we  may  keep  the  patient  on  this  diet  for  many 
weeks  before  venturing  to  make  a  trial  of  ordinary 
bread,  and  often  the  patient  has  to  be  content  to  do 
altogether  without  it.  The  speaker  preferred  to  in- 
crease the  potatoes,  for  he  was  of  the  belief  that  the 
starch  of  cereals  is  for  some  reason  more  productive 
of  glycosuria  than  that  of  potatoes. 

Dr.  Sidney  Coupl.and,  of  London,  said  that  no  one 
at  the  present  day  proscribes  entirely  the  carbohy- 
drates, but  he  agreed  with  Dr.  Saundby  that  we  are 
not  liberal  enough.  Each  case  is  a  law  unto  itself  in 
this  respect,  as  a  very  slight  restriction  is  necessary 
in  some  instances,  while  in  others  there  is  greater  call 
for  it.  Diet  alone,  however,  will  not  always  effect  all 
we  could  wish,  for  codeine  was  of  very  great  value  in 
one  of  the  speaker's  cases.  AVe  should  be  very  cau- 
tious about  restricting  the  diet  too  much,  for  such  a 
course  may  favor  the  occurrence  of  coma. 

Dr.  Shixgletox  Smith,  of  Bristol,  said  we  should 
be  very  clear  as  to  the  dietary  indications  in  each 
case,  and  in  young  patients  especially  we  must  re- 
strict the  ingestion  of  carbohydrates.  He  cited  one 
case  in  a  middle-aged  patient  in  whom  there  was  al- 
ways glycosuria  after  a  small  quantity  of  gluten  bread 
had  been  eaten,  even  after  the  sugar  had  been  absent 
for  years.  Certainly  there  should  be  more  liberality  in 
diet  than  is  usually  the  case.  Very  often  the  patients 
do  not  follow  out  the  orders  of  the  physician,  thereby 
materially  reducing  their  length  of  life.  Such  patients 
often  prefer  a  shorter  life  with  liberal  diet  than  a 
greatly  restricted  menu. 

Dr.  Ebenezer  Duxc.^x,  of  CJlasgow,  said  that  if 
diabetes  is  due  to  disease  of  the  pancreas  neither  diet 
nor  anything  else  will  have  much  effect  on  the  symp- 
toms. When,  however,  the  diabetes  is  of  neurotic 
origin,  then  more  can  be  effected.  He  thought  the 
diet  should  be  quite  strict  as  long  as  the  patient  could 
stand  it. 

1)k.  'I'vsox,  of  Philadelphia,  said  that  his  method 
was  practically  the  sanie  as  that  of  Dr.  Saundbv,  that 
is,  he  varied  the  diet  according  to  the  condition  of  the 
patient.  We  must  distinguish  between  the  mild  cases 
in  which  the  excretion  of  sugar  can  be  prevented  by 
careful  diet  and  the  severe  cases  in  which  no  treatment 
will  arrest  it.  He  felt  sure  that  many,  if  left  alone, 
would  outlive  their  diabetes.  He  was  in  the  habit  of 
l>lacing  diabetic  patients  for  two  days  each  month  on 
)iroteid  diet,  but  if  the  sugar  e.xceeds  two  per  cent,  the 
diet  must  be  very  strict.  The  polyuria  of  diabetes  is 
an  effort  of  the  system  to  rid  the  blood  of  sugar.  A 
proteid  diet  produces  diacetic  acid  in  the  urine,  and 
may  cause  the  coma.  It  is  pr.ictically  impossible, 
however,  to  keep  patients  on  purely  albuminous  diet, 
and  this  is  fortunate,  as  it  probably  often  saves  the 
patient's  life. 

Dr,  a.  Jacobi,  of  New  York,  described  the  course 
he  usually  pursued.     He  regulated  the  diet  according 


to  the  age :  young  patients  cannot  take  carbohydrates 
with  impunity,  while  old  patients  may  thrive  on  them. 
Children  will  live  longer  with  a  strict  proteid  diet, 
but  will  probably  never  get  well.  The  speaker  had 
never  seen  diabetic  patients  get  worse  with  milk  but 
nearly  always  they  improved,  and  it  was  his  custom  to 
give  it  in  some  form,  such  as  sweet  milk,  buttermilk, 
or  skin>:iiilk.  A  rigid  milk  diet,  however,  cannot  be 
recommended.  Old  persons  will  do  better  on  a  mixed 
diet  than  on  a  strict  diet. 

Dr.  Wright,  of  Ottawa,  drew  a  sharp  distinction 
between  glycosuria  and  diabetes.  The  former  occurs 
chiefly  in  elderly  people  and  these  patients  may  follow 
a  very  liberal  diet  rule.  He  spoke  of  a  t)-pe  of  cases 
which  he  had  encountered  in  apparently  healthy  young 
men  whom  he  examined  for  life  insurance.  In  these 
cases  sugar  appeared  in  the  urine  without  polyuria  or 
any  other  symptoms  of  diabetes.  One  patient,  who 
gave  a  history  of  hard  work  and  worry,  had  been  under 
observation  for  the  past  fifteen  years.  The  question 
was  whether  treatment  w as  necessar}-  in  cases  in  which 
only  this  symptom  was  present,  and  also  whether  such 
a  person  was  a  suitable  risk  for  life  insurance. 

Dr.  Mackenzie  thought  that  the  reaction  against 
the  blind  routine  would  undoubtedly  do  good.  In 
this  disease  there  is  greater  hope  for  good  results  than 
we  formerly  thought.  We  should  be  guided  in  our 
treatment  by  the  patient's  condition,  and  not  exclu- 
sively by  the  amount  of  sugar  in  the  urine. 

Dr.  Sauxdbv,  in  closing  the  discussion,  said  that 
at  the  commencement  of  his  adddress  he  had  expressed 
the  hope  that  some  of  those  present  would  be  able  to 
echo  his  opinions,  and  he  was  more  than  pleased  that 
so  many  held  the  same  views  of  treatment  as  he  did. 
Even  in  the  case  of  children  a  little  carbohydrate,  es- 
pecially potato,  four  to  six  ounces,  may  be  given  with- 
out bad  results.  Of  course  in  children  the  prognosis 
is  very  bad,  but  their  life  should  be  made  as  agreeable 
as  possible.  Giving  about  a  quart  of  milk  daily  he 
thought  w  as  very  beneficial.  The  percentage  of  sugar 
in  the  urine  is  misleading,  but  an  estimation  of  the 
total  amount  passed  in  twenty'-four  hours  is  a  good 
index. 

With  regard  to  Dr.  Wright's  question  he  thought 
that  such  cases  of  temporary  glycosuria  often  develop 
into  true  cases  of  diabetes;  this  at  least  was  the  opin- 
ion of  some  authorities. 


rWELFTH 


INTERNATIONAL 
CONGRESS. 


MEDICAL 


Held  in  Moscow,  August  ig,  20,  21,  22,  2J.  24.  -»j,  and 
26,  iSgj. 

(Special  Report  to  the  Medical  Record.) 

SFXTION   0>f   INTERNAL   MFPICINE. 

(Contiaued  from  paK<:  356.) 

First  Day — Friday,  August  20th. 

The  session  opened  with  Dr.  Pavlinov,  of  Moscow,  in 
the  chair.  The  following  were  appointed  presidents 
of  the  section  for  the  day;  Drs.  Senator  and  Gerhardt, 
of  Berlin;  Brault,  of  Paris;  Crocq,  of  Brussels;  Grun- 
mach,  of  Berlin ;  Ebstein,  of  Gottingen  ;  Le  Gendre,  of 
Paris;  Laache,  of  Christiania:  and  Ughetti,  of  Catania. 
Clinical  Classification  of  Nephritis.  —  Dr.  Brai'lt, 
of  Paris,  read  a  paper  with  this  title.  The  attempts 
at  classification  of  nephritis,  he  said,  have  been  nu- 
merous. The  first  were  due  to  the  labors  of  Bright 
and  of  Rayer,  but  for  anything  like  a  satisfactory  classi- 
fication we  must  come  down  to  our  own  day,  when 
the  pathology  of  the  kidney,  like  that  of  other  organs, 
has  been  completely  changed  by  the  studies  and  dis- 
coveries in  general  pathological  histology.     The  name 


September  ii,  1897] 


MEDICAL    RFCORD. 


393 


of  Virchow  marks  the  beginning  of  this  last  period. 
The  speaker  did  not  wish  to  say  that  only  good  came 
from  this  revolution,  for  there  is  even  some  question 
as  to  whether  the  pathology  of  the  kidney  has  reallv 
benefited  from  the  application  of  these  ideas.  It  -was 
in  order,  the  speaker  said,  to  inquire  of  what  use  is  a 
clinical  classification,  and  whether  it  is  more  rational 
and  practical  than  are  others.  The  most  used  of  the  his- 
tological classifications  divided  nephritis  into  paren- 
chymatous (Virchow,  1852)  and  interstitial  (Beer, 
1859).  The  discovery  of  the  connective  tissue  in  the 
kidney  and  its  importance  in  disease  led  Traube  to 
reject  completely  the  parenchymatous  nephritis  of 
Virchow.  Kelsch,  following  in  his  footsteps,  declared 
that  inflammation  could  develop  only  in  connective 
tissue.  The  improvements  in  the  microscope  soon 
cleared  up  the  question,  and  almost  all  microscopists 
accepted  as  exact  this  simple  division  of  parenchy- 
matous and  interstitial  nephritis.  Nevertheless  cer- 
tain authors  still  refused  to  admit  the  e.xistence  of  a 
parenchymatous  nephritis,  maintaining  that  intersti- 
tial nephritis  alone  was  capable  of  causing  atrophy  of 
the  organ.  Carrying  this  idea  to  extremes,  forgetting 
that  the  kidney  is  formed  after  the  type  of  a  gland, 
they  affirmed  tliat  its  epithelium  could  degenerate 
but  could  not  become  inflamed:  that,  finally,  all  the 
processes  of  nephritis  being  essentiallv  interstitial, 
acute  inriammation  of  the  kidney  is  an  acute  intersti- 
tial nephritis.  They  showed  as  an  example  of  this  the 
nephritis  of  scarlet  fever.  So  we  see  at  this  period, 
from  a  histological  point  of  view,  everything  was  con- 
fusion :  as  for  pathological  physiolog}'  and  etiology. 
they  were  of  so  little  importance  that  they  are  scarcelv 
mentioned.  In  1875  Bartholow  described  an  acute 
and  chronic  parenchymatous  nephritis,  and  an  inter- 
stitial nephritis  or  induration  of  the  cellular  tissue  of 
the  kidneys  (under  which  he  comprehended  simple 
atrophy,  cirrhosis,  sclerosis,  and  granular  atrophy). 
.\t  the  same  time  Lancereaux  substituted  for  intersti- 
tial nephritis  the  term  primary  diffuse  nephritis,  and 
for  parenchymatous  nephritis  epithelial  nephritis. 
Shortly  after  this  Charcot  called  attention  to  the  iden- 
tity of  parenchymatous  nephritis  and  large  white  kid- 
ney, and  of  interstitial  nephritis  and  small  contracted 
kidney. 

Following  this  came  the  studies  of  Klebs  and  Bam- 
berger, who  declared  the  division  into  large  white 
kidney  and  small  contracted  kidney  wrong,  because 
they  found  microscopically  in  each  form  lesions  affect- 
ing both  the  parenchyma  and  connective  tissue.  Wei- 
gert  (1879),  Cohnheim  (i88o),  and  Wagner  (1882) 
said  that  the  epithelial  lesions  alwavs  precede  the 
alterations  in  the  connective  tissue,  and  they  declared 
(especially  Weigert)  that  if  the  lesions  varied  in  dif- 
ferent cases  it  was  only  a  difference  of  degree.  Comil 
and  Ranvier  had  already  expressed  this  opinion  in 
1876. 

The  most  natural  classification,  Dr.  Urault  said, 
would  be  an  etiological  one.  In  1884  the  speaker, 
working  with  Comil,  wrote  a  thesis  on  diffuse  and 
systemic  nephritis,  and  in  1893  he  discussed  again 
the  division  of  nephritis.  At  that  time  he  contended 
that  there  was  no  longer  a  question  of  the  unir\-  or 
duality  of  Bright's  disease.  If  the  diseased  kidneys 
vary  in  their  size,  their  consistence,  their  form,  their 
coloration,  their  granulations,  etc.,  all  these  elements 
depend  on  whether  the  process  is  rapid  or  slow,  violent 
or  slight.  Infectious  diseases  irritate,  inflame,  de- 
stroy .//  masse ;  chronic  diseases,  the  dyscrasias,  and 
prolonged  intoxications  destroy  the  organ  by  a  series 
of  local  inflammations  or  cause  it  to  degenerate  little 
by  little. 

A  clinical  classification  is  possible  only  as  regards 
duration  :  as  transitory,  acute,  subacute  (or  prolonged  1. 
and  chronic  nephritis,  this  last  comprehending  only 


the  latent  \  arieties,  namely,  those  with  serious  lesions 
but  appearing  healthy.  A  symptomatic  classification 
such  as  Weigert  and  Wagner  have  proposed,  as  nephri- 
tis with  or  without  ctdema,  nephritis  with  or  without 
hemorrhage,  is  not  practicable,  for  allowing  such  a  no- 
menclature the  question  of  classification  still  remains. 

In  all  cases  of  nephritis  in  which  the  duration  is 
prolonged  we  see  constantly  hypertrophy  of  the  heart. 
It  is  therefore  useless  in  the  understanding  of  a 
nephritis  to  have  recourse  to  the  old  divisions  of 
parenchymatous  and  interstitial,  for,  if  we  have  (i)  the 
cause  of  the  nephritis  and  (2  )  the  date  of  its  appear- 
ance, we  possess  suflicient  data  to  explain  what  has 
already  taken  place,  to  foresee  the  future  course,  and 
to  deduce  the  corresponding  anatomical  form. 

Chronic  Parenchymatous  and  Interstitial  Nephri- 
tis.— l)k.  Croci.>.  of  Brussels,  then  presented  a  com- 
munication with  this  title.  He  said  that  albuminuria 
was  due  to  desquamation  of  the  renal  epithelium,  and 
we  could  not  have  even  a  so-called  physiological 
albuminuria,  a  transitory  condition,  without  such 
cause,  although  the  cause  of  the  albuminuria  might  be 
of  short  duration  and  so  escape  our  notice.  For  ex- 
ample, we  may  have  a  hyperjemia  which  can  be  active 
as  well  as  passive,  as  in  inflammation  of  the  kidneys 
due  to  valvular  disease  of  the  heart.  Moreover,  usu- 
ally a  parenchymatous  inflammation  of  the  kidneys  is 
the  cause  of  the  excretion  of  albumin,  which  almost 
invariably  points  to  chronic  Bright's.  Interstitial 
nephritis  is  quite  another  thing.  In  this  we  have  an 
inflammation  of  the  connective  tissue  which  binds  to- 
gether the  parenchymatous  elements.  If  the  epithe- 
lium is  not  affected  there  is  no  albumin  in  the  urine, 
but  if  the  inflammation  extends  to  the  epithelial  ele- 
ments it  at  once  appears.  Clinically  therefore  the 
author  would  distinguish  two  kinds  of  chronic  nephri- 
tis— one  with,  the  other  without,  albuminuria.  These 
are  identical  with  the  anatomical  forms  distinguished 
as  parenchymatous  and  interstitial.  " 

The  Pathogenesis  of  Chronic  Nephritis.  —  Dr. 
SEN.AfoK,  of  Berlin,  read  a  communication  on  this 
subject.  When  this  affection  is  not  due  to  the  persist- 
ence and  further  development  of  frank  acute  nephri- 
tis, he  said,  it  is  the  result  of  latent  inflammations  of 
the  kidney  long  continued.  Any,  even  the  smallest 
amount  of  albuminuria  is  a  sign  of  a  pathological  proc- 
ess in  the  kidney.  Albumin  can  leak  through  the 
filter  that  was  meant  by  nature  to  retain  it  onlv  when 
there  is  an  organic  affection  of  the  organ.  Chronic 
nephritis  is  often  due  to  this  latent  process  that  so 
easily  escapes  notice. 

In  discussing  this  paper.  Dr.  Gerh.ardt,  of  Ber- 
lin, said  that  he  did  not  think  slight  albuminuria  was 
always  due  to  organic  lesions  of  the  kidney,  but  often 
to  functional  derangement.  In  some  people,  in  fact, 
it  seemed  as  though  there  was  such  a  thing  as  physi- 
ological albuminuria. 

The  Employment  of  Bleeding  in  the  Treatment 
of  Uraemia. — Dr.  La.achk.  of  Christiania,  read  a  pa- 
per with  this  title,  in  which  he  recommended  bleeding 
in  certain  forms  of  kidney  disease,  accompanied  b)' 
uraemic  symptoms,  in  which  the  blood  pressure  is  in- 
creased. 

Etiology  of  Chronic  Nephritis. —  Dr.  I'.avlixo.  of 
Moscow,  said  that,  contrary  to  the  opinion  of  Charcot, 
Eichhorst,  and  Liebermeister,  his  observations  proved 
the  existence  of  a  chronic  scarlatinal  nephritis,  paren- 
chymatous and  interstitial,  and  in  this  he  was  sup- 
ported by  many  authorities.  In  accordance  with  the 
accepted  doctrine  concerning  inflammation  and  as  one 
would  naturally  deduce  from  observation  of  the  clini- 
cal evolution  of  nephritis,  we  find  at  the  autopsy  a 
chronic  epithelial  nephritis  when  the  duration  has 
been  short,  and  an  interstitial  nephritis  when  the 
course  of  the  disease  has  been  tedious.     It  is  necessary 


394 


MKDICAL    RECORD. 


[September  ii,  1897 


to  remember  that  the  duration  of  a  chronic  nephritis 
is  generally  much  longer  than  is  set  down  in  the  text- 
books, the  speaker  said,  and  according  to  his  own  ob- 
servations the  duration  of  the  parenchymatous  form  of 
chronic  nephritis  might  be  from  five  years,  and  that  of 
the  interstitial  form  from  twelve  to  seventeen  years. 
In  his  experience  chronic  nephritis  develops  in  sulj- 
jects  from  twenty-one  to  twenty-four  years  old,  and 
when  we  find  it  at  this  age  we  must  bear  in  mind  the 
possibility  of  its  origin  from  scarlet  fever.  Admitting 
scarlet  fever  as  one  of  the  causes  of  chronic  nephritis, 
we  can  explain  in  certain  cases  its  etiology  and  so 
diminish  the  number  of  cases  occurring  without  appar- 
ent cause. 

The  Pathogenesis  of  Obesity. — Dr.  P.  Lk  Gendre, 
of  Paris,  sent  a  paper  with  this  title,  which  w-as  read 
by  Dr.  Chavrin.  He  spoke  first  of  the  etiolog)'  of  the 
affection.  Heredity,  either  similar  or  under  the  ap- 
pearance of  arthritism,  is  active  among  the  predispos- 
ing causes,  as  is  also  sex,  women  being  more  liable  to 
suffer  than  men,  in  the  proportion  of  two  to  one.  The 
exciting  causes  are  unsuitable  diet,  especially  the  con- 
sumption of  starchy  and  saccharine  foods,  dyspepsia, 
the  abuse  of  alcohol  and  perhaps  the  ingestion  of  any 
fluids  in  too  large  quantity,  a  .sedentary  life,  and  (as 
was  observed  after  the  siege  of  Paris)  a  sudden  return 
to  comfort  after  long  privation.  The  speaker  then 
discussed  metabolism  as  it  related  to  the  disposition 
of  ingested  fat  or  the  formation  of  fat  in  the  organism 
from  other  substances,  such  as  sugar  or  albumin.  The 
factors  which  clinical  experience  has  shown  us  to  be 
active  in  the  production  of  obesity  may  be  grouped 
under  two  heads.  The  first  of  these  moments  are 
those  which  offer  a  resistance  to  the  destruction  of  fat 
in  the  economy  by  diminishing  the  supply  of  oxygen 
needed  for  its  combustion.  Among  these  are  anaemia 
and  chlorosis,  large  hemorrhages,  and  a  sedentary  life. 
Dyspepsia  also  acts  by  lessening  the  amount  of  bile 
and  pancreatic  juice,  and  so  preventing  the  splitting 
up  of  the  fats  in  the  intestine;  the  fat  is  thus  absorbed 
in  the  form  of  an  emulsion,  which  is  much  more  diffi- 
cult of  oxidation.  In  the  second  group  we  find  those 
causes  which  increase  the  production  of  fat  in  the 
economy,  either  through  an  increased  ingestion  of 
fatty  food  or  by  fa\oring  the  conversion  into  fat  of 
sugar.  Whether  the  ingestion  of  large  quantities  of 
water  favors  obesity  has  long  been  a  disputed  point, 
but  Robin's  experiments  have  shown  that  water  favors 
that  form  of  obesity  which  is  the  result  of  increased 
assimilation,  but  exerts  no  effect  when  the  increase  of 
fat  is  due  to  diminished  disassimilation.  The  action 
of  alcohol  is  exerted  in  sexeral  ways,  the  chief  of 
which  are  by  causing  dyspepsia  and  by  retarding  nu 
trition.  The  infiuence  of  the  nervous  system  in  the 
causation  of  obesity  is  very  evident  in  certain  cases, 
but  its  mechanism  is  not  verv  clear. 

The  Diagnosis  of  Internal  Diseases  by  Means  of 
the  Roentgen  Rays. — Dr.  ("jruxmai  h,  of  JSerlin,  ex- 
hibited several  skiagraphs  showing  enlargements  of 
the  heart,  aneurisms,  and  tumors  of  various  kinds. 
In  all  the  diagnosis  had  been  arrived  at  by  means  of 
the  .v-rays. 

The  following  papers  were  read  by  title:  "  The 
Pathogenesis  of  Vesical  Calculus,"  by  Dr.  Ebstein,  of 
Gottingen;  "The  Pathogenesis  and  Treatment  of 
Gout,"  and  "The  Therapeutic  Value  of  Prepared 
Foods,"  by  Dr.  B.  Laquer,  of  Wiesbaden;  "Febrile 
Ura;mia,"  by  Dr.  Ughetti  of  Catania;  and  "The  Clin- 
ical Classification  of  Nephritis,"  by  Dr.  von  Levden, 
of  Berlin. 


Second  Day — Saturday,  August  21st. 

The  following  were  appointed  honorary  presidents 
for  the  day:  Drs.  von  Ziemssen.  of  Munich:   Crocq,  of 


Brussels;  Widal,  of  Paris;  Marchiafava,  of  Rome; 
Daland,  of  Pliiladelphia :  and  Thayer,  of  Baltimore. 

The  High-Altitude  Treatment  of  Tuberculosis. 
—  Dr.  von  Ziemssen  read  the  first  paper  of  the  day. 
Looking  back  over  the  history  of  tuberculosis,  he  said, 
we  see  a  motley  conglomeration  of  methods  of  treat- 
ment, for  during  the  present  century  almost  every  year 
has  brought  w  ith  it  a  new  remedy.  All  these  have 
now  been  discarded  and  but  two  agents  remain  to  be 
considered,  namely,  tuberculin  and  climate.  In  re- 
gard to  the  first,  the  "  specific"  treatment,  there  is  lit- 
tle to  say.  Koch's  old  tuberculin  has  been  forgotten, 
the  value  of  the  new  has  not  yet  been  proven,  and 
most  people  already  doubt  its  efficacy.  In  speaking 
of  tuberculosis,  he  said,  he  meant  particularly  pul- 
monary tuberculosis;  other  forms,  such  as  lupus,  have 
without  doubt  been  cured,  but  for  the  pulmonary  form, 
the  most  frequent  and  therefore  the  most  serious,  noth- 
ing really  has  been  done.  The  complexity  of  the 
lesions  make  a  cure  by  means  of  a  specific  seemingly 
impossible.  Other  forms  have  their  specifics,  for 
tuberculin  will  often  cure  lupus,  and  iodoform  will 
cure  tuberculosis  of  the  joints,  but  as  yet  we  have  no 
specific  for  tuberculosis  of  the  lungs.  There  remains 
therefore  only  the  climatic  treatment.  As  far  back  as 
w-e  can  see  in  the  history  of  medicine  fresh  air  has 
been  one  of  the  requirements  in  the  treatment  of  tuber- 
culosis, but  it  is  only  of  late  that  the  advantage  of 
high  altitudes,  at  least  for  many  cases,  has  been  clearly 
demonstrated.  That  tuberculous  patients  can  gel  a 
quantity  of  fresh,  pure  air  in  these  regions  is  evident 
to  any  one  visiting  the  places.  On  the  mountains  in 
the  centre  of  Europe,  mountains  covered  with  snow 
during  the  entire  winter,  one  can  see  patients  sitting 
in  the  sun  drinking  their  morning  coffee,  with  snow  all 
around  them,  yet  the  sunbeams  are  so  warm  and  pleas- 
ant that  they  are  perfectly  comfortable.  But  the  fresh 
air  that  surrounds  them  is  not  all;  the  altitude  brings 
about  an  excitation  of  the  blood-making  organs  that 
increases  the  corpuscular  elements  in  the  blood.  Even 
in  health  this  reaction  takes  place,  but  not  so  markedly 
as  in  diseased  states.  There  are  contraindications  to 
high  altitudes  which  prevent  us  from  sending  all 
patients  there.  .\  tuberculous  patient  with  fever 
should  never  be  sent  to  a  height,  for  he  will  certainly 
become  worse  and  the  fever  will  be  increased.  W- 
most  always  patients  without  fe\er  do  well,  though 
they  sometmes  find  it  difficult  at  first  to  acclimatize 
themselves.  If  the  fever  is  due  wholly  to  the  presence 
of  bronchitis  or  pleurisy,  it  does  not  act  as  a  contra- 
indication. 

The  best  results  are  obtained  when  the  patient  is 
.sent  to  a  place  near  his  own  home,  for  a  long  journey 
is  always  depressing,  and  the  comfort  of  seeing  friends, 
especially  to  a  sick  man,  is  very  great.  The  stage  of 
the  disease  must  be  taken  into  account  in  deciding 
this  matter.  If  the  ca.se  is  much  advanced,  the  pa- 
tient should  be  kept  as  near  home  as  possible. 

The  speaker  took  up  the  subject  of  sanatorium 
treatment  for  the  poor.  He  feared  the  number  of  the 
rich  is  too  few  to  build  sanatoria  for  all  the  world, 
but  that  should  not  paralyze  all  effort,  for  every  case 
cured  and  every  case  isolated  are  steps  toward  the  con- 
quest of  the  disease. 

Dr.  Senator  said  that  his  personal  experience  with 
tuberculin  had  not  been  very  extensive.  He  had  tried 
it  carefully  in  a  dozen  cases,  but  without  good  results. 
In  a  few  it  seemed  to  moderate  stmiewhat  the  fever, 
but  in  the  others  it  acted  as  poison.  He  was  con- 
vinced that  the  only  treatment  of  value  was  the  cli- 
matic, and  he  believed  high  altitudes  were  often  of 
especial  value.  He  did  not  believe  that  good  was 
done  by  increasing  the  number  of  red  corpuscles  be- 
cause he  had  seen  more  than  one  case  in  which  eleva- 
tion had  no  visible  influence  on  the  corpuscular  ele- 


September  1 1,  1897] 


MEDICAL    RECORD. 


395 


Tuents  of  the  blood  and  yet  the  patient  improved.  He 
.agreed  with  the  reader  of  the  paper  that  the  principal 
contraindication  to  high  altitudes  was  fever,  for  there 
is  great  danger  in  such  cases  of  hfemoptysis.  Never- 
theless some  cases  of  hemoptysis  without  fever  (when 
the  hemorrhages  are  slight)  do  well  in  these  regions. 
He  regarded  altitude  as  a  factor  second  only  in  im- 
portance to  fresh  air.  Sunlight  is  also  of  great  \-alue 
and  the  sun's  rays  themselves  exert  a  particular  intlu- 
lence.  Pharyngeal  and  lar}'ngeal  cases  do  not  im- 
prove, and  in  fact  always  become  worse,  so  that  Dr. 
Senator  regarded  such  complications  as  a  positive 
contraindication  to  the  high-altitude  treatment  of  pul- 
monary tuberculosis. 

Dr.  von  Levden  said  that  in  his  hands  the  specific 
treatment  had  fafled,  and  he  did  not  believe  there  could 
be  any  sure  success  with  tuberculin.  The  specific  may 
come  but  we  cannot  wait  for  it.  We  must  not  look  to 
the  future;  we  are  living  in  the  present  and  must  treat 
in  the  present.  So  far  the  only  treatment  that  has 
given  any  positive  success,  he  said,  is  the  climatic. 
His  best  results  had  been  obtained  in  the  mountains, 
but  the  place  and  its  climate  must  be  selected  to  suit 
the  individual  patient.  A  patient  should  not  be  sent 
far  from  home,  for  the  nearer  he  is  to  friends  the  more 
comfortable  and  contented  he  will  be  and  the  better, 
as  a  rule,  will  be  the  results. 

Dr.  Kornig,  of  St.  Petersburg,  said  that  he  had 
found  an  increase  in  the  red  blood  cells  in  patients 
who  had  gone  to  high  altitudes,  and  he  was  inclined 
to  attribute  to  this  increase  a  large  part  of  the  benefit 
derived  from  a  stay  in  these  mountain  sanatoria. 

Dr.  Dehio,  of  Dorpat,  said  that  observations  of  the 
sanatoria  in  Russia,  for  instance  Hallila  in  Finland 
and  Lindheim  in  Livonia,  have  shown  that  the 
climatic  peculiarities  of  the  Russian  winters  have  an 
effect  on  tuberculosis  very  similar  to  that  of  high 
altitudes. 

Dr.  J.\rvein,  of  St.  Petersburg,  reported  the  results 
of  a  trial  of  tuberculin  in  the  clinic  of  Professor 
Janowsky  in  the  military  academy  at  St.  Petersburg. 
It  was  tried  in  eight  cases,  five  of  which  were  very 
mild  and  in  the  first  stage.  They  began  with  one- 
five-hundredth  of  a  gram  and  increased  daily  to  one 
milligram.  At  first  the  patients  showed  no  reaction 
to  the  drug,  but  when  the  dose  of  one-fiftieth  to  one- 
twenty-fifth  of  a  milligram  was  reached  the  tem- 
perature began  to  rise  to  from  37.8°  to  38.5°  (100'  to 
101.3^  F.)  and  after  two  weeks  three  of  the  patients 
began  to  have  hemorrhages.  From  this  time  (after 
two  weeks),  five  patients  began  to  grow  steadilywor.se, 
and  by  the  end  of  two  months  it  became  absolutely 
necessary  to  stop  the  use  of  the  tuberculin.  The 
three  other  cases  were  complicated  with  fever.  The 
reaction  occurred  sooner  and  the  rise  of  temperature 
was  greater.  The  last  case  was  that  of  a  physician 
with  tuberculosis  of  the  pharynx.  In  the  beginning 
he  reacted  feebly,  so  that  the  dose  was  gradually  in- 
creased to  three  milligrams.  Then  appeared  some 
fresh  miliary  tubercles,  the  temperature  rose  quickly 
to  38"  to  39"  to  40°  (100.2^-104'  F.),  and  in  three 
months  he  died  with  all  the  symptoms  of  general  mil- 
iary tuberculosis.  .\fter  listening  to  the  greatest 
authorities  in  Europe  on  the  treatment  of  phthisis  in 
sanatoria,  the  speaker  thought  that  there  can  be  liut 
little  doubt  left  in  the  minds  of  those  present  that  this 
is  at  present  the  only  mode  of  treatment;  and  as  to 
the  question  of  sanatoria  for  the  poor  he  was  sure  that 
there  were  in  Mo.scow  and  all  over  the  world  many 
rich  men  who  would  be  willing  to  give  generously  for 
such  a  purpose  if  it  was  properly  presented  to  them  on 
the  authority  of  the  international  medical  congress 
that  such  was  Uie  only  method  of  treatment. 

The  Climatic  Treatment  of  Tuberculosis.— Dr. 
ViVANT,  of   Monte  Carlo,  continued  the  discussion  by 


the  reading  of  a  carefully  prepared  paper.  The  dis- 
covery of  the  tubercle  bacillus,  he  said,  has  taken 
nothing  from  the  importance  of -the  climatic  treatment 
of  tuberculosis,  in  particular  that  of  pulmonary  tuber- 
culosis, the  most  difficult  to  handle.  The  bacillus  of 
tuberculosis  resists  alike  high  and  low  temperatures, 
so  that  there  is  no  climate  with  absolute  immunity. 
The  climates  most  justly  regarded  as  of  value  in  the 
treatment  of  this  disease  ofter  a  certain  number  of  fea- 
tures in  common,  viz. :  pure  air — that  is,  oxygen  in 
unlimited  quantity;  and  relative  dryness — that  is,  ab- 
sence of  fogs,  of  air  charged  with  moisture,  to  inter- 
rupt the  light,  heat,  and  chemical  action  of  the  sun's 
rays.  We  know  the  importance  of  light  for  animal 
and  vegetable  cells,  and  we  recognize  that  solar  light 
rapidly  kills  bacteria.  Air  to  be  pure  ought  not  to 
contain  dust,  especially  pathogenic  dust;  it  would  be 
therefore  useless  to  choose  a  windy  place.  Patho- 
genic dust  is  found  especially  in  the  midst  of 
crowded  places,  and  the  danger  of  mixed  infection 
arises;  hence  a  person  with  pulmonary  tuberculosis 
should  especially  avoid  large  cities.  The  temperature 
of  the  air  as  regards  its  infiuence  upon  the  respiratory 
tract  is  of  little  importance;  yet  there  is  an  advantage 
on  the  side  of  heat,  inasmuch  as  cold  climates  expose 
the  human  organism,  especially  when  feeble,  to  a  va- 
riety of  serious  circulatory  troubles  included  under  the 
general  term  "  colds."  The  stations  on  the  Riviera, 
the  plains  of  the  deserts,  the  high-altitude  resorts,  all 
offer  in  different  degrees  all  these  active  elements  in 
climatic  treatment ;  but  the  plains  and  the  deserts  offer 
no  shelter  from  the  heavy  winds,  the  principal  agents 
of  colds  and  principal  disseminators  of  dust.  The 
Mediterranean  resorts  offer  the  advantage  over  the 
mountains  that,  with  a  superior  solar  radiation,  they 
are  less  cold,  permitting  the  patient  to  live  in  the  open 
air  continually  in  light,  thin  clothes,  giving  the  air 
and  light  the  best  chance  to  exert  their  favorable 
therapeutic  action. 

The  Foundation  of  a  Rational  Treatment  of 
Phthisis. — Dr.  Drozda,  of  Vienna,  read  this  paper. 
The  subject,  he  said,  resolves  itself  into  several  parts: 
I.  It  is  necessary  to  destroy  the  accumulated  toxins 
following  the  invasion  of  tubercle  bacilli,  streptococci, 
and  staphylococci.  2.  Since  there  can  be  no  question 
of  an  immediate  rapid  excretion  of  micro-organisms, 
we  must  seek  to  diminish  as  much  as  possible  the  vir- 
ulence of  the  bacteria  already  present.  3.  We  must 
endeavor  to  strengthen  the  vital  energy  of  the  affected 
organs.  4.  V\'e  must  take  care  to  allow  the  f-ee  elim- 
ination of  infiltrated  masses  which  have  softened.  5. 
The  micro-organisms  which  have  already  passed  into 
the  lymphatic  system  must  be  rendered  innocuous. 

The  Malarial  Parasite Dr.  Gautier,  of  Mos- 
cow, read  a  paper  giving  certain  details  in  the  struc- 
ture of  the  parasites  of  Laveran  during  their  evolution. 
Following  in  the  path  marked  out  by  Gojgi  and  Ro- 
manofsky,  he  said,  we  can  study  the  details  of  the 
structure  of  the  parasite  which  are  not  to  be  distin- 
guished by  other  methods  of  staining.  In  cases  of 
intermittent  fever  studied  in  the  Caucasus,  the  author 
had  observed  in  the  blood  three  species  of  hamatozoa. 
Kach  of  these  had  a  characteristic  life  cycle,  by  which 
it  could  be  distinguished  from  the  other  two.  r)ne  of 
these  corresponded  to  the  parasite  of  tertian  fever,  and 
another  to  that  of  quartan,  as  Golgi  has  described 
them.  The  third  was  probably  identical  with  the  par- 
asite observed  in  Italy  by  Marchiafava  in  cases  of 
tertian  autumnal  fever.  According  to  the  author's 
observations,  the  life  cycle  of  the  last  parasite  was 
two  days.  The  fever  produced  by  it  might  be  classed 
among  the  irregular  fevers,  having  sometimes  a  tertian, 
sometimes  a  quotidian  type.  These  three  species  of 
hjematozoa,  different  one  from  the  other,  undergo  dur- 
ing their  evolution  a  series  of  modifications  common 


39^ 


MEDICAL    RECORD. 


[September  ii,  1897 


to  all.  The  most  interesting  of  these  processes  is  the 
development  of  the  nucleus,  the  retrograde  evolution 
of  this  nucleus,  its  disappearance,  the  reappearance  in 
the  body  of  the  parasite  of  new  rudimentary  nuclei, 
which  become  the  centres  for  the  formation  of  young 
parasites,  after  which  division  of  the  parasite  occurs 
and  a  new  generation  arises. 

This  paper  was  accompanied  by  colored  pictures, 
showing  the  different  parasites  in  all  their  stages. 

\)R.  Th.wer,  of  Baltimore,  said  that  he  had  been 
much  impressed  by  the  e.\tremely  interesting  observa- 
tions of  Dr.  Gautier,  with  .some  of  which  the  speaker 
was  already  familiar  through  Gautier's  excellent  book 
on  the  parasite  of  Laveran.  In  the  observation  of 
over  two  thou.sand  cases  of  malarial  fever  occurring  in 
Baltimore  during  a  period  extending  over  the  la.st  seven 
years,  in  si.vteen  hundred  and  thirteen  of  which  cases 
the  parasites  were  carefully  studied  and  the  types 
differentiated,  Dr.  Thayer  had  been  led  to  distinguish 
three  varieties  of  the  malarial  parasite — the  tertian. 
the  quartan,  the  jestivo-autumnal  or,  as  Welch  has  hap- 
pily termed  it,  tlie  hrematozoon  falciparum.  Each  of 
these  three  varieties  of  parasites  is  associated  with  a 
characteristic  type  of  fever.  The  speaker  said  that  he 
and  his  fellow-workers  had  not  been  able  to  separate 
the  EEstivo-autumnal  type  into  two  distinct  varieties, 
as  have  some  of  the  Roman  school  and  Mannaberg, 
and  they  believed  that  the  a;stivo-autumnal  parasite  is 
a  single  organism,  the  length  of  whose  cycle  of  devel- 
opment may  vary  materially  under  different  circum- 
stances, lasting  more  commonly  about  forty-eight 
hours,  but  not  infrequently  being  considerably  shorter. 
Between  these  three  varieties  of  parasites  they  had 
never  observed  any  transitional  stages,  nor  were  there 
any  facts  in  their  experiences  which  would  suggest  that 
such  transitional  forms  exist.  (!^ombined  affections 
may  occur,  but  they  are  rare;  they  were  present  in  a 
little  more  than  two  per  cent,  of  the  cases  studied  by 
the  speaker.  He  did  not  agree  with  those  observers 
who  consider  that  the  malarial  parasite  is  a  single 
though  polymoqjhous  organism,  for  his  experience  in- 
clined him  to  the  view  that  these  three  forms  represent 
separate  varieties  or  species  of  organisms.  While 
agreeing  entirely  with  Dr.  Gautier  as  to  the  types  of 
parasites,  he  had  to  confess  that  he  had  not  succeeded 
in  obtaining  the  same  beautiful  results  in  his  stained 
specimens.  It  is  not  impossible  that  this  might  be 
dut',  he  thought,  to  the  fact,  as  pointed  out  by  Dr. 
Gautier,  that  this  result  is  to  be  obtained  with  certainty 
only  when  especial  varieties  of  methylene  blue  are 
used. 

On  the  Increase  of  Eosinophilic  Cells  in  Trichi- 
nosis.—  Dr.  Thayer,  of  ISaltimore,  then  read  a  paper 
containing  a  rcs/inu' oi  the  studies  of  Dr.  Brown  on  two 
cases  of  trichinosis.  Dr.  P.rown's  paper,  he  said, 
would  appear  in  X\\&Jniiriiitl  of  KxptTiiiuiital Mrtlii-iiic. 

Case  I.  —  R.  T ,  aged   twenty-eight.     Previous 

history  negative.  The  subjective  and  objective  symp- 
toms all  pointed  to  trichinosis,  and  besides  a  .small 
piece  of  muscle  cut  from  the  biceps  showed  living 
trichiniB.  On  the  day  of  admission,  March  8th,  ex- 
amination of  blood  showed  red  blood  corpuscles,  4,232,- 
000;  leucocytes,  16,500.  Differential  count  of  leuc<i- 
cytes:  Small  mononuclear  leucocytes,  5  per  cent.: 
large  mononuclear  and  transitional  forms,  7  per  cent. ; 
polymorphonuclear  neutrophiles,  50  percent.;  eosin- 
ophiles,  38  per  cent.  The  total  number  of  leucocytes 
ranged  between  13,000  and  35,000.  The  percentage 
of  eosinophiles  ranged  between  8  and  68.  The  small 
and  large  mononuclear  elements  remained  throughout 
at  a  percentage  slightly  higher  than  one  would  have 
expected  with  the  degree  of  leucocytosis  existing, 
while  the  number  of  polymorphonuclear  neutrophiles 
was  in  directly  inverse  proportion  to  that  of  the  eosin- 
ophiles.    Thus,  on  the  23d  of  .\pril,  with  a  leucocy- 


tosis of  17,000,  the  differential  count  of  the  leucocytes- 
was:  Small  mononuclear  leucocytes,  19.5  per  cent.; 
large  mononuclear,  5.2  per  cent.;  polymorphonuclear 
neutrophiles,  6.6  per  cent.:  eosinophiles,  68.2  per 
cent. 

Cask   II. —  K.  B ,  twenty -nine  }ears  old,  showed 

few  if  any  of  the  classical  symptoms  of  trichinosis. 
Such  a  condition  was  not  thought  of  till  after  the 
blood  examination.  This  showed  red  corpuscles, 
5,000,000;  colorless  corpuscles,  13,000.  Differential 
count:  Small  mononuclear  forms,  11  per  cent.;  large 
mononuclear,  5  percent.;  polymorphonuclear  neutro- 
philes, 37  per  cent.:  eosinophiles,  44  per  cent.  Dr. 
Brown,  remembering  the  case  of  trichinosis  with  the 
high  percentage  of  eosinophiles,  examined  a  piece 
of  the  muscle  from  the  calf,  and  found  living  trichina:. 
In  this  case,  as  in  the  former,  the  same  inverse  pro- 
portion existed  between  the  number  of  neutrophilic 
and  the  eosinophilic  leucocytes. 

Conclusions:  i.  In  two  instances  of  trichinosis  the 
circulating  blood  has  been  found  to  contain  a  larger 
percentage  of  eosinophilic  cells  than  has  ever  pre- 
viously been  demonstrated.  2.  This  increase  in 
eosinophiles,  occurring  in  connection  with  a  moderate 
or  well-marked  leucocytosis,  always  occurs  at  the  ex- 
pense of  the  polymorphonuclear  neutrophiles,  which 
are  correspondingly  decreased  in  number,  the  small 
and  laige  mononuclear  and  transitional  forms  being 
present  in  normal  proportions  in  a  percentage  slightly 
below  normal,  not  far  from  what  one  would  expect 
with  a  leucocytosis  of  the  existing  degree.  3.  Whether 
these  changes  in  the  blood  are  characteristic  of  trichi- 
nosis, or  are  also  to  be  found  in  extensive  myositis- 
from  other  causes,  remains  to  be  shown.  4.  The  re- 
markable inverse  proportion  between  the  eosinophiles 
and  the  neutrophiles  in  these  instances,  as  well  as  the 
changes  observed  by  Brown  in  the  histological  study 
of  the  muscle,  forms  suggestive  evidence  in  favor  of 
the  view  that  the  increase  in  eosinophiles  in  these 
cases  occurred  by  a  direct  transition  from  the  poly- 
morphonuclear neutrophilic  elements. 

Dr.  D.\i,.\Nr),  of  Philadelphia,  said  that  without 
doubt  this  was  something  original  in  the  diagnosis  of 
trichinosis,  and  the  fact  of  an  increase  of  eosinophiles 
at  the  expense  of  the  polymorphonuclear  neutrophiles 
was  intensely  interesting. 

Dk.  F.WAi.n,  of  lierlin,  inquired  whether  Dr.  Thayer 
had  found  any  connection  between  the  toxins  created 
by  the  trichina:  and  the  increase  in  eosinophiles. 

Dr.  Thayer  said  that  he  believed  more  eosinophiles 
were  found  in  the  muscles  than  in  the  circulating 
blood,  so  much  so  that  it  seemed  to  suggest  that  the 
polynuclear  cells  after  leaving  the  vessels  became 
eosinophiles.  , 

The  following  papers  were  read  by  title:  "The 
Displacement  of  the  Heart  in  Left-sided  Pleural 
Effusions"  and  "The  Physio- Pathological  Significa- 
tion of 'Ictus  Cordis,'"  by  Dr.  Queirolo,  of  Pisa; 
"  .\re  the  Different  Forms  of  Malaria  Cau.sed  by  One 
or  Several  Parasites?"  by  Dr.  Celli,  of  Rome:  and 
another  with  the  same  title  by  Dr.  Sakharov,  of  Tit! is j 
"The  Unity  of  Paludism,"  by  Dr.  Coronado,  of  Ha- 
vana; "The  Para-site  of  Pernicious  Fever  and  its 
Clinical  Forms,"'  by  Dr.  Marchiafava,  of  Rome; 
'■  Some  Remarks  on  Diseases  of  Malarial  Type,"  hj' 
Dr.  Da  Rocha,  of  Coimbra:  "Note  on  the  History  of 
Epidemic  Paludism,'"  by  Dr.  Mejia,  of  Mexico;  "Tu- 
berculous Splenomegaly,"  by  Dr.  Widal.of  Paris:  and 
"The  Role  of  Heredity  in  tlie  Etiolog}-  of  Certain 
Diseases,"  by  Dr.  Rabanov,  of  Moscow ;  "  The  Cura- 
tive .Vction  of  Xitrate  of  Silver  and  of  Ergotin  in  Pul- 
monarv  Tuberculosis,"'  and  "  'The  Efficacy  of  Revul- 
sion in  the  Treatment  of  Pulmonary  Tuberculosis,"  by 
Dr.  Crocq,  of  Brussels. 

l/;.  he  C„KtiKHf,1.^ 


September  ii,  189/] 


MEDICAL    RECORD. 


397 


ttovrcspoml  encc. 

OUR  LOXDOX  LETTER. 

(  From  our  Special  Correspondent,  t 

TO    MOSCOW — TO    INDIA THE    MILITARY    MEDICAL    StR- 

VICES  —  CO.MB.\TANTS'  PREJUDICES — A    JUSTER   ABBRE- 
VLATIOX — THE       NETLEY-SCHOOL        PRIZES — GENERAL 

butler's  ADDRESS ADVERTISING    IN    LAY     JOURNALS 

A    GREATER     SCAND.\L     AT     MERCEr's     HOSPITAL 

STARVING    PATIENTS  — CHOLERA  ALARMS DANGEROUS 

ST.^TE     of    THE     RIVER    BRENT STATISTICS     OF     HOS- 
PITALS— ACCIDENT       TO        OUT  -  PATIENTS  PAUPER 

NURSING     ABOLISHED EXPLOSIVE      HAIR      W.ASHES 

CONGRKSES — DEATHS      OF      DRS.       NELSON      AND      DU 
PASQUIER. 

LoNuo.N',  August  20.  1S97. 

The  International  Medical  Congress  will  have  a 
fair  representation  from  these  islands,  as  in  spite  of 
■other  attractions  and  the  long  journey  a  number  of  our 
brethren  will  undertake  the  trip  to  Moscow. 

In  consequence  of  the  Indian  troubles  a  number  of 
army  medical  officers  have  been  detailed  for  duty  on 
the  northwestern  frontier.  Nine  surgeon-majors  and 
surgeon-captains  leave  London  to  day  to  catch  the  P. 
and  O.  steamer  at  Brindisi  for  Bombay.  Of  course 
all  leave  is  stopped  and  there  must  be  pressure  on  the 
■department 

Though  the  Indian  service  will  not  want  men,  the 
prospects  for  the  army  are  not  pleasant,  in  the  face  of 
the  failure  of  the  last  examination  to  attract  competi- 
tors. There  have  been  serious  rumors  as  to  Lord  W'ol- 
seley's  health,  and  though  these  were  contradicted  it  is 
again  affirmed  that  he  will  have  to  resign.  If  Sir  R. 
Buller  succeeds  as  commander-in-chief  it  will  be  only 
an  exchange  of  log  for  stork,  so  far  as  the  medical  staff 
is  concerned.  If  he  should  be  passed  by.  Lord  Roberts 
would  have  the  post,  and  he  is  held  to  be  a  just  man 
with  an  open  mind,  and  as  such  would  be  certain  to 
lend  an  ear  to  the  medical  sen-ice  and  then  the  grie- 
vances must  be  redressed. 

The  offensive  conduct  of  military  officers  is  so  con- 
stant a  source  of  annoyance  that  it  is  pleasant  to 
chronicle  an  occasional  appreciative  utterance,  such 
as  that  of  Major-General  Sir  \Vm.  Butler,  who  dis- 
tributed the  prizes  at  the  close  of  the  last  session  of 
the  Netley  School.  In  his  address  he  spoke  of  the 
profession  as  in  one  sense  the  highest,  and  told  the 
medical  officers  they  represented  the  humanizing  influ- 
ence, the  openness  or  freedom  of  mind  and  indepen- 
dent thought,  which  are  of  the  greatest  value  in  the  pro- 
fession of  arms,  w  here  the  chief  mental  danger  is  a  too 
restricted  idea  of  the  horizon  of  life.  In  illustration 
of  his  meaning  he  referred  to  the  two  brave  and  honor- 
able surgeons  at  St.  Helena,  who,  undeterred  by  official 
censure,  fixed  in  the  immutable  traditions  of  honor, 
truth,  and  justice,  protested  against  the  mean  and 
stupid  persecution  of  the  dying  Napoleon.  "  It  is 
tnie."  he  said,  "  they  lost  everything,  but  they  won 
more  than  the  world's  applause,  for  in  a  measure  they 
redeemed  the  national  honor  when  the  action  of  their 
official  superiors  had  compromised  it."  The  general 
also  referred  to  Baron  Larrey,  whom  Napoleon  pro- 
nounced the  '"most  virtuous  man  I  have  ever  known:"' 
and  in  conclusion  alluded  to  his  own  debt  for  the 
care  and  sympathy  and  skill  bestowed  on  him  at  Netley 
five  and  twenty  years  ago.  and  to  which  under  Provi- 
dence he  ascribed  his  survival  to  address  those  entering 
on  their  honorable  career,  in  which  he  wished  them 
prosperity  and  happiness.  Among  other  notabilities 
present  on  this  occasion  was  Sir  Joseph  Fayrer,  who 
also  made  a  short  speech,  in  which  he  pointed  out  to 
the  Indian  officers  the  grand  career  before  them  in  a 
service  which  had  produced  most  brilliant  men  and 


which  he  believed  would  be  even  better  in  the  future 
than  in  the  past. 

What  is  medical  advertising?  The  question  seems 
always  with  us.  An  anonymous  correspondent  of  the 
J/e(/itra/  jPress  attacked  Dr.  Brunton  for  permitting  a  re- 
view of  a  work  of  his  to  appear  in  the  Giasgou'  Herald. 
Dr.  Brunton  replied  regretting  he  had  not  specially  in- 
structed his  publishers  not  to  send  the  book  to  lay 
journals.  The  Herald  is  indignant  with  the  J'rcss 
and  the  doctor,  and  says :  "  Medical  etiquette  is  surely 
the  strangest  wild  fowl  in  the  whole  menagerie  of  con- 
ventions"^ — a  view  it  would  be  no  easy  task  to  refute. 
The  Herald  says  it  w  ill  not  be  deterred  by  the  tyranny 
of  medical  journals  from  giving  its  readers  the  best 
expert  opinion  of  whatever  publications  it  chooses,  and 
there  are  plenty  of  ways  of  obtaining  books  besides  the 
gifts  of  publishers.  The  Press  retorts  that  if  every 
lay  journal  were  to  give  a  lengthy  review  of  medical 
works  as  they  appeared,  the  nation,  would  soon  be  a 
collection  of  feeble-minded  neurotics  through  perus- 
ing the  lay  papers.  This  is  rather  strong,  certainly, 
but  is  it  true  in  any  degree?  Reviews  could  never  oc- 
cupy so  much  space  as  quack  advertisements  now  do. 
These  lay  papers  (by  the  way,  is  not  the  word  lay 
getting  very-  much  abused,  its  meaning  indefinitely 
extended?)  will  not  be  dictated  to  and  the  medical 
ones  are  open  to  the  retort  that  they  want  to  drive 
advertisements  into  their  own  columns.  It  is  not 
many  years  since  the  leading  medical  journals  adver- 
tised unblushingly  their  contents  in  the  ''  lay"  papers, 
and  the  contents  were  scarcely  ever  suitable  for  family 
reading.  When  this  became  too  blatant,  the  advertise- 
ments were  restricted  to  the  Times,  and  for  years  that 
paper  was  held  to  be  a  permissible  medium  for  adver- 
tising medical  books.  Now  the  purists  include  it  in 
their  objections.  Assuredly  the  Times  will  not  be 
intimidated  by  the  loss  of  a  few  advertisements  from 
commenting  upon  medical  as  well  as  sanitary  questions, 
and  it  is  somtimes  difficult  to  draw  the  line.  The 
■"lay"  papers  will  do  whatever  they  think  pleases  the 
great  public,  whatever  the  professional  journals  may 
say,  and  there  is  not  much  danger  of  medical  books 
becoming  popular.  Other  forms  of  advertising  are 
certainly  more  offensive  and  within  each  man's  own 
control,  while  publishers  have  a  finger  in  this. 

The  Mercer's  Hospital  scandal  has  developed  into 
something  that  looks  like  a  crime.  I  am  crediblv  in- 
formed that  the  house  committee  discharged  all  the 
patients  under  Mr.  O'Grady  and  in  order  to  compel 
them  to  leave  they  were  refused  all  food  for  twenty- 
four  hours,  \\hen  Mr.  O'Grady  heard  of  this  he 
bought  food  for  them  and  brought  it  in.  The  plan  of 
standing  the  patients  has  been  defended  by  the  regis- 
trar in  a  letter  to  the  newspapers.  How  long  is  such 
a  committee  to  be  suffered  to  afflict  the  sick?  If  one 
had  died,  a  verdict  of  manslaughter  might  have  been 
the  consequence.  Irish  lawyers  are  proverbially  acute, 
and  it  will  be  strange  if  none  of  them  can  bring  the 
members  of  this  committee  to  book  for  endangering 
the  lives  of  patients  intrusted  to  their  care.  Every 
one  of  those  who  were  guilty  of  this  act  should  be 
placed  in  the  criminal- dock. 

London,  -\ugiist  27,  1897. 

We  have  had  what  the  newspapers  call  a  "cholera 
scare,"  but  it  must  be  admitted  that  London  has  taken 
the  sensation  w  ith  abundant  sang Jroid,  and  w  ith  good 
reason,  too,  considering  the  circumstances  and  our 
state  of  sanitary  preparedness.  The  case  reported  cer- 
tainly exhibited  some  of  the  symptoms  of  cholera  and 
rhe  patient  died  in  a  state  of  collapse  after  se\enteen 
hours'  illness.  .\  working  girl  at  the  east  end  of  Lon- 
don went  to  bed  well  after  a  supper  of  bread,  butter, 
cheese,  tomatoes,  and  fried  potatoes.  She  was  at- 
tacked with  vomiting  and  diarrhora  in  the  night.     .\ 


MEDICAL    RECORD. 


[September  1 1,  i< 


doctor  was  called  in  the  morning,  who  found  her  in  a 
collapsed  condition  with  a  temperature  of  94  F.  At 
the  post-mortem  ecchymoses  were  found  on  the  brain, 
the  lungs  were  collapsed,  the  blood  was  tarry,  and  the 
intestines  contained  a  greenish  Huid.  Bacteriological 
examination  was  negative.  The  jury  at  the  inquest 
returned  a  verdict  of  English  cholera,  and  the  county 
council  on  the  strength  of  the  bacteriological  reports 
stated  it  could  not  be  the  Asiatic  scourge.  There  was 
absolutely  no  source  of  infection  to  be  incriminated 
and  the  disease  did  not  spread.  In  the  absence  of 
cholera  in  Europe  "scare"  was  uncalled  for  and  in 
fact  took  place  only  among  the  journalists  in  search 
of  sensation.  Cases  of  so-called  English  cholera  oc- 
cur during  most  summers,  and  it  must  be  admitted  that 
some  of  them  present  symptoms  that  are  held  to  be 
the  appanage  of  the  .\siatic  variety,  and  it  may  be  im- 
possible from  symptoms  alone  to  differentiate  all  the 
varieties  of  purging  and  vomiting  ending  fatally.  In 
this  case  it  is  possible  some  ptomain  poisonitig  may 
have  been  at  the  bottom  of  the  mischief. 

While  cholera,  whether  Asiatic  or  English,  e.vcites 
public  fears,  the  holocaust  of  infants  from  summer 
diarrhoea  goes  on  from  year  to  year  with  little  notice. 
The  mortality  of  London  and  all  the  large  towns  has 
lately  been  rising,  the  chief  cause  being  this  summer 
ailment  of  infants.  The  number  of  deaths  reported  in 
London  from  diarrhoea  has  been  270,  459,  575,  and 
651  in  the  four  weeks  up  to  the  14th  instant.  Of 
this  mortality  over  ninety  per  cent,  is  due  to  the 
deaths  of  children  under  five  years  of  age.  What 
must  have  been  the  extent  to  which  diarrhoea  in  some 
degree  aflfected  patients  who  recovered?  The  advent 
of  colder  weather  is  making  itself  felt,  but  it  is  diffi- 
cult to  reconcile  one's  self  to  the  annual  sacrifice  of 
these  young  lives.  While  much  is  doubtless  due  to 
waves  of  heat,  it  seems  impossible  to  admit  that  we  are 
helpless.  The  powerful  effect  of  diet  and  suitable 
regimen  ought  to  enable  us  to  save  many  of  these  in- 
fantile victims.  But  so  long  as  the  public  fancies  that 
every  disturbance  of  the  alimentary  canal  is  caused 
either  by  eating  fruit  or  by  "biliousness,"  the  great 
majority  will  go  on  feeding  their  progeny  in  an  im- 
proper way  and  calling  in  the  doctor  only  when  too 
late.  It  must  be  admitted,  however,  that  infantile 
diarrhoea  offers  a  broad  field  for  further  investigation 
into  its  etiolog}',  treatment,  and  prevention. 
'  The  foul  state  of  the  River  Brent  has  at  length 
roused  the  local  government  board  and  the  Middlesex 
County  council  has  been  instructed  to  cleanse  it 
forthwith.  None  too  soon,  for  the  stream  has  become 
in  places  an  open  stagnant  sewer  and  the  pleasant 
villas  on  its  banks  are  almost  uninhabitable  on  ac- 
count of  the  horrible  .stenches  arising  from  the 
sewage.  It  is  averred  that  all  the  local  authorities 
have  discharged  only  clear  effluents,  but  ocular  and 
olfactory  evidence  proves  that  some  of  them  have  only 
imperfectly  treated  their  sewage,  if  indeed  it  has  not 
been  allowed  to  escape  without  any  treatment  at  all. 
Another  cause  for  the  dangerous  and  nauseating  state 
of  the  stream  seems  to  be  that  a  canal  company  im- 
pounds the  water  under  an  old  act.  to  such  an  extent 
as  to  arrest  the  flow.  Now  that  the  government  board 
has  spoken,  men  are  at  work  in  an  effort  toward  im- 
provement, which  can  only  be  temporar)-.  It  must 
follow  up  its  action  by  some  legislative  measure  so  as 
to  restore  the  once  delightful  valley  to  a  sanitary  con- 
dition. 

Murdett's  "  Hospitals  and  Charities"  for  1897  opens 
with  a  chapter  on  the  (Queen's  commemoration.  Her 
Majesty  is  patroness  of  more  than  sixty  hospitals  and 
dispen.saries  and  of  some  ninety  other  charities.  .As 
an  example  of  the  progress  of  charitable  institutions 
it  may  be  stated  that  in  the  hospitals  patronized  by  the 
Queen  there  were,  in  i8^?7,  ^.300  beds,  which  had  in- 


creased in  1895  ^'^  3i33'-  I  hese  were  used  by  about 
28,000  patients  in  1837  and  the  past  year  by  36,514. 
The  book  gives  statistical  and  other  information  re- 
specting all  sorts  of  institutions  for  the  relief  of  the 
sick  and  suffering,  and  describes  the  various  systems 
of  relief  which  are  adopted  in  the  various  parts  of  the 
English-speaking  world.  These  institutions  expend 
collectively  a  sum  of  from  twenty  to  twenty-five  mil- 
lions sterling. 

A  singular  accident  occurred  at  .St.  Bartholomew's 
hospital  on  Saturday.  A  number  of  out-patients  were 
waiting  to  be  admitted  when  the  portico  under  which 
they  were  standing  collapsed.  Most  of  them  made 
good  their  escape  but  several  who  were  near  the  door 
were  caught  by  the  falling  debris,  and  so  injured  that 
they  had  to  be  taken  into  the  hospital. 

The  "  order"  of  the  local  government  board  forbid- 
ding the  employment  of  paupers  in  nursing  is  giving 
much  satisfaction  to  poor-law  reformers,  who  have  long 
urged  that  the  evil  should  be  abolished.  A  further 
"  order"  requires  a  superintendent  nurse  to  be  ap- 
pointed in  any  workhouse  employing  three  or  more 
nurses  under  the  medical  officers'  control.  The  J/cJ- 
ical  Press,  always  well  informed  on  these  matters, 
urges  the  Irish  board  to  follow  the  example,  stating, 
however,  that  this  authority  is  but  the  servant  of  the 
guardians,  and  although  possessed  of  good  intentions 
takes  years  to  consider  them,  while  the  English  board, 
being  master  and  controller  of  the  guardians,  can  act 
without  hesitation  and  so  effect  a  reform  in  a  few 
months. 

The  county  council  has  prosecuted  a  number  of 
hairdressers  for  keeping  petroleum  without  a  license. 
Considering  that  a  lady  was  lately  burned  to  death  in 
a  hairdresser's  establishment  through  a  petroleum 
wash  taking  fire,  it  seems  incredible  that  any  one 
should  go  on  employing  such  a  material  to  cleanse  the 
hair.  One  would  suppose  too  that  no  one  would  run 
the  risk  of  such  a  painful  death  as  that  which  lately 
shocked  the  community.  The  council  will  follow  up 
the  matter  and  exact  the  penalties  in  all  cases. 

Next  vear  the  Pharmaceutical  Congress  is  to  be  held 
at  Belfast  and  the  Institute  of  Public  Health  at  Dublin. 
The  British  Dental  Association's  annual  meeting  was 
held  in  Dublin  last  week  and  the  attendants  had  a 
splendid  reception  from  the  citizens.  This  is  but 
natural  when  we  remember  the  proverbial  Irish  hos- 
pitality, on  which  many  will  count  for  next  year. 

The  death  is  announced  of  the  venerable  Dr.  D.  H. 
Nelson,  formerly  professor  of  medicine  in  Queen's 
College,  Birmingham,  and  author  of  various  contribu- 
tions to  our  literature.  He  took  his  M.D.  at  Edin- 
burgh in  1848.  He  retired  some  years  ago.  He  was 
in  the  eighty-eighth  year  of  his  age  when  he  died  on 
the  loth  inst. 

The  death  of  Dr.  Du  Pasquier,  F.R.C.S.,  took  place 
last  Friday  at  the  age  of  eighty-six  years.  He  also 
had  long  retired,  though  he  is  well  remembered  by 
many  who  knew  him  when  he  practised  in  Pall  Mall 
and  was  surgeon -apothecary  to  the  Queen  and  the 
Prince  of  Wales. 


OUR   VIENNA  LETTER. 

( From  our  Special  CoirespoDdent.) 
.\  CON'SERV.ATIVE  MEDICAL  POSITION  AS  TO  BICYCLINt: 
FOR  SEDENTARY  PEOPLE — GROWING  DISFAVOR  OK 
CHLORATE  OF  POTASSIUM  OWING  TO  RECENT  -OCCI- 
DENTS— A  BRAIN  LESION  IN  POISONING  FROM  ILLUMI- 
NATING GAS — PROFF.SSOR  ADAMKIEWICZ  AND  THE 
PHYSIOLOGICAL  IMPOSSIBILITY  OF  INCRE.\SED  INTRA- 
CRANIAL pressurf:. 

\'|KNNA,    August  16,    1897. 

.\Boi'r  the  beginning  of  tiie  summer  most  of  the  both- 
er.some   police    regulations    affecting    bicyclists   were 


September  ii,  1897] 


MEDICAL    RECORD. 


399 


done  away  with.  It  is  no  longer  necessary  to  have  a 
police  license,  or  to  carr)-  a  number  prominently  dis- 
played, or  to  appear  at  the  prefecture  of  police  and 
exhibit  your  dexterity  in  riding  and  mounting  and  dis- 
mounting as  a  preliminary  to  the  license.  While  the 
liberty  thus  granted  has  led  to  a  great  increase  in 
the  number  of  riders,  it  has  by  no  means  caused  the 
rage  for  wheeling  that  was  anticipated.  For  a  town  of 
over  a  million  inhabitants,  bicycles  are  comparatively 
infrequent  on  the  streets  of  Vienna. 

For  a  good  deal  of  this  the  doctors  are  responsible. 
The  profession  is  extremely  conservative  here,  and  the 
bicycle  as  a  means  of  e.xercise  does  not  commend  itself 
overmuch  to  them.  Certain  of  the  older  practition- 
ers, when  consulted  about  its  advisability  by  patients, 
shake  their  heads  dubiously.  When  a  family  physi- 
cian is  asked  to  grant  permission  for  bicycle  riding, 
the  examination  of  the  individual  is  apt  to  be  as  com- 
plete as  if  there  were  question  of  application  for  an 
insurance  policy.  When  there  is  any  symptom  of 
heart  trouble  permission  is  at  once  refused,  or  allowed 
only  tentatively  and  with  the  most  careful  directions 
and  precautions.  If  the  urine  shows  any  signs  of  kid- 
ney trouble  the  same  result  is  to  be  expected.  There 
has  been  a  number  of  sudden  deaths  among  enthusi- 
astic bicyclists  reported  from  various  quarters  here  in 
Europ>e,  and  hence  the  medical  carefulness.  As  one 
of  the  best-known  clinical  professors  here  puts  it,  it 
constitutes  a  form  of  exercise  that  is  very  easily  over- 
done, because  the  rider  only  thoroughly  realizes  his 
fatigue  after  dismounting  from  his  machine.  After  a 
certain  time  the  habitus  of  the  monotonous  motion  re- 
quired for  pedalling  is  acquired  by  the  muscles  in- 
volved, and  they  do  not  give  the  usual  signs  of  fatigue. 
General  exhaustion  readily  supervenes,  and  the  wheel- 
man easily  exceeds  his  strength  before  he  realizes  it. 
When  there  are  circulatory  or  emunctory  disturbances 
already  at  play,  though  practically  symptomless,  they 
may  easily  lead  to  serious  consequences  as  a  result  of 
the  overexertion  and  tlie  exorbitant  call  for  additional 
energy  and  increased  elimination.  \\'ith  regard  to  the 
heart,  it  is  clear;  as  to  the  kidneys,  it  has  been  noted 
a  number  of  times  that  if  an  ordinarily  healthy  but  sed- 
entary indi\idual,  in  whom,  however,  there  is  not  the 
slightest  suspicion  of  kidney  trouble,  ride  with  ordi- 
nary speed  for  a  couple  of  hours,  blood  and  some  hya- 
line casts  with  some  traces  of  albumin  may  be  found 
in  his  urine.  .\11  this  would  seem  to  be  the  result  of 
sudden  call  for  excessive  elimination  on  organs  that 
were  unused  to  the  strain  of  getting  rid  of  so  much 
waste  muscular  material  at  a  time.  Perhaps  the  con- 
servatism may  not  be  entirely  old  fogyism,  but  be  a 
lesson  worth  considering  when  the  question  of  medi- 
cal advice  and  direction  in  the  matter  comes  up. 

.\  recent  death  from  chlorate-of-potassium  poison- 
ing here  has  reawakened  the  feeling  against  the 
drug.  It  was  a  simple  accident,  but  it  is  another 
warning  against  lightly  prescribing  the  drug  in  family 
practice.  During  the  past  winter  a  well-known  actor 
died  from  causes  that  his  physician  could  not  explain, 
and  the  autopsy  showed  that  it  had  been  chlorate-of- 
potassium  poisoning.  Subject  to  hoarseness  and 
chronic  sore  throat,  he  was  accustomed  to  take  a 
certain  amount  of  the  drug.  During  the  course  of 
a  severer  pharj-ngitis  than  usual,  he  sent  for  a  well- 
known  physician,  who  prescribed  chlorale-of-potas- 
sium  in  rather  large  doses,  but  so  combined  as  to 
disguise  its  taste.  The  patient  continued  his  own  ad- 
ditional doses  of  the  drug,  and  died  by  poisoning  from 
it.  .\s  the  most  recent  investigations  would  seem  to 
show  that  the  drug  has  no  specific  action  in  affections 
of  the  mouth  and  throat,  and  owes  its  clinical  efficacy 
to  its  rather  limited  antiseptic  power,  it  has  come  into 
general  disfavor  here.  There  are  many  better  antisep- 
tics known  now  that  liave  not  its  poisonous  properties, 


and  there  would  seem  to  be  no  reason  for  taking  the 
risks  involved  in  its  use.  This  has  come  to  be  con- 
sidered so  rational  that  there  is  even  question  of  leav- 
ing it  out  of  the  next  edition  of  the  Pharmacopoeia 
here  entirely. 

In  pathological  circles  considerable  remark  has 
been  occasioned  by  some  recent  deaths  from  illumi- 
nating gas.  The  difference  in  the  poisonous  properties 
of  the  new  water  gas  and  the  old-fashioned  coal  gas  is 
enormous.  The  amount  of  carbon  monoxide  —  the 
really  poisonous  element  in  illuminating  gas — is  mani- 
foldly increased  under  the  new  system.  Water  gas  is 
besides  almost  absolutely  odorless,  so  that  no  warning 
is  given  of  its  presence.  The  new  gas  is  supplied  in 
the  old  pipes  and  fittings,  nearly  always  leaky,  so  that 
there  is  eveiy  reason  to  believe  that  small  amounts 
at  least  of  the  gas  often  find  their  way  into  the  living- 
rooms  of  dwellings,  and  carbon  monoxide  is  one  of 
the  gases  that  even  when  diffused  in  extremely 
small  amounts  causes  symptoms  of  chronic  poisoning. 
In  cases  of  acute  poisoning  from  illuminating  gas 
here,  there  is  always  a  spot  of  brain  softening  found 
in  the  innermost  part  of  the  lenticular  nucleus  near 
the  knee  of  the  internal  capsule.  This  softening  is 
more  or  less  pronounced,  according  to  the  length  of 
time  that  has  elapsed  between  the  exposure  of  the  pa- 
tient to  the  poisonous  gas  and  the  occurrence  of  death. 
In  cases  in  which  artificial  respiration  has  been  em- 
ployed for  a  long  time  and  has  led  to  the  aspiration  into 
the  lungs  of  large  quantities  of  infectious  material  from 
the  mouth  and  nose,  the  consequent  pneumonia  may 
be  so  fulminant  that  ver}'  little  time  is  allowed  for  the 
development  of  brain  degeneration  and  only  its  pri- 
mary stages  may  be  noted.  In  cases  in  which  the  pa- 
tients fail  to  recover  from  their  first  stupor,  it  will,  of 
course,  be  absent  entirely;  but  in  all  other  cases  its 
occurrence  is  looked  for  with  confidence. 

The  etiolog)'  of  the  degenerative  process  is,  as  usual, 
a  circulatory  disturbance.  The  innermost  part  of  the 
lenticular  nucleus  is  supplied  by  a  set  of  minute  ar- 
teries that  come  oft"  from  the  arteria;  fissura;  Sylvii  just 
after  the  posterior  communicating  have  been  given  oft'. 
They  are  not  usually  set  down  in  ordinary  anatomical 
text-books,  but  it  is  the  interference  with  the  circula- 
tion in  them  which  causes  the  softening.  Sometimes 
they  are  found  thrombosed,  sometimes  widely  dilated. 
In  the  latter  case  Professor  Kollisko  considers  it  the- 
oretically probable  that  the  dilatation  of  the  arteries 
in  question,  together  with  the  lowered  blood  pressure, 
causes  such  a  slowing  of  the  circulation  in  the  impor- 
tant nerve  centres  involved  that  the  highly  organized 
nervous  elements  perish  from  insufiicient  nutrition. 

To  those  who  are  interested  in  the  curiosities  of 
medical  literature,  and  to  whom  pathological  and 
physiological  novelties,  especially  when  thoroughly 
paradoxical,  appeal,  a  recent  series  of  articles  from 
the  pen  of  Professor  Adamkiewicz,  sometime  professor 
of  experimental  physiology  in  the  University  of  Kra- 
cow,  but  now  engaged  in  original  investigation  in  his 
private  laborator)'  in  Vienna,  will  undoubtedly  com- 
mend themselves.  They  have  just  been  concluded  in 
the  IF/tw/rr  }iie<lizinisclie  Wochoischrift.  The  professor 
disagrees  and  has  done  so  for  some  time  with  most  of 
the  rest  of  the  world  as  to  the  physiological  possibility 
of  the  occurrence  of  increased  intracranial  pressure. 
The  whole  diploe  is,  in  his  opinion,  a  large  storage  res- 
ervoir, that  acts  as  a  safety  valve  for  the  relief  of  any 
intracranial  pressure  above  the  normal,  whenever  there 
is  a  tendency  for  that  to  occur.  When  the  thorax  is 
dilated  in  respiration,  there  is  a  negative  pressure  pro- 
duced in  the  veins  of  tlie  head  and  neck,  and  if  there 
is  the  slightest  increase  of  pressure  within  the  arach- 
noidal space  or  in  the  millions  of  canaliculi  of  the 
diploe  the  excess  of  fluid  is  aspirated.  Experimen- 
tally increased  intracranial  pressure  may  be  produced 


400 


MEDICAL    RFXORD. 


[SeptemVjer  ii,  1897 


by  injections  into  the  arachnoid  cavity,  when  a  thicker 
liquid  than  decinornial  salt  solution  is  used,  because 
the  bony  canalicula:  easily  become  blocked.  Oil,  for 
instance,  has  been  used  in  such  demonstrations,  and 
always  with  positive  results.  Using  decinornial  salt 
solution,  however,  Professor  Adamkiewicz  asserts  that 
it  is  impossible  to  produce  increased  pressure  within 
the  brain  membranes.  Hence  his  rather  startling  con- 
clusion, calculated  to  disturb  the  even  tenor  of  his  way 
for  the  earnest  but  simple  seeker  for  medical  truth, 
''  that  it  is  high  time  to  give  up  the  erroneous  patho- 
logical explanation  that  certain  well-known  symptoms 
are  due  to  increased  intracranial  pressure,  for  it  is 
founded  on  a  physiological  falsity  that  cannot  but  de- 
lay the  advance  of  neurology." 


IS  IT  EVER  IMPOSSIBLE  TO  PASS  A  CATH- 
ETER THROUGH  THE  URETHRA  INTO 
THE    BLADDER? 


To 


Kk 


Sir  :  The  above  question  is  almost  invariably  answered 
in  the  negative,  as  it  is  by  Dr.  Buckston  Browne,  in 
the  Medical  Record  of  August  21st.  I  had  a  case 
some  years  ago  in  which  repeated  attempts  with  in- 
struments of  all  shapes  and  sizes  failed  to  secure  a 
passage  of  the  obstruction.  The  case  was  of  long 
standing;  the  perineum  was  riddled  with  urinary  fis- 
tula;, and  I  proposed  a  perineal  section.  The  patient 
was  finally  treated  by  another  surgeon,  who,  as  he 
supposed,  passed  a  sound.  He  claimed  that  the  sound 
had  entered  the  bladder  and  that  the  stricture  had  been 
passed.  The  patient  died  on  the  third  day,  of  acute 
suppression  of  urine.  At  the  post-mortem  it  was 
found  that  a  false  passage,  of  about  two  inches  in 
depth,  had  existed  for  many  years.  This  false  passage 
was  in  a  direct  line  with  the  urethra,  and  into  it  all 
the  instruments  had  passed.  The  operator  had  forced 
his  sound  through  the  bottom  of  this  false  passage, 
and  by  his  manipulations  had  torn  up  the  connective 
tissue  at  the  base  of  the  bladder.  Even  after  the 
parts  were  removed  it  was  impossible  to  pass  the 
smallest  probe  through  the  very  short  but  narrow  and 
tortuous  canal  which  connected  the  two  portions  of  the 
urethra.  I  had  worked  hours  ineffectually  on  this 
case  before  it  passed  into  other  hands,  and  I  think  it 
would  have  been  absolutely  impossible  for  any  one 
to  pass  an  in.strument  through  this  obstruction,  even 
could  the  exact  condition  present  have  been  known. 
J.  F.  Baldwin,  M.D. 

CoLC.Mbus,  Ohio,  Augu^i  .17,  1^07. 


TAPEWORM    IN    MEN. 

To  TiiK  EunoK  oi-  TiiK  Medic.m.  Rf.cokd. 

Sir:  In  the  Medical  Record  of  August  28th  is  an 
article  by  Dr.  E.  C  Chamberlin,  on  the  treatment  of 
tapeworm,  in  which  the  author  says  that  he  has  not 
seen  a  single  case  of  tapeworm  in  a  man,  and  that 
tapeworm  is  almost  entirely  confined  to  womankind. 
He  quotes  the  statistics  of  French  military  surgeons 
for  ten  years,  showing  only  one  case  in  every  thirty- 
six  thousand  men. 

In  view  of  the  above  statement,  it  may  be  of  inter- 
est to  say  that  during  the  past  seven  years  of  practice 
in  general  medicine  I  have  had  five  cases  of  tape- 
worm, all  the  patients  being  men.  Four  of  these 
cases  occurred  in  a  town  of  seven  thousand  inhabi- 
tants; one  case  in  a  city  of  seventy-five  thousand  in- 
habitants. Among  these  eighty-two  thousand  people 
there  are  at  least  one  hundred  and  twenty-five  practis- 
ing physicians,  and  several  of  this  number,  no  doubt, 
must  have  found  cases  of    tapeworm   in    men.     The 


ages  of  these  five  men  were  between  twenty-two  and 
thirty-five  years,  and  the  specimens  pas.sed  ranged 
from  twelve  to  thirty  feet  in  length.  No  special 
symptoms  were  complained  of  in  these  cases,  the 
attention  of  the  patients  being  called  by  passing  seg- 
ments of  the  parasites. 

John   F.   Dowlinc,  M.D. 


Contagious  Diseases — Weekly    Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitar)'  Bureau,  Health  Department,  for  the 
week  ending  September  4,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. .  . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 

Chicken-pox 

Pertussis 


236 

125 

42 

67 

2 

1 

2 

37 

5 

119 

23 

A    Curious    Case    of   H3rpnotic   Suggestion A 

Hamburg  practitioner  was  consulted  by  a  young  mar- 
ried lady,  who  complained  of  terrible  hallucinations, 
driving  her  to  suicide.  She  came  to  him  unknown  to 
her  husband,  who  she  said  was  devoted  to  her,  and 
whom  she  could  not  bear  to  distress  by  the  knowledge 
of  her  affliction.  Beyond  the  hallucination  complained 
of,  there  seemed  nothing  to  indicate  mental  disease; 

but  a  sudden  light  dawned  on  Dr.  D when  in  the 

course  of  further  conversation  his  patient  told  him  of 
two  facts — one  that  Jier  husband  had  lately  insured  her 
life  for  a  large  sum,  and  the  second  that  he  was  fond 

of  making  hypnotic  experiments.     Dr.  D found  it 

easy  to  hypnotize  his  patient,  but  met  with  obstinate 
resistance  when  he  commanded  her  to  divulge  what 
had  been  suggested  to  her  to  do.  He  did  not,  however, 
relinquish  his  efforts,  but  continued  the  hypnotic 
sc'i7//crs  in  the  presence  of  a  witness,  and  at  last  over- 
came the  resistance  of  his  patient,  who  acknowledged 
that  her  husband  had  ordered  her  to  commit  suicide 
after  two  months  and  to  keep  his  command  secret  from 
every  one.  The  insurance  company  is  one  that  pays 
even  in  cases  of  suicide,  if  the  suicide  be  committed 
more  than  two  months  after  insurance. — British  Med- 
ical Joiiniiil. 

Health  Reports. —  The  following  statistics  concern. 
ing  yellow  ftver,  cholera,  small-pox,  and  plague  have 
been  received  in  the  office  of  the  United  States  Marine 
Hosjiital  service  during  the  week  ended  September 
4.  1897: 

S.MALL-Pox-VNrrKi.  St.xt. 


Birmingham,  .\lu Augti«it  aist  to  September  i:^t . . 

Blockton,  Ala .\uiriist  ayth  tii  September  ist . 

Small-Pox — Foreign. 

Rio  de  Janeiro,  Brazil July  24rh  to  31SI 4 

Sajrua  la  Grandr,  Cuba  . ..  AuKiist  7lh  tt>  21st 53 

Rotterdam,  Holland .Aii^i^i  14th  to  jist 2 

Warsaw,  Russia .August  ;th  to  14th 

St.  Petersburg,  Ru&sia .-Viigust  7th  10  14th 7 

Itarcclona,  .Si>ain Jime  ist  to  30th 

Odessa,  Russia Aukusi  7th  to  14th 1 

Bombay,  India July^idto  .Atigust  3d 


Madras,  India hilv  24th  ii>  ^oth . 

Bombay,  India "luly  i-th  to  AiiRust  ;d.. 

Calcutta,  India July  17th  to  a4th 


Cases.     1  >caths. 
■  36 


Bombay,  India J  uly  27th  to  August  3d.. . . 


Medical  Record 

A  IVeekly  yournal  of  Medicine  and  Sttrgery 


Vol.  52,  No.  12. 
Whole  No.  1402. 


New  York,   September    18,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


(Drtgiual  Jk^rticlcs. 

PATHOLOGICAL  HISTOLOGY  OF  INTES- 
TINAL END-TO-END  APPROXIMATION 
AFTER  THE  USE  OF  THE  FRANK  COUP- 
LER. 

By   J.\C0B   frank,    M.D. 


The  pathology  of  the  reparative  process  taking  place 
in  the  intestines  after  approximation  has  received  but 
little  attention  from  the  various  experimenters  in  this 
field,  it  no  doubt  having  been  looked  upon  as  of  little 
if  any  importance.  To  my  mind  it  is  of  vast  import- 
ance, for  by  microscopical  examination  only  can  we 
obtain  accurate  and  positive  knowledge  as  to  how 
soon  and  in  what  manner  reparation  takes  place. 

The  following  is  a  report  on  the  specimens  prepared 
for  me  by  Dr.  Fred  C.  Zapffe.  All  the  specimens 
with  the  exception  of  one,  in  which  Murphy's  button 
was  used,  were  obtained  from  dogs  operated  upon 
with  my  decalcified  bone  coupler,  used  in  the  manner 
as  already  published  in  the  Medical  Record  of  Oc- 
tober 3,  1896. 

Section  Removed  Ten  Days  after  Date  of  Oper- 
ation (Fig.  i). — Macroscopical  appearance:  There  is 
no  adhesion  or  matting  of  the  intestines  and  the  point 
of  approximation  can  be  found  only  by  running  the 
bowel  through  the  fingers,  when  a  slight  ridge  is  felt. 


Yu,.  1.— After  Ten  Days  (Frank  Coupler). 

There  is  a  little  thickening  of  the  bowel  at  this  point. 
On  the  inner  surface  of  the  bowel,  projecting  over  the 
mucosa,  is  a  smooth  line  marking  the  point  of  union. 

Microscopical  appearance :  All  the  layers  are  in 
juxtaposition. 

Mucosa:  This  is  somewhat  thickened  and  the  ridge 
above  mentioned  is  seen.  This  ridge  has  no  villi,  nor 
does  it  in  the  least  resemble  normal  mucosa ;  it  con- 
sists   entirely   of    small,    round,    inflammator\-  cells, 


closely  packed.  On  either  side  the  normal  mucosa 
is  seen,  but  no  attempt  at  regeneration  of  the  villi. 

Muscularis  mucosa;:  The  ends  are  separated:  the 
gap  is  filled  in  with  connective  tissue. 

Submucosa:  It  is  thickened  at  the  line  of   union. 


Fig.  2.— After  Sixty  Days  (Frank  Coupler). 

but  is  continuous.  It  is  very  vascular.  The  blood- 
vessel walls  are  also  thickened. 

Muscularis ;  The  circular  and  longitudinal  coats  are 
distinctly  cut  oft"  at  the  line  of  union.  The  cut  ends 
present  some  proliferation  of  the  muscle  cells,  but  the 
muscles  have  not  united,  the  gap  being  filled  in  with  a 
loose,  ver>'  vascular  connective  tissue. 

Serosa:  This  coat  is  ver\'  much  thickened  and  ver)' 
vascular.  The  new-formed  tissue  is  easily  distin- 
guished from  the  old  by  these  features.  The  connec- 
tive tissue  is  ver)'  loose,  having  the  appearance  of  a 
network  of  mesh. 

Section  Removed  after  Sixty  Days  (Fig.  2). — 
Macroscopical  appearance:  No  adhesions  or  mat- 
ting of  intestines  are  found.  The  point  of  operation  is 
hardly  distinguishable.  A  slight  line  is  felt  at  the 
line  of  union.  There  is  very  slight  contraction  of  the 
lumen  of  the  bowel,  the  index  finger  passing  easily. 
CJn  the  inner  surface  of  the  point  of  union  is  a  slight 
groove.  The  lymphatic  and  blood  vessels  run  across 
the  line,  giving  the  bowel  quite  a  normal  aspect. 

Microscopical  appearance:  The  various  layers  are 
in  perfect  juxtaposition.  Continuity  has  been  estab- 
lished in  ever)-  layer  except  the  muscular,  and  regen- 
eration has  been  established  in  the  mucosa,  submu- 
cosa, and  serosa. 

Mucosa  ( Fig.  4) :  The  mucosa  is  continuous  and 
shows  no  formation  of  new  tissue,  being  unchanged. 
There  is  at  the  site  of  union  a  falling  inward  of  the 
villi,  an  entropion,  as  it  were,  due  probably  to  the 
cicatricial  contraction  of  the  scar  tissue  beneath.  The 
tops  of  the  villi  thus  drawn  down  meet  with  those  of 
the  opposite  side,  presenting  an  appearance  as  though 
they  had  been  piled  up.  There  is  no  connective  tis- 
sue formed  between  the  villi. 


4o; 


■MEDICAL    RECORD. 


[September  i8,  1897 


Muscularis  mucosae  has  not  become  continuous,  the 
ends  of  the  cut  muscle  being  separated  by  scar  tissue. 

Submucosa  has  an  almost  normal  appearance.  It 
is  continuous  and  regenerative,  although  it  is  slightly 


1  IG.  3,— After  Sixty  Days  (Frank  Coupkrl. 

thickened.  Blood-vessels  are  prominent,  being  also 
thickened. 

Muscularis:  The  outer  layer  is  united  by  connective 
tissue,  into  which  a  few  muscle  fibres  project  from 
either  side.  There  is,  however,  no  regeneration. 
This  layer  is  closely  applied  to  the  serous  layer.  The 
ends  of  the  inner  layer  are  nearly  in  apposition,  and 
look  like  spindle-shaped  processes.  Connective  tis- 
sue connects  them,  and  no  muscle  fibres  can  be  seen 
projecting  into  it  as  in  the  other  layer.  Although 
there  is  some  proliferation  of  the  muscle  cells  in  the 
cut  ends,  there  is  no  regeneration.  The  connective- 
tissue  fibres  on  each  side  of  the  line  of  union  run  from 
the  muscular  to  the  serous  layers,  thus  forming  two 
bundles,  the  fibres  interlacing  as  they  cross. 

Serosa  is  tliickened  and  more  vascular  than  normal. 
The  cicatricial  tissue  is  distinguishable  at  the  line  of 
union,  and  is  arranged  as  above  mentioned. 

Two  Specimens  Removed  after  Sixty  Days. — 
The   macroscopical   appearance  was  the  same  in  both. 

Microscopically  the  first  specimen,  Fig.  t,,  differs 
somewhat  from  the  second,  Fig.  2,  in  that  the  gap  in 
Fig.  3  is  wider  than  in  Fig.  2,  in  which  the  layers  are 
almost  in  apposition.  This  is  due  to  the  different 
method  of  preparation — Fig.  3  specimen  being 
stretched  on  cork  with  pins;   Fig.  2  specimen  not  so. 

Section  Removed  after  Ninety  Days  ( Fig.  5 ). — 
Macroscopical  appearance:  There  are  no  adhesions 
between  omentum  and  bowel  or  loops  of  bowel.  Site 
of  operation  hardly  distinguishable,  except  for  a  slight 
line  which  is  felt.  Appearance  of  bowel  is  normal. 
On  the  inner  surface  hardly  anything  is  seen  to  indi- 
cate an  operation.  The  lymphatics  and  hlooil-vessels 
cross  the  line  of  union  and  are  readily  discernible, 
liowel  is  patulous  and  but  slightly  contracted,  the  fin- 
ger passing  easily. 

Microscopical  apiiearance:  There  is  little  differ- 
ence between  this  specimen  and  the  previous  one. 
The  scar  has  contracted  more  than  in  Fig.  2,  which 
has  brought  the  different  layers  into  closer  apposition, 
making  it  almost  impossible  to  distinguisli  the  line  ot 
union.  The  mucosa  and  submucosa  have  the  same 
api^earance  as  in   Fig.  2.     The  muscularis  niucos.v  is 


also  the  same.  The  muscularis  has  not  regenerated 
and  presents  the  same  appearance  as  in  the  previous 
section,  as  does  the  serosa. 

Section  Removed  after  Sixty  Days,  Murphy  But- 
ton (Fig.  6). — A  Murphy  button  was  carefully  intro- 
duced in  a  large  healthy  dog  and  the  section  removed 
after  si.xty  days.  The  mucosa,  muscularis  mucosae,  and 
submucosa  have  the  same  appearance  as  in  the  speci- 
mens obtained  from  my  coupler;  so  also  the  muscu- 
laris and  serosa.  On  the  whole,  this  specimen  varies 
but  slightly  from  the  sjjecimen  produced  from  the 
coupler,  the  difterence  being  that  the  ends  of  the  mus- 
cularis are  in  closer  apposition  in  the  coupler  speci- 
mens than  in  the  button  specimen.  There  is  no  regen- 
eration of  muscle  in  either  instance,  connective  tissue 
intervening  between  the  ends. 

The  following  is  a  report  furnished  by  Dr.  Evans, 
pathologist  of  the  College  of  Physicians  and  Sur- 
geons : 

Section  Removed  after  Eleven  Months  (Fig.  7). — 
Report  of  autopsy  on  large  Newfoundland  dog,  held 
Sunday,  May  2,  1897. 

Present,  Drs.  Frank,  Kunz,  and  Evans. 

The  old  dog  was  fat  and  healthy  looking.  The  line 
of  abdominal  incision  showed  union  without  adhesions 
of  the  underlying  viscera. 

The  intestines  showed  no  evidence  of  old  perito- 
nitis. The  point  of  operation  was  found  2.6  cm. 
from  the  csecum.  There  was  no  distention  of  the 
bowel  above  the  point  of  operation.  The  omentum 
is  attached  at  two  places.  One  is  over  the  line  of 
union;  the  other  is  i  cm.  therefrom.  Each  is  slight 
and  inconsequential ;  over  the  scar  the  peritoneal  coat 
lies  evenly.  The  blood  and  lymph  vessels  are  con- 
tinuous from  one  side  to  the  other. 

When  the  post-mortem  was  •  made,  the  intestines 
were  still  in  motion,  and  it  was  noticed  that  the  line 
of  union  caused  a  break  in  the  muscle  wave. 

Intestine  ///  s/fu  unopened:  There  is  noticed  a  V- 
shaped  indentation  over  the  free  side  of  the  intestine ; 


Ku;.  4.— Appcaraacc  of  the  Mucosa  after  Sixty  Pays  (^Frank  Couplrr). 

this  is  about  0.2  cm.  in  depth.  It  is  not  appreciable 
over  the  remainder  of  the  intestine.  Around  the  intes- 
tine is  a  linear  scar.  In  the  niesenterj-.  0.2  cm.  from 
the  intestine,  is  an  oval  mass  about  i  cm.  in  diameter. 
Over  it  tlie  peritoneum  glides  smoothly.      The  mass  is 


September  i8,  1897] 


MEDICAL    RECORD. 


403 


joined  in  the  scar  by  a  line  of  scar  tissue.  This 
piece  was  removed  for  microscopic  examination. 

Intestine  removed,  unopened.  The  finger  gently 
passed  through  the  lumen,  appreciated  the  line  of 
union  as  a  thread-like  band,  giving  the  sense  of  re- 
sistance to  expansion  rather  than  decrease  of  lumen. 

Intestine  removed,  opened :  The  mucosa  is  continu- 


There  is  some  inflammatory  thickening  in  the  se- 
rous coat.  No  sutures  were  found.  Nodule  from 
mesentery:  this  is  a  mass  of  inflammaton,-  tissue. 
In  the  centre  is  a  silk  suture. 

Dr.  G.  Fiitterer,  who  also  examined  the  microscopi- 
cal sections,  fully  agrees  with  Drs.  Evans  and  Zapffe 
in  their  reports  as  given  to  me. 


Fig.  5. — After  Ninety  Days  (Frank  Coupl 

ous  over  the  line  of  union.  Cross-section  over  the 
scar  shows  that  in  places  there  is  a  slight  projection 
into  the  lumen.  In  places  there  is  a  slight  furrow. 
In  the  submucosa  and  muscular  tunics  there  is  a  nar- 
row band  of  connective  tissue. 

The  sections  for  microscopic  examination  were  made 
longitudinally.  They  were  from  two  places  :  one  from 
the  distal,  the  other  from  the  proximal  side.  In  some 
sections  there  is  a  wedge-shaped  depression  that  i? 
about  0.6  mm.  in  depth. 
In  others  there  is  a  pyra- 
midal elevation  that 
rises  0.75  mm.  Mucosa 
is  joined  to  mucosa,  mus- 
cularisto  muscularis,etc. 

Mucosa :  This  coat  is 
continuous  over  the  scar 
without  a  break.  The 
epithelial  glands,  the  *i' 
villi,  and  the  cells  them-  ' 
selves  are  absolutely  un- 
changed. The  muscu- 
laris  mucosa;  runs  into 
the  cicatricial  tissue. 

In  the  area  of  circular 
muscular  fibres  the  scar 
reaches  its  greatest 
breadth.  It  is  here  0.8 
mm.  broad.  In  the  lon- 
gitudinal   niuscularis   it 

?     ,  7,  serosa. 

IS  less  broad. 

Scar :  The  connective-tissue  fibres  run  from  the  se- 
rous coat  to  the  muscular  coat:  generally  they  are  in 
two  groups,  with  what  appears  to  be  some  old  tissue 
remnants  between  the  two  bundles.  The  direction  of 
the  fibres  has  a  bearing  on  the  question  of  subsequent 
contraction.  The  fibres  are  as  old,  dense,  and  free 
from  nuclei  as  one  would  expect  in  inflammatory  con- 
nective tissue  that  is  a  year  old.  In  this  area,  and 
especially  near  the  summit,  the  region  corresponding 
to  the  old  submucosa,  there  is  an  abundance  of  blood- 
-issels.  Their  direction  is  generally  circular. 
»  heir  walls  blend  intimately  with  the  surrounding  tis- 
sue. That  transudation  is  not  accurately  balanced  is 
shown  bv  some  serous  ■  ' ''.'. tration  of  these  fibres. 


Fig.  7.— .\fter  Eleven  Months  (Frank  Coupler),     i,  Mu. 
3,  submucosa;  4,  inner  circular  muscle;  5,  scar  tissue;  6, 


■ixty  Days  (Murphy  Bunoa). 

Conclusions. — From  the  microscopical  examinations 
made  by  Professor  Evans  and  Dr.  Zapffe,  and  from 
their  reports  given  to  me,  I  have  come  to  the  follow- 
ing conclusions:  That  the  mucosa  in  all  the  speci- 
mens shows  an  entropion,  which  is  an  entirely  passive 
occurrence  and  is  due  solely  to  the  contraction  of  the 
underlying  scar  tissue.  There  is  a  complete  regener- 
ation of  the  mucosa. 

Garbarini,  who  did  the  microscopical  work  for  Dr. 
Achilla  Boari,  of  Italy, 
in  October,  i8g6,  after 
the  use  of  his  modified 
Murphy  button,  states 
that  there  is  no  regen- 
eration of  the  mucosa. 

Dr.  Hektoen,  who  re- 
ports the  microscopical 
work  for  Dr.Murphy  after 
the  use  of  his  button, 
claims  a  complete  regen- 
eration of  the  mucosa. 

Submucosa:  This  coat 
has  become  more  vascu- 
lar and  denser  at  the 
point  of  union,  otherwise 
presenting  no  change 
from  the  normal. 

Muscularis :     Quite    a 
difference     of      opinion 
exists    as  to  whether  or 
not    complete    regenera- 
tion takes  place  in  this  layer. 

In  all  the  specimens  prepared  for  me  by  Professor 
Evans  and  Dr.  Zapffe  there  was  no  restitution  or  re- 
generation of  the  muscular  coat.  At  the  cut  ends  of 
the  muscle  some  proliferation  of  muscle  cells  and  an 
attempt  at  regeneration  invariably  take  place,  but  I 
believe  that  the  connective  tissue,  like  a  weed,  fills  up 
all  interspaces,  forming  and  growing  so  rapidly  as  to 
replace  and  crowd  out  the  more  delicate  structures, 
thus  preventing  their  further  growth.  There  is  na 
question  as  to  the  proliferation  of  the  muscle  cells  in 
the  ends  of  the  cut  muscle,  but  it  is  insufficient  to  fill 
out  the  gap. 

Owing  to  the  pressure   of   the  coupler,  some  muscu- 


404 


MEDICAL    RECORD. 


[September  i8,  1897 


lar  fibres  are  no  doubt  separated  from  the  others,  and 
the  connective  tissue  then  growing  between  them  forces 
these  detached  fibres  out  into  the  body  of  the  scar.  It 
certainly  is  no  attempt  at  regeneration. 

Dr.  L.  Hektoen,  in  his  report  on  Dr.  Murphy's  but- 
ton-operation sections,  states  that  after  thirty  days  the 
longitudinal  muscular  coat  can  be  said  to  be  almost 
restored,  and  the  transverse  muscular  completely  united 
by  connective  tissue.  In  describing  the  section  which 
was  remo\ed  after  si.xty  days.  Dr.  Hektoen  says  that 
the  longitudinal  and  circular  muscular  layers  are  con- 
tinuous and  not  distinguishable  from  those  in  the  nor- 
mal intestine,  except  that  they  contain  some  small 
spaces  (blood-vessels)  and  occasional  traces  of  fibrous 
tissue. 

I  must  differ  with  Dr.  Hektoen,  as  I  have  not 
found  this  condition  in  any  of  my  specimens  nor 
in  that  made  with  the  Murphy  button  on  a  dog  killed 
sixty  days  after  operation.  The  most  conspicuous 
part  of  the  scar  is  the  non-regeneration  of  the  muscu- 
lar coats,  and  it  is  the  feature  which  at  once  attracts 
one's  notice  upon  looking  at  the  section  through  the 
microscope.  Dr.  Hektoen  further  says  that,  were  it 
not  for  the  thickening  described  in  the  submucosa  and 
muscularis  mucosae,  it  would  be  difficult  if  not  impos- 
sible to  recognize  the  line  of  union. 

The  submucosa  beyond  question  is  thickened,  but 
not  so  much  so  as  to  make  it  a  prominent  feature;  and 
as  for  the  muscularis  mucosa,  it,  like  the  muscular 
coats,  has  not  united  at  all — hence  is  not  regenerated. 

If  a  section  after  removal  is  at  once  placed  into 
Fleming's  solution  and  left  there  for  twenty-four  hours, 
then  washed  well  in  running  water,  followed  by  im- 
mersion in  ninety-five-per-cent.  alcohol,  each  layer  of 
the  bowel  can  be  distinguished  with  the  naked  eye,  and 
your  attention  is  directed  to  a  white  band,  the  muscu- 
laris, which  is  intersected  by  a  dark  line.  This  is 
the  scar  tissue.  Microscopic  examination  verifies  this. 
The  dark  intersection  is  also  seen  in  the  muscularis 
mucosae.  The  submucosa,  being  in  itself  connective 
tissue,  does  not  show  this. 

I  do  not  question  that  some  muscular  fibres  may 
grow  out  into  the  scar  and  meet,  but  they  are  not 
sufficient  in  number  to  call  the  process  a  regeneration. 
Even  this  is  not  found  in  any  of  my  specimens,  nor  in 
Murphy's.  The  cutting  of  the  muscular  coats  acts  as 
a  stimulus  and  the  result  is  a  proliferation  in  the  cut 
ends,  but  the  connective  tissue  grows  far  too  rapidly 
to  permit  a  regeneration. 

Among  the  influences  which  increase  the  capacity 
of  proliferation  of  the  cell  and  which  lead  to  a  new 
formation  of  cells,  increased  nutrition  brought  about 
by  a  hyperemia  plays  an  important  part.  This  in  a 
degree  explains  why  the  mucosa  regenerates,  being  so 
highly  vascular. 

I  am  now  making  experiments  with  various  suture 
methods,  in  order  to  ascertain  what  difference  if  any 
exists  in  the  process  of  repair.  The  results  of  this 
■work  I  will  publish  later  on. 

Serosa:  This  layer  is  invariably  united  perfectly  and 
is  closely  applied  to  the  muscularis.  Owing  to  the 
irritation  and  reaction  resulting  therefrom,  it  is  con- 
siderably thickened  and  more  vascular,  but  otherwise 
presents  no  change. 

As  mentioned  in  the  microscopical  reports,  the 
fibres  of  the  cicatricial  tissue  take  a  direction  from 
the  serosa  on  one  side  of  the  line  of  union  to  the  mus- 
cularis on  the  opposite  side,  thus  forming  two  bundles 
or  groups  of  fibres,  which  interlace  and  form  a  net- 
work. This  has  an  important  bearing  on  the  subject 
of  contraction  and  narrowing  the  lumen  of  the  bowel. 
The  fibres  not  only  pull  the  ends  of  the  bowel  to- 
gether, but  also  the  muscularis  and  overlying  tissues 
toward  the  serosa  on  the  one  hand,  and  the  serosa 
toward  the  muscularis  on  the  other.     If  these  fibres 


ran  around  the  bowel  in  the  same  direction  as  the  cir- 
cular muscular  fibres,  a  contraction  would  result;  but 
this  cannot  take  place  when  the  fibres  run  in  the  op- 
posite direction.  There  is  at  the  same  time  a  thin- 
ning of  the  wall  of  the  bowel  as  the  fibres  pull  both 
toward  serosa  and  mucosa. 

I  am  greatly  indebted  to  Mr.  \V.  G.  King  for  his 
kindness  and  labor  in  preparing  the  photographs  from 
the  microscopical  sections. 

■  7    L:.Vt01-.N    .ivt.SLE. 


THE    RISE    AXD    PROGRESS    OF    DERMA- 
TOLOGY.* 


I>v    M.\LCOLM    MORRIS,    F.R.C.b.   Edi.v, 


The  present  is  a  time  of  jubilees  and  centenaries — 
occasions  which  we,  in  common  with  toilers  in  other 
fields,  celebrate  by  reviewing  the  progress  that  has 
been  made,  and  giving  thanks  to  God  that  we  are  not 
as  our  predecessors  were  a  hundred  or  even  fifty  years 
ago.  The  custom  might  at  first  sight  seem  to  have  a 
tendency  to  engender  a  feeling  of  Pharisaic  self-com- 
placency. In  reality,  however,  such  retrospects  have 
a  chastening  effect,  as  showing  that,  if  we  have  any 
reason  to  look  upon  ourselves  as  jj.ist  in  a  scientific 
sense,  this  is  largely  the  result  not  of  our  own  merits 
but  of  those  of  the  men  who  prepared  the  way  for  us. 
They  have  the  still  greater  advantage  of  enabling  us 
to  see  exactly  where  we  stand  in  knowledge  of  the 
things  which  form  the  object  of  our  study,  by  showing 
us  what  has  been  done  and  what  yet  remains  to  do. 
As  embryolog}'  furnishes  the  key  to  the  riddles  of 
anatomy,  so  the  history  of  the  evolution  of  any  branch 
of  science  throws  light  on  many  points  that  would 
otherwise  be  dark,  explains  the  origin  of  terms  and 
theories,  rescues  from  oblivion  truths  overlooked  or 
forgotten,  and,  showing  the  pitfalls  which  hindered 
those  who  have  gone  before,  teaches  us  to  walk  more 
warily. 

It  is  remarkable  that  in  the  journalistic  pagans  in 
which  the  triumphs  of  medicine  in  the  glorious  reign 
of  Queen  Victoria  ha\e  lately  been  recounted  derma- 
tology has  had  no  part.  Why  should  this  branch  of 
our  art  be  thus  unhonored  and  unsung?  It  is  a  form 
of  specialism,  no  doubt;  but  specialism  is  no  longer 
looked  upon  as  an  unclean  thing — except  here  and 
there  by  some  survivor  of  an  antique  world.  Derma- 
tology, although  its  victories  have  perhaps  been  less 
showy  than  those  won  in  some  other  special  depart- 
ments, has  not  lagged  behind  in  the  onward  march  of 
medicine.  It  has  therefore  seemed  to  me  that  I  might 
on  the  present  occasion  fitly  endeavor  to  supply  the 
missing  chord  in  the  great  jiihihTtf  whose  echoes  are 
.still  ringing  in  our  ears.  A  review  of  the  progress 
that  has  been  made  in  the  knowledge  of  skin  diseases 
is  all  the  more  appropriate  at  the  present  time,  since 
what  I  take  leave  to  call  the  centenary  of  the  birth  of 
scientific  dermatolog)-  is  not  long  past.  In  1790  the 
Medical  Society  of  London  awarded  the  Fotliergillian 
gold  medal  to  Robert  Willan,  who  had  some  time  be- 
fore submitted  to  it  the  outline  of  his  plan  for  the 
arrangement  and  description  of  cutaneous  diseases.' 
Willan  may  justly  be  called  the  creator  of  dennatol- 
ogy.  lieforc  him  the  skin  was  looked  upon  more  as  a 
mirror  on  whose  face  internal  di.sease  "glassed  itself 
in  tempest"  than  as  an  important  organ  subject  to 
manifold  disorders  peculiar  to  itself.  A  review  of  the 
development  of  this  branch  of  medicine  during   the 

*  .\n  address  tlelivcred  at  the  opening  of  the  section  of  derma- 
tology at  the  annual  meeting  of  the  British  Medical  Association, 
Montreal,  .September  i,   IMJ7. 


I 


September  i8,  1897] 


MEDICAL    RECORD. 


405 


past  hundred  years  is  therefore  virtually  a  history  of 
it  from  its  beginning.  This,  of  course,  cannot  be  told 
in  detail  here,  although  a  full  record  of  the  work  of 
the  makers  of  dermatology  would  certainly  not  be 
lacking  either  in  interest  or  in  usefulness.  All  that 
can  be  attempted  in  the  time  at  my  disposal  is  a  rapid 
sketch  of  the  principal  changes  in  the  conceptions  of 
skin  diseases  and  in  the  manner  of  treating  them  that 
have  taken  place  since  Willan  reclaimed  this  waste 
land  of  pathology  and  brought  it  under  scientific 
cultivation. 

Forerunners  of  Willan. — Willan  was  not  the  first 
who  wrote  on  skin  disease.  As  our  terminolog}'  bears 
witness,  the  Greeks  gave  a  good  deal  of  attention  to 
the  subject.  Hippocrates  speaks  of  "  pityriasis," 
"lichen,"  "herpes,"  "poniphi,"  and  many  other  forms 
of  cutaneous  lesion,  and  roughly  classifies  them. 
Later  Celsus,  Galen,  Paul  of  Aigina,  and  after  them 
the  Arabians,  described  various  affections  of  the  in- 
tegument. The  mediaeval  writers  might  have  said 
with  Browning's  Karshis/i  : 

"  -Scalp  disease 
Confounds  me,  crossing  so  witli  leprosy.  " 

Much  of  the  skin  disease  they  saw  was  leprosy,  and 
they  doubtless  often  imagined  it  where  it  did  not  ex- 
ist. At  a  later  period  .syphilis  overshadowed  every- 
thing. 

The  first  treatise  professedly  devoted  to  diseases  of 
the  skin  was  that  of  Hieronymus  Mercurialis,  of  Ven- 
ice, which  was  published  in  1572  under  the  title,  "  De 
Morbis  Cutaneis  et  de  Omnibus  Corporis  E.xcremen- 
tis."  The  author  had,  however,  nothing  to  teach  be- 
yond what  he  found  in  the  ancient  writers.  In  the 
early  pqrt  of  the  eighteenth  century  Daniel  Turner 
produced  "  .V  Treatise  of  Diseases  Incident  to  the 
Skin,"  which  appeared  with  the  im(<rimatiir  of  the 
president  and  censors  of  the  Royal  College  of  Phy- 
sicians of  London,  to  whom  it  was  offered  in  an  "  Epis- 
tle Dedicatory"  in  1712.  Turner's  work,  though  it  is 
described  by  Kaposi  as  "  very  important,"  is  almost 
wholly  a  compilation  from  other  writers,  and  treats 
not  of  the  skin  alone,  but  of  all  "  distempers"  affect- 
ing "the  outward  Parts  or  Confines,  as  may  be  said, 
of  the  Human  Body."  Thus,  not  only  the  eruptive 
fevers,  the  "green  sickness,"  and  the  "yellow  jaun- 
dice," but  phimosis  and  paraphimosis,  hemorrhoids, 
"chaps  on  the  fundament,"  imperforate  conditions  of 
the  natural  passages  of  the  body,  ulcerations  of  all 
kinds,  burns,  stings,  and  bites  of  venomous  creatures, 
hydrophobia,  and  poisoned  wounds  are  looked  upon 
by  tlie  author  as  falling  within  his  province. 

Later  in  the  same  century  there  appeared  almost 
simultaneously  two  works,  each  of  whicli  in  its  own 
way  marked  a  distinct  advance  toward  a  scientific  der- 
matology. In  a  book  entitled  "  Doctrina  de  Morbis 
Cutaneis,"  which  was  published  at  Vienna  in  1776, 
Joseph  Jacob  von  I'lenck  for  the  first  time  attempted 
a  complete  classification  of  diseases  of  the  skin.  He 
arranged  them,  according  to  what  appeared  to  him  to 
be  the  most  characteristic  objective  feature,  in  four- 
teen groups  with  one  hundred  and  twenty  varieties. 
In  his  "Tractatus  de  Morbis  Cutaneis,  published  in 
Pari  >  i;i  1777,  Lorry,  besides  giving  good  descriptions 
of  clinical  phenomena,  discussed  the  pathology  of  cu- 
taneous affections  in  the  light  of  the  knowledge  of  the 
structure  of  the  skin  and  the  morbid  processes  of 
which  it  might  be  the  seat  as  they  existed  in  his  day. 

But  these  were  voices  of  men  crying  in  the  wilder- 
ness, and  neither  Plenck  nor  Lorry — meritorious  as 
were  the  works  of  both — did  much  to  dissipate  the 
darkness  that  was  upon  the  face  of  this  branch  of 
medicine.  .Vt  the  beginning  of  the  nineteentli  cen- 
tur)-  it  could  be  said  with  perfect  truth  that  little  im- 
provement had  been  made  in  the  subject  at  large  since 
the  days  of  .\vicenna.' 


The  Birth  of  Dermatology. — In  180S  there  ap- 
peared the  first  volume  of  Willan's  treatise  "  On  Cuta- 
neous Diseases,"  a  great  work,  which  its  author  did  not 
live  to  complete.  Ten  years  before,  he  had  given  to 
the  world  a  slender  volume  dealing  with  a  particular 
class  of  lesions  of  the  skin. '  Willan  set  himself  the 
task  of  reducing  the  chaos  of  skin  diseases  to  some- 
thing like  a  cosmos.  The  following,  to  quote  his  own 
words,  are  the  objects  at  which  he  aimed  in  the  execu- 
tion of  this  design  : 

"  I.  To  fix  the  sense  of  the  terms  employed  by  proper 
definitions. 

■■  2.  To  constitute  general  divisions  or  orders  of  the 
diseases  from  leading  and  peculiar  circumstances  in 
their  appearance;  to  arrange  them  into  distinct  genera; 
and  to  describe  at  large  their  specific  forms  or  varieties. 

"3.  To  classify  and  give  names  to  such  as  have  not 
been  hitherto  sufficiently  distinguished. 

"4.  To  specify  the  mode  of  treatment  for  each 
disease." 

Like  Plenck,  Willan  grouped  skin  diseases  accord- 
ing to  the  character  of  the  predominant  lesion;  and 
indeed  there  can  be  little  doubt  that  he  took  the 
groundwork  of  his  classification  from  Plenck.*  The 
English  dermatologist,  however,  reduced  the  fourteen 
orders  of  his  Austrian  forerunner  to  seven,  "  to  be 
characterized  by  the  different  appearances  of  papulae, 
scales,  rashes,  vesicles,  pustules,  tubercles,  and  ma- 
culae." To  these  another  order,  "  bulla:-,"  was  after- 
ward added.  This  classification  is  of  course  very 
defective,  inasmuch  as  it  takes  account  only  of  the 
outward  and  visible  signs  and  results  of  disordered 
action.  As  the  skin  has  but  a  limited  range  of  path- 
ological expression,  lesions  identical  in  appearance 
and  in  structure  are  produced  by  widely  different 
causes.  Hence  a  classification  based  solely  on  objec- 
tive appearances  inevitably  led  to  the  formation  of 
motley  groups  including  conditions  having  no  essen- 
tial feature  in  common ;  wherein,  for  instance,  variola 
was  classed  with  scabies  as  being  "pustular,"  and  va- 
ricella with  eczema  as  "  vesicular,"  diseases.  More- 
over, as  in  the  evolution  of  many  affections  of  the  skin 
the  lesions  run  through  almost  the  whole  gamut  of 
differences  in  appearance  which  constitute  the  several 
"orders,"  it  is  unsafe  to  look  only  at  them  in  seeking 
for  the  distinctive  characters  of  such  diseases.  But 
Willan's  classification,  defective  as  it  was,  at  least  in- 
troduced a  definite  principle  of  arrangement  into  a 
region  of  pathology  where  before  all  was  "most  ad- 
mired disorder."  If  he  got  the  idea  from  Plenck,  he 
must  be  allowed  the  credit  of  having  greatly  bettered 
the  instruction  which  he  received,  and  of  having  pre- 
sented it  to  the  medical  world  in  such  a  manner  as  to 
impress  it  on  the  mind  of  the  profession. 

It  is  not,  however,  Willan's  classification  that  cov- 
stitutes  his  chief  title  to  be  regarded  as  the  founder  of 
dermatology.  His  judicious  selection  and  accurate 
definition  of  terms;  his  astonishingly  faithful  word 
pictures  of  the  appearances  of  disease,  drawn  directly 
from  nature,  and  made  more  vivid  but  scarcely  more 
graphic  by  the  colored  engravings  with  which  he  sup- 
plemented his  descriptions,  and  his  rational  methods 
of  treatment,  were  all  his  own.  It  was  his  teaching 
that  transformed  a  confused  jumble  of  folklore  as  to 
"tetters,"  wet  and  dry,  and  of  figments  of  the  medical 
imagination,  embodied  in  words  of  learned  sound  but 
little  meaning,  into  a  science,  rudimentary  indeed,  but 
grounded  on  a  solid  foundation  of  observed  fact.  Wil- 
lan's work  is,  therefore,  rightly  looked  upon  as  the  true 
starting-point  in  the  history  of  dermatology. 

The  English  School. — Willan  died  before  he  could 
complete  his  work;  but,  fortunately,  he  left  behind  a 
disciple  well  worthy  to  wear  his  mantle.  This  was 
Thomas  Bateman,  who  had  been  in  constant  inter- 
course with  him   for  many  years,  and  who  was  thor- 


4o6 


MEDICAL    RECORD. 


[September  i8,  1897 


oughly  acquainted  not  only  with  the  teaching  but  with 
the  spirit  of  his  "  learned  preceptor."  Bateman  com- 
pleted Willan's  unfinished  "  Delineations  of  Cutane- 
ous Diseases,"  and  published  a  "Practical  Synopsis 
of  Cutaneous  Diseases,"  which  did  far  more  to  make 
his  master's  work  known  than  Willan's  own  unwieldy 
and  incomplete  book.  It  is  hardly  too  much  to  say 
that  without  Bateman  \\'illan  might  have  been  forgot- 
ten. Bateman,  however,  was  not  a  mere  expositor; 
he  was  a  man  of  truly  scientific  mind,  and  would 
doubtless  have  added  largely  to  knowledge  had  not 
he,  too,  been  cut  off  prematurely. 

Bateman's  "  Synopsis"  ran  through  several  editions 
in  his  lifetime,  and  afterward  found  an  editor  in  An- 
thony Todd  Thomson,  who  also  published  an  "  Atlas 
of  Delineations  of  Cutaneous  Eruptions"  illustrative 
of  the  descriptions  in  Bateman's  book.  Thomson  paid 
special  attention  to  diseases  of  the  skin  for  more  than 
thirty  years.  He  was  an  accurate  observer,  and  was 
very  successful  in  treatment.  Toward  the  end  of  his 
life  he  embodied  the  fruits  of  his  experience  in  a 
"Practical  Treatise  on  Diseases  Affecting  the  Skin," 
which,  however,  he  did  not  live  to  finish;  it  was  com- 
pleted by  his  nephew,  Edmund  Ale.xander  I^arkes,  who 
was  familiar  with  Thomson's  opinions  and  methods 
of  treatment  in  cutaneous  diseases,  and  published  in 
1850.  Thomson  held  that  there  could  be  "scarcely 
any  difference  of  opinion  respecting  the  necessity  of 
arranging  the  tribe  of  those  diseases  .  .  .  [of  the  skin  j 
according  to  the  physical  characters  of  the  eruptions," 
and  in  adopting  this  method  he  chose  "as  the  least 
exceptionable  the  orders  of  Willan."  °  But  although 
"forced,"  as  he  says,  to  adopt  the  arrangement,  he 
was  careful  to  guard  himself  against  the  supposition 
that  he  regarded  "  the  knowledge  of  their  physical 
characters  as  throwing  any  light  upon  the  nature  of 
the  diseases  which  originate  the  eruptions." 

Thomson  was  physician  to  University  College  Hos- 
pital, where  he  was  the  first  of  what  may  be  called  a 
dermatological  succession,  w-hich,  handed  on  in  turn 
by  Parkes,  Hillier,  and  Tilbury  Fox,  is  still  worthily 
continued  by  Radclift'e  Crocker. 

Almost  simultaneously  with  the  treatise  of  Thomson 
and  Parkes  there  appeared  a  work  which  is  one  of  the 
landmarks  in  the  history  of  the  English  school  of  der- 
matology. This  was  Erasmus  \\'ilson's  "  Diseases  of 
the  Skin,"  the  preface  to  which  is  dated  185 1.  Wil- 
son,'who  had  commenced  his  scientific  career  as  an 
anatomist,  had  already  done  a  good  deal  of  work  in 
dermatology,  particularly  in  the  microscopic  study  of 
the  cutaneous  tissues.  He  made  a  new  classification 
of  skin  affections,  grouping  them,  according  to  the 
structure  in  which  the  morbid  process  originated,  into 
four  primary  divisions:  (1)  Diseases  of  the  derma; 
(2)  diseases  of  the  sudoriparous  glands;  (3)  diseases 
of  the  sebiparous  glands;  (4)  diseases  of  the  hairs 
and  hair  follicles.  Each  of  these  included  numerous 
secondary  divisions,  corresponding  to  the  manner  in 
which  the  structure  was  changed  or  tlie  function  dis- 
ordered. Wilson's  influence  was  for  a  long  time  pre- 
dominant among  his  own  countrymen,  and  by  workers 
in  other  countries  he  was  looked  upon  as  the  foremost 
representative  of  British  dermatolog)-.  He  had  an  eye 
for  form  and  color,  and  often  found  tiie  right  word  to 
express  them.  His  description  of  diseased  conditions 
are  thus  almost  unrivalled  in  tiieir  picturesque  and 
yet  faithful  rendering  of  appearances.  He  added  lit- 
tle, however,  to  our  knowledge  of  the  pathology  and 
therapeutics  of  skin  diseases,  and  added  not  a  little  to 
the  confusion  which  existed  on  the  subject,  bv  his  arti- 
ficial classification  and  his  ever-changing  nomencla- 
ture. 

On  the  work  of  tlie  living  leader  of  our  British 
school  of  dermatology,  Mr.  Jonathan  Hutchinson,  it 
is  not  fitting  to  dwell  here.      It  may,  however,  be  per- 


missible to  say  that  he  has  brought  to  the  study  of  the 
pathology  of  the  skin  a  knowledge  of  disease  in  gen- 
eral such  as  probably  no  other  dermatologist  has  ever 
possessed.  This,  together  with  a  marked  originality 
and  independence  of  mind,  and  a  singular  power  of 
seeing  points  of  likeness  in  things  to  outward  seeming 
most  unlike,  has  enabled  him  to  throw  an  unexpected 
light  on  many  dark  places  of  dermatology. 

On  the  whole  it  may  be  said  that  the  characteristics 
of  the  British  school  of  dermatology  are  those  com- 
monly held  to  be  distinctive  of  the  British  intellect  in 
whatever  sphere  it  is  set  to  work.  We  are  a  practical 
people,  loving  facts  and  caring  little  for  theories. 
Accordingly  British  dermatologists  from  Willan  to 
Hutchinson  have  been  first  of  all  observers.  They 
have  striven  to  get  at  what  Magendie  called  the  /a// 
brut,  to  see  things  as  they  really  are,  and  to  describe 
what  they  saw  as  faithfully  as  they  could.  They  ha\  e 
been  distrustful  of  generalizations  and  cautious — per- 
haps overcautious — in  deductions.  But  the  facts  gath- 
ered by  them  have  endured  while  theories  and  systems 
have  followed  each  other  into  nothingness;  and  der- 
matology as  it  exists  to-day  is  largely  the  work  of 
their  hands. 

The  French  School. — In  France  a  school  of  der- 
matology arose  independently  in  the  early  years  of  the 
century.  In  1808  Alibert  published  his  "  Description 
des  Maladies  de  la  Peau  observees  k  I'Hopital  Saint 
Louis,"  which  he  followed  up  two  years  later  by  a 
"Traite  Theorique  et  Pratique  des  Maladies  de  la 
Peau,"  and  several  other  works.  The  most  valuable 
part  of  his  publications  was  the  illustrations ;  his  wTit 
ings  only  added  to  the  darkness  in  which  the  whole 
subject  of  diseases  of  the  skin  was  then  enshrouded. 
His  terminology  was  to  the  last  degree  confusing,  his 
classification  was  arbitrary,  his  descriptions  were  often 
fanciful.  Yet  he  contributed  to  the  advance  of  knowl- 
edge by  directing  the  attention  of  more  scientifically 
minded  workers  to  the  subject.  Among  these  was  Biett, 
who  adopted  Willan's  classification  with  some  modi- 
fications and  introduced  it  into  France.  Biett  taught 
for  many  years  at  St.  Louis,  but  the  only  record  of 
his  observations  and  experience  is  contained  in  the 
"Abregc  Pratique  des  Maladies  de  la  Peau"  of  his 
pupils  Cazenave  and  Schedel,  which  appeared  in 
1828.  Yet,  though  he  published  nothing  in  the  ordi- 
nary way,  his  teaching  had  a  much  more  far-reaching 
influence  than  that  of  .\libert.  In  183 1  Rayer  sketched 
out  a  plan  of  classification  of  skin  diseases  on  a  basis 
of  morbid  anatomy,  dividing  them  into:  (i)  Inflam- 
mations; (2)  morbid  secretions;  (3)  congestions  and 
hemorrhages;  (4)  aua;mias:  (5)  neuroses;  and  (6) 
deformities — thus  anticipating  Hebra  in  principle 
and,  to  a  considerable  extent,  in  detail.  Raver's 
work  is  a  mine  of  information  as  to  the  early  litera- 
ture of  dermatology,  and  embodied  the  results  of  ex- 
tensive clinical  observations  .so  accurate  and  so  clearly 
recorded  that  much  of  it  is  of  permanent  value. 

.Vniong  the  leaders  of  the  French  school  who  fol- 
lowed liiett  were  Cazenave,  Gibert,  Devergie,  and  Ba- 
zin,  all  of  whom  did  something  to  advance  the  knowl- 
edge of  skin  diseases,  though  they  were  apt  to  let 
themselves  be  misled  by  a  tendency  to  erect  systems 
on  unsound  foundations.  To  them  skin  diseases  were, 
for  the  ntost  jiart,  the  expressions  of  some  constitution- 
al dvscrasia,  which  at  best  was  an  unnecessary  hypoth- 
esis, and  was  sometimes,  as  in  the  case  of  the  so-called 
"dartrous,"  "  psoric,"  and  "herpetic"  diatheses,  a 
myth.  Indeed,  it  may  be  said  that  in  France  derma- 
tologv  was  the  "last  ditch"  in  wiiich  these  mediaeval 
notions  still  fought  for  life.  In  recent  years  the  yoke 
of  the  diatlieses  has  been  shaken  off,  and  the  labors  of 
Hardy,  Yidal,  Besnier,  and  Brocq  have  placed  the 
French  school  in  the  forefront  of  scientific  dermatol- 
ogv,  a  position  which,  with  such  men  as   Darier.  Thi- 


September  18,  1S97] 


MEDICAL    RECORD. 


407 


bierge,  Wickham  to  take  the  place  of  their  seniors 
when  they  have  to  fall  out  of  the  ranks,  it  is  in  no 
danger  of  losing. 

The  German  School. —  The  year  1844  marked  the 
beginning  of  a  new  era  in  the  study  of  diseases  of  the 
skin,  for  it  witnessed  the  first  appearance  of  Ferdinand 
Hebra  before  the  scientiiic  world.  That  remarka- 
ble man  breathed  a  new  life  into  the  dry  bones  of 
dermatology,  and  set  it  on  a  path  of  progress  which 
has  already  led  to  great  results.  Hebra  applied  to  the 
investigation  of  skin  diseases  the  pathological  teach- 
ing of  Rokitansky.  He  classified  them,  not  according 
to  their  objective  appearances,  or  to  the  structures 
supposed  to  be  primarily  or  mainly  affected,  but  ac- 
cording to  the  nature  of  the  pathological  processes  of 
which  they  were  examples.  He  used  the  e.xperimental 
method,  producing  various  lesions  on  healthy  skin  by 
artificial  means,  and  observing  the  changes  which  they 
underwent  when  allowed  to  run  their  own  course,  and 
when  modified  by  treatment  of  different  kinds.  In  this 
way  Hebra  rationalized  dermatolog}-,  ridding  it  of  the 
superstitions  as  to  dyscrasite  with  which  it  had  before 
been  infested,  and  giving  to  the  treatment  of  skin  dis- 
ease a  directness  of  purpose  and  a  simplicity  of  means 
undreamt  of  by  his  predecessors.  Students  of  skin 
disease  flocked  from  nearly  every  part  of  the  world  to 
sit  at  the  feet  of  the  Vienna  Gamaliel,  and  the  influ- 
ence of  his  teaching  was  felt  everjwhere  e.xcept  in 
France,  where,  as  has  been  said,  the  traditional  belief 
in  dyscrasiae  persisted  till  a  comparatively  recent  pe- 
riod. Hebra's  work  has  been  carried  on  by  Auspitz, 
Kaposi,  and  Xeimiann  in  Vienna,  by  Pick  in  Pragtie, 
.Schwimmer  in  Budapest,  Lewin  and  Lassar  in  Ber- 
lin, Neisser  in  Breslau,  and  many  others. 

If  VVillan  was  the  creator,  Hebra  must  be  acknowl- 
edged as  the  greatest  among  the  refoniiers  of  derma- 
tology. This  glory  must  be  his  in  spite  of  the  fact 
that  his  classification  in  its  leading  features  had  been 
anticipated  by  Rayer.  Hebra,  however,  worked  it  out 
so  fully  as  to  make  it  his  own:  and  his  classification, 
though  it  has  necessarily  been  modified  as  knowledge 
grew,  notably  by  the  influence  of  Virchow's  "cellular 
pathology"  and  by  the  newer  bacteriological  doctrine, 
can  never  be  superseded  till  an  arrangement  based  on 
etiology  becomes  possible.  Such  a  classification  has 
already  been  attempted  by  Auspitz  and  after  him  by 
Bronson,  but  the  time  for  it  is  not  yet. 

The  American  School The  history  of  dermatol- 
ogy' in  .\merica  has  been  written  by  Prof.  J.  C.  White, 
of  Harvard,  and  by  Prof.  Louis  A.  Duhring,  of  Phila- 
delphia, from  whom  all  that  can  here  be  said  on  the 
subject  is  taken.'  For  the  first  thirty  years  or  more  of 
the  century  little  or  no  interest  in  cutaneous  affections 
was  taken  in  America.  .\  story  is  told  which,  whether 
true  or  not,  serves  to  illustrate  the  state  of  things  in 
these  days.  A  student,  asking  a  physician  for  in- 
formation as  to  a  disease  of  the  skin,  was  met  with 
the  reply :  "  Sir,  I  know  nothing  of  skin  diseases ;  you 
must  go  to  a  surgeon."  On  his  applying  to  the  sur- 
geon, the  answer  was:  "Sir,  I  must  refer  you  to  the 
physician."  In  fact,  as  Duhring  tells  us,  a  disposition 
existed  to  consign  the  whole  of  this  branch  of  medi- 
cine to  those  outside  the  professional  pale.  No  one 
seemed  prepared  to  take  up  the  matter.  Still,  even 
at  that  period,  there  was  a  demand  for  information  on 
skin  diseases  which  booksellers  thought  it  worth  while 
to  supply.  Bateman's  "  Synopsis"  was  republished  at 
Philadelphia  in  18 18,  a  second  edition  being  issued 
in  1824,  and  a  translation  of  the  work  of  Cazenave 
and  Schedel  appeared  in  the  same  city  in  1829,  a  sec- 
ond edition  being  published  in  1832.  In  1845  ap- 
peared the  first  .\merican  work  on  dermatology.  It 
was  entitled  "  .\  Synopsis  of  the  Symptoms,  Diagnosis, 
and  Treatment  of  the  more  Common  and  Important 
Diseases  of  the  Skin,"  and  its  author  was  X.  Worces- 


ter, professor  of  physical  diagnosis  and  general  pa- 
thology in  the  Medical  School  of  Cleveland.  The 
book  is  described  by  Duhring  as  being  little  more 
than  a  compilation  from  the  works  of  the  French  and 
English  dermatologists  of  the  day. 

Meanwhile,  other  signs  of  a  growing  interest  in  the 
subject  were  not  wanting.  In  1836  an  infirmary  for 
diseases  of  the  skin  was  opened  in  New  York,  it  being 
the  first  institution  of  the  kind  established  in  the  Unit- 
ed States,  and  lectures  on  skin  diseases  were  deliv- 
ered there,  and  afterward  in  some  of  the  medical 
schools  of  Xew  York  between  the  vears  1837  and  1854 
by  Dr.  H.  D.  Bulkley,  father  of'  Dr.  L.  D.  Bulkley, 
whose  name  is  well  known  to  all  dermatologists. 

At  this  time  Paris  was  the  centre  of  the  dermatolog- 
ical  world,  and  American  students  accordingly  went 
there  for  instruction  in  the  subject.  Hence  for  many 
years  .\merican  dermatology  was  the  direct  offspring 
of  the  French  school,  the  influence  of  which  was  only 
slightly  tempered  by  reprints  of  the  works  of  \Vilson 
and  other  English  writers.  At  a  later  period  Ameri- 
cans flocked  to  Vienna,  and  on  returning  home  spread 
the  doctrines  of  Hebra  among  their  countrymen.  As 
earlv  as  1859  Hebra's  teaching  was  made  known  in 
.\merica  by  Prof.  James  C.  White,  who,  two  years 
later,  at  Har\-ard  gave  the  first  course  of  lectures  on 
diseases  of  the  skin.  After  the  civil  war  clinical 
lectureships  on  the  subject  were  established  in  sev- 
eral important  schools.  In  1870  the  foundation  of 
the  American  Jou/nn/ of  Syphilogrctphy  and  Dermaiology 
did  something  to  promote  the  advancement  of  the 
knowledge  of  skin  diseases  in  America,  and  the  estab- 
lishment of  the  American  Dermatological  Association 
in  1877  gave  a  powerful  impulse  in  the  same  direc- 
tion, which  was  further  aided  by  the  creation  of  the 
Arclihes  of  Dermatology.  Vet  in  1871  Prof.  James 
C.  White  complained  that  as  yet  America  had  contrib- 
uted little  to  dermatolog)-,  and  that  this  branch  of 
medicine  had  hardly  then  found  a  place  among  his 
countrymen  as  an  acknowledged  specialty.  Xow  this 
reproach  has  been  wiped  away,  and  American  derma- 
tolog}%  represented  by  Duhring,  J.  C.  White,  Bulkley, 
and  others,  is  recognized  as  being  in  the  van  of  prog- 
ress. 

The  Fusion  of  the  Schools Each  of   the   three 

great  schools  which  helped  to  lay  the  foundations  of 
modern  dermatology  had  certain  marked  characteris- 
tics. The  English  was  essentially  clinical,  using  clas- 
sification only  as  a  practical  help  in  diagnosis;  it  ob- 
served. The  French  systematized,  striding  somewhat 
impatiently  over  facts  to  get  at  general  formulas, 
which,  though  plausible  on  paper,  too  often  broke 
down  in  application.  The  German  was  pathological, 
giving  attention  mainly  to  the  mechanism  and  occa- 
sionally taking  too  little  heed  of  the  causes  setting  it 
in  motion.  Each  school  had  thus  the  defects  of  its 
qualities:  but  each  played  an  important  part  in  the 
development  of  dermatology,  and  much  of  what  was 
good  in  each  still  survives  in  the  cutaneous  medicine 
of  the  present  day. 

Xow  dermatology  is  truly  international,  the  differ- 
ent schools  which  were  formerly  as  separate  States 
having  become  fused  into  one  scientific  commonwealth. 
This  has  been  accomplished  by  the  translation  of  rep- 
resentative works  of  each  school  into  the  language  of 
the  others;  by  the  multiplication  of  journals  devoted 
to  this  special  branch  of  medical  science,  in  which 
everj'thing  of  value  that  is  published  in  any  part  of 
the  world  is  gathered  up  and  summarized;  by  the  fa- 
cilities of  communication,  which  make  it  easy  for  the 
scientific  pilgrim  to  visit  every  dermatological  shrine 
where  his  devotion  is  likely  to  be  rewarded  with 
knowledge  of  some  new  thing:  and  by  congresses, 
those  marts  for  the  e.xchange  of  scientific  wares  which 
have  so   powerfully  aided  in  the  diffusion  of  knowl- 


4o8 


MEDICAL    RECORn. 


[September  i8,  1897 


edge,  in  the  extinction  of  national  jealousies,  and  in 
the  correction  of  provincial  ways  of  thought.  Dr. 
Johnson  when  at  Oxford  was  overheard  to  say  that  he 
had  a  mind  to  see  what  was  being  done  in  foreign  uni- 
versities, "for  an  Athenian  blockhead  is  the  worst 
of  blockheads."  He  thus  vigorously  expressed  the 
truth  that  a  man  trained  in  a  particular  school  is  apt 
to  be  narrow  if  he  knows  nothing  of  any  other.  In 
the  sphere  of  dermatology  this  kind  of  narrowness  was 
especially  exemplitied  in  the  French  school,  but  nei- 
ther of  the  others  was  entirely  free  from  it.  How 
could  it  be  otherwise  when  they  knew  so  little  of  each 
other.'  How  slowly  the  work  even  of  so  brilliant  a 
dermatologist  as  Hebra  became  known  to  the  profes- 
sion in  other  countries  at  a  lime  comparatively  recent 
is  shown  by  the  following  passage  which  I  quote  from 
Prof.  James  C.  White.  Speaking  of  the  middle  of 
the  fifties  he  says:  "  It  was  not  until  the  intelligence 
began  to  spread,  slowly  borne  by  word  of  mouth  from 
country  to  country,  that  in  an  imperial  city  of  Austria 
there  was  a  man  teaching  skin  diseases  as  they  had 
never  been  taught  before,  with  unlimited  means  of 
clinical  illustration,  with  the  keenest  eye  for  observa- 
tion, with  an  unbounded  amount  of  information  drawn 
from  many  years  of  experience,  with  a  self-restraint 
which  no  desire  for  premature  fame  could  tempt  into 
hasty  publication,  and  with  a  sound  and  logical  mind, 
that  the  German  school  of  dermatology  some  fifteen 
years  ago  began  to  be  known  and  to  advance  to  that 
pre-eminent  position  it  now  holds.''  '  Fame  flies  faster 
nowadays,  but  the  very  ease  and  rapidity  with  which 
the  results  of  a  man's  work  can  be  made  known  now 
lead  to  the  publication  of  much  that  is  inaccurate 
observation  and  immature  speculation. 

Progress  in  Knowledge. —  Turning  now  from  the 
workers  to  the  work  that  has  been  done,  the  most  strik- 
ing feature  of  the  dermatology  of  to-day  as  compared 
with  that  of  the  beginning  of  the  century  is  the  knowl- 
edge of  the  nature  and  causes  of  skin  diseases  that  has 
been  gained.  VVillan  and  Kateman  left  little  in  the 
way  of  outward  appearances  for  those  who  came  after 
them  to  describe,  but  no  real  knowledge  of  pathologi- 
cal processes  was  possible  till  the  microscope  and 
other  modern  methods  of  research  were  applied  to  the 
study  of  diseases  of  the  skin.  This  is  the  special 
achievement  of  the  German  school.  The  attention 
directed  to  processes  has  led  us  to  recognize  that 
many  conditions  which  used  to  be  looked  upon  as  dis- 
tinet  affections  are  really  different  stages  in  the  evolu- 
tion of  one  and  the  same  disease.  In  this  way  der- 
matology has  been  greatly  simplified.  Compare,  for 
instance,  the  modern  teaching  as  to  eczema  with  that 
of  Erasmus  Wilson,  with  his  six  principal  varieties — 
erythematosum,  papulosum,  vesiculosum,  ichorosum, 
pustulosum,  squamosum ;  and  his  ten  subvarieties — 
marginatum,  fissum,  mucosum,  scabidum  scu  cvusta- 
ceum,  oedematosum,  tuberculosum,  spargosiforme, 
sclerosum,  verrucosum,  neurosum.  Then,  according 
to  the  parts  attacked,  there  was  eczema  capitis,  faciei, 
auriculare,  mammillare,  umbilicale,  perineale.  The 
varieties  of  psoriasis  were  still  m>)re  numerous — punc- 
tata, guttata,  alphoides,  nummularis,  scutellata,  orbi- 
cularis, annulata,  circinata,  vulgaris,  gyrata,  circum- 
scripta, diffusa,  contluens,  discoidea,  centrifuga,  im- 
bricata,  figurata,  inxeterata;  with  the  local  forms — 
palpebrarum,  labialis,  pnvputii,  scrotal  is  et  pudenda- 
lis,  palmaris,  unguium;  it  is  like  the  catalogue  of  the 
ships  that  bore  the  Danaans  to  Ilios.  And  for  a  long 
time  nearly  every  writer  on  skin  diseases  thought  it  due 
to  himself  to  show  his  inventiveness  in  the  same  way. 
It  is  no  wonder  that  dermatology  treated  in  this  wav 
was  a  terror  to  students  and  an  affliction  to  jiractition- 
ers. 

Further  simplification  lias  lesulled  imm  nur  iuu  ing 
learned   to   distinguish    between    the   primarv    lesions 


which  are  the  notes  of  a  particular  disease  and  the 
lesions  which  result  from  secondary  causes,  such  as 
injury  from  scratching  or  rubbing  and  the  invasion  of 
pyogenic  micro-organisms.  Much  confusion  and  need- 
less multiplication  of  types  were  caused  in  former 
days  by  mistaking  the  accidental  for  the  essential  in 
such  affections  as  scabies,  eczema,  ringworm,  impeti- 
go, and  other  conditions  liable  to  complication  by 
suppurative  processes. 

Pathological  research  has  done  much  to  elucidate 
the  nature  of  growths,  benign  and  malignant,  of  the 
skin.  The  work  of  Jacob  Warren,  Hutchinson,  Du- 
breuilh,  and  Xornian  Walker  in  regard  to  rodent  ulcer 
and  that  of  Kaposi  in  regard  to  sarcoma  of  the  skin 
and  xeroderma  pigmentosum  mark  distinct  advances. 

Keal  progress  in  the  science  of  medicine,  however, 
is  measured  by  the  increase  in  our  knowledge  of  the 
causes  of  disease.  In  this  respect  it  may,  I  think,  be 
said  that  as  much  has  been  done  in  dermatology  as  in 
any  branch  of  medicine.  Ihe  etiology  of  a  very  con- 
siderable proportion  of  skin  diseases  is  now  accurately 
known.  Among  the  causes  whose  operation  has  been 
clearly  traced,  a  prominent  place  is  occupied  by  inoc- 
ulable  viruses  which  infect  the  system,  such  as  syph- 
ilis, tuberculosis,  leprosy — to  mention  only  the  more 
common.  Ricord,  Fournier,  Sigmund.  and  Hutchin- 
son have  shown  how  many  and  various  are  the  cuta- 
neous manifestations  of  syphilis,  and  with  what  versa- 
tile mimicry  it  assumes  the  form  of  other  diseases  of 
the  skin.  Tuberculosis  has  been  proved  to  be  ac- 
countable not  only  for  lupus,  but  for  affections  for- 
merly classed  under  the  heads  of  lichen  and  erythema 
and  for  the  other  forms  of  skin  disease  included  under 
the  general  tenn  scrofuloderma.  The  sorting  out  of 
the  cutaneous  affections  due  to  these  two  causes  alone 
has  greatly  reduced  the  region  of  the  unknown  in  the 
map  of  derniatolog)'. 

The  Action  of  Parasites. — Another  direction  in 
which  the  etiology  of  skin  diseases  has  made  decided 
progress  is  the  recognition  of  the  action  of  parasites. 
The  idea  that  scabies  is  due  to  the  irritation  set  up  in 
the  tissues  by  an  animalcule,  and  ringworm  by  the 
growth  of  a  vegetable  mould  on  the  surface  of  the  skin, 
is  so  familiar  to  us  that  it  is  not  easy  to  realize  how 
recently  the  truth  of  these  doctrines  has  been  defi- 
nitely established,  and  with  what  incredulity  the  dis- 
coveries were  for  a  long  time  received.  The  sarcoptes 
scabiei  had  been  seen  by  .\venzoar  in  the  twelfth  cen- 
turv,  and  later  by  Guy  de  Chauliac,  Ambroise  Pare', 
and  others,  and  in  the  seventeenth  century  it  was  dis- 
tinctly indicated  by  ]5onomo  and  Cestoni  as  being  the 
cause  of  itch.  It  was  rediscovered  more  than  once 
afterward,  but  it  was  not  till  1834  that  Renucci,  in 
Alibert's  clinic,  was  able  to  show  how  it  could  always 
be  found.'  Vet  in  1850  Antony  Todd  Thomson  is  al- 
lowed to  say,  without  a  word  of  protest  from  his  editor, 
Parkes,  that  itch  is  certainly  "the  result  of  a  morbid 
poison,  and  that  the  fluid  of  the  vesicles  or  the  pus- 
tules is  the  agent  transmitting  the  disease;"  and  while 
awarding  Wilson  credit  for  his  accurate  description 
of  the  acarus  Thomson  expresses  his  inability  to  "ac- 
cord with  him  in  attributing  the  disease  to  that  in- 
sect."' Still  later  we  find  a  dermatologist  like  De- 
vergie  writing:  "  The  acarus  is  a  morbid  product  of 
the  itch  as  the  mycodenn  is  the  morbid  product  of 
ringworm,  as  the  insect  of  acne  punctata  is  tlie  morbid 
product  of  that  disease,  as  the  louse  is  the  morbid 
product  of  pediculous  prurigo.  Ringworm  is  conta- 
gious through  the  medium  of  this  mycodenn,  not  only 
from  child  to  child,  but  from  the  head  of  a  child  to 
the  bark  of  certain  trees,  and  the  lousy  evil  '"  from  per- 
.son  to  person.  Ringworm,  acne  punctata,  and  the 
lousy  evil,  do  they  originate  the  less  spontaneously  on 
that  account  ?  The  means  that  we  use  to  destroy  the 
acarus,  are  they  not  also  suitable  for  curing  the  erup- 


September  i8,  1897] 


MEDICAL    RFXORD. 


409 


tion  of  itch?"  The  fact  that  only  forty  years  ago  a 
dermatologist  of  the  first  rank  could  thus  in  one  sweep- 
ing anathema  condemn  root  and  branch  the  doctrine 
of  parasitism  in  skin  diseases  is  one  of  the  most  strik- 
ing proofs  of  the  youthfulness  of  scientific  dermatol- 
ogy,  and  of  the  progress  which  it  has  made  in  its  lusty 
childhood.' 

The  discovery  of  the  vegetable  fungi  which  cause 
ringworm,  favus,  tinea  versicolor,  and  er)-thrasma,  un- 
like that  of  the  itch  mite,  was  not  made  in  the  dark 
ages,  but  almost  in  the  full  glare  of  the  light  of  mod- 
em science;  yet  it  was  received  with  equally  resolute 
disbelief  by  some  of  the  leaders  in  dermatological  Is- 
rael. In  1839  Schoenlein  discovered  the  fungus  which 
produces  fa\us;  in  1844  Gruby  in  Paris,  and  Malms- 
sen  in  Stockholm,  almost  simultaneously  and  quite 
indei^endently  discovered  that  which  causes  ringworm. 
Here,  again,  we  find  A.  T.  Thomson,  in  1850,  assert- 
ing in  regard  to  favus  that,  though  the  disease  has  been 
ascribed  to  a  mycoderm,  '"  there  is  no  proof  of  that 
opinion,""  and  in  regard  to  ringworm  that  "the  pus- 
tules constitute  the  disease,  and  the  mycoderm  merely 
finds  its  habitat  on  them."  ''  In  the  same  year  Caze- 
nave"  could  scarcely  bring  himself  to  admit  the  ex- 
istence of  the  achorion  Schoenleinii,  and,  with  regard 
to  fungi  in  general  in  their  relation,  to  skin  diseases, 
he  was  emphatic  in  warning  investigators  against '"  the 
illusions  of  microphotography,"  and  denied  that  the.se 
'"mysterious  atoms"  possessed  any  pathogenic  prop- 
erty. In  1863  ("hausit,  a  pupil  of  Cazenave,  argued 
strongly  against  the  cryptogamic  origin  of  ringworm, 
concluding  that  "  in  the  present  state  of  dermatology 
there  is  no  disease  of  essentially  parasitic  nature,  and 
there  is  no  such  theory  as  antiparasitic  therapeusis."  " 

Gibert,  who  had  long  been  an  obstinate  recusant, 
gave  in  his  adhesion  to  the  parasitic  doctrine  in  1866, 
but  Cazenave  never  recanted  his  heresy,  and  Erasmus 
Wilson,  who,  after  Cazenave  had  passed  away,  stood 
alone  in  his  refusal  to  accept  the  teachings  of  modern 
science  on  this  subject,  also  died  an  unbeliever.  The 
brilliant  researches  of  M.  Sabouraud  have  recently 
proved  that  the  disease  liitherto  known  as  ringworm 
includes  two,  and  possibly  more,  distinct  conditions 
caused  by  different  species  of  fungi.  It  has  also  been 
shown  that  the  disease  may  be  transmitted  from  ani- 
mals—  particularly  the  horse — to  human  beings,  a  fact 
obviously  of  the  greatest  practical  importance.  Sa- 
bouraud and  other  obser\-ers  in  other  countries  ha\e 
thrown  light  on  the  geographical  distribution  of  tin- 
ringworm  fungus,  and  the  remarkable  fact  has  been 
brought  to  light  that  the  species  which  causes  the 
most  rebellious  form  of  the  disease  is  most  frequently 
met  with  in  London,  is  unknown  in  Italy,  and  is  very 
rare  in  Germany.  This  has  an  obvious  bearing  on 
the  records  of  the  results  of  treatment  in  those  several 
countries,  .\nother  point  which  is  suggested  in  re- 
cent investigations  is  that  the  boundary  line  between 
ringworm  and  favus  is  by  no  means  so  definite  as  has 
hitherto  been  believed.  It  is  clear  that  there  is  yet 
much  to  be  done  in  a  subject  which  a  short  time  ago 
was  looked  upon  as  worked  out. 

Bacteria  and  Skin  Diseases During  the  last  few 

years  our  ideas  as  to  the  action  of  parasites  have  under- 
gone expansion.  The  influence  of  the  great  revolu- 
tion in  pathology  brought  about  by  the  discoveries  of 
Pasteur,  Koch,  and  their  disciples  has  been  felt  in  the 
sphere  of  dermatology  as  in  other  departments  of  med- 
icine, and  we  have  learned  to  look  for  the  causes  of 
many  diseases  in  the  world  of  the  infinitely  little  which 
bacteriology  has  revealed  to  us.  Already  lupus,  lep- 
rosy, carbuncle,  glanders,  sycosis,  furuncle,  imi^etigo 
contagiosa  have  been  proved  to  be  the  result  of  the 
mischievous  activity  of  specific  micro-organisms.  It 
is  practically  certain  that  syphilis  has  a  like  origin, 
but  the  particular  microbe  responsible  for  its  produc- 


tion is  still  "wanted  "  by  our  scientific  police.  More 
than  one  has  been  arrested  on  suspicion,  others  are 
being  closely  shadowed,  and  there  is  every  hope  that 
the  actual  criminal  will  soon  be  found.  Eczema  is 
considered  by  Unna,  who  has  done  much  for  the  re- 
cent advance  of  dermatology,  to  be  of  microbic  origin. 
A  similar  causation  is  assigned  to  psoriasis,  and  by 
others  to  alopecia  areata,  acne,  and  certain  forms  of 
erythema.  Quite  recently  Sabouraud  has  brought  for- 
ward evidence  which  he  thinks  sufficient  to  prove  that 
seborrhocea  and  common  baldness  are  of  the  bacterial 
family  of  diseases.  These  views  are  not  yet  accepted 
by  all  dermatologists,  but  there  can  be  little  doubt  that 
as  methods  of  research  are  perfected  the  "  sphere  of 
influence"  of  bacteriology  in  relation  to  skin  diseases 
will  become  greatly  enlarged.  Already  it  extends  far 
more  widely  than  the  brief  list  of  diseases  which  have 
been  definitely  traced  to  microbic  agency  would  seem 
to  show.  In  almost  every  case  of  skin  disease  the 
primary  and  essential  process  is  at  some  period  of  its 
course  complicated,  and  it  may  be  overshadowed  by 
secondary  lesions.  To  bacteriolog}'  we  owe  the  knowl- 
edge that  these  are  due  to  the  action  of  pyococci  and 
streptococci,  whose  attacks  the  skin  resists  in  health, 
l)ut  to  which  it  falls  an  easy  prey  when  diseased.  The 
importance  of  this  knowledge,  Ixith  in  relation  to  diag- 
nosis and  to  treatment,  can  hardly  be  overestimated. 

Other  Lines  of  Advance. — I  can  make  only  the 
briefest  reference  to  other  lines  along  which  derma- 
tology has  advanced  in  recent  years.  Of  these  the 
most  important  has  been  the  increased  attention  be- 
stowed on  the  relations  of  various  fom^s  of  cutaneous 
affections  to  disorders  of  the  nervous  .system.  In  this 
field  the  most  notable  workers  have  been  Barensprung, 
Weir  Mitchell,  Morvnn,  Schwimmer,  Radcliffe  Crocker, 
and  above  all  Leloir,  whose  untimely  death  was  a 
grievous  loss  to  dermatolog}'.  A  large  number  of  skin 
diseases  presenting  the  greatest  diversity  in  their  ob- 
jective features  have  been  shown  to  be  dependent  on 
lesion  or  functional  disorder  of  some  part  of  the  ner- 
vous system.  Many  diseases,  such  as  zoster,  ervthema, 
pemphigus,  scleroderma,  and  various  forms  of  cuta- 
neous ctdema,  hemorrhage,  and  ulceration  which  used 
to  be  called  "  idiopathic'" — the  medical  equivalent  for 
the  "visitation  of  God"'  in  the  simple  etiolog}"  of  the 
British  juryman — are  now  recognized  to  be  conse- 
quences of  vasomotor  or  trophic  disturbance.  We  also 
know  that  defective  innervation  plays  a  considerable 
jiart  as  a  predisposing  cause,  making  the  skin  less  able 
to  resist  harmful  influences  of  any  kind — injury,  cold, 
heat,  and  irritants  whether  chemical  or  parasitic.  In 
this  way  nervous  disorder  comes  into  play  as  a  definite 
factor  in  many  cases  of  eczema,  lichen,  and  other  af- 
fections. The  late  Mr.  John  Marshall  threw  out  the 
pregnant  idea  that  cancer  might  be  an  ■"  anarchy  of 
cells"  due  to  loss  of  control  by  the  nervous  system, 
i'he  same  cause  might  account  for  some  diseases  of 
the  skin.  The  neuropathology  of  the  skin  is  a  field 
that  will  well  repay  further  cultivation. 

Another  line  along  which  we  have  advanced  is  the 
establishment  of  a  definite  relation  between  certain 
constitutional  states  and  affections  of  the  integument. 
The  tendency  of  the  French  school  to  look  to  the  gen- 
eral system  for  an  e.xplanation  of  every  blotch  and 
pimple  led  them  away  from  the  truth  no  doubt,  even 
to  the  invention  of  a  diathesis  when  one  was  wanted; 
but  some  dermatologists  ha\e  jaerhaps  now  gone  a 
little  too  far  in  the  opposite  direction.  It  is  well  that 
with  the  all-conquering  bacillus  on  every  side  extend- 
ing the  boundaries  of  his  empire,  we  should  not  forget 
that  other  agencies  have  still  to  be  taken  into  ac- 
count. Gout  has  not  the  far-reaching  influence  in 
the  production  of  cutaneous  affections  that  it  u;ed  to 
be  credited  with;  but  it  is  sometimes  a  factor  that 
must  be   reckoned  with.      i'he   connection   of    certain 


4IO 


MEDICAL    RECORD. 


[September  i8,  1897 


forms  of  pruritus  and  herpes,  of  boils  and  carbuncles, 
of  a  particular  variety  of  xanthoma  with  glycosuria  is 
well  known. 

The  influence  of  auto-intoxication  requires  to  be 
more  thoroughly  studied  than  it  has  yet  been :  the 
effects  of  ptomains  should  also  be  fully  investigated. 
The  serum  treatment  which  is  now  being  tried  in 
diphtheria  and  other  diseases  is  making  us  familiar 
with  toxin  rashes;  is  it  not  possible  that  the  prolonged 
operation  of  some  similar  cause  might  explain  the 
origin  of  some  skin  diseases? 

Progress  in  Power.  —  Bacon's  aphorism  that 
"  knowledge  is  power"  unfortunately  does  not  al- 
ways hold  good  in  medicine.  Yet  we  may  fairly 
congratulate  ourselves  on  a  verj-  decided  gain  in  our 
power  of  dealing  with  skin  diseases,  especially  in  the 
last  fifteen  years.  Progress  has  been  made  in  three 
ways:  (i)  We  have  got  rid  of  some  superstitions:  (2) 
we  know  better  where  to  direct  our  attack,  and  (3)  we 
have  more  effective  weapons. 

Among  the  superstitions  that  hindered  progress  one 
of  the  most  pernicious  was  the  notion  that  skin  dis- 
ease was  a  natural  issue  for  the  escape  of  peccant  hu- 
mors— a  safety  valve  for  the  constitution.  Hence  in 
many  forms  of  skin  affection,  and  particularly  in  the 
case  of  eczema,  it  was  believed  to  be  dangerous  to 
cure  the  cutaneous  lesions,  because  the  disease  was 
thus  "driven  in"  upon  the  internal  organs.  As  a 
quaint  illustration  of  this  belief  the  following  passage 
from  our  earliest  English  dermatologist,  Daniel  Tur- 
ner, is  interesting.  Speaking  of  "Children's  Scabs 
or  Breakings-out,''  he  quotes  with  implied  approval 
the  following  admonition  from  "the  most  excellent 
Hildanus"  : 

'■  Let  Mothers  have  a  Care  how  they  set  about  the 
Cure  of  this  Malady,  unless  it  be  so  virulent  as  to  haz- 
ard corrupting  the  Parts  it  lies  upon.  My  eldest  Son 
I  says  he]  till  he  was  seven  Years  old  had  not  a  Speck 
upon  his  Pjody,  wherefore  I  often  foretold  that  some 
sudden  and  mortal  Disease  would  seize  him;  and,  in- 
deed, being  taken  with  a  Stoppage  of  Urine,  he  died 
the  seventh  Day  of  the  Disease  of  a  great  Inflamma- 
tions of  the  Kidnies  and  Parts  adjoining  which  turned 
to  a  Gangrene:  Nature,  to-wit,  not  being  able  to  purge 
the  Body  of  vitious  Humours  by  the  Itch,  they  in  the 
seventh  Year,  as  by  a  critical  Expulsion,  fell  suddenly 
from  other  Parts  upon  the  Loins.  In  my  Practice  I 
have  met  with  several  Diseases  both  internal  and  ex- 
ternal in  young  Children  in  wliom  these  Breakings  out 
were  either  not  naturally  expell'd  or  violently  dry'd 
up.  Therefore,  let  the  honest  Physician  abstain  from 
Medicines;  and  if  there  be  a  Necessity,  let  the  pain  of 
this  Itch  in  Children  be  only  mitigated  with  Fresh  But- 
ter or  with  the  same  washed  in  Rosewater."  '"' 

Willan  and  the  other  dermatologists  had  tiie  fear  of 
"repelling"  diseases  of  the  skin  ever  before  them. 
Perhaps  the  most  grotesque  instance  of  superstition  is 
a  case  referred  to  by  Duhring  as  being  recorded  by  a 
Boston  doctor.  This  enlightened  practitioner,  finding 
two  African  children  afflicted  with  body  lice,  put  them 
into  a  warm  bath:  on  being  suddenly  freed  bj'  this 
means  from  their  vermin,  they  incontinently  "dropped 
down  and  expired  immediately.''  But  the  fear  of 
"driving  in"  skin  disease  is  not  yet  by  any  means 
extinct  in  the  medical  profession  or  even  among  der- 
matologists; it  would  be  easy  to  quote  passages  in 
proof  of  this  from  living  writers  of  authority. 

Increased  precision  in  the  direction  of  attack  natu- 
rally arises  from  increase  of  knowledge  as  to  the  na- 
ture, and  especially  as  to  the  causation,  of  cutaneous 
affections.  Nowad:iys  we  at  least  do  not,  as  Arch- 
bishop W'hately  said  of  the  common  run  of  preachers, 
"aim  at  nothing  and  hit  it."  The  polypharmacy  in 
which  the  older  school  of  dermatologists  delighted  is 
almost  a  thing  of  the  past,  and  patients  are  not  phys- 


icked in  the  wholesale  and  indiscriminate  mannei  that 
used  to  be  thought  necessary  for  the  correction  of  their 
constitutional  depravity.  Internal  medication  is  used 
only  in  response  to  definite  indications,  and  we  work 
the  "  miracle  of  cure,"  to  use  a  too  celebrated  phrase, 
with  the  help  of  a  simpler,  pleasanter,  and  more  effi- 
cient pharmacy.  The  improvement  in  our  weapons 
lies  mainly  in  the  methods  of  preparing  and  employ- 
ing the  old  remedies,  but  newer  ones  are  not  wanting. 

The  administration  of  remedies  by  hypodermic  in- 
jection may  be  mentioned  as  one  of  the  most  promis- 
ing improvements  in  constitutional  therapeusis;  the 
use  of  mercury  in  this  way  in  syphilis  is  becoming 
more  and  more  common.  The  serum  treatment  has 
not  yet  established  itself  in  dermatological  practice, 
but  good  results  from  it  have  been  reported  in  a  few 
cases  of  syphilis,  lupus,  leprosy,  and  one  or  two  other 
affections.  Tuberculin  as  first  prepared  by  Koch  has 
in  my  own  hands  and  in  those  of  some  other  observers 
proved  of  distinct  use  as  a  preliminary  to  surgical  treat- 
ment in  lupus.  The  newer  tuberculin  lately  '"  placed 
on  the  market" — I  am  sorry  to  have  to  use  this  com- 
mercial phrase,  but  it  accurately  expresses  the  fact — 
gives  promise  of  much  greater  usefulness,  but  it  is  too 
soon  yet  to  pronounce  a  definitive  judgment  as  to  its 
real  efficacy.  Thyroid  extract  has  a  powerful  imme- 
diate effect  on  the  integument,  but  my  own  experience 
does  not  lead  me  to  attach  much  value  to  it  as  a  rem- 
edy in  skin  disease,  and  that  opinion  is  confirmed  by 
the  experience  of  several  other  dermatologists. 

But  it  is  in  our  means  of  local  treatment  that  the 
improvement  of  our  weapons  is  most  marked.  The 
application  of  the  parasitic  doctrine  to  skin  diseases 
has  led  to  the  introduction  of  a  large  and  constantly 
increasing  number  of  parasiticides — powerful  agents 
that  the  midcentury  dermatologists  knew  not  of.  Then 
both  the  preparations  and  the  methods  of  applying 
them  are  cleanlier  and  more  eft'ective.  The  pastes, 
plaster  mulls,  varnishes,  soaps,  sticks,  and  other  de- 
vices for  the  application  of  remedies  which  we  owe  to 
the  ingenuity  of  Pick,  L^nna,  Lassar,  Brooke,  and 
others  have  revolutionized  the  local  treatment  of  skin 
disease.  Our  surgical  methods  and  appliances,  our 
antiseptics,  our  cauteries,  and  so  forth,  are  also  im- 
mensely superior  to  those  in  use  twenty  years  ago. 

Do  we  cure  more  than  our  scientific  forefathers  did? 
I  think  we  may  unhesitatingly  answer,  "  Yes."  Para- 
sitic diseases  are  certainly  more  under  our  control,  and 
in  nearly  every  form  of  skin  disease  we  can  treat  symp- 
toms more  eft'ectively,  and  give  relief  even  when  we 
fail  to  cure.  We  are  altogetlier  milder  in  our  methods 
than  the  dermatologists  of  a  former  day ;  we  soothe 
instead  of  irritating;  we  strengthen  instead  of  deplet- 
ing: we  leave  nature  to  herself  instead  of  thwarting 
and  teasing  her  into  active  rebellion.  But  tiiere  is 
still  a  good  deal  of  overtreatment,  and  I  not  infre- 
quently see  patients  whose  disease  has  been  aggra- 
vated into  frenzy,  so  to  speak,  by  the  continuous  goad- 
ing of  injudicious  treatment.  The  policy  of  "  masterly 
inactivity"  finds  a  large  sphere  of  application  in  der- 
matology. 

The  Future  of  Dermatology.  — I  have  given  a  re- 
view of  the  past,  very  hasty  and  imperfect,  but  I  can 
onl)-,  like  swift  Camilla,  skim  across  the  plain.  I 
may  be  allowed  to  conclude  with  a  peep  into  the  fu- 
ture. Whether  the  newer  medication  with  serums  and 
organic  extracts  holds  in  it  much  promise  for  the  treat- 
ment of  skin  disease  it  is  of  course  impossible  to  say; 
I  am,  however,  inclined  to  think  that  in  this  direc- 
tion, and  in  that  of  increase  of  power  of  dealing  with 
parasitic  affections,  lies  the  path  of  development  in 
dermatological  theraiieutics  likely  to  lead  to  the  best 
results.  It  will  be  long  before  a  complete  classifica- 
tions of  diseases  of  the  skin  is  possible,  but  this  is  of 
no  great  practical  importance.    A  real  stumbling-block. 


September  i8,  1897] 


MEDICAL    RECORD. 


411 


however,  is  the  confusion  of  terminology  that  still 
exists.  It  would  be  a  ver)-  real  help  to  progress  if  a 
nomenclature  at  once  simple,  precise,  and  yet  descrip- 
tive and  international  could  be  devised. 

REFEREMCES. 

1.  On  Cutaneous  Diseases,  vol.  i.,  London,  iSoS;  Introduction, 
p.  II. 

2.  W  illan,  loc.  cit. 

3.  Description  and  Treatment  of  Cutaneous  Diseases;  Order  I., 
Papulous  Eruptions  on  the  Skin:   London,  1798. 

4.  Willan's  pupil,  Bateman,  admits  this  (.\  Practical  Synopsisof 
Cutaneous  Diseases.  Preface,  p.  i.x.,  dated  1S13). 

5.  A  Practical  Treatise  on  Diseases  Affecting  the  Skin,  London. 
1850,  p.  1S8. 

6.  White,  Tames  C. :  Dermatology-  la  .\merica.  being  the  presi- 
dent's address  before  the  first  meeting  of  the  .\merican  Dermato- 
logical  Association,  at  Niagara  Falls,  New  York,  September  4. 
1877;  reprinted  from  the  Archivesof  Dermatologj-,  lanuarj-.  1S7S. 
Louis  A.  Duhring:  The  Rise  of  American  Dermatology-,  bein:; 
the  president's  address  at  the  third  annual  meeting  of  the  .\meri- 
can  Dermatological  Association  in  1579;  and  the  Foundation  ol 
American  Dermatolog)-,  being  the  president's  address  before  t'ne 
same  body  at  its  fourth  annual  meeting  in  iSSo. 

7.  Re\-iew  of  Modem  Dermatolog)-,  reprinted  from  the  .\mcri- 
can  Journal  of  the  Medical  Sciences,  April,  1871. 

8.  Dubreuilh  :  Les  Doctrines  Parasitaires  en  Dermatologie,  I!or- 
deau.x,  1S92. 

9.  A  Practical  Treatise  on  Diseases  Affecting  the  Skin,  London, 
1850,  pp.  134-13'J- 

10.  I  hope  I  may  be  allowed  to  use  a  phrase  which  has  the  au- 
thority of  Daniel  'Tunier  in  translating  Maladie  Pediculaire. 

11.  Traite  des  Maladies  de  la  Peau,  second  edition,  iS;7. 

12.  Op.  cit..  pp.  1 19-123. 

13.  Traite  des  Maladies  du  Cuir  Cheveiu. 

14.  Union  Medicale,  1S63. 

15.  A  Treatise  of  Disea.ses  Incident  to  the  Skin,  fifth  edition, 
London,  1736,  chap,  iv.,  p.  67. 


SOMK  PRACTICAL  OBSERVATIONS  OX  PUL- 
MONARY   TUBERCULOSIS. 

Bv    HUBBARD   WIXSLOW   MITCHELL.    M.D.. 


MBBR,     NEW    YORK 
COUNTY     OF     NEW     YO 
PHYSICI.\.NS'     MITCAL 
SOCIETY  ;     EX-VIS1TIS( 


•F  MEDICINE,  MEDICAL  SOCIETY  OF  THl 
K,  NEW  YORK  COCNTY-  MEDICAL  ASSOCIATION 
MD  .ASSOCIATION  ;  EX-PRESIDENT,  .MEDICO-LEGAI 
StRGEOS,    BELLEVCE    HOSPITAL,   OVT-rATlENT    DE 


PuLMOx.^RY  tuberculosis  is  a  disease  which  occurs  per- 
haps more  frequently  than  any  to  which  mankind  is 
subject,  appearing  in  persons  of  all  ages,  in  every 
clime,  and  under  all  conditions  of  life. 

It  is  now  accepted  as  a  fact  that  this  disease  is  due 
to  the  introduction  into  the  lungs  of  a  micro-organism 
known  as  the  tubercle  bacillus.  This  tubercle  bacil- 
lus is  a  short,  delicate  rod,  slightly  curved,  and  hav- 
ing a  length  of  from  one-half  to  one  diameter  of  a  red 
blood  globule.  When  stained  with  a  solution  of  car- 
bolic fuchsin  it  assumes  a  bright  red  color,  and  un- 
der the  microscope  presents  a  well-defined  body  with 
from  two  to  five  vacuoles.  These  vacuoles  give  it  a 
sort  of  beaded  appearance,  and  it  is  probable  that  they 
are  the  nuclei  of  new  bacilli,  which  are  formed  by  the 
fission  and  subdivision  of  the  parent  bacillus.  It  is 
doubtless  true  that  these  bacilli  multiply  by  a  rapid 
subdivision  of  themselves.  When  the  bacillus  is  thus 
stained  with  carbolic  fuchsin  it  slowly  assumes  a 
bright  red  color,  which  is  permanent  after  treatment 
with  strong  acids,  and  this  characterizes  it  from  all 
other  known  forms  of  bacteria.  It  can  be  cultivated 
in  various  media,  such  as  blood  serum  and  potato, 
when  the  cultures  are  kept  at  blood  heat.  They  grow- 
slowly  and  appear  at  about  the  end  of  two  weeks,  form- 
ing colonies  of  bacilli  in  grayish-white  masses  on  the 
surface  of  the  culture  medium.  But  little  is  yet 
known  of  the  chemical  composition  of  these  little 
organisms.  They  multiply  with  great  rapidity  in 
lung  tissue,  and  a  patient  suffering  with  pulmonary- 
consumption  discharges  them  in  the  sputum  in  con- 
siderable numbers.     It  is  an  exaggeration  to  state  that 


they  are  discharged  by  millions  by  everj-  patient 
daily  in  his  sputum.  They  do  not  occur  in  any  such 
vast  numbers.  They  are  plentiful,  it  is  true,  but  not 
by  millions.  They  are  extremely  tenacious  of  life, 
and  retain  power  to  do  harm  even  when  dried  for  a 
considerable  length  of  time.  When  they  are  expec- 
torated in  the  sputum  of  a  patient,  great  care  must 
be  taken  to  destroy  their  virulence,  else  they  became 
a  focus  of  danger  to  others  wherever  they  are  dis- 
charged. The  sputum  of  phthisis  is  a  dangerous 
substance  unless  it  is  most  carefully  disposed  of  or 
rendered  sterile. 

In  the  dust  collected  from  the  walls  and  bedsteads 
of  hospital  wards,  in  prisons  and  asylums  where 
phthisis  patients  have  been  kept,  bacilli  have  been 
found  in  considerable  numbers,  showing  that  in  these 
places  the  sputum  was  not  properly  rendered  sterile 
and  harmless,  and  new  foci  of  infection  were  thus 
formed. 

Mode  of  Infection. — It  is  doubtful  if  phthisis  is 
hereditary.  Hitherto  life-insurance  companies  have 
rejected  applicants  for  insurance  whose  parents  or 
members  of  the  family  have  died  of  phthisis,  even 
when  the  applicant  himself  was  in  perfect  health.  It 
is  a  disputed  point  how  far  the  theory  of  heredity  is 
true,  but  from  my  own  observations  and  studies  I  do 
not  believe  that  the  ancestors  of  such  persons  con- 
ferred a  taint  sufficient  to  warrant  his  rejection. 

If  a  woman  afflicted  with  phthisis  becomes  pregnant 
(and  this  is  a  common  occurrence),  it  is  very  doubtful 
if  she  can  transmit  it  to  her  child.  If  a  man  suffering 
with  phthisis  impregnates  a  woman,  the  venereal  act 
does  not  transmit  the  disease  to  her  or  her  child.  The 
semen,  so  far  as  known,  contains  no  bacilli.  Hered- 
ity, therefore,  is  of  little  value  to-day. 

The  following  is  a  case  in  point : 

Mrs.  A ,  aged  twenty-nine,  came  to  me  on  April 

I,  1894,  suffering  with  phthisis.  She  was  pale, 
ansemic,  e.xtremely  emaciated,  had  night  sweats,  and  no 
appetite.  She  had  had  several  hemorrhages  from  her 
lungs  during  the  preceding  six  months ;  her  right  lung, 
upper  lobe,  was  infiltrated  with  purulent  matter,  -with 
coarse  bubbling  rales;  her  cough  was  distressing,  her 
sputum  copious  and  contained  pus  cells  and  bacilli. 
She  was  eight  months  advanced  in  pregnancy.  She 
could  give  no  definite  account  as  to  when  she  first 
began  to  cough. 

April  30th  she  was  delivered  of  a  healthy  female 
child  at  fu'l  term. 

On  June  ist  I  began  to  give  her  treatment  relating 
especially  to  her  lung  disease.  This  was  continued 
steadily  until  December  of  that  year,  when  she  left  me, 
at  which  time  her  sputum  contained  no  bacilli  and 
all  her  symptoms  were  greatly  relieved. 

July  I,  1895,  she  gave  birth  to  a  boy  at  full  term  and 
perfectly  healthy. 

September,  1896,  she  gave  birth  to  a  third  child,  a 
boy,  at  full  term,  also  perfectly  healthy.  She  began 
to  cough  when  the  child  was  two  weeks  old,  and 
applied  to  me  for  treatment.  With  the  exception  of  a 
slight  bronchitis  she  was  well,  and  remained  so  till 
this  date.  Her  three  children  are  living  and  have 
shown  no  signs  whatever  of  receiving  any  taint  from 
their  mother.     The  father  is  a  perfectly  healthy  man. 

The  mode  of  infection,  then,  is  by  inhaling  a  germ 
from  some  outward  source,  and  doubtless  in  this  way 
only. 

Contagiousness  of  Phthisis. — Accepting  as  we  do 
the  theor\-  that  phthisis  pulmonalis  is  a  result  of  the 
introduction  into  tlie  lung  of  the  tubercle  bacillus,  then 
that  microbe  must  surely  be  introduced  from  without 
and  from  some  source  where  the  bacillus  has  retained 
its  activity  and  its  virulence.  Remembering  that  the 
sputum  from  phthisis  patients  contains  considerable 
numbers  of  these  bacilli,  which  are  distributed  widely 


412 


MEDICAL    RECORD. 


[September  i8,  1897 


through  dust  and  the  careless  voiding  of  sputum,  it 
w  ill  be  seen  that  the  danger  from  this  source  is  verj- 
evident  and  the  acquirement  of  the  disease  in  this  way 
is  very  certain. 

Kissing  a  phthisis  patient  is  a  .source  of  danger, 
from  the  fact  that  bacilli  may  be  present  upon  the 
lips  or  in  the  buccal  cavity  of  such  a  patient,  and  the 
person  thus  kissed  may  introduce  into  his  own  air 
passages  one  of  these  dangerous  microbes  and  thus 
acquire  the  disease. 

But  contagion  from  personal  contact  at  home,  in 
hotels,  or  sanatoriums,  or  from  inhaling  the  breath  of 
a  phthisis  patient  is  a  very  doubtful  source  of  danger, 
and  is  not  believed  in  by  the  majority  of  experienced 
and  competent  physicians. 

Cases  have  been  recorded  (with  more  or  less  truth) 
in  which  phthisis  has  been  acquired  by  inoculation,  as 
from  persons  washing  the  clothes  of  such  patients,  or 
the  bite  of  a  tuberculous  person,  or  inoculation  from 
a  cut  or  abrasion  where  the  sputum  has  been  dried  in 
contact  with  an  open  wound.  Further  light  on  this 
point  is  needed. 

The  common  house  Hy  (Musca  domestica),  feeding 
upon  sputum  containing  bacilli,  has  been  found  to 
contain  these  microbes  in  his  body,  and  has  thus  per- 
haps disseminated  them  more  or  less  widely.  Several 
observers  have  found  bacilli  in  the  bodies  and  upon 
the  surface  of  the.se  flies.  I'his  insect  may  possibly 
be  a  means  of  spreading  the  disease,  as  well  also  as 
some  other  members  of  the  order  Muscaria. 

Influence  of  Age. — Tuberculosis  occurs  in  all  pe- 
riods of  life.  The  nursing  babe  is  its  victim,  and  the 
innocent  child,  as  well  as  are  those  whose  sands  of  life 
are  nearly  run.  No  age  is  immune  to  this  dread 
disease.  In  young  persons  we  find  the  lymphatic 
glands  frequently  and  often  extensively  affected.  In 
the  middle-aged  and  the  old,  the  lungs  seem  to  be 
especially  prone  to  this  disease. 

Locality  and  Soil.  — My  jaersonal  experience  and 
observations  lead  me  to  say  that  locality  and  soil  play 
an  unimportant  part.  It  has  been  the  custom  and  the 
fashion  hitherto  to  send  patients  away  from  their 
homes  in  our  Eastern  cities  to  higher  altitudes,  in  the 
belief  that  an  elevation  of  from  three  thousand  to  eight 
thousand  feet  above  sea  level  is  beneficial  to  tubercu- 
lous diseases  of  the  lungs.  We  thus  get  rid  of  the  pa- 
tient, but  not  the  di.sease,  and  in  too  many  cases  He 
com^s  home  to  die,  or  dies  before  he  can  get  home. 
The  relief  he  obtains  in  being  sent  away  from  home 
is  very  doubtful. 

I  have  spent  considerable  time  in  travelling  in  the 
Catskills,  Adirondacks,  and  the  Rocky  Mountains,  in- 
vestigating with  some  care  these  localities,  with  their 
varying  altitudes  above  sea  level  and  their  influence 
vipon  the  lungs,  and,  while  perhaps  a  high  and  dry  and 
lighter  air  may  be  beneficial  in  some  diseases  and  for 
its  influence  upon  the  general  health,  I  do  not  believe 
that  it  has  the  slightest  effect  upon  the  growth  and 
proliferation  of  the  tubercle  bacillus  itself.  In  this 
opinion  I  am  heartily  confirmed  by  the  judgment  of 
many  able  and  careful  practitioners  with  whom  I  have 
most  earnestly  conver.sed,  and  I  repeat  that  altitude 
has  no  influence  whatever  in  destroying  the  tubercle 
bacillus.  .\  considerable  experience  v.  ith  this  disease 
has  led  me  to  believe  that  no  place  is  better  for  its 
treatment  than  New  York  t'ity.  I'atienls  ha\  e  come 
to  nie  from  every  State  in  the  ITnion,  from  Canada, 
from  the  Sandwich  Islands,  and  from  Europe;  and  it 
appears  to  be  the  general  belief  among  them  all  that 
the  climate  of  New  York  City,  with  its  clear  air  and 
bright  sunshine,  is  quite  as  favorable  under  all  circum- 
stances as  is  that  of  most  other  localities.  I  have  under 
my  care  at  this  time  patients  from  several  towns  in  t'ol- 
orado,  from  New  Mexico,  and  California,  and  all  are 
doing  better  in  this  city  than  in  their  own  localities. 


Action  of    Bacilli It  is  interesting  to   note  the 

changes  which  occur  in  the  pulmonary  tissue  when  a 
bacillus  has  been  successfully  introduced.  When  a 
bacillus  so  enters  the  lung  tissue  it  is  followed  almost 
immediately  by  an  inflammatory  action  of  the  spongy 
tissue  of  the  lung  and  the  formation  of  small  rounded 
masses,  which  are  termed  "tubercle."  \Vhen  these 
tubercle  masses  are  once  formed  they  quickly  undergo 
a  process  called  caseation.  This  caseation  is  a  proc- 
ess of  coagulation  going  on  in  the  lung  cells:  they 
lose  their  outline,  become  irregular,  and  are  converted 
tuially  into  a  structureless  substance,  and  are  gradually 
converted  into  a  yellowish-gray  pus,  in  which  the  ba- 
cilli are  more  or  less  abundant;  and  when  this  matter 
infiltrates  the  inflamed  lung  tissue  it  is  loosened  more 
or  less  bv  the  inspired  air,  escapes  first  into  the 
smaller  bronchi,  then  into  the  larger,  and  is  finally 
coughed  up  by  the  patient  in  the  form  of  a  thick,  yel- 
lowish, grayish,  or  greenish  sputum,  containing  bacilli 
more  or  less  abundantly. 

This  sputum  is  the  medium  of  contagion,  and  must 
be  rendered  sterile  if  we  \\ould  prevent  the  extension 
of  the  disease  to  new  and  helpless  and  innocent  \\c- 
tims. 

Temperament.  —  Temperament  seems  to  play  an 
important  part  in  the  acquirement  and  behavior  of 
phthisis.  Persons  who  are  tall  and  thin  and  anamic, 
and  those  with  red  or  sandy  or  light  hair,  and  thin, 
pallid  skin  and  pale  mucous  membranes,  and  weak 
sexual  organs,  seem  to  be  very  liable  to  tuberculous 
disease;  those  having  the  alkaline  temperament  far 
more  so  than  do  the  shorter,  darker-hued,  and  more 
athletic  persons,  or  those  of  the  acid  temperament, 
according  to  Dr.  Gibier. 

In  this  class  of  cases,  the  alkaline,  it  would  seem 
that  the  apices  of  the  lungs  and  the  subscapular  regions 
are  the  faxorite  localities  where  this  disease  loves  to 
burrow.  It  is  here  that  cavities  form  more  readily, 
and  the  disease  seems  more  persistent  than  when  in 
the  middle  or  lower  lobes.  When  the  patient  who  is 
tall  and  pale  and  badly  nourished,  whose  blood  is 
anamic,  acquires  phthisis,  one  or  the  other  apex  is 
\ery  often  involved,  and  he  resists  treatment  to  a  great 
degree.  In  this  class  of  cases  also,  and  when  the  dis- 
ease has  made  any  headway,  the  poisonous  principle 
of  the  disease,  whatever  it  may  be  (ptomains  or  what 
not),  seems  to  pervade  the  entire  body,  and  we  have  in 
consequence  diarrhcea,  night  sweats,  hemorrhages,  loss 
of  appetite,  and  an  inability  to  assimilate  the  little 
food  taken.  These  patients  seem  to  fall  before  this 
disease  as  readily  as  grass  before  the  mower's  scythe. 
In  this  class  of  cases  phthisis  is  so  difficult  and  per- 
sistent that  it  appears  almost  malignant. 

Not  all  jx-rsons  who  inhale  tubercle  bacilli  contract 
the  disease.  Were  it  so,  few  persons  would  escape; 
but  in  order  that  this  bacillus  may  gain  a  lodgment  in 
the  lung,  a  lowering  of  the  vitality  must  be  present, 
and  the  lung  tissue  must  be  weakened  from  some 
cause.  When  such  a  weak  lung  or  special  tempera- 
ment or  adaptability  to  receive  the  disease  is  found, 
it  becomes  a  ready  prey  to  the  immigrating  microbe. 
In  probablvthe  majority  of  cases  in  which  bacilli  are 
introduced  into  the  lung  tissue,  they  are  for  some  rea- 
son destroyed  at  once  and  do  no  harm,  and  this  reason 
is  either  an  acid  temperament  or  a  power  to  resist  dis- 
ease; but  in  other  cases,  in  which  I  have  said  the  lung 
for  some  reason  forms  a  congenial  habitat,  the  bacilli 
grow  luxuriantly,  caseation  and  softening  occur,  and 
the  in\  ading  army  of  bacilli  gains  a  victory  which  ends 
in  death,  unless  checked  at  the  outset  by  appropriate 
treatment. 

Tuberculosis  in  the  Lower  Animals. — In  the  ani- 
mal kingdom  we  lind  certain  species  that  contract  pul- 
monary tuberculosis  more  or  less  readily.  Animals 
who  thus  acquire  the  disease  are  those  which  come  in 


September  i8,  1897] 


MEDICAL    RECORD. 


41, 


contact  with  man,  either  in  the  feral  or  the  domestic 
state.  Among  the  feral  group  comes  first  the  order  of 
apes. 

Apes  may  be  divided  into  two  general  classes,  as 
follows:  The  Cynomorpha  or  dog  apes ;  the  Anthropo- 
morpha  or  man-like  apes.  All  of  these  have  been 
called  catarrhine  apes;  that  is.  having  a  nose  some- 
what narrow,  with  a  thin  septum. 

Some  years  ago,  while  I  was  visiting  West  .\frica,  I 
spent  some  time  on  the  Congo  River,  and  in  the  wild 
and  unknown  regions  bordering  the  south  bank  of  that 
great  stream  I  saw  considerable  numbers  of  baboons. 
Of  these,  the  anubis  baboon  (Cynocephalus  anubis) 
was  the  most  common  and  numerous.  They  are  a  very 
wary,  alert,  and  mischievous  animal,  living  in  troops 
of  twenty  or  more,  and  love  to  approach  the  dwelling 
of  man,  where  their  thievish  propensities  cause  them 
to  be  regarded  by  the  natives  as  a  great  nuisance. 

The  mandril  (Cynocephalus  mormon)  and  the 
magot  (Macacus  sylvanus)  are  also  frequently  met 
with  on  both  banks  of  the  Congo.  I  have  seen  them 
in  considerable  numbers,  and  their  curiosity  has  led 
them  to  approach  us  very  closely.  On  several  occ.i- 
sions,  while  we  were  hunting  for  deer  and  other  game, 
a  group  of  baboons  would  be  seen  hovering  over  one 
of  their  number  who  appeared  to  be  unable  to  move. 
It  was  easy  to  approacii  him,  as  he  was  too  feeble 
to  escape.  His  companions  scampered  away  and 
watched  me  at  a  short  distance,  with  amusing  curios- 
ity. Inquiring  of  the  natives  what  the  trouble  was,  1 
found  that  the  baboons  were  frequently  taken  ill  with 
some  chest  trouble  which  was  similar  to  that  from 
which  the  natives  themselves  suffered.  This  I  learned 
afterward  was  phthisis,  which  is  not  uncommon  among 
the  blacks  in  the  lower  Congo  district. 

In  the  wild  and  almost  uninhabited  country  about 
one  hundred  and  fifty  miles  north  of  Cape  Town  in 
South  Africa,  the  common  baboon  is  verj'  numerous 
and  a  most  unwelcome  visitor  to  the  negroes,  who 
suffer  severely  from  his  thievish  and  predatorj-  acts. 
On  several  occasions  during  the  twilight,  and  at  a 
distance  in  the  daytime,  I  have  mistaken  these  ani- 
mals for  small  negroes,  as  they  frequently  sit  uprigiu 
and  sometimes  walk  on  their  posterior  limbs  aided  by 
their  arms.  This  was  the  common  baboon  (Cynocepii- 
alus  papio).  They  are  found  in  this  locality  in  con- 
siderable numbers,  and  have  verv  little  fear  of  man. 
An  English  officer  who  lived  at  this  point,  whom  I 
visited,  told  me  that  the  natives  frequently  contracted 
phthisis  on  their  visits  to  Cape  Town,  and  it  seemed 
]5robable  that  the  sputum  of  these  people,  being  care- 
lessly voided  in  their  gardens  and  about  their  houses, 
was  communicated  to  the  baboons  in  some  of  their 
marauding  e.xpeditions,  and  tills  gentleman  told  nie  it 
was  not  an  uncommon  sight  to  see  a  sick  baboon  j^rc- 
senting  the  same  symptoms  as  the  natives  when  suffer- 
ing from  phthisis. 

I  soon  had  an  opportunity  to  \erify  this  fact.  One 
day,  while  hunting  in  the  adjacent  hills,  I  came  across 
a  baboon  lying  on  the  ground,  who  was  extremel} 
emaciated  and  had  a  severe  and  violent  cough.  .At 
that  time  the  existence  of  tiie  tubercle  bacillus  was  not 
known,  but  I  felt  sure  that  the  animal  was  suffering 
from  pulmonary  tuberculosis. 

The  Domestic  Group. — The  common  ox  (Bos  taurus) 
is  frequently  afflicted  with  pulmonary  tuberculosis; 
so  much  so,  in  fact,  as  to  make  necessary  a  rigid  sur- 
veillance of  our  great  abattoirs  by  competent  and 
authorized  inspectors.  Undoubtedly  these  animals 
contract  the  disease  from  tiieir  long  and  close  prcv- 
imity  to  the  genus  Homo. 

The  dogiCanisfamiliarisi  and  the  cat  (Felix  domes- 
tical are  both  extremely  liable  to  pulmonary  tubercu- 
losis, and  this  would  seem  almost  a  foregone  fact  from 
dieir  intimate  association  with  man. 


The  duck  (.\nas  bosciias),  the  goose  (Anser  anser), 
and  the  domestic  fowl  rarely  but  occasionally  contract 
this  disease.  It  is  not  improbable  that  other  animals 
fall  victims  to  tuberculosis,  but  they  do  not  specially 
interest  us  here.  It  is  those  animals  with  which  we 
deal  dail)-,  and  whose  tiesh  and  milk  we  consume  as 
articles  of  food,  that  interest  us  most  closely. 

Symptoms. — The  train  of  symptoms  of  pulmonary 
phthisis  are  well  known,  and  I  need  not  dwell  upon 
them  here. 

Diagnosis. — The  diagnosis  of  pulmonary  phthisis 
is  in  most  cases  ver}'  plain.  The  presence  of  cough, 
expectoration,  emaciation,  night  sweats,  diarrhoea, 
anore.xia  and  thirst,  loss  of  flesh  and  general  anjemia, 
with  hemorrhages  more  or  less  severe,  are  almost 
always  met  with,  and  point  to  the  true  nature  of  the 
disease.  But  the  unfailing  test  in  diagnosis  is  the 
presence  of  the  bacillus  in  the  sputum.  If  it  contains 
no  bacilli  then  the  disease  is  not  pulmonary  tuberculo- 
sis per  se.     A  very  early  diagnosis  can  thus  be  made. 

The  experienced  and  careful  physician  has  very 
little  difficulty  in  making  a  correct  diagnosis,  even 
without  the  immedir.te  examination  of  the  sputum. 
He  may  prescribe  at  once  for  a  case,  but  he  must  very 
soon  after  e.xamine  for  bacilli,  in  order  to  confirm  his 
judgment,  and  frequently  during  treatment,  that  he  may 
know  if  they  are  diminishing  (if  present)  and  whether 
his  patient  is  really  recovering  or  not. 

Prognosis. — Pulmonary  phthisis,  when  not  modified 
by  treatment,  is  an  e.xtremely  fatal  disease.  No  accu- 
rate percentage  of  deaths  can  be  given,  because  these 
percentages  differ  with  many  writers,  but  when  the  dis- 
ease is  allowed  to  run  its  course  without  treatment  it 
is  a  rapidly  and  terribh-  fatal  nialadv. 

The  Economic  Value  of  Disease.  —  Some  writers 
hold  that  disease,  and  especially  tuberculosis,  has  a 
certain  economic  value  in  preventing  the  overpopu- 
lousness  of  the  earth.  In  past  geological  ages,  the 
exuberance  and  overpopulousness  of  animal  life  on 
the  earth  has  been  regulated  and  held  in  check  by  the 
operation  of  several  influences.  The  lower  forms  of 
life  that  have  been  so  prolific  in  their  reproduction 
have  been  preyed  upon  by  the  higher  orders  of  ani- 
mals, which  used  them  as  food.  Every  species  of  ani- 
mal has  found  a  destructive  enemy  in  some  other  spe- 
cies of  animal,  and  this  process  of  one  animal  preying 
upon  another  has  ser\  ed  in  all  ages  as  an  effectual 
check  upon  the  overproduction  of  any  one  species. 

With  man  there  was  no  other  or  higher  animal  to 
hold  in  check  the  rate  of  his  increase.  To  regulate 
and  repress  his  too  exuberant  reproduction  three  influ- 
ences quickly  sprang  into  activity.  They  were  :  first, 
his  internal  destructive  warfare;  second,  the  ravages 
of  disease;   third,  his  own  individual  vices. 

His  early  tribal  quarrels  continued  until  supplanted 
by  more  destructive  modern  warfare,  and  these  influ- 
ences acted  with  such  baleful  force  as  on  several  occa- 
sions seriously  to  affect  the  welfare  of  mankind.  Thus 
in  the  reign  of  the  Roman  Emperor  Justinian,  a.d. 
5-7~565,  the  influences  of  his  wars,  with  the  famine 
and  disease  that  followed,  destroyed  one  hundred  mil- 
lion of  human  lives  and  caused  a  visible  diminution 
of  the  human  race. 

The  ravages  of  disease  have  acted  as  a  powerful 
check  upon  the  increase  of  mankind.  As  people  ag- 
gregated into  communities  and  nations,  and  lived  in 
close  contiguity,  they  w^ere  ignorant  of  sanitary  laws, 
and  they  suffered  severely  from  sporadic  and  epidemic 
disease.  Tuberculosis  played  a  malignant  and  de- 
structive part,  and  it  is  said  destroyed  one-third  of  all 
those  who  died  of  disease.  Whether  this  special  dis- 
ease has  any  economic  value  or  not,  we  can  hardly 
say;  but  while  the  question  is  being  argued  by  the 
theorist,  the  practical  physician  will  do  all  in  his 
power  to  abate  its  terrors. 


414 


MEDICAL    RECORD. 


[September  i8,  1897 


The  individual  vices  of  men  have  certainly  some 
economic  value.  The  habitual  criminal,  the  cruel  and 
morbidly  vicious,  the  drunkard  with  his  ungovernable 
craving  for  intoxicants,  and  the  prostitute,  are  all  vic- 
tims of  disease  and  lack  the  mental  balance  necessary 
to  make  them  sound  and  responsible  beings.  It  is 
from  the  ranks  of  these  classes  that  the  insane  are 
largely  recruited.  If  they  allow  unrestrained  action 
to  their  vicious  or  intemperate  habits,  the  prison,  the 
hospital,  or  the  grave  ends  their  career. 

Treatment. — At  the  outset  we  must  distinctly  re- 
member that  pulmonary  tuberculosis  is  an  inflamma- 
tory disease  of  the  spongy  tissue  of  the  lung,  due  to 
the  introduction  of  a  special  microbe,  and  followed  by 
a  true  ulcerative  and  suppurative  process  in  the  lung 
substance.  This  may,  then,  be  described  in  a  word 
as  a  special  ulceration  of  lung  tissue  with  an  expecto- 
ration of  the  suppurating  matter,  and  any  treatment 
which  is  destined  to  cure  or  even  relieve  it  must  be 
addressed  to  the  actively  ulcerating  condition  of  the 
lung. 

Many  remedies  have  been  advocated  for  the  treat- 
ment of  this  disease,  and  at  the  present  time  both 
the  lay  and  medical  journals  are  teeming  with  the 
discovery  of  this  or  that  person  who  has  a  "consump- 
tion cure."  In  many  cases  doubtless  this  activity  is 
due  to  an  earnest  desire  on  the  part  of  the  discoverer 
to  find  something  which  will  modify  or  cure  tuberculo- 
sis. Whether  serum  or  subcutaneous  injections  of 
any  special  remedy,  or  whether  medicated  inhalation 
will  be  of  lasting  benefit,  is  a  problem  yet  to  be 
solved.  When  we  remember  that  phthisis  is  an  active 
ulcerative  process  of  the  lungs,  it  would  seem  that 
these  lines  of  treatment  are  not  adapted  to  its  cure. 

It  would  also  seem  that  some  remedy  which  can  be 
introduced  into  the  body  at  short  intervals  and  for  a 
long  period  of  time,  something  that  will  act  as  an  an- 
tiseptic by  saturating  the  blood  and  so  modifying  or 
destroying  the  bacillus,  and  at  the  same  time  inflict  no 
injury  upon  the  other  organs  of  the  patient,  must  be 
the  ideal  remedy. 

If,  as  has  been  stated  above,  a  considerable  propor- 
tion of  cases  of  phthisis  belong  to  the  alkaline  tem- 
perament, then  a  remedy  of  an  acid  reaction  would 
appear  to  be  especially  indicated. 

My  own  experience,  which  has  been  large,  leads  me 
to  believe  that  a  solution  of  the  halogen  group  of 
salts  with  the  hypochlorite  of  sodium  is  the  best  rem- 
edy with  which  I  am  acquainted,  to  modif)'  and  per- 
haps cure  pulmonary  tuberculosis.  This  remedy  acidi- 
fies the  blood  when  saturated  with  it,  and  almost 
immediately  relieves  the  extreme  anaemia,  loss  of 
appetite  and  of  strength,  and  night  sweats,  which  form 
such  distressing  symptoms.  The  cough,  which  is 
almost  always  present  and  sometimes  distressing  and 
even  terrible,  can  easily  be  relieved  by  giving  a  mix- 
ture of  iodide  of  potassium  with  a  little  sulphate  of 
morphine  and  a  syrup  as  a  vehicle.  .-Vn  elegant 
preparation  can  be  made  by  properly  combining  these 
drugs. 

For  the  hectic  fever,  nothing  is  better  than  a  cap- 
sule containing  four  grains  of  sulphate  of  quinine  and 
one-fiftieth  of  a  grain  of  sulphate  of  strychnine,  once 
or  twice  daily.  Whiskey  and  brandv  may  be  given 
when  indicated,  but  never  wines  or  malt  liquors. 

Diet  should  receive  especial  attention,  and  nutritive 
and  easily  assimilated  articles  of  food  should  be  se- 
lected and  the  patient  particularly  instructed  in  their 
use.  Rest  should  be  enjoined  as  complete  as  the  case 
will  permit.  Nature  has  given  us  a  powerful  aid  in 
balmy  sleep. 

It  is  not  necessary  in  my  judgment  to  isolate  cases 
of  consumption,  for,  as  far  as  I  have  seen,  patients 
suffering  with  this  complaint  are  quite  amenable  to 
reason,  and  will,  if  properly  instructed,  exercise  care 


and  caution  in  the  matter  of  sputum  and  excreta  from 
themselves.  All  of  the  patients  whom  I  have  treated 
have  gone  to  their  own  homes,  and,  as  far  as  I  have 
been  able  to  discover,  none  of  them  has  communi- 
cated the  disease  to  those  immediately  about  him,  and 
the  treatment  has  continued  over  a  considerable  period 
of  time. 

The  ideal  treatment  of  pulmonary  phthisis  would  be 
the  above  carried  out  in  a  hospital  or  sanatorium 
especially  erected  for  this  line  of  work.  Such  a  hos- 
pital should  be  built  in  a  manner  which  will  make 
antisepsis  practical  in  every  way.  The  rooms  should 
be  small,  finished  in  hard  or  painted  wood,  with  hard- 
finished  ceilings  and  walls,  and  hardwood  floors. 
Iron  bedsteads,  a  washbowl  containing  hot  and  cold 
running  water,  and  a  small  bureau  and  chairs  would 
complete  the  furniture  equipment.  The  rooms  should 
be  lighted  by  electricity  and  heated  by  steam,  so  that 
an  equable  temperature  could  be  maintained  through- 
out the  year.  A  solarium  should  be  provided  in  the 
upper  part,  with  white  and  colored  glass,  where  pa- 
tients in  bad  weather  can  sit,  and  sheltered  walks 
should  be  provided  where  proper  exercise  can  be  had. 
Whatever  treatment  is  adopted  must  be  persisted  in 
faithfully  and  thoroughly  by  both  patient  and  physi- 
cian, and  for  long  periods  of  time;  and  with  such  an 
equipped  place  and  honest  treatment  I  believe  that 
a  considerable  percentage  of  cases  of  phthisis  can  be 
cured  and  many  others  greatly  relieved. 

747   M.^DISON   AVE.NLE. 


MENTAL    EVOLUTION    IN    MAN. 


Bv   R.    M.    BUCKE,    M.D. 


LONDON,    ONTAR 


About  sixty  years  ago  now,  in  the  time  of  the  Miller- 
ite  excitement,  a  man  who  believed  that  the  world  was 
about  to  end  expressed  his  fears  to  Emerson,  who  re- 
plied that  it  was  really  a  matter  of  little  consequence, 
"for,'"  said  he,  "we  can  do  very  well  without  it." 
There  are  wise  men  who  teach  that  each  man  creates 
the  world  he  lives  in,  and  as  he  gives  it  its  substance 
so  also  does  he  give  it  its  quality,  insomuch  that  it  is 
good  or  bed  as  he  is  good  or  bad.  Be  this  as  it  may, 
it  is  certain  that  each  one  of  us  is  of  more  consequence 
to  himself  than  is  all  the  outside  world,  be  it  shadowy 
or  be  it  solid;  be  it  created  by  each  inhabitant  or  be 
it  independent  and  self-existent.  Not  only  so,  but  the 
essential  part  of  each  man  is  what  we  call  his  mind, 
in  comparison  to  which  the  body  is  an  insignificant 
factor. 

The  Study  of  Psychology. — This  being  grantetl. 
it  would  seem  to  follow  that  psychologv  ought  to  be 
the  most  interesting  of  all  the  sciences,  and  as  a  mat- 
ter of  fact  it  undoubtedly  is  so,  though  it  has  been 
greatly  discredited  by  the  imperfection  of  the  method 
by  which  it  has  until  very  lately  been  studied.  That 
imperfection  is  so  great  tiiat  it  would  hardly  be  an 
exaggeration  to  assert  that  nearly  all  the  study  and 
thought  expended  upon  it  down  to  the  beginning  of 
our  own  age  has  been  fruitless  and  as  good  as  wasted, 
except  inasmuch  as  it  has  at  last  made  clear  the  im- 
passability  of  the  route  men  have  sought  to  follow,  the 
route,  namely,  of  introspection.  For  we  might  as  well 
study  the  human  body  alone  without  reference  to  tliat 
of  any  other  creature,  and  attempt  in  that  way  to  deci- 
pher its  genesis,  development,  and  meaning,  as  to  at- 
tempt to  comprehend  a  single  human  mind  without 
including   in  our  examination  not  only  other  human 

'  .\n  .iiiilress  dclivereil  at  the  opening  of  the  section  of  psychol- 
ogy, at  the  annual  meeting  of  the  British  .Medical  Association  at 
-Montreal,  September  I,  1S97, 


I 


September  i8,  1897] 


MEDICAL    RECORD. 


415 


minds  in  all  stages  of  evolution,  but  equally  all  other 
minds  to  which  our  own  is  related — that  is  to  say,  all 
minds  other  than  human  belonging  to  our  kinsfolk  the 
animals,  minds  which  stand  to-day  like  mileposts 
along  the  almost  infinite  length  of  the  path  which  our 
mind  has  followed  in  its  upward  march  across  the  im- 
mensities and  eternities  from  its  remote  infancy  to  the 
present  hour;  minds  which  in  a  thousand  faculties 
represent  to  us  everywhere,  in  infinite  sameness  and 
variety,  replicas  of  our  own  or  of  parts  of  our  own, 
showing  us,  as  the  poet  says,  tokens  of  ourselves 
which  we  "  negligently  dropped  as  we  passed  that  way 
huge  times  ago." 

Comparative  Psychology. — As  man's  bodily  life 
rests  upon  and  grows  from  that  of  countless  prehuman 
ancestors;  as  man  includes  in  his  structure  the  heart 
of  the  reptile,  the  gills  of  the  fish,  as  well  as  the  forms 
in  outline  of  innumerable  still  lower  races,  so  is  his 
so-called  human  mind  rooted  in  the  senses  and  in- 
stincts of  all  his  ancestral  species;  and  not  only  so, 
but  these  senses  and  instincts  still  live  in  him,  making 
up,  indeed,  far  the  larger  part  of  his  current  every-day 
life;  while  his  higher  psychical  life  is  merely  the  out- 
growth and  flower  of  them. 

As  truly  as  the  plant  is  an  embodiment  of  inorganic 
matter  vivified  by  the  transmuted  forces  which  in  the 
non-vital  world  about  us  we  call  light  and  heat,  so 
truly  is  man's  mind  the  outcome  of — the  expansion 
and  culmination  of — the  imperfect  sensation  of  the 
worm,  the  rudimentary  sight,  hearing,  and  taste  of 
the  fish  and  reptile;  and  the  simple  consciousness 
which,  springing  from  these,  passed  to  us  after  almost 
infinite  ages  of  slow  evolution  and  amelioration  through 
tens  of  thousands  of  generations  of  placental  mammals 
our  immediate  progenitors. 

In  the  growth  of  mind,  whether  that  of  the  race  or 
of  an  individual,  we  recognize  two  distinct  processes: 
First,  the  very  gradual  evolution  to,  or  toward,  perfec- 
tion of  faculties  that  have  already  come  into  existence; 
and,  secondly,  the  springing  into  existence  (as  new 
branches  start  from  a  growing  tree)  of  faculties  which 
had  previously  no  existence.  For  it  is  clear  to  the 
least  thoughtful  student  that  no  faculty  (as  no  organ) 
came  into  mature  and  perfect  life  at  once.  Hearing 
and  sight,  we  are  told,  developed  by  slow  degrees  from 
the  sense  of  touch;  and  in  the  region  of  the  intellect 
conceptual  life  was  born  from  ages  of  receptual,  and 
that  from  millenniums  of  perceptual. 

Mental  Growth  in  the  Individual  and  in  the 
Race. — Let  us  now  suppose  mind  growing  for  mil- 
lions of  years  in  the  way  set  fortii.  It  begins,  we  will 
say,  as  mere  excitability;  to  that  after  a  long  time  is 
added  what  may  be  called  discrimination,  or  choice 
and  rejection  of,  for  instance,  ditTerent  kinds  of  food. 
After  another  long  interval  of  almost  infinitely  slow 
advance  sensation  appears,  and  with  it  the  capacity  of 
pleasure  and  of  pain;  then,  later  still,  memory;  by 
and  by  recognition  of  offspring;  and  successively 
thereafter  arise  reason,  recognition  of  individuals,  and 
communication  of  ideas.  Concurrently  with  these  in- 
tellectual faculties  certain  moral  functions  such  as 
fear,  surprise,  jealousy,  anger,  affection,  play,  sym- 
pathy, emulation,  pride,  resentment,  grief,  hate,  re- 
venge, shame,  remorse,  and  a  sense  of  the  ludicrous 
have  also  arisen  in  the  nascent  mind.  We  have 
reached  now  the  mental  plane  of  the  higher  animals, 
which  is  equally  that  of  the  human  being  at  about 
two  years  of  age.  Then  occurs  in  the  child  the  men- 
tal expansion  which  separates  man  from  the  higher 
mammals — for  something  like  a  year  the  child  mind 
steadily  grows  from  the  status  of  the  latter  to  the 
status  of  the  human  mind.  This  year  in  the  indi- 
vidual, during  which  it  walks  erect,  but  possesses  a 
receptual  intelligence  onlv,  not  having  yet  the  power 
of  forming  either  concepts  or  true  words,  represents  in 


the  race  the  age  of  the  a/iiius  homo,  the  period  of  per- 
haps a  hundred  thousand  years,  during  which  our  an- 
cestors walked  erect,  but,  not  having  self-conscious- 
ness, had  no  true  language.  At  the  average  age  of 
three  years  in  the  individual  self-consciousness  is 
born,  and  the  infant,  from  the  point  of  view  of  psy- 
chologv,  has  become  a  human  being.  But  we  all  know 
that  after  the  attainment  of  the  distinctively  human 
faculty,  self-consciousness,  the  child  has  still  much  to 
acquire,  both  in  the  way  of  the  expansion  of  already 
possessed  faculties  and  in  the  acquisition  of  new 
ones,  before  it  is  mentally  a  mature  man.  Of  the  nu- 
merous faculties  which  it  still  has  to  acquire  I  shall 
mention  only  here  the  color  sense,  the  sense  of  fra- 
grance, the  human  moral  nature,  and  the  musical 
sense.  A  consideration  of  these  four  and  of  self-con- 
sciousness will  occupy  the  short  time  allotted  me 
to-day. 

And  first  a  word  as  to  that  basic  and  master  human 
faculty,  self-consciousness.  It  occurs,  as  said,  at  about 
the  average  age  of  three  years,  but  when  it  first  made 
its  appearance  in  the  race  it  must  have  done  so  at  full 
maturity;  perhaps  at  the  age  of  twenty,  both  life  and 
childhood  being  shorter  at  that  time  than  they  are  to- 
day. ^'ou  will  see  at  once  why  I  say  self-conscious- 
ness must  have  occurred  at  first  at  maturity.  Its  ac- 
quisition at  a  given  epoch  supposed  a  higher  mental 
life  than  had  hitherto  existed — such  higher  life  on  the 
part  of  the  race  could  not  have  come  to  the  individual 
liefore  his  maturity.  To  suppose  that  it  would  be  (if 
vou  will  think  of  it)  a  contradiction  in  terms.  The 
human  mind  attains  it  high-water  mark  at  maturity 
(that  is  what  the  word  means),  and  one  generation 
could  not  reach  before  maturity  what  the  preceding 
generation  had  not  reached  at  all.  \\'ell,  but  self- 
consciousness  occurs  to-day  at  three  years  of  age,  and 
we  reach  full  mental  maturity  (on  the  average)  only 
at  the  age  of  thirty-five.  The  advance  then  made  by 
the  individual  from  the  age  of  three  to  that  of  thirty- 
five  represents  the  advance  of  the  race  between  the 
date  of  the  appearance  of  self-consciousness  and  to- 
day, the  mental  status  of  the  three-year-old  child  to- 
day being  the  mental  status  of  the  adult  when  self- 
consciousness  first  appeared.  How  long  has  it  taken 
the  human  mind  to  grow  from  mere  self-consciousness 
to  its  present  stature.'  Not  less  certainly  than  several 
hundred  thousand  )ears.  Whatever  the  time  required 
is  the  time  during  which  man  has  inhabited  the  earth. 

Of  all  the  mental  faculties  below  self-consciousness 
each  one  has  its  own  time  for  appearing  in  the  human 
infant — as,  for  instance,  memory  and  simple  con- 
sciousness appear  within  a  few  daj's  after  birth,  curi- 
osity ten  weeks  after,  use  of  tools  twelve  months  after, 
shame,  remorse,  and  a  sense  of  the  ludicrous — all  of 
them  about  fifteen  months  after  birth.  Now  it  is  to 
be  noted  that  in  every  instance  the  time  of  the  appear- 
ance of  a  faculty  in  the  infant  corresponds  with  the 
stage  at  which  the  same  faculty  appears  (as  far  as  can 
be  at  present  ascertained)  in  the  ascending  animal 
scale;  for  instance,  memory  and  simple  consciousness 
occur  in  animals  as  primitive  as  the  echinodermata, 
while  the  use  of  tools  is  not  met  with  below  monkeys, 
and  shame,  remorse,  and  a  sense  of  tlie  ludicrous  are 
almost,  if  not  entirely,  confined  (among  animals)  to 
the  anthropoid  ape  and  the  dog. 

To  turn  now  to  the  true  subject  of  this  paper,  I  want 
to  say  in  the  first  place  that  as  in  prehuman  so  in  hu- 
man psychologv  each  superadded  faculty  was  acquired 
in  its  own  time  in  the  history  of  the  race,  and  that 
that  historic  period  corresponds  with  the  time  in  the 
life  of  the  individual  into  whom  the  faculty  is  born  to- 
day. For  instance,  self-consciousness  appears  in  the 
individual  at  the  age  of  about  three  years — it  appeared 
in  the  race  several  hundred  thousand  years  ago.  It 
has  been  proved  by  Geiger  and  others  ihat  our  color 


4i6 


MI'DICAL    RFXOKD. 


[September  i8,  1897 


sense  has  been  acquired  by  the  race  not  more  than 
about  thirty  thousand  years  ago.  Well,  it  is  acquired 
by  the  indi'-idual  at  the  age  of  about  five  or  six.  It 
is  thought  that  the  sense  of  fragrance  was  acquired  by 
the  race  later  than  tiie  color  sense;  it  is  also  acquired 
later  by  the  individual.  Some  considerable  study  of 
history  has  led  me  to  the  conclusion  that  our  human 
moral  nature  cannot  be  more  than  ten  thousand  years 
old.  For  a  careful  consideration  of  ihe  records  that 
have  come  down  to  us  from  the  early  Romans,  Hel- 
lenes, Hebrews,  Egyptians,  Assyrians,  and  Babyloni- 
ans, would  indicate,  I  think  unmistakably,  that,  as  we 
go  back  into  the  past,  this  faculty  taj^ers  down  toward 
the  vanishing-point,  and  that  if  it  continues  so  to  taper 
as  we  ascend  the  ages  all  of  what  we  distinctively  call 
our  human  moral  nature  would  certainly  have  disa])- 
peared  by  the  time  we  had  gone  back  the  number  of 
centuries  mentioned — that  is  ten  thousand  years. 

Well,  to-day  the  human  moral  nature  in  the  indi- 
vidual, instead  of  being  born  at  the  age  of  three  years 
as  is  self-consciousness,  or  at  live  or  si.x  as  is  the  color 
sense,  does  not  come  into  e.xistence  before  the  average 
age  of  about  fifteen  years.  As  to  the  musical  sense,  it 
is  almost  certainly  less  than  five  thousand  years  old  in 
the  race,  and,  when  it  occurs  at  all,  is  not  usually  born 
in  the  individual  before  adolescence. 

There  are  three  other  laws,  each  well  worthy  of 
notice,  which  govern  the  acquisition  of  new  faculties 
by  any  given  race.     They  are  as  follows: 

1.  The  longer  a  race  has  been  in  possession  of  a 
given  faculty,  the  more  universal  will  that  faculty  be 
in  the  race.  This  proposition  scarcely  needs  proof — 
every  new  faculty  must  occur  first  of  all  in  one  indi- 
vidual, and  as  other  individuals  attain  to  the  status  of 
that  one  they  too  will  acquire  it,  until  after  perhaps 
many  thousands  of  years,  the  whole  race  having  at- 
tained to  that  status,  the  faculty  sliall  become  univer- 
sal. 

2.  The  longer  a  race  iias  been  in  possession  of  a 
given  faculty,  the  more  firmly  is  that  faculty  fi.xed  in 
each  individual  of  the  race  who  jxjssesses  it.  In  other 
words:  the  more  recent  is  any  given  faculty,  the  more 
easily  is  it  lost.  High  authority,  such  as  that  of 
Charles  Darwin,  could  be  quoted  in  support  of  this 
proposition;  but  it  scarcely  seems  to  be  required;  it 
is  almost,  if  not  quite,  a  self-e\  ident  proposition. 

3.  .\  study  of  dreaming  seems  to  reveal  the  fact  that 
in  sleep  such  mind  as  we  have  differs  from  our  waking 
mind,  especially  by  being  more  primitive;  that,  in 
fact,  it  would  be  almost  strictly  true  to  say  that  in 
dreams  we  pass  backward  into  a  prehuman  mental 
life;  that  the  intellectual  faculties  which  we  possess 
in  dreams  are,  especially,  recepts  as  distinguished  from 
our  waking  concepts;  while  in  the  moral  realm  the\' 
are  those  faculties  sucii  as  remorse,  shame,  surprise, 
along  with  the  older  and  more  basic  sense  functions, 
which  belonged  to  us  before  we  reached  the  human 
plane ;  and  that  the  more  modern  mental  faculties,  sucli 
as  color  sense,  musical  sense,  self-consciousness,  the 
human  moral  nature,  liave  no  existence  in  this  condi- 
tion, or  if  any  of  them  do  occur  it  is  only  as  a  rare 
exception. 

Let  us  now  compare,  one  with  the  other,  a  few  of 
the  faculties  which  have  been  already  mentioned  in 
the  light  of  the  rules  laid  down.  To  do  this  will  give 
us,  more  clearly  than  ])erhaps  anything  else  could,  a 
definite  notion  of  the  growlh  of  mind  by  the  successi\  e 
addition  of  new  functions.  For  this  purpose  we  will 
take  simple  consciousness,  shame,  self-consciousness, 
color  sense,  the  human  moral  nature,  and  the  nuisical 
sense. 

Simple  Consciousness.  —  Simple  consciousness 
makes  its  appearance  in  the  human  infant  at  the  age 
of  a  fewdavs;  it  is  ab.soluteh'  universal  in  the  human 
race:    it  dates  back  certainh  to  the  earliest  mammals. 


and  probably  much  earlier;  it  is  lost  only  in  deep 
sleep  and  coma;   it  is  present  in  all  dreams. 

Shame.-  -Shame  is  said  to  be  born  in  the  human 
infant  at  the  age  of  fifteen  months;  it  is  a  prehuman 
faculty,  being  found  in  the  dog  and  in  apes,  and  un- 
doubtedly existed  in  our  prehuman  ancestry;  it  is 
almost  universal  in  the  race,  being  absent  only  in  the 
lowest  idiots;   it  is  very  common  in  dreams. 

Self-Consciousness. — Self-consciousness  makes  its 
appearance  in  the  child  at  the  average  age  of  three 
years;  it  is  not  present  in  any  species  but  the  human; 
it  is,  in  fact,  that  faculty  the  possession  of  which  by 
an  individual  constitutes  him  a  man.  It  is  not  uni- 
versal in  our  race,  being  absent  in  all  true  idiots;  that 
is,  it  is  permanently  absent  in  about  one  in  each  thou- 
sand human  beings  born  into  the  world.  In  our  an- 
cestry it  dates  back  to  the  first  true  man;  a  race,  we 
are  told,  unclothed,  walking  erect,  gregarious,  without 
a  true  language,  to  a  limited  extent  tool  using,  desti- 
tute of  marriage,  government,  or  of  any  institution, 
animal,  but  in  virtue  of  its  highly  developed  receptual 
intelligence  king  of  animals,  which  developed  self- 
consciousness,  and  by  that  fact  became  man.  It  is 
impossible  to  say  how  long  ago  it  was  when  this  event 
occurred,  but  it  could  not  have  been  less  than  several 
hundred  thousand  years.  This  faculty  is  lost  much 
more  easily  and  frequently  than  is  simple  conscious- 
ness. We  lose  it  in  coma  and  also  often  in  the  delir- 
ium of  fever;  in  certain  forms  of  insanity,  as  in 
mania,  it  is  often  lost  for  weeks,  even  months  at  a 
time;   and  lastly,  it  is  never  present  in  dreams. 

Color  Sense. —  I  have  elsewhere  written  at  large  on 
the  color  sense,  and  have  only  space  here  to  give  the 
facts  whicii  bear  on  the  present  inquiry.  That  these 
are  facts  the  argument  referred  to  I  think  demon- 
strates. This  faculty  appears  in  the  individual  at  the 
average  age  of  about  five  years.  It  is  absent  in  one 
adult  human  being  out  of  ever)' forty-seven;  it  ap- 
peared in  our  ancestors,  as  Geiger  has  shown  from  lin- 
guistic paleonotolog)-,  in  the  .Aryan  period,  probably 
less  than  thirty  thousand  years  ago.  It  is  seldom 
present  in  dreams,  and  when  it  does  occur — that  i.s, 
when  any  color  is  seen  in  a  dream — it  is  generally  that 
color  which  for  good  reasons  was  first  perceived  by 
man,  namely,  red. 

The  following  occurrence  illustrates  (I  think  in  a 
striking  manner)  the  usual  absence  of  the  color  sense 
during  the  partial  consciousness  which  occurs  in  sleep. 
.-V.  man  whose  hair  is  white  dreamed  that  he  was  look- 
ing in  a  glass  and  saw  plainly  tliat  his  i'.air  was  not 
only  much  thicker  than  he  knew  it  to  be  in  fact,  but 
instead  of  being  white,  as  he  also  knew  it  to  be,  it  was 
black.  Now,  he  well  remembered  in  his  dream  that 
his  hair  had  never  been  black.  It  had,  in  fact,  been 
a  light  brown.  He  wondered  (it  is  worth  mentioning 
here  that  wonder  or  surprise  is  a  prehuman  faculty, 
and  is  common  in  dreams)  in  his  dream  that  his  hair 
should  be  black,  remembering  distinctly  that  it  had 
never  been  so.  (I  may  say  here  that  memory  is  a 
prehuman  faculty,  and  is  common  in  dreams.)  The 
important  thing  to  note  about  the  dream  under  consid- 
eration is  that,  though  it  was  clear  to  the  dreamer's 
mind  that  his  hair  had  never  been  black,  yet  he  did 
not  remember  that  it  had  been  brown.  For  some  rea- 
son (and  1  think  the  reason  is  quite  clear")  there  was 
a  difficulty  in  calling  up  l)efore  consciousness  any 
color. 

Moral  Nature. —  The  human  moral  nature  belongs 
to  a  much  later  stage  of  evolution  than  any  of  the 
faculties  so  far  considered.  It  does  not  make  its  a|)- 
pearance  in  the  individual  before  the  average  age  of 
fifteen  years.  It  is  congenitally  and  permanently  ab- 
sent in  at  least  forty  human  beings  out  of  every  thou- 
sand, [t  would  seem  clear,  as  staled  already,  from  a 
consideration  of  our  historic  ancestors,  from  the  fact 


September  i8,  1897] 


MEDICAL    RFXORD. 


417 


that  this  faculty  rapidly  fades  out  as  we  ascend  into 
the  past,  that  it  cannot  have  existed  in  the  race  more 
than  ten  thousand  years  at  the  most.  It  is  far  more 
unstable  in  the  individual  than  are  older  faculties, 
such  as  self-consciousness.  It  is  never  present  in 
dreams. 

Musical  Sense. — Finally,  the  musical  sense  (a  fac- 
ulty which  is  now  in  act  of  being  born  into  the  race) 
does  not  appear  in  the  individual  before  the  average 
age  of  about  twenty  years.  It  does  not  e.\ist  in  more 
than  half  the  members  of  the  race.  It  hase.xisted  less 
(perhaps  considerably  less)  than  five  thousand  years 
in  the  race.  It  is  never,  oi  almost  never,  present  in 
dreams,  even  in  the  case  of  professional  musicians. 

The  Scheme  of  Mental  Evolution — You  see  now 
clearly  the  scheme  upon  which  I  suppose  the  mind  (as 
far  as  we  ha\e  got)  to  have  been  built.  I  say  advis- 
edly "as  far  as  wf  have  got,"  because,  if  the  mind  has 
grown  in  the  way  set  forth,  it  is  still  growing  and  is 
not  built  but  is  in  the  act  of  building.  No  man  can 
ever  say  positively  that  his  theory  (of  any  fact)  is  the 
true  one,  but  I  am  prepared  to  say  of  the  above  hy- 
pothesis that,  if  it  be  accepted,  it  will  enable  us  to 
understand  something  of  the  phenomena  of  mind  as 
we  observe  it,  whereas  if  we  should  prefer  to  hold,  as 
many  do,  that  the  human  mind  was  created  indepen- 
dently of  any  that  preceded  it  by  a  fiat  and/c"/-  saltiwi, 
then  I  say  deliberately  that  there  is  and  can  be  no 
such  thing  as  a  science  of  psychology,  and  that  every 
attempt  to  investigate  or  explain,  to  comprehend  or  di- 
vine the  rationale  of  the  facts  observed  as  to  its  origin 
and  growth  in  the  individual  must  remain  forever  fu- 
tile. And  if  I  could  find  the  right  words,  I  would 
bring  home  to  each  one  who  hears  me  the  ine.xtin- 
guishable  conviction  that,  in  this  idea  of  evolution, 
lie  enfolded  the  mystery  of  the  past,  the  explanation 
of  the  present,  and  the  sure  prescience  of  the  future — 
what  we  were,  what  we  are,  and  what  we  shall  be. 

The  Atavistic  Theory  of  Idiocy  and  Insanity. — 
In  conclusion,  I  desire  to  refer  briefly  to  two  coroUo- 
ries  which  How  from  this  hypothesis.  The  first  is  that 
if  it  is  correct  then  all  forms  of  insanity,  including 
all  forms  of  idiocy,  are  nothing  more  nor  less  than 
cases  of  atavism.  In  this  view  insanity  is  due  to  con- 
genital ab.sence  or  imperfection  (leading  to  break- 
down) of  some  faculty  or  faculties,  such  absence  or 
imperfection  being  due  to  more  or  less  complete  re- 
version to  an  ancestral  type.  In  my  opinion,  this 
view  explains  insanity  and  its  numerous  forms  more 
completely  than  these  can  be  explained  from  any  other 
point  of  view,  and  is  therefore  of  great  value  to  the 
thoughtful  student  of  these  phenomena.  Upon  this 
view,  the  comparatively  recent  origin  and  rapid  evolu- 
tion of  the  human  mind,  and  especially  the  rapid  men- 
tal evolution  of  the  so-called  Aryan  peoples  in  the  last 
four  or  five  thousand  years,  is  almost  solely  responsi- 
ble for  the  large  number  of  cases  of  insanity  in  the 
modern  civilized  world,  since  the  stability  of  any 
form,  function,  or  faculty  in  any  race  is  dependent 
upon  the  time  it  has  existed  in  that  race,  and  therefore 
the  more  recent  a  faculty  is  in  a  race  the  more  fre- 
quently will  it  be  found  absent,  defective,  or  unstable 
in  the  individuals  of  the  race. 

Future  Development  of  Mind. — The  second  corol- 
lary, which  is  even  more  important  than  the  first,  is 
that,  upon  the  view  here  set  fortii,  the  human  mind  at 
present  is  not  formed,  but  forming;  is  not  completed, 
but  in  process  of  construction.  By  slow  and  dubious 
steps  taken  in  darkness  our  remote  ancestors  wearily 
climbed  to  simple  consciousness.  After  another  im- 
mense interval  they  reached  self-consciousness.  But 
that  cannot  be  the  end — the  cosmic  process  cannot 
stop  there — cannot,  indeed,  stop  anywhere.  Evolu- 
tion, as  far  as  we  can  see,  has  always  gone  on,  is  go- 
ing on  to-day,  and  will  always  go  on.     Our  old  mental 


faculties  are  some  of  them  fading  out,  others  advanc- 
ing toward  greater  perfection,  and  alongside  of  them 
new  ones  are  springing  up,  some  of  which  will,  with- 
out doubt,  be  of  overshadowing  importance  in  the 
future. 

So-called  telepathy  and  clairvoyance  seem  to  be 
specimens  of  such  nascent  faculties.  I  place  in  the 
same  class  the  phenomena  of  what  is  often  named 
spiritualism.  The  labors  of  the  Society  for  Psychical 
Research  have. made  it  to  me  plain  that  these  phenom- 
ena, as  notably  in  the  case  of  \V.  Stainton  Moses, 
really  exist.  And  I  think  that  a  study  of  the  above- 
mentioned  case,  together  with  that  of  Mrs.  Piper  and 
that  of  Mary  J.  Fancher,  of  Brooklyn,  would  compel 
any  unprejudiced  person  to  make  the  same  admission. 
But  to  me  these  are  not  cases  in  which  outside  agents 
are  acting  on  or  through  a  human  being,  but  are  cases 
in  which  a  given  human  being  has  faculties  which  are 
not  commonly  possessed.  Whether  any  given  faculty, 
such  as  one  of  those  now  alluded  to,  shall  grow,  be- 
come common,  and  finally  universal  in  the  race,  or 
wither  and  disappear,  will  depend  upon  the  general 
laws  of  natural  selection,  and  upon  whether  the  pos- 
session of  the  nascent  faculty  is  advantagCvjus  or  not 
to  the  individual  and  to  the  race. 

But  of  infinitely  more  importance  than  telepathy  and 
so-called  spiritualism  (no  matter  what  explanation  we 
give  of  these,  or  what  their  future  is  destmed  to  be)  is 
the  final  fact  to  be  here  touched  upon.  This  is  that 
superimposed  upon  self-consciousness,  as  is  that  fac- 
ulty upon  simple  consciousness,  a  third  and  higher 
form  of  consciousness  is  at  present  making  its  appear- 
ance in  our  race.  This  higher  form  of  consciousness 
when  it  appears  occurs,  as  it  must,  at  the  full  maturity 
of  the  individual,  at  about  the  age  of  thirty-five,  but 
almost  always  between  the  ages  of  thirty  and  forty. 
There  have  been  occasional  cases  of  it  for  the  last  two 
thousand  years,  and  it  is  becoming  more  and  more 
common.  In  fact,  in  all  respects,  as  far  as  observed, 
it  obeys  the  laws  to  which  every  nascent  faculty  is 
subject.  Many  more  or  less  perfect  examples  of  this 
new  faculty  exist  in  the  world  to-day,  and  it  has  been 
my  privilege  to  know  personally,  and  to  have  had  the 
opportunity  of  studying,  several  men  and  women  who 
have  possessed  it.  In  the  course  of  a  few  more  mil- 
lenniums there  should  be  born  from  the  present  human 
race  a  higher  t}'pe  of  man  possessing  this  higher  con- 
sciousness. This  new  race,  as  it  may  well  be  called, 
would  occupy,  as  toward  us,  a  position  such  as  that 
occupied  by  us  toward  the  simple  conscious  alalus 
homo.  The  advent  of  this  higher,  better,  and  happier 
race  would  amply  justify  the  long  agony  of  its  birth 
through  the  countless  ages  of  our  past.  And  it  is  the 
first  article  of  my  belief,  some  of  the  grounds  of  which 
I  have  endeavored  to  lay  before  you,  that  a  race  is  in 
course  of  evolution. 


Treatment  of  Ulcers  by  Oxygen  Gas. — Possibly 
the  oxygen  acts  in  one  or  more  of  the  following  ways: 
I,  Diminution  of  irritation — any  dressing  applied  to 
an  open  sore  causes  more  irritation  than  a  mixture  of 
oxygen  and  pure  air;  2,  direct  stimulation  without  irri- 
tation; 3,  the  oxygen  may  oxidize  the  toxins  produced 
by  micro-organisms  in  the  surface  of  the  ulcer — this 
may  apply  more  especially  to  the  toxins  produced  by 
bacilli  when  present;  and  4,  as  stated  by  Mr.  Stoker, 
the  oxygen  has  possibly  a  selective  power  in  its  action 
on  micro-organisms  present  in  the  ulcer,  encouraging 
staphylococci,  which  then  outgrow  the  bacilli.  Stme 
of  the  foregoing  points  are  at  present  under  investiga- 
tion. Here,  as  yet,  we  have  only  the  practical  results 
of  a  few  cases  to  go  by,  all  of  which  are  in  favor  c.f  the 
oxygen  treatment. — Dr.  D.wid  Semfle,  Loik/oh  Lan- 
cet, May  29th. 


4ii 


MEDICAL    RECORD. 


[September  i8,  1897 


ON    LITHOTRITY    AS    THE    BEST    METHOD 
OF    TREATIN(i    LARGE    VESICAL   CALCULL' 

By    HERBERT    MILTON.    M.R.C.S.. 


I  HAVE  the  honor  to  lay  before  you  a  collection  of  100 
large  stones  taken  from  among  the  550  cases  of  vesi- 
cal calculi  that  I  have  had  occasion  to  treat  in  Egypt 
since  1892.  Of  these  stones  the  smallest  weighs  50 
grams,  the  largest  995.  Of  the  subjects,  82  were  oper- 
ated on  by  lithotrity,  with  6  deaths;  13  by  suprapubic 
lithotomy,  with  4  deaths;  4  by  abdominal  section,  with 
3  deaths;  and  i  case,  in  which  the  stone  was  half  in 
the  ureter  and  half  in  the  bladder,  required  a  special 
operation.  In  the  greater  number  of  cases  no  selection 
was  made  with  regard  to  operation ;  at  first,  before  I 
had  acquired  complete  confidence  in  lithotrity,  I  sub- 
mitted all  large  stones  to  suprapubic  lithotomy  or  to 
laparotomy;  but  I  have  for  the  last  four  years  practi- 
cally abandoned  in  tiie  treatment  of  large  stones  all 
operations  e.xcept  lithotrity.  I  still,  however,  practise 
suprapubic  lithotomy  for  small  stones  and  in  young 
subjects.  Under  these  conditions  I  have  operated 
some  thirty  times,  with  immediate  complete  suture  of 
the  bladder,  without  losing  a  patient.  My  experience 
with  laparotomy  has  been  disastrous.  My  only  success- 
ful case  was  the  first  one  performed,  and  I  was  able 
to  remove  a  stone  weighing  995  grams,  the  largest 
stone  which  has  ever  been  successfully  removed.  The 
other  three  cases  were  all  fatal. 

The  82  cases  treated  by  lithotrity  may  be  divided 
into  two  categories — those  in  which  I  have  performed 
the  classical  operation  of  Bigelow,  and  those  in  which 
I  have  introduced  a  lithoclast  through  a  perineal  in- 
cision. 

Bigelow's  operation  was  performed  in  47  cases, 
with  3  deaths.  Of  the  stones  removed  in  these  47 
cases,  37  weighed  between  50  and  99  grams,  with  i 
death;  5  weighed  between  100  and  199  grams,  with  i 
death;  i  weighed  204  grams,  another  209,  another 
240,  another  343,  and  the  largest  of  all  452  grams, 
or  over  16  ounces.  Of  these  5  cases  of  very  large 
stones  treated  by  Bigelow's  operation,  i  only  was  fatal, 
the  one  in  which  the  stone  weighed  240  grams.  I 
think  I  am  justified  in  saying  that  no  other  method  has 
ever  given  such  favorable  results.  It  must  be  ad- 
mitted, however,  that  the  operation  in  such  cases  is  not 
easy,  and  I  would  recommend  its  practice  only  to  those 
who  have  already  some  experience  of  litholapaxy. 
The  principal  difliculties  are: 

1.  From  the  great  force  necessary  to  crush  large 
and  hard  stones.  This  great  force  may,  however,  be 
safely  and  certainly  applied  if  specially  strong  instru- 
ments are  used. 

2.  From  the  contraction  of  the  walls  of  the  bladder 
on  the  stone,  preventing  the  introduction  of  the  litho- 
trite  and  tlie  seizure  of  the  calculus.  This  contraction 
is  best  corrected  by  the  application  of  hydrostatic 
pressure,  produced  by  a  column  of  water  and  contin- 
ued during  three,  four,  or  five  minutes. 

3.  From  the  length  of  time  necessary  for  the  com- 
plete extraction  of  the  Ji'/>ris.  In  some  of  my  opera- 
tions this  has  extended  to  two  and  one-half  hours  or 
even  more,  and  during  this  long  period  it  was  neces- 
sary to  keep  up  the  strength  not  only  of  the  patient 
but  of  the  operator  also. 

Perineal  lithotrity  was  performed  in  35  cases,  with 
3  deaths.  Of  the  stones  removed  18  weighed  between 
50  and  99  grams,  with  i  death;  15  between  100  and 
199,  with  I  death;  i  weighed  209  grams,  and  i 
weighed  387.     Of  these  2  cases,  the  latter  was  fatal. 

Perineal  lithotrity  is  much  easier  of  performance 

'  Paper  read  before  the  International  Medical  Congress,  at 
Moscow,  1^97. 


for  large  stones  than  Bigelow's  operation,  and  the  re- 
sults are  so  favorable  that  I  can  strongly  recommend 
it  to  every  surgeon.  But  its  mortalit)-  has  been  greater 
in  my  hands  than  that  of  Bigelow's  operation.  I  have 
been  troubled  with  consecutive  urinary  fistulse  in  two 
of  my  cases,  and  the  operation  entails  a  much  longer 
convalescence.  I  therefore  am  gradually  abandoning 
this  operation,  performing  it  only  in  a  few  special 
cases  and  for  demonstration  to  the  students. 

The  operation  invented  by  Bigelow  and  named  by 
him  litholapaxy  is  gaining  in  favor  day  by  day;  the 
limits  of  its  application  are  removed  one  by  one. 
Neither  extreine  youth  nor  extreme  old  age  need  any 
longer  be  taken  into  consideration;  the  diseased  con- 
dition of  the  bladder  and  of  other  organs  are  no  longer 
a  contraindication ;  and  I  trust  that  in  the  immediate 
future  the  limitations  due  to  the  size  and  hardness  of 
the  stone  will  entirely  disappear. 


progress  of  ^cdicaX  Jicicncc. 


Nervous  Cough. — Koch  reached  the  following  con- 
clusions: I.  The  existence  of  a  true  nervous  cough 
cannot  be  denied.  2.  This  cough,  emanating  from  a 
nerve  centre,  may  be  diagnosed  as  such  when  abdomi- 
nal and  thoracic  organs  are  intact,  when  one  can 
exclude  hysteria,  whooping-cough,  and  beginning 
phthisis.  3.  The  monotonous,  involuntary  cough,  al- 
ways the  same  in  each  patient,  forms  the  principal 
symptom  in  this  affliction.  4.  Medication  fail.s. 
The  cough  ceases  spontaneously  after  a  sea  voyage  or 
a  trip  to  the  mountains. 

Clinical  Relations  of  Auto-Intoxication. —  In  the 
course  of  a  recent  discussion  on  auto-intoxication,  by 
members  of  the  Chicago  Academy  of  Medicine,  a  re- 
port of  which  has  appeared  in  the  Journal  of  the 
American  Mcdkal  Association,  Dr.  V.  F.  W'augh  said 
that  the  clinical  field  of  auto-intoxication  has  been 
gradually  widening  until  about  a  year  ago  it  was 
claimed  in  an  editorial  in  The  London  Lancet  that  not 
only  is  the  materies  morbi  of  such  diseases  of  the 
alimentary  tract  as  cholera,  typhoid  fever,  and  all 
affections  characterized  by  fetor  of  the  stools,  gen- 
erated in  the  intestinal  canal,  but  also  of  rheumatism, 
epilepsy,  uraemia,  headache,  diabetes,  chorea,  skin 
diseases,  and  many  of  the  chronic  diseases  of  the 
brain  and  spinal  cord.  There  is  one  phase  of  the 
question,  he  said,  to  which  very  little  attention  has 
been  paid,  though  it  is  rather  an  important  one, 
and  that  is  the  part  played  by  auto-intoxication  in 
fevers.  "We  know  that  in  all  fevers  the  secretion  of 
the  bile  is  interfered  with:  it  is  greatly  lessened. 
We  know  that  the  bile  is  the  natural  antiseptic  of  the 
.system;  consequently  it  stands  to  reason  that  in  all 
fevers  on  account  of  the  lack  of  bile  and  the  increased 
temperature  w-e  have  an  increased  tendency  to  decom- 
position of  the  contents  of  the  alimentar}'  canal. 
There  is  in  fever,  then,  neces,sarily  a  certain  amount 
of  auto-intoxication,  and  the  symptoms  of  auto-into.xi- 
cation  are  added  to  those  which  are  due  to  the  fever 
proper.  By  a  system  of  efficient  intestinal  antisepsis 
these  can  be  separated,  and  when  the  effects  of  auto- 
intoxication have  thus  been  eliminated  we  find  that 
the  severity  and  the  danger  of  the  attack  have  been 
materially  lessened.  It  is  a  question,  of  course, 
whether  it  is  better  practice  to  stimulate  the  liver,  al- 
ready suft'ering  from  the  fever  in  such  cases,  or  whether 
antisepsis  should  he  secured  by  the  use  of  anti.septic 
drugs." 


September  i8,  1897] 


MEDTCAI.    RECORD. 


419 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery, 


GEORGE    F.    SHRADY,  A.M.,   M.D.,   Editor. 

Publishers 
WM.  WOOD  &  CO.,  43,  45,  &  47  East  Tenth  Street. 

New  York,  September  18,  1897. 


ORRHOTHERAPY    IN    ULCER.\TIVE     ENDO- 
CARDITIS. 

While  recovery  from  so-called  ulcerative  or  malignant 
endocarditis  is  difficult  of  demonstration,  it  would  be 
unrea.sonable  to  contend  that  the  disease  is  invariably 
fatal.  On  the  other  hand,  in  cases  in  which  recovery 
ensues  some  doubt  might  justly  remain  as  to  the  accu- 
racy of  the  diagnosis.  The  knowledge  that  the  le- 
sions present  in  the  cases  under  consideration  are 
often  dependent  upon  the  activity  of  streptococci  and 
staphylococci,  would  amply  justify  the  employment  of 
an  antitoxic  serum  when  the  diagnosis  may  be  ven- 
tured. The  report  of  a  case  of  probable  ulcerative 
endocarditis  in  which  successful  results  attended  the 
use  of  antistreptococcic  serum  is  therefore  not  without 
interest. 

The  case  occurred  under  the  care  of  Dr.  Margaret 
Dunn,  at  the  Canning  Town  Medical  Mission  Hospi- 
tal, and  is  reported  in  The  Lancet  of  July  10,  1897. 
The  patient  was  a  girl,  sixteen  years  old,  who  com- 
plained of  having  had  a  "cold"  for  three  weeks,  with 
tightness  in  breathing.  There  was  marked  dyspncea, 
pulse  and  respiration  were  accelerated,  and  the  tem- 
perature was  101°  F.  Cardiac  action  was  rapid  and 
exaggerated,  and  a  loud  mitral  systolic  murmur  could 
be  heard,  together  with  a  faint  diastolic  murmur  at 
the  aortic  area.  Under  treatment  with  salicylates  no 
improvement  took  place.  Upon  inquiry  it  was  learned 
that  the  symptoms  had  been  present  about  a  month. 
In  the  course  of  several  weeks  aching  pains  appeared 
in  the  left  shoulder,  together  with  palpitation  of  tiie 
heart  and  shortness  of  breath.  There  was  no  previous 
history  of  rheumatism,  and  there  had  been  no  rheu- 
matic manifestations  beyond  a  transient  erythema  the 
year  before. 

The  patient  did  not  appear  very  ill,  but  was  bright 
and  lively.  There  was  considerable  dyspnoea,  but 
the  girl  was  able  to  lie  down.  She  complained  of 
palpitation  and  of  slight  pain  in  the  left  shoulder. 
I'here  was  considerable  perspiration  without  acid 
odor.  Neither  rash  nor  nodules  nor  anaemia  was  pres- 
ent. The  apex  beat  of  the  heart  was  seen  and  felt  in 
the  fifth  left  interspace,  three  inches  from  midsternuni. 
The  area  of  cardiac  percussion  dulness  was  increased 
to  the  right.  The  sounds  were  muffled  at  the  apex, 
but  a  mitral  systolic  murmur  was  distinguishable,  as 


well  as  an  aortic  diastolic  murmur  and  some  pericar- 
dial friction  sounds.  At  the  base  of  the  right  lung 
dulness  on  percussion  and  diminished  breath  sounds 
indicated  a  small  effusion. 

For  a  week  the  patient  showed  signs  of  marked  gen- 
eral improvement.  The  dyspncca  lessened,  the  slight 
joint  pains  disappeared,  and  the  temperature  gradu- 
ally fell  almost  to  normal.  The  physical  signs,  how- 
ever, persisted  and  indicated  increase  in  the  peri- 
cardial effusion.  An  aortic  systolic  murmur  became 
audible,  in  addition  to  the  mitral  systolic  and  the 
aortic  diastolic.  The  edge  of  the  spleen  was  indefi- 
nitely felt  below  the  costal  margin.  During  the  fol- 
lowing week  the  condition  of  the  patient  remained 
pretty  much  the  same,  the  temperature  rising,  how- 
ever, to  102°  F.  in  the  evening.  An  erythematous 
rash  appeared,  which  spread  by  degrees  over  the  limbs 
and  face,  disappearing  after  three  days.  The  amount 
of  fluid  in  the  pericardium  and  at  the  right  base  di- 
minished slightly  in  amount.  The  urine  was  normal 
throughout.  In  the  next  week  the  temperature  re- 
mained elevated  and  the  pulse  became  accelerated. 
The  patient  now  complained  of  tenderness  on  palpa- 
tion of  the  spleen,  and  the  physical  signs  indicated  a 
slight  increase  in  the  pericardial  effusion. 

Treatment  with  salicylates  having  been  unattended 
with  satisfactory  results  and  the  increasing  severity  of 
the  symptoms  suggesting  the  probability  of  the  endo- 
carditis having  assumed  a  malignant  character,  it  was 
decided  to  try  the  effect  of  treatment  with  antistrepto- 
coccic serum.  Accordingly  seven  injections  were 
made  beneath  the  skin  of  the  abdomen  during  a  period 
of  two  weeks,  at  intervals  of  a  day  or  two,  in  amounts 
varying  from  two  and  one-half  to  twenty  cubic  centime- 
tres. During  this  period  sharp  pains  and  friction 
sounds  appeared  in  the  left  axilla,  and  a  transitory 
presystolic  murmur  became  audible,  intimately,  how- 
ever, the  temperature  declined,  improvement  took  place 
in  the  physical  signs,  and  the  case  proceeded  to  com- 
plete recovery. 

The  diagnosis  of  ulcerative  endocarditis  was  based 
upon  the  seriousness  of  the  patient's  condition,  the 
hectic  type  of  the  temperature  and  its  persistent  eleva- 
tion in  the  absence  of  fresh  rheumatic  manifestations 
or  increase  of  those  present,  the  appearance  and  dis- 
appearance of  the  heart  murmurs,  and  the  increase  in 
the  size  of  the  spleen.  Unfortunately  bacteriological 
examination  of  the  blood  was  not  undertaken  until 
after  treatment  with  the  antistreptococcic  serum  had 
been  instituted,  and  then  no  micro-organisms  were 
found.  The  possibility  of  typhoid  fever  was  excluded 
by  the  absence  of  characteristic  symptoms  excepting 
high  temperature  and  increase  in  the  size  of  the 
spleen.  Acute  tuberculosis  was  less  closely  simu- 
lated, and  the  outcome  of  the  case  apparently  decided 
against  this  possibility,  even  had  there  been  any  doubt 


Camden  Medico-Surgical  Society. — At  a  stated 
meeting  of  this  society,  held  on  September  6th,  Dr.  H. 
]'".  Sherk  read  a  paper  on  the  discovery  of  ether  as  an 
anesthetic. 


420 


MEDICAL    REf^ORD. 


[September  i8,  1897 


THE   CACHEXIA   OF    CANCER. 

Cancer  in  Great  Britain  is  increasing  at  a  most 
alarming  rate.  Tlie  proportional  mortality  is  more 
than  four  times  greater  than  it  was  a  century  ago;  as  a 
consequence,  attention  is  attracted  to  every  phase  of 
the  disease.  Much  still  remains  to  be  discovered,  al- 
though recent  progress  has  completely  revolutionized 
our  knowledge  on  the  subject.  Concerning  the  ca- 
che.xia  of  cancer,  Mr.  W.  Roger  Williams,  writing  in 
the  Edinburgh  Medical  Journal  for  June,  1897,  says 
that  "  after  a  cancerous  growth  has  existed  for  a  vari- 
able time,  which  is  generally  rather  long,  the  patient's 
health  begins  to  suffer,  even  in  the  absence  of  ulcera- 
tion, hemorrhage,  etc.  Pallor,  weakness,  emaciation, 
and  loss  of  appetite  are  among  the  most  obvious  man- 
ifestations. These,  as  the  disease  progresses,  become 
greatly  aggravated,  the  pallor  taking  on  a  peculiar 
earthy  or  straw-colored  tint;  while  other  indications 
of  profound  disturbance  of  the  general  nutrition  arise, 
which,  when  the  malady  runs  its  natural  course,  even- 
tually determine  death  from  asthenia.  This  condition 
is  the  cancerous  cachexia.  It  is  noteworthy  that  ca- 
chectic symptoms  never  precede  the  outbreak  of  the 
primary  disease;  from  this  we  may  infer  that  they  are 
a  consequence  of  its  local  progress.  We  may,  I  think, 
best  interpret  these  symptoms  as  the  result  of  a  gen- 
eral toxjemia."  Mr.  Williams  then  traces  the  disease 
through  its  various  stages,  terminating  in  asthenia, 
and  states  that  out  of  ninety  uterine  cancer  cases  that 
ran  their  natural  course  under  his  observation,  sixty- 
four  thus  ended;  and  in  twenty -four  out  of  forty  cases 
of  breast  cancer  the  final  results  were  similar.  These 
conclusions  as  to  the  existence  of  a  special  cancerous 
cachexia  are  not  in  accordance  with  the  views  held  by 
many  observers  of  the  disease.  The  condition  de- 
scribed above  is  attributed  by  them  rather  to  ulcera- 
tion of  the  growths  and  subsequent  absorption  of  the 
septic  products,  or  to  repeated  hemorrhages. 


MUNICIPAL    WATER    SUPPLY. 

Water  is  a  question  of  perennial  interest.  Volumin- 
ous of  late  has  been  the  literature  concerning  the  ne- 
cessity of  an  adequate  and  unpolluted  supply  of  water, 
and  it  may  appear  to  some  that  the  subject  is  in  dan- 
ger of  being  overwritten,  but  it  is  a  matter  that  will 
bear  much  discussion.  The  truth  cannot  be  too 
strongly  impressed  upon  the  public  that,  taken  all 
round,  the  supply  of  pure,  unadulterated  water  for 
municipal  purposes  is  defective,  and  that  the  large 
cities  of  Europe  are  far  in  advance  of  this  country  in 
this  respect.  Prof.  W.  T.  Mason,  in  a  lecture  deliv- 
ered before  the  Franklin  Institute  in  March  last,  says: 
"  The  day  is  past  when  we  could  feel  a  sense  of  supe- 
riority over  the  crowded  millions  of  the  old  world,  be- 
cause of  the  relative  magnitude  and  consequent  initial 
purity  of  the  sources  of  our  water  supplies.  Europe 
has  of  late  years  expended  much  labor  and  capital  in 
substantial  plants  that  make  for  sanitary  betterments, 
while  we  have  continued  upon  a  conservative  course, 
forgetful  that  our  populations  and    industries    have 


been  growing,  and  that  the  river  our  fathers  drank 
from  with  pleasure  and  safet}'  has  become  charged 
with  the  refuse  of  up-stream  communities,  and  con- 
verted into  what  may  be  properly  styled  the  county 
sewer." 

The  most  radical  difference  between  the  European 
and  the  American  systems  is  that  in  this  countrj'  the 
water  is  delivered  raw,  while  in  many  places  in  Europe 
it  is  carefully  filtered.  Hence  it  stands  to  reason  that 
the  greatest  possible  attention  should  be  paid  to  the 
storage  of  the  water,  as  regards  both  the  reser\'oirs  and 
house  tanks.  L'nfortunately  it  is  to  be  feared  that 
this  is  not  always  the  case.  In  New  York  City  a  re- 
cent examination  of  the  water  tanks  in  the  tenement- 
houses  has  shown  them  in  many  instances  to  be  in  a 
most  filthy  condition,  most  of  them  apparently  not 
having  been  cleaned  since  they  were  first  erected. 
There  are  many  otherwise  good  citizens  who  are  averse 
to  changing  the  present  order  of  things  and  introduc- 
ing extensive  improvements,  on  account  of  the  cost. 
Professor  Mason  says  in  regard  to  this  matter:  "  There 
is,  believe  me,  no  system  of  filtration  or  other  efficient 
method  for  purifying  a  polluted  water  so  expensive 
but  that  a  community  can  well  afford  to  introduce  it 
rather  than  to  drink  a  dangerous  water  in  its  raw  state: 
and  this,  too,  from  purely  economic  considerations, 
and  leaving  out  of  sight  all  ethical  questions  whatso- 
ever." 


ENGLISH  CONTRACT  DOCTORS  IN  THIS 
COUNTRY. 

The  Lancet  of  July  24th  publishes  a  verj-  voluminous 
letter  from  an  English  medical  man  who  is  practising 
in  Lower  California.  This  gentleman  bitterly  bewails 
his  fate,  and  strongly  warns  practitioners  in  England 
who  may  be  thinking  of  emigrating  either  to  this 
countr)-  or  Mexico,  to  take  warning  by  his  unfortunate 
experiences,  and  to  ponder  seriously  ere  they  leave 
their  native  soil.  Some  of  the  advice  given  in  this 
letter  is  certainly  judicious  and  to  the  point.  Dr. 
Millican  says:  ''First,  let  intending  emigrant  doctors 
be  sure  that  what  appears  to  them  a  large  salarj-  at 
home  is  of  the  same  relative  value  in  the  countr)- 
whither  they  propose  to  go.  Secondly,  have  every- 
thing reduced  to  writing  in  such  form  as  to  be  cogniz- 
able by  the  courts  of  both  countries.  Thirdly,  if  it  be 
the  United  States,  have  an  agreement  signed  in  Eng- 
land before  starting,  and  embodying  a  clause  to  the 
effect  that  a  new  agreement  embracing  the  same  terms 
shall  be  executed  in  America  on  landing.  Fourthly, 
insist  that  the  facts  upon  which  any  promised  advan- 
tages are  based  shall  also  be  reduced  to  writing. 
Fifthly,  do  not  take  any  'collateral  advantages'  as 
part  remuneration.  Get  money  value  for  your  ser- 
vices, and  pay  cash  for  your  collateral  advantages 
when  you  ha\'e  found  out  what  they  are  worth.  Lastly, 
insist  upon  a  clause  securing  your  return  passage  in 
any  case." 

Unfortunately  for  Dr.  Millican,  through  ignorance 
he  did  not  protect  himself  by  acting  up  to  any  of  these 
clauses.     He  has  learned  wisdom  by  bitter  experience. 


September  i8,  1897] 


MEDICAL    RECORD. 


421 


and  according  to  the  tale  he  unfolds  in  The  La/ia-t. 
luck  has  been  decidedly  against  him.  As  a  matter  of 
fact,  here  in  this  countr}-  there  is  little  scope  or  chance 
of  success  for  foreign  physicians.  America  can  easily 
supply  her  needs  in  that  respect  with  the  home-made 
article. 


OUR    CABLED    REPORT    FROM    MOSCOW. 

It  is  with  no  small  feeling  of  satisfaction  that  we  re- 
fer our  many  readers  to  the  comparative  fulness  and 
accuracy  of  our  cabled  report  of  the  recent  meeting 
of  the  International  Medical  Congress  at  Moscow. 
Although  occupying  no  more  space  in  the  Medical 
RtcoRD  than  the  reports  of  other  meetings  within  easy 
reach  of  home,  the  degree  of  trouble  and  amount  of 
expense  in  securing  the  one  in  question  can  hardly  be 
appreciated  by  the  subscriber^ who  is  being  educated 
to  believe  that  everything  is  possible  with  his  favorite 
journal.  The  latter  estimate  of  resources  applies  with 
particular  directness  to  the  Medical  Record,  as  it  is 
the  only  journal  of  any  kind  in  America  that  has  gone 
to  the  expense  of  securing  promptly  and  accurately  a 
cabled  report  of  the  Moscow  meeting.  It  is  in  keep- 
ing with  this  spirit  that  we  strive  to  be  on  the  alert 
for  anything  and  everjthing  that  may  keep  our  readers 
fully  abreast  of  the  times. 


||;etus  of  the  Sxllcch. 

Philadelphia  County  Medical  Society.  — At  a 
stated  meeting  of  this  society,  held  on  September  S, 
1897,  Dr.  Joseph  Price  exhibited  a  large  number  of 
varied  and  interesting  specimens  removed  by  abdomi- 
nal section  ;  among  them,  the  cjecum  and  four  inches 
each  of  ileum  and  colon,  removed  on  account  of  ma- 
lignant disease;  a  portion  of  ileum  removed  on  ac- 
count of  jjerforation,  possibly  tj-phoid;  and  also  a 
number  of  extra-uterine  gestation  products.  He 
pointed  out  that  in  his  experience  rupture  of  ectopic 
gestation  cysts  occurs  with  much  greater  frequency 
during  the  summer  months  than  during  any  other  pe- 
rio  1  of  the  year,  and  that  ectopic  pregnancy  occurs 
with  noteworthy  frequency  in  women  in  whom  lactation 
is  prolonged,  either  for  the  purpose  of  averting  preg- 
nancy or  from  other  cause.  It  seemed  to  be  the  con- 
sensus of  opinion  that  when  removed  neoplasms,  diag- 
nosed as  malignant,  failed  to  recur,  there  had  been 
an  error  in  diagnosis. 

Pathological  Society  of  Philadelphia.  —  At  a 
stated  meeting  of  this  society,  held  on  September  9, 
1897,  Dr.  A.  Ferree  Witmer  exhibited  a  specimen  of 
endothelioma  of  the  spinal  dura,  and  related  the  his- 
tory of  a  case.  Dr.  A.  A.  Eshner  exhibited  specimens 
from  a  case  of  uramia,  including  large,  white,  fatty 
kidneys  and  broncho-pneumonia,  with  little  if  any  hy- 
pertrophy of  the  heart.  A  noteworthy  feature  of  tie 
case  was  the  temperature,  which  ranged  between  103 
and  104"  F.,  illustrating  the  fact  that  uraemia  is  not 
necessarily  attended  with  normal  or  subnormal  tem- 
perature. 


A  Gift  to  the  Charity  Hospital  in  New  Orleans. 
— Mrs.  D.  A.  Milliken,  widow  of  the  late  Richard 
Milliken,  of  New  Orleans,  has  announced  her  purpose 
to  erect  and  endow  a  large  hospital  for  children,  to  be 
an  annex  to  the  New  Orleans  Charity  Hospital.  The 
hospital  is  to  be  a  memorial  to  her  husband. 

St.  John's  Guild  Floating  Hospital. — The  statis- 
tics for  the  past  summer  of  the  Floating  and  Seaside 
hospitals  of  St.  John's  Guild,  show  that  on  the  Float- 
ing Hospital  43,468  women  and  children  were  cared 
for  and  8,01 1  salt-water  baths  were  given  ;  and  that  at 
the  Seaside  Hospital,  at  New  Dorp,  Staten  Island, 
1,556  children  were  received  and  14,151  hospital  days 
of  treatment  were  given.  Many  times  during  the  sea- 
son more  sick  persons  were  at  the  wharf  waiting  to  be 
taken  aboard  the  Floating  Hospital  than  there  were 
accommodations  for,  and  the  managers  of  this  benefi- 
cent charity  will  therefore  provide  a  second  floating 
hospital  for  next  summer 

An  International   Epidemiological   Bureau The 

editor  of  y<?//// J,  a  review  published  in  Amsterdam,  de- 
sires to  establish  an  international  system  of  reporting 
epidemiological  data,  and  thus  to  give  warning  of 
epidemic  storms  in  somewhat  the  same  way  that  atmos- 
pheric disturbances  are  now  heralded,  so  that  precau- 
tionary measures  may  be  taken.  As  soon  as  arrange- 
ments can  be  made,  it  is  purposed  to  publish  a 
bi-montlily  record  of  the  progress  of  epidemiolog}-, 
which  shall  include:  (i)  Current  statistics  of  the  mor- 
bidity and  mortality  from  epidemic  diseases — conta- 
gious, miasmatic,  and  miasmatic-contagious  ■ —  from 
states,  provinces,  and  cities  for  which  such  data  are 
available,  accompanied  when  possible  by  the  meteor- 
olog)- ;  (2)  original  observations  on  epidemic  diseases ; 
(3)  historical  records  of  epidemics  in  particular  coun- 
tries and  cities,  and  their  periods  of  prevalence  and 
quiescence;  (4)  special  communications  on  subjects 
of  epidemiological  interest. 

The  Losses  of  Spain  in  Cuba.  —  Dr.  de  Larra  y 
Cerezo  publishes,  in  £a  Meiliciita  Aliliiar  EspaTiola, 
some  statistics  of  the  morbidity  and  mortalit}'  among 
the  troops  of  the  invading  army  in  Cuba.  During  the 
month  of  May  there  were  38,692  admissions  to  the 
general  hospitals:  of  these  523  died,  and  33,739  were 
discharged.  In  the  yellow-fever  hospitals  the  admis- 
sions for  the  same  time  were  814,  of  whom  226  died 
and  406  were  discharged.  In  the  general  hospitals  in 
Havana  there  were,  on  the  ist  of  June,  4.709;  there 
were  admitted  during  the  month,  9,931;  discharged, 
8,798;  died,  270:  and  there  remained  in  hospital, 
5,512,  on  July  ist.  Of  yellow  fever  the  statistics  are: 
Patients  in  hospital  on  June  1st,  213:  admitted  dur- 
ing the  month,  677  :  died,  170:  and  remaining  in  hos, 
pital,  331. 

The  Light  of  Teutonic  Science  Deflected  from 
America. — The  German  universities  have  had  new 
regulations  made  for  them  by  the  various  state  gov- 
ernments, under  which  many  American  medical  stu- 
dents will  be  excluded  from  the  clinics.  The  Berlin 
physicians,  however,  are  not  yet  satisfied,  and,  it  is 


42  2 


MEDICAL    RECORD. 


[September  i8,  1897 


said,  have  petitioned  the  government  to  draw  the  lines 
still  closer,  so  as  not  to  admit  students  from  Ameri- 
can medical  colleges  or  universities,  unless  they  pass 
a  preliminary  examination. 

A  Congress  Memorial  in  Moscow.  —  It  has  been 
proposed  by  a  number  of  wealthy  citizens  in  Moscow 
to  endow  an  infirmary  for  epileptics  and  the  weak- 
minded  of  both  sexes,  to  commemorate  the  congress. 

Obituary  Notes. — Dr.  Caleb  Lyon,  of  Rossville, 
Staten  Island,  died  at  his  home,  on  September  nth, 
of  heart  and  kidney  trouble.  He  was  born  in  this 
city,  fifty-five  years  ago,  and  was  graduated  from  the 
Albany  Medical  College  in  187 1. — Dr.  Braxton 
Hicks,  F.R.S.,  formerly  physician-accoucheur  to 
Guy's  and  afterward  to  St.  Mary's  Hospital,  London, 
died  August  28th,  aged  seventy-two  years.  He 
suffered  an  attack  of  influenza  three  months  ago,  from 
which  he  never  fully  recovered.- — Dr.  J.  C.  Howden, 
of  England,  died  on  August  17th.  He  was  superin- 
tendent of  the  asylum  for  the  insane  at  Montrose,  For- 
farshire, from  1857  until  last  June,  when  he  resigned 
on  account  of  ill  health.  He  early  recognized  the 
value  of  the  out-door  system  of  treatment  of  the  in- 
sane, and  carried  it  out  in  the  asylum  under  his 
charge.  Three  years  ago  he  had  an  attack  of  apo- 
plexy, but  recovered  sufficiently  to  resume  his  duties. 

English  Comments  on  the  Congress. — The  corre- 
spondents of  the  English  journals  are  not  extravagant 
in  their  praise  of  the  Moscow  congress.  As  is  usual 
at  such  gatherings,  absolutely  no  provision  was  made 
to  facilitate  the  work  of  the  reporters  for  the  medical 
press.  The  correspondent  of  the  British  Aledical 
Journal  writes,  in  relation  to  this:  "In  a  country 
where  practically  a  press  is  non-existent,  it  would  be 
perhaps  ridiculous  to  expect  that  the  convenience  of 
the  members  of  the  press  of  other  countries  should  be 
carefully  considered;  but  whether  it  was  expected  or 
not,  it  certainly  has  been  most  studiously  neglected. 
The  bureau  is  such  only  in  name;  in  it  one  finds 
neither  information  nor  officials,  nor  anything,  indeed, 
more  than  tables,  pen,  and  ink.  It  rests  therefore 
with  the  individual  correspondent  to  seek  such  infor- 
mation as  can  be  gleaned  from  overworked  secretaries 
and  personal  observation."  Our  own  correspondents 
have  told  us  the  same  story,  and  the  complete  and  ac- 
curate reports  which  they  have  sent  us  were  obtained 
only  by  following  each  speaker  and  taking  down  his 
words  as  they  were  spoken.  The  officials  of  the  con- 
gress gave  them  no  assistance  whatever.  The  Lamet 
representative  complains  of  the  lack  of  toilet  conven- 
iences, "of  the  shameful  inadequacy"  of  which,  he 
writes,  "  a  plain  word  must  be  spoken.  One  urinal 
.and  one  water-closet  were  placed  at  the  disposal  of 
the  whole  congress,  and  both  were  in  the  same  little 
wooden  hut,  divided  from  each  other  by  no  partition. 
Moscow  is,  according  to  European  ideas,  very  inade- 
quately supplied  with  latrines,  while  the  unblushing 
publicity  of  the  East  concerning  the  performance  of 
all  the  offices  of  nature  to  a  great  extent  prevails;  but 
those  responsible  for  the  arrangements  of  the  public 
niQCling  in   the   Manage  ought  to  have  remembered 


that  the  meeting  was  an  international  one,  and  not  an 
Oriental  one.''  Finally,  the  Medical  Press  says  that 
the  Russian  government  excluded  Jewish  physicfans 
from  the  congress — a  fact,  if  it  is  a  fact,  which  greatly 
surprises  us,  for  it  had  been  declared  officially  that  no 
distinction  would  be  made  against  Hebrews  on  this 
occasion.  "  Naturally  .enough,"  our  contempwrary 
says,  "  much  irritation  has  been  caused  by  the  exclu- 
sion of  Jews  from  the  Moscow  congress.  An  incident 
in  connection  therewith  has  been  referred  to  by  the 
Moscow  correspondent  of  the  Standard.  At  one  of  the 
dinners  held  in  honor  of  the  congress,  a  heated  dis- 
cussion took  place  across  the  table  between  a  Russian 
member  and  one  of  the  best-known  German  professors, 
a propos  of  the  prohibition,  in  the  course  of  which  the 
former  used  threatening  gestures  toward  his  confrere. 
who  was  an  elderly  man.  It  was  only  after  consider- 
able difficulty  that  an  adjustment  of  the  quarrel  was 
brought  about.  Such  asperities,  of  course,  should 
have  no  place  at  the  meetings  of  scientific  men.  Bu; 
neither  should  any  narrow-minded  exhibition  of  relig- 
ious or  racial  intolerance  be  permitted  by  those  re- 
sponsible for  the  organization  of  the  reunions." 

Smuggled  Phenacetin A  saloon-keeper  in  Hobo- 
ken  was  arrested  recently  for  having  four  hundred 
ounces  of  smuggled  phenacetin  in  his  possession.  The 
box  containing  the  drug  was  found  in  the  icebox  of 
the  saloon. 

The  German  Society  of  Naturalists  and  Physi- 
cians  The  sixty-ninth  annual  meeting  of  this  asso- 
ciation will  be  held  at  Brunswick,  September  20th  to 
25th,  under  the  presidency  of  Dr.  v.  Lang,  of  Vienna. 
The  subject  of  scientific  photography  and  its  applica- 
tion to  medicine  is  one  of  the  most  impoitant  of  the 
set  discussions. 

A  Perilous  Post. — Sir  Joseph  Tholozan,  physician 
to  the  late  shah  of  Persia,  died  a  few  weeks  ago.  and 
a  French  paper  says  that  it  is  currently  reported  that 
he  was  poisoned.  He  had  been  the  trusted  confidant 
of  Nasr-ed-Din  for  over  thirty  years,  and  was  ac- 
quainted with  many  of  the  secrets  of  the  court,  and  his 
removal  was  desired  on  this  account  by  the  new  gov- 
ernment. After  the  death  of  the  shah  Sir  Joseph 
Tholozan  wrote  to  a  friend  in  France,  stating  that  he 
intended  to  resign  his  post  because  his  life  was  not 
safe,  and  it  would  appear  that  his  fears  were  only  too 
well  founded.  His  predecessor  at  the  Persian  court  is 
stated  to  have  been  done  away  with  in  the  same  man- 
ner.— British  Medical  Journal. 

Yellow  Fever. — There  is  little  to  cause  alarm  in 
the  situation  in  the  towns  bordering  the  Gulf,  where 
yellow  fever  has  appeared.  The  disease  has  naturally 
spread  from  Ocean  Springs,  where  it  was  first  discov- 
ered, to  other  places.  The  largest  number  of  cases  is 
in  Edwards,  Miss.,  where  forty-two  persons  are  re- 
ported sick,  many  of  them  with  yellow  fever.  At  New 
Orleans  several  new  cases  are  reported  each  day,  but 
the  sanitary  authorities  are  doing  very  efficient  work 
and  there  is  no  apprehension  that  the  disease  will  as- 
sume epidemic  proportions.  The  fever  is  in  a  mild 
form,  and  the  mortality  thus  far  has  been  light 


I 


September  i8,  1897] 


MEDICAL    RECORD. 


42: 


^etrxous  and  Notices. 

The  Menopause.  A  Consideration  of  the  Phenomena 
which  Occur  to  Women  at  the  Close  of  the  Child-Bearing 
Period,  with  Incidental  Allusions  to  their  Relationship  to 
Menstruation.  Also  a  Particular  Consideration  of  the 
Premature  (Especially  the  Artificial )  Menopause.  By  .An- 
drew F.  Currier,  .A..B.,  .M.D.,  New  York  City.  New 
York:  D.   .-^ppleton  and  Company.      1897. 

The  main  object  of  the  author  in  writing  this  book,  he  tells 
us,  was  to  divest  this  physiological  period  of  the  atmosphere 
of  terror  with  which  it  has  become  surrounded.  '  •  The 
menopause,"  he  says,  ••  is /lof  a.  dangerous  time  or  experi- 
ence for  the  majority  of  women,  any  more  than  puberty  is. 
The  majority  of  women  pass  through  it  with  as  little  incident 
or  discomfort  as  they  experience  at  puberty. "  Still  there  are 
some  who  suffer  more  or  less,  and  these  the  follower  of  Dr. 
Currier's  simple  directions  will  be  in  a  position  to  relieve 
greatly.  In  some  cases  the  hastening  of  the  menopause  by 
surgical  measures  is  advised,  but  we  are  glad  to  find  that  the 
author  is  quite  conservative  when  he  comes  to  discuss  the  in- 
dications for  operation. 

EXCYKLUP.AEDIE     DER    THERAPIE.        \'on      OSCAR      LlEB- 

REICH,  Dr.  Med.,  Geheimer  Medicinalrath,  0.6.  Pro- 
fessor der  Heilmittellehre  an  der  Friedrich-\Vilhelms-L"ni- 
versitat.  unter  Mitwirkung  von  Martin  Mendelsohn. 
Dr.  Med.,  Privatdocent  der  inneren  Medicin  an  der 
Friedrich-Wilhelms-Universitat,  und  Arthur  \Vurz- 
BURG.  Dr.  Med.,  Kgl.  Sanitatsrath,  Bibliothekar  im 
Kaiserlichen  Gesundheitsamte.  I.  Band.  2  Abtheilung, 
und  II.  Band,  i  Abtheilung.  Berlin:  August  Hirschwald. 
1896  and  1897. 

This  first  number  of  the  second  volume  of  this  latest  and 
best  of  the  German  works  on  therapeutics  contains  the  titles 
from  Diaphoretica  to  Flaschenbouillon,  and  embraces  a  con- 
sideration of  such  important  subjects  as  digitalis,  diphtheria, 
diuretics,  dyspnoea,  iron,  eclampsia,  suppuration,  electro- 
therapeutics, empyema,  endocarditis,  epilepsy,  euthanasia, 
obesity,  and  fever.  The  second  number  of  volume  one  was 
delayed  in  transmission  and  was  consequently  not  reviewed 
in  its  proper  place.  It  is  of  the  same  general  excellence  as 
the  other  parts  of  the  series.  It  contains  the  titles  from  Auge 
to  Cera,  including  eyes,  autointoxications,  baths  and  balneo- 
therapy, bacilli  and  bacteria,  professional  neuroses,  lead-poi- 
soning, blindness,  blood  and  blood-poisoning,  gastro-enteritis, 
bronchitis,  broncho-pneumonia,  bubo,  carbuncle,  carcinoma, 
cataract,  and  many  others.  The  articles  are  excellent  of 
their  kind,  concise  but  complete,  and  of  just  the  sort  that  a 
busy  man  wants. 

.V  System  of  Medicine.  By  Many  Writers.  Edited  by 
Tho.mas  Clifford  Allbutt,  M.A.,  M.D.,  LL.D.. 
F.R.C.P.,  F.R.S.,  F.L..S.,  F.S.A.,  Regius  Professor  of 
Physic  in  the  University  of  Cambridge,  Fellow  of  Gon- 
ville  and  Caius  College.  Volume  III.  New  York:  The 
Macmillan  Company.      1897. 

We  call  this  the  third  volume  because  the  title-page  says  it  is. 
but  the  editor  and  publishers  are  apparently  unable  to  make 
up  their  minds  as  to  its  proper  place  in  the  series.  The  cover 
says  3,  the  title-page  says  3,  the  editor  in  his  preface  calls  it 
2,  and  on  the  last  page  is  printed  "  end  of  \'o\.  II."  This 
does  not  inspire  one  at  first  glance  with  confidence  in  the  sys- 
tematic arrangement  of  the  work  as  a  whole,  and  neither 
does  the  fact  that  it  has  been  found  neces.sar)'  to  insert  sev- 
eral addenda  to  articles  in  this  and  preceding  volumes.  The 
editor  unfortunately  placed  the  infectious  diseases  in  the  early 
volumes  of  the  series,  with  the  inevitable  result  that,  before 
the  last  volume  is  issued,  the  first  will  be  relegated  to  medi- 
cal histor)-.  In  these  days  of  rapid  advances  in  the  science  of 
bacteriology  such  an  arrangement  is  regrettable.  The  issue 
of  this  volume  was  delayed  in  order  to  profit  by  the  report  of 
the  British  commission  on  vaccination.  The  report  itself 
was  scarcely  worth  waiting  for,  but  it  is  a  pity  the  book  was  not 
delayed  a  little  longer  to  enable  the  writer  on  yellow  fever  to 
profit  by  Sanarelli's  discovery  of  the  bacillus  icteroides.  It 
is  hardly  fair,  we  admit,  to  criticise  a  single  volume  in  a 
series,  since  apparent  omissions  may  be  repaired  by  articles 
in  later  volumes,  but  we  cannot  understand  why  the  section 
on   "infective  diseases  of   chronic  course"   should    include 


only  tuberculosis,  leprosy,  actinomycosis,  and  Madura  foot. 
Tuberculosis  fills  less  than  forty  pages  and  the  section  on  its 
treatment  just  seven  lines,  no  mention  whatever  being  made 
of  the  labors  of  Koch  and  others  in  this  direction,  unless  we 
accept  as  such  the  statement  that  "  there  is  no  specific  treat- 
ment for  tuberculosis."  In  the  article  on  leprosy,  also,  the 
work  of  Carrasquilla,  of  Bogota,  is  completely  ignored.  The 
writer  of  the  article.  Dr.  Abraham,  admits  the  possibihty  of 
contagion,  but  evidently  regards  it  as  a  minor  factor  in  the 
spread  of  the  disease.  The  author  of  the  paper  on  typhus 
fever  says  that  the  disease  is  hardly  known  in  the  tropical 
and  subtropical  parts  of  North  and  South  America ;  a  trip  to 
Mexico  would  con\'ince  him  of  his  error.  The  article  on 
malaria  is  by  Dr.  Osier,  of  Baltimore.  It  is  a  disappointingly 
brief  and  superficial  sketch,  unworthy  of  the  author.  Surely 
malaria  is  as  important  a  subject  as  rabies  or  anthrax,  yet 
in  this  work  the  editor  has  allotted  to  the  latter  twenty-four 
and  twenty-eight  pages  respectively,  while  malaria  is  tossed 
off  in  twenty-two  pages. 

Reference  Book  of  Pr.a.ctical  Therapeutics.  By 
Various  Authors.  Edited  by  Frank  P.  Foster,  M.D., 
Editor  of  the  New  ^"ork  Medical  Journal  3S^^  of  Foster's 
Encyclopaedic  Medical  Dictionary.  Volume  II.  New 
York:  D.  Appleton  and  Company.      1897. 

With  the  second  volume  this  excellent  work  is  completed 
and  is  rendered  immediately  available  by  means  of  the  gen- 
eral index  and  index  of  diseases  and  remedies  as  a  book  of 
therapeutic  reference.  .A  supplement  of  nearly  fifty  pages 
bears  witness  to  the  rapid  strides  in  medical  science,  since  it 
is  filled  chiefly  with  matter  relating  to  knowledge  acquired 
since  the  appearance  of  the  first  volume.  The  work  is  well 
printed  and  well  bound,  and  the  brief  articles  on  every  sub- 
ject relating  to  the  treatment  of  disease  are  excellently  WTit- 
ten  and  in  the  main  satisfactory  as  to  the  information  they 
impart. 

Suppression  and  Prevention  of  Leprosy.  By  Al- 
bert S.  Ashmead,  M.D.,  Late  Foreign  Medical  Direc- 
tor. Tokyo  Hospital,  Japan.  Xorristown,  Pa.  :  Herald 
Printing  and  Binding  Rooms.      1897. 

This  is  a  reprint  of  a  number  of  letters  and  of  essays  by  the 
author  on  subjects  connected  with  the  suppression  of  leprosy. 
The  author,  who  at  first  opposed  strenuously  the  proposed 
leprosy  congress  at  Berlin,  now  gives  his  adherence  to  it. 
Dr.  Ashniead's  belief  is  that  Hansen's  discover)-  of  the  lep- 
rosy bacillus  has  been  of  no  use  and  can  be  of  no  use  to  the 
leper,  that  leprosy  is  absolutely  incurable,  and  that  the  only 
safety  for  the  well  is  to  isolate  all  lepers  strictly.  Conse- 
quently the  proposed  leprosy  congress  will  be  worse  than  use- 
less if  it  discusses  annhing  but  isolation.  This  shows  that 
Dr.  .Ashmead  has  firm  convictions,  but  it  can  scarcely  be 
accepted  as  a  specimen  of  scientific  reasoning. 

Eve  Strain  in  Health  and  Disease.  With  Special 
Reference  to  the  Amelioration  or  Cure  of  Chronic  Nervous 
Derangements  without  the  .A.id  of  Drugs.  By  Ambrose 
L.  Rannev,  A.m.,  M.D.,  .Author  of  "  Lectures  on  Ner- 
vous Diseases,"  "The  .Applied  Anatomy  of  the  Ner\-ous 
System,  "  etc. ;  Late  Professor  of  Ner\'ous  Diseases  in  the 
^Iedical  Department  of  the  L'niversity  of  \'ermont  and  of 
the  .Anatomy  of  the  Ner\-ous  System  in  the  New  York 
Post-Graduate  Medical  School,  etc.  Illustrated  with  38 
Woodcuts.  Philadelphia:  The  F.  A.  Davis  Company. 
1897. 

This  is  an  interesting  book,  for  it  deals  with  the  marvellous, 
which  always  makes  entertaining  reading.  For  example :  A 
man  had  failed  mentally  to  such  a  degree  that  he  had  to  be 
told  what  clothes  to  put  on.  would  chew  a  bolus  of  food  for 
an  hour  unless  told  to  swallow  it,  was  absolutely  unable  to 
do  any  work,  and  had  suffered  for  six  months  terribly  from 
insomnia.  He  had  four  degrees  of  hj-perphoria.  This  was 
corrected  by  a  graduated  tenotomy  of  the  left  superior  rec- 
tus. "The  night  following  the  operation  he  slept  soundly 
all  night.  He  arose  the  next  morning,  dressed  himself 
without  aid,  and  drank  three  goblets  of  milk  before  the  rest 
of  the  family  were  up.  He  then  sat  down  and  ate  a  good 
breakfast,  finishing  as  quickly  as  any  one."  Numerous  other 
instances  are  reported  of  cures,  by  correcting  %isual  defects, 
of  melancholia  with  delusions  or  .suicidal  impulses,  insomnia, 
and  ner\ous  prostration  of  many  years'  standing.     The  book 


424 


MEDICAL    RKCORD. 


[September  i8,  1897 


deals  with  the  influence  of  eye  strain  in  the  causation  of  head- 
ache and  neuralgia,  chorea,  insomnia,  chronic  gastric  and  di- 
gestixe  disturban'-es,  epilepsy,  ntr\ous  prostration,  and  in- 
sanity, as  well  as  of  variotis  other  affections  of  the  eye  itself. 
Dr.  Ranney  is  an  earnest  believer  in  his  theory',  and  the 
many  facts  he  cites  afford  stronif  evidence  in  favor  of  it,  even 
after  we  eliminate  the  chance  of  coincidence  and  the  possible 
effect  of  "suggestion."  Tlio.se  who  are  inclined  to  absolute 
incredulity  must  be  reminded  of  the  common  experience  that 
some  patients,  said  to  be  suffering  from  eye  headache,  have 
really  been  relieved  by  proper  glasses,  and  we  cannot  reject 
on  the  mere  argument  of  improbability  evidence  such  as  that 
furnished  in  abundance  by  Dr.  Ranney.  At  least,  before 
condemning  the  author  the  sceptic  should  in  fairness  read 
his  book. 

The  V'ertebr.^ie  SKELKtoN.  By  Sii>.\ev  H.  Rev- 
.\oi,DS,  M.A.,  Trinity  College,  Cambridge;  Lecturer  and 
Demonstrator  in  Geolog)-  and  Zoology  at  University  Col- 
lege, Bristol.    Cambridge:  At  the  University  Press.     1897. 

Thol'GH  the  title  does  not  suggest  it,  an  account  is  included 
of  the  skeleton  of  the  lowest  Chordata ;  the  description  of  the 
general  characters  of  each  gi'oup  is  first  given,  and  then  of 
the  subdivisions.  A  large  field  has  been  covered  without 
extending  the  work  beyond  the  limits  of  a  moderate-sized 
handbook. 

The  drawings,  which  are  numerous,  aie  original  or  from 
photographs  by  the  author  and  his  sister.  There  is  a  very 
full  index. 

The  volume  is  one  of  the  Cambridge  Natural  Science  Man- 
uals. The  author  is  to  be  congratulated  on  the  completion 
of  an  arduous  and  praiseworthy  task  in  a  \ery  successful 
manner. 

Fads  ok  .-vx  Old  Phvsici.a.n:  A  Sequel  to  "Ple.a 
FOR  A  Simpler  Life."  Bv  George  S.  Keith,  M. D.. 
LL.D.,  F.R.C.P.K.     London:  .Adam  &  Charles   Black. 


Thi.s  is,  as  the  title  indicates,  a  sequel  to  the  author's  "  I'lea 
for  a  Simpler  Life,"  noticed  in  the  Medic.m.  Record  some 
time  ago.  X'arious  matters  of  general  and  professional  in- 
terest are  treated  in  a  pleasing  manner.  Many  views  ad- 
vanced may  be  regarded  as  fads — hence  the  title.  Star\-ing. 
stimulants,  relief  of  pain  and  sleeplessness,  cancer,  self-mas- 
sage, and  methods  of  preser\ing  health,  are  some  of  the  topics 
worth  reading. 

The  Liver  of  Dyspeptics,  and  Particllari.v  the 
Cirrhosis  Produced  kv  Auto-Intoxicaitox  of 
Gastro-Ixtestinal  Orh;ix  (Clixical,  Axatomo- 
Pathological,  Pathogenic,  axd  Experi.mextai. 
Study;.  By  Dr.  Emilk  Boix,  Interne  Laureat  des  H6- 
pltaux  de  Paris :  Medaille  d'Or,  Concours  de  1 893  ;  Me- 
daille  d'Or  des  Epidemics  (Cholera.  1884).  .Authorized 
Translation,  from  the  Latest  French  Edition,  by  Paul 
Richard  Browx,  M.D.,  .Major  and  Surgeon,  L'nited 
States  .Anny.  New  York  and  London :  G.  V.  Putnam's 
.Sons.  The  Knickerbocker  I'ress.      1897. 

The  work  was  well  worth  the  translation,  and  Dr.  Brown 
has  done  it  well.  Causes  of  cirrhosis  other  than  those  ref- 
erable to  alcohol  and  its  abuse  are  taken  up.  'I'he  term 
"  dyspeptic  cirrhosis  "  is  employed  as  a  handy  means  of  ex- 
pression. In  Part  III.  a  series  of  experiments  is  given, 
showing  the  influence  of  the  various  dyspepsias  in  the  eti- 
ology of  cirrhosis. 

VORI.ESUXGEX  iJBER  KrIEGSCHIRURGIK.  \'(in  1)K.  I.. 
LlHF.  Generalarzt  a.  D.       Berlin:     .August    IlirsclnvaUl. 


This  work  consists  of  twelve  lectures  on  military  surgery 
given  by  the  author  to  German  army  surgeons.  Operative 
technique  is  considered  only  in  so  far  as  it  differs  from  that 
of  civil  surgerj'.  The  first  part  of  the  work  is  devoted  to  a 
description  of  the  wounds  inflicted  by  modern  projectiles, 
based  chiefly  upon  the  experiments  conducted  by  the  Ger- 
man commission.  The  author  then  describes  the  duties  of 
the  surgeon  during  and  after  battle,  the  aseptic  and  antisep- 
tic methods  which  are  practicable  in  the  field,  and  the  nature 
of  the  surgical  treatment  which  is  demanded  on  the  firing- 
line,  at  the  first  dressing-station,  and  in  the  field  hospital. 
He  differs  from  most  authors  in  advising  that  wounds  li,-  not 


exposed  by  litter  bearers  for  the  application  of  dressings,  and 
that  provisional  splints  be  applied  over  the  clothing.  The 
author  is  remarkably  well  acquainted  with  the  work  of  Amer- 
ican surgeons  and  quotes  American  writers  more  frequently 
than  any  others  outside  of  Germany.  The  work  is  emi- 
nently practical,  and  contains  many  suggestions  which  will 
prove  of  value  to  the  army  surgeon. 


Jiociettj  Reports. 

TWELFTH     INTERNATIONAL     MEDICAL 
CONGRESS. 

AVif  i/i  Mosivii.',  August  ig,  20,  21,  22,  2J,  24.  2f  and 
26,  iSgj. 

(Special  Repurt  for  the  .Mkuhal  Recokii.) 

■SI-:CTIOX    IX    SURGERY. 

iContinued  from  page  396.) 

First  Day — Friday,  August  20th. 

The  Surgery  of  the  Lung. —  Dr.  Tuffier,  of  Paris, 
read  ;i  long  paper  on  surgery  of  the  lung,  particularly 
of  tuberculous  cavities  and  pulmonary  gangrene.  The 
paper  was  one  that  greatly  interested  those  present,  in 
spile  of  its  length,  nearly  two  hours  being  occupied  in 
its  delivery.  It  was  an  exposition  of  the  indications 
for  surgical  intervention  in  various  pulmonary  affec- 
tions, and  a  plea  for  the  more  general  resort  to  the  use 
of  the  knife  in  such  cases. 

Dr.  Macewen,  of  Glasgow,  agreed  in  the  main  with 
Dr.  Tutfier,  but  considered  that  certain  phases  of  the 
practical  side  of  the  question  and  certain  details  in 
technique  justified  some  additional  remarks.  The 
physics  of  the  pleural  cavity  were  still  not  entirely 
settled.  The  general  belief  was  that  the  opposing 
surfaces  of  the  pleurae  were  kept  in  apposition  by  at- 
mospheric pressure.  Personally  he  did  not  believe 
this  traditional  opinion,  but  considered  that  the  phe- 
nomenon was  best  explained  as  the  result  of  molecular 
adhesion.  WTien  two  perfectly  smooth  surfaces,  such 
as  two  pieces  of  polished  glass,  were  firmly  pressed 
together,  they  adhered.  The  same  happened  with  re- 
gard to  the  two  pleural  surfaces.  As  the  result  of 
this,  when  the  pleura  has  been  slightly  incised,  though 
the  atmospheric  pressure  has  been  relieved  of  its  in- 
fluence, parts  of  the  pleura  in  the  neighborhood  adhere 
and  give  rise  to  a  collection  of  air  in  the  pleural  cav- 
ity. This  soon  causes  symptoms  of  dyspncea.  Punc- 
ture relieves  it  for  the  time  being,  but  accumulation 
begins  again  and  reproduces  the  symptoms.  Further 
aspiration  has  only  the  same  result.  If  the  pleura 
be  freely  incised,  however,  these  adhesions  fail  to  take 
place,  and  the  accumulation  of  air  in  the  pleural  cav- 
ity, with  the  consequent  symptoms,  does  not  take 
place.  Hence  in  all  cases  of  operations  involving  the 
pleura,  free  incision  should  he  practised.  With  re- 
gard to  tuberculous  cavities,  personal  experience  had 
taught  him  the  following  methods  of  treatment  for  va- 
rying circumstances :  In  small  tuberculous  cavities  it 
was  sufficient  to  resect  three  or  four  ribs,  and  allow  the 
cavities  to  collapse.  Large  cavities  should  be  freely 
incised,  emptied,  and  drained.  Very  large  cavities 
should  be  thoroughly  scraped  and  packed  with  iodo- 
form gauze.  The  improvement  noted  after  such  pro- 
cedures was  often  immediate  and  striking.  The  gen- 
eral condition  improved,  and  diseased  foci  in  the  other 
lung  were  graduallv  shut  of!'.  Such  improvement  had 
even  been  obser\  ed  to  follow  in  cases  in  which  disin- 
tegration of  the  operated  lung  took  place. 

Dr.  Coromilas,  of  Calamata,  Greece,  read  a  paper 
dealing  especially  with  surgical  interference  with  tu- 
berculous cavities.  His  paper  was  a  repetition  of 
what   had   been   said   bv  Tuffier,  but   illustrated  how 


September  i8,  1897] 


MEDICAL    RECORD. 


425 


widespread  is  becoming  the  realization  that  surgical 
interference  in  pulmonary  affections,  even  in  extensive 
tuberculous  processes,  is  perfectly  justifiable. 

Dk.  1-"ai:rikaxt,  of  Kharkov,  spoke  of  radical  extir- 
pation of  diseased  localities  down  to  healthy  tissue, 
when  the  affection  is  not  too  far  advanced,  early  oper- 
ation after  careful  diagnosis  being  the  requirement  in 
lung  surgery. 

The  Diagnosis  of  Pleural  Adhesions.  —  Dk.  .S.\- 
PECHKO,  of  Kiev,  read  a  communication  uith  this  title. 
-Alter  pointing  out  the  difficulties  of  exact  diagnosis  in 
the  matter  with  our  present  methods,  he  described  his 
own  mechanical  process  for  their  diagnosis.  When 
operations  are  to  be  made  on  the  lungs  for  tuberculous 
cavities  or  abscess  or  gangrene,  it  is  important  to  have 
the  incision  at  a  point  of  adhesion.  The  speaker  in- 
serts as  far  as  the  pleura  a  cannida,  to  which  is  attached 
a  U-tube  manometer  containing  decinormal  physiolog- 
ical salt  solution.  Sinking  of  the  liquid  shows  the 
existence  of  negative  pressure;  hence  non-adherence 
of  the  pleura.  When  the  level  of  the  liquid  remains 
undisturbed,  adhesions  are  present.  Dr.  Sapechko  has 
never  lost  a  patient  from  infection  of  pleura  after 
using  this  method.  He  suggested  that  when  adhe- 
sions cannot  be  found  they  may  be  produced  by  the 
introduction  of  an  irritating  though  sterile  liquid. 
Experiments  in  tiiis  line  have  succeeded  in  animals, 
and  promise  to  lessen  greatly  the  dangers  of  surgical 
interference  in  the  lungs. 

Perityphlitis Dr.  Roux,  of  Lausanne,  read  a  pa- 
per with  this  title.  He  considered  that  not  enough 
importance  was  attached  in  Europe  to  the  surgical 
treatment  of  the  affection.  He  had  seen  a  great  many 
cases,  and  had  operated  in  a  number.  He  did  not 
consider  that  all  cases  presenting  symptoms  located  in 
the  right  iliac  fossa  should  be  operated  upon,  as  many 
of  his  American  colleagues  seemed  to  think,  but  he 
considered  the  affection  properly  a  surgical  one.  Such 
opinions  as  that  of  Leyden,  of  Berlin,  that  practically 
all  cases  of  appendicitis  got  well  in  time  and  that  the 
fulminant  ca.ses  were  fatal  anyhow  even  under  surgical 
treatment,  he  could  not  consent  to.  He  believed  that 
death  took  place  from  peritonitis  after  secondary  per- 
foration, and  he  thought  the  patient  should  not  be 
moved  at  all,  especially  not  for  a  disturbing  ride  to  a 
hospital.  The  abscess  became  frankly  localized  in 
from  five  to  seven  days,  and  then  could  be  opened  from 
the  flank,  the  rectum,  or  the  vagina.  Ijne  must  always 
remember  that  there  is  a  meso-appendical  form  of  ab- 
scess, in  which  the  pus  is  located  behind  a  fold  of  peri- 
toneum. In  ojjening,  the  operator  may  come  upon  the 
serous  or  seropurulent  exudate,  which  is  always  found 
in  the  peritoneum,  due  to  the  presence  of  the  infiam- 
niatory  process,  and  erroneously  think  that  he  has 
opened  the  abscess.  This  form  resembles  a  general- 
ized peritonitis,  but  if  one  waits  for  a  few  days  local- 
ization takes  place  fully  and  the  case  is  easy  of  treat- 
ment. To  operate  during  the  first  period  in  such  cases 
means  the  death  of  the  patient.  The  speaker  believed 
in  expectant  treatment  until  firm  inflammatory  adhe- 
sions have  walled  off  the  exudate.  He  did  not  agree 
with  American  surgeons,  who  thought  we  could  operate 
soon  enough  as  to  suppress  the  appendicitis :  this  would 
be  the  ideal  way,  but  could  be  put  into  practice  only 
during  the  first  few  hours  of  the  attack.  It  would  be 
realizable  only  if  all  our  patients  lived  in  hospitals. 
When  a  patient  has  had  e\en  one  attack.  Dr.  Roux 
would  advocate  the  removal  of  the  appendix  some  six 
or  eight  weeks  after  recovery,  for  there  exists  no  other 
means  of  preventing  recurrences.  When  operating  in 
the  interval  he  always  separates  the  muscle  fibres  of 
the  belly  wall  in  the  direction  they  run,  in  order  to 
avoid  subsequent  hernia  or  eventration.  He  avoids 
thus  the  cutting  of  ner\-e  fibres,  which  have  a  trophic 
influence  on  the  muscle  fibres  and  keep  them  in  proper 


tone  to  retain  the  abdominal  viscera.  If  the  operation 
in  the  interval  between  attacks  is  difficult  of  perform- 
ance, it  is  a  sign  that  the  operator  has  not  waited  long 
enough,  for  it  should  be  extremely  easy. 

Relapsing  Appendicitis. — Dr."  Kl.mmel,  of  Ham- 
burg, read  a  paper  with  this  title,  which  was  a  review 
of  one  hundred  successful  resections  of  the  vermiform 
appendix.  In  addition  to  his  own  cases,  the  speaker 
had  collected  the  statistics  of  a  nearly  equal  number 
of  cases  of  relapsing  appendicitis,  in  which  the  opera- 
tion had  been  refused.  In  these  cases  the  mortality 
after  three  years  was  greater  than  in  the  operated 
cases,  while  the  morbidity  consequent  upon  the  recur- 
ring attacks  made  the  second  series  of  cases  incom- 
parably worse. 

Dr.  Soxnenbekg,  of  Berlin,  reported  two  hundred 
and  fifty  operative  cases  of  appendicitis,  exclusive  of 
several  of  tuberculous  disease  of  the  appendix.  There 
were  sixty-six  cases  of  simple  appendicitis,  one  hun- 
dred and  fifty-six  of  perforative  appendicitis,  and 
twenty-eight  of  gangrenous  appendicitis.  In  the  two 
hundred  and  fifty  cases  there  were  forty-three  deaths. 
This  mortality  of  seventeen  per  cent,  represents  the 
mortality  of  the  disease,  not  of  the  attacks,  while  sta- 
tistics so  far  have  been  mainly  concerned  with  the 
mortality  of  the  attacks.  The  forty-three  deaths  were 
encountered  in  cases  of  perforative  appendicitis  with 
complications  (_as  lung  and  pleural  affections,  throm- 
boses, peritonitis,  etc.)  and  in  cases  of  gangrenous 
appendicitis.  The  operated  cases  of  simple  appendi- 
citis and  of  simple  perforative  appendicitis  gave  no 
deaths.  It  is  to  the  surgeons,  he  said,  that  we  owe 
our  knowledge  of  diseased  conditions  of  the  appendix. 
The  most  interesting  thing  in  the  process  is  the  ten- 
dency ver)-  often  for  im|x>rtant  pathological  changes 
to  go  on  for  a  long  time  w  ithout  noticeable  symptoms. 
These  so-called  latent  cases  manifest  themselves  first 
in  a  stormy  attack  with  severe  clinical  symptoms,  usu- 
ally caused  directly  by  perforation  of  the  appendix. 
This  perforation  is,  however,  only  the  last  link  in  the 
chain  of  recurring  patliological  changes  in  the  chron- 
ically affected  appendix.  In  sixty  per  cent,  of  seem- 
ingly first  attacks  of  appendicitis  perforativa  without 
complications  operated  upon,  extensive  pathological 
changes  that  had  evidently  been  going  on  for  a  long 
time  were  found  in  the  appendix.  The  same  state  of 
affairs  was  recognized  in  seventv-four  per  cent,  of  the 
cases  of  perforative  appendicitis  with  complications, 
and  in  practically  all  the  cases  of  gangrenous  appen- 
dicitis. Of  these  one  hundred  and  twenty-four  pa- 
tients, only  seventeen  had  had  any  symptoms  before 
their  attack.  It  is  impossible  to  imagine,  however, 
that  such  cases  should  be  absolutely  symptomless,  so 
that  it  is  our  duty  to  pick  out  the  syniptoms.  It  is 
wonderful,  the  speaker  said,  to  see  how  seemingly  dis- 
connected with  the  appendix  the  symptoms  may  seem 
to  be  which  point  to  the  insidious  development  of 
pathological  changes  in  the  appendix.  (Jreat  success 
in  the  treatment  of  appendicitis  awaits  the  success  of 
our  efforts  in  this  direction.  .\s  to  the  question 
whether  the  appendix  should  be  searched  for  and  re- 
moved. Dr.  .Sonnenberg  believed  that  this  should  be 
done  in  all  cases  in  which  it  does  not  endanger  the 
patient's  life.  It  was  his  general  rule  to  leave  the 
appendi.x  in  situ  only  when  there  was  danger  of  break- 
ing up  the  adhesions  that  protect  the  general  }x;ritoneal 
cavity,  or  when  there  was  danger  of  injuring  the  ca;cum 
and  so  causing  subsequent  perforation,  or  when  it 
seemed  probable  that  in  the  process  of  healing  the 
apjDendix  would  be  completely  absorbed  with  the  ex- 
udate. While  in  most  other  conditions  where  medi- 
cine and  surgery  touch  the  domain  of  the  surgeon  has 
been  narrowed,  here  it  has  been  widened,  and  the 
sooner  we  recognize  that  it  is  often  properly  a  surgical, 
not  a  medical  condition,  the  better,      in  simple  appen- 


426 


MEDICAL    RECORD. 


[September  i8,  1897 


dicitis  it  is  in  the  interval  bet%veen  the  attacks  that 
the  operation  should  be  done,  and  this  is  extremely 
advisable  whenever  there  has  been  a  frank  attack. 
Out  of  sixty  cases  of  simple  apjsendicitis,  Dr.  Sonnen- 
berg  had  operated  only  twenty-four  times  during  the 
attack. 

The  Indications  for  the  Lumbo-Sacral  Incision  in 
Suppurative  Appendicitis.  —  Dr.  Grinda,  of  Nice, 
read  a  paper  setting  forth  the  indications  and  advan- 
tages in  the  operative  treatment  of  suppurative  appen- 
dicitis of  an  incision  following  the  external  border  of 
the  sacro-lumbar  mass  of  muscles,  curving  in  at  the 
lower  part,  prolonged  parallel  to  and  one  finger's 
breadth  above  the  iliac  crest  to  about  three  centime- 
tres from  the  anterior  superior  iliac  spine.  This  lumbo- 
iliac  incision  is  indicated  in  all  cases  in  which  the 
local  signs  permit  the  diagnosis  of  appendicular  ab- 
scess, especially  in  the  cases  in  which  there  is  pain  in 
Petit's  triangle  and  in  which  McBurney's  point  is  little 
if  at  all  tender,  ^\"ith  this  incision  better  drainage  is 
secured,  there  is  less  danger  of  wounding  the  small 
intestines  which  so  often  lie  adherent  above  the  in- 
flammatory exudate  around  the  appendix,  there  is  less 
danger  of  infection  of  the  general  peritoneum,  and  it 
is  also  much  easier  to  get  at  the  appendix  itself  for  a 
radical  operation.  Especially  is  this  incision  to  be 
commended  when  the  general  symptoms  indicate  ap- 
pendicitis and  nothing  points  to  a  special  localization 
of  the  suppurative  process. 

Dr.  Le  Dentu,  of  Paris,  agreed  with  Dr.  Roux  as 
to  the  necessity  for  waiting  until  the  process  had  thor- 
oughly localized  itself.  He  counselled  especially  the 
operation  in  the  inter\al  between  attacks.  He  did  not 
think  that  the  surgeon  should  spring  upon  the  patient 
at  the  first  sign  of  trouble  with  the  appendix.  Sudden 
perforation  with  general  peritonitis  or  fulminant  gan- 
grene of  the  appendix  was  too  rare  to  influence  the 
general  rule  of  action  in  the  matter. 

Dr.  Lavista,  of  Mexico,  thought  that  the  American 
surgeons  as  a  rule  were  sufficiently  conservative. 
They,  too,  counselled  the  operation  ii  froiti  in  relaps- 
ing cases  of  simple  appendicitis.  .Acute  cases  must, 
however,  be  watched  with  extreme  care,  as  the  patient's 
danger  is  always  great  and  the  surgeon  must  be  ever 
prepared  to  operate. 

The  Chairman  said  that  Dr.  Senn.  of  Chicago,  had 
asked  to  be  excused,  so  that  the  section  would  unfor- 
tunately not  have  the  pleasure  of  listening  to  his  paper 
on  ■■  Tile  Uses  of  the  Omentum  in  Surgery."  The 
paper  was  therefore  read  by  title. 

Treatment  of  Intestinal  Occlusion. — Dr.  .\.  vo.v 
EiSEi.sKERi;,  of  Konigsberg,  read  a  paper  on  the  treat- 
ment of  inoperable  stricture  of  the  intestinal  canal 
and  of  faecal  fistula  by  the  complete  shutting  off  of  the 
affected  portion  of  the  intestine.  In  carcinomatous 
strictures  the  operation  gives  complete  relief  from  pain 
and  the  painful  sense  of  pressure  that  so  often  char- 
acterizes these  cases.  In  fa-cal  fistula  after  appendi- 
citis, when  the  usual  methods  for  the  closure  of  the 
fistula  have  failed,  the  shutting  off  of  the  chronically 
inflamed  portion  of  intestine  and  the  bringing  together 
of  two  healthy  portions  are  indicated. 

Dr.  R.  von  Haracz,  of  Lemberg,  read  a  paper  on 
the  same  subject.  In  a  report  of  .seven  experiments 
which  he  had  made  on  dogs,  the  speaker  brought  out 
the  dangers  of  leaving  tlie  shut-off  portion  of  intestine 
in  such  cases  unoccluded,  and  demonstrated,  by  means 
of  specimens  taken  from  the  operated  animals,  the 
liability  to  serious  consequences  of  such  a  course. 

.V  paper  by  Dr.  Dovkn,  of  Paris,  "On  the  Surgery 
of  the  Stomach,"  was  read  by  title. 

Intestinal  Anastomosis. — Dr.  Martin  v  Gil,  of 
Malaga,  presented  a  communication  on  discs  of  ivory 
deprived  of  their  lime  salts  as  a  mechanical  help  for 
intestinal  anastomosis.     He  exhibited  the  discs  and 


explained  their  advantages  in  the  matter  of  flexibility 
and  absorbability. 

Dr.  Frank,  of  Chicago,  then  presented  a  paper  on 
his  new  absorbable  intestinal  coupler. 

Sarcoma  of  the  Omentum. — Dr.  Dje.mil  Pasha,  of 
Constantinople,  reported  a  case  of  sarcoma  of  the  great 
omentum  and  of  the  transverse  colon,  the  consequence 
of  a  silk  suture  left  in  the  stump  of  the  epiploon  dur- 
ing the  course  of  an  operation  for  the  radical  cure  of 
inguinal  hernia.  The  operation  wound  closed  by  first 
intention  and  the  patient  left  the  clinic  the  eleventh 
day  after  the  operation,  perfectly  cured.  Two  months 
later  he  began  to  have  intestinal  symptoms,  some  di- 
gestive troubles,  and  pains  around  the  umbilicus. 
The  symptoms  of  occlusion  of  the  intestine  super- 
vened, and  at  the  laparotomy  a  tumor  was  removed, 
which  was  found  on  microscopical  examination  to  be 
a  sarcoma.  This  was  the  second  time  in  his  practice 
that  the  speaker  had  seen  a  nimor  develop  when  a 
silk  ligature  had  been  left  in  the  tissues.  He  thought 
that  while  the  development  of  the  tumor  might  be  due 
to  the  accumulated  irritation  of  the  presence  of  the 
foreign  body  on  tissues  predispwsed  to  the  embryonal 
overgrowth,  it  was  much  more  probable  that  the  sar- 
coma was  due  to  the  presence  of  a  micro-organism  and 
that  the  sterilization  of  the  silk  even  at  a  temperature 
of  140^  C.  was  not  complete.  The  microbe  of  sarcoma 
resists  the  sterilizing  process,  and  afterward  excites 
neoplastic  formation. 

Splenectomy Dr.  Thomas  Joannescu,  of  Bucha- 
rest, read  a  paper  on  this  subject.  He  reported  the 
removal  of  the  spleen  twelve  times — eleven  times  for 
ague  cake,  once  for  hydatid  cysts.  He  had  never  found 
that  any  disadvantages  accrued  from  such  removal, 
but  said  that,  on  the  contrary,  the  patient's  general 
condition  improves  almost  immediately.  There  is  an 
almost  immediate  increase  in  the  number  of  red  blood 
corpuscles,  sometimes  preceded  by  a  short  interval  of 
diminution.  The  malarial  cachexia  becomes  less 
marked,  probably  owing  to  the  fact  that,  as  Laveran 
has  shown,  the  spleen  is  the  favorite  haunt  of  the  ma- 
larial organism  and  that  it  is  from  there  that  it  sallies 
from  time  to  time,  and  that  this  source  of  constant  re- 
infection is  removed.  The  speaker  stated  also  that 
the  urotoxic  coefficient  is  lessened  after  the  removal  of 
the  spleen  to  a  distinctly  noticeable  degree,  and  he  re- 
garded the  law  of  urinary  hypotoxicity  as  established 
for  asplenic  subjects,  whether  the  spleen  has  been 
surgically  removed  or  its  function  has  been  lessened 
by  disease  and  degeneration.  Neither  the  size  of  the 
spleen  nor  the  age  of  the  subject  constitutes  a  contra- 
indication to  splenectomy.  Dr.  Joannescu  regarded 
the  inefficacy  of  medical  treatment  continued  for  a 
long  time  as  an  all-sufiicient  indication  for  splenec- 
tomy. When  to  this  are  added  pain,  discomfort,  and 
commencing  malarial  cachexia,  then  the  indications 
are  absolute.  In  all  cases  the  operation  is  followed 
by  immediate  improvement  in  the  general  condition. 
In  fifteen  cases  of  splenectomy  there  were  three  deaths, 
a  mortality  of  15.+  per  cent. 


Second  Day — Saturday.  Aii,^ust  jrsf. 

Cancerous  Strictures  of  the  Digestive  Tract. — 
Dr.  Czernv,  of  Heidelberg,  read  a  paper  entitled 
"Therapy  of  Carcinomatous  Strictures  of  the  CEsoph- 
agus.  Pylorus,  and  Rectum,  with  the  Success  of  Va- 
rious Methods  of  Treatment."  He  considered  cancer 
of  the  itsophagus  above  the  tliorax  perfectly  amenable 
to  surgical  treatment,  either  radical  or  palliative,  ac- 
cording to  the  extent  of  tissue  involvement.  As  to 
intrathoracic  cesophageal  cancer,  the  question  was 
very  diflerent.  .Attempts  at  removal  were  so  danger- 
ous that  he  considered  the  operation  almost  unjustifia- 
ble,   although   by   the    posterior  route    the  operation 


September  i8,  1897] 


MEDICAL    RECORD. 


427 


might  be  feasible.  Tlie  improvement  of  its  technique 
is  one  of  the  problems  for  younger  surgeons  to  solve. 
Dilatation  of  strictures  by  means  of  bougies  is  of  the 
greatest  use  in  cases  in  which  nutrition  is  interfered 
with  by  the  impossibility  of  swallowing.  He  had 
seen  a  case  go  on  for  years  under  the  use  of  bougies, 
when  the  malignant  growth  was  not  rapid,  that  would 
have  been  fatal  from  inanition  without  them.  The 
oesophageal  somie  ,7  dcmcurc  might  have  its  indications; 
the  speaker  had  had  no  experience  with  it.  When  meth- 
ods of  dilatation  fail  to  make  alimentation  possible  in 
the  ordinary  way,  he  considered  gastrostomy  a  legiti- 
mate resource.  The  making  of  a  valvular  opening  by 
which  the  muscles  of  the  abdominal  wall  are  used  to 
form  a  sort  of  sphincter  is  especially  commendable. 
In  cases  of  cancer  of  the  pylorus,  the  main  difficulty 
is  one  of  early  and  positive  diagnosis.  It  is  only 
when  all  the  classical  symptoms  are  present  that  the 
surgeon  is  justified  in  operating.  There  are  many  sur- 
geons who  can  report  patients  living  from  four  to  si.x 
years  after  the  resection  of  the  pylorus  for  cancerous 
infiltration.  When  resection  is  not  possible,  owing  to 
the  size  of  the  tumor,  or  when  the  contraindication  of 
enlarged  glands  or  adhesions  of  the  pancreas  e.xists, 
then  gastro-enterostomy  is  our  only  resource.  It  spares 
the  patient,  restores  his  digestive  functions,  and 
lengthens  his  life  by  decreasing  the  irritation  of  the 
cancerous  mass.  For  gastro-enterostomy  the  Murphy 
button  is  e.xtremely  commendable.  The  speaker  had 
himself  used  it  in  fifty-six  cases.  It  very  materially 
shortens  the  time  of  operation,  which  is  an  important 
item  for  the  run-down,  poorly  nourished  patients  who 
come  for  such  operations;  it  thus  shortens  the  time  of 
anaesthesia — another  important  item;  it  is  just  as  sure 
when  carefully  and  properly  employed  as  the  most 
complicated  suture  method,  and  it  enables  us  to  feed 
the  patient  sooner  and  with  less  risk  after  the  opera- 
tion than  by  any  suture  method.  Besides  this,  there 
seems  to  be  less  tendency  to  stricture  after  the  use  of 
the  button  than  with  suture  methods.  Professor  Czerny 
had  noted  tliis  himself  in  two  patients  on  whom  the 
operation  had  been  done  three  years  before  death. 
Tlie  treatment  of  rectal  carcinoma  is  extremely  encour- 
aging, and  is  growing  more  and  more  so  as  our  meth- 
ods of  diagnosis  and  operation  improve.  The  speaker 
had  one  patient  alive  twelve  years  after  an  operation 
for  rectal  carcinoma,  and  another  seven  years  after. 
Many  reports  of  cured  cases  of  rectal  cancer  are  being 
made.  A  recent  set  of  statistics  has  given  the  recur- 
rences as  about  sixtv  per  cent.,  but  rectal  carcinoma 
recurs  sometimes  very  late.  Czerny  had  known  of  two 
cases  in  which  the  recurrence  had  taken  place  more 
than  twelve  years  and  eight  years  respectively  after 
operation,  so  that  it  is  hard  to  say  of  how  much  real 
value  statistics  of  cures  may  be.  When  rectal  carci- 
noma is  inoperable,  then  the  formation  of  an  artificial 
anus  becomes  the  surgeon's  duty,  as  in  the  correspond- 
ing ca.se  of  the  pylorus.  It  saves  the  patient  pain, 
helps  his  general  nutrition,  removes  irritation  of  can- 
cerous elements,  and  so  lengthens  the  patient's  life. 

Dk.  Ckccherki.i.i,  of  Parma,  read  a  paper  on  the 
same  subject.  In  cases  of  stricture  of  the  oesophageal 
Oldening,  he  employed  a  special  method,  which  fulfils 
the  three  important  conditions  of  giving  support  to  the 
stomach,  making  a  valve  for  the  opening,  and  forming 
this  opening  at  a  distance  from  the  pyloric  end.  For 
pyloric  strictures  he  believes  that  pyloroplasty  is  in- 
dicated when  there  exists  a  fibrous  ring.  In  ulcers  of 
the  stomach  gastro-enterostomy  is  useful  and  is  more 
definitely  indicated  than  resection,  except  in  cases  in 
which  the  ulcer  is  surely  single  and  does  not  extend 
into  the  pylorus.  He  had  made  a  special  study  of 
what  are  called  syphilitic  strictures  of  the  rectum,  and 
had  shown  histologically  that  syphilis  is  the  original 
cause,  but  that  an  ordinar}-  clironic  inflammatory  proc- 


ess supervenes  and  constitutes  the  morbid  after-con- 
dition. On  this,  of  course,  syphilitic  treatment  has 
no  effect,  and  the  stricture  must  be  dilated  or  treated 
radically  with  the  knife. 

Local  Anaesthesia  in  Abdominal  Operations. — 
Dr.  I.  F.  Van  Iterson,  of  Leyden,  followed  with  a 
communication  on  the  same  subject.  The  main  fea- 
ture of  his  paper  was  the  fact  that  all  of  the  speaker's 
intestinal  operations  were  accomplished  without  gen- 
eral anaesthesia.  Of  these  there  were  sixteen  gastros- 
tomies, twenty  gastro-enterostomies,  two  resections  of 
the  pylorus  (one  patient  still  living  and  well  sixteen 
months  after  the  operation),  one  jejunostomy,  and  ten 
colostomies.  His  plan  is  to  inject  two  syringefuls  of 
one-per-cent.  solution  of  cocaine  into  the  abdominal 
wall;  this  makes  the  external  incision  painless. 
Manipulation  of  the  intestine  causes  no  complaint  on 
the  part  of  the  patient,  unless  the  mesentery  is  pulled 
on.  -The  stitches  can  be  inserted  into  the  abdominal 
walls  after  the  operation  without  causing  much  pain, 
thanks  to  the  persistent  effect  of  the  cocaine  injections. 
The  advantages  of  the  method  are  that  the  exhausting 
effect  of  the  long  anaesthesia  on  patients  who  are 
already  weakened  by  inanition  is  avoided.  Besides, 
the  giving  of  food  may  be  begun  at  once.  While  the 
patients  are  still  on  the  table.  Dr.  Iterson  begins  to 
give  small  quantities  of  milk,  and  this  is  continued 
every  half-hour  afterward.  Another  feature  of  this 
paper  was  the  statement  that  the  author  usually  has 
his  patients  sit  up  during  the  convalescence  after  the 
operation,  and  has  their  position  frequently  changed. 
He  thus  avoids  the  hypostatic  pneumonias  that  so 
often  carry  off  weakened  patients  after  serious  opera- 
tions. Neither  the  operating  without  general  anaes- 
thesia nor  the  changes  of  position  afterward  are  un- 
grateful to  the  patients,  who  seem  very  well  satisfied 
with  the  methods  employed. 

Dr.  Sematzky,  of  St.  Petersburg,  in  a  paper  on  the 
methods  of  gastro-enterostomy  in  strictures  of  the  py- 
lorus, said  that  in  the  ordinary  method  of  making  gas- 
tro-enterostomies the  bile  and  pancreatic  fluid  would 
be  conducted  into  the  stomach  and  inevitably  lead  to 
nausea  and  vomiting.  This  was  a  great  defect  in  the 
present  methods.  After  a  series  of  experiments  on 
dogs,  he  had  devised  a  method  by  which  the  presence 
of  bile  in  the  stomach  may  be  avoided.  He  makes  a 
transverse  resection  of  the  lower  end  of  the  jejunum 
and  unites  the  lower  section  to  the  stomach;  the  upper 
part  is  joined  by  an  anastomosis  with  the  small  intes- 
tine, twelve  to  sixteen  centimetres  lower.  This  allows 
the  pancreatic  secretion  and  bile  to  find  their  way 
jjroperly  into  the  intestine,  but  not  into  the  stomach. 

The  Vaginal  Route  for  Rectal  Operations.—  Dr. 
HEiniiNREicH,  of  Nancy,  read  a  paper  on  "The  ^'agi- 
nal  Route  in  the  Resection  of  the  Rectum,"  in  which 
he  advocated  an  operation  through  the  posterior  vagi- 
nal wall  in  all  cases  of  carcinoma  of  the  rectum  in 
women.  The  operation  is  not  so  serious  or  so  bloody 
as  that  known  as  Kraske's.  In  the  case  of  smaller 
tumors  the  operation  commends  itself  by  its  extreme 
simplicity;  in  that  of  large  tumors  it  gives  the  most 
room  for  operation  :  and  when  tumors  are  situated  high 
up  in  the  rectum  it  enables  the  operator  to  get  at  them 
better  than  any  other  way.  The  external  sphincter  can 
be  easily  and  completely  preserved,  and  incontinence 
is  thereby  avoided. 

Treatment  of  Ischuria  following  Hypertrophy  of 
the  Prostate.  —  Dr.  Bottini,  of  Pavia,  in  a  paper  on 
this  .'>ubject,  demonstrated  his  new  method  of  dealing 
with  these  cases.  His  instrument  resembles  a  litho- 
trite.  The  movable  parts  can  be  used  as  a  galvano- 
cautery  for  burning  a  groove  through  the  p-ostate. 
The  current  is  supplied  by  a  specially  made  battery, 
and  the  strength  of  the  current  is  entirely  under  the 
control  of  the  operator.      After  the  blades  of  the  instru- 


428 


MEDICAL    RECORD. 


[SeptL-mber  18,  1897 


ment  have  been  inserted  in  the  prostatic  urethra,  they 
may  be  turned  in  the  direction  necessary  to  destroy 
that  portion  of  the  prostate  which  seems  to  offer  the 
greatest  obstruction  to  the  passage  of  urine.  The  re- 
sults of  the  method  are  excellent.  Within  a  few  days, 
sometimes  hours,  the  patient  urinates  voluntarily.  In 
ten  days  all  catheterization  can  be  stopped.  The  re- 
lief afforded,  according  to  the  author's  claim,  is  com- 
plete and  permanent.  The  instrument  may  be  em- 
ployed after  local  anaesthesia  by  cocaine.  It  obviates 
the  dangers  which  have  so  far  attached  to  all  surgical 
attempts  to  re-e.stablish  the  urethral  canal  through  the 
prostate,  especially  doing  away  with  the  liability  to 
hemorrhages.  The  cautery  acts  effectively  in  closing 
all  blood-vessels.  A  current  of  ice-cold  water  flowing 
through  the  instrument  effectually  protects  healthy 
tissue.  The  contraction  of  the  resultant  cicatrix  is 
never  sufficient,  when  the  cauterization  has  been  thor- 
ough, to  bring  back  the  old  symptoms  of  prostatism. 
Surgeons  from  other  lands,  among  them  P'reudenberg, 
of  Berlin,  and  Kummel,  of  Hamburg,  have  employed 
the  instrument  successfully,  and  the  reports  of  their 
cases  show  that  it  is  not  in  its  inventor's  hands  alone 
that  the  instrument  is  effective. 


Thii-il  Day — Monday,  August  _'j,/. 

Treatment  of  Infected  Wounds. — Dr.  E.  Ijr.^atz, 
of  Konigsberg,  read  a  paper  on  this  subject.  Infected 
wounds,  he  said,  must  be  treated  on  strict  antiseptic 
principles,  and  in  successive  dressings  every  care  must 
be  taken  that  instruments  and  everything  else  that 
comes  irt  contact  with  the  wound  are  thoroughly  ster- 
ilized. One  infection  may  be  followed  by  another  of 
severer  character,  and  this  mixed  infection  often  runs 
a  severe  course. 

Dr.  Le  Dentu,  of  Paris,  read  a  paper  on  the  same 
subject,  in  which  he  advocated  the  use  of  some  of  the 
newer  antiseptics  in  preference  to  sublimate  solutions. 

Silver  as  an  Antiseptic.  —  Dr.  Crede,  of  Dresden, 
read  a  paper  containing  an  interesting  report  on  his 
method  of  treating  wounds  with  silver,  which,  after  an 
application  of  nearly  two  years  with  a  considerable 
number  of  patients,  has  proved  to  be  most  successful. 
Although  admitting  all  the  advantages  of  asepsis,  he 
said  that  it  was  of  limited  application  and  was  im- 
practicable for  the  physician  who  had  no  modern  hos- 
pital at  his  disposal.  Crede's  method  is  based  upon 
the  antiseptic  value  of  the  lactate  and  the  citrate  of 
silver  and  their  non-toxic  properties.  Experiments 
made  with  the  internal  exhibition  of  silver  salts  showed 
that  they  possess  a  certain  power  as  general  antisep- 
tics, but  for  the  purpose  of  a  general  disinfection  only 
metallic  silver  can  be  used,  and  this,  of  course,  in  a 
condition  which  allows  it  to  dissolve  in  water  and 
albuminous  lluids.  The  speaker  believed  that  he  had 
discovered  in  soluble  metallic  silver  a  remedv  whicli 
is  able  to  disinfect  the  whole  of  the  body,  and  which 
represents  a  specific  against  septic  infections,  in  so  far 
as  these  have  not  caused  organic  lesions. 

Permanence  of  the  Results  in  the  Radical  Cure 
for  Hernia.  —  Dr.  LrcAs-CH.wiPioxxiiiRE,  of  Paris, 
read  a  communication  with  this  title.  In  seventeen 
years  he  had  had  more  than  six  hundred  cases  of  rad- 
ical operation  for  hernia,  and  so  lielieved  him.self  in  a 
position  to  formulate  some  practical  conclusions.  It 
is  the  rule  for  a  hernia  after  a  good  operation  not  to 
relapse,  even  when  no  support  is  worn.  .Anv  opera- 
tion that  does  not  ])enetrate  the  abdomen  and  leaves 
intact  the  contents  of  the  inguinal  canal  and  the  canal 
itself  must  be  considered  as  absolutely  without  \  alue. 
OperatiOhs  limited  to  the  external  orifice  of  the  canal 
are  not  radical  cures  in  the  true  sense,  .\ftcr  the  op- 
eration the  abdominal  wall  should  be  s.ubmitted  to 
regidar  and    methodical    movements,   and   the   patient 


should  avoid  as  far  as  possible  growing  very  stout  after 
the  operation.  The  fattening  of  the  subject  is  one  of 
the  chief  causes  which  lead  to  relapses  by  a  fatty  in- 
filtration of  the  muscles  of  the  abdominal  wall.  Grad- 
ual progression  in  the  taking  of  exercise  after  an  op- 
eration for  radical  cure  is  a  point  of  the  highest 
importance  in  obtaining  a  definite  .solidity  of  structure 
in  the  wall,  which  will  afford  the  necessary  resistance 
for  violent  exercises.  The  bicycle  is  eminently  suited 
to  this  purpose.  In  the  speaker's  experience  relapses 
have  always  come  from  one  of  two  causes,  namely,  the 
excessive  taking  on  of  fat  or  sudden  \  iolent  efforts, 
as  in  lifting. 

The  Suture   of   Large  Vessels   in   Continuity 

Dr.  J.  B.  Murphy,  of  Chicago,  read  a  paper  on  this 
subject,  in  which  he  described  the  experiments  already 
detailed  in  the  Medical  Recorp,'  and  gave  the  de- 
tails of  two  unreported  cases  and  demonstrated  his 
method  of  performing  the  operation  and  his  instru- 
ments for  it.  Communications  in  English  are  usually 
received  w  ith  brutal  discourtesy  at  international  con- 
gresses; this,  however,  did  not  share  the  usual  fate,  but 
was  listened  to  with  profound  attention.  The  more  re- 
markable of  the  two  cases  was  one  of  gunshot  wound  of 
the  subclavian,  in  which,  after  cutting  down  on  the  huge 
haematoma  which  had  formed  in  the  four  days  since 
the  accident  and  securing  the  arter)-.  Dr.  Murphy- 
resected  three-fifths  of  an  inch  of  the  artery  in  its 
second  portion,  sutured  it,  and  had  immediate  return 
of  pulsation  at  the  wrist.  The  paper  excited  the  great- 
est interest,  and  the  instruments  were  the  subjects  of 
marked  attention  and  discussion  at  the  close  of  the 
session. 

The  Radical  Treatment  of   Hernia Dr.   Cazi.s, 

of  Paris,  read  a  paper,  the  joint  work  of  himself  and 
Professor  Duplay.  on  a  new  method  of  treating  the  sac 
in  the  radical  cure  of  inguinal  hernia.  The  method 
has  two  essentials:  i,  The  sac  is  preserved  and  is 
used  for  the  purpose  of  making  a  solid  cicatrix,  form- 
ing a  sort  of  organizedstopper  between  the  peritoneum 
and  the  transversalis  fascia:  2.  buried  sutures  are 
dispensed  with,  and  this  the  authors  consider  a  de- 
cided advantage  when  it  can  be  done  without  compro- 
mising the  solidity  of  the  cicatrix.  For  suturing  the 
walls  of  the  hernial  opening,  they  employ  silver  wire, 
which  is  removed  on  the  sixth  day.  'Phe  operation  is 
not  suitable  for  all  classes  of  hernia,  for  when  there 
is  a  large  opening  into  the  canal  some  procedure  like 
Bassini's  must  be  employed  for  the  reconstruction  of 
the  abdominal  walls,  and  then  buried  sutures  must  be 
employed.  The  abandonment  of  buried  sutures  they 
consider  a  decided  advantage,  for  when  of  silk  these 
often  give  rise  to  late  infections  which  are  exceedingly 
troublesome ;  when  of  catg\it  they  are  sometimes  ab- 
sorbed so  readily  that  they  do  not  remain  long  enough 
to  sen'e  for  the  formation  of  a  firm  cicatrix.  The 
authors  had  operated  upon  thirty-three  cases  in  two 
years  with  their  method.  The  cure  was  without  inci- 
dent in  all  ca.ses,  and  the  relief  afforded  seemed  to  be 
permanent. 

Dr.  Corbin,  of  Jassy,  read  for  himself  and  Dr.  Vi- 
col  a  report  on  two  hundred  operations  for  the  radical 
cure  of  hernia  done  in  the  hospital  of  the  fourth 
l''rench  army  corps.  Of  tlie.se,  one  hundred  and  ninety- 
eight  were  inguinal  hernias,  one  was  crural,  another 
umbilical.  I'he  number  of  patients  operated  on  was 
one  hundred  and  ninetx'.  In  most  of  the  ingtiinal 
hernias  the  procedure  emploved  was  that  of  Lucas- 
Championniere.  .Ml  of  the  patients  survived  the  oper- 
ation, and  in  hut  twenty-one  was  there  elevation  of 
temperature  after  the  operation.  In  three  cases  there 
was  .some  deep  suppuration.  Since  the  operations 
there  had  been  relapses  in  twelve  cases.  .All  of  them 
occurred  as  a  consequence  of  the  heavy  work  the  n>en 
'Vol.  li.,  p.  73. 


September  i8,  1897] 


MEDICAL    RFXORD. 


429 


had  to  engage  in  after  leaving  the  hospital,  and  in 
nearly  all  the  relapses  there  is  a  histor}-  of  a  special 
violent  effort  made  at  the  time  of  the  recurrence  of  the 
hernia. 

Treatment  of  Spinal  Deformity. — Dr.  Calot,  of 
Berck-sur-Mer,  read  a  paper  on  the  treatment  of  the 
deformity  of  Pott's  disease.  He  became  tired  some 
time  ago  of  treating  Pott's  disease  in  the  way  usualh- 
recommended,  by  absolute  rest  and  fi.xation  of  the  parts. 
Seeing  the  deformity  increase  and  tlie  prominence  be- 
come more  pronounced,  despite  the  presence  of  a  cor- 
set or  jacket  or  other  fixation  apparatus,  he  looked 
around  for  another  mode  of  treatment.  Instead  of 
being  merely  passive,  he  adopted  active  measures.  He 
applied  pressure  to  the  prominence  while  e.vtension 
was  made.  Having  caused  the  hujnp  to  disappear, 
he  fixed  the  patient  in  the  position  of  correction  by 
a  carefully  applied  plaster  jacket,  which  was  retained 
or  replaced  by  a  similar  one  until  the  tuberculous  proc- 
ess had  ceased.  This  usually  takes  months;  it  may 
take  a  year  or  more.  I'he  important  part  of  the  proc- 
ess is  the  correction  of  the  deformity,  which  is  done 
gently  and  carefully,  but  with  sufficient  force  to  secure 
absolute  correction.  The  indications  for  this  correc- 
tion are  twofold :  First,  it  separates  the  diseased  por- 
tions of  the  vertebr.t  and  fixes  them  in  that  position 
so  that  they  fail  to  be  continual  sources  of  irritation 
to  each  other.  The  second  is  the  lessening  of  the  final 
deformity  of  the  case.  The  speaker  did  not  claim  that 
the  intervals  between  the  bodies  of  the  vertebra-  will 
be  filled  up  by  new  bone,  yet  during  the  process  of 
healing  there  is  undoubtedly  an  adaptation  of  bony 
structures  that  retains  the  spinal  column  in  its  cor- 
rected position.  The  treatment  is  especially  suitable 
for  recent  cases  of  Pott's  disease,  though  it  may  be  ap- 
plied with  due  circumspection  to  older  cases. 

Dr.  Joan'xescu,  of  Bucharest,  presented  a  paper  ad- 
vocating the  reduction  of  the  deformity  of  Pott's  dis- 
ease by  pressure  at  a  single  operation.  He  reported 
thirteen  cases  treated  during  the  past  year,  most  of 
which  had  been  exhibited  before  the  Academy  of 
Medicine  in  Bucharest.  His  attention  had  been  called 
to  the  subject  by  Dr.  Calot's  reported  cases,  and  it 
was  Dr.  Calot's  method  with  certain  modifications  that 
he  employed.  He  had  abandoned  traction  by  assis- 
tants, and  substituted  mechanical  means.  This  dis- 
penses with  the  need  for  so  many  assistants;  the  trac- 
tion force  is  absolutely  and  methodically  regulated;  it 
is  not  applied  by  fits  and  .starts,  as  is  almost  inexita- 
ble  in  manual  traction;  and  finally,  it  may  be  contin- 
ued not  only  during  the  process  of  reduction  but  also 
until  the  plaster  jacket  has  been  applied.  With  me- 
chanical means  the  alxsolute  minimum  of  force  neces- 
sary to  produce  the  reduction  may  be  employed,  which 
is  not  .so  easy  when  manual  traction  is  used.  In  his 
method  the  child  is  placed  face  downward  on  two  ele- 
vated cushions — the  one  under  the  upper  part  of  the 
sternum,  the  other  under  the  pehis.  Traction  is  ap- 
plied through  bandages,  having  their  attachments  so 
that  the  distance  between  pelvis  and  occiput  is  gradu- 
ally increased.  Then  pressure  is  applied  over  the 
gibbosity  until  it  is  reduced.  From  forty  to  sixt\ 
kilograms  of  tractive  force  and  forty  to  fift}-  kilograms 
of  pressure  are  sufficient  for  even  inveterate  cases. 
An;i:sthesia  is  necessary  only  during  the  period  of  re- 
duction, and  not  during  the  putting  on  of  the  plaster 
jacket.  The  results  of  the  procedure  have  been  emi- 
nently satisfactory  as  compared  with  the  old  methods, 
'i'he  only  immediate  danger  is  from  the  ana-sthesia, 
not  from  the  manipulations.  The  administration  of 
the  ana:sthetic  should  be  stopped  when  reduction  is 
complete,  and  in  recent  non-ankvlosed  cases  may  be 
dispensed  with  entireh. 

Dr.  Rkdakd,  of  Paris,  had  tried  Calot's  method  for 
the   immediate  reduction  of  the  prominence  of   i'ott's 


disease  in  thirteen  old  cases  with  ankylosis,  and  had 
not  succeeded  in  effecting  reduction  after  the  employ- 
ment of  the  maximum  of  pressure  and  traction  that  he 
thought  safe.  In  recent  cases  he  had  succeeded  in 
effecting  reduction  without  much  difficulty.  Even 
when  the  deformity  is  quite  large,  provided  it  is  not 
more  than  a  year  old,  the  manipulations  are  easy.  In 
some  cases  even  after  two  years  the  speaker  had  suc- 
ceeded in  eftecting  the  reduction.  Dr.  Redard  em- 
ployed mechanical  traction  and  mechanical  pressure 
to  accomplish  his  results,  and  considered  them  safer 
than  direct  manual  force,  because  their  amount  can  be 
exactly  measured.  He  did  not  think  the  old  methods 
should  be  entirely  abandoned  for  the  new. 

The  Fundamental  Principles  and  Methods  of  the 
Treatment  of  Scoliosis.  — Dr.  Doleija,  of  Leipsic, 
read  a  paper  on  this  subject.  According  to  the  gener- 
ally accepted  explanation  of  the  etiology  of  scoliosis, 
the  condition  is  a  functional  deformity  of  the  verte- 
bral column,  due  to  the  fact  that  certain  muscles, 
either  congenitally  or  from  some  lack  of  trophic  influ- 
ence, are  not  able  to  support  the  spine  properly. 
When  inveterate  it  is  complicated  by  the  fact  that  un- 
equal pressure  on  different  parts  of  the  vertebra-  has 
led  to  tlieir  uneven  development.  To  prevent  this 
and  to  correct  the  deformity  while  the  patient  is  young, 
there  are  four  indications:  (i)  General  gymnastics 
in  conjunction  with  massage  for  the  improvement  of 
general  muscle  tone.  (2)  Suspension,  which  relieves 
the  overstrained  muscles  for  a  time  and  enables  them 
to  catch  up  in  nutrition  and  tone.  (3)  Gradual  reduc- 
tion of  the  deformity  by  pressure,  which  puts  the 
weaker  muscles  in  a  better  position  to  act.  (4)  Re- 
tention of  all  that  has  been  gained  by  suspension  and 
corrective  pressure  by  the  wearing  of  an  apparatus. 

Staphylorrhaphy — Dr.  Le  Dentu,  of  Paris,  de- 
monstrated certain  instruments  for  use  in  staphylorrlia- 
phy.  Among  them  notably  were  a  mouth  gag  with  a 
crossbar,  which  rolls  the  tissues  forward  and  brings 
the  field  of  operation  nearer  to  the  surgeon ;  a  spe- 
cially constructed  dissector  with  a  curve  in  two  direc- 
tions, that  enables  it  to  be  used  to  best  advantage  as 
regards  the  curve  of  the  palate  and  the  confined  region 
in  which  it  has  to  be  manipulated:  a  needle  holder 
with  a  concealed  needle,  that  when  pushed  upon  de- 
scribes a  curve  that  brings  it  toward  the  operator,  and 
when  withdrawn  carries  the  ligature  through  the  tis- 
sues. 

Indications  and  Results  of  Lithotrity. — Dr.  Al- 
I'.ARRAN.  of  Paris,  re\iewed  this  subject  as  it  concerns 
present-day  practice.  It  used  to  be  said  that  there 
were  two  contraindications,  youth  and  extremely  large 
stones,  but  these  have  disappeared  before  the  march 
of  modern  surgery.  Scarcely  ever  is  it  necessary  to 
do  a  cutting  operation  for  stone.  It  is  the  rarest 
exception  to  find  stone  in  a  patient  too  young  for 
the  performance  of  lithotrity.  The  difticulty  used 
to  be  the  introduction  of  instruments  strong  enougli 
to  be  depended  on  into  the  urethras  of  young  male 
patients,  but  this  has  disappeared  before  the  gradual 
perfection  of  instruments.  .\s  to  the  size  of  stone, 
nothing  is  now  too  large  for  the  lithotrite.  He  con- 
siders lithotrity  one  of  the  great  triumphs  of  modern 
surgery — that  this  operation  should  have  reached  the 
perfection  and  universality  of  application  that  it  has. 
Instead  of  a  serious  bloody  operation  with  at  least 
fourteen  days  or  three  weeks  in  bed  in  the  most  favor- 
able cases,  there  is  a  simple  surgical  manipulation 
and  the  patient  is  able  to  he  out  of  bed  in  three  days 
and  resume  his  occupation  in  six  days. 

Ischuria  from  Prostatic  Hypertrophy. —  Dr.  Freu- 
DE.vnEUi.,  of  Berlin,  rexiewed  the  various  operations 
fordifiicult  urination  from  prostatic  hyjjertrophy.  He 
regarded  the  Hottini  method  as  the  best.  He  reported 
a  numl>er  of  successful  cases,  one  in  which,  after  every- 


430 


MEDICAL    RECORD. 


[September  i8,  1897 


thing  possible  had  been  done  for  the  patient  by  the  old 
methods,  the  prostatic  urethra  was  enlarged  by  Bot- 
tini's  electro-caustic  method;  he  was  able  to  urinate 
freely  some  hours  afterward  and  fourteen  days  after 
the  operation  all  catheterization  was  given  up. 

Dr.  Bottini  said  that  he  had  examined  Dr.  Freu- 
denberg's  modifications  of  his  apparatus.  They  con- 
cerned especially  the  possibility  of  thoroughly  asep- 
ticizing the  instrument,  and  certain  changes  in  the 
electrical  connections  and  battery  powers,  and  he  con- 
sidered them  distinct  improvements  and  recommended 
them  to  the  profession. 

Dr.  Watson,  of  Boston,  said  that  from  his  personal 
experience  he  did  not  think  Botiini's  apparatus  ap- 
plicable to  all  cases  of  prostatic  hypertrophy.  While 
it  w-ould  be  effective  in  the  simpler  cases  of  bar  at  the 
neck  of  the  bladder,  he  hardly  thought  it  would  re- 
lieve the  cases  in  which  there  was  extreme  prostatic 
hypertrophy.  No  amount  of  manipulative  skill 
would  enable  one  to  direct  the  instrument  so  as  always 
to  come  upon  the  offending  prostatic  hindrance. 

Dr.  Lavisfa,  of  Mexico,  did  not  consider  the  Bot- 
tini procedure  applicable  to  the  cases  of  extremely 
large  prostate.  He  thought  that  the  relief  afforded  in 
such  cases  would  be  only  temporary. 

Catheterization  of  the  Ureters. — Dr.  Albarran, 
of  Paris,  read  a  paper  on  catheterization  of  the  ureters 
in  the  male  and  female,  and  described  a  new^  instru- 
ment that  greatly  facilitates  the  manoeuvre.  With  his 
apparatus  he  is  able  to  introduce  a  rubber  catheter 
supported  by  a  sound  of  a  calibre  of  No.  10  French. 
After  the  manoeuvre  has  been  repeated  for  some  days 
a  No.  13  or  No.  14  may  be  introduced. 

Lithotrity. — Dk.  Herbert  Milton,  of  Cairo,  read 
a  paper  on  this  subject  (see  page  418). 

Tumors  of  the  Bladder. — Dr.  Nitze,  of  Berlin, 
read  a  paper  on  the  intravesical  removal  of  tumors  of 
the  bladder.  He  described  a  new  cystoscope  for  the 
employment  of  a  snare  under  full  light  in  the  cystic 
cavity.  Only  benign  tumors  can  be  removed.  For 
malignant  tumors  a  more  radical  operation  must  be 
employed  when  operation  is  indicated.  Small  tumors 
that  have  for  years  been  causing  serious  constitutional 
trouble  from  hemorrhage  can  be  easily  removed,  and 
even  reasonably  large  tumors  can  be  removed  piece- 
meal. In  the  speaker's  experience  this  method  has 
given  much  better  results  than  sectio  alta. 

D«.  Watson,  of  Boston,  asked  to  be  allowed  to  cor- 
rect the  impression  made  by  the  paper  of  Dr.  Albarran, 
that  cutting  operations  for  stone  were  the  favorite  pro- 
cedures for  vesical  calculus  in  America.  He  was  glad 
to  see  that  French  surgeons  had  so  thoroughly  taken 
up  the  rapid  method  invented  by  Bigelow  and  were 
carrying  it  out  with  such  perfection. 

Elephantiasis  of  the  Testicle.  — Dr.  Le  Dentu, 
of  Paris,  reported  a  case  of  elephantiasis  of  the  testicle, 
hydrocele,  lymphatic  varicocele,  and  lymphangioma 
of  the  inguinal  canal  and  of  the  pelvis  due  to  the 
presence  of  filaria  sanguinis  hominis.  The  change  of 
climate  ahvays  arrests  the  progress  of  the  filarial  dis- 
ease, he  said,  and  he  thought  it  probable  that  the  use 
of  electricity  may  be  found  to  cau.se  a  retrograde  proc- 
ess in  the  hyperlrophied  lymphatic  tissues. 

Pseudo-Cystitis Dr.  Guepin,  of  P-iris,  for  him- 
self and  Dr.  drandcourt,  read  a  paper  on  this  subject. 
They  hold  that  tliere  is  a  series  of  diseases  with 
bladder  manifestations  in  which  no  pathological  con- 
dition exists  in  the  bladder.  These  have  usually  been 
diagnosed  as  cystitis,  and  it  i:  only  careful  modern 
diagnosis  that  has  differentiated  ihem.  The  bladder 
symptoms  in  such  cases  are  the  result  of  nervous  re- 
flexes, principally  from  an  affected  posterior  urethra, 
but  they  may  also  come  from  the  anterior  urethra,  from 
the  ureter,  and  even  from  the  kidnev.  The  result  of 
the  reriex  nervous  excitation  brings  on  a  congestion 


that  aggravates  the  symptoms  and  makes  the  condition 
still  more  simulative  of  true  cystitis.  The  diagnosis 
is  often  extremely  difficult  and  depends  finally  on 
careful  local  examination.  It  is  to  be  remembered 
that  in  cases  of  false  cystitis  the  symptoms  are  ahvays 
aggravated  by  intravesical  medication. 

Absorption  by  the  Mucous  Membrane  of  the 
Bladder. — Dr.  Gerota,  of  Bucharest,  showed  by  a 
series  of  microscopic  plates  that,  while  there  was 
imbibition  on  the  part  of  the  mucous  lining  of  the 
bladder,  there  was  no  real  active  absorption.  Color- 
ing matters  were  found  to  have  penetrated  between  the 
cells,  but  they  were  not  taken  up  by  the  lymphatics. 
Poisons  such  as  str)chnine  might  thus  gradually  and 
very  slowly  find  their  way  into  general  circulation,  but 
they  were  not  reallv  absorbed. 

Spontaneous  Fracture  of  Vesical  Calculi.— Dr. 
Severeaxo,  of  Bucharest,  reported  a  case  of  spontane- 
ous fracture  of  a  large  calculus.  He  discussed  the 
theories  of  the  cause  of  the  fracture,  rejected  the  idea 
that  it  was  due  to  active  excessive  contraction  of  the 
bladder  walls,  but  thought  it  was  much  more  probably 
due  to  the  formation  of  carbonic  acid  within  the  cal- 
culous masses. 

Prostatectomy. — Dr.  Desmos,  of  Paris,  read  a 
paper  on  this  subject.  He  regarded  the  hypogastric 
route  the  preferable  one,  as  the  surgeon  has  to  grope 
less  in  the  dark,  can  more  readily  diagnosticate  the 
exact  condition  that  causes  the  urinary  difficulties,  and 
is  better  able  to  judge  what  the  indications  for  opera- 
tion really  are.  In  twenty-three  prostatectomies  he 
had  successful  results  in  thirteen,  the  patients  recover- 
ing almost  completely  their  urinary  potency;  in  four 
cases  there  was  distinct  improvement  in  the  urinary 
symptoms.  In  the  midst  of  the  new  inventions  for  the 
relief  of  prostatism  now  so  frequent,  he  believed  that 
the  old  traditional  procedures  still  had  their  place 
and  that  improved  technique  with  modern  methods 
made  them  often  the  operation  of  choice. 


Fourth  Day — TuiSilay.  August  34th. 

Gastric  Operations. — Dr.  Kader,  of  Breslau,  read 
a  communication  on  the  operations  on  the  stomach 
done  in  Mikulicz's  clinic  during  the  last  fifteen  years. 
There  were  seventy-one  operations  for  non-malignant 
troubles  of  various  kinds,  with  a  mortality  of  22.5  per 
cent.  In  all  uncomplicated  cases  the  mortality  was  but 
8.4  per  cent.,  while  in  uncomplicated  cases  "of  e.vcision 
of  gastric  ulcers  the  mortality  was  but  4  per  cent.  In 
cases  of  carcinoma  the  total  mortality  was  21.6  per 
cent.;  the  mortality-  of  uncomplicated  cases  was  but 
15.5  per  cent.  The  mortality  during  the  last  two 
years  had  been  a  little  higher  than  in  that  of  the  pre- 
ceding thirteen  years  from  1SS2  to  1895,  but  this 
was  due  to  the  fact  that  much  more  complicated  and 
difficult  cases  were  now  operated  upon,  .and  the  circle 
of  inoperable  cases  was  constantly  being  narrowed. 

Surgical  Treatment  of  Graves'  Disease.^  Dr. 
KocHKR.  of  Berne,  read  a  report  on  his  results  in  the 
surgical  treatment  of  exophtiialmic  goitre.  In  all  he 
had  treated  forty-three  cases,  which  he  divided  into 
three  classes:  (i)  struma;  vasculosse;  (2)  atypical 
cases;  (3")  typical  cases.  In  the  six  cases  of  vascular 
struma  surgical  interference  by  partial  excisions  and 
ligation  of  arteries  had  been  uniformly  successful. 
In  sixteen  atypical  cases  he  had  had  thirteen  complete 
cures  and  three  improvements.  In  the  typical  cases 
he  had  operated  in  various  ways.  In  three  cases  in 
which  one-half  the  gland  was  removed,  two  were  cured, 
one  was  improved.  In  three  cases  of  ligature  of  the 
superior  and  inferior  thyroid  arteries  on  one  side,  two 
were  cured,  one  was  improved.  In  five  cases  in  which 
two  arteries  on  one  side  and  one  on  the  other  were  tied, 
four  were  cured,  one  was  improved.     In  three  cases  in 


September  i8,  1897] 


MEDICAL    RECORD. 


431 


which  all  four  arteries  were  tied,  two  cases  were  cured 
and  one  proved  fatal.  The  author  formulated  the  fol- 
lowing conclusions:  (i  »  Graves'  disease  is  due  to  hy- 
perplasia of  the  thyroid  and  excessive  function  with 
presence  of  too  much  of  its  secretion  in  the  system. 
(2)  In  the  early  stage  of  the  disease  it  is  possible  to 
relieve  it  by  surgical  treatment  (3)  The  surgical 
treatment  must  be  different  for  different  cases,  but  the 
best  method  in  general  seems  to  be  the  removal  of  one- 
half  the  gland  and  the  ligature  of  one  artery  on  the 
other  side.  The  operation  is  not  an  easy  one,  so  that 
it  will  perhaps  be  best  as  a  rule  to  excise  the  smaller 
half.  It  is  in  the  early  stage  that  the  disease  is 
especially  benefited  by  surgical  treatment,  and  it  is 
consequently  in  this  stage  that  the  disease  must  be 
claimed  as  a  surgical  affection  and  come  at  once  into 
the  surgeon's  hands. 

Resection  of  the  Cervical  Sympathetic — Dr. 
Thomas  Joaxxescu,  of  Bucharest,  read  a  paper  entitled 
" Total  and  Bilateral  Resection  of  the  Cervical  Sym- 
pathetic." He  reported  three  cases  of  removal  of  the 
whole  of  the  cervical  sympathetic  for  exophthalmic 
goitre.  The  results  were  excellent.  The  exophthal- 
mos completely  disappeared  and  the  other  symptoms 
of  the  disease  were  almost  if  not  entirely  relieved. 
In  r\venty-eight  cases  of  epilepsy  he  had  also  divided 
the  cervical  sympathetic  and  with  excellent  results. 
In  fact,  for  epilepsy  and  exophthalmic  goitre  he  re- 
garded the  total  bilateral  section  of  the  cervical  sym- 
pathetic as  the  only  rational  surgical  interference. 
The  immediate  fatalit}-  of  the  operation  ought  in  good 
hand?  to  be  absolutely  nil.  No  after-effects  that  will 
inconvenience  the  patient  are  to  be  expected.  As  the 
possibility  of  resecting  all  three  ganglions  of  the  cer- 
vical sympathetic  had  been  questioned,  he  exhibited  the 
series  removed  by  himself  and  preser\-ed  in  alcohol. 

Subcutaneous  Extirpation  of  Lymphatic  Glands. 
— Dr.  Dollixger,  of  Budapest,  read  a  communica- 
tion entitled  "  Further  Experiences  with  the  Sub- 
cutaneous Extirpation  of  Tuberculous  Lymph  Glands 
in  the  Throat,  Xeck,  and  Submaxillar)'  Region." 
He  had  employed  in  a  variety  of  cases  and  with  ex- 
cellent results  the  subcutaneous  method  he  described 
some  time  ago.  With  care  the  danger  is  no  greater 
than  with  the  open  method  and  the  resulting  scar  is  so 
much  less  that  patients  readily  consent  to  the  opera- 
tion. The  greatest  surgical  cleanliness  is  absolutely 
necessary. 

Harelip — Dr.  Severeano,  of  Bucharest,  described 
his  operation  for  this  deformit)-.  He  splits  the  sides 
of  the  fissure  into  two  portions,  a  mucous  and  a 
cutaneous  one,  and  brings  them  together  by  separate 
sets  of  sutures.  He  thus  avoids  the  loss  of  substance 
necessitated  by  the  freshening  process  in  all  the  other 
harelip  procedures,  and  as  the  flaps  to  be  brought  to- 
gether are  thinner  he  secures  more  close  coaptation 
and  so  lessens  the  prominence  of  the  resulting  cica- 
trix. 

The  evening  session  on  this  day  was  held  in  union 
with  the  section  in  neurology. 

Brain  Surgery Dr.  Bergmaxn,  of  Berlin,  read  a 

paper  on  the  surgical  treatment  of  brain  tumors.  He 
reviewed  the  history  of  brain  surgery  and  cerebral  lo- 
calization. Great  as  has  been  the  progress,  there  itill 
remains  much  to  do.  Diagnostic  methods  are  still 
not  sure  enough  to  guard  the  surgeon  against  error. 
He  had  himself  opened  the  skull  for  tumor  without 
finding  one.  Such  is  now  the  perfection  of  surgical 
methods  as  regards  asepsis,  however,  that  in  case  of 
doubt  a  trepanation  for  diagnostic  purpxjses  in  serious 
cases  is  justifiable.  In  about  one  out  of  ten  cases 
operated  on  for  tumor  no  tumor  is  found,  and  in  one 
out  of  six  cases  operated  upon,  though  the  tumor  has 
given  definite  symptoms  of  localization,  its  removal  is 
impossible.     Though    he  had    spoken    lightly  of  the 


operation,  he  would  not  be  understood  as  denying  us 
grave  dangers,  not  alone  during  the  operation  itself 
and  immediately  after,  but  remotely  from  the  pressure 
of  the  resulting  cicatrix  causing  epilepsy. 

Dr.  Auguste  Voisin,  of  Paris,  reported  a  case  of 
Jacksonian  epilepsy  treated  successfully  by  craniec- 
tomy. The  case  was  that  of  a  young  man  of  seventeen 
affected  since  the  age  of  four  with  convulsive  attacks 
beginning  with  a  painful  aura  in  the  left  arm.  The 
number  of  attacks  had  become  so  frequent  that  he  was 
unable  to  leave  his  bed.  At  Dr.  Voisin's  request  Dr. 
Pe'an  made  a  large  craniectomy  over  the  fronto-parie- 
tal  ascending  convolutions.  The  dura  was  found  de- 
pressed, the  pia  was  hyperaemic,  the  brain  tissue  seemed 
to  be  sclerotic.  The  result  was  eminently  satisfac- 
tory. All  pain  in  the  left  arm  has  disappeared,  though 
there  still  occur  at  times  certain  slight  involuntary 
tsvitchings.  The  patient  has  completely  recovered 
his  intelligence  and  his  general  health,  and  has  gone 
back  to  work.  It  is  now  two  and  a  half  years  since 
the  operation.  The  patient  has  had  but  three  attacks 
since  the  operation. 

Dr.  J.  Lccas-Champioxniere,  of  Paris,  read  a 
pai>er  on  the  same  subject.  He  had  done  sixty-six 
trephining  operations  for  non-traimiatic  cerebral  le- 
sions, or  lesions  of  traumatic  origin  but  very  old,  and 
twenty  for  fracture  of  the  skull.  He  thought  the 
cases  of  Jacksonian  epilepsy  with  an  absolutely  local- 
ized lesion  not  very  common.  \Mien  definite  lesions 
are  found  there  are  always,  in  Dr.  Championniere's  ex- 
perience, besides  the  localized  convulsions,  localized 
paralyses,  or  contractures.  These  are  in  fact  the  best 
directing  symptoms  the  surgeon  can  have.  In  cases  of 
operation  for  epilepsy  one  must  avoid  having  too  nar- 
row an  operative  field,  for  otherwise  one  runs  the  risk 
not  alone  of  not  finding  anything  but  also  of  bringing 
no  relief  to  the  patient. 

The    Failures    in    Brain    Surgery    because     of 

Faulty    Diagnosis Dr.     Oppexheim,     of    Berlin. 

read  a  communication  with  this  title.  He  thought 
that  the  great  desideratum  now  in  brain  surger}'  is 
not  a  better  method  of  operation  but  more  assured 
diagnosis.  Brain  localization  is  often  most  doubt- 
ful; the  diagnosis  of  brain  abscess  from  brain  tumor 
is  often  almost  if  not  quite  impossible,  yet  a  surgical 
operation  for  the  one  or  the  other  condition  is  quite 
a  different  matter  as  regards  immediate  and  remote 
results.  Pressure  symptoms  are  often  deceitful,  and 
a  condition  of  cerebral  poliomyelitis  may  simulate 
in  all  respects  the  localization  symptoms  of  a  tumor. 
It  maybe  impossible  even  10  diagnose  the  hemisphere 
in  which  the  lesion  exists,  and  repwrts  of  paralysis 
with  the  lesion  on  the  same  side  of  the  brain  are 
growing  more  frequent.  The  pressure  against  the 
skull  on  one  side  owing  to  the  pathological  condition 
present  may  by  a  sort  of  contrecoup  be  manifested 
more  on  the  other  side  of  the  brain,  either  because 
the  pressure  is  exerted  more  directly  on  the  motor 
regions  on  the  other  side,  or  because  of  nutritional 
conditions  or  idiosyncrasy.  Then  a  lesion  on  one 
side  may  be  complicated  by  hydrocephalus  on  the 
other  side.  Finally  the  peripheral  symptoms  may 
be  deceptive. 

Dr.  Dovex,  of  Paris,  exhibited  a  set  of  instruments 
for  the  rapid  opening  of  the  cranium.  They  consist 
of  a  special  boring  machine  with  which  the  diploe  is 
penetrated  and  then  perforated  with  an  olive-pointed 
tool,  thus  avoiding  all  danger  of  wounding  the  dura 
even  when  there  are  extreme  irregularities  of  the 
cranial  vault.  He  makes  several  apertures  and  then 
connects  them  by  means  of  a  saw  making  one  thou- 
sand revolutions  a  minute,  run  by  electricity  and  pro- 
tected from  injuring  the  brain  or  membranes  by  a 
metal  director. 

Dr.  Bruxs,  of   Hanover,  read   a  paper  on   "  Some 


432 


MEDICAL    RECC)Rn. 


[September  i8,  189; 


Specially  Weighty  and  "Practically  Important  Diag- 
nostic Points  in  the  Differential  Diagnosis  and 
Localization  of  Brain  Tumors."  The  most  diiificult 
differential  diagnosis  is  that  between  tumors  of  the 
frontal  lobes  and  of  the  cerebellum.  i.  Disturb- 
ances of  equilibrium  may  occur  in  both,  and  so  mis- 
takes of  diagnosis  may  easily  be  made  as  to  tumors 
having  their  seats  in  either  of  these  locations.  Care- 
ful consideration  of  symptoms  makes  a  differential 
diagnosis  possible,  owing  to  important  special  symp- 
toms that  occur  with  frontal  tumors.  2.  Homony- 
mous hemianopsia  is  of  little  weight  for  differential 
diagnosis.  When  right-sided  homonymous  hemian- 
opsia with  alexia  and  optic  aphasia  is  present  from 
the  beginning,  we  may  conclude  as  to  the  presence 
of  a  tumor  in  the  white  matter  of  the  left  pos- 
terior lobes.  3.  Tumors  in  the  neighborhood  of  the 
central  convolutions,  especially  in  the  frontal  and 
parietal  convolutions,  on  account  of  the  pressure 
symptoms,  often  cannot  be  diagnosed  from  tumors 
of  the  central  convolutions  themselves.  4.  The  per- 
cussion signs  and  the  sensitiveness  of  the  skull  with 
the  presence  of  tympany  or  cracked-pot  sound,  when 
it  is  demonstrable  with  certainty  and  facility,  are  of 
the  greatest  importance  for  localizing  diagnosis  of 
tumors.  Especially  is  this  true  when  the  percussion 
symptoms  accord  in  their  indications  with  the  local- 
izing general  symptoms.  In  the  difficult  cases  of  dif- 
ferential diagnosis  of  the  central  convolutions  and 
their  immediate  neighborhood  evident  percussion 
symptoms  and  localized  tenderness  may  make  a  final 
and  absolutely  certain  diagnosis  possible.  In  these 
cases  the  percussion  symptoms  are  much  more  sig- 
nificant than  the  localizing  brain  symptoms.  Unfor- 
tunately these  percussion  symptoms  and  sensitiveness 
occur  only  when  the  tumor  is  very  superficially  lo- 
cated. 

Dr.  L.wisiA,  of  Me.vico,  read  a  paper  on  the  re- 
sults of  surgical  intervention  for  Jacksonian  epilepsy 
and  the  necessity  for  its  early  employment.  The 
efforts  of  surgeons  to  relieve  cerebral  disorders 
are  satisfactory  neither  to  themselves  nor  to  the  neu- 
rologists; he  could  not  believe  that  the  centres  and 
regions  of  the  cerebral  cortex  were  definitely  limited. 
Tiiey  represent  only  the  regions  where  there  is  the 
ma.Kimuni  of  nerve  force  for  a  particular  purpose. 
Besides,  we  know  nothing  of  the'superior  and  middle 
frontal  convolutions.  Notwithstanding  a  lack  of 
exact  knowledge  as  to  localizing  symptoms,  however, 
the  surgeon  is  tempted  to  interfere  because  otherwise 
the  course  of  the  disease  is  so  hopeless.  Our  only 
resource  under  the  circumstances  then  is  a  large 
opening  in  the  skull  at  the  time  of  operation,  so  that 
we  may  examine  as  much  of  the  cortex  as  possible. 
In  this  way  one  is  often  able  to  find  lesions  in  parts 
where  no  localizing  symptoms  could  be  expected. 
One  thing  more  must  the  surgeon  bear  in  mind  in 
operations  for  Jacksonian  epilepsy,  and  that  is  tiiat 
the  .sooner  the  operation  is  done  the  better.  The 
brain  tissues  acquire  a  habit  or  degenerate,  and  then 
operations  do  not  give  satisfactoiy  results. 

Dr.  a.  d'Anton.a,  of  Naples,  read  a  paper  on  the 
remote  results  of  operations  for  partial  and  general 
epilepsy.  He  believed  that  the  remote  results  would 
justify  the  operation  for  Jackonsian  epilepsy,  thougii 
perhaps  not  that  for  general  epilepsy.  He  wished  to 
protest  against  the  teaching  that  an  exploratory  tre- 
panation was  ever  justifiable.  He  said  the  use  of  very 
large  openings  for  diagnostic  piuposes  was  not  to  lie 
thought  of. 

Dr.  Jiwnnkscu,  of  Bucharest,  presented  a  communi- 
cation on  temporary  heniicraniectomy.  He  believed 
that  with  the  present  uncertain  state  of  cerebral  di- 
agnosis and  the  al)solute  freedom  from  risk  of  aseptic 
surgery,  a  large  opening  in  the  skull  was  the  only  one 


that  a  surgeon  should  make.  He  did  not  agree  with 
d'Antona  in  his  condemnation  of  large  openings, 
because,  while  it  might  seem  conservative,  it  was 
really  quite  as  risky  to  make  a  small  opening  as  a 
large  one,  and  in  the  latter  event  the  chances  of  doing 
good  were  greatly  increased. 

Dr.  Kocher,  of  Berne,  read  a  paper  on  the  trau- 
matic origin  of  Jacksonian  epilepsy  and  its  non- 
occurrence after  surgical  interference.  He  had  had 
in  the  last  ten  years  eighteen  cases  of  complicated 
skull  fractures  which  had  been  carefully  treated  sur- 
gically, but  in  which  there  must  have  followed  the 
formation  of  extensive  cicatrices.  All  of  them  had 
been  carefully  followed  and  in  none  had  there  been 
any  epilepsy.  There  would  seem  to  be  some  other 
cause  necessar\-  besides  the  mere  presence  of  a  scar 
to  account  for  the  epilepsy. 


BRITISH    MEDICAL    ASSOCIATION. 

Sixiy-FiJ'tli    Annua/   Meeting,    Held   at   Atoiitreal, 
Canada,  August  ji,  September  i,  2,  j,  iHgj. 


(Special  Report  for  the  Medical  Record.) 
SECTION   IN   SURGERY. 

iCoiuinued  from  pagi-  362.) 

I'irst  Day —  Wednesday,  Septemlnr  isf. 

The  Accurate  Measurements  of  Spinal  Curva- 
ture.— Mr.  k.  Tait  McKenzie  read  a  paper  with  this 
title,  in  which  he  stated  that  the  points  to  be  noted  in 
studying  this  disease  were  the  difference  in  level  of 
the  shoulder.',  of  the  points  of  the  scapulae,  and  of  the 
iliac  crests,  the  deviation  of  the  spinous  processes  at 
all  levels,  and  a  general  outline  of  the  hips  and  shoul- 
ders. We  should  also  find  the  amount  and  show  the 
nature  of  the  rotation.  He  refened  to  many  plans  or 
devices  for  measuring  the  deformities.  Mr.  Bernard 
Roth  had  an  ingenious  device,  consisting  of  a  plate 
of  pure  tin  with  which  diagrams  were  made.  He  pre- 
ferred a  device  of  his  own,  which  consisted  of  a  fixed 
horizontal  iron  stand  into  which  a  rigid  upright  rod  is 
screwed  firmlv.  To  this  rod  two  arms  are  attached  by 
collars  that  can  be  moved  up  and  down  or  clamped  by 
thumbscrews.  The  lower  arm  passes  behind  the  pa- 
tient and  clamps  the  hips,  preventing  any  side  move- 
ment. The  upper  arm  passes  in  front  of  the  patient 
and  fixes  the  shoulders.  To  the  collar  of  the  upper 
arm  is  attached  by  a  hinge  a  plate,  to  which  a  panto- 
graph is  .screwed,  set  so  as  to  make  a  tracing  reduced 
to  one  in  four.  The  paper,  which  is  stretched  over 
this  plate  and  held  by  clips  behind,  is  ruled  in  eight- 
inch  squares.  Hence  a  line  passing  vertically  through 
eight  squares  or  one  inch  would  represent  a  distance 
of  four  inclies  covered  by  the  pointer  tracing  the  de- 
formit}'. 

Mr.  Christdi'HKr  Heath,  of  London,  said  that  in- 
struments had  been  used  in  the  most  reckless  way,  and 
were  not  only  of  no  value  but  did  positive  injury. 
He  had  the  opixirtunity  of  observing  many  of  these 
cases  treated  by  muscular  exercises,  and  found  that 
they  had  done  well. 

Dr.  Gipnkv,  of  New  \ork,  said  that  until  he  had 
noticed  Mr.  Roth's  method,  he  used  to  employ  appara- 
tus for  the  treatment  of  lateral  curvature,  but  since 
that  time  he  had  almost  entirely  given  it  up  and 
found  that  his  successes  were  infinitely  better.  He 
found  one  or  two  difficulties  in  carrying  out  the  meth- 
od. One  was  the  difficulty  of  keeping  up  the  patient's 
interest  in  the  gymnastics  under  the  supervision  of  the 
speaker  himself  or  his  assistant,  the  friends  main- 
taining that  tliese  exercises  could  be  done  as  well  at 
home.      He  still  u.sed  tlie  instniments  in  cases  of  stu- 


September  i8,  1897] 


MEDICAL    RECORD. 


433 


pid  girls  who  absolutely  could  not  be  compelled  to 
carry  out  the  serious  treatment  of  their  cases.  He 
thought  Dr.  xMcKenzie's  apparatus  for  tracing  the 
best  he  had  seen  and  that  Mr.  Roth's  results  were 
very  satisfactory'.  He  was  very  much  impressed  when 
in  England  with  the  amount  of  pain  complained  of  by 
patients  suffering  from  lateral  curvature.  This  was 
noi:  the  case  in  the  United  States.  Perhaps  the  reason 
of  this  was  that  the  cases  he  saw  here,  being  chiefly 
among  the  poor,  were  more  inured  to  pain  than  the 
cases  (mostly  among  the  well-to-do)  which  he  saw  in 
England. 

Dr.  Ketch,  of  New  York,  said  that  he  had  made  an 
analysis  of  two  hundred  and  twenty-nine  cases.  Eifty- 
two  were  cases  of  deformity  which  had  existed  before 
the  fifth  year.  He  claimed  that  much  better  results 
could  be  obtained  if  cases  could  be  seen  early.  He 
said  it  was  very  difficult  to  get  patients  to  carry  out 
the  instructions  regarding  the  e.xercises.  The  cases  of 
lateral  curvature  divided  themselves  into  two  classes, 
namely,  those  in  which  the  extrinsic  muscles  were 
affected,  and  those  in  which  the  intrinsic  muscles  were 
affected.  In  the  first  class  there  was  usually  no  irri- 
tation and  there  was  little  difficulty  in  carrying  out 
the  treatment.  Those  in  the  second  class  were  very 
troublesome  to  treat. 

Dr.  Lee,  of  Philadelphia,  said  that  an  early  diag- 
nosis should  be  made  in  these  cases  of  lateral  cur\'a- 
ture.  He  had  found  that  the  lumbar  region  was  the 
first  affected.  If  the  deformity  is  allowed  to  go  on 
until  the  dorsal  region  is  involved,  perfect  results 
cannot  be  hoped  for.  He  fully  concurred  with  Mr. 
Roth  as  to  the  value  of  e.xercise  and  posture  in  these 
cases. 

Scioiul  Dav — Thursday,  September  2ii. 

Gunshot  Wound  of  the  Spinal  Cord. — Dr.  Geukue 
A.  Peters,  of  Toronto,  then  followed  with  a  paper  on 
this  subject.  He  stated  that  the  causes  of  death  in 
such  cases  are  shock,  hemorrhage,  and  septic  proc- 
esses, while  the  factor  which  most  largely  determined 
the  rate  of  mortality  is  the  proximity  of  the  cord  le- 
sion to  the  brain.  Cases  of  this  nature  in  civil  prac- 
tice are  very  infrequent.  Although  there  have  been 
cases  in  which  after  complete  transverse  lesion  of  the 
cord  at  various  levels,  the  individuals  have  survived 
for  periods  varying  from  one  to  twenty-six  years,  yet  it 
may  be  stated  as  a  rule  to  which  the  exceptions  are 
few  that  patients  with  such  lesions  die  within  a  _\ear 
of  the  injury.  The  determining  causes  of  death  are 
inflammation  of  the  bladder  and  its  sequelae,  bedsores 
and  other  trophic  lesions,  pvamia,  amyloid  disease, 
and  exhaustion.  The  speaker  recommended  median 
cystotomy  as  a  routine  practice  in  cases  of  this  injury 
in  male  subjects,  to  imitate  the  short  and  straight 
urethra  of  the  female,  as  the  latter  seems  to  suffer  less 
from  bladder  symptoms.  Dr.  Peters  then  referred  to 
the  difference  between  the  deep  or  tendon  reflexes 
which  are  permanently  lost  in  complete  transverse  le- 
sions of  the  cord,  and  the  superficial  or  skin  reflexes 
which,  as  in  a  case  narrated  by  him,  may  not  only  re- 
turn but  may  even  become  exaggerated.  The  speaker 
believed  that  in  the  case  of  the  skin  reflexes  the  reflex 
arc  remains  intact  and  the  exaggeration  is  accounted 
for  by  the  overflow  of  sensation  into  motor  regions  in 
the  cord,  which  are  relieved  of  the  natural  inhibitory 
influence  of  the  higher  centres  by  the  lesion;  while  in 
the  case  of  the  tendon  reflex  an  influence  is  normally 
transmitted  to  the  muscles  to  maintain  their  tone 
which  is  also  interrupted  by  the  lesion — hence  the  per- 
manent loss. 

The  Advantages  of  the  Absorbable  Suture,  Buried 
in  Aseptic  Wounds. — Dk.  He.xkv  O.  M.\rcy,  of  lios- 
ton,  read  a  paper  on  the  suturing  of  wounds.     He  said 


that  in  a  large  minority  of  operative  wounds  made  in 
healthy  structures  suppuration  in  some  degree  still 
occurs.  The  surgical  technique  is  complete  for  mak- 
ing a  wound  aseptic,  but  the  difficulty  is  in  main- 
taining it  in  this  condition.  The  cause  of  this  is 
definite,  viz.,  an  open  wound.  The  remedy  is  equallv 
definite:  "  Hermetically  close  the  wound  and  seal  at 
the  time  of  operation  without  drainage.'"  The  drain- 
age tube  was  then  discussed  with  disapproval.  'J  he 
most  usual  source  of  operative  infection,  he  said, 
comes  from  the  surgeon's  own  hands.  Careful  hand 
disinfection  is  of  much  greater  value  to  the  patient 
than  a  marble  hall  for  an  operative  amphitheatre. 
The  speaker  then  discussed  the  varieties  of  suture  ma- 
terial, and  stated  as  his  opinion  that  all  aseptic  wounds 
should  be  closed  by  absorbable  sutures  under  the  most 
careful  of  aseptic  conditions  and  that  subcuticular  su- 
tures should  be  used  for  the  coaptation  of  the  skin. 
The  carefully  disinfected  skin  should  be  dried,  the 
edges  carefully  coaptated  and  sealed  with  iodoform 
collodion,  reinforced  by  a  few  fibres  of  absorbent  cot- 
ton. Dr.  Marcy  condemned  catgut,  not  so  much  be- 
cause of  its  difficult)- of  sterilization,  as  of  its  inherent 
defects,  a  large  share  of  its  strength  resulting  from  its 
being  twisted  and  kept  dry;  when  wet  it  is  elastic, 
unreliable  in  knotting,  and  untrustworthy.  Before 
twisting  and  drying  it  is  a  very  thin  flat  band  of  con- 
nective tissue,  the  fibres  of  which  cross  obliquely,  and 
is  not  unlike  a  very  delicate  silk  fabric  cut  upon  the 
bias.  The  advantages  to  be  obtained  from  the  use  of 
connective  tissue  as  a  suture  material  are  apparent, 
not  only  because  it  is  absorbable,  but  because  it  is  first 
surrounded  by  leucocytes,  which  little  by  little  invade 
the  suture.  As  absorptions  go  on,  these  cells  are 
changed  into  connective-tissue  corpuscles,  and  the  su- 
ture material  is  thus  more  or  less  completely  replaced 
by  a  living  band  of  connective  tissue.  Formerly  Dr. 
Marcy  used  tendons  from  the  moose  and  caribou,  but 
subsequently  convinced  himself  that  the  tendons  taken 
from  the  tail  of  the  kangaroo  were  greatly  to  be  pre- 
ferred, since  they  are  smooth,  even,  in  any  variety  of 
size,  have  never  been  subjected  to  decomposition,  and 
are  therefore  much  less  difficult  of  sterilization,  while 
in  strength  they  exceed  any  other  animal  structure. 
When  properly  chromicized  they  hold  in  the  tissues 
about  three  months. 

Coaptation  and  fi,xation  at  rest,  with  as  little  force 
as  possible,  of  like  structures,  are  the  aim  of  suturing. 
Suture  material  more  than  required  to  secure  this  pur- 
pose is  detrimental.  The  interrupted  suture  is  faulty 
in  that  it  holds  at  only  the  single  points  of  insertion, 
and  each  stitch,  moreover,  requires  a  knot  which  is 
slow  of  absorption.  The  continuous  suture  requires 
but  a  single  knot,  and  undue  constriction  is  less  liable 
since  a  compensation  occurs,  equalizing  the  force  ap- 
plied to  the  entire  suture.  Like  structures  as  far  as 
possible  should  be  joined,  fascia  to  fascia,  muscle  to 
muscle,  etc.  When  coaptation  has  been  accurate  there 
are  no  pockets  left  for  the  retention  of  fluids,  and  as 
a  consequence  no  drainage  tube  is  required.  As  a 
rule,  fatty  structures  should  not  be  sutured,  since 
aseptic  fat  necrosis  not  seldom  results.  Coaptation 
of  these  fatty  structures  follows  the  fixation  of  the 
muscles,  fascia,  and  skin.  The  over-and-over  glov- 
er's stitch  is  faulty,  in  that  it  unduly  constricts  the  in- 
closed tissues.  The  speaker  applied  the  suture  deeply 
from  side  to  side;  the  needle  is  introduced  parallel  to 
the  long  axis  of  the  wound,  and  hence  it  is  called  by 
him  the  "parallel  suture."  Tlie  needle  is  introduced 
exactly  opposite  to  the  point  of  emergence  of  the  pre- 
ceding stitch,  and  when  it  is  drawn  upon  the  surfaces 
are  evenly  coaptated,  and  the  suture  is  deeply  implanted 
in  healthy  tissues,  crossing  the  wounded  edges  at  right 
angles.  The  subcuticular  suture  is  effected  in  pre- 
ciselv  the  same  manner,  and  the  wound  is  sealed. 


434 


MEDICAL    RKr:ORD. 


[September  i8,  1897 


Conclusions:  An  aseptic  wound  thus  closed  with 
buried  aseptic  tendon  sutures  will  remain  aseptic,  and 
in  well-vitalized  srtuctures  will  be  followed  by  primar}- 
union.  No  expensive  and  troublesome  dressings  are 
required.  The  subsequent  nursing  and  care  are  verj- 
greatly  diminished.  The  anxious  foreboding  of  the 
surgeon  "  lest  something  go  wrong  with  the  wound" 
is  avoided.  No  stitches  are  to  be  removed,  reducing 
greatly  the  dread  and  anxiety  of  many  patients. 
Safety  is  greatly  enhanced  and  the  period  of  con- 
valescence is  shortened.  When  the  work  has  been 
done  with  care,  often  the  resultant  cicatrix  is  scarcely 
visible — a  matter  of  much  importance  in  some  por- 
tions of  the  body. 

Some  operations  hitherto  impossible  have  been  ren- 
dered feasible  by  the  use  of  the  buried  absorbable  su- 
ture, e.g.,  the  reconstruction  and  reformation  of  the  in- 
guinal canal  in  the  male,  upon  which  is  dependent  the 
cure  of  hernia.  It  was  for  the  cure  of  hernia  that  Dr. 
Marcy  first  used  buried  animal  sutures  in  1870.  He 
is  now,  tie  said,  in  his  fourth  hundred  of  hernia  cases, 
and  has  obtained  a  permanent  cure  in  over  ninety 
per  cent,  of  the  entire  number,  without  a  single  death. 

In  laparotomy  the  permanent  closure  of  the  abdom- 
inal wound,  without  subsequent  hernia,  is  rendered 
almost  certain  by  the  use  of  aseptic  tendon  sutures. 

Traumatic  Aneurism  of  the  Internal  Maxillary- 
Artery,  Treated  by  Ligature  of  the  Common  Car- 
otid.— Dr.  Langlev  Browx  reported  a  case  of  this 
kind.  The  patient  was  a  man  who  had  been  kicked 
by  a  horse.  He  was  semiconscious  on  admission  to 
the  hospital,  perhaps  suffering  from  shock,  and  bleed- 
ing profusely  from  his  right  cheek,  right  ear,  nose,  and 
scalp.  The  right  side  of  his  face  was  much  swollen, 
the  right  eye  being  completely  closed,  and  the  swell- 
ing extended  half-way  down  the  neck.  The  lower 
jaw  was  found  to  be  fractured  on  the  left  side  close 
to  the  symphysis,  and  on  the  right  side  through  the 
neck  of  the  jaw.  Crepitation  was  also  detected  over 
the  right  malar  bone.  The  temperature  rose  to  100.2° 
F.  The  next  evening  it  fell  to  normal,  and  remained 
so  until  about  the  eighth  day,  when  it  registered 
101.8°  F.,  and  five  days  later  104.6°  F.  During  the 
next  three  days  the  swelling  slightly  decreased.  On 
December  5th  the  temperature  rose  again  and  fluctua- 
tion was  detected  in  the  neck,  from  which  six  ounces 
of  pus  was  evacuated  through  incision.  On  the  thir- 
teenth day  a  copious  hemorrhage  took  place  from  the 
incision.  The  swelling  now  increased  and  on  the 
15th  distinct  pulsation  was  detected  on  the  right 
cheek.  On  examining  the  mouth  the  soft  palate  was 
seen  to  be  greatly  depressed  on  the  right  side  and  con- 
gested, and  pulsation  was  easily  felt.  On  the  24th 
he  had  slight  hemorrhage  from  the  mouth,  and  on  the 
26th  a  more  copious  hemorrhage.  Mr.  Brown  de- 
cided to  ligature  the  carotid.  On  the  third  day  after 
the  operation  the  patient  passed  faces  involuntarily, 
but  since  that  time  he  has  had  perfect  control  and 
made  an  uninterrupted  recovery. 

Umbilical  and  Epigastric  Hernia.  —  Dk.  A.  S. 
Garrow,  of  Montreal,  reported  a  case  of  this  kind. 
He  had  found  but  one  similar  case  on  record.  In  this 
case  the  contents  of  tlie  supra-umbilical  protrusion 
consisted  of  large  and  small  intestines,  CKCum,  with 
appendix  and  omentum,  tlie  latter  being  spread  out  so 
as  to  form  a  more  or  less  complete  sac.  There  were 
adhesions,  and  tlie  hernia  could  be  reduced  only  with 
difficulty.  The  umbilical  hernia  was  small,  sausage 
shaped,  and  contained  but  a  single  loop  of  small  in- 
testine, whicli  was  not  adherent  and  was  very  readily  re- 
duced. The  lesson  he  had  learned  from  the  case  was 
that  as  in  such  cases  it  was  impossible  to  recognize 
the  double  protrusion  before  incision,  after  opening 
the  main  sac  and  replacing  its  contents,  a  careful 
search    should   be   made   from    within    to    determine 


whether  any  other  hernia  existed,  before  proceeding 
to  remove  the  adipose  tissue.  The  speaker's  case  was 
that  of  a  woman  who  had  been  married  twenty-one 
years,  and  had  had  three  children.  Some  months 
after  the  birth  of  the  third  child,  a  small  lump  made 
its  appearance  about  one  inch  above  the  umbilicus. 
This  gradually  increased  in  size  until  three  years  ago, 
and  since  then  had  grown  rapidly.  The  principal 
sjTnptoms  were  abdominal  pain,  a  dragging-down  sen- 
sation, and  later  disturbances  in  digestion.  The  tu- 
mor was  irregularly  hemispherical,  freely  movable, 
soft  and  doughy  in  some  parts,  but  tense  and  elastic 
in  others,  irreducible,  distinctly  lobulated,  somewhat 
tender  on  pressure,  and  palpation  occasionally  elicited 
gurgling  sounds.  The  tissues  above  the  part  were 
very  thin,  so  that  the  outline  of  the  contents  could  be 
readily  distinguished.  By  an  elliptical  incision  the 
sac  was  reached  and  opened  at  its  upper  and  left  side. 
The  contents  were  with  difficulty  disentangled,  and 
reduction  could  not  be  effected  until  the  opening  had 
been  enlarged  upward  about  one  and  one-half  inches, 
and  then  only  with  difficulty.  On  lifting  up  the  mass 
preparatory  to  moving  it,  a  gurgling  sensation  was  de- 
tected, and  upon  dissection  toward  the  middle  line 
about  two  inches  below  the  lower  border  of  the  upper 
opening,  another  sac,  one  and  one-half  inches  in  di- 
ameter and  about  three  and  one-half  inches  in  length, 
was  discovered,  which  on  being  opened  was  found  to 
contain  small  intestines,  was  not  adherent,  and  was 
readily  reduced.  The  edges  of  both  openings  were 
freshed  and  brought  together  by  stout  catgut  sutures. 
The  patient  made  a  good  recovery. 

The  Operative  Treatment  of  High  Cancer  of  the 
Rectum — Dr.  James  Bell,  of  Montreal,  opened  the 
discussion  on  this  subject.  It  is  only  twelve  years, 
he  said,  since  the  removal  of  diseased  middle  and  up- 
per portions  of  the  rectum  has  become  practicable 
through  the  introduction  of  Kraske's  operation.  As 
to  the  frequency  of  this  disease,  Mr.  Sutton  says  that 
of  every  one  hundred  cases  of  carcinoma  of  the  in- 
testine, seventy-five  occur  in  the  rectum.  The  same 
rule  applies  here  as  in  cases  of  cancer  of  the  breast, 
that  early  and  complete  removal  of  the  growth  and 
of  the  contiguous  glands  has  made  possible  many 
cases  of  cure.  In  no  case  had  the  speaker  seen  an 
absence  of  involvement  of  the  glands.  The  reason  the 
disease  progresses  so  far  before  discovery  is  that  there 
are  no  early  bad  symptoms.  Even  later,  when  loss  of 
flesh  occurs  with  irregularity  of  the  bowels,  flatulence, 
etc.,  the  disease  is  not  often  suspected.  It  is  only 
when  symptoms  of  autointoxication,  with  sanious  or 
mucous  discharges  from  the  bowel,  occur,  that  an  ex- 
amination of  the  rectum  is  made  and  reveals  the  true 
condition  of  affairs.  Operable  cases  are:  (i)  Those 
in  which  there  is  a  chance  of  removing  the  whole  mass 
with  permanent  cure;  (2)  those  in  which,  though  the 
mass  is  removable,  the  probability  of  recurrence  is 
strong.  In  still  another  class,  in  which  there  is  no 
hope  of  removal,  inguinal  colotomy  should  be  done. 
The  routes  chosen  for  operation  are:  (i)  From  the 
abdomen;  (2)  tlirough  the  sacral  region;  and  (3)  in 
females  through  the  vagina.  The  second  is  the  one 
most  generally  applicable.  The  line  of  the  third  sa- 
cral foramina  is  the  upi^er  limit  of  the  incision.  The 
rectum  is  exposed  bv  one  of  the  osteoplastic  methods. 
The  author  generally  adopted  the  Heinecke  incision. 
He  believed  that  a  preliminary  colotomy  was  neces- 
sary. This  enables  the  operator  to  estimate  the 
amount  of  glandular  involvement;  free  evacuation 
and  cleansing  of  the  bowel  are  thus  made  possible, 
and,  should  a  permanent  artificial  opening  become 
necessary,  the  inguinal  opening  is  much  better  than 
the  sacral  one.  The  essentials  to  successful  resection 
are  a  clean  field  of  operation,  free  descent  of  the  prox- 
imal end  of  the  bowel  without  tension,  and  careful  su- 


September  i8,  1897] 


MEDICAL    RECORD. 


435 


turing.  The  speaker  thought  that  there  was  quite  an 
unnecessar)'  dread  of  bringing  down  the  upper  seg- 
ment of  the  bowel  for  fear  of  sloughing.  The  danger 
was*  rather  of  pulling  and  stretching  and  otherwise 
depressing  the  blood  supply.  If  the  mesorectum  and 
mesocolon  are  carefully  snipped  at  some  little  distance 
from  the  wall  of  the  bowel,  the  rectum  can  easily  be 
brought  down  several  inches  without  danger  of  slough- 
ing. After  suturing  the  cut  extremities  of  the  bowel 
through  all  their  coats,  Dr.  Bell  invaginated  the  prox- 
imal into  the  distal  end  and  applied  a  row  of  sutures 
through  the  serous  and  muscular  coats.  He  thought 
it  was  unavoidable  to  open  the  peritoneum  in  high 
operations  on  the  rectum,  but  this  was  not  to  be  feared 
if  the  opening  was  afterward  closed  with  sutures  and 
the  site  of  the  wound  was  properly  dressed  and  drained. 
The  question  as  to  when  the  colotomy  wound  is  to  be 
closed  depends  upon  the  completeness  of  the  restora- 
tion of  the  continuity  of  the  bowel  and  upon  the  prob- 
ability of  recurrence.  The  operation  is  not  without 
considerable  danger  as  there  are  ahva)  s  more  or  less 
shock  and  hemorrhage  connected  with  its  performance. 
Statistics,  though  at  all  times  very  unreliable,  show 
that  the  average  rate  of  mortality  after  the  operation 
is  not  greater  than  twenty  per  cent.,  and  that  ten  per 
cent,  or  twelve  per  cent,  of  the  patients  remain  well 
and  without  recurrence  for  four  years.  Dr.  Bell  con- 
cluded his  paper  by  narrating  briefly  the  history  of 
three  cases  of  cancer  of  the  rectum,  on  which  he  had 
operated  since  June,  1896. 

Dr.  C.  B.  B.\ll,  of  Dublin,  said  that  he  did  not 
perform  an  osteoplastic  operation,  but  removed  the 
lower  segment  of  the  sacrum  entirely.  In  the  osteo- 
plastic and  his  operation  the  statistics  showed  that 
the  mortality  had  been  higher,  but  that  may  have  been 
due  to  the  greater  extension  of  the  disease  in  the  cases 
they  had  undertaken  to  operate  on.  He  believed  the 
perineal  route  should  be  discarded ,  except,  of  course, 
in  those  cases  in  which  the  anus  was  involved.  The 
best  recoveries  in  these  cases  were  those  in  which  the 
tumors  were  freely  movable.  As  preliminary  to  the 
operation  he  usually  gave  purgatives  for  several  days, 
together  with  rectal  enemata,  to  insure  thorough 
cleansing  of  the  bowel.  Then  he  used  a  two-per-cent. 
solution  of  creolin  to  wash  out  the  bowel,  and  then 
gave  opium  to  prevent  peristalsis.  One  danger  that 
had  been  pointed  out  was  that  of  sloughing  of  the 
parts.  This  could  be  avoided  largely  by  care  in  ma- 
nipulation. The  parts  should  not  be  too  tense  and 
should  not  be  pressed  upon.  He  reported  seventeen 
cases,  with  sixteen  recoveries,  from  the  preliminary 
operation.  He  thought  that  we  should  operate  even 
when  the  cancer  was  high  up  and  the  glands  were  in- 
volved, for  present  relief.  He  preferred  this  opera- 
tion to  colotomy.  In  two  of  his  cases,  of  ten  and 
eleven  years'  standing  respectively,  there  had  been  no 
recurrence.  He  thought  the  prognosis  depended 
largely  on  an  early  diagnosis,  for  in  the  early  stages 
of  the  disease  the  operation  was  very  satisfactory. 
He  would  advise  against  operation  if  the  tumor  was 
immovable. 

Dr.  W.  W.  Keen,  of  Philadelphia,  said  that  all  parts 
of  the  digestive  tract  were  now  in  reach  of  surgical 
treatment,  except  a  part  of  the  cesophagus.  It  was 
only  of  late  years  that  operation  for  high  cancer  of 
tlie  rectum  had  been  attempted.  There  was  no  doubt 
that  Kraske's  operation  was  of  great  importance  and 
offered  relief  to  many  sufferers.  F-ven  when  the 
glands  were  considerably  involved  he  had  found  that 
patients  improved  very  much.  He  did  not  think  the 
osteoplastic  method  was  at  all  necessary.  It  was  his 
custom  to  remove  the  coccyx  and  the  adjoining  por- 
tion of  the  sacrum,  but  he  differed  from  Dr.  Ball  and 
agreed  with  Dr.  Bell  as  to  the  advisability  of  doing  a 
preliminarj'  inguinal  colotomy,  whether  temporarj-  or 


permanent.  But  the  two  operations  should  never  be 
done  at  one  sitting.  The  main  object  of  this  pre- 
liminary procedure  was  to  prevent  infection  of  the 
bowel.  It  was  better  to  wait  two  or  three  weeks  for 
the  subsequent  operation.  Kraske's  view  was  that  a 
preliminary  colotomy  was  to  be  done  only  in  case  the 
obstruction  was  so  complete  that  this  cleansing  could 
not  be  effected  without  it.  Dr.  Keen  thought  the  op- 
eration was  necessary  to  unload  and  cleanse  the 
bowel.  In  many  cases  the  two  cut  ends  of  bowel  can- 
not be  accurately  joined,  or  the  whole  lower  bowel 
may  have  to  be  removed.  Colotomy  is  of  great  assist- 
ance. In  one  of  his  cases  the  preliminary  colotomy 
was  so  satisfactory-  that  the  patient  refused  the  radi- 
cal one  for  removal  of  the  cancer.  The  recurrence 
limit  is  four  years.  He  reported  twenty-five  cases. 
Of  these,  fifteen  involved  sacral  operations,  and  there 
were  twelve  recoveries.  Four  of  these  had  already 
passed  the  four-year  limit.  He  believed  in  prolonged 
purgation.  He  had  one  case  in  which  purgatives  were 
administered  for  seventeen  days,  and  still  at  operation 
the  bowel  was  loaded.  It  was  a  good  plan  to  examine 
the  urine  for  indican,  to  show  if  the  bowel  was  empty. 
Dr.  Ashhurst,  of  Philadelphia,  said  he  was  never 
ver)'  enthusiastic  about  operation  for  the  removal  of 
cancer  of  the  rectum,  although  his  views  had  become 
somewhat  modified  since  visiting  Montreal,  having 
seen  some  cases  in  which  it  had  proved  beneficial. 
He  thought  if  the  disease  had  gone  on  to  obstruction, 
it  was  better  to  make  an  artificial  anus.  He  was  rather 
in  favor  of  doing  the  preliminary  colotomy  as  a  safe- 
guard, for  in  some  cases,  if  resection  was  done  without 
his  preliminary  step,  there  occurred  a  low  form  of 
peritonitis,  accompanied  by  vomiting,  so  that  it  was 
difficult  to  nourish  the  patient:  whereas  if  there  was 
an  opening  in  the  colon,  this  could  be  used  for  the  in- 
troduction of  food,  saline  injections,  etc.,  without  in- 
terfering with  the  rectum  itself.  He  agreed  with  Dr. 
Ball  that  it  was  better  to  remove  the  coccyx  entirely. 
He  wished  to  speak  of  one  procedure  of  a  palliative 
character  which  he  found  very  useful ;  that  was  a 
small,  longitudinal  section  of  the  rectum  through  the 
mass  of  disease  in  the  median  line  posteriorly. 

(  To  be  Continued.') 


^otrcjespouclewce. 


OUR   LONDON    LETTER. 


CFr< 


■  Special  Correspondent.) 


OUR    OVERCROWDED     PROFESSION — PROSPECTS     OF     THE 

prince's      hospital      fund THE      OTHER      FUNDS — 

NEW      NURSING-HO.ME — IRISH      MEDICAL       LOY.ALTY 

RENOVATION    OF    LONDON    HOSPITALS. 

London,  September  3,  1897. 

.So.ME  of  the  newspapers  have  been  opening  their  col- 
umns, during  this  "silly  season,"  to  the  grievances  of 
our  "  overcrowded  profession."  The  correspondence 
has  been  about  as  instructive  and  will  have  about  as 
much  effect  as  previous  discussions  at  this  season.  It 
furnishes  fair  copy  to  fill  the  columns  of  the  paper, 
and  will  at  once  be  forgotten.  If  the  newspapers 
would  restrict  the  correspondence  to  the  grievances  of 
the  army  surgeons  and  would  careful Iv  examine  them 
and  editorially  insist  on  the  public  ser\ices  being  con- 
ducted solely  with  a  view-to  their  efficiency,  we  should 
soon  have  a  reform.  But  the  ventilation  of  the  heterc- 
geneous  difficulties  of  private  practitioners  does  not 
seem  calculated  to  enlist  the  sympathy  of  the  public. 
The  newspapers  which  pretend  so  far  to  feel  for  our 
"overcrowded  profession"  are  not  ashamed  to  fill  their 
columns  with  the  doings  of  quacks  and  to  receive  enor- 


436 


MEDICAL    RECORD. 


[September  i8,  1897 


mous  revenues  from  advertisements  the)'  know  to  be 
lying  snares  for  the  credulous  sick. 

The  precise  position  that  will  be  filled  by  the  I'rince 
of  Wales'  hospital  fund  has  been  the  subject  of  no  little 
speculation  in  medical-society  circles,  \\hat  it  will  do 
and  what  it  cannot  do  are  points  that  have  been  freely 
discussed — so  freely  that  I  may  as  well  draw  attention 
to  some  of  the  facts,  if  1  do  not  venture  to  add  to  the 
numerous  predictions  being  circulated.  First  of  all, 
^"150,000  has  been  raised  as  donations.  How  much 
of  this  may  be  regarded  as  likely  to  be  repeated  yearly  ? 
Some  experienced  managers  estimate  that  one-fourth 
of  the  donors  will  probably  continue  their  gifts  each 
year,  so  that  a  smn  of  ^?37,ooo  may  be  expected  from 
this  source.  Add  to  this  that  annual  subscriptions 
have  been  promised  amounting  to  _£"25,ooo.  Thus, 
apart  from  a  considerable  reserve  fund  that  has  been 
raised,  an  annual  income  may  be  expected  of  more 
than  _£'62,ooo — a  better  result  than  the  Sunday  fund. 
As  the  Prince's  fund  will  not  close  until  the  end  of 
the  year,  it  is  by  no  means  certain  that  the  _£,' 100,000 
a  year  originally  contemplated  may  not  be  obtained — 
a  great  triumph  for  the  Prince.  The  sale  of  hospital 
stamps — a  suggestion  of  the  Daily  Mail — has  been 
enormous,  and  it  is  thought  may  reach  a  sura  of  ,-{'50,- 
000;  there  is  talk  of  "hospital  stamps"  being  made  a 
source  of  permanent  income — an  additional  triumph 
for  the  Daily  Mail. 

What  will  be  the  result  of  the  success  of  the  new 
fund  on  hospital  finance.'  The  more  sanguine  spirits 
allege  that  it  will  be  a  simple  addition  to  hospital  in- 
come. 1  doubt  this.  My  experience  tells  me  that 
many  ha\e  given  to  the  Prince's  fund  what  would  in 
some  fonn  have  reached  some  hospitals.  It  is  true 
thit  tlie  Sunday  and  Saturday  funds  have  not  been  so 
much  behindhand  this  year  as  many  feared,  but  it  is 
by  no  means  certain  that  they  will  maintain  their  pres- 
ent position.  Certainly  the  Sunday  fund  will  not, 
unless  it  mends  its  manners — a  point  I  have  previously 
insisted  on.  I  have  advised  every  one  my  influence 
reaches  to  give  to  the  Prince's  instead  of  the  Sunday 
fund,  and  I  know  others  who  are  pursuing  the  same 
course.  This  must  e-ventually  tell,  and  if  only  the 
Prince's  advisers  avoid  the  rocks  on  which  the  Sundav- 
fund  committee  has  injured  its  craft  it  will  become 
the  most  popular  of  such  agencies.  Its  expenses  are 
expected  to  be  only  about  two  and  one-half  per  cent., 
perhaps  less,  and  thus  the  money  contributed  to  it  will 
go  direct  to  the  hospitals  without  a  great  deduction  for 
salaries  and  so  on. 

It  is  feared  in  some  quarters  that  the  Sunday  fund 
or  the  Charity  Organization  Society  may  get  a  finger 
in  the  distribution  of  the  Prince's  fund.  It  is  to  be 
hoped  that  neither  may,  for  neither  is  to  be  trusted. 
Burdett's  "  Hospitals  and  Charities"  urges  that  care 
will  have  to  be  taken  to  weigh  the  circumstances  of 
each  institution.  In  reviewing  that  book,  the  British 
Mciiiial /oiir/ial  wdiniA  to  know  who  is  to  weigh.-'  The 
idea,  says  your  contemporary,  of  a  central  board  as 
proposed  by  the  Charity  Organization  Societv,  "  has 
been  very  unfavorably  received  by  the  great  hospitals 
and  very  liostilely  criticised  by  Sir  Henry  lUirdett 
himself;"  and  further  adds  that  "no  one  [unless  it  be 
Sir  Henry  himself]  will  be  satisfied  to  put  the  weigh- 
ing machine  into  the  hands  of  the  Hospital  Sunday 
Fund."  .\s  I  long  ago  pointed  out  the  shortcomings 
of  that  fund,  I  am  glad  to  see  how  naturally  your 
contemporary  is  led  by  the  same  facts  to  this  view. 
Another  co  temporary,  T/tc- Hospital,  has  attempted  a 
defence  of  the  distribution  committee,  but  instead  of 
calmly  examining  the  case  indulges  in  ill-timed  and 
ill-tempered  abuse  of  the  critics  of  the  fund  and 
charges  them  with  not  taking  the  trouble  to  ascertain 
the  facts.  It  is  only  a  weak  case  that  the  plan  of 
abusing  opponents'  attorney  has  been   said   to   help. 


The  truth  is  that  those  who  complain  of  the  partiality 
of  the  distribution  committee  are  men  who  have  an 
intimate  acquaintance  with  the  facts  and  personal  ex- 
perience of  hospital  management.  . 

Two  of  our  London  hospitals  have  closed  their  out- 
patient departments  for  renovation  and  repair,  and  St. 
iVIary's  remains  entirely  closed  until  the  end  of  this 
month.  It  is  not  much  trouble  to  close  out-patient 
departments,  and  never  seems  to  produce  inconven- 
ience— a  fact  which  might  be  used  with  some  effect  bv 
the  Hospital  Reform  Association.  Of  course,  clos- 
ing the  wards  requires  special  arrangements  for  trans- 
fer of  those  patients  who  are  unfit  for  discharge,  and 
is  a  serious  trouble  to  the  managers,  though  it  gives  a 
complete  holiday  to  all  the  staff.  The  students  of  St. 
Mary's  have  been  granted  permission  to  attend  the 
practice  of  the  Middlesex  Hospital  until  the  reopening 
of  their  own  wards. 


S^XexUcal  ^ems. 


Contagious  Diseases — Weekly    Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitarj-  Bureau,  Health  Department,  for  the 
week  ending  September  11,  1897  : 


Cases. 


Tuberculosis I  1 5S 

Typhoid  fever 19 

Scarlet  fever |  77 

Cerebro-spinal  meningitis ,  o 

Measles |  40 

Diphtheria i  131 

Larj-ngeal  diphtheria  (croup) 6 

Chicken-pox •  i 


The  Effect  of  Weather  on  Haemoptysis. — Dr.  Eg- 

ger  (^Corrcspondeuzblatt fitr  Sch'iL'eizer  Aerzic,  1896.  Xo. 
18)  bases  his  conclusions  on  information  obtained 
from  the  records  of  the  Basle  Polyclinic,  with  the  fol- 
lowing results:  the  change  from  good  to  bad  weather, 
from  warm  to  cold  or  cold  to  warm  seasons,  corresponds 
with  a  change  for  the  worse  in  the  condition  of  many 
patients  with  pulmonary  disease.  In  a  large  number 
of  cases  coughing  is  increased,  and  in  some  the  cough 
causes  an  increase  of  pressure  in  the  pulmonar)"  circu- 
lation and  thus  favors  hemorrhage.  Changes  in  the 
weather  which  favor  catching  cold  have  serious  con- 
sequences; so  have  epidemics  of  bronchitis,  influ- 
enza, etc. 

Health  Reports. —  The  following  statistics  concern- 
ing yellow  fever,  cholera,  small-pox,  and  plague  have 
been  received  in  the  office  of  the  United  States  Marine 
Hospital  service  during  the  week  ended  September 
.,,  1897: 


Cases.       Deaths. 


. .  September  ist  to  6th. . 
Small*  Pox — Forbicx. 


-Vm 


St.vtes. 


New  Orleans  1^.,  September  loth. — L'p  to    this  date    there    have  been 
.Itath  and  12  cases  reported  as  suspicion";  by  the  bvtard  of  health. 

Ocean  Sprinj^,  Miss.,  September  loth. — There  have  beeu  3  deaths  aud 
;ases  of  yeJlow  fever. 
Perkinsion.    Miss.,   September    lolh. — One    case   reported;    contracted    ii 
Sprin>rs. 
agi>ula.  Ntiss.,  September  loth. — One  case  reported;  orisin  not  dear. 


Oo 


Yellow  Fevkk— Foreign. 


Cases.       Draths. 


Para,  Ilni/il August  14th  to  sist. 

Cholek.v. 

r.onibav,  India Au^:ust  i^d  to  loih  . . 

I  iilciitia,  India July  a4tn  to  51st  . .. 

» isaka  and  Hiogo,  Japan Auirust  ist  to  14th.. 


Medical  Record 


A  U^eekly  yotirnal  of  Medicine  and  Surgery 


Vol.  52,  No.  13. 
Whole  No.  1403. 


New  York,   September    25,    1S97, 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©viginal  l^rttcles. 

REMARKS  UPON  THE  XON-OPERATIVE 
TREATMENT  OF  CHRONIC  SUPPURA- 
TIVE DISEASE  OF  THE  ANTRUM  AND 
VAULT    OF   THE   TYMPANUM.' 


By    albert    H. 


iCCK.    M.I). 


CL1N1C.\L  PROFESSOR  OF  THE  DISEASES  OF  THE  EAR.  COLLEGE  OF  PHYSICIANS 
A«D  SURCEO.NS,  MEDICAL  DEPARTMENT  OP  COLUMBIA  UNIVERSITY',  NEW 
YORK  CITV  ;  CONSULTING  AURAL  SURGEON.  NEW  YORK  EVE  AND  EAK  IN- 
FlRilARV   A^ND   THE  PRESEY'TERIAN   HOSPITAL. 

Recent  otological  literature  is  full  of  treatises  which 
deal  with  the  subject  of  new  operative  methods  for  the 
cure  of  chronic  suppurative  processes  in  the  vault  of 
the  tympanum  and  the  mastoid  antrum.  Of  these  oper- 
ations ossiculectomy  (for  those  cases  in  which  the 
disease  is  limited  to  a  small  area  within  the  tympanum) 
and  the  so-called  Stacke's  operation  (for  those  in 
which  the  antrum  is  also  involved)  are  the  two  repre- 
sentative types.  It  is  not  necessary  here  to  enter  into 
any  further  details  regarding  these  operations  or  to 
discuss  their  relative  merits.  Suffice  it  to  say  that 
both  of  them  have  passed  the  probationary  stage  and 
are  now  generally  accepted  by  otologists  as  safe  and 
effective  surgical  procedures  for  the  cure  of  the  patho- 
logical conditions  referred  to  above.  Conceding, 
therefore,  as  I  do,  the  value  and  the  safety  of  these 
operations,  I  am  nevertheless  disposed  to  believe  that 
they  are  resorted  to  in  many  cases  in  which  the  sim- 
pler cleansing  methods  would  be  found  to  be  quite  as 
effective  in  curing  the  disease.  I  should  perhaps 
qualify  this  remark  by  stating  that  it  has  reference 
mainly  to  cases  which  are  seen  in  private  practice. 
In  the  treatment  of  infirmary  patients  it  is  not  often 
possible  in  our  large  cities  to  devote  at  least  half  an 
hour,  twice  or  three  times  a  week,  to  a  single  case; 
and,  furthermore,  our  experience  in  New  York  has 
shown  that  infirmary  patients  cannot  be  depended 
upon  to  attend  the  institution  regularly  for  treatment. 
But,  unless  these  cleansing  procedures  are  carried  out 
in  a  minute  and  painstaking  fashion,  and  at  rather 
frequent  inter\-als  (two  or  three  times  a  week),  at  best 
only  a  temporary  amelioration  of  the  disease  will  be 
secured.  I  am  satisfied,  therefore,  that  in  dealing 
with  this  class  of  patients,  the  otologist  is  quite  riglu 
in  urging  the  operative  rather  than  the  non-operative 
mode  of  treatment.  In  private  practice,  however,  the 
conditions  are  quite  different.  The  surgeon  can  give 
to  this  class  of  cases  all  the  time  that  may  be  required, 
and  the  patients  themselves  can  be  depended  upon  to 
be  regular  in  their  attendance.  Then  again  many 
private  patients  object  strongly  to  being  subjected  to 
an  operation  which  requires  the  use  of  ether  or  chloro- 
lOrm  as  an  anasthetic,  and  which  may  keep  them  con- 
fined to  the  bed  or  to  the  house  for  several  days.  It 
is  natural,  therefore,  that  these  individuals,  when  the 
situation   is  laid  before  them,  should   prefer  to  have 

'  Read  before  the  section  of  laryngology  and  otology  of  the 
British  Medical  .\ssociation,  at  its  meeting  in  Montreal,  Septem- 
ber 3,  iSg7. 


the  cleansing  or  non-operative  method  of  treatment 
tried  first.  It  is  not  in  every  case,  however — be  it 
clearly  understood — that  we  can  safely  offer  this 
choice  to  the  patient.  Symptoms  may  have  already 
developed  which  point  to  an  extension  of  the  disease 
to  important  neighboring  organs,  and  in  that  case  we 
must  recommend  strongly  the  more  radical  plan  of 
treatment  by  operation — either  Stacke's  or  the  regular 
mastoid  operation.  But  in  most,  if  not  all,  of  the 
cases  in  which  a  simple  ossiculectomy  is  performed, 
and  in  quite  a  large  proportion  of  those  operated  upon 
by  Stacke's  method,  no  such  threatening  symptoms 
exist,  and  consequently  we  are  at  liberty  to  deal  with 
the  problem  before  us  in  a  more  leisurely  manner. 
If,  in  such  cases,  the  opening  in  the  tympanic  mem- 
brane through  which  the  pus  and  other  products  of 
the  disease  escape  into  the  external  auditory  canal 
is  fairly  large — say  two  or  three  millimetres  in  diam- 
eter— and  particularly  if  it  occupies  a  high  position, 
theri  can  be  no  question  about  the  propriety  of  giving 
the  cleansing  method  a  fair  trial.  On  the  other  hand, 
if  the  opening  is  small — perhaps  not  more  than  a  mil- 
limetre in  diameter — or  if  it  occupies  a  low  position, 
the  simple  cleansing  method  is  more  likely  to  fail. 
But  even  here  a  limited  myringectomy  may  suffice  to 
overcome  this  drawback  and  so  place  these  cases  on  a 
par  with  the  others.  If,  however,  the  pus  finds  an 
outlet  through  the  membrana  flaccida,  it  is  better  to 
proceed  at  once  to  an  ossiculectomy  (including,  of 
course,  a  myringectomy).  The  necessity  for  a  Stacke's 
operation  or  for  a  mastoid  operation  in  this  class  of 
non-urgent  cases  becomes  clear  when  both  the  cleans- 
ing method  and  a  simple  ossiculectomy  (including  the 
anvil  as  well  as  the  hammer)  have  proved  unsuccessful 
in  arresting  the  foul-smelling  discharge. 

As  regards  the  details  of  the  cleansing  method  it  is 
enough  to  state  here  that  it  consists  essentially  of  only 
two  steps,  viz.,  the  removal,  chiefl)'  by  mechanical 
means,  of  all  granulation  tissue,  cast-off  epithelium, 
and  detritus  from  the  diseased  t}-mpanic  cavity  or  an- 
trum, and  the  destruction  by  chemical  means  of  all 
pathogenic  germs.  Injections  of  hydrogen  dioxide 
through  variously  curved  glass  tubes  play  a  very  im- 
portant part  in  the  procedure,  not  simply  on  account 
of  the  germicidal  action  of  this  fluid,  but  largely  be- 
cause the  active  effers-escence,  which  at  once  takes 
place  when  it  comes  in  contact  with  decomposing  or- 
ganic material,  aids  in  dislodging  the  obstructing 
substances.  When  once  the  cavity  has  been  cleared 
of  all  these  and  rendered  aseptic,  powdered  iodoform 
or  one  of  the  more  recent  antiseptic  powders  (euro- 
phen,  aristol,  etc.)  should  be  introduced  in  liberal 
quantit}-  and  allowed  to  remain  there  indefinitely. 
This,  in  brief,  is  the  mode  of  treatment  which  I  have 
termed  the  cleansing  method. 

In  conclusion,  permit  me  to  bear  further  testimony 
to  the  beneficial  results  which  are  obtained  from  the 
faithful  and  persistent  employment  of  this  method.  I 
believe  that  I  do  not  exaggerate  the  truth  when  I  say 
that  in  a  decided  majority  of  the  cases  treated  in  this 
manner  the  results  have  been  successful :  and  I  base 
this  belief  not  simply  upon  my  own  personal  experi- 
ence, but  also  upon  that  of  Other  otologists  with  whom 
I  have  had  an  opportunity  to  compare  notes. 


438 


MEDICAL    RECORD. 


[September  25,  1897 


SOME   OBSERVATIONS    ©N    THE    MANAGE- 
MENT   OF    EARLY    PHTHISIS. 

By  J.    L.    C.    WHITCOMl!,    M.Ii.. 

Personal  observation  and  a  clinical  experience  in 
a  large  number  of  cases,  in  a  climate  of  rare  efficacy 
in  this  disease,  have  led  me  to  the  conclusion  that, 
given  one  hundred  cases  of  incipient  phthisis, 
ninety  may  be  cured  by  proper  climatic  treatment, 
providing  only  such  treatment  be  begun  sufficiently 
early. 

It  is  needless,  perhaps,  to  say  that  on  this  proviso 
depends  the  whole  question  of  the  successful  treat- 
ment of  pulmonary  tuberculosis  to-day.  It  is  no  hy- 
perbole to  state  that  on  this  point  hangs  the  fate  of 
millions  of  lives.  In  other  words,  if  for  any  cause 
this  factor  of  treatment  must  be  omitted  in  any  given 
case  of  phthisis,  the  outlook  for  that  case  more  than 
justifies  the  terror  and  gloom  which  this  dread  malady 
inspires  in  the  minds  of  men.  Not  that  every  case 
of  phthisis  thus  left  without  the  benefit  of  a  proper 
climate  goes  on  invariably  to  a  fatal  termination. 
The  results  of  many  autopsies  give  us  reason  to  believe 
that  a  certain  percentage  recover  without  any  treat- 
ment whatever. 

In  such  cases  the  transient  hypotrophy  which  al- 
lowed a  slight  invasion  of  the  tubercle  bacilli  is  soon 
recovered  from.  The  reinforced  cells  rally  to  the 
rescue,  and  the  enemy  is  soon  surrounded  and  impris- 
oned m  a  mass  of  connective  tissue,  beyond  \Vhose 
protecting  walls  it  may  not  pass.  ISut  these  cases 
must  necessarily  be  few;  for,  a  foothold  once  obtained, 
the  morbid  products  of  germ  activity  tend  still  further 
to  vitiate  cell  vitality  alread}-  impaired  below  tlie 
point  of  successful  resistance,  and  unless  some  adven- 
titious aid  be  forthcoming  the  breach  must  become 
wider  and  wider  until  the  organism  succumbs.  The 
antitoxin  formed  by  bacillary  life,  and  which  tends  to 
limit  such  processes  in  nutrient  bouillon,  seems  unable 
to  perform  this  function  in  the  living  organism.  This 
fact  is  undoubtedly  due  to  the  blood  and  lymph  curr 
rents,  which  dissipate  the  antitoxic  principle  through- 
out the  system,  fertilizing  still  further  the  soil  essen- 
tial to  germ  propagation  and  rendering  phagocytic 
activity  less  potent      But  this  is  digressing. 

This  period  of  incipiency,  lasting  from  a  feu  weeks 
to  a  few  months  at  the  longest,  is  the  lime  and  the 
onYy  time  when  this  disease  can  be  attacked  with  any 
degree  of  certainty  as  to  the  final  result.  It  is  along 
this  line  of  primary  invasion  that  the  battle  must  be 
fought,  and  lost  or  won,  in  ninety-five  per  cent,  of 
cases.  It  is  at  this  point  that  all  the  resources  at  our 
command  must  be  brought  to  bear  if  the  subsequent 
treatment  of  the  disease  is  to  be  anything  but  a  blind 
trusting  to  chance  — a  helpless  drifting  on  to  sure  de- 
struction. When  this  fundamental  fact  in  the  treat- 
ment of  pulmonary  phthisis  is  grasped  in  all  its  vital 
significance  by  the  medical  professiim  at  large,  then 
and  then  only  will  the  apathy  born  of  ages  of  failure 
give  way  to  a  healthy  optimism. 

While  these  facts  are  recognized  in  a  general  \\a\', 
it  has  seemed  to  nie  that  this  critical  period  in  the 
history  of  phthisis — so  fraught  with  deepest  interest 
to  the  patient — is  not  given  the  attention  which  its 
importance  demands.  In  the  early  period  of  their 
di.sease,  how  many  are  told  that  they  have  "  weak 
lungs;  that  it  is  only  a  cold,  or  bronchitis,  or  any- 
thing, in  fact,  but  the  dreaded  truth? 

[  believe  that  all  physicians  must  plead  guilty  to 
this  weakness,  not  once,  but  many  times.  Frequently 
the  friends  are  piirti(ip<-s  (riiniiiis,  and  insist  that  all 
knowledge  of  the  real  condition  be  kept  from  the  pa- 
tient. On  what  code  of  ethics  can  such  practice  be 
justified?     The  very  life  of  the  patient  often  depends 


on  his  having  a  true  conception  of  his  disease.  No 
hard-and-fast  rule  can  be  formulated,  but  in  a  general 
way  all  persons  over  twenty  years  of  age  should  be 
told  their  exact  condition,  while  tho.se  under  that  age 
should  have  their  family  or  friends  as  fully  informed. 
It  is  safe  to  say  that  many  lives  have  been  sacrificed 
as  a  direct  result  of  this  moral  cowardice  of  the  medi- 
cal attendant.  This  mistaken  charity  that  would  as- 
sume the  added  responsibility  of  shielding  a  patient 
from  a  knowledge  of  his  disease  is  a  very  prolific 
source  of  harm  in  phthisis.  This  burden  rightfully 
belongs  to  the  patient  and  his  family,  and  no  one  can 
reasonably  ask  the  physician  to  carry  it.  It  is  a 
wrong,  not  only  to  the  patient,  but  to  the  physician's 
better  judgment  and  to  the  State  which  licensed  him 
to  practise.  Let  the  patient  face  his  condition  at  once 
and  become  familiar  with  it  in  all  its  bearings.  This 
knowledge  must  come  sooner  or  later;  and  the  sooner 
he  understands  the  seriousness  of  his  disease,  the  bet- 
ter for  all  concerned.  The  mental  shock  and  depres- 
sion following  such  knowledge  will  soon  give  way  be- 
fore the  hope  that  "springs  eternal  in  the  human 
breast,"  and  we  shall  win  the  hearty  co-operation  of 
our  patient  in  all  our  efforts  to  better  his  condition ; 
also  his  lasting  gratitude  and  respect,  and  not  infre- 
quently the  longer  continuance  of  his  confidence. 

While  I  have  always  held  these  views  on  this  mat- 
ter, my  convictions  have  been  strongly  confirmed  dur- 
ing my  residence  in  Liberty,  where  my  practice  is 
largely  among  consumptives  sent  here  for  their  health. 
It  has  been  a  matter  of  much  surprise  to  me  how  few 
of  these  patients  know  their  real  condition  and  how 
many  of  them  imagine  that  a  few  weeks  in  the  moun- 
tains is  going  to  make  them  well  men  and  women 
again. 

Unless  there  be  some  adequate  reason  which  makes 
such  a  course  inexpedient,  I  invariably  set  the  facts 
of  his  case  frankly  before  my  patient,  at  the  same  time 
giving  him  every  encouragement  which  such  facts  jus- 
tify, as  well  as  the  benefit  of  every  doubt.  Having 
done  this,  I  feel  that  half  the  battle  is  won.  When 
the  patient  realizes  that  his  return  to  health  depends, 
not  on  a  few  weeks'  vacation  in  the  country,  but  on 
months  and  perhaps  years  of  such  residence :  that  it  is 
to  be  a  long  pull  and  a  strong  pull  for  life — then  he 
will  make  calculations  accordingly  and  set  his  house 
in  order.  This  means  very  much  to  persons  of  family 
or  of  business  aft'airs.  'I'he  mind  is  now  no  longer 
haunted  by  fears  it  dare  not  express,  and  the  mental 
tranquillity  which  succeeds  is  highly  conducive  to 
physical  well-being. 

The  one  point  which  I  wish  to  emphasize  with  all 
the  force  of  which  I  am  capable — the  point  the  import- 
ance of  which  overshadows  and  minimizes  every  other 
consideration  in  the  treatment  of  this  subject — is  that 
suitable  climatic  environment  is  the  absolute  prerequi- 
site of  any  successful  treatment  of  phthisis  so  far  as 
medical  knowledge  can  affirm  at  the  present  time.  Of 
no  other  disease  can  this  be  said.  In  a  nutshell,  our 
onlv  rational  treatment  is:  ist,  an  early  diagnosis;  2d. 
a  suit.ible  climate.  Give  the  patient  the  benefit  of 
these,  and  we  give  him  nine  chances  to  get  well  to 
one  against  it.  True,  this  is  not  recent  knowledge: 
it  belongs  to  medical  classics.  Vet  one  sees  it  so 
often  ignored  in  practice  th.it  the  conclusion  is  forced 
that  it  is  not  assigned  its  true  importance  relative  to 
the  numerous  medicinal  remedies,  whose  name  is 
legion  :  many  of  which  are  forced  on  the  profession  by 
ambitious  and  designing  men  or  through  the  agency  of 
an  impertinently  aggressive  commercialism. 

Creosote  or  some  of  its  derivatives,  antiphthisin, 
nuclein.  asepiolin.  tuberculocidin.  and  many  others 
are  einploved,  one  or  all,  perhaps,  before  the  all-im- 
portant subject  of  climate  is  considered,  except  in  an 
incidental  manner  or  as  a  means  of  last  resort.     In 


September  25,  1897] 


MEDICAL    RECORD. 


439 


the  spirit  that  would  tr)-  all  things  and  hold  fast  to 
that  which  is  good,  I  have  tested  fairly  and  without 
prejudice  all  of  the  above-mentioned  much-vaunted 
"cures"  for  phthisis,  and  I  do  not  hesitate  to  say  that, 
with  the  exception  of  creosote,  I  consider  them  all  of 
no  practical  value.  Of  creosote  I  shall  have  more  to 
say. 

What  is  needed  is  o.xygen — the  o.xygen  of  pure  dry 
air.  This  alone  is  a  specific  in  early  phthisis.  It 
will  not  cure  every  case — no  specific  does  that;  but  it 
will  cure  nine  in  every  ten,  providing  enough  of  the 
remedy  is  utilized.  And  this  means  e.\ercise  in  the 
open  air  to  the  point  of  fatigue.  It  matters  little  what 
form  of  exercise  is  used,  so  long  as  the  lungs  are  ex- 
panded and  the  appetite  is  increased  and  rapid  tissue 
metabolism  is  promoted.  It  is  a  great  law  of  organic 
life  that  all  strength  comes  from  work;  that  is,  the  ex- 
ercise of  function,  whatever  that  function  may  be. 
The  muscle  becomes  strong  from  exercise;  in  other 
words,  rapid  metabolism.  Likewise,  ever)'  individual 
cell  in  the  body  must  work  or  functionate  up  to  a  cer- 
tain point,  in  order  to  maintain  its  physiological  in- 
tegrity. Otherwise  fatty  degeneration  supervenes. 
Fat  is  the  only  tissue  in  the  body  that  does  not  dimin- 
ish and  deteriorate  for  want  of  work;  for  it  is  itself 
potential  energy.  The  theory  has  already  been  ad- 
vanced that  phthisis  is  but  a  process  of  fatty  degener- 
ation and  that  the  so-called  germs  are  but  crystals  of 
fat.  While  this  position  cannot  be  sustained,  it  is 
worthy  of  note  that  phthisis  usually  occurs  in  those 
who  live  and  work  largely  indoors,  who  exercise  their 
lungs  the  least  and  consequently  have  narrow  chests. 
.\lsothe  usual  seat  of  primary  phthisis  is  at  the  apices, 
where  functional  activity  is  least.  If  a  muscle  is  not 
used  for  a  greater  or  less  period  of  time,  fatt)'  degen- 
eration results.  Would  it  not  be  rational  to  infer  that 
the  same  general  law  applied  with  equal  force  to  lung 
tissue  ? 

.\  degeneration  here,  however,  would  be  modified  by 
the  presence  of  air,  catarrhal  inflammation,  and  tuber- 
cle bacilli  always  present,  but  which  now  find  a  favor- 
able medium  for  their  activity.  Whether  the  primary 
condition  be  one  of  degeneration  or  not,  all  concede 
that  tl>ere  must  be  marked  hypotrophy  before  the 
germs  can  step  in  to  produce  by  their  propagation  and 
life  processes  the  morbid  entity  known  as  phthisis  pul- 
monalis.  In  other  words,  no  hypotrophy  no  phthisis, 
germs  or  no  germs. 

Even  if  we  admit  that  the  bacilli  are  essential  to 
the  fully  developed  disease,  although  of  secondary  im- 
portance to  the  pre-existing  hypotrophy,  is  this  fact 
sufficient  to  constitute  it  a  germ  disease?  If  so,  then 
it  differs  radically  from  all  other  germ  diseases.  It 
makes  a  vast  difference  in  the  treatment  of  this  dis- 
ease, according  as  we  consider  the  germs  or  the  hypo- 
trophy as  the  main  factor  in  its  causation,  and  there- 
fore the  one  to  be  attacked. 

Perhaps  one  of  the  strongest  arguments  that  can  be 
advanced  in  favor  of  the  degeneration  theory  of 
phthisis  is  found  in  the  far  superior  results  obtained 
in  treating  it  as  such.  If  an  organ  or  a  muscle  be  de- 
generated, we  restore  its  function  by  exercising  it  and 
thereby  promoting  its  nutrition.  We  use  electricit}' 
or  massage,  or  by  the  voluntary  use  of  a  striated  mus- 
cle. .\pplying  this  same  principle  of  treatment  to  a 
degenerated  lung  gives  results  that  far  exceed  those 
that  follow  treating  it  with  germicides.  At  present 
the  germ  theory  of  phthisis  is  in  the  ascendancy,  and 
it  seems  rather  heretical  and  reactionary  even  to  sug- 
gest anything  to  the  contrary.  However,  I  am  inclined 
to  think  that  "  not  proven"  would  be  the  verdict  of  by 
far  the  greater  number  of  those  who  see  the  most  of 
this  disease. 

Regarding  creosote,  I  believe  that  in  this  drug  we 
possess  a  remedy  of  undoubted  value   in   all  forms  of 


tuberculosis  and  of  special  value  in  phthisis.  Given 
to  the  point  of  tolerance,  it  seems  capable  of  exerting 
marked  curative  properties,  in  some  cases  amounting 
almost  to  a  specific  action.  There  are  but  few  per- 
sons who  cannot  take  it  in  moderate  doses,  while 
many  can  take  large  quantities  of  it.  My  experience 
with  creosote  coincides  with  that  of  Sommerbrodt, 
Gutmann  and  Beaumetz,  and  others  as  regards  the 
greater  value  of  large  doses.  I  also  find,  in  common 
with  Burlureaux,  that  it  has  a  prognostic  value. 
Those  who  can  tolerate  large  doses  are  much  more 
likely  to  recover  than  those  who  cannot,  although  the 
former  may  show  the  greater  lung  involvement — al- 
though I  have  seen  one  notable  exception  to  this  rule. 
A  lady  of  about  thirty  years  of  age  came  under  my 
treatment  three  years  ago.  She  had  a  large-sized  cav- 
ity in  the  right  upper  lobe,  and  at  one  time  was  very 
low.  She  rallied,  however,  and  became  a  great  walker, 
doing  her  twelve  and  fifteen  miles  nearly  every  day. 
She  walked  herself  into  excellent  health  and  returned 
to  the  city  about  a  year  ago,  where  she  works  at  her 
profession  of  t}'pewriting.  This  lady  could  not  take 
one  drop  of  creosote  without  bringing  on  a  severe  di- 
arrhoea. She  tried  it  several  times,  always  with  the 
same  result. 

The  following  case  exemplifies  the  more  common 
experience : 

Mr.  K ,  aged  thirty,   American,   letter  carrier; 

height,  five  feet  ten  inches;  weight,  one  hundred 
and  sixty  pounds.  Came  under  treatinent  one  year 
ago  with  phthisis,  second  stage.  He  was  taking  one 
of  the  numerous  preparations  of  cod  liver  oil  with  two 
or  three  minims  of  creosote  to  the  dose.  He  had 
been  gradually  losing  ground,  although  he  had  been 
up  here  in  the  country  for  two  months.  I  at  once  put 
him  on  creosote  in  capsules,  increasing  the  dose  one 
drop  each  dose  until  he  was  taking  three  hundred 
drops  a  day  without  the  slightest  ill  effect.  His  urine 
remained  normal  throughout,  and  his  stomach  and 
bowels  were  not  the  least  irritated.  His  appetite  im- 
proved immediately  and  he  gained  five  pounds  the 
first  month  of  treatment.  He  was  anxious  still  to  in- 
crease the  creosote,  but  I  advised  against  it.  Soon 
after  this  he  had  to  return  to  his  duties  and  I  lost 
sight  of  him. 

The  writer  has  taken  two  hundred  drops  of  creosote 
a  day  for  a  week  at  a  time  on  several  different  occa- 
sions, without  causing  any  gastric  or  bowel  disturb- 
ance, but  with  the  result  of  producing  a  large  flow  of 
colorless  urine  of  low  specific  gravity  but  never  contain- 
ing any  albumin  or  casts.  He  has  taken  one  hundred 
drops  a  day  for  months  at  a  time  without  anything  but 
the  happiest  results  in  improved  appetite  and  increased 
weight,  and  diminished  cough  and  night  sweats  and 
fever  and  other  symptoms  resulting  from  tuberculous 
involvement  of  both  lungs. 

I  consider  it  one  of  the  safest  medicinal  remedies 
we  can  employ  in  phthisis.  In  rather  a  busy  prac- 
tice, in  which  I  have  used  this  drug  quite  extensively 
for  a  number  of  years,  I  have  yet  to  see  the  first  case 
in  which  the  slightest  damage  has  been  done  or  anything 
but  the  most  trivial  disturbance  to  stomach,  bowels, 
or  kidneys  has  been  caused.  Of  course,  care  is  requi- 
site and  these  organs  must  be  watched.  I  have  never 
seen  a  case  of  haemoptysis  caused  by  it.  I  did 
have  one  experience  with  creosote,  however,  which  to 
me  was  unique. 

Mrs.  L ,  aged  twenty-eight,  married,  had  a  well- 
marked  cavity  in  the  left  lung  and  some  infiltration  of 
the  right  apex.  She  had  spent  two  years  in  a  sanatorium 
in  the  northern  part  of  this  State,  where  she  had  im- 
proved for  a  time.  Later,  however,  her  disease  be- 
came more  active  and  she  was  advised  to  try  Liberty. 
She  had  attempted  to  take  creosote  in  small  doses  dur- 
ing the  early  period  of  her  illness,  but  believing  that 


440 


MEDICAL    RECORD. 


[September  25,  1897 


It  disturbed  her  stomach  had  discontinued  it  after  a 
short  trial.  She  came  here  about  eighteen  months 
ago,  but  did  not  improve.  After  being  here  about 
three  months,  she  consulted  me  and  I  advised  her  to 
give  creosote  another  trial.  It  was  with  some  diffi- 
culty that  I  finally  induced  her  to  begin  it  in  small 
doses  and  gradually  increase  it  up  to  fifty-four  drops  a 
day.  This  seemed  to  be  the  point  of  tolerance  with 
her.  Her  appetite  improved  at  once  and  she  gained 
eighteen  pounds  during  the  next  three  months. 

The  peculiarity  of  this  case  which  made  it  unique 
in  my  experience  was  this:  Instead  of  the  cough  di- 
minishing, as  is  usual,  it  grew  continually  worse  until 
I  finally  stopped  the  creosote  because  of  this  distress- 
ing symptom.  The  expectoration  also  became  more 
abundant  and  changed  in  character.  It  became  more 
of  a  frothy  mucus,  such  as  results  from  a  congestion 
of  the  lungs  from  overexertion  or  from  inhaling  some 
irrititing  matter.  It  was  never  blood  stained,  how- 
ever. Auscultation  showed  harsh  breathing  and  moist 
rales  over  an  increased  area  surrounding  the  involved 
portions  of  lung.  This  indicated,  to  my  mind,  a  con- 
gestion in  and  around  these  tuberculous  areas.  In 
spite  of  this  she  gained  in  every  respect,  and  after 
stopping  the  creosote  she  held  the  ground  she  had 
gained,  while  her  cough  and  expectoration  diminished 
rapidly.  For  nearly  a  year  now  her  disease  has  been 
quiescent.  A  slight  dry  "  hack"  occasionally  reminds 
her,  however,  of  the  damage  already  done  and  of  the 
necessity  for  continual  care. 

This  case  is  of  especial  interest,  as  it  may  offer  a 
possible  explanation  of  the  modus  operandi  of  creo- 
sote in  piithisis.  Eeaumetz  claims  that  it  produces 
congestion  of  the  lungs,  and  may  even  produce  he- 
moptysis. The  elder  Loomis  claimed  that  when 
phthisis  was  cured  it  was  by  a  process  of  fibrosis,  the 
tuberculous  focus  becoming  sequestered  by  a  wall  of 
connective  tissue  and  thus  prevented  from  doing  fur- 
ther damage.  Koch  suggested  as  an  explanation  of 
the  curative  action  of  tuberculin  that  it  caused  a  zone 
of  congestion  around  the  tuberculous  foci,  promoting 
thereby  the  fibrosis  essential  to  a  cure.  Putting  all 
these  facts  and  theories  together  makes  it  conceivable 
that  creosote  acts  by  producing  a  certain  degree  of  hy- 
percemia  around  the  diseased  tissue,  and  thus  aiding 
the  conservative  process  of  connective-tissue  forma- 
tion. It  is  possible  that  it  is  this  property  of  creosote 
of  producing  the  requisite  amount  of  stimulation  of 
the  diseased  tissues  which  makes  it  the  agent /(?/■  ex- 
telknce  in  phthisis.  This  stimulation  if  carried  a  little 
farther  would  be  destructive  instead  .of  constructive, 
pathological  instead  of  conservative.  It  would  seem 
that  the  failure  of  tuberculin  as  a  safe  and  curative 
agent  lay  in  the  fact  that  it  carried  this  stimulation  of 
the  involved  tissue  beyond  the  point  of  reparative 
hyperasmia,  and  produced  in  some  cases  rapid  destruc- 
tion and  breaking  down  of  the  tuberculous  deposits, 
overwhelming  the  system  with  the  products  of  tissue 
decomposition  or  producing  an  eruption  of  miliary 
tubercle  over  extended  areas. 

Perhaps  we  would  not  be  justified  in  regarding 
creosote  as  a  specific  in  phthisis.  Yet  there  is  little 
doubt  that  it  has  an  elective  action  on  tuberculous 
processes  wherever  they  may  occur.  I  know  of  no 
more  efficient  remedy  than  creo.sote  in  tuberculous 
arthritis,  osteitis,  adenitis,  struma,  lupus,  or,  in  fact, 
the  local  or  general  manifestations  of  the  tuberculous 
diathesis  in  any  form.  In  this,  also,  it  resembles 
tuberculin. 

Besides  its  general  antituberculous  properties,  there 
is  reason  to  believe  that  in  pulmonary  tuberculosis  it 
is  pre-eminently  efficacious,  owing  to  the  fact  that  it 
is  largely  eliminated  liy  tlie  bronchial  mucous  mem- 
brane, it  being  an  excellent  expectorant  and  pulmo- 
nary alterative  in  other  than  tuberculous  affections  of 


the  lungs  and  bronchi.  This  action  is  seen  in  chronic 
bronchitis,  bronchiectasis,  pulmonary  fibrosis,  whoop- 
ing-cough, and  in  other  diseases  of  the  lungs. 

A  propos  to  this  subject,  the  matter  of  sanatoria  for 
the  special  treatment  of  phthisis  arises.  There  is 
much  said  and  written  of  late  about  the  advantages  of 
treatment  in  such  institutions.  Sanatoria  for  the  treat- 
ment of  phthisis  are  of  comparatively  recent  origin. 
A  quarter  of  a  century  would  cover  their  history. 
Both  the  medical  profession  and  the  laity  turned  to 
them  with  high  hopes  that  at  last  a  distinct  forward 
movement  had  been  made  in  the  treatment  of  this  dis- 
ease. It  is  needless  to  attempt  to  conceal  the  fact  that 
these  hopes  have  been  shattered  by  the  results  thus 
far  obtained.  The  yearly  reports  of  these  institutions, 
with  their  small  percentage  of  cures,  have  been  a  sad 
disappointment  to  all  who  are  interested  in  the  sub- 
ject; especially  so  when  it  is  considered  that  only  the 
incipient  and  most  favorable  cases  are  admitted.  Oc- 
casionally, with  blare  of  trumpets,  it  is  reported  that 
one  or  more  have  been  discharged  cured.  But  very 
little  is  said  about  the  scores  who  are  quietly  turned 
out  to  die.  That  all  who  are  thus  turned  out  worse 
.  .>an  when  they  entered  do  not  die  is  against  rather 
than  in  favor  of  hospital  treatment.  There  must  be 
something  inherently  and  radically  wrong  in  the  sys- 
tem. 

About  two  years  ago  a  party  of  five,  one  male  and 
four  females,  came  to  Liberty.  They  had  all  been  in 
a  noted  sanatorium  in  this  State,  for  periods  ranging 
from  six  months  to  two  years.  The  effect  on  their 
disease  of  their  residence  and  treatment  there  had  va- 
ried— sometimes  worse,  sometimes  better;  but  on  the 
whole  it  had  tended  downward,  until  they  were  advised 
to  change  climates.  This  they  did  by  coming  to  Lib- 
erty. Of  the  five,  one  died  within  three  itlonths.  She 
was  in  a  dying  condition,  in  fact,  when  she  came  here. 
The  other  four  are  well  to-day.  Their  improvement 
began  at  once  and  progressed  with  hardly  a  setback. 
If  anything,  their  gain  was  more  marked  during  the 
winter  months.  This  is  usual,  however,  in  my  experi- 
ence. It  was  the  unanimous  opinion  of  this  party,  as 
it  was  certainly  my  own,  that  they  would  never  have 
recovered  had  they  been  obliged  to  remain  in  a  sana- 
torium. The  life  had  become  so  intolerably  tedious 
and  obnoxious  that  their  chances  for  improvement  were 
greatly  diminished  at  least.  As  one  of  them  expressed 
it,  "  Death  would  have  been  a  blessing."  I  find  that 
this  is  invariably  the  case  with  those  who  have  once 
been  in  such  an  institution  and  live  to  tell  the  story. 
Usually  nothing  could  induce  them  to  repeat  the 
experience. 

Could  such  hospitals  be  opened  to  the  hopeless  and 
dying  cases  of  phthisis,  they  would  subserve  a  useful 
and  humane  purpose.  But  for  the  care  and  treatment 
of  early  cases  it  is  my  opinion  that  such  institutions 
are  not  only  useless,  but  diminish  the  chances  of  such 
cases  by  a  large  percentage.  I  have  reached  this 
opinion  only  after  careful  study  of  the  yearly  reports 
of  consumption  sanatoria  in  this  country  and  abroad, 
and  after  long  observation  of  phthisis  treated  within 
and  outside  such  places. 

The  causes  for  this  failure  are  not  far  to  seek.  The 
all-pervading  and  ever-present  depressing  effects  of 
institutionalism  and  hospitalism  on  the  mind  cannot 
help  being  detrimental  to  bodily  nutrition.  In  no 
disease  does  the  condition  of  the  mind  have  such  a 
powerful  effect  for  good  or  evil  as  in  phthisis,  and  in 
no  disease  is  it  so  essential  that  nutrition  be  pushed 
to  the  highest  possible  point. 

To  eat,  to  sleep,  to  awake,  and  to  exercise  by  the 
clock  and  under  orders  may  be  all  right  in  a  militarj' 
camp,  but  it  becomes  extremelv  monotonous  to  a  per- 
son ill  and  who  desires  relaxation  and  diversion  rather 
than  too  much  discipline.     Too  much  doctor,  nurse. 


September  25,  1897] 


MEDICAL    RECORD. 


441 


and  treatment,  too  much  looking  after  and  surveillance 
tend  to  produce  a  morbid  self-consciousness  and  sen- 
sitiveness to  slight  symptoms,  altogether  disastrous  to 
healtiiy  bodily  function.  In  habit  of  thought  and 
disposition  the  patient  soon  becomes  like  the  typical 
"rounder"  of  the  city  hospitals.  She  studies  her 
symptoms  and  treatment,  and  discusses  them  with  dis- 
gusting familiarity  in  season  and  out. 

The  constant  and  exclusive  association  with  the  sick 
in  the  dampening  social  atmosphere  of  a  hospital 
more  than  neutralizes  all  the  obvious  advantages  of 
such  treatment.  All  exercise  is  apt  to  be  half-hearted, 
perfunctory,  and  void  of  interest,  thereby  losing  half  of 
its  value.  The  outdoor  life  prescribed  soon  becomes 
nothing  more  than  sitting  wrapped  in  furs  on  a  veranda. 

That  far  better  results  are  obtained  outside  the  un- 
congenial influences  of  the  sanatorium  I  have  seen 
demonstrated  many  times.  About  eight  months  ago 
seven  young  fellows,  whose  ages  ranged  from  eighteen 
to  twenty-seven,  secured  board  in  a  private  boarding- 
house  near  by.  They  all  came  from  New  York  and 
vicinity  about  the  same  time,  and  all  were  suffering 
from  incipient  phthisis.  At  present  they  are  all  well 
and  robust,  and  remind  one  more  of  a  party  of  jovial 
college  boys  out  for  a  vacation  than  they  do  predes- 
tined candidates  for  an  early  grave.  They  have  all 
gained  much  in  flesh,  and  their  physical  signs  have 
so  far  disappeared  that  it  is  with  difficulty  that  any 
trace  of  their  former  existence  can  be  found.  One  of 
them,  the  youngest,  a  boy  of  eighteen  with  rather  a 
poor  physique  and  contracted  chest,  still  shows  a  ver\- 
few  bacilli  in  the  scant  sputum.  Otherwise  his  symp- 
toms have  all  disappeared. 

They  began  to  improve  immediately  on  coming 
here,  and  with  the  exception  of  slight  colds  occasion- 
ally, their  progress  has  been  uninterrupted.  All  of 
them  took  creosote  in  moderate  doses ;  also  cod-liver 
oil  part  of  the  time.  Hut  what  I  considered  to  be  the 
main  factor  in  their  rapid  improvement  was  the  pleas- 
antly active  outdoor  life  continually  followed.  The 
walks  and  drives,  the  fishing,  hunting,  and  skating 
parties,  and  frequent  e.vcursions  into  the  country,  all 
planned  with  some  definite  object  in  view,  tended  to 
produce  that  forgetfulness  of  self  and  bodily  function 
so  necessary  to  perfect  nutrition. 

No  aimless  and  spiritless  wandering  up  and  down 
in  glass-inclosed  balconies;  or  curling  up  in  furs  in 
torpid  inactivity,  like  a  hibernating  animal,  on  open 
porches,  can  produce  such  results.  It  may  be  all  that 
can  be  done  for  advanced  cases,  but  it  is  certainly  bad 
for  early  phthisis. 

Such  results  as  above  noted  have  been  so  common 
in  my  experience  that  I  do  not  hesitate  to  repeat  the 
statement  made  in  the  beginning  of  this  paper,  that 
ninety  per  cent,  of  incipient  phthisis  can  be  cured  by 
climatic  treatment — which  means  an  active  life,  out- 
of-doors  practically  night  and  day,  for  sleeping-rooms 
should  communicate  freely  with  the  outside.  And  this 
should  be  in  a  dry  climate,  at  an  altitude  of  from 
twelve  hundred  to  twenty-five  hundred  feet.  I  often 
advise  young  men  who  cannot  afford  to  board  in  the 
country  long  enough  to  get  well  to  hire  themselves 
out  to  farmers  for  their  keeping,  and  save  their  lives 
thereby.  Others  I  have  advised  to  club  together  and 
camp  out  in  tents  for  eight  or  nine  months  of  the  year. 
I  have  seen  excellent  results  from  such  practice. 
Nearly  all  who  sutler  from  early  phthisis  are  able  to 
work,  and  usually  do  work  for  a  year  or  more  before 
they  are  obliged  to  give  up.  If  such  persons  could  be 
given  some  outdoor  emiiloyment  in  a  suitable  climate, 
they  would  not  only  be  self-supporting,  but  would  gel 
well  much  sooner  than  if  they  did  nothing.  This  is 
the  most  difficult  feature  of  the  whole  problem — the 
inability,  from  lack  of  means,  to  take  advantage  of  a 
more  favorable  climate.      I  can  conceive  of  no  other 


practical  solution  of  the  question  of  treatment  of  the 
masses  of  consumptives.  If  those  who  have  millions 
to  give  to  charity,  instead  of  building  palatial  sanato- 
ria with  luxuriant  appointments  which  tempt  to  idle- 
ness, would  spend  but  a  moiety  of  the  amount  in  lay- 
ing out  farms  and  gardens  and  vineyards  in  proper 
climates,  and  let  those  whom  they  would  benefit  do  the 
work  on  them,  they  would  not  only  enjoy  the  blessings 
of  giving,  but  would  have  the  satisfaction  of  knowing 
that  their  beneficence  had  been  a  benefit  instead  of  a 
detriment  to  the  recipient.  At  present  there  is  much 
money  being  expended,  and  much  thought  and  inge- 
nuity are  being  employed  in  devising  sanatoria  that 
shall  be  perfect  from  a  hygienic  and  sanitary  point  of 
view.  It  would  seem  that  of  all  things  beneath  the  sky 
that  a  consumptive  needs,  four  walls  to  shut  out  the 
life-giving  sun  and  oxygen  would  be  the  least  indis- 
pensable.    While 

"  Wails  do  not  a  prison  makt-," 
they  go  a  long  way  toward  making  the  sepulchre  of 
the  victim  of  early  phthisis.  Give  him  the  broad  can- 
opy for  a  roof,  plenty  of  exercise  and  good  food — 
largely  albuminous — in  a  high,  dry  climate,  and  we 
may  almost  literally  in  this  disease- — 

"  Throw  physic  to  the  dogs." 

The  colonization  scheme  suggested  above  might  ap- 
pear rather  Utopian  at  first.  Yet  I  believe  it  is 
feasible,  and  in  my  opinion  it  is  ideal.  There  are 
large  and  fertile  areas  in  New  Mexico  and  Colorado, 
also  in  this  State,  where  the  climate  is  all  that  can  be 
desired.  Thriving  communities,  villages,  and  even 
cities  might  be  built  up,  and  the  whole  commonwealth 
be  benefited;  while  thousands  could  work  out  their 
destiny  under  conditions  favorable  to  life  and  health. 

In  the  further  management  of  phthisis  I  have  seen 
great  benefit  derived  from  cold  sponging  every  morn- 
ing, followed  by  a  vigorous  rubbing  down  with  a 
coarse  towel.  It  has  a  general  tonic  effect,  and  gives 
a  feeling  of  exhilaration  and  a  sense  of  well-being 
which  nothing  else  will  produce.  Pulmonary  gym- 
nastics, the  use  of  chest  weights  and  dumbbells,  also 
do  good  serv'ice  in  increasing  the  breathing-capacity. 


GASTRO-JEJUNOSTOMY    IN   GASTRECTASIS." 
Bv   A.    H.    CORDIEK,    M.D.. 

KANSAS  CITV,    .MO. 

The  surgery  of  the  abdomen,  as  it  stands  to-day,  is  a 
beautiful  demonstration  of  surgical  ingenuity  and 
the  application  of  methods  approaching  the  exact,  as 
practised  by  American  and  foreign  surgeons.  The 
peritoneum  is  as  "sacred"  to-day  as  of  old,  but  modern 
asepsis  has  robbed  this  dangerous-to-invade  sac  of 
most  of  its  bars  to  intrusion,  and  it  is  opened  to-day 
by  the  painstaking,  clean  surgeon  with  very  little 
danger.  Dirty  operations  bring  disaster  to-day  the 
same  as  in  former  years.  The  invasion  of  the  peri- 
toneum is  not  the  only  source  of  danger  to  the  pa- 
tient. The  character  and  thoroughness  of  the  work 
done  determines  the  success  or  failure.  The  perito- 
neum is  filled  with  hollow  organs  mostly,  or  in  part, 
essential  to  life.  These  naturally  contain  myriads 
of  pathogenic  germs,  and  the  opening  of  one  of 
these  organs  is  fraught  with  much  danger  unless 
the  work  is  most  carefully  and  exactly  performed.  An 
improperly  applied  stitch  may  lead  to  the  loss  of  a  life. 
Most  of  the  operations  on  the  alimentary  canal  have 
so  far  been  done  as  immediate  life-saving  procedures, 
and  the  chances  of  recoveries  are  not  so  great  as  in  the 
class  of  cases  that  I  propose  to  deal  with  in  this  arti- 

'  Read  by  title  before  the  Missouri  State  Medical  Society  at  St. 
Louis,  May  20,  1897. 


442 


MEDICAL    RKCORD. 


[September  25,   1897 


cle ;   that  is,  operations  having  in  view  comfort  giv- 
ing first,  and  later  prolongation  or  saving  of  life. 

While  gastrectasis  is  in  a  great  majority  of  cases 
due  to  some  form  of  pyloric  stenosis,  there  are  ether 
cases  in  which  there  is  no  constriction  of  the  pylorus. 
The  most  frequent  cause  of  pyloric  stricture  is  cancer, 
yet  it  must  be  remembered  that  dilatation  of  the  stom- 
ach is  a  chronic  slow  process,  and  it  is  rare  that  the 
patient  survives  the  disease  a  sufficient  time  to  permit 
the  stomach  to  become  dilated.  In  malignant  cases,  as 
a  rule,  the  contents  of  the  stomach  are  vomited  before 
fermentation  from  retained  food  takes  place,  both  fac- 
tors in  the  production  of  gastrectasis.  In  the  majority 
of  cases  dilatation  of  the  stomach  is  not  due  to  the 
presence  of  a  malignant  disease.  Nature,  in  her  imper- 
fect work  here  as  in  many  other  localities,  leaves  a  con- 
dition not  directly  dangerous  to  life,  but  a  menace  to 
comfort  and  health  primarily;  secondarily,  the  imper- 
fect repair,  or  rather  the  results  of  the  healing,  leave  a 
condition  acting  as  a  bar  to  proper  digestion  and  as- 


similation, thus  leading  to  retention,  fermentation,  and 
gastrectasis,  with  all  the  train  of  symptoms  of  a  dilated 
stomach.  The  amount  and  character  of  the  contents 
of  an  aggravated  case  of  gastrectasis  are  surprising. 
Even  gallons  may  be  evacuated  in  rare  instances.  Ar- 
ticles of  diet  ingested  months  before,  such  as  prune  or 
grape  skins  or  orange  peeling,  may  lie  found  verv  lit- 
tle changed. 

In  dealing  with  the  pathology  of  llie  abdomen  the 
all-important  question  of  diagnosis  must  not  be  lost 
sight  of,  as  under  the  guise  of  the  "justifiable  explor- 
atory incision"  too  many  abdomens  are  opened  bv  men 
who  should  be  diagnosticians  as  well  as  mechanics. 
The  diagnosis  of  the  exact  pathology  and  its  source 
can,  as  a  rule,  be  made  in  a  case  presenting  svmptoms 
of  a  pyloric  stenosis,  as  practically  only  two  conditions 
give  rise  to  a  stricture  in  this  locality,  one  being  be- 
nign (ulceration)  and  the  otiier  malignant.  By  far 
the  majority  of  the  cases  will  have  a  benign  (ulcera- 
tive) origin,  as  the  process  of  dilatation  is  a  slow  or 
gradual  one,  and  will  gix'e  the  usual  historv  of  a  gas- 
tric ulcer 

Movable  right  kidne\,  while  giving  rise  in  (|uilf  .1 


percentage  of  cases  to  gastrectasis,  does  not  produce 
that  variety  characterized  by  a  persistence  of  the 
symptoms  rthe  cause  being  intermittent),  such  as  is 
noticed  in  cancerous  or  benign  stenosis. 

In  a  large  percentage  of  the  cases  presenting  them- 
selves to  the  surgeon,  the  usual  methods  of  irrigation, 
electricity,  massage,  dieting,  etc.,  will  have  been  tried 
with  either  no  beneficial  results  or  simply  a  retarda- 
tion of  the  inroads  of  the  condition  on  the  patient's  gen- 
eral health.  Such  results  being  obtained  after  months 
of  careful  handling,  patients  will  tireof  any  temporizing 
procedure  involving  so  much  annoyance  and  self-sac- 
rifice and  promising  so  little  in  the  way  of  a  cure,  and 
will  gladly  accept  any  method  of  dealing  with  their 
cases,  having  in  view  a  permanent  relief  from  the 
treatment  and  a  fair  promise  of  a  cure  of  diseases 
from  which  they  suffer. 

In  any  form  of  pyloric  obstruction  the  condition  is 
a  mechanical  one,  and  the  method  of  giving  relief 
must  be  of  a  like  character,  /.<•.,  surgical. 

Loreta's  operation,  introduced  in  1883,  has  not  de- 
monstrated by  time  and  a  fair  trial  all  claimed  for  it  by 
its  originator.  Any  operation  having  for  its  aim  the 
permanent  dilatation  of  a  cicatricial  narrowing  of  a 
canal  must  of  necessity  extend  over  a  long  period  of 
time,  and  that,  too,  with  frequent  divulsions  or  stretch- 
ings. The  history  of  all  cicatricial  tissue,  especially 
when  the  process  of  healing  e.xtended  over  a  large 
muco-muscular  area,  is  to  return  to  its  contracted  state 
after  divulsion.  Tliis  is  notably  the  case  with  cicatrix 
of  the  pylorus  following  a  healed  gastric  ulcer.  The 
operation  of  Loreta  is  certainly  not  applicable  to  the 
closure  of  the  pylorus  due  to  malignancy. 

Pyloroplasty,  or  the  operation  devised  by  Heineke- 
Mikulicz,  is  one  that  promises  very  good  results.  It 
consists  in  making  a  longitudinal  incision  on  the  an- 
terior wall  of  the  duodenum  and  stomach,  in  all  about 
three  or  three  and  one-half  inches  in  lengtli.  This 
incision  is  closed  in  a  vertical  direction,  or  trans- 
verse to  the  way  in  which  the  cut  was  made.  By 
thus  closing  the  wound  a  new  pylorus  is  created,  with 
its  cicatricial  tissue  on  its  posterior  wall.  This  is  a 
very  good  procedure,  but  is  attended  by  unnecessary 
difficulties  to  be  encountered  by  the  surgeon  and  dan- 
gers to  which  he  is  unwarranted  in  subjecting  the  pa- 
tient. Time  is  an  important  factor  in  the  success  of 
any  abdominal  operation,  and  especially  is  this  true  in 
the  case  of  patients  much  debilitated  from  any  cause. 
Many  of  these  patients  are  much  run  down  as  a  result 
of  the  prolonged  suffering,  lengthened  star\'ation,  and 
chronic  poisoning  from  decomposed  food,  etc.  Much 
surgical  time  is  occupied  in  doing  a  pylorectomy  or  a 
pyloroplasty  (Heineke-Mikulicz). 

The  muscular  coat  of  the  stomach  in  gastrectasis  is 
first  liiinned  by  the  dilatation,  but  still  retains  more 
or  less  of  its  contractile  power.  The  organ  under 
some  circumstances  is  capable  of  making  an  approach 
to  its  natural  size  in  its  efforts  at  the  expulsion  of  its 
contents  through  the  pylorus  or  the  ("esophagus.  Later 
the  organ  becomes  permanently  dilated,  with  thick- 
ened walls  in  an  atonic  state,  with  very  little  power 
for  self-emptying.  The  pyloric  and  duodenal  fixation 
is  at  a  much  higher  point  than  the  bottom  of  the  sac- 
culated .stomach,  hence  the  inability  of  the  stomach 
to  empty  itself.  Any  operation  having  as  its  object 
the  relief  of  this  distention  and  retention  must  be 
made  with  a  recognition  of  the  above  facts,  and  a  site 
selected  for  the  ojsening  near  the  dependent  portion  ol 
the  dilated  organ.  This  will  at  once  be  recognized  a: 
the  only  location  for  proper  drainage.  In  reports  of' 
many  cases  of  pylorectomy  and  pylorojilasty  it  will  be 
noticed  that  the  patient  suffered  with  many  of  the  old 
symptoms,  and  the  stomach  required  irrigation  and 
emptying  with  the  tube,  after-effects  of  the  operation 
failing  to  fulfil  the  indications  to  be  met  bv  surgerv. 


11 

I 


September  25,  1897] 

Malignant  disease  of  the  pylorus,  giving  rise  to  an 
occlusion  or  partial  closure,  with  a  resulting  dilatation, 
is  best  relieved  by  the  operative  procedure  recom- 
mended in  this  paper.  It  must  be  remembered  that 
when  a  malignant  disease  of  the  pylorus  has  advanced 


MEDICAL    RECORD. 


443 


to  a  period  in  its  history  when  it  produces  a  closure  of 
the  pylorus,  it  has  also  advanced  beyond  the  limit  of 
probable  total  e.\tirpation ,  hence  temporizing  and 
comfort-giving  surgery  (by  methods  entailing  the  least 
immediate  danger  to  life)  is  to  be  applied  in  the  case. 
Pyloric  resection  of  cancer,  while  a  brilliant  procedure, 
has  not  been  crowned  with  such  success,  as  far  as  cure 
is  concerned,  as  would  entitle  it  to  be  placed  on  the 
list  of  advisable  and  warranted  surgical  operations. 
This  statement,  I  fully  recognize,  is  at  variance  with 
the  writing  and  practice  of  some  of  the  world's  great- 
est teachers  and  surgeons. 

Dreydorff  reports  in  a  series  of  collected  cases  of 
pyloroplasty  a  mortality  of  twentj-  per  cent.  The  same 
author  tabulates  (1894;  one  hundred  and  eighty-eight 
pylorectomies  with  a  mortalit}'of  seventy-five  per  cent., 
the  average  duration  of  life  in  those  recovering  from 
the  operation  being  only  eleven  months,  Czerny's  mor- 
tality from  this  operation  being  forty-one  per  cent. 
Any  operation  having  an  immediate  mortality  of  fifty 
per  cent,  to  si.xty  per  cent.,  with  an  average  duration 
of  life  of  only  eleven  months  following  the  procedure, 
should  be  banished  from  the  list  of  legitimate  surgical 
operations.  Especially  is  this  true  when  a  less  dan- 
gerous method  is  offered  as  a  substitute. 

In  leaving  a  large  cicatricial  mass  at  the  pylorus 
there  is,  as  is  claimed  by  some  surgeons,  a  disposition 
to  malignant  degeneration  at  the  site  of  the  fibrous  tis- 
sue, but  this  rare  change  is  best  a\-erted  by  diverting 
the  source  of  irritation  (the  passage  of  the  stomach's 
contents)  in  a  direction  farthest  removed  from  the  scar. 

Xomadic  surgical  procedures,  or  wandering  surgical 
operations,  usually  result  in  half  doing  any  or  all 
methods  tried.  With  a  few  surgeons  the  new  and  un- 
tried technique  presents  a  seductive  persuasion  hard 
to  resist,  but  the  adoption  of  this  technique  is  only 
too  often  disastrous  to  the  patient.  Surgical  calis- 
thenics ("keeping  the  hand  in"),  in  inoperable  cases 
of  any  nature,  should  be,  and  is  as  a  rule,  condemned 
by  the  majority  of  operators.  It  is  useless  and  unsur- 
gical  to  perform  a  pylorectomy  for  malignancy  far  ad- 
vanced when  it  is  known  that  nothing  but  a  specimen 
and  a  little  "■  surgical  exercise"  can  be  e.xpected. 


Surgical  procedures  of  long  duration  on  ansemic  pa- 
tients are  fraught  with  much  danger.  Malignant  dis- 
ease of  the  pelvis  soon  induces  profound  ansemia 
and  cachexia,  both  militating  against  successful  sur- 
gical work.  A  pylorectomy  or  a  pyloroplasty  takes  too 
long,  as  a  rule,  for  a  low  mortality  in  anaemic  patients. 
Lucke,  with  the  idea  of  keeping  the  intestinal  peri- 
stalsis in  line  with  that  of  the  stomach,  rotated  the 
bowel  and  anchored  it  in  that  position.  An  impor- 
tant factor  in  the  emptying  of  a  dilated  stomach  is 
gravit}-,  and  not  muscular  action  alone. 

Baum's  operation  not  only  reversed  the  direction  of 
the  gut's  calibre  but  made  multiple  anastomoses,  so 
that  the  operation  when  completed  resembled  a  com- 
plicated piece  of  plumbing,  his  idea  being  not  only  to 
keep  the  wave  of  the  intestine  in  a  direct  line  with 
that  of  the  stomach,  but  to  prevent  the  bile  from  run- 
ning into  the  stomach.  His  operation,  here  illustrated, 
is  too  complicated  to  be  useful  or  to  be  adopted.' 

I  have  performed  the  operation  of  gastro-jejunos- 
tomy  five  times,  with  five  recoveries.  A  report  of  one 
of  the  cases  will  suffice  to  illustrate  the  history, 
technique,  and  progress  of  the  case  after  operation. 
Stricture  of  Pylorus;  Gastrectasis;  Gastro-Je- 
junostomy;  Recovery. — This  man,  seventy  years 
of  age,  some  eight  years  ago  had  an  attack  of  hepat- 
ic colic,  lasting  several  hours,  followed  a  few  days 
later  by  a  jaundice  persisting  three  or  four  weeks. 
He  soon  regained  his  former  good  health,  and  re- 
tained it  until  two  years  ago  when  he  had  another 
colic  attack,  not  so  severe  as  the  first  and  not  followed 
by  jaundice.  Two  years  ago  he  began  having  more 
or  less  pain  and  uneasiness  in  the  epigastrium,  especial- 
ly noticeable  after  eating.  After  two  or  three  months  of 
this  uneasiness  he  began  losing  flesh  and  had  occasional 
spells  of  vomiting.  Xo  blood  was  vomited  at  any  time. 
\Vhen  I  first  saw  him  he  had  not  been  able  to  retain 
or  digest  much  solid  food  for  several  months  and  was 
greatly  emaciated.  From  his  former  weight  of  two 
hundred  and  fort}'  pounds  he  was  reduced  to  one  hun- 
dred and  thirty  pounds.  His  appetite  was  fairly  good, 
and  liquid  nourishment  was  taken  with  a  relish.  Solid 
food  caused  pain  and  nausea  until  relieved  by  vomit- 
ing. Upon  examining  him  I  find  that  he  is  greatly 
emaciated  and  has  a  "  swarthy"  look,  not  exactly  a 
malignant  cachexia.  Pulse  and  temperature  normal. 
Examination  of  the  abdomen  reveals  a  greatly  dilated 


-Stomach  Raised,  showing  the  Locatit 
Jejunum  and  Stomach 


Stomach,  its  peristaltic  action  being  plainly  felt  through 
the  thinned  abdominal  parietes.  No  pain  on  pres- 
sure in  the  region  of  the  pylorus.  Here  an  unnatural 
.sense  of  resistance  can  be  plainly  and  distinctly  made 

'  ll-.e  illustrations  were   made   bv   Ur.  II.  S.    [ones,  of   Kansas 
Citv. 


444 


MEDICAL    RECORD. 


[September  25,  1897 


out,  covering  an  area  about  as  large  as  the  palm  of  the 
hand,  or  smaller. 

A  diagnosis  of  a  malignant  stenosis  of  the  pylorus 
was  the  most  acceptable  theory  to  me,  yet  a  non-malig- 


— Showing  the   I. oration  of  thi:  Openin 
Completed 


gs  after  the  Operation  i 


nant  stricture  had  been  diagnosed  by  a  good  diagnos- 
tician before  I  saw  the  patient.  He  was  given  a  tonic 
of  iron  and  strychnine,  and  nutrient  enemas  were  or- 
dered in  the  twenty-four  hours.  Under  this  rc'ghnc  he 
gained  eight  pounds  in  thirty  days. 

An  operation  was  advised  and  assented  to.  A  me- 
dian incision,  four  inches  long,  extending  downward 
from  one  inch  below  the  xyphoid  cartilage  was  made. 
A  loop  of  jejunum  was  pulled  into  the  incision,  the 
transverse  colon  and  the  omentum  were  pushed  upward, 
and  a  spot  in  the  colon  mesentery  free  from  blood-ves- 
sels was  selected  and  an  opening  made  through  it,  thus 
exposing  the  posterior  wall  of  the  stomach.  A  pcy-tion 
of  the  latter  being  pulled  through  this  opening,  the 
most  dependent  part  of  the  stomach  should  be  selected 
for  the  site  of  the  anastomosis.  A  puckering-string 
stitch  was  then  put  at  the  proposed  site  of  the  new 
opening,  and  a  similar  procedure  was  carried  out  with 
the  jejunum.  The  opening  in  the  jejunum  was  made 
first,  and  one-half  of  the  largest  intestinal  Murphy 
button  put  in,  the  other  half  of  the  button  being  in- 
serted in  the  opening  now  made  in  the  stomach.  The 
button  was  pushed  together,  closely  approximating  the 
jejunum  and  stomach  serous  coats.  Care  was  taken 
that  no  fold  of  the  colic  mesentery  was  included  in  the 
grasp  of  the  button.  An  additional  "  backing  up" 
Lembert  stitch  was  run  around  the  button,  and  the 
operation  completed  by  closing  the  parietal  incision. 
The  patient  vomited  for  liie  first  time  ten  hours  later. 
The  bowels  moved  on  (lie  second  day.  His  convales- 
cence was  uninterrupted.  TTe  is  alive  to-day  and  has 
gained  sixty  pounds.  He  has  had  no  return  of  any  of 
his  former  symptoms  of  pyloric  stricture  or  gastric  dila- 
tation. Evidently  the  stricture  was  a  non-malignant 
one,  as  the  operation  was  performed  over  two  years 
ago. 

The  history  (clinical)  of  these  cases  will  vary  only 
as  the  pathology  is  of  a  different  character  or  severity. 
The  operative  technique  is  about  the  same  in  all  cases. 
The  cardinal  point  to  recognize  in  operating  is  to 
make  the  opening  in  the  .stomach  in  a  location  that 
will  drain  the  indolent  organ. 

I  append  tiie  history  of  an  aggravated  case  of  gas- 
trectasis  following  the  cicatrization  of  an  ulcer  near 
the  pylorus.  The  patient  being  an  intelligent  physi- 
cian, I  give  his  own  description  of  his  case: 


"  Raymore,  Mo.,  April  24th. 
"  Dr.  A.  H.  Cordier,  Kansas  City,  Mo. 

"Dear  Doctor:  In  1862,  while  in  the  army,  I  no- 
ticed first  a  pain  at  the  pylorus.  Continues  after  a  few 
weeks  from  its  inception.  This  was  present  in  greater 
or  lesser  degree  until  about  July,  1865,  when  I  became 
much  worse.  Accompanied  with  pain  were  indiges- 
tion, Hatulence,  and  a  sense  of  distention.  I  was  act- 
ively engaged  in  a  large,  laborious  country  practice, 
and  kept  up,  although  steadily  losing  weight.  In  Oc- 
tober, 1865,  I  did  an  enormous  amount  of  work,  and 
in  November  was  doing  more.  At  3  .\.yi.  on  Novem- 
ber 9th  I  aw'oke,  feeling  faint  and  sick,  and  attempted 
to  rise,  when  I  fell  off  the  bed,  unconscious.  My  wife 
raised  me  up  and  I  commenced  vomiting.  As  I  had 
eaten  no  supper,  the  contents  of  the  stomach  ejected 
showed  pure  blood.  I  bled  and  vomited  by  turns 
until  death  seemed  ready  to  claim  me  then  and  there. 
I  finally  recovered,  and  for  four  days  lay  on  an  in- 
clined plane  to  supply  the  brain  with  blood.  In  Feb- 
ruary, 1866,  I  resumed  my  practice,  but  the  same  old 
stomach  trouble  kept  up — stomach  full  of  gas,  con- 
tents fermenting,  and  a  general  disturbance  of  the  di- 
gestive process.  On  October  24,  1869,  I  had  another 
hemorrhage,  and  in  August,  1872,  another,  and  the 
last.  From  this  on  I  found  that  my  stomach  was  con- 
stantly troubling  me  with  the  usual  symptoms  of  acid- 
ity, etc.  In  1888  I  finally  found  that  my  stomach  was 
dilated,  and  I  would  take  a  hypodermic  injection  of 


5.— ,1  shows  the  Opening  in  the  Stomacii  Made  too  High  on  the  Wall 
of  that  Organ;  li  shows  the  Correct  Position  of  the  Openinfr. 


apomorphine  to  empty  it,  and  then  measure  tlie  con-  ; 
tents.     Four  to  six,  and  one  time  seven  quarts  was  ' 
found.     My  friends  used  to  say,  '  Doctor,  you  are  get- 
ting a  big  belly  on  you,"  joking  me.     In   1890,  seven 
vears  ago,  I  commenced  the  use  of  a  stomach  tube  and 


September  25,  1897] 


MEDTCAl.    RECORD. 


445 


lavage.  At  that  time  the  greater  curvature  rested  on 
the  pubes,  and  the  epigastrium  was  flat  or  retracted, 
the  stomach's  contents,  by  force  of  gravity,  pulling  tlit- 
stomach  out  of  position.  After  washing  the  stomach 
I  often  used  hydrozone  in  water,  and  still  do  when  1 
want  to  have  a  general  cleaning  up  of  the  organ.  From 
1890  up  to  date  I  have  used  the  stomach  tube  twice 
every  day,  and  sometimes  three  times,  which  amounts 
to  at  least  five  tliousand  times.  The  time  I  use  the 
tube  is  before  dinner  and  supper.  I  have  formed  the 
habit  of  lying  on  my  riglit  side  at  night,  thus  turning 
the  stomach  on  end  and  the  pylorus  down,  and  by 
force  of  gravity  and  remaining  so  long  in  that  posi- 
tion, the  process  of  digestion  is  carried  on,  and  the 
contents  pass  the  pylorus.  For  the  reason  (I  sup- 
pose) of  loss  of  elasticity,  due  to  dilatation,  and  the 
stenosis,  the  contents  from  morning  to  evening  are  not 
carried  through,  only  in  a  partial  way,  hence  the  neces- 
sity of  removing  residuum  before  dinner  and  supper. 
Being  a  medical  man,  of  course  1  looked  closely  after 
my  case,  and  to  the  use  of  the  tube  lavage  I  owe  my 
life  to-day.  At  present  I  use  three  pints  of  warm 
water  to  wash  the  stomach,  but  I  have  tried  to  see  how 
much  the  stomach  would  hold,  and  seven  to  eight  pints 
will  fill  the  stomach  and  drag  it  down  to  the  pubes. 
My  theory  is  that  I  had  a  bad  ulceration  at  the  py- 
lorus, which  finally  healed,  producing  stenosis  from 
cicatrization,  and  in  turn  this  caused  dilatation  of  tlie 
stomach  with  all  its  troubles.  My  weight  fell  from 
one  hundred  and  fifty-five  pounds  to  one  hundred  and 
seventeen  pounds  and  I  never  have  reached  more  than 
one  hundred  and  thirty-five  pounds  since.  If  I  am 
situated  so  that  I  am  unable  to  wash  my  stomach  1 
dare  not  eat,  but  must  omit  the  meal  until  I  can  {(ex- 
cept the  morning  mealj.  I  often  have  pain  now,  mild 
in  character,  at  the  pylorus,  but  it  is  not  continuous. 

"  I  can  truly  say  that  had  I  been  a  layman  I  should 
have  long  ago  been  dead,  for  it  is  only  by  the  un- 
remitting care  that  I  bestow  upon  myself  that  I  am 
so  well.  Truly  and  fraternally, 

"  W.    \V.    JoHxVSTOX." 

Deductions. —  i.  Cancer  of  the  pylorus,  even  thougli 
removed,  returns  quickly,  and  always  kills. 

2.  I'ylorectomy  is  attended  by  a  higii  mortalit) 
and  is  not  a  justifiable  surgical  procedure  in  advanced 
carcinoma  of  the  pylorus. 

3.  Gastreciasis  due  to  a  malignant  closure  of  iIk- 
pylorus  is  best  treated  by  a  gastro-jejunostomy. 

4.  The  operation  as  advised  by  ^■on  Hacker  besi 
raeets  the  indications. 

5.  It  is  not  necessary  to  twist  the  bowel,  in  making 
the  anastomosis,  to  prevent  the  bile  from  entering  the 
stomach. 

6.  The  anastomotic  oijening  in  the  stomach  should 
be  at  the  most  dependent  point  of  the  dilated  organ. 

7.  The  operation  is  attended  by  a  low  mortality. 

8.  In  all  cases  in  which  marked  dilatation  of  the 
stomach  exists,  accompanied  by  emaciation,  pain,  and 
invalidity,  the  operation  of  gastro-jejunostomy  should 
be  performed. 

9.  The  relief  of  pain,  due  to  the  effort  of  the  stom- 
ach to  relieve  itself,  follows  this  procedure  at  once. 
The  patient  gains  rapidly  in  weight  and  if  non-malig- 
nant disease  be  present  his  former  good  health  is 
restored. 


Emergency  Tracheotomy.^- Waste  no  time  in  gi\- 
ing  an  anaesthetic.  In  diphtheria  there  is  alreadx- 
a  blunting  of  the  sensibilities.  In  cyanosis  and  cold- 
ness of  the  skin  the  sensitiveness  to  pain  is  greatly 
diminislied.  In  burns  of  the  pharynx  and  larynx  be 
ready  to  operate  at  the  first  evidence  of  sudden  grave 
dyspnoea. 


IDEAL    ANESTHESIA. 

Bv    R.\WLIXGS    NICIIOL,    M.D., 

XowHERE  in  the  domain  of  surgery  may  graver  in- 
justice be  done  to  the  skill  and  reputation  of  the  prac- 
tising surgeon  than  in  that  class  of  cases  which  must 
be  left  unfinished,  or,  at  best,  in  a  condition  far  from 
satisfactory  to  the  operator  undertaking  the  surgical 
procedure,  because  of  an  unsuccessful  narcosis. 

There  are  in  use  two  agents,  chloroform  and  ether, 
under  the  influence  of  which  most  of  all  grave  surgical 
manoeuvres  are  conducted ;  in  the  remainder  combina- 
tions of  these,  made  with  and  without  the  addition  of 
alcohol  or  the  passing  of  oxygen  or  nitrous  oxide 
through  them,  are  employed.  As  yet  we  have  no  agent 
that  is  superior  to  the  two  playing  the  first  roles  in  the 
earliest  history  of  anaesthesia;  at  present  the  real  issue 
proposes  a  choice  between  them. 

It  cannot  be  doubted  that  if  we  measure  future 
progress  by  our  present  improvement  over  measures  in 
vogue  but  a  few  years  ago,  a  safer  and  better  anaes- 
thetic will  soon  be  at  the  disposal  of  the  operator. 
There  lurks  in  my  mind  a  modest  suspicion  that  when 
the  realms  of  electricity  shall  have  been  somewhat 
more  explored  one  may  be  derived  from  that  source, 
enabling  us  to  place  our  patient  in  a  condition  of 
unconsciousness,  from  which  he  may  return  to  con- 
sciousness not  shocked  but  rather  exhilarated. 

Chloroform. — The  manner  of  administering  chlo- 
roform or  ether  dififers  but  little  in  the  gross  par- 
ticulars. In  the  majority  of  cases  chloroform  is  the 
best  agent;  in  some  it  is  the  least  dangerous,  and 
in  the  hands  of  a  skilled  anaesthetist  its  risks  are 
reduced  to  the  minimum.  A  considerable  series  of 
experiments,  including  actual  exhibitions,  numbering 
over  five  hundred,  with  this  agent,  has  impressed  me 
with  the  accuracy  of  this  conclusion.  Different  anaes- 
thetists apparently  attain  equally  good  results  with 
diff'erent  agents;  therefore,  by  leaving  the  choice  of  an 
anaesthetic  to  such  an  individual,  the  best  results  are 
most  likely  to  obtain.  In  this  connection,  as  the  re- 
sponsibility of  a  successful  narcosis  rests  upon  him, 
it  is  well  to  allow  him  to  use  such  agent  or  agents  as 
in  his  skilled  judgment  he  considers  best  adapted  to 
the  case  in  hand.  Practice  develops  a  perspicacity 
which  anticipates  the  peculiarities  that  mark  types  of 
individuals,  and  his  training  de\'elops  perceptive  fac- 
ulties which  intuitively  guide  him  to  successful  re- 
sults. Dissimilar  types  require  distinctly  different 
methods;  certain  subjects  present  marked  varieties 
of  pulse,  respirator)'  sounds,  changes  of  color,  de- 
gree of  conjuncti\al  reflexes,  etc.,  and  each  has  its 
peculiar  natural  significance.  While  the  patient  is 
being  brought,  or  is  "■  under''  the  influence  of  the 
anaesthetic,  the  practised  anaesthetizer  notices  little 
gradations  of  symptoms  easily  escaping  the  observa- 
tion of  the  occasional  administrator,  disregarding 
those  which  possibly  alarm  the  tyro,  while  feeling 
grave  anxiety  where  the  casual  and  untrained  ob- 
ser^'er  thinks  all  is  progressing  favorably.  Most  of 
this  knowledge  is  empirical,  practical  experience 
being  the  only  possible  method  of  obtaining  it. 
To  use  but  one  favored  ana'Sthelic,  irrespective  of 
the  ojxiration  or  type  of  subject,  is  now  a  thing  of 
the  past.  An  anaesthetic  to  commend  itself  to  com- 
parative consideration  should  possess  these  qualities: 
Safety;  least  disagreeable  to  administer;  best  calcu- 
lated to  produce  muscular  relaxation,  followed  by 
no  ill  effects,  as  vomiting,  catarrh,  etc. ;  not  affect- 
ing prejudicially  the  question  of  hemorrhage;  best 
adapted  to  the  prevalent  characteristics  of  the  pa- 
tient. 

As  before  noted,  chloroform  will  fulfil  these  require- 
ments in  the  majority  of  cases,  especially  if  the  kid- 


446 


MEDICAL    RECORD. 


[September  25,  1897 


neys,  heart,  or  lungs  are  diseased.  The  two  conditions 
which  to  my  mind  might  constitute  occasion  for  hesi- 
tancy in  giving  an  anaesthetic  are  the  later  stages 
of  pulmonary  phthisis  with  marked  emphysema,  and 
severe  right  cardiac  diseases.  Any  interference  with 
the  patient  before  he  is  profoundly  "  under"  should  be 
deprecated,  as  in  the  condition  of  imperfect  anaesthesia 
the  dangers  are  considerably  increased,  the  frightful 
mental  phantasmagoria  possible  in  a  semiconscious 
state  necessarily  contributing  greatly  to  the  existing 
or  induced  shock.  Chloroform's  most  brilliant  field 
is  in  laparotomy,  suturing  of  large  surfaces,  opera- 
tions by  night;  in  extreme  old  and  young  subjects, 
brain  surgery,  acute  and  chronic  inflammatory  and 
catarrhal  affections  of  the  respiratory  tract,  chronic 
endarteritis,  renal  disease,  obstetrics,  operations  on 
chronic  alcoholics,  removal  of  tumors  or  foreign  bodies 
from  the  larynx;  in  those  delicate  and  minute  surgical 
operations  which  require  for  their  successful  perform- 
ance absolute  quietude;  finally,  in  all  conditions  in 
which  expedition  is  of  vital  importance. 

Chloroform's  greatest  recommendations  are  its 
rapid  action,  its  easier  administration  with  fewer  un- 
pleasant attendant  consequences,  and  its  less-irritating 
efTects  on  the  respiratory  organs.  Shock  is  less  after 
a  narcosis  with  it  than  with  ether,  though  it  must  be 
conceded  that  the  immediate  dangers  are  greater  with 
chloroform,  while  only  the  remoter  ones  obtain  with 
ether.  It  is  not  possible  fully  to  estimate  the  actual 
relations  in  this  respect,  but  the  dangers  attending 
chloroform  administration  may  be  almost  eliminated 
by  the  two  safeguards  of  proper  preparation  of  the 
patient  and  a  rational  administration  of  the  anees- 
thetic. 

Chloroform  is  suffering  from  past  practice,  when  it 
was  given  to  a  degree  and  in  a  manner  which  would 
not  now  be  tolerated.  Numberless  operators  prefer 
ether  to  chloroform,  as  at  some  time  in  their  expe- 
rience they  had  a  coincident  death  from  the  latter, 
causing  them  to  abandon  its  use.  The  mortality  from 
chloroform  seems  to  be  mucli  greater  than  that  from 
ether,  but  frequently  grave  disorders,  such  as  pneu- 
monia (especially  frequent  and  fatal  after  laparotomy), 
bronchitis,  broncho-pneumonia,  (tdema  of  the  lungs, 
and  nephritis,  result  from  the  exhibition  of  ether,  and 
deaths  from  these  complications  ought  to  be  regarded 
as  equivalent  to  deaths  from  ana;sthesia.  Doubtless 
these  effects  are  caused  by  the  chilling  of  the  blood 
stream  or  the  immediate  action  of  the  intense  cold  on 
the  lungs  and  the  necessarily  excessive  elimination  of 
ether  by  the  lungs  and  kidneys,  after  it  has  been  dis- 
integrated by  the  economy.  Korte  and  \\'underlicii 
affirm  that  chloroform  irritates  the  kidneys  more  than 
ether,  and  they  are  supported  in  this  by  VVyeth,of  New 
York,  who  has  made  extensive  reports  upon  this  par- 
ticular, but  this  is  hardly  the  general  opinion.  I  hope 
to  sulimit  comparative  data  with  respect  to  this  issue 
in  the  near  future. 

Preparation  of  the  Patient. — He  should  have  had 
no  solid  food  for  at  least  eight  hours  preceding  the 
time  of  operation ;  if  very  feeble,  concentrated  and 
readily  assimilated  liquid  nourishment  (not  milk  nor 
beef  tea)  might  be  given  up  to  within  three  hours  of 
the  contemplated  commencement.  Experience  has  in- 
duced me  always  radically  to  discountenance  the  so- 
called  "  ether  breakfast."  .V  mild  saline  purgative  the 
evening  before  and  a  rectal  injection  of  warm  water 
immediately  preceding  the  time  set  for  the  operation 
are  a  sinr  tjiia  luui  to  an  easy  and  featureless  ana-sihesia. 
Even  in  emergency  cases,  when  haste  is  demanded, 
a  high  enema  or  gastric  irrigation,  or  both,  ought  to 
be  insisted  upon;  this  will  minimize  if  not  absolutely 
prevent  the  stale  of  excitement,  and  will  increase  the 
efficacy  of  the  least  amount  of  the  anaesthetic  used, 
a  feature  alwavs  superlatively  desired  and  demanded. 


The  stage  of  excitement  marks  the  period  in  which 
most  of  the  fatal  cases  of  syncope  have  taken  place,  a 
term  which  has  been  in  the  past  ofttimes  a  misnomer  for 
obstructed  respiratory  function.  If  the  patient  strug- 
gles violently,  we  should  raise  his  upper  and  lower  ex- 
tremities in  the  air,  removing  the  fulcrumage  upon 
which  he  can  pivot  his  strength,  making  it  compara- 
tively easy  to  prevent  him  doing  himself  or  attendants 
injury,  and  at  this  time  the  anx-sthetic  should  be 
pushed,  as  struggling  is  the  chief  symptom  of  incom- 
plete ana.-sthesia. 

Frequently,  with  novices  as  anasthetists,  the  strug- 
gling patient  has  projected  upon  him  the  assistants 
present,  the  surgeon  orders  more  chloroform,  which  is 
hurriedly  thrown  into  the  cone  and  the  face  piece 
closely  applied,  and  this  is  speedily  followed  by  a  stage 
of  suspended  animation,  artificial  respiration,  anx- 
ious inquiries  for  brandy,  strychnine,  nitrite  of  amyl, 
ammonia  (any  of  which  are  rarely  at  hand);  then 
inversion  of  the  patient  is  tried;  a  galvanic  battery  is 
frequently  emploxed  but  is  of  little  use;  the  tout  eti- 
scm/i/t-  is  general  demoralization  of  all  concerned, 
and  after  a  more  or  less  extended  period  of  this  kind 
the  patient  may  be  resuscitated  and  the  operator  en- 
abled to  begin  or  complete  the  operation.  It  cannot 
be  expected  that  the  surgeon  will  be  at  his  best  after  the 
excitement  just  encountered,  and  he  is  morally  certain 
to  complete  his  labors  in  the  shortest  time  possible, 
fearing  another  excursion  of  his  patient  within  the  en- 
virons of  death.  A  rarely  recognized  danger  at  this 
stage  of  anassthesia  is  the  rupture  of  some  of  the  small- 
er vessels  in  the  brain,  giving  us  paralyses  of  various 
groups  of  muscles,  often  ascribed  to  the  toxic  effects 
of  the  agent  upon  tlie  centres,  but  generally  of  me- 
chanical origin. 

The  clothing  of  the  body  should  be  of  the  lightest, 
yet  sufficiently  warm  to  prevent  the  patient  from  be- 
ing mischievously  influenced  by  the  fall  of  tempera- 
ture incident  to  anaesthesia.  The  thoracic  movements 
should  be  in  plain  view  of  the  anresthetizer,  since  a 
close  observation  and  vigilant  attention  to  the  preser- 
vation of  the  respiratory  function  are  absolutely  nec- 
essary. When  I  speak  of  respiration,  I  do  not  mean 
fitful  and  feeble  contractions  of  the  diaphragm  inad- 
equate to  the  slightest  ingress  or  egress  of  air  to  the 
lungs.  The  habit  of  females  dressing  for  the  occasion 
in  belaced  and  beruffied  chemises  ought  to  be  pre- 
vented by  the  physician's  orders. 

The  Position. — This  should,  if  possible,  te  ihi 
lecumbent,  or  if  preferable  on  the  left  side,  with  the 
head  slightly  extended,  tlie  means  being  at  hand  of 
promptly  lowering  the  head  to  any  degree  desirable. 
The  head  should  rest  on  a  small  pillow,  the  face  be 
smeared  with  vaseline,  and  the  patient  instructed  to 
count  or  talk  as  long  as  he  is  able. 

The  cone  should  not  be  closely  applied  to  the  face 
until  the  sensibility  of  the  glottis  and  nasal  mucous 
membrane  is  dulled. 

When  the  patient  is  "  under"  the  influence  of  the 
anasthetic,  I  am  in  the  habit  of  passing  a  curved 
needle,  threaded  with  broad  silk,  through  the  tongue, 
as  it  gives  one  complete  control  over  that  organ,  al- 
lowing it  to  be  pulled  forward  instantly  if  necessary, 
and  leaves  but  a  small  wound  rarely  noticed  by  the 
patient,  giving  him  considerably  less  pain  or  trouble 
than  when  the  tongue  is  held  by  the  ordinary  tongue 
forceps.  Of  the  latter,  I  use  a  pair  the  blades  of 
wliich  cannot  become  disconnected  ;  the  ends  are  broad- 
ened out  into  a  circle,  of  which  the  centre  is  punched 
out,  allowing  the  needle  10  be  passed  through  them 
without  trouble.  I  find  them  extremely  useful.  If 
the  patient  gives  the  slightest  sign  of  commencing  to 
vomit  or  retch,  the  anasthetic  should  be  pushed  to 
cut  oft"  the  vomiting  reflex. 

Respiration,  color  of  skin,  condition  of  pupil,  and 


September  25,   1897] 


MEDICAL    RPXORD. 


447 


pulse  claim  my  closest  attention.  Gaskell  and  Shore 
in  their  brilliant  series  of  demonstrations  proved  that 
chloroform  stimulates  the  vasomotor  system  until 
long  after  the  respiratoiy  centre  is  paralyzed,  and  this 
discovery,  added  to  others  of  theirs  on  the  condition 
of  the  heart  muscle  during  anaesthesia,  made  clear 
liow  the  pulse  is  prevented  from  betraying  the  condi- 
tion of  tlie  heart  during  chloroform  narcosis. 

Time  of  the  Operation. — -The  time  of  the  day  most 
suitable  to  administer  an  anaesthetic  is  in  the  morning 
hours;  when  possible,  it  should  be  so  chosen,  as  it  al- 
lows the  patient  refreshing  sleep  to  fortify  him  for  the 
ordeal.  Thus  we  may  take  advantage  of  a  night's  rest 
and  all  the  salutary  effects  that  are  associated  with  it, 
leaving  the  nervous  system  in  the  best  possible  condi- 
tion and  in  an  essentially  tolerant  mood  successfully 
to  cope  with  the  great  changes  about  to  be  under- 
gone by  it;  at  this  period  of  the  day  the  physical  and 
psychical  forces  most  nearly  approach  a  condition  of 
happy  equipoise  that  is  such  a  desideratum  in  anaes- 
thesia. A  factor  of  importance  has  ofttimes  appeared 
in  my  experience  to  be  the  punctual  observance  of  the 
time  set  for  the  operation,  it  doing  much  to  prevent 
hysterical  attacks  in  those  who  have  steeled  their  ner- 
vous system  to  undergo  the  contemplated  surgical  pro- 
cedure and  only  weaken  as  the  time  slips  past  the 
hour  originally  engaged. 

The  practice  of  gi\ing  either  morphine,  chloral, 
catleine,  alcohol,  or  similar  drugs,  is  generally  repre- 
hensible, except,  as  in  very  rare  instances,  when  their 
exhibition  is  indicated  because  ot  certain  peculiar  con- 
ditions. They  seem  theoretically  correct  and  their  ad- 
ministration is  a  routine  practice,  but  careful  consider- 
ation has  impressed  me  with  a  desire  to  avoid  these 
frequently  mischievous  and  superfluous  addenda.  After 
the  operation  each  has  its  clearly  marked  occasion  for 
exhibition,  but  now  tiie  operator  has  become  the  sole 
judge  of  their  propriety.  Morphine  increases  the  lia- 
bility of  asphyxia  by  strongly  antagonizing  the  reflex 
phenomena,  protracting  the  return  to  consciousness 
after  the  operation  is  completed,  and  thus  frequentl)- 
demoralizing  the  patient's  friends,  mayhap  the  sur- 
geon too.  Added  to  these  undesirable  sequela;  may 
be  an  unexpected  opium  or  other  narcosis  supplant- 
ing the  anaesthesia.  Vomiting,  at  this  stage  espe- 
cially dangerous,  is  frequently  caused  and  invariably 
intensified  by  the  practice,  and  a  dangerous  train  of 
symptoms  may  be  incited  by  even  a  relatively  small 
hypodermic  injection.  It  obscures  signs  of  the 
greatest  importance  to  the  administrator,  prolongs 
unduly  the  stage  of  excitement,  naturally  followed 
by  a  corresponding  degree  of  wasted  natural  force. 
The  temperature  sinks  considerably  lower  than  in 
ordinary  anaesthesia,  and  headache  and  nausea  are  its 
most  constant  results.  The  only  point  which  can  in  any 
way  recommend  it  to  the  surgeon  is  that  it  lessens  the 
amount  of  the  agent  necessary  to  produce  aniiesthesia, 
but,  as  pointed  out  previously,  the  successful  ana-sthe- 
tist  can  accomplish  this  without  its  aid.  Koenig 
abandoned  this  practice  after  a  deliberate  trial  to 
test  its  efficacy  and  desirability  in  thousands  of  hos- 
pital and  army  cases,  concluding  it  to  be  either  posi- 
tively harmful  or  at  best  of  no  benefit.  Recently 
a  new  method  of  administering  chloroform  has  been 
proposed  by  Dr.  M.  Rosenberg,  who  contends  that  the 
greatest  dangers  to  both  heart  and  respiration  are  oc- 
casioned reflexly  by  the  irritating  action  of  the  chlo- 
roform on  the  termination  of  the  trigeminus  distrib- 
uted to  the  mucous  membrane  of  the  nose,  and  that 
this  may  be  obviated  by  first  anesthetizing  this  mem- 
brane with  cocaine.  Having  tried  this  method  in  fifty 
cases,  he  concludes  that  the  commencement  of  anaes- 
thesia is  less  disagreeable  to  the  patient,  the  excite- 
ment stage  is  often  wanting  and  always  slight  except 
in  alcoholic  cases,  and  that  it  is  rare  that  a  patient 


vomits ;  if  he  does  there  is  but  little  retching,  and  when 
he  awakes  he  has  no  disagreeable  sensation  and  is 
not  haunted  by  the  smell  of  chloroform  or  ether.  His 
method  is  to  direct  the  patient  to  blow  his  nose,  thus 
clearing  the  mucous  membrane;  then  leaning  forward 
or  sitting  (^never  lying),  to  snufl^  a  centigram  of  a  powder 
consisting  of  ten-per-cent.  cocaine  muriate  and  some 
inert  substance,  repeating  this  in  about  three  minutes 
before  general  anssthesia  is  commenced.  Another 
method  to  obtain  the  same  result  is  proposed  by  Dr.  A. 
Guerin,  of  Paris,  who  advises  that  the  nose  of  the  patient 
should  be  held  by  the  fingers  until  general  anaesthesia 
is  produced,  when  there  can  be  no  longer  any  reffex 
action  through  the  terminations  of  the  ner\'es  supply- 
ing the  nasal  mucous  membrane,  if  the  chloroform  is 
inhaled  exclusively  through  the  mouth.  Dr.  Guerin 
rightly  claims  that  when  death  occurs  from  stoppage 
of  the  heart,  the  cardiac  muscle  ceases  to  contract  un- 
der the  influence  of  the  reflex  action  exerted  by  these 
nerves  on  the  pneumogastric,  stimulating  the  inhibi- 
tory power  of  the  latter  on  the  heart ;  he  further  shows 
that  when  a  rabbit  is  subjected  to  tracheotomy,  and 
then  made  to  inhale  chloroform  directly  through  the 
trachea,  the  drug  has  no  effect  whatever  on  the  heart; 
on  the  contrary,  when  it  was  held  before  the  nose  of 
the  rabbit,  the  heart  almost  immediately  stopped. 
The  trachea  being  cut  transversely,  it  is  obvious  that 
the  chloroform  inhaled  by  the  nostrils  could  not  reach 
the  heart  through  the  bronchi ;  therefore  the  doctor  as- 
sumes that  the  anaesthetic  agent  exerts  an  injurious 
action  upon  the  movements  of  the  heart  through  the 
intervention  of  the  nasal  ner\-es  and  cardiac  branches 
of  the  pneumogastric,  the  former  acting  reflexly  on  the 
latter.  I  have  tried  both  these  practices  and  they 
have  given  excellent  results  in  a  few  of  my  late  cases. 

The  essential  characteristics  of  an  anasthetizer  are 
the  possession  of  a  knowledge  of  the  subject  as  far  as 
it  may  be  gained  by  constant  and  practical  study,  and 
familiarity  with  the  literature,  especially  that  concerned 
with  the  portrayal  of  clinical  cases  and  accepted  sta- 
tistical records  growing  out  of  the  use  of  anaesthetic 
agents.  He  should  be  gentle,  quick,  perfectly  cool 
and  self-contained,  courageous,  not  rashly  bold  or 
liable  to  lose  his  ner\'e  or  head  at  critical  moments. 
He  should  possess  in  the  greatest  degree  the  suaviter 
in  modi)  ct fortiter  in  ir,  as  there  is  no  contingency  of  a 
professional  character  that  requires  such  tact  and  vel- 
vet-tongued  diplomacy  as  when  he  has  to  soothe  a  semi- 
sensible  or  hysterical  patient  in  order  to  continue  or 
commence  the  administration  of  an  anaesthetic.  The 
trained  operator  of  this  description,  with  his  thoroughly 
equipped  satchel  and  his  special  experience,  both  to 
stand  in  good  stead  at  critical  moments,  cannot  fail  to 
aid  the  operator  to  obtain  best  residts  and  be  necessa- 
rily of  use  in  every  well-planned  ^'iV^.'/ir.  The  demand 
for  specialism  in  this  branch  of  medicine  is  obvious 
and  will  tend  to  effect  a  notable  saving  of  human  life. 
With  regard  to  the  equipment,  I  make  it  a  point  to 
carry  my  own  supply  of  chloroform  and  ether  obtained 
from  reputable  manufacturers,  stored  in  small  contain- 
ers sealed  and  protected  from  the  action  of  light,  ena- 
bling one  to  dispense  with  anasthetics  which  have  been 
kept  for  an  indefinite  time  on  drug-store  shelves,  ex- 
posed to  conditions  extremely  liable  to  promote  their 
decomposition;  I  never  use  any  anaesthetic  left  over 
from  a  previous  case,  for  after  it  has  been  uncorked  it 
rapidly  deteriorates. 

Essentials  for  Administration  of  Anaesthetics. — 
.Vn  open  and  closed  inhaler  (I  prefer  Townshend's  and 
the  small  modified  Clover  inhaler),  chloroform  and 
ether,  Ferguson  mouth  gag,  tongue  forceps,  needle 
holder  and  needles,  a  pocket  or  tracheotomy  case,  hy- 
podermic syringe,  and  tablets  of  strychnine,  nitrogly- 
cerin, atropine,  morphine,  digitalin.  Aqua  ammonia; 
fortior  and  a  silver  catheter  are  sometimes  of  use. 


448 


MEDICAL    RECORD. 


[September  25,  1897 


The  many  complicated  and  cumbersome  apparatuses 
to  be  found  at  all  surgical-instrument  makers',  intended 
to  dilute  and  automatically  administer  the  vapor,  are 
the  illogical  result  of  the  fallacious  premises  that  tlie 
anaesthetic  agent  must  be  accompanied  by  definite  pro- 
portions of  atmospheric  air.  Any  complicated  mech- 
anism in  the  construction  of  which  intricate  valves 
are  employed  (to  get  out  of  order  at  unfortunate 
moments)  are  to  be  decried.  The  simpler  the  de- 
vice for  giving  the  vapor,  the  more  serviceable  and 
satisfactory  will  it  prove.      Of  late  I  have"  employed 


one  devised  by  Dr.  Townshend,  of  this  city,  with  ex- 
cellent results  for  either  agent;  it  is  modestly  simple, 
cannot  get  out  of  order,  and  it  is  possible  thorough- 
ly to  cleanse  it  instantaneously.  The  older  ones 
frighten  patients  immediately  they  see  them,  especially 
children  and  hysterical  subjects — certainly  not  to  be 
wondered  at  considering  tiie  lethal-like  aspect  of  the 
majority  of  these  pseudo-scientific  toys. 

From  the  teaching  laid  down  by  men  clearly  un- 
trained carefully  to  observe  or  practically  unacquaint- 
ed with  the  phenomena  of  anaesthesia,  fallacious  ideas 
have  been  associated  with  various  inhalers,  so  that 
operators  proceed  with  the  idea  that  no  harm  can  occur 
to  the  patient  if  the  vapor  is  measured  with  one  of 
these  automatic  contrivances.  The  susceptibility  of 
patients  to  anesthetics  is  not  governed  by  any  law  that 
applies  with  equal  force  to  all  individuals;  there- 
fore, to  prescribe  definite  hard-and-fast  rules  to  all  is, 
to  ^ay  the  least,  poor  practice;  on  the  contrary,  they 
may  be  adapted  with  special  significance  to  the  pecu- 
liarities of  each  subject.  Idiosyncrasies,  disparity  of 
temperament,  the  latent  strength  of  the  patient  coupled 
with  his  occult  moral  force,  pliysical  conditions,  the 
position  and  preparation  of  the  patient,  and  numerous 
other  concomitant  features  are  all  factors  of  little  im- 
portance to  the  occasional  administrator,  but  pregnant 
with  meaning  to  the  specialist.  These  factors  cannot 
be  regulated  by  any  known  mechanism,  however  subtle ; 
the  role  each  jilays  has  to  be  ajjiiro-ximately  gauged  by 
the  skilled  amvsthetist,  constituting  in  a  great  meas- 
ure the  necessity  for  his  aid.  Numberless  patients 
have  been  asphy.viated  and  the  result  has  been  calmly 
chronicled  as  being  due  to  a  greater  percentage  of 
vapor  than  tiio  human  organism  can  safely  tolerate. 

Chloroform  Syncope — Tliis  term  is  universally  ac- 
cepted as  the  correct  designation  of  the  sudden  deaths 
occurring  in  chloroform  narcosis;  it  may  happen  when 
only  a  few  whiffs  have  been  inhaled,  but  there  is  no 
doubt  that  primary  syncope  is  returned  as  the  cause 
of  death  when  it  could  be  traced  to  other  causes. 
Dr.  Richardson  says:  "  I  should  be  inclined  to  put 
down  '  fear'  as  one  of  the  most  determined  causes  of 
fatality  from  chloroform  anesthesia.  I  have  before  me 
now  several  instances  in  which  it  is  impossible  that 
chloroform — minus  fear^ — could  have  been  the  direct 
cause  of  death,  because  sufficient  of  it  was  not  admin- 


istered to  produce  this  result."  To  avoid  this  danger, 
it  is  absolutely  necessary  that  the  patient  should  be 
completely  anaesthetized  without  anything  to  disturb 
his  quietude,  being  cheered  and  comforted  by  the  an- 
resthetizer  alone;  all  hysterical  relatives  and  friends 
should  be  kept  from  him  ;  if  he  has  a  dear  friend,  who 
is  of  sterner  stuff  and  for  whom  the  patient  has  great 
affection,  he  may  be  allowed  to  stand  near  him  or 
hold  his  hand.  All  talking,  slamming  of  doors,  or 
the  rattle  of  instruments  about  to  be  used  should  be 
prevented,  and  it  is  imperatively  desirable  that  not 
even  the  locality  to  be  operated  upon  be  uncovered  or 
examined  until  he  is  completely  narcotized.  Neces- 
sarily, patients  with  fatty  hearts,  aortic  or  advanced 
mitral  lesions,  are  more  liable  to  syncope.  A  point  of 
some  importance  is  the  fact  that  robust  and  vigorous 
patients  form  the  greater  proportion  of  those  who 
have  these  attacks  at  the  initial  stage,  frequently,  no 
doubt,  due  to  the  fact  that  the  chloroform  is  timidly 
given,  instead  of  the  ana^sthetizer  rapidly  pushing  on 
to  complete  anaesthesia.  Syncope  occurring  in  the 
second  stage  of  anaesthesia  is  probably  due  to  the  re- 
flex inhibition  of  the  heart  through  the  vagus;  its  most 
dangerous  stage  is  just  before  the  patient  sinks  into 
complete  surgical  anaesthesia,  and  it  seems  that  at  this 
period  a  special  sensitiveness  of  reflex  mechanism  is 
brought  about,  death  occurring  from  apparently  trifling 
causes,  frequently  in  attempts  at  vomiting. 

In  case  of  intestinal  obstruction  and  like  condi- 
tions, this  particular  time  seems  to  be  fraught  with  jie- 
culiar  danger;  at  this  stage  the  anaesthesia  must  be 
pushed  rapidly  to  completion  and  the  patient  kept 
thoroughly  "  under"  until  the  operation  is  finished.  If 
the  syncope  is  profound  the  chloroform  must  be  re- 
moved, investigation  made  to  discover  if  any  coinci- 
dent asphyxia  is  present,  and  the  cause  eliminated. 
Artificial  respiration,  with  or  without  the  use  of  Fell's 
apparatus,  is  to  be  employed  ;  flagellation  with  towels 
alternately  wet  with  hot  and  cold  water;  pressure  on 
the  floating  ribs;  rhythmical  traction  of  the  tongue; 
fresh  air  admitted  into  the  room  in  plenty;  hot  saline 
solution  thrown  into  the  rectum;  nitrite  of  amyl  and 
ammonia  by  inhalation;  strychnine,  nitroglycerin, 
and  ammonia  hypodermically.  Stretching  of  the 
sphincter  ani  is  often  an  extremely  good  measure. 
I  have  but  little  faith  in  oxygen  or  the  use  of  a  far- 
adic  battery;  the  latter  stimulates  the  vagus  and  in- 
creases the  inhibitory  action  of  this  nerve,  seeming 
to  me  positively  harmful ;  by  pressure  on  the  lower 
ribs  and  carefully  conducted  artificial  respiration  the 
phrenic  can  be  stimulated  to  excite  the  diaphragm. 
Traction  on  the  tongue  can  be  employed  to  prevent 
the  approximation  of  tiie  aryteno-epiglottidean  folds, 
thus  allowing  free  ingress  of  air  to  the  lungs  and  re- 
moving the  chance  of  accident  from  the  tongue  fall- 
ing backward  upon  the  epiglottis.  It  was  pointed  out 
some  time  ago  by  a  careful  observer  that  rhythmical 
traction  on  the  tongue  will  stimulate  respiratory  move- 
ment. 

Syncope  occurring  during  the  third  stage  of  anxs- 
thesia  is  least  frequent  and  is  due  to  an  overdose  act- 
ing on  the  intrinsic  centres  of  the  heart  in  this  muscle 
itself  (Ludwig,  of  Leipsic,  and  Von  Recklinghausen 
showed  that  the  heart  is  under  the  control  of  these 
ganglia  and  can  perform  its  normal  mechanism  even 
when  disconnected  from  the  brain  or  cord)  or  to  para- 
lyzation  of  the  nerve  centres  in  the  medulla.  Doubt- 
less a  great  portion  of  the  mischief  comes  from  the 
carbonization  of  the  blood  in  the  capillaries  of  the 
lungs,  retarding  the  stream  mitil  this  reaction  is  felt 
by  the  larger  vessels  and  culminating  in  paralysis  of  the 
heart  muscle  in  the  eftort  to  empty  its  ventricles.  The 
concentration  of  the  anesthetic  atmosphere  is  not  of 
so  great  importance  at  this  stage  of  the  narcosis  as 
is  the  amount  of  chloroform  circulating  in  the  blood. 


September  25,  1897] 


MEDICAL    RECORD. 


449 


"  The  amount  coming  from  the  inhaler  varies  greatly 
from  time  to  time  as  fresh  anaesthetic  may  be  dropped 
into  the  cone ;  the  danger  exists  greatest  when  the  most 
concentrated  vapor  coincides  with  the  period  when  the 
patient  is  inspiring  deeply"'  (Lister).  The  treatment 
of  syncope  occurring  during  complete  surgical  narcosis 
is  practically  the  same  as  outlined  for  that  occurring 
during  the  second  stage  of  anaesthesia,  with  the  marked 
exception  that  the  anaesthetic  must  be  removed  and 
fresh  air  in  abundance  admitted  into  the  room. 

The  administration  of  a  few  doses  of  digitalis  or 
strychnine  hypodermically  in  subjects  with  weak  hearts 
was  recommended  and  practised  by  the  late  Dr. 
Wood,  who  was  a  firm  believer  that  it  lessened  the 
danger  of  syncope  and  that  it  could  be  profitably  em- 
ployed in  most  cases. 

If  it  is  ever  necessary  to  perform  tracheotomy  on  a 
patient,  the  method  proposed  by  Dr.  Von  Donhoft", 
of  this  city,  being  so  simple  and  requiring  such  an 
infinitesimal  time  renders  it  of  momentous  service  in 
connection  with  spasm  of  the  glottis,  occasionally  hap- 
pening in  narcosis.  A  curved  needle  threaded  is 
passed  through  the  trachea;  then  the  tracheal  rings  are 
cut,  and  the  thread  is  caught  by  a  blunt  hook;  this 
thread  is  divided  in  the  middle  and  the  two  strings  ii 
forms  are  loosely  tied  at  the  back  of  the  neck. 

Ether "  Any  one  can  give  ether"  has  been  the 

stereotyped  cry  of  surgeons  of  the  last  decade,  when 
the  question  of  a  suitable  anesthetic  in  a  given  case 
has  had  to  be  considered.  Of  late,  this  belief  has  been 
renounced  by  many  of  the  most  able;  certainly  those 
who  have  had  considerable  practical  experience  in  the 
administration  of  this  anaesthetic  are  the  firmest  be- 
lievers in  the  renunciation,  readily  affirming  that  it 
requires  a  greater  skill  to  administer  ether  than  chlo- 
roform. It  is  not  so  apt  to  kill  the  subject  on  the  op- 
erating-table, though  grave  dangers  are  encountered 
hours  or  days  after  the  surgical  sciuia- ;  these  are  often 
lost  sight  of  or  ascribed  to  other  causes. 

Eliminating  asphyxia,  but  little  is  known  by  e\  en 
our  advanced  physiologists  of  the  manner  in  which  an- 
aesthetics kill ;  no  one  has  discovered  the  subtle  secret. 
though  plausible  theories  have  been  advanced  by  the 
score.  In  records  of  autopsies  of  death  from  anaesthet- 
ics, how  often  is  the  return  marked:  "  .\11  the  organs 
were  healthy  and  the  cause  of  death  was  not  shown. '' 

The  preparation  of  the  patient  should  be  the  same  as 
prescribed  for  chloroform,  especial  care  being  taken  in 
secure  an  empty  stomach  and  to  insure  that  the  patient 
is  kept  warmly  covered,  hot  water  bags  being  applied 
to  the  extremities  if  necessar}',  as  the  fall  of  tempera- 
ture is  greater  when  ether  is  used.  The  first  few  in- 
spirations should  contain  only  a  small  quantity  of 
ether  vapor  until  the  sensibility  of  the  glottis  is 
dulled,  the  administrator  gradually  increasing  the 
amount  until  the  stage  of  excitement  is  reached, 
then  pushing  the  anasthetic  until  surgical  anaesthe- 
sia is  induced  and  keeping  the  patient  thoroughly 
"under,"  accomplished  by  a  small  amount  of  ether  if 
judiciously  administered.  The  anassthetizer  should 
be  prepared  to  meet  at  the  onset  any  difficulties  of 
respiration  that  may  arise,  the  delicate  circulation 
in  the  lobes  of  the  ears  giving  ample  warning  of 
disturbed  circulation;  if  present  it  is  to  be  promptly 
met  by  allowing  the  patient  to  breathe  one  or  two 
inspirations  of  unmodified  air.  The  patient  should 
not  be  removed  to  a  cooler  atmosphere  until  he  has 
recovered  from  the  anesthetic;  indeed,  it  is  well  to 
keep  him  for  about  twelve  hours  in  a  warm  room 
to  minimize  any  bronchial  trouble  that  may  occur 
as  a  result  of  the  etherization.  This  is  especially 
important  if  infants  or  elderly  people  are  the  subjects. 
If  a  closed  inhaler  is  used,  the  patient  should  be  al- 
lowed a  breath  of  unsaturated  air  from  time  to  time, 
best  accomplished  by  removing    the  cone    from  the 


face.  If  ether  is  incautiously  pushed  for  a  prolonged 
period  without  allowing  the  patient  to  renew  the  air 
in  his  lungs  from  time  to  time,  his  respiration  may 
stop,  although  the  muscles  may  be  flaccid ;  this  condi- 
tion appears  to  ensue  from  the  overloading  of  the 
blood  with  ether,  leading  to  paralysis  of  the  respira- 
torj'  centre  and  a  condition  of  collapse  similar  to  the 
syncope  of  chloroform  narcosis.  The  increased  secre- 
tion from  the  mouth  and  respiratory  tract  should  be 
occasionally  sponged  out,  but  the  experienced  ana.sthe- 
tizer  encounters  considerable  less  of  this  disagreeable 
symptom  than  the  novice.  Vomiting  and  coughing 
should  at  all  times  be  overcome  by  pushing  the  ether 
to  tolerance.  Warning  of  vomiting  is  generally  given 
by  the  occurrence  of  irregular,  shallow  breathing,  yawn- 
ing inspirations,  efforts  at  swallowing,  retching,  and 
dilatation  of  the  pupil.  The  latter  sign  must  be  dif- 
ferentiated from  that  which  occurs  when  syncope  is 
about  to  be  induced ;  it  is  one  of  the  most  dangerous 
symptoms,  and  its  true  import  should  be  instantly 
recognized.  In  case  of  the  administration  of  ether  to 
patients  in  a  state  of  collapse,  very  dilute  vapor  must 
be  given,  the  room  kept  about  85  '  F.,  and  dry  heat  ap- 
plied to  various  portions  of  the  subject.  Schilling  is 
in  the  habit  of  giving  one-grain  doses  of  camphor  hy- 
podermically as  a  stimulant,  reporting  good  results 
from  this  procedure. 

The  following  conditions  are  looked  upon  as  being 
specially  suited  to  the  administration  of  ether,  but 
mitigating  circumstances,  as  with  the  field  mapped 
out  for  chlorofonn,  may  contraindicate  its  use:  surgi- 
cal shock,  epilepsy,  tendency  to  syncope,  fatty  heart  or 
advanced  aortic  or  mitral  disease,  acute  alcoholism 
and  delirium  tremens,  fatty  or  obstructed  liver,  spina 
bifida,  hydrocephalus,  w'hen  any  heart-depressing  drug 
has  been  administered  in  large  doses.  No  alcoholic 
stimulant  should  be  given  before  or  during  collapse 
following  or  occurring  at  its  administration;  it  only 
increases  the  narcotization,  and  therefore  the  dangers; 
for  the  same  reason  opium  should  also  be  withheld. 

Obstructed  respiration  may  occur  from  simple  fall- 
ing back  of  the  tongue,  the  presence  of  blood,  mu- 
cus, etc.,  in  the  the  larynx,  or  from  spasm  of  the 
glottis.  A  good  anesthetist  can  administer  this  agent 
to  patients  of  any  age,  but  it  will  be  generally  found 
that  elderly  people  do  best  under  chloroform,  they 
having  often  a  condition  of  chronic  bronchitis. 

In  aortic  diseases  it  acts  as  a  stimulant  and  is  often 
beneficial,  but  if  there  is  a  tendency  of  the  venous  sys- 
tem to  be  turgescent,  as  in  mitral  diseases  or  dilated 
right  heart,  chloroform  will  be  more  suitable,  if  admin- 
istered on  right  principles. 

Ether  exercises  a  much  less  dangerous  action  on 
the  ganglia  of  the  heart;  this  would  relegate  chloro- 
form into  disuse  but  for  the  fact  that  the  after-effects 
of  its  administration  are  often  so  dangerous.  Thus 
the  superior  safety  of  ether  is  frequently  more  than 
counterbalanced,  necessitating  careful  consideration 
as  to  which  should  be  employed.  The  danger  from 
reflex  inhibition,  producing  primary  syncope,  is 
less  liable  to  occur  than  when  chloroform  is  used, 
and  can  be  best  treated  by  pushing  the  anesthetic, 
unless  this  is  contraindicated.  Tiius,  even  with  the 
so  considered  safer  and  more  fashionable  anesthetic, 
the  supersaturation  of  the  blood  and  nervous  tissues, 
with  its  sequence  of  paralyzed  respiratory  and  cardiac 
action,  is  a  possibility  not  to  be  lost  sight  of. 

When  one  considers  that  the  aim  and  result  of  all 
anesthetic  procedures  is  to  paralyze  nerve-cell  func- 
tion, it  must  not  be  forgotten  that  the  distance  is  not 
far  to  paralyzed  centres,  which  portends  so  much.  In 
all  anesthesias,  whatever  substance  is  used,  the  true  an- 
aesthetist strives  to  remain  in  that  narrow  limit  between 
reflex  inhibitory  influences  and  paralyzed  nerve  centres. 

63  West  Te.nth  Street. 


450 


MEDICAL    RECORD. 


[September  25,  1897 


THE    PATHOLOGY   OF    EVOLUTION. 


By   CORA     HOSMER   FLAGG,    .M.D. 


INSTRrCTOR 


Since  biology  no  longer  places  man  in  a  separate 
order  by  himself  but  considers  him  as  the  last  link  in 
the  long  chain  of  organism,  it  has  become  absolutely 
necessary  for  a  broad  and  progressive  knowledge  of 
man"s  structure,  its  physiology  and  pathology,  that 
our  medical  schools  should  present  these  subjects 
from  a  comparative  standpoint. 

The  great  progress  made  in  anatomy  during  the  last 
few  years  has  been  wholly  due  to  the  study  of  the  evo- 
lution of  organs  and  tissues  through  lower  to  higher 
forms.  Thanks  to  the  work  of  those  great  masters 
of  comparative  anatomy — Wiedersheim,  Cunningham, 
Osborn,  Sutton,  Wilson,  Cope,  Howes,  Humphry, 
Rathke,  and  a  host  of  others — this  subject  is  at  the 
present  time  the  most  progressive  of  all  the  biological 
sciences. 

It  now  remains  for  physiology  and  pathology,  based 
as  they  necessarily  are  upon  morphological  data,  to 
profit  by  the  consideration  of  the  possibilities  of  com- 
parative anatomy  for  elucidating  many  of  the  patho- 
logical conditions  to  which  man  is  subject. 

It  IS  a  common  idea  that  the  human  body  is  ti.xed  or 
stable  in  its  structure,  that  it  is  perfectly  and  marvel- 
lously adapted  to  supposed  uses  for  definite  ends, 
■while  all  the  evidences  from  comparative  anatomy, 
embryology,  and  ph\siology  go  to  show  that  the  ma 
jority  of  our  organs  are  combinations,  rearrangements, 
and  compromises  necessitated  by  the  accidents  of 
growing  complexities.  These  same  biological  sci- 
ences show  many  indications  that  changes  in  man's 
organism  are  still  continuing,  and,  by  pointing  out  to 
us  the  centres  of  most  rapid  evolution,  give  us  a  hint 
as  to  what  the  man  of  the  future  will  be  like. 

Much  of  this  instability  of  structure  is  directly  due 
to  the  mechanics  of  the  upright  position  and  to  the 
fact  that  the  body  with  its  quadrupedal  ancestry  has 
not  yet  become  perfectly  adapted  to  this  condition. 
Every  region  of  the  body  shows  evidences  of  this  mal- 
adaptation.  Some  structures  are  in  a  state  of  progres- 
sion— that  is,  they  are  tending  toward  more  perfect 
adaptation;  others  are  slowly  retrogressing,  some  hav- 
ing gone  so  far  m  this  direction  as  to  have  dropped 
out' of  use  entirely,  remaining  now  as  vestiges.  Some 
nave  disappeared,  only  to  reappear  as  reversions  or 
anomalies.  Our  developing,  degenerating,  rudimen- 
tary, and  reversional  organs  show  conclusively  that 
man  is  now  in  active  process  of  evolution. 

It  is  the  purpose  of  this  paper  to  place  in  view  the 
relations  which  exist  between  maladaptation  and  cer- 
tain pathological  conditions  of  various  structures  of 
the  human  body,  or  rather  some  di-seases  or  pathologi- 
cal processes  that  are  most  obviously  due  to  the  fact 
that  man  has  evolved  from  lower  conditions  of  organ- 
ism. 

Naturally  we  should  expect  to  find  in  the  pelvis 
marked  modifications  adaptative  to  the  upright  posi- 
tion, for  instead  of  a  pelvis  which  transmits  the  weight 
of  the  posterior  end  of  the  spinal  column  merely  to  the 
femora,  we  now  have  a  pelvis  whicli  tr.tnsmits  the 
weight  of  the  whole  column  and  upper  extremities,  and 
supports  the  weight  of  the  viscera.  In  conformity  to 
this  change  of  function,  instead  of  the  "box-shaped" 
pelvis  of  the  quadruped,  with  its  long,  narrow,  straight 
ilia,  straight  sacrum  with  no  projecting  promontory, 
and  straight  birth  canal,  we  have  a  "bowl-shaped" 
pelvis  with  wide-flaring  ilia  and  contracted  inlet, 
curved  sacrum  with  projecting  promontor)',  and  a 
cun-ed  birth  canal.  It  should  be  noticed  that  this 
latter  t)'pe  of  pelvis  is  not  found  in  the  newborn  in- 
fant, but  commences  to  take  shape  as  soon  as  the  child 


becomes  accustomed  to  the  upright  gait,  and  it  i.- 
creases  in  this  direction  as  long  as  the  plasticity  of 
the  bones  allows.  Litzmann  finds  that  the  European 
infant  at  birth  has  a  pelvis  much  like  that  of  the 
lower  mammals,  i.<'.,  the  cavity  is  deeper,  the  sacrum 
scarcely  curbed,  and  there  is  more  inclination  of  the 
pelvis,  so  that  the  entrance  to  it  is  round  and  large, 
differing  much  from  the  later  adult  form.  This  infant 
pelvis  is  as  good  evidence  as  to  the  shape  of  the  pel- 
vis in  the  early  mammalian  stage  of  human  phylogeny 
as  the  gill  slits  are  to  the  ichthyoid  stage.  The  adult 
pelvis,  while  better  adapted  for  support,  is  not  the 
shape  best  adapted  for  easy  and  safe  parturition.  The 
curved  birth  canal,  together  with  the  changed  angle  of 
pelvic  inclination,  causes  the  canal  tovarj-  at  different 
depths,  making  necessary  a  series  of  changes  of  posi- 
tion of  the  child's  head  during  deliver}-.  The  pro- 
jecting sacral  promontory,  most  marked  in  civilized 
races,  still  further  lessens  the  dimensions  of  the  pelvic 
inlet.  All  these  characters  increase  the  danger  to  life 
during  delivery  of  both  mother  and  child,  and  it  is 
well  known  that  the  death  of  thousands  of  mothers 
and  children,  otherwise  perfectly  healthy  and  well 
formed,  can  be  traced  to  this  evolutionar}-  factor  alone. 

The  highest  e.xpression  of  modification  is  found  in 
the  pelvis  of  the  civilized  woman.  In  her  we  have 
well  illustrated  the  struggle  that  has  been  and  still  is 
going  on  between  expanding  ilia  and  contracting  inlet 
for  better  support  on  the  one  hand,  and  the  increasing 
size  of  the  child's  head,  which  is  correlated  with  an 
increased  capacity  for  brain  development,  on  the  other. 
It  is  of  significance  to  note  in  this  connection  that  the 
pressure  of  the  viscera  upon  the  pelvis  is  artificially 
increased  by  the  corset-wearing  habit.  The  civilized 
races  are  more  or  less  mixed  races,  and  so  there  is  a 
constant  discrepancy  between  the  shape  of  the  child's 
head  and  the  shape  of  the  pelvic  inlet  of  the  mother, 
which  increases  the  difficulty  of  parturition.  Primi- 
tive races  are  usually  homogeneous  races,  and  the 
shape  of  the  foetal  cranium  and  the  maternal  pelvis  are 
usually  well  correlated,  hence  we  rarely  find  such  diffi- 
cult parturition  arising  from  this  cause  among  them. 
The  pelvic  contents  of  the  other  mammals  and  the 
human  infant  are  not  the  same  as  those  of  adult  man. 
A  downward  shifting  of  the  viscera  occurs  when  the 
child  begins  to  walk,  and  the  protruding  abdomen,  so 
like  that  of  the  anthropoids,  disappears.  The  urinary 
bladder  and  its  appendages,  uterus,  vagina,  and  their 
appendages,  vesicula;  seminales,  rectum,  sigmoid  flex- 
ure, and  lower  part  of  the  ileum,  are  all  pelvic  organs 
of  the  adult  man.  In  the  other  mammals  and  the 
human  infant  the  sigmoid  flexure,  lower  part  of  the 
ileum,  and  fundi  of  the  bladder  and  uterus  are  always 
in  the  abdomen.  No  other  reason  can  be  assigned  for 
this  downward  shifting  except  gravity ;  hence  any  path- 
ological condition  arising  from  their  presence  within 
the  pelvis  must  be  due  to  the  upright  position.  Of 
the  pelvic  organs  affected  by  downward  pressure,  the 
uterus  probably  suffers  most.  The  various  folds  of 
peritoneum,  so-called  ligaments,  and  the  round  liga- 
ments, while  distinctly  functional  in  the  quadrupedal 
position,  to  act  as  "  guy  ropes,"  to  prevent  the  gravid 
uterus  from  falling  too  far  forward  and  interfering 
with  the  function  of  lungs  and  heart,  practically  do 
not  support  the  uterus  in  the  upright  position.  Adap- 
tative changes  have  taken  place  in  a  measure  in  the 
tissues  about  the  cervix  uteri,  the  health  and  tonicity 
of  which  will  be  more  generally  recognized  by  gynae- 
cologists as  important  agents  in  preserving  uterine 
position.  The  inadequacy  of  this  makeshift,  however, 
is  shown  by  the  very  great  frequency  of  uterine  dis- 
placements, which,  together  with  the  ven,'  serious  dis- 
turbances accompanying  them,  furnish  one  of  the 
most  obvious  pathologies  of  evolution. 

Man  is  tlie  onlv  animal  that  fullv  extends  the  thigh 


I 


September  25,  1897] 


MEDICAL    RECORD. 


451 


at  the  hip-joint.  This  straightening  of  the  legs  when 
the  child  begins  to  walk  is  effected  by  the  develop- 
ment of  a  lumbar  curvature  in  the  spinal  column. 
This  convexity  forward  in  the  lumbar  region  has  re- 
ceived much  attention  from  comparative  anatomists, 
many  of  whom  claimed  it  as  a  distinctive  human  char- 
acteristic until  Cunningham  demonstrated  a  beginning 
development  of  it  in  certain  of  the  semi-erect  anthro- 
poids. It  is  never  found  in  the  spines  of  animals 
habituallv  quadrupedal  in  gait.  A  cervical  convexity 
also  appears  when  the  human  infant  acquires  strength 
to  raise  its  head  and  balance  it  on  the  summit  of  the 
spinal  column. 

The  single,  large,  dorsally  directed  curve  of  the 
quadrupedal  spine  has  been  modified  to  the  require- 
ments of  the  upright  position  by  the  formation  of  these 
two  antagonizing  curves,  and  the  massive  development 
of  the  erector-spinse  group  of  muscles.  Wiedersheim 
finds  evidences  of  its  present  evolution  toward  more 
perfect  adaptation  in  the  increase  of  all  of  its  cur\a- 
tures,  especially  the  lumbar,  the  shortening  of  the 
centra  of  the  lumbar  vertebra;,  and  the  upward  shift- 
ing of  the  pelvis  on  the  coliomn,  which  is  shown  by 
finding  the  fifth  lumbar  vertebra  in  all  stages  of  pro- 
gression toward  becoming  incorporated  into  the  sa 
crum.  Undoubtedly  there  was  a  point  in  man's  phy- 
lum when  the  spinal  cord  accompanied  the  whole 
length  of  the  column,  which  was  much  longer  than  at 
present,  the  coccvx  being  the  vestigial  representative 
of  this  shortening.  An  atrophy  of  the  cord  upward 
has  taken  place,  and  now  it  reaches  only  to  the  first 
lumbar  vertebra.  In  view  of  this  fact  the  attention  is 
directed  to  the  relation  between  those  tabetic  affec- 
tions to  which  this  part  of  the  cord  is  subject  and  this 
upward  degeneration. 

There  are  evidences  that  the  upper  part  of  the  spine 
possessed  more  ribs  than  at  present,  for  a  proof  of  the 
existence  of  cervical  ribs  in  mammals  is  found  in  the 
Edentata.  The  seventh  and  sometimes  the  sixth  cer- 
vical vertebra  of  the  human  embryo  almost  ahvays  pos- 
sesses vestiges  of  ribs,  and  cases  are  not  at  all  rare  in 
which  a  seventh  cervical  sternal  rib  has  been  found  in 
adult  man.  Sometimes  it  is  paired,  and  often  it  does 
not  reach  the  sternum.  Often  the  first  pair  of  thoracic 
ribs  show  such  marked  degnerative  characteristics  that 
Howes  says  '"  the  question  might  be  raised  whether 
this  tendency  toward  reduction  at  the  upper  end  of  the 
thorax  may  not  be  a  determining  factor  in  the  degen- 
eration so  frequently  found  to  be  commencing  at  the 
apices  of  the  lungs." 

Since  the  upright  gait  frees  our  anterior  limbs  from 
the  supporting  and  walking  function — a  function  nec- 
essarily demanding  equal  use  of  the  limbs  of  both 
sides — we  have  acquired  right-handedness,  no  satisfac- 
tory explanation  of  which  has  as  yet  been  suggested. 
Whatever  the  cause,  there  is  associated  with  it  an  in- 
equality of  muscular  de\elopnient  between  the  two 
sides.  This  inequality  of  muscular  development  may 
be  assigned  as  one  of  the  causes  of  lateral  spinal 
curvature,  a  pathological  condition  found  only  in  man. 

In  the  lower  mammals  the  fibula  is  nearly  eijual  in 
size  to  the  tibia,  and  both  articulate  with  the  femur, 
contributing  to  the  formation  of  the  knee-joint.  We 
find  this  same  condition  of  the  two  bones  in  the  human 
embryo  at  one  period  of  its  development. 

In  the  upright  position  during  phylogenetic  devel- 
opment the  weight  of  the  body  has  come  to  rest  on  the 
tibia  alone,  and  the  fibula  has  shifted  downward  and 
dwindled  to  a  mere  appendage,  saved,  however,  from 
still  further  degeneration  by  its  connection  with  the 
heads  of  the  peronei  and  the  part  it  takes  in  the  for- 
mation of  the  ankle.  It  is  not  strongly  functional ; 
hence  it  is  a  weak  structure,  and,  being  in  a  position 
exposed  to  strains  and  impacts,  is  very  frequently 
fractured. 


Fractures  of  the  neck  of  the  femur  are  probably 
rendered  more  frequent  from  the  fact  that  the  angle 
it  makes  with  the  shaft  of  the  bone  is  increased  by 
the  weight  of  the  body  as  age  advances. 

While  the  viscera  as  a  whole  were  nearly  as  well 
adapted  for  use  in  an  upright  position  as  in  a  horizon- 
tal one,  yet  the  change  to  verticality  did  bring  about 
certain  disadvantageous  conditions,  aside  from  those 
resulting  from  pressure,  which,  have  caused  pathologic- 
al conditions.  Clevenger  has  shown  that  in  the  quad- 
rupedal position  the  circulation  in  the  intercostal  and 
lumbar  veins  has  to  be  maintained  against  gravity;  con- 
sequently we  find  in  them  an  abundant  supply  of  val\  es. 
In  the  upright  position  the  direction  of  the  blood  cur- 
rent in  these  veins  is  horizontal,  and,  although  valves 
are  of  no  functional  value,  yet  they  are  always  present 
in  various  stages  of  retrogression.  This  interesting 
phvlogenetic  fact  is  still  more  emphasized  by  our  find- 
ing many  more  valves  in  the  human  embryo  than  at- 
tain to  complete  development  in  the  later  adult  form. 
While  there  is  no  reason  for  valves  in  the  horizontally 
disposed  portal  system  of  the  quadruped,  their  absence 
in  the  hemorrhoidal  and  other  parts  of  our  portal  sys- 
tem has  an  important  influence  on  the  development  of 
certain  diseases  due  to  congestion,  one  of  the  most 
common  of  which  is  hemorrhoids  or  piles.  Much 
suffering  is  caused  also  by  the  frequent  absence  of 
valves  in  the  ovarian  veins,  especially  in  the  vein  of 
the  left  side,  which  almost  never  possesses  a  valve. 

The  heart  works  at  a  great  disadvantage,  because  it 
has  to  force  the  blood  column  to  a  higher  level  and 
against  greater  hydrostatic  pressure.  We  might  find 
here  a  cause  for  the  tendency  to  heart  affections  from 
which  man  suffers.  The  difficulty  of  lifting  the  blood 
column  against  gravity  is  shown  by  the  frequent  occur- 
rence of  varicose  veins,  varicocele,  etc. ;  and  as  disor- 
ders secondary  to  heart  affections  we  have  anasarca, 
congestions  of  the  liver,  ascites,  cardiac  dropsy,  etc. 

The  upright  position  has  exposed  the  great  ves- 
sels of  the  leg  and  arm,  increasing  the  danger  to 
fatal  hemorrhages  from  their  greater  liability  to 
injury. 

The  cacum  and  colon  are  not  favorably  located  in 
the  upright  position  for  carrying  oft"  facal  matter;  and 
the  rectum,  forced  to  follow  the  curve  of  the  sacrum 
by  pressure  of  other  organs,  is  because  of  this  the  seat 
of  numerous  ills. 

The  weakest  spots  in  the  abdominal  walls  are  those 
openings  in  the  abdominal  muscles  just  above  Pou- 
part's  ligaments  for  the  transmission  of  certain  struc- 
tures from  the  abdominal  cavity.  When  the  visceral 
stress  is  in  the  ventral  direction,  this  weak  part  is  in 
a  protected  position  ;  but  with  visceral  stress  in  the 
caudal  direction  these  weak  places  are  most  unfa- 
vorably located.  Adaptative  modifications  of  tissues 
about  the  inguinal  canals  ha\e  taken  place,  but  when 
the  abdominal  muscles  are  powerfully  actuated  they 
are  often  strained,  the  openings  enlarged,  and  the 
intestine  is  forced  out,  constituting  the  pathological 
condition  known  as  inguinal  hernia. 

Every  region  of  the  body  shows  some  record  of  the 
past  history  of  the  race,  in  the  large  number  of  vesti- 
gial structures,  the  present  representatives  of  parts  once 
of  value  when  environmental  conditions  were  different 
from  what  they  are  now.  These  vestiges  through  lack 
of  function  and  consequent  lessened  metabolism  be- 
come more  quickly  overloaded  with  the  katastates  of 
their  own  cell  life,  and  so  fall  the  more  readily  a  prey 
to  adverse  conditions.  So  great  is  their  liability  to 
be  attacked  by  disease  that  "  an  unused  part  is  a  dis- 
eased part"  has  become  a  medical  axiom. 

Many  obsolete  canals  which  were  functional  in  our 
remote  ancestors,  instead  of  filling  up  and  becoming 
cords,  have  sometimes  a  lumen  left  in  them,  which 
occasionally  fills  with   fluid,  making  tumors.     Many 


452 


MRDTCAL    RECORD. 


[September  25,  1897 


of  the  ducts  and  organs  connected  with  the  genito- 
urinary apparatus,  being  tertiary  adaptations  from  a 
primitive  kidney  system,  through  a  secondary  kidney 
system,  are  peculiarly  liable  to  disease,  not  only  on 
account  of  their  late  and  complex  evolution,  but  from 
the  persistence  of  many  vestigial  structures  connected 
with  them.  The  parovarium  is  one  of  these — the  re- 
mains of  the  Wolffian  body.  It  consists  of  a  series  of 
short  vertical  tubes,  dipping  into  the  hilum  of  the 
ovary  and  ending  blindy  above  in  a  duct.  From  some 
cause  these  tubes  are  often  the  seat  of  cysts  which  may 
attain  great  size.  They  are  sometimes  accompanied 
by  ascites,  sometimes  infect  the  peritoneum,  and  often 
cause  death  by  malignant  degeneration. 

Because  an  organ  in  a  pathological  condition  may 
cause  widespread  systemic  derangement  is  no  proof 
that  such  an  organ  is  now  of  physiological  value,  when 
there  is  no  other  evidence  as  to  its  function.  The 
fact  that  the  thyroid  gland,  when  diseased,  may  give 
rise  to  goitre,  acromegalia,  and  other  systemic  dis- 
turbances, is  no  proof  that  the  thyroid  in  health  is  of 
functional  value,  and  that  it  should  not  be  classed  as 
a  vestigial  organ. 

Not  enough  of  experiments  have  been  made  as  yet 
of  removal  of  the  thyroid,  unaccompanied  by  other 
conditions,  to  give  us  data  as  to  any  normal  function. 
What  has  just  been  said  is  also  applicable  to  the 
thymus  gland  and  the  suprarenal  capsules. 

In  many  places  where  canals  open  on  a  free  surface, 
the  orifices  are  usually  surrounded  with  glands  and  a 
mass  of  adenoid  tissue.  The  tonsils  are  an  example 
of  this,  located  in  the  fauces  and  marking  the  inner 
orifices  of  the  gill  slits.  There  is  a  third  tonsil, 
identical  in  structure  with  the  tonsils  of  the  fauces,  in 
the  pharyngeal  vault,  which,  although  not  associated 
with  a  gill  slit,  is  situated  at  the  pharyngeal  orifice  of 
a  duct,  which  in  the  embr)'o  traverses  the  floor  of  the 
pituitary  fossa  and  opens  into  the  roof  of  the  pharynx. 
These  are  very  troublesome  vestiges,  often  giving  rise 
to  tonsillitis  and  malignant  tumors,  and  from  their  ves- 
tigial character  are  the  seat  of  the  initial  lesion  in 
many  pathological  affections  of  the  throat.  As  is  well 
known,  adenoid  tissue  has  an  inherent  tendency  at 
slight  provocation  to  increased  activity  of  its  cellular 
elements,  thus  enlarging  the  mass;  and  it  is  this  hy- 
pertrophy, especially  of  the  third  tonsil,  that  causes  so 
much  trouble  in  childhood. 

It  has  been  conclusively  shown  that  the  intestinal 
CiBCum,  owing  to  changes  in  diet  and  habits,  has  be- 
come much  shortened  in  man — the  vermiform  appendix 
being  left  as  a  rudiment  of  this  shortened  part.  It  has 
all  the  characteristics  of  a  rudiment,  noticeably  varia- 
bility in  both  length  and  occlusion,  and  a  greater  de- 
velopment in  the  embryo  than  in  the  adult.  Appen- 
dicitis is  now  a  well-recognized  lesion,  and  to  it  other 
infiammatory  conditions,  as  the  different  forms  of 
typhlitis  and  peritonitis,  can  be  traced. 

All  of  that  great  number  of  our  retrogressive  and 
progressive  structures  which  are  now  becoming 
changed  to  secondary  uses,  or  becoming  more  highly 
differentiated  by  the  modification  of  their  cell  habits, 
offer  a  less  vigorous  resistance  and  more  readily  suc- 
cumb to  disease  than  do  those  structures  that  have  de- 
veloped along  one  line  alone,  so  retaining  their  earlier 
cell  habits  in  constant  vigorous  activity. 

While  congenital  abnormalities  are  usually  the  re- 
sult of  local  disturbances  or  malnutrition,  they  are 
usually  of  a  type  recalling  the  original  evolution  of 
that  part;  so  that  local  disturbances  seem  to  be  more 
effective  on  an  atavistic  line.  We  have  cleft  i)alate 
from  failure  of  the  maxillary  plates  of  the  first  gill 
arch  to  approximate;  anterior  cleft  palate  and  harelip 
from  a  failure  of  the  frontal  process  to  project  suffi- 
ciently far  downward ;  supernumerary  auricles  and 
branchial  fistula-  at  the  <iill-slit  localities  from  arrested 


developmental  processes;  hypospadias  from  failure  of 
the  genital  furrow  to  unite  in  the  male. 

It  is  a  noticeable  fact  that  the  most  common  brain 
lesions  are  those  of  the  latest  developed  and  most 
highly  specialized  convolutions;  that  the  rarest  le- 
sions are  those  affecting  the  deeper  parts  of  the  brain, 
where  lie  the  primal  emotions  and  desires  common  to 
nearly  all  animal  life. 

The  external  parts  of  the  brain,  which  during  the 
course  of  evolution  have  developed  and  specialized  in 
response  to  individual  need,  rather  than  of  species 
necessity,  are  the  most  complex  and  hence  the  most 
unstable  parts.  Consequently  we  find  them  the  most 
liable  to  disease  and  the  most  easily  disturbed  by  dis- 
ease in  other  parts  of  the  body.  The  more  complex 
parts  of  the  brain  are  associated  with  the  more  com- 
plex phenomena  of  the  mind,  such  as  the  more  intri- 
cate correlations  from  which  arise  generalizations  of 
concrete  experiences,  and  hence  deductions  as  to  the 
nature  of  new  but  analogous  conditions.  These  com- 
plex functions,  being  the  latest  acquired,  are  the  most 
easily  disturbed,  and  their  derangement  furnishes  the 
most  satisfactory  explanation  of  delusions,  double  per- 
sonality, and  other  morbid  mental  manifestations. 
The  insane  will  readily  commit  suicide,  as  the  primi- 
tive savage  will  readily  sacrifice  his  life,  but  both  will 
instinctively  struggle  against  another  injuring  them  in 
the  same  way.  The  appreciation  of  value  of  one's 
ow  n  life  to  one's  self  is  a  later  acquirement — the  strug- 
gle for  existence  against  another  being  a  primal  ten- 
dency. In  those  brain  lesions  of  the  cortex  which 
produce  insanities,  the  deep-seated  primal  emotions 
are  freed  from  the  repression  which  this  part  of  the 
brain  has  gradually,  during  the  course  of  evolution, 
come  to  exercise  over  them. 

Between  these  two  extremes  of  primal  emotions  and 
complex  correlations  there  lie  the  vast  series  of  ever- 
specializing  centres  of  organic  and  muscular  activities. 
The  lesions  in  these  centres,  in  the  frequency  of  their 
occurrence,  lie  between  the  comparati\e  lack  of  them 
in  the  case  of  the  deep-seated  parts  of  the  brain,  and 
the  constant  occurrence  of  them  in  the  later,  higher 
psychic  development  of  the  external  portions. 

In  this  cursory  review  of  pathological  conditions 
due  to  the  evolutionary  nature  of  man's  origin,  we  have 
only  touched  upon  those  which  have  the  most  clearly 
arisen  from  the  action  of  this  principle  in  him. 
Broadly  speaking,  however,  the  pathologies  of  evolu- 
tion should  not  be  thus  confined;  for  in  the  broader 
view,  which  takes  in  the  action  of  this  principle 
throughout  nature,  we  should  include  within  our  in- 
quiry all  factors  that  affect  man. 

Before  we  are  prepared  fully  to  understand  the  de- 
tails of  pathology,  they  must  be  carefully  verified  and 
collated  under  a  broad  system  of  comparative  study, 
which  not  only  takes  into  account  the  individual  dis- 
ease as  it  now  exists,  but  which  will  trace,  as  far  as 
possible,  the  factors  in  the  long  history  of  our  growth 
that  gave  rise  to  it  and  from  which  it  too  has  evolved. 


The  Treatment   of   Chorea Dr.    De   Renzi   has 

confidence  in  onlv  tiiree  remedies:  i.  Absolute  rest, 
avoiding  any  external  excitation  whatever,  and  plac- 
ing the  patient  in  a  dark  room.  2.  The  ascending 
electric  current  along  the  spinal  cord — the  best  results 
with  a  gentle  current,  progressively  increased.  3.  Ar- 
senic in  large  doses,  commencing  with  twenty  drops  of 
Fowler's  solution  each  day  for  children,  and  double 
this  amount  for  adults.  When  the  chorea  ceases  the 
medicine  should  be  continued,  for  the  disease  returns 
readily.  The  nutrition  of  the  patient  must  be  main- 
tained, and  good  food  and  gymnastics  are  useful. — 
Gazzethi  dcgli  OspcJali  c  dclk  'CHniclu: 


September  25,  1897] 


MEDICAL    RECORD. 


45: 


TOBACCO    AMBYLOPIA. 
By    RICHARD   ELLIS,    M.D., 


A  cHKOXic  retrobulbar  neuritis  may  arise  from  a  vari- 
et)'  of  causes,  chief  of  which  is  the  abuse  of  tobacco. 
From  its  most  common  cause  the  disease  has  been  called 
'"tobacco  amblyopia,"  though  it  is  better  to  keep  the 
term  '"  retro-bulbar  neuritis"  as  derived  from  the  pa- 
thology, rather  than  to  accept  a  name  derived  from  the 
etiology.  The  victim  usually  comes  early  to  the 
physician,  complaining  of  some  loss  of  sight  with  pos- 
sibly a  slight  cloudiness  obscuring  vision.  In  such 
cases  the  ophthalmoscope  reveals  no  signs  of  a  special 
pathological  state,  and  nonnal  vision  soon  returns  on 
the  discontinuance  of  the  use  of  tobacco. 

In  advanced  cases,  vision  may  range  from  .r^'-  to 
Tt^.  Reading  is  impossible;  a  hazy  cloud  is  ex- 
tremely annoying;  central  vision  is  so  poor  that  me- 
chanically the  patient  will  turn  his  head  to  either  side 
in  order  to  use  the  peripheral  parts  of  the  retina.  He 
is  often  sure  he  sees  better  at  night,  at  least  he  does 
not  see  this  haziness  quite  so  disagreeably.  This  oft- 
observed  nyctalopia  caused  Arlt,  ignorant  of  the  pa- 
tholog}-,  to  call  this  form  of  neuritis  "  retinitis  nyctalo- 
pica."  The  patient  does  not  know  when  the  trouble 
Ijegan.  He  may  early  detect  his  inability  to  read  as 
well  as  formerly,  but  many  of  these  patients  (who  read 
but  little)  are  not  troubled  much  until  failing  vision 
interferes  with  their  work.  Then  some  consult  the 
physician  at  once:  others,  not  realizing  the  trouble, 
lose  their  positions,  and  console  themselves  with  their 
beloved  pipes  and  coddle  their  cud  until  a  condition 
of  almost  complete  blindness  drives  them  to  some  hos- 
pital to  seek  advice. 

The  patient  tells  enough  to  suggest  at  once  the 
diagnosis.  If  the  ophthalmoscopic  examination  is 
negative,  the  physician  examines  for  central  color 
scotomata  in  that  part  of  the  field  corresponding  to 
the  part  of  the  retina  supplied  by  the  papillo-macular 
bundle  of  the  optic  nerve.  A  careful  examination 
will  show  a  color  scotoma  in  both  eyes,  with  loss  of 
central  vision.  As  the  retina  is  very  easily  exhausted, 
especially  at  the  border  lines  of  the  scotomata,  it  is  not 
advisable  to  try  to  map  out  the  boundary  lines  too 
carefully.  Have  the  patient  look  at  a  black  lead  pen- 
cil a  few  feet  in  front  of  him,  and  then  quickly  present 
to  the  nasal  field  of  the  eye  examined  a  small  black 
disc  with  a  red  centre.  At  once  the  patient  recognizes 
the  color.  When  the  disc  is  brought  to  the  temporal 
side,  the  patient  cannot  possibly  recognize  the  color 
in  the  oval  field  corresponding  to  the  maculo-papillary 
retinal  region,  or  in  mild  cases  he  will  at  once  notice 
that  the  color  is  less  bright.  In  advanced  cases  he  may 
not  recognize  bright  blue  or  even  white. 

The  peripheral  parts  of  the  field  are  color  blind  in 
the  normal  eye.  The  nearer  the  color  approaches  the 
centre  of  the  field,  the  more  acutely  is  the  color  recog- 
nized. In  this  form  of  amblyopia,  since  there  is  an 
atrophy  of  the  very  nerve  fibres  that  best  distinguish 
colors,  we  expect  the  patient  to  have  central  color 
scotomata  and  should  remember  this  as  the  leading 
point  for  diagnosis  in  tliis  form  of  amblyopia. 

The  ophthalmoscopic  examination  is  usually  nega- 
tive. From  a  close  examination  the  physician  is  usu- 
ally convinced  (from  the  breath)  that  most  of  these 
patients  indulge  in  the  abuse  of  whiskey  as  well  as  in 
that  of  tobacco,  so  that  in  many  cases  it  is  a  question 
which  should  take  the  greater  blame.  I  am  convinced 
from  the  pathology  of  the  abuse  of  alcohol  (increase 
of  connective  tissue,  decrease  of  normal  cells)  as  well 
as  from  the  breath,  that  alcohol  must  be  considered  as 
an  adjuvant  to  the  tobacco  in  such  cases.     Some  be- 


lieve that  alcohol  alone  can  produce  this  retrobulbar 
neuritis.  Xoyes  states  in  his  text-book  that '"  in  alco- 
holic amblyopia  we  find  usually  a  dull  red  nerve  with 
swollen  veins,  rather  hazy  borders,  and  torpid  circu- 
lation. Atrophy  may  subsequently  ensue.  ...  In 
tobacco  amblyopia  the  nerve  is  brighter  and  more 
nearly  normal,  or  it  may  show  tokens  of  atrophy  or  of 
interstitial  inflammatory  exudation.  Generally  there 
is  little  lesion  to  be  recognized." 

Since  Samelsohn  showed  that  the  pathologj-  of  this 
form  of  amblyopia  lies  in  the  maculo-papillar  bundle 
within  the  optic  canal,  we  look  closely  at  that  part  of  the 
fundus  which  is  supplied  by  this  bundle  of  ner\-e  fibres. 
We  are  not  surprised  to  find  the  temporal  side  of  the 
ner\e  whiter  than  the  rest  of  the  ner\-e,  so  white  in 
some  cases  as  to  indicate  atrophy  and  to  cause  surprise 
that  this  peculiarity  has  not  been  more  particularly 
mentioned. 

The  workingman  living  out  of  doors,  and  consuming 
tremendous  quantities  of  food  and  oxygen  as  well  as 
tobacco,  is  usually  the  victim.  The  cigarette  smoker 
escapes  because  his  stomach  gives  out  before  his  optic 
nerve  is  in  the  least  danger.  Were  the  "  gentleman" 
smoker  to  consume  the  qualit}-  and  the  quantity  of  to- 
bacco that  some  of  our  workingmen  smoke  with  keen 
pleasure,  the  result  would  be  an  attack  of  acute  nico- 
tine poisoning. 

I  personally  am  very  fond  of  tobacco,  but  a  few- 
whiffs  from  a  hod  carrier's  vademecum  would  satisfy 
my  tobacco  craving,  at  least  until  after  dinner.  There 
is  more  nicotine-paralyzing  ability  in  the  smoke  from 
one  pipeful  of  black  "'juicy"  tobacco  than  in  a  hun- 
dred mild  cigarettes,  yet  occasionally  we  hear  of  mild 
amblyopia  from  cigarette  smoking,  ^^'ere  the  work- 
ingman to  use  milder  tobacco  and  to  clean  out  his  pipe 
occasionally,  this  form  of  amblyopia  would  rarely  be 
seen ;  but  so  long  as  the  strongest  kinds  of  tobacco 
are  sought  for  and  enjoyed,  so  long  will  tobacco  am- 
blyopia be  encountered.  A  patient  recently  seen  at 
the  Sherwood  Eye  Infirmary,  in  the  service  of  Dr. 
Scott,  was  a  stalwart  Bohemian,  who  had  been  grad- 
ually growing  blind.  His  friends  kindlj-  diagnosed 
his  trouble  as  due  to  "  advancing  years."  He  acqui- 
esced in  the  diagnosis,  and,  losing  his  position  as  a 
stonecutter,  he  engaged  in  the  occupation  of  keeping 
his  pipe  warm,  until  his  sight  was  almost  gone,  when 
he  wisely  thought  it  time  to  consult  a  physician  to 
have  his  friends'  diagnosis  verified.  He  was  sur- 
prised to  learn  the  true  diagnosis  and  promised  to 
give  up  smoking  at  once.  Two  weeks  later  he  proudly 
stated  he  had  not  smoked  in  this  time,  but  found 
"  chewing  about  as  satisfactory."  He  was  as  innocent 
of  any  wrong  doing  as  a  former  patient  who  promised 
to  smoke  "  less  often,"  and  a  month  later  showed  me 
his  pipe,  which  he  proudly  stated  he  smoked  but 
"three  times  a  day."  It  was  made  to  order  and  about 
the  size  of  a  beer  keg.  The  ophthalmoscopic  exami- 
nation of  this  Bohemian  patient  was  negative  save  for 
the  whiteness  of  the  temporal  side  of  the  disc,  which 
was  so  very  white  as  to  suggest  atrophy  at  once.  Vi- 
sion of  right  eye,  ^V^  :  left  eye,  ^^  ;  white  square  on 
black  background  scarcely  seen  in  field  where  red  and 
blue  scotomata  were  clearly  made  out.  Colors  easily 
distinguished  on  nasal  side.  The  patient  chiefly  com- 
plains of  loss  of  central  vision  and  blurring  of  vision. 
He  says  he  sees  better  at  night  and  turns  his  head  to 
either  side  in  order  more  clearly  to  see  a  light  in  front. 
The  patient  has  been  soaked  in  nicotine  so  long  that  a 
bad  prognosis  is  given,  though  the  majority  of  cases 
improve  if  tobacco  is  stopped  and  str)^chnine  is  pre- 
scribed. I  have  seen  a  case  regain  |^  from  |^  in  a 
few  weeks ;  |^  may  be  regained  from  *^  in  a  compar- 
atively short  time,  but  ^§77  sight  is  so  very  poor  as  to 
make  the  prognosis  very  unfavorable.  Certainly  the 
white  atrophic  appearance  of  the  temporal  region  of 


454 


MEDICAL    RECORD. 


[September  23,  1897 


the  disc  makes  one  realize  that  the  nerve  has  really 
been  poisoned  to  death. 

Though  we  do  not  know  why  these  special  fibres  of 
the  optic  nerve  should  be  affected,  we  do  know  that 
this  great  manly  fellow  has  lost  much  of  his  sight 
through  ignorance,  and  his  family  has  lost  the  bless- 
ing of  his  support. 

It  is  indeed  a  pity  that  the  average  man  does  not 
realize  the  danger  that  lurks  in  this  seductive  weed. 
Like  a  siren,  the  charming  Nicotina  soothes  her  vic- 
tim while  she  slowly  but  cruelly  blinds  him.  Ac- 
cursed be  such  a  siren,  and  accursed  again  I  say,  as  I 
see  this  great  fellow  blind  and  his  family  in  wantl 
Such  a  siren  should  be  e-xposed  as  she  lies  on  the 
watch,  concealed  by  the  ignorance  of  those  most  in 
danger — the  abusers  of  tobacco.  The  use  of  tobacco 
is  indeed  a  great  "■  comfort."  It  satisfies  a  craving  so 
well  that  perhaps  a  majority  of  the  inhabitants  of  the 
world  worships  at  the  throne  of  Xicotina.  Of  nothing 
else  is  this  true  excepting  alcohol.  If  the  real  value  of 
tobacco  among  all  classes  of  men,  especially  the  work- 
ingman,  the  soldier,  and  the  sailor,  could  be  esti- 
mated, it  would  be  found  to  be  of  more  value  than  all 
the  nuggets  of  the  Klondike.  Certainly  it  has  been 
truthfully  and  well  said  that  "tobacco  is  a  lone  man's 
companion,  a  bachelor's  friend,  a  hungry  man's  food, 
a  sad  man's  cordial,  a  wakeful  man's  sleep,  and  a 
chilly  man's  fire." 

We  know  tobacco  is  a  powerful  poison,  yet  we  be- 
lieve in  its  use.  The  two  things  most  desired  by  the 
out-of-doors  man  are  tobacco  and  coffee,  and  of  these 
two,  tobacco  always  comes  first.  He  who  has  never 
enjoyed  an  after-dinner  cigar  will  not  be  in  sympathy 
possibly  with  those  using  tobacco,  yet  he  will  agree 
that  the  use  of  tobacco  cannot  be  stopped,  and  that  it 
is  the  abuse  that  injures,  not  the  use  of  tobacco.  He 
will  agree  with  the  writer  that  only  men  should  use 
tobacco,  and  they  only  with  intelligent  moderation, 
proceeding  from  a  knowledge  of  the  dangers  as  well 
as  the  pleasures  concealed  in  the  world-worshipped 
yet  poisonous  weed. 


^^rogress  of  ^edical  Science. 

Nasal  Micro  -  Organisms. —  i.  In  all  bacterioscopic 
investigations  of  the  nasal  fossa;,  in  all  researches  as 
to  the  action  of  nasal  mucus,  etc.,  a  clear  distinction 
must  be  made  between  the  vestibule  of  the  nose  and 
the  proper  mucous  cavity.  The  former  is  lined  with 
skin,  and  is  not  part  of  the  nose  cavity  proper,  but 
only  leads  to  it.  2.  Contamination  with  the  lining  of 
the  vestibule  is  difficult  to  avoid,  even  when  this  source 
of  error  has  been  realized.  3.  In  the  dust  and  crusts 
of  mucus  and  di'hris  deposited  among  the  vibrissa- 
of  healthy  subjects  micro-organisms  are  never  absent, 
and  are  usually  abundant.  4.  On  the  Schneiderian 
membrane  the  reverse  is  the  case.  Under  normal 
conditions  micro-organisms  are  never  plentiful  here, 
are  rarely  even  numerous,  and  in  more  than  eighty  per 
cent,  of  cases  no  organisms  whatever  are  found  and 
the  mucus  is  completely  sterile.  5.  The  occurrence 
of  pathogenic  organisms  must  be  so  infrequent  that 
their  presence  on  the  Schneiderian  membrane  can 
be  regarded  only  as  quite  exceptional. — Thompson 
ami  Hewi.k.tt,  Arch,  of  OfoL,  x.xiv.,  3  and  4. 

The  Bacteriology  of  Typhoid  Fever.— In  the 
course  of  observations  made  in  eighty-three  cases  of 
typhoid  fever,  Besson  yReviic  de  Mi'dfcim,  June  10, 
1897)  found  albumin  in  the  urine  in  forty-seven. 
Bacteriologic  examination  of  the  urine  in  thirty-three 
of  these  disclosed  the  presence  of  typhoid  bacilli  in 
six,  princioally  in  those  in  wliicli  llie  albuminuria  was 


pronounced.  In  none  of  the  cases  examined  w  ith  this 
end  in  view,  and  these  included  especially  those  at- 
tended by  complications,  such  as  hemorrhage,  phle- 
bitis, and  suppuration,  were  the  bacilli  found  in  the 
blood  and  but  once  in  the  contents  of  a  rose  spot.  It 
is  therefore  believed  that  the  cutaneous  exanthem  is 
of  toxic  origin.  Of  fourteen  cases  presenting  angina, 
bacteriologic  examination  of  material  obtained  from 
the  tonsils  disclosed  the  presence  of  tjphoid  bacilli 
in  six.  In  thirly-three  cases  suppurative  complica- 
tions were  apparently  dependent  upon  the  staphylo- 
coccus pyogenes  and  in  five  upon  the  streptococcus. 
Meningitis  complicating  one  case  and  urethritis  com- 
plicating another  were  found  associated  with  the  bac- 
terium coli  commune.  The  typhoid  bacillus  alone 
was  found  attending  suppurative  complications  in  six 
cases.  From  the  foregoing  obser\-ations  the  conclu- 
sion is  reached  that  suppuration  due  to  the  typhoid 
bacillus  is  frequent  in  the  course  of  typhoid  fever. 
It  is  usually  unattended  by  constitutional  phenomena 
or  febrile  reaction;  the  temporature  may  even  be  sub- 
normal. The  complication  is  insidious  in  develop- 
ment and  may  require  exploratory  puncture  for  its  de- 
tection. It  develops  most  commonly  during  the  period 
of  defervescence  or  in  convalescence  and  is  usually 
benign  in  course,  a  fact  that  may  be  related  to  the 
phagocytic  activit)-  displayed  by  the  pus. 

The  Relation  between  Tissue  Change  and  the 
Leucocytes  in  Connection  with  Blood  Dissolution. — 
As  a  result  of  obseivations  in  a  case  of  malarial  inter- 
mittent fever,  supplemented  by  experimental  studies  in 
w-hich  blood  dissolution  in  animals  was  effected  in 
various  ways,  Kiihnau  {Archiv  Jur  kliiiisiht-  Mcdkiii, 
vol.  Iviii.,  Nos.  4  and  5)  found  that  such  dissolution 
is  attended  by  a  considerable  degree  of  leucocytosis, 
together  with  metabolic  changes,  as  manifested  by 
increased  elimination  of  uric  acid  and  xanthin  bases; 
primary  increase  with  secondarj-  diminution  in  the 
elimination  of  phosphoric  acid;  and  increased  elimi- 
nation of  chlorides.  The  chlorides  and  the  phosphoric 
acid  appear  to  stand  in  vicarious  relations  with  one 
another,  the  retention  of  the  one  corresponding  with 
increased  elimination  of  the  other.  The  increased 
elimination  of  alloxur  bodies  is  dependent  principally 
upon  destruction  of  the  leucocytes.  Probably  other 
nucleated  cellular  elements  take  part  in  this  process 
and  in  slight  degree  also  the  nuclein-containing  al- 
buminous constituents  of  disintegrated  red  blood  cells. 
The  mother  substance  for  the  formation  of  alloxur 
bodies  is  in  large  part  contained  in  the  plasma  and 
the  serum  and  in  smaller  degree  in  the  red  blood 
corpuscles.  The  amount  of  uric-acid-forming  sub- 
stance depends  upon  the  number  of  leucocytes  in  the 
blood.  Normal  blood  serum  induces  only  a  slight  in- 
crease in  the  elimination  of  alloxur  bodies  and  leuco- 
cytosis; typhoid  serum  none  at  all;  and  leukemic 
serum  a  very  considerable  increase.  The  primary- 
increase  induced  by  leuk;rmic  serum  results  from  the 
presence  of  uric-acid-forming  substances;  the  secon- 
dary increase  is  the  result  of  the  increased  production 
and  destruction  of  leucocytes  dependent  upon  the 
activity  of  the  leukremic  serum.  The  leucocytosis 
attending  blood  dissolution  is  an  effect  of  the  co-op- 
eration of  three  causes:  (.7)  the  direct  leucotactic  ac- 
tion of  the  blood  poison;  (/')  the  chemical  substances 
(especially  nucleins)  set  free  as  a  result  of  the  destruc- 
tion of  the  cellular  elements  of  the  blood;  (<•')  the  re- 
mains of  disintegrated  blood  corpuscles  circulating  in 
the  blood.  The  leucocytosis  induced  by  injection  of 
corpuscular  elements  into  the  blood  is  a  pure  phago- 
cytosis and  leads  to  no  notable  destruction  of  leu- 
cocytes. The  increased  destruction  of  leucocytes  in 
the  blood  in  ca.><es  of  infectious  diseases  is  due  to  the 
presence  of  a  leucocytolytic  substance. 


September  25,  1897] 


MEDICAL    RECORD. 


455 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE    F.    SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &.  47  East  Tenth  Street. 


New  York,  September  25,  1897. 


THE   YELLOW-FEVER    OUTLOOK. 

The  situation  in  those  parts  of  the  Soutii  where  yellow- 
fever  prevails  remains  at  the  present  writing  practi- 
cally unchanged.  New  cases  are  reported  daily  in  the 
towns  where  the  disease  gained  an  entrance  before  its 
true  nature  was  recognized,  but  this  is  only  what  must 
be  expected  for  some  time  to  come,  especially  in  view 
of  the  fact  that  in  many  of  these  places  the  sanitary 
conditions  are  far  from  being  perfect.  There  is  no 
cause,  however,  to  fear  a  disastrous  epidemic  or  a  wide 
extension  of  the  disease,  for  the  health  authorities  are 
thoroughly  alive  to  the  gravity  of  the  situation  and 
may  be  relied  upon  to  keep  the  fever  practically  con- 
fined to  the  localities  where  it  now  exists  until  cold 
weather  shall  set  in. 

The  epidemic  of  fear  which  seized  upon  the  entire 
population  within  a  radius  of  five  hundred  miles,  when 
the  occurrence  of  yellow  fever  at  Ocean  Springs  was 
first  announced,  seems  to  be  gradually  subsiding,  al- 
though its  influence  is  still  seen  in  the  shotgun  quar- 
antine which  nearly  every  hamlet  in  Alabama  and 
Mississippi  has  established  against  its  neighbors.  In 
some  places  there  is  a  double  line  of  shotguns,  one  at 
the  outskirts  of  the  town,  guarding  it  against  approach 
from  the  country,  and  the  other  a  short  distance  out- 
side of  that,  guarding  the  surrounding  country  from 
an  invasion  by  the  urban  population.  In  the  mean 
while  in  neither  locality  is  there  any  fever,  and  the 
result  of  this  senseless  panic-inspired  quarantine  is 
to  keep  the  community  in  a  state  of  constant  appre- 
hension, to  shut  out  the  necessary  supplies,  and  to  put 
an  end  to  all  business.  The  sooner  such  baseless 
alarm  as  this  subsides,  the  better  it  will  be  for  the 
country  at  large  as  well  as  for  the  communities  where 
it  prevails.  The  fear  exists  chiefly  in  places  where 
ihere  is  not  the  slightest  danger  of  an  outbreak,  while 
in  those  where  the  disease  actually  prevails  the  situa- 
tion is  regarded  with  comparative  calm. 

The  effective  work  of  the  Marine  Hospital  physi- 
cians and  of  the  local  boards  of  health  is  aided  by  the 
weather,  which  has  become  cool  all  over  the  country. 
Although  no  frosts  can  be  expected  on  the  Gulf  Coast 
and  the  neighboring  parts  of  the  interior  for  some 
time,  the  temperature  has  nevertheless  fallen  suffi- 
ciently to  exert  a  very  favorable  influence  upon  the 
course  of  the  epidemic,  if  the  mild  prevalence  of  the 


disease  at  this  time  can  be  dignified  with  such  a  title. 
It  is  a  fortunate  circumstance  that  the  disease  ap- 
peared so  late  in  the  season,  for,  however  well  it  might 
have  been  gotten  under  control,  it  would  almost  cer- 
tainly have  lingered  in  the  large  cities  until  the  ad- 
vent of  cold  weather,  thus  making  them  dangerous  for 
unacclimated  persons  to  visit.  As  it  is,  however, 
there  are  only  a  few  weeks  of  warm  weather  remain- 
ing in  which  yellow  fever  is  possible  in  those  lati- 
tudes. According  to  Dr.  Touatre,  of  New  Orleans, 
the  history  of  all  previous  outbreaks  of  yellow  fever  in 
that  city  shows  that  no  epidemic,  however  severe,  can 
long  survive  the  cold  that  is  sure  to  come  in  October. 
The  great  epidemics  have  always  begun  to  wane  with 
the  first  cold  of  that  month,  and  have  practically  dis- 
appeared entirely  in  November.  Several  years  are 
recalled  in  which  the  fever  broke  out  in  August  or 
later,  and  was  quickly  killed  by  the  frost  before  it  had 
the  opportunity  to  assume  the  proportions  of  an  epi- 
demic. 

With  the  coming  of  frost  and  the  disappearance  of 
the  fever  the  danger  will  not  be  over,  however,  for  the 
frosts  of  an  entire  winter  do  not  always  destroy  all 
the  concealed  germs  of  the  disease.  It  will  be  a  mat- 
ter of  general  concern,  therefore,  that  the  places  which 
have  been  invaded  by  yellow  fever  this  year  be  thor- 
oughly cleaned  and  put  to  rights  during  the  winter,  for 
unless  the  warning  of  the  present  visit  is  heeded 
some  of  the  infected  cities  will  very  probably  see  a  re- 
turn of  the  disease  with  the  first  heats  of  summer.  To 
trust  to  the  efficiency  of  quarantine  while  neglecting 
local  cleanliness,  is  to  live  in  a  fool's  paradise. 


THE    MODERN    TREND    OF    PHARMACY. 

Any  one  who  will  persue  carefully  the  number  of  excel- 
lent papers  read  at  the  recent  meeting  of  the  American 
Pharmaceutical  Association,  will  be  impressed  by 
the  fact  that  legitimate  pharmacy,  both  from  scientific 
and  business  standpoints,  is  in  a  bad  way. 

Mr.  William  C.  Alpers,  the  chairman  of  the  scien- 
tific section  of  the  association,  in  an  able  address  on 
the  "  Modern  Trend  of  Pharmacy,"  is  quite  emphatic 
in  the  declaration  that  the  conscientious  and  scientific 
pharmacist  of  to-day  is  by  no  means  a  thriving  and 
prosperous  member  of  the  business  community.  To 
give  becoming  emphasis  to  his  position,  he  signifi- 
cantly repeats  what  very  many  of  his  confreres  have 
said  often  enough  before,  that  "  Pharmacy  has  ceased 
to  be  a  science;  it  is  a  mere  trade,  and  a  poor  one  at 
that."  In  this  respect  its  t^vin  sister,  medicine,  can 
give  it  due  sympathy  and  meet  it  on  common  grounds 
of  mutual  condolence.  Both  sciences  are  threatened 
by  the  monopolistic  tendencies  of  wholesale  prescrib- 
ers  and  wholesale  manufacturers.  What  the  hospital 
and  dispensary  abuse  is  to  medical  practice,  such  is 
the  modern  phaimaceutical  plant  with  large  capital  and 
advertising  push  to  the  ordinary  dispensing  pharma- 
cist. 

In  this  connection  Mr.  Alpers  significantly  asks: 
■■  How   many   truly   pharmaceutical     laboratories  con- 


156 


MEDICAL    RRCORn. 


[September  25,  1897 


nected  with  the  shops  are  there  to-day?  How  many 
pharmacists  can  vouch  for  the  correctness  of  their 
preparations  because  they  made  them?  If  we  aslc  a 
voung  graduate  from  any  of  our  pharmaceutical  col- 
leges whether  he  prepares  his  own  potassium  iodide 
or  iron  sulphate,  he  will  probably  consider  us  jokers; 
and  yet  there  are  old  pharmacists  now  living  who  were 
taught  to  prepare  their  chemicals  themselves  and  who 
actually  did  so  in  their  younger  years." 

While  this  state  of  affairs  may  interfere  in  a  great 
measure  with  shop  preparation  of  different  compounds, 
it  IS  nevertheless  the  fact  that  the  large  manufacturers 
can  afford  to  make  and  sell  their  products  much  cheaper 
than  a  retailer  who  cannot  buy  expensive  machinery 
and  who  has  not  the  necessary  capital  for  competition 
in  an  open  market.  For  purely  business  reasons  there 
is  hardly  any  other  argument  to  be  offered  than  that 
which  applies  to  the  survival  of  the  fittest.  It  has 
come  to  pass,  then,  that  the  competent  retail  com- 
pounder cannot  compete  with  the  equally  conscientious 
wholesale  manufacturer.  This,  however,  does  not  in- 
terfere with  the  retail  pharmacists  being  the  recognized 
dispensers  of  such  cheapened  articles.  But  there  are 
many  other  troubles  in  the  way,  as  duly  noted  by 
different  members  at  the  meeting  in  question. 

It  is  cl  imed  with  reasonable  show  of  truth  that  the 
doctors  and  apothecaries  too  often  cross  forbidden 
lines  in  relative  interpretation  of  privileges.  The 
doctors,  for  instance,  are  given  to  dispensing  their  own 
medicines;  while,  on  the  other  hand,  the  apothecaries 
are  constantly  indulging  in  counter  prescribing.  The 
bone  of  contention  is  held  at  either  end  by  the  oppos- 
ing parties,  while  the  real  meat  is  in  the  middle. 
Each  to  get  the  whole  is  pulling  with  all  his  might  in 
different  directions. 

The  remedy  suggested  by  one  writer,  Dr.  F.  E.  Stew- 
art, who  is  both  M.D.  and  Ph.G.,  is  that  the  apothe^ 
cary  split  the  difference  by  prescribing  for  minor  cases 
and  be  legally  qualified  to  do  so.  This  is  claimed  to 
be  the  remedy  for  increasing  the  prescription  business, 
while  it  would  not  seriously  harm  the  doctor.  The 
apothecary  would  be  sure  to  sell  some  medicine,  when 
the  doctor  would  not  be  likely  to  see  the  patient  at  all. 
Thus  it  is  tacitly  admitted  that  the  doctors  and  drug- 
gists are  natural  rivals,  and,  taking  a  pharmaceutical 
view  of  the  situation,  the  house  is  divided  against  it- 
self. While  the  respective  parties  muse  the  fire  burns, 
and  the  innocent  cause  of  the  trouble — the  patient 
himself — either  buys  his  drug  without  question,  pre- 
scribing for  himself,  or  becomes  the  easy  dupe  of  the 
advertising  quack.  The  doctor,  to  keep  what  patients 
he  has,  gives  medicines  with  his  advice;  and  the 
apothecary  ekes  out  extra  profits  by  selling  tooth  picks, 
hair  brushes,  and  perfumery.  Thus  it  appears  that 
both  professions  are  degenerating  into  the  merest 
trades,  and  are  forced  to  deplore  the  lamentable  exist- 
ence of  a  cut-throat  competition. 


Contagion  and  Prison  Discipline. — The  lockstep 
has  been  abolished  at  the  Detroit  house  of  correction 
because  it  was  thought  to  facilitate  the  spread  of  con- 
tagion. 


THE     MILK     PHILANTHROPIST    AND     THE 
HEALTH  BOARD. 

The  health  board  has  scored  a  mild  sensation  by  se- 
curing the  technical  conviction  of  a  well-known  and 
well-meaning  philanthropist,  on  the  charge  of  selling 
a  specimen  of  milk  below  the  claimed  nutritive  stand- 
ard. In  the  testimony  for  the  prosecution  it  was 
stated  by  the  inspector  that  "the  sample  from  one 
can,  when  analyzed  by  the  chemist  for  the  health  de- 
partment, was  found  to  be  a  trifle  below  the  required 
standard."  On  the  contrary,  it  was  also  admitted  that 
the  methods  of  sterilization  adopted  by  Mr.  Straus, 
the  defendant  in  question,  had  been  formally  ap- 
proved by  the  board,  that  the  milk  at  other  depots  had 
been  found  to  be  of  excellent  quality,  and  was  far 
above  the  legal  standard.  Even  the  justice,  in  pass- 
ing sentence  on  what  he  acknowledged  was  merely 
technical  grounds,  was  impelled  to  apologize  for  his 
decision,  and  took  occasion  to  compliment  the  alleged 
culprit  on  the  truly  laudable  motives  of  his  enterprise. 
The  motives  of  the  health  board  were  apparently  not 
under  discussion,  save  in  the  very  paradoxical  asser- 
tion that  the  said  board  had  no  desire  to  cast  any  re- 
flections on  the  work  or  to  hinder  it  in  any  way.  It 
is  somewhat  difficult  to  understand,  in  view  of  the  lat- 
ter assertion,  why  legal  proceedings  should  have  been 
instituted  because  of  a  single  accident  or  oversight, 
when  a  more  prompt  remedy  could  have  been  found  by 
notifying  the  proprietor,  who  would  doubtless  have 
been  only  too  glad  to  remedy  the  difficulty.  It  would 
appear  to  be  a  matter  in  which  strictly  legal  right 
on  the  part  of  the  board  should  have  been  tem- 
pered with  a  little  discretionary  mercy.  The  board 
has  immense  powers  under  the  law,  but  it  cannot  be 
too  circumspect  in  using  them.  Above  all,  it  should 
be  particularly  careful  to  guard  against  all  suspicion 
of  persecution.  In  spite  of  the  verdict,  the  public  will 
not  believe  that  the  good  citizen  is  really  guiltj-  of 
any  culpable  wrong,  while  the  board  will  miss  much 
of  the  credit  which  might  have  belonged  to  a  well- 
considered  action. 


ORIGIN    OF    THE   VERTEBRATES. 

Despite  the  many  strides  made  in  recent  years — more 
particularly  in  chemistry,  biology,  and  astronomy — 
it  may  be  doubted  whether  the  problems  of  the  origin 
of  life  are  much  nearer  their  solution;  in  truth,  so 
many  fresh  facts  have  been  accumulated  and  so  many 
new  sources  of  discovery  have  been  opened,  that  in 
many  ways  we  would  seem  to  be  in  more  of  a  fog  than 
before.  That  Darwin  has  not  said  the  last  word  in 
regard  to  evolution  is  certain.  Dr.  Stuart  Jenkin,  of 
Sudbury,  Ontario,  proposes  to  explain  man  and  the 
other  vertebrates  by  the  theory  of  parasitism.  There 
is,  he  thinks,  but  "one  theory  which  seems  adequately 
to  explain  the.se  hitherto  obscure  points;  and  it  is 
this — that  the  vertebrate  organism,  instead  of  being  a 
single  organism  which  has  been  evolved  from  a  sim- 
ple to  its  present  highly  complex  form  by  a  gradual 
and  cumulative  differentiation,  is,  in  fact,  a  compound 
made  up  of  two  distinct  organisms  constantly  associ- 


September  25,  1897] 


MEDICAL    RECORD 


457 


ated.  In  other  words,  that  the  divergence  of  the  ver- 
tebrates from  the  lower  type  was  caused  by  the  para- 
sitic implantation  of  one  organism  of  the  ganglionic 
type  upon  another,  the  implanted  organism  giving  rise 
to  the  cerebro-spinal  nerve  system  and  internal  skele- 
ton. More  than  this,  I  am  convinced  that  the  gangli- 
onic type  is  itself  a  compound,  the  ganglions  being 
parasitic  on  a  simple  cellular  matrix." 

The  paper  explaining  these  views  was  first  published 
in  the  Medical  Age,  and  has  been  issued  as  a  reprint. 
Dr.  Jenkins'  theory  cannot  be  said  to  be  lacking  in 
ingenuity,  whatever  else  may  be  thought  of  it. 


Setus  0f  Viiz  'WitQk. 

Hospital  Ships. — The  Red  Cross  Society  of  Japan 
has  given  orders,  it  is  said,  for  the  construction  of  two 
thoroughly  appointed  floating  hospitals,  of  twenty-six 
hundred  tons  each,  for  the  treatment  of  the  wounded 
in  time  of  war.  The  good  accomplished  by  the  hos- 
pital ships  during  the  war  between  Greece  and  Turkey 
is  said  to  have  been  the  inspiration  for  this  move  on 
the  part  of  the  Japanese  Red  Cross. 

The  Women's  Medical  School  in  St.  Petersburg. 

— The  first  course  has  begun  in  this  new  school  for 
women,  with  a  class  of  one  hundred  and  si.xty  stu- 
dents, nearly  an  equal  number  of  applicants  having 
been  refused  admission  for  want  of  room.  It  was  at 
first  determined  that  only  orthodox  Christians  should 
be  admitted  to  the  school,  but  a  recent  ukase  had 
modified  this  to  the  extent  that  women  other  than 
Christians  may  be  received,  provided  the  number  of 
them  shall  not  exceed  five  per  cent,  of  the  total.  There 
are  accordingly  eight  such  in  the  first  class,  so  many 
having  applied  that  the  full  complement  allowed  b\ 
law  was  admitted.  They  are  obliged  to  pursue  the 
same  course  of  studies  as  their  orthodo.x  sisters,  and 
this  includes  the  study  for  six  months  of  dogmatic 
theology.  The  other  subjects  for  the  first  year  are 
anatomy,  histology,  physiology,  botany,  and  chemistry. 

Rheumatism  a  Form  of  Pyaemia. — Dr.  Singer,  of 
Vienna,  asserts  that  acute  articular  rheumatism  is  due 
to  the  presence  of  pus  microbes  in  the  tissues,  and 
that  it  is  therefore  a  modified  form  of  pyeemia.  Fol- 
lowing out  this  theory,  he  believes  that  the  true  spe- 
cific treatment  of  the  disease  consists  in  the  intrave- 
nous injection  of  a  sublimate  solution,  and  he  claims 
that  this  will  cut  short  the  disease  and  prevent  valvu- 
lar complications  much  more  effectually  than  salicin 
or  salicylic  acid.  His  experiments  and  investigations 
were  conducted  in  Weichselbaum's  clinic. 

Bowery  Liquor The  health  board  of  this  city  has 

been  making  an  analysis  of  the  beer  and  whiskey  sold 
in  the  "dead-houses"  for  three  cents  a  glass.  Tlie 
beer  was  said  to  be  of  good  quality,  containing  only 
hop  bitters,  and  no  injurious  adulterants  were  found. 
The  whiskey  was  artificial  in  almost  every  sample 
analyzed,  being  made  from  cologne  spirits  (containing 
about  fifty  per  cent,  of  alcohol  by  volume),  colored  by 


caramel,  and  flavored  by  a  small  amount  of  a  non- 
injurious  essence.  In  the  chemist's  report  it  was  said 
that  this  made  whiskey  is  probably  less  injurious  to 
the  system  than  a  genuine  new  whiskey  of  the  same 
alcoholic  strength,  containing  twenty-five  per  cent,  or 
over  of  fusel  oil.  The  proportion  of  alcohol  in  the 
diluted  stufl''  sold  for  three  cents  an  ounce  was  only 
about  si.xteen  per  cent. 

Sir  William  Gowers  has  been  elected  an  honorary 
member  of  the  Russian  Medical  Society  of  St.  Peters- 
burg. This  society  was  established  in  1833,  and  is 
one  of  the  oldest  medical  associations  in  Russia. 
Professor  Popoff,  of  the  Imperial  Military  Medical 
School,  was  elected  president  of  the  society  at  the  be- 
ginning of  the  present  year. 

The  American  Public  Health  Association. — The 
coming  meeting  of  this  association  in  Philadelphia, 
from  October  26th  to  29th,  will  be  the  silver  anniver- 
sary of  the  association,  and  the  attendance  and  the 
number  of  papers  read  will  probably  be  larger  than  at 
any  previous  meeting.  A  feature  of  the  meeting  will 
be  an  exhibit  of  hygienic  and  sanitary  appliances, 
preparations,  etc.,  including  all  articles  capable  of 
furthering  or  preserving  public  or  personal  health.  ' 

New  York  State  Association  of  Railway  Sur- 
geons.— The  seventh  annual  meeting  of  this  associa- 
tion will  be  held  at  the  Academy  of  Medicine,  New 
York  City,  on  Tuesday,  November  16,  1897.  under 
the  presidency  of  Dr.  J.  Frank  Valentine,  the  chief 
surgeon  of  the  Long  Island  Railway.  Dr.  C.  B.  Her- 
rick,  of  Troy,  is  the  secretary  of  the  association. 

A  Great  Medical   Journal The   London   Lancet 

for  August  21,  1897  (students'  number),  consists  of 
eighty  pages  of  text  and  one  hundred  and  forty-four 
pages  of  advertisements — in  all,  two  hundred  and 
twenty-four  pages.  It  is  said  to  have  a  subscription 
circulation  of  twenty  thousand  copies  a  week. 

Dr.  Stephen  Smith  has  been  appointed  by  Mayor 
Strong  a  charities  commissioner,  to  succeed  Mr.  Silas 
C.  Croft,  who  has  been  appointed  to  a  federal  office. 
Dr.  Smith  has  been  a  member  of  the  State  Charities 
Aid  Association,  and  is  thoroughly  familiar  with  the 
work  of  the  charities  department. 

Delaware  County   (Pa.)    Medical   Society The 

regular  monthly  meeting  of  this  society  was  held  at 
Chester,  Pa.,  on  September  loth.  Dr.  E.  Marshall 
Harvey,  of  Media,  read  a  paper  on  "  Cholera  Infan- 
tum"; Dr.  Frank  J.  Evans,  of  Chester,  one  on 
"Milk";  and  Dr.  J.  F.  Forwood  exhibited  a  fibrocys- 
tic tumor. 

<'The  Zoological  Bulletin"  is  the  title  of  anew 
journal,  issued  as  a  companion  to  \!s\%  Journal  of  Mor- 
pkology,  designed  for  shorter  contributions  in  animal 
morphology  and  general  biology.  It  is  published  by 
Ginn  and  Company,  under  the  editorial  supervison  of 
C.  O.  Whitman  and  W.  M.  Wheeler,  of  the  University 
of  Chicago.  The  first  number,  that  for  August,  1897, 
contains  articles  on  "The  Morphology^  of  the  Petrosal 
Bone  and  of  the  Sphenoidal   Region   of   the  Skull  of 


458 


MEDICAL    RECORD. 


[September  25,  1897 


Amia  Calva,"  by  Edward  Phelps  Allis,  Jr. ;  "  Recent 
Experiments  on  Regeneration,"  by  Charles  W.  Har- 
gitt;  "  Tlie  Metamerism  of  Nephelis:  A  Contribution 
to  the  Morphology  of  the  Nervous  System,  together 
with  a  Description  of  Nephelis  Lateralis,"  by  Charles 
Lawrence  Bristol ;  and  "  Remarks  on  the  Question  of 
Intercalation  of  Vertebras,"  by  G.  Bauer. 

To  Further  Woman's  Health — A  lady  in  St.  Pe- 
tersburg, Mme.  Woltov,  has  in  hand  the  establishment 
of  a  new  club  or  association,  the  sole  object  of  which 
is  to  be  the  hygienic  development  of  women.  The 
Tsaritsa  is  said  to  approve  heartily  of  the  project  and 
to  have  lent  it  the  aid  of  her  influence. 

Dr.  S.  Henry  Dessau  has  resigned  his  position  as 
chief  of  clinic  to  the  children's  department,  Mt.  Sinai 
Hospital  Dispensary.  In  a  letter  from  the  chairman 
of  the  dispensar}'  committee,  Dr.  Dessau's  resignation 
was  accepted  with  expressions  of  appreciation  of  his 
faithful  services. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
ger}%  Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
September  18,  1897.  September  i6th. — Assistant 
Surgeon  H.  La  Motte  was  placed  on  the  retired  list, 
September  15th,  for  physical  disability. 

The  Victorian  Order  of  Nurses.  —  Notwithstand- 
ing the  vote  of  the  British  Medical  Association  in  fa- 
vor of  this  scheme,  the  medical  profession  in  Canada 
does  not  support  it  with  much  enthusiasm.  The  Ca- 
nadian Medical  Review  says  that  it  thought  the  move- 
ment was  dead,  but  it  would  seem  that  there  is  still  a 
little  vitality  in  the  cause,  or  rather  a  little  sympathy 
for  it  in  its  moribund  condition.  At  the  meeting  of 
the  British  Medical  Association,  Dr.  Roddick  moved 
that  the  scheme  be  approved,  and  in  courtesy  to  him, 
our  contemporary  says,  the  motion  was  allowed  to  pass. 
But^  it  adds  that  "the  Ontario  Medical  Council,  the 
Ontario  Medical  Association,  many  smaller  medical 
societies,  many  medical  men,  and  especially  those  in 
Manitoba,  have  expressed  themselves  as  opposed  to  the 
whole  scheme.  These  should  know  better  than  our 
British  visitors.  This  resolution  of  the  British  Medi- 
cal Association  may  let  the  affair  down  easily,  by 
showing  that  some  at  least  sympathized." 

Drinking  in  England — The  report  of  the  inspector 
of  inebriate  asylums  in  England,  which  has  just  been 
issued,  states  that  drunkenness  is  increasing  not  only 
among  the  poor,  but  also  among  the  upper  classes,  and 
especially  among  women  of  all  classes.  Out  of  442 
male  inebriates  treated  at  the  Dalrymple  Home  and 
discharged  as  cured,  loi  were  university  men,  and  316 
of  the  remainder  were  well  educated;  235  were  mar- 
ried, and  the  others  were  widowers  or  bachelors.  In 
228  cases  sociability  was  said  to  be  the  cause,  ill- 
health  caused  the  downfall  in  36  cases,  and  overwork 
was  given  as  the  excuse  for  taking  to  drink  in  32 
cases.  In  fifty-five  per  cent,  of  the  cases  the  excess 
was  traceable  to  predisposing  hereditary  causes. 
.\bout  one-third  of  the  cases  treated  are  permanently 
cured.     Out  of  the  442   patients  discharged  from  the 


Dalrymple  Home,  372  were  kept  trace  of,  and  of  these 
149  were  said  to  be  entirely  cured,  24  had  improved, 
164  had  relapsed,  31  were  dead,  and  4  were  insane. 

The  Westchester  (N.  Y.)  County  Medical  Society. 

— The  annual  meeting  of  this  society  was  held  at 
New  Rochelle  on  Tuesday,  September  21st.  Dr.  Her- 
mance  delivered  the  presidential  address.  A  paper 
on  tuberculosis  was  read  by  Dr.  Stubbert,  of  Liberty; 
and  one  on  hysteria  by  Dr.  Grainger,  of  Bronxville. 

The  Plague  is  reported  to  be  increasing  in  the 
Bombay  presidency.  Several  Europeans  are  among 
those  who  have  been  attacked  at  Poonah.  A  despatch 
to  the  London  Daily  News  from  Odessa  says  that  the 
plague  has  broken  out  in  the  northern  Caucasus.  A 
sanitar)'  commission  has  been  sent  from  Tiflis  to  de- 
termine the  nature  of  the  disease  prevailing  there,  and 
to  take  all  necessary  measures  to  prevent  its  spread  in 
case  it  proves  to  be  the  bubonic  plague. 

Obituary  Notes. — Dr.  Samuel  McNutt  Ross  died 
at  Altoona,  Pa.,  on  September  13th,  aged  seventy- 
three  years,  in  consequence  of  injuries  received  by  be- 
ing knocked  down  by  a  wagon.  He  was  graduated 
from  Jefferson  Medical  College  in  1850,  and  had  been 
engaged  in  the  practice  of  medicine  at  Altoona  since 
1875. — Dr.  Francis  Rizzo  died  at  Philadelphia  on 
August  nth,  at  the  age  of  fifty  years.  He  was  a  na- 
tive of  Italy,  and  was  graduated  from  the  medical 
department  of  McGill  University  in  1877.  For  five 
years  he  resided  in  Florida,  subsequently  removing  to 
Philadelphia. — Dr.  John  Rendell,  of  Brooklyn,  was 
thrown  from  his  surrey  on  Wednesday  of  last  week, 
sustaining  a  fracture  of  the  skull,  and  died  in  St. 
John's  Hospital  the  following  day,  without  having  re- 
gained consciousness.  He  was  a  graduate  of  the 
Long  Island  College  Hospital  Medical  School. — Dr. 
Theron  Tuttle,  of  Brooklyn,  died  at  his  home  in 
that  city  on  September  1 6th.  He  was  born  in  Hart- 
ford in  1833,  and  was  a  graduate  of  the  College  of 
Physicians  and  Surgeons,  New  York,  in  1854.  He 
had  practised  medicine  in  Brooklyn  for  nearly  twenty- 
five  years. 

The  Late  Dr.  John  J.  H.  Love. — At  a  regular 
meeting  of  the  Orange  Mountain  Medical  Sbciet)-, 
held  September  10,  1897,  the  following  resolutions 
were  adopted : 

"  Resolved,  That  in  the  death  of  our  late  friend  and 
associate,  Dr.  John  J.  H.  Love,  this  society  has  sus- 
tained a  loss  which  we  deeply  mourn.  A  constant 
attendant  upon  its  meetings,  its  welfare  was  ever  his 
earnest  care.  His  voice  was  invariably  raised  in  be- 
half of  progressive  medicine  and  surgery,  and  his  well- 
weighed  opinions  were  received  with  that  attention 
and  respect  which  they  always  merited. 

•'  Resolved,  That  we  tender  to  his  family  our  sincere 
sympathy  in  their  bereavement,  and  that  a  cop)'  of 
these  resolutions  be  spread  upon  the  minutes  of  this 
society  and  published  in  the  medical  press. 

•"William  Pierson,  M.D., 
"  H.   B.  Whitehorne,  M.D., 
"James  S.  Brown.  M.I)., 

"  Co  mm.' 'fee." 


September  25,  1897] 


MEDICAL    RECORD. 


459 


TWELFTH     INTERNATIONAL     MEDICAL 
CONGRESS. 

Hihl  in  Mosco'iv,  August  ig,  20,  21,  22,  2j,  24,  2J  and 
26,  i8gj. 


(Special  Report  for  the  Mh 


SECTION   IN   SURGERY. 

t  Continued  from  page  432. ) 

Fifth  Day —  Wednesday,  August  2jt/i. 

Orthopaedic  Treatment  of  Tuberculous  Joint  Dis- 
ease.— Dr.  DoLLiNciER,  of  Budapest,  read  a  paper  on 
this  subject.  He  thought  the  important  principle  of 
the  treatment  of  tuberculous  joints  with  apparatus  is 
as  far  as  possible  the  absolute  fixation  of  the  joint 
with  separation  of  the  articular  surface  by  gentle  but 
firm  extension.  The  apparatus  must  be  as  light  and 
as  unobtrusive  as  possible,  and  so  arranged  that  the 
points  of  pressure  will  not  interfere  with  nutrition  of 
the  skin. 

Dr.  Hoffa,  of  \\"urzburg,  exhibited  apparatus  for 
practically  treating  all  the  affections  of  the  lower  ex- 
tremities that  may  demand  the  help  of  the  orthopaedic 
surgeon.  The  principle  worthy  of  attention  was 
that  the  employment  of  flexible  steel  in  the  apparatus 
practically  takes  the  surgeon  out  of  the  hands  of  the 
instrument  maker.  One  of  the  great  objections  to  the 
iree  employment  of  apparatus  had  been  the  state  of 
servile  dependence  on  the  mechanic  in  which  they 
placed  the  doctor.  The  fulfilment  of  special  indica- 
tions was  often  almost  impossible,  as  the  instrument 
maker  would  follow  his  models,  but  with  this  flexi- 
ble steel  the  shape  of  the  apparatus  could  be  changed 
at  will,  and  yet  would  be  finn  enough  for  all  practical 
purposes. 

Orrhotherapy  of  Cancer. — Dr.  Sematzivy,  of  St. 
Petersburg,  presented  a  communication  on  the  serum 
treatment  of  malignant  neoplasms.  Streptococcic  se- 
rum was  employed,  but  absolutely  without  results. 
X'irulent  cultures  of  streptococci  were  also  employed; 
these  seemed  not  only  to  do  no  good,  but  to  be  abso- 
lutely harmful.  A  thorough  trial  was  given  them, 
frequently  several  times  in  the  same  patient,  though 
often  against  the  speaker's  better  judgment,  but  no 
encouraging  results  could  be  obtained. 

Dr.  Pavlovskv,  of  Moscow,  in  discussing  the  sub- 
ject, reported  the  case  of  a  teacher  in  the  public 
schools  in  whom  a  tumor  developing  on  the  jaw  was 
diagnosed  as  sarcoma.  It  seemed  inoperable  from  its 
size  and  from  the  probability  of  deep  glandular  in- 
volvement. Erysipelas  toxins  were  used  and  with 
success,  for  the  tumor  had  disappeared  and  for  mort- 
than  a  year  the  man  had  been  entirely  well. 

Dr.  I-'abrikant,  of  Kharkov,  said  that  in  his  expe- 
rience the  serum  treatment,  as  well  as  that  by  aniline 
injections,  had  given  absolutely  no  results  in  cancer. 

Permanganate  of  Potassium  in  Lupus.  —  Dr. 
Racha.vovskv,  of  St.  Petersburg,  read  a  paper  on  this 
subject.  He  employs  powdered  permanganate  of  po- 
tassium. The  powder,  freshly  prepared  from  dehy- 
drated dried  crystals,  is  applied  in  a  layer,  three  to 
five  millimetres  in  thickness,  over  the  whole  surface  of 
the  lupus  and  the  suspected  portions  of  the  surround- 
ing tissues.  In  case  of  deeper  ulcerations  with  under- 
mined edges,  the  powder  is  applied  after  curetting 
two  or  three  times  in  order  to  level  the  uneven 
surface.  In  all  cases  a  layer  of  medicated  cotton  is 
put  over  it  to  keep  the  powder  in  place  and  absorb  the 
secretions  and  eliminated  material.  In  most  cases  a 
single   application  of   the  powder   suffices.     He    has 


employed  the  powder  now  in  more  than  thirty  cases 
since  1878,  and  always  with  complete  success. 

Hot-Air  Treatment  of  Lupus. — Dr.  E.  Hollander, 
of  IJerlin,  had  first  tried  the  local  application  of  steam 
for  lupus  but  without  result,  as  the  patients  were  un- 
able to  stand  a  temperature  sufliciently  high  to  affect 
the  diseased  tissues.  Then  he  tried  hot  air.  His  ap- 
paratus consists  of  a  Eunsen  burner,  on  the  top  of 
which  is  mounted  a  coil  with  a  tube  passing  through 
it.  To  one  end  of  the  tube  is  attached  an  air-pressure 
bulb  for  driving  a  current  of  air  through  the  coil;  the 
other  end  is  left  open.  A  current  of  air  heated  to  300° 
C.  may  be  driven  through  the  coil  and  directed  very 
exactly  by  the  patient  himself,  so  that  it  affects  only 
the  diseased  parts.  The  mode  of  action  of  the  process 
is,  according  to  the  author,  as  follows:  The  intensely 
hot  air  produces  an  active  contraction  of  the  vessels 
of  the  skin  and  of  the  diseased  tissues.  They  become 
blanched  and  bloodless;  after  two  or  three  days  the 
blood  returns  to  the  supporting  framework  of  connec- 
tive tissue,  but  not  to  the  diseased  granulation  tissue. 
Cicatrization  sets  in  and  a  radical  cure  results. 

Dr.  Schulz,  of  Duisburg,  had  had  very  good  re- 
sults from  extirpation  of  the  diseased  part  followed  by 
Thiersch's  skin  transplantation.  The  success  of  the 
process  depends  on  the  thorough  removal  of  the  dis- 
eased tissue.  If  any  of  this  is  left,  reinfection  of  the 
whole  surface  will  often  follow  and  absolutely  prevent 
the  skin  grafts  from  taking. 

Conservative  Treatment  of  Hip  Disease. — Dr.  V. 
Me.vard,  of  Berck-sur-Mer,  read  a  paper  on  this  sub- 
ject. From  1894  to  1897  he  had  had  under  treatment 
six  hundred  and  fifteen  cases  of  coxalgia.  Two  hun- 
dred and  sixty-one  of  the  cases  were  without  the  for- 
mation of  pus.  These  were  treated  without  question 
of  operation,  the  lighter  cases  being  kept  at  rest  with 
continuous  extension,  the  severer  cases  with  absolute 
immobilization  by  plaster  apparatus.  During  conva- 
lescence the  patients  were  allowed  to  move  around  with 
an  immobilization  apparatus.  In  one  hundred  and 
eight  cases  an  abscess  had  to  be  treated.  All  were 
treated  with  modifying  injections  of  camphorized 
naphthol.  In  iiinetj'-four  cases  a  cure  was  obtained 
after  from  two  to  ten  injections,  very  seldom  more. 
In  six  cases  a  persistent  fistula  remained,  and  in  eight 
cases  in  which  after  a  long  series  of  injections  no  im- 
provement was  noticed  resection  of  the  hip  was  done 
and  was  followed  in  seven  cases  by  primarj"  union,  in 
the  eighth  by  a  fistula  that  persisted  for  five  months. 
In  the  six  hundred  and  fifteen  cases  of  hip  disease,  in 
five  years  the  mortality  was  twenty-two.  There  were 
nine  deaths  without  operation,  from  meningitis,  ca- 
chexia, and  visceral  tuberculosis;  thirteen  after  oper- 
ation, four  of  these  from  shock.  The  principle  of 
treatment  insisted  on  was  not  to  convert  a  closed  asep- 
tic hip-joint  abscess  into  an  open  one  with  all  the 
dangers  of  mixed  infection. 

Intra-Articular  Injection  in  Tuberculous  Joint 
Disease. — Dr.  Cazin  read  the  paper  in  his  own  name 
and  that  of  Dr.  Duplay,  of  Paris.  After  having  tried 
intra-articular  injections  of  iodine  for  some  time,  the 
authors  now  limit  themselves  to  the  use  of  iodoform, 
either  in  the  form  of  a  mucilage  or  a  ten-per-cent. 
ethereal  solution.  The  solution  in  ether  has  the  incon- 
venience of  causing  considerable  pain,  so  they  prefer 
the  mucilage  holding  in  suspension  one  and  one-half 
grams  of  iodoform.  The  injections  are  made  twice  a 
week,  unless  improvement  is  slow,  when  they  are  made 
every  second  day.  The  results  have  been  very  satis- 
factory. It  is  especially  in  white  swelling  of  the  knee 
that  the  injections  of  iodoform  have  given  good  results 
when  combined  with  immobilization,  compression,  and 
extension. 

Massage  in  Surgery. — Profp;ssor  Zabloudowsky, 
of  Berlin,  read  a  paper  with  the  title,  "Remarks  on 


460 


MEDICAL    RECORD. 


[September  25,  1897 


the  Employment  of  Massage  in  Surgery  Supported  by 
Observations  from  the  Berlin  University  Surgical 
Clinic."  He  regarded  massage  as  of  the  greatest  use 
to  the  surgeon,  and  said  that  the  metliod  was  so  sim- 
ple and  its  employment  required  so  little  time  that  all 
surgeons  could  practise  it. 

Flatfoot. — Dr.  Bloch,  of  Paris,  presented  a  com- 
munication on  "  The  Treatment  of  Painful  Flatfoot — 
Tarsoptosis  and  Tarsalgia — and  the  Cuboid  Symp- 
tom." He  said  that  there  is  a  solidarity  in  the  struc- 
tures of  the  foot,  and  that  the  plantar  arch  like  every 
other  depends  on  the  strength  of  each  of  its  component 
parts.  There  is  in  the  foot  a  locus  minoris  resistentice, 
and  it  is  found  in  the  cuneo-cuboidal  convexity.  Any 
muscular  or  ligamentary  insufficiency  uncompensated 
for  makes  itself  felt  at  this  joint  and  produces  the 
so-called  painful  flatfoot.  For  this  Dr.  Bloch  pro- 
posed the  name  tarsoptosis. 

Suture  of  Arteries. — Dr.  Djemil  Pacha,  of  Con- 
stantinople, read  a  paper  on  this  subject.  He  reported 
two  cases  of  wounds  of  large  arteries  closed  by  sutures. 
In  one  of  his  cases,  during  an  operation  for  mammary 
cancer,  the  a.xillary  artery  was  torn,  a  slit  fifteen  mil- 
limetres long  resulting.  With  a  fine  needle  he  sutured 
the  arterial  tear  together,  using  five  sutures.  Then  the 
connective-tissue  coat  was  sutured  above  it.  The  ar- 
terial current  was  at  once  established,  and  only  slight 
pressure  for  a  few  minutes  was  necessary  to  stop  the 
exudation  of  blood  at  the  points  of  suture.  This  was 
two  and  one-half  years  ago,  and  there  is  not  the  slight- 
est trace  of  traumatic  aneurism  or  any  abnormality  of 
the  vessel.  A  second  case  of  the  same  kind  was 
treated  in  the  same  way,  with  like  result. 

Dr.  Nitze,  of  Berlin,  presented  a  communication 
on  the  same  subject,  and  exhibited  an  instrument  for 
the  preservation  of  the  arterial  coats  from  undue  pres- 
sure after  suture.  The  divided  halves  of  a  cylinder  of 
ivory  or  bone  are  fastened  to  the  ends  of  a  small  pin- 
cette. When  brought  together  around  the  artery  the\' 
cover  the  sutured  place  and  relieve  the  parts  from 
pressure,  so  preventing  the  danger  from  secondary 
hemorrhage  which  might  result  from  overtension  on 
the  sutures.  He  considers  that  it  is  no  longer  justi- 
fiable for  a  surgeon  to  tie  a  large  artery  and  run^the 
risk  of  gangrene.  Even  when  an  artery  is  torn  com- 
pletely across  its  lumen  may  be  restored  after  resection 
and, suture. 

Metastases  of  Endotheliomata. — Dr.  Scriba,  of 
Tokio,  read  a  paper  "  On  the  Clinical  Diagnosis  of 
Endotheliomata  and  their  Special  Manner  of  Giving 
Metastases."'  He  said  that  these  tumors,  arising  from 
the  endothelium  of  the  smallest  vessels,  are  much 
more  frequent  all  over  the  body  than  is  generally  sup- 
posed. They  have  been  taken  for  carcinomata  most 
frequently,  from  their  tendency  to  metastasis  in  the 
lymph  glands,  .but  sometimes  also  for  sarcomata. 
Clinically  they  may  be  differentiated  by  their  metas- 
ta.ses  differing  from  sarcomata,  in  that  they  give  metas- 
tases to  the  lymph  glands,  and  from  cancer  because 
tlieir  metastases  are  not  so  hard,  grow  more  rapidly, 
and  are  not  painful. 

Spontaneous  Gangrene. — Dr.  I.  Munk  reported  a 
case  of  spontaneous  gangrene  of  the  fingers,  occurring 
in  a  child,  three  years  old,  within  a  short  time  after  a 
severe  attack  of  scarlet  fever.  He  thought  it  very 
probable  that  spontaneous  gangrene  in  run-down  sub- 
jects is  due  to  the  fact  that  the  lowered  resistance  of 
the  tissues  enables  microbes  in  the  blood  current  to 
make  an  extremely  rapid  growth  when  the  blood  cur- 
rent is  slow  in  the  extremities,  with  the  resulting  pro- 
duction of  an  amount  of  toxin  tliat  acts  fulminantly 
in  the  local  tissues,  causing  their  death. 

Roentgen  Rays  in  Diagnosis Dk.  Lew,  of  Ber- 
lin, read  a  paper  on  a  new  development  in  the  appli- 
cation of  the  .v-rays  for  diagnostic    purposes.      The 


new  method  avoids  all  the  disadvantages  of  inflamma- 
tion of  the  skin,  long  exposure,  etc.  Its  success  is 
based  upon:  (i)  A  special  form  of  tubes,  which  gives 
double  and  triple  the  usual  quantity  of  A-rays;  (2)  by 
using  a  special  "  shortening"  fluorescent  screen ;  and 
(3)  by  employing  special  plates  or  films  which  are 
coated  with  the  sensitive  material  on  both  sides.  By 
means  of  this  apparatus  it  is  possible  to  take  a  radio- 
graph of  any  part  of  the  human  body,  even  the  pelvis, 
in  a  time  not  exceeding  one  minute. 

Excision  and  Suture  of  the  Ulnar  Nerve,  Six 
Months  after  Accidental  Division. — Dr.  G.  B.  Fer- 
guson, of  Cheltenham,  England,  reported  the  case  of  a 
young  lady  who  fell  through  a  skylight  and  cut  herself 
seriously,  including  the  right  ulnar  nerve.  This  was 
not  noticed  at  first,  and  the  wounds  were  sewn  up. 
Very  soon,  however,  muscular  weakness  was  noticed 
in  the  healed  arm  and  total  ulnar  anaesthesia.  An  op- 
eration for  suture  was  proposed  and  declined,  and 
every  alternative  plan  of  rubbing  and  electricity  was 
employed.  At  the  end  of  six  months  the  arm  was 
much  shrunken  and  of  but  slight  use,  and  the  hand 
was  quite  claw-like,  owing  to  the  shrivelling  of  the 
interossei.  Owing  to  the  ana;sthesia  the  affected  side 
of  .the  hand  was  constantly  receiving  unperceived  in- 
juries, and  on  one  occasion  she  literally  boiled  her 
little  finger  to  warm  it.  This  was,  of  course,  followed 
by  long  and  painful  sores.  At  last,  after  six  months, 
the  parents  asked  for  an  operation.  The  divided  ends 
were  soon  found,  much  separated  and  much  degener- 
ated. Fully  an  inch  was  excised,  which  made  it  hard 
to  bring  the  ends  together.  But  after  considerable 
separation  and  stretching  this  was  effected,  and  a 
splice  was  made  with  catgut.  After  two  days  sensa- 
tion began  to  return  and  the  parts  soon  became  even 
hyperffisthetic.  It  was  many  months  before  the  plump- 
ness of  the  muscles  began  to  return,  but  return  it  did, 
and  now,  rather  more  than  two  years  after  the  opera- 
tion, all  is  strong  and  normal,  save  that  that  hand  is 
wont  to  be  colder  on  the  ulnar  side. 

Skin  Grafting.  —  Dr.  Linxgrenn,  of  Trelleborg, 
Sweden,  read  a  paper  "  On  the  Faculty  of  the  Human 
Epithelium  to  Preserve  its  Vitality  apart  from  the  Or- 
ganism for  Purposes  Especially  of  Skin  Transplanta- 
tion." He  has  in  a  large  number  of  cases  transplanted 
to  the  surface  of  fresh  and  granulating  wounds  por- 
tions of  human  epidermis,  after  they  had  been  kept 
for  from  one  day  to  six  months  in  sterile  serum.  In 
most  of  the  cases  the  grafts  took  and  formed  a  layer 
of  skin  just  as  in  the  ordinary  method  of  skin  trans- 
plantation. 

Irrigation  Treatment  of  Gonorrhoea. — Dr.  Vigxe- 
RON,  of  Marseilles,  read  a  paper  on  the  results  of 
the  irrigation  treatment  with  permanganate  of  potas- 
sium in  eighty-three  cases  of  urethritis  in  which  gono- 
cocci  could  be  demonstrated.  In  twenty-three  cases 
treatment  was  begun  within  forty-eight  hours  after  the 
appearance  of  the  discharge.  These  gave  the  most 
favorable  results,  viz.,  eighteen  cures  after  from  four  to 
fourteen  irrigations;  four  cures  after  from  six  to  eight 
weeks  of  treatment ;  one  case  disappeared  from  ob- 
servation after  the  ninth  irrigation,  still  having  some 
discharge  but  without  gonococci.  All  the  others  were 
perfectly  well  fifteen  days  after  their  last  treatment. 
All  the  twenty-three  cases  except  three  were  cured  by 
the  permanganate.  'I'hese  had  to  have  two  or  four 
irrigations  with  sublimate  to  complete  the  cure. 

Pathogenesis  of  Deformities. — Dr.  C  Ghillini,  of 
Bologna,  read  a  paper  on  this  subject.  He  held  that 
all  deformities  of  bones  are  due  to  pathological  con- 
ditions in  the  epiphyseal  cartilages.  This  is  true  not 
only  for  deformities  that  occur  in  the  articular  ends 
of  the  bones  and  in  the  immediate  neighborhood  of 
the  epiphyses,  but  also  in  deformities  occurring  in 
the  diaphyses  of  long  bones.     It  is  true  that  here  ab- 


I 


September  25,  1897] 


MEDICAL    RECORD. 


461 


normal  tension,  pressure,  and  traction  play  a  role  in 
producing  deformity-,  but  they  act  by  affecting  pri- 
marily the  epiphyseal  cartilage. 

Incision  of  the  Pericardium — Dr.  Vointch  Sino- 
GENSKY,  of  St.  Petersburg,  read  a  paper  on  "  The  Re- 
moval of  Moderately  Large  Purulent  Exudate  in  the 
Pericardial  Sac  by  Open  Incision.'"  He  said  that, 
while  a  number  of  methods  may  be  employed  to  remove 
the  purulent  e.xudate  from  within  the  pericardium  when 
it  is  of  considerable  size,  most  of  these  methods  are 
not  so  applicable  to  small  quantities  of  exudate.  The 
weightiest  consideration  in  the  matter  is  the  position 
of  the  anterior  edges  of  the  pleura  as  regards  the  an- 
terior thoracic  wall.  The  space  between  the  pleura  in 
front  is  not  very  uniform  in  size  and  position.  Small 
amounts,  not  more  than  one  hundred  and  fifty  cubic 
centimetres  of  purulent  pericardia!  exudate,  do  not  alter 
the  position  of  the  heart  and  pericardium  as  he  has 
noted  in  thirteen  cases  on  the  cadaver,  but  a  number 
of  different  diseases  of  the  internal  organs  materiallv 
change  the  position  of  all  the  thoracic  vi.scera.  In 
general  it  may  be  said  that  there  is  more  room  for  a 
longitudinal  than  for  a  transverse  incision.  Despite 
the  various  positions  possible  to  the  pleura  in  front, 
there  are  certain  points  that  act  as  guides.  An  incision 
made  between  the  fifth  and  seventh  costo-sternal  articu- 
lations avoids  the  pleura  and  pericardium.  An  explor- 
atory puncture  made  in  this  line  with  a  fine  needle 
which  is  inserted  only  moderately  deep,  1.5  to  2.5  cm., 
is  absolutely  without  danger.  The  tubercle  of  the 
sixth  left  sterno-costal  articulation  serves  best  as  a 
guide  for  the  skin  incision  and  is  usually  easy  to  find 
on  the  surface. 


SKCTKJX    IN    MKDICINE. 

I'hird  Day — Monday,  August  2jd. 

Clinical  Forms  of  Hepatic  Cirrhosis Dr.  Ch.wf- 

FARii,  of  Paris,  read  a  paper  with  this  title.  The 
clinical  analysis  of  the  different  types  of  hepatic 
cirrhosis,  to  be  complete,  should  show  in  each  individ- 
ual case  the  anatomical  process,  the  pathogeny,  and 
the  course.  First  he  defined  what  was  to  be  under- 
stood by  the  term  cirrhosis  of  the  liver.  Three 
conditions  must  be  present  in  order  to  justify  the 
diagnosis  of  cirrhosis:  (t)  The  proliferation  should 
be  general,  distributed  throughout  the  entire  liver;  it 
may  predominate  in  one  or  another  region,  but  it  must 
always  be  diffuse.  A  pericystic  or  pericalculous 
sclerosis  cannot  be  called  cirrhosis.  (2)  The  new- 
formed  connective  tissue  must  be  fibrous  and  full 
grown,  rich  in  elastic  fibres  approaching  that  of  cica- 
tricial tissue.  (3)  The  process  must  not  be  absolutely 
confined  to  the  interstitial  elements,  but  the  cells  must 
also  be  affected.  To  classify  properly  the  hepatic 
cirrhoses  one  must  lake  into  consideration  the  anatomi- 
cal changes  and  the  nature  of  the  agent  producing 
them;  in  other  words,  the  classification  ought  to  ha 
anatomical  and  at  the  same  time  etiological.  We 
cannot  understand  why  some  hepatic  cirrhoses  run 
an  acute,  others  a  subacute,  and  still  others  a  chron- 
ic course,  unless  we  appreciate  that  we  are  in  the 
presence  of  a  process  more  or  less  distinctive,  accord- 
ing to  the  manner  and  the  duration  of  its  action, 
("linically,  as  well  as  by  experimental  pathology,  we 
know  that  every  toxic  agent  or  infection  capable  of 
producing  a  cirrhosis  can,  imder  proper  conditions, 
provoke  any  degree  of  inflammatory  or  degenerative 
reaction  in  the  hepatic  cell.  We  learn  this  by  the 
study  of  the  principal  forms  of  cirrhosis,  where  we  see 
that  the  irritant  action  of  large  doses  of  a  given  agent 
kill  the  cell,  while  the  same  agent  in  small  doses  con- 
tinued over  a  long  period  provokes  sclerosis  and  only 
later  or  secondarily  affects  the  cell.      So  the   irritant 


agent  may  be  too  powerful  or  too  feeble  to  produce  cir- 
rhosis, as  we  see  in  the  case  of  phosphorus  or  lead  poi- 
soning. Again,  under  proper  conditions  the  one  agent 
may  act  only  on  the  cell  or  it  may  act  to  produce  cir- 
rhosis; thus  the  toxin  of  syphilis  in  the  second  stage 
may  cause  a  syphilitic  icterus,  while  at  another  period, 
when  less  virulent,  it  is  essentially  cirrhogenic.  Tu- 
berculosis shows  this  even  better.  If  we  inoculate  the 
liver  experimental  ly  with  human  tuberculosis,  it  causes 
not  only  tuberculosis  but  fatty  and  coagulation  ne- 
crosis in  the  liver;  if  we  inoculate  it  with  aviary  tuber- 
culosis, sclerosis  is  the  usual  result.  Cirrhosis  is 
therefore  always  the  result  of  the  action  of  a  poison  in 
small  doses  long  continued;  the  sclerotic  reaction  of 
the  connective  tissue  corresponds  to  a  defensive  resist- 
ance on  the  part  of  the  liver  to  the  poison,  and  when 
the  toxic  agent  is  too  violent  it  provokes  necrobiotic 
degeneration,  but  not  cirrhosis.  All  this  applies  to 
venous  cirrhosis.  As  to  biliary  cirrhosis,  the  question 
is  much  more  obscure,  since  we  know  nothing  certain 
of  its  pathogeny.  If  it  is  infectious  in  origin,  as  af- 
firmed by  Hanot,  it  would  appear  to  depend  on  a  pro- 
longed bacillary  infection,  and  so  comes  under  the  laws 
just  demonstrated.  A  cirrhosis  once  begun  becomes 
soon  a  definite  disease  with  its  symptoms,  its  compli- 
cations, its  evolution,  and  its  termination.  These 
different  clinical  elements  so  group  themselves  as  to 
individualize  a  series  of  types  of  cirrhosis,  of  which 
the  descriptions  are  classic.  But  one  has  a  very  in- 
complete idea  unless  he  takes  into  consideration  also 
the  anatomical  and  functional  condition  of  the  hepatic 
cells.  Hanot  expresses  this  very  aptly  when  he  says 
that  the  diagnosis  of  cirrhosis  is  made  from  the  con- 
dition of  the  connective  tissue,  the  prognosis  from  the 
condition  of  the  hepatic  cells.  From  experiments  on 
animals  (the  removing  of  portions  of  the  liver)  we 
know  tiiat  histologically  hepatic  lobules  hypertrophy, 
that  they  can  double  or  triple  their  size,  at  the  same 
time  that  new  lobules  are  appearing  and  developing 
alongside  them;  so  we  can  believe  that  compensator)- 
hypertrophy  is  a  general  law.  Acknowledging  this, 
we  may  distinguish  three  groups  of  facts:  (i)  The 
compensatory  hypertrophy  is  insuiificient  or  masked  by 
the  destruction  more  or  less  rapid  of  the  glandular  ele- 
ments. Such  is  the  case  in  the  atrophic  cirrhosis  of 
Lfennec.  (2)  The  compensatory  hypertrophy  may  be 
sufficient  to  allow  the  patient  years  of  life,  but  not  a 
cure.  The  sclerotic  process  continues  its  work  till 
one  day  secondary  icterus  appears  and  the  patient  dies. 
It  is  thus  that  the  hypertrophic  biliary  cirrhosis  of 
Hanot  kills.  We  know  how  long  the  course  of  this 
disease  is,  and  if  the  patient  dies  of  an  intercurrent  af- 
fection we  find  the  hepatic  cells  healthy,  hypertrophied, 
or  in  full  karyokinetic  activity.  But  if  the  cirrhosis 
has  time  to  complete  itself  we  find  the  trabeculre  parted, 
the  hepatic  cells  fragmented,  deprived  of  their  nuclei, 
or  even  fatty  granular,  and  this  especially  in  the  centre 
of  the  lobules.  (3)  Finally  the  compensation  may  re- 
main sufticient  for  such  a  long  time  that  an  apparent 
cure  has  taken  place.  We  see  this  in  the  hypertrophic 
alcoholic  cirrhosis  of  Gilbert  and  Hanot.  From  the 
works  of  these  authors  we  know  how  different  is  the 
prognosis  when  the  liver  is  atrophied  or  hypertrophied. 
In  the  latter  case  it  is  not  rare  to  .see  under  milk  diet 
and  diuretic  medication  tiie  ascites  disappear  and  the 
general  condition  improve  to  the  point  of  apparently 
perfect  health.  The  patient  seems  actually  to  be  cured. 
The  conclusion  therefore  is,  the  author  said,  that  the 
liver  reacts  under  the  form  of  cirrhosis  only  when  the 
pathogenic  agent  is  relatively  moderate  and  is  pro- 
longed; that  the  sclerotic  process  is  to  a  certain  point 
a  proccess  of  protection  and  defence  to  the  hepatic 
cell;  that  this  in  its  turn  participates  in  the  disease 
either  by  compensatory  hypertrophy  or  following  the 
conditions  is  destroved. 


462 


MEDICAL    RECORD. 


[September  25,  1897 


Dr.  Gilbert,  of  Paris,  followed  with  a  communica- 
tion on  the  same  subject.  He  distinguished  two 
grand  categories,  after  Hanot:  simple  cirrhosis  and 
complicated  cirrhosis.  In  the  latter,  by  addition  to 
the  sclerosis  and  atrophy  or  hypertrophy  of  the  hepatic 
cells,  there  were  various  degenerations  always  extend- 
ing to  the  parenchymatous  element.  In  simple  cirrho- 
sis the  pathogenic  agent  may  come  from  within  or  from 
without  the  organism.  The  cirrhoses  of  auto-intoxi- 
cation are  the  dyspeptic,  the  gouty,  and  the  diabetic. 

In  dyspeptic  cirrhosis  Uoix  described  the  liver  as 
large,  smooth,  remarkably  hard,  without  increase  in 
volume  of  the  spleen,  without  icterus,  ascites,  or  collat- 
eral venous  ciculation.  The  duration  is  very  long, 
even  ten  years.  As  a  cause  of  this  we  may  suspect  the 
action  of  acetic  acid,  which  is  so  frequently  formed  in 
the  stomach  of  dyspeptics,  .\mong  the  poisons  from 
without  which  cause  cirrhosis,  the  speaker  mentioned 
lead  and  alcohol.  It  is  more  than  a  disputed  ques- 
tion, he  said,  whether  the  former  can  cause  cirrhosis; 
the  latter  causes  it  under  two  forms,  viz.,  atrophic 
(Laennec)  and  hypertrophic  (Hanot  and  Gilbert). 
Under  the  head  of  infectious  cirrhosis,  he  men- 
tioned those  caused  by  the  eruptive  fevers,  by  typhoid 
fever,  cholera,  syphilis,  and  tuberculosis.  Under  the 
head  of  cirrhosis  by  auto-infection  we  have  the  biliar)- 
cirrhosis  of  Hanot  andbiliar)-  cirrhosis  by  obstruction. 
Mechanical  cirrhosis  is  another  name  for  cardiac  cir- 
rhosis. The  complicated  forms  of  cirrhosis  are  those 
accompanied  by  fatty,  amyloid,  or  pigmentary  degen- 
eration, necrobiosis,  diffuse  or  nodular  hyperplasia, 
and  adeno-epitheliomatous  changes. 

Intercellular  Hepatitis.- 1;)r.  Cakmoxa  y  Valle, 
of  Mexico,  described  a  special  form  of  hepatic  cirrho- 
sis, occurring  in  the  city  of  Mexico,  which,  he  said,  is 
not  spoken  of  in  the  text-books.  It  is  characterized  by 
an  enlargement  with  induration;  constant  icterus; 
continued,  remittent,  or  intermittent  fever;  hemor- 
rhage; digestive  disturbances  with  continuous  bilious 
diarrhoea;  cerebral  disturbances  with  ataxo-adynamic 
phenomena;  frequently  ascites;  and  it  finally  termi- 
nates in  death.  Its  mean  duration  is  six  or  eight 
months;  but  it  may  kill  in  much  less  time,  or  may  last 
as  long  as  a  year  and  a  half.  It  differs  from  the  hy- 
pertrophic biliary  cirrhosis  of  Hanot  by  its  much  more 
rapid  progress,  by  its  almost  continuous  fever,  by  the 
frequency  of  ascites,  and  by  the  fact  that  the  spleen 
does  not  hypertrophy.  The  proliferation  begins  in  the 
intra-hepatic  veins,  e.xtends  rapidly  to  the  trabecula- 
of  the  lobules  and  afterward  to  the  ramifications  of 
the  portal  vein.  There  is  always  destruction  of  the 
cells,  and  in  some  cases  the  connective-tissue  prolif- 
eration is  so  abundant  that  it  obstructs  the  vessels,  so 
causing  nodules,  more  or  less  large,  of  necrobiotic  tis- 
sue which  softens  and  forms  cavities  full  of  a  creamv 
fluid. 

Orrhodiagnosis  of  Typhoid  Fever. — Dr.  Widai., 
of  Paris,  read  a  paper  on  the  serum  diagnosis  of  ty- 
phoid fever,  in  which  he  gave  in  detail  his  method  of 
obtaining  the  reaction  and  offered  a  theoretical  expla- 
nation of  its  production. 

Dr.  a.  Mills,  of  Brussels,  followed  with  a  paper  en- 
titled "  On  the  Gruber-U'idal-Griinbaum  Sero-Diag- 
nostic  .Method  of  Typhoid-Fever  .\uto-Reactions." 
In  twenty-eight  serum  reactions  made  with  cultures 
of  like  ages,  but  of  variable  virulence,  the  speaker 
said,  he  had  constantly  found  that  the  rapidity  with 
which  agglutination  was  produced  was  inverse  to  the 
power  of  the  virulence  of  the  typhoid  bacillus.  He 
thought  therefore  tliat  it  was  necessary  to  mention 
three  elements  before  giving  the  results  of  a  serum 
reaction.  These  are  (i)  the  dilution  of  the  serum  of 
the  patient.  (2)  the  duration  before  the  appearance 
of  the  serum  reaction,  and  (^^)  tlie  virulence  of  the 
culture  employed.     Dr.  Mills  then  spoke  of  auto-reac- 


tions. It  was  interesting,  he  said,  to  determine  whether 
the  action  of  the  blood  in  typhoid  fever  was  the  same 
when  placed  in  the  presence  of  other  bacteria  as  when 
made  to  react  through  its  own  infecting  bacteria.  Out 
of  eight  cases  the  hetero-serum  reaction  was  six  times 
produced  more  quickly  than  the  auto-serum  reaction. 
In  two  cases  the  contrarj-  took  place.  These  differ- 
ences were  in  perfect  accord  with  the  state  of  virulence 
of  the  cultures.  In  discussing  the  question  as  to 
whether  the  serum  reaction  is  due  to  a  natural  or  to  an 
acquired  immunity,  he  said  that  it  could  not  be  a  nat- 
ural immunity,  because  he  had  always  observed  that 
the  agglutinative  power  increases  with  the  infection  so 
long  as  the  intoxication  of  the  blood  is  not  too  con- 
siderable, and  that  it  does  not  disappear  immediately 
with  the  infection.  Consequently  it  must  be  an  ac- 
quired immunity. 

Dr.  Widal,  of  Paris,  asked  Dr.  Mills  how  he 
came  to  associate  three  names  in  this  reaction,  when 
up  till  now  it  has  always  gone  under  one  name. 

Dr.  Mills  answered  that  Gruber  was  the  first  to 
point  out  certain  points  in  regard  to  this  agglutinative 
reaction,  and  after  Widal  Griinbaum  had  suggested 
certain  modifications. 

Dr.  Widal  said  that  personally  he  esteemed  both  the 
gentlemen  mentioned,  admired  the  work  that  they  had 
done,  and  felt  it  an  honor  to  be  associated  with  them, 
but  till  now  he  had  not  known  that  Griinbaum  had 
modified  the  reaction  to  any  such  extent  that  would 
justify  the  addition  of  his  name,  and  Gruber  did  not 
apply  the  reaction  to  the  diagnosis  of  the  disease. 
The  principal  point,  however,  was  that  he  did  not 
think  Mills  had  the  right  to  call  the  reaction  by 
names  not  before  associated  without  the  permis- 
sion of  the  men  in  question.  As  Mills  had  not  asked 
his  (Widal's)  permission,  he  requested  that  his  name 
be  withdrawn  from  the  title  of  the  paper,  and  if  it  was 
lawful  for  the  president  to  make  the  change  he  de- 
sired him  to  do  so. 

Thl  President  said  that  under  the  circumstances 
the  three  names  would  be  erased  from  the  title. 

Orrhodiagnosis,  Orrhoprognosis,  and  Orrhotherapy 
of  Relapsing  Fever. —  Dk.  Luewexthal,  of  Moscow, 
read  a  paper  with  this  title. 

Orrhodiagnosis:  The  foundation  of  this  method 
consists  in  the  influence  of  the  specific  bactericidal 
properties  of  the  blood  during  each  apyrexia  of  relaps- 
ing fever.  The  author  had  had  thirty  cases  with  a 
positive  result,  as  shown  by  the  course  of  the  disease; 
nine  cases  of  other  acute  infectious  diseases,  with  neg- 
ative result;  and  fourteen  cases  verifying  the  speci- 
ficity of  the  blood  during  tlie  apyrexia.  From  a  study 
of  these  experiments  he  had  come  to  the  following 
conclusions:  (i)  The  serum  diagnosis  furnishes  us 
with  a  positive  method  for  diagnosticating  the  disease 
in  the  course  of  one  or  two  hours,  when  the  patient  is 
first  seen  in  the  apyretic  period.  {2)  This  is  true  even 
in  abortive  attacks  (third  and  fourth  attacks,  or  slight 
paroxysms)  when  the  blood  contains  but  very  few  spi- 
rilla. (3)  After  inoculating  the  patient  with  the  anti- 
spirillum  serum  there  will  be  no  relapse  in  half  of  the 
cases.  (41  The  stay  in  the  hospital  will  be  shorter  for 
the  patient,  especially  since  by  error  such  cases  are 
now  often  diagnosed  as  simple  malarial  fever. 

Orrhoprognosis :  The  procedure  is  the  same  as 
in  that  of  serum  diagnosis.  This  method  gives  an 
exact  criterion  by  whicli  to  prognosticate  the  cause  of 
the  disease,  .\cccording  to  Dr.  Loewenthal's  re- 
searches (fifty-eight  cases),  when  the  duration  of  the 
reaction  was  for  one  hour  seven  days  after  tlie  first 
apyrexia,  a  relapse  never  followed. 

Orrhotherapy:  The  speaker  had  inoculated  eighty- 
four  patients  at  tlie  beginning  of  the  first  apyrexia — 
fifty-three  per  cent,  relapsed,  forty-six  per  cent,  ended 
after  one  attack.    During  the  same  time,  of  one  hundred 


11 


September  25.  1897] 


MEDICAL    RFXORD. 


46: 


and  fifty -two  cases  not  treated  by  the  serum,  in  only 
sixteen  per  cent,  did  the  disease  end  with  one  attack. 

Dr.  Metchxikov  suggested  that  the  explanation  of 
the  spirillicidal  action  of  the  blood  during  the  apyretic 
period  of  recurrent  fever  was  not  so  simple  as  Dr. 
Loewenthal  would  seem  to  regard  it.  The  whole  reac- 
tion would  seem  to  prove  that  there  is  some  other  in- 
fluence at  work  besides  spirillicidal  material  freely 
circulating  in  the  blood.  Gabrichevsky  has  shown 
that  no  definite  rule  can  be  laid  down  as  to  the  spiril- 
licidal power  of  the  apyretic  blood.  Sometimes  it 
kills  in  one  and  one-half  hours,  sometimes  only  in 
eighteen,  sometimes  not  for  thirt}'-six  hours.  Normal 
human  blood  will  do  the  same  thing  m  eighteen  to 
twenty  hours  as  a  rule.  In  experiments  on  apes  Bar- 
dach  has  shown  that  during  the  crisis  of  the  fever  .",nd  in 
convalescence  living  spirilla  appear  in  the  spleen  and 
are  infective  when  inoculated  into  other  apes.  If  the 
liquid  obtained  from  the  spleen  be  gently  heated  it 
loses  its  infective  property,  thus  showing  that  it  is  not 
in  the  form  of  spores  that  the  organisms  are  present. 
It  is  almost  proven  then  that  it  is  not  a  new  genera- 
tion of  organisms  with  grfeater  virulence  that  cause> 
the  second  attack  after  the  apyrexia,  but  that  some  in- 
fluence holding  the  organisms  in  check  has  been  re- 
moved or  paralyzed  in  its  action.  This  is  not  likely 
to  be  any  substance  circulating  freely  in  the  serum, 
but  is  much  more  probably  some  living  influence  that 
in  its  cycle  of  existence  loses  its  resistant  power. 
This  would  speak  very  strongly  for  the  phagocytic  ac- 
tion of  the  leucocytes  in  relapsing  fever.  The  irrita- 
tion in  the  blood-making  organs  during  an  attack 
causes  a  leucocytosis  which  sets  free  a  number  of  pha- 
gocytes to  englobe  the  spirilla  and  hamper  their  ac- 
tion ;  after  a  while  this  generation  dies  off,  setting  free 
the  spirilla  that  have  not  been  killed  and  so  leading  tu 
another  attack. 

The  Pathogenesis  of  Typhoid  Fever. — Dr.  Frax- 
GVLE.-i,  of  Roumania,  read  a  paper  entitled  "  The  Path- 
ogenesis of  Typhoid  Fever  and  the  Errors  of  the 
Current  Microbian  Theor\',"  of  which  the  following  is 
a  resume:  (i)  Typhoid  fever  may,  under  certain 
conditions,  arise  spontaneously,  that  is,  without  the 
presence  of  the  bacillus  of  Eberth.  (2)  The  bacillu.-; 
coli  communis  may,  under  favorable  conditions,  ac- 
quire pathogenic  properties  and  produce  typhoid  fever. 
(3)  It  can  preserve  and  transmit  these  new  qualities 
to  future  generations.  ( 4)  These  new  generations  may 
adapt  themselves  to  new  conditions,  and,  obeying  the 
law  of  atavism,  return  to  their  primitive  state.  (5)  It 
is  incorrect  to  say  that  a  germ  must  always  and  every- 
where preserve  its  form  and  specificit}',  especially  an 
absolute  specificity. 

The  Malarial  Parasite  of  Tertian  Fever  (with 
Demonstration  by  Lantern  Slides  1. — Dr.  Jl-d.son 
D.\L.\.N-D,  of  Philadelphia,  read  the  paper.  The  pho- 
tographs from  which  these  lantern  slides  were  made 
were  secured  in  the  following  manner:  The  thumb 
was  cleansed  first  with  water,  then  with  alcohol,  and 
finally  with  ether.  It  was  then  punctured  :  the  emerg- 
ing droplet  of  blood  was  placed  upon  a  slide  and  then 
upon  a  warm  stage  and  photographed  within  from 
twenty  to  forty  minutes.  The  initial  magnification  was 
from  one  thousand  to  two  thousand  diameters,  and  a 
Zeiss  apochromatic  oil-immersion  lens  was  employed. 
Not  infrequently  three  photographs  of  the  same  parasite 
were  taken  at  intervals  of  three  or  five  minutes.  The 
first  picture,  from  a  case  of  tertian  fever,  showed  a  large 
and  small  matured  extracorpuscular  malarial  parasite, 
the  pigment  showing  very  well  but  not  sharply  out- 
lined, as  these  particles  were  in  a  rapid  dancing-move- 
ment at  the  time  the  photograph  was  made.  The 
second  picture  showed  a  large  moderately  matured 
intracorpuscular  plasniodium.  The  red  blood  cor- 
puscle acting  as  the  host  of  the  parasite  was  a  ma- 


crocyte.  The  original  attack  of  the  tertian  malaria 
four  years  ago  was  acquired  in  India,  since  which 
time  the  disease  recurred  each  succeeding  autumn. 
This  patient  had  received  several  hypodermatic  injec- 
tions of  the  bimuriate  of  quinine  and  urea  with  but 
little  benefit.  The  third  picture  showed  a  matured 
extracorpuscular  body  photographed  thirt}-  minutes 
after  removal  from  the  patient  during  the  interparoxys- 
mal  period.  The  duration  of  the  exposure  was  one 
second  and  the  magnification  two  thousand  diameters. 
A  second  photograph  was  made  in  four  minutes  and 
no  change  was  observed.  A  third  photograph  v.as 
made  in  six  minutes,  when  the  body  was  seen  in  the 
act  of  disintegrating.  The  large  masses  of  pigment 
were  seen  free  in  the  plasma  and  the  protoplasm 
that  had  formed  the  parasite  was  seen  as  a  number 
of  globules  of  various  sizes.  This  observation  was 
especially  interesting  as  showing  the  last  step  in 
the  life  historj-  of  a  matured  extracorpuscular  ma- 
larial body.  The  sixth  picture  showed  a  free  mala- 
rial body;  the  pigment  granules  were  quite  large 
and  when  photographed  were  in  lively  motion.  The 
blood  was  taken  from  a  case  of  tertian  intermittent 
fever  at  the  beginning  of  a  chill.  The  seventh  pictiae 
showed  the  same  parasite  ten  minutes  later,  during 
which  interval  the  pigment  had  shown  a  tendency  to 
a  bipolar  distribution  with  a  clear  space  in  the  central 
region.  The  eighth  picture  showed  the  same  parasite 
ten  minutes  later,  when  the  beginning  of  an  hour-glass 
contraction  may  be  plainly  seen.  The  ninth  picture 
showed  the  same  parasite  forty  minutes  later,  when 
the  body  had  completed  its  division.  It  would  seem 
from  the  series  that  one  of  the  methods  of  the  mul- 
tiplication of  the  Plasmodium  is  by  division.  The 
last  picture  showed  beautifully  a  crescentic  body. 
Plainly  could  be  seen  what  appeared  to  be  the  shell 
of  the  red  corpuscle  in  which  the  parasite  was  in- 
closed. The  pigment  was  motionless.  The  case  was 
one  of  quotidian  fever  and  the  photograph  was  taken 
upon  the  third  day  of  the  absence  of  fever,  during 
which  time  the  patient  received  sixty  grains  of  quinine 
in  divided  doses.  Five  days  later,  or  eight  davs  after 
the  last  paro.xysm.  these  crescentic  bodies  were  still  to 
be  seen,  although  but  few  in  niunber.  It  seems  not 
improbable  that  these  crescents  represent  certain  of 
the  parasites  that  have  come  under  the  influene  of  the 
quinine  and  have  been  arrested  in  their  development. 
Gastroscopy. — Dk.  Revidzuv,  of  Moscow,  read  a 
paper  on  the  technique  of  gastroscopy.  The  author 
proposed  the  following  modification  in  order  to  re- 
place the  direct  introduction  of  the  metallic  tube, 
which  is  sometimes  dangerous :  An  English  oesopha- 
geal sound,  almost  equal  in  size  to  the  exterior  metal- 
lic tube  of  Rosenheim's  gastroscope,  is  introduced 
while  the  patient  is  in  the  sitting  posture.  Then,  with 
the  head  bent  backward,  the  othe.  two  tubes  of  Ro- 
senheim's gastroscope  are  introduced — a  procedure 
which  can  usually  be  done  without  difficult)-. 


(To  l-t  CoHtiHUed.^ 


Surgery  of  the  Lung,  like  that  of  the  viscera,  has 
of  late  made  much  progress,  thanks  to  the  perfection 
of  our  anatomical  knowledge  and  to  the  improvement 
in  operative  procedures  for  the  arrest  of  hemorrhage. 
Equally  favorable  conditions  for  surgical  intervention 
do  not  occur  in  all  affections  of  the  lungs.  Wounds 
caused  by  contusing  bodies,  by  stabbing  and  cutting 
instruments,  and  by  gunshot  projectiles  of  small  and 
medium  calibre,  usually  heal  well  without  causing 
suppuration  or  troublesome  reaction.  The  danger 
which  results  from  such  injuries  is  due,  not  to  the  in- 
jur}- of  the  lung  structure  itself,  but  rather  to  the 
multiplicity  and  extent  of  the  wounds  and  to  the  lesions 
of  important  neighboring  parts.  The  surgeon  should 
not  intervene  too  hastily  in  these  injuries. — Pt.xN. 


464 


MEDICAL    RFXORD. 


[September  25,  1897 


BRITISH    MEDICAL   ASSOCIATION. 
SECTION    IX    SURCKRV. 

(Continued  from  page  435  ) 

Third  Day— Friday,  September  jd. 

Resection  of  the  Intestine. — Dr.  F.  J.  Shepherd,  of 
Montreal,  reported  a  case  of  successful  removal  of  six 
and  one-half  feet  of  intestine.  The  patient  was  a 
man,  twenty-eijiht  years  old,  who  had  noticed  for  some 
months  an  enlargement  of  the  abdomen.  The  diagno- 
sis was  a  retroperitoneal  lipoma.  On  opening  tiie 
abdomen,  the  tumor  was  found  adherent  anteriorly 
and  laterally.  It  grew  from  the  mesentery.  Three 
feet  of  ileum  attached  to  the  growth,  as  well  as  nearly 
two  feet  on  cither  side,  had  to  be  removed. 

Penetrating  Wounds  of  the  Abdomen.  — Du.  I'o- 
BiAS  Nunez,  of  Me.\ico  City,  presented  a  paper  on 
"The  Diagnosis  and  Treatment  of  Penetrating  Wounds 
of  the  Abdominal  Cavity."  He  pointed  out  how  diffi- 
cult it  was  to  ascertain  the  true  extent  of  wounds  of 
this  sort  and  the  amount  of  damage  done.  The  two 
great  dangers  were  peritonitis  and  internal  hemor- 
rhage, the  symptoms  of  which  were  well  known.  These 
complications  might  occur  separately  or  together.  If 
it  was  clear  that  the  intestine  was  wounded,  laparot- 
omy was  called  for.  ]!ut,  generally,  if  the  indications 
did  not  call  for  radical  measures,  the  speaker  leaned 
to  conservatism  in  treatment. 

Surgery  of  the  Bile  Ducts Dr.  \.  H.  Fergu- 
son, of  Chicago,  read  a  paper  on  this  subject.  He 
said  that  the  surgeon  alone  could  treat  these  cases 
successfully.  Stone  in  the  gall  bladder  or  any  of  the 
bile  ducts  was  as  clearly  a  case  for  the  surgeon  as 
stone  in  the  bladder.  He  did  not  mean  that  opera- 
tion should  always  be  performed  as  .soon  as  a  diagno- 
sis was  made,  but  a  surgeon  should  be  at  hand  to  sit 
in  judgment  upon  the  clinical  evidence.  The  speaker 
reported  forty-si.x  cases  of  various  affections  in  this 
region  which  had  come  under  his  care. 

Intestinal  Obstruction. — Dr.  A.  R.  Atherton,  of 
Fredericton,  New  Urunswick,  reported  a  case  of  intes- 
tinal obstruction  caused  by  strangulation  of  a  loop  of 
ileum  by  Meckel's  diverticulum.  The  patient,  a  man 
with  a  small  umbilical  hernia,  had  suffered  from  at- 
tacks of  cramps  once  or  twice  yearly,  attended  latterly 
by  vomiting  and  looseness  of  the  bowels,  induced 
apparently  by  errors  in  diet.  After  a  dose  of  calomel 
these  symptoms  were  relieved  until  the  last  attack, 
when  this  did  not  produce  movement  of  the  bowels. 
Vomiting  was  persistent,  and  when  the  man  was  seen 
by  the  speaker  in  consultation  the  facial  expression 
was  bad.  The  temperature  was  99^^  F.  The  belly 
was  distended.  Tympanites  was  marked  in  the  inn- 
bilical  region.  Tenderness  and  pain  were  especially 
marked  below  and  to  the  right  of  the  navel.  There 
was  no  induration.  Meckel's  diverticulum  was  of  the 
size  and  shape  of  a  pear  and  partly  gangrenous.  A 
good  dejl  of  force  was  needed  to  draw  tiie  diverticu- 
lum out.  The  patient  rallied  fairly  well,  but  his  pulse 
ran  up  to  150,  temperature  to  loi"  F.  within  twenty- 
four  hours,  and  the  face  looked  pinched.  The  tem- 
perature afterward  fell  to  normal,  but  the  pulse  re- 
mained high  and  the  patient  became  delirious,  and 
died  tiiirty  hours  after  the  operation.  Autopsv  showed 
a  loop  of  ileum  protruding  through  a  hole  in  the  mesen- 
tery. Three  «as  considerable  intestinal  distention  in 
the  neighborhood,  but  no  peritonitis.  Only  one  case 
like  this,  so  far  as  the  speaker  knew,  had  been  re- 
ported. 

Ureteral  Stones.  Dr.  Jordan  Lovn,  of  Birming- 
ham, presented  a  comnnmication  on  stone  in  the 
ureter  and  its  treatment.  Me  was  struck  some  ten 
years  ago,  when  work  in  renal  surgery  began,  by  the 
number  of    failures  in  discovering  renal  calculi.      It 


happened  in  the  hands  of  many  men  that  in  pa- 
tients who  presented  all  the  symptoms  of  renal  cal- 
culi none  was  found.  Some  had  gone  so  far  as  to 
remove  the  kidney,  and  then  had  found  no  stone.  In 
.some  of  these  cases  the  speaker  was  sure  the  condi- 
tion was  one  of  stone  in  the  ureter.  He  reported 
the  case  of  a  man  who  had  suffered  from  typical 
symptoms  of  renal  calculus  for  three  and  a  half 
years.  An  operation  was  performed,  but  no  stone  was 
found.  Forty-five  days  later  the  patient  was  seized 
with  acute  pain  which  lasted  a  few  seconds  and  then 
disappeared.  In  five  or  six  hours  a  calculus  was 
passed.  In  his  next  patient  suffering  in  this  way  he 
resorted  to  the  expedient,  which  he  considered  of  great 
importance,  of  giving  the  patient  a  sudden  very  strong 
blow  over  the  suspected  site  of  the  stone.  This  hurts 
only  for  a  moment,  causing  a  stabbing  pain,  very  char- 
acteristic of  stone.  This  patient,  besides  paroxysmal 
nephralgia,  had  shooting  pains  about  the  lower  abdo- 
men and  hips.  Haematuria  was  present.  There  was 
absence  of  kidney  tenderness.  His  first  step  in  diag- 
nosis was  to  examine  the  bladder  to  determine  that 
there  was  no  stone  there.  'The  urine  should  be  exam- 
ined microscopically  for  blood.  Then  a  group  of 
symptoms  should  be  looked  for  which  are  always  asso- 
ciated with  what  he  called  "  water-logged  kidney,"  a 
"  urotoxa?mia."  The  patient  looks  excessively  ill. 
The  skin  is  moi.st,  the  pulse  rapid  (160  to  180),  and 
the  temperatuie  is  subnormal.  There  is  abdominal 
distention  caused  by  paresis  of  the  intestines  and  the 
distress  is  extreme.  He  had  been  called  in  consulta- 
tion to  see  a  man  by  his  physician,  who  stated  that  a 
curious  condition  was  present — that  the  heart  and  lungs 
seemed  to  be  much  crowded  upward,  and  he  was  unable 
to  tell  wjiv.  '!"he  man  on  inquiry  gave  a  history  of 
stone,  and  had  left  lumbar  colic.  This  gave  a  clew. 
The  ureter  had  become  impacted  and  water-logged 
kidney  was  present,  ns  indicated  by  one  of  its  typical 
signs,  viz.,  intestinal  distention,  which  accounted  for 
the  crowding  up  of  the  thoracic  viscera.  Aspiration 
was  done  to  relieve  the  distention.  At  the  autopsy 
the  pelvis  of  the  kidney  and  the  ureter  were  much 
dilated.  Lumbar  nephralgia  with  localized  tenderness 
pointed  to  the  position  of  the  stone.  Most  cases  of 
impacted  stone  would  be  found  within  the  lower  three 
inches  of  the  ureter.  The  treatment  in  these  cases 
was  to  cut  for  tlie  stone,  the  sooner  tiie  better.  If  it 
was  located  near  the  bladder  a  suprapubic  cystotomy 
gave  the  best  results.  The  bladder  should  be  0]5ened, 
the  ureter  split  up,  and  the  stone  extracted. 

Dr.  ^^■.  \\'.  Keen  reported  a  ca.se  in  which  there 
were  svmptonis  of  appendicitis.  The  fever  was  slight; 
the  pain  centred  around  the  umbilicus,  later  being  felt 
in  the  iliac  fossa.  There  was  nothing  suggesting  ure- 
teral or  renal  trouble.  On  opening  the  abdomen  no 
appendix  was  found.  He  did  not  think  of  stone  in 
the  ureter  until  the  next  day,  when  he  did  so  with  a 
strong  twinge  of  conscience.  Ten  months  later  he  re- 
moved a  calodus  from  the  patient's  bladder.  Dr. 
Keen  said  he  thought  that  in  every  case  of  renal  colic 
in  which  within  two  or  three  days  no  stone  is  passed 
the  bladder  sJKndd  lie  evacuated  with  a  Higelow  evac- 
uator. 

Appendicitis  and  Pyosalpinx. — Dr.  L.\pthornk 
S.Mrrii,  of  Montreal,  gave  a  brief  account  of  seven 
cases  of  apjiendicitis  complicating  pus  tubes.  He 
explained  a  new  method  of  dealing  with  the  appendix. 
Instead  of  leaving  a  stump  and  searing  with  carbolic 
acid,  which  he  said  was  frequently  followed  by  fistulse 
by  reason  of  the  mucous  surfaces  not  uniting,  he  cuts 
the  appendix  off  flush  with  the  bowel,  thus  practically 
treating  a  hole  in  the  bowel. 

Dr.  Marcv,  of  Boston,  said  that  he  united  the  mus- 
cular and  mucous  coats  and  then  invaginated  the 
stump  .so  as  to  bring  the  peritoneal  co.ats  together. 


September  25,  1897] 


MEDICAL    RFXORD. 


465 


SECTION    IN    MEDICINE. 

Second  Day — Thursday,  September  2d. 

Crossed  Hemiplegia Dr.  J.  E.  Graham,  of  Toron- 
to, reported  a  case  of  crossed  hemiplegia,  tfie  result  ot 
injur)'  of  the  pons  Varolii,  which  came  under  his  ob- 
servation five  years  ago.     The  history  taken  at  that 

time  was  as  follows:     A.  L ,  aged  ten  years,  v. as 

perfectly  well.  When  eighteen  months  old,  fell,  while 
playing,  and  a  slender  jagged  end  of  a  spruce  .stick, 
about  two  feet  long,  entered  the  mouth  and  pene- 
trated the  soft  palate.  In  the  fall,  the  stick  broke 
off  at  the  line  of  the  teeth  and  was  so  firmly  em- 
bedded in  the  tissue  that  it  had  to  be  moved  from 
side  to  side  and  much  force  used  before  it  could 
be  drawn  out.  The  sliver  measured  between  three  and 
four  inches.  Profuse  hemorrhage  followed.  The 
accident  occurred  at  5  p.m.  and  the  patient  cried 
until  II  P.M.,  when  vomiting  of  clotted  blood  com- 
menced and  immediately  after  vomiting  convulsions 
set  in  which  lasted  two  hours.  A  second  series  of 
convulsions  similar  to  the  first,  but  shorter  in  dura- 
tion, came  on  the  next  day.  On  the  third  night  hu 
had  a  third  convulsive  attack  and  during  the  afternoon 
a  fourth.  The  latter  was  followed  by  pain,  which  con- 
tinued till  morning,  when  paralysis  of  the  right  arm 
and  right  leg  was  noticed  with  affection  of  the  left 
side  of  the  face.  The  left  eye  was  turned  slightly  in- 
ward and  the  pupil  was  contracted.  He  swallowed 
liquids  with  difficulty.  No  sol  id  food  was  given.  He 
vomited  occasionally  for  two  weeks  and  remained  in 
bed  for  seven  months.  Since  the  recovery  of  his 
strength,  he  had  had  convulsions,  at  first  several  in  a 
day,  but  latterly  less  frequent.  The  series  would  often 
last  seven  or  eight  hours.  Latterly  they  have  been 
only  ten  or  fifteen  minutes  and  sometimes  five  minutes 
in  duration.  For  the  last  five  years  they  have  oc- 
curred at  night  and  are  more  frequent  during  the  fall 
of  each  year.  Constipation  seems  to  bring  on  the 
convulsions.  His  mind  is  always  clear,  but  he  is' not 
so  bright  as  other  boys.  The  affected  side  is  always 
colder  than  the  other  and  the  right  hand,  which  is 
rigid  during  the  day,  becomes  flaccid  at  night.  On 
examination  in  1892  the  right  chest  was  one  and 
three-quarters  inches  smaller  than  the  left,  while  tlie 
circumference  of  the  right  arm,  forearm,  thigh,  and  leg 
averaged  about  one  inch  less  than  the  corresponding 
parts  of  the  left  side.  The  face  was  drawn  slightly  to 
the  left.  No  motion  of  the  muscles  of  the  right  forearm 
was  possible  except  slight  additional  flexion  of  the 
fingers,  which  were  always  considerably  flexed  and 
could  not  be  extended  by  ordinary  force.  Motion  of  all 
the  muscles  of  the  humeral  region  could  be  made  witli 
some  awkwardness.  In  the  lower  extremity  all  the 
muscles  seemed  capable  of  motion,  but  the  foot  was 
capable  of  only  about  half  the  normal  flexion  on  tlie 
leg.  The  patient  had  an  awkward  limp  which  seemed 
due  in  part  to  the  loss  of  motion  in  the  ankle-joint  and 
in  part  to  lessened  general  power  over  the  muscles  of 
the  joint.  The  patellar  reflex  was  less  on  the  right 
than  on  the  left  side,  .\nkle  clonus  was  absent,  also 
the  cremasteric  reflex.  The  condition  present  now 
differs  very  little  from  that  of  five  years  ago,  except 
that  now  there  is  no  squint.  No  similar  case,  as  far  as 
the  speaker  knew,  had  been  reported. 

Dr.  Mackknzie,  of  London,  said  that  the  fact  that 
the  paralyses  did  not  develop  for  three  days  siiowed 
that  it  was  due  to  an  inflammatory  condition. 

Dr.  AN<;ELr.,  of  Rochester,  spoke  of  a  case  of  tumor 
of  the  pons  he  had  had,  which  gave  similar  symptoms 
and  which  showed  no  reaction  of  degeneration  in  the 
muscles.  He  considered  the  paralysis  in  Dr.  Graham's 
case  therefore  due  to  hemorrhage  outside  of  tiie  pons 
and  not  in  it,  otherwise  the  muscles  would  have  shown 
reaction  of  degeneration. 


Bacteriology  of  Pertussis. — Dr.  Koplik,  of  New 
York,  read  a  paper  on  this  subject.  The  small  white 
pellets  found  in  the  sputa  when  examined  show  a  very 
small  bacillus.  In  sixteen  cases  examined  the  bacil- 
lus was  found  in  thirteen.  It  is  motile,  grows  on  agar, 
gelatin,  blood  serum,  not  on  potato.  It  is  one-half 
or  one-third  the  length  of  the  diphtheria  bacillus,  and 
is  an  exceedingly  delicate  organism. 

Cardiac  Murmurs — Dr.  Musser,  of  Philadelphia, 
read  a  paper  on  the  murmurs  of  heart  disease.  Or- 
ganic munnurs  often  disappear  on  change  of  posi- 
tion of  the  patient,  but  only  rarely  is  there  a  disappear- 
ance of  the  mitral  murmur  due  to  organic  disease. 
Often  cases  in  which  murmurs  are  present  for  a  long 
time  before  death  show  no  evidences  at  the  autopsy  of 
disease  of  the  valves.  The  order  of  disappearance  of 
organic  murmurs  is:  (i)  mitral  obstruction,  (2)  aortic 
regurgitation,  and  (3)  mitral  regurgitation. 

Tuberculin. — Dr.  Whitaker,  of  Cincinnati,  re- 
ported his  six  years'  experience  in  the  use  of  tuber- 
culin. He  mentioned  the  various  theoretical  objec- 
tions to  its  use,  but  said  that  in  no  c^  during  the 
past  six  years  had  any  bad  effects  had  been  observed, 
nothing  other  than  the  characteristic  reaction.  It  was 
without  doubt  a  most  valuable  means  of  diagnosis. 
As  soon  as  tolerance  of  the  treatment  has  been  effected 
it  should  be  stopped  and  later  commenced  again.  In 
nearly  all  cases  there  was  improvement  at  the  first, 
but  as  the  fever  in  late  cases  was  due  to  the  prod- 
ucts of  other  micro-organisrits,  streptococcus,  etc.,  tu- 
berculin would  not  be  of  much  service  here.  Many 
times  cases  showed  very  great  improvement,  and  al- 
though it  could  not  be  said  that  this  was  due  to  tuber- 
culin entirely  it  certainly  had  a  beneficial  effect.  Tu- 
berculin was  contraindicated  only  in  miliary  tuber- 
culosis. 

Arthritis  Deformans Dk.   James     Stewart,    of 

Montreal,  opened  the  discussion  on  arthritis  de- 
formans, especially  its  relation  to  rheumatism,  ner- 
vous diseases,  and  tuberculosis.  He  based  his  re- 
marks on  the  observation  of  forty  cases  which  he  had 
had  in  Montreal;  of  these  twenty  were  in  males  and 
twenty  in  females.  This  proportion  varies  from  the 
usual  figures  of  five  males  to  one  female.  There 
was  a  family  history  of  some  form  of  rheumatic  af- 
fection in  eight  cases,  of  tuberculosis  in  five,  and 
of  a  neuropathic  tendency  in  four  cases.  As  to  ex- 
citing causes  the  following  were  noted:  There  was 
a  history  of  gonorrhcea  in  thirty  per  cent,  of  the 
male  cases,  and  in  three  of  the  male  cases  was  a 
history  of  two  or  more  attacks.  In  the  female  pa- 
tients, however,  there  was,  with  the  exception  of  one 
case,  an  entire  absence  of  symptoms  pointing  to  a 
past  genito-urinary  disturbance.  For  a  long  time  it 
had  been  thought  that  there  was  an  intimate  relation 
between  uterine  disease  and  rheumatic  arthritis.  Next 
to  gonorrhcea,  exposure  to  cold  was  considered  the  most 
likely  exciting  cause.  It  appeared  to  be  the  sole  or 
chief  cause  in  five  of  the  forty  cases.  The  next  most 
frequent  cause  was  worry,  which  was  present  in  four 
cases.  Three  patients  had  had  subcutaneous  ab- 
scesses, two  double  otitis  media,  two  influenza,  and 
two  tonsillitis.  Typhoid  fever,  pertussis,  and  diph- 
theria were  each  considered  the  chief  cause  in  one  case. 
In  fifteen  per  cent,  no  cause  could  be  ascertained. 
More  than  fifty  per  cent,  of  the  cases  had  thus  some 
previous  infective  trouble,  the  most  frequent  being 
gonorrhcea.  The  reasons  usually  advanced  for  adopt- 
ing the  nervous  origin  of  rheumatoid  arthritis  are:  (i) 
The  fact  that  in  certain  diseases  of  the  spinal  cord,  as 
tabes,  syringomyelia,  progressive  muscular  atrophy, 
joint  changes  of  a  somewhat  similar  character  are  met 
with.  (2)  The  very  frequent  early  and  pronounced 
muscular  atrophy  observed  in  cases  of  rheumatoid  ar- 
thritis.     (3)  The  history  frequently  obtained  of  causes 


466 


MKDICAL    RECORD. 


[September  25,  1897 


which  have  a  marked  affect  in  lowering  the  resisting- 
power  of  the  central  nervous  system  to  disease.  (4) 
The  frequent  onset  of  rheumatoid  arthritis  with  symp- 
toms of  a  nervous  character,  symptoms  pointing  to  a 
central  or  peripheral  nerve  disturbance.  In  ten  of  the 
forty  cases  tingling  and  numbness  of  the  e-\tremities 
preceded  the  attack.  It  is  difficult  to  explain  the 
marked  and  early  atrophy  of  muscles  that  occurs  in 
rheumatoid  arthritis.  No  matter  what  the  cause  is, 
it  must  be  due  in  the  first  place  to  some  change  in  the 
joint  and  not  to  any  supposed  changes  in  the  spinal 
cord.  It  is  in  the  first  place  an  arthritic  affection. 
The  speaker  had  never  been  able  to  ascertain  t'rat  there 
was  an  objective  disturbance  of  sensation  in  rheumatoid 
arthritis.  There  was  never  a  loss  of  sensation.  Of 
the  series  of  forty  reported  cases  in  only  three  was 
there  a  history  of  tuberculous  trouble,  a  proportion  not 
greater  than  if  as  great  as  in  people  in  good  health. 
Indirectly  a  tuberculous  tendency  may,  by  lowering  the 
resistance,  tend  to  bring  about  rheumatoid  arthritis, 
and  it  is  only  in  this  sense  that  there  is  a  connection 
between  the  two  diseases.  In  a  very  considerable  pro- 
portion of  all  cases  a  history  of  rheumatism  is  forth- 
coming. In  four  of  the  forty  cases  there  was  a  very 
clear  history  of  acute  rheumatism.  In  at  least  thirty 
per  cent,  the  onset  was  that  of  either  acute  or  subacute 
rheumatism — the  unavoidable  inference  being  that  a 
very  intimate  connection  exists  between  rheumatoid 
arthritis  and  acute  and  subacute  rheumatism.  There 
is  no  recognized  well-marked  dividing  line  between 
chronic  rheumatism  and  rheumatoid  arthritis.  In 
Germany  and  France  it  is  the  custom  to  call  cases 
chronic  rheumatism  which  in  England  would  be  called 
rheumatoid  arthritis.  As  yet  we  have  no  absolute 
proof  of  rheumatoid  arthritis  being  due  to  a  micro-or- 
ganism, but  it  is  highly  probable  that  it  is.  In  the 
speaker's  opinion  the  most  valuable  of  all  methods 
of  treatment  is  the  use  of  baths  of  superheated  dry 
air.  Generally  a  considerable  increase  in  the  mobil- 
ity follows  the  use  of  a  few  baths. 

Dr.  Kingston  .S.mith,  of  liristol,  said  that  the  dis- 
ease was  a  chronic  polyarthritis  and  not  rheumatism. 
The  fact  that  thirty  per  cent,  of  male  cases  had  had 
gonorrhoea  speaks  strongly  in  favor  of  microbic  origin. 
It  is  perfectly  clear  that  the  wasting  of  the  muscles  is 
due  to  non-use.  The  carbonate  of  guaiacol  is  said  to 
have  been  useful  in  early  cases. 

Dr.  Lindsay,  of  Belfast,  thought  there  was  no  justi- 
fication of  a  relationship  between  rheumatoid  arthritis 
and  tuberculosis;  b'lt  the  nervous  theory  could  not  be 
disposed  of  so  summarily,  on  account  of  the  presence 
of  acute  atrophy.  He  had  seen  many  cases  develop 
after  chronic  rheumatism. 

I)k.  Jacoi'.i,  of  New  York,  said  that  in  acute  artic- 
ular rheumatism  we  have  to  do  with  an  affection  of 
the  synovial  membranes,  while  in  rheumatoid  arthritis 
the  cartilages  are  the  parts  affected. 

Di;  J.  C.  Wilson,  of  Philadelphia,  said  the  term 
rheumatism  should  be  confined  to  the  acute  articular 
trouble.  In  rheumatoid  arthritis  there  is  a  develop- 
ment in  the  early  stages  of  successive  attacks  similar 
to  liglit  attacks  of  rheumatic  fever. 

Dr.  T.  D.  Griki'ith,  of  Swansea,  regarded  tiie  con- 
dition as  a  symptom  similar  to  eczema,  and  not  a  spe- 
cific disease  like  gout  or  small-pox. 

Dr.  Gimnev,  of  New  York,  advised  tiie  use  of  lK)t 
air  and  of  an  appliance  regulating  the  amount  of  mo- 
tion of  the  joints;  absolute  rest  was  necessary  in  the 
early  stages. 

Du.  Tyson,  of  Philadelphia,  \ised  general  ionic 
treatment,  arsenic,  etc. 

Atony  of  the  Rectum. — Dr.  Gkorck  .Vche.son-,  of 
Gait,  read  a  paper  on  this  subject.  In  the  treatment 
of  these  cases  it  is  of  the  first  importance  to  discover 
and  renidve,   if  possible,  the  cause,  such  as  anv  dis- 


placement of  the  uterus,  a  pelvic  tumor,  etc.  Much 
may  be  accomplished  by  a  hygienic  mode  of  living: 
regular  habits;  attention  to  diet;  using  more  of  the 
coarser  foods,  vegetables,  fruits,  and  fats;  exercise 
in  the  open  air;  cold  bathing;  massage;  drinking 
plenty  of  water,  preferably  hot,  ijefore  breakf a.st :  above 
all  regularity  in  going  to  stool  at  a  certain  time  every 
day.  Purgatives  should  not  be  administered  in  a  rou- 
tine way ;  an  occasional  gentle  laxative  may  be  of  use 
to  stimulate  peristalsis.  A  general  nerve-muscular 
tonic  is  indicated,  such  as  nux  vomica  or  strychnine, 
either  alone  or  combined  with  iron,  aloes,  belladonna, 
and  ipecac.  In  more  obstinate  cases  it  may  be  nec- 
essary to  use  tonic  injections,  such  as  extract  of 
rhatany  dissolved  in  alcohol,  once  a  day.  He  cautioned 
against  large  injections  of  warm  water. 

The  Treatment  of  Diabetes  by  Uranium  Nitrate. 
— Dr.  Kbenezer  Duncax,  of  Glasgow,  in  a  paper  on 
this  subject,  said  that  ten  to  fifteen  grains  had  been 
given  by  Dr.  West  in  the  London  Hospital  with  rather 
favorable  results.  Very  little  has  been  done  in  other 
hospitals.  In  dogs,  cats,  rabbits,  uranium  nitrate  pro- 
duces a  nephritis.  Doses  up  to  fifteen  or  twenty  grains 
in  the  human  patient  produce  no  bad  results  and  may 
1)6  used  for  two  or  three  months. 

Dr.  Tyson  said  it  was  twenty  years  since  he  had 
used  the  drug  until  last  fall,  when  he  tried  it  again  in 
much  larger  closes;  two  grains  three  times  a  day  being 
the  old  dose.  This  last  time  he  gave  five  grains  thrice 
daily.  In  his  cases  diarrhoea  often  resulted  and  his 
results  had  not  been  good. 

Dr.  Saundhy  said  that  in  his  e.xperience  uranium 
was  not  a  specific,  but  it  did  good  in  some  cases,  al- 
though he  had  not  given  such  large  doses  as  fifteen 
grains,  but  had  given  ten  grains  thrice  daily.  Dr. 
Duncan,  in  reply,  said  he  did  not  consider  it  a  spe- 
cific; he  simply  had  stated  what  occurred  when  the 
drug  was  given  in  his  cases. 

Third  Day — Friday,  September  jd. 

Gall  Stones — Dr.  William  Hunter,  of  London, 
opened  the  discussion  on  cholelithiasis,  dealing  princi- 
pally with  tlie  causation  of  that  affection.  He  said 
the  disease  was  a  very  common  one,  aft'ecting  nearly 
seven  percent,  of  the  population.  During  the  preced- 
ing half  century  very  little  had  been  found  out  about  it. 
but  recently  some  light  had  been  thrown  on  the  sub- 
ject. Obstructed  circulation  has  long  been  known  to 
be  a  potent  factor  in  the  production  of  gall  stones. 
Bile  is  a  fluid  of  low  specific  gravity,  composed  of 
water  which  holds  certain  specific  constituents  formed 
by  the  liver  cells  in  solution,  together  with  bile  pig- 
ments and  bile  salts.  Certain  additions  are  made  to 
the  bile  in  its  passage  along  the  bile  ducts  and  ca- 
nals. The  secretion  of  these  passages,  though  for- 
merly considered  a  mucin,  is  really  a  nucleo-albumin. 
The  bile  also  contains  a  small  amount  of  cholesterin 
which  is  held  in  solution  by  the  bile  salts.  The  nu- 
cleo-albumin is  secreted  constantly  in  the  gall  blad- 
der, but  most  actively  four  or  five  hours  after  food 
has  been  taken.  During  digestion  the  exit  of  the 
common  duct  is  closed  and  the  fluid  is  driven  back 
into  the  gall  bladder.  Gall  stones  as  a  rule  are  com- 
posed of  a  centre  of  bilirubin  and  calcium  surrounded 
liv  cholesterin.  Cholesterin  is  a  substance  found  abun- 
dantly in  many  tissues  of  the  bod)'  very  widely  distrib- 
uted. The  cholesterin  of  bile  stones  is  secreted  in  the 
liver  cells  or  is  a  product  of  degeneration  of  the  epithe- 
lial cells  of  mucous  membranes.  In  bile  only  a  very 
small  quantity  is  present,  while  in  phthisical  sputa 
it  exists  in  abundance.  Tlie  inflamed  mucous  mem- 
branes of  the  biliary  channels  and  gall  bladder  are  in 
a  great  measure  the  sources  of  the  cholesterin  of  the 
"all  stones.      IJilirubin  and  calcium  are  found  free  in 


September  25,  1897] 


MEDICAL    RECORD. 


467 


bile,  but  do  not  form  combinations  with  eacli  other  in 
health.  Free  albumin  will  precipitate  them  as  an  in- 
soluble mass  of  bilirubin  and  calcium.  In  inflamma- 
tion of  those  passages  the  necessary  amount  of  the  al- 
bumin is  present  for  that  precipitation.  The  catarrh 
may  be  caused  by  the  stagnation  of  bile  which  oc- 
curs in  man\'  conditions,  (•.^'.,  pregnancy,  tight  lac- 
ing, indolent  habits,  constipation,  etc.  This  stagna- 
tion was  not  sufficient  in  itself  to  excite  inflammation, 
as  the  bile  is  an  aseptic  fluid,  but  it  is  very  liable  to 
infection  by  the  bacillus  coli  communis  from  the  in- 
testine. This  is  not  tiie  only  organism  found  here,  for 
the  typhoid  bacillus  has  frequently  been  found  in  an 
inflamed  gall  bladder  existing  with  typhoid  fever. 
The  chief  indication  of  treatment  is  to  flush  the  bile 
passages.  This  can  be  accomplished  in  the  following 
ways:  (i)  Taking  food;  (2)  Presence  of  bile  salts; 
{3)  The  only  drug  which  would  thin  and  increase  the 
amount  of  bile  was  salicylate  of  sodium.  It  is  better 
given  in  combination  with  Karlsbad  and  Vichy  wa- 
ters. No  drug  has  any  effect  in  dissolving  stones  ex- 
cept olive  oil,  but  this,  when  given  internally,  has  not 
effected  the  desired  results. 

Dr.  W.  Osler,  of  Baltimore,  spoke  of  the  relation 
of  typhoid  fever  to  cholelithiasis.  The  typhoid  ba- 
cillus may  e.xist  in  the  body  without  causing  typhoid 
fever,  resembling  in  that  respect  the  pneumococcus. 
In  one  case  under  observation  the  bacillus  was  found 
in  a  case  of  cholecystitis  in  pure  culture  without  any 
previous  history  of  typhoid  fever.  Orth,  of  Neusser's 
clinic,  said  there  was  an  acute  infection  in  cholelithia- 
sis— enlargement  of  spleen,  albumin  in  the  urine,  etc. 
Sometimes  no  gall  stones  are  found,  as  in  a  case  oper- 
ated on  by  Mayo  Robson.  The  term  "  hepatic  inter- 
mittent fever"  should  be  limited  to  cases  in  which  a 
long  series  of  malaria-like  attacks  occur,  which  may  be 
followed  by  jaundice;  in  the  intermissions  the  patient 
is  perfectly  well.  The  stone  is  probably  in  the  com- 
mon duct  in  those  cases.  Suppurative  fever.  This 
gives  more  alarming  symptoms — chill,  rigors,  etc.  1  )r. 
Osier  said  that  a  great  deal  of  our  knowledge  of  this 
interesting  subject  is  due  to  many  of  the  recent  excel- 
lent papers  by  the  surgeons. 

Dr.  H.  H.\nufori>,  of  Nottingham,  Eng.,  said  he 
had  had  a  large  number  of  cases  of  typhoid  fever 
but  had  never  observed  jaundice  with  that  disease 
and  he  thought  the  condition  must  be  rare.  In 
young  people  gall  stones  occur  but  rarely,  but  he 
had  seen  a  case  in  a  young  girl.  He  saw  a  girl  three 
years  ago  who  had  had  intense  jaundice  one  and  a 
half  years  and  she  was  still  well,  though  the  jaundice 
was  very  marked.  In  biliary  colic  very  many  cases 
are  not  associated  with  the  passage  of  gall  stones,  and 
hence  it  is  infrequent  to  find  these  bodies  in  the 
stools.  Morphine  is  unsafe  when  there  is  intense 
jaundice  and  it  should  be  given,  if  at  all,  carefully. 

Dr.  Baumciarte.n',  of  St.  Louis,  said  that,  with  re- 
gard to  gall  stones  and  cancer,  in  many  cases  the  can- 
cer was  the  primary  condition  and  the  gall  stones  de- 
veloped secondarily,  but  the  reverse  might  occur. 
He  reported  a  case  of  peritonitis  following  perfora- 
tion, in  which,  after  death,  a  very  small  rupture,  ])in 
point  in  size,  was  found,  but  there  was  no  evidence  of 
ulceration.     The  gall  bladder  was  contracted. 

Dr.  Pasteur,  of  London,  Eng.,  spoke  of  the  very 
great  difficulties  of  diagnosis  in  these  cases.  He  re- 
ported a  case  in  which  a  man  of  fiftv-two  years  had 
had  a  very  acute  attack  of  colic  with  se\ere  hama- 
temesis.  He  lost  flesh  rapidly.  No  enlargement  of 
the  liver  or  gall  bladder  could  be  made  out.  The 
speaker  advised  an  operation,  but  no  stones  were 
found.  The  liver  was  contracted  as  well  as  the  gall 
bladder.  After  operation,  however,  the  man  improved 
very  much. 

Dr.  Rogers,  of  Denver,  mentioned  a  case  in  which  a 


young  girl  became  suddenly  attacked  by  colic  and 
rigors.  The  attacks  recurred.  On  operation  there  was 
found  a  contraction  of  the  gall  bladder.  The  operator 
connected  the  gall  bladder  with  the  small  intestine  by 
means  of  Murphy's  button;  death  followed  on  the 
second  day.  He  expected  to  find  peritonitis  at  the  au- 
topsy, but  instead  found  an  obstruction  at  the  lower 
part  of  the  small  intestine.  The  site  of  operation  was 
healthy. 

Dr.  Acheson,  of  Gait,  Ont.,  said  that  there  was  a 
large  quantity  of  lime  salts  in  the  water  around  Gait, 
and  he  had  obser\-ed  that  many  of  his  patients  suffered 
from  bilious  attacks.  He  asked  Dr.  Hunter  if  the 
e.xcess  of  lime  had  anything  to  do  with  the  biliousness. 

Dr.  Stephen  Mackenzie,  of  London,  Eng.,  spoke  of 
the  importance  of  the  investigations  of  Dr.  Hunter. 
A  most  important  fact  was  the  relationship  of  gall 
stones  with  typhoid  fever.  He  said  Osier  had  shown 
that  typhoid  bacilli  might  be  present  in  the  bile  with- 
out producing  any  inflannnation  of  the  bile  passages. 
The  fact  that  no  calculus  can  be  found  in  the  fa;ces 
does  not  prove  that  none  has  been  passed.  In  a  case 
in  which  Dr.  Mackenzie  had  diagnosed  gall  stones 
nothing  was  found  on  operation.  Subsequently  another 
attack  occurred  and  about  one  year  later  the  patient 
came  to  him  in  triumph,  showing  a  stone  which  she 
claimed  to  have  passed. 

Dr.  Hunter,  in  closing  the  discussion,  said  he  did 
not  think  the  association  ofrfyphoid  fever  with  jaun- 
dice was  common,  but  that  it  did  sometimes  occur. 
The  typhoid  bacillus,  however,  had  frequently  been 
found  in  the  gall  bladder  when  stone  existed.  The 
bacillus  coli  communis  was  much  more  common.  He 
said  there  was  no  conclusive  evidence  that  an  excess 
of  lime  in  the  drinking-water  would  produce  chole- 
lithiasis, for  gall  stones  occurred  frequently  in  places 
where  no  lime  existed  in  the  water. 

Pneumonic  Empyema. — Dr.  Angus  Macki.xnon, 
of  Guelph,  Ont.,  read  a  paper  on  the  empyema  of  pneu- 
monia. He  thought  many  cases  of  so-called  abscess 
of  the  lung  were  nothing  more  or  less  than  a  localized 
empyema  which  had  opened  into  a  bronchial  tube. 
He  considered  the  empyema  to  be  due  to  the  pneumo- 
coccus in  the  majority  of  cases.  He  cited  several 
cases  of  this  affection  which  he  had  successfully 
treated. 

Medical  Uses  of  tne  Roentgen  Rays.  —  Dr. 
Francis  H.  Williams,  of  iioston,  read  a  paper  on  this 
subject.  Charts  were  shown  illustrating  the  various 
organs  in  their  normal  position  in  the  healthy  body 
and  then  those  of  various  diseases  such  as  tubercu- 
losis, emphysema,  pleurisy,  etc.,  which  had  been  ob- 
tained by  means  of  the  fluoroscope.  The  excursions  of 
the  diaphragm  in  ordinary  and  deep  inspiration  were 
well  marked.  When  a  pleural  effusion  displaced  the 
heart,  he  said,  that  displacement  could  plainly  be  seen. 
The  fluoroscope  outlined  the  shape  of  the  heart  and 
aorta  quite  plainly,  so  that  aneurisms  or  other  diseases 
could  often  be  detected  when  auscultation  and  percus- 
sion gave  no  signs.  Early  tuberculous  deposits  in  the 
lungs  could  often  be  seen  when  percussion  and  auscul- 
tation revealed  nothing. 

The  Use  of  Terms  to  Indicate  Myocardial 
Changes. — Dr.  Ja.mes  Tyson,  of  Philadelphia,  read  a 
paper  on  this  subject.  The  importance  to  the  clinician 
and  experimenter  of  using  the  same  terms  to  indicate 
like  conditions  is  illustrated  by  the  term  "dilatation" 
as  applied  to  the  heart.  The  word  may  be  applied 
(I)  to  a  condition  of  distention  or  stretching  possible 
within  limits  in  an  organ  whose  walls  are  normal, 
when  overfilled  with  blood,  such  as  occurs  in  an  early 
stage  of  insufficiency  or  stenosis  or  increased  blood 
pressure  from  any  cause;  or  (2)  to  an  organ  which 
has  yielded  as  the  result  of  pathological  weakness. 
This  may  be  acute  or  chronic,  commonly  it  is  chronic. 


468 


MEDICAL    RECORD. 


[September  25,  1897 


To  such  pathological  enlargement  the  term  dilatation 
should  be  restricted,  while  for  the  former  the  word  dis- 
tention is  more  suitable.  It  is  the  first  which  precedes 
hypertrophy,  while  the  second  succeeds  upon  hypertro- 
phy. The  first  stimulates  hypertrophy,  while  the  sec- 
ond is  the  result  of  failing  nutrition  in  a  hypertrophied 
heart.  As  such,  the  term  dilatation  of  the  heart  should 
be  limited  to  a  relative  enlargement  of  one  or  more  of 
its  cavities  associated  with  fatty  degeneration  of  its 
walls  and  consequent  weakening  of  contractile  power. 
Such  walls  may  be  thicker  than  the  normal  walls,  though 
they  are  usually  thinner.  Whence  it  is  doubtful  whether 
the  term  hypertrophy  with  dilatation  should  be  used 
as  synonymous  with  eccentric  hypertrophy,  for  in  the 
latter  condition  the  muscular  integrity  is  unchanged, 
or  at  least  not  degenerated.  For  this,  the  term  hyper- 
trophy with  expansion  might  be  used,  the  term  expan- 
sion to  imply  no  dej;eneration  and  an  active  state, 
while  dilatation  implies  at  once  degeneration  and 
passiveness. 

SKCTION    IN   OBSTETRICS   AND   GYNECOLOGY. 

First  Day —  Wednesday,  September  isf. 

Operation  of  Choice  in  the  Treatment  of  Pelvic 
Disease. — Dr.  F.  Hen'rotin,  of  Chicago,  read  the  first 
paper.  When  the  surgeon,  he  said,  operates  on  a  pus 
sack  in  this  region  he  finds  usually  that  he  has  re- 
moved the  ovar}'.  .\n  ovarian  abscess  is  frequently 
overlooked  when  it  is  the  primaiy^  seat  of  disease. 
Streptococci  are  conveyed  by  certain  channels  di- 
rectly to  the  ovary  and  an  abscess  forms.  With  free 
incision  of  the  abscess  and  drainage  complete  recov- 
ery is  ver)'  probable.  (Jompleteness  of  recovery  de- 
pends on  early  operation.  The  incision  usually 
should  be  made  in  Douglas'  pouch.  The  speaker  had 
made  this  incision  in  one  hundred  and  twenty-five 
cases  with  no  deaths.  Pus  in  the  ovary  should  be  let 
out  as  well  as  pus  in  other  localities.  No  cure  is  pos- 
sible without  operation.  Early  vaginal  incision  at  any 
stage  accomplishes  good  result  in  ninety  per  cent,  of 
cases  if  properly  carried  out. 

Causation  and  Treatment  of  Hyperemesis  Gra- 
vidarum.— Dr.  J.  A.  Templk,  of  Toronto,  read  a  pa- 
per on  tins  subject.  The  great  majority  of  the  views 
regar^"iing  vomiting  of  pregnancy  are  speculative.  It 
is  much  more  frequent  in  primigravid.T?.  The  simple 
morning  sickness  is  functional,  but  pernicious  vomit- 
ing is  associated  with  some  patliological  process.  The 
fatality  is  probably  greater  than  tlie  records  would 
show. 

Most  writers  think  it  is  due  to  reflex  irritation — tlie 
nerve  endings  in  the  uterus  and  ovaries  being  dis- 
turbed in  the  morning  by  the  sinking  of  the  abdominal 
organs,  .\nother  view  is  that  the  cause  is  pressure  of 
the  growing  uterus.  Stretching  of  the  os  has  been 
beneficial  in  some  cases.  Gastric  and  intestinal  ulcers 
are  also  said  to  cause  Ihc  vomiting  of  pregnancy.  .\ 
centre  akin  to  the  vomiting  centre  in  the  medulla  has 
been  made  out. 

Du.  Gii.es,  of  London,  said  he  agreed  entirely  with 
Dr.  Temple.  TJiere  had  been  no  sickness  in  thirty- 
three  per  cent,  of  his  cases.  He  considered  vomiting 
pathological  and  not  physiological.  In  fifty  per  cent, 
there  was  no  sickness  in  tlie  first  three  months.  The 
most  striking  characteristic  was  the  association  of  dys- 
menorrha'a,  and  hence  he  connected  the  nervous  system 
with  this  condition. 

Dr.  Wili.i.am  G..\Rr)NER,of  Montreal,  said  his  expe- 
rience had  been  that  after  the  uterus  had  been  emp- 
tied the  patients  made  rapid  recovery.  Dilatation  of 
the  cervix  may  stop  the  vomiting  at  once,  but  it  fre- 
quently fails.  The  bougie  method  may  also  fail  and 
then  rapid  dilatation  of  the  cervix  must  be  performed. 


Dr.  I.  M.  Lawrie,  of  Weymouth,  Eng.,  said  he  had 
not  been  able  to  find  sufficient  pathological  condi- 
tions, displacements,  etc.,  to  account  for  the  vomiting. 
A  good  rule  which  he  had  followed  was  always  to 
have  a  consultant  with  him  before  inducing  an  abor- 
tion. He  regarded  rapidly  increasing  pulse  and  the 
dark  brown  and  black  vomit  as  dangerous  symptoms 
and  indicating  the  time  for  operation.  He  usually 
tamponed  the  lower  segment  of  the  uterus  for  twent)'- 
four  hours  and  allowed  labor  to  go  on  the  next  day. 

Dr.  Ske.ne,  of  Brooklyn,  said  he  recognized  the 
fact  that  long-continued  functional  disturbance  might 
lead  to  some  pathological  condition.  He  believed  in 
using  nervous  and  gastric  sedatives  first  and  in  the 
event  of  failure  emptying  the  uterus.  Lavage  of  the 
stomach  he  had  tried  with  success  in  some  cases. 

Dr.  Harris,  of  New  York,  considered  the  treatment 
of  this  condition  should  always  be  carried  out  with  re- 
gard to  its  etiology.  Erosion  of  the  cervix  requires 
application  of  nitrate  of  silver  and  in  many  instances 
the  case  may  be  tided  over  without  emptying  the 
uterus.  Slow  dilatation  by  gauze  packing  remaining 
in  utero  over  night  is  better  than  the  rapid  method. 

Dr.  Charles  Jewett,  of  Brooklyn,  regarded  bro- 
mides and  chloral  as  the  best  sedatives  administered 
per  rectum.  It  was  imperative  to  operate  before  the 
stomach  became  much  diseased. 

Dr.  J.  C.  Cameron,  of  Montreal,  said  no  rule  of 
treatment  can  be  formulated  in  this  condition.  We 
treat  our  patient,  not  the  disease.  Interference  is  im- 
perative before  the  patient's  vitality  had  become  so 
impaired  as  to  render  the  operation  useless.  He 
agreed  with  Dr.  Giles  regarding  the  causation  of  this 
condition. 

Second  Day —  Tkiirsday,  September  2d. 

The   Injuries    of   Parturition,    the   Old   and  the 

New Dr.  W.  Japp  Sinclair,  of  Manchester.  Ejig., 

chairman  of  the  section,  said  that  he  had  selected  the 
subject  of  his  address  because  of  the  frequency  with 
which,  as  a  gynecologist,  he  had  been  called  upon  to 
deal  with  injuries  produced  by  parturition,  and  the 
growing  conviction  that  in  many,  if  not  in  the  majority 
of  those  injuries,  their  existence  has  not  appeared  to 
be  altogether  satisfactorily  explained  as  inevitable, 
and  not  a  few  have  been  proved  by  irrefragable  evi- 
dence to  be  produced  by  operative  proceedings  alto- 
gether unwarranted  by  the  circumstances. 

Some  time  last  year  he  was  asked  to  see  a  young 
primipara  who  was  very  ill  toward  the  end  of  the 
first  week  of  the  puerperium.  He  was  infonned  by 
the  practitioner  in  charge  that  the  case  had  been  quite 
straightforward,  from  first  to  last,  and  the  latter  could 
not  in  any  way  account  for  the  patient's  condition. 
On  making  a  physical  examination  without  moving  the 
patient  from  the  dorsal  position,  the  speaker  discov- 
ered a  deep  and  wide  laceration  of  the  vaginal  vault; 
die  examining  finger  passing  easily  into  the  tissues  of 
the  parametrium.  Xo  mention  of  forceps  was  made  in 
the  conversation  before  seeing  the  patient,  and  it  was 
only  after  the  examination  and  in  reply  to  a  question, 
that  the  attending  physician  explained  why  and  when 
they  had  been  applied. 

A  few  years  ago  he  made  several  repairing  opera- 
tions on  the  injured  pudenda  of  a  young  married  wo- 
man. She  had  been  by  all  accounts  perfectly  sound 
and  active  a  year  l>efore.  but  meanwhile  she  had  got 
married  and  she  had  become  a  mother.  The  uterus 
was  found  to  be  completely  prolapsed,  and  it  was  so 
lacerated  that  the  anterior  and  ptTsterior  halves  of  the 
cervix  projecting  from  between  the  nates  looked  like 
two  separate  organs,  and  the  perineum  was  torn  com- 
pletely through  into  the  anus.  This  patient  then 
suffered   from   dislocation    of    the    uterus,  transverse 


September  25,  1897] 


MEDICAL    RECORD. 


469 


laceration  of  the  cervix,  and  complete  rupture  of  the 
perineum.  She  was  treated  by  Emmet's  operation, 
restoration  of  the  perineum,  and  shortening  of  the  round 
ligaments,  and  then  she  was  fairly  comfortable  with  a 
pessar)'.  It  was  learned  aftenivard  that  this  case  had 
been  one  of  normal  labor  in  a  primipara,  and  that  the 
delivery  had  been  effected  instrumentally  within  six 
hours  from  the  commencement  of  the  pains.  Com- 
paring this  sort  of  practice,  still  possible  at  the  pres- 
ent day,  with  what  occcurred  in  a  former  age,  attention 
was  directed  to  the  teachings  of  Mauriceau.  From 
these  a  glimpse  was  given  of  the  helplessness  of  the 
seventeenth  century  in  the  practice  of  obstetrics.  With 
the  resourcefulness  at  the  end  of  this  nineteenth  cen- 
tury it  may  still  be  alleged,  not  without  reason,  that 
there  is  to  be  seen  in  the  contrast  only  one  more  illus- 
tration of  how  '"knowledge  comes,  but  wisdom  lin- 
gers." The  results  of  our  modem  practice  do  not 
make  it  so  perfectly  obvious  that  in  obstetrics  we  are 
much  wiser  than  our  sires.  While  we  have  much  to 
congratulate  ourselves  upon,  yet  we  may  fairly  ask  if 
there  is  not  much  room  for  improvement  in  the  use 
which  we  make  of  our  resources.  He  thought  that  a 
warning  note  should  be  sounded  against  the  too  free 
application  of  surgical  methods  in  g}-necological  prac- 
tice. Surgical  interference  in  midwifery  practice  was 
the  great  provider  of  surgical  work  for  the  gynecologist. 
In  addition  to  the  avoidable  childbed  mortality,  there 
is  the  very  serious  question  of  childbed  morbidity, 
which  is  largely  owing  to  the  abuse  of  the  forceps  in 
the  practice  of  midwifery. 

After  reviewing  the  practice  as  outlined  by  Smellie 
in  the  seventeenth  centurj-,  reference  was  made  to  the 
influence  on  obstetrics  by  Simpson's  introduction  of 
anaesthetics.  Next  came  the  combination  of  anaesthet- 
ics and  antiseptics  and  the  triumphs  of  abdominal 
and  pelvic  surgery  applied  to  the  diseases  of  women. 
.\fter  strongly  protesting  against  the  meddlesome 
and  mischievous  midwifery-  for  which  some  reform,  he 
thought,  was  urgently  required,  figures  were  given 
showing  the  details  of  two  years  of  practice  at  Man- 
chester Maternity  Hospital.  From  these  it  was  seen 
that  the  forceps  deliveries  were  about  1.4  per  cent,  in 
charity  cases,  but  within  the  same  area  of  population, 
and  among  the  class  of  people  who  could  afford  to  pay 
for  private  medical  attendance,  the  proportion  of  for- 
ceps deliveries  was  from  twent}'  to  thirty  per  cent.  Such 
a  striking  contrast  surely  supplied  food  for  reflection 
and  called  for  explanation.  Experience  now  points 
to  the  fact  that  we  have  replaced  the  one  great  injur}" 
of  parturition  in  former  generations — vesico-vaginal 
fistula — by  a  host  of  others,  vesico-vaginal  fistula  by 
laceration  instead  of  by  sloughing  included,  and  it  is 
only  reasonable  to  conclude  that  there  must  be  some- 
thing seriously  wrong  with  our  theories  or  our  practice, 
or  with  both. 

Treatment  of  Fibroids  of  the  Uterus  by  Vaginal 
Ligature  of  the  Broad  Ligament.— Dk.  Fraxklin 
H.  Marti.v,  of  Chicago,  read  a  paper  on  this  subject. 
He  advocated  the  operation  in  cases  of  interstitial 
and  intramural  fibroids  and  considered  it  much  prefer- 
able to  hysterectomy.  He  passed  a  double  silk  liga- 
ture round  the  broad  ligament  about  one  inch  from  the 
uterus,  and  including  the  uterine  artery.  This  opera- 
tion was  usually  successful  in  bringing  about  such 
atrophy  of  the  fibroid  that  parturition  might  go  on  as 
usual. 

Dr.  Hiram  Vineberg,  of  New  York,  submitted  sta- 
tistics showing  a  total  failure  of  the  operation  in  his 
series  of  cases. 

Dr.  Skene,  of  Brooklyn,  advocated  curettage  of  the 
uterus  as  a  proceeding  absolutely  necessary  along  with 
Dr.  Martin's  operation.  He  laid  great  stress  on  the 
treatment  of  the  attendant  endometritis. 

The  Vaginal   Versus   the    Abdominal    Route   in 


Dealing  with  Inflammatory  Conditions  and  Tumors 
in  the  Pelvis.  —  Dr.  E.  W.  Ccshing,  of  Boston,  read 
this  paper.  The  selection  of  either  method  depended 
much  on  the  personal  equation  of  the  operator;  some 
surgeons  being  proficient  in  one  of  the  methods,  some 
in  the  other.  Some  points  in  favor  of  the  vaginal  route 
were  the  absence  of  a  cicatrix,  the  slight  degree  of 
shock,  and  the  lessened  liability  of  wounding  the  in- 
testines and  other  abdominal  organs.  He  advocated 
the  removal  of  fibroid  tumors  through  the  abdomen. 
For  the  cenix  the  vaginal  route  was  preferable  and 
always  when  the  thickness  of  the  abdominal  wall  ren- 
dered the  suprapubic  operation  difficult.  For  p)-osal- 
pinx  with  removal  of  all  the  appendages  either  route 
was  available. 

Dr.  Skene,  of  Brooklyn,  said  he  advocated  twenty 
years  ago  the  employment  of  the  vaginal  route  and 
consequently  was  pleased  to  see  modern  operators  re- 
turning to  his  ideas. 

Dr.  Hanks,  of  New  York,  entered  a  protest  against 
the  practice  of  attacking  a  ruptured  tubal  pregnancy 
through  the  vagina.  He  cited  two  instances  in  which 
uncontrollable  hemorrhage  resulted,  apparently  from 
the  tube  of  the  opposite  side. 

Dr.  Ross,  of  Toronto,  entered  a  strong  protest 
against  the  adoption  of  the  French  method  of  operat- 
ing per  vaginam  and  said  he  still  was  a  warm  advo- 
cate of  the  older  and  safer  abdominal  route. 


Third  Day — Friday,  September  jd. 

Diagnosis  and  Treatment  of  Intxapelvic  Tuber- 
culous Disease Dr.  Ross,  of  Toronto,  presented  a 

paper  with  this  title,  in  which  he  gave  it  as  his  opin- 
ion that  in  the  great  majority  of  these  cases  tubercu- 
losis of  the  intestines  coexisted.  Only  one  case  had 
come  under  his  notice  which  showed  no  intestinal  dis- 
ease. He  discussed  the  diagnosis  of  this  affection 
very  thoroughly  and  laid  great  stress  upon  the  value 
of  the  clinical  thermometer  in  distinguishing  these 
cases  from  hysterical  manifestations.  With  reference 
to  treatment  he  was  disposed  to  doubt  the  theory  that 
air  was  the  curative  factor,  because,  if  this  were  so,  why 
were  the  lungs  and  pleurce  so  frequently  affected  with 
tuberculosis?  He  advocated  abdominal  section  in  the 
great  majorit}-  of  cases.  If  late  operation  is  advisable, 
so  much  the  more  so  is  operation  in  the  early  stages  of 
the  disease.  He  considered  the  cessation  of  men- 
struation and  relief  of  congestion,  consequent  upon  re- 
moval of  tubes  and  ovaries,  as  a  most  important  factor 
in  the  cure. 

Conservative  Treatment  of  the  Ovary.  —  Dr. 
How^\RD  Kelly,  of  Baltimore,  sent  a  paper  which  was 
read,  in  his  absence,  by  the  secretar\%  Dr.  Giles.  He 
entered  a  strong  plea  against  the  modern  practice  of 
removing  ever)'  vestige  of  ovarian  tissue  unnecessarily. 
Coupled  with  the  discussion  on  this  paper  was  one  by 
Dr.  T.  More  Madden,  of  Dublin,  on  the  conser\-ative 
treatment  of  Fallopian-tube  disease. 

Dr.  .\.  P.  Dudley,  of  New  York,  said  he  made  it  a 
rule  to  leave  oehind  as  much  of  the  ovary  and  appen- 
dages as  is  consistent  with  the  cure  of  the  disease. 
He  had  removed  half  an  ovar\',  scraped  out  cysts,  and 
removed  one  ovary  and  one  tube  in  cases  in  which  mod- 
em practice  would  lead  one  to  deprive  the  woman  of 
all  her  genital  organs. 

Dr.  Gordon,  of  Portland,  Me.,  protested  against 
the  ultra-conservatism  of  leaving  the  uterus  after  re- 
moval of  the  appendages.  A.ll  cases  didlDetter  when 
complete  removal  was  persisted  in. 

Dr.  Giles,  of  London,  Eng.,  deplored  the  absence 
of  statistics  showing  the  ultimate  result  of  these  ope- 
rations, as  this,  he  considered,  was  the  only  true  man 
ner  of  determining  their  efficacy  or  otherwise. 


470 


MEDICAL    RKf'ORD. 


[September  25,  1897 


Diagnosis  and  Treatment  of  Retroversion  of 
the  Uterus  with  Fixation. — Dr.  A.  Lapthorxe  Smith, 
of  Montreal,  read  this  paper.  He  thought  the  subject 
of  displacements  was  often  treated  too  lightly  by  most 
men,  but  he  wished  to  call  attention  to  the  importance 
of  this  subject.  Palliative  measures  were  advisable  to 
begin  with,  but  radical  treatment  was  in  many  cases 
necessary.  This  comprised  the  t\vo  operations,  ventral 
fixation  and  Alexander's  operation,  the  technique  of 
which  he  described. 


®0rKjesvaixdeuce. 

OUR    LONDON    LKTTER. 


(Fr 


■  Special  Correspondent.) 


LUNACY        IN       SCOTLAND PRESSURE       ON       ASYLUMS — 

PECULIAR    PEOPLE — BABY     FARMING FATALITIES     IX 

THE  PROFESSION  —  BLACK  SHEEP — AMERICAN   JUBILEE 

FUND MORTALITY    RETURNS. 

London,  September  lo,  1897. 

The  Scotch  lunacy  commissioners  have  just  issued 
their  blue  book,  in  which  the  statistics  show  that  in 
Great  Britain  the  increase  of  certified  limatics  is  as 
noteworthy  in  the  northern  kingdom  as  in  the  south- 
ern. No  doubt  much  of  the  increase  is  due  to  causes 
similar  to  those  in  England.  The  remark  of  Dr.  C. 
Macpherson  in  his  last  report,  that  "a  wider  view  is 
now^  commonly  taken  of  what  constitutes  insanity, 
or  at  least  certifiable  insanity,  than  was  the  case 
twenty  years  ago,"  sums  up  the  situation.  Neverthe- 
less the  progressive  figures  are  calculated  to  give  un- 
easiness and  to  foster  the  alarm  felt  by  some.  On 
January  ist  of  this  year  the  number  of  certified  luna- 
tics in  Scotland  was  14,086,  approaching  to  double  the 
number  in  1874,  viz.,  7,885.  A  continuance  at  the 
same  rate  will  certainly  show  that  in  a  quarter  of  a 
century  the  number  will  have  doubled.  The  increase 
has  been  more  rapid  of  late.  Thus  it  took  four  years 
to  add  the  eighth  thousand  co  the  number  of  1874  just 
quoted.  In  eight  years  the  tenth  thousand  was  passed, 
so  that  in  1886  there  were  10,895.  But  by  1895  there 
were  12,950,  and  in  1896  no  less  than  13,703,  while, 
as  stated  above,  on  the  ist  of  January  last  there  were 
14,086. 

The  great  bulk  of  the  increase  was  naturally  in  pau- 
per lunatics,  as  their  wants  are  met  by  the  law.  In 
fact,  the  poorer  class  of  private  patients  is  less  pro- 
vided for,  as  between  the  rich  and  the  pauper  classes 
tlie  accommodation  of  the  asylums  is  fully  taken  up. 
Contracts  have  been  entered  into  for  the  reception  by 
the  asylums  of  the  paupers  of  certain  districts,  while 
the  excellent  provision  attracts  wealthy  patients  from 
a  distance — even  from  England  and  Ireland.  This 
accounts  for  the  difficulties  of  the  less  affluent  private 
patients  in  finding  accommodation,  and  it  is  suggested 
that  legislation  might  meet  the  case  by  authorizing 
district  boards  to  provide  for  such  private  patients. 

.\  coroner's  jury  has  returned  a  verdict  of  man- 
slaughter against  one  of  the  "  Peculiar  People" — a 
sect  which  is  founded  on  the  literal  interpretation  of 
a  passage  in  St.  James'  Epistle,  directing  the  elders 
to  anoint  the  sick,  etc.  The.se  people  therefore  refuse 
all  medical  aid  to  themselves  and  their  children.  The 
coroner  told  the  father  he  was  bound  by  law  to  call  in 
a  doctor,  and,  if  his  neglect  to  do  so  accelerated 
death,  he  was  liable  to  punishment;  his  religion  had 
nothing  to  do  with  the  matter.  Evidence  was  ofiered 
that  medical  aid  would  have  prolonged  the  child's  life. 
.\s  the  father  is  committed  for  trial,  we  may  expect  an 
authoritative  statement  of  the  law  on  the  subject. 

The  county  council  seems  to  be  exercising  its  con- 
trol   over    baby    farming    with    commendable   vigor. 


The  annual  report  of  the  committee  charged  witli  this 
work  shows  that  under  the  act  sixty  houses  were  regis- 
tered during  the  year  for  keeping  infants.  A  watch 
was  kept  on  newspaper  advertisements  oft'ering  to  take 
infants,  man)'  were  answered,  and  the  cases  followed 
up.  The  inspectors,  it  seems,  keep  in  touch  with  the 
police,  the  registrars  of  births  and  deaths,  and  with 
other  officials  whose  duties  bring  them  into  contact 
with  infants  separated  from  their  parents.  In  all, 
twenty-four  hundred  and  thirty-seven  reports  were 
made  as  to  the  investigations  made  by  the  inspectors 
during  the  year,  and  fifteen  persons  were  found  to 
have  broken  the  law.  Proceedings  were  taken  against 
four  of  these,  but  it  does  not  appear  why  the  others 
should  not  have  been  prosecuted.  It  is  the  fear  of 
prosecution  which  is  the  chief  deterrent,  and,  as  it  is 
generally  admitted  that  the  law  is  good,  I  fail  to  see 
why  the  council  should  not  take  proceedings  in  every 
case  of  breach  of  the  law. 

Some  sad  fatalities  have  lately  occurred.  Dr. 
Starkey  Smith,  of  Warrington,  expired  suddenly  while 
attending  to  a  patient.  He  was  well  known  and  was 
a  magistrate  for  Warrington.  Dr.  E.  Barber,  of 
Sheffield,  also  died  suddenly  as  he  was  leaving  the 
dining-room  after  dinner.  He  was  only  twenty-nine 
years  old.  Dr.  Wyllie,  of  Elie  on  the  coast  of  Fife, 
met  with  his  death  by  drowning  while  bathing  last 
week.  He  was  an  expert  swimmer,  but  was  appar- 
ently seized  with  syncope  or  cramp,  and  carried  away 
by  a  current  before  assistance  could  reach  him.  The 
wife  of  Dr.  Bryan,  of  Northampton,  has  also  met  a 
tragic  end  under  strange  circumstances  while  return- 
ing home  by  rail.  She  was  last  seen  alone  in  a  first- 
class  carriage,  but  on  its  arrival  the  carriage  was 
found  empty.  Search  along  the  line  was  made,  and 
the  body  found  horribly  mutilated.  Dr.  Lammiman, 
of  Tunbridge  Wells,  was  in  a  railway  accident  when 
four  carriages  rolled  over  an  embankment.  He  es- 
caped with  minor  injuries  in  an  unaccountable  man- 
ner, and  after  recovering  from  a  dazed  state  was  able 
to  render  his  services  to  those  who  were  more  injured. 

Sadder,  in  one  sense,  are  cases  in  which  doctors 
have  been  charged  with  fraud  or  crime.  There  is 
one  now  under  investigation,  in  which  a  charge  of 
wholesale  swindling  by  a  surgeon  in  conjunction  with 
a  "titled  lady"  is  made.  Another  surgeon  is  accused 
of  bigamy.  The  details  are  unsavory.  Such  aggra- 
vated cases  are  sometimes  cited  as  a  disgrace  to  the 
profession,  but  they  are  very  few  in  proportion  to  the 
numbers  on  the  register  when  compared  with  other 
classes  of  the  community.  Still  every  one  is  to  be  la- 
mented, and  one  can  only  say  with  the  old  proverb, 
"There  are  black  sheep  in  every  flock."  When  they 
are  mentioned  to  me,  I  point  to  the  great  roll  of  those 
of  the  profession  whose  names  are  everj'where  honored 
as  among  the  benefactors  of  the  race  and  "the  excel- 
lent of  the  earth." 

The  committee  of  the  American  Victoria  jubilee 
fund  has  sent  _£  1,000  to  Guy's  Hospital,  to  endo^v  in 
perpetuity  a  "Queen  Victoria  bed."  Another  sum  of 
like  amount  has  been  sent  to  the  London  Hospital  on 
the  same  condition,  and  a  third  thousand  to  Charing 
Cross  Hospital. 

The  London  mortality  last  week  was  twenty  per 
thousand,  including  in  the  total  deaths  twenty-eight 
from  diphtheria.  There  was  no  death  registered  from 
small-pox  in  London  or  any  of  our  large  towns. 


Tinea  Favosa.— After  washing  with  green  .soap  and 
shaving  the  scalp  apph-: 

H  Ac.  carbol., 

Hals.  Peruvian in  I  iiss. 

Petrolci. 

( Ilyierini ia  3  iij. 


September  25,  1897] 


MEDICAL    RECORD. 


471 


A   SCHOOL   FOR   FAVUS  CHILDREN. 


To 


Editor  of  the  Me 


Sir:  In  the  hope  that  it  may  be  possible  to  secure 
educational  facilities  for  the  large  number  of  children 
excluded  from  the  schools  by  the  recently  organized 
system  of  inspection,  I  ask  for  a  brief  space  in  the 
Medical  Record  and  bespeak  its  influential  co-oper- 
ation. Several  years  ago  I  began  to  realize  the  dan- 
gerous increase  in  the  number  of  contagious  scalp  dis- 
eases in  the  public  schools,  and  sought  to  interest  the 
school  authorities  in  the  matter  of  establishing  some 
system  of  inspection  and  exclusion.  U'hen  the  pres- 
ent system  to  shut  out  contagious  diseases  was  put  into 
operation,  I  was  much  gratified  to  learn  that  the  scalp 
was  to  come  in  for  its  due  share  of  scrutiny. 

The  result  has  been  that  already  dispensaries  in 
certain  quarters  of  the  town  are  overrun  with  ring- 
worm, pediculosis,  and  favus  cases,  detected  and  sent 
home  by  the  wide-awake  school  inspectors.  Naturally 
few  of  the  favus-affected  children  can  or  should  be  al- 
lowed to  return  to  school  for  a  year  at  least,  even  if 
they  can  be  forced  to  carry  out  treatment;  while 
many  with  scalp  ringworm  cannot  get  a  clean  bill  of 
health  for  perhaps  a  like  period,  or  at  least  for  many 
months. 

It  is  for  this  class  that  I  would  urge  the  establish- 
ment of  one  or  more  schools,  where  not  only  can 
their  education  be  continued,  but  where  treatment  can 
be  inforced  until  a  permanent  cure  is  established.  .\s 
conditions  now  exist,  there  is  danger  of  driving  these 
children  out  of  the  schools  into  occupations  in  which 
their  affections  will  still  endanger  others. 

So  far  as  my  personal  experience  goes,  it  is  ex- 
tremely difficult  to  keep  victims  of  favus  sufiiciently 
long  under  treatment  outside  of  or  even  in  an  institu- 
tion if  parents  can  remove  them  at  will. 

Charles  W.  Allen,  M.D. 

i2«  East  Sixtieth  Stkket. 


THE  SOCIAL  SIDE    OF   THE    MOSCOW   CON- 
GRESS. 

CFrom  our  Special  Correspondent.^ 

St.  Peteksbibg,  .August  30,  1897. 

The  series  of  social  events  arranged  to  make  the  Stay 
of  the  members  of  the  International  Medical  Congress 
an  agreeable  one  came  to  a  close  to-night  with  a  recep- 
tion given  by  the  physicians  of  St.  Petersburg  in  the 
Nobles'  Club.  The  three  days  since  the  close  of  the 
congress  have  been  crowded  with  social  events  gotten 
up  for  the  visitors.  There  was  an  excursion  to  tlie 
islands  by  steamboat  on  the  Neva  and  the  Grand 
Nevka  on  Saturday  afternoon,  with  the  promenade  in 
the  botanical  gardens,  at  which  many  of  the  high- 
est Russian  aristocracy  were  present  and  the  wants  of 
the  inner  man  not  forgotten.  On  Sunday  aftemooon 
there  was  an  excursion  to  the  palace  at  Peterhof,  with 
the  view  of  the  grounds,  the  palace,  and  the  magnifi- 
cent fountains,  and  a  royal  spread  for  which  the  two 
hours'  ride  over  the  Gulf  of  Finland  had  properly 
whetted  the  appetites  of  the  invited  guests.  Then  on 
.Monday,  beside  the  soiree,  there  was  lunch  at  the  In- 
stitute of  Experimental  .Medicine  and  a  chance  to  see 
the  magnificent  laboratories  for  experimental  re.search 
in  everything  connected  with  medicine  that  are  here  so 
[Perfectly  equipped.  .\11  this  in  a  city  almost  a  thou- 
sand miles  away  from  where  the  congress  was  held, 
the  railroad  tickets  to  and  fro  costing  nothing  and 
many  of  the  visiting  doctors  being  lodged  absolutely 
free  of  expense  in  various  public  institutions  of  the 
capital.  It  is  a  fitting  climax  to  tlie  succession  of 
agreeable  surprises  that  Russian  hospitality  has  pre- 
pared for  her  medical  visitors  since  tliey  reached  the 


frontier.  Most  people  were  a  little  anxious  about  how 
this  putting  one's  self  into  the  grasp  of  the  Russian 
bear  was  going  to  turn  out;  but  from  the  moment 
when  at  the  frontier  the  medical  committee  smoothed 
out  all  difficulties  as  to  passports,  luggage,  and  cus- 
toms, there  has  been  coming  the  gradual  realization 
that  bruin's  hug  is  a  hearty,  cordial  one,  and  emi- 
nently friendly  and  hospitable.  This  has  been  true 
not  in  Moscow  and  St.  Petersburg  only,  but  every- 
where that  members  of  the  congress  stopped  for  even 
a  day.  Visitors  from  the  south  cannot  speak  highly 
enough  of  their  cordial  reception  by  the  committee  at 
Odessa  or  of  their  pleasant  hours  in  Kiev,  the  Jerusa- 
lem of  Russia,  under  the  friendly  care  of  brotherly 
and  (may  we  add  ?)  sisterly  solicitude.  It  was  the  same 
thing  at  Warsaw  and  at  points  off  the  main  lines  where 
members  stopped  for  a  day  or  two. 

The  arrangements  at  Moscow  itself  were  excellent, 
and  too  much  cannot  be  said  in  praise  of  the  general 
committee  for  the  excellent  way  in  which  it  accom- 
plished the  immense  task  of  handling  the  ten  thou 
sand  visitors  to  the  congress.  The  Manege — a  huge 
building  meant  for  manoiuvres  and  about  five  hundred 
by  one  hundred  and  twenty  feet — made  an  e.xcellent 
place  of  reunion  for  the  midday  lunch,  where  one  could 
meet  one's  friends  and  learn  the  news.  The  magnifi- 
cent Imperial  Theatre,  with  a  seating-capacity  of  over 
four  thousand,  made  an  ideal  assembly  hall  for  the 
general  sessions  and  such  as  cwild  be  supplied  bv  but 
few  cities  of  the  world. 

The  general  impression  produced  on  the  members 
of  the  congress  is  an  excellent  one,  and  every  one  is 
perfectly  free  in  confessing  how  agreeably  he  has  been 
surprised  by  the  extent  to  which  Russian  hospitality 
has  gone  in  providing  entertainment  for  us.  We  have- 
been  the  nation's  guests  and  have  been  made  to  feel  it. 
Every  Russian  seems  to  have  felt  it  a  personal  duty  to 
do  his  little  mite  to  help  produce  a  favorable  impres- 
sion on  the  Western  visitors,  who  for  the  first  time 
found  themselves  in  considerable  numbers  in  his  sup- 
posedly Oriental  country.  The  cordiality  of  the  peo- 
ple was  noteworthy,  and  manifested  itself  in  the  ex- 
tremest  readiness  to  be  of  help  when  the  difficulties  of 
the  Russian  tongue  paralyzed  our  efforts  at  being  un- 
derstood by  cabman,  shopkeeper,  or  passerb'' .  With- 
out exception,  it  is  with  feelings  of  deepest  apprecia- 
tion for  all  this,  and  of  lasting  gratitude  for  kindness 
from  our  "stranger  hosts,"  that  the  members  of  the 
congress  take  their  leave. 

But  we  have  learned  more  than  the  lesson  of  grati- 
tude. We  have  seen  the  magnificent  medical  institu- 
tions of  Moscow  and  St.  Petersburg,  and  we  have 
learned  to  appreciate  how  much  the  Russians  are  do- 
ing for  scientific  medicine.  Moscow,  after  all.  most 
of  us  thought  of  as  a  thoroughly  mediaeval  place,  whose 
hospitals  and  clinics  doubtless  smacked  of  antiquity. 
The  visit  to  the  university  clinics  was  a  revelation — 
one  after  another  piles  of  magnificent  buildings, 
none  of  them  more  than  ten  years  old,  all  of  them 
thoroughly  up  to  date;  the  gynaecological  and  ophthal- 
mological  clinics  and  the  Pathological  Institute,  beau- 
tiful structures  architecturally  and  arranged  to  facili- 
tate the  very  best  scientific  work  in  these  branches, 
all  of  the  university  clinics  spread  out  over  acres  and 
acres  of  ground,  magnificently  lighted,  airy,  and  com- 
fortable, up  to  date  in  every  respect. 

Here  in  St.  Petersburg  was  the  same  story  almost  to 
tell.  Money  has  been  no  object  in  providing  clinical,, 
scientific,  and  teaching  facilities  of  the  highest  order 
— the  culmination  of  it  all  to  be  seen  in  the  magnifi- 
cent Institute  of  Experimental  Medicine,  which  has 
nothing  to  compare  with  it  in  the  world.  Here,  on 
ample  grounds  on  a  large  arm  of  the  river,  is  a  series 
of  buildings,  all  with  one  exception  erected  for  the 
purpose,  in  which  all  branches  of  science  connected 


472 


MEDICAL    RECORD. 


[September  25,  1897 


with  medicine  may  be  studied  practically.  Everything 
— materials,  cultures,  even  animals — is  supplied  and 
cared  for  by  the  institute ;  the  student  works  under  the 
direction  of  a  distinguished  professor,  and  the  charges 
for  the  year  are  only  25  rubles  ($13)!  The  internal 
arrangements,  the  mechanical  appliances,  even  to  rail; 
ways  and  elevators  for  the  transportation  of  animals, 
the  bathing  and  sterilizing  apparatus,  the  operating- 
rooms,  the  kennels — everj'ihing  is  most  perfect  and 
nothing  seems  to  have  been  forgotten. 

Can  anything  good  come  out  of  Russia?  the  medi- 
cal scientific  world  might  have  asked  some  years 
ago;  but  now  the  answer  to  the  question  is  obvious: 
some  of  the  best  scientific  work  is  being  done  here. 
The  Western  visitor  to  the  congress  was  sometimes, 
I  think,  conscious  in  the  applause  given  at  the  sections, 
and  in  their  relations  to  one  another  outside,  of  a 
closer  bond  of  union  between  the  Russians,  the  Poles, 
and  the  Bohemians,  than  between  the  other  members. 
They  are  the  representatives  of  the  Slav  races  of  Eu- 
rope to-day.  There  is  an  impression  among  them  that 
the  future  is  theirs.  The  Celts  and  the  Teutons  have 
had  their  day,  and  are  degenerating;  the  descendants 
of  the  Romance  nations  need  scarcely  be  counted  with 
at  all ;  and  so  must  come  from  the  East  once  more  a 
people  whose  acme  of  culture,  civilization,  and  science 
shall  represent  the  latest  step  in  the  world's  evolution. 
Such  is  their  dream. 


pXedicaX  ^^ism& 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  September  18,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. .  . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox . 


268 

Sq 

33 

65 

6 

5 

I 
28 

3 

119 

21 

Medical  Practice  in  Washington. — There  have  been 
much  discussion  and  correspondence  in  regard  to  the 
custom  of  some  town  doctors  visiting  health  resorts 
in  New  England  and  there  practising.  The  resident 
medical  men  have  complained  loudly  of  the  injustice 
of  this  procedure.  A  Washington  correspondent  of 
the  Atlantic  Medical  Weekly  presents  in  a  long  letter 
the  reverse  of  this  picture,  that  is  to  say,  the  view  of 
the  question  as  taken  by  a  tovi'n  physician.  From  the 
subjoined  account  it  would  seem  that  the  lot  of  the 
average  medical  man  is  not  a  happy  one.  "  Boston 
practitioners  complain  of  oversupply  because  of  one 
physician  for  every  five  hundred  inhabitants.  Here 
we  have  one  for  every  two  hundred,  not  to  mention 
numerous  "sundowners,"  faith  curists.  Christian  sci- 
entists, and  other  advertising  charlatans.  Bright  men, 
with  the  qualifications  of  both  home  and  European 
education,  are  languishing  at  the  prospect  before  them 
of  conspicuous  failure  and  are  not  making  enough  to 
supply  the  bare  necessities  of  life.  I  know  of  one 
poor  struggling  fellow,  a  qualified  man  of  good  hab- 
its, who  passed  Christmas  week  with  no  gas  or  coal  in 
his  house,  while  he  and  his  family  subsisted  during 
that  season  on  corn  meal  and  hot  water  exclusively. 
Next  to  the  free-dispensary  abuse  which  we  have  with 
us  in  full-blown  proportions  one  of  the  most  serious 


things  a  Washington  physician  has  to  contend  with  is 
the  matter  of  collections.  It  is  said  that  the  laws  of 
the  district  seem  to  have  been  framed  with  a  view  to 
prevent  the  collection  of  honest  debts.  Add  to  this 
the  fact  that  the  pay  of  government  employees  cannot 
be  attached  or  garnisheed,  and  the  virtual  protection 
afforded  them  by  heads  of  departments  almost  places 
a  premium  on  dishonesty  and  increases  the  difficulty 
among  many  victims.  I  know  of  one  practitioner  who 
has  more  than  three  thousand  dollars  in  small  bills 
which  he  cannot  get  from  delinquent  government 
clerks. "' 

The   First   Medical   Degree   in   New  England 

Dr.  Francis  R.  Packard  writes  in  the  Journal  of  tfu 
American  Medical  Association  that  the  first  medical  de- 
gree granted  in  these  parts  was  an  honorary  one,  be- 
stowed on  Daniel  Turner,  of  Connecticut,  by  Yale 
College  in  1720.  As  this  was  intended  as  a  token  of 
gratitude  for  Dr.  Turner's  liberal  gifts  to  the  college 
and  not  as  a  recognition  of  any  particular  fitness  on 
his  part  to  practise  medicine,  a  wit  of  the  time  inter- 
preted M.D.  to  signify  mill  turn  donavit. 

Smoke. — At  a  debate  on  smoking,  among  the  mem- 
bers of  the  British  Association,  many  speakers  de- 
nounced and  others  advocated  the  practice.  Professor 
Huxley  said :  "  For  forty  years  of  my  life  tobacco  has 
been  a  deadly  poison  to  me.  [Loud  cheers  from  the 
antitobacconists.]  In  my  youth,  as  a  medical  stu- 
dent I  tried  to  smoke.  In  vain;  at  every  fresh  at- 
tempt my  insidious  foe  stretched  me  prostrate  on  the 
floor.  [Repeated  cheers.]  I  entered  the  navy ;  again 
I  tried  to  smoke  and  again  met  with  a  defeat.  I  hated 
tobacco.  I  could  almost  have  lent  my  support  to  any 
institution  that  had  for  its  object  the  putting  of  tobacco 
smokers  to  death.  [Vociferous  applause.]  A  few  years 
ago  I  was  in  Brittany  with  some  friends.  We  went  to 
an  inn.  They  began  to  smoke.  They  looked  very 
happy  and  outside  it  was  very^  wet  and  dismal.  I 
thought  I  would  try  a  cigar.  [Murmurs.]  I  did  so. 
[Great  expectations]  I  smoked  that  cigar;  it  was 
delicious!  [Groans.]  From  that  moment  I  was  a 
changed  man;  and  now  I  feel  that  smoking  in  moder- 
ation is  a  comfortable  and  laudable  practice,  and  is 
productive  of  good.  [Dismay  and  confusion  of  the 
antitobacconists.  Roars  of  laughter  from  the  smokers.] 
There  is  no  more  hannin  a  pipe  than  there  is  in  a 
cup  of  tea.  You  may  poison  yourself  by  drinking  too 
much  green  tea  and  kill  yourself  by  eating  too  many 
beefsteaks."  [Total  rout  of  the  antitobacconists  and 
complete  triumph  of  the  smokers.] 

Dipping  Cattle  as  a  Remedy  for  Texas  Fever. — 
A  somewhat  novel  series  of  experiments  is  being  tried 
in  the  case  of  cattle  suftering  from  Texas  fever,  and 
one  which  is  stated  to  have  been  followed  by  most 
satisfactory  results.  For  some  considerable  time  there 
has  been  in  Kansas  a  rigid  quarantine  against  cattle 
from  the  Texas-fever  district.  It  has  lately  been  dis- 
covered that  ticks  were  the  means  of  spreading  the 
contagion,  but  that  by  dipping  the  cattle  these  have 
been  got  rid  of.  The  experiments  of  dipping  cattle 
for  the  destruction  of  ticks  were  undertaken  at  the 
agricultural  experiment  station  of  the  University  of 
the  State  of  Missouri,  at  Columbia,  Mo.  Mr.  R.  I. 
Kleberg,  the  manager  of  the  Santa  Gertrude  ranch, 
constructed  a  dipping-vat  large  enough  to  allow  the 
complete  immersion  of  a  full-grown  animal.  Many 
preparations  of  different  kinds  are  used  in  which  to 
dip  the  cattle,  the  most  successful  being  a  mixture  of 
certain  oils  containing  a  small  proportion  of  carbolic 
acid.  At  Fort  Worth  the  cattle  are  being  dipped  in 
chloro-naphthol.  The  experiment  there  is  being  con- 
ducted by  the  department  of  animal  industry. 


Medical  Record 

A  Weekly  Journal  of  Medicine  and  Surgery 


Vol.  52,  No.  14. 
Whole  No.  1404. 


New  York,   October    2,    1897. 


$5.00  Per  Annum. 
Single  Copies,  lOc. 


©riginat  |trticXes. 

KATATONIA  (KATATOXIE  OK  KAHLLALM 
—  KATATONISCHE  VERRUCKTHEIT  OF 
SCHULE).' 

I!V    FKKDERICK    rETEKSON,    M.U., 


<MKRI.V  FIKSr  ASSISTANT  PHYSICIAN  AT  THE  HUDSON'  KIVEK  S 
HOSPITAL  FOR  THE  INSANE  ;  CUNICXL  PROFESSOR  OF  INSANITY  IN 
women's  medical  COLLEGE  OF  THE  NEW  YORK  INFIRMARY  ;  CONSn 
PHV-ilCIAN   TO  THE   MANHATTAN  STATE   HOSPITAL  FOR  THE   INSANF., 


CHAREES    H.    LANGUON,     M.D. 

POUGHKEEPSIE,    N.    Y., 
SICIAN    AT  THE    IICUSUN    RIYER    STATE 


OND  ASSISTANT 


History. —  Katatonia,  derived  from  the  Greek  word 
xaxaTtijiii,  meaning  "  I  stretch  tightly,"  is  a  term  ap- 
plied to  a  certain  group  of  ps)-chical  and  motor  symp- 
toms presently  to  be  described,  which  has  often  been 
considered  as  constituting  a  new  and  distinct  form  of 
insanity.  There  is,  however,  a  great  diversity  of 
opinion  in  regard  to  this.  This  opinion  \vas  first  held 
by  Kahlbaum,  of  Gorlitz,  who  wrote  and  discussed  the 
subject  fully  in  a  monograph  which  he  published  in 
Berlin  in  1874.  Dr.  Kiernau,  in  an  article  on  kata- 
tonia, published  in  1882,  mentions  that  Meynert,  two 
years  before  Kahlbaum,  described  the  syndrome  as  a 
''  peculiar  form  of  melancholia  attonita,"  as  "charac- 
terized by  a  series  of  flu.xionary  excitations,  toned 
down  by  coexistent  cerebral  pressure,  microscopic  ex- 
udations, ventricular  dropsy,  and  perhaps  premature 
ossification  of  the  sutures.  From  these  will  result 
forced  and  theatrical  activities  on  the  part  of  the  ]5a- 
tient.  The  convulsive  state  indicates  the  control  of 
the  irritative  factors;  the  cataleptoid  conditions,  the 
triumph  of  the  depressing  factors.  The  ideas  of 
grandeur  following  upon  stupor  are  the  results  of  ideas 
previously  caused  by  rtuxionary  conditions." 

Katatonia  has  been  defined  by  .Spitzka  (18831  as 
"a  form  of  insanity  characterized  by  a  pathetical  emo- 
tional state  and  verl)igeration,  combined  with  a  con- 
dition of  motor  tension."  To  this  Dr.  Nolan  would 
add,  "running  a  quasi-cyclic  course  of  expansion, 
hysteria,  and  stupor,"  stating  that  this  "would  help 
to  define  the  disease  in  unmistakable  terms." 

Katatonia  commences  with  headache,  usually  occip- 
ital, insomnia,  a  general  feeling  of  mental  distress  and 
uneasiness,  followed  sooner  or  later  by  an  attack  of 
convulsions,  epileptiform  in  character,  or  a  condition 
of  excitement  or  melancholia  agitata.  This  is  soon 
followed  by  a  condition  of  rigidity  and  immobility — 
the  "attonita"  stage.  Recovery  may  now  take  place 
or  the  patient  may  drift  into  a  condition  of  terminal 
dementia.  .\s  already  stated,  authors  and  alienists 
are  not  in  accord  as  to  whether  katatonia  should  or 
should  not  l)e  placed  as  a  distinct  form  among  mental 
diseases.  The  following  are  some  of  the  most  impor- 
tant opinions  that  have  been  expressed  on  this  suliject : 

Dr.  Arndt,  in  a  paper  read  before  the  meeting  of  the 

'  Ke.a<l  before  the  .\mericaii  Medico-Psychological  .\ssoci.iiiciii. 
May  13,  l8y7. 


Psychological  Society  of  lierlin,  1874,  said  that  he 
agreed  to  an  extent  with  Kahlbaunvs  theories,  but  that 
he  did  not  accept  katatonia  as  a  new  form  of  psychic 
disease.  He  said  that  katatonia  may  have  the  most 
varying  causes  and  relations,  and  cannot  therefore  be 
considered  a  special  form  of  disease. 

Dr.  Ewald  Hecker  says  that  Kahlbaum's  statements 
and  clinical  diagnostic  methods  are  excellent  and  re- 
liable, and  he  discusses  the  subject  in  full,  its  etiology, 
symptoms,  etc.,  and  he  reports  two  cases  in  a  paper 
which  he  published  in  the  AUgctn.  Zcitschr.J.  Psych., 
vol.  33,  1877.  In  the  same  volume  of  the  AUgem. 
Zcitschr.J.  Psych.,  Dr.  Brosius  discusses  this  subject. 
He  says  that  the  "  symptomatic  entity"  of  the  mental 
disturbances  joined  together  under  the  name  of  kata- 
tonia is  specific,  and  that  the  separation  of  katatonia 
as  a  distinct  form  of  disease  is  thereby  justified. 

Dr.  James  G.  Kiernan,  in  the  same  year,  1877,  pub- 
lished an  article  on  katatonia  as  a  clinical  form  of 
insanity,  in  the  American  JoKriial  of  Insanity.  He 
considers  that  katatonia  is  entitled  to  a  distinct  place 
as  a  form  of  insanity,  so  far  as  frequenc}^  of  occurrence 
gives  any  right  to  the  same.  He  gave  in  this  paper  an 
account  of  some  thirty  cases.  In  1882  he  published 
an  important  article  on  this  subject  in  the  Alienist 
and  A-eiiroIogisf,  and  in  1884  a  third  article  in  the 
Detroit  Lancet. 

In  1878  Professor  Westphal  discussed  this  subject 
in  a  paper  in  the  Allgem.  Zeitschr.J.  Psych.,  and  said 
that  clinicians,  in  the  effort  to  study  and  separate 
mental  diseases,  are  apt  to  be  narrow  in  one  way  or 
another,  and  that  this  was  true  of  Kahlbaum  in  re- 
spect to  his  study  of  katatonia.  He  thought  that 
Kahlbaum's  katatonics  were  insane  patients  exhibiting 
variations  in  the  manner  of  development  of  their  in- 
sanity and  variations  in  the  subsequent  course  of  its 
psychical  manifestations.  He  did  not  consider  the 
manifestations  which  Kahlbaum  declared  to  be  specific 
to  be  such,  nor  that  they  were  entitled  to  a  place  in 
the  clinical  group.  He  further  said  that  Kahlbaum 
"mistakenly  ascribes  a  spasmodic  cliaracter  to  these 
manifestations." 

In  1878  Dr.  N.  B.  Donkersloot  wrote  an  article,  in 
which  he  said  that  katatonia  should  be  used  as  a  name 
for  a  certain  set  of  cases,  the  principal  symptom  being 
incai^acity  of  action  from  disturbance  in  cerebro-motor 
centres,  and  stated  that  it  often  complicated  nervous 
diseases,  such  as  catalepsy,  hysteria,  epilepsy,  melan- 
cholia with  stupor,  etc.,  so  that  to  give  it  a  special 
etiology  and  treatment  was  not  well  possible. 

Dr.  Tigges,  in  the  Allgem.  Zeitschr.  J.  Psych.,  1878, 
discussed  one  hundred  and  four  cases  of  melancholia 
with  stupor,  and  said  tiiat  he  could  not  agree  \^ith 
Kahlbaum's  scheme  of  katatonia,  but  that  it  stood  on 
an  equal  footing  with  the  other  fonns  of  melancholia, 
and  at  times  ran  into  them:  that  it  showed  the  symp- 
toms of  such  transition  forms,  and  was  connected,  as 
were  the  other  forms  of  melancliolia.  in  multiple  ways 
with  other  psychical  groups. 

Dr.  von  Reinecker,  in  a  discussion  published  in  the 
All.g-m.  Zeitschr.  J.  Psych.,  in  1880,  said  he  did  not 
believe  that  katatonia  should  he  considered  a  distinct 
clinical  form  of  insanity. 

Dr.  Sander,  of  Dalldort,  and  Dr.  .Mendfl,  of  lUiiin. 


474 


MEDICAL    RECORD. 


[October  2,  1897 


in  the  same  article,  expressed  their  opposition  to  plac- 
ing katatonia  in  the  list  of  separate  mental  diseases. 

In  188 1  Dr.  Hack  Tuke,  in  a  paper  on  "Mental 
Stupor,"  published  in  "Transactions  of  the  Interna- 
tional Medical  Congress,"  London,  vol.  3,  said  he 
Uiought  that  Kahlbaum,  in  making  the  disorders  of 
motility  the  essential  part  of  the  malady,  carried  his 
views  too  far.  The  morbid  mental  state  conditioned 
the  motor  trouble,  and  it  was  right  to  take  the  former, 
not  the  latter,  as  a  basis  of  classification.  It  was  im- 
portant, however,  to  bring  the  motor  and  psychical 
troubles  into  relation.  In  conclusion,  he  summed  up 
by  saying  that  he  thought  "the  cataleptic  variety  of 
mental  stupor  (and  probably  other  varieties  also)  was 
a  condition  to  be  regarded  as  caused  by  the  exclusive 
direction  of  the  mind  upon  a  melancholy  delusion;  or. 
if  this  be  absent,  by  brain  exhaustion  due  to  various 
causes  calculated  to  paralyze  volition  and  allow  of 
involuntary  action." 

In  188 1  Dr.  M.  E.  Fink,  in  the  AU};cm.  Zcitschr.J. 
Psych.,  wrote  an  article  recognizing  katatonia  and 
giving  the  differential  diagnosis  of  it  and  hebephrenia. 
In  1882  Dr.  Karl  Laufenauer  gave  two  cases  of  kata- 
tonia in  the  Pest,  miuf.-c/iir.  Presse,  and  this  author 
evidently  accepted  Kahlbaimi's  definition  of  kata- 
tonia. In  the  same  journal,  18S2,  Dr.  Eugene  Kon- 
rad  accepted  Kahlbaum's  theories  in  part,  but  thought 
K.ahlbaum  went  too  far  in  considering  all  psychoses 
exhibiting  katatonic  symptoms  as  phases  of  katatonia. 

In  1883  Dr.  v.  Krafft-F:bing,  in  the  second  edition 
of  his"Lehrbuch  der  I'sychiatrie,"  mentioned  kata- 
tonia as  a  form  of  disease  defined  by  Kahlbaum,  made 
up  of  symptoms  given  by  the  author  under  a  division 
of  "  Circulares  Irresein."  In  the  same  year  Dr.  Wil- 
liam A.  Hammond  read  a  paper  before  the  New  York 
Neurological  Society,  in  whicii  he  accepted  Kahl- 
baum's definition  of  katatonia;  and  Dr.  S.  V.  Cleven- 
ger,  in  an  article  in  \.\\ft  Aini-riiaii  Journal  of  Neiirology 
and  Psyi-lilatry,  on  •■  Insanity  of  Children,"  mentioned 
katatonia  apparently  without  questioning  the  validity 
of  the  name,  and  referred  to  Kiernan's  obser\-ation  of 
it  in  a  boy  of  eleven.  In  this  year  Dr.  Richard 
Neuendorff,'in  the  Ccntralbl.fiir  Nct-ienhcilk..  reported 
two  cases  and  evidently  accepted  Kahlbaum's  defini- 
tion of  katatonia.  In  1886  Dr.  Knecht  wrote  on  kata- 
tonia in  the  Allgcm.  /.cifschr.  f.  Psych.,  and  reported 
cases  giving  the  differential  diagnosis  and  also  the 
report  of  two  autopsies.  In  the  same  year  Dr.  W.  P. 
Verity  wrote  on  katatonia  for  the  Journal  of  Scnoiis 
and  Sicntal  Disease.  He  quoted  Kiernan.  with  whom 
he  evidently  agreed,  and  mentioned  that  Clevenger 
expressed  the  opinion  that  katatonia  "seems  allied 
etiologically  to  some  rheumatoid  disease,  though  its 
origin  may  be  in  nerves  or  blood."  He  cited  one  case 
of  his  own.  In  1886  Schiile,  in  the  Klinischc  Psychi- 
atric, Leipzig,  gave  an  exhaustive  and  perfect  picture 
of  clinical  katatonia,  and  divided  it  into  three  varie- 
ties— the  religious  expansive  form,  the  depressed  form, 
and  hysterical  katatonia.  Clemens  Xeisser,  of  Stutt- 
gart, wrote  on  katatonia  in  1887,  and  also  furnished  a 
valuable  article  on  katatonia  for  Tuke's  dictionary. 

In  1889  Dr.  \V.  Julius  Mickle  furnished  a  long  and 
comprehensive  article  on  katatemia  in  vol.  12  of 
Brain.  He  believed  that  Kahlbaum  has  demanded 
for  katatonia  an  application  far  wider  than  can  be 
admitted,  but  conceded  to  it  a  "separate  existence  as 
at  le.ist  a  varietv  or  sub-form,  if  not  as  a  separate  and 
distinct  form  of  mental  disease,  for  which  last  view 
there  is  much  to  be  said."  "  .Vt  least  as  a  symptom 
assemblage,  or  syndrome,  the  name  katatonia  will 
have  its  uses  in  mental  medicine."  He  said  tliat  no- 
sologically  it  should  be  placed  as  an  appendix  to  tlie 
class  of  psycho-neuroses.  Tiiere  were  elements  in 
katatonia  leading  one  to  consider  it  equally  well 
placed  in  the  second  great  group  of  mental  maladies 


(as  classified  by  the  author),  namely,  that  in  which 
hereditary  infiuences  have  formed  from  ordinary  neu- 
roses, of  "  ps\choses  of  hereditary  or  other  morbid  con- 
stitutional neurosal  or  mental  degeneration,  of  defec- 
tive organs,  mental  constitution,  or  of  incomplete  or 
arrested  brain  development."  Here  it  might  stand 
between  the  cla.ss  of  periodical  and  circular  psychoses 
on  the  one  hand,  and  on  the  other  the  adjoining  class 
containing  hebephrenia,  paranoia,  simple  hereditar)' 
insanity,  etc.  He  further  stated  that  the  views  ex- 
pressed by  Drs.  Seglas  and  Chaslin  are  partly  similar 
to  his  own.  These  authors,  whose  writings  on  this 
subject  are  to  be  found  in  the  Arch,  de  Neurol,  for 
1888,  and  Brain,  vol.  12,  do  not  accept  katatonia  as  a 
distinct  disease,  but  consider  it  a  variety  of  melancho- 
lia, simple  or  sympathetic,  with  stupor  more  or  less 
marked,  perhaps  more  distinctly  related  to  hysteria. 
Dr.  Nicholaus  Ostermayer,  in  the  Allf^cm.  Zcitschr.  J. 
Psych.,  vol.  48,  expressed  the  opinion  that  clinically 
we  must  accept  Kahlbaum's  theories;  and  that,  while 
katatonia  is  probably  not  a  frequenily  occurring  form 
of  psychical  disease,  it  is  not  one  of  the  rarest  forms. 

In  1892  Dr.  Edwin  Goodall.  in  i\iQ  Journal  of  A  fen - 
tal  Science,  London,  published  a  paper  entitled  "Ob- 
servations upon  Katatonia."  He  was  undecided  as  to 
whether  katatonia  should  or  should  not  be  considered 
a  separate  malady.  Dr.  R.  Percy  Smith,  in  the  Jour- 
nal of  Mental  Science  iox  1892,  cited  a  case  of  "so- 
called  katatonia."  He  considered  the  term  "kata- 
tonia" as  dubious. 

In  1894  Dr.  E.  D.  Kondurant  published  an  article 
on  katatonia  w  ith  six  illustrative  cases,  in  the  Medical 
Ne7iis,  vol.  64.  He  considered  katatonia  a  convenient 
name  for  a  "rare  and  interesting  group  of  symptoms." 

Clouston,  in  his  work  on  "Mental  Diseases,"  1897. 
states  that  "katatonia  is  simply  a  variety  of  alternat- 
ing insanity,  in  which  the  functions  of  the  motor- 
trophic  centres  are  especially  involved." 

Bevan  Lewis,  in  his  text-book  on  "Mental  Dis- 
eases," 1890,  says:  "The  more  closely  we  study  these 
cases  of  katatonia  described  by  Kahlbaum,  the  more 
convinced  we  are  that  we  are  not  dealing  with  any  dis- 
tinct pathological  entity,  but  with  some  of  the  multi- 
ple forms  of  hysteria.  .  .  .  Melancholia  attonita 
closely  approximates  to  the  state  to  which  we  now  al- 
lude." 

Conolly  Norman,  in  a  monograph  on  "Acute  Con- 
fusional  Insanity,"  states  incidentally  that  katatonia 
is  probably  to  be  regarded  as  a  tyjse  of  the  above- 
named  disorder. 

We  thus  see  that  katatonia  has  been  described  va- 
riously as  a  clinical  entit)-,  as  a  variety  of  melancho- 
lia, as  a  form  of  circular  insanit}-,  as  a  type  of  acute 
confusional  insanity,  as  a  species  of  hysterical  insan- 
itv,  and  bv  one  author  (Schiile >  as  attonic  mania. 

A  careful  study  of  the  subject  as  detailed  by  the  au- 
thorities cited,  together  with  observations  of  our  own. 
gi\  es  us  the  following  facts  in  the  etiolog)',  pathology, 
and  symptomatology  of  katatonia: 

Etiology.— tine  of  the  most  important  predisposing 
causes  of  katatonia  is  hereditary  influence.  Kataton- 
ics  are  often  members  of  .families  showing  hereditary 
psvchic  degeneration.  Scrofulous  and  tuberculous 
diatheses  are  frequently  predisposing  causes.  The 
other  most  important  predisposing  causes  are  age  and 
sex,  the  majority  of  cases  being  youthful  and  belonging 
to  the  male  se.\.  Students  and  teachers  are  said  to  be 
especiallv  prone  to  have  diis  trouble.  The  influence 
of  stimulants  may  act  as  a  predisposing  or  exciting 
cause.  The  principal  exciting  causes  are  masturba- 
tion, sexual  exhaustion  and  excess,  religious  and 
emotional  excitement,  mental  strain,  worry,  anxiety, 
svphilis;  indeed,  all  of  the  usual  factors  in  the  causa- 
tion of  ordinar)-  melancholia. 

Pathology.  —  Kiernan  found  that  the  disease  is  most 


October  2,  1897] 


MEDICAL    RFXORD. 


475 


frequently  preceded  during  infancy  by  a  basilar  me- 
ningeal process  of  a  tuberculous  character.  Kahl- 
baum's  post-mortems  show  evidences  of  a  healed-up 
hydrocephalus  and  a  basilar  meningitis.  Meynert's 
deduction  from  Kahlbaum's  cases  is  that  the  disease 
has  been  preceded  by  a  patho-meningeal  process  lo- 
cated at  the  base  of  the  brain  and  over  the  fissure  of 
Sylvius.  Kiernan  further  says:  "In  a  patho-psycho- 
logical  aspect  the  localization  of  the  process  would  be 
over  the  base  of  the  brain,  in  the  fourth  ventricle,  and 
over  the  fissure  of  Sylvius."  Dr.  Julius  Mickle  says 
that  the  post-mortems  show  brain  atrophy,  anaemia, 
marked  basal  meningeal  changes,  or  passive  hyper- 
emia and  oedema  of  meninges — all  of  which  indicate 
a  profound  alteration  of  brain  nutrition.  The  pia  is 
at  times  found  to  be  adherent  in  patches  to  the  brain, 
and  superficial  layers  of  gray  matter  are  separated 
when  tlie  membranes  are  stripped  ofi^.  These  patches 
are  situated  at  the  anterior  part  of  the  inferior  mesial 
surfaces  of  the  cerebral  hemispheres.  The  arachnoid 
is  slightly  thickened  and  opaque  over  the  base  of  the 
brain,  and  there  are  thickening  and  opacity  over  the  su- 
perolateral gyri 

We  are  inclined  to  belie\e  that  the  more  this  class 
of  cases  is  investigated,  the  greater  will  be  the  accord 
shown  with  the  pathological  findings  in  melancholia. 

Kahlbaum's  theory  of  the  cause  of  verbigeration  was 
that  it  was  a  kind  of  co-ordinated  spasm  originating 
in  the  centre  of  speech. 

Symptomatology. — The  symptoms  of  katatonia  are 
essentially  somewhat  variable  in  nature.  There  is  a 
tendency  to  change  from  phase  to  phase,  often  return- 
ing to  a  previous  one  as  if  by  a  sort  of  relapse.  The 
earliest  symptoms  noticed  are  abnormal  sensations  in 
the  head,  pain  in  the  occipital  region,  vertigo,  insom- 
nia, irritabilit}-,  change  of  temper,  general  restless- 
ness, a  certain  amount  of  gradually  increasing  melan- 
cholia. 

The  second  stage  may  be  ushered  in  with  convul- 
sions, epileptic  or  epileptiform  in  character,  or  tlie 
patient  may  become  suddenly  maniacal  or  greatly  agi- 
tated. The  patient  now  presents  the  marked  condition 
of  melancholia.  Muscular  tension  or  spasmodic  move- 
ments are  present.  It  has  been  said  that  in  about 
fifty  per  cent,  of  cases  there  are  spasmodic  conditions 
of  the  most  varied  nature,  often  existing  for  years 
before  the  beginning  of  the  actual  mental  disease 
(hysteria  [.']).  Rhythmical  movements  about  the 
face  and  limbs  are  often  seen  in  this  and  subsequent 
periods.  These  rhythmical  motions  or  movements 
are  always  under  the  control  of  the  will,  thereby  differ- 
ing from  those  seen  in  chorea.  The  refiexes  are  in- 
creased. The  delusions  are  usually  of  fear  or  self- 
accusation,  and  may  concern  the  commission  of 
imaginary  sins,  masturbation,  etc.  Auditory  and 
visual  hallucinations  of  the  most  terrifying  cliaracter 
are  often  present.  .Sometimes  there  is  a  condition  of 
religious  ecstasy  or  excitement,  suddenly  or  gradually 
developed.  The  patient  may  have  confused  but  e.x- 
pansive  ideas  of  a  religious  or  social  order,  and  he 
may  be  given  to  elocutionar\-  displays  with  much  ges- 
ticulation. There  is  sometimes  a  tendency  to  talk 
and  act  theatrically.  The  patient  is  given  to  making 
pompous  harangues,  consisting  of  but  fragments  of 
sentences.  There  is  a  verbigeration  or  a  repetition 
of  unintelligible  words  or  syllable  successions  not  be- 
longing to  any  language,  with  an  especial  tendency  to 
rhyming.  These  are  often  spoken  witli  much  etTort. 
emphasis,  and  forcibleness.  There  is  a  tendency  to 
contradict,  oppose,  and  resist  everything,  to  refuse 
food,  resist  being  washed,  dressed,  etc.  There  are  a 
peculiar  erectness  of  carriage,  slowness  of  movements, 
and  immobility  of  features,  a  pathos  of  expression  in 
speaking  and  writing,  and  a  tendency  sometimes  to 
mystical  language,  together  with  the  effort  to  discover 


mysterious  allusions  in  the  sayings  of  others.  The 
characteristic  katatonic  condition  of  tension  in  psy- 
chical and  muscular  spheres  may  be  observed  in  any 
stage,  but  it  may  be  said  here  that  the  division  into 
stages  as  attempted  by  some  authors  is  not  altogether 
practical  or  practicable. 

In  the  so-called  attonita  stage  there  are  rigidity  and 
immobility,  which  is  more  or  less  complete.  Cata- 
lepsy is  often  extreme.  There  is  an  absence  of  spon- 
taneous movements,  but  when  we  attempt  to  produce 
passive  movement  there  is  a  powerful  resistance.  The 
muscles  are  generally  in  a  state  of  tension.  Opisthot- 
onos or  tonic  spasms  are  sometimes  present.  The 
tendon  reflexes  are  often  greatly  exaggerated.  There 
is  a  tendency  for  the  limbs  to  smainfor  some  time  in 
the  position  given  them,  thus  forcing  the  patient  into 
uncomfortable  positions,  as  in  the  condition  of  "  flexi- 
bilitas  cerea."  The  head  may  be  just  raised  above  the 
pillow,  the  thighs  flexed  on  the  abdomen,  and  the  legs 
on  the  thighs.  This  immobility  is  often  interrupted 
by  rhythmic  monotonous  movements  incessantly  re- 
peated in  an  automatic  manner.  These  stereotyped 
movements  are  called  '"  Kewegungsstereotypie."  An- 
other very  important  symptom  is  '"  mutism"  or  '•  muta- 
cismus,"  or  a  pathological  tendency  to  be  silent. 
This  mutism  or  dumbness  altemates  often  with  verbig- 
eration and  other  varieties  of  repetition.  Constipation 
is  frequently  present,  and  occasionally  retention  of 
urine.  The  faradic  irritability  is,  as  a  rule,  normal; 
the  galvanic  is  at  times  often  diminished.  "Stadia, 
with  obstinate  taciturnity,  confusion  of  thought  and 
speech,  may  occur  in  some  cases."  Dementia  super- 
venes only  slowly,  and  rarely  becomes  extreme.  Dr. 
Julius  Mickle  has  this  to  say  of  the  grouping  of  symp- 
toms: The  order  in  which  stages  occur  is  irregular. 
The  circular  nature  of  the  disease  is  extremely  irregu- 
lar or  abortive.  One  or  any  of  the  stages  is  apt  to  be 
absent  in  a  given  case.     There  may  be  alternately : 

A.  — Stuporous-cataleptic  phases  and  e.\cited  phases. 
Or, 

H. — T)epressed  and  excited. 

Or, 

f  Melancholic-iiepressed. 
I  Stuporous. 
C — Successively    ■{  Excited. 
Confused. 
I  Depressed. 
Or, 

D. — Con^■ulsive  phase  followed  by  apparent  temporarj-  re- 
cover)-, then  successively. 

Depressed  and  e.xcited  phases  /  . 

Depressed  and  hallucinator)-  phases  )' ""  s^"<^^- 

The  most  frequent  complication,  whether  preceding 
or  following  upon  the  appearance  of  the  mental  dis- 
ease, is  tuberculosis.  The  tendency,  if  recovery  does 
not  take  place,  is  for  the  patient  to  drift  into  a  condi- 
tion of  dementia  or  for  phthisis  pulmonalis  to  develop 
and  carry  the  patient  off. 

There  are  many  abortive  forms  of  katatonia,  which 
might  be  termed /urmts /n/s/is,  and  it  is  in  atypical 
cases,  which  are  so  often  similar  to  other  varieties  of 
psychosis,  that  diagnosis  is  difficult.  For  our  part 
we  do  not  believe  that  all  of  the  cases  which  have  been 
recorded  in  literature  are  cases  of  katatonia  in  the 
strictest  sense. 

Katatonia  has  been  divided  into  two  forms-^-kata- 
tonia  mitis  and  katatonia  protracta  (Neisser).  With 
katatonia  mitis  there  is  probably  simple  cerebral 
ana;mia  or  oedema,  and  with  the  disappearance  of  the 
oedema  and  a  general  constitutional  improvement  the 
katatonic  symptoms  gradually  disappear.  The  kata- 
tonia protracta  is  a  meningitic  form,  being  connected 
with  the  remains  of  a  meningitis. 

Katatonia  is  not  a  common  disorder.      Bondurant 
gives  its  frequency  as  one-half  of  one  per  cent. ;  eleven- 


4/6 


MEDICAL    RFXORD. 


[October  2,  1897 


ger,  one  and  one-half  per  cent.:  and  Kiernan,  two  per 
cent.  We  ourselves  are  inclined  to  consider  kata- 
tonia  as  an  extremely  rare  syndrome,  taking  it  in  its 
strict  sense.  It  is  a  symptom  complex,  any  one  of  the 
manifestations  of  which  is  frequently  to  be  observed 
in  various  forms  of  insanity,  and  this  has  doubtless 
led  to  the  diagnosis  of  Kahlbaum's  entitj^  in  cases 
which  would  often  prove  by  more  exact  limitations  to 
be  quite  different  from  the  true  Kahlbaum  type.  We 
report  in  this  paper  four  cases,  the  only  ones  we  have 
•met  with  in  a  considerable  experience  in  large  asy- 
lums for  a  period  of  fifteen  years. 

Differential  Diagnosis. — The  kaiatonic  state  can  be 
distinguished  from  hebephrenia  or  the.  insanity  of 
pubescence,  in  which  occasionally  cataleptic  condi- 
tions occur,  by  attention  being  paid  to  the  following 
symptoms:  The  delusions  of  the  former  are  intellec- 
tual, commonly  depressed,  and  vary  indefinitely;  the 
delusions  of  the  latter  are  vague  and  stupid.  There 
is  seldom  a  spasmodic  element  in  the  insanit)'  of 
pubescence,  and  the  serial  phases  are  not  present. 
The  chief  diagnostic  difficult)-  lies,  of  course,  in  the 
differentiation  of  this  syndrome  from  such  cases  of 
melancholia  as  manifest  attonital  or  cataleptic  states, 
but  the  presence  at  some  time  in  the  course  of  the 
katatonic  type  of  cheerful  or  exalted. and  e.vcited  con- 
ditions, together  with  rhythmic  gesticulations,  attitu- 
dinizing, and  verbigeration,  would  be  distinctive. 
The  flexibilitas  cerea  of  katatonia  sometimes  differs 
from  that  occurring  in  melancholia  attonita,  by  not 
coming  on  in  sudden  and  brief  attacks  of  cataleptic  or 
ecstatic  character,  but  by  lasting  for  a  long  time  (for 
weeks).  The  katatonic  syndrome  is  differentiated 
from  hystero-epilepsy  by  the  different  general  history 
of  the  disease  rather  than  by  isolated  symptoms. 
Chorea  complicating  insanity  is  diagnosed  by  the  pe- 
culiar involuntary  and  irregular  movements  of  the 
former,  as  distinguished  from  the  voluntary'  and  often 
rhythmical  movements  and  gesticulations  of  katatonia. 
Furthermore,  insanit)'  with  chorea  is  not  apt  to  ex- 
hibit such  variet)-  of  phases.  Narcolepsy  shows  none 
of  the  mental  or  motor  symptoms  of  katatonia,  but 
consists  of  periodical  attacks  of  quiet  slumber. 

Prognosis. — The  prognosis  should  be  guarded,  as 
in  any  severe  form  of  melancholia.  Complete  recov- 
ery is  said  to  occur  in  only  about  three  per  cent. 
RecQver)'  may  follow  immediately  upon  the  stage  of 
attonita,  gradually  or  suddenly.  Prognosis  is  rather 
more  unfavorable  if  a  state  of  e.xcitement  follows  upon 
the  attonita.  This  excitement  may  be  interrupted  by 
a  new  stage  of  depression.  It  may  remit  and  the  pa- 
tient appear  nearly  well,  but  generally  ends  in  de- 
mentia. If  there  is  to  be  an  unfavorable  termination, 
periods  of  excitement  and  stupidity  recur  with  in- 
creased frequency.  Three-fourths  of  the  fatal  cases 
are  said  to  die  from  tuberculous  disease.  It  maybe 
here  said  that  Kahlbaum  himself  was  inclined  to  look 
upon  the  prognosis  as  favorable,  which  is  rather  incon- 
sistent with  his  idea  of  an  organic  basis  for  katatonia. 

Treatment. — Treatment  consists  in  the  main  of  fol- 
lowing the  indications  common  to  melancholia,  in 
paying  attention  to  symptoms,  administering  tonics, 
sedatives,  and  stimulants  when  needed.  Faradization 
of  the  chest  muscles  has  been  recommended  as  a 
prophylactic  against  tuberculosis,  though  we  confess 
to  little  faith  in  its  value.  Constipation  should  be 
combated  by  the  administration  of  laxatives.  It  is 
often  necessary  to  resort  to  artificial  alimentation 
when  the  patient  refuses  food.  Occasionally,  though, 
the  patient  will  eat  small  portions  of  food  when  he  is 
alone.  Retention  of  urine  is  occasionally  present  and 
may  require  attention.  Amyl  nitrite  is  useful  in  cata- 
leptic and  stuporous  phases.  Hydrotherapy  is  valua- 
ble as  a  general  tonic  and  stimulant.  Naturally  the 
moral  treatment  followed  in  in.stitutions  for  tlio  insane 


is  of  the  greatest  service.  Intestinal  antisepsis  and 
the  opium  treatment  will  be  found  valuable  in  this,  as 
in  other  forms  of  melancholia. 

As  an  appendix  to  this  article  we  publish  four  cases 
that  have  come  under  our  observation,  together  with 
our  comments  and  conclusions: 

Illustrative  Cases. — Case  I.  —  li.  R ,  female, 

aged  thirty-one;  married,  with  four  children;  He- 
brew; common  education:  born  in  the  United  States: 
admitted  to  the  Hudson  River  State  Hospital  in  J"eb- 
ruar)-,  1884;  no  heredity.  The  first  evidence  of  men- 
tal disturbance  was  in  August,  1883,  after  the  birth  of 
her  last  child,  which  she  nursed  for  two  months,  when 
she  became  sleepless,  restless,  and  inclined  to  refuse 
food.  Soon  she  developed  the  idea  that  she  would 
never  recover,  began  to  bemoan  her  condition,  and 
said  it  was  hard  to  die  so  young.  There  was  complete 
anorexia.  She  took  no  interest  in  anything,  became 
careless  of  her  person  and  dress,  and  negligent  (f 
everjihing  in  which  she  had  formerly  been  interested. 
Three  weeks  before  admission  she  became  suicidal, 
spoke  of  it,  and  attempted  to  choke  herself  and  to  cut 
herself  with  glass.  She  would  bite  her  caretakers, 
and  took  every  means  possible  to  make  away  with  her- 
self. Her  menstruation  was  regular.  There  was  con- 
siderable constipation.  The  case  was  regarded  as  one 
of  puerperal  melancholia. 

February  1  ith,  two  days  after  admission,  she  tried  to 
beat  her  head  against  the  bedstead;  said  some  one  vas 
killing  her  children  and  putting  them  in  a  box;  said 
arsenic  was  put  in  her  coffee  and  that  her  mother  was 
in  the  asylum;  was  sleepless  and  had  to  be  fed  forci- 
bly. She  became  rapidly  worse  during  the  next  few 
days,  went  into  a  condition  of  noisy  excitement,  call- 
ing for  her  mother,  whom  she  believed  to  be  in  the 
building,  mentioned  her  delusions  of  poisoning,  beat 
and  bruised  herself  against  the  bedstead,  and  refused 
all  food.  She  was  very  suicidal.  Her  mouth  and 
tongue  became  dry,  she  showed  symptoms  of  exhaus- 
tion, and  was  fed  with  the  tube  for  a  considerable 
period. 

She  continued  to  refuse  food,  to  resist  all  care  stren- 
uously, and  to  be  desperately  suicidal  until  March 
15th,  when  she  became  cataleptic  with  marked  flexi- 
bilitas cerea,  absolutely  silent,  noticing  nothing,  not 
even  her  husband,  who  visited  her;  would  swallow 
food  put  in  her  mouth:  made  no  voluntary  motions: 
pulse  good,  bowels  moved  byenemata;  she  began  to 
wet  and  soil  the  bed,  and  as  she  grew  stronger  was 
looked  upon  as  rapidly  becoming  demented.  This 
state  of  catalepsy  continued,  with  variations  from  time 
to  time,  for  a  month  or  more,  when  she  began  to  be 
destructive  of  her  clothing,  would  strip  herself  naked, 
and  was  filthy  in  her  habits. 

She  remained  in  that  condition,  seldom  uttering  a 
word  for  months,  until  about  the  last  of  November, 
1884,  when  she  began  to  cry  out  loudly,  "Bring  me 
home  to  my  children  in  New  ^'ork,"  "  Bring  me  home 
to  my  children  in  .\ew  York."  reiterating  this  ovtr 
and  over  from  morning  till  night,  and  accompanying 
the  phrase  with  rhythmic  movements  of  the  hands  and 
arms,  as  if  she  were  waving  them  in  the  direction  she 
wished  to  go.  There  was  a  rhvthm  in  the  days,  too, 
for  every  alternate  day  she  was  quiet  in  her  chair  and 
would  whis)3er.  This  continued  without  variation  for 
some  two  months,  during  all  of  which  time  she  was 
eating  and  sleeping  well  and  gaining  in  flesh. 

.\bout  the  middle  of  January,  18S5,  her  verbigera- 
tion took  another  character,  the  gesticulations  remain- 
ing the  same.  She  began  to  recite  all  day  long,  even, 
other  day,  with  great  rapidity  and  with  infinite  varia- 
tion in  rhymes  of  unintelligible  words  as  follows: 
"Moccasins,"  "voccasins,"  "doccasins,"  "crocka- 
sins,"  "  lockasins,'"  ■' tockasins,''  "  jockasins,"  "hock- 
asins,"  "  b.abies,"  "'tahies."  "<rabies,"  "habies,"  "  sa- 


October  2.  1897] 


MEDICAL    RECORD. 


477 


bies,"  '"labies,'  "  mabies,''  "  kabies,'  "' nobis,"  ■"go- 
bis,"  "jobis,"  "chobis,"  "sobis,"  ""pobis."  "tikater," 
'"likater,"  "sikater,"  "likater,"  "'mikater,"  and  so  on, 
iid  injinitum.  Siie  changed  to  another  word  only  when 
the  possibilities  of  rhyme  were  exhausted.  She  was 
mentally  confused.  When  asked  why  she  made  these 
rhymes,  she  said  some  one  told  her  to,  but  this  was 
probably  an  answer  given  because  she  could  not  ex- 
plain why,  for  she  had  now  no  hallucinations  or  delu- 
>ions.  She  was  so  confused  that  she  did  not  feel  sure 
it  was  her  husband  who  came  to  see  her. 

A  few  months  later  she  gave  up  the  rhyming  asso- 
nances and  returned  to  the  old  phrase,  with  occasional 
variations:  "I  want  to  go  home  to  my  children  in 
New  York,"  '"  Won't  I  be  glad  when  I  get  home  to  my 
children  in  New  Vork,"  "  What  good  times  I'll  have 
when  I  get  home  to  my  children  in  Xew  Vork,  ...  to 
ray  cozy  home  in  New  York,  .  .  .  when  I  get  into  the 
car  which  takes  me  to  my  husband  and  children  in 
.Vew  York."  This  was  the  refrain  for  many  months 
on  alternate  days,  accompanied  as  before  by  rh)-thniic 
gestures  of  both  arms  in  the  supposed  direction  of  New 
York. 

In  the  spring  of  i886,  on  the  quiet  alternate  days, 
she  began  to  sew.  She  steadily  improved  in  tiesh  and 
was  looked  upon  as  in  a  state  of  dementia.  There 
was  no  appreciable  change  in  her  condition  during  the 
summer.  The  verbigeration  and  gesticulation  alter- 
nated with  quiet  and  industrious  days  until  the  au- 
tumn of  1886,  when  improvement  began  to  manifest 
itself  in  every  way,  and  in  November  she  was  dis- 
charged as  improved  and  went  home  with  her  husband 
on  trial.  There  she  recovered  perfectly,  so  that  not  a 
vescige  of  the  insanity  remains,  and  she  is  to  this  day 
in  full  charge  of  Jier  household  and  family,  as  reported 
to  us  not  long  since  by  her  husband. 

In  this  case  we  have,  first,  an  ordinary  suicidal  mel- 
ancholia, with  delusions  of  poisoning,  the  killing  of 
her  children,  etc.,  and  hallucinations  of  taste  and 
hearing  and  possibly  of  sight,  rapidly  becoming  an  ag- 
gravated case  of  melancholia  agitata  (of  almost  mani- 
acal character),  with  a  sudden  lapse  into  a  cataleptic 
condition  lasting  about  a  month :  after  which  she  was 
for  some  months  silent,  stupid,  having  to  be  dressed., 
undressed,  and  cared  for  in  every  way,  when  she  began 
to  show  symptoms  of  verbigeration  and  rhythmic  ges- 
tures described  above.  During  most  of  the  long  pe- 
riod presenting  these  symptoms  she  was  mentally  con- 
fused, but  her  mood  was  rather  cheerful.  She  used 
often  to  smile  when  any  one  would  ask  her  why  she 
talked  in  that  way,  and  she  seemed  to  take  pleasure  in 
what  she  was  constantly  reiterating. 

Case  II. — M.  S.  E ,  male;  admitted  to  Hudson 

River  State  Hospital,  July  21,  1891 :  single,  aged  fifty, 
merchant,  native  of  New  York;  common-school  edu- 
cation; habits  temperate;  heredity,  insane  relations 
on  father's  side.  On  admission  physical  condition 
feeble;  alleged  cause  of  insanity,  ill  health. 

History:  Patient  said  to  have  been  naturally  of  a 
cheerful  disposition,  easily  influenced,  but  up  to  fifteen 
years  ago  to  have  been  successful  in  business.  At  this 
time  a  change  took  place  in  his  disposition ;  he  became 
worrisome  and  fretful,  hypochondriacal,  neglected  his 
business,  and  was  generally  depressed.  Ten  months 
a;:o  he  gave  up  all  work,  said  that  he  "  could  not  walk, 
could  not  talk,  or  care  for"  himself.  He  became  si- 
lent, melancholy,  and  preoccupied.  Three  weeks  aiji) 
he  became  greatly  agitated  and  confused,  and  since 
then  has  paid  no  attention  to  anything  said  to  him, 
and  has  not  spoken  except  to  rejjeat  constantly  mean- 
ingless syllable  combinations,  like  "  Oh,  warmee," 
"Oh,  warmee,"  "Oh,  warmee,"  "Oh,  huminum," 
'"Oh,  huminum,"  "Oh,  huminum,"  "Oh,  wow^  wow 
woro,"  "  Oh,  wow  wow  woro,"  ''  Oh,  wody  wody 
wody,"  "  Oh,    wody   wody   wody."    ""  Oh,    wody    wody 


wody,"  "Oh,  kody  body,  '  "Oh,  kody  body,"  "Oh, 
kody  body,"  "  Oh,  w  iddy  widdy,"  "  Oh,  widdy  widdy," 
"Oh,  hum  yank-um,"  "Oh,  hum  yank-um,'"  "Oh,  hum 
yank-um."  He  would  constantly  repeat  these  words 
with  greater  or  less  rapidity  in  varying  keys  and  with 
strange  gesticulations  and  great  earnestness  o£  man- 
ner, for  fifteen  or  twenty  minutes,  when  he  would  be 
silent  for  some  hours  and  then  start  off  with  another 
combination.  When  spoken  to  he  would  become  irri- 
table, and  commence  repeating  some  syllable  combi- 
nation. His  appetite  has  been  capricious.  His  face, 
head,  and  neck  at  times  are  much  congested,  and  at 
other  times  he  is  very  pale. 

On  admission  he  was  much  agitated,  moaned,  and 
wrung  his  hands,  but  refused  to  say  anything  intelli- 
gible ;  w hen  spoken  to  he  would  only  repeat  the  above 
meaningless  jargon,  with  gestures.  Bowels  are  con- 
stipated, tongue  is  coated,  pupils  are  dilated,  heart's 
action  is  weak. 

July  22,  1891,  restless  last  night,  moans  constantly; 
pays  no  attention  to  what  is  said  to  him,  but  repeats 
his  combinations,  as  "  Oh,  body  body,"  "  Oh,  yixm 
yank-um,"  etc.,  and  with  increased  rapidity  when  an 
attempt  is  made  to  interrupt  him. 

July  23,  1891,  is  in  bed  all  the  tim.e  in  semicata- 
leptic  condition,  lies  in  awkward  positions,  resists  all 
care;  bowels  constipated,  but  would  not  submit  to 
enema. 

August  14,  189 1,  no  speciaf  change  in  past  month. 
In  bed;  keeps  legs  and  thighs  flexed;  resists  all  care; 
never  pays  attention  to  any  one ;  is  always  silent  ex- 
cept when  repeating  his  meaningless  syllables,  like 
"  Oh,  te  it,"  etc.  Bowels  are  obstinately  constipated ; 
frequently  troubled  with  emesis;  is  cared  for  with 
difficulty  on  account  of  his  persistent  resistance;  often 
moans  and  groans,  often  has  rhythmical  movements  of 
upper  e.xtremities. 

During  August,  September,  October,  and  November 
there  was  but  little  change  in  his  condition. 

In  December  he  became  stronger  physically;  was 
less  resistive  to  care,  would  dress  and  imdress  himself ; 
appeared  to  imderstand  what  was  said  to  him,  but 
never  made  any  intelligible  replies,  but  would  fre- 
quently make  harangues  in  meaningless  syllables,  re- 
peating one  combination  from  twenty  minutes  to  one- 
half  hour,  and  then  changing  to  another. 

January  27,  1892,  spoke  to-day  intelligibly  for  the 
first  time  since  admission;  said  to  the  attendant  who 
was  about  to  take  him  out  to  walk,  "  Don't  let  them 
take  me  out  to-day." 

January  28,  1892,  is  again  disturbed  and  excited. 
Verbigeration  marked. 

During  February  and  up  to  the  25th  of  March  he 
was  much  disturbed,  often  noisy  for  hours  at  a  time. 
An  almost  persistent  insomnia  was  present.  The  lat- 
ter part  of  February  chronic  diarrhoea  developed,  and 
persisted  in  spite  of  treatment. 

March  25,  1892,  he  again  spoke  coherently  and  his 
verbigeration  now-  stopped.  Is  very  depressed  and 
resists  care.  Has  become  thin  in  flesh  and  is  quite 
feeble  physically ;  is  in  condition  of  attonita;  muscles 
in  condition  of  tension ;  resists  every  change  of  posi- 
tion. 

April  7,  1892,  has  been  quiet  since  last  date,  but 
has  resisted  takingfood  and  all  care  most  strenuously; 
has  had  chronic  diarrhoea  and  has  been  steadily  failing 
for  some  weeks.      Died  this  morning. 

Post-mortem  refused  by  friends. 

Case  III. — W.  J ,  admitted  to  Huason  River 

State  Hospital,  November  17,  1894.;  aged  forty-four, 
male,  married,  railroad  employee,  native  of  Ireland; 
common-school  education,  habits  intemperate,  hered- 
itj-  denied.  Physical  condition  on  admission,  fair; 
alleged  causes,  intemperance  and  worry  and  anxiety 
on  account  of  loss  of  position. 


478 


MEDICAL    RFXORD. 


[October  2,  1897 


Histor}':  Six  months  prior  to  admission  patient  lost 
his  position  on  the  railroad,  and  was  unable  to  obtain 
work,  and  he  and  his  family  suffered  much  privation 
in  consequence;  he  worried  much  at  not  being  able  to 
obtain  employment,  and  gradually  became  depressed 
and  despondent,  and  about  four  months  ago  attempted 
suicide  by  cutting  his  throat.  The  wound  healed,  but 
he  became  more  and  more  despondent  and  suffered 
much  anxiety  at  not  getting  work;  is  now  troubled 
with  insomnia  and  headache.  A  few  days  ago  he 
.suddenly  went  into  a  condition  of  extreme  excitement, 
broke  his  watch,  upset  the  table,  and  was  generally 
destructive  and  violent.  He  was  taken  to  the  lockup 
for  care.  This  condition  lasted  about  three  days, 
when  he  became  quiet  and  appreciated  his  condition. 

On  admission  he  was  profoundly  depressed  and  in- 
different to  his  surroundings;  answered  questions  co- 
herently but  very  unwillingly.  After  being  here  two 
days  he  went  into  a  condition  of  melancholia  agitata, 
which  lasted  two  days;  he  suddenly  became  stupid, 
confused,  and  was  in  a  condition  of  semicatalepsy, 
refused  to  talk  or  to  speak.  After  being  this  way  for 
two  days  he  again  became  greatly  disturbed,  and  con- 
tinued so  for  five  days.  During  this  time  he  resisted 
all  care,  seemed  utterly  indifferent  to  his  surroundings, 
at  times  was  noisy,  strenuously  resisted  all  care  and 
taking  food,  and  it  became  necessary  to  nourish  him 
through  the  oesophageal  tube.  He  now  became  quiet, 
but  continued  to  refuse  food  and  was  fed  through  the 
tube  nearly  two  months.  He  had  delusions  of  poison- 
ing and  would  rarely  answer  questions,  but  would  fre- 
quently groan  and  moan. 

On  February  13,  1895,  he  had  two  very  severe  epi- 
leptiform convulsions.  During  February  and  March 
he  refused  food,  often  moaned  and  sighed,  but  had  no 
conversation  with  any  person  and  resisted  strenuously 
all  efforts  at  care.  During  April  and  May  mutism  was 
marked,  patient  lay  quietly  in  bed  and  did  not  speak  a 
word,  resisted  care,  kept  lower  limbs  flexed  and  eyes 
shut  half  of  the  time;  muscles  were  in  a  state  of  ten- 
sion. 

On  June  loth  verbigeration  appeared.  He  kept  re- 
peating for  hours,  '"  O  Lord,  what  will  I  do?"  "O 
Lord,  what  will  I  do?"  "  O  Lord,  what  will  1  do?" 
but  otherwise  was  mute  and  paid  no  attention  to  any 
one  or  to  his  surroundings,  but  always  resisted  most 
strenuously  being  changed,  cared  for,  or  interfered 
with 'in  anyway.  This  condition  continued  with  but 
little  variation  for  six  months.  During  this  time  he 
was  visited  repeatedly  by  his  wife  and  family,  but  at 
no  time  did  he  pay  any  attention  to  them  or  hold  any 
communication  with  them.  He  was  continually  in  a 
state  of  attonita,  but  would  often  groan  and  moan,  and 
at  times  would  repeat  for  half  an  hour  or  an  hour  at 
a  time,  "  0  my  God,  what  will  I  do?"  "O  my  God, 
what  will  I  do?"  ■"  O  my  God,  what  will  I  do?"  with 
automatic  gestures. 

The  latter  part  of  1895  he  developed  phthisis  pul- 
monalis.  He  was  in  bed  almost  continuously  during 
i8g6,  and  his  condition  was  that  of  attonita  generally. 
His  muscles  were  usually  rigid  and  in  a  state  of  ten- 
sion, his  lower  extremities  flexed  on  the  abdomen,  and 
the  face  on  his  chest,  his  lips  pouting  out,  his  eyes 
usually  half-closed,  paying  no  attention  to  any  one, 
but  always  making  the  most  strenuous  and  persistent 
resistance  to  all  efforts  of  care.  He  would  daily  have 
periods,  of  varying  duration,  of  repeating  in  varying 
tones  of  voice  sentences  such  as,  "  What  will  I  do?" 
"What  will  I  do?"  "What  will  1  do?"  "O  my 
God!"  "O  my  God!"  "O  my  God!"  "Lord,  have 
mercy  on  me!"  "Lord,  have  mercy  on  me!"  "Lord, 
have  mercy  on  me!"  etc.  These  repetition  sentences 
varied  from  time  to  time. 

He  is  now,  in  April,  1897,  in  the  last  stages  of 
phthisis  pulmonalis.     He  occasionally  has  verbigera- 


tion, but  only  once  in  three  or  four  days.  He  is 
almost  constantly  in  a  stuporous  condition.  With  the 
exception  of  his  periods  of  repetition  of  words  and 
sentences,  he  has  been  mute  for  more  than  two  years 
and  has  held  no  communication  with  anybody.  He 
is  much  emaciated  and  is  steadily  and  slowly  failing. 

Died  May  5,  1897. 

Case   I\'.  —  I).    M ,  admitted   to   Hudson    River 

State  Hospital,  May  26,  1896:  male,  married,  aged 
fifty-four,  railroad  employee,  native  of  Ireland;  com- 
mon-school education;  habits  intemperate;  heredity 
denied.  On  admission  physical  condition  feeble. 
Alleged  causes  of  insanity,  intemperance  and  ill 
health. 

Patient  enjoyed  fair  physical  health  up  to  about 
twenty  months  ago,  when  on  returning  from  his  work 
he  complained  of  being  sick  and  went  to  bed  for  a 
few  days,  and  ever  since  then  he  has  been  more  or 
less  depressed  and  troubled  with  insomnia.  He 
would  often  moan  and  groan  all  night,  frequently 
wringing  his  hands.  He,  however,  worked  in  an  auto- 
matic manner  up  to  two  months  ago,  but  he  took  no 
interest  in  anything,  and  on  returning  home  in  the 
evening  he  would  moan  and  pace  the  floor  until  two 
o'clock  in  the  morning,  when  he  would  lie  down  on  a 
lounge  for  three  or  four  hours.  He  was  very  hypochon- 
driacal and  restless;  thought  that  everything  he  did 
and  every  move  he  made  were  wrong.  His  condition 
gradually  became  worse.  At  present  he  cannot  sleep 
or  rest  day  or  night,  paces  the  floor  until  his  feet  are 
blistered,  rubs  his  forehead  and  wrings  his  hands  un- 
til they  bleed ;  refuses  to  go  out  of  doors ;  says  that  he 
is  miserable  and  wants  to  die,  that  there  is  no  hope 
for  him.  After  several  hours  of  excited  hand-wring- 
ing and  pacing  up  and  down,  he  becomes  more  com- 
posed and  says  to  his  wife,  "  What  a  bad  spell  I  have 
had."  He  has  had  severe  occipital  headaches  for  the 
past  two  years,  often  sees  black  specks  floating  in 
front  of  him,  and  is  troubled  much  with  hearing  imagi- 
nary voices  and  noises.  Has  numerous  delusions  of 
a  depressing  nature,  is  very  self-accusatory,  says  that 
he  has  committed  a  mortal  sin  by  practising  masturba- 
tion, and  that  he  must  die. 

During  the  first  three  days  in  the  hospital  he  was 
quiet,  depressed,  reticent:  eyes  had  a  furtive,  shifting 
appearance;  said  he  was  in  great  mental  trouble; 
had  periods  of  walking  the  floor  and  rubbing  and 
wringing  his  hands  in  a  strange  manner. 

May  29,  1896,  had  a  convulsive  attack  this  after- 
noon ;  afterward  was  very  confused  and  was  put  to 
bed.  He  now  became  much  disturbed,  moaned  and 
groaned  a  great  deal,  was  very  emotional,  often  cried 
and  wept,  had  periods  of  picking  the  bedclothes,  lay  in 
one  position,  and  resisted  being  changed  and  cared 
for. 

This  condition  continued  until  August,  when  he  be- 
gan having  periods,  lasting  for  some  hours,  of  being 
in  a  cataleptic  condition.  At  all  times  he  was  de- 
pressed, but  would  often  talk  and  declaim,  with 
gestures,  about  the  money  he  had  made  and  how  suc- 
cessful he  had  been  at  times.  No  special  change  oc- 
curred in  his  condition  during  September  and  Octo- 
■  ber.  The  fore  part  of  November  he  became  very 
confused,  and  the  symptoms  of  verbigeration  occurred 
now.  He  would  sit  or  stand  and  repeat,  with  monot- 
onous and  continued  gesticulations,  "  I  want  to  go 
home,"  "  I  want  to  go  home,"  "  I  want  to  go  home." 
..."  I  want  to  go  home,"  "  I  want  to  go  home,"  "  I 
want  to  go  home,"  etc. 

During  November  and  December  verbigeration  was 
very  marked.  He  would  frequently  repeat,  "  I  beg 
your  pardon,"  "  I  beg  your  pardon,"  "  I  want  to  go 
home,"  ■'  I  want  to  go  home,"  etc. 

During  lanuarv  he  was  confused  and  quiet.  Verbig- 
eration was  less  frequent.     In  the  fore  part  of  Febru- 


October  2,  1897] 


MPZDH'AI.    RFXORD. 


479 


ary  verbigeration  again  appeared,  and  often  for  hours 
he  would  repeat,  "I  am  wrong,"  "I  am  wrong,"  "I 
want  to  go  home,"  "  I  want  to  go  home,"  "  I  do,"  ""  I 
do,"  etc.,  with  monotonous  gestures.  This  condition 
continued  during  P'ebruary  and  March.  These  periods 
of  noisy  excitement  would  alternate  with  conditions  of 
comparative  quietude,  when  he  would  be  in  a  .semi- 
cataleptic  condition. 

In  April  his  excitement  increased,  and  he  frequently, 
while  making  his  harangues,  would  pull  or  tear  his  ears 
in  addition  to  his  other  gestures.  Often  he  repeated, 
"  I  know  it,''  "  I  know  it,"  "  Kill  me,"  "  Kill  me,"  "  1 
should  not  be  this  way,"  '"  I  should  not  be  this  way," 
"Why  should  I  be  so  filthy?"  "Why  should  I  be  so 
filthy.'"      He  often  seemed  to  be  in  great  fear. 

The  patient  is  still  under  observation  and  is  be- 
coming verj-  thin  in  flesh:  often  resists  care;  is  very 
emotional,  and  has  periods  of  noisy  verbigeration 
alternating  with  comparative  quiet. 

Observations. — If  there  is  one  feature  which  im- 
presses itself  strongly  upon  the  mind  in  reading  the 
histories  of  the  four  cases  just  described,  it  is  that  of 
the  melancholia  present  in  each  and  characteristic  in 
every  respect  of  common  types  of  this  form  of  insanity. 
The  cataleptic  and  allied  motor  phenomena  observed 
in  katatonia  are  not  infrequently  obser\'ed  in  severe 
forms  of  melancholia,  in  which  the  terrible  nature  of  the 
ideas  seems  to  exercise  a  paralyzing  influence  over  the 
whole  motor  mechanism,  but  the  physiology  of  these 
symptoms  is  not  yet  understood.  As  cataleptic  condi- 
tions are  often  noted  in  insanity  associated  with  hys- 
teria, in  pubescent  insanit),  in  epileptic  insanity, 
sometimes  in  general  paresis,  and  in  hypnotic  states, 
they  cannot  be  regarded  as  constituting  a  distinctive 
feature  of  katatonia.  The  most  important  character- 
istic of  the  katatonic  syndrome  serving  to  distinguish 
it  from  melancholia  with  catalepsy  would  seem  to  lie 
in  the  verbigeration  and  rhythmic  gesticulations.  But 
even  these  symptoms  are  met  with  in  other  forms  of 
insanit)',  and  the  automatic  repetitions  of  set  phrases 
with  automatic,  even  rhythmical  movements,  though 
not  so  marked  as  in  these  extreme  forms  to  which  the 
name  katatonia  has  been  applied,  are  familiar  enough 
phenomena  in  long-continued  cases  of  ordinary  melan- 
cholia. 

Conclusions. — Our  study  of  the  subject  and  of  our 
own  cases  leads  us  to  the  following  conclusions: 

1.  Katatonia  is  not  a  distinct  form  of  insanity,  not 
a  clinical  entity. 

2.  There  is  no  true  cyclical  character  in  its  mani- 
festations; hence  it  cannot  properly  be  classed  as  a 
form  of  circular  insanity. 

3.  It  is  simply  a  type  of  melancholia. 

4.  It  is  not  desirable,  therefore,  to  retain  the  name 
katatonia. 

5.  The  term  "  katatonic  melancholia"  or  "  katatonic 
syndrome"  may  be  usefully  retained  as  descriptive  of 
melancholia  with  cataleptic  symptoms,  verbigeration, 
and  rhythmical  movements,  but  should  be  strictly  lim- 
ited to  this  symptom  complex. 

6.  The  prognosis  in  melancholia  with  katatonic 
symptoms  is  more  grave  than  in  any  other  form. 

7.  The  treatment  of  the  katatonic  syndrome  is  the 
same  as  for  other  types  of  melancholia. 


KIlll.KlCRArilV. 

Arndt:  Ueber  Katalepsie  ii.  I'sychose.  Allg.  Zeitschr.  f. 
Psych.,  .\xx.,  1874,  S.  53. 

Amdt;  Ueber  Tetanie  und  I'sychose.  Allg.  Zeitschr.  f. 
Psych.,  .\xx.,  1S74,  S.  28. 

Brosius:  Die  Katatonic.  Allg.  Zeitschr.  f.  Psych.,  vol.  xxxiii., 
p.  770. 

Bondurant:  Katatonia,  with  Six  Illustrative  Cases.  Med. 
News.  vol.  Ixiv. ,  iSi;4.  p.  253. 

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Behr:   iJie  Frage  der  Katatonic.      Kiga,  1S91. 

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and  Psych.,  vol.  ii.,  p.  585. 

•  'louston:   Mental  Diseases,  p.  238,  1897. 

Donkersloot:  Ueber  Aetiol.  u.  Behandl.  d.  Katatonic.  Cong. 
Period.  Internal,  des  Sciences  .Med.,  Con_yt.  Kend.,  1S78, 
Amst.  Si,  vi.,  part  ii.,  p.  173. 

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p.   2f. 

Fink:  Beitr.  z.  Kenntnissdes  Jugendirreseins.  .\llg.  Zeitschr. 
f.  Psych.,  vol.  xxxvii.,  p.  4()(). 

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166,  edition  of  1S86. 

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Xeur.  and  Psych.,  1S83,  p.  302. 

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Zeitschr.  f.  Psjxh.,  vol.  .xxxiii.,  p.  602. 

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Kahlbaum,  Karl:  Klin.  Abhand.  iiber  psych.  Krankheiten. 
Heft  i..  Die  Katatonic,  Berlin,  Hirschwald,  1874. 

Kiernan:   Katatonia.      .\lienist  and  Neurologist,  18S2,  p.  55S. 

Kiernan:   Katatonia.      Detroit  Lancet,  February,  1884. 

Kiernan:  Katatonia.  .\iner.  Jour,  of  Insanity,  vol.  xxxiv., 
1877. 

Knechf  Ueber  die  katatonischen  Erschein.  i.  d.  Paral. 
Allg.  Zeitschr.  f.  Psych.,  vol.  Ixii.,  1886. 

Konrad;  Zur  Lehre  v.  d.  Katatonie.  Or\'osi,  Hetilap,  1SS2; 
also  Pest,  med.-chir.  Presse,  1882,  p.  856. 

Krafft-Ebing:  Lehrbuch  der  P.sychiatrie.  Second  and  fifth 
editions  (Circulares  Irresein). 

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1S82;  also  Pest,  med.-chir.  Presse.  18S2,  vol.  xviii.,  p.  152. 

Lewis,  Bevan:  Text-Book  of  .M^tal  Diseases,  p.  238.  Phila- 
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Marzocchi:  Sopra  un  Caso  di  Catatonia.  Arch.  Ital.  per  le 
Mai.  Nerv.,  Milano,  1SS9,  vol.  xxvi.,  p.  229. 

Mickle,  \V.  Julius:   Katatonie.      Brain,  vol.  xii.,  i88g,  p.    503. 

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99. 

Neisser,  Clemens:  Tuke's  Dictionary  of  Psychological  Medi- 
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Neisser,  Clemens:   Ueber  die  Katatonie.      Stuttgart,  1887. 

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Nervenheilk.,  18S3,  p.  529. 

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480 


MEDICAL    RECORD. 


[Octrber  2.   1897 


A    CASE   OF    ACQUIRED    ATRESIA    OF    THE 
VAGINA,  COMPLICATED  BY  PREGNANCY.' 

]{Y    AUf;U.STA   VKDIN,    M.!)., 

A  rri'.Nn!KO    niVSICIAN,    CLASS   OI-    tiVN.r.COLOGV.     DISl'KNSAK  V      "i     M  \N      \"!<K 
INFIRMARY    AN'D    DKMII.T   DISPUNSAICV. 

M.    C ,   Italian,   aged    thirty-five   years,  came    to 

the  dispensary  September  10,  1896,  on  account  of  sup- 
pression of  the  menses  for  six  months.  She  had  been 
married  fifteen  years,  had  given  birth  to  one  child 
fourteen  years  ago,  and  since  had  menstruated  regu- 
larly until  six  months  ago.  On  my  suggesting  an  exam- 
ination for  pregnancy,  she  said  that  this  was  impossi- 
ble, and  explained  that  the  vagina  had  been  "closed 
up"  for  fourteen  years.  Examination  showed  this  to 
be  really  the  case.  The  vagina  ended  blindly  at  the 
junction  of  the  lower  and  middle  third  or  about  one 
inch  from  the  introitus,  being  constricted  in  a  funnel- 
siiaped  manner  by  a  very  den.se  cicatricial  ring,  the 
apex  consisting  of  a  small  diaphragm  of  very  firm  un- 
yielding tissue,  which  seemed  completely  imperforate, 
but  on  close  inspection  through  a  speculum  showed  a 
minute  opening,  which  admitted  on  pressure  a  fine 
probe,  and  through  this  the  menstrual  flux  had  escaped 
s;uUatim  during  all  these  years.  The  parts  were  sen- 
sitive to  pressure.  The  vulva  gaped  somewhat,  on 
account  of  the  perineum  having  been  lacerated,  and 
presented  a  rectocele  and  cystocele  below  the  cicatri- 
cial occlusion,  making  the  stenosis  appear  nearer  the 
vulvar  orifice  than  it  really  was.  Above  the  symphy- 
sis was  a  globular,  elastic  tumor,  which  could  not 
very  well  be  anything  but  the  i^regnant  uterus  of  about 
four  months. 

The  history  of  the  case  was  as  follows:  The  pa- 
tient became  pregnant  for  tlie  first  time  fifteen 
years  ago,  with  the  result  of  a  stillbirth  at  term,  after 
a  protracted  labor  superintended  by  a  midwife.  She 
slates  that  the  head  descended  into  the  soft  parts  of 
the  pelvis,  and,  remaining  there,  made  no  further  prog- 
ress. The  parts  became  ttdematous  and  very  painful 
and  "turned  black,"  but  the  midwife  did  not  consider 
it  necessary  to  call  a  physician.  Finally  a  dead  child 
was  born  without  any  operative  interference,  the  labor 
having  lasted  twenty-four  hours.  She  states  that  after 
this  she  was  very  ill  and  had  fever,  but  cannot  give 
any  further  intelligent  account  of  the  puerperiuni ; 
twen^ty-two  days  after  delivery  she  discovered  that  the 
vagina  was  completely  occluded,  and  sought  the  ad- 
vice of  a  physician  in  Palermo,  who  recommended 
operation.  This  she  refused,  and  the  condition  that 
existed  then  had  now  existed  for  fourteen  years,  with 
this  variation  only,  that  a  pregnancy  had  now  super- 
vened. There  is  no  doubt  that  the  atresia  in  this 
case  was  due  to  the  prolonged  pressure  of  the  head 
on  the  vaginal  walls,  thereby  causing  necrosis  and 
extensive  loss  of  tissue,  residting  in  the  formation  of 
cicatricial  tissue.  The  patient  had  in  no  way  been 
aware  of  any  narrowing  of  the  vagina  previous  to  her 
accouchement. 

Heing  informed  of  her  condition,  and  toUl  iluu  an 
operation  was  necessary,  she  consented,  although  in- 
credulous as  to  her  pregnancy.  Five  days  later  she 
w.is  etherized;  the  pin-hole  opening  was  incised  until 
tlie  finger  could  be  admitted,  wiiich  revealed  the  fact 
that  the  very  dense  annular  stricture  was  about  one- 
half  inch  in  thickness,  thinning  out  toward  the  lumen. 
Above,  the  vagina  was  ample,  and  a  softened  cervix 
was  felt  and  bimanually  the  pregnant  uterus  of  about 
four  months.  With  the  galvano-cautery  knife  the 
thick  cicatricial  tissue  was  cut  through  in  several 
places — care  being  taken  to  avoid  the  urethra  and  rec- 
tum— until  a  large  Cusco  speculum  could  be  introduced 
and  opened  widely.     A  tiiick  plug  of  iodoform  gauze 

'  Read  before  the  AluiniiA'  .VssDci.ition  of  t!ic  Woman's  Medic.il 
College  of  the  New  York  Infirnuiry,  Xhiivh  12.  iSq;. 


was  placed  in  the  vagina  and  renewed  daily  after  an- 
tiseptic douches,  until  the  vagina  was  healed  and 
promised  well  to  remain  in  a  good  condition.  But  it 
was  soon  evident  that  contraction  was  beginning 
again,  in  spite  of  the  tamponing.  The  patient  ceased 
coming  regularly  to  the  clinic  which  she  had  attended 
after  the  vagina  was  sufficiently  healed,  and  when  she 
returned  after  a  time  of  absence  it  was  found  so  con- 
tracted that  it  with  difficulty  admitted  the  index  finger, 
and  attempts  at  dilatation  were  of  no  avail.  The 
pregnancy  was  advancing,  and  the  patient  herself  was 
now  becoming  con\inced  of  her  condition.  It  was 
then  decided  to  wait  for  a  time  to  .see  if  any  spontane- 
ous softening  would  take  place,  but  such  not  having 
been  the  case  in  the  cour.se  of  three  months,  it  was 
decided  to  open  the  vagina  again  and  introduce  a 
large  Sims  glass  plug.  It  seemed  reasonable  to  think 
that  whatever  ground  could  be  gained  before  the  ad- 
vent of  labor  would  be  an  advantage,  obviating  the  de- 
pendence on  incisions  and  forceps  sub pariii,  with  incal- 
culable rents  and  surely  a  field  for  infection. 

On  December  20th  the  patient  was  etherized  again, 
being  at  this  time  nearly  seven  and  a  half  months 
pregnant.  The  stricture  now  just  admitted  the  ex- 
treme tip  of  the  little  finger.  The  galvano-cautery 
knife  was  again  used,  as  it  seemed  on  the  whole  pref- 
erable to  avoid  hemorrhage  in  a  pregnant  woman 
already  anatmic,  and  also  it  seemed  that  a  large  glass 
plug  ought  to  overcome  efl^ectually  the  greater  tendency 
to  cicatrization  and  further  solidification  consequent 
on  using  the  cautery.  Several  incisions  were  made 
around  the  entire  circumference  of  the  cicatricial 
mass,  avoiding  urethra  and  rectum,  laterally  cutting 
more  deeply  than  the  previous  time,  to  secure  as  much 
space  as  possible.  Judging  from  the  not  inconsidera- 
ble bleeding  as  it  was,  it  must  have  been  excessive 
had  a  bistoury  been  used.  A  Sims  glass  plug,  four 
and  three-fourths  inches  in  circumference,  the  largest 
that  could  be  secured  then,  was  introduced  and  held 
in  place  b)- a  stem  inserted  into  the  hollow  of  the  tube 
(in  this  case  the  large  vaginal  nozzle  of  a  fountain 
syringe)  with  four  bands  attached,  the  latter  being 
fastened  to  a  waistband.  Cotton  was  packed  around 
the  stem  in  the  hollow  of  the  tube,  and,  planted  firml\ 
in  this  way  in  the  cotton,  it  proved  an  effectual  means 
of  keeping  the  tulie  in  place.  There  were  no  un- 
toward effects  from  the  operation.  Two  days  later  a 
slightly  larger  glass  tube  was  secured  and  introduced 
before  any  contraction  had  taken  placx-.  After  a  few 
days  digital  examination  showed  the  vagina  healed 
and  spacious  without  any  vestige  of  the  constricting 
ridge,  the  mucous  membrane  being  uniformly  smootli 
and  relaxed.  The  glass  plug  was  now  exchanged  for 
a  Sims  plug  of  hard  rubber,  to  avoid  the  danger  of 
breaking;  this  latter  measured  five  and  one-fourth 
inches  in  circumference,  and  was  thought  to  be  as  large 
as  the  patient  could  wear  without  too  great  inconven- 
ience. To  prevent  irritation,  cotton  was  padded  about 
the  vulva  under  the  flanges  of  tlie  tube  and  under  thr 
bands.  It  was  rem<ived  dailv  for  cleansing  and  irri- 
gation of  the  vagina,  being  worn  otherwise  constantly 
and  without  much  discomfort.  But  on  the  fourteentli 
day  after  the  operation  the  patient  allowed  the  tube 
to  come  out,  and,  having  left  it  out  for  sixteen  hours, 
was  unable  to  replace  it.  I  fountl  the  vaginal  lumen 
contracted  and  could  not  replace  either  the  tube  worn 
daily  or  the  next  smaller  size,  and,  having  no  other 
with  me,  the  patient  liad  to  spend  the  night  without  a 
lube. 

The  following  morning,  January  31!.  I  found  to  my 
chagrin  lii.U  the  only  tube  that  could  be  introduced 
was  the  fourth  in  order  of  size  from  the  one  worn 
daily,  being  one  inch  smaller:  the  constrictor  vagina- 
resisted  as  firmly  as  if  already  transformed  into  a 
cicatricial    band.      Januarv   ^Ih.   T    fovmd    the    vagina 


October  2,  1897] 


MEDICAL    RECORD. 


481 


more  relaxed,  the  constrictor  vagina  having  been  par- 
tially paralyzed  by  the  tube,  so  that  the  next  larger 
could  be  inserted  with  ease.  Januarj'  5th,  I  replaced 
the  tube  by  one  ne.vt  larger,  without  difficulty.  In  this 
way  having  gradually  returned  to  the  largest  hard- 
rubber  tube  this  was  worn  up  to  the  commencement  of 
labor,  except  for  daily  irrigation  of  the  vagina,  the  pa- 
tient continuing  in  a  good  condition  throughout. 

Thus  the  calibre  gained,  five  and  one-fourth  inches, 
was  maintained  up  to  the  very  beginning  of  labor,  but 
as  for  any  further  spontaneous  softening  or  increased 
dilatabilit)'  as  the  pregnancy  advanced,  none  could  be 
detected.  The  vagina  continued  to  feel  spacious,  no 
constriction  or  ridge  being  discoverable  by  the  examin- 
ing finger,  but  through  a  large  glass  tube  one  could 
see  a  pale  zone  of  tissue,  the  path  of  the  former  stric- 
ture, half  an  inch  wide  and  surrounding  the  entirt- 
vagina,  and  attempts  to  stretch  this  with  two  fingers 
showed  it  to  be  unyielding.  The  iniroiius  vagina- 
and  adjacent  parts  also  showed  a  noticeable  lack  of 
softening,  and  the  varicose  condition  and  consequent 
violaceous  or  purple  hue  conimon  in  advanced  preg- 
nancy was  almost  absent. 

Labor  pains  commenced  on  February  12th  at  mid- 
night (at  term,  having  been  predicted  for  February 
I oth),  becoming  frequent  and  violent  at  7  a.m.  V\'hiie 
the  cer\'ix  was  dilating,  which  it  did  but  slowly — tht 
amniotic  fiuid  having  escaped  gradually  during  the 
last  three  days — the  condition  below  did  not  seem 
unpromising,  except  fur  a  slight  bridge  of  tissue  in 
the  right  upper  quadrant  of  the  vagina,  the  only  part 
of  the  zone  formerly  a  stricture  that  in  any  way  sug- 
gested a  stricture,  and  had  it  not  been  for  previous 
knowledge  of  the  condition  of  the  vagina  one  would 
not  have  thought  of  any  abnormality  or  noticed  any 
barrier  to  delivery,  except  for  tlie  slight  ridge  just 
mentioned,  wliich  was  elected  as  a  site  for  incision 
should  such  i)e  needed.  The  recto-vaginal  septum 
was  smooth,  relaxed,  and  thin,  and  there  surely  no  in- 
cisions could  be  made.  But  no  .sooner  had  the  head 
passed  the  cervix  than  it  became  too  evident  that  the 
zone  of  new  ti.ssue  was  a  most  formidable  barrier 
to  the  further  progress  of  the  head.  The  channel  of 
five  and  one-fourth  inches  that  had  been  attained 
through  the  operation  was  of  no  more  yielding  nature 
than  the  pin-hole  opening  first  discovered,  and  formed 
a  hard  circle  on  which  the  violent  pains  had  no  eftect 
whatever.  Instead  of  dilating,  the  aperture  seemed  to 
become  actually  smaller,  with  the  head  pressing  hope- 
lessly against  it.  This  opinion  was  concurred  in  liy 
Dr.  Frances  Young  and  four  students  who  witnessed 
the  case  with  me,  who  an  hour  before  had  been  unable 
to  discover  any  signs  of  a  stricture  and  now  like 
myself  became  convinced  of  the  unyielding  nature  of 
this  new  tissue.  After  a  period  of  terrific  pains  and 
no  yielding,  two  incisions  were  made  with  a  probe- 
pointed  bistoury  introduced  between  the  head  and  the 
vaginal  ring,  in  the  right  upper  quadrant,  one  rather 
superficial,  one  deeper,  causing  considerable  hemor- 
rhage but  no  apparent  progress.  The  incisions  were 
made  during  the  pains,  and  the  patient  felt  then  com- 
paratively little  on  account  of  the  severity  of  these. 
Half  an  hour  later,  nothing  having  been  gained,  two 
more  and  rather  deeper  incisions  were  made,  one  in 
the  left  upper  quadrant  of  the  circle,  the  other  laterally 
on  the  left  side,  with  profuse  hemorrhage,  which,  how- 
ever, was  soon  checked  by  the  on-pressing  head.  The 
violent  expulsive  pains  were  now  effectual,  and  in  a 
few  moments  the  child  was  delivered,  slightly  cyanosed 
but  soon  revived.  The  placenta  followed  immediately 
and  the  uterus  contracted  well.     The  child  was  fol- 

i lowed  by  a  gush  of  meconium  and  had  meconium  in 
the  mouth,  'i'he  labor  had  lasted  in  all  ten  hours, 
with  severe  pains  the  last  three  hours.  The  patient 
was  in  a  good  condition  and  had  felt  the   incisions 


only  slightly,  except  the  last  one.  On  examining  the 
vagina  it  was  found  that  the  incisions  had  enlarged 
into  considerable  rents,  which,  however,  had  not  ex- 
tended into  dangerous  ground.  The  last  deep  cut 
proved  to  be  rather  closer  to  the  vicinity  of  the  rectum 
than  was  intended,  but  there  was  no  tear  into  the  rec- 
tum. The  deep  incision  on  the  right  side  made  a 
pocket-like  rent  upward  in  the  vagina.  The  thinned, 
now  bell-shaped  cervix  was  well  constricted  at  the  in- 
ternal OS  and  the  vaginal  roof  all  around  the  cervix 
was  intact,  no  tear  having  reached  up  to  that  vicinity. 
The  cervix  was  prolapsed  so  that  it  partly  protruded 
at  the  vulva.  There  was  very  moderate  hemorrhage 
after  deliver)-.  The  vagina  was  syringed  out  with 
warm  carbolized  water.  It  was  thought  best  to  leave 
the  wounds  unsutured,  as  it  seemed  that  the  lochia 
flowing  over  them  would  delay  their  healing  and  thus 
prevent  contraction  to  some  extent. 

The  infant  was  of  the  male  sex,  weighed  seven 
pounds,  and  was  to  all  appearance  healthy.  It  pre- 
sented the  anomaly  of  a  supernumerary  toe  on  the 
right  foot. 

The  puerperium  was  uneventful  and  recovery  unin- 
terrupted. The  vagina  was  irrigated  daily  with  steri- 
lized water.  There  was  at  no  time  any  rise  of  temper- 
ature. On  the  eighth  day,  the  vaginal  wounds  being 
healed  and  no  longer  tender,  a  vaginal  speculum  was 
introduced  with  instructions  io  wear  it  two  or  three 
hours  dail)-  if  possible,  which  W'as  done  for  some  days. 

In  searching  through  the  literature  for  information 
while  obser\-ing  this  case,  it  was  found  that  of  313 
cases  of  atresia  vaginae  complicated  by  pregnancy— 
299  of  which  are  collected  by  Neugebauer  '• — 257  were 
delivered /('r  TW  ;/<?/«/v/ //•.»■,  while  56  required  Cesa- 
rean section.  Of  the  257,  spontaneous  delivery  oc- 
curred in  82  cases,  the  majoritj'  of  these  being  of  the 
membranous  or  congenital  variety,  or  simply  narrow- 
ings  of  the  vagina,  1 1,  however,  resulting  fatally  from 
rupture  of  the  uterus  or  vagina  or  from  peritonitis.  In 
122  cases  delivery  was  accomplished  by  incisions  or  by 
forceps,  or  by  both,  with  18  deaths  from  rupture  of 
uterus  or  vagina,  peritonitis,  and  eclampsia.  In  21 
cases  version,  perforation,  or  embryotomy  was  required, 
6  ending  fatally  for  the  mother,  the  death  rate  for  the 
child  being  in  all  the  cases,  by  whatever  mode  of  de- 
liverj',  naturally  much  larger.  The  remaining  cases, 
32  in  number,  are  incompletely  described.  Of  the  56 
cases  that  required  Cesarean  section,  several  had  con- 
tracted pelvis  in  addition  to  the  atresia. 

Of  operative  measures  during  pregnancy  on  account 
of  atresia  vagine,  eight  cases  have  been  gleaned — one 
of  artificial  abortion  in  the  fifth  month,"  two  of  artificial 
abortion  in  the  seventh  month,  one  with  perforation  of 
the  head  (159  and  233) ; '  one  of  operation  for  a  mem- 
branous stricture  (293)  ;  one  case  operated  by  Eehn 
(62),  in  which  incisions  had  to  be  made  during  labor 
nevertheless;  one  (98)  in  v.liich  stricture  returned,  jw^- 
partu  incisions  and  forceps,  eclampsia  and  death;  one 
(254)  in  which  the  lumen  of  the  vagina  was  enlarged 
sufficiently  to  admit  two  fingers,  by  means  of  two 
longitudinal  incisions  laterally,  one  of  which  was  su- 
tured transversely,  the  other  covered  by  a  bit  of  tissue 
from  a  colporrhaphy  case  just  operated  upon — later, 
contraction  so  that  one  finger  only  was  admitted,  sub- 
partii  incisions  and  forceps;  one*  of  operation  in  the 
third  month  for  congenital  absence  of  vagina  with 
enlarged  meatus  urinarius,  aborting  on  third  day. 

As  regards  the  post-partuni  return  of  the  stricture, 
mention  is  made  in  onl)-  ten  of  the  cases,  in  nine  of 

'Neugebauer:  "  Zur  Lehre  von  den  angeborenen  und  erwor- 
benen  Verwachsungen  und  Verens;erungen  der  Scheide,"  Berlin, 
iS,)5. 

'  Bazzani  :  Sperimentale,  Firenze,  1878,  xlii.,  2£y. 

'  Numerical  order  of  case  in  Neugebauer's  collection. 

'Sale:  Tr.  Mississippi  Association,  Jackson,  1880,  xiii., 
162. 


MEDICAL    RECORD. 


[October  2,  1897 


which  there  was  almost  complete  return,  in  one  no  re- 
turn in  five  weeks.  In  the  present  case  the  vagina  is 
as  yet  ample,  four  weeks  after  c'eliver\-. 

234  East  Fifteenth  Stkeri. 


THE  EARLY  DIAGNOSIS  OF  SPORADIC 
CRETINISM,  WITH  A  REPORT  OF  TWO 
CASES  OF  CONGENITAL  SPORADIC  CRE- 
TINISM. 

Bv    HENRV    KOi'LIK,    M.D.. 


Infants  or  children  who  are  the  subjects  of  sporadic 
cretinism,  in  whom  the  disease  has  existed  for  a  year 
or  more  before  the  diagnosis  is  made  and  treatment 
with  thyroids  begun,  are  not  always  restored  to  a  men- 
tal and  physical  state  exactly  equivalent  to  the  normal 
one.  The  writer  has  observed  in  two  cases  which 
have  come  under  his  observation  that  although  the 
symptoms  of  idiocy  and  myxoedema  disappeared,  the 
children  after  fully  two  years  of  treatment  remained 
somewhat  deficient  in  physical  and  mental  develop- 
ment. In  one  case,  a  boy,  fifteen  months  old  when 
treatment  was  begun,  after  two  years  of  constant  ad- 
ministration of  thyroids,  is  still  unable  to  talk  sen- 
tences. The  vocabulary  seems  limited  to  a  few  words 
of  one  or  two  syllables.  The  physical  development  is 
that  of  a  child  a  year  or  so  younger.  In  another  case, 
in  which  the  treatment  was  begun  after  the  disease 
had  existed  fully  a  year  or  more,  the  child,  though 
bright,  talks  to  a  very  limited  extent. 

If  these  things  are  to  be  confirmed  by  other  observ- 
ers, as  I  am  certain  they  will  be,  it  would  seem  highly 
desirable  to  recognize  this  disease  ery  early  in  its  de- 
velopment, before  the  nervous  system  has  been  seriously 
compromised  by  a  more  or  less  prolonged  period  of 
retarded  growth  or  action  of  infectious  agents  or  influ- 
ences which  are  active  in  this  affection.  In  the  pub- 
lished .\merican  literature  of  sporadic  cretinism,  we 
have  no  cases  of  congenital  cretinism  (sporadic)  pub- 
lished as  such.  Townsend,'  in  1894,  reported  a  case 
of  congenital  rickets  which  terminated  fatally  in  nine 
days.     If  we  accept  the  classification  of  Horsley,  we 

should  now  in- 
clude this  case 
as  one  of  congen- 
ital sporadic  cre- 
tinism. Of  the 
cases  published 
by  foreign  au- 
thors, w  e  find 
that  only  a  men- 
tion of  the  con- 
genital cases  is 
made  by  Fletcher 
Beach,"  who  in  a 
study  of  fifty- 
t  w  o  cases  of 
j'poradic  cretin- 
ism found  onh 
nine  cases  which 
siiowed  symp- 
toms at  periods 
from  birth  up  to 
the  ninth  month. 
There  is  reason 
to  believe  that  a  vast  number  of  the  cases  published, 
especially  those  cases  which  have  come  under  treatment 
at  the  age  of  one  and  one-half  years  to  two  vears,  form- 
ing the  mass  of  the  literature  in  America,  must  have 
been  sufferers  from  the  disease  long  before  the  symp- 

'  .\rcliives  of   Pediatrics. 

■  Rritish  Medical  Toumal,  iSi)6. 


Fig.  2. — Congenital  Sporadic 
Cretinism.  Child  shown 
in  Fig.  I,  after  four  months 
of  treatment. 


toms  were  discovered  by  the  physician.  In  many  of 
the  younger  cases  of  sporadic  cretinism  the  history 
will  state  that  the  mother  first  noted  the  illness  of  the 
infant  at  the  fifth  or  sixth  or  twelfth  month.  These 
statements  are  fully  unreliable.  It  will  be  seen  that 
in  the  two  rare  cases  here  reported  by  the  writer,  the 
mothers  did  not  notice  any- 
thing wrong  with  the  general 
condition  of  the  patients  and 
came  for  relief  in  other  direc- 
tions (intestinal  colic  or  jaun- 
dice) .  In  one  case  a  physician 
failed  to  notice  the  symptoms 
which  were  characteristic  of 
beginning  cretinism.  The 
children  or  infants  who  are  as 
a  rule  brought  for  treatment 
to  the  clinics,  and  who  are  suf- 
fering from  sporadic  cretinism, 
are  brought  at  a  period  when 
all  the  symptoms  have  devel- 
oped in  their  most  pronounced 
types,  so  pronounced  and 
marked  that  not  only  the 
mothers  but  strangers  are  cog- 
nizant that  the  patient  is  well  started  on  a  form  of 
severe  disease.  It  is  for  these  reasons  and  to  aid  the 
early  discovery  of  the  cases  of  this  disease,  that  the 
following  rare  examples  of  early  cretinism  are  pub- 
lished as  a  distinct  set  of  cases. 

Case  I. — -Female  infant,  aged  one  month,  seen  first 
December  24,  1896.  This  infant  is  a  sister  to  a  fully 
developed  cretin,  and  is  the  first  infant  born  to  the 
mother  after  the  cretin  referred  to  had  been  under 
treatment  fully  two  years.  Mother  and  father  are  first 
cousins;  no  goitre  in  either.  The  birth  was  a  normal 
one.  When  the  child  was  four  days  old  icterus  neona- 
torum appeared  and  persisted  six  weeks.  At  the  age  of 
one  month,  the  mother  brought  the  infant  to  me  for 
jaundice.  I  saw  a  fairly  nourished  infant  still  jaun- 
diced;  the  expression  of  the  face  was  strikingly  prog- 
nathous. The  infant  did  not  cry  unless  severely  teased  ; 
it  seemed  very  torpid.  The  head  was  broad  at  the 
base  of  the  skull,  smaller  at  the  summit,  not  markedly 
pointed.  The  abdomen  was  distinctly  rotund.  The 
extremities  were  short,  but  not  deformed.  The  child 
was  short  and  thick  set.  There  was  no  my.xcedema  of 
the  skin,  but  the  whole  surface  was  cool  to  the  touch; 
the  lips  were  slightly  puffed ;  the  tongue  was  very  large 
and  thick  (macroglossia) :  the  neck  was  short  and 
thick. 

Head:  circumference,  38  cm.;  antero-posteriorly, 
23  cm.;  bitemporal.  20  cm.:  rather  of  the  o.xycephalic 
type. 

Fontanel le,   anterior,  3. 1    l)y    . 
open  to  the  occipital  depression 

Thyroid  gland  not  palpable. 

Ha;moglobin,  85. 

Temperature,  rectum,  96     F. 

As  said  above,  the  child  was  stupid,  and  clapping 
of  the  hands  failed  to  attract  its  attention.  Under  thy- 
roid treatment  the  temperature  gradually  rose  in  the 
rectum  to  98  F.  The  infant  became  bright  and 
seemed  to  notice  surroundings,  and  smiled.  The 
tongue  became  markedly  thinner  and  the  face  normal 
in  expression.  It  played  and  laughed  and  cried  as 
other  infants ;  the  forehead  was  broader  and  had  lost  its 
wrinkled  appearance. 

February  15th,  hemoglobin.  60.  Temperature. 
rectal,  98.4  F.  .\t  no  time  could  the  thyroid  be  felt 
and  no  supraclavicular  masses  of  fat  were  present. 

In  this  case  we  find  a  newborn  babe,  whose  mother 
had  previously  gi\en  birth  to  a  cretin,  showing  symp- 
toms of  slight  cretinism.  The  stupidity  of  the  infant, 
the  reduced  internal   tomper.iture,   the   peculiar  con- 


cm.  ;  sagittal  suture 


October  2,  1897] 


MEDICAL    RECORD. 


483 


formity  of  the  extremities  as  related  to  the  trunk,  the 
wrinkled  skin  on  the  forehead  and  hands,  the  narrow 
animal  forehead,  the  thick  lips,  the  thick  immense 
tongue  ( macroglossia),  the  coarse  cry,  the  immediate 
improvement  of  the  stupidity  under  thyroid,  and  the 
reduction  of  the  thickened  and  hypertrophied  tongue 
— all  point  to  the  inevitable  conclusion  that  here  we 
had  to  deal  with  a  congenital  cretin,  who  if  allowed 
to  progress  would  develop  the  symptoms  of  the  disease 
in  their  more  pronounced  forms.  It  is  an  interesting 
fact  that  in  this  case,  early  in  the  disease,  the  haemo- 
globin was  greater  than  later  on,  though  the  infant 
was  immediately  placed  upon  thyroids.  This  was 
also  the  case  with  the  second  patient,  in  whose  history 
blood  data  are  given  and  which  will  be  discussed 
later  on. 

May  25th,  at  the  present  day,  with  six  months  of 
treatment,  we  ha\e  a  very  bright  and  interesting  in- 
fant, in  every  way  resembling  the  normal  infant.  It 
attempts  to  stand  and  utters  sounds.  The  infant  is 
still  under  thyroid  therapy,  one-half  grain  t.i.d.  On 
the  whole,  the  infant  is  a  much  more  satisfactory  case 
after  six  months  of  treatment,  as  far  as  restoration  to 
normal  conditions  is  concerned,  than  its  brother  was 
after  the  same  period  of  treatment.  The  brother  came 
under  my  care  at  the  age  of  fifteen  months,  at  ih.a 
time  a  fully  developed  cretin.  He  is  also  still  und-  ■ 
observation.  Though  two  years  under  treatment,  :i 
stated  above,  the  brother  is  not  the  complete  equal  >''. 
other  children  of  his  age.  He  cannot  talk  sentence^ 
is  an  interesting  child,  but  impresses  one  as  equal  i  > 
a  child  of  two  years  of  age  rather  than  one  nearly  four 
years  old. 

Case    II. — W.  F ■,    female    infant,  nine    weeks 

old.  Mother  and  father  healthy ;  mother  or  father 
have  no  goitre  nor  any  other  abnormalities;  no  con- 
sanguinity. This  is  the  first  baby  ;  breastfed.  Moth- 
er from  birth  of  the  baby,  which  was  normal,  head  pre- 
sentation, noticed  that  the  baby  was  stupid.  The 
baby  did  not  resemble  either  parent,  having  a  small 
low  forehead,  flat  nose,  puffy  eyelids,  thick  lips,  and 
large  tongue.  The  abdomen  has  been  quite  large,  and 
the  baby  cried  incessantly,  so  much  so  that  the  mother 
took  the  baby  to  a  physician,  who  diagnosed  an  ob- 
struction of  the  gut.  She  then  brought  the  infant  to 
the  writer. 

Status  pnesens :  Looking  at  the  infant,  it  has  the 
gross  characteristics  in  expression  of  a  typical  cretin, 
but  in  less  pronounced  form.  The  forehead  is  low 
and  narrow,  the  eyelids  are  puffy  and  cedematous  in  ap- 
pearance, the  bridge  of  the  nose  is  Hat,  the  lips  are  thick- 
ened :  the  tongue  is  large,  broad,  thick,  and  protruding 
at  times.  The  abdomen  is  large,  and  the  thighs  and 
legs  are  quite  dwarfish  as  compared  with  the  size  of  the 
trunk.  The  skin  has  a  greenish  hue;  no  thyroid  can 
be  felt;  the  external  temperature  of  the  skin  is  much 
below  normal,  hands  and  feet  are  cool;  skin  of  hands 
has  a  finely  wrinkled  look.  Cry  is  coarse  and  deep. 
Internal  rectal  temperature,  97.8*^  F.  The  bowels  are 
constipated. 

Measurements,  head:  fontanelle,  anteriorly  and 
posteriorly,  open;  glabella  to  occiput,  i8  inches: 
vertex,  8'^  inches;  bitemporal  diameter,  9  inches. 
Chest,  14  inches.  Length  of  arm,  i3'.{  inches: 
length  of  forearm,  8'j  inches.  length  of  body,  18 
inches. 

Hlood,  May  15th  (Fleischl)  :  Harmoglobin,  105  :  red 
cells,  3,026,000;  white  cells,  13,500.  .\pril  29th, 
hiemoglobin,  55.     May  2 2d,  haemoglobin,  65. 

Course  of  case:  The  infant  improved  in  its  general 
appearance  from  the  first  week  of  treatment.  The  writ- 
er noticed  that  it  became  quieter  or  brighter.  The  puf- 
finess  of  the  eyelids  has  gradually  subsided.  The  lips 
have  become  thinner,  and  the  tongue  has  improved, 
so  that  to-day  it  is  quite  slender  and   much   like  the 


normal  tongue.  The  temperature  has  gradually  risen 
to  the  normal,  and  the  color  of  the  skin  has  lost  its 
greenish  tint  and  taken  on  a  healthy  hue.  The  cry 
is  no  longer  deep  and  hoarse.  The  abdomen  is  not 
large  and  distended,  and  the  dwarfish  appearance  of 
the  legs  has  disappeared.  The  baby  seems  as  bright 
as  a  normal  baby  of  its  age  (three  and  one-half 
months).  The  expansion  and  growth  of  the  forehead 
and  bridge  of  the  nose,  both  of  which  have  lost  their 
cretinal  conformity,  are  most  intere.sting,  and  now  the 
face  has  a  tolerably  pleasant  appearance.  The  baby 
is  beginning  to  remember  its  mother.  Takes  thyroid, 
one-half  grain  t.i.d. 

In  the  above  case  we  have  a  typical  cretin  of  the 
congenital  type.  There  were  all  the  symptoms  of  cre- 
tinism developed  in  an  early  stage.  The  beginning 
myxcedema  of  the  skin,  the  prognathous  expression  of 
the  face,  the  low  forehead,  the  flattened  bridge  of  the 
nose,  the  thickened  eyelids,  the  thickened  lips,  the  en- 
larged and  thickened  and  broad  tongue,  the  dwarfish 
conformity  of  the  body  extremities  as  compared  to  the 
length  of  the  trunk,  the  protuberant  abdomen,  the  skin 
of  a  greenish  hue,  the  marked  torpor,  reduced  internal 


temperature — all  point  inevitably  to  the  diagnosis  of 
congenital  sporadic  cretinism. 

It  may  be  remarked  that  the  hair  in  this  case  was 
not  as  yet  dry  and  sparse,  but  glossy  and  abundant. 

The  blood  examinations  in  both  these  cases  were  of 
interest,  showing  that  in  the  ver)'  early  stages  of  the 
disease  the  blood  is  not  affected  by  an  ancemia  such 
as  we  find  in  advanced  cases  which  have  not  been  the 
subject  of  treatment.  Thus  in  an  advanced  case,  aged 
fifteen  months,  the  ha;moglobin  before  treatment  was 
18  (P'leischl);  in  another,  aged  twenty  months,  25 
(Fleischl).  In  the  first  case  reported  in  this  paper,  the 
heemoglobin  fell  to  60,  and  now  is  65.  In  this  case 
the  haemoglobin  was  taken  after  treatment  had  been 
begun.  In  the  second  case,  hamoglobin  at  the  outset, 
105;  red  cells,  3,026,000;  white  cells,  13,500.  April 
2gth,  haemoglobin,  55;  May  ist,  haemoglobin,  53; 
May  22d,  haemoglobin,  65. 

Thus  we  have  at  the  outset  nothing  otherw-ise  than 
is  found  in  the  normal  infant,  as  far  as  the  haemoglo- 
bin is  concerned ;  the  blood  has  the  characteristics 
practically  of  the  so-called  foetal  blood  of  Hayem. 

(>6  Ea^t  Fiftv-Eighth  Street. 


Chronic  Otorrhoea. — 

B  Iodide  of  potassium gr.  .\x. 

Tincture  of  iodine 3  ''j- 

.Mcohol. 

(ilycerin aa   3  iv. 

lodofomi gr.  .\x. 

.\  small  quantity  to  be  injected  into  thie  auditor)-  canal. 

— A'lcdiail  Press  and  Circular.  April  7th. 


484 


MEDICAL    RECORD. 


[October  2,  1897 


ROUGH    NOTES    ON    SOME   ANOMALIES 
IN    ANATOMY.' 

I5Y    R.  IIARCOURT   ANDERSON,    M.D., 


>%5SISTANT   : 


The  anomalous  anatomical  conditions,  or,  to  use  tlie 
term  of  the  biologist,  specimens  coming  under  the  title 
of  variation,  found  in  the  dissecting-room  as  a  rule 
are  viewed  by  the  average  student  in  the  light  of  those 
conditions  which  we  are  wont  to  designate  mere  scien- 
tific curiosities,  or,  if  attention  be  devoted  to  the  etio- 
logical factors  in  the  production  or  evolution  of  the 
same,  the  subject  is  usually  viewed  in  a  superficial 
sense.  The  modern  student  of  human  anatomy,  ever  on 
the  alert  for  the  practical,  and  looking  at  these  devia- 
tions from  the  normal  with  the  eyes  of  the  author  of 
his  text-book,  little  knows  the  fund  of  information  to 
be  gained  by  an  investigation  which  would  lead  into 
the  domain  of  the  comparative  anatomist  or  thinks 
the  requisite  knowledge  of  human  anatomy  to  be  so 
difficult  of  attainment  that  the  time  spent  in  the  con- 
sideration of  anomalies  would  be  wasted. 

There  is  so  much  drudgery  of  thought  connected  with 
acquirement  of  the  almost  endless  details  of  practical 
anatomy  that  it  will  be  admitted  fair  treatment  to 
make  use  of  any  honest  means  to  fi.\  the  composite 
parts  of  the  complex  subject  in  our  minds,  and  so  the 
study  of  anomalous  conditions  will  be  seen  to  be  one 
of  the  pleasant  byroads  to  our  goal,  although  perhaps 
more  applicable  to  the  advanced  thinker  than  the  col- 
lege student.  To  review  this  subject  it  is  necessary 
that  the  ploughshare  of  thought  be  forced  into  ground 
which  has  already  been  deeply  furrowed,  but  it  is  not 
the  object  of  this  short  paper  (which  is  arranged  in 
the  form  of  notes,  more  or  less  closely  connected)  to 
enter  deeply  into  the  very  interesting  but  mostly  the- 
oretical disputations  concerning  the  causation  of 
anomalies,  which  necessarily  include  those  very  com- 
plex subjects,  viz.,  evolution  and  heredity 

It  will  answer  our  purpose  to  touch  lightly  on  some 
of  the  more  prominent  facts  and  theories,  recalling  at 
this  time  the  words  of  that  great  thinker,  Darwin, 
that  '■  we  are  extremely  ignorant  on  this  subject." 

Now  we  may  state  in  passing  that  even  the  least 
important  deviations  from  the  normal  which  may  be 
found  form  certain  or  uncertain  indices  to  the  proc- 
esses'intimately  connected  with  knowledge  of  changes 
that  are  to  be  considered  in  the  study  of  evolution. 

According  to  the  verdict  of  advanced  thinkers  and 
investigators,  man  now  takes  his  place  in  the  zoologi- 
cal system,  and  therefore  comparati\e  anatomy  is 
recognized  as  an  infallible  key  to  human  anatomy. 
Such  low  forms  of  structure  as  the  cranial  bones 
of  the  osseous  fishes,  though  exhibiting  numerous 
varieties,  admit  of  being  compared  with  even  those  of 
the  human  subject;  again,  in  the  mu.scular  system  we 
see  that  the  musculus  psoas  parvus,  which  is  often 
absent  in  the  Caucasian  race  (although  Cruveilhier  has 
found  it  even  double  on  both  sides),  exists  frequently 
although  sometimes  unilaterally  in  the  negro  and  is 
invariably  present  on  both  sides  in  the  ape.  Many 
illustrations  are  possible,  but  so  much  for  adult  struc- 
ture. 

Regarding  the  influences  of  stages  of  embryonal 
development,  those  in  the  higher  structural  organiza- 
tions bear  a  certain  definite  relation  to  permanent 
arrangements  in  the  lower  animals,  viz.,  the  inter- 
maxillary bone,  which  in  man  is  found  only  in  the 
earliest  foetal  period,  occurs  in  all  the  mammalia  and 
supports  the  incisor  teeth,  except  when  there  are 
none.  A  vast  number  of  examples  can  be  quoted,  all 
pointing  to  analogy  in  the  growth  of  higher  and  lower 
organisms. 

'  Read  Ijcfore  the  New  York  Medical  Associatioa. 


Before  the  views  of  Charles  Darwin  were  given  to 
the  world,  most  naturalists  believed  that  species  were 
distinctly  created  and  immutable  productions,  although 
there  were  not  wanting  at  that  time  observers  whose 
words  indicate  the  belief  that  species  do  undergo 
modification  and  that  existing  forms  of  life  are 
descended  by  true  generation  from  pre-existing  forms. 
Even  prior  to  this,  referring  to  classical  writers,  Aris- 
totle, in  "  Physical  .Vuscultationes,"  '  foreshadows  the 
theory  of  natural  selection. 

Lamarck  in  1801  upheld  the  doctrine  that  all  spe- 
cies, including  man,  are  descended  from  other  species, 
?nd  that  all  change,  in  organic  as  well  as  in  inorganic 
structures,  is  the  result  of  certain  laws,  chance  never 
entering  into  evolutionary  factors.  These  conclusions 
were  based  on  gradual  change  of  species  by  difficulty 
in  distinguishing  species  and  varieties,  by  gradation 
of  certain  forms,  and  by  production  of  analogical  char- 
acters. He  attributes  something  to  the  direct  action 
of  the  physical  conditions  of  life,  something  to  the 
crossing  of  already  existing  forms,  taking  into  consid- 
eration use  and  disuse,  i.e.,  habit.  He  held  to  a  law 
of  progressive  development,  that  all  forms  of  life  thus 
tend  to  progress,  and  he  accounts  for  the  present  exist- 
ence of  simple  productions  by  the  view  that  they  are 
now  generated  spontaneously. 

Geoffrey  St.  Hilaire,  as  early  as  1795,  suspected 
that  what  are  now  known  as  "  species"  are  various 
degenerations  of  the  same  type,  though  he  did  not 
believe  that  existing  species  are  now  undergoing 
modification. 

Dr.  VV.  C.  Wells,  in  his  famous  "  Two  Essays  upon 
Dew  and  Single  Vision,"  recognizes  distinctly  the 
principles  of  natural  selection,  applying  it  only  to 
races  of  man  and  to  certain  characters  alone. 

Mr.  Herbert  Spencer  concluded  that  species  have 
become  modified,  attributing  the  modification  to 
change  of  circumstances. 

In  view  of  the  investigations  made  by  many  illus- 
trious observers  during  this  century  in  the  domain  of 
comparative  anatomy,  we  may  define  an  anomaly 
proper  as  the  deviation  at  birth  from  what  is  recog- 
nized to  be  the  ordinary  structural  composition  and 
form,  comprehending  in  the  analysis  various  influ- 
ences, such  as  habit,  nationality,  climate,  heredity,  the 
transmission  of  mutilations;  and  space  is  given  by 
some  observers  to  the  retrograde  change  called  de- 
generation, the  influence  of  which  on  some  races  and 
individuals  is  abundantly  shown.  And  here  it  may  be 
admitted  that  some  organs  in  man  are  distinctly  de- 
generative and  anomalous;  for  instance,  his  teeth  are 
mechanically  inferior  to  those  of  the  domestic  cat; 
some  of  his  senses,  suchas  smell,  are  also  lacking  in 
acuteness;  but  by  virtue  of  his  massive  brain  and  com- 
plicated hand  he  is  the  most  adaptable  and  intelli- 
gent vertebrate  on  the  surface  of  the  globe. 

Regarding  the  role  which  anomalies  play  in  the 
evolution  of  man,  at  least  as  far  as  the  muscular  sys- 
tem is  concerned,  I  will  quote  Osborn  :  "  The  evolution 
of  a  new  type  must  consist  in  the  accumulation  of 
anomalies  in  a  certain  definite  direction  by  heredity, 
and  therefore  an  anomalous  condition  in  one  genera- 
tion may  become  typical  in  another." 

Galton  has  very  aptly  said  that  the  human  organiza- 
tion is  a  new  building  built  up  of  fragments  of  old 
ones,  the  old  ones  corresponding  to  various  types  of 
life  extending  into  the  back  ages;  at  least  the  evidence 
on  tills  point  is  just  as  conclusive  and  even  more  so 
than  that  upon  which  geologists  recognize  the  age  of 
tliis  terrestrial  globe. 

It  is  more  reliable,  in:u>inuch  as  dependence  is  not 
based  altogether  upon  fossil  characters.  Such  rudi- 
mentary structures  as  the  appendix  vermiformis  and 
the  musculus  ]vinniculus  carnosus  were  \inclouhtedly 
'  Lib.  II.  cap.  viii. 


October  2,  1897] 


MEDICAL    RECORD. 


485 


formerly  of  some  specific  use,  functionally  or  other- 
wise, to  the  requirements  of  the  economy  at  that  time. 
The  presence  of  these  and  other  structures  included 
as  anomalies  partially  illustrates  the  conservative 
power  of  heredity. 

Probably  no  organ  is  stationary  in  development, 
although  apparently  it  would  seem  so  under  certain 
conditions  of  environment;  this,  however,  is  occa- 
sional, and  physiological  and  biological  evidence  goes 
far  toward  proving  that  almost  all  organs  are  in  a 
state  of  change,  some  more  rapidly  than  others,  and 
here  it  may  be  mentioned  that  man,  as  a  whole,  is  in 
a  state  of  evolution  almost  as  rapid  as  that  which  has 
produced  the  modern  horse  from  its  small  five-toed 
ancestors. 

Looking  into  the  subject  practically,  tiie  difference 
in  determining  whether  an  organ  is  developing  or 
degenerating  at  the  same  time  is  great;  its  variability 
or  tendency  to  present  individual  anomalies  indicates 
that  some  change  is  taking  place.  This  is  shown  in  the 
very  variable  peronceus  tertius  (Wood)  and  numerous 
other  muscles,  among  which  is  the  palmaris  longus. 

Now,  as  change  of  organ  is  associated  with  degree 
of  utility,  in  the  analysis  we  must  include  the  amount 
of  service  rendered  by  the  part,  and,  as  this  is  often 
determined  by  the  amount  called  upon  for  the  main- 
tenance of  function  necessary  to  health  under  various 
conditions  of  life,  a  few  words  upon  the  influence  of 
habit  will  not  be  amiss. 

In  the  production  of  anomalies  in  individuals  we 
have  as  factors  the  destructive  power  of  degeneration, 
which  is  essentially  adaptive  as  against  the  protective 
power  of  heredity,  and  the  result  may  be  viewed 
minus  or  plus  the  influence  of  habit  and  the  various 
conditions  of  life.  It  is  collateral  to  this  sentence  that 
the  part  found  to  be  degenerating  by  disuse  in  the 
individual  will  almost  invariably  be  found  to  be 
degenerating  in  the  race,  illustrating  again  the  con- 
servative influence  of  iieredity  and  also  of  conditions 
of  life  upon  racial  characteristics. 

Some  of  the  most  conspicuous  features  of  modern 
habit  are  the  considerations  of  the  fashions  and  occu- 
pations which  demand  complicated  movements  of  the 
thumb  and  fingers,  the  outward  turning  of  the  foot  in 
walking,  and  movements  of  the  forearm. 

Thompson  concludes  that  the  tibia  is  the  most  vari- 
able in  form  and  length  of  any  long  bone  in  the  body. 
Piatycnemia  or  flattened  tibia  is  most  frequent  in  peo- 
ple following  occupations  involving  climbing,  etc., 
and  is  usually  associated  with  great  development  of 
the  musculus  tibialis  posticus. 

The  influence  of  the  squatting-habit  is  seen  in  some 
races  in  the  formation  of  a  facet  upon  the  neck  of  the 
astragalus  by  the  tibia.  This  is  almost  always  absent 
in  European  races,  although  it  has  been  found  well 
developed  in  certain  occupations,  such  as  that  of  the 
tailor,  etc. 

Professor  Dwight,  of  Harvard  Medical  College, 
believes  that  when  a  third  trochanter  of  the  femur 
is  found  the  condition  is  one  of  true  reversion 
and  not  an  acquired  variation,  as  it  is  found  among 
the  Siou.K  Indians  in  fifty  per  cent,  and  in  the  Lap- 
landers to  the  extent  of  sixty-four  per  cent.  Here  we 
see  the  instance  of  an  anomaly  becoming  the  normal 
conditions  in  two  nationalities.  It  is  present  in 
Swedes  in  thirty-seven  per  cent,  of  the  cases,  and  like 
the  condylar  foramen  is  an  ancient  mammalian  char- 
acteristic. 

It  might  be  said  that  the  bones  of  the  foot  are 
developing  on  the  inner  and  degenerating  on  the  outer 
side,  with  slight  loss  of  movement  in  the  small  toe. 
The  anomalies  in  muscles,  owing  to  various  difficulties 
in  tabulation  and  analysis,  have  never  been  adequately 
analyzed,  but  it  may  be  stated  generally  that  the 
number  of    muscles  has    been   steadily  increasing  in 


the  primates  while  the  number  of  bones  has  been 
diminishing.  In  man  the  number  of  muscles  has 
probably  been  increasing  in  the  lower  arm  and  dimin- 
ishing in  every  other  region;  it  is  difficult  to  consider 
this,  because  some  muscles  revert  to  a  former  condi- 
tion of  greater  specialization  of  movement.  Under 
the  usual  physical  conditions  of  life,  degeneration  is 
an  extremely  slow  process,  so  much  so  that  the 
change  which  is  produced  in  the  normal  tissues  can 
hardly  be  observed,  but,  given  favorable  conditions,  de- 
generation can  become  very  rapid ;  indeed  some  organs 
are  so  far  on  the  down  grade  that  they  are  supplied 
with  nutrition  for  past  services,  performing  none  at 
present. 

One  symptom  of  decline  is  variability  where  the 
organ  seems  to  show  its  own  uselessness  by  being 
absent.  Humphrey  says:  "The  muscles  which  are 
most  frequently  absent  by  anomalies  are  in  fact  those 
which  can  disappear  with  least  inconvenience,  either 
because  they  can  be  replaced  by  others  or  they  play 
an  altogether  secondary  role  in  the  organism." 

The  rudiment  first  becomes  variable  as  an  adult 
structure,  then  as  a  foetal  structure;  then  the  absences 
slowly  increase  until  they  reappear  as  reversions; 
finally,  they  cease  to  revert  and  are  lost.  The  varie- 
ties in  the  muscles  of  the  thumb  and  carpus  are  very 
numerous,  which  would  seem  to  indicate  that  those  in 
this  region  are  being  graefually  and  progressively 
developed  for  specialized  movements.  Baker  says: 
"On  comparing  the  human  hand  with  that  of  the  an- 
thropoids, it  may  be  seen  that  efficiency  is  produced 
in  two  ways.  First,  increase  in  the  mobility  and 
variety  of  action  of  thumb  and  fingers.  Second, 
reducing  the  muscles  used  mainly  to  assist  prolonged 
grasp,  they  being  no  longer  necessary  to  an  organ  for 
delicate  work  requiring  constant  readjustment. 

The  reduplication  of  the  inferior  tendon  of  the 
abductor  pollicis  (or  extensor  ossis  metacarpi  poUicis) 
(Wood),  which  is  sometimes  provided  with  a  distinct 
muscle,  points  to  the  birth  of  a  second  abductor. 
Duval  believes  that  the  flexor  longus  pollicis  in  evolu- 
tion between  man  and  animals  a  little  lower  in  organ- 
ization reverts,  as  in  the  ape.  Its  place  is  supplied 
by  a  division  of  the  flexor  profundus,  and  the  latter 
arrangement  I  have  observed  many  times  in  the  dis- 
secting-room. Our  grasping  muscle,  the  palmaris 
longus,  which  varies  greatly  and  like  the  plantaris  of 
the  leg  has  been  replaced  by  other  muscles,  in  ne- 
groes reverts  to  its  former  function  by  flexing  the 
fingers,  due  to  its  insertion  into  the  metacarpals;  this 
variation  may  partially  explain  the  grasping-power  of 
infants,  which  is  so  great  that  the  reflex  contraction 
of  the  fingers  will  sustain  their  weight  upon  a  slender 
crossbar. 

The  conclusions  of  Wood  and  Testut  are  that  vari- 
ability is  independent  of  age  or  sex,  of  general  mus- 
cularity, and  of  abnormal  mental  development.  Wood 
found  981  anomalies  in  102  subjects,  and  of  these  623 
were  developed  on  both  sides  of  the  body,  while 
358  were  unilateral.  Statistics  collected  by  Wood, 
between  1867-1868  in  the  dissecting-room  of  Kings 
College,  London,  upon  36  subjects  (18  of  each  sex), 
show  that  there  are  more  anomalies  in  the  limbs  than 
in  the  trunk,  that  anomalies  are  rare  in  the  pelvis,  that 
there  were  292  anomalies  in  the  arms  to  119  in  the 
legs,  and  that  in  both  limbs  the  anomalies  increase 
toward  the  distal  segments,  culminating  in  the  muscles 
of  the  thumb,  where  they  rise  to  ninety  per  cent. 

The  study  of  myology  in  the  lower  vertebrates  shows 
that  muscles  arising  from  or  inserted  into  bones  in 
the  vicinity  of  joints  sometimes  become  metamor- 
phosed into  tendons  near  their  attachments,  and  with 
this  change  there  is  tendency  for  alteration  in  the  point 
of  attachment.  Thus  a  muscle  originally  inserted 
below  a  joint  may  eventually  have  its  insertion  above 


486 


MEDICAL    RECORD. 


[October  2,  1897 


the  joint,  and  vice  versa;  this  change  is  usually  known 
as  migration  of  muscles.  The  human  ligaments  have 
in  most  cases  been  evolved  as  the  result  of  secondary 
changes  in  muscles  adjacent  to  joints.  Sometimes 
ligaments  represent  remnants  of  cartilaginous  and 
even  bony  structures,  the  capsular  ligament  being 
usually  derived  from  the  periosteum. 

In  the  knee-joint  the  adductor  magnus,  having 
shifted  its  insertion  from  the  tibia  to  the  femur,  leaves 
part  of  its  tendon  as  the  internal  lateral  ligament;  the 
e.xternal  lateral  ligament  represents  the  tendon  of  the 
peroneus  longus  migrated  from  the  femur  to  the  head 
of  the  fibula.  The  ligamentum  teres  in  the  hip-joint 
was  probably  the  tendon  of  the  pectineus  detached 
from  the  muscle  during  evolutionar}-  changes.  Again, 
the  greater  sacro-sciatic  ligament  was  originally  the 
tendon  of  origin  of  the  biceps  femoris.  The  lesser 
sacro-sciatic  is  derived  from  the  fibrous  regression  of 
portions  of  the  coccygeus.  The  sacro-sciatic  ligaments 
represent  the  muscles  which  lift,  depress,  and  wag  the 
tail  in  those  mammals  furnished  with  such  an  ap- 
pendage; and  indeed  these  structures  I  have  ob- 
served to  be  occasionally  replaced  by  muscular  tis- 
sue. The  coraco-humeral  ligament  is  derived  from 
the  original  tendon  of  insertion  of  the  pectoralis  minor, 
and  not  infrequently  the  muscle  is  inserted  into  the 
lesser  tuberosity  of  the  humerus,  the  ligament  being 
then  replaced  by  the  tendon  of  the  muscle.  The 
coraco-clavicular,  the  rhomboid,  and  gleno-humeral 
ligaments  are  probably  derived  from  modifications  of 
the  subclavius  muscle. 

I  append  below  a  list  of  some  anomalous  muscles 
which  have  been  observed  once,  twice,  and  even  three 
times  in  cadavers  during  the  last  two  years,  and  the 
presence  of  which,  while  unimportant  in  themselves, 
may  act  as  a  link  in  a  chain  of  reasoning  by  investi- 
gators coming  after,  as  they  are  not  mentioned  by  most 
of  the  standard  te.\t-books  on  anatomy, 

1.  The  abductor  ossis  metatarsi  quinti  arising  from 
the  outer  tubercle  of  the  calcaneum,  inserted  into  the 
tuberosity  at  the  base  of  the  fifth  metatarsal  bone.  .Ac- 
cording to  Sutton  this  muscle  is  present  in  two  out  of 
every  three  subjects,  and  when  not  represented  by  mus- 
cular fibres  its  place  is  occupied  by  a  band  of  fibrous 
tissue. 

2.  The  extensor  primi  internodii  hallucis  longus, 
is  usually  an  offset  from  the  extensor  proprius,  but 
in  orie  instance,  arising  separately  from  the  fibula,  it 
is  inserted  in  the  inner  part  of  the  base  of  the  first 
phalanx  of  the  great  toe. 

3.  A  fourth  gluteal  muscle,  the  gluteus  quartus, 
wh  ch  had  its  origin  from  the  anterior  part  of  the  in- 
fenor  gluteal  ridge  of  the  ilium  and  is  inserted  into 
the  top  of  the  great  trochanter  of  the  femur  in  front 
of  the  insertion  of  the  gluteus  minimus. 

4.  The  peroneo-calcaneus  internus  arises  from 
lower  part  of  the  posterior  surface  of  the  fibula  and  is 
inserted  into  the  forepart  of  the  inner  surface  of  the 
calcaneum. 

5.  The  rectus  sternalis,  arising  from  the  sheath  of 
the  rectus  abdominis,  is  inserted  into  the  fascia  cover- 
ing the  origin  of  the  sterno-mastoid.  According  to 
Sutton  this  may  be  present  on  both  sides. 

It  has  been  repeatedly  denied  that  mutilations  can 
have  any  influence  in  not  only  the  production  of 
anomalies,  but  also  in  that  of  congenital  malforma- 
tions, and  in  this  connectica  I  v.'^ll  quote  the  experi- 
m.'ntal  evidence  of  the  horeditu.y  transmission  of 
mutilations  adduced  by  Dr.  Cixarles  E.  Lockwood  (and 
already  quoted  by  Osborn).  "Mice  being  used  in 
this  experiment,  I  selected  a  pair  of  white  mice  on 
account  of  their  rapid  breeding.  I  bred  them  in  and 
in  for  ninety-six  generations,  as  they  breed  every 
thirty  days,  and  when  they  are  thirty  days  old  they 
are  able   to   reproduce  themselves.     I   destroyed    all 


sickly  and  defective  ones  by  breeding  only  the  fit- 
test. I  bred  all  disease  out  of  them,  and  had  a 
pure-blooded  animal,  larger  and  finer  every  way  than 
the  original  pair.  In  breeding  their  tails  ofi,  I  se- 
lected a  pair  and  put  them  in  a  cage  by  themselves, 
and  when  they  had  young  I  took  the  young  and 
clipped  their  tails  off.  When  old  enough  to  breed  I 
selected  a  pair  from  the  j'oung  and  bred  them  together, 
and  when  they  had  young  I  clipped  their  tails.  I 
continued  this  breeding  in  and  in,  clipping  each  gen- 
eration, and  selecting  a  pair  of  the  last  young  each 
time  in  seven  generations.  Some  of  the  young  came 
without  tails,  until  I  got  a  perfect  breed  of  tailless 
mice.  I  then  took  one  with  a  tail  and  one  without  a 
tail  and  bred  them  together,  and  by  changing  the 
sexes  each  time — a  male  without  a  tail,  a  female  w  ith  a 
tail,  and  next  a  female  without  a  tail  and  a  male  with 
a  tail — I  was  finally  rewarded  with  all-tail  mice." 

As  the  same  laws  (more  or  less  modified)  are  sup-: 
posed  to  govern  the  reproduction  of  the  higher  and 
the  lower  vertebrata,  the  significance  of  the  above  ex- 
periment will  at  least  cause  us  to  ponder  upon  analogi- 
cal characters  in  the  transmission  of  abnormalities,  and 
in  this  connection  comes  the  thought  as  to  what  are  the 
relations  existing  between  diseased  structures  and  the 
suitable  soil  for  the  production  or  hereditary  trans- 
mission of  the  same.  It  can  hardly  be  contradicted 
that  in  certain  diseases  there  is  a  reproduction  of  a 
suitable  constitution  in  which  by  accident,  direct  in- 
fection, or  otherwise  the  disease  is  reproduced  in  the 
offspring.  The  most  common  of  these  diseases  is 
tuberculosis,  and  will  not  our  knowledge  of  the  proc- 
esses involved  in  the  production  of  this  peculiar 
transmission  of  an  anomalous  type  of  health  give  us  a 
more  powerful  weapon  in  fighting  this  disease  than  all 
the  constituents  of  the  various  lists  of  advocates  of 
serum  therapy,  etc.  ?  As  has  been  said  by  many  ob- 
servers, the  best  treatment  of  this,  perhaps  our  most 
important  disease,  is  that  which  begins  at  birth.  In 
families  in  which  tuberculosis  is  known  to  exist,  we 
have  almost  invariably  an  anomalous  conformation  of 
the  thorax,  perhaps  not  as  regards  individual  bones, 
but  as  a  whole;  and  as  has  been  previously  stated  this 
can  be  remedied,  if  treated  at  birth  and  afterward  by 
massage,  diet  containing  in  addition  to  others  proper 
bone  constituents,  proper  hygienic  surroundings,  non- 
residence  in  crowded  cities,  etc.,  and  as  far  as  pos- 
sible excluding  family  contagion  by  explaining  to 
parents  the  contagious  or  infectious  nature  of  this 
disease — in  a  word,  all  the  prophylactic  measures  set 
down  by  other  observers.  In  this  connection  may  be 
noted  Krown-Sequard's  experiments  on  guinea-pigs,  in 
which  was  shown  not  only  the  transmission  of  epilepsy 
but  in  certain  individual  cases  a  peculiarity  or  anomal)- 
of  constitution  in  which  the  disease,  although  not  pres- 
ent at  birth,  could  be  produced  by  very  slight  causes. 
It  would  seem  important  to  pay  more  attention  to  the 
anomalous  physical  conditions  in  which  various  micro- 
organisms produce  ravishes  of  a  di.seased  nature  than 
to  the  life  history  of  these  microbes  themselves,  for 
it  has  been  shown  that  without  the  proper  soil  these 
low  forms  cannot  propagate  or  even  exist.  To  the 
earnest  observer  the  connection  between  mere  physical 
conformation  of  not  only  the  bony  skeleton  but  of  tlie 
muscular  system,  and  the  soil  suitable  for  the  produc- 
tion of  various  diseases,  is  seen  to  be  much  greater 
than  would  at  first  be  supposed.  The  various  abnor- 
malities in  heart  structure  would  require  much  time  to 
consider  in  full,  but  it  will  be  remembered  that  in  its 
development  the  organ  passes  through  various  stages, 
some  similar  to  its  normal  development  in  inferior 
animals,  so  that  malformations  for  the  most  part  de- 
pend upon  arrested  development  in  some  stage,  and 
while  most  malformations  are  incompatible  with  pro- 
longation of   life,  yet  1   believe   that   in   some  cases. 


October  2,  1897] 


MEDICAL    RP:C0RD. 


487 


more  numerous  than  commonly  supposed,  we  see  sub- 
jects who  live  norma!  if  not  prolonged  periods.  In 
going  over  a  large  number  of  cases  there  will  be  found 
individuals  presenting  well-developed  murmurs,  oft- 
times  diagnosed  as  organic  lesions,  which  would 
present  at  autopsy  slight  abnormalities  lightly  in- 
cluded under  the  heading  of  anomalies.  Almost  every 
clinical  observer  has,  I  think,  seen  some  subjects  well 
nourished  and  well  developed  physically  presenting 
murmurs  which  are  not  anaemic,  not  due  to  habit  such 
as  tobacco,  not  affected  by  medication,  yet  persistent 
through  life.  Such  a  case  suggests  the  possibility  of 
a  slight  abnormality,  either  in  the  conformation  of  the 
heart  as  a  whole  or  else  insufficient  valvular  develop- 
ment. As  our  statistics  are  based  generally  upon  so 
many  hundred  cases  examined  in  this  hospital,  or  so 
many  thousand  in  that  dissecting-room,  we  are  apt  to 
forget  that  by  far  the  greatest  number  of  persons  dying 
from  this  or  any  other  lesion  are  not  examined  at  all. 
The  importance  of  anomalous  structures  to  the 
operating  surgeon  is  great  in  some  regions.  In  the 
variety  of  enlargements  of  the  thyroid  gland  in  which 
we  have  an  abnormal  varicose  condition,  the  varying 
bifurcations  of  the  common  carotid  artery,  the  numer- 
ous variations  in  branches  of  the  external  carotid,  to 
say  nothing  of  enormously  developed  (as  to  size  and 
number)  trunks  of  the  thyroid  artery,  have  all  to  be 
considered  in  ligation  of  some  or  all  of  the  latter. 
Dr.  Mott  mentions  a  case  in  which  he  operated  and  in 
which  these  latter  branches  were  increased  in  number 
and  as  large  as  the  end  of  the  little  finger.  In  hyper- 
plastic and  hypertrophic  enlargements  it  would  seem 
a  wise  procedure  to  curtail  the  amount  of  blood  sup- 
plied to  the  organ.  Thyroid  enlargements  occur  very 
frequently  in  some  of  the  lower  animals  and  experi- 
mentation on  the  same  is  suggested. 


THE  ABSORPTION'  BY  WATER  OF  FREE 
AND  ALBUMINOID  AMMONIA  UNDER 
VARIOUS    CONDITIONS 

By    X.    KNIGHT,    I'u.D.. 
W.    M.    BLANCHARD,    A.M., 


SDOLI'H-MACON- 


The  water  used  in  these  investigations  was  obtained 
from  a  spring  in  the  vicinity  of  Ashland,  Va.,  known 
as  "Rock  Spring."  \"arious  analyses  showed  a  con- 
stancy of  the  mineral  constituents  of  the  watfr.  'I'he 
small  quantity  of  free  and  albuminoid  ammonia  it 
contains  was  determined  from  time  to  time  and  de- 
ducted from  the  amounts  obtained  in  the  following  ex- 
periments. The  ammonias  were  determined  by  a 
slight  modification  of  the  Wankyln-Nessler  process. 
Two  hundred  cubic  centimetres  was  usually  distilled 
for  a  determination,  and  50  c.c.  nesslerized.  Tiiis 
made  it  possible  to  repeat  a  test  easily  when  it  seemed 
desirable  to  do  so.  It  should  be  understood  that  the 
ammonium  nitrate  and  nitrite  which  are  present  in 
small  quantities  in  the  atmosphere  are  included  in  the 
albuminoid  ammonia.  The  figures  given  express  in 
every  case  the  number  of  parts  in  a  million. 

Experimental  Part.— Five  hundred  cubic  centime- 
tres of  the  water  was  placed  in  a  porcelain  evaporating- 
dish  of  two  litres'  capacity.  The  dish  was  thoroughly 
cleaned  each  time  before  using.  The  water  was  al- 
lowed to  stand  in  a  room  occupied  by  two  students  as 
a  .study-room  in  the  daytime  and  sleeping-room  at 
■night.  The  room  was  well  ventilated  by  a  wood  fire 
and  by  open  windows.  After  thirty-nine  hours  500 
c.c.  more  of  the  water  was  added  to  the  dish  to  sup- 


ply loss  by  evaporation.  The  whole  was  then  allowed 
to  stand  twenty-one  hours  longer.  Making  the  neces- 
sary corrections  for  the  ammonia  in  the  water,  it  con- 
tained: rree  ammonia,  0.264;  albuminoid  ammonia, 
0.400. 

A  litre  of  the  water  w-as  placed  in  a  room  occupied 
by  two  students  as  a  sleeping-apartment.  The  water 
remained  six  hours,  from  11  p.m.  to  5  a.m.  The  night 
was  cool  and  the  room  was  tightly  closed.  It  con- 
tained: F'ree  ammonia,  0.032;  albuminoid  ammonia, 
0.048. 

A  litre  of  the  water  was  placed  in  a  fairly  well- 
ventilated  room,  occupied  by  a  student  sick  with  the 
measles.  After  standing  twenty  hours  the  water  con- 
tained :  Free  ammonia,  0.120;  albuminoid  ammonia, 
0.048. 

A  litre  of  the  water  remained  during  the  night  in  a 
ventilated  sleeping-room  of  a  private  residence  in  the 
town.  The  room  was  occupied  by  two  grown  persons 
and  a  child.  In  the  morning  the  water  contained: 
F"ree  ammonia,  0.120:  albuminoid  ammonia,  0.102. 

Five  hundred  cubic  centimetres  of  the  w^ater  was 
kept  for  ten  hours  in  an  unventilated  clothespress. 
It  contained:  Free  ammonia,  0.447  ;  albuminoid  am- 
monia, 0.062. 

Five  hundred  cubic  centimetres  of  the  water  was 
placed  in  the  chemical  laboratory  and  allowed  to  re- 
main three  hours.  No  amm«nia  was  used  by  the  stu- 
dents during  this  time.  It  contained:  Free  ammonia, 
0.624;  albuminoid  ammonia,  0.086. 

Five  hundred  cubic  centimetres  of  the  water  was 
left  five  and  one-half  hours  in  the  chemical  lecture- 
room.  A  class  of  forty  occupied  the  room  during  one 
hour  of  the  time.  It  contained:  Free  ammonia,  0.088  ; 
albuminoid  ammonia,  0.038. 

A  litre  of  the  water  was  allowed  to  remain  seven- 
teen hours  in  the  biological  laboratory  of  the  college. 
It  contained:  Free  ammonia,  0.200;  albuminoid  am- 
monia, 0.102. 

Five  hundred  cubic  centimetres  of  the  water  re- 
mained in  the  Latin  lecture-room  of  the  college  six 
and  one-half  hours,  during  which  there  were  recitations 
in  progress  about  half  the  time.  It  contained:  Free 
ammonia,  0.024;  albuminoid  ammonia,  0.030. 

A  litre  of  the  water  was  placed  early  Sunday  morn- 
ing in  the  Ashland  Methodist  Church  and  left  for 
twenty-four  hours.  Two  services  were  held  in  the 
church,  at  each  of  which  one  hundred  and  twenty-five 
persons  were  present.  The  day  was  warm  and  the 
church  was  well  ventilated  by  open  windows.  The 
water  contained:  Free  ammonia,  0.148;  albuminoid 
ammonia,  0.124. 

On  the  following  Sunday  the  foregoing  experiment 
was  repeated.  The  conditions  were  similar,  except  the 
day  was  cool  and  the  windows  were  closed.  The  wa- 
ter contained :  Free  ammonia,  0.056;  albuminoid  am- 
monia, 0.142. 

A  litre  of  the  water  was  allowed  to  remain  twenty- 
four  hours,  beginning  Sunday  morning,  in  the  Shiloh 
Baptist  Church  (colored)  of  Ashland.  The  building 
was  poorly  ventilated.  Two  services  were  held  during 
the  time,  at  each  of  which  about  fifty  persons  were 
present.  The  water  contained  :  Free  ammonia,  0.056; 
albuminoid  ammonia,  o.i66. 

A  litre  of  the  water  was  placed  in  a  urinal  at  8:30 
P..M.  After  nine  hours  it  contained:  Free  ammonia, 
0.744;  albuminoid  ammonia,  0.048. 

Two  litres  of  the  water  was  placed  in  the  large 
watercloset  of  the  college  at  10  a.m.  After  half  an 
hour  500  c.c.  was  tested.  It  contained:  Free  ammo- 
nia, 0.056;  albuminoid  ammonia,  0.072. 

After  standing  one  hour  another  500  c.c.  of  the 
water  mentioned  in  the  foregoing  was  withdrawn  and 
tested.  It  contained:  Free  ammonia,  0.088;  albu- 
minoid ammonia,  0.032. 


4«8 


MKOTCAI.    RlT'ORn. 


[October  2,  1897 


After  two  hours  another  500  c.c.  contained :  Free 
ammonia,  0.264;   albuminoid  ammonia,  0.032. 

After  three  hours  another  portion  contained:  Free 
ammonia,  0.356;  albuminoid  ammonia,  0.064. 

On  another  occasion  500  c.c.  was  allowed  to  .stand 
fifteen  minutes  in  the  same  place.  It  contained:  F'ree 
ammonia,  0.136;  albuminoid  ammonia,  0.048. 

Five  hundred  cubic  centimetres  after  five  minutes 
contained:  Free  ammonia,  0.064;  albuminoid  ammo- 
nia, 0.062. 

Five  hundred  cubic  centimetres  after  one  minute 
contained:  Free  ammonia,  0.048 ;  albuminoid  ammo- 
nia, 0.000. 

To  compare  the  amount  absorbed  by  water  standing 
in  a  shallow  vessel,  like  an  evaporating-dish,  with  the 
absorption  in  a  narrow-necked  chemical  flask,  the  fol- 
lowing experiments  were  made : 

1.  Five  hundred  cubic  centimetres  of  the  water 
was  placed  in  a  chemical  Hask,  whose  neck  was  one 
and  one-half  inches  in  diameter,  and  left  for  one  hour 
in  the  watercloset  of  the  college.  It  contained:  Free 
ammonia,  0.064;  albuminoid  ammonia,  0.062. 

2.  After  four  hours  under  similar  conditions  it  con- 
tained: Free  ammonia,  0.080 ;  albuminoid  ammonia. 
0.078. 

3.  Five  hundred  cubic  centimetres  of  the  water  was 
placed  in  a  well-ventilated  sleeping-room,  occupied  by 
two  students.  After  eight  hours  it  contained ;  Free 
ammonia,  0.000;  albuminoid  ammonia,  0.006. 

F'ive  hundred  cubic  centimetres  of  the  water  in  the 
evaporating-dish  was  allowed  to  remain  ten  hours  in 
a  cow  stable.  It  contained:  Free  anunonia,  1.784; 
albuminoid  ammonia,  0.235. 

F'ive  hundred  cubic  centimetres  of  the  water  re- 
mained six  hours  in  a  horseshed.  It  contained: 
Free  ammonia,  0.593;  albuminoid  ammonia,  0.407. 

The  Absorption  of  Ammonia  from  the  Air  at 
Different  Elevations.  —  A  litre  of  water  in  the  evapor- 
ating-dish was  placed  on  the  ground  on  the  college 
campus.  A  similar  portion  was  placed  above  this  on 
a  tower  sixty  feet  high.  Both  remained  ten  hours. 
The  former  contained:  Free  ammonia,  0.080;  albu- 
minoid ammonia,  o.  182.  The  latter  contained  :  Free 
ammonia,  0.068 ;  albuminoid  ammonia,  0.102,  This 
experiment  was  made  on  April  28th. 

May  17th,  placed  500  c.c.  of  the  water  on  the  col- 
lege campus  at  9  v.m.,  and  the  same  quantity  on  the 
towej".  After  ten  hours  the  former  contained :  Free 
ammonia,  0.312;  albuminoid  ammonia,  0.838.  And 
the  latter:  Free  ammonia,  0.040;  albuminoid  ammo- 
nia, 0.222. 

The  foregoing  was  repeated  on  May  18th,  the  tem- 
perature of  the  air  having  increased.  The  water  on 
the  ground  contained:  Free  ammonia,  0.072;  albu- 
minoid ammonia,  0.142.  The  water  on  the  tower 
contained:  F'ree  ammonia,  0.072  ;  albuminoid  ammo- 
nia, 0.086. 

May  19th,  the  foregoing  experiments  were  repeated. 
The  water  on  the  ground  contained:  Free  ammonia, 
0.176;  albuminoid  ammonia,  0.292.  The  water  on 
the  tower  contained:  F'ree  ammonia,  0.048;  albumi- 
noid ammonia,  0.092. 

May  20th,  water  placed  as  in  the  foregoing,  on  the 
ground,  contained  :  Free  ammonia,  0.064;  albuminoid 
ammonia,  0.070.  On  a  cloudy  day  500  c.c.  of  the 
water  remained  five  hours  (from  12  m.  to  5  p.m.)  on  the 
tower.  It  contained:  Free  ammonia,  0.160;  albumin- 
oid ammonia,  0.118. 

May  27th,  a  sunny  day,  500  c.c.  of  the  water  re- 
mained on  the  campus  under  the  shade  of  the  trees 
from  7  A.M.  until  5  I'.m.  It  contained  :  Free  ammonia, 
0.232;  albuminoid  ammonia,  0.686.  The  same  quaii- 
tity  on  the  tower  in  the  sunlight  contained:  F'ree  am- 
inoni.i,  0.008;   albuminoid  ammonia,  0.038. 

Ammonia  in  Rain  Water.  -Previouslv  to  Mav  i  ,;tl> 


there  had  been  almost  no  rainfall  for  several  weeks. 
On  the  night  of  the  12th  there  were  frequent  showers. 
.At  five  o'clock,  on  the  morning  of  the  J3th,  the  evapo- 
rating-dishes  were  placed  in  the  of>en  air.  There  was 
a  gentle  rainfall  during  the  day.  Five  hundred  cubic 
centimetres  of  water  had  collected  at  i  p.m.  It  con- 
tained: Free  ammonia,  0.128;  albuminoid  ammonia, 
0.230. 

At  3:15  P.M.  another  500  c.c.  had  collected.  It 
contained :  Free  ammonia,  0.088 ;  albuminoid  ammo- 
nia, 0.252. 

Later,  after  clear  weather  for  several  days,  there 
were  heavy  rains.  Five  hundred  cubic  centimetres  of 
the  water  caught  at  the  beginning  of  the  shower  con- 
tained: Free  ammonia,  o.  160 :  albuminoid  ammonia, 
0.108. 

After  it  had  raineil  for  some  time,  500  c.c.  showed : 
Free   ammonia,   0.144:    albuminoid  ammonia,  0.078. 

Conclusions. —  These  conclusions,  arrived  at  also 
by  other  exp)erimenters,  .seem  justified  from  the  fore- 
going work.  The  ammonias  may  be  regarded  as  a 
type  of  the  impurities  in  the  air. 

1.  The  purity  of  the  air  increases  with  the  eleva- 
tion. 

2.  The  sunlight  is  a  purifier  of  the  air. 

3.  The  amount  of  absorption  depends  upon  the  sur- 
face exposed. 

4.  The  great  absorbing-power  of  water  and  its  puri- 
fying effect  upon  the  air  of  a  room. 

5.  The  beneficial  effects  of  lakes,  rivers,  and  other 
large  bodies  of  water  in  purifying  the  air  of  the  sur- 
rounding country. 

It  is  purposed  to  investigate  the  absorbing-power  of 
milk  and  other  liquids,  for  comparison  with  water. 

July,  1897. 


^xrogrcss  of  l^lcdical  Science. 

Malarial  Disease  Prevented  by  Small  Doses  of 
Quinine Laveran  reviews  the  reports  of  many  medi- 
cal officers  in  charge  of  the  health  of  bodies  of  Euro- 
pean and  American  men  exposed  to  severe  malarial 
influences  {The  Nao  York  Ahdical  Joiirnar).  His 
conclusion  is  that  quinine  usually  proves  very  potent 
in  preventing  or  at  least  mitigating  malarial  disease, 
even  in  very  unhealthful  localities.  Against  its  use 
the  objection  has  been  made  that  daily  administra 
tion  of  this  drug  induces  attacks  of  indigestion,  and 
that  quinine  becomes  less  potent  in  a  given  case  if 
administered  constantly,  the  system  becoming  habitu- 
ated to  it.  Yet  these  objections  are  not  sound.  A 
dose  of  from  one-fifth  to  three-tenths  of  a  gram  a 
day  can  be  employed  for  months  with  impunity. 
Quinine  destroys  the  causative  microbes  by  its  power 
as  a  parasiticide.  The  microbes  of  paludism  that 
chance  to  get  into  the  blood  of  a  person  who  has  been 
treated  preliminarily  by  the  small  preventive  doses 
find  it  a  medium  wholly  or  quite  unfavorable  to 
their  development.  At  the  most,  they  develop  only 
with  difficulty.  The  daily  dose  should  not  exceed 
three-fifths  of  a  gram  nor  be  less  than  a  seventh  of 
a  gram.  Some  prefer  a  dose  of  one  gram  thrice 
weekly.  To  procure  a  rapid  absorption,  the  hydro- 
chloride is  preferable  to  the  sulphate,  and  is  better 
supported.  The  best  time  to  take  quinine  is  at  meal- 
times. The  best  way  is  to  dissolve  it  in  wine,  al- 
though cachets  or  pills  suflice.  If  added  to  coffee, 
that  precipitates  a  portion  of  the  quinine. 


Cancer. — It  wo  suspect  cancer  in  a  woman  I  fear  we 
often  go  too  far  in  concealment  of  the  danger  from  the 
patient. — Walker. 


October  2,  1897] 


MEDICAL    RECORD. 


489 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &  CO.,  43,  45,  &.  47  East  Tenth  Street. 


New  York,  October  2,  1897. 


OVERCROWDIXG    Or    THE    MEDICAL    PRO- 
FESSION. 

Some  few  months  ago  the  Daily  Telegraph  in  London 
took  up  the  matter  of  dispensary  abuse,  and  the  sub- 
ject was  thoroughly  ventilated  in  the  pages  of  that 
journal.  Now  the  Standard  is  following  in  the  foot- 
steps of  its  rival,  and  has  opened  its  columns  to  a  dis- 
cussion on  the  overcrowding  of  the  medical  profes- 
sion. Many  harrowing  tales  are  being  told  of  the 
straits  to  which  struggling  practitioners  are  reduced 
in  their  efforts  to  gain  a  living.  One  medical  man 
writes  to  say  that  the  average  income  of  a  doctor  in 
Great  Britain  at  the  present  day  does  not  reach  the 
sum  of  Si, 200  yearly;  another  one  dwells  upon  the 
much-vexed  point  of  the  way  in  which  hospitals  are 
made  use  of  by  persons  for  whom  they  were  never 
meant,  and  many  instances  are  quoted  to  bear  out  this 
contention.  This  correspondence  comes,  as  was 
doubtless  intended  it  should,  at  a  most  appropriate 
season.  The  medical  schools  are  on  the  point  of  re- 
opening. It  is  certainly  for  the  ultimate  benefit  of 
those  about  to  enter  the  profession  of  medicine  that 
they  should  be  made  to  understand  the  difficulties 
that  they  will  have  to  encounter  and  the  hard  road 
they  must  expect  to  travel,  before  any  sort  of  a  goal  is 
reached.  It  would  appear,  too,  that  the  position  of 
the  medical  man  here  is  more  or  less  identical  with 
that  of  his  English  brother,  for  while  in  America  the 
fees  are  higher,  on  the  other  hand  the  profession  is 
perhaps  even  more  crowded  here  than  in  England. 
The  Lancet,  referring  to  the  outlook  so  far  as  medical 
students  are  concerned,  says  that  the  facts  of  the  case 
should  be  present  in  the  mind  of  every  3-oung  man 
who  contemplates  entering  the  medical  profession. 
To  men  who  realize  the  dignit}'of  medical  ser%-ice  and 
of  the  medical  calling,  our  contemporar)-  says,  there  is 
still  room  in  our  profession ;  but  those  who  look  for 
their  reward  in  large  incomes  will  do  well  to  pause. 
That  the  present  unsatisfactor}'  position  of  the  medi- 
cal profession,  both  as  regards  the  overcrowding  and 
the  abuses  in  connection  with  it,  should  be  openly 
discussed  and  kept  before  the  public  in  everj'  possible 
way,  is  to  the  best  interests  of  its  members.  The 
more  fully  a  grievance  is  aired,  the  more  quickly  is  it 
Ukelv  to  be  remedied. 


ASEPTIC    BARBERING. 

The  sanitary  authorities  of  Paris  have  instituted  a 
verv-  important  regulation  respecting  aseptic  barbering, 
which  desenes  to  be  imitated  in  ever}-  town  and  city 
in  which  the  knights  of  the  scissors  and  the  wielders 
of  the  razor  are  to  be  found.  The  only  strange  thing  is 
that  the  regulations  regarding  cleanliness  in  hands 
and  instruments  have  not  been  enforced  long  ago. 
There  is  hardly  a  person  who  has  not  been  reminded 
of  the  necessity-  of  the  measure.  Even  the  ordinary 
patron  appreciates  the  glaring  fact  that  at  every 
seance  he  is  liable  to  some  form  of  skin  disease  of 
the  scalp  or  face,  communicated  more  or  less  directly 
by  a  previous  customer  through  the  proverbial  care- 
lessness of  the  fussy  and  oftentimes  positively  dirty 
manipulator.  In  Paris  barbers  are  now  required  to 
use  aseptic  tools,  sterilized  towels,  metallic  combs, 
and,  above  all,  their  hands  are  to  be  kept  scrupulously 
clean  by  being  washed  for  every  sitter.  Nothing 
could  be  simpler,  nothing  more  popular,  and  certainly 
nothing  safer.  Why  could  not  our  own  health  board, 
alwavs  so  alert  in  serving  the  community,  demon- 
strate  its  usefulness  in  this  direction  ?  It  would  be 
certain  to  have  the  entire  public,  excepting  possibly 
that  part  composed  of  dirty  and  lazy  barbers,  on  the 
side  of  such  a  verj-  necessary  reform. 


THE   PUNISHMENT    OF    UNLICENSED 
PRACTITIONERS. 

There  seems  to  be  some  doubt  in  the  minds  of  cer- 
tain members  of  the  Medical  Society  of  the  County  of 
New  York  regarding  the  rights  of  a  so-called  bone- 
setter  to  practise  his  alleged  profession  in  New  York. 
This  delectable  individual,  who  modestly  confesses  the 
possession  of  a  peculiar  sensitiveness  of  touch  and  a 
remarkable  manipulative  power,  has  been  giving  such 
public  exhibitions  in  smoothing  bones  in  place  and  in 
working  out  the  stiffness  of  creaky  joints  that  he  has 
now  a  flourishing  clinic  of  his  own  and  may  seriously 
affect  the  business  of  many  of  the  free  dispensaries. 
Although  at  best  his  method  of  work  is  a  rude  and 
unscientific  form  of  massage,  his  claim  for  reducing 
dislocations  thereby  would,  it  seems  to  us,  clearly 
place  him  within  the  present  law  against  practising 
without  a  license.  Reducing  dislocations  is  certainly 
a  recognized  surgical  procedure,  and  even  an  attempt 
in  that  direction  would  make  the  pretender  clearly 
indictable.  Comparatively  speaking,  however,  it 
would  appear  to  be  hardly  to  the  purpose  to  make  a 
martjT  of  this  blatant  quack,  so  long  as  the  society  in 
question  quietly  winks  at  the  many  abortionists  and 
others  of  that  ilk  who  openly  bid  for  business  in  all 
the  daily  papers.  At  least  it  does  not  seem  to  have 
the  power  to  touch  the  worst  of  all  quacks. 


The    Contagious   Period   of    Whooping-Cough. — 

According  to  the  British  Medical  Journal,  Dr.  Weill, 
a  French  physician,  has  made  a  series  of  e.xperiments 
which  indicate  that  whooping-cough  is  contagious 
only  before  the  patient  begins  to  whoop. 


490 


MEDICAL    RECORD. 


[October  2,  1897 


THE  CONTAGIOUS-DISEASES  ACT  IN  INDIA. 

It  has  been  decided  to  bring  again  into  force  in  India 
the  "contagious-diseases  act  for  women."  This  de- 
cision has  been  arrived  at  in  consequence  of  the 
frightful  increase  of  venereal  diseases  among  the  Eng- 
lish army  in  that  country.  That  the  situation  is  one 
of  extreme  gravity  statistics  easily  prove.  In  1895 
the  admissions  into  hospitals  for  venereal  diseases 
were  36,681,  and  of  these,  22,702  were  cases  of  syphi- 
lis. The  ratio  for  primary  syphilis  had  increased  one 
hundred  and  thirty-seven  per  cent,  since  1887,  and 
secondary  syphilis  was  in  1895  four  times  more  preva- 
lent than  in  1873.  The  government  does  not  propose 
compulsory  examination,  but  it  feels  that  some  decided 
steps  must  be  taken  to  prevent  the  army  from  being 
decimated  by  syphilis,  and  also  that  innocent  women 
and  children  must  be  protected  against  the  risk  of  in- 
fection by  this  disease.  This  resolution  on  the  part 
of  the  authorities  has  raised  a  storm  of  indignation 
and  protest  among  a  small  but  noisy  section  of  the 
British  public.  Nevertheless,  in  the  ranks  of  those 
averse  to  the  measure  occur  some  notable  names,  and 
women  especially  are  up  in  arms  against  it.  The 
medical  men  of  Great  Britain  as  a  body  concur  in  the 
advisability  of  prompt  and  effective  action  being  taken 
to  endeavor  to  check  the  ravages  of  this  insidious 
affection,  though  even  with  them  there  are  exceptions. 

Dr.  Charles  Taylor,  in  an  address  on  the  subject, 
published  in  the  Medical  Times  and  Hospital  Gazette, 
tries  his  hardest  to  prove  that  alteration  in  the  present 
law  is  quite  unnecessary,  and  he  goes  to  absurd 
lengths  in  his  attempts  to  show  that  all  venereal  dis- 
eases are  comparatively  innocuous.  After  dismissing 
gonorrhoea  as  a  complaint  so  trifling  as  not  to  be 
worthy  of  discussion,  he  proceeds  to  whitewash  syphi- 
lis. The  great  majority  of  patients  who  contract  true 
or  constitutional  syphilis,  he  says,  are  readily  and  per- 
manently cured,  and  then  do  not  transmit  disease  to 
their  offspring.  He  then  goes  on  to  say :  "  Let  me  lay 
a  little  evidence  before  you  in  proof  of  this  last  asser- 
tion, i.e.,  that  true  syphilis  is  not  such  a  formidable 
disease  as  we  have  been  led  to  suppose,  and  that  in 
the  great  majority  of  cases  it  is  so  easily  controlled 
that  we  need  not  fear  any  of  its  manifestations.  Of 
course,  we  all  know  that  syphilis  has  been  on  the 
wane  all  over  the  world  for  centuries;  that  it  has  de- 
clined both  in  strength  and  virulence  in  every  country 
under  the  sun ;  that  the  sibbens  of  Scotland,  the  rade- 
syge  of  Norway,  and  the  yaws  of  Africa  are,  practically 
speaking,  things  of  the  past;  that  the  diseased  bones, 
the  sloughing  phagedena,  and  serpiginous  ulceration 
are  no  more  to  be  seen ;  and  that  a  man  may  practise 
— in  ordinary  general  practice — for  a  lifetime  without 
meeting  with  a  single  case  of  malignant  or  tertiary 
syphilis."  Dr.  Taylor  then  quotes  several  authorities 
in  support  of  these  contentions,  among  them  Jonatlian 
Hutchinson. 

Notwithstanding  this  eloquent  defence  of  syphilis, 
it  will  be  difficult  to  convince  a  very  large  number 
of  those  qualified  to  pass  an  opinion  that  it  is  so 
harmless  a  disease  as  Dr.  Taylor  tries  to  demonstrate 
it  to  be.     It  is  probably  true  tliat  at  one  time  the 


gravity  of  syphilis  was  exaggerated,  and  no  doubt  with 
modern  rational  treatment  it  is  not  the  dread  scourge 
it  was  in  bygone  days;  but  the  contention  that  it  is  a 
more  or  less  harmless  complaint,  if  advanced  by  any 
man  of  ability  or  authorit)',  would  be  pernicious  in  its 
consequences.  The  line  of  opposition  that  Dr.  Tay- 
lor takes  against  the  bill  is  not  only  that  it  is  unnec- 
essary, but  that  it  tends  to  curtail  the  liberty  of  the 
subject,  as  well  as  to  the  creation  of  what  he  terms  a 
far  worse  and  more  fatal  disease,  "syphiliphobia." 
Doubtless  many  objections  can  be  urged  against  this 
"  contagious  act,"  but  a  very  strong  point  in  its  favor 
is  that  it  was  eiTective  when  in  force  formerly,  and 
until  better  methods  have  been  devised  the  govern- 
ment of  India  will  be  found  to  have  taken  the  wisest 
course  in  again  adopting  the  system  that  worked  well 
in  the  past.  Of  course,  this  is  a  very  different  thing 
from  the  licensing  and  compulsory  examination  of 
prostitutes  in  cities,  which  many  sociologists  and  phy- 
sicians regard  as  useless. 


^eius  ot  the  <?mceTi. 

The  Alvarenga  Prize  of  the  College  of  Physi- 
cians of  Philadelphia  for  1897  has  been  awarded  to 
Dr.  Joseph  Collins,  of  this  city,  for  an  essay  entitled 
''Aphasia:   .\  Contribution  and  Critical  Study." 

American   Electro-Therapeutic  Association The 

seventh  annual  meeting  of  the  ,\merican  Electro- 
therapeutic  Association  was  held  at  Harrisburg,  Pa., 
on  September  21st,  22d,  and  23d.  Dr.  William  T. 
Bishop,  of  that  city,  presided.  An  address  of  welcome 
was  delivered  by  Mayor  Patterson,  to  which  reply  was 
made  by  Dr.  Robert  Newman,  of  New  York  City. 
Among  the  papers  read  on  the  first  day  were  the  fol- 
lowing: "  Sources  of  Atmospheric  Electricity,"  Dr.  R. 
J.  Nunn,  of  Savannah,  Ga. ;  "  Some  Thoughts  and 
Suggestions  on  .v-Ray  Work,"  Dr.  Eugene  R.  Corson, 
of  Savannah,  Ga. ;  "  A  New  Electrode  for  Use  with 
the  Static  Machine,"  Dr.  Lucy  Hall-Brown,  of  Brook- 
lyn, N.  Y. ;  "  Some  Considerations  Relative  to  the 
Therapeutic  Application  of  the  Current,"  by  invita- 
tion. Dr.  George  E.  Bill,  of  Harrisburg.  On  the  sec- 
ond day  Dr.  Eli  H.  Coover,  of  Harrisburg,  read  a 
paper  on  heart  failure  in  cardiac  diseases  due  to  de- 
fective circulation;  and  Dr.  Margaret  A.  Cleaves,  of 
New  York  City,  one  on  expenditures  of  electrical 
energy.  On  the  third  day  the  following  papers  were 
read:  "What  Has  Electricit)'  Accomplished  in  the 
Treatment  of  Mental  Diseases.'"  Dr.  Robert  S.  New- 
ton, of  New  York  City;  "Mental  Electricit}-,"  Dr.  W. 
S.  \\'atson,  of  Fishkill-on-Hudson.  N.  Y. ;  "  Electric- 
ity in  Orthopaedic  Practice,"  Dr.  L.  A.  Weigel.  of 
Rochester,  N.  Y. ;  "  .\  New  Electrode,  Preventing  the 
Diffusion  of  the  Current;"  "  Palliative  Electric  Treat- 
ment of  the  Tic  Douloureux  of  the  Face;"  "The 
Action  of  the  Roentgen  Rays  on  the  Vitality  and  \\\- 
ulenceof  Koch's  Bacilli  in  Cultures,"  Dr.  J-  Bergonie, 
of  Bordeaux,  France.  The  following  officers  were 
elected  for  the  ensuing  year:    President,  Dr.  Charles 


October  2,  1897] 


MEDICAL    RECORD. 


491 


R.  Dickson,  of  Toronto,  Ont. ;  Vke-Fresidents,  Dr.  F. 
S.  Shavoir,  of  Stamford,  Conn. ;  Dr.  Caleb  Brown,  of 
Sac  City,  Iowa;  Secretary,  Dr.  Henry  Gerin,  of  Au- 
burn, N.  Y. ;  Treasurer,  Dr.  Robert  J.  Nunn,  of  Sa- 
vannah Ga. ;  Executive  Council,  Dr.  Robert  Newman, 
of  New  York;  Dr.  G.  Betton  Massey,  of  Philadelphia; 
Dr.  W.  T.  Bishop,  of  Harrisburg;  Dr.  W.  J.  Morton, 
of  New  York  City;  Dr.  W.  J.  Herdman,  of  Ann  Arbor, 
Mich.  The  next  meeting  is  to  be  held  at  Buffalo, 
N.  Y. 

Hog  Cholera  in  Delaware. — Hog  cholera  is  epi- 
demic in  the  northern  part  of  Kent  County,  Del., 
scarcely  a  single  animal  escaping  infection. 

Generous  Bequests. — By  the  will  of  the  late  Mrs. 
Eliza  W.  S.  P.  Field,  who  died  recently  in  England, 
$10,000  is  bequeathed  to  the  Philadelphia  Home  for 
Incurables,  for  the  endowment  of  two  free  beds;  $500 
to  the  Germantown  Hospital  and  Dispensary;  $1,000 
to  the  Children's  Hospital  of  Philadelphia;  and  to 
the  University  of  Pennsylvania  $10,000  in  trust  for 
the  establishment  of  two  scholarships,  the  income  to 
be  used  to  defray  the  expenses  of  such  ambitious  and 
diligent  students  from  the  Central  High  School  as  the 
trustees  of  the  university  may  deem  worthy;  $5,000 
for  the  endowment  of  a  free  bed  in  its  hospital;  $5,- 
000  for  the  endowment  of  a  free  bed  in  its  Maternity 
Hospital;  $20,000  in  trust  for  the  general  uses  and 
purposes  of  its  hospital;  $20,000  in  trust,  the  income 
to  be  devoted  to  the  Maternity  Hospital,  and  the  fur- 
ther sum  of  $20,000  for  the  general  uses  of  the  uni- 
versit}'.  The  testatrix  bequeathed  her  residuar)'  estate 
al?o  to  tb.e  university. 

Proper  Dispensary  Fees. — At  last  New  York  has 
had  filled  a  "  long  felt  need,"  as  the  nostrum  adver- 
tisement usually  puts  it  We  have  contended  that  the 
dispensary  should  provide  ever}-  attraction  for  the 
patient  and  make  an  effort  to  draw  in  clients  from 
every  walk  in  life.  During  the  past  week  notices  have 
been  sent  out  of  a  new-  dispensary  which  should  prove 
an  attraction  to  a  large  class  of  dispensarj^  goers. 
The  fee  for  treatment  is  placed  at  $25.  This  will 
naturally  keep  away  undesirable  individuals  and  se- 
cure to  patrons  a  certain  exclusiveness,  often  too  much 
neglected  in  the  institutions  already  established. 
Since  there  must  always  be  a  "very  best"  for  the 
ultra-exclusive  set,  we  may  look  for  some  rival  insti- 
tution in  which  the  entrance  fee  has  been  advanced  to 
$50.  The  one  which  has  taken  the  initiative  in  es- 
tablishing a  proper  fee  is  for  the  exclusive  treatment 
of  inebriates. 

An  Unfavorable  View  of  the  Montreal  Meeting. 
— The  sixty-fourth  convocation  of  this,  the  greatest  of 
all  Anglo-Saxon  medical  gatherings,  has  passed  into 
history.  The  cit)'  of  Montreal  as  a  corporation,  and 
the  medical  profession  of  the  city,  "did  themselves 
proud"  in  matters  of  hospitality.  The  attendance  was 
large,  over  eight  hundred  registering;  and  a  large 
number  of  medical  men  gathered  besides,  ostensibly 
to  attend  the  meeting  but  never  registered,  their  aims 
being  of   a  social   rather   than  a  scientific  character. 


The  greatest  drawback  was  the  lack  of  proper  hotel 
accommodations ;  indeed,  for  a  city  of  the  pretensions 
of  Montreal  such  were  woefully  deficient.  The  general 
addresses,  that  of  the  president  excepted,  were  decid- 
edly mediocre,  being  "  chestnutty"  in  flavor,  and  in 
one  instance  so  self-laudatory  and  egoistic  as  to  pro- 
voke most  unenviable  comment.  The  papers  pre- 
sented to  the  sections,  with  few  exceptions,  were  of  like 
character;  remarkably,  not  a  single  new  idea  was 
evolved  or  even  suggested.  Their  tone  was  such  they 
might  pass  for  papers  read  at  any  of  half  a  dozen  meet- 
ings of  like  character,  convened  during  the  past  five 
years.  Even  the  discussions  were  fiat,  stale,  and  un- 
profitable, hence  the  attendance  daily  became  more 
meagre — so  meagre  in  fact  that  it  was  a  common  cause 
of  comment.  Nevertheless  the  British  Medical  Asso- 
ciation was  a  success — a  great  success- — as  a  social 
body.  Scientifically  it  was  mediocre,  repetitious, 
hea\y,  and  wearisome;  dull  as  ditch  water,  relieved 
only  by  the  manifest  attempts  of  the  little  chaps  to  be 
thought  big  and  the  larger  ones  to  grow  greater  in  the 
estimation  of  their  fellow-men. — T/ie  Medical  Age. 

A  Physician   Crazed   by   Sympathy.^Dr.  T.  M. 

Angstadt,  a  graduate  of  Jefferson  Medical  College 
practising  in  Nova  Scotia,  found  himself  baffled  by  a 
perplexing  case  for  which  he  was  able  to  do  nothing. 
The  patient  suffered  greatly,  and  no  medicines  or  even 
surgical  treatment  availed  anything.  The  thought  of 
the  patient's  sufferings  and  of  his  own  powerlessness 
so  weighed  upon  the  physician's  mind,  that  he  killed 
himself,  after  making  a  will  in  which  he  devised  all 
his  property,  amounting  to  about  $2,000,  to  the  patient. 

An  Old  People's  Convention. — The  old  folks  of 
Manchester,  Vt.,  hold  occasional  meetings  for  the  pur- 
pose of  comparing  notes  and  exchanging  reminis- 
cences. The  latest  was  held  there  on  September 
24th.  Of  one  hundred  and  fifty  invitations  extended 
to  persons  over  seventy  years  of  age,  over  one  hundred 
responded,  half  of  them  being  between  seventy  and 
eighty.  Two  were  over  ninet}-,  the  oldest  person  pres- 
ent being  ninety-three  years  old,  and  the  second  oldest 
ninety-one  years  of  age.  Of  the  one  hundred  and  ten 
persons  who  attended  the  first  reunion  in  i8go,  more 
than  half  are  dead.  At  the  reunion  two  years  ago 
more  than  one  hundred  registered,  twenty-two  of  whom 
are  dead.     The  next  reunion  will  be  held  in  two  years. 

Dr.  Eugenio  Sanchez  Agramonte,  a  surgeon  in  the 
army  of  the  Cuban  republic,  is  at  present  in  New 
York,  and  was  recently  entertained  at  dinner  by  the 
Oscar  Primelles  Club,  a  society  established  to  aid  the 
sick  and  wounded  in  the  patriot  army. 

A  Typhoid  Epidemic  at  Maidstone. — It  is  re- 
ported that  an  alarming  outbreak  of  typhoid  fever  has 
occurred  at  Klaidstone,  in  England,  over  six  hundred 
people  being  ill  with  the  disease  at  the  present  time. 
The  epidemic  is  attributed  to  pollution  of  the  water 
supply  bv  drainage  from  an  encampment  of  hop  pickers, 
among  whom  several  had  been  sick  with  typhoid. 

The  Plague  is  steadily  increasing  again  in  the 
Bombay  presidency,  the  strange  neglect  of  the  sani- 


492 


MEDICAL    RECORD. 


[October  2,  1897 


tary  authorities  having  permitted  the  disease  to  creep 
unobserved  from  hamlet  to  hamlet  until  a  wide  area 
has  become  alTected.  The  newspapers  assert  that  the 
withdrawal  o£  the  medical  officers  for  service  with  the 
troops  on  the  frontier  will  entail  consequences  in  the 
way  of  a  recrudescence  of  the  plague  infinitely  more 
disastrous  than  anything  happening  on  the  frontier. 

A  Charge  of  Inhumanity  against  New  York 
Hospitals. — In  the  management  of  ambulance  cases 
the  ambulance  first  arriving  at  the  spot  where  an  indi- 
vidual requires  immediate  medical  or  surgical  aid  is 
supposed  to  take  the  patient  to  the  nearest  hospital ; 
but  a  recent  case,  in  which  a  man  had  his  skull  fractured 
in  the  vicinity  of  Roosevelt  Hospital  and  was  taken 
by  an  ambulance  of  that  hospital  a  long  distance  to 
Bellevue,  where  he  died  in  a  few  hours,  has  called  re- 
newed attention  to  the  practice  of  the  large  private 
hospitals  maintaining  an  ambulance  service,  all  of 
which  receive  more  or  less  assistance  from  the  public 
funds,  of  sending  dying  patients,  sometimes  taken  di- 
rectly from  their  own  wards,  to  the  public  hospitals. 
Naturally,  such  transfers  are  not,  as  a  rule,  beneficial 
to  the  patient;  but  it  is  highly  desirable  that  the 
death  rate  in  such  hospitals,  which  depend  to  a  greater 
or  less  extent  on  private  contributions  for  their  sup- 
port, should  be  kept  as  low  as  possible,  in  order  that 
in  their  annual  reports  a  favorable  showing  may  be 
made  to  their  patrons. — Boston  Medical  anil  Surgical 
Journal. 

Dr.  Charles  E.  Nammack  has  been  appointed 
visiting  physician  to  the  non-collegiate  division  of 
Bellevue  Hospital. 

Salt  in  the  British  Navy. — The  British  naval 
authorities  have  just  added  salt  to  the  rations  of  the 
sailors,  that  necessary  condiment  having  hitherto  been 
denied  them  except  as  they  paid  for  it  themselves. 

American  Academy  of   Railway  Surgeons. — The 

fourtli'  annual  meeting  of  this  society  will  be  held  in 
Chicago,  October  6,  7,  and  8,  1897.  The  president  of 
the  academy  is  Dr.  L.  E.  Lemen,  of  Denver;  the  sec- 
retary. Dr.  D.  C.  Bryant,  of  Omaha. 

The  Turkish  Troops  in  Thessaly  are  suffering 
greatly  from  sickness.  Ten  thousand  soldiers  have 
been  sent  home  or  are  awaiting  the  means  of  transport 
to  Constantinople  on  account  of  invalidism.  Typhoid 
fever  is  the  disease  causing  the  greatest  morbidity  and 
mortality. 

The  Fourth  French  Congress  of  Internal  Medi- 
cine will  be  held  at  Montpellier  on  April  12,  iSgS, 
and  following  days.  The  questions  proposed  for  dis- 
cussion are:  (i)  "Clinical  Forms  of  Pulmonary  Tu- 
berculosis," to  be  discussed  by  MM.  Rard,  of  Lyons, 
Vergely,  of  Bordeaux,  and  Revilliod,  of  Geneva;  (2) 
"Microbic  Association  and  Mi.xed  Infections,"  to  be 
discussed  by  MM.  Spillmann,  of  Nancy,\Vidal,  of  Paris, 
and  Malvoy  of  Li^ge;  (3)  "The  Therapeutic  Utiliza- 
tion of  Organs  with  an  Internal  Secretion,"  to  be  dis- 
cussed by  MM.  Lemoine,  of  Lille,  Mosse,  of  Toulouse, 
and  Cerenville,  of  Lausanne. 


Bellevue  Hospital  Medical  College. — The  Bellevue 
Hospital  Medical  College  was  thrown  open,  September 
28th,  for  the  first  time  since  the  fire  which  almost  de- 
stroyed it.  The  building  has  been  almost  entirely  re-' 
constructed,  being  provided  with  a  new  dissecting- 
room,  an  almost  new  lecture-room,  a  museum,  and  a 
new  office  for  .ii^-  clerk.  The  most  important  changes 
in  the  faculty  are :  Dr.  Edward  G.  Janeway  succeeding 
the  late  Professor  Lusk  as  president.  Dr.  Henry  C. 
Coe  succeeding  Professor  Lusk  as  clinical  professor 
of  gynsecology.  Dr.  Henry  H.  Rusby  succeeding  Prof. 
Herman  M.  Biggs  as  professor  of  materia  medica  and 
pharmacology,  and  Prof.  John  A.  Mandel  succeeding 
Prof.  Ogden  B.  Doremus  as  professor  of  chemistry. 

Death  of  Dr.  W.  H.  Booth.— Dr.  \V.  H.  Booth,  a 
prominent  physician  of  Utica,  N.  Y.,  died  at  the  Mur- 
ray Hill  Hotel,  September  25th,  after  a  brief  illness. 
Dr.  Booth  had  been  a  sufferer  from  a  chronic  disease 
for  years.  He  was  on  a  pleasure  trip  with  Mrs.  Booth 
when  fatally  stricken.     He  was  forty-five  years  old. 

Tri-State  Medical  Society.  —  The  ninth  annual 
meeting  of  the  Tri-State  Medical  Society  of  Alabama, 
Georgia,  and  Tennessee  will  be  held  in  Nashville, 
Tenn.,  Tuesday,  Wednesday,  and  Thursday,  October 
12,  13,  and  14,  1897. 

Mississippi    Valley    Medical    Association The 

twenty-third  annual  meeting  of  the  Mississippi  Val- 
ley Medical  Association  will  be  held  in  Louisville, 
Ky.,  October  5,  6,  7,  and  8,  1897. 

The  Miami  Valley  Medical  Society  (Ohio)  will 
hold  its  fortieth  semi-annual  meeting  in  Loveland, 
Ohio,  Tuesday,  October  12,  1897. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  L^nited  States  navy  for  the  week  ending 
September  25,  1897.  September  iSth. — Assistant 
Surgeon  C.  E.  Riggs  detached  from  the  New  York 
navy  yard  October  4th,  and  ordered  to  the  Nc^vport 
October  4th.  Passed  Assistant  Surgeon  J.  F.  Leys 
detached  from  the  Helena  September  20th,  and  ordered 
to  the  Vesuvius.  Surgeon  N.  H.  Drake,  ordered  to  the 
Minneapolis,  Cohnnbia,  and  other  vessels  in  reser\'e  at 
League  Island,  Pa.  Passed  Assistant  Surgeon  M.  F. 
Gates  detached  from  the  Minneapolis,  on  relief,  and 
ordered  to  the  Boston  Hospital.  Surgeon  G.  P.  Lums- 
den  detached  from  Port  Royal,  on  relief,  and  ordered 
to  special  duty  attending  oflJicers  at  Norfolk,  Va. 
Passed  Assistant  Surgeon  G.  A.  Lung  detached  from 
the  Boston  Hospital,  on  relief,  and  ordered  to  naval 
station,  Port  Royal,  S.  C.  Passed  Assistant  Surgeon 
M.  S.  Guest  detached  from  the  J'esurius,  and  ordered 
to  the  Helena  September  20th.  September  23d. — Sur- 
geon F.  Rodgers,  when  detached  from  Boston  navy 
yard,  ordered  home  and  to  be  ready  for  sea.  Surgeon 
H.  E.  Ames,  ordered  to  the  navy  yard,  Norfolk,  Va., 
October  2d.  September  24th. — Assistant  Surgeon  M. 
S.  Elliott  detached  from  the  Indiana  and  ordered  to 
the  Forter. 


October  2.  1897] 


MEDICAL    RECORD. 


493 


^tvicvos  and  Notices, 

Braithwaite's  Retrospfxt  OF  Medicine.  Vol.  C.W. 
January  to  June,  1897.  London:  Simpkin,  Marshall, 
Hamilton,  Kent  &  Co. 

This  publication  keeps  up  its  usual  high  standard,  and  as  a 
handy  reference  book  cannot  be  too  highly  recommended. 

Transactions  OF  the  Medical  Society  of  the  Statk 
OF  New  York.     For  the  year  1897. 

The  ninety-first  annual  meeting  of  this  society  was  held  at 
Albany  in  January  last,  under  the  presidency  of  Dr.  James 
D.  Spencer,  of  Watertown,  and  is  reported  in  the  volume 
under  notice.  A  feature  of  this  volume  is  the  report  of  dis- 
cussions in  which  different  speakers  handle  special  subjects. 

Problems  of  Nature.  Researches  and  Discoveries  of 
Gustav  Jaeger,  M.D.,  Selected  from  his  Published 
Writings.     New  York  :  Brentano.      1 897. 

Dr.  Jaeger  has  made  for  himself  a  world-wide  reputa;ion 
as  the  introducer  of  a  special  form  of  underclothing,  but  as 
a  man  of  science  he  is  little  known — at  any  rate  to  English- 
speaking  people.  It  appears,  however,  that  he  is  an  in- 
vestigator in  the  field  of  organic  science  as  well  as  a  deep 
student  of  philology.     His  work  is  well  worth  a  perusal. 

Transactions  of  the  Association  of  American- 
Physicians.  Twelfth  Session,  held  at  Washington. 
D.  C.     Vol.  XII.      1897. 

Tins  the  twelfth  volume  of  these  transactions  is  fully  as  in- 
teresting as  the  preceding  volumes.  The  account  of  a  case 
of  acromegaly  with  numerous  excellent  illustrations  is  es- 
pecially worthy  of  note. 

Lippincott's  Medical  Dictionary.  A  Complete  Vo- 
cabulary of  the  Terms  Used  in  Medicine  and  the  Allied 
Sciences,  with  their  Pronunciation,  Etymology,  and  Sig- 
nification, including  much  Collateral  Information  of  a 
Descriptive  and  Encyclopaedic  Character.  Prepared  on 
the  Basis  of  Thomas'  Complete  Medical  Dictionary. 
By  Ryland  W.  Greene,  B.A.,  with  the  Editorial  Col- 
labaratioa  of  JOH.v  Ashhurst,  Jr.,  M.D.,  Barton  Pro- 
fessor of  Surgery  and  Professor  of  Clinical  Surgery  in  the 
University  of  Pennsylvania;  GEORGE  A.  Piersol,  M.D., 
Professor  of  Anatomy  in  the  University  of  Pennsylvania ; 
Joseph  P.  Re.mington,  Ph.M.,  F.C.S.,  Professor  of 
Theory  and  Practice  of  Pharmacy  in  the  Philadelphia 
College  of  Pharmacy.  Complete  in  one  imperial  octavo 
volume  of  about  1,100  pages.  Philadelphia:  J.  B.  Lip- 
pincott  Company.      1897. 

This  dictionary,  although  stated  by  the  editor  to  be  based 
on  Thomas'  dictionary,  is  practically  a  new  work,  as  a 
brief  comparison  of  the  two  shows.  A  careful  comparison 
of  the  book  with  several  of  the  most  popular  medical  dic- 
tionaries and  also  a  practical  test  of  it  in  daily  use  during  a 
period  of  several  weeks,  have  convinced  us  of  its  complete- 
ness, the  discriminating  nicety  of  its  definitions,  and  its 
general  excellence  as  an  authoritative  guide.  The  system 
of  diacritical  marks  for  indicating  pronunciation  is  altogether 
too  complicated  for  a  work  of  this  kind,  and  would  be  very- 
apt  to  puzzle  or  even  mislead  one  whose  previous  education 
has  bscn  such  as  to  make  him  dependent  upon  a  dictionar)- 
for  his  pronunciation.  This  is,  however,  a  matter  of  minor 
importance,  and  detracts  in  no  way  from  the  value  of  the 
work  as  an  authority  for  the  definition  of  medical  terms. 

TwEN  iieth  Century  Practice.  An  International  En- 
cyclopedia of  Modern  Medical  Science  by  Leading  .Au- 
thorities of  Europe  and  America.  Edited  by  Thomas  I., 
Stedman,  M.D.,  New  York  City.  In  Twenty  Volumes. 
Vol.  IX.,  Disea-ses  of  the  Digestive  Organs.  New  York  : 
William  Wood  and  Company.      1897. 

The  list  of  contributors  gives  a  fair  idea  of  the  worth  of  this 
volume.  It  includes  the  names  of  Ewald,  Franks,  Gibney, 
Gioffredi,  Kiimmel,  Mikulicz.  Murphy.  Semmola,  Stengel. 
and  Walker. 

The   list  of  subjects  embraces  "  Local    Diseases  of  the 
Mouth,"   "Diseases  of  the   Intestines."    "Hernia,"  "Dis- 


eases of  the  Spleen,  '  "  Diseases  of  the  Liver,"  "  Diseases  of 
the  Gall  Bladder,"  and  "  Movable  Kidney." 

Mikulicz  and  Kiimmel  are  already  known  as  authorities 
upon  mouth  diseases,  and  they  have  conjointly  produced  a 
ver\-  readable  monograph  whose  interest  is  increased  by  the 
illustrations.  Carl  Ewald's  chapter  on  intestinal  diseases 
does  not  include  those  associated  with  the  various  infectious 
processes,  nor  those  due  to  parasites,  these  as  well  as  her- 
nia having  received  consideration  in  another  portion  of  the 
work.  Ewald's  words  carry  weight  in  this  special  branch, 
and  the  chapter  is  written  in  the  author's  characteristically 
impressive  style. 

Mariano  Semmola  and  Carlo  (iioffredi  have  combined 
their  efforts  in  the  production  of  the  chapter  on  diseases  of 
the  liver,  which  covers  three  hundred  and  thirty  pages,  and 
includes  all  the  biliarj-  and  hepatic  affections  not  elsewhere 
discussed.  Dr.  John  B.  Murphy,  of  Chicago,  follows  with 
an  excellent  chapter  on  the  gall  bladder,  which  is  in  a  man- 
ner supplementary. 

Echinococcus  of  the  liver  was  included,  if  we  mistake 
not,  in  a  chapter  on  hydatid  disease  in  a  preceding  vol- 
ume, but  as  the  present  one  is  short  no  great  harm  will  be 
done,  we  being  able  to  compare  the  views  of  two  different 
authors  whose  observations  have  be;n  made  in  different 
geographical  quarters.  The  concluding  chapter  of  this 
very  interesting  volume  is  on  "Movable  Kidney,"  by  the 
pen  of  Kendal  Franks,  of  Johannesburg,  S.  A.  Republic, 
formerly  of  Dublin,  and  well  known  for  his  excellent  work 
in  this  obscure  subject.  The  manner  in  which  the  author 
has  condensed  the  present  stock  of  available  information  con- 
cerning movable  kidney  amply  justifies  his  selection  by  the 
editor. 

Swedish  Movements  or  Medical  Gymnastics. 
Translated  from  the  text  of  T.  J.  Hartelin.  by  A.  B. 
Olsen,  M.D. 

This  is  simply  a  monotonous  enunieraiion  of  the  several 
movements  to  be  performed  to  obtain  certain  beneficial  re- 
sults. The  book  will  be  a  great  aid  to  the  professional  mas- 
seur or  the  mechano-therapeutist,  but  the  general  practi- 
tioner will  find  litde  in  it  to  engage  his  attention.  It  is  an 
almost  literal  translation,  in  consequence  of  which  the  trans- 
lator's English- suffers  severely.  Part  second,  on  "  Diseases 
and  their  Treatment  by  Medical  Gymnastics. "  contains  much 
that  is  good,  inasmuch  as  it  demonstrates  that  a  great  num- 
ber of  ahections  will  be  more  benefited  by  judiciously  applied 
e.xercise  than  by  the  administration  of  drugs. 

Twentieth  Century  Practice.  An  International  En- 
cyclopedia of  Modern  Medical  Science  by  Leading  Authori- 
ties of  Europe  and  America.  Edited  by  Thom.as  L. 
Stedman,  M.D.,  New  York  City.  In  Twenty  Volumes. 
Vol.  XL,  Diseases  of  the  Nervous  System.  New  York: 
William  Wood  and  Company.      1897. 

In  putting  out  vol.  xi.,  the  editor  of  this  century-anticipat- 
ing work  must  have  much  the  feeling  of  the  mountain 
climber  when  he  has  passed  the  half-way  house.  Not  so 
with  the  writers,  for  the  names  are  new  to  the  work  and  to 
judge  by  their  productions  they  have  entered  with  fresh 
vigor  upon  the  task. 

Bruns,  of  Hanover,  and  W'indscheid,  of  Leipsic,  have 
given  an  extensive  and  satisfactory  account  of  diseases  of 
the  spinal  cord.  Mobius.  of  Leipsic.  treats  of  tabes  dorsalis 
in  about  eighty  well-written  pages.  Striimpell,  of  Eriangen, 
has  a  chapter  entitled  "The  Combined  System  Diseases  of 
the  Spinal  Cord."  By  "system  diseases"  the  author  means 
affections  in  which  only  nerve  cells  and  ncr\-e  fibres,  that  is. 
neurons  which  have  a  definite  physiological  function,  are  at- 
tacked. This  chapter  is  very  short  but  includes  "Fried- 
reich's Disease"  and  "Hereditary  Spastic  .Spinal   Paralysis." 

"Pain"  is  elucidated  by  Dr.  Witiner,  of  Philadelphia, 
and  Dr.  Lloyd,  of  the  same  city,  has  accomplished  the  diffi- 
cult task  of  describing  in  an  acceptable  manner  the  diseases 
of  the  cerebro-spinal  and  sympathetic  nerves.  This  chapter 
takes  up  about  one-half  of  the  volume's  space.  Two  hun- 
dred and  forty  bibliographical  references  are  given. 

Trophoneuroses,  excluding  scleroderma,  acromegaly,  and 
adiposis  dolorosa,  are  described  by  Dr.  Mills,  of  Philadelphia, 
while  Dr.  Dercum,  of  the  same  city,  takes  up  these  latter  sub- 
jects. 

This  is  the  second  volume  upon  the  nerves,  but  being 
freely  illustrated  is   rather  more  attractive  on  this  account 


494 


MEDICAL    RFXORD. 


[October  2,  1897 


than  the  first.  It  may  be  safely  predicted  that  if  the  suc- 
ceeding volumes  of  the  second  half  of  this  series  come  up  to 
the  standard  set  by  Vol.  XI.  the  work  as  a  whole  will 
prove  a  successful  undertaking  to  the  publisher,  and  will 
surely  be  a  credit  to  the  editor. 

Tr.^vnsactions  of  the  Southern  Surgic.'^l  .-vnd 
Gynecological  A.ssociation.  Vol.  IX.  Published 
by  the  Association. 
This  is  the  report  of  the  ninth  session  of  the  association, 
held  at  Xashville,  Tenn.,  November  lo,  ii,  and  12,  1896, 
under  tlie  presidency  of  Dr.  George  Ben  Johnston.  This 
is  one  of  the  most  interesting  volumes  published  by  this 
association,  containing  over  four  hundred  and  seventy  pages, 
well  printed  and  well  edited. 

Transactions  of  the  American  Pediatric  Society. 

Vol.  VIII.     Reprinted  from  the  A7cliives  of  Pediatrics. 

1896. 
This  is  a  report  of  the  eighth  session  of  the  a.ssociation,  held 
in  Montreal,  Canada,  May  25,  26,  and  27,  1896,  under  the 
presidency  of  Dr.  Samuel  S.  Adams.  This  volume  contains 
thirty-five  papers  on  subjects  that  are  of  interest  to  the 
general  practitioner. 

Sixteenth  Report  ok  the  State  Board  of  Health 
OF  Wisconsin.  1895-96.  Madison  Democrat  Printing 
Company,  State  Printer.      1 897. 

This  little  volume  is  made  up  largely  of  extracts  from  health 
officers'  correspondence. 

A  Course  of  Practical  Histology.  By  Edward 
Albert  Sch.Xfer,  LL.D.,  F.R.S.,  Jodrell  Professor  of 
Physiology  in  University  College,  London.  Philadelphia : 
Lea  Bros.  &  Co.      1 897. 

In  the  preface  Dr.  Schafer  explains  the  i)lan  of  this  work. 
He  says  that  "  it  is  designed  to  afford  those  engaged  in  prac- 
tical histology  plain  and  intelligible  directions  for  the  suit- 
able preparation  of  the  animal  tissues,  so  that  they  may  be 
able  to  carry  on  their  histological  studies  without  the  con- 
stant presence  of  a  teacher."  This  design  is  carried  out  in 
the  most  satisfactory  manner ;  the  descriptions  throughout 
the  book  are  plain,  clear,  and  concise,  and  a  student  by 
reading  and  digesting  the  contents  should  gain  a  good  in- 
sight of  practical  histolog)'. 

Urinalysis:  A  Guide  for  the  Busy  Practitioner. 
By  Heinrich  Stein,  Ph.D.,  M.D.  New  York:  E.  R. 
Pelton.      1897. 

This  little  book,  as  its  full  title  denotes,  is  intended  for  the 
use  of  the  general  practitioner,  and,  judging  from  a  perusal 
of  its'^ages,  should  excellently  fulfil  the  object  for  which  it  is 
intended.  The  reading-matter  is  thoroughly  to  the  point, 
and  equal  to  the  requirements  of  an  ordinar)^  practice. 
Each  printed  page  of  this  book  alternates  with  a  blank  one, 
very  useful  for  notes,  a  device  that  in  the  case  of  text-books 
might  be  more  generally  adopted. 

A  Practical  Manual  of  Diseases  of  Women  and 
Uterine  Therapeutics  for  Students  and  Prac- 
titioners. By  H.  Macnaughton  Jones,  M.  D., 
M.Ch.,  M.A.  '  (Hon.  Caus.),  F.R.C.S.  Ireland  and 
Edinburgh.  7th  Edition.  New  York :  William  Wood 
and  Company.      1897. 

That  this  work  has  since  18S4  gone  through  several  edi- 
tions is  a  sufficient  guarantee  of  its  worth  and  popularity. 
There  is  probably  at  the  present  time  no  subject  on  which 
it  is  more  difficult  to  write  a  really  up-to-date  text-book  than 
that  of  diseases  of  women.  Opinions  of  g)'na;cological  au- 
thorities differ  so  widely  and  every  year  sees  so  great  ad- 
vances in  abdominal  surger\-,  that  views  which  might  be 
taken  as  almost  conclusive  but  a  short  time  ago  are  to-day 
regarded  as  obsolete.  Dr.  Jones  has  surmounted  in  the 
most  able  manner  all  the  diflkulties  with  which  he  has  had 
to  grapple,  and  in  the  present  edition  of  his  work  pro- 
duced a  book  which  is  a  complete  survey  of  the  position  of 
gynecology  of  the  day,  including  in  its  pages  all  the  recent 
progress  made  in  this  branch  of  medicine  anil  surgcr\\ 
Possibly  the  most  interesting  reading  is  that  on  the  pa- 
thology of  the  cysts  of  the  ovan,-.  In  connection  with  this 
subject  the  author  quotes  Mr.  Bland  Sutton,   to  whom  he 


acknowledges  his  indebtedness.  One  feature  which  de 
serves  mention  is  the  number  of  really  excellent  illustrations 
and  plates ;  in  fact,  the  book  is  in  everj'  respect  a  credit  to 
the  publishers. 


<§iocieti3  Reports. 


TWPXFTH 


INTERNATIONAL     MEDICAL 
CONGRESS. 


Held  in  Mosco-w,  August  ig,  20,  21,  22,  2j,  24,  25  and 
26,  iSgj. 

(Special  Report  for  ihe  Mkimcal    Rkcukd.) 

SECTION    IX    MEDICINE. 

i  Continued  from  page  463.) 

Fourth  Day — Tuesday,  August  24th. 

The  Causes  of  Essential  Chlorosis.  —  Dr.  Gil- 
bert, of  Paris,  read  the  paper.  Seven  years  ago,  the 
speaker  said,  he  proposed  the  theor)*  of  arterial  hypo- 
plasia; to-day  he  returned  to  its  defence.  The  genital 
theory  was  proposed  by  Hippocrates,  who  attributed 
the  disease  to  the  retention  of  blood  in  the  uterus. 
The  idea  that  chlorosis  may  be  an  expression  of  an 
intoxication  caused  by  suppression  of  the  menstrua- 
tion has  also  been  formulated.  Montard-Martin  has 
adopted  this  theory;  more  recently  it  was  defended 
by  Charrin,  and  still  later  by  Spillmann  and  Etienne. 
These  last  observers  do  not  attribute  chlorosis  solely 
to  amenorrhaa,  but  say  the  cause  is  a  pathological 
condition  of  the  ovaries  which  prevents  ovulation  and 
prevents  too  the  secretion  of  the  glands;  in  this  latter 
we  see  an  analogy  to  the  important  role  of  the  testicle 
in  general  nutrition.  But  this  does  not  explain  the 
cases  of  chlorosis  in  boys  nor  the  absence  of  chlorosis 
in  women  who  have  undergone  castration.  Sydenham 
and  Morton  were  the  first  promulgators  of  tJie  ner\-ous 
theory,  but  Trousseau  was  its  chief  defender.  The 
latter  contended  that  the  nervous  impression  produced 
was  never  lost  even  though  the  blood  condition  en- 
tirely disappeared,  in  fact  even  when  later  there  was 
plethora. 

The  defenders  of  the  digestive  theory  differ  greatly 
among  themselves.  Stockman  says  the  condition  is 
due  to  the  lack  of  iron  in  the  food,  Luton  ascribes  it 
to  ulcer  of  the  stomach,  Meinert  togastroptosis  caused 
most  frequently  by  the  corset,  Forchheimer  to  changes 
in  the  small  intestine  causing  a  reduction  in  the  for- 
mation of  hamoglobin,  Duclos  and  Andrew  Clark  to 
constipation  causing  an  autotoxa-mia,  Bean  and  Mon- 
gour  to  dyspepsia  in  its  general  sense.  The  liver  has 
been  accused  by  F'ox,  who  attributes  chlorosis  to  atro- 
phv  of  this  organ;  while  Clement  says  it  is  hypertro- 
phy of  the  spleen. 

Vascular  Theory. — The  author  divides  the  cases 
of  chlorosis  into  three  classes:  (i)  Chlorosis 
with  vascular  hypoplasia  w  ithout  change  in  the  sexual 
apparatus;  (2)  Chlorosis  with  vascular  hypoplasia 
and  excessive  development  of  the  genital  apparatus: 
(3)  Chlorosis  with  vascular  hypoplasia  and  defective 
development  in  the  genital  apparatus.  Even  though 
later  researches  may  show  that  the  vascular  hypoplasia 
is  not  constant,  the  lesions  of  the  vessels  and  the  heart 
will  occupv  nevertheless  a  prominent  place  in  the  pa- 
thological anatomy  of  chlorosis.  The  wiiole  arterial 
system  is  affected,  but  this  pathological  condition  is 
particularly  appreciable  in  the  aorta  which  is  modified 
in  its  calibre,  its  structure,  and  in  the  manner  of  emer- 
gence of  its  collaterals  (aorta  chloroticaK  The  artery 
is  narrow,  infantile:  its  lumen  scarcely  admits  the  lit- 
tle finger  and  the  abdominal  portion  has  only  the  di- 
mensions of   a  normal   crural   artery.     Its  walls  are 


October  2,  18^7] 


MEDICAL    RECORD. 


495 


thin,  with  an  exaggerated  elasticit}-;  its  internal  sur- 
face is  reticulated  and  shows  fatty  degeneration.  The 
intercostals,  instead  of  being  parallel,  come  off  irregu- 
larly. The  condition  of  the  heart  is  variable.  In  a 
cenain  number  of  cases  it  is  dilated  and  hypertro- 
phied,  in  others  it  is  small,  with  or  without  dilatation 
of  the  right  ventricle,  and  the  endocardium  is  thin  and 
transparent.  The  dilatation  and  hypertrophy  of  the 
heart  are  a  consequence  of  the  narrowness  of  the 
aorta ;  the  smallness  of  the  latter  is  the  result  of  a  gen- 
eral vascular  hypoplasia. 

Chlorosis  may,  however,  appear  independently  of  the 
arrest  of  development  of  the  vascular  system ;  moreover, 
these  defects  may  be  sometimes  demonstrated  without 
a  s\Tnptom  of  chlorosis.  Especially  is  this  latter  true 
in  young  tuberculous  patients,  in  whom  genital  in- 
fantilism and  even  narrowness  of  the  aorta  are  not 
rare. 

At  the  author's  suggestion  M.  Jolly  had  studied 
chlorotics  in  relation  to  tuberculosis.  Out  of  fifty- 
four  cases,  in  twenty-five  the  father  or  mother  of  the 
patient  had  died  of  this  disease:  in  seven  the  grand- 
parents, the  uncles,  aunts,  brothers,  or  sisters  were 
affected ;  and  in  eight  the  patients  themselves  showed 
indisputable  signs  of  tuberculosis. 

Dr.  Saxsom,  of  London,  said  he  agreed  with  Vir- 
chow  that  in  many  cases  chlorosis  depends  upon  an 
imperfect  development  of  the  aorta  whereby  this  vessel 
is  comparatively  small.  But  he  had  observed  that  the 
smallness  of  the  aorta  depended  often  on  the  small- 
ness of  the  pulmonar)-  arter\'.  He  had  seer,  a  case  of 
profound  ansemia  without  cyanosis  in  an  infant  in 
whom  he  found  extreme  smallness  of  the  pulmonary 
artery.  In  many  other  cases  all  the  signs  of  stenosis 
of  the  pulmonary  artery  were  present,  but  eventually 
by  treatment  all  these  signs  disappeared.  This  shows 
the  importance  of  treatment  in  such  cases — e.xercises, 
baths,  etc.,  directed  to  the  increase  of  the  capacity  of 
the  lungs,  of  course  accompanied  by  medicinal  treat- 
ment and  the  use  of  the  salts  of  iron  and  arsenic. 

Dr.  Ewald,  of  Berlin,  said  that  at  present  the 
theory  of  vascular  hypoplasia  appealed  most  to  him 
and  he  believed  that  in  the  near  future  it  would  be 
placed  on  a  solid  basis. 

Dr.  Gilbert  ended  by  saying  that  he  was  verv-  much 
pleased  to  find  his  theory  defended  by  Professor  Ewald. 
In  relation  to  what  Professor  Sansom  had  said,  he  ' 
wished  to  repeat  that  while  he  believed  vascular  hypo- 
plasia to  be  usually  the  cause  of  chlorosis,  it  was  not 
an  absolutely  constant  one. 

Morphology  of  the  Blood  in  Leukaemia. — Dr. 
Dock,  of  Ann  Arbor,  reported  a  case  of  chronic  leu- 
karmia  with  an  increase  of  only  small  mononuclear 
cells  in  the  blood,  in  which  the  period  of  time  during 
which  the  blood  was  examined  and  the  opportunity  for 
examining  the  tissues  post  mortem  seemed  to  furnish 
important  data  for  the  study  of  leukjemia.  The  pa- 
tient was  a  man  fifty-two  years  old.  When  forty -eight 
years  old  he  had  influenza,  from  which  he  never  en- 
tirely recovered,  but  remained  pale  and  weak.  Two 
years  later  he  discovered  a  tumor  in  the  left  side. 
This  grew  larger  slowly,  causing  after  a  time  marked 
dyspnoea.  The  speaker  saw  the  patient  one  and  one- 
half  years  after  he  discovered  the  tumor.  He  was 
pale,  dyspnoeic,  and  had  slight  oedema  of  the  ankles. 
The  spleen  and  liver  were  much  enlarged,  the  former 
reaching  from  the  eighth  rib  ii:  the  axillary  line  to 
the  middle  of  the  left  rectus  muscle  and  the  iliac 
fossa;  the  liver  extended  to  the  level  of  the  navel. 
The  lymphatic  glands  of  the  axilla  and  inguinal  region 
were  slightly  enlarged.  He  complained  of  pain  in 
the  sternum,  in  some  of  the  ribs,  and  in  the  tibite. 
The  blood  was  pale  and  watery.  Examination  showed 
red  blood  cells  1,923,000,  leucocytes  312,500,  hemo- 
globin, by  Fleischl's  method,  forty  per  cent.     .Almost 


all  of  the  leucocytes  were  of  the  size  and  appearance 
of  small  lymphocytes,  rareh"  exceeding  the  diameter  of 
the  average  red  cells.  The  multinuclear  cells  were 
decreased  in  number.  Eosinophiles  were  present  in 
the  proportion  of  one  to  one  thousand,  sometimes  only 
one  to  three  thousand.  Leucocytes  with  round  or  oval 
nuclei  and  coarse  neutrophile  granulations  were  pres- 
ent in  proportion  of  one  to  five  per  thousand.  Nu- 
cleated red  cells — noniioblasts — were  present  in  pro- 
f>ortion  of  about  one  per  thousand.  The  blood  always 
contained  large  numbers  of  degenerated  leucocytes 
recognizable  only  in  stained  preparations.  It  is  possi- 
ble many  of  these  were  overlooked  in  the  counts  of 
fresh  blood.  The  patient  died  four  months  after  the 
speaker  had  first  seen  him,  of  influenza  with  bron- 
cho-pneumonia. In  the  last  illness  the  condition  of 
the  blood  remained  unaltered.  Charcot's  crystals  were 
never  found.  The  coagulability  of  the  blood  was  di- 
minished. Just  before  the  influenza  the  blood  exami- 
nation showed  red  blood  cells  1,542,000,  white  cells 
580,000,  haemoglobin,  by  Fleischl's  method,  thirty  per 
cent.  The  histological  changes  in  the  various  organs 
were  found  to  consist  essentially  in  a  marked  increase 
or  new  growth  of  lymphoid  tissue.  The  following  were 
Dr.  Dock's  conclusions:  ( i)  The  peculiarities  of  leu- 
ksemic  blood  depend  on  the  kind  rather  than  the  seat 
of  the  alterations:  yz )  The  e.\gess  of  cells  may  be  de- 
rived from  any  tissue  in  which  they  are  formed,  pro- 
vided means  are  present  for  entering  the  circulation ; 
(3)  In  leukaemia  the  blood  may  be  characterized  either 
by  a  polymorphism  of  leucocrtes  or  by  a  marked  pre- 
ponderance of  one  particular  kind  of  cell,  especially 
of  cells  having  the  general  appearance  of  lymphocytes, 
but  at  present  these  cells  should  not  be  described  as 
lymphocytes,  without  details  of  their'exact  peculiari- 
ties, especially  their  tinctorial  peculiarities. 

The  Haematokrit Dr.  Dalaxd,  of  Philadelphia, 

demonstrated  the  ha;matokrit  with  a  number  of  impor- 
tant and  practical  modifications.  These  were  new  ca- 
pillary tubes,  upon  which  had  been  placed  a  scale  and 
a  lens  front,  by  the  aid  of  which  the  column  of  red 
blood  corpuscles  could  be  easily  and  accurately  read. 
He  also  gave  a  careful  and  detailed  description  of  a 
new  technique  by  which  the  entire  study  of  the  blood 
may  be  completed  within  three  or  four  minutes. 

The  Blood  Test  of  Diabetes  by  Means  of  Aniline 
Dyes — Dr.  Ludwig  Bremer,  of  St.  Louis,  read  a  pa- 
per in  which  he  described  the  following  simplifica- 
tion of  his  method  of  diagnosing  diabetes  from  the 
blood :  Spread  a  drop  of  blood  obtained  from  the 
finger  tip  of  a  diabetic  of  a  glass  slide,  by  means  of 
another  slide;  the  film  must  be  rather  thick.  Spread- 
ing in  a  wavelike  fashion  is  preferable.  Make  a 
number  of  such  preparations,  say  ten,  and  an  equal 
number  of  preparations  of  non-diabetic  blood  for  the 
purpose  of  control.  Place  them  in  a  metal  oven,  the 
tray  on  which  they  rest  being  at  least  six  inches  from 
the  bottom  of  the  heating  apparatus.  The  thermom- 
eter must  be  so  adjusted  that  the  bulb  rests  on  the 
tray.  Turn  on  the  flame  and  let  the  heat  nm  up  to 
about  135"  C,  which  is  the  best  temperature  for  the 
test,  although  a  few  degrees  either  way  do  not  make 
much  difference.  The  time  to  be  consumed  in  heat- 
ing, until  the  desired  degree  is  reached,  is  from  six  to 
ten  minutes.  The  apparatus  is  allowed  to  cool,  until 
the  preparations  can  be  handled  conveniently.  Now 
prepare  a  one-per-cent.  aqueous  solution  of  Congo  red, 
in  a  Naples  tube  or  any  other  similar  kind  of  glass 
jar.  Place  two  specimens,  one  of  diabetic,  the  other 
of  non-diabetic  blood,  back  to  back,  in  the  reagent. 
After  one  and  a  half  or  two  minutes  rinse  in  water, 
when  it  will  be  found  that  the  non-diabetic  blood  has 
assumed  the  pronounced  Congo-red  stain,  whereas  the 
diabetic  has  proved  refractor)-  or  is  only  slightly 
stained,  not  red,  but  orange.     Methyl  blue  (not  meth- 


496 


MEDICAL    RECORD. 


[Cfctober  2,  1897 


ylene  blue)  gives  equally  satisfactory  results.  Bie- 
brich  scarlet  stains  the  diabetic,  but  not  the  non-dia- 
betic blood  film.  There  are  many  other  dyes  which 
show  a  diflerential  behavior  toward  diabetic  and  non- 
diabetic  blood.  The  essential  of  .success  is  the  ol)- 
taining  of  the  proper  temperature.  The  specimens 
may  remain  in  the  reagent  longer  than  two  minutes, 
say  five  or  ten,  but  if  retained  too  long  the  selective 
principle  determining  the  reaction  is  drawn  out,  and 
both  preparations  are  stained  alike. 

The  constituent  of  the  blood  determining  the  posi- 
tive or  negative  stain  is  the  red  blood  corpuscles. 
They  are  in  an  abnormal  state  in  diabetes,  which  is 
calculated  to  render  .some  of  the  diabetic  phenomena 
intelligible.  Contrary'  to  Le'pine  and  Lyonnet,  who 
have  experimented  with  the  older  method  recom- 
mended by  the  author,  tlie  latter  holds  that  the  reac- 
tion is  not  one  merely  of  greater  or  lesser  alkalinity. 
There  exists  a  peculiar  state  of  the  hemoglobin,  in 
consequence  of  which  the  oxygen  carriers  are  ham- 
pered in  their  functions.  The  test  lends  color  to  the 
opinion  expressed  by  Spitzer,  that  the  glycolytic  fer- 
ment is  contained  in  the  red  blood  corpuscles.  Lu- 
pine and  L)-onnet  have  also  claimed  that  leukaemia 
showed  the  same  color  reaction.  This  is  true  of  over- 
heated specimens.  If  the  details  of  the  test  recom- 
mended by  the  speaker  are  strictly  adhered  to,  leuka;- 
niic  blood  behaves  like  non-diabetic  blood.  Marie 
and  L2  Goff,  of  Paris,  have  verified  Bremer's  experi- 
ments and  repeated  them  before  the  Socie'td  des  H6- 
pitaux.  Dr.  Bremer  claimed  that  even  in  diabetics 
whose  urine  is  temporarily  free  from  .sugar  his  blood- 
test  holds  good  and  proves  the  existence  of  the  dis- 
ease. Even  in  the  prediabetic  stage,  a  disturbed  taste 
of  the  metabolic  equilibrium  is  revealed  by  the  test. 
In  addition  to  the  well-known  experimental  phlor- 
rhidzin  diabetes.  Dr.  Bremer  said  that  there  exists  also 
a  phloroglucin  diabetes.  The  former  is  kidney  dia- 
betes, the  latter  blood  diabetes. 

Diabetes  Mellitus. — Dr.  William  Pavy,  of  London, 
read  a  paper  on  this  subject  which  was  one,  he  said, 
that  had  hitherto  puzzled  all  investigators,  but  modem 
research  has  cleared  up  the  difficulties;  diabetes  mel- 
litus is  no  longer  the  intricate  disease  of  formerly  and 
we  can  look  at  it  now  in  a  sensible  light.  Diabetes 
mellitus  consists  in  a  malassimilation  by  the  animal 
organism  of  the  carbohydrates  of  the  food.  Ordina- 
rily the  carboh)-drates,  when  properly  neutralized,  go 
to  benefit  the  system,  but  in  diabetes  instead  of  bene- 
fiting they  simply  pass  through  as  waste  products. 
The  province  of  the  physician  is  to  investigate  the  na- 
ture of  the  error  which  causes  this,  and  then  bring 
back  to  the  system  its  natural  powers.  The  first  se- 
rious fault  is  in  the  villi  of  the  small  intestine. 
Under  normal  conditions  of  health,  they  so  change  the 
carbohydrates  that  little  or  no  sugar  as  such  gets  into 
the  portal  vein,  and  so  our  first  step  in  the  treatment 
of  diabetes  is  to  prevent  the  carbohydrates  from  pass- 
ing unchanged  into  the  portal  vein.  In  order  that 
sugar  may  appear  in  the  urine  it  must  have  been  in  the 
general  circulation,  and  so  if  we  prevent  it  from 
reaching  the  general  circulation  we  shall  stop  its  elim- 
ination by  the  urine.  It  is  absolutely  true  that  un- 
der conditions  of  health  there  is  no  sugar  in  the  gene- 
ral circulation,  for  if  we  inject  sugar  into  the  vein  of 
any  individual,  just  so  much  as  has  been  injected  will 
later  be  found  in  the  urine.  It  was  formerly  said  that 
the  carbohydrates  as  such  went  to  the  muscles  to  make 
heat,  but  this  we  can  demonstrate  to  be  false  and  we 
can  say  with  certainty  that  the  carbohydrates,  whether 
under  the  form  of  glucose,  maltose,  or  starch,  getting 
into  the  general  circulation  cannot  be  used  by  the  or- 
ganism and  -SO  are  eliminated  as  waste.  Between  the 
intestines  and  the  liver  the  carbohydrates  must  all  he 
converted   into  principles  which  the  general  circula- 


tion can  distribute,  and  the  speaker  believed  that  most 
of  this  conversion  takes  place  in  the  intestine  itself. 
That  carbohydrates  are  changed  into  fat  there  is  no 
doubt,  since  we  can  find  almost  as  much  fat  in  the  lac- 
teals  after  the  ingestion  of  carbohydrates  as  after  that 
of  fatty  food.  Consequently  when  we  find  sugar  in 
the  urine,  we  appreciate  at  once  that  the  power  in  the 
intestine  of  proper  assimilation  has  been  weakened. 
In  a  perfect  condition  this  power  is  such  that  even  ex- 
cesses do  not  disturb  it,  but  we  can  easily  imagine  an 
individual  whose  power  of  assimilation  is  just  so  bal- 
anced that  when  he  eats  normally  there  is  no  trouble, 
but  a  banquet  or  the  ingestion  of  an  excess  of  carbohy- 
drates for  any  reason  will  precipitate  some  of  them 
into  the  general  circulation  and  they  will  consequently 
appear  in  the  urine.  Such  a  man  may  go  to  Dr.  A., 
who,  finding  sugar,  will  tell  him  he  has  diabetes,  and 
later  to  Dr.  B.,  who  will  contradict  the  first.  This  has 
happened  more  than  once  and  is  to  be  remembered. 
But  in  actual  diabetes  the  condition  is  much  worse; 
the  power  of  assimilation  of  starches  may  be  almost 
entirely  gone.  When  this  is  so  the  patient  rapidly 
loses  flesh  and  strength,  since  carbohydrates  are  nec- 
essary for  the  animal  organism. 

The  indications  for  treatment  are  evident,  and  in 
the  majority  of  cases  the  assimilative  powers  can  be 
brought  back,  if  not  to  the  normal,  at  least  to  a  condi- 
tion approaching  it.  The  first  indication  is  to  pre- 
vent the  sugar  from  getting  into  the  urine.  Keep  it 
from  the  intestine,  and  this  is  easy;  therefore,  stop  the 
carbohydrates  for  a  time,  limiting  the  patient  to  other 
foods.  At  once  on  limited  diet  the  sugar  in  the  urine 
lessens,  after  a  time  it  stops,  and  still  later  the  grad- 
ually increasing  ingestion  of  carbohydrates  will  have 
the  effect.  For  the  present  we  can  say  only  that  then 
intestine  is  at  fault,  but  Dr.  Pa\'y  could  not  help 
thinking  we  shall  later  find  it  to  be  a  ner\-ous  condi- 
tion acting  on  the  vessels  of  the  intestine. 

Dr.  Bre.mf.n,  of  St.  Louis,  said  that  he  had  listened 
with  much  pleasure  to  this  paper  and  he  desired  to 
call  attention  again  to  his  discovery.  He  claimed  that 
his  test  with  the  aniline  colors  showed  the  red  cor- 
puscles to  be  at  fault,  and  he  believed  that  the  red 
corpuscles  normally  contain  a  glycolytic  ferment. 

Dr.  Hughes,  of  St.  Louis,  said  that  through  the  la- 
bors of  the  eminent  men  of  to-day  diabetes  was  not  the 
terror  it  was  years  ago,  and  he  was  very  glad  to  be 
present  to  hear  Dr.  Pavy  say,  he  believed  for  the  first 
time,  that  diabetes  was  probably  due  to  a  ner\'ous 
condition. 

Cessation  of  Respiration  before  that  of  Circula- 
tion.— Sir  Dvce  Duckworth,  of  London,  repwrted 
briefly  four  cases,  three  of  cerebral  or  cerebellar  ab- 
scess consecutive  to  otitis  media  suppurativa  and  one 
of  cerebral  hemorrhage  from  tumor,  in  which  the  pa- 
tient absolutely  ceased  to  breathe  for  periods  varying 
from  three  to  five  hours  before  the  action  of  the  heart 
was  arrested.  Artificial  respiration  was  of  no  avail  in 
restoring  the  lost  function  and  hypodermic  injections 
of  strychnine  and  ether  were  equally  powerless  to  re- 
establish it.  Experiments  were  quoted  to  show  that 
this  occurrence  has  been  noted  in  cases  of  injury  to 
the  brain  from  gunshot  wounds,  and  the  author  dis- 
cussed the  possible  explanation  of  this  peculiar  con- 
dition. 

Fifth  Day—  Wednesday,  August  2jt/i. 

The  Relation  of  Nervous  Dyspepsia  to  Genera' 
Nervous  Disturbances.  —  Dk.  Rosenheim,  of  Berlin, 
read  a  paper  on  this  subject.  He  defined  nervous 
dyspepsia  as  a  sensory  neurosis  differing  from  hyperaes- 
thesia  in  that  the  disturbances  are  intimately  asso- 
ciated with  digestive  activity  of  the  stomach  and  that 
the  symptoms  are  very  similar  to  those  of   different 


October  2,  1897] 


MEDICAL    RECORD. 


49; 


forms  of  gastritis.  In  nenous  dyspepsia  both  motor 
.md  sensory  functions  may  be  disturbed.  There  may 
be  an  acidity,  subacidity,  or  hyperacidity.  Diminu- 
tion in  the  amount  of  the  gastric  juice,  hypemiotility. 
and  atony  are  often  found.  If  the  functional  disturb- 
ance is  marked  and  continues  a  long  time,  ner\'ous 
dyspepsia  may  be  easily  confounded  with  other  affec- 
tions, especially  witli  one  or  other  of  the  forms  of  gas- 
tritis. Nervous  dyspepsia,  thus  defined,  is  not  the 
frequent  affection  it  is  commonly  supposed  to  be  and 
not  all  dyspeptic  s}Tnptoms  in  a  nervous  individual 
point  to  nervous  dyspepsia.  In  fifty  such  cases,  post- 
mortem examination  revealed  the  fact  that  more  than 
one-half  of  the  patients  had  suffered  from  other  dis- 
eases of  the  stomach,  principally  inflammatory  proc- 
esses, and  only  in  eleven  cases  were  the  complex 
symptoms  of  nervous  dyspepsia  found. 

Nervous  dyspepsia  usually  brings  with  it  other 
ner\ous  symptoms,  sometimes  giving  us  a  complete 
picture  of  neurasthenia  or  (more  seldom)  of  hysteria. 
That  nervous  dyspepsia  is  always  a  symptom  of  neu- 
rasthenia has  been  maintained,  and  it  often  happens 
that  nervous  symptoms  depend  on  stomach  disturb- 
ances and  disappear  when  the  latter  are  cured. 
Nevertheless,  in  nervous  dyspepsia  the  treatment  of 
the  stomach  symptoms  is  very  useful,  especially  when 
combined  with  the  treatment  of  the  general  condition 
and  the  pathogenesis. 

Neuropathic  Dyspepsia  and  its  Relations  to 
Changes  in  the  Rhythm  of  the  Heart. — Dr.  Sa.\- 
so.M,  of  London,  read  a  paper  with  this  title.  He  said 
he  had  made  a  clinical  study  of  a  considerable  number 
of  cases  in  which  there  were  disturbances  of  tht 
rhythmic  action  of  the  heart,  in  order  to  determine  if 
there  was  an  association  between  it  and  dyspepsia. 
The  conclusions  arrived  at  from  this  study  were  the 
following:  I.  In  the  essential  tachycardias  without 
complications  the  manifestations  of  dyspepsia  are  not 
marked.  In  forty-six  cases  there  was  not  one  of 
dyspepsia  which  persisted.  2.  In  the  cases  of  tachy- 
cardia following  influenza  dyspepsia  was  much  more 
frequent,  five  out  of  thirt\-seven  cases.  3.  Tachy- 
cardia accompanied  by  exophthalmic  goitre  was  often 
associated  with  serious  dyspepsia.  4.  Arrhythmia  of 
the  heart  without  organic  complications  was  often  as- 
sociated with  dyspepsia.  5.  Persistent  brachycardia 
was  evidently  associated  with  marked  dyspepsia,  but 
intermittent  brachycardia  was  also  accompanied  by 
epigastric  pains,  vomiting,  and  other  signs  of  dys- 
pepsia. 

The  Dress  of  Woman  and  the  Position  of  Her 
Stomach. — Dr.  Bexderskv,  of  Kieff,  read  a  paper  in 
which  he  described  a  new  sign  which  he  had  found  to 
be  an  aid  in  defining  the  position  of  the  stomach. 
The  corset  is  well  known  to  be  injurious,  but  it  is  not 
the  corset  alone  that  is  the  whole  cause.  The  lower 
part  of  the  corset  may  even  be  useful,  by  protecting 
the  stomach  from  injury  by  the  petticoats,  etc.,  for  il 
the  skirts  are  fastened  tightly  without  a  corset  much 
more  harm  is  done  on  account  of  the  linear  constric- 
tion. With  the  stomach  in  the  normal  position,  the 
waistband  of  the  dress  lies  between  the  stomach  and 
transverse  colon,  but  if  there  is  gastroptosis  the  lines 
of  the  dress  will  not  follow  the  greater  curvature  of 
the  stomach  (the  author  has  seen  such  cases  even 
in  men)  but  lie  above  it.  In  looking  at  the  female 
abdomen  we  see  vertical  and  curved  lines  caused  by 
the  corset,  but  besides  there  is  evident  a  horizontal 
line  caused  by  the  waistband  of  the  dress.  The 
author  calls  this  line  the  gastric  line  because  it  de- 
fines the  lower  border  of  the  stomach.  It  may  also  be 
found  in  men  wearing  tight  waistbands. 

Massage  in  the  Treatment  of  Internal  Diseases. 
—  Dr.  Dolec.^,  of  Leipzig,  read  a  paper  on  this  sub- 
ject.    He  first  reviewed   briefly  the  history  of  treat- 


ment by  massage.  He  showed  that  although  many 
therapeutic  discoveries  had  been  made,  massage  still 
held  its  own  high  place.  Moreover,  many  physicians 
who  formerly  were  sceptical  as  to  its  usefulness,  now 
ordered  it,  since  physiological  and  experimental  re- 
search had  demonstrated  its  action  and  proved  its 
worth.  He  gave  the  special  indications  for  massage 
in  the  treatment  of  internal  diseases;  and  said  that 
mechano-therapy,  especially  massage,  was  destined  to 
hold  in  the  future  even  a  still  higher  place  in  treat- 
ment and  that  the  time  had  come  when  institutes  of 
massage  should  be  founded. 

Gonorrhoea!  Endocarditis. — Dr.  Thayer,  of  Balti- 
more, read  a  paper  on  this  subject.  The  accumulat- 
ing observations  of  recent  years  have  demonstrated  the 
fact  that  the  pathogenesis  of  die  different  complica- 
tions of  gonorrhcea  may  vary  materially  in  different 
instances,  i.  That  the  complicating  process  may  be 
of  purely  gonorrhceal  origin  hds  been  shown  particu- 
larly by  tlie  numerous  cases  of  arthritis,  occurring  in 
connection  with  gonorrhcea  in  which  the  specific  micro- 
organism has  been  demonstrated  microscopically  and 
obtained  in  pure  cultures  from  the  affected  joints.  2. 
That  complications  may  be  due  to  a  mixed  or  secon- 
dary infection  with  other  pyogenic  organisms  has  long 
been  known,  and  the  manner  of  development  of  such 
secondary  processes  has  been  \v%ll  pictured  by  Finger 
in  a  recent  article.  3.  There  is  good  reason  to  be- 
lieve that  serious  focal  lesions  may  occur  in  gonor- 
rhoea without  the  actual  presence  of  either  the  gono- 
coccus  or  other  micro-organisms,  the  lesions  being 
due  solely  to  the  presence  of  circulating  toxic  sub- 
stances. Definite  proof  of  this  hypothesis  has  not  yet 
been  advanced,  but  in  view  of  the  complete  absence 
of  bacteria  on  microscopical  examination,  as  well  as 
of  the  complete  sterility  of  cultures  taken  from  the 
iiffected  regions  in  cases,  for  instance,  of  neuritis  or 
myelitis  secondary  to  gonorrhoea,  as  well  as  from 
analogy  with  other  similar  infectious  processes,  there 
is  strong  probability  that  such  lesions  exist.  The 
presence  of  local  foci  of  infection  at  remote  points 
from  the  region  originally  affected,  joints,  tendon 
sheaths,  etc.,  would  lead  us  to  infer  that  a  true  gonor- 
rhceal septicaemia  may  occur.  Everything  points 
to  the  blood  as  the  means  by  which  the  organisms 
are  transferred  to  distant  points.  This  was  prac- 
tically proved  when  Dr.  Blumer  and  the  speaker  suc- 
ceeded for  the  first  time  in  obtaining  the  gonococcus  in 
pure  culture  during  life  from  the  circulating  blood  of 
a  case  of  ulcerative  endocarditis.  The  case  was  then 
detailed.  The  blood  was  taken  from  the  median 
basilic  vein  with  a  sterilized  syringe  and  mixed  with 
melted  agar  which  was  immedately  plated.  The  first 
culture  was  negative,  but  the  second  and  third  showed 
minute  white  colonies  representing  apparently  a  pure 
culture  of  small  biscuit-shaped  diplococci  which  failed 
to  grow  on  transmission  to  agar-agar,  gelatin,  potato, 
bouillon,  and  litmus  milk.  The  autopsy  confirmed 
the  diagnosis,  revealing  an  extensive  ulcerative  endo- 
carditis of  the  mitral  valve.  In  the  thrombi  upon 
the  valve  were  found  large  numbers  of  small  oval 
diplococci  having  all  the  morphological  and  tinctorial 
characteristics  of  gonococci.  In  this  case  the  gonor- 
rhoea was  not  recognized  during  life,  but  in  a  second 
case  the  gonorrhoea  was  recognized  and  every  precau- 
tion was  taken  to  make  the  bacteriological  examination 
of  the  blood  without  question.  In  this  case  (tliat  of  a 
boy  aged  nineteen)  two  cubic  centimetres  of  blood  were 
drawn  from  the  median  basilic  vein  and  mixed  with 
four  cubic  centimetres  of  nutrient  agar  and  plated. 
.\t  the  end  of  forty-eight  hours  numerous  colonies  half 
the  size  of  a  pinhead,  granular  in  appearance  with 
somewhat  irregular  borders,  were  found.  They  were 
of  biscuit  or  kidney  shape,  the  flattened  sides  of  the 
cocci  being  turned  toward  each  other,  forming  pairs. 


498 


MEDICAL    RFXORD. 


[October  2,  1897 


They  stained  well  with  the  ordinary  basic  stains  and 
decolorized  by  Gram's  method.  Transplanted  to 
human  blood-serum  agar  by  a  smear  upon  the  surface, 
there  developed  a  fair  number  of  colonies  similar  to 
the  above  and  made  up  of  diplococci  having  ihe  same 
morphology  and  tinctorial  reactions.  Transplanted 
to  ordinary  agar  there  resulted  a  growth  of  a  very  few 
fine  colonies  made  up  of  the  same  diplococci.  On 
gelatin,  o.\-blood  serum,  and  bouillon  there  was  no 
growth.  At  the  end  of  eighteen  days  cocci  had  all 
died  out  on  the  orginal  plates.  Later  two  cultures 
were  made  that  acted  in  the  same  way.  The  autopsy 
showed  the  tricuspid  valve  to  be  the  seat  of  an  exten- 
sive thrombus  formation.  (The  speaker  showed  an 
admirably  executed  painting  of  this  thrombus.)  ]5ac- 
teriological  examination  of  this  thrombus  also  showed 
gonococci  in  pure  culture.  The  gonorrhoeal  nature  of 
the  endocarditis  as  well  as  the  actual  existence  of  a 
gonorrhceal  septica;niia  seemed  to  be  demonstrated 
beyond  a  doubt  by  the  di-scovery  and  reproduction  of 
the  gonococcus  in  pure  culture  from  the  circulating 
blood  during  life  and  after  death  from  the  affected 
cardiac  valves  and  from  the  pleural  and  pericardial 
exudates. 

Trial  of  the  Electrical  Synthesis  of  Franklini- 
zation and  of  Currents  of  High  Frequence.— Dr. 
Apustoli,  of  Paris,  read  a  paper  on  this  subject.  The 
speaker's  conclusions  were:  i.  No  form  of  electricity 
can  be  constantly  and  absolutely  the  best  in  ever)- 
case,  since  each  form  preserves  its  therapeutic  useful- 
ness under  proper  circumstances.  2.  The  symptomatic 
reactions  of  one  or  the  other  form  may  be  useful  in 
electro-diagnosis,  and  they  show  us  the  therapeutic 
inclinations  better. 

So-Called  Hypertrophic  Pulmonary  Osteo- Arthrop- 
athy of  Pierre  Marie,  without  Pulmonary  Disease. 
■ — ^Dr.  John  Linds.ay  Steve.v,  of  Glasgow,  described 
a  case  of  peculiar  enlargement  of  the  hands  and  feet 
due  to  a  subperiosteal  new  formation  of  bone  in  the 
affected  parts,  which  had  all  the  clinical  characters  of 
the  affection  which  Marie  has  designated  hypertrophic 
pulmonary  osteo-arthropathy.  The  paper  was  illus- 
trated by  photographs  and  skiagrams  which  showed 
very  well  the  peculiar  deformity,  the  skiagram  in  par- 
ticular demonstrating  the  nature  of  the  bone  affection. 
The  patient  was  a  laborer,  aged  forty-eight,  who  had 
been  ill  in  all  about  a  year  before  his  admission  to 
Dr.  Lindsay  Steven's  wards.  He  first  noticed  en- 
largement of  the  hands  and  feet,  at  first  painless,  but 
latterly  disabling  him  on  account  of  pain  and  stiffness 
in  the  ankles  and  knees.  About  four  tnonths  before 
his  admission  he  had  a  cough  which,  however,  never 
laid  him  aside  from  work,  and  which  had  entirely 
gone  fully  a  month  before  his  admission  to  the  in- 
firmary. There  was  absolutely  no  sign  of  cardiac  or 
pulmonary  disease.  The  hands  were  greatly  thickened, 
especially  the  fingers — the  nails  also  were  so  curved 
that  the  point  of  the  finger  was  covered  by  nail  and 
not  by  skin.  The  lower  end  of  the  foreann  bones 
were  greatly  thickened  and  rough,  the  roughness  being 
traceable  half-way  up  the  arm.  This  was  well  de- 
monstrated by  the  Roentgen  rays.  Sensation  was 
normal  everywhere.  Vision  was  slightly  defective, 
and  the  temporal  half-field  was  slightly  diminished. 
There  ivas  no  kyphosis,  no  retrosternal  dulness,  no 
prognathism,  or  mental  defect.  The  quantity  of  urine 
was  excessive,  averaging  ninety  ounces  daily,  but  not 
otherwise  abnormal.  The  ankles  and  feet  presented 
characters  on  the  whole  similar  to  those  observed  in 
the  upper  extremities.  The  trunk  and  chest  as  regards 
their  form  were  normal.  Treatment  had  been  un- 
availing. 

The  interest  of  the  case  was  tiiai  we  had  all  the 
clinical  features  of  Marie's  cumbrously  named  pul- 
monary hypertrophic  osteo-arthropathy  without  the  pul- 


monary disease,  which  in  this  case  could  not  have 
been  caused  by  reason  of  the  non-absorption  of  pul- 
monary toxins.  Its  relationships  to  acromegaly  and 
to  Paget's  osteitis  deformans  were  also  considered,  but 
Dr.  Lindsay  Steven  did  not  think  that  the  clinical 
features  corresponded  to  those  of  either  of  these  affec- 
tions. On  the  whole,  he  was  inclined  to  regard  the 
peculiar  deformity  as  essentially  rheumatic  in  nature. 
Several  papers  were  then  read  by  title,  after  which 
the  section  was  adjourned. 


AMERICAN     ASSOCIATION'     OF     OIJSTETRI- 
CIANS    AND    GYNAECOLOGISTS. 

Tenth  Annual  Meeting,  Held  at  Niagara  Falls,  New 
York,  August  ij,  18,  ig,  and  20,  i8gj. 

First  Day — Tuesday,  August  rytli. 

The  association  met  at  the  Cataract  House,  under  the 
presidency  of  Dr.  James  F.  W.  Ross,  of  Toronto. 

An  address  of  welcome  was  delivered  by  Dr.  \V.  R. 
Campbell,  of  Niagara  Falls,  which  was  responded  to 
by  The  President. 

Puerperal  Eclampsia  with  Special  Reference  to 
Treatment. — Dr.  \\n  liam  Warrlx  Potter,  of  }!uffa- 
lo,  read  the  first  paper.  The  principal  object  of  the 
paper  was  to  advocate  principles  which  the  speaker 
grouped  under  the  following  heads:  i.  Though  the 
pathogenesis  of  eclampsia  is  unsettled,  it  belongs 
solely  to  the  pregnant  or  puerperal  state.  It  is  not 
apoplectic,  epileptic,  or  hysterical  in  character.  2.  It 
depends  upon  to.xa:mia  due  to  overproduction  of  toxins 
and  underelimination  by  the  emunctories.  3.  These 
toxins  probably  have  their  origin  in  the  ingests,  in 
intestinal  putrefaction,  in  foetal  metabolism,  one  or 
all,  and  there  is  coexisting  sluggishness,  impairment, 
or  suspension  of  elimination.  4.  When  the  prodromes 
of  eclampsia  appear,  the  kidney  should  be  interro- 
gated as  to  its  functions  and  all  symptoms  carefully 
watched.  5.  Treatment  is  preventive  and  curative. 
Preventive  treatment  is  medicinal  and  hygienic;  cura- 
tive treatment  is  medicinal  and  obstetric.  6.  Milk 
diet  and  distilled  water  should  be  given  in  the  pre- 
eclampsic  state  to  dilute  the  poison,  hasten  its  elimina- 
tion, and  nourish  the  patient.  7.  Bloodletting  should 
be  employed  only  in  plethora  or  cyanosis.  It  is  lia- 
ble to  cause  anamia  if  persisted  in  or  repeated,  whereas 
red  blof)d  corpuscles  must  be  conserved,  not  wasted. 
Glonoiu  diminishes  vasomotor  spasm,  hence  may  be 
given  freely  in  appropriate  cases.  Veratnnn  viride  is 
a  cardiac  depressant  and  a  dangerous  remedy  if  pushed 
to  an  extent  that  will  control  convulsions.  8.  Kclamp- 
sia  is  the  expression  of  a  further  maternal  intolerance 
of  the  fietus;  hence  as  a  prime  measure  the  uterus 
should  be  speedily  emptied  of  its  contents.  9.  Medi- 
cinal treatment  alone  is  delusive,  and  when  relied 
upon  exclusively  is  fraught  with  danger  to  both  mother 
and  fatus ;  whereas  in  the  prompt  induction  of  labor 
is  found  a  rational  application  of  science  to  a  desper- 
ate condition.  10.  Finally,  induced  labor  furnishes, 
in  the  present  state  of  our  knowledge,  the  only  basis  of 
expectation  for  a  diminished  mortalitv  in  a  toxaemic 
disease  of  high  do.uh  rate. 

Puerperal  Diphtheria Dr.  H.  \V.  Loxgyear,  of 

Detroit,  read  a  paper  on  this  subject,  the  object  of 
which  was  to  bring  before  the  profession  the  fact  that 
the  Klehs-LoefHer  bacillus  is  a  potent  factor  in  the 
etiologv  of  puerperal  infection,  si.x  cases  being  reported 
in  proof  of  the  position  of  the  writer.  The  diphthe- 
ritic character  of  each  case  was  determined  not  only  by 
clinical  evidence,  but  by  bacteriological  examination, 
made  bv  the   bacteriologist  of  the    Detroit   board  of 


October  2.  1897] 


MEDICAL    RECORD. 


499 


health.  Five  of  the  patients  recovered  and  one  died, 
the  one  death  occurring  in  .the  only  case  in  which  anti- 
diphtheritic  senim  was  not  used. 

The  Source  of  Puerperal  Sepsis. — Dr.  John  M. 
Di'FF,  of  Pittsburg,  said  that  the  e.xact  source  of  puer- 
peral sepsis  in  any  given  case  was  not  always  easy  to 
determine.  In  a  large  proportion  of  cases,  however, 
a  careful  inquir)-  would  be  rewarded  with  the  revela- 
tion of  a  source.  When  found,  it  generally  proved  to 
be  one  which  could  have  been  avoided.  Aseptic  mid- 
wifer)-  had  done  much  to  prevent  puerperal  sepsis,  and 
consequently  to  lower  the  rate  of  mortalitj-  following 
childbirth.  He  had  heard  the  opinion  expressed  that 
the  accoucheur  who  was  so  unfortunate  as  to  have  a 
case  of  puerperal  sepsis  was  guiltj-  of  malpractice. 
Such  expressions  he  thought  were  extravagant  and 
were  not  warranted  by  our  present  knowledge  and  ex- 
perience. Sepsis  does  occur  sometimes,  despite  the 
best  efforts  of  the  practitioner  to  prevent  it.  WTiile 
he  believed  that  puerperal  sepsis  cannot  always  be 
prevented,  he  did  believe  that  with  ideal  surround- 
ings, with  a  careful  and  skilful  physician,  assisted  bv 
an  educated  and  conscientious  nurse,  the  number  of 
cases  could  be  reduced  to  a  minimum.  Frequentlv 
too  much  reliance  was  placed  upon  antiseptics.  For 
instance,  a  well-known  member  of  the  profession  had 
said  in  his  hearing  a  short  time  since  that  he  felt 
perfectly  safe  in  attending  a  case  of  labor  after  wait- 
ing upon  a  case  of  erysipelas  or  diphtheria,  if  he 
washed  his  hands  well  in  a  strong  bichloride  solution. 
Dr.  Duff  thought  the  patients  would  be  safer  if  he 
went  to  them  under  such  circumstances  with  fear  and 
trembling,  which  would  cause  him  to  perform  further 
ablutions,  if  possible. 

Toxaemia  of  Pregnancy. — Dr.  AD.\>t  H.  Wright, 
of  Toronto,  read  a  paper  in  which  he  said  that  the 
chief  symptoms  of  this  condition  were  salivation;  dis- 
orders of  digestion,  with  sometimes  a  peculiar  taste 
and  constipation ;  general  malaise,  anjemia,  ner\-ous 
disturbances  or  headache,  disorders  of  vision,  irrita- 
bilit)',  deficient  excretion  of  urine  or  some  of  its  con- 
stituents, and  albuminuria.  To  speak  briefly,  he 
thought  any  sign  of  the  slightest  departure  from  ordi- 
narj'  health  during  pregnancy  should  make  us  suspect 
the  advent  of  general  toxamia,  and  should  receive 
careful  investigation  and  thorough  treatment.  If.  for 
instance,  there  were  general  malaise  with  slight  head- 
ache, but  no  albumin  in  the  urine,  we  should  not  be 
deceived,  since  albuminuria  was  only  one  of  the  symp- 
toms of  systemic  poisoning,  and  sometimes  the  last  to 
appear.  Its  absence  proved  absolutely  nothing. 
Coming  to  the  treatment,  reference  was  made  to  milk 
diet  for  toxsemia  of  pregnancy.  He  believed  that  a 
purely  milk  diet  is  good  for  young  babes  and  calves, 
but  he  did  not  think  that  it  is  suitable  for  adult  hu- 
man beings.  Yeo,  in  his  admirable  book  on  "  Food 
in  Health  and  Disease,"  shows  clearly  that  milk  is  not 
a  suitable  food  for  healthy  adults,  because  it  contains 
an  excess  of  albuminates  and  fats,  and  that  it  should 
be  mixed  with  other  foods,  especially  the  carbohy- 
drates. If  it  be  conceded  that  milk  alone  is  not 
the  best  food  for  healthy  adults,  it  is  difficult  to  con- 
ceive how  it  can  be  the  most  suitable  in  any  case  of 
disease. 

The  Treatment  of  Puerperal  Endometritis  by 
the  Carossa  Method. — Dr.  Emv.ARri  J.  Ii.i,,  of  New- 
ark, X.  J.,  read  a  paper  with  this  title.  There  appeared, 
early  in  the  winter  of  1896,  a  pamphlet  by  K.  Carossa, 
describing  a  method  which  consists  simply  in  the  use 
of  alcohol  as  an  irrigating  material,  supplemented  by 
gauze  packing  of  the  uterus  in  such  a  way  that  the  al- 
cohol may  find  its  way  into  the  most  distant  recesses 
of  the  uterus.  .\  catheter  is  introduced  into  the  ute- 
rus, an-1  this  organ  is  filled  with  absorbent  gauze.  .\t 
the  external  end  of  this  catheter  a  funnel   is  attached, 


through  which  a  twentj-  to  twent3--five  volume  per  cent, 
alcohol  solution  is  poured  so  as  to  flow  into  the  gauze 
with  which  the  uterus  is  filled.  The  quantit}'  to  be 
used  is  from  thirt)-  to  fifty  cubic  centimetres  every-  hour, 
day  and  night.  In  from  three  to  six  days  the  gauze 
is  removed.  The  originator  of  this  method  had  some 
fantastic  theory  of  the  evaporation  of  alcohol,  with 
which  the  author  of  the  paper  could  not  agree.  Dr. 
Ill  has  used  the  above  method,  slightly  modified,  with 
good  results,  and  recommends  it  for  further  trial,  espe- 
cially so  on  account  of  its  great  simplicitj-. 

Sequelae  Following  Supravaginal  Hysterectomy. 
— Dr.  Runs  B.  Hall,  of  Cincinnati,  read  this  paper. 
He  said  he  thought  the  profession  had  been  too  hast}' 
in  approving  the  present  methods.  It  had  taken 
the  stand  that  there  was  nothing  more  to  be  desired — 
the  operation  was  complete.  While  the  doctor  had  no 
new  method  to  otter,  he  hoped  the  discussion  of  his 
paper  would  suggest  something  to  improve  the  tech- 
nique of  the  present  methods.  He  referred  to  objec- 
tions to  the  e.xtraperitoneal  method,  and  then  spoke 
more  in  detail  of  total  extirpation.  He  was  one  of  the 
first  to  advocate  and  make  this  operation,  and  he  had 
attained  excellent  results  with  it.  However,  it  did  not 
meet  his  ideas  of  a  perfect  operation.  The  final  re- 
sults were  good,  but  there  was  a  primarj-  difficulty  that 
was  disagreeable.  Suppuration  about  the  ligatures 
necessarily  took  place  on  the  sixth  or  seventh  day,  caus- 
ing a  slight  rise  in  temperature.  To  overcome  the  sup- 
puration, he  used  specially  prepared  catgut  for  the  lig- 
atures below  the  peritoneum.  He  found  the  catgut 
unreliable  on  account  of  the  danger  from  hemorrhage 
through  slipping  of  the  knots,  and  so  abandoned  its 
use.  The  doctor  closed  his  paper  by  saying  that 
in  spite  of  the  fault  he  had  to  find  with  total  extir- 
pation, he  preferred  it  to  supravaginal  hysterectomy 
as  practised  by  Baer  and  modified  by  others.  He 
felt  more  certain  of  his  final  results  with  the  formei 
method. 

The  Sequelae  of  Dead   Ligatures  and  Sutures 

Dr.  George  M.  Hughe-S,  of  Philadelphia,  read  a  paper 
with  this  title.  While  assisting  Dr.  Joseph  Price  in 
his  abdominal  work,  he  had  recently  been  greatly  in- 
terested in  a  number  of  cases  in  which  he  reopened  the 
abdomen  for  the  freeing  of  adhesions  and  the  removal 
of  dead  ligatures  and  sutures.  Sutures  and  ligatures 
should  be  of  that  material  which  is  most  easily  sterilized 
and  which  combines  great  strength  in  a  small  bulk.  It 
was  always  preferable  to  use  a  material  capable  of  be- 
ing rendered  aseptic  by  heat  or  boiling.  If  this  could 
be  done,  we  could  at  all  tiroes  have  the  means  at  hand 
to  render  perfectly  sterile  our  ligatures.  For  this  pur- 
pose he  finds  that  for  pedicle  ligatures  and  for  bowel 
work  the  twisted  Chinese  silk  is  the  best,  of  finest 
qualit}-  and  sufficiently  small  to  secure  safe  t}ing; 
for  closure  of  the  abdominal  incision,  silkworm  gut 
and  the  through-and-through  method.  What  becomes 
of  the  ligatures?  If  small  and  sterile,  they  become  en- 
capsulated and  are  rapidly  absorbed.  If  plaited  liga- 
tures and  large  hawsers  are  used,  whether  infected  or 
not,  they  are  never  absorbed,  but  their  presence  as 
foreign  bodies  gives  a  train  of  symptoms  unbearable 
in  their  distress  and  constant  in  their  duration.  The 
same  conditions  are  found  about  the  pedicles,  only 
here  we  have  adhesions  of  omentum,  large  and  small 
bowel,  and  bladder  to  both  pedicles.  To  obviate 
postOf)erative  accidents,  we  should  select  that  method 
of  applying  ligatures  which  gives  safety  with  the  least 
quantit}-  of  material.  For  pedicles  the  simple  figtu-e- 
of-eight  tie  is  the  best,  in  that  it  gives  a  firm,  small, 
strong  tie,  and  one  not  liable  to  slip.  The  pedicle  is 
then  cut  cone  shape.  The  pedicle  must  be  made  as 
small  as  possible:  large  pedicles  are  prone  to  behave 
badly,  and  to  this  are  due  the  postoperative  adhesions 
of  omentum,  bowel,  or  bladder. 


5cx> 


MEDICAL    RECORD. 


[October  2,  1897 


Second  Day —  Wedrusday,  August  jHIIi. 

Postclimacteric  Conditions  that  Simulate  Ad- 
vanced Uterine  Cancer.  —  Dr.  M.  Rosknwassf.r,  of 
Cleveland,  Ohio,  read  a  paper  on  this  subject.  The 
writer  commended  the  teaching  that  irregular  hemor- 
rhages and  sero-sanguinous  discharges,  whether  occur- 
ring during  the  parturient  age  or  long  after  the  meno- 
pause, are  good  and  sufficient  reasons  to  suspect 
malignancy.  We  carefully  watch  for  early  symptoms, 
,ind  ijy  their  detection  occasionally  succeed  in  remov- 
ing the  disease  while  it  is  still  local.  On  the  other 
hand,  we  sometimes  are  caught  off  our  guard  when 
confronted  by  poslcliniacteric  cases  presenting  all  the 
classical  characteristics  of  advanced  malignant  dis- 
ease. The  te.vt-books  are  deficient  in  not  sounding  a 
note  of  warning  against  possible  errors  in  the  late 
stages.  The  so-called  classical  symptoms  maybe  due 
to  other  (not  malignant)  conditions  of  the  genital 
tract.  Owing  to  effacement  of  the  vaginal  portion  of 
the  cervix  in  old  age,  the  differential  diagnosis  is  in 
most  cases  limited  to  corporeal  diseases  of  the  uterus. 
Ilefore  the  diagnosis  of  corporeal  cancer  can  be  made, 
other  diseases  must  be  excluded.  The  conditions 
which  are  likely  to  simulate  advanced  cancer  are  the 
following:  i.  Senile  vaginitis;  2,  foreign  bodies  in 
the  vagina;  3,  gangrenous  fibroids;  ^,  atrophic,  senile, 
or  postclimacteric  endometritis;  5,  postclimacteric 
pyometra.  Of  these  conditions,  the  last  is  especially 
hable  to  lead  to  errors.  In  conclusion,  the  author 
called  attention  to  the  singular  fact  that  in  the  pres- 
ence of  the  essential  predisposing  conditions — age, 
low  vitality,  cicatricial  tissue,  adhesions,  chronic  in- 
rtammation,  and  irritating  discharges — cases  of  trans- 
formation into  malignant  disease  are  either  unknown 
or  exceedingly  rare. 

Certain  Cysts  of  the  Abdominal  Wall. — Dr.  Rich- 
ard Douglas,  of  Nashville,  Tenn.,  followed  with  a 
contribution  on  this  subject.  He  confined  himself  to 
a  consideration  of  abnormalities  of  tiie  urachus,  and 
reported  an  interesting  case  of  urachal  cyst  which  oc- 
curred in  a  woman,  thirty-six  years  of  age,  married 
eleven  years,  and  sterile. 

Conservation  of  the  Ovary. — Dr.  T..  Sherwood 
Dunn,  of  Los  Angeles,  Cal.,  read  a  paper  on. this  sub- 
ject. He  said  that  Biown-Sequard  believed  and 
taught  as  a  principle  of  physiologj'  that  every  gland, 
whether  provided  or  not  witli  excretory  ducts,  gives  to 
the  blood  a  certain  useful  principle,  the  absence  of 
wliich  is  felt  and  made  apparent  after  destruction  or 
modification  of  the  functional  activity  of  the  gland 
by  disease.  In  observations  made  upon  100  cases 
operated  upon  in  liroca  and  St.  Louis  hospitals  in 
Paris,  he  found  that  when  women  had  prematurely  lost 
both  ovaries  78  per  cent,  subsequently  suffered  a  no- 
table loss  of  memory;  60  per  cent,  were  troubled  with 
flashes  of  heat  and  vertigo;  50  per  cent,  confessed  to 
a  change  in  tlieir  character,  having  become  more  irri- 
table, less  patient,  and  some  so  changed  as  to  give  way 
to  violent  and  irrepressible  fits  of  temper;  42  per 
cent,  suffered  more  or  less  from  mental  depression,  and 
10  per  cent,  were  so  depressed  as  to  verge  upon  mel- 
ancholia. In  75  per  cent,  there  was  a  diminution  in 
sexual  desire,  and  some  of  these  claimed  they  experi- 
enced no  sexual  pleasure;  13  per  cent,  were  not  re- 
lieved of  the  pain  from  which  they  suffered;  35  per 
cent,  increased  in  weight,  and  some  became  abnormally 
fat.  Some  complained  of  a  diminution  in  the  power 
of  vision  ;  1 2  per  cent,  noted  a  change  in  the  tone  of 
their  voice  to  a  heavier,  more  nia.sculine  quality. 
Some  15  per  cent,  suffered  from  irregular  attacks  of 
minor  skin  affection;  25  per  cent,  had  severe  head- 
aches, as  a  rule  increased  in  intensity  at  the  menstrual 
period.  Equally  as  many  complained  of  nightm'are, 
more  or  less  consant,  while  about   5  per  cent,  suffered 


from  insomnia.  In  a  few  cases  there  existed  a  sexual 
hyperexcitability  not  present  prior  to  the  castration. 
He  particularly  noted  a  few  cases  presenting  gastric 
refiexes,  in  which  without  any  premonitory  symptoms  or 
apparent  cause  the  stomach  would  reject  food  or  refuse 
to  prepare  it  for  intestinal  digestion,  and  the  conse- 
quent distress  following  the  fermentation  compelled 
the  patient  to  seek  relief.  It  should  be  noted  that 
usually  these  troubles  were  more  marked  in  women 
under  thirty  or  thirty-three  years  of  age.  He  had  for 
some  time  been  favorably  disposed  to  the  hypothesis  ad- 
vanced by  Brown-Sequard,  and  any  scepticism  that  he 
might  have  entertained  of  the  theory  of  ovarian  se- 
cretion and  its  usefulness  and  necessity  to  the  equi- 
poise of  the  whole  system  had  been  completely  dissi- 
pated by  the  results  of  experiments  made  with  ovarian 
substance  in  patients  who  had  lost  both  ovaries  or 
were  suffering  from  troubles  which  in  a  greater  or  less 
measure  were  due  to  a  diseased  condition  of  the  ovarj'. 

Some  Observations  upon  Ventral  Fixation. — Dr. 
Herman  E.  Havd,  of  Buffalo,  in  a  paper  on  this  sub- 
ject, stated  that  ventral  fixation  or  suspension  of  the 
uterus,  coupled  with  the  various  plastic  operations 
upon  the  cervix  and  vagina,  was  the  only  means  surgi- 
cal or  anatomical  which  will  fix  and  support  for 
future  comfort  and  well-being  an  extremely  prolapsed 
uterus.  In  his  last  six  cases  of  ventral  fixation,  he 
sewed  the  uterus  to  the  abdominal  wall  with  chromi- 
cized  catgut.  No.  3,  and  did  not  even  scarify  tlie  peri- 
toneal covering  of  the  uierus.  He  held  the  organ  by 
thin  sutures,  which  took  in  simply  the  peritoneum  and 
the  connective  tissue  over  it;  but  in  one  case  in  which 
the  organ  was  very  heavy  and  the  woman  short  and 
stout,  he  hitched  on  to  the  rectal  fascia  and  muscles. 
He  has  invariably  sewed  the  anterior  surface  of  the 
uterus,  feeling  more  satisfied  with  the  position  assumed 
under  these  circumstances  than  when  the  sutures 
catch  the  superior  and  posterior  surface,  as  is  advo- 
cated in  ventral  suspension.  In  patients  he  has  op- 
erated on  and  those  he  has  examined  after  operation 
of  ventral  suspension,  he  has  found  the  organ  in  a  too 
anteflected  position,  and  it  may  be  the  cause  of  some 
future  annoyance.  He  has  discarded  silk  and  all  un- 
absorbable  ligature  materials,  believing  that  catgut 
can  be  sterilized  and  rendered  absolutely  safe  and  is 
perfectly  manageable. 

Surgery  and  Facts. — Dr.  James  F.  W.  Ross,  of 
Toronto,  then  delivered  the  president's  address.  He 
said  the  work  of  members  of  the  association  was  con- 
fined between  the  diaphragm,  the  perineum,  and  the 
abdominal  walls,  and  that  they  had  met  to  cultivate 
and  promote  a  knowledge  of  whatever  relates  to  ab- 
dominal surgery,  obstetrics,  and  gyna-cology.  Atten- 
tion was  ilrawn  to  some  unsettled  questions,  the  first 
being  peritonitis.  Are  we  able  to  do  more  to  save  the 
lives  of  patients  suftering  from  this  disease  in  its 
acute  form  than  we  were  ten  years  ago?  Are  we  not 
but  little  better  ofi,  with  all  our  antiseptic  and  aseptic 
washes,  gauze  and  tube  drains,  and  purgatives?  He 
was  satisfied  that  surgery  could  carry  us  no  farther 
when  battling  with  this  liisease.  The  questions  of 
operating  upon  the  appendix  and  the  diagnosis  and 
treatment  (if  ectopic  gestalitm  had  been  fairly  well 
settled,  'i'he  method  of  dealing  with  the  pedicle  in 
ovariotomy  had  been  .settled,  except  for  the  fact  that 
some  operators  preferred  silk,  while  otliers  were  as- 
sured of  the  safety  of  catgut.  Operations  upon  the 
gall  bladder  and  gall  ducts  had  lieen  performed  many 
times  during  the  p.ust  ten  years,  and  they  were  now 
well  recognized  as  proper  surgical  proceclures.  The 
operations  of  nephrectomy  and  nephrotomy  were 
looked  upon  as  every-day  procetlures.  justified  by  the 
consensus  of  surgical  opinion.  Abdominal  hysterec- 
tomy was  an  operation  that  had  been  much  improved 
and  simplified,  some  operators  lieing  still  wedded  to 


I 


October  2,  1897] 


MFOTTAT.    RECORD. 


501 


the  clamp,  while  others  prefeiTed  some  of  the  other 
methods.  The  advisability  of  oophorectomy  for  some 
liliroids  could  not  be  doubted.  There  were  two  oper.i- 
tions  that  Dr.  Ross  thought  were  of  doubtful  value, 
namely,  the  fastening  of  the  kidney  to  the  side,  and 
the  fastening  of  a  uterus  anywhere.  He  considered 
that  these  operations  had  been  recklessly  performed 
and  unnecessarily  undertaken.  Certain  operations  to 
which  more  thought  must  be  given  are  those  for  intra- 
abdominal and  intrapelvic  cancer.  When  peritoneal 
cancer  has  been  diagnosed,  surely  exploratory  opera- 
tion is  uncalled  for.  Operations  for  other  forms  of 
cancer  are  of  questionable  utility.  Take,  for  instance, 
lesection  of  a  cancerous  intestine,  gastro-enterostomy 
lor  pyloric  cancer,  and  removal  of  the  uterus  for  uter- 
ine cancer.  Gastro-enterostomy  and  resection  of  tlie 
intestine  are  poor  makeshifts.  For  carcinoma  uteri, 
\  a^inal  hysterectomy  is  the  only  operation  that  siiould 
he  contemplated,  but  at  best  it  prolongs  life  for  hut  a 
'short  time. 

Treatment  of  Uterine  Displacements. — Dr.  C.  C. 
Fkkderick,  of  Buffalo,  N.  Y.,  read  a  paper  entitled 
■■  Which  is  the  Preferable  Operative  Method  of  Hold- 
ing the  Uterus  in  Position?"  .A.U  retroversions  do  not 
produce  symptoms,  but  a  certain  proportion  is  accom 
panied  by  hypertrophy  of  the  uterus,  endometritis, 
leucorrhoea,pain,  backache,  menorrhagia,  metrorrhagia, 
or  general  malaise.  Constitutional  treatment  fails  to 
relieve  a  large  proportion  of  them  without  restoration 
of  the  uterus  to  a  normal  position  and  a  cure  of  the 
accompanying  hypertrophy  and  endometritis  by  repo- 
sition. The  large  factors  in  the  continuance  of  the 
ill  effect  of  retroversion  are  torsion  of  vessels,  infec- 
tion of  the  endometrium,  and  defective  drainage  of  the 
uterine  cavitv.  Retroversion  is  a  first  stage  of  pro- 
lapse, and  the  uterus  ought  for  that  reason  alone  to  be 
replaced  and  held  in  position.  Sterility  is  one  fre- 
quent result  of  retroversion.  Results  of  treatment  are 
good  by  operation  or  by  holding  the  uterus  in  position 
by  a  pessary,  if  possible  together  with  general  tonic 
treatment.  Weir  Mitchell  rest  treatment,  etc.  Many 
patients  are  cured  and  eventually  get  strong  and  well 
again.  Ventrofixation  has  l^een  discontinued  by  the 
writer  in  women  liable  to  hear  children.  He  uses  it 
only  to  hold  up  the  uterus  in  operations  for  prolapse 
and  in  those  cases  in  which  he  has  removed  both 
tubes  and  desires  to  hold  the  uterus  in  position,  time 
being  an  element  in  the  operation.  The  writer  has 
seen  no  ill  results  during  labor,  and  knows  of  none  oc- 
curring in  his  own  patients,  although  se\eral  have  borne 
children.  He  had  seen  no  recurrence  of  retroversion, 
even  in  those  who  have  borne  children.  His  prefer- 
ence was  ff)r  the  Alexander  operation  or  some  of  its 
modifications,  in  cases  of  women  who  have  borne  chil- 
dren and  when  there  are  no  adhesions  or  disease  of 
the  adnexa.  Women  who  have  never  been  pregnant 
are  liable  to  have  poorly  developed  round  ligaments, 
prone  to  tear  away  from  the  anchoring  sutures.  In 
these  he  opened  the  abdomen  and  shortened  the  roiind 
ligaments  by  one  of  the  methods  devi.sed  by  Mann, 
Dudley,  or  Wylie.  He  gave  Mann's  method  the  pref- 
erence. Several  of  the  patients  have  borne  children 
both  after  the  internal  and  external  shortening  of  the 
round  ligaments,  with  good  results.  The  writer  used 
unabsorbable  ligatures  or  sutures,  always  employing 
plain  catgut  or  chromici/.ed  catgut  when  a  suture  is  used 
for  a  long  period.  He  never  had  used  any  of  the  vagi- 
nal methods  of  fixation,  not  being  pleased  with   them. 

Third  I)a\ —  Thurulay.  .luf^i/s/  iijtii. 

The  Technique  of  the  Dry  Method  was  tlie  title 
of  a  paper  by  Dr.  Fdwin  W.m.kk.k,  of  Fvansville,  Ind., 
in  which  he  said  that  by  the  dry  method  is  meant  a 
technique  in  which  no  water  or  other  fluid  is  used. 


This  does  not  apply  to  the  preparation  before  the 
operation.  After  the  first  stroke  of  the  knife  until  the 
wound  is  closed,  not  a  drop  of  water  is  used.  The 
writer  has  employed  it  exclusively  for  several  years 
with  good  results.  The  technique  is  as  follows: 
Xurses  are  instructed  to  use  every  precaution  to  pre- 
vent soiling  the  hands  in  septic  cases,  and  thoroughly 
to  disinfect  the  hands  after  any  suspicion  of  contami- 
nation. Every  instrument  used  is  sterilized  before 
it  is  put  away.  The  hands  are  scrubbed  thoroughly 
with  a  brush,  with  liquid  soap  (equal  parts  of  green 
soap,  glycerin,  and  alcohol),  and  repeatedly  rinsed  in 
sterile  water.  They  are  then  wiped  off  with  alcohol, 
dipped  for  two  minutes  in  bichloride  solution,  i  to. 
1,000,  and  then  washed  off  with  salt  solution.  The 
field  of  operation  is  simil.irly  prepared,  except  that  the 
scrubbing  is  repeated  daily  for  two  or  three  days  before 
the  operation,  and  a  soap  poultice  used  at  night.  The 
instruments  are  boiled  in  soda  solution  for  five  or  ten 
minutes,  wrapped  in  towels,  or  placed  in  metal  boxes, 
which  are  opened  only  at  the  time  of  operation.  Plain 
gauze  is  used  for  every  purpose  except  packing  the 
uterus,  and  in  rare  instances  when  drainage  is  used 
iodoform  gauze  is  preferred.  The  silk  ligatures  are 
wrapped  on  spools  and  placed  in  glass  boxes,  and  the 
silkworm  gut  and  silver  wire  in  long  glass  tubes,  and 
all  sterilized  h\  steam,  as  are  the  dressings.  The 
pl.iin  catgut  is  boiled  in  alcohol,  and  the  chromicized 
is  prepared  after  Fdebohls'  method  .Vfterthe  patient 
is  placed  on  the  table,  tlie  dressing,  which  consists 
usually  of  plain  gauze,  is  removed  from  the  field  of 
operation,  and  sterilized  towels  are  adjusted  as  usual. 
The  instruments  are  unwrapped  and  everything  is  in 
readiness.  The  sponges  are  used  dry,  and  thrown 
away  when  soiled.  The  Hat  sponges  in  the  abdomen 
are  also  used  dry,  and  are  provided  with  a  cord  which 
is  clamped  with  a  pincette.  Tlie  latter  is  left  outside, 
so  that  the  sponge  cannot  be  forgotten  and  left  in  the 
abdomen. 

Surgical  Shock  and  Hemorrhage.  —  Dr.  W  alter 
]!.  CH.ASK,  of  Brooklyn,  N,  ^'.,  read  a  paper,  of  which 
the  following  are  the  conclusions:  i.  The  treatment 
of  shock  should  be  preventive  and  curative,  and  to  a 
large  degree  the  indications  for  the  former  define  the 
lines  of  treatment  in  the  latter.  2.  The  proper  exhi- 
bition of  preventive  measures  includes  a  careful  study 
of  the  functional  activity  and  organic  status  of  all  im- 
portant organs,  and  such  treatment  by  hygienic,  die- 
tetic, and  therapeutic  measures  as  will  elevate  the 
standard  of  bodily  and  mental  health  to  a  degree  in 
which  the  maximum  power  of  resistance  may  be  pro- 
duced and  maintained.  3.  Special  emphasis  should 
be  given  to  litha?mic  and  lu'.xmic  excretion,  and  to 
the  condition  of  the  circulatory  and  nervous  systems. 
|.  Knowledge  as  to  inherited  power  of  resistance  to 
and  recovery  from  serious  di.sease  and  accidents  is  of 
the  highest  value  in  determining  the  course  of  proce- 
dure and  in  estimating  the  chances  for  recovery  after 
capital  operations.  5.  A  supply  of  facilities  and  drugs 
for  meeting  all  emergencies  should  be  in  constant  read- 
iness, with  exact  knowledge  for  the  indications,  dosage, 
physiological  and  therapeutic  effect  of  special  heart 
tonics  and  stimulants,  including  strychnine,  digitalis, 
nitroglycerin,  etc.  6.  Limit  the  time  of  an  operation 
to  the  shortest  space  compatible  with  thorough  work 
and  proper  technique.  7.  Save  the  patient  to  the  ut- 
most from  the  shock  of  fear,  and  in  selected  cases  pro- 
ceed to  operation  without  informing  the  patient  of  your 
purpose.  8.  In  shock  with  hemorrhage  supply  the 
volume  of  venous  and  arterial  loss  liy  direct  transfu- 
sion of  decinormal  salt  solution  into  the  patient's  veins. 
9.  Bear  in  mind  the  influence  position  has  on  the  cir- 
culation under  both  shock  and  hemorrhage,  especially 
in  ana;mic  conditions  of  the  cerebro-spinal  nerve  cen- 
tres and  tlie  heart. 


502 


MEDICAL    Ri:(ORD. 


[October  2,  1897 


Placenta  Praevia. — Dr.  W.  H.  Wekxing,  of  Cin- 
cinnati, Ohio,  read  a  paper  on  the  treatment  of  this 
condition.  The  following  is  a  summary  of  the  treat- 
ment laid  down  by  the  author  in  the  order  of  time  of 
the  accident,  amount  of  hemorrhage,  and  condition  of 
the  patient:  (it)  Before  labor:  i.  Hemorrhage  slight 
— rest,  expectant  treatment.  2.  Hemorrhage  moderate 
■ — tampon  vagina.  3.  Hemorrhage  profuse — also  try 
tampon  and  induce  labor.  (/')  In  the  beginning  of 
labor:  i.  Hemorrhage  moderate — Braxton  Hicks' 
method,  provided  the  obstetrician  has  skilled  assist- 
ance at  hand;  otherwise  tampon  the  cervix  with  the 
cervical  bag,  until  (<)  labor  is  well  in  progress,  then 
rupture  membranes  and  deliver  by  podalic  version  ;  or, 
if  hemorrhage  is  arrested  by  the  descending  hand,  de- 
liver by  forceps  or  permit  spontaneous  expulsion  if 
pains  are  good.  At  any  stage,  when  hemorrhage  is 
excessive  or  cannot  otherwise  be  arrested,  manual 
dilatation,  followed  by  aa-ouchcment  force.  The  tam- 
pon is  indicated  :  ( i )  In  hemorrhage  toward  the  end  of 
pregnancy;  (2)  in  the  beginning  of  labor  when  the  os 
is  closed;  (3)  in  moderate  dilatation  of  the  cer^-ix, 
then  use  cervical  tampon.  It  is  contraindicated:  (i  ) 
When  dilatation  is  complete  or  nearly  so;  (2)  when 
it  fails  to  arrest  hemorrhage  even  if  dilatation  is 
not  far  advanced.  Rupture  of  the  membranes  is  indi- 
cated: (i)  When  the  os  is  well  dilated  and  either 
spontaneous  labor  or  artificial  delivery  may  occur: 
(2)  when  by  this  method  hemorrhage  is  better  con- 
trolled than  by  other  means;  (3)  when  in  the  absence 
of  labor  pains  it  will  be  followed  by  immediate  pres- 
sure of  the  presenting  part.  It  is  contraindicated: 
(i)  When  the  os  is  undilated  and  pains  are  good;  (2) 
in  faulty  presentation  of  the  ftetus,  unless  it  can  be  fol- 
lowed immediately  by  version.  Version  is  indicated: 
(i)  \\'hen  the  os  will  admit  two  fingers  and  combined 
version  can  readily  be  made,  Braxton  Hicks'  method; 
(2)  when  the  os  is  well  dilated  or  dilatable  and  hem- 
orrhage is  profuse,  direct  or  internal  version;  (3)  in 
desperate  cases,  aa-ciiirlu-mcut Jorce.  It  is  contraindi- 
cated:  (i)  When  with  a  moderately  dilated  os  com- 
bined version  cannot  be  skilfully  made  (the  cervical 
tampon) ;  (2)  when  with  a  well-dilated  os  after  rupture 
of  the  membranes  the  head  immediately  engages  in  the 
cervix. 

Complete  Hysterectomy  after  Injury  during  Par- 
turition and  Caesarean  Section.  —  Dr.  Joseph  H. 
HkaNham.  of  Baltimore,  reported  two  cases  and  then 
discussed  the  causes  and  prominent  symptoms  of  rup- 
ture of  the  uterus.  When  symptoms  of  uterine  rup- 
ture occur,  he  said,  delivery  should  be  completed  as 
rapidly  as  possible  h\  the  use  of  whatever  means  may 
best  bring  about  the  results.  The  child  nearly  always 
dies  in  a  few  minutes,  so  that  only  the  mother  should 
be  considered.  If  the  child  has  escajjed  into  the  ab- 
dominal cavity,  immediate  laparotomy  is  indicated. 
After  the  child  has  been  delivered,  two  methods  of 
procedure  are  recommended.  One  is  the  closing  of 
the  tear  by  packing  with  iodoform  wicking  and  drain- 
age of  the  parts  with  gauze.  The  other,  which  in 
complete  ruptures  is-  often  more  popular,  is  to  do  a 
laparotomy,  cleansing  the  peritoneal  cavity.  In  suit- 
able cases  the  tear  may  be  closed  by  the  Sanger  meth- 
od. If  the  tears  are  very  extensive  and  there  is  a 
strong  probability  of  uterine  infection,  a  Porro  opera- 
tion or  complete  hysterectomy  is  the  best  method.  The 
preventive  method  consists  in  the  early  relief  of  diffi- 
cult labor  by  suitable  operative  interference,  instituted 
before  the  uterus  has  become  very  thin  and  damaged 
by  long-continued  pressure  between  the  presenting  part 
and  the  bones  of  the  jielvis. 

Tonic  and  Spasmodic  Intestinal  Contractions. — 
Dr.  X.  O.  Werdkr,  of  Pittsburg,  read  a  paper  on  this 
subject,  in  which  he  reviewed  five  cases — one  by  Dr. 
Murphy,  two  by  Dr.  Long,  and  two   of   his   own — re- 


ported by  Dr.  Long  at  the  Richmond,  Va.,  meeting  of 
the  association,  and  added  some  additional  cases  of  a 
similar  condition  that  he  had  observed  subsequently. 
He  referred  to  cases  reported  by  L.  Heidenhain,  and 
applied  the  term  enterospasm,  dividing  the  cases  ac- 
cording to  their  nature  and  severity  into  spasmodic  and 
tonic  or  tetanic  forms.  He  thought  that  these  cases 
are  perversions  of  normal  peristalsis,  due  to  a  reflex 
chemical  or  mechanical  irritation  exerted  at  the  seat 
of  contraction  (either  on  the  mucous  or  serous  surfaces 
of  the  bowel)  or  elsewhere  in  the  alimentar)'  canal  or 
abdomen.  He  said  that  they  assume  surgical  im- 
portance when  in  the  spasmodic  varieties  they  simu- 
late neoplasms — as  in  three  cases  of  that  variety 
reported — or  when  they  cause  obstruction  to  the  fecal 
current,  becoming  true  cases  of  dynamic  ileus. 

Dynamic  Ileus  Following  Operations  Involving 
the  Abdominal  Cavity,  with  Remarks  on  Ady- 
namic Ileus — This  paper  was  read  by  Dr.  Freder- 
ick Bi.iME,  of  Allegheny,  Pa.  The  author  said  that 
the  differential  diagnosis  between  post-operative  in- 
testinal obstruction  and  dynamic  ileus  is  practically 
impossible,  but  that  in  either  case  the  only  chance 
for  the  patient  is  afforded  by  early  operative  inter- 
ference. The  surgeon,  however,  must  distinguish 
these  forms  of  ileus  and  a  very  obstinate  form  of 
constipation  so  often  met  with  and  so  difficult  to 
overcome,  after  operations  in  the  abdominal  cavity. 
The  occurrence  of  farcal  vomiting  is  not  always  a 
pathognomonic  sign  of  ileus,  as  this  vomiting  some- 
times occurs  in  other  conditions,  and  when  there  ex- 
ists no  indication  for  surgical  interference. 

The  Fate  of  Ovaries  in  Connection  with  Retro- 
version and  Retroflexion  of  the  Uterus — Dr.  Al- 
liERT  (ror.nsPOHx,  of  Chicago,  read  a  paper  with  the 
following  conclusions:  (i)  In  all  cases  of  retrover- 
sion and  retroflexion  of  the  uterus  a  knowledge  of  the 
ovaries  as  to  their  location,  mobility,  and  general 
physical  condition  should  comprise  an  essential  part 
in  the  diagnosis,  as  determining  largely  the  nature  and 
urgency  of  the  treatment.  (2)  The  welfare  of  ovaries, 
in  general,  demands  such  a  degree  of  anterior  inclina- 
tion of  the  longitudinal  axis  of  the  uterus  as  will 
enable  intra-abdominal  pressure  to  bear  upon  tlie  pos- 
terior surface  of  the  organ,  and  thereby  to  act  in  uni- 
son with  its  other  supports  to  retain  it  and  its  adnexa 
in  normal  position  and  fimction.  (3)  Inasmuch  as  in 
the  female  pelvis  as  well  as  elsewhere  in  the  human 
body  the  natural  and  considerable  abilities  of  healthy 
tissues  to  defend  themselves  against  microbic  invasion 
(infection)  are  lowered  or  annulled  in  direct  propor- 
tion to  any  degree  of  mechanical  embarrassment  of  the 
venous  circulation  in  the  tissues  or  organs,  it  behooves 
gyni^ecologists  especially  to  be  alert  in  recognizing  and 
correcting  all  material  anomalies  in  place  or  posture 
of  the  female  generative  organs  or  in  securing  to  them 
iheir  normal  freedom. 

The  Administration  of  Phosphate  of   Strychnine 

during  Gestation Dr.  W.M.n.R  15.  Drosett,  of  St. 

Louis,  Mo.,  read  a  paper  with  this  title.  The  follow- 
ing good  results  have  been  gained  by  him  in  the  use  of 
this  drug  during  the  gestation  of  weak  and  debilitated 
patients:  A  good  appetite  and  good  assimilation  are 
obtained  in  the  general  weakness  and  debility  of  the 
ana*mic.  Constipation  is  relieved,  the  patient  is  built 
up  and  placed  in  a  good  condition  to  pass  through 
the  ordeal  of  labor.  The  uterus  contracts  promptly 
after  the  third  stage  of  labor,  and  the  use  of  ergot  is 
entirely  dispensed  with.  If  he  finds  it  necessary  to 
use  the  forceps  the  patient  is  given  a  hypodermic  in- 
jection of  one-thirtieth  grain  of  sulphate  or  phosphate 
of  strychnine  as  soon  as  the  amtsthetic  is  commenced, 
but  no  ergot  is  ever  used.  .After  the  continuous  use 
of  the  phosphate  of  strychnine,  the  uterus  contracts 
promptly  after  the  second  stage  of  labor,  and  in  many 


October  2.  1897] 


MEDICAL    RECORD. 


503 


cases  the  application  of  Crede's  method  of  expression 
of  the  placenta  is  not  needed  to  bring  it  away,  and  no 
post-partum  hemorrhages  have  occurred.  The  fre- 
quently obser\ed  chilliness  or  rigors  which  in  the 
majority  of  cases  follow  labor  have  been  noticed  in  but 
few  cases.  For  some  time  in  his  abdominal  surgerv 
he  has  used  str\-chnine  for  the  purpose  of  preventing 
shock  and  to  control  the  pulse  in  operations,  and  in 
this  way  was  led  to  its  use  in  obstetrics.  As  phos- 
phorus and  strychnine  are  remedies  used  in  the  treat- 
ment of  rachitis  with  good  results,  would  it  not  be  the 
remedy  during  the  gestation  of  the  rachitic  foetus? 

Fourth  Day — Friday,  August  20th. 

Appendicitis — Dr.  George  S.  Peck,  of  Youngs- 
town,  Ohio,  read  a  paper  in  which  he  reported  fift}--two 
cases  illustrating  his  personal  experience  with  the 
medical  and  surgical  treatment  of  appendicitis.  He 
said  there  were  four  cardinal  symptoms  which  will 
almost  invariably  insure  a  correct  diagnosis,  if  they 
occur  in  the  order  given.  First,  sudden  severe  pain 
in  the  abdomen,  generally  of  a  colick)-  nature,  located 
in  any  part  or  e.xtending  over  the  entire  abdomen. 
Second,  always  nausea  and  frequently  vomiting. 
Third,  increased  temperature.  Fourth,  localized  ten- 
derness in  the  right  iliac  region.  Some  patients  will 
have  diarrhoea,  while  others  may  be  constipated.  He 
had  never  failed  to  make  a  correct  diagnosis  when  the 
four  cardinal  symptoms  were  present.  Surgeons  differ 
in  their  methods  of  operating.  Some  advise  in  the 
acute  suppurative  form  simple  incision  and  evacuation 
of  pus.  If  the  appendi.x  cannot  be  easily  found,  it 
should  be  left,  drained,  and  packed,  and  then  in  the 
interval  between  attacks  the  appendix  should  be  re- 
moved, always  provided  one  can  get  the  consent  of 
the  patient,  which  the  speaker  has  found  to  be  diffi- 
cult. A  few  surgeons  advise  the  liberating  of  all  ad- 
hesions and  the  removal  of  the  appendix  in  all  cases  of 
acute  suppurative  appendicitis,  and  have  reported  good 
results.  He  believes  it  is  the  duty  of  every  surgeon 
to  make  a  complete  operation  in  the  vast  majority  of 
cases,  and  thinks  that  the  time  is  not  far  distant  when 
all  surgeons  will  advise  the  breaking  up  of  all  ad- 
hesions, the  removal  of  every  diseased  appendix,  and 
the  closing  of  the  incision  as  is  now  done  in  the  opera- 
tion for  pyosalpinx,  as  advised  by  Morris,  Price,  and 
McMurtr)'.  In  his  last  three  cases  he  had  followed 
this  method"  and  the  results  had  been  far  beyond  his 
expectations.  Two  of  the  cases  were  discharged  in 
three,  and  one  in  four  weeks. 

Dr.  Lewis  S.  McMurtrv,  of  Louisville,  Ky.,  fol- 
lowed with  a  paper  entitled  "  The  Operation  Itself  in 
.\ppendicitis,"  in  which  he  considered  the  subject 
under  the  following  headings:  i,  the  incision:  2,  deal- 
ing with  adhesions  and  with  abscesses:  3,  removal  of 
the  appendix:  4,  drainage  and  isolation  of  the  perito- 
neum by  gauze.  Concerning  the  incision  three  import- 
ant considerations  must  be  observed.  The  first  is  to 
obtain  easy  access  to  the  caput  coli  with  sufficient 
working-space;  second,  to  secure  all  natural  advan- 
tages to  facilitate  drainage;  third,  to  do  the  least 
damage  possible  to  the  parietal  structures  incised  in 
order  that  firm  union  may  be  secured  and  hernia 
thereby  prevented.  The  early  operations  for  appen- 
dicitis are  mostly  in  extreme  cases,  wherein  suppura- 
tion has  obtained,  and  consist  in  cutting  down  into 
an  abscess  and  evacuating  and  draining  the  same. 
For  this  purpose  the  vertical  incision  was  adopted  and 
is  yet  practised  by  many  surgeons.  This  incision 
does  not.  however,  in  his  opinion  give  so  easy  access 
to  the  appendix  and  to  the  outer  and  posterior  areas 
adjacent  thereto,  which  are  so  frequently  involved,  as 
does  the  oblique  incision.  \  method  of  dividing  the 
abdominal    wall  by  a   combination    of    incision    and 


blunt  dissection  has  been  described  by  McBumey  and 
commended  by  many  writers  on  surgery  of  the  appen- 
dix. This  incision  was  described  at  lengtli.  In 
dealing  with  adhesions  and  abscesses  the  same  gen- 
eral rules  of  surgical  treatment  should  be  observed 
in  appendicitis  as  in  similar  conditions  affecting 
other  organs  inclosed  within  the  peritoneum.  When- 
ever practicable,  adhesions  should  be  separated, 
abscesses  emptied,  disintegrated  structures  composing 
foci  of  infection  removed,  and  cleansing  and  drainage 
secured  by  measures  of  assured  efficiency. 

In  his  early  operations  he  ligated  the  appendix  with 
the  meso-appendLx,  using  fine  silk  sterilized,  cut  away 
the  appendix,  and  applied  pure  carbolic  acid  to  the 
stump.  Later  he  adopted  the  modern  method  of  trans- 
fixing the  meso-appendix  at  its  base,  cutting  it  away, 
stripping  back  a  cuff  of  peritoneum  from  the  appendix 
down  to  its  junction  with  the  cscum,  ligating  the 
appendix  with  fine  silk  and  cutting  it  away,  sterilizing 
the  stump,  invaginating  the  stump  into  the  cacum  and 
covering  w  ith  peritoneum  by  careful  stitching  after  the 
Lembert  method.  Nothing  in  the  progress  of  healing 
or  in  ultimate  results  indicated  any  advantage  of  the 
latter  method  over  the  former  simple  ligature,  excision, 
and  cauterization. 

Senile  Irritable  Uterus.  —  Dr.  Thomas  J.  M.«c- 
w^ELL,  of  Keokuk,  Iowa,  contributed  a  paper  on  this 
subject.  In  three  cases  he  was  unable  to  relieve  this 
condition  by  tentative  treatment,  and  finally  resorted 
to  hysterectomy  with  complete  success  in  all  of  them. 

The  Election  of  Officers  resulted  as  follows;  Presi- 
dent, Dr.  Charles  A.  L.  Reed,  of  Cincinnati,  O.; 
I'ice-PresiJents,  Dr.  Richard  Douglas,  Nashville, 
Tenn.,  and  Dr.  Walter  B.  Dorsett,  St  Louis,  Mo.: 
Secretary,  Dr.  William  Warren  Potter,  Buffalo,  X.  Y. ; 
JVeasurer,  Dr.  X.  O.  Werder,  Pittsburg,  Pa. 

Place  of  meeting,  Pittsbiu-g,  Pa.  Time,  September 
20,  21,  and  22,  1898. 


2'hcvapcutic    Hints. 

Diphtheritic  Paralyses. — 

B  Tinct.  nuc.   vom 1-4  gtt. 

Strych.  sulphat o.ooi  gm. 

Aquae i  gm. 

>I.      S.   Two  to  eight  drops  \rith  each  meal,  for  children  over 
four  years  of  age. 

— L.    Sl.MON. 

Antiseptic  Powder 

E  Hydrarg.  chlor.  corros 0.0012 

-\c.  boric 2S.54 

Ac.  tannic 0.60 

Sacch.  lact 56-63 

M.     S.  For  e.xtemal  use. 

—Pick. 
Gout. — 

K    I'r.  stramonii 3  i. 

Tr.  colchici 3  iss. 

Tr.  guaiaci ?  ij. 

Nf.      S.    Teaspoonful  three  times  a  day  in  milk. 

— G.WLE. 

Non-Diphtheritic  Throat  Affections  in  Children 

K  Saiol :  ss. 

Sweet  almond  oil 3  i. 

Syrup 3  ss. 

Distilled  water 3  iiss. 

Peppermint,  orange-flower  water,  vanilla,  or  cherrj- 
laurel  water  may  be  added  to  make  aromatic.  Salol 
should  be  suspended  if  the  urine  appears  of  a  dark 
color. — De  l.\  C.arriere. 

Treatinent  of  Laryngeal  Tuberculosis Dr.  Jan- 

kenevitch  says  the  principal  element  of  treatment  con- 
sists in  the  application  of  chloride  of  zinc  and  carbo- 


504 


MEDICAL    RECORD. 


[October  2,   1897 


lated  glycerin,  in  strength  of  i  to  10  or  i  to  5,  according 
to  the  nature  of  the  case.  The  following  antiseptic 
spray  is  advised : 

1(  Acid,  boric 5  £'■"■ 

Acid,  phenic  .  -  , 60  C'^u\. 

Glycerin 50  g"'- 

AqUiE  laurocerasi 50  g'"' 

Aqux 450  gin- 

This  is  especially  valuable  in  the  initial  catarrhal 
stage. — Journal  de  Mddccine^  February  10,  1897. 

Treatment  of  Epilepsy. — As  an  adjuvant: 

1^  Zinc,  oxid o.io  cgni. 

Pulv.  valerian o.io 

Pulv.  ballad o.oi      " 

Sapon.  medic q.s. 

S.   To  make  one  pill       Take  four  daily. 

Treatment  of  Fetid  Bronchitis — 

1^  HyposLiIphate  of  sodium 15  gm. 

Distilled  water 60    ' ' 

Simple  syrup 25 

—  POLM. 

Treatment  of  Diabetes. — In  an  article  upon  treat- 
ment by  means  of  a  diet  from  which  all  carbohydrates 
have  been  excluded,  Ur.  Kdward  L.  Munson  draws 
the  following  conclusions  in  2'lie  Journal  of  ilic  Attieri- 
caii  Medical  Associalioii,  May  15,  1897:  i.  Sugar  is 
always  present  in  the  blood.  2.  The  absence  of  car- 
bohydrates from  the  diet  does  not  cause  a  disappear- 
ance of  the  blood  sugar.  Hence  sugar  must  have 
some  other  source  than  the  carbohydrates  ingested. 
3.  This  other  source  of  sugar  is  the  ingested  and  sys- 
temic alb\imin  elaborated  through  a  process  of  de- 
composition. 4.  An  increased  albumin  decomposition 
due  to  the  rigid  enforcement  of  a  purely  nitrogenous 
diet  means  an  increased  metabolism  and  consequent 
loss  of  body  weight.  Hence  the  cutting  off  of  carbo- 
hydrates from  the  diet  directly  produces  an  increased 
metabolism.  5.  Vh\'  versa,  the  administration  of  car- 
bohydrates retards  metabolism.  6.  The  diabetic  has 
an  especial  predisposition  toward  metabolism.  7.  The 
diabetic  has  by  no  means  lost  the  power  of  burning 
sugar;  therefore  sugar  must,  even  more  than  in  health, 
be  allowed,  in  order  to  prevent  loss  of  weight  and  mus- 
cular weakness,  which  may  result  in  one  of  the  natu- 
ral endings  of  diabetes,  death  by  asthenia.  8.  The 
abnormal  albumin  metabolism,  which  is  especially 
produced  by  a  rigid  proteid  diet,  results  in  the  produc- 
tion of  toxic  bodies,  g.  The  depressed  nervous  con- 
dition of  the  diabetic  is  especially  favorable  for  the 
action  of  these  bodies,  ro.  The  production  of  toxic 
bodies  is  prevented  or  retarded  by  the  administration 
of  carbohydrates.  Hence  carbohydrates  should  be 
administered  to  the  diabetic  to  prevent  the  formation 
of  certain  toxic  bodies  and  the  severe  and  often  fatal 
nervous  and  cerebral  symptoms  which  they  induce. 

Faulty  Hydrotherapy.  —  Dr.  Baruch  concluded, 
in  a  paper  read  before  the  German  Medical  Society 
of  New  York :  i.  That  the  therapeutic  application  of 
water  demands  at  least  as  much  care  as  the  use  of  me- 
dicinal agents.  2.  That,  owing  to  the  flexibility  of 
wat€r  as  a  remedial  agent,  in  its  use  greater  demands 
are  made  upon  the  practitioner  than  in  the  use  of 
medicines.  3.  That  the  best  results  may  be  obtained 
only  by  following  an  exact  technique  in  each  case.  4. 
That  the  reason  different  results  are  obtained  by  dif- 
ferent physicians  from  the  application  of  water  may 
be  found  in  the  technical  errors  committed  on  account 
of  an  erroneous  conception  of  the  ratioiiah-  of  hydro- 
therapy. 

Chorea.  Krafft-Kbiiig  {All,s;.  Wieu.  nud.  Ztg., 
1897,  I>.  iii.,  S.  5),  in  speaking  of  the  treatment  of 
this  disease,  lays  stress  upon  the  attainment  of  '"peace 


of  mind  and  body."'  A  milk  diet  may  be  given  and 
the  patient  should  be  out  of  doors  as  much  as  possible. 
Warm  baths  are  recommended.  In  chorea  gravis 
sleep  may  be  produced  by  means  of  the  wet  pack;  if 
hypnotic  drugs  are  called  for,  amyl  hydrate,  four 
grams  per  diem,  trional,  urethan,  and  in  the  worst 
cases  chloral  hydrate,  are  employed.  In  treating  the 
general  condition  nothing  approaches  arsenic  for  al- 
laying the  general  irritability-  of  the  nervous  system ; 
nux  vomica  may  also  be  of  service.  Chorea  in  adults 
over  thirty  years  comes  on  slowly,  is  difficult  to  sub- 
due, and  its  victims  often  develop  tedium  vita  and 
suicidal  impulses.  In  one  case  of  this  kind  it  was 
found  that  hyoscine  acted  with  benefit  for  a  time,  but 
later  on  the  disease  progressed. 

Cancer  of  Stomach — To  control  the  vomiting: 

R  Picrotoxin 0.05  cg^. 

Morph.  hydroch 0.05  cgm. 

.\tropin.  sulph.  neut o.oi  cgm. 

Aq.  laurocerasi 20  gm. 

S.    Five  to  eight  drops  before  meals. 

— Albert  Robin. 
Diabetes  Mellitus. — 

V,  Litliii  carbonat gr.  xuc. 

Sodii  arseniat gr.  i. 

Ext.  gentians gr.  xv. 

M.   ft.  massa  ct  in  pil.    No.  20  div.       S.   One  pill  morning 
and  evening. 

—  V'iGiER.  Annual  Univ.  Med.  Set. 
Follicular  Tonsillitis. — 

R  Olei  creosoti gtt.  viij. 

Tinct.  myrrha-, 

Glycerini ail  3  ij. 

.\q ad  5  viij . 

S.    Use  as  a  gargle  every  two  hours. 

— Levy,  Mediral  and  Surgiral  Reporter. 

Itching  of  Urticaria — 

R  Distilled  water 450  parts. 

Clieriy-laurel  water   50     " 

Chloral  hydrate 5     " 

Cocaine  hydrochlorate 3      " 

— Provence  M^dicale. 
Scarlatina. — 

1}  Tinct.  ferri  chloridi   3  ij- 

Potassii  chloratis 3  i.-ij. 

Syr.  simplicis §  iv. 

.M.     .S.   A  teas|)oonful  every  hour  or  two  to  a  child  of  four 
or  five  years. 

— J.  I>;wis  Smith. 

Superficial  Cancer  without  Ganglionic  Involve- 
ment. — 

R  Acidi  arseniosi i  gm. 

.Mcohol,  ethyl., 

.•\q.  dest aa  75     " 

Paint  the  surface  daily.      .\s   the   eschar  grows  thicker  in- 
crease the  strength  to  t  in  40, 

— (';^ERNV  .Axn  Trttxf.oek,  La  Sevi.  Med..  May  ist. 

Malignant  Pustule. 

R  Hydrarg.  bicyanid i 

Aq.  dest 100 

Cocaina;  salicylat q.s. 

M.     S.   Inject   from   half  to  one  syringeful  subculancously 
and  cover  the  area  with  sublimate  compresses. 

— Kedrofk. 

Ergot  in  Post-Partum  Hemorrhage. — Dr.  Lombe 
.A.tthill  {Britis/i  Medical  Journal,  March  6th)  gives  the 
following  results  of  his  e.\perience  in  regard  to  the 
use  of  ergot:  i.  When  administered  previous  to  the 
termination  of  pregnancy  in  the  case  of  women  in 
whom  a  marked  tendency  to  post-partum  hemorrhage 
is  known  to  exist,  it  tends  in  a  marked  manner  to  pre- 
vent   the    occurrence   of    hemorrhage.      2.   When    so 


October  2,  1897] 


MEDICAL    RECORD. 


505 


I 


administered  in  ordinar}'  doses,  it  does  not  induce  any 
injurious  effect  on  either  mother  or  child,  and  its 
exhibition  seems  to  delay  the  commencement  of  labor 
in  such  cases.  3.  It  tends  to  make  the  involution  of 
the  uterus  more  perfect,  and  lessens  the  chance  of  oc- 
currence of  subsequent  uterine  troubles,  many  of  which 
depend  for  their  cause  upon  imperfect  involution  of 
that  organ.  4.  It  will  not  bring  on  premature  labfir 
or  induce  abortion,  unless  uterine  action  has  previous!)- 
been  set  going.  5.  In  cases  of  threatened  abortion  its 
administration  frequently  seems  to  act  as  a  uterine 
tonic,  and  in  some  cases  tends  to  avert  the  danger  of 
a  miscarriage,  provided  the  ovum  be  not  blighted.  6. 
If  the  ovum  be  blighted,  and  especially  if  it  be  de- 
tached, ergot  usually  iiastens  its  expulsion. 


©ovrcsponcleiice. 

OUR    LONDON    LETTER. 

t  From  our  Special  Correspondent.  J 

UNE.XPECTtD      ELECTION — MEMORIAL    ON     .MEDICAL-AID 

ASSOCIATIONS  —  SANITARY    CONGRKSS H  n  S  P  I  T  A  1 

KI'NDS — DEATH    (>V    DR.    TURNBVLL. 

I.n-.i.;,-.,    Sc|Jlclnl«r   17,    ,507. 

We  are  soon  to  be  troubled  with  another  election  of  a 
representative  of  the  registered  practitioners  in  the 
General  Medical  Council,  for  Ur.  R.  R.  Rentoul  has 
already  resigned  his  seat,  having  apparently  had 
enough  of  it  in  one  session.  I  very  much  regret  his 
resignation,  his  supporters  generally  are  grievouslv 
disappointed,  and  even  those  who  are  opposed  to  his 
views  seem  sorry  that  he  should  throw  up  the  oppor- 
tunity of  keeping  them  before  the  profession  in  the 
council  itself  where  other  opinions  prevail.  Howbeit, 
he  perhaps  has  sufficient  reason  to  ju.stify  himself  in 
his  own  mind  for  abandoning  this  important  part  of 
his  work.  It  is  to  be  hoped  he  will  not  give  up  the 
special  dep;irtment  of  reform  which  .secured  his  elec- 
tion. 

Who  is  to  succeed  him  is  the  question  of  the  day. 
Two  former  candidates  are  already  in  the  field — Mr. 
lackson,  the  nominee  ot  the  Incorporated  Practition- 
ers' Society;  and  Dr.  Diver,  who  is  an  independent 
candidate.  'I'wo  others,  l)rs.  Woodcock  and  Drage, 
decline  to  conte.st  the  seat  on  this  occasion,  but  art- 
willing  to  come  forward  in  the  future. 

Mr.  Victor  Horsley,  F. R.S.,  is  also  willing  to  serve, 
and  the  excellent  work  he  has  done  for  medical  dt-- 
fence  should  insure  him  a  wide  supjwrt,  while  his  sci- 
entific position  would  give  him  a  respectful  iiearing 
in  the  council. 

It  is  suggested  in  some  quarters  that  Sir  W.  Foster 
should  be  induced  to  resume  his  jjlace  in  the  council, 
but  I  see  no  reason  for  inviting  the  return  of  one  who 
might,  had  he  desired,  have  continued  to  sit:  and  he 
is  merely  the  moutlqjiece  of  the  older  clique  of  iht- 
liritish  Medical  Association.  In  reference  to  this,  it 
is  curious  to  notice  the  change  in  tone  toward  the  as- 
sociation lately  adopted  by  'J'hr  I.aiiut,  which  now 
seems  to  think  that  this  numerous  body  should  nomi- 
nate a  canflidate  and  carry  him  by  force  of  numbers 
and  a  readv-niade  organization.  Now,  on  the  ist 
inst..  The  'J'imcs,  referring  to  the  meeting  at  Montreal, 
took  occasion  to  deli\er  a  scathing  criticism  on  the 
uselessness  of  the  association,  which,  while  it  has  been 
bitterly  resented  by  the  wirepullers,  lias  given  no  little 
.satisfaction  to  many  tiiinking  men.  Of  course  tin- 
fniintal  could  not  ignore  tlie  attack,  and  on  the  i  i  lli 
inst.  entered  on  its  defence,  and  as  usual  claimed  the 
[credit  of  having  initiated  and  carried  all  the  reforms, 


legislative  or  other,  which  have  been  accomplished  in 
matters  medical  for  this  long  time.  More  curiously, 
too.  The  Lancet  of  the  same  day  took  up  its  parable 
on  behalf  of  the  association  it  has  so  often  had  occa- 
sion to  criticise.  Perhaps  The  Times  article  was  a 
little  severe  and  not  absolutely  free  from  inaccuracy, 
but  its  appearance  has  given  profound  satisfaction  to 
a  large  number  of  the  profession,  both  within  and 
without  the  association. 

The  medical  men  of  Yarmouth  have  agreed  upon 
a  memorial  to  the  various  licensing  bodies  anent  the 
aid  associations,  in  which  they  ask  the  corporations 
whether  they  consider  holding  these  appointments 
compatible  with  the  conditions  on  which  the  diplomas 
or  degrees  were  granted ;  if  holding  them  does  not  con- 
travene the  regulations;  whether  they  consider  that  in 
the  interests  of  the  public  and  the  profession  bylaws 
forbidding  such  practice  should  be  adopted;  and 
whether  they  do  not  consider  holding  such  appoint- 
ments should  be  declared  by  the  Medical  Council 
■'  infamous  conduct  in  a  professional  respect,"  and, 
if  so,  whether  they  will  instruct  their  representatives 
on  the  council  to  support  such  a  declaration. 

The  memorial  gives  a  summary  statement  of  the 
abuses  which  have  led  to  this  action,  and  may  perhaps 
be  followed  up  by  other  local  medical  societies.  Un- 
less a  general  movement  of  the  kind  takes  place,  it  is 
probable  that  the  universities  and  corporations  will 
continue  their  course  of  inaction. 

The  Si.xteeth  Sanitary  Congress  was  opened  at 
Leeds  on  Tuesday,  and  is  still  sitting.  The  addresses 
on  "River  Pollution"  and  "Sanitary  Inspection"  ex- 
cited a  good  deal  of  interest.  Major  Flov.er  traced 
brieriy  the  history  of  the  management  of  the  great 
northeastern  watershed,  covering  six  hundred  miles, 
which  furnishes  a  considerable  proportion  of  the  Lon- 
don water  supply.  He  urged  the  necessity  of  further 
legislation  as  to  the  fouling  of  streams,  and  advocated 
the  abolition  of  all  exceptions  or  special  clauses,  and 
would  make  it  a  penal  offence  to  pollute  any  river  or 
stream. 

The  Prince  of  Wales'  hospital  fund  now  amounts  to 
nearly  ^£.'184,000. 

Dr.  J.  Muter  TurnbuU,  F'.R.C.P.,  formerly  of  Liver- 
pool, died  on  the  7th  inst.,  aged  eighty,  having  been 
for  years  a  martyr  to  chronic  rheumatic  arthritis.  He 
was  physician  to  the  Royal  Infirmary  from  1849  ^^ 
1876,  and  enjoyed  a  leading  position  in  the  north  of 
England.  In  188 1  he  went  to  Cannes  for  failing 
health,  and  there  the  rheumatic  affection  declared 
itself.  After  the  manner  of  this  dire  disease,  succes- 
sive attacks  followed  pnd  eventually  completelv  crip- 
pled him.  For  several  years  he  had  lived  at  Tun- 
bridge  Wells,  which  seemed  to  suit  him  as  well  as 
anywhere,  and  where  I  had  the  opportunity  of  witness- 
ing his  patience  in  his  suffering  and  infirmitie.'-. 
which  were  as  far  as  possible  alleviated  by  the  minis- 
trations of  his  de\ored  wife. 


WHO     I.NTRODUCED    THE     TERM     "APPEN- 
DICITIS"? 

:■■     lllE    HuiroK    l.K     lllK    .MKDjr.M.    KkCOKD. 

Sir:  In  the  Medical  Record  for  January  23,  1897, 
page  142.  Dr.  Gerster,  of  New  York  devotes  nearly  an 
entire  column  to  an  attempt  to  "abolish  appendicitis;" 
.md  although  he  says  he  neither  "knows  nor  cares" 
who  is  responsible  for  this  "  philological  monstrosity," 
and  "that  the  reckless  ease  with  which  the  word  was 
coined  cannot  be  excused  by  the  difficulty  or  impossi- 
bility of  finding  a  better,  more  rational,  and  yet  intel- 
ligible expression,"  and  goes  on  to  offer  "scolecitis" 
as  a  substitute,  the  pages  of  the  Medical  Record 
fail  to  show  that  his  suggestion  has  as  yet  met  with 


5o6 


MEDICAL    RECORD. 


[October  2,  1897 


any  favor.  It  is  more  than  probable  that  "  appen- 
dicitis'" has  come  to  stay.  In  Mr.  Christopher  Heath's 
annual  address  before  the  surgical  section  of  the 
British  Medical  Association  recently  at  Montreal,  he 
said ;  "  I  do  not  know  to  whom  we  are  indebted  for 
the  hybrid  term  appendicitis,  but  it  did  not  appear 
in  the  inde.x  to  the  Brilish  Mi-dicnl  Journal  before 
1891.'' 

The  fact  that  the  origin  of  this  term  was  unknown 
to  these  t«o  eminent  surgeons  led  me  to  think  that 
it  was  not  very  widely  known  that  Dr.  Reginald  H. 
Fitz,  of  Hanard,  is  responsible  for  the  term  appen- 
dicitis. In  the  article  on  "Appendicitis,"  in  the 
"Practice  of  Medicine"  by  H.  C.  Wood  and  R.  H. 
Fitz,  p.  876,  is  this  statement: 

■•  The  importance  of  recognizing  the  vermiform  ap- 
pendix as  the  usual  source  of  the  inflammations  in  the 
right  iliac  fossa,  whether  designated  iliac  abscess, 
iliac  phlegmon,  typhlitis,  perityphlitis,  paratyphlitis, 
or  typhlo-enteritis,  led  Fitz  to  offer  the  term  appen- 
dicitis to  indicate  the  primary  disease  whose  results 
were  so  variously  named.  Despite  the  barbarism  of 
the  tenn,  its  practical  importance  has  made  it 
welcome."  A.  B.   Rosenberry,  M.D. 

Arlok  ViT.t,  Wis.,  September  17,  iSr,;. 


TAPEWORM    IN    MAN. 


To  THE  Editor  of  i 


Sir:  In  reference  to  the  statement  of  Dr.  E.  C. 
Chamberlin  in  your  issue  of  August  28th,  that  tapeworm 
is  confined  to  females,  I  beg  to  state  that  one  of  the 
most  perfect  s]3ecimens  I  have  ever  seen  came  from 
one  of  the  students  of  the  Atlanta,  Ga.,  Medical  Col- 
lege last  winter.  So  perfect  was  it  that  I  secured  the 
worm  for  the  college  museum.  This  is  one  case,  at 
least,  in  a  male.  C.  M.   Bl.a.ckford,  Jr.,  M.D. 

.Vtlant.\,  G.\. 


■  HOSPITAL    ENTERPRISE." 


Sir:  The  undersigned  physicians  and  surgeons,  con- 
stituting the  medical  and  surgical  staff  of  the  Omaha 
Hospital  and  Deaconess  Home,  wish  to  state,  in  refer- 
enc'e  to  an  item  which  appeared  in  the  Medical  Rec- 
ord of  August  28,  1897,  under  the  title  of  "Hospital 
Enterprise,"  that  they  are  in  no  way  responsible,  di- 
rectly or  indirectly,  for  the  appearance  of  the  circular 
referred  to  in  said  item.  Said  circular  was  prepared 
by  the  members  of  the  board  of  trustees,  and  by  them 
ordered  to  be  mailed  to  every  Methodist  minister 
within  a  certain  radius  of  Omaha,  without  consulta- 
tion with  or  the  knowledge  of  any  member  of  the  staff. 
Tlie  clerk,  in  accordance  with  her  instructions,  began 
mailing  the  circular,  when  accidentally  a  member  of 
the  attending  staff  discovered  the  nature  of  the  mail 
matter,  and  after  his  remon.strance,  and  after  only  a 
small  number  had  been  mailed,  its  further  distribution 
was  promptly  discontinued  and  the  remainder  de- 
stroyed. 

We  therefore  desire  in  the  most  public  manner  pos- 
sible to  express  our  most  emphatic  disapproval  of  said 
circular.  W.  O.   Bridges,  M.D., 

Harold  Gifford,  M.D., 
A.   F.   loNws,  M.D., 
\V.  S.  GiBHS,  M.D., 
J.  M.  AiKix,  M.D. 


The  Vagina  when  washed  out  with  sublimate  or 
carbolic  solution  in  strength  sufficient  to  free  it  from 
germs  will  become  dry  and  chapped. — Dodkri.ein". 


|lcuT  instruments. 

THE  AMPLIPHONE— A  NEW  INSTRUMENT 
DESIGNED  TO  REPLACE  THE  ORDINARY 
STETHOSCOPE. 

Bv    1\    H.    CLARK,    M.D.. 


Some  few  weeks  ago  my  attention  was  called  to 
a  new  instrument  which  had  but  just  made  its  ap- 
pearance before  the  medical  public,  and  being  in- 
terested in  any  appliance,  device,  or  means  by  which 
physical  diagnosis  may 
be  made  more  simple 
and  at  the  same  time 
more  correct  (and  as 
well  a  bit  curious)  I 
secured  one  of  the 
instruments,  which  I 
have  used  for  perhaps 
six  weeks  with  results 
which  have  been  highly 
satisfactory  in  nearly 
if  not  quite  every  case; 
in  fact  it  has  devel- 
oped a  condition  of 
affairs  in  several  in- 
stances which  has 
been  of  the  greatest 
importance  not  only 
to  the  examined  but 
to  the  examiner  as 
well ;  and  thinking 
others  might  be  interested,  I  venture  to  report  the 
result  of  my  experiments  with  this  latest  addition  to 
the  list  of  stethoscopic  instruments. 

The  instrument  consists  of  two  aluaiinium  dia- 
phragms of  two  and  a  half  inches  in  diameter.  The 
metal,  which  is  extremely  thin,  is  corrugated  in  cir- 
cular lines.  Between  the  diaphragms  is  placed  a 
brass  ring,  about  a  quarter  of  an  inch  wide,  into 
grooves  in  which  the  edges  of  the  diaphragms  are 
spun  or  pressed.  .\n  air  chamber  is  thus  left  between 
the  inner  convolutions  of  the  diaphragms.  Projecting 
from  the  upper  diaphragm  is  a  metal  stud,  covered 
with  hard  rubber,  for  convenience  in  handling. 
Through  this  stud  passes  a  tube  one  end  of  which  is 
attached  to  the  tubing  which  carries  the  sound  to  the 
ear,  as  in  the  phonograph.  This  tube  runs  down  to 
the  air  chamber  between  the  two  diaphragms.  To 
the  centre  of  the  opposite  diaphragm  is  attached  a  bell- 
shaped  terminal,  through  which  a  tube  runs  to  the 
outer  surface  of  the  diaphragm.  This  cup-shaped 
terminal  is  applied  to  the  localit)'  from  which  the 
sound  is  supposed  to  emanate.  .\n  extension  piece  is 
provided  to  facilitate  the  handling  of  the  terminal  in 
certain  cases  by  the  practitioner.  The  whole  appli- 
ance weighs  about  two  ounces  and  can  be  carried  in 
the  pocket. 

The  following  cases  coming  under  my  obser\'ation 
and  in  which  the  ampliphone  was  used  may  be  of 
some  interest,  \iz. :  i'hree  cases  of  pregnancy,  in  two 
of  which  the  diagnosis  was  doubtful  owing  to  the 
absence  of  certain  symptoms  and  the  uncertainty  of 
others.  The  doubtful  cases  were  examined  carefully 
with  several  varieties  of  stethoscopes  without  the  fcEtal 
heart  or  uterine  soutHe  being  heard  until  the  ampli- 
phone was  tried,  when  botii  were  recognized;  not  only 
was  the  diagnosis  confirmed  but  a  fairly  correct  idea 
of  the  position  was  secured. 

The  third  case  was  one  in  which  circumstances  did 
not  permit  the  removal  of  the  clothing,  but  the  sounds 
were  transmitted  witli   remarkable  clearness  through 


October  2,  1897] 


MEDICAL    RECORD. 


507 


the  ordinan-  dress  worn  by  the  patient  and  heard  with  • 
out  the  slightest  difficulty. 

Two  cases,  one  of  organic  heart  lesion  complicated 
with  emphysema,  and  the  other  of  uraemic  coma,  in 
both  of  which  the  respiratory  murmur  was  so  greatlv 
exaggerated  that  the  heart  sounds  were  rendered  indis- 
tinct, furnished  an  opportunity  to  test  the  pulse  with 
the  ear  as  well  as  the  finger,  and  in  both  cases  the 
sound  was  transmitted  with  sufficient  strength  and 
clearness  to  enable  it  to  be  counted  with  ease,  while 
its  volume  and  character  could  be  determined  without 
difficult}';  there  were  two  other  physicians  present  on 
this  occasion,  both  of  whom  listened  and  expressed 
their  satisfaction  at  the  result. 

In  a  case  of  lobar  pneumonia  the  tubular  breathing 
seems  magnified  or  intensified  very  considerably  bv 
this  instrument  as  compared  with  the  ordinarv'  stetho- 
scope, while  the  whistling  rales  of  emphysema,  the 
coarse  rattle  of  bronchitis,  and  the  friction  of  pleurisy 
are  carried  to  the  ear  so  pronouncedly  louder  that  one 
with  difficulty  realizes  what  he  hears.  I  believe  this 
little  instrument  possesses  several  decided  advantages 
over  other  appliances  for  a  like  purpose  and  that  its 
field  of  usefulness  is  of  the  widest  range;  in  the  hands 
of  men  of  skill  and  intelligence  it  will  be  of  the  greatest 
assistance  in  diagnosing  and  treating  disease. 


HYSTERECTOMY    FORCEPS. 


Bv  \\.    K. 


fkVOK,    M.D. 


For  two  years  and  more,  I  have  been  using  a  kind  of 
forceps  in  my  vaginal  work  which  seem  to  have  advan- 
tages over  and  to  be  devoid  of  objectionable  features 
which  attach  to  other  forceps.  They  are  verj-  easily 
applied;  and  the  forceps  placed  to  secure  the  uterine 
arteries  are  scarcely  felt  to  be  in  the  way  while  the  ma- 
nipulation of  the  higher  structures  is  being  performed. 
Furthermore,  the  forceps  without  their  handles,  when 
moved  by  the  operator's  hands,  exercise  less  leverage 
upon  the  stumps  than  do  longer  instruments.  The 
catch  is  perfectly  secure,  and  is  made  in  such  a  way 
that  the  points  of  the  bite  meet  when  the  first  catch 
is  closed. 

After  the  operation  is  completed  and  the  forceps  are 
surrounded  by  a  gauze  dressing,  the  mass  of  instruments 
does  not  interfere  with  the  use  of  a  catheter  and  does 
not  prevent  the  patient  turning  about  when  restless: 
there  are  no  long  handles  to  be  jarred  by  her  thighs. 
In  removing  the  forceps  the  keys  are  applied  and  the 
instruments  released  one  by  one.  I  have  stipulated 
with  the  makers  that  these  instruments  shall  be  made 
of  tempered  steel  from  one  end  to  the  other.  If  there 
be  flaws  in  a  pair  they  will  break  in  their  application, 
and  not  bend  and  twist  under  the  strain  and  admit  of 


bleeding.  They  render  the  after-conduct  of  hyster- 
ectomy cases  simpler,  and  lessen  the  discomfort  inci- 
dent to  the  operation.  They  have  been  so  thoroughly 
tried  that  I  feel  I  can  recommend  their  use  to  the  pro- 
fession. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitar)-  Bureau,  Health  Department,  for  the 
week  ending  September  25,  1897  : 


Cases. 

Tuberculosis iSi 

Trphoid  fcTer 3S 

Scarlet  fever 67 

Ceiebro-spinal  meningitis o 

Measles 25 

Diphtheria 114 

Laryngeal  diphtheria  (croup) 2 

Chicken-pox ]  ; 


Earth-to-Earth  Burial. — At  the  recent  nineteenth 
annual  meeting  of  the  Church  of  England  Burial-Re- 
form Association,  Dr.  Toore,  on  contributing  a  paper 
on  ■■  Earth-to-Earth  Burial,'  laid  stress  upon  the  fact 
that  the  earth  was  a  source  of  life  in  this  world  and  the 
necessar)'  recipient  of  all  dead  organic  matter.  \Yith 
due  regard  to  scientific  principles  it  was  quite  possible 
to  carry  out  the  rite  of  burial,  not  only  without  harm, 
but  with  a  certain  amount  of  benefit  to  the  living.  If 
bodies  were  buried  in  the  upper  layers  of  the  soil,  and 
in  contact  with  it,  a  complete  disappearance  of  the  or- 
ganic matter  would  be  eff'ected  in  about  twelve  months. 
A  cemeterj'  scientifically  used  and  planted  fonned  an 
open  space  which  was  invaluable  to  crowded  centres 
of  population,  and  by  aflfording  nourishment  to  trees 
and  other  green-leaved  plants  had  the  power  of  fresh- 
ening the  air.  The  simplification  of  funerals  and  sci- 
entific burial,  so  that  the  ground  might  be  used  a  sec- 
ond time  after  a  certain  inten-al,  were  both  important 
steps  in  the  advance  of  sanitation. 

The  Origin  of  the  Word  <<  Deadhead."— Fift}- 
years  ago  the  principal  avenue  of  Detroit,  Mich., 
passed  close  to  the  entrance  of  the  plank  road  leading 
to  Elmwood  Cemetery.  As  this  cemetery  had  been 
laid  out  some  time  previous  to  the  construction  of  the 
road,  it  was  arranged  that  all  funeral  processions 
should  be  allowed  to  pass  along  the  latter  toll  free. 
One  day  as  Dr.  Pierce,  a  well-known  physician, 
stopped  to  pay  his  toll,  he  obser\-ed  to  the  gate  keeper: 
■■  Considering  the  benevolent  character  of  our  profes- 
sion, I  think  you  ought  to  let  us  pass  free  of  charge." 
''So,  no,  doctor,'"  replied  the  gate  keeper;  "we  can't 
afford  that.  You  send  too  many  deadheads  through 
as  it  is."  The  stor)- travelled  around  the  country,  and 
the  word  "deadhead"  was  eventually  applied  to  those 
who  obtained  free  admission  to  the  theatre. 

The  Physical  Effects  of  Music. — Experiments  on 
the  influence  of  music  upon   respiration,  recorded   bv 
MM.    A.    Hinet  and    I.    Courtier    in    the 
Anr?ie    Fsychologiqiie     for    1897,    indicate 
that     musical      sounds,   chords,  andmusic 
in   general,  as    a  sensorial    excitation    in- 
dependent of   all  suggested    feelings,  pro- 
'.  oke  acceleration  of  respiration,  increasing 
.IS  the  movement  is   more   lively,  without 
disturbing  the  regularity  or  augmenting  its 
amplitude.     The  major  mode  is  more  ex- 
citing than  the  minor.     The  heart  is  simi- 
larly affected.      The    distinction  between 
sad  or  solemn  and  lively  music  appears  to  be   for  the 
most  part  wholly  theoretical,  and  hardly  squares  with 
the  complexity  of  the  musical  emotions  produced   by 
the  melodies  with  the  infinite  shadings   suggested  by 
the  ideas  of  the  libretto.     The  authors,  however,  infer 
from   their    researches   that   the    acceleration    of    the 


qo8 


MEDICAL    RECORD. 


[October  2,  1897 


heart  and  of  the  respiration  was  not  so  marked  during 
the  hearing  of  sad  pieces  as  in  those  in  which  joy 
and  high  excitation  of  musical  emotions  prevail. — 
Apph' ton's  Science  'Monthly. 

The  Antivivisection  Pledge. — "I  pledge  to  never 
knowingly  employ  a  physician  practising  or  upholding 
vivisection  unless  in  case  of  immediate  danger  or 
death."  The  antivivisectionist  is  evidently  as  great 
a  foe  to  grammar  as  she  is  to  any  other  science. 

<<  Cock-Matrons." — Subsequent  editions  of  diction- 
aries of  the  English  language  will  have  to  find  space 
for  a  new  compound  word,  namely,  "  cock-matrons." 
Possibly  some  of  our  readers  will  be  curious  to  know- 
whence  this  term  originated.  \A'e  will  enlighten  them. 
The  term  heads  an  editorial  article,  which  appeared 
last  week  in  a  contemporary  published  in  the  sole  in- 
terests of  nurses,  called  the  Nursing  Kcconi.  This 
journal,  as  is  generally  known,  is  conducted  by  a  lady, 
who  may  be  assumed  to  know  something  about  ma- 
trons, inasmuch  as  she  was  once  matron  herself  to  a 
large  general  hospital  in  London.  The  article  in 
question  altogether  disapproves  of  men  having  any- 
thing to  do  with  the  appointment  or  selection  of  the 
nurses  at  hospitals.  "  It  has,"  says  the  writer,  "  been 
proved  over  and  over  again  that  man  is  rarely  a  com- 
petent judge  of  the  capacities  of  women  for  work. 
Smartness,  good  looks,  a  taking  manner,  or  a  pretty 
bonnet  have  often  turned  the  scale  in  favor  of  a  can- 
didate for  a  post  when  the  appointment  is  made  by 
men."  Upon  these  grounds,  then,  '•  cock-matrons" 
must  be  condemned  as  impracticable  hermaphrodite 
officials,  whose  judgment  would  always  be  certain  to 
be  biassed  and  at  fault.  Hut  perhaps  the  best  way  of 
dealing  with  this  subject  is  to  discuss  the  objection- 
able species  of  "  cock-matrons"  from  a  morphological 
point  of  view.  It  is  then  that  the  matter  becomes  very- 
interesting,  as  those  having  a  taste  for  morphology  will 
soon  discover.  Upon  the  whole,  however,  we  prefer 
to  leave  to  our  readers  the  pastime  of  working  out  for 
themselves  the  various  problems  which  it  suggests. — 
Medical  Press,  Augu.st  4,  1897. 

Health  Reports. — The  following  statistics  concern- 
ing cholera  and  yellow  fever  have  been  received  in 
the  office  of  the  United  States  Marine  Hospital  ser\  ice 
during  the  week  ended  September  25,  1897  : 


ll  Hiojro,  Japan August  i4lh  lo  ai> 

Yellow  Fever— United  St.\tes. 
Mobile Seplumber  i8th 


September  i^th   ■-■ 

September  20th i 

September  21st i 

September  22d 4 

September  23d 2 

September  24th 3 

. .  .September  23d 1 

,..Septembt!r  19th 2 

.September  20th 2 

...  September  23d 1 

...September  i8lh 6 

September  19th s 

September  20lh 18 

September  2ist g 

September  22d 12 

September  23d i 

24th i.> 


.Septen.lH 
.S<-ptemlH 
SeptemlH' 
■H-pteinbt 


iSth. 
■gth. 


September  2isl i-- 

September  aad 13 

Seplemlier  23d 23 

Septemb^rr  24lh 29 

. .  September  18th 2 

September  22d 4 

SepteinN-r  J3d 6 

September  J4lh.    .  i 

.  .s<-ptember  iglh i 

*'<-|>teniber  20th 15 

^*-ptember  22d 4 

Septeml>er  :*ld 6 


The  Use  of  Sugar   after  Severe  Musctilar  Exer- 
cise  K.xperimcnts  of  an  interesting  nature  have  lately 

been  made  at  the  instigation  of  the  Prussian  war  office, 
to  endeavor  to  decide  the  question  as  to  whether  the 
consumption  of  small  quantities  of  sugar  renders  the 
tired  muscles  capable  of  renewed  exertion.  In  order 
to  obtain  a  practical  result,  the  person  who  was  made 
the  subject  of  the  experiment  was  kept  totally  ignorant 
of  the  object  of  the  experimenters.  On  one  day  a 
sweet  liquid  was  administered,  containing  thirty  grams 
of  sugar;  on  the  next  day  a  similar  liquid,  containing 
a  sufticient  amount  of  saccharin  to  render  it  indistin- 
guishable from  the  other  as  regarded  taste.  After  a 
very  large  amoimt  of  muscular  work  had  been  per- 
formed, it  was  found  that  better  results  could  be  ob- 
tained on  the  days  when  the  sugar  was  given  than  on 
the  days  when  saccharin  was  given.  The  blood  had 
become  very  poor  in  sugar  in  cons-equence  of  the  severe 
muscular  effort,  and  the  administration  of  a  compara- 
tively small  quantity  of  sugar  had  a  markedly  invigor- 
ating effect. 


^00  ka  ^eceiiJjed. 

While  the  Medical  Recorm  is  fieaieJ  to  receive  allntw putli- 
eations  li'kiek  may  be  sent  to  it,  and  an  acktwTvUdgment  will  he 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  Judgment  of  its  editor  vnll  »;>/  he 
of  interest  to  its  renders. 

The  American  .-Xcademv  i.<t  k.\u.w.AY  Slkgeons.  Vol. 
III.,  iSg6.  Edited  by  Dr.  Harvey  Reed.  l2mo,  282  pasro. 
Illustrated.      American  Medical  .Association  Press.  Chicago. 

Proceedi.\<;s  oi-  i  he  Nebraska  State  Medical  SociKrv. 
1S97.  Svo,  373  pages.  Illustrated.  Nebraska  State  Medical 
Society,  Lincoln,  Neb. 

A.NNLAL     REI'UKT    <iF     illE     Si  .VTE    BoAKl>    l.)K    CHARITIES    l>K 

THE  .Staik  <iK  New  York.  1S96.  Svo,  641  pages.  Wyn- 
koop,  Hallcnbeck,  Crawford  Company,  New  York. 

Medical  Cli.matoIjOgv.  By  Or.  S.  Edwin  Solly.  Svo,  470 
pages.     Illustrated.     I-ea  Brothers  &  Co. ,  New  York. 

International  Clinics.     Vol.   II.  Seventh   Series.     i»i)7. 

Edited  by  Dr.  J.    Daland,    Dr.   J.    M.  Bruce,  and  Dr.    D.   W. 

Kinlay.  Svo,  371  pages.  Illustrated.  J.  15.  Lippincott  C<mi- 
pany,  Philadelphia,  I'a. 

Oi'KK.\TlvE  Dentisirv.  Edited  by  Edward  C.  Kirk,  D.i'.S. 
Smi,  702  pages.      Illustrated,      lea  Brothers  &  Co.,  New  York. 

RlIEl  .MATIS.M     AND     ITS    TREATMENT    BY     I  HE    USK    OK"    IIIE 

I'ERCcsso-Pc.NCTATOR.  Sccond  Edition.  By  J.  B.  James. 
M.R.C.S.  l6mo,  39  pages.  The  Rcbman  Publishing  Com- 
pany, London.     Price,  2s. 

The  New  Psvchkloc.v.  By  E.  \V.  Scripture,  Ph.D.  121110, 
500  pages.  IIlustrate<l.  Charles  Scribner's  Sons,  New  York. 
I'rice.  !r;i.2:. 

The  rsvcHOLoi;Y  nK  the  E.moiions.  By  Th.  Rilot. 
i2mo,  45;  pages.  Illustrated.  Charles  Scribner's  Sons,  New 
York.      I'rice,  Si-25. 

-SciENiiKlc  Basis  he  Medicine-  By  Dr.  1.  \V.  Heysingcr. 
i2mo,  122  pages.  Hoericke  iS.  Tafel.  Philadelphia.  Price,  50 
cents. 


UN  P.vtiuiLocv.      By  J  >r.   \V.  .\.    Kvaiis.      l2mo,  472 
I'he    \V.    T.     Keener  Company,   Chicago,    III.        IVirc. 


Children.     By    Dr.   Walter 
imo,   256  p.iges.      Boericke  .V 


Nor 
pages. 

St.  50. 

Diseases    oi-    1-'emai.v_s    ani 
AVilliamson.      Kourth   Edition. 
Tafel,  Philadelphia.      I'rice,  Si.< 

Diseases  uf  Women.  By  Dr.  B.  button,  F.R.C.S.,  ami  l>r. 
.\rthur  E.  Giles.  Jvo,  43(1  p.-i',;es.  Illustrateti.  W.  B.  SaumU-rs, 
I'hil.idelphia. 

liACTEKIiil.Oi'.v.      By  Prof.  K.  I!,  l.ehmann    and    Dr.  R.  Ne<v 
mann,  I2mi>,  204  pages.      Illustrated.      William  Wood  and  C< 
p.iny.  New  N'ork       Price,  S3. 50. 

TEXT-B01.1K  or  DisKvsEs  iiK  WoMLN.  liv  Dr.  Charles 
Penrose.  Svii,  j2i)  pages.  Illustrate<l.  \V.  B.  Saundri 
Philadelphia. 


Medical  Record 

A  Weekly  journal  of  Medicine  and  Surgery 


Vol.  52,  No.  15. 
Whole  No.  1405. 


New  York,   October    9,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©ricjinaX  Articles. 

THE   CHANGE  OF   LIFE  AND   THi:   DIAG- 
NOSIS   OF    CARCINOMA   UTERI." 

Bv   EDWARD  J.    ILL,    M.D., 

NEWARK,    N.    J 

Upon  inquiry  among  ray  medical  friends  what  subject 
for  an  address  might  be  of  sufficient  interest  and  im- 
portance to  the  county  society,  I  found  the  most  di- 
versified opinion.  The  gentlemen  all  agreed  in  this, 
however,  that  the  early  diagnosis  of  carcinoma  of  the 
uterus  was  frequently  very  difficult  and  often  gave  them 
much  annoyance.  Having  occasion  to  look  over  my 
notes  of  cases  of  cancer  of  the  uterus,  I  was  astonished 
at  the  number  of  patients  who  came  with  the  opinion 
that  they  suffered  from  symptoms  of  the  menopause. 
Thus  this  subject  seemed  to  me  the  proper  one  for  dis- 
cussion. Cases  are  often  referred  to  me  months  after 
the  first  symptoms,  these  symptoms  being  spoken  of  as 
belonging  to  the  change  of  life.  Of  course,  operative 
interference  cannot  be  thought  of,  the  disease  having 
gone  beyond  the  limit  of  the  uterus,  much  to  the  dis- 
gust of  the  family  of  tlie  patient,  and  often  to  the  pro- 
fessional and  business  detriment  of  the  attendant,  not 
to  speak  of  the  misery  of  the  poor  sufferer,  when  there 
might  have  been  a  chance  for  cure.  Somewhere  I  read 
this  very  true  statement :  "  The  best  therapy  which  a 
woman  with  carcinoma  of  the  uterus  can  receive  at 
the  hands  of  the  practitioner  consists  in  an  early 
diagnosis." 

It  is  the  duty  of  those  who  have  family  practice  to 
give  women  some  idea  of  the  innocent  symptoms  ac- 
companying the  menopause:  to  teach  them  that  the 
menopause  means  a  cessation  of  the  flow,  not  an  in- 
crease, and  to  insist  on  an  immediate  examination  if 
anything  occurs  which  is  not  plainly  and  solely  at- 
tributable to  this  condition.  It  will  be  better  to  err 
on  the  wrong  side  and  make  too  many  examinations. 
Nowadays,  women  rarely  object  when  the  matter  is 
properly  placed  before  them.  I  would,  however, 
strongly  disapprove  of  frightening  the  patient  into  an 
examination  by  threatening  her  with  the  word  cancer. 
With  that  word  one  can  get  a  woman  to  consent  to 
almost  anything. 

I  will  not  annoy  you  with  a  lengthy  enumeration  of 
the  symptoms  accompanying  the  menopause.  A  few, 
however,  will  be  of  value  as  compared  with  the  symp- 
toms of  malignant  disease.  The  chief  factor  that  will 
interest  us  in  this  regard  is  the  quantity,  quality,  and 
regularity  of  the  flow  of  blood.  By  the  change  of  life 
is  understood  that  condition  in  which  the  woman  nor- 
mally and  finally  ceases  to  have  a  regular  monthly 
bloody  flow.  The  ideal  change  would  take  place  if 
she  gradually  ceased  flowing  by  longer  and  longer  in- 
tervals. This,  however,  is  rare,  and  she  suffers  more 
or  less  from  irregular  flow,  at  times  anticipating  and 
more  frequently  postponing.  Usually  the  flow  be- 
comes more  and  more  scanty,  rarely  excessive.  When 
the  latter,  it  is  commonly  due  to  endometritic  changes, 
and  frequently  is  found  in  women  who  were  sufferers 

'  President's  address,  read  before  the  annual  meeting  of  tl  t- 
Essex  County  Medical  Society,  April  6,  i?97. 


from  some  pelvic  difficulty  for  years.  Now  and  then 
there  is  no  apparent  cause,  and  I  was  once  obliged  to 
extirpate  the  uterus  to  save  the  patient's  life.  It  was 
then  discovered  that  a  small  polypus  was  the  cause  of 
the  hemorrhage.  Nervous  symptoms  are  the  rule,  but 
rarely  consist  of  more  than  vasomotor  disturbances  of 
the  skin,  hot  flashes,  profuse  and  sudden  perspiration. 
Vertigo  and  palpitation  of  the  heart  are  not  infre- 
quently met  with.  Now  and  then  we  see  neuralgia, 
insomnia,  and  mental  depression. 

With  the  laity  change  of  life  means  almost  any  ab- 
normal symptoms,  physical  or  otherwise,  which  a  wo- 
man may  have  from  the  time  she  is  thirty-five  until 
she  has  reached  sixty,  so  vague  is  the  woman's  notion 
of  this  dreaded  time  oi  life.  It  will  be  irrelevant  to 
our  subject  to  draw  your  attention  to  the  peculiar 
atrophic  changes  going  on  in  the  genital  organs  with 
the  normal  cessation  of  menstruation,  except,  perhaps, 
that  malignant  or  ovarian  growths  are  not  affected  by 
the  menopause;  but  fibromyomata  commonly  undergo 
retrograde  changes  by  which  they  become  smaller,  and 
in  several  cases  I  have  seen  complete  absorption  take 
place.  Now  and  then  malignant  changes  have  been 
said  to  take  place  in  fibromyomata  and  ovarian 
timiors  at  this  time  of  life.  There  is,  however,  noth- 
ing especially  to  characterize  this  change.  After  what 
has  been  said,  the  diagnosis  of  climacteric  changes 
and  disturbances  should  not  be  difficult.  The  prog- 
nosis is  good,  provided  a  careful  examination  has  re- 
vealed no  pathological  changes  in  the  uterus  which 
would  lead  to  a  suspicion  of  malignant  degeneration. 

This  brings  us  to  the  discussion  of  the  diagnosis  of 
carcinoma  of  the  uterus.  There  are  no  symptoms 
characteristic  of  carcinoma  of  the  uterus.  Pain,  hem- 
orrhage, or  other  discharges  are  also  factors  in  other 
ailments  than  carcinoma.  It  is  here  that  we  have 
committed  grave  sins  of  omission,  because  we  have  not 
insisted  upon  an  immediate  and  thorcmgh  pelvic  ex- 
amination in  a  woman  who  presented  symptoms  refer- 
able to  the  genital  tract  in  the  time  of  life  under  dis- 
cussion. We  must  start  out  with  the  knowledge  that 
women  at  forty-five  or  fifty  years  of  age  do  not  flow- 
excessively  without  local  or  general  cause,  any  more 
than  do  women  at  twenty  or  thirty.  In  more  than 
fifteen  thousand  gynaecological  cases  I  have  seen  hem- 
orrhage but  three  times  at  this  period  of  life  which 
could  not  be  explained  by  some  special  ailment. 
There  are  predisposing  causes  in  the  chronic  inflam- 
matory changes  about  the  uterus.  L'^nfortunately, 
early  symptoms  of  carcinoma  of  the  uterus  are  not 
always  so  prominent  as  to  induce  the  patient  to  seek 
timely  medical  advice.  Nor  should  the  doctor  look 
for  symptoms  which  do  not  come  on  until  the  later 
stages  and  often  the  last  stages  of  the  disease  are 
reached.  All  this  proves  to  be  a  great  calamity  for 
our  women. 

When  a  woman  has  a  return  of  a  protracted  bloody 
flow  anywhere  after  six  to  ten  months  from  what  was 
thought  to  be  her  last  menstruation,  our  suspicion 
must  be  directed  to  a  probable  malignancy  as  a 
cause.  In  fact,  we  shall  rarely  find  anything  else 
if  such  a  return  takes  place  two  years  or  more 
since  the  last  period.  Now  and  then  a  mucous  poly- 
pus is  found  to  be  the  cause.     Besides  this  bloody 


5IO 


MEDICAL    RECORD. 


[October  9,  li 


flow,  a  constant  serous  or  sero-sanguinolent  discharge 
is  almost  invariably  present.  Unfortunately,  however, 
this  is  not  always  an  early  symptom.  These  few 
symptoms  alone  make  an  examination  imperative. 
Greater  difficult}',  however,  is  experienced  in  detecting 
the  earlier  symptoms  in  women  who  are  still  in  the 
active  period  of  sexual  life.  Here  we  rarely  find  more 
than  an  mcrease  in  the  quantity  of  menstrual  flow, 
possibly  a  little  prolonged.  This  is  most  frequently 
due  to  an  accompanying  hyperplastic  enaometritis. 
A  little  later  the  flow  will  be  more  frequent  and  soon 
it  becomes  constant. 

Carcinoma  of  the  body  is  more  apt  to  present  these 
symptoms  than  carcinoma  of  the  cervix.  With  car- 
cinoma of  the  cervix,  often  the  earliest  symptom  which 
brings  the  patient  to  the  doctor  will  be  a  show  of 
blood  after  marital  intercourse,  severe  e.xertion,  or  a 
constipated  movement.  When  we  once  get  irregular 
hemorrhages,  and  by  hemorrhage  I  mean  excessive 
flows  of  blood,  we  have  already  reached  the  stage  of 
erosion  or  breaking  down  and  have  generally  passed  the 
time  when  operative  interference  offers  a  fair  chance. 
Pain  and  cachexia  are  always  late  symptoms.  I  am 
sorry  the  word  "  cachexia'"  was  ever  invented — so  many 
rely  on  the  appearance  of  this  symptom  before  they 
dare  to  diagnose  cancer.  .\s  has  been  said,  pain  also 
is  a  late  symptom  and  shows  itself  when  the  disease 
has  reached  beyond  the  uterus  proper.  There  is  an 
exception  to  this  in  many  cases  of  carcinoma  of  the 
body  of  the  uterus,  when  an  intermittent,  agonizing 
pain,  most  frequently  late  in  the  afternoon  or  toward 
morning,  is  recognized  early.  Foul  odors  are  not 
pathognomonic  of  malignant  disease.  The)'  are  a  late 
symptom  and  should  not  be  waited  for.  They  come 
on  comparatively  early  in  the  unclean  and  those  who 
have  been  treated  locally,  from  the  fact  that  air  with 
its  decomposing  germs  has  entered  the  passages. 

You  will  see  from  what  has  been  said  that  an  early 
diagnosis  from  subjective  symptoms  belongs  to  the 
difficult  problems.  With  these  subjective  symptoms 
we  must  consider  the  objective  as  presented  by 
thorough  and  exhaustive  physical  examination.  It 
is  not  in  the  province  of  this  paper  to  go  into  the 
fundamentals  of  a  pelvic  examination:  let  it  be  suffi- 
cient to  touch  on  those  points  which  at  the  bedside 
will  make  the  diagnosis  highly  probable.  For  con- 
venience' sake  malignant  disease  of  the  cer\-ix  and 
corpus  will  be  spoken  of  separately. 

Of  the  several  fcjrms  of  cervical  carcinoma,  the 
cauliflower  growth  will  give  us  the  least  difficulty  in 
diagnosis.  The  uneven,  friable,  and  easily  bleeding 
surface  projects  so  far  from  the  cervLx  itself  that  the 
cervix  proper  can  hardly  be  reached.  The  mass  fills 
up  a  considerable  portion  of  the  vagina.  This  condi- 
tion is  quite  pathognomonic,  and  is  easily  distin- 
guished from  the  hard  solid  polypus  or  the  hyj)ertro- 
phic  cervix.  The  superficial  surface  of  the  excrescence 
is  eroded  and  covered  with  a  grayish  dirty  mucus. 

The  ulcerating  epithelioma  of  the  cervi.x  is  easily 
known  by  its  distinct  hard  edges,  the  hardness  extend- 
ing somewhat  beyond  the  ulcerating  portion.  The 
bottom  of  the  ulcer  is  remarkably  hard,  but  so  friable 
that  a  curette  will  easily  remove  a  large  piece.  A  te- 
naculum will  find  no  hold  in  it.  In  the  speculum  it 
appears  as  covered  by  a  dirty  grayish  matter.  The 
ordinary  erosion,  on  the  contrar)*,  appears  of  a  red 
color,  has  no  infiltration  of  its  edges,  and  is  smooth 
and  velvety  to  the  touch.  The  curette  will  make  little 
impression  on  it,  except  to  remove  a  ven,-  superficial 
layer. 

I  will  not  detain  you  with  the  differentiation  of  the 
rare  tuberculous  ulcer. 

The  syphilitic  ulcer  will  be  recognized  by  its  gen- 
eral symptoms. 

When  there  is  any  doubt  excision  of  a  portion  of 


the  ulcer  should  be  made  and  subjected  to  a  micro- 
scopical examination.  It  is  always  well  to  remove  some 
healthy  tissue  with  the  diseased  structure  for  this  pur- 
pose, and  is  very  satisfactorj-.  Scrapings,  on  the  con- 
trary, are  most  unsatisfactory. 

When  carcinoma  of  the  cer\ical  canal  exists  it  will 
show  only  when  the  cer\ix  is  dilated  and  the  curette 
produces  the  friable  masses.  By  palpation  the  cervix 
is  found  enlarged,  and  hard,  deeply  situated  nodules 
are  felt.  Cenucal  carcinoma  will  have  to  be  differ- 
entiated from  fibromyomata,  which  will  not  be  difficult. 

Carcinoma  of  the  body  cannot  be  diagnosed  in  its 
earlier  stages  by  palpation.  Here  again  the  curette, 
besides  the  subjective  symptoms,  must  tell  us  the  true 
state  of  affairs.  Carcinoma  in  this  location  offers  the 
very  best  chance  for  permanent  cure  by  operation. 
I  would  rather  diagnose  this  condition  by  the  curette 
than  by  the  microscope  even  in  the  hands  of  the  ex- 
pert. The  microscope  can  rarely  be  relied  ujwn  in 
the  examination  of  scrapings.  It  will  often  mislead 
and  will  be  of  value  only  when  it  gives  positive  results 
in  connection  with  other  symptoms. 

Of  all  cases  of  carcinoma  that  came  into  my  hands 
hardly  one  in  five  was  presented  sufficiently  early  for 
operation.  When  we  consider  that  only  twenty-five 
per  cent  of  those  operated  upon  remain  free  from 
recurrence,  we  can  easily  understand  that  but  one 
case  in  twenty  of  those  coming  to  the  operator  re- 
mains well,  a  most  discouraging  aspect  were  it  not 
for  the  fact  that  even  this  one  would  prove  fatal  were 
it  not  for  the  interference.  You  will  understand, 
then,  why  I  dare  to  urge  you  to  employ  ever\-  means 
for  an  early  diagnosis  and  a  possible  operation  ;  and, 
if  you  will  -permit  me  to  say  it,  the  diagnosis  of 
change  of  life  must  be  the  very  last,  and  after  everj- 
other  explanation  of  the  symptoms,  both  subjective 
and  objective,  fails.  The  deaths  from  operation  have 
been  lowered  to  a  very  small  number,  and  we  can  con- 
scientiously recommend  an  early  operation,  even 
though  it  offers  so  small  a  chance  for  permanent  cure. 


IMPERFFXTIONS    IX     INTRA-AHDOMIXAL 
DIAGNOSIS. 

i;v    HVROX    B.    D.WiS,    .\.H.,    M.I). 

UM.\HA,    NEB., 
SI  KG  EON'  TO   I,M.M.\NL"EL  HOSPITAL 

Th.\t  progress  in  recognizing  intra-abdominal  disease 
is  being  made  is  certain.  That  perfection  has  been 
reached  the  most  rashly  optimistic  do  not  claim.  For 
if  the  subject  is  looked  fairly  in  the  face,  all  cant  laid 
aside,  self-glorification  suppressed,  and  the  question 
put  squarely:  How  many  of  the  last  twenty  operations 
have  been  destitute  of  surprises  in  the  operative  or 
postoperative  findings? — the  honest  answer  will  shock 
our  lay  friends  and,  if  he  is  not  accustomed  to  look  at 
the  subject  from  this  point  of  view,  appall  the  operator 
himself. 

An  accurate  and  complete  diagnosis  beforehand  is 
important,  because  then  only  can  the  operation  be 
planned  and  executed  in  the  manner  which  will  give 
the  patient  the  best  chance  for  life,  conserve  blood, 
hasten  the  work,  save  tissue,  and  avert  shock.  In  the 
great  majority  of  cases  unfortunately  the  diagnosis  is 
correct  in  the  rough  only,  unsuspected  conditions  be- 
ing too  often  found.  Supposedly  benign  obstructions 
at  the  pylorus  are  found  to  be  malignant:  disease  of 
the  uterine  adnexa  is  found  much  more  serious  than 
was  anticipated,  rendering  the  operative  ditliculties 
greater  and  much  increasing  the  dangers:  sometimes, 
happily,  ovaries  and  tubes  supjxjsed  to  be  irreparably 

'  Read  before  the  Western  .Vssociation  of  Surgeons  and 
livnnecologists  at  Topeka,  Kan.,  Pecember  29.  iSo6. 


October  9,  1897] 


MEDICAL    RECORD. 


5TI 


diseased  are  found  merely  to  be  imprisoned  by  adhe- 
sions and  no  sacrifice  of  the  organs  is  demanded;  and 
very  often  after  a  carefully  planned  operation  the  ex- 
pected relief  does  not  come,  the  symptoms  not  having 
been  correctly  interpreted. 

It  seems  to  be  a  matter  of  pride  with  some,  espe- 
cially in  pelvic  disease,  to  make  their  diagnosis  from 
the  physical  e.xamination,  paying  only  slight  atten- 
tion to  the  patient's  past  history  and  present  subjec- 
tive symptoms.  The  woman  is  overshadowed  by  her 
pelvic  viscera.  Men  who  do  this  most  are  likely  to 
meet  with  many  unpleasant  surprises.  The  palpable 
lesion  is  often  the  least  part  of  the  disease. 

In  approaching  a  case  of  suspected  abdominal  dis- 
ease, it  is  necessary  to  have  more  in  mind  than  a  few 
cardinal  diagnostic  points.  Advantage  must  be  taken 
of  every  resource  which  can  be  enlisted  having  even 
a  remote  bearing  upon  the  case.  A  little  point  pre- 
viously overlooked  has  been  known  to  clear  up  an 
obscure  case  and  make  it  so  plain  as  to  occasion 
wonder  at  the  former  ditficulty.  To  be  satisfied  that 
a  case  is  one  for  operation  is  not  enough — the  merest 
tyro  can  do  that;  but  the  wide-awake  surgeon  is  con- 
tent only  when  by  careful  exclusion  his  diagnosis  has 
been  brought  down  to  an  absolute  certainty.  The 
man  who  attempts  this  always,  even  though  such  nice- 
ties of  distinction  are  often  of  no  practical  value,  will 
soon  find  that  his  operative  surprises  are  becoming 
rare. 

The  very  imperfect  and  often  misleading  histories 
obtained  from  patients  are  a  frequent  cause  of  error. 
Some  wilfully  misrepresent  by  exaggeration  or  sup- 
pression of  facts;  more  mislead  because  of  weak  pow- 
ers of  observation  or  inabilit)'  to  make  a  clear  state- 
ment. One  patient  with  slight  symptoms  will  lead  her 
physician  to  suppose  her  to  be  a  great  sufferer ;  another 
with  more  stoicism  will  make  light  of  a  desperate 
condition.  Most  of  the  chronic  cases  are  migratory 
and  do  not  remain  long  under  the  obser\-ation  of  any 
one  man.  A  new  man  is  then  "  tried,"  and  he  takes 
up  the  case  de  novo,  losing  the  benefit  of  previous  ob- 
servations. Before  he  has  been  able  to  get  the  case 
well  in  hand,  the  patient,  true  to  her  instincts,  has 
often  passed  on  to  the  next  physician. 

If  each  person's  medical  histor\-  were  made  a  matter 
of  record,  the  same  as  a  title  to  a  piece  of  real  estate, 
the  patient  always  presenting  an  abstract  when  con- 
sulting a  new  doctor,  it  would  be  a  great  aid.  The 
labor  of  such  a  system  would  be  slight  when  compared 
with  its  advantages.  No  one  would  then  think  of 
consulting  a  physician  without  presenting  a  medical 
history  as  formulated  by  previous  attendants,  and 
many  costly  blunders  would  be  thus  avoided. 

.\t  a  recent  meeting  of  the  Brooklyn  GynjEcological 
Society,  the  case  was  reported  of  a  woman  dying  of 
slow  hemorrhage  from  a  ruptured  tubal  pregnancy,  in 
which  three  prominent  gyna-cologists  had  had  no  sus- 
picion of  the  real  condition.  One  of  them  stated  that 
if  he  had  been  in  possession  of  facts  acquired  bv 
another  physician  consulted  a  short  time  before,  the 
diagnosis  would  have  been  cleared  up  and  the  woman's 
life  might  have  been  saved.  It  is  evident  how  such  a 
record  as  has  been  sugge.sted  would  have  been  of  great 
service. 

The  diagnosis  of  extra-uterine  pregnancy,  although 
sometimes  extremely  easy,  is  often  beset  with  the 
greatest  difficulties.  To  distinguish  it  from  pyosal- 
pinx  or  appendicitis  frequently  requires  the  most  care- 
ful weighing  of  evidence  on  the  part  of  the  surgeon. 
.\fter  painstaking  effort  to  reject  all  sources  of  error, 
even  then  the  scales  sometimes  tip  the  wrong  way. 
In  a  recent  case  of  my  own,  after  a  thorough  study  of 
all  the  symptoms  and  as  rigid  a  physical  examination 
as  the  condition  of  the  patient  would  permit,  I  could 
not  make  a  positive  diagnosis.     The  final   conclusion 


was  that  appendicitis  was  the  most  probable  lesion; 
a  ruptured  tubal  pregnancy  with  slow  hemorrhage, 
there  being  a  slowly  rising  temperature,  came  next  in 
probability:  and  it  was  not  possible  entirely  to  ex- 
clude pyosalpinx.  The  other  men  who  saw  the  case 
were  equally  mystified.  The  operation  revealed  the 
presence  of  slow  hemorrhage  from  a  tubal  abortion. 

Presence  of  a  surgical  lesion  of  the  kidney  has  been 
the  source  of  much  diagnostic  uncertainty,  it  being 
often  diflicult  or  impossible  to  determine  which  kid- 
ney is  diseased  or  whether  both  are  implicated.  Since 
the  cystoscope  and  ureteral  catheter  have  been  per- 
fected, the  accurate  diagnosis  of  kidney  diseases  has 
been  greatly  simplified.  In  like  manner  chemistry 
has  come  to  our  aid  in  gastric  lesions.  Only  a  begin- 
ning has  been  made  in  this  matter,  but  promise  is 
made  of  much  development  along  these  lines.  When 
it  is  possible  to  make  an  early  and  accurate  diagnosis 
of  cancer  of  the  stomach,  surgery  for  its  relief  can  be 
relied  upon  to  be  followed  by  better  results  than  the 
past  has  given. 

The  region  of  the  gall  bladder  and  ducts  is  also  of 
great  interest  to  the  abdominal  surgeon.  Here,  as 
well  as  in  some  other  regions,  some  of  the  recent  sur- 
gical work  has  been  more  brilliant  than  the  diagnosis 
has  been  refined.  It  is  yet  no  uncommon  thing  to 
explore  for  stones  in  the  gall  bladder  or  ducts,  and 
find  disease  of  the  hepatic  flexure  of  the  colon  or  can- 
cer of  the  pylorus,  and  sometimes  to  find  nothing  at 
all.  An  abnormally  long  transverse  colon,  as  pointed 
out  by  McGravv,  doubtless  figures  frequently  in  these 
cases.  As  he  states,  if  the  transverse  colon  is  too 
long  it  must  bend  up  or  down :  it  cannot  bend  up, 
therefore  it  bends  down  at  the  middle,  assuming  a  V- 
shape.  When  farces  accumulate  at  the  point  of  the 
V,  the  bowel  becomes  heavy  enough  to  put  the  hepatico- 
duodenal  ligament  upon  the  stretch  and  twist  it  suffi- 
ciently to  occlude  the  common  duct,  and  symptoms 
analogous  to  those  of  gall-stone  obstruction  result. 
McGraw  suggests  that  when  doubt  exists,  if  the  knee- 
elbow  position  relieves  the  pain,  the  symptoms  are 
due  to  an  abnormally  long  transverse  colon  and  not  to 
disease  within  the  gall  ducts.  In  all  cases  of  sus- 
pected gall  stones,  one  will  do  well  to  keep  this 
abnormality  in  mind. 

In  addition  to  the  necessity  of  making  a  fairly 
accurate  diagnosis  of  the  pathological  condition  pres- 
ent in  intra-abdominal  disease,  it  is  still  more  impor- 
tant to  determine  whether  the  symptom  complex  for 
which  the  patient  presents  himself  is  dependent  upon 
the  lesion  found.  Will  an  operation  be  followed  by 
enough  relief  to  warrant  the  operative  risk,  or  will  the 
symptoms  be  made  worse  or  remain  unchanged? 
This,  I  take  it,  is  one  of  the  most  important  questions 
with  which  the  abdominal  surgeon  has  to  deal.  A 
retroverted  adherent  uterus  sometimes  produces  severe 
symptoms:  sometimes  this  condition  exi.sts  for  years 
with  the  individual  in  robust  health.  Severe  symp- 
toms may  exist  in  a  patient  with  a  fixed  uterus,  and 
the  symptoms  he  due  entirely  to  the  condition  of  the 
uterus:  sometimes  the  uterus  has  nothing  to  do  with 
the  symptoms.  A  perfect  diagnosis  depends  more 
upon  the  proper  interpretation  of  the  symptoms  than 
upon  the  accurate  estimation  of  the  size,  position,  and 
degree  of  fixation  of  the  uterus.  And  so  it  is  with 
salpingitis,  ovaritis,  and  a  host  of  other  palpable 
lesions. 

Movable  kidney  is  very  frequent — being  present,  it 
is  said,  in  one  of  every  five  to  seven  women.  Some- 
times it  produces  symptoms;  usually  it  does  not. 
When  unpleasant  symptoms  are  present,  they  may  be 
due  to  the  movable  kidney  or  to  something  entirely 
different.  The  ability  to  make  a  sharp  distinction 
between  symptoms  due  to  movable  kidney  and  those 
due  to  other  causes,  and  the   inability  to  make  such 


512 


MEDICAL    RECORD. 


[October  9,  1897 


'distinction,  mean  all  the  difference  between  brilliant 
results  on  the  one  hand  and  the  most  bitter  disap- 
pointment on  the  other.  Many  an  operation  has  been 
performed  for  anchoring  a  movable  kidney  or  a  pro- 
lapsed uterus,  when  the  symptoms  were  due  to  general 
abdominal  ptosis,  and  of  course  the  symptoms  were 
not  relieved. 

But,  do  the  best  one  can,  it  often  happens  that  a 
full  and  accurate  diagnosis  is  impossible  until  the 
operation  is  in  progress,  and  here  there  are  also  many 
vexatious  questions.  In  a  given  case  of  gall-stone 
disease,  will  a  simple  cholecystotomy  be  best,  or  a 
cholecystenterostomy,  or  is  the  trouble  due  to  the  ball- 
valve  action  of  a  stone  in  the  common  duct,  which  can 
be  removed  by  an  incision  into  the  duct  followed  by 
suture  and  drainage?  Must  this  tube  and  ovary  be 
sacrificed,  or  will  the  patient's  best  interest  be  sub- 
served by  puncturing  the  cysts  of  the  ovary,  breaking 
up  adhesions,  and  straightening  the  tube,  and  perhaps 
anchoring  in  a  new  position?  Should  this  suppurat- 
ing kidney  be  removed,  or  is  it  worth  while  to  incise 
and  drain  ?  These  and  many  other  questions  are  con- 
stantly coming  up  during  the  progress  of  the  majority 
of  abdominal  sections,  and  the  operator's  mind  must 
be  both  swift  and  accurate,  else  he  will  be  guilty  of 
many  surgical  crimes. 

In  conclusion  and  by  way  of  summary,  it  is  desired 
to  urge : 

1.  Great  care  in  getting  at  an  exact  anatomical  di- 
agnosis, calling  in  every  resource  which  can  have  the 
remotest  bearing  upon  the  case,  whether  it  be  in  the 
patient's  history,  the  tactile  examination,  the  use  of 
chemistr)',  physics,  or  instruments  of  precision. 

2.  To  work  out  carefully  the  relationship  between 
the  palpable  lesion  found  and  the  symptom  complex. 
Is  it  a  relationship  of  cause  and  effect,  or  a  simple 
coincidence?  Everything  depends  upon  the  correct 
interpretation  of  the  symptoms. 

3.  When  the  operation  is  in  progress,  swiftly  and 
correctly  to  weigh  the  evidence  as  to  whether  the 
results  will  be  better  with  sacrifice  of  an  entire  organ, 
or  will  it  be  possible  to  preserve  it  in  whole  or  in  part. 
Is  it  better  to  proceed  with  the  operation,  or  will  the 
patient's  best  interests  be  protected  by  closing  the 
abdomen,  leaving  the  condition  unchanged? 


WHAT     ARE     THE     MUSC^     VOLITANTES? 
AN    ENTOPTICAL   STUDY. 


By   frank   p.    PR.VTT,    M.D. 


The  histolog)-  of  the  vitreous  body  is  a  subject  upon 
■which  the  leading  authorities  differ.  This  is,  no 
doubt,  due  to  the  extreme  difficulty  experienced  in 
preparing  sections  for  microscopical  study.  In  fact, 
the  possible  changes  in  structure,  due  to  hardening 
and  preservative  fluids,  have  entered  largely  into  the 
consideration  and  modified  the  conclusions  of  many 
investigators.  Whether  the  vitreous  has  an  inclosing 
hyaloid  membrane  or  not,  whether  the  more  or  less 
fluid  substance  proper  is  su.stained  in  a  transparent 
reticulum  of  fibres,  or  distinct  membranous  walls  in- 
close it;  whether  three  distinct  cells  are  found,  or 
whether  they  are  merely  different  forms  of  the 
same  cell  or  leucocyte ;  whether  it  has  distinct  nutri- 
tive vessels  or  not — are  all  questions  which  have 
ardent  advocates  on  one  side  or  the  other. 

Probably  the  latest  and  most  widely  accepted  views 
are  as  follows :  The  vitreous  is  a  clear,  more  or  less  fluid 
substance,  inclosed  in  a  delicate,  structureless  hyaloid 
membrane;  throughout  its  substance  runs  an  equally 
delicate  reticulum,  or  felted  work  of  fibres;  its  central 
canal  or  lymph  channel  begins  at  the  papilla  of  the 


optic  nerve,  and  extends  to  the  posterior  pole  of  the 
lens.  The  matured  vitreous  contains  no  vessels,  but 
obtains  its  nutrition  from  the  surrounding  structures, 
principally  the  ciliarj- vessels.  Retzius  says:  "Under 
high  amplification,  the  entire  tissue  (vitreous  sub- 
stance) is  resolved  into  a  feltwork  of  exceptional  in- 
tricacy, composed  of  the  finest  fibres,  which  cross  one 
another  in  various  directions  and  here  and  there  join 
in  narrow  nodal  points,  without,  however,  constituting 
network."  Retzius  has  also  observed  peculiar  glis- 
tening spherules  or  granules  in  many  of  the  fibres. 
He  is  in  doubt  as  to  their  nature.  Piersoll  believes 
that  not  only  are  these  spherules  due  to  the  action  of 
the  reagents  used,  but  that  some  at  least  of  the 
densely  felted  delicate  fibrilla;  seen  in  certain  prep- 
arations are  also  due  to  the  same  cause. 

Retzius  rejects  as  untenable  the  supposition  that 
"  the  presence  of  the  spherules  is  attributable  to  the 
action  ■  of  reagents  employed,  since  the  intervening 
ground  substance  remains  homogeneous."  It  is-  the 
purpose  of  the  writer  to  offer  evidence,  gained  through 
an  entoptical  study  of  the  so-called  muscae  voli- 
tantes,  in  support  of  the  statement  that  a  "  feltwork 
of  exceptional  intricacy"'  does  exist,  but  that  this  ap- 
pearance of  the  fibre,  so  aptly  described  by  Retzius,  is 
largely  due  to  post-mortem  changes;  that  the  spher- 
ules noted  by  him  in  the  so-called  fibres  are  not  due 
to  reagents  employed,  as  claimed  by  Piersoll,  but  are 
clearly  histological  elements  of  the  vitreous;  that  the 
muscEe  volitantes,  often  described  as  resembling  a 
string  of  pearlS;  when  seen  entoptically  under  proper 
conditions  resolve  themselves  into  what  appear  to 
be  vessels  with  well-defined  walls,  which  contain 
within  their  lumen  corpuscles  or  spherules;  that  the 
general  arrangement  of  these  vessels  answers  to  the 
description  of  the  "felted  fibres"  of  Virchow,  Henle, 
and  Retzius;  that  if  these  are  vessels  at  all,  which 
seems  probable,  they  are  the  lymphatic  vessels  of  the 
vitreous  substance. 

Most  writers,  when  describing  the  macular  region 
of  the  retina,  point  out  how  the  vascular  arrangement 
of  this  region  may  be  seen  entoptically.  As  this 
image  will  be  the  starting-point  in  our  investigations, 
we  will  consider  it  first.  From  the  trial  case  take  the 
metallic  disc  with  central  aperture,  apply  the  disc  to 
the  right  eye,  so  that  the  puncture  will  be  opposite  the 
pupil;  look  steadily  at  the  blue  sky,  or  a  luminous 
cloud,  while  moving  the  disc  rapidly  from  side  to 
side.  Presently  a  distinct  picture  of  the  fovea  cen- 
tralis with  its  surrounding  network  of  capillaries  will 
be  seen.  If  the  movements  are  skilfully  made,  even 
the  beginning  venous  radicles  in  the  immediate  neigh- 
borhood may  be  clearly  made  out.  The  veins  are 
dark,  the  rest  of  the  picture  has  a  bluish  metallic 
lustre.  No  capillaries  appear  over  the  fovea,  but  its 
surface  is  covered  with  exceedingly  fine,  apparently 
rectangular  tracings,  resembling  closely  the  delicate 
tracings  on  a  diatome.  These  lines  appear  wavy. 
This  is  due,  however,  to  the  motion  of  the  disc,  as 
the  wave  motion  changes  its  directi,on  whenever  the 
motion  of  the  disc  is  changed.  When  a  circular  mo- 
tion is  given  to  the  disc,  the  fovea  region  shows  a  tes- 
sellated arrangement,  much  as- it  would  appear  if  we 
were  viewing  the  surface  of  the  cones  of  this  region  in 
a  microscopical  section. 

As  stated  in  a  former  paper,'  the  cones  offer  little  or 
no  obstruction  to  the  passage  of  unchanged  light 
vibrations,  which  pass  on  through  ihein  as  tlirough  the 
other  histological  structure,  and,  like  the  latter,  cast 
their  shadows  upon  the  pigmentary  epithelial  layer. 
It  thus  appears  probable  that  we  view  here  the  image 
of  the  cone  cells.     If  these  tracings  on  the  surface  of 

'  rv./^  Medical  Record.  dateiSg-,  "  What  are  the  Functions 
of  the  Rods  and  Cones  and  the  Pigment  Epithelium  Layer  of  the 
Human  Retina  ?" 


October  9,  1897] 


MEDICAL    RECORD. 


513 


the  fovea  have  been  hitherto  described,  it  has  escapied 
the  notice  of  the  writer.  The  capillary  network  about 
the  fovea  greatly  resembles  a  finely  spun  spider  web 
with  its  centre  removed. 

Now  stop  the  motion  of  the  disc  and  the  image 
will  immediately  disappear,  but  when  the  axis  of 
vision  is  suddenly  changed  and  again  fixed  on  the 
cloud  fine  fibrillary  particles  containing  bright  spher- 
ules v.ill  be  seen,  gradually  settling  do\vn  in  the 
field.  When  these  are  discovered,  renew  the  motion 
of  the  disc;  the  retinal  image  will  again  appear,  and 
between  it  and  the  obser\-er  will  be  noticed  the  float- 
ing fibrillfE.  It  thus  becomes  evident  that  they  are 
not  in  the  retina;  therefore,  they  are  internal  to  it, 
and,  as  they  are  capable  of  motion  within  certain  well- 
defined  limits,  as  will  be  presently  shown,  they  must 
lie  in  the  vitreous. 

For  purposes  of  more  accurate  study  of  these  so- 
called  fibrilljE  or  muscfe.  we  have  recourse  to  the  mi- 
croscof>e,  not  because  of  any  amplification  to  be  de- 
rived therefrom,  but  for  its  convenience  in  regulating 
the  amount  and  quality  of  light  admitted  and  convey- 
ing the  rays  to  a  point  close  to  the  cornea.  Use  a 
one-inch  eyepiece  and  either  a  one-twelfth-inch  ob- 
jective or  the  centrally  perforated  metallic  disc:  they 
answer  equally  well,  as  the  object  is  to  admit  divergent 
rays  from  a  luminous  pwint  situated  close  to  the  cornea. 
The  larger  the  opening  in  the  disc,  the  less  distinct  the 
image,  so  that,  if  no  disc  or  objective  is  placed  over 
the  farther  end  of  the  tube,  the  field  appears  compara- 
tively clear.  No  fibril lae  are  discovered.  A  strong 
steady  light  must  be  used;  artificial  light  is,  perhaps, 
preferable.  WTien  thus  viewed,  it  will  be  seen  that 
the  floating  particles,  which  at  first  resembled  a  string 
of  pearls  or  fibrillre  containing  spherules,  resolve 
themselves  into  what  appear  to  be  distinct  vessels, 
with  well-defined  walls,  probably  composed  of  in- 
definite protoplasmic  substance.  In  one  of  the  largei 
vessels  seen  by  the  wTiter,  the  walls  showed  a  thick- 
ness of  about  one-half  the  diameter  of  the  contained 
corpuscles.  This  was  shown  by  two  indistinct  lines 
running  parallel  with  the  axis  of  the  vessel,  the  inter- 
vening substance  being  of  slightly  difi'erent  refractive 
inde.K  than  the  vitreous  fluid  TFigs.  6  and  7).  Most 
of  the  vessels  do  not  show  this  thickness  of  walls,  a 
single  dark  line  alone  being  seen.  The  calibre  of 
the  vessels  is  of  sufficient  size  to  accommodate  tlic 
diameter  of  a  single  cell:  therefore  the  cells  fill  tlie 
vessel  in  one  layer.  The  cells  in  each  vessel  appear 
to  be  all  of  the  same  size,  but  some  are  bright  and 
stand  out  prominently  in  the  field,  sometimes  two  or 
more  lying  in  apposition:  then  a  space  equal  to  the 
diameter  of  from  two  to  twelve  cells  may  inter%'ene: 
this  space  being  filled  v.  ith  corpuscles  much  dimmer  in 
outline  but  of  the  same  character.  After  careful  and 
repeated  observations,  it  cannot  be  definitely  stated 
that  the  cells  have  either  active  or  passive  motion. 
This  may  be  due  to  the  fact  that  these  vessels  cannot 
be  fi.xed,  but  must  be  studied  by  indirect  vision.  The 
vessels  seem  to  be  perfectly  flexible,  bend  freely  in 
all  directions,  the  bend  occurring  where  the  corpuscles 
touch,  and  in  this  resemble  a  .string  of  pearls.  The 
fieM  impresses  the  observer  as  being  a  transparent 
fluid  mass  of  great  depth,  throughout  which  float  the 
vessels,  closely  corresponding  to  the  description  by 
Retzius  of  the  felted  fibrillar)-  arrangement  seen  in 
prepared  specimens.  F.special'.y  is  this  true  after 
violently  agitating  the  intra-ocular  contents  by  rapid 
movements  of  the  eyeball,  and  then  fixing  on  a  certain 
spot  in  the  field.  The  first  impression  is  that  the 
vessels  are  perfectly  free  in  the  vitreous,  crossing,  in- 
terlacing, and  branching  in  all  directions  and  changing 
their  position  with  every  movement  of  the  eye.  On 
closer  e.xamination,  however,  it  will  be  seen  that 
while   the    motion    is  apparently   free  each  vessel   is 


limited  to  a  certain  and  definite  portion  of  the  field, 
so  that  it  can  be  studied  repeatedly  after  an  interval  of 
days  or  weeks.  The  sensation  of  depth  is  given  by  a 
vessel  passing  in  a  more  or  less  straight  course  across 
the  field  from  above  downward  to  about  the  middle 
of  the  lower  half,  then  tirming  upon  itself,  passing 
and  repassing  in  a  tortuous  manner  across  the  main 
vessel,  but  diverging  from  it  toward  the  obser\-er  or 
by  the  principal  vessels  in  the  field,  passing  in  front 
of  or  behind  others  that  grow  dimmer  as  they  recede. 
Here  and  there  a  bright  corpuscle  will  stand  out 
clearly  in  the  field,  giving  the  impression  that  it  is 
outside  of  the  vessel,  but  if  care  is  given  to  the  exam- 
ination the  hazy  outline  of  the  inclosing  vessel  will 
usually  be  made  out.  These  corpuscles  always  move 
with  the  other  vessels  and  cell  elements,  and  reappear 
repeatedly  in  the  same  part  of  the  field.  The  wTiter 
has  discoverd  no  cells  outside  the  vessel  walls.  The 
vessels  do  not  branch  in  the  field,  nor,  as  far  as  can 
be  made  out,  join  a  nodal  point. 

Fig.  1  represents  the  general  direction  of  the 
vessels  at  rest,  with  the  head  in  the  normal  position 
and  the  eye  fixed  on  the  dot  near  the  upper  tangent. 
After  a  person  has  looked  rapidly  down,  then  up,  then 
fixed  the  dot,  the  vessels  after  a  short  inter%-al  move 
rapidly  downward,  then  upward,  the  latter  movement 
continuing  some  time  after  the  eye  is  fixed;  then  they 


J 


^top  for  an  instant  before  again  sinking  rapidly  down- 
ward in  the  field,  the  motion  gradually  becoming  slower 
until  the  vessels  assume  the  general  appearance  here 
represented,  remaining  practically  stationary  while 
the  eyeball  is  absolutely  fixed.  Any  excursion  of  the 
visual  axis  toward  a  vessel  causes  it  immediately  to 
recede,  all  the  other  vessels  moving  in  the  same  direc- 
tion. It  will  be  seen  that  the  vessels  are  arranged  in 
parallel  lines,  with  intervening  clear  spaces  apparently 
from  two  to  four  millimetres  wide.  Several  vessels, 
however,  can  be  seen  occupying  the  space  here  repre- 
sented by  one  vessel,  but  they  are  at  dift'erent  depths 
in  the  vitreous,  and  they  dimly  cross  and  recross  in 
front  or  back  of  the  one  shown  here.  If  the  head  is 
now  turned  sideways,  so  that  the  outer  angle  of  the 
right  eye  corresponds  to  the  upper  part  of  the  field, 
the  vessels  gradually  change  their  position,  first  appear- 
ing mixed  in  all  directions,  then  bundles  appearing  at 
different  levels,  finally  the  vessels  gradually  straight- 
ening out  and  assuming  much  the  same  arrangement 
as  shown  in  Fig.  i. 

Fig.  2  represents  a  general  mix-up  after  violent  agi- 
tation of  the  eyeball  and  fixation  on  the  central  dot. 

Figs.  3,  4,  and  5  show  a  part  of  a  vessel  that  was 
studied  several  hours  with  reference  to  the  position  of 
the  bright  corpuscles  represented.  No  apparent 
change  could  be  discovered.  Changes  in  the  shape 
and  relation  of  the  vessels,  however,  are  evident. 

Figs.  6  and  7  show  the  appearance  of  a  single  loop 
observed  at  inten,'als  during  tliree  weeks.  The  cor- 
puscles have  nearly  the  same  relative  positions,  but 
what  appeared  in  Fig.  6  to  be  a  loop  with  blind  ends 
now  appears  continued  on  in  the  usual  form  until  it 
fades  away  in  the  distance. 

Figs.  8,  9,  10,  and  1 1  show  the  behavior  of  a  single 
vessel  when  the  visual  axis  is  moved,  first,  down ; 
second,  up;    third,  right:  fourth,    left.      The  up-and- 


514 


MEDICAL    RECORD. 


[October  9,  1897 


down  movements  are  accomplished  by  changes  and 
contortions  of  the  loop,  all  taking  place  in  a  perpen- 
dicular direction.  The  lengthening  of  the  vessel  is  at 
the  expense  of  the  loop,  and  vice  versa.  The  main 
part  of  the  vessel  otherwise  changes  its  position  verj' 
slightly,  moving  en  masse  in  the  field,  with  its  course 
tortuous  or  straight  according  to  the  movements  of 
the  eye.  In  the  motion  to  the  right,  the  loop  passes 
rapidly  to  the  right  and  is  separated  widely  from  the 
tnmk.'  The  opposite  holds  true  of  motion  to  the  left. 
The  loop  passes  and  repasses  between  the  observer 
and  the  main  part  of  the  vessel  and  its  elements  appear 
less  amplified  but  more  distinct,  thus  emphasizing  the 
sensation  of  depth. 

Now  discontinue  further  consideration  of  these 
vessels  for  the  moment,  change  the  eyepiece  from  a 
one  to  a  one-half  inch,  move  the  visual  axis  slowly 
up  and  down,  and  you  will  observe  another  system  or 
layer  of  vessels  that  differ  in  no  way  from  those  first 
described,  except  that  they  are  dimmer  in  outline,  of 


larger  calibre,  contain  larger  corpuscles,  and  lie  closer 
to  the  light;  that  is,  beyond  the  vessels  first  described 
and  between  them  and  the  light.  The  general  move- 
ment of  these  vessels,  moreover,  is  opposite  to  that 
first  described,  so  that  when  the  eyeball  is  turned 
upward  the  vessels  move  rapidly  downward  and  then 
ascend  slowly  toward  their  original  position.  This 
behavior  of  the  two  layers  of  vessels  shows  that  the 
former  lie  in  the  posterior  and  the  latter  in  tlie  anterior 
part  of  the  vitreous.  Again  resort  to  the  one-inch 
eyepiece  and  place  the  eye  about  one  inch  from  it. 
Then  will  be  observed  another  image  that  diflers  en- 
tirely from  those  already  described.  It  consists  of  an 
irregular  stellate  arrangement  of  fibres  or  markings 
that  have  no  resemblance  to  vessels,  and  which  contain 
no  corpuscular  bodies. 

Fig.  12.  This  image  is  stationary  and  lies  between 
the  light  and  the  last-described  vessels.  This  the 
writer  believes  to  be  the  image  of  the  lens  itself, 
seen  entoptically,  showing  very  accurately  the  arrange- 
ment of  its  various  fibres  or  layers. 

We  have  thus  seen  and  studied  the  following  struc- 
tures : 

I  St.  Three  layers  of  the  retina:  \a)  the  fovea  with 
the  image  of  the  cones;  {h)  the  capillaries;  (c)  the 
veins. 

2d.  A  layer  of  vessels  in  the  posterior  part  of  the 
x'itreous,  lying  between  the  light  and  the  observer  and 
internal  to  the  retina. 


3d.  A  layer  of  vessels  in  the  anterior  part  of  the 
vitreous,  lying  between  the  light  and  the  vessels  men- 
tioned above. 

4th.  The  image  of  the  lens  lying  between  No.  3 
and  the  light.  Finally,  by  moving  the  eye  back  from 
the  eyepiece  a  little  and  gently  opening  and  closing 
the  lids,  floating  particles  of  dust  can  be  noted  on  the 
surface  of  the  cornea,  which  with  each  movement  of 
the  lids  move  between  the  lens  and  the  light. 

Are  these  floating  structures  containing  corpuscles 
vessels?  If  so,  they  must  be  one  of  two  kinds,  blood- 
vessels or  lymphatics.  That  they  are  not  blood- 
vessels is  quite  evident  from  the  one  fact  that  no 
circulation  can  be  definitely  discerned.  If  they  are 
lymphatics,  they  are  specialized  to  the  vitreous  and  dif- 
fer greatly  from  the  beginning  radicals  of  this  system 
in  the  more  solid  tissues  of  the  body.  Indeed  this 
might  be  expected  of  vessels  that  float  more  or  less 
freely  in  the  body  they  are  designed  to  nourish.. 
Blood  moves  in  the  capillaries  about  six  or  nine  milli- 
metres per  second.  This  is  es- 
timated to  be  several  hundred 
times  slower  than  in  the  arteries. 
Lymph,  in  the  largest  vessels, 
moves  about  4.5  mm.  per  second 
If  it  can  be  said  that  this  stream' 
is  several  hundred  times  faster 
than  in  the  lymphatic  capillaries, 
this,  in  connection  with  the  fact 
that  the  vessels  are  usually  mov- 
ing and  must  be  studied  by  in- 
direct vision,  may  account  for 
the  statement  that  no  corpuscu- 
lar movements  can  be  definitely 
noted.  The  blood  after  death 
largely  leaves  the  capillaries. 
This  no  doubt  holds  true  of  the 
lymph  also,  and  especially  here 
in  the  eye  as  the  blood  pressure 
is  removed  and  the  tension  of  the  eye  is  diminished, 
which  condition  would  favor  the  transudation  of  both 
the  lymph  plasma  and  the  corpuscles,  it  being  prob- 
able that  in  the  living  normal  vessels  the  leucocytes 
do  not  undergo  amceboid  motion. 

The  writer  has  endeavored  to  demonstrate  these 
vessels,  with  their  contained  corpuscles,  in  freshly 
removed  eyes,  by  the  usual  methods  of  injecting 
lymphatic  capillaries,  but  thus  far  with  negative  re- 
sults. If  these  observations  are  correct,  the  follow- 
ing conclusions  may  be  deduced  from  them : 

1st.  That  the  so-called  muscae  volitantes  are  normal 
to  ever}-  eye,  and  become  annoying  only  when  there  is 
sufticient  bunching  of  vessels  to  offer  noticeable  ob- 
struction to  light  rays. 

2d.  That  they  are  not  due,  therefore,  to  hemorrhage, 
diseases  of  the  retina,  choroid,  or  ciliary  body. 

3d.  That  the  felted  fibrillar  containing  bright 
spherules  described  by  Retzius  and  others  are  in  a 
measure  due  to  post-mortem  changes,  the  ante-mortem 
normal  condition  being  that  above  described. 

4th.  That  in  all  probability  they  are  the  lymphatic 
capillaries  of  the  vitreous. 

3th.  That  this  feltwork  cif  lymphatic  capillaries 
sustains  the  semifluid  vitreous  substance. 

It  may  be  asked:  How  is  it  possible  to  demonstrate 
vessel  walls  and  corpuscles  in  the  vitreous,  when  the 
same  cannot  be  demonstrated  in  the  retina?  When 
a  persons  looks  at  a  pencil,  light  radiates  from  every 
point  on  the  pencil,  and  the  rays,  focussed  upon  the  pig- 
ment epitlielial  layer  of  the  retina,  fonn  a  true  image. 
The  size  of  this  image  is  inversely  proportioned  to  the 
distance  of  the  object  from  the  eye.  Thus,  the  farther 
away  the  pencil  is,  the  smaller  the  image,  and  vue 
versa.  In  viewing  an  object  entoptically,  however,  a 
different  principle  is   involved.     Xo    light   emanates 


I 


October  9,  1897] 


MEDICAL    RECORD. 


515 


from  the  object  itself,  bin  it  comes  from  a  luminous 
point  inside  the  principal  anterior  focus.  The  rays 
that  proceed  from  this  point,  therefore,  are  too  diver- 
gent to  be  brought  to  a  focus  beyond  the  cornea,  but 
still  continue  diverging  to  infinity.  Therefore  any 
object  lying  between  the  percipient  element  of  the 
retina  and  the  source  of  light  will  obstruct  these  rays, 
and  instead  of  a  true  image  an  upright  shadow  will 
fall  upon  the  retina.  The  closer  the  object  to  the 
light,  the  greater  the  shadow;  the  nearer  to  the  retina, 
the  smaller  the  shadow.  The  vessels  and  corpuscles 
in  the  anterior  part  of  the  vitreous  should,  therefore, 
be  amplified  in  the  shadow,  while  those  that  lie  closer 
to  the  retina  should  be  less  so.  The  entoptical  study 
of  the  ocular  tissues  verities  these  statements.     Fig.  13 


illustrates  the  proposition.  Let  A  represent  a 
schematic  eye  with  a  single  refracting  substance;  B 
and  B  the  visual  axis — B  the  near  point,  B'  the  prin- 
cipal posterior  focus.  Light  rays  emanating  from 
B  will,  by  the  aid  of  all  the  powers  of  accommoda- 
tion, be  focussed  at  B' .  Let  the  light  be  brought  grad- 
ually closer  to  the  cornea,  and  their  point  of  reunion 
recedes  farther  from  the  principal  posterior  focus 
\mtil  a  point  is  reached  where  the  rays  are  practicallv 
parallel,  h.  The  posterior  focus  will  then  be  infinitv. 
The  anterior  luminous  point,  B" ,  is  called  the  principal 
anterior  focus.  Xow  bring  the  light  still  nearer  the 
cornea  at  C.  The  incident  rays  now  become  so  diver- 
gent that  the  refracted  rays  c  do  not  reach  parallelism, 
but  continue  diverging  to  infinit)".  Any  object,  there- 
fore, that  lies  between  the  light  and  the  retina  will 
cast  a  shadow  inversely  proportionate  to  the  distance 
of  the  object  from  the  light.  The  nearer  to  the  light, 
the  greater  the  shadow  on  the  retina  and  rice  'ursa. 

The  difference  in  brightness  of  the  corpuscles  is 
probably  due  to  the  great  flexibility  of  the  vessel, 
allowing  some  corpuscles  in  a  single  vessel  to  be 
nearer  and  others  farther  from  the  retina.  If  the 
whole  vessel  were  absolutely  on  the  same  level,  we 
should  expect  the  corpuscles  to  show  equally  well. 


A    SUGGESTION    IN'    THE    TREATMENT    OF 
DIABETES.' 

Jiv  G.  \V.  .MURDOCK,  .M.D.. 

COLD  SPRIXG,  K.  Y. 

I  MAY  state  in  the  beginning  that  in  presenting,  as  I 
intend  to  do,  some  brief  notes  of  a  case  of  diabetes  I 
am  fully  aware  of  the  liabilitj-  of  error  in  making  de- 
ductions from  the  result  of  a  single  case.  Knowing, 
however,  as  we  all  do,  the  e.xtraordinary  fatalit}'  of 
this  disease  in  the  young  subject,  I  think  that  any 
method  which  will  arrest  it  in  even  one  such  case  is 
at  least  worth  consideration. 

To  dwell  a  moment  upon  the  average  prognosis: 
Pavy  says  that  he  has  not  personally  seen  the  recovery 
of  a  patient  under  twenty  j'ears  of  age.  Lauder  Krunton 
says:  "When  the  disease  occurs  in  patients  under  die 
age  of  twenty,  few,  if  any,  recover."  Dr.  Purdy  says : 
"Under  twenty  years  of  age  the  disease  is  very  fatal. 

'  Read  at  the  thirteenth  annual  meeting  of  the  Fifth  District 
Branch  of  the  New  York  State  Medical  Association,  held  in 
Brookljm  on  May  25,  1897. 


Indeed,  few  recoveries  are  recorded.''  Man}-  other 
authors  might  be  quoted  to  the  same  effect. 

The  salient  points  of  the  case  that  I  wish  to  present 
are  as  follows:  L'pon  June  26,  1896,  I  was  consulted 
by  a  lad  of  nineteen,  who  stated  that  for  some  weeks 
he  had  noticed  that  he  was  passing  too  much  urine. 
He  considered  himself  strong,  had  always  a  great  ap- 
petite, and  was  a  large  meat  eater.  He  had  been 
imder  my  care  before  with  a  troublesome  dermatitis, 
and  I  had  foimd  it  necessan,-  to  cut  down  his  supply 
of  meat  verj-  largely  before  I  could  cure  it.  I  found 
that  he  was  passing  about  six  pints  of  urine  daily. 
The  first  specimen  gave  a  specilic  gravity  of  1.040 
and  was  loaded  with  sugai.  He  had  lost  a  brother 
with  diabetes,  at  nearly  his  own  age,  which  added,  if 
it  were  possible  to  add  anjthing,  to  the  gravity  of  his 
case. 

I  will  not  enumerate  the  details  of  treatment  during 
the  next  three  months.  I  did  what  is  ordinarily  done. 
'  I  put  him  on  the  diabetic  diet,  and  did  my  best,  as  we 
generally  do,  to  arrange  a  sufficient  variety,  so  that  he 
should  have  enough  to  eat,  such  as  it  was.  I  tried  one 
after  another,  alone  or  in  combination,  many  of  the 
best-known  medicines,  and  the  result  was  just  about  as 
it  usually  is  in  these  cases.  His  urine  was  diminished 
in  quantit)-,  and  the  specific  gravity  fell  to  an  average 
of  about  1.302,  but  the  sugar  was  always  to  be  found, 
and  he  was  evidently  losing  ground  in  spite  of  treat- 
ment— losing  in  weight,  in  strength,  and  in  ambition. 
At  that  time  I  had  privately  little  hope  of  any  but  a 
fatal  termination,  and  I  then  determined  upon  a  radi- 
cal change  of  treatment  in  some  way.  While  looking 
up  the  literature  of  the  subject  in  search  of  new  ideas, 
I  was  struck  by  a  passage  in  Dr.  Purdy's  monograph, 
which  I  will  quote : 

■■  The  beneficial  effects  of  temperate  eating  in  dia- 
betes were  prominently  illustrated  during  the  siege  of 
Paris,  as  Bouchardat  tells  us  that  sugar  entirely  dis- 
appeared from  the  urine  of  diabetics,  in  whom  up  to 
that  time  it  had  persisted,  even  although  they  had 
been  living  on  a  carefully  regulated  diet" 

Dr.  Purdy  accompanies  this  with  some  remarks  on 
the  evident  value  of  temperate  eating,  but  seems  to  me 
hardl)-  to  follow  the  proposition  out  to  its  logical  con- 
clusion. I  reasoned  that  if  semistarvation  did  such 
good,  why  not  adopt  it  in  practice?  Instead  of  tn.ing 
to  find  things  that  our  patients  can  eat  freely,  why  not 
cut  the  supply  down  to  the  strict  necessities  of  the 
system?  Acting  upon  this,  I  reduced  my  patient's 
diet  list  thirty-three  per  cent,  at  one  stroke,  without 
changing  its  qualit)-  or  giving  any  new  medicines. 
This  was  upon  September  24,  1896,  and  it  was  fol- 
lowed by  immediate  improvement.  In  four  days  the 
urine  became  for  the  first  time  free  from  sugar,  and  it 
remained  so  for  two  weeks.  Frequent  slight  relapses 
occurred,  however,  always  traceable  to  imprudence  in 
eating,  until  Januar}-  i,  1S97,  when  I  made  a  still 
greater  reduction  in  his  allowance  of  food  and  brought 
him  down  to  the  point  of  being  ravenously  hungry- 
pretty"  much  all  the  time.  L'nder  this  regimen,  im- 
provement has  been  steady  and  great.  Sugar  dis- 
appeared at  once,  and  has  reappeared  but  twice  since 
for  brief  inter\-als,  each  time  being  due  to  overeating. 
He  lost  a  few  poimds  in  weight  at  first,  under  the  re- 
duced food  supply,  but  has  now  regained  it  and  ap- 
pears as  well  as  ever.  His  appetite  is  verj-  keen,  but 
it  is  not  the  insatiable  one  characteristic  of  the  dis- 
ease, and  he  has  now  no  unusual  thirst.  He  passes 
now  about  forty  ounces  daily;  specific  gravity.  1.020 
to  1.028. 

How  long  this  regimen  will  have  to  be  continued  I 
cannot  tell,  but  probably  a  long  time,  with  very  cau- 
tious trials  of  more  food.  He  is  now  allowed  twelve 
ounces  of  meat  daily,  and  six  ounces  of  toasted  white 
bread,  with  a  small  amount  of  selected  vegetables  and 


5i6 


MEDICAL    RECORD. 


[October  9,  1897 


fruits.  He  is  taking  some  medicine,  but  rather  as  a 
placebo,  and  none  tiiat  I  had  not  given  him  before 
without  notable  result.  Perhaps  it  will  not  be  easy 
to  carry  this  treatment  out  in  every  case,  but  if  a  young 
fellow  clearly  understands  what  depends  upon  it  he 
will  generally  go  through  it  pretty  faithfully.  My 
experience  is  that  the  more  things  we  give  our  pa- 
tients to  do  and  to  take,  the  more  highly  they  esteem 
us. 

I  conclude  then  that  the  regulation  of  food  with  re- 
spect to  quality  only  is  not  enough  in  diabetes.  It 
seems  to  me  that  a  diabetic's  digestive  and  assimila- 
tive apparatus  may  be  roughly  compared  to  a  mill  which 
from  some  defect  will  grind  certain  kinds  of  grain 
better  than  others,  but  will  grind  well  only  a  small 
quantity  of  any  kind,  and  clogs  up  if  it  is  fed  too 
rapidly.  If  this  reasoning  is  correct,  we  should,  as  I 
have  said  before,  select  the  most  favorable  kinds  of 
food,  and  then  limit  the  supply  to  near  the  lowest 
point  possible.  It  goes  without  saying  that  this  doc- 
trine will  not  be  universally  accepted.  I  saw  an  arti- 
cle in  a  prominent  journal  a  few  days  ago,  in  which 
the  writer  argued  against  any  restriction  in  diet,  aver- 
ring that  it  was  useless,  and  therefore  unwise.  This 
is  only  one  more  illustration  of  the  differences  of 
opinion  which  men  with  practically  the  same  sources 
of  information  will  hold.  I  regret  that  I  can  re- 
port only  a  single  case,  but  it  chances  to  be  the  only 
one  that  has  been  under  my  personal  care  since  adopt- 
ing this  line  of  treatment.  Whether  it  would  be  suc- 
cessful in  diabetes  of  advanced  life  I  cannot  say.  I 
somewhat  doubt  if  it  would  be  so,  but  as  the  disease 
is  then  less  fatal  it  does  not  so  much  matter.  This 
case  is  still  under  treatment  and  observation,  but  I 
see  no  reason  now  why  it  should  not  go  on  to  full 
recovery,  and  I  have  thought  it  worth  presenting,  even 
if  incomplete. 

RHINITIS  ATROPHICA  FCETIDANS  IN  ITS 
RELATION  TO  DISEASES  OF  THE  ACCES- 
SORY  SINUSES.' 

Uy    THOMAS    J.    HARRIS,    M.D., 


Of  the  numerous  forms  of  disease  which  present 
themselves  to  us  as  specialists,  none  is  more  annoy- 
ing in  its  symptoms  or  more  baffling  in  its  results  as 
regards  complete  cure  than  that  form  known  to  us  as 
ozaena.  Discussion  of  its  true  nature  has  engaged  the 
attention  of  the  best  rhinologists  for  many  years,  with- 
out any  settlement  of  the  vexatious  question.  Nor  do 
I  come  this  evening  with  any  idea  of  offering  a  settle- 
ment, nor,  indeed,  can  I  lay  claim  to  do  more  in 
what  is  to  follow  than  to  state  briefly  tlie  results  of 
some  of  the  more  recent  investigations  on  this  subject. 
This  paper  will  consist  largely  of  a  statement  of  the 
views  held  by  Ludwig  Griinwald." 

At  the  outset  a  clear  understanding  of  what  is  to- 
day regarded  as  oza;na  is  in  order.  Ozaena  may  be 
defined  as  a  peculiar  individual  disease  of  the  nose, 
characterized  by  a  chronic  course  and  by  the  three 
symptoms  of  atrophy  of  tlie  mucous  membrane  as  well 
as  of  bone,  secretion  forming  in  crusts,  and  odor. 

The  common  view,  then,  is  one  of  an  individual 
disease.  This  Griinwald  strongly  combats.  He  first 
states  the  inconsistencies  in  this  theory.  We  find, 
first,  conditions  of  atrophy  and  secretion,  but  without 
odor.  This  difficulty  has  been  met  by  describing  a 
disease,  "rhinitis  atrophica  sine  fcetore."  Then  it 
is  the  experience  of  every  gentleman  present  to  meet 

'  Keail  before  the  section  on  laryngology  on  the  New  York 
Academy  of  Medicine,  M.-iy  26,  1897. 

* "  Die  Lehrc  von  N.iseneiterungen."  page  41  <■'  ^'Y- 


with  cases  presenting  hypertrophy  in  certain  spots  next 
to  well-defined  atrophy.  This  is  commonly  met  by 
the  theory  of  B.  Frankel,  that  a  condition  of  general 
hypertrophy  has  at  first  existed.  A  distinguished 
member  of  the  section  has,  however,  stated  that  he  has 
never  met  a  single  case  in  which  he  could  discover  the 
previous  hypertrophy,  and  to  this  statement  I  think  we 
will  all  give  our  assent.  With  a  definition  such  as 
given  above,  there  is  no  proof  that  the  same  cause 
lies  at  the  bottom  of  the  atrophy  and  of  the  stink- 
ing crust  formation.  Any  assertion  like  this  permits 
the  natural  inference  that  the  secretion  proceeds  from 
the  diseased  mucous  membrane  alone.  This  certainly 
is  a  deduction  without  proof.  Even  if  we  admit  that 
the  same  actual  conditions  are  met  with,  we  have  still 
to  prove  that  these  are  the  chronic  causes  of  the  pic- 
ture and  not  accidental  or  consecutive  appearances. 

The  consideration  of  each  mark  regarded  by  differ- 
,  ent  authorities  as  characterizing  the  disease  falls  into 
two  questions: 

ist.  Is  this  sign  constant  in  all  cases? 

2d.  Is  there  proof  that  the  condition  of  the  nose  at 
the  present  time  is  the  cause  of  the  other  appear- 
ances ? 

The  results  of  the  microscopic  examination  by  differ- 
ent observers  do  not  agree.  Gottstein  found  in  two 
cases  fibrous  degeneration  of  the  mucous  membrane, 
with  partial  infiltration  and  atrophy  of  glands  and 
normal  epitlielium.  Krause  believes  in  the  actual 
change  of  tlie  epithelium  into  pavement  cells  and  the 
accumulation  of  fat  cells.  Schuchardt  found  cicatri- 
cial disappearance  of  the  mucous  membrane.  Seibert 
lays  emphasis  on  the  change  from  cylindrical  into 
pavement  epithelium  and  a  cornification  and  decom- 
position of  the  raised-up  lamellag;  while  B.  Frankel, 
after  seeing  this  cornification  in  many  cases,  found  it 
absent  in  two.  Finally,  Rethe  rests  the  nature  of 
"ozrena"  in  changes  in  the  glands  and  in  fatty  degen- 
eration. Any  uniform  anatomical  picture  cannot  be 
established  from  these  investigations. 

Secondly,  the  sum  of  all  the  conditions  discovered 
in  the  nose  does  not  answer  our  second  question. 
The  assertion  that  the  altered  mucous  membrane  gives 
rise  to  an  altered  secretion — namely,  the  characteristic 
malodorous  crusts— is  only  an  assertion.  Authorities 
differ.  E.  Fraenkel  regards  the  crusts  as  the  products 
'of  an  abnormal  chemical  synthesis  of  the  secretion  of 
the  anatomically  altered  gland  elements,  and  denies 
a  purulent  secretion  of  the  atrophic  mucous  membrane; 
while  Zuckerkandl,  without  giving  any  proof,  speaks 
of  a  purulent  nasal  catarrh  as  the  cause  of  the  atrophy. 

No  single  microscopical  result  proves  to  us  that 
the  secretion  present  proceeds  from  areas  found  al- 
tered, nor  is  it  against  the  possibility  that  the  deposit 
of  secretion  on  the  mucous  membrane  causes  seconda- 
rily the  change. 

Griinwald  next  considers  some  of  tiie  common  the- 
ories of  the  origin  of  ozaena. 

I.  The  bacteriological  theory:  Loewenberg,  in  his 
"  Kokko-bacillen,"  found  a  constant  bacillus  of  ozwna, 
but  proof  that  it  caused  the  atrophy  or  crusts  is  lack- 
ing; nor  did  he  once  succeed  in  getting  the  odor  in 
his  cultures. 

II.  The  heredity  theory  has  many  supporters. 
Many  gentlemen  here  have  seen  whole  families  affect- 
ed. That  this  is  far  oftener  not  the  case  we  fail  to 
bear  in  mind,  and,  if  this  were  the  case,  proof  of  a 
genuine  atrophy  is  still  lacking.  I'urther,  Griinwald 
found,  in  five  cases  of  oza-na  in  blood  relatives,  pus 
centres,  ciiiefly  in  the  accessory  sinuses  in  each  in- 
stance. 

As  a  further  proof  of  this  heredit}'  theory,  Hagemann 
has  asserted  that  he  has  found  in  all  oz;viia  cases  an 
abnormally  shoit  diameter  of  the  septum  from  the 
nasopharynx  to  the  tip  of  the  nose,  and  an  abnormally 


October  9,  1897] 


MEDICAL    RECORD. 


517 


deep  nasopharynx.  Griinwald  has  found  that  the  de- 
ductions, however,  differ  according  to  the  particvihir  na- 
tionality investigated.  Further,  it  is  not  the  depth  ot 
the  nose  but  its  abnormal  width  which  interests  us; 
and  we  see  abnormally  wide  noses  with  no  malodorous 
crust  formation,  and  narrow  nostrils  with  such  crusts. 
.\s  regards  the  contention  that  in  connection  with 
oza;na  a  healthy  condition  of  the  adjacent  regions  is 
found,  and  therefore  the  atrophy  nuist  be  primary,  it  is 
to  be  said  that  often  the  original  causes  of  the  atrophy 
vanish.  In  proof  of  this,  the  author  cites  two  cases  of 
marked  atrophy  with  crusts  associated  with  adenoid 
tissue,  in  which  all  crust  formation  and  secretion  dis- 
appeared after  removal  of  the  adenoids,  but  the  atrophy 
remained.  We  can  correctly  speak  of  genuine  atrophy 
only  when  an  atrophy  of  the  mucous  membrane  at 
a  given  time  was  followed  at  a  later  period  by  a  de- 
posit of  crusts.      This  has  never  been  shown. 

The  author  now  proceeds  to  study  the  question 
more  carefully  under  the  following  three  heads: 

1.  From  where  does  the  secretion  proceed? 

2.  Why  does  it  possess  this  offensive  odor.' 

3.  Why  has  it  the  form  of  crusts.' 

(1)  Whence  the  secretion?  With  the  exception  of 
Michael's  theory  that  it  proceeds  from  the  sphenoidal 
sinus,  all  authorities  ha\e  agreed  up  to  this  time  that 
it  must  come  from  the  mucous  membrane  of  the  nose. 
Gottstein  and  Juratz  assert  that  they  have  witnessed 
it  born  in  situ  in  the  form  of  minute  globules.  Griin- 
wald states  that  after  the  examination  of  many  cases 
he  finally  succeeded,  as  bethought,  in  discovering  one 
case  in  which  this  occurred.  More  careful  examination 
showed  that  this  secretion  proceeded  out  of  both  fron- 
tal and  maxillary  sinuses.  Other  observers  had  been 
undoubtedly  deceived.  A  phenomenon  had  occurred 
similar  to  what  can  be  daily  seen  in  certain  urinals 
washed  with  a  flow  of  water.  But  as  positive  proof 
of  this  statement,  one  has  only  to  tampon  thoroughly 
all  avenues  of  approach  into  the  nose  from  the  sinuses. 
to  find  a  cessation  of  the  secretion. 

But  the  chief  argument  of  all  believers  in  the  origin 
of  secretion  from  the  mucous  membrane  has  been  that 
autopsies  by  various  observers  have  shown  no  serious 
trouble  in  cases  of  oz^na.  Grimwald,  disregarding 
quoted  statements,  has  consulted  the  original  reports 
in  each  case,  and  at  length  reviews  the  different  cases 
as  reported:  Hartmann,  one  case;  Krause,  two  cases ; 
Fraenkel,  six  cases;  Zuckerkandl,  four  cases;  Harke, 
six  cases. 

As  a  result  of  his  labors,  fifteen  cases  of  ozana  and 
one  case  of  rhinitis  atrophica  sine  fcetore  are  given  in 
detail.  Of  these  sixteen  cases,  eleven  cases  are  shown 
positively  to  have  had  involvement  of  the  accessory 
sinuses.  Of  the  five  remaining,  in  one  the  condition 
of  the  important  accessory  sinuses  is  not  mentioned. 
In  four  the  condition  of  other  important  areas,  as  of 
the  nasopharynx,  is  omitted. 

Turning  now  from  any  further  consideration  in  this 
direction,  the  author  rightly  claims  that  the  only  posi- 
tive proof  IS  this:  If  the  secretion  is  from  the  diseased 
mucous  membrane,  treatment  of  diseased  areas  else- 
where cannot  possibly  effect  any  cure.  On  the  other  ■ 
hand,  if  disease  of  the  latter  is  the  true  cause  and  in- 
volvement of  the  mucous  membrane  is  only  secondary, 
relief  of  secretion  from  these  diseased  areas  must  re- 
lieve the  secretion.  In  line  with  this  assertion, 
Griinwald  makes  the  iihportant  statement  that  in  the 
past  five  years  no  ca.se  of  oza;na  has  been  seen  by  him 
which  did  not  fail  to  show  some  disease  or  diseased 
areas  elsewliere  than  in  the  nose.  .A.  series  of  twenty- 
five  cases  is  then  given  in  cxteitso,  showing  in  eacii 
sinus  involvement  or  involvement  of  the  nasopharynx. 
0£  these,  ten  show  complete  cessation  of  all  .secretion 
under  proper  treatment  of  the  diseased  area,  and  nine 
show  disappearance  of  odor  with  a  change  from  crust 


formation  to  fluid  secretion.  These  nineteen  cases 
can  positively  be  asserted  to  be  due  to  focus  disease. 
Three  cases  of  the  remaning  six  were  not  treated,  and 
three  he  will  not  positively  declare  to  have  focus  dis- 
ease. 

The  great  point  for  consideration  rests  on  the  ques- 
tion; Are  these  foci  of  disease  the  sole  source  of  the 
secretion,  or  are  they,  as  Zuckerkandl  asserts,  second- 
ary to  inflammation  and  disease  in  the  nose?  If  the 
latter  is  the  case,  the  secretion  in  the  nose  continues 
w hen  the  foci  of  disease  elsewhere  are  healed.  This  in 
ninteen  of  the  twenty-three  instances  was  not  the  case. 
Therefore  it  can  be  justly  stated  that  in  these  nine- 
teen cases  the  mucous  membrane,  without  the  partici- 
pation of  the  treated  foci,  had  nothing  to  do  with  the 
secretion.  If  now  we  add  the  remaining  six  cases 
in  which  the  conditions  are  so  probable  as  to,  permit 
them  being  included,  it  can  be  asserted  that  it  is  proved 
that,  for  Griinwald's  cases  at  least,  the  discovered  foci 
of  disease  were  not  accidental  but  actual  causes  of  the 
disease. 

Bresgen  then  is  quoted,  who  in  eleven  cases  of 
ozKna  found  foci  inflammation  in  every  one.  At  the 
same  time  the  author  meets  a  very  plausible  objection 
suggested  by  Rethe's  report,  who  in  sixty-four  cases 
found  only  two  cases  of  sinus  disease.  The  result  will 
correspond  with  that  obtained  by  many  of  the  gentlemen 
present  this  evening.  Griinwald's  explanation  is  the 
great  difficulty  in  the  diagnosis  of  sinus  disease 
in  many  instances.  In  his  judgment  many  observers 
even  to-day  are  overlooking  sinus  disease,  just  as  a 
few  years  ago  it  was  universally  regarded  as  a  most 
rare  affection.  He  adds  that  in  the  last  two  years  he 
has  himself  treated  two  cases  for  a  year's  time  unsuc- 
cessfully before  he  recognized  the  presence  of  sinus 
disease.  He  gives  the  history  of  a  case  illustrating 
this  difficulty  in  his  own  practice. 

In  conclusion,  as  a  result  of  all  these  facts,  he  de- 
clares, on  this  first  point  of  tiie  origin  of  the  secre- 
tion: I  St,  that  its  origin  from  the  mucous  membrane 
of  the  nose  is  not  at  all  proven;  2d,  on  the  contrary, 
that  proof  of  the  origin  from  foci  of  disease  in  adjacent 
areas  has  been  positive  in  a  large  series  of  cases.  In 
another  series  the  probability  is  very  strong. 

(2)  Why  does  the  secretion  possess  the  peculiar 
odor?  Griinwald  is  strongly  of  the  opinion  that  the 
cause  is  purely  mechanical.  In  proof  of  this,  he  states 
that  those  conditions  the  removal  of  which  cause  a 
disappearance  of  the  odor-ntust  be  the  cause  of  the 
odor.  These  conditions  are  varied.  In  ten  cases  the 
establishment  of  free  drainage  for  the  pus  removed  the 
odor;  here  decomposition  due  to  retention  was  the  fac- 
tor. In  two  cases  removal  of  adenoid  tissue  served 
the  same  result.  In  one  case  the  odor  disappeared 
after  a  sequestrum  was  removed.  In  three  cases  it 
depended  on  crusts  which  continually  reformed;  in 
these  three  cases  the  fluid  ])us,  as  it  proceeded  from 
the  sinus  opening,  was  odorless. 

The  important  question  naturally  suggests  itself: 
What  shall  we  say  of  those  cases  of  atrophic  rhinitis 
without  odor?  Here  nature  has  given  the  same  aid  in 
establishing  drainage  that  the  surgeon  does.  Odor 
existed  previously,  but  all  sequestra  have  been  re- 
moved or  roomy  openings  from  the  sinuses  have  been 
produced  by  the  atrophy.  Syphilis  even  is  not  to  be 
excluded  in  this  ruling.  Granted  that  the  odor  of 
syphilis  of  the  nose  is  intense,  it  is  due  only  to  necrosis 
in  the  nose  or  neighboring  sinuses.  With  removal  of 
sequestra  and  widening  of  tiie  nares  the  odor  ceases, 
as  we  know.  '  In  a  word,  when  disease  of  bone  exists, 
or  secretion  is  retained  in  enclosed  cavities  or  in  nares 
with  roomy  recesses,  we  may  look  fur  odor.  In  cases  in 
which  it  does  not  exist  with  crust  formation,  the  nostril 
is  favorably  formed  by  nature  at  birth  or  in  self-heal- 
ing for  an  easy  voiding  of  the  crusts.     The  fact  that 


5'! 


MEDICAL    RECORD. 


[October  9,  1897 


the  fresh  secretion  has  no  odor  is  proof  that  bacilli 
begin  to  exist  only  as  a  factor  of  decomposition. 

(3)  As  regards  the  question  of  the  form  of  crusts 
which  the  secretion  assumes:  This  is  regarded  as 
purely  dependent  on  a  physical  condition,  lack  of 
water,  and  that  they  cannot  be  blown  out  because  they 
are  too  tenacious. 

As  a  result  of  these  observations,  the  following  in- 
ferences are  drawn : 

1.  An  individual  pathological-anatomical  picture 
attended  by  malodorous  crust  formation  in  wide  noses 
does  not  exist. 

2.  Any  hereditary  or  anatomical  disposition  pro- 
ducing a  condition  called  ozaena  does  not  exist. 

3.  In  general,  any  peculiar  inflammation  of  the 
nasal  mucous  membrane  producing  odor  with  crusts 
and  atrophy  is  unproven. 

4.  The  existence  of  a  genuine  atrophy  is  unproven. 

5.  That  all  cases  of  malodorous  crust  formation 
rest  on  sinus  empyema  is  refuted. 

On  the  contrary,  it  is  proven: 

1.  That  in  a  series  of  cases  carefully  studied,  the 
secretion  proceeded  from  foci  of  suppuration  in  va- 
rious manners. 

2.  That  the  formation  of  cru.sts  as  well  as  of  odor 
ari.ses  under  different  conditions. 

3.  That  l)oth  conditions  often  occur  together,  but 
often  each  by  itself,  and  as  well  with  as  without  atro- 
phy of  the  mucous  membrane. 

As  a  deduction  of  this  we  must  conclude  that  the 
name  ozfena  has  no  correct  usage  save  in  a  sympto- 
matic sense. 

We  have  thus  in  a  hurried  manner  attempted  to  ab- 
stract Griinwald's  earnest  arguments.  Great  thanks 
are  due  him  for  his  laudable  scientific  work  on  a  sub- 
ject so  baffling  to  the  whole  school  of  rhinologists. 
What  avail  our  many  plans  of  treatment,  our  ever- 
growing li.st  of  new  drugs!  Nature  in  time  cures 
these  cases,  but  do  we  ?  What  can  we  honestly  claim 
in  the  vast  majority  of  our  cases  as  a  result  of  treat- 
ment but  cleanliness,  and  thus  relief  as  long  as  treat- 
ment continues?  Who  of  us  by  any  line  of  treatment 
can  point  to  seventy-four  per  cent,  of  our  cases  cured, 
as  does  Grimwald  ? 

Before  proceeding  to  examine  a  little  in  detail  his 
arguments,  a  slight  reference  to  some  of  the  other 
more  recent  theories  is  in  order.  Many  of  them,  as 
those'  of  Loewenberg.  P'rankel,  Krause,  and  Taufel, 
have  already  been  referred  to.  The  views  of  Bos- 
worth,  who  regards  ozfena  as  dependent  on  a  purulent 
rhinitis  of  childhood,  are  well  known  to  us  and  corre- 
spond in  the  main   to  the  position   held  by  1!.  Frankel. 

Berliner'  believes  that  an  abnormal  enlargement  of 
the  middle  turbinated  with  contact  with  the  septum, 
causing  a  damming  up  of  secretions  with  altered  blood 
conditions  in  the  sphenti-palatine  foramen,  is  the  cause. 
That  there  is  truth  in  this  theory  in  certain  instances 
is  undoubted.  In  the  large  majority  of  cases,  how- 
ever, we  believe  the  contact  acts  mechanically  to  hin- 
der free  escape  of  pus.  Watson, ''  without  proof,  re- 
gards oza;na  as  a  form  of  lupus;  while  Mackenzie" 
thinks  the  atrophy  is  the  result  of  the  pressure  of  the 
crusts.     But  whence  then  the  crusts.' 

The  most  important  connnunication,  however,  is  by 
.\bel.'  In  a  very  exhaustive  article  Abel  claims  in 
one  hundred  cases,  previously  diagnosed  by  a  clinician 
as  oznena,  to  have  found  a  bacillus  which  he  calls  the 
■' ozrena  bacillus."  This  he  regards  as  the  same  as 
tiie  bacillus  of  Loewenlierg  and  similar  to  the  pneu- 
mococcus  of  Friedliinder,  but  with  distinct  differences. 
He  regards  ozsena  as  an  infectious  disease  which  soon 

'  Deutsclie  mctl.  Wochenschrift,  iSScj. 

'•■  I.ancet,   i8yo. 

■'  lirit.  Metl.  Jour.,  1S95. 

'  Zcitschrift  fi'ir  Hygiene,  1895. 


causes  changes  in  the  mucous  membrane.  Whether 
hypertrophy  followed  by  atrophy  is  the  case  is  uncer- 
tain. In  any  case  atrophy  is  the  final  stage.  He  re- 
gards the  odor  w  hen  present  as  the  result  of  a  bacillus 
yet  to  be  isolated,  for  ozana  with  the  presence  of  the 
"ozana  bacillus"  occurs  without  odor.  In  one  case 
he  succeeded  in  originating  the  disease  in  an  individual 
by  introduction  of  the  bacillus.  • 

In  five  hundred  and  fift)-  cases  not  ozaena  examined 
by  himself  and  by  Paulsen,  an  independent  Italian  ob- 
server, no  "  oza-na  bacillus"  was  discovered.  Others 
have  claimed  to  discover  this  bacillus  in  healthy 
throats  and  noses.  Either  they  were  mistaken  and 
it  was  the  Friedlander  bacillus  which  so  closely  re- 
sembles it,  or  the  seeming  normal  nostril  on  careful 
examination  will  reveal  a  chronic  catarrhal  process, 
the  first  stage  of  ozrena.  Finally,  the  bacillus  will 
not  alone  cause  the  disease.  Certain  other  reducing 
causes  are  demanded  in  addition. 

When  no"w  we  come  to  consider  (iriinwald's  argu- 
ments, we  are  compelled  to  admit  that  they  are  very 
reasonable  in  the  main.  He  has  certainly  refuted  one 
of  the  chief  objections  to  histheorj-  when  he  shows  that 
the  result  of  the  various  autopsies  in  cases  of  oz»na 
is  not  to  prove  the  presence  of  healthy  sinuses.  It 
will  be  observed  that  he  does  not  claim  disease  of  the 
sinuses  is  alone  the  cause,  but  what  he  designates  fo- 
cal disease;  that  is,  areas  of  suppuration  elsewhere 
than  in  the  nose.  The  whole  contention  in  my  judg- 
ment rests  on  whether  such  a  disease  as  genuine  atro- 
phy ever  exists.  Most  of  us  who  have  been  observing 
our  cases  carefully  must  concede  the  important  role  of 
sinus  disease  in  a  large  number  of  instances,  and  ade- 
noid growth  each  one  of  us  present  has  recognized  as 
a  cause,  but  can  we  regard  these  as  the  sole  causes? 

1.  Gninwald  admits,  as  to  his  series  of  twenty-six 
cases,  that  six  or  twenty-six  per  cent,  cannot  be  proved 
to  be  due  to  sinus  or  focal  disease. 

2.  Again,  consider  the  number  of  cases  of  sinus 
disease  we  meet  without  atrophv  or  crusting  with 
odor. 

3.  It  is  true  that  the  ditficulty  in  the  diagnosis  of 
sinus  disease  is  at  times  great,  but  many  competent 
observers  have  failed  to  recognize  such  a  proportion 
of  sinus  disease  in  their  oz;tna  cases  as  does  Griin- 
wald.  It  is  scarcely  possible  that  Rethe  could  have 
erred  to  the  extent  of  finding  only  two  cases  in  sixty- 
four. 

4.  Grant,  too,  that  it  is  not  proven,  is  it  reasonable 
to  assume  that  in  no  instance  does  a  disease  of  mu- 
cous membrane  originate  secretion? 

5.  Griinwald  further  in  his  enthusiasm  pushes  his 
objection  to  the  anatomical  investigation.  While 
there  are  certain  differences,  the  reports  of  the  best 
necroscopists  in  the  main  agree  regarding  the  condi- 
tion of  the  mucous  membrane. 

6.  .\nd  are  we  not  going  too  far  to  affirm  that  every 
case  of  ozffina  in  children  possesses  "focal  disease""? 

7.  To  my  mind,  however,  the  strongest  proof  against 
the  Griinwald  theory  of  no  genuine  atrophy  is  found 
in  Abel's  investigations.  Griinwald  felt  he  could 
brush  aside  Loewenberg's  uncertain  work.  This  can- 
not be  brushed  aside.  One  hundred  cases  of  ozana 
showing  a  bacillus  constantly,  and  five  hundred  and 
fifty  cases  not  ozana  not  showing  it,  means  something, 
and  to  my  mind  is  strongly  suggestive  of  furnishing 
proof  in  connection  with  constitutional  and  anatomi- 
cal defects  for  the  existence  of  a  genuine  atrophy  in 
certain  cases,  attended  by  secretion  forming  itself  into 
crusts  due  to  pliysical  causes. 

My  own  series  of  cases  is  so  far  quite  limited.  In 
ten  cases  I  find  the  following  results: 

C.-vsE  I.  —  -Vged  twenty-eight.  Duration,  four 
months.     Ethnioiditis,  etc. 

C.\SE    II. — .\ged    twelve.      Duration,    many    years. 


October  9,  1897] 


MEDICAL    RECORD. 


519 


Double  ethmoiditis.  Operation  relieved  odor.  Sister, 
aged  four,  similarly  affected. 

Case  III.  —  Aged  twenty-one.  Duration,  four 
years.  Occasional  pain  in  frontal  sinus;  both  middle 
turbinals  polypoid;   pus  on  anterior  portion. 

C.\SE  IV.  —  Aged  nineteen.  Duration,  fourteen 
years.     Double  ethmoiditis. 

C.\SE  V.  —  Aged  twenty.  Duration,  five  years. 
Much  odor,  atrophy,  and  crusting;  empyema  of  left 
sphenoid,  with  ethmoiditis.     Operation. 

C.\SE  VI. — Duration,  twenty  years.  No  sinus  trou- 
ble. 

Case  VII. —  Ethmoiditis,  etc. 

Case  VIII.  —  Aged  twenty-two.  Duration,  ten 
years.     Adenoid  growth. 

Case  IX. — Aged  thirty-five.  Duration,  fifteen 
years.  Much  atrophy,  free  discharge,  no  odor,  no 
sinus  disease. 

Case  X. — -Much  odor  and  crusting;  necrosis  of  sep- 
tum;  syphilis. 

This  shows  that  out  of  the  ten  cases  five  possess 
sinus  disease,  one  has  associated  adenoid  growth,  one 
is  due  to  syphilis,  and  three  do  not  show  any  involve- 
ment of  the  sinus.  The  six  cases  of  focal  disease  are 
still  under  observation,  so  do  not  permit  of  any  final 
report  as  regards  the  result  of  the  operations  at  this 
time,  though  they  were  greatly  benefited,  \\hile  this 
;ieries  is  quite  small,  it  is  significant  as  being  in  line 
with  Griinwald's  result — seventy  per  cent,  showing  in- 
volved sinus  disease. 

.\s  a  result  of  these  considerations,  we  feel  forced  to 
conclude: 

I  That  there  is  no  single  constant  cause  for  ozaina. 
Ozaena  is  rightly  to  be  regarded  only  as  a  symptom. 

2.  That  a  genuine  atrophy  until  recently  unproved, 
from  Loewenberg's  studies  confirmed  by  Abel  and 
Paulsen,  in  all  probability  does  e.xist. 

3.  That  focal  disease,  including  especially  disease 
of  the  accessory  sinuses,  while  not  the  only  cause,  is 
a  very  important  and  common  cause. 

4.  And  as  a  most  practical  conclusion  for  the  rhi- 
nologist,  each  case  of  ozasna,  in  addition  to  being 
treated  with  the  proper  constitutional  and  local  meas- 
ures, is  to  be  thoroughly  and  repeatedly  examined  for 
evidence  of  such  sinus  involvement. 


BLUEWEED;     CHEMIC.VL     AND     PVSIOLOCI- 
CAL   NOTES.' 

By  .AUGUST    DRESCHEK.  .\.B.    Ph.G., 

NEW.\RK,  N.    J. 

Some  time  in  January  last,  the  writer  was  asked  by 
Prof.  Phil.  E.  Hommell  (one  of  our  active  members) 
to  make  an  examination  of  a  specimen  oftered  at  the 
time,  said  by  Professor  Hommell  to  be  derived  from 
tlie  common  "blueweed"  (Echium  vulgare;  natural 
order  Boraginace*).  Dr.  Hommell  was  inclined  to 
attribute  pharmaco-dynamic  virtues  to  this  plant,  and 
wished  me  to  search  for  alkaloids.  A  well -mounted 
specimen  of  the  plant  will  be  presented  for  your  in- 
spection by  Dr.  Hommell,  together  with  the  botanical 
description,  while  I  will  here  confine  myself  to  the 
account  of  the  chemical  and  physiological  laboratory 
doings. 

The  sample  handed  to  me,  being  in  good  condition, 
weighing  a  little  over  ten  grams,  was  coarsely  powdered 
and  treated  as  follows: 

Preliminary  Examination One  gram  was  mace- 
rated with  Prollius'  fiuid  modified  {viiie  Dr.  A.  B. 
Lyons'  work  on  drug  assaying).     The  filtered   fluid, 

'  Contributed  to  the  Xew  Jersey  Pharmaceutical  Association  at 
its  annual  meeting  at  Princeton,  N.  J.,  May  5,  lit)-. 


after  evaporation  having  next  been  shaken  out  witii 
water  acidulated  with  H„SO„  was  now  subjected  to 
the  group  tests:  (i)  Potassium  iodide  +  iodine  (Wag- 
ner);  (2)  potassio-mercuric  iodide  (Mayer);  (3)  tan- 
nic acid. 

Tannic  acid  gave  only  a  faint  precipitate. 
Dragendorff's  regular  scheme,  alternating  with  the 
various  solvents  in  acid  and  alkaline  solution,  was 
then  applied  upon  five  grams  of  the  sample,  the  re- 
sults showing  presence  of  chlorophyl,  wax,  fat,  and 
resinous  and  gummy  matter.  The  mineral  ash  was 
not  estimated. 

The  sublimation  test  (between  watch  glasses)  was 
negative — absence  of  salicylic  and  benzoic  acids,  vola- 
tile alkaloids,  and  other  volatile  matter. 

The  bulk  of  the  extract,  prepared  as  above,  was  now 
divided  into  two  parts,  dn  for  chemical  tests,  (/')  for 
physiological  tests.  The  water}-  solution,  acidulated 
with  H,^SO„  upon  evaporation  assumed  a  purplish 
color,  which  upon  dilution  vanished.  After  it  had 
been  shaken  out  with  Ijenzol,  and  the  evaporated 
residue  tested  with  potassium  bichromate  +  H.SO  ,  no 
play  of  colors  was  observable  (absence  of  strychnine, 
etc.).  The  concentrated  residue,  however,  gave  the 
reaction  quite  distinctly,  which  would  indicate  "cura- 
rine"  (this  not  being  soluble  in  benzol,  while  strych- 
nine is).  The  best  solvents  for  curarine  are  given 
by  the  authors  cited  as  alcohol  and  water,  while  in 
chloroform  and  carbon  bisulphide  it  is  claimed  to  be 
almost  insoluble,  as  well  as  in  benzol,  etc.  Strych- 
nine, methyl-strychnine,  etc.,  are  insoluble  in  water, 
but  more  or  less  soluble  in  the  other  fluids.  The  color 
reactions  of  the  purified  residue  obtained  by  the  writer 
were,  with  nitric  acid,  purple,  and  also  with  H„SO  ; 
with  potassium-bichromate  -f  H,.SO„  the  above  noted 
"  play  of  colors." 

This,  the  chemical  work,  being  in  itself  not  entirely 
satisfactory,  physiological  experiments  were  considered 
as  absolutely  necessary  and  truly  decisive.  In  inor- 
ganic analysis,  on  the  other  hand,  if  skilfully  con- 
ducted, the  results  seldom,  if  ever,  need  to  leave  a 
doubt  as  to  the  nature  of  the  object  under  considera- 
ton,  as  we  all  know. 

Physiological  Tests — Being  well  acquainted  with 
Dr.  ^'et.  Med.  Otto  Leis,  a  recently  graduated,  talented 
young  practitioner,  with  a  thorough  clinical  experience 
at  the  New  York  Veterinary  College,  I  asked  him  to 
assist  us  in  this  interesting  work.     The  results: 

Dr.  Leis  into  a  young  guinea-pig  (weight,  }2  lb.)  in 
good  health  injected  hypodermically  t^venty  minims 
of  the  clear  water  solution  prepared  by  me.  After  two 
minutes,  eye  dilatation  was  excessive;  after  three 
minutes,  paralysis  of  hind  joints,  rapidly  progressing: 
convulsions  appeared  at  intervals,  of  a  "clonic,'"  not 
a  "tonic"  kind;  no  tetanus;  no  rigidit)-  of  muscles 
(even  one-half  hour  after  death).  Difficulty  of  breath- 
ing; gasping;  death  in  twenty-four  minutes  (from 
asphyxia),  the  body  remaining  quite  limber;  slight 
nose  bleeding.  The  post-mortem  examination  showed 
no  signs  of  organic  lesion.  The  urine,  removed  from 
the  bladder  after  death,  immediately  and  completely 
reduced  an  equal  volume  of  Fehling's  solution  on 
boiling. 

Resume  and  Notes — The  results  of  these  investiga- 
tions would  seem  to  point  to  three  possibilities,  thus: 
methyl-strychnine,  curarine,  or  picrotoxine. 

The  literature  on  Kchium  vulgare  is  scant.  Huse- 
mann,  "Die  Pflanzenstofte,"  quotes  a  work  by  Buch- 
heim,  published  at  (liessen,  1870,  "  The  Phannacology 
of  Curarine''  (as  found  in  Echium). 

Curarine  was  first  prepared  by  Preyer  in  1865  in 
crystal  form  from  commercial  curare  (the  South  Ameri- 
can arrow  poison).  The  three  above-named  sub- 
stances have  analogies  in  common — similar  crystal 
form,  chemical  reactions,  etc. ;  but  methyl-strj-chnine 


520 


MEDICAL    RECORD. 


[October  9,  1897 


produces  letanus  (though  otherwise  differing  from 
strychnine).  Curarine  has  not  been  observed  to  in- 
duce rigidity  of  the  muscles  and  true  tetanic  convul- 
sions. 

Picrotoxine,  treated  with  nitre,  H.^SO„  and'NaHO 
in  excess,  gives  a  brick-red  color.  Authors  differ 
somewhat  as  to  the  chemical  and  even  the  physiologi- 
cal properties  of  curarine  {vide  Allen's  "  Organic 
Chemical  Analysis";,  even  .Allen  attributing  to  it  a 
tetanic  effect;  in  the  case  under  consideration  such 
action  was  not  observed. 

Although  the  watery  extract  of  our  sample  e-xerted 
such  a  deadly  activity,  it  was,  in  spite  of  the  most 
earnest  efforts,  found  impossible  to  isolate  a  single 
pure  crystal.  The  oily  droplets  finally  remaining 
could  not  be  bought  to  crystallization  in  the  desiccator 
over  H,.SO,.  In  the  summer  witli  new  material,  the 
work  maybe  continued.  If  this  alkaloid  (?)  should 
turn  out  to  be  a  remedy  against  hydrophobia,  etc.,  the 
pains  taken  in  preparing  it  would  be  handsomely 
rewarded. 


^Kogrcss  of  I^XccUcal  Science. 

Nature    and    Treatment    of    Tetany.  —  Dr.    Oddo 

{Mevue  lie  Medecine)  shows  that  the  theory  of  the  etiol- 
ogy of  tetany  has  an  important  bearing  on  its  treat- 
ment. In  children  he  does  not  think  it  due  to  nckets, 
though  rickets  may  favor  the  appearance  of  tetany. 
He  thinks  that  the  nervous  symptoms  are  caused  by 
a  form  of  toxa;mia  due  to  the  absorption  of  poisonous 
bodies  produced  in  the  gastro-intestinal  canal.  The 
form  of  indigestion  most  likely  to  lead  to  tetany  is  that 
attended  by  dilatation  of  the  stomach  and  long  reten- 
tion of  the  food.  Tetany  in  tlie  adult  is  believed  to  be 
connected  with  a  special  form  of  indigestion,  attended 
by  hypersecretion  of  the  gastric  juice  containing  an 
excessive  quantity  of  hydrochloric  acid.  Kassowitz 
objects  to  this  theory,  since  dyspepsia  is  very  common 
in  children  and  tetany  is  relatively  rare.  Oddo  replies 
to  this  objection  by  saying,  i,  that  for  the  produc- 
tion of  tetany  it  is  probably  necessary  that  there  should 
be  some  special  form  of  perverted  digestion  possibly 
associated  with  some  form  of  microbe,  or  some  pecu- 
liar-condition  of  the  gastric  secretion;  2,  that  for 
the  production  of  tetany  there  is  necessary  a  special 
vulnerability  of  the  nervous  system.  He  would  not 
have  tetany  accepted  as  essentially  a  disease  of  the 
nervous  system,  but  that  a  special  form  of  toxa;mia 
causes  its  characteristic  effects  only  when  there  is  a 
predisposition  in  the  nervous  system.  He  notes  the 
fact  that  Weiss  in  the  adult,  and  Bonome  and  Cerve- 
sato  in  children,  have  described  certain  lesions  of  a 
degenerative  nature  in  the  gray  substance  of  the  spinal 
cord,  most  pronoimced  in  the  anterior  horns  in  cases 
of  tetany.  Beginning  with  hyperEemia  and  swelling, 
they  go  on  to  degeneration  of  the  cells,  with  over- 
growth of  the  neuroglia.  As  to  diagnosis,  he  does  not 
accept  theopinion  of  some  of  the  German  writers  that 
laryngeal  spasm  is  pathognomonic  of  tetany.  .  It  is 
frequent  in  children  under  two  years  of  age,  and  as  it 
may  cause  death  the  early  diagnosis  of  tetany  is  im- 
portant, for  mucli  may  be  done  to  remove  the  cause 
underlying  the  nervous  instability.  Among  the  less 
common  manifestations  of  tetany  are  retraction  of  the 
head  and  squint,  which  may  lead  to  the  diagnosis  o£ 
meningitis.  In  meningitis  the  tetanic  spasms  of  the 
hands  and  feet  are  seldom  present,  vomiting  is  more 
persistent,  and  constipation  is  the  rule;  whereas  in 
tetany  there  is  nearly  always  diarrhoea.  In  tetany  the 
pupils  are  not  unequal  and  tire  jnilse  is  frequent.  In 
the  treatment  of  tetany  the  two  objects  are  to  expel  tiie 
toxic  sub.stances  and  to  prevent  their  formation.      Doth 


indications  are  met  by  calomel,  which  should  be  given 
every  other  day  in  doses  of  three-fourths  of  a  grain  or 
more  according  to  the  age  of  the  child.  Washing  out 
the  stomach  is  beneficial,  provided  care  is  taken  to 
avoid  the  risk  of  exciting  laryngeal  spasm.  Any  errors 
in  the  diet  of  the  child  should  be  corrected.  If  there 
is  a  deficiency  of  acids  in  the  gastric  contents,  hydro- 
chloric acid  should  be  given  after  each  feeding;  if  an 
excessive  amount  of  acid  is  present,  a  small  dose  of 
sodium  carbonate  or  lime  water  should  be  administered. 
He  recommends,  in  addition  to  calomel,  benzonaph- 
thol,  which  may  be  combined  with  subnitrate  of  bis- 
muth. Boiled  'water  medicated  with  boric  acid  may 
lie  used  to  wash  out  the  large  intestine.  The  cliild 
should  be  guarded  from  cold  and  excitement.  For  the 
immediate  relief  of  the  spasms  warm  baths  are  very 
effective.  Chloral  may  be  given  as  an  enema  to 
relieve  an  attack.  Bromide  of  strontium  is  a  good 
sedative  to  be  used  continuously  during  tlie  tetanic 
state.  If  laryngeal  spasm  becomes  suddenly  serious, 
a  sponge  .soaked  in  very  hot  water  should  be  applied 
to  the  neck,  followed  if  necessary  by  inhalation  of 
chloroform,  which  must,  however,  be  used  with  much 
care. 

The  Roentgen  Rays  as  an  Aid  in  the  Diagnosis 
of  Thoracic  Affections  and  Lesions  of  the  Respira- 
tory Apparatus. — Drs.  Declerc,  Oudin,  and  Barthe 
lemy  {Le  Bulletin  Medical,  June  29,  1897)  publisli  the 
results  of  a  series  of  ex]Deriments  showing  that  the 
radiograph  :s  useful  in  the  diagnosis  of  lesicns  of 
the  respiratory  apparatus  as  well  as  in  aneurisms  of 
the  aorta  inaccessible  by  auscultation  and  percussion 
The  first  tests  were  made  before  and  after  thoracente- 
sis on  a  patient  having  an  abundant  efTusion  of  the 
left  pleura.  The  opacity  of  the  effusion  was  clearly 
shown,  its  superior  limit,  and  the  return  of  the  trans- 
parency of  the  pulmonary  tissue  after  puncture.  It  is 
shown  that  the  thoracic  aorta  at  its  union  with  the 
aortic  arch  is  dilated  and  projects  to  the  left  of  the 
vertebral  column,  at  the  point  of  the  fifth  dorsal  ver- 
tebra, as  is  observed  in  most  subjects  in  whom  the 
peripheral  arteries  are  hard  and  sinuous.  Anothei 
radiograph  of  the  tliorax  of  a  child  afifected  with 
adenopathic  tracheo-bronchial  tuberculosis  shows,  be- 
sides a  ganglionic  mass  beliind  the  sternum  accessible 
to  the  ordinary  means  of  examination,  profoundly  situ 
ated  in  the  thick  part  of  the  lungs,  around  the  hiUim. 
numerous  and  voluminous  ganglions  esjjecially  at  the 
right  and  extending  the  length  of  the  bronchial  ramifi- 
cations. A  fourth  picture,  showing  the  thorax  of  a 
tuberculous  patient  with  right  pneumothorax,  reveals 
the  pleural  cavit}'  filled  with  air  and  so  transparent, 
especially  in  the  space  between  the  base  of  the  re- 
tracted lung  and  the  surface  of  the  purulent  efTusion. 
that  at  this  point  the  bodies  of  the  vertebra  can  be 
distinguished,  w  itli  their  fibro-cartilages  and  tlie  articu- 
lations of  the  neighboring  sides.  An  opaque  zone 
limited  above  by  a  horizontal  line  corresponds  with 
the  purulent  effusion  and  fills  the  entire  right  costal 
diaphragmatic  sinus.  The  diseased  lung,  diminished 
in  volume  and  retracted  toward  the  hilum,  appears  dis- 
tinct; one  can  see  its  rounded  apex,  its  external 
oblique  edge,  its  slightly  concave  base,  and  an  adhe- 
sion from  its  base  to  the  wall.  One  can  measure 
its  exact  volume,  its  form,  its  dimensions,  its  situation 
in  the  thoracic  cavity.  It  is  probable  that  repeated 
examinations  of  the  same  patient  would  enable  one  to 
measure  the  variations  of  the  effusion  and  detect  all 
the  changes  which  are  produced  in  the  size  and  form 
of  the  lung.  If  the  perforation  becomes  cicatrized  and 
if  reabsorption  of  the  intrapleural  air  by  tlie  lung  takes 
place,  and  if  the  lung  approaches  its  wall,  all  would  be 
shown  before  auscultation  would  reveal  it.  The  left 
lung  in  this  patient  was  supposed  to  be  healthy  but 


October  9,  1897] 


MEDICAL    RECORD. 


52^ 


showed  bronchia!  rales  in  the  upper  half;  it  was  the 
seat  of  profound  tuberculous  lesions.  One  sees  here 
the  utility  of  the  Roentgen  rays  in  the  diagnosis  of  tu- 
berculous infiltrations  inaccessible  by  the  other  modes 
of  exploration.  The  last  experiment  gave  additional 
evidence  of  this  utility.  A  young  girl  who  presented 
no  certain  signs  of  tuberculosis  was  examined  by  this 
method.  The  right  lung  showed  opacity  at  the  apex 
in  the  middle  part,  that  is  to  say,  a  profound  lesion. 
Without  detracting  from  the  value  of  the  other  clinical 
methods  of  exploration,  the  Roentgen  method  confirms, 
completes,  and  sometimes  corrects  the  diagnosis  of 
thoracic  affections. 

Etiology  of  Asthma. — Dr.  Kuss  holds  that  among 
the  various  causes  of  true  asthmatic  dyspncea,  the 
principal  one  is  a  defective  evaporation  caused  by  a 
want  of  sufficient  lluid  in  the  epithelial  cells  of  the 
pulmonary  vesicles.  This  insufficiency  of  fluid  must 
be  attributed  to  the  reflex  affection,  from  various 
causes,  of  the  vasomotor  ner\'es  governing  the  nutri- 
tion of  the  cells,  and  produces  the  same  effect  as  a 
sudden  and  considerable  reduction  in  area  of  the  active 
pulmonary  surface.  The  convulsive  action  of  the  res- 
piratory muscles  might  easily  be  a  consequence  of  this 
dyspnoeic  condition.  In  the  treatment  of  asthma  (i) 
increased  activity  must  be  given  to  the  secretory  pow- 
ers of  epithelial  cells  by  acting  on  the  secretory  vaso- 
motor ner\-es;  (2)  the  determining  cause  of  the  harm- 
ful reflexes  must  be  obviated  by  various  recognized 
methods;  (3)  the  physiological  and  anatomical  sound- 
ness of  the  alveolar  walls  should  be  maintained  by 
appropriate  nutrition. 

Acute  Pulmonary  Gangrene  with  Pyopneumo- 
thorax  in   a   Healthy   Youth Ewart  and    Sheild, 

writing  in  T/ie  Lancet,  June  19,  1897,  report  the  case 
of  a  young  man,  eighteen  3ears  old,  who  came  under 
observation  on  account  of  pain  in  the  back  and  cough. 
A  week  previously  he  had  been  suddenly  seized  with 
a  feeling  of  chilliness  and  on  the  following  day  severe 
pain  appeared  in  the  left  supraspinous  region,  extend- 
ing downward.  A  day  later  there  were  pain  and  cough, 
without  expectoration,  and  great  weakness.  For  the 
succeeding  four  days  pain  and  cough  persisted,  still 
without  expectoration.  Sensations  of  heat  and  cold 
alternated.  The  patient  looked  ill  and  complained  of 
weakness.  The  lips  and  ears  were  slightly  but  dis- 
tinctly cyanotic.  The  pulse  was  86,  the  respirations 
were  36.  No  cardiac  abnormality  could  be  made  out. 
On  auscultation  scattered  rales  could  be  heard  on  both 
sides  of  the  chest  in  front.  Posteriorly  on  the  left 
side  there  was  dulness  from  the  inferior  angle  of  the 
scapula,  with  enfeebled  breathing  and  deficient  vocal 
fremitus.  Scattered  rales  were  heard  on  both  sides. 
Pain  and  fixation  of  the  chest  prevented  the  ejection  of 
sputum.  Thetongue  was  heavily  furred  :  the  urine  was 
normal;  the  temperature  was  101°  F.  P>roncho-pneu- 
monia  following  influenza  was  diagnosticated.  The 
breath,  however,  became  offensive,  and  a  fit  of  cough- 
ing culminated  in  the  expulsion  of  a  large  amount 
of  whitish,  foul-smelling  muco-pus.  Later,  signs 
of  left-sided  empyema  appeared.  Preparations  were 
made  for  aspiration,  but  this  was  deferred  temporarily 
because  the  dulness  in  the  left  scapular  region  was 
replaced  by  hyperresonance.  The  occurrence  of  a 
limited  pneumothorax  was  suspected,  but  as  the  heart 
was  found  on  careful  examination  not  to  be  displaced 
toward  the  right  an  alternative  diagnosis  was  made  of 
bronchiectasis  with  sudden  evacuation  of  the  contents 
of  a  cavity.  Subsequently  the  cough  became  trouble- 
some and  orthopncea  set  in;  cyanosis  became  marked, 
the  pulse  rapid,  and  exhaustion  extreme;  the  tempera- 
ture rose  to  102'^  F.  The  apex  beat  of  the  heart  was 
now  displaced  to  the  right  and  the  upper  half  of   the 


left  side  of  the  chest  was  hyperresonant,  front  and 
back,  with  obliteration  of  the  breath  sounds,  while  the 
lower  portion  was  dull.  The  breath  was  offensive  and 
the  difficulty  in  breathing  was  urgent.  The  conclusion 
w^as  now  reached  that  a  gangrenous  lung  had  ruptured 
into  the  left  pleural  cavity,  with  the  development  of 
pyopneumothorax.  Accordingly  an  incision  \\as  made 
in  the  sixth  left  intercostal  space  behind  the  midaxil- 
lary  line,  and  a  large  amount  of  fetid  pus  and  gas 
escaped.  An  empyema  tube  was  introduced.  1  he 
heart  immediately  returned  to  its  normal  position  and 
the  general  condition  soon  improved.  At  the  second 
dressing  more  fetid  pus  came  away  and  the  discharge 
continued  for  some  time.  After  a  while  the  breath 
sound  could  be  heard  close  up  to  the  margin  cf  the 
\vound  in  front  and  above  and  also  posteriorly  down  to 
the  level  of  the  incision.  Behind  and  below  the 
breath  sounds  were  not  audible  and  in  this  area  there 
was  dulness  on  percussion.  The  left  side  cf  the  chest 
had  fallen  in.  The  patient  had  had  measles  in  child- 
hood, but  had  escaped  other  illness.  The  family 
history  was  good  and  without  tuberculous  taint. 

The  Surgical  Treatment  of  Intussusception  in 
Infants. — Pitts  has  reported  seven  cases  of  intussus- 
ception of  the  bowel  in  children  between  the  ages  of 
ten  weeks  and  two  years  and  a  half,  of  which  two  were 
of  long  standing  and  the  remainder  of  recent  occur- 
rence, and  all  of  which  were  treated  by  abdominal  sec- 
tion, with  recovery  in  six  and  death  in  one  of  the 
acute  cases.  Upon  the  basis  of  this  together  with 
earlier  experience  it  is  recommended  that,  in  cases  of 
recent  acute  intussusception,  distention  of  the  bowel  by 
air  or  water,  in  conjunction  with  gentle  external  ma- 
nipulation, may  be  tried  under  an  anaesthetic.  The 
surgeon  should,  however,  be  present  and  be  prepared 
to  open  the  abdomen  at  once  if  a  satisfactory  result  is 
not  quickly  obtained.  In  many  cases  the  effect  of  such 
inflation  is  to  reduce  the  main  mass  of  the  tumor,  but 
to  leave  an  irreducible  portion  in  the  right  iliac  and 
lumbar  regions.  This  amount  of  success  aids  the  sub- 
sequent operation  and  allows  the  tumor  to  be  delivered 
easily  through  a  smaller  incision  and  with  less  ma- 
nipulation. If  inflation  has  apparently  been  success- 
ful the  child  should  be  carefully  watched,  and  with 
evidence  of  continued  trouble  abdominal  section 
should  be  resorted  to  and  further  inflation  tried.  An 
exploratory  operation  should  be  undertaken  without 
preliminary  inflation  when,  from  the  severity  of  the 
symptoms  or  the  chronicity  of  tlie  case,  there  is  reason 
to  believe  that  such  inflation  would  be  dangerous  or 
unlikely  to  succeed.  The  time  required  for  insuffla- 
tion adds  considerably  to  the  shock.  The  median  in- 
cision is  suitable  in  the  majorit}-  of  cases,  but  when 
the  tumor  is  in  the  cscal  region  a  limited  incision  in 
the  right  semilunar  line  may  be  found  most  convenient. 
For  the  reduction  of  the  final  portion  of  an  intussus- 
ception the  tumor  should  be  brought  outside  the 
wound,  so  that  the  operator  may  clearly  see  the  condi- 
tion of  the  bowel  and  make  sure  that  the  reduction  is 
complete.  Thickening  about  the  ileo-cjecal  valve  may 
be  easily  mistaken  for  an  incomplete  reduction. 
When  doubt  exists  an  incision  may  be  safely  made 
into  the  colon  and  the  parts  examined  from  within  the 
bowel.  An  incomplete  reduction  will  certainly  lead 
to  further  trouble.  In  some  of  the  cases  of  spontane- 
ous cure,  or  cure  by  inflation  or  manipulation,  it  is 
highly  probable  that  complete  reduction  is  not  effected 
and  the  chances  of  recurring  symptoms  are  therefore 
greater  than  after  careful  operation.  In  none  of  the 
seven  cases  reported  did  it  seem  desirable  after  reduc- 
tion to  attempt  any  fixation  of  the  bowel — such  as  by 
suture  of  the  mesentery — as  a  security  against  recur- 
rence. Such  a  procedure  seemed  contraindicated,  as 
it  would  have  added  to  the  length  of  the  operation  and 


522 


MEDICAL    RECORD. 


[October  9,  1897 


have  been  uncertain  as  to  the  effect  produced.  .\11  of 
the  children  were  given  small  doses  of  tincture  of 
opium  and  kept  under  constant  medical  supervision  for 
a  considerable  time  after  convalescence  from  the  im- 
mediate condition.  When  reduction  is  found  impos- 
sible a  resection  inside  the  colon  would  seem  to  afford 
the  best  chance.  The  junction  between  the  large  and 
small  bowel  must  be  made  secure  before  any  part  is 
cut  away.  When  gangrene  is  present  the  condition  in 
young  children  is  almost  hopeless.  Complete  section 
and  end-to-end  union,  whether  by  Murphy's  button  or 
by  suture,  has  so  far  been  practically  without  success. 
Perhaps  rapid  resection,  with  lateral  implantation  of 
the  small  bowel  into  a  healthy  portion  of  the  colon, 
and  bringing  the  cut  edge  of  the  large  bowel  to  the 
surface  as  a  temporarj-  vent  for  the  escape  of  flatus, 
would  be  the  quickest  and  safest  method  to  adopt. 
Safely,  however,  as  infants  withstand  a  short  opera- 
tion, a  prolonged  one  under  such  circumstances  seems 
almost  bevond  their  power. — The  Lana-t.  |une  12, 
1897. 

Terminal  Infections  in  Chronic  Diseases — Dr. 
Flexner  has  published  the  results  of  a  statistical  and 
experimental  study  of  terminal  infections,  based  on 
the  bacteriological  examination  of  the  necropsies  of 
two  hundred  and  fifty-five  cases  of  chronic  heart  or 
kidney  disease,  or  of  the  two  combined  [Britls/i  Med- 
ical Jouniat).  Of  these,  two  hundred  and  thirteen 
gave  positive,  and  fort}"-two  gave  negative  results. 
The  infections  may  be  (i)  local — these  are  far  the 
commoner — or  (2)  general.  In  the  general  infections 
there  was  a  striking  predominance  of  the  usual  pyogenic 
cocci ;  streptococci  were  the  \ariet)"  most  often  present, 
but  were  not  highly  pathogenic  for  laboratory  animals. 
The  usual  lesions  found  were  acute  splenic  enlarge- 
ment and  parenchymatous  degenerations  in  the  vis- 
cera; in  a  large  proportion  of  cases  visible  focal  le- 
sions were  not  present.  The  portals  of  entiy  of  the 
micro-organisms  in  these  cases  of  general  infection 
could  not  always  be  determined.  In  the  local  infec- 
tions the  micro-organisms  were  for  the  most  part  the 
same  as  in  the  general  infections.  The  colon  bacillus 
was  so  frequently  found  in  the  kidneys  and  lungs,  and 
streptococci  were  so  commonly  present  in  congested 
and  cedematous  lungs,  that  these  organs  must  be  re- 
garded as  specially  favoring  the  growth  of  these  micro- 
orgaiiisms.  In  the  great  majority  of  cases  the  pres- 
ence of  the  colon  bacillus  was  not  regarded  as  of 
pathological  importance;  the  exceptions  were  when  it 
was  met  with  generally  all  over  the  body  and  in  large 
numbers,  and  when  it  was  present  together  with  pyo- 
cocci. Lists  of  the  micro-organisms  found  and  of 
their  portals  of  entry  are  given,  and  it  is  seen  that  the 
intestine  is  the  portal  of  entrj-  for  many  of  the  bacteria 
found  not  only  in  peritonitis,  but  also  in  pleurisy,  en- 
docarditis, etc.  The  statistics  show  the  value  of  sys- 
tematic bacteriological  examination  in  routine  post- 
mortem work,  and  illustrate  Osier's  remark  that 
secondar)-  infections  carry  off  many  incurable  cases. 
In  order  to  throw  light  on  the  factors  which  render  a 
patierit  with  chronic  disease  so  much  more  susceptible 
to  infection  than  a  healthy  person,  Flexner  examined 
the  bactericidal  power  of  blood  serum  obtained  from 
cases  of  chronic  disease,  and  compared  it  with  that  of 
normal  blood  serum  and  of  placental  blood  serum. 
The  bactericidal  power  was  tested  on  cultivations  of 
the  staphylococcus  aureus.  He  found  that  normal 
blood  serum  pos.sessed  distinct  bactericidal  properties, 
and  that  this  power  was  absent  or  diminished  in  at 
least  some  cases  of  advanced  chronic  disease. 

Frequency  of  Spontaneous  Recovery  from  Ap- 
pendicitis.- Or.  Rotter  states,  in  his  report  of  the  two 
hundred  and  thirteen  cases  treated  in  the  meilical  and 


surgical  departments  of  the  St.  Hedwig  Hospital  at 
Berlin,  1893  to  1895,  that  the  mortality  in  appendicitis 
is  not  so  large  as  is  usually  assumed,  amounting  in  his 
experience  to  only  8.9  per  cent,  of  the  total  number  of 
cases,  and  to  onlv  2.5  per  cent,  in  the  circumscribed 
cases  (  The  Joiinidl oj  the  Anuriian  Medieal Association). 
He  reviews  also  the  results  secured  by  others,  espe- 
cially Sonnenberg,  which  imparts  extra  interest  to  his 
communication.  He  is  more  conservative  than  Son- 
nenberg, who  advises  removing  the  appendix  even  in 
mild  cases  that  begin  "stormily,"'  particularly  if  there 
is  any  chronic  tendency,  stating  that  mere  incision  of 
the  abscess  is  never  sufficient.  Rotter's  practice  is 
immediate  operation  in  diffuse  jseritonitis,  conservative 
treatment  in  the  circumscribed  cases.  He  does  not 
accept  Sonnenberg's  seven  forms,  but  divides  all  cases 
into  the  two — general  and  localized  peritonitis.  He 
found  that  of  the  localized  cases,  ninety  per  cent,  re- 
covered spontaneously,  and  eighty-four  per  cent,  of  the 
total  number  of  cases  received  at  the  hospital  during 
the  first  six  days  of  the  attack.  He  ascribes  great  im- 
portance to  the  fever,  which  he  classifies  into  five 
groups;  I.  Cases  begin  with  high  fever,  up  to  40 
C. ;  decrease  third  or  fourth  day;  rapid  convales- 
cence. 2.  Begin  the  same,  with  fever  up  to  40^  C; 
fever  lasts  longer,  but  not  over  39"^  C.  by  fifth  day. 
In  fourteen  cases  of  this  kind  all  recovered;  three  re- 
quired operation  for  circumscribed  abscesses.  In  the 
absence  of  fever,  he  operates  upon  such  cases  on  the 
ninth  day.  3.  Same,  with  temperature  over  39°  C.  longer 
than  the  fifth  day;  grave  virulent  infection;  prognosis 
unfavorable.  In  eleven  cases  there  were  two  deaths; 
the  fever  disappeared  spontaneously  in  two  cases  the 
eighth  or  ninth  day;  four  were  operated;  three  pa- 
tients recovered  after  a  protracted  stay  in  bed  (perfora- 
tion into  the  intestine).  This  group  requires  prompt 
surgical  intervention,  not  later  than  the  sixth  day,  and 
earlier  than  this  with  symptoms  of  progressive  perito- 
nitis. 4.  After  an  earlier  fall  in  the  temperature  it 
rises  again,  which  alwavs  indicates  larger  accumula- 
tions of  pus.  Four  patients  of  the  six  in  this  categor}- 
were  operated  upon;  one  died  of  general  peritonitis, 
and  another  left  after  the  third  remission,  apparently 
cured.  These  cases  should  be  operated  upon  during 
the  first  remission.  5.  General  peritonitis;  the  tem- 
perature is  low,  often  subnormal  in  severe  infection, 
higher  in  progressive  cases;  the  pulse  indicates  the 
severity  of  the  attack;  recovery  is  to  be  expected  only 
with  surgical  intervention.  He  believes  that  pus  is 
always  present  in  acute  attacks,  whether  found  or  noL 
It  may  be  discharged  through  the  lumen  or  the  per- 
foration and  absorbed  by  the  peritoneum. 

Retroperitoneal  Tumors — In  a  recent  issue  of 
the  British  Medieal  JiMinmi  is  reported  an  interesting 
debate  bearing  on  retroperitoneal  tumors  which  took 
place  at  a  meeting  of  the  Royal  Medical  and  Chirur- 
gical  Societ)',  in  connection  with  Mr.  Marmaduke 
Sheild's  ca.se  of  successful  removal  of  a  large  fibre- 
myomatous  tumor  arising  from  the  retroperitoneal 
space.  The  origin  of  such  tumors  may  be  difficult  to 
determine,  as  they  tend  to  spread  far  and  wide  behind 
the  peritoneum  ;  some  may  be  derived  from  the  smooth 
muscular  tissue  which  extends  from  the  uterus  into  the 
broad  ligament,  and  has,  we  believe,  been  termed  the 
uterine  platysma;  while  Mr.  Eve  suggested  that  the 
smooth  muscular  tissue  said  to  be  present  at  the  root 
of  the  mesentery  might  be  the  starting-point  of  some 
fibromyomata.  Probably  many  of  the  growths  de- 
scribed as  retroperitoneal  sarcomata  are,  like  most 
"sarcomata"'  of  the  breast,  allied  more  closely  to  soft 
fibromata  than  to  malignant  tumors,  as  evidenced  by 
the  facts  that  they  displace  rather  than  invade  adja- 
cent tissues,  and  do  not  recur  after  removal,  though 
that  o]ieration   may  be  extremely  hazardous  from  the 


October  9,  189"] 


MEDICAL    RECORD. 


523 


extent  and  size  of  the  growth.  The  retroperitoneal 
fibromata  may  be  extremely  (edematous  or  may  con- 
tain fat,  as  in  Sir  Spencer  Wells'  case  examined  by 
Mr.  Eve.  Occasionally  they  may  be  almost  or  en- 
tirely composed  of  fat,  and  form  enormous  tumors, 
which  may  somewhat  resemble  malignant  tumors  or 
more  closely  ascites.  From  malignant  tumors  their 
course  and  the  absence  of  cachexia  distinguish  them, 
while  the  effects  of  paracentesis  differentiate  them  from 
ascites.  Mr.  Lockwood  drew  attention  to  the  areas  of 
resonance  which  vary  in  their  position  as  a  clinical 
feature  of  retroperitoneal  growths;  but  this  fact,  to- 
gether with  fluctuation,  met  with  in  fatty  tumors,  would 
tend  to  make  the  resemblance  of  ascites  and  retroper- 
itoneal lipomataall  the  more  close.  Xo  wonder,  then, 
that  such  semisolid  growths  have  been  subjected  to 
paracentesis. 

Diagnosis  of  Primary  Malignant  Tumors  of  the 
Pleura  and  Lungs — Dr.  Zagari  {^Anh.  Clin,  dc  Bor- 
t/fiiiix,  March,  1897)  groups  the  special  clinical  symp- 
toms as  follows:  i.  Insidious  commencement  of  the 
affection.  2.  Marked  general  debility.  3.  Absence 
■of  fever.  4.  Persistent,  increasing  pain.  5.  Circum- 
scribed cedema  of  the  chest.  6.  Development  of  the 
lymphatic  ganglia  on  one  side  of  the  thorax,  exclu- 
sively or  more  prominently;  possible  turgescence  of 
the  veins  in  the  anterior  and  lateral  parts  of  this  side. 
7.  Sweats  and  more  elevated  temperature  on  one  side 
of  the  thorax.  8.  Distress  in  breathing  and  more  in- 
tense oppression  than  can  be  ascribed  to  the  quantitv 
of  fluid  obtained  by  puncture.  9.  Irregular  distention 
of  the  thoracic  cage,  especially  in  the  superior  and 
anterior  region  of  the  chests  10.  Intercostal  spaces 
neither  prominent  nor  dilated,  i  i .  Complete  dulness, 
without  the  slightest  elasticity,  in  the  superior  and 
anterior  region  of  the  thorax;  zones  of  dulness  close 
to  zones  of  resonance.  12.  Dulness  over  the  manu- 
brium or  the  sides  of  the  sternum,  which  indicates  not 
only  the  displacement  of  the  mediastinum  toward  the 
sound  side,  l»ut  also  the  irregularity  of  this  displace- 
ment. 13.  Skodaic  resonance  over  the  clavicle  and 
sternum.  14.  The  laryngo-tracheal  murmur  distinctly 
transmitted  to  the  superior  regions.  15.  Persistence 
of  the  plessimetric  and  acoustic  phenomena  even  after 
evacuation  of  the  fluid  in  the  pleural  cavity.  16.  This 
fluid  is  very  thick,  rich  in  fibrin,  hemorrhagic,  with 
histologic  elements  special  to  the  neoplasm.  17. 
Peculiar  sensation  of  ha\  ing  penetrated  into  a  compact, 
deep,  thick  mass,  when  inserting  the  needle.  18. 
Puncture  is  without  eft"ect,  or  the  fluid  forms  rapidly 
again.  19.  Displacement  of  the  heart  and  liver,  out 
of  all  proportion  to  the  amount  of  liquid  withdrawn. 

Lavage  in  Chronic  Gastritis. — Dr.  Hehrens  {St. 
J.oiiis  Mctliciil  iiiiil  Sit)-i;ica!  Journal,  April,  1897),  in 
an  article  on  this  subject,  summed  up  the  uses  to  be 
derixed  from  lavage  as  follows:  Mucus  and  mucous 
plaques  are  washed  out,  stimulating  the  cells  to  secrete 
a  juice  that  is  acid,  w  ith  no  alkalinity  to  neutralize  it. 
P>y  the  direct  application  of  warmth  we  insure  in  time 
muscular  reaction,  consequently  a  relief  of  this  atonic 
or  sluggish  condition  of  the  .stomach,  raising  the  func- 
tion of  this  organ  to  the  capabilities  required  of  it.  <  )f 
the  solutions,  sodium  bicarbonate  is  preferably  used 
in  these  cases  to  facilitate  removal  of  mucus,  and  when 
acids  other  than  normal  exist  causes,  to  a  degree,  neu- 
tralization, {"he  last  washing  should  be  with  clear 
warm  water,  1  10  to  112'  P.;  afterward  the  medica- 
tion indicated  may  be  given  to  continue  stimulation, 
viz.,  bitter  tonics — preferably  strychnine  in  its  various 
combinations.  By  testing  the  contents  we  facilitate 
<liagnosis  in  stomach  disorders.  Lavage  should  be 
done  about  one-half  hour  before  the  main  meal,  to 
clear  the  stomach  of  unnecessarv  secretions  and  also  to 


avoid  clogging  the  lube  with  food  from  the  last  meal. 
Lavage  should  not  be  done  on  those  having  aneurism, 
arterial  sclerosis,  severe  valvular  lesions,  in  the  later 
stages  of  pregnancy  (if  first  introduction  of  tube  causes 
much  distress),  oesophageal  cancer,  gastric  ulcer  or  gas- 
tric cancer  when  there  is  rapid  disintegration  of  tissue, 
in  those  afflicted  w  ith  spasm  of  glottis,  enlarged  tonsils 
(interfering  or  causing  obstruction  to  respiration),  or 
the  severe  asthmatics.  Cleanliness  must  be  strictly 
observed  in  tube  introduction.  All  solutions  being 
ready  and  at  a  proper  temperature,  a  fairly  stiff  tube 
is  selected;  the  patient  is  seated  on  a  firm  chair, 
.vith  strong,  straight,  high  back,  and  covered  with  a 
rubber  apron  (to  prevent  soiling  clothing  by  vomitus, 
etc.),  and  over  this  a  clean  white  towel  should  be  laid: 
the  head  is  tilted  slightly  backward,  the  mouth  opened 
about  one  inch  :  the  tube,  being  lubricated,  is  passed 
directly  back;  it  turns  readily  in  the  pharynx  with  just 
a  little  force.  About  this  time  the  patient  gags,  and  it 
is  necessary  to  watch  that  the  tube  is  not  jerked  out  by 
him.  Ask  him  to  swallow:  assure  him  e\erything 
is  all  right  (though  most  patients  feel  the  first  time  as 
if  they  were  going  to  strangle).  Then  quickly  pass  the 
tube  to  the  mark  outlined  for  adults;  after  a  moment's 
rest  have  him  breathe  a  few  times.  Being  assured  that 
it  has  passed  into  the  stomach,  pour  in  about  five  hun- 
dred cubic  centimetres  of  warm  water,  and.  the  work 
from  this  time  on  is  readily  accomplished.  Patients  be- 
come so  accustomed  to  its  introduction  after  a  few 
times  this  it  is  not  looked  on  with  any  fear.  In  many 
cases  of  chronic  gastritis  one  washing  has  been  of  such 
benefit  that  it  is  not  difficult  to  continue  this  form  of 
treatment,  whicli  apparently  seems  at  first  impossible. 

Different  Varieties  of  Aortic  Regurgitation Dr. 

Handford,  at  a  meeting  uf  the  Xottinghain  Medico- 
Chirurgical  Society,  held  on  March  3d,  stated  that  the 
chief  characteristics  of  the  rheumatic  cases  were:  (i) 
The  disease  came  on  at  a  much  earlier  period  of  life 
than  atheroma,  and  was  the  main  cause  of  aortic  re- 
gurgitation arising  between  the  ages  of  five  and  thirty- 
five  years;  (2)  the  arteries  were  generally  .sound:  (3) 
the  heart  muscle  was  comparatively  sound:  and  (4) 
apart  from  fresh  attacks  the  valvular  disease  soon 
ceased  to  be  progressive.  In  all  these  respects  rheu- 
matic aortic  regurgitation  differed  essentially  from  the 
atheromatous,  and  the  prognosis  was  very  much  more 
favorable.  Not  infrequently  free  regurgitation  might 
exist  for  years  with  a  complete  absence  of  symptoms, 
even  though  the  patient  led  an  active  life.  The  athe- 
romatous cases  were  by  far  the  most  numerous  and  se- 
rious, and  presented  the  following  distinctions:  (i) 
The  disease  was  essentially  a  degeneration  and  arose 
in  middle  life,  rarely  before  the  age  of  thirt)^-five 
years,  except  when  syphilis  was  the  main  cause;  (2) 
the  arteries  were  always  involved  to  a  considerable  ex- 
lent;  (3)  the  heart  muscle  was  rarely  sound;  (4)  the 
disease  was  almost  always  progressive,  and  (j)  it 
affected  the  male  much  more  frequently  than  the  female. 
Of  the  atheromatous  cases  there  were  four  chief  sub- 
divisions, according  to  the  mode  of  production:  (i) 
The  syphilitic,  arising  generally  between  the  ages  of 
thirty  and  fifty  years,  affecting  sometimes  mainly  the 
aorta  and  branches,  and  sometimes  mainly  the  valves, 
difficult  to  distinguish  from  fusiform  aneurism,  and 
lapidly  progressive:  (2)  those  arising  from  laborious 
work  in  strong,  muscular  men,  generally  between  the 
ages  of  forty  and  fift\'  years:  (3)  the  arterio-sclerotic, 
arising  between  the  ages  of  fifty  and  sixty-five  years 
in  the  gouty  and  in  men  wiio  habitually  ate  and  drank 
too  much,  especially  when  combined  with  hard  mental 
work;  and  (4)  cases  arising  from  "old  age,"  about 
seventy  years.  No  general  rule  could  be  laid  down 
for  all  cases  as  regarded  the  use  of  digitalis.  It  was 
most  useful  when  there  was  consecutive  mitral  disease 


524 


MEDICAL    RHCOkl). 


[October  9,  1897 


with  dropsy,  next  in  tlie  rheumatic  cases  and  those 
■arising  from  laborious  work;  the  latter  could  often  be 
enabled  to  continue  their  work  by  daily  doses  of  digi- 
talis. The  chief  cause  of  failure  of  compensation  was 
degeneration  of  the  ventricle  from  fibroid  change,  the 
prognosis  of  which  depended  mainly  upon  the  degree 
of  occlusion  of  the  coronary  arteries.  When  the  fibroid 
change  was  advanced  digitalis  had  little  tonic  stimu- 
lating effect  upon  the  heart,  and  not  only  failed  to  do 
good,  but  did  positive  harm,  because  it  still  caused 
tonic  contraction  of  the  small  arteries  and  increased 
the  work  of  the  failing  heart.  Digitalis  was  of  great 
use  in  failure  of  compensation  from  temporar)'  causes. 
It  generally  did  harm  in  the  syphilitic,  the  arterio- 
sclerotic, and  the  aged  cases. — Lancet,  March  13,  p. 
741. 

Diuretic  Treatment  of  Renal  Dropsy. — Dr.  Nestor 
Tirard  {British  Medical  Joiirual,  March  20th),  in  a 
lecture  on  this  subject,  states:  -"Ifmay  be  well  to  re- 
mind you  that  Manquat  classified  diuretics  as  follows: 
I.  Meclianical  diuretics,  with  the  subdivisions  {a) 
cardio-vascular  diuretic.  (/')  aqueous  diuretics.  2. 
Renal  diuretics,  subdividing  into  ia)  functional  epi- 
thelial diuretics,  (/')  irritant  epithelial  diuretics. 
You  will  see  from  this  classification  that  digitalis  and 
diuretin,  salicylate  of  theobromine  and  sodium,  prob- 
ably belo'ng  to  different  groups.  Digitalis  stands  as  a 
'  cardio-vascular  diuretic,'  which  wall  act  partly  by 
increasing  the  blood  pressure  generally,  and  partly  by 
increasing  the  speed  of  the  How  of  blood  through  the 
glomeruli;  in  fact,  digitalis  is  to  be  grouped  together 
with  convallaria,  squills,  ergot,  strophanthus,  and 
caffeine.  Of  the  '  aqueous  diuretics '  in  the  above 
classification,  we  made  use  both  of  Imperial  drink  and 
of  milk;  and  these  act  by  increasing  the  volume  of 
the  blood,  and  by  thus  directly  raising  the  arterial 
tension.  All  classifications  of  remedies  are  necessarily 
imperfect.  Some  of  the  '  aqueous  diuretics,'  notably 
milk,  might  with  equal  propriety  fall  into  the  second 
group  of  '  renal '  diuretics,  which  act  directly  on  the 
renal  epithelium.  Huchard  has  grouped  together  the 
indications  for  diuretic  medication,  as  set  forth  by  ■ 
various  authors,  in  the  following  way:  i.  To  maintain 
the  action  of  the  kidney;  2,  to  evacuate  fluid  effu- 
sions; 3,  to  soothe  and  diminish  irritation  of  the 
genjto-urinary  organs;  4,  to  modify  the  urinary  excre- 
tion, to  prevent  urinar)'  calculi ;  5,  to  e.xert  a  derivative 
action  through  the  renal  passages;  6,  to  hasten  elimi- 
nation of  to.xic  substances  from  the  organism;  7,  to 
free  the  blood  of  morbid  matters  which  are  capable 
of  elimination  by  the  kidneys.  With  cases  of  acute 
dropsy,  such  as  occur  subsequently  to  scarlet  fever,  you 
well  know  that  ou"  practice  is  to  stimulate  the  action 
of  the  skin  so  far  as  possible  by  the  employment  of 
diaphoretics,  or  by  using  the  hot-air  bath  or  the  wet 
pack;  and  while  we  endeavor  in  this  way  to  relieve 
strain  upon  the  engorged  vessels  of  the  glomeruli,  we 
almost  as  a  matter  of  routine  administer  hydragogue 
purgatives,  by  means  of  which  we  hope,  by  reducing 
the  volume  of  blood  within  the  vessels  lining  tlie 
intestine,  to  exert  an  absorbent  action  through  the  ves- 
sels of  the  remoter  tissues.  There  are  few  facts  in 
medicine  which  appear  to  be  more  conclusively  proved 
than  that  the  total  quantity  of  fluid  circulating  within 
the  blood-vessels  always  tends  to  remain  the  same,  so 
that  when  the  vessels  are  depleted  at  one  part  of  the 
body  the  loss  is  replaced  by  absorption  from  other 
parts." 

Remarks  on  Arthritic  Gout. — Dr.  Wade  [British 
Medical  Journal,  February  2  7  th)  says :  "  The  neurosis  is 
the  primar)'  and  essential  element.  If  a  sensory  nerve 
is  attacked,  we  get  pain  and  tenderness ;  if  a  vasomotor 
one,  we  get  redness  and  swelling;  if  the  nutritive 
nerve  of  a  joint,  we  get  changes  in  the  joint,  one  result 


of  which  may  be  a  deposit  of  urates.  I  submit  from 
this  that  this  theorj-,  more  completely  than  any  other, 
brings  into  line  the  various  manifestations  of  gout. 
But  it  may  be  asked  how  it  is  that  one  toxin  (uric 
acid)  affects  now  an  external,  now  an  internal,  sensory 
nen'e;  now  a  motor,  now  a  vasomotor,  now  a  trophic 
nerve,  now  an  excretory  one.  This  rai.ses  an  impor- 
tant question,  on  which  Dr.  Ewart  says:  'We  still 
hesitate,  then,  to  admit  without  further  investigation 
that  gout  is  primarily  dependent  upon  uric  acid  as 
a  cause,  or  that  uric  acid  necessarily  exerts  any  ex- 
clusive influence  on  the  production  of  the  phenomena 
of  goutiness.'  Dr.  Kwart's  hesitation  is  shared  by 
many.  It  is  enhanced  in  my  mind  by  the  fact  that 
different  toxins  have  an  elective  affinity  for  different 
nerve  tracts.  Conversely  we  perhaps  may  infer  that 
affections  of  diff^erent  nerve  tracts  imply  different  tox- 
ins. That  such  may  be  the  case  in  gout  receives 
strong  support  from  the  ingenious  and  teborious  re- 
searches of  Dr.  Haig.  This  uncompromising  advo- 
cate of  the  uric-acid  theory  claims  to  have  proved  that 
other  bodies  chemically  allied  to,  but  not  identical 
with,  uric  acid  resemble  it  in  their  action  upon  the 
human  body.  This,  then,  is  a  matter  which,  like  the 
state  of  the  local  nerves,  deserves  a  much  more  criti- 
cal investigation  than  either  has  as  }'et  received." 

Amoeboid  Bodies  in  the  Blood  of  Vaccinated  Mon- 
keys and  Children  and  in  that  of  Cases  of  Variola. 

— As  the  result  of  an  experimental  study.  Surgeon 
Walter  Reed,  U.  S.  A.  {Journal  oj  Experimental  Medi- 
cine, vol.  ii..  No.  5,  September  iS,  1897,  p.  515^  has 
been  able  to  confirm  the  observation  that  small  granu- 
lar amoeboid  bodies  are  present  in  the  blood  of  vac- 
cinated children  and  calves,  and  in  that  from  cases  of 
variola  during  the  stage  of  fever.  Nuclei  in  any  of 
these  bodies  could  not  be  positively  made  out.  Simi- 
lar granular  amoeboid  bodies,  having  a  diameter  about 
one-third  that  of  a  red  blood  cell,  were  found  also  in 
the  blood  of  monkeys  during  the  active  stage  of  vac- 
cination, disappearing  with  the  decline  of  the  local 
inflammation.  A  body  of  like  appearance,  granula- 
tion, and  size  was  occasionally  found  in  the  normal 
blood  of  monkeys  and  children.  Pale  auKeboid  bod- 
ies containing  a  few  dark  pigment-like  granules  were 
found  in  the  blood  from  cases  of  variola  and  in  that 
of  a  variolated  monkey.  Bodies  of  like  appearance 
were  occasionally  found  in  the  blood  of  vaccinated 
children  and  monkeys. 

The  Spinal  Lesions  of  Progressive  Pernicious 
Anaemia  and  of  the  Secondary  Anaemias  of  Adults. 
— Lenoble  reports  a  fatal  case  of  progressive  perni- 
cious ana'inia,  attended  by  hemorrhage  into  the  spinal 
cord;  and  also  one  of  anremia  secondary  to  pregnancy. 
in  which  no  spinal  lesion  could  be  detected.  From  a 
study  of  the  literature,  he  expresses  the  opinion  that 
both  forms  of  disease  may  be  attended  by  spinal  lesions 
varying  from  hemorrhage  to  extensive  areas  of  sclerosis 
occupying  a  large  portion  of  the  white  fibres;  the  gray 
matter  also  may  be  more  or  less  profoundly  involved 
up  to  a  disappearance  of  various  groups  of  ganglion 
cells.  The  lesions  may,  upon  the  one  hand,  be  un- 
attended by  any  physical  evidence  of  their  exist- 
ence, or,  on  the  other  hand,  they  may  be  attended  by 
symptoms  attributable  to  irritation  of. the  cord  or  even 
of  true  paralysis,  in  accordance  with  the  extent  and 
distribution  of  the  lesions.  These  alterations  appear 
to  be  especially  physical,  the  poison  of  pernicious 
anajmia  acting  upon  the  elements  from  which  the  red 
blood  corpuscles  are  derived,  the  ha?niatoblasts.  In 
the  symptomatic  ana?mias,  a  similar  mechanism  may 
give  rise  to  hemorrhage  consecutive  to  the  auto-in- 
toxication tint  constitutes  a  part  of  the  clinical  syn- 
drome.— Revue  dc  Mcdrcine,  June  10,  1897. 


I 


October  9,  1897] 


MEDICAL    RECORD. 


52s 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
V/M.  WOOD  &  CO.,   43,  45,  &  47  East  Tenth  Street. 


New  York,  October  9,  1897. 


NATIONAL    QUARANTINE. 

The  inefficiency  of  independent  local  quarantines  in 
the  yellow-fever  districts  demonstrates  in  a  striking 
way  the  need  for  a  national  system  which  shall  com- 
prise all  others  and  direct  all  others.  The  practical 
sanitarian  need  only  study  the  present  situation  in  all 
its  details  of  senseless  and  conflicting  restrictions,  to 
be  convinced  of  the  fact  that  quarantine  as  at  present 
carried  on  has  been  an  utter  failure.  The  lack  of 
systematic  direction  by  centralized  power  is  strikingly 
shown  by  the  inconsistent  and  ill-timed  actions  of  the 
health  boards  and  municipal  governments  of  the  dif- 
ferent localities  in  the  stricken  districts.  Not  only 
has  each  State  a  health  law  of  its  own,  but  each  city 
presumes  to  dictate  by  means  of  shotgun  methods 
who  shall  enter  or  leave  a  given  place,  and  in  many 
instances  the  panic-stricken  citizens  have  practically 
resorted  to  mob  rule  in  holding  up  railroad  trains, 
interfering  with  traffic,  arresting  government  experts, 
hindering  food  supplies,  and  attacking  temporary 
hospitals.  It  is  quite  true  that  the  various  State 
health  boards  specially  interested  in  the  present 
means  of  protection  have  done  their  best  to  establish 
some  uniform  system  of  quarantine  and  have  held 
conferences  to  that  end,  but  behind  all  seeming  agree- 
ment on  mooted  points  re.st  their  obligations  in  main- 
taining the  legal  rights  of  their  respective  States. 
Therein  in  fact  is  the  principal  difficulty  in  coming  to 
an  understanding  as  to  what  may  be  done  for  several 
States  as  a  consistent  whole  and  in  the  common  inter- 
ests of  wide  ranges  of  territory. 

In  the  various  national  health  bills  that  have  here- 
tofore been  framed,  the  intentions  have  been  very 
clearly  expressed  not  to  interfere  with  the  rights  of 
any  State  in  the  codification  or  enforcement  of  its  own 
laws.  The  leading  ideas  were  unifonnity  in  quaran- 
tine regulations,  and  such  assistance  from  a  central- 
ized power  as  might  be  necessary  in  times  of  great 
emergency  to  enforce  consistent  and  concerted  action 
among  different  States. 

Some  attempt  at  national  control  has  been  made 
during  the  past  few  years  by  enlarging  the  powers  of  the 
Marine  Hospital  department,  but,  while  due  credit  is 
to  be  accorded  to  the  Supervising  Surgeon-General  and 
his  alert  staff,  it  has  become  more  and  moreevident 
that  something  more  is  needed  to  give  due  scope  and  effi- 


ciency to  a  model,  far-reaching,  and  thoroughly  practi- 
cal national  law.  We  must  needs  have  some  such  enact- 
ment ere  long.  Every  time  we  have  a  practical  object 
lesson  in  the  shape  of  an  epidemic  the  real  necessity 
for  such  a  measure  becomes  more  and  more  manifest. 
Just  now  the  subject  forces  itself  on  our  attention,  and 
w^e  duly  note  current  facts  as  contributing  to  the  his- 
tory of  a  discussion  in  which  every  sanitarian  in  the 
country  should  be  duly  interested. 


MODERN    ATHLETICS    AND    HEALTH. 

Are  athletics  as  now  carried  on  conducive  to  health  ? 
is  a  question  often  asked,  and  some  curiosity  is  evinced 
as  to  what  point  of  barbarity  they  will  attain  ere  pub- 
lic sentiment  revolts  against  their  methods.  There  is 
an  ever-growing  tendency  among  sensible  and  thought- 
ful men  to  deplore  the  manner  in  which  our  modern 
sports  and  games  are  conducted.  The  spirit  of  emula- 
tion is  an  excellent  quality,  but  even  that  may  be  car- 
ried too  far;  and  when,  as  not  infrequently  happens, 
limbs  are  broken  and  fatal  casualties  occur  in  what 
are  supposed  to  be  friendly  football  games  between 
boys  at  school  or  university,  it  is  time  that  the  situa- 
tion should  be  reviewed  dispassionately.  As  with  the 
mode  of  playing  football,  so  it  is  with  the  methods  rul- 
ing the  conduct  of  modern  athletics  generally.  The 
system  is  not  only  not  beneficial  but  is  prejudicial  to 
health.  In  the  journals  of  England  a  heated  discus- 
sion is  now  being  waged  with  regard  to  this  much- 
vexed  question.  Letters  are  being  written  and  opin- 
ions aired  by  all  sorts  and  conditions  of  men,  and  from 
these  it  would  appear  that  the  conclusions  arrived  at 
are  unfavorable  to  the  view  of  the  healthfulness  of 
modern  athletic  training.  The  British  Medical  Jour- 
nal has  taken  up  the  subject,  and  says :  '"  We  quite  ad- 
mit that  many  athletes  are  extraordinarily  healthy  fel- 
lows, but  that  does  not  touch  the  question.  None  but 
strong  and  healthy  men  are  likely  to  enter  on  or  at  any 
rate  to  persevere  in  athletic  pursuits,  and  the  question 
really  is  not.  Do  some  of  them  remain  healthy?  but. 
Do  they  remain  as  healthy  when  they  devote  them- 
selves to  the  one  object  of  developing  muscle  as  they, 
the  same  people,  would  if  they  led  an  ordinary  out- 
door life,  eating  ordinary  food  and  taking  a  reasonable 
amount  of  exercise  without  any  attempt  at  interfering 
with  their  weight  or  increasing  their  muscles?  The 
key  to  the  answer  lies  in  the  fact  that  health  depends 
on  the  integrity  of  the  digestive  and  assimilative  or- 
gans, and  that  perfection  of  muscle  is  quite  a  secon- 
dary consideration.  .  .  .  Notwithstanding,  then,  the 
array  of  vigorous  and  hearty  middle-aged  and  even 
elderly  men  who  have  survived  the  ordeal,  we  cannot 
shut  our  eyes  to  the  fact  that  the  record  breaking  which 
is  now  the  aim  of  every  self-respecting  athlete  is  pro- 
ductive of  such  an  amount  of  strain,  especially  to  the 
vascular  system,  as  when  oft  repeated  must  do  harm. 
The  athlete  is  often  healthy,  but  is  so  in  spite  of  rather 
than  by  virtue  of  his  athleticism." 

These  are  true  words,  and  apply  probably  even  more 
directly  to  American  athletes  and  to  the  American  sys- 
tem of  training  than  to  athletes  of  England  who  follow 


526 


MEDICAL    RECORD. 


[October  9,  1897 


the  system  in  vogue  there.  The  course  of  training  at 
universities  in  this  country  is  much  more  severe  than 
in  England.  However,  there  is  small  room  for  doubt 
that  in  both  countries  athletics,  and  more  particu- 
larly among  amateurs,  is  carried  to  excess.  Of  course 
if  a  man  is  a  professional  and  gains  his  livelihood  by 
the  exercise  of  his  thews  and  sinews,  he  must  expect 
to  run  some  risks,  but  with  those  who  hope  in  after-life 
to  work  at  a  profession  or  trade  it  is  foolish  in  the 
extreme  to  mortgage  their  future  by  injuring  their 
health  when  at  school  or  college.  Moderation  is 
good,  excess  is  bad. 


HIRED    EXPER'l'   TESTIMONY. 

The  sensational  trial  of  Luetgert  throws  its  glary 
sidelights  on  the  anatomical  experts  who  are  disput- 
ing over  the  identity  of  the  bones  found  in  the  sausage 
vat.  The  public  is  being  amused  by  the  flat  contra- 
dictions of  alleged  scientists  regarding  certain  points 
which  distinguish  the  bones  of  a  woman  from  those  of 
a  hog.  What  a  credit  to  anatomy  such  a  lamentable 
possibility  of  radical  disagreement  entails !  It  is  such 
spectacles  in  court  that  show  the  utter  fallacy  of  hired 
expert  testimony.  How  much  better  would  it  be  for 
the  court  to  appoint  an  impartial  commission  of  skilled 
anatomists,  which  could  decide  once  for  all  without 
the  disgraceful  wrangle  and  without  the  temptation  for 
disagreement  which  the  mere  payment  of  a  nominal  fee 
would  appear  to  invite! 


"THE    URIC-ACID    DIATHESIS." 

Dr.  Haig  has  imparted  a  good  deal  of  breezy  fresh- 
ness into  the  dry  "uric-acid  diathesis"  question,  and 
his  theory  as  to  the  cause  of  uric  acid  in  the  body  is 
worthy  of  much  consideration.  Nevertheless  it  can 
hardly  be  said  that  his  researches,  valuable  and  in- 
teresting as  they  are,  have  finally  settled  the  point  in 
dispute.  In  fact,  those  holding  his  ideas  on  the 
subject  are  in  the  minority-.  In  the  Edi?iburgh  Medi- 
cal Journal  for  July  is  printed  a  paper  which  Dr. 
Haig  read  before  the  Medical  Society  of  London  in 
November  last,  and  in  which  his  views  are  clearly 
and  concisely  set  forth.  He  begins  by  saying:  "It 
has  been  taught  for  many  years  that  uric  acid  given  to 
mammals  appears  in  the  urine  as  urea.  If  this  is  so, 
then  it  is  impossible  to  increase  the  uric  acid  in  a 
man's  body  and  blood  by  administering  it  in  his  food. 
Thus  almost  the  only  way  in  which  a  man  can  come 
to  have  excess  of  this  substance  in  his  body  and 
blood  is  by  excessive  formation.  That  some  have 
such  e.\cessive  formation  and  suffer  from  excessive 
uric  acid  as  the  result  of  it,  is  the  belief  of  those  who 
write  about  the  '  uric-acid  diathesis.'  "  Dr.  Haig  then 
states  that  as  the  result  of  investigations  he  found  that 
uric  acid  did  get  into  the  blood  and  eventually  into 
the  urine,  and  that  from  further  investigations  he  has 
completely  convinced  himself  that  to  speak  of  "  a  uric- 
acid  diathesis"  is  altogether  misleading.  He  thinks 
the  excess  of  uric  acid  in  the  body  and  all  the  diseases 


to  which  it  gives  rise  can  be  quite  as  well  accounted 
for  by  the  gradual  accumulation  of  the  quantities 
daily  swallowed  in  the  food.  When  a  diet  in  every 
respect  free  from  all  uric  acid  has  been  tried,  and 
when  the  urine  of  the  individual  who  has  thus  been 
dieted  has  been  found  quite  free  from  uric  acid,  then 
Dr.  Haig's  assumption  undoubtedly  will  be  accepted; 
but  as  yet  the  theory  needs  support. 


Dr.  H.  Davison  Schwarschild  announces  that  he 
has  assumed  the  name  of  Dr.  H.  Davison  Saril,  by 
virtue  of  an  order  of  the  supreme  court. 

Prof.  Adami,  of  McGill  Universit}-,  Montreal,  has 
accepted  the  invitation  of  the  University  Medical  Col- 
lege to  deliver  a  course  of  lectures  on  general  pathol- 
og)'.     The  course  began  on  Friday,  October  8th. 

St.  Mark's  Hospital  Alumni  Association.  —  The 
graduates  of  St.  Mark's  Hospital  have  formed  an 
alumni  association.  Meetings  will  be  held  monthly 
at  the  hospital.  The  ofBcers  are  Dr.  L.  F.  Gar- 
xigw&s.  President ;  Dr.  Martin  J.  Schuh,  6^iT^/arj',-  Dr. 
Casper  Stock,  Treasurer. 

The  American  Laryngological,  Rhinological,  and 
Otological  Society. — The  fourth  annual  meeting  of 
this  society  will  be  held  in  Pittsburg,  Pa.,  on  May  i  \ 
and  12,  1898.  The  president  is  Dr.  William  H. 
Daly,  of  Pittsburg,  Pa. ;  and  the  secretan,',  Dr.  Robert 
C.  Myles,  46  West  Thirtj'-eighth  Street,  New  York 
City. 

A  State  Medical  Examination  in  England. — Mr. 
Victor  Horsley  is  a  candidate  for  the  vacancy  in  the 
General  Medical  Council.  At  a  recent  meeting  of 
medical  men  he  delivered  an  address,  in  which  he  de- 
clared in  favor  of  what  he  called  the  one  portal  sys- 
tem^ — that  is,  a  single  State  examination  instead  of  the 
dozen  or  more  conducted  by  various  corporations  and 
schools,  on  which  the  authorities  at  present  are  em- 
powered to  grant  medical  diplomas. 

Opposition  to  the  Establishment  of  a  Sanato- 
rium.— The  New  York  State  board  of  health  recently 
asked  the  attorney -general  to  give  an  opinion  as  to 
whether  a  local  board  of  health  has  the  right  to  pre- 
vent the  establishment  within  its  jurisdiction  of  a 
sanatorium  for  the  treatment  of  pulmonary  tuberculo- 
sis. A  physician  of  this  city  had  made  application  to 
the  village  authorities  of  Liberty,  in  Sullivan  Countj-, 
for  permission  to  establish  one.  The  application  was 
refused  on  the  ground  that  its  existence  would  be  a 
menace  to  the  general  health  of  the  village.  He  ap- 
pealed to  the  State  board  of  health  for  the  annulment 
of  the  decision  of  the  local  board.  In  response  to  this 
request,  Attorney-General  Hancock  has  written  an 
opinion,  in  which  he  says  that  "  the  members  of  the 
State  board  of  health  are  sufficiently  familiar  with  the 
disease  called  tuberculosis  to  advise  whether  such  a 
resolution  as  has  been  adopted  is  reasonable  or  proper. 
In  my  opinion  the  mere  fact  that  this  disease  is  com- 


October  9,  1897] 


MEDICAL    RECORD. 


527 


municable  under  certain  circumstances  would  not  jus- 
tify an  ordinance  or  regulation  preventing  the  estab- 
lishment of  a  properly  regulated  sanatorium  within 
the  corporate  limits  of  the  village." 

A  Modern  Epidemic  of  Mediaeval  Type.— A  strik- 
ing proof  that  the  great  plagues  of  antiquity  and  the 
middle  ages  are  kept  away  only  by  modern  sanitarj- 
measures  is  furnished  by  the  epidemic  of  t)'phoid  fever 
now  raging  at  Maidstone  in  England.  In  this  town 
of  thirty-two  thousand  souls  there  are  more  than  thir- 
teen hundred  cases  of  typhoid  fever,  the  greater  pro- 
portion of  them  among  the  well-to-do.  The  streets 
are  nearly  deserted,  the  shops  are  closed,  the  church 
bells  are  silent.  The  origin  of  the  epidemic  is  most 
evident,  and  the  presence  of  the  disease  is  a  disgrace 
to  the  sanitar)-  authorities.  Ninet)--si.x  per  cent,  of  all 
the  cases  have  been  traced  to  one  water  supply,  which 
receives  the  drainage  from  a  field  where  there  was  an 
encampment  of  hop  pickers.  The  first  cases  of  the 
fever  occurred  just  tivo  weeks  after  the  hop  pickers 
arrived  from  London.  These  people  were  huddled  to- 
gether like  sheep  and  lived  under  frightfully  insani- 
tarj'  conditions,  more  like  swine  than  human  beings. 
The  attention  of  the  authorities  has  been  called  to  this 
state  of  affairs  in  previous  years  during  the  hop-pick- 
ing season,  but  they  did  nothing  to  avert  the  danger. 

The  Surgeon-General  of  the  Navy The  President 

has  appointed  Dr.  Newton  C.  Bates  surgeon-general 
and  chief  of  the  bureau  of  medicine  and  surgery  of 
the  navy,  .to  succeed  Surgeon-General  Tryon.  Dr. 
Bates  is  an  old  friend  of  Mr.  McKinley,  and  has  been 
his  family  physician  since  the  inauguration. 

American  Medical  Association  of  Colored  Physi- 
cians.— The  second  biennial  session  of  the  American 
Medical  Association  of  Colored  Physicians  will  be 
held  at  Nashville,  Tenn.,  October  15th  and  i6th.  A 
number  of  papers  has  been  promised  by  the  leading 
colored  physicians  of  the  North  and  South. 

Obituary  Notes. — Dr.  James  T.  Sothorax,  of 
Washington,  died  in  that  city  on  September  27th,  aged 
fifty-five.  He  was  a  native  of  Maryland,  but  had  re- 
sided in  the  District  of  Columbia  since  early  youth. 
During  the  civil  war  he  served  as  a  medical  cadet  in 
one  of  the  army  hospitals  at  Washington.  He  was  a 
graduate  of  the  medical  department  of  the  University 
of  Georgetown  in  1865. — Dr.  William  P.  Jones,  of 
Nashville,  died  in  that  city  on  September  2Sth,  aged 
sevent\--eight  years.  He  was  a  native  of  Adair  Coun- 
t}%  Ky.,  and  had  been  a  resident  of  Tennessee  for 
nearly  fifty  years.  Dr.  Jones  had  been  postmaster  of 
Nashville  and  president  of  the  Nashville  Medical  Col- 
lege. He  was  a  graduate  of  the  Medical  College  of 
Ohio  in  1854. — Dr.  Samuel  J.  Craig,  who  was  at- 
tached to  the  Ward's  Island  Hospital,  died  September 
30th,  at  the  home  of  his  father  in  Williamsburg,  of 
typhoid  fever.  He  was  nvent)--si.x  years  old,  and 
graduated  three  years  ago  from  the  College  of  Physi- 
cians and  Surgeons  in  this  cit)\ — Dr.  Charles  'I". 
Rvax,  of  this  city,  died  on  October  ist,  aged  fiity 
vears.      He  was  a  graduate  of  Bellevue  Medical   Col- 


lege, but  never  practised  medicine. — Dr.  Robert  N. 
FuiGG,  of  Yonkers,  died  in  this  city  on  September 
30th,  from  injuries  received  by  jumping  out  of  a  win- 
dow while  insane.  He  had  been  ill  for  some  time, 
but  was  thought  to  be  better,  and  had  been  married 
only  a  short  time  before  his  death. ^ — Dr.  Joseph  J. 
Sweet,  Jr.,  of  Albany,  died  in  the  City  Hospital 
there  on  October  3d.  He  was  bom  in  New  Hamp- 
shire in  1865,  and  was  graduated  from  the  Albany 
Medical  College  in  1894. 

The  Health  of  New  York  State, — According  to 
the  bulletin  of  the  State  board  of  health  for  August, 
the  total  number  of  deaths  during  the  month  was 
10,084,  which  is  2,300  less  than  in  August,  1896,  and 
is  almost  500  less  than  the  average  for  August  for  the 
last  ten  years.  Last  year  there  were  1,125  deaths  from 
sunstroke  during  the  month  of  August,  but  very  few 
during  the  same  month  this  year.  In  the  cities  of  New- 
York  and  BrookhTi  there  were  1,750  fewer  deaths  than 
in  the  corresponding  month  last  year.  The  death  rate 
for  the  month  was  18.75,  against  23.25  last  year. 

Hotel  Suicides. — On  the  last  day  of  September  there 
were  seven  attempts  at  suicide  in  different  hotels  in 
this  cit}-,  all  of  which  were  successful.  Six  persons 
found  death  by  inhalation  of  illuminating  gas,  and  one 
died  by  jumping  from  a  window. 

The  Plague  in  Bombay  is  rapidly  assuming  its 
former  proportions.  During  the  last  week  of  Septem- 
ber there  were  sixty  deaths  from  that  disease  in  the 
city  of  Bombay,  and  many  more  in  the  presidency. 
The  plague  has  reappeared  in  Kurrachee  and  is 
spreading  to  other  towns,  having  already  invaded 
Sholapur. 

Dr.  A.  E.  Sansom,  president  of  the  Medical  Soci- 
ety of  London,  well  known  to  Americans  through  his 
writings  on  diseases  of  the  circulatory  system,  has 
been  elected  an  honorary  member  of  the  Therapeutical 
Societ)'  of  Moscow. 

Dr.  Eng,  a  Chinese  lady,  said  to  be  a  graduate  of 
the  Women's  Medical  College  in  Philadelphia,  has 
been  appointed  physician  to  the  women  of  the  house- 
hold of  Li  Hung  Chang.  She  has  also  been  ap- 
pointed, with  Miss  Wang,  a  delegate  from  China  to 
the  Worhen's  Congress  which  is  to  be  held  in  London 
in  1898. 

Dr.  William  L.  Rodman,  of  Louisville,  has  been 
called  to  the  chair  of  the  principles  and  practice  of 
surger)'  and  clinical  surgery  in  the  Medico-Chirurgi- 
cal  College  of  Philadelphia.  He  will  deliver  a  course 
of  lectures,  didactic  and  clinical,  between  October  i, 
1897,  and  January  i,  i8g8,  and  will  then  resume  his 
work  in  the  Kentucky  School  of  Medicine,  where  he 
has  held  the  chair  of  surgery  for  several  years. 

Professor  Virchow  and  the  Lady  Doctors. — .\fter 
the  scientific  proceedings  of  the  International  Medical 
Congress  at  Moscow  had  been  brought  to  a  close,  a 
deputation  of  Russian  lady  doctors  waited  on  Prof. 
Rudolf  Virchow,  who  received  them  in  the  apartments 
assigned  to  him  by  the  Czar   in  the  Krenilin.     The 


528 


MEDICAL    RECORD. 


[October  9,  1897 


spokeswoman  of  the  deputation  thanked  the  great  pa- 
thologist in  the  name  of  her  professional  sisters  for  his 
championship  of  the  cause  of  the  medical  education  of 
women.  Professor  Virchow,  in  returning  thanks, 
spoke  highly  of  the  ability  shown  by  Russian  female 
students  of  medicine,  and  expressed  the  opinion  that 
the  Medical  Institute  for  Women,  recently  opened  in 
St.  Petersburg,  had  a  future  of  usefulness  before  it. 
He  invited  the  Russian  lady  doctors  to  make  free  use 
of  his  Anatomico-Pathological  Institute  if  they  ever 
had  occasion  to  visit  Berlin. — British  Medical  Journal. 

Dispensary  Abuse  in  Philadelphia — The  mana- 
gers of  the  Presbyterian  Hospital  in  Philadelphia,  in 
conjunction  with  the  medical  staff,  have  instituted  an 
inquiry  into  the  extent  of  the  abuse  of  its  privileges 
by  those  who  are  able  to  pay.  The  result  of  a  careful 
investigation  shows  that  about  twenty  per  cent,  of  those 
who  are  treated  freely  in  the  out-patient  department 
are  not  proper  subjects  for  charity;  about  half  of  these 
are  willing  to  pay  moderate  fees,  but  apply  because 
their  friends  are  treated  gratuitously  and  successfully; 
they  have  no  family  physician.  They  have  no  incen- 
tive to  seek  medical  attention  outside  when  it  is  so 
easy  to  get  advice  free  of  charge  in  institutions.  A 
plan  of  personal  visitation  will  be  adopted,  by  which 
an  effort  will  be  made  to  give  sen'ices  only  to  those 
who  are  really  unable  to  pay  for  medical  attendance; 
thus  the  needy  poor  will  receive  more  satisfactory 
treatment  and  the  objects  for  which  the  founders  and 
contributors  of  such  an  institution  maintain  it  will  be 
conserved.  Co-operation  by  other  hospitals  will  help  to 
remedy  a  great  evil. — Internatiojial  Aledical  Magazine. 

Dr.  Alarik  Frithiof  Holmgren,  professor  of  physi- 
ology at  the  University  of  Upsala,  died  recently  at  the 
age  of  sixty-five  years.  He  graduated  in  medicine  in 
186 1,  and  was  called  to  the  chair  of  physiology  by  his 
alma  mater  in  1864.  He  was  best  known  abroad  per- 
haps by  his  labors  in  relation  to  color  blindness,  and 
the  worsted  test  for  color  perception  is  known  as 
Holmgren's  test.  He  was  founder  and  editor  of  the 
Skandinavian  Archives  of  Physiology,  and  was  president 
of  the  International  Physiological  Congress. 

A  Well-Equipped  Medical  School — Among  the 
million  or  more  medics]  colleges  in  this  great  country 
there  is  one  with  thirty-eight  professors,  twenty-three 
assistant  professors  and  instructors,  and  fifty-one  stu- 
dents. This  gives  one  professor,  assistant  professor, 
or  instructor  to  each  student,  with  ten  left  over.  It  is 
suggested  that  a  new  medical  journal  be  started,  to 
give  the  idle  ten  something  to  do. 

War  by  Anaesthesia. — A  Russian  chemist  is  re- 
ported by  the  British  and  Colonial  Druggist  to  have 
discovered  a  substance  with  most  powerful  anesthetic 
properties,  which  exerts  its  influence  over  a  wide  area 
even  when  greatly  diluted  with  air.  It  is  proposed  to 
determine  whether  it  will  not  be  possible  to  inclose 
the  anresthetic  in  bombs,  which  could  be  thrown  into 
an  enemy's  ranks  and  there  exploded,  thus  anesthetiz- 
ing large  bodies  of  troops  and  rendermg  them  an  easy 
prey.  This  would  give  a  new  application  to  the 
phrase,  "  putting  one's  adversary  to  sleep." 


A  Quarrel  of  Kneipp's  Successors — Dr.  Baum- 
garten  and  Father  Reile  are  engaged  in  a  sharp  strug- 
gle to  determine  which  shall  be  the  successor  of  the 
late  Father  Kneipp  in  the  management  of  the  water- 
cure  establishments  at  Woerishofen.  The  newspa- 
pers, inhabitants,  and  patients  are  taking  sides  in  the 
quarrel,  and  a  manifesto  signed  by  two  hundred  pa- 
tients has  just  been  published  against  Father  Reile 
and  in  support  of  Baumgarten. 

A  Suit  against  Montreal — A  bicyclist,  while  rid- 
ing his  wheel  on  one  of  the  public  streets  of  Montreal, 
fell  and  was  severely  injured.  He  attributes  his  fall 
to  the  bad  condition  of  the  roads,  and  thinks  the  city 
can  be  made  by  law  to  keep  good  roads,  since  it  forces 
all  wheelmen  to  pay  a  tax  for  the  privilege  of  riding 
on  them.     He  sues  for  $5,000  damages. 

Ferran's  Anti-Cholera  Injections. — Dr.  Ferran,  of 
Barcelona,  recently  sent  a  communication  to  the  Paris 
Academy  of  Medicine,  in  which  he  seeks  to  establish 
his  claim  of  priority  in  the  treatment  of  cholera  by 
anticholeraic  injections,  as  practised  by  him  in  Spain 
in  1885.  It  was  objected,  however,  that  the  results  of 
these  injections  were  not  always  as  favorable  as  Fer- 
ran claimed ;  indeed,  the  treatment  was  said  to  have 
been  so  injurious  that  it  was  formally  forbidden  by 
the  Spanish  government.  Furthermore,  Ferran  re- 
fused in  1885  to  give  up  the  formula  of  the  composi- 
tion of  his  vaccine,  and  still  persists  in  this  refusal. 
Under  these  conditions  the  academy  has  declared  that 
it  can  neither  give  any  decision  as  to  the  curative  vir- 
tues of  a  preparation  of  which  it  knows  nothing,  nor 
give  any  support  to  Dr.  Ferran  in  his  claim  for  pri- 
orit}-. 

A  Leper  Hospital  in  Iceland. — The  Odd  Tel  lows 
in  Denmark  have  recently  raised  by  subscription 
about  $30,000  to  build  a  hospital  for  lepers  in  Iceland. 
The  city  of  Reykjavik  has  presented  for  the  site  the 
peninsula  Langarnaes,  which  is  about  two  miles  out 
of  town,  and  all  running-expenses  are  to  be  borne  by 
the  government  of  Iceland.  A  law  has  recently  been 
passed  by  the  Althing  empowering  the  health  authori- 
ties in  the  island  to  compel  the  isolation  of  patients 
wherever  such  a  precautionary  measure  seems  to  be 
necessary.  The  erection  of  the  hospital  is  the  direct 
outcome  of  an  investigation  by  Dr.  Edward  Ehlers  of 
leprosy  in  Iceland,  which  showed  that  the  disease  is 
steadily  on  the  increase  while  little  has  been  done 
hitherto  to  prevent  its  spread. 

End  of  the  Small-pox  in  Montreal. — The  health 
authorities  of  Moirtrcal  have  declared  that  the  small 
epidemic  of  small-pox,  from  which  the  city  has  suffered 
for  some  time,  is  now  over,  there  having  been  no  cases 
there  for  upward  of  three  weeks. 

Trichinous  Pork  in  Germany. — .\  man  in  Cologne 

was  recently  detected  selling  trichinous  pork,  and 
when  brought  up  for  trial  said  the  hams  and  sides  of 
bacon  were  of  American  origin  and  in  their  original 
packages,  but  the  evidence  at  the  trial  disproved  this. 
All  the  trichinous  hams,  fourteen  hundred  and  ninety 
altogether,  had  been  imported  from  Servia. 


Octxiber  9,  1897] 


MEDICAL    RECORD. 


529 


^cuicxus  and  ^ottcea. 

The  American  Text-Book  of  Operative  Den- 
tistry. In  contributions  by  eminent  American  Author- 
ities. Edited  by  Edward  C.  Kirk,  D. D.S.,  Professor 
of  Clinical  Dentistr>',  University  of  Pennsylvania.  Depart- 
ment of  Dentistry'.  Philadelphia:  Lea  Brothers  &  Co 
1897. 

One  whose  knowledge  of  dentistrj-  was  obtained  only  a  few- 
years  ago  but  who  has  not  kept  thoroughly  in  touch  with 
the  rapid  advances  in  this  branch  of  medical  science  would 
be  astonished  on  opening  this  work  to  see  what  has  been 
accomplished  Ln  tlie  past  decade ;  almost  a  new  science  has 
been  created.  Dentistry  is  sometimes  regarded  as  a  special 
branch  of  surger)-,  but  in  reality  it  is  a  profession  in  itself, 
divided  iruo  almost  as  many  specialties  as  is  the  profession 
of  medicine.  Because  of  this  high  specialization  the  prepa- 
ration of  this  work  has  been  intrusted  to  many  hands,  the 
writers,  in  addition  to  the  editor  Dr.  Kirk,  being  Drs.  R.  R. 
Andrews,  H.  H.  Burchard,  C.  S.  Case,  W.  E.  Christensen, 
D.  M.  Clapp,  M.  H.  Cr>'er  E.  T.  Darby,  C.  L.  Goddard, 
L.  H.  Guilford,  Louis  Jack,  L.  Ottofy,  C.  N.  Pierce,  J.  D. 
Thomas,  and  A.  H.  Thompson. 

The  work  is  dinded  into  three  parts,  dealing  respectively 
with  (1)  dental  anatomy,  histologj-,  and  embrjology- ;  (2) 
operative  dentistrJ^  and  (3)  dental  orthopsedics,  including 
orthodontia  and  the  modification  of  facial  contours.  The 
subject  of  prosthetic  dentistr)-,  including  crown  and  bridge 
work,  is  touched  upon  only  incidentally,  the  reader  being 
referred  to  a  companion  volume  for  the  discussion  of  this 
interesting  subject.  The  volume,  while  intended  primarily, 
of  course,  for  the  use  of  practising  dentists,  will  be  found  of 
great  interest  and  utility  to  physicians  as  well,  not  only  be- 
cause an  intelligent  conception  of  this  cognate  science  is  an 
accomplishment,  but  also  because  physicians  are  often  called 
upon  to  do  more  or  less  dental  work,  and  in  any  event 
should  be  able  to  recognize  the  nature  of  buccal  disorders 
and  to  decide  which  belong  properly  within  the  domain  of 
the  dental  surgeon.  The  book  is  profusely  illustrated, 
handsomely  printed,  and  well  bound. 

Encyklopaedie  der  Therapie.  Herausgegeben  von 
Oscar  Liebreich,  Dr.  Med.,  Geheimer  Medicinalrath, 
0.6.  Professor  der  Heilmittellehre  an  der  Friednch-\\il- 
helms-Universitat,  unter  Mitwirkung  von  ^Lartin  Men- 
delsohn, Dr.  Med.,  Privatdocent  cler  inneren  Medicin  an 
der  Friedrich-Wilhelms-L'niversitat,  und  .Arthur 
WuRZBURG,  Dr.  Med.,  Kgl.  Sanitatsrath,  Bibliothekar 
im  Kaiserlichen  Gesundheitsamte.  Zweiter  Band,  II. 
Abtheiltmg,  I.  Lieferung.  Berlin :  August  Hirschwaid 
1897. 

This  first  section  of  the  second  part  of  the  second  volume 
of  this  e.xcellent  cyclopedia  of  therapeutics  carries  the  work 
as  far  as  Gly.  Among  the  more  important  titles  are  flatu- 
lence, foreign  bodies,  furuncle,  bile,  gall-bladder,  galvano- 
cautery,  gangrene,  gastritis,  secret  remedies,  brain,  apoplexy, 
brain  surgerj-,  cerebral  meninges,  mental  diseases,  articular 
rheumatism,  gout,  facial  atrophy,  oedema  of  the  glottis, 
glycerin,  licorice,  and  glossitis.  The  high  standard  of  this 
valuable  work  is  fully  maintained  in  the  present  fasciculus. 

A  Handbook  of  Medical  Climatology.  Embodying 
its  Principles  and  Therapeutic  Application,  with  Scientitic 
Data  of  the  Chief  Health  Resorts  of  the  World.  By 
S.  Edwin  Sollv.  M.D.,  M.R.C.S.,  late  President  of 
the  American  Climatological  Association.  Illustrated  in 
black  and  colors.  Philadelphia:  Lea  I'.rothers  &  Co. 
1897. 

This  is  an  attempt,  and  a  fairly  successful  one.  to  meet  the 
want,  which  has  long  been  felt,  of  an  authoritative  work  on 
climatotherapy.  The  work  is  divided  into  three  parts,  the 
first  dealing  broadly  with  climatology  in  general  and  medical 
climatotherapy  in  particular ;  the  second  treating  of  climato- 
theraphy,  strictly  speaking ;  and  the  third  describing  special 
climates  and  individual  health  resorts.  All  parts  of  the 
world  are  considered,  and  the  principal  resorts  of  Europe  in 
especial  are  described  as  regards  the  indications  which  they 
offer  in  the  management  of  individuals,  yet  naturally  the  re- 
sorts in  the  United  States  receive  particular  attention  and 
arc  described  at  greatest  length.     The  author,  as  might  be 


expected,  betrays  an  enthusiastic  admiration  of  the  climate 
of  Colorado,  which  is  not  shared  by  all  who  have  experi- 
enced its  rigors.  Vet  his  praise  is  innocent  enough,  and  the 
reader  can  temper  it  sufficiently  by  noting  the  temperature 
statistics.  The  book  is  provided  with  a  number  of  charts 
showing  elevation,  rainfall  for  different  seasons,  etc.  We 
can  safely  recommend  Dr.  Solly's  work  to  all  who  need  a 
book  of  reference  on  climatotherapy,  and  this  means  all 
practising  physicians. 

The  Pocket  Therapist.  A  Concise  Manual  of  Modern 
Treatment  for  Students  and  Junior  Practitioners.  (Ar- 
ranged alphabetically  for  ready  reference.)  By  Thos. 
Stretch  Dowse,  M.D..  F.R.'C.P.  Ed.  Bristol:  John 
Wright  &  Co.      1897. 

This  is  a  useful  little  work  which  contains  many  a  hint  as  to 
treatment  that  may  serve  one  in  good  stead  when  worried 
by  an  obstinate  case.  The  author  has  not  jumbled  together 
a  mass  of  prescriptions  for  every-  imaginable  malady,  but 
suggests  usually  one  line  of  treatment  for  each  disease, 
recommending  in  many  cases  that  which  he  has  found  by 
practical  experience  to  be  of  greatest  value. 

The  Diseases  of  Women.  A  Handbook  for  Students 
and  Practitioners.  By  J.  Bland  Sutton.  F.R.C.S. 
Eng.,  Surgeon  to  the  Chelsea  Hospital  for  Women,  As- 
sistant Surgeon,  Middlesex  Hospital.  London;  and 
Arthur  E.  Giles,  M.D.,  B.Sc,  F.R.C.S.  Edin.,  As- 
sistant Surgeon,  Chelsea  Hospital  for  Women,  London. 
With  115  illustrations.  Philadelphia:  W.  B.  Saunders. 
1S97. 

This  is  a  handy  volume  of  small  size.  The  entire  subject 
of  gynaecology  is  satisfactorily  covered  in  the  four  hundred 
and  thirty  pages,  though  necessarily  the  different  topics  are 
treated  with  considerable  brevity  and  conciseness  of  language. 
The  binding  is  poorly  done,  many  of  the  pages  ha\ing  be- 
come loose  during  the  reading  of  the  book  by  the  reviewer. 

The  Ophthalmoscope.  A  Manual  for  Students.  By 
Gust.avus  Hartridge,  F.R.C.S..  Surgeon  to  the 
Royal  Westminster  Ophthalmic  Hospital,  Ophthalmic 
Surgeon  to  St.  Bartholomew's  Hospital,  Chatham,  etc. 
Third  Edition.  Philadelphia:  P.  Blakiston,  Son  &  Co. 
1897. 

These  instructions  in  the  use  of  the  ophthalmoscope  are 
exceedingly  clear  and  understandable,  and  any  one  who  might 
find  it  necessary  to  learn  how  to  use  this  really  indispensable 
instrument,  and  had  not  the  advantage  of  a  teacher,  could 
almost  certainly  teach  himself  by  means  of  this  book.  The 
comprehension  of  the  text  is  greatly  facilitated  by  the  illus- 
trations, of  -vvhich  there  are  over  seventy,  some  of  them 
colored. 

Notes  on  Pathology.  For  Students'  Use.  By  W.  A. 
Ev.-iNS,  B.Sc,  M.D.,  Professor  of  Pathology  in  the  Med- 
ical School  in  the  University  of  Illinois,  Professor  of 
Pathology  in  the  Milwaukee  Medical  College,  Patholo- 
gist to  the  Columbus  Medical  Laboratorj-,  etc.  Chi- 
cago: The  W.  T.  Keener  Company.      1897. 

These  "notes"  are  well  and  systematically  arranged; 
probably  after  the  order  of  the  author's  lectures,  and  so 
will  ser\-e  admirably  for  the  use  of  those  who  have  the  privi- 
lege of  sitting  under  his  instruction.  But  other  students 
may  profit  by  them  as  well,  and  can  take  their  own  notes 
when  the  lecturer  expresses  his  facts  in  another  way.  To 
facilitate  this  extra  note  taking,  the  book  is  so  printed  that 
ever)-  other  page  is  blank.  The  book  is  of  a  handy  size  to 
be  carried  to  the  lecture  room. 

A  Text-Book  of  Diseases  of  Women.  By  Charles 
B.  Penrose,  M.D.,  Ph.D.,  Professor  of  G>-nsBcolog)^  in 
the  Universit)'  of  Pennsylvania,  Surgeon  to  the  Gynecean 
Hospital,  Philadelphia.  Illustrated.  Philadelphia:  W. 
B.  Saunders.      1897. 

The  appearance  of  a  new  work  on  gj-ntecology  at  this  time 
does  not  strike  us  as  in  response  to  an  urgent  demand  from 
a  profession  thirsting  for  knowledge  on  an  obscure  subject. 
This  book,  however,  possesses  the  advantage  of  having  been 
written  professedly  for  the  student,  and  may  possibly  there- 
fore be  of  service  to  the  practitioner  who  grudges  the  time 
wasted  in  reading  details  of  anatomy  and  physiology.      Dr. 


550 


MEDICAL    RECORD. 


[October  9,  1897 


Penrose  refers  his  readers  to  the  ordinary  anatomical  tcM- 
books  if  they  lack  the  necessary  familiarity  with  these  ele- 
ments. In  discussing  treatment,  the  author  recommends 
usually  but  one  method  for  each  individual  disease,  thereby 
avoiding  creating  confusun  in  the  mind  of  the  student  or 
young  practitioner  who  turns  to  the  work  for  instruction. 
The  illustrations  are  fairly  artistic  and  are  for  the  most  ])art 
helpful. 

CnNVl.KGEXT    STK.VI'.IS.ML'.S    AND     iTS      rRF..\T.MKM  .        By 

EiiwiN  HoLTHolsE,  M.A.,  F.R.C.S.,  Surgeon  to  the 
Western  Ophthalmic  Hospital.  Philadelphia:  P.  ISlakis- 
ton,  Son  &  Co.      1897. 

This  is  an  essay  based  upon  a  careful  study  of  the  cases  of 
squint  coming  under  treatment  during  a  period  of  about 
two  years  in  one  of  the  classes  at  the  Royal  London  Oph- 
thalmic Hospital.  The  author  shows  quite  conclusively  that 
strabismus  is  not  such  a  threshed-out  subject  as  it  is  gener- 
ally supposed  to  be,  for  he  advances  much  that  is  novel  in 
this  study,  and  makes  suggestions  that  may  well  serv-e  as  a 
basis  for  other  and  further  investigations  in  this  interesting 
field. 

Crime  asu  Cri.minals.  By  J.  Sanderson  Chris- 
TISON,  M.D.,  formerly  of  the  New  York  City  Asylums 
for  the  Insane,  BlackwelKs  Island  and  Ward's  Island, 
etc.     Chicago-  The  \V.  T.  Keener  Company.      1897. 

Dr.  Chris'd.son  may  well  pray  to  be  saved  from  his 
friends,  for  he  states  in  his  preface  that  it  was  they  who 
urged  him  to  publish  in  book  form  a  series  of  articles  con- 
tributed to  the  Chicago  TrihiiHi-.  .Separately  the  sketches 
of  types  of  criminals  might  have  served  to  amuse  the  read- 
ers of  a  Sunday  edition,  but  collectively  they  lack  unity, 
weight,  and  all  the  qualities  necessary  to  make  a  useful 
treatise  on  criminal  anthropology  or  any  other  subject. 

Die  GESCHICHTLILHE  Entwickelung  der  sogenann- 

TEN      HiPPOKRATlSCHEN      MeDICIN      IM     LICHTE     DER 

NEUESTEN  FoRSCHUNG.  Eine  geschichtlich-medicinische 
Studie.  \'on  Dr.  Med.  Franz  Spaet.  Berlin:  S. 
Karger.      1897. 

Thls  is  an  interesting  study,  by  a  man  who  knows  his  sub- 
ject, of  the  teachings  of  Hippocrates  and,  incidentally,  of 
their  influence  upon  the  development  of  scientific  medicine  of 
the  present  day.  The  brochure  is  a  valuable  addition  to  the 
literature  of  historical  medicine. 

The  Edinburgh  Medical  Tolrnal.  Edited  bv(..  .\. 
Gibson,  M.D.,  F.R.C.P.  Ed.  New  .Series.  Vol.  1. 
Edinburgh  and  London:  Young  J.  Pentland.      1897. 

This  bound  volume  of  the  first  of  the  new  series  of  <his  old 
established  journal  is  one  which  the  new  editor  may  well  regard 
with  pride.  It  is  filled  with  articles  of  permanent  value, 
written  by  well-known  authorities,  and  is  profusely  and  ex- 
cellently illustrated. 

DiFFERENTi.\i.  Diagnosis  and  Treatment  ok  Com.v, 
Embracing  Points  in  the  Lectures  of,  and  Revised  by, 
A.  P.  Grin.xell,  M.D.,  .Medical  Department,  Univer- 
sity of  \"ermont.  Arranged  by  Georg.e  X.  Htn  it.ev, 
M.D.,  Burlington,  Vt. 

This  is  a  well-arranged  table  of  the  chief  points  in  the 
differential  diagnosis  of  the  various  forms  of  coma.  .Vm- 
bulance  surgeons  and  police  surgetms,  the  former  especially, 
might  avoid  many  serious  and  humiliating  blunders  if  they 
would  make  themselves  thoroughly  familiar  \\ith  the  sjTnp- 
toms  of  the  different  states  of  unconsciousness  as  arranged 
■n  this  chart. 

lilSEASES  OK  THE  LlVER,  GaLL  BI. ADDER,  AND  BILI- 
ARY .System.  Their  Pathology,  Diagnosis,  and  .Sur- 
gical Treatment.  By  H.  J.  ^VAR1NG,  M.S.,  B..Sc. 
Lond.,  F.  R.C.S.  New  York  :  The  Macmillan  Companv. 
1897. 

.After  a  concise  description  of  the  anatomy  and  physiolog\- 
of  the  liver,  the  author  describes  in  an  exhaustive  ami 
thorough  way  all  the  diseases  of  this  organ  and  its  attach- 
ments. Waring  does  not  recognize  a  '•  hematogenic" 
jaundice,  and  is  herein  in  harmony  with  most  recent  writers; 
for  it  has  been  conclusively  proved  that  if  the  liver  be  ex- 
tirpated, or  rendered  functionless  by  isolation,  no  accumula- 


tion of  biliarj-  constituents  results.  The  section  on  symptoma- 
tolog)-  and  diagnosis  of  "abscess  of  the  liver"  is  one  of 
especial  merit  by  reason  of  the  clearness  by  which  the  author 
depicts  the  characteristic  signs  by  which  the  existence  of  this 
condition  can  be  recognized.  The  operative  treatment  in 
affections  of  the  liver  and  gall  liladder  is  given  full  weight 
and  is  minutely  described.  -As  a  whole  the  book  can  be  highly 
recomnien<led  and  the  reader  will  greatly  profit  by  its  perusal. 

Bii.LiiiN  (PI  the  Harvard  Medical  .Alumni  .As- 
soci.\TioN.     No.  10.     Catalogue.     Boston.      1897. 

This  number  is  given  up  almost  wholly  to  the  local  lists  of 
members,  etc.,  including  an  alphabetical  list  of  members 

Illustrated  Skin  Diseases.  .An  Atlas  and  Text-Book, 
with  Special  Reference  to  Modern  Diagnosis  and  the  Most 
.Approved  Methods  of  Treatment.  By  Willi.a.m  S. 
CloTTHEiL,  M.D..  Professor  of  Skin  and  \'enereal  Dis- 
eases at  the  JN'ew  York  School  of  Clinical  Medicine,  etc. 
New  York:  E.  B.  Treat  &  Co.  1897.  Portfolios  7,  8, 
and  9. 

The  uncoiored  pictures  of  this  atlas  are  the  best,  and  in 
saying^  this  we  would  not  convey  the  impression  that  they 
are  above  the  average.  Indeed,  unless  the  label  were  at- 
tached, difficulty  would  at  times  be  found  in  telling  whether 
an  eruption  were  papular  or  pustular,  and  the  old  lady  with 
furunculosis  of  the  face  might  as  well  have  been  said  to  have 
one  of  a  half-dozen  affections.  The  tints  of  the  lesions,  of 
the  surrounding  healthy  skin,  of  the  hair)'  portion,  and  of 
the  background  do  not  show  sufficient  contrast,  and  it  is 
difficult  to  tell  in  some  of  the  lithographs  whether  the  blue- 
ness  of  the  skin  is  a  pathologic  or  an  artistic  effect.  There 
have  been  so  many  skin  atlases  produced  of  late  that  one 
scarcely  sees  what  field  can  be  filled  by  works  other  than 
those  of  exceptional  merit  of  production.      The  text  is  good. 

Excretory  Irritation  and  the  .Action  of  Certain 
Internal  Remedies  on  the  Skin.  By  David 
Walsh,  M.D.  Ed.,  Physician  to  the  Western  Skin 
Hospital,  London,  W.  London :  Bailliere.  Tindall  & 
Cox.      1 897. 

This  is  a  little  work  of  sixty  odd  pages,  neatly  bound  in  red, 
comprising  an  inaugural  thesis  and  a  paf)er  read  at  the  Lon- 
don Congress  of  Dermatology-.  The  theor)-  is  maintained 
that  certain  eruptions  are  due  to  direct  irritation  of  excretor%- 
glands  in  the  skin,  and  that  if  the  theory  is  correct  their  in- 
ternal disorders  must  often  depend  upon  a  like  cause.  On 
page  61,  where  Dr.  Duhring  of  New  A"ork  is  referred  to,  the 
author  probably  means  Dr.  Duhring  of  Philadelphia. 

Om  Endokardit,  dens  Pathologiske  Anatomi  og 
.liTiOLOGL  Af  Francis  Harbitz,  iste  Assistant  ved 
Rigsho.spitalets  Pathologisk-.Anatomiske  Institut.  Kris- 
tiania:  .Steenske  Bogtr\'kkeri.      1897. 

This  work  contains  the  results  of  the  author's  studies  dur- 
ing a  period  of  three  years  in  the  Pathological  Institute  in 
the  public  hospital  at  Christiania.  He  divides  the  cases  into 
two  classes,  according  as  the  endocarditis  is  manifestly  of 
infectious  origin  or  as  a  careful  study  fails  to  demonstrate 
any  such  pathogenesis.  The  book  is  a  valuable  addition  to 
the  world's  literature  of  this  interesting  subject. 

Le  Trattement  nu  Mal  de  Pott.  Par  le  Dr.  .A.  Chi- 
PAULT.     Paris:  Masson  et  Cie.      1897. 

The  author  of  this  brochure  has  recently  revived  the  ancient 
method  of  forcibly  straightening  out  the  kyphotic  spine  in 
Pott's  disease,  and  here  describes  it,  as  well  as  his  method  of 
apophyseal  ligatures.  The  book  is  one  which  orthopaedic 
surgeons  will  read  with  interest,  as  it  is,  we  believe,  the  first 
presentation  in  connected  and  systematic  fonn  of  the  thera- 
peutic measures  so  ably  advocated  by  Dr.  Chipault. 

Formulaire  des .Medicaments  NorvEAUX  pour  1S97. 
Par  H.  BocQUlLl.oN-LlMOUSiN,  Phamiacien  de  Primicre 
Classe,  Laureat,  Medaille  d'Or  de  I'Kcole  de  Phamiacie. 
Membre  des  Societes  de  Pharmacie  et  de  Therapeutique. 
.Avec  uiie  Introduction  par  HENRI  HucHARD,  Membre 
de  r.Academic  de  Medecine.  Medecin  de  I'Hopital  Necker. 
I'aris.  Librairie  J.-H.  Bailliere  et  Fils.     1897. 

This  1897  edition  of  the  '•  Fomiular\"  is  an  improvement  in 
some  respects  over  the  last.      In  others  it  is  not.      Almost 


October  9,  1897] 


MEDICAL    RECORD. 


evervthing  new  in  the  way  of  methods,  modes  of  admhi- 
istration  of  remedies,  was  given  in  the  former  volimie. 
New  remedies,  good  and  bad,  have  been  especially  con- 
sidered in  the  present  \\-ork.  So  many  drugs  still  in  their 
experimental  stage  find  a  place  here  that  it  is  only  those 
who  have  much  time  to  devote  to  their  study  who  will  care 
to  read  the  book  through. 

Periodische  Defressionszustaxde  l'xd  iHRE  Patho- 
genesis. \'on  Prof.  C.  Lange  in  Kopenhagen. 
Deutsch  von  Dr.  Hans  Kurei.i.a.  Hamburg;  Leopold 
Voss.      1 896. 

This  little  work  treats  of  the  blues  in  a  scientific  way,  and 
elevates  the  condition  to  the  dignity  of  an  actual  disease. 
The  author  shows  that  periodical  mental  depression,  while 
resembling  in  some  respects  a  mild  form  of  melancholia,  is 
yet  far  removed  and  easily  differentiable  from  it.  The  cause 
he  finds  to  reside  in  the  action  of  uric  acid  upon  the  nervous 
centres,  and  deduces  from  this  pathogenesis  a  rational 
therapy. 

Some  Aspects  of  Infantile  Syphilis,  being  the 
Hunterian  Lectures  Delivered  at  the  Royal 
College  of  Surgeons  in  1896.  By  J.  A.  Coutts, 
M.B.  Cantab.,  ^LR.C.P.,  formerly  Professor  at  the  Col- 
lege, Physician  to  the  East  London  Hospital  for  Children. 
London;  Rivington,  Percival  &  Co.      1897. 

A  little  book  of  on^  hundred  and  thirt)'  pages,  just  large 
enough  to  take  in  the  pocket  for  an  hour's  journey.  The 
text  is  large  and  pleasing  to  the  eye.  and  the  subject  matter 
is  pleasantly  put. 

The  Retrospect  of  Practical  Medicine  and  Sur- 
gery. Being  a  Half-Yearly  Journal,  Edited  by  James 
Braithwaite,  M.D.  Lond.,  Obstetric  Physician  and 
Surgeon  to  the  Leeds  General  Infirmar\' ;  Assisted  bv  E. 
F.  Trevelyan,  M.D.  Lond.,  B..Sc.,'  M.R.C.I^  Vol- 
ume CXIV.  New  York :  C.  P.  Putnam's  Sons.  Jany- 
ar>',  1897. 

The  "  Retrospect"  maintains  its  general  average  of  excel- 
lence, and  covers  in  a  brief  way  the  literature  of  the  half-year 
in  an  essentially  practical  manner.  The  index,  covering 
several  volumes,  gives  facility  for  looking  up  quickly  any 
given  subject. 

AuToscopv  (jF  the  Larynx  and  the  Trachea. 
Direct  Examination  without  Mirror.  By  Alfred  Kir- 
STEIN,,M.D.,  Berlin.  Authorized  Translation  (Altered. 
Enlarged,  and  Revised  by  the  Author)  by  Max 
Thorner,  A.m.,  M.D.,  Cincinnati,  Ohio,  Professor  of 
Clinical  Laryngology'  and  Otology,  Cincinnati  College 
of  Medicine  and  Surger\-.  Philadelphia :  The  F.  .\. 
Davis  Company.      1897. 

The  aim  of  this  little  work  is  to  show  how  the  air  passages 
can  be  directly  examined  and  treatment  applied  without  the 
use  of  complicated  instruments.  It  is  the  author's  aim  u> 
add  to  prevailing  methods  rather  than  to  supplant  them. 

The  illustrations  add  much  to  the  ready  understanding  of 
the  methods  of  direct  inspection  of  the  lar^-nx  and  trachea 
by  pressure  upon  the  tongue.  The  translation  has  been 
well  done. 

A  Pictorial  Atlas  of  Skin  Diseases  and  Syphilitic 
Affections.  From  the  Museum  of  the  St.  Louis  Hos- 
pital, Paris.  Edited  by  J.  J.  Pringle,  .M.B..  F.R.C.P. 
Parts  \T1I.  and  IX.  London.  The  Rebman  Publishing 
Company,  Ltd.;  Philadelphia    W.  B.  Saunders.      1897. 

The  illu.strations  rn  these  two  numbers  are  in  the  same  class 
as  those  which  have  previously  appeared.  That  of  pustular 
scabies  is  very  true  to  life,  while  the  several  pictures  of  chil- 
blain lupus  give  a  good  idea  of  this  rather  unusual  con- 
dition. The  woodcut  pictures  accompanying  Jacquet's  arti- 
cle on  epithelioma  arising  from  lupus  tissue,  as  well  as  the 
colored  plate,  show  what  fearful  ravages  this  malignam 
disea.se  c;ui  make  in  the  region  of  the  face.  There  is  a  very 
fair  picture  of  lichen  planus,  but  not  of  a  strictly  typical 
case. 

Comparatively,  u  e  cannot  see  wherein  this  work  possesses 
advantage  over  the  large  and  very  complete  atlases  of  Mor- 
row and  of  Taylor,  so  recently  published  in  this  country. 
It  would  almost  seera   as  if  medical-book  publishers  were. 


some  of  them,  overreaching  themselves  in  crowding  upon  the 
profession  such  a  multiplicity  of  books  upon  the  same  sub- 
ject. This,  however,  is  their  affair,  and  our  part  is  only  to 
advise  our  subscribers  that  it  is  well  to  exercise  caution  in 
buying  books,  however  good,  when  they  may  have  already 
in  their  libraries  others  which  are  not  excelled. 

Medical  and  Si'Ri.icAL  Report  of  ihe Presbyterian 
Hospital  in  the  Cnv  of  New  York.  Volume  II. 
January,  1897.  Edited  by  Andrew  J.  McCosH,  M.D., 
and  Walter  B.  James,  M.D.  New  York;  Trow 
Director\-  Printing  Company. 

Besides  the  usual  number  of  interesting  reports  of  cases  and 
operations,  the  present  volume  is  well  illustrated  with  views 
of  the  hospital  operating-rooms,  etc.,  from  photographs  by 
Dr.  Stevens.  A  well-illustrated  article  on  renal  tuberculosis, 
by  F.  Tilden  Brown,  deser\-es  mention.  Drs.  McCosh  and 
James  are  to  be  congratulated  on  the  appearance  of  the  sec- 
ond volume. 

International  Clinics.  A  (Quarterly  of  Clinical  Lec- 
tures on  Medicine,  Neurology,  Surgery-,  Gyna;colog>-, 
Obstetrics,  Ophthalmology,  Laryngology,  Pharyngology, 
Rhinology,  Otolog)',  and  Dermatology-,  and  Specially 
Prepared  Articles  on  Treatment.  By  Professors  and  Lec- 
turers in  the  Leading  Medical  Colleges  of  the  L'nited 
States,  Germany:  Austria,  France,  Great  Britain,  and 
Canada.  Edited  by  Judson  Daland.  M.D.,  University 
of  Pennsylvania,  Philadelphia;  Instructor  in  Clinical  Medi- 
cine and  Lecturer  on  Physical  Diagnosis  in  the  University 
of  Pennsylvania,  Assistant  Physician  to  the  Hospital  of  the 
University  of  Pennsylvania ;  J.  Mitchell  Bruce,  M.D., 
F.R.C.P.,  London,  England.  Physician  to  and  Lec- 
turer on  the  Principles  and  Practice  of  Medicine  in  the 
Charing  Cross  Hospital;  David  W.  Finlay,  M.D., 
P\R.C.P. ,  London,  England;  Professor  of  Practice  of 
Medicine  in  the  University  of  Aberdeen,  Physician  to 
and  Lecturer  on  Clinical  Medicine  in  the  Aberdeen 
Royal  Infirmar\-.  \'olume  I.  Seventh  Series.  Phila- 
delphia; J.  B.  Lippincott  Company.      1897. 

This  very  praiseworthy  publication  comes  with  fresh  wel- 
come to  the  libraiy  table.  The  lectures  are,  as  usual,  of  a 
bright  and  instructive  nature,  and  all  show  evidence  of  care 
in  preparation.  Dr.  Daland,  the  able  editor,  selects  his 
contributors  with  much  judgment,  and  the  list  comprises 
well-known  names. 

There  are  in  the  present  volume  forty-three  articles,  cover- 
ing the  various  branches  of  medicine,  and  written  mostly  by 
specialists  in  the  particular  subject  discussed.  England, 
France,  Germany,  the  United  States,  and  often  other  coun- 
tries are  represented.  The  illustrations  are  well  made,  and 
the  volume,  as  a  whole,  is  produced  with  careful  attention 
to  detail. 


Habitual   Constipation The   causes   of   habitual 

constipation  are:  Heredity;  the  habit  of  suppress- 
ing the  desire;  unsuitable  diet — too  abundant,  de- 
ficient in  water,  too  easily  absorbed,  or  insuflficient  in 
variety ;  sedentary  habits  (although  obstinate  habitual 
constipation  may  occur  even  in  those  who  lead  an  ac- 
tive life);  disturbances  in  the  circulation  (heart  dis- 
ease, mechanical  pressure,  pregnancy)  ;  displacement 
of  the  bowel,  intestinal  adhesions.  The  treatment 
is  given  as  follows;  (i)  dietetic,  (2)  physico-mechan- 
ical,  (3)  medicinal.  In  the  first  method  such  foods 
should  be  given  as  are  known  to  increase  peristalsis. 
I'he  '■  physico-mechanical"  includes  suitable  massage 
(often  of  great  value),  electricity,  and  enemata.  The 
disadvantage  of  enemata  is  that  ultimately  small  quan- 
tities of  fiuid  do  not  suffice,  and  large  quantities  over- 
distend  the  intestine  and  become  useless.  Regular 
attempts  at  defecation  with  slight  pressure  are  recom- 
mended. Medicinal  treatment  is  discussed  under  two 
groups,  mild  and  more  powerful  purgatives.  An  effi- 
cient rhubarb  preparation  is  very  useful.  Calomel  is 
very  useful  in  children.  Castor  oil  is  unsuitable  for 
constant  use.  -Large  injections  of  olive  oil  are  of 
value.  — Btrliii.  Klinik. 


5:^2 


MEDICAL    RECORD. 


[October  9,   1897 


REPORT  OF  A  CASE  OF  FRACTURE  AT  THE 
BASE  OF  THE  SKULL,  WITH  A  PECULIAR 
HISTORY. 

Dy   L.    W.    ATLEE.    M.D.,  U.S.N. 

H.  G ,  ■white,  native  of  England,  aged  seventy 

years,  at  present  a  pensioner  of  the  United  States; 
former  occupation,  sailor.  He  was  brought  to  this 
hospital  on  December  2,  1896,  at  3:45  p.m.,  in  the 
police-patrol  wagon,  with  a  history  of  having  been 
picked  up  bleeding  profusely  from  the  left  ear.  On 
admission  he  showed  evidences  of  alcoholism; 
bleeding  had  stopped.  He  was  placed  in  bed  and 
bromide  of  potassium  was  administered,  other  treat- 
ment being  expectant. 

December  3d,  ex:.mination  revealed  contusion  of 
the  lateral  occipital  and  mastoid  region  on  the  left 
side.  The  patient  complained  of  constant  pain  in  the 
head,  and  could  not  lie  with  the  occipital  region  on  the 
pillow.  It  was  difficult  to  arou.se  him,  but  he  was  ra- 
tional when  spoken  to  loudly.  Urine  and  fa;ces  were 
passed. 

December  4th,  he  was  transferred  to  the  care  of 
another  surgeon. 

"  December  sth,  patient  was  rather  restless  yester- 
day, getting  up  and  wandering  about  tlie  building; 
there  is  some  mental  impairment.  His  replies  to 
questions  are  irrational;  he  is  easily  confused,  does 
not  recognize  his  surroundings  or  attendants.  He 
admits'  that  he  has  headache,  although  he  does  not 
complain;  is  rather  drowsy  and  spends  most  of  the 
time  in  sleeping.  The  bowels  were  well  opened  by 
repeated  doses  of  magnesium  sulphate.  He  is  rather 
brighter  to-day,  more  quiet.  There  is  no  muscular 
impairment.  Pupils  normal.  Tongue  slightly  coated. 
Pulse  good,  rather  full,  regular.  No  fever,  Marks  of 
contusion  about  left  ear  and  occipital  region  of  scalp. 
Treatment:  Rest  in  bed;  potassium  bromide,  gr.  xx., 
four  times  a  day.     Ice  bag  to  head.     Milk  diet. 

"December  6th,  better;  more  quiet  and  rational. 
Mind,  however,  not  entirely  clear.  Bromide  con- 
tinued. 

"December  Sth,  improving  slowly;  mind  still 
clou;led.     Treatment  continued. 

"  December  14th,  improving  slowly;  is  strong  phys- 
ically, but  the  mind  is  still  impaired.  Still  has  some 
headache.     Treatment  continued. 

"  December  i6th,  about  tlie  same.  Mind  continues 
impaired.  His  talk  is  rambling  and  foolish.  Last 
night  he  got  up  in  the  nurse's  absence,  and  was  found 
wandering  about  the  building.  Appetite  and  diges- 
tion good.  Bowels  regular.  Spends  the  greater  part 
of  the  time  in  sleep.  When  closely  questioned  he  says 
he  has  headache,  but  he  does  not  complain  unless 
questioned.  No  signs  of  contusion  about  the  scalp 
except  slight  discoloration  behind  the  left  ear.  Bro- 
mide continued.  He  was  placed  in  small  ward  with 
two  other  patients,  and  the  doors  and  windows  were 
secured  so  that  he  could  not  wander  about. 

"December  23d,  there  is  very  little  if  any  mental 
impairment.  Is  up  and  about  under  ciiarge  of  atten- 
dant.    General  condition  good.     Bromide  continued. 

"December  31st,  mental  condition  slightly  im- 
proved. Is  regaining  memorj'  and  is  now  conscious 
of  his  whereabouts.  Medicine  stopped.  To-day 
placed  in  general  ward. 

"January  4th,  mental  condition  greatly  improved; 
is  rational  and  conscious  of  his  surroundings,  but 
memory  is  still  impaired.     General  condition  good." 

January  5th  he  was  discharged,  having  been  under 
treatment  thirty-three  days.  An  'interval  of  two 
months  passed,  during  which  he  attracted  no  special 


notice  in  tlie  place  he  lived,  being  able  to  take  care  of 
himself,  though  his  associates  remarked  about  him 
that  he  was  never  "quite  the  same"  as  before  the  ac- 
cident. 

On  March  9,  1897,  he  was  brought  to  this  hospital 
in  a  small  pushcart,  with  a  history  of  having  been 
found  lying  unconscious  on  the  sidewalk  in  the  street. 
Being  a  very  small  man,  not  more  than  five  feet  in 
height,  he  was  taken  up  in  the  arms  of  one  of  the 
nurses  and  carried  into  the  ward.  A  thick  dark 
stream  of  blood  was  oozing  from  the  left  external 
auditory  meatus  and  running  down  his  cheek,  collar, 
and  coat.  He  was  unconscious,  there  was  a  strong 
odor  of  alcohol  about  his  breath.  Pulse,  64,  regular; 
respiration,  18.  Pupils  normal,  reacting  slightly  to 
light  stimulus.  There  was  no  perceptible  mark  of 
injury  to  the  head.  As  he  was  being  undressed  he 
partially  regained  consciousness,  and,  looking  from 
one  to  the  other  of  the  people  about  his  bed,  he  said 
very  distinctly,  "  I  am  a  poor  old  sailorman,  and 
wouldn't  harm  any  one."  As  soon  as  his  clothes  were 
removed  he  was  placed  in  bed  with  the  head  slightly 
elevated.  By  this  time,  some  ten  minutes  after  his 
admission,  he  could  be  aroused  by  a  loud  voice,  but 
he  began  slowly  to  pass  into  a  deeply  comatose  condi- 
tion. His  pulse  and  breathing  became  slow  and  ir- 
regular; the  pupils  were  somewhat  contracted,  not 
reacting  to  light,  but  were  even.  The  blood  con- 
tinued oozing  slowly  from  the  left  ear.  About  3  .30 
P.M.  swelling  and  bogginess  were  perceptible  about 
the  left  mastoid  and  occipital  regions.  At  4  p.m.  he 
began  to  gasp  and  choke  as  if  some  foreign  body  had 
gotten  in  the  pharynx,  and  ejected  from  his  mouth  and 
throat  a  mass  that  might  equal  six  or  seven  ounces  (of 
blood  clots)  The  ear  still  continued  to  ooze,  and  at 
intervals  of  about  three-quarters  of  an  hour  he  ejected 
quantities  of  clotted  blood.  .-\t  9  p.m.  he  ceased  to 
breathe. 

Necropsy,  performed  seventeen  hours  after  death : 
On  refiexing  the  scalp  the  parts  about  the  left  mastoid 
and  occipital  regions  were  seen  to  be  infiltrated  with 
dark  semifluid  blood.  On  removing  this  tliere  was 
plainly  seen  a  horizontal  fracture  in  the  mastoid  por- 
tion of  the  temporal  bone,  extending  backward  hori- 
zontally through  the  occipital  bone  almost  to  its  cen- 
tre. The  skull  cap  was  removed  after  being  carefully 
sawed  through,  and  the  dura  mater  raised.  The  whole 
left  hemisphere  was  covered  by  a  thick,  well-formed 
clot,  thickest  over  the  petrous  portion  of  the  temporal 
bone,  leaving  a  marked  depression  in  the  brain  sub- 
stance when  it  was  removed.  The  brain  was  now  lifted 
out  and  the  dura  mater  removed  from  the  fossa?;  then, 
by  introducing  the  handle  of  the  scalpel  into  the  ex- 
ternal fracture  in  tlie  mastoid  and  making  gentle  pry- 
ing movements,  the  fracture  could  be  traced  by  Uie 
blood  caused  to  well  up  along  its  track,  which  passed 
horizontally  backward  across  the  occipital  bone  to 
near  the  protuberance,  and  forward  across  the  middle 
fossa  through  the  petrous  portion  of  the  temporal  hone, 
tlirough  the  greater  wing  of  the  spiienoid  to  some- 
where in  the  neighborhood  of  the  foramen  ovale. 

Remarks:  We  have  here  a  case  involving  some  es-* 
pecial  points  of  interest.  In  the  first  place  it  is  fairly 
reasonable  to  conclude  that  there  was  fracture  at  the 
base  of  the  skull  on  the  first  admission,  though  hem- 
orrh.nge  from  the  ear  alone  after  injury  to  the  head  is 
not  necessarily  surely  svmptomatic  of  fracture,  unless 
it  is  prolonged  for  several  days.  The  ear  bleeding, 
in  conjunction  with  the  swelling,  coming  on  some 
hours  after  the  injury,  the  pain  and  mental  condition 
described  in  the  history  of  the  case,  tend  strongly  to 
this  conclusion.  .Vdding  to  this  the  fact  that  the 
man  is  of  short,  slight  build,  and  also  the  statements 
of  those  who  saw  liiin  fall  as  he  was  walking  on  the 
pavement  before  his  first  admission,  and  considering 


October  9,  1897] 


MHDICAL    RECf^RD. 


^00 


the  extent  of  the  injury  shown  at  the  necropsy,  there 
must  have  been  a  fracture  already  existing  at  the  time 
of  his  second  fall.  In  ihe  "  International  Encyclopedia 
of  Surgery,"  '  edited  by  John  Ashhurst,  Jr.,  M.D.,  it  is 
stated  that  '"  even  months  or  years  after  a  fracture  at 
the  base  no  attempt  at  union  may  be  found,  while  in 
other  cases  the  union  may  be  merely  by  fibrous  tissue 
or  partly  a  tliin  plate  of  bone,  partly  membrane."' 

The  immediate  effects  of  fractures  of  the  skull  arc 
the  same  as  those  from  a  solution  of  continuity  in  any 
bone,  viz.,  rupture  of  blood-vessels,  of  the  sinus  of  the 
diploe,  of  the  m'lddle  meningeal  artery,  effusion  of 
blood,  separation  or  tearing  of  the  pericranium  and 
of  the  dura  m.iter — phenomena  thr.t,  owing  to  the  na- 
ture of  the  parts  where  they  have  occurred,  take  on  a 
most  serious  character,  and  become  not  so  much  com- 
plications as  new  diseases,  much  more  di.squieting 
than  the  lesion  which  they  have  followed — such  as 
compression  of  the  brain  substance  by  blood,  pus, 
fragments  of  bone,  or  wounds  of  the  brain  itself  by 
spicule  of  bone;  and  there  is  also  the  probability  of 
meningitis  or  encephalitis  arising  subsequently. 

In  this  case,  unfortunately,  the  idea  of  examining 
the  vessels  about  the  seat  of  fracture  that  had  given 
rise  to  the  hemorrhage  did  not  suggest  itself  until  the 
dura  mater  had  been  disturbed,  but  the  immediate 
cause  of  death  was  the  large  effusion  on  the  brain  sub- 
stance. 

In  these  cases  absolute  rest  is  recommended  as 
treatment,  to  prevent  injury  to  the  adjoining  parts  by 
the  movement  communicated  to  the  fractured  bone, 
and  secondarily  to  ward  oft'  the  possibility  of  inllam- 
mation  of  the  brain  or  its  membrane. 

From  the  greatly  lessened  danger  of  wound  infec- 
tion in  the  present  state  of  asepticism  and  our  ad- 
vanced knowledge  in  brain  surgery,  the  use  of  the 
trephine  for  the  relief  of  pressure  from  hemorrhage  fol- 
lowing a  fracture  is  suggested  as  a  surgical  procedure 
which  in  such  cases  might  be  practicable  for  good. 
In  the  first  half  of  the  present  century  effusion  follow- 
ing fracture  was  given  among  the  causes  calling  for 
the  use  of  that  instnunent.''  But  later  it  was  discon- 
tinued by  the  experience  particularly  of  Desault,  who 
found  it  unsuccessful ;  and  in  Nelaton's  "  Patholo- 
gic Chirurgicale,"  Pans,  184.7,  tome  ii.,  p.  597 
(•'.■Affections  Traumatiques  de  la  Tete"),  the  autlior 
states  that  of  sixteen  trephinings  for  traumatic  effusious 
not  one  was  successful.  On  the  same  page,  however. 
he  gives  the  following  advice :  '"  This  operation  is  only 
rationally  indicated  in  the  cases  in  which  a  wound 
of  the  scalp  exists  with  the  fracture  and  the  hemi- 
plegia indicates  the  existence  of  an  effusion  at  the 
seat  of  fracture.  In  these  cases  the  air  can  reach  the 
seat  of  fracture,  and  the  trephine  adds  but  little  to  the 
already  existingdangers."  Now  our  improved  aseptic 
surgical  technique  should  make  this  view  have  much 
less  weight  than  at  the  time  this  advice  was  written. 

As  to  the  extent  of  operative  interference  that  may 
sometimes  be  undertaken  with  a  successful  result  in 
these  injuries,  and  even  in  the  days  when  asepticism 
l)layed  but  a  small  role,  the  following  case  is  quoted 
from  the  above-mentioned  classical  work  of  IJoyer,  p. 
71,  vol.  v.:  "Dionis  relates  in  his  '  ("ours  d'Opera- 
tions'thata  man,  falling  from  his  horse,  struck  his 
head  on  the  pavement  and  remained  unconscious. 
The  surgeon  found  on  the  frontal  bone,  which  was 
fractured,  a  wound  which  he  dilated  sufficiently  to  ap- 
ply the  trephine.  Tliis  operation,  performed  the  day 
after  the  fall,  produced  no  change  in  the  sick  man's 
condition,  who  still  remained  unconscious.  Three 
days  after  this  a  swelling  appeared  on  the  occipital 
bone.      Dionis _opened  this  .-.nd  discovered  n  fracture 

'Vol.  v.,  p   37. 

•See  "  rraitc  des  Maladies  Chirurgicales  ct  les  Operations  qui 
leur  Conviennent,"  by  Boyer,  Paris,  1834,  tome  v.,  p.  75. 


by  contrecoup  in  this  bone.  A  trephine  was  applied 
in  this  neighborhood,  and  a  great  deal  of  blood  came 
out  from  the  two  openings  in  the  cranium,  which 
brought  about  a  perfect  recovery." 

We  might  conclude  these  remarks  with  the  advice  of 
the  famous  French  surgeon  to  his  class :  "  Above  all, 
gentlemen,  do  no  harm." 


EXFOLIATION  OF  THE  MUCOUS  MEM- 
BRANE OF  THE  (ESOPHAGUS  AND  PART 
OF  THE  STOMACH  IN  A  COMPLETE 
CAST    AFTER    CORROSIVE    POISONING. 

Kv   J.    C.    BROWN,    M.l)., 

On  the  27th  day  of  April,  1897,  I  was  called  out  in 
the  country  about  four  miles.     I  found  on  my  arrival, 

about  5  P.M.,  a  Mr.  B ,  thirty -two  years  old,  about 

six  feet  in  height,  strong  and  robust.  He  had  a  rather 
anxious  expression  and  was  unable  to  speak  above  a 
loud  whisper,  but  said  he  had  no  pain  to  speak  of. 
His  temperature  was  100"  F. ;   pulse,  iio. 

Upon  opening  the  mouth  I  found  the  mucous  mem- 
brane falling  in  shreds  from  every  part  of  tlie  moutli 
and  pharynx,  e.xcepting  about  an  inch  of  the  anterior 
part  of  the  tongue  and  about  the  same  of  the  anterior 
jjart  of  the  roof  of  the  mouth. 

He  told  me  that  oit  the  previous  day  about  10  a.m., 
while  walking  along  the  road,  he  found  a  bottle  con- 
taining what  he  supposed  to  be  whiskey  and  drank  it; 
tliat  he  immediately  e.xperienced  a  burning  sensation 
in  the  mouth  and^throat,  and  was  taken  intensely  sick 
at  his  stomach;  that  he  went  into  a  barn,  where  he 
remained  until  the  next  morning,  and  that  he  vomited 
and  retched  nearly  all  of  the  remainder  of  that  day 
and  all  night,  being  unable  to  swallow  anything  after 
he  had  taken  the  contents  of  the  bottle ;  that  he  came 
to  a  hotel  in  Smethport  in  the  morning  about  6  A.i,\. 
and  went  to  bed,  where  he  remained  until  about  noon; 
that  he  then  got  up  and  walked  home,  a  distance  of 
about  two  miles  over  a  steep  hill,  and  that  he  stopped 
on  the  way  at  springs  and  tried  to  drink  but  could  not 
swallow  a  drop. 

Now,  of  course,  seeing  the  condition  of  the  mouth, 
I  knew  that  if  the  material  which  caused  it  was  also 
taken  into  the  stomach  there  must  be  a  great  deal  of 
destruction  of  mucous  membrane,  but  I  had  only  his 
word  for  it,  and  did  not  know  but  he  might  be  mis- 
taken as  to  swallowing  it;  besides,  the  symptoms  did 
not  indicate  the  same  condition  extending  into  the 
stomach;  therefore  I  could  say  nothing  as  to  prognosis. 

I  left  a  mouth  wash  containing  tannic  acid  and  anti- 
septics, also  an  antiseptic  solution  to  use  with  the 
atomizer.  I  ordered  milk  and  white  of  egg  alternated 
with  extract  of  beef  by  enema  once  in  four  or  five 
hours  and  rubbing  with  alcohol  three  or  four  times 
daily,  and  said  I  would  see  him  the  following  day  if 
I  did  not  hear  from  them.  The  next  day  I  received 
word  that  he  was  somewhat  better  and  had  been  able 
to  swallow  some  water. 

On  the  29th  I  was  called  and  found  that  at  the  sug- 
gestion of  his  mother  he  had  swallowed  two  teaspoon- 
fuls  of  kerosene  oil,  which  produced  a  great  deal  of 
nausea  and  vomiting;  oiherwi.se  he  was  about  the  same 
as  when  last  seen. 

He  continued  in  about  this  condition,  the  corroded 
IJortions  of  the  mouth,  of  course,  turning  somewhat 
tiark  by  the  mouth  wash,  temperature  ranging  between 
99*^  and  102°  F.,  pulse  between  80  and  120,  spitting 
lip  a  great  deal  of  purulent  material,  sometimes  mixed 
V.  ith  blood,  until  the  7lh  of  .\pril,  when  from  2  a.m. 
until  5  130  A.M.  he  had  very  profuse  hemorrhage,  vomit- 
ing nearly  a  pint  of  blood  every  half-hour,  so  the  nurses 


534 


MKDKAL    RPXDRD. 


[October  9,   1897 


said,  until  I  saw  him  aboui  5  -.^o  a.m.  and  gave  him  a 
hypodermic  of  one-fouith  of  a  grain  of  morphine  sul- 
phate and  one-thirtieth  of  a  grain  of  strychnine  nitrate, 
which  seemed  to  control  the  hemorrhage  pretty  well. 
He  had  another  hypodermic  about  1 1  a.m.;  there  was 
not  much  hemorrhage  during  the  day. 

About  5  P.M.  of  the  same  day  [  called,  and  before  I 
got  into  the  house  the  patient's  brother  came  to  me, 
somewhat  excited,  and  said  that  his  brother  had  just 
vomited  something  very  peculiar.  He  brought  it  to 
me,  and  at  first  sight  I  thought  it  was  a  blood  clot,  but 
after  washing  it  I  found  it  to  be  the  mucous  membrane 
and  submucous  tissue  of  the  ctsophagus  and  stomach, 
and  it  was  afterward  examined  by  Dr.  H.  U.  Williams, 
pathologist  in  the  University  of  Huffalo,  and  found  to 
contain  also  a  part  of  the  muscular  coat  of  the  ctsoph- 
agus.  The  oesophageal  portion  was  in  perfect  shape 
with  the  exception  of  a  few  small  holes  which  might 
have  been  made  in  the  effort  to  expe\  it,  which  it  was 
said  was  quite  difficult. 

The  stomach  portion  was  torn  somewhat  in  strips, 
due  perhaps  to  a  more  pronounced  effect  of  the  corro- 
sive agent.  The  whole  was  about  sixteen  inches  long. 
It  can  be  seen  in  the  museum  of  the  University  of 
iiuffalo.  After  the  vomiting  of  this  membrane  the 
hemorrhage  continued  very  profuse  for  thirty-six  hours 
and  then  stopped ;  there  was  no  hemorrhage  afterward. 
He  could  swallow  after  this,  biit  we  did  not  allow  him 
to  do  so  for  three  days,  and  then  began  by  letting  him 
swallow  a  few  teaspoonfuls  of  chicken  soup,  then  milk, 
and  milk  and  brandy  in  small  quantities,  gradually 
increasing  until  on  the  fifteenth  he  was  taking  about  a 
quart  of  milk  in  twenty-four  hours  beside  some  toast 
and  one  or  two  raw  eggs,  and  of  course  all  this  time 
we  kept  up  the  enemata  of  milk  and  extract  of  beef, 
which,  excepting  once  or  twice,  were  well  retained. 

On  the  1 8th  of  May  we  took  him  to  the  Buffalo 
dencral  Hospital,  where  he  was  seen  by  Dr.  Allen  A. 
Jones.  We  brought  him  back  the  next  day,  he  stand- 
ing the  ride  very  vi'ell,  and  he  continued  about  the 
same  until  May  30th.  I  will  say  here  that  I  was 
satisfied  that  the  food  which  he  was  taking  by  the 
.stomach  was  not  being  digested  and  I  found  afterward 
that  it  was  simply  passed  on  into  the  intestines,  where 
it  was  stored  for  a  time  and  then  passed  per  rectum 
in  about  the  same  condition  in  which  he  took  it.  His 
brother  said  that  at  one  time  four  or  five  quarts  passed 
per  rectum  in  an  undigested  condition.  V'ou  will  ask, 
why  was  anything  given  by  the  stomach.'  Simply 
because  he  craved  it  and  retained  it  without  distress, 
and,  as  death  was  inevitable,  I  thought  we  might  just 
as  well  give  it  to  him. 

On  the  30th  of  May  I  tried  to  introduce  a  tube  into 
the  stomach.  I  could  get  it  down  to  within  three  or 
four  inches  of  the  stomach  but  no  farther.  1  tried 
again  on  the  following  day  with  the  same  result,  show- 
ing that  contraction  had  already  taken  place  at  that 
point,  and,  as  we  must  expect  in  such  cases,  I  found 
afterward  that  it  had  contracted  the  whole  length  of 
the  cesophagus. 

After  my  visit  on  the  31st  of  May  I  did  not  .see  him 
again  until  the  loth  of  June,  but  heard  from  him  fre- 
quently. I  learned  from  his  brother  that  on  the  ist 
of  June  he  began  vomiting  shreds  of  a  brownish  ma- 
terial, of  very  foul  odor.  This  continued  for  two  or 
three  days,  followed  by  a  yellowish  material  still  more 
foul  smelling  than  the  r)ther,  and  lasted  for  a  few  days. 
[  can  form  no  opinion  as  to  what  this  material  was,  as 
I  have  onl)'  the  nurse's  description  of  it.'  At  this  time 
the  taking  of  food  by  the  stomach  had  been  stopped. 
He  continued  in  this  condition,  gradually  getting 
weaker,  vomiting  and  retelling  a  groat  deal,  until  he 
died  on  the  24lh  of  June. 

I  was  not  allowed  the  oi)|)(irtunily  ol  making  ,i  post- 
mortem,   which    would    have    been    most    interesting. 


I'he  length  of  time  wliich  had  elapsed  after  he  had 
swallowed  the  material  and  his  inability,  feigned  or 
otherwise,  to  tell  us  what  he  did  with  the  bottle  pre- 
vented our  finding  out  just  what  the  corrosive  was. 

Now,  of  course,  corrosive  poisoning  is  not  an  un- 
common occurrence,  but  the  interesting  points  to  me 
are:  W'hat  corrosive  would  bring  about  the  separation 
of  those  structures  to  such  a  depth :  and  w  hy  did  not 
death  occur  from  hemorrhage  during  or  after  the  sepa- 
ration of  those  membranes?  Again,  how  was  he  able 
to  take  such  a  large  amount  of  material  into  the 
stomach  without  distress.' 

I  forgot  to  mention  that  while  he  could  perform  the 
act  of  swallowing  satisfactorily  from  the  time  he  vom- 
ited the  cast  up  to  within  two  weeks  of  his  death, 
fluids  nearly  always  produced  coughing,  owing,  I 
think,  to  the  partial  destruction  of  the  epiglottis 
allowing  some  of  the  fluid  to  trickle  into  the  larynx. 
I  should  have  made  an  effort  to  keep  the  oesophagus 
o|3en  had  I  not  been  satisfied  that  the  .stomach  was  al.so 
destroyed,  as  far  as  its  digestive  function  was  con- 
cerned. 

Perhaps  it  would  not  be  out  of  place  to  state  that 
this  patient  suffered  a  great  deal  with  hiccough,  and  I 
found  that  it  could  be  stopped  nearly  alwavs  by  pre.ss- 
ing  the  tongue,  as  in  an  examination  of  the  pharynx, 
and  holding  it  down  twenty  or  thirty  seconds:  then  it 
would  be  sometimes  an  hour  and  sometimes  .several 
hours  before  another  paroxvsm. 


TWO    (O.MI^LU  .VTKl)    AHDOMIXAL   HVSTER- 
KCTCnnES.' 


Hv    AU(;USTI\    II.    COELET.    .\I.I>.. 


Thesk  cases  are  particularly  interesting  on  account 
of  the  difficulties  encountered  in  removing  the  speci- 
mens here  presented. 

The   first  patient.   Miss   F ,  aged    twenty-three 

years,  was  referred  to  me  by  Dr.  S.  P.  Cahen,  of  this^ 
city,  under  whose  care  she  had  been  for  several  years, 
during  which  time  she  had  a  severe  and  prolonged  at- 
tack of  pelvic  peritonitis  following  a  short  time  after 
dilatation  and  curettage  for  dysmenorrhcea.  When 
she  first  came  under  my  observation  in  November  last 
she  had  a  daily  temperature  ranging  from  100°  to  104' 
F.,  which  she  had  been  having  for  a  month  or  more,^ 
and  she  was  emaciated  and  suffered  constant  pain.  At 
that  time  it  was  impossible  to  make  a  satisfactory  ex- 
amination, but  the  whole  pelvis  appeared  to  be  a  mass 
of  exudation,  including  the  whole  pelvic  contents. 
She  was  put  upon  daily  applications  of  faradization 
and  immediately  experienced  relief.  .-Vfter  a  few 
weeks  the  temperature  returned  to  the  normal  point 
and  she  had  no  further  e.xacerbations.  At  this  time 
examination  showed  that  much  of  the  exudation  had 
been  absorbed  and  the  uterus,  which  was  at  first  fixed, 
was  somewhat  movable  and  it  could  be  outlined.  On 
the  left  there  was  a  mass  of  exudation  sensitive  to 
toucli.  On  the  right,  where  the  exudation  had  to  a 
great  extent  disapix;ared,  neither  the  ovary  nor  the 
tube  could  be  made  out.  Tiie  speciinen  shows  them 
glued  to  the  front  of  the  fuiuhis. 

The  condition  at  this  time  pointed  strongly  to  the 
necessfty  for  an  abdominal  operation  and  the  subse- 
quent treatment  was  instituted  with  that  end  in  view. 
The  faradization  was  continued  three  or  four  times 
each  week  ami  she  was  put  upon  tonics  and  a  nutri- 

'  ricseiUcvl  at  the  .\l;iy  meetinj;'  of  the  New  \'ork  >redico- 
Siir"ioal  .SH-it'tv. 


October  9,  1897] 


mp:i)ical  rfxord. 


535 


tious  diet.  She  improved  steadil)-  and  soon  began  to 
feel  that  she  could  resume  her  duties. 

She  entered  my  sanatorium  April  5th,  and  on  the 
fith  the  operation  was  performed.  On  opening  the 
abdomen  marked  congestion  of  the  peritoneal  vessels 
was  noticed  and  the  intestines  were  adherent  every- 
where to  the  lower  region  of  the  abdominal  wall,  to 
the  sides  of  the  pelvis,  and  to  the  uterus  and  bladder. 
These  were  separated  with  great  difficulty,  particularly 
those  posterior  to  the  uterus,  and  those  binding  the 
sigmoid  flexure  to  the  mass  on  the  left  of  the  uterus. 
In  separating  the  adhesions  at  this  point  the  gut  was 
opened,  but  it  was  promptly  closed  by  Lembert  sutures. 
Subsequently  an  abscess  was  broken  into,  which 
proved  to  be  an  ovarian  abscess.  This  constituted 
the  mass  on  the  left,  surrounded  by  a  thick  wall  of 
exudation. 

The  tube  and  ovary  on  tlie  right,  as  the  specimen 
shows,  were  folded  over  on  the  front  of  the  fundus  and 
were  fastened  firmly  there  by  dense  adhesions.  Several 
.small  cy.sts  in  this  mass  were  ruptured  in  separating 
the  adherent  loops  of  intestines.  At  once  it  was  seen 
that  removal  of  the  uterus  with  both  masses  was  im- 
(x;rative. 

To  shorten  the  operation,  which  had  already  con- 
sumed considerable  time,  supravaginal  amputation 
was  done  and  the  cervix  left.  The  pelvis  was  flushed 
with  normal  salt  solution,  which  was  permitted  to  re- 
main on  closing  the  abdomen.  Something  over  two 
hours  was  consumed  in  completing  the  operation,  and 
the  patient  was  gotten  to  bed  in  a  fairly  good  condi- 
tion. The  highest  temperature  for  the  first  four  days 
was  100"  F.  On  the  mornnig  of  the  fifth  day  the  tem- 
perature was  99"  F.,  but  the  dressing  was  found  to  be 
soiled  by  pus  which  was  oozing  from  the  lower  angle 
of  the  abdominal  wound.  .\n  opening  was  made  in 
the  posterior  cul-de-sac  of  the  vagina  and  a  consider- 
able amount  of  pus  was  evacuated.  A  drainage  tube 
was  inserted  through  the  vaginal  incision,  and  the 
lower  angle  of  the  abdominal  wound  was  opened  and 
a  drainage  tube  inserted  into  the  j^elvis.  Through- 
and-through  irrigation  with  bichloride  .solution  was 
thoroughly  done.  The  temperature  at  once  dropped 
to  98°  ¥. 

(ieneral  sepsis  was  at  this  time  manifest,  but  she 
improved  very  much  for  the  first  few  days  after  this. 
On  the  third  day  after,  however  (the  eighth  day  after 
the  operation),  she  had  a  sharp  chill  and  the  tempera- 
ture jumped  up  to  105  F.  She  continued  to  sink  from 
overwhelming  sepsis  in  spite  of  good  drainage  and  re- 
]3eated  irrigation,  and  died  .\pril  19th,  thirteen  days 
after  the  operation. 

The  autopsy  showed  that  the  abdominal  wound  was 
healed  except  at  the  lower  angle  where  the  drainage 
tube  was  inserted;  the  pelvic  roof  was  also  healed,  as 
had  the  wound  in  the  intestine,  but  a  perforation  of 
the  gut  was  found  a  short  distance  from  the  rent. 
This  probably  occurred  because  of  some  thin  point  in 
the  wall  of  the  gut,  left  where  the  adhesions  wei^e 
separated. 

The  other  patient.  Miss  R ,  aged  forty -four  years, 

was  referred  to. me  by  Dr.  Grace  Pulver,  of  'i'orring- 
ton,  Conn.  In  December  she  had  a  pelvic  peritonitis 
and  again  in  February  of  this  year  she  had  another 
attack.  Following  this  there  was  an  intenuittent 
bloody  discharge  from  the  uterus,  which  at  times 
amounted  to  a  sharp  hemorrhage.  During  this  time 
she  had  acute  exacerbations  of  fever,  and  later  the 
discharge  became  offensive.  March  17th  of  this  year 
she  entered  my  sanatorium  and  two  days  later  an  ex- 
amination was  made  under  ana;sthesia.  The  uterus 
was  partially  fixed  and  to  the  left  there  was  a  mass  in- 
volving the  tube  and  ovary  on  that  side.  On  tlie  riglit 
the  appendages  appeared  to  lie  normal.  .\  thorough 
curettage  was  done  and  the  scrapings  were  preserved  for 


microscopical  examination.  The  uterus  was  soft  and 
easily  dilatable,  and  the  endometrium  was  broken 
down  and  spongy. 

She  improved  \ery  much  after  the  curettage,  the 
bleeding  ceased,  and  there  was  no  return  of  the  in- 
creased temperature  from  which  she  had  been  suft'er- 
ing  for  so  long  a  time  previous!)-.  But  the  micro- 
scopical examination  showed  that  the  uterus  was  the 
seat  of  adeno-carcinoma  and  a  hysterectomy  was 
therefore  decided  upon. 

The  operation  was  done  April  7th.  On  opening  the 
abdomen  the  intestines  were  found  to  be  adherent  every- 
where to  the  pehic  organs.  The  adhesions  to  the  uterus 
and  bladder  were  easily  separated,  but  those  binding 
the  intestines  to  the  mass  involving  the  left  broad  liga- 
ment were  very  firm  and  unyielding.  A  small  abscess 
in  the  mass  was  invaded  in  the  process  of  enucleation, 
but  with  care  infection  of  the  peritoneum  was  avoided 
The  mass,  which  was  soft  and  friable  in  places,  was 
firmly  attached  to  the  left  posterior  wall  of  the  pelvis 
in  close  proximity  to  the  ureter,  and  was  with  difficulty 
removed.  After  getting  it  free  from  the  pelvic  wall 
the  uterus  was  removed  in  the  following  manner,  viz. : 
the  left  uterine  artery  was  tied  and  divided  after  in- 
cising the  peritoneal  covering  of  the  uterus  in  front 
and  behind  and  stripping  it  down.  The  cervix  was 
then  separated  from  the  vagina  at  the  cervico-vaginal 
fold  all  around;  then  the  right  uterine  artery  was 
clamped  and  divided  between  the  clamp  and  the  ute- 
rus: next  the  round  ligament  with  its  \essel  was 
clamped  and  divided  close  to  the  uterus:  and  finally 
the  right  ovarian  artery  was  clamped  and  divided  and 
the  uterus  with  the  mass  was  lifted  out.  This  left  a 
clear  field  for  tying  off  the  vessels  on  the  right.  The 
vaginal  vault  and  pelvic  roof  were  closed  by  a  con- 
tinuous suture  of  fine  chromicized  catgut  and  no 
drainage  was  employed. 

The  patient  was  lowered  from  the  Trendelenburg 
posture,  and  the  pelvic  cavity  was  flushed  with  warm 
decinormal  salt  solution  and  the  abdomen  closed. 
The  operation  consumed  something  more  than  an  hour. 

The  highest  temperature  recorded  after  the  operation 
was  100^  F.,  on  the  fifth  day.  The  abdominal  sutures 
were  removed  on  the  fourteenth  day.  The  patient  has 
made  an  uneventful  recovery  without  a  single  compli- 
cation. 

The  question  may  be  raised  why  the  vaginal  route 
was  not  utilized  for  removing  these  two  uteri,  since  it 
has  many  points  of  advantage  over  the  abdominal 
route  in  certain  cases.  In  the  first  case  a  hysterec- 
tomy was  not  thought  to  be  necessary  until  the  ab- 
domen was  opened,  and,  could  it  have  been  decided 
before,  the  adhesions  to  the  bowels  were  too  exten- 
sive and  firm  to  admit  of  a  safe  and  satisfactory  vagi- 
nal hysterectomy.  In  such  cases,  even  if  the  organ 
and  diseased  appendages  can  be  gotten  away  safely 
through  the  vagina,  the  greater  liability  to  fre.sh  ad- 
hesions to  the  bladder  and  stumps  of  the  broad  liga- 
ments w^ould  offer  a  strong  argument  against  it.  I 
have  been  obliged  to  open  the  abdomen  several  times 
to  do  away  with  adhesions  following  vaginal  hysterec- 
tomy, which  were  causing  most  inten.se  suffering.  I 
believe  that  adhesions  occur  more  frequently  after 
vaginal  than  after  abdominal  hysterectomy,  because 
the  pelvic  vault  is  not  clo.sed  perfectly,  and  frequently 
extensive  raw  surfaces  are  left  exposed  to  contact  w  ith 
the  inte.stines  which  prolap.se  into  the  empty  pelvis. 

In  the  second  case  there  was  involvement  of  the 
broad  ligament  on  the  left,  which  pointed  strongly  to 
cancer  and  more  perfect  removal  could  be  accom- 
])lished  through  the  abdomen. 

.  K-    Wksi    SrxKNTV.-rilimi  St«hkt. 

Before  operation  a  good  night's  sleep  is  of  the 
greatest  value  to  both  patient  and  operator. 


536 


MEDICAL    RECORD. 


[October  9,  1897 


Society  Reports. 

MEDICAL    SOCIETY    OF     JHK    COUNTY    OF 
XEVV   YORK. 

St,it,-d  Meeting,  Seplembcr  2j,  J^gj. 

Landon  Caktkr  Gray,  M.D.,   I'rksideni. 

Nominations. — JWsiiknt,  Urs.  Henry  Dwight  Chapin 
and  A.  M.  Jacobus;  First  Vice-J'resideiit,  Urs.  J.  Rid- 
dle Goffe,  VVickes  Washburne,  and  N.  E.  Brill;  Sftond 
Via-Prcsitkiit,  Urs.  R.  P.  Lincoln  and  B.  F.  Curtis; 
Secretary,  Ur.  Charles  H.  Avery;  Assistant  Secretary, 
Ur.  W.  E.  Bullard ;  Treasurer,  Ur.  John  S.  Warren ; 
Censors,  Urs.  H.  L.  CoUyer,  F.  M.  Crandall,  E.  I'raen- 
kel,  M.  J.  Burstein,  Whitehead  Gilfillan,  L.  C.  Gray, 
W.  L.  Carr,  F.  H.  Daniels,  R.  A.  Murray  (declined), 
W.  Stevens,  S.  U.  Powell,  and  J.  L.  l?arton. 

Certain  Sources  of  Neurosis  in  Woman.  —  Ur. 
Egberf  H.  Grandin  read  a  paper  with  tliis  title.  'I'he 
term  "  neurosis,"  he  said,  was  of  necessity  a  very  vague 
one,  and  often  was  a  mere  cloak  for  ignorance.  This 
ignorance  was  sometimes  due  to  faulty  e.xamination, 
and  sometimes  to  the  fact  that  a  specialist  had  been 
consulted  who  had  confined  his  search  to  the  narrow 
limits  of  his  particular  branch.  The  following  cases 
were  cited  by  way  of  illu.stration : 

Fissure  it  Neck  of  Bladder. — A  married  woman 
came  to  him  with  the  statement  that  sexual  intercourse 
was  impossible.  The  woman  was  intensely  neurotic, 
and  she  complained  of  pain  in  nearly  every  portion  of 
the  body.  Digital  e.xamination  showed  the  pelvic 
organs  apparently  normal ;  there  was  not  even  a  pro- 
lapse of  the  ovaries,  as  had  been  suspected.  On  ex- 
amination of  the  neck  of  the  bladder  a  fissure  was 
found.  Uilatation  and  the  application  of  phenic  acid 
cured  the  case. 

Adhesions  of  Clitoris.— It  should  be  remembered 
that  the  clitoris  exerts  a  powerful  influence  in  the  pro- 
duction of  various  neuroses.  Many  a  case  of  nym- 
|)homania  and  masturbation  would  find  its  explanatien 
in  adhesions  of  the  clitoris.  For  example,  a  lady  of 
thirty-five  had  consulted  him  for  the  relief  of  an  intol- 
erable pruritus  of  the  vagina.  Sugar  was  absent  from 
the  urine,  and  many  remedies  had  been  tried  in  vain. 
The. prepuce  of  the  clitoris  was  firmly  adherent,  and 
there  was  a  collection  of  smegma.  Removal  of  these 
adhesions  effected  a  prompt  cme. 

Anal  Fissure. — The  speaker  said  that  he  was  in- 
clined to  think  that  the  role  of  the  sphincter  ani  was 
not  appreciated  so  fully  as  it  should  be  as  a  factor  in 
disease.  Fissure  of  the  anus  was  a  common  cause  of 
reflex  irritation;  hence  the  rectum  and  anus,  as  well 
as  the  vagina  and  pelyis,  should  be  subjected  to  care- 
ful scrutiny.  For  instance,  an  intensely  neurotic  lady 
had  consulted  him  after  two  years  of  married  life,  be- 
cause of  meuorrhagia  and  intense  dyspareunia.  The 
spasm  of  tiie  hymen  was  so  great  that  the  vaginal  ex- 
amination could  be  made  only  under  ana;sthesia.  In- 
spection of  the  rectum  showed  a  deep  ulcer.  The 
sphincter  ani  was  dilated  and  the  ulcer  cauterized. 
Slie  made  a  rapid  recovery. 

Coccygodynia. — The  coccyx  is  a  relatively  frequent 
.source  of  neurosis,  because  of  tiie  liability  of  the  coc- 
cyx to  be  injured,  not  only  during  labor  but  by  falls 
on  the  back.  Fracture  of  the  coccyx,  even  though 
caries  does  not  result,  often  causes  pressure  on  the 
nerve  filaments,  and  hence  reflex  irritation.  In  seven 
c.ises  he  had  removed  the  coccyx  because  of  actual 
disease  or  because  a  fracture  accounted  for  reflex  ner- 
vous phenomena  not  otherwise  explained.  In  every 
instance  the  operation  had  brought  the  desired  relief. 
In  the  operation  for  the  extirpation  of  the  coccyx,  he 
would  insist  tiiat  drainage  was  unnecessary,  assertions 


to  the  contrary  notwithstanding.  After  the  removal  of 
the  bone,  with  a  large  curved  Hagedorn  needle  the 
suture  could  be  made  to  travel  entirely  around  tiie 
wound,  which  could  thus  Ix;  easily  and  completely 
closed. 

Diseased  Uterine  Appendages. — The  speaker  then 
took  up  the  consideration  of  the  part  played  in  the 
production  of  neuroses  by  disease  of  the  tubes  and 
ovaries.  He  remarked  incidentally  that  he  looked 
upon  menstruation  as  the  most  obscure  of  all  the  fem- 
inine neuroses.  A  woman  of  about  thirty-five  had 
Ijeen  brought  to  him  by  her  husband  from  a  retreat  for 
the  insane,  where  she  had  been  placed  by  a  neurolo- 
gist. She  exhibited  deep  melancholia,  erotomania, 
and  suicidal  tendencies,  flxamination  showed  peri- 
metritis and  endometritis,  and  the  husband  was  told 
that  these  findings  did  not  necessarily  account  for  her 
condition.  Nevertheless,  the  appendages  were  re- 
moved by  laparotomy,  and  the  woman  was  completely 
cured,  altliough  they  were  not  markedly  diseased. 
This  was  an  example  of  empirical  operating.  Another 
patient,  suffering  from  hystero-epilepsy,  had  such  vio- 
lent attacks  that  anasthesia  was  necessary  to  control 
them.  It  was  ascertained  that  these  attacks  occurred 
chiefly  at  the  menstrual  period;  hence  in  an  empirical 
way  the  removal  of  the  appendages  was  advised.  The 
operation  was  performed  about  three  years  ago.  After 
the  operation  the  attacks  diminished  in  frequency  and 
severity,  and  there  had  been  no  attack  for  the  last  two 
years.  The  organs  were  found  to  be  infantile  in  type. 
The  next  case  was  cited  as  an  example  of  the  failures 
following  empirical  operating.  The  patient,  a  woman 
'  of  thirty,  married  to  a  man  of  fifty,  suffered  from  hys- 
tero-epilepsy. Examination  showed  the  appendages 
to  be  markedly  enlarged  but  freely  movable.  There 
was  no  evidence  of  increase  of  the  symptoms  at  the 
menstrual  periods.  The  operation  was  requested,  on 
the  ground  that  everything  else  had  failed.  It  was 
performed,  and  the  attacks  diminished  for  a  few 
months;  then  a  pseudo-menstrual  flux  appeared  and 
the  attacks  returned  as  liefore.  The  case  was  unques- 
tionably one  of  essential  epilepsy,  and  the  result  was 
what  was  to  be  expected.  In  conclusion,  the  reader 
of  the  paper  entered  a  plea  for  a  more  careful  exami- 
nation of  the  body  as  a  whole,  before  concentrating  the 
attention  on  one  set  of  special  organs. 

Dr.  RoiiERT  A.  Murray  congratulated  the  reader  of 
the  paper  on  having  presented  so  many  facts  in  proof 
of  the  frequency  of  faulty  diagnoses.  He  could  cite 
from  his  own  experience  many  similar  examples,  all  of 
which  only  served  to  emphasize  the  tendency  to  over- 
look minor  abnormal ites  wjiile  searching  for  grave 
pathological  lesions. 

Ur.  H.  N.  \iNEiiERGsaid  that  he  was  surprised  tliat 
in  the  first  case  reported  the  neck  of  the  bladder  had 
been  examined  without  the  existence  of  symptoms 
pointing  to  some  affection  there,  for  certainly  this 
would  not  be  generally  done  by  the  practitioner.  He 
was  inclined  to  be  sceptical  regarding  the  part  played 
by  clitoridal  adhesions  in  tiie  production  of  neuroses 
— at  least,  the  tendency  was  to  overdo  this  matter  and 
too  hastily  conclude  that  these  were  .responsible  for 
the  symptoms  present.  The  majority  of  cases  with 
reflex  nervous  symptoms  would  be  made  worse  by  tlie 
renio\al  of  the  tubes  and  ovaries,  unless  there  was  evi- 
dence of  a  distinctly  pathological  state  of  these  organs. 
\\'hen  .such  a  condition  existed  and  it  was  considered 
justifiable  to  operate,  the  uterus  as  well  as  tiie  tubes 
and  ovaries  should  be  removed.  Regarding  incom- 
plete sexual  commerce,  he  said  tiiat  it  was  often  ob- 
served in  iiuuried  women  who  had  borne  a  luiniber  of 
children  tiiat  tiiey  began  to  sutTer  from  various  neu- 
rotic symptoms.  Inquiry  would  frequently  elicit  the 
fact  that  the  woman  made  no  elTort  to  prevent  concep- 
tion Init  tliat  the  husband  practised  "withdrawal." 


October  9,  1897] 


MEDICAL    RECORD. 


537 


Dr.  C.  a.  Von  Ramdohr  said  that  laceration  of  the 
cervi.x  not  infrequently  gave  rise  to  epilepsy.  He  had 
seen  a  number  of  cases  in  which  the  simple  closure  of 
the  everted  cervix  cured  an  epilepsy  which  had  not 
been  diagnosticated  as  hystero-epilepsy  until  after  a 
thorough  examination.  He  also  referred  to  those  neu- 
roses occurring  during  confinement,  in  which  there  was 
no  obliteration  of  the  cer\ix,  and  in  which  the  cause 
was  to  be  found  in  a  tissure  of  the  urethra,  anus,  or 
vulva,  or  possibly  in  an  abnormp.lity  of  the  coccyx. 

True  Epilepsy  Never  Cured  by  Operations. — Dr. 
Louis  Faugeres  Bishop  said  that  epilepsy  was  a  dis- 
ease of  the  motor  cells  of  the  brain — a  fact  which 
should  be  borne  in  mind  in  all  efforts  to  cure  it  by 
attacking  certain  regions  of  the  body.  He  did  not 
think  true  epilepsy  had  ever  been  cured  by  operations 
or  by  local  means.  Postoperative  neurasthenia  was  a 
very  common  condition,  and  should  receive  thoughtful 
consideration  by  the  surgeon  before  he  decided  too 
hastily  to  operate  upon  neurotic  individuals. 

Dr.  H.  L.  Collyek  said  that  he  had  seen  three 
cases  presenting  no  bladder  symptoms,  and  yet  exam- 
ination readily  revealed  fissure  of  the  vesical  neck. 
As  to  adhesions  of  the  clitoris,  it  should  be  remem- 
bered that  there  was  hardly  one  woman  in  a  hundred 
who  did  not  have  such  adhesions.  The  effect  was 
similar  to  that  observed  in  the  male  from  similar  ad- 
hesions. The  great  sensitiveness  of  the  clitoris  was 
well  shown  by  the  struggling  produced  by  an  attempt 
to  separate  the  adhesions  unless  the  patient  was  ver}- 
deeply  anesthetized. 

Dr.  W.  M.  Leszyn.sky  referred  to  the  removal  of 
the  healthy  ovaries  for  the  cure  of  epilepsy  or  insanity. 
He  had  written  an  article  upon  this  subject  some  ten 
or  twelve  years  ago,  and  hence  was  greatly  astonished 
very  recently  to  find  two  cases  in  v.hich  such  an  oper- 
ation had  been  performed.  The  practice,  in  his 
opinion,  was  not  only  not  justifiable,  but  was  positively 
criminal. 

Neurologists  Sceptical  about  Pelvic  Disease  Caus- 
ing Epilepsy.  —Dr.  L.  C.  Gray  said  that  he  fully  be- 
lieved, with  the  reader  of  the  paper,  that  a  neurosis 
was  a  very  indefinite  thing,  with  the  exception  of  epi- 
lepsy. Epilepsy  had  a  certain  definite  group  of  symp- 
toms whicli  marked  it  as  something  apart,  although  we 
knew  very  little  of  the  causes  of  it  in  the  so-called  idio- 
patliic  variety.  All  the  vague  nervous  symptoms  oc- 
curring so  frequently  in  women  from  disease  of  the 
pelvic  viscera  could  hardly  be  called  a  neurosis,  in  the 
meaning  tliat  we  could  always  recognize  the  cause  by 
the  symptoms.  It  had  always  been  his  custom  to  as- 
sume that  a  case  of  true  epilepsy — an  absolute  loss  of 
consciousness,  with  or  without  clonic  and  tonic  con- 
vulsions— could  not  be  caused  by  disease  of  any  of 
the  pelvic  viscera,  simply  because  there  had  been  no 
proof  adduced  that  such  a  cause  could  bring  about  such 
an  effect.  Future  study  might  bring  forward  such 
proof.  Neurologists  were  becoming  more  and  more 
sceptical  regarding  epilepsy  resulting  from  disease  of 
the  pelvic  viscera.  ]!ut  there  were  many  forms  of 
neurasthenia,  and  many  more  or  less  vague  neuralgias, 
together  with  the  manifold  phenomena  of  hysteria,  in 
which  the  cause  could  be  found  in  some  disturbance 
of  the  pelvic  viscera.  In  every  case  in  which  a  posi- 
tive diagnosis  of  epilepsy  could  not  be  made,  it  was 
well  to  have  the  patient  examined  by  a  competent 
gynaecologist.  He  was  sorry  to  say  that  he  had  him- 
self repeatedly  treated  without  success  cases  which 
were  afterward  promptly  cured  by  appropriate  treat- 
ment directed  to  the  pelvic  organs.  As  to  the  removal 
of  the  ovaries  and  Fallopian  tubes  in  hysterical  and 
epileptic  cases,  he  had  never  yet  seen  it  do  more  than 
temporary  good,  provided,  of  course,  the  tubes  and 
ovaries  were  healthy.  He  recalled  one  case  in  which 
a  prominent  gyn.Tcologist  of  this  city  had  removed  one 


ovary  because  of  vomiting.  This  had  given  relief  for 
a  time,  but  the  vomiting  had  returned,  and  he  had  then 
removed  the  other  ovary.  Again  there  had  been  relief 
for  a  few  months,  and  on  the  return  of  the  vomiting 
the  gynecologist  had  once  more  operated,  separating 
some  adhesions.  When  the  patient  had  again  relapsed, 
she  had  been  referred  to  him.  She  was  a  perfectly 
typical  case  of  hysteria,  and,  although  she  asserted 
that  she  vomited  constantly  and  had  been  unable  to 
retain  food  for  weeks,  he  did  not  believe  her.  She 
was  followed,  and  was  seen  to  walk  through  the  street 
complacently  eating  peanuts. 

Dr.  Grandin",  in  closing  the  discussion,  said  that 
he  was  not  prepared  to  say  that  in  the  first  case  cited 
there  had  been  no  bladder  symptoms,  but  if  they  had 
existed  they  had  been  masked  by  the  uterine  symp- 
toms. If  more  general  practitioners  looked  to  the  cli- 
toris, even  at  birth,  it  was  not  improbable  that  fewer 
cases  would  go  to  the  neurologist  or  to  the  gynecolo- 
gist in  later  life.  He  was  thoroughly  convinced  that 
adherent  prepuce  of  the  clitoris  was  responsible  for 
many  nervous  manifestations  in  women,  vhich  would 
even  simulate  actual  disease  of  the  uterus,  tubes,  or 
ovaiies.  He  could  have  cited  at  least  fifteen  or  twenty 
such  cases  from  his  records.  He  was  firmly  convinced 
that  at  the  birth  of  the  female  infant,  the  physi- 
cian should  look  out  for  preputial  adhesions  of  the 
clitoris,  even  as  it  was  the  custom  now  for  the  careful 
physician  to  look  for  similar  trouble  in  the  male 
infant. 

Retrodeviations  of  the  Uterus. — Dr.  Eugene  Cole- 
.M.\N  Savidge  read  this  paper,  and  called  attention  to 
the  fact  that  all  pelvic  suppurations  were  excluded 
from  consideration.  He  said  that  this  malady,  called 
after  one  of  its  most  prominent  symptoms,  was  one  of 
the  most  common  of  female  ills.  It  was  always  a 
symptom  of  enfeebled  muscular  power,  and  almost 
always  an  accompaniment  of  downward  displacement 
of  the  abdominal  viscera.  It  was  evident,  therefore, 
that  it  should  not  be  treated  as  an  isolated  mechanical 
condition.  As  to  its  frequency,  several  authors  had 
asserted  that  about  twenty  per  cent,  of  v.omen  suffered 
from  it.  It  was  found  in  two  hundred  and  forty  out 
of  one  thousand  cases  coming  to  him  for  gynacologi- 
cal  treatment.  In  about  eighty  or  ninety  per  cent,  of 
the  cases  the  displacement  could  not  be  permanently 
reduced.  The  treatment  should  be  directed  to  the  re- 
lief of  the  congestion  and  strengthening  the  muscular 
powder.  When  vitality  and  muscular  power  failed, 
there  would  be  a  return  of  the  congestion  and  also  of 
the  former  symptoms.  In  a  case  of  non-adherent  and 
uncomplicated  retrodeviation,  the  surgeon  would  do 
an  -Alexander's  operation.  In  a  paper  read  by  Dr. 
George  M.  F.debohls  before  the  Geneva  congress,  it 
was  stated  that  out  of  one  hundred  and  fifteen  Alexan- 
der operations,  seventy-seven  had  been  "anatomical 
successes;"  the  remaining  thirty-eight  cases  showed 
an  instructive  list  of  hernias,  failures,  and  mishaps  of 
various  kinds.  As  about  twenty-five  cases  of  movable 
kidney  developed  after  the  operation,  it  would  now 
be  in  order  to  suggest  that  the  next  modification  of  the 
.\lexander  operation  should  be  the  sewing  of  the  kid- 
ney to  the  abdominal  wall.  The  author's  views  of 
the  conditions  underlying  retrodeviation  of  the  uterus 
may  be  briefly  stated  as  follows:  (i)  Passive  conges- 
tion and  an  engorged  venous  system  lead  to  renal  and 
arterial  changes  which  materially  shorten  life;  (2) 
enfeebled  muscle  is  readily  stretched ;  (3)  in  addition 
to  the  columnar  base  of  the  vagina,  the  uterus  has 
eight  ligaments  for  its  support,  and  these  ligaments 
depend  for  much  of  their  power  upon  the  muscular 
fibres  from  the  muscular  coat  of  the  uterus,  and  these 
fibres  partake  of  the  health  of  the  uterus;  and  (4) 
general  muscular  and  vital  debility-  bring  about  pas- 
sive congestion — in  a  word,  the  subject  may  be  said 


538 


MEDICAL    RECORD. 


[October  9,  1897 


to  be  comprised  in  the  reciprocal  relation  of  conges- 
tion and  muscular  debility.  In  addition  to  the  time- 
honored  routine  treatment,  the  speaker  said,  markedly 
benelicial  results  would  follow  the  persistent  use  of 
diuretics,  combined  with  iron  and  digitalis.  Outdoor 
exercise  and  daily  massage  and  baths  were  all  of  ser- 
vice. After  two  or  three  months  of  such  treatment,  all 
the  symptoms  usually  disappeared,  but  the  patient 
should  be  told  that  the  same  causes  would  bring  about 
a  return  of  the  symptoms. 

Uterine  Fixation,  Not  Displacement,  the  Chief 
Factor. —  Dr.  W.  (hll  W'ylik  said  that  about  fifteen 
3'ears  ago  he  had  made  a  careful  study  of  the  dynamics 
of  the  pelvis,  with  verj'  much  the  same  results  as  had 
been  given  in  the  paper.  He  was  of  the  opinion  that 
many  of  the  cases  under  consideration  were  the  re- 
sult of  imperfect  development,  and  that  too  much 
attention  had  been  given. to  the  mere  mechanical  dis- 
placement. He  had  never  opened  the  abdomen  for 
the  purpose  ot  correcting  the  uterine  displacement, 
although  he  had  devised  an  operation  for  shortening 
the  round  ligaments  in  cases  in  which  the  abdomen 
had  been  opened  for  some  other  reason.  He  had 
never  been  able  to  convince  himself  that  it  was  right 
to  fi.x  the  uterus  to  the  abdominal  wall.  It  was  not  the 
mechanical  displacement,  but  the  fixation  of  the  uterus, 
which  gave  rise  to  the  troublesome  symptoms. 

Every  Displacement  does  Not  Demand  Treatment. 
— Dr.  P.m'l  F.  Mund,':  said  tliat  the  subject  had  been 
presented  in  a  very  novel  and  original  manner,  and  the 
author's  facile  pen  had  almost  convinced  him  that  he 
really  meant  all  that  he  had  said.  The  author  had 
ridiculed  the  methods  of  the  gynaecologist  and  tiie  ab- 
dominal surgeon,  and  had  even  made  it  appear  that 
the  gynaecologist  knew  very  little  about  medicine.  He 
agreed  thoroughly  with  him  when  he  mentioned  meth- 
ods of  prevention,  but  he  wished  him  to  state  how  he 
W'as  going  to  carry  out  these  methods.  It  was  right  in 
theory,  but  impossible  in  practice.  For  example,  as 
a  prevention  of  subinvolution  he  had  himself  many 
years  ago  recommended  that  every  parturient  woman 
should  have  a  pessaiy  introduced  before  she  was  al- 
lowed to  get  out  of  bed.  It  was  a  nuisance,  of  course, 
1:)ut  so  was  a  crutch;  yet  it  was  useful  and  at  times 
desirable.  He  would  like  to  put  himself  on  record 
once  more  as  saying  that  he  did  not  think  that  every 
displacement  of  the  uterus  produced  symptoms  or  re- 
quired treatment.  In  many  cases  he  was  sure  that  the 
backache  complained  of  was  not  dependent  upon  the 
retrodisplacement,  but  upon  the  uterine  catarrh  and 
chronic  congestion,  with  the  consequent  dragging  upon 
the  ligaments.  Nevertheless,  he  believed  that  a  retro- 
deviation of  a  major  degree  should  be  remedied  when 
detected,  because  sooner  or  later  it  would  produce  un- 
pleasant symptoms.  He  would  even  apply  this  rule 
to  si>me  voung  single  women. 

Nothing  New  in  the  Paper,  and  Its  Teaching 
Dangerous.  -Dr.  Gedrc.e  M.  Euehohls  said  that  such 
a  paper  as  this  certainly  did  no  good,  and  might  be 
productive  of  a  good  deal  of  harm.  There  w'as  abso- 
lutely nothing  new  in  the  paper,  although  the  facts  had 
been  presented  in  a  very  felicitous  manner.  It  left  us 
where  we  were  ten  or  fifteen  years  ago.  I'revenlion 
was,  of  course,  most  desirable  if  practicable,  but  it 
could  be  carried  out  only  within  narrow  limits.  Kven 
if  some  women  were  restored  to  good  health,  there  was 
.still  a  class  of  cases  which  must  be  put  under  what  the 
author  had  very  hapjjily  termed  "  recurring  treatment." 
The  speaker  said  that  one  of  his  recent  papers  had  been 
referred  to  by  the  author,  but  it  had  been  apjiarently 
misquoted,  for  out  of  the  one  hundred  and  fifteen  cases 
there  w-ere,  if  his  memory  served  him,  at  least  one 
liundred  and  five  satisfactory  anatomical  cures,  and  in 
these  cases  his  observations  had  extended  over  an 
average  period  of  sixteen  months. 


Dr.  Vin'eberg  protested  against  the  criticisms  made 
in  the  paper  concerning  the  operative  work  of  modern 
gyna;cologists.  Either  the  reader  of  the  paper  was 
not  serious,  or  else  he  was  not  sincere.  It  seemed  to 
him  that  the  keynote  of  the  whole  paper  was  intended 
to  be  renal  insufficiency.  As  to  the  part  played  by 
the  general  health,  he  would  say  that,  although  he  was 
visiting  physician  to  a  home  for  chronic  invalids,  he 
found  very  little  occasion  to  treat  uterine  displace- 
ments among  the  inmates.  It  was  a  mistake  to  sup- 
pose that  renal  insufficiency,  heart  disease,  or  lung 
disease  would  produce  marked  disease  or  displacement 
of  the  uterus.  He  thoroughly  indorsed  the  statement 
made  by  Dr.  Munde,  that  when  there  was  marked 
retrodisplacement  it  was  prettj'  sure  in  time  to  cause 
trouble. 

Dr.  Julius  Rosenberg  said  that  the  symptoms  of 
which  the  patients  complained  often  persisted  after  the 
correction  of  the  displacement.  In  a  small  percentage 
of  cases  operations  were  necessary,  but  this  percentage 
was  growing  steadily  smaller. 

Dr.  S.AViDiiE,  in  closing  the  discussion,  said  that  he 
did  not  in  any  way  give  renal  insufficiency  as  a  cause 
of  retroversion,  nor  was  he  a  disparager  of  the  Alexan- 
der operation.  He  had  in  his  hand  the  paper  of  Dr. 
Edebohls,  and  thought  he  had  quoted  the  figures  cor- 
rectly. In  proof  of  this,  he  proceeded  to  read  the  re- 
sults from  the  tables  there  given. 


^tierapnttlc  Mints. 

Hypodermic  Purgative — 

K  Caffeine  and  chloral aa  gr.  viiss. 

Water "l  Ixxv. 

S.   Inject  fifteen  minims. 

— Ew.-VLD,  Jou?-iia!  lit-  Medccine  de  Paris. 

Cough  Mixtures. ^Dr.  James  K.  Crook  says  that 
the  following  formulas  have  been  thoroughly  tested  in 
both  hospital  and  private  practice  and  render  good  ser- 
vice m  suitable  cases.     For  irritative  coughs: 

R  Phenacetin gr.  xx.-xl. 

Exl.  glycyrrhiz;e gr.  xx. 

Sacch.  aibi 3    ij. 

Fiat  pulvis,  in  chartulas  20  dividendus.     S.   One  to  be  taken 
at  one,  two,  or  three  hour  intervals. 

For  the  same  of  more  obstinate  character: 

I^  Phenacetin    gr.   I. 

Ext.  glycyrrhiz;^ gr.  xx. 

Codein.-c  sulphatis gr.  ij.-iv. 

Sacch.  albi 3   ij- 

Fiat  pulvis,  in  chartulas  20  dividendus.      S.   One  to  be  taken 
every  two,  three,  or  four  hours. 

"B,  Ammonii  carbonatis 3  ij- 

Acidi  salicylici J  iiss. 

Aqua?  cinnaniomi aa  §  ij. 

M.     S.   Teaspoonful  in  a  little  water  every  three  hours 

— Henry  R.  Sl.ack. 

Carcinoma. — Although  local  treatment  is  useless  in 
carcinoma,  in  ca.ses  of  doubt,  as  when  there  is  ulcera- 
tion or  fissure,  the  following  ointment  is  useful.  If 
healing  does  not  take  place  in  two  weeks  operate,  as 
carcinoma  never  heals  in  this  way. 

1{   lialsaiii.  pcruviani. 

I'nguent.  hydrargyri  nitratis .ia  3  >• 

Petrolati 3  i. 

M. 

—J.  H.  Hearn. 

Use  of  the  Stomach  Tube.     Dr.    Murdoch    {New  HI 

York  M  i/iui/  Ji'iiriui/,  vol.  Ixv.,  \o.  3)  says  the  tube 
should  be  used  :  i.  For  diagnt)Stic  purposes.  An  hour 
after  a  test  meal  the  contents  of  the  stomach  are  with- 


October  9,  1897] 


MEDICAL    RECORD. 


539 


drawn  by  the  tube  and  examined  for  hydrochloric  and 
other  acids,  peptone,  etc.  2.  To  empty  the  stomach  in 
poisoning  except  when  due  to  caustic  alkalies,  be- 
cause of  the  danger  of  perforation.  3.  For  lavage.  In 
stagnation  of  food  in  the  stomach,  in  accumulations 
of  large  amounts  of  mucus,  and  sometimes  in  simple 
glandular  atony  with  lack  of  liydrochloric  acid.  Its 
best  results  are  obtained  in  dilatation  of  the  stomach 
by  cleansing  the  mucous  membrane  of  stale  food  and 
mucus,  and  restoring  the  vital it}^  of  the  secretory 
glands.  It  should  not  be  used  in  acute  and  semi- 
chronic  gastric  disturbances,  and  is  positively  contra- 
indicated  in:  I,  thoracic  aneurism;  2,  serious  car- 
diac disease;  3,  recent  bleeding  from  any  part;  4, 
great  debility  or  advanced  age;  5,  gastric  ulcer. 

Tapeworm. — 

i^  Olei  terebinthinse, 

Oleoresinse  filicis  maris aa  ;  vi. 

Mucilag.  acacife 3  ij. 

M.  ft.  emulsion.  S.  Day  before  treatment,  a  milk  or  thin- 
soup  diet,  and  one  drachm  of  compound  jalap  powder.  The 
emulsion  is  taken  the  following  morning,  fasting,  and  a  half-hour 
later  a  dose  of  castor  oil. 

— F.  A.  A.  Smith. 
Expectorant. — 

^  Ext.  glycyrrhizoe gr.  x.x. 

Phenacetin gr.  x.x.-xl. 

Ammonii  muriatis 3  i.-ij. 

Sacch.  albi J  ij. 

M.  et  in  chart.  20  dividendus.  S.  One  powder  to  be  taken 
in  a  little  water  every  two,  three,  or  four  hours. 

Purgative  Pill. — 

1}  Podophyliin, 
Leptandrin, 

Ext.  colocynth.  comp aa  3  >• 

01.  menth.  pip gtt.  vi. 

M.  ft.  pil.  No.  60.  S.  One  for  a  laxative;  two  for  a  pur- 
gative  and  three  for  a  drastic  effect. 

— D.  E.  Ruff. 
Antineuralgia  Pill. — 

15  Str)xhninit  sulph gr.  i. 

Quininx  sulph 3  '. 

Ferri  redaoti ....   gr.  xv. 

Ext.  gentianae 3  ss. 

M.   ft.   pil.   No.  60.      .S.    One  three  times  a  clay. 

This  is  especially  good  for  facial  and  stomach  neural- 
gias. If  there  is  a  marked  malarial  element  present, 
add  arsenious  acid,  five  grains,  to  the  formula. — D.  K. 
Ruff. 

Garfield  Tea. — The  "  Standard  Formulary''  gives 
the  following  as  the  appro.ximate  composition  of  "  Gar- 
field tea": 

Q  Triticum 31. 

Liverwort 3  i . 

Senna ?  viij. 

Pulmonary  Tuberculosis 

IJ  Creosote  (beechwood) gr.  374 

Camphor gr.  225 

.Bristol gr.  150 

Eucalyptol gr   450 

Sterilized  neat's-foot  oil 3     8 

M.      S.   To  be  used  as  a  hypodermic  injection. 

Each  cubic  centimetre  of  this  solution  contains  a 
grain  and  a  half  of  creosote,  six-tenths  of  a  grain  of 
aristol,  and  three-quarters  of  a  grain  of  eucalyptol. — 
GiLBF.RT,  J'raft.  Drug,  and  Jievicw  nf  Rcrinvs. 

Haematophilia — All  the  observations  which  have 
been  made  upon  the  nature,  history,  and  progress  of 
this  disease  may  be  resolved  into  two  essential  and 
congenital  conditions:  an  abnormal  vitality  of  the 
blood,  and  a  delicate  construction  of  the  capillaries. 
The  circumstances  of  the  disease  appear  to  support 
the  following  propositions:  i.  Its  intermitting  char- 
acter.    2.  The  strong  action  of  the  arterial  svstem,  as 


shown  by  the  mental  excitement  before  the  attack.  3. 
The  immunity  from  excessive  hemorrhage,  even  after 
wounds,  in  the  intervals  between  the  attacks.  4.  The 
rare  occurrence  of  bleedings  in  persons  who  have 
some  steady  outlet,  as  hemorrhoids.  5.  The  facility 
with  which  bleedings  are  sometimes  prevented  or  ar- 
rested by  means  which  lower  the  vitalit)-  of  the  blood, 
as  diarrhoea  or  smart  purging,  etc.  6.  The  readiness 
with  which  ecchymoses  form  under  the  skin,  from  very 
trifling  injuries. — Hopkins,  Occidental  Aledica!  Times, 
March,  1897. 

Vulvar  Vegetations. — .\n  active  application  is  the 
following : 

"Sf  Powdered  savin. 

Iodoform, 

.Salicylic  acid aa    equal  parts. 

M. 

- — LUTACD. 

Nephritis — 

K  Ergotini 5  gm. 

Ac.  gall 8  gm. 

Extr.  et  pulv.  rad.  rhatan.  q.s.  ut  ft.  pil.  nr.  viginti. 
S.   Take  one  pill  four  times  a  day. 

IJ  Ergotini 2         gm. 

.\c.  gall 4         gm. 

Saccharini 0.05  cgm. 

Muc.  gumm.  arab 200         gm. 

M.      .S.    Teaspoonful  twice  a  day. 

■ — PULVIRKNTI. 

The  Therapeutical  Action  of  the  Cold  Bath  in 
Typhoid  Fever — Drs.  Robin  and  Binet  {Archives 
Geiicrales  de  Mc'deciiic,  November,  1896)  report  after 
careful  chemical  investigations  that  the  cold  bath  in- 
creases the  amount  of  air  inspired  and  expired  and 
increases  the  amount  of  carbonic-acid  gas  excreted  and 
the  amount  of  oxygen  absorbed.  They  conclude:  i. 
That  in  typhoid  fever  there  is  an  exaggerated  loss  of 
nutrition,  and  large  quantities  of  waste  products  as 
well  as  of  ptomains  invade  the  tissues,  and  are  not 
excreted  as  fast  as  they  are  formed.  These  products 
are  not  split  up,  owing  to  the  decreased  absorption  of 
o.xygen.  2.  That  our  aim  m  such  cases  should  be  to 
increase  oxidation.  3.  That  cold  baths  have  a  re- 
markable oxidizing  power.  4.  That  they  increase  the 
respiratory  processes,  but  above  all  they  increase  the 
total  amount  of  oxygen  taken  in  and  increase  its  ab- 
sorption. 5.  That  the  respiratory  change  does  not  be- 
gin to  take  place  until  half  an  hour  after  the  bath  and 
reaches  its  maximum  at  the  end  of  an  hour.  6.  That 
the  duration  of  tiie  process  cannot  be  sharply  fixed. 
7.  That  if  the  bath  does  not  reduce  the  temperature  it 
does  not  produce  the  above-mentioned  change.  The 
cold  bath  by  diminishing  the  temperature  lessens  the 
increased  tissue  destruction  and  the  production  of 
toxins.  Increased  oxidation  transforms  the  bacterial 
toxins  into  harmless,  easily  eliminable,  soluble  prod- 
ucts. The  cold  bath  raises  the  arterial  tension  and 
increases  the  heart  action,  from  which  causes  diuresis 
recurs  and  the  products  of  tissue  change  are  more 
easily  carried  off.  •  These  effects  are  all  due  to  a  re- 
flex action  from  the  nervoiis  .system. 

Hints  for  Patients  on  Sea  Voyages Dr.  George 

Walter  Barber  i  'J'/ic  British  Medical  Journal,  Decem- 
ber 19,  1896)  gives  some  good  advice  for  patients  sent 
away  for  the  benefit  of  their  health.  In  the  first  jilace 
a  crowded  ship  should  be  avoided  and  an  entire  cabin 
should  be  secured,  especially  for  phthisical  patients. 
The  cabin  should  be  amidship,  where  the  motion  and 
vibration  of  the  ship  are  least  felt.  The  patient 
should  wear  a  cummerbund  over  his  pajamas,  as  the 
neglect  of  this  precaution  frequent] v  leads  to  severe 
abdominal  pain  and  diarrhcea,  and  often  colitis,  owing 
to  the  free  perspiration  which  occurs  in  the  tropics 
being  checked  by  a  stream  of  cold  air  from  an  open 


540 


MEDICAL    RECORD. 


[October  9,  1897 


port,  etc.  The  patient  should  never  sleep  on  deck, 
and  as  soon  as  he  arrives  in  the  tropics  he  should  wear 
a  solar  tope  as  a  protection  against  sunstroke,  sun 
headache,  and  thermic  fever.  The  patient  should  be 
told  to  keep  on  deck  as  much  as  possible,  but  should 
not  sit  under  a  single  awning,  which  allows  the  sun's 
rays  to  penetrate.  Clothing  should  be  suited  to  the 
varying  climates.  All  alcoholic  subjects  should  be  put 
under  the  ship's  surgeon  at  the  beginning  of  the  voy- 
age, as  he  is  then  able  to  make  sure  that  they  get  no 
liquor.  The  morning  bath  should  be  taken  warm  by 
malarial  subjects  and  those  who  are  very  delicate. 
Very  strict  orders  should  be  given  as  to  diet,  most 
persons  eating  too  much  and  e-xercising  too  little.  Dr. 
Barber  recommends  the  following  for  seasickness: 

^  Chloroform!  purif nii. 

Tr.  nuc.  vom I'li. 

Tr.  lavand mx. 

Aq ad3i- 

M.  ft.  mist.  S.  To  be  well  shaken,  and  taken  every  hour 
until  the  nausea  is  relieved;  liquor  morphinar  acetatis,  m  v. ,  if 
there  is  much  pain . 

Alcohol  is  unnecessary  in  most  cases;  milk  and  soda, 
beef  tea,  or  beef  jelly  should  be  given  in  small  quanti- 
ties at  short  intervals.  A  letter  describing  the  case 
should  be  given  the  patient,  which  may  be  handed  to 
the  .ship's  surgeon  if  his  services  are  required. 


^itvgiciil  J»wggesttous. 

Osteotomy  of  the  Femur. — In  the  treatment  of  tu- 
berculous disease  of  the  hip  in  its  early  stages  Dr. 
R.  F.  Tobin  (B rittsh  Mcifical Journal,  April  24th)  gives 
the  following  summary  of  his  views:  i.  That  no  treat- 
ment better  than  re.st,  combined  with  constitutional  rem- 
edies, is  known  for  tuberculous  disease  of  the  hip.  2. 
That  a  large  proportion  of  cases  of  this  disease,  espe- 
cially those  in  which  flexion  has  occurred,  go  on  to 
suppuration,  and  that  one  of  the  chief  causes  of  their 
doing  so  is  the  difficult}'  of  giving  the  joint  rest.  3. 
That  much  of  this  difficult)-  lies  in  the  fact  that  the 
position  of  greatest  ease  for  the  tuberculous  hip-joint 
is  one  in  which  it  is  very  awkward  for  the  patient  to 
carry  the  limb,  very  difficult  for  the  surgeon  to  lix  it, 
and  Jherefore  one  in  which  the  joint  is  constantly  ex- 
posed to  disturbance.  4.  That  it  is  possible,  and  in 
many  cases  advisable,  to  remove  this  difficulty  by  such 
an  osteotomy  of  the  femiu"  iis  will  allow  the  limb  to 
be  put  straight,  while  the  upper  of  the  fragments  re- 
tains "the  natural  position  of  rest."  5.  That  the 
operation  also  does  good  in  some  cases  by  relieving 
tension  in  the  bone.  6.  That  an  osteotomy  of  the 
femur  when  done  in  this  respect  is  not  so  formidable 
an  undertaking  as  it  is  under  ordinary  circumstances, 
for  it  is  not  the  division  of  the  bone  that  is  formidable 
in  this  operation,  but  the  constrained  position  in 
splints  and  the  long  period  of  rest  required  for  union. 
Now  since  these  latter  incidents  ;>re  a  great  gain  for 
the  tuberculous  joint,  they  must  be  put  to  the  credit  of 
the  operation,  thus  leaving  very  little  to  be  entered  on 
the  debit  side. 

Treatment  of  Fractures.  —  Dr.  Davis  concludes  an 
article  in  the  y/ww/f  (2/ .SV//y<v;i' as  follows:  i.  It  is  my 
belief  that  massage  and  passive  motion  are  not  used  to 
the  extent  that  they  should  be  in  the  treatment  of  frac- 
tures. 2.  That  immobility  of  the  fractured  ends  favors 
quick  union  with  little  deformity.  3.  That  there  are 
some  cases  in  which,  owing  either  to  peculiarities  of 
the  fracture  or  to  the  impaired  constitution  of  the  in- 
dividual, the  tendency  to  the  formation  of  callus  is 
marked.  Motion  in  these  tends  to  the  formation  of  ex- 
uberant callus  and  deformity.     4.  That  there  are  others 


in  which  union  is  unduly  delayed;  disturbance  of  the 
fractured  ends  in  these  hinders  union.  5.  That  it  is 
wise  to  wait  until  the  fractured  parts  are  glued  together, 
usually  eight  or  ten  days,  before  attempting  any 
except  the  lightest  massage,  and  any  extensive  passive 
motion  after  that  lime  should  be  used  carefully  but 
diligently.  6.  That  passive  motion  and  massage  when 
first  attempted  should  be  of  the  most  gentle  character, 
and  not  so  violent  as  to  disturb  the  relation  of  the  broken 
bones.  7.  That  any  marked  pain  and  inflammatory 
reaction  following  passive  motion  and  massage  are  evi- 
dence tiiat  it  has  been  too  violent.  8.  That  the  limb 
should  receive  massage  and  manipulation  at  each 
inspection  or  change  of  dressing,  often  daily.  9.  That 
in  some  cases  it  is  advisable  to  administer  such  mas- 
sage as  is  possible  without  removing  the  splints.  10. 
The  persistent  stiffness,  particularly  in  fractures  or 
injuries  of  the  wrist,  is  often  due  to  a  rheumatoid 
affection  locating  itself  in  the  injured  region.  Mas- 
sage is  valuable  in  the  treatment  of  such.  11.  That 
massage  should  be  given  to  that  part  of  a  limb  beyond 
the  seat  of  fracture,  to  preserve  it  in  a  normal  condition. 
12.  That  such  dressings  and  methods  of  treatment 
should  be  adopted  as  will  allow  of  the  greatest  use  of 
massage  and  passive  and  active  movements  consistent 
with  proper  retention  of  the  fragments. 

Empyema  of  the  Antrum. — In  discussing  a  new 
operation  for  the  cure  of  obstinate  instances  of  disease 
of  the  antrum  of  Highmore,  Dr.  H.  A.  Lothrop  {Boston 
Medical  and  Surgical  foutnal.  May  13th)  presents  the 
following  conclusions:  That  the  relation  of  the  open- 
ings of  the  accessor}'  nasal  cavities  is  not  constant, 
and  that  fluid  may  gravitate  from  one  to  another  ac- 
cording to  the  position  of  the  head.  That  the  antrum 
is  a  resenoir  for  pus,  of  primary  or  secondary  origin. 
That  many  cases  of  empyema  of  the  antrum  are  never 
cured;  therefore  further  efforts  are  needed,  which  must 
be  in  the  line  of  surgerj-.  That  the  more  radical 
operation  with  the  idea  of  drainage  have  relieved 
cases  hitherto  incurable.  That  there  are  important 
objections  to  a  large  canine  or  alveolar  opening  with 
the  idea  of  establishing  permanent  drainage.  That 
permanent  nasal  drainage  is  less  objectionable  than 
oral  drainage.  That  the  removal  of  the  lower  half  of 
the  naso-antral  wall  prevents  further  pus  retention 
and  thereby  allows  the  antral  mucous  membrane  to 
resume  a  healthy  condition.  That  the  operation  sug- 
gested is  of  short  duration  and  not  severe,  although 
most  radical.  That,  by  this  procedure,  the  antral 
cavity  is  rendered  easily  accessible  to  frequent  irriga- 
tions by  the  patient  and  to  local  applications  and  oc- 
casional inspection  by  the  surgeon. 

Sprains  of  the  Ankle-joint. — As  a  result  of  mas- 
sage in  the  treatment  of  twelve  hundred  and  thirty- 
one  cases  of  sprain  of  this  joint,  these  deductions  are 
made:  i.  Prevent  swelling  or  rapidly  disperse  it  if 
present.  2.  Prevent  pain  or  quickly  remove  it  when 
due,  as  it  must  be,  to  tension.  3.  Prevent  stiffness  or 
overcome  it  when  already  present  from  disuse.  4. 
Prevent  the  sense  of  weakness  and  restore  the  part  to 
its  original  vigor  and  strength.  5.  Reduce  the  time 
of  treatment  from  weeks  to  a  corresponding  number  of 
days.  6.  Permit  the  immediate  use  of  the  injured 
member. —  Drs.  Van  Arsd.m.e  and  Gallant. 

The  first  strip  for  a  sprain  of  the  external  malleolus 
is  applied,  beginning  just  above  tlie  ankle  on  the  un- 
affected side  of  the  foot,  and  ending  on  the  affected 
side  about  hulf  the  way  up  the  calf.  This  strip  is 
usually  alongside  the  tendo  Achillis  and  makes  firm 
support  under  the  heel.  The  second  strip  starts  on 
the  inner  side  of  the  unaffected  part  of  the  foot,  near 
the  ball  of  the  toe,  comes  around  over  the  back  of  the 
heel,  and   ends  about  the  base  of  the  little  toe.     It 


October  9,  1897] 


MEDICAL    RECORD. 


541 


crosses  the  first  one  just  above  the  border  of  the  heel. 
The  third  strip  overlaps  the  first  half-way,  the  fourth 
the  second,  and  so  on  until  the  part  sprained  is  fully 
covered  by  this  criss-cross  strapping.  A  cheese-cloth 
bandage  is  applied  more  with  the  idea  of  securing 
Close  adhesion  of  the  plaster  and  is  removed  within 
twenty-four  hours.  As  soon  as  the  dressing  is  com- 
pleted the  stocking  and  boot  should  be  applied.  The 
patient  is  now  ready  to  begin  walking,  and  this  should 
be  insisted  upon  in  the  presence  of  the  surgeon. 
Direct  him,  for  instance,  to  walk  about  the  room  eight 
or  ten  times.  At  the  end  of  a  week  it  is  well  to  re- 
move the  strips  and  reapply  in  the  same  manner  as 
above.  Two  or  three  such  dressings  suffice  to  com- 
plete the  cure. — Dennis'  "Surgery,"  vol.  ii.,  p.  362. 


OUR    PARIS    LE'iTER. 

(From  our  Special  Correspondent.) 
HEALTH    OF    PARIS — EXOPHTHALMIC   GOITRE — ITS     BEST 
TREATMENT  —  THOMSEN's       DISEASE  —  A      PACKERS' 
NEEDLE    INSTEAD  OF    FORCEPS,    ETC. 

P.\Ris,  September  22,  1897. 

The  coid  weather  of  the  last  week  has  been  making  it- 
self felt  not  only  by  bringing  back  to  Paris  members  of 
the  faculty  and  general  practitioners  as  well,  but  also 
in  an  increase  in  the  number  of  cases  of  colds,  laryn- 
gitis and  bronchitis,  and  even  pneumonia.  Nevertlie- 
less,  the  health  risitt/h'  of  the  w-eek,  according  to  the 
Bulletin  Hcbdomadaire  tie  Statistiqi:c  Aluiiicipale,  is  sat 
isfactory.  During  the  week  from  the  5th  to  the  T2th 
of  September  there  were  735  deaths  instead  of  830, 
the  mean  of  the  September  weeks.  The  zymotic  dis- 
eases are  but  little  prevalent,  causing  8  deaths,  to  wit: 
typhoid  fever,  4,  instead  of  11 — the  average;  .measles, 
I,  instead  of  7 — average;  whooping-cough,  2,  instead 
of  5 — average;  and  diphtheria,  i,  instead  of  10 — aver- 
age, Paris  is  absolutely  free  from  smallpox,  and  no 
one  has  died  in  the  week  referred  to  of  scarlet  fever. 
Although  there  has  been  a  slight  increase  in  the  num- 
ber of  cases  of  inflammatory  diseases  of  the  respira- 
tory organs,  it  is  still  below  the  average;  there  were 
55  deaths  from  these,  instead  of  5  i  as  in  the  preced- 
ing week,  and  instead  of  67,  the  average  of  the  season 
On  the  other  hand,  there  has  been  a  decrease  in  the 
number  of  deaths  from  pulmonary  phthisis — 147 
instead  of  173,  the  average. 

The  Academy  of  Medicine  met  on  the  i  ith  inst.,  and 
listened  to  a  ver)'  important  communication  on  the 
dangers  of  operations  on  exophthalmic  goitre,  by  Dr. 
Poncet,  professor  of  the  surgical  clinic  at  the  Faculty 
of  Medicine  of  Lyons. 

Here  is  his  opinion :  "  In  all  cases  of  true  Basedow's 
disease,  try  at  first  internal  medications,  and  continue 
their  use  e\en  if  the  amelioration  is  slow.  In  cases 
belonging  to  the  poorer  clas.ses,  in  those  that  go  rap- 
idly into  cachexia  or  relapse  after  a  momentary  ame- 
lioration by  medical  treatment,  advise  an  operation  as 
soon  as  the  functional  troubles  interfere  with  the  acts 
of  every-day  life  and  before  the  general  condition  is 
too  much  altered,  but  warn  the  patient  that  there  are 
risks  to  run. 

"  If  the  tumor  is  of  medium  volume,  remove  it  by 
massive  enucleation  or  by  partial  thyroidectomy.  If 
it  is  larger  and  very  vascular,  give  preference  to  exo- 
thyropexia  in  spite  of  the  perhaps  more  numerous 
chances  of  failure.  It  will  be  time  enough  to  have 
recourse  to  a  secondary  excision  of  the  goitre  when  the 
partial  thrombosis  of  its  vessels  caused  by  exposure  to 
tlie  air  shall  have  diminished  the  operative  difficulties 
and  the  chances  of  intoxication.  Some  surgeons, 
among  others  Kocher  and  Rydygier  more  especially, 


have  strongly  recommended  the  ligature  of  the  thyroid 
arteries  as  an  innocent  and  efficacious  therapeutic 
measure  in  the  treatment  of  exophthalmic  goitre. 

''  My  own  personal  experience  in  the  treatment  01 
the  different  forms  of  goitre  is  that  the  continued  current 
gives  by  far  the  best  results,  and  oftenest  brings  about 
a  complete  cure;  and  I  have  completely  resorbed  by  its 
use  a  simple  hyperplasia  of  the  thyroid  body  as  large 
as  a  good-sized  hen's  egg.  In  the  treatment  of  a  case 
of  e.xophthalmic  goitre  I  reduced  the  growth  by  at 
least  one-third.  In  this  case  the  galvanic  current  was 
supplemented  by  the  faradic  current.  Both  were  ap- 
plied as  follows:  Five  minutes  on  the  goitre,  by  plac- 
ing the  large  positive  pole  on  the  seventh  cervical  ver- 
tebra and  the  small  negative  one  on  the  tumor  itself; 
then  five  minutes  by  placing  the  positive  pole  with  a 
small  tampon  below  the  thyroid  body  and  the  nega- 
tive pole  above  it;  then  five  minutes  with  one  pole 
either  side  of  the  growth.  These  applications  were 
followed  by  five  m.inutes'  faradization  of  the  sympa- 
thetic— three  minutes  on  the  heart  and  one  on  each  of 
the  eyes,  the  positive  pole  always  being  placed  on  the 
seventh  cer\'ical  vertebra,  excepting  for  the  tumor  itself 
and  of  course  the  two  sympathetics." 

A  disease  about  which  but  little  is  known  beyond 
the  general  description  in  some  of  the  more  recent 
works  on  the  pathology  of  the  ner\-ous  system  is 
Thomsen's  disease.  It  is  a  myotonia,  and  this  is  the 
characteristic  of  the  disease — a  special  muscular  con- 
traction, produced  at  the  beginning  of  a  voluntary 
movement  or  change  of  direction  of  a  given  movement, 
its  intensity  and  duration  varying  in  proportion  to  the 
importance  of  the  effort,  but  remaining  absolutely 
painless.  As  regards  frequency,  these  motor  troubles 
affect  chiefiy  the  lower  limbs,  more  rarely  the  arms 
and  preferably  the  hands,  then  the  back  of  the  neck, 
the  face,  the  body,  the  pharynx,  the  tongue,  etc.  The 
rela.xation  of  the  muscle  or  muscles  affected  is  more  or 
less  slow,  according  as  the  effort  was  greater  or  less. 

I  have  had  quite  recently  a  case  of  this,  in  which 
both  the  lower  limbs  were  affected.  The  patient  at 
the  beginning  of  his  walk  would  be  suddenly  taken 
with  an  inability-  to  proceed.  His  legs  refused  lO 
move;  there  was  an  absence  of  all  pain  or  numbness, 
such  as  we  often  see  in  some  forms  of  paralysis.  The 
inability  was  the  only  symptom,  and  this  passed  off  in 
a  few  seconds.  The  muscular  contraction  was  scarcely 
perceptible,  but  general — the  kind  of  contraction  that 
takes  place  in  rigor  mortis  but  more  rapid,  all  the 
groups  of  muscles  seeming  to  become  contracted  at 
once,  if  contraction  there  was — a  kind  of  nailing  to 
the  ground.  This  affection,  which  is  often  congenital, 
may  also  be  acquired.  Hereditary  alcoholism  is  a 
productive  soil  for  it.  The  case  referred  to  was  symp- 
tomatic— that  is,  Thomsen's  disease  was  associated 
with  a  uric-acid  diathesis  and  rheumatoid  arthritis,  the 
patient's  nerve  centres  being  irritated  and  poisoned 
by  uric  acid.  But  as  a  general  rule  an  organic  disease 
of  the  nervous  system  lies  at  the  bottom.  Dr.  Korn- 
'  holb,  in  his  thesis,  1897,  has  thrown  considerable  light 
on  this  obscure  affection,  and  from  observations  taken 
in  the  service  of  Professor  Raymond  finds  that  the 
principal  causes  are  spinal  sclerosis,  epilepsy,  syphilis, 
polyneuritis,  with  muscular  atrophy  and  meningo- 
myelitis. 

As  regards  treatment,  that  rests  entirely  upon  the 
iiiilicatio  caiisalis.  As,  however,  the  circulation  is 
almost  always  involved,  massage,  electricity,  and 
douches  to  the  spine  are  our  best  remedies.  As  re- 
gards internal  medicines,  hyoscyamine,  arsenic,  and 
Indian  hemp  may  be  given  with  advantage.  Person- 
ally I  find  strychnine  the  most  valuable  remedy,  in 
doses  of  one-one-hundred-and-twentieth  of  a  grain 
twice  daily  with  meals,  and  continued  for  three  weeks. 

Paris  is  to  have  another    sensational    trial.      The 


542 


MEDICAL    RECORD. 


[October  9,  1897 


court  is  now  taking  cognizance  of  an  affair  the  main 
features  of  which  are  as  follows :  The  wife  of  a  pdtis- 
siit  being  in  labor,  a  doctor  was  called,  who,  not  being 
able  to  deliver  the  woman  with  a  faulty  forceps,  asked 
the  husband  to  assist  him.  The  latter  brought  a  bo.x 
of  tools,  in  which  was  found  a  packers'  needle.  This, 
it  appears,  was  used  to  pierce  the  cranium  of  the  child, 
which  was  afterward  taken  away  in  pieces.  Shortly 
after  the  woman  was  taken  with  fever  and  delirium, 
followed  soon  by  death.  Dr.  Socquet,  the  legal  medi- 
cal e.xpert,  demonstrated  that  the  woman  had  died  not 
as  a  consequence  of  the  deliver}-,  but  by  the  perfora- 
tions that  had  been  made  in  different  places  in  the 
intestines,  bladder,  and  peritoneum. 


HYGIENE   IN    THE   B.\RBER    SHOP. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  Without  trespassing  too  largely  upon  your  corre- 
spondence department,  I  would  like  a  word  bearing 
upon  ■'  .\septic  Barbering,"  as  mentioned  by  you  edi- 
torially in  the  last  issue.  In  my  communication  to 
the  Medical  Record  two  weeks  ago  upon  "A  School 
for  Favus  Children,"  I  failed  to  bring  out  the  point  that 
the  majority  of  the  male  subjects  of  favus  resort  to  the 
barber  shop  for  their  hair  cutting.  During  the  past 
five  months,  out  of  a  total  of  nearly  three  thousand 
skin  cases  I  have  seen  eighty  odd  subjects  of  favus,  the 
great  majority  of  whom  I  have  questioned  regarding 
their  habits  in  this  respect,  and  have  found  that  almost 
without  exception  the  barber's  services  are  sought  and 
freely  received. 

The  hair  is  usually  cut  with  the  patent  clipper.  It 
was  only  yesterday  that  a  man  of  twenty-one  years, 
whose  disease  had  existed  from  childhood,  informed 
me  that  he  went  regularly  to  the  barber,  who  cut  his 
hair  without  protest,  although  abundant  yellow  crusts 
were  present  at  the  time.  I  always  make  it  a  point  to 
instruct  such  patients  in  regard  to  the  danger,  and 
tell  them  to  have  their  hair  cutting  done  at  home. 
Having  failed  to  secure  proper  co-operation  in  sev- 
eral instances,  I  now  have  the  hair  of  favus  patients 
at  the  Good  Samaritan  cut  at  tlie  institution  as  part 
of  the  routine  treatment. 

In  regard  to  the  relative  frequency  of  the  af- 
fection in  the  district  in  which  this  institution  is 
located,  I  may  say  that  in  the  last  report  of  the 
American  Dermatological  Association  there  are  but 
thirty-five  instances  given  for  the  year,  out  of  a  total 
of  over  eleven  thousand  cases,  and  the  general  record 
from  1887  to  1893  gave  for  the  whole  country  but 
three  hundred  and  seventy-three  cases  out  of  over 
ninety-one  thousand.  It  is  safe  to  predict  that  unless 
proper  steps  are  taken,  the  disproportion  will  not  al- 
ways continue  to  exist.     Charles  \V.  .\llex,  M.D. 

\■if^  East  Sixtieth  Stkfki 


THE   PREVALENCE   OF   TAPEWORM. 

To  the  Editor  of  the  Medical  Record 

Sir:  Regarding  Dr.  E.  C.  Chamberlin's  article  on 
tapeworm  in  your  issue  of  August  28th,  I  think  his 
statistics  are  not  borne  out  by  common  experience. 
During  my  residence  of  three  years  in  Watertown 
(population  thirty-five  hundred),  I  have  had  four  cases 
of  tapeworm,  all  in  men,  ages  from  twenty-two  to 
thirty-five  years;  occupations,  two  butchers,  one  shoe- 
maker, one  railroadman. 

My  friend.  Dr.  H.  M.  Fininond,  residing  here  since 
1890,  has  had  six  cases,  only  one  of  which  occurred 
in  a  female. 

From  what  I  know  of  physicians  in  the  neighboring 
towns,  their  experience  is  very  similar. 

George  G.  S.axe.  M.D. 

Watkktown,  S.  Dak.,  September  2i*t. 


S^edical  Stems. 

Contagious  Diseases — Weekly    Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  October  2,  1897: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. . . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 


153 

III 

27 

4 

1)2 

5 

Are  the  Bodily  Organs  Friends  or  Enemies  ? — 
In  answering  this  question  most  physiologists  would 
probably  say,  "Friends:  for  they  act  together  for  the 
support  of  the  whole  organism."  M.  J.  Kunstler  takes 
another  view.  He  tells  us  that  they  are  enemies,  or 
perhaps  rather  rivals;  for  an  advantage  given  to  one 
invariably  results  in  its  outstripping  the  others,  to 
their  injury  {Lih-rary  Digest).  It  is  not  verj-  long 
since  general  biology,  he  says,  in  some  of  its  parts, 
was  based  on  certain  theories,  mostly  philosophical, 
that  ruled  supreme  over  our  conceptions  of  the  living 
organism.  Such  is  without  doubt  the  theoretical 
view,  often  advanced,  but  dating  back  as  far  as  Aris- 
totle, according  to  which  the  different  parts  of  a  being 
form  a  harmonious  whole,  in  which  they  all  aid  each 
other,  in  a  manner,  and  complete  one  another,  so  that 
they  work  together,  each  in  its  own  way  and  for  the 
best  advantage,  to  the  common  good  of  the  whole.  An 
organism  would  then  be  comparable  to  a  society  wisely 
constituted  of  bodies  of  workers,  who  labor  together 
in  such  wise  as  to  protect  the  whole  body  from  injuri- 
ous outside  influences.  This  specious  and  seductive 
manner  of  treatment  can  be  refuted  only  by  a  some- 
what rigorous  scientific  analysis.  Far  from  giving 
mutual  aid,  the  different  parts  of  the  bodies  of  living 
beings  seem,  on  the  contrary,  to  be  in  perpetual  strife 
with  one  another.  F^er}-  development  of  one  of  them 
has  for  correlative  result  a  diminution  of  importance 
in  the  others.  In  other  words,  every  part  that  in- 
creases determines  the  enfeeblement  of  the  other  parts. 

.  .  Not  only  do  the  organs  fight  each  other,  but  all 
other  parts  do  the  like,  whatever  they  may  be.  For 
example,  there  is  conflict  among  the  tissues,  even 
among  the  elements  of  the  same  tissue.  The  evolu- 
tion of  the  feebler  ones  is  diminished  or  arrested: 
they  are  pitilessly  sacrificed  to  the  good  of  the  strong, 
which  thus  become  more  flourishing.  Things  seem 
to  take  place  as  if  living  organisms  possessed  only 
one  determinate  amount  of  evolutive  power.  If,  by 
means  of  some  artifice,  this  force  of  development  is 
taken  from  an  organ  or  a  part,  the  other  organs  are 
more  or  less  completely  brought  to  a  standstill,  or 
they  may  even  retrograde.  These  facts,  taken  to- 
gether, lead  the  mind  quite  naturally  to  a  comparison 
with  what  we  see  every  day  in  regard  to  patrimonial 
succession.  In  the  case  in  which  one  of  the  children 
of  the  same  family  is  favored  in  the  p:irtition  of  the 
father's  estate,  the  share  of  the  others  is  by  the  same 
fact  diminished  by  that  amount.  Kunstler  has  this  to 
say  about  the  eftects  of  exercise :  In  moderate  amounts, 
exercise  has  a  favorable  effect,  and  facilitates  the  prog- 
ress of  the  organism,  while  a  continual  excess  of  it 
brings  injury.  Every  degree  of  exercise  cannot  be 
considered  of  use  to  the  development  of  the  organs 
that  are  subjected  to  it.  any  more  than  to  the  organism 
as  a  whole.     The  well-known   example  of   a  certain 


I 


October  9.  1897] 


MEDICAL    RECORD. 


543 


fencing-master  whose  continued  professional  exercise 
brought  on  symptoms  of  atrophy  is  a  case  in  point. 
But  without  considering  extremes,  exercise  even  in 
relatively  moderate  amounts  can  produce  undesirable 
effects,  if  it  is  too  exclusive  and  too  continued.  By  a 
kind  of  balancing  of  the  organic  energy,  if  one  part  is 
specially  trained  the  neighboring  organs  cease  to  act, 
in  greater  or  less  degree,  and  this  part  becomes  rela- 
tively preponderant,  to  the  detriment  of  the  others. 
Besides,  it  is  well  known  that  as  a  general  rule  men 
with  powerful  muscular  and  organic  development  are 
often  not  those  that  present  the  most  intellectual  habit 
of  mind.  This  extreme  application  of  the  principle 
of  the  balance  of  organs  has  even  been  the  object  of 
popular  consecration,  if  we  may  be  allowed  to  recall 
the  fact  that  when,  in  colloquial  language,  a  man  is 
called  "fat"  or  "heavy,"  it  is  never  taken  as  evidence 
of  his  intelligence.  .  .  .  The  process  that  has  been 
indicated  has  also  a  general  signification  and,  besides 
exercise,  a  multitude  of  causes  can  conspire  to  hasten 
the  development  of  the  bodily  elements.  All  the 
agents  of  excitation,  such,  for  example,  as  alcoholic 
drinks,  physical  or  intellectual  fatigue,  grief,  all  ex- 
cesses, act  thus,  and  make  us  "live  faster.'"  Trees 
taken  from  Europe  to  Algeria  come  in  a  half-dozen 
years,  under  the  influence  of  the  permanent  excitation 
due  to  the  high  temperature  of  the  African  cl  imate,  to 
the  same  stage  of  development  that  they  would  reach 
in  double  the  time  in  a  temperate  region.  But  then, 
having  used  up  their  whole  vital  energy,  they  die. 
Their  leaves  have  scarcely  fallen  in  autumn  when  they 
are  replaced  by  a  new  growth ;  they  are  the  seat  of  an 
intense  life  that  uses  them  up  quickly.  So,  also, 
great  workers  become  weak  and  feeble  before  their 
time.  The  ephemeral  successes  of  great  bicycle  racers 
are  striking  examples  from  daily  life.  M.  Kunstler 
believes  that  this  lack  of  vitality,  due  to  the  abnormal 
de\elopment  of  one  part  or  faculty,  is  inheritable,  and 
hence  has  its  effect  on  the  history  of  the  human  race. 
For  instance,  he  points  out  that  city  children,  com- 
pared with  those  of  the  country,  are  more  precocious, 
but  have  less  vitality,  owing  to  maturity  hastened  by 
tlie  excitement  of  city  life  for  generations.  He  ap- 
plies his  rule  also  to  the  cases  of  certain  families  or 
of  precocious  children  in  the  same  family,  and  finds 
that  everywhere,  whether  in  the  individual,  the  family, 
or  the  race,  overdevelopment  in  one  part  or  faculty, 
instead  of  helping  on  the  others,  invariably  retards 
them. 

Ought  Physicians  to  Write  Poetry  ? — A  volume 
of  Dr.  Frederick  Peterson's  poems  was  recently  pro- 
duced in  a  courtroom  where  he  was  giving  expert  tes- 
timony in  a  murder  trial,  presumably  in  order  to  de- 
tract from  the  value  of  his  testimony.  Les/le's  Wcekh 
makes  the  following  comment:  "Whenever  a  medical 
man  writes  poetry  it  is  viewed  with  some  suspicion ; 
the  example  of  Dr.  Oliver  Wendell  Holmes  to  the 
contrary  notwithstanding.  But  Dr.  Peterson,  like  Dr. 
Weir  Mitchell,  has  wooed  the  muse  to  some  purpose, 
and  his  verses  are  distinctly  good.  The  volume  in 
question  was  the  second  he  has  produced,  each  of 
them  containing  a  number  of  chamiing  lyrics  and 
some  clever  translations  from  the  .Swedish." — Boston 
Mt-dical  anil  Surgical  Jounuil. 

The  Yukon  Fever  versus  the  Medical  Fever — 
It  may  be  asked  by  many  a  young  man  just  now  wheth- 
er he  should  go  to  the  Yukon  or  to  a  medical  col- 
lege. So  far  as  the  Rcvino  is  concerned  it  would  not 
seriously  advise  either  course  to  glory,  a  fortune,  or 
the  grave.  If,  however,  some  youths,  ambitious  for 
fortune  or  fame  are  determined  to  go  to  one  or  the 
other  of  the  above  places,  then  really  the  balance  of 
argument  lies   in   favor  of  the   Yukon.     By  going  to 


the  latter  place  one  will  make  something  soon  or  lose 
everything  in  the  attempt.  Of  two  forms  of  death,  it 
would  appear  that  being  frozen  is  full  as  easy  as  the 
gradual  one  of  starving  to  death  by  the  slow  academi- 
cal method  of  attending  a  medical  college.  What 
though  fifty  per  cent,  should  meet  with  death  by  freez- 
ing or  speedy  starvation  in  the  search  for  gold  in  the 
Klondyke,  would  not  the  results  in  the  end  be  better 
than  that  ninety  per  cent,  should  meet  with  disappoint- 
ment in  the  search  for  gold  after  spending  many  years 
in  the  study  of  medicine?  If  either  form  of  fever  is 
to  attack  young  men,  we  think  the  prognosis  is  decid- 
edly in  favor  of  the  Yukon  type,  as  compared  with  the 
medical-school  type.  The  latter  is  a  very  lingering 
disease. —  Canadian  Aledical  Rci'iiw. 

A  Give-Away  of  the  Doctor. — The  most  curiously 
decorated  graves  in  the  world,  perhaps,  are  the  negro 
graves  in  Zululand.  Some  of  these  mounds  are  gar- 
nished with  the  bottles  of  medicine  used  by  the  de- 
parted in  their  final  illness,  and  the  duration  of  the 
malady  and  skill  of  the  physician  are  indicated  in  a 
measure  by  the  number  of  bottles. 

Duke  Carl  of  Bavaria,  the  oculist,  has  performed 
nearly  three  thousand  operations  for  cataract.  Every 
one  of  these  operations  has  been  performed  between 
the  hours  of  six  and  eight  in  the  morning,  as  the  Duke 
declares  his  nerves  are  strongest  at  this  early  hour  and 
his  hand  most  steady. 

The  Plague  in  China. — .V  Chinese  paper  estimates 
that  tlie  victims  of  the  plague  in  Foochow  this  year 
will  not  fall  far  short  of  fort}'  thousand. 

Business  Improving The  physicians  of  Kearney, 

Neb.,  recently  challenged  the  lawyers  of  that  place  to 
a  friendly  game  of  ball,  and  the  members  of  the  bar 
hurled  the  challenge  back  in  their  teeth,  stating  that 
they  were  too  busy  at  present  settling  up  the  estates 
left' by  the  doctors'  patients. — Medn-al  IdrraM. 

Children   and   Poisonous    Flowers  and  Plants. — 

Buttercups  and  daisies  are  generally  associated  in 
one's  mind  with  Wordsworth,  children,  and  Arcadian 
simplicity.  It  is  difficult  to  conceive  of  anything  hurt- 
ful or  dangerous  in  connection  with  the  pretty  little 
vellow  flower,  but  unfortunately  it  is  not  always  the 
most  modest  and  retiring  plants  or  flowers  that  are  the 
least  harmful,  for  example,  the  deadly  nightshade 
(Atropa  belladonna).  Not  that  the  buttercup  can  vie 
with  the  deadly  nightshade  in  poisonous  qualities,  and 
still  when  consumed  in  sufficient  quantities  it  will 
cause  death.  A  proof  of  this  has  lately  been  afforded 
in  England  in  the  case  of  a  boy  who  after  eating  some 
buttercups  died  within  a  few  hours  with  all  the  symp- 
toms of  irritant  poisoning.  The  buttercup  belongs  to 
the  ranunculacea;,  and  nearly  all  the  members  of  this 
group  possess  poisonous  qualities,  chiefly  of  an  irri- 
tant nature,  though  in  a  few  narcotic  principles  are  to 
be  found.  P'.very  year  some  children  lose  their  lives 
by  eating  poisonous  seeds  or  flowers,  and  care  should 
be  taken  to  exclude  from  gardens  or  parks  where  chil- 
dren play,  plants  or  shrubs  of  a  poisonous  nature,  as 
deadly  nightshade,  laburnun,  and  yew.  Fortunately 
buttercups,  though  nice  to  look  at,  do  not  as  a  rule 
tempt  children  to  eat  them  wholesale,  otherwise  the 
mortality  from  this  cause  would  be  much  greater  than 
it  is  at  ])resent — Pidiatrifs. 

Tears  are  Good  for  Woman,  says  Dr.  Campbell, 
in  I'lu  Hospital.  The  heneticial  efi^ect  of  a  good  cry 
to  a  woman,  he  asserts,  is  partly  due  to  tlie  increased 
depth  of  respiration  and  the  improvement  in  the  often 
languid  circulation  thereby  induced,  but  to  a  large 
extent   it   is  the   result  of   the  muscular  exercise   in 


544 


MEDICAL    RP:C0RD. 


[October  9,   1897 


volved,  by  which  the  general  vascular  tension,  and 
especially  the  blood  pressure  in  the  brain,  is  much 
reduced.  The  profuse  flow  of  tears  no  doubt  also  acts 
strongly  on  the  cerebral  circulation  in  still  further  re- 
ducing tension.  The  sobbing  movements,  again,  have 
a  good  influence  upon  the  venous  circulation  in  the 
abdominal  and  pelvic  viscera,  while  the  exhaustion 
produced  tends  to  cause  sleep,  and  tlius  to  give  the 
nervous  system  its  best  chance  of  recuperation. 

Arterio-Sclerosis. — M.  Huchard,  in  his  treatise  on 
diseases  of  the  heart,  says  that  arterio-sclerosis  is  pe- 
culiarly the  disease  of  physicians,  politicians,  and 
financiers,  their  liability  to  which  is  largely  due  to 
their  practising  professions  in  which  emotion  is  often 
intensified  and  which  involve  great  liability  to  over- 
work. In  addition,  doctors  have  to  e.xperience  una- 
voidable irregularities  in  hours  and  sometimes  contin- 
uous periods  of  work  without  rest.  The  single  means 
of.  arresting  and  avoiding  these  consequences  is  by  a 
diminution  of  anxiety  and  an  avoidance  of  overwork, 
with  measures  taken  as  far  as  possible  for  repair  of 
the  wasted  tissues. 

Bacteriology  in  Japan.— Nothing  in  these  days  is 
more  wonderful  than  the  extraordinary  progress  made 
by  Japan  in  almost  every  branch  of  civilization.  Not 
only  has  she  modelled  her  government  upon  the  best 
civilized  examples,  drilled  and  armed  her  army,  and 
built  and  armed  her  navy  on  the  most  approved  Euro- 
pean plans,  but  she  also  has  taken  a  high  place  in 
scientific  and  medical  research  Her  system  of  medi- 
cine has  been  completely  revolutionized,  and  espe- 
cially in  so  far  as  the  bacteriological  element  is  con 
cerned.  Dr.  Kitasato  is  probably  one  of  the  foremost 
living  bacteriologists,  and  an  interesting  account  of 
some  of  his  work  is  given,  in  Science  for  August  27th, 
by  another  Japanese,  Dr.  Nakagawa,  a  graduate  of 
Princetc  University.  To  a  private  citizen,  Mr. 
Fakasawa,  the  credit  is  due  of  building  at  his  own  ex- 
pense a  laboratory  for  Dr.  Kitasato  and  initiating 
in  Japan  the  teaching  of  bacteriology.  Subsequently 
the  imperial  government  built  and  endowed  the  "In- 
stitute for  Infectious  Diseases,"  at  Tokio,  which  is 
under  the  direction  of  Dr.  Kitasato,  and  where  he  con- 
ducts his  investigations.  Perhaps  the  most  instruc- 
tive part  of  these  researches  is  that  which  relates  to 
the  "bacillus  pestis."  In  respect  to  this  germ,  Dr. 
Nakagawa  says:  "The  discovery  of  the  plague  bacilli 
is  too  well  known  to  need  mentioning  in  this  connec- 
tion, were  it  not  for  the  fact  that  it  seems  to  be  utterly 
unknown  to  the  world  that  the  bacillus  claimed  to  be 
the  specific  germ  of  the  plague  by  Dr.  Yersin  is  abso- 
lutely different  from  that  described  by  Dr,  Kitasato. 
Dr.  Kitasato's  bacilli  are  almost  exactly  like  those  of 
chicken  cholera  (in  shape),  i.e.,  each  bacillus  presents 
the  appearance  of  a  pair  of  diplococci,  and  is,  as  a 
rule,  considerably  smaller  than  Dr.  Yersin's  bacillus. 
Kitasato's  bacilli  can  be  stained  according  to  Gram's 
method,  while  the  other  is  decolorized  by  tlie  regular 
procedure  Kitasato's  bacillus  is  surrounded  by  a 
distinct  capsule,  which  is  wanting  with  Yersin's. 
Moreover,  Kitasato's  bacilli  are  motile,  but  Yersin's 
are  not.  There  are  at  present  two  distinct  bacilli 
held  to  be  the  etiological  factor  of  the  disease  in  ques- 
tion. It  is  to  be  hoped  that  the  members  of  the  com- 
mission sent  out  to  Bombay  will  help  to  clear  up  tlie 
confusion."  The  "  Institute  for  Infectious  Diseases" 
appears  to  be  an  establishment  complete  in  all  its  de- 
tails, and  is  fitted  up  throughout  with  the  latest  up-to- 
date  scientific  appliances.  The  library  contains  most 
works  on  infectious  diseases,  bacteriology,  and  hy- 
giene, and  is  supplied  with  medical  periodicals  in  the 
Knglish,  French,  (ierman,  Italian,  and  Japanese  lan- 
guages.    The  clinical  department  has  beds  for  fift}- 


patients,  and  all  contagious  diseases  are  admitted, 
with  the  exception  of  cholera  and  small-pox.  It  is 
stated  that  one  hundred  and  eighty  cases  of  leprosy 
have  been  treated  in  the  out-patient  department  with 
Kitasato's  recently  discovered  remedy  for  that  disease, 
in  four  instances  with  complete  success.  A  full  re- 
port of  '"leprine,"  the  name  given  to  the  new  remedy, 
will  shortly  be  published.  Japan  must  be  congratu- 
lated on  the  possession  of  such  an  institution  as  the 
one  just  briefly  described.  In  bacteriological  investi- 
gation she  has  taken  the  lead  of  nations  far  older  in 
civilization  and  richer  in  resources. 

Fasting  and  In'ection. — The  eflfect  of  fasting  upon 
the  power  of  the  system  to  resist  infection  from  mi- 
crobian  toxins  has  been  investigated  by  MM.  I.  Teis- 
sier and  L.  Guinard,  and  they  find  it  a  strengthening 
one.  Animals  which  had  been  kept  fasting  held  out 
against  inoculation  much  better  than  the  control  ani- 
mals, and  the  resisting  power  seemed  to  increase  with 
the  length  of  the  fast. 

A  Hospital  for  Consumptives  in  Paris. — Madame 
Boucicaut,  widow  of  the  founder  of  the  Bon  Marche', 
has  left  the  bulk  of  her  fortune  to  the  Assistance  Pub- 
lique  de  Paris,  a  department  which  .'supervises  the 
public  charitable  institutions  of  the  city.  Among  the 
sufferers  from  various  diseases  who  will  benefit  from 
this  legacy  are  the  consumptives.  A  building  con- 
structed on  the  most  approved  system  and  located  in 
an  ideal  situation  has  just  been  completed.  Although 
the  building  is  large,  it  contains  but  one  hundred  and 
sixty  beds.  The  treatment  will  be  conducted  on  the 
open-air  plan,  and  the  greatest  attention  will  be  paid 
to  antiseptic  principles.  This  establisimient  should 
prove  a  great  boon  to  the  poor  of  Paris,  among  whom 
tuberculosis  is  common  and  whose  conditions  of  life 
are  favorable  to  the  contracting  of  the  disease. 

Health  Reports. — The  following  statistics  concern- 
ing yellow  fever,  small-pox,  and  plague,  have,  been 
received  in  the  office  of  the  United  States  Marine 
Hospital  ser\-ice  during  the  week  ended  October  2, 
1897: 

Yellow  Fbvek— Ukitrd  Status. 

Cases.  Deaths. 

Alabama.  Mobile September  24th  to  October  1st...     ao  6 

Louisiana,  New  Orleans  ....September  ajtb  to  Uctcber  ist  ..  100  15 

Mississippi,   Biloxi     September  25ih  to  llctobcr  ist. ..   117  3 

Edwards. ..  ....September  25th  to  October  :st ..  126  4 

McHcnry September  30th  to  October  ast .,       4 

Ocean  Springs  .Septenib<r  25th  to  October  isC  ..      5  1 

Perkinsiun September  lotb 1 

Scraiiton  September  26th  to  2gth \\  \ 

Yellow  Fevek— Fokkign. 

Brazil,  Riode  Janeiro August  sist  to  aSth 1 

Cuba,  Cardenas September  4th  to  nth 1 

Cienfuegcs Septernbt-r  5ih  to  igih .,  16 

Havana September  1 6th  to  23d 23 

Matanzas Septemb<:r  Sth  to  220 ■\ 

I".  S.  of  Colombia,  ranaiua  .September  loth  to  13th a 

India,  liombay August  17th  103151 193 

Calcutta August  7th  to  21SL 9 

Madras August  21st  to  27th 7 

Singapore July  1st  to  31st > 

Japan,  Kanagawa August  24th  to  September  3d  . . .      i  i 

Osal;a  and  Hiogo. ..  .August  21st  to  28tD 1 

Tokio August  sath  to  September  2d.. . .     14  * 


India,  l-x 


PlAGIB— FuKEICN. 

.\ugiist  i7th  to  34th  . . .. 

.i,\LL-Pox— United  States. 
September  iSth  to  asth  . 

Small-Pox— FoKEiGN. 
J"Iy  isit0  3ist. 


Athens,  Greece....  ^    . 

Glasgow,  Scotland SepttinlK-r  4th  to  nth 

Alexandria,  F-g>'pt July  asd  to  August  12th 

Havana,  Cuba September  t6th  to  23d 

Rio  de  Janeir\>,  Brazil August  jist  to  aSth 

Rrtisscis,  Belgium August  s8th  to  September  4tli .. 

Cairo,  Egj'pt July  23d  to  August  lath 

Hong  Kong,  China August  1st  to  14th 

Paris  France August  aoih  to  September  nth  . 

Madrid.  Spain September  ist  to  7th 

Warsaw,  Russia August  rSth  to  September  nth  . 

St.  Petersburg,  Russia September  4th  to  nth 

Madras,  India August  ix^x.  to  a7th 

Calcutta.  India August  uth 'to  aist 

Bombay,  India August  24th  to  y\%x 

Prague,  Bohemia September  4th  to  1  iih 


Medical  Record 

A  JVeekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  16. 
Whole  No.  1406. 


New  York,   October    16,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


®riginaX  Articles. 

A  PLEA  FOR  THERAPEUTIC  CONSERVA- 
TISM." 

Bv  SETH    A.    MERENESS,    M.D., 

The  extraordinary  progress  made  in  certain  depart- 
ments of  medical  science  during  tlie  present  century, 
and  especially  its  latter  half,  sometimes  makes  it  ap- 
pear as  if  the  physician  has  at  last  reached  tena 
firma  in  the  treatment  of  disease.  In  histology  and 
physiology,  pathology  and  diagnosis,  and  in  surgery 
and  bacteriology  the  progress  has  certainly  been  great 
and  most  satisfactory. 

Physiological  chemistry  and  experimental  pharma- 
cology' have  also  made  rapid  strides  and  the  physio- 
logical action  of  many  substances  used  in  the  treat- 
ment of  disease  is  now  definitely  known. 

But  in  spite  of  all  this  advancement  of  our  knowl- 
edge of  the  human  economy  in  health  and  disease, 
and  of  the  materials  used  to  allay  suffering  or  bring 
about  a  restoration  to  the  normal,  it  is  not  certain 
that  we  are  better  able  to  combat  individual  disease 
with  pharmaceutical  remedies  than  were  the  phy- 
sicians of  two  and  indeed  twenty  centuries  ago. 

The  average  duration  of  life  is  undoubtedly  longer 
now  than  formerly,  but  when  the  prevention  of  infec- 
tious and  often  malignant  diseases  by  vaccination  or 
hygienic  measures  is  taken  into  account,  together  with 
the  better  general  knowledge  of  how  to  live  and  avoid 
disease,  it  is  very  probable  that  were  it  not  for  these 
conditions  human  mortality  would  be  as  great,  if  not 
greater,  now  than  in  times  past. 

Ever  since  the  beginning  of  the  Christian  era  and 
even  long  before,  if  we  may  credit  our  medical  his- 
torians, there  has  been  a  continual  change  in  medical 
theory  and  practice."  Methods  which  are  deemed  well- 
nigh  infallible  in  one  generation  are  supplanted  by 
others  in  the  next,  and  by  the  third  generation  the 
old  method  is  mentioned  as  being  not  only  unscientific 
and  useless,  but  exceedingly  injurious.  Sometimes 
after  a  period  of  obscurity  an  old  method  is  again 
taken  up  and  lauded,  to  be  soon  criticised,  condemned, 
and  retired.  One  has  only  to  .aad  over  the  list  of  tlie 
various  therapeutic  sects  to  lie  made  sceptical.  If 
therapeutics  rests  on  a  scientific  foundation,  why  this 
endless  array  of  contradictions?  We  iiave  only  one 
scientific  anatomy  and  physiology,  one  chemistry,  and 
one  bacteriology;  why  then  a  dozen  or  more  sects  in 
theoretical  and  practical  therapeutics?  Obviously,  its 
theories  and  their  application  rest  on  insecure  scien- 
tific foundations.  By  this  it  is  not  intended  to  dis- 
credit the  really  scientific  knowledge  of  the  physiolog- 
ical action  of  pharmaceutical  or  natural  compounds  on 

'  Read  at  the  annual  meeting  of  the  Schoharie  County  Medical 
Society,  June  i,  iSgy. 

■' Daremberg.  Ch.:  "  Histoire  des  Sciences  Medicales,"  I'aris, 
1870.  Tome  I.,  "  Depuis  les  temps  historiques  jusqu'a  Har- 
vey;" Tome  TI.,  "  Depuis  Harvey  jusqu'au  XlXme  siccle." 

Bouchut,  E.  :  "  Ilistoire  de  la  Medecine  et  des  Doctrines  Medi- 
cales."     Tome  I.  et  11.,  I'aris,  1S73. 

Haeser:  "  Lehrbuch  der  Geschichte  der  Medicin  und  der  epi- 
demischen  Krankheiten,"  2  Bd.,  3  Auf. ,  1875-1882. 


the  animal  economy,  but  only  the  utility  of  the  admin- 
istration of  such  in  many  pathological  conditions. 
■  The  almost  universal  acceptance  of  cellular  pathol- 
ogy as  established  and  persistently  advocated  by  Vir- 
chow'  and  others,  in  the  middle  of  the  present  century, 
opened  a  new  field  of  inquiry  and  has  been  the  means 
of  explaining  satisfactorily  many  of  the  phenomena  of 
vital  organization. 

Before  this  the  fundamental  anatomical  processes 
of  organic  growth,  tissue  destruction  and  repair,  or 
degeneration  and  regeneration,  were  explained  by  the 
most  diverse  hypotheses,  many  of  which  were  more 
remarkable  for  their  dogmatic  incongruities  than  for 
their  scientific  explanations. 

But  that  attribute  or  essence  of  living  organisms 
which  distinguishes  them  from  inorganic  substances 
is  not  more  definitely  known  now  than  in  times  past. 
It  still  remains  the  sphinx  of  biology,  and  the  cellular 
pathology  no  more  explains  the  nature  of  the  funda- 
mental vital  principle  than  did  the  ancient  humoral, 
and  its  bitter  antagonist,  solidar  pathology,  or  the 
iatro-mechanical  theory  of  more  recent  times. 

During  all  the  centuries  of  which  we  have  a  record 
of  medical  science  there  has  been  the  belief  that  there 
was  a  specific  sometliing  which  distinguished  living 
from  dead  material;  which  caused,  under  certain  con- 
ditions, organic  substances  to  live,  grow,  and  repro- 
duce themselves;  and  a  deterioration  or  loss  of  which 
brought  about  changes  and  eventually  a  return  to  in- 
organic compounds.  Of  these  material  changes  cel- 
lular pathology  has  taught  us  much;  but  of  the  primi- 
tive causes  of  the  changes  almost  nothing. 

The  ultimate  analysis  of  natural  phenomena  leads 
to  the  acceptance  of  two  primary  factors,  viz.,  matter 
and  motion,  and  as  a  hypothesis  it  has  been  assumed 
that  from  the  interaction  of  these  the  various  kinds  of 
matter  and  manifestations  of  force  have  been  caused. 

The  application  of  force  to  matter  may  change  the 
latter,  as  is  shown  by  subjecting  various  substances  to 
the  action  of  heat,  light,  or  electricity,  whence  changes 
in  volume  and  in  consistency,  and  even  new  chemical 
combinations,  occur. 

Again,  daily  experiences  in  mechanics  and  the  arts 
demonstrate  the  convertibility  of  one  force  into  some 
other.  Mechanical  motion  may  be  converted  into  heat 
or  electricity  and  vice  versa,  while  heat  and  electricity 
may  be  converted  into  light  and  chemical  action.  From 
this  it  may  be  considered  that  mechanical  force,  heat, 
electricity,  light,  and  chemism  are,  as  Tyndal ''  ex- 
presses it,  but  modes  of  motion  and  may  be  trans- 
formed the  one  into  another.  According  to  this  view, 
the  rapidity  and  amplitude  of  molecular  motion  deter- 
mine the  varieties  of  force  which  are  only  to  be  dif- 
ferentiated by  the  phenomena  resulting  from  their 
action  on  matter. 

The  changes  which  in  this  way  lead  to  varieties  of 
structure  are  still  material  and  inorganic.  That  is, 
they  do  not  present  the  characteristic  biological  phe- 
nomena common  to  living  organisms.  Indeed  all  the 
known  kinds  of  matter  and  the  varieties  of  physical 
force  may  be  present,  but  the  selective  ability  of  liv- 

'  "  Die  Cellular- Pathologie."  4  Auf.,  1871. 
'  "  Heat  as  a  Mode  of  Motion,"  London,  1863,  and  "  Contribu- 
tions to  Molecular  Physics,"  1872. 


546 


MEDICAL    RECORD. 


[October  i6,  1897 


ing  organisms  to  maintain  themselves  for  a  definite 
time,  to  transform  spontaneously  one  motion  into  an- 
other, and  then  to  perpetuate  themselves  is  wanting. 
Here  is  the  necessary  missing  link  between  inorganic 
and  living  organic  phenomena.  Is  this  missing  link 
matter  or  motion?  If  material,  what  is  it?  And  if 
force,  how  does  it  differ  from  the  other  modes  of  mo- 
tion, and  can  it  be  transformed  into  the  others  or  7'ice 
Tfrsa  i 

These  are  questions  the  answers  to  which  underlie 
the  whole  groundwork  of  biological  and  consequently 
medical  science,  and  until  they  are  definitely  and  cor- 
rectly answered  exact  knowledge  of  organic  phenom- 
ena cannot  obtain. 

That  this  missing  link  is  not  matter  seems  to  be 
demonstrated  by  the  capability  of  living  organisms  to 
maintain  themselves,  increase  in  volume,  and  perform 
their  functions  by  transforming  inorganic  materials; 
and  when  because  of  natural  limitation  or  on  account 
of  environment  the  living  functions  cease,  organic 
substances  become  changed  into  inorganic.  Besides,  to 
consider  vital  phenomena  as  being  caused  by  a  specific 
material  substance  necessitates  the  hypothesis  that 
either  a  material  substance  can  cease  to  e.xist,  or  can 
continue  to  exist  without  its  characteristic  attributes, 
either  of  which  the  law  of  persistence  of  matter  and 
its  attributes  disposes  of  at  once. 

Excluding  a  material  substance  as  the  cause  of  vi- 
tality, there  are  but  two  alternatives:  either  to  believe 
the  cause  to  be  immaterial  and  supranatural,  or  to 
admit  a  primitive  or  modified  specific  force.  The 
first,  while  possible,  has  nothing  but  belief  to  defend 
it,  and  can  never  be  expected  to  be  proven  or  disproven 
on  scientific  grounds.  The  second  explains  much  and 
is  supported  by  analogies  if  by  nothing  more. 

How  the  first  vital  phenomena  occurred  is  not,  prob- 
ably never  will  be,  known,  but  once  grant  its  occur- 
rence and  the  way  for  hypotheses  is  clear. 

Scientists  tell  us  that  the  vegetal  cell  through  the 
agency  of  solar  force  assimilates  inorganic  matter  and 
transforms  it  into  organic,  and  that,  too,  without  change, 
other  than  molecular,  of  the  elementary  materials. 
The  inorganic  elements,  oxygen,  nitrogen,  carbon,  or 
whatever  they  may  be,  remain  the  same 'in  the  living 
structure  as  in  the  inorganic,  only  their  relations  to 
each  other  change,  either  as  to  quantity  or  the  relative 
position  of  their  molecules.  During  this  transforma- 
tion a  portion  of  the  solar  force  is  stored  up  in  the 
organic  substances,  \\hich  is  again  liberated  when  the 
cell  is  destroyed  or  undergoes  retrogressive  changes. 

Aside  from  the  peculiar  property  possessed  by  a  liv- 
ing cell  to  assume  automatically  a  definite  structure 
and  to  transmit  this  capability  to  its  offspring,  there 
is  very  little  in  vital  phenomena  which  does  not  ap- 
pear to  be  governed  by  the  laws  of  inorganic  nature. 

But  this  property  is  now,  as  it  has  been  for  centuries, 
so  characteristic  and  inexplicable  that  it  has  been  ac- 
cepted as  a  distinct  entity  and  designated  by  various 
names,  of  which  vitality  and  vital  force  are  represen- 
tative. It  has  never  been  demonstrated,  however,  that 
vital  force  is  primitive  or  specific,  and  its  acceptance 
as  sue!)  is  purely  hypothetical.  Indeed,  there  is  much 
to  justify  the  belief  that  vital  force,  if  there  is  really 
such,  is  simply  another  mode  of  motion,  capable  of 
being  transformed  into  other  forces  but  never  destroyed, 
and  alile  to  alter  the  properties  but  not  the  essence  of 
inorganic  elementary  substances. 

Perhaps  the  future  may  sliow  that  what  we  call  vital- 
ity is  neither  specific  matter  nor  force,  but  the  resul- 
tant of  the  interaction  of  both,  under  certain  conditions 
now  entirely  unknown. 

What  we  do  know,  however,  is  that  this  vitality,  he 
it  what  it  may,  is  a  sine  i/iic  non  for  the  assimilation 
of  inorganic  materials,  tlie  maintenance  of  life,  and 
the  occurrence  of  reproduction. 


One  of  the  great  merits  of  the  cellular  pathology  is 
that  it  necessitated  a  careful,  scientific  examination  of 
what  is  now  accepted  as  the  foundation  of  organic 
structures,  viz.,  the  cell.  Whether  with  or  without  a 
membrane  the  essential  material  is  its  protoplasm, 
which,  according  to  Huxley,'  may  be  considered  as  a 
type  of  all  primitive  Jiving  substance. 

This  almost  homogeneous  organic  compound  has 
above  all  other  characteristics  one  in  particular,  and 
that  is  instability.  Being  of  a  most  complex  struc- 
ture, not  only  from  its  containing  several  elements  but 
from  its  multiple  molecular  combinations,  it  is  not  at 
all  strange  that  the  compound  is  so  unstable.  More- 
over, when  it  is  considered  that  in  chemical  unions 
the  rearrangement  of  even  one  molecular  group  pro- 
duces a  substance  with  entirely  different  character- 
istics, it  is  easy  to  conceive  that  even  an  elementary 
organism  may  present  millions  of  changes,  and  while 
all  the  time  retaining  a  typical  structure  the  individ- 
ual is  never  twice  alike  during  its  existence. 

Herbert  Spencer^  maintains  that  the  higher  the  or- 
ganization of  matter  the  more  unstable  the  resulting 
substance  becomes,  since  there  is  always  a  tendency 
to  equilibration.  In  living  organic  substances  the 
vital  principle  strives  to  bring  the  organic  unit  to  a 
definite  structure  and  maintain  it,  while  the  environ- 
ment constantly  endeavors  to  reduce  it  to  a  more  sim- 
ple structure,  even  to  its  primitive  inorganic  constitu- 
ents. 

To  remain  in  a  condition  in  which  the  protoplasmic 
mass  can  perform  its  functions  normally — that  is,  in 
health — is  the  constant  automatic  aim  of  every  biologi- 
cal unit,  otherwise  an  enduring  condition  of  vitalitv 
would  be  impossible.  In  order  that  an  organic  unit 
may  preserve  its  vitality  and  perform  its  functions, 
force  must  be  constantly  expended.  The  assimilated 
material  with  its  stored-up  solar  energy  is  of  service 
only  so  long  as  the  reorganization  of  its  molecules 
develops  force. 

The  principal  physical  function  of  an  elementary 
organism  is  to  decompose  various  substances  and  to 
change  potential  into  kinetic  energy,  or  vice  versa,  and 
this  decomposition  produces  various  modifications  of 
motion,  as  heat,  chemical  action,  and  changes  in  polar- 
ity for  the  lower  organisms,  while  in  the  higher,  in 
addition  to  these,  there  is  developed  muscular  con- 
tractility and  perhaps  even  cerebration.  When  pro- 
toplasm can  no  longer  make  use  of  its  potential  or  has 
used  what  is  available,  its  own  molecular  structure 
probably  changes  to  a  more  elementary  condition  in 
order  to  evolve  more  force,  resist  external  and  internal 
harmful  influences,  and  to  maintain  a  suitable  temper- 
ature. This  phenomenon  continues  until  the  living 
protoplasm  loses  its  essential  characteristics  and  is  no 
longer  capable  of  producing  vital  phenomena,  in  other 
words  the  protoplasm  is  dead. 

Vitality  is  then  only  a  relative  term  and  expresses 
the  degree  of  organization  necessary  to  life,  which  is 
probably  not  the  same  for  all  living  material.  Hence 
molecular  complexity  varies,  and,  while  its  falling  be- 
low a  certain  grade  causes  impairment  of  function  and 
death,  its  development  is  limited  only  by  the  original 
vital  intensity  and  the  possibilities  which  the  en- 
vironment allows. 

Health  and  disease  are  also  only  relative  terms,  the 
one  signifying  the  condition  of  an  organism  when  it  is 
able  to  maintain  a  degree  of  organization  necessary  to 
produce  normal  functions,  and  the  other  expresses  the 
condition  when  organization  and  consequently  func- 
tion are  below  the  normal.  The  dividing  line,  if  there 
is  one,  is  entirely  unknown  for  the  lower  organisms. 
For  complex  organisms,  however,  the  disturbance  of  a 
collective  function  may  very  properly  be  termed  dis- 

'  ••  riie  I'liysio.-il  fosis  of  life,"   London,  :?6?. 
•  "  I'linciples  of  lUology,"  vol.  i.,  London,  18(14. 


October  i6,  1897] 


MEDICAL    RECORD. 


547 


ease,  although  the  constituent  cells  of  the  organ  caus- 
ing the  function  are  in  various  conditions,  some  nor- 
mal, others  living  but  feeble,  while  others- are  hors  dc 
combat. 

The  most  characteristic  physical  phenomena  of  liv- 
ing protoplasm  is  its  reaction  to  external  antagonistic 
inlluences.  This  presents  itself  to  our  senses  by  cer- 
tain movements,  contractility,  and  the  general  property 
of  protoplasm  to  recognize  injurious  contacts  is  termed 
irritability:  and  this  irritability  is  the  most  apparent 
and  reliable  index  we  have  of  cellular  vitality. 

From  its  physical  manifestations  it  is  possible  to 
learn  in  a  restricted  sense  the  behavior  of  a  cell  in  its 
environment  and  to  note  the  effect  of  the  latter  on  its 
vital  phenomena.  According  to  Engelmann'  the  appli- 
cation of  force  from  without  under  certain  conditions 
constantly  causes  the  irritability  of  living  protoplasm 
to  manifest  itself;  whether  the  force  be  mechanical 
motion,  heat,  electricity,  light,  or  chemical  action,  the 
result  appears  to  be  the  same  except  as  to  intensity. 
When  very  feeble  force  is  applied  the  reaction  is  so 
mild  that  it  cannot  always  be  recognized,  but  we  are 
not  to  suppose  from  this  that  no  molecular  changes 
have  taken  place,  ^^'hen  a  sufficiently  strong  force  is 
applied  protoplasm  quickly  manifests  its  irritability 
by  contracting,  which  in  itself  must  demand  a  libera- 
tion of  energy,  and  molecular  changes  probably  suc- 
ceed each  other  more  rapidly  than  under  normal  con- 
ditions. 

The  length  of  time  for  which  protoplasm  continues 
to  manifest  its  irritability  depends  on  the  intensity  of 
the  irritant  and  the  amount  of  potential  possessed  by 
the  cell.  Contractility  ceases  at  once  under  intense 
stimulus,  but  may  appear  again  after  a  variable  time  if 
the  irritation  is  not  too  intense  or  too  long  applied. 
Under  moderate  irritation  the  power  of  contracting  re- 
mains for  a  relatively  longer  time  and  finally  is  lost, 
but  is  regained  after  a  period  of  rest. 

Very  strong  stimuli  seem  to  arrest  the  movements 
of  protoplasm  at  once,  evidently  because  of  the  molec- 
ular changes  induced  by  the  irritant  directly  and  not 
indirectly  by  the  organism  in  defence  of  its  existence. 
Certain  substances  without  any  apparent  manifestation 
of  force  also  cause  the  phenomena  of  protoplasmic 
irritability  to  appear,  and  this  is  notable  of  the  irri- 
tant poisons.  Their  application  causes  at  first  increase 
of  motion  and  later  paralysis.  The  duration  and  ex- 
tent of  the  one,  as  well  as  the  time  necessary  to  pro- 
duce the  other  are  determined  by  the  concentration  of 
the  poison  and  its  specific  power  of  producing  vital 
reaction.  The  explanation  of  the  action  of  irritant 
poisons  is  not  so  satisfactorv'  as  that  of  the  applica- 
tion of  force.  -Since,  however,  living  protoplasm  nor- 
mally requires  a  nearly  neutral  environment,  it  is  quite 
obvious  that  certain  inorganic  poisons,  such  as  the 
mineral  acids  and  the  alkalies,  owe  their  harmful 
action  to  the  property  of  rendering  the  surrounding 
media  either  acid  or  alkaline. 

Other  poisons  and  especially  the  alkaloids  are,  as 
Kiihne"  showed  many  years  since  of  veratrum,  able  to 
produce  a  very  intense  irritation,  even  when  applied  in 
neutral  solution.  But  these  poisonous  alkaloids  are 
highly  complex  organic  compounds,  and  for  this  reason 
may  ha\e  a  specific  action  which  easily  disintegrates 
the  molecular  combinations  of  the  more  highly  orga- 
nized protoplasm.  Again,  it  may  be  believed  that  the 
more  complex  the  molecular  arrangement  the  higher 
the  function  produced.  For  this  reason  the  protoplasm 
of  the  highest  order  would  be  utilized  in  carrying  on 
the  nervous  function.  When  from  the  presence  of 
poisons   like  the    acro-narcotics  the   arrangement   of 

'  "  V'erhalten  des  Protoplasma  gegen  kiinstliche  Reize."  Her- 
mann's "  Ilandbuch  der  Pliysiologie."  Band  i.,  S.  365-373. 

-  "  Untersuchung  iiber  das  Protoplasma  und  die  Contraktilitat," 
l.€ipzig,  1S64. 


the  molecular  groups  is  simplified  and  the  cells  are  no 
longer  capable  of  continuing  their  highly  specialized 
nervous  function,  it  is  still  possible  for  the  cells  to 
retain  their  vitality  and  continue  their  nutritive  func- 
tions. 

From  the  facts  recorded  by  many  painstaking  inves- 
tigators of  physiological  and  pathological  cellular  phe- 
nomena, notably  Ch.  Robin,'  Ziegler,"  and  O.  Hert- 
wig,^  it  may  be  said  in  general  that  the  application  of 
any  of  the  various  forces  as  well  as  certain  poisonous 
materials  agree  in  so  far  as  they  all  cause  at  first  ac- 
celeration of  protoplasmic  movements,  then  inhibi- 
tion, and  finally  paralysis.  The  cell  increases  in  size, 
its  contents  become  clouded  and  opaque,  and  its  func- 
tions are  at  first  impaired,  later  destroyed.  In  fact 
these  conditions  are  ver\'  similar  to  those  that  obtain 
in  acute  inflammatory  processes,  especially  of  the 
spinal  cord  when  the  neural  cells  are  undergoing  a 
process  of  acute  degeneration. 

There  would  be  no  life  were  it  not  for  the  automatic 
capability  of  an  organism  so  to  arrange  its  struc- 
ture as  best  to  antagonize  harmful  influences  of  its 
surroundings.  The  observations  of  Darwin'  alone, 
which,  however,  have  been  supplemented  by  scores  of 
other  scientists,  leave  no  doubt  as  to  the  variation  of 
type  which  follows  a  modification  of  environment. 
Not  only  do  plants  and  the  higher  animals  become 
changed,  but  also  the  lower  orders. 

Thus  Maupas'  has  shown  that  certain  salt-water  in- 
fusoria when  removed  to  fresh  water  died  at  once. 
However,  when  the  change  was  made  gradually,  the 
organism  not  only  lived  but  lost  entirely  its  salt-water 
characteristics  and  became  like  the  analogous  fresh- 
water varieties.  When  the  animal  was  returned  to 
salt  water  its  former  characteristics  returned.  Here 
is  seen  an  attempt,  and  a  successful  one,  of  a  living 
organism  so  to  change  its  structure  as  to  be  able  not 
only  to  resist  e.xternal  influences,  but  also  to  assimi- 
late material  which  it  had  been  unused  to  and  thus 
maintain  itself  in  its  new  surroundings. 

This  selective  capability  of  vital  maintenance  in 
the  sense  of  causing  recovery  from  disease  has  been 
believed  and  maintained  from  comparatively  ancient 
times  and  constitutes  the  much  used  but  sometimes 
little  heeded  vis  mcdicatrix  natiirce.  That  the  human 
economy  possesses  the  power  of  resisting  influences 
antagonistic  to  life,  and  is  able  when  these  influences 
are  not  too  harmful  or  long  continued  to  perform  its 
normal  functions,  is  certainly  not  to  be  doubted,  even 
if  the  cause  and  rationale  of  the  phenomena  are  but 
imperfectly  or  not  at  all  known. 

Can  these  harmful  influences  be  modified  or  neutral- 
ized by  means  that  are  under  human  control?  Or  can 
the  living  protoplasm  be  aided  in  its  resistance  to  de- 
structive environing  forces?  If  the  answer  to  either 
or  both  is  in  the  affirmative,  then  therapeutic  meas- 
ures are  of  service;  if  in  the  negative,  they  will  have 
no  practical  value  except  that  of  causing  a  temporary 
relief  from  disagreeable  symptoms. 

Certainly  the  application  of  hygienic  measures  se- 
curing satisfactory  nourishment  and  assisting  the  econ- 
omy in  excreting  poisonous  materials  has  been  of 
inestimable  service,  and  without  doubt  has  been  the 
means  of  restoring  to  health  or  prolonging  the  life  of 
myriads.     A  criticism  of  these  measures,  when  tlieir 

'  "Anatomie  et  Physiologfie  Cellulaires  ou  des  Cellules  Animals 
et  V'egetales,  du  Protoplasmas  et  des  elements  Nom)au.x  et  Patho- 
logiques  qui  en  Derivent,"  Paris,  1S73. 

*  "  Allgemeine  pathologische  Anatomie,"  Bd.  i.,  7  Auf.,  1892. 

■"  "  Die  Zelle  und  die  Gewebe.  Grundzlige  der  allgemeinen 
.Anatomie  und  Physiologie . "  Bd.  xi.,  S.  296.   1S92. 

*"  Variation  of  Animals  and  Plants  under  Domestication," 
1868. 

"  "Recherches  Experimentales  sur  la  Multiplication  des  In- 
fusoires  Cilies. "  Archives  de  Zoologie  Experimentale  et  Gene- 
rale,  ser.  ii.,  tome  vi.,  p.   165  et  seq.,  (888. 


548 


MEDICAL    RECORD. 


[October  i6,  1897 


application  is  judiciously  accomplished,  would  be  a 
most  thankless  task. 

But  can  the  administration  of  substances,  many  of 
which  are  never  normally  present  in  the  economy,  aid 
the  natural  processes  in  their  struggle  to  overcome 
disease?  Perhaps  nearly  all  physicians  would  answer 
this  in  the  affirmative,  and  yet  not  a  few  of  the  more 
conservative  would  impose  restrictions — in  the  affir- 
mative because  theoretically  at  least  it  would  seem  pos- 
sible to  supply  the  cellular  structure  with  materials 
the  absence  or  deficiency  of  which  prevented  the 
necessary  normal  metabolic  changes;  and  with  re- 
strictions because  many  of  the  commonly  used  phar- 
maceutical compounds  are  irritant  poisons,  the  bene- 
ficial action  of  which  is  still  problematical. 

Of  tliose  substances  which  a  priori  might  be  ex- 
pected to  increase  the  efficiency  of  cellular  metabolism 
a  number  are  prominent,  viz.,  iron,  calcium,  phospho- 
rus, potassium,  magnesium,  and  sulphur,  mostly  in 
combination  with  oxygen  or  as  substitute  compounds  in 
the  various  acids.  All  of  these  elements  are  normally 
present  and  are  necessary  to  organic  tissues.  The 
amount  of  most  of  these  necessary  mineral  substances 
is  comparatively  small,  and,  since  the  vegetal  proc- 
ess has  already  combined  them  and  stored  them  in  or 
around  the  cell,  it  is  a  question  whether  they  may  be 
of  service  except  when  the  food  is  deficient  in  these 
elements. 

Again  the  various  ferments  as  found  in  the  gastric, 
hepatic,  and  intestinal  secretions,  which  are  necessary 
to  change  the  food  into  cell  pabulum,  may  be  fur- 
nished in  too  small  quantities  or  be  of  impaired  quality'. 
Under  such  conditions  the  administration  of  these  fer- 
ments, as  elaborated  by  normal  organs,  should  be  of 
service.  Also  to  prevent  the  accumulation  of  certain 
unknown  toxic  substances  the  administration  of  the 
various  internal  secretions  of  certain  glands,  as  the 
thyroid  and  suprarenals,  seems  to  be  indicated. 

All  of  these  measures  under  proper  circumstances 
are  no  doubt  of  the  utmost  importance  to  the  diseased 
organism.  Experimentally,  physiologically,  and  em- 
pirically they  have,  according  to  our  most  competent 
investigators,  caused  a  restoration  to  health  sooner 
than  would  have  obtained  without  them,  or  have  brought 
about  a  normal  condition  when  it  could  not  have  been 
expected  from  the  77>  nudicatrix  natiirir  under  hygienic 
and  nutritive  measures  alone. 

Thes'e  therapeutic  measures,  however,  constitute  only 
a  part,  and  in  acute  diseases  a  very  small  part  of  those 
usually  recommended,  and  are  generally  used  to  restore 
the  tissues  to  their  normal  nutritive  states  or  functional 
activity  rather  than  to  combat  individual  symptoms. 

In  the  acute  diseases,  which  for  the  most  part,  thanks 
to  bacteriology,  are  now  universally  believed  to  be  due 
to  living  organisms,  the  administration  of  remedies 
has  quite  a  different  object  in  view,  and  it  is  in  this 
domain  of  therapeutics  that  the  writer  would  plead 
for 'more  conservatism  in  the  use  of  jiharmaceutical 
remedies. 

The  treatment  of  many  acute  diseases,  notably  tiie 
specific  pulmonary  and  enteric  inllammations  and  the 
exanthemata,  with  many  physicians  resolves  it.self  into 
combating  symptoms  which  are  unpleasant  to  the 
patient  or  are  considered  dangerous  to  the  economy. 
To  subdue  pain,  reduce  the  temperature,  and  inhibit 
or  paralyze  cardiac  action  are  the  main  ends  sought 
through  the  use  of  drugs;  and  it  might  seem  on 
superficial  inquiry  that,  since  various  symptoms  are 
not  present  in  the  healtliy  human  subject,  all  that  is 
necessary  is  to  cause  their  disappearance  and  you 
have  the  patient  in  a  condition  of  health.  lUit  from 
a  standpoint  of  empiricism,  as  well  as  experimentally, 
it  is  known  that  the  removal  of  symptoms  does  not  at 
all  constitute  a  rrslitii/iii  a<l  i/itixrnm.  In  fact  pain, 
pyrexia,    and    increased    pulse    rate    are    universally 


known  to  be  only  a  result  of  disease  and  not  a  cause. 
When  certain  living  organisms,  such  as  bacteria,  re- 
main long  in  contact  with  the  tissues  a  reaction  occurs, 
just  the  same  as  when  a  force  is  applied.  Whether 
the  growth  of  these  cellular  organisms  would  alone 
cause  this  reaction  is  not  known,  since  it  is  impossi- 
ble to  isolate  living  bacteria  from  their  poisonous  ex- 
cretions for  any  considerable  length  of  time.  How- 
ever, those  which  do  not  elaborate  toxic  substances 
may  remain  long  in  the  tissues  without  causing  mani- 
festations of  irritability,  although  their  growth  may 
afifect  the  tissues  by  withdrawing  nourishment. 

Bacteria  cause  disease  then  directly  by  disturbing 
nutrition,  true  parasitism,  and  indirectly  by  toxins 
which  they  produce.  Thus,  true  parasitism  tends  to 
weaken  cellular  vitality  by  withdrawing  necessary 
nutrient  materials,  while  the  poisons  elaborated 
irritate  the  protoplasm,  causing  increased  molecular 
changes  and  a  more  or  less  rapidly  progressive  degen- 
eration. 

If  the  pathogenic  bacteria  were  able  to  develop  con- 
tinually there  could  be  but  one  termination  of  all  in- 
fectious diseases,  and  that  a  fatal  one.  However,  as 
has  been  stated,  when  living  organisms  liberate  force 
to  antagonize  untoward  influences,  changes  take  place 
which  simplify  or  reduce  the  molecular  structure  of 
protoplasm,  and  thus  it  happens  that  there  is  formed 
at  last  an  end  product  whicli  is  still  nitrogenous  and 
of  complex  structure,  but  not  sufficientl)'  so  to  carrj- 
on  vital  functions.  Wherever  there  is  life  there  will 
be  found  as  a  necessary  accompaniment  these  end 
products,  which  not  only  are  of  no  further  use  but  act 
as  an  irritant  poison  on  the  economy  which  produced 
them.  Thus  there  are  produced  in  the  animal  econ- 
omy urea  and  allied  compounds,  while  the  vegetal 
cellular  process  gives  as  end  products  many  nitro- 
genous substances,  some  of  which  are  highly  poison- 
ous, as  the  various  alkaloids,  while  living  bacteria 
produce  substances  which  are  not  yet  well  known  but 
which  are  nitrogenous  and  chemically  similar  to  the 
crystalloids  and  colloids  produced  by  animal  and  veg- 
etal organisms. 

Fortunately  the  li\  ing  cell  is  able  to  excrete  these 
poisonous  products  and  thus  free  itself  from  their 
deleterious  action,  and  this  happens  in  all  living  or- 
ganisms but  in  various  ways;  for,  while  animals 
have  a  definite  excretory  apparatus,  plants  have  not, 
and  because  of  this  the  poisonous  products  of  vegetal 
metabolism  can  be  excreted  by  the  cell  but  cannot  be 
further  disposed  of  except  by  storing  them  where  they 
cannot  come  in  contact  with  the  living  protoplasm. 
Manv  end  products  from  urea  of  the  animal  tissues 
are  not  only  chemically  analogous  to  strychnine,  mor- 
phine, and  other  alkaloids  and  to  the  bacterial  toxins, 
but  have  in  many  instances  a  similar  physiological  ac- 
tion. Again,  these  poisons  not  only  produce  character- 
istic phenomena  when  administered  to  an  animal  but 
affect  all  living  organisms  to  a  greater  or  less  extent. 
As  is  well  known,  the  poisonous  alkaloids  are  not  only 
capable  of  destroying  animal  life  but  are  able  to  de- 
stroy the  vitality  of  the  plant  which  originated  them, 
and,  as  Marcacci'  has  shown,  are  especially  iiarmful 
to  the  developing  plant.  Urea  and  allied  substances 
are  toxic  to  the  human  economy  and  also  to  the  vege- 
tal \vhen  applied  in  a  concentrated  solution,  as  ever)' 
well-informed  agriculturist  knows,  while  the  poison- 
ous action  of  certain  vegetable  alkaloids  as  well  as 
bacterial  toxins  on  the  animal  organism  is  beyond 
dispute. 

The  reaction  of  the  animal  economy  to  these  vari- 
ous poisons  differs  according  to  the  nature  of  the  ani- 
mal and  its  environment,  the  quantity  and  concentra- 
tion  of  the   poisons,  and   finally  its   specific  nature. 

'  "  l.'.izione  ilejjii  .ilc-iloidi  nel  regno  vegetale  e  aniniale. "     An- 

nali  <li  Cliiin.  c  di  Farmacol.,  1SS7,  p.  3  tt  siu/. 


October  16,  1897] 


MEDICAL    RECORD. 


549 


But  in  general  tissue  metabolism,  body  temperature, 
and  blood  circulation  are  increased,  while  muscular 
and  nervous  energy  is  decreased. 

While  it  is  not  impossible  that  the  increased  tissue 
metabolism  is  the  principal  if  not  the  sole  cause  of 
the  other  phenomena,  it  can  be  exactly  determined 
only  by  quantitive  estimation  of  the  products  of  retro- 
grade tissue  changes,  which  under  the  various  means 
of  e.xcretion  and  the  difficulty  of  collecting  the  prod- 
ucts is  almost  impossible.  And  even  more  diificult 
is  the  precise  quantitative  determination  of  the  nutri- 
tive states  and  the  d'ssipation  of  energy. 

The  physician,  then,  as  a  general  inde.x  of  the  inten- 
sity of  the  morbid  process,  relies  on  various  symptoms, 
of  which  pain  as  the  psychical  expression  of  proto- 
plasmic irritation,  fever  the  result  of  increased  heat 
production  or  diminished  radiation,  and  abnormal 
cardiac  action  from  irritation  of  the  cardiac  motor 
ganglia  or  the  vasomotor  nervous  system,  as  well  as 
the  disturbed  inhibitory  action  of  the  pneumogastric, 
are  the  most  conspicuous. 

Very  often  indeed  the  combating  of  these  symptoms 
seems  to  be  the  sole  aim  of  pharmacological  thera- 
peusis,  and  it  must  be  admitted  that  not  infrequentlv 
the  object  is  accomplished. 

Thus  the  administration  in  physiological  doses  of 
the  vegetable  narcotics,  opium,  hyoscyamus,  and  can- 
nabis indica,  certainly  can  very  often  prevent  the 
patient  from  being  conscious  of  pain;  aconite,  vera- 
trum,  digitalis,  and  many  others  reduce  the  pulse  rate; 
While  kairine,  thalline,  and  quinine,  as  well  as  many 
modern  phenol  derivatives  certainly  reduce  the  bodv 
temperature.  But  is  it  not  to  be  questioned  whether 
all  these  really  assist  the  economy  in  its  struggle  with 
disease?  And  may  not  the  very  physiological  or 
pathological  action  which  causes  the  improvement  in 
or  removal  of  the  symptoms  be  inimical  to  normal 
vital  functions.^ 

An  infectious  disease  may  be  recovered  from  only 
through  limitation  of  the  growth  of  bacteria  which 
produce  it.  Two  factors  may  ser\e  to  accomplish 
this.  First  bacteria  can  live  and  remain  normal  only 
in  suitable  culture  media,  and  since  the  peculiar  pab- 
ulum necessary  to  nourish  them  is  limited  in  quantitv 
it  occurs  that  when  this  is  exhausted  nutrition  is  im- 
possible, and  development  and  vitality  cease.  In 
the  second  place  the  poisons  excreted  by  the  bacteria 
serve  to  restrict  their  growth  and  destroy  them.  It  is 
not  known  to  what  extent  each  of  these  factors  con- 
tributes toward  recovery.  But  theoretically  it  would 
.seem  that  the  first  means  is  alone  to  be  trusted,  since 
the  animal  economy  may  be  able  to  dispense  with  a 
part  of  its  organic  material  which  contributed  to  the 
nourishment  of  the  parasite  without  much  permanent 
harm,  while  the  second  factor  may  not  only  kill  the 
bacteria  but  the  patient,  as  the  results  of  a  famous 
modern  toxin  remedy  seem  conclusively  to  have 
shown. 

Life  has  often  been  maintained  for  years  under  the 
most  excruciating  pain  without  apparent  physical  de- 
terioration, as  cases  of  neuralgias  and  other  chronic 
nervous  diseases  testify. 

Again,  there  are  those  who  without  apparent  dis- 
ability have  a  high  pulse  rate  during  their  entire  life, 
while  cases  of  tachycardia  are  occasionally  met  with  in 
which  a  pulse  rate  of  140-200  per  minute  for  several 
days  or  weeks  not  only  does  not  cause  death  but  does 
not  seem  to  disturb  very  much  the  patient's  general 
health  except  as  to  nervous  phenomena. 

In  the  same  way  a  moderate  rise  of  temperature, 
according  to  Cantani,'  has  been  endured  for  months 
without  death,  and  healthy  animals  have  been  sub- 
jected to  a  temperature  considerably  higher  than  nor- 

'  "Ueber Antipyrese,"  \erhandl.  d.  x.  internal.  Congr.,  Berlin, 
iScio. 


mal  for  months  without  causing  untoward  results,  as 
has  been  shown  by  Naunyn.' 

Also  the  observations  of  Tait,"  Bryant,'  Unverricht,' 
and  many  others,  show  that  often  patients  w'ith  a  tem- 
perature as  high  as  43'  or  44°  (io9°-iii°  F.)  have 
been  met  with  and  have  recovered. 

These  facts  serve  only  to  show  that  these  various 
symptoms  may  exist  for  a  long  time  and  be  very  severe 
without  a  fatal  result,  and  that  too  often  when  but 
little  medicine  was  administered. 

Again,  every  physician  is  familiar  with  the  fact  that 
the  danger  to  life  is  not  at  all  proportionate  to  the 
severity  of  tiie  symptoms.  It  is  not  the  pneumonias 
with  the  highest  fever  and  very  severe  pains  that  are 
most  fatal,  as  the  mortality  from  this  disease  in  the 
aged,  with  whom  all  the  symptoms  are  usually  mild, 
shows,  or  the  infectious  processes  with  the  highest 
temperature  and  pulse  rate,  as  pysemia  and  certain 
mixed  infections  testify. 

It  has  never  been  demonstrated  that  combating 
symptoms  ever  of  itself  has  caused  a  cure,  in  the 
sense  of  complete  restoration  to  the  normal,  or  has 
even  assisted  the  natural  forces,  since  there  are  no  sta- 
tistics, at  least  none  that  the  writer  has  knowledge  of, 
covering  a  long  period  and  including  a  large  number 
of  cases  in  which  acute  diseases  have  been  treated  by 
iiygienic  measures  alone.  Certainly  a  large  propor- 
tion of  patients,  in  fact  a  majority,  recover  after  the 
administration,  even  in  considerable  quantities,  of 
poisonous  drugs,  but  whether  because  of  their  action 
or  in  spite  of  it  has  never  been  proven.  And  it  is  not 
less  certain  that  in  many  even  grave  cases  recovery  en- 
sues without  the  use  of  pharmaceutical  remedies,  as 
the  recoveries  in  many  hydropathic  and  hvgienic  in- 
stitutions show. 

Our  text-books  and  teachers  of  therapeutics  are 
mainly  responsible  for  the  propagation  of  symptomatic 
medication.  The  student  is  often  informed  that  when 
a  patient  presents  such  and  such  symptoms  an  active 
attempt  should  be  made  at  once  to  remove  them.  "  Ad- 
minister aconite,  gelsemium,  and  morphine,"  says  one. 
"This  will  bring  about  relief  from  pain,  a  reduction 
of  the  pulse  rate,  and  lowering  of  temperature." 
"  But,"  says  another,  '"  I  get  better  results  from  vera- 
trum,  hyoscyamus,  and  belladonna."'  After  these  rem- 
edies have  been  diligently  administered,  perhaps  re- 
covery has  not  taken  place,  but  the  rise  in  temperature 
and  other  symptoms  have  become  still  more  serious. 
"Now  choose  among  a  dozen,  antipyrin,  acetanilid, 
thallin,  or  kairin,  according  to  circumstances;  and 
perhaps  very  large  doses  of  quinine  will  be  more  effi- 
cacious and  less  harmful."  After  a  time  in  conse- 
quence of  the  disease,  perhaps  aided  by  drugs,  the 
heart  action  becomes  very  weak  and  rapid.  "Now  is 
the  time  to  administer  digitalis,  strophanthus,  caffeine, 
strychnine,  and  alcoholic  stimulants,"  says  the  thera- 
peutist, "  if  you  hope  for  recovery."  And  yet  in  spite 
of  all  this  the  patient  does  not  recover.  "Well,  you 
accomplished  all  that  was  possible  in  the  present  state 
of  our  knowledge,"  he  continues,  and  proceeds  with 
other  symptomatic  indications  and  the  drugs  neces- 
sary to  annihilate  them. 

When  recovery  takes  place  the  novice  has,  or  thinks 
he  has,  pn'ma-Jacie  evidence  that  the  various  drugs 
caused  a  cure,  and  so  continues  perhaps  from  day  to 
day  to  attribute  all  recoveries  to  his  narcotics,  anti- 
pyretics, cardiac  depressants,  stimulants,  et  id  genus 

'  "  Kritisches  und  ENperimentelles  zur  Lehre  vom  Fieber  und 
von  der  Kaltwasserbehandlung."  Archiv  fiir  e.xper.  Path,  und 
I'harm.,   Bd.  iS. 

'  "  Two  Instances  of  Remarkable  Elevation  of  Temperature." 
Lancet,  July,  18S4. 

'  "  One  Hundred  Cases  of  Hyperpyrexia."  Guy's  Hospital  Re- 
ports, vol.  1.,  p.  3S5. 

*  "  Ueber  das  Fieber."  Sammlung  klin.  Vortrage  (Volkmann), 
X.  F.,  No.  159,  1896. 


550 


MEDICAL    RECORD. 


[October  i6,  1897 


omne ;  and  when  a  fatal  result  follows  their  use  be- 
lieves that  it  might  have  been  because  a  wrong  selec- 
tion was  made,  or  that  no  system  of  treatment  would 
have  been  of  service. 

The  science  of  pharmacological  therapeutics,  as 
applied  to  acute  diseases,  is  very  often  expounded  in 
an  oracular  manner  and,  now  as  for  centuries  past, 
rests  on  almost  no  other  foundation  than  empiricism 
and  pure  dogma.  Contraria  contra  rib  us  atraii/iir,  one 
of  the  oldest  and  most  universally  accepted  of  these 
dogmas,  has  certainly  been  a  sheet  anchor,  lut  even 
this  cannot  be  true  for  diseases  which  are  caussd  by 
micro-organisms,  if  the  real  cause  is  considered,  since 
the  various  alkaloidal  remedies  used  are  similartothe 
tcxins  in  almost  every  particular.  Moreover  the  sup- 
posed physiological  antagonism  between  certain  alka- 
loids has  received  but  scant  support  in  the  last  few 
years,  and  even  if  true  cannot  aid  in  making  an  exact 
therapeusis  until  the  specific  action  of  the  various  tox- 
ins has  been  determined  and  substances  can  be  found 
which  will  not  antagonize  the  symptoms  produced  by 
the  toxin,  but  will  destroy  its  harmful  influence  on  the 
vital  units. 

The  discovery  of  phagocytosis  and  of  means  wliereby 
it  may  be  artificially  produced,  and  the  results  of  re- 
cent serum  therapy,  have  invigorated  the  old  doctrine 
of  the  vis  mediratrix  naturie ;  while  experiments  on 
the  living  animal  are  showing  more  and  more  clearly 
not  only  the  inadequacy  of  symptomatic  therapeusis 
to  bring  .about  a  restoration  to  the  normal,  but  also  the 
possible  dangers  which  can  be  caused  by  tlie  adminis- 
tration of  poisonous  alkaloids  and  the  recently  dis- 
covered antipyretics. 

Authorities  such  as  Binz,'  Rossbach,^  and  Rosen- 
thal ■'  have  shown  conclusively  that  protoplasm  cannot 
produce  normal  manifestations  of  energy  when  acted 
on  by  the  poisonous  alkaloids.  And  otliers,  as  Robin,' 
Kast,'  and  many  more,  have  found  that  the  normal  tis- 
sue metabolism  cannot  continue  under  the  influence  of 
various  modern  antipyretics. 

Perhaps  the  time  will  come  when  our  text-books  on 
therapeutics  will  devote  most  of  their  space  to  the 
consideration  of  causal  and  not  symptomatic  indica- 
tions, and  therapeutic  specialists  will  be  unnecessary. 
When  the  student  learns  from  his  pharmacology  the 
doses,  physiological  action,  and  manner  of  elimination 
of  drugs,  and  from  biology  the  exact  nature  of  organs 
and  functions,  he  will  no  longer  need  a  dogmatic  opin- 
ion as  to  the  indications  for  the  administration  of 
drugs.  Then,  too,  he  may  be  taught  to  look  at  disease 
from  a  causal  point  of  view,  and  learn  that  it  requires 
more  scientific  attainment  to  know  when  not  to  admin- 
ister a  drug  than  it  does  to  treat  symptoms.  And  long 
before  this  takes  place  let  it  be  hoped  that  the  thera- 
peutic vadc  mcciim  in  which  the  student  has  only  to 
look  in  the  index  for  the  name  of  a  disease  and  on 
referring  to  it  find  from  one  to  ten  poisonous  drugs  in- 
dicated as  a  regular  treatment,  will  have  become  a  thing 
of  th'„'  past.  Drugs  without  doubt  have  been  of  very 
great  benefit  to  mankind  and  will  continue  to  be  more 
and  more  of  real  service,  but  it  should  be  remembered 
that  they  are  able  to  cause  harm  as  well  as  good;  that 
the  indications  for  their  u.se,  especially  in  acute  infec- 
tious diseases,  rest  for  the  most  j^art  on  unproven  dog- 
mas:  and  that  when  the  indications  for  the  use  of  a 


'  "  Ueber  die  Kinwirkung  dcs  Cliinin  auf  rrotoplasmabewe- 
gung."     Arch,  fiir  microscop.  .\n.itomic.  ]!d.  iii..  S.  383,  1S67. 

''  "  Ucber  die  Kinwirkung  der  Alcaloidc  auf  die  organischen 
Substrate  des  Thierkiirpers."  Wiirzb.  med.-phys.  Verhandl., 
iii.,  p.  346,   1S73. 

^  "  Ueber  die  Wirkung  des  C'liinolins. "  Heutsches  .Xrchiv  f. 
klin.  Med.,  lid.  .\lii.,  S.  10b. 

■*"  I.,'. -Vntipyrine,  son  Action  sur  la  Nutrition."  Gaz.  Med.  de 
Paris,"  No.  50,  1SS7. 

'  "  Ueber  den  Werthdcrarzneilichen  Antipyretica."  Wriiand. 
des  Kongresses  fiir  innerc  Medi/in.  Wiesbaden,  l8g6. 


drug  are  doubtful  or  wanting,  it  had  better  be  with- 
held. In  all  cases  the  antagonism  between  living 
material  and  irritating  surroundings  should  be  borne 
in  mind,  and  an  attempt  made  to  keep  the  cellular 
vitality  and  energy  at  its  most  efficient  point  by  sup- 
plying proper  materials  for  nourishment,  pure  air,  and 
water,  to  assist  the  chemico-vital  processes,  and  finally 
to  assist  the  excretory  organs  in  the  removal  of  the 
poisonous  products  of  animal  and  vegetal  cellular 
metabolism.  And  in  the  mean  time  the  ancient  mean- 
ingless contraria  contraribiis  curaiitttr,  as  well  as  its 
more  modern  fanciful  opposite,  similia  similibus  ciiran- 
tiir,  will  receive  due  honors  if  they  are  laid  away  with 
other  famous  media;val  curiosities,  such  as  the  prob- 
lem of  circular  quadratics  and  the  philosopher's  stone. 


THE  EARS  OF  GRASSHOPPERS,   FLIES,  AND 
BEETLES. 

Ev   JAMES   WEIR,    Jr..    M.D.. 

OWENSBORO,    KV. 

By  far  the  larger  number  of  entomologists  locate  the 
auditory  organs  of  insects  in  their  antennee.  I  have 
only  to  mention  the  names  of  such  men  as  Kirby, 
Spence,  Burmeister,  Hicks,  Wolff,  Newport,  Oken, 
Strauss,  Durkheim,  and  Carus.  who  advance  this  opin- 
ion, to  show  what  a  formidable  array  of  talent  main- 
tains it.  Yet  my  observations  lead  me  to  believe 
otherwise,  though  these  authorities  are  in  part  correct. 


Fig.  I.— SitboWs  Orvan.  Tracli.a;,  i-c.  (after  tinibtrl.     tT.    Front   t>-m- 

Eanum  .  //  'I\  hinder  typanuin  ;  f  Tr,  front  branch  of  trachea  ;  A  Tr,  hinder 
ranch  o!  trachea ;  i^.  supratymjianal  ganglion  ;  Gr,  group  of  vesicles;  so, 
ncr\-e  terminations  of  the  organ  of  Siebold,  A'.V,  nerves  of  the  oryan  of  Sie- 
bold  :  .S/,  space  between  the  trache.x-. 

As  far  as  Lepidoptera  are  concerned  and  certain  of 
Hemiptera,  they  are  right — the  antenna^  in  these  crea- 
tures are  the  seat  of  the  organs  of  audition.  But  in 
Orthoptera.  in  most  of  Coleoptera.  in  Hymenoptera,  in 
Diptera,  and  in  certain  bugs  (Hcmipterai,  they  ;.re 
located  elsewhere.  The  habit  that  almost  all  insects 
have  of  retracting  their  antenna;  when  alarmed  by 
noise  or  otherwise  has  done  much  to  advance  and 
strengthen  the  opinion  that  these  appendages  are  the 
seat  of  insect  ears;  yet  I  am  confident  that  in  nine 
cases  out  of  ten  the  antenna;  are  retracted  through  fear 
of  injury  to  them,  and  not  through  any  impression 
made  on  them  by  sound.  The  antenna'  are  the  most 
exposed  and  least  protected  of  any  of  the  appendages 


October  i6,  1S97] 


MEDICAL    RF.CORD. 


551 


. — Ear  of  Horsefly  (after  Lowne,  modified 
by  the  author) 


or  members  of  the  insect  body;  hence  their  retraction 
by  insects  when  alarmed  is  an  instinctively  protective 
action.  They  shelter  them  as  much  as  possible  in 
order  to  keep  them  from  being  injured.  Again, 
althougii  the  antennae   of   most   insects  are  provided 

w  i  t  h  numerous 
sensitive  hairs  or 
seta;,  we  have  no 
right  t  o  assume 
that  these  hairs 
are  auditory  ;  n  o 
"auditory  rods." 
otoliths,  etc.,  are 
to  be  found  gene- 
rally in  antenna-, 
yet  there  are  ex- 
ceptional instan- 
ces. Leydig  found 
auditory  rods  in 
the  antennae  of 
DyiicHS  m  a  ig  i  - 
mil  is  (Furneaux) 
(giant  water 
beetle),  and  I 
myself  have  ob- 
served them  i  n 
Cory^dalus  cornu- 
tus  (its  larva  is 
the  well-known 
'"dobson"  of  ang- 
lers') and  other  neuropterous  insects.  I  am  inclined 
to  believe  that  the  entire  order  of  Neuroptera  has 
antennal  ears,  and  should  therefore  in  this  respect  be 
classed  with  Lepidoptera. 

In  grasshoppers  and  crickets  the  ears  are  situated 
in  the  anterior  pairs  of  legs.  If  the  tibia  of  a  grass- 
hopper's anterior  leg  be  examined,  two  (one  before 
and  one  behind)  shining,  oval,  membranous  discs, 
surrounded  by  a  marginal  ridge,  will  be  at  once  ob- 
served. These  are  the  tympana  or  ear  drums  of  the 
ear  of  that  leg.  Where  the  trachea  or  air  tube  enters 
the  tibia  it  becomes  enlarged  and  divides  into  two 
channels;  these  two  channels  unite  again  lower  down 
in  the  shaft  of  the  tibia.  The  trachea;  of  non-stridu- 
lating  grylli  are  much  smaller  than  those  of  sound- 
producing  grasshoppers.  The  same  may  be  said  of 
the  tibial  air  tubes  of  the  so-called  dumb  crickets.  In 
grasshoppers  and  crickets  the  ear  drums  lie  bathed  in 
air  on  both  sides  — the  open  air  on  the  external  side 
and  the  air  of  the  air  tube  or  trachea  on  the  inside. 
Lubbock  calls  attention  to  the  fact  that  "the  trachea 
acts  like  the  Eustachian  tube  in  our  own  ear;  it  main- 
tains an  equilibrium  of  pressure  on  each  side  of  the 
tympanum,  and  enables  it  freely  to  transmit  atmos- 
pheric vibrations." 

In  grasshoppers  the  auditory  nerve,  after  entering 
the  tibia,  divides  into  two  branches,  one  forming  the 
supratympanal  ganglion,  the  other  descending  to  the 
tympanum  and  forming  a  ganglion  known  as  Siebold's 
organ.  This  last-mentioned  ganglion  is  strikingly 
like  the  organ  of  Corti  in  our  own  ear,  and  undoubt- 
edly serves  a  like  purpose  in  the  phenomenon  of  audi- 
tion. The  organ  of  Corti  is  composed  of  some  four 
thousand  delicate  vesicles,  graduated  in  size,  each  one 
of  which  vibrates  in  unison  v.  ith  some  particular  num- 
ber of  sound  vibrations.  The  organ  of  Siebold  in  the 
grassiiopper's  ear  begins  with  vesicles,  of  which  a  few 
of  the  first  are  nearly  equal  in  size;  these  vesicles 
then  regularly  diminish  in  size  to  the  end  of  the  se- 
ries. Each  of  these  vesicles  contains  an  auditory  rod, 
and  is  in  communication  with  the  auditory  nerve 
through  a  delicate  nerve  fibril.  I  have  observed  that 
each  of  these  nerve  fibrils  swells  into  a  minute  gan- 
glion immediately  after  leaving  its  particular  vesicle; 
the  function  of  these  ganglia  is,  I  take  it,  to  strengthen 


and  reinforce  nerve  energj\  No  other  observer  men- 
tions these  ganglia,  as  fur  as  I  have  been  able  to  de- 
termine; they  may  have  been  absent,  however,  in  the 
specimens  studied  by  others,  yet  in  the  specimens 
studied  by  myself — the  "  red-legged  locust"  (Alclano- 
pliis  fciiiiir-nilinaii,  Comstock)  and  the  "  meadow 
grasshopper"  (Xiphidium) — they  were  always  present. 

That  grasshoppers,  locusts,  and  crickets  can  hear, 
no  one  who  has  observed  these  creatures  during  the 
mating-season  will  for  one  instant  deny;  they  hear 
readily  and  well,  for  in  most  of  them  the  sense  of 
hearing  is  remarkably  acute. 

Immediately  behind  the  wings  of  flies  two  curious 
knobbed  organs  are  to  be  observed ;  these  are  consid- 
ered to  be  rudimentary  hinder  wings  by  entomologists, 
and  are  called  the  halteres.  BoUes  Lee  and  others  of 
the  French  scientists  call  them  ks  balanciers.  This 
latter  name  I  consider  the  correct  one,  for  these  organs 
unquestionably  preside  over  alate  equilibrium;  they 
are  true  balancers.  I  do  not  propose  to  enter  into  any 
discussion  as  to  whether  these  organs  are  rudimentary 
wings  or  not;  suffice  it  to  say  that  they  appear  to  me 
to  be  organs  fully  developed  and  amply  sufficient  to 
serve  the  purposes  for  which  they  were  created. 
Whether  or  not,  in  the  process  of  evolution,  there  has 
occurred  a  change  of  function,  is  a  point  which  will 
not  be  discussed  in  this  paper.  As  they  now  exist,  I 
deem  them  to  be  the  auditory  organs  of  Diptera  (flies, 
gnats,  etc.). 

The  semicircular  canals  are,  to  a  great  extent  if  not 
entirely,  the  seat  of  equilibration  in  man.  Any  de- 
rangement or  disease  of  these  canals  interferes  with 
equilibration  ;  this  is  well  shown  in  Meniere's  disease, 
in  which  there  is  always  marked  disturbance  of  the 
equilibrating  function. 

If  the  balancers  of  a  horsefly  [Ihki/uts  atratus,  Com- 
stock) be  removed,  the  insect  at  once  loses  its  equili- 
brium; it  cannot  direct  its  flight,  but  plunges  head- 
long to  the  ground.  The  same  can  be  said  of  Chrysops 
niger — in  fact,  of  tlie 
entire  family  of  Taba- 
nida-,  of  the  gall  gnat 
yDiplosis  .  rcsinicola, 
Comstock),  and  of  the 
March  flies  (Bibioni- 
dae).  These  widcl\- 
differing  flies  consti- 
tute the  material  from 
which  I  Jiave  deri\L'd 
my  data ;  I  will  ven- 
ture to  assert,  howe\t  1, 
without  fear  of  contra- 
diction, that  what  has 
been  said  about  the 
flies  mentioned  above 
is  equally  true  of  all 
flies. 

When  the  knobbed 
ends  of  the  balancers  of 
the  horsefly  {Tabciiuis 
atratus,  Comstock)  are 
examined  with  the 
microscope,  the  cuticle 
will  be  found  to  be  set 
with  minute  hairs  or 
setae;  some  of  these 
hairs  penetrate  both 
cuticle  and  hypoderm, 
are  hollow,  and  receive 
into  their  hollows  delicate  nerve  fibrils.  These  nerve 
fibrils  pass  inward  toward  the  centre,  and  enter  gan- 
glia, which  in  turn  are  in  immediate  connection  with 
the  great  nerves  of  the  balancers.  There  is  but  one 
nerve  in  the  insect's  body  that  is  larger  than  the  bal- 
ancer nerve,  and  that  is  the  optic  nerve:  hence  it  is 


Fig.  3.— Head  of  Gnat,  showing  .\uditory 
Hairs  {after  Johnson). 


552 


MEDICAL    RECORD. 


[October  i6,  1897 


natural  to  infer  that  the  balancer  nerve  leads  to  some 
special-sense  centre.  This  centre,  in  my  opinion,  is 
unquestionably  the  seat  of  the  auditor}'  function.  It 
has  been  demonstrated  beyond  doubt  that  analogous 
hollow  hairs  or  setffi  are  prominent  factors  of  audition 
in  many  animals,  notably  crustaceans,  such  as  the 
lobster,  the  crab  and  the  crayfish,  and  many  of  the 
insect  family;  hence  it  is  logically  correct  to  conclude 
that  the  hollow  hairs  on  the  balancers  of  flies  are  like- 
wise auditory  hairs.  Moreover,  there  are  grouped 
about  the  bases  of  these  knobbed  organs  certain  rows 
of  vesicles,  which  contain  auditory  rods  almost  identi- 
cal in  appearance  with  the  auditory  rods  of  the  grass- 
hopper. I  have  determined  that  in  the  horsefly  {Ta- 
baiiiis  atratiis)  there  are  six  rows  of  these  vesicles,  and 
that  they  are  of  graduated  sizes.  There  are  in  the 
knobs  of  the  balancers  minute  spiracles,  through  which 
air  passes  into  the  large  vesicular  cells  which  make 
up  the  greater  portion  of  the  knobs;  spiracles  are  also 
to  be  found  in  the  shafts  of  the  balancers,  thus  provid- 
ing an  abundance  of  air  to  the  internal  structures  of 
these  organs  and  allowing  tor  the  free  transmission  of 
sound  vibrations.  I  am  well  aware  of  the  fact  that  in 
considering  these  organs  to  be  the  ears  of  flies  I  an- 
tagonize Lee,  Hicks,  Wolff,  and  others  who  consider 
them  olfactory  in  character;  but  from  their  position, 
their  structure,  and,  above  all,  the  markedly  evident 
part  they  play  in  alate  equilibrium,  I  think  the  posi- 
tion I  take  in  regard  to  these  organs  is  a  tenable  one 
and  one  that  cannot  easily  be  overthrown. 

The  ears  of  Lepidoptera  (butterflies)  are  situated  in 
their  antenna;.  This  fact  has  been  cleverly  demon- 
strated by  Lubbock,  Graber,  Leydig,  and  Wolft";  but 
in  Coleoptera  (beetles)  my  experiments  and  micro- 
scopical researches  compel  me  to  assert  that  I  differ 
somewhat  from  the  conclusions  of  the  above-men- 
tioned authorities.  These  gentlemen  locate  the  ears 
of  beetles  in  their  antennas.  Lubbock  bases  his  con- 
clusion on  an  experiment  of  Will — an  experiment 
which,  if  it  had  been  carried  a  little  further,  would 
have  demonstj'ated  the  fact  that  the  ears  of  beetles  are 
not  in  their  antenna;,  but  are,  on  the  contrary,  in  their 
maxillary  palpi. 

Will  put  a  female  Cerambyx  beetle  in  a  box,  which 
he  placed  on  a  table;  he  then  put  a  male  Cerambyx 
on  the  table,  some  four  inches  from  the  box.  When 
he  touched  the  fehiale  she  began  !o  chirrup,  whereupon 
the  male  turned  his  antennae  toward  the  box,  "as  if  to 
determine  from  which  direction  the  sound  came,  and 
then  marched  straight  toward  the  female."  Will  con- 
cluded from  this  that  the  ears  of  the  beetle  were  located 
in  its  antenna\  Seeing  that  Will's  experiment  as  de- 
scribed by  him  was  incomplete,  1  took  a  pair  of  bee- 
tles belonging  to  the  same  family  (genus  Frioiius), 
and  determined  the  true  location  of  their  ears  by  a 
system  of  rigid  and  absolute  exclusion.  These  bee- 
tles, when  irritated,  make  a  squeaking  chirrup  by  rub- 
bing together  the  prothorax  and  mesothorax.  When 
I  irritated  the  female  she  began  to  chirrup,  and  the 
male  immediately  turned  toward  the  small  paper  box 
in  which  she  was  confined.  I  then  removed  the  an- 
tenna- of  the  male,  and  again  made  the  female  stridu- 
late:  the  male  heard  her  and  at  once  crawled  toward 
her,  although  his  antennii;  were  entirely  removed. 
This  showed  conclusively  that  the  organs  of  audition 
were  not  located  in  the  antenna,  as  Will  supposed 
and  as  Lubbock  advocates.  I  then  removed  the  max- 
illary palpi  of  the  male,  after  which  the  insect  re- 
mained deaf  to  all  sounds  emanating  from  tlie  female. 
Again,  I  took  an  unmutilated  male,  which  at  once 
turned  and  crawled  toward  the  chirruping  female.  I 
then  removed  its  l.ibial  palpi,  leaving  maxillary  jialpi 
and  antennx-  intact:  it  heard  the  female  and  made 
toward  her.  The  maxillary  jjalpi  were  then  removed 
(the  antenn.T  being  left  ///  situ\,  and  at  once  the  crea- 


ture became  deaf.  If  the  maxillary  palpi  of  long- 
horned  beetles  be  examined,  certain  vesicular  organs, 
each  containing  a  microscopic  hair,  will  be  observed 
in  the  basal  segments;  these,  I  take  it,  are  auditor)- 
vesicles.  In  some  of  the  Coleoptera  I  have  found 
auditory  rods  in  the  apical  segments,  though  this  is  by 
no  means  a  common  occurrence.  In  Cicindelida 
and  Carabida:  these  auditory  vesicles  are  exceedingly 
small,  and  require  a  very  high-power  objective  in  order 
to  be  clearly  seen.  In  justice  to  other  observers  I 
must  say,  however,  that  I  am  inclined  to  believe  that 
in  all  beetles  the  antenna;  in  some  way  aid  or  assist 
audition,  but  they  are  adjuncts,  as  it  were,  and  not 
absolutely  necessary.  It  is  a  matter  of  easy  demon- 
stration to  show  that  some  of  these  insects  hear  less 
acutely  when  they  are  deprived  of  their  antenna;. 


SOME    PRACTICAL     POINTS    ON    THE    AD- 
MINISTRATION   OF    CHLOROFORM." 

By   LEO   ETTIXGER,    M.D., 

A  RECENT  editorial  on  the  subject  of  anaesthesia  sug- 
gested to  me  the  propriety  of  some  remarks  on  the 
above  subject.  -\s  may  be  observed,  the  suggestions 
are  based  upon  personal  experience  largely,  but  it  is 
to  be  hoped  that  they  will  meet  with  indulgent  ap- 
proval, though  some  may  run  counter  to  prejudices 
prevalent  in  this  section. 

I  shall  confine  myself  to  chloroform  anresthesia,  for 
which  I  possess  a  decided  personal  predilection.  It 
may  be  conceded  that  a  varied  personal  experience  of 
some  six  years  in  its  administration  would  justify  the 
judgment  that,  properly  administered,  it  is  a  practically 
safe  and  convenient  ana;sthetic.  As  a  result  of  this 
experience,  the  writer  is  no  party  to  the  fear  of  the 
danger  from  chloroform  so  general  among  the  prac- 
titioners of  this  city.  I  have  also  had  some  experi- 
ence with  ether,  and  such  observations  as  I  have 
made  did  not  impress  me  favorably.  Its  administra- 
tion is  attended  by  such  disagreeable  features  as  the 
intense  stage  of  preliminary  excitement,  the  cyanosis 
and  salivation,  combined  with  the  objectionable  after- 
effects, the  intense  nausea  and  retching,  lasting  from 
twelve  to  forty-eight  hours,  seldom  less  than  twenty- 
four,  that  ptr  Si.-  it  certainly  cannot  be  deemed  an  eli- 
gible anesthetic.  All  of  these  facts  are  more  or  less 
true  of  ether  (and  rather  more  than  less),  even  in 
the  most  skilful  methods  of  administration;  and  on 
the  other  hand  chloroform  is  practicallv  so  free  from 
them  that,  were  the  two  of  equal  safety,  chloroform 
would  be  decidedly  preferable.  It  also  seems  rather 
difficult  to  judge  the  exact  quantity  of  ether  needed. 
In  order  to  maintain  the  ana;sthesia,  its  rather  free 
use  becomes  absolutely  necessar)'.  In  this  respect, 
chloroform  does,  it  seems,  possess  a  striking  advantage, 
as  its  administration  can  be  gauged  with  the  utmost 
nicety. 

The  only  reason  generally  assigned  for  the  prefer- 
ence for  ether  is  its  supposed  superior  safety  as  com- 
pared with  chloroform.  Other  things  being  equal, 
this  feeling,  it  must  be  said,  is  not  shared  bv  me.  But 
so  much  has  been  said  of  the  resultant  pneumonia; 
and  nephritides,  many  fatal,  that  there  arises  the  ques- 
tion of  its  actual  safetv.  Some  years  ago,  when  the 
German  hospital  of  this  city  substituted  ether  for 
chloroform,  there  was  a  rumor  that  more  patients  died 
within  a  week  or  so  following  operation  than  had  ever 
died  before  from  chloroform  in  a  given  period. 

Now  it  is  to  be  hoped  that  the  charge  of  egotism 
may  not  arise  against  me,  on  asserting  that,  certain 
rides  salted  down  with  some  judgment  and  intelligence 

'  Re.id  before  the  Metropolitan  Medicil  Society.  May  25,  1S97. 


October  i6,  1897] 


MEDICAL    RECORD. 


553 


being  followed,  we  have  in  chloroform  an  entirely 
eligible  and  practically  safe  ana:sthetic  for  virtually 
all  surgical  cases.  There  are  a  few  cases  in  which 
its  use  in  the  pure  state  would  be  inadmissible.  It  is 
to  be  questioned  whether  in  these  cases  ether  would 
prove  any  safer.  When  in  such  cases  general  anaes- 
thesia is  an  absolute  necessity,  probably  the  alcohol, 
chloroform,  and  ether  mixture  (so  called  A.C.E.  mi.v- 
ture).  in  the  proportions  of  one,  two.  three,  would  be 
better.  This  is  to  be  administered  in  the  same  way 
that  chloroform  is. 

First,  in  the  administration  of  chloroform  the  ad- 
ministrator must  confine  his  attention  to  the  narcosis, 
and  to  that  and  nothing  else.  This  might  seem  a 
needless  injunction,  but  as  a  matter  of  fact  it  is  very 
rarely  adhered  to.  Its  importance  cannot  be  over- 
estimated. The  respirations,  facial  appearance,  and 
pulse  should  be  continually  observed.  As  to  the 
face,  stress  is  to  be  laid  upon  the  appearance  of  the 
nose  and  lips.  The  jaw  should  be  kept  well  forward 
to  prevent  swallowing  the  relaxed  tongue.  While 
cases  may  arise  in  which  it  will  become  necessary 
to  pass  a  silk  ligature  through  the  tongue,  person- 
ally I  have  never  found  it  necessary  to  do  so.  In 
fact  this  should  be  a  very  last  resort.  When  pos- 
sible it  is  preferable  to  avoid  even  the  tongue  for- 
ceps, thrusting  forward  the  angles  of  the  jaw  sufficing 
in  nearly  all  cases.  In  determining  the  sensibility  of 
the  conjunctiva,  the  pulp  of  the  ring  finger  placed  over 
the  outer  part  of  the  eyeball,  and  not  over  the  cornea, 
should  be  employed.  The  cornea  should  not  be 
touched  at  all,  and  the  conjunctiva  very  lightly.  In 
fact  the  relaxed  state  of  the  lids  is  usually  a  sufficient 
index  to  the  depth  of  the  anesthesia.  Conjunctivitis 
of  a  severe  type,  and  even  ulcer  of  the  cornea,  have 
been  said  to  follow  careless  manipulations  of  the  eye. 

Here  it  may  not  be  inappropriate  to  refer  to  cer- 
tain of  the  relations  betv.een  the  narcoiiseiir  and  the 
operator.  While  the  former,  it  must  be  conceded, 
should  defer  to  the  wishes  and  expressed  desires  of 
the  latter,  still  in  the  actual  conduct  of  the  narcosis  he 
should  be  free  from  any  interference :  for,  if  he  is  unfit 
to  be  trusted  with  his  discretion,  he  is  unfitted  for  the 
administration  of  the  drug.  On  the  other  hand,  he 
should  not  worry  the  operator  with  remarks  about  his 
patient  unless  it  becomes  necessary  to  discontinue 
the  operation,  either  temporarily  or  absolutely. 

The  writer  carries  his  armamentarium  in  a  small 
box.  The  latter  contains  four  small  vials:  one  of 
alcoholic  solution  of  nitroglycerin,  i  to  1,000;  one  of 
spirits  of  camphor;  one  of  nitrate  of  strychnine  of  the 
strength  of  two  grains  to  the  ounce ;  and  one  of  a  so- 
lution as  follows : 

R  Morph.  sulph i     c.c. 

.\trop.  sulph 0.02  " 

Chloral o.  50  " 

-Vquaj  dest ad  30      " 

M.      .S.   Magendie. 

Besides  this  there  is  a  tube  of  hypodermic  tablets  of 
digitalin,  each  one-one-hundredth  of  a  grain.  Then 
there  is  an  Esmarch  mask  and  a  chloroform  drop  bot- 
tle. The  mask  frame  is  in  two  pieces,  the  one  readily 
detachable  from  the  other.  The  mask,  which  is  thus 
easily  removed,  is  made  of  Jaeger  white  stockinette. 
It  is  advisable  to  have  a  number  of  masks  handy,  so  as 
to  have  a  fresh  one  for  each  narcosis.  The  drop  bottle 
should  be  only  partly  filled,  and  the  larger  tube  should 
be  always  kept  closed,  the  chloroform  being  poured 
drop  by  drop  from  the  smaller  one. 

When  expedient  it  is  always  well  to  be  supplied 
with  a  jar  of  oxygen,  or  preferably  of  a  t\Yent)--five  per- 
cent, mixture  of  nitrous-oxide  gas  and  oxvgen.  This 
is  a  precautionar)-  measure  simply.  Also  it  is  well 
for  the  narcotiseiir  to    have  a  nurse   detailed   for  his 


special  use.  The  latter  is  not  absolutely  necessar}-, 
but  often  proves  a  material  aid.  False  teeth  should 
be  removed:  also  the  condition  of  the  heart  should  be 
ascertained.  If  the  latter  be  not  satisfactory,  or  the 
pulse  be  120  or  more  to  the  minute  in  the  absence  of 
any  acute  inflammatory  process,  it  would  be  better  not 
to  use  a  general  anesthetic.  Or  if  the  latter  be  in- 
evitable, it  will  become  necessary  to  modify  the  admin- 
istration of  the  chloroform  in  such  manner  as  shall  be 
indicated  farther  on. 

As  a  preliminary  step  to  the  administration  of  the 
ana;sthetic,  the  hypodermic  administration  of  from 
seven  to  ten  minims  of  the  morphine  solution  as 
above,  preferably  ten,  is  advised,  except  of  course  with 
children  and  when  there  is  a  distinct  contraindication 
to  its  use.  Of  its  great  value  the  wTiter  is  con- 
vinced. It  allows  the  anesthesia  to  be  maintained 
with  much  less  chloroform,  while  at  the  same  time 
obtaining  the  tonic  effect  of  the  morphine  on  the 
heart  and  the  atropine  on  the  respiration.  This  meas- 
ure should  precede  all  capital  operations.  For  these 
the  ten-minim  dose  should  be  employed.  In  fact, 
often  as  much  as  fifteen  minims  may  be  given  with 
distinct  advantage.  Not  only  will  it  render  the  ad- 
ministration of  the  anesthetic  much  easier  and  safer, 
but  it  will  eliminate  almost  entirely  all  danger  of 
surgical  shock. 

The  chloroform  should  be  administered  drop  by 
drop,  and  no  more  should  be  used  than  is  absolutel)' 
necessary.  It  is  surprising  how-  far  a  little  will  go  if 
carefully  administered.  It  is  my  custom  seldom  to 
e.xceed  a  half-ounce  for  an  operation  lasting  an  hour 
and  a  half.  Some  time  ago  two  ounces  sufficed  for 
nine  different  cases,  including  three  laparotomies, 
all  nine  of  not  less  than  a  half-hour  duration,  some 
an  hour  or  more.  A  short  time  ago  there  came 
imder  my  notice  an  account  of  a  fatal  case  of  acute 
hepatitis  following  the  administration  of  two  and  a 
half  ounces  of  chloroform  during  two  and  a  half 
hours.  Judging  from  experience,  the  writer  has  no 
hesitation  in  saying  that  about  one-third  should  have 
sufficed.  These  results  are  attainable  even  without 
the  use  of  morphine  and  atropine.  When  the  lat- 
ter are  employed,  even  less  will  suffice.  It  is  in  this 
careful  and  guarded  manner  of  administration  that 
the  safety  of  chloroform  lies.  Thus  given,  it  is  my  im- 
pression that  it  is  as  safe  as  ether. 

During  the  anesthesia  one  should  have  at  hand 
a  twenty  or  twenty-five  minim  hypodermic  syringe 
charged  with  the  strychnine  solution,  in  which  two  of 
the  digitalin  tablets  have  been  dissolved,  i.e.,  pro- 
vided in  the  individual  case  in  question  no  contra- 
indication to  digitalin  exists. 

There  are  cases  in  which  the  administration  of 
either  chloroform  or  ether,  as  such,  would  be  inadmis- 
sible. At  the  same  time  general  anesthesia  may  be 
an  absolute  necessity.  In  such  cases,  if  no  renal  or 
pulmonary  trouble  exists,  the  A.C.E.  mixture  should  be 
used.  At  the  same  time  either  oxygen  or  preferably 
the  twenty-five-per-cent.  nitrous-oxide  mixture  should 
be  kept  flowing  constantly  under  the  mask.  If  renal 
or  pulmonary  trouble  coexists,  chloroform  itself  must  be 
used  in  conjunction  with  the  gas  as  noted.  The  writer 
is  contemplating  the  construction  of  a  frame  which  will 
allow  the  administration  of  the  oxygen  at  its  lower 
part,  while  above  is  a  detachable  stockinette  mask  on 
which  the  chloroform  is  to  be  dropped  for  use  in  these 
cases.  If  otherwise  permissible,  the  anesthesia  should 
be  preceded  by  the  hypodermic  administration  of  from 
one-twenty-fourth  to  one-fifteenth  of  a  grain  of  the 
strychnine  nitrate,  with  or  without  the  digitalin.  Dur- 
ing the  operation,  if  no  hemorrhage  exist,  the  nitro- 
glycerin solution  should  be  used,  the  half  or  all  of  a 
syringeful  at  a  time.  Of  course  these  measures  are  for 
this  class  of  cases,  and  when  otherwise  the  need  might 


554 


MEDICAL    RFXORD. 


[October  i6,  1897 


arise.      J I  is  iiol  intended  that  they  should  be  routine 
practice. 

Another  ingenious  modification  of  the  cliloroform 
narcosis  is  its  alternate  administration  with  pure  ni- 
trous-oxide gas,  commencing  witli  the  chloroform  and 
following  with  the  gas,  and  from  time  to  time  repeat- 
ing the  chloroform. 

The  possible  results  attainable  by  one  modification 
or  other  of  the  narcosis  were  recently  demonstrated  in 
a  very  satisfactory  manner  in  two  instances.  The  first 
was  an  extreme  case.  It  occurred  in  the  person  of  a 
short,  very  fat,  parturient  Bohemian.  She  at  the  time 
was  suffering  from  the  effects  of  a  heart  lesion  of  ex- 
treme gravity.  That  organ  was  enormously  hyper- 
trophied  and  dilated  and  presented  loud  aortic  and 
mitral  murmurs,  both  of  insufficiency.  The  pulse 
was  from  120  to  150  per  minute,  extremely  small  but 
rather  tense.  The  patient  was  profoundly  cyanotic  and 
intensely  dyspnceic.  As  above  said,  at  this  time  she 
was  in  labor.  Her  physician,  Dr.  Chevcik,  realized 
the  gravity  of  the  case,  and  called  in  Dr.  S.  Marx  for 
council.  The  latter  advised  immediate  delivery  by 
accoiniicmcnt  Jorce.  Here  the  A.C.E.  mixture  was  em- 
ployed in  conjunction  with  the  oxygen  gas,  which  was 
kept  steadily  flowing  under  the  mask.  The  anaesthesia 
was  preceded  by  the  nitroglycerin  solution  injected  hy- 
podermically,  repeated  at  intervals  during  the  narcosis. 
After  delivery  the  patient's  condition  was  much  better 
than  before  the  operation.  When  the  oxygen  was  ex- 
hausted, it  was  followed  by  the  twenty-five-per-cent. 
nitrous-oxide  mixture,  kept  up  for  some  hours,  while 
caffeine  citrate  and  strychnine  were  injected  hypoder- 
mically  every  two  hours.  That  night,  for  the  first 
time  in  months,  she  was  able  to  lie  upon  her  back. 
Tw'o  weeks  later  she  died  of  an  attack  of  acute  tedema 
of  the  lungs,  thus  showing  the  extreme  gravity  of  the 
heart  lesion. 

In  the  second  case  tiie  patient,  while  exhibiting  no 
urgent  symp'.um,  was  much  exsanguinated  from  re- 
peated hemorrhages;  her  urine  was  loaded  with  sugar 
and  albumin,  and  she  weighed  two  hundred  and  ten 
pounds.  Here  the  pure  chloroform  was  used  combined 
with  the  coincident  inhalation  of  the  nitrous-oxide 
mixture.  The  patient  went  through  the  narcosis  with- 
out a  single  accident,  and  emerged  from  it  in  the  best 
of  spirits.     Many  similar  cases  could  be  cited. 

The  experiments  of  the  Hyderabad  commission  in- 
dicate that  chloroform  primarily  attacks  the  respiratory 
centres;  further  that  it  does  not  overwhelm  the  lat- 
ter, but  gives  warning  of  approaching  danger.  This 
met  with  in  time,  in  these  experiments  was  always 
overcome.  The  writer's  personal  experience  bears 
out  the  above  in  its  entirety.  As  a  measure  of  resus- 
citation, artificial  respiration  occupies  the  very  front 
rank,  especially  when  associated  with  pure  oxygen  or 
the  twenty-five-per-cent.  nitrous-oxide  mixture,  and  it 
should  always  be  employed.  As  adjuvants,  the  strych- 
nine and  nitroglycerin  solutions,  used  as  above,  are  of 
signal  value.  In  the  light  of  recent  experience,  La- 
borde's  method  of  lingual  traction  is  a  measure  of  the 
greatest  value,  often  attended  by  results  when  all 
else  seems  to  fail,  and  its  use  should  never  be  lost 
sight  of.  With  children,  suspension  by  the  heels  with 
artificial  respiration  is  a  very  valuable  expedient. 

In  conclusion,  I  have  no  hesitation  in  saying  that 
chloroform,  thus  used  with  caution  and  judgment,  is 
the  an;t;sthetic /<r/- (Uiv/Ztv/Ci,'.  Its  administration  can 
be  gauged  with  the  utmost  nicety ;  further,  it  is  simple, 
and  agreeable  to  both  patient  and  nanotisctir.  The 
rest  is  altogether  a  question  of  the  intelligence,  skill, 
and  judgment  of  the  latter.  Were  it  a  question  of  in- 
tru-sting  the  an;vsthesia  to  untried  and  inexperienced 
hands,  ether  would  admittedly  be  much  safer,  but 
there  is  no  valid  reason  for  not  exacting  the  above 
qualities  in   this  fiekl   as  wo  should  in  any  other;   and 


I  am  confident  that  when  they  are  present  chloroform 
is  quite  as  safe  as  ether,  and  for  other  reasons  far  more 
eligible.  Thus  used  it  is  practically  free  from,  dan- 
ger, and  never  characterized  by  the  disagreeable  phe- 
nomena, both  with  and  after,  so  common  to  the  use  of 
ether.  In  the  vast  majority  of  ca.ses  it  should  be  used 
pure;  in  exceptional  cases  it  may  be  modified  as  above 
indicated. 


progress  of  f^t^cdical  J>cicnce. 

Some  Points  of  Preventive  Treatment  in  the 
Diseases  of  Women — Dr.  A.  E.  Giles,  writing  in  The 
Hospital,  says  that  the  first  question  here  is  of  over- 
study.  Probably  the  average  girl  can  acquire  as 
much  learning  as  the  average  boy ;  but  to  do  so  she 
requires  bodily  health  and  strength  equal  to  his.  Now 
the  boy  and  girl  work  under  different  conditions, 
which  if  ignored  lead  to  disaster.  Let  girls  pursue 
their  study,  but  more  leisurely;  they  will  arrive  at  the 
same  goal,  but  a  little  later.  Physically  and  emotion- 
ally a  girl  arrives  at  womanhood  earlier  than  a  boy 
arrives  at  manhood;  this  necessitates  a  corresponding 
saving  of  energy  in  some  direction,  and  the  direction 
in  which  this  economy  of  energy  is  to  be  sought  is  in 
intellectual  activity.  Secondly,  it  should  be  im- 
pressed upon  parents  that  premature  emotional  excite- 
ment is  bad;  sensational  love  novels  should  be 
avoided,  and  the  "  sex  question"  left  dormant  as  long 
as  possible.  The  idea  that  marriage  is  the  only  goal 
of  a  girl's  existence  should  be  discouraged,  for,  while 
it  may  be  true  that  in  the  role  of  wife  and  mother  the 
average  woman  is  seen  at  her  best,  the  preparation  for 
this  position  is  best  attained,  not  by  directly  aiming 
at  it,  but  by  the  development  of  physical  health,  by 
the  training  of  the  mind,  by  breadth  of  thought  and 
widening  of  interests. 

Methylene  Blue  in  the  Diagnosis  of  Renal  Perme- 
ability.—  Drs.  Achard  and  Castaigne  (Z«r  Bulletin 
Aledical,  June  23,  1897)  have  applied  the  methylene- 
blue  test  to  fifty  new  cases.  In  twenty-two  cases  in 
which  the  elimination  of  the  blue  was  normal,  five 
autopsies  have  shown  the  integrity  of  the  kidney.  Out 
of  twenty-eight  cases  in  whfch  there  was  a  tardy  elim- 
ination, lesions  of  the' kidney  were  found  at  thirteen 
autopsies.  In  this  series  three  cases  of  urinary  infec- 
tion with  suppurative  pyelo-nephritis  were  found,  one 
case  of  interstitial  nephritis  w  iih  considerable  atrophy 
of  the  kidneys,  cystic  kidneys  in  a  cardiac  case  with- 
out albuminuria,  and  a  kidney  presenting  evidences  of 
obstruction  in  a  woman  who  died  of  uramia.  It  was 
also  noted  in  the  case  of  circumscribed  lesions  of  the 
kidney  that  the  permeability  remains  normal  if  the 
remainder  of  the  parenchyma  is  healthy.  \'ariations 
of  permeability  and  a  return  to  the  normal  after  recov- 
ery from  acute  disease,  as  in  pneumonia,  were  noted; 
again,  after  finding  a  normal  permeability  in  a  tuber- 
culous patient,  there  would  be  a  sudden  delay  and 
albuminuria  and  anasarca  would  come  on.  This  test 
is  useful  not  only  in  medicine,  but  also  in  surgery,  as 
it  indicates  whether  the  kidneys  perform  their  func- 
tions in  a  normal  manner.  Dr.  Schwartz  reports  a 
case  of  hydronephrosis  in  which  catheterism  permitted 
the  urine  from  each  kidney  to  be  examined  separately. 
The  blue  did  not  pass  from  the  hydronephrosic  side, 
and  it  flowed  with  some  delay  from  the  supposedly 
healthy  side,  from  which  side,  too,  the  urine  showed 
traces  of  albumin.  Kpithclial  nephritis  gives  rise  to 
an  excessive'permeability,  according  to  Dr.  Hard,  who 
has  not  demonstrated  this  statement  anatomically ;  how- 
ever, the  facts  agree  with  the  experiments  of  the  authors. 


October  i6,  1S97] 


MEDICAL    RECORD. 


300 


Relative  to  the  variations  liable  to  occur  from  a 
defective  absorption  of  the  blue,  it  is  found  that 
even  considerable  ctdema  does  not  prevent  the  normal 
appearance  of  the  blue  in  the  urine  and  does  not  de- 
tract from  the  results  of  the  test.  To  verify  the  state 
of  absorption,  injections  of  twenty  grains  of  chlorate 
of  sodium  may  be  given,  this  substance  being  elimi- 
nated by  the  saliva  and  the  urine  at  the  same  time,  and 
possessing  the  advantage  over  iodide  of  potassium  of 
producing  no  pain  and  no  local  irritation.  The  ap- 
pearance of  the  chlorate  in  the  urine  is  slower  than  in 
the  saliva  with  subjects  in  whom  defective  permea- 
bility is  also  attested  by  methylene  blue.  As  regards 
the  technique  of  the  procedure,  it  is  advisable  to  make 
deep  injections  in  order  to  avoid  the  formation  of 
indurated  nodules.  It  is  also  absolutely  essential  to 
employ  methylene  blue,  since  the  other  aniline  blues 
do  not  give  the  same  results.  Methylene  blue  can  be 
distinguished  by  examining  a  dilute  solution  with  the 
spectroscope,  it  gives  a  dark  line  in  the  red  portion, 
which  the  other  blues  of  commerce  do  not  give.  Drs. 
Hauser  and  Yoisin  have  inquired  concerning  the  col- 
orless derivative  of  methylene  blue  in  the  urine  of 
patients  submitted  to  the  test.  This  colorless  com- 
pound of  methylene,  when  heated  in  urine  with  acetic 
acid,  becomes  green.  This  chromogene  can  be  sepa- 
rated, as  it  is  insoluble  in  chloroform.  The  colorless 
methylene  above  mentioned  is  not  the  same  as  methy- 
lene white.  The  chromogene  can  be  transformed  into 
the  blue  and  administered  in  this  state.  In  twenty- 
nine  subjects  a  comparative  study  of  blue  and  chromo- 
gene have  been  made.  In  nine  instances  the  two  sub- 
stances appeared  simultaneously  after  the  normal  delay 
of  one  hour.  In  nine  patients  there  was  an  equal  de- 
lay for  both  the  blue  and  the  chromogene.  In  cases 
having  more  or  less  profound  lesions  of  the  kidney  as 
demonstrated  by  autopsy,  the  chromogene  passed  be- 
fore the  blue.  "  The  chromogene  seems  to  be  more 
diffusible  and  to  traverse  the  diseased  kidney  sooner 
than  the  blue.  In  eleven  cases  there  was  a  delay  of 
the  blue  only,  the  chromogene  appearing  normally. 
Several  clinical  facts  of  this  kind  seem  to  show  that 
in  such  cases  there  are  functional  disturbances  of 
the  kidney ,  two  autopsies  have  shown  degenerative 
lesions  of  the  epithelium.  To  sum  up :  A  delay  of  the 
same  time  in  both  blue  and  chromogene  is  a  sign  of 
defective  permeabilit}' .  a  delay  of  the  blue  only  is 
met  with  when  the  trouble  with  the  permeability  is 
less  profound:  functional  trouble  of  the  kidney  may 
be  the  e.xclusive  cause  of  a  delay  limited  to  the  blue 
alone.  A  number  of  cases  are  cited,  showing  how- 
useful  this  test  may  be  in  difficult  diagnosis. 

Hysteria  in  Early  Life. —In  PediatrUs  of  August 
1st  is  a  paper  of  much  interest  by  Dr.  Eshner  on  this 
important  subject.  Ideas  concerning  that  form  of 
neurosis  known  as  hysteria  have  undergone  a  revolu- 
tion, and  the  widespread  belief  that  women  alone  were 
subject  to  this  disease,  though  not  quite  e.^tinct  in  the 
minds  of  some,  has  by  the  great  majority  been  rele- 
gated to  the  limbo  of  the  past.  The  French  school, 
and  especially  Charcot,  must  be  thanked  for  our  im- 
proved knowledge  of  h.ysteria,  and  i".  may  now  be  said 
to  be  a  well-recognized  fact  that  hysteria  may  attack 
men  and  e\en  quite  young  children.  When  it  occurs 
in  infants  the  cause  is,  according  to  the  English  school, 
due  to  hereditary  neurosis.  Hysterical  affections  ar.e 
often  found  at  an  early  age  in  children  of  a  neurotic 
predisposition.  Clouston  says  in  hysterical  cases  oc- 
curring in  children  there  is  no  doubt  "  a  pathologically 
premature  development  of  the  emotional  brain  centres 
due  to  bad  heredity,  and  this  is  sometimes  accompanied 
by  a  premature  .sexual  development."  Dr.  Eshner  says 
that  the  disorder  has  a  pathology  of  its  own.  as  he  be- 
■  lieves  the  results  of  future  investigations  will  demon- 


strate; but  as  yet  we  need  more  knowledge,  especially 
in  the  domain  of  physiological  and  pathological  chem- 
istrj',  before  we  may  hope  for  a  solution  of  this  aspect 
of  the  problem  Dr.  Eshner  reports  eight  cases  in  his 
paper,  which,  although  not  all  quite  typical,  possess 
instructive  features. 

Radiant  Heat  in  Ulcers  of  the  Leg Dr.  CoUe- 

\  ille  describes  in  the  London  Lancet,  May  29,  1897,  a 
simple  way  of  treating  ulcers  of  the  leg  by  heat  with- 
out any  verj-  elaborate  apparatus.  A  square  plate  of 
metal  that  will  stand  heating  and  a  Bunsen  burner  are 
all  that  is  required.  The  metal  is  brought  to  a  dull 
red  heat  by  the  burner  and  the  ulcer  is  exposed  to 
this  heat  at  a  distance  of  about  ten  inches,  the  remain- 
der of  the  limb  being  protected  by  a  bandage.  The 
temperature  is  about  45  C,  which  is  easily  borne  and 
the  burner  is  regulated  to  maintain  the  heat  at  just 
this  point  during  the  whole  of  the  sitting,  which  lasts 
from  twenty  minutes  to  an  hour.  This  glazes  the  sur- 
face, and  large  granulations  are  visible  through  the 
thin  semitransparent  coating.  It  is  best  to  leave  the 
ulcer  exposed  to  the  air  for  some  time  and  to  be  care- 
ful in  dressing  the  wound  not  to  touch  the  surface 
with  aseptic  gauze  or  other  materials  used.  Some 
improvement  is  generally  noticeable  after  the  first  sit- 
ting and  the  wound  is  cicatrized  after  from  five  to 
twent}--five  sittings  In  the  later  sittings,  when  the 
ulcer  is  almost  healed,  a  more  moderate  degree  of  heat 
may  be  used.  When  gas  is  not  available,  the  sun  or 
the  heat  of  a  fire  may  be  utilized.  The  beneficial 
effects  of  the  treatment  are  attributable  to  the  com- 
bined action  of  heat,  light,  and  ventilation. 

Two  Hundred  Cases  of  Serum  Diagnosis. — Dr 
Gasser  reports  in  La  Prcssi  Aledicalc,  June  26,  1897, 
that  he  has  had  occasion  to  use  the  serum  diagnosis 
of  Widal  in  two  hundred  cases.  In  each  of  these  the 
diagnosis  of  typhoid  fever  was  questionable  on  the 
first  day  of  clinical  observation.  He  has  constantly 
used  Widal's  extemporaneous  process  with  a  mixture 
of  one  to  ten.  In  one  hundred  and  twelve  of  the 
doubtful  cases  the  reaction  was  positive.  This  re- 
action took  place  in  one  case  on  the  third  day,  once 
on  the  fourth  day,  twelve  times  on  the  fifth  day,  and 
on  the  eighth  to  tenth  day  in  the  others;  that  is,  from 
the  time  that  the  patient  entered  the  hospital.  In  one 
case  the  reaction  did  not  take  place  until  the  twentieth 
day.  Dr.  Gasser  was  able  to  test  on  himself  the  dis- 
appearance of  the  agglutinative  power.  He  entered 
upon  his  convalescence  May  29,  1897,  and  October  ist 
his  serum  was  still  agglutinative,  but  it  was  no  longer 
so  on  November  ist.  He  has  tried  the  reaction  in  a 
large  number  of  cases  suspected  of  being  typhoid 
fever,  complicated  in  fifty-two  cases  w  ith  gastric  fever, 
in  thirty  with  continued  marsh  fever,  in  five  cases  w  ith 
phthisis,  in  one  with  generalized  subacute  tubercu- 
losis, and  in  two  with  true  pneumonia.  In  all  these 
cases  the  reaction  was  negative  save  in  the  two  pneu- 
monias. In  these  two  instances  the  measure  of  the 
agglutinative  power  was  not  known.  For  one  of  the 
cases  the  reaction  was  sought  by  the  slow^  process; 
the  clarification  of  the  tube  was  observed  after  boiling 
a  mixture  of  one  part  of  serum  to  twenty  parts  of 
bouillon.  Perhaps  these  two  patients  had  been  under 
tiie  influence  of  a  frustrated  typhoid  infection.  One 
of  them  lived  in  a  locality  that  had  furnished  a  certain 
number  of  typhoid  cases,  the  other  had  suffered  from 
diarrhcea  for  a  short  time  before  entering  the  hospital. 
In  a  large  number  of  cases  examined  the  diagnosis 
was  difficult  and  doubtful,  and  the  reaction  of  Widal 
has  proven  a  very  useful  guide. 

Intestinal  Antisepsis. — Dr.  Heinrich  Stein  (Cen- 
tralhlatt  fin  die  i^esammfe  Thcrapie,  1896,  vi.,  321) 
enumerates  the  various  agents  bv  means  of  which  in- 


556 


mp:dical  record. 


[October  16,   1897 


testinal  antisepsis  can  be  obtained.  In  abnormal 
acidity  he  recommends  calcium  carbonate  (two  and 
one-half  drachms  per  day  in  one-grain  doses)  or  mag- 
nesia (ninety  grains  per  day).  Creosote,  guaiacol, 
and  resorcin  are  useful ;  their  action  is  shorter  but 
they  may  act  after  absorption  on  distant  areas.  Men- 
thol (one  and  one-half  grains  twice  or  thrice  daily), 
naphthalin  (one  and  one-half  to  seven  grains  at  a 
dose  or  seventy-five  grains  per  day),  thymol  (one  and 
one-half  grains  several  times  daily  in  alcoholic  solu- 
tion);  this  latter  is  an  excellent  parasiticide.  Since 
absorption  limits  the  action  of  the  drug  in  the  intes- 
tine various  antiseptics  have  been  prescribed  with  in- 
soluble substances,  salol,  parachlorsalol,  kresosalol, 
beta-naphtholsalol,  or  betol,  the  latter  being  slightly 
poisonous.  These  are  broken  up  in  the  intestine  by 
the  action  of  the  pancreatic  juice  and  by  unformed 
intestinal  ferments  into  salicylic  acid  and  kresol,  etc. 
Other  substances  proper  for  this  purpose  are  benzo- 
naphthol,  ammonium  sulpho-ichthyolate,  salophen, 
etc.  The  absolutely  insoluble  antimicrobic  remedies 
can  be  given  in  much  larger  doses;  such  are  phenol- 
bismuth  (fifteen  to  forty-five  grains  per  day),  the  same 
dose  for  kresol-bismuth,  chlorophenol-bismuth,  bis- 
muth salicylate,  zinc  salicylate,  trioxymethylen.  For 
irrigation  solutions  of  salicylic  acid  in  sterilized  water 
(one  to  two  parts  per  thousand),  silver  nitrate  (two- 
tenths  to  iive-tenths  per  thousand),  boric  acid  (five- 
tenths  per  hundred),  creolin  (one  one-hundredth  to 
two  one-hundredths  per  hundred),  tannin  (two  to  five 
per  hundred).  Applications  of  an  insoluble  antiseptic 
powder,  as  afforded  by  the  bismuth  preparations,  may 
be  used  during  irrigation. 

Treatment  of  Erysipelas. — Dr.  H.  Roster  ('J'/iera- 
pcutische  MonatsIn'fti\  i8g6,  vi.,  299)  states  that  paint- 
ing the  affected  parts  twice  daily  with  vaseline  and 
covering  the  application  with  linen  and  fastening 
with  a  gauze  bandage  has  given  good  results.  In 
addition  to  this  the  treatment  is  purely  symptomatic- 
for  headache,  acetanilid  orantipyrin;  if  the  temper- 
ature is  above  104  F.,  quinine  in  seven-grain  doses; 
if  cerebral  symptoms  are  present,  ice  bag  to  the  head, 
and  a  cathartic  such  as  calomel  or  senna;  foi  delir- 
ium, chloral;  for  heart  weakness,  digitalis  and  alco- 
hol. One  hundred  and  thirty  patients  treated  in  this 
way  Show  results  equally  as  good  as  those  obtained  by 
other  methods.  The  duration  of  the  fever  is  the  same 
as  when  lead  lotion,  painting  with  iodine,  ichthyol-vas- 
eline,  or  sublimate-lanolin  are  resorted  to.  By  this 
method  extension  of  the  process  takes  place  about  as 
frequently  as  when  other  methods  are  used.  Coinpli- 
cations  by  phlegmonous  processes  are  no  more  fre- 
quent in  this  method,  which  presents  no  danger  of  ex- 
citing untoward  symptoms,  such  as  burning  or  poison- 
ing, and  it  possesses  the  additional  advantage  of  being 
inexpensive. 

Abscess  of  the  Liver  Six  Years  after  Tropical 
Dysentery — At  a  recent  meeting  of  the  Acadcmie  de 
Medecine,  Eerger  yGasc-tte  licbdomadaiie  de  Medicine  e/ 
dc  Cliinirgic,  July  18,  1897)  related  the  history  of  a 
man  who  had  sulTered  from  dysentery  in  Tonquin  six 
years  previously,  in  association  with  congestion  of  the 
liver.  The  latter  yielded  to  the  application  of  a 
blister.  On  returning  to  I'rance  at  the  end  of  six 
months  he  was  again  seized  with  dysentery,  which 
lasted  for  three  years.  In  the  sequence  of  an  attack 
of  influenza  six  months  before  he  came  under  observa- 
tion, acute  pain  appeared  in  the  hepatic  region  fol- 
lowed liy  lumefaction  in  the  right  hypociiondrium. 
At  the  same  lime  there  were  loss  of  appetite  and  ema- 
ciation, though  but  little  fever.  The  upper  limit  of 
hepatic  percussion  dulness  reached  to  the  level  of 
the  third   rib.      A  diagnosis   of  abscess  uf  the   liver 


was  made  and  evacuation  proposed,  but  the  accumula- 
tion ruptured  into  the  lung  and  was  being  gradually 
expectorated.  Tiie  patient,  however,  continued  "to  fail 
and  it  was  decided  to  attack  the  abscess  directly.  In 
accordance  with  the  evidence  yielded  by  physical  ex- 
ploration, ten  centimetres  of  the  seventh  and  eighth 
ribs  was  resected,  the  seventh  intercostal  space  and  the 
diaphragm  were  incised,  and  a  large  abscess  in  the  liver 
was  disclosed.  This  was  drained  and  tamponed.  The 
expectoration  at  once  subsided,  the  cavity  gradually 
diminished  in  size,  and  in  the  course  of  a  month  and  a 
half  the  patient  was  restored  to  health. 

Percussion  of   the  Spleen Dr.  Baumler   {  Wiener 

klin.  IVoe/iense/iriJt,  1896,  No.  40,  p.  909)  thinks  that 
we  can  ascertain  the  size  of  the  spleen  by  percussion 
better  than  by  palpation,  as  is  usually  done.  He  holds 
that  a  large  spleen  can  rarely  be  detected  by  palpation 
even  when  there  is  no  tympanites,  while  even  moderate 
enlargement  can  be  made  out  by  percussion.  He  says 
that  dulness  in  an  oval  area  seven  to  eight  by  ten  cen- 
timetres indicates  enlargement.  It  is  important  to 
percuss  with  diiferent  degrees  of  force  in  different 
parts  in  order  to  avoid  the  difficulty  caused  by  the 
position  of  the  thin  spleen  between  organs  of  different 
degrees  of  resonance.  Dr.  Baumler  holds  that  even 
the  posterior  and  upper  parts  of  the  spleen  can  be 
made  out.  Usually  the  diagonal  position  of  the  pa- 
tient is  best,  but  sometimes  it  is  well  to  try  various 
positions.  Dr.  von  Ziemssen  agrees  in  general  with 
Dr.  Baumler,  and  urges  the  desirability  of  marking  out 
and  measuring  the  area  of  dulness. 

Wine  and  Cirrhosis. — M.  Lancereaux,  who  is  one  of 
the  greatest  living  authorities  on  the  action  of  alco- 
hol, has  lately  given  his  opinion  with  regard  to  the 
true  cause  of  drinkers'  cirrhosis.  His  conclusions  are 
deduced  from  personal  observations  of  two  hundred 
and  ten  persons  addicted  to  drink  in  Paris.  M.  Lan- 
cereaux disputes  the  statement  that  the  usual  cause  of 
cirrhosis  is  the  consumption  of  an  excess  of  alcohol, 
but  says  that  it  is  due  to  drinking  large  quantities  of 
wine,  and  especially  of  red  wine.  He  lays  the  blame 
upon  the  potassium  salts,  and  gives  tiie  result  of  cer- 
tain experiments  made  upon  animals.  By  means  of 
these  experiments  it  was  proved  that  potassium  salts 
when  administered  to  animals  usually  killed  in  from 
fifteen  to  eighteen  months,  and  cirrhosis  was  discovered 
in  the  majority  of  them.  M.  Lancereaux  demonstrated 
by  other  experiments  tlie  fact  that  alcohol  taken  in 
excess  produced  fatty  degeneration  of  the  hepiitic  cells 
and  subsequently  fatty  cirrhosis.  The  final  conclu- 
sions arrived  at  from  this  series  of  experiments  were 
that  wine,  and  plastered  wine  in  particular,  is  the 
cause  of  atrophic  cirrhosis. 

The  Treatment  of  Chronic  Articular  Rheumatism. 

—  Dr.  Ott,  in  liis  address  before  the  ("lerman  Congress 
of  Internal  Medicine,  June  9-12,  1897,  recommended 
woollen  clothing  and  especial  attention  to  the  diet, 
with  meat  as  a  foundation,  together  with  eggs,  fish, 
vegetables,  butter,  and  cheese:  especially  milk. 
Water  is  the  best  beverage;  alcohol  and  the  carbohy- 
drates should  be  much  restricted,  moral  depression 
avoided;  a  journey  may  be  found  beneficial  in  some 
cases.  Treatment  should  be  prompt  and  meet  every 
stage  of  the  disease,  which  should  be  carefully  watched 
even  long  after  convalescence,  .\cute  symptoms  must 
be  surmounted  by  every  possible  means — fever,  by 
repose  in  bed  and  restricted  diet:  local  pains  and 
swellings,  by  Priesnitz  compresses,  liniments,  or  salves 
containing  opiates,  or  by  injections  of  morjihine.  Ab- 
sorption is  hastened  by  painting  with  iodine.  Punc- 
ture is  useful  in  severe  swellings;  so,  too.  the  elastic 
bandage.  Some  observers  find  salol  beneficial ;  others 
prefer  antipyrin,  acetanilid,  piienacelin,  etc.      U'hen 


i 


October  i6,  1897] 


MEDICAL    RECORD. 


557 


there  is  swelling  of  the  joints  without  much  loss  of 
mobility  or  dislocation  of  the  ends  of  the  bones,  exter- 
nal treatment  is  indicated,  such  as  will  favor  absorp- 
tion. Tincture  of  iodine  and  ichthyol  are  sometimes 
successfully  employed.  Baths  should  be  recommended 
when  there  is  no  acute  or  subacute  intlammation,  but 
should  be  suspended  as  soon  as  inflammatory  symp- 
toms reappear.  In  all  baths  the  main  point  is  heat. 
This  can  be  attained  by  the  new  partial  steam  and 
hot-air  baths;  mud  baths  produce  a  mechanical  stim- 
ulation of  the  surface  beside  the  effect  of  heat,  and 
hot  mud  compresses  have  been  found  useful  in  weak 
patients.  The  simple  hot  springs  have  been  found 
useful  for  persons  of  great  nervous  excitability.  The 
success  of  sulphur  baths  is  probably  due  to  the  heat. 
The  speaker  also  recommended  hydriatic  processes 
which  combine  hot  and  cold  baths,  to  tone  up  a  system 
debilitated  by  the  effects  of  heat.  In  the  raw  seasons 
it  is  better  to  resort  at  once  to  the  hydriatic  process. 
He  also  recommends  active  and  passive  movements. 
The  most  favorable  climate  for  persons  affected  with 
polyarthritis  deformans  should  be  warm,  drj-,  and  shel- 
tered from  winds,  with  hot  springs  convenient.  Bat- 
taglia  and  Ischia  in  Italy,  and  Algiers,  fulfil  these 
conditions.  Medication  should  aim  to  strengthen  and 
tone  up  the  system.  Iron,  quinine,  and  cod-liver  oil 
are  indicated.  Singer  has  cured  one  case  of  typical 
acute  rheumatism  with  intravenous  injections  of  sub 
limate. 

Goat's  Milk  as  a  Food  for  Children. — Since  the 
observations  of  Schwatz  have  been  published,  consid- 
erable interest  has  been  taken  in  the  spread  of  tuber- 
culosis by  the  use  of  cow's  milk,  and  as  a  remedy  it 
was  proposed  that  all  such  foods  should  be  boiled  be- 
fore being  used  by  the  infant.  Since  that  dictum  was 
promulgated,  further  chemical  analysis  of  boiled  milk 
has  shown  that  the  nutrition  of  the  fluid  is  greatly  re- 
duced. Keer  has  demonstrated  that  fresh  unboiled 
cow's  milk  contains  fat  globules  with  granular  con- 
tents, which  are  immediately  taken  into  the  blood  to 
build  up  the  cellular  structure,  while  cooking  totally 
destroys  this  constituent;  the  fluid  albuminoid  constit- 
uent is  also  so  much  transformed  that  it  is  difficult  to 
dissolve  and  assimilate  in  the  alimentary  canal.  He 
is  persuaded  that  milk  should  not  be  boiled  when 
its  nutritious  value  is  required,  and  he  therefore  pro- 
poses the  milk  of  goats  for  the  feeding  of  children, 
as  this  animal  is  immune  from  tuberculosis.  He  fur- 
ther proposes  the  precaution  of  having  the  vessels 
containing  the  milk  sterilized  and  covered  to  prevent 
aerial  germs  from  infecting  the  food.  Anotiier  ad- 
vantage in  the  goat's  milk  is  the  constancy  of  its  con- 
stituents, owing  to  the  animal  carefully  selecting  its 
own  food  and  avoiding  a  great  quantity  of  fluid  matter. 
It  can  be  fed  in  the  stall  with  the  same  ease  and  satis- 
faction as  the  cow. —  Vienna  Cor.  Med.  Press  and  Cir- 
cular. 

To  Combat  Syphilis Dr.  Chistiakov,  of  St.  Peters- 
burg, in  a  paper  on  the  prophylaxis  and  therapy  of 
syphilis,  says  that  treatment  should  be  both  specific 
and  general.  Results  are  the  best  when  the  case 
comes  under  observation  early.  Treatment  should  be 
persisted  in  after  the  symptoms  have  disappeared  in 
order  to  prevent  their  return.  During  a  relapse  we 
must  return  to  specific  treatment.  In  regard  to  the 
dilTerent  processes  of  administering  mercury,  and  their 
relative  value,  he  says  that  when  mercury  is  given  by 
the  mouth  its  absorption  is  very  slow  and  the  result 
mediocre.  When  friction  is  resorted  to,  the  mercury 
is  sometimes  absorbed  in  too  small  a  quantity  and 
sometimes  in  too  large  an  amount,  consequently  the 
results  are  uncertain.  When  injections  are  used,  ab- 
sorption takes  place  with  more  regularity,  and  the  re- 
sults are  more  definite.      Experiments  have  convinced 


the  author  that  the  best  method  of  administering  mer- 
cury is  that  which  can  be  varied  according  to  the  pe- 
riod of  the  disease  and  the  condition  of  the  patient. 
All  methods  have  their  inconveniences.  The  intro- 
duction of  mercury  by  the  digestive  tract  may  cause 
gastro-intestinal  trouble,  friction  may  poison  those 
about  the  patient,  and  injections  may  produce  serious 
local  affections.  Hence,  we  should  avoid  giving  mer- 
cury by  the  mouth  when  there  is  gastro-inlestinal 
trouble,  and  avoid  friction  when  the  skin  is  disposed 
to  erythematous  eruptions,  and  avoid  subcutaneous  in- 
jections in  ner\-ous  individuals  and  in  children.  Fric- 
tions to  succeed  must  be  carefully  carried  out  and  in- 
jections must  be  frequently  repeated  Intramuscular 
injections  of  salicylate  of  mercury  in  suspension  in  oil 
or  sterilized  vaseline  are  one  of  the  best  means  of  ad- 
ministering mercury,  the  dose  used  being  one  to 
one  and  one-third  grain  every  third,  fifth,  and  seventh 
day  for  the  first  injections.  U"e  must  not  forget  that 
specific  treatment  predisposes  to  certain  affections, 
such  as  stomatitis,  gastro-enteritis,  anamia.  etc.  Often 
these  dejaend  on  causes  outside  the  treatment  and  pro- 
duce a  temporary  intolerance  for  specific  treatment. 
It  is  necessary  to  eliminate  the  cause  and  accustom 
the  system  to  specific  medicines.  Iodide  of  potassium 
is  an  excellent  therapeutical  agent  in  the  secondary 
and  tertiary  stages,  but  to  prevent  relapses  it  is  neces- 
sary to  combine  it  with  mercury.  All  means  that 
tend  to  strengthen  the  organism  should  be  employed 
concurrently  with  the  specific  treatment.  Transform 
the  pathological  condition  of  the  patient,  give  him 
strength  enough  to  withstand  new  manifestations  of 
syphilis  in  the  intervals  of  treatment  and  care  for  him 
as  a  convalescent.  A  syphilitic  may  marry  after  five 
years  without  infecting  his  wife  and  producing  syph- 
ilitic children.  This  term  may  sometimes  be  short- 
ened to  three  years  if  the  patient  has  been  well  cared 
for  and  during  the  second  and  third  years  has  had  no 
secondary  or  tertiary  manifestations,  and  if  he  adopts 
preventive  treatment  before  as  well  as  after  marriage. 
To  diminish  the  influence  of  syphilis  on  posterity, 
specific  treatment  is  recommended  during  pregnancy 
when  there  are  any  symptoms  of  the  disease  in  the 
pregnant  woman ;  when  the  woman  becomes  pregnant 
during  the  first  five  years  of  her  disease  ;  and  when  signs 
of  syphilis  were  observed  in  her  last  pregnancy;  when 
there  existed  secondary  manifestations  in  her  husband 
at  the  time  of  conception. 

A  Contribution  to  the  Knowledge  of  the  Anat- 
omy of  the  Levator  Ani  Muscle. — Dr.  William  W. 
Browning,  of  Brooklyn,  concludes  a  paper  {Medical 
Neios,  June  12th')  with  the  following  propositions:  i. 
That  in  the  human  subject  it  belongs  to  the  class  of 
rudimentary  muscles.  2.  That  the  weakness  of  its 
origin  as  well  as  the  direction  and  the  insertion  of  its 
fibres  is  consistent  with  such  design.  3.  That  it  is 
unphysiologic  for  a  muscle  to  furnish  a  continuous 
support.  4.  That  the  recto-vesical  fascia  is  in  itself 
sufficient,  when  intact,  to  afford  the  required  support. 
5.  That  the  muscle  is  no  better  developed  in  the  female 
(in  whom  support  is  most  required)  than  in  the  male. 

Abductor  Paralysis  in  Stricture  of  (Esophagus. 
— In  a  recent  issue  of  The  hospital  some  practical 
observations  are  made  by  Drs.  Feli.x  Semon  and 
Savery  in  commenting  on  a  case  of  bilateral  paraly- 
sis of  the  abductors,  due  to  malignant  stricture  of 
the  cesophagus.  While  more  or  less  incomplete  pa- 
ralysis of  both  these  nerves  is  of  not  infrequent 
occurrence,  complete  bilateral  paralysis  is  rarely 
met  with,  owing  to  the  fact  that  death  almost 
always  occurs  before  the  lesion  has  caused  the  pa- 
ralysis to  be  complete.  The  case  observed  teaches 
that,  in  addition  to  complete  aphonia  and  dyspniea, 


558 


MEDICAL    RECORD. 


[October  i6,  1897 


the  latter  on  exertion  only,  another  important  symp- 
tom may  result  from  the  complete  paralysis,  viz.,  the 
impossibility  of  taking  nourishment  in  the  ordinary 
erect  position.  The  explanation  is  that  when  both 
recurrents  are  paralyzed  the  closure  of  the  glottis  is 
impossible,  and  food  and  drink  are  therefore  apt  to 
pass  into  the  larynx.  But  the  mucous  membrane  of 
the  larynx  is  supplied  by  the  internal  branch  of  the 
superior  laryngeal  nerve;  hence  .sensation  is  not  af- 
fected, and  cough  ensues  when  the  food  particles 
enter  the  larynx.  The  position  recommended  by  Wol- 
fenden  for  cases  of  painful  dysphagia  was  found  to  be 
successful,  viz.,  horizontal  position  on  the  side,  with 
the  head  well  over  the  edge  of  the  bed;  fluid  nour- 
ishment is  to  be  taken  through  a  feeding-cup  inserted 
into  the  lower  angle  of  the  mouth,  ^^'hen  taken  in 
this  position  the  fluid  passes,  not  over,  but  by  the  side 
of  the  larynx  through  the  hyoid  fossa,  and  penetrates 
into  the  oisophagus  without  coming  in  contact  with 
the  posterior  surface  of  the  larynx. 

The  Indigestion  of  Breast-Fed  Babies — It'is  stated 
in  the  Airhirrs  of  Pediiitrus  tliat  for  many  reasons  less 
attention  has  been  paid  to  tlie  gastro-intestinal  affec- 
tions met  with  in  breast  Isabies  than  in  those  nursed 
artificially.  Breast  milk  is  the  natural  and  ought  to 
be  the  sole  food  of  the  infant,  under  physiological 
conditions,  during  the  first  year  of  life.  Unfortunately 
there  is  too  often  a  departure  from  the  normal  state, 
and  the  child,  perhaps  also  the  mother,  may  suffer 
during  the  lactating  period.  The  natura'  pride  and 
instinct  of  the  mother  are  apt  to  lead  to  the  presump- 
tion that  all  is  going  well  with  her  and  the  infant, 
when  in  reality  she  is  not  a  good  nurse,  and  the 
child  is  suffering  more  or  less.  In  America  the 
question  of  infant-feeding  in  all  its  aspects  has  re- 
ceived the  attention  which  it  deserves,  and  which 
it  has  not  met  with  in  England.  The  greatei 
prevalence  of  diarrhceal  disease  during  the  tropical 
summer  of  the  American  continent  has  stimulated 
study  and  research  on  this  important  subject.  Milk 
laboratories  ha\-e  been  established  in  the  larger  cities, 
and  the  feeding  of  infants  has  been  placed  on  a 
comparatively  sure  and  scientific  footing.  Owing  to 
the  researches  of  such  men  as  Jacobi,  Rotch,  Holt, 
Lewis  Smith,  Meigs,  and  others,  we  are  now  furnished 
with  scientific  data  to  guide  us  in  the  study  of  the 
subject.  In  the  writer's  own  country  the  question  of 
milk  supply  is  now  receiving  some  attention  from 
sanitaiians,  but  there  is  as  yet  no  ready  means  avail- 
able to  the  general  public  of  obtaining  pure  or  prop- 
erly sterilized  milk  in  quantity,  nor  of  having  milk 
analyzed  ot  tested  in  laboratories  established  for  the 
purpose.  Whenever  the  milk  of  tlie  mother  is  defec- 
tive in  quantity  or  quality,  the  child  is  apt  to  suffer. 
It  does  not  thrive  or  grow  at  the  normal  rate.  Instead 
of  being  plump  and  firm  and  happy,  it  is  soft  and 
flabby,  and  is  always  crying,  and  never  appears  to  be 
satisfied.  Its  skin  is  harsh  and  dry.  'I'he  tongue  is 
somewhat  red,  often  slightly  furred.  Vomiting  from 
gastric  catarrh  is  not  infrequent.  The  stools  are  un- 
natural, and  present  various  appearances  depending 
on  the  quality  of  the  milk.  They  are  generally  loose, 
and  seldom  have  the  natural  mustard  color  or  consist- 
ence, but  are  usually  pale,  and  often  of  an  ashy  grav 
color,  sometimes  greenish,  or  mixed  gray  and  green. 
The  soft  curd  of  the  mother's  milk  is  present  undigested 
in  little  granular-looking  masses.  There  is  an  excess 
of  mucous  secretion,  sometimes  there  are  little  streaks 
of  blood.  .\s  a  rule,  indigestion  of  mother's  milk  is 
more  frequently  intestinal  than  gastric,  diarrhcta  being 
more  common  than  vomiting.  This  appears  to  be 
largely  due  to  indigestion  of  the  fatty  and  proteid  ele- 
ments of  the  milk.  Infants,  in  regard  to  their  diges- 
tive capabilities,  are  but  little  men  and  women,  and  it 


is  certain  they  have  their  idiosyncrasies  likewise. 
The  milk  of  a  mother  seems  to  be  suited  to  her  own 
child  under  physiological  conditions.  Irregular  suck- 
ling is  one  of  the  commonest  causes  of  indigestion 
in  l^abies.  It  produces  a  milk-too  concentrated,  which 
inevitably  causes  indigestion  in  the  child.  Regula- 
tion of  the  suckling  is  generally  sufficient  to  give  re- 
lief. Irregular  suckling  may  be  due  to  two  principal 
causes.  It  may  occur  in  cases  in  which  the  milk  is 
normal  in  quantity  and  quality,  from  bad  habit  on  the 
part  of  the  mother  in  being  over  anxious  about  her 
child,  and  carelessly  giving  it  the  breast  at  irregular 
times  or  whenever  it  cries.  The  more  frequent  cause, 
however,  is  deficient  quantity  of  milk.  In  this  case 
the  child  is  unsatisfied  and  gets  the  breast  too  fre- 
quently in  consequence,  with  the  result  that  the  milk 
becomes  too  concentrated  and  causes  indigestion. 
The  remedy  is  the  addition  of  some  substitute  feed- 
ing. Inseparably  connected  with  the  question  of  ma- 
ternal feeding  is  the  no  less  important  one  of  the 
artificial  rearing  of  infants  who  are  unable  to  obtain 
breast  milk.  The  huge  mortality  of  infants  under  one 
year  is  hardly  reduced  to  a  lower  level  than  it  was 
half  a  century  ago,  when  in  England  and  Wales  no 
less  than  76,328  children  under  twelve  months  died, 
out  of  a  total  of  350,101  deaths  in  one  year.  Want  of 
breast  milk  and  bad  artificial  feeding  are  largely  re- 
sponsible for  this.  Surely  it  is  our  duty,  as  a  profes- 
sion, to  try  and  stem  this  tide  of  mortality.  There  is 
no  way  to  attain  this  end  but  by  education:  and  let 
us  hope  in  the  near  future  that  we  will  be  in  a  better 
position  in  this  respect,  and  have  greater  facilities  for 
showing  good  results  in  what,  ifmust  be  admitted,  is 
an  important  branch  of  preventive  medicine,  too  much 
neglected. 

Postpuerperal  Endocarditis  of  the  Left  Heart  Prop- 
agated to  the  Right  Heart  by  Perforation  of  the 
Septum, — An  interesting  observation  by  Dr.  Charrin 
is  found  in  the  columns  of  the  Alihoaiikee  Medical  Jour- 
nal, as  follows;  The  patient,  a  woman  of  twenty-three 
years,  was  taken  three  weeks  after  confinement  with 
intense  headache,  anorexia,  severe  lumbar  and  epigas- 
tric pains,  palpitation,  swelling  of  the  face  and  eye- 
lids, and  oedema  of  the  extremities.  When  she  entered 
the  hospital,  the  face  was  pale,  there  was  considerable 
weakness .  and  she  had  some  metrorrhagia.  The  re- 
spiratory apparatus  presented  a  few  rales  of  congestion 
at  the  bases.  Tlie  intense  dyspna-a  was  evidently 
caused  by  a  cardiac  lesion.  .\t  the  apex  was  heard  an 
intense  souffle  and  from  time  to  time  a  systolic //i; ///<•- 
iiu'iit.  On  the  following  days  appeared  a  go-and-come 
bruit  at  the  middle  part  of  the  heart;  at  the  apex  there 
was  an  almost  metallic  resonance;  there  was  no  />(■- 
missi»u-iit.  The  dyspncea  increased,  and  during  the 
evening  the  patient  expectorated  ha-moptoic  sputa. 
Delirium  supervened  and  the  patient  died  during  the 
night.  .Vutopsy  ;  Blood  from  the  heart  sown  on  dilTer- 
ent  media  remained  sterile.  The  endocardiac  vegeta- 
tions alone  gave  cultures  of  staphylococcus  aureus.  The 
right  ventricle  contained  a  fibrinous  clot.  The  aortic 
sigmoid  valves  presented  vegetations  which  completely 
deformed  them ;  tiiese  vegetations  were  ulcerated,  the 
valves  perforated.  There  was  no  valvular  aneurism. 
At  the  site  of  one  of  the  valves  existed  a  perforation 
of  the  interventricular  septum,  establishing  a  com- 
munication between  the  two  ventricles.  On  the  upper 
surface  of  the  left  leaflet  of  the  tricuspid  valves  ex- 
isted a  pediculated  polypoid  vegetation  at  whose 
base  opened  the  interventricular  fistulous  tract.  There 
was  nothing  on  the  mitral  \alve.  .Vt  the  apex  of 
the  left  lung  was  an  infarct,  black  in  color  and  of  the 
size  of  a  small  apple.  The  right  lung  was  cedematous 
but  still  crepitating:  at  the  base  of  the  lower  lobe 
existed  a   large  infarct,      in  a   pulmonary  vein,  at  this 


October  i6,  1897] 


mp:dicai.  rfxord. 


559 


level,  the  clots  were  almost  puriform.  The  uterine 
mucosa  was  red,  the  cavity  dilated ;  and  there  was 
thrombosis  of  the  uterine  veins  without  true  suppura- 
tion. The  most  interesting  revelation  was  the  commu- 
nication of  the  two  ventricles  by  ulceration  of  the  septum 
and  the  probable  propagation  by  that  way  to  the  tricus- 
pid. The  lesions,  already  remote  at  the  time  of  au- 
topsy, were  probably  produced  shortly  after  labor,  re- 
maining latent  for  some  time.  This  communication, 
produced  at  the  site  of  congenital  lesions,  permits  us 
to  suppose  that  in  the  latter  the  mechanism  may  have 
been  also  an  endocarditis. 

Latent  Ulcer  of  the  Stomach. — In  a  late  number 
of  Health  an  account  is  given  of  a  remarkable  case  of 
latent  ulcer  of  the  stomach,  which  came  under  M.  Dieu 
lafoy's  observation.  The  first  symptom  which  mani- 
fested itself  was  perforation ,  there  had  been  no  pre- 
vious gastric  symptom.s,  no  dyspeptic  troubles,  and  no 
vomiting  of  blood.  The  patient  was  a  young  woman 
who  was  apparently  in  good  health,  although  about 
two  months  before  she  had  complained  of  pain  in  the 
stomach,  to  which,  however,  she  did  not  attach  much 
importance.  Her  appetite  was  good  and  she  never 
complained  of  indigestion,  and  on  the  day  that  per- 
foration took  place  she  performedsher  usual  work  and 
appeared  to  be  perfectly  well.  Shortly  after  dinner 
she  was  suddenly  seized  with  a  horrible  pain  in  the 
epigastric  region,  and  a  physician  was  called.  But 
he  could  not  make  an  e.xact  diagnosis,  and,  thinking 
that  it  might  be  a  case  of  hysteria,  prescribed  an 
enema  containing  laudanum.  On  the  following  day 
M.  Dieulafoy  saw  the  patient.  The  pain  was  then 
somewhat  mitigated,  but  it  extended  over  the  entire 
abdomen;  the  abdominal  wall  was  tense  rather  than 
swollen,  and  the  slightest  touch  or  pressure  over  the 
abdomen  was  intolerable.  The  pulse  was  frequent, 
but  the  general  condition  was  rather  good:  the  e.x- 
pression  of  the  tace  was  not  anxious,  there  were  no 
peritoneal  facies,  no  hiccough,  and  no  vomiting. 
However,  M.  Dieulafoy  gave  a  diagnosis  of  general- 
ized peritonitis,  and  the  patient  was  immediately 
taken  to  the  hospital,  where  an  operation  was  per 
formed.  At  the  time  of  her  admission  the  temperature 
was  101.6'  F  ,  and  the  pulse  120.  The  abdomen  was 
swollen  and  tense.  Median  subumbilical  laparotomy 
was  practised,  and  when  the  abdomen  was  opened  a 
stream  of  yellowish  liquid  escaped.  The  intestines 
appeared  to  oe  congested,  and  their  surface  presented 
creamy-like  false  membranes  of  recent  formation.  The 
appendix  was  found  to  be  in  a  healthy  condition,  and 
the  genital  organs  were  not  involved;  the  seat  of  the 
peritoneal  lesion  was  evidently  the  upper  part  of  the 
abdomen.  During  the  exploration  the  patient's  gen- 
eral condition  became  so  aggravated  that  it  was  not 
thought  prudent  to  lengthen  the  incision  and  prolong 
the  operation ;  so  the  abdomen  was  closed  after  the 
peritoneum  had  been  subjected  to  lavage  with  boiled 
water.  The  patient  died  on  the  following  morning. 
.\t  the  autopsy  the  integrity  of  the  appendix  and  the 
genital  organs  was  verilied,  but  on  the  anterior  surface 
of  the  stomach,  at  a  distance  of  about  a  centimetre 
from  the  small  curvature,  and  at  an  equal  distance 
from  the  cardia  and  the  pylorus,  a  large  perforation 
was  found ;  it  was  of  about  the  size  of  a  florin,  and  its 
borders  were  not  thick,  there  were  no  surrounding 
jjeritoneal  changes.  On  the  posterior  surface  of  the 
stomach  there  were  some  adhesions  which  united  it 
with  the  pancreas;  these  adhesions  were  verj'  loose, 
and  were  easily  torn  away  with  the  finger.  They  sur- 
rounded a  second  perforation,  which  corresponded  ex- 
actly in  size,  shape,  and  situation  with  the  first  one. 
The  appearance  of  these  ulcers  resembled  the  classic 
type  of  simple  ulcer  of  the  stomach,  and  they  iiad  cer- 
tainly existed  a  long  time  before  perforation  occurred. 


It  is  incomprehensible,  says  M.  Dieulafoy,  how  an 
ulcer  which  was  serious  enough  to  cause  perforation 
could  have  remained  completely  indolent;  it  is  possi- 
ble, he  thinks,  that  symptoms  had  manifested  them- 
selves at  som.e  time,  and  that  they  had  been  forgotten 
by  the  patient  or  neglected  by  those  who  observed 
them.  M.  Dieulafoy  thinks  that  this  case  demon- 
strates that,  in  the  presence  of  a  sudden  attack  of 
peritonitis,  the  physician  should  not  attribute  it  only 
to  appendicitis,  salpingitis,  intestinal  perforation,  or 
perforations  of  the  biliary  tracts,  but  to  perforations 
of  the  stomach  as  well,  although  there  may  be  no  his- 
tory of  previous  gastric  troubles.  At  the  present  time, 
he  says,  when  surgical  intervention  in  peritonitis  is 
of  daily  occurrence,  an  early  and  correct  diagnosis 
may,  in  favorable  cases,  assure  the  recovery  of  the 
patient. 

The  Removal  of   Cancerous  Gall-Bladder Hei- 

denhain  has  recorded  the  case  of  a  woman,  aged  sixty- 
one,  who  during  nine  months  previous  to  admission  to 
hospital  had  suffered  from  pain  in  the  upper  part  of  the 
abdomen,  with  occasional  severe  exacerbations.  At 
this  time  the  liver  dulness  began  at  the  fifth  rib,  and 
did  not  extend  below  the  costal  margin  in  the  mam- 
mary line.  The  enlarged  gall  bladder  was  ver\-  dis- 
tinctly felt,  and  presented  an  uneven  surface,  attributed 
to  omental  adhesions.  The  abdomen  w  as  opened  by  an 
incision  along  the  outer  edge  of  the  right  rectus  mus- 
cle. Kxtensive  adhesions  had  to  be  separated.  The 
enlarged  gall  bladder  and  adjacent  part  of  the  liver 
were  drawn  out  of  the  wound.  The  liver  in  the  neigh- 
borhood ofthe  gall  bladder  was  grayish-white  in  color, 
which  was  attributed  to  interstitial  changes.  The 
walls  of  the  gall  bladder  were  much  thickened,  and 
gall  stones  were  easily  felt  inside  it.  An  incision 
into  the  wall  of  the  gall  bladder  showed  that  it  was 
the  seat  of  malignant  disease.  The  ca\  ity  of  the  gall 
bladder  was  according!)-  not  laid  open,  but  a  portion 
of  the  liver,  with  the  gall  bladder,  was  resected  by 
means  of  Paquelin's  cautery.  The  cut  edges  of  the 
liver,  as  well  as  its  general  surface  so  far  as  it  was 
open  to  exa.mination,  showed  no  evidence  of  malig 
nant  disease.  The  cystic  duct  was  ligatured  and 
divided  and  the  whole  removed.  The  patient  made  a 
good  recovery  from  the  operation,  and  was  discharged 
six  weeks  later.  There  was  a  stone  as  big  as  a  wal- 
nut in  the  gall  bladder,  and  eighty-four  smaller  stones 
of  the  size  of  a  pea  were  also  found.  The  mucous 
membrane  of  the  gall  bladder  showed  papillary  ex- 
crescences Microscopic  examination  of  the  liver 
substance  also  revealed  malignant  disease.  The  prog- 
nosis appeared  here  to  be  fairly  good,  as  the  growth 
seemed  to  be  limited  to  the  parts  removed.  Early 
diagnosis  of  carcinoma  of  the  gall  bladder  is  hardly 
possible,  and  the  case  is  usually  too  far  advanced  for 
operation  when  it  is  discovered.  Courvoisier,  in  one 
hundred  and  three  collected  cases  of  carcinoma  of  the 
gall  bladder,  found  gall  stones  in  seven-eighths  of  the 
cases.  The  more  it  is  recognized  that  long-continued 
gall-stone  disease  is  best  treated  by  operation,  the 
more  often  will  it  happen  that  carcinoma  of  the  gall 
bladder  will  be  capable  of  being  dealt  with. — Dctilsche 
medicinische  Wocheuschrift. 

The  Requisites  of  a  Pure  Water  Supply Krauss 

{Clevclaint  Journal  of  Mc-dicinc.  March,  1897)  says: 
I.  That  the  water  supply  of  any  city  or  village 
should  not  in  any  possible  way  be  liable  to  pollution 
or  contamination  from  the  sewage  of  any  other  com- 
munity. 2.  That  the  sewage  of  a  city  should  not  be 
emptied  into  any  watercourse  not  having  a  current  of 
three  to  five  miles  per  hour,  and  then  the  sewage  en- 
trance should  be  at  a  distance  of  one  mile  or  more 
from  the  intake.     3.   That  when  the  water  supply  of  any 


56o 


MEDICAL    RECORD. 


[October  i6,  1897 


city  or  village  is  a  navigable  stream,  the  water  should 
be  sand  filtered  before  being  pumped  into  the  reservoirs 
or  water  mains.  4.  That  for  ordinary  drinking-pur- 
poses  the  water  should  not  be  taken  in  its  primitive  or 
raw  state,  but  be  either  filtered,  boiltd,  or  distilled  and 
aerated.  5.  That  not  only  chemic  but  bacteriologic 
examinations  of  the  water  should  be  made,  at  least 
once  weekly,  to  determine  its  character  as  a  safe  or 
dangerous  water  for  domestic  use,  and  if  contamination 
is  shown  to  e.xist  the  services  of  an  engineer  should  be 
enlisted  to  detect  if  possible  the  cause  and  origin 
of  such  contamination. 

Chloroform  versus  Ether. — Gay  says  that  the  ac- 
cumulated testimony  of  the  past  fifty  years  tends  to 
prove  conclusively  that  ether  kills  slowly,  chloroform 
quickly;  that  ether  kills  by  asphyxia,  chloroform  by 
cardiac  paralysis,  that  ether  gives  plenty  of  warning, 
chloroform  often  none  whatever;  that  ether  is  safer  in 
healthy  and  strong  people  than  in  the  weak  and  pros- 
trated, but  that  chloroform  is  nearly  as  fatal  in  the 
vigorous  as  in  the  debilitated.  Ether  does  not  demand 
any  especial  skill  in  its  administration;  chloroform 
does.  Proper  treatment  easily  and  effectually  over- 
comes the  unfavorable  symptoms  from  ether;  treatment 
often  does  no  good  whatever  in  accidents  from  chloro- 
form. In  short,  ether  is  the  safest  general  anaesthetic 
known;  chloroform  is  not. — Boston  Medical  and  Sur- 
gical Journal. 

Chemical  Examination  of  Human  Breast  Milk — 
Adriance  {Pediatrics,  vol.  xiv.,  Xo.  21  sums  up  a  re- 
port upon  the  chemical  examination  of  two  hundred 
specimens  of  human  breast  milk,  as  follows:  1.  Exces- 
sive fats  or  proteids  may  cause  gastro-intestinal  symp- 
toms in  the  nursing  infant.  2.  Kxcessive  fats  may 
be  reduced  by  diminishing  the  nitrogenous  elements 
in  the  mother's  diet.  3.  Excessive  proteids  may  be  re- 
duced by  a  proper  amount  of  exercise.  4.  Excessive 
proteids  are  especially  apt  to  cause  gastro-intestinal 
symptoms  during  the  colostrum  period.  5.  The  pro- 
teids, being  higher  during  the  colostrum  period  of 
premature  confinement,  present  dangers  to  the  un- 
timely born  infant.  6.  Deterioration  in  human  milk 
is  marked  by  a  reduction  in  the  proteids  and  total  sol- 
ids, qr  in  the  proteids  alone.  7.  This  deterioration 
takes  place  normally  during  the  later  months  of  lacta- 
tion, and,  unless  proper  additions  are  made  to  the  in- 
fant's diet,  IS  accompanied  by  a  loss  of  weight  or,  again, 
is  below  the  normal  standard.  8.  When  this  deteri- 
oration occurs  earlier,  it  may  be  the  forerunner  of  the 
cessation  of  lactation,  or  well-directed  treatment  may 
improve  the  condition  of  the  milk. 

A  Study  of  Chlorosis.  —  Dr.  Simon  {^American 
Journal  of  the  Medical  Sciences,  .\pril)  concludes:  r.  .\n 
anatomical  basis  of  chlorosis  has  not  been  satisfacto- 
rily determined.  2.  A  perversion  of  the  appetite — 
excessive  consumption  of  starches  and  sugars — is  a 
common  symptom  of  chlorosis.  3.  The  development 
of  chlorosis  is  due  to  an  insufficient  consumption  of 
animal  proteids.  4.  Chlorosis  is  far  more  common 
than  is  generally  supposed,  and  occurs  in  both  sexes 
and  at  almost  all  ages.  5.  The  diagnosis  of  chlorosis 
should  be  based  altogether  upon  an  examination  of  the 
blood.  6.  The  term  chlorosis  should  be  discarded, 
and  "  simple  ana-mia'' substituted.  7.  Iron  is  not  a 
specific  in  the  trc:itment  of  chlorosis.  8.  In  tlie  treat- 
ment of  the  disease  attention  should  primarily  be  di- 
rected to  the  diet.  9.  In  cases  in  which  iron  fails 
satisfactory  results  may  be  obtained,  without  medi- 
cation, from  a  suitable  diet,  in  which  animal  proteids, 
bone  marrow,  and  dark  beer  are  the  principal  f.ictors. 
10.  The  beneficial  effects  of  bone  marrow  are  not  due 
to  the  amount  of  iron  which  it  contains. 


Epidemic  Mastitis. — The  Budapest  correspondent 
of  The  Lancet  cites  an  epidemic  of  mastitis,  occurring 
in  twelve  women,  in  all  of  whom  the  disease  developed 
during  the  first  week  following  childbirth.  In  none 
could  the  disease  be  traced  to  lesions  of  the  skin  cov- 
ering the  nipples  or  to  sores  in  the  mouths  of  the 
suckling  infants.  All  of  the  patients  had,  however, 
been  attended  by  the  same  midwife,  who  it  was  learned 
had  charge  of  an  infant  suffering  from  stomatitis,  and 
who  was  assumed  to  be  the  channel  of  infection.  The 
mastitis  ran  a  course  different  from  that  usually  ob- 
served. The  onset  was  marked  by  a  severe  rigor, 
which  was  soon  followed  by  hyperpyrexia,  swelling  of 
both  breasts,  and  rapid  formation  of  deep  abscesses. 
Incisions  liberated  a  quantit}'  of  thick  pus,  which  was 
found  to  contain  large  numbers  of  streptococci  and 
staphylococci.  The  healing  of  the  abscesses,  though 
appropriately  treated,  was  somewhat  protracted. 

Pregnancy  in  a  Rudimentary  Uterine  Horn,  with 
Rupture  and  Death,  Probable  Migration  of  Ovi:m 
and  Spermatozoid. — C'ulien  and  Wilkins  {Johns  Bop- 
kins  Hospital  Reports,  vol.  vi.,  1897)  have  reported  the 
case  of  a  married  woman,  twent}'-nine  years  old, 
who  had  previously  borne  a  child  and  died  in  the 
fourth  month  of  pregnancy  with  signs  of  hemorihage. 
Death  occurred  six  hours  after  rupture  of  the  foetal 
sac.  Upon  post-mortem  examination  the  abdominal 
cavity  was  found  to  contain  four  thousand  cubic  cen- 
timetres of  blood  and  a  fcetus  of  three  or  four  months' 
development.  The  uterus  consisted  of  a  well-devel- 
oped right  horn,  to  which  was  attached  by  a  muscular 
band  an  impregnated  left  rudimentary  horn.  The  lat- 
ter had  ruptured,  and  the  corpus  luteum  was  found  on 
the  side  opposite  to  that  of  the  pregnancy.  Micro- 
scopically the  right,  well-developed  uterus  was  shown 
to  possess  a  tj'pical  decidua,  and  the  right  tube  con- 
tained the  remains  of  the  placenta  lying  free  in  its 
cavit}'.  The  cells  of  the  corpus  luteum  resembled 
closely  normal  decidual  cells.  The  pedicle  joining 
the  two  horns  contained  a  canal  five  millimetres  in 
diameter,  lined  by  a  single  layer  of  cylindric  epithelial 
cells  resting  on  a  delicate  stroma,  external  to  which 
was  a  longitudinal  muscular  coat,  and  covering  this 
in  turn  a  coat  of  circular  muscular  fibres.  The  canal 
was  closed  at  both  ends,  and  there  was  no  communi- 
cation between  the  two  horns.  Migration  of  the 
ovum  and  spermatozoid  occurred  probably  by  way  of 
the  abdominal  cavity.  It  is  pointed  out  that  cases  of 
this  kind  are  rare,  rupture  usually  taking  place  be- 
tween the  fourth  and  fifth  months  and  the  patient  dy- 
ing with  signs  of  internal  hemorrhage.  Some,  how- 
ever, advance  to  term,  and  two  classes  can  be  estab- 
lished: (i)  those  attended  with  rupture;  (2)  those 
in  which  rupture  does  not  take  place.  Anatomically 
these  cases  dift'er  from  those  of  tubal  pregnancy,  in 
that  the  uterus  is  flexed  toward  the  side  opposite  to 
the  pregnancy,  in  that  the  pedicle  of  the  fcttal  sac 
springs  from  the  uterus  at  the  internal  os  instead  of 
where  the  tube  comes  off,  and  in  that  the  round  ligament 
springs  from  the  outer  side  of  the  sac  instead  of  from 
the  uterus.  Clinically  tiie  symptoms  of  tubal  preg- 
nancy and  of  pregnancy  in  a  rudimentar)-  uterine  licm 
when  rupture  has  taken  place  are  virtually  the  same. 
On  examination  of  the  uterus,  however,  the  sourd  re- 
veals that  in  the  latter  case  the  canal  is  flexed  at  the  in- 
ternal OS  and  the  uterus  deviates  to  the  side  away  from 
the  tumor.  The  pedicle  of  the  sac  commences  at  the 
internal  os  instead  of  at  the  uterine  cornu.  and  is  usu- 
ally of  sufficient  length  to  allow  free  mobility  of  the 
impregnated  rudimentan,-  horn.  The  treatment  con- 
sists in  amputation  of  tlie  impregnated  rudimentary 
horn.  Migration  of  the  ovum  and  spermatozoid  oc- 
curs frequently  when  the  impregnation  of  a  rudimen- 
tary uterine  horn  takes  place. 


October  i6,  1S97] 


MEDICAL    RECORD. 


561 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &.  CO.,  43,  45.  6.  47  East  Tenth  Street. 


New  York,  October  16,  1897. 


THE   CHARITY    ABUSE. 

With  the  commencement  of  the  college  terms  and 
with  the  necessaril}'  more  active  clinical  work  in  the 
metropolitan  hospitals  the  struggle  for  clinical  ma- 
terial will  be  proportionately  manifest.  Thus  it  is  to 
be  reasonably  expected  that  the  old  abuse  of  medical 
charit}-  will  boom  along  as  destructively  to  the  higher 
interests  of  the  profession  as  ever,  and  will  revive  the 
old  complaints  against  the  atrocious  unfairness  of  the 
entire  system.  It  is  some  comfort  to  know,  however, 
that  the  large  majorit}'  of  a  suffering  profession  is 
still  on  the  side  of  radical  reform,  and  has  not  yet 
lost  heart  in  its  efforts  to  right  a  most  grievous  and 
far-reaching  wrong. 

In  witness  of  this  indication  we  note  that  one  of  the 
papers  which  called  forth  a  verj-  extended  discussion 
at  the  meeting  of  the  State  Medical  Association  was 
upon  the  subject  named.  Dr.  Wiggin  certainly 
handled  the  abuse  of  charity  in  a  straightforward, 
sensible,  and  practical  way.  It  was  the  old  storj- 
retold,  but  it  always  bears  rehearsal  at  a  time  when 
the  young  practitioner  is  wearily  waiting  for  business 
and  weighing  his  chances  for  ordinary  success 
against  very  hea\-y  odds.  The  fight  against  the  ab- 
ominable evil  of  indiscriminate  medical  charit}'  is  now 
one  for  actual  existence  as  a  profession.  Think  of 
the  statistics  quoted  by  Dr.  Wiggin  from  Dr.  Stephen 
Smith's  report!  Either  we  are  living  in  an  age  of 
pauperism  or  else  charit}',  pure  and  simple,  is  an 
outrageous  lie!  \Vhat  answer  is  there  to  the  state- 
ment, founded  on  the  study  of  the  present  dispensary 
and  hospital  systems,  that  fully  forty-nine  per  cent,  of 
the  entire  population  of  Xew  York  are  virtually  un- 
willing to  pay  for  private  medical  attendance?  It  is 
not  difficult  to  explain  the  reason  for  this  when  we 
look  into  the  outrageous  methods  of  free  treatment  as 
carried  on  at  the  Vanderbilt  Clinic  for  all  classes  of 
pretended  paupers,  and  when  we  note  the  gross  wrongs 
connected  with  the  well-advertised  bids  for  pay  pa- 
tients at  the  Roosevelt  and  other  ostensibly  charitable 
institutions.  Even  the  Sloane  Maternity  levies  a 
mortgage  on  the  good  intentions  of  the  coming  mother 
by  offering  to  care  for  her  during  her  confinement,  for 
sums  var)-ing  from  fifteen  to  twent\'-five  dollars  for  her 
entire  term.  How  about  the  new  lying-in  hospital 
founded  by  a  multi-millionaire  for  so-called  charit)-. 


which  institution,  to  prove  its  reason  for  being,  must 
have  its  beds  filled  at  am-  cost  to  the  self-respect  of 
the  patient  or  the  ultimate  impoverishment  of  the 
doctor?  The  boards  of  managers  draw  the  line  be- 
tween the  propriety  and  impropriet)-  of  the  thing,  and 
the  profession  is  expected  gracefully  and  resignedly  to 
toe  the  mark.  But  we  still  maintain  that  there  may 
be  hope  for  us  yet. 

The  best  of  all  indications  is  that  the  public  in 
general  is  beginning  to  understand  the  true  situation 
of  affairs.  The  daily  press  and  the  pulpit  are  inclin- 
ing to  attack  the  questionable  motives  of  the  so-called 
Christian  philanthropists.  The  more  the  subject  is 
ventilated  the  better  will  it  be  for  the  real  truth.  It 
is  quite  true,  as  claimed  by  one  of  the  speakers  at  the 
meeting  in  question,  that  the  profession  is  verj-  much 
to  blame  for  tacitly  submitting  to  the  present  tactics 
of  charity.  The  only  way  to  reconcile  differences  in 
regard  to  mooted  points  of  responsibilit}-  between 
Managing  boards  and  medical  staffs  is  to  create  an 
authoritative  bureau  of  arbitration,  as  indorsed  by  the 
speaker  in  question  and  often  enough  advocated  be- 
fore. Dr.  Wiggin  covers  this  and  many  other  essen- 
tial points  in  his  summing  up  of  remedies.  In  fact, 
this  was  the  central  idea  of  the  bill  which  passed  the 
legislature  last  winter,  but  which  failed  to  become  a 
law  because  of  the  weak-kneed  condition  of  our  pres- 
ent governor,  who  was  persuaded  to  miss  the  opportu- 
nit)-  of  gaining  the  good  will  and  support  of  the  med- 
ical profession  by  listening  to  the  arguments  of  fno  or 
three  gentlemen  who  represented  merely  the  college 
interests  as  to  clinical  material.  But,  as  we  have  al- 
ready said,  the  profession  is  still  earnest  in  its  en- 
deavors to  right  the  monstrous  wrong  and  will  again 
be  heard  before  the  next  legislature,  college  or  no 
college,  governor  or  no  governor.  It  is  simply  a 
question  of  right  and  fair  play,  and  we  can  afford  to 
wait  and  have  still  courage  to  fight.  The  Medical 
Record  has  always  been  on  the  side  of  the  great  ma- 
jorit)- of  the  profession  in  this  matter,  and  is  more 
than  ever  determined  to  do  its  best  to  bring  this  bitter, 
burning  wrong  within  the  pale  of  candid  and  fearless 
discussion. 


THE    PROGRESS    OF    YELLOW    FEVER. 

The  epidemic  of  yellow  fever  in  the  South  begins  to 
show  signs  of  subsidence,  owing  no  doubt  to  the  fa- 
vorable weather  conditions  which  have  prevailed  dur- 
ing the  past  few  days  on  the  Gulf  coast.  The  daily 
mean  of  temperature  is  gradually  falling  and  the  course 
of  the  disease  is  apparently  checked  somewhat  by  the 
cooler  weather.  A  slight  frost  is  usually  encountered, 
according  to  the  records  of  the  weather  bureau,  some 
time  between  the  216.  and  29th  of  this  month,  and 
when  that  comes  we  may  look  for  a  speedy  termina- 
tion of  the  epidemic.  From  the  date  when  the  disease 
prevailing  at  Ocean  Springs  was  recognized  to  be 
yellow  fever  to  Monday  of  this  week,  the  total  number 
of  cases  in  the  five  places  most  severely  afflicted  by 
the  scourge  was  exactly  sixteen  hundred.  The  mor- 
talit)-  has  fortunately  been  slight,  being  only  about  7.5 
per  cent.,  a  remarkably   low   figure  for  the    disease 


562 


MEDICAL    REC:ORD. 


[October  i6,  1897 


when  occurring  in  communities  where  it  does  not 
prevail  habitually. 

There  are  at  present  cases  in  quarantine  in  Boston, 
Baltimore,  and  most  of  the  important  northern  Atlantic 
ports;  but  of  course  there  is  no  danger  of  the  spread 
of  yellow  fever  in  the  North  at  this  season  of  the  year. 
The  disease  has  been  prevailing  for  the  past  three 
months  in  the  island  of  Jamaica,  the  latest  reports, 
dated  October  9th,  giving  the  total  number  of  cases  in 
Kingston  as  fifty-three,  with  eighteen  deaths.  One  of 
those  who  have  had  the  disease  is  the  newly  appointed 
United  States  consul,  Mr.  Dent.  The  physicians  of 
Kingston  are  not  of  one  mind,  however,  concerning 
the  nature  of  the  disease,  some  calling  it  malignant 
typhoid  fever.  It  hardly  seems  possible  that  there 
could  be  a  confusion  of  this  sort,  and  the  suspicion  is 
forced  upon  the  reader  of  the  conflicting  reports  that 
this  is  only  an  attempt  to  conceal  the  true  nature  of 
the  disease.  If  this  is  the  case,  the  physicians  are 
scarcely  acting  for  the  good  of  the  island,  for  the  oc- 
currence of  yellow  fever  is  an  accident,  and  the  dis- 
ease may  reasonably  be  expected  to  disappear  when 
the  cooler  weather  sets  in,  but  the  existence  of  a  wide- 
spread epidemic  of  t}'phoid  fever  would  point  to  a 
grave  and  probably  permanent  defect  in  the  water 
supply. 

A  cable  dispatch  to  The  Sun,  dated  October  loth, 
states  that  Dr.  Sanarelli,  the  discoverer  of  the  bacil- 
lus of  yellow  fever,  announces  that  he  has  discovered 
a  curative  serum.  He  will  shortly  publish  the  results 
of  his  experiments.  This  is  interesting  as  a  matter  of 
news,  but  it  is  fortunately  too  late  for  us  to  profit  by 
his  discovery,  even  if  it  should  be  substantiated. 


THE  HFALTH  OF  THE  CITY  AND  THE  DIN- 
NER TO  THE  MAYOR. 

Considering  the  present  disgraceful  condition  of  our 
streets,  with  their  noisome  emanations  from  reeking 
trenches  and  their  odorous  banks  of  obstructing  dirt, 
it  is  quite  amusing  to  learn  from  the  daily  papers  that 
our  good  mayor  has  been  the  willing  and  grateful  re- 
cipient of  a  congratulatory  dinner  from  a  political  club. 
There  is  a  grim  humor  about  the  affair  which  can  find 
its  full  vent  only  in  the  meaningless  and  frothy  enco- 
miums of  post-prandial  oratory.  Considering  that  all 
the  heads  of  departments  were  present  and  took  part 
in  the  proceedings,  it  was  a  becoming  opportunity  for 
the  delectable  city  government  to  lift  itself  by  its  own 
breeches.  There  were  so  many  pleasant  things  said 
on  the  score  of  reciprocal  politeness  that  the  finest 
possible  opportunities  were  offered  for  balancing  a 
pleasant  joke  on  the  point  of  a  grave  fact,  thus  making 
the  dinner  a  grand  success.  Doubtlesa  the  health  of 
the  city  was  the  merriest  toast  of  all.  We  quite  agree 
with  the  good  intentions  of  the  guests  in  avoiding 
disagreeable  subjects,  as  otherwise  the  dinner  would 
have  missed  its  avowed  purpose  and  the  distinguished 
city  official  would  have  been  deprived  of  the  hearty 
indorsement  of  his  sham  and  impotent  policy  of  mu- 
nicipal reform. 


THE    BOOM    FOR   THE    CIGARETTE. 

It  is  reported  that  a  committee  of  experts  has  exam- 
ined all  the  different  brands  of  cigarettes  and  has  pro- 
nounced them  free  from  all  adulterations.  All  the 
specimens  are  declared  to  contain  nothing  but  pure 
tobacco.  So  far  so  good ;  but  what  about  the  tobacco 
and  the  nicotine  they  contain?  If  no  tobacco  or 
paper  w-as  used  in  the  construction  of  the  cigarette,  nor 
anything  else  to  make  it  what  it  is,  we  should  be  still 
better  off.  At  best  it  is  the  most  objectionable  form 
in  which  tobacco  can  be  used,  and  sorely  needs  all 
the  apologies  that  are  so  persistently  made  for  it. 


Iltcaus  of  the  "SStcefe. 

Long  Island  Road's  Hospital  Service.— The  new 
emergency  hospital  car,  which  has  been  under  con- 
struction in  the  shops  of  the  Long  Island  Railroad 
Company,  at  Morris  Park,  Long  Island,  for  several 
weeks,  has  been  completed  and  will  be  put  into  com- 
mission some  time  next  week.  The  car  is  sixt)-  feet 
in  length,  with  sliding  doors  at  both  ends  and  also  on 
either  side.  It  is  fully  equipped  with  all  the  neces- 
sary modern  surgical  apparatus,  and  will  be  in  readi- 
ness for  use  at  all  times,  though  it  will  not  be  used  in 
the  case  of  minor  accidents.  About  one-third  of  the 
car  will  be  used  as  an  operating-room  and  the  remain- 
ing space  will  be  occupied  by  twenty-four  cots  of  an 
improved  pattern,  which  can  be  converted  into  stretch- 
ers. The  car  will  be  in  charge  of  Dr.  J.  Frank  Valen- 
tine, the  surgeon-in-chief  of  the  Long  Island  Railroad 
Company,  who  is  also  the  president  of  the  New  York 
State  Society  of  Railroad  Surgeons. 

Mr.  Ernest   Hart We    regret   to    learn    that   the 

health  of  Mr.  Ernest  Hart,  the  accomplished  editor  of 
the  British  Medical  Journal,  has  been  for  a  long  time 
impaired.  Recently  it  was  found  necessary  to  ampu- 
tate his  leg  on  account  of  necrosis  of  the  bones  of  the 
foot,  Mr.  Bryant  and  Mr.  Mitchell  Bruce  performing 
the  operation.  The  patient  rallied  well,  and  is  re- 
ported to  be  now  making  satisfactory  progress  toward 
recovery.  The  many  friends  of  Mr.  Hart  in  this 
country  will  sympathize  deeply  with  him  in  learning  of 
this  misfortune,  and  they  will  join  us  in  the  earnest 
hope  that  he  may  soon  be  restored  to  health  and 
strength  and  may  long  be  spared  to  continue  the  edi- 
torial labors  which  he  has  discharged  so  faithfully  and 
so  well,  to  his  own  credit  and  in  the  best  interests  of 
the  profession  in  Great  Britain. 

A  Bureau  of  Clinics. — It  is  announced  that  the 
physicians  connected  with  the  teaching  institutions  in 
Philadelphia  have  organized  a  central  bureau  where 
all  information  will  be  given  inquirers  concerning  the 
work  for  the  day  in  the  various  branches  of  surger)' 
and  medicine  at  different  hospitals  in  the  city.  This 
is  accomplished  by  notice  to  the  bureau  by  postal 
card  or  telephone.  By  this  means  the  physicians  who 
visit  the  city  may  be  able  to  take  advantage  of  the 
clinical  facilities  offered  by  the  hospitals  of  Philadel- 
phia, and  any  one  calling  at  the  central  bureau  can 


October  i6,  1897] 


MEDICAL    RECORD. 


56: 


ascertain  what  medical  or  surgical  work  may  be  going 
on  during  that  da\'  in  any  one  of  the  different  hos- 
pitals. 

Typhus  Fever  at  San  Francisco. — The  officials 
of  the  San  Francisco  board  of  health  recently  discov- 
ered a  case  of  typhus  fever  at  St.  Luke's  Hospital  in 
that  city.  The  patient,  a  man,  aged  twenty-three 
years,  was  removed  to  the  pesthouse. 

Death  from  a  Siphon  Explosion. — A  child  re- 
cently died  in  this  city  from  injuries  received  in  the 
explosion  of  a  siphon  of  carbonated  water  which  she 
was  carrj'ing  at  the  time. 

Dr.  D.  W.  Hanger,  of  Fishersvilie,  Va.,  recently 
took  by  mistake  an  overdose  of  strophanthus,  and  was 
saved  only  by  the  exertions  of  Drs.  Watson,  Morrison, 
and  F.  M.  Hanger,  of  Staunton.  We  congratulate  our 
confrere  on  his  escape. 

Tapeworm  and  the  Fair  Sex. — We  have  received 
eleven  communications  from  friends  in  various  parts 
of  the  country  who  protest  against  the  statement  made 
by  a  contributor  that  woman  alone  was  privileged  to 
entertain  a  taenia.  Each  of  these  writers  reports  from 
one  to  seven  cases  under  his  own  obser\'ation  of  tape- 
worm occurring  in  male  subjects.  We  are  forced  to 
the  conclusion  that  women  have  no  monopoly  of  this 
attenuated  parasite. 

Texas  Fever  Not  in  Iowa. — Dr.  William  Home, 
of  Mt.  Ayr,  Iowa,  writes  that  the  report  that  Texas 
fever  had  been  found  among  cattle  in  southwestern 
Iowa  is  incorrect,  and  that  there  is  not  a  single  case 
within  four  hundred  miles  of  Mt.  Ayr. 

Death  of    Professor  Roy Dr.    Charles   T.    Roy, 

professor  of  pathology  at  the  University  of  Cambridge, 
England,  died  October  5th.  He  was  born  in  1854, 
was  a  surgeon  in  the  Turkish  army  during  the  Servian 
war,  was  professor  superintendent  of  the  Brown  Insti- 
tution, and  was  called  to  the  chair  of  pathology  at 
Cambridge  in  1884. 

State  Aid  for  Johns   Hopkins  University.  —  The 

Baltimore  board  of  trade  will,  it  is  reported,  memorial- 
ize the  State  legislature  at  its  approaching  session, 
setting  forth  the  great  advantage  to  Baltimore  in  a 
hundred  different  ways  of  having  the  Johns  Hopkins 
University  there,  and  drawing  attention  to  the  serious 
loss  it  has  suffered  through  the  lapsing  of  dividends 
on  Baltimore  and  Ohio  stock,  upon  which  it  depended 
for  a  large  part  of  its  income.  The  board  will  ask  the 
legislature  to  extend  aid  to  the  university  from  the 
public  treasury. 

Philadelphia  County  Medical  Society.  — At  a  stated 
meeting  of  the  Philadelphia  County  Medical  Societ)', 
held  on  September  22d,  Dr.  Edward  Martin  read  a 
paper  on  "  The  Operative  Treatment  of  Goitre,"  and 
exhibited  a  series  of  cases  in  which  partial  excision  of 
the  enlarged  thyroid  gland  had  been  successfully  per- 
formed. In  one  of  the  cases  the  gland  became  the 
seat  of  suppuration,  with  rupture  and  spontaneous  cure. 
The  majority  were  instances  of  simple  goitre,  although 
one  or  another  exhibited  symptoms  of  exophthalmic 


goitre.  The  results  in  all  of  the  cases  were  eminently 
satisfactory,  from  both  a  surgical  and  a  medical  point 
of  view.  The  operation  would  seem  indicated  when 
medical  measures  have  failed  or  afford  no  promise  of 
relief. 

Milk  Inspection  in  Philadelphia.^ — Acting  upon  a 
communication  from  a  number  of  prominent  physi- 
cians, who  plead  for  a  closer  inspection  of  milk,  con- 
tending that  the  depots  for  retailing  milk,  and  espe- 
cially the  general  grocery  store,  should  be  under  rig- 
orous control  of  the  board  of  health,  the  sanitary 
committee  of  this  board  has  adopted  a  resolution  in- 
structing the  director  of  the  Laboratory  of  Hygiene  to 
institute  in  conjunction  with  the  milk  division  of  the 
board  a  methodical  bacteriological  examination  of 
the  milk  supply. 

Schuylkill  County  (Pa.)  Medical  Society At  a 

meeting  of  the  Schuylkill  County  Medical  Society, 
held  at  Tamaqua,  Pa.,  on  October  5th,  Dr.  G.  M. 
Hamilton,  of  Shenandoah,  read  a  paper  on  "  Burns," 
and  Dr.  B.  C.  Maude  Coble  one  on  "  Spina  Bifida." 

Obituary  Notes. — Dr.  J.  A.  Mayer,  of  Mauch 
Chunk,  Pa.,  died  at  Philadelphia  on  October  5th,  from 
heart  disease,  at  the  age  of  sixty-seven  years.  He  was 
a  native  of  Germany,  but  had  been  a  resident  of  Mauch 
Chunk  for  forty  years. — Dr.  Henry  E.  Brannin  died 
at  Blackwood,  N.  J.,  on  October  4th,  in  consequence 
of  an  apoplectic  seizure,  at  the  age  of  sixty-one  years. 
He  was  graduated  from  Jefferson  Medical  College  in 
1858,  and  was  from  1879  attending  physician  to  the 
Camden  County  Almshouse  and  Insane  Asylum,  tak- 
ing an  active  part  in  an  epidemic  of  typhus  fever  that 
broke  out  in  these  institutions  in  188 1. — Dr.  J.  K. 
EsHLEMAN  died  at  his  farm.  Glen  Isle,  near  West 
Chester,  Pa.,  on  October  7th,  in  his  eighty-eighth  year. 
He  was  a  graduate  of  Jefferson  Medical  College,  but 
for  many  years  had  withdrawn  from  the  active  practice 
of  his  profession. — Dr.  John  A.  Raub  died  at  Phila- 
delphia on  September  29th,  at  the  age  of  sixty-one 
years.  He  was  graduated  from  the  medical  depart- 
ment of  the  University  of  Pennsylvania  in  1862,  en- 
gaging in  the  practice  of  medicine  at  Mount  Bethel, 
Northampton  County.  He  was  at  one  time  president 
of  the  Northampton  County  Medical  Society.  He 
came  to  Philadelphia  in  1872. — Dr.  P.  Y.  Frye,  of 
Oyster  Bay,  N.  Y.,  died  at  his  home  on  October  9th, 
aged  eighty  years.  He  was  a  graduate  of  Dartmouth 
Medical  School  in  the  class  of  1846. — Dr.  Robert  B. 
Bradford  died  at  the  Home  of  the  Incurables  in 
Washington  on  October  9fh,  aged  sixty-six  years.  He 
was  born  in  Virginia,  and  resided  first  in  New  York 
after  his  graduation.  He  early  went  into  politics  and 
had  not  practised  for  many  years. — Dr.  Jarrard  K. 
Smith,  government  physician  at  Koloa,  in  the  Sand- 
wich Islands,  was  shot  down  in  his  doorway,  on  Sep- 
tember 24th,  by  a  native  whose  mother  and  sister  Dr. 
Smith  had  declared  lepers  and  ordered  to  Molokai. 
Dr.  Smith  was  born  on  the  island  of  Kaui.  He  was 
educated  at  Honolulu,  but  received  his  medical  training 
in  this  city. — Dr.  W.  Stoeder,  professor  of  materia 
medica  in  Amsterdam,  is  reported  to  have  been  frozen 


564 


MEDICAL    RECORD. 


[October  16,  1697 


to  death  on  Mt.  Ararat,  during  an  ascent  of  the  moun- 
tain by  members  of  the  International  Geological  Con- 
gress.— Dr.  Muxro,  of  Union,  S.  C,  died  at  Atlanta, 
Ga.,  on  October  nth.  He  was  a  graduate  of  the  Uni- 
versity Medical  College,  in  this  city,  in  the  class  of 
1876. 

Pathological  Society  of  Philadelphia. — A  stated 
meeting  of  the  Pathological  Society  of  Philadelphia 
was  held  on  September  24th,  the  president.  Dr.  J.  H. 
Musser,  occupying  the  chair.  Dr.  D.  Riesman  exhib- 
ited a  specimen  of  primary  carcinoma  of  the  gall  blad- 
der, with  extensive  metastasis  or  extension  by  conti- 
guity to  the  liver.  A  stone  was  present  in  the  gall 
bladder.  Dr.  Joseph  McFarland  read  a  paper  upon 
'■  Coccidium  Oviforme,"  exhibiting  macroscopic  and 
microscopic  preparations  and  specimens.  The  disease 
had  broken  out  among  rabbits  used  for  experimental 
purposes,  and  had  proved  fatal  on  a  large  scale.  The 
disease  is  occasionally  encountered  in  man.  Dr.  A. 
Hand,  Jr.,  exhibited  specimens  from  a  case  of  tuber- 
culosis in  a  child,  two  years  old — lungs,  intestines, 
and  spleen  being  profoundly  involved  and  a  tubercu- 
lous tumor  being  present  beneath  the  epicardium. 
Dr.  J.  P.  Arnold  exhibited  a  tumor  as  large  as  a  hen's 
egg,  arising  from  the  dura  and  embedded  into  the  me- 
dian aspect  of  the  left  hemisphere.  Death  resulted 
from  unrecognized  pneumonia.  The  lungs  showed, 
besides,  evidences  of  tuberculosis.  In  addition  to 
hemiplegia,  convulsions,  and  loss  of  sight,  there  was 
optic  neuritis,  more  pronounced  on  the  right.  Dr. 
M.  H.  Fussell  exhibited  button-hole  narrowing  of  the 
mitral  orifice. 

University  of  Texas.  —  Dr.  William  S.  Carter, 
demonstrator  of  physiology  in  the  University  of  Penn- 
sylvania, has  been  elected  professor  of  physiology  in 
the  University  of  Texas. 

College   of   Physicians   of   Philadelphia.  —  At   a 

stated  meeting  of  the  College  of  Physicians  of  Phila- 
delphia, on  October  6th,  Dr.  A.  A.  Eshner  read  a  pa- 
per entitled  "  A  Case  of  Obscure  Diagnosis  exhibiting 
Hysteric  Stigmata,"  and  presented  the  patient.  There 
had  been  present  vertigo,  vomiting,  hiccough,  disor- 
dered gait,  and  nystagmus,  with  hemihypalgesia;  and 
marked  improvement  followed  hypnotic  suggestion. 
Dr.  G.  H.  Makuen  exhibited  a  case  of  imperfect 
voice  and  one  of  stammering  cured  by  the  employment 
of  scientific  educational  methods.  The  first  occurred 
in  a  young  man  of  about  twenty  who  had  used  the 
high-pitched  voice  of  youth,  and  the  second  in  a 
woman  who  had  stammered  badly  for  quite  thirty 
years.     In  both  the  results  were  extremely  satisfactory. 

Insanity  in  Prussia  is  reported  to  be  increasing  so 
rapidly  that  the  asylums  are  entirely  inadequate  to 
accommodate  the  large  number  of  patients  requiring 
\:reatment.  In  187 1  the  total  number  of  lunatics  in 
Prussia  was  55,063,  in  1880  it  had  risen  to  66,345, 
while  in  1S96  it  had  gone  up  to  82,850.  It  is  inter- 
esting to  note  also  that,  while  the  growth  of  insanity 
is  general,  it  is  more  marked  among  men  than  among 
women.  Of  100,000  Prussian  males  there  are  278 
insane,  and  of  a  like  number  of  women,  243. 


Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
October  9,  1897.  October  2d. — Medical  Inspector  J. 
C.  Wise,  Passed  Assistant  Surgeon  F.  A.  Hesler,  As- 
sistant Surgeon  R.  K.  Smith,  detached  from  the  Phil- 
adelphia and  ordered  to  the  Baltimore ;  Medical  Di- 
rector N.  L.  Bates  detached  from  the  Museum  of  Hy- 
giene and  ordered  to  duty  as  chief  of  the  bureau  of 
medicine  and  surger)-.  October  5th. — Medical  Di- 
rector J.  R.  Tr)-on  detached  from  the  bureau  of  medi- 
cine and  surgerj'  and  ordered  to  New  York  as  general 
inspector  of  United  States  naval  hospitals.  October 
6th. — Medical  Inspector  H.  J.  Babin  ordered  as  presi- 
dent of  the  naval  examining  board.  New  York,  Octo- 
ber 9th;  Medical  Director  C.  H.  White  detached  as 
president  of  the  naval  examining  board,  New  York, 
October  9th,  and  ordered  to  Washington  in  charge  of 
Naval  Museum  of  Hygiene.  October  8th. — Assistant 
Surgeon  J.  C.  Pryor  detached  from  the  naval  hospital. 
Mare  Island,  and  ordered  to  the  Adams. 

Of   Sound   and   Disposing  Mind  and   Memory. — 

The  Paris  correspondent  of  the  Therapeutic  Gazette 
tells  of  a  young  poet  who  for  some  time  had  been  ac- 
customed to  use  both  hashish  and  morphine,  who 
recently  committed  suicide  by  means  of  an  overdose 
of  the  latter  drug.  By  his  will  he  left  the  greater 
part  of  his  fortune,  amounting  to  $120,000,  to  his 
mistress,  and  $1,000  to  a  member  of  the  legal  profes- 
sion. If,  however,  his  will  were  attacked  by  any 
members  of  his  family  on  account  of  supposed  undue 
influence,  the  entire  amount  was  to  go  to  the  latter 
legatee.  The  brother-in-law  of  the  poet  endeavored  to 
have  the  will  annulled,  not  on  account  of  undue  in- 
fluence, but  because  of  the  well-known  abuse  of  mor- 
phine which  the  deceased  had  suffered  from.  The 
court  decided  that  inasmuch  as  the  abuse  of  morphine 
could  not  be  considered  as  in  any  sense  doing  away 
with  the  culpability  of  the  individual  in  a  criminal 
case,  it  could  not  be  regarded  as  diminishing  the  re- 
sponsibility of  the  individual  in  a  civil  cause. 

Antisepsis  in  the  Barber  Shop A  cable  dispatch 

to  the  Sun  says  that  the  sanitary  authorities  of  Paris 
have  induced  the  prefect  of  police  to  issue  stringent 
instructions  to  barbers,  informing  them  that  all  metal 
instruments  must  be  plunged  directly  after  use  into 
boiling  soapy  water.  All  combs  of  tortoise  shell, 
ivory,  or  celluloid  must  be  replaced  as  far  as  possible 
by  metal,  so  as  to  be  more  easily  cleansed  and  disin- 
fected. Scissors,  razors,  clippers,  and  brushes  must 
be  heated  to  100"  C,  or  placed  in  a  receptacle  con- 
taining a  prescribed  chemical  solution,  before  use. 
Shaving-brushes  must  be  dipped  in  boiling  water. 
Instead  of  powder  puflFs  blowers  must  be  used.  Fi- 
nally, hairdressers  must  wash  their  hands  before 
passing  to  another  customer. 

Influenza  in  peculiarly  virulent  form  has  for  some 
months  been  raging  in  Mero,  in  Asia,  and  alarm  is 
felt  in  Russia  lest  anotlier  wave  of  the  disease  spread 
thence  over  the  Western  world. 


October  i6,  1S97] 


MEDICAL    RFXORD. 


565 


J^ociety  Reports. 

NEW  YORK  STATE  MEDICAL  ASSOCIATION. 

Fourteenth  Annual  Meeting,  Held  in  New  York,  October 
12,  ij,  anil  14,  i8gj. 

Charles  Phelps,  M.D.,  President. 

First  Day —  Tuesday,    October  12th. 

The  meeting  was  called  to  order  by  the  president. 
Dr.  Charles  Phelps,  at  10:30  \.s\. 

Report  of  the  Committee  of  Arrangements. — Dr. 
Charles  E.  Dexisox,  of  New  York,  read  the  report 
of  this  committee,  and  extended  to  the  members  a 
hearty  welcome. 

Annual  Report  of  tho  Council. — It  was  stated  that 
there  was  in  the  general  fund  in  the  treasury  a  bal- 
ance of  $3,510  to  the  credit  of  the  association. 

Cruel  Treatment  of  Animals  in  Transportation. 
— A  communication  was  read  from  the  New  York 
State  Society  for  the  Prevention  of  Cruelty  to  Animals 
and  Children.  It  asked  the  co-operation  of  the  asso- 
ciation in  preventing  the  cruelties  now  imposed  on 
animals  while  in  transit,  stating  that  during  the  past 
year  at  Buffalo  sixteen  thousand  sheep  and  hogs  had 
been  taken  out  of  the  cars  dead,  and  more  than  eight 
thousand  had  been  removed  at  the  same  place  in  a 
diseased  or  disabled  condition  :  moreover,  these  ani- 
mals were  sold  for  public  food  and  consumption. 

Resolutions  Concerning  the  "Hospital  Grab." — 
Before  the  acceptance  of  the  report.  Dr.  Thus.  H.  Max- 
ley  asked  what  action  had  been  taken  by  the  council 
on  the  resolutions  that  he  had  presented  to  them  at 
the  two  preceding  meetings  of  the  association.  These 
resolutions,  it  would  be  remembered,  were  in  regard 
to  the  injustice  done  to  the  medical  profession  here 
by  the  wholesale  turning  out  of  the  members  of  the 
visiting  staffs  of  the  city  hospitals.  The  secretary  ex- 
plained that  reference  had  been  made  to  this  matter 
in  the  printed  volume  of  Transactions,  and,  on  being 
pressed  for  a  more  specific  answer,  stated  that,  so  far 
as  he  recollected,  the  council  had  practically  refused 
to  take  any  action. 

Acute  Catarrh  of  the  Middle  Ear  as  a  Sequel 
of  the  Grippe. — Dr.  Samuel  \V.  S.mith,  of  New  York 
County,  presented  the  first  scientific  paper,  with  the 
above  title.  He  said  that  the  physician  should  be 
able  to  recognize  and  treat  intelligently  acute  inflam- 
mation of  the  middle  ear,  but  it  was  true  that  the 
average  practitioner  did  not  do  so.  Ordinarily,  the 
victim  of  chronic  otorrhoea  would  state  that  the  physi- 
cian who  had  attended  him  at  the  time  of  his  first 
attack  had  practically  advised  him  to  "  do  nothing,'' 
or,  at  most,  sjTinge  the  ear  with  soap  and  water.  One 
of  the  early  and  prominent  symptoms  was  a  deep- 
seated  pain,  throbbing  in  character,  and  increased  by 
talking  or  any  sudden  expiratory  act  through  the  nos- 
tril. Recumbent  posture  would  increase  the  pain.  A 
tickling  sensation  was  experienced  in  the  pharyngeal 
organs,  with  dulness  of  hearing  and  tinnitus  aurium 
in  the  affected  ear.  After  a  few  hours  the  pain  would 
extend  frequently  from  th';  ear  to  the  eye,  and  along 
the  side  of  the  head  to  the  occipital  region,  over  the 
mastoid  process  and  down  the  neck.  About  this  time 
the  pain  would  be  very  severe,  and  would  be  asso- 
ciated with  a  rise  of  temperature  to  101°  or  103"  F., 
and  perhaps  also  with  delirium  and  great  constitutional 
disturbance.  Speculum  examination  would  show  a 
loss  of  the  normal  line  of  the  drumhead,  and  the  latter 
wouid  soon  begin  to  bulge  toward  the  meatus.  In 
favorable  cases  there  would  be  a  rupture  either  through 
the  drumhead  into  the  external  canal,  or  into  the  throat. 
Not  infrequently,  connective-tissue  bands  would  con- 


nect the  ossicles  to  the  walls  of  the  tympanum,  and  so- 
give  rise  to  a  permanent  impairment  of  hearing.  If 
early  paracentesis  were  performed,  the  disease  might 
be  cut  short.  It  was  a  lamentable  truth  that  about 
seventy-five  per  cent,  of  these  patients,  through  im- 
proper treatment,  lost  at  least  a  portion  of  their  hear- 
ing. More  than  this,  this  complication  of  the  grippe 
might  endanger  even  life.  Pachymeningitis  and 
thrombosis  sometimes  occurred,  and  even  embolism 
and  metastatic  abscesses  might  result. 

Differential  diagnosis:  In  periostitis  of  the  osseous 
portion  of  the  e.xternal  canal  the  differential  diagnosis 
was  more  difficult.  In  periostitis  there  was  an  itching 
sensation  along  the  osseous  portion  of  the  external 
auditory  canal;  in  otitis  media,  if  these  symptoms 
were  present  they  were  referable  to  the  pharyngeal 
orifice  of  the  Eustachian  tube,  and  travelled  along  the 
tube  to  the  middle  ear.  In  periostitis,  the  pain  grad- 
ually developed:  in  otitis,  its  onset  was  sudden. 
Again,  the  speculum  would  aid  in  drawing  the  line 
between  the  two  diseases;  for  in  periostitis  the  mem- 
brana  tympani  was  rarely  the  seat  of  any  special 
change,  whereas  in  otitis  media  the  drum  was  always 
changed  in  appearance.  Exploration  with  a  blunt 
probe  would  aid  in  making  the  diagnosis,  because 
when  the  latter  touched  a  spot  which  was  the  seat  of  a 
periostitis  it  would  cause  severe  pain;  this  would  not 
be  observed  in  otitis  media. 

Dr.  Leroy  J.  Brooks,  of  Chenango  County,  said 
that  although  not  a  specialist,  he  had  made  it  a  prac- 
tice to  do  two  things  in  these  cases,  viz.:  (i)  to  Po- 
litzerize  the  patient  two  or  three  times  a  day,  begin- 
ning as  soon  as  the  symptoms  and  signs  of  otitis 
appeared:  and  (2)  to  siphon  hot  saline  solution  inta 
the  affected  ear  at  short  intervals.  It  was  difficult 
for  the  general  practitioner  in  private  practice  to  ob- 
tain permission  to  perform  paracentesis  of  the  drum- 
head. He  was  confident  that  the  measures  he  hat 
just  recommended  would  often  abort  these  trouble- 
some, not  to  say  serious  attacks. 

Dr.  Bernard  Cohen,  of  Buffalo,  also  favored  the 
use  of  the  Politzer  bag,  and  thought  it  a  decided  ad- 
vantage first  to  put  a  few  drops  of  chloroform  in  the 
tube.  This  seemed  to  assist  the  dilatation  of  the  tube, 
and  at  the  same  time  give  almost  instant  relief.  The 
instillation  of  oils  in  the  ear  was  objectionable  on 
account  of  their  tendency  to  become  rancid ;  if  such  an 
agent  must  be  used,  it  was  better  to  use  some  hydro- 
carbon like  albolene,  or  else  to  use  glycerin.  Although 
a  general  practitioner,  he  did  not  hesitate  to  perform 
paracentesis  quite  earl\-,  and  it  ^\as  certainlv  much 
better  to  do  this  than  to  run  the  risk  of  the  serious  com- 
plications which  were  liable  to  develop  when  this  so- 
called  conservative  policy  was  adopted.  He  l;ad  found 
that  ear  affections  did  badly  when  quinine  was  give.'. 

Dr.  Morris  E.  Davis,  of  New  York,  agreed  with 
the  last  speaker  regarding  the  inadvisability  of  admin- 
istering quinine.  In  these  cases  complicating  the 
grippe,  the  treatment  should  consist  in  a  saline  purge, 
large  doses  of  salicylate  of  sodium,  hot  applications 
to  the  ear,  and  hot  gargles  to  allay  the  inflammation 
in  the  throat. 

Dr.  S.mith,  in  closing  the  discussion,  said  that  he 
did  not  favor  the  use  of  the  Politzer  bag,  because  of 
the  pain  that  it  produced.  He  felt  sure  that  if  any 
physician  having  an  occluded  Eustachian  tube  should 
use  this  air  bag  upon  himself,  he  would  not  be  dis- 
posed to  inflict  this  treatment  upon  others.  In  chil- 
dren, relief  would  be  afforded  by  using  a  dropping- 
tube,  and  with  it  instilling  hot  water  into  the  affected 
ear,  the  patient  lying  on  the  side  with  this  ear  upper- 
most. When  the  Eustachian  tube  became  so  occluded 
that  the  discharge  was  pent  up  and  forced  tiie  drum 
outward,  it  seemed  to  him  proper  to  perform  paracen- 
tesis, and  so  prevent  rupture  of  the  drum  membrane. 


;66 


MEDICAL    RECORD. 


[October  i6,  1897 


What  Shall  We  Do  to  be  Saved?— Dr.  T.  J. 
HiLLis,  of  New  York,  presented  a  paper  with  this 
rather  startling  title.  He  read  only  a  portion  of  the 
paper, -which  was  intended  to  depict,  in  a  graphic 
manner,  the  ruin  that  had  been  wrought,  by  dispensary 
abuse.  It  was  an  allegorical  presentation  of  the  sub- 
ject, and  contained,  among  other  descriptive  pieces, 
one  entitled  "The  Deacon's  Confession."  According 
to  the  story,  Dr.  White— better  known  as  Deacon 
White — felt  impelled,  one  evening  at  a  religious  meet- 
ing, to  unburden  his  mind  regarding  the  sinfulness  of 
his  career.  He  said  that  before  studying  medicine  he 
had  been  a  shrewd  business  man,  and  had  carried  his 
hard  business  methods  even  into  his  subsequent  pro- 
fessional life.  It  was  he  who  had  plotted  the  estab- 
lishment of  the  "free-to-all  memorial  dispensar)-"  in 
order  to  outdo  his  fellow-practitioners  in  the  vicinity. 
He  had  succeeded  in  gratifying  his  ambition,  but  in 
doing  so  had  pauperized  the  community,  as  he  ex- 
pressed it :  '■  It  has  been  said  that '  the  evil  that  men 
do  lives  after  them,'  but  the  evil  that  I  have  done 
lives  now."  As  a  result  of  his  act,  the  honorable  and 
competent  medical  practitioners  of  his  locality  had 
been  compelled  to  close  their  doors;  their  patrons 
had  been  allured  to  the  dollar-a-month  banquet,  and  it 
had  proved  to  be  the  banquet  of  death.  At  first  his 
medical  brethren  had  fought  manfully  for  their  rights, 
but  they  liad  soon  succumbed  in  the  unequal  struggle. 

A  Curious  Condition  of  the  Appendix  Vermiformis 
as  Found  at  Operation. — Dr.  E.  D.  Fergvsox,  of 
Troy,  read  this  paper,  and  presented  a  specimen. 
The  latter  he  considered  to  be  unique.  It  had  been 
removed  from  a  man,  thirty-two  years  of  age,  whose 
previous  history  had  been  good.  He  had  had  his  first 
attack  of  appendicitis  in  March,  1S93.  This  attack 
had  been  a  protracted  one,  and  an  abscess  had  opened 
into  the  bowel.  In  December  of  tiie  same  year  he 
also  had  a  mild  attack.  In  December  of  1896  he  had 
another  attack,  but  was  not  seen  by  Dr.  Ferguson  until 
last  January.  There  were  at  that  time  much  pain  and 
fever.  An  ice  bag  was  kept  over  the  affected  part, 
and  the  patient  fed  on  albumen  water.  The  operation 
was  not  done  until  February  3d.  A  broncho-pneu- 
monia developed  three  days  after  the  operation,  and  an 
abscess  developed  five  or  si-x  days  after  the  operation. 
It  was  opened,  drained,  and  packed  with  iodoform 
gauze.  After  this,  recover)-  was  uneventful  and  com- 
plete. At  the  operation,  many  firm  adhesions  were 
encountered,  and  after  a  long  search  a  mass  was  found 
near  the  iliac  muscle,  situated  between  the  small  in- 
testine and  the  colon.  This  mass  was  found  to  con- 
tain the  distal  portion  of  the  appendix,  which  liad 
become  separated  by  gangrene.  The  canal  had,  how- 
ever, been  maintained.  No  remnant  of  the  mesentery 
could  be  discovered,  nor  was  there  evidence  of  pus  or 
recent  inflammatory  exudate.  The  opening  into  the 
ca.'cuni  was  infolded  and  closed,  and  the  abdomen 
closed  without  drainage. 

Amputation  of  the  Appendix  by  Gangrene.  — 
The  specimen  was  a  fine  example  of  amputation  by 
gangrene,  and  from  the  history  it  was  probable  that 
this  occurred  in  1893.  In  connection  witii  this  speci- 
men, another  case  was  reported.  He  had  first  seen 
the  patient  last  February,  but  had  deferred  operation. 
.\nother  and  more  severe  attack  occurred  on  Septem- 
ber 23.  1897,  and  tiien  the  operation  had  been  done 
within  six  hours  of  the  onset  of  the  symptoms.  The 
appendix  was  greatly  congested,  and  the  mucous  coat 
thrown  into  folds.  At  the  point  of  separation  of  the 
two  portions  of  the  appendix  was  a  black  circular  line 
of  uniform  width. 

Operations  for  Appendicitis.  —  The  speaker  said 
that  if  all  patients  were  to  be  protected  from  the  pos- 
sible contingency  of  an  acute  general  septic  peritoni- 
tis, we  must  operate  in  all  cases,  because  there  was 


no  means  of  foreseeing  the  occurrence  of  this  grave 
complication.  The  most  common  fault  now  seemed 
to  be  to  minimize  the  risks  of  the  operation.  Some 
recent  and  trustworthy  statistics  placed  the  mortality 
even  higher  than  ten  per  cent.  It  was  probable  that, 
taking  all  cases,  eighty  to  ninety  per  cent,  of  patients 
would  recover  from  the  first  attack  without  perforation 
or  suppuration  :  of  those  who  did  not  recover,  eight}-  to 
ninet)-  per  cent,  would  have  a  circumscribed  collection 
of  pus,  and  could  be  relieved  by  a  simple  and  compar- 
atively safe  surgical  procedure:  in  the  remainder  the 
affection  would  be  more  serious,  and  a  large  percentage 
of  them  would  perish.  But  to  save  these  last,  we  were 
asked  to  operate  in  everj-  case  I  Dr.  Ferguson  concluded 
that  in  all  cases  of  appendicitis  during  the  first  attack 
the  operation  should  not  be  undertaken  unless  suppura- 
tion or  diffuse  peritonitis  demanded  it;  but  in  relapsing 
or  recurring  appendicitis,  in  which  it  was  probable 
that  permanent  distortion  of  the  appendix  existed,  we 
should  operate. 

Dr.  F.  H.  Wiggix,  of  New  York,  thought  that  all 
cases  of  appendicitis  should  be  considered  as  surgical 
after  the  diagnosis  had  once  been  clearly  established 
At  first,  we  sliould  simply  use  enemata  and  apply 
cold  locally,  but  if  the  symptoms  were  more  severe 
after  thirty-six  hours  the  patients  should  be  operated 
upon.  If  the  pulse  became  more  rapid,  it  indicated 
serious  peritonitis  and  the  need  for  operation.  No 
case  in  the  first  attack  should  be  subjected  to  opera- 
tion unless  there  was  evidence  of  pus.  He  thought 
the  experience  of  good  operators  would  justify  the 
statement  that  the  mortality  should  not  exceed  four 
per  cent.,  unless  the  patients  were  already  the  victims 
of  organic  disease. 

Dr.  Ch.^ri.es  Phelps,  of  New  York,  was  of  the 
opinion  that  the  great  majority  were  examples  of  sim- 
ple catarrhal  inflammations,  and  that  many  would  re- 
cover under  the  use  of  the  ice  coil  alone.  So  far  as 
he  had  been  able  to  follow  the  patients  upon  whom  he 
had  not  operated,  there  had  not  been  recurrence.  In 
suppurative  and  gangrenous  cases,  of  course  imme- 
diate operation  w-as  demanded.  Probably  no  opera- 
tion was  more  often  done  unnecessarily  than  that  for 
appendicitis,  largely  owing  to  the  very  general  discus- 
sion of  appendicitis  in  the  lay  as  well  as  the  medical 
press.  A  pulse  of  120  should  be  looked  upon  as  an 
indication  of  great  danger.  The  operation  should  be 
done  before  this  stage  had  been  reached. 

The  Abuse  of  Medical  Charity,  a  Critical  Re- 
view of  Recent  Literature. — Dr.  Frederick  Holme 
Wii-.tnx,  of  New  \'ork,  read  a  paper  with  this  title. 
He  said  that  liis  object  was  not  so  much  to  present  in- 
dividual views  as  to  cull  from  recent  literature — both 
lay  and  medical — the  opinions  of  many  writers.  He 
said  that  it  was  easy  to  demonstrate  conclusively  that, 
as  at  present  administered,  medical  charity  is  demor- 
alizing to  both  the  recipients  and  the  donor.  Some 
idea  of  the  alarming  growth  and  extent  of  this  evil 
might  be  gained  from  the  carefully  compiled  report  of 
Dr.  Stephen  Smith  to  the  State  board  of  charity.  He 
showed  that,  during  1S95,  897,971  persons  applied  for 
and  received  free  medical  treatment  at  105  dispensa- 
ries in  this  city;  that  1,418.847  free  visits  were  made 
by  those  applicants  to  these  dispensaries;  and  that 
78,000  persons  received  free  board,  lodging,  nursing, 
drugs,  surgical  dres-;ings,  and  treatment  —  in  other 
words,  that  more  than  forty-nine  per  cent,  of  all  who 
live  within  our  borders  claimed  in  one  year  to  be  un- 
able to  care  for  themselves.  This  should  be  contrasted 
with  another  statement  by  Dr.  Smith,  to  the  efiect  that 
during  the  period  from  1791,  when  the  first  dispensary 
had  been  established  in  New  York,  to  about  1S70,  the 
applicants  for  charity  bore  a  ratio  to  the  total  popula- 
tion of  1.5  per  cent. 

Dr.  Wiggin  then  went  on  to  quote  from  an  editorial 


October  i6,  1897] 


MEDICAL    RECORD. 


567 


in  the  New  York  Herald,  to  show  that  Greater  New 
York  spent  fiftj"  millions  of  dollars  every  year  on  char- 
ities, and  that,  according  to  a  conser\ative  estimate, 
fully  fifty  per  cent,  of  the  donors'  money  was  diverted 
from  the  purpose  for  which  it  was  intended  and  was 
practically  filched  from  the  poor,  to  whom  it  rightfully 
belonged.  Again,,  according  to  one  author,  Dr.  J.  13. 
Huber,  one  might  find  in  large  numbers  at  dispensa- 
ries such  people  as  actors,  gamblers,  bartenders,  po- 
licemen, farmers,  prosperous  businessmen  and  those 
owning  houses,  lawyers,  and  perhaps  even  a  stray  rail- 
way president.  .According  to  another  author,  fully  fifty 
per  cent,  of  the  applicants  in  the  reception,  room  of  a 
well-known  institution,  which  he  dubs  "the  Diamond 
Dispensary,"  were  well  dressed;  ten  per  cent,  were 
finely  dressed;  more  than  half  of  the  men  bore  no  evi- 
dence of  poverty;  and  among  the  women  there  was  an 
attractive  display  of  fine  millinery — yet  all  obtained 
the  free  treatment  supposed  to  be  given  only  to  poor 
persons.  A  reporter  on  one  of  the  daily  papers,  in 
describing  what  he  saw  at  a  well-known  "clinic,"" 
stated  that  not  more  than  one  in  fifty  was  at  all  shab- 
bily dressed,  a  large  majority  were  fairly  well  dressed, 
one-third  of  them  were  quite  presentably  dressed,  and 
perhaps  one-fifth  were  positively  well  dressed.  The 
reader  of  the  paper  said  that  he  knew  of  a  man  who 
paid  an  enormous  rent  in  a  fashionable  apartment 
house  near  Central  Park,  and  who  spent  many  thousand 
dollars  a  year  on  living  expenses,  yet  he  went  to  what 
iias  been  so  aptly  termed  ""  the  Diamond  Dispen- 
sarv-,'"  on  the  plea  that  his  expenses  were  so  hea%y  that 
he  could  not  afford  to  pay  a  fee  to  a  doctor.  "  Cer- 
tainly," the  author  continues,  these  instances  "  show 
the  spirit  in  which  charit)"  is  asked  for  and  accepted : 
it  is  largely  a  desire  to  save  money,  without  appar- 
ently thinking  that  self-respect  is  lost  in  the  effort  or 
that  a  wTong  is  done  to  the  really  poor  and  to  the  phy- 
sician, who  is  certainly  as  much  entitled  to  his  hire  as 
are  the  clerg)-men  or  other  members  of  the  community, 
as  he  too  has  social  obligations  to  fulfil.  '  More  than 
this,  as  Dr.  Schweck  had  well  said  in  the  Philadel- 
phia Press  :  "  People  of  means  who  go  to  charity  dis- 
liensaries  and  receive  treatment  free  of  charge,  repre- 
senting themselves  to  be  too  poor  to  pay  for  medical 
services,  commit  a  criminal  act,  for  they  obtain  what 
they  are  not  entitled  to  and  do  it  under  false  pre- 
tences."" 

Another  and  important  aspect  of  this  subject  had 
been  revealed  in  a  communication  from  Dr.  G.  M.  Roe, 
medical  superintendent  of  the  Boston  City  Hospital, 
to  the  Boston  Herald.  He  says:  "It  is  a  generally 
accepted  fact  among  people  who  have  had  large  expe- 
rience in  doing  charitable  work  that  the  first  thing 
that  a  man  or  woman  will  accept  as  charity  is  medical 
attendance.  They  will  accept  free  ser\-ice  from  the 
doctor  when  you  could  not  prevail  upon  them  to  accept 
rent  or  fuel  or  anything  of  the  kind  as  a  gift.  The 
acceptance  of  gratuitous  medical  attendance  is  the  first 
step  toward  pauperism.  There  is  already  a  tendency 
toward  what  is  generally  known  as  '  nationalism  ' — a 
belief  among  the  common  people  that  the -city  and  the 
State  owe  them  a  living,  and  that  medical  attendance, 
;niong  other  things,  should  be  furnished  them  by  com- 
mon taxation,  regardless  of  their  financial  standing  as 
individuals."'  -Again,  as  Dr.  J.  J.  .Stevenson  had  ex- 
pressed it  in  the  Mail  and  Express:  "  If  recoveryjrom 
disease  be  secured  at  the  expense  of  self-denial,  the 
memory  of  the  cost  will  lead  in  ordinary  cases  to  care 
that  a  recurrence  of  disease  and  attendant  expenses 
may  be  prevented.  But  if  the  careless  feel  that  treat- 
ment, medicine,  and  even  diet  can  be  had  simply  for 
the  asking,  there  can  be  no  reason  for  resisting  the 
natural  tendency  to  neglect  the  laws  of  health.  ...  It 
is  not  surprising  that  the  reckless  poor  see  in  such 
careless  giving  an  acknowledgment  of  the  unequal  dis- 


tribution of  wealth,  and  believe  that  it  is  founded  on 
injustice;  nor  is  it  strange  that  the  anarchist's  cr}'  is 
not  for  opportunity  to  earn  by  labor,  but  for  such  dis- 
tribution of  wealth  as  may  enable  all  to  enjoy  the 
luxury  of  idleness."' 

The  following  are  the  conclusions  arrived  at  by  Dr. 
Wiggin  after  a  critical  review  of  the  subject:  (i)  That 
medical  charity,  as  at  present  administered,  is  an  un- 
qualified evil  and  is  seriously  menacing  our  existing 
social  conditions;  (2)  that  the  application  for  free 
treatment  of  those  able  to  pay  the  physician  a  moder- 
ate fee  for  his  services  robs  the  really  poor;  (3)  that 
all  medical  charitable  institutions  should  be  under  the 
direction  and  control  of  State  and  local  boards  of 
charities,  which  should  have  the  power  to  enforce  their 
rules ;  (4)  that  all  applicants  for  medical  charity  should 
be  investigated  by  local  charit\-  boards,  and  the  un- 
worthy e.xcluded;  (5)  that  no  medical  charitable  insti- 
tution should  be  allowed  to  charge  nominal  sums  for 
medicines  or  appliances;  (6)  that  all  physicians  con- 
nected with  charitable  institutions  should  be  paid  for 
the  ser\'ice  which  they  render;  (7)  that  it  should  be 
made  a  misdemeanor,  punishable  bv  fine,  for  anv  per- 
son to  receive  free  medical  treatment  by  reason  of  false 
representations  as  to  financial  condition;  and  (8)  that 
State  or  city  aid  should  not  be  granted  to  private 
medical  charities. 

Dr.  Wickes  Washburn,  of  New  York,  opened  the 
discussion.  He  referred  to  the  investigations  made, 
from  January  1,  1897,  to  the  present  time,  by  the  Char- 
ity Organization  Society,  of  cases  sent  to  it  by  several 
dispensaries  and  out-patient  departments  in  this  city. 
Out  of  a  total  of  four  hundred  and  forty-three  cases 
investigated  in  this  way,  one  hundred  and  eighty-nine, 
or  a  trifle  over  fifty-five  per  cent.,  were  reported  to  be 
unable  to  pay  a  moderate  fee.  The  decision  as  to  the 
financial  condition  was  based  on  the  following  data: 
11)  the  total  income  of  the  family;  (2)  the  number  in 
the  family;  (3)  the  ages  of  the  children — whether  old 
enough  to  work  or  not ;  (4)  who,  if  any,  in  the  family 
were  out  of  work,  and  how  long;  (5)  if  working, 
the  wages  paid;  and  (6)  the  general  impressions  of  the 
visitor.  After  reviewing  the  work  connected  with  the 
presentation  of  "the  dispensarv-  bill"  to  the  legislature 
last  w  inter,  the  speaker  suggested  that  section  six,  em- 
powering the  State  board  of  charities  to  enforce  the 
regulations  contained  in  the  act  and  to  punish  those 
who  wilfully  violated  its  provisions,  might  be  made 
less  objectionable  by  requiring  "  the  app^roval  of  the 
judge  of  the  supreme  court  sitting  in  the  count}-  where 
such  failure  to  comply  with  the  rules  had  occurred." 

John  Harsen  Rhoades,  Esq.,  continued  the  dis- 
cussion. He  said  that  at  the  outset  he  felt  compelled 
to  criticise  the  medical  profession  sharply,  but  in  a 
kindly  spirit,  for  it  was  in  large  measure  to  blame  for 
the  existing  abuse  of  medical  charity.  One  cause  was 
to  be  found  in  the  great  multiplication  of  hospitals  and 
dispensaries — not  always  from  the  most  worthy  mo- 
tives. This  multiplication  was  too  often  brought  about 
through  the  ambition  of  _young  medical  men  to  attach 
themselves  to  those  institutions  or  to  found  new  ones, 
that  they  might _gain  not  only  experience,  but  reputa- 
tion and  a  livelihood.  Another  cause  of  the  present 
state  of  affairs  was  to  be  found  in  the  natural  repug- 
nance of  jDhysicians  and  others  to  prjing  into  the  pri- 
vate affairs  of  those  who  may  quite  possibly  be  worthy 
objects  of  charity.  Another  reason  was  the  secret 
willingness  of  many  young  practitioners  to  conceal  the 
facts  for  purposes  of  private  gain.  Still  another  and 
a  very  important  cause  was  to  be  found  in  the  absence 
of  a  "clearing-bureau,"  where  all  cases  and  applica- 
tions for  charitable  relief  of  all  kinds,  medical  and 
otherwise,  could  be  investigated  for  the  benefit  of  all 
charitable  institutions  of  all  classes  and  sects.  With- 
out such  a  bureau  the  work  must  necessarily  be  dupli- 


;68 


MEDICAL    RPXJORD. 


[October  i6,   li 


cated  many  times  and  at  great  expense  and  disadvan- 
tage. Each  institution  should  share  the  expenses  of 
the  bureau  in  proportion  to  the  number  of  patients  re- 
corded against  each.  If  the  law  compelled  each  insti- 
tution to  send  weekly  lists  of  all  applicants  to  such  a 
central  bureau,  it  was  more  than  probable  that  the  re- 
sult would  be  the  disclosure  of  an  appalling  amount  of 
fraud  and  a  reduction  of  fifty  per  cent,  in  the  number 
of  those  applying  for  charity.  He  had  long  been  an 
advocate  of  a  paid  staff  at  such  institutions,  provided 
that  the  physicians  from  a  certain  grade  down  were 
permitted  to  remain  only  a  specified  time.  If  the  ex- 
isting system  of  medical  charity  were  allowed  to  con- 
tinue, we  would  soon  build  up  a  nation  of  paupers. 

Dr.  J.  E.  Janvrin,  of  New  York,  dwelt  upon  the 
circumstances  leading  up  to  the  presentation  of  the 
dispensary  bill,  particularly  upon  the  interview  which 
a  committee  of  which  he  was  a  member  had  had 
with  Governor  Black.  The  executive  had  objected 
to  the  bill  ostensibly  on  the  ground  that  it  gave 
too  much  power  to  one  association — the  State  board  of 
charities.  Incidentally  he  had  expressed  the  belief 
that  any  one  who  was  wealthy  had  a  perfect  right  to 
establish  a  medical  or  other  charity,  and  educate 
young  men,  rich  or  poor,  without  any  fees  whatever, 
and  if  necessary  even  to  assist  them  afterward  in  ob- 
taining business.  When  asked  if  he  would  have  ap- 
proved of  such  a  state  of  affairs  when  he  was  a  young 
lawyer,  he  replied:  "Asa  lawyer  I  should  have  ob- 
jected to  it.''  The  speaker  said  that  he  had  long  felt 
that  dispensaries  and  hospitals  should  be  conducted 
more  on  business  principles,  and  that  the  medical  offi- 
cers should  be  properly  remunerated.  He  thought  the 
proposed  amendment  of  section  six  of  the  dispensary 
bill  would,  if  enacted,  give  rise  to  many  contentions 
and  much  annoyance. 

Dr.  E.  D.  Ferguson,  of  Troy,  said  he  thought  that 
from  the  lawyer's  standpoint  legal  objections  to  the 
bill  might  arise,  particularly  in  regard  to  those  insti- 
tutions that  had  been  incorporated  prior  to  the  estab- 
lishment of  the  State  board  of  charities. 

Dr.  Leroy  J.  Brdoks,  of  Chenango  County,  thought 
that  an  important  factor  in  causing  the  enormous  in- 
crease of  applications  for  medical  charity  in  the  period 
since  1870  was  the  enormous  increase  in  the  number, 
clinical  facilities,  and  iniluence  of  the  medical 
schools.  From  information  recently  received  from 
Albany,  he  had  been  led  to  believe  that  the  medical 
schools  were  exerting  a  persistent  though  perhaps 
silent  opposition  to  this  dispensary  bill. 

Dr.  Eden  V.  Delphy,  of  New  York,  suggested  that 
a  remedy  might  be  found  in  an  ethical  restriction,  mak- 
ing it  contrary  to  the  dignity  of  the  profession  for  a 
member  to  act  as  a  physician  in  a  dispensary  which 
permitted  abuse  of  medical  charity.  The  attitude  of 
those  managing  the  medical  schools  would  suggest  the 
necessity  for  some  retaliatory  measure  on  the  part  of 
the  rank  and  file  of  the  profession,  such  as  avoiding 
tliese  men  in  consultations. 

Du.  MANEEvhad  no  faith  in  legislation  as  a  remedy 
for  the  abuse;  the  evil  was  not  with  the  dispensary 
managers,  but  with  the  medical  profession.  More  than 
this,  he  did  not  feel  that  its  members  could  be  depended 
on  to  enforce  penalties  against  brethren  in  the  profes- 
sion who  transgressed  in  these  matters. 

Dr.  J.  R.  Maw.recor,  of  New  York,  said  that  the 
question  was  one  of  fraud  on  the  part  of  individuals  of 
the  community  who  imposed  upon  tlie  profession.  We 
must  have  the  authority  of  law  if  we  expected  to  do 
away  witii  sucii  imposition.  He  thought  if  tiie  dispen- 
sary bill  liad  been  passed  earlier  in  the  last  session  of 
the  legislature,  it  might  have  been  passed  even  over 
the  governor's  veto.  Probably  the  real  reason  the  ex- 
ecutive refused  to  affix  his  signature  was  the  pressure 
brougiit  to  bear  upon  him  by  tiie  medical  colleges. 


The  Status  of  Medicine. — Dr.  Nelson  L.  Worth, 
of  Kings  County,  presented  this  paper.  He  said  that 
if  half  the  care  were  bestowed  upon  the  passage  of 
proper  laws  regulating  marriage  (and  hence  indirectly 
the  procreation  of  the  species)  that  was  given  by  the 
ordinary  farmer  to  stock  raising,  an  enormous  gain  to 
the  race  would  be  easily  apparent  in  the  lifetime  of  a 
single  individual.  The  reader  of  the  paper  then  pro- 
pounded the  following  suggestive  questions:  How- 
much  of  the  cause  of  disease  did  we  yet  know  ?  Was 
it  the  germ  or  the  toxin  of  the  germ?  Could  the  germ 
be  destroyed  without  injury  to  the  individual?  Could 
we  positively  cure  the  disease  by  controlling  the  toxin  ? 
Was  consumption  curable  now?  Was  it  any  more  so 
than  before  the  discovery  of  the  bacillus  of  tuberculo- 
sis? Did  as  many  subjects  of  phthisis  get  well  now  as 
before  Koch's  great  discovery?  Was  not  the  practice 
of  medicine  in  relation  to  phthisis  more  unsettled  and 
ineffective  now  than  before  the  discovery  of  the  tuber- 
cle bacillus?  Was  not  the  neglect  of  hygienic  and 
climatic  and  medicinal  methods  doing  more  harm  than 
the  direct  germ  treatment  was  doing  good?  In  con- 
clusion, he  expressed  the  belief  that  the  medicine  and 
surgery  of  the  closing  years  of  this  century  were 
largely  unstable  and  experimental. 

The  Growth  of  Commercialism  in  Medicine.  —  Dr. 
John  Shradv,  of  New  York,  read  a  philosophical  es- 
say on  this  subject.  He  thought  that  the  older  prac 
titioners  saw  more  of  gratitude  and  tender  remem- 
brances than  those  practising  at  the  present  time.  He 
then  gave  a  humorous  description  of  the  various  sub- 
terfuges resorted  to  by  the  Jin-de-sihle  physician  in 
order  to  secure  for  himself  a  proper  amount  of  adver- 
tising without  apparently  committing  any  breach  of 
the  code  of  medical  ethics. 

The  President's  Address,  "The  Causes  of  the 
Decline  in  the  Average  Income  of  General  Practi- 
tioners of  Medicine." — Dr.  C'harles  Phelps,  of  New- 
York,  presented  his  address,  taking  for  his  theme  the 
above  topic.  He  said  that  the  earnest  effort  made 
before  the  last  legislature  to  obtain  relief  from  certain 
abuses  of  medical  charity  was  proof  of  the  general 
diminution  in  the  incomes  of  physicians,  paiticularly 
in  this  city.  But  this  was  only  one  cause;  there  were 
others,  and  it  should  be  remembered  that  medical 
practice,  like  other  things,  was  largely  regulated  by 
the  well-known  principle  of  supply  and  demand.  It 
was  also  easily  demonstrable  that  liie  amount  of  sick- 
ness in  our  community  had  notably  diminished.  This 
increased  healthfulness,  even  the  public  was  now  will- 
ing to  admit,  was  largely  due  to  the  advances  made  in 
tiie  bacteriological  and  pathological  laboratories,  and 
to  a  better  control  over  disease  by  the  proper  sanitary 
authorities.  Thus,  epidemic  dysentery  had  become 
unknown  here,  and  variola  was  practically  unknown. 
The  maintenance  of  a  reasonable  standard  of  purity 
for  milk  and  proper  supervision  of  plumbing  had  done 
much  to  diminish  gastro-intestinal  disorders.  Tiie 
eftect  of  the  improved  cleanliness  of  the  streets  on  the 
public  health  was,  in  his  opinion,  problematical. 
Among  other  causes  mentioned  were  the  general  busi- 
ness depression,  the  want  of  a  proper  adjustment  of 
the  fees  to  the  incomes  of  the  patients,  the  business 
methods  in  vogue  at  the  present  time,  the  more  com- 
plicated mechanism  for  the  treatment  of  disease,  and 
the  increasing  custom  of  sending  patients  to  sanitaria 
and  hospitals.  The  speaker  concluded  by  expressing 
tlie  belief  that  the  remedy  would  not  be  found  in  leg- 
islation except  by  an  inordinately  rigid  and  di.stasleful 
surveillance,  whicli  would  be  unbecoming  an  honora- 
ble profession. 

A  Study  of  Alcohol,  Tobacco,  Tea,  and  Coffee  as 
Causative  Factors  in  the  Production  of  Nervous 
Disorders.  —  Dr.  Charles  E.  Eockwood,  of  New 
York,  read  this  paper.      He  said  that  in  the  United 


October  i6,   1897] 


MEDICAL    RECORD. 


56q 


States  in  1895,  the  total  amount  of  distilled  spirits  con- 
sumed was  78,823,561  gallons;  of  wines,  19,644,000: 
of  malt  liquors,  143,232,106  gallons.  Statistics  were 
also  quoted  to  show  that  the  consumption  of  tea  and 
coffee  has  decreased,  while  the  use  of  malt  liquors  has 
greatly  increased.  In  brief,  it  might  be  said  that 
alcohol  is  a  stimulant  in  moderate,  and  a  narcotic  in 
toxic  doses:  tobacco  is  a  stimulant  and  sedative  in 
moderation,  but  relaxing  and  paralzying  in  toxic 
doses;  while  coffee  and  tea  are  nervous  stimulants 
in  moderate  doses,  and  depressing  but  not  narcotic  in 
toxic  doses.  Recent  experiment  seemed  to  prove  that 
small  quantities  of  alcohol  do  not  interfere  with  gas- 
tric digestion,  and  at  times  even  assist  it.  Wines 
retard  pancreatic  and  salivary  digestion,  and  malt 
liquors  retard  salivary  digestion.  Alcohol  first  at- 
tacks the  cerebrum,  then  the  cerebellum,  cord,  and 
automatic  centres  in  the  medulla,  in  the  order  named. 
Alcohol  acts  on  the  nerve  cells  directly  as  a  func- 
tional poison,  and  hence  the  subsequent  depression. 
According  to  Gowers,  epilepsy  is  occasionally  an 
effect  of  alcoholic  excess.  It  has  not  yet  been  deter- 
mined beyond  dispute  that  amblyopia  and  optic-nerve 
atrophy  may  result  from  alcoholism.  A  very  com- 
mon result  of  alcoholism  is  peripheral  neuritis.  The 
effects  of  tobacco  are  largely  inlluenced  by  the  per- 
sonal equation,  and  are  often  shown  by  various  func- 
tional disorders.  Coffee  in  excess  produces  insomnia, 
disorders  of  special  sense,  frequent  irregular  heart 
action,  and  muscular  tremor.  The  effects  of  tea  are 
those  produced,  in  a  general  way,  by  overstimulation. 

Resolution  Concerning  the  Dispensary  Abuse. — 
Dr.  E.  1).  Ferguson  offered  the  following  resolution, 
which  was  unanimously  adopted: 

''^Resolved,  That  this  association  is  heartily  in  svm- 
pathy  with  the  efforts  being  made  to  correct  the  hospi- 
tal and  dispensary  abuses  in  the  State,  and  that  a 
committee  of  five  be  appointed  by  the  president  to  rep- 
resent the  association  in  efforts  to  be  made  to  correct 
the  said  abuses." 


Second  Day —  Wednesday,  October  ijf/i. 

Stricture  of  the  Rectum. — Dr.  W.  S.  McL.^ren, 
of  Litchfield,  Conn.,  read  this  paper.  He  said  that  it 
had  been  customary  to  divide  rectal  strictures  into  two 
large  classes,  viz.:  (i)  congenital,  (2)  acquired. 
We  did  not  see  congenital  strictures,  although  in  rare 
instances  one  observed  imperfect  development  of  the 
anus,  but  not  a  true  stricture.  A  stricture  in  its  very 
nature  was  acquired.  The  author  divided  rectal  stric- 
tures into  malignant  and  non-malignant  strictures. 
The  former  were  subdivided  into  (i)  traumatic,  (2) 
dysenteric,  (3)  tuberculous,  (4)  simple  ulcerative,  and 
(s)  venereal.  Under  the  head  of  the  causes  of  trau- 
matic stricture  were  to  be  mentioned  kicks  and  blows, 
operative  procedures,  and  the  use  of  irritating  fluids. 
It  must  be  extremely  rarely,  if  at  all,  that  stricture  of 
the  rectum  was  caused  by  kicks  or  blows.  In  the 
many  cases  of  dysentery  occurring  in  the  army  during 
the  late  war,  not  one  had  a  stricture  of  the  rectum; 
dysentery  usually  affects  the  upper  part  of  the  bowel. 
Simple  ulceration,  if  extensive  enough  to  involve  the 
deep  layers  of  the  rectum,  might  cause  stricture.  Su- 
perficial ulcerations  were  frequently  observed  to  heal 
without  causing  any  contraction  whatever.  The  vene- 
real division  naturally  included  the  great  majority  of 
rectal  strictures. 

Symptomatology:  The  chief  if  not  the  only  symp- 
tom was  obstruction.  The  "ribbon  stool"  could  not 
be  looked  upon  as  of  the  slightest  diagnostic  value, 
for  although  commonly  found  in  connection  with  rec- 
tal stricture,  it  was  also  an  accompaniment  of  other 
conditions.     One  could  hardly  lay  too  much  stress  on 


the  importance  of  making  a  digital  examination  in 
suspected  cases,  for  the  records  showed  all  too  fre- 
quently that  physicians  were  prone  to  neglect  this  very 
necessary  preliminary  step  to  intelligent  treatment. 
In  some  cases  it  would  be  noted  that  the  patient  would 
have  a  free  evacuation  at  first ;  then  there  would  be  an 
interval  of  a  few  minutes,  and  another  stool.  This 
might  be  again  repeated  after  another  short  interval. 

Treatment :  Bougies  should  be  chosen  which  easily 
pass  the  stricture,  and  these  should  be  introduced 
daily  and  allowed  to  remain  for  ten  or  fifteen  minutes. 
The  bowel  should  be  unloaded  by  mild  laxatives  and 
enemata.  In  performing  the  radical  cure  the  stricture 
should  be  divulsed  and  a  gauze  plug  inserted  in  the 
centre.  This  prevented  hemorrhage  and  secured  good 
drainage. 

Dr.  E.  D.  Ferguson  said  that  the  successful  treat- 
ment of  these  difficult  cases  depended  very  largely 
upon  the  thoroughness  with  which  the  mucous  ano 
muscular  coats  and  the  connective  tissue  around  the 
gut  itself  were  divided.  Unless  the  incision  was  car- 
ried down  to  normal  connective  tissue,  the  cure  would 
not  be  permanent.  The  treatment  by  bougies  mighl 
possibly  effect  an  occasional  cure,  but  the  treatment 
was  protracted  and  was  not  entirely  devoid  of  danger. 

Pyothorax  in  Children — Dr.  Dougl.as  Avres,  of 
Montgomer}'  County,  read  a  paper  with  this  title.  He 
said  that  statistics  showed  that  pyothorax  occurred 
most  frequently  during  the  first  five  or  six  years  of 
life,  and  that  the  tendency  to  it  diminished  rapidly 
with  advancing  age.  According  to  a  conservative  es- 
timate, one-third  of  all  the  cases  of  effusion  into  the 
pleural  cavity  in  young  children  were  purulent  in 
character.  Among  the  diseases  predisposing  to  this 
condition  were  pneumonia,  scarlatina,  acute  desqua- 
mative nephritis,  tuberculosis,  diphtheria,  and  whoop- 
ing-cough. General  effusion  was  the  rule,  and  cystic 
effusion  the  exception  in  infants  in  whom  there  was 
no  previous  inflammatory  action.  The  speaker  di- 
rected attention  to  the  very  great  importance  of 
making  frequent  and  thorough  examinations  of  the 
chest  in  children  suffering  from  acute  diseases.  This 
was  more  necessary  in  infancy  than  at  any  other  period 
of  life.  Owing  to  the  yielding  nature  of  the  chest 
walls  in  young  children,  the  examiner  might  often  de- 
tect fluctuation.  The  constitutional  symptoms  varied 
so  greatly  in  children  as  to  make  it  unsafe  to  place 
much  reliance  upon  them.  If  fluid  were  found  and  it 
had  accumulated  ver}'  rapidly,  especially  if  there  were 
at  the  same  time  an  elevation  of  temperature,  it  was 
probable  that  the  fluid  was  purulent.  The  degree  of 
temperature,  however,  was  not  a  sure  indication  of  the 
character  of  the  effusion.  The  point  could  be  easily 
and  definitely  determined  by  the  use  of  the  aspirating 
needle.  It  should  be  borne  in  mind  that  children  did 
not  bear  delay  in  operating  as  well  as  adults;  hence 
the  need  in  these  cases  for  an  early  evacuation  of  the 
fluid.  While  statistics  seemed  to  prove  that  early  and 
repeated  aspiration  effected  many  cures,  his  own  ex- 
perience had  been  that  even  after  such  treatment  it 
had  been  usually  necessary  ultimately  to  make  a  free 
incision  into  the  chest.  Late  operating  was  more 
difficult  and  dangerous,  and  the  chance  of  effecting  a 
complete  and  permanent  cure  was  not  so  good.  The 
incision  was  preferably  made  in  the  sixth  intercostal 
space,  under  antiseptic  precautions.  A  large  single 
tube  would  answer  in  infants  under  three  years  of  age, 
but  for  older  children  a  double  tube  was  better.  The 
tube  should  be  carefully  secured  by  a  shield  and 
safety  pins.  If  the  pus  was  not  offensive  and  the 
temperature  not  high,  irrigation  was  not  indicated  and 
might  prove  harmful.  If  the  pus  was  offensive  or 
there  were  present  clots  of  considerable  size,  irriga- 
tion with  boric  acid  or  Labarraque's  solution  should 
be  employed.     This  irrigation  should  be  repeated  daily 


570 


MEDICAL    RECORD. 


[October  i6,  1897 


as  long  as  fetor  continued  or  until  the  discharge  be- 
came serous. 

The  author's  conclusions  were  as  follows:  (1)  The 
time  for  operation  is  when  the  symptoms,  verified  by 
exploratory  puncture,  reveal  the  presence  of  pus;  (2) 
the  operation  of  incision  and  drainage  is  followed 
by  the  best  results  and  early  and  perfect  recovery :  (3) 
aspiration  does  not  remove  the  pus  fully,  the  treatment 
is  necessarily  slow,  and  it  is  likely  to  prove  a  source 
of  inflammation,  necessitating  the  secondarj'  operation 
by  incision ;  and  (4)  incision  is  followed  by  a  large 
percentage  of  recoveries,  the  drainage  is  rapid,  and 
leaves  no  nucleus  for  future  trouble. 

Dr.  Ferguson  said  that  it  had  seemed  to  him  that 
the  key  to  the  frequency  of  empyema  in  early  child- 
hood was  to  be  found  in  the  susceptibility  of  that  pe- 
riod of  life  to  broncho-pneumonitis.  We  had  only  to 
conceive  of  the  involvement  of  a  lobule  near  the  sur- 
face of  the  lung  to  understand  how  the  inflammatory 
process  might  extend  to  the  surface,  how  the  pleural 
surface  might  be  altered  mechanically,  and  how,  as  a 
result,  the  germs  might  readily  find  their  way  into  the 
pleural  cavity. 

Report  of  Some  Unusual  Cases  of  Appendicitis. 
— Dr.  Joseph  D.  Bryant,  of  .New  York,  read  this 
paper.  The  first  cases  cited  were  examples  of  a  class 
of  chronic  appendicitis  characterized  by  an  abundant 
fibrinous  e.xudation.  His  conclusions  regarding  this 
series  were:  (i)  That  enormous  deposits  of  lymph 
may  be  the  only  product  of  disease;  (2)  though  even 
repeated  attacks  occur,  suppuration  is  not  a  common 
sequel;  (3)  free  incision  of  the  mass  and  gauze  pack- 
ing were  followed  by  rapid  absorption  and  ultimate 
cure;  (4)  suppuration  may  occur — hence  the  apendix 
should  be  removed ;  (5)  fibrous  induration  due  to 
chronic  appendicitis  may  be  mistaken  for  sarcoma  of 
the  caecum;  and  (6)  the  influence  of  malaria  may 
stimulate  this  manifestation  of  chronic  appendicitis. 
Several  miscellaneous  cases  were  then  reported.  In 
one,  notwithstanding  the  assertion  of  the  patient  that 
his  appendix  had  alreadN-  been  removed  by  operation. 
Dr.  Br)-ant  was  able  to  find  and  remove  a  complete 
vermiform  appendix,  three  inches  in  length.  In  an- 
other case  there  was  an  unusually'long  appendix,  ex- 
tending upward  along  the  outer  aspect  of  the  ascend- 
ing colon;  and  the  unusual  extent  of  the  gangrene  at 
the  time  of  the  operation  showed  conclusive!)'  that  the 
gangrenous  process  had  existed  at  the  time  that'he  had 
first  seen  the  case — in  other  words,  when  the  symp- 
toms and  signs  had  been  so  mild  as  to  make  the  sur- 
geon feel  justified  in  postponing  operative  interference. 
Another  case  was  cited  in  illustration  of  the  fact  that 
there  might  be  an  early  and  excessive  febrile  reaction, 
without  a  proportionately  severe  lesion. 

Absence  of  the  Vermiform  Appendix. — The  last 
case  was  that  of  a  young,  ner\-ous,  and  robust  woman, 
who  experienced  pain  on  deep  pressure  over  the  ap- 
pendix, but  operation  was  declined.  The  following 
year  a  return  of  the  symptoms  made  the  patient  consent 
to  operation.  There  were  at  this  time  a  well-marked 
point  of  tenderness  and  a  small  tumor,  revealed  by 
deep  pressure.  At  the  operation  the  most  careful 
scrutiny  failed  to  disclose  the  least  inflammation  or 
the  presence  of  an  appendix.  According  to  one  ob- 
server the  appendix  was  absent  only  once  in  two  hun- 
dred cases.  A  small  tumor  was  found  on  the  poste- 
rior wall  of  the  ca2cum,  at  the  usual  location  of  the 
appendix. 

The  Surgery  of  Tuberculosis  of  the  Peritoneum. 
— Dr.  P.arker  Svms,  of  New  York,  presented  a  com- 
munication on  this  subject.  He  said  that  in  a  large 
proportion  of  cases  of  tuberculous  peritonitis  a  simple 
laparotomy  would  effect  a  permanent  cure.  This  phe- 
nomenon was  without  an  analogue  in  surgery.  The 
following  theories  had  been   advanced  to  explain   it: 


{I)  That  it  was  due  to  the  chemical  disinfectants 
used;  (2)  that  it  was  to  be  attributed  to  drainage;  (3) 
that  it  was  due  to  the  exposure  of  the  abdominal  cav- 
ity to  light  and  air;  (4)  that  it  depended  upon  the  re- 
moval of  the  ascitic  fluid;  (5)  that  it  resulted  from 
the  accidental  introduction  of  bacteria  and  the  pro- 
duction of  a  toxalbumin  which  was  fatal  to  the  tuoer- 
cle  bacillus;  (6)  that  the  operation  and  attendant  han- 
dling of  the  peritoneum  constituted  a  traumatism,  and 
resulted  in  a  fibrinous  peritonitis  and  encapsulation  of 
the  bacillus:  (7)  that  the  cure  was  due  to  the  advent 
of  leucocytes  and  the  resulting  phagocytic  action  ;  and 
(8)  that  the  mere  opening  of  the  abdominal  cavity 
brought  about  a  physiological  change  in  the  perito- 
neum, and  consequently  rendered  the  peritoneum  an 
unsuitable  soil  for  the  growth  of  the  tubercle  bacilli. 
In  a  long  series  of  cases  in  which  antiseptics  were 
employed,  the  percentage  of  recoveries  was  slightly 
higher  than  in  those  cases  in  which  no  such  agents  had 
been  used.  Again,  the  patients  recovered  better  with- 
out drainage  than  with  it.  The  last  of  the  theories 
mentioned  was  perhaps  the  most  plausible,  but  even 
this  was  but  little  better  than  begging  the  question. 
Dr.  Syms  said  that  in  1890  he  had  presented  a  paper  in 
which  he  expressed  the  following  views,  and  these  he 
still  held:  (i)  That  the  danger  of  the  operation  was 
very  slight — the  mortalit}-  being  about  three  percent.: 
(2)  that  sepsis  was  not  so  likely  to  occur  in  these 
cases,  owing  to  the  pathological  changes  in  the  peri- 
toneum :  (3)  that  tuberculous  infection  of  the  wound 
did  not  occur:  (4)  that  disinfectants  were  useless  and 
drainage  should  not  be  used;  (5)  that  in  successful 
cases  the  operation  did  no  harm;  (6)  that  established 
but  not  advanced  pulmonary  tuberculosis  was  an  indi- 
cation for  and  not  against  this  operation,  for  it  enabled 
the  patient  better  to  withstand  the  phthisis;  and  (7) 
that  laparotomy  was  the  proper  treatment  for  these 
cases.  From  a  pathological  standpoint  there  were 
three  varieties  of  peritoneal  tuberculosis,  viz.:  (i) 
the  ascitic,  (2)  the  fibrino-plastic,  and  (3)  the  case- 
ous or  suppurative  form.  As  a  matter  of  fact  these 
represented  stages  rather  than  varieties  of  the  disease, 
and  they  were  frequently  associated  in  the  same  case. 
Clinically  there  were  two  varieties,  viz.,  those  with 
and  those  without  ascites.  The  incision  should  be 
large  enough  to  allow  satisfactory  exploration  of  the 
abdominal  cavity.  The  ascitic  fluid  should  be  evacu- 
ated. If  there  were  much  granulation  tissue  with  ad- 
hesions, the  latter  should  be  separated,  if  this  could 
be  done  bv  gentle  manipulation.  He  advised  against 
irrigation  or  attempted  medication  of  the  abdominal 
cavity.  Drainage  delayed  healing,  and  this  was  se- 
rious in  such  cases.  Of  course,  careful  attention 
should  be  given  to  the  general  condition  of  the  pa- 
tient. Statistics  seemed  to  show  that  at  present  the 
mortality  was  a  little  over  two  per  cent.,  that  marked 
improvement  was  noted  in  about  eighty  per  cent.,  and 
that  permanent  cure  was  effected  in  about  thirty  per 
cent,  of  all  cases  operated  upon. 

Dr.  Sw.^n,  of  Saratoga,  said  that  while  at  the  Johns 
Hopkins  Hospital  he  had  seen  about  ten  cases  of 
tuberculous  peritonitis  in  Dr.  t^sler's  wards,  and  their 
course  had  seemed  to  confirm  the  claim  made  by  Dr. 
Osier  that  a  large  number  of  these  cases  would  go  on 
to  recovery-  without  operation:  he  had  also  seen  in 
the  same  hospital  twelve  cases  operated  upon  by  Dr. 
Howard  Kelly,  by  simple  laparotomy  and  closure  of 
the  abdomen  without  drainage.  These  patients  were 
all  improved  before  leaving  the  hospital,  but  Dr. 
Kelly  claimed  that  only  about  fifty  per  cent,  of  the 
patients  were  "cured" — /.(■.,  remained  free  from  all 
relapse  for  a  period  of  five  or  six  years.  The  speaker 
then  reported  a  case  of  tuberculosis  confined  to  the 
pelvic  peritoneum— a  very  rare  condition.  At  the 
time  of  operation  several  loops  of  intestine  were  found 


October  i6,  1897] 


MEDICAL    RECORD. 


571 


to  be  adherent  by  "cystic"  peritonitis,  and  three  of 
these  loops  were  studded  with  miliary  tubercles.  The 
woman  promptly  recovered  from  this  operation,  and 
he  had  then  opened  the  main  cyst  through  the  vagina, 
and  evacuated  about  one  quart  of  caseous  material. 

Dr.  H.  D.  Did.\ma,  of  Syracuse,  asked  if  Dr.  Syms 
would  advise  laparotomy  in  a  case  in  which  the  diag- 
nosis of  tuberculous  peritonitis  was  reasonably  clear, 
even  if  there  was  no  fluid  to  be  drawn  otT. 

Dr.  Syms  replied  in  the  affirmative. 

Dr.  Ely  Van  de  Warker,  of  Syracuse,  said  that  he 
believed  he  had  had  the  honor  of  introducing  this 
subject  into  English  literature,  in  a  paper  read  before 
the  American  Medical  .Association  in  1883,  on  "The 
Cure  of  Tuberculosis  of  the  Peritoneum  by  Laparot- 
omy." These  cases,  he  said,  bore  drainage  ver}- 
badly.  Occasionally,  when  there  was  pus  accumu- 
lations beneath  the  pelvic  fascia,  drainage  through  the 
vaginal  roof  would  be  required.  The  good  results 
from  the  surgical  treatment  of  tuberculosis  of  the  peri- 
toneum he  believed  were  largely  attributable  to  the 
free  flushing  of  the  cavity. 

Dr.  Syms  closed  the  discussion.  He  said  that  in 
using  the  word  "  cure"  in  connection  with  these  cases 
he  had  adopted  Koenig's  standard,  viz. :  that  cases 
going  for  two  years  after  the  operation  without  a  re- 
lapse might  fairly  be  looked  upon  as  "cures."  Ac- 
cording to  this  criterion,  Koenig's  cases  showed  about 
twenty-four  per  cent,  of  cures.  In  the  succcessful 
cases  the  improvement  was  so  rapid  and  so  remarka- 
ble that  it  could  not  reasonablv  be  explained,  as  some 
would  have  us  believe,  on  the  theory  of  coincidence. 
In  estimating  the  curability  of  tuberculosis  of  the 
peritoneum  without  operation,  one  should  give  due 
weight  to  the  fact  that  in  a  very  large  majority  of 
cases  it  was  an  utter  impossibility  to  make  a  positive 
diagnosis  without  opening  the  abdomen. 

Tetanus. — Dr.  Frederic  S.  Dennis,  of  New  York, 
presented  a  paper  on  this  subject,  in  which  he  dwelt 
particularly  on  the  treatment  of  tetanus  by  the  anti- 
to.\in.  He  said  that  it  had  been  proved  beyond  doubt 
that  tetanus  is  an  infectious  disease,  caused  by  the 
presence  of  a  germ  that  had  been  discovered  by  Xico- 
laier  in  1884.  A  case  had  been  reported  in  which 
this  bacillus  had  gained  entrance  without  an  abrasion 
of  any  kind.  Such  an  origin  might  be  possible,  but 
certainly  the  usual  mode  of  entrance  was  through  an 
abrasion  or  trifling  wound  of  the  skin.  The  spores  of 
the  tetanus  bacillus  resist  death  for  a  long  time;  they 
have  after  eleven  jears  been  found  alive  on  a  piece  of 
wood  taken  from  the  body  of  a  boy  who  died  of  tetanus. 
The  toxin  of  tetanus  could  be  obtained  in  much  the 
same  manner  as  that  of  diphtheria.  There  was,  how- 
ever, an  important  clinical  difference,  since  the  toxin 
of  tetanus  was  capable  of  producing  all  the  phenomena 
of  the  disease  without  the  pathogenic  presence  of  the 
tetanus  bacilli.  The  toxin  of  tetanus  is  a  most  viru- 
lent poison ;  it  had  been  estimated  that  one-three-hun- 
dredth grain  would  kill  a  human  being.  It  produced 
its  lethal  effect  very  rapidly.  The  fact  that  the  lesions 
were  located  in  the  nervous  system  explained  the  good 
effects  that  had  been  obtained  from  the  administration 
of  chloral  and  similar  drugs.  In  discussing  the  treat- 
ment, a  sharp  distinction  must  be  made  between  acute 
and  chronic  tetanus.  A  study  of  the  effects  of  the 
antitoxin  enabled  him  to  fix  upon  the  fourteenth  day 
as  a  point  of  differentiation  between  the  two  varieties 
of  the  disease.  As  a  result  of  his  thorough,  exhaus- 
tive, and  scientific  study  of  the  subject  bz  felt  impelled 
to  state  that  the  facts  did  not  at  pre.sent  warrant  the 
concluiion  that  in  the  tetanus  antitoxin  a  remedy  ex- 
isted which  would  invariably  cure  tetanus,  yet  they 
did  show  that  it  was  a  remedy  of  the  greatest  value, 
particularly  in  connection  with  immunization  and  pre- 
vention.    The  antitoxin  of  tetanus  was  obtained  from 


the  serum  of  horses  that  had  been  immunized  against 
tetanus  by  hypodermatic  injections  of  the  toxins  of  the 
bacillus  of  tetanus.  No  animal  had  ever  died  from 
tetanus  which  had  been  rendered  immune  by  the 
tetanus  antitoxin  before  inoculation  with  the  disease. 
According  to  Welch,  the  results  were  better  in  propor- 
tion to  the  length  of  the  inoculation  period,  and  that 
this  remedy  was  of  little  or  no  value  if  this  period 
was  less  than  ten  days,  or  if  convulsions  had  already 
set  in.  The  prophylactic  treatment  of  tetanus  was 
limited  to  those  cases  in  which  the  wound  had  been 
inflicted  in  such  a  manner  as  to  allow  garden  earth, 
or  the  plaster  from  walls,  or  a  rusty  nail  to  come  in 
contact  with  it. 

As  regards  other  methods  of  treatment,  statistics 
pro\ed  that  chloroform  was  a  very^  valuable  adjuvant, 
having  reduced  the  death  rate  ten  per  cent,  in  one 
series  of  cases.  Chloral,  given  in  doses  of  one  hun- 
dred to  two  hundred  grains  daily,  was  also  very  use- 
ful, having  decreased  the  mortality  si.x  per  cent.  In- 
deed, it  was  because  of  the  evident  value  of  these 
agents  in  tetanus  that  it  had  been  so  difficult  to  judge 
of  the  part  played  by  the  tetanus  antitoxin  in  those 
reported  cases  in  which  both  had  been  used. 

Regarding  the  prognosis,  the  speaker  said  that  the 
mortality  was  eight  times  greater  in  chronic  tetanus  in 
those  over  twenty-five  years  of  age  than  in  those 
younger  than  this.  The  period  of  incubation  was  also 
an  important  element  in  the  prognosis.  He  had' col- 
lected twenty-four  cases  of  tetanus,  in  twelve  of  which 
the  duration  of  the  period  of  incubation  was  above 
fourteen  days,  and  in  twelve  below  fourteen  days.  In 
the  former  series  there  were  two  deaths,  or  a  mortality 
of  si.Kteen  per  cent. ;  in  the  latter,  there  were  eleven 
deaths,  or  a  mortality  of  ninety-one  per  cent.  Expe- 
rience had  shown  that  large  doses  of  antitoxin  (twenty 
cubic  centimetres  or  more,  three  times  a  day  for  adults) 
were  necessarj-,  and  also  that  it  must  be  continued  for 
some  time.  Success  was  greatly  enhanced  by  proper 
treatment  of  the  wound.  Carbolic  acid  and  bichloride 
had  little  influence  on  the  spores  unless  a  little  hydro- 
chloric acid  was  added.  .A.  half-per-cent.  solution  of 
iodine  trichloride  was  especially  potent.  As  the  toxins 
of  tetanus  were  eliminated  chiefly  by  the  kidneys,  free 
diuresis  should  be  established. 

In  conclusion.  Dr.  Dennis  said  that  he  thought  it 
had  been  fairly  well  demonstrated  that  the  mortality 
in  cases  of  tetanus,  treated  without  the  antitoxin,  was 
si.xty  per  cent.,  as  against  a  death  rate  of  thirty  per 
cent,  under  the  antitoxin  treatment. 

Dr.  B.  Cohen,  of  Buffalo,  described  the  difficulties 
encountered  with  the  older  methods  of  treatment,  and 
e.xpressed  the  hope  that  the  serum  would  soon  be  ac- 
cessible to  all  practitioners. 

Dr.  Hanan,  of  Rensselaer  Count)-,  asked  if  this 
antitoxin  proved  efficacious  in  tetanus  of  the  newborn. 

Dr.  Ferguson  called  attention  to  the  fact  that  in 
certain  regions  the  tetanus  bacillus  was  known  to  be 
generated  more  freely  in  connection  with  the  soil  than 
in  others.  The  prevalence  of  trismus  nascentium  in 
the  West  Indies  was  explained  by  the  uncleanly  hab- 
its of  the  negro  midwives,  and  the  fact  that  they  were 
brought  a  good  deal  in  contact  with  the  soil.  Where 
special  precautions  were  taken  to  avoid  infection  of 
the  umbilical  cord,  the  number  of  cases  of  tetanus  had 
been  lessened. 

Dr.  Dennis,  in  closing,  said  that  within  a  few  days 
five  cases  had  been  reported  in  which  the  antitoxin 
in  small  doses  had  been  used  in  trismus  nascentium, 
with  complete  success  in  all  of  the  cases. 

(  To  be  Continued,^ 


Salol  and  Starch,  two  parts  of  the  former  to  one  of 
the  latter,  are  found  to  be  an  efficient  dressing  in  specific 
ulcers. — Schwimmer. 


572 


MEDICAL    RECORD. 


[October  i6,  1897 


NEW   YORK    ACADEMY    OE    MEDICINE. 

Slated  Mfetiiig.    October  7,  1897. 

Edw.ard  G.  Jaxeway,  M.D.,  Preside.nt. 

Treatment  of  Puerperal  Septic  Diseases. — This  was 
the  general  topic  selected  for  the  discussion,  which 
was  under  the  charge  of  the  section  on  obstetrics  and 
gynx'cology. 

Medical  Treatment;  Prophylaxis. —  Dr.  Charles 
Jewett,  of  Brooklyn,  discussed  the  medical  treatment. 
He  said  that  for  the  occurrence  of  sepsis  in  childbirth 
the  attending  physician  must  usually  hold  himself  to 
blame;  puerperal  sepsis  was  .1  preventable  disease. 
Immunity  depended  chiefly  upon  the  cleanly  conduct 
of  the  l)ing-in,  but  prophyla.\is  must  begin  many 
weeks  before  labor.  Debility,  anaemia,  syphilis,  rheu- 
matism, paludal  poisoning,  and  toxaemias  of  various 
forms  were  all  predisposing  causes.  Retained  excre- 
nientitious  products  constituted  a  very  important  pre- 
disposing factor,  hence  particular  attention  should  be 
given  to  the  condition  of  the  kidneys.  The  origin  of 
puerperal  fever  was  to  be  found  sometimes  in  the  con- 
dition of  the  vagina.  The  presence  of  leucorrhceal 
discharges  which  were  fetid,  or  which  excoriated  the 
skin,  should  not  be  overlooked  if  proper  attention 
were  given  to  recording  the  history,  even  without  mak- 
ing a  direct  examination.  The  streptococcus  was  fre- 
quently associated  with  gonorrhceal  infection.  The 
presence  of  a  pathological  secretion  called  for  douch- 
ing with  I  to  5,000  bichloride  solution,  followed  by  a 
washing  out  with  plain  water.  Dusting  the  vaginal 
surface  ever}-  two  or  three  days  with  the  subnitrate  of 
bismuth  was  sometimes  beneficial.  In  the  presence  of 
active  gonorrhoea,  the  usual  specific  treatment  for  this 
disease  should  be  carried  out.  Obstetricians  of  spe- 
cial training  had  practically  no  death  rate  in  private 
practice,  and  in  time  the  wealthy  lying-in  woman 
might  pass  through  her  confinement  as  safely  as  her 
pauper  sister  in  a  lying-in  institution.  Yaginal  douch- 
ing during  and  after  labor  in  conditions  of  health  was 
not  only  unnecessary  but  injurious.  .\t  no  lime  was 
the  liability  to  infection  greater  than  in  the  first  few- 
hours  after  the  expulsion  of  the  child,  for  the  tissues 
were  in  a  condition  favorable  to  such  a  process,  and 
the  vitality  of  the  patient  was  at  a  low  ebb.  Manipu- 
lations in  the  passages  were  especially  dangerous  at 
the  close  of  labor,  and  hence  the  introduction  of  the 
hand  into  the  uterus  after  labor  should  not  be  under- 
taken lightly. 

Curative  Local  Treatment. — A  pelvic  exploration 
should  be  made  as  soon  as  there  was  reason  to  suspect 
infection.  This  should  include  a  speculum  examina- 
tion of  the  vagina.  Septic  vaginal  wounds  should  be 
cleansed  once  or  twice  daily,  and  touched  with  car- 
bolic acid  or  chloride-of-zinc  solution.  A  strip  of 
iodoform  gauze  should  then  be  left  in  the  vagina  to 
keep  the  walls  apart.  Vaginal  douching  was  useful 
in  the  presence  of  foul  discharges.  .'\n  antiseptic  was 
more  efficacious  than  a  plain  injection,  and  to  a  mild, 
non-toxic  antiseptic  there  could  be  no  objection. 
Such  an  agent  was  to  be  found  in  peroxide  of  hydro- 
gen, or  a  one-to-ten  Labarraque's  solution.  Douches 
should  be  given  only  by  the  physician,  and  with  the 
greatest  care.  No  active  interference  witiiin  the  uterus 
should  be  undertaken  until  the  physician  was  assured 
that  it  w-as  involved  in  the  septic  process.  A  gaping 
cervix  and  a  foul  discharge  were  presumptive  evidence 
of  such  a  condition. 

Curettage — To  the  trained  hand  the  dull  curette 
was  almost  as  satisfactory  as  the  finger  for  examina- 
tion of  the  interior  of  the  uterus,  and  was  decidedly 
safer,  and  with  it  small  shreds  of  secundines  could  be 
removed  without  injury  to  the  endometrium.     .\  few- 


drops  of  the  lochia  might  also  be  obtained  for  bacteri- 
ological examination.  If  the  membranes  were  re- 
tained, curetting  should  be  done  at  once.  It  had 
been  objected  that  a  sharp  curette  laid  open  sinuses 
and  dislodged  thrombi,  but  as  the  same  result  follow-ed 
the  use  of  the  dull  curette,  and  the  latter  was  not  so 
efficient  an  instrument,  the  writer  preferred  the  sharp 
instrument.  The  uterus  should  next  be  washed  out 
with  a  proper  antiseptic.  The  empirical  and  routine 
use  of  the  curette  had  done  harm.  The  extension  of 
the  infection  to  the  parametrium  did  not,  in  his  opin- 
ion, preclude  the  use  of  the  curette — it  rather  empha- 
sized the  need  for  its  immediate  employment.  The 
endometrium  might  be  painted  with  the  tincture  of 
iodine,  or  with  a  fifty-per-cent.  carbolic-acid  solution, 
the  uterus  having  first  been  washed  out  with  salt  solu- 
tion. Finally,  a  loose  packing  of  iodoform  gauze 
should  be  left  in  the  cavity.  He  suspected  that  the 
chief  benefit  from  the  iodoform  gauze  was  due  to  the 
iodoform,  and  not  to  the  gauze,  and  acting  upon  this 
idea  he  had  repeatedly  used  with  satisfaction  iodoform 
pencils  instead  of  the  gauze.  Intra-uterine  irrigation 
was  chiefly  of  value  to  wash  away  dead  animal  matter 
lying  free  in  the  uterine  cavity,  and  as  its  action  was 
chiefly  mechanical  many  obstetricians  preferred  ster- 
ilized water  to  active  antiseptic  solutions.  Tarnier 
advised  iodine  water.  Frequent  douching  was  decid- 
edly injurious. 

Systemic  Treatment — The  speaker  said  that  gen- 
eral measures  were  indicated  to  combat  the  constitu- 
tional effects  of  the  poison  as  well  as  to  control  the 
local  process.  Alcoholic  stimulants,  tonics,  elimi- 
nants,  and  proper  alimentation  must  be  our  main  reli- 
ance. Alcohol  should  be  given  to  the  point  of  intox- 
ication, the  maximum  daily  dose  being  a  quart  of 
brandy  or  its  equivalent.  Frequently,  however,  this 
dosage  must  be  reduced,  owing  to  the  intolerance  of 
the  stomach.  Strychnine  and  quinine  were  useful  as 
tonics,  especially  the  former,  given  in  doses  of  one- 
thirtieth  of  a  grain,  three  or  six  limes  a  day.  Quinine 
was  of  value  in  doses  of  three  or  four  grains  every  six 
or  eight  hours;  in  larger  doses  it  was  injurious  by 
hindering  oxidation.  The  diet  should  consist  only  of 
liquid  food,  given  at  short  intervals.  All  measures 
tending  to  promote  elimination  should  be  employed. 
To  this  end  it  was  important  that  ihe  patient  should 
be  made  to  drink  large  quantities  of  pure  water,  or  of 
alkaline  waters.  The  judicious  employment  of  saline 
purgatives  also  had  a  rational  therapeutic  basis  as 
eliniinants.  To  limit  the  diffusion  of  the  poison  from 
the  primary  focus,  it  had  been  suggested  by  some  to 
use  ergot.  As  the  coal-tar  products  were  not  only 
cardiac  depressants  but  hindered  elimination,  they 
should  be  very  sparingly  used;  on  the  other  hand, 
cold  bathing  increased  oxidation  and  favored  elimi- 
nation. 

Serum  Treatment  Unsatisfactory. — The  statistics 
of  the  serum  treatment  of  puerperal  sepsis  were  thus 
far  unsatisfactory.  His  own  experience  had  been 
limited  to  six  cases;  in  only  one  was  any  improve- 
ment noted,  and  this  was  temporary,  and  possibly  not 
due  to  the  serum.  In  but  few  instances  liad  injurious 
effects  been  observed,  but  there  was  still  some  reason 
for  believing  that  this  treatment  was  not  entirely  free 
from  danger.  I'he  dose  varied  from  ten  to  one  hundred 
and  twenty  cubic  centimetres  daily,  the  serum  being 
injected  subcutaneously  under  aseptic  precautions. 
Certain  inoculation  experiments  would  seem  to  show- 
that  the  serum  had  no  protective  power  whatever,  and 
hence  it  was  not  probable  that  it  possessed  any  cura- 
tive power.  Nuclein  had  been  recently  employed  in 
puerperal  sepsis,  and  some  observers  had  expressed 
the  opinion  that  it  was  better  than  the  antistreptococ- 
cus  serum.  He  had  personally  u.sed  it  in  only  three 
cases,  and  no  definite  results  had   been   obtained  in 


October  i6,  1897] 


MEDICAL    RECORD. 


573 


these.  He  used  doses  of  thirty  minims,  given  sub- 
cutaneously  at  intervals  of  four  hours. 

The  Surgical  Treatment. — Dr.  Egbert  H.  Gran- 
din  discussed  this  pliase  of  tlie  subject.  He  said  that 
the  general  adoption  of  the  view  that  puerperal  infec- 
tion was  simply  wound  infection  had  greatly  simpli- 
fied the  study  of  the  subject,  and  had  led  to  the  adop- 
tion of  well-known  general  surgical  principles  for 
treatment.  To-day  it  was  believed  that  puerperal  in- 
fection was  dependent  either  upon  to.xins  or  a  patho- 
genic infection.  When  the  condition  was  due  to 
non-pathogenic  germs,  it  was  called  "sapra-mia;" 
when  due  to  pathogenic  microbes,  "  septica;mia."  In 
the  former  the  elements  of  putrefaction  tended  to  re- 
main localized  at  the  site  of  their  origin,  and  for  this 
reason  sapramia,  treated  early  and  properly,  could  usu- 
ally be  controlled.  Septicaemia,  on  the  other  hand, 
depended  upon  the  rapid  multiplication  of  pathogenic 
germs,  so  that  the  surgeon  must  deal  not  only  with 
local  but  with  systemic  infection.  A  saprasmia  by 
improper  or  delayed  local  treatment  might  pass  into 
puerperal  septicaemia. 

Indications  for  Curettage. — The  commonest  form 
was  saprsemia,  and  the  surgical  measure  in  vogue  for 
its  control  was  curettage.  He  was  satisfied  that  this 
procedure  was  resorted  to  unneccessarily,  and  often  to 
the  detriment  of  the  patient.  He  had  himself  been  a 
culprit  in  this  matter,  and  so  could  speak  with  the 
positiveness  born  of  personal  experience.  In  saprae- 
mic  endometritis  the  curette  was  a  valuable  instrument, 
but  in  the  case  of  endometritis  due  to  the  presence  of 
pathogenic  microbes  resort  to  the  curette  caused  a 
dissemination  of  these  microbes  throughout  the  body. 
The  careful  researches  of  German  investigators  showed 
that  underlying  the  putrescent  mass  in  the  uterus  was 
a  granulation  bed  of  leucocytes,  which  opposed  a  bar- 
rier to  the  microbes  endeavoring  to  gain  entrance  to 
the  system.  If  this  barrier  were  broken  down  by  the 
curette,  the  local  infection  would  be  made  a  general 
one.  The  object  of  treatment  of  puerperal  septic  con- 
ditions should  be  to  favor  local  conditions,  and  when 
operation  was  demanded  it  should  be  done  before  the 
occurrence  of  systemic  infection.  There  were  two 
varieties  of  puerperal  endometritis — the  putrid  and  the 
septic.  In  the  former,  a  granulation  barrier  formed; 
in  the  latter,  if  the  barrier  were  present  at  all,  it  was 
extremely  thin.  Putrid  endometritis  at  the  present 
time  usually  became  septic  only  when  there  was  some 
fault  in  the  technique  at  the  time  of  delivery  or  during 
the  puerperium.  It  was,  therefore,  possible  in  the 
majority  of  cases  to  differentiate  the  form  of  endome- 
tritis present.  This  differentiation  was  accomplished 
by  exploring  the  uterine  cavity  with  the  fingers,  under 
an  anaesthetic,  prior  to  a  resort  to  the  curette.  If 
secundines  or  debris  were  found  to  be  retained,  the 
curette  should  be  used;  if  these  were  not  found,  then 
the  curette  was  contraindicated.  The  curette  should 
remove  only  the  putrid  mass,  and  the  instrument  should 
work  down  only  to  the  granulation  layer.  The  uterine 
cavity  was  next  to  be  irrigated  freely,  and  filled  with 
sterile  gauze,  not  with  the  idea  of  drainage  but  rather 
with  the  object  of  keeping  the  cavity  open  for  further 
inspection  or  treatment,  should  this  be  required.  He 
favored  the  removal  of  the  gauze  in  most  cases  after 
thirty -six  hours. 

Iodoform  Gauze  Packing  Dangerous  and  Mis- 
leading.—  Dr.  Grandin  rejected  iodoform  gauze  for 
the  reason  that  not  infrequently  it  caused  iodoform 
toxremia,  which  aggravated  the  symptoms  already 
present,  and  often  misled  the  physician  into  believing 
that  the  disease  was  passing  into  the  graver  or  septic 
form.  In  the  septic  variety  of  endometritis  the  exam- 
ination of  the  interior  of  the  uterus  under  anaesthesia 
and  perfect  asepsis  would  not  reveal  retained  mem- 
branes.    As  a  rule,   in  the  septic  form  the  less  the 


physician  resorted  to  active  measures  the  better^  his 
aim  should  be  to  kill  the  germs,  if  possible,  while 
active  only  in  the  uterus.  He  preferred  to  give  one 
intra-uterine  irrigation,  and  then  pack  with  gauze 
wetted  with  absolute  alcohol.  The  surgical  treatment 
applicable  after  the  uterus,  tubes,  ovaries,  and  perito- 
neum had  become  involved,  consisted  in  their  removal. 
The  technique  of  the  operation  was  the  same  in  dis- 
eases of  the  appendages  when  the  seat  o!  puerperal 
sepsis  as  when  this  factor  did  not  appear.  There  was, 
however,  a  vast  difference  in  the  symptomatology  and 
prognosis  following  the  operation.  This  difference 
might  be  best  described  as  due  to  a  "puerperal''  influ- 
ence. When  there  were  local  peritonitis,  salpingitis, 
etc.,  and  the  symptomatology  became  more  grave,  it 
was  probable  that  the  plastic  peritonitis  or  cellulitis- 
was  becoming  purulent,  and  if  expectant  treatment 
were  continued  general  infection  might  ensue,  or  the 
process  might  extend  and  end  fatally  in  a  general 
septic  peritonitis.  The  patient  should  be  anes- 
thetized, the  location  of  the  purulent  foci  determined,, 
and  then  these  should  be  evacuated  and  drained.  In 
reality,  this  suppurative  process  at  the  beginning  w-as- 
extraperitoneal.  When  local  peritonitis  was  associ- 
ated with,  or  merged  into  a  metritis,  early  recognition 
and  very  radical  surgery  were  necessary  to  save  life. 
The  speaker  said  that  although  he  had  read  many  re- 
ports of  apparently  desperate  cases  that  had  terminated 
in  recovery  under  treatment  by  hysterectomy,  he  had 
never  been  convincid  of  the  wisdom  of  this  method. 
The  difficulty  in  deciding  was  owing  to  the  fact  that  the 
clinical  picture  which  would  seem  to  demand  hysterec- 
tomy had  over  and  over  again  proved  fallacious.  For 
this  reason  he  favored  the  surgical  treatment  of  each 
complicating  factor  as  it  arose,  in  the  hope  that  the 
patient  could  be  tided  over  the  acute  stage,  and  the 
case  would  progress  to  a  symptomatic  cure,  or  that 
conclusive  evidence  of  the  necessity  for  hysterectcmy 
would  be  forthcoming. 

General  Septic  Puerperal  Peritonitis.— General 
septic  peritonitis,  he  said,  might  well  be  termed  the 
/>.:fe  noil-  of  the  surgeon,  and  particularly  when  it  ccm- 
plicated  the  puerperal  state.  He  did  not  believe  that 
a  well-authenticated  instance  of  the  successful  use  of 
the  streptococcus  serum  in  general  septic  puerperal 
peritonitis  had  been  reported.  Asa  rule,  general  sep- 
tic peritonitis  was  consecutive  to  puerperal  metritis,  or 
a  perforation  of  septic  pus  into  the  cavity.  In  these 
cases  systemic  infection  was  \ery  rapid,  and  the  best 
that  surgery  could  offer  was  multiple  incision,  free 
irrigation,  and,  if  found  effective,  the  removal  of  the 
uterus,  tubes,  and  ovaries.  The  exudative  or  plastic 
type  of  peritonitis  was  more  frequently  met  with  at  the 
present  time,  and  this  was  the  variety  of  peritonitis 
which  formerly  was  successfully  treated  with  enoimous 
doses  of  opium — that  drug  which  to-day  had  an  im- 
portant place  in  the  treatment  of  the  same  condition. 
When  the  exudative  type  went  on  to  the  formation  of 
pockets  of  pus,  the  best  the  surgeon  could  do  was  to 
open  them  and  drain,  remembering  that  whenever  pos- 
sible he  should  drain  in  nature's  way — i.e.,  downward. 

Serum  Treatment  Inefficient  and  Not  without 
Danger — Dr.  C.  P.  Noble,  of  Philadelphia,  opened 
the  general  discussion.  He  said  that  the  serum  treat- 
ment of  puerperal  sepsis  had  not  been  very  satisfac- 
tory in  Philadelphia.  In  that  city  an  evening  had 
been  devoted  to  a  consideration  of  the  subject,  and 
twelve  cases  had  been  reported.  Of  the  twelve  patients, 
six  recovered.  It  was  believed  that  in  six  the  treatment 
did  no  good,  that  in  two  it  was  distinctly  harmful,  and 
that  in  four  it  proved  useful.  Inquiry  seemed  to  show 
that  since  that  time  like  results  had  been  obtained. 
Undoubtedly  the  very  high  mortality  in  these  cases 
was  to  be  explained  by  the  fact  that  the  serum  treat- 
ment had  been  used    in    exceptionally  severe   cases. 


574 


MEDICAL    RECORD. 


[October  i6.   1897 


Personally  he  would  not  feel  inclined  to  use  this  treat- 
ment unless  the  bacteriological  examination  showed 
distinctly  that  the  sepsis  was  due  to  the  presence  of 
streptococci;  under  other  circumstances  such  treat- 
ment seemed  to  him  irrational. 

Vaginal  Lesions  a  Common  Source  of  Infection. 
— He  agreed  most  heartily  with  Dr.  Grandin  regarding 
the  great  importance  of  making  an  accurate  differential 
diagnosis  at  the  outset.  He  would  not  only  make  the 
e.xamination  under  an  anaesthetic,  but  he  would  look 
very  carefully  into  the  condition  of  the  vagina  as  well 
as  the  uterus.  It  was  not  at  all  uncommon  for  the  in- 
fection to  be  due  to  lesions  in  the  vagina,  and  under 
such  circumstances  if  the  vaginal  lesions  were  touched 
with  pure  carbolic  acid  it  was  improbable  that  the 
septic  process  would  extend.  In  cases  seen  at  a  later 
stage,  this  examination  and  treatment  might  be  of  ser- 
vice as  a  means  of  ditterentiation. 

A  Plea  for  Conservative  Surgery. — His  experi- 
ence had  been  that  in  puerperal  infection  the  patient 
was  much  more  likely  to  recover  with  intact  pelvic 
organs  than  when  the  infection  was  non-puerperal. 
For  this  reason  we  should  be  slow  to  do  radical  opera- 
tions in  puerperal  cases.  He  had  had  a  number  of 
cases  in  which  there  had  been  extensive  pelvic  exu- 
dates, and  yet  by  ordinary  surgical  measures  recovery 
had  been  effected,  and  the  woman  had  subsequently 
become  pregnant.  He  cited  one  case  in  which  there 
had  been  very  extensive  agglutination  of  the  tissues, 
and  yet  some  time  afterward,  having  occasion  to  oper- 
ate for  a  hernia,  he  had  had  an  opportunity  of  inspect- 
ing the  abdomen  and  pelvis.  He  had  been  greatly 
surprised  at  that  time  to  note  that  only  one  small  pel- 
vic adhesion  remained  The  speaker  advocated  drain- 
age operations  in  puerperal  cases,  resorting  if  need  be 
subsequently  to  a  more  radical  procedure,  sucli  as  the 
removal  of  a  tube.  If  the  radical  operation  were  done 
in  the  first  instance,  the  surgeon  would  often  feel  called 
upon  tD  remove  organs  which  later  on,  owing  to  changed 
condiuons,  he  would  not  feel  justified  in  extirpating. 
Regarding  irrigations,  lie  said  that  if  they  did  not 
limit  and  control  the  puerperal  sepsis  in  one  or  two 
days,  they  should  not  be  persisted  in  for  a  longer  time. 
His  experience  with  intravenous  injections  of  salt  so- 
lution iiad  been  particularly  favorable. 

Good  Results  from  the  Serum.  — Dr.  P.\ri.  F. 
Mr.NE).';  said  that  he  had  been  exceedingly  gratified  at 
the;  conservative  position  taken  by  the  readers  of  the 
p.ipers regarding  surgical  measures.  His  practice  had 
been  to  trust  largely  to  stimulants  and  good  feeding  to 
bring  about  the  recovery  of  cases  of  puerperal  septi- 
caemia in  which  no  retained  septic  matter  was  found  in 
the  vagina  or  uterus.  He  had  had  two  very  successful 
cases  in  which  the  streptococcic  serum  had  been  used, 
yet  he  would  not  say  that  the  patients  had  recovered 
because  of  the  use  of  the  serum.  In  such  a  desperate 
condition  one  would  clutch  at  almost  anything,  and  for 
the  present  at  least  he  would  be  willing  to  employ  it. 
Tiie  speaker  said  that  in  1883  he  had  read  a  paper  on 
the  use  of  antipyrin  in  puerperal  septica-mia.  At  that 
time  it  had  seemed  to  be  the  one  useful  agent,  as  it 
effectively  reduced  the  temperature  and  to  this  extent 
prevented  exhau.stion.  IMienaclin  had  taken  its  place 
in  his  practice,  but  it  was  a  very  poor  substitute. 

Use  of  the  Curette.  — He  had  changed  his  views 
regarding  curettage.  When  there  was  no  septic  prod- 
uct to  be  removed  from  the  uterus,  and  there  was 
simply  a  septic  endometritis,  no  matter  how  thick  the 
mucous  membrane  might  be,  the  curette  should  not  be 
used,  for  under  these  circumstances  it  would  serve  only 
to  promote  general  septic  infection.  The  treatment  of 
the  results  of  puerperal  septicaemia  should  be  carried 
out  on  the  old  surgical  principle  of  evacuating  pus 
wherever  found.  By  the  time  the  uterus  had  become 
so  infected  as  to  make  it  seem  necessarv  to  extirjiate 


it,  he  was  of  the  opinion  that  no  known  measure — 
hysterectomy  or  any  other-^ — would  save  that  patient's 
life.  When  there  was  a  purulent  peritonitis,  whether 
puerperal  or  not,  he  believed  the  abdomen  should 
be  opened  freely,  and,  if  necessary,  drainage  estab- 
lished from  below.  The  results  were  not  good,  but 
occasionally  a  patient  recovered  under  such  treat- 
ment; whereas  without  such  surgical  interference  all 
the  patients  died. 

Dr.  Henry  C.  Coe  recalled  one  case  in  which  he 
had  curetted  a  sloughing  uterus,  and  within  two  hours 
the  patient  had  died  of  pulmonarj- embolism.  He  was 
in  accord  with  the  view  held  by  the  late  Dr.  Lusk,  that 
we  should  not  curette  or  stir  up  a  sloughing  uterus. 
It  was  not  possible,  he  thought,  to  make  the  differen- 
tial diagnosis  in  these  cases  of  puerperal  sepsis  with- 
out giving  an  anaesthetic  and  examining  the  interior  of 
the  uterus  very  carefully  with  the  finger  or  curette ; 
even  then  it  was  difficult. 

Anteflexion  a  Common  Cause  of  Imperfect  Drain- 
age.— He  believed  that  imperfect  drainage  of  the 
uterus,  due  to  anteflexion,  was  a  more  common  cause 
of  puerperal  sepsis  than  was  generally  conceded.  He 
was  inclined  to  favor  in  these  cases  the  use  of  irriga- 
tions with  peroxide  of  hydrogen,  as  he  had  never  seen 
any  harm  from  its  use  and  had  observed  a  great  deal 
of  good  from  it. 

Oxygen  and  Saline  Injections  Useful — He  had 
found  the  intravenous  use  of  saline  solution  beneficial 
in  some  desperate  cases  of  puerperal  sepsis.  In  some 
cases  he  had  used  oxygen  inhalations  for  weeks  at  a 
time,  and  with  e.xceedingly  gratifying  results.  So  far 
as  he  had  tried  Dr.  Ill's  method  of  packing  the  uterus 
with  gauze  and  keeping  it  moist  for  several  days  with 
forty-percent,  alcohol,  he  had  been  favorably  im- 
pressed with  it.  He  had  been  looking  (or  a  suitable 
case  for  hysterectomy,  but  so  far  had  not  met  with  one 
in  which  this  procedure  seemed  to  him  justifiable. 
The  operation  for  general  septic  peritonitis  was  an 
almost  hopeless  one. 

Dr.  C.  a.  Vox  R.\mdohr  said  that  his  views,  based 
on  personal  experience,  could  be  briefly  summarized  as 
follows,  (i)  Never  use  bichloride,  for  it  had  been 
proved  again  and  again  that  under  certain  circum- 
stances, when  used  in  thegenital  puerperal  canal,  even 
in  dilute  solution  (i  to  5.000  or  10,000),  it  would  give 
rise  to  nephritis.  (2)  Wherever  there  was  a  sapr.amia, 
as  indicated  by  fever,  foul  lochia,  open  os,  the  pres- 
ence of  retained  membranes,  etc.,  remove  the  cause 
and  give  one  thorough  intra-uterine  douche.  Gauze 
drainage  was  optional.  (3)  Whenever  there  was  a  pus 
collection,  it  should  be  treated  like  anv  other  abscess. 
(4)  If  extensive  peri-uterine  abscesses  were  present  and 
the  uterus  proved  an  obstacle  to  drainage,  this  organ 
should  be  removed,  because  it  would  eventually  prove 
a  nidus  for  disease,  and  the  organ  would  never  again 
be  able  to  fulfil  its  special  mission.  (5)  Whenever 
there  was  septica-mia  present,  indicated  only  by  the 
temper.iture  and  pulse,  and  without  local  signs  or 
.symptoms,  we  should  combat  the  multiplication  of  the 
cocci,  the  high  temperature,  and  the  resulting  heart 
weakness.  For  this  purpose,  alcohol  in  large  doses 
and  hydrotherapeutics  seemed  to  have  given  the  best 
results.  (6)  The  use  of  the  coal-tar  products  as  anti- 
pyretics constituted  a  step  backward.  (7)  Local  treat- 
ment, when  systemic  infection  had  taken  place,  was 
worse  than  useless. 

Puerperal  Sepsis  Successfully  Controlled  by 
Hysterectomy.-  Dk.  H.  X.  \i.\Er.EKG  referred  to  a 
recent  case  of   puerperal  sepsis  in  which  he   had  ojier- 

ated.     The  patient,  Mrs.  F ,  eighteen  years  of  age, 

was  delivered  of  her  first  child  on  May  31st.  Her 
physician  had  informed  him  that  the  labor  had  been 
easy  and  normal,  and  that  the  placenta  had  come  away 
entire.     .\  chill  and  fever  occurred  on   the  sixth  dav. 


October  i6,  1897] 


MEDICAL    RECORD. 


and  when  first  seen  by  him,  two  days  later,  the  tem- 
perature was  103"  F.,  the  pulse  was  120,  soft  and  com- 
pressible, and  she  was  slightly  delirious.  Kxamina- 
tion  showed  the  perineum  intact,  the  labia  majora  quite 
oedematous,  no  vaginal  discharge  or  fetor,  the  cervix 
but  slightly  lacerated,  and  the  canal  well  closed.  The 
uterus  was  large  and  not  specially  sensitive  to  pres- 
sure, and  the  adnexa  were  free  from  exudate.  A  diag- 
nosis of  septic  endometritis  was  made,  and  curettage 
and  repeated  irrigations  were  advised.  With  a  sharp 
curette  he  had  removed  considerable  grayish-white 
tissue,  and  had  then  irrigated  the  uterus  with  bichlo- 
ride, I  to  3,000.  followed  by  salt  water.  Three  days 
later,  June  nth,  he  was  again  sent  for,  and  learned 
that  owing  to  the  miserable  surroundings  of  the  pa- 
tient his  directions  had  not  been  carried  out.  There 
had  been  only  temporary-  improvement  after  the  curet- 
tage. Her  condition  at  this  time  was  very  bad,  and 
she  was  removed  to  St.  Mark's  Hospital  in  the  even- 
ing. She  was  given  an  intra-uterine  douche,  but 
nothing  came  away.  By  the  evening  of  June  12th  her 
condition  had  become  so  bad  that  he  had  performed 
total  abdominal  hysterectomy.  The  broad  ligaments 
were  quite  oedematous,  but  the  adnexa  were  apparently 
normal.  At  the  close  of  the  operation  her  pulse  was 
fully  as  good  as  it  had  been  at  the  beginning.  For 
the  next  three  or  four  days  the  temperature  continued 
to  1)2  high,  owing  to  the  suppuration  in  the  portions 
of  the  broad  ligament  remaining  behind.  Drainage 
was  then  established  through  the  vagina.  The  patient 
eventually  made  a  good  recover}'.  On  opening  the 
uterus  after  its  removal,  a  large  portion  of  retained 
placenta  was  found,  which  had  become  organized.  It 
filled  the  left  horn  and  occupied  most  of  the  anterior 
wall  of  the  uterus.  It  was  particularly  fetid,  and  al- 
though the  uterus  had  been  irrigated  a  short  time  be- 
fore the  interior  was  covered  with  mucus.  He  was 
inclined  to  think  that  if  the  cervical  canal  had  been 
dilated  and  the  uterus  subjected  to  constant  irrigation, 
the  patient  might  have  recovered  without  such  a  radi- 
cal operation. 

Use  of  Ergot  an  Important  Safeguard — Dr.  Rob- 
ert A.  Mi'RRAV  said  he  thought  septic  cases  were 
often  met  with  because  the  old  rule  about  the  use  of 
ergot  had  been  neglected.  In  a  very  large  outdoor 
obstetric  experience,  at  one  time  amid  the  most  misera- 
ble surroundings,  he  had  not  had  a  single  septic  case, 
and  he  attributed  this  to  the  use  of  carbolic  acid  and 
glycerin  as  the  lubricant  for  the  examining  finger,  and 
to  the  administration  of  ergot  to  insure  good  uterine 
contraction  after  deliver}-.  This  prevented  the  forma- 
tion and  retention  cf  blood  clots  in  the  uterus.  If 
there  were  the  slightesr  rise  of  temperature,  the  inte- 
rior of  the  uterus  should  be  systematically  and  mi- 
nutely explored  with  the  finger.  If  on  the  withdrawal 
of  the  finger  the  physician  perceived  a  foul  odor,  he 
should  take  this  as  an  indication  that  the  uterus  de- 
manded local  treatment.  The  best  local  treatment  in 
his  opinion  was  by  the  curette,  followed  by  a  swabbing 
out  with  tincture  of  iodine,  alcohol,  or  carbolic  acid. 
He  knew  of  no  drug  so  efficacious  in  the  control  of  the 
fever  as  veratrum  viride,  given  in  small  doses  at  short 
intervals  until  the  pulse  became  slow.  If  it  proved 
too  depressing,  alcohol  would  always  be  found  an 
excellent  antidote.  He  had  yet  to  see  at  autopsy  a 
case  of  diffuse  peritonitis  that  had  led  him  to  think 
that  anything  could  have  been  done  surgically  to  save 
the  patient's  life.  He  agreed  with  Dr.  Grandin  as  to 
the  advisabilit}-  of  draining  in  the  extremely  localized 
cases,  and  postponing  more  radical  measures. 

Dr.  J.  Riddle  Goffe  said  that  he  preferred  to  ex- 
plore the  interior  of  the  uterus  in  these  cases  with  the 
curette  rather  than  with  the  finger,  as  there  seemed  to 
him  less  danger  of  sepsis  from  such  a  mode  of  exami- 
nation.     He  had  kept  careful  records  during  the  past 


six  years  of  the  cause  of  sepsis  in  the  cases  that  he 
had  seen  in  consultation,  and  in  ever}'  instance  the 
hand  had  been  carried  into  the  uterus. 

Unfavorable  Experience  with  the  Antistrepto- 
coccic Serum — Dr.  S.  Marx  said  that  Dr.  Grandin 
had  clearly  stated  the  limitations  of  the  curette,  bat 
had  neglected  to  say  how  the  operator  was  to  know- 
when  he  had  reached  that  "granulation  barrier."  The 
serum  treatment  had  been  found  successful  in  ordinary 
surgical  cases,  but  not  in  puerperal  ones.  This  was 
probably  due  partly  to  the  modifying  influence  of  the 
puerperium,  and  partly  to  the  occurrence  of  mixed  in- 
fection and  the  difficult)- of  removing  the  source  of  the 
infection.  In  a  large  number  of  cases  reported  as 
cured  by  the  serum,  the  condition  had  been  a  saprje- 
mia,  and  not  a  true  septiciemia.  He  had  had  five 
cases  in  which  ihe  serum  had  been  used.  In  the  first 
case  a  bacteriological  examination  showed  the  strepto- 
coccus and  the  colon  bacillus.  In  that  case  there  was 
an  antepartum  infection,  and  although  the  serum  was 
used  early  the  patient  died  very  quickly.  In  the 
second  case  nothing  but  the  streptococcus  was  found 
by  the  bacteriologist.  Fresh  Mamiorek's  serum  was 
used,  notsvithstanding  the  apparently  fair  condition  of 
the  patient,  yet  she  died  within  five  hours,  and  appar- 
ently as  a  result  of  the  injection  of  the  serum.  In  the 
third  case  the  woman  developed  an  acute  endocarditis, 
an  embolism  of  the  lung,  and  diff'use  emboli  of  the 
skin.  She  died  quite  suddenly  at  the  end  of  the  sec- 
ond week  from  pulmonary  embolism.  In  the  fourth 
case  a  bacteriological  examination  showed  streptococ- 
ci, and  the  patient  died  at  the  end  of  a  week.  In  the 
fifth  case  no  bacteriological  examination  had  been 
made.  Instead  of  the  usual  fall  of  temperature  after 
the  use  of  the  serum,  in  this  case  the  temperature  rose. 

Dr.  J,  Milton  Mabbott  called  attention  to  the  im- 
portant aid  to  diagnosis  sometimes  afforded  b}'  qui  • 
nine  or  by  an  examination  of  the  blood  for  the  mala- 
rial Plasmodium.  In  this  way  some  fevers  might  be 
explained  which  other^vise  the  attending  physician 
might  be  led  to  attribute  to  sepsis. 

The  Method  of  Intra-Uterine  Irrigation. — Dr.  W. 
Evelyn  Porter  said  that  but  little  had  been  said 
about  the  method  of  employing  the  intrauterine  irri- 
gation treatment.  Undoubtedly  the  frequent  introduc- 
tion of  the  Chamberlin  tube  would  give  rise  to  much 
discomfort  and  exhaustion,  but  if  a  flexible  sterilized 
catheter  were  introduced  well  up  to  the  fundus  and  left 
in  place,  a  rubber  drainage  tube  being  attacked  to  it 
and  brought  out  of  the  vulva,  frequent  irrigation  could 
be  employed  with  most  excellent  results.  When  a  re- 
tained portion  of  placenta  could  be  located  with  the 
finger,  the  placental  forceps  would  be  found  very- 
much  better  than  either  the  blunt  or  the  sharp  curette. 

Dr.  a.  M.  Lesser  cited  a  case  in  which  the  mala- 
rial origin  of  the  fever  had  been  clearly  proved  bv  '.he 
results  of  treatment  with  quinine.  In  his  experience 
it  had  not  been  necessary  to  use  such  large  doses  of 
alcohol  as  had  been  recommended  this  evening.  Dur- 
ing the  period  of  high  fever  his  patients  were  given 
water  and  but  little  food;  when  the  temperature  was 
lower  more  nourishing  food  was  administered.  He 
favored  the  use  of  gauze  in  the  uterus,  kept  moist  with 
alcohol. 

Dr.  Jewett  said  that  he  did  not  think  the  distinc- 
tion between  sapramia  and  sepsis  was  so  sharp  or  so 
important  as  many  were  inclined  to  believe.  He 
would  use  the  curette  in  every  case  in  w  hich  the  uterus 
contained  decomposing  clots,  necrotic  shreds  of  mem- 
brane, or  fragments  of  placenta.  He  had  been  struck 
with  the  frequency  with  which  malarial  poisoning  was 
combined  w  ith-  sepsis. 

Dr.  Grandin,  in  closing  the  discussion,  took  excep- 
tion to  the  statement  made  by  one  speaker  that  the  cu- 
rette was  preferable  to  the  finger  in  exploring  the  uter- 


576 


MEDICAL    RECORD. 


[October  16,  1897 


ine  cavity.  When  the  retained  portion  of  secundines 
had  been  removed  by  the  curette,  it  would  be  found 
that  tlie  instrument  had  reached  down  to  the  "  granu- 
lation layer." 


©tintcaX  gepjtrtmcnt. 

SOME  PRACTICAL  POINTS  GATHERED  FROM 
SOURCES    WISE   AND    OTHERWISE.'  . 

l!v    WILL    B.    DAVIS,    M.IX, 


Onck  upon  a  time  a  Texas  cowboy  gave  me  a  remedy 
for  that  disease  of  as  many  names  as  the  many  derma- 
tologists who  have  tried  to  investigate  it  have  seen 
proper  to  call  it — most  commonly  known  as  prairie  or 
winter  itch.  The  remedy  was  a  saturated  solution  of 
bichloride  of  mercury  in  alcohol,  about  one  liundred 
and  sixty  grains  to  the  ounce.  I  use  it  in  the  strength 
of  from  thirty  to  sixty  grains  to  the  ounce.  My  method 
of  applying  it  is  lightly  to  sponge  a  surface  of  about 
three  inches  square  at  a  time,  selecting  a  different 
site  for  each  successive  sponging,  repeating  the  pro- 
cedure morning  and  evening;  and  if  prompt  relief  is 
not  obtained,  sponging  over  a  larger  and  larger  extent, 
until  a  surface  of  six  inches  square  is  attained.  Usu- 
ally in  three  or  four  days  a  complete  and  permanent 
cure  is  effected — long  before  one-tenth  of  the  body 
surface  has  been  gone  over. 

In  selecting  the  sites  for  making  the  appplications, 
those  most  affected  are  to  be  preferred,  if  for  no  other 
reason  than  that  the  itching  immediately  where  the 
remedy  is  applied  is  instantly  relieved,  which  indeed 
is  a  great  temptation  to  the  sufferer  to  push  the  treat- 
ment too  far.  It  does  not  blister  or  cause  any  incon- 
venience, and  in  the  many  cases  in  which  I  have  thus 
used  the  treatment  there  was  no  constitutional  disturb- 
ance. 

The  fact  that  the  disease  was  permanently  cured 
when  a  comparatively  small  surface  of  the  body  had 
been  sponged,  satisfied  my  mind  that  its  action  was 
not  altogether  local ;  yet  in  giving  the  bichloride  in- 
ternally in  as  large  doses  as  I  dared  it  seemed  to  have 
no  effect  upon  the  itch.  Perhaps  the  dermatologist 
can  explain  this.  I  only  know  that  the  remedy  as 
giveji  is  a  quick  and  certain  specific.  To  be  sure,  it 
must  be  given  with  caution,  and  its  dangers  fully  ex- 
plained if  it  is  committed  to  the  hands  of  a  patient. 
The  fault  in  any  untoward  result  would  not  be  with  the 
remedy,  but  in  its  careless  or  reckless  use;  for  at  a 
modest  estimate  I  have  used  it  in  at  least  one  hundred 
cases,  and  know  from  personal  observation  the  entire 
correctness  of  the  foregoing  statements. 

Some  sixteen  years  ago  a  barber  gave  me  a  remedy 
for  ringworm.  It  was  a  saturated  solution  of  salicylic 
acid  in  alcohol — about  two  and  one-half  drachms  to 
the  ounce.  It  can  be  applied  with  a  hair  pencil,  or 
sponged  over  the  surface  before  retiring  at  nigiit. 
The  alcohol  soon  evaporates,  leaving  a  deposit  of  sali- 
cylic acid  in  the  form  of  a  wliite  film  or  powder,  which 
can  be  readily  washed  otf  when  desired.  One  appli- 
cation will  suffice.  In  a  few  days  the  epithelium  over 
the  affected  surface  peels  off,  and  in  a  week  or  ten  days 
the  parts  return  to  their  normal  appearance.  Nothing 
could  be  more  elegant  or  satisfactory. 

We  all  know  that  salicylic  acid  is  iiold  in  high  es- 
teem by  our  dermatologists  now,  especially  in  skin 
diseases  accompanied  witli  pruritus,  but  had  I  waited 
for  my  cue  from  these  sources  I  would  have  been  sev- 
eral years  later  in  adopting  it.  All  I  could  learn  of 
the  barber's  information  who  gave  it  to  me  was  that 
he  learned  it  from  another  barber. 

'  Re:ui  before  the  Colorado  State  Medical  Society,  at  Denver, 
June  if),   1897, 


Scarcely  a  year  or  six  months  have  passed  since  I 
joined  the  ranks  of  the  profession  but  the  files  of  the 
medical  journals  have  indicated  some  remedy  for  ob- 
stinate hiccough.  But  somewhere  in  the  early  eighties 
I  read  in  the  Mkdical  Record  a  common-sense  rem- 
edy—  one  which  I  found  to  succeed  in  one  case  of 
nearly  seventy-two  hours'  duration,  after  all  customary 
medicinal  remedies  had  failed,  and  I  have  successfully 
tried  it  in  several  cases  since.  It  was  to  make  pressure 
against  the  diaphragm.  Pressure  upon  an  affected 
muscle  will  readily  relieve  local  spasm  anywhere,  for 
a  time  at  least,  as  in  blepharospasm,  itself  sometimes 
annoying,  which  pressure  upon  the  orbicularis  palpe- 
brarum will  check. 

The  causes  of  local  spasms  are  sometimes  very- 
remote,  and  when  ascertainable  may  or  may  not  be 
readily  relieved;  but  hiccough  is  sometimes  so  dis- 
tressing and  persistent  that  it  is  a  satisfaction  to  be 
able  to  relieve  it  even  temporarily,  or  until  from 
some  imprudence  or  a  fit  of  coughing  the  spasms  are 
renewed,  when  again  the  same  remedy  may  be  used 
with  effect.  The  technical  application  consists  in  the 
operator  sitting  on  a  firm  table,  placing  one  knee  on 
the  spine  of  the  patient,  and,  with  both  hands  reaching 
around  either  side,  pressing  his  fingers  well  up  under 
the  ribs  to  the  right  and  left  of  the  epigastric  region, 
the  patient  at  the  same  time  inclining  forward,  thus 
relaxing  the  abdominal  muscles  and  facilitating  the 
effort  to  make  pressure  upon  the  diaphragm.  When  the 
hiccough  is  checked,  which  is  usually  at  once,  and  the 
operator  tires  of  maintaining  his  position,  the  pressure 
should  be  so  gradually  relaxed  that  the  patient  would 
scarcely  know  when  the  hands  were  removed. 

The  patient  could  also  be  taught  how  to  make  pres- 
sure himself  on  his  diaphragm,  in  the  event  hiccough 
should  return,  by  pressing  his  fingers  up  under  the 
ribs  as  did  the  operator,  and  assuming  a  position  to 
relax  completely  the  abdominal  muscles  which  would 
be  self-suggestive,  whether  lying,  sitting,  or  standing. 

For  chronic  constipation,  from  which  so  many  of 
the  human  family  suffer,  I  wish  most  heartily  to  in- 
dorse and  recommend  thorough  divulsion  of  the  rec- 
tum. So  universal  has  been  the  relief  from  chronic 
constipation  following  all  my  rectal  operations  in 
which  divulsion  was  required  that  I  have  recom- 
mended divulsion  in  many  such  cases  and  have  suc- 
ceeded in  inducing  some  to  submit  to  the  treatment, 
with  complete  cures  in  all  that  did.  Just  how  the  cure 
comes  about  it  is  not  the  purpose  of  this  paper  to  dis- 
cuss. I  simply  commend  divulsion  as  the  best  and 
only  permanent  cure  known  to  me.  In  the  train 
of  chronic  constipation  there  may  be  many  other  inci- 
dental troubles  which  also  are  thereby  relieved,  and 
this  fact  alone  accounts  for  many  of  the  so-called 
wonderful  cures  by  the  orificial  surgeon. 

I  believe  that  advocacy  of  this  treatment  and  its 
adoption  by  the  profession  would  do  more  than  any 
one  thing  to  bankrupt  the  patent-medicine  traffic  in 
this  country.  The  main  difficulty  in  its  application  is 
to  induce  the  patient  to  undergo  anrtsthesia  and  re- 
main in  bed  a  few  days — say  five  or  six.  The  dangers 
of  the  procedure  pertain  only  to  the  use  of  an  anass- 
thetic,  which  all  can  estimate  for  themselves.  For  my 
own  part,  I  will  sav  that  iuu  ing  been  a  lifelong 
sufferer  from  chronic  constipation  and  later  from  piles, 
and  having  submitted  to  the  treatment  myself  and 
having  since  enjoyed  such  luxurious  relief  from  con- 
stipation and  its  attendant  ills,  I  count  the  possible 
dangers  from  anaesthesia  as  nothing  compared  to  the 
immensity  of  the  gain  to  be  obtained. 

In  doing  the  operation,  to  secure  full  and  permanent 
benefit  it  should  be  done  thoroughly  and  well.  That 
is  to  say,  the  divulsion  should  be  thorough,  from 
muco-cutaneous  fold  to  rectal  ampulla.  Every  resist- 
ing fiiire  should  be  completely  paralyzed,  according  to 


October  i6,   1897] 


MEDICAL    RFXORD. 


577 


the  methods  described  in  the  books.  This  will  re- 
quire general  anesthesia,  for  local  anaesthetics  will  not 
avail. 

On  the  subject  of  appendicitis  I  beg  to  refer  to  one 
point  only — that  is,  to  the  license  which  some  sur- 
geons take,  on  the  strength  of  the  good  advice  of  Mc- 
Burney,  Morris,  and  others,  not  to  search  too  persis- 
tently for  the  appendi.x,  as  well  as  not  to  run  too  great 
a  risk  of  breaking  through  the  peritoneal  barricade  to 
remove  it  radically  when  found.  That  such  advice 
was  not  intended  to  warrant  the  opening  of  an  appen- 
dical  abscess  and  packing  with  gauze  as  a  routine 
course  is  clear  enough.  Such  men  neither  do  that 
kind  of  work  nor  advise  it. 

1  am  led  to  speak  of  this  on  account  of  the  large 
proportion  of  cases,  in  the  few  operations  I  have  done, 
which  had  been  thus  dealt  with  formerly.  I  could 
not  but  feel  that  had  reasonable  intelligence  been 
exercised  at  the  first  operations,  such  patients  would 
not  have  been  subjected  to  further  attacks  or  opera- 
tions. 1  have  been  strongly  impressed  more  than  once 
that  neither  valor  nor  its  better  part,  discretion,  had 
had  a  fair  show. 


HERNI.A.    IX    AX    IXFANT    TEiX    WEEKS    OF 
AGE. 

liv   S.    H.    CHAMPLIN,    M.IJ., 

CBICAGO,    ILL. 

In  the  Medic.a.l  Record  of  June  12th  there  is  an  ex- 
tract from  an  article  by  Dowd,'  on  "Strangulated 
Hernia  in  an  Infant  Four  Months  Old."  On  June 
27th  and  previous  to  reading  the  above,  I  was  called 
to  see  an  infant,  ten  weeks  old,  which  was  said  by  the 
mother  to  be  suffering  from  suppression  of  urine.  The 
mother  said  the  child  had  a  severe  paroxysm  of  cough- 
mg  at  four  o'clock  that  morning,  and  had  cried  con- 
tinuously up  to  the  time  of  my  visit,  at  2  r.:^.,  and  had 
not  passed  urine  during  the  interval. 

On  examination  a  small  tumor  on  the  right  side, 
about  as  large  as  the  end  of  a  man's  thumb,  was  found 
extending  through  the  external  abdominal  ring  into  the 
upper  part  of  the  scrotum,  the  testicles  were  in  their 
normal  position.  Previous  to  that  morning  the  child 
had  shown  no  evidence  of  rupture. 

Suggesting  the  possibility  of  operation  to  the  parents, 
I  told  them  that  taxis  would  first  be  attempted.  For 
thirty  minutes  very  careful  manipulations  were  tried, 
with  the  child  in  different  positions,  without  success. 

Finally  I  placed  the  baby's  head  and  shoulders  on 
my  right  knee  and  the  buttocks  on  my  left  knee  at  a 
somewhat  higher  level  than  tlie  right,  and  instructed 
the  mother  to  hold  down  the  feet,  thus  putting  the  ab- 
dominal wall  on  the  stretch.  After  about  one  minute 
of  delicate  manipulation  in  this  position,  the  bowel 
was  reduced  with  an  audible  gurgle;  and  immediately 
following  the  reduction  the  l:)aby  passed  about  two 
ounces  of  clear  straw-colored  urine.  Five  minutes 
later  the  child  was  sound  asleep. 

July  7th  I  saw  the  baby  again;  there  had  been  no 
return  of  the  hernia,  and  the  little  one  seemed  none 
the  worse  for  its  rather  severe  experience. 

I  do  not  wish  to  appear  as  an  advocate  of  prolonged 
taxis,  especially  in  children ;  but  the  parents  in  this 
case  strenuously  objected  to  an  operation,  and  I  had 
no  choice  in  the  matter.  However,  I  advised  opera- 
tion in  case  there  was  a  reappearance  of  the  hernia. 

1,002  Madison  Stkeht. 


OUR    LONDON    LETTER. 


CFr 


:  Special  Correspondent.) 


Incise  and  disinfect  at  once,  instead  of  waiting  for 
suppuration  to  occur  in  infected  wounds. — Intenia- 
tional  Journal  oj  Surgery. 

'  Archives  of  Pediatrics,  May,  1S97. 


THE     MEDICAL     COUNCIL     ELECTION A    NEWSPAPER    ON 

ABUSE  OF  MEDICAL  CHARITIES — "  OUIDa"  ON  CRUELTY 

—  MEDICAL       RETICENCE CYCLE       ACCIDENT       TO      A 

DOCTOR HEALTH    OF    MR,    E.    HART — SIR    S.  WILKS — 

EPIDEMIC    OF     TYPHOID — DEATHS    OF    DRS.    FLETCHER 

AND    RYE DIPHTHERIA. 

London,  September  24,   1B97. 

The  election  of  a  direct  representative  to  the  Medical 
Council,  which  I  announced  as  imminent  last  week, 
presents  curious  perplexities.  Dr.  Rentoul's  resigna- 
tion necessitated  the  election.  <>n  Monday  it  was  an- 
nounced that  he  had  withdrawn  his  resignation  in  a 
letter  to  the  president  dated  the  i8th.  This  letter  was 
referred  to  the  legal  advisers  of  the  council,  who  pro- 
nounce the  resignation  inoperative.  So  the  election 
proceeds.  Another  candidate  has  come  forward  in  the 
]5erson  of  James  Arthur  Rigby,  M.D.,  of  the  London 
L'niversity,  etc.  In  a  long  address  he  gives  some  ac- 
count of  his  thirty-three  years'  experience  and  the 
views  he  advances.  He  is  a  strong  advocate  of  the 
claims  of  the  general  practitioners,  and  takes  almost  a 
trades-union  view  of  their  rights.  He  laments  that 
"  the  old-fashioned  consulting  physician  is  rapidly  be- 
coming a  thing  of  the  past  and  is  being  superseded  by 
the  modern  specialist."  To  the  latter  he  scarcely  ac- 
cords justice,  but  this  may  perhaps  be  excused  in  an 
election  address.  If  we  are  to  have  specialists  at  all, 
he  would  have  them  attain  their  position  through  ex- 
aminations and  diplomas  for  the  dignity,  such  as  have 
been  inaugurated  in  the  public-health  service.  Few 
people,  however,  whom  I  have  met  consider  the  public- 
health  diplomas  a  blessing  save  to  the  corporations  and 
individuals  that  finger  the  fees.  This  item  in  his  pro- 
gramme is  far  less  taking  than  his  denunciation  of 
medical-aid  societies,  prescribing  chemists,  advertising 
quacks,  and  the  newspapers  which  sell  their  columns 
to  the  worst  impostors.  In  a  summary  he  announces 
first  of  all,  that  he  will  "try  and  suppress  all  mis- 
chievous, lying,  and  filthy  advertisements  which  dis- 
figure what  should  be  a  respectable  press."  If  sending 
Dr.  Rigby  to  the  council  would  be  likely  to  accomplish 
this  one  of  his  proposed  reforms,  he  might  reckon  on 
his  return  by  an  overwhelming  majority. 

Dr.  Dolan,  of  Halifax,  is  another  candidate,  as  he 
was  at  the  last  election.  He  stands  as  a  general  prac- 
titioner, and  says  he  is  willing  to  give  way  to  any  such 
who  may  be  more  widely  supported,  but  not  to  a  con- 
sultant like  Mr.  Horsley.  This  cry  that  representation 
was  given  to  the  general  practitioners  as  such  is  inac- 
curate. They  are  not  recognized  as  a  distinct  class  in 
the  act.  It  is  registered  practitioners  who  have  a  vote, 
and  of  course  consultants  of  all  kinds  are  registered. 
It  is  true  the  generals  are  in  an  overwhelming  majority 
and  can  carry  any  election,  but  it  is  quite  possible  a 
consultant  may  be  a  model  representative  of  their  in- 
terests, and  Mr.  Horsley 's  work  on  the  Defence  Union 
has  produced  the  widespread  impression  that  he  is 
such  a  one.  He  addressed  an  influential  meeting  of  the 
profession  at  Manchester  on  Tuesday,  and  was  assured 
of  the  almost  unanimous  support  of  those  ])resent. 

The  rumor  that  Sir  \V.  Foster  might  come  forward 
is  confirmed,  I  regret  to  say.  He  had  his  day  in  the 
council,  and,  though  it  is  the  cue  of  the  wire-pullers  in 
the  British  Medical  Association  to  extol  him  and  his 
own  cue  to  talk  of  "our  great  association,"  it  is  diffi- 
cult to  see  what  he  achieved.  He  could  have  kept  the 
seat  when  he  had  it,  but  having  left  it  should  be  con- 
tent to  see  it  occupied  by  some  one  else.  The  council 
will  be  all  the  better  for  new  blood. 


578 


MEDICAL    RFXORD. 


[October  i6,  1897 


The  Globe  came  out  last  Monday  with  an  editorial 
note  on  the  abuse  of  dispensaries  and  hospitals,  which 
is  gratifying  to  medical  reformers.  It  is  refreshing  to 
find  one  of  our  best-conducted  newspapers  denouncing 
■'  the  exceedingly  mean  people  who,  without  the  excuse 
of  poverty,  victimize"  medical  charities,  and  urging 
subscribers  '"  to  exercise  all  possible  care  in  complying 
with  requests  for  letters  of  recommendation." 

Here  the  Globe  hits  the  nail  on  the  head,  for  it  is 
undoubtedly  a  fact  that  ver)-  few  subscribers  consider 
it  a  duty  to  make  any  inquiry  about  an  applicant  for 
a  letter.  Many,  indeed,  look  upon  their  subscription 
as  purchasing  so  many  letters  to  distribute  among  their 
dependants  as  a  cheap  charity. 

"  Ouida"  has  been  denouncing  in  vigorous  terms  the 
slaughter  of  birds  which  goes  on  in  Italy  and  to  some 
extent  in  England  too.  Quite  recently  some  rare 
birds  were  shot  as  soon  as  they  appeared  here.  Every- 
one will  agree  with  "Ouida"  so  far,  but  she  unfortu- 
nately joins  to  her  denunciation  equal  condemnation  of 
dog  muzzles  and  Pasteurism,  and  declares  that  if  the 
public  does  not  close  the  laboratories  "the  whole  hu- 
man race  will  be  blood  poisoned."  She  adds:  "The 
danger  is  clearly  enough  recognized  by  those  who  are 
not  the  dupes  of  scientists.  I  think  the  domination  of 
these  empirics  is  the  greatest  calamit)'  that  has  ever 
befallen  mankind."  "Ouida"  in  her  tantrums  is  less 
amusing  than  at  other  times,  and  the  scientists  will 
survive  her  anger. 

The  responsibilities  of  practitioners  as  to  the  ob- 
servance of  reticence  about  patients  seem  to  increase, 
and  juries  are  talcing  a  severe  view  of  remarks  affect- 
ing the  friends  or  guardians  of  the  sick.  A  case  of 
libel  was  tried  on  Saturday  against  a  parish  doctor, 
who,  in  defending  himself  against  a  charge  of  neglect- 
ing a  child  with  diphtheria,  wrote  to  the  board  of 
guardians  that  the  neglect  was  on  the  parents'  side  in 
not  calling  in  a  doctor  earlier.  He  added  that  the 
child's  life  was  insured,  and  that  when  the  mother 
came  for  the  certificate  of  Jeath  she  was  intoxicated. 
His  letter  was  read  to  the  board  and  an  action  was 
brought.  The  jury  found  for  the  parents  and  assessed 
the  damages  at  ^200,  but  notice  of  appeal  was  given 
on  the  ground  that  the  amount  was  excessive.  The 
judge  advised  the  parents  to  accept  much  less,  said 
half  would  have  been  sufficient,  and  the  case  was  ad- 
journed. Unless  substantial  reduction  is  made,  the 
judge  promised  to  grant  a  new  trial. 

Mr.  R.  J.  Stephens,  M.R.C.S.,  met  his  death  from  a 
bicycle  accident  on  the  iith  inst.  He  was  riding 
down  a  hill  with  his  feet  on  the  rest,  in  company  with 
professional  friends,  when  the  cycle  suddenly  swerved 
and  he  fell  on  his  head.  He  died  the  same  night, 
without  having  recovered  consciousness,  from  cerebral 
hemorrhage  of  considerable  extent.  He  was  only 
thirty-four  years  old. 

Mr.  Ernest  Hart,  whose  indilTerent  health  was  well 
known  in  certain  circles,  has  had  to  undergo  a  serious 
operation,  amputation  of  the  leg,  for  necrosis  of  bone 
in  the  foot  supervening  on  ulceration,  probably  con- 
nected with  the  glycosuria  of  which  he  was  the  subject. 
The  operation  was  well  borne,  and  I  hear  to-day  that 
he  is  convalescent  from  it. 

The  old  pupils  and  friends  of  Sir  S.  Wilks  propose 
to  entertain  him  at  a  dinner. 

A  serious  outbreak  of  typhoid  has  occurred  at 
Maidstone,  Kent.  More  than  three  hundred  cases 
have  been  notified. 

Dr.  .Adam  Fletcher,  of  Kury,  where  he  had  practised 
for  nearly  half  a  century,  died  on  the  28th  ult.  He 
was  a  justice  of  the  peace  and  greatly  respected. 

Mr.  Brisley  Rye  died  on  the  ist  inst.  He  had  for 
some  years  retired.  He  was  born  in  1S12,  and  took 
his  M.R.C.S.  in  1S36. 

The  deaths   registered   last   week   from   diphtheria 


numbered  thirty-five,  being  ten  in  excess  of  the  preced- 
ing week,  but  six  below  the  corrected  decennial  aver- 
age. In  reference  to  this  disease.  Dr.  F.  J.  Allan,  the 
able  medical  officer  of  health  of  the  Strand  district, 
remarks  in  his  report  that  in  the  first  nine  weeks  of 
the  quarter  the  number  of  cases  notified  in  London 
had  been  two  hundred  and  fifty-nine  per  week,  the 
number  for  the  corresponding  week  of  last  year  hav- 
ing been  two  hundred  and  sixty-four.  So  far  the  cases 
notified  were  under  the  number  of  the  same  period  of 
1896.  He  thinks  the  reason  why  considerable  alarm 
has  been  expressed  is  that  the  asylums  board  has  not 
in  its  hospitals  sufficient  accommodation  for  the  in- 
creasing class  of  patients  who  are  ready  to  resort  to 
them.  Within  the  next  two  months  the  disease 
reaches  its  usual  maximum,  and  from  present  appear 
ances  Dr.  .Allan  does  not  consider  it  probable  that 
there  will  be  so  manv  cases  as  last  vear. 


THE   PREVENTION  OF  UTERINE  DISPLACE- 
MENTS. 

To  THE  Editor  of  the  Medical  Record 

Sir:  Permit  me  to  correct  a  remark  attributed  to  me 
in  your  report  of  the  discussion  on  Dr.  Savidge's  pap)er 
on  "  Retrodeviations  of  the  Uterus,'  in  last  week's 
Medical  Record.  I  did  not  say  that  I  had  for  many 
years  recommended  "  that  every  parturient  woman 
should  have  a  pessary  introduced  before  she  was  al- 
lowed to  get  out  of  bed"  "as  a  prevention  of  subinvo- 
lution.'' That  would  be  an  unnecessary  and  very 
useless  practice,  and  decidedly  "  meddlesome  gynacol- 
og)'."  What  I  did  say  was  that  I  had  for  many  jears 
advised  the  introduction  of  a  pessary  as  a  cure  for  an 
old  retrodisplacement  of  the  uterus  before  a  parturient 
woman  so  afflicted  was  allowed  to  leave  her  bed,  at  the 
time  when  all  her  pelvic  organs  were  undergoing  invo- 
lution. That  is  quite  a  different  thing  from  inserting 
a  pessary  into  every  puerpera  as  a  prevention  of  a  pos- 
sible subsequent  displacement  or  the  occurrence  of 
subinvolution.  Paul  F.  Munde,  M.D. 

20  West  Foktv-Fifth  Street,  October  9,  1897. 


%zm  |!nstmraents. 

A   NEW   SEPTUM    KNIFE. 
Bv   JOSEPH    E.    FULD.    M.D.. 


N'DERBILT    CLINIC. 


The  accompanying  illustration  represents  a  new  in- 
strument which  I  have  devised  and  used  with  great 
satisfaction  in  removing  cartilaginous  obstructions 
in  the  nasal  passages.  It  consists  of  a  thin-bladed 
knife,  about  two  and  one-half  inches  long,  narrowing 
toward  a  blunted  point:  the  cutting  edge  is  patterned 
somewhat  similarly  to  that  of  the  modern  household 
knife,  but  the  knife  differs  from  the  latter  in  being 
sharpened  on  both  sides,  and  this  I  consider  a  great 
advantage,  as  it  tinis  keeps  its  edge  better  and  it  can 
be  used  for  either  side  of  the  nose.  It  may  safely 
be  said  that  the  majority  of  surgeons  who  operate  on 
the  nose  have  been  confronted  with  the  same  obstacles 
which  lead  me  to  present  this  instrument  to  the^ pro- 
fession. -Among  the  more  important  of  these  I  would 
mention; 

1.  The  difficulty  of  catching  hold  of  soft  cartilage 
with  a  saw,  owing  to  its  elasticity  and  free  mobilit)-. 
This  difficulty  is  overcome  by  my  instrument,  which 
combines  the  action  of  both  saw  and  knife. 

2.  The  astonishingly  small  amount  removed  at  the 
first  attempt;  especially  is  this  the  case  in  operating 
on  deviated  septa;    we  begin  to  saw  at  the  base,  and 


October  i6,  1897] 


MEDICAL    RECORD. 


579 


when  we  have  fairly  gotten  hold  with  the  saw  we 
find  our  instrument  at  the  tip  of  the  projection.  Con- 
sequently but  a  small  portion  of  cartilage  over  the 
point  is  removed,  and  for  tlie  removal  of  the  remaining 
cartilage  a  second  or  third  operation  is  necessarj-. 

3.  The  slowness  of  the  operation,  which  generally 
taxes  the  patience  of  both  the  physician  and  the  pa- 
tient.    This  is  a  consideration  of  g^eat  moment  in 


the  case  of  children,  in  whom  rapidil}'  ot  o;xi.ui'>n  is 
of  first  imporlance. 

A  single  trial  of  this  new  septum  knife  will  con- 
vince the  operator  of  its  usefulness  and  advantages 
over  the  saw  in  removing  ecchondromata  and  deviated 
septa. 

My  ideas  were  carefully  carried  out  by  W.  F.  Ford 
&  Co.,  of  New  York,  by  whom  the  instrument  is  man 
ufactured. 

165  East  Eighty-Second  Street. 


pCMioil  Stems. 

Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitar}-  Bureau,  Health  Department,  for  the 
week  ending  October  g,  1897  : 


Cases. 


Tuberculosis 211 

Typhoid  fever 42 

Scarlet  fever I  qp 

Cerebro-spinal  meningitis :  o 

Measles 64 

Diphtheria I  I54 

Larj'ngeal  diphtheria  (croup) I  S 

Chicken-pox i 


Ptomain  Poisoning. —  Some  deaths  which  have  re- 
cently occurred  in  Lichfield,  England,  from  ptomain 
poisoning  after  the  eating  of  frozen  mutton,  have 
caused  quite  a  flutter  in  the  breasts  of  importers  and 
purveyors  of  frozen  meat.  The  Auslralian  Trading 
World,  commenting  on  the  matter,  suggests  a  some- 
what novel  theory  as  to  the  cause  of  ptomain  ]3oison- 
ing  —  a  theory  which  is  not  without  a  suspicion  of 
having  been  suggested  by  self-interest.  The  editor 
holds  that  in  ancient  cities,  like  Lichfield,  where  many 
of  the  houses  are  from  one  hundred  and  fifty  to  two 
hundred  years  old,  although  these  places  may  be  out- 
wardly clean,  nevertheless  the  condition  under  the  sur 
face  is  deplorable,  and  that  in  most  instances  to  this 
hidden  unsanitary  state  must  be  attributed  the  food 
poisoning  rather  than  to  the  meat  itself. 

The  Temperature  of  Newborn  Children. — .\s  the 

result  of  a  clinical  study,  Miihlmann  (^Ari/iiv  fiir 
Kindcrhfilkiindc,  I!,  .xxiii.,  H.  iv.,  v.,  p.  291 )  has  found 
that  the  average  temperature  of  all  children  does  not 
differ  from  that  of  adults.  Occasionally  temperatures 
as  low  as  34.5"  C.  (94.1'  F.)  are  found,  but  like  con- 
ditions may  be  observed  exceptionally  in  very  old 
persons.  The  average  temperature  of  twenty -one  new- 
born children,  however,  taken  in  the  rectum  with  an 
exposure  of  ten  minutes,  was  found  to  be  36.3°  C. 
(97.3°  F.).  No  appreciable  difference  was  noted  be- 
tween the  temperature  of  boys  and  that  of  girls;  the 
differences  between  the  two  sexes  was  not  greater  than 
that  between  newborn  children  of  the  same  sex.  With 
regard  to  temperature  variations,  there  was  in  the 
twenty-one   cases   studied   no  correspondence  in   the 


daily  course.  A  correspondence  existed  among  a  cer- 
tain group  of  children  when  the  temperature  was  taken 
upon  the  same  day  and  in  the  same  room.  Ihe  regu- 
larity of  the  temperature  course  observed  in  some  chil- 
dren did  not  correspond  with  that  found  in  adults, 
maxima  appearing  at  times  during  the  night,  and 
minima  during  the  day.  The  maxima  could  not  be 
attributed  to  digestive  or  muscular   activity,  as  food 

was  so  given  and  the  observations  were  so 
^M    timed  as  to   avoid   these   influences.      Special 

muscular  activity  appeared  without  influence 
upon  the  temperature,  although  bathing  was  attend- 
ed by  the  greatest  activity  and  was  the  cause  of  the 
greatest  variation  in  temperature.  The  usual  in- 
fluences believed  to  be  responsible  for  the  daily 
maxima  in  adults — e.g.,  daylight,  activity,  nervous 
excitement,  etc. — appeared  without  influence  upon 
children,  the  temperature  actually  declining  at  a  time 
when  all  of  these  were  in  operation.  The  belief  is 
expressed  that  the  most  important  factor  in  causing 
the  variations  in  the  temperature  of  the  newborn  is 
to  be  found  in  the  surrounding  atmosphere. 

A  Feat  of  Memory — The  purely  intellectual  at- 
tribute we  call  memory,  which  '"  is  not  a  function,  but 
only  a  resultant  due  to  the  concurrence  of  the  various 
elementary  functions  of  the  mind,"  is  capable  of  almost 
illimitable  development,  as  Max  Miiller's  accounts  of 
the  recitations  of  the  Brahmins  or  Sir  William  Hamil- 
ton's references  to  the  feats  of  the  humanists  of  the 
Renaissance  sufficiently  demonstrate.  Both  the  phi- 
lologist and  tlie  metaphysician,  however,  are  at  one  in 
thinking  that  the  habits  of  the  present  time — above 
all  the  desultory,  particularly  the  ephemeral,  reading 
now  well-nigh  universal — are  not  favorable  to  such 
feats.  Indeed,  ^L^.x  Miiller  says  that  the  daily  perusal 
of  the  Times  for  ten  years  would  have  sufficed  to  im- 
pair the  strongest  memory  ever  Brahmin  possessed. 
That  the  feats,  however,  of  a  Scaliger  or  a  Lipsius 
are,  even  at  the  close  of  the  nineteenth  century,  quite 
possible,  was  demonstrated  the  other  day  at  Sondrio 
(capital  of  the  Valtellina),  where  the  advocate  Signer 
Edoe,  professor  in  the  Istituto  di  San  Lorenzo,  re- 
peated, for  a  wager,  in  twenty  hours  consecutively — 
from  6  P.M.  till  2  p.m.  of  the  next  day — without  prompt- 
ing or  aid  of  any  sort,  the  entire  "  Divina  Commedia" 
of  Dante.  The  achievement  came  oft'  in  presence  of  a 
committee  of  brother  professors  and  literary  men,  who 
afterward  entertained  the  performer  at  a  banquet,  not 
unwelcome,  one  would  imagine,  to  either  party  after 
such  an  effort  of  brain  tension  and  vocal  articulation 
on  the  one  hand,  and  sustained  surveillance  ad  aper- 
tiiram  Ubri  on  the  other.  The  '"  Divina  Commedia,"  I 
need  hardly  remind  the  reader,  consists  of  nearly  a 
hundred  cantos,  and  of  all  poetical  compositions  is 
the  least  diffuse— characterized,  that  is  to  say,  by  the 
closest  condensation  of  thought  and  expression.  The 
late  Duke  of  Sermoneta  (Sir  Walter  Scott's yf(/«j-  Acha- 
tes on  his  memorable  visit  to  Rome  in  1832)  could 
also  repeat  the  "  Divina  Commedia"  from  first  to  last, 
but  that  was  the'  result  of  lifelong  study,  not,  as  in 
Signor  Edoe's  case,  the  outcome  of  comparatively 
short  preparation,  begun  and  ended  for  the  purpose  of 
winning  a  wager. — Rome  Correspondent  oj  The  Lancet. 

Sunlight  and  Bacteria — In  view  of  the  destructive 
effect  of  sunlight,  especially  of  the  blue  to  the  ultra- 
violet rays,  upon  bacteria  in  water.  Prof.  H.  Marshall 
Ward  would  explain  the  comparative  freedom  of  river 
waters  under  the  blazing  hot  summer  sun  from  bacte- 
ria, as  against  the  more  abundant  infection  of  the 
same  waters  in  winter.  Pasteur  and  Miguel  found 
that  the  germs  lloating  in  the  air  are,  for  the  most  part, 
dead — killed,  the  author  holds,  by  the  sun.  Yeasts 
which  normally  vegetate  on   the  exterior  of  ripening 


58o 


MEDICAL    RECORD. 


[October  i6,  1897 


grapes  are  destroyed,  according  to  Martinaud,  if  the 
heat  be  very  intense;  and  Guinti  has  observed  that 
the  ingress  of  sunlight  hinders  acetic  fermentation. 
When  the  typhoid  bacillus  falls  into  turbid  dirty  water 
in  summer,  it  finds  a  congenial  propagating  place. 
The  dirt  furnishes  it  food,  absorbs  heat  to  increase  the 
warmth,  and  keeps  off  the  hostile  blue  and  violet  rays. 
— Popular  Science  Alonthly. 

A  Surgeon's  Culinary  Skill. — According  to  the 
London  Evening  News,  Mr.  Lawson  Tait  is  a  wonder- 
ful cook  and  concocter  of  new  dishes.  He  frequently 
invites  his  confreres  to  strange  meals  all  the  items  of 
which  have  been  either  prepared  or  invented  by  him- 
self. 

Somatic  Therapeutics. — Gain  in  body  weight  and 
improvement  in  neurasthenic  conditions  usually  go 
together,  but  there  are  enough  e.xceptions  to  the  rule 
to  show  that  nervous  nutrition  is  something  more  than 
a  mere  sample  of  the  general.  The  more  nearly  symp- 
toms approach  in  character  to  the  "  fi.xed  idea"  of  the 
insane,  the  less  amenable  are  they  to  the  beneficial 
effect  of  mere  somatic  therapeutics. — Medical  Times 
ami  Hospital  Gazette. 

Worry. — Moden.  science  has  brought  to  light  noth- 
ing more  curiously  interesting  than  the  fact  that  worry 
will  kill,  and  the  way  in  which  it  kills  is  stated  to  be 
that  worry  injures  beyond  repair  certain  cells  of  the 
brain.  The  brain  being  the  nutritive  centre  of  the 
body,  the  other  organs  become  gradually  injured,  and 
when  some  disease  of  these  organs  or  a  combination 
of  them  arises  death  finally  ensues.  Occasional 
worrying  of  the  system  the  brain  can  cope  with,  but 
the  iteration  and  reiteration  of  one  idea  of  a  disquiet- 
ing sort  the  cells  of  the  brain  are  not  proof  against. 
—  P/iannaeeiitical  Products. 

Vital    Statistics  of   Philadelphia For  the  week 

ending  September  4th  there  were  reported  to  the 
Philadelphia  board  of  health  399  deaths,  12  more 
than  during  the  preceding  week,  and  .37  more  than 
during  the  corresponding  week  of  the  previous  year. 
Of  the  whole  number,  159  occurred  in  children  under 
five  years  of  age.  The  principal  individual  causes  of 
death  were  as  follows-  Pulmonary  tuberculosis,  37; 
cholera  infantum,  36,  marasmus,  26;  heart  disease, 
25  ;' nephritis,  21;  gastro-enteritis  and  old  age,  each 
18,  diphtheria  and  pneumonia,  each  17;  apople.xy, 
carcinoma,  and  convulsions,  each  13  ;  typhoid  fever  and 
inanition,  each  11;  inflammation  of  the  brain  and 
whooping  cough,  each  10.  There  were  reported  dur- 
ing the  week  also  80  cases  of  typhoid  fever,  67  of 
diphtheria,  and  35  of  scarlet  fever. 

Bacterial  Mud. — An  instance  of  oxide  of  iron  asso- 
•ciated  with  bacteria  occurring  on  a  large  scale  has 
"been  investigated  by  Prof.  Manabu  Miyoshi,  who 
holds  the  chair  of  botany  in  the  University  of  Tokio 
in  Japan.  The  material  examined  by  him  was  a  fer- 
ruginous mud  from  the  hot  springs  of  Ikao.  This 
mud  consists  entirely  of  bacteria.  The  bacteria  seem 
to  resemble  the  leptothrix  ochracea  of  Kiitz,  but 
further  observations  will  be  necessary  in  order  to 
determine  whether  they  constitute  a  new  species  or 
not.  From  experiments  made  with  hydrochloric  acid 
Professor  Miyoshi  is  led  to  belie\e  that  the  oxide  of 
iron  is  not  deposited  on  the  walls  of  the  cells  but  is 
more  or  less  intimately  incorporated  with  them.  No 
others  of  the  more  common  iron-containing  bacteria, 
such  as  crenothrix  Kiihmana,  were  found  in  this 
particular  mud. — Lancet. 

Health  Reports. — The  following  statistics  concern- 
ing yellow  fever,  cholera,  plague,  and  small -pox  have 
been   received  in    the    office   of    the   supervising   sur- 


geon-general of  the   United  States    Marine  Hospital 
service  during  the  week  ended  October  9,  1897  ; 


Fever— United  States. 

Cas«    Deaths. 

-■\labaina,  AIco October  8th x 

Mobile October  i5t  to  8th ..  ....      4 

Louisiana.  New  Orleans October  1st  to  8th 277  22 

Mississippi,  Biloxi    ....October  ist  to  8th m  5 

Clinton To  date  (October  8th) 10  i 

Edwards October  ist  to  Sth 118  11 

Henderson's  Point  October  7th 3 

McHenry October  1st  to  5th 2 

Nitta  Vunia October  3d  toSth 9 

Scranton October  ist  to  8th 68  z 

Yellow  Fever — Foreign. 

Brazil,  Para September  nth  to  18th 3 

Cuba,  Cardenas September  nth  to  25111 5 

Matanzas September  22d  to  2ytii 3 

Santiago September  18th  to  25th 10 

Jamaica,  Kington August  28th  to  September  18th      5  4 

Mexico,  Mazatlan ,  .September  25th  to  October  2(i.      ..  9 

tJ.  S.  of  Colombia,  Panama.  ...September  15th  to  23d i  1 


Chol 


-Foreign. 


India,  Bombay September  ist  to  7th 

Calcutta August  31st  to  28th. . .  

Madras .\ugust  2Sth  to  September  3d  . 

Japan,  Osaka  and  Hiogo August  28th  to  September  4th 

Pl.^gle— Foreign. 

India,  Bombay September  ist  to  7th 

Sm.^ll-Pox— United  States. 

.\labama,  Bessemer September  25th  to  October  2d.. 

Small-Pox— Foreign, 

Uohemia,  Prague September  nth  to  18th   

Canada,  Montreal .- October  1st  to  6th 

Egypt,  .\Ie.vandria .\ugust  13th  to  26th   

Cairo August  13th  to  26th 

England,  Sheffield .September  nth  to  18th 

India,  Calcutta .\ugust  21st  to  28th 

Madras .\ugust  28th  to  September  3d. . 

Scotland.  Glasgow September  nth  to  i8th 

Spain,  Barcelona July  ist  to  31st 

Madrid September  7th  to  14th 

Russia,  Moscow September  4!h  to  nth 

Warsaw September  nth  10  18th...    


^ooka  glcceiiicd. 

While  the  Medical  Record  is  pleased  to  receive  all  new  publi- 
caticns  which  may  be  sent  to  it^  and  an  aeknowUdgment  ivill  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  -with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  will  not  be 
of  interest  to  its  readers. 


Medicines.     By   Dr.    T 
The  Macmillan  Company. 


I.ECTIKES     ON      THE     ACTION      OF 

Lauder   Brunton.      Svo,  673  pages. 
New  Vork. 

Essentials  ok  Obstetrics.  By  Dr.  C.  Jewett.  assisted 
by  Dr.  H.  F.  Jewett.  i2mo,  35S  pages.  Illustrated.  Lea 
Brothers.^:  Co.,  riiiladelphia.      Price,  $2.25. 

TlBERClLOSIS  OF  THE  GeNITO-UrINARV  ORGANS.  By  Dr. 
X.  Senn.  Svo,  317  pages.  Illustrated.  W.  B.  Saunders, 
Philadelphia. 

Circulation  ok  the  iCIentral  Xervois  System.  By  Dr. 
\Vm.  Browning.  Svo,  173  pages.  Illustrated.  I.  B.  Lippin- 
cott  Company.  Philadelphia.      Price,  $1.50. 

.\  Qriz  Manual  ok  Histology.  By  Dr.  Charles  B.  Reed 
anil  F.  B.  Noyes,  B..\.,  D.D.S.  l2mo,  203  pages.  TheW,  T. 
Keener  Company.  Chicago. 

Manual  of  Bacteriology.  By  Dr.  R.  Muir  and  Dr.  L 
Ritchie.  i2mo,  519  pages.  Illustrated,  The  Macmillan  Com- 
pany, New  Vork.      Price,  $3.25. 

.■Vl'PENDlcnis.  By  Dr.  11.  Mynter.  Svo.  303  pages.  L  B. 
l.ippincott  Company,  Philadelphia,  Pa.      Price,  $2.00. 

.\  System  of  Medicine.  Vol.  III.  Edited  by  Dr.  T.  C. 
.Mlbutt.  Svo.  1,176  pages.  Illustrated.  The  Macmillan  Com- 
pany, New  York. 

Origin  of  Dise.\se.  By  Dr.  A.  V.  Meigs.  Svo,  229  pages. 
Illustrated.     J.  B.  Lippincott  Company,  Philadelphia. 

Constipation.  By  Dr.  H.  Illoway.  Svo,  495  pages.  Illus- 
trated.    The  Macmillan  Company.  New  York.      Price,  $4.00. 

Text-Book  ok  Medical  and  Surgical  Gyn.ccology'.  By 
Dr.  R.  \V.  Garrett.  Svo,  419  pages.  Illustrated.  J.  A.  Car- 
veth  vS:  Co. ,  Toronto,  Ont.      Price,  $2. 50. 

Diseases  of  the  Gall  Bladder  and  Bile  Ducts.  By  A. 
W.  M.  Kobson,  F.R.C.S.  Svo,  177  pages.  Illustrated.  Wil- 
liam Wood  and  Company,  New  Vork. 


Medical  Record 

A  IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  17. 
Whole  No.  1407. 


New  York,   October    23,    1897. 


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©vigiiml  Articles. 

A  CLINICAL  REVIEW  ILLUSTRATING  THE 
DIFFERENCE  BETWEEN  ASEPSIS  AND 
ANTISEPSIS.^ 

By  J.    block,    M.D., 

K.\NS.\S  CITV,    MO. 

That  medicine  as  an  art  had  its  origin  in  a  spirit  of 
benevolence  seems  easily  conceivable,  observing  the 
promptness  and  eagerness  with  which  the  modern 
practitioner,  whether  surgeon  or  physician,  exhibits  or 
applies  a  drug  or  chemical.  The  ways  of  the  primi- 
tive man  are  reflected  by  the  hurried  application  of 
this  or  that  remedy  or  dressing,  lest  something  be  left 
undone,  though  occasionally  we  find  a  physician  be- 
traying less  of  this  solicitude  for  the  art  than  an  apti- 
tude for  obsening  nature's  masterly  methods.  Though 
here  and  there  we  find  a  Louis,  or  some  master  mind 
absorbed  in  the  study  of  nature's  revelations,  deducing 
la-.vs  for  practical  guidance  that  distinctly  indicate  a 
noli  me  tangere,  the  atavistic  tendency  has  such  a  firm 
grasp  upon  the  mass  of  the  profession  that  the  appear- 
ance of  any  nostrum,  whether  it  be  a  mud  or  a  vapor 
(of  course  under  some  less  antiquated  name),  is  hailed 
with  delight  and  accepted  without  recognizing  its  limi- 
tations for  good  or  its  positive  influence  for  evil. 

This  benevolent  desire  to  do  something  for  the 
sufferer,  descending  as  a  heritage  from  one  generation 
of  medical  men  to  another,  has  finally  developed  into 
an  instinct  difficult  to  eradicate.  It  is  clear  that  in 
the  very  beginning  of  a  society  indicating  even  a  rudi- 
mentary division  of  labor  the  man  set  aside  to  care  for 
the  sick  and  the  wounded,  governed  by  an  impulse  to 
preserve  his  kind,  regarded  nature  as  his  enemy,  and. 
loth  to  accept  her  teachings,  poured  tlie  supposed 
balm  updn  their  wounds,  to  be  finally  delighted  with 
its  fancied  efl'ect  when  she  rose  superior  to  a  twofold 
infliction.  Even  to-day  the  ine.xorable  law  of  heredity 
is  revealed  in  the  imitative  facult}-,  the  frock  of  the 
modern  practitioner  scarcely  sufficing  to  conceal  the 
simian  appendage  of  his  remote  ancestor. 

It  remained  for  two  Frenchmen  to  determine  the 
something  in  the  air,  previously  mysterious  and  mysti- 
fying, which  in  the  one  case  sustained  organic  life  and 
in  the  other  destroyed  it  by  parasitic  devastation. 
The  great  chemist,  Lavoisier,  laid  the  foundation  for 
modem  chemistrv'  by  the  discover}'  of  oxygen  as  a 
ponderable  something  upon  wtiicli  terrestrial  existence 
depended;  and  his  worthy  successor,  Pasteur,  in  an- 
other department,  contributed  the  substratum  for  mod- 
ern bacteriology  by  revealing  the  presence  of  some- 
thing else  in  the  air,  upon  which  fermentative  processes 
depended,  little  dreamt  of  by  his  illustrious  predeces- 
sor. 

Lister,  to  whom  humanitv'  must  ever  remain  grateful, 
a  pioneer  in  a  hitherto  practically  unexplored  field, 
still  fettered  by  the  inexorable  statute  of  heredity, 
proceeded  to  destroy  the  pestiferous  micro-organism, 
assuming  a  belligerent  attitude  with  devices  for  offen- 
sive warfare  best  suited  to  the  purpose  and  the  maxim 

'  Read  before  the  Kansas  City  .\cademy  of  Medicine,  Novem- 
ber 29,  1S96. 


"eternal  vigilance  is  the  price  of  life  and  health." 
That  he  suspected  his  agents  to  be  as  formidable  to  one 
organism  as  to  another  must  be  evident  to  those  who 
practised  his  methods  when  first  introduced;  his  pro- 
tective immediately  applied  to  the  tissues  being  in 
evidence.  He  was  the  father  of  antisepticism.  What 
he  scientifically  demonstrated  was  empirically  prac- 
tised by  his  predecessors.  Though  essaying  to  be 
prophylactic,  it  was  essentially  therapeutic.  He  was 
still  the  chemist,  and  not  the  broad-gauged  philoso- 
pher peering  into  the  grand  vista  of  future  preventive 
medicine. 

Perhaps  the  title  I  have  chosen  under  which  I  might 
present  a  summary  of  a  few  cases  recently  imder  ob- 
serv-ation  is  not  altogether  literally  fitting;  but  it  is 
often  found  more  convenient  and  perhaps  more  effec- 
tive to  demonstrate  a  thing  by  what  it  is  not  than  by 
what  it  is,  and  with  a  view  of  eliciting  a  discussion 
from  the  fellows  on  a  subject  perhaps  trite  to  some, 
but  to  me  always  new  and  attractive,  I  attempt  to  in- 
clude the  following  report  under  the  above  caption : 

Case  I. — Miss  F ,  about  nineteen  years  of  age, 

first  consulted  me  for  what  was  clearly  a  case  of  chronic 
appendicitis  of  four  months'  standing;  sharply  acute 
at  first,  becoming  chronic  with  a  continued  fever, 
pain,  intestinal  disturbance,  right  iliac,  lumbar,  and 
hypochondriac  intumescence  and  tenderness,  extreme 
flexion  and  adduction  of  the  corresponding  thigh  and 
leg,  with  a  degree  of  fixation  suggesting  disease  at 
the  hip-joint.  Operation  was  declined,  and  after  a 
month's  obser\-ation  and  simulated  treatment  she  so 
far  improved  as  to  be  able  to  return  to  her  home, 
fancying  she  had  escaped  the  knife  of  the  surgeon. 
This  was  four  years  ago.  During  the  succeeding  years 
she  had  recurrent  attacks,  never  so  accentuated  or  se- 
rious, however,  as  the  primarv-  invasion.  Finally,  be- 
coming disgusted  with  a  state  of  chronic  invalidism, 
she  returned  for  operation.  This  was  performed  with 
the  usual  pre-operative  and  postoperative  precaution- 
ary measures.  Before  the  incision  was  closed  the  ex- 
tensive intestinal  adhesions  were  broken  up  and  a 
drainage  was  placed  over  the  site  of  the  appendical 
stump.  The  wound  was  dressed  with  the  customary 
iodoform  gauze,  and  renewed  stcinidiim  artcm  after  the 
fourth  day,  when  the  drainage  was  removed.  I  wish  to 
call  your  attention  for  further  reference  to  the  last  item 
in  this  short  narration  of  a  verv'  interesting  case.  The 
patient  made  an  uneventful  recover)-  with  very  slight 
reaction,  and  was  dismissed  from  the  hospital  at  die 
end  of  three  weeks,  much  improved  and  without  sub- 
sequent trouble,  save  the  appearance  later  of  a  small 
hernia  at  the  site  of  the  drainage,  for  which  I  finally 
succeeded  in  persuading  the  young  woman  to  submit 
to  another  operation  for  its  closure,  up)on  my  return 
from  my  summer  vacation.  This  was  done  in  the  fol- 
lowing manner;  An  incision  including  the  entire 
length  of  the  old  cicatrix  exposed  the  muscular  and 
fascial  planes  of  the  former  wound ;  the  latter  (the  ab- 
domen at  this  point  being  rather  thin)  were  divided 
with  a  knife  so  as  to  represent  two  superimposed 
halves,  each  of  which  was  stitched  by  a  running  suture 
of  chromicized  gut,  after  the  manner  of  Edebohls. 
The  skin  was  closed  by  a  continuous  suture  of  plain 
gut  sterilized  with  sublimate,  and  the  wound   sealed 


582 


MEDICAL    RECORD. 


[October  23,  1897 


with  seven  or  eight  narrow  strips  of  iodoform  gauze 
and  a  ten-per-cent.  solution  of  iodoform  collodion. 
There  was  practically  no  reaction  and  recovery  was 
apparently  uneventful.  On  the  tenth  day,  however, 
the  attendants  became  alarmed,  or  perhaps  suspicious 
that  all  was  not  well;  an  oozing  about  the  margins  of 
the  gauze  placed  over  the  seal,  and  an  annoying  burn- 
ing and  pruritus  over  the  abdomen  of  the  patient,  call- 
ing for  a  removal  of  the  dressings.  This  revealed  a 
primary  union  of  the  wound  and  absorption  of  the  ex- 
ternal suture,  but  the  skin  of  the  abdomen  presented 
an  intense  mahogany-colored  injection,  interspersed 
with  coalescing  and  confluent  vesicles,  large  bulls 
distended  with  pure  serous  fluid,  which  had  given  way 
at  some  places,  so  that  the  upper  layers  of  the  derma 
were  displaced  in  large  strips  with  an  exposed  oozing 
surface  underneath — in  short,  an  iodoform  dermatitis. 
A  dusting-powder  of  talcum  fortunately  put  an  end  to 
the  antiseptic  disease,  but  what  a  fertile  soil  for  a 
serum  culture  and  subsequent  infection  had  not  the 
wound  closed  primarily.  This  wound,  made  with 
aseptic  preliminaries  (the  catgut  prepared  by  myself 
and  subjected  to  culture  experiments  proving  its  ster- 
ility), was  unnecessarily  supplemented  and  endan- 
gered by  antiseptic  provision,  and  convalescence  was 
prolonged. 

Case  II. — A  robust  individual  in  the  neighborhood 
of  fifty,  so  devoid  of  intelligence  as  to  be  on  the  brink 
of  idiocy,  therefore  incapable  of  furnishing  any  relia- 
ble antecedent  data,  first  consulted  me  about  two  years 
ago  with  what  objectively  proved  to  be  an  obstinate 
sciatica,  which  yielded  to  cauterization  repeated  at 
intervals  of  five  days,  the  iron  being  applied  some  five 
or  six  times.  About  four  months  ago  he  again  applied 
for  treatment,  claiming  to  have  the  same  affection  in 
ihe  opposite  member,  and  insisted  upon  an  application 
of  his  old  friend,  the  cautery.  Not  being  able  to 
elicit  any  history  and  observing  an  incipient  lameness, 
I  accommodated  him.  Some  four  or  five  days  there- 
after, being  sir.viuioned  to  his  home,  I  found  him  suffer- 
ing excruciatingly,  and,  pushing  my  investigation,  di- 
agnosticated an  osteo-periostitis  ot  tiie  upper  third  of 
the  fibula,  advising  incision,  to  which  he  objected. 
After  a  week's  flirtation  with  morphine  and  poultices, 
he  finally  consented  to  go  to  the  hospital — a  free  inci- 
sion evacuating  the  pus  confirming  the  diagnosis  and 
bringing  prompt  relief.  Iodoform  packing  after  the 
usual  manner,  subsequent  flushing  with  sterilized 
water,  and  redressing  at  intervals.  During  my  absence 
a  colleague  kindly  consented  to  care  for  the  case,  and 
upon  my  return  informed  me  that  the  iodoform  proved 
so  irritating  that  he  was  obliged  to  substitute  boric 
acid.  About  seven  weeks  ago  I  proceeded  to  the  re- 
moval of  an  almost  cylindrical  sequestrum,  incising  the 
cicatrix,  thoroughly  removing  all  adventitious  material 
with  the  knife,  scissors,  and  curette — converting  the 
entire  field  into  a  clean  aseptic  ground,  but,  unmind- 
ful of  my  colleague's  previous  experience,  resorted  to 
the  stereotyped  iodoform  tamponade.  There  was  abso- 
lutely no  reaction  ;  pulse  and  temperature  were  normal. 
On  the  fourth  day  the  dressings  appearing  saturated, 
I  removed  them,  expecting  to  encounter  a  serous  ooz- 
ing from  the  wound,  but  instead  exposed  the  packing 
in  the  eight-inch  incision  dry  and  sweet,  but  found  the 
epiderm  of  almost  the  entire  leg  practically  lifted  <•// 
//iiix.fc-  by  a  series  of  enormous  bulla-,  a  few  remaining 
unruptured~an  iodoform  dermatitis.  Nor  was  the 
effect  limited  to  a  local  disturliance.  Though  plain 
gauze  dressings  and  asepticized-water  lavage  with 
sterilized  talcum  dustings  over  the  denuded  derma 
secured  an  aseptic  course  in  the  healing  of  the  wound, 
an  intensely  pruritic  generalized  rellex  eczema  set  in, 
with  gastro-intestinal  disturbances  difficult  to  control. 
The  eczema  still  remains  in  patches,  with  a  prosjiec- 
ive  chronicity  not  very  complimentary  to  the  surgeon. 


As  in  the  former  case,  the  thoroughness  of  the  asepti- 
cism  proved  a  safeguard  against  the  possibility  of  the 
stupid  antisepticism  employed  in  the  face  of  previous 
warnings. 

In  considering  the  disastrous  effects  of  the  antisep- 
tic, several  cogent  objections  may  be  urged  against 
my  aversion  to  the  employment  of  this  particular  agent 
It  is  possible  that  it  was  impure  and  that  the  impuri- 
ties were  responsible  for  the  dermic  lesion.  Yet  the 
operations  were  performed  in  two  different  institutions, 
though  it  is  very  probable  that  the  chemical  was  de- 
rived from  the  same  source,  .\gain,  individual  sus- 
ceptibility or  idiosyncrasy  may  be  invoked  as  a  possi- 
ble explanation.  But  arc  we  always  able  to  determine 
this  in  advance?  Finally,  the  degree  of  concentration 
of  the  drug  and  the  unnecessarily  prolonged  contact  of 
the  dressings  may  have  been  responsible.  In  the  first 
case  this  was  probably  true,  for  no  untoward  effects 
were  observed  when  the  dressings  were  changed  after 
the  fourth  day.  In  the  latter  the  period  of  immunity 
from  irritation,  if  this  was  an  element  in  its  produc- 
tion, must  have  been  much  shorter.  But  though  all 
this  may  be  true  under  modern  methods  and  practice, 
the  longer  the  primarj'  dressing  may  be  allowed  to  re- 
main the  better,  wound  rest  being  no  inconsiderable 
factor  in  the  promotion  of  primarj'  union.  I  do  not 
underrate  the  value  of  this  excellent  drug  where  it  is 
clearly  indicated,  and  am  not  very  partial  to  the  many 
substitutes  that  are  being  continually  offered  to  the 
profession,  realizing  the  pithiness  of  the  remark  of 
Mosetig,  that  "though  there  were  many  chancellors, 
there  was  but  one  Bismarck,"  when  extolling  its  vir- 
tues; yet  I  cannot  help  believing  that  it  adds  nothing 
to  the  assurance  of  a  thoroughly  asepticized  wound, 
but  often  offers  a  premium  for  a  local  or  systemic  con- 
flagration. To  see  the  surgeon  applying  his  dressing, 
the  perforated  container  in  hand,  dusting  the  wound 
with  an  air  of  satisfaction  as  he  views  his  work,  one 
would  think  he  would  no  more  omit  this  pleasing 
stroke  than  the  seasoning  of  his  steak,  the  penetrating 
odor  of  the  one  being  as  important  as  the  savor  of  the 
other.  Surely  this  must  be  from  force  of  habit,  since 
there  can  be  but  little  good  reason  for  this  final  cere- 
mony. 

Cask  III. — Mr.  \V ,  aged  fifty,  of  good  habits, 

whose  previous  history  is  unimportant,  save  a  very 
remote  syphilis,  met  with  a  painful  accident  some  two 
months  ago  while  riding,  both  horse  and  rider  falling. 
The  animal  fell  in  such  a  manner  as  to  crush  the  pa- 
tient's right  leg  to  the  ground,  the  brunt  of  the  force 
coming  upon  the  antero-lateral  face  of  the  member,  just 
above  the  knee-joint.  Though  the  whole  leg  below  this 
point  exhibited  evidences  of  a  contusion  in  an  iris- 
hued  swelling,  just  above  the  patella  there  was  a  super- 
ficially contused  lacerated  wound — indeed,  little  more 
than  an  abrasion,  exposing  in  part  the  corium  and  at 
other  points  the  subcutaneous  fat,  as  though  excori- 
ated by  particles  of  sand.  The  surface  might  have 
extended  over  an  area,  say,  of  about  one  and  one-half 
inches  square;  beyond,  looking  toward  and  including 
the  surface  to  the  biceps  tendon,  and  extending  upward 
above  the  wound  for  about  one  inch,  liie  parts  looked 
angry  and  inflamed.  There  was  no  constitutional  dis- 
turbance. It  was  doubtful  whether  he  was  more  than 
momentarily  stunned  at  the  time  of  the  accident.  He 
complained  of  some  headache  on  the  same  side  and 
pain  about  the  shoulder,  though  an  examination  pre- 
sented no  gross  evidences  of  injur)'  at  these  points.  I 
first  saw  him  about  two  davs  after  the  accident,  some 
domestic  remedies  and  dressings  having  been  applied 
meanwhile.  From  the  first  I  felt  confident  that  the 
parts  included  in  the  brush  burn  would  slough,  and  so 
informed  the  patient,  and  after  cleansing  the  parts 
prescribed  lead-and-opium  lotion  and  absolute  rest  in 
bed.     My  prediction  proved  true,  and  nature  was  soon 


October  23,  1897] 


MEDICAL    RECORD. 


583 


throwing  up  a  line  o£  healthy  granulations  about  and 
underneath  the  superficial  slough,  though  the  exposed 
area  as  well  as  the  skin  about  the  knee-joint  was  at 
times  painful  and  even  tender,  especially  after  motion. 
The  "headache  and  pain  about  the  shoulder  disappeared. 
The  patient  grew  restive  and  impatient,  regarding  the 
injur}-  as  trivial,  objected  to  his  enforced  confine- 
ment, and  in  about  ten  days  insisted  upon  applying  a 
dressing  relatively  permanent,  so  that  he  might  at  least 
sit  up.  Submitting  under  protest,  I  again  cleansed 
the  woimd  and  adjacent  area,  removing  the  hair  by 
shaving,  omitting  the  customary  iodoform  dust,  not 
from  choice,  but  in  deference  to  the  sensitive  olfacto- 
ries of  his  wife,  who  had  some  vague  notion  regarding 
its  reputed  unfortunate  associations;  and  applied  an- 
other less  odoriferous  substance  uf)on  plain  gauze,  in- 
closing the  v.hole  with  absorbent  cotton  and  a  light 
bandage,  telling  the  patient  he  might  sit  up  with  the 
leg  supported  upon  a  chair,  and  left  him  with  the  in- 
junction not  to  go  about  and  to  inform  me  at  once  if 
it  proved  uncomfortable,  for  I  told  him  pla'inly  that  I 
had  misgivings  as  to  the  result.  When  I  was  summoned 
the  following  morning,  he  complained  of  an  aching  and 
fever  in  the  parts,  and  removing  the  dressing  I  found 
not  only  the  wound  dr\-,  angrj',  red,  and  swollen,  but 
the  parts  beyond,  especially  over  the  edge  of  the  vas- 
tus extemus  and  in  the  sulcus  between  it  and  the  ex- 
ternal hamstring.  The  former  lotion  was  reapplied 
and  absolute  recumbency  enjoined,  and  calling  again 
in  the  afternoon  I  found  he  had  had  a  chill  with  the 
usual  constitutional  disturbance  accompanying  a  local 
inflammatory  reaction  ;  a  spreading  erysipelas  soon  set 
in,  extending  up  the  thigh  and  down  the  leg,  and  an 
area  the  size  of  a  silver  dollar,  opposite  and  distinct 
from  the  abrasion  above  and  e.xternal  to  the  patella, 
began  to  slough,  opening  a  communicating  branch 
from  the  external  to  the  internal  saphenous  and  expos- 
ing the  outer  hamstring  tendon.  The  usual  constitu- 
tional symptoms  of  var)-ing  severit)-  accompanied  the 
erjsipelas  for  about  ten  days,  and  during  the  seques- 
tration of  the  slough  an  annoying  hemorrhage,  though 
not  difficult  to  control,  added  to  the  anxiety  of  the 
sufferer  and  his  friends.  After  the  parts  had  cleaned 
off  and  begun  to  granulate,  the  exposed  surface  prov- 
ing refractory  because  of  its  relations  to  the  tendon,  it 
required  more  than  a  month's  splintage  and  dressing 
before  it  would  heal. 

Case  IV. — Mr.  B ,  aged  forty,  of*  large  frame 

and  somewhat  inclined  to  obesity,  of  temperate  habits, 
but  old  specificity,  consulted  me  upon  a  Saturday  some 
six  weeks  ago,  for  what  appeared  to  be  an  ischio-rectal 
abscess  just  beyond  incipiency.  He  had  a  cough  uf 
which  he  made  light,  and  some  little  fever.  I  advised 
incision  to  prevent  fistula,  but  he  preferred  a  poultice 
and  asked  for  delay.  When  he  called  again  Monday, 
with  the  local  condition  much  aggravated,  I  insisted 
upon  his  repairing  to  the  hospital  at  once  for  operation. 
On  the  foll'.wing  morning,  under  anaesthesia  I  incised 
the  swelling.  At  that  time  the  whole  left  ischio-rectal 
base  was  swollen,  cedematous,  bright  red,  and  fluctu- 
ating. Making  a  large  longitudinal  incision  midway 
between  the  anus  and  tuberosity,  I  was  surprised,  af- 
ter the  thin,  horribly  fetid  ichorous  fluid  was  evacu- 
ated, to  find  the  entire  space  greenish  and  black  with 
a  gangrenous  mass,  to  remove  which  I  made  a  trans- 
verse incision  to  the  tuberosity  and  another  around 
behind  the  anus  to  the  right,  as  it  had  already  extended 
in  that  direction.  Everjthing  was  thoroughly  cleansed, 
exposing  the  rectum  and  levator  ani,  leaving  a  cavity 
admitting  a  good-sized  fist.  After  packing  the  cavity 
with  iodoform  gauze  and  applying  the  bandage,  I  no- 
ticed a  small  arborescent  engorgement  superficially 
located  about  the  raphe  of  the  scrotum,  inclined  to 
lividitv'.  By  evening  I  found  the  constitutional  symp- 
toms more  pronounced,  the  patient  inclined  to  wander. 


and  perspiring  profusely.  When  he  was  placed  upon 
the  table  the  next  morning,  after  removal  of  the  dress- 
ings marked  evidence  of  an  extension  of  the  process  was 
present.  The  scrotum  was  enormously  swollen,  oedem- 
atous,  and  livid,  and  the  scroto-femoral  space  up  to 
the  groin  swollen  and  red ;  and  continuing  the  incision 
up  into  this  region  I  found  the  subcutaneous  tissue 
black  and  the  odor  frightful.  Removing  the  sphace- 
lated mass,  the  same  dressings  were  applied.  Whiskey 
in  abundance  and  strjxhnine  were  prescribed.  The 
patient  grew  steadily  worse  and  the  sweats  profuse; 
in  a  word,  he  was  profoundly  septic.  On  removing 
the  dressings  the  next  day  the  wound  looked  red  and 
dry,  with  a  scarcely  perceptible  secretion  at  a  few- 
points,  and  the  scrotimi  was  larger,  but  there  was  no 
fluctuation  to  indicate  the  presence  of  pus.  Lateral 
incision  into  the  purse  revealed  neither  sphacelus  nor 
fluid.  The  urine  was  examined,  but  found  negative 
as  to  albumin  or  sugar.  I  renewed  the  dressings, 
dusting  iodoform  lightly  over  the  entire  surface. 
Subsequently,  fearing  the  possible  constitutional 
effects  of  the  chemical,  I  substituted  Peruvian  bal- 
sam, but  without  inducing  the  presence  of  a  healthy 
secretion.  A  colleague,  seeing  the  patient  with  me, 
suggested  packing  with  an  antiseptic  preparation, 
which  in  sheer  desperation  was  adopted.  L'p  to  that 
time,  although  there  was  but  little  secretion,  the  sur- 
face was  comparatively  clean,  no  longer  malodorous, 
and  the  surrounding  tissues  about  the  buttock  and  in 
the  groin  were  only  slightly  hyperarmic,  showing  the 
ordinary  circumferential  erythema  of  limiteo  area  about 
open  wounds;  the  scrotum  was,  however,  still  largely 
swollen  and  blue.  A  small  incision  into  the  raphe 
proved  the  tissues  underneath  free  from  gangrene.  The 
next  day  the  wound  surface  assumed  a  grayish  or  rather 
opalescent  appearance,  the  margins  became  slightly 
indurated  and  darker,  and  upon  the  follov.ing  morn- 
ing, the  dressing  having  been  renewed,  the  appear- 
ances were  more  pronounced — diphtheritic-like  upon 
the  surface,  with  brawny  livid  borders  and  an  extend- 
ing er)-thema  suggesting  er}'sipelas.  Constitutional 
symptoms  worse:  delirium,  chills,  rapid  and  weak 
pulse,  and  dark  tongue,  and  high  temperature.  The 
erysipelas  spread  rapidly  upon  the  left  thigh  to  the 
knee,  around  the  back  and  buttock  on  both  sides,  and 
half-way  up  the  right  thigh,  with  a  number  of  phleg- 
mons. Though  the  case  looked  hopeless,  we  dropped 
all  antiseptics,  using  sterilized  gauze  dressings  and 
sterilized  water,  pushing  the  whiskey  and  strvchnine, 
with  codeine  for  the  violent  cough  caused  by  a  dry 
bronchitis,  and  morphine  at  night  to  quiet  the  delirium. 
This  process  continued  for  about  fifteen  days,  with  re- 
peated chills,  colliquative  sweats,  and  pulse  at  times 
reaching  160,  though  in  the  mean  time  the  wound  sur- 
face began  to  secrete  clean  piis  and  the  scrotum  toward 
the  end  of  the  erysipelatous  process  began  to  undergo 
resolution.  .Vfter  much  labor  and  painstaking  dressing 
the  patient  now,  after  nearly  six  weeks,  has  so  far  pro- 
gressed as  to  be  free  from  fever,  with  a  clean  tongue  and 
good  appetite,  and  the  wounds  are  reduced  to  about  one- 
fourth  their  original  dimensions,  though  he  still  has  a 
frequent  pulse  and  a  furunculosis  of  the  scalp,  but  is 
now  very  certain  of  an  escajje  from  what  seemed  almost 
certain  death. 

Reviewing  the  last  two  cases,  I  shall  anticipate  two 
or  three  ver\- probable  criticisms  from  those  I  have  the 
honor  to  address,  viz. :  that  the  appearance  of  that 
dreaded  malady,  erysipelas,  and  a  change  in  the  dress- 
ings were  merely  coincidences;  or  perhaps  that  the 
infection  was  conveyed  from  the  one  to  the  other;  and, 
last  but  not  least,  that  the  presence  of  the  streptococci 
about  sloughing  wounds  is  very  prone  to  cause  diffuse 
inflammatory  processes. 

But  I  take  it  that  all  three  of  these  explanations  are 
net  very  tenable  but  are  susceptible  of  successful  con- 


584 


MEDICAL    RECORD. 


[October  23,  1897 


troversion.  In  both  cases  the  appearance  of  the  spread- 
ing infection  followed  too  closely  upon  the  change  of 
treatment  to  be  ignored  as  a  factor;  had  it  occurred  in 
only  one  I  might  rest  content  and  not  accuse  the  much- 
lauded  antiseptic  preparation,  but  I  cannot  refrain 
from  the  aspersion  in  the  case  of  two  such  apparently 
positive  indictments.  Had  the  man  with  the  contu- 
sion been  infected  subsequent  to  the  gangrenous  case, 
I  might  have  thought  myself  the  culpable  carrier  of 
the  infection  ;  but  the  reverse  was  true.  Besides,  dur- 
ing this  period  I  performed  quite  a  number  of  impor- 
tant operations  and  assisted  several  friends  in  many 
more,  some  of  which  were  capital,  and  in  no  single 
instance  was  there  a  repetition  of  this  experience. 
Finally,  it  is  doubtful  that  the  gangrenous  case  had  a 
streptococcus  etiology.  Though  there  was  no  macro- 
scopic connection  with  the  bowel,  might  there  not 
have  been  a  virulent  coli-communis  infection?  or,  as 
suggested  by  my  colleague,  the  bacillus  fcetidus  may 
have  been  the  infecting  agent.  Here  it  might  be  per- 
tinent to  remark  that  though  the  subcutaneous  tissues 
were  gangrenous,  the  skin  was  not  involved  and  there 
was  no  emphysematous  crackling  to  suggest  malignant 
oedema,  nor  was  the  sufferer  a  broken-down  subject, 
but  apparently  in  the  vigor  of  health  with  only  this  as 
a  possible  mode  of  infection.  He  supposed  himself 
chafed,  and  applied  some  old  patent  ointment  recom- 
mended and  furnished  by  a  friend.  It  was  said  to  have 
been  exposed  se\>eral  months  and  possibly  had  become 
rancid.  Surely  the  vascular  supply  in  the  fossa  is  so 
free  that  sloughing  from  obstruction  could  hardly  be 
thought  of. 

By  returning  to  the  study  of  nature's  methods  of  re- 
pair in  wounds,  we  may  possibly  get  a  hint  as  to  what 
is  meant  by  meddlesome  antisepsis.  Is  it  not  plain 
that  an  antiseptic  agent  to  be  availing  must  be  of  suffi- 
cient strength  to  destroy  the  micro-organism  to  whose 
presence  is  chargeable  the  septic  process  with  which 
the  practitioner  is  contending?  Is  it  not  equally  true 
that  to  be  effective  it  must  be  renewed  or  continuously 
present  in  that  degree  of  concentration  scientifically 
determined  as  inhibitive  to  the  growtii  and  develop- 
ment of  succeeding  generations?  Is  it  to  be  supposed 
that  the  territory  upon  which  this  warfare  is  being 
waged  remains  indiflerent  to  the  ravages  of  the  con- 
tending forces? 

Tissues  already  impaired  by  injury  or  disease  re- 
quire' but  the  devitalizing  contact  of  some  chemical  to 
render  them  a  suitable  pabulum  for  the  omnipresent 
micro-organism.  The  delicate  barriers  that  nature 
has  put  up  as  a  defence  against  further  damage,  be- 
coming gradually  maturer  and  stronger  in  response  to 
the  demand  for  tissue  repair,  are  ruthlessly  swept  away 
in  their  incipiency,  by  assuming  that  the  host  has 
greater  endurance  and  vitality  than  the  parasite.  Is 
not  this  notion  contrary  to  the  teachings  of  bacte- 
riology? Is  it  not  contrary  to  common  sense?  Is 
there  any  ground  for  believing  that,  in  obedience  to 
antiseptic  idealism,  the  tissues  electively  resent  the 
presence  of  the  germ  and  welcome  the  chemical? 

Those  engaged  in  sterilizing  ligatures  and  dress- 
ings by  chemicals  or  heat  tell  us  of  the  high  concen- 
trations and  prolonged  contact  of  the  one  or  continued 
exposure  to  the  other  necessary  to  be  effective.  If  this 
is  true,  why  should  we  depend  upon  lesser  potencies  to 
accomplish  the  ])urpose  in  diseased  or  injured  tissues? 
If  of  full  strength,  why  sliould  they  not  be  as  destruc- 
tive to  the  latter  as  to  the  intruder?  .V  little  unbiassed 
reflection,  and  it  must  be  evident  that  asepsis  and  an- 
tisepsis are  different  etymologically  as  well  as  surgi- 
cally. It  is  not  true,  as  has  been  advocated  by  anti- 
septic enthusiasts,  that  it  is  merely  juggling  with 
terminology.  Wliile  asepsis  is  antiseptic,  antisepsis 
is  not  aseptic.  Of  what  use  are  antiseptics  in  tissues 
pullulating  with  infective  material?     Is  it  not  a  re- 


minder of  the  legendary  attitude  of  the  ostrich,  or  the 
method  of  the  indolent  housewife  concealing  the  filth 
upon  the  shelves  and  furniture  by  tawdry  contrivances 
of  paper  or  other  cheap  material  ?  Of  what  avail  if 
the  field  of  operation  or  injured  territory  is  properly 
asepticized  ?  Is  not  the  bacteriologist  content  with  a 
cotton  plug  to  resist  intrusion  when  preparing  his  cul- 
ture tubes?  If  this  method  answers  the  exacting 
demands  of  the  most  delicate  of  all  scientific  studies, 
why  should  we  not  be  content  with  an  aseptic  protec- 
tive envelope? 

Again,  if  the  current  trend  of  research  is  correct, 
why  are  investigators  abandoning  chemicals  and  seek- 
ing to  recover  nature's  essences  of  immunization  for 
practical  application?  To  treat  an  individual  already 
septic  either  locally  or  constitutionally  with  antiseptic 
drugs  or  chemicals  in  the  doses  tolerated  is  honaoe- 
opathy  as  to  effect,  and  may  be  aptly  compared  with 
veterinary  practice  if  the  dosage  exceeds  this.  In  the 
one  instance  the  result  would  be  nil,  in  the  other  it 
would  increase  human  mortality  without  appreciably 
affecting  that  of  the  microbes — another  instance  of  the 
vagaries  of  modern  medicine. 

For  years,  despite  the  exhibition  of  every  new  anti- 
septic introduced  to  the  profession,  we  have  been 
obliged  to  rely  upon  stimulants  to  sustain  the  powers 
of  life  and  intestinal  and  local  drainage,  pending  the 
self -immunization  of  the  septic  patient,  and  as  yet 
there  remains  no  case  or  series  of  cases  with  incontro- 
vertible proof  that  recovery  ensued  consequent  upon 
the  administration  of  drugs  alone.  In  a  word,  it  has 
been  a  natural  result  achieved  after  the  manner  of 
bacteriological  laboratory  experiments  in  immuniza- 
tion. As  yet,  therefore,  our  great  hope  for  the  future 
looks  to  prophylaxis  and  not  to  cure ;  to  asepsis  and 
not  antisepsis. 

Reserve  your  antiseptics  in  injuries  and  wounds 
intentionally  induced  for  the  sterilization  of  surgical 
material,  instruments,  and  the  healthy  tissues  of  the 
operator,  and  render  the  field  of  operation  aseptic 
mechanically,  if  at  all  possible,  and  you  will  then  aid 
and  not  handicap  nature  in  her  processes  of  repair. 
The  dressings  should  be  sterilized  by  heat  when 
practicable,  and  if  not  the  chemicals,  after  having  ren- 
dered the  ligature  or  suture  material  aseptic,  should 
themselves  be  eliminated  to  prevent  irritation.  An 
ideal  dressing  fulfils  the  physiological  and  bacterio- 
logical indications  mechanically  when  it  is  light, 
porous,  absorbent,  and  aseptic,  providing  for  drainage 
and  support,  and  sufficiently  occlusive  to  maintain  the 
surgical  cleanliness  originally  provided,  thus  insuring 
physiological  rest,  avoiding  the  necessity  for  frequent 
changes — a  most  important  factor  in  the  successful 
management  of  wounds. 

If  Hilton  had  done  nothing  else,  he  merits  ever- 
lasting praise  for  the  classical  manner  in  which  this 
was  demonstrated  in  his  "  Rest  and  Pain."'  Surgery 
is  not  a  question  to  be  solved  by  chemicals,  but  essen- 
tially one  of  mechanics.  In  injuries  and  wounds  not 
susceptible  of  permanent  dressing,  primary  cleanliness, 
mechanicallv  induced  with  a  knife,  scissors,  curette, 
and  brush,  will  in  the  majority  of  instances  fare  better 
with  simple  aseptic  gauzes,  wools,  etc.,  and  boiied 
pure  water  for  the  removal  of  detritus  and  discharges. 
This  recommends  itself  at  once  as  inexpensive,  effi- 
cient, and  not  likely  to  interfere  with  nature's  kindly 
help.  Medicine  and  surgery  are  human  institutions 
and  therefore  imperfect,  and  can  approximate  perfec- 
tion only  by  utilizing  the  devices  of  nature  and  not 
running  counter  to  them.  Observe  and  then  imitate 
her.  Reserve  your  chemicals  for  specific  ulcers,  si- 
nuses, suppurating  cavities,  where  from  necessity  or 
from  choice  mechanical  interference  is  either  declined 
or  impossible.  Here  they  may  be  useful  to  disinfect  or 
correct  foul  discliarges,  stimulate  repair,  anaesthetize 


October  23.  1897] 


MEDICAL    RECORD. 


58: 


locally,  or  minimize  septic  absorption;  but  be  sure 
that  in  trying  to  cure  one  evil  you  do  not  substitute 
another  perhaps  worse. 

The  ancients  imagined  they  saw  their  enemies  in 
the  original  four  elements:  let  us  destroy  those  in  the 
air  and  in  the  earth  by  fire,  and  employ  fired  water  as 
a  convenient  vehicle  to  dispense  the  blessings  of  a 
more  enlightened  pathology. 


SOME  PRACTICAL  DEDUCTIONS  FROM  BAC- 
TERIOLOGICAL   RESEARCH. 

By   given   CA.MPBELL,    M.D., 


In  presenting  this  paper  I  have  thought  it  best  to 
consider  it  under  two  heads:  first,  to  review  some 
of  the  important  facts  of  immunity  and  predisposi- 
tion, and  second,  to  see  how  we  can  apply  these  facts 
in  the  treatment  of  our  patients.  As  is  of  course 
known,  immunity  is  the  name  given  to  that  condition 
of  an  animal's  body  which  enables  it  to  resist  the  at- 
tack of  an  infectious  disease,  being  in  contrast  with 
predisposition  or  that  bodily  condition  which  must 
exist  in  order  for  the  germ  to  grow  at  the  expense  of 
the  body  and  thus  produce  that  train  of  symptoms  we 
call  an  infectious  disease.  The  importance  of  these 
laws  of  immunity  cannot  be  overestimated.  Bacteri- 
ology is  important  to  a  physician  in  two  ways:  First, 
as  an  aid  to  diagnosis,  and  second,  in  enabling  us  to 
understand  the  laws  of  immunity.  The  first  is  fairly 
well  understood  by  all  of  us  and  we  find  its  knowledge 
useful,  but  the  second  is  of  vastly  more  importance 
and  unfortunately  is  not  so  generally  studied  as  its 
importance  merits:  and  in  my  opinion  a  broad  knowl- 
edge of  the  laws  of  i  mm  unit)-  will  go  farther  toward 
making  a  successful  physician  of  one  than  any  other 
one  study.  We  will  now  first  consider  the  circum- 
stances under  which  the  system  is  found  immune,  and 
then  the  direct  mechanism  of  this  immunity  so  far  as 
known.  We  find  immunity  and  predisposition  run- 
ning through  the  entire  animal  kingdom.  The  inver- 
tebrates are  subject  to  certain  diseases  to  which  the 
vertebrates  are  immune,  and  vice  -ersa.  One  germ  is 
able  to  attack  fowls  and  rarely  mammals,  another  can 
attack  mammals  and  not  fowls.  Herbivorous  animals 
are  predisposed  to  disease  to  which  camivora  are 
immune. 

Field  mice  and  house  mice  each  have  diseases  pecu- 
liar to  themselves.  Different  races  of  men  have  im- 
munities from  different  diseases,  and  individuals  of 
the  same  race,  yes,  even  of  the  same  family  circle,  ex- 
hibit marked  differences  in  their  power  to  resist  an 
infectious  disease.  Many  of  these  differences  seem 
easy  of  comprehension.  To  explain  others,  our  knowl- 
edge is  not  sufficiently  complete.  The  different  im- 
munities in  the  gross  divisions  of  the  animal  kingdom 
probably  depend  on  the  great  differences  in  the  anat- 
omy and  physiology  of  these  animals.  Thus,  frogs 
are  immune  to  anthrax,  the  bacillus  of  which  does  not 
grow  readily  at  a  temperature  so  low  as  that  of  their 
bodies,  but  if  a  frog  is  immersed  in  warm  water  and 
its  body  temperature  raised  to  a  point  near  that  of 
warm-blooded  animals,  it  becomes  susceptible  to  the 
disease;  and  again,  if  a  hen,  whose  body  temperature 
is  higher  than  that  at  which  anthrax  best  grows,  be 
refrigerated  before  inoculation  with  anthrax,  it  takes 
the  infection,  while  if  not  so  chilled  it  is  immune. 
This  refrigeration  may  not  be  the  only  cause  of  the 
immunit\-,  but  is  probably  a  cause,  and  many  more 
such  instances  could  be  cited. 

The  most  probable  explanation  of  race  immunity  is 
that  an  immunity  is  built  up  in  certain  races  of  men 


by  a  process  of  hereditarj-  selection.  A  certain  race 
is  exposed  to  the  ravages  of  a  certain  disease.  Cer- 
tain individuals  of  that  race  are  more  susceptible  tc^ 
that  disease:  others  are  less  so.  Those  most  suscep- 
tible die  and  are  not  liable  to  leave  offspring.  Those 
more  immune  live  and  produce  children  who  probably 
inherit  the  immunity  of  their  parents,  and  those  to 
whom  the  immunity  does  not  descend  die  and  the 
others  live,  and  thus  the  disease  constantly  weeds  out 
the  susceptible  and  leaves  the  immune  until  a  race 
immunity  is  built  up.  Thus  we  know  measles  is  a 
mild  disease  with  us,  but  some  years  ago  the  disease 
was  conveyed  to  the  Pacific  Islands  by  a  European 
child.  The  disease  had  never  been  known  to  exist 
there,  and  thus  implanted  on  a  virgin  soil  it  became 
very  virulent  and  was  fatal  in  a  large  percentage  of 
cases.  The  rise  and  fall  of  leprosy  in  Europe  after 
the  crusades  is  possibly  dependent  on  the  above 
cause.  Of  course,  when  a  member  of  one  race  is 
transplanted  to  another  race  and  climate,  he  loses  the 
protection  of  his  hereditary  immunity,  for  he  is  ex- 
posed to  a  new  set  of  diseases  and  his  vital  expectancy- 
is  lowered  (witness  the  much  higher  mortality  of 
our  colored  than  of  our  white  population).  Before 
considering  the  direct  mechanism  of  immunity  let  us 
consider  some  of  our  means  of  increasing  or  diminish- 
ing immunity.  Immunity  is  produced  or  increased  by- 
having  the  disease  in  question.  This  usually  confers 
an  immunity  lasting  a  variable  time,  but  longer  in  a 
general  infectious  disease  than  in  a  local  one,  yet  the 
remarkable  fact  exists  that  a  local  infection  will  often 
produce  a  persistent  local  immunity.  Thus  the  ear  of 
a  rabbit  may  be  inoculated  with  erysipelas  and  an  in- 
fection produced  which  is  limited  to  that  ear.  and 
while  the  other  ear  may  be  subsequently  infected,  the 
one  in  which  the  infection  has  taken  place  remains 
immune  for  a  period  of  many  months.  Other  meaRS 
of  producing  an  acquired  immunity  are:  ist.  To  in- 
ject gradually  increasing  doses  of  the  toxin  of  the 
disease.  2d.  Infection  with  a  similar  but  milder  dis- 
ease, as  vaccinia  or  rabies.  3d.  To  inject  the  toxin  of 
some  other  germ.  4th.  To  inject  the  serum  of  an 
animal  immune  to  the  disease  in  question.  Immu- 
nity may  be  lessened  by,  ist.  local  injury  to  the  body; 
2d,  by  fatigue  of  individual ;  3d,  by  change  of  body- 
temperature:  4th,  by  modifying  the  reaction  of.  blood 
or  tissue;  5th,  by  increasing  the  virulence  or  numbers 
of  infecting  organisms;  6th.  by  injecting  together 
with  the  organisms,  first,  certain  chemical  substances; 
second,  the  toxin  of  the  germ  itself;  third,  some  other 
germ  or  its  ptomain  (and  please  notice  that  this  other 
germ  need  not  be  a  virulent  one,  nor  its  ptomain  poi- 
sonous). 

Passing  on  to  the  direct  mechanism  of  immunity  let 
me  state  that,  while  some  other  elements  may  enter 
slightly  into  its  production,  immunity  depends  chiefly 
on  two  factors:  ist,  the  presence  in  the  body,  naturally 
or  acquired,  of  some  chemical  substance  which  in- 
creases the  vital  resistance  of  the  body  to  the  toxin  of 
the  germ;  and  2d,  the  activity  of  the  phagocytes  in 
destroying  the  germs.  Our  reason  for  believing  in 
the  first  of  these  factors  depends  on  Uie  following  ex- 
periments, which  have  been  frequently  repeated  and 
thoroughly  verified:  Ordinary  sterile  bouillon  may  be 
prepared,  and  a  number  of  guinea-pigs  procured ;  into 
each  of  several  of  these  guinea-pigs  one-tenth  cubic 
centimetres  of  this  bouillon  is  injected.  Xo  harm  re- 
sults in  any  w-ay.  Xow  more  of  this  same  bouillon  is 
inoculated  with  the  tetanus  bacillus,  and  after  growth 
has  taken  place  the  bouillon  is  filtered  through  a 
Chamberlain  bougie,  and  thus  all  the  bacilli  are 
removed  and  nothing  but  substances  in  solution  in 
the  bouillon  pass  through  the  bougie.  More  of  the 
guinea-pigs  are  now  selected,  and  into  each  of  these 
one-tenth  cubic  centimetre  of  this  filtrate  is  injected. 


586 


MEDICAL    RECORD. 


[October  23,  1897 


All  these  guinea-pigs  exhibit  tetanic  spasms  and  die. 
The  bouillon  has  undoubtedly  changed,  and  this  new 
property  is  not  due  to  the  presence  of  the  bacilli,  for 
they  are  absent,  but  must  be  due  to  something  in  so- 
lution in  the  bouillon.  A  horse  is  now  procured  and 
his  immunity  to  tetanus  is  greatly  increased;  the  horse 
is  what  is  called  immunized.  Take  the  blood  serum 
from  this  horse  and  mix  one  part  of  it  with  five  thousand 
parts  of  the  filtered  bouillon  which,  we  have  just  seen, 
kills  guinea-pigs  in  the  quantity  of  one-tenth  cubic 
centimetre.  Take  more  of  the  guinea-pigs  and  in- 
ject into  them  of  this  mixture  amounts  varying  from 
one-tenth  culjic  centimetre  to  one  cubic  centimetre, 
and  even  much  more.  It  will  be  found  that  they  have 
suffered  no  harm.  Something  then  was  present  in  the 
serum  of  this  immunized  horse  which  prevented  the 
poison  produced  by  the  tetanus  bacilli  from  affecting 
the  guinea-pig.  If  the  serum  of  a  non-immune  horse 
be  mixed  with  the  bouillon  it  does  not  prevent  the 
bouillon  causing  death  to  the  guinea-pig,  so  it  must 
be  something  formed  in  the  horse's  blood  during  im- 
munization. No  bacteria  are  present  in  the  horse's 
blood,  and  there  is  every  reason  to  believe  the  sub- 
stance in  question  is  an  albuminoid  substance  in  the 
nature  of  an  enzyme.  Now  we  have  seen  tliat  the  symp- 
toms produced  by  the  filtered  culture  broth  are  very  sim- 
ilar to  those  produced  in  an  animal  by  tetanus  itself, 
and,  moreover,  we  can  take  the  blood  serum  of  an  ani- 
mal dead  of  tetanus,  and  after  proving  it  free  from  the 
bacilli  of  tetanus  inject  it  into  a  guinea-pig  and  pro- 
duce death  with  the  same  S)'mptoms,  and,  further,  we 
can  mix  immune  serum  with  this  serum  and  thus  neu- 
tralize its  effects.  The  severity  of  the  symptoms  pro- 
duced by  the  filtered  bouillon  and  by  the  serum  from  an 
animal  dead  of  tetanus  varies  directly  as  to  the  quantity 
injected,  and  does  not  so  vary  when  inoculation  with 
the  bacilli  takes  place.  So  we  may  safely  conclude 
that  the  bacillus  of  tetanus  makes  a  toxin  in  the  body 
of  an  animal  similar  to  that  which  we  have  seen  it 
make  when  grown  in  bouillon.  And  again,  an  animal 
suffering  from  the  disease  itself,  if  injected  with  the 
blood  serum  of  an  animal  immunized  to  tetanus,  re- 
covers, or  if  injected  before  inoculation  with  tetanus 
proves  immune,  while  a  control  animal  similarly 
affected  and  without  the  serum  of  an  immunized  ani- 
mal invariably  dies;  so  there  is  every  reason  to  be- 
lieve that  the  animal  owes  its  immunity  to  the  serum 
from  the  immunized  animal  counteracting  the  effects 
of  the  poison — which  brings  us  to  acknowledge  that 
immunity  to  a  disease  is  accompanied  by  the  presence 
of  some  substance  in.  the  blood  and  serum  which 
counteracts  the  effects  of  the  poison  made  by  germ  of 
that  disease. 

As  to  just  how  this  immunity-giving  substance  acts 
we  are  unable  to  say.  It  certainly  is  not  in  any  way 
adisinfectantor  antiseptic,  for  tetanus  bacilli  will  grow 
freely  in  highly  antitoxic  antitetanus  serum.  It  is  not 
a  chemical  antidote,  for  a  mixture  of  toxin  and  anti- 
toxin which  is  perfectly  harmless  to  one  animal  is 
fatal  to  another  kind  of  animal.  It  is  not  a  physio- 
logical antagonist  to  the  toxin,  for  its  injection  with- 
out the  toxin  produces  no  symptoms,  nor  does  it  in 
any  dose  produce  symptoms  opposite  to  those  of  toxin. 
Its  action  probably  is  to  increase  the  vital  resistance  of 
the  body  in  general  and  of  the  leucocytes  in  particular 
to  the  action  of  the  poison.  Once  formed  it  persists 
in  the  immune  animal  and  is  not  readily  eliminated 
from  the  body;  some  of  it  is  lost,  however,  for  animals 
rendered  immune  while  pregnant  give  birth  to  young 
in  which  the  immunity  is  also  present,  and  the  amount 
lost  continues  probably  to  be  replaced,  and  thus  im- 
munity is  preserved. 

The  second  factor  in  the  mechanism  of  immunity 
is  the  activity  of  the  piiagocytes  in  dcstroving  bac- 
teria.    The  theory  of  phagocytosis  is  well  known,  and 


the  profession  is  too  well  acquainted  with  it  for  me 
to  give  any  lengthy  description  of  it  here.  As  will  be 
remembered,  the  theory  was  first  ardently  supported 
and  then  just  as  completely  dropped.  .As  is  quite 
often  the  case,  truth  lay  in  the  mean  between  oppos- 
ing opinions,  and  our  best  knowledge  seems  to  in- 
dicate that  phagocytes  do  engulf  and  destroy  bac- 
teria, and  living  bacteria  at  that,  but  that  their  ability 
to  do  so  depends  on  the  absence  of  the  toxin  of  an 
organism  which  is  pathogenic  for  the  individual. 
When  a  capillary  tube,  closed  at  one  end,  and  con- 
taining a  culture  of  a  non-pathogenic  germ,  is  intro- 
duced under  the  skin,  vast  numbers  of  phagocytes 
enter  the  tube  and  in  a  short  time  have  engulfed  and 
destroyed  the  germs.  If  the  tube  contain  a  culture  of 
a  pathogenic  germ  very  virulent  to  that  animal,  no 
such  condition  occurs,  but  on  the  contrarj'  the  phago- 
cytes retreat  from  near  the  tube.  This  ability  of  the 
phagocytes  to  seek  and  destroy  bacteria  is  called 
chemiotaxis,  and  the  presence  of  the  toxin  of  a  patho- 
gen paralyzes  it,  as  do  also  the  toxins  of  other  bac- 
teria if  present  with  the  one  inoculated.  This  phago- 
cytosis is  not  the  only  part  the  leucocytes  take  in 
immunity.  There  is  good  reason  to  believe  they  are 
the  chief  factors  in  producing  the  antitoxin,  and 
Kanthack  has  reported  some  observations  which,  if 
confirmed,  will  prove  very  important. 

He  and  Hardy  added  anthrax  bacilli  to  a  drop  of 
frog's  lymph  and  examined  them  under  the  microscopye 
for  four  or  five  hours.  The  first  thing  noticed  was 
that  the  eosinophilous  leucocytes  moved  up  to  the 
bacilli  and  arranged  themselves  along  them.  Then 
the  protoplasm  of  these  leucocytes  undenvent  rapid 
streaming  motion  and  the  cells  discharged  their  coarse 
granules  at  the  bacilli.  These  granules  dissolved  in 
contact  with  the  bacilli  and  the  bacilli  were  readily 
seen  to  become  granular  and  disintegrated.  All  this 
time  the  true  phagocytes  have  kept  out  of  the  way. 
But  they  now  come  forward,  arrange  themselves  in  a 
plasmodial  mass  around  the  bacilli,  and  the  eosino- 
philous leucocytes  retire.  These  phagocytes  now  en- 
gulf the  fragments  of  the  bacilli  and  finally  separate 
and  complete  their  digestion  of  the  bacilli  apart.  The 
reason  we  believe  that  the  phagocytic  theory  holds 
good,  so  far  as  stated,  are:  first,  the  phagocytes  can  be 
seen  in  the  act  of  engulfing  bacteria;  second,  these 
bacteria  can  be  seen  to  disintegrate  and  disappear  in 
the  body  of  the  phagoc3'te ;  third,  destruction  is  greater 
when  the  animal  recovers;  fourth,  bacteria  to  which 
phagocytes  exhibit  positive  ciiemiotaxis  are  destoved, 
and  bacteria  to  which  phagocytes  exhibit  negative  or 
no  chemiotaxis  are  much  more  virulent  for  the  indi- 
vidual; fifth,  the  fact  of  chemiotaxis  itself  is  a  proof. 

The  argument  has  been  advanced  that  while  phago- 
cytes do  engulf  and  destroy  bacteria,  they  do  so  only 
to  those  already  killed  bv  the  disinfectant  action  which 
blood  serum  to  some  extent  possesses.  .Against  this 
it  may  be  said:  first,  that  when  the  struggle  between 
the  system  and  the  germ  is  evenly  matched,  phago- 
cytes may  be  seen  to  engulf  bacteria,  and  these  bac- 
teria grow  inside  the  bodies  of  phagocytes,  the  phago- 
cyte being  thus  destroyed  and  the  living  bacteria  being 
liberated;  second,  that  phagocytes  destroy  germs  in 
an  animal  whose  blood  serum  has  no  such  antiseptic 
action  as  that  mentioned  above;  third,  that  in  a  non- 
immunized  animal  no  phagocytic  destniction  of  bac- 
teria takes  place,  while  after  immunization  the  germs 
are  readilv  destroyed,  but  the  disinfectant  action  of 
the  serum  may  be  greater  in  the  first  case  than  in  the 
second;  and  fourth,  that  bacteria  which  would  be 
quickly  destroyed  if  injected  into  the  body  live  and  grow 
if  placed  inside  the  body,  but  protected  from  phagocytes 
by  interposition  of  an  animal  membrane. 

We  thus  have  two  factors  in  the  defence  of  the  system : 
first,  the  presence  in  the  body  of  an  antitoxin,  a  chemical 


October  23,  1897] 


MEDICAL    RECORD. 


587 


substance  probably  albuminoid  in  nature,  which  in- 
creases the  vital  resistance  of  the  body  to  the  toxin  of 
the  germ  and  thus  neutralizes  all  the  bad  effect  of  the 
disease  (for,  practically  speaking,  the  only  means 
the  germ  has  of  harming  the  body  is  through  the  tox- 
ins it  can  produce) ;  and  second,  that  after  the  effects 
of  this  toxin  have  been  neutralized  (and  not  until 
then)  the  phagocytes  destroy  tlie  bacteria  and  thus 
prevent  the  formation  of  any  more  toxin  ;  and  that,  be- 
sides the  phagocytes  destroying  the  bacteria,  other 
forms  of  leucocytes  are  probably  largely  instrumental 
in  forming  the  antitoxin.  We  saw  above  that  blood 
serum  has  some  bactericidal  action,  but  this  action  is 
really  much  greater  outside  the  body  than  in  it,  and 
probably  plays  a  very  small  part  in  immunity. 

Going  to  the  second  division  of  this  paper,  the 
practical  application  of  bacteriological  knowledge,  I 
desire  to  preface  my  remarks  by  the  statement  of  a  fact, 
familiar  to  all  of  us  but  not  often  enough  remembered. 
An  individual's  chance  of  having  an  infectious  dis- 
ease may  be  weighed  by  a  balance  which  contains  on 
one  side  the  amount  of  his  natural  or  acquired  immu- 
nity, and  on  the  other  the  number  and  virulence  of 
the  infecting  organisms.  As  the  balance  leans,  so  do 
his  chances  incline.  Now  it  is  important  to  remember 
that  virulence  is  more  a  habit  of  a  germ  than  an  inte- 
gral part  of  it,  and  can  be  gained  or  lost  by  a  germ  in 
accommodating  itself  to  the  surroundings  in  which 
that  germ  is  placed.  To  illustrate:  The  streptococcus 
pyogenes  may  be  taken  from  a  very  virulent  case  of 
sepsis  and  inoculated  on  agar.  Much  difficulty 
may  be  experienced  in  getting  it  to  grow,  for  tha 
germ  may  have  very  thoroughly  accommodated  itself 
to  growing  inside  the  body,  and  to  grow  on  dead  mat- 
ter or  as  a  saprophpte  requires  a  change  of  habit. 
Some  of  the  individual  germs  of  the  culture,  however, 
will  be  able  to  adapt  themselves  to  the  new  conditions 
and  these  will  produce  others  like  themselves,  and  each 
succeeding  inoculation  will  grow  more  easily  until  by 
a  sort  of  hereditary  selection  the  germ  has  completely 
changed  its  habit.  If  some  of  the  germs  had  been  in- 
oculated directly  from  the  case  of  sepsis  to  an  animal, 
death  would  have  surely  followed;  but  if  now  we  in- 
oculate some  of  these  same  germs  which  have  had  to 
grow  outside  of  the  body  for  several  weeks,  we  find  that 
in  so  growing  they  have  lost  their  ability  to  grow  as  a 
disease  producer.  They  have  ceased  to  be  virulent. 
This  virulence  is  lost  gradually,  and  the  longer  the 
germ  has  had  to  live  as  a  saprophyte,  the  more  com- 
plete is  the  loss  of  virulence. 

Now  most  of  the  bacteria  occurring  in  the  air  or 
in  the  houses  inhabited  by  healthy  people  are  either 
by  nature  saprophytes  or  else  have  lost  their  habit 
of  virulence  to  a  greater  or  less  extent;  while  those 
coming  directly  from  an  infection  have  this  habit 
of  virulence  strongly  on  them,  and  we  should  be 
very  careful  to  keep  them  where  they  can  do  no 
harm.  But  virulence  is  relative,  and  a  but  slightly 
virulent  germ  may  produce  infection  if  present  in 
sufficient  numbers  or  in  an  individual  whose  im- 
munity is  below  par.  As  we  have  seen,  the  presence 
of  the  toxin  of  one  germ  paralyzes  chemiotaxis 
against  another  germ,  and  in  a  sluggish  condition  of 
the  intestinal  tract  we  have  a  fruitful  source  of  auto- 
intoxication, thus  lowering  general  immunity;  and 
it  is  for  this  reason  that  0  saline  or  mercurial  evacu- 
ant  is  so  useful  in  the  beginning  of  any  infectious  dis- 
ease or  when  wound  infection  is  feared.  The  in- 
halation of  sewer  gas  has  a  paralyzing  effect  on  the 
leucocytes,  and  it  is  from  this  diminished  immunity 
rather  than  from  any  germs  that  are  inhaled  that  peo- 
ple living  in  badly  trapped  houses  are  subject  to  in- 
fectious diseases.  The  presence  of  one  germ  or  its 
ptomain,  although  both  by  themselves  be  harmless, 
often  greatly  increases  the  virulence  of  a  pathogenic 


organism,  and  it  is  for  this  reason  that  mixed  infec- 
tions in  phthisis  and  diphtheria  are  of  more  grave 
prognosis,  and  the  reason  why  laboratory  experiments 
and  bedside  experiences  so  often  give  different  results 
is  that  mixed  infection  is  present  almost  always  in 
clinical   work  and   never   in   laboratory  experiments. 

As  to  antiseptics  and  disinfectants  in  surgery,  let  me 
say  in  a  general  way  that  all  disinfectants  that  we  use 
act  as  irritants  to  protoplasm,  and  only  as  irritants  to 
protoplasm;  that  bacterial  protoplasm  is  as  a  rule 
more  resistant  to  their  action  than  the  protoplasm  of 
the  animal  tissues;  that  a  non-irritant  germicide 
has  yet  to  be  discovered;  that  inside  the  body  and 
on  clean  open  wounds  much  more  harm  than  good  is 
done  by  using  germicides.  It  is  impossible  by  any 
means  short  of  the  use  of  the  cautery  to  kill  all  the 
bacteria  in  a  wound,  for  all  our  agents  act  by  combin- 
ing with  albumin,  and  the  germ  albumin  is  always 
present  in  much  smaller  quantities  than  the  tissue 
albumin,  and  the  distribution  of  the  disinfectant  is 
not  selective  hut  j^ro  rata.  In  using  such  a  disinfec- 
tant we  kill,  say,  ninety  per  cent,  of  the  germs,  and  in 
so  doing  prepare  a  layer  of  dead,  non-resistant  tissue 
for  the  remaining  ten  per  cent,  to  grow  on,  and  the 
germs  we  have  left  are  able  to  grow  faster  in  this  un- 
resisting location  and  do  more  harm  than  the  one  hun- 
dred per  cent,  could  have  done  in  healthy  tissue  with 
good  resisting-power.  It  is  a  known  fact  that  we  can 
inject  large  numbers  of  virulent  pus  cocci  into  the 
uninjured  peritoneal  cavity  and  with  no  infection,  but 
if  an  irritant  be  injected  with  them,  or  if  the  perito- 
neum be  injured,  or  even  if  blood  be  injected  at  the 
same  time,  fatal  peritonitis  results.  The  best  plan, 
then,  is  to  use  disfectants  as  strong  as  need  be  to  ren- 
der aseptic  all  substances  which  come  in  contact  with 
the  wound;  to  use  fairly  strong  antiseptics  in  cleans- 
ing the  skin  of  patient,  but  when  it  comes  to  the  wound 
itself  to  use  as  little  besides  sterile  salt  solution  as 
possible.  The  foregoing  remarks  apply  to  a  clean-cut 
wound  and  not  to  a  wound  in  which  the  vital  resist- 
ance of  tlie  tissues  has  been  already  lowered  by  bruis- 
ing or  previous  infection,  for  in  this  case  we  have 
already  lost  the  vital  resistance  and  no  harm  will  be 
done  by  attacking  the  germ  vigorously.  To  put  the 
point  more  plainly,  let  us  be  sure  when  interfering  in 
this  struggle  between  the  human  .system  and  the  germ 
that  in  striking  a  blow  at  tlie  germ  we  do  not  strike 
the  system  a  more  disabling  one.  Antiseptics  in  the 
intestinal  tract  are  under  somewhat  the  same  con- 
ditions as  those  used  in  skin  disinfection,  and  there 
is  some  reason  to  believe  that  verj'  slightly  soluble 
substances  may  be  used  with  benefit  in  intestinal  anti- 
sepsis. As  to  the  treatment  of  the  throat  in  diph- 
theria, the  membrane  should  be  kept  removed,  for  it  is 
the  source  and  the  only  source  from  which  the  toxin 
comes,  but  the  membrane  should  be  removed  by  some 
agent  which  attacks  dead  matter  and  does  not  irritate 
living  tissue.  Such  agents  we  possess  in  the  digestive 
ferments,  such  as  papain  and  trypsin. 

Recent  experiments  have  proven  that  the  vaginal 
mucus  of  healthy  women  has  a  very  marked  action  in 
destroying  pathogenic  and  pyogenic  bacteria,  thus 
rather  arguing  against  the  too  frequent  use  of  the 
douche  in  the  puerperal  state,  and  the  above  fact  may 
explain  the  success  our  gynaecologists  are  having  in 
their  operations. 

The  thermal  death  point  of  the  gonococcus  is  quite 
low,  a  temperature  of  40°  C.  (104"  F.)  killing  it  in  a 
short  time  on  media,  and  it  is  probably  partly  for  this 
reason  that  urethral  irrigations  are  so  useful  when 
given  as  hot  as  can  be  well  endured.  Other  reasons 
might  be  cited  to  explain  the  success  of  hot  irriga- 
tions, namely,  that  the  action  of  most  chemical  dis- 
infectants is  greater  in  hot  solutions,  and  that  heat  is 
useful  in  most  inflammatory  conditions,  whether  in- 


588 


MEDICAL    RECORD. 


[October  23,  1897 


fectious  ones  or  not.  On  the  other  hand,  it  might  be 
stated  that  a  man  with  gonorrhfta  may  suffer  from 
a  fever  of  105°  F.  or  over  and  the  gonorrh<jL-a  persist, 
although  the  discharge  is  usually  lessened  thereby. 

Before  leaving  the  subject  of  disinfectants,  a  plea 
should  be  made  for  more  sunlight.  Direct  sunlight  is 
probably  as  good  a  disinfectant  as  i  to  2,000  bichlo- 
ride, and  it  acts  at  low  temperatures. 

A  new  avenue  for  error  has  been  recently  discov- 
ered in  searching  for  the  tubercle  bacillus  in  urine. 
It  depends  on  the  fact  that  the  smegma  bacillus,  which 
frequently  finds  access  to  the  urine,  stains  capriciously, 
and  frequently  cannot  by  any  staining  peculiarity  be 
distinguished  from  the  tubercle  bacillus.  The  error 
may  be  minimizecl  by  rendering  the  meatus  as  clean  as 
possible  and  then  examining  the  urine  drawn  through 
a  clean  catheter. 

The  tetanus  bacillus  is  known  to  be  unable  to  grow 
in  the  presence  of  oxygen.  Its  spores  are  often  found 
in  the  earth,  and  it  is  for  this  reason  that  a  punctured 
wound  produced  by  something  which  has  been  in  the 
soil  (as  a  rusty  nail)  is  so  apt  to  produce  tetanus. 

The  micrococcus  lanceolatuscan  produce  pneumonia 
only  when  it  gets  down  to  the  air  vesicles.  It  can- 
not reach  there  if  the  cilia  lining  the  respiratory 
tract  are  in  good  condition;  but  chilling  and  cold 
air  paralyze  ciliary  motion,  and  it  is  somewhat  for  this 
reason  that  pneumonia  follows  exposure  to  cold,  and 
especially  breathing  very  cold  air  through  the  mouth. 
In  speaking  of  diphtheria,  I  may  say  that  its  antitoxic 
treatment  has  almost  passed  out  of  the  hands  of  the 
bacteriologist  and  belongs  now  to  the  clinician.  I 
may^  say,  though,  tliat  a  sufficient  number  of  units 
should  always  be  used  (rarely  less  than  fifteen  hun- 
dred), and  these  in  as  concentrated  a  serum  as  is  ob- 
tainable. Much  time  can  often  be  saved  in  the  diag- 
nosis by  an  examination  of  a  cover-glass  preparation 
from  the  throat,  and  the  technique  is  very  simple. 

As  to  the  antitoxic  treatment  of  pulmonary  tuberculo- 
sis it  may  be  said  that  there  are  greater  difficulties  in 
the  way  than  in  diphtheria.  Tuberculosis  is  not  a  local 
disease,  and  the  bacilli  occur  in  little  patches  or  tuber- 
cles. Each  of  these  is  walled  in  to  some  extent  by 
fibroid  or  necrotic  tissue.  Now,  when  the  antitoxin  is 
used,  the  toxin  is  neutralized  and  the  symptoms  im- 
prove; but  the  walls  of  the  tubercle  prevent  the  pha- 
gocytes from  getting  in  to  attack  the  bacilli  and  so 
they'  are  not  destroyed,  and  when  the  antitoxin  is 
stopped  their  toxin  is  no  longer  unneutralized  and 
the  symptoms  recur.  In  niiliarv  tuberculosis  these 
tubercles  are  not  so  thick-walled  and  many  of  the 
bacilli  are  not  in  tubercles,  and  in  this  disease  anti- 
toxin seems  to  be  somewhat  more  beneficial.  Perhaps 
when  tubercle  antitoxin  is  improved  and  its  antitoxic 
strength  is  more  often  definitely  stated  in  units,  we 
may  use  it  with  more  success. 

Considerable  help  can  be  obtained  in  infectious 
diseases  by  a  cover-glass  preparation  of  the  blood. 
Malaria  will  of  course  be  recognized,  and  a  study  of 
the  degree  of  leucocytosis  present  aids  as  much  in 
prognosis. 

The  blood  test  for  typhoid  is  attracting  much  atten- 
tion just  now.  It  depends  on  the  fact  that  when  but 
slightly  virulent  typhoid  bacilli  from  a  culture  tube 
are  placed  in  some  blood  serum  from  a  case  of  true 
typhoid  fever  they  lose  their  motility  and  tend  to 
cling  together  in  clumps,  or  agglutinate.  Wiiile 
typhoid  serum  has  this  property  to  a  greater  extent 
than  other  blood  serum,  serum  in  the  normal  in- 
dividual and  in  some  other  diseases  possesses  the  prop- 
erty to  a  lesser  degree,  and  to  make  sure  the  case  is 
typhoid  it  seems  necessary  to  dilute  the  serum  in  the 
proportion  of  sixteen  to  one  and  to  form  our  opinion 
from  the  reaction  under  liiese  conditions  of  dilution. 
The  reaction  is  not  usuallv  elicited  until  the  disease 


has  been  present  some  days,  and  dried  blood  does  not 
seem  to  give  the  same  satisfaction  as  does  the  diluted 
serum. 

SOI-203    ViSTA  BVILDIS'G. 


SURGICAL  CASES  IN  GENERAL  PRACTICE.' 
By  g.  w.  Kixt;,  M.t).. 

HELENA,    MO.ST. 

Case  I. — J.  P ,  miner,  aged  thirty-five,  fell  a  dis- 
tance of  twenty  feet,  his  head  coming  in  contact  with 
a  stull  (timber)  in  the  descent.  The  only  visible 
signs  of  external  injury  were  found  to  be  a  scalp 
wound,  one  and  one-half  inches  in  length,  beginning 
one-half  inch  to  the  right  and  the  same  distance  below 
the  occipital  protuberance.  No  evidence  of  fracture 
could  be  found.  The  symptoms  of  profound  shock 
were  present;  the  patient  being  unconscious,  with 
moderately  dilated  pupils,  muscular  relaxation,  irregu- 
lar respiration,  coldness  of  extremities,  etc.  The  treat- 
ment adopted  was  that  for  shock  in  general,  viz., 
warmth  to  the  extremities  and  epigastrium,  hypodermic 
injections  of  strychnine  repeated  according  to  indica- 
tions. Reaction  came  on  slowly  twenty-four  hours 
later;  consciousness  returned,  followed  by  rapid  im- 
provement-in  all  the  symptoms;  and  at  the  end  of  the 
seventh  day  there  remained  no  appreciable  signs  of 
intracranial  injury.  The  case  was  kept  under  observa- 
tion, and  the  possible  dangers  that  might  result  from 
imprudence  on  his  part  were  fully  explained  to  the  pa- 
tient. On  the  twenty-second  day  after  the  injury  there 
was  a  sudden  onset  of  symptoms  pointing  to  severe 
cerebral  complication;  the  temperature  was  101°  P., 
with  great  disturbance  of  the  sensorium,  which  soon 
merged  into  a  condition  of  coma.  On  the  following 
day  a  trephine  opening  was  made  at  the  site  of  the  in- 
jury, the  dura  was  incised,  and  a  careful  exploration  of 
the  underlying  portion  of  the  brain  was  made  with  an 
exploring  needle.  Nothing  definite  was  learned  from 
this  source,  and  as  the  condition  of  the  patient  did  not 
permit  of  further  search  the  operation  had  to  be  aban- 
doned without  discovery  of  the  lesion.  There  were 
encouraging  symptoms  immediately  following  the  op- 
eration, consciousness  returned,  the  temperature  fell 
to  the  normal.  This  apparent  relief,  however,  proved 
to  be  but  temporary,  continuing  about  fourteen  hours, 
when  coma  again  supervened  and  death  occurred  the 
next  clay.  It  is  much  to  be  regretted  that  an  autopsy 
could  not  be  obtained  to  demonstrate  the  location  and 
nature  of  the  lesion.  Doubtless  the  relief  obtained 
was  due  to  the  lessening  of  intracranial  tension,  and 
possibly  had  the  skull  been  opened  at  another  point 
permanent  good  might  have  been  accomplished. 

These  cases  are  instructive,  inasmuch  as  the  ques- 
tion of  trephining  in  the  absence  of  localizing  symp- 
toms is  a  debatable  one.  The  indications  of  brain 
lesions  following  head  injuries  are  in  many  instances 
too  obscure  to  be  of  any  value  as  to  the  exact  location 
of  the  trouble;  hence  the  operator  should  be  prepared 
to  make  one  or  several  openings  in  the  skull  if  neces- 
sary. 

C.\SE  11. — J.  W ,  farmer,  aged  sixty-two,  received 

contusions  of  the  frontal  bone  by  accidentally  falling 
against  the  edge  of  an  open  door.  The  scalp  being 
uninjured,  little  attention  was  given  to  the  injury  at 
the  time.  Subsequently  a  swelling  appeared  over  the 
bruised  area,  gradually  increasing  in  size;  but,  ac- 
companied by  little  if  any  pain,  it  was  still  ne- 
glected until  it  had  reached  dimensions  sufficient  to 
cause  anxiety  as  to  its  nature.  When  he  presented  him- 
self for  treatment,  the  appearance  of  the  swelling,  to- 

'  Rcail  at  a  meeting  of  the  Montana  State  Medical  .\ssociation, 
Helena,  .\pril,  1S96. 


October  23,  1897] 


MEDICAL    RECORD. 


589 


gether  with  the  history  of  a  contusion,  made  the  diag- 
nosis of  abscess  with  probable  necrosis  of  the  outer 
layer  of  the  frontal  bone  the  correct  one.  The  abscess 
was  evacuated  and  the  conditions  were  found  as  an- 
ticipated.    The  wound  was  dressed  and  the  patient  put 


>'*«  ^^' 

w^ 


upon  the  "mixed  treatment"  as  a  tentative  measure. 
It  was  impossible  to  carry  out  direct  and  continuous 
treatment,  as  the  case  could  be  seen  only  at  irregular 
inters  als.  Three  months  later  a  free  opening  was  made 
in  the  scalp,  revealing  a  large  cavity  in  the  outer  layer 
of  the  frontal  bone.  The  incision  was  kept  open  by 
gauze  packing,  and  time  allowed  for  exfoliation  of  the 
necrosed  bone  tissue.  The  administration  of  iodides 
was,  however,  continued.  As  there  were  no  symptoms 
of  involvement  of  the  dura,  nothing  further  was  at- 
tempted. The  slow  progress  of  the  disease  being  rec- 
ognized, it  was  hoped  that  separation  of  the  necrosed 
bone  would  eventually  take  place. 

Nothing  worthy  of  comment  occurred  until  tiie  early 
part  of  January,  1896,  some  six  months  later,  when 
summons  was  received  to  visit  the  patient  immedi- 
ately, as  he  had  suddenly  become  insane  and  could 
with  difficulty  be  controlled.  The  case  did  indeed 
look  unpromising.  The  history  of  the  attack  as  stated 
by  those  present  was  that  upon  the  evening  previous, 
without  apparent  cause,  he  had  become  delirious;  he 
became  unable  to  recognize  members  of  his  own  family, 
constantly  endeavored  to  get  down  upon  the  floor  in 
search  of  imaginary  objects,  and  was  very  restless. 
There  was  no  paralysis  of  speech  or  motion.  Exam- 
ination of  the  necrosed  portion  of  the  skull  showed 
that  the  disease  had  progressed  with  probable  infec- 
tion within  the  cranial  cavity.  .\s  soon  as  arrange- 
ments could  be  made  for  operation,  the  trephine 
was  applied  and  an  abscess  opened  between  the 
inner  and  outer  tables;  the  opening  was  enlarged  with 
the  rongeur  forceps,  and  all  of  tiie  diseased  bone  re- 
moved. The  dura  was  not  incised,  as  it  presented  no 
evidence  of  being  invaded  by  the  disease  process. 
The  large  cavity  remaining  was  packed  with  gauze  and 
the  patient  put  to  bed.  The  immediate  effect  of  the 
operation  was  a  subsidence  of  the  extreme  irritation, 
the  patient  being  quiet,  though  his  intellect  remained 
clouded.  The  wound  progressed  favorably  and  his 
general  condition  improved  rapidly.  Moderate  doses 
of  iodides  had  been  used  from  the  beginning.  It  was 
now  decided  to  try  larger  doses;  accordingly  sixty 
grains  three  times  daily  was  ordered.  The  beneficial 
results  of  this  plan  of  treatment  were  soon   apparent. 


and  at  the  present  time  the  patient  is  relieved  of  the 
cerebral  complication  and  is  in  a  fair  way  to  recovery. 
The  prognosis  is  of  course  a  matter  which  time  alone 
can  demonstrate. 

Case  III. — Prospector,  aged  fifty-four,  of  dissolute 
habits,  came  in  from  the  hills  for  treatment  of  a  drop- 
sical effusion  in  the  lower  extremities.  The  effusion 
was  found  to  be  due  to  an  attack  of  nephritis,  from 
which  he  recovered  in  due  time.  The  left  eye  had 
been  sightless  for  ten  years,  with  no  history  as  to  the 
cause.  Some  months  later  he  consulted  me  for  what 
he  supposed  was  an  inflammation  of  the  lower  lid  of 
the  unsound  eye.  The  appearance  of  the  part  was  not 
unlike  that  of  a  case  of  aggravated  trachoma.  Treat- 
ment was  directed  toward  allaying  the  irritation,  but 
without  producing  the  slightest  effect.  It  soon  became 
evident  that  there  was  something  more  than  simple  in- 
flammation to  deal  with.  The  rapid  increase  of  the 
growth,  its  general  appearance  and  locatios,  left  little 
doubt  as  to  its  malignant  nature.  Within  two  months 
from  the  time  of  the  first  inspection  it  had  attained  the 
size  shown  in  the  illustration  (Fig.  i)  here  presented. 
Incidentally  it  may  be  mentioned  that  a  medium- 
sized  lipoma  situated  in  the  occipital  region  had  been 
growing  for  a  long  time.  The  accompanying  illustra- 
tion (Fig.  2)  defines  its  situation  and  appearance. 
Both  tumors  were  removed  at  one  operation,  for  the 
lipoma  a  simple  excision  only  being  necessary.  The 
removal  of  the  orbital  tumor  required  more  care;  the 
eye  was  enucleated,  and  with  it  the  contents  of  the 
orbit.  Hemorrhage  was  of  course  very  free,  but  easily 
controlled  by  packing.  Figs.  3  and  4  represent  the 
patient  as  he  appeared  six  weeks  after  the  operation. 

An  interval  of  quiescence  followed  the  removal  of 
the  orbital  tumor,  but,  as  the  sequel  proved,  the  opera- 
tion was  by  no  means  curative.  Recurrence  is  the  rule 
with  sarcoma,  especially  that  of  the  melanotic  variety. 
The  complete  removal  of  all  infected  tissues  within 
the  orbit  is  very  difficult,  if  not  impossible.  The 
astonishing  rapidity  which  characterizes  the  secondary 
growths  in  this  form  of  sarcoma  is  their  most  distinc- 
tive feature.  In  the  after-treatment  of  the  case  strict 
attention  was  given  to  cleanliness,  and  the  applica- 
tion of  arsenical  paste  was  made  to  all   suspicious 


points.  Notwithstanding  these  precautions,  the  dis- 
ease appeared  in  the  upper  angle  of  the  orbit  and 
steadily  advanced  until  the  growth  had  reached  one- 
half  its  former  size,  when  a  second  operation  was  un- 
dertaken and  thorough  removal  again  effected.     The 


590 


MEDICAL    RI-;C()RD. 


[October  23,  1897 


upper  eyelid  was  included  in  the  growth.  This  pro- 
cedure served  to  hold  the  disease  in  check  for  a  lim- 
ited time  only.  Its  next  appearance  was  in  the  lower 
part  of  the  orbit  and  its  growth  was  progressive.  For 
a  third  time  the  knife  was  applied  and  all  visible  por- 


tions of  the  tumor  were  taken  away.  The  after-treat- 
ment was  careful  and  thorough,  yet  unavailing.  Op- 
portunity was  taken  to  try  some  of  the  stronger  caustics 
— chromic  acid  and  hydrofluoric  acid;  the  latter  gave 
the  best  results.  It  was  used  with  caution,  the  most 
prominent  parts  of  the  tumor  being  merely  touched 
with  a  glass  rod  previously  dipped  in  the  acid.  Evi- 
dence of  general  infection  was  now  unmistakable,  the 
patient's  nutrition  became  defective,  and  he  lost 
strength  rapidly.  All  attempts  to  do  more  than  re- 
lieve the  most  urgent  symptoms  were  abandoned.  The 
actual  cautery  had  been  tried  during  the  progress  of 
the  case.  The  patient  lingered  in  this  condition  for 
two  months,  finally  yielding  to  the  inevitable  one  year 
from  the  date  of  the  first  operation. 

From  the  experience  gained  in  the  treatment  of  this 
case,  I  believe  that  in  attacking  like  tumors  all  the 
soft  tissues  surrounding  the  orbit  should  be  removed 
without  regard  to  cosmetic  results,  which  are  but  sec- 
ondary considerations  when  we  are  dealing  with  a  dis- 
ease so  formidable. 

Case  IV. — Atheromatous  tumor  of  the  scalp.  This 
case  is  cited,  not  that  it  possesses  any  features  of  spe- 
cial interest,  but  rather  as  a  record  of  the  successful 
use  of  the  infiltration  method  for  securing  local  anajs- 
thesia.  The  tumor  was  of  considerable  size.  The 
following  formula  was  used: 

IJ  Muriate  of  rocaiiic gr.  ss. 

Muriate  of  morphine gr.  J^. 

Chloride  of  sodium gr.  i. 

Distilled  water 5  i. 

About  thirty  minims  was  injected  in  the  line  of  the 
proposed  incision.  No  pain  was  experienced  during 
the  operation,  including  the  placing  of  the  sutures. 
This  method  seems  to  be  safe  and  efficient,  and  is 
therefore  recommended  for  further  trial. 

Cases  V.  and  \'I. — At  a  former  meeting  (1894)  I 
presented  to  the  association  a  patient  upon  whom  I 
had  operated  for  the  radical  cure  of  hernia.  When 
last  examined,  some  three  months  since,  the  parts  were 
found  in  good  condition,  firm  and  solid.  He  wears  no 
truss,  is  doing  heavy  work  without  any  inconvenience 
whatever.     At  this  time  I  have  two  more  cases  to  re- 


cord. A  carpenter,  aged  thirty -five  years,  had  left  in- 
guinal hernia  of  fifteen  years' standing;  it  was  imper- 
fectly controlled  bj-  a  truss,  hence  a  constant  menace  to 
life  from  danger  of  strangulation.  By  an  incision 
over  the  inguinal  canal  the  inner  ring  was  exposed  and 
then  closed  as  nearly  as  possible  with  kangaroo-tendon 
sutures.     Primary  union  followed. 

The  second  case :  Prospector,  aged  fifty-four  years, 
had  recent  double  inguinal  hernia  complicated  upon  the 
right  side  by  hydrocele.  The  hydrocele  was  treated  by 
incision  and  the  hernia  of  the  same  side  operated  upon 
in  the  usual  manner.  The  result  has  been  good;  the 
only  thing  to  be  regretted  was  the  use  of  silkworm  gut 
for  the  buried  sutures,  which  subsequently  caused  so 
much  irritation  as  to  necessitate  removal. 

Before  leaving  the  subject  a  brief  reference  to  two 
cases  of  strangulated  hernia  may  be  of  interest  at  this 
time — the  one  neglected  and  in  a  hopeless  condition; 
the  other  seen  early  and  amenable  to  treatment.  When 
one  is  familiar  with  the  operation  for  hernia  it  is 
always  an  unpleasant  experience  to  be  confronted  with 
conditions  like  these:  An  elderly  man  with  reducible 
hernia  of  many  years'  duration,  after  a  prolonged  de- 
bauch, during  which  it  became  strangulated,  at  the  last 
moment  called  the  physician.  The  strangulation  had 
existed  seven  days  and  the  patient  was  of  course  be- 
yond surgical  aid.  An  incision  over  the  tumor  re- 
vealed a  gangrenous  and  sloughing  gut.  It  was  seen 
at  a  glance  that  nothing  further  could  be  done,  and  the 
patient  died  a  few  hours  later.  The  other  case  illus- 
trates a  plan  of  treatment  which, while  not  always  safe  to 
pursue,  may  under  favorable  circumstances  be  adopted : 
Middle-aged  man,  right  inguinal  hernia  retained  by  a 
truss.  Having  returned  home  late  one  night,  he  re- 
moved the  truss  and  the  hernia  slipped  down.  Being 
unable  to  retitrn  it  in  the  accustomed  way,  he  sent  im- 
mediately for  assistance.  Not  being  an  advocate  of 
taxis  except  to  a  limited  extent,  and  finding  that  the 
tumor  did  not  yield  to  careful  manipulation,  I  decided 
to  elevate  the  hips  and  give  a  hypodermic  injection  of 
morphine,  as  no  very  urgent  symptoms  were  present. 
The  patient  was  informed  that  an  operation  would  be 
necessary  in  the  morning,  provided  the  intestine  had 
not  returned.     Upon  the  morning  visit  it  was  found 


tliat  under  the  relaxing  etTects  of  the  morphine  aided 
by  position  the  hernia  had  become  replaced  with  ease. 
Probably  had  tiie  necessary  assistance  been  at  hand, 
the  operation  would  have  been  performed  at  the  first 
visit.     There  is  no  doubt  that  manv  cases  could  be 


October  23,  1897] 


MEDICAL    RECORD. 


591 


successfully  treated  in  this  way,  if  forcible  attempts      of  the  foot,  with  the  heel  drawn  up  by  the  contracted 
at  reduction  were  avoided.     The  irritation  caused  bv      tendons  (Fisr.  c-).     tlndfr  ^^n.-^^th^.;.  t»r,^f ,  ^(  .u„ 


at  reduction  were  avoided.  The  irritation  caused  by 
rough  handling  adds  to  the  difficulties  of  the  case. 
Palliative  measures  should  not  be  persisted  in  if  after 
a  reasonable  time  it  should  appear  that  no  progress 
is  being  made.  Under  such  circumstances  there  is  but 
one  thing  to  do — operate,  close  up  the  internal  ring, 
and  cure  the  patient. 

Case  VII. — Epithelioma  of  scrotum  and  penis. 
Miner,  aged  forty  years,  first  noticed  a  small  sore  on  the 
outer  side  of  the  foreskin,  gradually  increasing  in  size 
without  induration  or  swelling.  Some  weeks  later  a 
similar  sore  appeared  upon  the  right  side  of  the 
scrotum.  At  this  time  he  presented  himself  for  treat- 
ment There  was  no  history  of  venereal  infection. 
An  accurate  diagnosis  could  not  be  made  from  the  ap- 
pearance of  the  pans.  Xo  enlargement  of  the  inguinal 
glands  could  be  discovered.  Local  treatment  was  ap- 
plied and  the  patient  put  upon  specific  remedies  as  a 
test.  No  improvement  followed;  on  the  contrarj',  the 
disease  steadily  advanced.  The  health  of  the  patient 
remained  good.  Several  weeks  were  spent  in  vain  en- 
deavors to  bring  about  healing  of  the  sores.  At  this 
time  the  peculiar  appearance  of  the  one  sitnared  upon 


tendons  (Fig.  5).     Under  anesthesia  tenotomy  of  the 


Achilles  tendons  of  both  feet  was  done,  andplaster-of- 
Paris  dressing  applied  while  the  feet  were  held  in  an 
overcorrected  position.  After  the  tendons  had  healed 
a  Scarpa's  shoe  was  adjusted  and  worn  until  the  patient 
was  able  to  control  his  limbs  sutticiently  to  wear  an 
ordinary  shoe  well  stiffened  at  the  ankles  (Fig.  6). 
The  after-treatment  in  this  case  was  faithfully  carried 
out  by  the  parents  and  materially  aided  in  the  result. 

Girl,  aged  si.x  years,  had  congenital  talipes  equino- 
varus,  more  aggravated  in  type  than  in  the  preceding 
case;  she  was  walking  upon  the  dorsum  of  the  feet 
The  accompanying  illustration  (Fig.  7)  indicates  the 
position.  Attempts  had  been  made  to  correct  the  de- 
formity without  operation,  but  as  a  matter  of  course  had 
failed  to  influence  it  in  any  degree,  and  owing  to  the 
pain  and  discomfort  attending  this  treatment  it  had 
been  abandoned.  Evidently  the  first  step  in  the  treat- 
ment was  the  division  of  the  contracted  tendons.  Ac- 
cordingly tenotomy  of  the  Achilles  tendon  with  a  thor- 


the  scrotum  created  the  suspicion  of  epithelioma.  A 
section  was  placed  under  the  microscope  and  the  sus- 
picion verified.  No  time  was  lost  in  removing  a  por- 
tion of  the  scrotum,  going  wide  of  the  disease.  Cir- 
cumcision was  also  performed,  sufficient  tissue  being 
taken  to  guard  against  recurrence.  The  parts  healed 
perfectly,  leaving  no  trace  of  the  growth;  and  up  to 
the  present  time  the  patient  has  remained  well. 

Cases  VIII.  and  IX.— Talipes  equino-varus.  The 
treatment  of  talipes  is  occasionally  forced  upon  the 
physician.  While  it  is  true  that  these  cases  are 
perhaps  better  cared  for  in  institutions  devoted  to  that 
branch  of  surgery,  much  may  be  done  and  quite  satis- 
factory results  obtained,  if'  the  requisite  time  and 
patience  can  be  secured.  To  illustrate  the  method 
and  results  of  treatment  the  following  cases  are  cited: 

.\boy,  aged  seven,  for  congenital  talipes  equino-varus 
had  received  treatment  from  infancy,  but  probably  had 
not  been  kept  strictly  under  medical  supenision.  He 
was  wearing  hea\7  steel  braces  entirely  unsuited  to  the 
case.  His  feet  were  tender  from  the  e.vcoriations 
caused  by  pressure  of  the  instruments  over  the  bony 
points.  Indeed  it  was  with  the  greatest  difficult}'  that 
he  could  walk  at  all.  The  deformity  was  such  that 
the  weight  of  the  body  was  thrown  upon  the  outer  side 


ough  division  of  all  the  tendons  and  fascia  upon  the 
inner  side  of  the  foot  by  open  incision  was  the  opera- 


592 


MEDICAL    RECORD. 


[October  2^,  1897 


tion  chosen.  The  corrected  position  was  maintained 
by  plaster-of-Paris  dressing.  The  wounds  healed 
without  suppuration.  The  plaster  dressing  was  fol- 
lowed by  the  Scarpa's  shoe  at  the  proper  time.  This 
treatment  was  continued  as  in  the  other  case,  with  the 
result  shown  in  the  illustration  (Fig.  8).  Since  that 
time  there  has  been  some  degree  of  relapse  in  the  left 
foot  due  to  neglect  of  the  parents  in  supplying  her  with 
proper  shoes. 

Case  X. — Necrosis  of  the  crest  of  the  ilium.  This 
history  is  valuable,  illustrating  as  it  does  the  ineffective 
employment  of  medicinal  treatment  under  a  mistaken 


diagnosis  in  a  case  strictly  surgical:  A  man  who 
formerly  had  been  a  miner,  aged  forty-five  years,  com- 
plained of  shifting  pains  in  the  back,  radiating  from 
the  left  hip  and  extending  down  the  thigh.  There  was 
no  local  tenderness,  but  there  was  some  stiffness  of  the 
muscles  of  the  back  when  he  attempted  to  arise.  Noth- 
ing abnormal  could  be  discovered  in  connection  with 
the  heart,  lungs,  kidneys,  or  -bdominal  viscera.  The 
diagnosis  of  rheumatism  had  been  made  and  the  pa- 
tient put  upon  antirheumatic  treatment.  Taking  into 
consideration  the  frequency  with  which  miners  past 
middle  life  contract  rheumatism,  and  also  the  symp- 
toms and  histor}-  presented  in  this  instance,  it  is  quite 
probable  that  had  he  been  examined  by  one  hundred 
physicians  there  would  have  been  no  dissenting  opin- 
ion. The  futility'  of  medicinal  treatment  was  perplex- 
ing, for  it  is  usually  possible  to  alleviate  if  we  fail  to 
cure.  The  patient  visited  the  Hot  Springs  in  the 
hope  of  obtaining  relief  from  the  constant  pain,  but 
without  success.  During  the  following  months  but 
little  change  took  place  in  his  condition.  Treatment 
was  discontinued  and  the  case  passed  from  observation 
for  the  time.  When  next  seen  he  was  confined  to  bed 
and  had  a  temperature  of  102"  F.  A  large  circumscribed 
swelling  had  appeared  at  the  left  of  the  spinal  column, 
about  the  level  of  the  last  dorsal  vertebra.  Fluctua- 
tion being  present,  an  incision  was  m.ide"  over  the 
tumor  and  a  quantity  of  pus  evacuated.  Relief  of 
pain  was  immediate.  Ry  the  use  of  a  probe  search 
was  made  for  diseased  bone.  .Vfter  prolonged  effort 
the  location  of  the  trouble  was  found  to  be  at  the  pos- 
terior part  of  the  crest  of  the  ilium.  Free  discharge 
from  the  abscess  cavity  took  place,  eventually  forming 
a  sinus  which  continued  to  discharge  for  six  months. 
An  operation  had  been  suggested  from  the  first  but 
had  been  persistently  refused.  Seeing  no  pros|5ect  of 
permanent  relief  without  it,  he  at  last  consented.     Free 


incision  was  made  and  a  thorough  removal  of  the  ne- 
crosed bone  accomplished.  Prompt  and  satisfactory 
healing  took  place,  and  in  a  few  weeks  the  patient 
was  discharged  cured. 

Remarks — The  cases  herewith  submitted  are  but  a 
type  of  those  constantly  coming  within  the  obser\'ation 
of  the  busy  practitioner.  What  shall  we  do  with  them? 
In  the  larger  cities  the  physician  can  refer  them  to  the 
hospital  surgeon  without  assuming  the  responsibility 
of  treatment.  In  the  field  which  we  occupy  this  can- 
not be  done,  and  we  are  forced  to  recognize  the  fact 
that  medicine  and  surgerj'  are  so  inseparably  con- 
nected in  actual  practice  that  he  who  would  be  the 
most  successful  in  the  future  must  acquire  a  fair  facil- 
ity in  operative  work.  The  question  of  what  to  do  in 
a  given  case  is  not  more  important  than  how  it  is  to  be 
done.  Generalization  will  not  do;  a  definite  plan  of 
procedure  must  characterize  ever)-  operation,  no  mat- 
ter how  trivial.  To  choose  the  best  methods  from 
the  vast  amount  of  surgical  literature  available  is  not 
always  possible,  as  in  emergencies  when  action  must 
necessarily  take  the  precedence.  What  surgical  knowl- 
edge we  possss  must  therefore  be  practical.  I  am 
aware  that  our  opportunities  for  perfecting  technical 
skill  are  limited,  but  if  we  choose  to  employ  a  portion 
of  our  leisure  moments  in  training  the  hands  to  famil- 
iarity with  the  use  of  instruments,  we  shall  become 
something  more  than  mere  "bunglers"  in  the  art  of 
operating.  The  progress  in  surger\'  which  marks  the 
present  era  has  in  no  wise  limited  the  field  of  the  gen- 
eral practitioner.  It  has,  on  the  contrary,  enlarged  it 
by  enabling  him  to  become  more  proficient  by  being 
more  scientific  in  his  attainments  and  consequently 
more  successful  in  practice.  To  undertake  the  treat- 
ment of  surgical  cases  is  not  a  matter  of  choice  but  a 
necessity.  The  care  of  wounds  and  all  the  various 
injuries  that  may  occur  are  but  part  of  our  daily  duties. 
The  only  limit  which  the  true  physician  is  compelled 
to  recognize  is  that  which  exists  in  his  own  ability  to 
observe,  to  investigate,  to  acquire. 


THE  NEED  OF  INSPECTION  OF  THE  EYES 
OF  THE  CHILDREN  IN  THE  NEW  YORK 
PUBLIC    SCHOOLS. 

By   WILLIAM    .MERLE   D'.\UBIGXE   C.VKHART,    M.D., 


ASSISTANT  SURGEON,  MANHATTAN"  EYE  AND  EAR  HOSPITAL  ;  INSTRV'CTOR  IM 
DISEASES  OF  THE  EYE  AND  EAR  IN  THE  NEW  YORK  rOST-CRADI'ATB 
.MEUICAI.  school;    ophthalmic    and     AL-RAL    SURGEON,     HELPING     HASU3 


The  accompanying  figures,  showing  the  percentages  of 
ages  of  one  thousand  school  children  recently  exam- 
ined by  me,  are  suggestive.  Two  factors  are  probably 
operative  in  causing  this  steady  decrease  in  attendance 
from  the  24.1  per  cent,  of  the  ages  of  eleven  to  twelve, 
to  the  2.4  per  cent,  of  the  ages  of  seventeen  to  eigh- 
teen. Some  children  are  withdrawn  from  school  to 
assist  in  supporting  the  family,  and  the  parents  of 
many  others  are  indifferent  about  graduation,  thinking 
the  advanced  grades  not  essential  for  the  success  in 
life  of  their  offspring.  This  factor  applies,  however, 
mainly  to  the  older  scholars,  while  my  figures  show 
that  children  begin  to  drop  out  before  they  are  old 
enough  to  become  wage  earners  and  long  before  they 
have  reached  the  advanced  grades. 

Attendance  by  ages  of  one  thousand  school  children : 
From  five  to  ten,  42.3  per  cent.;  eleven  to  twelve, 
24.1  per  cent.;  thirteen  to  fourteen,  19.5  per  cent.; 
fifteen  to  sixteen,  1 1.7  per  cent. :  seventeen  to  eighteen, 
2.4  per  cent.;  total,  ico  per  cent. 

Children  leave  school  in  many  instances  because 
high  refractive  error  makes  study  unendurable  for 
them.  Attention  to  lessons  and  close  application  to 
study  are  difficult,  if  not  impossible,  when  there  is 


October  23,  1897] 


MEDICAL    RECORD. 


593 


any  considerable  refractive  error  left  uncorrected  in 
the  eyes.  When  we  see  a  liealthy  boy  or  girl,  bright 
and  active  on  the  playground,  but  restless,  inattentive, 
and  careless  in  the  schoolroom,  we  may  be  confident 
that  the  child  has  imperfect  eyes.  Such  children  can- 
not concentrate  their  attention  on  their  books  for  any 
lengtli  of  time,  in  consequence  of  the  strain  upon  the 
ciliary  muscle  in  the  effort  to  maintain  visual  acuity. 
They  are  apt  to  be  called  stupid  and  lazj-  when  they 
fall  behind  in  their  studies,  and  because  they  are 
bright  and  quick  about  everything  except  their  lessons 
they  may  be  considered  mischievous  and  bad.  Often 
the  condition  of  the  eyes  is  not  brought  to  the  notice 
of  either  teacher  or  parent,  since  not  all  such  children 
complain  of  supra-orbital  headache.  Many  of  them 
merely  feel  tired  and  listless  after  school  hours,  and 
are  restless  and  inattentive  while  at  school. 

Children  are  markedly  tolerant  of  refractive  error. 
During  my  school  examination  I  found  many  cases  of 
children  struggling  along  without  glasses,  when  the 
Javal  ophthalmometer  showed  several  diopters  of  as- 
tigmatism ;  and  also  not  a  few  who  were  wearing  lenses 
for  nearsightedness  when  they  were  really  not  myopic 
at  all — a  condition  of  affairs  which  no  adult  could 
endure  for  a  day.  But  tolerance  is  not  immunity. 
Every  such  case  presented  a  striking  picture  to  the 
ophthalmoscope :  a  retina  covered  with  dilated  blood- 
vessels and  congested  over  its  entire  area :  an  optic 
disc  infiltrated  and  swollen  so  that  its  outline  was 
indistinct  and  its  color  grayish ;  and  surrounding  the 
disc  a  conus,  broad  and  deep,  through  which  the  scle- 
rotic tissue  could  be  seen  to  share  in  the  general  con- 
gestive infiltration.  Externally  many  children  showed 
congestion  of  the  palpebral  and  bulbar  conjunctiva, 
with  blepharitis  marginalis,  and  subjectively  photo- 
phobia and  asthenopia  were  not  uncommon. 

These  children  suffer  from  congestion  and  infiltra- 
tion of  the  eye  and  its  appendages,  due  to  continual 
strain  of  accommodation  at  close  work.  The  soft  and 
elastic  tissues  of  the  immature  eye  of  childhood  yield 
gradually  both  at  the  posterior  pole  and  at  the  anterior 
surface,  and  so  we  find,  in  addition  to  symptoms  of 
retinal  irritation,  an  alteration  of  structure,  which  re- 
sults in  the  lengthening  of  the  optic  axis  and  the  de- 
velopment of  corneal  astigmatism.  I  have  elsewhere' 
given  statistical  tables  of  the  refraction  of  one  thou- 
sand school  children,  and  I  will  here  merely  refer  to 
three  significant  items.  Astigmatism  of  all  varieties 
increased,  from  35.65  per  cent,  at  the  ages  of  five  to 
eight,  to  61.69  P^""  cent,  at  the  ages  of  thirteen  to 
eighteen.  Myopia  and  compound  myopic  astigmatism 
combined  increased,  from  2.61  per  cent,  at  the  ages  of 
five  to  eight,  to  6.43  per  cent,  at  the  ages  of  thirteen 
to  eighteen.  Hypermetropia  decreased,  from  53.48 
per  cent,  at  the  ages  of  five  to  eight,  to  22.81  per  cent. 
at  the  ages  of  thirteen  to  eighteen.  Space  does  not 
permit  further  reference,  but  even  the  three  citations  I 
have  made  will  prove  the  elongation  of  the  eyeball 
and  the  alteration  of  the  cur\-e  of  the  cornea  caused 
by  distention. 

Dr.  Ingalls  has  said  :  "  It  is  a  waste  of  time  to  send 
a  child  to  school  when  'is  eyes  are  not  in  proper  con- 
dition to  do  the  work  assigned."  More  than  that, 
permanent  injury  to  the  eyesight  is  the  jienalty  of  the 
violation  of  nature's  laws.  Not  only  is  the  existing 
refractive  error  aggravated  by  the  efforts  of  the  child 
to  keep  up  with  his  more  fortunate  comrades,  but 
inflammatorj'  and  degenerative  changes  are  easily  en- 
grafted upon  retinal  irritation  if  the  strain  is  persistent. 
Many  a  child  also  is  urged  beyond  his  physical  limi- 
tations, until  his  health  gives  way  in  a  general  ner- 
vous collapse.  A  high  authority  has  said  that  "eye 
strain  in  childhood  means  neurasthenia  in  the  adult." 
This  is  certainly  true  in  many  instances. 

'  New  York  Medical  Journal,  .\pril  17,  1597. 


The  schools  have  thus  far  been  able  to  do  little 
toward  recognition  of  ocular  defects,  and  so  children, 
handicapped  by  high  refractive  error,  have  received 
much  the  same  treatment  as  those  with  perfect  eyes. 
Is  it  not  a  natiu-al  consequence  that  children  begin  to 
leave  school  at  an  early  age  and  continue  to  drop  out 
in  ever-increasing  numbers  as  they  grow  older?  A 
beginning  at  school  inspection  has  been  recently  made 
in  several  cities.  Dr.  Frank  Allport,  in  the  June  num- 
ber  of  the  Rei'iew  ofRevieii's,  gave  a  description  of  the 
plan  he  has  put  into  effect  the  past  three  years  in  the 
schools  of  Minneapolis.  He  has  examined,  with  the 
help  of  the  principals  of  the  schools,  23,049  school 
children,  among  whom  he  found  "  7,093  defectives,'' 
the  parents  of  whom  were  notified  of  the  state  of  their 
children's  eyes  and  advised  accordingly.  A  somewhat 
similar  plan  has  been  carried  out  by  Dr.  Harlan  and 
Dr.  Wood,  in  the  schools  of  Baltimore,  where  nearly 
53,000  children  were  examined  and  9,051  were  found 
with  abnormal  vision.  Recently  the  children  in  the 
schools  of  Bridgeport,  Conn.,  were  examined  person- 
ally by  my  friend,  Dr.  Miles,  with  similar  results; 
and  one  year  ago  I  went  over  the  public  schools  of 
Peekskill,  the  published  tables  of  which  examination 
I  have  already  referred  to  in  this  article. 

Problems  of  school  inspection  are  of  particular  in- 
terest at  the  present  time,  since  it  is  proposed  to  insti- 
tute a  thorough  examination  of  the  eyes  of  the  children 
in  the  New  York  schools.  The  need  is  urgent,  as  I 
think  I  have  shown,  and  now  it  remains  for  the  great- 
est city  on  the  continent  to  do  this  work  intelligently, 
carefully,  and  scientifically.  How  this  work  will  be 
done  is  a  matter  for  consideration,  but  as  an  ophthal- 
moscopic examination  of  the  eye  is  essential  for  any 
accurate  knowledge  of  its  condition,  it  would  seem 
hardly  feasible  to  utilize  Dr.  Allport's  plan  to  any 
considerable  extent  in  depending  upon  the  assistance 
of  the  teachers  of  the  schools. 

It  is  neither  desirable  nor  necessary  that  treatment 
be  instituted  by  the  proposed  health-board  inspectors, 
and  therefore  no  elaborate  refraction  test  rooms  need 
be  established.  Cards  of  notification  of  ocular  defect 
could  be  issued,  and  the  necessary  treatment  would 
then  prof)erly  be  carried  out  by  whatever  oculist  the 
family  physician  recommended.  In  this  way  there 
need  be  no  interference  with  the  practice  of  our  pro- 
fessional brethren,  and  little  temptation  for  the  inspect- 
ors to  attempt  to  build  up  a  private  clientele.  In 
order  further  to  avoid  unpleasant  complications  and 
also  to  save  time,  it  might  be  well  to  omit  any  chil- 
dren who  had  been  within  one  or  two  years  under  the 
care  of  any  competent  oculist.  The  number  of  school 
children  in  New  York  is  enormous,  but  a  corps  of 
twent)'  inspectors  should  be  able  to  cover  the  ground 
in  two  years,  according  to  my  estimate,  and  of  course 
all  could  be  examined  within  the  year  by  double  that 
number  of  inspectors  if  such  a  course  were  deemed 
necessar)'. 

147  West  Forty-Fovrth  Street. 


Typhoid  Fever. — 

R  Creosote  carbonate 3  xLx. 

Thymol 3  vi. 

Alenthol 3  iij. 

Eucalyptol 3  viss. 

Alcohol,  commercial q.s.  ad  |  viij. 

M.  ft.  solutio.     S.  This  is  stock  solution. 

To  make  an  emulsion  from  the  above,  in  order  to 
facilitate  administration,  use: 

V,  .Solution  creosote  carbonate  compound ^  v. 

Powdered  gum  arabic 3  iss. 

Pure  water 3  iv. 

M.     S.  One  teaspoonful  even.' three  hours  in  a  wineglass  of 
water,  followed  by  a  drink  of  water. 

— T.  W.   S1M.MONS,    Va.  Med.  Semi-Monthly. 


594 


MEDICAL    RECORD. 


[October  23,  i< 


GUAIACOL   IN    CHRONIC    COUGHS. 
By   ADOLPH   GOLDHAMMER,    M.D.. 


Although  guaiaco'.  is  recognized  as  a  valuable  anti- 
tuberculous  remedy,  its  value  in  the  treatment  of 
chronic  coughs  of  various  character  is  not  so  well  es- 
tablished. Having  had  remarkable  success  with  this 
drug  in  many  cases  of  cough  of  long  standing,  in  which 
no  tuberculous  element  could  be  recognized,  I  venture 
to  suggest  its  use  in  every  case  of  cough  of  more  than 
two  weeks'  duration. 

I  was  first  led  to  the  employment  of  this  remedy 
in  a  case  in  which  the  cough  had  existed  for  tno 
years  and  in  which  numerous  other  drugs  had  been 
used  without  avail.  Under  the  use  of  guaiacol 
daily  for  one  month,  the  cough  disappeared  and  the 
patient  has  been  entirely  free  from  it  ever  since — 
a  period  of  ten  months.  The  details  of  this  case 
will  be  described  farther  on.  Since  then  I  have 
used  guaiacol  in  every  case  of  cough  of  more  than 
two  weeks'  duration,  irrespective  of  origin,  with  un- 
varj-ing  success.  I  have  found  it  of  decided  value  in 
cases  of  chronic  bronchitis  with  or  without  asthma. 
In  the  chronic  coughs  of  children  guaiacol  has  proved 
especially  beneficial.  I  have  employed  it  even  in  sev- 
eral cases  of  whooping-cough  with  astonishing  results. 
The  paro.xysms  were  rendered  less  severe  and  less  nu- 
merous, and  the  duration  of  the  attack  was  cut  short  to 
two  or  three  weeks.  For  children  of  a  delicate  temper- 
ament, who  have  a  poor  appetite  and  who  occasion- 
ally have  a  slight  cough,  guaiacol  is  a  very  valuable 
remedy.  It  stops  the  cough  entirely  in  a  short  time, 
increases  the  appetite,  and  causes  the  patient  to  gain 
flesh.  It  is  my  opinion  that  many  a  case  of  incipient 
tuberculosis  could  be  prevented,  if  every  old  cough, 
no  matter  how  slight,  were  treated  by  the  administra- 
tion of  guaiacol.  I  therefore  strongly  recommend  it  as 
a  prophylactic  against  tuberculosis;  but  I  desire  es- 
pecially to  emphasize  the  fact  that  guaiacol  is  of  im- 
mense benefit  in  cases  of  cough,  not  acute,  in  which  no 
tuberculous  element  exists.  In  acute  coughs,  guaiacol 
does  not  act  beneficially  and  should  not  be  employed. 
I  have  carefully  recorded  thirty  cases  of  cough  of  varied 
origin  and  description,  in  which  no  distinct  tuber- 
culous element  could  be  recognized,  and  in  which  I 
emplpyed  guaiacol  as  a  remedy.  In  twenty-six  of 
these  cases  the  cough  disappeared  entirely  after  the 
drug  was  used  for  periods  of  from  t^vo  to  six  weeks.  In 
the  four  remaining  cases  the  cough  was  decidedly  im- 
proved, although  not  entirely  cured.  Eighteen  of 
these  cases  were  in  children  under  ten  years,  nine 
were  in  adults,  three  of  whom  were  over  sixty-five 
years  of  age.  The  details  of  a  few  of  these  cases 
follow. 

C.'iSE  I. — Mrs.  H ,  aged  sixty-two  years.      i'he 

patient's  appearance  was  quite  robust  and  her  color 
good.  She  had  been  coughing  for  about  two  years 
almost  every  day.  She  very  frequently  had  severe 
coughing-spells  during  the  night.  Sometimes  with  the 
coughing-spells  she  had  severe  pain  in  the  back  and 
over  the  sternum.  Her  appetite  was  fairly  good;  she 
never  sweated  in  the  afternoon ;  she  had  never  spit 
up  any  blood.  Her  jiulse  was  72;  respiration,  26; 
temperature,  98. 6~^  F.  She  suffered  from  dyspnaa  on 
going  up  or  down  the  stairs.  Physical  examination 
showed  the  breathing  somewhat  loud,  with  the  expira- 
tion somewhat  prolonged  and  sibilant,  and  sonorous 
riles.  Percussion  gave  a  hyperre.'^'mant  note.  1  di- 
agnosed the  case  as  one  of  chronic  bronchitis  with 
asthma.  She  told  me  that  she  had  been  treated  by 
many  different  physicians  and  had  taken  all  sorts  of 
cough  mi.xtures,  sometimes  with  temporary  improve- 
ment, but  had  received  permanent  relief  from  none. 


It  was  in  this  case  that  I  first  determined  to  try  guaia- 
col. She  began  by  taking  five  drops  three  times  a 
day,  in  milk,  the  dose  being  gradually  increased  until 
she  took  twelve  drops  three  times  a  day,  at  the  end  of 
three  weeks.  She  noticed  decided  improvement  in 
her  cough  after  she  had  been  taking  the  drops  for  four 
days;  in  ten  days  the  cough  was  very  slight  and  not 
troublesome;  at  the  end  of  four  weeks  the  cough 
stopped  entirely  and  has  not  reappeared  now  for  ten 
months. 

Case    II. — L.    M ,  aged   twenty-eight   months. 

The  mother  informed  me  that  the  child  had  had  an 
attack  of  whooping-cough  when  eighteen  months  old 
and  had  been  coughing  more  or  less  since.  The  ap- 
petite was  not  good  and  the  child  was  kept  awake 
much  at  night  by  the  cough.  I  found  signs  of  chronic 
bronchitis  on  examination.  I  administered  guaiacol, 
beginning  with  two  drops  and  increasing  to  four  drops, 
three  times  daily.  .\t  the  end  of  two  weeks  the 
cough  had  entirely  disappeared,  the  child  slept  well 
and  began  to  look  much  healthier,  and  gained  flesh. 
The  child  has  coughed  verj-  little  since. 

C-ASE  III. — Sidney  R ,  aged  eight  years.     He 

had  always  been  a  delicate  child  and  his  appetite  was 
never  very  good.  Occasionally  he  had  slight  cough- 
ing-spells; sometimes  he  coughed  very  severely.  His 
mother  said  that  the  cough  had  lasted  several  years. 
On  examination  I  found  that  he  was  chicken  breasted, 
but  otherwise  there  was  nothing  to  account  for  the 
cough.  He  took  guaiacol  for  six  weeks,  beginning 
with  three  drops,  gradually  increased  to  seven  drops 
thrice  daily.  He  also  took  wine  and  cod-liver  oil. 
His  cough  disappeared  entirel)',  his  color  is  now  ruddy, 
and  altogether  he  is  much  livelier  and  brighter  than 
he  used  to  be. 

Case  IV. — Mr.  M.  G ,  aged  seventy-one  years. 

For  many  years  he  had  been  suffering  from  a  severe 
chronic  bronchitis  with  frequent  very  distressing  asth- 
matic attacks.  He  had  taken  many  medicines,  but  he 
said  that  they  always  made  him  worse  and  sometimes 
they  nearly  choked  him.  Finally  he  refused  to  take 
any  medicine  whatever,  although  he  suffered  severely, 
and  I  had  to  use  much  persuasion  to  get  him  to  try 
guaiacol.  After  he  had  taken  the  drug  for  a  week  his 
cough  was  immensely  relieved  and  the  asthmatic  at- 
tacks were  not  so  frequent  and  severe.  The  old  gen- 
tleman is  so  delighted  with  the  remedy  that  he  now^  ab- 
solutely refuses  to  stop  taking  the  "devil's  drops,"  as 
he  calls  them,  on  account  of  the  taste  I  suppose.  He 
still  coughs  a  little,  but  his  cough  is  slight  and  not 
troublesome. 

Case  V. —  Sadie  D ,  aged  six  years.  This  pa- 
tient had  an  ordinary  attack  of  whooping-cough.  Dur- 
ing the  first  week  I  gave  her  tincture  of  belladonna 
and  quinine,  the  drugs  I  ordinarily  employ  in  such 
cases.  There  w  as  not  much  improvement,  and  she  had 
severe  paro.xysms  of  coughing  and  vomited  frequently. 
During  the  second  week  I  thought  I  would  try-  guaia- 
col, and  I  was  much  astonished  at  the  result.  The 
cough  improved  very  much  after  two  days'  use  of  this 
drug  and  after  seventeen  days  there  was  no  sign  of  the 
cough  left,  although  I  had  v.sed  no  other  drug  than 
guaiacol. 

.\s  regards  the  administration  of  guaiacol,  it  is  very 
well  borne  in  the  majority  of  cases,  if  well  diluted 
with  milk,  although  it  has  a  nasty  taste.  It  very  sel- 
dom deranges  the  digestion.  Those  who  cannot  bear 
its  odor  or  taste  can  easily  take  it  in  capsules.  I  usu- 
ally begin  by  giving  five  drops  three  times  a  day,  in 
milk,  to  an  adult.  The  dose  may  then  be  increased 
one  drop  daily  up  to  fifteen  drops  three  times  a  day. 
-V  child  one  year  old  can  take  two  drops  at  a  dose  to 
start  with,  and  then  the  dose  may  be  increased  slowly 
to  four  or  five  drops. 

W5  r.AST  Sevkxtv-Folkth  Street. 


October  23,  1897] 


MEDICAL    RECORD. 


595 


progress  0f  2]tXccUcal  ^cieitce. 

The  Treatment  of  Tuberculosis  with  Tuberculin. 
— Spengler  {Deutsche  medkiiiische  Wocheiisclirijt,  No. 
36,  1897)  makes  an  interesting  contribution  to  the 
subject  of  the  treatment  of  tuberculosis  with  Koch's 
new  product.  He  states  that  tuberculin  has  never 
been  entirely  discarded  at  Davos  since  it  was  first  used 
nearly  seven  years  ago.  He  now  relates  his  later 
experiences  with  the  present  modification.  There 
were  treated  with  tuberculin  fifty-nine  patients,  twenty, 
however,  only  from  three  to  seven  weeks,  in  the  absence 
of  colleagues  under  whose  care  they  were.  The  whole 
number  received  nine  hundred  and  twenty-two  injec- 
tions, with  a  total  of  one  hundred  and  eighty-one  cubic 
centimetres.  In  not  a  single  instance  was  an  untoward 
effect  noted,  although  at  times  there  was  pronounced 
reaction.  All  cases  of  tuberculosis  in  which  fever  was 
absent  were  considered  suitable  for  treatment;  that  is, 
those  in  which  the  rectal  temperature  did  not  exceed 
37.5°  C.  (99.5"^  F._)  and  the  temperature  of  the  mouth 
37.2°  C.  (99'^  F.).  Axillary  temperatures,  especially 
in  emaciated  tuberculous  subjects,  cannot  be  relied 
upon  unless  the  thermometer  has  been  exposed  for 
twenty  minutes.  Exceptionally,  cases  in  which  the 
rectal  temperature  exceeds  37.7°  C.  (99.9"  F.)  may  be 
submitted  to  the  treatment  when  careful  examination 
of  the  sputum  demonstrates  the  absence  of  marked 
mixed  infection.  The  injections  may  be  made  from 
the  initial  dose  up  to  one  milligram  every  second  dav, 
in  doses  of  from  one  to  six  milligrams  every  third  day, 
in  doses  of  six  to  twenty  milligrams  every  fourth  or 
fifth  day.  The  latter  dose  may  be  reached  if  the  rem- 
edy is  well  borne  and  its  use  is  unattended  with 
marked  exhaustion  and  loss  of  weight  or  profound 
ansmia.  Then,  according  to  circumstances,  from 
five  to  ten  milligrams  are  administered  weekly,  and 
later  every  seven  or  ten  days.  When  the  larger  doses 
are  used,  longer  intervals  are  necessary-,  as  the  sub- 
stance displays  a  sort  of  cumulative  action.  Intercur- 
rent menstruation  is  not  a  contraindication  for  the 
continuance  of  the  treatment.  If  haemoptysis  occurs 
the  injections  are  temporarily  suspended,  subsequently 
beginning  with  a  minimal  dose,  especially  if  the  hem- 
orrhage is  accompanied  by  fever.  Haemoptysis  occurs, 
however,  with  comparative  rarity  in  conjunction  with 
the  use  of  tuberculin,  the  old  as  well  as  the  new.  The 
injections  were  made,  so  far  as  possible,  on  the  exten- 
sor aspect  of  the  forearms,  for  facility  of  observation. 
Should  local  swelling  be  marked,  a  longer  time  than 
usual  should  be  permitted  to  elapse  before  the  next 
injection  is  made,  and  great  care  should  be  exercised 
in  regard  to  increasing  the  dose.  If  febrile  reaction 
occurs,  the  dose  should  under  no  circumstances  be  in- 
creased. Temperature  exacerbations  of  more  than  half 
a  degree  should  be  avoided.  Should  the  febrile  reac- 
tion continue  for  more  than  a  day  or  two,  the  subse- 
quent injection  must  be  distinctly  smaller  than  the 
previous  one.  Some  patients  appear  so  susceptible  to 
the  remedy  as  to  be  totally  unsuited  for  the  treatment 
with  subcutaneous  injections.  In  these  the  remedy 
may  be  employed  by  percutaneous  introduction  (by 
means  of  energetic  friction  upon  the  cleansed  skin). 
Of  the  thirty-nine  personal  patients  subjected  to  the 
treatment,  not  less  than  thirty  had  been  under  obser- 
vation for  six  months  and  more;  twenty-five  were  sub- 
jects of  pulmonary  tuberculosis,  while  in  eleven  others 
there  was  both  pulmonary  and  laryngeal  involvement. 
Of  tlie  latter  seven  had  been  considered  cured  before 
the  institution  of  the  new  treatment.  In  six  slight 
reddening  of  the  cicatrices  became  evident  only  in 
conjunction  with  febrile  reactions.  In  none  was  there 
any  aggravation  of  the  laryngeal  condition,  but  in  two, 
in  whom  the  injections  were  repeated  frequently  dur- 


ing three  months,  there  occurred  diminution  in  the 
thickenings  present  in  the  mucous  membrane  of  the 
larj-nx.  In  one  case  there  was,  in  conjunction  with 
the  febrile  reaction,  complaint  of  slight  pain  referred 
to  the  cicatrix.  Kxisting  ulcers  displayed  only  slight 
redness  of  their  margins.  The  impression  was  gained 
that  ulceration  improved  more  rapidly  under  the  com- 
bined treatment  than  under  treatment  with  lactic  acid 
alone.  Just  as  the  febrile  reaction  was  less  marked 
than  after  the  use  of  the  old  tuberculin,  so  also  was 
cough  increased  to  a  less  degree  and  the  local  auscul- 
tatory phenomena  were  less  pronounced.  In  all  pa- 
tients who  Jiad  noteworthy  expectoration  striking  and 
permanent  diminution  was  observed.  Under  such  con- 
ditions the  impairment  of  resonance  grew  less,  as  did 
also  the  rales,  and  the  physical  signs  of  infiltration  re- 
ceded distinctly.  No  renal  or  intestinal  complications 
were  noted,  although  albumin  was  found  in  the  urine 
in  eight  per  cent,  of  the  cases  treated  with  the  old  tu- 
berculin. In  the  case  of  a  patient  not  entirely  free 
from  mixed  infection  the  treatment  was  employed  in 
view  of  the  relatively  low  temperature  (37.7"^,  37.8"  C. 
— 99.9°,  100°  F.),  but  it  had  soon  to  be  interrupted, 
as  it  proved  useless. 

Rembold  publishes,  in  the  same  journal,  an  an- 
alysis of  eighty-two  cases  of  pulmonary  tuberculosis 
treated  in  1890-91  with  tuberculin.  Of  these,  reports 
could  be  obtained  concerning  seventy.  Of  this  num- 
ber twenty-seven  could  now  be  recognized  as  being 
instances  of  mixed  infection  and  thus  unsuited  for  the 
treatment.  All  of  these  died — twenty-three  during 
the  first  year  following  the  treatment,  two  in  the  sec- 
ond, and  two  in  the  third.  Of  the  remaining  forty- 
three  cases  of  unmixed  tuberculosis,  twelve  were  clas- 
sified as  severe,  fifteen  as  of  moderate  severity,  and 
sixteen  as  mild.  Of  the  first,  ten  died  in  the  course  of 
the  first  four  years  following  the  termination  of  the 
treatment.  Two  were  still  living  and  permanently  im- 
proved. Of  the  second  group,  seven  died  also  during 
the  first  four  years,  and  seven  were  living  and  perma- 
nently improved,  while  one  was  permanently  cured. 
Of  the  third  group,  one  had  died  in  the  fourth  year, 
three  were  permanently  improved,  and  twelve  were 
permanently  cured.  Upon  the  basis  of  this  experience 
the  conclusion  is  expressed  that  in  case  of  mi.xed  in- 
fection tuberculin  is  without  any  favorable  action; 
and  that,  while  in  cases  of  unmixed  tuberculosis  of 
the  lungs  little  is  to  be  hoped  for  in  severe  cases, 
marked  and  permanent  improvement  may  be  antici- 
pated in  many  cases  of  moderate  severity,  and  almost 
certainly  good  results,  even  to  complete  cure,  in  the 
mild  cases. 

Acute  Yellow  Atrophy  of  the  Liver  in  a  Girl 
Twelve  Years  Old — In  The  Lancet  {ox  July  17,  1897. 
Fison  reports  the  case  of  a  girl,  twelve  years  old,  who 
three  weeks  before  coming  under  observation  had 
complained  of  general  pains,  lasting  for  three  days  and 
followed  by  what  was  thought  to  be  a  bilious  attack, 
with  vomiting  after  eating  and  headache.  Jaundice 
had  been  present  for  ten  days,  'i'here  was  no  history 
of  fright  or  menial  shock.  The  jaundice  was  pro- 
nounced and  the  child  appeared  very  ill.  The  tem- 
perature was  1 01. 4'  F.,  and  the  pulse  92.  The  tongue 
was  coated.  There  was  much  bile  in  the  urine,  but 
none  in  the  faces.  No  physical  abnormality  of  heart 
or  lungs  could  be  detected,  but  the  liver  appeared  to 
be  considerably  enlarged.  There  was  complaint  of 
persistent  pain  in  the  right  hypochondrium,  with  oc- 
casional nausea  and  impaired  appetite.  The  jaundice 
varied  greatly  in  intensity  from  day  to  day.  In  the 
course  of  a  few  days  the  temperature  returned  to  nor- 
mal, but  the  jaundice  and  the  other  symptoms  re- 
mained the  same.  Several  days  later  the  liver  ap- 
peared to  be  smaller,  but  the  general  condition  was 


596 


MEDICAL    RECORD. 


[October  23,  1897 


unaltered.  On  the  following  day  the  child  suddenly 
became  drowsy  and  unable  to  perform  any  action  or 
answer  questions.  The  reflexes  were  not  abolished, 
but  urine  and  fajces  were  passed  into  the  bed.  The  tem- 
perature was  slightly  above  the  normal;  there  was  no 
delirium.  In  the  course  of  a  little  while  hemorrhages 
were  noticed  over  the  sacrum  and  convulsive  move- 
ments took  place  in  the  arms,  followed  by  rigidit)". 
Coma  now  set  in,  and  death  took  place  si.xty  hours  from 
the  onset  of  the  acute  symptoms.  .\o  leucin  or  tyro- 
sin  was  found  in  the  urine.  Upon  post-mortem  exam- 
ination a  number  of  subcutaneous  petechial  hemor- 
rhages were  found.  The  liver  weighed  three  pounds 
and  eight  ounces  and  was  flabby;  the  capsule  was 
wrinkled,  especially  on  tiie  under  surface  of  the  right 
lobe.  On  section  the  substance  of  the  organ  was  dis- 
tinctly firm,  of  a  light  yellow-ochre  tint,  but  free  from 
red  areas,  although  there  were  a  few  minute  hemor- 
rhagic patches.  The  lobules  were  indistinctly  out- 
lined. The  gall  bladder  was  filled  with  green  bile 
mixed  witli  an  excess  of  mucus.  The  ducts  were  nor- 
mal and  unobstructed,  but  at  the  papillary  orifice  in 
the  duodenum  there  were  some  slight  inflammation 
and  oedema,  which  prevented  the  ready  expression  of 
tiie  bile.  The  portal  vein  was  normal.  The  glands 
in  the  portal  fissure  were  slightly  enlarged.  On  mi- 
croscopical section  very  few  natural  liver  cells  were 
seen,  and  they  were  full  of  granules.  The  liver  tissue 
was  to  a  great  extent  replaced  by  granular  and  fatty 
debris  contained  in  a  reticulated  homogeneous  nu- 
cleated structure,  the  nuclei  probably  being  derived 
from  liver  cells.  No  leucin  or  tyrosin  was  observed. 
The  capsule  of  the  liver  was  slightly  thickened.  The 
pancreas  was  normal  The  spleen  was  greatl)'  con- 
gested and  rather  soft.  The  kidneys  weighed  three 
and  one-half  ounces  each;  the  cortex  was  pale.  The 
adrenals  were  normal.  The  stomach  contained  altered 
blood  and  presented  patches  of  submucous  hemorrhage. 
The  intestines  also  were  the  seat  of  a  large  number  of 
submucous  hemorrhages,  especially  in  the  aecal  re- 
gion. The  bladder  was  normal.  The  muscle  of  the 
uterus  was  bile  stained.  The  brain  weighed  three 
pounds  two  ounces;  the  dura  was  bile  stained  and 
the  brain  tissue  was  normal.  The  lungs  weighed 
eight  oimces  each,  and  presented  a  few  subpleural  pe- 
techial hemorrhages.  They  were  edematous  and  the 
larger  bronchi  contained  muco-pus.  Larynx,  trachea, 
bronchial  glands,  and  thyroid  were  all  normal.  The 
heart  weighed  one  and  one-half  ounces;  its  muscular 
structure  was  bile  stained,  as  was  also  the  pericardial 
fluid ;  the  valves  were  normal.  The  peritoneal  cavity 
contained  a  considerable  amount  of  bile-stained  fluid: 
numerous  subperitoneal  hemorrhages  were  present, 
especially  along  the  greater  curvature  of  the  stomach 
and  in  the  great  omentum. 

Gastri:  Ulcer  Perforating  into  the  Pericardium. 
—  Fenwick  {lAina-l,  August  1.4.,  1897)  has  refjorted 
tlie  case  of  a  man,  fifty-five  years  old,  who  suddenly 
became  ill  and  died  within  a  few  minutes.  He  had 
previously  been  in  perfect  health,  and  had  not  com- 
plained of  pain  after  eating  and  had  not  suftered  from 
vomiting  or  other  symptom  of  disease  of  the  stomach. 
After  partaking  of  a  meal  consisting  of  tea,  fish,  and 
bread  and  butter,  he  arose  from  tiie  table,  complaining 
of  pain  and  palpitation.  .Vfter  walking  a  few  yards 
he  sat  down,  and  his  wife,  noticing  that  he  looked 
very  pale,  administered  some  whiskey  and  water,  but 
he  expired  in  about  a  minute.  Upon  post-mortem 
examinaiion  tlie  pericardium  was  found  to  contain 
several  ounces  of  tea,  which  smelt  of  whiskey,  together 
with  some  particles  of  fisii.  On  the  lower  surface  of 
the  pericardium  a  small  aperture  was  discovered,  ad- 
mitting a  stout  probe,  which  passed  downward  through 
the  diaphragm  into  the  abdominal  cavity.     The  ante- 


rior surface  of  the  stomach  was  firmly  adherent  to  the 
under  surface  of  the  diaphragm,  and  on  opening  the 
viscus  a  chronic  ulcer,  almost  one  inch  in  diameter, 
with  indurated  edges,  w-as  seen  to  be  situated  about 
the  centre  of  the  lesser  curvature.  From  the  base  of 
the  ulcer  a  sinuous  track  led  upward  and  to  the  right, 
through  the  substance  of  the  pericardium.  The  stom- 
ach contained  fourteen  ounces  of  undigested  material, 
composed  of  tea,  fish,  and  sodden  bread.  The  lungs 
were  emphysematous,  the  right  adherent  to  the  chest 
wall.  The  heart  was  extensively  infiltrated  with  fat; 
the  valves  were  normal.  All  the  other  organs  were 
apparently  healthy. 

A  New  and  Easy  Method  of  Examining  Malarial 
Blood. — In  a  paper  published  in  The  Laiiat  of  July 
10,  1897,  Macleod  points  out  that  for  diagnostic 
purposes  the  examination  of  fresh  malarial-blood 
films  immediately  after  preparation  is  without  doubt 
most  to  be  relied  upon.  This  is,  however,  not  al- 
ways convenient,  and  in  a  large  practice  it  is  often 
very  inconvenient,  so  that  one  is  driven  to  the  exami- 
nation of  stained  films  at  more  convenient  times. 
The  staining  of  such  films  is  an  uncertain  and  trouble- 
some process,  so  far  as  results  that  can  be  relied  upon 
for  diagnostic  purposes  are  concerned.  Macleod  has 
succeeded  in  finding  plasmodia  in  a  preparation  made 
by  drawing  across  one  cover  glass  the  edge  of  another 
square  cover  charged  with  a  drop  of  blood.  He  sub- 
sequently found  that  the  same  result  could  be  effected 
by  the  use  of  a  strip  of  ordinary  notepaper,  instead  of 
the  cover  glass,  for  the  purpose  of  spreading  the  film. 
The  straight  edge  of  a  half-inch  strip  is  drawn  its  full 
length  through  a  drop  of  blood  on  the  finger  tip  not 
larger  than  the  head  of  a  pin,  the  finger  tip  and  the 
cover  glass  being  previously  cleansed  thoroughly  in 
the  usual  way.  If  too  much  blood  be  taken  on  the 
strip  the  film  will  be  too  thick  and  useless.  The  edge 
of  the  strip  is  quickly  drawn  across  the  cover  glass,  the 
strip  being  held  nearly  at  right  angles  to  the  surface  of 
the  glass  and  before  the  blood  has  had  time  to  dry 
upon  the  paper.  In  this  way  is  spread  on  the  cover 
glass  (or  slide  if  preferred)  a  fine  film  of  blood  which 
dries  very  quickly,  and  in  it  many  excellent  fields  will 
be  found,  with  the  corpuscles  lying  on  the  fiat  and 
practically  unaltered.  The  cover  glass  must  not  be 
fi.xed  to  the  slide  by  any  medium  that  will  rub  between 
the  two,  causing  everything  to  disappear  from  view, 
but  it  must  be  mounted  dry.  It  can  be  gummed  to  the 
slide  by  a  strip  of  thin  paper,  with  a  window  exposing 
the  blood  smear,  when  the  latter  can  be  examined  with 
a  dry  or  an  immersion  lens.  Witii  a  good  quarter-inch 
objective  crescents  and  the  larger  pigmented  parasites, 
and  with  an  oil  twelfth  the  smaller  pigmented  forms, 
can  easily  be  seen.  The  specimens  can  be  thus  pre- 
served and  examined  at  any  subsequent  time,  and  even 
stained  later.  The  film  on  a  slide  can  be  examined 
with  a  dry  lens  without  the  intervention  of  a  cover 
glass;  then  stained,  dried,  and  examined  without  a 
cover  glass  or  with  a  cover  glass  witli  or  without  bal- 
sam. If  an  oil-immersion  lens  is  used,  the  film  when 
dried  and  unstained  should  be  on  the  cover  glass,  as 
the  layer  of  air  between  the  cover  glass  and  the  slide, 
if  the  film  is  on  the  latter,  prevents  the  oil  working  at 
its  best.  The  films  should  be  carefully  protected  from 
dust  before  they  are  mounted.  The  color  of  the  proto- 
plasm of  the  par-nsite  is  not  quite  the  same  dried  as 
undried,  and  of  course  no  movement  of  parasite  or  of 
pigment  is  possible  in  the  dried  state.  Even  the  un- 
pigniented  parasites  ha\e  been  detecteil  in  the  dried 
form  as  rings  or  signets,  ami  tliey  have  been  sUiined. 
Hlood  films  treated  in  the  manner  outlined  are  sub- 
jected to  less  interference  than  when  fixed  by  heat, 
alcohol,  ether,  or  other  means,  or  when  treated  with 
one  or  more  staining  solutions,  washed,  dried,  etc. 


I 


October  23,  1897] 


MEDICAL   RECORD. 


597 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.    SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &  CO.,  43,  45,  ^  47  East  Tenth  Street. 


New  York,  October  23,  1897. 

THE    EFFECTS    OF    CHANGE    OF     CLIMATE 
UPON    MAN    AND    ANIMALS. 

The  problems  of  the  relations  of  climate  to  the  health 
of  man  are  varied  and  complicated.  That  environ- 
ment does  exercise  a  very  strong  influence  on  race  is 
universally  allowed,  although  we  are  still  greatly  in 
the  dark  as  to  its  effects  on  the  human  organization. 
Much  light  has  been  brought  to  bear  on  the  subject  of 
climatology  within  recent  years,  it  has  been  intelli- 
gently studied,  and  in  consequence  a  more  accurate 
knowledge  is  spreading  of  the  influence  of  climate  in 
regard  to  health  and  disease.  Especially  is  this  the 
case  in  relation  to  disease.  Change  of  air  is  often  as 
curious  as  it  is  beneficial  in  its  effects.  Extreme  pur- 
ity is  naturally  an  important  factor,  but  after  all  it  is 
but  one  factor.  In  many  instances  it  is  by  no  means 
essential  that  a  patient  should  go  to  the  seaside  or 
even  to  the  country  in  search  of  health ;  a  change  in 
itself  is  often  of  the  greatest  benefit.  It  is  related  on 
good  authority  that  a  man  suffering  from  asthma  and 
bronchitis,  who  lived  in  a  healthy  part  of  the  country, 
found  great  relief  by  residing  for  a  time  in  the  slums 
of  Whitechapel.  Change  of  climate  has  an  even  more 
powerful  effect  on  animals  than  on  man;  in  fact,  man 
is  the  only  animal  that  can  adapt  himself  to  any  cir- 
cumstance of  life  or  meet  any  environment.  Dr.  Rich- 
ard Newton,  in  a  paper  read  before  the  American 
Climatological  Society,  gives  the  results  of  his  obser- 
vations on  the  effects  of  climate  on  men  and  animals 
at  Fort  Stanton,  N.  Mex.,  sixty-one  hundred  and  fifty 
feet  above  sea  level.  His  opportunities  for  study 
were  limited,  but,  as  he  remarks:  "The  great  need  in 
the  study  of  climatology  at  the  present  moment  ap- 
pears to  be  more  investigation  of  individual  cases, 
more  ascertained  and  established  facts  in  relation  to 
the  action  of  climatic  changes  upon  people  or  animals." 
He  describes  the  effect  of  the  change  of  climate  upon 
the  fever-stricken  Texan  cattle,  and  points  out  that  if 
they  survive  the  winter,  and  when  the  disease  germs 
are  killed  by  the  frost,  they  soon  wonderfully  im- 
prove and  increase  in  weight.  Horses  suffer  acutely 
when  brought  from  the  plains  to  high  altitudes,  and 
it  is  stated  that  it  takes  twelve  months  or  even  longer 
for  them  to  become  acclimatized.  Dogs,  as  is  well 
known,  endure  climatic  changes  better  than  any  ani- 
mal except  man. 


Dr.  Newton's  deductions  as  to  the  effect  of  change 
of  climate  on  man  agree  in  the  main  with  those  of 
other  observers.  He  disagrees,  however,  with  the 
view  held  by  Dr.  Solly,  that  high  altitudes  are  inimical 
to  rheumatism;  his  experience  teaches  the  reverse. 
No  one  will  dispute  the  point  that  change  of  climate 
is  of  benefit  in  phthisis,  yet  climate  treatment  of  this 
disease  is  beset  with  many  difficulties  and  needs  to  be 
applied  with  much  discrimination.  The  rule  may  be 
laid  down  as  one  to  be  followed  in  most  cases,  that  in 
the  early  stages  of  phthisis  a  sea  voyage  or  journey  to 
a  distant  clime  will  do  good,  but  that  when  the  pro- 
gress of  the  disease  is  far  advanced  if  a  change  be  taken 
at  all  it  should  be  limited.  The  fact,  too,  should  not 
be  forgotten  that  one  of  the  most  important  desiderata 
for  consumptive  invalids  is  plenty  of  sunshine.  The 
causes  for  the  health-giving  properties  of  a  change  of 
air  are  obscure;  at  any  rate,  up  to  the  present  they 
have  not  been  satisfactorily  explained.  A  biological 
solution  of  the  problem  is  sometimes  suggested,  that 
as  early  man  was  of  necessity  a  wanderer,  these  no- 
madic habits  have  left  their  impression  upon  every 
cell  and  fibre  of  his  being,  and  thus  it  is  largely  a 
question  of  heredity. 


THE     COMPARATIVE     INTELLECTUAL     CA- 
PACITY  OF    MEN    AND    WOMEN. 

Sir  William  Turner,  at  the  meeting  of  the  British 
Medical  Association  at  Montreal,  once  again  brought 
forward  the  old  assertion  that  because  the  brain  of  a 
man  weighs  absolutely  more  than  that  of  a  woman, 
therefore  a  man  is  possessed  of  a  greater  amount  of 
brain  power  than  is  a  woman.  This  theory  until  re- 
cent times  was  on  all  sides  conceded  to  be  true,  and 
was  regarded  as  a  convincing  proof  of  woman's  intel- 
lectual inferiority.  The  Russian  Professor  Darkche- 
vitch  took  up  the  cudgels  in  defence  of  the  weaker 
sex,  and  demonstrated  to  the  satisfaction  of  the  major- 
ity that  the  fact  of  a  man's  brain  weighing  slightly 
more  than  a  woman's  was  worthless  as  a  testimony  of 
his  superior  intellectual  capacity.  Professor  Darkche- 
vitch  contends  from  the  result  of  his  researches  that 
the  sexes  as  regards  brain  power  are  on  an  equality, 
and  backs  up  the  argument  in  support  of  his  theory 
with  many  convincing  illustrations.  For  instance, 
Skobeleff's  brain  weighed  less  than  that  of  forty  indi- 
vidual common  soldiers;  yet  no  one  would  dream  for 
this  reason  of  making  the  assertion  that  these  men 
were  the  superior  of  Skobeleff  in  ability.  Liebig's 
brain  also  was  under  the  average  weight. 

The  opinions  on  this  matter  are  diverse  and  various. 
A  large  number  of  persons  still  hold  to  the  views  of 
Sir  William  Turner,  and  with  him  conscientiously  be- 
lieve that  the  lesser  weight  of  woman's  brain  implies 
in  itself  the  possession  of  less  mental  power.  On  the 
other  hand,  many  side  with  Darkchevitch  and  say  that 
her  cumulative  and  retentive  powers  are  fully  equal  10 
those  of  a  man.  The  question  may  here  be  asked: 
Has  woman's  intellectual  inferiority  ever  been  clearly 
proved?  That  it  has  been  is  probably  the  opinion  of 
most  persons.     From  an  anatomical  and  physiological 


59S 


MEDICAL    RECORD. 


[October  23,  1S9; 


point  of  view  also  she  is  by  many  authorities  relegated 
to  a  position  lower  than  that  occupied  by  man.  The 
supporters  of  the  theory  of  woman's  intellectual  in- 
feriority point  out,  too,  with  triumph  that  in  scarcely 
any  branch  of  science,  art,  or  literature  has  she  ever 
reached  quite  the  front  rank.  This  is  all  true  enough, 
but  it  must  at  least  be  granted  that  the  cause  for  a  part 
of  her  failure  should  be  put  down  to  her  comparative 
lack  of  opportunity,  and  the  fact  should  be  taken  into 
consideration  that  up  to  the  present  time  from  the 
conditions  of  her  life  she  has  been  heavily  handi- 
capped in  the  race  for  fame.  May  not  also  the  differ- 
ence in  the  brains  of  men  and  women  be  looked  for 
not  so  much  in  the  ponderosity  as  in  the  quality?  A 
woman's  brain  from  the  nature  of  things  is  to  a  cer- 
tain extent  of  another  tj-pe.  The  natural  role  of  a 
woman  differs  widely  from  that  of  a  man,  and  she  is 
provided  with  or  has  evolved  brains  suited  to  her  sit- 
uation. Nevertheless,  in  these  times  it  often  happens 
that  a  woman  from  the  stress  of  circumstances  is  pre- 
vented from  fulfilling  her  natural  mission  and  is  com- 
pelled to  compete  with  men.  She  has  shown  her 
capability  successfully  to  do  so,  but  in  the  action  must 
necessarily  lose  many  of  her  feminine  characteristics. 
The  wisest  course  to  take  will  perhaps  be  to  leave  the 
final  settlement  of  the  question  in  abeyance  until  the 
evolution  of  the  new  woman  has  been  more  fully 
accomplished. 


ULCERATIVE  ENDOCARDITIS  SUCCESS- 
FULLY TREATED  WITH  ANTISTREPTO- 
COCCIC   SERUM. 

A  FURTHER  addition  is  made  to  the  small  number  of 
cases  of  ulcerative  endocarditis  thus  far  treated  with 
antistreptococcic  serum.  Washbourn  (Lancet,  Septem- 
ber 18,  1897,  p.  707)  reports  the  case  of  a  ward  maid, 
twenty  years  old,  who  came  under  observation  com- 
plaining of  pains  in  the  joints  and  general  malaise. 
The  only  significant  point  in  the  family  historj'  was 
the  death  of  her  father  from  pulmonary  tuberculosis 
and  heart  disease.  The  patient  had  previously  en- 
joyed good  health.  Her  immediate  illness  had  e.x- 
isted  for  four  days,  setting  in  with  pains  in  the  joints, 
headache,  and  shivering.  She  was  well  nourished 
and  appeared  healthy.  Especial  complaint  was  made 
of  headache  and  pains  in  the  knee  and  thigh.  Heart, 
lungs,  and  urine  were  found  normal,  and  there  was  no 
swelling  or  other  evidence  of  disease  in  any  of  the 
joints.  The  temperature  was  100.6°  F.;  the  respira- 
tion, 24;  the  pulse,  104.  By  the  following  day  the 
temperature  had  become  normal,  and  it  remained  so 
for  three  days.  At  the  end  of  this  time  it  again  rose, 
and  for  six  weeks  thereafter  the  patient  suffered  from 
irregular  pyrexia,  the  temperature  rising  as  high  as 
105°  F.,  and  rigors  and  perspiration  were  frequent. 
Heart,  lungs,  urine,  ears,  eyes,  vagina,  and  rectum  ap- 
peared to  be  perfectly  normal.  The  blood  show-ed 
slight  leucocytosis  and  slight  decrease  in  hjemoglobin. 
Some  carious  teeth  were  removed,  but  there  was  no 
sign  of  inflammation  in  the  alveoli.  The  patient 
suffered  much  from  constipation,  which  required  the 


frequent  use  of  aperients.  In  spite  of  treatment  with 
quinine  and  sodium  salicylate,  she  gradually  became 
worse;  the  rigors  were  more  frequent,  the  appetite  was 
lost,  and  pallor  and  emaciation  set  in.  A  distinct 
diastolic  bruit  now  developed  on  the  left  side  of  the 
sternum,  with  its  point  of  maximum  intensity  in  the 
third  intercostal  space.  It  was  decided  that  the  pul- 
monary valve  was  affected  and  that  the  patient  was 
suffering  from  ulcerative  endocarditis.  Antistrepto- 
coccic serum  was  injected,  the  injections  being  con- 
tinued daily,  with  the  exception  of  three  days,  for 
nearly  nine  weeks.  At  first  doses  of  t\venty  cubic 
centimetres  were  employed,  but  later  these  were  re- 
duced. Throughout  the  period  of  treatment  one  thou- 
sand and  thirty  cubic  centimetres  of  serum  were  in- 
jected in  fifty-nine  doses.  During  the  first  fortnight 
of  treatment  there  were  only  two  slight  rigors,  although 
the  pyrexia  persisted.  At  the  end  of  this  time  the 
temperature  became  normal  and  remained  so  for 
twenty  days.  The  patient  now  appeared  so  well  that 
the  injections  were  given  on  alternate  days,  but  the 
temperature  rising  again,  the  injections  were  once 
more  given  daily.  The  general  condition  of  the  pa- 
tient began  to  improve  five  or  six  days  after  the  com- 
mencement of  the  injections,  and  three  weeks  later 
she  was  to  all  appearances  quite  well.  When  she 
passed  from  obser\-ation  she  appeared  to  be  in  perfect 
health,  although  the  diastolic  bruit  in  the  pulmonary 
region  was  still  present.  At  no  time  did  the  heart 
show  any  sign  of  enlargement.  The  only  inconven- 
ience noticed  from  the  frequent  injection  of  the  serum 
was  slight  pain  at  the  site  of  injection  and  an  urtica- 
rial rash  which  lasted  for  a  few  days. 


HVSTERICAL    PARALYSIS   OF   THE    EXTER- 
NAL   RECTI    MUSCLES    OF   THE   EYES. 

While  the  symptomatology  of  hysteria  is,  compara- 
tively speaking,  an  open  page,  the  patholog}-  of  the 
disease  conversely  is  practically  a  sealed  book.  Al- 
though the  recognition  of  well-marked  and  t}-pical 
examples  of  the  disease  is  easy,  it  is  to  be  feared  that 
many  cases  are  forced  into  the  category  of  hysteria 
"by  exclusion" — tliat  is,  from  ignorance  as  to  their 
exact  nature  and  inability  to  e.xplain  the  symptoms 
present.  Hysteria  may  simulate  almost  any  form  of 
organic  disease,  and  there  is  scarcely  a  symptom,  sub- 
jective or  objective,  that  it  may  not  reproduce;  so 
that  at  times  the  diagnosis  may  remain  shrouded  in 
the  deepest  doubt.  A  decision  can  sometimes  be 
reached  empirically,  one  may  say,  by  the  skilled  ob- 
ser\'er,  from  a  ready  appreciation  of  the  significance 
of  minor  and  collateral  phenomena  that  attain  scarcely 
to  the  dignity  of  symptoms  and  do  not  lend  themselves 
readily  to  verbal  description — in  a  word,  from  the  tout 
ensemble  of  the  case. 

A  case  illustrating  some  of  the  points  referred  to 
has  been  reported  recently  by  Dr.  Buchanan,  in  The 
Lancet  iox  July  17,  1897.  This  occurred  in  a  young 
woman,  thirty  years  of  age,  who  complained  of  head- 
ache, giddiness,  and  difficulty  of  vision.     The  head- 


October  23,  1897] 


MEDICAL    RECORD. 


599 


ache  had  been  present  for  thirteen  days  and  was  soon 
associated  with  giddiness,  and  this  in  turn  was  fol- 
lowed by  the  difficulty  in  vision.  There  was  nothing 
significant  in  the  family  or  personal  history  of  the  pa- 
tient, and  there  was  no  evidence  suggestive  of  a  neu- 
rotic basis  for  the  symptoms.  In  other  respects  than 
those  noted  she  was  in  perfect  health.  The  headache 
was  almost  entirely  frontal,  not  tending  to  one  side 
more  than  to  the  other,  generally  beginning  with  pain 
in  the  eyes.  It  was  distinctly  worse  after  using  the 
eyes  for  a  time,  ceasing  at  night,  and  often  being  pres- 
ent on  waking,  more  especially  after  the  patient  had 
been  at  work  as  a  dressmaker  the  night  before.  The 
vertigo  was  general  and  there  was  no  tendency  to  fall 
to  one  side  more  than  to  the  other.  The  patient  could 
stand  well  with  the  eyes  closed,  the  feet  together,  and 
the  hands  raised  high  Jlbove  the  head.  She  could  not 
"  walk  a  line"  well,  and  an  attempt  to  grasp  anything 
evidently  increased  the  difficulty  of  the  process,  so 
that  the  visual  effort  appeared,  in  part  at  least,  to  be 
the  cause  of  the  deficiency. 

On  examination  the  external  rectus  muscle  of  the 
right  eye  was  found  to  be  almost  completely  paralyzed, 
without  convergent  strabismus,  however.  Homony- 
mous diplopia  also  was  present.  Ophthalmoscopic  ex- 
amination revealed  neither  error  of  refraction  nor 
change  in  any  degree  of  the  fundus  of  either  eye,  and 
there  was  no  evidence  of  internal  ophthalmoplegia. 
The  visual  fields  were  normal  for  both  color  and  white 
light.  The  knee-jerks  were  normal,  and  there  was  no 
evidence  of  any  organic  disorder.  The  headache  and 
the  vertigo  appeared  to  be  rather  the  results  than  the 
companion  symptoms  of  the  paralysis.  A  guarded 
prognosis  was  given,  complete  ocular  rest  was  ordered, 
and  the  prolonged  use  of  a  mixture  containing  potas- 
sium iodide  and  bromide  with  nux  vomica  was  recom- 
mended. The  paralysis  rapidly  became  complete,  and 
convergent  strabismus  developed.  The  headache  be- 
came much  less  severe  and  less  frequent,  but  the  ver- 
tigo continued  in  much  the  same  degree. 

After  the  lapse  of  six  weeks  it  was  found  that  the 
right  eye  had  entirely  regained  its  powers  of  move- 
ment, whereas  the  external  rectus  of  the  left  eye  was 
paralyzed  and  there  was  marked  left  convergent  stra- 
bismus. The  left  eye  also  ultimately  recovered  com- 
pletely its  powers  of  movement,  and  in  a  short  while 
the  patient  was  able  to  resume  her  work  without  in- 
convenience. She  continued  in  perfect  health  during 
the  subsequent  two  years  that  she  remained  under  ob- 
servation. 

After  a  careful  consideration  of  all  of  the  possibili- 
ties in  the  case,  it  came  to  be  looked  upon  as  one  of 
hysterical  origin,  and  it  must  be  admitted  that  in  the 
present  state  of  knowledge  this  diagnosis  cannot  be 
controverted.  In  cases  of  this  sort  the  clinician  is 
pretty  much  in  the  position  of  the  man  who  persisted 
in  spelling  socks  "  sox,"  and  when  spoken  to  upon  the 
subject  propounded  the  somewhat  startling  and  un- 
answerable query:  "  If  s-o-x  don't  spell  socks,  what  in 
thunder  does  it  spell?" 


Chicago  has  entered  a  claim  as  a  meeting-place  for 
the  fourteenth  international  medical  congress  in  1903. 


THE  INFLUENCE  OF  ENVIRONMENT  UPON 
THE  BIOLOGIC  PROCESSES  OF  THE  VA- 
RIOUS MEMBERS  OF  THE  COLON  GROUP 
OF    BACILLI. 

As  a  result  of  an  experimental  study  carried  out  in  the 
laboratory  of  hygiene  of  the  University  of  Pennsylva- 
nia, Dr.  Adelaide  Ward  Peckham  {Journal  of  Experi- 
mental Medicine,  vol.  ii..  No.  5,  September,  1897,  p. 
549),  starting  from  the  assumption  that  the  typical 
colon  bacillus  and  the  typical  typhoid  bacillus  repre- 
sent the  types  of  the  colon  group  of  bacilli  that  present 
the  greatest  divergences  in  biologic  peculiarities, 
reaches  the  conclusion  that  there  is  a  series  of  closely 
related  forms  that  may  be  regarded  as  intermediate  or 
transitional,  and  which  serve  to  establish  a  biologic 
relationship,  either  near  or  remote,  between  these  two 
typical  processes.  The  t)'pical  colon  bacillus  may  be 
regarded  as  the  type  of  this  group,  for  the  reason  that 
its  functional  equilibrium,  as  obser\'ed  in  the  intestine, 
is  so  permanent  a  quality  that  it  may  readily  be  per- 
petuated in  what  are  ordinarily  regarded  as  favorable 
artificial  circumstances,  and  that  with  the  continuance 
of  such  conditions  there  is  no  conspicuous  tendency  on 
the  part  of  this  organism  to  deviate  from  what  may  be 
considered  its  norm ;  whereas,  on  the  other  hand,  with 
all  the  other  members  of  this  group  that  were  studied 
there  is  not  only  a  lack  of  uniformity  in  the  adjust- 
ment of  the  functions,  but  such  as  exists  is  readily  dis- 
turbed under  artificial  environment — though  even  with 
the  tj'pical  colon  bacillus  functional  modifications  are 
possible  under  particular  conditions. 

When  the  members  of  the  colon  group  are  cultivated 
under  circumstances  favorable  to  the  development  of 
both  the  function  of  fermentation  and  that  of  proteoly- 
sis, fermentation  invariably  takes  precedence,  and  no 
evidence  of  proteolysis  is  manifested  until  after  fer- 
mentation has  ceased.  The  cultivation  of  all  the 
members  of  the  colon  group  under  circumstances  that 
favor  the  development  of  one  function,  viz.,  that  of 
proteolysis,  at  the  expense  of  another,  viz.,  that  of  fer- 
mentation, results  first  in  an  apparent  increase  of 
vigor;  but  this  is  of  temporary  duration,  and  is  quickly 
followed  by  decline  and  death  of  the  cell.  The  result 
of  this  increased  activity  of  the  proteolytic  functions 
is  the  formation  of  much  larger  amounts  of  indol  by 
typical  colon  cultures  than  was  obtained  by  any  other 
method.  By  the  method  of  experimentation  through 
which  it  was  possible  to  accentuate  the  proteolytic  ac- 
tivit)'  of  the  typical  colon  bacillus,  as  caused  by  an 
increase  of  indol  formation,  the  function  of  indol  for- 
mation was  induced  not  only  in  typical  colon  bacilli 
that  had  been  devoid  of  it,  but  as  well  in  every  speci- 
men of  typical  typhoid  bacilli  to  which  access  was  had. 
One  of  the  differential  tests  between  the  typhoid  and 
the  colon  bacillus — namely,  that  of  indol  formation 
upon  the  part  of  the  latter  and  the  absence  of  this 
function  from  the  former — is  regarded  as  of  questiona- 
ble value,  for  the  reason  that  by  particular  methods  of 
cultivation  indol  production  was  shown  to  accompany 
the  development  of  a  number  of  specimens  that  there 
was  every  reason  to  regard  as  genuine  typhoid  bacilli. 

As  the  result  of  the  experiments  made,  together  with 


6oo 


MEDICAL   RECORD. 


[October  23,  1897 


the  observations  of  others,  there  seems  no  doubt  that 
the  bacillus  coli  communis  at  limes  possesses  patho- 
genic properties,  and  that  by  artificial  methods  of 
treatment  it  may  often  be  brought  from  a  condition  of 
benignity  to  one  of  virulence. 

The  spleen  of  a  typhoid  patient  has  always  been  re- 
garded as  the  only  trustworthy  source  from  which  to 
obtain  the  typical  typhoid  bacillus.  In  addition,  it 
was  found  that  other  members  of  the  colon  group  may 
also  be  present  in  this  viscus;  in  fact,  from  such 
spleens  could  be  isolated  practically  all  of  the  known 
varieties  of  this  group. 

From  the  experience  thus  gained  the  value  of  the 
serum  test  for  the  differentiation  of  typhoid  and  colon 
bacilli  would  seem  to  be  questionable.  The  irregu- 
larities noted,  however,  may  be  attributed  as  due  more 
to  the  method  of  application  than  to  defects  of  the 
principles  involved;  for  by  the  use  of  dried  blood  it 
is  not  possible  to  make  the  test  with  constant  or  accu- 
rate or  even  approximately  accurate  dilution  of  the 
serum. 


^cxxis  0f  the  ^mccfe. 

New  York's  Lepers The  four  lepers  who  have  been 

confined  for  some  time  on  North  Brother  Island 
escaped  a  few  days  ago,  with  the  apparent  consent  of 
the  health  authorities,  and  came  to  the  city.  They  are 
now  in  the  temporary  charge  of  the  commissioners  of 
charity,  aw-aiting  permanent  disposition.  One  was  a 
Chinaman,  one  a  colored  man,  one  a  Swede,  and  one 
an  Irishman.  According  to  the  daily  papers,  the 
health  board  is  not  at  all  troubled  about  the  escape, 
as  its  members  do  not  regard  leprosy  as  sufficiently 
contagious  to  be  a  source  of  danger  to  the  community. 

A  Gift  to  London  Hospitals. — The  firm  of  Barnato 
Brothers  has  distributed  a  sum  equivalent  to  over 
§80,000  among  the  London  hospitals.  It  is  announced 
that  the  money  is  given  in  fulfilment  of  the  known  in- 
tentions of  Barney  Barnato,  the  South  African  million- 
aire who  committed  suicide  last  June  by  jumping  over- 
board from  the  steamer  on  which  he  was  travelling 
from  Cape  Town  to  England. 

The  Yellow  Fever.— Up  to  October  19th  the  total 
number  of  cases  of  yellow  fever  in  the  South  has  been 
1,649.  ^ '^^  proportion  of  deaths  has  been  rather 
higher  during  the  past  week,  bringing  the  mortality 
rate  up  a  little  above  ten  per  cent.  The  disease  has 
invaded  Baton  Rouge  and  some  other  places  where 
what  was  supposed  to  be  a  most  effective  quarantine 
has  been  maintained  from  the  first  day  the  disease 
prevailing  at  Ocean  Springs  was  pronounced  to  be 
yellow  fever.  The  authorities,  who  cannot  believe  that 
their  shotgun  quarantines  could  possibly  be  evaded, 
comfort  themselves  with  the  assertion  that  the  doctors 
know  nothing  of  the  fever,  either  of  its  nature  or  of 
the  mode  of  its  spread.  The  record  for  Tuesday  of 
this  week  was:  New  Orleans — new  cases,  37;  total 
cases,  865  ;  deaths  to-day,  7 ;  total  deaths.  100.  Mo- 
bile— new  cases,  6;  total  cases,  170;  deaths  to-day, 
i;    total  deaths,  22.     Edwards— new  cases,  4;    total 


cases,  463 ;  deaths  to-day,  3 ;  total  deaths,  30.  Pat- 
terson— new  cases,  3;  deaths  to-day,  1.  Baton  Rouge 
— new  cases,  i .  Pascagoula — new  cases,  2 ;  total 
cases,  15.  Scranton — new  cases,  13;  total,  194. 
Cayuga — new  cases,  3;  total  cases,  18 ;  deaths  to-day, 
I.  Flomaton,  Ala. — new  cases,  16;  total,  20.  It  is 
said  that  a  suspicious  fever  has  been  prevailing  for 
five  or  six  weeks  in  Montgomery,  Ala.,  but  the  health 
board  has  steadily  maintained  that  it  was  not  yellow 
fever.  Early  this  week,  however,  the  board  admitted 
that  there  were  two  genuine  cases  in  the  city,  and  now 
the  impression  prevails  that  all  the  other  cases  were 
also  of  the  same  disease. 

The  Plague  is  reported  from  Madras,  so  that  now 
it  prevails  on  both  coasts  of  the  Indian  peninsula. 

The  Leprosy  Congress The  closing  session  of  the 

International  Leprosy  Congress  was  held  in  Berlin  on 
October  i6th.  The  discussions  covered  nearly  every- 
point  relating  to  the  etiology,  pathology,  bacteriology, 
symptomatolog}',  and  treatment  of  leprosy.  To  judge 
from  the  cable  reports  of  the  congress,  there  has  been 
little  brought  forward  that  added  to  our  knowledge  of 
the  disease.  Babes,  of  Bucharest,  in  a  paper  on  the 
bacteriology  of  leprosy,  stated  that  Hansen's  bacilli 
were  found  in  great  numbers  in  the  mucous  excretion, 
which  was  thus  one  of  the  chief  means  for  conveying 
infection.  The  members  of  the  congress  were  unani- 
mous in  their  belief  that  Hansen's  bacillus  was  the 
specific  pathogenic  micro-organism,  and  that  it  finds 
in  man  alone  of  all  animals  a  suitable  soil  for  its 
growth.  The  treatment  was  declared  to  be  as  yet  palli- 
ative only  and  not  curative;  orrhotherapy  was  dis- 
cussed at  length,  and  the  conclusion  arrived  at  was 
that  it  has  not  yet  been  found  of  service  in  leprosy. 
The  question  of  isolation  in  the  prevention  of  the  dis- 
ease was  also  thoroughly  discussed.  Hansen,  of  Ber- 
gen, Norway,  argued  at  length  in  favor  of  isolation, 
and  said  that  his  experience  justified  the  prediction 
that,  owing  to  the  rigid  isolation  so  long  practised  in 
Norway,  the  disease  would  disappear  entirely  there  by 
the  beginning  of  the  twentieth  century.  If  the  same 
measures  were  followed  universally,  leprosy  would  be 
eradicated  quickly.  He  insisted  upon  the  observance 
of  the  most  scrupulous  cleanliness.  This,  he  added, 
was  more  strictly  observed  in  the  United  States  than 
in  Europe,  the  result  being,  despite  immigration,  that 
the  disease  had  not  spread  there.  Besnier,  of  Paris, 
held  Uiat  isolation  was  not  necessary  if  proper  precau- 
tions were  taken  to  guard  against  contagion.  At  the 
closing  session  the  opinion  was  adopted  by  the  con- 
gress that  leprosy,  while  contagious,  is  not  hereditary, 
and  it  was  held  that  isolation  is  desirable  and  under 
certain  circumstances  is  to  be  enforced  by  the  author- 
ities. The  congress  was  closed  by  Virchow,  who  urged 
the  co-operation  of  government  and  science.  He  hoped 
this  congress  would  be  the  first  of  a  series  of  interna- 
tional debates  concerning  various  "diseases  of  as  yet 
obscure  nature. 

The  Strafford  District  (N.  H.)  Medical  Society. 
— The  nineteenth  annual  meeting  of  this  society  was 
held  in  Dover  on  October  13th,  under  the  presidency 


October  23,  1897] 


MEDICAL    RECORD. 


601 


of  Dr.  A.  Noel  Smith.  The  title  of  the  presidential 
address  was  "  The  Economic  Worth  of  the  Physician." 

A  Decision  against  the  Health  Board. — The  ap- 
pellate division  of  the  supreme  court  has  handed  down 
a  decision  that  the  health  department  of  this  citj-  ex- 
ceeded its  authority  and  acted  without  due  warrant  of 
law  in  condemning  and  destroying  four  rear  tenements 
ia  Mott  Street  some  time  ago.  It  was  not  denied  that 
the  tenements  were  unfit  for  human  habitation,  but  it 
was  contended  that  the  buildings  might  have  ser\ed 
some  other  purpose  and  should  not  have  been  razed. 
The  appellate  co-ut  decision  will  be  appealed  to  the 
court  of  appeals. 

Typhus  Fever  in  Mexico  City. — The  unsanitary- 
condition  of  the  city  and  the  protracted  rainy  season 
are  causing  much  sickness  in  Mexico.  During  the 
past  three  months  over  six  hundred  cases  of  t)-phus 
fever  have  been  reported,  and  there  have  been  about 
one  hundred  and  fitty  deaths  from  that  disease. 

Ambulance  Ships. — It  is  stated  in  the  ^nnual  re- 
port of  the  surgeon-general  of  the  navy,  recently  made 
public,  that  new  methods  of  succor  for  the  wounded 
must  be  devised  to  meet  new  conditions,  and,  with  this 
object  in  view,  plans  for  an  ambulance  ship  have  been 
prepared  under  the  super\-ision  of  Medical  Director 
W.  K.  Van  Reypen.  A  recommendation  for  authority 
to  establish  a  hospital  corps  for  the  navy  is  also  con- 
tained in  the  report. 

Small-pox  in  Atlanta. — Several  cases  of  small-pox 
have  developed  in  Atlanta  within  the  past  two  weeks, 
and  as  a  result  the  board  of  health  has  decided  to  be- 
gin compulsory  vaccination  throughout  the  city.  It  is 
not  thought  here  that  the  disease  will  assume  an  epi- 
demic form. 

Health  Statistics  of  New  Brunswick.— In  the  an- 
nual report  of  the  board  of  health  of  the  city  of  New- 
Brunswick  to  the  New  Jersey  State  board  of  health, 
the  population  of  New  Brunswick  at  the  last  census  is 
given  as  19,010;  the  number  of  births  for  the  year 
ending  June  30th  were  408;  deaths,  499;  drowning 
cases,  13;  deaths  from  railroad  accidents,  11;  and 
suicides,  3. 

A  Memorial  Operating-Room  in  the  Jamaica  Hos- 
pital.—  Miss  Mar)-  R.  King,  of  Great  Neck,  Long 
Island,  has  offered  to  furnish  and  equip  the  operating- 
room  of  the  Jamaica  Hospital,  now  Building  on  New- 
Vork  Avenue,  in  memory  of  her  aunt,  the  late  Miss 
Cornelia  King,  of  Jamaica,  who  had  taken  great  in- 
terest in  this  work.. 

Hydrophobia  in    Prussia .\ccording  to  official 

statistics,  107  persons  died  of  hydrophobia  in  Prussia 
in  the  years  from  1877  to  1894,  but  there  was  not  a 
single  death  from  that  cause  in  1895,  although  368 
cases  of  mad  dogs  were  reported  and  906  suspected 
animals,  in  addition,  were  killed  by  the  police. 

Dr,  Lewis  Balch,  ranking  major  of  the  national 
guard,  has  been  retired  from  the  tenth  battalion,  of 
.Albany,  of  which  he  was  the  surgeon. 

Lay  Treatment  of  Enuresis. — According  to  news- 
paper accounts  two  little  girls,  inmates  of  an  orphan 


home  at  Madalin,  -R'ere  shut  up  in  a  pigpyen  and  kept 
there  for  forty-eight  hours  on  bread  and  water,  as  a 
punishment  for  wetting  the  bed.  If  this  report  is  true, 
it  would  seem  in  order  for  the  trustees  to  engage  a 
new  matron  or  instil  a  little  common  sense  and  hu- 
manit}'  into  the  head  and  heart  of  the  present  incum- 
bent. 

KiUed  for    Evading  Quarantine A   negro  was 

lynched  by  a  mob  at  a  small  settlement  about  fifteen 
miles  from  New  Orleans,  because  he  had  been  in  the 
city  and  had  evaded  the  shotgun  quarantine  established 
everywhere  against  the  yellow  fever. 

The  Chicago  Medical  Society  has  recently  moved 
into  the  Stewart  Building,  where  sufficient  space  has 
been  rented  to  provide  for  a  meeting-hall,  committee 
rooms,  a  reading-room  and  librar}-,  cloak  rooms,  etc. 
It  is  hoped  to  make  this  the  centre  for  all  the  medical 
societies  of  the  city.  The  society  has  been  in  existence 
fort}--five  years,  and  has  a  membership  of  nearly  eight 
hundred. 

Illegal  Practice  of  Dentistry A  man  who  was  re- 
cently convicted  of  practising  dentistr}-  without  pre- 
vious registration,  as  required  by  the  law  of  this  State, 
was  fined  $150  in  special  sessions.  The  three  justices 
agreed  in  regarding  the  accused's  action  as  a  clear 
violation  of  the  law,  and  said  that  they  believed  the 
dental  law  to  be  for  the  general  good  of  the  public, 
and  expressed  their  pleasure  in  the  opportunity  afforded 
them  of  upholding  the  law.  The  man's  employer  was 
sharply  rebuked  for  consenting  to  his  violation  of  the 
dental  act,  and,  perhaps  as  a  mark  of  contrition  or  in 
reparation  of  his  wTong,  he  paid  the  prisoner's  fine. 

The  Syracuse  CoUege  of  Medicine Four  names 

have  been  added  to  the  facult}-  of  this  college,  the 
opening  session  of  which  for  the  new  year  was  held 
on  October  5th.  Dr.  Charles  \V.  Hargitt  has  been 
appointed  lecturer  on  embrj-ology,  and  will  be  assisted 
by  Dr.  F.  P.  Knowlton.  Drs.  W.  L.  Wallace  and 
George  B.  Broad  have  been  appointed  instructors  in 
anatomy. 

Premature  Burial. — The  United  States  consul  at 
Turin  has  sent  a  communication  to  the  state  depart- 
ment, stating  that  leading  physicians  in  Italy  are  now 
engaged  in  preparing  reports  and  exhibits  relating  to 
the  phenomena  of  trance,  and  that  papers  on  the  means 
of  distinguishing  real  from  apparent  death  are  expected 
from  wTiters  in  all  parts  of  Europe.  Prizes  will  be 
awarded  for  papers  offering  the  best  solution  of  this 
problem.  The  consul  says  that  not  only  the  medical 
profession  but  many  lay  persons  are  interested,  and 
that  the  medical  section  of  the  national  exposition  to 
be  held  at  Turin  in  1898  is  to  be  largely  devoted  to 
the  subject. 

A  Dental  College  "  in  Petto." — It  is  reported  that 
Dr.  Thomas  W.  Evans,  the  well-known  dentist  in  Paris, 
intends  to  leave  the  bulk  of  his  large  fortune,  estimated 
by  some  at  upward  of  $30,000,000,  to  charitable  and 
educational  institutions  in  this  country.  It  is  said 
that  he  purposes  to  establish  an  elaborately  equipped 
dental  college  in  Philadelphia,  in  which  the  tuition  is 


6o2 


MEDICAL    RECORD. 


[October  23,  1897 


to  be  practically  free  to  deserving  students.  He  has 
recently  been  in  this  country,  and  has  consulted  with 
many  members  of  the  dental  profession  in  the  leading 
cities  concerning  his  plans  for  a  new  school. 

Racial  Immunity  to  Tuberculosis. — Some  inter- 
esting observations,  we  learn  from  the  Medical  Press, 
have  recently  been  made  public  by  two  Parisian  phy- 
sicians in  respect  of  a  group  of  people  inhabiting  St. 
Ouen,  a  district  of  suburban  Paris,  who  appear  to  en- 
joy complete  immunity  from  the  scourge  of  phthisis. 
These  observations  bear  on  ninetj'-eight  families, 
comprising  five  hundred  and  eleven  members,  of  whom 
none  has  succumbed  to  consumption  since  1883.  As 
a  matter  of  fact,  this  immunity  seems  of  old  standing, 
for  researches  extending  as  far  back  as  1870  revealed 
no  record  of  death  due  to  this  cause.  Tuberculosis  is 
responsible  for  something  like  three  deaths  per  thou- 
sand inhabitants  per  annum,  and  it  is  specially  fatal 
among  nurses  and  hospital  attendants;  indeed,  during 
the  last  ten  years  phthisis  claimed  two  hundred  and 
seventeen  victims  out  of  five  hundred  and  ninety-nine 
deaths  among  hospital  attendants  in  Paris  alone. 

Decline  of  the  Plague  in  China.  —  The  United 
States  consul  at  Amoy  has  reported  to  the  state  depart- 
ment that  the  bubonic  plague,  which  has  raged  in  that 
section  of  China  for  three  months,  is  now  regarded  as 
having  run  iiS  course. 

A  Trial  of  Typhoid  Vaccine  is  being  made  on  a 
large  scale  at  Maidstone,  England,  where  one  of  the 
severest  epidemics  of  the  disease  ever  known  is  now 
prevailing,  fifteen  hundred  people  out  of  a  population 
of  thirty-two  thousand  having  already  been  stricken. 
The  experiments  are  being  conducted  under  the  direc- 
tion of  the  pathological  laborator}'  of  the  State  Army 
School  at  Netley,  by  Professor  Wright  and  Surgeon- 
Major  Temple.  It  is  said  that  these  have  so  improved 
the  method  that  they  are  able  to  obtain  Widal's  reac- 
tion from  the  blood  of  the  vaccinated,  which  is  taken 
as  a  proof  that  the  individual  is  protected  by  the  in- 
jection. Enough  vaccine  has  been  sent  to  Maidstone 
to  inoculate  the  whole  population  if  necessary. 

Navy  Department,  Bureau  of  Medicine  and  Surgerj', 
Washington,  D.  C. — Changes  in  the  medical  corps  of 
the  United  States  navy  for  the  week  ending  October 
16,  1897.  October  9th. — Assistant  Surgeon  A.  Faren- 
holt  detached  from  the  Vcnnont  and  ordered  to  New 
York  navy  yard.  October  nth. — Surgeon  C.  G.  Hern- 
don  ordered  on  temporar}'  duty  at  the  naval  museum 
of  hygiene.  October  12th. — Assistant  Surgeon  W.  B. 
Grove  detached  from  naval  laboratory,  New  York,  and 
ordered  to  Mare  Island  Hospital.  October  13th. — 
Passed  Assistant  Surgeon  C.  P.  Bagg  detached  from 
the  Marion  and  ordered  to  the  Adams;  Assistant 
Surgeon  M.  K.  Johnson  detached  from  the  Ne^o  York 
and  ordered  to  duty  with  the  Vicksbiirg;  Assistant 
Surgeon  R.  Spear  detached  from  the  naval  laborator}'. 
New  York,  and  ordered  to  the  Nrui  York,  October 
14th. — Surgeon  C.  Biddle  detached  from  marine  ren- 
dezvous, San  Francisco,  ordered  to  Washington  in 
charge  of  patient,  then  to  report  at  the  navy  department. 


Malignant  Malaria It  is  reported  from  St.  Peters- 
burg that  malaria,  which  has  been  prevalent  at  Tash- 
kend,  Asiatic  Russia,  for  four  years,  has  now  become 
virulent,  and  the  deaths  from  that  cause  are  estimated 
to  number  several  thousand.  The  Russian  garrison  at 
Merv,  where  influenza  as  well  as  malaria  prevails,  has 
been  transferred  to  Krasnovodsk,  on  the  Caspian  Sea, 
to  prevent  its  being  annihilated  by  disease. 

The  Idaho  State  Medical  Society  held  its  fifth 
annual  meeting  at  Boise  City  on  Tuesday  and  Wed- 
nesday, September  15  and  16,  1897.  The  newly 
elected  officers  are:  Dr.  C.  A.  Hoover,  Montpelier, 
President ;  Dr.  R.  C.  Coffey,  Moscow,  Vice-President ; 
and  Dr.  Exi.  E.  Maxey,  Caldwell,  Secretary  and  Treas- 
urer. The  next  meeting  will  be  held  at  Moscow, 
Idaho,  the  first  Tuesday  in  September,  1898. 

The  New  Jamaica  Hospital.— The  laying  of  the 
cornerstone  of  the  new  building  for  the  Jamaica,  Long 
Island,  Hospital,  which  is  to  be  located  on  New  York 
Avenue,  that  village,  took  place  on  Saturday  afternoon 
last.  The  cornerstone  was  laid  by  Miss  Gale,  the 
president  of  the  board  of  trustees  of  the  Hospital  As- 
sociation. The  new  building  will  probably  be  com- 
pleted by  Januar)-. 

Obituary  Notes — Dr.  Theodore  Todd  Mukro,  of 
Union,  S.  C,  died  by  suicide  on  October  10th,  at  At- 
lanta, Ga.,  whither  he  had  been  taken  for  treatment  of 
the  opium  habit. — Dr.  Joseph  C.  Wheaton  died  at 
Millville,  N.  J.,  on  October  13th,  after  a  brief  illness. 
He  enjoyed  a  large  practice  and  was  active  among  tlie  ■ 

poor  and  needy.— Dr.   Newton   E.   Bates,   surgeon-  • 

general  of  the  United  States  na\-}%  died  in  Washington 
on  October  i8th,  at  the  age  of  sixty  years.  He  was 
appointed  surgeon-general  to  succeed  Surgeon-General 
Tryon  on  October  ist,  and  was  obliged  on  account  of 
the  illness  which  finally  resulted  in  his  death  to  take 
the  oath  of  office  in  bed.  His  illness  at  that  time  was 
not  regarded  as  serious,  but  developed  alarming  symp- 
toms a  few  days  ago.  Dr.  Bates  was  appointed  assis-  _ 
tant  surgeon  in  the  navy  from  New  York  State  in  June,  ■ 
1861.  He  became  surgeon  in  1865,  medical  inspector  ^ 
in  1881,  and  for  nine  years  prior  to  his  appointment 
as  surgeon-general  was  a  medical  director  wiUi  the  rel- 
ative rank  of  captain.  He  was  the  President's  family 
physician. — Dr.  James  P.  Daly,  of  this  city,  the  Tam- 
many candidate  for  coroner  in  the  Borough  of  the 
Bronx,  died  suddenly  on  October  isth.  He  was  a 
graduate  of  Bellevue  Hospital  Medical  College  in  the 
class  of  1886. — Dr.  Girard  Robinson  Ricketts  died 
at  his  home  in  Procton'ille,  Ohio,  September  20, 
1897.  He  was  bom  in  Virginia  in  1S28,  and  was 
graduated  from  the  Western  Reser\e  Medical  College 
of  Cleveland,  Ohio,  in  1855.  His  three  sons,  Drs. 
Edwin  S.,  B.  Merrill,  and  Joseph  V.  Ricketts,  are  all 
practising  physicians  in  Cincinnati. — Dr.  \Villiaxi  H. 
Ford,  president  of  the  board  of  health  of  Philadel- 
phia, died  suddenly,  October  i9tli,  at  his  summer  home 
in  Belmar,  N.  J.,  aged  fifty-eight  years.  He  was  well 
known  as  a  writer  on  hygiene  and  sanitation.  He  had 
been  a  member  of  the  board  of  health  for  twenty- 
seven  vears. 


October  23,  1897] 


MEDICAL    RECORD. 


^ocietij  Reports. 

NEW  YORK  STATE  MEDICAL  ASSOCIATION. 

Fourteenth  Annual  Meeting,  Held  in  New  York,  October 
12,  13,  and  14,  i8gj. 

Charles  Phelps,  M.D.,  President. 
Second  Day —  Wednesday,  October  13th. 

(Continued  from  pa-o  571. 1 

Hysteria  and  a  Study  of  the  Symptoms  Ob- 
served during  the  Inter-Paroxysmal  Period — Dr. 

William  D.  Granger,  of  Westchester  County,  read 
this  paper.  He  said  that  hysteria  must  be  considered 
as  essentially  a  psychosis,  the  predominant  symptoms 
of  which  were  attributable  to  the  cortex  of  the  brain. 
The  symptoms  of  the  interparoxysmal  period  were 
classified  thus:  (i)  Disturbances  of  sensation,  such  as 
anaesthesia,  paraesthesia,  and  hyperesthesia;  (2)  dis- 
turbances of  motion,  such  as  paralysis,  contractures, 
and  tremor;  (3)  vasomotor,  visceral,  and  nutritional 
disturbances;  (4)  mental  symptoms;  and  (5)  unclassi- 
fied symptoms.  Disturbances  of  sensation,  particu- 
larly analgesia,  were  rarely  absent  in  the  graver  forms 
of  hysteria.  The  most  frequent  form  of  disturbance 
was  a  hemi-anaesthesia  affecting  exactly  one-half  of 
the  body.  Every  one,  the  speaker  said,  was  familiar 
with  the  "hysterical  spine."  Pains  in  the  joints  were 
generally  confined  to  the  larger  joints.  All  sorts  of 
pains  were  experienced  in  the  head  and  face.  The 
classical  "  hysterical  clavus"  of  Sydenham  was  an  in- 
tense pain  of  circumscribed  area,  usually  at  the  ver- 
tex. The  pains  in  the  abdomen  were  quite  scattered, 
yet  in  general  they  were  more  or  less  connected  with 
the  ramifications  of  the  ovarian  plexus  of  ner\'es.  The 
ovarian  zone  was,  of  course,  the  one  most  commonly 
affected.  In  hysterical  paralysis  the  patient  usually 
dragged  the  limb,  instead  of  swinging  it  as  did  the 
true  paralytic.  The  electrical  reactions  would  also 
be  found  to  be  normal  and  the  skin  would  be  un- 
changed. In  connection  with  the  well-known  hysteri- 
cal spasm  of  the  throat,  one  often  observed  that  the 
patient  would  refuse  food.  It  was  here  that  we  met 
with  the  cases  of  deception,  commonly  called  "fasting 
girls,"  but  aside  from  the  cases  of  palpable  fraud  there 
were  well-authenticated  instances  in  which  such  hys- 
terical patients  had  been  able  to  live  for  a  long  time 
upon  a  comparatively  small  amount  of  nourishment. 
The  symptoms  connected  with  the  chest  were  insignifi- 
cant when  compared  with  those  referable  to  the  ab- 
domen. Vomiting  of  blood  was  occasionally  one  of 
the  stigmata  of  hysteria.  Hysterical  oedema  was  a 
very  rare  condition,  due  to  vasomotor  disturbance. 
The  reports  of  extremely  high  temperature  could  be 
put  down  as  fallacious,  although  a  pseudo-hysterical 
fever  had  been  noted,  in  which  there  was  no  actual 
rise  of  the  body  temperature.  A  rise  of  only  two  or 
three  degrees  was  sometimes  observed  in  hysterical 
cases,  and  was  not  amenable"  to  treatment  by  the  usual 
antipyretic  drugs.      ^ 

Dr.  Ha.vam,  of  Rensselaer  County,  detailed  at  length 
his  experience  with  a  case  of  hysteria,  which  some 
surgeons,  notably  a  certain  eminent  one  from  New 
York  City,  had  insisted  was  a  case  of  organic  pelvic 
disease  demanding  immediate  operation.  He  had 
been  astounded  and  disgusted  to  see  this  patient  placed 
on  the  operating-table,  and  then  at  the  last  moment 
the  operator  refuse  to  operate.  Notwithstanding  va- 
rious diagnoses  and  treatments,  this  patient  was  still 
in  much  the  same  condition  as  at  first. 

Dr.  Van  de  Warker  said  that  to  his  mind  the 
most  remarkable  thing  about  this  case  was  that  the 
woman  had,  during  all  this  trying  period,  succeeded  in 
retaining  her  tubes  and  ovaries. 


Massage  as  an  Occupation  for  the  Blind. —  Dr. 

Arthur  Y.  Bennett,  of  Erie  County,  in  a  paper  with 
this  title,  made  the  statement  that  there  were  over  four 
thousand  blind  persons  in  New  York  State,  and  that 
so  far  as  he  had  been  able  to  ascertain  from  circular 
letters  of  inquiry  probably  not  more  than  from  six  to 
ten  per  cent,  were  able  to  support  themselves.  Among 
blind  women  the  percentage  was  very  much  smaller. 
He  was  of  the  opinion  that  the  blind  should  be  able 
to  make  massage  their  own  peculiar  profession.  One 
of  their  special  qualifications  for  such  work  was  their 
well-known  extraordinary  delicacy  of  touch.  More- 
over, the  blindness  itself  was  an  actual  advantage,  be- 
cause it  enabled  the  massage  operators  to  carry  on  the 
necessary  manipulations  without  being  able  to  detect 
various  bodily  deformities  and  blemishes,  about  which 
most  people  were  very  sensitive.  It  was  bad  enough 
to  expose  the  body  to  their  physician,  but  it  was  many 
times  worse  to  do  this  in  the  presence  of  a  strange 
massage  operator. 

Dr.  Thornton,  of  Buffalo,  expressed  the  belief  that 
this  valuable  suggestion  should  receive  the  hearty  co- 
operation and  support  of  the  medical  profession. 

Differential  Diagnosis  of  Pelvic  Cellulitis  and 
Peritonitis.— Dr.  Ely  Van  de  Warker,  of  Onondaga 
Count)',  read  the  paper.  He  said  that  it  was  his  aim 
to  show  that  pelvic  peritonitis  and  cellulitis  were  dis- 
tinct entities,  and  that  each  disease  had  clinically  dis- 
cernible traits  by  which  each  could  be  differentiated. 
For  example,  the  masses  of  peritonitis  and  cellulitis 
occupied  positions  so  different  that  this  alone  should 
prevent  the  confusion  of  the  two  conditions.  He  had 
found  one  important  symptom  in  cases  of  cellulitis — 
i.e.,  retraction  of  the  thigh.  There  was  a  good  ana- 
tomical explanation  for  the  fact  that  this  symptom  was 
so  characteristic  of  cellulitis.  It  was  never  seen  in 
uncomplicated  pelvic  peritonitis.  Phlebitis  and  en- 
largement of  the  limb  were  also  indicative  of  the  con- 
dition. Another  very  highly  characteristic  and  unfail- 
ing sign  of  pelvic  cellulitis  was  the  existence  of  a 
well-defined  mass  of  cellular  infiltration  into  the  later- 
al wall  of  the  vagina  and  continuous  with  the  lateral 
vaginal  vault.  The  remainder  of  the  paper  was  de- 
voted to  an  elaboration  of  these  views. 


Wednesday,    October  ijth — Night  Session. 

The  New  Epoch  in  the  Study  of  Pathology,  by  Dr. 
Ira  Van  Gieson,  was  the  first  paper.  Dr.  Van  Gie- 
son  said  it  sounded  a  little  sententious  to  speak  of  the 
"  new  epoch,"  but  we  could  often  speak  of  the  old  with 
new  terms  and  better  ideas.  There  were  four  cardinal 
factors  which  gave  new  views  of  the  pathology  of  the 
nervous  system.  First,  that  the  nerve  fibre  was  not 
separate  and  distinct  in  character  from  the  cells,  but 
was  the  extension,  as  it  were,  of  the  cell.  The  two 
were  anatomically  and  physiologically  a  unit.  The 
tendency  to  think  that  the  white  matter  and  gray  mat- 
ter of  the  brain  dift'ered  led  to  confusion,  and  it  was 
a  great  gain  to  understand  that  the  fibre  was  the  out- 
growth of  the  cell,  whether  that  be  motor  or  sensory. 
Second,  that  the  linking  of  physiological  chemistry  and 
pathological  anatomy  aided  in  the  understanding  of 
the  phenomena  hitherto  obscure.  Third,  the  great  ad- 
vancement in  cytology,  by  which  it  was  known  that  the 
cells  were  in  themselves  a  microcosm.  This  advance- 
ment in  the  knowledge  of  ner\'e-cell  structure  had  been 
made  by  the  biologists  in  the  last  few  years.  It  was 
to  be  expected  that  tlie  study  of  pathology  would  now 
be  devoted  more  to  the  changes  in  the  cells  themselves 
than  to  the  mass,  for  the  cells  had  structural  relations 
within  themselves  even  as  had  the  different  organs 
of  the  body.  Fourth,  the  comparison  of  the  pathology 
of  the  nerve  cells  with  that  of  other  parts  of  the  body. 
Singularly  the  nervous  system  had  been  studied  as  a 


6o4 


MEDICAL    RECORD. 


[October  23,  1897 


separate  part  of  tlie  body.  The  fact  that  the  pathology 
of  the  nervous  system  had  not  been  correlated  with  that 
of  other  parts  of  the  body,  had  retarded  its  study. 
What  will  happen  in  the  cellular  structure  of  the  kid- 
neys and  the  liver  when  toxins  come  in  contact  with 
them  may  be  assumed  as  happening  also  when  toxins 
come  in  contact  with  cellular  tissues  of  tiie  nervous 
system.  We  might  flatter  ourselves  that  we  knew 
much  of  the  physical  basis  that  underlay  disease  of 
the  nervous  system,  but  to  say  that  locomotor  ataxia 
was  caused  by  sclerosis  of  the  posterior  columns  of  the 
spinal  cord  was  to  give  not  the  cause,  but  the  result  of 
some  changes  that  had  taken  place  in  the  nerves.  It 
did  not  explain  the  beginning  of  the  disease.  We 
were  acquainted  with  what  could  be  seen  with  the 
naked  eye  or  the  lower  power  of  the  microscope,  but  as 
to  cell  structure  nothing  was  known,  for  it  was  not 
visible  when  sections  were  hardened  in  Miiller's  fluid. 
Dr.  Van  Gieson  emphasized  the  point  that  the  method 
of  examining  nerve  cells  by  the  use  of  Miiller's  fluid 
destroyed  all  opportunity  of  studying  the  interna! 
structure  of  the  cell.  Pathological  conditions  seemed 
complicated,  but  he  thought  they  could  all  be  reduced 
to  three  forms — degeneration,  inflammation,  and  ne- 
crosis. Instead  of  each  disease  having  a  different 
pathological  lesion,  he  thought  all  could  be  traced  to 
one  of  these  three  acting  with  varying  intensity. 
These  processes  were  found  in  the  nervous  system, 
and  while  the  results  might  be  moditied,  yet  they  were 
homologous  to  the  same  processes  in  the  kidney  or 
liver.  Disease  might  be  defined  as  the  chemical  re- 
action between  the  toxin  forces  on  the  one  hand  and 
the  body  forces  on  the  other.  If  X  represented  the 
toxic  forces  and  Y  the  body  forces,  the  disease  was 
represented  by  the  ratio  between  these.  The  disease 
varied  as  the  toxic  forces  varied  or  the  body  force 
varied;  hence  it  might  be  represented  as  dX :  dY,  in 
which  d  represented  diff^erentially  the  varying  force. 
The  toxic  force  was  influenced  by  amount  of  poison, 
how  long  acting,  etc. ;  the  body  force  by  age,  sex, 
heredity,  etc. 

Dr.  Van  Gieson  discussed  at  some  length  the  resist- 
ing forces  of  the  body,  and  showed  how  they  counter- 
acted the  toxic  forces  and  how  disease  varied  in  rela- 
tive proportion  to  the  variation  in  these  forces.  By 
toxin  he  did  not  mean  the  result  of  bacterial  life,  but 
used  the  term  in  the  broader  sense  of  applying  to  all 
deleterious  material  which  might  impair  the  body. 
The  results  of  the  varying  of  body  and  toxic  forces 
might  be  compared  to  the  changing  of  the  relative 
position  of  a  few  pieces  of  glass,  producing  many 
varying  conditions.  He  then  compared  tlie  structure 
of  the  brain  to  that  of  the  kidney.  The  kidney  was 
composed  of  parenchyma  and  stroma.  The  paren- 
chyma was  composed  of  cells  which  could  be  com- 
pared to  the  nerve  cells;  the  stroma  to  the  neuroglia. 
When  there  was  a  disturbance  in  the  kidney,  a  lack  of 
blood  supply,  too  much  blood,  presence  of  any  toxins, 
we  saw  the  result  in  what  we  called  cloudy  degenera- 
tion. The  cells  were  affected,  became  cloudy,  broke 
down,  and  were  destroyed,  the  result  varying  with  the 
amount  of  toxin  and  the  length  of  time  it  acted.  The 
brain  did  not  escape  this  similar  result  and  hence  fol- 
lowed delirium  of  fevers,  etc. ;  cloudy  swelling,  it  might 
be  said,  of  the  brain  cells.  This  swelling  is  not  seen 
on  examination,  because  of  the  use  of  Miiller's  fluid. 
By  tlie  use  of  the  blackboard  Dr.  Van  Gieson  showed 
how  the  fibrilla;  of  the  nerve  cells  crossed,  and  how 
wliere  they  crossed  tliere  were  minute  nodes  called  mi- 
crosomes. These  were  acted  upon  by  the  toxin,  began 
to  break  down,  and  if  the  process  continued  the  result 
would  be  the  cloudy  swelling  of  tiie  cell  and  finally 
its  destruction.  This  cloudy  swelling  explained  de- 
lirium, which,  when  occurring  by  itself,  was  called 
insanity. 


As  we  conclude  in  the  case  of  the  kidney  what  the 
prognosis  is  to  be,  so  with  the  brain.  The  kidney  re- 
covered in  full  if  not  affected  too  long  and  too  severely; 
so  the  brain.  The  one  was  the  homologue  of  the  other. 
The  prognosis  was  affected  by  the  body  force.  Thus 
insolation  occurring  in  alcoholics  was  of  doubtful  prog- 
nosis on  account  of  the  body  force  and  the  condition 
of  the  cellular  structure.  The  following  diagram  illus- 
trated his  idea  of  recovery : 


Cytolysis  - 


Cytoclasis- 


< Cytothesis  | 

There  was  a  point  beyond  which  there  was  no  recov- 
er)-^ — -where  the  cell  structure  was  afifected ;  where  the 
cells  became  broken  down  (cytoclasis,  cell  destruc- 
tion)— but  up  to  this  point  there  was  a  possibility  of 
recover)'  when  the  poison  was  removed  (cytolysis,  cell 
resolution).  When  the  poison  ceased  to  act,  the  cells 
began  to  restore  their  normal  condition  (cytothesis). 

There  was  more  hope  of  restitution  in  cases  of  acute 
infection  than  in  chronic.  A  small  amount  of  poison 
acting  for  a  long  time  would  make  repair  less  hopeful 
than  the  action  of  the  acute  attack.  Thus  syphilis 
produced  in  its  insidious  way  more  damage  to  the  cell 
than  the  acute  fever,  and  made  cytothesis  less  likely 
to  take  place.  On  the  ground  of  cytoclasis  it  was 
easy  to  understand  the  existence  of  locomotor  ataxia. 
The  nerve  cell  underwent  degeneration  by  the  action 
of  insidious  poison.  This  resulted  in  the  death  of 
the  fibre,  and  finally  by  inflammatory  restitution  its 
place  was  taken  by  tissue  and  it  became  a  jjermanent 
lesion.  Seeming  improvement  could  be  explained  by 
understanding  that  some  of  the  cells  had  not  gone  on 
to  cytoclasis,  and  when  the  poison  abated  for  a  short 
time  they  began  cytothesis  and  thus  the  symptoms 
might  improve  for  a  week  or  so. 

The  Conservative  Surgical  Treatment  of  Fibro- 
Myoma. — Dr.  E.  E.  Montgomery  read  a  paper  upon 
this  subject.  He  said  that  hysterectomy,  vaginal  or 
abdominal,  could  be  considered  conservative  when 
performed  to  save  life.  He  would  not  justify  the  re- 
tention of  the  uterus  if  there  was  disease  of  the  tubes 
and  ovaries,  but  in  many  cases  these  could  be  saved. 
Growths  could  be  attacked  per  vaginam  or  by  way  of 
the  abdomen^per  vaginam  by  dilatation  of  the  cervix, 
incision  of  the  cervix,  removal  by  torsion  or  by  enuclea- 
tion from  the  capsule.  Curetting  of  the  uterus  might 
be  employed  to  stop  bleeding.  A  tumor  that  was  pe- 
dunculated could  be  removed  by  three  or  four  tvvists,  but 
this  could  not  be  done  if  the  tumor  was  encapsulated 
and  partially  inclosed  in  the  walls  of  the  uterus.  Then 
there  was  danger  from  hemorrhage.  Some  had  ob- 
tained favorable  results  by  cutting  oft"  the  blood  sup- 
ply from  the  tumor.  This,  as  done  by  Martin,  included 
ligation  of  the  whole  base  of  the  broad  ligament.  It 
could  be  done  without  entering  the  peritoneal  cavit}', 
but  there  was  some  danger  of  ligating  the  ureter.  This 
arrest  of  blood  supply  caused  diminution  of  the  tumor. 
He  wished  to  assert  that  by  using  these  various  meth- 
ods it  was  possible  to  reinove  tumors  without  sacrific- 
ing the  body  of  the  uterus.  If  the  growth  was  in  a 
woman  near  the  climacteric,  the  uterus  might  well  be 
removed,  but  if  in  a  young  woman  the  organ  ought  to 
be  saved  if  possible.  The  cervix  could  be  dilated  with 
the  finger  or  with  tents,  using  one  large  one  or  sewral 
small  ones,  allowing  them  to  remain  from  twelve  to 
twenty-four  hours.  Careful  cleansing  was  necessary. 
The  vagina  and  cervix  could  be  cleansed  with  forma- 
lin solution,  the  vagina  being  afterward  packed  with 
iodoform  gauze.  If  the  growth  was  near  the  fundus  the 
cervix  might  be  incised,  a  lateral  incision  extending 
well  up  but  not  entering  the  peritoneum  being  prefera- 
ble. If  pedunculated,  the  tumor  might  be  removed  by 
torsion;  if  encapsulated,  by  splitting  Uie  capsule, 
enucleating  with  a  blunt  dissector  in  preference  to  the 


October  23,  1897] 


MEDICAL    RECORD. 


605 


finger;  and  if  the  tumor  was  large,  some  morcellation 
might  be  necessarj'.  After  removal  the  incisions  in  the 
cervix  were  brought  together  by  sutures,  and  the  whole 
was  thoroughly  cleaned  and  packed  with  gauze.  For  the 
ready  accomplishment  of  removal  of  a  tumor  through 
the  vagina  the  uterus  must  be  movable  and  the  tumor 
not  larger  than  the  fist.  If  the  case  was  not  suited  to 
this  method,  the  tumor  must  be  removed  through  the 
abdominal  wall.  Mural  or  intramural  tumors  were 
not  to  be  thus  considered. 

Some  Remarks  on  Ovarian  Surgery — Dr.  A. 
Palmer  Dudley  read  the  paper  on  this  subject.  He 
read  this  paper  in  answer  to  some  criticism  on  his 
work  and  to  put  on  record  some  work  he  had  done  in 
contradistinction  to  radical  operations.  He  thought 
the  pendulum  had  swung  too  far,  and  radical  opera- 
tions were  often  done  when  conser\'ative  work  would 
give  better  results.  The  operation  of  hysterectomy 
had  become  almost  perfect  The  French  were  so  ex- 
pert that  child-bearing  was  becoming  a  verj-  grave 
question,  the  government  offering  pensions  to  those 
who  raised  large  families.  He  thought  the  govern- 
ment might  well  pension  its  surgeons  and  thus  save 
the  child-bearing  power  of  the  women.  The  question 
was:  To  what  extent  can  conservative  operations  be 
performed  with  safety  to  the  patient?  A  number  of 
years  ago  he  had  seen  the  removal  of  a  healthy  ovary 
followed  by  the  recover}-  of  the  patient,  and  had  deter- 
mined to  see  if  the  ovaries  when  only  partly  involved 
could  not  be  operated  upon  and  the  unaffected  por- 
tion saved.  He  had  operated  on  a  woman,  removed 
a  portion  of  oue  ovary,  brought  the  edges  together, 
and  se-.red  them  with  fine  silk.  The  woman  became 
pregnant  in  a  few  months  afterward.  He  had  records 
of  sixt)- -eight  patients  and  all  had* done  well.  Eight 
of  these  had  since  borne  children.  In  all  these 
cases  he  had  not  seen  a  recurrence  of  any  inflamma- 
tion that  could  be  detected  by  manual  touch.  He 
had  never  treated  the  ovaries  with  the  cauten,-;  he 
punctured  the  cysts,  sometimes  scratching  the  sac  until 
it  filled  with  blood.  He  thought  the  cautery  destroyed 
too  much  healthy  tissue.  It  was  best  to  save  all  the 
tissue  possible,  but  when  necessary  the  operation  had 
included  nearly  the  entire  ovarj-.  In  operations  on 
the  ovary  he  never  used  animal  sutures,  but  fine  silk. 
The  tubes  could  be  partially  removed  with  good  re- 
sults. Even  pus  tubes  could  be  saved  by  removing 
the  portion  in  which  there  was  pus,  splitting  the  end 
remaining,  sewing  the  mucous  membrane  to  the  peri- 
toneal covering,  thus  lea\ing  a  cup-like  end  which 
performed  the  function  of  the  fimbriated  extremity. 
To  this  the  ovary  was  attached  by  a  single  suture  of 
silk.  Some  reasons  why  radical  operations  should  not 
be  performed  when  avoidable  were,  retaining  the  in- 
tegrity of  the  home,  avoiding  nervous  s)'mptoms  some- 
times worse  than  the  original  disease,  and  saving  the 
women  from  barrenness. 

Dr.  Fred  Holme  Wigoix  presented  a  large  tumor 
removed  from  a  patient  at  the  Cin-  Hospital.  The 
woman  was  forty-t^ivo  years  old,  was  never  pregnant, 
and  had  suffered  from  tumor  over  a  year.  She  was 
weak,  but  suffered  such  pain  that  she  and  her  husband 
asked  for  the  operation.  On  account  of  the  patient's 
condition  the  tumor  was  rapidly  removed  and  the  uterus 
served  up;  the  patient  recovered. 

Dr.  Dudley  mentioned  a  case  of  a  young  girl  suf- 
fering from  a  large  tumor.  He  opened  the  abdomen 
and  the  uterus,  removed  the  tumor,  and  sewed  the 
uterus  up,  leaving  a  gauze  drain  from  the  abdominal 
wall  through  the  vagina.  Afterward  the  gauze  was 
drawn  up  a  little,  cut  off,  and  the  remainder  with- 
drawn through  the  vagina.     The  patient  recovered. 

Dr.  E.  D.  Ferguson  said  he  considered  the  ques- 
tion of  myomectomy  important.  Fibroraas  were  seldom 
single  but  were  multiple — many  small  ones,  seeds  as 


it  were.  It  was  a  question  if  leaving  the  uterus  in 
this  condition  was  conservative  surgery  for  the  patient 
In  subjects  nearing  the  climacteric  he  thought  it  best 
to  perform  hysterectomy,  but  of  course  in  the  case  of 
a  young  woman  it  was  necessarj'  to  save  the  uterus  if 
possible.  Still  it  was  a  question  if  myomectomy  would 
not  become  a  fad,  to  the  detriment  of  the  patient 

Dr.  J.  E.  Jaxvrin  said  he  wished  to  congratulate 
Dr.  Dudley  on  his  conserv-ative  work.  Most  of  the 
men  who  did  much  operating  took  this  same  ground 
of  consers-ative  surger)-.  He  thought  this  was  the  safe 
ground.  Dr.  Montgomer\''s  paper  had,  in  a  new  way, 
presented  facts  relating  to  an  old  field  and  he  congratu- 
lated the  doctor  on  his  success.  The  removal  of  tumors 
from  the  uterus  had  been  done  in  a  somewhat  crude 
■  way  for  years.  All  tumors  of  the  uterus,  when  the  tubes 
and  ovaries  were  in  a  healthy  condition  and  the  woman 
was  young,  should  be  dealt  with  in  this  wav. 

Dr.  Wiggin  said  that  in  women  under  fort}'  years 
of  age  he  always  left  the  uterus  unless  it  was  so  dis- 
eased as  to  demand  removal. 

Dr.  Montgomerv  said  he  would  not  suggest  opera- 
tion to  save  the  uterus  if  the  climacteric  was  near  at 
hand.  He  was  interested  in  Dr.  Dudley's  paper,  and 
he  had  not  before  heard  the  suggestion  as  to  leaving 
the  end  of  the  tube  with  a  cup- like  receptacle  for  the 
reception  of  the  ovum.  He  had  known  removal  of 
a  diseased  ovarj'  to  bring  about  the  return  of  menstrua- 
tion in  a  woman  who  had  been  irregular  but  who  was 
not  at  the  time  of  operation  pregnant. 


Third  Day — Thursday,  October  J4ih. 

Officers  Elected — President,  Dr.  Douglas  Ayres,  of 
Fort  Plain:  Vice-Presidents,  Second  District,  Dr.  C.  E. 
Fritts,  of  Hudson;  Third  District,  Dr.  H.  W.  Carpen- 
ter, of  Oneida;  Fourth  District,  Dr.  C.  C.  Frederick, 
of  Buffalo;  Fifth  District,  Dr.  N.  W.  Leighton,  of 
Brooklyn;  Members  of  the  Council,  First  District,  Dr. 
VV.  H.  Robb,  of  Amsterdam ;  Second  District,  Dr.  E. 
M.  Lyon,  of  Plattsburg;  Third  District,  Dr.  W.  L. 
Ayer,  of  Owego;  Fourth  District,  Dr.  J.  G.  Truax,  of 
New  York. 

Subscription  to  the  Rush  Monument  Fund. — Dr. 
Thomas  H.  Maxlev,  of  New  York,  moved  that  the 
treasurer  of  the  association  be  authorized,  in  confor- 
mity with  the  pledge  of  the  representative  at  the  last 
meeting  of  the  American  Medical  Association,  in  Phil- 
adelphia, to  pay  to  the  Rush  monument  fund  the  sum 
of  $2,000,  in  the  name  of  the  New  York  State  Medical 
Association.  After  Some  discussion  and  explanation 
the  motion  was  carried  without  a  dissenting  vote. 

General  Considerations  concerning  Auto-Intoxi- 
cation.—  Dr.  H.  A.  Hanbold,  of  New  York,  read  a 
paper  with  this  title.  He  said  that  the  theor}-of  auto- 
intoxication had  found  but  little  acceptance  in  the 
profession  up  to  recent  times.  The  explanation  was 
to  be  found  in  the  statement  of  Albu,  of  Berlin,  that 
the  general  practitioner  knew  but  little  of  physiologi- 
cal chemistr}-,  which  was  necessary  to  an  understand- 
ing of  the  subject.  But  recent  investigations  into  the 
poisons  developed  spontaneously  in  the  body  in  con- 
nection with  general  metabolism  had  given  the  subject 
considerable  importance.  The  development  of  the 
science  of  bacteriolog}'  had  led  to  the  belief  that  the 
infection  itself  constituted  only  a  portion  of  the  etio- 
logical factors  concerned  in  disease.  In  the  majority 
of  instances  intoxication  was  secondary  to  infection, 
the  intoxicants  being  the  products  of  infection;  but 
we  were  also  justified  in  believing  that  primary  intox- 
ication was  a  frequent  cause  of  disease,  and  that  poi- 
sons might  develop  within  the  body.  Examples  were 
to  be  found  in  the  saliva  of  poisonous  snakes,  animals 
affected  with  rabies,  and  in  tetanus.  The  facts  in  our 
pHDSsession  substantiating  the  theor}'  of  auto-intoxica- 


6o6 


MEDICAL    RECORD. 


[October  23,  1897 


tion  were  still  few  in  number,  but  they  constituted  a 
firm  basis  for  experimentation.  Auto-intoxication 
consisted  in  a  poisoning  of  the  organism  with  the 
products  of  metabolism,  existing  normally  but  present 
in  excessive  quantity,  or  with  abnormal  toxic  sub- 
stances. The  latter  chiss  was  again  divided  into 
those  undergoing  further  modification  and  those  exist- 
ing in  the  body  only  in  minute  quantity.  In  the  gas- 
tro-intestinal  canal  the  nutriti\-e  constituents  under- 
went certain  changes  which  rendered  them  capable  of 
assimilation.  The  end  products  of  disassimilation 
were  for  the  most  part  simple  compounds,  such  as 
water,  the  inorganic  salts,  urea,  and  the  urinary  salts, 
but  the  intermediate  products  of  metabolism  were  far 
more  complex  in  nature  and  difficult  of  investigation. 
Under  pathological  conditions  they  accumulated  in . 
the  body  and  acted  as  auto- intoxicants.  Gautier  called 
these  intermediate  substances  "  leucomains,"  and  be- 
lieved them  to  be  the  cause  of  many  pathological  con- 
ditions. Disturbances  of  metabolism  resulting  in 
auto-intoxication  were  not  limited  to  the  albuminoids, 
but  were  due  to  the  accumulation  of  intermediary  prod- 
ucts of  the  fats  and  carbohydrates.  Under  normal 
conditions  it  was  claimed  there  always  existed  small 
quantities  of  certain  toxic  substances  formed  in  con- 
nection with  the  processes  of  metabolism,  but  under 
unnatural  conditions  these  poisonous  substances  might 
accumulate  in  the  system  in  such  quantity  as  to  give 
rise  to  auto-intoxication.  The  toxicants  circulating  in 
the  blood  acted  as  irritants  to  tlie  organs.  If  this  ir- 
ritation were  transitory,  the  intoxication  would  be 
acute;  if  the  disturbance  were  frequently  repeated,  it 
would  result  in  a  chronic  auto-intoxication.  It  was 
naturally  a  task  of  much  difficulty  to  prepare  a  clearly 
defined  classification  of  these  newly  born  poisons. 
Under  the  head  of  auto-intoxications  von  Jaksch,  Ro- 
bert, Schwalbe,  and  Bouchard  included  all  the  diseases 
the  result  of  a  contai^iiim  vh'iim — i.e.,  the  infectious  dis- 
eases; but,  although  our  present  knowledge  justified 
the  belief  that  most  of  the  symptoms  of  the  infectious 
diseases  were  produced  by  an  intoxication  with  the 
modified  products  of  metabolism,  it  should  be  remem- 
bered that  these  modifications  were  caused  by  micro- 
organisms. This  was  but  another  way  of  saying  that 
these  intoxicants  were  the  result  of  matters  introduced 
from  without — that  they  were  exogenous  poisons. 

The  author  then  took  up  briefly:  (i)  The  origin  or 
source' of  auto-intoxication;  (2)  the  conditions  govern- 
ing its  development;  and  (3)  its  manifestations  or 
symptomatology.  Under  the  first  head  were  mentioned 
auto-intoxications  arising  from:^r)  The  skin — as  tlie 
phenomena  following  severe  burns;  (2)  the  lungs — as 
carbonic-acid  poisoning;  (3)  the  kidneys — as  uramia 
and  eclampsia;  (4)  the  suprarenal  capsules — as  Addi- 
son's disease;  (5)  the  gastro-intestinal  canal  (includ- 
ing not  only  the  various  constitutional  disturbances 
consequent  upon  diseases  of  the  stomach  and  intes- 
tines, but  acute  yellow  atrophy  of  the  liver,  icterus 
gr.ivis,  cholajmia,  and  diabetes  mellitus);  and  (6)  the 
thyroid  gland — as  myxoedema,  cachexia  strumipriva, 
and  possibly  Basedow's  disease. 

.\s  to  the  conditions  governing  the  development  of 
auto-intoxication,  it  sliould  be  said  that  it  occurs  only 
when  secreting  or  excreting  organs  are  functionating 
improperly.  Individual  predisposition  was  an  impor- 
tant factor  in  the  causation  of  auto-intoxication,  and 
was  almost  certainly  a  neuropathic  one.  It  was  evi- 
dent that  if  this  individual  element  was  not  an  impor- 
tant etiological  factor,  auto-intoxications  would  be 
much  more  frequent. 

As  miglu  be  expected,  the  symptomatology  was  ex- 
tremely complex;  for,  although  a  single  organ  might 
be  at  fault,  the  resulting  disturbances  were  usually 
very  general  in  character,  .\side  from  the  ver)'  large 
number  of  auto-intoxications  referable  to  an  organ  or 


definite  part  of  the  body,  there  were  a  number — such 
as  chlorosis,  pernicious  anaemia,  leukeemia,  and  the 
various  cachexias — that  found  expression  only  in  a 
general  disturbance  of  the  metabolism. 

Asepsis  and  Antisepsis  in  Obstetrics,  from  the 
Standpoint  of  Present  Scientific  Knowledge. — Dr. 
Geor.k  Tucker  Harrison,  of  New  York,  read  this 
paper.  lis  said  that  in  the  whole  histor}'  of  medicine 
he  knew  ot  no  more  pathetic  story  than  that  of  the 
illustrious  Semmelweiss,  whose  memory  should  be 
cherished  and  revered  by  all  who  took  an  interest  in 
obstetrics  and  in  the  welfare  of  puerperal  women.  It 
was  left  for  this  great  man  to  make  the  first  grand  and 
successful  effort  to  reduce  the  appalling  mortality 
from  puerperal  fever.  The  first  clew  that  he  had  re- 
ceived was  at  an  autopsy  on  a  medical  man  who  had 
died  as  a  result  of  infection  from  a  dissection  wound. 
He  was  at  once  impressed  with  the  fact  that  the 
changes  in  the  blood  and  lymph  channels  bore  a  strik- 
ing resemblance  to  those  observed  in  post  mortems  on 
women  dying  of  puerperal  fever,  and  this  picture  pur- 
sued him  night  and  day  until  the  truth  dawned  upon 
him.  He  found  that,  in  the  division  of  the  hospital  in 
which  the  mortality  among  puerperal  women  was  so 
terrible,  it  was  the  custom  for  the  students  to  come  di- 
rectly from  the  post-mortem  room  to  the  obstetric 
wards.  The  order  accordingly  went  forth  that  all 
those  in  attendance  on  these  lying-in  women  should 
invariably  wash  the  hands  with  chlorine  water  before 
making  any  examinations.  The  good  effect  of  this 
innovation  was  immediate  and  remarkable,  the  mortal- 
ity being  greatly  diminished;  indeed,  at  the  present 
time  the  key  to  avoidance  of  this  dreadful  scourge  was 
found  in  careful  cleansing  and  antisepsis  of  the  hands, 
and  in  making  as  iew  examinations  as  possible.  The 
author  of  the  paper  said  that  he  wished  to  enter  a  most 
emphatic  protest  against  douching  and  scrubbing  the 
vagina  before  labor — a  practice  advocated  by  some 
obstetricians.  In  his  opinion  such  treatment  was  not 
only  unnecessary  but  pernicious,  if  for  no  other  reason 
than  that  it  removed  the  normal  protective  vaginal 
mucus  and  caused  abrasions  of  the  vaginal  mucous 
membrane.  The  dr)%  harsh  feeling  of  the  vagina 
after  a  bichloride  douche  was  an  indication  that  the 
use  of  antiseptics  might  even  sene  to  retard  and  ob- 
struct labor.  Only  the  external  genitals  should  be 
cleansed;  cleansing  of  the  internal  genital  organs 
should  be  entirely  omitted.  We  should  distinguish 
clinically  between  putrid  or  saprophytic  endometritis 
and  the  septic  variet}'.  In  the  former  a  granulation 
area  was  soon  formed  and  afforded  a  barrier  which  the 
bacteria  could  not  penetrate.  If  this  barrier  was 
broken  down  by  the  curette,  general  infection  might 
ensue.  He  believed  that  the  exaggerated  use  of  local 
therapeutics  was  responsible  for  many  deaths.  We 
had  no  means  of  ascertaining  with  certaint}'  when  the 
process  might  be  considered  to  be  localized.  He  had 
long  since  ceased  to  use  disinfectant  irrigations  before 
and  after  operative  procedures. 

Dr.  Eden  V.  Dklphy  asked  if  Dr.  Harrison  objected 
to  all  operative  measures  in  puerperal  sepsis. 

Dr.  Harrison  replied  that  his  doctrine  was  that 
local  therapeutic  measures  were  justifiable  only  when 
it  might  be  safely  assumed  that  the  septic  process  was 
localized  in  the  uterus.  If  it  was  not  thus  localized, 
there  could  be  no  sense  in  such  treatment. 

Dr.  Dei.phv  cited  the  case  of  a  puerperal  woman, 
who  had  had  a  rapid  pulse  and  a  temperature  of  105° 
F.  at  the  time  he  had  been  called.  On  curetting  the 
uterus,  foul  pus  had  escaped.  The  patient  was  in  col- 
lapse for  two  liours  after  the  operation,  but  eventually 
recovered.  He  had  operated  upon  other  severe  cases 
with  good  results.  It  was  true  that  there  had  been  too 
much  meddling  with  the  vagina,  both  before  and  dur- 
ing labor.     It  ought  to  suffice  for  the  physician  to  get 


October  23,  1897] 


MEDICAL    RFXORD. 


607 


himself  and  the  outside  of  his  patient  clean.  Of 
course  it  was  possible  that  auto-infection  might  occur 
from  an  old  pyosalpinx.  He  did  not  know  how  the 
physician  was  to  tell  whether  or  not  the  septic  process 
had  stopped  at  the  uterine  wall. 

Dr.  Harrison",  in  closing,  remarked  that  he  thought 
Dr.  Delphy  had  been  very  fortunate  in  the  case  he  had 
cited,  if  there  had  been  pus  in  the  uterus. 

Gyves   and  Trigs   (Bonds   and   Obstacles) Dr. 

H.  D.  Didama,  of  Syracuse,  read  a  paper  with  this 
quaint  title.  He  took  up  first  the  question  of  venesec- 
tion, and  showed  that  previous  to  1847  the  medical 
profession  had  been  held  in  the  "  gyves"  of  a  so-called 
experience,  and  that  the  leaders  and  authorities  had 
become  so  habituated  to  the  bonds  that  they  felt  no 
galling.  Only  forty  years  ago  it  was  still  the  opinion 
of  such  masters  as  the  great  Thomas  Watson  that  the 
value  of  phlebotomy  in  pneumonia  was  well  attested 
by  experience.  Nevertheless  the  treatment  was  not 
such  a  great  success  after  all,  for  the  statistics  of  one 
of  the  English  hospitals  were  published  about  that 
time,  and  they  showed  that  out  of  six  hundred  and 
forty-eight  patients  treated  by  venesection,  two  hundred 
and  twenty-two — or  more  than  one  in  three— died.  In 
1865  John  Hughes  Bennett  had  published  in  detail  the 
cases  treated  by  him  for  fifteen  years  in  the  University- 
Hospital  by  mild  supporting  treatment  without  vene- 
section. The  mortality  in  this  series  was  one  in  forty, 
and  in  the  simple  uncomplicated  cases  scarcely  one  in 
one  thousand.  In  i860  our  own  Flint  had  given  utter- 
ance to  the  opinion  that  experience  and  pathological 
knowledge  showed  that  general  blood-letting  did  not 
exert  a  direct  controlling  effect  on  an  inflammatory 
disease. 

The  remainder  of  the  paper  was  devoted  to  a  con- 
sideration of  the  place  alcohol  should" hold  in  rational 
medicine.  The  author  quoted  from  various  sources  to 
show  the  inconsistencies  and  absurdities  of  teaching 
of  which  medical  observers  were  guiltj'  in  connection 
with  the  use  of  alcoholics  in  the  treatment  of  disease. 
Thus,  on  the  one  hand,  there  were  those  who  thought 
alcohol  was  a  depressant  rather  than  a  stimulant,  that 
it  was  not  a  food,  that  it  did  not  promote  but  on  the 
contrary  retarded  digestion,  and  that  it  was  the  cause 
of  many  diseased  conditions.  On  the  other  hand,  the 
great  majority  of  the  teachers  of  medicine  continued 
to  advocate  alcohol  as  the  best  of  all  stimulants,  and 
appealed  to  the  experience  of  the  wise  and  illustrious 
physicians,  extending  back  to  the  dawn  of  history,  as 
ample  justification  of  their  practice.  How  many  had 
laid  aside  all  prejudice,  and  had  actually  tested  in  a 
dispassionate  and  scientific  manner  the  non-alcoholic 
treatment  of  disease?  History  was  prone  to  repeat 
itself,  and  the  end  of  venesection  should  be  remem- 
bered. Dr.  Didama  then  read  a  list  of  names  of  emi- 
nent members  of  the  medical  profession  who  indorsed 
the  non-alcoholic  treatment  of  disease,  after  a  double 
experience — an  ancient  and  a  modem  one — and  closed 
with  an  earnest  plea  for  the  more  general  adoption  of 
these  views. 

The   Modern  Treatment   of   Yellow  Fever Dr. 

A.  M.  pERNANnE/i  DE  Ybarra,  of  New  York,  read  this 
paf)er.  He  said  that  the  best  practice  consisted  in 
giving  at  the  outset  of  yellow  fever  a  cathartic,  a  full 
dose  of  castor  oil  being  preferred  to  mercurials  or  sa- 
lines. Quinine  acted  badly,  and  for  the  control  of  the 
fever  it  was  much  better  to  use  moderate  doses  of 
aconite  or  digitalis.  Jaborandi  was  used  by  some 
physicians,  and  it  acted  beneficially  in  a  double  way 
— I.e.,  it  promoted  perspiration  and  relieved  the  con- 
gestion of  the  kidneys.  Under  no  circumstances 
should  opium  be  used  in  any  form ;  it  was  extremely 
dangerous,  owing  to  its  effect  upon  the  heart  and  kid- 
neys. Care  should  be  taken  that  the  surface  of  the 
body  was  not  suddenly  chilled,  as  this  would  increase 


the  visceral  congestion.     As  a  rule,   alcoholics  were 
not  well  borne,  unless  it  might  be  iced  champagne. 

Committee  on  Hospital  and  Dispensary  Abuses. 
— The  following  were  appointed  on  this  committee: 
Drs.  F.  H.  Wiggin,  S.  B.  W.  McLeod,  and  Parker 
Syms,  of  New  York;  Dr.  A.  A.  Hubbell,  of  Buffalo; 
and  Dr.  E.  D.  Ferguson,  of  Troy. 

(.To  ie  Continued.) 


MISSISSIPPI    VALLEY    MEDICAL     ASSOCIA- 
TION. 

T'cventy-Third  Aimual Meeting,  Held  in  Louisville,  Ky., 
October  2,  6,  7,  and  8,  i8gj. 

The  association  was  called  to  order  by  Dr.  Horace 
H.  Grant,  chairman  of  the  committee  of  arrange- 
ments. Prayer  was  offered  by  the  Rev.  E.  L.  Powell, 
after  which  an  eloquent  address  of  welcome  was  de- 
livered by  Governor  Bradley.  Dr.  William  Bailey 
followed  with  an  address  on  behalf  of  the  local  pro- 
fession. 

The  president.  Dr.  Thomas  H.  Stvcky,  of  Louis- 
ville, then  delivered  his  address,  in  which  he  summa- 
rized the  splendid  work  that  had  been  done  by  the 
association. 

Drs.  Love  and  Wheaton  offered  resolutions 
against  the  present  quarantining  of  Louisville  by  the 
State  of  Indiana. 


SURGICAL   SECTION'. 

Cases  in  Ophthalmic  Surgery.— The  first  paper 
read  before  this  section  was  by  Dr.  J.  M.  Ball,  of  St. 
Louis,  entitled  '"  Report  of  Some  Cases  of  Ophthalmic 
Surger)-."  The  author  reported  several  cases  of  injury 
to  the  eye  in  which  the  proper  surgical  treatment 
proved  satisfactory.  One  case  of  interest  was  a  pseudo- 
glioma  removed  by  enucleation.  The  specimen  was 
exhibited.  Another  was  the  case  of  a  man,  sixty  years 
of  age,  who  had  been  given  sixty  grains  of  quinine 
within  twelve  hours,  in  whom  the  next  morning  there 
was  total  blindness.  A  diagnosis  of  quinine  amau- 
rosis was  made. 

Dr.  Wheelock.  inquired  if  there  could  not  possibly 
be  a  syphilitic  infection  in  the  case  of  amaurosis  re- 
ported, to  which  the  author  replied  that  such  a  possi- 
bility had  been  eliminated  from  the  diagnosis. 

Plastic  Operation  for  Restoring  Closed  Lids. — Dr. 
K.  K.  Wheelock,  of  Fort  Wayne,  contributed  a  paper 
with  this  title.  He  reported  a  case  in  which  an  eye 
had  been  enucleated  in  188 1  in  consequence  of  small- 
pox. An  artificial  eye  had  been  worn  for  twelve  years, 
when  the  socket  had  become  so  contracted  that  it  was 
impossible  longer  to  introduce  the  artificial  eye.  The 
technique  of  the  operation  for  the  restoration  of  the 
cavity  to  its  normal  size  was  described. 

Dr.  Stephenson  said  that  these  were  always  inter- 
esting cases.  Those  occurring  as  the  result  of  bums 
usually  gave  the  most  trouble  in  fitting  an  artificial 
eye.  Much  could  be  done  oftentimes  by  any  method 
which  would  gradually  stretch  the  tissues. 

Dr.  Wilder  said  that  there  was  no  more  difficult 
class  of  work  in  ophthalmic  surgery.  The  general  sur- 
geon should  appreciate  the  necessity  of  preserving  as 
much  of  the  conjunctiva  as  possible.  Most  patients 
wanted  to  wear  an  artificial  eye  too  soon  after  enuclea- 
tion. 

Dr.  Wheelock,  in  closing,  remarked  that  if  he  had 
a  similar  case  to  deal  with  he  would  operate  entirely 
with  the  Thiersch  grafts.  These  should  be  applied 
from  the  tip  of  the  finger,  so  as  to  be  adapted  to  any 
part  of  the  orbit. 

The  Removal  of  Adenoids  from  the  Vault  of  the 
Pharynx. — This  paper  was  read  by  Dr.  L.  C.  Kline, 


6o8 


MEDICAL    RECORD. 


[October  23,  1897 


of  Indianapolis.  The  author  stated  that  there  was 
a  great  diversity  of  opinion  regarding  the  use  of 
anasthetics  for  the  removal  of  adenoids.  The  majority 
of  patients  could  be  operated  upon  with  equally  good 
results  by  the  use  of  cocaine.  The  author  preferred 
the  gradual  operation  to  that  done  at  one  sitting,  for 
the  reason  that  there  was  less  danger  of  otitis  and 
hemorrhage.  A  forceps  which  the  author  uses  was 
exhibited.  When  an  anajsthetic  is  employed  a  mouth 
gag  is  used.  In  tuberculous  cases  the  application  of 
ichthyol  was  very  beneficial.  Various  astringents 
could  be  used  with  advantage,  but  surgery  was  the  only 
sure  relief. 

Surgery  of  the  Air  Passages  in  Children.— Dr. 
J.  Homer  Coulter,  of  Chicago,  followed  with  this 
paper.  He  considered  the  subject  one  of  great  import- 
ance, because  of  the  high  percentage  of  deaths  from 
diseases  of  the  air  passages  during  childhood,  be- 
cause the  respiratory  and  circulatory  functions  were 
being  crowded  to  their  vital  capacity,  and  because  re- 
flexes in  childhood  were  more  prominent  and  frequent 
than  in  adult  life.  The  parents  of  to-day  should  be 
taught  that,  with  our  modem  methods,  technique,  and 
usually  favorable  prognosis,  surgery  in  children  was 
not  the  nightmare  it  formerly  was.  There  was  no 
longer  any  question  of  the  bad  effect  of  nasal  obstruc- 
tion upon  adjacent  organs.  Any  of  the  causes  of  na- 
sal obstruction  in  children  would  tend  to  septum  de- 
flection in  adult  life,  and  if  for  no  other  reason  the 
physician  was  bound  to  give  them  possible  relief. 
Catarrhal  deafness  was  almost  always  due  to  nasal  ob- 
struction. The  entire  field  for  pathological  condi- 
tions of  the  nose  did  not  lie  in  the  postnasal  space, 
nor  was  there  any  good  reason  why  occlusion  of  the 
anterior  chambers  of  the  nose  should  not  produce  as 
many  reflexes  as  does  hypertrophy  of  Luschka's  tonsil. 
Foreign  bodies  in  the  nose  and  throat  and  the  method 
of  their  removal  were  then  considered.  The  after- 
treatment  was  important,  and  could  not  often  be  left 
to  parents  with  any  degree  of  satisfaction. 

Dr.  Crile  said  that  in  all  cases  of  surgery  of  the 
air  passages  an  important  point  was  the  considera- 
tion of  the  "arrest  area."  Ordinarily  the  physician 
should  not  perform  a  cricothyrotomy  unless  it  was 
necessary. 

Dr.  Thomas  suggested  that  many  diseases  of  the  air 
passages  in  children  were  due  to  a  systemic  disturb- 
ance or  to  reflexes.  Judgment  to  differentiate  when 
to  use  surgery  and  when  therapeutics,  was  absolutely 
essential. 

Treatment  of  Wounds  by  the  Open  Method.— A 
paper  on  this  subject  was  read  by  Dr.  J.  B.  Taulbee, 
of  Mount  Sterling,  Ky.  Our  present  methods  of  treat- 
ing amputations  were  different  from  those  of  a  quarter 
of  a  century  ago.  A  routine  method  was  never  a  good 
one;  hence  each  individual  case  was  a  law  unto  itself, 
both  as  to  irrigation  and  the  kind  of  drainage,  and 
as  to  whether  or  not  temporary  drainage  should  be 
instituted. 

Dr.  Ochsner  said  that  the  least  irritation  to  the  tis- 
sues in  abdominal  wounds  should  always  be  observed. 
Large  wounds  would  always  heal  primarily  if  there 
were  lack  of  irritation  of  the  tissues,  exact  coaptation, 
and  the  stitches  were  not  drawn  too  tightly.  The 
number  of  infected  wounds  in  herniotomy  was  greater 
than  in  laparotomy,  because  the  tissues  were  more 
greatly  dama';ed. 

Dr.  Lawrknce  said  that  it  was  more  reasonable  to 
suppose  a  wound  would  be  healthy  if  drainage  was  free. 
A  properly  cleansed  private  room  at  home  with  a  good 
nurse  was  better  than  any  general  hospital.  Silver- 
wire  buried  sutures  would  produce  both  sinuses  and 
atrophy  of  the  nuiscles. 

Dr.  Goldsi'ohn  stated  that  the  only  microbes  that 
had  indefinite  life  were  those  of  the  bacillus  of  tuber- 


culosis and  the  gonococcus.     Primarily  aseptic  wounds 
should  be  treated  as  such  and  not  as  open  wounds. 

Dr.  Dunn  said  that  when  we  did  not  have  germs 
we  could  not  have  pus.  In  over  two  thousand  abdom- 
inal sections  which  he  had  seen  there  had  been  no 
failure  to  secure  primary  union,  and  a  stitch-hole  ab- 
scess developed  in  only  one  case. 

To  Drain  or  Not  to  Drain — Dr.  Arch.  Dixon,  of 
Henderson,  Ky.,  read  this  paper.  For  some  time  past 
drainage  after  abdominal  section  had  been  growing 
less  and  less  in  favor.  There  were  wounds  which  re- 
quired drainage,  and  others  which  did  not.  Aseptic 
wounds  did  not  require  it,  but  contaminated  or  in- 
fected wounds  did.  The  author  reviewed  the  argu- 
ments against  the  use  of  drainage  in  the  peritoneal 
cavity.  Drainage  was  not  effective  in  removing  in- 
fection; infection  might  occur  through  the  drainage 
tube.  The  removal  of  the  tube  was  painful,  bladder 
complications  were  possible,  hernia  might  result,  and 
frequent  removal  of  the  tube  was  necessary. 

Dr  Goldspohn  called  attention  to  the  two  methods 
of  abdominal  operations — one  in  which  the  smallest 
possible  opening  was  made,  and  the  other  in  which  a 
large  wound  was  made.  He  pointed  out  the  advan- 
tages claimed  for  each  method  of  operating. 

Dr.  Cordier  said  that  if  two  cases  exactly  alike 
were  taken,  and  the  operation,  surroundings,  and  care 
of  each  be  identical,  one  drained  and  the  other  not,  we 
would  almost  invariably  obtain  more  satisfactory  re- 
sults in  the  case  in  which  drainage  was  employed. 

Hysterectomy Dr.  F.  F.  Lawrence,  of  Colum- 
bus, read  a  paper  with  this  title.  In  what  cases  is 
hysterectomy  justifiable?  We  must  consider:  (1) 
How  many  would  have  died  without  it;  (2)  who  many 
would  have  been  hopeless  invalids  without  it;  (3)  how 
many  could  have  been  cured  by  other  means;  and  (4) 
the  remote  conditions  or  reflex  results  in  those  upon 
whom  the  operation  has  been  performed.  Hysterec- 
tomy was  ordinarily  performed  for  cancer,  pyosalpinx, 
fibroma  and  myoma,  tuberculosis,  and  prolapsus. 
Hysterectomy  for  cancer  was  of  doubtful  utility,  but 
when  necessary  should  be  done  by  the  abdominal  route. 
In  the  case  of  pus  tubes  the  operation  should  be  limited 
to  those  in  which  the  walls  of  the  uterus  were  the  seat 
of  the  disease.  Simple  adhesions  were  not  sufficient 
grounds  for  the  performance  of  this  operation.  Small 
fibroids  involving  the  lower  segment  of  the  uterus  only 
should  be  treated  tentatively.  If  the  small  fibroids  were 
in  the  body  of  the  uterus,  they  should  be  treated  either 
by  curetting,  by  removal  of  the  tubes  and  ovaries,  or  by 
hysterectomy,  as  the  case  demanded.  If  small  fibroids 
occurred  near  the  menopause,  curettage  with  elec- 
tricity was  sufficient.  For  enlarged  fibroids  after  the 
menopause,  hysterectomy  was  the  only  thing  to  be 
considered.  In  myoma  or  tuberculosis,  this  opera- 
tion was  likewise  the  only  thing  to  be  resorted  to.  Hy 
removing  the  ovaries  and  tubes,  all  of  the  diseased 
tissue  was  not  taken  away.  Any  method  of  operating 
was  to  be  judged  by  the  safety  from  complications,  by 
the  preservation  of'a  firm  pelvic  floor,  by  the  facility 
of  operating,  and  as  it  afforded  the  best  satisfaction 
and  general  results  to  both  patient  and  operator. 

Dr.  Goldspohn  opposed  the  removal  of  the  uterus 
for  septic  disease  alone  in  every  case.  The  vaginal 
route  should  be  more  appreciated  by  American  opera- 
tors. 

Dr.  Ochsner  said  that  while  his  experience  with 
hysterectomy  had  been  favorable,  yet  he  was  becoming 
more  and  more  cautious  about  advising  its  perform- 
ance. In  one  case  he  advised  the  ovieration,  as  he 
considered  the  case  beyond  the  help  of  even  this  oper- 
ation. The  woman  was  treated  tentatively,  had  since 
given  birth  to  two  children,  and  was  now  healthy. 

Dr.  Newman  said  th.it  better  results  would  follow] 
a  perfected  technique. 


October  23.  1897] 


MEDICAL    RECORD. 


609 


Pelvic  Disease  without  Local  Symptoms This 

paper  was  read  by  Dr.  Hexkv  P.  Xewmax,  of  Chica- 
go. The  speaker  said  that  pelvic  disease  of  an  aggra- 
vated t\pe  was  often  present  without  noticeable  local 
symptoms;  that  reflex  symptoms  began  in  mere  func- 
tional disturbance,  and  might  become  so  serious  as  to 
endanger  the  life  and  health  of  the  patient,  and  give  rise 
to  misdirected  treatment  which  did  not  recognize  the 
causes  of  the  real  trouble.  It  was  necessary  to  under- 
stand the  relative  importance  of  pelvic  irritation,  and  of 
certain  obstinate  and  severe  affections  of  more  distant 
organs.  This  was  very  essential  to  a  correct  diagno- 
sis in  many  cases.  In  all  cases  of  chronic  invalidism 
in  the  female,  failure  to  exclude  pelvic  disease,  in  the 
same  manner  as  we  excluded  diseases  of  the  other 
important  organs,  was  unscientific  and  reprehensible. 
The  cause  of  medicine  would  be  advanced  when  prac- 
titioners made  comprehensive  diagnoses. 

The  Diagnosis  of  Surgical  Diseases  of  the  Kid- 
neys, Bladder,  and  Prostate. — Dr.  Bayard  Holmes, 
of  Chicago,  contributed  this  paper.  The  author  called 
attention  to  some  methods  of  diagnosis  of  special 
value,  and  related  at  length  his  experience  in  their 
application,  demonstrating  by  means  of  the  Kasper 
cystoscope  his  method  of  catheterizing  the  ureters. 
He  further  demonstrated  that  the  kidney  could  be 
exactly  localized  by  auscultatory  percussion. 

Diagnosis  by  Inspection  of  the  Urinary  Tract 

Dr.  Joseph  R.  Eastmax,  of  Indianapolis,  read  this 
paper.  The  use  of  the  cystoscope  was  particularly 
important  in  the  male.  Its  value  in  diagnosticating 
vesical  calculus,  foreign  bodies,  neoplasms,  and  patho- 
logical conditions  resulting  from  gonorrhoea,  locating 
fragments  after  litholapaxy,  etc.,  was  verj-  apparent. 
In  the  female  its  range  of  usefulness  was  still  wider 
and  its  application  more  simple.  The  author  de- 
scribed and  demonstrated  in  a  clear  manner  the  diffi- 
culties and  technique  of  catheterization  of  the  ureters. 

Dr.  Cordier  said  he  had  recently  made  some  ex- 
periments with  the  .v-rays  in  bladder  work.  He  had. 
by  placing  a  small  photographic  plate  in  the  vagina  and 
the  tube  above  the  abdomen,  secured  very  excellent 
photographs.  In  the  male  the  plate  could  be  placed 
in  the  rectum  and  similar  results  secured.  Foreign 
bodies  or  calculi  could  thus  be  positively  detected. 

Primary  Tuberculosis  of  the  Rectum,  with  Re- 
port of  Cases Dr.  Leox  Straus,  of  St.  Louis,  read 

a  paper  on  this  subject.  Tuberculosis  of  the  rectum 
was  a  surgical  disease.  A  thorough  microscopical 
examination  must  be  made  in  everj-  case  of  suspected 
ulceration.  The  author  reported  four  cases  of  removal 
of  the  ulcerated  rectal  tissue  and  described  his  opera- 
tion. Recovery  followed  in  all  of  the  cases  but  one. 
His  conclusions  were  that:  (i)  Primary  tuberculosis 
of  the  rectum  is  not  so  infrequent  as  is  generally  sup- 
posed. (2)  It  is  surgical.  (3)  It  cannot  be  diagnos- 
ticated positively  and  invariably  by  the  usual  clinical 
symptoms;  the  microscope  must  be  employed.  (4) 
Local  treatment  will  not  cure  these  cases;  they  can 
be  cured  only  by  thorough  curettage  or  by  e.xcision, 
or  by  both.  (5)  Some  of  the  most  hopeless  cases  are 
cured  by  repeated  operations.  (6)  All  suspicious  cases 
should  be  subjected  to  the  microscope.  (7)  ^^'e  have 
sufficient  evidence  that  the  cases  reported  are  cured. 

Diseases  of  Rectum  and  Sigmoid  as  a  Factor  in 
General  Disturbances. — Dr.  J.  R.  Pennixgtox,  of 
Chicago,  read  this  paper.  Undoubtedly  various  au- 
thorities are  agreed  that  the  maferies  morbi  of  a  large 
number  of  somatic,  mental,  and  nervous  diseases  have 
their  origin  somewhere  in  the  gastro-intestinal  tract. 
At  just  what  point  in  the  canal  is  a  mooted  question. 
The  importance  of  the  rectum  and  sigmoid  in  many 
auto-intoxications  is  entirely  overlooked  and  the  con- 
sequent primal  defect  not  located. 

Treatment   of    Hernia   in   Old   Men Dr.  A.   J. 


Ochsxer,  of  Chicago,  read  the  paper.  It  was  a  well- 
known  fact  that  hernias  in  men  become  more  trouble- 
some after  the  age  of  fifty,  due  to  relaxation  of  tissue, 
a  tendency  to  obesity,  and  lowered  vitality  in  general, 
according  to  most  authorities;  but  the  author  was  con- 
vinced that  the  more  important  cause  was  the  pres- 
sure exerted  in  evacuating  the  bladder  and  rectimi,  or 
the  presence  of  an  enlarged  prostate.  The  authqf 
described  his  operation  for  the  radical  cure  of  hernia 
in  connection  with  castration  for  enlarged  prostate. 
In  cases  in  which  there  was  simply  hypertrophy,  the 
gland  subsequently  decreased  in  size  very  rapidlj', 
affording  much  relief.  If  the  surgeon  had  f>erfect  con- 
trol of  his  methods,  securing  perfect  asepsis,  the  oper- 
ation was  perfectly  safe.  It  relieves  the  patient  of 
much  discomfort,  and  every  argument  in  favor  of  oper- 
ation for  the  radical  cure  of  hernia  was  applicable  to 
the  operation  for  resection  of  the  spermatic  cord  for 
the  relief  of  conditions  due  to  enlargement  of  the 
prostate  gland.  It  was  as  yet  too  early  positively  to 
determine  v/hether  or  not  the  favorable  results  obtained 
by  the  author  in  his  cases  would  be  permanent,  but  he 
had  every  reason  to  believe  that  they  would. 

Postoperative  Hernia  in  Appendicitis. — Dr.  Rob- 
ert T.  Morris,  of  New  York,  read  a  paper  on  this 
subject.  Operators  for  appendicitis  were  now  using 
a  much  smaller  incision  than  formerly,  in  order  to 
avoid  the  unfortunate  effects  of  a  hernia.  These  her- 
nias were  caused  by  the  fact  that  the  lines  of  muscle 
traction  at  this  point  were  different  in  different  mus- 
cles. A  pad  over  the  seat  of  operation  induced  hernia 
by  bringing  on  absorption  of  the  new  connective  tissue 
as  it  was  being  formed.  The  margin  of  each  muscle 
should  be  separated  with  the  greatest  care  in  operat- 
ing; care  should  likewise  betaken  in  dividing  the 
peritoneum.  In  closing  the  wound  each  different 
layer  of  muscular  tissue,  as  well  as  the  peritoneum  and 
fascia,  should  be  united  with  the  same  tissue  from 
which  it  was  separated  at  the  beginning,  so  that  the 
lines  of  muscular  traction  would  not  be  disturbed,  and 
hernia  was  not  so  likely  to  be  produced.  No  bandage 
or  pad  should  be  applied.  The  patient  should  be  kept 
in  bed  for  at  least  twenty-one  days  following  the 
operation. 

Dr.  John  Young  Browx,  of  St.  Louis,  made  some 
remarks  on  appendicitis,  in  which  he  said  conserva- 
tism had  given  place  to  knowledge  in  this  disease. 
This  knowledge  was  sufficiently  comprehensive  and 
accurate  to  afford  a  satisfactor\-  working  basis.  Infec- 
tious appendicitis  should  be  isolated,  for  the  same 
reason  that  a  case  of  diphtheria  was  isolated. 

Dr.  Morris,  of  New  York,  said  that  making  a  date 
to  operate  in  a  case  of  appendicitis  was  certainly  un- 
desirable. The  surgeon  could  not  always  wait  until 
the  third  day.  Rigor  meant  that  toxins  were  entering 
the  circulation  and  producing  an  impression  upon  the 
sympathetic  system. 

Tuberculin  in  Dermatology  was  the  title  of  a  paper 
by  Dr.  .\.  Ravogli,  of  Cincinnati,  in  which  the  author 
drew  the  following  conclusions:  i.  Tuberculin  is  a 
valuable  aid  in  dermatology,  both  as  a  diagnostic  and 
therapeutic  measure.  2.  In  lupus  it  acts  remarkably 
well  as  a  S)'stemic  treatment,  particularly  in  conjunc- 
tion with  other  means  for  the  purpose  of  reducing 
infiltrations.  3.  After  a  large  number  of  injections 
he  has  never  had  any  bad  effects.  4.  Old  tuberculin 
has  given  him  more  marked  reaction,  both  general  and 
local,  than  the  new.  5.  In  cases  in  which  ordinary 
remedy  had  an  influence,  tuberculin  promptly  caused  a 
disappearance  of  the  eruption,  healing  of  the  ulcera- 
tions, and  a  general  improvement  in^the  condition.  6.  If 
relapses  occur  after  the  use  of  the  remedy  has  been  dis- 
continued, we  are  not  justified  in  blaming  the  remedy 
therefor.  7.  To  insure  recover}-,  tuberculin  must  be 
used  in  small  doses  for  a  long  time  at  short  intervals. 


6io 


MEDICAL    RECORD. 


[October,  23  1897 


Mothers  and  Daughters. — Dr.  B.  Sherwood  Dunx, 
of  Boston,  read  a  paper  with  this  title,  in  which  he 
stated  that  higher  education,  according  to  many  au- 
thorities, was  detrimental  to  motherhood.  He  pointed 
out  some  of  the  fundamental  errors  in  modern  educa- 
tion and  the  training  of  girls,  showing  that  although 
on  the  care  of  our  children  depended  their  lives,  their 
msral  welfare  or  ruin,  yet  in  our  modern  system  of 
education  not  a  word  of  instruction  relative  to  the 
treatment  of  offspring  was  ever  given  to  those  who 
would  become  parents.  He  considered  at  length  the 
necessity  of  more  careful  physical  training  of  girls. 
Labor,  exercise,  and  food  were  considered  important 
elements  in  their  training,  and  above  all  they  should 
have  a  proper  knowledge  of  the  physiological  func- 
tions peculiar  to  their  sex.  Parents  must  decide  them- 
selves as  to  how  these  important  points  should  be 
taught. 

Dr.  Joseph  Eichberg,  of  Cincinnati,  read  a  paper 
descriptive  of  cases  of  typhoid  fever  treated  with  cold 
baths. 

Further  Observations  in  the  Use  of  Hydrogen 
Dioxide  in  the  Treatment  of  Blepharitis  Marginalis. 
— This  was  the  title  of  a  paper  by  Dr.  S.  C.  Avres, 
of  Cincinnati.  This  disease  unchecked  produces 
gradual  destruction  and  atrophy  of  the  hair  bulbs  from 
ulceration.  Mercurial  ointments  have  long  been  used, 
and  are  well  adapted  to  some  cases  but  irritating  to 
others.  An  alkaline  wash  is  very  beneficial  in  soften- 
ing the  crusts,  but  in  hydrogen  dio.xide  the  author 
thinks  .we  have  a  remedy  which  both  softens  and  dis- 
solves. After  using  the  remedy,  with  a  dressing  probe 
or  scoop  the  crusts  can  be  lifted  off.  The  dioxides 
will  always  be  a  valuable  adjunct  to  other  rational 
measures  in  the  treatment  of  this  disease. 

Dr.  Max  Thorner,  of  Cincinnati,  said  he  had  used 
this  remedy  extensively  and  had  seen  the  results  from 
its  use  in  Dr.  Ayres'  hands,  and  almost  invariably  he 
had  most  satisfactory  results.  However,  in  recent 
years  the  remedy  had  fallen  into  disuse. 

Chronically  Diseased  Tonsils Dr.  H.  W.  Whit- 

t.\ker,  of  Columbus,  read  a  paper  on  this  subject. 
Seriously  diseased  tonsils  are  frequently  underesti- 
mated in  importance  and  left  untreated,  when  they 
are  undoubtedly  very  injurious  to  general  health. 
In  chronic  disease  of  the  tonsils  there  may  be  either 
hypertrophy,  hyperplasia,  or  atrophy.  Hypertrophy 
of  the  tonsil  is  found  in  the  child;  hyperplasia  in  the 
adult.  The  causes  which  induce  chronic  tonsillitis 
may  be  predisposing  or  exciting.  Among  the  former 
the  most  important  is  heredity;  among  the  latter 
are  diphtheria,  scarlet  fever,  and  the  exanthemata. 
The  author  gave  a  comprehensive  description  of 
the  symptoms  usually  present.  Prognosis  is  good, 
providing  excision  is  properly  performed.  The  voice 
is  vastly  improved  both  in  tone  and  quality  after 
excision  of  the  tonsils,  and  no  deleterious  sexual 
changes  or  perversion  will  ensue.  In  the  treatment 
it  is  necessary  to  consider  the  hygienic,  prophylactic, 
local,  constitutional,  and  surgical  measures.  The  de- 
tails of  each  were  noticed  and  thoroughness  was  in- 
sisted upon. 

Hypertrophied  Faucial  Tonsils Dr.  J-  F.  Barn- 
hill,  of  Indianapolis,  followed  with  this  paper.  It 
was  strange  that  tlie  laity  still  had  absurd  notions 
relative  to  the  functions  of  the  various  tonsils.  The 
system  suffered  little  or  nothing  from  ablation  of  nor- 
mal glands.  The  author's  classification  of  cases  was: 
(i)  those  in  which  the  patient  claims  never  to  have 
suffered  inconvenience  from  the  tonsils;  (2)  those  in 
which  there  is  quinsy  or  tonsillitis  one  or  more  times 
a  year;  (3)  a  small,  flat,  yet  pathological  gland.  In 
all  cases  the  diseased  ciypts  should  be  cleared  out. 
The  patient  was  a  most  valuable  assistant.  The  bad 
results  of  pathological  tonsils  were  enumerated,  and 


they  were  stated  to  be  a  cause  of  reflex  neiuroses  and 
to  act  as  obstructive  bodies,  as  absorbents,  and  as 
auto-infectious  bodies.  Various  methods  of  treatment 
and  removal  of  the  tonsils  were  considered,  and  the 
merits  of  each  were  pointed  out. 

Insanity  of  Adolescence. — Dr.  Frank  P.  Noreury, 
of  Jacksonville,  read  a  paper  on  this  subject,  in  which 
he  drew  the  following  conclusions:  (1)  Adolescent  in- 
sanity is  a  pure  psychosis,  dependent  upon  hereditary 
factors  and  acquired  conditions  which  especially  in- 
hibit the  higher  psychical  centres  and  later  the  sen- 
sor)' motor  functions  of  the  cortex.  (2)  The  vaso- 
motor and  trophic  centres  are  involved  in  it.  (3)  The 
sympathetic  nen'ous  function  is  disturbed,  from  which 
it  is  apt  eventually  to  lead  in  the  female  to  suppressed 
menstruation,  or  even  excitation,  producing  nympho- 
mania. (4)  Masturbation  is  a  complication  which  in 
the  male  is  apt  to  cause  reflexes.  (5)  There  is  no 
period  in  life  more  important  than  adolescence. 

The  Treatment  of  Cerebro-Spinal  Syphilis.— Dr. 
A.  E.  Sterne,  of  Indianapolis,  read  the  paper.  In 
the  treatment  of  syphilis  of  the  brain  and  cord,  the 
ordinary  therapy  is  wholly  inadequate,  if  not  entirely 
wrong.  The  dose  is  too  small ;  the  potassium  salt  is 
inferior  to  the  sodium  salt,  particularly  in  large  doses. 
The  syphilitic  lesions  of  the  brain  and  cord  may  in- 
volve the  meninges,  the  brain  and  cord  tissues  vilh 
gumma  formation,  the  bony  parts,  and  the  blood  ves- 
sels. The  author  drew  attention  to  three  important 
points  in  diagnosis  and  therapy :  First,  in  producing 
the  reflex  with  the  percussion  hammer  there  occurs  at 
the  moment  of  the  hammer  blow  a  second  prolonged 
contraction  across  the  muscle.  Second,  the  iridic  re- 
flex to  light  is  sometimes  difficult  to  determine  and  is 
not  always  present.  The  third  point  is  wholly  prcg- 
nostic  in  value,  and  relates  to  capillary  pulsation ; 
when  this  .occurs,  it  indicates  high  arterial  tension 
and  serves  as  a  guide  in  the  use  of  heart  stimulants. 

The  Motor  Neuron  in  Practical  Diagnosis  was 
the  title  of  a  paper  by  Dr.  High  T.  Patrick,  of  Chi- 
cago. The  author  made  a  concise  statement  of  the 
more  practical  relations  of  tlie  neurons  of  the  motor 
tract.  A  neuron,  as  he  explained,  is  simply  a  nerve 
unit,  and  the  motor  tract  is  made  up  entirely  of  two 
distinct  sets  of  neurons,  an  upper  and  lower.  A  le- 
sion of  either  set  causes  paralysis,  but  the  customary 
accompanying  symptoms  are  radically  different  in  the 
different  groups.  The  rationale  of  these  differences 
was  briefly  pointed  out,  and  it  was  explained  that 
in  a  lesion  of  the  upper  neurons  the  paralysis  is  spas- 
tic, accompanied  by  increased  deep  reflexes,  no  atro- 
phy, and  no  change  in  electrical  reactions.  On  the 
other  hand,  in  a  lesion  of  the  lower  neurons,  the  ac- 
companying and  distinctive  signs  are  flaccidity,  loss 
of  deep  reflexes,  atrophy,  and  reaction  of  degenera- 
tion. It  was  further  stated  that  it  makes  no  difference 
whatever  which  part  of  the  neuron  is  affected,  the  re- 
sult in  all  respects  being  exactly  the  same. 

Tobacco  Neuroses. ^Dr.  Zenker,  of  Cincinnati, 
read  a  paper  on  this  subject.  In  very  many  instances 
tobacco  is  only  one  of  the  many  causes  of  the  exist- 
ing malady.  Among  the  other  factors  often  conjoined 
with  tobacco  and  which  make  the  diagnosis  more  diffi- 
cult, are  alcohol,  coffee,  mental  strain,  worry,  etc. 
Syphilis  also  often  plays  an  important  part.  The  neu- 
roses traced  to  tobacco  are  functional  diseases  of  the 
heart,  amblyopia,  tremor,  \ertigo,  neurasthenia,  some 
forms  of  neuralgia,  rarely  angina,  and  tlie  lesser  ner- 
vous disturbances,  epilepsy,  and  various  psychoses; 
even  paresis  has  been  attributed  to  it,  although  with- 
out sufficient  reason  in  every  case.  The  treatment  is 
entire  abstinence  from  the  use  of  the  weed.  The  mere 
lessening  of  the  amount  usually  fails  altogether.  Fre- 
quentlv  entire  abstinence  for  a  year  or  more  permits  a 
return  to  the  use  of  tobacco  in  moderation  without  harm. 


October  23,  1897] 


MEDICAL    RECORD. 


611 


Penetrability  of  Vaporized  Medicaments  in  Air 
Passages. — A  very  instructive  and  exhaustive  paper 
was  read  by  Dr.  Homer  M.  Thomas,  of  Chicago,  en- 
titled '■  Experimental  Work  on  the  Penetrability  of 
Vaporized  Medicaments  in  the  Air  Passages."  Do 
vapors  enter  the  alveoli  of  the  lungs?  All  obser\'ers 
thus  far  have  questioned  such  a  possibility.  The 
greatest  difficulty  has  been  in  the  mechanism  of  the 
instruments  for  vaporization,  in  that  they  have  failed 
to  break  up  the  oil  in  sufficiently  fine  particles  for  it 
to  enter  the  alveoli.  The  author  related  in  detail  the 
results  of  his  experiments,  mostly  on  animals,  during 
the  past  two  years,  and  gave  his  reasons  for  believing 
that  under  proper  conditions  the  medicament  will  enter 
the  healthy  lung,  even  to  the  alveoli.  A  variety  of 
microscopical  slides  were  exhibited,  taken  from  the 
lung  of  a  patient  in  whom  inhalation  had  been  prac- 
tised shortly  before  death,  which  plainly  showed  the 
oil  globules  in  the  alveoli. 

Dr.  C.  a.  Johxson,  of  Chicago,  followed  with  a 
paper  on  the  same  subject.  He  related  his  experience 
in  the  use  of  the  instrument  in  forty  tuberculous  cases, 
and  directed  attention  to  the  point  that  the  solution 
employed  must  be  a  weak  one,  as  too  strong  a  solu- 
tion produces  irritation  and  consequent  hypersecre- 
tion. The  first  symptom  of  improvement  was  relief 
from  the  dyspnoea,  and  the  next  a  lowering  of  the  tem- 
perature. 

Epistaxis  in  the  Most  Serious  Form,  with  Re- 
port of  a  Case  Necessitating  Ligation  of  the  Com- 
mon Carotid — Dr.  Max  Thorner,  of  Cincinnati, 
the  author,  said  that  in  using  the  term  epistaxis,  refer- 
ence was  made  to  hemorrhages  in  which  blood  comes 
from  the  nose,  and  those  cases  in  which  it  merely 
passes  through  the  nose.  In  the  latter  category  is 
included  bleeding  from  the  pharynx,  naso-pharynx, 
the  accessory  cavities,  larynx,  lungs,  and  stomach,  as 
well  as  in  cases  of  fracture  at  the  base  of  the  skull. 
The  author  considered  serious  cases  only,  those  in 
which  the  ordinary  styptics  fail  to  check  the  hemor- 
rhage. He  referred  to  four  cases  in  which  the  radical 
operation  of  tying  one  or  both  carotids  was  practised, 
two  of  which  proved  fatal.  The  paper  closed  with  a 
reference  to  a  case  in  his  own  practice.  It  was  that 
of  a  man  struck  with  an  iron  ring  across  the  bridge  of 
the  nose  and  right  side  of  the  face.  Unconsciousness 
and  profuse  bleeding  from  the  nose  followed.  The 
patient  was  removed  at  once  to  the  hospital  and  the 
nose  plugged.  During  the  next  eighteen  days  the 
nose  was  tamponed  repeatedly  both  anteriorly  and 
posteriorly,  but  each  time  after  removal  of  the  tam- 
pons the  hemorrhage  started  afresh  within  seventy-two 
hours.  The  patient  becoming  almost  exsanguinated, 
with  high  pulse  and  increased  temperature,  an  opera- 
tion was  decided  upon.  The  common  carotid  was 
ligated.  The  hemorrhages  did  not  recur,  and  the  pa- 
tient was  discharged  one  month  after  the  operation. 

Scoliosis. — Dr.  William  E.  Wirt,  of  Cleveland, 
contributed  a  paper  on  the  treatment  of  scoliosis,  in 
which  he  referred  to  the  use  of  dry  heat  at  high  tem- 
perature for  the  treatment  of  this  condition.  He  re- 
called the  fact  that  he  had  originated  this  treatment 
three  years  ago,  and  had  been  experimenting  exten- 
sively along  this  line  continuously  ever  since.  He 
explained  in  detail  the  apparatus  used  to  inclose  the 
heat  about  the  joint,  and  by  reference  to  several  well 
authenticated  cases  showed  the  certain  value  of  dry 
heat  in  the  therapeutics  of  scoliosis. 

The  Thyroid  Glands.  — Dr.  I.  N.  Love,  of  St. 
Louis,  spoke  on  '•  The  Thyroid  Glands  from  a  Clinical 
Standpoint."  He  gave  an  interesting  historical  review 
of  serum  therapy,  and  particularly  of  thyroid  therapy, 
and  drew  valuable  deductions  from  his  experience 
with  it. 

Some  Phases  of  Extra-Uterine  Pregnancy. — Dr. 


A.  H.  Cordier,  of  Kansas  City,  read  a  paper  entitled 
"  Some  Phases  of  Extra-Uterine  Pregnancy."  This 
condition  was  not  recognized  and  diagnosticated  as  it 
should  be  by  the  general  practitioner.  The  applica- 
tion of  common  sense  and  good  judgment  was  the  best 
guide  to  the  successful  termination  of  ruptured  tubal 
pregnancy.  If  a  blood  vessel  was  injured  and  bleeding 
it  should  be  tied.  The  diagnosis  was  usually  not  very 
difficult.  A  very  important  point  was  the  menstrual  his- 
tor)',  and  this  should  be  thoroughly  investigated.  The 
pathology  of  these  cases  was  of  little  value  at  the  bed- 
side. A  tube  having  once  ruptured  would  continue 
to  give  trouble.  The  dangers  of  the  condition  far 
outweighed  the  dangers  of  good  surgery  employed  in 
these  cases.  Operation  should  be  performed  at  the 
earliest  possible  moment.  Clots  did  not  always  form. 
No  case  was  devoid  of  danger  until  the  bleeding  vessel 
was  firmly  tied. 

The  Treatment  of  Suppurating  Fistulous  Tracts. 
— This  paper  was  read  by  Dr.  E.  J.  Senk,  of  Chi- 
cago. The  primar}-  dressing  should  not  be  disturbed 
for  four  or  five  days,  when  it  is  removed  and  repeated 
if  necessary.  Nitrate  of  silver  or  other  caustics  should 
not  be  used,  as  the  granulations  are  only  superficially 
destroyed,  leaving  a  necrotic  area,  which  should  be 
avoided.  If  the  granulations  are  persistently  slug- 
gish, the  wound  should  occasionally  be  packed  with 
gauze  saturated  with  balsam  of  Peru,  as  this  agent 
stimulates  the  regenerative  capacity  of  embryonal 
cells  without  impairing  the  vitality  of  the  surround- 
ing tissues.  In  the  author's  hands  most  obstinate  fis- 
tulae  have  yielded  under  the  treatment  suggested  when 
previous  antiseptic  irrigation  over  estimated  periods 
of  time  proved  of  no  value. 

One  of  the  pleasant  features  of  the  closing  scenes 
of  the  meeting  was  the  presentation  of  some  handsome 
pieces  of  furniture  to  Drs.  Stucky,  Grant,  and  Tuley, 
on  behalf  of  the  exhibitors  present,  in  recognition  of 
the  work  done  by  these  gentlemen  for  the  success  of 
the  meeting. 

Amendments  to  the  constitution,  enlarging  the  duties 
of  the  secretary  and  providing  a  salary  for  his  ser- 
vices, were  adopted;  action  was  also  taken  with  re- 
gard to  the  permanent  preservation  of  the  transactions 
of  the  association. 

A  resolution  rescinding  the  action  previously  taken 
relative  to  the  reported  quarantining  of  Louisville  by 
the  State  of  Indiana  was  unanimously  passed. 

Officers  Elected. — The  following  officers  were 
elected:  FrcsiJeiit,  Dr.  John  Young  Brown,  of  St. 
Louis;  Vice-Presidciits,  Drs.  A.  J.  Ochsner,  of  Chi- 
cago, and  A.  P.  Buchman,  of  Fort  Wayne ;  Secretary, 
Dr.  Henry  E.  Tuley,  of  Louisville,  Ky. ;  Treasurer, 
Dr.  Charles  A.  Wheaton,  of  St.  Paul.  Place  of  meet- 
ing, Nashville.  Time,  second  Tuesdav  in  November, 
1898. 

After  adopting  resolutions  of  thanks  to  the  various 
committees,  the  association  adjourned. 


For  Injection  in  Small  Dose,  for  emaciation,  ca- 
chexia, etc.,  after  lingering  chronic  diarrhoea,  just  as 
in  the  adult  in  tardy  convalescence,  postoperative 
shock,  and  neurasthenia,  Cheron's  solution  : 

H  Ac.  phenic, 

Sod.  chlor.. 

Sod.  phos.. 

Sod.  sulphat aa      i  gram. 

Aq.  dest too     " 

M.     S.   Kive  g^ams  injected  twice  daily. 

Debilitated  children  often  increase  in  weight  under 
this  medication,  but  if  continued  too  long  the  injec- 
tions produce  a  condition  of  sleeplessness,  unrest,  with 
crying,  etc.,  and  may  cause  true  lymphatic  engorge- 
ment.— Thiercelin. 


6l2 


MEDICAL    RECORD. 


[October  23,  1897 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE    GENERAL     MEDICAL    COUNCIL     ELECTION — SIR     W. 

FOSTER— MR.     HORSLEY — TYPHOID    AT     MAIDSTONE 

INCREASE  OF  THE  EPIDEMIC — WATER  SUPPLY  POL- 
LUTED— DR.  WASHBOURN  FINDS  THE  BACILLUS  — 
A  DANGER  TO  EAST  LONDON  SUPPLY — DR.  PARKES 
ON    SANITATION — MEDICAL    SOCIETY    OF    LONDON. 

London,  October  i,  1S97. 

The  contest  for  the  seat  in  the  Medical  Council  so 
inauspiciously  vacated  by  Dr.  Rentoul  is  creating  un- 
usual interest.  In  London  and  the  large  centres  the 
excitement  is  rising  as  the  day  for  decision  approaches, 
but  it  is  feared  that  in  country  districts  the  apathy  of 
the  profession  may  prevent  the  poll  being  as  heavy  as 
could  be  wished.  The  indifference  that  has  marked 
some  elections  has  prevented  some  reforms  and  has 
rendered  governments  unwilling  to  enlarge  the  powers 
of  the  council.  The  voting-papers  will  be  issued  to- 
morrow and  must  be  returned  on  or  before  the  9th. 
They  will  be  counted  on  the  i  ith,  and  the  result  stated 
at  a  meeting  on  the  15th.  Mr.  Jackson  has  withdrawn 
in  favor  of  Sir  Walter  Foster,  M.P.,  M.D.,  who  on  re- 
turning from  the  meeting  in  Canada  immediately  issued 
an  address.  His  views  are  pretty  well  known,  as  he 
was  a  member  of  the  council  for  ten  years  and  was  not 
willing  to  come  forward  last  year  for  a  third  term. 
This  in  some  degree  is  against  him,  as  is  also  his  close 
association  with  the  British  Medical  Association  and 
the  manner  in  which  he  was  first  nominated  by  that 
body.  On  the  other  hand.  Sir  Walter's  experience  in 
parliament  is  a  valuable  qualification,  and  in  the  House 
of  Commons  he  has  been  a  consistent  advocate  of 
professional  rights.  As  parliamentary  secretary  to 
the  local  government  board,  he  gave  general  satisfac- 
tion and  was  able  to  further  professional  interests. 
Should  the  Liberal  party  regain  power  within  a  moder- 
ate period,  he  might  obtain  higher  office.  On  Wed- 
nesday there  was  an  influential  meeting  in  London  to 
support  him,  in  which  he  stated  his  opinions  and  re- 
plied to  questions — in  fact,  was  subjected  to  a  rather 
unpleasant  and  personal  cross-examination.  On  a 
vote  being  taken,  his  supporters  were  fifty-four  against 
seven. 

To-night  there  is  to  be  a  meeting  of  Mr.  Victor 
Horsley's  supporters  at  the  West  End  and  another  in 
the  Northeast  of  London,  and  to-morrow  a  meeting  at 
Norwich.  His  candidature  has  been  received  with 
such  favor  that  he  might  have  confidently  looked  for 
success,  but  the  appearance  of  Sir  W.  Foster  in  the 
field  quite  alters  the  conditions.  The  contest  will 
most  probably  lie  between  these  two.  I  have  previ- 
ously stated  the  names  and  claims  of  the  other  candi- 
dates. Mr.  Horsley's  scientific  position  and  Sir  W. 
Foster's  political  opportunities  seem  to  be  the  points 
most  talked  about. 

The  typhoid,  fever  epidemic  at  Maidstone,  an- 
nounced in  my  last,  has  spread  during  the  week  with 
such  rapidity  that  it  is  becoming  a  national  calamity. 
More  than  a  thousand  cases  are  notified,  and  that  in  a 
population  of  a  little  over  thirty-two  thousand.  In 
fact,  at  6  P.M.  yesterday  eleven  hundred  and  forty 
cases  had  been  notified.  The  previous  day  the  num- 
ber reported  was  nine  hundred  and  fifty,  and  there  is 
no  sign  of  the  rapid  rate  of  increase  diminishing.  Of 
course  all  business  in  the  town  and  district  is  practi- 
cally suspended,  and  the  one  thought  of  the  survivors 
is  how  to  arrest  the  plague.  The  hospital  accommo- 
dation was  of  course  insuflicient  to  coix;  with  such  an 
emergency,  but  other  buildings  have  been  fitted  up  in 


the  greatest  haste.  Thus  the  Salvation  Army  placed 
its  barracks  at  the  service  of  the  sanitar}'  committee, 
as  did  the  trustees  of  the  Wesleyan  schools.  Boiled 
milk,  soup,  and  other  supplies  are  being  freely  distrib- 
uted, and  a  large  number  of  nurses  has  been  engaged, 
while  more  than  one  hundred  young  men  are  working 
as  night  nurses  in  order  to  give  some  rest  to  the  friends 
and  attendants  of  the  patients.  On  the  advice  of  the 
government  inspector,  three  substations  have  been 
opened  by  the  guardians,  at  which  the  nurses  can  ob- 
tain all  necessaries  for  the  patients  on  applying  for 
them. 

The  origin  of  this  deadly  epidemic  has  been  traced 
to  pollution  of  one  of  the  springs  from  v.-hich  the  town 
draws  its  drinking-water.  The  medical  oflricer  of 
health  seems  to  have  been  alive  to  the  possibility  of 
this  contamination,  and  at  an  early  period  to  have 
fixed  on  the  source  of  danger  and  brought  the  matter 
under  the  notice  of  the  authorities.  The  incriminated 
springs  were  unprotected  in  open  meadows,  where  hop- 
pickers  had  been  allowed  to  encamp,  and  it  has  since 
been  ascertained  that  cases  of  typhoid  had  occurred 
among  them.  To-day  the  water  company  is  discussing 
the  necessity  of  cutting  oflf  all  the  supply  from  these 
springs.  It  seems  there  was  some  difficulty  in  obtain- 
ing enough  water  from  tlie  others,  but  a  gentleman  of 
the  neighborhood  has  placed  at  the  disposal  of  the  au- 
thorities some  additional  springs  of  undoubted  purity. 
Surely  at  the  very  first  the  suspected  supply  should 
have  been  shut  off,  and  there  will  be  no  little  discus- 
sion as  to  where  the  blame  of  not  doing  so  must  rest. 
Dr.  Washbourn  was  called  in  as  a  bacteriological  ex- 
pert, and  has  found  the  bacillus  typhosus  in  the  water 
of  the  suspected  springs. 

A  terrible  object-lesson  is  thus  before  the  country, 
and  the  newspapers  are  full  of  details  and  sugges- 
tions. And  yet  ver)'  little  attention  has  been  paid  to 
a  statement  that  in  East  London  boys  and  men  are  in 
the  habit  of  bathing  in  one  of  the  tanks  of  the  water 
company.  This  must  be  rendered  impossible,  for  the 
danger  is  obvious,  and  the  company  ought  to  take  im- 
mediate measures  to  protect  its  water  from  such  a 
source  of  danger  and  pollution. 

Dr.  L.  Parkes  gave  a  lecture  on  Monday  at  the 
Parkes  Museum,  on  the  "Outcome  of  Sanitation,"  in 
which  he  showed  how  much  sanitary  science  has  done 
for  this  country. 

Next  week  the  work  of  the  Medical  Society  will  be- 
gin, when  Dr.  Sansom,  the  incoming  president,  will 
give  an  address  on  "  Nervous  Disturbances  of  the 
Heart,"  and  Mr.  Anderson  will  read  a  paper  on  "John 
Ardern,  the  Father  of  English  Surgerj'." 


OUR   PARIS    LETTER. 

(From  our  Special  Correspondent.) 

DR.  LAPORTE's  CASE  —  SYMPATHY  FOR  HIM  —  THB 
PRACTICE  OF  MEDICINE — OVERCROWDING  AGAIN  THE 
SUBJECT  OF  AN  ESSAY — TREATMENT  OF  CORYZA — 
VOMITING  DURING  PREGNANCY — INCREjVSE  IN  THE 
PRICK    OF    BREAD,    ETC. 

Pari!!,  September  30,  1807. 

The  unfortunate  case  of  Dr.  Laporte,  about  which  I 
wrote  you  in  my  last,  is  arousing  considerable  sympa- 
thy, not  only  among  the  laity  but  more  especially  among 
the  medical  profession.  It  seems  that  the  doctor  was 
absolutely  without  the  means  to  procure  the  instru- 
ments (forceps)  necessary  in  such  cases,  and  that  in 
the  operation  on  Madame  Fresquet  the  packer's  needle 
was  used  in  place  of  the  basiotribe.  For  his  defence 
Dr.  Laporte  cites  the  authority  of  Pcnard  and  Abelin, 
who  iiave  published  a  much-appreciated  treatise  on 
obstetrics,  and  who  state  very  judiciously,  at  least  so 


October  23,  1897] 


MEDICAL    RECORD. 


61 


affirms  the  accused,  that  if  the  accoucher  or  doctor  has 
not  at  hand  the  necessary  instruments  he  is  justi- 
fied in  using  such  objects  as  they  may  deem  best 
adapted  to  the  accomplishment  of  their  task.  Other 
and  distinguished  surgeons  have  done  the  same,  only 
they  were  successful.  If  the  operation  in  this  case 
had  succeeded  perfectly  and  the  mother  had  made  a 
good  recover)-.  Dr.  Laporte  would  have  been  a  ver)- 
clever  man  instead  of  being  in  prison.  As  there  was 
also  no  criminal  intent  whatever,  but  evidently  only  a 
humanitarian  effort  to  deliver  the  woman  and  alleviate 
her  sufferings,  numerous  physicians  are  taking  active 
step"  to  have  the  judge,  M.  Bertulos,  place  Dr.  La- 
porte at  liberty  provisorily. 

The  question  of  mental  unsoundness  has  also  been 
raised,  but  Dr.  Laporte  is  considered  as  absolutely  re- 
sponsible for  his  acts,  and  he  himself  assumes  the  re- 
sponsibilit}-,  stating  that  while  he  used  instruments 
such  as  works  on  surgery  do  not  recommend,  he  was 
constrained  to  do  so  by  the  urgency  of  the  case. 

The  governmental  authorities  are  still  at  work  regu- 
lating the  practice  of  medicine,  determined  to  prevent 
illegal  exercise,  and  the  following  details  of  an  official 
act  will  be  read  with  interest:  By  decree,  the  law  of 
November  30,  1892,  on  the  practice  of  medicine  in 
France,  is  rendered  applicable  to  the  colonies,  except- 
ing protectorate  countries.  There  are,  however,  cer- 
tain specifications,  of  which  the  principal  are:  ist,  The 
list  of  epidemic  diseases,  the  divulging  of  which  does 
not  engage  professional  secresy,  shall  be  drawn  up  by 
order  of  the  minister  of  the  colonies  in  accordance 
with  the  opinion  of  the  Academy  of  Medicine  and 
that  of  the  consulting  committee  of  hygiene  of  France. 
The  declaration  should  be  made  by  ever}-  or  any  civil 
or  military  doctor,  health  officer,  indigenous  doctor,  or 
sage  fcinme  practising  in  the  colonies.  2d.  In  French 
colonies  in  the  Indies  is  maintained  an  institution  for 
indigenous  doctors.  Further,  where  it  is  deemed  neces- 
sary the  practice  of  medicine  may  be  authorized  by 
decree,  and  special  schools  for  indigenous  doctors  shall 
be  established  under  the  same  regulations. 

The  right  to  practise  dentistrj-,  in  conformity  with 
the  provisions  of  article  82,  is  given  to  every  dentist 
proving  that  he  was  inscribed  on  the  patent  roll  on 
January  i,  1897. 

The  work  at  the  ficole  de  Medecine  just  now  is  not 
exactly  of  a  scientific  character  and  is  limited  to  get- 
ting things  in  order  for  the  beginning  of  the  scholastic 
or  academic  year  next  month.  One  of  the  most  im- 
portant changes  is  the  new  library.  The  transfer  from 
the  old  to  the  new  librar}'  having  been  completed  some 
time  since,  many  thousands  of  volumes  are  now  in 
their  places  on  the  shelves  of  the  new  library,  which 
is  quite  imposing  in  appearance  and  is  provided  with 
long  tables  for  the  use  of  professors,  students,  and 
general  practitioners. 

Among  recent  publications  is  one  that  only  accen- 
tuates what  has  been  several  times  referred  to  in  my 
letters  from  Paris,  viz.,  the  overcrowding  of  the  med- 
ical profession.  The  title  is  "  Obstruction  [Encom- 
brement]  and  Depreciation  of  the  Medical  Profession," 
and  the  author  is  Dr.  L.  Grellety,  consulting  physician 
at  Vichy. 

The  abortive  treatment  of  coryza.  a  disease  or  the 
commencement  of  a  disease  so  common  at  this  time  of 
the  year,  is  attracting  professional  attention.  Dr. 
Maurel,  of  Toulouse,  suggests  placing  small  wads  of 
iodoform  cotton  in  the  nostrils,  which  he  finds  occa- 
sions neither  inconvenience  nor  irritation.  He  also 
recommends  iodoformic  vapors,  placing  them  in  direct 
contact  with  the  staphylococci  of  the  nasal  cavities. 
The  coryza  heals  rapidly  under  their  influence,  and, 
what  is  more  important,  the  descending  bronchitis 
that  so  often  follows  is  prevented  or  reduced  to  a 
minimum.      Dr.  Maurel,  however,  wisely  adds  that   in 


order  to  obtain  these  results  the  coryza  must  be  taken 
at  the  very  beginning.  In  my  own  experience  I  have 
never  found  anything  better  than  a  snuff  consisting  of 
equal  parts  of  subnitrate  of  bismuth,  chlorate  of  po- 
tassium, and  sulphate  of  quinine. 

Professor  Tibone,  of  the  Faculty  of  Medicine  of 
Turin,  finds  the  best  and  most  rapid  way  of  stopping 
persistent  vomiting  during  pregnancy  to  be  hypoder- 
mic injections  of  cocaine  given  in  the  epigastrium. 
He  recently  tried  it  very  successfully  in  a  number  of 
cases  in  which  hypodermic  injections  of  morphine 
had  had  no  effect.  Thanks  to  these  injections  of  co- 
caine in  doses  of  one  centigram  or  about  one-fifth 
of  a  grain,  repeated  once  or  twice  a  day,  almost 
immediately  after  meals,  the  patients  were  able  to 
retain  what  they  had  eaten,  without  the  cocaine  hav- 
ing any  bad  after-effects  upon  either  the  pulse,  res- 
piration, or  temperature.  Little  by  little  the  general 
condition  of  the  patients  improved,  the  weight  of 
the  body  increased  considerably,  and  the  vomitings 
did  not  recur  even  after  the  injections  of  cocaine  had 
been  stopped. 

A  propos  of  the  case  of  Dr.  Laporte,  who  has  not 
only  some  of  the  leading  newspapers  but  the  profession 
and  public  sympathy  with  him,  I  quote  from  a  recent 
"  Pre'cis  d'Obstetrique"  by  no  less  men  than  Drs.  Ribe- 
mont-Dessaigne  and  Le  Page,  of  the  Faculty  of  Paris, 
a  standard  work  (see  page  1,215).  There  is,  so  to 
speak,  no  instrument  that  has  not  been  used  to  open 
the  cranial  cavity  of  the  fcetus.  Numbers  of  doctors, 
not  having  at  their  disposal  special  instruments,  have 
used  what  they  had  at  hand — kitchen  kn.ves,  scissors, 
etc.  There  is  therefore  no  lack  of  authority  for  per- 
forming craniotomy  with  whatever  instrument  may,  in 
the  judgment  of  the  physician,  be  deemed  most  fitting 
in  want  of  the  regular  instruments  prescribed  for  that 
purpose  and  in  cases  of  great  and  immediate  urgency. 

The  annual  meeting  of  the  Anglo-American  Conti- 
nental Medical  Society  takes  place  next  month.  The 
date  is  October  12th.  The  question  of  the  formation 
of  a  branch  society  on  the  Riviera  is  still  pending. 

Just  now  many  of  those  physicians  who  practise  in 
the  south  of  France  and  on  the  Riviera  are  passing 
through  Paris — our  confrere.  Dr.  Linn,  of  Nice, 
among  others,  is  returning  thither.  Dr.  Linn's  book 
on  the  health  resorts  of  Europe  has  taken  a  well- 
merited  place  as  authoritative  in  climatological  liter- 
ature. He  has  observed  cases  of  catarrhal  affection 
cured  by  a  simple  sojourn  in  the  dry  air  of  Nice. 

The  rise  in  the  price  of  bread,  which  falls  heavily 
upon  the  Paris  poor,  has  been  caused  by  the  unusu- 
ally bad  year  for  cereals.  All  the  railways,  in  a  spirit 
of  alleviation,  have  reduced  their  tariffs  for  the  trans- 
portation of  cereals. 

Yesterday  was  the  second  anniversary  of  Pasteur's 
death,  and  it  was  fittingly  remembered  at  the  Institut. 


THE    PULMONARY    ORIGIN  OF   THE    CREP- 
ITANT   RALE. 

To  THE  Editor  of  the  Medical  Record, 

Sir:  "If  we  are  to  draw  conclusions,  our  methods 
must  be  accurate,  our  deductions  must  be  logical,  they 
must  stand  the  test  of  careful  scientific  analysis,  they 
must  conform  to  known  physical  laws."  These  are 
the  exact  words  used  iiy  Dr.  Louis  H.  Jones,  in  his 
article  supporting  the  interpleural  origin  of  the  crepi- 
tant rale,  which  appeared  in  the  issue  of  the  Medical 
Record  of  June  5,  1897.  I  fear,  however,  that  the 
above  just  considerations  can  in  no  wise  be  applied  to 
the  paper  with  which  the  doctor  would  have  us  join 
him  in  considering  the  crepitant  rale  of  interpleural 
origin.  I  heartily  indorse  the  doctor  in  the  .sentiment 
expressed  in  the  closing  sentence  of  his  article,  that 


6i4 


MEDICAL    RECORD. 


[October  23,   1897 


we  should  not  accept  all  new  teachings  without  inves- 
tigation, but  likewise  object  to  the  resuscitation  of  in- 
dividual opinions  that  have  justly  never  received  any 
serious  consideration  from  scientific  medical  men. 

Before  beginning  my  defence  for  the  pulmonary 
origin  of  the  crepitant  rale,  let  me  say  that  the  point 
at  issue  is  not  whether  we  can  have  a  real  pleural  rub 
not  to  be  distinguished  from  a  crepitant  rale,  but 
whether  or  not  this  rale  is  of  pulmonary  origin.  We 
know  that  at  times  we  may  have  a  pericardial  rub  in- 
distinguishable from  a  heart  murmur,  yet  this  does  not 
establish  its  endocardial  origin.  So,  therefore.  Dr. 
Jones'  quotation  from  Osier  has  no  direct  bearing  on 
the  subject. 

The  study  of  Learning's  work  on  the  lungs  leads  me 
to  believe  that  his  enthusiasm  led  him  to  fit  the  cases 
to  his  theory  rather  tlian  the  reverse.  In  all  his  post 
mortems  in  which  he  had  heard  crepitant  rales,  he 
found  signs  of  either  recent  or  of  adhesive  pleurisy, 
but  he  also  found  presence  of  pneumonia  or  of  phthi- 
sis; therefore  the  presence  of  crepitant  rales  prior  to 
death  could  be  explained  either  by  the  pneumonic  or 
tuberculous  process  without  the  presence  of  the  pleural 
condition.  Had  he  in  any  of  his  post  mortems  been 
able  to  demonstrate  undoubted  crepitant  rales  with 
only  pleural  inflammation,  then  his  opinion  would 
have  been  greatly  strengthened.  We,  on  the  other 
hand,  who  hold  the  opposite  view,  can  present  cases 
in  which  crepitant  rales  were  present,  and  in  which  at 
the  post-mortem  table  no  evidence  of  pleural  involve- 
ment was  found  complicating  the  pneumonia.  These 
cases  are  uncommon,  but  they  do  exist.  This  is  par- 
ticularly true  of  central  pneumonia*. 

Learning  states  (page  23)  that  "central  pneumonia 
without  interpleural  plastic  exudation  is  unaccompa- 
nied by  rales,  either  crepitant  or  subcrepitant;"  but 
in  contradiction  to  this  I  quote  from  the  article  by 
Juergensen  on  "  Pneumonia,"  in  Ziemssen's  Encyclo- 
pajdia,  page  84:  "  Even  in  central  inflammation  of  the 
lungs  the  rale  may  often  be  detected;  but  Laennec 
makes  too  sweeping  a  statement  when  he  says  that  a 
comparatively  unpractised  ear  can  discover  by  the 
crepitation  the  existence  of  central  infiltrations  no 
larger  than  an  almond."  If  the  crepitant  rale  depended 
for  its  existence  on  the  movement  of  one  layer  of  pleura 
on  the  other,  why  would  it  not  be  present  at  times 
during  expiration,  as  is  frequently  found  in  real  pleu- 
ral friction  sounds,  and  why  should  we  not  hear  it  dur- 
ing the  stage  of  complete  consolidation,  when  the 
quantity  of  e.xudate  is  greatest  in  amount? 

Dr.  Jones  states  that  the  crepitant  rale  is  sometimes 
heard  in  this  stage;  this  is  undoubtedly  the  case,  but 
then  it  is  due  to  the  fact  that  some  vesicles  are  not 
quite  full  of  exudate,  or  to  the  presence  of  inflamma- 
tory oedema  in  the  vicinity  of  the  pneumonic  area. 

In  support  of  this  I  again  quote  from  Juergensen: 
'■'Over  the  parts  which  have  become  solid  with  infiltra- 
tion, this  sign  is  absent,"  etc.  Furthermore,  we  all 
have  seen  cases  of  pneumonia  in  which  during  the 
course  of  the  disease  eitlier  in  the  adjoining  lobe  of 
the  same  side  or  on  the  opposite  side  have  developed 
pure  crepitant  or  subcrepitant  rales,  and  yet  on  post- 
mortem nothing  but  a  little  hypostatic  congestion  or 
cedema  was  found.  It  has  been  observed  that  if  a  pa- 
tient lies  on  his  back  for  a  short  time  or  sits  up  in  bed 
in  a  cramped  position,  it  is  possible  to  hear  dis- 
tinctly over  the  lower  parts  of  the  lung  posteriorly  typ- 
ical crepitant  rales,  w-hich  disappear  at  once  after  a 
few  deep  inspirations.  This  is  due  to  a  temporary 
atelectasis,  and  the  rales  are  produced  by  the  air  sepa- 
rating the  collapsed  vesicles.  Here  the  (ileura  cannot 
be  involved.  We  know  that  in  tiie  real  friction  rub 
the  phenomenon  is  best  heard  over  the  more  movable 
parts  of  the  lung,  and  that  after  a  few  deep  inspira- 
tions it  often  disappears.     But  this  is  not  so  in  the 


case  of  the  crepitant  rale.  The  supporters  of  the  in- 
trapleural origin  claim  that  the  sound  is  heard  directly 
beneath  the  ear,  and  therefore  originates  in  the  pleural 
cavity.  Is  not  the  rale  generated  in  the  vesicles  im- 
mediately beneath  the  visceral  layer  of  pleura  just  as 
close  to  the  ear;  and  furthermore  is  not  the  lung  in 
this  state  of  consolidation  in  excellent  condition  to 
convey  to  the  ear  most  distinctly  those  rales  generated 
more  deeply  in  the  lung?  Is  it  not  for  this  reason 
that  Skoda  called  these  rales  "consonating  rales'"? 

I  hope  these  few  arguments  will  succeed,  if  not  in 
convincing  the  readers  where  the  crepitant  rale  is 
generated,  at  any  rate  in  persuading  them  that  the  rale 
is  not  of  intrapleural  origin.  Let  us  go  a  few  steps 
farther  and  attempt  to  establish  the  site  of  origin  of 
this  disputed  rale.  Dr.  Jones  says  that  crepitant  rales 
cannot  be  produced  by  the  separation  of  the  walls 
of  the  air  vesicle,  for,  he  says,  atmospheric  pressure 
prevents  the  collapse  of  the  vesicle  and  the  residual 
air  prevents  the  tidal  air  entering  the  smaller  bronchial 
tubes  in  mass.  Regarding  this  latter  opinion  I  will 
say  that  physiology  teaches  us  that  the  residual  air  is 
in  excess  of  the  tidal,  and  it  constantly  occupies  the 
bronchioles  and  the  air  vesicles;  but  is  it  not  this 
very  air  that  rushes  in  to  dilate  the  air  vesicles  during 
an  act  of  inspiration  pushed  onward  by  the  means  of 
the  tidal  air  entering  the  trachea  and  bronchi?  Dur- 
ing expiration  a  portion  of  this  same  residual  air  is 
forced  out  into  the  bronchioles  again,  and  in  the  mean 
while  constant  exchange  of  gases  according  to  the  laws 
of  diffusion  is  going  on.  Learning  himself  says,  on 
page  20:  "In  unhurried  healthy  respiration  the  air 
enters  in  a  body  to  the  bronchi  as  far  as  the  third  or 
fourth  division,  when  it  becomes  instantly  mixed  with 
the  residual  air,  becoming  a  component  part  of  it, 
and  by  its  addition  equally  dilating  the  distensible 
true  respiratory  system."  Regarding  the  atmospheric 
pressure  preventing  total  collapse  of  the  air  vesicle,  I 
concur,  but  this  does  not  prevent  the  air  vesicle  be- 
coming filled  with  exudate  thrown  out  from  its  walls. 
This  exudate,  in  my  opinion,  is  at  first  only  small  in 
amount,  so  that  when  the  intrapulmonary  pressure  is 
lowered  by  an  inspiratory  act  the  air  rushes  in,  as  ex- 
plained above,  until  the  pressure  rises  sufficiently  to 
overcome  the  cohesive  power  of  the  exudate,  distend- 
ing the  vesicle  and  giving  rise  to  the  crepitant  rale. 
This  of  course  would  occur  toward  the  end  of  inspira- 
tion when  intrapulmonary  pressure  is  greatest,  and  it 
is  exactly  at  this  period  that  crepitant  rales  in  pneu- 
monia are  best  heard.  It  may  be  objected  to  this 
opinion  by  those  holding  the  other  view  that,  if  such 
is  the  case,  w-hy  do  we  not  get  the  same  condition  in 
the  so-called  stage  of  complete  consolidation?  The 
reason  is  that  in  this  latter  stage  of  pneumonia  the 
vesicle  is  overfilled  with  exudate,  so  that  it  might  be 
considered  as  distended  by  the  e-xudate  as  it  would  be 
in  health  by  air.  This  can  be  proved  on  post-mortem 
by  the  fact  that  the  lobe  affected  with  pneumonia  is 
larger  than  normal,  so  much  so  that  the  imprints  of 
the  ribs  are  on  its  surface;  also  by  the  fact  that  the 
pressure  of  the  exudate  on  tiie  capillaries  of  the  alve- 
oli of  the  lungs  is  sufficient  to  produce  ischa-mia  of 
the  lobe.  Furthermore,  the  exudate  becomes  more 
solid  in  the  alveoli,  and  the  air  would  tend  to  press 
the  exudate  more  firmly  against  the  wall  of  the  vesicle. 
Wintrich  has  succeeded  by  auscultating  the  excised 
lung  of  an  animal  to  hear  rales  distinctly  when  air  was 
forced  into  it. 

This  is  briefly  what  I  ha\e  to  olTer  in  objection  to 
the  intrapleural  origin  of  the  crepitant  rale;  I  sincerely 
hope  it  carries  some  conviction  with  it  to  those  who 
have  been  patient  enough  to  follow  to  the  end  the 
pathological  and  clinical  facts  mentioned  in  my  dis- 
cussion. GuiDO  K.  Caui.ikri,  H.Sc,  M.l). 

530  MONTGOMERV  StRKKT,  San    Fka.NCISCO. 


October  23,  1897] 


MEDICAL    RECORD. 


615 


TAPEWORMS. 

Tn  THE  Editor  of  the  Medical  Record. 

Sir  :  Referring  to  the  recent  article  by  Dr.  Chamber- 
lin,'  in  which  he  makes  the  statement  that  tapeworm 
disease  seems  to  be  almost  entirely  confined  to  woman- 
kind, and  to  the  later  communication  by  Dr.  Dowling," 
in  which  he  cites  cases  in  men,  I  have  thought  that 
the  following  statistics  upon  the  subject  would  not  be 
uninteresting  to  the  readers  of  the  Medical  Record: 

Cases  of  Tapeworm  in  Man. 

Total  Number  of  Sex  of  Patients.  .    ..     .. 

Cases  Reported.  Female.  Male.  Authority. 

173 117  56  WawTuch. 

247 151  96  Crisp. 

26 16  10  Seeger. 

240^ I2g  III  Monti. 

10' 7  3  Roger. 

367 241  126  Krabbe. 

1,063  661  402 

It  will  be  seen  from  these  statistics  that  about 
sixty-two  per  cent,  of  the  cases  reported  by  the  si.x  au- 
thors cited  were  among  women,  and  about  thirt}--eight 
per  cent,  among  men. 

A  moment's  thought  will,  I  believe,  make  the  reason 
of  this  difference  clear  to  us.  We  certainly  cannot 
assume  that  women  are  from  se.x  predisposed  to  tape- 
worm infection,  but  we  should  recall  that  they  are 
more  exposed  to  such  infection  from  the  fact  that 
they,  more  than  men,  prepare  food  for  the  table. 

I  am  not  familiar  with  the  statistics  which  Dr. 
Chamberlin  cites  from  the  French  army,  namely,  one 
case  of  tapeworm  disease  in  every  36,000  men,  but 
find  it  extremely  difficult  to  accept  the  proportion 
given.  Be'renger-Feraud  *  gives  the  following  figures 
for  the  maritime  hospitals  in  France,  but  does  not 
state  the  sex  of  the  patients: 

(  .vsES    OF  Tapeworm    in  Man  in  Maritime   Hospitals  of 
Fr.\nce — 1861  to  1890. 

i36i  to  1865  33  cases  in  130,927  patients,  or  0.20 per  1,000 
i856  "  1S70  95  "  "  152,822  "  "  0.62  "  1,000 
1S71  "  1875  422  ■'  "  137.361  "  "  3.06  "  1,000 
1S76  "  1880  1,108  "  •'  130,898  "  "  8.45  "  1,000 
1881  "  1885  1,565  '•  •'  155,646  ■•  "  10.05  "  1,000 
1886  "18902,253     "      "  152,352        '■        "  14.80   "   1,000 

The  statistics  for  our  own  country  are  very  incom- 
plete, but  I  have  shown  elsewhere'  that  on  the  Federal 
side  during  our  late  war,  "  in  a  total  of  5,548,854  pa- 
tients from  July  i,  1862,  to  June  30,  1866,  only  566 
were  diagnosed  as  having  tapeworms,  or  i  in  9,803." 

Unfortunately  our  .\merican  statistics  have  not  taken 
the  various  species  of  tapeworm  into  account,  but  so 
far  as  I  can  judge  from  the  specimens  which  phy- 
sicians and  others  have  sent  to  this  bureau  for  deter- 
mination from  various  parts  of  tlie  countr}-,  Tania  sa- 
ginata,  the  beef-measle  tapeworm,  is  by  far  the  most 
common  form  with  us:  Ta;nia  solium,  the  pork-measle 
tapeworm,  is  much  less  common.  I  have  seen  oply 
three  cases  of  Bothriocephalus  latus  in  the  United 
States,  and  only  one  case  oi  Hymenolepis  diniinuta 
I'l'c-tnia  flavopunctata).  No  cases  in  man  of  Hymeno- 
lepis murina  (Ta:;nia  nana,)  Dipylidium  caninum,  Da- 
vainea  -Vladagascariensis,  Bothriocephalus  cordatus, 
Kothriocephalus  Mansoni,  or  Krabbea  grandis  have 
as  yet  been  sent  to  us. 

'  "  The  Treatment  of  Tapeworm,  with  Report  of  Cases,"  Medi- 
cal Record,  Hi.  (9),  August  28th,  1897,  p.  313. 

•'"Tapeworm  in  Men,"  Medical  Record,  Hi.  (11),  September 
II,  1897,  p.  400. 

'  Children. 

'Original  reference  not  consulted;  table  is  copied  from  Rail- 
Hct,  1893,  Traite  de  Zool.  Med.  et  .\gric.,  i.,  p.  238. 

■  "  Notes  on  Para.sites."  32:  "  On  the  Rarity  of  Tenia  solium 
in  North  America."  Veterinary  Magazine,  ii.  (5),  May.  189;,  pp. 
281  to  286. 


As  for  Ward's  new  species  (Tcenia  confusa),  his 
original  specimen  is  the  only  material  of  this  kind  I 
have  examined.  This  worm,  which  presents  most  re- 
markable segments,  will  soon  be  described  in  detail 
by  one  of  \\'ard's  pupils,  and  until  this  publication 
appears  it  will  be  lost  time  to  discuss  the  form.  Suf- 
fice it  to  say  that  physicians  should  be  on  the  lookout" 
for  a  tapeworm  with  enormously  long  (twenty-seven  to 
thirty-five  millimetres)  segments,  and  should  send  the 
specimen,  if  found,  either  to  Prof.  Henry  B.  Ward, 
University  of  Nebraska,  Lincoln,  Neb.,  or  to  me,  or  to 
some  other  helminthologist  for  zoological  determina- 
tion. I  am  particularly  anxious  to  obtain  a  complete 
specimen  with  head,  for  I  feel  convinced  that  the  head 
which  Ward  has  described  does  not  belong  to  the  body 
he  studied,  but  to  a  specimen  of  Dipylidium  caninum — 
a  view  which  has  already  occurred  to  Ward. 

In  connection  with  the  question  of  treatment  which 
Dr.  Chamberlin  discusses,  I  take  the  liberty  of  adding 
three  suggestions  which  may  be  of  service  to  your 
readers.  Two  of  these  suggestions  are  based  upon 
the  natural  habits  of  the  tapeworm. 

It  is  generally  assumed  that  a  tapeworm  is  a  low 
kind  of  animal  without  nenes.  On  the  contrary,  he 
has  a  very  complicated  nervous  system  which  demands 
that  we  must  treat  him  with  a  certain  amount  of  re- 
spect. In  the  head  the  tapewonn  possesses  well -de- 
veloped ganglia,  and  running  from  these  are  two  enor- 
mous lateral  nerves  which  e.xtend  through  the  entire 
worm,  giving  oft"  branches  to  every  segment.  An  in- 
sult to  the  end  segment  will  thus  be  communicated  to 
the  head.  Now,  it  is  a  frequently  observed  phenom- 
enon that  if  a  tapeworm,  more  particularly  a  delicate 
species,  is  suddenly  thrown  into  cold  water,  it  will 
often  break  into  several  pieces.  It  is  also  a  fre- 
quently observed  fact  among  physicians  that  when  a 
patient  is  passing  a  tapeworm  the  parasite  will  sud- 
denly break  in  two.  A  moment's  reflection  will  show- 
that  the  tapewonn  in  this  latter  case  is  passing  from 
the  warm  bowels  to  the  cold  air,  perhaps  into  a  cold 
porcelain  vessel.  To  fool  the  parasite,  care  should 
be  taken  to  prevent  this  sudden  change  of  temper- 
ature. This  can  be  very  easily  done.  The  patient 
should  be  instructed  to  use  a  vessel  containing  warm 
water. 

Again,  tapeworms  have  a  habit  of  "  tying  themselves 
up  into  a  knot,''  with  the  head  in  the  centre,  and  they 
are  frequently  expelled  in  this  form.  If,  however, 
they  meet  with  any  obstruction  in  the  lower  bowels, 
they  have  an  opportunity  of  extricating  their  heads 
and  thus  of  gaining  hold  of  the  walls  of  the  intestine. 
The  clearing  out  of  the  lower  bowels  is  therefore  all- 
important  in  treating  for  tapeworms. 

Finally,  it  is  essential  that  the  mixture  used  for 
treatment  should  not  be  so  old  that  it  has  lost  all  its 
anthelmintic  properties. 

Disregard  of  the  three  details  in  treatment  here 
suggested  will  account,  I  believe,  for  the  majority  of 
the  failures  in  treating  for  tapeworms. 

Dr.  Chamberlin  well  remarks  that  the  symptoms  of 
tapeworm  disease  are  not  well  defined.  If  we  take  all 
the  symptoms  ever  described  for  all  diseases,  shake 
them  up  in  a  hat,  and  pick  out  any  combination  of 
them  at  random,  we  obtain  a  clinical  histor)'  of  tape- 
worm disease.  In  experimenting  upon  myself  with 
tapeworm  infection  (Ta-nia  saginata  was  the  species 
used),  tlie  most  constant  symptom  I  have  noticed  is 
one  which  I  have  never  seen  directly  mentioned  in 
any  article.  During  the  time  of  infection,  it  would 
very  frequently  happen  as  I  walked  along  the  street 
or  across  the  room  that  I  suddenly  felt  a  peculiar  sen- 
sation almost  exactly  similar  to  the  sensation  one  feels 
upon  the  sudden  descent  of  an  elevator. 

Notwitlistanding  the  indefinite  clinical  picture  (its 
indefiniteness  almost  makes  it  definite),  I  can  see  no 


6i6 


MEDICAL    RECORD. 


[October  ^3,  1897 


earthly  excuse  for  diagnosing  tapeworm  when  no  tape- 
worm is  present.  At  the  first  suspicion  of  tapeworm  a 
microscopic  examination  of  the  fa;ces  should  be  made. 
If  tapeworms  are  present  and  large  enough  to  cause 
any  trouble,  they  will  also  be  large  enough  to  fill  the 
faices  with  their  characteristic  eggs.  If  no  eggs  are 
found  in  this  examination,  we  can  conclude  either 
that  there  are  no  tapeworms  present,  or  that  if  present 
they  are  too  young  to  cause  any  serious  trouble.  It  is 
indeed  to  be  regretted  that  the  microscopic  examina- 
tion of  the  faices  is  not  so  general  as  that  of  the  urine. 
Ch.  Wardell  Stiles,  Ph.D., 
Medical  Zoologist,  Bureau  of  Animal  Jndustry. 

Washington,  D.  C. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
v;eek  ending  October  16,  1897: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. . . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox 


Medical  Men  in  Germany.  —  Statistics  recently 
published  show  that  the  proportion  of  medical  men  to 
population  in  the  leading  towns  of  the  German  em- 
pire is  as  follows:  In  Charlottenberg  the  ratio  is  i 
doctor  to  every  624  inliabitants;  in  Halle-on-Saak,  i 
to  684;  in  Munich,  i  to  778;  in  P>ankfort-on-the- 
Main,  1  to  785;  in  Konigsberg,  i  10792;  in  Berlin, 
I  to  807;  in  Stuttgart,  1  to  810;  in  Breslau,  i  to  834; 
in  Dresden,  i  to  943;  in  Hanover,  i  to  974;  in  Stettin, 
I  to  1,042;  in  Danzig,  i  to  1,064;  in  Leipzig,  i  to 
1,082;  in  Aachen,  i  to  1,162;  in  Brunswick,  i  to 
1,203;  '"  Dusseldorf,  i  to  1,227;  '"  Cologne,  1  to 
1,250;  in  Hamburg,  i  to  1,284;  in  Nuremberg,  i  to 
1,336;  in  Magdeburg,  i  to  1,339;  i"  Bremen,  1  to 
1,364;  in  Dortmund,  i  to  1,556;  in  Altona,  i  to 
1,752;  in  Eiberfeld,  i  to  1,960;  in  Chemnitz,  i  to 
1,987;  in  Barmen,  i  to  2,082,  and  in  Crefeld,  1  to 
2,145. — British  Medical  Journal. 

Nightsoil  and  Ashes  for  Manure. — Experiments 
made  by  the  farm  coTumiltee  of  the  town  council  of 
Crewe  in  the  direction  of  mixing  crude  nightsoil  with 
fine  ashes  and  sulphuric  acid  proved  so  successful  in 
1895  that  last  year  covered  mixing  sheds  and  screens 
were  erected  for  that  purpose.  Tlie  dry  ashes  are 
thrown  on  the  screen  by  hand.  The  screen  is  a  two- 
decker,  and  as  it  moves  the  broken  crockery,  glass, 
tins,  etc.,  are  thrown  off  to  the  top  screen,  whence  they 
are  removed  and  used  in  road-making.  The  lower 
screen  catclies  the  combustible  matter  (chietly  cin- 
ders), which  is  put  in  the  stokehole  and  used  to  raise 
the  steam.  There  is  left  only  the  fine  ash  under 
the  screen,  which  is  wheeled  to  another  part  of  the 
shed  and  spread  on  iron  plates  covering  the  Hue  lead- 
ing from  a  small  furnace  to  the  boiler  chimney.  This 
small  furnace  is  used  for  the  combustion  of  paper  and 
large  articles  which  could  not  conveniently  be  put  in 
the  stokehole,  and  supplies  heat  to  the  Hue  over  which 
the  fine  ashes  are  spread.  When  the  asiies  are  fairly 
dry,  they  are  sprinkled  with  commercial  sulphuric  acid 


to  the  extent  of  about  four  per  cent,  by  weight.  After 
a  few  days  the  acidulated  ashes  are  wheeled  into  the 
mixing-shed  and  thrown  on  the  top  of  the  crude  night- 
soil, which  has  been  tipped  there  during  the  previous 
night.  From  an  analysis  which  has  been  made  the 
manure  is  found  to  contain  twenty-six  per  cent,  of 
organic  matter. 

A  Propos  of  the  recent  French  barber-shop  sanita- 
tion, the  following  clipping  from  the  Medical  Press  is 
of  interest :  "  A  proprietor  of  a  barber's  shop  has  very 
justly  been  fined  ^5  and  costs  for  attending  to  his 
business  wniie  still  passing  through  the  peeiing-siage 
of  scarlet  fever." 

Toads. — The  ancient  belief  that  the  toad  was  a 
venomous  animal  has  been  lately  shown  to  be  not 
altogether  without  foundation.  The  cutaneous  glands 
of  the  toad  do  secrete  a  venom  which  is  in  a  high 
degree  toxic  when  introduced  into  the  circulation. 
The  production  of  venom  is  by  no  means  confined  to 
the  common  toad  and  land  salamander,  but  is  met  with 
in  allied  species,  the  natterjack  and  tropical  toads, 
and  to  a  small  extent  the  frogs.  The  creatures  are 
unable  voluntarily  to  eject  the  venom,  which  is 
secreted  only  in  response  to  some  reflex  irritation  and 
has  a  purely  defensive  function. — Science  Progress. 

Nitroglycerin  in  Children. — Dr.  Angel  Money 
states  in  The  Lancet  \hiA  nitroglycerin  appears  to  have 
no  toxic  effects  in  infants  and  small  children  even  in 
very  large  doses.  He  constantly  prescribes  one  minim 
of  a  one-per-cent.  solution  to  infants  under  the  age  of 
two  years  every  two  or  three  hours  in  place  of  sweet 
spirits  of  nitre. 

Health  Reports. — The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  super\-ising  surgeon- 
general  of  the  United  States  Marine  Hospital  service, 
during  the  week  ended  October  16,  1897: 


R— tjNiTEU  States. 


.Alabama,  Bayminette October  14th 

Flomaton October  14th 4 

Wagar October  11th i 

Mobile October  1st  to  15th 77 

Gforsia,  .\tlanta October  8th 1 

Louisiana,  New  Orleans October  ist  to  15th 546 

Franklin October  14th i 

Mississippi,  Biloxi October  ist  to  isth 208 

Clinton October  9th  to  14th 2 

Edwards October  1st  to  15th 179 


Cases.  Deaths. 


5th. 


Pascagoula  .. .   -October  14th 

Scranton October  1st  to  islh  . , 

Texas,  Galveston   October  glh  to  12th  . 

Houston October  nth 


Yellow  Fever — Foreign. 

Brazil,  Para September  18th  to  25th 

Rio  de  Janeiro    ..    .  August  38th  to  September  nth.  i 

Cuba,  Cardenas September  25th  to  October  ad..  .. 

Cienfuegos September  26th  to  October  3d..  .. 

Sagua  la  Grande September  iSth  to  October  2d..  75 

Tamaica,  King.ston September  18th  to  25th 4 

Mexico,  Vera  Cruz October  1st  to  7th 3 

U.  S.  of  Colombia,  Panama.  September  23d  to  October  3d. . .  i 

Cholera — Foreign. 

India,  Bombay September  7th  to  14th 

Calcutta August  zSlh  tj  September  4th..     .. 

Madras September  3d  to  loth 

Plagi'e — Foreign. 

India,  Bombay September  7th  to  14th 

Small-Pox — L'niteu  States. 

Alalianui,  Birmingham October  id  lo  9th 4  (3  % 


Small-Pox— Foreign. 


6S 


Brazil,  Manaos September  nth  to  25th.. 

Rio  de  Janeiro August  28th  to  Seolcmbc'r  1  mi.     11 

China,  Hong  Kong...  August  21st  to  28tn 

Cuba,  Suviua  la  Grande September  iSth  to  Ott.iber  2d..    40 

India,  Cilcutta .\ugust  jSth  10  Septemlver  4th..     .. 

Spain,  Madrid September  14th  to  28th 

Russia,  Moscow September  nth  to  iSth 1 

Odessa September  18th  to  25th i 

St.  Petersburg September  nth  to  25th 13 

Warsaw September  iStb  to  25th 


Medical  Record 

A  JVeekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  18. 
Whole  No.  1408. 


New  York,   October    30,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


®t:igiual  Jk-rticles. 

ANTISEPTICS    IN    EYE    SURGERY.' 

By    HEXRV    D.    NOVES,    M.D.. 


For  operations  on  the  eye,  meaning  especially  extrac- 
tion of  cataract,  experience  has  shown  that  the  usual 
antiseptic  methods  of  surgery  must  be  modified  in  sev- 
eral particulars.  I  can  best  set  forth  my  own  practice 
and  the  practice  of  my  colleagues  of  the  New  York 
Eye  and  Ear  Infirmary,  under  the  heads  of,  first,  the 
operator;  second,  the  instruments;  third,  the  field  of 
operation;  fourth,  the  dressings. 

I  St.  As  a  rule  the  surgeon  puts  on  a  clean  w  hite  sack, 
either  over  or  in  place  of  his  ordinary  coat.  His 
hands  are  carefully  scrubbed  with  soap  and  water,  and 
powdered  borax  is  freely  sprinkled  on  the  brush.  Spe- 
cial attention  is  given  to  the  nails,  and  the  borax  has 
a  potent  effect  in  getting  rid  of  grease  and  dirt,  .-^fter 
the  scrubbing,  immersion  in  a  sublimate  solution,  i  to 
3,000,  leaves  the  hands  sufficiently  purified  for  an  oper- 
ation when  the  fingers  do  not  come  in  contact  with 
the  field,  and  with  the  sense  of  touch  unimpaired. 
The  operator  will  not  have  need  to  touch  any  other 
part  than  the  lids,  and  all  other  contacts  are  by  instru- 
ments. 

2d.  All  instruments,  e.xcept  knives  and  needles,  are 
put  in  boiling  distilled  water  for  about  ten  minutes, 
then  laid  in  ninety-five-per-cent.  alcohol  for  ten 
minutes,  and  transferred  to  a  clean  and  sterilized  por- 
celain tray  and  covered  by  a  towel  wet  in  sublimate 
solution,  I  to  1,000.  The  alcohol  is  used  for  this 
purpose  only  once.  Knives  and  needles  are  sim]jlv 
plunged  for  a  minute  in  boiling  water  and  then  laid 
in  alcohol  with  the  other  instruments.  All  are  very 
carefully  wiped  with  muslin  or  cotton  wet  in  alcohol. 
Sometimes  at  the  last  moment  a  knife  or  curette  or 
probe  may  be  dipped  in  a  bottle  of  alcohol  and 
smartly  shaken  to  throw  off  excess  of  fluid.  If  made 
of  platinum,  a  probe  or  spatula  may  be  passed  through 
an  alcohol  flame.  Rubbing  carefully  will  cleanse 
smooth  and  straight  instruments.  Forceps,  scissors, 
and  speculum,  and  all  instruments  having  joints  and 
holes  are  subjected  to  rigorous  treatment  before  and 
after  an  operation.  They  must  be  perfectly  clean 
when  put  away  and  will  then  be  ready  for  steriliza- 
tion when  next  required.  They  are  stored  in  metal 
racks  on  glass  shelves  within  a  tight  cabinet. 

,^d.  The  patient  has  a  warm  bath,  and  is  to  be  at- 
tired in  clean  clothes  for  lying  in  bed.  Should  there 
be  manifest  irritation  of  the  lids  or  of  the  conjunctiva, 
suitable  treatment  is  adopted  until  a  .safe  condition  is 
attained.  It  is  the  habit  of  some  surgeons  to  ban- 
dage the  eye  for  twenty-four  hours  in  order  to  detect 
chronic  conjunctivitis,  and  not  to  operate  so  long  as 
any  secretion  exists.  The  majority  of  surgeons,  and  I 
include  myself,  are  satisfied  with  inspection  to  dis- 
cover the  condition  of  the  parts,  and  regard  bandaging 
as  giving  occasion  to  secretion,  and  so  far  tending  to 

'  Read  in  the  section  of  ophthalmology  at  the  meeting  of  the 
British  Medical  Association  in  Montreal,  September  i,  1S97. 


create  what  we  wish  to  avoid.  A  moderate  degree  of 
chronic  conjunctivitis  is  common  to  old  persons,  and 
if  the  secretion  is  mucoidal  and  not  copious  it  does 
not  forbid  an  operation,  neither  will  treatment  wholly 
remove  it.  Chronic  inflammation  of  the  lid  borders 
and  ectropion  demand  effectixe  treatment.  Chronic 
dacryo-cystitis,  as  is  well  known,  constitutes  a  serious 
danger.  There  is  usually  no  time  for  ordinary  treat- 
ment, and  the  destruction  of  the  sac  by  cautery  or  its 
removal  by  dissection  is  doubtless  the  wisest  proceed- 
ing, and  will  demand  at  least  two  or  three  weeks  be- 
fore extraction  can  be  ventured.  We  do  not  fail  to 
realize  the  dangers  of  the  complication  when  the  lac- 
rymal  disease  is  clearly  manifest,  but  I  speak  from  a 
sad  experience  when  I  remember  that  suppuration  may 
attack  the  cornea  several  days  after  the  operation,  as 
the  result  of  dacrj'o-cystitis  which  had  for  years  been 
in  abeyance,  but  was  lighted  to  fresh  activity  by  the 
reaction  of  a  perfectly  normal  cataract  extraction. 
One  must  therefore  not  be  satisfied  by  negative  ob- 
jective evidence  as  to  lacrymal  disease,  but  also 
remember  to  inquire  into  past  history  on  this  point. 
Bad  nasal  catarrh  has  also  a  dangerous  character  and 
might  be  inhibitory  until  sufficiently  mitigated  by 
treatment.  Pterygion  as  an  evidence  and  complica- 
tion of  chronic  conjunctivitis  may  demand  removal 
and  subsequent  treatment  until  no  serious  irritation 
remains.  It  is  well  known  that  germs  are  found  in 
great  numbers  under  the  edges  of  a  pterygion,  and  their 
hiding-places  must  be  abolished.  Supposing  the  case 
free  from  or  relieved  of  the  complications  specified, 
and  the  patient  in  bed,  the  parts  about  the  eye  are 
scrubbed  with  soap  and  water,  special  attention  being 
given  to  the  eyebrows,  and  rinsed  oft'  with  a  sublimate 
solution,  I  to  3,000.  The  edges  of  the  lids  are  care- 
fully wiped  with  a  pledget  of  cotton  dipped  in  boric- 
acid  solution. 

Towels  wrung  out  of  sublimate,  1  to  1,000,  are 
wrapped  around  the  head  and  under  the  chin.  The 
lids  being  separated  by  the  speculum,  the  conjunc- 
tival sac  is  thoroughly  flushed  with  a  two-per-cent. 
solution  of  boric  acid  or  the  physiological  salt  solu- 
tion. The  stream  from  the  rubber  bulb  is  directed 
especially  into  the  culs-de-sac  abo\e  and  below,  into 
the  semilunar  fold,  and  into  the  outer  angle.  Shreds 
of  secretion  may  be  caught  by  the  speculum,  and  great 
pains  must  be  taken  to  remove  all  such  material.  By 
this  proceeding  all  coarse  flocculi  are  removed,  and 
this  is  all  that  can  safely  be  attempted.  Sublimate 
solution,  1  to  10,000,  is  equally  admissible  and  has  a 
coagulating  property  greater  than  the  above  solutions, 
but  in  no  case  is  any  fluid  of  an  irritating  character 
employed.  It  is  well  known  that  micro-organisms  are 
always  present  on  the  normal  conjunctiva,  and  wash- 
ing cannot  remove  them,  but  it  does  carry  away  shreds 
and  flocculi  in  which  doubtless  plenty  of  germs  are 
contained.  What  proportions  are  harmless  and  what 
are  pathogenic  we  cannot  know.  Hut  all  strong  anti- 
septics cause  irritation  and  unfavorably  influence  the 
healing  process.  Perhaps,  as  Randolph  has  suggested, 
this  is  explained  by  conversion  of  harmless  germs  into 
others  of  a  pathogenic  quality.  The  anesthetic  solu- 
tions of  cocaine  or  any  other  drug,  and  in  my  practice 
atropine  solution,  four  grains  to  the  ounce,  which  have 


6i8 


MEDICAL    RECORD. 


[October  30,  1897 


already  been  employed,  are  absoluiely  sterile  and  fur- 
nished fresh  for  each  operation  in  half-drachm  bottles, 
corked  and  sealed,  and  not  used  again  unless  ster- 
ilized anew. 

At  the  close  of  the  operation  I  frequently  let  the 
stream  from  the  bulb  play  forcibly  on  the  wound  to 
wash  away  clots  and  de'bris,  and  it  often  forces  its 
way  into  the  anterior  chamber.  I  may  gently  press 
open  the  wound  and  often  succeed  in  e.xpelling 
material. 

I  have  given  up  the  practice  of  irrigating  the  an- 
terior chamber  by  a  pipette  or  instrument  entered 
within  it.  Panas'  fluid,  the  biniodide  of  mercury,  i  to 
20,000,  injected  into  the  chamber,  I  have  seen  in  several 
instances  to  bring  about  patchy  opacity  of  Descemet's 
membrane,  and  I  have  ceased  to  use  it.  In  flushing 
the  eye,  whether  before  or  after  the  section,  the  specu- 
lum may  be  lifted  from  the  globe  to  give  the  fluid 
freer  access.  If,  as  is  usual  with  me,  the  speculum 
has  been  removed  before  the  lens  is  delivered,  the 
upper  lid  is  held  by  a  strabismus  hook  and  the  lower 
lid  by  the  finger  of  an  assistant.  It  is  none  the  less 
easy  to  wash  off  the  eyeball. 

If  prolapse  of  the  vitreous  has  occurred,  the  greatest 
care  should  be  used  to  excise  all  that  may  intrude 
between  the  lips  of  the  wound,  because  it  is  a  most 
fertile  medium  of  infection.  This  remark  applies  to 
the  normal  and  not  to  fluid  vitreous. 

4th.  Dressings.  The  absorbent  cotton,  the  bandage 
whether  of  gauze  or  flannel,  the  muslin  patches,  have 
been  kept  in  an  oven  for  two  hours  at  a  temperature 
of  about  300^  F.,  inclosed  in  a  perforated  tin  box  and 
then  are  placed  in  a  covered  glass  jar  and  are  exposed 
to  the  air  only  at  the  moment  when  called  for.  No 
antiseptic  substances  are  employed  to  medicate  them 
— reliance  is  placed  upon  the  eflicacy  of  dry  heat  and 
careful  seclusion  and  frequent  renewal.  If  a  bandage 
is  to  be  used,  the  muslin  patch  is  dipped  in  sublimate, 
I  to  3,000;  the  dry  cotton,  as  it  lies  upon  the  eye  be- 
fore the  bandage  is  applied,  is  wetted  with  the  same 
solution.  The  moist  dressing  is  a  comfort  to  the  pa- 
tient and  facilitates  escape  of  fluid  from  the  lids.  It 
is  my  habit  to  remove  and  renew  the  dressing  everj- 
twenty-four  hours,  and  imder  the  same  precautions.  I 
always  assure  myself  whether  a  normal  process  of 
iiealing  is  taking  place,  and  if  any  sign  of  infection 
appears  I  am  prepared  immediately  to  institute  treat- 
ment; I  may  remark  that  the  continuous  use  of  water 
as  hot  as  can  be  borne,  about  iio"*  to  115"  F.,  with 
cotton  compresses,  is  the  effective  treatment  to  stay 
the  progress  of  suppuration.  If  there  be  exudation  in 
the  anterior  chamber,  I  usually  remove  it  and  may 
also  attempt  irrigation  by  sublimate,  i  to  3,000.  I 
iiave  seldom  used  the  actual  cautery  or  pure  carbolic 
acid  on  the  wound,  and  in  most  cases  the  degree  of  re- 
action forbids  much  interference  beyond  the  use  of 
liot  fomentations. 

Within  five  years  in  my  private  practice  two  cases 
have  occurred  in  houses  where  at  the  time  of  operat- 
ing I  have  discovered  that  there  was  a  foul  water- 
closet  in  the  vicinity  of  the  patient's  room.  I  adopted 
all  available  precautions  to  prevent  mischief  in  the 
details  above  narrated,  and  ventilated  the  rooms  thor- 
oughly before  operaticm,  yet  suppuration  attacked  the 
wounds.  One  eye  escaped  unharmed.  The  eye  of  the 
other  patient  was  badly  damaged.  In  such  cases  the 
pernicious  germs  must  be  in  the  air  in  too  great  num- 
bers 10  be  dispelled  or  neutralized,  and  the  lesson  is 
to  refuse  to  operate  in  places  of  such  unsanitary  sur- 
roundings. Whatever  exceptions  may  seem  to  invali- 
date the  riile,  it  is  certainly  the  wi.sest  and  most  salu- 
tary for  the  patient  to  restrict  operations  to  properly 
constructed  and  properly  administered  hospitals.  It 
is  evident  that  in  eye  surgery  we  are  limited  in  great 
degree  to  measures  of  asepsis  rather  than  of  antisepsis. 


and  that  our  attention  must  be  given  chiefly  to  the  pur- 
ity of  the  hands  and  especially  of  the  instruments,  the 
solutions,  and  the  dressings. 


THE     PRECIPITATION    OF    EARTHY    PHOS- 
PHATES   FROM    URINE   BY    HEAT. 

By   J.    li.   NICHOLS,    M.D., 

t:i.INIt:AL   ASSISTANT,    t  .    S.    SOLDIERS*    JK»MF.,    WASHINGTON,    D.    C. 

The  frequent  appearance  of  a  cloudiness  or  precipi- 
tate upon  boiling  urine,  clearing  with  the  addition  of 
acid,  is  a  phenomenon  familiar  to  those  who  have  had 
the  least  experience  in  the  examination  of  this  fluid. 
Some  explanations  have  been  offered  as  to  the  cause 
of  the  precipitation,  most  of  them  in  a  measure  true, 
but  no  one  of  them  adequate  alone  to  account  for  all 
the  phenomena  which  present  themselves.  The  sub- 
ject is  usually  mentioned  very  briefly  and  imperfectly 
in  the  standard  works  on  the  urine,  and  it  seems  gen- 
erally to  be  little  understood.  It  is  the  purpose  of 
this  paper  to  present  the  results  of  a  study  of  this 
point. 

The  phenomena  ]jresent  in  the  ordinary  manipula- 
tions of  urine  are  these:  On  being  heated  in  a  test 
tube,  as  in  testing  for  albumin,  to  a  point  at  or  near 
the  boiling  temperature,  a  white  cloudiness  or  precip- 
itate appears  in  some  (not  all)  specimens  of  urine, 
which  clears  up  when  a  drop  or  two  of  acid  is  added 
— a  reaction  which  distinguishes  phosphates  from  an 
albuminous  precipitate.  If  the  urine  be  cooled  again 
after  the  cloudiness  has  been  developed  by  boiling, 
the  precipitate  is  totally  or  partially  redissolved,  and 
the  fluid  clears  either  entirely  or  in  part. 

Composition  of  the  Precipitate. — The  precipitate 
thus  thrown  down  by  heat  consists  of  phosphates  of 
calcium  and  magnesium.  Some  observers  have  as- 
serted that  calcium  carbonate,  calcium  sulphate,  cal- 
cium oxalate,  and  a  proteid  compound  also  occur  in  the 
precipitate  (Sommer  and  .Scharling,  Stokvis,  Mehu), 
while  by  others  the  presence  of  magnesium  phosphate 
has  been  denied  and  ignored.  In  a  couple  of  analvses 
made  by  me,  the  precipitate  being  very  profuse,  I 
found  the  phosphates  of  both  calcium  and  magnesium 
present,  while  carbonates  and  sulphates  were  absent. 
The  magnesium  phosphates  being  more  soluble  than 
those  of  calcium,  it  is  probable  that  the  calcium  salt 
might  be  present  alone  in  cases  in  which  only  a  slight 
precipitate  is  produced  by  heat;  the  carbonate,  sul- 
phate, and  oxalate  of  calcium  are  probably  precipi- 
tated in  boiling  urine  only  exceptionally,  if  ever, 
while  proteid  substances  would  be  absent  in  non- 
albuminous  urine. 

The  "earthy  phosphates"  which  occur  in  the  urine 
are  the  orthophosphates  of  calcium  and  magnesium. 
These  phosphates  are  as  follows; 

CaH,(PO,).,,  variously  called  tetrahydro-calcic  phos- 
phate, acid  calcium  phosphate,  dibasic  calcium  phos- 
phate, monocalcic  phosphate. 

CaH  PO,  monohydro-calcic  phosphate,  monobasic 
calcium  phosphate,  dicalcic  phosphate,  neutral  cal- 
cium phosphate. 

('a.,(PO,),,  tricalcic  phosphate,  normal  calcium 
phosphate:  it  is  also  frequently  called  basic  calcium 
phospiiate,  though,  it  would  seem,  from  the  strict 
meaning  of  the  term,  inaccurately. 

MgH  ^(  l'( ), )  ,  tetrahydro-magnesic  phosphate,  mono- 
magnesic  phosphate,  acid  or  dibasic  magnesium  phos- 
phate. 

MgH  PL),  monohydro-magnesic  phosphate,  dimag- 
iicsic  piiosphate,  neutral  or  monobasic  magnesium 
phospiiate. 

Mg^d'O^V.  Irimagnesic  phosphate,  normal  or 
■■  basic''  magnesium  phosphate. 


October  30.  1897] 


MEDICAL    RECORD. 


619 


These  phosphates  are  readily  transformed  from  one 
to  another  by  changes  in  the  surrounding  conditions; 
they  exist  in  the  urine  in  rather  indefinite  proportions, 
\arying  according  to  circumstances.  In  general,  they 
are  only  slightly  soluble  in  pure  water,  the  normal 
salts  being  least  and  the  dibasic  salts  most  soluble: 
the  magnesium  phosphates  are  somewhat  more  soluble 
than  the  calcium  phosphates.  They  are  quite  soluble 
in  acid  fluids,  even  if  only  slightly  acid.  Certain 
neutral  salts,  as  sodium  chloride,  also  have  considera- 
ble solvent  power  over  the  earthy  phosphates.  Their 
solution  in  the  urine  is  believed  to  be  chiefly  due  to 
the  presence  of  acid  salts,  esi^ecially  acid  sodium 
phosphate,  NaH,PO^,to  which  the  acidity  of  the  urine 
is  generally  mainly  attributed,  also  to  CO.,  XaCl,  etc. 
The  earthy  phosphates  are  insoluble  in  alkaline 
media,  and  hence  are  precipitated  from  the  urine  upon 
the  addition  of  alkalies. 

Cause  of   the  Precipitation Numerous   e.xplana- 

tions  have  been  offered  as  to  the  cause  of  the  pre- 
cipitation of  the  earthy  phosphates  from  urine  by 
heat. 

1.  The  appearance  of  the  precipitate  when  urine  is 
heated  and  its  re-solution  on  cooling  readily  suggest 
the  hypothesis  that  the  earthy  phosphates  are  less  sol- 
uble in  hot  than  in  cold  media.  This  explanation  is 
offered  by  Dalton,  Roberts,  Kober,  Fowler,  and 
Woody,  and,  partially,  by  Jones.  It  is  perhaps  a 
superficial  conclusion  and  not  based  on  critical  inves- 
tigations (which  in  this  case,  indeed,  present  peculiar 
difficulties) ;  yet  in  the  various  discussions  of  the  sub- 
ject which  I  have  found  I  have  never  seen  this  view 
specifically  denied  or  questioned.  It  is  certainly  very 
unusual  for  the  solubility  of  solids  to  decrease  with 
heat,  but  such  cases,  as  that  of  calcium  hydrate,  occur. 
While  this  factor  may  possibly  be  operative,  and  per- 
haps in  high  degree,  the  occasional  failure  of  the  pre- 
cipitate entirely  to  redissolve  on  cooling  shows,  how- 
ever, that  it  can  not  be  the  sole  element  involved  in 
the  case  of  the  urine. 

2.  One  of  the  chief  explanations  of  the  precipitation 
of  the  phosphates  by  heat  is  based  on  the  supposition 
tliat  the  chemical  nature  of  the  phosphates  varies  with 
changes  of  temperature,  less  soluble  salts  being  formed 
by  heat.  This  theory,  which  is  generally  attributed 
to  .Scherer,  has  been  held  or  concurred  in  by  Carles, 
Huppert,  Jones,  Ott,  l^arkes,  Schattner,  Smith,  Stokvis, 
\'an  Niiys,  and  Wynkoop,  and  quoted  by  numerous 
others. 

According  to  Hupjiert's  revision  of  Neubauer  and 
X'ogel's  work  on  urine  analysis,  which  apparentl\- 
presents  the  best  chemical  knowledge  of  the  subject, 
the  solubilities  of  the  earthy  phosphates  and  the 
clianges  effected  in  them  by  heat  are  as  follows: 
(  aH^(POJj  is  soluble  in  about  700  parts  of  pure  cold 
water;  CaHPO,  in  about  6,700  parts;  Ca,(PO,)..  in 
about  100,000  parts.  MgH^iPO,).  is  quite  soluble  in 
water;  MgHPO^  (anhydrous)  in  about  1,000  parts  of 
cold  water;  Mg  (PC),) ,  (tlie  freshly  precipitated  amor- 
phous salt)  in  about  5,000  parts.  Their  solubilities 
are  increased  in  the  urine  by  the  presence  of  acid  and 
neutral  salts,  which  also  retard  the  changes  brought 
about  by  heat.  Dibasic  phosphate,  if  in  sufficiently 
concentrated  solution,  on  being  heated,  partially 
l)reaks  up  into  phosi)horic  acid  and  monobasic  phos- 
phate, thus: 

CaH^(PO,)^  =  H  PO,  --  CaHPO,. 

The  monobasic  salt  being  much  less  soluble  remains 
jiartially  undissolved.  Owing  to  the  in.sufficient  con 
centration  of  the  .solution  (jf  CaH,(PO,).  this  reaction 
is  not  supposed  to  take  place  in  the  urine.  On  heat 
ing  sufficiently  concentrated  solutions  of  the  monobasic 
salts,  they  partially  break  up  into  the  dibasic  phos- 
pliates,   which    remain    in    .solution,  and    the    normal 


phosphates,   which    being   only    slightly    soluble    are 
partially  precipitated,  thus: 

(CaHPOJ.  =  CaH,(PO,)„  -f-  Ca.  (PO,),. 
(MgHPOj.  -  MgH,(^PO,X  +  Mg^CPOJ,. 

The  chemical  theory  of  Scherer  and  others,  then,  is 
this :  On  heating  urine,  if  the  earthy  phosphates  are  in 
sufficiently  concentrated  solution,  the  monobasic  salts 
partially  break  up  into  the  insoluble  normal  phos- 
phates, which  precipitate,  and  the  soluble  dibasic 
phosphates.  On  cooling,  the  reverse  process  is  sup- 
posed to  take  place  and  the  precipitate  wholly  or  par- 
tially disappears.  Under  the  conditions  present  in 
the  urine  the  occurrence  of  any  changes  in  the  dibasic 
phosphates  is  disregarded. 

According  to  this  theory,  accompanying  the  forma- 
tion and  precipitation  of  normal  phosphates  there 
should  be  an  increase  in  the  acidity  of  the  solution 
due  to  the  increased  quantity  of  the  acid  dibasic  phos- 
phates formed.  That  boiling  increases  the  acidity  of 
urine  which  precipitates  phosphates  on  heating  has 
been  asserted  by  some  observers,  and  this  is  coniirma- 
tor)'  of  the  hypothesis  under  consideration.  Other 
obser\-ers  have  not  found  this  increase  of  acidity;  and 
Brett  asserted  that  it  is  apparent  rather  than  real,  and 
is  due  to  a  more  marked  action  of  fluids  upon  litmus 
paper  while  hot.  My  own  experiments  have  been  too 
few  to  warrant  any  definite  conclusion  as  to  the  relative 
acidity  of  such  urine  while  hot;  still,  I  have  not  been 
able  to  find  any  increase  in  the  acidity  over  what  it 
was  before  boiling.  I  have  constantly  found  boiled 
urine  after  cooling  to  be  materially  diminished  in 
acidity.  It  is  worthy  of  notice  that  an  increase  of 
acidity  would  probably  promote  the  solution  of  the 
normal  phosphates  formed. 

Ky  adding  to  a  solution  of  CaCl..  or  of  MgSO^  one 
of  Na„HPO,  (not  in  excess),  and  filtering  away  the 
precipitates,  clear  solutions  free  from  CO„  will  be  ob- 
tained, containing  phosphates  of  calcium  and  mag- 
nesium respective!)',  which,  on  boiling,  will  give  pre- 
cipitates that  will  clear  partially  but  not  wholly  on 
cooling.  This  result  may  in  the  case  of  fresh  solutions 
be  partly  due  to  a  more  active  reaction  between  the 
sodium  phosphate  and  the  calcium  and  magnesiimi 
salts  taking  place  under  the  influence  of  heat,  result- 
ing in  an  increased  production  of  calcium  and  magne- 
sium phosphates:  but  aside  from  this  it  cannot  be 
explained  on  any  other  theory  yet  offered  than  that  of 
a  chemical  change  in  the  earthy  phosphates  being 
effected  by  heat.  This  theory  is,  therefore,  at  least  in 
part,  probably  true  with  respect  to  the  occurence  of 
the  phenomenon  in  urine.  That  it  is  the  chief,  or 
even  a  prominent,  factor  in  the  case  cannot,  I  be- 
lieve, be  affirmed  until  it  is  shown  that  these  phos- 
phates are  not  absolutely  less  soluble  in  hot  than  in 
cold  fluids. 

3.  It  has  occurred  to  me  that  the  supposition 
(hinted  at  in  the  preceding  paragraph)  might  be  enter- 
tained that  under  the  influence  of  heat  a  more  vigor- 
ous reaction  might  occur  between  the  sodium  and 
potassium  phosphates  and  calcium  and  magnesium 
salts. other  than  phosphates  in  solution  in  the  urine, 
resulting  in  an  increased  formation  of  the  earthy 
phosphates.  This  supposition  may  be  dismissed  with 
the  remark  that  these  phosphates  may  be  precipitated 
by  heat  from  artificial  solutions  in  which  no  other 
phosphates  are  present,  and  that  in  the  urine  calcium 
and  m.agnesium  do  not  normally  occur  to  any  extent 
except  as  phosphates. 

4.  Salkowski  about  1883  presented  the  theory  that 
calcium  phosphate  occurs  in  the  urine  in  a  weak  com- 
liination  with  sodium  or  potassium  phosphate,  which  is 
broken  up  by  heat,  causing  the  calcium  phosphate  to 
separate  and  precipitate.  No  other  authorit)-  appears 
to  have  accepted  this  view,  and  it  has  been  combated 


620 


MEDICAL    RFXORD. 


[October  30,  1897 


by  Smith.  As  the  precipitation  by  heat  may  occur  in 
artificial  solutions  in  which  no  sodium  or  potassium 
salts  are  present,  this  theory  may  be  dismissed  from 
consideration. 

5.  After  prolonged  heating  the  precipitate,  or  its 
persistence  after  cooling,  may  be  partially  due  to  loss 
of  fluid  by  evaporation.  This,  however,  cannot  ac- 
count for  the  precipitation  as  it  occurs  in  the  ordinary 
brief  boiling  in  a  test  tube. 

6.  An  explanation  of  the  phenomenon  in  question 
which  has  gained  considerable  currency  is  that  the 
earthy  phosphates  are,  partially  at  least,  held  in  solu- 
tion in  the  urine  by  free  carbon  dioxide,  CO,,  and  that 
upon  its  expulsion  by  heat  they  are  precipitated.  This 
theory  was  first  presented  by  Brett,  in  1836;  it  has 
been  held  also  by  Heller,  Landois,  Loebisch,  Neu- 
bauer,  Salkowski  and  Leube,  Tyson,  Ultzmann  and 
Hofmann,  Vogel  and  Ziilzer. 

Carbon  dioxide  dissolved  in  water  gives  it  a  degree 
of  acidity,  due  to  the  presence  of  virtual  carbonic  acid, 
H.CO,.  The  gas  is  expelled  from  watery  solution  by 
heating;  it  may  also  be  driven  out  with  some  facility, 
without  heat,  by  vigorous  agitation.  The  earthy 
phosphates  of  the  urine  are  soluble  in  water  contain- 
ing CO,,,  as  in  other  acid  media;  and  a  pennanent 
precipitate  is  obtainable  in  such  solutions  on  dissipat- 
ing the  gas  either  by  heating  or,  to  a  less  extent,  by 
vigorous  agitation.  Free  CO.,  is  a  normal  ingredient 
of  urine;  and  the  natural  inference  follows  that  it  has 
some  solvent  infiuence  over  the  earthy  phosphates 
there  and  that  its  expulsion  by  heat  or  otherwise 
would  tend  toward  their  permanent  precipitation. 

The  acidity  of  urine  is  usually  (after  the  fluid  has 
cooled,  at  least)  materially  and  markedly  diminished 
by  boiling.  This  fact,  pointed  out  by  Brett  in  1836, 
I  have  verified  by  repeated  trials,  determining  the 
acidities  by  titration  with  decinormal  sodium  hydrate 
solution,  phenolphthalein  being  used  as  the  indicator; 
the  color  of  urine  interferes  somewhat  with  a  close 
estimation  of  the  point  of  neutralization  when  phenol- 
phthalein is  used,  but  the  results  were  sufficiently  accu- 
rate for  comparative  purposes.  Within  certain  limits 
it  appears  that  the  longer  the  heat  is  applied  the 
greater  is  the  decrease  of  acidity  and  the  more  profuse 
is  the  precipitation.  I  have  also  been  able  to  effect  a 
slight  diminution  of  the  acidity  of  urine  by  vigorouslv 
shaking  it,  though  I  have  never  produced  a  precipitate 
in  this  way. 

It  is  probable  that  the  decrease  of  acidity  of  urine 
caused  by  heating  is  due  to  the  expulsion  of  CO„. 
From  a-priori  considerations  precisely  that  result  is  to 
be  expected  from  the  presence  of  CO..  in  the  urine; 
reasoning  by  exclusion  there  is  no  other  acid  princi- 
ple in  the  urine  upon  which  heat  is  capable  of  produc- 
ing so  marked  and  rapid  an  etfect ;  and  the  behavior 
of  urine  in  this  respect  corresponds  closely  with  that 
of  solutions  of  CO.,. 

The  expulsion  of  C0„  and  the  diminution  of  acidity 
caused  by  heating  urine,  with  the  resultant  decrease 
of  solvent  power  over  the  earthy  phosphates,  readily 
suggest  themselves  as  a  cause  of  the  precipitation  of 
the  latter.  Moreover,  I  have  found  the  precipitate  pro- 
duce<l  by  boiling  when  the  urine  is  fresh  (CO..  being 
then  present)  to  be  more  profuse  than  on  subsequent 
boiling  (when  CO..  is  absent)  after  the  first  precipitate 
is  filtered  out.  The  re-solution  of  the  precipitate  on 
cooling,  and  the  fact  that  lurhidily  can  be  produced 
by  heat  in  solutions  of  the  phosphates  free  from  CO„, 
on  the  contrary,  show  that  the  expulsion  of  this  gas 
is  not  the  chief  cause  of  the  precipitation:  but  it  must 
have  some  action  in  the  case,  especially,  perhaps,  in 
the  instances  in  which  the  precipitate  does  not  en- 
tirely redissolve  on  cooling. 

.\  cursory  investigation  was  made  to  determine 
whether  the  expulsion  of  CO.^  might  not  account  for 


the  occasional  precipitation,  by  heat,  of  the  carbonate, 
sulphate,  and  oxalate  of  calcium  reported  by  some 
observers.  Calcium  carbonate  is  somewhat  soluble  in 
water  containing  CO,.,  and  is  precipitated  by  heating; 
but  I  could  produce  no  similar  result  with  the  sulphate 
or  oxalate.  Calcium  carbonate  is  also  precipitated 
on  boiling  solutions  of  calcium  bicarbonate  or  calcium 
carbajnate,  which  may  under  certain  unusual  circum- 
stances occur  in  urine. 

7.  The  transformation  of  urea  to  ammonium  carbo- 
nate by  heat  is  an  old  explanation,  attributed  to  Henry, 
of  the  precipitation  of  the  earthy  phosphates,  and  has 
recently  again  been  presented  by  Shattock.  The  re- 
solution of  the  precipitate  on  cooling  is  fatal  to  this 
theon,-;  also  the  fact  that  the  precipitation  may  occur 
in  solutions  free  from  urea.  Heat,  it  is  true,  slowly 
decomposes  urea,  and  if  the  ammonium  carbonate  pro- 
duced remained  in  the  urine  the  effect  would  be  a  de- 
crease of  acidity ;  but  the  heat  that  acts  on  the  urea 
also  drives  out  the  NH,  and  CO,,  and  it  is  hardly 
conceivable  that  under  ordinarj'  circumstances  ammo- 
nium carbonate  could  remain  in  the  fluid.  The  pre- 
cipitation after  prolonged  boiling,  cited  by  Shattock 
in  favor  of  his  theory,  is  probably  due  to  evaporation 
of  the  fluid. 

8.  'Ihe  theory  that  the  earthy  phosphates  are  held 
in  solution  in  urine  by  ammonium  chloride,  whose  de- 
composition by  heat  causes  them  to  be  precipitated, 
was  presented  by  Rees  and  Barlow  in  1836,  but  has 
received  no  support.  This  hypothesis  may  jwssibly 
be  correct  enough  in  a  degree  so  far  as  artificial  solu- 
tions are  concerned,  but  it  can  have  little  share  in  the 
explanation  of  the  phenomenon  as  it  occurs  in  the 
urine,  for  the  following  reasons:  The  clearing  of  the 
precipitate  on  cooling  alone  overthrows  it.  Ammo- 
nium chloride  occurs  in  normal  urine  only  in  minute 
|5roportion,  and  its  solvent  influence  on  the  earthy 
phosphates  is  insignificant  in  comparison  with  that  of 
sodium  cliloride  and  the  acid  salts  of  the  urine.  The 
earthy  phosphates  give  a  precipitate  on  heating  also 
when  dissolved  in  an  aqueous  solution  of  sodium  chlo- 
ride, which  is  certainly  not  dissipated  by  boiling; 
and  the  same  precipitate  is  obtainable  in  numerous 
other  artificial  solutions  containing  no  ammonium 
chloride.  Rees  stated  that  the  acidity  of  urine  is  in- 
creased by  boiling,  and  accounted  for  it  by  loss  of 
ammonia. 

.•\mong  the  experiments  made  by  me  tlie  following 
may  be  cited  for  its  general  bearing  on  the  subject: 
.-V  quantity  of  earthy  phosphates  was  obtained  by  add- 
ing sodium  hydrate  to  urine,  and  filtering,  washing, 
and  drying  the  precipitate  at  room  temperature.  A 
saturated  solution  of  these  phosphates  was  made  in 
water  containing  CO,;  on  boiling  in  a  test  lube  a 
profuse  precipitate  was  obtained,  clearing  somewhat 
but  still  marked  on  cooling,  and  about  half  the  CO.., 
as  determined  by  volumetric  acidimetry,  was  expelled: 
after  vigorously  shaking  in  a  test  tube  a  slight  precip- 
itate was  obtained,  the  CO.  being  decreased  one-half. 
-A  saturated  solution  of  the  phosphates  was  made  in  a 
solution  of  \aH.rO,  of  a  strength  about  equal  to  that 
of  the  urine:  on  boiling  in  a  test  lube  a  profuse  pre- 
cipitate appeared,  whicii  on  cooling  was  nearly  or 
entirely  redissolved,  the  acidity  of  the  solution  not 
being  diminished;  on  dilution  with  about  double  the 
amount  of  the  N'aH.PO,  solution  no  precipitate  oc- 
curred on  heating.  .\  solution  of  the  phosphates  was 
made  in  the  above-noted  solution  of  XaH  TO,  10 
which  CO.,  had  been  added;  on  boiling  a  profuse 
precipitate  was  formed,  wiiich  cleared  only  partially  on 
cooling,  most  of  the  CO..  being  expelled;  no  precipi- 
tate could  be  obtained  by  brisk  agitation,  although 
CO.J  was  driven  out  to  the  same  extent  as  by  boiling. 
.\  saturated  solution  of  the  phosphates  in  one-per- 
cent, solution  of   XaCl   gave  a  slight   precipitate   on 


October  30,  1897] 


MEDICAL    RECORD. 


621 


boiling,  clearing  when  cool.  It  thus  appears  that  the 
precipitate  forms  on  heating  whether  CO,  is  present 
or  not;  but  when  it  is  present  the  precipitate  is  more 
persistent  on  cooling.  The  expulsion  of  CO,  by  shak- 
ing has  much  less  effect  in  producing  the  precipitate 
than  has  heating. 

From  all  the  considerations  above  presented  the 
following  conclusions  seem  justified:  The  precipita- 
tion of  the  earthy  phosphates  from  urine  by  heat  is 
mainly  due  either  (n)  to  their  chemical  nature  being 
altered  by  heat,  less  soluble  salts  being  formed,  while 
the  process  is  reversed  on  Cooling  and  the  salts  redis- 
solve;  or  (^)  to  their  being  less  soluble  in  hot  than  in 
cold  media  and  being  therefore  thrown  down  by  heat, 
redissolving  on  cooling.  Possibly  both  these  factors 
are  operative,  and  the  former  one  certainly  is  to  some 
degree,  .\nother  cause,  which  is  f>erhaps  especially 
manifest  in  those  cases  in  which  the  turbidity  persists 
after  cooling,  is  the  expulsion  of  CO„  and  loss  of  acid- 
it)'  caused  by  heating,  which  diminish  the  solvent 
power  of  the  urine  over  the  earthy  phosphates,  .\fter 
prolonged  boiling  the  precipitate  or  its  persistence  on 
cooling  may  be  also  partially  attributed  to  evaporation 
of  a  portion  of  the  fluid. 

This  statement  does  not  entirely  clear  up  the  ob- 
scurity of  the  subject,  but  it  defines  the  sphere  of  oper- 
ation of  certain  factors  and  limits  the  field  within 
which  the  true  main  cause  of  the  precipitation  is  to  be 
found. 

Circumstances  under  which  Precipitation  Occurs. 
— The  occurrence  of  the  precipitate  depends  upon  the 
degree  of  concentration  of  the  earthy  phosphates  in 
solution  in  the  urine:  turbidit}' will  be  produced  by 
heating  only  when  the  concentration  is  so  great  that 
when  the  fluid  is  heated  the  point  of  saturation  is 
passed.  This  e.xplains  why  the  phenomenon  does  not 
occur  with  all  specimens  of  urine.  If  in  relatively 
strong  solution,  the  phosphates  will  be  profusely  pre- 
cipitated by  heat,  and  (especially  in  connection  with 
the  lessened  acidity  caused  by  boiling)  the  precipitate 
will  not  entirely  clear  on  cooling;  in  a  less  degree  of 
concentration  the  fluid  will  become  turbid  on  boiling 
and  entirely  clear  again  after  cooling:  while  in  rela- 
tively weak  solution  there  will  be  no  precipitate  what- 
ever on  heating.  This  view  is  confirmed  by  the  fact 
that  upon  cautiously  adding  alkali  to  urine  that  gives 
no  precipitate  on  boiling,  thus  increasing  the  relative 
concentration  of  the  phosphatic  solution  by  diminish- 
ing the  acidity,  a  point  can  be  reached  where  the  fluid 
will  become  cloudy  on  heating  and  clear  again  when 
cool ;  and  by  carrsing  the  process  still  further  a  preci- 
pitate which  persists  on  cooling  can  be  obtained  with 
heat.  -A  similar  result  can  be  obtained  by  adding 
calcium  chloride,  which  increases  the  amount  of  cal- 
cium phosphates  present  and  so  augments  the  phos- 
phatic concentration. 

It  is  to  be  observed  that  the  concentration  of  the 
solution  of  phosphates  in  the  urine  depends  upon  two 
distinct  factors:  (a)  the  absolute  quantity  of  earthy 
phosphates  present,  and  (fi)  the  amount  of  the  sub- 
stances (acid  phosphates,  CO.,,  chlorides,  etc.)  which 
hold  the  earthy  phosphates  in  solution.  Hence  the 
occurrence  of  the  precipitate  on  healing  urine  has  in 
itself  no  significance  as  to  the  quantity  of  earthy  phos- 
phates present:  it  indicates  simply  their  relative  con- 
centration in  the  fluid,  and  may  be  due  either  to  ex- 
cess of  phosphates  with  high  acidity  of  the  urine,  or, 
as  is  usually  the  case,  to  low  acidity  with  a  smaller 
amount  of  phosphates.  It  is  to  a  slight  degree  suscep- 
tible of  a  positive  or  corroborative  interpretation, 
taken  in  connection  with  a  known  high  acidity  as  to 
the  quantity  of  earthy  phosphates,  or  in  the  presence  of 
a  sediment  as  to  its  phosphatic  nature.  The  phenome- 
non occurs  alike  in  urine  from  healthy  and  diseased 
persons,  and  has  little  or  no  clinical  significance. 


Literature. — I  have  been  unable  to  find  the  origi- 
nal writings  of  Henry,  Scherer,  Schaftner,  Sommer  and 
Scharling,  and  Beneke,  who  have  made  studies  of  this 
subject.  .Aside  from  numerous  works  which  make 
only  a  bare  mention  of  the  phenomenon,  the  following 
list  exhibits  the  literature  bearing  on  the  subject 
which  I  have  found : 

BIBLIOGRAPHY. 

Aldridge,  J.:  Dublin  Hospital  Gazette,  November  15,  1845, 
vol.  ii.,  p.  104. 

Bermingham,  E.  J.,  editor:  Encyclopaedic  Index  of  Medicine 
and  Surger)-,  New  York,  18S2,  p.  8S2. 

Brett,  R.  H.:  London  Medical  Gazette,  February  27,  1836, 
vol.  xvii.,  p.  846  ;  .\pril  16  and  30,  1S36,  vol.  xviii.,  pp.  94  and 
174. 

Carles,  P. :  Bulletin  des  Travaux  de  la  Societe  de  Pharmacie  de 
Bordeaux.  13S4,  p.  149.  Journal  de  Pharmacie  et  de  Chimie. 
Paris,  January  15,  1886,  vol.  xiii.,  fifth  series,  p.  49.  Journal 
de  Pharmacie  d' Alsace-Lorraine.  May,  1SS6,  vol.  xiii.,  p.  93. 

Daiton.  John  C:  Human  Physiology.  Seventh  edition. 
Philadelphia,  1SS2,  p.  331. 

Fowler.  George  B. ;  Chemical  and  Microscopical  Analysis  of 
the  Urine  in  Health  and  Disease.  Second  edition.  New  York, 
1S76,  pp.  19  and  38. 

Heller,  T-  F.:  Die  Harnconcretionen.  Yienna,  i86o,  pp.  iSi- 
183. 

Jones,  Henr)'  Bence  :  Philosophical  Transactions  of  the 
Royal  Society  of  London,  1S45,  p.  343.  Animal  Chemistry  in 
its  Application  to  Stomach  and  Renal  Diseases,  London,  1850, 
P-  93- 

Kober,  George  M.:  Urinology  and  Its  Practical  .Applications, 
Louisville,  1S75,  p.  11. 

Krabbe,  H.:  Om  Phosphorsyrema?ngden  i  Urinen  og  om  de 
Phosphorsure  Jordarters  Udf.-elning  deraf  ved  kogning,  Copen- 
hagen, 1857  ;  abstract  in  Yirchow's  .\rchiv  fiir  pathologische 
.\natomie  und  Physiologie  und  fiir  klinische  Medicin,  TS57, 
vol.  xi. ,  p.  47S. 

Landois,  L.:  Human  Physiolog)-.  Translated,  etc.,  by  Wilb'am 
Stirling.      Fourth  edition,  Philadelphia,  1892,  p.  523. 

Loebisch.  W.  F. :  Anleitung  zur  Ham-Analyse,  Yienna,  187S, 
pp.  112  and  135. 

MacMunn,  C.  A.:  Outlines  of  the  Clinical  Chemistry  of 
Urine,  Philadelphia,  1SS9.  p.  121. 

Mehu.  C:  L'Urine  Normale  et  Pathologique,  Paris,  18S0,  pp. 
284  and  326. 

Neubauer,  C,  and  Vogel,  J.:  Anleitung  zur  qualitativen  und 
quantitativen  Analyse  des  Hams.  Sixth  edition,  NYiesbaden. 
1872,  p.  68;  ninth  edition,  \Viesbaden,  1890,  part  I.,  revised 
by  H.  Huppert,  p.  15. 

Ott,  .\dolf :  Zeitschrift  fiir  phvsiolog^sche  Chemie,  18S6,  vol. 
X.,  p.  5- 

Parkes,  Edmund  .\. :  Composition  of  the  Urine  in  Health  and 
Disease  and  under  the  Action  of  Remedies,  London,  i860,  p. 221. 

Rees,  George  Owen,  and  Dr.  Barlow  :  Guy's  Hospital  Reports, 
1836,  vol.  i.,  p.  401. 

Rees,  George  Owen  :  London  Medical  Gazette,  April  23,  1836, 
vol.  xviii.,  p.  145. 

Roberts,  William  :  Practical  Treatise  on  Urinarj'  and  Renal 
Diseases.      Fourth  edition,  London,  1SS5,  p.  103. 

.Salkowski,  E. ,  and  Leube.  W. :  Die  I.ehre  vom  Ham,  Berlin, 
1SS2,  pp.  191,  207,  and  349. 

Salkowski,  E.:  Zeitschrift  fiir  physiologische  Chemie,  1882- 
S3,  vol.  vii.,  p.  119. 

Shattock,  S.  G. :  Transactions  of  the  Pathological  Society  of 
London,  1891-92,  vol.  xliii.,  p.  200. 

.Smith,  Walter  G. :  Dublin  Journal  of  ^fedical  Science,  1SS3, 
vol.  Ixxvi.,  p.  18.      British  Medical  Journal,  1883,  ii. ,  p.  68. 

Stoti'is,  B.  J.:  Nederlandsch  Tijdschrift  voor  Geneeskunde. 
-Vmsterdam,  1SS2,  vol.  xviii.,  second  series,  supplement,  p.  105; 
abstracts  in  Centralblatt  fiir  die  medicinischen  Wissenschaften, 
Berlin.  December  8,  18S3,  vol.  xxi.,  p.  885,  and  Chemisches 
Centralblatt,  January  16,  1884,  vol.  xv.,  third  series,  p.  42. 

Tyson,  James  :  Guide  to  the  Practical  Examination  of  Urine. 
Fourth  edition.  Philadelphia,  1S83,  p.  117. 

Ultzmann,  Robert,  and  llofmann,  K.  B.:  .Anleitung  zur  Un- 
tersuchung  des  Harns.  Yienna,  1S71,  p.  ex. 

Van  Nnys,  T.  C. :  Chemical  Analysis  of  Healthy  and  Dis- 
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Yogel,  Julius :  Yirchow's  Handbuch  der  speciellen  Pathologic 
und  Therapie.  vol.  vi.,  part  ii.,  Erlangen,  1S64,  p.  513. 

Woody,  Sam  E. :  Essentials  of  Medical  Chemistry  and  Uri- 
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Zulzer  :   Lehrbuch  der  Hamanalyse,  1880  (cited  from  Stokvis). 


The  rank  and  file  of  the  profession  manifests  the 
strongest  possible  feeling  against  the  present  dispen- 
sar}'  abuses. 


622 


MEDICAL    RECORD. 


[October  30,  1897 


THE   DIFFERENTIAL    DIAGNOSIS   BETWEEN 
MALARIAL   AND    TVPHOID    FEVERS.' 

By  J.  F.  JENKINS,  M.D., 

THCUMSEH,  MICH. 

The  difficulties  in  making  a  diagnosis  between  mala- 
rial and  typhoid  fever  are  in  many  instances  very 
great,  from  the  fact  that  typhoid  fever  presents  itself 
under  so  many  and  varied  conditions,  the  type  at  one 
time  being  very  marked,  at  another  time  assuming 
many  of  the  phases  of  malarial  fever.  Sporadic  cases 
occurring  in  country  districts  and  very  generally  in 
villages  are  not  infrequently  diagnosed  malarial  fever, 
and  doubtless  the  deaths  reported  to  local  boards  of 
health  under  the  head  of  malarial  fever  are  usually 
due  to  typhoid  fever. 

Dr.  Osier  states  in  a  paper  recently  read  by  him 
that  "north  of  Mason  and  Di.xon's  line  physicians  are 
prone  to  diagnose  malaria  for  other  disease;  south  of 
the  line  they  are  more  prone  to  diagnose  other  disease 
for  malaria;  in  both  regions  it  is  a  source  of  greater 
error  than  any  other  affection."  There  are  many  lo- 
calities in  this  State,  as  well  as  other  States  north  of 
Mason  and  Dixon's  line,  where  malarial  fever  still 
prevails,  especially  during  the  autumnal  months,  and 
it  is  in  these  sections  that  it  is  so  frequently  found 
a  difficult  question  to  determine  w'hether  the  patient 
has  malarial  or  typhoid  fever. 

In  each  and  every  case  the  source  of  infection  should 
be  thoroughly  investigated,  and  in  many  instances  such 
an  investigation  will  give  material  aid  in  arriving  at  a 
correct  diagnosis. 

It  is  seldom  that  typhoid  fever  commences  with  a 
pronounced  chill,  while  malarial  fever  is  usually  ush- 
ered in  with  a  chill,  more  or  less  severe,  followed  by 
high  fever;  sometimes  typhoid  fever  commences  with 
a  distinct  chill — that  is,  with  a  shaking  chill;  but  the 
temperature  rise  is  not  so  abrupt,  never  reaching  103'^ 
to  105^  F.,  as  it  usually  does  in  malarial  fever  within 
the  first  twenty-four  or  forty-eight  hours.  The  de- 
velopment of  typhoid  fever  is  in  the  large  majority  of 
cases  slow  and  insidious;  there  are  a  feeling  of  weari- 
ness, general  malaise,  some  fever,  which  increases  day 
by  day,  and  under  these  conditions  quinine  may  be 
administered  in  antiperiodic  doses  and  may  lessen 
the  pyrexia,  but,  like  the  annual  overflow  of  the  Nile, 
it  is^  certain  again  to  make  its  appearance.  In  ma- 
laria epistaxis  is  rare,  while  in  typhoid  fever  in  its 
incipient  stage  it  is  frequently  present,  especially 
among  the  young,  but  seldom  occurring  in  patients 
beyond  the  age  of  fifty.  In  malarial  fever  the  pulse 
rate  will  not  be  very  much  increased  by  taking  the 
patient  suddenly  from  bed  and  placing  him  in  the  up- 
right position,  while  in  the  incipient  stage  of  enteric 
fever  the  pulse  rate  is  greatly  increased  by  such  a 
change  of  position.  In  the  early  stage  of  tj'phoid 
fever  this  alteration  of  position  will  frequently  assist 
in  determining  the  nature  of  the  fever. 

Where  the  malarial  fever  prevails,  and  it  is  a  ques- 
tion whether  or  not  the  infection  is  the  product  of  the 
Eberth's  bacillus  or  the  hajmatazoa  of  malaria,  ten 
grains  of  quinine  given  every  three  or  four  hours  until 
thirty  grains  are  administered,  and  this  amount  re- 
peated every  twenty-four  hoursf  or  two  or  three  days, 
will  materiall)'  assist  in  differentiating  the  disease. 
The  infection  of  malaria  will  be  destroyed  by  qui- 
nine, while  in  typhoid  fever  the  drug  may  reduce  the 
pyrexia,  but  it  will  soon  reappear,  .\mong  the  la- 
goons of  Northern  Indiana,  more  than  a  quarter  of  a 
century  ago,  the  writer  followed  out  a  plan  similar  to 
the  one  above  mentioned,  and  frequently  found  that 
instead  of  malarial  infection  the  only  factor  in  the 
case  was  the  infection  of  typhoid  fever.     These  fevers 

'  Read  at  the  annual  meeting  of  the  Michigan  State  Medical 
Society. 


commonly  had  all  the  characteristics  of  typhoid  fever, 
excepting  that  they  were  invariably  accompanied  by 
profuse  perspiration.  The  local  physicians  termed 
them  "  slow  fevers,"  and  finally  they  assumed  the 
name  of  typho-malarial  fevers,  but  post-mortem  ex- 
aminations whenever  made  disclosed  the  pathological 
lesions  of  typhoid  fever. 

The  importance  of  making  an  early  diagnosis  in 
typhoid  fever  is  generally  admitted,  because  the  hy- 
gienic and  dietetic  management  of  the  disease  is 
absolutely  of  more  importance  than  internal  medica- 
tion ;  the  lesion  in  the  alimentary  canal  often  leading 
to  fatal  results,  even  in  apparently  the  mildest  form  of 
enteric  fever. 

Within  the  past  few  years  the  microscope  has  made 
us  familiar  with  the  typhoid  bacillus,  and  bacteriolo- 
gists have  mde  us  acquainted  with  its  natural  history, 
its  growth,  its  favorite  habitat  for  development,  how  it 
behaves  within  and  without  the  body,  its  most  favor- 
able conditions  for  propagation,  and  how  to  avoid  and 
destroy  the  bacilli  outside  the  body.  These  facts  are 
still  leading  us  to  more  certain  methods  of  diagnosis, 
and  we  may  look  forward  to  methods  which  will  be 
more  definite  in  making  out  a  differential  diagnosis 
of  fevers  instead  of  depending  upon  symptoms. 

Ehrlich's  te^t,  or  what  is  termed  the  diazo-reaction. 
appears  to  have  a  limited  value.  This  test,  which  it 
is  not  necessary  to  describe  here,  tj'phoid  fever  re- 
sponds to  after  the  first  week;  it  maybe  used  to  deter- 
mine whether  the  infection  is  due  to  the  Eberth's 
bacillus  or  the  ha;matozoa  of  malaria. 

Another  means  of  diagnostic  import  in  fever  sup- 
posed to  be  typhoid  is  in  the  examination  of  the 
stools  microscopically  for  the  Eberth's  bacillus;  if  it 
is  found,  it  is  evident  the  patient  has  enteric  fever. 

The  serum  diagnosis  of  typhoid  fever  has  been 
undergoing  investigation  during  the  past  year,  but  its 
practical  usefidness  is  still  an  unsettled  question. 
The  difficult)-  in  Widal's  or  Johnston's  test,  as  well  as 
others  above  mentioned,  is  that  it  requires  an  expert, 
and  hence  it  is  almost  useless  in  general  practice. 

The  discover)-  of  the  hamatozoa  of  malaria  by  La- 
veran  is  at  least  next  in  importance  to  the  discovery  of 
the  tubercle  bacillus  by  Koch.  It  has  given  the  med- 
ical profession  an  intelligent  concept  of  malarial  fever 
in  its  various  manifestations,  and  the  literature  on  this 
subject  has  already  been  cleared  of  an  immense  amount 
of  rubbish  which  has  enveloped  the  medical  practice 
of  the  past. 

The  combined  infection  of  Eberth's  bacillus  and 
the  ha'matozoa  of  malaria  seldom  occurs,  excepting 
as  it  may  still  linger  in  the  mind  of  some  medical 
hayseed,  who,  Rip-Van-^^"inkle-like,  continues  to  hold 
fast  to  the  opinion  that  malarial  fever  develops  into 
typhoid  fever,  or  is  in  some  way  dovetailed  into  it. 
On  this  question  permit  me  to  quote  Dr.  Osier,  who 
states  that  "  among  the  one  thousand  cases  of  malaria 
and  the  five  hundred  cases  of  typhoid  fever  which  have 
been  at  my  clinic,  almost  ever)'  one  of  which  has  had 
a  blood  examination,  there  has  been  but  one  doubtful 
case  of  double  infection." 

Double  infection  so  infrequently  occurs  that  it  will 
seldom  enter  as  a  factor  in  the  differential  diagnosis 
betAveen  malarial  and  typhoid  fever. 


Dyspnoea  of  Uraemia.— 

^  .'Ether  sulph 5  i. 

S.  Two  or  three  teaspoonfuls  in  a  little  sweetened  water. 

Or  ether  can  be  administered  hypodermatically  in 
doses  of  two  or  three  cubic  centimetres,  every  three 
hours,  and  in  the  intervals  it  can  be  given  by  the 
mouth.  It  produces  abundant  diuresis  and  calms 
respiratory  spasm. — Lemoine  <i/iii  Gallois. 


October  30,  1897] 


MEDICAL    RECORD. 


A  NEW  OPERATION  FOR  MALIGNANT  DIS- 
EASE OF  THE  TESTICLE^-THE  NECES- 
SITY OF  A  MORE  EXTENSIVE  OPERATION 
THAN  CASTRATION  FOR  CARCINOMA, 
SARCOMA,    ETC.,    OF   THE   TESTICLE. 

Bv  J.  COPLIX   STIXSOX,  M.I>., 


Ik  deciding  on  an  operation  for  malignant  disease  of 
the  testicle,  the  problem  is  to  remove  the  disease  thor- 
oughly. Castration  is  an  operation  which  can  be  per- 
formed with  very  small  danger  to  life,  but  whether  for 
sarcoma  or  carcinoma  the  operation  is  not  attended 
by  large  success,  so  far  as  complete  cure  is  con- 
cerned. There  is  some  evidence  that  it  may  be  at- 
tended by  permanent  success,  and  there  is  still  fur- 
ther evidence  that  the  operation  may  be  an  e.xcellent 
palliative  measure,  even  when  there  is  no  cure.  Thus 
in  ninety-nine  cases  collected  by  Butlin  there  were 
four  deaths  from  causes  directly  connected  with  the 
operation.  Many  of  the  patients  were  not  traced,  but 
there  were  five  cases  of  sarcoma  well  at  the  end  of  from 
twenty  months  to  two  years,  and  two  cases  of  carci- 
noma without  recurrence  at  the  end  of  forty-two 
months  and  one  hundred  and  eight  months  respec- 
tively. While  these  results  are  encouraging,  yet  I  am 
sure  that  with  a  radical  operation  still  more  encourag- 
ing results  can  be  obtained.  The  objects  of  my  paper 
are  to  describe  an  of)eration  which  will  yield  a  greater 
number  of  permanent  cures  than  will  castration,  and 
to  report  a  case  in  which  I  operated  by  the  radical 
method. 

The  following  structures  should  be  removed  by  oper- 
ation in  order  to  give  our  patient  the  best  possible 
chance  for  pennanent  ture : 

t.  The  diseased  testicle  and  its  coverings. 

2.  The  portion  of  the  scrotum  containing  the  dis- 
eased organ,  including  in  addition  the  raphe  of  the 
scrotum  and  the  septum  scroti. 

3.  The  spermatic  cord,  its  vessels,  etc.,  as  high  as 
the  internal  inguinal  ring. 

4.  The  inguinal  glands,  fat,  adhesions,  etc. 
The  operation  is  performed  as  follows : 

1.  An  incision  is  made  from  the  e.xternal  inguinal 
ring  downward  and  inward  to  the  beginning  of  the 
raphe  of  the  scrotum.  The  cut  follows  the  sulcus  be- 
tween the  scrotum  and  penis.  It  is  then  carried  down- 
ward and  backward,  parallel  with  and  external  to  the 
raphe  of  the  scrotum,  and  terminates  at  the  scroto- 
perineal  junction.  ■  The  incision  divides  the  tissues 
of  the  scrotum. 

2.  A  second  incision,  which  is  slightly  curved,  is 
made  from  the  e.xternal  ring  downward,  following  the 
sulcus  between  the  scrotum  and  the  thigh  and  the  peri- 
neum. It  tenninates  by  joining  the  first  incision  at 
the  scroto-perineal  junction.  This  also  divides  the 
layers  which  fonii  the  scrotum. 

3.  The  scrotum,  the  testicle,  and  its  coverings,  the 
median  raphe,  the  septum  scroti,  etc.,  are  as  a  rnass 
freed  from  all  their  attachments  except  to  the  cord,  up 
to  the  external  inguinal  ring.  Any  masses  of  fat, 
glands,  adhesions,  etc.,  should  also  be  freely  removed 
with  these  structures. 

4.  A  third  incision  is  made  parallel  with  and  about 
one-half  an  inch  above  Poupart's  ligament,  from  the 
external  ring  to  one-half  an  inch  above  the  internal 
inguinal  ring.  It  divides  the  structures  superficial  to 
the  aponeurosis  of  the  external  oblique.  The  latter 
is  well  exposed  and  divided  in  the  direction  of  its 
fibres  to  about  one-half  an  inch  above  the  internal 
ring.  The  cut  edges  are  lifted  and  freed  from  the 
structures  beneath,  so  as  to  expose  the  cord,  etc.,  up 
to  the  internal  ring.  The  cord,  etc.,  are  separated 
from  the  surroundings  from  the  external  ring  to  high 
up  within  the  internal  ring,  care  being  taken  also  freely 


to  remove   all  mass  of  fat,  glands,  adhesions,  etc.,  in 
the  rings  and  canal. 

5.  Make  moderate  traction  on  the  cord  so  as  to 
draw  it  out  as  far  as  possible  from  the  internal  ring, 
and  secure  it  high  up  within  the  internal  ring  with  a 
clamp.  Divide  below  it.  Any  bleeding  vessel  or  ves- 
sels are  ligated  separately  with  fine  catgut.  The  raw 
surface  of  the  stump  is  covered  over  by  bringing  to- 
gether with  continuous  sutures  of  catgut  the  cut  edges 
of  the  external  coat  of  the  cord.  When  the  clamp  is 
removed  the  sutured  edges  of  the  cord  at  once  slip 
back  into  the  abdomen. 

6.  The  cut  edges  of  the  aponeurosis  of  the  external 
oblique  and  the  pillars  of  the  external  inguinal  ring 
are  brought  together  with  continuous  sutures  of  chro- 
micized  tendon  or  chromicized  catgut. 

7.  The  flap  of  skin  covering  the  inguinal  glands  is 
dissected  downward  and  all  of  the  inguinal  glands  and 
fat  removed.  If  the  glands  are  adherent  to  the  skin, 
the  latter  is  also  freely  removed. 

8.  The  flap  is  now  replaced  and  the  cut  edges  of  the 
skin  of  the  groin  and  the  scrotum  are  united  with  fine 
silk  sutures  without  drainage.  A  small  strip  of  bi- 
chloride gauze  may  be  inserted  for  a  short  distance  in 
the  lower  angle  of  the  scrotal  wound  and  left  in  place 
for  a  day  or  so.  All  hemorrhage  should  be  arrested 
before  the  wound  is  closed. 

Dressings  and  after-treatment :  Bichloride-of-mer- 
ciu^'  gauze  or  sterilized  gauze  is  placed  next  to  the 
wound.  The  dressing  is  held  in  position  b}'  long 
strips  of  adhesive  plaster,  then  a  layer  of  cotton,  and 
then  a  firm  spica  and  T- bandage.  Care  should  be 
taken  to  avoid  infection  from  urine  and  faces;  keep 
the  patient  in  bed  two  weeks.  Dress  the  wound  on 
the  seventh  day  or  earlier,  if  there  are  indications 
when  the  silk  sutures  are  removed.  The  firm  dressings 
on  the  inguinal  region  are  not  removed  till  one  month 
after  the  operation. 

In  June,  1897, 1  had  an  opportunit}'  of  operating  on 
a  patient  for  carcinoma  of  the  testicle  by  this  radical 
method. 

History  of  the  patient:  Age,  forty-five  years: 
general  condition  good.  In  the  last  week  of  May  or 
the  ist  of  June,  1897,  he  noticed  that  something  was 
the  matter  with  the  left  testicle,  which  was  about 
twice  the  normal  size.  Some  days  afterward  the 
skin  in  front  of  the  body  of  the  testicle  broke  down 
and  a  sloughy  mass  formed.  It  was  not  painful.  I 
saw  the  patient  June  23,  1897.  Examination  showed 
the  left  testicle  enlarged  to  about  three  times  the  nor- 
mal size,  not  painful  or  tender  to  the  touch.  In 
front  and  connected  with  the  skin  was  a  sloughy  con- 
vex surface,  about  an  inch  and  one-quarter  in  diame- 
ter. The  mass  was  part  of  the  testicle  and  bled  freely 
on  being  picked  with  thumb  forceps.  The  skin  for 
about  one-quarter  of  an  inch  around  the  protruding 
mass  was  moderately  hard  and  indurated :  the  edges 
were  raised  and  appeared  to  grip  the  mass.  The  cord 
was  thickened.  The  glands  in  the  left  groin  had  been 
removed  about  a  year  before  for  chancroidal  infection 
and  abscesses.  The  prostate  appeared  to  be  normal 
for  a  man  of  his  age.  I  made  oj^eration  Jime  24, 
1897.  Chloroform  was  administered  by  the  drop 
method  by  Dr.  G.  Gross.  The  steps  of  the  operation 
were  the  same  as  described  above,  with  two  e.xceptions : 
the  skin  incision  made  from  the  external  ring  down- 
ward and  inward  to  the  penis,  and  external  to  the 
raphe  of  the  scrotum,  was  carried  higher  on  the  root 
of  the  penis  and  encroached  on  the  scrotal  tissue  of 
the  normal  testicle  for  about  one-half  an  inch.  This 
was  done  in  order  that  the  incision  should  be  removed 
as  far  as  possible  from  the  indurated  skin.  No  dis- 
section was  done  for  the  removal  of  glands  in  the 
groin,  as  these  had  been  extirpated  about  a  year  be- 
fore.    The  stump  of  the  cord  was  whipped  over  with 


624 


MEDICAL    RECORD. 


[October  30,  i! 


fine  chromicized  catgut.  The  cut  edges  of  the  apo- 
neurosis of  the  external  oblique  and  the  pillars  of  the 
external  inguinal  ring  were  united  with  chromicized 
catgut  sutures.  The  cut  edges  of  the  skin  of  the  groin 
and  the  scrotum  were  brought  together  with  fine  cat- 
gut. A  narrow  strip  of  moist  bichloride  gauze  was 
inserted  for  a  short  distance  in  the  lower  angle  of  the 
scrotal  wound.  This  strip  was  removed  thirty  hours 
after  the  operation,  and  the  dressings  were  reapplied. 
The  wound  healed  by  primary  union.  Recovery  was 
uninterrupted.  The  patient  will  be  kept  under  ob- 
-servation.  I  believe  that  in  treating  cases  of  malig- 
nant disease  of  the  testicle  a  more  thorough  operation 
than  castration  should  be  performed. 

In  the  radical  operation  I  describe,  the  incisions 
are  made  wide  of  the  diseased  organ.  The  cord, 
etc.,  are  removed  as  high  as  possible  away  from  the 
testicle,  while  the  thorough  extirpation  of  the  in- 
guinal glands,  fat,  etc.,  also  removes  channels  by  the 
way  of  which  infection  might  spread  or  in  which  in- 
fection is  already  present.  No  incision  is  made  into 
diseased  tissues,  and  thus  secondary  infection  is  pre- 
vented. The  septum  scroti  and  the  raphe  of  the 
scrotum  are  removed,  as  they  are  formed  by  the  junc- 
tion of  the  series  of  coverings  which  invest  the  testicle 
and  which  make  up  the  different  layers  of  the  scrotum. 
Even  with  such  free  removal  of  the  scrotum  there  is 
quite  sufficient  of  this  tunic  left,  so  that  its  cut  edges 
can  be  brought  accurately  together  without  tension, 
and  without  making  the  slightest  degree  of  pressure 
on  the  testicle.  This  is  due  to  the  extreme  flabbiness 
of  the  scrotal  tissues.  There  is  every  reason  why  this, 
the  thorough  operation,  should  be  performed.  It  can 
be  easily  and  quickly  done.  The  mortality  should  be 
at  or  about  nil,  and  I  am  sure  time  will  show,'  if 
our  cases  of  malignant  disease  of  the  testicle  are  oper- 
ated upon  by  this  radical  method,  that  we  shall  have 
a  large  percentage  of  permanent  cures. 

326  Kearnv  Street. 


THE  TREATMENT  OF  HYDROCELE  BV 
THE  INSERTION  OF  STERILIZED  CAT- 
GUT WITHIN    THE   TUNICA   VAGINALIS. 

By    CEORGE    G.  VAN    SCHAICK,   M.I.)., 


SURGEON  AND 


The  treatment  of  hydrocele  by  the  insertion  of  ster- 
ilized catgut  within  the  tunica  vaginalis  is  due  to  a 
French  surgeon,  to  the  best  of  my  belief.  I  first  heard 
of  it  in  France  a  couple  of  years  ago,  but  have  failed 
to  find  the  name  of  its  originator. 

The  object  of  this  operation  is  to  cause  an  aseptic 
inflammation  of  the  serous  lining  of  the  tunica,  result- 
ing in  a  modification  of  its  secreting  power.  This  is 
also  obtained  by  the  injection  of  iodine  and  other  irri- 
tants, and  by  scoring  the  serous  lining  by  means  of 
nitrate  of  silver  fused  upon  a  probe.  It  would  appear 
from  the  results  I  have  obtained  that  the  use  of  catgut 
is  commonly  followed  by  less  pain  than  the  other 
methods,  and  the  success  of  the  treatment  is  fully  as 
good. 

The  technique  consists  simply  in  the  following 
steps:  Thorough  disinfection  of  the  scrotum,  which 
is  tapped  with  a  small  trocar,  in  order  to  secure  a 
rather  slow  evacuation  of  tiie  fluid.  A  catgut  ligature 
of  medium  size  is  introduced  within  the  cannula  as 
soon  as  the  serum  begins  to  flow,  and  rapidly  pushed 
within  the  tunica  through  the  cannula,  until  about 
eight  inches  has  passed  through  it.  When  all  the 
liquid  is  evacuated  the  cannula  is  removed,  and  the 
catgut  hanging  out  of  the  puncture  is  snipped  ofi'  with 


scissors  as  close  as  possible  to  the  scrotum.  By  ma- 
nipulation of  the  scrotum  we  secure  the  complete  en- 
trance of  the  catgut  within  the  tunica.  The  wound  is 
then  sealed  with  collodion. 

If  the  asepsis  has  been  perfect  there  is  no  possibil- 
ity of  the  occurrence  of  any  infection.  The  rather 
nauseating  pain  that  sometimes  occurs  after  iodine 
injections  is  commonly  absent.  No  febrile  movement 
occurs.  I  have  so  far  observed  nine  cases,  whose  his- 
tories may  be  briefly  given  : 

Case  I. — A.  W ,  carpenter,  aged  forty-one  years, 

had  noticed  a  swelling  for  six  months,  but  never  did 
anything  for  it.  The  scrotum  was  tapped  and  the  cat- 
gut inserted  in  October,  1894.  Seven  ounces  of  liquid 
flowed  away.  The  next  day  the  patient  said  he  had 
felt  rather  uncomfortable  during  the  night,  but  had  no 
severe  pain.  A  week  later  there  seemed  to  be  a  slight 
amount  of  fluid  in  the  tunica.  This  rapidly  dis- 
appeared. Inquiry  six  months  afterward  revealed 
the  fact  that  there  had  been  no  return. 

C'.\SE  II. —  L.  ('.  H ,  lawyer,  seen  in  November, 

1894.  He  came  to  the  office  saying  that  his  regu- 
lar physician  was  out  of  town,  and  his  hydrocele  must 
be  tapped  at  once.  He  had  been  tapped  thirteen  times 
before,  the  hydrocele  having  existed  for  eight  years. 
He  accepted  my  proposition  to  use  the  catgut.  Nine 
ounces  of  fluid  was  evacuated.  The  operation  was 
followed  by  slight  occasional  pain  for  two  weeks.  In 
quir)'  in  August,  1897,  resulted  in  the  answer  that  he 
had  never  had  a  recurrence. 

Case  III. — F.  B — ,  saloon-keeper,  has  had  a  hydro- 
cele for  five  years:  it  has  been  tapped  six  times.  In- 
sertion of  catgut  in  March,  1895,  appeared  to  cause 
more  pain  than  usual,  but  the  patient  was  very  emo- 
tional. Fourteen  ounces  was  evacuated.  The  man 
complained  of  sharp  pain  during  the  night,  and  in- 
sisted upon  receiving  a  hypodennic  injection  of  mor- 
phine. He  said  he  felt  much  worse  than  after  simple 
tapping,  and  remained  in  bed  for  four  days.  At  the 
end  of  this  time  the  tunica  appeared  to  contain  nearly 
as  much  fluid  as  before,  and  the  patient  was  much  dis- 
couraged. A  fortnight  later  the  fluid  had  all  dis- 
appeared, and  has  not  returned  at  the  present  writing. 

Cases  IV.,  V.,  and  VI. — Each  of  these  patients  had 
a  hydrocele  of  moderate  size,  and  all  were  cured  with- 
out any  disagreeable  complications. 

Case  VII. — F.  R— — ,  musician,  has  had  a  very 
large  hydrocele  for  ten  years,  and  thinks  it  has  been 
tapped  fourteen  or  fifteen  times.  In  this  case  I  used 
a  rather  large  size  of  catgut  (No.  6  instead  of  No.  3,  as 
usual)  and  introduced  about  twelve  inches.  The  oper- 
ation was  performed  in  October,  1896.  Seventeen 
ounces  of  fluid  was  evacuated.  The  patient  felt  no 
pain  until  the  next  day,  when  he  complained  of  a  dull 
aching.  Some  fluid  returned,  and  within  a  week  the 
tunica  appeared  to  contain  about  seven  or  eight  ounces. 
The  testicle  then  began  to  swell,  and  remained  very- 
large  for  three  weeks,  but  caused  no  pain.  At  the 
end  of  this  time,  during  which  he  was  seen  in  consul- 
tation by  Dr.  James  E.  Kelly,  this  condition  rapidly 
subsided,  and  the  hydrocele  has  not  yet  recurred. 
During  the  whole  time  there  was  no  evidence  of  sep- 
sis, and  I  attribute  the  trouble  to  an  exaggerated  irri- 
tability of  the  parts. 

Cases  VIII.  and  IX. — These  patients  were  botli 
seen  in  February,  1897,  and  had  hydroceles  of  moder- 
ate size.     There  was  no  recurrence  after  treatment. 

One  other  patient  operated  on  last  month  appears 
to  be  doing  very  well,  but  the  case  is  too  recent  to  be 
included  in  the  list. 

This  little  operation  is  one  of  great  ease  and  sim- 
plicity, and  certainly  has  given  excellent  results  as  far 
as  I  have  h.id  an  opportunity  to  try  it.  No  one  who  is 
not  Cfitain  that  he  can  obtain  perfect  asepsis  in  ever)' 
detail  should  undertake  it,  but  in  careful  hands  it  can 


October  30,  1897] 


MEDICAL    RECORD. 


625 


hardly  give  rise  to  any  severe"  complication,  and  is 
worth  trying  in  every  case  in  which  the  Vollunann  or 
other  cutting  operation  is  refused  by  the  patient. 


23  We 


Thirty-Seventh  Stree 


TROUBLES      ARISING        FROM      PHIMOSIS, 
WITH   REPORT    OF    CASES.' 

By    F.    D.    REESE,    M.D., 


I  DO  not  intend  to  weary  you  with  a  long  paper  on 
this  subject,  for  Dr.  Sayre  in  1870  and  others  since 
have  written  too  well  and  explicitly  for  me  to  add  to 
their  accurate  and  exhaustive  observations.  But  I 
believe  that  it  is  well  for  us  occasionally  to  be  re- 
minded of  the  evils  that  are  due  to  neglected  phimosis. 

Phimosis  is  an  elongation  and  constriction  of  the 
prepuce,  making  it  difficult  or  impossible  to  expose  the 
glans  penis.  It  is  quite  probable  that  convulsions  are 
the  most  frequent  complication  due  directly  to  this 
condition.  As  Peterson  says,  an  infant  is  a  bundle  of 
nerves  and  nerve  centres  and  reflexes,  in  a  state  of 
great  activit)',  prepared  to  receive,  store  up,  and  re- 
energize a  world  full  of  new  impressions  suddenly 
thrust  upon  it.  The  continual  irritation  of  the  nerves 
from  accumulation  of  confined  smegma  and  subacute 
inflammation  of  the  mucous  lining  of  the  prepuce 
overbalances  the  inhibitory  action  of  the  higher  motor 
centres,  and  causes  convulsions. 

These  are  called  reflex  spasms,  because  the  nervous 
irritation  does  not  arise  primarily  in  the  higher  motor 
centres,  but  in  the  peripheral  nerves  of  the  genifal 
organs.  Then,  if  this  is  the  case,  we  as  physicians, 
to  be  faithful  to  our  charge,  should  examine  the  penis 
of  every  boy  baby  at  his  birth,  and  if  there  is  a  con- 
genital phimosis  or  an  adherent  prepuce  it  should  be 
relieved  at  the  earliest  opportunity.  What  is  there 
more  pitiable  and  lamentable  than  a  confirmed  epilep- 
tic? 

Hare,  in  his  essay  on  "Reflex  Epilepsy,"  says: 
"Further  than  this,  the  mere  temporary  irritabilit}"  of 
a  cicatrix  does  not  throw  the  patient  into  convulsion 
after  convulsion  immediately,  but  the  convulsive  con- 
dition, having  once  been  begun  by  such  a  cause,  may 
be  brought  back  even  when  no  irritation  longer  exists 
of  an  acute  form,  by  some  central  disturbing  mental 
condition  entirely  separated  from  the  periphery." 

What  he  says  in  regard  to  irritability  due  to  a 
cicatrix  is  equally  true  of  any  other  cause  of  irrita- 
tion. And  further,  he  says  the  law  may  be  laid  down 
as  an  almost  unvarying  one,  that  every  nervous  act 
is  followed  by  other  similar  nervous  acts,  rapidly  or 
slowly,  according  to  the  severity  and  frequency  of  the 
first  acts;  and  if  this  predisposition  be  once  set  up, 
the  subsequent  acts  may  readily  be  excited  by  agents 
which  primarily  would  have  produced  no  effect. 

Then,  if  this  law  be  true,  and  I  have  no  reason  for 
disbelieving  it,  for  experience  confirms  it,  we  should 
remove  everv-  irritation  that  might  be  a  primary  cause 
of  convulsions,  of  whatever  form  or  wherever  found, 
whether  it  is  a  depressed  portion  of  the  skull,  errors 
of  refraction,  tumors  of  the  rectum,  or  congenital  phi- 
mosis. 

To  show  that  congenital  phimosis  does  cause  reflex 
spasms,  I  will  report  the  two  following  cases: 

William  W ,  aged  two  and  one-half  years,  fam- 
ily history  negative,  was  always  a  colicky,  crying  baby, 
well  nourished,  but  undersized;  bowels  regular.  Dur- 
ing six  months  the  following  symptoms  developed: 
He  became  restless  at  night,  jumping  up  in  bed  and 
staring  as  if  frightened  ;  also  in  the  daytime  he  would 

'  Paper  read  before  the  third  district  branch  of  the  Medical 
Association  of  Xew  York,  Norwich,  June  8,  1897. 


Stop  and  stare  and  lose  himself  for  an  instant.  These 
spells  soon  developed  into  complete  spasms,  number- 
ing three  during  the  night  and  one  every  two  or  three 
hours  in  the  daytime. 

Upon  examination  I  found  a  constriction  of  the  pre- 
puce, with  adhesions  to  the  glans  penis.  In  the  ab- 
sence of  any  other  pathological  condition,  I  concluded 
the  spasms  were  of  reflex  origin  and  due  to  the  con- 
genital phimosis  and  adhesions. 

I  operated  April  23,  1896,  freely  exposing  the 
glans  and  turning  out  the  confined  smegma.  The 
spasms  began  immediately  to  occur  less  often,  and  on 
May  29th,  one  month  and  six  days  after  the  operation, 
he  had  his  last  spasm.  Since  then  he  has  been  as 
well  and  rugged  as  any  child  could  be. 

On  December  5,  1894,  I  was  called  to  see   Master 

McD ,  aged   three  and  one-half   years.      He   was 

born  of  healthy  parents,  but  was  very  much  under  size 
and  suffered  from  spasm  of  the  right  sterno  cleido- 
mastoid  muscle,  with  head  turned  to  the  right,  jerking 
of  the  eye  muscles,  and  squinting.  He  complained 
of  colic  and  had  indigestion  and  malnutrition.  He 
was  also  restless,  irritable,  and  anarmic.  An  exami- 
nation revealed  a  congenital  phimosis  and  adhesions  of 
the  prepuce.  I  operated  December  15,  1894.  There 
was  a  gradual  improvement  from  the  first.  While  the 
boy  is  still  small  for  his  age,  he  seems  perfectly 
healthy,  with  a  tranquil  disposition. 

The  following  case  illustrates  the  influence  of  pre- 
putial irritation  upon  the  disposition: 

Howard  L ,  aged   twelve  years,  family  history 

negative,  is  small  in  stature.  He  has  a  bright  intel- 
lect, but  formerly  did  not  like  to  play  with  his  mates 
of  either  sex,  and  was  non-communicative  and  despon- 
dent. He  complained  to  his  mother  of  frequent  and 
difficult  micturition ;  he  also  said  to  her  that  he 
wished  he  had  been  made  like  other  boys.  He  was 
brought  to  my  office  March  20,  1897.  An  examination 
revealed  a  very  small  penis,  with  almost  complete 
closure  of  the  prepuce,  which  was  chronically  inflamed. 
An  operation  was  advised,  and  when  the  boy  was  in- 
formed of  it  he  said  he  would  gladly  have  it  done  if  it 
would  make  him  like  other  boys.  The  vesical  irrita- 
tion and  difficulty  in  urinating  were  relieved  at  once 
by  the  operation,  and  his  whole  demeanor  has  been 
changed  as  a  result.  He  has  become  more  communi- 
cative and  is  developing  into  a  leader  among  his  com- 
panions. 

I  am  led  to  believe  from  my  own  experience  that  in 
many  cases  hernia  claimed  to  be  of  congenital  origin 
is  due  directly  to  the  straining  caused  by  difficulty  in 
urinating. 

The  next  and  last  case  that  I  shall  report  is  unique, 
as  far  as  I  have  been  able  to  ascertain,  for  it  illus- 
trates the  possibility  and  probability  that  phimosis  is 
at  times  the  primary  cause  of  septicemia. 

Baby  R — - —  was  born  July  15,  1896,  of  healthy  pa- 
rents, in  normal  labor.  He  nursed  the  mother's  breast. 
I  discovered  that  the  infant  had  congenital  phimosis 
and  advised  an  operation,  but  the  parents  objected. 
Occasionally  I  saw  the  child,  and  found  that  he 
suffered  from  colic,  difficulty  in  micturition,  and  con- 
stipation. 

October  15,  1896,  at  7  a.m.,  I  was  sent  for.  The 
patient  had  been  vomiting,  and  this  was  followed  by 
a  sinking-spell.  His  extremities  were  cold  and  he 
was  covered  with  a  clammy  sweat.  The  mother  said 
he  had  been  passing  pus,  tinged  with  blood,  in  his 
urine.  The  temperature  was  102°  F.,  the  pulse  was 
frequent,  the  boy  was  constipated,  and  his  abdomen 
was  tympanitic.  I  ordered  oleum  ricini  and  gave  a 
digestive  ferment:  I  also  had  him  fed  with  sterilized 
cow's  milk.  There  seemed  to  be  no  special  ciiange 
after  the  reaction  from  the  sinking-spell  until  October 
19th,  when  the  patient  began  to  take  on  an  icteric  hue. 


626 


MEDICAL    RECORD. 


[October  30,  1897 


Counsel  was  called  and  the  opinion  was  given  tliat  it 
was  a  case  of  acute  hepatitis.  One-tenth  grain  of  cal- 
omel was  given  every  two  hours,  but  was  of  no  avail. 
The  vomit  became  tinged  with  black  mucus  and  the 
urine  was  freely  mixed  with  pus.  The  child  died  Oc- 
tober 2ist,  just  six  days  after  he  was  taken  ill. 

A  post-mortem  was  held  a  few  hours  after  death, 
Drs.  Higgins  and  Watson  being  presetit.  The  body 
was  well  nourished,  but  jaundiced  :  the  thoracic  organs 
were  healthy.  On  opening  the  abdomen  the  bowel.-> 
were  found  empty  of  fa:;cal  matter,  but  filled  w  ith  gas. 
'i'he  stomach  contained  a  little  brownish-black  mucus; 
otherwise  it  was  empty.  The  liver  was  about  twice 
the  normal  size,  the  gall  bladder  was  normal,  the 
spleen  was  slightly  enlarged.  I'he  kidneys  were  lobu- 
lated,  capsules  slightly  adherent;  the  pehes  of  the 
kidneys  contained  urine  and  pus,  and  the  lining  mem- 
brane was  congested.  The  bladder  was  contracted, 
and  its  contents  and  the  condition  of  its  mucous  mem- 
brane were  the  same  as  in  the  pehes  of  the  kidneys. 
The  microscope,  in  the  hands  of  Dr.  Higgins,  revealed 
pus  and  blood  in  the  urine  and  congested  kidneys. 

My  theory  of  the  cause  of  death  in  this  case  is  as 
follows:  The  boy  had  congenital  phimosis  which  con- 
fined the  smegma,  causing  an  irritation  of  the  mem- 
brane of  the  prepuce,  and  finally  suppuration,  which 
infected  the  urethra.  This  infection  extended  along 
the  urethra  into  the  bladder,  ureter,  and  pehis  of  the 
kidney,  and  finally  a  general  absorption  of  pus  took 
place,  causing  septicaemia  and  death. 

These  cases  and  otiiers  that  might  be  cited  appear 
to  enforce  very  strongly  the  importance  of  detecting 
and  removing  phimosis.  Surgical  treatment  is  often 
remedial  in  troubles  that  might  seem  very  remote, 
and  if  generally  applied  to  congenital  phimosis  would 
certainly  prove  in  many  cases  the  proverbial  ounce  of 
prevention  which  is  better  than  the  pound  of  cure. 


progress  of  iJtXctlical  Science. 

Pseudo  -  Tuberculosis     Hominis     Streptothrica.  — 

Flexner  reports  the  case  of  a  colored  man,  seventy 
years  old,  presenting  extensive  consolidation  of  both 
lungs  and  symptoms  generally  of  pulmonaiy  tuber- 
culosis. No  sputum  could  be  secured  for  examina- 
tion'. Death  resulting,  the  lungs  were  found  to  be 
voluminous,  but  free  from  adhesions.  The  entire  left 
lung,  with  the  exception  of  the  anterior  edge  of  the 
upper  lobe,  was  more  or  less  perfectly  consolidated. 
In  those  portions  in  which  the  consolidation  was  frank 
the  lung  presented  an  opaque  appearance  and  was 
grayish  in  color,  and  softening  had  set  in.  Some  of 
the  cavities  contained  the  products  of  disintegration, 
but  all  appearances  of  active  encapsulation  were  want- 
ing. Where  the  hepatization  was  less  complete  the 
pulmonary  structure  was  adematous  and  swollen,  al- 
though perhaps  not  completely  airless,  and  discrete 
tubercle-like  nodules  were  visible.  The  pleura  over 
the  hepatized  areas  was  covered  with  a  fibrinous  ex- 
udate. In  the  riglit  lung  the  consolidation  was  less 
extensive  and  more  focal  in  character.  The  pleural 
cavity  contained  a  small  quantity  of  pink-colored  lluid 
in  which  floated  flakes  of  fibrin.  The  intestines  were 
moderately  dilated.  The  omentum  was  rolled  up,  oc- 
cupying a  position  i)eneath  the  transverse  colon  and 
extending  across  the  abdominal  cavity.  The  pelvis 
contained  about  half  an  ounce  of  fluid  of  brownish 
color  and  mucilaginous  consistence.  Between  the 
loops  of  intestine  were  delicate  shreds  of  fibrin.  In 
addition  smaller  and  larger  nodules  resembling  tuber- 
cles, mostly  translucent,  were  scattered  irregularly 
over  all  the  exposed  peritoneal  surface,  being  more 
uniformly  distributed  upon  and  within  the  thickened, 


rolled-up  omentum.  The  liver  and  spleen  on  sec- 
tion exhibited  similar  nodules.  Cover-slip  prepara- 
tions from  the  lungs  stained  by  Gabbett's  method 
showed  no  micro-organisms  resembling  tubercle  ba- 
cilli. Stained  with  the  carbol-fuchsin  were  numer- 
ous examples  of  a  branching  organism  in  many  places 
collected  into  clumps  or  convoluted  masses.  Cultures 
from  the  left  pleural  cavity  and  the  jDeritoneun;  re- 
mained sterile.  Three  separate  sets  of  cultures  were 
prepared  from  the  lungs.  In  all  at  the  end  of  twenty- 
four  hours  a  vigorous  growth  of  bacteria  identifiable 
as  belonging  to  the  group  of  the  bacillus  coli  com- 
munis had  taken  place.  An  inoculated  guinea-pig 
showed  no  noteworthy  local  reaction,  nor  could  the 
adjacent  lymph  glands  be  felt  at  any  time.  The  ani- 
mal, however,  lost  in  weight,  and  died  at  the  end  of 
the  seventh  week.  Upon  post-mortem  examination 
none  of  the  lymphatic  glands  was  found  enlarged  and 
there  was  no  lesion  resembling  a  tubercle  in  any 
organ.  Cultures  upon  glycerin-agar  made  from  sev- 
eral sources  remained  sterile.  Cover  slips  from  the 
serous  cavities,  the  blood,  and  the  viscera  also  yielded 
negative  information.  In  cover  slips  prepared  from 
the  lungs  at  the  time  of  the  autopsy,  as  well  as  in  sec- 
tions, the  micro-organisms,  as  stained  by  the  ordinary 
methods  employed  for  tubercle  bacilli,  with  decolor- 
ization  by  acids,  held  the  dj'e  vet}-  loosely.  The  best 
method  of  staining  proved  to  be  Gram's  or  Weigert's 
modification  for  fibrin.  Two  kinds  of  lesions  were 
present.  In  the  peritoneal  cavity  tubercle-like  nod- 
ules were  found,  consisting  of  epithelioid  and  lym- 
phoid cells,  with  occasional  granular  cells.  Necrosis 
by  fragmentation  was  not  uncommon  in  the  centres  of 
the  tubercles,  and  fibrin,  either  before  or  coincident 
with  necrosis,  was  commonly  observed  in  the  nodules. 
In  the  lungs  also  tubercles  were  present,  but  were  less 
striking  than  was  a  diffuse  exudation  of  leucocytes, 
plasma,  and  fibrin,  which  filled  the  air-cells,  infil- 
trated tiie  stroma,  and  tended  to  undergo  necrosis,  pro- 
ducing larger  and  smaller  spreading  caseous  foci  of 
degeneration.  The  number  of  masses  of  the  strepto- 
thrix  was  very  great  and  bore  an  intimate  relation  to 
the  pathologic  process.  It  is  believed  that  the  or- 
ganism found  present  in  the  case  reported  is  a  new- 
species,  for  which  the  name  streptothrix  pseudo-tu- 
berculosa  is  proposed,  and  further  that  it  is  capable  of 
causing  in  human  beings  a  rapidly  spreading  and  de- 
stnictive  disea.se  resembling  florid  tuberculosis,  for 
which  the  appellation  of  pseudo-tuberculosis  hominis 
streptothrica  seems  warranted. — Johns  Hopkins  Hospi- 
tal Kcf^orls,  June,  1897. 

Ulceration  and  Rupture  of  Gail-Bladder ;  Opera- 
tion ;    Recovery \'erral    {British    Mediial  Journal, 

August  7,  1S97,  p.  341)  has  reported  the  case  of  a 
woman,  forty-four  years  old,  who  had  sulTered  for  four 
days  from  pain  over  the  upper  part  of  the  abdomen, 
together  with  nausea.  The  bowels  had  acted  natu- 
rally, but  the  patient  took  a  laxative.  On  the  follow- 
ing day  the  bowels  moved  slightly,  but  the  abdomen 
was  somewhat  swollen.  Subsequent  laxatives,  as  well 
as  enemata,  were,  however,  without  effect.  The  wo- 
man had  previously  had  several  attacks  of  colic,  witli 
jaundice,  which  passed  oft"  after  the  taking  of  a  laxa- 
tive. She  presented  the  expression  characteristic  of 
abdominal  disease,  and  there  was  much  distention, 
especially  in  the  flanks,  wliere  tliere  was  also  some 
dulness  on  percussion.  The  area  of  liver  dulness  was 
diminished  and  displaced  slightly  upward.  There 
was  a  sense  of  hardness  over  the  gall  bladder.  The 
abdomen  moved  with  respiration.  Tiie  rectum  was 
empty  and  ballooned.  Nausea  was  frequent.  The 
tongue  was  furred  but  not  brown.  .\n  incision  five 
inches  long,  three  inches  above  the  umbilicus  and  two 
below,   was  made,  and  the  cavity  exposed.     It   was 


October  30,  1897] 


MEDICAL    RECORD. 


627 


bathed  in  bile-stained  fluid,  with  flakes  of  lymph  on 
parts  of  the  intestines.  On  the  under  surface  of  the 
gall  bladder  was  a  round  hole,  about  one-third  of  an 
inch  in  diameter:  stones  could  be  felt  in  the  bladder, 
and  a  dozen  or  so  of  small  and  verj-  sharp  fragments 
and  one  small  perfect  stone  were  pressed  through  the 
hole  with  the  fingers.  No  stones  could  be  felt  in 
any  of  the  ducts.  The  whole  abdominal  cavity  was 
searched,  but  no  stones  or  fragments  were  found.  All 
but  one  of  the  first  row  of  stitches  introduced  to  close 
the  opening  had  to  traverse  the  whole  wall  of  the  blad- 
der, as  it  was  too  much  thinned  for  Lembert  stitches 
to  hold.  This  row,  being  doubled  in,  was  covered  by 
Lembert  stitches,  taking  a  good  hold,  placed  at  right 
angles  to  the  first  row.  The  abdomen  was  freely 
flushed,  a  large  glass  drain  carried  down  to  the  gall 
bladder,  and  the  wound  closed;  but  before  the  edges 
could  be  drawn  even  fairly  close,  the  intestine  had  to 
be  punctured  and  gas  let  out.  Calomel  was  given  and 
followed  by  a  saline,  and  nutrient  enemata  were  admin- 
istered every  four  hours,  with  one  or  two  teaspoonfuls 
of  hot  w  ater  by  the  mouth  occasionally.  The  drainage- 
tube  was  removed  after  forty-eight  hours,  the  gauze 
drain  put  into  it  having  been  frequently  changed. 
Flatus  was  passed  frequently,  with  and  without  a  rec- 
tal tube.  The  bowels  acted  loosely  twenty-si.x  hours 
after  the  operation,  and  from  this  time  nutrient  ene- 
mata were  necessarily  given  up,  as  they  were  not  re- 
tained, and  increasing  quantities  of  milk  and  beef  tea 
with  brandy  were  taken  by  the  mouth ;  and  there  was 
no  nausea.  The  tongue  remained  moist  and  the  ab- 
dominal distention  gradually  lessened.  Suppuration 
took  place  around  nearly  all  the  sutures,  but  the  wound 
was  soundly  healed  in  less  than  three  weeks. 

The  Treatment  of  Coxalgia.— Jalaquier  {La  Fresse 
Medicak,  June  26,  1897)  is  opposed  to  resection, 
and  thinks  that  this  operation  should  be  reserved 
for  coxalgias  complicated  with  constantly  discharging 
fistulas  or  abscesses  that  have  resisted  punctures  fol- 
lowed with  injections  of  camphorated  naphthol  or  of 
iodoform  ether.  The  operations  of  the  author  have 
been  at)'pical,  and  he  never  has  felt  sure  that  he  has 
arrived  at  an  entire  curettage  of  the  articulation.  He 
agrees  with  Menard  that  preliminary  injections  create 
a  condition  favorable  to  the  success  of  the  oper- 
ation. In  the  treatment  of  non-suppurative  co.xalgias 
he  is  not  e.xclusive.  In  the  hospital  and  where  the 
patient  can  be  closely  watched  he  employs  continued 
extension.  When  the  pains  have  disappeared  at  the 
end  of  the  seventh  or  eighth  month  he  usually  applies 
a  plaster  dressing  and  permits  walking  on  crutches, 
having  the  patient  wear  a  raised  shoe  on  the  healthy 
side.  When  the  case  cannot  be  attentively  watched 
Dr.  Jalaquier  applies  the  plaster  at  first  after  resect- 
ing under  chloroform,  if  the  position  is  defective. 
The  author  agrees  with  Brun  in  saying  that  abscesses 
do  not  follow  more  frequently  in  children  treated  by 
this  method  than  in  those  treated  by  continued  exten- 
sion. The  author  does  not  share  the  fears  expressed 
by  Kirmisson  relative  to  resecting  under  chloroform  a 
coxalgia  in  defective  position  with  or  without  disloca- 
tion, but  he  emphasizes  the  statement  that  he  does  not 
employ  this  method  in  coxalgias  complicated  with  ab- 
scess. When  coxalgias  are  cured  or  almost  cured  in 
a  defective  position,  subtrochanteric  osteotomy  gives 
good  results.  Of  one  hundred  and  twenty-two  cases 
treated  at  the  Trousseau  Hospital  sixty-seven  have 
presented  abscesses.  Of  the  one  hundred  and  twenty- 
two  patients  eleven  died,  seven  of  meningitis,  four 
of  pulmonary  complications.  This  mortality  rate 
is  not  accurate,  as  many  of  the  children  were  not 
watched  to  the  end.  Of  the  one  hundred  and  twenty- 
two  cases  forty-six  were  treated  by  simple  continued 
extension,  and  it  is  curious  that  in  this  series  we  find 


five  deaths  from  meningitis  and  four  from  pulmonary 
complications.  Eighteen  were  treated  by  simple  im- 
mobilization without  resetting;  they  furnished  two 
deaths  from  meningitis.  Forty-one  patients  submitted 
to  resecting  under  chloroform.  In  this  series  he  found 
no  deaths  from  meningitis  or  pulmonary  complica- 
tions. This  may  be  due  to  good  fortune,  but  the  au- 
thor thinks  it  is  because  he  has  never  applied  forced 
resection  in  children  having  abscesses  or  when  the 
general  condition  was  bad.  As  to  the  comparative 
value  of  camphorated  napthol  and  iodoform-ether  in 
the  treatment  of  abscess,  he  states  that  eighteen  ab- 
scesses were  cured  after  sixty-eight  injections  of  cam- 
phorated napthol,  or  an  average  of  three  or  four  punc- 
tures for  each  patient.  Twenty-three  abscesses  were 
cured  after  fifty-two  injections  of  iodoform  ether,  or 
about  two  punctures  for  each  patient.  Twenty-two 
abscesses  were  cured  by  the  combination  of  the  two 
agents.  Abscesses  that  proved  refractory  under  cam- 
phorated napthol  were  cured  after  several  injections 
of  iodoform-ether.  For  these  reasons  the  author  pre- 
fers iodoform-ether.  Some  abscesses  thus  treated  be- 
come fistulous,  but  the  proportion  cannot  be  exactly 
given;  this  occurred  only  when  the  skin  was  ready 
to  break  spontaneously.  The  cure  of  these  fistulas 
can  be  obtained  if  care  is  taken  to  avoid  secondary 
infection  and  resort  is  had  to  frequent  touchings  with 
a  solution  of  lactic  acid,  one  in  three. 

Dilatation  of  the  Stomach  in  Nursing  Children. 
— Comby  {La  Presse  McilUalc,  June  26,  1897)  after 
having  studied  the  symptoms  of  dilatation  of  the 
stomach  in  children  of  all  ages,  found  opportunity  to 
measure  the  gastric  capacity  on  the  cadaver  in  eighty 
subjects  less  than  two  years  of  age,  and  has  been  con- 
firmed in  his  opinion  as  to  the  extreme  frequency  of 
dilatation  of  the  stomach  in  poorly  nourished  infants. 
According  to  his  observations  the  physiological  capac- 
ity of  the  stomach,  varjing  of  course  according  to  the 
height  and  weight  of  the  children,  will  be  as  follows: 
.\t  birth,  30  to  40  c.c. ;  first  month,  50  to  60  c.c. ;  sec- 
ond to  third  month,  80  to  100  c.c. ;  three  to  six  months, 
120  to  150  c.c;  six  to  twelve  months,  200  to  220  c.c; 
one  to  two  years,  300  to  350  c.c.  The  results  of  eighty- 
two  autopsies  made  at  the  Hopital  des  Enfants  Ma- 
lades,  excluding  those  cases  in  which  the  stomach  was 
altered  and  softened  or  so  enormously  dilated  that  it 
could  not  be  measured  accurately,  he  found  :  In  twenty- 
six  children  from  eighteen  days  to  three  months  of  age, 
six  only  had  a  normal  or  subnormal  capacity,  twenty  had 
from  double  to  triple  the  normal  capacity.  The  mini- 
mum figures  were  45  c.c.  in  a  child  of  six  weeks;  in 
another  of  two  months  the  condition  was  that  of  a 
newborn  or  premature  child.  The  maximum  was  300 
to  310  in  children  of  from  two  to  three  months,  over- 
fed and  having  considerable  dilatation.  Between 
these  figures  we  find  150,  200,  260,  which  indicate  a 
more  moderate  deviation.  With  nineteen  children, 
aged  from  three  to  six  months,  we  find  four  having  a 
moderate  or  subnormal  capacity.  Two  of  these  were 
fed  at  the  breast  and  two  were  tuberculous.  All  the 
others  had  enormous  stomachs  reaching  300,  330,  340 
c.c.  or  double  the  physiological  capacity.  Between 
six  and  twelve  montiis  six  out  of  twenty-six  had  nor- 
mal or  subnormal  capacity;  these  were  children  fed 
with  more  care  than  is  usual,  or  of  tardy  development 
or  tuberculous.  .V  small  and  retracted  stomach  is 
often  found  in  tuberculous  children.  Fourteen  other 
children  in  this  series  gave  capacities  of  350,  400, 
440,  480,  63s  c.c.  All  these  children  were  fed  on  the 
bottle  and  overfed.  The  remaining  seven  between  one 
and  two  years  had  a  gastric  capacity  of  from  400  to 
740  C.C;  this  last  figure  was  reached  by  a  rachitic 
child  of  two  years.  As  a  result  of  these  figures  we 
see  that  a  large  majority  of  the  bottle-fed  children 


628 


MEDICAL    RECORD. 


[October  30,  1897 


entering  the  hospital  have  a  more  or  less  marked  dila- 
tation of  the  stomach.  This  dilatation  of  the  stomach 
is  responsible  for  a  slowness  in  digestion  and  an  auto- 
intoxication which  results  seriously.  The  use  of  the 
stomach  pump  six  or  seven  hours  after  the  injection  of 
food  has  demonstrated  the  presence  of  curdled  milk 
and  putrid  matter.  At  autopsy  punctiform  ulcerations 
of  the  mucous  membrane  are  often  found,  together  with 
serous  products  and  blackish  spots  caused  by  capil- 
lary hemorrhage.  This  dilatation  often  plays  an  im- 
portant part  in  the  pathology  of  the  nursing  child  and 
is  often  the  direct  or  indirect  cause  of  death.  Lavage 
of  the  stomach  with  a  Nelaton  tube.  No.  20,  22,  or  24, 
according  to  the  age  of  the  child,  is  servicable,  as  it 
removes  putrid  food  and  has  a  soothing  effect.  If 
there  is  vomiting  it  usually  ceases.  Lavage  is  more 
easily  performed  in  children  than  in  adults. 

The  Serum  Diagnosis  of  Typhoid  Fever — Gue- 
rard  {Journal  of  the  American  Medical  Association, 
July  3d)  concludes:  From  an  analysis  of  the  re- 
sults which  have  so  far  been  obtained  in  the  appli- 
cation of  the  Widal  test,  it  would  seem,  in  the  first 
place,  that  the  serum  reaction  is  by  no  means  specific, 
in  the  strict  acceptation  of  the  term.  In  the  second 
place,  it  is  evident  that  this  test  has  certain  limita- 
tions in  its  practical  utility,  and  that  unless  properly 
applied  with  a  due  appreciation  of  these  limitations 
it  is  liable  to  lead  to  false  conclusions.  The  chief 
precautions  to  be  observed  in  making  the  serum  test 
are:  i.  The  virulence  of  the  typhoid  cultures  em- 
ployed. 2.  The  dilution  of  the  serum.  3.  The  time 
limit  for  the  reaction.  The  culture  should  be  of  high 
and  known  degree  of  virulence  and  the  bacilli  actively 
motile;  the  dilution  should  be  in  the  proportion  of  at 
least  I  to  10,  with  a  limit  of  fifteen  minutes  for  the 
reaction  to  appear.  Others  recommend  a  dilution  of 
1  to  30  or  50,  with  a  time  limit  of  one  or  two  hours, 
but,  according  to  our  judgment,  there  is  no  special  ad- 
vantage to  be  gained  by  using  these  higher  dilutions. 
The  possibility  of  error,  which  in  either  method  is 
sometimes  unavoidable,  is  in  our  method  at  least  on 
the  right  side.  It  is  better  to  err  occasionally  in  giv- 
ing a  false  positive  diagnosis  than  by  a  negative  result 
to  exclude  perhaps  many  true  cases  of  typhoid.  In  our 
collective  investigation  it  was  found  that  sixteen  of  the 
forty,-two  observers  had  used  the  higher  dilutions,  i  to 
20  to  I  to  50,  while  twenty-six  had  adhered  to  the 
original  i  to  10  dilution  of  Widal.  It  should  be  re- 
membered, however,  that,  aside  from  this  possible 
source  of  error,  the  reaction  may  also  be  due  at  times 
not  to  a  present  but  to  a  past  case  of  typhoid  so  mild  in 
character  that  it  has  been  entirely  forgotten.  The  ab- 
sence of  a  reaction  in  any  single  case  does  not  neces- 
sarily exclude  the  diagnosis  of  typhoid  fever,  as  the 
reaction  tnay  be  delayed  till  late  in  the  disease.  But 
if  on  repeated  examinations  no  reaction  appears,  it  is 
strong  presumptive  evidence  of  the  absence  of  typhoid  ' 
fever.  Dried  blood  and  lluid  .serum  give  very  much 
the  same  results,  but  there  is  a  decided  advantage  in 
the  use  of  fluid  serum,  because  the  proportions  in  the 
mixture  witli  the  serum  can  be  more  accurately  deter- 
mined. The  best  mode  of  procuring  the  serum  is  by 
means  of  cantharides  blisters.  When  the  subject  of 
the  serum  diagnosis  of  typhoid  fever  was  first  brought 
before  the  public,  it  was  hoped  that  at  last  the  long- 
sought  infallible  diagnostic  test  for  typhoid  fever  had 
been  discovered,  which  was  at  once  rapid,  simple,  and 
suitable  for  clinical  use  at  tlie  bedside.  With  the 
non-fulfilment  of  these  hopes,  some  physicians  have 
come  to  look  upon  Widal's  test  as  practically  useless 
for  diagnostic  purposes.  But,  nevertheless,  the  results 
which  have  been  obtained  by  many  different  observers 
with  an  extended  application  of  this  method  of  diag- 
nosis would  seem  to  warrant  the  conclusion  that,  in 


the  hands  of  the  expert  bacteriologist,  it  is  capable  of 
rendering  valuable  assistance  to  the  physician,  along 
with  the  other  signs  of  typhoid  fever,  in  a  large  ma- 
jority of  cases,  although,  like  other  signs  of  disease, 
it  is  sometimes  wanting  or  indecisive. 

The  Antitoxic  and  Therapeutic  Activities  of  Hu- 
man Blood  after  Recovery  from  Infectious  Diseases. 

— It  has  been  shown  by  numerous  observers  that  the 
blood  of  convalescents  from  a  number  of  the  infectious 
diseases  contains  protective  substances,  and  attempts 
have  been  made  to  use  the  serum  obtained  from  such 
blood  in  the  treatment  of  the  respective  diseases. 
Observations  of  a  similar  character,  covering  a  period 
of  about  a  year,  have  been  made  at  the  medical  clinic 
of  Professor  Leyden  at  the  University  of  Berlin,  by 
Huber  and  Blumenthal,  with  especial  reference  to 
scarlet  fever,  measles,  pneumonia,  and  erysipelas; 
and  the  results  are  embodied  in  a  communication 
published  in  the  Berliner  klinische  Wochenschrift,  Au- 
gust 2,  1897.  The  antitoxic  substances  were  obtained 
by  mixing  at  once  the  blood  (from  one  hundred  to  one 
hundred  and  fifty  cubic  centimetres)  obtained  by  vene- 
section with  a  like  amount  of  sterile  physiological  so- 
lution of  chloride  of  sodium,  and  adding  one  per  cent,  of 
chloroform.  After  the  mixture  was  shaken  and  stirred 
it  was  put  aside  for  twenty-four  hours  and  permitted  to 
stand,  when  it  was  gently  expressed  through  sterile 
linen  and  finally  filtered  through  sterile  gravel.  The 
resultant  fluid  was  clear,  of  a  dark-red  color,  was  ster- 
ile, and  remained  so  permanently  on  the  addition  of 
chloroform.  If  it  be  desired  to  remove  the  haemoglo- 
bin, a  second  infiltration  is  practised,  and  the  fluid 
then  becomes  lighter  in  color.  The  fluid  was  found  to 
contain  the  specific  antitoxic  substances  of  the  blood 
of  convalescents,  and  it  proved  of  equal  antitoxic 
activity  with  serum  prepared  in  the  usual  manner, 
while  the  amount  obtained  was  almost  twice  as  large. 
About  one  hundred  injections  were  made,  and  in  no 
instance  did  an  abscess  form.  It  was  found  that  the 
fluid  had  no  appreciable  effect  upon  healthy  persons. 
Temporary  infiltration,  with  redness  and  sensitiveness, 
often  appeared  at  the  site  of  injection.  Of  thirteen 
cases  of  scarlet  fever  treated  with  the  filtrate  of  blood 
obtained  from  convalescents,  a  distinctly  favorable 
effect  was  observed  in  three.  In  the  remainder  the 
result  was  less  positive,  and  none  at  all  was  noted  in 
one.  The  temperature  declined  between  the  third  and 
the  sixth  day  in  nine  cases,  as  compared  with  the 
average  of  the  sixth  or  the  seventh  day;  reaching  nor- 
mal between  the  fifth  and  the  tenth  day,  as  compared 
with  the  ninth  to  the  eleventh  day.  The  duration  of 
the  disease  was  thus  distinctly  shortened.  The  injec- 
tions were  not  rarely  followed  by  a  transitory  elevation 
of  temperature.  No  serious  complication  was  ob- 
served in  any  of  the  cases.  Of  nine  cases  of  measles 
treated  with  the  filtrate  of  blood  obtained  from  conva- 
lescents, a  distinctly  favorable  effect  was  noted  in  two 
•or  three.  In  the  remainder  the  result  was  rather  doubt- 
ful. In  none,  however,  was  the  critical  defervescence 
deferred  later  than  the  third  day.  Of  fourteen  cases 
of  pneumonia  treated  with  the  filtrate  of  blood  ob- 
tained from  convalescents,  death  took  place  in  two;  in 
eleven  the  crisis  occurred  between  the  third  and  the 
eleventh  days.  In  four  a  conspicuous  decline  in  the 
temperature  took  place  following  the  injections,  with 
improvement  in  the  general  condition.  Similar  re- 
sults were  not  obtained  with  the  filtrate  of  blood  from 
convalescents  from  scarlet  fever  and  from  measles,  and 
not  in  cases  of  other  kinds  treated  with  the  filtrate  of 
blood  from  convalescents  from  pneumonia.  This  fil- 
trate from  the  blood  of  convalescents  from  pneumonia 
also  proved  capable  of  protecting  rabbits  from  infec- 
tion, although  mice  were  not  so  protected.  The  con- 
clusion is  expressed  that  the  blood  of  convalescents 


October  30,  1897] 


MEDICAL    RECORD. 


629 


from  pneumonia  contains  antitoxic  substances  capable 
of  specific  activity  with  regard  to  pyogenous  and  other 
deleterious  products  of  the  disease,  but  not  capable  of 
causing  or  not  present  in  sufficient  amount  to  cause  a 
definite  crisis  to  modify  appreciably  the  morbid  ana- 
tomic process  and  to  prevent  extension  of  the  disease. 
In  ten  cases  of  erysipelas  treated  with  the  filtrate  of 
blood  obtained  from  convalescents,  no  definitely  favor- 
able results  were  noted,  and  this  is  in  accord  with  the 
opinion  that  antitoxic  substances  do  not  appear  in  the 
blood  after  an  attack  of  this  disease.  Further,  com- 
plications were  not  prevented,  and  the  injections  were 
followed  by  pain,  redness,  swelling,  and  infiltration. 
The  fluid  appeared,  however,  to  have  some  local  influ- 
ence, inasmuch  as  the  site  of  inoculation  escaped 
involvement. 

Calomel  and  Acids. — Ever  since  calomel  was  intro- 
duced into  therapeutics  classic  authors  have  drawn  at- 
tention to  the  minute  precautions  that  its  use  requires 
if  one  wishes  to  avoid  serious  results.  It  is  well 
known  that  this  substance  is  unstable.  Chemistry 
teaches  that  it  is  easily  decomposed  upon  contact  with 
salts  and  acids,  and  is  transformed  into  corrosive  sub- 
limate. There  are  authors  who  will  not  admit  the  truth 
of  this  idea.  They  hold  tiiat  the  cases  of  poisoning  ob- 
served are  due  to  idiosyncrasies;  others  assure  us  that 
they  have  never  found  sublimate  in  the  digestive  tract; 
others  again  have  a  theory  of  intoxication,  and  think 
that  tlie  accidents  arise  from  a  reaction  between  calo- 
mel and  albumin.  The  dangers  that  this  drug  pre- 
sents cannot  be  contested,  as  the  experiments  of  Otto- 
lenghi  prove.  This  author  has  given  calomel  in 
therapeutical  doses  to  dogs  and  compelled  them  to 
drink  salts  and  acids.  The  animals  always  presented 
symptoms  of  intoxication,  which  appeared  with  more 
rapidity  and  severity  than  if  the  calomel  had  been 
taken  alone.  In  these  experiments  the  symptoms 
were  not  the  same  as  those  observed  after  the  ingestion 
of  corrosive  sublimate.  Ottolenghi  aflirms  that,  con- 
trary to  the  current  opinion,  calomel  is  not  decom- 
posed in  the  stomach;  in  fact,  if  we  place  calomel  in 
solutions  of  salts  or  acids,  no  phenomenon  will  appear 
if  the  temperature  is  no  higher  than  that  of  the  body, 
37'"  C.  That  which  does  not  take  place  in  the 
laboratory  does  not  take  place  in  the  stomach  in  those 
cases  to  which  we  refer.  The  exaggeration  of  the 
toxic  effect  of  calomel  after  the  ingestion  of  salts  or 
acids  arises  from  the  fact  that  its  combination  with 
albuminoid  substances  contained  in  the  stomach  will 
be  facilitated  and  will  yield  products  much  more  solu- 
ble, so  that  calomel,  which  is  normally  absorbed  in 
ver}'  small  quantities,  will  pass  in  much  larger 
amounts  into  the  circulation,  thus  provoking  signs  of 
grave  intoxication. —  Gaz.  Med.  de  Liege,  June  24, 
1897. 

Antiseptic  Properties  of  Bile. — Mayo  Robson,  in 
an  article  on  "  Diseases  of  the  Gall  Bladder  and  Bile 
Ducts"  (London  Lauaf,  May  29th),  says;  "It  has 
been  supposed  that  the  bile  is  an  antiseptic  fluid 
which  tends  to  prevent  decomposition  in  the  ali- 
mentary canal,  but,  in  a  series  of  observations  which 
I  published  some  years  ago  on  a  case  of  biliary  fis- 
tula, I  found  that  the  absence  of  bile  from  the  intes- 
tine of  a  woman  during  a  period  of  fifteen  months  did 
not  lead  to  any  irregular  fermentative  process,  show- 
ing that  the  alleged  antiseptic  effect  of  bile  on  the 
fajces  is  probably  imaginary.  Normal  bile  is,  how- 
ever, generally  sterile.  This  was  proved  by  Netter, 
in  1884,  who  experimented  on  dogs,  and  the  fact  has 
been  confirmed  by  Gilbert  and  Clirode  and  later  by 
Naunyn,  who  found  it  sterile  in  two  cases  within  a  few- 
hours  of  death.  Frequent  inoculative  experiments  on 
animals  have  confirmed  these  observations,  thus  ex- 
plaining a  well-known  fact  that  in  many  cases  bile  has 


been  extensively  poured  out  into  the  peritoneal  cavity 
without  setting  up  peritonitis;  but  in  disease  of  the 
gall  bladder  or  bile  ducts  the  bile  is  seldom  or  never 
sterile,  and  is  capable  of  producing  severe  peritonitis. 
Bloch  has  demonstrated  that  the  bile  in  cases  of  dis- 
ease of  the  gall  bladder  or  bile  ducts  always  contains 
micro-organisms;  hence  he  thinks  it  advisable  to  per- 
form cholecystotomy  in  two  stages,  in  order  to  avoid 
soiling  the  peritoneum  and  producing  infective  peri- 
tonitis. When  the  flow  of  bile  along  the  ducts  is  ar- 
rested, micro-organisms  often  invade  the  gall  bladder 
either  from  the  blood  or  the  intestine.  Charcot  and 
Gombault  demonstrated  the  presence  of  organisms 
within  it  after  ligaturing  the  common  duct  in  dogs. 
This  was  confirmed  by  Netter  in  1886,  who  found  that 
twenty-four  hours  after  aseptic  ligature  of  the  common 
duct  in  dogs,  organisms,  both  staphylococcus  and  ba- 
cillus coli  communis,  could  be  cultivated  from  the  bile. 
The  bacillus  coli  communis  exists  normally  in  the  hu- 
man body,  and  is  said  to  be  the  most  abundant  and 
most  constant  of  the  bacteria  found  in  man  in  health. 
At  one  time,  as  shown  by  Escherich,  it  may  act  as  an 
ordinary  pyogenic  organism  producing  local  abscesses, 
at  another  as  an  active  pathogenic  germ  producing  fa- 
tal septicaemia.  Mr.  C.  B.  Lockwood  found  strepto- 
cocci and  other  organisms,  but  no  amoebae  coli,  in  an 
empyema  of  the  gall  bladder.  Netter  found  staphylo- 
cocci and  streptococci  present  in  pathological  human 
bile,  and  Martin,  Gilbert  and  Girode,  and  Bouchard 
have  found  the  bacillus  coli  communis  in  the  bile  in 
cases  of  inflammation  of  the  biliary  passages.  In 
acute  or  phlegmonous  cholecystitis  the  walls  of  the 
gall  bladder  are  swollen  and  cedematous,  and  may  be 
infiltrated  with  pus.  In  three  out  of  five  of  such  cases 
Naunyn  found  the  bacillus  coli  communis  in  the  pus. 
Barbacci  and  others  have  shown  that  peritoneal  sepsis 
may  occur  without  perforation  of  the  gut.  The  spread 
of  infection  through  the  walls  of  the  gall  bladder  can 
readily  be  explained  on  the  same  hypothesis,  showing 
how  virulent  peritonitis  may  arise  in  these  cases, 
though  there  be  no  perforation.  Gilbert  and  Girode 
found  typhoid  bacilli  in  the  pus  from  a  case  of  empy- 
ema of  the  gall  bladder  which  came  on  as  a  sequence 
of  enteric  fever.  Gilbert  and  Dominici  also  assert 
that  they  produced  suppuration  in  the  gall  bladder  and 
liver  of  rabbits  by  injecting  a  culture  of  typhoid 
bacilli  into  the  common  duct.  These  biological  facts 
are  borne  out  by  the  clinical  obseiTations  of  Dr.  Mur- 
chison  and  of  Dr.  Hale  White,  who  have  found  evi- 
dence of  inflammation  and  ulceration  in  the  gall 
bladder  in  well-marked  and  fatal  cases  of  typhoid  fever, 
there  being  no  other  cause  than  the  specific  disease  to 
account  for  the  trouble.  Chiari  investigated  systemat- 
ically a  series  of  twent)--two  cases  of  typhoid  fever. 
With  the  exception  of  three  cases,  one  of  which  was  in 
the  infiltrating  and  two  were  in  the  necrotic  stage,  he 
obtained  typhoid  bacilli  invariably  out  of  the  gall 
bladder,  and  in  fifteen  cases  they  were  obtained  in 
pure  culture.  In  thirteen  of  the  nineteen  cases  in 
which  a  positive  result  was  obtained  there  was  inflam- 
mation of  the  gall  bladder,  with  small-celled  infiltra- 
tion, cedema,  and  hyperemia.  In  all  twenty-tw-o  cases 
the  diagnosis  of  typhoid  fever  was  confirmed  by  culti- 
vations from  the  spleen,  mesenteric  glands,  or  liver, 
or  from  the  larger  bile  ducts.  How  do  they  reach  the 
gall  bladder?  There  are  three  possibilities:  either 
they  enter  by  the  bile  ducts,  or  from  the  blood,  or 
directly  through  the  wall  of  the  gall  bladder.  The 
last-mentioned  manner  must  be  very  exceptional. 
Their  entrance  from  the  blood  has  been  apparently 
disproved,  and  it  is  therefore  probable  that  they  enter 
by  the  bile  ducts.  There  is  no  doubt  that  the  bacilli 
multiply  in  the  gall  bladder,  and  it  is  possible  that 
they  may  be  responsible  for  post-typhoidal  cholecysti- 
tis, for  gall  stones,  and  also  for  relapses  of  the  disease. 


630 


MEDICAL    RECORD. 


[October  30,  1897 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &  CO.,  43,  45,  &  47  East  Tenth  Street. 


New  York,  October  30,  1897. 

THE  AMERICAN  PHYSICIAN  AS  A  PARTI- 
CIPANT IN  FUTURE  INTERNATIONAL 
MEDICAL   CONGRESSES. 

No  one  will  gainsay  the  fact  that  the  recent  Interna- 
tional Medical  Congress  in  Moscow  was  a  success 
from  every  point  of  view.  It  is  probably  the  convic- 
tion of  every  participant  that  it  was  carefully  and 
thoroughly  planned,  splendidly  organized,  and  satis- 
factorily executed.  Judged  solely  from  the  enormous 
attendance  and  from  the  amount  and  character  of  the 
work  done,  the  meeting  justified  the  existence  of  inter- 
national reunions  of  this  kind.  From  the  purely 
scientific  side  alone,  although  there  were  no  epoch- 
making  communications,  the  sessions  of  the  majority 
of  the  sections  fully  realized  the  expectations  of  the 
participants.  Confronted  with  this  knowledge,  we  are 
led  to  inquire  what  share  the  members  of  the  medical 
profession  of  this  country  contributed  to  the  success 
either  by  their  presence  or  by  their  contributions.  It 
has  been  stated  that  upward  of  one  hundred  physicians 
from  the  United  States  were  in  attendance,  but  this 
we  believe  to  be  entirely  beyond  the  mark.  It  is  very 
probable  that  the  number  of  hona-fide  physicians  who 
participated  in  the  congress  from  this  country  was  not 
much  above  fifty.  This  estimate  does  not  include 
medical  students,  reporters,  and  "doctors"  of  other 
kinds  than  medical.  Numerically,  therefore,  the  con- 
tribution from  the  United  States  was  about  one-one- 
hundredth  of  the  entire  body.  This  alone  was  a 
serious  handicap  in  making  their  presence  felt,  but  it 
is  not  to  be  compared  with  the  obstacle  offered  by 
reading  papers  poor  in  thought  and  poorer  yet  in  prep- 
aration. We  would  not  be  understood  as  saying  that 
many  of  the  communications  presented  by  American 
congressists  were  not  worthy  of  the  audiences  to  which 
they  were  offered,  and  were  not  listened  to  with  be- 
coming deference.  But  this  cannot  be  said  of  them 
all.  It  was  noticeable,  moreover,  that  although  quite 
a  large  number  of  papers  was  announced  by  Ameri- 
cans, when  the  time  came  to  read  them  the  readers 
were  thousands  of  miles  away  from  Moscow.  This 
happened  in  so  many  instances  that  the  disagreeable 
thought  came  lo  one  that  this  method  at  least  had  the 
advantage  of  bringing  the  writer's  name  prominently 
before  the  eyes  of  a  few  hundreds,  yes,  thousands  of 
his  colleagues,  although  the  article  in  question  might 


still  be  .secreted  in  the  recesses  of  his  brain.  It 
would  seem  that  a  man  who  informs  the  secretarj'  of 
a  society  or  a  congress  that  a  paper  from  his. pen  may 
be  announced  morally  obligates  himself  to  fulfil  his 
engagement.  Naturally  there  are  many  extenuating 
circumstances,  but  the  fortuitous  exigencies  which 
prevent  congressional  participation  usually  do  not 
arise  so  soon  before  the  congress  that  the  officials 
cannot  be  notified  in  time  to  keep  the  title  of  the  re- 
calcitrant's paper  from  appearing  on  the  final  pro- 
gramme. 

It  practically  has  been  decided  that  the  next  inter- 
national congress  will  be  held  in  Paris  during  the 
opening  year  of  the  dawning  centur)'.  The  fact  that 
a  universal  exposition,  which  is  planned  to  surpass  all 
predecessors,  will  be  held  there  the  same  year,  will 
undoubtedly  attract  a  great  number  of  our  people, 
physicians  among  the  rest.  We  believe  that  the  time 
will  be  opportune  for  the  profession  of  this  country, 
participants  in  the  prospective  congress,  to  make  their 
presence  felt  and  to  justify  that  reputation  for  bril- 
liancy and  integrity-,  not  alone  in  practical  fields,  but 
in  bacteriology,  physiology,  and  hygiene  as  well,  which 
they  de.servedly  sustain  at  home  and  which  they  are 
partially  accorded  abroad.  One  or  two  hints  at  this 
time  may  be  serviceable  in  contributing  to  such  an 
end. 

A  physician  should  not  presume  upon  the  time  and 
patience  of  his  colleagues  by  reading  a  paper  com- 
posed of  truisms,  some  facts  borrowed  from  text-books, 
and  much  padding.  Such  exhibitions  contribute  to 
international  ill-feeling  and  to  personal  disdainment. 
No  more  should  he  report  procedures  based  on  alleged 
chemical  or  physiological  experiments  which  he  is  not 
ready  and  able  to  demonstrate  by  chemical  or  physio- 
logical tests.  Above  all,  he  assiduously  should  refrain 
from  announcing  papers  that  he  does  not  anticipate 
being  able  to  present.  This  latter  procedure  has 
already  been  done  to  death.  If  he  will  take  the  results 
of  his  honest  work  and  intelligent  thought,  it  matters 
not  whether  they  be  based  on  experimentation  or 
observation,  he  may  be  assured  of  kindly  reception 
and  courteous  attention.  Moreover,  he  will  have  the 
satisfaction  of  feeling  that  he  is  doing  for  the  reputa- 
tion of  the  profession  in  his  country  what  his  Latin 
confreres  did  so  conspicuously  at  the  last  congress, 
enhancing  its  scientific  position. 


THE   YELLOW-FEVER    SITUATION. 

There  are  no  signs  of  improvement  in  the  yellow- 
fever  situation  in  the  South  as  yet,  the  number  of  new 
cases  reported  in  New  Orleans  each  day  being  be- 
tween fifty  and  sixty,  and  until  a  frost  or  a  notable 
fall  in  temperature  occurs,  of  which  there  is  no  present 
prospect,  little  improvement  can  be  hoped  for.  The 
area  of  infection  continues  also  to  spread,  cases  having 
been  discovered  during  the  past  week  in  Memphis, 
Tenn.,  and  Selma,  Ala.,  and  consequently  the  territory 
of  the  shotgun  quarantine,  with  its  prostration  of  trade 
and  financial  loss,  is  constantly  widening.  The  exo- 
dus that  ensued  upon  the  announcement  that  the  fever 


October  30,  1897] 


MEDICAL    RECORD. 


631 


had  invaded  Selma  furnishes  a  typical  illustration  of 
the  unreasoning  fear  that  possesses  the  minds  of 
people  in.  times  such  as  these.  The  panic  that  seizes 
upon  ever}'body  the  moment  a  case  of  yellow  fever  is 
discovered  in  some  hitherto  unvisited  place  is  almost 
incredible,  and  would  be  ludicrous  were  it  not  pitiable. 
On  Saturday  last  it  was  announced  that  some  cases 
had  occurred  in  Selma,  and  by  Sunday  evening  all  but 
about  three  hundred  of  the  white  inhabitants  of  the 
city  had  left  it,  over  §12,000  worth  of  railway  tickets 
having  been  sold  in  that  time.  The  regular  passen- 
ger ser\'ice  was  insufficient  to  take  away  all  the  fugi- 
tives, and  many  special  trains  were  made  up  to  accom- 
modate those  who  were  clamoring  for  a  means  of 
escape  from  the  pest.  These  trains,  once  filled,  were 
nm  through  the  State  without  stopping,  every  little 
hamlet  having  its  guard  at  the  station  to  shoot  any  one 
who  would  attempt  to  leave  the  cars.  Atlanta  is  the 
city  of  refuge  for  all  these  frightened  men  and  women, 
and  such  numbers  have  gone  there  that  it  is  feared  it 
will  soon  be  impossible  to  find  accommodations  for 
them.  Many  of  those  who  cannot  get  as  far  as  Atlanta 
or  some  Northern  city  are  camping  out  in  tents  or  huts 
in  the  woods,  having  isolated  themselves  completely, 
fearing  to  let  a  human  being  approach,  lest  he  bring 
the  dread  pestilence  with  him.  The  death  rate  in  the 
present  visitation  has  been  remarkably  low,  but  this 
seems  to  have  had  no  effect  in  calming  the  apprehen- 
sions of  those  who  have  been  exposed  or  fear  they 
may  be.  The  psychology  of  this  epidemic  will  make 
an  interesting  study. 

In  the  Herald  oi  recent  date  is  a  cable  despatch  from 
Buenos  Ayres,  giving  the  results  of  an  interview  said 
to  have  been  had  with  Sanarelli  in  Montevideo  con- 
cerning his  curative  serum.  .According  to  this  account, 
the  serum  is  useful  solely  as  a  curative  agent  and  is 
unavailable  as  a  means  of  protection  against  the  dis- 
ease. He  said  he  had  tried  to  immunize  dogs,  horses, 
and  other  animals,  but  the  method  was  slow  and  un- 
certain. In  the  way  of  a  cure  of  yellow  fever,  how- 
ever, he  claimed  that  his  experiments  had  been  suc- 
cessful in  animals,  though  he  had  been  unable  as  yel 
to  make  a  practical  test  on  man.  ''This  new  serum," 
the  report  continues,  "  if  compared  with  other  serums 
intended  for  preventive  or  curative  purposes,  will  be 
found  to  be  far  above  them  in  efficacy,  though  it  is  not 
yet  perfect.  Before  announcing  his  final  conclusions 
and  the  composition  of  his  curative  serum.  Dr.  Sana- 
relli will  try  to  make  a  more  potent  serum  for  experi- 
ment on  a  fever  patient.  He  will  soon  leave  Monte- 
video for  Rio  Janeiro,  where  he  will  continue  his 
experiments." 

It  is  rather  difficult  to  tell,  from  this  report,  just 
-what  the  serum  is  or  what  it  is  expected  to  do,  and  we 
shall  doubtless  have  to  wait  until  Sanarelli  arrives  in 
Genoa,  to  which  place  the  Italian  papers  state  he  is 
now  on  his  way,  before  knowing  what  stage  he  has 
reached  in  his  experiments  looking  toward  the  elabor- 
ation of  a  curative  or  prophylactic  serum. 

The  Pasteur  Monument  Fund,  .so  it  is  announced, 
'has  reached  the  verv  satisfactorv  sum  of  S6o,ooo. 


THE   FAVUS    QUESTION. 

As  will  be  noted  in  our  news  columns,  the  authori- 
ties in  Washington  have  taken  the  timely  and  wise 
step  of  ordering  that  immigrants  affected  with  that 
loathsome,  contagious,  and  highly  undesirable  disease, 
favus,  be  excluded  from  our  shores. 

The  position  which  the  Record  took  in  this  matter 
over  two  years  ago  makes  this  action  highly  gratifying 
to  us,  to  say  the  least.  We  have  fought  to  exclude  the 
disease  as  one  wholly  unnecessary  for  us  to  add  to 
our  already  long  list  of  exotics.  In  view  of  a  failure 
in  this  direction  we  have  urged  that  it  be  kept  out  of 
the  schools  and  out  of  the  barber  shops.  It  is  now 
being  quite  generally  excluded  from  the  schools  in 
this  city,  but  how  many  children  of  foreign  birth  are 
endangering,  not  perhaps  the  lives,  but  possibly  the 
lifelong  happiness  of  our  American  schoolchildren 
throughout  the  country  no  one  can  tell.  In  an  edi- 
torial upon  the  "  Increase  of  Favus"  in  the  Medical 
Record  of  June  i,  1895,  we  pointed  out  that  while  in 
1877,  so  far  as  reports  were  available,  there  were  but 
thirty-two  instances  in  the  whole  count' y,  sixty  had 
been  reported  from  this  city  alone  in  1893. 

We  said  at  that  time  that  it  was  a  great  mistake  not 
to  keep  these  children  from  landing  in  the  country, 
and  that,  if  they  could  not  be  stopped  at  quarantine, 
some  means  of  segregation  should  be  instituted.  An 
alarming  increase  of  late  would  seem  to  be  indicated 
by  the  statement  of  a  recent  correspondent  in  the 
Medical  Record,  who  has  observed  over  eighty  in- 
stances in  one  dispensary  during  a  period  of  five 
months. 

The  following  is  the  closing  sentence  of  our  com- 
ment two  years  ago : 

"  This  is  much  too  young  a  country  to  compete  with 
the  old  world  in  the  matter  of  favus  statistics,  and 
there  should  be  a  quick  return  to  the  good  old  times 
when  New  York  could  boast  but  four  instances  of  the 
disease." 

May  not  the  Medical  Record's  plea  have  had  an 
influence  in  bringing  about  the  praiseworthy  action 
just  taken  by  the  national  government? 


THE   ASEXUALIZATION    OF    CRIMINALS. 

For  many  thousands  of  years  among  civilized  people 
and  savages  alike,  one  of  the  most  difficult  problems 
to  solve  has  been  "  what  to  do  with  confirmed  crimi- 
nals." At  this  date  the  solution  seems  as  far  off  as 
ever.  The  methods  of  punishment  by  the  ancients 
were  strictly  deterrent.  Xo  mercy  was  shown  the  de- 
linquent, but  he  was  punished  for  his  sin  with  the 
greatest  severity.  Possible  reformation  by  less  harsh 
means  did  not  enter  into  the  question.  With  the  ad- 
vent, however,  of  the  Christian  era,  more  merciful 
treatment  was  introduced,  and  now  in  some  countries 
the  inmates  of  prisons  are  better  housed  and  fed  than 
the  honest  poor.  Notwithstanding  all  this,  the  most 
sanguine  of  penologists  can  hardly  say  that  the  results 
have  been  commensurate  with  the  efforts,  and  probably 
the  present  system  is  no  more  successful  than  the  old 
one  of  severe  punishment.     We  have  several  times  re- 


632 


MEDICAL    RECORD. 


[October  30,  1897 


ferred  to  the  few  reformers  who  contend  that  society 
must  organize  to  prevent  by  means  of  asexualization 
the  propagation  of  degenerates  and  criminals.  Dr. 
Barnard  Eastman  recently  read  a  paper  before  the 
Kansas  Medical  Society  at  Topeka,  upholding  these 
views,  but,  after  all  the  arguments  which  he  advanced 
in  support  of  this  drastic  measure,  he  is  forced  to  the 
tame  conclusion,  that  "the  practical  difficulties  which 
would  be  encountered  in  attempting  to  carrj-  out  this 
theoiy,  with  that  disregard  of  fear  or  favor  necessary 
to  its  success,  are  at  present  insurmountable." 


DEATH    FROM    GEXER.\L   AX.-E.STHESIA. 

Many  deaths  occurring  as  the  result  of  the  administra- 
tion of  general  anaesthetics  undoubtedly  are  not  widely 
heralded  and  some  may  not  even  be  reported  as  due 
to  this  cause.  Three  instances  of  sudden  death  during 
anaesthesia  have  occurred  in  a  single  New  York  insti- 
tution within  the  current  year:  two  from  chloroform 
and  one  from  ether. 

A  recent  issue  of  The  Hospital  c^\\s>  attention  to  the 
alarming  frequency  of  deaths  from  anaesthesia  in  Eng- 
land, especially  from  chloroform.  At  the  time  of  writ- 
ing there  had  been  twenty-two  cases  reported  in  three 
months,  and  at  the  time  of  going  to  press  four  more 
deaths  from  this  cause  had  been  made  public.  One 
naturally  wonders  in  how  many  cases  tlie  true  cause 
of  death  has  been  concealed.  In  The  Hospital oi  April 
24th,  there  are  reported  seven  additional  cases  col- 
lected from  the  daily  papers,  four  of  these  having  been 
reported  in  one  day.  In  one  instance  the  jury  found 
that  death  was  due  to  e.xcitement  in  anticipation  of 
the  operation.  In  regard  to  this  finding  we  call  atten- 
tion to  the  investigation  of  Dr.  Leonard  Hill,  who  says: 
"  Chloroform  paralyzes  the  splanchnic  vasomotor  tone 
just  as  shock  does,  and  in  the  condition  of  shock  or 
emotional  fear  the  compensatory  mechanism  for  the 
effect  of  gravity  is  almost  abolished,  and  chloroform 
may  easily  be  the  last  straw  to  paralyze  completely 
the  circulation.  It  is,  no  doubt,  in  this  way  that  an 
expectation  of  disaster  has  sometimes  conduced  to  its 
occurrence."  Again,  the  Hospital  Nurse^s  Mirror  of 
April  3d  reported  a  case  from  the  Windsor  Royal  In- 
firmary, of  a  nurse  who  collapsed  suddenly  under  gas 
and  ether,  while  having  some  teeth  extracted. 

A  few  figures  taken  from  the  statistics  of  Goult  as  a 
result  of  a  collective  investigation  of  the  German  Sur- 
gical Society  of  Berlin,  as  to  the  number  of  deaths 
from  the  various  anassthetics  and  their  combinations, 
may  be  of  interest.  During  the  five  years,  from  i8go 
to  1895,  there  were  88  deaths  from  chloroform  out  of 
2,286  cases,  7  deaths  from  ether  out  of  6,020  cases,  i 
death  out  of  10,162  cases  in  which  chloroform  and 
ether  were  combined,  i  death  out  of  5,744  cases  in 
which  chloroform,  ether,  and  alcohol  had  been  used. 

Would  it  not  be  more  scientific  to  have  an  honest 
report  of  deaths  from  anesthetics  and  a  more  careful 
study  of  the  subject  of  anjpsthesia?  These  reports 
bespeak  likewise  the  need  of  a  more  careful  examina- 
tion of  the  patient  before  the  administration  of  an 
an-o-sthetic.     The  duty  of  administering  an  anaesthetic 


in  hospitals  usually  falls  to  some  recent  graduate  or  to 
the  junior  member  of  the  staff.  His  practical  knowl- 
edge of  the  subject  is  usually  very  limited,  and  the 
operator,  being  aware  of  this,  feels  it  necessary  to  have 
an  eye  upon  this  part  of  the  work,  when  he  ought  to  be 
able  to  concentrate  his  entire  attention  on  the  opera- 
tion. So  far  as  we  have  been  able  to  learn,  the  Phil- 
adelphia Polyclinic  is  the  only  institution  that  has 
appointed  an  instructor  especially  for  the  purpose  of 
training  the  hospital  staff  and  students  in  this  branch 
of  medicine.  We  are  not  in  favor  of  carrying  special- 
ism to  extremes,  but,  as  we  have  stated  on  one  or  two 
previous  occasions,  there  is  room  for  a  few  specialists 
in  ansesthesia,  as  only  a  physician  who  is  thoroughly 
acquainted  with  the  work  and  has  had  practical  in- 
struction and  experience  should  be  chosen  for  this 
important  part  of  a  surgical  operation. 


SPECIAL    INSTITUTIONS    FOR  THE   TREAT- 
MENT   OF    PULMONARY    TUBERCULOSIS. 

More  is  probably  known  of  the  etiology  and  pathology 
of  pulmonary  tuberculosis  than  of  any  other  disease, 
and  it  will  be  thought,  considering  this  minute  knowl- 
edge, that  the  ravages  made  by  consumption  might  be 
curtailed  to  a  greater  extent  than  is  now  the  case. 

The  treatment  of  phthisis  in  special  institutions  has 
met  with  a  large  measure  of  success  abroad,  as  our 
readers  may  have  gathered  from  the  discussion  on  this 
subject  at  the  Moscow  congress,  and  there  would  ap- 
pear to  be  no  reason  why  similar  establishments  should 
not  have  a  like  success  in  this  country.  The  rational 
method  of  treating  tuberculosis  is,  without  doubt,  for 
the  sufferer  to  live  under  those  conditions  which  fulfil 
in  the  highest  possible  degree  the  laws  of  hygiene  and 
diet.  In  private  life,  e.xcept  by  the  ver}'  rich,  these 
conditions  are  very  difficult  to  attain.  Climate  and 
situation,  which  play  so  prominent  a  part  in  the  cura- 
tive treatment  of  lung  affections,  are  naturally  impor- 
tant in  the  choice  of  a  site  for  a  sanatorium,  and  as  the 
climate  in  many  parts  of  this  continent  is  peculiarly 
favorable,  these  objects  are  easily  obtained. 


UNAUTHORIZED   AUTOPSIES. 

The  very  laudable  eagerness  for  autopsies  in  cases  of 
doubtful  cause  of  death  very  often  tempts  hospital 
internes  to  strain  a  point  to  gratify  it.  A  recent  case 
in  point  is  reported  from  the  Hahnemann  Hospital  in 
this  city,  in  which  such  an  examination  was  made 
without  the  permission  of  the  immediate  relatives  or 
friends,  and  without  an  order  from  tlie  coroner.  While 
there  can  be  no  question  as  to  the  motive  of  the  act  on 
the  part  of  the  participants,  it  is  nevertheless  quite 
evident  that  they  exceeded  their  authority  in  the 
premises  and  became  liable  for  prosecution.  The 
trouble  was  initiated  by  the  undertaker,  who  informed 
the  widow  that  an  autopsy  had  been  performed  upon 
th«  body  of  tiie  deceased,  and  that  in  consequence  the 
corpse  was  not  fitted  for  exhibition  at  the  funeral. 
While  it  does  not  appear,  from  the  standpoint  either 
of  reason  or  of  fact,  that  the  mere  examination  of  the 


October  30,  1897] 


MEDICAL    RECORD. 


633 


brain  and  the  necessary  remo%-al  of  the  calvarium 
would  cause  notabls  disfigurement,  the  original  and 
unwarranted  assumption  of  responsibility  for  the  act 
itself  is  none  the  less  apparent. 

If  the  facts  are  as  stated  in  the  preliminary  court 
examination,  the  parties  involved  in  the  affair  are 
technically  guilty  before  the  law.  Whether  or  not  the 
case  be  brought  before  the  grand  jury,  as  has  been 
threatened,  the  discussion  of  the  principle  upon  which 
the  charge  of  misdemeanor  is  founded  is  timely  and 
proper,  in  view  of  the  constant  temptation  to  dodge 
the  law  in  the  interests  of  pathological  science.  In 
cases  of  doubt  as  to  the  real  character  of  the  disease 
causing  death,  and  when  an  autopsy  is  denied  by  the 
friends  of  the  deceased,  the  physician  can  decline  to 
give  a  death  certificate;  but  he  can  go  no  further 
without  permission  from  the  coroner,  to  whom  all  such 
doubtful  questions  should  be  referred.  It  is  always 
better  to  be  sure  first  than  to  try  to  explain  after\vard. 


Sews  0t  the  Witch. 

The  Detroit  Medical  and  Library  Association.— 
— At  the  annual  meeting  held  on  October  4th,  Dr. 
Andrew  P.  Biddle  was  elected  president. 

The  Public  Library  (consolidation  of  Astor,  Leno.x, 
and  Tilden)  has  secured  the  ser\'ices  of  Dr.  John  S. 
Billings  in  the  preparation  of  a  complete  catalogue. 

Schools  of  Midwifery  in  Chicago  will  be  affected, 
it  is  said,  by  the  recent  ruling  of  the  State  board  of 
health  that  all  medical  instruction  must  hereafter  be 
carried  on  in  the  English  tongue. 

Favus  Subjects  Excluded. — Immigration  and  cus- 
toms officials  have  been  informed  by  a  circular  just 
sent  out  by  Commissioner-General  Powderly  that  they 
are  henceforth  to  send  back  immigrants  affected  with 
favus. 

The  Department  of  Charities,  finding  that  the  city 
is  supporting  about  twice  as  many  would-be  paupers 
as  is  necessar)-  for  the  city  to  pay  for,  has  begun  to  cut 
down  salary  expenses  by  discharging  nurses,  druggists, 
and  examining  physicians. 

Dr.  Ludwig  Weiss  has  been  appointed  consulting 
dermatologist  to  the  Hebrew  Orphan  .\sylum  in  this 
city. 

A  Dinner  to  Sir  William  Gowers. — The  members 
cf  the  Society  of  Medical  Stenographers  in  England 
have  decided  to  celebrate  by  a  dinner  the  conferring 
of  knighthood  upon  the  founder  of  the  society,  Sir 
William  Gowers.  The  dinner  is  to  be  held  on  the 
25th  ef  November,  and  Sir  William  Broadbent  has 
expressed  his  willingness  to  take  the  chair  on  the 
occasion. 

Obituary  Notes. — Dr.  J.\coe  H.4v  died  at  York. 
Pa.,  on  October  i8th,  at  the  age  of  sixty-four  years,  in 
consequence  of  disease  of  the  stomach  and  heart,  from 
which  he  had  long  suffered.  He  was  graduated  from 
the  University  of  Maryland  in   1854,  and  he  was  a 


member  of  count}',  State,  and  national  medical  socie- 
ties. He  had  been  president  of  his  local  medical  so- 
ciety, and  had  for  several  years  been  a  member  of  the 
local  board  of  school  control.  He  had  also  ser\'ed  as 
a  member  of  the  board  of  pensioner  examiners,  and  he 
was  a  member  of  the  Masonic  fraternit)-. 

A  Medical   Service   at   St.  Paul's   Cathedral  in 

London At  the  request  of  the  Guild  of  St.  Luke  a 

sermon  to  the  members  of  the  medical  profession  was 
preached  in  St.  Paul's  by  the  Archbishop  of  Vork  on 
October  rgth.  The  ser\-ice,  which  was  held  in  the 
evening,  -was  largely  attended  by  the  medical  men  of 
London,  all  wearing  academical  costume  and  accom- 
panied by  the  ladies  of  their  families. 

Johns  Hopkins  University. — There  are  one  hun- 
dred and  seventy  medical  students  at  the  Johns  Hop- 
kins University.  Some  of  them  are  women.  Dr. 
Michael  Foster,  professor  of  physiolog}-  in  the  L^niver- 
sity  of  Cambridge,  England,  delivered  an  address  be- 
fore the  students  on  October  nth. 

Diphtheria  and  Typhoid  in  Maryland The  prev- 
alence of  diphtheria  and  typhoid  fever  in  various 
parts  of  Maryland  has  given  the  State  board  of  health 
an  increase  of  work.  There  has  been  complaint  at 
Cumberland  on  account  of  the  contamination  of  the 
Potomac  River  from  places  above  Cumberland.  This 
same  contamination  has  had  a  very  bad  effect  on  the 
drinking-water  of  Washington. 

Maryland  Association    of    Military    Surgeons 

The  various  staff  surgeons  of  the  militia  of  Mar}-land 
have  formed  a  permanent  organization,  called  the 
Maryland  Association  of  Military  Surgeons. 

Our  Lucrative  Profession. — There  are  nearly  four 
hundred  doctors  in  St.  Louis  who  are  practically  starv- 
ing, says  Dr.  Lamphear,  and  in  Brooklyn  physicians 
are  said  to  be  hiring  as  motormen.  Dispensaries  and 
patent  medicines  are  the  alleged  causes. —  T/i^  Medical 
Examiner. 

Against  Lodge  Physicians. — It  is  stated  that  the 
Quebec  College  of  Physicians  and  Surgeons  has  issued 
a  decree  prohibiting  medical  men  from  accepting  po- 
sitions as  physicians  of  charitable  or  benefit  societies, 
under  pain  of  withdrawal  of  the  privilege  to  practise. 

Sanarelli  in  Italy. — The  Rome  correspondent  of 
The  Lancet  writes  that  Dr.  Sanarelli,  the  discoverer  of 
the  bacillus  icteroides,  is  expected  shortly  at  Genoa, 
whence  he  will  start  on  a  series  of  visits  to  the  lead- 
ing medical  schools  in  Italy,  at  each  of  which  he  will 
deliver  a  lecture  on  his  discovery  of  the  bacillus  of 
yellow  fever  and  set  forth  his  maturer  recommendations 
for  the  prophylaxis  as  well  as  treatment  of  this  dis- 
ease. 

Medical  Society  of  the  County  of  Broome  (N. 
Y.). — The  annual  meeting  of  this  society  was  held  in 
Binghamton  on  October  5,  1897.  Dr.  J.  D.  .\ppley  re- 
ported a  "case  of  chronic  abscesses  following  typhoid 
fever,"  Dr.  W.  S.  Overton  one  of  "  chorea  complicating 
pregnancy,"  and  Dr.  L.  D.  Famham  two  of  "  cancer  of 


634 


MEDICAL    RECORD. 


[October  30,  1897 


the  breast  cured  by  operation."  A  communication  on 
"Hypnosis  and  the  Phenomena  of  Consciousness," 
presented  at  the  last  meeting  by  Dr.  VV.  A.  White,  was 
discussed.  The  presidential  address  was  delivered  by 
Dr.  B.  E.  Hadeker. 

Dr.  W.  F.  G.  Hunter,  of  Kentucky,  who  was  re- 
cently acquitted  of  the  charges  of  bribery  in  the  sena- 
torial contest  in  that  State,  has  been  appointed  by 
President  McKinley  United  States  minister  to  Guate- 
mala. 

Small-pox  is  prevailing  to  an  alarming  extent  in 
Larnaca  in  the  island  of  Cyprus,  and  many  of  the  in- 
habitants are  fleeing  from  the  town  to  the  open  coun- 
try in  hope  of  escaping  infection. 

Cincinnati  Justice. — Not  long  ago  a  woman  was 
arrested  in  Cincinnati  for  riding  a  bicycle.  She  was 
modestly  dressed  and  was  behaving  properly,  yet  the 
Solon  of  the  police  court  fined  her  fifty  dollars  and 
sentenced  her  to  the  workhouse  for  thirty  days  on  a 
charge  of  loitering.  The  woman  was  a  prostitute,  but 
it  is  a  strange  law  that  punishes  a  person  engaged  in 
the  pursuit  of  health  and  happiness  on  a  wheel.  Rid- 
ing a  bicycle  will  become  a  dangerous  pastime  if  one 
can  be  accused,  in  so  doing,  of  loitering  as  well  as  of 
scorching. 

Those  Printers  again. — A  local  paper,  speaking 
of  a  street  accident,  says:  "Dr.  Jones  was  quickly 
summoned,  who,  after  examining  the  patient's  purse, 
decided  that  the  case  was  hopeless." — Medical  Times. 

The  French  Urological  Association  held  its  sec- 
ond annual  meeting  in  Paris  on  October  21st,  2 2d, 
and  23d,  under  the  presidency  of  Professor  Guyon. 
The  questions  proposed  for  discussion  are:  1.  "The 
Operations  Performed  on  the  Testicle  and  its  Adne.xa 
for  the  Relief  of  Prostatic  Hypertrophy,"  to  be  intro- 
duced by  Drs.  Albarran  and  Carlier.  2.  "Non-Gono- 
coccic  Urethritis,"  to  be  introduced  by  Drs.  Eraud  and 
Nogufes. 

A  Plea  for  a  Department  of  Public  Health.— At 
a  meeting  of  the  board  of  trade  and  transportation,  held 
in  this  city  on  October  13th,  Dr.  Warren  E.  Anderson, 
of  Pensacola,  formerly  a  member  of  the  Florida  State 
board  of  health,  read  a  paper  advocating  the  creation 
of  a  United  States  department  of  public  health  inde- 
pendent of  the  treasury,  war,  navy,  or  any  other  de- 
partment of  the  national  government.  He  said  that 
■'  uniformity  of  quarantine  laws  and  regulations  can  be 
obtained  only  through  Federal  control.  This  is  greatly 
to  be  desired,  as  it  alone  can  prevent  the  wild,  reck- 
less, and  absurd  shotgun  quarantines,  allay  panics, 
restore  confidence,  and  prevent  commercial  rivalry  of 
seaports  in  their  greed  for  trade  from  endangering  the 
public  health  of  the  entire  country.  The  State  should 
be  represented  in  the  national  health  councils,  and 
the  laws  there  made  should  be  executed  through  this 
representative.  All  sanitary  or  quarantine  officials 
should  be  residents  of  the  State  whose  health  interests 
they  are  to  protect,  and  no  official  should  be  appointed 
in  the  way  of  political  preferment,  but  only  upon  per- 
sonal qualifications  approved  by  commercial  organi- 


zations where  such  exist.  The  foreign  tonnage  tax 
should  be  applied  to  the  purposes  of  quarantine,  and 
thus  relieve  the  people  and  the  commerce  of  the  coun- 
try from  the  hea\'y  and  unjust  burdens  laid  upon  them 
by  the  present  system  of  health  protection.  The  Ma- 
rine Hospital  ser\'ice  should  be  remanded  to  the  per- 
formance of  that  duty  which  it  has  so  faithfully  done 
for  the  past  hundred  years — the  care  of  sick  and  dis- 
abled American  seamen.  A  failure  upon  the  part  of 
the  Federal  Congress  to  provide  the  citizen  with  ade- 
quate protection  against  the  invasion  of  imported 
disease  and  the  prevention  of  the  recurrence  of  such 
scenes  as  are  being  enacted  along  the  lower  Missis- 
sippi Valley  and  the  Gulf  coast,  will  be  regarded  as  a 
national  calamitj'." 

College  of  Physicians  of  Philadelphia. — At  a 
stated  meeting  of  the  section  on  general  medicine  of 
the  College  of  Physicians  of  Philadelphia  on  October 
nth,  Dr.  C.  W.  Burr  read  a  report  of  two  cretinoid 
brothers.  Dr.  S.  M.  Hamill  read  a  paper  on  "The 
Condition  of  the  Salivarj'  Digestion  in  Anaemia." 
The  investigations  upon  which  the  paper  was  based 
led  to  the  conclusion  that  there  were  no  constancy  and 
no  distinctiveness  in  the  characters  and  properties  of 
the  saliva  under  the  various  conditions  of  anaemia. 
Dr.  D.  L.  Edsall  read  a  paper  on  "  The  Gastric  Con- 
ditions in  Anemia,"  in  which  he  pointed  out  essen- 
tially that  while  in  cirrhosis  the  acidity  of  the  gastric 
juice  is  likely  to  be  increased  and  in  pernicious  anae- 
mia to  be  diminished,  the  condition  of  this  secretion 
bears  no  constant  relation  to  the  state  of  the  blood. 
Dr.  J.  C.  Wilson  exhibited  the  brain  from  a  man  who 
was  originally  supposed  to  be  suffering  from  tj'phoid 
fever,  with  the  development  finally  of  cerebral  symp- 
toms. Death  ensuing,  an  accumulation  of  pus  was 
found  in  the  region  of  the  vermiform  appendix,  and 
also  an  intracranial  abscess  containing  some  six 
ounces  of  pus,  situated  between  the  dura  and  the  brain, 
actually  involving  neither  of  these,  and  included 
within  a  dense  pyogenic  membrane. 

Philadelphia  Pediatric  Society. — A  stated  meet- 
ing of  the  Philadelphia  Pediatric  Society  was  held  on 
October  12th.  Dr.  F.  A.  Packard  demonstrated  a 
number  of  cases  exhibiting  congenital  deformities  of 
the  extremities.  Dr.  C.  W.  Burr  read  a  report  of  a 
fatal  case  of  chorea  occurring  in  the  course  of  an  at- 
tack of  nephritis  following  scarlet  fever.  Dr.  T.  S. 
Westcott  described  a  simple  method  for  calculating 
the  quantities  of  cream  and  whole  milk  to  make  any 
formula  for  home  modification.  Dr.  Alfred  Hand, 
Jr.,  reported  a  case  of  scurv-y  in  a  child. 

.  Hospital  Diagnosis. — A  barkeeper  in  London  felt 
out  of  sorts  and  had  a  rash  on  his  face.  He  applied 
for  treatment  at  the  outdoor  department  of  one  of  the 
large  hospitals,  and  was  told  that  his  blood  was  poi- 
soned in  consequence  of  his  frequent  nibbling  of 
potted  meats  and  fish  at  the  lunch  counter.  He 
returned  to  work  and  stopped  nibbling,  but  got  no 
better  and  returned  to  the  hospital.  This  time  he  was 
told  he  had  small-pox  and  was  bundled  off  to  die  pest- 
house,  his  neighbors  and  patrons  of  the  dive  where  he 


October  30,  1897] 


MEDICAL    RECORD. 


635 


dispensed  wet  goods  being  thrown  into  a  state  of  con- 
sternation. UTiile  they  were  bemoaning  his  lot  and 
theirs  he  suddenly  reappeared,  having  been  assured 
at  the  small-pox  hospital  that  his  case  was  one  simply 
of  varicella.  Now  the  hospital  authorities  are  inves- 
tigating the  hospital  doctors,  and  threaten  to  dismiss 
them  for  their  blunder:  the  inevitable  result  will  be  a 
falling  off  in  the  number  of  patients,  and  consequently 
a  less  effective  appeal  to  the  charitably  disposed. 

Pathological  Society  of  Philadelphia A  stated 

meeting  of  the  Pathological  Society  of  Philadelphia 
was  held  on  the  evening  of  October  14th,  the  presi- 
dent, Dr.  J.  H.  Musser,  in  the  chair.  Dr.  D.  Riesman 
demonstrated  a  specimen  exhibiting  extensive  gelati- 
nous infiltration  of  all  parts  of  the  peritoneal  cavit)-, 
together  with  a  considerable  quantit}-  of  gelatinous 
material  derived  from  this  source.  The  morbid  proc- 
ess was  believed  to  be  a  form  of  colloid  carcinoma. 
Dr.  H.  W.  Cattell  exhibited  the  stomach  and  kidneys 
from  a  case  of  carbolic-acid  poisoning.  The  former 
presented  a  characteristic  lustrous  silvery  appearance. 
It  was  pointed  out  that  occasionally  the  odor  of  car- 
bolic acid  can  be  perceived  about  the  kidneys  when 
not  detectable  about  the  stomach.  The  president  de- 
livered his  annual  address  and  the  treasurer  read  his 
annual  report.  According  to  the  latter  the  receipts 
during  the  past  year,  including  a  balance  on  hand  of 
$1,318.91,  amounted  to  $2,225.81,  and  the  disburse- 
ments to  $1,198.29.  The  number  of  active  members 
of  the  society  is  two  hundred  and  seven.  An  election 
for  officers  was  held,  with  the  following  result:  Presi- 
dent, Dr.  W.  E.  Hughes;  Vice-Presidents,  Drs.  F.  A. 
Packard,  C.  \V.  Burr,  Alfred  Stengel,  John  Guiteras: 
Secretary,  Dr.  D.  Riesman:  Recorder,  Dr.  A.  E.  Tay- 
lor; Treasurer,  Dr.  T.  S.  Westcott;  Curator,  Dr.  J. 
D.  Steele. 

Expulsion  from  a  Medical  Society  for  Unethical 

Conduct The  Cumberland  County  Medical  Society, 

at  its  semi-annual  meeting  at  Bridgeton,  N.  J.,  on 
October  12th,  expelled  from  its  membership  Dr.  S.  M. 
Wilson,  a  graduate  of  the  University  of  Pennsylvania 
and  a  practitioner  of  twent\--eight  years'  standing,  for 
unethical  conduct  in  acting  as  physician  for  a  com- 
pany engaged  in  the  employment  of  a  proprietar)-  cure 
for  alcoholism. 

"The  National  Medical  Review." — With  the 
October  number  of  this  interesting  journal  Dr.  Charles 
H.  Stowell  retires  from  the  editorship,  and  will  te 
succeeded  by  Drs.  Thomas  E.  McArdle  and  George 
W.  Johnston.  Dr.  Stowell  has  made  a  most  readable 
paper,  and  his  successors  will  have  no  sinecure  in 
maintaining  the  high  standard  he  has  set,  though  we 
have  no  doubt  they  will  do  so.  We  wish  the  retiring 
editor  full  measure  of  success  in  his  new  field  of 
usefulness. 

Philadelphia  County  Medical  Society. — .\  stated 
meeting  of  the  Philadelphia  County  Medical  Societ)- 
was  held  on  October  14th,  the  president.  Dr.  James 
Tyson,  in  the  chair.  Dr.  E.  W.  Holmes  read  a  paper 
on    "  Hay  Fever,"  in  which  he  maintained    that   the 


disease  was  a  neurosis  dependent  upon  disorder  of 
terminal  ner\-e  filaments  in  the  nares,  the  exciting 
agent  consisting  of  some  form  of  fine  powder,  such  as 
the  pollen  of  plants,  etc.  Of  treatment  he  could  not 
speak  hopefully,  but  recommended  change  of  resi- 
dence. 

D.  Hayes  Agnew  Memorial  Pavilion. — This  new- 
addition  to  the  hospital  of  the  University  of  Pennsyl- 
vania was  opened  at  Philadelphia  on  October  isth, 
with  appropriate  ceremonies.  The  building  is  a  sub- 
stantial three-story  brick  structure,  with  a  front  of  one 
hundred  and  fifty-four  feet  and  a  depth  of  one  hundred 
and  eighty-four  feet.  Its  erection  cost  $150,000,  and 
it  has  a  capacitj'  of  one  hundred  and  twentj'  beds.  It 
includes  also  an  amphitheatre  with  a  seating  capacity 
of  two  hundred  and  sevent}-,  and  two  others  with  a 
capacity  of  one  hundred  and  twent}'-five  each,  together 
with  hospital  wards,  dispensary  rooms,  etc. 

Prof.  Rudolf  Heidenhain,  the  well-known  profes- 
sor of  physiolog}-  at  the  University  of  Breslau,  died 
October  13th,  at  the  age  of  si.xt}--three  years.  After 
receiving  his  diploma  in  1854  he  entered  the  labora- 
tory of  Professor  DuBois-Reymond,  under  whose 
direction  he  conducted  his  researches  into  experi- 
mental physiolog}-.  He  had  held  the  chair  of  physi- 
ology at  Breslau  since  1859. 

A  Midwife  Fined. — A  midwife  was  recently  ar- 
rested here  on  the  charge,  made  by  the  Countv'  Medical 
Societ}-,  that  she  practised  medicine  without  a  license. 
She  was  convicted  and  made  to  pay  a  fine  of  $50. 

The  Anniversary  of  Pasteur's  Death  was  cele- 
brated on  September  28th  in  Paris.  The  members  of 
the  staff'  of  the  Pasteur  Institute  met  in  the  crypt  and 
placed  wreaths  on  the  tomb.  On  the  same  day  a 
mass  was  celebrated  in  the  presence  of  the  family  in 
ihe  parish  church  at  Arbois,  Pasteur's  birthplace. 

The  Surgeon-General  of  the  Navy The  President 

..as  appointed  Medical  Director  William  K.  Van  Ripen 
to  be  surgeon-general  of  the  navy,  to  fill  the  vacancy 
caused  by  the  death  of  Dr.  Bates.  Dr.  Van  Ripen  is 
.1  graduate  of  the  New  York  Universit}-  Medical 
.School  in  the  class  of  1862. 

The  Plague  is  steadily  increasing  in  India.  It  is 
Officially  announced  that  an  outbreak  has  occurred  in 
the  Jalandhar  district  of  the  Punjab.  The  village  of 
Khartkarhalan,  the  seat  of  the  infection,  has  been 
cordoned.  In  the  hospitals  of  Poonah  two  hundred 
and  ninety-four  cases  of  the  plague  are  being  treated, 
and  the  physicians  are  attending  one  hundred  and 
fifteen  cases  in  the  Bombay  hospitals.  There  were 
fort}'-two  deaths  at  Hardwar  up  to  October  26th. 
Thus  the  disease  is  now  prevailing  in  the  interior  as 
well  as  on  both  the  east  and  west  coasts  of  the  Indian 
peninsula. 

The  People's  Baths. — According  to  the  annual  re- 
port of  the  New  York  Association  for  Improving  the 
Condition  of  the  Poor,  of  the  work  done  at  its  People's 
Baths,  No.  9  Centre  Market  Place,  the  number  of 
baths  taken  from  October   i,  1896,  to  September  30, 


6.^,6 


MEDICAL    RECORD. 


[October  30,  1897 


1897,  inclusive,  was  as  follows:  Men,  75,454;  women, 
12,935;  children,  12,634;  total,  101,023.  T'^^ 
increase  over  the  corresponding  period  of  1896  was 
7,215.  The  total  number  of  baths  taken  since  the 
work  began  was  502,675.  A  fee  of  five  cents  is 
charged,  which  entitles  the  bather  to  a  new  piece  of 
soap,  clean  towels,  and  the  use  of  a  compartment  for 
twenty  minutes. 

The  Microbe  of  Trachoma.— It  is  announced  from 
Vienna  that  one  of  the  university  professors  there  has 
discovered  the  specific  diplococcus  of  Egyptian 
ophthalmia. 

Segregating  the  Consumptives. — The  State  board 
of  health  of  California  has  issued  orders  directing 
physicians  in  charge  of  asylums  to  segregate  consump- 
tives and  report  the  number  in  each  asylum.  This  is 
preliminary  to  the  enforcement  of  stringent  rules  by 
the  board  for  segregating  coniumptives  in  all  health 
resorts.  Many  persons  in  Southern  California  have 
been  clamoring  for  such  action.  The  southern  coun- 
ties are  overrun  with  consumptives,  and  in  most  places 
they  are  a  menace  to  healthy  persons. 

Another  Jack  the  Ripper. — France  has  a  "  Ripper," 
who  can  give  points  to  the  English  Jack  of  former 
days.  He  has  confessed  to  twelve  of  the  nineteen 
murders  he  is  supposed  to  have  committed. 

Diphtheria  prevails  to  such  an  extent  in  a  part  of 
Hoboken  that  it  has  been  found  necessary  to  close  one 
of  the  public  schools,  interrupting  the  studies  of  over 
one  thousand  children. 

Explosion  on  a  Warship's  Launch. — Dr.  W.  R. 
Dubose,  two  other  officers,  and  a  number  of  the  men 
of  the  battleship  Texas  were  injured  by  the  explosion 
of  the  boiler  of  one  of  the  steam  launches  of  that 
vessel  in  Boston  Harbor,  on  Friday  last.  No  one  was 
killed,  but  several  of  the  sailors  were  seriously 
injured. 

Dr.  Laporte,  whose  misfortune  in  losing  a  patient 
in  childbirth,  after  he  had  performed  craniotomy  with 
a  packer's  needle,  as  told  by  our  Paris  correspondent, 
was  convicted  on  October  22d  of  homicide,  and  was 
sentenced  to  three  months'  imprisonment.  The  sen- 
tence appears  from  the  evidence  to  have  been  a  most 
unjust  one,  and  the  unfortunate  has  the  comfort,  slight 
though  it  may  be,  of  knowing  that  he  has  the  sympa- 
thy of  his  confreres  everywhere. 

The  President's  Physician.  —  It  is  reported  in 
Washington  that  Capt.  Leonard  Wood,  passed  assis- 
tant surgeon  of  the  army,  will  probably  succeed  the 
late  Surgeon-General  Bates  of  the  navy  as  medical 
attendant  to  President  McKinley.  Dr.  Wood  is  sta- 
tioned in  Washington  as  attending  physician  to  army 
officers  and  their  families.  He  was  appointed  to  the 
army  as  assistant  surgeon  from  Massachusetts  in 
1886. 

Dr.  Van  Fleet,  of  this  city,  was  sued  for  libel  in 
consequence  of  some  remarks  made  by  him  at  a  meet- 
ing of  the  County  Medical   Society,  concerning  the 


advertisement  of  an  optician  in  the  Medical  Register. 
The  case  has  been  recently  tried  and  resulted  in  the 
acquittal  of  Dr.  Van  Fleet.  Judge  Wallace  ruled  that 
there  was  nothing  in  the  advertisement  to  cast  reflec- 
tion, but,  as  Dr.  Van  Fleet  was  seeking  the  removal 
of  the  advertisement  before  a  body  competent  to  grant 
it,  his  remarks  constituted  a  privileged  communica- 
tion ;  and  further,  there  was  nothing  to  show  personal 
malice  on  the  part  of  Dr.  Van  Fleet.  He  directed 
the  jury  to  bring  in  a  verdict  for  the  defendant. 

The  Hodynsky  Plain  Disaster.— The  commission- 
ers appointed  to  inquire  into  the  disaster  on  the  Ho- 
dynsky Plain  in  Moscow  during  the  coronation  festiv- 
ities, have  reported  that  the  number  of  lives  lost  was 
fourteen  hundred  and  twenty-nine. 

"  United  Statestians  "  is  the  uncouth  appellation 
which  the  editor  of  the  Practitioner  gives  us,  at  the 
suggestion  of  some  anonymous  word-coiner.  The  in- 
habitants of  this  glorious  country  are  very  well  satis- 
fied to  be  called  Americans,  but  if  some  jealous  Cana- 
dian objects  we  would  modestly  suggest  the  designation 
"  United  Statesmen." 

Physicians  for  Bombay The  Indian  government 

has  asked  for  twelve  medical  men  to  be  sent  out  from 
England  to  the  Bombay  presidency  for  duty  in  the 
plague-stricken  districts.  The  conditions  of  engage- 
ment are:  ^25  for  expenses  previous  to  starting,  a 
free  passage  to  Bombay  and  back,  and  500  rupees  a 
month.  ' 

Injured  by  Kissing. — A  curious  tale  is  related  in 
the  Miinchciicr  yacluichten  of  a  man  who  lost  conscious- 
ness after  implanting  thirty-seven  hundred  and  fifty 
kisses  upon  a  young  woman's  lips  in  the  course  of 
three  hours.  He  had  made  a  wager  that  he  could  kiss 
his  sweetheart  ten  thousand  times  within  ten  hours, 
but  soon  realized  the  universal  truth  that  there  can  be 
too  much  of  a  good  thing. 

Alcoholism  in  the  Army. — The  annual  report  of 
Surgeon-General  Sternberg,  made  public,  says  that 
alcoholism  is  not  so  prevalent  as  it  was  in  the  army, 
but  the  improvement  has  been  slight.  The  admission 
rate  for  intemperance  was  29.08  per  1,000  for  the  army 
as  a  whole,  31.20  among  the  white  soldiers,  and  5.70 
among  the  colored  soldiers.  Seven  deaths  among  the 
whites  were  due  directly  to  alcoholism. 

Deaths  from  Starvation  in  Cuba. —  Dr.  Brunner, 
medical  inspector  of  the  Marine  Hospital  service  sta- 
tioned in  Havana,  reports  to  Surgeon-General  ^Vyman 
that  the  death  rate  in  Havana  is  enormous  and  that 
the  sanitary  conditions  in  the  city  are  going  constantly 
from  bad  to  worse,  .\bout  two-fifths  of  the  total  deaths 
are  due  to  the  lack  of  sufficient  food  among  tiie  country- 
people,  whom  Weyler's  infamous  and  inhuman  policy 
has  driven  into  the  city.  Dr.  Brunner  writes,  in  the 
latest  report  of  the  Marine  Hospital  service:  "An  in- 
spection of  a  pest  hole,  known  as  Los  Fosos,  was  made 
by  me  on  Thursday,  October  14th.  This  place  has 
been  set  aside  for  the  country  people  sent  to  Havana. 
Los  Fosos  consists  of  a  large  wooden  building,  about 
one  hundred  and  fifty  feet  in  length  and  .sixty  in  width. 


October  30,  1897] 


MEDICAL    RECORD. 


637 


The  building  is  situated  in  an  inclosure  whicli  is  used 
for  the  storing  of  carts  of  tlie  municipality.  There 
were  five  hundred  people  found  in  and  around  this 
building,  and  of  that  number  over  two  hundred  were 
found  lying  on  the  floor,  sick  and  dying.  I  saw  no 
child  under  ten  years  of  age  who  could  be  considered 
in  good  health.  They  were  invariably  suffering  from 
some  form  of  enteritis  or  dysentery.  The  emaciation 
of  their  bodies  was  startling.  This  place  is  not  a 
hospital,  but  simply  a  place  of  residence  for  these 
people,  and  a  conser\'ative  estimate  of  the  death  rate 
would  be  about  ten  per  day.  The  number  is  re- 
cruited by  fresh  accessions  from  the  countr}-.  There 
were  over  one  hundred  and  fifty  children  below  the 
age  of  ten  years,  and  I  did  not  observ-e  one  whose 
chance  for  living  thirty  days,  under  the  existing 
conditions,  was  good.  There  are  two  other  such 
places  in  the  city  where  the  same  conditions  ex- 
ist." The  hospitals  of  the  cit}'  are  frightfully  over- 
crowded, the  Mercedes,  for  example,  having  five  hun- 
dred patients  while  it  has  accommodations  for  only  two 
hundred,  and  now  they  are  forced  to  refuse  to  receive 
any  new  patients. 

To  Test  the  Antiseptic  Treatment  of  Typhoid 
Fever. — In  response  to  the  suggestion  of  a  correspon- 
dent that  the  value  of  the  antiseptic  treatment  of 
t)-phoid  fever  be  put  to  a  careful  scientific  test,  Dr. 
W'oodbridge  writes,  in  the  Journal  of  the  American 
Medical  Association,  that  he  will  cheerfully  accept  the 
conditions.  He  says  he  w-ill  meet  the  suggested  com- 
mission "whenever  it  may  command  my  services  and 
wherever  it  may  choose  to  hold  its  sessions,  whether 
in  some  typhoid-stricken  cit)-  in  the  United  States,  in 
England,  on  the  Plains  of  Thessaly,  or  wherever  the 
disease  may  occur;  only  show  me  the  patients  and  I 
will  supervise  the  treatment  of  as  many  cases  of  typhoid 
as  maybe  necessary  to  enable  the  commission  to  make 
a  final  and  decisive  report.  No  one  shall  be  ta.\ed 
either  for  my  services  or  for  my  expenses."  .  Another 
writer  in  the  same  journal  suggests  that  the  Paris 
Academy  of  Medicine  be  asked  to  make  the  inquiry. 


when  he  was  mustered  out  of  service.  In  1863  he  was 
elected  resident  physician  in  the  Philadelphia  Hospi- 
tal, and  in  the  following  )ear  he  was  re-elected.  In 
1865  he  went  abroad  and  spent  three  years  in  general 
and  medical  study.  In  1868  he  began  the  practice  of 
medicine  in  private,  and  from  1869  to  1871  he  was  as- 
sistant demonstrator  of  anatomy  in  the  Philadelphia 
School  of  Anatomy.  During  the  Centennial  exposi- 
tion in  1876  hewas  a  member  of  the  Centennial  medi- 
cal commission  of  Philadelphia,  being  also  chairman 
of  the  committee  of  this  body  on  sanitary  science.  In 
the  same  year  he  was  a  delegate  to  the  International 
Medical  Congress  held  at  Philadelphia.  In  187 1  Dr. 
Ford  became  a  member  of  the  Philadelphia  board  of 
health,  in  1875  its  secretary,  and  in  1877  its  president, 
continuing  in  the  latter  office  until  his  death.  During 
his  connection  with  this  board  he  planned  and  had 
issued  a  weekly  bulletin  of  vital  statistics  of  Philadel- 
phia. He  was  largely  instrumental  in  organizing  the 
odorless  system  of  cleaning  wells,  the  public  collection 
of  garbage,  and  in  establishing  a  department  for  reg- 
ulating house  drainage  in  Philadelphia.  The  organi- 
zation of  a  department  of  milk  inspection  was  also 
due  to  his  efforts.  In  1S93  Dr.  Ford  planned  and 
supen-ised  for  the  board  of  health  the  construction  and 
fitting  up  with  all  modern  appliances  of  a  large  pavil- 
ion hospital  for  the  treatment  of  cholera  and  conta- 
gious diseases  in  conjunction  with  the  Municipal  Hos- 
pital. He  took  an  active  interest  in  the  construction 
of  a  large  and  complete  disinfection  plant  at  the 
Lazaretto,  and  proposed  the  erection  of  a  hospital  for 
tuberculosis  at  this  station.  In  1876  Dr.  Ford  was 
elected  physician  to  the  Foster  Home.  In  1879  he 
w-as  made  a  member  of  the  board  of  managers  of  the 
Sanitarium  Association  of  Philadelphia,  and  in  the 
same  year  he  became  a  member  of  the  board  of  direc- 
tors of  the  Tenth  Ward  Charity  Society  and  was 
elected  chairman.  Dr.  Ford  was  the  author  of  a  thesis 
on  "Gunshot  Wounds  of  the  Chest,"  founded  upon  his 
experience  in  militar)-  hospital  wards.  From  1872  to 
1876  he  edited  the  reports  of  the  board  of  health,  and 
from  1872  to  1875  he  compiled  the  vital  statistics  of 
Philadelphia.  He  was  the  author  of  '"  Statistics  of 
Births,  Marriages,  and  Deaths  in  the  City  of  Philadel- 
phia, '  published  in  1874.  He  was  for  several  years 
one  of  the  associate  editors  of  the  Philadelphia  Medical 
Times. 


PASSED    .ASSISTANT    SURGEON    BRATTON. 


HOSPITAL   SE 


©tituavnv 

DR.    WILLIAM    H.    FORD, 

FHILADELPHIA,    PA. 

Dr.  William  H.  Ford,  president  of  the  Philadelphia 
board  of  health,  died  suddenly  of  heart  disease  at  his 
summer  home  at  Belmar,  X.  J.,  on  October  iStli,  at 
the  age  of  fifty-eight  years.  He  was  graduated  from 
Princeton  College  in  i860  and  from  Jefferson  Medical 
College  in  1863.  He  was  in  1862  appointed  acting 
medical  cadet  in  the  United  States  army,  being  sta- 
tioned at  the  Wood  Street  United  States  .-Vrmy  General 
Hospital  in  Philadelphia.  Later  he  was  detailed  as 
medical  officer  on  board  the  hospital  steamer  Whilldin 
in  the  Pamunkey  River,  where  he  continued  in  sercivc 
for  a  short  time,  when  he  was  again  stationed  at  the 
W'ood  Street  Hospital,  remaining  there  until  the  spring 
of  1863.  In  the  following  summer  he  was  appointed 
assistant  surgeon  of  the  forty-fourth  regiment,  Penn- 
sylvania volunteers,  and  soon  afterward  he  was  made 
surgeon.  He  remained  with  his  regiment  until  the 
defeat  of  General  Lee  after  the  battle  of  C»ettysburg, 


Passed  Assistant  Surceox  William  DuBose  Brat- 
ton,  of  the  United  States  Marine  Hospital  serv^ice, 
died  at  Sabine  Pass,  Tex.,  on  October  2d,  under  pecu- 
liarly distressing  circumstances.  In  the  need  of  med- 
ical officers  during  the  present  yellow-fever  epidemic. 
Dr.  Bratton,  though  an  invalid  and  therefore  on  wait- 
ing orders,  voluntered  his  services  to  meet  the  emer- 
gency. He  was  ordered  to  Sabine  Pass  to  assume 
charge  of  matters  relating  to  the  quarantine  service 
at  that  port.  On  October  ist  he  had  been  superin- 
tending'the  disinfection  of  a  vessel,  and,  returning  to 
the  ship  to  reassure  himself  upon  the  work  done,  he 
fell  through  a  ventilating-hole,  striking  his  head  on 
an  iron  knee,  producing  concussion  of  the  brain.  He 
remained  undiscovered  for  several  hours,  and  when 
found  was  unconscious  and  remained  so  until  death 
occurred,  eighteen  hours  after  the  accident.  He  was 
born  in  South  Carolina,  June  23,  i860,  and  was  grad- 
uated at  the  Medical  College  of  South  Carolina,  March 
I,  1884,  and  for  the  year  following  was  house  surgeon 
at  the  Charleston  City  Hospital.  He  entered  the  Ma- 
rine Hospital  service  in  1885,  his  first  station  being 
in  this  city. 


638 


MEDICAL    RECORD. 


[October  30,  1897 


^etiicius  and  glottces. 

Vita  Medic  a  :  Chapters  of  Medical  Life  and  Work. 
By  Sir  Benjamin  Ward  Richardson,  M.D.,  LL.D., 
F.R.S.  London,  New  York,  and  Bombay:  Longmans, 
Green  &  Co.      1897. 

These  chapters  upon  incidents  in  the  medical  and  scientific 
life  of  the  autobiographer  will  have  for  his  admirers  a  pecu- 
liar interest  in  the  fact  that  only  two  hours  after  their  com- 
pletion the  author  was  seized  wnth  the  illness  which  ended 
fatally  three  days  later. 

The  work  is  published,  therefore,  fresh  from  the  pen  with- 
out the  author's  revision  or  correction.  It  is  somewhat  pa- 
thetic to  read,  in  the  preface,  written  so  short  a  time  before 
the  end,  that  some  studies  of  like  nature  were  still  in  hand, 
but  that  he  had  thought  it  best  to  issue  at  the  present  time 
what  he  had  dared  to  imprint  upon  these  pages.  Chapter 
xxviii.,  page  496,  the  shortest  in  the  book,  is  entitled  "  A 
Last  Word,"  in  which  he  said:  "I  have  set  myself  to 
record  a  medical  life  from  the  medical  side  of  my  own 
life ;  not  in  any  sense  as  a  model  picture,  but  in  the  earnest 
hope  of  the  day  when  men  of  physic  shall  find  in  the  study 
of  the  natural  body  the  grandest  work  the  human  intellect 
can  command." 

Digest  of  Criticisms  on  the  United  States  Phar- 
macopceia.  Seventh  Decermial  ReWsion  (1890).  Pub- 
lished by  the  Committee  of  Re\nsion  and  Publication  of 
the  Pharmacopoeia  of  the  United  States  of  America, 
I S90- 1 900.  Part  I . .  Comprising  Abstracts  of  Papers  up  to 
July  1,   1896.     New  York.      1897. 

The  committee  on  revision  has  here  presented  in  a  hundred 
and  eighty  pages  the  first  portion  of  the  digest  of  criticisms 
and  suggestions  for  improving  the  National  Pharmacopoeia. 

A  Text-Book  of  Mental  Diseases,  for  the  Use  of 
Students  and  Practitioners  of  Medicine.  By 
Theodore  H.  Kellogg.  M.D.  New  York:  Wil- 
liam Wood  and  Company. 

The  time  is  particularly  opportune  for  the  appearance  of  an 
authoritative  American  treatise  on  mental  diseases.  The 
author  of  the  text-book  before  us  has  embraced  the  oppor- 
tunity, and  the  result  is  a  volume  that  enhances  at  the  same 
time  his  reputation  as  an  alienist  and  litterateur,  and  ad- 
vances the  desen-ed  position  of  .American  psychiatry-.  No 
one  acquainted  with  the  literature  of  insanity  and  who  has 
had  intimate  contact  with  the  insane  can  fail  to  be  impressed 
by  the  fact  that  the  author  has  made  himself  intimately  fa- 
miliar with  both,  and  has  given  forth  as  the  result  a  distinctly 
indindual  and  praiseworthy  treatise.  The  volume  of  about 
eight  hundred  pages  is  divided  into  two  parts,  the  first 
being  concerned  with  general  mental  pathology-,  the  latter 
with  the  special  groups  and  the  t\-pical  forms  of  insanity. 
L'nder  the  fonner  are  discussed  the  histor\-.  the  statistics, 
the  nosology,  the  etiolog\-,  and  the  evolution,  stadia,  clinical 
progression,  and  termination  of  mental  diseases.  The 
syraptomatolog)-  is  then  taken  up  in  great  detail :  first,  the 
psychical,  then  the  somatic  s\Tnptoms,  the  different  sub- 
divisions of  each  being  considered  in  a  separate  chapter — 
for  instance,  under  the  former,  disorders  of  the  intellect,  of 
the  emotions,  and  of  volition;  under  the  latter,  the  disorders 
of  the  various  systems  making  up  the  body.  The  pathology-, 
diagnosis,  prognosis,  and  treatment  are  then  considered  be- 
fore the  special  forms  of  insanity  are  discussed.  The  ar- 
rangement of  the  volume  leaves  nothing  to  be  desired. 
The  subject  is  unfolded  in  a  natural  way,' and  for  the  begfin- 
ner  in  psychiatr)-  the  work  cannot  fail  to  be  impressive,  sug- 
gestive, and  very  useful. 

In  the  chapter  on  the  nosology'  of  insanity  the  author  re- 
cites the  various  classifications  that  have  been  given  by  jisv- 
chiairists.  and  then  points  out  the  necessity  of  a  new 
classification  based  particularly  on  etiological  ground,  which 
he  proceeds  to  give.  The  virtues  of  Dr.  Kellogg's  classifi- 
cation are  ver^'  apparent  to  the  reviewer:  nevertheless  lu- 
believes  that  serious  objections  can  be  urged  against  its 
adoption.  It  is  unwieldy  and  too  complex  for  all  save  tlu- 
psychologist  and  advanced  psychiatrist;  in  short,  a  classifi- 
cation of  in.sanity  that  befits  a  te.xt-book  for  students  and  prac- 
titioners should   be  simple,  lucid,  and  as  brief  as  possible. 


even  though  these  qualities  are  opposed  to  absolute  scientific 
accuracy  and  detail. 

The  chapter  on  the  etiolog)'  of  insanity  is  comprehensive, 
well  put  together,  and  one  of  the  best.  The  same  may 
be  said  of  the  chapter  on  treatment,  by  all  means  the 
best  one  in  the  volume.  It  is  doubtful  if  any  more  reliable 
guide  can  be  put  in  the  hands  of  the  ine.xperienced  physi- 
cian or  the  developing  alienist  than  the  chapter  now  under 
discussion.  It  is  stamped  throughout  with  the  hallmark  of 
one  who  has  come  into  intimate  association  with  the  insane 
under  three  ver\-  different  conditions,  viz. :  in  private  life,  in 
public  institutions,  and  in  sanatoria.  The  advantages  and  dis- 
advantages of  each  are  specifically  and  judiciously  set  forth. 
The  chapter  on  the  prognosis  of  insanity  is  clearly  the  work 
of  one  who  has  lived  with  the  insane  and  whose  conclusions 
are  based  on  the  experience  such  intercourse  has  given.  In 
other  words,  one  is  convinced  that  the  conclusions  of  the  au- 
thor are  not  the  mirroring  of  work  in  the  library-.  The 
author  is  apparently  alive  to  the  value  of  simple  statement 
and  of  emphasis,  and  does  not  indulge  in  the  latter  when  the 
former  is  sufficient.  The  chapter  on  the  pathology  of  in- 
sanity- is  brief,  devoid  of  illustration,  and  disappointing.  It  is 
the  only  chapter  in  the  book  that  does  not  reflect  credit  on  its 
author.  The  formula  for  the  diagnostic  examination  of  pa- 
tients will  no  doubt  fulfil  the  expectations  of  the  author,  who 
believes  ■'  that  it  may  prove  highly  suggestive  and  useful  to 
the  general  practitioner,"  providing  the  latter  can  have  Dr. 
Kelljgg's  book  before  him  when  he  is  examining  a  patient, 
but  the  general  practitioner  will  probably  find  his  strength 
unequal  to  memorizing  it. 

That  Dr.  Kellogg  has  made  one  of  the  most  important 
additions  to  text-book  literature  of  insanity"  must  be  ap- 
parent to  ever)-  one  who  carefully  examines  this  volume. 
We  believe  that  it  will  become  a  standard  for  American 
students.  It  is  not  without  serious  inherent  shortcom- 
ings, and  a  number  of  minor  deficiencies,  syntactical, 
orthographical,  and  other,  might  have  been  eliminated  by 
careful  proofreading.  Although  the  style  of  many  passages 
is  ver\'  impressive,  the  re\iewer  has  a  feeling  after  finish- 
ing the  volume  that  oftentimes  the  phraseology  is  unneces- 
sarily learned  and  weighty,  and  although  moderately  familiar 
with  the  literature  of  the  subject  which  the  book  so  com- 
mendably  exposits,  still  he  found  it  necessary-  on  more  than 
one  occasion  to  lean  on  an  encyclopedic  dictionary-,  and  in 
one  instance  that  staff  failed  him. 

A  Manual  of  Physiology,  with  Practical  Exer- 
cises. By  G.  N.  Stewart,  M.A.,  M.D.  With  nu- 
merous illustrations.  Philadelphia:  W.  15.  Saunders. 
1897. 

The  author  herein  gives  the  result  of  years  of  teaching 
physiology-  to  medical  students.  A  series  of  practical  ex- 
ercises is  given,  which  are  well  adapted  for  practical  work 
in  a  laboratory-.  In  fact  the  book  should  be  used  only  as  a 
guide  for  work  in  the  laboratory-.  .All  the  various  chap- 
ters on  the  blood,  l\-mph,  respiration,  digestion,  nervous 
system,  the  senses,  are  clearly  written,  and  the  instruments 
described  are  up  to  date.  The  illustrations  are  excellent, 
and  the  book  is  certainly  a  credit  to  (he  writer. 

Sir  James  Y.  Simp.son.  By  Kve  Hi.antvre  Simpson. 
Famous  Scots  Series.  New  York ;  Charles  Scribner's 
Sons. 

This  tells  in  a  pleasing  style  of  the  school  days,  start  in  life, 
rise,  popularity,  honors,  hospitality,  religion,  failings,  etc.. 
of  a  man  whose  life  must  have  something  of  interest  in  it 
for  ever\-  physician. 

.\  Text-B(»uk  of  Special  I'ArHoi.<.iGicAL  Anaio.mv. 
By  Ernst  Ziegi.er,  Professor  of  Pathology-  in  the 
University  of  Freiburg.  Translated  and  Edited  from 
the  German  Edition  by  Donald  Mac.\lister,  M.A.. 
M.D..  Linacre  Lecturer  of  Physic  and  Tutor  of  St. 
John's  College.  Cambridge,  and  Henry  W.  Catteli.. 
M..\..  M.I)..  Demonstrator  of  Morbid  .Anatomy  in  the 
I'niversity  of  Pennsylvania.  Sections  I.-\'III.  New 
York:  The  Macmillan  Company.  London:  Macmillan 
vt  Co.,  Limited.      1896. 

The  present  volume  includes  eight  .sections:  section  i.. 
blood  and  lymph  :  section  ii. .  the  vascular  mechanism ;  sec- 
tion iii.,  the  spleen  and  the  lymph  glands;  section  iv.,  the 
osseous  svstcm :  section  v..  the  muscles  and  tendons;  sec- 


October  30,  1897] 


MEDICAL    RECORD. 


639 


tion  \-i. ,  the  central  nen-ous  system ;  section  \-ii. ,  the  peri- 
pheral ner\ous  system;  section  viii. ,  the  skin. 

^'olume  II.,  when  published,  will  contain  the  pathology 
of  the  alimentarj-  tract,  liver,  pancreas,  respirator)-  and 
genito-urinary  systems,  eye,  and  ear. 

The  translation  has  been  done  with  e\idences  of  the 
utmost  care  and  attention  to  detail.  The  illustrations  are 
e.iccellent,  and  the  publishers'  portion  of  the  work  is  all  that 
could  be  desired. 

Telepathy  and  the  Subliminal  Self.  An  account 
of  Recent  Investigations  Regarding  H>-pnotism,  Autom- 
atism, Dreams.  Phantasms,  and  Related  Phenomena. 
By  R.  Osgood  Mason,  A.M.,  M.D.,  Fellow  of  the 
New  York  Academy  of  Medicine.  New  York:  Henr)' 
Holt  and  Company.      1897. 

The  new  psychology-,  as  it  is  called,  has  an  attractiveness 
about  it  w-hich  brings  forth  writers  and  readers. 

The  present  series  of  papers  give  studies  in  the  outl)-ing 
fields  of  psychology-,  and  is  intended  as  an  aid  and  intro- 
duction to  the  study  of  '  •  the  more  subtle  forces  in  our 
being."  Interesting  material  will  be  found  in  the  chapters 
on  thought  transference,  lucidit)-,  double  personality,  autom- 
atism, cr\-stal  gazing,  phantasms,  etc. 

A  Treatise  on  the  Surgery  of  the  Alimentary 
Canal,  Comprising  the  QEsophagl's,  the  Stomach, 
the  Small  and  Large  Intestines,  and  the  Rec- 
tum. By  A.  Ernest  Maylard,  M.B.,  B.S.  Lond.. 
Surgeon  to  the  Victoria  Infirmar)-.  Glasgow,  etc.  Pp. 
xxiv. +724.     Philadelphia:  P.  Blakiston,  Son  &  Co.    1896. 

It  is  impossible  in  a  brief  re\-iew  to  do  justice  to  this  elab- 
orate exposition  of  the  subject  of  gastric  and  intestinal  sur- 
gery-. Some  idea  of  the  scope  of  the  work  may  be  obtained 
from  a  glance  at  the  table  of  contents  and  list  of  case  re- 
ports, from  which  it  will  be  eWdent  that  the  author  has  gone 
most  expansively  into  the  literature  of  the  subject,  Ameri- 
can as  well  as  foreign.  Apparently  no  important  case  has 
escaped  him. 

Part  I.,  on  the  oesophagus,  includes  si.xteen  chapters, 
neoplasms  being  most  thoroughly  discussed.  Among  the 
many  admirable  plates  is  one  excellent  skiagraph  (p.  24). 

In  Part  II..  on  the  stomach  (fourteen  chaptersi,  we  note 
as  especially  worthy  of  study  the  two  chapters  on  ulcer,  two 
on  pyloric  and  cardiac  obstruction,  and  the  descriptions  of 
gastrostomy  and  gastrectomy. 

Part  III.,  dealing  with  the  intestines,  includes  nearly 
three  hundred  pages,  and  is  exhaustive.  Three  chapters  are 
devoted  to  appendicitis,  and  a  large  number  of  operations 
for  entero-anastomosis  are  carefully  described  and  illus- 
trated.    More  than  a  hundred  pages  are  given  to  the  rectum. 

Each  di\-ision  of  the  subject  is  introduced  by  a  chapter  on 
anatomy  and  physiolog)-.  The  pathologj-,  symptoms,  and 
prognosis  of  each  lesion  are  first  presented,  followed  by  the 
treatment.  The  operations  are  described  in  separate  chap- 
ters, the  descriptions  being  clear  and  concise,  with  the  omis- 
sion of  all  useless  details.  Each  subject  is  thoroughly  elu- 
cidated by  the  introduction  of  clinical  reports  of  cases. 

Many  of  the  illustrations  (one  hundred  and  seventeen 
in  number),  are  unusually  valuable.  In  fact  there  seems  to 
be  little  room  for  criticism,  unless  the  busy  reader  may  ob- 
ject to  a  certain  amount  of  ••padding"  in  a  book  which 
is  supposed  to  be  devoted  purely  to  operative  surgery.  But 
the  temptation  to  write  a  bulky,  rather  than  a  practical  work- 
ing monograph,  seems  to  be  what  most  medical  writers  find 
hard  to  resist. 

The  Menopause  and  Its  Disorders.  Bv  A.  D.  Leith 
Napier,  M.D..  F.R.C.S.  Ed.,  M.R.C.P.  Lond.. 
F. R.S.  Ed.,  etc..  Senior  Surgeon  and  Surgeon  in 
charge  of  Gyniccological  Cases,  and  Lecturer  in  Clinical 
Surgery-  and  in  Gynaecology,  General  Hospital,  Adelaide, 
etc.  Pp.  XV.  +  307.  London  :  Scientific  Press,  Limited. 
1897. 

.\s  stated  in  the  preface,  the  aim  of  the  author  is  to  set  forth 
the  results  of  the  latest  studies  in  menstruation  and  the 
phenomena  attending  its  cessation. 

There  are  thirteen  chapters,  each  of  which  is  succeeded 
by  a  copious  list  of  references.  The  introductor\-  chapter 
on  menstruation  is  quite  interesting,  considerable  atteniiun 
being  paid  to  modem  theories.  The  author  leans  to  the 
■    ner\e  theory,  "  fortifying  his  position  very  well.     The  suc- 


ceeding chapter  on  "  Anatomical  Considerations"  is  an  able 
one.  The  author's  theory-  is  briefly  as  follows :  The  action 
of  the  utricular  glands  causes  a  peripheral  uterine  irritation 
which  sends  afferent  impulses  to  the  ner\-e  centre  regulat- 
ing menstruation.  Thence  efferent  impulses  are  sent  to  the 
uterus,  determining  continued  growth  of  the  glands,  stroma, 
and  vessels.  The  menstrual  flow  is  due  to  the  breaking 
down  of  congested  capillaries  and  shedding  of  the  superficial 
epithelium.  The  rh)-thm  of  menstruation  is  due  (i)  to  meta- 
bolic changes  in  the  endometrium,  followed  by  katabolic 
changes  for  the  removal  of  effete  matters;  (2)  to  periodic 
enlargement  of  the  uterine  glands:  (3)  to  automatic  nerve 
action. 

In  chapter  iii.  the  physiology-  of  menstruation  is  dis- 
cussed at  length;  in  chapter  iv.  the  normal  climacteric; 
chapters  v.  to  ix.  (inclusive;  deal  with  its  ordinary  dis- 
orders, blood  dyscrasias  and  constitutional  affections,  and 
the  psychoses ;  Chapters  x.  and  xi. ,  on  fibroids  and  malig- 
nant disease,  are  exceedingly  interesting  and  will  repay 
careful  study ;  the  concluding  chapter  treats  of  vaginal  and 
uterine  displacements  in  elderly  women. 

We  have  no  hesitation  in  commending  this  monograph  as 
the  best  which  has  yet  appeared  on  this  important  subject. 
It  is  not  only  original,  but  presents  special  points  of  excel- 
lence, notably  the  clear  scholarly  arrangement  of  the  mate- 
rial, the  summar\'  which  concludes  each  chapter,  and  the 
exhaustive  bibliography.  The  therapeutical  side  of  climac- 
teric disorders,  which  has  hitherto  received  but  little  atten- 
tion, is  carefully  handled,  and  will  be  especially  helpful  to 
the  general  practitioner.  In  this  age  of  overproduction  in 
medical  literature,  it  is  always  gratifying  to  meet  with  a 
book  which  needs  no  apology,  but  is  its  own  raison  d^etre. 

An  Account  of  the  Life  and  Works  of  Dr.  Robert 
Watt,  Author  of  the  •  •  Bibliotheca  Britannica. "  By 
Dr.  James  Finlayson,  M.D.,  Physician  to  the  Glas- 
gow "VVestem  Infirmar\-  and  the  Royal  Hospital  for  Sick 
Children.  With  a  Portrait.  London:  Smith,  Elder  & 
Co.      1897. 

A  NE.\T  little  volume  of  forty-inch  thick  paper  and  large- 
print  page,  ha\-ing  a  delicately  tinted  frontispiece  fjortrait. 
An  appendix  contains  dates  of  interest  in  Watt's  life. 

Obstetrical  Pocket-Phantom.  By  Dr.  K.  Shibata, 
Specialist  in  G\-na?cology  and  Obstetrics,  Tokio,  Japan. 
Preface  by  Professor  Franz  von  Winckel.  With  eight  illus- 
trations, one  pelvis,  and  two  jointed  manikins.  Translated 
from  the  third  edition  by  Ada  Howard-Audenried, 
M.D.,  Physician  to  the  Children's  Clinic  at  the  Woman's 
Hospital.  Philadelphia.  Philadelphia:  P.  Blakiston,  Son 
&  Co.,   1012  Walnut  Street.      1895. 

The  twentieth  century  approaches.  Its  advent  is  heralded 
by  a  work  written  by  a  Japanese  professor  and  translated  by 
a  medical  man  of  the  gentler  sex.  To  be  sure  it  is  small, 
but  then,  too.  it  is  good, — and  a  small  good  thing  often 
shows  in  what  direction  the  wind  is  pushing  the  world  along. 
Students  \nU  find  this  an  aid  in  the  study  of  parturition. 

New  York  County  Medical  Association  Register 
FOR  1S97. 

This  book  contains  the  names  and  addresses,  with  office 
hours,  of  the  1,056  members  of  the  New  York  County  Med- 
ical Association,  and  also  the  names  and  addresses  of  all 
other  regular  physicians  in  this  cit)-.  In  addition  to  these  lists 
the  book  contains  much  valuable  information  concerning 
medical  laws,  etc.,  and  several  short  essays  on  topics  of  cur- 
rent interest,  one  of  which  is  a  brief  statement  of  the  ad- 
vantages to  be  derived  from  the  adoption  of  Modem  Greek 
as  the  international  language. 

A  System  oy  Surgery.  By  .American  authors.  Edited 
by  Frederic  S.  Dennis,  Si.D..  Professor  of  the  Princi- 
ples and  Practice  of  Surger\-.  Belle\-ue  Hospital  Medical 
College,  New  York,  President  of  the  American  Surgical 
Association,  etc.;  assisted  by  John  S.  Billings,  M.D., 
LL.  D..  D.C.L.,  Deputy  Surgeon-General  L'.  S.  A. 
Profusely  illustrated  with  figures  in  colors  and  in  black. 
8vo,  pp.  908.     Philadelphia:  Lea  Brothers  &  Co. 

The  third  volume  of  this  valuable  work  appears  with  com- 
mendable promptness,  and  contains  a  large  anwunt  of  inter- 
esting and  practical  material.  It  comprises  chapters  on  the 
surgerj'  of   the  larj-nx.  tongue.  Jaws,  teeth,  salivar>-  glands. 


640 


MEDICAL    RECORD. 


[October  30,  1897 


neck  and  chest,  eye,  ear,  skin,  genito-urinan'  system,  and 
syphilis,  and  may  be  considered  as  a  collective  work  mostly 
in  special  lines.  In  a  general  way  it  may  be  said  that  each 
author  has  done  his  best  to  present  his  subject  from  the 
authoritative  standpoint  of  an  e.xpert  and  with  due  considera- 
tion for  the  purposes  of  the  work  as  a  whole.  Dr.  D.  Br>-son 
Delavan's  chapter  on  the  Surs^er^'  of  the  Larjn.x  and  Trachea 
is  a  judicious  resutn^  of  the  subject,  well  written,  clearly  pre- 
sented, and  practically  considered.  The  Surgerj-  of  the 
Mouth  and  Tongue,  by  Professor  Mudd,  compasses  a  large 
field,  and  each  portion  receives  its  due  attention.  The  de- 
scriptions of  pathological  conditions  and  operative  procedure 
are  clearly  and  concisely  presented.  The  Diseases  of  the 
Salivar\-  Glands  forms  a  short  and  practical  paper  by  Pro- 
fessor Porter,  of  Har\'ard.  The  Surger\'  of  the  Neck,  by 
Dr.  Willard  Parker,  gives  e\idence  of  an  earnest  study  of 
the  subject,  but  with  too  much  apparent  deference  to  other 
surgical  authorities.  The  editor,  with  the  universal  adapt- 
ability of  his  kind,  assigns  himself  to  a  passing  emergency  by 
treating  in  a  thoroughly  ex-cathedra  fashion  the  Surgical  In- 
juries and  Diseases  of  the  Chest.  Professor  De  Schweinitz,  of 
Philadelphia,  gives  an  excellent  chapter  on  the  General  Dis- 
eases of  the  Eye,  which  will  be  especially  appreciated  by  the 
general  surgeon,  while  Drs.  Noyes  and  Weeks  treat  the  Op- 
erative Procedures  on  the  Eye  in  a  thoroughness  of  manner 
and  detail  leaving  nothing  to  be  desired.  The  Surgery  of  the 
Ear,  by  Dr.  Bacon,  makes  an  interesting  and  instructive 
chapter  within  the  short  limits  of  its  assignment  of  space. 
The  Surgical  Diseases  of  the  Jaws  and  Teeth,  by  Professor 
Tiffany,  is  a  thoroughly  scientific  presentation  of  principles 
and  practice  too  little  k-nown  and  appreciated  by  both  the 
general  practitioner  and  the  dentist.  The  chapter  on  Sur- 
gical Diseases  of  the  Skin,  by  Professor  Hardaway,  of  St. 
Louis,  has  a  good  selection  of  the  varieties  of  the  subject, 
and  treats  them  in  an  intelligently  practical  manner.  Pro- 
fessor J.  William  White,  of  Philadelphia,  assisted  by  Dr.W.H. 
Turner,  contributes  an  exhaustive  section  on  Genito-Urinar\' 
Diseases,  making  almost  a  book  by  itself,  and  Professor  R.  W. 
Taylor,  with  an  equally  elaborate  and  painstaking  chapter  on 
Syphilis,  closes  the  volume.  The  usual  number  of  illustra- 
tions embellish  the  book,  a  good  proportion  of  which  are  in 
colors. 


NEW   YOKK   ACADEMY    OF    MEDICINE. 

Stated  Meeting,   October  21,  iSgj. 

Edward  G.  J.\neway,  M.D.,  President. 

The  Wesley  M.  Carpenter  Lecture. — Dr.  Willia.m 
Hallock  Park  delivered  the  lecture,  which  was  the 
special  order  of  the  evening,  taking  for  his  subject, 
"The  Contributions  of  Bacteriology  to  Therapeutics." 
He  said  that  bacteria  caused  disease  by  their  mechani- 
cal presence  in  the  tissues,  by  the  poisons  produced  in 
their  growth,  or  by  the  withdrawal  from  the  body  of 
their  food  substances,  or  in  other  ways,  as  yet  unknown. 
They  caused  injury  to  the  body  chiefly  by  their  action 
on  the  body  cells  through  their  poi-sons.  The  most 
important  determining  factor  was  whether  or  not  the 
body  at  the  time  and  place  of  infection  was  in  proper 
condition  for  the  growth  of  the  bacteria.  Ordinarily, 
the  human  body  was  not  a  good  place  for  bacterial 
growth.  We  must  look  to  the  living  tissues  for  some 
decided  influences  in  addition,  otherwise  it  would  be 
impossible  to  offer  a  reasonable  explanation  for  the 
very  variable  degrees  of  virulence  exhibited.  It  was 
long  ago  noticed  that  people  were  not  apt  to  contract 
certain  diseases  a  second  time.  If  a  few  virulent  an- 
thrax bacilli  were  injected  .  into  a  susceptible  animal, 
the  bacilli  would  soon  begin  to  increase,  and  would 
give  rise  to  fever  and  other  evidences  of  disease,  and 
finally  cause  death.  More  minute  examination  would 
reveal  the  fact  that  the  bacteria  apparently  attracted 
great  numbers  of  leucocytes;  in  an  immunized  animal 
no  such  phenomenon  would  be  observed.     This  at- 


traction of  the  leucocytes  by  bacteria  was  not  due  ap- 
parently to  any  inherent  property  of  the  leucocytes,  but 
rather  to  the  effect  of  substances  in  the  serum  on  the 
leucocytes.  Besides  this  action  of  the  leucocj-tes,  it 
was  probable  that  the  blood  contained  substances  di- 
rectly bactericidal.  As  to  the  nature  of  the  action  of 
toxins  and  antitoxins  on  each  other,  it  might  be 
stated,  as  a  working  hypothesis,  that  a  toxin  was  a 
substance  directly  poisonous,  according  to  the  inten- 
sity of  its  affinity  for  the  cell  substance  of  any  living 
body.  Thus,  a  chicken  might  be  injected  with  three 
times  as  much  tetanus  toxin  as  would  be  fatal  to  a 
horse,  and  still  the  chicken  would  live:  but  sufficient 
could  be  injected  to  cause  its  death.  According  to 
his  view  of  the  subject,  an  antitoxin  might  be  defined 
as  a  toxin  which,  by  contact  with  living  cell  substance, 
either  within  or  without  the  cell,  had  been  changed. 
The  toxin  might  have  been  changed  by  uniting  with 
a  portion  of  the  cell  substance,  or  might  have  been 
simply  acted  upon  by  it.  He  could  not  conceive  of 
cells  being  so  constituted  as  to  have  a  response  for 
each  specific  toxin ;  but  if  we  considered  the  anti- 
toxins to  be  toxins  altered  by  contact  or  union  with 
the  cells,  the  specific  action  was  easily  explicable. 
As  these  substances  had  not  been  obtained  in  a  pure 
state  chemically,  we  could  only  theorize  regarding 
them.  Antitoxins  do  not  remain  permanently  in  the 
blood,  but  are  gradually  eliminated,  disappearing  after 
a  few  weeks  or  months.  Bacteria  differ  as  to  the  por- 
tions of  the  tissues  in  which  they  can  develop.  Thus, 
a  few  tetanus  bacilli  driven  by  a  splinter  into  the 
foot  multiply  but  slightl)-,  but  they  find  sufficient  soil 
to  produce  a  toxin  quickly,  and  in  sufficient  quantity 
to  cause  death.  The  bacillus  of  diphtheria  requires  a 
different  soil;  it  is  practically  harmless  in  the  skin 
and  intestine,  but  when  inhaled  causes  diphtheria. 
The  tubercle  bacillus  invades  the  tissues  very  slowly. 
Clinically,  as  well  as  bacteriologically.  it  was  known 
that  lack  of  food,  exposure  to  heat  and  cold,  overex- 
ertion, extreme  youth,  and  other  influences  predispose 
to  disease,  while  the  opposite  conditions  help  the  body 
to  protect  itself. 

Tetanus. — The  lecturer  then  took  up  the  considera- 
tion of  a  few  of  the  more  important  diseases.  He  said 
that  since  the  advent  of  aseptic  and  antiseptic  surgery 
tetanus  had  become  less  frequent  in  operation  wounds, 
but  a  sufficient  number  of  cases  were  still  reported  an- 
nually in  this  locality  to  make  the  disease  of  practical 
importance.  The  tetanus  bacillus  was  now  accepted 
as  being  the  cause  of  all  the  various  forms  of  tetanus 
— puerperal  tetanus,  tetanus  neonatorum,  idiopathic 
and  traumatic  tetanus.  There  must  always  be  some 
wound  in  which  the  bacillus  could  find  lodgement.  At 
one  stage  of  the  development  of  the  bacillus  it  con- 
tained a  very  resistant  spore.  The  tetanus  bacilli 
had  been  found  ver)'  commonly  in  the  soil,  in  horse 
and  cow  manure,  and  in  hay.  The  tetanus  bacillus 
remained  at  the  seat  of  infection,  and  did  not  spread 
through  the  body;  hence,  the  disease  was  a  true  tox- 
a.*mia.  In  practice,  the  infection  was  usually  one  of 
the  tetanus  spores,  and  these  spores  required  special 
conditions  for  their  development.  F-arly  and  thorough 
cleansing  of  even  seemingly  insignificant  wounds  was 
an  important  prophylactic  in  those  regions  in  which 
tetanus  was  common.  The  toxins  in  the  wound  were 
almost  as  dangerous  as  the  bacilli  themselves.  Tet- 
anus antitoxin  had  been  applied  practically  on  a 
large  scale  in  immunizing  animals  against  possible 
tetanus.  This  plan  had  been  adopted  among  the  ani- 
mals kept  by  the  board  of  health  for  experimentation, 
and  in  this  way  it  had  been  possible  materially  to  re- 
duce the  mortality  among  these  animals.  Some  op- 
erators favored  giving  an  immunizing  dose  of  tetanus 
antitoxin  before  performing  an  operation  on  a  valu- 
able animal,  such  as  a  horse.    The  results  of  the  cura- 


October  30,  1897] 


MEDICAL    RECORD. 


641 


tive  treatment  were  not  so  brilliant  as  those  of  im- 
munization; hence  the  great  importance  of  such 
propliylaxis.  After  the  appearance  of  the  first  tetanic 
symptoms,  the  administration  of  the  tetanus  antitoxin 
was  ordinarily  useless,  in  both  the  lower  animals  and 
in  man.  When  the  incubation  period  was  long,  the 
results  were  much  better.  Dr.  Alexander  Lambert  had 
found  that  in  thirty-one  cases  developing  in  eight  days 
after  infection  the  mortality  was  61.3  per  cent.,  while 
in  similar  cases  not  treated  with  the  tetanus  antitox- 
in the  mortality  was  estimated  to  be  as  high  as  eighty 
per  cent.  From  the  available  statistics,  it  seemed  cer- 
tain that  the  tetanus  antitoxin  possessed  a  certain  cur- 
ative effect.  From  twenty  to  fifty  cubic  centimetres 
should  be  given,  twice  daily,  in  all  cases  of  tetanus, 
and  the  treatment  should  be  begun  at  the  earliest  pos- 
sible moment. 

Diphtheria. — Diphtheria  antitoxin  had  been  sin- 
gled out  among  the  antitoxins  because  of  its  success 
in  the  treatment  of  diphtheria.  The  great  mass  of 
physicians  was  at  the  present  time  convinced  that  diph- 
theria antitoxin,  in  doses  of  from  two  hundred  to  three 
hundred  units,  would  confer  immunity  against  diph- 
theria for  from  two  to  four  weeks,  and  that  the  period 
could  be  lengthened  at  will  by  a  repetition  of  the  in- 
jections. They  were  also  convinced  that  when  cases 
were  seen  early,  and  before  general  poisoning  had  en- 
sued, the  antitoxin  could  be  relied  upon  to  arrest 
nearly  all  cases  of  diphtheria.  In  the  more  advanced 
cases,  as  seen  commonly  in  practice,  it  was  fair  to 
state  that  the  antitoxin  treatment  greatly  reduced  the 
mortality,  in  both  pure  and  mixed  infections.  The 
speaker  fully  indorsed  the  view  held  by  Drs.  Biggs 
and  Girard,  viz.,  it  mattered  not  from  what  point  the 
subject  was  regarded,  only  one  conclusion  could  be 
reached,  and  that  was  that  there  had  been  an  average 
reduction  of  mortality  of  not  less  than  fifty  per  cent., 
and,  under  the  most  favorable  conditions,  a  reduction 
to  one-fourth,  or  even  less,  of  the  previous  death  rate. 
This  had  occurred  in  different  seasons  and  different 
countries,  and  always  in  proportion  to  the  extent  of 
the  use  of  the  antitoxin.  The  experience  with  diph- 
theria antitoxin  very  naturally  led  to  the  question : 
"  Why  should  tetanus  and  diphtheria  antitoxin  differ 
so  greatly  in  their  curative  action?"  The  answer  was 
to  be  found  in  the  fact  that  the  tetanus  toxins  devel- 
oped unnoticed  for  a  number  of  days,  and  the  disease 
was  only  detected  only  after  general  poisoning  had 
taken  place;  whereas  the  diphtheria  poisoning  started 
on  the  surface,  and  before  its  toxins  had  been  ab- 
sorbed there  was  abundant  evidence  of  the  presence 
of  the  disease.  The  hope  had  been  expressed  that  it 
would  be  possible  to  avoid  the  rashes  that  sometimes 
follow  the  administration  of  diphtheria  antitoxin,  but 
there  was  no  more  hope  now  than  five  years  ago  of 
separating  the  antitoxin  from  the  horse  serum.  We 
had,  however,  a  much  more  concentrated  serum,  and, 
therefore,  less  horse  serum  was  introduced  at  a  dose. 
By  better  attention  to  the  selection  of  the  animals  and 
to  their  general  condition,  we  might  hope  to  obtain  a 
diphtheria  antitoxin  so  pure  as  to  give  practical  im- 
munity from  these  unpleasant  com]3lications.  In  the 
dried  antitoxin  we  had  a  preparation  which  could  be 
preserved  indefinitely.  The  dose  of  diphtheria  anti- 
toxin, in  the  curative  treatment  of  diphtheria,  should 
be  from  one  thousand  to  three  thousand  units,  accord- 
ing to  the  severity  of  the  case  and  the  age  of  the  pa- 
tient, and  this  dose  should  be  repeated  in  from  twelve 
to  eighteen  hours  if  no  improvement  was  noted  or 
the  case  remained  severe.  Dr.  Park  stated  that  the 
absolute  mortality  from  diphtheria  in  New  York,  Paris, 
and  Berlin  was  lower  than  last  year.  Formerly,  the 
death  rate  in  Berlin  had  been  80  per  100,000,  now  it 
was  26;  in  Paris,  the  average  death  rate  had  been  63, 
but  last  year  it  was  only  17,  and  this  year  also  17 ;  in 


New  York,  the  average  mortality  had  been  140,  but 
last  year  it  was  91,  and  this  year  86. 

Tuberculosis. — Regarding  tuberculosis,  the  lecturer 
said  that  it  was  now  universally  admitted  to  be  caused 
by  infection  with  the  tubercle  bacillus.  Other  micro- 
organisms might  become  associated  with  the  tubercle 
bacillus,  and  their  symptoms  might  even  eventually  pre- 
dominate. Tuberculous  diseases  of  the  glands,  bones, 
and  joints  frequently  became  arrested  without  treat- 
ment, and  the  same  was  true  probably  in  frqm  ten  to 
twenty  per  cent,  of  cases  of  pulmonary  tuberculosis, 
but  a  natural  cure  or  arrest  was,  after  all,  the  exception. 
Nor  could  we  say  that  after  such  a  cure  there  was  any 
immunity,  for  it  was  well  known  that  people  easily 
contracted  tuberculosis  a  second  time. 

Tuberculin. — A  study  of  the  tuberculous  processes 
in  man,  in  spite  of  their  subacute  course,  inclined  one 
to  approach  the  treatment  by  immunizing  injections 
or  treatment  by  antitoxins  with  considerable  scep- 
ticism, albeit  with  some  hopefulness.  Koch's  old  tu- 
berculin had  now  been  largely  displaced  by  the  new 
tuberculin.  According  to  Koch,  after  each  injection 
there  was  a  noticeable  improvement  in  the  tuberculous 
process,  and,  after  several  months,  all  reactions  ceased, 
the  patients  having  become  immune  to  the  toxin.  Fur- 
ther injections  were  useless  until  this  immunity  had 
passed  off.  Many  cases  of  true  tuberculosis  were 
claimed  to  be  cured  or  greatly  benefited  by  several 
periods  of  such  treatment.  The  old  tuberculin  of 
Koch  neutralized  the  tuberculosis  toxins,  but  was  not 
bactericidal,  and  consequently  Koch  had  sought  to 
obtain  the  bactericidal  action  in  the  new  tuberculin. 
He  had  found  that  the  envelope  of  the  tubercle  bacil- 
lus was  so  resistant  that  it  could  be  destroyed  only  by 
agents  and  processes  which  would  render  the  prepara- 
ation  useless.  In  the  new  tuberculin,  the  bacilli  are 
dried  in  a  vacuum,  ground  in  an  agate  mortar,  placed 
in  distilled  water,  and  centrifugalized.  The  sedi- 
ment is  then  removed,  dried,  and  again  ground  in  a 
mortar,  and  mixed  with  sterilized  water.  The  clear 
fluid  is  the  pure  tuberculin.  It  could  be  readily  seen, 
Dr.  Park  said,  that  contamination  was  difficult  to  avoid 
by  such  a  method  of  preparation,  and  the  strength  of 
the  solution  must  vary  greatly  at  different  times.  As 
a  preser\ative,  twenty  per  cent,  of  glycerin  was  added. 
It  was  claimed  that,  in  marked  contrast  to  the  old  tu- 
berculin, the  new  tuberculin  was  strongly  immunizing. 
The  initial  dose  should  be  one  five-hundredth  milli- 
gram, the  proper  dilution  being  made  with  decinormal 
salt  solution.  The  dose  should  be  gradually  increased, 
and  the  remedy  given  on  alternate  days.  Temperature 
reactions  of  only  about  half  a  degree  had  been  re- 
|5orted.  The  full  dose  of  the  new  tuberculin  was  twenty 
milligrams.  Unfortunately,  only  general  accounts  had 
been  published  of  Koch's  experimental  work  on  ani- 
mals. In  lupus  cases,  and  cases  of  phthisis,  Koch  had 
reported  marked  improvement  in  every  instance,  with 
no  bad  symptoms,  and  all  the  patients  had  improved 
in  their  general  condition  and  in  the  physical  signs. 
Koch  gave  no  hope  of  benefit  in  advanced  cases  of 
tuberculosis,  or  in  cases  of  pronounced  mixed  infection. 
This  necessarily  excluded  a  large  number  of  cases  seen 
in  ordinary  practice.  The  results  from  the  old  tuber- 
culin in  this  country  had  been  very  slight.  It  was 
claimed  that  the  new  tuberculin  not  only  neutralized 
the  poison,  but  directly  killed  the  bacilli  through  the 
substances  produced  by  the  body  cells  from  the  tu- 
berculin. 

Preparations  of  Tuberculin. — With  regard  to  the 
different  preparations  of  tuberculin,  it  was  probably 
safe  to  say  that  there  was  none  better  than  that  made 
by  Koch  himself,  but  the  tuberculin  sent  out  by  the 
manufacturers  deputed  by  Koch  to  make  tuberculin 
did  not  have  the  characteristics  insisted  upon  by  Koch, 
but  gave  every  evidence  of  contamination   and  varia- 


642 


MEDICAL    RECORD. 


[October  30,  1897 


bility.  This  had  been  the  experience  at  Dr.  Trudeau's 
sanatorium,  where  they  had  also  found  that  when  the 
contents  of  a  vial  of  the  new  tuberculin  were  centrifu- 
galized,  not  only  did  many  samples  contain  tubercle 
bacilli,  but  these  bacilli  were  alive  and  capable  of 
causing  infection.  In  this  connection,  it  was  worthy 
of  note  that  two  of  Koch's  animals  which  were  being 
immunized  by  tuberculin  developed  tuberculosis,  as  a 
result  of  the  tubercle  bacilli  injected. 

Present  Status  of  Tuberculin  Treatment. — Re- 
ports from  abroad  seemed  to  indicate  that  lupus 
showed  even  more  benefit  from  the  new  than  from  the 
old  tuberculin.  Regarding  phthisis,  larjngeal  tuber- 
culosis, and  other  tuberculous  processes,  no  definite 
opinion  was  e.xpressed,  even  by  those  obser\'ers  who 
had  used  it  under  specially  favorable  circumstances. 
.^11  urged  great  care  in  increasing  the  do.se,  especially 
from  new  vials. 

Serum  Treatment  of  Tuberculosis. — Turning  to 
the  discussion  of  the  serum  treatment  of  tubercu- 
losis, Dr.  Park  said  that  since  1894  attempts  had 
been  made  to  treat  tuberculosis  in  man  and  animals 
with  serum.  The  majorit)-  of  observers  claimed  the 
power  of  neutralizing  the  effect  of  tuberculin  when 
injected  into  tuberculous  guinea-pigs,  but  this  test 
was  insufficient,  as  tuberculin  was  not  the  same  as  the 
unaltered  products  of  the  tubercle  bacillus.  Moreover, 
Trudeau  had  shown  that  other  non-specific  substances 
had  the  same  effect  in  neutralizing  the  tuberculin. 
Ver}'  few  observers  had  been  able  to  obtain  appreci- 
able effects  with  serum  obtained  from  different  sources. 

At  the  Trudeau  sanatorium  several  patients  had  in- 
sisted upon  the  serum  treatment  and  had  received  it. 
No  effect,  either  good  or  bad,  had  been  observed  in 
them.  Many  of  the  tuberculins  on  the  market  now 
were  apparently  no  better  than  normal  horse  serum. 

Diseases  Due  to  the  Pneumococcus. — Typical  lobar 
pneumonia,  as  well  as  certain  forms  of  endocarditis, 
pericarditis,  cerebro-spinal  meningitis,  etc.,  are  now- 
known  to  be  caused  by  the  pneumococcus.  Lobar 
pneumonia  had  the  peculiar  characteristic  of  fre- 
quently terminating  suddenly  by  crisis.  This  had 
been  supposed  to  be  due  to  the  development  of  anti- 
toxins in  the  blood,  but  there  were  certain  facts  which 
made  this  view  e.xtremely  doubtful.  For  instance, 
some  cases  developed  a  pneumococcus  septiccemia  at 
the  very  time  when  liberation  of  these  antitoxins  was 
to  be  expected.  Again,  the  majority  of  pneumococci 
died  in  cultures  after  five  or  seven  days.  It  was  pos- 
sible, therefore,  that  in  the  lung  certain  conditions 
develop  which  render  the  solid  unsuitable  for  the  fur- 
ther growth  of  the  bacillus  or  for  the  development  of 
the  toxins.  In  i886,  A.  Fraenkel  had  begun  immu- 
nizing-experiments  on  animals.  The  serum  used  in 
over  forty  cases  of  pneumonia  in  man  gave  doubtful 
results;  it  was  apparently  neither  harmful  nor  bene- 
ficial. Of  a  number  of  animals,  some  could  be  im- 
munized, while  others  succumbed.  The  curative  power 
of  the  serum  was  probably  ver)'  weak.  As  yet,  the 
serum  could  not  be  said  to  be  of  practical  value  in 
the  treatment  of  pneumococcus  infections,  and  it  prob- 
ably never  would  be.  The  serum  was,  however,  prac- 
tically harmless,  so  that  further  experimentation  was 
justifiable. 

Streptococcus  Infections — Most  of  the  forms  of 
tonsillitis,  erysipelas,  cellulitis,  and  septica.mia  were 
due  to  streptococci.  In  none  of  the  streptococcus  in- 
flammations had  there  been  noticed  much  tendency  to 
the  development  of  immunizing  substances  in  the 
blood.  It  was  true  that  cases  of  cellulitis,  erysipelas, 
and  abscess,  after  a  period  of  a  few  days  or  months, 
tended  to  recovery,  so  that,  to  a  certain  extent,  it 
might  be  assumed  that  protective  processes  had  been 
called  forth.  Experimentation  on  man  had  shown 
that  but  little   immunizing  substance  was  developed 


by  repeated  attacks  of  erysipelas.  Two  methods 
had  been  used  for  immunizing  and  in  attempts  to 
establish  a  curative  treatment.  One  method  was  to 
heat  to  a  certain  point  bouillon  cultures  of  virulent 
streptococci;  in  the  other  method,  living  and  virulent 
streptococci  were  themselves  injected.  Marmorek  had 
given  the  most  attention  to  this  subject.  The  serum 
had  been  found  to  be  verj-  unreliable  and  to  lose  its 
virtue  rapidly.  Thus,  Dr.  A.  W.  Williams,  in  some 
experiments  carried  on  at  the  laboratory  of  the  New- 
York  board  of  health,  had  found  that  the  contents  of 
a  vial  which  were  potent  last  June  exhibited  no  effect 
in  September.  He  had  obtained  directly  from  Mar- 
morek a  vial  supposed  to  contain  a  very  high-grade 
serum,  yet  it  had  lost  its  power  in  two  months.  Other 
experimenters  had  noticed  the  same  result  as  from 
Marmorek's  serum.  It  could  not  be  said  that  any  of 
the  antistreptococcus  serums  on  the  market  now  were 
reliable,  and  certainly  all  were  very  variable  in  their 
action.  In  1895,  Marmorek  had  published  ninety--six 
cases  of  scarlet  fever,  four  hundred  and  eleven  of  ery- 
sipelas, and  sixteen  of  puerperal  fever  treated  with  his 
serimi.  Marked  improvement  was  reported  in  all  of 
those  due  to  streptococci.  Seven  of  the  sixteen  cases  of 
puerperal  fever  were  due  to  streptococci,  and  in  all  of 
these  the  patients  recovered.  On  the  other  hand,  four 
cases  in  which  the  streptococci  were  associated  with 
colon  bacilli  proved  fatal.  In  phthisis,  w-hen  no  cavi- 
ties had  yet  appeared,  the  fever  and  sweatings  dimin- 
ished under  the  use  of  the  serum,  but  no  cures  were 
claimed  to  have  been  effected.  The  speaker  said  that  he 
had  seen  two  cases  of  puerperal  fever  in  which  distinct 
results  had  been  observed  from  the  use  of  the  serum, 
but  in  neither  case  were  any  streptococci  obtained  from 
the  blood.  The  results  obtained  here  in  New-  York, 
by  both  physicians  and  surgeons,  had  not  been  spe- 
cially favorable.  It  might  be  fairly  concluded  (i) 
that  the  preparations  of  anti- streptococcus  serum  now 
on  the  market  are  either  weak  or  entirely  wanting  in 
curative  substances;  (2)  that  we  are  justified  in  using 
the  serum  only  when  it  has  been  recently  tested  and 
shown  to  have  some  value ;  and  (3)  that  we  should, 
as  far  as  possible,  establish  the  variety  of  bacteria 
causing  the  infection,  in  every  case  in  which  the  servun 
is  used. 

Treatment  of  Sarcoma  by  Erysipelas  Toxins. — 
This  subject,  Dr.  Park  said,  had  received  attention  in 
this  country-  chiefly  from  Dr.  W.  B.  Coley,  and  conse- 
quently the  views  presented  were  those  of  that  observer. 
He  found  that  the  inhibitory  action  of  the  toxins  on  car- 
cinoma had  proved  nearly  always  to  be  temporary,  and 
that  in  no  case  had  the  disease  after  their  use  remained 
in  abeyance  sufficiently  long  to  allow  it  to  be  considered 
cured.  In  sarcoma,  the  only  form  in  which  he  had  advo- 
cated this  treatment,  the  toxins,  when  injected  subcuta- 
neously  into  the  tumor  substance  or  into  more  remote 
parts  exercised  a  distinctly  inhibitor}-  action  on  the 
growth  of  the  tumor.  This  was  the  least  marked  in  the 
melanotic  form.  On  round-cell  sarcoma  this  action  was 
far  more  powerful.  In  a  number  of  cases  of  round-cell 
sarcoma,  in  which  the  diagnosis  was  unquestioned,  the 
patients  remained  well  beyond  three  years.  Nearly 
one-half  of  all  the  cases  treated  showed  no  appreciable 
decrease  in  size;  others  decreased  at  first,  and  then 
increased.  In  the  spindle-cell  variety,  the  tumor  dis- 
appeared entirely  in  half  of  the  cases,  and  the  patients 
remained  well  sufficiently  long  to  be  regarded  as 
cured.  .-Ml  the  cases  treated  were  considered  as  in- 
operable. Three  cases  of  spindle-cell  sarcoma  re- 
mained well  for  three  years.  One  after  three  years 
and  three  months  had  a  recurrence  in  the  abdomen. 
This,  in  itself,  substantiated  the  diagnosis.  Dr.  Park 
said  that  it  was  curious  that  the  largest  percentage  of 
successes  occurred  in  the  spindle-cell  sarcomata — just 
that  variety  in  which  mistakes  in  diagnosis  were  prac- 


October  30,  1897] 


MEDICAL    RECORD. 


64; 


tically  impossible.  In  every  case  the  diagnosis  of  the 
clinician  had  been  corroborated  by  the  pathologist  be- 
fore the  treatment  was  begun.  In  estimating  the  value 
of  this  method,  it  should  be  remembered  that  the  treat- 
ment was  sometimes  deleterious  to  the  general  health, 
and  that  occasionally  these  sarcomata  disappeared 
spontaneously.  Nevertheless,  the  proof  was  verj-  strong 
that  some  sarcomatous  tumors  had  been  arrested  and 
caused  to  disappear  by  the  treatment.  When  a  sar- 
coma was  inoperable  and  progressive,  he  thought  the 
treatment  should  be  tried. 

The  Plague. — It  was  now  known  that  the  plague 
was  due  to  a  specific  bacillus,  and  that  the  infection 
was  transmitted,  not  only  by  the  infected  bodies  of 
men,  but  by  rats,  insects,  and  tiies.  These  animals 
had  been  thought  to  be  a  frequent  cause  of  the  dissem- 
ination of  the  disease.  A  serum  which  possessed  a 
ver)'  fair  degree  of  immunizing  power  had  been  ob- 
tained from  animals.  Out  of  500  persons  immunized 
with  this  serum,  only  5  contracted  the  disease,  and  3 
of  these  died.  In  149  cases  of  the  plague  treated  with 
the  serum,  the  mortality  was  fort}--nine  per  cent.,  as 
against  eighty  per  cent,  in  the  untreated  cases.  In 
these  cases  a  weak  serum  had  been  used  which  had 
been  hastily  prepared  by  Rou.x  in  response  to  an  ur- 
gent and  unexpected  demand.  A  better  serum  gave 
only  2  deaths  in  26  cases.  Haffkine's  treatment  had 
been  tried  on  1,300  exposed  persons,  of  whom  55  con- 
tracted the  disease  and  died.  Some  immunity  seemed 
to  have  been  produced.  Fever  and  prostration  fol- 
lowed the  injections,  and  lasted  one  or  two  days. 

Typhoid  Fever  and  Cholera. — Animals  could  be 
immunized  to  both  typhoid  fever  and  cholera.  The 
serum  possessed  feeble  antitoxic  and  bactericidal 
power.  There  was  reason  to  believe  that  in  a  severe 
epidemic  of  typhoid  fever  it  would  be  possible  to 
carry  out  immunization,  although,  of  course,  it  would 
be  ordinarily  far  easier  to  enforce  the  well-known 
prophylactic  measures.  The  curative  treatment  of  ty- 
phoid fever  with  serum  had  given  no  marked  results, 
although  a  few  claimed  a  decided  reduction  in  the 
duration  of  the  disease. 

Hydrophobia. — Xo  specific  micro  -  organism  for 
rabies  had  yet  been  discovered  in  the  brain  or  spinal 
cord,  but  it  was  certain  from  the  phenomena  of  the 
disease  that  one  did  exist.  The  preventive  treatment 
of  Pasteur  had  been  subjected  to  much  severe  criti- 
cism, but  the  speaker  believed  that  to-day  its  efficacy 
was  firmly  established.  The  reported  diminution  in 
the  percentage  of  those  developing  hydrophobia  after 
bites  of  rabid  animals  seemed  hard  to  believe,  yet  a 
conser\'ative  estimate  of  the  death  rate  from  hydro- 
phobia in  those  not  treated  by  the  Pasteur  method 
was  from  ten  to  twenty  per  cent.,  as  against  a  little 
more  than  one  per  cent,  under  the  Pasteur  treatment. 
Occasionally,  though  verj-  rarely,  a  person  developed 
rabies  some  weeks  after  the  treatment,  when  im- 
munitj'  should  have  been  conferred.  This  had  never 
yet  been  explained.  He  believed  that  hydrophobia 
had  never  occurred  among  the  thousands  treated  at 
the  Pasteur  Institute,  Paris,  as  a  direct  result  of  the 
treatment. 

The  Future  Contributions  of  Bacteriology.— .As 
K)  the  future  therapeutic  results  from  bacteriology,  the 
lecturer  asserted  that  the  outlook  was  bright  for  ob- 
taining through  serums,  or  the  toxic  substances  of  the 
micro-organisms  themselves,  the  means  of  immunizing 
against  most,  if  not  all,  the  diseases  due  to  specific 
micro-organisms.  This  immunit)-  was  not  usually  of 
long  duration,  but  could  be  prolonged  by  repeated  in- 
jections. The  prospect  of  securing  serums  which  would 
promptly  arrest  the  development  of  diseases  already 
established,  by  destruction  of  the  micro-organisms  and 
their  poisons  in  the  body,  was  rather  less  encouraging 
now  than  shortly  after  the  discovery  by  Behring  of 


diphtheria  antitoxin.  We  could  hope  only  to  stop  all 
growth  of  micro-organisms  and  prevent  further  action 
of  bacterial  poisons  at  the  moment  when  a  case  came 
under  treatment.  From  the  fact  that  substances  had 
been  obtained  which  strongly  inhibited  certain  bac- 
teria, without  affecting  other  bacteria,  it  seemed  prob- 
able that  we  might  find  chemical  substances  which 
would  have  specific  bactericidal  power.  The  expense 
of  experimentation  was  now  very  great,  as  many  ani- 
mals were  required,  and  an  additional  obstacle  to  the 
work  of  laboratory-  investigators  was  found  in  a  lack 
of  co-operation  on  the  part  of  the  clinicians.  So  far, 
the  work  in  bacteriolog)-  seemed  to  indicate  that  our 
advancement  would  be  rather  in  the  way  of  preventing 
disease.  At  the  present  time,  outside  of  the  diphtheria 
antitoxin,  tetanus  antitoxin,  and  the  plague  antitoxin, 
we  had  no  serums  which  would  give  practically  cura- 
tive or  immunizing  results  at  a  time  when  danger  of 
infection  was  imminent  or  infection  had  already  taken 
place. 

National  Bureau  of  Health. — Dr.  A.  Jacobi  said 
that  the  New  York  Academy  of  Medicine  had  ap- 
pointed years  ago  a  committee  to  frame  a  bill,  and 
to  urge  its  adoption  by  the  Congress  of  the  United 
States,  favoring  the  nationalization  of  the  sanitarj-  in- 
terests and  rules  of  the  whole  countrj-.  In  the  past, 
as  at  present,  the  prevention  and  treatment  of  conta- 
gious diseases,  both  imported  and  indigenous,  were 
matters  of  municipal,  county,  or  State  concern.  When, 
a  number  of  years  ago,  cholera  appeared  at  our  doors, 
the  necessit)-  of  centralizing  national  safeguards  be- 
came evident  to  every  unbiassed  mind :  when,  how- 
ever, the  immediate  danger  had  passed,  the  democratic 
instincts,  natural  enough  a  century  ago  when  the  pop- 
ulation was  small  and  communication  difficult,  of  ego- 
tistic individualism  and  jealous  territorialism  became 
again  superior  to  legitimate  anxiety  and  the  teachings 
of  recent  experience.  Late  occurrences  in  the  South- 
west had  furnished  another  proof  of  the  fact  that  in 
the  actual  or  alleged  dangers  of  a  newly  imported  con- 
tagion, not  only  the  sanitary  interests  of  seventy  mil- 
lions of  human  beings,  but  also  the  commercial  neces- 
sities of  the  whole  countr}-,  were  at  the  mercy  of  every 
State  government,  ever}-  county  commission,  ever)- vil- 
lage supervisor,  ay,  ever)-  mob,  both  ignorant  and 
criminally  reckless.  Travel  and  trade  had  been 
stopped,  high  State  affairs  interfered  with,  health  offi- 
cers of  the  county  and  of  States  had  been  prevented 
by  force  from  attending  to  their  duties  and  labors  in 
behalf  of  public  health  and  hygiene.  This  was  why 
yellow  fever,  instead  of  being  stamped  out  at  once, 
had  spread,  and  disseminated  both  its  actual  and  in- 
sane terrors.  Instead  of  applying  the  methods  of  sci- 
entific prevention  and  extermination  of  yellow  fever, 
the  accumulated  knowledge  of  the  centur)-  pertaining 
to  the  care  and  extinction  of  contagious  scourges  was 
thrown  to  the  winds.  That  would  always  be  so  imtil 
the  commonwealth  of  the  Union  should  take  the  re- 
sponsibilit)'  of  caring  for  the  health  and  life  of  one 
and  all. 

Dr.  Jacobi  then  made  the  following  motion,  which 
was  seconded  and  carried  unanimously: 

'•  That  the  New  York  .\cademy  of  Medicine  author- 
izes its  president  to  call  the  committee  appointed  years 
ago,  and  never  discharged,  and  direct  it  to  resume  its  in- 
terrupted labors  and  to  report  to  the  Academy  of  Medi- 
cine, for  presentation  to  the  Congress  of  the  United 
States  for  adoption,  the  old  bill,  or  a  new  bill,  or  to 
support  a  proper  bill  offered  by  great  medical  or  com- 
mercial bodies,  contemplating  the  centralization  under 
the  national  government  of  the  means  to  protect  effi- 
ciently the  health  of  the  .Vinerican  people  against  the 
importation  and  dissemination  of  contagious  diseases.'" 

Committee  on  Public  Baths. — ^This  committee,  con- 
sisting of  Drs.  S.  Baruch,  G.   B.   Fowler,  and  R.  Van 


644 


MEDICAL    RECORD. 


[October  30,  1897 


Santvoord,  reported  through  Dr.  Baruch  tliat  the  com- 
mittee had  called  on  Mayor  Strong  on  the  day  follow- 
ing the  appointment  of  the  committee,  and  had  directed 
his  attention  to  the  fact  that  there  was  no  longer  any 
good  reason  for  delay  in  erecting  the  public  baths. 
The  mayor  was  convinced,  and  suggested  a -city  lot 
in  Rivington  Street  as  appropriate.  Since  then  plans 
had  been  drawn  up  and  bids  advertised  for,  prelimi- 
nary to  the  erection  of  a  public  bath  on  this  site. 

Donations  to  the  Academy  from  a  Layman. — 
Dr.  F.  a  Castle  said  that  it  was  not  very  common 
to  receive  donations  from  the  laity,  and  in  view  of  this 
fact,  and  particularly  in  view  of  the  cordial  interest 
taken  in  the  welfare  of  the  academy  by  Mr.  S.  P. 
Avery,  he  had  thought  it  but  right  to  bring  before  the 
fellows  some  recent  gifts  from  this  gentleman,  and  to 
suggest  that  a  suitable  acknowledgment  of  his  kind- 
ness be  made  through  the  secretary.  Among  other 
things  were  an  anonymous  manuscript  on  materia 
medica,  dating  back  to  1792,  and  a  very  rare  volume, 
nearly  two  hundred  years  old,  entitled  "  The  Statutes 
of  the  College  of  Physicians  of  London." 


SECTION    ON    GENER.'VL    MEDICINE. 

Stah'd  Mteting,   Octobrr  ig,   iSgj. 

Louis  Faugeres  Bishop,  M.D.,  Chairman. 

Marked  Cardiac  Hypertrophy  and  Dilatation ;  Per- 
tussis.— 1)R.  RicHAKij  C.  Newton,  of  Montclair,  pre- 
sented the  heart  and  lungs  removed  from  a  child  nine 
years  of  age,  who  had  died  of  consumption.  The  child 
had  had  whooping-cough  at  the  age  of  five  years.  The 
heart  showed  hypertrophy  of  the  right  and  dilatation 
of  the  left  ventricle.  The  very  great  thickness  of  the 
walls  of  the  right  ventricle  was  worthy  of  note. 

Internal  Medicine  as  a  Vocation. — Dr.  William 
OsLER,  of  Johns  Hopkins  Cniversity,  Baltimore,  read 
a  paper  with  this  title.  He  said  that  he  wished  there 
was  some  other  term  to  designate  that  wide  field  left 
after  the  separation  of  surgeiy,  midwifery,  and  gynaecol- 
ogy. Not  in  itself  a  specialty,  but  embracing  some  half- 
dozen  fields,  its  cultivators  could  not  be  called  special- 
ists, but  must  bear  the  good  old  name  of  "  general 
practitioner."  In  spite  of  assertions  to  the  contrary 
he  would  maintain  that  the  opportunities  for  a  general 
practitioner  were  still  great  and  the  harvest  was  plenty. 
The  laborers,  while  not  a  few,  were  scarcely  sufficient 
to  meet  the  demand.  He  had  often  told  his  students 
that  syphilis  was  the  only  disease  that  they  must  know 
thoroughly — if  one  knew  syphilis,  one  knew  internal 
medicine.  His  hearers  could  easily  recall  the  names 
of  great  physicians — Swett,  Alonzo  Clark,  Austin  Flint, 
Loomis;  their  works  remained,  but  the  best  of  a  great 
physician's  experience  unfortunately  died  with  him. 

How  to  Prepare  for  Consultation  Practice. — 
\\'herewithal  should  a  young  man  prepare  himself  if 
lie  desired  to  follow  in  the  footsteps  of  such  a  man,  for 
example,  as  Austin  Flint?  He  would  assume  that  he 
started  w-ith  equivalent  advantages,  though  this  was 
taking  a  great  deal  for  granted,  because  Austin  Flint 
had  a  strong  bias  for  medicine  and  he  early  fell  under 
the  care  of  such  great  men  as  James  Jackson  and  Hige- 
lovv.  These  men  had  influenced  Flint  most  conspic- 
uously. His  well-known  address  on  "  The  Self-Limi- 
tation of  Disease"  was  really  a  worthy  commentary  on 
Bigelow's  celebrated  essay  on  this  subject. 

But  to  return  to  the  student  who  had  just  left  the 
hospital.  Should  he  go  abroad?  It  was  not  neces- 
sary; the  n:an  chosen  for  his  exemplar  did  not  fuid  it 
necessary  to  do  so.  Would  a  trip  abroad  be  u.-^eful  to 
him?  Undoubtedly,  for  he  would  have  a  broader 
foundation  on  which  to  build.  To  walk  the  wards  of 
Guy's  or  St.   Bartholomew's  or  the  Salpetrifere,  to  put 


in  a  few  quiet  months  of  study  at  one  of  the  German 
university  towns,  would  store  the  young  man's  mind 
with  priceless  treasures.  It  was  assumed,  of  course, 
that  he  had  a  mind.  If  he  could  not  go  abroad,  let 
him  spend  part  of  his  vacation  in  seeing  what  was  be- 
ing done  in  the  various  medical  centres.  A  New 
Yorker  might  learn  something  at  the  Massachusetts 
General  Hospital,  or  in  Philadelphia,  or  even  with 
Welch  at  the  Johns  Hopkins  Hospital.  The  success- 
ful consulting  physician  of  to-day,  it  would  be  found, 
had  evolved  either  from  general  practice  or  from  the 
laboratory  and  clinical  work.  Many  of  the  most 
prominent  had  risen  from  the  ranks  of  the  general 
practitioner. 

The  speaker  said  that  it  was  his  object  in  this  ad- 
dress to  speak  particularly  of  the  training  of  men  who 
started  out  with  the  object  of  becoming  purely  physi- 
cians. From  the  vantage-ground  of  many  years  of 
hard  work.  Sir  .Andrew  Clark  had  told  him  that  he 
had  striven  ten  years  for  bread,  ten  years  for  bread  and 
butter,  and  twenty  years  for  cakes  and  ale.  A  dispen- 
sary assistantship  should  be  available,  and  anything 
should  be  acceptable  which  brought  the  young  medical 
man  in  contact  with  patients;  but  let  him  see  to  it, 
as  he  valued  his  future  life,  that  he  was  not  entangled 
early  in  the  meshes  of  specialism.  Having  become 
thus  established,  he  could  begin  his  medical  education. 
At  the  present  time  he  could  follow  three  lines  of  work 
— chemistry,  physiology,  and  morbid  anatomy.  The 
professional  chemist  looked  askance  at  the  physiolog- 
ical chemist,  and  ricc  Jc-rsa  :  but  there  could  be  no 
doubt  about  the  value  to  the  physician  of  a  thorough 
training  in  organic  chemistry.  In  this  country  men 
possessed  of  such  training  were  sorely  needed.  If  at 
the  time  of  starting  our  student  had  not  had  a  good 
chemical  training,  the  other  lines  should  be  more 
closely  followed,  because  of  the  very  long  time  re- 
quired to  get  a  proper  knowledge  of  organic  chemis- 
try. Physiology  opened  a  wider  view  and  rendered 
possible  a  deeper  grasp  on  the  problems  of  disease. 
A  thorough  chemical  training  and  a  complete  equip- 
ment in  methods  of  experimental  research  were  less 
often  met  with  in  a  good  clinical  physician  than  a 
good  knowledge  of  morbid  anatomy.  If  he  must  limit 
his  work,  chemistry  and  physiology  should  yield  to  the 
claims  of  the  deadhouse.  In  this  early  period  he 
should  see  deadhouse  work,  if  possible,  daily.  It  was 
of  special  value  in  diagnosis,  enabling  him  to  correct 
his  mistakes,  and,  if  he  read  his  lessons  aright,  might 
possibly  keep  him  humble.  After  a  thorough  course 
of  this  training,  it  was  a  good  plan  to  go  to  a  German 
or  French  clinic  for  the  summer  only,  which  could  be 
done  at  a  very  moderate  expense. 

The  Dry-Bread  Stage. — .\t  this  stage  the  young 
physician  should  live  on  the  "crumbs,"  the  pickings 
from  men  in  the  '"  cakes-and-ale  stage."  Some  finan- 
cial assistance  could  also  be  derived  from  class  fees 
or  from  journal  work.  Success  in  the  first  ten  years 
meant  endurance  and  perseverance.  '"  -\11  things 
come  to  him  who  has  learned  to  work  and  labor."  In 
this  dry-bread  decade  the  young  physician  should  not 
despise  dispensary  work.  Many  of  the  best-known 
men  in  London  had  served  from  fifteen  to  thirty  years 
in  the  out-patient  department  before  getting  a  hospital 
ward.  Dr.  Lauder  Brunton  only  got  a  ward  at  St. 
Bartholomew's  Hospital  two  years  ago,  yet  he  had 
been  assistant  physician  and  seen  cases  in  the  out- 
patient dispensary  for  more  than  twenty-  years.  Dr. 
Samuel  West  liad  been  an  assistant  physician  for  over 
twenty  years.  Dispensary  work  was  of  incalculable 
value  in  the  development  of  the  young  physician;  it 
was  also  of  inestimable  service  in  teaching.  In  this 
period  he  should  not  lose  the  substance  of  ultimate 
success  while  grasping  at  the  shadow-  of  present  oppor- 
tunity.    Time  in  these  years  was  his  money,  and  he 


October  30,  1897] 


MEDICAL    RECORD. 


64: 


must  not  barter  away  too  much  of  it  in  profitless  work 
— i.e.,  in  work  which  would  not  be  of  value  in  his  edu- 
cation. Too  many  e.xcellent  clinical  physicians  had 
been  ruined  by  spending  too  much  time  in  journal 
work,  thereby  temporarily  gaining  but  losing  in  the 
end. 

A  very  serious  problem  confronted  the  large  schools 
of  this  country.  He  knew  of  no  single  physician 
in  this  country  with  wards  enough  to  give  his  third 
and  fourth  year  students  thorough  practical  bedside 
instruction.  Therefore,  to  relieve  the  extraordinan- 
congestion  that  must  come  in  the  schools,  now  that 
there  is  a  four-year  course,  the  younger  men  must  be 
utilized  in  two  ways,  viz.:  (i)  in  the  dispensaries  in 
which  first-class  clinical  instruction  could  be  given ; 
and  (2)  by  the  adoption  of  some  such  method  as  exists 
in  Edinburgh,  of  individual  clinical  instruction  by 
those  possessing  an  equipment  and  qualifications  that 
met  the  approval  of  the  authorities  of  the  medical 
schools.  The  hospitals  could  not  begin  to  give  the 
amount  of  clinical  instruction  needed. 

The  Bread-and-Butter  Stage.— The  young  physi- 
cian would  find  that  ten  years  of  hard  work  would  tell 
with  his  colleagues.  The  second,  or  "  bread-and- 
butter"  period,  was  more  trying  to  most  men,  for  the 
risks  were  greater.  At  this  time  many  dropped  out  by 
the  wayside  and  drifted  into  specialties.  Success  came 
more  slowly  to  the  phjsician  than  to  the  surgeon. 
Some  surgeons  were  in  full  practice  at  forty  years  of 
age:  not  so  with  the  physician.  The  surgeon  must 
have  hands,  and,  better,  young  hands ;  he  should  have  a 
head  too,  but  this  seemed  not  so  essential. 

The  Cakes-and-Ale  Stage. — After  these  years  of 
work  our  future  consultant  would  probably  have  but 
little  funds  in  the  bank,  but  he  should  have  a  great 
stock  of  interest-bearing  funds  in  his  brain  marrow. 
It  was  not  improbable  that  he  might  awaken  suddenly 
after  twenty  years  of  quiet  work,  done  for  the  love  of 
it,  to  find  that  success  was  assured.  In  this  State 
there  were  probably  a  score  of  small  hospitals,  offer- 
ing splendid  material  for  good  men,  on  which  to  build 
up  a  reputation.  .-V  young  man  should  look  for  a 
consultation  practice  after  twenty  years  of  hard  work 
in  any  town  of  forty  or  fifty  thousand  inhabitants. 
■■  Many  are  called:  few  are  chosen.'"  But  even  after 
he  had  reached  the  period  of  "  cakes  and  ale,"  there 
were  many  drawbacks.  There  were  two  circles — an 
intraprofessional  and  an  extraprofessional  one.  In  his 
efforts  to  keep  up  with  a  trying  consultation  practice, 
and  at  the  same  time  keep  abreast  with  all  the  new 
things  known  to  the  younger  men  in  the  "  bread-and- 
butter  stage,"  the  consultant  should,  indeed,  arouse 
our  sincere  sympathy.  Again,  the  consultant  must 
walk  with  the  boys,  or  he  would  be  gradually  but  in- 
evitably lost.  In  order  to  keep  his  own  mind  recep- 
tive and  impressionable,  he  must  travel  with  physicians 
between  twenty-five  and  forty  years  of  age.  .\t  some 
time  or  other  there  would  come  the  temptation  to  court 
the  Delilah  of  the  press — lay  or  medical.  It  should 
be  ever  borne  in  mind  that  she  was  sure  to  play  false 
in  the  long  run,  and  that  the  young  physician  yielding 
to  her  allurements  would  certainly  be  shorn  of  his 
strength  and  reputation.  It  could  not  be  denied  that 
a  little  humbug  succeeded  immensely  with  the  public, 
but  it  was  not  necessan,-.  In  a  certain  city  were  three 
physicians  of  such  eminence  that  all  pre.sent  would 
recognize  them  if  their  names  were  mentioned.  The 
first  was  a  good  physician,  but  no  humbug:  the  second 
was  no  physician,  but  a  great  humbug:  the  third  was 
a  great  physici.in  and  a  great  humbug.  The  first 
achieved  the  greatest  success.  "  Better  a  handful  of 
quietness  than  both  hands  filled  with  vexation  of 
spirit.'" 

Relation  of  General  Medicine  to  the  Specialties. 
— Dr.  William  M.  Polk:  said   that,  in  common   with 


the  other  members  of  the  academy,  he  felt  much  in- 
debted to  the  distinguished  gentleman  who  had  come 
all  this  distance  in  order  to  give  his  impressions  of  the 
right  path  to  follow  to  attain  success  in  interna!  medi- 
cine. If  that  man  were  not  sitting  here  in  person  be- 
fore us,  it  would  not  be  out  of  place  to  draw  attention 
to  the  great  success  which  he  had  attained  by  practi- 
cally following  the  line  which  he  had  so  gracefully 
sketched  out  this  evening.  There  was  certainly  a 
good  deal  in  the  statement  made  by  Dr.  Osier  con- 
cerning the  surgeons  and  the  amount  of  cerebral  tissue 
required  by  them  as  compared  with  that  which  was 
essential  to  the  success  of  those  who  confined  them- 
selves to  internal  medicine:  yet  no  one  could  practise 
medicine  in  any  department — even  surgery — unless 
he  had  a  knowledge  of  internal  medicine.  The  sur- 
geon took  it  up  where  the  man  of  internal  medicine 
left  oft".  The  poorest  surgeon  was  he  who  began  work 
as  a  surgeon,  for  the  reason  that  he  inevitably  magni- 
fied his  method  to  the  detriment  of  that  of  the  physi- 
cian, and  in  so  doing  frequently  stepped  in  when  his 
confrere  would  have  been  able  to  carry  the  case  to  a 
successful  conclusion.  The  great  good  that  internal 
medicine  had  done  was  in  ridding  us  of  the  necessity 
of  taking  medicine — in  teaching  us  how,  by  living  and 
moving,  we  can  escape  many  of  the  ills  that  tlesh  is 
heir  to. 

Legitimate  Advertising  a  Prime  Requisite. — Re- 
garding what  was  the  best  way  of  making  a  good  con- 
sultant. Dr.  Polk  said  that  one  of  the  first  things  was 
to  know  how  to  write  and  when  to  write — in  other 
words,  the  aspirant  for  such  a  position  must  learn  the 
legitimate  method  of  professional  advertising.  If  this 
were  done,  there  was  not  the  slightest  danger  of  the 
young  medical  man  drifting  into  advertising  in  the 
public  press.  But  it  should  be  borne  in  mind  that 
the  two  could  not  be  mixed.  .Another  important  ele- 
ment in  his  preparation  for  this  great  work  had  been 
strenuously  insisted  upon  by  the  late  Dr.  .\lonzo  Clark, 
viz. :  In  the  early  part  of  one's  career  two  or  three 
cases  sifted  to  the  ver\-  bottom  would  teach  more  to  the 
young  and  receptive  mind  than  a  whole  hospital  full  of 
cases  not  so  carefully  and  minutely  studied. 

Specialism  a  Curse — To-day  the  curse  of  medi- 
cine was  specialism.  That  seemed  a  broad  statement : 
nevertheless  it  was  a  true  one,  because  it  was  respon- 
sible for  narrow-minded,  poorly  educated,  and  dishon- 
est physicians.  By  this  he  meant  that  the  human 
mind  was  so  constituted  that,  given  any  problem  to 
work  out,  it  continued  to  build  upon  it  and  ma^ify  it 
until  oftentimes  ever)-  other  structure,  no  matter  what 
its  importance,  was  overshadowed.  While,  therefore, 
specialism  had  in  many  instances  done  much  good, 
it  was  to-day  demoralizing  the  profession  in  large 
measure  by  bringing  it  into  contempt  with  the  laity. 
Many  a  patient— perhaps  honestly  on  the  part  of  the 
physician — was  made  to  feel  and  to  believe  that  con- 
ditions which  were  amply  met  by  many  of  the  ordinary 
rules  of  hygiene  and  living  were  of  such  overshadow- 
ing importance  that  they  must  be  attended  to  there 
and  then,  or  dire  calamity  would  overtake  the  individ- 
ual. This  might  be  the  low  side  of  specialism,  but  it 
had  a  low  as  well  as  a  high  side.  In  the  past  twenty 
years,  during  the  rapid  growth  of  specialism,  it  could 
not  be  denied  that  we  had  often  allowed  ourselves  to 
drift  into  this  side  of  it,  which  was  by  no  means  the 
highest.  No  man  could  be  a  good  specialist  who  had 
not  been  a  general  practitioner.  In  this  connection 
the  example  of  the  carrier  pigeon  should  be  emulated. 
The  carrier  pigeon,  when  loosed  to  execute  a  special 
mission,  rose,  ever  circulating  upward  and  upward, 
casting  its  eyes  in  ever)'  direction,  so  as  to  get  the 
broadest  possible  view  of  the  entire  field  before  gather- 
ing to  itself  its  strength  and  making  straight  for  its 
goal. 


646 


MEDICAL    RFXORD. 


[October  30,  i< 


Dk.  .\xdkkw  H.  Smith  said  that  he  had  been  par- 
ticularly interested  in  the  way  the  two  preceding  speak- 
ers had  approached  this  subject  from  opposite  stand- 
points. As  he  had  understood  Dr.  Osier,  the  student 
should  start  out  with  the  idea  of  making  himself  a 
consultant,  and  in  no  way  to  become  a  family  physi- 
cian. On  the  other  hand.  Dr.  Polk  had  an  eye  to  the 
main  chance,  and  advocated  starting  out  with  a  view 
to  success  in  practice.  Possibly  after  all  the  best 
would  be  the  happy  medium.  Certainly  all  the  time 
mentioned  by  Dr.  Osier  would  be  required  in  order  to 
reach  the  goal  that  he  had  fixed.  In  the  study  of  in- 
ternal medicine  it  was  necessary  to  take  in  a  consider- 
able knowledge  of  specialties.  What  was  a  man  to 
do  who  approached  a  case  of  renal  disease  unless  he 
was  familiar  with  the  ophthalmoscope?  He  had  only 
done  a  part  of  his  work  when  he  had  taken  the  history, 
noted  the  symptoms  and  signs,  and  examined  the  urine. 
Moreover,  a  careful  chemical  and  microscopical  exami- 
nation of  the  urine  was  in  itself  considered  a  specialty. 
In  order  to  become  master  of  so  many  specialties, 
it  was  evident  that  he  must  refu.se  the  opportuni- 
ties for  obtaining  practice  other  than  that  of  a  consul- 
tant. He  was  reminded  of  what  John  Hunter  had  said 
when  called  to  a  sick  person  while  he  was  earnestly 
engaged  in  the  study  of  some  subject.  He  put  off  go- 
ing again  and  again,  until  he  thought  the  patient's 
patience  had  become  exhausted ;  then  he  left  his  work, 
saying:  "I  svippose  I  must  go  and  earn  that  d — d 
guinea." 

Great  Consultants  as  Scarce  as  Great  Statesmen. 
— The  speaker  said  that  it  seemed  to  him  that  the 
great  consultants  of  the  future  were  going  to  be  as 
scarce  as  great  statesmen  were  at  the  present  time. 
At  the  time  that  Austin  Flint  was  so  prominent  as  a 
consultant  there  were  also  many  prominent  statesmen, 
but  they  had  died  out.  In  medicine  there  was  a  mul- 
titude of  very  clever  men,  but  only  a  few  who  stood 
head  and  shoulders  above  the  rest  of  the  profession. 
Aside  from  a  special  training,  there  must  be  some  pe- 
culiar fitness.  Take,  for  example,  Dr.  Flint.  He 
could  not  use  the  larj'ngoscope,  and  probably  not  the 
ophthalmoscope;  nor  did  he  believe  that  Flint  would 
have  had  a  person  swallow  a  bucket  of  water,  to  ha\e 
it  brought  up  again  and  the  digestive  fluids  minutely 
examined.  But  Flint  possessed  certain  habits  of  ob- 
servation and  perception;  there  was  something  about 
him'which  enabled  him  to  see  further  into  a  millstone 
than  others  perhaps  could  see,  even  with  the  microscope 
or  by  means  of  the  .v-rays. 

Dr.  Smith  said  that  he  had  often  been  asked  by 
young  medical  men  for  advice  as  to  how-to  shape  their 
career.  He  had  always  told  them  to  put  themselves 
in  touch  with  disease  in  any  way  that  they  could,  but 
at  the  same  time  to  attempt  to  handle  only  so  much  of 
it  as  they  could  attend  to  thoroughly  and  exhaustively. 
He  also  told  them  to  treat  evt-ry  patient,  whether  a 
tramp  or  a  millionaire,  with  precisely  the  same  care 
and  conscientiousness.  This  kind  of  work,  continued 
year  after  year,  without  seeking  the  plaudits  of  the 
world  in  any  way,  and  with  the  interest  of  the  patient 
at  heart  more  than  one's  own  aggrandizement,  would 
almost  inevitably  lead  one  in  the  end  into  a  success- 
ful business.  He  thought  all  would  agree  that  a  good 
specialist  must  have  first  been  a  good  practitioner. 

A  Distinction  between  a  Good  Diagnostician  and  a 
Good  Practitioner. — .\  \ery  important  distinction  was 
that  made  between  a  good  diagnostician  and  a  good 
practitioner.  It  used  to  be  said  a  few  years  ago  of  the 
French  school  that  its  followers  wished  to  make  a  diag- 
nosis, r.nci  that  then  they  were  an.xious  to  have  the  pa- 
tient die  in  order  that  the  diagnosis  could  be  confirmed 
at  the  post-mortem  table.  This  tendency  was  often  ob- 
servable among  our  own  consultants.  The  pathologi- 
cal  conditions  were  often   carefully  and  elaborately 


explained  by  consultants,  but  when  it  came  to  treatment 
we  received  no  further  light.  The  consultant  would 
often  ask:  "What  have  you  been  doing  for  the  pa- 
tient.'" and  after  hearing  the  answer  of  the  attending 
physician  would  advise  him  "to  continue  the  same." 

The  Therapeutic  Instinct. — Trous.seau  used  to 
speak  of  "the  therapeutic  instinct."  He  believed 
there  was  something  in  this.  Some  consultants  would 
inevitably  strike  out  a  nice  idea  in  treatment;  others 
would  merely  tell  you  what  the  patient  had,  and  leave 
you  to  find  out  the  best  way  of  securing  relief.  The 
therapeutic  instinct  was  often  extremely  well  devel- 
oped among  practitioners  in  the  rural  districts,  who 
had  been  largely  thrown  on  their  own  resources.  He 
had  often  been  astonished  at  their  fertility  of  resource 
— at  how  often  they  could  "  get  there,'  when  men  much 
more  thoroughly  equipped  halted  by  the  way. 

Internal  Medicine  Not  Now  in  Public  Favor.— 
Dr.  A.  Jacobi  said  that  the  chairman  had  asked  to 
hear  from  those  who  wished  to  speak  on  the  question, 
and  had  called  on  him.  He  did  not  wish  to  speak  on 
the  subject,  and  came  entirely  unprepared  except  what 
he  might  have  gathered  from  a  practice  of  forty  years 
in  this  city.  Perhaps  when  he  had  practised  for  sixty 
years  he  might  be  able  to  say  something.  He  would 
accordingly  make  only  a  few  commonplace  remarks. 

Dr.  Smith  had  already  pointed  out  that  Dr.  Osier 
had  spoken  of  a  particular  class  of  men  practising 
only  internal  medicine.  This  class  was  a  very  small 
one.  But  there  was  a  very  large  class,  to  which  he 
himself  belonged,  who  had  made  internal  medicine 
their  vocation.  This  class  of  practitioners  had  lost 
ground  in  the  last  twenty  years,  in  favor  of  the  spe- 
cialist of  all  degrees — particularly  the  lowest  degree 
alluded  to  by  Dr.  Polk.  Internal  medicine  had  cer- 
tainly lost  ground  with  the  public.  The  physician, 
by  many  months  of  careful  study,  might  diagnosticate 
a  tumor  and  its  location,  but  this  counted  for  little 
with  the  laity.  When,  however,  the  surgeon  came  and 
removed  it,  the  people  said:  "  What  a  brilliant  opera- 
tion!" and  in  many  instances  they  might  have  added 
very  pertinently  :  "  Did  he  run  off  with  the  physician's 
fee?"  At  the  present  time,  if  a  woman  had  a  head- 
ache, she  must  needs  have  a  neurologist;  if  she  had  a 
pain  about  the  chest — it  might  be  a  pleurisy — she 
would  go  to  a  neurologist;  if  she  had  pain  around  the 
eye,  she  would  seek  advice  from  the  ophthalmologist: 
if  the  pain  were  in  the  foot,  she  might  perhaps  go  to 
the  chiropodist.  The  nose  mu.st  be  blown  by  a  rhinol- 
ogist.  The  laryngologist  now  took  away  from  the  gen- 
eral practitioner  even  the  cases  of  catarrhal  croup. 
Then  there  was  the  abdominal  surgeon  and  the  appen- 
dicitis man,  the  stomach  specialist  and  the  hemorrhoi- 
dal specialist.  There  appeared  to  be  nothing  left  for 
the  general  practitioner;  it  appeared,  in  fact,  that  the 
vocation  of  internal  medicine  had  gone.  Still,  it  had 
not  really  gone.  He  had  been  a  general  practitioner 
for  many  years,  and  expected  to  die  a  general  practi- 
tioner. He  was  perfectly  satisfied  with  his  position. 
Many  had  become  specialists  because  they  did  noi 
know  anything  about  general  medicine. 

The  Sacred  Position  of  the  Family  Physician 

To  him  internal  medicine  as  a  vocation  was  a  sacred 
position  in  life.  Such  a  practitioner  not  only  had  to 
deal  with  every  organ  of  those  who  confided  in  him. 
but  he  was  expected  to  know  a  great  deal  about  their 
persons  and  their  past — he  knew  not  only  their  lives, 
but  their  hearts.  It  was  his  duly  to  look  out  not  only 
for  present  diseases,  but  for  such  diseases  as  might 
develop — in  other  words,  he  was  the  hygienist  of  the 
family.  If  one  wanted  a  good  sanitarian,  one  must 
look  for  him,  not  among  the  surgeons,  the  lar}-ngolo- 
gists,  or  even  the  bacteriologists,  but  among  the  well 
and  broadly  educated  practitioners  of  internal  medi- 
cine.    If  the  duties  and  the  rights  and  the  accomplish- 


October  30,  1897] 


MEDICAL    RECORD. 


64; 


ments  of  the  general  practitioner  were  compared  with 
the  dexterit}-  of  the  most  eminent  specialist,  it  would 
he  found  that  there  was  more  influence,  private  and 
public,  associated  with  the  achievements  of  the  general 
practitioners.  Internal  medicine,  as  a  vocation,  was 
really  the  complex — the  one-in-all  of  general  medicine. 

The  Fame  of  Physicians  Outlives  that  of  Sur- 
geons.— We  spoke  of  the  great  physicians  of  olden 
times  and  all  the  way  down  to  modern  times.  All  the 
great  names  mentioned  this  ex'ening  were  of  those  who 
had  made  internal  medicine  their  vocation — Austin 
Flint,  Alonzo  Clark,  Mitchell,  Physick,  and  others — 
every  one  a  general  practitioner.  The  surgeons  of 
their  times  had  almost  disappeared  from  the  history 
of  medicine,  and  certainly  from  the  history  of  man- 
kind and  from  the  memory  of  the  profession.  Spe- 
cialism, with  the  features  characterized  by  Dr.  Polk, 
was  now  about  at  its  height — not  at  the  top  of  the 
ladder,  however.  It  would  certainly  be  remodelled, 
and  we  would  have  in  the  future  fewer-but  better  spe- 
cialists. Whatever  was  good  and  useful  for  the  com- 
mon weal  would  have  to  be  looked  for  in  internal 
medicine,  which  would  then  be  the  vocation  of  the 
profession. 

In  closing.  Dr.  Jacobi  quoted  the  words  of  a  good 
specialist  in  this  city:  "The  internal  practitioner,  the 
general  practitioner,  is  the  statesman  of  the  profes- 
sion;" and  added:  '"So  it  is,  and  so  it  will  be." 

Dr.  Osler,  in  closing  the  discussion,  said  that  he- 
hoped  he  had  not  been  misunderstood  as  reflecting 
too  strongly  on  the  surgeons;  he  had  intended  to  say 
only  what  was  well  known,  that  success  to  the  surgeon 
came  earlier  than  to  the  physician,  and  it  was  more  a 
matter  of  the  heart  than  of  the  head.  He  saw  no  rea- 
son why,  in  our  large  cities,  the  younger  men  who 
looked  forward  to  having  a  hospital  ward  should  not 
do  some  general  medical  practice,  but  they  should  look 
forward  to  building  their  reputation  chiefly  on  their 
work  in  the  dispensary  and  hospitals.  He  was  quite 
sure  that  the  method  used  in  London  had  proved  ver}- 
successful.  Some  of  the  brightest  and  most  successful 
medical  men  had  not  been  in  general  practice,  but  had 
develoi^ed  directly  from  dispensary  and  hospital  work. 
There  was  no  reason  why  the  young  medical  man,  in 
his  first  few  years,  should  not  learn  the  mere  technical 
use  of  the  laryngoscope  and  of  the  ophthalmoscope ; 
indeed,  some  of  this  knowledge  was  now  acquired  in 
the  senior  year  at  the  medical  school. 

The  Consultant  Must  Keep  Young He  was  sure 

if  Dr.  Flint  did  not  know  nuich  about  bacteriology  he 
always  took  care  to  have  around  him  young  men  who 
did.  The  great  feature  of  Dr.  Flint  was  that  he  re- 
tained to  the  last  a  great  deal  of  receptivity;  he  had 
less  lime  salts  in  the  cells  of  his  cortex  than  any 
other  man  of  his  age  whom  he  had  met.  He  was 
young  to  the  end,  and  apparently  because  he  kept  young 
men  always  about  him. 

The  Diagnosis  All-Important. —  In  a  large  propor- 
tion of  cases,  he  thought,  the  only  important  function 
of  the  consultant  was  to  establish  the  diagnosis.  Tlie 
last  three  cases  that  he  had  seen  in  twenty-four  hours 
illustrated  this  very  well.  One  man  was  dying  of  per- 
nicious anaemia,  because  it  had  not  been  recognized, 
and  he  was  being  treated  for  malaria.  The  diagnosis 
would  certainly  prolong  his  life,  to  say  the  least.  In 
the  second  case  the  diagnosis  was  not  of  importance, 
as  it  happened  to  be  a  cancer  of  the  stomach.  In  the 
third  case  the  diagnosis  might  or  might  not  save  the 
woman's  life — it  depended  upon  the  surgeon.  She 
had  a  stone  in  the  common  duct.  Hundreds  of  dollars 
had  been  uselessly  expended  on  her  for  medicine,  all 
for  the  lack  of  a  correct  diagnosis.  One  sad  feature 
about  the  life  of  the  consultant  was  that  he  came  often 
as  a  nunc  dimittus — as  simply  the  one  who  preceded  the 
undertaker. 


A  Brighter  Future  for   Internal  Medicine.  —  Dr. 

Osier  said  that  he  thought  tlie  position  of  internal 
medicine  would  become  better  and  better  in  this  coun- 
try, because  the  younger  men  would  in  greater  num- 
bers devote  themselves  to  internal  medicine  in  the 
broader  sense  of  that  term.  After  all,  as  Dr.  Jacobi 
had  said,  the  chief  prizes  of  the  profession  did  not 
fall  into  the  hands  of  the  specialist,  but  into  the  hands 
of  men  who  had  passed  through  many  years  of  faithful 
and  unremitting  toil. 

Vote  of  Thanks. — On  motion  of  Dr.  Polk,  the 
academy  tendered  Dr.  Osier  a  vote  of  thanks  for  tlie 
eloquent  paper  that  he  had  so  kindly  presented. 


SECTION    OK    SURGERY. 

Stated  Meeting,  October  11,  fSgj. 

R.  Farquhar    Curtis.   M.l).,  in    rHE  *Chair. 

Intra-Uterine  Fracture  Complicated  with  Congeni- 
tal Absence  of  the  Toes  and  Metatarsal  Bones. — 
Dr.  A.  M.  Phelps  exhibited  an  infant  with  this  con- 
dition. At  the  sixth  month  of  iritra-uterine  life  the 
mother  while  in  a  street  car  had  been  injured  by  a 
heavy  woman  falling  upon  her.  She  gave  birth  to  the 
child  at  full  term,  after  a  dry  labor.  It  was  then  dis- 
covered that  the  infant's  tibia  and  fibula  midway  be- 
tween the  knee  and  ankle  were  bent  at  a  right  angle, 
the  sole  of  the  foot  looking  directly  backward.  There 
was  also  an  absence  of  three  of  the  toes.  The  child 
had  been  brought  to  him  when  it  was  four  months 
old,  and  he  had  advised  postponing  operation  until 
the  age  of  nine  months.  He  had  then  operated,  cut- 
ting down  upon  the  point  of  fracture.  He  was  able 
to  demonstrate  that  it  was  indeed  a  fracture,  because 
the  upper  fragment  overlapped  the  lower,  the  latter 
being  joined  at  right  angles  to  the  upper.  A  suffi- 
cient amount  of  bone  was  cut  away  to  allow  the  foot 
to  be  placed  in  the  normal  position.  Radiographs  of 
the  condition  were  presented,  and  they  illustrated  the 
points  brought  out.  Photographs  of  the  case  before 
operation  were  also  shown.  At  the  present  time  there 
was  a  shortening  both  of  the  femur  and  of  the  tibia 
and  fibula,  of  about  three  inches.  The  points  of  in- 
terest were  these:  (i)  An  intra-uterine  fracture  occur- 
ring with  a  congenital  deformity  of  the  foot;  (2)  the 
importance  of  the  operation  which  was  performed,  as 
it  placed  the  foot  in  such  a  position  as  allowed  the 
foot-bearing  socket  for  an  artificial  limb  to  be  worn 
with  great  comfort;  (3)  it  might  also  permit  the  limb 
to  grow.  An  amputation  at  any  time  before  adult  life 
would  very  probably  result  in  a  conical  stump,  and  if 
the  foot  and  limb  were  left  in  their  original  position 
there  might  result  extreme  non-development  with  great 
shortening. 

Chronic  Hydrocele  with  Calcification  of  the  Sac. 
— Dr.  IJ.  Farquhar  Curtis  presented  a  man,  forty- 
one  years  of  age,  a  native  of  Nassau,  who  for  over 
twenty  years  had  had  what  had  been  supposed  to  be  a 
tumor  of  the  testicle.  Nothing  was  done  in  the  way 
of  treatment,  as  it  was  neither  painful  nor  a  source  of 
great  discomfort.  On  his  admission  to  the  hospital 
there  was  a  tumor  occupying  the  left  side  of  the  scrotum. 
It  had  a  smooth  hard  surface,  and  the  testicle  could 
not  be  felt.  Very  firm  pressure  gave  one  the  impres- 
sion that  the  tumor  was  cystic.  The  test  with  light 
was  negative.  At  first  it  was  thought  that  a  hydrocele 
could  be  excluded  on  account  of  the  absence  of  trans- 
lucency,  yet  the  tumor  had  the  shape  and  form  of  a 
chronic  hydrocele  in  which  the  sac  had  become  greatly 
thickened.  The  latter  condition,  of  course,  would  ex- 
]jlain  the  absence  of  translucency.  .\t  one  examina- 
tion an  ''egg-shell  crackling"  was  obtained.  At  the 
operation  the  knife  could  not  be  made  to  penetrate  the 


648 


MEDICAL    RECORD. 


[October  30,  1897 


mass.  The  cord  was  healthy,  and,  as  the  testicle  could 
not  be  found  anj'where,  it  was  thought  best  to  remove 
the  whole  mass.  This  was  done,  and  then  examina- 
tion showed  the  condition  to  be  a  chronic  hydrocele 
with  an  unusual  amount  of  calcification.  There  was 
no  history  of  tapping  or  anything  else  which  would  be 
likely  to  cause  calcification.  The  entire  sac  had  been 
converted  into  a  firm  shell.  The  sac  contained  a  fluid 
very  much  like  pea-soup  in  appearance,  but  examina- 
tion showed  it  to  be  a  mixture  of  cholesterin  crystals 
with  some  fatty  detritus.  On  the  inner  surface  were 
some  rounded  masses,  evidently  due  to  some  haemato- 
celes  that  had  formed  there.  The  testicle  lay  at  the 
back  of  the  sac,  and  the  latter  w  as  so  distended  that  it 
had  pushed  down  the  epididymis  quite  flat.  The  oper- 
ation had  been  done  on  September  30th,  and  the 
patient  liad  made  a  good  recoveiy. 

Mammary  Carcinoma;  Operation  by  Meyer's 
Method.  — Dr.  Franz  J.  A.  Torek  presented  a  patient 
from  whom  a  carcinoma  of  the  mamma  had  been  re- 
moved by  Meyer's  method  of  operating.  It  had  been 
objected,  he  said,  that  this  method  was  very  mutilat- 
ing, and  was  unnecessarily  severe  in  many  cases.  An 
examination  of  his  patient  would,  he  thought,  refute 
the  statement  that  the  operation  was  a  mutilating  one, 
notwithstanding  the  fact  that  the  operation  wound 
was  very  extensive;  i.e..  its  upper  boundar)' was  the 
clavicle,  the  inner  boundary  the  sternum,  the  lower 
boundary  the  lower  portion  of  the  pectoral,  and  the 
posterior  and  outer  boundary  the  latissimus  dorsi 
muscle.  Even  by  careful  tests  it  was  difficult  to  de- 
tect any  distinct  loss  of  function:  even  the  adduction 
of  the  arm  posteriorly  was  perfectly  well  carried  out 
by  the  anterior  and  posterior  fibres  of  the  deltoid. 
This  patient  got  up  on  the  seventh  day;  the  wound 
was  entirely  healed  at  that  time,  and  she  was  dis- 
charged from  the  hospital  on  the  fourteenth  day.  It 
would  be  observed  that  the  tumor  in  the  breast  was 
comparatively  small.  About  an  inch  and  a  half  from 
the  sternum  and  under  the  clavicle  there  had  been  a 
minute  carcinomatous  gland  which  no  one  could  have 
possibly  detected  and  removed  except  by  this  radical 
method.  This  in  itself  was  a  sufficient  justification  of 
this  plan  of  operating.  He  had  frequently  found  the 
glands  infected  under  the  pectoralis  major  muscle,  and 
on  this  account  believed  that  carcinoma  of  the  breast 
should  be  removed  by  this  method,  and  that  we  should 
not  individualize  and  select  other  operations  for  cer- 
tain cases.  According  to  his  experience,  motion  was 
better  when  the  pectoral  muscles  were  entirely  re- 
moved than  when  they  were  cut  through  and  united 
again,  owing  to  the  fact  that  when  they  were  operated 
upon  by  the  latter  method  there  was  more  downward 
traction.  The  tumor  had  first  been  noticed  by  the 
patient  last  April,  and  the  operation  had  been  done 
on  .September  3d. 

Amputation  of  Shoulder- Joint  for  Carcinoma ; 
Skiagraphs. — Dr.  Artiu'k  L.  Fiskf,  presented  a  man, 
thirty-nine  years  of  age,  who  had  entered  his  service 
at  the  Cancer  Hospital  on  August  30th.  The  family 
and  personal  records  were  good.  Last  January  the 
man  had  first  experienced  a  slight  pain  in  the  shoul- 
der, and  this  had  gradually  become  more  severe.  In 
the  early  part  of  June  a  swelling  had  been  noticed 
about  the  shoulder,  accompanied  by  more  or  less  dis- 
ability. There  was  no  history  of  any  injury.  The 
clinical  diagnosis  was  subjieriosteal  sarcoma.  On 
September  iith,  the  shoulder  was  removed.  This 
case  illustrated  well  the  value  of  skiagraphy  in  the 
diagnosis  of  such  conditions.  The  skiagrapii  ex- 
hibited showed  the  difference  in  density  between  the 
tumor  itself  and  the  muscle  mass  about  the  shoulder. 
In  carrying  out  the  amputation  a  long  incision  had 
been  made  over  the  head  of  the  bone  in  order  to  ex- 
plore the  tumor.     It  had  been  found  to  extend  up  into 


the  region  of  the  scapula.  The  vessels  having  been 
ligated  through  the  incision,  a  circular  amputation 
had  been  done,  and  the  end  of  the  clavicle  and  the 
glenoid  cavity  of  the  scapula  removed.  The  patho- 
logical diagnosis  of  the  tumor  was  a  sarcoma  under- 
going myxomatous  degeneration.  The  patient  had 
had  for  a  considerable  time  a  good  deal  of  cough  and 
expectoration,  and  in  the  sputum  numerous  tubercle 
bacilli  had  been  found. 

Volvulus  with  Enormous  Distention  of  Bowel.^ — 
Dr.  Howard  Lilienthal  exhibited  a  man,  forty-six 
years  of  age,  who  had  been  admitted  to  the  Mount 
Sinai  Hospital  last  August,  with  a  diagnosis  of  appen- 
dicitis. He  had  been  sick  for  two  days,  and  consti- 
pated for  a  long  time  previously.  The  constipation 
at  the  beginning  of  the  attack  had  really  amounted  to 
obstipation.  On  admission  he  had  a  temperature  of 
over  101'  F. ;  there  was  slight  icterus;  the  face  was 
anxious;  the  pulse  was  100  and  of  good  quality,  yet  the 
extremities  were  cold.  There  was  an  intensely  pain- 
ful point  on  the  right  side,  but  it  was  somewhat  re- 
moved from  the  location  of  the  appendix.  There  was 
also  general  abdominal  tenderness,  with  so  much  dis- 
tention that  the  speaker  had  been  inclined  to  suspect 
general  peritonitis.  The  patient  was  at  once  put 
under  chloroform,  and  the  usual  incision  was  made 
for  appendicitis.  This  exposed  a  very  dark  mass, 
which  was  tympanitic  on  percussion.  Only  on  close 
examination  was  it  possible  to  discern  the  striations 
characteristic  of  the  large  intestine.  A  very  large 
coil  of  intestine  was,  with  difficulty,  removed  after 
enlarging  the  incision.  Actual  inspection  showed  the 
caecum  and  ascending  colon  to  be  in  their  normal 
positions.  The  direction  of  the  fibres  indicated  that 
the  condition  was  probably  a  volvulus  of  the  cscura, 
and  this  proved  to  be  the  case.  The  volvulus  was 
readily  reduced,  but  still  there  was  no  effort  at  evacu- 
ation. With  a  rather  large  trocar  it  was  punctured  at 
the  upper  part,  and  a  considerable  quantity  of  gas 
evacuated.  Xotwithstanding  this  it  was  still  impos- 
sible to  replace  the  intestine,  so  he  deliberately  made 
an  incision,  one  inch  long,  into  it.  This  gave  vent 
to  an  enormous  quantity  of  fascal  material.  Although 
he  did  not  expect  the  patient  to  recover,  the  operation 
was  completed,  the  openings  in  the  bowel  being  care- 
fully closed  with  sutures.  A  packing  was  inserted 
down  to  these  points,  and  the  intestine  stitched  there 
to  the  abdominal  wall.  Strangely  enough,  the  patient 
had  made  a  perfectly  smooth  recovery,  and  the  bowels 
had  been  easily  kept  open  from  the  day  after  the 
operation. 

Dr.  B.  F.  Curtis  said,  with  reference  to  Dr.  Pheljjs' 
case,  that  there  was  a  clear  history  of  fracture,  and  the 
bone  also  showed  it  clearly.  He  thought  that  Dr. 
Phelps'  theorj-  that  this  was  entirely  independent  of 
the  condition  of  the  toes  must  be  accepted  as  correct. 

Dk.  Lilienthal  asked  what  was  the  theory  on 
which  the  calcification  in  the  hydrocele  case  was  to 
be  explained.  There  was  no  evidence  of  tuberculosis, 
and  the  patient  did  not  have  atheromatous  arteries. 

Dk.  Robert  T.  Morris  said  that  if  the  tension  had 
been  sufficiently  great  to  cause  fatty  degeneration  of 
the  endothelium,  the  neutral  fat  might  have  become 
absorbed  and  the  fatly  salts  replaced  by  calcareous 
salts.  It  would  be  necessary,  however,  to  account  first 
for  the  fatty  degeneration  of  the  endothelial  cells. 
Such  a  degeneration  might  arise  from  excessive  pres- 
sure, probably  from  an  acute  necrosis. 

Dr.  Ci'RTis  said  that  he  was  inclined  to  attribute 
the  calcification  to  the  same  causes  as  those  which 
give  rise  to  calcification  of  the  spleen.  The  case  was 
certainly  a  very  rare  one. 

Dr.  C.  \.  Down,  referring  to  Dr.  Torek's  case, 
spoke  of  the  advantage  of  the  routine  removal  of  the 
pectoral  muscles  in  cases  in  which  there  was  a  clear 


October  30,  1S97] 


MEDICAL    RECORD. 


649 


diagnosis  of  carcinoma  of  the  breast.  There  had  been 
a  remarkable  improvement,  he  said,  in  the  statistics 
of  breast  amputations  in  proportion  as  the  very  radical 
method  of  operating  had  become  more  generall)-  ac- 
cepted. The  mutilating  effects  were  certainly  not  so 
great  as  had  been  at  first  supposed.  He  had  himself 
operated  at  least  twenty  times,  and  all  of  these  patients 
had  had  good  use  of  the  arm,  and  in  some  of  them  the 
functional  result  had  been  remarkably  good,  the  pa- 
tient being  able  to  do  considerable  manual  labor. 
The  danger  of  amputation  of  the  breast  had  not  been 
especially  increased  by  the  more  radical  method  of 
operating. 

Dr.  Fiske  was  inclined  to  favor  a  higher  incision 
even  than  that  used  by  Meyer,  for  there  had  been  less 
subsequent  cedema  and  binding  down  in  the  axilla  in 
cases  in  which  the  higher  incision  had  been  used. 

Dr.  Torek  said  that  in  the  case  presented  he  had 
used  an  S-shaped  incision,  and  had  found  it  a  very 
convenient  one.  He  also  liked  the  high  incision,  and 
the  straighter  it  was  made,  the  less  would  be  the  diffi- 
culty experienced  in  operating.  It  was  his  own  prac- 
tice, however,  not  to  adopt  any  conventional  method  of 
making  the  incision,  preferring  to  shape  it  to  suit  the 
individual  case. 

Dr.  Curtis  said  that  he  felt  that  the  operation  was 
too  severe  for  mild  cases,  although  he  hesitated  to 
say  so,  in  view  of  the  improvement  in  the  statistics 
since  the  more  radical  method  had  been  adopted. 
But  we  should  not  allow  ourselves  to  be  misled.  Ac- 
cording to  his  experience,  the  tendency  had  been  for 
the  recurrence  to  take  place  in  the  skin,  and  hence  he 
was  inclined  to  sacrifice  more  and  more  of  the  integu- 
ment. In  the  case  presented,  it  was  true  the  tumor 
was  a  small  one,  yet  the  case  was  undoubtedly  .severe, 
as  shown  by  the  extensive  involvement  of  the  glands. 
It  seemed  to  him  that  in  the  average  case  it  was  illog- 
ical to  cut  away  the  muscle  extensively,  when  it  was 
impossible  to  cut  very  much  beyond  the  disease  in  the 
glands.  He  had  been  one  of  the  first  surgeons  in  this 
city  to  operate  by  Heidenhain's  method.  The  case 
was  one  of  recurrent  carcinoma.  A  year  later  the 
patient  had  returned  with  a  carcinoma  in  the  opposite 
breast.  The  entire  muscle  on  that  side  had  also  been 
removed,  and  when  the  patient  was  last  heard  from, 
three  years  afterward,  there  had  been  no  further  re- 
currence. .Although  the  functional  result  in  these 
cases  seemed  to  be  good,  it  could  not  be  denied  that 
there  was  a  decided  loss  of  power.  This  could  be 
best  observed  by  causing  the  patient  to  keep  the  elbows 
close  to  the  side,  at  the  same  time  separating  the  hands 
widely,  and  by  testing  the  patient's  power  to  squeeze 
one's  hand. 

Dr.  J.  A.  Wyeth  said  that  he  believed  with  Dr. 
Torek  that  in  dealing  with  malignant  growths  we 
could  scarcely  go  wrong  in  adopting  a  wide  and  free 
extirpation.  A  good  deal  depended  upon  the  length 
of  time  the  neoplasm  had  been  present,  upon  what 
part  of  the  mammary  gland  it  had  primarily  involved, 
and  upon  how  extensive  were  the  adhesions  of  the 
mammary  and  pectoral  fascia;.  When  the  upi^er  part 
of  the  breast  was  first  in\olved,  it  seemed  to  him  that 
a  wide  extirpation  should  be  done  in  every  instance: 
it  should  also  be  done  in  those  cases  in  which  there 
was  a  reasonable  doubt  on  this  point.  In  a  certain 
proportion  of  cases — and  that  proportion  was  increas- 
ing, because  people  were  coming  earlier  for  operation 
— in  which  there  was  a  limited  area  of  invasion  in  the 
lower  and  outer  quadrant,  the  removal  of  the  pectoralis 
major  or  its  clavicular  fibres  was  not  essential.  He 
removed  a  part,  or  nearly  all  of  the  sternal  and  costal 
portions  of  the  pectoralis  major,  and  was  particular  to 
take  away  all  of  the  pectoralis  minor.  It  was  a  clini- 
cal fact  that  the  lymphatics  of  the  pectoralis  minor 
were   most  frequently   engorged  with  the   metastases. 


In  almost  all  cases  it  was  necessary  to  remove  the  ax- 
illary contents  from  above  downward. 

Dr.  Torek,  said  that  he  had  become  firmly  con- 
vinced by  experience  of  the  advisability  of  removing 
the  pectoral  muscles.  In  cases  apparently  much 
milder  than  the  one  just  presented  by  him,  he  had 
found  repeatedly  an  infection  of  the  glands  under  the 
pectoralis  minor  at  a  point  where  it  would  have  been 
impossible  to  detect  it  e.xcept  by  this  method  of  operat- 
ing. He  had  not  intended  to  lay  much  stress  upon 
removal  of  the  muscle,  but  this  course  enabled  him  to 
extirpate  the  visibly  diseased  tissues — the  small  glands 
underneath  the  muscles. 

Dr.  Wyeth,  referring  to  Dr.  Fiske's  case,  said  that 
so  far  as  he  knew,  there  was  not  a  successful  case  on 
record  of  an  operation  like  the  amputation  of  the 
shoulder  just  described  by  Dr.  Fiske.  He  had  him- 
self done  two  of  these  operations,  and  both  cases  had 
terminated  fatally  within  six  months. 

Dr.  A.  M.  Phelps  said  that  about  five  years  ago  he 
had  operated  in  a  case  of  sarcoma.  The  microsco- 
pist  had  been  in  doubt  as  to  whether  the  case  was  one 
of  pure  sarcoma  or  of  fibro-sarcoma,  but  from  the  fact 
that  recurrence  took  place  it  was  undoubtedly  a  pure 
sarcoma.  It  began  in  the  glenoid  cavity  and  involved 
the  scapula  more  than  the  humerus.  At  the  time  of 
the  operation  there  was  no  involvement  of  the  humerus. 
He  extirpated  the  scapula  and  saved  the  arm.  A  year 
and  a  half  later  the  disease  recurred  in  the  head  of  the 
humerus.  He  then  removed  the  humerus.  At  the 
present  time  the  man  was  alive  and  well — two  years 
since  the  second  operation.  After  the  removal  of  the 
scapula  the  man  had  had  a  traumatic  empyema  which 
had  ruptured  into  the  wound  in  two  weeks,  and  after 
this  had  discharged  for  three  or  four  weeks  recovery 
had  taken  place. 

Dr.  Fiske  said  that  he  had  removed  a  sarcoma  of 
the  shaft  of  the  humerus  on  January  r,  1897.  He  had 
seen  the  woman  in  the  middle  of  last  July,  and  up  to 
that  time  there  had  been  no  recurrence.  A  photograph 
of  this  subject  was  exhibited. 

Dr.  V\'veth  said  that  he  had  presented  to  this  sec- 
tion two  years  and  a  half  ago  an  enormous  osteo-sar- 
coma  involving  the  head  of  the  humerus.  He  tied  the 
subclavian  artery  under  cocaine  anaesthesia,  in  the 
third  surgical  division,  in  order  to  arrest  hemorrhage 
occurring  during  an  exploration  that  he  had  made. 
He  had  afterward  cut  off  the  bone  at  the  shoulder- 
joint,  and  presented  the  patient  to  the  section  while 
the  wound  was  still  an  open  one.  This  man  was  in- 
oculated three  times  with  erysipelas  toxins,  and  waa 
now  well  and  strong,  and  he  was  beginning  to  think 
that  the  recovery-  was  due  to  the  erysipelas  inocula- 
tions. 

Dr.  Curtis  referred  to  the  case  of  a  young  girl  who 
had  had  a  small  tumor  involving  only  the  acromial 
end  of  the  scapula,  but  so  situated  as  to  require  the 
removal  of  the  entire  upper  extremity.  This  he  had 
done  in  September,  1896,  and  she  had  made  a  good 
recovery  from  tiie  operation.  However,  recurrence 
took  place  in  the  scar  very  shortly  afterward,  and  the 
girl  died  in  the  course  of  about  three  months. 

Dr.  Phelps  thought  the  age  of  the  patient  and  the 
character  of  the  tumor  had  much  to  do  with  the  mat- 
ter of  recurrence.  His  patient  had  been  about  thirty- 
eight  years  of  age.  In  younger  persons  osteo-sarcoma 
was  usually  much  more  malignant. 

Dr.  Torek  asked  if  any  one  had  had  a  case  of  apo- 
plexy and  death  occurring  after  amputation  of  the 
shoulder-joint.  He  had  performed  such  an  amputa- 
tion on  one  patient,  and  she  had  done  well  up  to 
the  sixth  day,  when  she  had  suddenly  been  attacked 
with  apoplexy  and  died.  In  another  case  of  carci- 
noma of  the  neck,  in  which  an  extensive  operation 
had  been  required,  an  apoplexy  had  occurred  on  the 


650 


MEDICAL    RECORD. 


[October  30,  1897 


third  day  after  the  operation,  and  death  had  taken 
place  about  two  months  later. 

Dr.  George  E.  Brewer,  speaking  of  Dr.  Lilien- 
thal's  case  of  volvulus,  said  that  the  distention  of  the 
bowel  had  been  something  enormous;  the  mass  was 
certainly  as  large  as  a  man's  thigh.  From  what  he 
had  seen  of  this  case  he  had  felt  that  it  would  have 
been  utterly  impossible  for  anybody  to  make  a  cor- 
rect diagnosis  before  the  operation. 

Dr.  Morris  inquired  as  to  where  the  bowel  had  been 
sutured  to  the  abdominal  wall  after  the  operation. 

Dr.  Lilienthal  replied  that  he  had  made  it  fast  to 
the  abdominal  parietes  by  a  suture  above  and  below. 

Dr.  Morris  said  that  a  German  surgeon  had  pub- 
lished a  method  of  preventing  the  recurrence  of  volvu- 
lus by  suturing  the  entire  affected  part  to  the  perito- 
neum of  the  abdominal  wall. 

Dr.  Lilienthal  said  that  in  his  case  the  volvulus 
had  been  altogether  too  large  to  sew  in  this  manner  to 
the  wound. 

rjR.  Wveth  said  of  the  plan  of  suturing  to  the 
abdominal  wall,  that  a  suspicious  point  in  the  line  of 
suture  was  an  important  part  in  the  technique  of  in- 
testinal surgery  which  was  too  often  neglected,  and 
which  was  not  infrequently  responsible  for  the  fatal 
result. 

Strangulated  Hernia ;  Extensive  Intestinal  Re- 
section ;  Recovery Dr.  Thomas  H.  Manlev  pre- 
sented a  specimen  of  intestine  that  had  been  removed 
from  a  young  Chinaman  who  had  developed  a  strangu- 
lation of  the  bowel.  No  medical  aid  had  been  sought 
for  four  days,  and  there  had  then  been  enormous  dis- 
tention of  the  abdomen,  a  temperature  of  103.5°  ^-t 
incessant  vomiting,  and  a  feeble  pulse  of  130.  The 
point  of  strangulation  in  the  hernia  was  found  in  the 
usual  situation,  and  the  intestine  was  found  to  be  per- 
forated in  several  places  and  completely  divided  at 
one  point,  [n  this  case  he  had  used  a  running  Lem- 
bert  suture  and  had  made  a  lateral  intestinal  anasto- 
mosis. The  wound  had  been  left  open  in  the  manner 
which  had  been  so  wisely  insisted  upon  by  the  preced- 
ing speaker,  and  he  believed  that  it  was  owing  to  this 
fact  that  his  patient  had  recovered.  I'he  portion  re- 
moved measured  twenty-eight  inches. 

Dr.  Morris  said  regarding  this  matter  of  leaving 
an  open  wound  at  a  suspicious  point  that  it  was  dan- 
gei;ous  teaching,  albeit  safe  enough  practice  in  the 
hands  of  a  surgeon  of  judgment  and  experience.  Such 
a  method  always  left  a  weak  point,  and  exposed  the 
patient  to  the  danger  of  fistula. 

Dr.  Lilien  rHAL  said  that,  while  no  doubt  leaving 
the  wound  open  prevented  one  from  obtaining  an  ideal 
surgical  result,  it  would  often  be  found  a  means  of 
saving  life,  and  certainly  the  danger  of  a  fistula  was  a 
slight  one  compared  with  danger  to  life. 

Epispadias.  —  I .  A  perineal  fistula,  made  by  cutting 
from  the  outside,  upon  the  finger  introduced  into  the 
bladder  above  to  distend  the  perineum  or  by  the  use 
of  Watson's  perineal  drainage  tube.  The  subsequent 
steps  may  be  jjroceeded  with  at  once  or  ten  days 
after,  when  time  and  rest  have  allowed  drying  and 
healing  of  excoriations.  2.  Dissecting  up  the  urethra, 
which  lies  open  upon  the  upper  surface  of  the  peri- 
neum. 3.  Separation  by  blunt  dissection  of  the 
loosely  connected  cavernous  bodies.  4.  The  urethra, 
laid  in  the  gutter  then  formed,  is  secured  by  two  su- 
tures through  the  lower  Hoor  of  the  urethra  and  skin  of 
tiie  under  surface  of  the  penis.  5.  The  free  edges  of 
the  urethra  are  united  with  continuous  catgut  ligature 
over  a  silver  catheter  extending  to  the  bladder.  6. 
The  cavernous  bodies  are  then  united  w  ith  continuous 
catgut,  and  tiie  skin,  which  is  usually  abundant,  with 
interrupted  silkworm  gut. —  ('antwklt.,  Antin/s  of 
Surgery. 


©orrjespontlcnce. 

OUR    LONDON    LETTER. 

CFroin  our  Special  Correspondent.) 
THE    MEDICAL    COUNCIL;    CLAIMS    OF    THE   CANDIDATES; 

PERSONAL    NOTES OPENING    OF   THE     SCHOOLS;    THE 

LECTURES — DR.     MANSON,    DR.    GOW,    DR.    PYE-SMITH, 

SIR     J.      CRICHTON-BROWNE,  "DR.     CARTER TYPHOID 

EPIDEMIC  AT    MAID.STONE— SIR  SAMUEL  WILKS,  BART. 
DEATH    Ol'    CAMBRIDGE    PROFESSOR. 

L(jNnci\,  October  8,  i8v7. 

The  contest  for  the  medical  council  is  producing  a 
fine  crop  of  electioneering  circulars,  to  say  nothing  of 
the  meetings,  which  have  attracted  larger  numbers  than 
was  expected.  If  the  excitement  continues  to  increase 
until  Monday,  we  shall  redeem  the  profession  from  its 
apathy.  But  this  interest  in  the  election  may  affect 
only  the  larger  centres.  It  is  impossible  to  gauge 
the  effect  of  the  many  circulars  on  the  scattered  coun- 
try practitioners.  If  they  rally  around  their  own  order 
they  can  easily  elect  either  Dr.  Diver  or  Dr.  Rigby, 
and  either  would  be  efficient  as  a  councillor.  But  if, 
as  I  think  likely,  they  do  not  consider  general  prac- 
tice in  the  country  the  chief  qualification,  the  contest 
will  lie  between  Mr.  \'ictor  Horsley,  F. R.S.,  and  Sir 
Walter  Foster.  Those  who  think  we  should  be  repre- 
sented by  a  man  of  the  highest  repute  must  support 
Mr.  Horsley,  whose  fame  as  a  surgeon  is  supplemented 
by  his  position  in  science,  for  he  grasped  its  blue  rib- 
bon at  an  unusually  early  age.  Sir  Walter  Foster 
calls  himself  a  provincial  physician,  but  his  opponents 
say  that  as  a  political  man  with  a  residence  in  London 
this  is  only  an  electioneering  pretence.  He  is  con- 
sulting physician  to  the  Birmingham  Hospital,  where 
he  was  on  the  active  staff  for  many  years  and  dis- 
charged its  duties  satisfactorily.  His  little  manual 
on  the  sphygmograph  (1866)  is  being  again  talked  of. 
though  not  in  a  way  to  gratify  him:  for  he  gave  a  sit- 
ting to  an  interviewer  and  photos  of  himself  in  his 
consulting-room,  witii  the  instrument  prominent  as 
well  as  a  post  card  from  Mr.  (Gladstone  congratulating 
him  on  his  skill.  The  paper  containing  the  interview 
was  produced  at  a  meeting  in  his  support,  when  he  ex- 
cused it  on  the  ground  that  as  a  member  of  Parliament 
the  public  desired  information  about  him,  and  com- 
plained that  the  matter  was  sprung  upon  him  without 
notice,  at  which  some  of  his  supporters  affected  indig- 
nation but  others  were  evidently  rather  shocked,  while 
his  opponents  chuckled. 

But  it  is  as  a  medical  politician  that  Sir  Walter  is 
best  known.  He  has  served  ten  years  in  the  council, 
having  first  been  nominated  by  the  British  Medical 
Association,  but  that  in  a  manjier. which  was  con- 
demned at  the  time  and  has  caused  him  to  bear  the 
burden  ever  since  of  being  regarded  as  the  tool  of  the 
then  ruling  clique. 

But  Victor  Horsley  is  also  a  medical  politician,  and 
bids  fair  to  take  a  place  in  this  respect  such  as  that 
of  the  late  Mr.  Rivington. 

The  inidwives  question  is  the  one  which  is  most 
prominent  at  the  present  time  and  which  agitates  all 
ranks  of  the  profession.  On  this  Sir  W.  Foster  in  the 
council  and  in  Parliament  has  proved  weak-kneed  and 
is  largely  regarded  as  a  dangerous  or  unsatisfactory 
representative.  Vet  to  the  amazement  of  many  he  has 
secured  the  support  of  Dr.  Rentoul,  the  most  energetic 
opixineiit  of  the  miilwives  bills,  wiiich  Sir  Walter  sup- 
ported. Mr.  Horsley  is  much  sounder  on  this  ques- 
tion: he  is  opposed  to  any  legislation  upon  it  which 
does  not  place  midwives  under  the  absolute  control  of 
registered  practitioners.  Moreover  he  advocates  re- 
form of  the  council,  amendment  of  tiie  acts,  and  sup- 
pression of   illegal   practices.     This   is  an  attractive 


October  30,  1897] 


MEDICAL    RECORD. 


651 


programme,  and  as  to  the  last  item  his  experience  as 
tlie  moving  spirit  of  the  Defence  Union  would  be  of 
great  service. 

The  medical  schools  opened  with  the  month  in  the 
usual  manner,  though  defections  from  the  ancient  cus- 
tom of  introductory  addressesKiontinue.  Consequently 
convcrzationi  and  other  reunions  are  gradually  supplant- 
ing the  more  time-honored  opening.  These  latter,  too, 
have  a  more  limited  interest,  each  school  caring  little 
how  the  others  celebrate  the  occasion.  This  year,  too, 
the  interest  in  the  opening  day  has  been  overshadowed 
by  the  election.  The  addresses,  however,  were  quite 
equal  to  the  average. 

.\t  St.  George's  Hospital  Dr.  Patrick  Manson  urged 
the  importance  of  a  study  of  tropical  diseases.  The 
hospital  has  lately  secured  his  services  as  a  lecturer 
on  this  subject,  one  on  which  his  experience  in  the 
Kast  eminently  qualifies  him.  Dr.  Manson's  work  on 
the  filariais  universally  known,  and  his  writings  on  this 
and  cognate  subjects  are  always  regarded  with  interest. 
He  is  now  physician  to  the  Seamen's  Hospital  and 
inedical  adviser  to  the  Colonial  Office.  He  had  long 
service  in  the  East  as  medical  officer  of  Her  Majesty's 
consulates  (China,  Amoy,  Takao,  Kowloon,  etc.). 

.\t  King's  College  the  address  was  given  by  the  new 
principal,  Dr.  .Vrchibald  Robertson,  who  succeeds  Dr. 
Wace.  The  lecturer  lamented  the  "  hope  deferred"  of 
.1  teaching  university  for  London,  though  he  thought 
the  injury  to  the  higher  general  culture  by  the  present 
state  of  things  did  not  so  much  affect  medical  educa- 
tion as  might  be  supposed. 

Dr.  William  John  Gow  gave  the  address  at  St. 
Mar)''s  Hospital.  He  is  the  assistant  obstetrician 
there  and  distinguished  himself  at  the  London  Uni- 
versity. He  was  not  educated  at  this  school  but  at 
"  Dart's."  His  position  will  improve  if  he  remains, 
l)ut  St.  Mar}''s  has  recently  been  negligent  of  her  sons 
and  this  has  given  rise  to  many  speculations  about  her 
system  of  appointments,  once  so  lauded,  but  this  year 
leading  to  the  loss  <^f  three  men  who  had  spent  years  in 
her  ser\'ice.  Dr.  Gow  ga\e  e.xcellent  practical  advice 
to  the  students  and  displayed  therein  much  "common 
sense" — an  admirable  quality  which  he  recommended 
'.hem  to  cultivate. 

Dr.  Pye-Smith,  nmv  the  senior  physician  at  Guy's, 
went  to  Sheffield  to  give  the  address,  and  Sir  J.  Crich- 
ton- Browne  to  Birmingham.  I'cr  contra,  provincial 
gentlemen  came  to  London's  opening  day.  Dr.  Carter, 
of  Liverpool,  addressed  the  students  of  Charing  Cross 
and  the  principal  of  Mansfield  College,  Oxford  (Rev. 
Dr.  Fairbairn),  those  of  St.  Thomas'  Hospital. 

The  epidemic  of  t)-phoid  at  Maidstone  has  gone  on 
extending  its  ravages  all  the  week,  though  with  vary- 
ing degrees  of  advance.  Some  days  over  sixty  new- 
cases  were  added  to  the  roll.  Yesterday  there  were 
twenty-eight,  making  the  tota!  attacks  one  thousand 
four  hundred  and  fift)--seven.  Visitors  to  the  town 
have  also  carried  infection  to  other  places  and  caused 
considerable  alarm,  but  they  are  easily  isolated— ^a 
very  different  thing  from  a  polluted  water  supply. 
The  supply  from  the  infected  spring  has  been  stopped, 
but  why  this  stej)  was  .so  long  delayed  remains  to  be 
ascertained.  It  is  widely  asserted  that  the  company 
was  reluctant  on  account  of  the  cost,  but  surely  it 
could  have  cut  off  that  spring  for  the  period  that  the 
bacilli  can  live  in  water,  and  a  dreadful  responsibility 
has  been  incurred  by  not  having  done  so.  It  is  stated 
to-day  that  Dr.  Semple  has  gone  from  Netley  to  offer 
a  vaccine  with  which  experiments  have  been  made  at 
that  army  school,  where  he  is  assistant  professor  of 
pathology. 

The  president  of  the  College  of  Physicians,  Sir 
Samuel  Wilks,  baronet,  has  always  been  regarded  with 
the  greatest  esteem,  and  on  Wednesday  about  two  hun- 
dred and  sixty  of  his  friends  and  pu])ils  honored  him 


by  a  dinner.  In  replying  to  the  toast  of  the  evening 
he  gave  some  extremely  interesting  remarks  on  his 
own  career.  He  has  been  known  to  be  exceedingly 
modest  and  destitute  of  any  self-assertion.  Now  he 
tells  us  that  as  a  child  he  was  shy — so  much  so  as  to 
be  a  misery  to  himself  and  those  about  him.  At  school 
his  master  said  he  needed  a  spur  and  all  his  life  he  has 
found  he  wanted  a  spur.  Let  alone,  he  initiated  noth- 
ing, having  no  ambitions.  He  had  fallen  into  his  ap- 
pointments and  supposed  he  had  been  fit  for  them. 
He  had  fallen  into  several  posts  in  his  life  and  ac- 
cepted the  last  and  highest  reluctantly.  That  was  his 
outer  professional  life  he  said,  but  every  one  had  an 
inner  one  known  only  to  himself.  He  had  had  trou- 
bles which  brought  headaches,  want  of  sleep,  and  all 
that  made  a  man  the  victim  of  his  organization.  He 
had  never  courted  reputation  or  cared  a  straw  for  pub- 
lic opinion.  The  only  thing  he  cared  for  was  the 
respect  of  his  medical  brethren,  so  he  had  the  greatest 
satisfaction  in  having  his  present  position  thrust  upon 
him.  He  said  a  good  deal  more,  but  as  illustrating 
the  man  I  need  only  quote  a  remark  that  as  far  as 
he  knew  only  three  Samuels  were  famous,  viz.,  the 
prophet.  Dr.  Johnson,  and  Mr.  Weller,  Jr. 

Dr.  C.  S.  Roy,  F.R.S.,  professor  of  patholog)'  at 
Cambridge  University,  died  on  Monday,  and  his  fu- 
neral is  to-day.  He  was  only  forty-three  years  old,  and 
had  been  ailing  some  two  years.  He  had  been  direc- 
tor of  the  Brown  Institution,  and  had  worked  there  and 
on  the  continent  before  being  appointed  to  Cambridge. 
His  most  important  researches  were  those  on  the  heart, 
but  he  also  invented  a  number  of  physiological  instru- 
ments, and  he  gave  a  great  impetus  to  scientific  work 
in  his  department  and  enlisted  a  number  of  students 
in  the  great  work  of  research.  There  will  scarcely  be 
a  vacancy  in  the  chair,  as  some  time  ago,  in  conse- 
quence of  his  ill-health.  Dr.  Kanthack  was  appointed 
assistant  professor  and  has  discharged  its  duties. 


OUR    PARIS    LETTER. 

(From  our  Special  Corresp<.»ndent.  I 
I)KCL.AR.\TIOX  OF  EPIDEMIC  DISEASES — TRANSPORTATION 
OF    P.VriENTS    WITH    INFECTIOUS    DISEASES    IN    PUBLIC 

CONVEYANCES THE     NEW     BUILDINGS     AT    THE    SOR- 

BONNE HYDROPHOBI.^ THE   FACULTY  OF    MEDICINE, 

ETC. 

P.vKis,  October  ii,  iSo;. 

There  is  nothing  that  touches  the  public  health  so 
closely  as  the  spread  of  epidemic  diseases.  The 
French  authorities  have  laid  down  explicit  rules  in 
conformity  with  the  law  regulating  the  declaration  of 
contagious  disease  in  the  colonies.  Those  as  ac- 
tually applied  in  Paris  are  now  claiming  attention. 
Differing  somewhat  as  to  detail  from  those  in  force  in 
the  colonies,  they  are  as  follows: 

•■  .\RricLE  15.  Every  doctor,  health  officer,  and  mid- 
wife is  held  to  declare  to  the  public  authority,  as 
soon  as  his  or  her  diagnosis  is  established,  the  follow- 
ing epidemic  diseases  that  may  come  under  observa- 
tion:  typhoid  fever,  exanthematic  typhus,  variola  or 
varioloid,  scarlatina  (scarlet  fever),  diphtheria  (croup 
and  membranous  angina),  suette  miliare,  cholera  and 
choleriform  diseases,  plague,  yellow  fever,  dysentery, 
puerperal  affections  (when  professional  secrecy  with 
reference  to  pregnancy  has  not  been  demanded ),  and 
ophthalmia  of  the  new-born. 

"  Article  21.  The  doctor  of  medicine  or  health  offi- 
cer who  does  not  make  the  declaration  prescribed  by 
article  15  shall  be  punished  by  a  fine  of  from  fifty  to 
two  hundred  francs." 

It  will  be  seen  that  the  list  of  epidemic  and  con- 
tagious diseases,  while  embracing  suette  miliare  or 
sudor  Anglicus,  a  comparatively  rare  disea.se,  omits 
measles,    mumps,    whooping-cough,    and    erysipelas, 


652 


MEDICAL    RECORD. 


[October  30,  1897 


which,  of  almost  daily  occurrence,  are  not  only  con- 
tagious and  infectious  but  epidemic  as  well. 

The  nature  of  the  disease  being  determined  and  the 
declaration  made,  a  question  of  perhaps  even  greater 
importance  at  once  presents  itself.  It  is  this:  The 
transportation  of  patients  affected  with  contagious  dis- 
eases to  the  hospital.  This,  of  course,  should  be  done 
in  wagons  or  ambulances  specially  designed  and  set 
apart  for  such  service,  made  in  such  a  manner  that 
thev  can  be  hermetically  closed  and  thoroughly  dis- 
infected by  means  of  formaldehyde  or  sulphurous  gas 
after  each  trip.  The  public  health  authorities  in  Paris, 
appreciating  the  fact  that  such  patients  leave  behind 
them  the  germs  of  infection  for  other  passengers  that 
mav  come  after  them  when  they  are  transported  in 
public  carriages,  tramways,  or  omnibuses,  have  insti- 
tuted a  special  service  of  this  kind.  Nevertheless 
such  patients  are  still  sometimes  transported  in  ordi- 
nary hired  carriages.  These  should  never  be  allowed 
to  return  without  having  first  been  disinfected  with  an 
atomized  solution  of  sublimate.  .\t  the  Aubervalliers 
Hospital  they  give  the  coachman  an  indemnity  for  the 
time  lost  by  the  disinfection.  There  ought  also  to  be 
a  law  enacted,  as  none,  I  believe,  now  exists  in  Paris, 
against  persons  aware  of  their  condition  using  pub- 
lic carriages  for  transport.  Such  an  act  e.\ists  in  Lon- 
don, and  its  violation  is  punishable  by  a  fine  up  to 
^'40.  In  case  of  urgency  the  occupant  must  notify 
the  coachman  and  indemnify  him,  he  himself  being 
subject  to  a  like  fine  if  he  does  not  immediately  after 
have  his  vehicle  disinfected. 

Speaking  of  public  health,  some  ver\-  interesting 
special  health  mamtuvres  for  the  military  government 
of  Paris  will  take  place  on  October  12th  and  continue 
to  the  16th.  They  consist  of  conferences  to  be  held  at 
the  Bellechasse  barracks  and  the  docks  of  the  sanitary 
service  department,  followed  by  mobilization  and  de- 
parture of  the  sanitary  corps  for  Sartor}-.  During  the 
man(i;uvres  there  will  be  a  march  and  fight  of  a  divi- 
sion between  Versailles  and  Velizy.  The  battlefield 
will  be  illuminated  and  the  wounded  sought  for  dur- 
ing the  night;  there  will  be  a  sanitarj'-service  e.xercise 
or  drill  after  the  combat,  with  functioning  of  the  hos- 
pital of  evacuation  at  the  des  Matelos  station,  the  am- 
bulance leaving  on  the  i6th,  when  there  will  be  a 
rcsum:  of  the  operations. 

The  old  buildings  of  the  Sorbonne,  which  those  who 
have  passed  their  doctorate  at  Paris  will  remember, 
are  about  to  disappear:  in  fact  workmen  have  already 
begun  the  work  of  demolition.  At  the  same  time  the 
new  buildings  are  being  rapidly  put  into  condition 
and  furnished.  t)n  the  5th  of  November  the  amphi- 
theatre of  anatomy  and  the  library  will  be  ready  for 
use.  The  ceiling  of  the  latter  is  by  William  Dubufe 
and  was  in  the  last  .salon  of  the  Champs  de  Mars. 
These  changes  will  take  place  without  any  special 
ceremony  and  tlie  new  buildings  will  be  occupied,  a 
few  rooms  at  a  time,  as  the  work  of  finishing  up  and 
installation  progresses. 

.V  fatal  case  of  hydrophobia  has  just  occurred,  in 
which  it  was  at  first  supposed  that  some  insignificant 
scratch  on  the  hand  of  the  young  girl  who  died  had 
unconsciously  come  into  contact  with  some  object  con- 
taminated by  the  saliva  of  a  dog.  It  turned  out, 
however,  upon  investigation  that  she  actually  had 
been  bitten  about  a  month  ago.  The  bite,  however, 
was  very  slight,  and  as  the  dog  showed  no  symptoms 
of  hydrophobia  no  attention  was  paid  to  it.  The  ani- 
mal had  evidently  been  previously  bitten  by  a  mad 
dog,  and  was  thus  in  a  condition  to  give  hydrophobia 
before  tl-.e  disease  developed  in  him.  This  explana- 
tion accords  fully  with  the  uncertainly  e-xistins;  as  re- 
gards the  incubation  period  of  hydrophobia,  which  is 
always  long,  sometimes  extraordinarily  so. 

Professor  Ravmond  has  issued  the  second  series  of 


his  ■■  lemons'  on  "  Diseases  of  the  Nervous  System,"" 
held  at  the  Salpelriere.  It  is  a  volume  of  the  same  size 
and  scientific  comprehension  as  the  first.  It  is  done 
in  the  author's  masterly  style  and  is  a  continuation  of 
what  is  the  greatest  work  on  diseases  of  the  nervoxis 
system  of  our  day.  Professor  Raymond  will  shortly 
resume  his  work  at  the  Salpetriere  for  the  winter. 

The  Faculty  of  Medicine  has  just  published  the 
regular  programme  and  regulations  regarding  inscrip- 
tions, student  cards,  tmiaux  fraliqius,  etc.  An  inno- 
vation is  the  following,  taken  from  the  text  of  the  reg- 
ulations :  "  Those  students  who  may  desire  the  card  with 
photograph  will  have  the  photograph  pasted  on  the  back 
of  the  card,  which  they  will  subsequently  present  at 
window  No.  4,  on  Mondays  and  Tuesdays  from  twelve 
to  three  o'clock,  for  affixation  of  the  seal  of  the  faculty.'' 
This  detail  is  not  without  its  importance,  and  will 
not  only  prevent  the  loan  or  exchange  of  cards  but 
will  also  serve  as  a  means  of  positive  identification. 


mjedicaX  gtmws. 


Contagious  Diseases— Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitar}-  Bureau,  Health  Department,  for  the 
week  ending  October  23,  1897  : 


Tuberculosis 196 


Typhoid  fever. 

Scarlet  fever 

Cerebro-spinal  meningitis. . . . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup). 
Chicken-pox 


104 
144 


116 

S 


Health  Reports. — The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  super\'ising  surgeon- 
general  of  the  United  States  Marine  Hospital  service, 
during  the  week  ended  October  23,  1897  : 

VtLLOw  Fevkr  — I'mted  States. 

Cases.  Deaths. 

Alabama,  Mobile October  i6th  to  aad 49  7 

Montgomery October  18th  to  20th 1 

Louisiana,  Baton  Rouge October  tSth  to  23d. a  i 

Franklin October  uih  to  21st. 3  i 

New  Orleans  . . .  .(^tober  16th  lo  sad 300  53 

Mississippi,  Bay  St.  Louis  .  .October  17th  to  19th 7  i 

Biloxi October  i6rh  10  22d no  6 

Cayuga October  i6th  to  zad 19  j 

Clinton October  16th  to  22d 16 

Edw-ards October  i6th  to  23d :io  ^ 

McHenry October  16th 1 

Nitta  Yuma October  16th  to  21st 3 

Pascagoula October  iSth  to  aad 13  i 

Scranton October  i6th  to  zad 77  a 

Waveland October  19th a 

c,  Memphis October  22d i 


Yellow  Fevbr — Foreign. 
Cuba,  Cardenas October  2d  to  qth 

Havana (October  ist  to  Mth 

Matanzas September  30th  to  October  2d.. 

Rcgla September  ist  to  14th 

Santiago  de  Caba  ....  October  2d  to  9th 

Sagua  la  Grande October  2d  to  vth 

Jamaica,  Kingston September  i si  to  October  ad  . . 

Cholera— FoRKinN. 

India,  Bombay September  14th  to  21st 

Calcutta Scptcmlx-r  4th  to  nth 

Madras September  nth  to  17th 

Plagi'k— Foreign. 

Ind'a.  Bombay September  14th  to  aiSt 

Small-Pox— United  States. 
Alabama,    Birmingham   and 

suburbs <^ctol>cr  oth  to  16th 

Pennsylvania,  McKeesport.  .October  gth  to  i6th 

rennesscc,  Memphis October  14th 


Small-Pox-Fokeicn. 

Hraxil,  Rio  de  laneiro September  nth  to  aSth 7 

Cuba,  Cienfucgos October  3d  to  loth 

S.igua  la  Grande October  2d  to  9th 30 

India,  Calcutta. September  4th  to  nth 

Russia,  Odessa. September  35th  to  October  ad.       t 

St.  Petersburg September  25ih  to  October  ad.     16 

Warsaw September  25th  to  October  ad .     , . 

Scotland    T.lasgow    September  jsth  to  (Vtober  ad.      17 

Spain,  ^ladrid September  iSth  to  October  asth     . . 


Medical  Record 

A  IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  52,  No.  19. 
Whole  No.  1409. 


New  York,    November    6,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riginal  J^rtic^es. 

EXPERIMENTS    0.\    URIXARY   TOXICITY. 

Bv    M.ARV    PUTNAM    JACOBI,    M.D.. 

AND 

MARY    MITCHELL    KVDD,    M.D.. 

Ten  years  ago  Bouchard  remarked :  "  In  certain  cases 
of  albuminuria,  the  innocuity  of  the  urine  is  remarka- 
ble; the  kidneys  seem  to  have  separated  the  toxic  sub- 
stances from  the  urine,  keeping  them  within  the 
organism."  ' 

In  thirteen  cases  of  nephritis  we  examined  the  tox- 
icity of  the  urine  by  Bouchard's  method,  making  the 
injection,  however,  not  into  the  auricular  vein  of  the 
rabbit,  but  into  the  superficial  jugular.  The  toxicit}- 
was  found  to  be  diminished  in  nine  cases,  increased 
in  five. 

There  is  no  necessary  relation  between  the  toxicity 
of  the  urine  and  the  toxic  condition  of  the  organism 


cases.  Of  healthy  urine,  between  30  and  60  c.c.  per 
kilogram  of  rabbit's  weignt  is  required  to  kill  the 
animal,  the  average  being  45  c.c.  The  following  cases 
show  the  diminished  toxicity  of  albuminous  urines: 

Case  I. — \Yoman,  with  chronic  parenchymatous 
nephritis;  albumin,  one-fifth  the  volume  of  urine  in 
the  test  tube.  Amount  of  day  urine,  585  c.c.  The 
urine  was  allowed  to  run  into  the  superficial  jugular 
vein  of  a  rabbit,  from  a  burette,  at  the  rate  of  10  c.c. 
per  minute.  The  rabbit  weighed  2,450  gm.,  and  suc- 
cumbed when  205  c.c.  had  been  introduced.  Thus 
83.67  c.c.  would  have  been  required  to  poison  1,000 
gm.  The  urinar}'  toxicity  was  represented  by  the  fig- 
ure 83.67,  one-seventh  quantity  of  day  urine.  As  the 
weight  of  the  patient  was  not  known,  nor  the  amount 
of  urine  for  the  entire  twenty-four  hours,  the  urotoxic 
coefficient  could  not  in  this  case  be  determined.  The 
following  tracing  shows  the  amplification  and  slo\vir>g 
of  the  respiration  which  immediately  followed  the  in- 
jection. The  respirator}-  movements  were  collected 
by  means  of  a  Marey  drum  attached  to  the  thorax  and 
communicating  in  the  usual  way  with  a  second  drum, 
lever,  and  revolving  cvlinder.     Mvosis  began  after  the 


Before  injection. 


from  which  the  urine  is  derived.  "The  unity  of  tox- 
icity or  urotoxic  [I  again  quote  from  Bouchard]  is  the 
quantity  of  toxicity  (toxic  substance)  necessary  to  kill 
a  kilogram  of  a  living  organism." 

The  urotoxic  coefficient  is  the  quantity  of  urotoxic 
which  a  kilogram  of  human  tissue  can  produce  in 
twenty-four  hours.  Thus:  "A  healthy  man  of  60 
kgm.  excretes  in  twenty-four  hours  1,200  c.c.  of  urine. 
If  50  c.c.  of  this  urine  kill  1,000  gm.  or  i  kgm.  of  ani- 
mal tissue,  1,200  c.c,  or  the  whole  amount,  will  kill  24 
kgm.  Thus:  60  kgm.  of  human  tissue  produce  and 
eliminate  in  twenty-four  hours  enough  toxic  material 
to  kill  24  kgm.  of  animal.  Therefore  i  kgm.  of  tlie 
human  tissue  produces  J^  of  this,  or  (j,^j  0.4  kgm. 
of  animal,  or  400  gm.  The  average  coefficient  de- 
duced from  observation  of  a  sufficient  number  of 
healthy  individuals  is  0.464;  or,  in  other  words,  1 
kgm.  of  healthy  human  tissue  should  in  twenty-four 
hours  produce  enough  toxic  substance  to  kill  464  gm. 
of  living  matter,  as  contained  in  the  organism  of  the 
rabbit."  ' 

The  toxicity  of  the  organism  can  be  estimated  from 
thit  of  the  urine  only  if  the  kidneys  are  in  a  condition 
normally  to  perform  their  work  of  elimination. 
H-nce,  under  circumstances  which  imply  that  the  usual 
amount  of  toxin  is  being  elaborated  in  the  organism, 
diminution  in  the  urinary  toxicity,  like  marked  dimi- 
nution in  the  amount  of  urea,  itself  suffices  to  suggest 
inadequacy  in  the  secreting  mechanism  of  the  renal 
glands. 

This  inference  is  confirmed  by  the  diminished  tox- 
icity of  the  urine  in  so  large  a  number  of  albuminuria 

'  "  Le9ons  sur  les  .\uto-Into.\ications."  p.  27.   l'a-i<.   i""" 
'  Loc.  cit..  p.  3S. 


Injection  be^n.  Immediate  amplification  and  reUu'dati.:>n  of  respirations.  -  Respirations,   76. 

Kic.  I  (Case  I.l. 

injection  of  lo  c.c.  E.xophthalmos  begin  after  1 15  c.c 
There  was  no  convulsion  until  that  which  immediately 
preceded  death.  This  confirms  the  statement  of  Bou- 
chard that  the  day  urine  contains  narcotic  substances, 
but  not  those  which  tend  to  produce  convulsions. 

Case  II. — Slight  trace  of  albumin.  L'rea,  23.56 
gm.  L'rine  scanty  and  dark,  760  c.c.  A  rabbit 
weighing  1,000  gm.  was  killed  with  93  c.c.  of  urine. 
The  patient  weighed  70  kgm.,  and  the  calculated  uro- 
toxic coefficient  was  o.  1 16. 

In  this  case  there  were  very  few  symptoms  of  renal 
disease  and  the  amount  of  urea  was  fairly  adequate, 
but  the  low  toxicity  of  even  scanty  and  concentrated 
urine,  and  the  very  low  urotoxic  coefficient,  indicated 
more  renal  inadequacy  than  would  have  been  other- 
wise suspected.  The  patient's  mother  had  died  of 
Bright's  disease  a  few  months  previous  to  the  obser\'a- 
tion. 

Case  III. — Parenchymatous  nephritis.  Much  al- 
bumin in  urine.  Night  urine,  475  c.c.  The  toxicity 
was  represented  by  88  c.c.  per  1,000  gm.  of  rabbit. 
The  injection  was  followed  by  a  series  of  convulsions, 
the  first  beginning  when  25  c.c.  had  been  injected; 
the  seventh  after  164  c.c.  had  been  injected  (the  rabbit 
weighing  1,860  gm.),  and  followed  by  death.  Myosis 
began  with  30  c.c,  and  the  pupil  was  contracted  to  a 
pin  point  at  142  c.c. 

The  case  illustrated  the  specially  convulsive  proper- 
ties of  night  urine. 

Case  IV. — Man,  weighing  75  kgm.  The  urine 
was  only  slightly  albuminous,  but  contained  granular 
casts.  The  toxicity  of  the  mixed  urine  was  just  be- 
low the  normal  minimum,  but  the  urotoxic  coefficient 
was  decidedly  diminished,  0.301. 


654 


MEDICAL    RECORD. 


[November  6,  1897 


Bouchard  says  that  the  toxicity  of  the  mixed  urines 
may  easily  appear  too  low,  because  the  opposing  toxic 
principles  of  the  day  and  night  urines  may  partly  neu- 
tralize each  other.  The  precaution  of  separating  the 
two  was  unfortunately  not  obser\'ed  in  this  case. 

Case  V. — Advanced  case  of  chronic  interstitial 
nephritis.  Patient  much  emaciated.  Weight,  about 
no  lbs.,  or  55  kgm.  Trace  of  albumin  in  day  urine: 
amount,  960  c.c. ;  specific  gravity,  1.005;  urea,  2.88 
gm.  In  night  urine,  urea,  5.965  gm. ;  quantity,  1,193 
gm.  Total  quantity,  2,153  c.c.  Total  quantity  of 
urea,  8.845  S™-  With  day  urine,  221  c.c.  were  re- 
quired to  poison  1,000  gm.  of  rabbit,  and  there  was 
only  one  slight  convulsion,  the  animal  dying  with 
arrest  of  respiration  without  tetanus.  With  the  night 
urine  the  toxicity  was  174,  and  there  were  several  con- 
vulsions. The  urotoxic  coefficent,  calculated  on  the 
average  toxicity  of  the  total  urine,  was  0.208.  The 
toxicity  of  either  day  or  night  urine  was  less  than  that 
of  pure  water,  of  which  90  c.c.  per  kilogram  of  animal 
is  fatal.  The  toxicity  of  the  day  urine  was  less  than 
that  of  the  night,  a  circumstance  which  Teissier  calls 
"  a  paradoxal  character,"  and  to  which  he  attaches 
considerable  importance.  He  had  observed  it  in  five 
out  of  twenty  cases. ' 

Case  VI. — Examinations  of  the  urine  of  this  pa- 
tient were  made  on  several  occasions  and  under  in- 
teresting circumstances.  Previous  to  the  fall  of  1893, 
the  patient  had  been  in  apparently  good  health,  but 
had  had  several  pregnancies,  which  terminated  either 
prematurely  after  a  prolonged  discharge  of  watery 
fluid  from  the  uterus,  or  in  the  birth  of  a  child  which 
lived  only  a  few  hours.  In  the  fall  of  1893  the  pa- 
tient began  to  suffer  from  headaches  and  from  inde- 
finable malaise.  There  was  at  the  time  no  albumi- 
nuria, but  two  or  three  hyaline  casts  in  a  minute  urinary 
sediment  were  obtained  by  the  centrifuge.  Under  a 
milk  diet  the  headaches  disappeared  and  the  patient 
felt  perfectly  well.  The  urine  was  tested  for  toxicity 
as  follows:  The  patient  then  being  on  an  exclusively 
milk  diet,  with  the  addition  of  lithia  water,  the  total 
amount  of  urine  was  1,440  c.c;  the  amount  of  urea, 
34.56  gm.,  as  calculated  from  the  nitrogen.  The 
morning  urine  was  u.sed  for  the  injection,  and  the 
toxicity  per  kilogram  of  rabbit  was  104.34. 

On  November  8th,  after  the  patient  had  been  for  a 
week  on  an  ordinary  mixed  diet  including  meat,  the 
amount  of  urine  was  810  c.c;  of  urea,  17.82  gm.,  al- 
most exactly  half  the  amount  excreted  on  milk  diet. 
The  urine  submitted  to  the  centrifuge  contained  three 
hyaline  and  one  epithelial  casts,  but  no  albumin.  Its 
specific  gravity  was  1.020.  The  morning  urine  (390 
c.c.  in  quantity)  was  again  used  for  the  injection,  and 
showed  a  toxicity  of  97.7. 

On  November  15th,  after  a  second  week  of  mixed 
diet,  the  amount  of  urine  was  795  c.c;  of  urea,  19.875 
gm.  The  specific  gravity  of  the  day  urine  was  1.025  ; 
of  the  night  urine,  1.026,  with  an  abundant  deposit  of 
urates.  The  toxicity  of  the  day  urine  was  38.13,  a 
figure  within  the  normal  range.  The  patient  was  feel- 
ing bad. 

January  24,  1895,  aljout  twenty-seven  months  later, 
the  patient  was  two  weeks  pregnant,  and  the  urine  was 
examined  again.  The  amount  was  1,283  c.c. ;  specific 
gravity,  i.oii.  No  albumin  or  casts.  The  amount 
of  nitrogen  was  0.024  nigm.  to  i  c.c,  which,  if  attrib- 
uted entirely  to  urea,  would  imply  30.792  gm.  But 
when  leucomains  had  first  been  precipitated  by  phos- 
pho-tungstic  acid,  the  nitrogen  estimated  in  the  filtrate, 
and  the  urea  again  calculated,  the  amount  was  only 
13.471  gni.  The  toxicity  of  tlie  urine  was  73  per 
1. 000. 

The  urotoxic  coefficient  was  0.230  (normal,  0.464). 

If  the  amount, of  urine  required  to  kill  1,000  gm.  of 

'  Comptes  RcruUis  .\cad.  des  Sciences.  iSSS,  7,107,  p.  172. 


rabbit  tissue  be  compared  in  these  four  cases  with  the 
amount  of  urine  eliminated  in  twenty-four  hours,  fur- 
ther significance  may  be  attached  to  the  figures;  thus: 

October,  1893,  milk  diet:  Amount  of  urine,  1,440 
c.c;  toxicity  per  1,000,  104.34.  Proportion  to 
amount,  i  to  13. 

November  8,  1893,  meat  diet:  Amount  of  urine,  810 
c.c;  toxicity  per  1,000,97.7.  Proportion  to  amount, 
I  to  8.35. 

November  15,  1893,  mixed  diet :  Amount  of  urine, 
795  c.c;  toxicity  per  1,000,  39.13.  Proportion  to 
amount,  i  to  20. 

January,  1895,  mixed  diet,  pregnancy  of  two  weeks: 
Amount  of  urine,  1,283  ^-C-;  toxicity  per  1,000,  73. 
Proportion  to  amount,  1  to  17.57. 

In  other  words,  the  poisonous  dose  of  the  urine  was 
one-eighth,  one-thirteenth,  one-seventeenth,  or  one- 
twentieth  of  the  whole  amount.  The  poisonous  qual- 
ities of  the  urine  were  evidently  inversely  proportional 
to  these  figures,  the  urine  being  most  highly  toxic 
when  only  one-twentieth  of  its  total  quantity  was  re- 
quired to  kill  the  kilogram  of  rabbit  tissue,  and  least 
toxic  when  one-eighth  of  its  amount  was  required. 

The  two  observations  were  made  at  only  a  week's 
interval.  But  on  November  8th  the  patient,  although 
eating  meat,  was  still  under  the  influence  of  the  milk 
diet,  which  had  only  just  been  interrupted  and  which 
had  suited  her.  On  the  meat  or  mixed  diet  the  quan- 
tity of  urine  had  greatly  diminished,  and  this  seems 
to  have  been  the  reason  why  the  toxicity  of  the  urine, 
though  aljnormally  low,  was  expressed  by  so  high  a 
proportion  of  the  total  amount.  But  the  elimination 
of  toxins  was  evidently  inadequate,  and  at  the  end  of 
the  second  week  the  patient  was  beginning  to  feel  verj' 
badly.  At  this  time,  however,  the  toxicity  of  the  urine 
had  risen  to  normal.  But  apparently  this  was  due  to 
the  large  quantity  of  toxins  accumulating  in  the  or- 
ganism under  the  meat  diet,  and  not  to  any  increase 
in  the  adequacy  of  the  eliminative  processes,  so  that 
there  was  reason  to  believe  that  more  poison  was 
formed  in  the  body  than,  with  diminished  quantity  of 
urine,  was  carried  out  of  it.  The  patient  was  feeling 
very  badly,  and  was  relieved  only  upon  return  to  the 
milk  diet  and  by  the  attendant  diuresis. 

It  was  the  diminished  toxicity  of  urine  in  this  case 
which  first  suggested  the  diagnosis  of  an  interstitial 
nephritis.  The  diagnosis  was  remarkably  confirmed 
by  the  subsequent  evolution  of  the  case,  thus : 

May,  1895,  cedema  of  feet;  attack  of  angina  pecto- 
ris. Later,  attacks  of  dizziness  and  numbness  of 
tongue.     Pregnancy  continues. 

September,  1895,  ura-mic  attack  indicated  by  thick 
speech,  giddiness,  temporary  right  hemiparesis;  face 
puffy;   albuminuria. 

October,  1895,  face  puffy,  albuminuria  increased, 
granular  and  epithelial  casts  in  urine,  marked  systolic 
murmur  over  tricuspid  valve,  dulness  of  right  ventri- 
cle encroaches  on  sternum. 

On  October  6th  confined  of  a  very  small  child, 
which  was  completely  cyanosed  and  breathed  six  hours. 
The  placenta  was  markedly  atrophied. 

.\fter  delivery  the  patient  suftered  for  a  while  from 
redema  of  the  lower  extremities :  then  this  disappeared, 
as  also  the  albuminuria.  The  patient  considered  her- 
self well,  and  again  became  pregnant.  This  time  the 
pregnancy  ran  its  course  without  unvmic  accidents. 
At  six  months  tiie  urine  contained  no  albumin,  but 
granular  and  epithelial  casts.  .\t  seven  months  an 
abundant  albuminuria  supervened  and  iiome  ivdema 
of  the  feet.  However,  the  pregnancy  continued  to 
term,  and  this  time  a  healthy  child  was  born,  which. 
five  months  after  birth,  still  survives.  'I'wo  weeks  after 
confinement,  however,  the  mother  had  a  severe  attack 
of  (li)ul>le  phlebitis,  then  an  attack  of  pvelitis,  during 
which  the  urine  became  almost  solid  with  pus.     After 


November  6,  1897] 


MEDICAL    RECORD. 


655 


four  months'  severe  illness  she  finally  recovered,  but 
with  persistent  albuminuria. 

In  other  cases  of  undoubted  nephritis  the  toxicity  of 
the  urine  was  diminished  on  one  occasion  and  in- 
creased on  another. 

Case  VII. — March  28th,  night  urine,  830  c.c,  very 
albuminous;  6.225  gm.  urea  (as  per  nitrogen).  Tox- 
icity, 63.91.  Day  urine  of  same  date,  415  c.c.  Total, 
1,245  c.c.  Much  albumin.  Urea,  17.0525.  Toxic- 
ity, 68.  But  on  March  27th  the  toxicity  of  the  day 
urine  had  been  11.32 — an  enormous  increase.  The 
patient  had  been  taking  no  medicines. 

Case  VIII. — Nephritis  of  seven  years'  standing; 
neuroretinitis;  abundant  albuminuria;  granular  casts. 
March  8th,  amount  of  urine,  2,500  c.c;  toxicit}',  135 
to  1,000 — a  marked  decrease  as  thus  estimated,  but 
less  marked  in  proportion  to  the  large  quantity  of 
urine  secreted.  The  proportion  for  poisoning  to  the 
whole  amount  is  i  to  18. 

On  March  6th  the  conditions  were  apparently  the 
same — the  amount  of  urine,  2,500  c.c;  of  urea,  25 
gm.;  the  specific  gravity,  i.oio;  the  toxicity  was  16 
c.c.  per  1,000  gm.  of  rabbit.  Convulsive  twitchings 
began  when  only  16  c.c.  of  urine  had  been  injected, 
and  at  30  c.c.  a  violent  convulsion  occurred,  wliich 
proved  fatal  in  twenty  seconds.  The  rabbit  weighed 
2,250  gm. ;  YTS  P^"^  °f  the  total  amount  of  urine  se- 


kilogram,  which  in  itself  would  be  normal.  But  com- 
parison with  the  total  amount  of  urine  and  the  body 
weight  of  the  patient  yielded  a  urotoxic  coefficient  of 
0.722,  showing  an  enormous  increase  in  the  amount  of 
toxic  material  elaborated  by  this  patient's  organism 
and  eliminated  in  consequence  of  the  polyuria.  This 
fact  is  especially  interesting  in  view  of  the  small  ex- 
cretion of  nitrogen  and  urea.  The  toxicity  of  the  urine 
and  its  urea  bore  no  proportion  to  each  other,  and  the 
moderate  percentage  of  toxic  material  in  the  urine  was 
overcom  pen  sated  by  the  e.\cessive  amount  of  urine.' 

It  seems  probable  that  the  deficiency  of  urea  was 
due  to  an  extensive  destruction  of  the  renal  epithe- 
lium, and  that  effete  matter  which  failed  to  be  elimi- 
nated as  urea  accumulated  in  the  organism  in  more 
toxic  forms.  This  accumulation  may  be  considered 
as  the  probable  cause  of  the  diuresis,  since  a  paren- 
chymatous nephritis  of  two  months'  duration  is  not 
likely  to  be  associated  with  such  local  rise  of  arterial 
tension  in  the  kidney  as  occurs  in  chronic  interstitial 
nephritis  on  account  of  the  destruction  of  many  Mal- 
pighian  bodies. 

The  conditions  were  in  instructive  contrast  with 
those  of  the  chronic  interstitial  nephritis  of  Case  V. 
Here  the  prolonged  disease  had  so  depressed  nutritive 
metabolisms  that  little  toxic  material  was  elaborated 
in  the  organism;  the  urine  was  scarcely  more  toxic 


creted  by  the  patient  in  twenty-four  hours  was  sufficient 
to  poison  I  kgm.  of  animal  tissue. 

In  the  next  three  cases  either  the  toxicity  or  the 
urotoxic  coefficient  of  the  urine,  instead  of  being  di- 
minished, was  increased. 

C.\SE  IX.— Chronic  diffuse  nephritis.  The  amount 
of  day  urine  was  450  c.c,  albuminous,  with  a  specific 
gravity  of  1.015.  The  urea  was  not  diminished,  />., 
if  all  the  nitrogen  expressed  urea,  the  quantity  per 
cubic  centimetre,  being  0.027,  would  correspond  to 
12.15  g'"-  ^"  the  day  urine  alone.  But  of  this  urine 
14.4  c.c.  sufficed  to  poison  a  kilogram  of  rabbit.  It  is 
probable  that  this  high  toxicity  was  due  to  the  dimi- 
nution in  quantity  of  the  urine  and  consequent  concen- 
tration of  its  toxic  qualities. 

Case  X. — Chronic  parenchymatous  nephritis  in  a 
patient  weighing  82.5  kgm.,  and  taking  0.004  of  bi- 
chloride of  mercury  three  times  a  day.  The  total 
amount  of  urine  e.Kcreted  was  2,040  c.c;  of  urea, 
26.52  gm.  When  only  5  c.c.  of  urine  had  been  in- 
jected into  the  jugular  vein  of  a  large  rabbit,  convul- 
sions ensued — that  is  to  say,  after  an  exceptionally 
small  quantity.  The  pupil  dilated  before  contracting; 
myosis  set  in  only  after  the  injection  of  66  c.c.  Fifty- 
two  cubic  centimetres  of  urine  per  kilogram  sufficed  to 
kill  the  rabbit,  which  is  an  amount  within  the  normal 
limits,  and  would  seem  to  imply  that  the  minute  quan- 
tity of  corrosive  sublimate  ingested  had  had  no  toxic 
influence.  But  the  urotoxic  coefficient  was  slightly 
increased,  being  0.475  instead  of  0.464  (see  cut). 

Case  XI.  —  Nephritis,  two  months'  standing. 
Urine,  2,600  gm.  Specific  gravity,  1.007.  Albumin, 
casts;  nitrogen,  0.005;  uft:^,  13  gm.  The  rabbit's 
respiration  was  markedly  slowed  almost  immediately 
after  the  injection,  but  the  pupil  did  not  contract  at  all. 
Tiie  urinary  toxicity  was  represented  by  50.98  c.c.  per 


than  water,  and  the  urotoxic  coefficient  was  half  the 
normal. 

In  Case  X.  the  destruction  of  the  eliminating  ap- 
paratus had  been  effected  with  relative  rapidity  while 
nutritive  metabolisms  were  active,  and  toxic  material 
abundantly  accumulated  in  the  organism. 

Case  XII. — Chronic  pyelitis  of  the  right  kidney  of 
many  years'  standing,  habitually  attended  with  few 
subjective  symptoms,  though  the  urine  was  loaded  with 
pus.  Total  amount,  760  c.c.  Toxicity,  82.60  c.c. — 
thus  decidedly  diminished.  The  pus  was  filtered  off 
before  the  rabbit  injection  was  made.  The  urotoxic 
coefficient  was  0.105,  thus  markedly  diminished.  In 
this  experiment  the  respiration  of  the  rabbit  became 
accelerated,  in.stead  of  slackened  as  usual.  There 
was  no  convulsion  until  57  c.c.  had  been  injected,  and 
no  myosis  till  just  before  death. 

Eight  days  later,  immediately  after  the  patient  had 
suffered  a  severe  attack  of  renal  colic,  and  when  she 
was  on  a  milk  diet  and  taking  lithiated  hydrangea, 
the  urine  was  examined  again.  .An  abundance  of 
pus  was  found  in  the  urine;  total  amount  of  urine,. 
1,3150.0.;  toxicity,  100.4  per  1,000  gm.  of  rabbit;  uro- 
toxic coefficient,  0.148.  Thus  this,  as  well  as  the 
toxicity,  was  markedly  diminished.  The  toxicity  of  the 
urine  was  almost  the  same  as  that  of  Case  V.  with  in- 
cipient nephritis,  in  which  the  patient  was  also  on 
milk  diet,  and  passed  in  consequence  a  large  amount 
of  urine  (1,440  c.c). 

'  .Seventy-eight  c.c.  of  urine  killed  a  rabbit  weighing  1,530 
grams.  Thus:  i,  530  :  7S  ::  1,000 :  .r  =50.92,  the  amount  of 
urine  required  to  kill  1,000  grams.  2. 600 c.c. ,  passed  in  twenty- 
four  hours,  would  kill  as  many  kilograms  of  rabbit  as  50.92  could 
be  contained  in  2,600  =  51,  or  5i,o<x)  grams.  .Vs  this  amount 
was  elaborated  by  a  man  weighing  66  kilograms,  i  kilogram  of 
his  body  would  kill  H^Pif*  —  0.772  kilogram,  the  urotoxic  coeffi- 
cient. 


656 


MEDICAL    RECORD. 


[November  6,  1897 


It  is  noticeable  that  although  the  percentage  of  tox- 
icity was  lower  in  the  second  than  in  the  first  experi- 
ment with  the  same  patient,  the  urotoxic  coefficient 
was  higher.  Toxic  elimination  was  actually  increased, 
but  the  increased  diuresis  reduced  the  percentage  of 
urinary  toxicity. 

A  milk  diet,  by  cutting  off  the  important  source  of 
urinary  toxins  contained  in  meat,  is  expected  to  dimin- 
ish the  toxicity  of  the  urine,  not  only  relatively  but 
absolutely.  But  if  the  urotoxic  coefficient  be  higher, 
we  must  infer  either  that  on  the  milk  diet  nutritive 
metabolisms  had  been  increased  and  a  greater  quan- 
tity of  toxins  elaborated  in  the  organism,  which  com- 
pensated for  the  privation  of  meat  toxins;  or  that 
elimination  had  been  increased,  the  tissues  more  thor- 
oughly washed  out,  the  result  being  expressed  in  the 
larger  quantity  of  urine  secreted. 

This  patient,  in  the  intervals  of  acute  exacerbations 
of  her  chronic  pyelitis,  considered  herself  quite  well. 
The  first  of  the  above  observations  was  made  five  days 
after  a  severe  attack  of  acute  renal  colic ;  the  second, 
three  days  later  and  at  the  beginning  of  an  illness 
prolonged  several  weeks,  and  attended  with  such  tume- 
faction in  the  region  of  the  affected  kidney  as  in- 
dicated a  perinephritis.  The  diminished  toxin 
elimination  coincided  with  a  period  of  acute  renal 
inadequacy  grafted  on  the  chronic  disease  which  lay 
outside  the  secreting  apparatus.  No  opportunity  was 
afforded  to  examine  the  urine  at  a  time  when  the  pa- 
tient was  free  from  subjective  symptoms.  Three 
years  from  date,  and  after  a  prolonged  residence  in 
Bermuda,  she  claims  to  be  in  good  health,  though  the 
pyuria  persists  as  before. 

Case  XIII. — Symptoms  indefinite.  Square-topped 
sphygmographic  trace  of  litha;mia,  with  a  maximum 
developed  under  pressure  of  9  oz.  Urine  (lithia  med- 
ication), 1,170  c.c.  Total  urea,  14  gm.  No  albumin; 
some  broken  granular  casts;  large  renal  cells;  many 
leucocytes.  Specific  gravity,  1.015.  Urinary  toxicity, 
64.5  I,  or  just  below  Bouchard's  minimum.  The  pa- 
tient returned  to  Texas,  and  the  evolution  of  her  case 
is  not  known. 

The  following  cases  did  not  present  symptoms  of 
renal  disease,  but  more  or  less  pronounced  indications 
of  litha^mia: 

Case  XIV. — Woman,  sixty  years  old,  living  on  milk 
and  grape  diet.  Pupil  of  injected  rabbit  dilated  niark- 
■edly  before  myosis  set  in.  Urine  fatal  at  145  c.c.  per 
kilogram;  urotoxic  coefficient,  0.231 — about  half  the 
^normal.  This  may  be  attributed  to  the  diet,  upon 
which  the  patient  was  thriving.  A  diagnosis  of  myo- 
carditis had  been  made  three  months  previously. 

Case  XV. — Had  suffered  from  musca;  volitantes; 
otherwise  robust.  Urine  albuminous;  urea,  2  1.90  gm., 
but  urinary  toxicity,  84.  Myosis  was  not  induced  in 
rabbit  till  68  c.c.  had  been  injected. 

Case  XVI.  —  Hysteria  and  lithtemia,  frequent  head- 
aches. Urine  scanty,  but  not  at  all  high  colored; 
amount  only  550  c.c.  Nitrogen,  0.009  P^^  cubic  cen- 
timetre. Urea,  4.95.  The  urinary  toxicity  was  62, 
only  slightly  diminished — diminution  not  in  any  way 
proportionate  to  the  diminution  in  the  amount  of 
urea.  This  fact,  taken  together  with  the  symptoms  of 
auto-intoxication  frequently  presented  by  the  patient, 
implies  that  the  same  perversion  of  metabolism  (per- 
haps especially  in  the  liver)  which  lessened  the  forma- 
tion of  urea  had  increased  the  formation  of  other  toxic 
excretory  material. 

The  urine  of  one  diabetic  i^atient  was  examined 
with  peculiar  results: 

Case  XVII. — The  woman  was  enormously  stout, 
weighing  200  lbs.  The  glycosuria  was  moderate,  had 
lasted  only  a  short  time.  The  patient  suffered  from 
loss  of  strength  and  constant  thirst,  but  no  Inilimia. 
The  amount  of  urine  passed  was  2,880  c.c,  witii  37.44 


gm.  of  urea.  Into  the  jugular  vein  of  a  rabbit  weigh- 
ing 1,320  gm.  was  injected  185  c.c.  of  urine  without 
causing  immediate  death;  the  urinary  toxicity  being 
thus  less  than  140  c.c.  per  kilogram  of  animal.  Mod- 
erate convulsions  occurred  at  the  beginning  of  the  in- 
jection, but  none  after  19  c.c,  and  no  myosis  occurred 
till  150  c.c.  had  been  injected.  But  when  the  injec- 
tion was  interrupted,  signs  of  pulmonary  congestion 
had  appeared,  and  the  animal  was  found  dead  the 
next  day.     The  lungs  were  intensely  congested. 

As  there  was  no  renal  disease,  the  defect  in  the 
urinary  toxicity  must  be  attributed  to  defective  elabo- 
ration in  the  normal  toxins  of  the  organism,  or  at  least 
to  a  defect  in  their  elaboration  into  such  forms  as 
would  seek  elimination  by  the  kidneys.  The  normal 
convulsibility  of  the  urine  may  have  been  neutralized 
by  an  unusual  proportion  of  narcotic  toxins,  which  did 
not  tend  to  kill  the  animal  directly,  but  indirectly 
through  pulmonary  congestion. 

Case  XVIH. — The  urine  was  examined  in  one  case 
of  epilepsy,  thirty-six  days  after  one  attack  and  twenty- 
four  days  before  another.  The  patient  was  taking  bro- 
mide of  lithium  and  chiefly  milk  diet,  and  the  amount 
of  urine  was  1,331  c.c.  The  injection  caused  only 
slight  convulsions  in  the  rabbit,  but  very  abundant 
diuresis.  The  toxicit)'  of  the  urine  was  expressed  by 
120  c.c.  per  kilogram — half  the  normal  minimum. 
The  urotoxic  coefficient  was  0.170.  No  opportunity 
was  afforded  to  examine  the  urine  just  before  or  after 
an  attack. 

Fe're','  examining  a  series  of  epileptic  patients, 
found  that  the  urine  just  before  the  paroxysm  gave 
an  excessive  urotoxic  coefficient  in  seven  out  of 
eight  cases.  However,  in  five  out  of  the  eight  cases 
the  urotoxic  coefficient  remained  excessive  also  after 
the  paro.xysm.^  In  these  cases  the  paroxysms  were  so 
frequently  repeated  that  there  was  no  reason  to  sup- 
pose an  intermittent  accumulation  of  toxins  in  the 
organism  as  a  cause  of  the  attack — rather  a  condition 
of  chronic  hypertoxicity,  possibly  due  to  intestinal 
fermentations,  not  relieved  by  the  convulsive  attacks 
or  coincident  with  them,  but  persisting  as  the  attacks 
recurred. 

Deny  and  Chauppe  found,  in  ten  out  of  thirteen  epi- 
leptic patients,  a  moderate  diminution  of  urinary  tox- 
icity, represented  by  60,  80,  90  c.c.  required  as  fatal 
doses.  But  the  amount  of  urine  was  so  much  increased, 
that  the  urotoxic  coefficient  did  not  greatly  differ  from 
normal.  In  another  patient,  who  passed  only  750  c.c. 
of  urine,  this  proved  fatal  at  a  dose  of  20  c.c.  per  1,000 
kgm.  of  rabbit.' 

Voisin  examined  the  urine  of  epileptic  patients  sub- 
ject to  attacks  in  series.  He  found  that  the  urine  was 
hypotoxic  before  and  during  the  series,  but  that  the 
toxicity  rose  and  exceeded  the  normal  if  the  series  had 
really  terminated,  but  failed  to  do  so  if  further  attacks 
were  destined  to  occur.  The  examination  of  the  urine 
by  this  method,  therefore,  offered  important  data  for 
the  prognosis.  When  the  epileptic  patients  had  be- 
come demented,  the  urine  was  constantly  hypotoxic. 

Chambulent '  showed  that  the  serum  of  the  blood 
became  more  and  the  urine  less  toxic  during  a  series  of 
epileptic  attacks. '  "  When  albuminuria  coexists," 
observes  Voisin,  "the  elimination  of  toxins  is  slack- 
ened, and  their  accumulation  may  become  as  danger- 
ous as  in  acute  infectious  diseases.  The  itat  de  mat 
is  established,  and  the  temperature  rises." 

Lanoine  compares  epileptic  crises  to  the  crisis  which 
marks  the  decline  of  an  infectious  disease."     "  Aulo- 

'  Comptes  Kendus  Soc.  Biol.,  1S90. 
■  Ibid. 

^  IbiJ.,  November  30,  iSSg. 
*  Ibid.,  Kebruary,  iSg2. 

'•  In   1807  Ilerter  showed  the  s-imc  thing  in  regard  to  attacks 
of  puerperal  ecl.impsia.     (Trans.  .\.  Y.  .\cad.  Medicine,  1897.) 
H'.az.  des  Hop..  lS8q. 


November  6,  1897] 


MEDICAL    RECORD. 


657 


intoxication  is  the  principal  element  of  the  paroxysmal 
attack,  but  the  auto-intoxication  is  favored  by  the  con- 
dition of  the  ner\-ous  system,  which  is  defective 
through  heredity  or  acquired  deterioration."  ' 

A  few  experiments  were  made  with  the  urine  of  wo- 
men immediately  after  their  confinement,  on  the  sup- 
position that  the  processes  of  tissue  involution  would 
throw  a  large  amount  of  detritus  into  the  circulation, 
whose  ultimate  products  would  be  eliminated  with  the 
urine  and  thus  increase  its  toxicity.  The  few  experi- 
ments made,  however,  showed  that  this  condition  of 
hypertoxicity  was  insufficient  to  counteract  the  effect  of 
the  low  diet  of  the  puerperal  regime;  or  else  that  such 
elimination  did  not  become  active  before  the  sixth 
day.  For  convenience  these  facts  are  thrown  together 
in  the  following  table: 


I        Day  after      I  Urinary  Tonicity  |  uroto:tic  C«fficient. 
Confinement.        per  Kilogram.     1 


Case    II 

Third.            , 

92 

o.r79 

Case  III 

Fifth. 

96.5 

0.23S 

Case  IV  .   Albu- 

Second. 

86.16 

No     u  r  s  m  i  c 

min  ;    casts; 

-Si.'cth. 

29 

symptoms. 

urea,       7-29; 

Seventeenth. 

34.61 

milk  diet. 

Case      V 

Third. 

Si 

In  the  fourth  case  the  rise  of  toxicity  on  the  sixth 
day  to  a  little  above  the  normal  minimum  was  all  the 
more  noteworthy  because  the  urine  was  albuminous,  a 
condition  habitually  associated  w  ith  hypotoxicity  ;  and 
because,  on  account  of  the  albuminuria,  the  patient 
had  not  been  restored  to  the  usual  mixed  diet,  but  was 
living  exclusively  on  milk  diet. 

In  three  women  obsened  just  before  confinement, 
the  urine  was  hypotoxic.  Of  these  the  first,  the  albu- 
minuria patient  of  the  preceding  table,  was  on  a  milk 
diet;  the  others  were  on  ordinary  mixed  diet. 


Case      I  . . . . 

Case    II 

Casein.... 

Two    days    before 
confinement. 

Three  days  before 
confinement. 

Fifteen  days  before 
confinement. 

Urinary     tox- 
icity, 94  per 
kilogram. 
6S 

97.7 

Two   days  after, 
toxicity,  86.16. 

Three  days  after, 
toxicity,  92. 

The  injection  of  the  last  patient's  urine  into  the 
jugular  vein  of  a  female  rabbit  caused  the  latter  to 
abort  of  three  young  animals  nearly  at  term,  of  whom 
two  were  alive  and  lived  for  fifteen  hours.  Only  30 
c.c.  of  urine  had  been  injected  when  the  abortion 
occurred. 

Abortion  is  not  a  necessary  consequence  of  the  in- 
jection of  such  a  small  amount  of  urine,  for  after  the 
death  of  a  rabbit  killed  with  a  much  larger  amount 
five  foetuses  have  been  found  in  the  uterus  of  the 
mother.  It  would  seem,  therefore,  that  the  abortion  in 
the  above  case  was  due  to  the  specific  action  on  the 
uterine  spinal-cord  centres  of  a  toxin  contained  in  the 
urine,  and  not,  as  might  plausibly  be  supposed,  to  a 
simple  mechanical  disturbance  of  the  circulation. 

The  diminished  toxicity  of  the  urine  during  preg- 
nancy, as  noted  in  the  above  cases,  corresponds  with 
the  results  of  Chambulent's  observations.  In  a  series 
of  six  cases  of  pregnancy  near  term,  this  experimenter 
found  the  urotoxic  coefficient  to  range  from  0.22  to 
0.35 — an  average  of  0.25  fnormal,  0.464).  To  what- 
ever this  diminished  urinary  toxicity  be  due,  we  may, 
from  the  nine  cases  (three  of  them  ours,  six  of  them 

'  Voisin,  1.  c.  Herter's  experiments  in  auto-intoxication  in 
epilepsy  were  centred  on  the  estimate  of  ptomains  in  the  urine, 
as  shown  by  its  content  in  ethereal  sulphates.  N.  V.  Medical 
fournal.  i88g. 


Chambulent's),  infer  that  it  is  the  normal  condition, 
and  a  deviation  from  it  to  imply  something  abnormal, 
hence  possible  danger. 

In  two  other  cases  of  women  observed  just  before 
confinement,  the  urinary  toxicity  was  not  diminished, 
but  remained  within  the  limits  normal  to  the  non- 
pregnant state.  This  fact  was  all  the  more  significant, 
because  at  a  previous  confinement  one  of  these  women 
had  suffered  from  convulsions,  and  during  this  preg- 
nancy had  a  slight  albuminuria. 


Case    I 

Daily  expecting 
confinement. 

Urinary    tox- 
icity, 56  per 

urine.  1,040 

1,000. 

c.c. 

Case  II.  Had  con- 
vulsions at  previ- 

Daily expecting 
confinement. 

29 

576  c.c. 

ous    confinement; 

at  present  has  al- 
buminuria. 

A  larger  number  of  obser\'ations  on  puerperal  urine 
is  a  great  desideratum,  in  order  to  ascertain  whether  at 
this  time  and  for  any  reason  the  usual  law  is  reversed, 
so  that  while  the  diminution  of  toxicity  is  an  alarming 
circumstance  in  nephritis,  it  should  be  the  normal 
condition  at  the  close  of  pregnancy.  May  it  imply 
that  general  tissue  metabolisms  are  slackened  in  in- 
tensity during  the  concentration  of  nutritive  energy 
upon  the  spinal  centres  about  to  enter  upon  the  tre- 
mendous effort  of  parturition?  If  defective  elimina- 
tion were  the  cause,  puerperal  accidents  due  to  an  ac- 
cumulation of  toxins  in  the  body  might  be  expected  to 
occur  far  more  frequently  than  they  do.  Therefore  it 
would  seem  more  probable  that  at  this  time  a  smaller 
amount  of  toxic  substance  is  elaborated,  thus  lessening 
the  strain  to  which  the  organism  is  to  be  exposed  dur- 
ing the  accumulation  of  detritus  after  the  confinement. 
At  this  time  the  urinar}'  toxicity  should  normally  be 
expected  to  rise.  We  have  had  as  yet  no  opportunity 
to  examine  the  urine  earlier  in  pregnancy. 

Our  observations  in  cases  of  renal  diseases  tend  en- 
tirely to  confirm  the  dicta  of  Teissier:  "The  toxicity 
of  the  urine  offers  signs  of  the  greatest  importance  for 
the  prognosis  of  albuminuria.  The  toxicity  varies  in- 
versely with  the  aggravation  or  amelioration  of  the 
disease.  The  urinary  toxicity  may  vary  from  day  to 
day.  A  large  amount  of  albumin  in  the  urine  is  im- 
portant only  if  the  renal  elimination  be  incomplete. 
A  urine  containing  only  a  small  quantity  of  albumin 
may  nevertheless  indicate  very  serious  disease  if  the 
renal  elimination  be  insufficient;  thus  in  interstitial 
nephritis,  where  Professor  Bouchard  has  shown  that 
the  toxicity  of  the  urine  is  always  diminished.  In 
some  cases  the  urotoxic  coefficient  falls  to  0.193,  0.146, 
0.123  [see  our  Cases  II.,  IV.,  V.,  VI.].  Albuminuria 
in  kidney  disease  becomes  a  symptom  of  second  rank." 

Teissier  cites  two  cases  where  in  apparently  grave 
disease,  he  gave  a  favorable  prognosis  based  on  the 
normal  or  even  excessive  toxicity  of  the  urine,  and  in 
both  cases  the  prognosis  was  justified  by  the  result. 
The  first  was  an  albuminuria  with  colloid  casts  m 
the  urine,  but  with  a  urotoxic  coefficient  of  0.490 
(normal,  0.464).  It  was  subsequently  discovered  that 
the  albuminuria  was  due  to  a  renal  calculus. 

In  the  second  case  there  were  a  rheumatic  nephritis 
and  a  bruit  de  galop  at  the  heart,  with  frequent  syn- 
cope. But  the  toxic  coefficient  of  the  urine  was  0.664, 
indicating  that  the  kidneys  were  doing  their  full  duty ; 
and  the  patient  recovered  so  completely  as  to  be 
accepted  in  the  army. 

In  the  case  of  pyelitis  (Case  XII.)  the  low  urinary 
toxicity  and  urotoxic  coefficient  seemed  to  indicate  an 
extension  of  disease  from  the  pelvis  to  the  parenchyma 
of  the  kidney.  Yet  it  is  possible  that  the  renal  in- 
adequacy was  functional  and  independent  of  any  se- 
rious anatomical  lesion,  for  not  only  did  the  patient 


658 


MEDICAL    RECORD. 


[November  6,  1897 


entirely  recover,  remaining  in  fair  (subjective)  good 
health  three  years  later,  but  she  had  recovered  from 
similar  attacks  at  least  half  a  dozen  times  in  the 
course  of  eight  or  ten  years,  no  symptom  remaining 
between  the  attacks  but  the  pyuria.  Of  the  two  ex- 
periments made  in  this  case,  the  first  preceded,  the 
second  followed  a  severe  attack  of  renal  colic.  On 
the  first  occasion  the  patient  was  taking  an  ordinarj' 
mixed  diet ;  on  the  second,  was  living  exclusively  on 


healthy  persons,  noticed  that  an  exclusively  milk  diet, 
to  the  amount  of  three  or  four  litres  a  day,  mark- 
edly increased  the  toxicity  of  the  urine;  and  observes 
that  "  the  primary  cause  of  urinar}'  toxicity  must  be 
sought  in  the  phenomena  of  intimate  molecular  nutri- 
tion"— thus  not,  as  Bouchard  would  have  it,  primarily 
in  the  diet  or  in  absorption  from  the  intestine. 

In  Case  V.  diminution  in  the  urinary  toxicity  was 
the  first  positive  indication  of  renal  disease,  which 


No. 

Nature  of  Case. 

Amount  and 
Character  of  Urine. 

Weight 
Rabbit. 

Amount  of 
Urine  Injected. 

Amount  in 
c.c.  per 

o't  Rabbit. 

Weight 
Patient. 

Urotoxic 
Coefficient. 

Remarks. 

] 

Chronic    parenchyma- 

385 c.c.  (day);  albuminous. 

2,450  gm. 

205  cc 

83.67  cc 

Myosis  after  lo  c.c;  exophthal- 

tous nephritis. 

mos  after  no  c.c;    no  convul- 

sion until  immediately  before 
death. 

, 

Incipient  nephritis. 

Slight  trace  of  albumin;  urine 

1,000    " 

93  c-c. 

93  c.c 

70  kgm. 

o.»6 

dark,  scanty;  amount=:76o 

3 

Parenchymatous   n  e  - 
phritis. 

Much   albumin;  night  urine 
=  475  c.c. 

1,860    " 

164  cc 

88  cc 

Respiration  accelerated  to  102, 
then  retarded  to  72.  One  slight 
convulsion  at  25  c.c  ;  seven  scri- 

4 

Chronic  nephritis. 

Moderate  albumin;    granular 
casts;  amount  =  1.400 c.c. 

1.74=    " 

109  c.c. 

62  cc 

75kgm. 

0.301 

Myosis  began  at  30  CC;  myosU 
to  pin  point  at  T42. 

5 

Advanced   chronic   in- 

Trace of  albumin;  amount  = 

1,56°    '• 

345  c.c.  (day 

221  c.c. 

55   kgm.; 

No  convulsions  till  lao  cc,  then 

terstitial  nephritis. 

2,153    c.c;      total   urea  = 
8.845 gm.;  specific  gravity, 
1.005. 

urine);  2.88 
gm.     urea    in 
day  urine. 

ated. 

very  slight. 

Idem. 

Advanced   chronic   in- 

Trace of  albumin;  amount  = 

i,S6°    " 

208  cc  (nigh  t 

174  cc 

(Calculated 

First  convulsion  at  155  cc;  myo- 

terstitial nephritis. 

2,153    c.c  ;     total    urea  = 
8,845  gms.;  specific  gravity, 
1.005. 

urine);      5.965 
gm     urea    in 
mght  unne. 

from  aver- 
age of  day 
and   night 

0.208. 

sis  marked  at  95  c  c 

6 

Incipient    ncphr  i  t  i  s  ; 
milk  diet. 

1,440  c.c. ;  urea  =  34.56  gm. 

1,150    " 

120  cc. 

amount. 

Idem. 

After  a  week  of  mixed 

810  c.c;  urea  =  17.82 gm. 

1,740    " 

170  cc 

97-7  c.c.  =  i 
of  amount. 

Myosis  at  locc-  exophtbalmM 
just  before  death. 

diet. 

Idem. 

After  two  weeks  mixed 
diet;    patient  feeling 
very  badly. 

795  c.c;    urea=  19,875  gm. 
(day  unne). 

1,180    " 

45  c.c 

amount. 

Idem  ;  a 

Pregnancy  a  weeks. 

1,283  c.c;  '"■e*  =  30.79^  8™. 

8o«    " 

59  cc 

73  cc 

65  kgm. 

0.239 

Transient  urzmic  symptoms  twice 

U^" 

or     13,471*      when     Icuco- 

during     pregnancy;    in    last    6 

mains  precipitate;    no   al- 

weeks albuminuria  and  granular 

bumin. 

casts;  child  bom  cyanosed;  mi- 
perfect  respiration  for  6  hours; 
death;  placenta  markedly  atro- 
phied  and  sclerotic 

7 

Diffuse   nephritis ;    no 

830  c.c;  very  albuminous. 

medicines. 

Idem. 

Day  urine  =  830 c.c;  urea  = 
7,885  gm. 

2,120 

24  cc 

ll.JJCt 

No  myosis  until  final  tetanus;  00 
exophthalmos. 

Idem; 

Night  urine  =  415  cc  ;  urea 

2,300    •■ 

147  c.c 

63.91  c.c 

Slight  myosis;  great  turgesceace 

next  24 
hours. 

8 

j     =  6.225  gm. 

and  dilatation  of  vulva. 

Nephritis,  7    y  e  a  r  s  ;  Amount  =  2,500  c.c. ;    much 
neuroretinitis;      milk!     albumin;  granular  casts. 

2,250    " 

305  c.c. 

135  cc 

Rabbit's  urine  showed    trace  ot 

albumin. 

diet;  strophanthus.    j 

Idem  :  3 

Nephritis     7    y  ear  s  ;  Amount  =  2,500  c.c;    much 

1,800    •' 

30  c.c. 

i6icc. 

Could  discover  no  reason  for  this 

days 

neuroretinitis;     milk 

albumin;  granular  casts. 

enormous  exaggeration  of  toxi- 

earlier. 

diet;  strophanthus. 

city,  especially  as  the  amount  of 
unne  was  the  same,  and  the 
medicine  unchanged. 

9 

Chronic    diffuse    n  e  - 
phrilis. 

Day  urine  =  450  c.c;  albu- 
minous ;    specific   gravity. 

l,t8o    " 

17  c.c. 

14  cc 

10 

Chronic    parenchyma- 

1.015; urea=  12.15. 
2,040  c.c;  urea=  26.5?  gm. 

2,090    " 

110  c.c.  ' 

52  cc 

82.5  k^rm* 

0.475 

Convulsions  began  after  only  5  ex 

tous  nephritis;  0.004 

had  been  injected. 

bichloride      mercury 

I, 

Nephritis  2  month  s' 

2,600  gm.;  specific  gravity. 

1.53°    " 

78  cc 

50.98  cc 

66 

0.77a 

No  myosis. 

duration. 

1.007;    albuminous    casts; 

X9 

Chronic      pyelitis     of 

760  cc.  loaded  with  pus;  fil- 

1,150   " 

95  c.c. 

82.60  cc 

88 

O.I05 

Respiration  accelerated  instead  of 

right  kidney. 

trate  from  this  used  for  in- 
jection;    urea  =  7.98    gm. 
(filtrate  from  leucomaius). 

slowed. 

Idem    8 

Immediately  after  se- 
vere renal  colic;  milk 

1,31s  cc;  filtrate  used;  urea 

1.742    *' 

175  c.c 

100.4  c.c 

88 

0.148 

days. 

as  estimated  in  supernatant 

later. 

diet  and  lithiated  hy- 
drangea. 

fluid  after  precipitating  leu- 
comaius =  32.50  gm. 

milk,  and  taking,  in  addition,  lithiated  hydrangea. 
Under  these  circumstances  the  quantity  of  urine  was 
considerably  increased,  and  the  urinary  toxicity  con- 
siderably diminished — from  95  (already  abnormally 
low)  to  175.  Nevertheless,  the  urotoxic  coefficient 
rose  from  0.105  to  0.148,  and  the  proportion  of  urine 
required  for  a  fatal  dose,  which  was  as  much  as  one- 
eighth  before  the  acute  attack,  fell  after  the  attack 
to  one-thirteenth  of  the  whole  amount  passed  in 
twenty-four  hours.  The  concentrated  urine  before  the 
attack  was  thus  really  less  toxic  than  the  dilute  urine 
which  followed;  and  although  meat  is  held  by  Bou- 
chard to  constitute  a  principal  source  of  urinary 
toxins,  yet  in  this  patient  the  urine  from  the  meat 
diet  was  proportionately  less  toxic  than  that  from 
the  diet  of  milk.     Lapicque,  experimenting  on  two 


became  fully  developed  later.  Discovery  of  this 
latent  disease  was  all  the  more  important,  because  it 
seemed  to  help  to  explain  the  accidents  of  five  succes- 
sive pregnancies,  which  were  either  terminated  pre- 
maturely or  resulted  in  the  birth  of  non-viable  chil- 
dren. There  remained  a  mystery,  however,  for  in 
the  si.\th  pregnancy  granular  casts  were  present  in 
the  urine,  and  abundant  albuminuria  developed  during 
the  last  six  weeks;  yet  a  healthy  child  was  bom  at 
term,  and  five  months  later  was  still  living  and  thriv- 
ing. The  acute  pyelitis  which  developed  a  month 
after  delivery  suggested  the  possibility  that  the  albu- 
minuria which  had  previously  existed,  but  only  at 
long  inter\-als  and  in  the  last  month  or  two  of  succes- 
sive preg:nancies,  had  really  been  due  to  a  catarrhal 
pyelitis,  and  not  to  parenchymatous  disease;  while  the 


1 


November  6,  1897] 


MEDICAL    RECORD. 


659 


other  symptoms — diminished  urinary  toxicity,  second- 
ary' indigestion,  transient  ureemic  aphasia  and  paral- 
ysis, chorion  dropsy,  and  atrophy  of  the  placenta — 
would  be  attributable  to  a  more  insidious  interstitial 
lesion,  which  for  a  long  time  spared  the  secreting  epi- 
thelium and  the  Malpighian  tufts,  and  caused  no 
albuminuria. 

Sufficient  comment  has  already  been  made  upon  the 
single  case  of  epilepsy  submitted  to  experiment. 

The  single  experiment  in  diabetes  gave  remarkable 
results,  and  such  as  I  have  not  seen  elsewhere 
recorded. 


UNEXPECTED    FORMS    OF    DEATH    AMONG 
THE   INSANE. 

By   E.    M.    SOMERS,    M.D., 

ASSISTANT    PHYSICIAN,   ST.   LAWRENCE    STATE   HOSPITAL,   OGDENSBURG,   N.    V. 

In  every  hospital  for  the  insane  a  certain  percentage 
of  deaths  will  occur  without  any  warning,  save  those 
symptoms  which  are  intimately  associated  with  the 
moribund  state ;  and  such  occurrences  set  one  to  think- 
ing whether  some  signs  or  symptoms  ought  not  to  have 
been  observed  during  the  usual  condition  of  the  pa- 
tient to  put  the  physician  on  his  guard,  although  know- 
ing that  no  essential  treatment  would  have  more  than 
modified  or  delayed  the  occurrence.  Again,  one  con- 
gratulates himself  that  such  deaths  did  not  happen 
while  the  patients  were  under  some  vigorous  treatment, 
medical  or  surgical,  or  during  the  course  of  forced 
feeding  or  surgical  restraint. 

Of  the  many  causes  of  sudden  deaths  among  the  in- 
sane, cerebral  apoplexy  and  embolism  are  not  uncom- 
mon, and  these  seldom  present  symptoms  or  lesions  so 
remarkable  as  to  need  reporting.  Ruptures  of  the 
heart,  larger  arteries,  and  liver  are  much  less  often 
found,  and  therefore  make  more  striking  impressions. 
Still,  there  are  now  and  then  cases  showing  but  a 
scanty  array  of  symptoms.  The  patients  suddenly 
sink  to  the  floor,  with  face  intensely  congested,  and 
very  rapidly  pass  into  a  fatal  coma;  or,  partially 
arousing,  become  restless  for  a  time,  and  expire  in  a 
few  hours.  During  life  such  cases,  which  are  essential- 
ly senile,  show  mentally  the  ordinary  symptoms  of  de- 
mentia, and  physically  increasing  feebleness  of  health. 
The  heart  action  is  generally  feeble,  the  arteries  are 
much  sclerosed,  the  urine  always  contains  albumin, 
and  mild  uraemic  attacks  are  common.  At  the  ne- 
cropsy we  find  the  ordinary  signs  of  arterio-sclerosis 
and  cirrhotic  kidneys.  The  heart  is  possibly  soft  and 
its  muscular  fibres  are  flabby  and  easily  lacerated;  or, 
conversely,  the  muscle  may  be  quite  firm,  and  upon 
close  inspection  we  may  be  able  to  observe  the  stri- 
ations  cloudy  and  indistinct,  the  aortic  intima  con- 
taining atheromatous  and  calcareous  patches,  most 
plentiful  about  the  coronary  ring,  while  the  brain 
seems  macroscopically  unchanged  save  for  some  gen- 
eral softening. 

A  case  in  detail  may  illustrate  the  above  descrip- 
tion. 

Case  I. — Male,  aged  forty-four  years,  German,  farm- 
er; alleged  habits  temperate;  duration  of  attack  pre- 
vious to  admission,  four  years;  diagnosis,  terminal  de- 
mentia. His  history  is  that  of  an  ordinary  case  of 
maniacal  excitement  before  admission,  followed  by  dul- 
ness  and  confusion,  neglect  of  person,  etc.  During  the 
patient's  life  in  the  institution  (nearly  five  years)  he 
showed  very  early  the  evidences  and  facies  of  a  de- 
ment, occasionally  having  outbreaks  of  loud  talking 
with  motor  restlessness,  and  seldom  making  assaults. 
Soon  his  physical  state  showed  beginning  enfeeble- 
ment  as  evinced  by  poor  nutrition,  increasingly  feeble 
gait,  and  dyspnoea  upon  exertion ;  the  urine  from  time 
'  As  distinguished  from  indigestion  in  thefrimce  i>i,<. 


to  time  showed  albumin  and  casts.  It  might  be  well 
to  state  that  the  physical  examination  upon  admission 
showed  no  organic  changes.  During  the  last  month 
of  the  patient's  life  all  the  symptoms  of  enfeeblement, 
both  of  mind  and  body,  were  intensified.  His  periods 
of  usual  disturbance  would  tire  him  very  noticeabl)', 
and  he  would  perspire  profusely  even  when  not  espe- 
cially exercising.  On  April  15,  1897,  he  showed  no 
unusual  symptoms  other  than  those  above  described, 
except  a  tendency  to  restlessness.  While  walking 
along  the  floor  he  suddenly  sank  with  face  intensely 
congested,  remained  in  this  comatose  condition  only 
a  few  minutes,  and  expired.  The  necropsy  showed  the 
brain  substance  to  be  slightly  softened,  nothing  fur- 
ther. The  cerebral  arteries  were  sclerosed,  the  cere- 
bro-spinal  canal  and  ventricles  were  filled  with  clear 
fluid.  The  heart  was  contracted,  the  left  ventricle 
hypertrophied,  the  muscular  tissue  pale  and  showing 
fine  granular  stria  throughout  its  stroma,  but  its  sub- 
stance was  of  fairly  good  consistence.  The  aortic 
intima  and  valves  were  crusted  with  patches  of  athe- 
roma and  lime.  Liver  nutmeg;  kidneys  large  and 
tough ;  capsules  non-adherent ;  surface  of  kidneys  nod- 
ular; cortex  atrophied;   markings  indistinct. 

Case  II. — F"emale,  aged  sixty-three  years,  Irish; 
habits  said  to  be  good ;  by  occupation  a  domestic.  She 
presented  essentially  the  same  mental  symptoms  as  the 
patient  in  Case  I.  On  admission  she  was  in  poorer 
physical  health,  however,  and  gradually  became  more 
and  more  enfeebled.  Occasionally  the  patient  would 
remain  in  bed  for  a  few  days.  F-equent  examination 
of  the  urine  always  revealed  casts  and  albumin,  and 
during  her  latter  days  oedema  of  the  feet  and  muscu- 
lar weakness  were  noted.  January  13,  1897,  the  pa- 
tient was  observed  to  have  slight  spasms  of  the  right 
arm  and  leg  with  dilatation  of  the  right  pupil.  The 
attending  physician  was  called  and  found  the  arm  in 
marked  spasmodic  movements,  though  of  a  feeble  char- 
acter. The  right  pupil  was  widely  dilated,  the  left  ap- 
parently normal ;  the  jaw  was  dropped  and  the  tongue 
apparently  paralyzed.  From  the  above  condition  she 
passed  into  one  of  stupor  with  right  hemiplegia,  and 
a  few  hours  later  expired;  but  for  a  short  time  previ- 
ous to  death  she  was  feebly  restless.  The  autopsy 
showed  the  following  important  conditions:  calvaria 
thin,  porous,  and  difficult  to  remove,  due  to  quite  firm 
adhesion  of  the  dura,  especially  along  the  posterior  con- 
vexit}\  The  sinuses  were  engorged,  the  pia  was  much 
injected,  and  a  large  quantity  of  cerebro-spinal  fluid 
was  collected;  the  brain  substance  was  of  good  con- 
sistency. The  cerebral  arteries,  especially  at  the  base, 
were  ver)'  much  degenerated,  containing  calcareous 
plates  and  surrounded  by  yellowish  patches.  The  ven- 
tricles were  distended  with  fluid.  Careful  sections  of 
the  entire  brain  substance  showed  to  the  eye  no  sites  of 
hemorrhage  or  of  softening.  Heart  in  diastole;  con- 
siderable deposits  of  fat  about  the  base  of  the  ventri- 
cles; myocardium  soft,  easily  macerated,  and  of  cloudy 
appearance;  valves  thickened,  indurated,  and  con- 
tracted. Liver  small,  dark-colored,  nodular,  and  its 
substance  in  appearance  "nutmeg."  Kidneys  typical 
of  advanced  interstitial  nephritis. 

Both  of  these  subjects  were  uraemic,  and  the  cause  of 
death  could  safely  be  attributed  to  nephritis.  The 
mode  of  death,  however,  was  unusual  and  in  an  un- 
expected form,  as  neither  had  had  coma  before,  or 
any  of  the  severe  symptoms  of  urajmia.  Pepper'  says : 
'"  Hemiplegia,  with  or  without  aphasia,  maybe  the  first 
symptom  to  call  attention  to  a  nephritis.  .  .  .  There 
is  loss  of  motion  alone,  or  of  both  motion  and  sensa- 
tion." Case  II.  had  hemiplegia  with  aphasia.  Sen- 
sation in  the  paralyzed  parts  before  stupor  supervened 
was  indefinite,  owing  to  the  patient's  confused  mental 

'  "  American  Text-Book  of  Theory  and  Practice,"  vol.  ii. ,  p. 
653- 


66o 


MEDICAL    RECORD. 


[November  6,  1897 


state.  Further  he  says:  "These  attacks  have  been 
ascribed  to  localized  fcdema  of  the  brain."  And :  ■"  In 
cases  that  I  have  seen  there  were  no  changes  in  the 
brain  tissue,  but  the  cerebral  arteries  were  damaged 
by  chronic  endarteritis."  The  brain  in  this  case  was 
waterlogged,  but  no  one  locality  seemed  more  espe- 
cially oedematous  and  no  hemorrhagic  foci  were  re- 
vealed. Nevertheless,  there  were  abundant  evidences 
of  advanced  cerebral  endarteritis,  and  the  perivascular 
spaces  were  prominent  throughout  the  entire  brain 
substance.  On  the  following  page  he  says:  "Persons 
apparently  in  good  health  are  attacked  without  warn- 
ing by  convulsions,  coma,  delirium,  or  hemiplegia.  .  .  . 
They' may  die  in  the  first  attack  or  live  to  go  through 
subsequent  ones."  Case  I.  seemed  to  be  of  the  coma- 
tose type,  which  rapidly  became  fatal.  The  brain  was 
less  waterlogged  than  "in  Case  II.,  but  had  nearly  as 
much  arterial  degeneration.  The  myocardium  showed 
neither  fibroid  nor  fatty  changes  to  the  eye,  and  the 
coronary  sinuses  were  freely  open.  At  no  time  in  his 
history  were  there  attacks  indicating  a  possible  angina 
pectoris  and  his  last  symptoms  were  of  an  apoplecti- 
form character.  Examination  of  the  urine  shortly 
after  death  showed  the  presence  of  the  usual  amount 
of  albumin.  Although  the  symptoms  and  evidences 
do  not  so  strongly  point  to  a  fatal  angina,  yet  the 
symptomatology  in  a  dement  must  obviously  be  ob- 
scure, and  in  this  case  the  cause  of  death  be  neces- 
sarily an  open  one. 

Rupture  of  the  heart  has  been  the  cause  of  death  in 
less  than  two  per  cent,  of  cases  at  this  institution. 
Occasionally  one  will  read  of  this  occurrence  among 
the  insane.  Dr.  Mickie,  in  the  February  number  of 
the  Edinburgh  Medical  Jounia/  for  1884,  reported  three 
ruptured  hearts.  Dr.  Pilgrim,  in  t\\&  Journal  of  Insan- 
ity for  Januar}-,  1895,  mentioned  one  similar  case. 
Another  was  presented  by  Dr.  Tompkins,  in  the  Brit- 
ish Medical  Journal  for  May,  1885.  Three  out  of  these 
five  ruptures  were  in  cases  diagnosed  as  melancholia; 
another  was  a  case  of  senility  with  marked  states  of 
depression.  The  remaining  one  was  terminal  de- 
mentia due  to  chronic  alcoholism.  In  four  of  these 
the  site  of  rupture  was  in  the  body  of  the  left  ventri- 
cle. The  fifth  case,  however,  had  the  rupture  in  the 
right  ventricle.  Again,  in  three  out  of  the  series 
death  occurred  rather  slowly.  There  are  two  other 
cases  which  the  writer  desires  to  add  to  the  list: 

C.\SE  I. — Female,  aged  eighty-one  years,  widowed, 
native  born  ;  habits  good;  occupation,  domestic.  Di- 
agnosis, senile  melancholia.  Cause,  epidemic  influ- 
enza. Before  admission  she  was  depressed  to  a  mild 
degree,  neglected  to  care  for  herself,  and  became  very 
hypochondriacal.  During  the  fifteen  months  the  pa- 
tient was  here  she  presented  no  interesting  mental 
symptoms  other  than  those  commonly  found  in  a 
large  majority  of  senile  melancholiacs.  Her  physical 
condition  upon  entry  was  feeble;  pulse  very  fibrous: 
heart  action  fairly  good  and  without  murmurs.  Lungs 
normal.  Urine  showed  no  albumin  or  casts.  Gen- 
eral enfeeblement  kept  her  in  bed  frequently  while 
here,  but  her  usual  condition  immediately  before  her 
death  seemed  to  be  in  no  wise  more  decrepit.  The 
circumstances  pertaining  to  her  death  were  simply  that 
the  night  nurse  found  her  in  a  condition  of  collapse 
about  4  A.M.  The  pulse  was  feeble;  she  breathed  gasp- 
ingly, and  soon  life  was  extinct.  Autopsy  showed  the 
following  interesting  facts :  The  brain  was  not  structu- 
rally changed,  though  the  basal  arteries  were  markedly 
atheromatous.  There  were  a  number  of  foci  of  soft- 
ening in  the  basal  ganglia,  some  being  as  large  as  a 
pin's  head.  Lungs  slightly  cedematous.  Liver  soft- 
ened and  showing  granulo-fatty  changes.  Kidneys  of 
the  moderately  cirrhotic  type.  Heart  in  partial  sys- 
tole; myocardium  firm;  pericardium  contained  about 
one  ounce  of  bloody  serum.     On  the  anterior  surface  of 


the  left  ventricle  was  noted  a  purplish  extravasation 
running  lengthwise  of  the  organ  for  about  two  inches, 
giving  to  the  touch  a  feeling  of  hardness  surrounded 
by  a  dissolution  of  continuitj-.  At  the  ape.x,  involv- 
ing the  muscular  substances  of  both  ventricles  and  in- 
termuscular septum,  was  an  area  of  very  friable 
muscular  tissue  mingled  with  clotted  blood.  The 
muscular  fibres  were  ruptured  and  separated  in  the 
centre  of  the  degenerated  spot,  yet  the  visceral  peri- 
cardium was  intact,  so  that  there  was  no  actual  ex- 
ternal communication.  At  one  site  under  the  injected 
area  on  the  anterior  surface  of  the  left  ventricle  was 
a  thick  coagulum  looking  like  muscle  detritus,  min- 
gled with  a  thrombus,  and  through  the  centre  of  this 
mass  the  walls  were  attenuated  to  a  layer  of  tough 
connective  tissue,  enclosing  this  purplish  softened  tis- 
sue, and  the  whole  was  held  in  place  by  the  endoperi- 
cardium.  Attempts  to  reach  the  site  by  a  probe  in  the 
coronary  arterj'  failed.  The  cardiac  valves  were  thick- 
ened but  apparently  competent.  Plaques  of  thicken- 
ing were  noted  in  the  aortic  arch.  The  kidneys  were 
contracted  and  cystic  to  a  mild  degree. 

Case  II. — Female,  aged  seventy  years,  Canadian; 
domestic;  a  morphine  habitue.  Her  tendencies  be- 
fore admission  were  suicidal,  she  having  jumped  from 
a  second-story  window.  Duration  of  attack,  several 
years;  cause  unknown.  Diagnosis,  dementia  (senile). 
The  accompanying  history  stated  in  substance  that 
the  patient  thought  the  pain  which  had  been  constantly 
in  her  stomach  for  seventeen  years  was  due  to  '"  a  nest 
of  cats"  therein,  and  that  she  jumped  from  the  second- 
story  window  "because  the  devil  was  in  her."  She 
was  loud  in  her  demand  for  arsenic,  that  she  might 
quiet  the  pain  or  do  away  with  herself.  On  admission 
the  patient  was  emotional,  agitated,  and  depressed,  re- 
peating constantly,  "Give  me  arsenic."  The  physical 
condition  was  feeble,  with  indistinct  heart  sounds, 
though  no  murmurs  could  be  detected.  After  the  pa- 
tient had  been  at  the  hospital  a  few  weeks  she  was 
daily  given  a  dose  of  morphine  for  its  possible  mental 
effect,  but  the  rest  was  temporary.  During  her  life 
here  the  patient  was  entirely  absorbed  in  the  one  idea 
that  animals,  "cats,"  "little  pigs,"  etc.,  were  "gnaw- 
ing" her  stomach,  and  she  was  almost  hourly  pleading 
to  be  cut  open  so  that  the  animals  could  be  removed, 
or  to  be  killed  and  freed  from  pain.  Repeated  physi- 
cal examinations  were  made  with  unsatisfactory  re- 
sults, as  she  kept  the  muscles  over  the  epigastrium 
rigid.  .Although  her  appetite  was  poor,  she  accepted 
a  varied  diet  and  showed  no  symptoms  pointing  to  any 
organic  changes  of  heart,  stomach,  or  liver.  There 
was  a  continued  failure  of  physical  strength,  the  last 
few  months  the  patient  remaining  in  bed  much  of  the 
time.  One  morning  while  walking  along  the  floor  she 
suddenlv  fell  unconscious,  and  quickly  expired  without 
further  symptoms.  The  post-mortem  evidences  of  im- 
portance were  as  follows:  Heart  relaxed;  pericardium 
filled  with  about  one  and  a  half  pounds  of  blood  clot; 
myocardium  very  soft  and  of  a  cloudy  appearance.  At 
the  left  ventricular  apex  a  small  rent  was  detected  in 
the  muscle  wall  externally,  communicating  with  a  cav- 
ity. The  muscular  tissue  about  the  rupture  was  blood- 
stained and  very  much  softened.  Nothing  in  other 
viscera  was  of  interest  beyond  the  evidences  of  com- 
mon senile  changes. 

The  two  cases  just  detailed  resemble  in  two  f)oints 
the  five  cases  summarized:  ist,  they  were  senile;  and, 
2d,  mentally  depressed — the  sites  of  rupture  differ- 
ing, however,  in  that  they  were  both  apical. 

Anaemic  necrosis,  a  tenn  used  to  indicate  localized 
degenerative  changes  taking  place  in  the  myocar- 
dium as  the  frequent  result  of  an  obliterative  endar- 
teritis of  the  coronary  branches,  seems  to  have  been 
well  pointed  out  in  Case  I.  The  patch  on  the  anterior 
ventricular  surface,  evidently  of  long  standing,  showed 


November  6,  1897] 


MEDICAL    RECORD. 


661 


its  centre  to  be  quite  sclerotic.     The  ruptured  site  at 
the  cardiac  tip  was  an  acute  aneurism. 

In  Case  11.  the  heart  muscle  in  general  was  much 
more  softened,  and  it  would  be  difficult  to  attribute  this 
apical  rupture  to  a  myomalacia  cordis,  at  which  site 
it  is  reported  as  most  frequently  occurring,  in  prefer- 
ence to  the  possible  fact  of  this  spot  being  simply  the 
more  advanced  in  the  grand  fatty  decay.  The  more 
interesting  feature  of  Case  II.  is  the  very  well-defined 
illustration  of  "  coanaesthetic  illusions"  of  Regis,'  who 
says:  "  There  is  a  special  class  of  illusions  which  can- 
not be  properly  referred  to  any  of  the  special  senses, 
and  which  are  known  by  the  name  of  internal  or  coan- 
jesthetic  illusions.  .  .  .  They  consist  in  false  interpre- 
tations of  actual  organic  sensations.  .  .  .  Thus  ver}- 
frequently  affections  of  the  intestines,  the  stomach,  or 
the  uterus,  induce  in  the  patients,  by  the  reaction  they 
cause,  ideas  that  they  have  animals  in  their  bellies, 
that  they  have  been  violated,  etc.  .  .  .  These  internal 
illusions  are  especially  frequent  in  the  so-called  sym- 
pathetic insanities."  The  reflex  action  of  an  organic 
heart  disease  was  referred  to  the  epigastrium  (probably 
in  the  form  of  an  intense  neuralgia),  and  the  ideas 
held  by  this  patient  that  animals,  "mice,"  "cats," 
etc.,  were  "■  gnawing,"  were  truly  typical  of  a  sympto- 
matic or  cardiac  insanity. 

The  last  case  to  be  reported  is  one  of  a  traumatic 
rupture  of  the  liver.  Male,  Prussian,  aged  fifty-one 
years,  single,  baker.  Habits  intemperate;  duration 
of  insanit)-,  ten  or  twelve  years.  Diagnosis,  terminal 
dementia.  His  mental  historj-  is  uninteresting,  as  it 
is  characterized  throughout  by  the  classical  symptoms 
of  early  involution.  His  physical  state,  which  was 
fairly  robust  till  about  three  years  ago,  gradually  be- 
came more  and  more  frail  until  he  presented  the  anje- 
mic  and  drawn  features  of  one  possibly  suffering  from 
chronic  pulmonary  tuberculosis.  The  man's  gait, 
which  was  always  feeble,  was  much  hampered,  owing 
to  the  fact  that  his  left  foot  had  been  amputated. 
On  March  ro,  1897,  while  walking  along  with  a  num- 
ber of  other  patients,  he  was  suddenly  pushed  with 
considerable  force  against  the  wall  by  another  patient. 
Shortly  after  he  sank  to  the  floor  in  a  condition  of  col- 
lapse, and  soon  life  was  extinct.  The  necropsy,  which 
was  performed  in  the  presence  of  the  coroner,  gave  the 
following  data:  Calvaria  unusually  dense  and  heavy; 
brain  well  formed  and  presenting  no  gross  changes. 
Heart  relaxed;  myocardium  firm ;  valves  slightly  thick- 
ened. Lungs  partialh'  collapsed  and  ansemic.  When 
the  abdomen  was  ojsened,  about  four  pounds  of  free 
blood  was  found  in  the  jseritoneal  cavity,  and  the  source 
of  the  blood  was  discovered  to  be  a  rent  in  the  liver 
substance.  The  site  of  rupture  was  about  the  central 
part  of  the  right  lobe  on  its  antero-superior  surface. 
The  tear  was  four  inches  long  by  two  and  a  half  inches 
in  depth,  with  ragged  edges,  and  running  in  an  antero- 
posterior direction.  The  liver  substance  was  in  a  state 
of  marked  granulo-fatt}-  degeneration,  and  but  little 
effort  was  necessary  to  tear  or  break  down  any  part  of 
the  putt)--like  organ.  The  site  about  the  rupture  was 
not  more  degenerated  than  usual.  The  seventh  and 
eighth  costal  cartilages  were  fractured  opposite  the  liver 
lesion,  and  a  moderate  bloody  extravasation  in  the  cel- 
lular tissue  covering  the.se  cartilages  was  detected. 
No  skin  evidences  of  injurj*  were  apparent. 

The  general  opinion  in  this  case  seemed  to  be  that 
the  patient  was  crowded  and  squeezed  against  some 
firm  object,  so  that  a  sufficient  amount  of  pressure  v.as 
exerted  to  cause  a  rupture  of  the  already  diseased 
gland. 

To  Prevent  Nausea  after  Chloroform. — Pour  vine- 
gar upon  the  mask  after  the  operation  and  let  the 
patient  inhale  as  he  is  coming  to. 

'  Regis  :  "  Practical  Manual  of  Mental  Medicine." 


THE   RELATION    OF    SEX    TO    MENTALITY. 
Bv   CH.\RLES   A.    WHITE,    M.D., 

WASHINGTON,    D.    C. 

Much  has  been  written,  especially  by  German  au- 
thors, concerning  the  relation  of  sex  to  mentalit}-  from 
the  standpoints  of  psychologj-,  criminology,  and  social 
science,  but  it  is  my  purpose  only  to  remark  briefly 
upon  that  relation  with  reference  to  the  sequelse  of 
sirrgical  operations  upon  the  sexual  organs,  especially 
those  of  ovariotomy.  The  literature  of  those  sequela 
is  extensive,  but  it  is  all,  or  nearl)'  all,  confined  to  the 
physical  and  pathological  conditions  which  result  more 
or  less  directly  from  the  operation.  That  is,  judging 
from  the  literature  referred  to,  the  possible  effects  of 
ovariotomy  upon  the  mentality  of  the  patient  has  rarely 
been  taken  into  consideration  by  the  operating  sur- 
geon. This  assumed  fact  has  lately  been  called  to 
my  attention  in  a  somewhat  forcible  manner. 

A  daughter  each  of  three  friends  of  mine  has  been 
made  the  subject  of  ovariotomy,  each  by  a  different 
surgeon,  neither  of  whom  was  cognizant  of  the  other 
cases.  One  case  was  that  of  a  woman,  aged  thirty -eight 
years,  the  mother  of  three  children;  another  that  of 
an  unmarried  woman,  aged  thirty-nine  years,  and  the 
third  that  of  a  girl  of  eleven  years.  All  three  of  the 
operations  were  successful,  as  such.  The  two  women 
are  living  in  good  physical  health  and  unimpaired 
mentalit}-.  The  girl  died  after  complete  recovery 
from  the  operation,  but  before  reaching  the  usual  age 
for  the  establishment  of  the  menses. 

In  each  of  these  cases  the  father  unsuccessfully  so- 
licited from  the  surgeon  some  prognosis  of  the  prob- 
able effect  of  the  operation  upon  the  mentality  of  the 
patient.  Being  men  of  broad  information,  they  fully 
comprehended  the  general  character  of  the  operation 
and  were  also  well  aware  of  the  reputed  psychological 
effect  of  castration  upon  the  human  subject.  They 
therefore  naturally  inferred,  or  feared,  that  a  similar 
result  might  follow  the  removal  of  the  ovaries.  The 
necessity  for  the  operation  seemed  to  be  imperative, 
and  they  consented  without  further  questioning. 

After  the  operation  in  each  case  had  been  performed 
and  recover)-  from  its  immediate  effects  practically  as- 
sured, the  father  of  each  patient  conferred  with  me, 
not  professionally  but  as  an  intimate  friend,  upon  the 
question  they  had  respectively  raised  with  the  sur- 
geons. I  could  not  reply  from  any  actual  experience 
of  my  own  in  surgerj',  nor  could  I  refer  them  to  any 
literature  bearing  directly  upon  the  question,  for  I  had 
vainly  sought  for  it  in  the  great  librar}-  of  the  United 
States  Army  Medical  Museum.  I  had,  however,  given 
some  attention  to  related  subjects,  and  the  following 
remarks  embrace  the  substance  of  my  replies  to  their 
inquiries.  They  are  based  largely  upon  the  proposi- 
tion that  sex  and  a  certain  phase  of  mentality  or  of 
psychological  manifestation  are  intimately  correlated 
in  their  development 

UTiile  the  greater  part  of  the  sum  total  of  human 
mentality  is  developed  in  like  manner  and  is  of  simi- 
lar quality  in  both  sexes,  it  is  too  obvious  to  need 
more  than  passing  mention  that  certain  prominent 
mental  characteristics  are  peculiar  to  each.  It  is  also 
just  as  ob\nous  that  differences  of  mental  habit,  and 
one  might  almost  say  of  instinct,  exist  between  the 
two  sexes  in  childhood,  and  that  those  differences  are 
strongly  marked  before  the  age  of  puberty.  At  that 
age  the  differences  quickly  merge  into  the  peculiar 
psychological  attributes  of  manhood  and  womanhood 
respectively.  Those  attributes  being  due  to  sex,  it 
necessarily  follows  that  if  the  ovaries  or  testes,  the 
primary  organs  of  sex,  should  not  be  potentially  de- 
veloped, or  if  they  are  removed  before  the  full  estab- 
lishment of  manhood  or  womanhood,  as  the  case  maj 
be,  the  development  of  those  psychological  character- 


662 


MEDICAL    RECORD. 


[November  6,  1897 


istics  which  distinguish  the  sexes  respectively  will  be 
thereby  arrested.  Thus,  as  is  shown  by  the  published 
records  of  eunuchism,  if  a  boy  be  castrated  in  child- 
hood, although  his  body  and  a  large  degree  of  general 
intellect  are  subsequently  developed,  certain  features 
of  his  mentality  remain  deficient.  That  is,  he  is  char- 
acterized throughout  his  whole  life  by  an  unmistakable 
puerility  of  thought,  effeminacy  of  habit,  and  a  lack  of 
manly  responsibility  of  conduct. 

The  absence  of  an  actuating  motive  for  and  the 
difficulty  of  the  operation  of  ovariotomy,  as  compared 
with  that  of  castration,  has  doubtless  prevented  the 
barbarism  of  man  from  mutilating  woman  as  he  has 
done  his  fellow-man,  and  therefore  ovariotomy  in 
childhood  is  unknown  except  as  a  remedial  operation. 
Furthermore,  such  diseases  of  the  ovaries  as  require 
their  removal  rarely  occur  before  the  age  of  puberty, 
and  consequently  only  a  few  cases  of  ovariotomy  be- 
fore that  age  are  known  to  surgery.  Some,  how-e\^er, 
are  known,  and  from  its  analogy  to  castration  one  can- 
not doubt  that  in  all  such  cases  certain  girlish  or  im- 
mature mental  characteristics  will  remain  throughout 
life.  The  changes  which  take  place  as  a  result  of 
early  castration  present  the  strong  contrast  with  the 
natural  male  condition  which  exists  between  virility 
and  effeminacy,  but  because  of  the  more  delicate  na- 
ture of  woman  it  is  not  to  be  expected  that  so  great  a 
contrast  will  be  the  result  of  ovariotomy.  Certainly 
no  converse  tendency  toward  mannishness  is  to  be  ex- 
pected. Still,  it  is  reasonable  to  expect  that  the  psy- 
chological deficiencies  produced  by  ovariotomy  upon 
an  immature  patient  may  be  so  strongly  marked  as  to 
be  a  source  of  grief  and  disappointment  to  her  friends. 
In  these  cases  at  least  it  is  within  the  province  of  the 
surgeon  to  inform  the  friends  of  the  patient  as  to  the 
mental  as  well  as  the  physical  condition  in  which  she 
w  ill  probably  be  left  when  the  wounds  are  healed  which 
his  knife  has  made. 

Modern  surgery  has  made  ovariotomy,  in  competent 
hands,  one  of  the  safest  of  the  capital  operations,  and 
recovered  subjects  of  that  operation  are  therefore 
somewhat  numerous.  And  yet,  as  already  mentioned, 
no  satisfactory  records  of  their  mental  sequela;  seem 
to  have  been  published.  This  deficiency  of  record  is 
doubtless  due,  not  to  remissness  on  the  part  of  sur- 
geons, but  to  the  extreme  difficulty  of  obtaining  accu- 
rate information  of  this  kind.  The  sequela;  referred 
to  are' manifested,  if  at  all,  after  the  case  has  passed 
out  of  the  surgeon's  hands  and,  for  obvious  reasons, 
the  friends  of  the  patient  do  not  willingly  make  them 
public.  Therefore  the  doctrine  of  probabilities  must 
enter  largely  into  any  prognosis  of  such  sequelae,  and 
it  legitimately  suggests  the  following  statements,  as  it 
has  some  of  those  made  in  preceding  paragraphs : 

While  it  may  he  expected  that  the  full  establish- 
ment of  the  attributes  of  womanhood  will  secure  the 
subject  of  ovariotomy  from  adverse  mental  effects,  it 
is  possible  that  if  the  operation  be  performed  in  the 
first  years  of  her  potentially  fertile  period  there  may 
result  some  degree  of  impairment  of  the  sexual  phase 
of  her  mentality,  because  it  requires  a  few  years  after 
the  appearance  of  the  menses  fully  to  establish  the 
mental  habit  of  womanhood.  It  is  believed,  however, 
that  if  such  a  result  should  occur  it  would  be  too  slight 
to  be  observed  by  any  but  her  most  intimate  friends. 
In  all  the  cases  here  suggested  it  is  assumed  that  both 
ovaries  are  removed,  for  the  removal  of  one  ovary  does 
nor  necessarily  prevent  subsequent  fertility. 

After  the  middle  or  later  part  of  the  period  of  poten- 
tial fertility  no  degree  of  mental  impairment  is  to  be 
reasonably  exjDected  as  a  result  of  ovariotomy.  In  all 
such  cases  the  surgeon's  knife  transfers  the  patient  to 
that  respected  condition  of  non-fertility  which  is  the 
natural  heritage  of  every  woman  who  reaches  her  later 
sexual  climacteric  and  she  is  transferred  to  that  con- 


dition only  a  little  in  advance  of  the  time  when  she 
would  naturally  have  entered  it.  That  is,  the  mental 
condition  is  no  more  changed  in  the  one  case  than  in 
the  other,  and,  save  for  the  loss  of  a  little  diseased 
and  therefore  worthless  tissue,  the  physical  condition 
of  the  recovered  patient  is  the  same  as  is  that  of  the 
woman  vho  becomes  infertile  by  the  natural  process. 

In  support  of  my  proposition  that  certain  childish 
characteristics  are  likely  to  remain  with  those  who 
have  been  deprived  of  the  essential  element  of  sex  in 
childhood,  as  well  as  with  those  in  whom  it  may  have 
never  been  developed,  I  gave  the  three  friends  referred 
to  the  following  illustration  drawn  from  my  experience 
with  mule  packtrains  in  Western  exploration.  The 
low  grade  of  these  animals,  as  compared  with  man, 
does  not  make  the  illustration  inapt,  because  it  is 
only  a  small  part  of  that  great  aggregate  of  human 
mentality  which  distinguishes  man  from  those  ani- 
mals that  is  specially  affected  by  sex.  Therefore  the 
contrast  in  this  illustration  is  not  so  great  as  it  might 
appear  to  be. 

Mules  are  more  serv'iceable  for  packing  than  are 
any  other  animals,  but  they  cannot  be  managed  alone 
with  full  success.  Therefore  a  horse,  much  preferably 
a  female,  is  always  provided  to  lead  them.  She  wears 
a  small  bell  and  is  called  the  bell  mare.  The  train 
marches  single  file,  and  at  the  first  start  it  is  the  set- 
tled ambition  of  every  mule  in  it  to  march  next  the 
bell  mare.  A  contest  takes  place  with  much  kicking 
and  biting,  the  strongest  or  most  persistent  one  secures 
the  place,  and  the  others  gradually  fall  into  line.  After 
the  first  or  second  day  out  every  mule  knows  its  place 
in  the  train  and  keeps  it  without  further  trouble. 

Upon,  those  marches  the  animals  subsist  wholly 
upon  the  grasses  which  grow  along  the  route.  When 
they  are  turned  loose  to  graze,  it  is  only  necessary  to 
picket  the  bell  mare,  for  the  mules  will  all  graze 
around  and  never  lose  sight  of  her.  A  thief  needs 
to  get  away  only  with  the  bell  mare  and  all  the  mules 
will  follow.  A  case  once  occurred  in  which  the  bell 
mare  broke  her  picket  rope  on  a  stormy  night  and 
wandered  off,  followed  by  all  the  mules.  She  fell, 
broke  a  leg,  and  perished  in  the  storm.  When  found 
by  the  party  several  days  afterward,  the  dead  mare 
was  surrounded  by  all  the  mules,  and  they  were  dying 
of  hunger  when,  by  wandering  only  a  short  distance 
away,  they  might  have  found  plenty  of  food.  All 
these,  and  others  which  might  be  mentioned,  are  ob- 
viously coltish  traits. 

Mules  are  infertile  because  ovules  are  not  matured 
in  the  ovaries  of  the  females,  nor  spermatozoa  in  the 
testes  of  the  males.  That  is,  there  is  no  complete  de- 
velopment of  the  essential  element  of  sex  in  either 
case  and  consequently  no  correlation  of  that  ele- 
ment w'itii  their  psychological  development.  There- 
fore, psychologically,  the  mule  remains  a  colt  all  its 
life,  although  in  physical  strength  and  general  intelli- 
gence it  is  the  equal  and  often  the  superior  of  either 
parent. 

Smithsonian  Institi-tion,  October  2,  1897. 


Deformities  after  Fracture. — Deformity  after  un- 
successfully treated  fractures  may  be  prevented  or 
relieved  by  refracturing  die  callus  which  unites  the 
fragments.  This  is  occasionally  necessary  in  in- 
stances in  which  no  treatment  has  been  given.  The 
bone  is  bent  across  the  edge  of  a  padded  table  or 
over  the  surgeon's  knee,  and  after  the  band  of  union 
has  been  ruptured  is  treated  as  a  recent  accidental 
fracture.  This  may  be  done  with  success  at  the  ex- 
piration of  even  six  months,  since  the  seat  of  fracture 
remains  weaker  than  the  rest  of  the  bone  for  a  long 
time. — Roberts,  Medical  and  Surgical  Reporter,  Oc- 
tober 31,  1896. 


November  6,  1897] 


MEDICAL    RECORD. 


663 


DIAGNOSIS    BY    BLOOD    EXAMINATION.' 
Bv    II.    W.    FURNISS,    M.D.,    Ph.D., 

INDI.^NAPOLIS. 

That  blood  examinations  have  taken  such  a  stride  of 
late  is  due  to  the  improvement  in  instruments  for 
examination,  differential  stains,  and  consequent  les- 
sened labor  and  increased  accuracy.  About  all  that 
is  necessary  to  be  known  about  the  blood  in  a  given 
case  can  be  ascertained  in  fifteen  minutes,  and  since 
there  are  several  diseases  in  which  it  is  possible  to 
make  a  positive  diagnosis  by  blood  examination  alone, 
several  others  in  which  an  examination  will  materi- 
ally aid  in  diagnosis,  others  in  which  the  negative 
result  obtained  aids  us,  to  say  nothing  of  the  valuable 
assistance  rendered  in  those  cases  in  which  we  cannot 
communicate  with  the  patient  either  because  of  stupid- 
ity, insanity,  age,  maligning,  or  unconsciousness — I 
deem  it  well  worth  even  the  busiest  practitioner's 
time  to  avail  himself  of  this  aid  to  diagnosis,  and 
particularly  so  in  the  case  of  fever,  as  there  is  no  case 
on  which  a  blood  examination  would  not  throw  light. 

To  make  a  thorough  examination  of  blood,  it  is 
necessary  to  find  out  the  following  facts:  Number  of 
red  cells  in  a  given  quantity,  which  is  usually  a  centi- 
metre; number  of  white  cells  in  the  same;  ratio  of 
white  to  red ;  number  of  each  kind  of  white  cells ;  ratio 
to  each  other;  size,  shapes,  peculiarities,  and  contents 
of  cells ;  percentage  of  hemoglobin ;  color  value  or 
relative  amount  of  haemoglobin  per  red  cell;  relative 
amount  of  fibrin;  and  finally,  if  any  substance  other 
than  the  above  occurs,  and  if  so,  of  what  nature. 

The  methods  of  examining  blood,  its  histology,  prep- 
aration of  specimens,  stains  used,  etc.,  have  been  de- 
scribed from  time  to  time  in  the  medical  journals  and 
descriptions  can  be  found  also  in  any  good  book  upon 
the  subject,  so  I  shall  not  take  time  to  review  them. 

Naturally  the  first  diseases  that  my  paper  would 
bring  to  your  mind  are  anaemia  and  chlorosis,  and 
rightly  too,  as  no  little  of  the  diagnosis  and  prognosis 
can  be  told  from  a  blood  examination. 

Ar.£emia  is  a  diminution  in  red  blood  corpuscles, 
haemoglobin,  or  both,  and  is  independent  of  the  color 
of  the  skin  or  the  mucous  membrane.  The  greater 
number  of  times  it  is  impossible  to  tell  pernicious 
anaemia  from  chlorosis  except  by  blood  examination. 
In  the  former  you  nearly  always  have  decrease  in  the 
number  of  cells  and  a  great  alteration,  decrease  or 
increase,  in  size  and  form  of  the  red  corpuscles,  the 
color  value  being  high;  while  in  chlorosis  you  may 
have  decrease  in  red  cells,  but  the  principal  thing  is 
lack  of  cell  ha-moglobin  or  color  value.  Then  we 
may  have  megaloblasts  in  chlorosis,  but  normoblasts 
predominate;  while  the  reverse  is  true  of  ana;mia. 
True,  we  have  fewer  red  cells  in  malignant  disease, 
but  then  we  nearly  always  have  leucocytosis,  which 
will  help  to  distinguish;  then  normoblasts  predomi- 
nate in  malignant  disease,  megaloblasts  in  ancemia. 

Those  diseases  which  do  not  cause  leucocytosis  but 
lessen  corpuscles  do  not  have  megaloblasts  or  high 
color  value,  and  leuksemia  can  always  be  made  out  by 
the  greater  number  of  myelocytes.  In  an.Temia  search 
carefully  for  nucleated  corpuscles,  for  if  any  are  pres- 
ent they  will  aid  much  in  prognosis.  The  presence 
of  megaloblasts  with  no  other  nucleated  forms  is  a 
bad  sign.  It  is  the  kind  of  nucleated  corpuscles  and 
not  the  number  that  is  of  interest — the  ratio  of  mega- 
loblasts to  normoblasts  that  is  important.  Low  color 
index  and  normal  cells  show  improvement  at  the  time; 
high  color  index  is  a  bad  sign. 

In  leukitmia  the  red  cells  are  slightly  diminished,  the 
white  markedly  increased.     About  thirty  per  cent,  of 

'  Abstract  of  paper  read  before  the  Marion  County  Medical  So- 
ciety, February  23,  1897,  and  the  Indiana  State  Medical  Society, 
Terre  Haute,  May  20,  1897. 


the  white  cells  are  myelocytes,  and  in  lymphatic  forms 
ninety  per  cent,  are  lymphocytes.  Leukemia  is  dis- 
tinguished from  Hodgkin's  disease,  which  has  the 
same  symptoms,  by  the  blood  being  normal  in  the  early 
stages  of  the  latter  disease,  and  in  the  later  stages 
not  more  than  a  slight  anaemia  existing. 

It  is  possible  by  a  blood  count  to  diagnose  shock 
of  hemorrhage  from  that  of  concussion  or  compression, 
there  being  a  marked  decrease  in  red  corpuscles  in 
the  former  and  none  in  the  latter.  In  the  same  way 
internal  hemorrhage  can  be  told  from  peritonitis  or 
obstruction,  and  the  advisability  of  an  operation  after 
loss  of  blood  can  be  safely  told  by  estimation  of  the 
ha;moglobin,  any  percentage  lower  than  thirty  being 
a  contraindication. 

Again,  it  is  possible  by  making  a  blood  count  to 
tell  if  one's  patient  has  been  in  reality  fasting,  when 
if  it  is  so  there  will  be  marked  decrease  in  leucocytes; 
but  it  must  be  borne  in  mind  that  diseases  of  the  stom- 
ach and  small  intestine  may  prevent  leucocytosis. 
Then  it  must  be  remembered  that  pregnancy,  violent 
exercise,  cold  baths,  and  massage  may  cause  leucocy- 
tosis, but  in  each  of  these  cases  the  condition  of 
white  cells  remains  about  the  same,  only  that  the 
number  is  increased.  We  may  expect  leucocytosis  to 
be  present  after  hemorrhage  in  malignant  disease  and 
inflammation;  and  absent  in  malaria,  measles,  typhoid 
fever,  and  all  forms  of  tuberculosis. 

Typhoid  fever  is  easily  told  by  Widal's  method  or  by 
Johnson's  modification.  The  diagnosis  depends  upon 
the  fact  that  blood  or  blood  serum  from  a  patient  with 
typhoid  will  cause  a  drop  of  actively  motile  ty-phoid 
bacilli  to  cease  motion  and  clump.  Positive  results 
are  not  always  obtained,  but  they  are  nearly  always. 
Acuteness  or  mildness  of  attack  does  not  seem  to  have 
any  appreciable  difference  on  the  clumping.  John- 
son's method  consists  in  collecting  a  specimen  of 
blood  on  a  sterilized  paper  and  allowing  it  to  dry,  thus 
permitting  transportation — a  great  factor  in  municipal 
laboratory  work.  The  dried  blood  is  dissolved  in  a 
few  drops  of  sterilized  water,  and  a  small  portion  of 
the  solution  added  to  a  drop  of  bouillon  containing  ac- 
tively motile  bacilli.  To  make  a  success  of  the  test, 
it  is  necessary  to  have  a  pure  fresh  culture  of  typhoid, 
and  it  has  been  observed  that  attenuated  cultures  work 
better  than  more  virulent  ones.  The  time  necessary 
for  the  specimen  to  cause  clumping  should  not  exceed 
thirty  minutes,  and  this  clumping  does  not  seem  to  be 
a  killing  of  the  bacilli,  but  just  a  paralyzing.  It  is 
said  that  this  clumping  cannot  be  caused  by  any  other 
disease,  yet  it  is  quite  necessary  that  the  serum  or 
blood  should  be  considerably  diluted,  as  it  has  been 
observed  that  sometimes  healthy  blood  may  cause  this 
reaction,  while  typhoid  blood  diluted  one  to  thirty 
will  produce  it. 

Pneumonia  is  distinguished  from  typhoid,  malaria, 
or  plain  influenza,  when  only  symptoms  are  present  and 
no  physical  signs,  by  the  marked  leucocytosis  of  the 
first-named  disease.  There  is  no  means  of  diagnosing 
pneumonia  from  capillary  bronchitis.  In  pneumonia 
there  is  always  a  marked  fibrin  network.  So  far  as 
prognosis  goes,  the  absence  of  leucocytosis  is  always 
an  unfavorable  sign,  unless  the  case  is  of  the  mildest 
kind,  while  its  presence  leaves  the  matter  in  doubt, 
though  favorable  for  recovery. 

Septicaemia  can  be  diagnosed  by  bacteriological 
examination  of  the  blood;  rheumatism  and  diphtheria 
cannot  be  told;  and  the  grippe,  according  to  Cannon, 
can  be  diagnosed  by  finding  the  specific  micro- 
organism in  stained  specimens  of  the  blood. 

Scarlet  fever  is  distinguished  from  measles,  in  that 
the  latter  never  has  leucocytosis,  while  the  former 
always  has.  In  scarlet  fever  eosinophiles  are  absent 
in  bad  cases  and  increased  in  favorable  cases. 

Appendicitis  cannot  be  told  from  pus  tubes  by  exam- 


664 


MEDICAL    RECORD. 


[November  6,  1897 


ination  of  the  blood,  but  can  be  told  from  colic,  con- 
stipation, floating  kidney,  ovarian  or  pelvic  neuralgia, 
gall  stone  and  renal  colic,  if  uncomplicated,  because 
of  the  leucocytosis  in  the  former  and  the  lack  of  it  in 
all  other  cases. 

Cholera  can  be  diagnosed  in  much  the  same  way  as 
typhoid  fever,  blood  from  a  cholera  patient  causing  a 
cessation  of  motion  of  cholera  germs. 

In  peritonitis  we  have  marked  leucocytosis  and 
increase  in  fibrin  network,  but  there  is  no  leucocytosis 
in  tuberculous  peritonitis,  and  it  may  thus  be  diag- 
nosed. 

Pericarditis  with  effusion  can  be  told  from  hyper- 
trophy or  dilatation  on  account  of  the  marked  leuco- 
cytosis in  the  former  case. 

In  meningitis  we  always  have  leucocytosis,  while 
in  no  other  form  of  intracranial  disease  except  abscess 
and  apople.xy  do  we  have  this  phenomenon.  On 
account  of  the  always-present  leucocytosis,  meningitis 
can  be  told  from  typhoid,  which  it  simulates,  but  can- 
not be  told  by  blood  examination  from  pneumonia. 

Justus  claims  to  be  able  to  diagnose  syphilis  before 
the  secondary  symptoms  have  appeared.  He  first 
estimates  the  percentage  of  haemoglobin,  then  gives 
inunction  or  injection  of  mercury,  and  finds  that  the 
haemoglobin  falls  from  ten  to  twenty  per  cent,  in  a 
day,  which  he  attributes  to  the  action  of  the  mercury 
on  the  weaker  blood  cells.  After  a  few  days  this 
marked  diminution  is  followed  by  a  gradual  rise,  and 
soon  the  percentage  of  haemoglobin  is  higher  than  it 
was  before.  He  claims  that  syphilis  is  the  only 
disease  in  which  the  facts  stated  occur.  Blood  exam- 
inations otherwise  are  negative,  except  so  far  as  indi- 
cating the  severity  of  the  affection,  large  numbers  of 
young  white  cells  and  small  percentage  of  haemoglobin 
being  diagnostic  of  severer  cases.  Cases  having 
myelocytes  are  serious,  while  we  look  for  leucocytosis 
after  the  primary  stage. 

According  to  Bremmer,  of  St.  Louis,  it  is  possible 
to  diagnose  diabetes  by  blood  examination  long  before 
it  could  otherwise  be  told.  His  method  is  simple. 
He  heats  two  blood  films,  one  normal  and  the  other  of 
suspected  blood,  in  a  hot-air  sterilizer  for  six  or 
seven  minutes,  at  a  temperature  of  135°  C.  He  then 
allows  the  specimens  to  cool,  and  when  cold  he  e.xposes 
the  two  to  a  one-per-cent.  aqueous  solution  of  Congo 
red  or  methyl  blue  for  two  minutes,  when  the  normal 
blood  M'ill  be  stained  red  or  blue  according  to  the  color 
used,  and  the  other  if  diabetic  will  resist  the  action  of 
the  stain. 

In  purpura  ha;morrhagica,  haemophilia,  and  scurvy, 
diseases  in  which  you  would  expect  to  learn  a  great 
deal  from  blood  examination,  there  is  little  or  no 
characteristic  change. 

In  examining  the  blood  for  malaria,  it  is  best  to 
take  the  specimen  before  or  after  the  chill,  as  then  the 
Plasmodium  is  larger  and  is  pigmented.  It  does  not 
take  much  skill  to  find  the  plasmodium,  provided  you 
know  what  you  are  looking  for  and  are  patient  and 
painstaking;  and  once  you  find  it,  it  will  be  quite  easy 
in  the  future  to  recognize  it.  Staining  has  its  advan- 
tages, as  by  it  it  is  easier  to  see  the  organism  and  one 
can  examine  it  at  one's  leisure;  also  there  is  not  the 
danger  of  confusing  the  plasmodium  with  other  things 
found  in  the  blood.  The  best  stain  to  use  is  Phlen's, 
which  is  a  combination  of  eosin  dissolved  in  alcohol, 
and  methylene  blue.  The  blue  stains  the  Plasmo- 
dium itself,  and  the  corpuscular  substance  is  in  contrast 
stained  pink.  In  all  cases  of  suspected  malaria  the 
blood  sliould  be  examined,  as  clinical  symptoms  alone 
often  warrant  a  diagnosis  of  malaria  when  tuberculosis, 
syphilis,  septic  infection,  or  something  else  is  the  true 
cause  of  the  symptoms. 

Pleurisy  may  be  diagnosed  from  empyema,  pneumo- 
nia, and  malignant  lung  trouble,  and  cyst  of  kidney 


from  perinephritic  abscess,  by  the  absence  of  leucocy- 
tosis. 

Holmes,  of  Denver,  claims  to  be  able  to  diagnose 
tuberculosis,  even  in  its  earliest  stages,  by  blood  ex- 
amination, even  when  it  is  impossible  to  tell  it  either 
by  physical  signs  or  sputum  examination.  He  bases 
his  theory  upon  the  assertion  that  each  individual  has 
a  biological  prototype  in  the  leucocytes  of  his  own 
blood.  He  further  claims  the  following  characteris- 
tics of  tuberculous  blood :  "  Marked  deviation  from 
normal  percentage  of  all  varieties  of  leucocytes.  Great 
decrease  in  percentage  of  small  lymphocytes.  Usu- 
ally marked  increase  in  percentage  of  large  lympho- 
cytes. Many  giant  lymphocytes  with  irregular  contour 
and  protruding  globules  of  hyaloplasm.  Eosinophile 
cells  absent  or  few  in  number  only  in  severe  cases. 
Myelocytes  occasionally  present.  Marked  cell  disin- 
tegration. Many  groups  of  dc'bris  from  disintegrating 
leucocytes.  Phagocytes  with  indistinct  cell  contour 
and  granules  few  in  number,  poorly  stained,  and  scat- 
tering. Marked  irregularity  in  size  and  appearance 
of  phagocytes,  dwarf  phagocytes  as  small  as  small 
lymphocytes,  giant  phagocytes  double  usual  size,  with 
five  or  more  nuclei.  Often  a  clear  narrow  and  sharply 
defined  ring  separating  the  nucleus  from  the  cell  body 
in  small  and  large  lymphocytes.  Phagocytes  with 
granules  taking  a  basophilic  tint,  evidence  of  ap- 
proaching dissolution.  Grouping  together  of  a  large 
number  of  phagocytes  observed  before  dissolution. 
Very  little  disintegration  of  red  cells." 

Finally,  the  examination  of  blood  in  post-operative 
pyrexia  is  of  value  to  determine  if  pus  is  present,  as 
with  pus  there  is  always  leucocytosis. 

New  132  West  New  York  Street. 


MEDICAL   AND    SURGICAL    ICONOCLASM. 

By    MARVIN    L.    GRAVES,    M.A..    M.D., 

WACO,    TEXAS. 

Art  admits  no  model  but  perfection.  Science  permits 
no  result  but  truth.  Medicine  acknowledges  its  em- 
piricism;  surgery  its  experimentalism.  Evolution  and 
revolution  have  touched  and  inliuenced  every  thougkt 
known  to  man.  Scepticism  has  been  the  point  01  ori- 
gin of  many  truths.  Agnosticism  has  been  tlie  inva- 
riable and  essential  accompaniment  of  many  facts, 
finally  demonstrated  and  accepted.  Doubt,  question, 
and  negation  have  resulted  in  greater  progress  than 
ignorant  affirmation  or  blind  belief  ever  accomplished. 
Interrogation  and  investigation  will  never  injure  truth 
nor  aid  error.  In  seeking  to  draw  your  attention  to 
iconoclasm  and  its  always  preceding  or  accompanying 
scepticism  or  agnosticism,  no  reference  whatever  is 
made  to  the  use  of  these  terms  in  religion.  They  have 
their  practical  application  to  the  creed  and  practice 
of  our  profession.  Iconoclasm  literally  means  the 
smashing  of  idols  or  images,  and  it  denotes  either 
partial  or  complete  destruction  of  the  object  together 
with  the  accompanying  superstition  or  fanaticism 
attending  its  existence.  Medical  and  surgical  icono- 
clasm means  the  destruction  of  false  theories  and 
wrong  and  harmful  practice  in  medicine  and  surgery. 
It  means  that  the  cold,  critical,  searching  flashlight 
of  experiment  and  investigation  will  dedirone  error 
and  enthrone  truth.  It  means  the  exposure  of  all 
forms  of  sham  and  deception,  accidental  or  intentional. 
It  means  the  unmasking  of  charlatanr}',  whether  inside 
or  outside  the  regular  profession.  It  means  the 
total  rejection  of  harmfid  doctrine  and  evil  practice, 
wheresoever  found.  It  means  that  the  insanities  of 
spiritualism,  the  frauds  of  Christian  science,  and  the 
hollow  pretences  of  vitapathy  and  magnetism,  and  all 
other   medical    and    surgical    isms    and    pathies    not 


November  6,  1897] 


MEDICAL    RECORD. 


665 


founded  on  truth  and  supported  by  reason,  shall  fall 
beneath  the  guillotine  of  an  art  that  is  skilful  and  of 
a  science  that  is  inexorable.  But  iconoclasm  is  not 
merely  destructive ;  it  is  also  constructive  by  reflex 
action.  It  is  creative  by  reaction.  It  may  tear  down, 
but  it  will  also  build  up.  The  one  may  be  radical, 
the  other  may  be  conservative,  yet  when  the  pendulum 
ceases  from  its  excessive  oscillations  to  and  fro  it  is 
almost  certain  it  will  then  traverse  an  arc  of  right  and 
safety.  Life  in  nature  is  said  to  come  through  death. 
Sacred  Writ  hath  taught  this  great  lesson  in  the  "  corn 
of  wheat."  Certain  it  is  that  in  the  creative  chemistry 
of  nature  and  the  artificial  laboratory  there  is  a  change, 
a  transformation,  if  not  an  actual  destruction  of  one 
or  more  elements  in  the  formation  of  another. 
Through  this  process  of  destruction  a  newer  and  per- 
chance a  better  life  is  born.  Theories  and  doctrines 
have  passed  unquestioned  from  century  to  century,  till 
some  earnest,  honest  sceptic  began  to  doubt,  then 
question,  then  deny — 

"  Till  out  of  the  darkness  future  brightness  is  bom. 
As  after  the  night  comes  the  sunrise  of  mom." 

Gravitation  and  the  revolution  of  the  heavenlj-  bodies 
never  met  their  correct  explanation  till  Newton  and 
Kepler,  the  iconoclasts  of  astronomy,  disproved  a  host 
of  false  theories,  smashed  the  idols  of  error,  and 
established  truth. 

The  pivotal  point  of  modern  progress  is  the  "  origin 
of  species"  and  Charles  Darwin's  iconoclasm  of  hoary- 
headed  errors.  The  inspiration  of  the  new  phil- 
osophy was  born  in  the  death  agonies  of  the  old. 
What  may  be  said  of  the  fanciful  and  foolish  notions 
of  the  circulation  of  the  blood,  of  the  different  func- 
tions of  nerve  and  nerve  cells,  of  the  pathology  of 
disease,  before  Harvey  and  Bell  and  Bernard  and  Char- 
cot, mighty  men  of  genius,  medical  and  surgical  icon- 
oclasts, whose  scientific  minds  revolted  at  error  and 
never  failed  or  faltered  till  modem  physiolog}'  and 
pathology  were  established  on  accurate  foundations? 
Who  but  an  iconoclast  like  Lord  Lister  disputed 
the  darkest  of  surgical  heathenisms  and  illuminated 
the  entire  field  of  surgery  by  asepsis  and  antisepsis? 
Who  but  iconoclast  Koch  rejected  the  erroneous  doc- 
trines of  tuberculosis  and  cholera,  and  after  years  of 
patient  uncomplaining  toil  demonstrated  their  germal 
origin  and  erected  a  triumphal  arch  under  which  shall 
yet  pass  successful  treatment?  Who  but  Marion  Sims 
doubted  and  denied  the  older  practice  of  gjnfficology 
and  revolutionized  this  branch  of  surgery  throughout 
the  civilized  world?  Who  but  Jenner  and  Pasteur 
tore  aside  the  cobwebs  of  ignorance  and  superstition 
from  small-pox  and  hydrophobia,  and  gave  to  suffer- 
ing, terror-stricken  humanit}'  a  hope  and  a  practice 
that  have  saved  multitudes  of  lives?  In  the  reactionar)' 
construction  which  follows  destruction,  it  matters  not 
whether  each  reformer  or  revolutionist  himself  estab- 
lished the  complete  truth.  He  may  have  only  blazed 
the  path  and  destroyed  monster  obstacles,  and  later 
investigators,  led  on  by  his  flickering,  perhaps  feeble, 
but  never-dying  light,  have  solved  the  problems  and 
blessed  humanity.  It  was  not  necessary  for  Semmel- 
weiss  to  live  to  see  every  obstetrician  acknowledge 
that  puerpera*  fever  was  a  septic  disease  and  due  to 
infection  by  the  surgeon  at  delivery.  It  was  not  nec- 
essary for  the  immortal  Long  to  live  to  see  anasthesia 
practised  in  every  hamlet  on  the  globe  and  agonizing 
pain  relieved  under  its  blessing.  It  was  necessary 
that,  amid  ridicule  and  derision,  they  gave  to  the  world 
a  new  thought  and  improved  practice.  Nowhere  in 
all  the  realm  of  science  and  art  have  scepticism  and 
agnosticism  been  more  truly  the  stepping-stones  and 
starting-points  of  progress — real,  true,  beneficent  ad- 
vance— than  in  medicine  and  surger}-.     In  the  very 


nature  of  our  art  empiricism  and  experimentation  were 
necessary. 

Kxactitude  was  impossible,  perfection  unattainable, 
when  knowledge  was  minus  and  ignorance  plus — ■ 
when  so  many  factors,  as  heredity,  season,  climate,  age, 
constitution,  and  incomplete  pharmacy,  blocked  the 
way.  Out  of  all  these  difficulties  patient  investiga- 
tion has  tabulated  results,  until  to-day  etiology,  physi- 
ology, and  pathology  have  much  of  certainty,  and 
diagnosis,  prognosis,  and  treatment  are  growing  more 
exact  and  more  certain.  But  the  mountain  top  has  not 
yet  been  reached.  Many  fogs  and  sloughs  and  quag- 
mires still  remain.  Modern  medical  science  is  throw- 
ing the  searchlight  full  upon  some  modern  fads  and 
fancies,  and  exposing  some  deep-rooted  fallacies.  Of 
all  men,  the  physician  of  to-day  is  the  most  sceptical. 
It  is  only  after  the  most  thorough  trial  and  careful 
examination  that  he  gives  his  approval  to  the  theory  of 
post  hoc  ergo  propter  hoc.  He  waits,  he  watches,  and 
tries  each  new  remedy  or  operation  suggested  or  doc- 
trine expounded,  before  he  adds  his  sanction  or  ex- 
presses his  rejection.  Eversthing  is  rigidly  tested: 
eclecticism  in  its  broadest  and  truest  interpretation 
demands  it.  Humanity,  the  victim  or  grateful  bene- 
ficiary, demands  it.  No  great  man's  ipse  dixit  will 
now  make  tuberculin  cure  consumption  or  antitoxin 
destroy  diphtheria. 

Let  me  point  out  to  you  some  of  the  dangers  that  will 
threaten  us  if  we  lose  this  spirit  of  beneficent  icono- 
clasm in  our  professional  work.  We  do  not  record  ac- 
curately and  fully  our  cases  in  detail.  We  do  not  take 
time  to  study  fully  the  disease  we  treat.  We  do  not  ex- 
amine each  case  and  note  all  signs  and  symptoms.  We 
do  not  group,  tabulate,  and  analyze  series  of  cases,  and 
thus  get  at  correct  conclusions.  We  do  not  report  or 
write  up  our  cases  and  subject  them  to  the  kindly 
criticism  and  discussion  of  the  profession.  Our  haste 
and  inaccurate  style  are  illustrated  in  the  following: 
How  many  of  us,  called  to  a  man  suffering  intense 
pain,  ever  stop  to  examine  him  carefully  before  shoot- 
ing a  hypodermic  of  morphine  into  his  arm?  Admit 
the  immediate  necessity  of  relief — how  many  of  us 
leave  the  house  when  pain  has  ceased  without  further 
effort  to  find  out  what  really  was  the  matter?  How 
often,  when  asked  to  prescribe  for  piles,  we  write  a 
prescription  without  even  requesting  an  examination 
or  knowing  the  condition,  and  later  find  the  patient 
in  the  hands  of  an  advertising  quack,  being  cured 
of  ulcer  in  the  rectum?  How  frequently  complaint 
of  headache  receives  a  routine  prescription  without 
question,  when  urasmic  toxsemia  or  uterine  disorders 
are  the  offenders?  How  often  does  a  uric-acid  storm 
or  a  bilious  attack  find  itself  labelled  malarial  fever 
and  cured  in  twelve  hours  with  calomel  and  quinine 
and  arsenic?  How  frequently  does  a  slight  dermatitis, 
insignificant  in  nature  and  effect,  flame  out  a  violent 
erj-sipelas  and  require  all  the  skill  of  Dr.  Blowhard 
to  cure  it  in  two  days?  How  often,  ohl  how  often  is 
typhoid  fever  turned  into  febricula  and  chased  off  the 
field  of  action  in  four  days  by  the  specific  treatment 
of  Dr.  Greatman?  How  frequently  is  an  ordinary 
bronchitis  with  engorged  liver  and  pain  in  the  side 
kept  under  dim  gaslight  and  slippered  tread  and  whis- 
pered consultation  for  tw o  weeks ;  or,  on  the  other 
hand,  a  terrible  pneumonia  throttled  in  twenty-four 
hours  by  the  heroic  treatment  of  Dr.  Allgas? 

Let  not  criticism  assume  a  personal  form  or  question 
smite  an  individual.  It  matters  but  little  that  the  full 
value  of  hydrotherapy  has  been  established  by  hydrop- 
athists  as  a  clique.  It  matters  but  little  that  simpler 
methods  and  smaller  doses  have  been  the  results  of 
homoeopathy  as  a  sect.  It  matters  but  little  that  many 
new  and  reliable  drugs  have  been  introduced  by  eclec- 
ticism as  a  faction.  It  matters  still  less  that  spirit- 
ualism and  Christian  science  as  creeds  have  estab- 


666 


MEDICAL   RECORD. 


[November  6,  1897 


lished  hypnotism  and  suggestive  theraf)eutics.  But  it 
matters  much  that  whatsoever  doctrine  advanced  shall 
be  truth ;  that  whatsoever  remedy  offered  shall  be  good. 
It  matters  much  that  education  is  getting  broader  and 
more  catholic;  that  art  demands  skill,  science  com- 
mands exactness.  It  matters  much  that  physicians  are 
learning  that  they  can  no  longer  diagnose  a  simple 
urethritis  as  a  virulent  gonorrhcea,  and  cure  the  pa- 
tient in  two  days;  that  the  victim  of  a  cough  can  no 
longer  be  called  consumptive  and  cured  with  a  patent 
consumption  cure — when  microscopical  analysis  of 
the  former  shows  absolutely  no  gonococci,  and  laryn- 
geal exploration  of  the  latter  shows  a  polyp  easily  re- 
moved. It  matters  much  that  dropsy  can  no  longer 
be  attributed  to  jaundice,  but  under  the  blaze  of 
science  reveals  its  cardiac,  renal,  hepatic,  or  abdomi- 
nal origin.  It  matters  much  that  typhoid  fever  can 
no  longer  be  purged  with  calomel  and  tortured  with 
quinine,  when  proper  nourishment  and  careful  nursing 
will  tide  the  patient  through.  It  matters  much  that 
everything  is  no  longer  congestion  and  the  stomach 
no  longer  a  swilltub  into  which  may  be  poured  all  the 
refuse  of  the  pharmacists.  It  matters  much  that  our 
doctors  are  once  again  learning  that  water  properly 
applied,  the  stomach  wisely  preserved,  nutrition  sup- 
ported, and  vitality  stimulated,  will  save  many  a  life 
when  polypharmacy  will  dig  many  a  grave.  It  mat- 
ters much  that  nervous  exhaustion  is  now  not  always 
due  to  overwork  and  loss  of  sleep,  when  we  know  the 
patient  never  worked  three  hours  a  day  and  sleeps 
nine  out  of  twenty-four.  It  matters  much  that  thirty 
grains  of  calomel  are  no  longer  specific  for  constipa- 
tion and  torpij  liver,  and  orange  blossoms  can  no 
longer  be  applied  to  the  vagina  for  endometritis.  It 
matters  much  that  poultices  are  no  longer  applied  to 
ruptured  tubal  pregnancies  and  that  iodine  is  no  longer 
painted  over  large  pelvic  abscesses.  It  matters  much 
that  a  little  uterine  inertia  is  no  longer  the  occasion 
for  the  application  of  the  long  forceps  and  the  com- 
bined strength  of  Hercules  and  Samson  to  tear  a  child's 
head  through  a  safe  passage  with  tremendous  velocity, 
when  thirty  grains  of  quinine  or  two  ounces  of  sugar 
will  deliver  the  babe  safely  at  the  end  of  forty  minutes 
and  still  leave  the  mother  a  cervix,  a  urethra,  and  a 
perineum.  It  matters  much  that  public  sentiment  and 
professional  conscience  no  longer  allow  every  tvro  to 
open  bellies  indiscriminately  in  search  of  ovaries  with 
imaginar)-  inflammation  or  tumors  of  doubtful  exist- 
ence. 

Then,  all  hail  iconoclasm  in  its  active  destruction 
and  its  reactionary  construction  of  safe  practice  and 
legitimate  surgery ! 

600  .\IST1N   AlE.srt. 

Sprains  and  their  Treatment.— (iraham  delines 
a  sprain  as  a  wrench  or  twist  of  a  joint;  a  sudden, 
partial  displacement  of  two  articulating  surfaces,  fol- 
lowed by  immediate  replacement.  The  symptoms  in- 
clude pain,  swelling,  discoloration,  and  usually  heat, 
with  impaired  mobility.  The  diagnosis  may  be  ob- 
scured by  swelling,  which  may  conceal  also  a  fracture 
of  bone.  Whatever  will  quickly  reduce  the  heat,  the 
pain,  and  the  swelling— such  as  massage,  snug  ban- 
daging, and  an  elevated  position  of  the  joint—  will  pro- 
portionately make  the  diagnosis  easier.  The  means 
just  mentioned  are  therefore  valuable  not  onlv  for 
diagnosis,  but  also  for  treatment;  and  their  use  in 
many  cases  of  sprains  of  all  degrees  of  severity  shows 
that  recover)' follows  in  one-third  of  the  time  required 
under  absolute  rest  and  fi.xed  dressings  without  mas- 
sage. Even  the  condition  of  a  sprain  involving  a 
joint  previously  weakened  by  malignant  disease  may 
be  rapidly  ameliorated  by  massage,  and  useful  motion 
be  gained  before  amputation.-  /Boston  Medical  and 
Surgical  Journal.  June  17  and  24,  1897. 


progress  ot  Medical  J>ciencc. 

Acute  Partial  Enterocele — Upon  this  subject  Stahl 
{Journal  of  the  American  Medical  Association,  October 
2,  1897,  p.  683)  reaches  the  following  conclusions:  i. 
Acute  partial  enterocele  does  occur.  2.  The  symp- 
toms of  this  condition  are  of  a  milder  type  than  those 
of  an  acute  complete  enterocele;  if  it  is  strangulated, 
the  vomiting  is  not  stercoraceous  and  constipation  not 
absolute.  Exceptionally  the  reaction  is  so  slight  that 
the  condition  continues  unrecognized.  3.  Because  of 
mildness  of  symptoms,  smallness  of  size,  and  tendency 
to  disappear,  it  requires  most  careful  differentiation. 
4.  Acute  partial  enterocele  is  to  be  especially  differ- 
entiated in  its  early  forms  from  a  large  inguinal  gland  : 
in  its  later  or  inflammatory  form  from  suppurative 
adenitis.  5.  The  acute  form  of  partial  enterocele,  if 
not  relieved,  either  induces  the  usual  reactionary 
changes  of  an  acute  hernia  or  it  is  converted  grad- 
ually into  the  chronic  form  of  partial  enterocele.  6. 
The  treatment  consists  in  reduction  by  taxis  or  in 
herniotomy. 

Foot-and-Mouth  Disease. — Loeffler  and  Frosch 
(Deutsche  medicinische  ll'ochcnschri/t,  September  23, 
1897,  p.  617),  constituting  a  commission  appointed  to 
investigate  foot-and-mouth  disease,  report  the  follow- 
ing summary  of  the  conclusions  reached  by  them:  (i) 
All  of  the  bacteria  hitherto  described  as  the  exciting 
cause  of  this  disease  have  been  accidental  associa- 
tions. The  disease  can  be  induced  by  inoculation 
with  sterile  lymph  obtained  from  the  vesicles,  which 
contains  morphotic  elements  of  various  kind.  Proto- 
zoa have  not  been  demonstrated  as  the  causative 
agents.  (2)  Beef  and  swine  have  been  also  shown 
experimentally  to  be  especially  susceptible  to  the  dis- 
ease. Sheep  and  goats  could  not  be  infected  arti- 
ficially at  first,  as  well  as  dogs,  rabbits,  guinea-pigs, 
ordinary  mice,  field-mice,  and  fowl.  (3)  The  most 
certain  mode  of  infection  consists  in  the  injection 
into  the  circulation  of  lymph  obtained  from  vesicles. 
Infection  could  be  induced  also  by  injection  of  such 
lymph  into  the  abdominal  cavit)-  and  into  the  muscles, 
as  well  as  by  its  introduction  into  the  mucous  mem- 
brane of  the  mouth  previously  injured  by  puncture. 
Uncertain  results  followed  subcutaneous  and  cutane- 
ous inoculation.  In  animals  inoculated  by  intra- 
venous injection  vesicles  appeared  first  in  the  mouth, 
and  in  milch  cows  upon  the  udders,  after  the  lapse  of 
from  one  to  three  days — in  accordance  with  the  amount 
and  virulence  of  the  lymph — in  conjunction  w'ith 
febrile  manifestations,  and  one  or  two  days  later  ves- 
icles appeared,  first  upon  the  extremities.  Both  sets 
of  vesicles  are  thus  to  be  attributed  to  virus  circulat- 
ing in  the  blood  and  not  to  direct  infection  from  the 
skin.  W'ith  the  development  of  the  vesicles  the  virus 
disappears  from  the  circulation.  4.  To  effect  inocu- 
lation with  certainty,  one-five-thousandth  of  a  cubic 
centimetre  of  fresh  lymph  was  sufficient  Smaller 
quantities  up  to  one-twenty-thousandlh  cubic  centi- 
metre were  uncertain  in  their  effects,  and  still  smaller 
quantities  were  innocuous.  (5)  The  lymph  was  ren- 
dered innocuous  when  heated  to  37°  C.  for  twelve 
hours,  or  to  70°  C.  for  half  an  hour,  and  also  on  drj-ing 
for  twenty-four  hours  at  summer  temperature.  Pre- 
.served  in  refrigerators,  the  lymph  inclosed  within  ca- 
pillar}- tubes  retained  its  virulence  for  fourteen  days, 
at  times  even  longer.  Individual  germs  proved  capa- 
ble of  continued  existence  for  eight  or  nine  weeks. 
Large  quantities  of  lymph  were  necessary  to  induce 
infection.  (6)  In  opposition  to  prevailing  views  it 
was  demonstrated  that  immunity  was  conferred  upon 
infected  animals  two  or  three  weeks  after  recover)-  from 
an  attack.     On   the  one  hand  some  animals  are  natu- 


November  6,  1897] 


MEDICAL    RECORD. 


667 


rally  immune,  while  on  the  other  hand  others  are  ex- 
tremely susceptible.  The  latter  are  not  rendered  im- 
mune by  a  single  attack,  but  more  fully  so  by  a  sec- 
ond. The  blood  of  immunized  animals  contains  sub- 
stances which  when  mixed  with  fresh  lymph  seem 
capable  of  neutralizing  the  effects  of  the  latter  in  sus- 
ceptible animals.  (7)  Beef  and  swine  can  be  immu- 
nized artificially  by  means  of  injections  of  lymph 
warmed  until  its  infectiousness  is  removed,  as  well  as 
by  injection  of  mixtures  of  lymph  and  blood  from 
immune  animals.  The  majority  of  animals  were  ren- 
dered immune  by  a  single  injection,  which  apparently 
induced  no  bad  effects.  (8|  It  thus  appears  scientifi- 
cally demonstrated  that  foot-and-mouth  disease  can  be 
successfully  treated  by  means  of  protective  inoculation. 

Successful  Treatment  of  a  Large  Aneurism  of 
the  Aorta  by  Increasing  Artificially  the  Coagula- 
bility of  the  Blood.  -- At  a  recent  meeting  of  the 
Academic  de  Medecine,  Lancereaux  {Deutsche  medi- 
cinische  Wiuhenschrijt,  August  12,  1897)  reported  the 
case  of  a  man  with  an  aneurism  of  the  ascending 
aorta,  as  large  as  a  child's  head,  which  had  eroded  a 
portion  of  the  sternum  and  the  cartilages  of  several 
ribs,  was  palpable  immediately  beneath  the  skin,  and 
appeared  about  to  rupture.  I'pon  the  basis  of  pre- 
vious experiments  upon  animals,  an  attempt  was  made 
bv  means  of  injections  of  gelatin  to  increase  the  coag- 
ulability of  the  blood,  in  order  to  augment  the  forma- 
tion of  clots  along  the  v\all  of  the  sac.  Accordingly 
injections  were  made  in  the  gluteal  region,  until  in 
the  course  of  t«o  months  the  amount  of  gelatin  in 
solution  injected  equalled  more  than  two  quarts.  In 
the  mean  time  the  tumor  became  firmer  and  di^'inctly 
reduced  in  size,  although  some  pulsation  continued  to 
be  transmitted.  The  severe  subjective  discomfort 
present  at  first  wholly  disappeared,  so  that  the  patient 
declined  to  continue  the  treatment  longer. 

The  Treatment  of  Tympanites.  —  Porter  \Mtd- 
kal  News,  July  31,  1897,  p.  134)  contends  that  intra- 
intestinal  tympanites  often  causes  death  in  patients 
suffering  from  abdominal  and  pelvic  disease,  and  that 
it  may  do  so  also  in  cases  in  which  the  abdominal 
and  pelvic  organs  are  free  from  disease.  Tympanites 
occurring  in  the  course  of  any  serious  illness  should 
be  considered  a  symptom  of  ill  omen,  and  measures 
for  its  relief  should  be  promptly  instituted.  If  relief 
fails  to  attend  the  use  of  cathartics,  posture,  enemata, 
and  the  rectal  tube,  cotliotomy  and  incision  of  the 
bowel  should  be  undertaken  without  delay.  In  cases 
of  general  peritonitis  and  obstruction  of  the  bowel,  no 
trial  should  be  made  of  other  methods,  but  cceliotomy 
and  incision  of  the  bowel  should  be  undertaken  as 
soon  as  the  diagnosis  is  made.  Puncture  of  the  bowel 
should  be  practised  only  in  cases  in  which  the  patient 
is  in  extremis,  and  then  only  in  cases — such  as  those 
of  typhoid  fever  without  perforation,  pneumonia,  etc. 
— which  present  no  other  indication  for  cceliotomy 
than  the  tympanites  itself. 

The  Prophylactic  Utility  of  the  Diphtheria  Anti- 
toxin. —  The  Roman  correspondent  of  the  British 
ytedieal  Journal  cites  the  report  of  an  epidemic  of 
diphtheria  in  the  town  of  Baricella.  in  the  province  of 
Hologna,  the  progress  of  which  was  arrested  by  pre- 
ventive injections  of  the  diphtheria  antitoxin.  The 
outbreak  developed  among  a  population  of  fifty-five 
hundred  jiersons,  exposed  to  the  worst  possible  hy- 
gienic and  dietetic  conditions.  Fifty-eight  case.s 
occurred  in  the  course  of  a  few  months.  Of  this  n\im- 
ber  fifty-four  were  treated  with  the  antitoxin  of  diph- 
theria, with  five  deaths — a  mortality  of  8.6  per  cent. 
The  usual  prophylactic  measures,  i.e.,  isolation,  disin- 
fection, closure  of  the  schools,  etc.,  failed  to  bring  the 


epidemic  to  an  end.  Recourse  was  therefore  bad  to 
preventive  inoculations  on  a  large  scale,  four-fifths  of 
the  children  of  the  poor,  between  one  and  twelve  years 
of  age.  receiving  the  treatment.  At  once  new  cases 
failed  to  appear  among  the  vaccinated  children,  al- 
though they  continued  to  develop  with  their  previous 
frequency  among  those  not  subjected  to  the  prophylac- 
tic treatment:  and  the  epidemic  was  soon  brought  to 
an  end. 

The  Treatment  of  Lupus  Vulgaris  with  the  New 
Tuberculin. — Morris  and  Whitfield  report,  in  the 
British  Medical  Journal  oi  July  24,  1897,  six  cases  of 
lupus  vulgaris  submitted  to  treatment  by  means  of  in- 
jections of  the  new  tuberculin  of  Koch,  and  summarize 
as  follows  the  eflfects,  in  the  order  in  which  they  were 
obser\ed:  A  diminution  of  the  surrounding  halo  of 
redness  in  those  cases  in  which  this  had  been  present 
to  a  marked  degree  before  the  commencement  of  the 
treatment;  in  cases  in  which  there  were  simply  yel- 
lowish-brown nodules  in  a  white  scar,  the  injections 
produced  no  visible  elfect  at  this  stage.  The  next 
change  noticed  was  a  slight  depression  in  the  centre 
of  the  nodules,  leading  to  wrinkling  and  later  to  des- 
quamation of  the  cuticle.  Then  there  occurred  a 
steady  healing  of  all  ulcerated  surfaces,  and  slow  sub- 
sidence of  the  previously  permanent  oedema  of  the 
lips,  ears,  etc.  In  two  cases  actual  disappearance  of 
the  characteristic  lupus  nodules  was  obser\-ed.  In 
Dther  cases  there  was  distinct  shrinking  of  nodules, 
with  diminution  in  the  scaling  of  the  surface.  An- 
other eflect  of  the  injections  was  the  softening  and 
flattening  of  pre-existing  scars.  In  no  case  was  there 
the  slightest  progress  after  tlie  institution  of  the  treat- 
ment. In  the  sequence  of  the  injections  there  was  at 
first  little  or  no  reaction,  although  in  some  cases  a 
feeling  of  heaviness  and  drowsiness  was  complained 
of.  When  the  larger  doses  were  reached  there  was 
considerable  febrile  disturbance,  sometimes  with  head- 
ache and  pains  in  the  limbs,  and  even  some  trouble  in 
breathing,  and  a  general  feeling  of  depression,  with 
broken  sleep.  Locally  the  erythema  was  generally  in- 
creased, and  the  whole  aff^ected  area,  including  even 
old-standing  cicatricial  tissue,  was  swollen.  In  two 
cases  in  which  there  were  sound  scars,  probably  from 
previous  lupus,  no  reaction  was  observed  in  the  scars. 
The  phenomena  of  reaction  quickly  disappeared  and 
were  followed  by  a  better  feeling  on  the  part  of  the 
patients.  On  the  whole,  the  opinion  is  expressed  that 
the  local  effects  of  the  new  tuberculin  in  the  cases  of 
lupus  vulgaris  in  which  it  was  employed  were  uni- 
formly good,  in  some  cases  distinctly  brilliant.  The 
constitutional  disturbance  was  in  no  sense  severe  and 
always  of  a  transitory  character.  As  far  as  could  be 
judged,  the  injections  did  no  harm. 

Multiple  Neuritis  Following  Influenza.  —  Al- 
lyn,  writing  in  \h&  Journal  of  the  American  Medical 
Association,  July  24,  1897,  reports  several  cases  of 
multiple  neuritis  following  attacks  of  influenza,  and 
from  these  and  a  study  of  the  literature  of  the  subject 
he  reaches  the  conclusion  that  inriuenza,  like  other 
infectious  diseases,  may  be  followed  by  neuritis  and 
multiple  neuritis.  One  sex  does  not  seem  to  be  more 
liable  to  this  complication  than  the  other.  It  occurs 
most  frequently  in  jjersons  between  the  twenty-fifth 
and  forty-fifth  years,  and  appears  during  convalescence 
in  a  few  days  or  two  or  three  weeks  after  the  attack  of 
influenza  has  subsided.  It  may  present  sensory,  mo- 
tor, vasomotor,  or  trophic  symptoms,  or  all  combined; 
but  sensor}'  and  vasomotor  symptoms  are  more  promi- 
nent than  in  diphtheria  and  some  other  causes  of  mul- 
tiple neuritis.  In  the  great  majority  of  cases  recovery 
ensues,  both  as  regards  restoration  of  function  and 
power,  as   well    as   regards   life.      Recovery  does  not 


668 


MEDICAL    RECORD. 


[November  6,  1897 


usually  take  place  in  less  time  than  four  weeks,  and 
may  be  delayed  for  months.  Treatment  should  consist 
first  in  absolute  rest  in  bed.  Anodynes  must  be  given 
in  sufficient  doses  to  relieve  pain,  when  that  is  a  prom- 
inent symptom.  Morphine  hypodermically  may  be 
necessar}-,  but  may  be  often  replaced  by  codeine.  The 
antipyretic  anodynes  are  insufficient  in  safe  doses  if 
the  patient  has  pains  for  many  days.  Cinchonidine 
salicylate  is  distinctly  valuable,  especially  when  the 
pain  is  not  of  the  greatest  severity.  At  a  later  stage 
potassium  iodide  and  mercuric  chloride  in  small  doses 
are  helpful.  When  the  pain  is  seated  in  an  extremity 
firm  pressure  with  a  flannel  bandage  yields  great  com- 
fort. Blisters  over  the  painful  nerve  trunks  when 
they  are  superficial  are  also  valuable  in  relieving  pain. 
Close  watch  must  be  kept  on  the  action  of  the  heart 
and  the  character  of  the  breathing.  In  most  of  the 
fatal  cases  death  results  through  paralysis  of  the  dia- 
phragm. The  closest  attention  must  be  given  through- 
out the  course  of  the  case  to  the  nutrition  of  the  pa- 
tient and  to  the  condition  of  the  skin,  especially  over 
portions  of  the  body  exposed  to  pressure.  As  far  as 
possible  the  stomach  should  be  reser\-ed  for  food. 
Medicines  in  these  cases  act  better  when  given  hypo- 
dermically, and  the  stomath  is  less  likely  to  be  de- 
ranged. This  caution  applies  especially  to  the  giving 
of  anodynes. 

The  Treatment  of  Scleroderma. — Philippsohn 
{Deutsche  medicinische  Wochetisehi-if/,  Angnst  12,  1897) 
reports  the  successful  treatment  of  a  case  of  sclero- 
derma by  Biilau  with  sodium  salicylate,  in  doses 
of  fifteen  grains  three  or  four  times  daily,  and  reports 
two  cases  of  the  same  disease  also  successfully  treated 
with  salol  in  doses  of  seven  and  one-half  grains  three 
or  four  times  daily.  From  this  experience  it  is  con- 
cluded that  scleroderma  is,  with  respect  to  the  indura- 
tion of  the  skin,  capable  of  improvement  and  cure  by 
means  of  salicylic  acid.  Early  administration  would 
be  likely  to  prevent  deformity  and  secondary  atrophy. 
The  best  form  in  which  to  administer  salicylic  acid  is 
that  of  the  phenyl  or  ether.  Salol,  which  is  also 
capable  of  controlling  the  itching,  can  be  taken  for 
long  periods  of  time  without  deranging  the  digestion. 
The  daily  dose  is  from  thirty  to  fort)--tive  grains.  If 
after  the  disease  has  existed  for  some  time  shortening 
of  muscles  and  tendons  or  stiffness  of  joints  takes 
place',  this  must  be  overcome  by  systematically 
directed  gymnastic  exercises. 

A  Fatal  Case  of  Addison's  Disease  in  a  Young 
Girl — Bury  reports  in  The  Lancet  of  June  19,  1897, 
the  case  of  a  girl,  thirteen  years  old,  w-ho  had  always 
been  a  delicate  child,  tiring  easily  and  being  con- 
stantly sleepy.  As  an  infant  she  had  been  treated 
for  rickets  anddiarrhrea.  She  had  never  had  a  severe 
fall  or  received  any  bodily  injury.  At  the  age  of 
eleven  years,  after  a  stay  of  several  weeks  in  the  coun- 
try, her  skin  became  dark  colored,  as  if  sunburned, 
but  in  the  course  of  a  few  weeks  her  natural  color  was 
restored.  The  existing  illness  had  begun  about  a  year 
previously,  with  symptoms  of  gastric  disturbance — 
discomfort  after  food,  nausea,  and  vomiting.  She 
suffered  also  from  headache,  and  on  three  occasions 
had  fainted.  In  the  course  of  a  few  weeks  a  change 
in  tlie  color  of  the  skin  was  noticed,  and  it  gradually 
became  darker.  For  two  months  there  had  been  daily 
vomiting  and  weakness  had  become  marked.  The  girl 
was  thin  and  of  slender  build,  and  had  obviously 
wasted.  All  parts  of  the  body  were  of  a  brown  color, 
like  that  of  a  mulatto.  The  tint  varied  in  depth  in 
different  parts,  but  the  transition  between  a  dark 
brown  and  a  light  brown  was  everywhere  quite  gradual. 
The  bronzing  was  most  intense  at  the  back  of  the 
neck,  on  the  dorsum  of  the  hands,  on  the  lower  part  of 


the  abdomen,  and  over  the  knees:  and  least  intense 
on  the  palms  of  the  hands,  the  soles  of  the  feet,  and 
over  the  calves  of  the  legs.  No  pigmented  moles  could 
be  found.  The  nails  were  of  normal  color  and  the 
conjunctiva;  were  pearly  white.  A  faint,  patchy  pig- 
mentation was  seen  on  the  mucous  membrane  of  the 
lips  and  the  inside  of  the  mouth.  The  tongue  was 
free  from  discoloration.  No  enlarged  glands  could  be 
found,  and  no  abnormality  could  be  detected  on  care- 
ful physical  examination  of  the  chest  and  abdomen. 
There  was  complaint  of  pain  in  the  epigastrium,  which 
was  aggravated  by  the  taking  of  food ;  and  there  was 
slight  tenderness  on  pressure  in  each  lumbar  region, 
palpation  setting  up  spasm  of  the  abdominal  muscles. 
The  pulse  was  96,  regular,  and  feeble.  The  urine 
presented  no  abnormalit}'.  There  were  no  paralysis, 
and  no  alteration  of  cutaneous  sensibility.  The  knee 
jerks  were  increased  and  the  wrist  jerks  appeared  un- 
duly irritable.  No  ankle  clonus  could  be  elicited. 
The  superficial  epigastric,  abdominal,  and  plantar  re- 
flexes were  exaggerated.  Varied  treatment  was  em- 
ployed, including  adrenal  extract  in  one  form  or  other, 
but  progressive  deterioration  took  place,  and  death 
followed  a  convulsion  succeeded  by  coma.  Upon  post- 
mortem examination,  in  addition  to  congestion  of  the 
cerebral  meninges,  hemorrhages  beneath  the  visceral 
layer  of  the  pericardium,  slight  pleural  adhesions  on 
the  left  side  of  the  chest,  and  diminished  size  of  the 
thyroid  gland,  the  adrenals  were  found  enlarged  and 
firm  and  adherent  to  surrounding  tissues.  Upon  mi- 
croscopic study  the  latter  presented  histologic  changes 
of  tuberculosis.  The  semilunar  ganglion  and  the  left 
great  splanchnic  ner\-e  exhibited  no  pathologic  altera- 
tion. 

Traumatic  Rupture  of  the  Duodenum,  with  Sur- 
vival for  Sixteen  Hours. — Close  reports  the  case 
of  a  boy,  thirteen  years  old,  who  had  been  kicked  by 
a  horse,  and  when  seen  twelve  hours  later  was  found 
lying  in  bed  with  the  hip-joints  slightly  flexed  and  the 
face  pale  and  anxious.  There  was  complaint  of  some 
pain  in  the  lower  part  of  the  abdomen,  which  was 
slightly  distended  and  very  tender.  There  was  no  vis- 
ible bruise  or  external  wound.  The  abdominal  mus- 
cles were  rigidly  contracted  and  free  manipulation 
could  not  be  made.  The  percussion  note  was  quite 
dull  over  the  whole  of  the  lower  part  of  the  abdomen 
and  in  the  left  flank,  while  there  was  a  band  of  tym- 
panitic resonance  below  the  costal  margin  and  ensi- 
fomi  cartilage:  and  in  the  right  flank  also  the  note 
was  tympanitic  in  character.  The  temperature  in  the 
mouth  was  102.5°  F-  The  pulse  was  140,  rather 
small,  but  not  thready.  Consciousness  was  preser\-ed 
and  the  patient  was  able  to  give  a  connected  account 
of  the  accident.  It  was  learned  that  the  boy  walked 
for  some  distance  after  the  accident.  Subsequently 
he  was  taken  home,  and  after  the  application  of  hot 
flannels  he  so  far  recovered  that  he  was  able  to  get 
about  for  some  hours,  and  walked  upstairs  and  down- 
stairs. Later  vomiting  took  place.  Clear  urine,  free 
from  blood,  was  obtained  by  catheterization.  The 
conclusion  was  reached  that  a  nipture  of  the  intestine 
had  taken  place,  and  cceliotomy  was  decided  upon,  but 
before  the  operation  could  be  begun  the  patient  was 
moribund,  the  abdomen  becoming  greatly  distended. 
Upon  post-mortem  examination  the  peritoneum  was 
found  to  contain  about  two  pints  of  cloudy  fluid  mixed 
with  partially  digested  food.  The  intestines  were 
much  reddened  and  coated  with  flakes  of  recent  lymph. 
On  turning  back  the  omentum  and  coils  of  small  intes- 
tine, a  rent  was  found  in  the  second  part  of  the  duo- 
denum, from  which  the  chyme  was  escaping.  The 
opening  was  large  enough  to  admit  four  fingers,  and 
was  four  and  one-half  inches  from  the  pyloric  orifice. 
—  The  Lancet,  July  17,  1897. 


November  6,  1897] 


MEDICAL    RECORD. 


669 


Medical  Record: 

A    Weekly  Jouryial  of  Medicine  and  Surgery. 


GEORGE   F.   SHEADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &  47  East  Tenth  Street. 


New  York,  November  6,  1897. 


REMEDIES    AXCIEXT    AXD    MOUERX. 

Present-day  medicine  discards  more  and  more  the 
use  of  drugs.  It  puts  its  trust  rather  in  natural  agen- 
cies and  recognizes  the  fact  that  each  person  possesses 
a  separate  individualit)-,  instead  of,  as  in  the  old  days, 
lumping  people  together  and  prescribing  to  them  the 
same  drugs,  without  considering  their  differing  tem- 
peraments or  dispositions.  An  intelligent  doctor  will 
study  the  character  and  temperament  of  his  patient,  so 
as  to  act  on  the  body  through  the  influence  of  the  mind. 
In  a  few  words,  the  tendency  of  modem  practice  is  to 
treatment  by  suggestion.  The  doctor  therefore,  should 
be  a  many-sided  man,  of  a  wide  and  warm  nature, 
with  active  sympathies,  and  possessed  of  much  tact. 
We  all  know  that  contact  with  a  man  of  this  type  in 
many  instances  does  a  sick  person  more  good  than  a 
prescription.  Faith  goes  a  long  way,  and  the  battle 
against  disease  is  often  half  won  when  we  resolve  in 
our  own  minds  to  get  well.  In  the  face  of  this  con- 
dition of  things  it  is  both  curious  and  interesting  to 
read  a  description  of  some  of  the  old-time  remedies. 
In  a  work  that  appeared  in  Frankfort  in  1701,  entitled 
"  A  Good  and  Careful  Medicus,"  by  Dr.  Johann  Helff- 
rich  Jiingken,  an  account  of  some  of  the  remedies  in 
use  at  that  period  is  given.  For  instance,  it  is  stated 
that  "sores  of  the  lips  could  be  cured  if  the  oil  or  fat 
which  runs  out  when  a  wooden  spoon  is  held  over  the 
fire  was  applied  to  the  sores."  For  the  cure  of  jaundice 
the  advice  is  tendered  "  to  fasten  a  live  fish,  preferably 
the  '  schleye,'  around  the  body  or  against  the  soles  of 
the  feet,  and  let  it  die  there."  For  hydrocele,  appli- 
cations of  a  mi.xture  of  goat  manure,  crushed  snails, 
powdered  sulphur,  and  kiimmel  were  made.  The  nas- 
tier the  mixtures  were,  the  more  efficacious  were  they 
esteemed.  Another  alteration  for  the  better  that  has 
been  made  in  administering  drugs  is  that  they  are  not, 
as  formerly,  given  in  e.xcessive  combination,  but  are 
much  more  frequently  prescribed  singly. 

Yet  great  as  has  been  the  advance  in  medical 
treatment  and  in  the  preparation  and  prescribing  of 
drugs,  we  are  nowadays  rather  too  apt  to  plume  our- 
selves on  our  superior  knowledge,  and  to  regard  the 
pioneers  in  medicine  with  a  pitying  contempt.  It 
should  be  remembered  that  the  Egyptians,  Greeks, 
and  Romans  had  a  very  fair  acquaintance  with  both 
medicine  and  surgery,  and  especially  with  drugs  and 


their  properties.  Most  of  the  drugs  on  which  we 
chiefly  rely  date  very  far  back.  Xearly  all  those 
most  commonly  in  use  were  known  thousands  of  years 
ago.  Castor  oil  and  rhubarb  were  prescribed  by  the 
old  Arabians,  ergot  was  used  in  parturition  by  the  peas- 
ants <5f  Germany  hundreds  of  years  ago,  male  fern  in 
tapeworm  by  the  early  Greeks  and  Romans.  Mercury- 
has  been  the  specific  for  s)-philis  almost  from  time 
immemorial,  and  the  list  can  be  indefinitely  length- 
ened. The  most  ancient  pharmacopceia  known  was 
found  between  the  legs  of  a  mummy  about  1500  B.C.. 
and  even  the  principles  of  modem  treatment  were 
practised  by  Asclepiades  of  Brussa,  who  was  a  sceptic 
in  the  use  of  dmgs,  and  declared  "  that  the  cure  must 
be  effected  by  the  physician,  who  must  do  this  safely, 
quickly,  and  pleasantly." 

History  has  a  tendency  to  repeat  itself.  It  is  prob- 
able, too,  that  the  people  who  inhabit  this  earth  in  a 
hundred  years  from  now  will  regard  our  methods  of 
treatment  as  antiquated  and  crude,  or  possibh^  as 
superfluous.  The  prophecy  that  in  the  course  of  time 
many  diseases  will  be  altogether  stamped  out  is  not  too 
bold  a  one  to  make.  Prevention,  not  cure,  will  be 
the  motto  of  the  future. 


THE  SIGXIFICAXCE  OF  IXEQL'ALITY  OF 
THE  PUPILS  IX  CASES  OF  CARCIXOMA 
OF   THE   OESOPHAGUS. 

The  occurrence  of  inequality  of  the  pupils  in  conjunc- 
tion with  tumors  of  the  oesophagus  is  not  at  all  rare, 
and  is  to  be  attributed  sometimes  to  involvement  of 
the  sympathetic  nerve,  sometimes  to  involvement  of 
the  anterior  root  of  the  first  dorsal  nerve,  in  which 
pass  the  oculo-pupillary  fibres  of  the  sympathetic.  In 
the  latter  event  there  e.xists,  in  addition  to  atrophic 
palsy  of  the  small  muscles  of  the  hand,  with  char- 
acteristic sensory  derangement,  narrowing  of  the  cor- 
responding pupil  and  palpebral  fissure,  with  retraction 
of  the  eyeball  and  sluggish  reaction  of  the  pupil  to 
light.  Inequality  of  the  pupils,  with  narrowing  of  the 
palpebral  fissure  and  retraction  of  the  eyeball,  having 
been  obsen-ed  at  the  clinic  of  Professor  Eichhorst  at 
the  Universit)'  of  Zurich,  in  a  case  of  carcinoma  of 
the  oesophagus,  attention  was  directed  to  the  frequency 
of  the  association,  and  the  results  are  detailed  by  Hit- 
zig  in  the  Deutsche  medicinische  Wochenschrift,  X'o.  36, 
1897.  In  the  course  of  the  year  following  the  original 
observation,  inequality  of  the  pupils  was  found  in  four 
of  nine  cases  of  carcinoma  of  the  oesophagus.  In 
twenty-seven  earlier  cases  this  peculiarity  had  been 
noted  but  once.  In  five  of  the  cases  the  left  pupil 
was  contracted  and  there  were  no  further  oculo-pupil- 
lary or  vasomotor  manifestations.  In  the  si.xth  case 
there  had  been  also  paralysis  of  the  right  recurrent 
laryngeal  nerve,  and  the  right  pupil  and  palpebral  fis- 
sure were  smaller  than  the  left,  and  the  eyeball  was 
somewhat  retracted.  There  was,  however,  no  atrophy 
of  the  muscles  of  the  right  hand.  Subsequently  there 
was  also  paresis  of  the  left  recurrent  laryngeal  nerve. 
The  post-mortem  examination  disclosed,  in  addition 


670 


MEDICAL    RECORD. 


[November  6,  1897 


to  carcinoma  of  the  oesophagus,  at  the  same  level,  to 
the  right  of  the  oesophagus,  a  large  carcinomatous  lym- 
phatic gland  involving  the  vessels  and  ner\-es. 


IDIOPATHIC    SALIVATION. 

Salivation'  may  arise  from  a  variety  of  causes — some 
local,  some  remote.  In  some  instances  an  etiologic 
factor  is  not  obvious.  Among  the  local  causes  are 
inflammatory  processes  in  and  about  the  mouth  and  its 
glandular  appendages;  for  instance,  stomatitis,  glos- 
sitis, gingivitis,  pharjTigitis,  etc.  Mercurial  and  other 
forms  of  metallic  intoxication,  such  as  plumbism  and 
poisoning  with  antimony,  may  likewise  be  placed  in 
this  category.  Among  the  remote  influences  related  to 
salivation,  some  of  which  are  constitutional  and  others 
reflex,  may  be  enumerated  gastro-intestinal  disorders, 
nausea,  vomiting,  gastralgia,  pregnancy,  suppression  of 
menstruation,  hysteria,  mania,  epilepsy,  hydrophobia. 
Kxcessive  discharge  of  saliva  sometimes  occurs  as  a 
critical  manifestation  in  the  course  or  at  the  close  of 
attacks  of  pneumonia,  dysentery,  septic  intoxication, 
typhoid  fever.  It  may  also  take  place  with  the  disap- 
pearance of  a  pre-existing  leucorrhcea  or  cedematous 
state.  Jaborandi  or  its  alkaloid,  pilocarpine,  is  almost 
the  only  drug  directly  capable  of  inducing  excessive 
salivary  secretion.  Finally,  there  is  a  small  number 
of  cases  in  which  no  cause  for  the  morbid  condition 
can  be  ascertained.  In  these  the  disorder  is  desig- 
nated essential  or  idiopathic,  but  such  a  distinction 
can  be  considered  only  tentative,  to  be  supplanted  by 
a  more  accurate  and  distinctive  one  when  the  expan- 
sion of  our  knowledge  shall  disclose  the  previously 
hidden  cause. 

In  a  recent  communication  upon  this  subject,  Jordan 
(^Birmingham  Medical  Review,  September,  1897,  p.  173) 
has  reported  two  interesting  cases  of  so-called  idio- 
pathic salivation  occurring  in  children.  In  one  the 
patient  was  a  boy,  four  years  old,  who  came  under 
observation  on  account  of  constant  dribbling  of  saliva 
from  the  mouth.  The  child's  clothing  for  some  dis- 
tance below  his  neck  was  thoroughly  soaked.  It  was 
stated  that  he  had  always  dribbled,  very  much  so  dur- 
ing dentition.  The  dribbling  continued  at  night,  so 
Viat  the  pillow  was  wet,  but  to  a  less  extent,  and  the 
amount  of  saliva  that  escaped  varied  from  time  to 
time.  The  boy  appeared  quite  happy,  and  but  for  the 
salivation  perfectly  healthy.  He  was  said  to  be  in 
good  health,  to  eat  well,  and  have  no  digestive  trouble, 
but  to  be  always  thirsty.  He  used  ordinary  diet  and 
was  very  fond  of  porridge.  He  was  intelligent  for  his 
age  and  talked  plainly.  Examination  disclosed  no 
latent  mischief  or  defect,  general  or  local.  The  mu- 
cous membrane  6f  the  mouth  was  healthy;  the  left 
tonsil  was  perhaps  slightly  enlarged ;  and  of  the  teeth, 
which  were  cut  normally,  the  lower  premolars  were 
already  decaying.  Four  other  children  in  the  family 
were  in  good  health  and  displayed  no  tendency  to 
salivation. 

Three  months  later  another  boy,  aged  two  and  one- 
half  years,  presented  himself,  giving  a  history  almost 
identical  with  that  detailed.     This  child  too  had  drib- 


bled very  much  during  dentition,  which  began  when 
he  was  four  months  old,  and  was  completed  eight 
months  later.  The  dribbling  continued,  but  received 
little  attention  until  the  child  was  two  years  old. 
From  this  time  it  had  grown  gradually  worse,  although 
it  varied  in  degree.  The  clothing  was  saturated.  At 
one  time  the  dribbling  had  continued  through  the 
night.  The  general  health  was  said  to  be  good  except 
for  attacks  of  tonsillitis.  This  child  also  had  fed 
much  on  porridge.  His  teeth  and  the  mucous  mem- 
brane of  the  mouth  were  in  a  healthy  state,  but  the 
tonsils,  especially  the  left,  were  much  hypertrophied. 
No  other  lesion  of  any  sort  was  discovered  on  exami- 
nation. The  boy  was  intelligent,  although  he  did  not 
speak  plainly. 

The  condition  described  appears  to  be  a  rare  one. 
Finlayson  has  reported  a  case  in  which  salivation  ap- 
peared rather  suddenly  in  a  child  at  the  age  of  six 
)'ears,  and  Bohn  has  contributed  an  article  on  the  sub- 
ject to  Gerhardt's  "  Handbuch  der  Kinderkrankhei- 
ten,"  Bd.  iv.,  Abth.  2.  The  disorder  may  set  in  in 
early  life,  during  dentition,  and  continue  indefinitely 
thereafter.  In  some  cases  it  occurs  for  the  most  part 
only  in  the  erect  posture,  ceasing,  as  a  rule,  during 
sleep.  It  may  be  diminished  by  emotions  of  the  most 
varied  kind.  Iron  has  proved  of  undoubted  influence 
in  the  treatment,  but  although  anaemia  was  present  in 
some  cases  this  is  not  thought  to  be  a  cause  of  the 
disorder.  The  affection  presents  some  features  of  a 
neurosis.  The  intermittent  character  of  the  salivation, 
its  subordination  to  psychic  influences,  its  tendency  to 
abate  with  the  development  of  the  body  or  to  yield  to 
remedial  drugs,  point  to  a  peculiar  and  isolated  affec- 
tion of  the  salivary-gland  ner\es  in  the  developing  or- 
ganism of  the  child.  How  late  in  life  the  disorder 
may  continue  is  a  matter  of  uncertainty.  The  ques- 
tion arises:  How  far  may  the  salivation  be  the  result 
of  an  increased  flow,  and  how  far  due  to  a  failure  to 
acquire  the  habit  of  automatically  swallowing  the  sa- 
liva? In  the  presence  of  hypertrophied  tonsils  it  is 
possible  that  as  a  result  of  difficulty  in  swallowing 
there  may  be  a  failure  to  acquire  the  habit  of  perform- 
ing this  act  automatically. 


A   DISPENSARY   NEEDED. 

Not  unduly  to  prolong  the  suspense,  it  should  be 
stated  in  passing  that  we  are  not  speaking  of  New  York. 
In  a  recent  number  of  the  Korth  Carolina  Medical 
Journal  the  editorial  department  is  devoted  exclusively 
to  a  plea  for  the  establishment  of  more  dispensaries 
and  hospitals  in  the  South.  The  burden  of  caring  for 
the  sick  poor  in  many  regions  now  falls  wholly  upon 
the  physician,  who  must  often  supply  medicines  be- 
sides giving  his  services  and  time,  to  say  nothing  of 
wear  and  tear  to  gig  and  horseshoe  and  perhaps  pneu- 
matic tire.  There  would  appear  to  be  a  lack  of 
"  charity"  in  certain  portions  of  our  Southern  States. 
The  >vriter  says:  "  In  only  three  or  four  of  the  larger 
towns  is  there  any  effort  being  made  to  dispense  medi- 
cal aid  to  the  poor  from  the  public  funds." 

The  good-natured  doctor  seems  to  accept  the  bur- 


November  6,  1897] 


MEDICAL    RECORD. 


671 


den  placed  upon  him  as  a  necessan'  part  of  his  pro- 
fessional duties.  If  in  some  wa)-  the  oversupplv  of 
philanthropists  of  this  city,  consumed  with  a  desire  to 
establish  dispensaries,  could  have  their  attention  di- 
verted to  the  South,  what  a  double  blessing  it  would 
be!  Or  even  if  a  few  of  our  institutions  now  depend- 
ing upon  the  "  better  classes"  for  material  would  con- 
sent to  transfer  the  seat  of  their  operations,  what  a 
relief  to  the  army  of  willing,  waiting,  weary  men  who 
have  been  drawn  into  the  metropolis  by  the  false  idea 
that  private  practice  could  be  here  pursued  excepting 
among  the  verj'  wealthy ! 


RECENT  HAPPENINGS  BEARING  UPON  THE 
LEPROSY    QUESTION. 

DuRiXG  the  past  fortnight  there  has  appeared  an  un- 
usual amount  of  leprosy  literature  in  the  public  prints 
of  this  cit}-.  It  is  announced  by  cable  that  Dr.  Bes- 
nierhas  returned  to  Paris  from  the  leprosy  congress  in 
Berlin,  and  again  startled  his  compatriots  with  a  report 
that  there  are  at  least  one  hundred  lepers  abroad  in 
the  French  capital.  This,  of  course,  has  nothing  very 
startling  about  it,  since  the  same  announcement  was 
made  over  a  year  ago.  New  Yorkers  seem  to  be  de- 
veloping a  taste  somewhat  similar  to  that  of  the  Pari- 
sians for  shocking  and  being  shocked.  A  year  ago 
the  health  board  of  this  cit}'  tried  the  effect  upon  the 
public  of  allowing  its  small  colony  of  lepers  to  es- 
cape from  North  Brothers  Island  into  the  city.  The 
shock  produced  was  not  marked,  but  seems  to  have 
been  sufficient  to  encourage  the  board  to  perpetrate 
the  farce  a  second  time.  We  expressed  our  opinion 
of  the  whole  procedure  at  the  time,  as  well  as  of  the 
board's  attempt  to  secure  the  Countj-  Medical  Soci- 
et}-'s  backing  for  its  act.  Humanit}-  would  seem  to 
demand  that  this  class  of  patients  be  treated  with 
more  consideration  and  not  run  down  like  beasts,  to 
be  confined  until  the  time  comes  around  to  turn  them 
loose  for  another  grand  leper  hunt. 

If  the  health  board  has  no  jurisdiction  over  the  leper, 
why  does  it  not  leave  him  alone  ? 

In  the  Sunday  edition  of  one  of  our  most  prominent 
daily  journals.  Dr.  Fox  adds  to  the  health  board's 
attempted  shock  by  giving,  in  a  half-page  article,  a 
detailed  account  of  New  York's  lepers.  The  number 
at  large  is  put  down  at  twent)--five.  He  says  that  the 
disease  is  not  contagious,  and  dilates  upon  the  at- 
tractiveness of  our  climate  and  hygienic  surroundings, 
under  whose  influence,  combined  with  certain  drug 
treatment,  foreign  lepers  improve  and  even  get  well. 
The  Skin  and  Cancer  Hospital,  he  says,  receives  and 
keeps  lepers  for  treatment.  The  writer  invites  atten- 
tion to  moral  treatment  of  the  patient  as  a  therapeutic 
agent  which  is  commonly  overlooked.  An  appeal  is 
made  for  the  establishment  by  some  wealthy  individ- 
ual of  a  special  hospital  for  the  study  and  care  of 
leprosy  cases. 

In  a  reply  to  Dr.  Fo.x's  article,  published  in  the 
same  paper,  Dr.  Ashmead  maintains  the  proven  con- 
tagiousness of  the  disease,  and  quotes  the  conclusions 
of  the  Leprosy   Congress,   whose  sessions  have  just 


closed  in  Berlin,  in  support  of  this  view.  The  bacil- 
lus, he  says,  exists  only  in  man,  and  treatment  so  far 
is  merely  palliative  and  not  curative.  Hansen's  re- 
cently expressed  opinion  is  cited,  to  the  effect  that 
if  measures  of  isolation  were  universally  adopted  lep- 
rosy would  be  quickly  eradicated.  He  asks  Dr.  Fox 
how  leprosy  can  be  regarded  as  a  disease  of  insalubri- 
ous surroundings  and  filth  if,  as  the  latter  has  just 
claimed,  it  exists  in  this  city  in  subjects  close  te  the 
four  hundred. 

The  most  recent  repK^rt  of  an  epidemic  of  leprosy 
comes  from  far-off  Tiflis,  where  the  disease  is  reported 
to  be  assuming  alarming  proportions. 

However,  the  practical  and,  it  seems  to  us,  important 
point  to  be  determined  for  this  countrj-  is  whether  we 
are  destined  to  become  burdened  by  the  scourge.  Is 
it  not  possible  to  make  and  maintain  this  a  leper-free 
countT}-,  or  rather,  was  it  not  possible  some  years  ago 
■when  the  Medical  Record  pointed  out  the  dangers 
and  undesirableness  of  fostering  leprosy?  We  believe 
that  even  to-day,  despite  the  reported  increase,  proper 
measures,  such  as  have  already  been  advocated  in  these 
columns,  would  in  time  save  us  from  this  preventable 
and  most  assuredlv  unwelcome  disease. 


Bcuis  cif  the  ti^celi. 

An  Editor's  Misfortune. — Dr.  George  Wilson,  of 
Oxford,  the  editor  and  owner  of  the  Medical  Magazine, 
has  disappeared,  leaving  behind  many  liabilities  and 
no  assets.  He  started  the  Medical  Magazine,  a  most 
readable  publication  by  the  way,  about  six  years  ago, 
on  borrowed  capital.  The  venture  ruined  him,  for  the 
magazine  was  not  of  the  character  to  win  a  large  cir- 
culation at  once,  and  notes  fell  due  before  subscriptions 
came  in. 

Death  of  Dr.  Charles  H.  Avery Dr.  Charles  H. 

Aver)-,  a  practising  physician  in  this  city  for  thirtj- 
years  and  the  secretarj-  of  the  Medical  Society  of  the 
County  of  New  York,  died  on  Tuesday  night  at  his 
home,  No.  238  East  Eighteenth  Street.  He  was  born 
in  Perrj'ville,  Madison  County,  N.  Y.,  sixtj'-three  years 
ago.  He  was  graduated  from  the  Long  Island  Col- 
lege Hospital  and  commenced  his  practice  in  a  small 
village  in  the  oil  region  of  Pennsylvania.  From  there 
he  came  to  this  city.  A  chronic  disease  from  which 
he  had  suffered  for  many  years  was  the  cause  of  his 
death. 

Permanganate  of  Potassium  in  Opium  Poisoning. 
— Surgeon-Major  J.  D.  Reckitt  reports,  in  the  British 
Medical  Journal  of  October  9,  1897,  a  case  of  a  man, 
twenty-five  years  old,  who  had  drank  two  ounces  of 
laudanum.  Permanganate  of  potassium,  in  five-grain 
doses  repeated  several  times,  was  administered,  and 
the  man  made  a  good  recovery.  He  was  seen  too  late 
to  permit  of  removal  of  the  poison  from  the  stomach, 
so  that  the  entire  amount  taken  was  absorbed. 

In  Memory  of  Benjamin  Ward  Richardson. ^ — A 
subscription  list  was  opened  some  time  ago  to  endow 
a  bed  in  the  London  Temperance  Hospital  as  a  me- 


672 


MEDICAL    RECORD. 


[November  6,  1897 


morial  of  the  late  Sir  B.  W.  Richardson,  who  was  one 
of  the  attending  physicians  to  the  hospital.  The 
amount  desired  is  one  thousand  pounds,  but  as  yet 
only  about  one  hundred  pounds  has  been  raised.  Sir 
Benjamin  was  an  ardent  worker  in  the  cause  of  total 
abstinence,  having  been  perhaps  the  most  active  mem- 
ber of  the  British  Medical  Temperance  Association. 

The  Alvarenga  Prize  of  the  College  of  Physicians 
of  Philadelphia. — The  ne.xt  award  of  the  Alvarenga 
prize,  being  the  income  for  one  year  of  the  bequest  of 
the  late  Senor  Alvarenga,  and  amounting  to  about 
$180,  will  be  made  on  July  14,  1898,  provided  that  an 
essay  deemed  by  the  committee  of  award  to  be  worthy 
of  the  prize  shall  have  been  offered.  Essays  intended 
for  competition  may  be  upon  any  subject  in  medicine, 
but  cannot  have  been  published,  and  must  be  received 
by  the  secretary  of  the  college  on  or  before  May  i, 
1898.  Each  essay  must  be  sent  without  signature, 
but  must  be  plainly  marked  with  a  motto  and  be  ac- 
companied by  a  sealed  envelope  having  on  its  outside 
the  motto  of  the  paper  and  within  the  name  and  ad- 
dress of  the  author.  The  Alvarenga  prize  for  1897 
was  awarded  to  Dr.  Joseph  Collins,  of  New  York,  for 
an  essay  entitled  "Aphasia." 

American  Students  in  Germany. — Referring  to 
the  difficulties  the  German  authorities  have  placed  in 
the  way  of  foreign  medical  students,  the  editor  of  the 
Columbus  Medical  Journal  Yemdixk.s:  "We  admire  the 
position  taken  by  our  German  brothers  in  attempting 
to  annihilate  the  fad  that  has  swept  over  this  country 
like  a  tidal  wave,  to  the  effect  that  no  medical  student 
had  completed  his  education  without  having  attended 
some  medical  school  in  Berlin,  Germany;  and  still 
worse,  if  he  attended  some  foreign  school,  if  it  were 
but  for  two  or  three  weeks,  that  he  was  far  superior  to 
his  brother  practitioner  who  had  remained  in  the  land 
of  his  nativity  and  studied  hard  in  schools  of  equal 
facilities  in  America.  We  do  not  blame  the  Germans 
for  drawing  the  line  on  these  half-educated  medical 
students  and  practitioners  who  rush  into  their  schools 
from  America,  as  it  is  certainly  a  nuisance,  and  detri- 
mental to  the  advanced  standing  of  the  German 
schools  and  reflects  no  credit  on  the  medical  profes- 
sion of  the  United  States.  We  are  a  firm  believer  in 
utilizing  the  facilities  offered  for  medical  as  well  as 
other  forms  of  education  in  America  before  we  seek 
admission  to  foreign  schools.  It  is  a  fad  which  de- 
serves severe  criticism,  and  we  hope  our  ambassador 
will  sustain  the  action  of  the  German  government  in 
this  direction." 

The  Physical  Condition  of  Applicants  for  Enlist- 
ment in  the  Army — ^According  to  the  recently  pub- 
lished report  of  Surgeon-General  Sternberg,  of  the 
United  States  army,  the  total  number  of  men  examined 
for  enlistment  during  the  calendar  year  was  14,659, 
of  whom  8,654,  or  590.35  per  1,000,  were  accepted; 
5,448,  or  371.65  per  1,000,  were  rejected  on  primary 
examination;  and  557,  or  38  per  1,000,  subsequently 
declined  enlistment.  The  ratio  of  accepted  men  per 
1,000  of  those  examined  was  considerably  larger  than 
in  previous  years.     This  must  be  regarded,  says  Gen- 


eral Sternberg,  as  meaning  that  better  men  physically 
are  coming  up  as  candidates  for  examination  for  en- 
listment. The  rejections  among  the  colored  men  were 
relatively  somewhat  more  numerous  than  among  the 
white  candidates  for  enlistment — 379,  compared  with 
371.04  per  1,000  respectively.  Although  the  foreign- 
born  recruit  has  the  advantage  over  the  native  white  in 
weight  and  chest  measurement,  the  latter  is  taller  by 
one-half  inch. 

English  Medicines   in   Germany At   the  recent 

meeting  of  the  German  Apotheker-Verein  at  Stras- 
burg.  Dr.  Tschaschel,  of  Wulsdruff,  brought  before 
his  fellow-members  the  question  of  the  importation  of 
foreign  medicines.  He  specially  referred  to  the  man- 
ufactures of  an  English  firm,  which  had  recently  dis- 
tributed among  medical  men  a  pamphlet  in  which  the 
properties  and  uses  of  the  firm's  preparations  were  de- 
scribed. He  moved  that  the  executive  of  the  Verein 
should  take  steps  to  prevent  the  introduction  of  these 
articles  into  pharmacies,  and  explain  the  state  of  the 
case  to  medical  men.  He  said  that  he  had  bought  a 
bottle  containing  twenty-five  morphine  tablets,  which 
professed  to  contain  one  centigram  of  morphine  hy- 
drochloride in  each.  The  tablets  weighed  five  cen- 
tigrams, and  therefore  it  was  clear  they  contained 
some  other  substance  besides  the  alkaloid,  so  that  the 
pharmacist  could  not  take  any  responsibility  for  them. 
A  long  discussion  followed,  and  in  the  course  of  the 
discussion  it  was  mentioned  that  the  Frankfort  phar- 
macists put  a  red  wrapper  on  the  boxes  containing  the 
tablets,  on  which  was  printed  a  statement  that  they 
were  not  responsible  for  the  contents.  A  pharmacist 
said  that  in  his  town  they  had  informed  the  physicians 
that  they  made  such  preparations  themselves,  and 
would  dispense  the  ready-made  one  only  if  they  were 
expressly  ordered.  A  druggist  of  Hamburg  said  the 
medical  society  of  that  city  had  issued  a  circular  to 
the  physicians  there,  pointing  out  that  if  they  pre- 
scribed packed  medicines  they  took  a  special  risk,  for 
the  apothecary  who  dispensed  them  could  not  tell  what 
such  medicines  contained. 

Typhoid  Fever  in  Ireland. — A  serious  outbreak  of 
typhoid  fever  is  reported  to  have  occurred  at  a  suburb 
of  Belfast,  and  it  is  feared  the  disease  will  become 
epidemic  in  the  city. 

A  Question  of  Sanatorium  Rights.  —  A  case 
involving  the  right  of  the  proprietor  of  a  mineral 
spring  to  empty  its  waters  into  a  stream  flowing  across 
the  land  of  another,  after  the  water  has  been  used  for 
bathing-purposes,  has  recently  been  decided  by  the 
supreme  court  of  Indiana.  The  defendants  were  the 
proprietors  of  a  medicinal  spring  and  had  established 
a  sanatorium.  After  being  used  for  bathing-purposes 
the  water  was  allowed  to  flow  into  a  stream  which 
crossed  land  not  belonging  to  the  owners  of  the  min- 
eral spring.  One  of  the  adjoining  landowners  sued 
the  sanatorium  managers,  asking  that  they  be  restrained 
from  permitting  to  flow  into  the  stream  any  water  which 
had  been  used  in  bathing  persons  afflicted  with  syphi- 
litic or  other  disorders.  The  court  granted  the  injunc- 
tion, but  on  appeal  the  supreme  court  set  it  aside  and 


November  6,  1897] 


MEDICAL    RECORD. 


673 


directed  judgment  for  the  defendants,  on  the  strength 
of  the  evidence  offered  that,  although  the  water  had  an 
unclean  and  repulsive  appearance,  it  was  not  poison- 
ous or  injurious  to  live  stock  or  human  beings. 

Football  Barbarism. — At  a  game  of  football  be- 
tween the  University  of  Georgia  and  the  University  of 
Virginia  on  October  30th,  one  player  was  killed  and 
another  seriously  injured.  The  authorities  at  the 
Georgia  State  University  have  not  abolished  the  game, 
and  a  bill  prohibiting  football  in  the  State,  which  failed 
to  pass  the  last  session  of  the  legislature,  will  be  rein- 
troduced this  year,  and  will  doubtless  pass  this  time 
by  reason  of  the  sentiment  aroused  by  these  casual- 
ties. 

Yellow  Fever. — The  beginning  of  the  end  of  the 
yellow-fever  visitation  in  the  South  is  at  last  in  sight. 
There  has  been  more  or  less  cold  weather  throughout 
the  affected  region,  and  in  many  parts  of  Louisiana 
sharp  frosts  are  reported.  Even  when  the  appearance 
of  frosty  weather  is  delayed,  the  history  of  previous 
epidemics  shows  that  the  fever  decreases  with  the  gen- 
eral lowering  of  temperature  always  obtaining  at  this 
time. 

A  Colored  Woman  Physician  was  among  the  appli- 
cants for  a  license  to  practise  medicine  at  Atlanta, 
Ga.,  recently.  She  is  a  graduate  of  the  Woman's 
Medical  College  in  Philadelphia. 

The   Pray  Medical   Prize   Essay The   late   Dr. 

Thomas  J.  W.  Pray  left  to  the  New  Hampshire  Medi- 
cal Society  a  sum  of  money  making  possible  the  offer- 
ing by  the  society  of  a  prize  of  $100  for  the  best  orig- 
inal essay  upon  some  medical  topic,  written  by  a 
member  of  the  society.  Essays  must  be  in  the  hands 
of  the  trustees  on  or  before  April  i,  1899.  Each  essay 
must  bear  some  signature,  and  be  accompanied  by  an 
envelope  marked  by  the  same  signature  and  contain- 
ing the  name  of  the  writer.  This  envelope  is  not  to 
be  opened  unless  the  essay  gains  the  prize.  The  name 
of  the  successful  writer  will  be  announced  at  the  annual 
meeting  and  the  prize  will  then  be  awarded;  and  if 
the  trustees  so  direct  the  paper  shall  be  read  before 
the  society  and  published  in  the  annual  report.  The 
essays  are  to  be  legibly  written  or  typewritten,  and 
not  to  be  less  than  four  thousand  words  and  not  more 
than  ten  thousand  words  in  length.  If  no  paper  is 
presented  which  the  trustees  deem  worthy  of  the  prize, 
no  award  will  be  made. 

Obituary  Notes. — Dr.  George  F.  Matter  died  at 
Shenandoah,  Pa.,  on  October  22d,  of  cerebro-spinal 
meningitis,  at  the  age  of  fifty-seven  years.  He  served 
as  a  hospital  steward  during  the  war  of  the  rebellion 
with  the  two  hundred  and  tenth  regiment,  Pennsylva- 
nia volunteers,  and  he  was  graduated  from  Jefferson 
Medical  College  in  i866.— Dr.  Frank  L.  Sallade 
died  at  Womelsdorf,  Pa.,  on  October  24th,  in  conse- 
quence of  a  self-administered  overdose  of  morphine 
and  atropine  taken  unintentionally.  He  was  fifty-three 
years  old  and  a  graduate  of  Jefferson  Medical  College. 
In  addition  to  the  care  of  a  large  practice,  he  was  be- 


sides an  accomplished  artist. — Dr.  A.  L.  Hummel,  of 
Hummelstown,  Pa.,  died  at  Denver,  Col.,  October 
26th,  at  the  age  of  forty  years.  He  was  a  graduate  of 
the  University  of  Maryland,  and  for  a  number  of  years 
was  connected  in  different  capacities  with  various 
medical  journals. — Dr.  Stephen  Parsons  died  at 
Chester,  Pa.,  on  October  27th,  at  the  age  of  eighty 
years.  He  was  graduated  from  the  Baltimore  College 
of  Dental  Surgery  in  1846,  and  from  the  Philadelphia 
College  of  Medicine  in  1849.— Dr.  Clarence  G. 
Abbott,  of  Woodbury,  N.  J.,  died  at  Easton,  Pa.,  on 
October  27th,  at  the  age  of  thirty -eight  years,  after  a 
long  illness. — Dr.  William  Henry  Corse  died  at 
Philadelphia,  on  October  28th,  at  the  age  of  seventy- 
seven  years.  He  was  a  graduate  of  the  Philadelphia 
College  of  Pharmacy  and  also  of  the  medical  depart- 
ment of  the  University  of  Pennsylvania.  Until  eight 
years  ago  he  was  engaged  in  the  practice  of  his  pro- 
fession at  Wilmington,  Del. — Dr.  Alexander  Mil- 
ton Ross,  of  Montreal,  well  known  as  a  naturalist  of 
high  order,  died  in  Detroit  on  October  28th.  He 
was  bom  in  Belleville,  Ontario,  in  1832.  When  a  lad 
he  came  to  New  York  and  worked  as  a  compositor  on 
a  daily  paper,  and  while  still  at  this  work  studied 
medicine  under  Valentine  Mott,  and  received  his  de- 
gree in  1855.  H^  ^^ss  a  surgeon  with  Walker's  fili- 
busters in  Nicaragua,  in  the  Union  army  during  the 
civil  war,  and  in  the  Mexican  army  under  Juarez. 
After  his  return  to  Canada  he  became  a  member  of  the 
College  of  Physicians  and  Surgeons  of  Quebec  and 
Ontario,  and  was  one  of  the  founders  of  the  society  for 
the  diffusion  of  physiological  knowledge  in  188 1.  He 
then  began  to  collect  and  classify  the  fauna  and  flora 
of  that  countr}',  a  work  that  had  never  before  been  at- 
tempted by  a  native.  He  collected  and  classified  hun- 
dreds of  species  of  birds,  eggs,  mammals,  reptiles,  and 
fresh-water  fish,  thirty-four  hundred  species  of  insects, 
and  two  thousand  species  of  Canadian  flora.  Among 
his  published  works  were:  "  Birds  of  Canada"  (1872) ; 
"  Butterflies  and  Moths  of  Canada"  (1873)  ;  "  Flora  of 
Canada"  (1873);  "Forest  Trees  of  Canada"  (1874); 
"  Ferns  and  Wild  Flowers  of  Canada"  (1877);  "Mam- 
mals, Reptiles,  and  Fresh-Water  Fishes  of  Canada" 
(1878). — Mr.  Hermon  M.  Atwood,  vice-president  of 
the  New  York  College  of  Pharmacy,  died  at  his  home 
in  this  city  on  October  2gth.  Mr.  .\twood  was  born  in 
Hartford  fifty-eight  years  ago.  He  came  to  this  city 
in  1858,  and  was  one  of  the  oldest  druggists  in  the 
cit}-  at  the  time  of  his  death.  In  1870  he  became 
connected  with  the  New  York  College  of  Pharmacy, 
and  in  1882  he  was  elected  a  member  of  the  board  of 
trustees. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
October  30,  1897.  October  27th.— Medical  Director 
W.  K.  Van  Reypen  detached  as  member  of  the  board 
of  inspection  and  survey  and  made  chief  of  the  bureau 
of  medicine  and  surgery.  October  28th. — Assistant 
Surgeon  T.  W.  Richards  detached  from  the  Maine, 
ordered  home  to  Washington,  and  granted  two  months' 
leave. 


674 


MEDICAL    RECORD. 


[November  6,  1897 


^ocietig  §lejjorts. 

MEDICAL    SOCIETY    OF    THE    COUNTY   OF 
NEW    YORK. 

Annual  Meeting,    October  2^,  JfSgj. 

Landon  Cartkr  Gray,  M.D.,  President. 

Report  of  the  Treasurer. — Dr.  John  S.  Warren 
read  his  report.  The  disbursements  had  been 
$6,509.43,  and  the  balance  in  the  treasury  was 
i?82i.39. 

Report  of  Committee  on  Hygiene. — Dr.  W.  H. 
Katzenbach  presented  in  this  report  an  account  of 
what  had  been  done  regarding  the  action  of  the  board 
of  health  requiring  notification  of  cases  of  tuberculo- 
sis. The  details  had  been  presented  to  the  societj' 
last  March. 

Report  of  the  Counsel.— Dr.  Seneca  D.  Powell, 
in  calling  attention  to  this  report,  said  that  some  idea 
of  the  work  done  by  the  legal  counsel  of  the  society 
might  be  gained  from  the  statement  that  since  the  new 
law  had  been  in  operation  one  hundred  and  twenty- 
four  arrests  had  been  made  for  illegal  practice  of 
medicine,  and  seventy-six  convictions  had  been  se- 
cured.     The   aggregate   fines   imposed    amounted    to 

Report  of  Committee  on  Ethics. — Dr.  Arthur  M. 
Iacobus,  after  presenting  a  summary  of  the  work  done 
by  this  committee  during  the  year,  suggested  that,  in 
view  of  the  fact  that  the  rules  of  ethics  of  this  society 
did  not  harmonize  with  those  of  the  State  society,  and 
the  rules  concerning  enforcement  of  discipline  were 
not  clear,  this  matter  should  be  referred  to  the  incom- 
ing comitia  minora,  and  that  power  be  given  the  co- 
mitia  minora  to  enforce  minor  degrees  of  discipline 
without  publicity  and  without  appeal  to  the  societ}'. 

Dr.  N.  E.  Brill  moved  that  the  report  be  referred 
to  the  incoming  comitia  minora  for  action.     Carried. 

Committee  on  Prize  Essay. — Dr.  William  Ste- 
vens stated  that  the  committee  had  received  and  care- 
fully examined  three  essays.  The  committee  recom- 
mended that  the  prize  be  awarded  to  Dr.  Heinrich 
Stern,  the  author  of  the  essay  entitled  "  A  Contribu- 
tion to  the  Pathogenesis  and  Etiology  of  Diabetes 
Mellitus." 

Amendments  to  the  Bylaws. — In  order  to  pre- 
vent unusual  and  unwarranted  inroads  on  the  treasury, 
the  bylaws  were  so  amended  as  to  require  the  comitia 
minora  to  pass  upon  proposed  appropriations  and  re- 
port to  the  society. 

Committee  on  Legislation. — After  a  prolonged  and 
somewhat  heated  discussion  as  to  whether  medical 
legislation  in  Albany  could  be  best  attended  to  by  the 
board  of  censors,  as  heretofore,  or  by  the  proposed 
committee  on  legislation,  the  bylaws  were  amended 
so  as  to  make  the  latter  a  standing  committee,  work- 
ing under  the  direction  of  the  comitia  minora. 

The  Case  against  Dr.  Van  Fleet  Non-Suited.— 
1)R.  D.  B.  Si.  JnHN  RoosA  announced  that  the  presi- 
dent of  the  society  and  some  other  members  of  the 
profession  had  attended  the  trial  in  the  United  States 
court.  It  would  be  remembered  that  the  society  had 
voted  to  sustain  Dr.  Van  Fleet.  After  hearing  tiie 
plaintifi's  testimony  and  the  argument  made  bv  the 
society's  counsel,  the  judge  refused  to  allow  the  ca.se 
to  go  to  the  jury;  in  other  words,  the  court  had  prac- 
tically decided  that  the  society's  meeting-place  was  a 
place  of  privilege,  and  that  if  reporters  came  there  it 
was  at  their  own  peril. 

Vote  of  Thanks  to  Dr.  Van  Fleet. — On  motion 
of  l)u.  RoosA,  the  society  tendered  to  Dr.  \'an  Fleet 
a  vote  of  thanks  for  his  courageous  defence  of  its 
rights  at  great  trial  and  inconvenience  to  himself. 


Resolution  of  Sympathy  for  Dr.  Avery — Dr.  E. 

H.  Grandin  offered  the  following  resolution,  which 
was  unanimously  adopted: 

"Resolved,  That  the  Medical  Societ)'  of  the  County 
of  New  York  sympathizes  deeply  with  Dr.  Averj'  in 
his  illness,  and  expresses  the  hope  that  before  long 
he  will  again  be  able  to  preside  as  secretary  with  his 
accustomed  fidelity  over  the  meetings  of  this  society." 

Election  of  Officers.  —  President,  Dr.  Arthur  M. 
Jacobus;  First- Viie-President,  Dr.  Nathan  E.  Brill; 
Second  Vice-Presidnt,  Dr.  B.  Farquhar  Curtis;  Secre- 
tary, Dr.  Charles  H.  Avery;  Assistant  Secretary,  Dr. 
William  E.  Bullard;  Treasurer,  Dr.  John  S.  Warren; 
Censors,  Drs.  Landon  Carter  Gray,  Walter  Lester  Carr, 
Herman  L.  Collyer,  Floyd  M.  Crandall,  and  Frank 
H.  Daniels. 

A   Contribution    to   the    Surgery   of    Empyema, 

with  the   History  of   an    Illustrative    Case Dr. 

Charles  E.  Lockwood  read  a  paper  on  this  subject 
After  referring  to  the  histology  of  the  pleural  sac  and 
to  the  different  varieties  of  pleurisy,  he  said  that  it  was 
now  believed  that  every  empyema  was  due  to  microbic 
invasion  of  the  pleural  cavity.  Statistics  seemed  to 
.show  that  fifty  per  cent,  of  all  cases  were  caused  by 
streptococci,  twenty-five  per  cent,  by  pneumococci,  and 
the  remaining  twent)-five  per  cent,  by  several  forms, 
of  which  tuberculosis  was  relatively  the  most  common. 
In  children  the  pneumococcus  caused  from  sixty  to 
seventy-five  per  cent,  of  all  cases,  the  remainder  being 
mostly  the  result  of  infection  with  streptococci  or  sta- 
phylococci. In  all  the  different  varieties  of  purulent 
pleurisy  the  treatment  consisted  of  the  immediate 
evacuation  of  the  pus.  There  were  four  methods  of 
accomplishing  this,  viz. :  (i)  Aspiration,  (2)  simple 
incision,  (3)  thoracotomy  with  resection,  and  (4)  si- 
phon drainage.  Dr.  L.  E.  Holt  had  collected  one 
hundred  and  twenty-one  cases  in  which  aspiration  had 
been  done.  Twenty-three  of  the  patients  were  cured, 
six  died,  and  ninety-two  came  to  further  operation. 
This  gave  twenty  per  cent,  of  cures;  hence  this  opera- 
tion was  applicable  in  certain  cases,  and  was  worthy 
of  trial  in  the  mild  cases  and  in  those  in  which  delay 
was  not  dangerous.  It  should  not  be  done  more  than 
once.  In  children  it  had  been  found  relatively  more 
successful,  probably  because  the  empyemas  of  early 
life  were  usually  produced  by  the  short-lived  and 
comparatively  non-virulent  pneumococcus.  In  some 
cases  of  tuberculous  empyema  which  were  latent,  aspi- 
ration would  seem  to  be  most  conservative.  One  ob- 
server had  reported  ten  successful  cases  in  adults 
suffering  from  pneumococcus  empyema.  Simple  in- 
cision would  seem  to  be  especially  applicable  when 
general  anaesthesia  was  not  admissible  and  in  the 
case  of  children.  Morrison  had  given  a  series  of 
thirty-four  cases  in  which  this  operation  had  been 
done  with  only  two  deaths  and  an  average  duration  of 
treatment  of  thirty-two  days.  Local  anaesthesia  by 
one-per-cent.  .solution  of  cocaine  could  be  used. 
Thoracotomy  with  resection,  in  all  cases  not  included 
in  the  cases  heretofore  mentioned,  had  seemed  to  give 
the  most  favorable  results.  In  one  hundred  and 
seven  cases  in  which  incision  h.id  been  done,  there 
were  sixty  complete  cures,  or  fifty  per  cent.,  and  twelve 
fistula-;  while  seventy-nine  cases  of  resection  gave 
fifty-five  complete  cures,  or  seventy  per  cent.,  and  six 
fistula;.  The  most  important  point  was  to  secure  thor- 
ough drainage,  and  if  possible  to  avoid  irrigation, 
which  seemed  to  be  dangerous  and  liable  to  prolong 
suppuration.  From  1S76  to  1880  all  empyemas 
treated  at  one  of  the  German  clinics  had  been  irrigated 
daily  for  an  average  period  of  one  hundred  and  one 
days,  with  thirty  per  cent,  of  complete  cures.  From 
i88o  to  1S85  only  one  irrigation  was  given,  and  the 
average  duration  was  eighty-four  days,  and  there  were 
seventj-per  cent,  of  cures.     From  1885  to  1890  irriga- 


November  6,   1897] 


MEDICAL    RECORD. 


6?-. 


tion  had  been  discarded  entirely  except  in  putrid  cases, 
and  the  duration  was  fift\'-two  days,  and  there  were 
ninety-six  per  cent,  of  cures.  Siphon  drainage  con- 
sisted in  tapping  the  chest  with  a  large  trocar,  and 
after  drawing  off  most  of  the  pus  inserting  a  soft  cath- 
eter with  a  rubber  tube  attached,  the  distal  end  of 
this  tube  dipping  into  an  antiseptic  fluid  contained  in 
a  bottle.  The  method  was  chiefly  applicable  to  the 
chronic  tuberculous  empyemas  and  perhaps  to  the 
pneumococcus  empyemas  of  adults. 

A   Septic  Fever  Controlled   Only   by  Antiseptic 
Irrigation — Dr.  Lockwood  then  reported  the  following 

case :  C.   B ,  sixteen  years  of  age,  a  student,  had 

lost  three  brothers,  one  sister,  and  one  maternal  uncle 
from  pulmonary  tuberculosis.  His  own  health  had 
previously  been  good.  On  December  lo,  1S96,  he 
had  a  chill,  and  then  the  temperature  rose  to  104.8'^ 
F.,  the  pulse  to  108,  and  the  respirations  to  28.  Ex- 
amination showed  an  acute  pneumonia  of  the  lower 
lobe  of  the  right  lung  and  friction  sounds  indicating 
involvement  of  the  pleura.  For  six  days  the  morning 
temperature  was  102'  F.,  and  the  afternoon  tempera- 
ture 103^  F.  On  the  tenth  day  it  was  normal  at  3 
A.M.,  but  had  reached  100  F.  at  3  p.m.  For  the  next 
few  days  the  temperature  was  normal  in  the  morning 
and  slightly  elevated  in  the  afternoon.  Physical  ex- 
amination at  this  time  showed  pleurisy  with  effusion. 
On  the  seventeenth  day  the  morning  temperature  was 
99  F.,  and  the  evening  temperature  103  F.,  and  the  pa- 
tient suffered  considerably  from  difiicult  breathing  and 
pain  in  the  right  side.  On  the  following  day,  December 
28th,  the  speaker  had  seen  him  for  the  first  time,  and 
had  aspirated  the  chest  between  the  fourth  and  fifth  ribs 
on  the  right  side,  drawing  off  twenty  ounces  of  laudable 
pus.  The  next  day  the  temperature  was  normal  at  9 
A.M.,  and  loi'  F.  at  6  p.m.  Examination  of  the  sputum 
by  Dr.  Harlow  Books  showed  considerable  numbers  of 
the  diplococci  of  pneumonia,  but  no  tubercle  bacilli. 
On  January  3d  the  boy  was  again  aspirated  between 
the  fifth  and  sixth  ribs,  and  twenty  ounces  of  pus  were 
removed.  On  January  5  th  an  incision  was  made  by  Dr. 
W.  T.  Bull  on  the  right  side  in  the  axillary  line,  over 
the  eighth  and  ninth  ribs,  and  portions  of  these  ribs, 
one  and  one-half  inches  long,  were  removed.  When 
the  pleural  cavity  was  opened  a  large  quantity  of  fibrin 
and  pus  escaped.  The  cavity  was  irrigated  with  steri- 
lized water  and  two  large  rubber  tubes  were  inserted 
and  fastened.  To  guard  against  danger  from  break- 
age, silk  was  passed  through  from  end  to  end.  The 
next  day  the  morning  temperature  was  98.4°  F.,  and 
in  the  evening  it  was  99.8'  F.  The  dressings  were 
changed  three  times  in  twenty-four  hours.  On  January 
16th  the  tubes  were  removed  and  the  wound  was  irri- 
gated, for  the  first  time  since  the  operation,  with  steri- 
lized decinormal  salt  solution,  and  the  tubes  were 
cleaned  and  reinserted.  For  about  one  week  the  irri- 
gations with  sterilized  water  were  done  once  a  day,  and 
it  was  then  noted  that  the  evening  temperature  seemed 
to  have  been  higher  since  these  irrigations  had  been 
used.  However,  they  were  continued  for  about  anoth- 
er week.  The  patient  now  had  night  sweats,  an  anaimic 
murmur  over  the  base  of  the  heart,  and  slight  ttdema 
of  the  lower  extremities.  Dr.  Janeway  then  saw  the 
case.  He  expressed  the  opinion  that  the  fever  was 
septic,  and  recommended  irrigation  of  the  chest  cavity 
with  one  drachm  of  carbolic  acid  to  sixteen  ounces  of 
water,  care  being  taken  to  measure  the  quantity  intro- 
duced and  removed,  .so  as  to  make  it  certain  that  none  of 
the  solution  was  allowed  to  remain  behind.  The  tem- 
perature was  103'  F.  at  that  time.  On  the  following 
day,  February  4th,  the  temperature  remained  normal  all 
day  and  the  irrigation  was  repeated.  It  should  be  noted 
that  the  septic  fever  prevailed  about  one  month,  and 
that  it  did  not  abate  until  the  use  of  the  weak  carbo- 
lized  solution.     By  February  i8th  the  patient  was  able 


to  take  a  short  ride,  and  on  April  26th  the  dressings  were 
discontinued.  On  May  15th  careful  measurements  of 
the  chest  were  taken,  and  it  was  found  that  the  differ- 
ence between  the  two  sides  on  inspiration  was  five- 
eighths  of  an  inch,  and  on  expiration  one-fourth  of  an 
inch — a  good  showing  considering  the  severity  of  the 
case.  Great  care  was  taken  throughout  the  tedious 
convalescence  to  secure  the  highest  possible  nutrition. 
That  there  was  a  perforation  in  the  lung  was  shown 
by  the  fact  that  the  patient  could  breathe  through  the 
opening  in  the  chest  when  the  nostrils  and  mouth  were 
closed,  and  it  was  probable  that  infection  occurred 
through  the  introduction  of  micro-organisms  in  this 
way  from  the  outside  air. 

Do  Not  Neglect  Exploratory  Puncture. — Dr.  Bev- 
erley RoBixsox  said  that  he  had  had  under  his  care 
at  St.  Luke's  Hospital  last  spring  a  little  child  who 
had  been  operated  upon  for  pyothorax.  The  child  was 
here  this  evening.  He  came  in  from  the  Orphan  Asy- 
lum with  the  history  of  a  pneumonia  preceding  his 
admission  by  some  weeks.  F'rom  the  appearance  of 
the  child  and  from  the  physical  examination  it  was 
supposed  that  the  boy  was  possibly  suffering  from  some 
malignant  disease  of  the  chest.  Puncture  of  the  chest 
was  made,  and  purulent  fluid  withdrawn.  A  day  or  two 
later  the  rib  was  resected.  After  about  tvvo  months  he 
left  the  hospital  cured,  and  was  now  in  good  condition. 

With  regard  to  the  treatment  of  empyema,  the  speaker 
said  that  his  individual  opinion  was  that  it  was  a  mis- 
take to  allow  ourselves  to  believe  that  mere  puncture  of 
the  chest  wall  and  withdrawal  of  the  fluid  one  or  more 
times  was  the  best  treatment,  as  he  had  found  that  it 
was  not  usually  curative.  Cases  so  treated  usually 
required  subsequent  operation,  preferably  by  resection 
of  one  or  more  ribs.  The  relative  increase  in  surgical 
shock  from  resection  of  a  rib,  as  compared  with  simple 
incision,  he  believed  to  be  slight  and  unimportant. 
Simple  aspiration  was  tedious  and  inefficient,  and  non- 
curative in  a  large  number  of  cases;  moreover,  it  did 
not,  as  a  rule,  allow  of  such  efficient  drainage  as  when 
the  rib  was  resected.  It  was  a  mistake  to  attempt  to 
operate  on  children  under  local  anaesthesia,  if  for  no 
other  reason  than  the  bad  mental  impression  created. 
The  only  real  risk  attendant  upon  the  operation  of 
opening  the  chest  and  resecting  a  rib  was  that  asso- 
ciated with  the  anesthetic.  He  did  not  think  that  in 
the  diagnosis  of  empyema  we  had  any  right  to  rely 
upon  the  general  symptoms ;  unless  we  resorted  to  ex- 
ploratorj'  puncture  we  would  almost  certainly  make 
grievous  mistakes.  It  was  a  common  but  very  erro- 
neous belief  that  pleurisy  was  apt  to  change  from  the 
serous  to  the  purulent  form.  Acute  broncho-pneumo- 
nia in  childhood  was  the  most  frequent  cause  of  empy- 
ema in  children,  and,  whenever  there  was  any  reasona- 
ble doubt  during  the  course  of  the  disease  or  following 
it,  resort  should  be  had  to  puncture  to  establish  the 
diagnosis.  There  should  be  no  danger  from  punctur- 
ing the  lung  with  an  aseptic  needle.  He  had  never 
seen  any  harm  from  such  punctures  when  made  with 
proper  precautions.  It  was  ver\-  difficult  to  recognize 
an  empyema  in  connection  with  a  pneumonia  during 
the  acute  process;  it  was  not  so  difficult  after  the  pe- 
riod of  crisis.  He  believed  that  it  was  bad  practice 
to-day  to  irrigate  the  pleural  cavity  after  an  operation 
for  empyema,  unless  we  were  compelled  to  do  so  by  a 
fetid  discharge,  with  or  w'ithout  rise  of  temperature, 
or  by  the  presence  of  clots  in  the  pleural  cavity.  Care 
should  be  taken,  if  a  poisonous  antiseptic  fluid  was 
used,  that  it  should  not  be  allowed  to  remain  in  the 
cavity.  Personally  he  would  prefer  to  use  some  non- 
poisonous  antiseptic,  such  as  boric  acid  or  Labarraque's 
solution.  Free  drainage  was,  of  course,  all-important, 
and  as  it  was  difficult  if  not  impossible  in  many  chil- 
dren to  secure  this  by  simple  incision,  the  advantage 
of  resection  of  a  rib  was  obvious.      In  an  adult  whose 


676 


MEDICAL    RECORD. 


[November  6,  1897 


pleural  cavity  had  contained  fluid  for  a  considerable 
time  it  was  difficult  to  see  how  the  chest  wall  could 
retract  sufficiently  to  allow  healing  of  the  abscess 
cavity  unless  a  rib  was  resected. 

Treat  Pyothorax  Like  Any  Other  Abscess.— Dr. 
John  B.  Walker  said  that  it  seemed  to  him  that  the 
treatment  of  empyema  should  be  the  same  as  the  sur- 
gical treatment  of  an  abscess  in  any  other  locality. 
As  an  ordinary  abscess  was  not  treated  by  aspiration, 
it  was  not  advisable  to  aspirate  an  empyema.  The 
simple  incision  had  the  disadvantage  of  making  it 
quite  difficult  to  keep  the  wound  sufficiently  open  to 
allow  free  drainage,  and  hence  he  favored  resection 
of  the  rib.  The  tubes  used  should  be  as  large  as  pos- 
sible. In  the  case  reported  in  the  paper  the  tubes 
were  about  one-half  inch  in  diameter,  and  the  dress- 
ings were  changed  as  often  as  they  became  moist. 
The  effect  of  the  weak  carbolized  solution  upon  the 
suppurative  process  had  been  exceedingly  satisfactory. 

Better  do  Too  Much  than  Too  Little.  —  Dr. 
Harry  R.  Purdy  said  that  a  rather  extensive  experi- 
ence among  children  had  taught  him  that  empyema 
was  not  an  uncommon  disease  in  early  life,  and  also 
that  there  was  no  other  disease  that  was  so  commonly 
overlooked.  If  after  scarlatina,  diphtheria,  measles, 
and  pertussis  a  careful  physical  examination  was 
made,  these  mistakes  would  not  be  so  frequent.  The 
most  important  physical  signs  were  entire  absence  of 
vocal  fremitus,  immobility  of  the  affected  side,  and 
the  result  of  light  and  skilful  percussion.  He  could 
not  agree  with  the  reader  of  the  paper  in  calling  any 
case  of  empyema  "mild."  In  his  opinion  delay  was 
always  dangerous,  and  common  sense  would  seem  to 
indicate  that  the  pus  should  be  promptly  evacuated  by 
the  resection  of  one  or  more  ribs.  Why  waste  time  on 
the  minor  operations,  when  seventy-five  or  eighty  per 
cent,  of  cures  could  be  obtained  by  this  method? 
The  dread  of  giving  an  anaesthetic  was  not  a  proper 
excuse  for  delaying  such  an  operation.  He  had  seen 
children  so  weak  that  they  had  to  be  carried  around 
on  a  pillow  stand  the  anesthetic  perfectly  well.  He 
recalled  one  case  in  which  the  mother  would  not  con- 
sent to  an  operation,  and  the  child  got  well  owing  to 
the  fortunate  circumstance  that  the  pus  discharged 
through  a  bronchus.  The  operation  of  simple  inci- 
sion was  not  a  good  one  for  children,  because  of  the 
narrowness  of  the  intercostal  spaces.  The  operation 
of  resection  should  not  be  confined  simply  to  so-called 
cases  of  empyema,  for  at  times  the  so-called  serous 
effusions  did  certainly  become  purulent.  In  cases  of 
protracted  pleurisy  or  of  frequent  reaccumulation  of 
the  fluid,  he  would,  with  Koplik,  advise  resection. 
There  was  more  likelihood  of  failure  in  these  cases 
from  doing  too  little  than  from  doing  too  much.  In 
illustration,  he  cited  the  case  of  a  baby  who  had  been 
brought  to  him  one  year  ago  in  a  feeble  condition.  It 
h.id  apparently  suffered  from  empyema  for  many  weeks, 
and  was  also  enfeebled  from  pertussis.  About  two- 
thirds  of  a  pint  of  pus  was  removed  by  operation,  and 
with  very  marked  improvement  in  the  general  condi- 
tion. The  discharge  was  continuous,  but  the  mother 
would  not  consent  to  another  operation.  He  had 
therefore  dressed  the  child  faithfully  for  a  year,  and 
then  the  little  one  had  been  admitted  to  St.  Mary's 
Hospital.  Here  she  had  been  operated  upon  again 
on  July  27,  1897,  an  incision  being  made  along  the 
old  sinus.  The  fourth,  fifth,  and  si.xth  ribs,  with  por- 
tions of  the  seventh,  were  removed,  together  with  the 
periosteum  and  parietal  pleura.  The  latter  was  enor- 
mously thickened.  The  wound  was  packed,  and  a 
week  later  the  child  was  sent  to  the  country.  Here 
chicken-pox  developed.  A  sinus  was  left,  and  a  week 
ago  a  further  resection  was  done.  The  present  condi- 
tion of  the  child  was  quite  good,  considering  the  his- 
torv  of  the  case. 


Remove  Coagula  through  a  Pleural  Speculum. — 

Dr.  Carl  Beck  said  that  several  years  ago  he  had 
presented  to  this  society  a  paper  on  this  subject.  Fif- 
teen )-ears  ago  he  had  recommended  resection  of  the 
rib  for  all  cases  of  empyema  without  exception,  and 
had  been  bitterly  opposed  by  distinguished  members 
of  the  profession.  It  was  therefore  with  great  satis- 
faction that  he  obsened  this  evening  the  harmony  of 
opinion  regarding  the  advisability  of  treating  these 
cases  by  resection,  incision,  and  drainage.  There  was 
no  reason  why  such  cases  should  not  be  treated  on  the 
same  principles  as  governed  the  modern  surgeon  in 
the  treatment  of  any  abscess.  In  the  treatment  of  an 
abscess  the  surgeon  would  not  only  secure  a  large 
opening  and  free  drainage,  but  he  would  scrape  the 
lining  membrane  and  remove  the  necrotic  tissue  and 
the  attached  microbes.  He  would  not  think  of  using 
irrigation,  for  after  such  careful  treatment  it  would  not 
be  necessarj'.  Irrigation  of  the  necrotic  membrane 
meant  irrigating  dirt ;  it  was  better  to  remove  the  dirt. 
In  cases  of  empyema  there  were  often  very  large  solid 
masses — sometimes  as  large  as  a  man's  fist — and  he 
could  not  understand  how  such  cases  could  be  success- 
fully treated  by  aspiration  or  even  by  simple  incision. 
It  was  evident  that  these  masses  under  such  circum- 
stances must  be  left  behind  to  dissolve  and  escape 
slowly  in  the  discharge.  It  seemed  to  him  that  in  the 
case  reported  in  the  paper  there  must  have  been  ne- 
crotic membrane  which  had  been  gradually  washed  out 
with  the  irrigations.  He  was  not  inclined  to  think 
that  it  was  the  carbolic  acid  that  should  be  credited 
with  the  improvement,  but  rather  the  mechanical  effect 
of  the  irrigation.  If  more  attention  had  been  given 
to  the  removal  of  necrotic  tissue  at  the  beginning,  the 
history  of  the  case  would  have  probably  been  different. 
He  advised  the  use  of  a  "  pleural  speculum,"  with  the 
aid  of  which  it  was  easy  to  see  the  fibrinous  clots  and 
remove  them.  Only  at  this  time  was  it  necessary  to 
irrigate  the  cavit)-.  In  recent  years  he  had  preferred 
to  pack  the  cavity  with  iodoform  gauze,  packing  it 
tightly  for  two  or  three  days,  and  after  this  using  a 
loose  packing.  Since  the  adoption  of  this  treatment 
he  had  but  rarely  seen  death  occur  in  an  uncomplicated 
case.  He  preferred  to  call  these  cases  "  pj'othorax," 
because  empyema  referred  to  collections  of  pus,  with- 
out designating  the  locality. 

Remove  the  Cause  by  the  Use  of  Strong  Car- 
bolic Acid. — Dr.  Seneca  D.  Powell  said  that  a  pus 
pocket  was  a  pus  pocket,  no  matter  where  it  was  found  or 
whether  in  a  child  or  in  an  adult.  The  two  important 
points  in  the  treatment  were  (i)  the  establishment 
of  perfect  drainage,  and  (2)  the  removal  of  the  cause 
of  the  infection.  In  order  to  remove  the  cause,  one 
should  use  a  germicide  which  could  be  employed 
safely  in  a  strength  that  would  be  efficient.  He 
claimed  that  the  only  germicide  fulfilling  these  condi- 
tions was  carbolic  acid.  Pure  carbolic  acid  could  be 
applied  to  one's  hands  for  a  moment,  and  then  the  ac- 
tion of  the  acid  could  be  limited  by  washing  in  alco- 
hol. He  would  advise  swabbing  out  the  cavity  with 
pure  carbolic  acid  after  having  curetted  away  the  ne- 
crotic tissue,  and  then  packing  the  cavit)-  with  gauze. 
If  good  drainage  could  be  obtained  by  an  incision, 
then  all  was  accomplished  that  was  necessar)-.  ELxcept 
in  long-standing  cases,  he  thought  it  was  but  rarely 
necessar}-  to  resort  to  any  extensive  resection. 

Dr.  Lockwood,  in  closing  the  discussion,  said  that 
he  was  very  glad  that  the  discussion  had  emphasized 
the  fact  that  the  best  treatment  was  the  recognized 
surgical  treatment  for  abscess.  It  was  also  well  to 
remember  w  hat  Dr.  Robinson  had  said  about  the  great 
importance  of  exploratory  puncture  in  establishing  a 
positive  diagnosis. 

The  Clinical  Importance  of  Impacted  Pelvic  Tu- 
mors  Dr.  Hexrv  C  Coe  read  only  a  portion  of  this 


I 


November  6,  1897] 


MEDICAL    RECORD. 


677 


paper,  because  of  the  lateness  of  the  hour.  He  said 
that  the  subject  was  one  which  really  concerned  the 
general  practitioner.  Pelvic  neoplasms  often  re- 
mained unrecognized,  and  the  pressure  symptoms  to 
which  they  gave  rise  were  often  misinterpreted.  A 
small  tumor,  from  the  size  of  an  English  walnut  to 
that  of  a  baseball,  might  cause  no  special  symptoms 
until  it  became  impacted  in  Douglas'  pouch  or  sur- 
roimded  by  inflammatory  exudate.  In  the  latter  case 
the  symptoms  were  often  quite  marked,  and  the  pa- 
tient's general  health  would  probably  suffer  greatly. 
The  symptoms  produced  by  impacted  pelvic  tumors 
were  often  referred  to  the  pelvic  and  abdominal  viscera, 
and  the  physician  was  thereby  misled.  The  amount 
of  pain  was  frequently  entirely  out  of  proportion  to 
the  size  of  the  growth,  and  distant  organs  might  be 
affected — as,  for  instance,  through  pressure  on  the 
ureters.  When  such  tumors  complicated  pregnancy, 
they  deserved  the  serious  attention  of  every  practi- 
tioner. The  importance  of  intrapelvic  tumors  varied 
according  to  their  anatomical  character,  their  mode  of 
development,  and  their  localitj-.  Thus  a  rapidly 
growing  cystoma  would  possess  more  significance  than 
a  small  subperitoneal  fibroid.  Again,  a  tumor  im- 
pacted in  Douglas'  pouch  possessed  more  importance, 
from  a  clinical  standpoint,  than  an  intraligamentous 
growth  of  the  same  size  and  variet)'.  For  practical 
purposes,  as  the  tumors  impacted  in  Douglas'  pouch 
were  the  most  common,  they  alone  would  be  considered. 
Reflex  Pressure  Symptoms  Liable  to  Mislead. 
— The  most  obvious  effects  of  such  tumors  were  those 
resulting  from  pressure.  The  uterus,  from  its  mobil- 
ity and  anatomical  relation  to  the  neoplasm,  was  apt 
to  be  first  affected.  Procidentia,  occurring  in  a  young 
woman  with  a  good  pelvic  floor,  should  be  regarded 
as  probably  an  indication  of  pressure  from  above. 
The  rectum  would  always  be  more  or  less  encroached 
upon  by  growths  in  the  cul-de-sac,  and  the  bladder 
naturally  shared  in  the  pressure  effects.  Still  more 
serious  were  the  results  of  direct  pressure  of  fibroids 
in  the  lower  uterine  segment.  The  results  of  pressure 
on  the  intrapelvic  portion  of  the  ureter  were  well 
known.  The  general  venous  congestion  of  the  pelvic 
organs  in  connection  with  impacted  tumors  was  fre- 
quently noted  on  the  operating-table.  Varicose  veins 
of  the  labia  and  hemorrhoids  presented  external  evi- 
dence of  obstruction  to  the  circulation.  The  distinc- 
tion between  an  impacted  and  an  adherent  tumor  was 
important.  WTien  the  neoplasm  was  attached  to  the 
uterus  and  rectum,  the  pressure  effects  were  exagger- 
ated. A  small  tumor,  which  previously  gave  rise  to 
no  symptoms  whatever,  might,  under  the  influence  of 
pregnane}-,  not  only  increase  in  size,  but  contract  ad- 
hesions which  would  permanently  imprison  it  in 
Douglas'  pouch.  A  case  was  cited  in  which  a  cystic 
tumor  complicated  pregnancy.  He  had  been  able  to 
push  it  up  out  of  the  way  of  the  descending  head  and 
to  deliver  easily,  but  in  a  second  pregnancy  the  tumor 
was  found  to  be  impacted,  and  it  became  necessary,  to 
perform  abdominal  section.  Colicky  pains  and  pains 
in  the  appendical  region  were  common  in  connection 
with  extensive  intestinal  adhesions.  In  two  cases  of 
sudden  dislocation  of  subperitoneal  fibroids,  seen  in 
consultation,  the  symptoms  exactly  simulated  those  of 
a  ruptured  ectopic  sac.  Obstruction  to  the  passage  of 
faecal  matter,  tenesmus  after  defecation,  and  a  sensa- 
tion as  if  the  lower  bowel  had  not  been  completely 
emptied  were  all  suggestive  of  pressure  on  the  lower 
bowel.  More  or  less  complete  obstruction  of  the  lu- 
men might  be  indicated  by  the  small  size  of  the  fsecal 
masses.  One  might  be  frequently  led  to  suspect  the 
presence  of  an  intrapelvic  growth  in  young  girls  by 
persistent  hemorrhoids,  which  could  not  be  explained 
in  any  other  way.  The  bladder  symptoms  were  some- 
times the  only  evidence  of  a  pelvic  growth  encroach- 


ing upon  the  pelvic  organs.  In  the  absence  of  satis- 
factory evidence  of  disease  of  the  genito-urinar}'  tract, 
the  possibilit)'  of  pressure  upon  or  dislocation  of  the 
bladder  should  be  borne  in  mind.  Rectal  palpation 
should  never  be  omittted ;  in  young  girls  it  alone  was 
permissible,  and  fortunately  the  information  thus  ob- 
tained was  often  conclusive.  If  the  examination  were 
not  at  first  entirely  satisfactor)-,  it  should  be  repeated 
under  an  anaesthetic.  The  present  comfort  and  the 
future  safety  of  the  patient  had  both  to  be  considered. 
Constant  and  severe  pain,  steadily  increasing  in  spite 
of  local  treatment,  was  a  sufficient  indication  for  oper- 
ative interference.  Marked  pressure  symptoms,  in 
connection  with  the  steady  growth  of  a  tumor,  were  an 
ample  excuse  for  operation.  Only  an  imperfect  idea 
of  the  extent  of  pelvic  adhesions  could  be  gained 
through  a  vaginal  incision,  and  the  operation  could  be 
done  more  thoroughly  and  intelligently  through  a  free 
abdominal  incision. 

Impacted    Tumors    Complicating    Pregnancy 

When  impacted  tumors  complicated  pregnancy  they 
were  especially  dangerous,  because  they  gave  rise  to 
no  symptoms  directing  the  attention  of  the  patient  or  of 
her  physician  to  the  condition  in  the  early  months. 
This  should  emphasize  the  importance  of  a  routine 
examination  during  pregnancy,  even  though  the  physi- 
cian had  previously  attended  the  patient  in  confine- 
ment. Before  the  seventli  month,  if  repeated  and  care- 
ful attempts  to  dislodge  the  mass  failed,  the  patient 
being  in  the  knee-chest  position  and  if  necessary  under 
anaesthesia,  the  question  of  interference  at  once  arose. 
Previous  to  the  fourth  month  the  induction  of  labor 
might  be  elected.  After  four  and  one-half  months  he 
would  insist  upon  the  choice  of  coeliotomy,  even 
though  the  tumor  was  small  and  accessible  through 
the  vagina.  Should  premature  deliver)'  occur,  no 
harm  would  result.  He  disliked  the  vaginal  route  for 
the  removal  of  growths  in  pregnant  women.  The  fre- 
quency with  which  dermoids  became  impacted  in  the 
cul-de-sac,  and  their  liability  to  undergo  changes, 
made  it  imperative  that  they  should  not  be  subjected 
too  long  to  pressure  by  the  uterus.  Induction  of  labor 
offered  a  little  more  chance  to  the  child,  and  exposed 
the  mother  to  practically  the  same  risk  as  at  term. 
Coeliotomy  must  eventually  be  performed,  because  of 
complications  resulting  from  mechanical  injury  to  the 
tumor.  The  management  of  labor  at  term,  when  com- 
plicated by  impacted  tumors,  was  a  purely  mechanical 
problem.  Sometimes  the  sac  could  be  diminished  in 
size  by  tapping  or  even  by  incision.  In  the  presence 
of  an  impacted  solid  growth,  one  must  be  governed  by 
its  size  and  relations  to  the  birth  canal.  The  perfor- 
mance of  coeliotomy  did  not  necessarily  imply  Cffisa- 
rian  section,  as  the  tumor  could  be  removed  by  ab- 
dominal section  and  the  child  delivered  through  the 
natural  passages. 

Place  the  Pregnant  Woman  under  Medical  Su- 
pervision.—  Dr.  Edw.\rd  H.  Grandin  accepted  the 
position  taken  by  the  reader  of  the  paper.  The  first 
thought  suggested  to  him  by  the  paper  was  the  neces- 
sity for  examining  a  pregnant  woman  as  early  in  preg- 
nancy as  possible.  He  believed  that  the  medical 
profession  had  become  convinced  of  the  necessitj-  of 
this,  but  it  yet  remained  to  educate  the  laity  to  the 
fact  that  the  interests  of  both  mother  and  child  de- 
manded that  the  pregnant  woman  should  place  herself 
under  the  care  of  her  physician  as  soon  as  she  was 
aware  that  she  was  pregnant.  It  was  surprising  how 
far  a  woman  might  be  advanced  in  pregnancy  before 
a  tumor  would  become  impacted ;  hence  the  great  im- 
portance cf  its  early  recognition,  that  such  a  catastro- 
phe might  be  averted.  In  his  opinion  it  was  as  .?afe 
at  the  present  lime,  even  in  the  early  months  of  preg- 
nancy, to  remove  the  tumor  as  to  interfere  with  the 
progress  of  gestation.     It  was  not  traumatism  that  did 


678 


MEDICAL    RECORD. 


[November  6,  1897 


damage,  but  dirt.  He  did  not  think  we  were  called 
upon  to  interrupt  the  progress  of  gestation  in  any  case 
when  a  properly  performed  abdominal  section  would 
enable  one  to  remove  the  growth.  He  would  always 
prefer  attacking  such  a  tumor  from  above,  except  when 
he  was  satisfied  that  it  was  really  a  pus  collection,  in 
which  case  the  vaginal  route  was  the  proper  one. 
Through  the  abdominal  opening  the  operator  could 
best  determine  the  relations  of  the  tumor,  the  e.xtent 
of  the  peritoneal  adhesions,  and  also  whether  or  not 
the  appendix  vermiformis  was  affected — a  not  uncom- 
mon complication.  Later  on  in  pregnancy,  unless  the 
symptoms  were  urgent,  as  the  chances  were  in  favor 
of  a  radical  operation,  it  was  better  to  postpone  the 
operation,  if  possible,  until  the  child  was  viable.  The 
vaginal  route  should  never  be  selected  for  such  an 
operation,  unless  pus  was  present. 

Does  the  Gravid  Uterus  Press  upon  the  Ureters  ? 
^Dr.  Freeland  Barhour,  of  Edinburgh,  being  in- 
vited to  participate  in  the  discussion,  said  that  he  de- 
sired to  emphasize  the  importance  of  the  statements 
made  regarding  examination  through  the  vagina  and 
rectum  in  determining  the  position  and  fixation  of 
these  tumors.     He  related  the  two  following  cases: 

The  first  case  was  one  of  a  dermoid  tumor  impacted 
in  the  pelvis.  It  had  given  rise  to  no  symptoms  until 
the  woman  had  become  pregnant.  At  the  time  he 
had  seen  her,  the  symphysis  and  the  tumor  were 
only  about  two  inches  apart;  the  tumor  was  em- 
embedded  in  the  cellular  tissue  and  could  not  have 
been  taken  out  without  a  very  serious  operation.  The 
patient  was  unwilling  to  be  exposed  to  such  a  risk, 
and  therefore  labor  was  induced  at  the  seventh  month, 
and,  by  turning,  a  living  child  was  delivered.  In  the 
Edinburgh  school,  he  said,  they  did  not  attach  so 
much  importance  to  the  induction  of  premature  labor 
as  had  been  intimated  in  the  remarks  made  this  even- 
ing. This  patient  recovered  perfectly,  and  had  since 
been  quite  well. 

The  other  case  had  impressed  upon  his  mind  the 
great  seriousness  of  these  tumors  through  implication 
of  the  ureters.  He  would  like  to  know  what  theory 
those  present  entertained  regarding  the  manner  in 
which  the  ureter  was  affected.  His  own  theory  was 
that  the  tumor  simply  pushed  the  ureter  aside  in  the 
same  way  that  the  pregnant  uterus  did,  and  that  when 
pressure  occurred  it  was  due  rather  to  inflammation. 
He'knew,  of  course,  that  some  had  held  that  the  preg- 
nant uterus  compressed  the  ureters  at  times,  but  some 
years  ago  he  had  made  a  number  of  dissections  and 
had  carefully  traced  the  course  of  the  ureters,  and  in 
this  way  had  satisfied  himself  that  the  risk  of  the  ure- 
ter being  compressed  between  the  bony  walls  of  the 
pelvis  and  the  gravid  uterus  was  very  small.  In  the 
case  referred  to  there  was  also  a  hydronephrosis,  and 
on  tracing  the  ureter  it  was  found  that  the  ureter  was 
completely  embedded  in  and  occluded  by  cicatricial 
tissue,  which  had  developed  in  connection  with  the 
growth  of  the  tumor. 

More  Tumors  Imprisoned  than  Impacted Dr. 

A.  Palmer  Dudley  said  that  the  clinical  importance 
of  impacted  pelvic  tumors  grew  with  our  knowledge 
of  pelvic  disease,  and  the  clinical  importance  of  the 
same,  with  respect  to  the  patient,  depended  upon  our 
ability  to  explain  that  condition  properly  to  her.  He 
believed  that  more  pelvic  tumors  were  found  impris- 
oned than  impacted.  It  was  sometimes  very  difficult 
to  convince  the  patient  that  distant  reflex  pains  had 
their  origin  in  pelvic  disease.  One  of  the  most  im- 
portant of  such  reflex  affections  was  neuralgia  about 
the  eye.  Any  condition  which  interfered  with  tlie 
diaphragmatic  action  of  the  pelvic  floor  became  just 
as  dangerous  to  the  patient  as  an  impacted  tumor. 
The  retrofle-xed  uterus  might  become  an  impacted  tu- 
mor.    Our  object  should  be  carefully  to  differentiate 


between  the  dift'erent  growths,  and  in  doing  this  we 
should  take  into  consideration  the  age  of  the  patient. 
In  probably  nine  out  of  ten  cases  the  abdominal  route 
was  the  better  one  for  both  the  patient  and  the  oper- 
ator. 

Pressure  on  the  Ureters  Leads  to  Serious  Disease. 
— Dr.  George  W.  Jarman  said  that  in  a  recent  autop- 
sy he  had  found  distinct  evidence  that  the  tumor  had 
produced  sufficient  pressure  on  the  ureter  to  cause  the 
death  of  the  patient.  If  an  impacted  tumor  involved 
one  or  the  other  side  of  the  broad  ligament,  even 
though  there  were  no  bladder  or  rectal  symptoms, 
operation  was  especially  indicated.  He  was  convinced 
that  many  deaths  after  operations  for  fibroids  were 
due  to  latent  kidney  disease  caused  by  pressure  upon 
the  ureter. 

Danger  from  these  Tumors  even  after  Delivery. 
— Dr.  Robert  A.  Murray  said  that  about  fifteen 
years  ago  there  had  been  an  important  discussion  re- 
garding the  effect  of  tumors  on  the  pregnant  condition. 
At  that  time  the  opinion  seemed  to  be  that  these  tu- 
mors should  be  left  alone,  and  that  as  a  rule  they  would 
be  sufficiently  lifted  up  out  of  the  way  to  admit  of  de- 
livery. But  fifteen  years  had  made  a  great  difference 
in  our  opinions,  and  also  in  the  mortality  in  these 
cases.  While  it  was  true  that  sometimes  the  tumor 
rapidly  disappeared  during  the  involution  of  the  uterus 
after  labor,  it  was  equally  true  that  the  patient  not 
infrequently  became  septic  as  a  result  of  the  injury 
caused  by  labor.  In  a  Cesarean  section  done  at  full 
term  on  a  uterus  containing  many  fibroid  tumors, 
there  was  great  danger  of  septic  peritonitis.  He 
would  favor  in  these  cases  extirpation  of  the  uterus. 
We  should  never  hope  against  hope,  believing  that  the 
tumor  would  be  lifted  out  of  the  pelvis,  delivery 
effected,  and  that  then  no  further  complication  was 
likely  to  take  place.     This  was  a  serious  mistake. 

Dr.  Coe,  in  closing  the  discussion,  said  that  he 
agreed  with  Dr.  Barbour  that  in  most  cases  of  com- 
pression of  the  ureter  the  result  was  due  to  inflamma- 
tory action,  yet  he  had  seen  one  or  two  autopsies  in 
which,  so  far  as  could  be  ascertained,  hydronephrosis 
was  due  to  direct  pressure,  particularly  from  intralig- 
amentous growths. 


'T^HE  NEW  YORK  PATHOLOGICAL  SOCIETY. 

SMc\/  Meeting,  May  26,  iSgj. 

John  Sl.\de  Ely,  M.D.,  President. 

Lipoma  of  the  Diaphragm. — Dr.  Lewis  A.  Con- 
ner presented  several  specimens.  The  first  was  a 
fatt)'  tumor  which  projected  from  the  diaphragm  into 
the  left  pleural  cavity.  It  was  found  at  an  autopsy  on 
an  old  woman  who  died  of  cerebral  hemorrhage.  The 
tumor  was  situated  a  little  to  the  left  of  the  cardiac 
apex  and  more  posteriorly.  It  measured  four  by  three 
centimetres,  was  sessile,  and  was  covered  with  the 
diaphragmatic  pleura.  On  the  under  side  was  to  be 
seen  what  appeared  to  be  a  deficiency  in  the  dia- 
phragm which  might  possibly  explain  the  origin  of 
the  tumor.  There  were  no  adhesions  to  the  surround- 
ing organs  beneath  the  diaphragm,  or  evidence  of  at- 
tachment to  the  omentum.  This  was  the  first  time  that 
the  speaker  had  met  with  a  tumor  in  this  situation. 

Malignant  Endocarditis.  —The  ne.xt  two  specimens 
were  hearts  exhibiting  the  lesions  of  endocarditis. 
The  first  one  had  been  taken  from  a  laborer,  thirty 
years  of  age,  who  had  been  admitted  to  the  Hudson 
Street  Hospital  on  December  2d.  He  had  had  rheu- 
matism years  before,  and  had  been  told  that  there  was 
some  cardiac  affection,  but  it  had  caused  him  no  in- 
convenience.    Shortly  before  deatli  he  had  been  sud- 


November  6.  1897] 


MEDICAL    RECORD. 


679 


denly  attacked  with  irregular  chills,  fever,  and  sweat- 
ing, and  on  admission  had  a  temperature  of  100.4'  F- 
The  heart  dulness  was  increased,  and  at  the  apex  were 
to  be  heard  a  diastolic  thrill  and  murmur,  and  there 
were  all  the  signs  of  an  old  mitral  stenosis.  The  spleen 
was  enlarged,  and  there  were  a  few  spots  over  the  ab- 
domen which  resembled  the  eruption  of  typhoid  fever: 
indeed,  both  the  tongue  and  the  general  appearance  of 
the  patient  suggested  this  disease.  Examination  of 
the  blood  showed  no  malarial  organisms.  A  specimen 
of  the  blood  was  sent  to  the  board  of  health,  and  was 
reported  to  have  given  the  typhoid  reaction  with  the 
serum  test.  A  few  days  later  a  distinct  double  mur- 
mur developed  over  the  base  of  the  heart,  in  the  aortic 
area,  and  the  pulse  became  harder.  A  diagnosis  was 
then  made  of  endocarditis.  He  lived  ten  days  longer. 
and  during  this  time  the  murmur  was  changeable. 
During  the  last  three  or  four  days  there  were  distinct 
pericardial  friction  sounds.  With  the  exception  of 
the  chills  the  clinical  picture  was  that  of  typhoid 
fever.  At  autopsy  the  pericardium  was  found  to  con- 
tain ten  ounces  of  red  fluid,  and  the  parietal  and  vis- 
ceral layers  were  injected  and  everywhere  covered 
with  a  thin  layer  of  fibrinous  exudate,  giving  a  granu- 
lar appearance  to  the  surface.  The  heart  was  moder- 
ately enlarged:  its  cavities  were  all  dilated;  the  mus- 
cle was  rather  soft.  The  mitral  orifice  admitted  only 
the  tip  of  the  little  finger;  the  valve  was  much  thick- 
ened and  the  chordae  tendines  were  shortened.  At  the 
base  of  the  posterior  cusp  of  the  mitral  valve  was  a 
soft,  recent,  reddish  thrombus,  measuring  two  centime- 
tres at  the  base  and  one  centimetre  in  thickness.  On 
the  anterior  cusp  of  the  anterior  valve,  midway  between 
the  mitral  and  aortic  valves,  was  a  large  whitish  vege- 
tation, measuring  two  centimetres  at  the  base  and  1.5 
cm.  in  thickness.  The  cusp  was  considerably  thick- 
ened, and  the  sinus  of  Valsalva  was  greatly  enlarged 
by  what  appeared  to  be  an  aneurismal  dilatation.  This 
formed  a  prominence  on  the  wall  of  the  left  auricle, 
corresponding  to  the  seat  of  the  first-mentioned  throm- 
bus. The  other  valves  were  normal.  Both  kidneys 
contained  a  number  of  small  yellow  infarcts.  The 
aneurismal  pouching  of  the  sinus  of  \'alsalva  was  evi- 
dently the  cause  of  the  thrombus,  although  there  was 
no  perforation. 

The  next  specimen  showed  a  malignant  endocardi- 
tis affecting  the  pulmonarj'  valves.  The  specimen  had 
been  removed  from  a  woman,  thirty-eight  years  of  age, 
who  had  been  admitted  to  the  New  York  Hospital 
after  an  illness  of  a  few  days.  She  had  had  several 
chills  and  at  the  time  of  entering  the  hospital  pre- 
sented the  clinical  picture  of  a  lobar  pneumonia. 
This  was  the  diagnosis  made  in  the  hospital.  A  loud 
systolic  murmur  w^as  heard  over  the  base  of  the  heart. 
The  autopsy  showed  the  spleen  to  be  enlarged  to  three 
times  its  normal  size.  The  kidneys  were  normal  ex- 
cept for  some  cloudy  swelling.  There  were  areas  of 
recent  exudation  over  both  pleural  surfaces.  The  left 
lung  contained  two  areas  of  hemorrhagic  infarction  in 
the  lower  lobe.  In  the  centre  of  each  small  area  of 
broken-down  tissue  in  the  right  lung  were  several 
small  but  similar  areas  of  infarction,  and  near  some 
of  these  were  found  emboli  in  the  branches  of  the  pul- 
monary artery.  In  the  lower  part  of  the  upper  lobe 
there  was  quite  an  extensive  area  of  consolidation, 
with  an  area  of  softening  in  the  centre.  The  heart 
itself  was  about  of  normal  size.  The  mitral,  aortic, 
and  tricuspid  valves  were  apparently  normal.  There 
was  a  mass  of  fresh  friable  vegetation  arising  from 
the  posterior  and  under  surface  of  the  pulmonary- 
valve. 

The  speaker  called  attention  to  the  great  difference 
in  the  clinical  picture  in  the  two  cases  of  endocarditis. 
V^egetations,  he  said,  were  very  much  more  common 
on  the  left  side  of  the  heart  than  on  the  right.     When 


the  left  side  of  the  heart  was  involved,  emboli  were 
washed  into  the  general  circulation,  instead  of  into  the 
pulmonary  circulation :  hence  the  great  difference  in 
the  clinical  picture  in  the  two  classes  of  cases. 

Aneurisms  of   the  Aorta ;    Rupture The   next 

specimen  presented  by  Dr.  Conner  consisted  of  a  re- 
markable series  of  aneurisms  of  the  aorta.  It  had  been 
taken  from  an  old  man,  seventy-three  years  of  age,  who 
had  been  admitted  to  the  Hudson  Street  Hospital  on 
March  14,  1897,  in  a  state  of  coma.  The  man  had 
been  found  ill  in  the  street,  but  had  been  able  to  walk 
to  the  police  station.  A  few  hours  later  he  had  been 
removed  to  the  hospital  in  an  ambulance.  No  com- 
plete physical  examination  was  made  before  his  death, 
which  occurred  in  a  few  hours.  At  the  autopsy  the 
left  pleural  cavit)-  was  found  completely  filled  with 
clotted  and  fluid  blood.  The  pericardium  and  heart 
were  displaced  to  the  right  beyond  the  median  line. 
Occupying  the  normal  position  of  the  heart,  and  push- 
ing forward  the  parietal  pleura  in  that  region,  was  a 
rounded  tiunor,  the  size  of  a  large  orange.  The  left 
lung  was  completely  collapsed  and  its  apex  converted 
into  fibrous  tissue.  The  apex  of  the  right  lung  showed 
some  fibrous  nodules  and  tuberculous  deposits.  The 
heart  was  extremely  small;  its  valves  were  apparently 
competent.  The  aorta,  from  its  beginning  to  its  pas- 
sage through  the  diaphragm,  was  enormously  dilated 
and  converted  into  a  series  of  irregular  pouches,  the 
largest  being  ten  centimetres  in  diameter.  About 
twenty^  centimetres  from  the  aortic  valve,  in  the  upper 
part  of  the  descending  aorta,  was  a  transverse  linear 
rupture,  about  three  centimetres  long.  The  sac  con- 
tained for  the  most  part  fluid  blood.  The  dilatation 
of  the  aorta  continued  down  to  within  about  six  or 
seven  centimetres  of  the  bifurcation.  The  intima  of 
the  aorta  everywhere  was  the  seat  of  atheroma  and 
calcareous  deposits. 

Dr.  Warren  Colemax  said  that  he  had  seen  several 
cases  of  malignant  endocarditis  occurring  on  the  right 
side  during  the  puerperium.  He  had  never  seen  the 
pulmonar)'  valve  so  affected. 

The  President  said  that  he  had  seen  a  few  cases  in 
which  the  pulmonary  valve  had  been  affected.  Natur- 
ally in  these  cases  pulmonary  emboli  were  also  found. 

Dr.  Conner  said  that  in  the  cases  he  had  reported 
there  had  been  no  evidence  of  an  outside  infection; 
in  other  words,  it  was  a  secondar}-  process.  The 
streptococcus  pyogenes  was  found  in  each  of  them. 

The  society  then  adjourned. 


Fractures  of  the  Skull. — In  a  consideration  of  the 
permanent  or  later  results  of  these  fractures  Dr.  Wil- 
liam N.  Bullard  [Boston  Medical  and  SurgUal  Journal, 
April  29th)  draws  the  following  conclusions:  "  i.  Out 
of  seventy  persons  with  fractures  of  the  skull,  thirty- 
seven  presented  no  symptoms  when  examined  some 
time  later.  2.  Only  seven  persons  presented  serious 
symptoms,  and  in  at  least  four  of  these  it  is  doubtful 
whether  the  symptoms  were  due  to  the  injury.  3.  The 
most  frequent  consequences  found  were  headache, 
deafness,  dizziness,  and  inability  to  resist  the  action 
of  alcohol  on  the  brain.  4.  Out  of  the  fifteen  cases 
in  which  operation  (trephining,  etc.)  was  performed, 
t^velve  had  no  symptoms;  in  another  it  was  doubtful 
whether  the  symptoms  present  were  due  to  the  injury; 
in  another  the  symptoms  were  slight  (headache  rare, 
tension  over  the  wound  while  lying  in  bed) ;  the  other 
was  deaf,  but  had  no  other  trouble.  We  are  justified, 
therefore,  in  concluding,  so  far  as  our  statistics  lead, 
that  those  cases  in  which  trephining  was  performed 
have  shown  much  better  results,  as  far  as  the  symp- 
toms discussed  are  concerned,  than  those  in  which  no 
operation  was  performed." 


68o 


MEDICAL    RECORD. 


[November  6,  1897 


©litiicat  gcpartmeiit 

TENOTOMY    IN    CONVERGENT    SQUINT. 
By   a.    BETHUNE    PATTERSON,    M.D., 

ATLANTA,  GA. 

The  guiding  muscles  of  the  eyeball  are  the  internal 
and  external  recti,  the  superior  and  inferior  recti,  and 
the  oblique,  and  are  the  muscles  involved  in  strabis- 
mus. There  are  several  methods  of  treating  strabis- 
mus, which  are  based  upon  the  theories  entertained  as 
to  the  cause,  and  which  will  not  be  taken  into  discus- 
sion here,  as  the  principal  object  is  to  call  attention  to 
the  too  frequent  and  unscientific  operation  of  cutting 
the  internal  rectus  muscle  in  convergent  squint. 

The  indications  in  cross-eye  have  always  been  to 
straighten  the  eye ;  modern  research  has  led  us  a  step 
farther,  a.id  established  a  second  indication — that  of 
re-establishing  the  function  of  observing  with  the 
deviating  eye,  for  binocular  vision  becomes  suspended 
soon  after  parallelism  of  the  visual  lines  is  lost;  coin- 
cident with  the  deviation,  double  vision  makes  its  ap- 
pearance and  is  usually  of  short  duration,  for  the 
squinting  eye  soon  learns  to  suppress  its  image.  The 
fusion  of  the  two  images  when  once  suspended  is  by 
no  means  easily  restored ;  it  is  a  tedious  and  painstak- 
ing task  to  bring  about  a  restoration  of  the  physiolog- 
ical function,  and  should  be  of  grave  concern  to  the 
conscientious  operator.  It  must  not  be  understood 
that  the  straightening,  or  more  properly  the  apparent 
straightening,  has  restored  to  the  eye  its  former  habit 
of  seeing;  but,  on  the  other  hand,  when  fusion  takes 
place  it  is  proof  positive  of  the  parallelism  of  the 
lines  of  vision. 

I  hold  that  the  treatment  can  be  regarded  as  suc- 
cessful only  when  these  several  conditions  are  realized, 
for  the  eye  is  useless  and  virtually  blind  so  long  as 
the  image  is  allowed  to  remain  suppressed;  then  it 
should  be  the  principal  object  in  the  treatment  or 
management  of  squint  to  restore  to  the  eye  its  physio- 
logical usefulness.  This  becomes  e.vceedingly  difficult 
and  in  many  cases  impossible  after  cutting  the  internal 
rectus  muscle,  because  after  a  complete  severance  of 
the  internal  rectus  the  eye  turns  a  little  up  and  re- 
mains in  this  position.  This  hyperphoria  becomes  a 
grava  complication,  and  must  be  overcome  before 
binocular  vision  is  attained. 

It  might  be  said  that  considering  the  strabismus 
operation  from  a  cosmetic  standpoint  only  is  an  obso- 
lete custom,  yet  there  are  a  few  old  operators  who  con- 
tinue the  practice  of  twenty  years  ago.  It  is  to  be 
regretted  that  this  branch  of  eye  surgery  has  been  ne- 
glected by  many  of  our  distinguished  operators.  It  is 
true  that  the  simple  tenotomy  is  the  quickest  and  easi- 
est way  of  disposing  of  these  cases,  and,  coupled  with 
the  fact  of  the  improvement  in  the  appearance  of  the 
subject  that  follows,  it  is  satisfactory  to  those  who 
are  ignorant  of  the  true  condition. 

In  an  article  published  in  the  Southern  Aledical 
Record  six  or  seven  years  ago,  I  protested  against  the 
indiscriminate  cutting  of  the  internal  rectus  in  conver- 
gent squint.  The  following  I  select  from  a  number  of 
cises  illustrative  of  the  evils  of  which  this  paper 
complains,  of  operating  wholly  from  a  cosmetic  stand- 
point : 

Miss  P had  her  internal  rectus  muscles  cut  for 

convergent  strabismus  by  a  distinguished  surgeon  a 
short  time  after  the  squint  appeared.  The  double 
vision  had  subsided  only  a  few  weeks.  The  operator 
was  ignorant  of  the  existing  hypermetropia,  or  far- 
sight, which  was  three  and  one-half  diopters.  When 
she  came  under  my  treatment  there  was  still  a  slight 
convergence,   with  the  usual  turning  up  (eso-hyper- 


phoriaj.  I  succeeded  in  re-establishing  binocular 
vision  by  doing  a  graduated  tenotomy  and  correcting 
the  hypermetropia  with  glasses.  I  feel  very  confident, 
if  her  hypermetropia  had  been  corrected  at  the  time  of 
the  first  operation,  and  accommodation  had  been  kept 
quiet  by  the  instillation  of  atropine  for  some  time,  that 
the  cutting  of  the  muscles  would  not  have  been  neces 
sary. 

Very  many  cases  of  convergent  strabismus  in  chil- 
dren are  due  to  far-sight,  and  if  taken  in  hand  early 
can  be  cured  by  glasses  which  correct  the  refractive 
error;  then  again  there  are  many  others  due  to  a  weak 
external  rectus,  which  can  be  cured  by  developing  the 
weak  muscle.  A  complete  severance  of  the  muscle 
should  be  made  only  after  a  due  consideration  of  all 
the  conditions  incident  to  strabismus. 


PAROXYSMAL   TETANOID. 
By   N.    GORDON"    PRICE,    M.D., 

NEW    YORK. 

Under  this  heading  I  desire  to  mention  a  train  of  pe- 
culiar tetanic  symptoms  arising  as  the  result  of  men- 
tal overexertion.  This  condition  was  brought  to  my 
notice  several  months  ago  by  my  friend.  Dr.  Rosen- 
tover,  who  has  been  for  quite  a  time  subject  to  these 
paroxysms,  and  I  have  had  occasion  to  confirm  the 
existence  of  this  phenomenon  and  to  become  more  fa- 
miliar with  its  details  through  personal  experience. 

I  bring  this  condition  before  my  medical  brethren, 
not  because  the  condition  per  se  is  of  much  importance, 
but  because  I  am  in  the  hope  that  its  recital  may  throw 
some  new  light  upon  the  influence  of  prolonged  cere- 
bration upon  the  motor  apparatus  of  the  human  econ- 
omy, the  motor  centres  primarily  and  the  muscular  and 
nervous  system  secondarily. 

The  only  etiological  factor  I  am  familiar  with  is 
hypercerebration,  brought  about  in  numerous  ways; 
as,  for  example,  the  result  of  close  and  constant  appli- 
cation of  the  mind  to  reading  material  requiring  deep 
thought  and  concentrated  attention,  or  as  the  result  of 
brooding  over  unhappy  thoughts. 

Apparently  this  factor  disturbs  the  cerebral  equilib- 
rium, rendering  the  happy  harmony  of  will  and  action 
discordant ;  it  severs  tlie  normal  relationship  of  the 
motor  and  volition  centres,  and  permits  for  a  time  the 
motor  apparatus  to  act  independently,  although  the 
will  power  retains  its  normal  vigor — the  motor  centres 
being  in  a  state  of  revolt,  as  it  were. 

The  attack  is  most  prone  to  come  on  when  the  sub- 
ject is  in  the  supine  recumbent  position,  and  especially 
at  night  on  retiring,  provided  cerebral  activity  is  al- 
lowed to  continue.  Quite  a  remarkable  fact  is  that  if 
a  person  is  once  attacked,  tetanoid  may  be  brought  on 
voluntarily  merely  by  fulfilling  the  above  condition. 
I.e.,  deep  thought  after  prolonged  mental  work  on  re- 
tiring. 

The  attack  is  usually  ushered  in  by  prodromal  signs., 
whose  proper  significance  only  experience  can  teach 
one  to  interpret.  These  signs  are  as  various  as  are 
those  of  the  epileptic  aura,  though  most  frequently 
they  are  of  the  auditory  type;  hearing  is  acutely  and 
painfully  exaggerated,  and  peculiar  hallucinatory 
noises  are  heard,  such  as  the  rushing  of  water  down  a 
fall.  Sometimes  the  aura  is  of  a  sensory  type,  in  the 
form  of  one  of  the  parajsthesiiE,  the  sense  of  formica- 
tion being  most  frequent.  These  premonitory  symp- 
toms last  a  few  seconds,  when  the  attack  itself  comes 
on.  If  these  symptoms  are  correctly  interpreted,  the 
oncome  of  the  attack  may  be  prevented  by  moving 
any  of  the  voluntary  muscles. 

In  the  attack  itself  we  have  a  faithful  representation 
of  the  tonic  rigidity  of  a  tetanic  convulsion — the  vol- 


November  6,  1897] 


MEDICAL    RECORD. 


681 


untary  muscles  contract  spasmodically,  trismus  is 
present,  die  extremities  are  violently  extended,  and 
palpitation  of  the  heart  is  a  frequent  accompaniment. 
Consciousness  is  maintained  throughout  the  attack, 
opisthotonos  is  absent  or  slight,  and  the  contractions 
are  perfectly  painless.  The  will  power  is  normal;  in- 
tellection is  normal,  as  a  rule,  though  in  some  attacks 
it  is  impaired;  there  is  a  dread  of  death  present,  and 
the  person  feels  as  though  he  were  bound  in  chains. 
being  unable  to  move  any  of  his  muscles. 

One  is  taught  by  experience  that  if  he  succeed  in 
exerting  his  will  to  such  an  extent  as  to  enable  him  to 
move  any  of  the  voluntarj-  muscles,  as  the  vocal  cords 
or  even  the  levatores  palpebrarum,  he  will  cut  short 
the  attack  and  compel  the  motor  centres  and  muscular 
system  to  reassirme  their  natural  subservience  to  the 
will.  The  seizure  lasts  a  few  minutes,  though  to  the 
aftiicted  it  seems  so  many  ages;  its  withdrawal  is  a 
signal  for  a  free  general  sweat  and  for  a  grateful  re- 
lief from  all  the  symptoms,  mental  and  physical.  If 
cerebral  activity  is  still  continued,  as  many  as  five  or 
six  attacks  may  be  brought  on,  one  following  the  other 
in  rapid  succession.  The  attacked,  to  eliminate  fur- 
ther seizures,  must  drive  away  all  thought,  lie  in  the 
semiprone  position,  and  imagine  nothing,  except  that 
he  is  a  log,  incapable  of  thought. 

The  specific  cause  and  precise  nature  of  this  phe- 
nomenon are,  I  must  admit,  entirely  obscure.  The  at- 
tack will  probably  be  explained  as  epileptiform,  but 
this  will  be  merely  evasion,  and  resemble  the  answer 
of  the  philosopher,  who,  when  asked,  "What  is  mind?'' 
answered,  "No  matter;""  and  when  asked,  "What  is 
matter?"  replied,  "Never  mind.'" 

The  elucidation  of  this  peculiar  puzzle  I  will  leave 
to  those  who  are  more  qualified  than  I  am  to  probe 
into  the  depths  of  neurological  phenomena. 

136  Columbia  Street. 


FLOATING    KIDNEY. 
By    SARAH    E.    POST,    M.D., 

BROOKLYN,    N.    Y. 

Recently  a  patient  sent  for  me,  complaining  of  ab- 
i  dominal  pain,  nausea,  anxiety,  and  general  distress. 
I  found  the  woman  in  bed.  Examination  easily  found 
the  right  kidney  presenting,  its  upper  border,  I  think, 
inclining  to  the  abdominal  wall.  The  patient  is  the 
mother  of  ten  children.  I  have  found  the  relative  fre- 
quency of  these  cases  somewhat  determinable.  My 
first  case  I  came  to  in  the  dispensary  of  the  Woman's 
College,  as  early  as  1883  or  1884,  my  first  year  of 
practice.  The  complaint  was  in  a  young  woman, 
who  appeared  at  the  clinic  of  general  medicine.  Dif- 
ficult urination  was  the  prominent  symptom.  The 
kidney  was  not  made  out,  and  the  diagnosis  de- 
pended upon  the  nausea  and  the  general  distress. 
Another  case  was  met  about  five  years  later  in  the 
Demilt  Dispensary,  evening  class,  then  devoted  to 
general  medicine.  This  woman  did  not  show  the 
displacement  at  the  time.  Another  time  I  was 
called  to  her  house  and  found  her  in  bed,  with  the 
kidney  easily  recognizable.  This  woman  was  about 
thirty-five  years  of  age,,  and  had  an  unyielding  retro- 
flexion of  the  uterus.  A  truss  was  fitted  to  the  kid- 
ney. A  third  case  was  met  almost  five  years  later 
in  the  same  clinic,  then  given  up  to  gynaecological  and 
skin  troubles.  I  mention  the  latter  because  the  pa- 
tients did  not  have  to  ask  care  for  a  gynecological 
complaint,  and  the  inference  is  not  clear  that  this  one 
came  even  suspecting  such  a  trouble.  In  my  last  case 
my  first  thought  was  to  anticipate  miscarriage  and  to 
look  for  the  enlarged  uterus.  Even  with  the  third 
case  in  mind,  however,  I  have  no  ground  for  thinking 
that  the  patients  themselves  ever  make  this  mistake. 


The  third  case  was  in  a  woman,  twent}--five  years 
of  age.  She  came  in  the  height  of  the  distress,  with 
all  the  symptoms  marked — flushed  face,  difficult  urina- 
tion, nausea,  and  pain,  distress  and  anxietj-  predom- 
inating. The  kidney  could  be  found  protruding.  It 
could  be  returned  and  held  by  a  compress  and  bandage. 
In  fifteen  years'  practice,  including  dispensar)-  work, 
four  of  these  cases  have  come  to  me,  the  intervals  be- 
ing nearly  uniform,  each  being  about  five  years.  The 
first  year  brought  a  case  as  serious  as  those  that  came 
to  me  later.  The  use  of  a  compress  and  bandage  with 
a  week  in  bed  has  been  the  usual  treatment.  I  have 
not  found  the  cases  such  as  to  suggest  operation.  The 
second  patient  has  returned  to  me.  One  has  such  at- 
tacks only  now  and  then.  Another  had  had  one  such 
attack  six  years  previously. 


A    METHOD    FOR    PREPARING    STERILIZED 
CATGUT. 

By  S.    H.    CHAMPLIN,    M.D., 

CHICAGO,   ILL. 

If  a  catgut  ligature  be  chromicized  and  then  boiled 
thirt)'-five  minutes  in  water,  it  will  resist  absorption  in 
the  tissues  from  ten  to  twenty  days,  according  to  size. 
The  following  is  the  method  I  have  adopted :  A  cat- 
gut ligature  of  any  length  desired  is  wound  in  a  single 
layer  around  a  No.  5  or  No.  7  cork;  it  is  then  sunk  in 
absolute  ether  for  twent)--four  or  thirty-six  hours.  On 
removal  from  the  ether  the  cork  is  placed  in  the  open 
air  until  the  ether  in  the  catgut  has  entirely  evaporated. 
The  cork  is  then  sunk  in  the  following  solution :  Po- 
tassium bichromate,  two  parts;  formalin  (forty  per 
cent.),  four  parts;  water,  ninet)--four  parts.  At  the 
end  of  four  days  the  cork  is  taken  from  this  solution 
and  washed  a  few  minutes  in  running  water,  and  is 
then  sunk  in  boiling  water  for  thirty-five  minutes. 
The  catgut  may  then  all  be  stored  in  one  large  steri- 
lized jar — or,  better,  each  ligature  may  be  kept  sepa- 
rately in  a  small,  wide-mouthed  bottle,  the  bottle  and 
cork  having  been  previously  boiled. 

Corks  are  used  instead  of  glass  spools,  because  a 
certain  amount  of  shrinkage  takes  place  in  the  gut, 
and  if  wound  on  glass  the  ligature  becomes  flattened 
into  a  ribbon-like  strand  and  loses  much  of  its  tough- 
ness. 

Catgut  prepared  in  this  way  does  not  become  brittle 
if  boiled  only  once,  and  it  may  even  be  boiled  a  sec- 
ond time  for  ten  minutes  without  detriment.  If  boiled 
only  fifteen  minutes  the  first  time  it  may  be  boiled  a 
second  or  a  third  time  for  fifteen  minutes  each  time. 
The  water  should  be  at  the  boiling-point  before  the 
catgut  is  dropped  into  it. 

A  piece  of  No.  6  catgut  prepared  as  above  was 
passed  through  the  abdominal  wall  of  a  patient  on 
whom  I  performed  abdominal  section,  and  used  to- 
gether with  others  of  silkworm  gut  as  an  approximation 
suture.  On  the  tenth  day  the  sutures  were  removed, 
and  the  catgut,  like  the  others,  had  to  be  cut.  It  was 
found  to  be  very  pliable  and  about  one-half  its  original 
size,  and  required  considerable  force  to  break  it.  The 
peritoneum,  recti  muscles,  and  fascia  had  been  closed 
by  continuous  sutures  of  catgut  from  the  same  cork. 

Later  I  buried  three  pieces  of  No.  6  gut  under  the 
skin  of  a  dog.  One  piece,  removed  the  seventh  day, 
was  bleached  from  a  brown  to  an  opaque  while,  but 
otherwise  was  very  little  changed;  the  second  piece, 
removed  on  the  twelfth  day,  was  very  much  reduced  in 
size,  and  after  being  dried  it  was  broken  with  moderate 
force;  the  third  piece  was  looked  for  on  the  twentieth 
day,  but  could  not  be  found. 

This  catgut  has  been  used  in  pelvic  operations,  her- 
niotomy, and  a  great  variet)'  of  subcutaneous  opera- 
tions, and  no  infection  has  taken  place. 


682 


MEDICAL    RECORD. 


[November  6,  1897 


It  seems  to  me  that  a  No.  12  catgut  prepared  as 
above  would  make  an  ideal  bone  suture.  I  have  pre- 
pared only  sizes  Nos.  4,  6,  and  8;  probably  the  larger 
sizes  would  have  to  remain  in  ether  and  the  bichromate 
solution  somewhat  longer. 

1002  Madison  Street. 


OUR   LONDON    LETTER. 

( From  our  Special  Correspondent.) 

THE    ELECTION;    MR.    HORSLEV  SUCCESSFUL — THE  MAID- 
STONE   EPIDEMIC TYPHOID    IN    A    LONDON    HOSPITAL 

MEDICAL    SOCIETY    OF    LONDON CLINICAL  SOCIETY 

— DR.    ALEX.    HILL DR.    BISHOP    HICKS — MR.  ERNEST 

HART — DEATHS    OF    DRS.    BARRY,    R.    SMITH,    J.    LONG, 
AND   WICKHAM. 

London,  October  15,  1S97. 

The  election  is  over  and  Mr.  Victor  Horsley  is  our 
new  direct  representative  in  the  General  Medical 
Council.  It  is  estimated  that  more  than  thirteen  thou- 
sand votes  were  recorded  and  that  Mr.  Horsley's 
majority  is  nearly  six  hundred,  but  the  exact  figures 
cannot  be  given  for  another  day  or  two.  The  result 
will,  I  believe,  give  general  satisfaction. 

The  epidemic  of  typhoid  at  Maidstone  is  still  ex- 
tending. Last  night  the  total  number  of  cases  notified 
had  risen  to  1,642  and  the  deaths  to  91.  The  rate  of 
increase  has  some  days  seemed  less  and  inspired  hopes 
of  a  rapid  decline  which  have  been  disappointed.  On 
Monday  the  cases  were  1,574,  of  which  20  were  new. 
On  Tuesday  the  number  rose  to  1,593,  \\'ednesday  to 
1,620.  From  September  i8th  to  21st  the  attacks  were 
at  the  rate  of  82.7  per  diem;  for  the  week  ending 
September  28th  at  the  rate  of  74.4;  for  that  ending 
October  5th,  69.4;  October  13th,  26.4.  There  is  so 
great  distress  in  consequence  of  the  epidemic  that 
subscriptions  have  been  opened  in  various  towns  to 
help.  The  Lord  Mayor  of  London  has  also  opened  a 
fund. 

I  mentioned  that  the  water  company  was  to  discuss 
the  disinfection  of  the  Farleigh  mains.  On  Monday 
it  was  determined  that  this  should  be  done  on  Wed- 
nesday or  Thursday,  but  the  work  has  not  been  done. 
The  town  is  now  promised  that  the  disinfection  shall 
be  (Carried  out  between  to-morrow  and  Monday,  and 
the  inhabitants  naturally  want  to  know  why  it  was  not 
done  three  weeks  or  more  ago.  It  is  now  to  be  done 
under  the  supervision  of  Dr.  Sims  Woodhead.  It  is 
proposed  to  mix  eleven  tons  of  chloride  of  calcium  with 
225,000  gallons  of  water  and  pass  the  solution  through 
all  the  pipes  supplied  by  the  Farleigh  Springs.  So 
simple  an  operation  as  this  could  surely  have  been 
adopted  at  first,  and  the  water  company  has  much  to 
answer  for  without  adding  to  its  faults  this  delay. 
There  is  an  outcry  for  governmnent  investigation  and 
confiscation  of  the  monopoly,  a  demand  which  meets 
with  sympathy  wherever  people  feel  themselves  at  the 
mercy  of  water  companies.  Dr.  Semple  inoculated 
eighty  of  the  attendants  in  the  asylum  with  the  vaccine 
prepared  at  Netley.  Some  of  the  nurses  in  the  town 
also  submitted  to  the  experiment,  but  very  few  of  tlie 
inhabitants.  Forty  medical  men  and  more  than  one 
hundred  nurses  are  engaged  in  the  town.  I  regret  to 
hear  that  Dr.  Semple  is  ill  with  Malta  fever  contracted 
during  his  Netley  experiments. 

London  has  been  alarmed  by  reports  of  cases  im- 
ported from  Maidstone,  and  much  has  been  made  dur- 
ing the  week  of  the  occurrence  of  cases  in  University 
College  Hospital,  where  too  great  reticence  was  ob- 
served toward  the  press:  but  typhoid  does  not  appear 
to  have  been  in  excess  of  the  average  in  London  at 


this  season.  The  alarm  will  be  productive  of  good 
if  it  rouses  the  public  to  the  disgraceful  state  of  the 
River  Lea,  from  which  East  London  draws  water.  The 
company  is  warned  that  there  is  great  danger  from 
this  source,  and  neglect  on  its  part  will  be  severely 
visited. 

The  cases  at  University  College  Hospital  have  been 
confined  to  certain  nurses  and  wardmaids.  In  the 
course  of  rebuilding-operations  their  dining-room  had 
to  be  demolished.  In  the  one  to  which  they  were  re- 
moved a  different  water  supply  was  used,  and  this  had 
become  contaminated  from  a  tank  in  which  soiled 
linen  was  soaked  before  boiling.  About  eighteen 
cases  have  thus  occurred,  but  the  source  of  infection 
was  soon  traced  and  cut  off. 

The  societies  are  at  work.  Last  week  the  Obstetri- 
cal and  Clinical  held  meetings.  This  week  the  Medi- 
cal met  on  Monday ;  yesterday  the  Gynaecological  and 
the  Society  for  the  Study  of  Inebriety.  The  Patho- 
logical is  to  meet  next  Tuesday. 

The  new  president  Dr.  Sansom  took  the  chair  at  the 
meeting  of  the  Medical  Society  and  discoursed  on 
nervous  disorders  of  the  heart  not  associated  with 
obvious  organic  lesions,  and  urged  that  such  abnormal 
conditions  should  be  more  carefullly  observed  and 
examined  in  a  methodical  manner.  Among  symptoms 
often  met  with  in  functional  cardiac  disturbance  he 
mentioned  protuberance  of  the  eye,  inharmonious 
action  of  the  muscles  of  the  globe,  retraction  of  the 
upper  lid,  inequality  of  the  pupils  and  other  eye 
symptoms.  Auditory  signs,  the  pulse,  and  muscular 
tremors  were  also  to  be  noticed. 

The  mechanism  of  cardiac  dilatation  and  the  signifi- 
cance of  systolic  murmurs  at  the  apex  or  near  it  were 
further  considered. 

A  very  interesting — not  to  say  amusing— paper  fol- 
lowed by  Mr.  Anderson.  It  was  a  biographical  sketch 
of  John  Anderne,  born  in  1307,  and  accepted  by  Mr. 
Anderson  "  with  pride  and  veneration  as  the  father  of 
English  surger}'."  Lovers  of  early  medical  literature 
will  be  delighted  with  this  paper. 

At  the  Clinical  Society  meeting  the  new  president, 
Mr.  Langton,  thanked  the  fellows  for  the  honor  they  had 
accorded  him  of  succeeding  the  late  Mr.  Hulke,  whose 
office  he  had  temporarily  occupied  in  consequence  of 
the  latter's  lamented  decease.  He  then  remarked  on 
the  history  of  the  society  and  the  work  it  had  done,  es- 
pecially in  the  last  two  years.  In  illustration  of  the 
value  of  its  work  he  instanced  the  report  on  myxcedema, 
which  elucidated  the  patholog)'  of  the  disease  and  even 
led  to  the  discovery  of  its  successful  treatment.  An- 
other piece  of  work  was  that  done  in  connection  with 
the  vermiform  appendix.  He  mentioned  that  at  St. 
Bartholomew's  Hospital  operation  on  this  organ  had 
been  done  in  fourteen  cases  during  the  last  year,  in 
all  of  which  the  patients  had  recovered.  In  ten  of 
these  there  was  suppuration,  in  four  inflammation. 
He  promised  to  give  the  usual  inaugural  address  at 
the  first  meeting  of  the  coming  year. 

A  case  of  Loreta's  operation  was  then  related  by 
Dr.  White  and  Mr.  Langton,  after  which  Dr.  Phear 
read  an  account  of  a  case  of  cerebral  sinus  thrombosis 
in  a  child  of  seven.  There  was  an  interesting  discus- 
sion on  each  of  these  cases. 

Dr.  .Alex.  Hill  has  been  appointed  vice-chancellor 
of  the  University  of  Cambridge — the  highest  executive 
oflSce.  Dr.  Hill  is  the  lecturer  on  advanced  anatomy 
and  has  been  Ilunterian  professor  at  the  College  of 
Surgeons.  He  will  be  known  to  you  as  an  eminent 
neurologist,  the  author  of  the  "  Physiologist's  Note 
Book"  and  numerous  papers  on  the  anatomy  and 
physiology  of  the  nervous  system. 

Dr.  Hicks,  the  newly-appointed  bishop  of  Blomfon- 
.stein,  is  a  well-kown  medical  man  and  author  of  a 
"Standard  Text- Book  of  Inorganic  Chemistry." 


November  6,  1897] 


MEDICAL    RECORD. 


683 


Mr.  Ernest  Hart's  convalescence  has  continued,  and 
he  has  left  town  for  Brighton. 

Frederick  William  Barry,  M.D.,  D.Sc.  Ed.,  F.B.S. 
Ed.,  D.P.H.  Cantab.,  the  senior  inspector  of  the  local 
government  board,  was  found  dead  in  his  bedroom  at 
Birmingham  Hotel  on  Tuesday.  He  arrived  the  even- 
ing before  in  order  to  confer  with  the  board  of 
guardians.  He  was  the  writer  of  numerous  important 
reports  in  the  course  of  his  duties  on  cholera,  vaccina- 
tion, fever,  and  other  matters  relating  to  the  public 
health.  He  was  government  sanitarj'  commissioner 
in  Cyprus  from  1880  to  1882,  a  member  of  the  Epi- 
demiological and  other  societies  and  also  a  barrister 
of  the  Middle  Temple.  At  the  inquest  a  verdict  of 
death  from  natural  causes  was  found.  Dr.  Barry  is 
deeply  regretted  in  the  health  service  and  by  all  who 
knew  him. 

Dr.  Rob.  Smith,  medical  superintendent  of  Gates- 
head Aslyum,  died  under  chloroform  last  week  in  the 
Stockholm  Hospital,  to  which  he  had  gone  to  have  an 
operation  performed  for  fistula.  He  was  M.B.  Aberd. 
1854,  M.D.  1858. 

Dr.  James  Long,  a  retired  deputy  inspector-general, 
was  found  dead  in  his  sitting-room  on  Friday.  The 
body  was  under  the  table  in  a  position  to  which  it 
might  have  slipped.  He  lived  quite  alone.  He  was 
M.D.  of  Edinburgh,  1850. 

"  Dear  old  Dr.  Wickham,''  of  Tetbur}',  Gloucester- 
shire, died  on  the  30th  ult.  in  his  ninty-fifth  year. 
He  went  to  Tetbury  about  fifty  years  ago. 


OUR    PARIS    LETTER. 

<From  our  Special  Correspondent.) 

DUSTS    AS    PROPAGATORS    OF     INFLAMMATORY     DISEASES 
— DONATION     TO     THE     FACULTY     OF     MEDICINE     TO 

FOUND      THE       LEGROUX       PRIZE TRANSMISSION       OF 

MUMPS  TO  THE  DOG — ABDOMINAL  SURGERY — CYON's 
NERVE — FLOATING  KIDNEY  AND  VIURATORY  TREAT- 
MENT,   ETC. 

Paris,  October  22,  1807. 

The  role  played  by  dusts  of  different  kinds  as  factors 
in  the  causation  of  disease  is  more  important  than  is 
generally  admitted.  The  metallic  dusts,  by  their  irri- 
tative action  upon  the  membranes  of  the  finer  bronchial 
tubes,  frequently  give  rise  to  bronchitis  and  pneu- 
monia; and  all  are  familiar  with  the  calico-like  ap- 
pearance of  a  lung  impregnated  with  coal-dust  deposit. 
But  it  is  to  other  dusts  than  these  that  are  due  many 
cases  of  eruptive  fevers,  diphtheria,  pneumonia,  and 
almost  always  tuberculosis.  We  refer  to  the  dusts  that 
are  concealed  in  the  cracks  of  floors,  along  the  cor- 
nice, on  the  tops  of  window-frames,  and  in  the  angles 
of  walls.  It  is  for  this  reason  that  modern  hospital 
wards  should  be  built  with  rounded  corners  and 
vaulted  ceilings,  without  cracks  or  confractuosities  of 
any  kind. 

By  decree,  the  Faculty  of  Medicine  is  authorized  to 
accept  the  donation  of  a  sum  of  10,000  francs,  made 
in  its  favor  by  Madame  Legroux  for  the  foundation  of 
a  prize  to  be  given  every  five  years  under  the  name  of 
the  Charles  Legroux  prize.  The  prize  is  in  perpetua- 
tion of  Dr.  Charles  Legroux's  memory,  late  professor 
agre^e  at  the  Faculty  of  Medicine  of  Paris. 

There  have  been  several  important  and  interesting 
communications  made  recently  at  the  Academy  of 
Medicine.  In  the  first  instance.  Dr.  Laveran  related 
a  curious  observation  of  the  transmission  of  mumps 
from  man  to  the  dog.  It  should  be  noted,  however, 
that  Dr.  Laveran  made  this  communication  on  behalf 
of  Dr.  Busquet,  of  Bordeaux,  adding  that,  although  Dr. 
Busquet thought  he  had  observed  such  transmission,  it 
seemed  to  him  (Dr.  Laveran)  not  probable. 


The  military  doctors  took  part  in  the  proceedings. 
Dr.  Moty  entertained  the  academy  on  the  accidents  of 
the  wisdom  tooth.  The  word  "accidents"  is  given  in 
the  French  sense,  meaning  diseases  and  their  compli- 
cations. 

Dr.  Chauvel  confirmed  with  two  observations — the 
one  by  a  successful  operation,  the  other  by  a  death — 
the  necessity  of  immediate  intervention  in  all  cases  of 
penetrating  wounds  of  the  abdomen.  He  advocates 
opening  at  once  the  abdomen,  suturing  the  intestine, 
and  washing  the  peritoneum.  This  is  the  ground 
taken  by  some  of  the  leading  American  surgeons  many 
years  ago.  Sims  was  among  the  first  to  propose  it, 
and  although  the  operation  was  talked  of  in  Garfield's 
case  it  was  unfortunately  not  undertaken.  With  our 
modern  system  of  antisepsis,  the  abdomen  could  be 
opened  in  all  cases  of  penetrating  wounds,  certainly 
without  increasing  the  already  existing  danger.  Not 
only  does  the  surgeon  thus  become  doubly  sure  of  his 
diagnosis,  but  the  chances  of  the  patient's  ultimate 
recovery  are  largely  increased  thereby. 

All  heart  specialists  are  familiar  with  Cyon's  nerve 
— a  sensitive  nerve  of  the  heart  by  which  that  organ 
provokes  a  reflex  action  dilating  the  peripheric  circu- 
latory system  and  thus  diminishing  the  energy  and 
number  of  its  efforts.  Dr.  Cyon,  who  was  for  some 
time  editor-in-chief  of  a  Paris  newspaper,  is  now  dis- 
coursing at  the  Academy  of  Sciences  on  the  thyroid 
gland  and  iodothyrin,  the  product  of  its  secretion, 
with  reference  to  the  treatment  and  cure  of  exophthal- 
mic goitre.  It  is  strange  in  so  learned  a  body  as  the 
Academy  of  Medicine,  that  is  intended  to  represent 
all  branches  of  medical  science  and  practice,  how  rare 
the  neurologists  are!  The  vast  and  magnificent  de- 
partment of  nervous  pathology  has  as  yet  no  special 
section.  Certainly  the  academy  should  create  one 
and  admit  into  its  ranks  Professors  Raymond  and 
Joffroy,  also  {agreges)  Professors  Brissaud,  Dejerine, 
and  Gilbert-Ballet,  none  of  whom,  although  leading 
lights  in  the  world  of  nerves,  is  a  member  of  the  Acad- 
emy of  Medicine. 

Dr.  Ferrand  is  one  of  the  most  active  neurologists 
now  in  the  academy.  He  is  a  spiritualist  as  well,  and 
has  brought  his  synthesis  to  dualism,  differentiating 
the  psychical  from  the  intellectual  functions,  the 
faculties  of  the  soul  from  the  properties  of  the  cerebral 
cell. 

Dr.  Lanceraux,  who  is  evidently  an  advocate  of  vi- 
bratory medicine,  reported  the  case  of  a  client  affected 
with  painful  floating  kidney,  who  one  day  took  the 
train  for  Bordeaux,  some  seven  or  eight  hours'  journey 
from  Paris,  for  the  purpose  of  obtaining  there  a  suita- 
ble bandage  to  support  the  wandering  organ.  After 
six  hours  of  railway  travel,  she  experienced  a  cessa- 
tion of  the  pain  and  a  return  of  the  kidney  to  its  cus- 
tomary place,  where  it  remained  for  three  years  with- 
out occasioning  any  trouble  whatever.  The  patient 
thought  herself  permanently  cured,  when  the  kidney 
again  left  its  normal  position.  She  took  a  second 
time  the  train  for  Bordeaux,  and  again  after  six  hours 
of  travel  the  pain  ceased,  the  tumor  in  the  right  hypo- 
chondrium  disappeared,  and  the  kidney  returned  «« 
situ. 

W'e  had  already  the  vibratory  helmet  and  chair  of 
Charcot,  such  excellent  remedies  in  the  treatment  of 
neurasthenia,  but  should  be  at  a  loss  to  account  for 
the  happy  action  of  trepidation  in  this  case,  unless  we 
accept  Cheron's  idea  that  floating  kidney  is  a  ptosis  of 
neurasthenia,  and  the  trepidation  or  vibration  acted  as 
a  stimulus  to  the  ner\'e  cells — a  treatment  that  is  cer- 
tainly indicated  in  neurasthenia. 

The  trial  of  Dr.  Laporte,  who  recently  performed 
craniotomy  with  a  mattress  needle,  began  yesterday. 
The  operation,  it  will  be  remembered,  was  followed 
by  the  death  of  the  mother  as  well. 


684 


MEDICAL    RECORD. 


[November  6,  1897 


OUR    BERLIN    LETTER. 


(From  our  Special  Correspondent.) 


THE    NEW    ORDER    IN    OUR     UNIVERSITIES — THE     INTER- 
NATIONAL   MEDICAL    CONGRESS    IN    RUSSIA. 


The  German  ministry  has  formulated  a  new  rule  gov- 
erning the  study  of  medicine  in  all  the  allied  German 
States.  This  has  already  been  made  public  by  means 
of  the  telegraph,  but  it  is  of  such  vital  importance  to 
Americans  studying  in  Germany  that  I  may  be  excused 
for  dwelling  upon  it  at  length.  It  has  been  ruled  that 
only  such  persons  as  have  passed  the  preparatory 
medical  examination  in  Germany,  or  one  similar 
thereto  in  other  countries,  may  be  admitted  to  visit  and 
study  at  the  clinics,  etc.  As  a  degree  from  a  German 
college  (gymnasiumj  is  required  of  all  candidates  for 
the  "■  kstamcn  physiciim,^'  and  as  there  exists  in 
America  no  arrangement  corresponding  to  the  German 
"■  physiaim^''  the  importance  of  this  new  law  is  very 
apparent,  for  it  excludes  Americans  from  clinical 
studies  in  the  German  States.  This  bureaucratic  rul- 
ing is,  however,  a  double-edged  sword.  It  serves  the 
good  purpose  of  excluding  from  our  universities  the 
unworthy  element  which  has  heretofore  brought  such 
disrepute  to  the  German  medical  title;  on  the  other 
hand,  it  at  the  same  time  excludes  the  good  and  desir- 
able element  whose  purpose  in  coming  here  is  to  fur- 
ther medical  knowledge.  Germany  will  suffer  in  con- 
sequence, for  as  a  natural  result  Americans  and  others 
affected  by  the  new  law  will  visit  other  countries. 

The  medical  post-graduate  courses  are  in  no  wise 
affected.  Many  of  the  Americans  who  attended  the 
Moscow  congress  are  at  present  actively  attending 
these  courses. 

As  the  scientific  proceedings  of  the  congress  are  to 
be  reported  by  the  international  press  bureau  of  the 
congressional  committee,  I  will  omit  any  mention 
thereof  and  speak  only  of  the  open  arrangements  and 
public  proceedings.  I  will  begin  by  stating  that  at  no 
previous  international  congress  was  there  such  perfect 
organization  as  at  this  one.  Government  and  private 
individuals  vied  with  each  other  in  trying  to  add  to 
the  pleasures  and  comforts  of  the  foreign  guests,  to 
make  their  stay  in  Russia  memorable. 

The  granting  of  a  free  railroad  ride,  in  first-class  com- 
partments, from  the  border  to  Moscow  and  thence  via 
any  sel  ^cted  route  to  Petersburg  and  return  to  the  border 
— an  allowance  never  yet  made  by  any  other  govern- 
ment— secured  the  good  will  and  the  good  humor  of  the 
guests.  A  nod  from  one  high  in  authority  (in  Russia 
always  a  magic  talisman)  relieved  us  from  all  those  in- 
convenient and  vexatious  passport  and  customs  difficul- 
ties one  encounters  nowhere  so  ubiquitously  as  in  Rus- 
sia. In  fact,  there  was  a  marked  absence  of  customs 
revision.  We  Europeans,  who  are  not  so  accustomed  to 
long-distance  travelling  as  our  American  colleagues, 
regarded  with  horror  the  thirty-hours'  ride  in prospcifn 
from  Warsaw  to  Moscow.  It  was  a  most  agreeable 
surprise  to  us,  therefore,  to  find  ourselves  at  our  jour- 
ney's end  in  nowise  tired  out — in  fact,  in  very  fresh 
condition,  so  excellent  and  comfortable  are  the  Rus- 
sian railway  coaches,  which  are  in  this  respect  as  well 
equipped  as  the  American.  The  excellent  railway 
restaurants  added  not  a  little  to  our  comfort. 

Delegates  from  the  congress  accompanied  all  trains 
and  also  met  them  at  the  railroad  station  at  Moscow, 
where  each  visitor  was  assigned  his  quarter  and  given 
all  necessary  directions  and  help.  Many  lived  gratis 
in  the  clinics,  which  were  empty  on  account  of  the 
vacation;  others  with  Russian  colleagues,  especially 
the  professors;  the  majority,  however,  located  at  ho- 
tels and  private  residences  at  remarkably  low  prices. 


The  committee  had  a  list  with  prices,  thus  excluding 
any  extortion. 

The  headquarters  were  at  the  "  Manege,"  in  the 
very  centre  of  the  city.  Here  one  learned  details 
about  the  sessions,  the  arrangements  for  the  festivities, 
excursions,  city  attractions,  etc.  The  national  com- 
mittees had  their  bureaus  here,  one  met  acquaintances 
or  formed  new  ones,  got  general  information,  obtained 
return  tickets — in  short,  it  was  the  place  where  all 
concerned  met  and  obtained  or  learned  what  they 
wished.  This  arrangement  was  an  ideal  one.  Every- 
thing was  well  regulated — no  confusion,  no  crushing, 
no  pushing  or  rushing,  as  was  the  case  in  Rome; 
everything  went  along  smoothly.  Male  and  female 
students,  most  of  them  speaking  English,  French,  and 
German,  did  voluntary  service  and  proved  very  useful. 
Every  participant  in  the  congress  received  gratis  a 
"  Guide  to  Moscow"  in  French,  and  there  was  issued 
almost  daily  a  French  journal.  The  official  pro- 
gramme was  also  made  public  here. 

The  general  sessions — there  were  three  in  all — were 
held  at  the  Imperial  Theatre,  an  immense  building 
with  a  seating  capacity  of  three  thousand.  Each  ses- 
sion could  be  attended  by  about  one-half  of  the  total 
number  of  members.  The  first  one,  which  was  opened 
by  the  uncle  of  the  Czar,  was  most  brilliant;  the  fore- 
most members  of  the  profession  in  the  entire  world 
were  present.  The  greatest  honors  were  paid  to  Vir- 
chow,  an  almost  unceasing  applause  greeting  his  every 
appearance  upon  the  platform.  Section  meetings  were 
held  at  various  buildings  not  widely  separated,  and 
those  intimately  as.sociated  were  when  possible  as- 
signed to  the  same  building — for  instance,  general 
medicine  and  general  surgery  in  the  Adels  Club,  a 
magnificent  edifice.  Many  sections  were  held  at  the 
old  and  new  universities  and  at  the  principal  clinics. 
In  spite  of  the  heat  the  attendance  was  very  good. 
Proceedings  were  held  mostly  in  the  German  language ; 
English  and  French  were  also  employed;  Russian  very 
little.  The  French  complained  later  in  their  profes- 
sional papers  about  the  prevalence  of  German  ;  in  spite 
of  their  alliance  they  felt  themselves  set  back.  I  be- 
lieve their  complaint  is  unjust,  the  Russians  being 
unbiassed  in  their  hospitality.  We  cannot  blame  them 
for  feeling  more  closely  in  sympathy  with  their  Ger- 
man colleagues,  who  are  in  a  great  measure  their 
teachers.  Their  text-books  are  German  or  transla- 
tions thereof,  and  the  number  of  Russian  physicians 
studying  in  Paris  is  very  small  compared  with  the 
number  of  those  in  Berlin. 

The  hospitality  of  the  Russians  is  beyond  praise; 
classical  in  fact.  Delightful  beyond  description  were 
the  festivals  given  by  the  city  of  Moscow,  by  the  phy- 
sicians of  Moscow,  and  by  the  different  colonies.  At 
one  affair  fourteen  thousand  guests,  including  repre- 
sentatives of  the  city  itself,  were  present.  Until  3  a..m. 
there  prevailed  the  greatest  good-humored  animation 
— this  in  spite  of  the  babel  of  tongues  and  the  large 
attendance.  .\  moderate  estimate  would  place  the  ex- 
pense of  this  festival  at  not  less  than  $25,000.  There 
was  such  a  superabundance,  that  late  at  night  when 
the  guests  departed  the  tables  were  still  loaded  with 
eatables.  For  the  eye,  the  ear,  and  the  tongue,  there 
was  more  than  enough.  So  with  all  the  festivals.  Spe- 
cial thanks  are  due  to  the  Russian  ladies  who  looked 
after  the  comforts  of  the  female  guests.  They  were 
most  amiable,  and  their  efforts  were  entirely  success- 
ful. 

A  word  about  Moscow  itself,  for  with  the  exception 
of  Rome  no  city  of  Europe  presents  so  much  of  his- 
toric interest.  In  spite  of  the  great  destruction  by  fire 
of  its  older -churches,  there  still  are  many  which  date 
their  existence  back  eight  hundred  years  or  more. 
The  Kreml,  with  the  coronation  cathedral,  the  impe- 
rial palace,  and  the  treasure  chamber,  in  which  latter 


November  6,  1897] 


MEDICAL    RECORD. 


685 


are  kept  the  coronal  insignia  of  all  the  crowned  mon- 
archs  of  Russia  and  where  are  immense  quantities  of 
jewels  and  gold,  offer  enough  of  interest  to  the  visi- 
tor to  occupy  several  days.  When  one  considers  in 
addition  the  other  interesting  churches  and  monaster- 
ies, the  museums,  picture  galleries  (including  the 
Tretiokoff,  in  which  most  of  Verestschagin's  are  to  be 
seen),  the  unique  foundling  and  lying-in  house,  the 
curious  streets  and  pretty  parks  and  squares,  it  will  be 
easily  understood  that  the  congress  members  could 
well  employ  the  time  left  them  outside  of  the  section 
meetings. 

Bodily  wants  were  also  well  provided  for;  the  Rus- 
sian cuisine  is  e.xcellent  and  the  prices  are  moderate. 
One  soon  learns  to  eat  caviar  and  to  drink  tea.  The 
pavements  are  miserable,  but  carriage  hire  is  so  cheap 
that  riding  is  no  costly  luxury.  The  drivers — isswo- 
schtschiks — are  an  institution  peculiar  to  the  country 
itself.  There  is  no  fixed  tariff,  so  one  must  bargain 
beforehand  in  engaging  a  droschke  (carriage).  .Tt  is 
the  rule  to  give  only  one-half  of  the  price  asked  by 
the  isswoschtschik.  The  latter  is  a  model  of  patience : 
no  matter  how  much  you  scold  him,  he  is  always  po- 
lite and  quiet. 

.V  bird's-eye  view  of  the  city  makes  a  panorama 
never  to  be  forgotten— one  gets  such  a  view  from  the 
bell  tower  of  the  Kreml  in  the  centre  of  the  city,  or 
from  the  "  sparrow  hill"  at  the  southwest  border  of 
the  city.  Every  member  of  the  congress  has  in  all 
probability  visited  at  least  one  of  these  lookout  points. 
Though  numbering  not  more  than  one  million  inhabi- 
tants, Moscow  is  much  spread  out.  The  dwellings 
are  low  and  broad ;  churches,  monasteries,  parks,  and 
squares  are  in  large  number.  Here  and  there  the 
blue,  green,  and  golden  tower  of  a  Greek  Catholic 
church  stands  out  proudly  above  this  vast  sea  of 
houses.  Each  nationality  has  its  peculiarities;  the 
Russians  are  marked  by  their  hospitality  and  outward 
piety.  This  first  quality  has  succeeded  in  making  the 
Twelfth  International  Congress  memorable  to  those 
who  attended.  St.  Petersburg,  ranking  with  the  large 
American  cities  as  a  very  modern  city,  is  a  jewel  in 
the  diadem  of  modern  Russia.  We  cannot  but  speak 
in  warmest  terms  of  praise  of  the  Russian  government 
and  people  for  their  grand  reception  of  us  all. 

In  the  ne.xt  letter  I  report  on  the  "  Lepra-Confer- 
enz,"  which  has  taken  place  here  in  the  last  few  days. 


BOVINE   TUBERCULOSIS. 


Sir  :  A  few  years  ago  we  were  surprised  and  alarmed 
by  the  discovery  that  a  large  number  of  the  dairy  cows 
of  this  country  and  Europe  were  affected  with  bovine 
tuberculosis.  The  public  was  much  excited,  and  I 
believe  that  most  of  the  diseased  cows  were  destroyed 
and  the  expenses  added  to  our  already  overburdened 
tax  list.  .\nd  there  the  matter  seemed  to  have  ended, 
so  far  as  the  institution  of  any  preventive  measures 
was  concerned. 

Since  that  time  during  my  summer  vacations  in  all 
parts  of  the  United  States  I  have  endeavored  to  find 
out  the  cause  of  bovine  tuberculosis,  and  the  answer 
has  invariably  been  "  over-milking,"  viz.,  not  allowing 
the  cows  any  rest  during  pregnancy,  but  milking  them 
from  one  year  to  the  other  until  they  die.  In  many 
instances  I  know  this  to  be  true,  as  the  farmers  have 
assured  me  that  their  cows  never  "went  dry;"  but 
these  same  farmers  would  never  allow  their  own  chil- 
dren to  be  nursed  during  their  mother's  pregnancy. 

I  am  assured  that  bulls,  steers,  and  unimiiregnateti 
heifers  never  contract  tuberculosis. 

That  there  are  other  secondary  causes,  such  as  too 
close  confinement  in  warm  houses  or  stables,  I   have 


no  doubt;  but  the  primary  and  principal  cause  is  as  I 
have  stated  above,  and  it  must  and  will  be  remedied; 
not  by  forever  killing  the  cows  as  they  develop  the 
disease,  but  by  removing  the  cause. 

The  law  should  compel  every  farmer  or  dairyman 
to  allow  his  cows  to  go  dry  for  the  last  three  months 
of  gestation. 

This  is  a  very  important  matter,  and  I  hope  that 
other  physicians  will  investigate  for  themselves. 

JoH.N-   H.  Trent,  M.D. 

196  Seventeenth  Street,  BKOOKL^N. 


THE  ALTERNATIVE  OR  "RECURRENT 
TREATMENT"  IN  RETRODEVIATIONS  OF 
THE   UTERUS. 


Editor  of  the  Med 


,  Record. 


Sir:  In  my  recent  paper  on  "Retrodeviations  of  the 
Uterus,"  the  following  heads  were  elaborated:  (i) 
Retrodeviation,  per  se,  does  not  always  give  symp- 
toms, although  favoring  the  congestion  which  does 
give  them.  (2)  As  the  congestion  gives  the  symptoms, 
it  is  more  important  to  remove  this  cause  than  to  an- 
chor the  womb  forward.  (3)  Every  case  will  therefore 
be  helped  by  "  treatment"  removing  this  cause,  even 
though  ultimately  an  operation  is  required.  (4)  Many 
cases,  if  not  most  cases,  will  lose  symptoms  under 
comprehensive  treatment  (including  reparative  work), 
even  though  the  womb  remains  to  the  rear.  This  re- 
lief from  symptoms  usually  continues  for  a  period  va- 
rying in  length.  It  may  be  only  three  months;  it  has 
frequently  been  five  years.  In  favorable  cases  "  re- 
current treatment"  is  a  reasonable  alternative  to  be 
weighed  before  selecting  any  of  the  operations,  con- 
sidering their  drawbacks.  By  this  is  meant  a  few 
weeks  of  treatment  each  year,  or  every  two  or  even  five 
years.  (5)  When  the  periods  of  relief  are  too  short, 
or  when  nothing  but  the  rear  position  of  the  womb 
prevents  recovery,  unquestionably  operation  should  be 
done — but  never  as  routine,  ignoring  the  safer,  cheap- 
er, more  comfortable  alternative.  (6)  The  malady 
called  retrodeviation  is  a  complex  one,  always  includ- 
ing pelvic  congestion,  and  frequently  general  enterop- 
tosis  or  downward  displacement  of  the  abdominal  vis- 
cera. Sewing  the  womb  forward  will  not  always  cure 
it.  If  surgery  is  the  only  resource  for  the  condition, 
anchoring  the  kidneys  will  be  the  next  amendment  to 
the  present  operations. 

Edebohls  strongly  supports  my  view  in  his  experi- 
ence, though  we  shift,  and  deduce  differently  therefrom. 
His  paper,  "Shortening  the  Round  Ligament,"  gives 
a  most  complete  resiniic  of  its  subject  and  a  compre- 
hensive bibliography.  In  addition  are  tabulated  one 
hundred  and  fifteen  operations  by  this  painstaking  sur- 
geon. The  results  are  most  frankly  given.  Seventy- 
seven  were  uncomplicated  anatomical  successes. 
Thirty-four  were  complicated  successes;  that  is,  cases 
in  which  th  re  were  suppurations,  tearings  of  the  liga- 
ment, opening  of  the  abdominal  cavity,  hernia,  floating 
kidneys,  or  trouble  with  the  appendages  existing  at 
the  time  of  the  operation  or  discovered  thereafter. 
These  complicated  cases,  added  to  the  uncomplicated 
cases,  make  one  hundred  and  eleven  final  anatomical 
successes  out  of  one  hundred  and  fifteen  operations. 
Few  surgeons  can  point  to  a  better  record.      He  writes : 

"The  frequent  association  of  movable  kidney  or 
kidneys  and  retrodeviation  of  the  uterus  has  been  ob- 
served by  the  writer  since  1890,  and  it  is  drastically 
illustrated  by  the  recorded  observations  made  in  the 
one  hundred  and  fifteen  cases  tabulated.  No  less 
than  twenty-five  pati'  nts  are  noted  as  suffering  from 
movable  kidney  or  kidneys,  either  existing  at  the  time 
the  round  ligaments  were  shortened  or  developed  (dis- 
covered [?])  after  the  operation.     Of  these  twenty-five 


686 


MEDICAL    RECORD. 


[November  6,  1897 


patients  with  movable  kidney  or  kidneys,  eleven  were 
cured  by  right  nephropexy  and  two  by  bilateral 
nephropexy." 

It  will  be  seen  that  Edebohls  has  already  amended 
the  Alexander  operation  by  the  addition  of  nephropexy. 
He  further  says: 

"While  the  anatomical  results  may  be  thus  readily 
and  succinctly  stated,  an  accurate  report  upon  the 
therapeutic  results  becomes  a  more  complicated  matter. 
The  less  searchingly  we  cross-question  our  patients, 
...  the  more  likely  are  we  to  record  a  large  number 
of  therapeutic  successes.  But  closer  investigation 
often  reveals  one  or  more  stumbling-blocks  to  perfect 
satisfaction,  in  the  shape  of  complicating  diseases  pres- 
ent at  the  time  of  the  operation  or  developing  (discov- 
ered [?])  soon  thereafter,  which  complications  more 
or  less  fully,  more  or  less  permanently,  mar  the  thera- 
peutic result." 

This  is  but  another  way  of  saying  that  even  though 
the  womb  is  safely  stitched  forward  by  a  competent 
surgeon,  the  condition  is  not  always  cured. 

.Vll  the  special  surgical  devices  for  retrodeviation 
have  drawbacks.  To  hide  them,  to  evade  their  dis- 
cussion, is  not  only  unscientific  but  unfair.  These 
drawbacks  are  entitled  to  serious  consideration  in 
weighing  the  alternatives,  operation  Tersiis  "  recurrent 
treatment" — both  involve  so  much  time,  so  much 
money,  so  much  disability;  and  there  is  a  balance  to 
be  struck. 

The  Alexander  is  the  least  objectionable  of  the  op- 
erations, but  "  recurrent  treatment"  is  better,  cheaper, 
safer,  in  all  cases  in  which  it  gives  the  therapeutic  re- 
sults. Of  course  it  cannot  compete  in  anatomical  re- 
sults. Eugene  Coleman  Savidge,  M.D. 

66  West  Fiftieth  Stkeet,  New  York. 


EXPERT 


EXAMINATION     FOR 
TARY    CAPACITY. 


TESTAMEN- 


Medicai.  RECORr. 


Sir  :  Quite  recently  there  has  been  no  small  amount 
of  litigation,  in  the  courts  of  this  district  and  presum- 
ably in  the  courts  of  other  districts,  regarding  the 
validity  of  wills.  In  the  vast  majority  of  these  cases 
the  ground  is  taken  by  the  plaintiff  that  the  testator 
was  mm  (ompos  mentis  at  the  time  of  the  execution  of 
tiie  will  in  question.  Some  endeavor  to  establish 
that,  while  the  testator  may  not  have  been  actually 
insane,  yet  the  mental  faculties  were  in  a  state  of 
mild  degeneration  or  something  of  that  nature,  so 
that  the  testator  was  abnormally  susceptible  to  the 
inrtuence  of  interested  parties.  It  often  happens,  too, 
that  the  cause  of  death  of  these  people  who  have  left 
unsatisfactory  wills  is  due  to  some  disease  other  than 
that  of  the  mind  or  nervous  .system.  The  physician 
wiio  attended  perhaps  saw  no  need  of  a  thorough 
examination  of  the  nervous  system — certainly  did  not 
examine  it  with  a  view  of  establishing  the  competency 
or  incompetency  of  the  patient  to  execute  a  will.  As 
a  result,  the  physician,  when  called  to  testify,  is  not 
infrequently  unable  to  .set  forth  the  case  with  that 
clearness  which  would  obtain  had  he  deemed  it  neces- 
sary to  examine  the  nervous  system  with  reference  to 
its  stability  or  instability. 

In  view  of  these  undisputed  facts,  the  conviction 
forces  itself  upon  me  that  a  pathological  condition  of 
existing  laws  is  the  real  cause  of  this  diseased  con- 
dition of  affairs. 

A  law  should  be  enacted  providiiiL;  in  tlie  main  as 
follows: 

I  St.  The  intending  testator  must,  on  tlie  same  day 
on  which  he  proposes  to  make  his  last  will  and  testa- 
ment, be  carefully  examined  by  a  reputable  physician 
of  at  least  three  years'  practice,  as  to  his  sanity  and 


ability  to  execute  a  will  understandingly.  If  the  tes- 
tator is  found  to  be  possessed  of  his  normal  faculties 
and  able  to  execute  a  will  understandingly,  the  physi- 
cian shall  so  certify  in  his  own  handwriting.  This 
certificate  must  be  sworn  to  before  any  person  em- 
powered by  law  to  administer  oaths  for  general  pur- 
poses. The  signature  to  the  certificate  must  also  be 
witnessed  by  two  persons  wlio  can  write.  This  cer- 
tificate is  then  to  be  attached  to  and  become  a  part  of 
said  will. 

2d.  In  case  the  testator,  at  any  subsequent  time, 
desires  to  change  his  will,  a  physician  must  re-examine 
and  certify  as  before. 

3d.  In  cases  in  which  it  can  be  shown  that  the  cir- 
cumstances connected  with  the  making  of  the  will  were 
such  as  to  render  the  presence  of  a  physician  impos- 
sible, or  when,  the  physician  being  present,  the  condi- 
tion of  the  patient  precludes  examination,  then  the 
will  must  be  reduced  to  writing  and  may  be  considered 
valid  without  a  physician's  certificate.  Even  in  these 
cases  the  physician  should  hastily  examine  as  best  he 
may,  and  certify,  if  he  so  believes,  that  to  the  best  of 
his  judgment,  knowledge,  and  belief  the  testator  is  in 
full  possession  of  his  normal  faculties  and  entirely 
capable  of  executing  a  will  understandingly. 

Exception:  This  law  shall  not  apply  to  wills  which 
in  the  aggregate  bequeath  real  or  personal  property, 
or  both,  less  in  value  than  $500. 

I  do  not  wish  to  be  understood  as  taking  the  ground 
that  the  attachment  of  the  physician's  certificate  is  to 
render  a  will  incontestable,  but  I  do  affirm  that  the 
existence  of  the  certificate  would  in  the  vast  majority 
of  cases  be  considered  too  great  an  obstacle  to  sur- 
mount, and  so  prevent  litigation.  The  absence  of 
this  certificate,  however,  should  in  every  case,  except 
as  mentioned  above,  render  a  will  absolutely  null  and 
void. 

The  only  objections  to  which  this  system  might  give 
rise  would  be  the  extra  trouble  and  slight  expense 
incurred — objections  which,  when  compared  with  its 
advantages,  appear  ver}'  insignificant  indeed. 

The  conveyance  of  real  estate  by  deed  requires  an 
acknowledgment  under  oath  from  the  conveyer.  Is 
the  conveyance  of  real  estate  by  will  any  less  impor- 
tant? A.  C.  Matthews,  M.D. 


Wounds  of  the  Air  Passages. —  1.  Suicidal  wounds 
of  the  throat  should  be  treated  by  primary  suture  in 
all  cases  in  which  the  general  condition  of  the  patient 
permits.  2.  Antiseptic  precautions  are  most  impor- 
tant. 3.  If  necessary,  chloroform  should  be  adminis- 
tered, and  is  perfectly  safe.  4.  Divided  muscles 
should  be  sutured,  and  in  bringing  together  the  edges 
of  the  skin  the  inversion  caused  by  the  platysma  muscle 
should  be  corrected.  5.  The  wound  in  the  air  passage 
should  be  completely  clo.sed.  6.  In  many  cases  it  is 
quite  safe  to  dispense  with  the  use  of  a  tracheotomy 
tube.  If  a  tube  be  deemed  necessary  it  should  not  be 
introduced  through  the  suicidal  wound  in  the  air  pas- 
sage, but  through  a  fresh  vertical  cut  at  a  lower  level 
7.  Silk  is  the  best  material  for  suturing  the  laiynx  o; 
trachea.  8.  During  the  after-treatment  it  is  unnece^■ 
sary,  except  in  certain  special  cases,  to  feed  by  a  tube 
or  by  the  rectum.  9.  If  the  above  methods  of  treat- 
ment be  adopted,  not  only  will  a  very  large  proportion 
of  even  dangerous  and  extensive  wounds  of  the  air 
passages  recover,  but  the  period  of  recover}-  will  be 
greatly  shortened,  the  patient  will  not  be  exposed  to 
tlie  same  risks  of  secondarj-  intlammatory  complica- 
tions, and  he  will  be  much  less  liable  to  the  occur- 
rence of  permanent  stenosis  of  the  trachea  or  tlie  for- 
mation of  an  aerial  fistula. —  Pl.\tt,  The  British 
Medical  Journal,  May  8th. 


November  6,  1897] 


MEDICAL    RECORD. 


687 


pCMical  Stems. 

Contagious  Diseases — Weekly    Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  October  30,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. . . 

Measles 

Diplitheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox 


24 
log 


149 

145 


106 

5 


Medicine  for  "Threading  Ideas." — According  to 
a  French  paper,  an  American  physician  advises  stu- 
dents to  combat  the  nervous  asthenia  which  paralyzes 
their  faculties  and  causes  them  to  lose  the  thread  of 
their  ideas  by  taking  ten  drops  of  tincture  of  gel- 
semium  three  times  a  day.  For  the  same  purpose  an 
English  specialist  prescribes  wine  of  opium  to  be 
taken  by  actors  and  singers  before  going  on  the  stage. 
From  five  to  si.x  drops  he  says  will  give  to  the  most 
timid  actress  the  self-possession  of  the  most  spirited 
old  player. 

Abuse  of  Alcohol. — Speaking  of  the  abuse  of  alco- 
hol, M.  Van  den  Corput,  at  the  International  Con- 
gress on  Drink  lately  held  at  Brussels,  said  it  was  the 
direct  outcome  of  the  storm  and  stress  of  life  under 
the  conditions  created  by  modern  progress.  Neuro- 
pathy was  a  sign  of  the  times,  and  the  remedy  for  this 
was  intelligent  feeding  with  the  use  of  beverages,  such 
as  sound  and  generous  beer,  milk,  tea,  coffee,  etc. 

Suicide  by  Hanging. — Professor  Brouardel  remarks 
that  suicide  by  hanging  has  a  peculiar  fascination  for 
dipsomaniacs,  children,  and,  generally  speaking,  all 
persons  whose  intellects  are  weak  or  undeveloped. 
He  says:  "In  some  families  self-murder  by  hanging 
would  seem  to  be  a  hereditary  failing.  Not  far  from 
Etampes  there  is  a  large  farm  with  which  I  am  ac- 
quainted. One  day,  without  any  apparent  cause,  the 
proprietor  hanged  himself,  leaving  a  family  of  seven 
sons  and  four  daughters.  Ten  out  of  the  eleven  sub- 
sequently followed  their  father's  example,  but  not 
until  they  had  married  and  begotten  children,  who  in 
turn  all  likewise  put  an  end  to  themselves  with  the 
cord.  There  is  now  but  one  representative  left  of 
this  remarkable  group,  an  old  man  of  sixty-eight,  who 
has  passed  the  family  hanging-age." 

The  Sale  of  Ice  Cream  in  Glasgow The  Glas- 
gow municipal  authorities  deal  with  the  ice-cream 
vendors  in  that  city  in  a  somewhat  novel  way.  Some 
few  years  ago  the  city  fathers,  alarmed  at  the  amount 
of  sickness,  especially  typhoid,  clearly  traceable  to 
the  consumption  of  ice  cream,  attempted  to  place  ice 
cream  in  the  same  category  as  milk.  Their  efforts 
at  first  were  unsuccessful.  However,  resolved  not  to 
be  beaten,  they  obtained  special  powers,  and  now  the 
sellers  of  ice  cream  in  Glasgow,  alone  of  all  cities,  are 
under  the  same  regulations  as  those  which  control  the 
dairies.  If  the  example  of  Glasgow  were  to  be  fol 
lowed  in  more  than  one  of  the  cities  of  America,  the 
result  might  be  for  the  public  good. 

Headaches,  if  due  to  pelvic  disturbances  in  the 
female,  are  usually  located  at  the  top  of  the  head  and 
are  accompanied  by  soreness  of  the  scalp;  if  due  to 
digestive  disturbances,  they  are  occipital  or  frontal; 
if  to  disease  of  the  pharynx,  they  involve  the  entire 


vault,  as  though  the  pharynx  were  expanded  and  ex- 
tended upward;  if  due  to  migraine,  they  are  usually 
one-sided,  local,  and  accompanied  by  soreness  at  the 
supra-orbital  foramen  ;  if  to  eye  strain,  generally  super- 
ciliary or  frontal,  sometimes  occipital;  if  to  disease 
of  the  nares,  between  the  eyes  and  extending  back- 
ward.— Dercum. 

Treatment  of  Epilepsy Opium,    beginning   with 

five-sixths  of  a  grain  daily,  distributed  in  three  doses, 
and  steadily  increased  until  four  or  five  grains 
daily  are  administered.  At  the  end  of  six  weeks  the 
opium  is  stopped,  and  bromides  are  used — in  large 
doses,  seventy-five  to  one  hundred  grains  a  day,  for  a 
period  of  at  least  two  months.  The  fits  generally 
yield  to  the  first  dose  of  bromide.  The  treatment 
should  be  adopted  only  in  chronic  intractable  cases 
of  epilepsy  in  which  the  administration  of  bromides 
alone  has  failed.  The  contraindications  are  the  status 
epilepticus,  plethora,  and  cerebral  focal  lesions. — 
Flechsig. 

How  Does  Malaria  Enter  the  Human  Body? — 
The  mosquito,  as  is  well  known,  deposits  its  eggs  in 
water  or  in  damp  places;  from  the  eggs  are  hatched 
lan'ae,  which,  very  voracious,  devour  everything  they 
encounter,  among  other  things  the  bodies  of  the  dead 
mosquitoes  and  the  envelopes  from  which  they  have 
emerged.  They  then  pass  into  the  state  of  nympha;, 
from  which  emerge  the  young  mosquitoes.  During 
this  long  period  of  life  in  damp  soil  or  in  water,  and 
especially  in  the  state  of  larvae,  one  may  imagine  that 
they  load  themselves  with  malarial  germs,  which  every- 
thing leads  us  to  believe  are  found  most  abundantly 
in  the  soil,  and  which  afterward  in  the  last  period  of 
life,  when  the  female  mosquitoes  live  as  suctorial  in- 
sects, might  inoculate  man.  This  hypothesis  would 
naturally  give  rise  to  other  problems.  The  malarial 
germs,  having  entered  into  the  young  larva,  might  live 
in  them  as  parasites,  going  through  a  necessary  stage 
of  their  life  in  this  host  before  arriving  at  man.  On 
the  other  hand,  one  might  suppose  these  diptera  to  be 
simply  carriers  of  the  germ  into  man. — Bignami. 

Is  Crime  a  Disease  ? — Of  394  thieves,  74  are  doli- 
chocephalic, 129  mesocephalic,  191  brachycephalic; 
of  107  homicides,  21  are  dolichocephalic,  31  meso- 
cephalic, 54  brachycephalic;  of  92  sexual  offenders, 
there  are  18  dolichocephalic,  30  mesocephalic,  38 
brachycephalic;  of  54  swindlers,  there  are  9  dolicho- 
cephalic, 15  mesocephalic,  30  brachycephalic.  A 
study  of  the  individual  indices  shows  a  considerable 
proportion  to  be  entirely  outside  of  the  physiologic 
limit.  This  is  most  marked  among  the  sexual  offend- 
ers, in  whom  the  cephalic  index  was  in  itself  abso- 
lutely pathological  in  about  fifteen  per  cent. ;  that  is 
to  say,  considering  the  antero-posterior  diameter  of 
the  cranium  as  100,  then  the  transverse  was  repre- 
sented by  less  than  76  or  more  than  87,  the  former 
being  extremes  of  dolichocephalic  and  the  latter  of 
brachycephalic  skulls.  The  brachycephalic  skulls 
much  predominated  in  the  entire  group  of  criminals. 
— W.  A.  McCoM. 

Diphtheria  in  London. — Despite  the  great  outlay 
on  sanitation  in  London,  diphtheria  goes  on  increas- 
ing in  prevalence.  According  to  the  clerk  of  the 
Metropolitan  Asylums  Board  it  has  been  steadily 
gaining  ground  for  a  considerable  time  past,  and  its 
continuous  development  has  puzzled  all  who  have 
examined  into  the  matter.  The  same  increase  is 
observed  in  the  provincial  towns,  but  not  to  the  same 
extent.  Thus  in  them  the  death  rate  from  diphtheria 
rose  in  ten  years  from  0.27  to  0.38,  while  in  the  same 
period  in  London  it  has  increased  from  0.41  to  0.60 
per   1,000.      This   increase  obtains  even    in   parts  of 


MEDICAL    RECORD. 


[November  6,  1897 


London  otherwise  creditable  in  their  sanitary  condi- 
tions. The  disease  is  five  times  more  fatal  at  present 
than  scarlet  fever,  according  to  the  experience  of  the 
Metropolitan  Asylums  Board's  hospitals,  although  the 
mortality  has  been  greatly  reduced  by  the  antitoxin 
treatment. 

Sterility.  — Dr.  Vedder,  of  Christiania,  Sweden,  re- 
ports the  results  of  examination  of  three  hundred  and 
ten  married  women  who  had  never  been  pregnant 
though  married  at  least  one  year.  In  fifty  of  these 
cases  he  was  able  to  examine  the  husband  also.  He 
draws  the  conclusion  that  in  seventy  per  cent,  of  these 
cases  the  husband  is  to  blame  for  the  sterility,  either 
through  impotence  or  through  infecting  his  wife  with 
gonorrhoea. — Norsk  Magazinjer  Ldgevid. 

The  Mystery  of  Heredity. — Out  of  two  hundred 
and  twenty-two  pupils  in  the  grammar  schools  in  Chi- 
cago who  attained  a  certain  percentage  of  efficiency, 
only  twenty-five  were  boys.  This  would  indicate  that 
girls  are  about  four  times  as  bright  as  boys.  It  is 
hard  to  understand  these  things  and  straighten  up  the 
rules  of  heredity.  It  is,  we  believe,  the  accepted  rule 
that  boys  "  take  after"  their  mothers  and  the  girls  after 
their  fathers.  If  they,  the  women,  are  the  smarter, 
the  boys,  "taking  after  their  mothers,"  should  also  be 
the  smarter.  If  the  men  are  the  smarter,  then  the 
girls,  "taking  after  their  fathers,"  should  be  smarter. 
It  is  a  difficult  riddle  to  unravel. 

Health  Reports. — The  following  statistics  concern- 
ing small-pox,  yellow  fever,  cholera,  and  plague  have 
been  received  in  the  office  of  the  supervising  surgeon- 
general  of  the  United  States  Marine  Hospital  service, 
during  the  week  ended  October  30,  1897  : 


^ofea  lleceitied. 


-Uni- 


St 


Cas( 


Alab.i 


flot. 


367 


.Mobile October  23d  to2<jth. 

Montgomery October  21st  to  29th 

Notasulga October  25th 

Sandy  Ridge October  25th    

Selraa October  23d  to  26th. 

Whistler October  29th 

<;eorKia,  Atlanti  (refugee) .  .October  24th 

(detention  camp) October  27th 

Louisiana,  Baton  kouge October  22dto28th. 

Franklin Octob.r  loth  to  21st 

New  Orleans October  zi,A.  to  jglh  . 

Patterson October  21st 1 

Mississippi,  Hay  St.  Louis  . .  October  23d  to  2«th 33 

Biloxi October  23d  to  29th 91 

Cayuga      October  23d  to  2Sth 5 

Clinton October  23d  to  29th 7 

County  Farm..  .October  25th i 

Edwards October  23d  to  29th 19 

'                 Hinds  County  con- 
vict camp October  23d  t"  27th 6 

McHenry October  23d  to  29th 6 

Nitta  Vunia October  23d  to  24th 6 

Pascagoula October  23d  to  29th 11 

Scranton October  23d  to  20th 75 

Tennessee,  Memphis October  23d  to  aoth 31 

Texas,  dalveston     October  27th,  yellow  fever  present 


EiR-F. 


Brazil,  Para 

Cuba,  Cienfuegos. .. 


Ha 


.Oi 


ngston lulv  r,ih  In  October  gth 44 

Manchester- luly  9th  to  October  9th 7 

Port  Antonit July  gth  to  October  9th i 

St.  l\li/abeth )uly  9th  to  October  9th l 

San  Salvador July  1st  to  31st 38 

August  1st  to  31st 54 

September  ist  to  30th 34 

ClIOI.KRA-FoREUiN. 

China,  Hong  Kong September  4th  to  nth 

India,  Calcutta September  nth  to  25th 

Madras October  i8th  to  24th 

Singapore August  1st  to  31st 

Japan,  Kanagawa  Ken September  33d  to  30th  .   ...       t 

'I'okyo  Fu Scjitcmber  23d  to  30th 3 

Smai.i.-Pox— Uniteu  Statks. 

Louisiana,  New  Orleans  . . .  .October  16th  to  23d i 

Pennsylvania,  McKeesport.. October  16th  to  23d 

Small-Pox — Forf.ign. 

F.gypt,  Alexandria .\ugust  7th  to  September  iCith     .. 

Cairo August  7th  to  September  iclh     .. 

India,  Calcutta September  4th  to  2Sth 

Scotland,  ll  lasgow October  2d  to  gth 10 

Rus-sia,  Odessii October  2d  to  pth .     .       1 

Moscow September  25th  to  October  2d      3 

St.  Petersburg    October  2d  to 9th 4 

\Varsaw October  2d  to  9th 

PLAai'E— FORKIf.N. 

tndia.  Bombay September  14th  to  aist 


While  the  Medical  RECORn  is  pleased  to  receive  all  new  publi- 
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Transactions  of  the  Wisconsin  State  Medical  .Soci- 
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.\  Manlal  of  Legal  Medicine.  By  Dr.  J.  Herold.  Svo, 
678  pages.  Illustrated.  J.  B.  Lippincott  Company,  Phila- 
delphia. 

Transactions  of  the  American  Climatological  .A.sso- 
ciation  for  1897.     Vol.  XIII.     Svo,  250  pages. 

Lectures  on  the  Malarial  Fevers.  By  Dr.  W.  S. 
Thayer.     8vo,  326  pages.      D.  Appleton  &  Co.,  New  York. 

Facial  Diagnosis.  By  Dr.  A.  F.  Reinhold.  Svo,  106 
pages.      Illustrated.     A.  F.  Reinhold,  New  York  City. 

Transactions  of  the  Chicago  Pathological  Society 
from  December,  1895,  to  April,  1897.  Vol.  II.  12010,328 
pages.     Illustrated. 

Cutaneous  Medicine.  Part  II  By  Dr.  L.  A.  Duhring. 
Svo,  404  pages.      Illustrated.      I.  B.  Lippincott  Company,  Phila- 

deljSjia. 

Pathological  Technique.  By  Dr.  F.  B.  Mallory  and  Dr. 
J.  H.  Wright.  Svo,  397  pages.  Illustrated.  W.  B.  Saunders. 
Philadelphia.      Price,  $2.  50. 

A  Te.\t-Book  of  Special  Pathological  Anato.mv.  Sec- 
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by  Dr.  D.  Mac.\lister  and  Dr.  II.  W.  Cattell.  Svo,  1,250  pages. 
Illustrated.      The  Macmillan  Company,  New  York. 

Practice  of  Medicine.  By  Dr.  J.  M.  .Anders.  Svo,  1.2S7 
pages.  Illustrated.  W.  B.  Saunders,  Philadelphia.  Price. 
$5-50. 

A  Manual  of  Injuries  and  Surgical  Diseases  of  the 
Face,  Mouth,  and  Jaws.  By  Dr.  J.  S.  Marshall.  Svo,  716 
pages.  Illustrated.  The  S.  S.  White  Dental  Manufacturing 
Company,  Philadelphia. 

Medical  Jurisprudence.  By  Dr.  .\.  S.  Taylor,  Revised 
and  edited  by  Dr.  T.  Stevenson.  Twelfth  .American  Edition. 
Edited  by  Clark  Bell,  LL.D.  Svo.  S32  pages.  Illustrated. 
Lea  Brothers  and  Company,  New  York. 

Transactions  of  the  Michigan  .State  Medical  Society 
for   1897.     Vol.  XXI.      Svo,  526  pages.      Illustrated. 

Ringworm  and  .Alopecia  .\reat.\.  By  II.  Aldersmith, 
M.B.,  F.R.C.S.  Fourth  Edition.  Svo,  327  pages.  Illustrated. 
H.  K.  Lewis,  London.   Price,  los.  6d. 

A  System  of  Medicine.  By  Many  Writers.  Edited  by  Dr. 
T.  C  .Mlhutt.  Vol.  IV.  Svo,  1,001  pages.  Illustrated.  The 
MacmillaTi  iJompany.   New  York. 

Essentials  of  Bacteriology.  Third  Edition,  Ke^^sed. 
By  Dr.  M.  V.  Ball.  i2mo,  218  pages.  Illustrated.  W.  B. 
Saunders.  Philadelphia. 

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pages.     Illustrated.     H.  K.  Lewis,  London.     Price,  6s. 

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©viginat  Articles. 

ON    SOME    UNUSUAL   FORxMS    OF    APOPLEC 
TIC    ATTACK. 

Bv    M.   ALLEX    STARR,    M.D.,    I'li.i).. 


PROFESSOR 

PHYSICIANS  AND    SURGEONS, 
VERSITY  ;    CONSULTING     PHVSICI 

AND    EAR    INFIRMARY, 


SYSTE.M,    COLLEGE 
:t    of    COLU.MBIA     t'l 
I.\N,    ORTHOP-tDIC.    : 


To  the  lay  mind  and  to  many  physicians  apoplexy 
and  paralysis  appear  to  be  synonymous  terms.  Even 
in  many  of  the  text-books  the  varieties  of  apoplectic 
attack  possible  are  not  clearly  stated.  Hence  it  seems 
proper  to  call  the  attention  of  the  profession  to  cases 
which,  though  exceptional,  occur;  and  in  which  the 
sudden  onset  of  cerebral  symptoms,  quite  of  the  na- 
ture of  apoplexy,  is  not  attended  or  followed  by  any 
paralysis. 

If  a  moment's  consideration  is  given  to  ordinary 
apoplexy,  it  will  be  recalled  that  its  chief  feature  is 
a  sudden  attack,  usually  characterized  by  complete 
loss  of  consciousness,  in  which  the  person  falls  as  if 
struck;  ('ir..r/./;(Tff£:>,  to  strike),  and  followed  by  more 
or  less  complete  hemiplegia,  which  is  attended  by 
aphasia  w'hen  the  paralysis  is  upon  tiie  right  side  of 
the  body.  This  is  so  commonly  the  history  that  the 
ordinary  association  of  the  hemiplegia  with  the  apo- 
plexy has  led  to  the  conclusion  that  such  ao  associa- 
tion is  inevitable.  Such  apoplectic  attacks  are  usu- 
ally due  to  a  hemorrhage  in  the  brain,  or  to  embolic 
or  thrombotic  suspension  of  circulation  in  the  cerebral 
arteries;  although  it  is  never  to  be  forgotten  that  such 
a  stroke  may  be  the  first  sign  of  a  brain  tumor. 

But  the  various  parts  of  the  brain  differ  widely  in 
their  function,  and  hence  it  is  to  be  expected  that 
hemorrhage  or  embolism  will  produce  different  effects 
according  to  the  part  of  the  brain  which  is  affected. 
It  is  well  known  that  hemorrhage  and  embolism  are 
far  more  common  in  the  domain  of  the  middle  cere- 
bral artery  than  in  that  of  other  blood-vessels.  -And 
the  middle  cerebral  artery  supplies  the  motor  area  of 
the  brain  and  its  adjacent  speech  areas  with  blood. 
Hence  the  usual  etTect  of  a  rupture  or  an  obstruction 
in  this  vessel  is  the  production  of  the  ordinary  form 
of  apoplexy  with  paralysis. 

If,  however,  some  other  vessel  in  the  brain — the 
anterior  cerebral  artery,  the  posterior  cerebral  artery, 
or  some  branch  of  the  basilar  arterj' — is  obstructed  or 
ruptured,  the  motor  area  of  the  brain  will  escape,  and 
in  such  a  case  there  is  not  necessarily  any  paralysis 
attendant  upon  the  attack.  In  such  ca.ses  the  local 
symptoms  of  the  attack  will  vary  according  to  the 
region  of  the  brain  affected.  In  every  case  there  will 
be  evidence  of  brain  destruction,  just  as  serious,  just 
as  permanent,  as  the  paralysis  attending  the  ordinary 
attack;  and  the  prognosis  regarding  recovery  must 
be  as  guarded  and  the  care  of  the  patient  during  re- 
covery as  rigid  as  though  a  severe  hemiplegia  were 
present.  I  call  attention  to  these  facts  because  I  wish 
to  emphasize  the  need  of  care  both  in  prognosis  and 
in  treatment,  for  it  has  been  my  experience  that  too 


little  importance  is  often  attached  by  physicians  to 
attacks  of  an  apoplectic  nature  when  it  is  found  that 
they  are  not  followed  by  paralysis. 

The  following  cases  illustrate  the  statements  made: 

Case  I. — Male,  aged  forty-one,  while  convalescent 
from  a  short  continued  fever,  liis  only  illness  for 
several  years,  went  to  Las  Vegas,  an  elevation  of 
seven  thousand  feet,  arriving  in  a  weak  condition. 
On  the  night  after  his  arrival  he  awoke  twice  with 
very  intense  pain  in  the  left  frontal  region,  and  was 
obliged  to  rise  and  pass  unusually  large  quantities  of 
water.  On  the  second  occasion  he  suddenly  felt  a 
numb  sensation  over  the  entire  right  side,  the  pain  in 
the  head  became  more  intense,  and  he  fell  over  upon 
his  bed.  He  did  not  lose  consciousness  and  soon  got 
up  to  call  some  one,  but  on  opening  his  door  he  found 
that  he  could  not  recollect  the  name  of  any  one  or 
speak.  He  made  a  noise,  however,  attracting  help. 
When  seen  by  a  physician  within  an  hour  he  seemed 
bewildered,  talked  in  a  rambling  manner,  misplacing 
\vords  so  that  it  was  difficult  to  understand  what  he 
wished  to  say,  but  he  had  no  paralysis  anywhere.  For 
several  days  this  condition  remained  stationary,  his 
mind  being  bewildered  and  anxious,  his  speech 
becoming,  however,  clearer,  his  chief  complaint  being 
of  a  sensation  of  numbness  in  his  right  side,  which 
was  not,  however,  attended  by  actual  anaesthesia  or  by 
any  paralysis.  He  was  brought  to  Kansas  City  after 
two  weeks,  and  thought  he  improved  as  he  came  down 
to  a  lower  altitude.  During  the  following  two  months 
there  was  a  slow  but  continuous  change  for  the  better, 
though  his  memory  for  recent  events,  for  things  he  read 
or  heard  from  day  to  day,  was  wholly  untrustwoithy. 

Examination  here  ten  weeks  after  the  onset  showed 
a  thin,  pale,  anxious,  nervous  man,  able  to  tell  his 
story  slowly,  with  some  slight  hesitation  for  words  at 
times,  but  a  fairly  clear  consciousness  of  his  condition. 
In  talking  the  effort  of  attention  wearied  him;  he 
would  seem  distressed,  bewildered,  and  lose  the  thread 
of  his  conversation.  He  complained  that  he  could 
not  concentrate  his  attention,  that  it  was  a  great  effort 
to  think,  that  he  could  not  read  or  write  without  ex- 
haustion, and  that  he  was  confused  and  forgetful.  Yet 
examination  failed  to  show  actual  aphasia,  agraphia, 
or  alexia;  there  was  no  paralysis,  no  loss  of  sensation, 
no  hemiopia  or  deafness.  The  pupils  were  equal  and 
normal  in  size  and  action.  'l"he  discs  were  clear. 
The  knee  jerks  were  equal.  There  was  no  cardiac 
or  arterial  disease,  and  no  nephritis.  The  subsequent 
history  was  one  of  slow  improvement,  and  at  the  end 
of  ten  years  he  is  alive  and  able  to  work,  but  has  a 
feeling  that  his  mental  capacity  is  not  so  good  as  it 
was  before  his  attack. 

Case  II. — Male,  aged  fifty-four,  previously  in  good 
health,  was  suddenly  seized,  while  reading  quietly, 
with  severe  pain  in  his  right  frontal  region  and  with 
vertigo,  attended  by  great  anxiety  and  prostration. 
He  soon  vomited  and  had  a  movement  of  the  bowels, 
after  which  he  was  very  weak  and  confused  in  his 
mind  and  talked  with  difficulty.  \)\.  (Jill  Wylie  saw 
him  within  an  hour,  found  him  in  a  state  of  shock, 
with  slow  feeble  pulse,  profu.se  sweat,  great  weakness, 
and  extreme  mental  confusion;  a  slight  lett  facial 
paralysis  with  deviation  of  the  tongue  to  the  left  was 


690 


MEDICAL    RECORD. 


[November  13,  1897 


noticed.  He  reacted  to  stimulation,  but  for  ten  days 
appeared  to  be  ill,  was  too  weak  to  stand,  and  any  exer- 
tion produced  vertigo  and  nausea.  He  suffered  con- 
stantly from  headache  in  the  right  frontal  region. 

Examination  on  the  tenth  day  showed  a  large,  mus- 
cular, well-nourished  man.  Pupils  equal  and  acting 
normally;  discs  clear,  with  veins  rather  large;  very 
slight  paresis  of  the  left  side  of  the  face  and  tongue; 
no  paralysis  of  the  arm  or  leg,  though  the  left  knee 
jerk  is  greater  than  the  right;  and  no  anassthesia  or 
subjective  numbness;  speech  clear.  His  chief  com- 
plaint is  one  of  great  mental  confusion.  He  cannot 
fix  his  attention  on  anything,  and  any  effort  to  think, 
to  read,  to  listen  to  talking,  or  to  talk  is  painful,  so 
that  he  feels  completely  incapacitated  for  all  mental 
activity.  This  mental  feebleness  is  in  striking  con- 
trast to  his  physical  condition.  He  does  not  trust 
his  memory  or  judgment,  and  is  much  distressed  at 
his  failure  of  mind.  This  condition  gradually  passed 
off.  At  the  end  of  a  month  there  was  no  trace  what- 
ever of  any  facial  paralysis  and  his  knee  jerks  were 
equal.  He  still  had  occasional  headache  and  vertigo 
on  any  physical  effort.  Slowly  his  feeling  of  mental 
confusion  subsided.  At  the  end  of  six  months  he  was 
able  to  return  to  his  business,  and  during  the  past  ten 
years  he  has  had  no  return  of  his  symptoms  and  no 
recurrence  of  the  attack. 

Case  III. — Male,  aged  sixty-seven,  who  had  been 
failing  in  vigor  and  in  mental  power  for  three  years, 
was  suddenly  seized  with  an  attack  of  great  weakness, 
prostration,  and  confusion  of  mind  and  distress, 
attended  by  great  difficulty  in  respiration,  inability  to 
inhale,  with  apj.  arent  obstruction  at  the  larynx.  He 
was  seen  by  Dr.  R.  P.  O'Neill,  who  found  a  weak, 
slow,  intermittent  pulse;  irregular  respiration,  much 
labored;  profuse,  cold  perspiration;  and  a  marked 
mental  confusion  and  a  slight  weakness  of  the  left  side 
of  the  face.  From  this  attack  he  gradually  recov- 
ered, but  he  has  never  been  well.  He  has  no  control 
over  his  emotions.  He  cries  or  laughs  indifferently 
when  he  talks,  there  being  no  actual  connection  be- 
tween the  train  of  thought  and  the  emotional  exhibition. 
To  ordinary  questions  lie  replies  intelligently,  but  his 
memory  is  poor  for  recent  events,  his  judgment  is 
weakened,  he  has  no  confidence  in  his  own  mental 
actions,  appeals  constantly  to  his  wife  for  correction 
of  his  statements,  and  his  emotional  instability  is 
most'  painfully  apparent.  He  laughs  at  nothing  and 
cannot  stop,  or  he  cries  and  sobs  and  recovers  his 
composure  with  much  difficulty,  complaining  that  he 
cannot  control  himself,  and  yet  that  there  is  no  occa- 
sion for  this  evidence  of  emotion.  There  is  no  corre- 
sponding mental  state  of  amusement  or  of  distress. 
The  emotional  act  is  as  uncontrollable  as  a  convulsive 
twitching  or  spasm  would  be,  and  equally  without 
intention.  There  is  no  paralysis,  there  is  no  sensory 
disturbance  except  a  subjective  tingling  of  the  left 
hand.  His  knee  jerks  are  increased.  There  are  no 
cranial  nerve  symptoms. 

This  patient  has  been  under  my  observation  for  the 
past  four  years,  during  which  his  condition  has  been 
practically  stationary.  He  is  more  feeble,  lias  to  make 
a  great  effort  to  talk  aloud,  and  has  never  recovered 
his  emotional  control  to  any  degree,  but  he  has  had 
no  attacks  and  he  has  no  paralysis  or  disturbance  of 
sensation.  His  blood-vessels  are  rigid  and  his  heart 
is  weak  and  at  times  intermittent. 

C.\SE  IV.  -  Female,  aged  fifty-two,  had  suffered  from 
trigeminal  neuralgia  for  many  years  at  intervals,  but 
was  otherwise  in  fairly  good  health  without  evidence 
of  nephritis  or  cardiac  disease.  On  the  12th  of  June 
it  was  noticed  that  she  was  unusually  drowsy  and  dull 
during  the  morning,  and  this  drowsiness  gradually 
increased  to  a  state  of  semiconsciousness,  in  which  it 
was  difficult  to  arouse  her  attention  or  to  make  her 


move.  This  was  associated  with  a  very  great  contrac- 
tion of  the  pupils,  with  superficial  rapid  respiration, 
and  a  feeble  but  not  rapid  pulse.  There  was  no  ap- 
parent paralysis,  but  there  was  no  control  of  the 
sphincters.  For  thirty-six  hours  she  remained  in  this 
condition,  there  being  no  rise  of  temperature,  and  then 
the  stupor  became  somewhat  less,  but  she  could  not  be 
aroused  sufficiently  to  talk  intelligently.  There  was 
no  apparent  loss  of  sensibility,  but  the  left  side  of  the 
face  was  slightly  flattened  and  the  left  side  of  the 
tongue  was  partly  paralyzed.  The  pupils  were  less 
contracted;  pulse,  78 ;  respiration,  24;  temperature, 
99"  F.  She  was  able  to  swallow,  but  still  allowed 
everything  to  pass  from  her  without  notice.  During 
the  following  week  there  was  a  gradual  but  steady 
improvement  in  the  condition.  She  became  brighter 
mentally,  conscious  of  her  surroundings,  recognized 
her  family,  was  able  to  answer  questions  intelligently, 
but  slept  most  of  the  time  when  not  actively  aroused 
by  the  nurses.  By  the  end  of  two  weeks  but  little 
trace  was  left  of  the  facial  paralysis  and  the  tongue 
no  longer  deviated;  the  pupils  had  come  to  their  nor- 
mal condition,  reacted  perfectly;  there  was  no  evi- 
dence of  congestion  of  the  retinal  vessels;  the  motion 
of  the  eyes  was  perfect,  vision  good;  there  was  no- 
deafness,  no  anasthesia  or  paralysis  in  any  part  of  the 
body ;  and  from  this  time  there  was  a  gradual  but 
steady  recovery  of  health,  until  she  returned  to  her 
previous  normal  condition.  It  is  thought,  however,. 
by  her  family  that  she  is  a  little  less  active  mentally, 
that  her  memory  is  not  quite  so  reliable,  and  that  her 
emotional  control  is  somewhat  defective,  as  she  be- 
comes excited  and  irritable  more  easily  than  formerly 
and  shows  more  emotional  excitement  upon  little  pro- 
vocation than  she  did  in  a  state  of  health. 

I  think  it  is  evident  from  these  histories  that  attacks- 
quite  of  the  nature  of  apoplexy  occurred  in  each  case, 
but  not  attended  by  paralysis  of  a  permanent  or  very 
noticeable  character. 

The  location  of  the  lesion :  In  these  four  cases 
the  location  of  the  lesion  was  probably  in  the  frontal 
lobe  of  the  brain.  This  was  evident  from  the  loca- 
tion of  the  sudden  severe  pain  in  the  frontal  region 
and  upon  the  side  of  the  lesion,  from  the  symptoms  of 
slight  confusion  of  speech  and  slight  facial  paresis  of 
temporary  character,  and  more  especially  from  the 
mental  symptoms.  It  is  an  accepted  fact  that  mental 
confusion  and  dulness,  an  inability  to  concentrate  the 
attention,  to  pursue  a  train  of  thought,  to  exercise  self- 
control,  and  to  conduct  the  highest  mental  processes 
are  almost  uniformly  produced  by  lesions  in  the  fron- 
tal lobes.'  These  were  the  most  marked  symptoms  in 
the  first  three  cases.  An  emotional  condition  of  unu- 
sual character  also  points  to  the  frontal  lobe  as  the 
site  of  the  lesion.  Seguin  called  attention  to  this 
many  years  ago,  and  recently  Brissaud'  has  confirmed 
the  fact  by  recording  a  number  of  such  cases.  It 
seems  to  be  more  commonly  caused  by  lesions  of  the 
right  frontal  lobe,  and  hence  is  often  associated  with 
left  hemiplegia  in  patients  who  are  paralyzed.  The 
condition  is  one  of  a  more  or  less  complete  loss  of 
control  over  the  outward  manifestations  of  the  emo- 
tions, so  that  crying  or  laughing  without  cause  is  ob- 
served, and  the  patients  atlmit  that  they  do  not  know 
why  they  are  showing  such  emotion  and  cannot  help 
it.  In  all  these  cases  the  lesion  must  have  been  in 
the  domain  of  tlie  anterior  cerebral  arter}-. 

In  the  ft)llowing  cases  somewhat  different  symp- 
toms were  manifested: 

Case  V. — Male,  aged  fifty-four,  was  suddenly 
seized,  while  in  the  act  of  walking,  with  a  sensation 
of  numbness  and  coldness  in  the  left  foot,  which  ex- 

'  See   "  Contribution   to  Cerebral   Surgery."      McBurney  and 
Starr,  American  Journal  of  the  Medical  Sciences.  June,  lSq3. 
*  "  Lejons  sur  les  Maladies  du  Systime  Nerveu.r,"  Paris. 


November  13,  1897] 


MEDICAL    RECORD. 


691 


tended  up  the  leg,  involved  the  side  of  the  body  and 
the  arm  and  side  of  the  neck,  but  did  not  reach  the 
face.  It  was  not  attended  by  any  loss  of  conscious- 
ness, pain,  vertigo,  or  sense  of  prostration,  and  he 
had  no  feeling  of  weakness.  When  I  saw  him  three 
months  later  the  sensation  of  numbness  persisted  and 
was  attended  by  a  feeling  of  intense  cold  in  the  left 
leg,  body,  and  arm,  so  that  he  insisted  even  during  the 
heat  of  summer  in  having  the  arm  swathed  in  cotton. 
He  could  perceive  a  light  touch  of  cotton  everywhere, 
but  felt  it  differently  on  the  two  sides,  the  left  being 
numb.  The  sensation  of  pain  was  less  acute  in  his 
left  side  except  upon  the  face.  All  warm  objects  were 
felt  as  cold,  and  cool  or  cold  objects  were  painfully 
cold  in  the  left  arm  and  to  a  less  intense  degree  in 
the  left  leg  and  side  of  the  body.  There  was  no  pa- 
ralysis, no  loss  of  muscular  sense.  All  the  cranial 
nerves  were  normal.  There  were  no  general  symp- 
toms. His  arteries  were  rigid,  but  the  heart  was  not 
diseased.  The  condition  remained  stationary  for  sev- 
eral years. 

Case  VI. — Male,  aged  sixty-two,  who  has  a  well- 
marked  mitral  regurgitant  murmur  and  extremely 
rigid  arteries,  suffered  in  1893  from  a  slight  attack  of 
left  hemiplegia  which  passed  away  gradually,  leaving 
a  disagreeable  and  permanent  sensation  of  numbness 
in  the  left  hand.  During  the  summer  of  1896  he  had 
an  attack  in  which  he  noticed  a  headache,  a  sensation 
of  vertigo,  and  a  sudden  obscuration  of  vision  in  the 
left  eye.  This  was  attended  by  a  condition  of  pros- 
tration, in  which  he  was  seen  by  Dr.  W.  C.  Campbell, 
who  found  his  heart  very  weak  and  intermittent,  but 
his  mind  perfectly  clear.  There  was  no  anxiety,  no 
aphasia,  no  paralysis,  but  an  examination  showed  that 
the  supposed  dimness  of  vision  in  the  left  eye  was 
really  a  bilateral  left  hemianopsia.  In  the  course  of 
two  weeks  the  general  symptoms  subsided  under  ap- 
propriate treatment,  and  since  that  time  he  has  been 
attending  to  business.  But  the  left  homonymous 
hemianopsia  remains,  a  careful  perimetric  diagram  of 
the  visual  fields  taken  in  October  and  again  in  De- 
cember, 1896,  showing  that  the  blindness  in  the  left 
half  of  both  eyes  is  a  pennanent  symptom.  The  field 
of  vision  is  shown  in  Fig.  i. 

Case  VII. — M ,  aged  sixty-five,  a  hard-working 

banker,  had  been  apparently  in  good  health  until 
March  14,  1897,  when  he  suddenly  fainted  and  had 
a  slight  convulsion.  This  was  followed  by  a  condi- 
tion of  prostration  of  an  unusual  degree,  and  for  a 
week  he  was  confined  to  his  bed.  Then,  on  attempt- 
ing to  get  up  and  move  about,  he  had  a  second  slight 
convulsion,  which  is  said  to  have  been  limited  to  the 
right  side  of  his  body.  This  attack  was  followed  by 
great  confusion  of  mind,  by  a  slight  weakness  of  the 
riglit  hand,  and  a  mild  degree  of  aphasia,  in  which  he 
misplaced  words  though  he  talked  freely.  The  paral- 
ysis and  aphasia  had  entirely  passed  away  three  days 
later,  when  I  saw  him,  but  his  mental  condition  of 
confusion,  inability  to  concentrate  the  attention,  to 
give  a  connected  and  intelligent  account  of  his  condi- 
tion continued,  and  he  complained  of  great  distress 
and  pain  all  over  the  top  of  his  head. 

Examination  showed  a  loud,  direct,  aortic  murmur, 
and  very  tortuous  and  rigid  arteries  without  any  in- 
creased tension.  There  was  no  nephritis.  He  was 
extremely  pale  and  mentally  he  was  very  feeble,  being 
apparently  unable  to  conduct  a  connected  conversation, 
though  his  speech  was  in  no  way  affected  and  he  was 
not  at  all  paralyzed.  He  was  able  to  read  and  to 
write,  but  it  was  found  that  he  could  not  add  up  figures 
or  make  ordinary  computations,  although  this  was  part 
of  his  daily  business.  Further  examination  showed  a 
right  bilateral  hemianopsia  which  had  not  been  no- 
ticed by  himself  or  by  his  physician.  He  was  advised 
to  remain  in  bed,  not  to  exert  himself  in  any  way,  and 


was  ordered  caffeine  and  iodide  of  potassium,  five 
grains  three  times  a  day.  On  the  4th  of  April  he  had 
another  attack  of  faintness  and  increased  mental  con- 
fusion, after  which  the  sensation  was  slightly  affected 
in  the  right  hand  and  leg.  He  continued  in  a  feeble 
condition,  gradually  losing  weight  and  becoming  more 
and  more  exhausted,  and  died  the  ist  of  July.  He 
never  recovered  his  mental  balance  or  his  power  of 
thought  and  judgment,  and  although  he  developed  no 
further  symptoms  of  the  nature  of  paralysis,  his  hemi- 
anopsia and  hemianfEsthesia  remained  until  the  end. 
He  died  suddenly  in  an  attack  of  unconsciousness. 

In  these  cases  the  lesion  must  have  been  in  the 
domain  of  the  posterior  cerebral  artery.  This  was 
clearly  the  case  in  the  patients  who  suffered  from 
hemianopsia.  It  will  be  noticed  on  the  chart  that  the 
hemianopsia  was  not  exactly  homonymous;  that  is, 
the  field  of  vision  differed  in  the  two  eyes.  This  is 
supposed  to  indicate  a  subcortical  lesion  in  the  course 
of  the  visual  tract,  as  distinguished  from  a  strictly 
cortical  lesion  in  the  cortex  of  the  calcarine  fissure, 
which  Henschen  has  shown  conclusively  to  be  the  site 
of   the  primary  visual    centres.'     We  may   conclude 


therefore  in  these  cases  that  some  branch  of  the  pos- 
terior cerebral  artery  passing  into  the  base  of  the  oc- 
cipital lobe  was  occluded. 

The  course  of  tactile  and  temperature  sense  fibres 
through  the  brain  is  still  not  satisfactorily  settled. 
My  belief  is  in  the  existence  of  the  cortical  receptive 
centres  for  these  sensations  in  the  parietal  lobe,  and 
hence  in  the  patient  with  constant  sensations  of  cold 
in  the  arm  I  should  locate  the  lesion  within  the  pari- 
etal lobe  beneath  the  cortex. 

Case  VIII. — Female,  aged  forty-nine,  who  had  been 
decidedly  nervous  while  going  through  the  menopause, 
was  suddenly  seized  with  a  sensation  of  numbness  in 
the  left  hand,  which  soon  extended  to  the  left  side  of 
the  body  and  leg,  and  then  was  felt  in  the  right  side 
of  the  face.  The  feeling  was  as  if  the  entire  left  body 
and  right  face  were  asleep  or  dead,  the  sensation 
extending  up  the  neck  and  over  the  back  of  the  head  to 
the  vertex  on  the  left  side,  and  involving  the  forehead, 
face,  and  jaw  on  the  right  side.  .\t  the  same  time 
she  noticed  a  ringing  in  the  ears,  a  difficulty  in  swal- 
lowing, and  when  she  attempted  to  move  and  to  talk 
she  found  her  motions  awkward  and  some  defect  in 
the  pronunciation  of  words.  She  was  seen  immedi- 
ately by  Dr.  Runyon,  of  South  Orange,  who  found 
her  in  great  mental  distress  and  alarm,  with  a  weak 
puLse,  but  no  disturbance  of  consciousness  or  paraly- 
sis. Her  condition  had  remained  stationary  when  I 
saw  her  within  a  week  of  the  attack. 

Examination  shows  vision  normal  in  the  right  eye, 
slightly  defective  vision  in  the  left  eye  from  an  old 
atrophy  of  the  optic  nerve,  but  the  visual  field  is 
good.  The  right  pupil  is  sluggish  and  does  not 
dilate  in  the  dark,  but  reacts  normally,  like  the  left, 
to  strong  light  and  in  accommodation.  The  eye- 
balls move  upward  and  downward  well,  but  do  not 
converge  to  near  objects,  and  cannot  be  turned  to- 

'  "  Pathologie  des  Gehirns,  "  Llpsala,  1895-96. 


692 


MEDICAL    RECORD. 


[November  13,  1897 


gether  toward  either  side  beyond  20  degrees;  yet 
each  alone  can  be  moved  freely  when  the  other  is 
shaded,  hence  there  is  defect  of  conjugate  action  of 
the  eyes.  There  is  marked  nystagmus  on  any  attempt 
to  conjugate  action.  In  rest  the  eyes  look  forward 
without  strabismus;  there  is  no  ptosis.  She  com- 
plains of  a  constant  sensation  about  the  eyes,  "as 
if  they  were  set  in  stone  in  her  head."  The  right 
side  of  the  face  feels  numb  and  cold,  and  tingles  con- 
stantly. It  is  hypersensitive  to  touch,  to  heat  and  to 
cold,  and  to  pain  •  any  contact  making  the  paraesthesia 
most  intensely  disagreeable.  This  condition  extends 
to  the  inside  of  the  mouth  and  to  the  gums,  but  not  to 
the  tongue.  The  face  is  not  flushed  or  pale,  and  is 
not  paralyzed.  The  left  side  of  the  face  is  perfectly 
normal.  Hearing  is  normal.  She  complains  of  diffi- 
culty in  swallowing,  and  occasionally  chokes.  The 
tongue  protrudes  toward 
•^hV         ^  the  left  without  tremor, 

and  her  speech  is  some- 
what thick  and  lisping 
on  this  account.  All 
motions  of  the  head  and 
neck  are  perfect.  Her 
pulse  is  uniformly  rapid, 
1 10  to  130;  respirations 
are  regular  and  normal. 
On  the  left  side  of  the 
head  at  the  back,  includ- 
ing the  neck  and  back 
of  the  ear,  and  over  the 
entire  left  side  of  the 
body,  including  the  ex- 
tremities, there  is  a  con- 
t  i  n  u  a  1  sensation  o  f 
tingling  and  numbness, 
which  is  increased  by 
''  "^  .     ,    ^        any  contact.      There  is 

Fig.  2.— The  Sensory  Tract  m  the  Cms,     .     •' ,  .  .  , 

Pons,  and   Medulla,   showing  Nucleus     in  thlS  region    hypersen- 

::us5°°h1nSin'aiI;he?iir'"  =  ston"l   sitiveuess  to  pain  and  to 

causes     alternating     hemianiesthesia,    Jieat  and  Cold,  and  tOUCh 
right    face    and    left   side    of     body.     .  •  ,  ^     i  i  i 

Lesion  B  in  Case  viii.  IS  Said  to  be  more  keenly 

felt,  but  the  jesthesiom- 
•eter  shows  that  two  points  are  felt  as  one  on  the  tips 
of  the  fingers  of  the  left  hand  at  three  millimetres' 
distance,  while  they  are  felt  as  two  at  two  millimetres' 
distance  on  those  of  the  right  hand.  .411  movements 
of  tJTfe  left  extremities  are  extremely  ataxic,  but  there 
is  no  loss  of  power.  She  holds  the  hand  in  an  awk- 
ward position,  fingers  and  thumb  being  overextended. 
In  attempts  to  make  motions  there  is  a  lack  of  adap- 
tation, it  being  impossible  to  execute  any  voluntary 
movement  accurately  with  the  eyes  closed.  She  is  not 
able  to  state  in  what  position  her  fingers  and  hand  are 
when  her  eyes  are  closed,  and  cannot  reproduce  in  the 
right  hand  positions  given  to  the  left,  though  she  can 
place  tlie  left  hand  at  once  in  positions  given  to  the 
right  hand.  Slie  cannot  distinguish  with  any  degree 
of  accuracy  between  different  weights  in  the  left  hand. 
Thus  there  is  a  very  marked  loss  of  muscular  sense  in 
the  left  hand.  The  same  condition  is  present. in  the 
left  leg,  all  motions  being  awkward  and  standing 
being  impossible.  No  wrist  or  elbow  jerks;  knee 
jerks  equal  and  normal ;  no  ankle  clonus;  no  inconti- 
nence of  urine  or  fa'ces;  no  paralysis  of  arms  or  leg; 
systolic  murmur  at  apex  of  heart  and  accentuation  of 
the  second  sound  at  the  base. 

Three  weeks  later  her  condition  was  not  materially 
changed  in  any  way,  the  pulse  being  still  130  and  the 
tingling  being  constant  and  almost  unendurable. 
During  the  following  months,  however,  her  symptoms 
gradually  subsided,  and  when  I  saw  her  one  year  after 
the  attack  the  tingling  had  become  less  intense  though 
it  was  still  piesent;  the  ataxia  had  disappeared:  the 
eves  could  be  moved  in  all  directions  well,  though 


nystagmus  was  produced  by  all  conjugate  movement 
laterally:  and  her  pulse  was  still  rapid.  She  could 
walk  well  and  was  able  to  attend  to  household  and 
social  duties. 

The  diagram  explains  the  necessary  situation  of  the 
lesion  in  the  pons  Varolii  in  all  such  cases. 

Cases  of  alternating  hemianjesthesia  are  quite  rare. 
I  have  recorded  two.' 

To  these  cases  I  add  two  cases  of  cerebellar  apo- 
plexy : 

Case  IX. — Male,  aged  seventy-three,  was  suddenly 
seized  on  July  10,  1895,  with  vertigo  and  soon  after 
with  headache  and  vomiting  attended  by  great  pros- 
tration. The  latter  symptoms  gradually  subsided 
and  after  two  weeks  he  was  able  to  be  up  and  about, 
but  he  has  suffered  ever  since  from  vertigo  and  he 
staggers  in  walking.  He  is  never  dizzy  when  lying 
down  or  when  ceated  quietly,  but  as  soon  as  he  attempts 
to  walk  he  becomes  unsteady,  feels  as  if  he  were  going 
to  fall,  and  in  his  attempts  to  steady  himself  sways 
somewhat  from  side  to  side  and  walks  with  an  irregu- 
lar gait  which  resembles  exactly  the  gait  seen  in  cere- 
bellar disease.  Any  physical  or  mental  exertion  will 
increase  the  staggering  and  the  vertigo.  He  occasion- 
ally suffers  from  a  sense  of  pressure  and  fulness  in  the 
back  of  the  head  and  from  headache,  and  when  these 
symptoms  are  present  he  staggers  more  and  his  legs 
feel  hea\')'.  He  has  no  trouble  with  sight  or  hearing. 
His  ears  are  normal.  His  digestion  is  perfect,  and 
there  is  no  evidence  that  the  vertigo  is  from  the  stom- 
ach, eyes,  or  ears.  He  has  no  paralysis  and  his  knee 
jerks  are  normal.  He  has  no  sensory  symptoms.  For 
two  years  there  has  been  a  stationary  condition,  but 
gradually  he  has  noticed  that  motion  of  his  eyes  up- 
ward causes  vertigo  even  when  he  is  seated. 

Case  X.  —  Female,  aged  sixty,  had  a  slight  hemi- 
plegic  attack  in  1889  from  which  she  recovered  en- 
tirely. About  August,  1893,  she  had  a  sudden  attack 
of  a  cerebral  nature,  attended  by  vertigo,  headache, 
and  prostration,  from  which  she  recovered  slowly,  her 
feebleness  and  apparent  sense  of  weakness  being  out 
of  proportion  to  any  actual  objective  symptoms.  From 
that  time,  however,  until  I  saw  her  with  Dr.  T.  M. 
Markoe,  in  March,  1895,  and  again  in  October,  1895, 
she  had  suffered  constantly  from  a  sense  of  unsteadi- 
ness whenever  she  stood  up  or  walked.  There  was 
no  vertigo  while  she  was  seated  or  lying  down,  but 
any  attempt  at  standing,  at  walking,  or  going  up  and 
down  stairs  produced  the  sensation  of  instability  and 
uncertainty,  so  that  she  required  a  cane  or  the  aid  of 
an  arm.  When  thus  steadied  she  felt  relieved  and 
could  walk  fairly  well,  but  without  support  she  had  a 
typical  cerebellar  gait. 

The  examination  showed  nystagmus  on  movement 
of  the  eyes  in  any  direction.  There  was  no  paralysis. 
The  knee,  jerks  were  normal.  There  was  a  loud  aortic 
direct  murmur,  and  her  arteries  were  rigid.  There 
was  no  condition  of  the  eyes,  ears,  or  stomach  at  all 
sufficient  to  account  for  the  \ertigo. 

The  diagnosis  in  these  two  cases  was  a  small  vascu- 
lar lesion  in  the  cerebellum  affecting  the  mechanism 
of  equilibrium,  which  is  known  to  be  located  in  that 
organ.  The  cases  could  not  be  classed  with  ordinarj- 
vertigo,  because  the  vertigo  was  never  felt  when  the 
patients  were  lying  down  or  when  they  were  seated, 
was  not  caused  by  gastric  or  aural  disease,  and  was 
permanent  and  continuous  for  years.  In  one  case  it 
was  associated  with  nvstagmus,  and  in  the  other  it 
was  produced  bv  looking  upward.  It  is  known  that 
the  cerebellum  controls  and  has  a  close  relation  to 
ocular  movements.  Hence  these  symptoms  confirmed 
the  suspicion  of  the  cerebellar  origin  of  the  disease. 
Furthermore,  the  characteristic  gait  of  cerebellar  dis- 

'  New  York  MuDic.M.  Recori\  Februarj-  II,  1893,  "Familiar 
Forms  of  Nervous  Disease,  "  Case  XVII.,  p.  121. 


November  13,   1897] 


MEDICAL    RECORD. 


693 


ease  was  manifest  in  both  patients  to  a  marked  de- 
gree. The  persistence  of  the  knee  jerks  in  these 
cases  cannot  be  asserted  as  pointing  to  a  normal  cere- 
bellum. The  loss  of  knee  jerk  is  not  a  constant 
symptom  of  cerebellar  disease,  as  has  been  recently 
asserted.  I  have  records  of  twenty-six  tumors  of 
the  cerebellum,  in  twenty  of  which  the  knee  jerks 
were  increased,  in  three  they  were  normal,  and  in 
three  only  were  they  lost.  The  knee  jerk  was  not 
lost  in  any  one  of  eight  cases  of  cerebellar  tumor  re- 
cently reported  by  Jacobson  and  Jamene.'  It  must  be 
regarded  as  a  rare  symptom  of  disease  of  this  organ. 

The  nature  of  the  lesion  in  cases  which  are  not 
fatal  is  always  a  matter  of  conjecture,  as  there  are  no 
positive  means  of  difrerentiating  hemorrhage  from 
thrombosis.  That  the  lesion  was  avascular  one  in  all 
these  cases  is  evident  from  its  sudden  occurrence. 
That  the  attack  was  not  the  first  symptom  of  a  tumor, 
as  it  may  be  in  any  case,  is  demonstrated  by  the  pro- 
gressive recovery  or  stationary  state  of  all  the  pa- 
tients. The  recovery  does  not,  however,  prove  that 
the  lesion  was  a  hemorrhage  and  that  the  clot  was 
absorbed;  for  in  many  cases  of  thrombosis,  especially 
of  cortical  blood-vessels,  the  collateral  circulation  is 
so  perfect  tliat  repair  is  quite  commonly  eti'ected. 
Hence  the  nature  of  the  lesion  must  be  left  uncertain. 
When  such  attacks  occur — as  they  frequently  do — in 
the  course  of  a  case  of  general  paresis,  they  are  due 
to  a  ha;matoma  of  the  pia  or  dura. 

The  severity  of  the  lesion  differed  in  the  differ- 
ent cases.  Here  the  resemblance  of  these  cases  to 
those  of  hemiplegia  becomes  apparent.  In  some 
cases  of  hemiplegia  the  symptoms  subside  slowly  and 
power  returns;  in  others  a  permanent  paralysis  results. 
This  is  due  to  the  e.xtent  and  position  of  the  lesion, 
and  to  the  degree  of  damage  done  to  the  motor  tract. 
The  same  thing  is  true  in  cases  of  apople.xy  with  men- 
tal or  with  sensory  symptoms,  and  the  fact  that  no 
paralysis  is  present  does  not  argue  that  recovery  will 
ensue.  In  the  emotional  patient  and  in  the  patient 
with  hemianopsia  there  has  been  no  improvement  at 
all  and  never  will  be.  The  same  is  true  of  the  cases 
of  cerebellar  disease.  Hence  caution  must  be  exer- 
cised in  giving  a  prognosis  in  all  these  cases.  And 
it  is  well  to  remember  that  as  complete  incapacity 
for  professional  work  or  for  business  may  be  caused 
by  a  lesion  of  the  frontal  lobe  causing  mental  weak- 
ness, or  by  a  cerebellar  lesion  causing  vertigo,  as  by  a 
lesion  of  the  motor  zone  causing  paralysis  or  aphasia. 

As  to  the  treatment  of  such  cases,  it  is  to  be  remem- 
bered that  all  the  precautions  against  allowing  effort 
of  mind  or  of  body  during  the  period  of  repair  are  to 
be  enforced  just  as  they  would  be  in  a  case  of  hemi- 
plegia. A  hemiplegic  is  kept  quiet  for  weeks  after 
his  attack.  There  is  no  reason  for  allowing  a  man 
with  equally  extensive  lesion  in  the  frontal  lobe  to  go 
about  because  he  does  not  happen  to  be  paralyzed.  In 
hemiplegia  attempts  to  improve  the  condition  are  made 
by  regulating  the  circulation,  dilating  the  blood-ves- 
sels by  nitroglycerin,  and  aiding  the  heart  in  cases  of 
thrombosis  and  cardiac  weakness;  enforcing  perfect 
quiet  and  using  laxatives,  cold  applications  to  the 
head  and  iodide  of  potassium  in  cases  in  which  hem- 
orrhage is  thought  probable.  The  same  treatment 
should  be  carried  out  in  these  cases.  And  too  great 
care  cannot  be  taken  to  prevent  a  too  hasty  return  to 
ordinary  occupations  and  to  those  business  and  social 
anxieties  which  tend  to  put  a  strain  upon  brain  action 
or  upon  the  cardiac  and  vascular  systems. 

Catarrhal  Pneumonia   in  Children. — Tincture  of 
veratrum  viride  in  small  but  frequently  repeated  doses 
until  the  pulse  and  respirations  are  lowered. — Sutliff. 
'  Arch.  f.  Psych.,  .xxix. ,  80.  1897. 


DISEASES     OF     THE     MASTOID:       THEIR 
COURSE  AND   TREATMENT." 


By    frank    S.    MILBURY,    M.O., 


OTOLOGIST,    OPTHALMOLOGIST,    AND 

LARYNGOLOGIST  TO 

THE 

BEDFORD 

DIS- 

PENSARY    AND     HOSPITAL,   AND     1 

HE      NORTH      BROOKL 

VN      E 

YE,     EAR, 

ANI» 

THROAT  HOSPITAL. 

Before  beginning  the  consideration  of  this  paper,  I 
wish  to  request  your  attention  for  a  few  moments  to 
some  of  the  anatomical  features  of  the  middle  ear  and 
mastoid. 

It  is  an  air-containing  space,  lined  throughout  with 
.nucous  membrane,  and  continuous  with  the  covering 
of  the  nasopharynx  and  adjacent  parts.  Its  divisions 
are  the  Eustachian  tubes,  the  tympanic  cavity,  and 
the  mastoid  cells.  Thetirst  is  the  channel  of  connec- 
tion between  the  pharynx  and  the  tympanum,  and  con- 
sists of  two  portions,  the  cartilaginous  and  osseous, 
the  widest  opening  being  pharyngeal  and  the  narrow- 
est point  at  the  junction  of  the  soft  and  the  bony  parts. 
It  is  from  one  inch  to  one  and  one-third  inches  long, 
the  osseous  portion  constituting  about  one-third  of  its 
length ;  the  two  portions  are  formed  at  an  obtuse  angle. 
Its  directfon  is  obliquely  outward,  backward,  and 
slightly  upward.  The  tubal  mucous  membrane  con- 
tains throughout  a  ciliated  epithelium  destitute  of 
glands,  the  movements  of  the  cilia  being  away  from 
the  tympanic  cavity,  thus  aiding  in  the  drainage  of 
the  tympanum  and  partially  preventing  its  invasion  by 
pathogenic  organisms  from  the  rhinopharynx. 

The  tympanic  cavity  is  an  irregular  pneumatic 
space,  with  its  longest  diameters  vertical  and  lat- 
eral, containing  the  ossicula;  it  consists  of  two 
portions — the  atrium,  immediately  behind  the  mem- 
brana  tympani,  and  the  attic,  which  lies  above  the 
membrane.  The  communication  between  these  two  is 
quite  narrow,  owing  to  the  arrangement  of  the  ossicles 
and  folds  of  mucous  membrane,  and  therefore  a  slight 
inflammation  and  swelling  of  the  tissues  may  easily 
shut  off  the  attic  space,  producing  interference  with 
its  drainage,  this  being  a  serious  factor  in  middle-ear 
pathology.  The  mucous  membrane  lining  the  tym- 
panic cavity  is  thin  and  delicate,  and  closely  adherent 
to  the  underlying  bone;  its  epithelium  is  usually 
tessellated,  and  may  in  places  be  ciliated,  as  is  most 
frequently  the  case  in  the  vicinity  of  the  Eustachian 
orifice.  A  little  above,  continuous  and  posterior  to 
the  attic,  the  mastoid  antrum  is  situated;  it  is  the 
only  pneumatic  space  developed  at  birth,  the  others 
being  formed  subsequently.  Not  infre(|uently  a  sec- 
ond cell  of  considerable  size  is  found  at  the  tip  of 
the  process.  The  mastoid  process,  both  externally 
and  internally,  varies  greatly  in  its  construction;  thus 
we  may  have  those  which  are  entirely  pneumatic, 
those  which  are  pneumatic  and  diploetic,  those  which 
are  wholly  diploetic,  and,  lastly,  those  which  are 
altogether  sclerotic,  e.xcepting  the  antrum.  Zucker- 
kandl,  in  the  examination  of  two  hundred  and  fifty 
bones,  found  36.8  per  cent,  completely  pneumatic, 
while  42.8  per  cent,  were  partly  diploetic  and  partly 
pneumatic,  and  20.4  per  cent,  entirely  diploetic  or  com- 
posed of  dense  osseous  tissue  throughout.  These  con- 
ditions are  also  found  to  vary  on  the  two  sides,  one 
side  being  partly  pneumatic  and  the  other  completely 
so.  From  such  examinations  it  is  evident  that  a  scle- 
rotic process  does  occur  normally  and  also  as  the  re- 
sult of  inflammatory  action.  The  position  of  the 
lateral  sinus  varies  greatly  in  different  individuals, 
sometimes  being  one  inch  or  more  posterior  to  the  wall 
of  the  meatus;  and,  again,  the  bend  of  the  sinus  is  so 
sharp  that  it  extends  forward  so  near  to  the  posterior 

'  Read  before  the  section  on  otology  and  laryngology  at  the 
forty-eighth  annual  meeting  of  the  American  Medical  Associa- 
tion held  at  Philadelphia,  June  1-4,   1897. 


694 


MEDICAL    RECORD. 


[November  13,  1897 


wall  of  the  meatus  that  opening  the  antrum  would  be 
impossible  without  wounding  this  venous  channel. 
To  the  operator  the  position  of  the  sinus  and  the  mid- 
dle cerebral  fossa  is  of  special  importance,  and  many 
efforts  have  been  made,  by  the  examination  of  speci- 
mens, measurements  of  the  skull,  and  its  outward  con- 
formation, to  determine  the  location  of  the  sinus;  but 
all  such  researches  have  proven  useless.  Dr.  Politzer 
states  that  in  five  hundred  temporal  bones  which  he 
examined  he  found  the  position  of  the  sinus  most  fa- 
vorable when  the  mastoid  process  was  strongly  devel- 
oped and  entirely  filled  with  pneumatic  cells.  In 
these  cases  there  is  a  broad  space  between  the  sigmoid 
sinus  and  the  posterior  wall  of  the  e-\ternal  meatus, 
which  in  operating  permits  access  to  the  antrum  with- 
out danger  of  wounding  the  sinus.  He  found  the  re- 
lations less  favorable  in  the  diploetic  and  compact 
mastoid  processes.  How  are  we  to  know  positively 
whether  the  process  is  diploetic  or  pneumatic? 
Hence  for  practical  purposes  these  investigations 
prove  as  useless  as  others. 

We  will  now  take  up  the  individual  mastoid  dis- 
eases. 

Primary  periostitis  is  very  rare,  and  when  it  does 
occur  is  usually  the  result  of  traumatism  or  exposure, 
but  sometimes  is  without  any  traceable  cause;  the  lat- 
ter is  usually  the  case  in  persons  of  a  cachectic  condi- 
tion.    Only  a  few  cases  have  been  reported. 

Secondary  periostitis,  however,  is  quite  frequent, 
and  is  due  to  acute  or  chronic  middle-ear  suppuration 
or  necrosis,  the  process  extending  outward  from  the 
tympanum  until  the  mastoid  covering  is  reached.  It 
occurs  oftener  in  early  than  in  adult  life,  owing  to  the 
much  greater  liability  of  the  young  to  ear  disease.  In 
acute  middle-ear  suppuration  it  is  most  frequent  when 
free  drainage  is  interfered  with,  as  from  a  very  small 
perforation  badly  placed,  or  from  a  possible  pus  re- 
tention by  the  blocking  up  of  the  opening  with  pow- 
ders— as  boric  acid,  alum,  and  some  of  the  more  ad- 
hesive new  products.  The  fluid  must  find  exit,  and 
will  do  so  at  the  point  of  least  resistance.  This 
may  be : 

1.  Through  the  external  mastoid  cortex  or  into  the 
external  meatus. 

2.  Through  the  digastric  fossa. 

3.  Through  the  roof  of  the  antrum  or  the  tympanic 
wall  into  the  middle  cranial  fossa. 

4.  Into  the  posterior  cranial  fossa,  by  rupture  usu- 
ally, into  the  groove  lodging  the  lateral  sinus. 

If  the  cranial  cavity  is  invaded,  meningitis  is  in- 
duced, and  may  be  diffuse  or  circumscribed.  In  the 
latter  the  limit  appears  to  be  caused  by  the  formation 
of  an  epidural  abscess,  the  infectious  material  being 
walled  in  on  all  sides  by  adhesions  between  the  dura 
and  adjacent  walls.  Internal  rupture  may  occur,  or 
the  free  anastomosis  between  the  blood-vessels  and 
the  dura  and  the  pericranium  may  provide  the  channel 
through  which  the  infectious  material  may  pass  to  the 
brain,  producing  an  intracranial  abscess  or  a  throm- 
bosis of  the  lateral  sinus.  Unfortunately  these  lesions 
often  occur  simultaneously,  thus  greatly  increasing  the 
danger  to  life. 

Until  within  a  comparatively  recent  period  the  op- 
eration for  acute  disease  of  the  mastoid  was  the  prin- 
cipal surgical  operation  upon  the  ear.  It  was  near 
the  end  of  the  fifteenth  century  that  Riolanus  proposed 
opening  the  mastoid  cells;  later,  about  the  year  1655, 
Sir  Thomas  Brown  advised  against  such  a  procedure; 
and  it  was  not  until  one  hundred  years  later  that  the 
operation  was  first  performed  by  Petit  for  the  removal 
of  secretions.  In  1776  Jasser  performed  the  operation 
for  necrosis  of  the  bone  with  great  success,  but  after 
his  decease  surgeons  lost  sight  of  the  true  indications 
for  operating  and  perforated  the  bone  for  various  pur- 
poses, until  the  death  of  Bergen,  a  noted  Danish  sur- 


geon, upon  whom  the  operation  was  performed  for  the 
relief  of  deafness  and  ended  in  fatal  meningitis.  This 
caused  the  procedure  to  fall  into  disrepute,  and  nearly 
a  century  elapsed  before  it  was  revived  by  Forget 
(1849;,  Follin,  and  Troeltsch  (1859). 

When  there  were  inflammation,  swelling,  and  tender- 
ness over  the  mastoid,  Troeltsch  made  an  incision  down 
to  the  bone  to  prevent  necrosis,  and  if  the  symptoms 
indicated  a  deeper  seat  of  the  disease  he  perforated 
the  bone  with  a  blunt  probe.  To  prevent  injury  to 
the  brain  or  lateral  sinus,  he  placed  the  instrument  on 
a  line  with  the  meatus,  and  worked  it  forward  and  in- 
ward in  a  horizontal  plane.  If  the  cortex  was  thick 
he  used  a  small  trephine.  The  sinus  was  kept  open 
by  means  of  a  piece  of  gauze. 

To  Schwartze  is  due  the  credit  of  developing  the 
operation;  by  1883  he  had  reported  one  hundred 
cases,  which  was  the  largest  number  reported  up  to 
that  time. 

Acute  inflammation  of  the  mastoid  cells  varies  ac- 
cording to  the  stage  in  which  the  patient  comes  under 
observation.  Acute  otitis  media  without  perforation 
is  often  accompanied  by  symptoms  of  mastoid  irrita- 
tion, which  usually  subside  with  slight  antiphlogistic 
measures.  In  acute  inflammation  of  the  mastoid  cells 
the  prominent  symptoms  are:  (i)  Intense  continuous 
pain  over  the  mastoid  and  radiating  over  the  side  of 
the  head  and  in  the  neck,  which  is  increased  on  pres- 
sure and  percussion ;  redness,  heat,  and  oedema  of  the 
skin.  When  the  abscess  becomes  localized  the  pain 
generally  remains  fi.xed  at  one  point.  (2)  The  mem- 
branatympani  appears  strongly  bulged  forward  before 
the  pus  perforates;  following  perforation  a  nipple- 
like projection  is  often  found  in  the  posterior-superior 
quadrant  of  the  membrane,  on  the  tip  of  which  the 
perforation  is  situated.  (3)  A  swelling  and  bulging 
of  the  posterior-superior  wall  of  the  canal,  causing  a 
narrowing  of  its  lumen,  and  shutting  from  view  all  or 
a  part  of  the  membrane.  These  two  latter  points  are 
very  indicative  symptoms.  Free  discharge  from  the  ear 
exists,  which  rarely  ever  ceases  while  the  mastoid  in- 
flammation continues.  However,  the  only  absolutely 
positive  sign  of  a  mastoid  abscess  is  pus  found  within 
its  interior  on  opening  it.  The  temperature  usually 
ranges  from  99.5^  to  102^  F.,  but  is  seldom  higher. 

The  course  of  the  affection  varies  considerably  in 
different  cases — in  some  running  to  a  fatal  termination 
in  a  few  days,  and  in  others  requiring  weeks  and 
months  and  possibly  years  before  indicating  positive 
symptoms.  In  chronic  otitis  media  purulenta  tlie  ex- 
tension to  the  mastoid  is  often  without  characteristic 
symptoms.  The  quality  and  quantity  of  the  discharge 
varies  greatly,  now  very  sliglit,  now  copious,  accord- 
ing as  there  is  a  narrow  or  a  free  outlet  for  drainage 
from  attic  and  antrum.  A  thickened  cheesy  pus  may 
exist  for  a  long  time  in  the  mastoid  cells  without  indi- 
cating itself  by  any  symptoms  except  a  stubborn  fetid 
otorrhcea,  resisting  cure  in  spite  of  thorough  cleansing 
of  the  tympanic  cavity.  We  may  be  almost  sure  of 
retention  of  pus  in  the  antrum,  provided  caries  of  the 
external  canal,  ossicles,  or  walls  of  the  tympanic  cav- 
ity may  be  excluded. 

Inflammation  of  the  mastoid  process  and  fever  oc- 
cur only  through  traumatism  or  the  retention  of  pus 
in  the  cells.  They  may  subside,  only  to  reappear. 
Sharp  pain  on  pressure,  united  with  oedema,  may  have 
existed  a  long  time  witliout  producing  any  perceptible 
change  in  the  periosteum  and  the  bone  surface.  If  the 
bone  is  greatly  sclerosed  and  very  dense,  and  the  cor- 
tex much  thickened,  which  conditions  may  be  congeni- 
tal or  occur  as  a  result  of  chronic  middle-ear  suppura- 
tion, such  acute  symptoms  may  never  arise,  even  in  a 
long  course  of  the  disease.  However,  the  absence  of 
the  same  cannot  be  looked  upon  favorably  as  a  prog- 
nostic sign,  for  it  is  often  just  such  cases  that  prove 


November  13,  1897] 


MEDICAL    RECORD. 


695 


rapidly  fatal  through  pyamia.  Zaufal  and  others  have 
called  attention  to  the  frequent  existence  of  optic  neu- 
ritis, neuro-retinitis,  and  choked  disc  in  inflammation 
of  the  mastoid  process,  at  times  bilateral,  at  times 
unilateral,  and  not  always  on  tiie  affected  side.  The 
course  of  the  morbid  process  in  bone  affection  varies 
in  different  cases.  E.xtension  of  the  inflammation  in 
an  outward  direction,  with  periostitis  and  abscess,  is 
the  most  common  course.  Several  such  abscesses,  in 
more  or  less  rapid  succession,  over  the  mastoid  proc- 
ess, are  indicative  of  disease  of  the  bone.  Occasion- 
ally the  pus  finds  its  way  down  the  side  of  the  neck, 
and  forms  a  swelling  of  considerable  size;  or  it  may 
pass  forward  to  the  side  of  the  pharynx,  and  down- 
ward even  as  far  as  the  pleura ;  or  it  may  extend  into 
the  cranial  cavity  and  set  up  trouble  in  the  lateral 
sinus,  or  involve  the  Fallopian  aqueduct  and  the  mem- 
branes of  the  brain. 

Next  to  opening  through  the  cortex  of  the  mastoid, 
the  most  frequent  point  is  through  the  posterior- 
superior  wall  of  the  external  canal.  If  not  recognized 
early  it  may  cause  such  excessive  bulging  of  the  canal 
wall  as  to  prevent  free  discharge.  If  seen  at  the 
proper  time  a  generous  opening  followed  by  copious 
syringing  may  suffice  to  empty  the  mastoid  process  of 
all  deleterious  substances,  such  as  pus,  cholesteatoma, 
the  cheesy  exudate,  epidermis  masses,  and  even  se- 
questra if  very  small.  Bezold  has  well  described 
those  uncommon  cases  as  mentioned  above.  When 
rupture  takes  place  toward  the  digastric  groove,  or  on 
the  median  surface  of  the  mastoid  process,  owing  to 
its  deep  position  beneath  the  fascia  the  pus  easily 
finds  its  way  into  the  submuscular  tissues  and  along 
th^  course  of  the  large  vessels,  and  causes  swelling 
in  the  side  of  the  neck  with  abscess  formation.  In 
the  early  stages  no  perceptible  difference  may  be  seen 
between  the  sound  and  the  diseased  side.  After  the 
swelling  beneath  and  on  each  side  of  the  sterno-cleido- 
mastoid  muscle  has  developed,  deep  pressure  over  the 
tip  of  the  mastoid  elicits  acute  pain.  An  early  recog- 
nition of  the  condition  is  necessary,  since  from  the 
consolidation  of  the  parts  invasion  of  the  cranial 
cavity  is  likely  to  occur.  In  favorable  cases  the  cari- 
ous and  necrotic  portions  are  exfoliated,  the  granula- 
tion tissue  is  absorbed,  and  healing  takes  place.  Sev- 
eral good  recoveries  have  been  reported,  even  after 
the  whole  of  the  mastoid  process  has  been  exfoliated. 
Again,  only  small  portions  of  bone  may  be  detached, 
and  fistulous  openings  may  remain  indefinitely  or 
until  properly  dealt  with. 

The  prognosis  in  these  cases  of  mastoid  disease 
varies  with  the  cause,  extent,  and  severity  of  the 
affection  and  with  the  general  health  of  the  patient. 
Following  an  acute  otitis  media,  promptly  attended 
to,  the  prognosis  is  usually  favorable,  but  in  some 
such  cases  the  advance  may  be  so  rapid  as  to  baffle 
all  efforts  to  check  it.  It  is  unfavorable  in  tuber- 
culosis and  in  chronic  purulent  otitis  with  pent-up 
secretions,  when  the  case  has  been  neglected  and  has 
a  history  of  intermittent  febrile  attacks  and  several 
previous  attacks  referable  to  the  mastoid  region  which 
have  disappeared  spontaneously  or  under  palliative 
measures.  The  prognosis  is  always  serious  whenever 
there  are  symptoms  of  e.xtension  of  inflammation  to 
the  membranes  of  the  brain.  Attacks  of  partial  or 
complete  unconsciousness,  restlessness,  and  feverish- 
ness  are  of  extremely  grave  import  when  occurring 
in  a  person  suffering  from  disease  of  the  mastoid  proc- 
ess. 

In  the  treatment,  if  the  case  is  seen  early,  an  attempt 
should  be  made  to  abort  the  attack  by  antiphlogistic 
measures.  If  the  membrana  tympani  appears  greatly 
congested,  swollen,  and  bulged  outward,  simultane- 
ously with  pain  in  the  mastoid  process,  which  is  in- 
creased on  pressure,  a  paracentesis  of  the  membrana 


tympani  should  be  made  at  once  to  permit  the  pus  in 
the  middle  ear  an  opportunity  of  free  exit;  and  in  a 
spontaneous  rupture,  when  not  sufficiently  large,  it 
must  be  enlarged.  After  free  drainage  has  been  ob- 
tained, frequent  antiseptic  irrigations  should  be  insti- 
tuted and  carried  out  faithfully.  A  brisk  purge 
should  be  administered,  followed  by  the  application  of 
cold  to  the  mastoid  by  means  of  the  ice  bag,  iced 
cloths,  or,  what  is  better,  the  Leiter  coil.  The  ear  may 
be  syringed  with  the  apparatus  in  place.  It  is  better 
to  keep  the  coil  in  position  continuously  for  twenty-four 
hours,  and  under  no  condition  should  it  be  kept  on 
longer  than  from  forty  to  fifty  hours.  Painting  with 
iodine,  blood  letting  by  means  of  leeches,  and  rest  in 
bed  are  also  to  be  employed.  In  influenza  cases  the 
Leiter  coil  does  not  appear  very  effectual  in  stopping 
the  formation  of  abscesses.  Cold  is  usually  very 
soothing  and  is  borne  well.  Often  the  pain  will  en- 
tirely disappear  through  these  means  while  the  patient 
is  in  bed  and  quiet,  but  on  exertion  in  his  duties  the 
symptoms  return.  And  hence  it  is  said  by  some 
writers  that  if  marked  improvement  has  not  occurred 
within  forty-eight  hours,  operative  treatment  will  be 
necessary  subsequently,  if  not  at  once.  If  abortive 
measures  have  not  been  successful,  then  operative  in- 
terference must  be  resorted  to,  and  the  following 
symptoms  as  laid  down  by  Politzer  and  others  are 
generally  recognized  as  indicating  the  operation: 

(i)  Painful  inflammatory  infiltration  of  the  covering 
of  the  mastoid  process,  especially  if  an  accompanying 
narrowing  of  the  meatus  or  obstruction  of  the  tympa- 
num by  granulations  renders  it  probable  that  a  septic 
condition  exists  in  the  mastoid  process.  The  opera- 
tion becomes  imperative  when  there  are  high  fever  and 
signs  of  meningeal  irritation,  and  when  the  symptoms 
in  the  mastoid  process  have  repeatedly  occurred  and 
resisted  all  antiphlogistic  treatment. 

(2)  Spontaneous  pain  in  the  mastoid  process,  in- 
creased by  pressure  and  accompanied  by  bulging  of 
the  posterior-superior  wall  of  the  meatus. 

(3)  Persistent  or  occasionally  remittent  pain  in  the 
mastoid  process,  with  marked  tenderness,  even  if  there 
be  no  swelling  of  the  external  integument  and  no 
apparent  obstruction  to  the  escape  of  discharge  from 
the  tympanic  cavity.  ! 

(4)  When  cholesteatoma  existing  in  the  tympanic 
cavity  cannot  be  removed,  or  after  its  extraction  with 
the  malleus  and  incus  the  condition  is  not  improved 
by  careful  irrigation. 

(5)  Fistulse  in  the  mastoid  region  and  gravitation 
abscesses  below  them. 

(6)  Extensive  caries  and  necrosis  of  the  posterior 
osseous  wall  of  the  meatus. 

(7)  In  all  cases  of  middle-ear  suppuration,  during 
which  symptoms  of  meningeal  irritation  or  of  incipi- 
ent sinus  phlebitis  make  their  appearance. 

(8)  Continued  septic  suppuration  in  the  attic,  the 
symptoms  remaining  unchanged  after  removal  of  the 
malleus  and  incus  and  several  months'  energetic  treat- 
ment, even  if  there  are  no  general  symptoms  excepting 
an  offensive  otorrhoea. 

(g)  Pain  in  the  mastoid  process,  developing,  in  cer- 
tain rare  cases  of  connective-tissue  hypertrophy,  in 
osteo-sclerosis,  and  in  osseous  scars  after  the  healing 
of  a  mastoid  operation. 

The  Operation. — A  few  hours  before  the  operation 
the  patient  should  be  given  a  thorough  bath,  the  parts 
within  a  radius  of  three  or  four  inches  of  the  ear 
should  be  carefully  shaved,  and,  if  the  patient  is  a 
man,  the  beard  should  be  removed ;  then  the  whole  side 
of  the  head  and  neck  must  be  energetically  washed 
with  soap  and  water,  rinsed  with  sterilized  water,  and 
rubbed  with  ether  to  remove  all  oily  sub.stances.  The 
ear  is  syringed  with  a  solution  of  iDichloride  of  mer- 
cury (i  to  1,000),  and  a  wet  dressing  of  the  same  is 


696 


MEDICAL    RFXORD. 


[November  13,  1897 


applied  over  the  entire  field  of  operation  until  the  pa- 
tient is  anajsthelized. 

The  antiseptic  dressing  is  now  removed,  and  the  parts 
are  again  cleansed  with  bichloride  and  the  ear  is  tam- 
poned. All  instruments  are  sterilized  by  boiling,  and 
the  hands  and  dress  of  the  operator  and  assistants 
should  receive  the  same  careful  attention  as  is  de- 
manded in  all  surgical  operations.  To  some  all  these 
precautions  may  seem  unnecessary,  but  when  he  be- 
gins a  mastoid  operation  the  surgeon  never  knows 
what  he  may  be  compelled  to  do,  as  through  anoma- 
lous positions  of  the  parts,  or  owing  to  extensive 
necrosis,  the  cranial  cavity  may  be  entered,  either  ac- 
cidentally or  as  he  may  find  it  necessary  to  extend  the 
operation  to  these  parts. 

The  incision  through  the  soft  parts  should  be  made 
from  the  tip  of  the  mastoid  and  carried  upward  in  a 
curved  line,  one-fourth  inch  posterior  to  the  insertion 
of  the  auricle  and  to  its  upper  attachment.  It  is  bet- 
ter to  make  the  cut,  if  possible,  with  one  sweep  of  the 
knife.  This  is  practically  what  is  known  as  Wilde's 
incision,  and  its  value  has  been  greatly  overestimated, 
as  it  is  admissible  in  cliildren  only  when  the  cortex  is 
very  thin  and  may  be  opened  by  firm  pressure  of  the 
knife  or  a  sharp  curette;  or  the  pus  may  itself  find  an 
outlet.  In  the  adult,  however,  experience  has  taught  all 
operators  that  it  is  not  advisable  to  stop  here,  as  the 
cortex  is  too  dense  and  non-permeable.  It  certainly  is 
not  wise  to  do  this  and  delay  to  ascertain  what  further 
may  develop,  and  subject  the  patient  to  a  second  anes- 
thetization and  operation  when  the  whole  work  should 
have  been  completed  at  first.  Dench  states  that  the  di- 
vision of  the  soft  parts  within  the  meatus  over  the  mas- 
toid practically  meets  all  the  indications  of  external 
incision.  Next  elevate  the  periosteum,  pushing  the 
entire  anterior  flap  forward.  The  bleeding  vessels 
should  be  taken  up  with  artery  forceps  or  ligated. 
The  parts  are  held  back  with  retractors  so  that  the 
posterior  and  superior  margins  of  the  bony  canal 
are  distinctly  seen,  and  the  whole  field  of  operation 
is  laid  bare.  The  bone  .should  be  carefully  exam- 
ined for  fistulae  or  carious  spots,  which  if  found  will 
serve  as  a  guide  for  entrance  into  the  bone.  If  none 
is  found  we  proceed  to  open  into  the  antrum,  which  is 
just  behind  the  posterior  margin  of  the  meatus  and 
just  below  its  superior  margin.  Until  entrance  has 
been  gained  to  the  antrum  the  opening  through  the 
cortex  should  never  extend  above  the  superior  wall  of 
the  meatus,  and  the  operator  should  keep  close  to 
the  posterior  wall,  thus  avoiding  the  middle  cranial 
Eossa  and  a  possible  wounding  of  the  lateral  sinus, 
which  may  be  misplaced.  The  cortex  is  best  re- 
moved with  a  broad  chisel  and  mallet,  the  chisel  held 
parallel  to  the  surface  of  the  skull,  and  the  bone  cut 
away  in  thin,  broatl  chips,  the  opening  extending 
inward  and  forward  and  gradually  lessening  in 
size  until  the  antrum  is  reached.  This  never  lies 
less  than  one-half  inch  below  the  surface,  although 
large  pneumatic  spaces  may  be  found  near  the 
surface,  which  may  lead  us  astray  unless  we  are  cau- 
tious. To  prove  it,  bend  a  probe  at  the  tip  and 
pass  it  downward,  forward,  and  inward  for  a  dis- 
tance of  three-fourths  of  an  inch  or  more,  at  which 
depth  it  ^lould  pass  into  the  tympanic  cavity ;  thus 
we  know  that  the  antrum  has  been  reached  and  passed 
through. 

A  free  entrance  to  the  antrum  having  been  gained, 
any  particles  of  bone  or  cholesteatomatous  masses  of 
granulations  must  be  removed,  and  the  opening  to  the 
middle  ear  freely  curetted  and  enlarged  to  give  suffi- 
cient drainage.  We  occasionally  read  of  cases  in 
which,  after  penetration  to  the  extreme  line  of  safety 
(about  five-eighths  of  an  inch),  no  antrum  is  reached 
and  the  operation  is  abandoned.  This  need  never 
happen.     If  we  cut  to  tiie  usual  depth  without  finding 


the  cavity,  we  should  direct  our  canal  more  forward, 
so  as  to  bring  its  apex  over  the  meatus,  when  we  can 
easily  chisel  into  the  attic.  The  membranous  meatus 
may  be  dislodged  from  the  posterior  wall  and  pushed 
forward,  or  the  entire  cartilaginous  meatus  turned  out, 
thereby  making  entrance  to  the  attic  quite  easy.  The 
latter  method  will  apply  to  a  sclerotic  process.  If, 
after  the  antrum  is  entered,  no  pus  is  found,  the  large 
cell  at  the  apex  of  the  mastoid  must  be  particularly 
investigated,  all  carious  and  necrotic  bone  removed 
from  the  mastoid,  and  its  tip  excised  if  carious. 

The  operation  should  be  continued  until  sound  bone 
is  encountered  in  every  direction.  If  the  inner  plate 
is  disea.sed  it  may  be  removed  with  almost  perfect 
safety,  as  an  exposure  of  the  dura  is  not  a  grave  mat- 
ter under  proper  precaution,  whereas  to  leave  carious 
bone  at  this  point  is  very  dangerous.  Exposure  or 
even  a  wound  of  the  lateral  sinus,  either  accidentally 
or  intentionally,  is  not  so  serious  a  matter  as  has  here- 
tofore been  considered.  It  can  be  recognized  by  its 
bluish-gray  color.  If  the  vessel  is  opened  sharp  hem- 
orrhage ensues,  which  if  easy  of  access  may  be  readily 
controlled  by  a  firm  compress  of  iodoform  gauze  held 
by  an  assistant,  when  the  operation  is  proceeded  with 
as  if  this  had  not  happened. 

The  good  effects  of  opening  the  mastoid  antrum 
and  cleansing  the  middle  ear  are  often  manifested 
within  a  few  hours  after  the  operation.  The  pain  and 
temperature  are  both  diminished,  alarming  symptoms 
.subside,  while  the  state  of  the  middle  ear  rapidly  im- 
proves. Subsequent  to  the  operation,  when  the  septic 
suppuration  continues  after  weeks  or  months  of  care- 
ful treatment  there  probably  exists  a  carious  affection 
of  the  tympanic  cavity  or  of  the  ossicula.  If  lumps  of 
epidermis  repeatedly  appear  in  the  irrigating  fluid,  it 
is  certain  that  there  is  a  cholesteatoma  in  the  attic, 
which  indicates  an  operation  on  the  tympanic  cavity; 
this  will  be  described  later. 

The  operation  being  completed,  dressing  the  wound 
is  in  order.  I  insert  into  the  antrum  a  drainage  tube 
and  pack  loosely  around  it  dry  iodoform  gauze,  but 
not  the  external  wound,  merely  keeping  the  edges 
separated  by  a  strip  of  gauze.  A  tampon  is  placed 
in  the  meatus  and  the  whole  well  covered  with  steri- 
lized gauze  and  cotton.  With  a  favorable  course  of 
healing  it  is  sufficient  to  change  the  bandage  every 
five  or  six  days.  If  the  temperature  does  not  exceed 
101°  F.  at  any  time  during  the  first  five  or  six  days, 
or  if  elevated  and  not  persistent,  there  will  be  no 
necessity  of  changing  the  dressing.  When  it  is  changed 
for  the  first  time,  the  wound  and  canal  should  be  irri- 
gated with  a  sublimate  solution  (i  to  8,000  or  10,000), 
and  the  wound  cavity  examined  carefully  for  remain- 
ing granulations  and  roughness,  which  if  found  must 
be  scraped  away. 

If  there  are  a  return  of  pain  after  tlie  operation,  in- 
creased temperature,  and  much  septic  discharge,  which 
would  be  indicated  by  a  rapid  soaking  of  the  bandages 
and  a  fetid  odor,  a  daily  change  of  dressing  is  indicated. 
So  long  as  the  secretion  is  ill-smelling  I  use  sublimate 
solution  in  the  strength  indicated  above.  After  the 
bad  smell  disappears  I  use  a  one-per-cent.  boric-acid 
solution.  This  must  be  continued  until  suppuration 
ceases.  The  supposition  of  Kiister  and  Bergmann, 
that  syringing  out  tlie  operation  cavity  should  be 
avoided,  has  not  been  sustained  by  the  profession.  So 
long  as  there  is  suppuration  in  the  tympanic  cavity 
the  communication  between  it  and  the  w'ound  must  be 
kept  open  for  free  drainage,  and  only  when  there  is  a 
certainty  that  suppuration  has  ceased  may  the  wound 
be  allowed  to  heal.  Occasionally  there  remains,  after 
the  most  careful  treatment,  a  sinus  in  the  mastoid  proc- 
ess connected  with  an  abscess  cavity  which  requires 
a  second  operation.  The  duration  of  after-treatment 
varies  from  three  or  four  weeks  to  one  or  two  years 


November  13,  1897] 


MEDICAL    RECORD. 


697 


before  suppuration  ceases,  and  sometimes  cannot  be 
controlled  no  matter  what  is  done. 

It  is  wonderful  what  beneficial  effect  the  operation 
often  has  upon  the  general  system,  which  may  be 
readily  understood  when  we  realize  that  the  blood  is 
kept  constantly  in  a  more  or  less  septic  condition. 

Since  189 1  the  mastoid  operation  described  above 
has  been  the  typical  one,  but  the  collective  experience 
in  aural  surgery  for  the  last  few  years  has  shown  that 
it  proves  insufficient  in  many  cases,  and  so  search  for 
a  more  efTectual  process  has  developed  several  meth- 
ods. In  189 1  Stacke,  of  Erfurt,  Germany,  made  known 
a  new  operation  in  chronic  cases,  based  upon  the  sur- 
gical principles  involved  in  the  treatment  of  suppura- 
tions within  rigid-walled  cavities;  namely,  upon  the 
complete  and  free  laying  open  of  the  cavity,  so  that  it 
can  be  curetted,  tamponed,  and  treated  surgically,  and 
the  operator  not  be  compelled  to  satisfy  himself  with  a 
more  or  less  imperfect  irrigation.  The  method  of 
Stacke  is  practically  as  follows:  The  cutaneous  inci- 
sion is  made  a  little  ditferently  than  has  been  described, 
the  upper  part  being  kept  closer  to  the  auricle  and 
carried  well  around  to  the  front.  The  lower  end  must 
also  cur\-e  more  forward  and  extend  to  the  tip  of  the 
process,  the  cut,  as  it  were,  circumscribing  the  auricle. 
The  bone  being  bared,  the  membranous  meatus  is  sep- 
arated from  the  posterior  and  superior  walls,  and,  its 
attachment  internally  being  cut,  is  in  its  entirety 
shelled  out  of  the  osseous  canal.  With  a  small  gouge 
or  Bench's  cutting  forceps  the  most  medial  portion  of 
the  superior  wall  of  the  osseous  meatus  (lower  lateral 
wall  of  the  attic)  is  cut  away,  and,  if  present,  the 
malleus  and  incus  are  removed.  The  superior  wall 
is  to  be  chiselled  away  near  the  drum  insertion  till  a 
bent  sound  touching  the  tegmen  tympani  meets  w'ith  no 
resistance  on  being  drawn  outward.  The  probe,  as  a 
guide,  is  then  turned  toward  the  antrum,  and  the  pos- 
terior wall  of  the  meatus  chiselled  away  till  that  cavity 
is  freely  opened  up.  In  this  way  Stacke  converts  attic, 
tympanum,  antrum,  and  meatus  into  one  large  cavity. 
After  being  cleansed,  the  auricle  is  replaced  and  su- 
tured; the  lining  membrane  of  the  osseous  canal  is 
split  and  pressed  as  far  back  into  the  enlarged  cavity 
as  possible  by  the  iodoform  gauze.  All  subsequent 
treatment  is  done  through  the  meatus. 

This  operation  proving  extremely  difficult  and  un- 
satisfactory, other  methods  were  suggested,  and  now 
what  may  be  known  as  the  Schwartze-Hergmann- 
Stacke  operation  has  been  quite  generally  adopted.  My 
experience  has  taught  me  that  it  is  the  ideal  one 
in  all  chronic  conditions  which  have  resisted  cure 
after  the  ossicula  have  been  removed.  I  now  rarely 
perform  any  other,  and  am  exceedingly  happy  with 
the  results  obtained.  It  is  much  quicker,  easier,  and 
safer  than  the  Stacke  operation,  and  is  done  as  follows: 
The  incision  over  the  mastoid  and  the  entrance  to  the 
antrum  is  made  as  in  the  original  mastoid  operation. 
The  membranous  meatus  is  dislodged  as  in  the  Stacke, 
and  held  well  for^vard  by  a  retractor.  The  operative 
field  now  shows  the  posterior-superior  osseous  canal, 
the  antrum,  and  a  bridge  of  bone  separating  them. 
This  bridge  is  now  removed  by  rongeur  forceps  and 
chisel,  the  section  being  triangular  in  shape,  the  apex 
at  the  neck  of  the  antrum.  Thus  the  antrum,  tympa- 
num, and  meatus  will  be  converted  into  one  large 
cavity.  Care  must  be  taken  at  this  point  not  to  wound 
the  facial  and  semicircular  canals  which  lie  directly 
across  from  this  point.  As  a  protection,  if  a  sound 
is  passed  through  the  antrum  into  the  middle  ear,  or, 
if  not  possible  in  that  direction,  from  the  middle  ear 
as  far  as  possible  into  the  attic,  and  we  confine  our 
operating  to  that,  we  shall  be  within  safe  limits.  A 
wound  in  the  external  semicircular  canal  is  more 
unlikely  to  occur  than  one  of  the  facial  nerve. 

As  much  of  the  bone  should  be  removed  as  is  com- 


patible with  safety,  so  as  to  make  the  antrum  and  attic 
as  accessible  as  possible  from  the  external  canal. 
There  must,  however,  be  a  ridge  remaining  between 
the  meatus  and  antrum.  In  this  operation  I  find  the 
dental  engine  a  most  useful  adjunct.  The  posterior 
membranous  canal  is  now  split  outwardly  to  the  con- 
cha as  in  the  Stacke,  and  pressed  back  as  far  as  possi- 
ble into  the  enlarged  cavity  and  held  in  place  by 
tamponing. 

According  to  Stacke,  the  tamponing  of  the  mem- 
branous meatus  into  the  artificial  opening  has  a  double 
advantage:  (i)  it  secures  the  formation  of  a  persistent 
skin-covered  communication  between  the  antrum  and 
meatus;  (2)  it  is  a  skin  transplantation,  from  which 
the  formation  of  epidermis  over  the  entire  cavity  can 
take  place.  The  better  way,  I  believe,  is  to  suture  the 
wound  over  the  mastoid  and  get  primary  union  if  pos- 
sible, and  do  the  entire  treating  through  the  meatus. 
If  all  goes  well  the  dressings  are  to  remain  five  or 
six  days,  after  which  daily  tamponing  must  be  most 
carefully  followed  out. 

The  granulations  must  be  kept  down  and  the  cavity 
kept  as  freely  accessible  and  of  the  same  size  as  just 
after  the  operation.  Even  when  the  utmost  care  is 
taken,  minute  necrotic  pieces  of  bone  become  sur- 
rounded by  granulations,  and  small  fistulous  canals 
are  formed  leading  to  these  dead  pieces,  around  which 
the  suppuration  continues  even  after  it  has  entirely 
ceased  elsewhere. 

The  duration  of  the  after-treatment  varies  in  these 
cases  also,  but  is,  on  an  average,  as  experience  has 
shown,  several  months  shorter  than  by  the  old  method, 
and  the  cure  is  much  more  permanent.  The  indica- 
tions for  this  operation  are  about  the  same  as  for  the 
ordinary  mastoid. 

215  Jefferson  Avence. 


TRAUMATIC     PARALYSIS     OF    THE    UPPER 
EXTREMITIES.' 

By   JOHN    1'.    ERDMANN,    M.D., 

ATTENDING  SURGEON  To  ST.  MARK-'s  AND  GOUVl 


Considered  from  a  medico-legal  standpoint,  these 
lesions  are  of  sufficient  importance  to  entitle  them  to 
more  elaborate  consideration  than  can  be  found  in  the 
text-books  of  the  present  day.  The  literature  is  sparse, 
possibly  on  account  of  these  conditions  having  arisen 
less  frequently  before  the  modern  operating-tables 
came  into  vogue,  as  a  large  number  of  the  traumatic 
paralyses  classed  as  postoperative  or  ancesthetic  pa- 
ralyses are  due  to  the  arms  of  the  patients  being  al- 
lowed to  fall  on  the  sharp  or  narrow  edge  of  these 
tables,  and  as  a  result  pressure  takes  place  and  paral- 
ysis of  certain  muscles  or  groups  of  muscles  follows. 

In  a  recent  article  entitled  ''  Anaesthesia  Paralysis,"  " 
Dr.  H.  J.  Garrigues  presents  histories  of  fourteen 
cases,  of  which  five  occurred  in  his  own  practice.  He 
also  quotes  Kron  as  stating  that  elevation  of  the  arm 
backward  and  outward  causes  the  median  nerve  to  be 
stretched  over  the  head  of  the  humerus,  and,  as  this  is 
a  position  of  the  arms  favored  by  some  antesthetists, 
it  can  readily  be  seen  to  form  one  of  the  causes  of 
these  conditions. 

Biidinger,  also  quoted  in  the  same  article,  states 
that  a  frequent  cause  of  these  paralyses  is  pressure, 
occurring  between  the  clavicle  and  the  anterior  sur- 
face of  the  first  rib,  on  the  brachial  plexus  as  it  emerges 
between  the  scaleni  in  the  neck.  It  would  appear  to 
the  author  that  frequently  in  these  anesthetic  cases, 

'  Read  by  title  before  the  New  Vork  State  Medical  Associa- 
tion, October  13,  1897. 

'Journal  of  the  American  Medical  Association,  January,  iSg7. 


698 


MEDICAL    RP:C()RD. 


[November  13,  1897 


apart  from  the  position  of  the  arms  and  forearms, 
trouble  is  caused  by  the  ansesthetizer  in  one  or  more 
of  the  following  ways:  In  attempting  to  prevent  the 
dropping  of  the  inferior  maxilla  the  fingers,  well  ab- 
ducted, are  very  often,  particularly  in  beginners, 
placed  very  firmly  along  the  neck,  so  as  to  give  a  strong 
brace  for  the  index  in  supporting  the  angle  of  the 
jaw;  by  this  means  one  or  more  of  the  fingers  press 
upon  the  fifth,  sixth,  and  seventh  cervical  nerves  (these 
being  the  most  frequently  involved),  near  the  exit  be- 
tween the  scaleni,  and,  as  frequently  is  the  case,  the 
head  is  rotated  to  one  side  and  the  nerve  or  nerves 
are  compressed  between  the  fingers  and  the  vertebrae. 
Again,  as  has  often  been  observed  by  the  writer,  the 
anaesthetist  will  be  found  leaning  or  bearing  his 
weight  upon  the  patient's  arm  or  forearm,  especially 
so  when  the  patient's  arms  are  drawn  above  the  head, 
thus  causing  pressure  of  the  nerves  to  take  place  be- 
tween the  humerus  of  the  patient  and  the  anesthetist's 
arm  or  between  the  humerus  and  the  operating-table. 
Again,  some  of  the  assistants,  in  their  overassiduous 
endeavors  to  hold  a  patient  down  during  the  stage  of 
excitement,  produce  the  trauma  either  by  firmly  encir- 
cling the  arm  with  the  hand  and  thus  compressing  the 
nerves,  or  by  holding  the  arm  down  against  the  sharp 
or  narrow  edges  of  the  table.  The  author  has  on 
several  occasions  seen  one  of  these  assistants  throw 
his  entire  weight  upon  the  upper  extremity  and  chest, 
using  the  trunk  of  his  body  to  hold  down  one  arm, 
and  by  reaching  across  the  patient's  chest  hold  down 
the  arm  of  the  opposite  side  with  his  hands. 

Recently  a  case  of  this  class,  i.e.,  of  postoperative 
paralysis,  was  referred  to  me  with  the  following  his- 
tory: 

Case  I. — Male,  aged  about  thirty-six,  bartender  by 
occupation,  had  his  forearm  cut  by  the  explosion  of  a 
siphon  of  seltzer  on  June  10,  1897.  The  injury  was 
at  the  junction  of  the  lower  and  middle  thirds  of  his 
forearm,  and  cut  the  flexors  of  his  little,  ring,  and 
middle  fingers,  possibly  also  that  of  the  flexor  carpi 
ulnaris.  No  attempt  was  made  to  unite  the  severed 
tendons,  and  the  injur)'  was  healed  in  three  weeks. 
The  only  impairment  of  function  was  in  the  fingers 
mentioned.  The  thumb  and  index  finger  were  unin- 
jured, as  the  patient  stated  that  he  used  them  con- 
stantly. 

On  July  19th  he  was  operated  upon  with  a  view  to 
uniting  the  severed  tendons.  An  incision  eight  inches 
in  length  was  made  on  the  ulnar  border  of  the  fore- 
arm, and  as  far  as  can  be  judged  at  the  present  time 
with  perfect  success  as  far  as  union  of  the  divided 
tendon  is  concerned. 

September  5th,  he  was  referred  to  me,  and  exami- 
nation revealed  a  complete  paralysis  of  all  the  muscles 
of  the  forearm.  The  only  motion  of  the  forearm  re- 
tained was  feeble  supination,  and  that  was  demon- 
strated as  being  due  to  the  action  of  the  biceps. 

The  operator  in  the  case  was  an  able  and  careful 
surgeon,  and  the  incision  certainly  could  not  have  im- 
plicated any  but  the  ulnar  nerve.  That  this  lesion 
could  not  have  been  an  ascending  neuritis  entirely,  is 
evident  from  the  fact  that  the  function  of  the  thumb 
and  index  and  of  all  extensors  was  perfect  previous  to 
the  operation  ;  and  that  these  functions  were  abolished 
shortly  after  the  operation  points  to  a  pressure  trauma 
of  operative  origin,  possibly  to  the  use  of  an  Esmarch 
bandage  for  a  bloodless  operation,  in  addition  to  the 
table  pressure  by  reason  of  the  extension  of  the  fore- 
arm and  arm. 

In  addition  to  the  postoperative  or  so-called  anres- 
thetic  paralyses,  it  happens  frequently  enough  that  the 
surgeon  sees  cases  of  paralysis  following  dislocations 
of  the  shoulder,  especially  when  not  reduced  for  some 
time;  cases  of  fracture  of  the  humerus,  in  which  the 
musculo-spiral  is  involved  in  the  callus  or  in  fibrous 


tissue,  or  by  stretching  of  the  nerve  over  an  angular 
deformity;  contusions  of  the  shoulder  followed  by 
deltoid  paralysis  due  to  the  involvement  of  the  cir- 
cumflex, etc. ;  paralyses  due  to  pressure  in  the  axilla 
caused  by  the  use  of  crutches  or  by  tumors,  etc. ;  paraly- 
sis caused  by  sleeping  with  the  head  resting  upon  the 
arm  or  forearm ;  and,  as  in  one  case  recently  seen  by 
the  author,  implication  of  the  ulnar  ner\'e  in  a  marks- 
man who  used  his  elbow  as  a  rest  while  shooting  in 
the  prone  position  at  the  Creedmoor  rifle  range. 

Cask  II. — Complete  paralysis  of  the  upper  extrem- 
ity following  unreduced  dislocated  shoulder  of  three 

weeks'  standing.     D.   S ,  about  twenty-two  years 

of  age,  sustained  an  injury  to  his  left  shoulder  while 
bicycling  at  Liberty,  N.  Y.  .\  diagnosis  of  disloca- 
tion of  the  shoulder  was  made  and  the  ordinary  treat- 
ment applied.  Twenty-one  days  after  the  injur}'  he 
was  referred  to  me,  and  upon  examination  a  subcora- 
coid  displacement  was  found  to  exist,  which  appar- 
ently was  rather  firmly  retained  by  adhesions.  He 
complained  of  inability  to  use  the  arm,  considerable 
pain  in  his  elbow,  and  tingling  with  numbness  of  the 
fingers,  particularly  those  supplied  by  the  ulnar  nerve. 
A  complicating  pressure  neuritis  was  diagnosticated, 
and  the  possibilities  of  paralysis  were  told  the  patient. 
As  will  be  seen,  this  was  a  wise  precaution. 

After  the  patient  was  anesthetized  in  my  office,  the 
shoulder  was  reduced  with  some  difficult)'.  Within 
ten  days  after  the  reduction  there  was  a  total  paraly- 
sis of  the  entire  arm  and  forearm,  with  rapid  atrophy 
particularly  marked  in  the  muscles  of  the  hand.  Elec- 
trical reaction  was  retained  both  to  the  faradic  and 
galvanic  currents,  but  was  finally  lost.  The  return 
of  reaction  to  the  galvanic  current  was  manifested 
about  twenty-one  days  after  its  loss  and  within  six 
weeks  the  return  of  contraction  with  the  faradic  was 
observed.  The  patient  left  my  care  about  eight  months 
after  the  injury  was  received,  with  an  arm  and  forearm 
considerably  smaller  than  those  of  the  opposite  side, 
but  with  restored  function  in  all  of  the  muscles. 

Case    III.  —  Complete    upper-arm    paralysis   from 

contusion.     Mr.  R ,  track  inspector,  was  struck  by 

the  Empire  Express  and  was  thrown  about  twenty 
feet.  He  was  referred  to  me  two  days  later  by  Drs. 
fiatti  and  Thompson,  of  Greenwich,  Conn.  Upon 
examination  he  was  found  to  have  sustained  a  com- 
pound fracture  of  each  of  the  bones  of  the  right  fore- 
arm near  the  wrist,  and  a  simple  one  of  the  ulna  at  its 
middle.  Drs.  Piatti  and  Thompson  had  made  an  ex- 
cellent skiagraph,  which  showed  the  latter  fracture 
very  distinctly.  In  addition,  the  entire  right  shoulder 
and  right  half  of  his  thorax  were  ecchymosed.  The 
fractures  were  treated  as  usual  in  these  cases,  and 
complete  repair  was  observed  in  the  sixth  week.  It 
was  noted  at  this  time  that  the  deltoid,  which  formerly 
was  exceptionally  well  developed,  had  atrophied  to  a 
very  .small  and  useless  mass  of  tissue,  allowing  the 
shoulder  to  drop  so  that  it  was  mistaken  for  a  disloca- 
tion. He  was  again  referred  to  me,  and  in  addition 
to  the  deltoid  atrophy  we  found  a  complete  paresis  of 
the  entire  upper  arm.  A  cure  was  obtained  in  about 
six  months  in  this  case. 

Case    IV. —  Musculo-spiral    paralysis  following    a 

fracture  of  the  humerus.     \V.  K ,  aged  thirty-nine, 

driver,  while  attempting  to  check  a  runaway  on  Sep- 
tember 2,  1S96,  was  knocked  down  and  sustained  a 
fracture  of  his  left  humerus  about  the  junction  of  the 
lower  and  middle  thirds.  He  came  under  my  care  on 
November  23d,  witii  a  history  of  paralysis  of  his  lower- 
arm  muscles,  etc. 

Upon  examination  it  was  found  that  the  fragments 
had  united  without  the  formation  of  any  excess  callus, 
but  with  a  slight  angular  deformity,  the  lower  fragment 
being  forward.  In  examining  the  functions  of  the 
wrist  and  fingers  it  was  noted  that  extension  was  abol- 


November  13,  1897] 


MEDICAL    RECORD. 


699 


ished,  with  the  exception  of  extension  of  the  distal  and 
mid  phalanges  of  the  index,  middle,  ring,  and  little 
fingers.  This  naturally  was  ascribed  to  the  action  of 
the  lumbricales  and  interossei.  Supination  was  lost, 
except  to  a  slight  degree  obtained  by  the  action  of  the 
biceps.  He  complained  of  tingling  in  the  region  of 
the  radial-nerve  supply,  numbness  of  the  fingers,  and 
some  pain  in  the  course  of  the  nerve. 

Operation  was  advised  to  release  the  musculo-spiral, 
and  accepted.  November  24th,  with  the  patient  under 
ether,  the  musculo-spiral  was  cut  down  upon,  and  in- 
stead of  being  found  in  a  bed  of  callus  it  was  found 
to  be  compressed  by  a  dense  band  of  fibrous  tissue 
binding  it  over  the  angle  formed  by  the  vicious  union. 
The  angle  of  vicious  union  being  so  slight,  refracture 
was  deemed  inadvisable,  and  chiselling  away  the  point 
of  bony  pressure  was  resorted  to.  This  patient  was 
discharged  with  good  function  in  the  previously  para- 
lyzed muscles  about  six  weeks  after  the  operation. 

Diagnosis,  as  a  rule,  is  an  easy  matter.  The  his- 
tory of  an  injury  with  a  following  loss  of  power  and 
atrophy  in  one  or  more  muscles  or  a  part  of  the 
extremity,  with  tingling,  numbness,  shooting  pains, 
sometimes  loss  of  sensation  in  certain  areas,  and  fre- 
quently cedema  or  swelling  of  the  extremity  or  fingers 
—  all  point  to  traumatic  paralysis. 

Prognosis  usually  is  good,  but  it  may  require  eight 
or  twelve  months  for  a  return  of  proper  functions,  while 
the  return  of  power  as  it  existed  before  injury  may 
take  from  one  to  two  years.  If  the  patient  is  placed 
at  work  as  soon  as  voluntary  muscle  contractions  re- 
turn it  will  assist  very  materially  in  bringing  about  a 
rapid  recovery.  The  mere  fact  of  loss  of  reaction  to 
galvanism  after  loss  to  faradism  need  not  provoke  an 
unfavorable  prognosis,  as  this  condition  usually  abates 
within  a  few  weeks. 

Treatment  resolves  itself  into  the  use  of  strychnine 
and  potassium  iodide  internally;  massage  from  one 
stance  weekly  to  a  se'ance  daily ;  the  use  of  the  faradic 
and  galvanic  currents,  as  indicated  by  the  return  of  re- 
action of  degeneration  ;  and  a  support  to  the  extremit}', 
particularly  to  overcome  the  possibility  of  stretching 
that  will  take  place  in  one  set  of  muscles  (the  para- 
lyzed ones)  at  the  expense  of  the  other,  as  by  the  use  of 
a  palmar  splint  to  prevent  wristdrop,  etc.  The  use  of 
a  splint  will  also  be  found  to  aid  materially  in  the 
return  of  power  in  the  paralyzed  muscles.  The  use 
of  artificial  muscles  cannot  be  too  strongly  com- 
mended; in  two  of  the  reported  cases  the  writer  had 
ordinary  dress  hooks  sewed  upon  a  leather  glove  of  the 
Dent  or  Fowne  variety,  a  hook  sewed  upon  each  of 
the  fingers  of  the  glove  corresponding  to  the  paralyzed 
fingers,  and  a  set  of  hooks  above  the  wrist  in  direct 
line  of  traction  of  the  tendons;  then  ordinary  elastic 
bands  were  hooked  on,  until  a  slight  degree  of  over- 
tension  was  obtained.  This  glove  was  worn  in  the 
daytime,  and  at  night  the  splint  was  applied. 

149  West  Forty-Fourth  Street. 


Gastro-Intestinal  and  Hepatic  Relations  of  Gout. 
— I.  Gout  is  a  definite  disease  to  which  certain  indi- 
viduals are  predisposed,  but  which  depends  for  its 
development  upon  causes  largel}'  unknown.  2.  Lazi- 
ness and  full  nitrogenous  diet  and  the  use  of  fer- 
mented liquors  predispose  to  the  disease.  3.  So- 
called  lithx'mia,  as  the  term  is  popularly  applied,  is 
not  gout,  but  is  an  auto-intoxication  depending  upon 
gastro-intestinal  and  hepatic  derangements.  4.  The 
diet  in  gout  should  be  largely  free  from  nitrogenous 
substances.  5.  The  diet  in  lithjemia  must  be  ascer- 
tained by  a  careful  study  of  the  primarj'  digestion,  the 
urine,  and  the  general  health  of  the  patient,  but  a 
nitrogenous  diet  is  often  the  most  satisfactory  one. — 
Charles  G.  Stockton. 


ALCOHOLISM       IN     WOMEN  —  ITS      CAUSE, 
CONSEQUENCE,  AND    CURE." 

By   AGNES   SPARKS,    M.D., 

BROOKLYN,   N.   V. 

Alcoholism  in  women  has  heredity  as  a  genetic  factor 
to  a  lesser  degree  than  in  men.  Departures  from  an- 
cestral health  find  their  entailment  in  the  gentler  sex 
more  often  along  the  line  of  other  and  less  complex 
neuroses. 

Alcoholism  in  women  presents  somatic  factors  in 
causation  in  larger  measures  than  in  men.  The  mis- 
taken ethics  of  a  social  code  that  impels  to  accept,  all 
too  often,  the  proffered  poison,  and  so  tend  steadily 
down  to  a  disturbed  physique  that  involves  structural 
impairment  and  a  badly  crippled  morale,  does  not  ob- 
tain so  largely  among  them. 

Apart  from  the  frequency  with  which  alcohol  is 
used  to  spur  flagging  energy,  to  obtund  distressful 
feeling,  or  bring  oblivion  from  cark  and  care,  probably 
the  genetic  condition  most  often  met  with  is  one  in- 
volving painful  performance  of  her  special  function. 
The  average  woman  finds  this  a  time  of  discomfort 
more  or  less  pronounced,  to  relieve  which  rum  in  some 
form  is  used — a  heritage  of  tradition  both  in  precept 
and  practice  unsafe — with  a  result,  just  as  in  the  per- 
nicious plan  of  giving  opiates  at  these  periods,  of  in- 
ducing a  recurring  condition  of  rise  and  fall  as  regards 
well  being  until  the  interim  is  fully  bridged,  and  a 
state  of  more  or  less  steady  inebriety  ensues. 

The  most  potent  cause  is  twofold.  First  in  fre- 
quency is  a  neurasthenic  condition  due  to  lack  of  nu- 
trition and  the  wear  and  worry  of  domestic  life  and 
social  demands — an  exhaustion  for  which  relief  is 
mistakenly  sought  in  the  transient  aid  of  alcohol,  all 
unaware  or  unmindful  of  the  vital  fact  that  its  taking 
involves  large  risk  of  creating  a  morbid  condition  that 
often  finds  expression  in  inebriety. 

The  other  factor  is  the  pain  and  unrest  incident  to 
disorders  of  their  sex,  for  which  solace  is  found  in  the 
anesthetic  and  paralyzing  effects  of  alcohol — an  effect 
that  with  startling  and  sorrowful  frequency  ends  in 
this  toxic  disease. 

Inebriety  from  a  fondness  for  alcohol /c"^  ^f — vicious 
indulgence — obtains  less  often  in  women.  Why  this 
is  so  goes  without  saying,  and  so  this  neurosis  in  them 
presents  the  strongest  possible  proof  that  its  origin 
lies  in  perturbed  physical  conditions;  in  fine,  that  it 
is  a  disease:  no  mere  moral  obliquity,  as  many— well 
meaning,  but  mistaken — would  have  us  believe. 

The  consequence  of  alcoholism  in  women  is  less 
promptly  patent  than  in  men.  Albeit  none  the  less 
sure,  it  obtains  more  slowly.  This  from  varied  causes 
that  act  over  larger  area  and  with  greater  energy  in 
men.  In  the  earlier  stages  of  inebriety  in  those  cases  in 
which  volition  is  not  entirely  ended,  a  peculiar  shrink- 
ing from  publicity  protects  some  women  against  the 
objective  symptoms  noted  among  men  at  a  like  period 
of  their  disease;  but  with  increase  of  toxic  power  due 
to  constant  or  recurrent  taking  this  protective  shield 
gives  way,  and  a  well-marked  consensus  of  symptoms, 
psychical  and  somatic,  lays  bare  the  varied  ravages  of 
the  disease.  Among  them  the  latter  lead,  and  early 
and  often  those  along  gastric  lines.  To  detail  is  not 
needed;  but — so  well  masked  maybe  the  true  status 
— in  every  case  of  marked  disorder  in  this  regard,  if 
not  yielding  to  the  usual  remedies,  the  doctor  should 
make  bold  to  question  the  patient,  direct,  as  to  rum 
being  a  factor  for  ill. 

With  progress  of  the  toxic  force  widespread  disturb- 
ance of  functions  presents — scarcely  any  escape — and 
as  the  disorder  deepens   into  structural  change  the 

'  Read  before  the  New  York  Medico-l-egal  Society,  October 
20,  1S97. 


700 


MEDICAL    RECORD. 


[November  13,  1897 


signs  of  health  infraction  become  more  pronounced 
and  prolonged. 

On  ovulation  the  alcoholic  impress  is  one  of  de- 
ranged rather  than,  as  in  opium  inebriety,  suspended 
action,  and  so  it  comes  to  pass  unfortunately  that  the 
average  female  alcoholist  is  not  sterile.  Just  the  re- 
verse obtains  with  the  woman  morphinist,  and  it  is  one 
of  the  mysteries  of  a  divine  economy  that  this  benefi- 
cent law  does  not  extend  the  same  wholesome  result  in 
her  alcoholic  sister,  and  so  shut  off  in  large  measure  a 
diseased,  depraved  progeny  that  tends  to  curse  ever)' 
community  with  a  physical  and  moral  blight,  the  ex- 
tent of  which  is  beyond  compute,  and  with  which  no 
other  agent  for  ill  can  compare. 

Sequelling  visceral  disturbance  comes  psychical  de- 
rangement, ranging  from  slightly  erratic  outbreaks  to 
furious  maniacal  outbursts,  or  a  more  or  less  steadily 
stupid  condition.  The  latter  is  less  frequent  than  in 
men,  the  inebriet)'  of  women  more  often  being  peri- 
odic. While  the  signs  of  psychical  ill-health  may  be 
less  gross  than  in  men,  they  just  as  surely  show  the 
fell  power  of  this  poison  to  distort  and  destroy  along 
higher  lines  of  life,  and  transform  many  a  winsome 
woman  into  one  far  removed  from  her  gentle  self  and 
deserving  the  largest  measure  of  sympathy  and  relief. 

The  prognosis  of  alcoholism  in  women  eligible  for 
treatment  is  better  than  in  men.  Barring  advanced 
cases,  the  outlook  for  recovery  is  hopeful  to  an  e.xtent 
that  warrants  placing  every  patient  under  proper  care. 
The  betterment  gained  by  well-directed  treatment  in 
some  cases  is  surprising,  and  were  this  fact  well 
known,  would,  it  is  safe  to  say,  lead  to  a  larger  opti- 
mism among  medical  men  as  to  cure.  Risk  that  the 
disease  will  recur  is  large.  This,  however,  by  persis- 
tent treatment,  favoring  environment,  and  watchful 
care,  may  be  brought  largely  to  a  minimum,  and  many 
a  life  seemingly  given  over  to  a  rum  bondage  till 
death  can  be  reclaimed. 

The  treatment  of  alcoholism  in  women,  to  be  most 
effective,  must  be  twofold — curative  and  preventive. 
Touching  the  former,  modern  medicine  has  made  such 
advance  as  places  present  treatment  much  in  the  van 
of  everything  that  has  been.  As  a  valued  psychical 
adjunct,  the  doctor  must  be  firmly  impressed  with  a 
belief  in  his  power  to  help,  and  the  impress  of  this 
opinion  must  be  made  on  the  patient  to  the  full  if  the 
maximum  of  good  would  be  gained.  A  supreme  con- 
fidence along  this  line  is  an  immense  factor  in  reach- 
ing the  goal  desired,  and  so  far  as  concerns  non- 
coercive care  is  almost  a  sine  qua  noii. 

The  remedial  agents  of  greatest  worth  in  warring  on 
this  disease  are  strychnine,  arsenic,  electricity,  and 
hypnotism.  But  before  any  of  them  can  be  made  of 
most  service  certain  untoward  conditions  claim  at- 
tention. The  gastro-alvine  status  must  be  righted, 
and  nothing  will  better  do  this  than  a  mild  nightly 
mercurial  and  a  morning  aperient  water.  Uterine 
luxations  should  be  reduced,  ovarian  discomfort  must 
be  ended,  and,  unless  removal  be  called  for,  galvanism 
holds  out  the  largest  promise  for  good. 

The  question  of  abrupt  or  gradual  rum  quitting  will 
present.  Case  conditions  must  decide.  If  possible, 
the  former  should  obtain.  .\s  a  rule,  fear  of  ill  result 
is  unfounded,  and  the  effect  on  the  patient's  morale 
will  be  good.  If  sudden  stopping  be  deemed  unwise, 
let  the  usual  stimulant  be  discarded,  and  alcohol  in 
like  amount  be  given  with  milk,  to  be  ended  as  soon 
as  possible;  or,  better  still,  the  compound  tincture  of 
cinchona  combined  with  nux  vomica  and  tincture  of 
gentian,  or  the  mineral  acids. 

The  way  for  the  main  treatment  having  been  paved, 
strychnine  leads  the  list.  There  have  been  such  a 
consensus  of  opinion  and  such  a  volume  of  fact  to  this 
effect  as  cannot  be  gainsaid  or  set  aside.  It  is  best 
given  subcutaneously,  in  the  form  of  nitrate,  one-thir- 


tieth to  one-twentieth  of  a  grain  thrice  daily.  As  a 
rule,  it  will  be  best  not  to  exceed  the  latter  dose,  and 
if  strychninism  presents  a  decrease  is  in  order.  The 
average  alcoholic  is  very  tolerant  of  this  drug;  this 
fact  should  not  be  forgotten.  These  full  doses  may 
be  given  a  month,  if  well  borne;  after  that,  one- 
sixtieth  to  one-fortieth  of  a  grain  will  suffice,  and  with 
or  without  arsenic  should  be  given  for  months. 

Arsenic  in  inebriety  is  not  given  the  credit  it  de- 
serves. It  is  a  miiltum-in-pano  remedy — a  general 
tonic,  a  non-neuralgic,  an  antimalarial,  a  nutrition 
promoter;  in  fine,  an  all-round  roborant,  admirably 
adapted  to  the  cure  of  this  disease.  Fowler's  solution 
is  best — four  to  eight  drops  after  each  meal.  It  may 
sequel  the  strychnine  giving,  and  not  be  pushed  beyond 
slight  face  puffing.  It  should  be  long  continued — in 
this  is  its  chief  value — four  to  twelve  months. 

Electricity  is  another  remedy,  the  worth  of  which  in 
the  treatment  of  inebriety  is  much  more  than  the  aver- 
age doctor  will  admit.  Ignorance  of  its  value  comes 
from  inexperience.  Study  and  practice  of  this  valued 
aid  must  be  had  if  one  would  be  well  equipped. 
There  are  few  facts  in  medicine  better  fixed  than  the 
power  of  galvanism  to  raise  the  lowered  nerve  tone 
and  relieve  the  varied  neuralgias  so  common  to  this 
disease.  Constant-current  se'ances,  ten  to  twenty  min- 
utes each,  may  be  given  daily  for  weeks,  and  a  spe- 
cially opportune  time,  when  sleep  is  impaired,  is  at 
night.  When  used  for  neuralgia,  each  of  the  attacks, 
be  they  frequent  or  few,  must  be  met  promptly.  The 
faradic  current,  while  less  widely  useful  than  the  con- 
stant, may  be  given  dail}%  twenty-minute  seances,  gen- 
eral faradization,  as  a  tonic  and  to  remove  the  pecu- 
liar unrest — "  fidgets" — noted  in  some  cases. 

Hypnotism  acts  best  in  periodic  cases.  Seances 
should  be  had  between  drinking-bouts.  No  case 
should  be  deemed  unyielding  till  several  attempts 
have  proved  futile.  It  is  very  effective  in  some  tem- 
peraments. The  condition  of  each  case  must  govern 
as  to  time  and  extent  of  seances.  To  a  minor  degree 
most  women  can  be  brought  under  hypnotic  influence 
if,  as  we  have  urged,  the  physician  be  largely  optimis- 
tic as  to  treatment  and  will  stamp  the  impress  of  that 
optimism  on  the  patient.  In  ever)'  case  effort  to  this 
end  should  be  made.  Despite  adverse  opinion,  hyp- 
notism is  sometimes  an  immense  power  for  good. 

We  have  noted  the  biggest  guns  in  the  battle  with 
this  disease.  Minor  ones  are  of  value.  Full  feeding 
ranks  first;  generous  diet,  with  cod-liver  oil  and  malt 
if  need  be,  must  be  given.  If  patients  be  pallid  or 
heart  action  weak,  steel  and  strophanthus  should  be 
used.  The  Turkish  Isath  fills  an  important  role  as 
sedative,  eliminant,  and  soporific.  -A.  morning  cold 
shower  is  a  capital  tonic.  If  a  hypnotic  be  needed, 
trional  outranks  all  others;  dose,  fifteen  to  thirt)- 
grains,  dr)'  on  the  tongue,  at  7  p.m.,  or  in  hot  milk  or 
bouillon  at  bedtime. 

The  pain  peculiar  to  chronic  alcoholism  can  often 
be  eased  by  cannabis  and  quinine.  If  not,  coal-tar 
products  may  succeed.  .\11  failing,  an  opiate  can  be 
given,  but  it  must  not  be  morphine;  that  is  unsafe;  it 
is  snareful,  chronic  alcoholics  take  to  it  too  kindly. 
Codeine  may  be  given.  This  drug — for  the  greatly 
increased  use  of  which  in  .\merica  during  the  last  six 
years  the  profession  is  mainly  indebted  to  Dr.  J.  B. 
Mattison — one-half  to  two  grains  of  the  phosphate  or 
sulphate  by  skin  or  mouth,  is  an  efficient  anodyne,  and 
the  risk  of  tolerance  is  vastly  less  than  with  morphine. 

One  remedy,  radical  and  a  dtrnur  ressort,  remains 
to  be  noted.  Granting  the  woman  has  been  given 
treatment  projjer,  persistent,  and  prolonged,  without 
avail,  she  should  be  asexualized.  This,  whether 
maid  or  matron — for  many  a  former  would  not  have 
the  courage  of  conviction  equal  to  that  of  a  young 
woman  brought  to  my  notice,  who  refused  an  alluring 


November  13.  1897] 


MEDICAL    RECORD. 


701 


offer  of  marriage  solely  because  she  was  a  periodic 
alcoholic.  It  might  be  curative,  it  surely  would  be 
preventive;  and  better  by  far  unsex  the  woman  than 
have  her  beget  a  brood  tainted  with  this  curse  of  the 
world. 

Special  stress  must  be  laid  on  the  need  for  treat- 
ment long  continued.  Lack  of  this  is  the  largest  fac- 
tor in  failure.  It  is  absurd  to  suppose  that  a  system, 
bruised  and  battered  by  alcoholic  excess  for  years, 
can  be  brought  back  to  health  in  a  few  weeks  or 
months.  The  good  work  must  go  on,  if  need  be,  for 
years.  True,  much  may  be  done  in  some  cases  by  less- 
protracted  care,  but  as  a  rule  the  risk  of  recurrence 
makes  the  longer  treatment  of  greatest  worth.  The 
skilful  doctor  repairs  or  retards  the  ravages  of  renal 
or  cardiac  disease  by  care  years  continued,  and  the 
same  wise  effort  along  alcoholic  lines  must  obtain  if 
the  largest  measure  of  good  would  be  gained.  There 
is  great  incentive  to  such  effort.  Even  now,  from  thirty 
to  fifty  per  cent,  of  alcoholic  inebriates  properly  treated 
recover,  and,  with  a  clearer  insight  of  causative  condi- 
tions and  a  more  extended  remedial  ri/ghite,  there  is 
full  warrant  to  think  this  good  result  will  be  greater. 

No  case  should  be  deemed  beyond  hope  till  ever)- 
aid  that  scientific  treatment  can  now  surely  extend, 
under  either  willing  or  coercive  care,  and  continued  if 
need  be  for  years,  shall  prove  of  no  avail. 

So  much  as  a  present  spur.  When  we  face  the  fu- 
ture, and  realize  the  fact  that  in  the  new  centurj',  so 
near,  the  question  of  the  effects  of  alcoholism  on  the 
physical  weal  of  humankind  will  be  the  question  out- 
ranking all  others,  phthisis  not  excepted,  to  engage  at- 
tention of  scientist  and  sanitarian;  when  we  give  due 
thought  to  the  fact  that  alcoholism  is  not  only  a  curable 
but  a  preventable  disease — we  must  be  profoundly  im- 
pressed by  the  immensity  of  its  importance;  and  let 
our  ever)'  effort  array  against  it,  for  it  compasses  not 
only  the  welfare  of  a  present  host,  but  that  of  millions 
yet  to  be. 

140  South  Portland  Avenl-e. 


©litiicaX  gepfartmimt. 

HEMORRHAGE     INTO    THE    PERICARDIUM. 
By    U.    S.    bird.    M.D.. 

On  July  20,  1897,  during  a  cutting-affray,  a  healthy, 
middle-aged  negro  man  received  several  wounds, 
which  were  properly  treated.  July  24th  I  was  called 
to  see  him.  The  only  serious  wound  was  a  stab  in  the 
left  side,  in  the  axillary  line,  at  the  level  of  the  sev- 
enth and  eighth  ribs.  This  wound  was  horizontal, 
about  one  inch  long,  extending  upward  and  inward  for 
some  two  and  one-half  inches.  From  it,  especially 
when  he  coughed,  came  a  large  quantit)'  of  bloody  se- 
rum. There  was  some  whistling  through  the  lips  of  the 
wound  during  respiratory  movements,  but  this  ceased 
after  a  few  days.  His  respiration  was  labored  and 
rapid,  preventing  him  from  sleeping.  Morphine  par- 
tially relieved  this  symptom.  As  there  appeared  to 
be  an  accumulation  of  liquid  in  the  chest,  I  used  a 
large  aspirating  needle  in  the  first  interspace  below 
the  wound,  but  found  nothing.  By  July  29th  the  dis- 
charge had  lessened  in  quantity,  but  had  become  puru- 
lent. On  August  2d  1  made  an  opening  a  little  lower 
than  the  original  wound,  and  packed  lightly  with  gauze. 
By  August  4th  the  discharge  seemed  enough  only  to 
dampen  the  gauze.  On  this  day  his  condition  was 
good.  His  breathing,  which  had  been  rapid  and  dis- 
tressed, was  24  and  easy.  His  pulse  was  120,  but  im- 
proved. His  appetite  was  good,  and  his  bowels  and 
bladder  acted  well.  His  feet  became  swollen  a  few 
days  after  I  first  saw  him,  and  continued  in  that  con- 


dition. Wednesday  morning  I  saw  him  last.  When  I 
called  August  5th,  his  nurse  told  me  that  he  had 
coughed  a  little  about  daylight.  After  being  raised 
to  a  sitting  position  he  coughed  up  a  little  t  lood  and 
immediately  collapsed.  She  thought  that  b)  the  time 
she  laid  him  down  he  was  dead. 

About  2  P.M.  I  made  an  autopsy.  When  the  ster- 
num with  the  costal  cartilages  attached  was  removed, 
the  pericardium  was  seen  to  be  distended  and  of  a 
bluish  tint.  This  was  opened  and  some  ounces  of 
black  clot  removed.  The  heart  was  compressed  and 
empty.  There  were  firm  and  extensive  adhesions  be- 
tween its  left  surface  and  the  pericardium,  and  be- 
tween this  part  of  the  pericardium  and  the  pleura. 
The  heart  was  not  wounded,  but  the  pericardium  had 
here  sustained  an  extensive  incised  wound,  similar  to 
the  external  injury.  There  was  a  ragged  wound  in  the 
lower  edge  of  the  left  lung,  which  was  also  consoli- 
dated and  adherent.  There  were  no  accumulation  of 
liquid,  and  no  apparent  communication  with  the  ex- 
ternal wounds.  His  death  was  probably  due  to  com- 
pression of  the  heart  by  the  hemorrhage  into  the  peri- 
cardium, which  was  probably  due  to  the  rupture  of  a 
weakened  pulmonary  vessel,  caused  by  the  exertion  of 
coughing.  In  a  sense,  death  was  accidental.  The 
loss  of  that  quantity  of  blood  was  not  likely  to  have 
caused  death.  A  few  days  longer  might  have  been 
sufficient  for  the  formation  of  adhesions  which  would 
have  made  such  a  result  improbable. 

HYSTERICAL   APHONIA. 
By   \.    C.    FOLLETT,    M.D.. 

SCHENEvrs,   N.    V. 

In  a  recent  issue  of  the  Medical  Record  is  an  article 
by  Dr.  Sanger  Brown,  of  Chicago,  upon  a  cure  of  this 
affection  by  suggestion.  I  had  my  first  and  only  case 
of  this  sort  about  two  years  ago,  and  I  cured  the  pa- 
tient (at  least  she  recovered)  in  four  days  by  means  of 
suggestion.  She  had  been  aphonic  for  several  months. 
I  really  brought  her  voice  in  one  night.  I  told  her 
to  do  this,  that,  and  the  other  for  three  days — none  of 
the  things  prescribed  being  more  than  a  placebo.  I 
gave  minute  directions  to  be  accurately  followed,  and 
emphatically  directed  her  to  speak  upon  the  fourth 
morning,  which  she  did  and  not  before.  I  previously 
had  examined  her  vocal  apparatus  with  the  lar)'ngo- 
scope  and  had  found  nothing  pathological. 


A  CASE  OF  PUERPERAL  SEPTICEMIA 
SUCCESSFULLY  TREATED  BY  ANTISTREP- 
TOCOCCUS    SERUM.' 

By    H.    SIFF,    M.D., 

The  object  of  this  paper  is  not  to  try  your  patience 
with  scientific  speculations,  numerous  quotations,  or 
new  discoveries:  I  desire  to  report  to  you  a  case 
based  on  solid  facts  and  supported  by  the  opinion  of 
some  very  eminent  authorities,  and  if  my  views  prove 
to  be  correct,  and  you,  after  weighing  the  cons  and 
pros  of  the  case  should  finally  coincide  with  me,  then 
the  medical  world  may  congratulate  itself  upon  its 
success  in  dealing  with  and  destroying  the  dreaded 
micro-organisms  which  are  constantly  at  work 
undermining  our  vitality.  The  case  I  refer  to  is  one 
of  puerperal  septicaemia  successfully  treated  by  anti- 
streptococcus  serum. 

On  the  morning  of  March  19th  I  was  invited  to  see 

Mrs.   M ,  on  Grand  Street.     The  nurse  gave   me 

the  following  brief   histon,-  of  the  ca.se:  Mrs.  M , 

a  primipara,  after  labor  pains  which  lasted  only  about 
three  hours,  was  delivered  six  days  ago  of  a  healthy 
little  female  child,  weighing  about  nine  pounds.     The 

'  Read  before  the  Eastern  Medical  Society,  April  9,  1897. 


702 


MEDICAL    RECORD. 


[November  13,  1897 


midwife  had  no  trouble  witli  the  placenta,  and  mother 
and  child  were  in  perfect  health.  This  occurred  on 
Friday  evening,  March  12th.  During  the  following 
Sunday  and  Monday  the  parturient  complained  of 
headache,  and  Monday  evening  she  had  a  prolonged 
chill. 

On  Tuesday  a  physician  was  called  in.  Cathartics 
and  antipyretics  were  prescribed,  but  the  patient  grew 
worse.  The  temperature  ranged  between  1 05 '  and 
106  F.  During  the  following  two  days  a  similar  line 
of  treatment  was  followed,  some  intra-uterine  antisep- 
tic douches  were  given,  and  the  physician  in  attend- 
ance wanted  to  curette,  but  the  family  objected.  On 
Thursday  vomiting  set  in,  which  resisted  all  treatment, 
and  the  temperature  continued  to  range  between 
104.5^  and  106"  F. 

On  examination  I  found  the  uterus  prettj'  firmly 
contracted  and  the  os  closed,  although  not  completely, 
but  sufficiently  to  exclude  the  probability  of  any  re- 
tained secundines.  There  was  no  lochial  discharge, 
no  offensive  odor,  no  excessive  tenderness  anywhere. 
Only  a  few  small  areas  of  slight  tenderness  over  the 
fundus  of  the  uterus  could  be  mapped  out.  The  tem- 
perature was  105.8"  F. ;  the  pulse  thready  and  hardly 
perceptible:  the  heart's  action  feeble,  accelerated,  and 
beating  130  times  per  minute.  The  entire  body  was 
covered  with  a  cold  and  clammy  perspiration,  a  pecu- 
liar sweetish  odor  emanating  from  it.  The  face  was 
flushed  (showing  several  ecchymotic  spots),  the  teeth 
and  gums  were  covered  with  sordes,  the  tongue  was 
brown,  and  the  extremities  were  cold. 

The  mental  condition  of  the  patient  was  the  one 
characteristic  of  septicaemia — sliglit  delirium,  general 
apathy,  and  indifference,  always  begging  not  to  be 
disturbed,  to  be  allowed  to  die,  etc.  The  expression 
of  die  eyes  was  dull  and  lifeless.  The  two  most  dis- 
tressing symptoms  were  persistent  vomiting  and  in- 
somnia, the  patient  not  having  slept  for  nearly  seventy 
hours. 

As  the  attending  physician  refused  to  treat  the  case 
for  not  being  permitted  to  curette,  I  at  his  request  took 
charge  of  it.  I  prescribed  large  doses  of  musk,  nux 
vomica,  strophanthus,  and  digitalis  to  prevent  collapse, 
and  ordered  three  ten-grain  doses  of  sulphonal  with 
some  cocaine  and  sparteine  to  produce  sleep  and  check 
the  vomiting. 

I  pronounced  the  case  septicaemia,  but  advised 
against  curetting,  as  I  was  positive  that  there  was 
nothing  in  the  uterus  to  justify  any  such  interference. 
Although  I  was  confident  of  my  diagnosis,  I  invited 
Dr.  A.  Jacobi  in  to  the  case.  After  a  careful  examina- 
tion he  expressed  himself  satisfied  with  the  diagnosis 
of  puerperal  septicaemia,  and  advised  intra-uterine  in- 
jections of  a  solution  of  permanganate  of  potassium, 
I  to  3,000. 

On  the  next  morning  vomiting  had  ceased,  the  pa- 
tient had  slept  a  few  hours,  but  the  temperature  was 
again  106°  F.,  and  the  condition  of  the  heart  was  so 
alarming  that  I  had  to  give  heroic  doses  of  powerful 
stimulants,  like  musk,  etc.  I  wanted  to  tiy  some  anti- 
toxin, but  I  met  with  objection  on  the  part  of  the  fam- 
ily, as  they  had  had  some  bad  experience  with  diph- 
theria antitoxin.  Dr.  P.  F.  Mundc,  who  by  invitation 
saw  the  case  w-ith  me  on  that  day,  agreed  with  me  on 
every  point,  and  as  there  was  nothing  to  lose,  a  fatal 
prognosis  having  been  given,  he  also  advised  trying 
antitoxin.  I  procured  antistreptococcus  serum  and 
injected  into  the  hip  ten  cubic  centimetres.  This 
took  place  at  9  p.m.,  the  patient's  temperature  then  be- 
ing 104.5°  ^-  15uring  the  night  the  patient  had  diar- 
rhoea in  consequence  of  a  powder  of  ten  grains  each  of 
calomel  and  jalap,  which  I  administered  on  the  pre- 
ceding evening.  The  diarrhoea  was  violent,  about 
twelve  or  fifteen  movements  within  eight  hours;  tlie 
patient  became  exhausted  and  seemed  to  be  rapidly 


sinking.  I  hurriedly  prescribed  some  opium,  bismuth, 
and  salol,  and  succeeded  in  checking  the  diarrhoea. 

At  9  A..M.,  twelve  hours  after  the  injection  of  the 
serum,  the  rectal  temperature  for  the  first  time  since 
the  onset  of  the  disease  was  only  103'  F.,  instead  of 
the  regular  106"  of  the  preceding  four  days.  The  de- 
lirium had  ceased  and  the  patient  was  easier.  I  again 
injected  ten  cubic  centimetres  of  the  serum.  'J'his 
time  the  injection  seemed  to  cause  some  pain,  as  the 
patient  made  quite  an  outcry,  while  during  the  first 
inoculation  she  seemed  to  be  entirely  indifferent  to  the 
pain  of  the  needle. 

Twelve  hours  later  the  thermometer  registered 
102.5''  F-  The  appearance  of  the  patient  had  changed. 
There  was  no  longer  that  gaze  of  apathy  and  indiffer- 
ence, and  the  ecchymotic  spots  on  the  face  had  almost 
vanished.  The  tongue  was  no  longer  brown ;  it  was 
still  coated,  but  white,  and  the  sordes  on  the  gums 
and  teeth  were  half  gone.  The  senses  of  the  patient, 
however,  were  at  short  intervals  blunted,  and  she 
would,  while  speaking  rationally,  all  of  a  sudden  in- 
terpose an  incoherent  sentence.  I  examined  the  urine, 
and  as  the  result  was  negative  (thus  satisfying  me  that 
the  serum  was  assimilated,  as  otherwise  the  kidneys 
would  have  excreted  some  albumin)  I  again  injected 
ten  cubic  centimetres  of  the  antitoxin.  This  time  I 
met  with  violent  resistance  on  the  part  of  the  patient; 
she  was  sensitive  to  pain  and  was  fully  conscious  of 
what  was  going  on. 

The  next  morning,  thirty-six  hours  after  the  first  in- 
jection, the  temperature  was  102''  F.  and  the  lochial 
discharge  reappeared.  At  noon  the  thermometer  reg- 
istered 100.5  F-'  ^""^  '"  '^he  evening  99.5'  F.  The 
temperature  afterward  never  rose  higher  than  102^  F. 
But  then  new  trouble  began — the  heart's  action  became 
very  irregular  and  alarmingly  intermittent,  especially 
so  whenever  the  temperature  was  below  loi  F. ;  it 
would  then  very  frequently  leave  out  two  beats  succes- 
sively. After  three  days  of  stimulation  by  large  doses 
of  musk,  cardiac  action  became  normal  and  the  pa- 
tient completely  recovered. 

The  question  now  arose  in  my  mind;  Was  this  re- 
covery the  work  of  the  antitoxin,  or  was  it  merely  a 
coincidence?  Perhaps  the  septic  poison  was  elimi- 
nated by  the  diarrhcea.  Dr.  Munde,  whose  opinion 
should  certainly  command  respect,  ascribes  this  recov- 
ery to  the  antitoxin.  Discussing  this  subject  in  a  let- 
ter I  received  from  him,  he  says:  "I  do  not  believe 
that  the  purgative  did  it.  I  am  glad  there  seems  to  be 
at  last  an  antidote  for  septic  poison."  I  myself,  con- 
servative as  I  would  like  to  appear,  am  convinced  of 
the  correctness  of  this  opinion,  not  so  much  by  the  re- 
covery itself  as  by  the  rapidity  of  its  occurrence.  To 
see  a  temperature  of  106""  F.  fall  to  99.5°  F.  in  forty- 
eight  hours  is  not  usual  with  septicKraia  of  this  type. 
I  must  admit  that  a  rapid  recovery  may  take  place  in 
some  cases  of  puerperal  septica?mia,  but  it  should  be 
borne  in  mind  that  only  in  such  cases  of  septicamia 
can  this  occur  in  which  the  cause  is  early  discovered 
and  promptly  removed— as,  for  instance,  in  case  of 
retained  secundines. 

As  to  the  possibility  of  the  septic  poison  having 
been  eliminated  by  the  diarrhcea,  I  do  not  think  this 
can  encroach  upon  the  credit  which  I  wish  to  claim 
for  the  antitoxin,  for  we  all  know  that  excretion  is  the 
rule  in  septicaemia;  cold  sweats  and  offensive  diar- 
rhcea are  generally  the  agents  which  usher  in  the  fatal 
issue,  and  cases  of  septictemia  which  do  terminate  in 
reco\ery  are  mostly  such  as  were  not  aggravated  by 
diarrhcea. 

Now  some  conservative  minds  may  ask:  Is  septicir- 
mia  always  fatal.'  To  this  I  would  reply  that,  while 
there  may  occasionally  be  recorded  a  case  of  recovery 
from  pueri^eral  septicaemia  when  the  cause  was  not 
discovered  and  certainly  not  removed,  I  do  not  think 


November  13,    ic>u7] 


MEDICAL    RECORD. 


703 


recovery  probable  in  a  case  of  such  grave  character 
accompanied  bj'  all  of  the  distressing  symptoms  which 
I  fully  described  above.  Then,  again,  I  would  refer 
the  sceptic  to  the  rapidity  of  the  recover)' — fortj'-eight 
hours !     That  certainly  is  not  usual. 

While  I  am  fully  aware  of  the  fact  that  it  requires 
more  than  one  test  to  convince  a  physician  of  the  effi- 
cacy of  a  certain  therapeutic  agent  or  mode  of  treat- 
ment, I  trust  that  the  case  described  by  me  will  give 
the  obstetrician  sufficient  inducement  to  test  this  se- 
rum treatment.  There  is  no  reason  why  the  strepto- 
coccus should  enjoy  more  protection  than  the  Klebs- 
Loeffler  bacillus.  There  was  a  time  not  long  ago 
when  men  high  in  the  profession  who  are  now  ar- 
dent advocates  of  diphtheria  antito.xin  were  relent- 
lessly denouncing  it  as  useless,  dangerous,  etc.  They 
were  quite  sincere  in  that  denunciation,  w'hich  they 
claimed  to  base  on  the  result  of  numerous  statistics, 
unfil  they  finally  were  conquered  by  other  numbers. 
Maybe  we  can  now  declare  war  on  the  streptococcus. 

The  fact  that  there  are  other  pathogenic  micro- 
organisms present  in  the  blood  of  a  septicasmic  patient 
should  not  deter  us  from  attempting  to  destroy  the  one 
which  is  always  present,  even  if  this  could  result  only 
in  slightly  lessening  the  virulence  of  the  septic 
poison. 

160  Madison  Street. 


BILATERAL  SUBLUXATION  OF  THE  CRYS- 
TALLINE LENSES  WITH  ECTOPIA  OF 
THE   PUPIL   OF   THE   LEFT    EYE. 

By    G.    N.    BRAZEAU,    M.D., 

FOND    DV   LAC,    WIS. 

About  two  weeks  ago  a  man  came  to  consult  me  about 
his  eyes,  complaining  of  the  great  diminution  in  his 
acuteness  of  vision.  The  patient  is  thirty-four  years 
old,  healthy,  and  has  a  good  family  historJ^  I  found 
upon  inspection  a  tremulous  condition  of  both  irides 
with  ectopia  of  the  pupil  of  the  left  eye.  The  pupil 
was  at  the  sclero-corneal  junction. 

Ophthalmoscopic  e.xaminalion  of  the  right  eye,  for 
it  was  impossible  in  the  left,  revealed  a  lateral  sub- 
luxation of  the  lens  toward  the  outside.  The  border 
of  the  lens  was  perceptible  only  on  dilating  the  pupil. 
The  margin  of  the  lens  appeared  as  a  heavy  dark  curve, 
since  the  rays  coming  from  the  fundus  of  the  eye  to 
the  margin  of  the  lens  were  deflected  from  their  course 
by  virtue  of  the  difference  in  the  refractive  media. 
There  were  a  large  staphyloma,  however,  not  encroach- 
ing upon  the  region  of  the  macula,  and  a  small  papilla, 
two  conditions  peculiar  to  myopic  eyes.  The  patient 
was  highly  myopic,  and  despite  the  peculiar  condition 
of  the  pupil  in  the  left  eye  he  could  see  with  that  eye 
sufficiently  to  find  his  way. 

The  tremulous  condition  of  the  irides  suggested  im- 
mediately to  my  mind  the  probability  of  an  abnormal 
position  of  the  lenses,  which  true  enough  was  very 
manifest  on  ophthalmoscopic  examination,  and  which 
I  afterward  verified  by  instilling  atropine  and  secur- 
ing that  visual  condition  so  peculiar  to  displacements 
of  the  lenses  referred  to  above. 

It  was  impossible  to  elicit  from  the  patient  or  his 
friends  positive  information  concerning  the  date  of 
the  origin  of  the  tremulousness  of  the  iris;  however, 
the  fact  that  he  attended  school  until  the  age  of  eigh- 
teen, though  myopic,  and  his  chief  complaint  dated 
from  September,  1869,  lead  me  to  believe  in  an  ac- 
quired dislocation  rather  than  congenital  one. 

On  the  other  hand  ectopia  of  the  lens  usually  ac- 
companies ectopia  of  the  pupil,  which  is  itself  a  con- 
genital condition.  From  that  fact  together  with  the 
tremulousness  of  the  iris,  I  believed  in  a  displacement 
of  the  lens,  although  I  was  not  able  to  see  it  as  in  the 


other  eye.  There  exists  with  this  ectopia  of  the  lens 
either  marked  hypermetropia,  myopia,  or  astigmatism ; 
in  this  case  it  was  myopia  and  astigmatism.  The 
myopia  in  the  right  eye  was  partly  overcome  by  the 
removal  of  the  lens.  The  true  anatomical  cause  for 
dislocation  of  the  lenses  lies  in  the  alterations  in  the 
zonule  of  Zinn,  which  consist  in  either  elongation,  re- 
laxation, or  degeneration  of  its  fi:bres.  Both  the  lens 
and  iris,  being  deprived  of  proper  support,  naturally 
must  tremble.  Any  displacement  of  the  lens  gives 
rise  to  changes  in  the  vision,  particularly  if  it  occupies 
a  portion  of  the  pupillar)'  space.  The  part  containing 
the  lens  becomes  myopic  on  account  of  the  extreme 
convexit}-  of  the  lens  permitted  by  the  relaxed  zonule, 
and  the  other  hypermetropic  from  absence  of  the  lens. 

Astigmatism  is  also  very  marked,  because  the  light 
is  refracted  unequally  in  the  different  meridians  of  the 
lens,  a  condition  called  regular  astigmatism.  Diplo- 
pia is  also  explained  by  the  fact  that  the  margin  of 
the  lens  acts  as  a  prism  whose  apex  corresponds  to  the 
equator  of  the  lens.  Diplopia  also  results  and  neither 
of  the  two  images  is  distinct,  for  one  is  seen  by  a 
hypermetropic  eye  and  the  other  by  a  myopic  one — 
the  former  corresponding  to  that  part  of  the  pupil  de- 
prived of  the  lens,  and  the  latter  to  that  containing 
the  greatly  conve.xed  lens.  In  time  nearly  all  sub- 
luxated  lenses  became  luxattd  and  opaque.  Irido- 
cyclitis is  apt  to  result  from  the  constant  jerkings  of 
the  lens  and  iris  in  this  latter  condition. 

The  treatment  consists  in  remedying  by  glasses 
properly  fitted — a  plus  glass  for  the  side  deprived  of 
a  lens,  or  a  minus  for  the  side  with  it,  besides  proper 
correction  of  the  astigmatism.  Uveal  complications 
require  their  special  treatment. 


A    CASE    OF    STRANGULATED    APPENDICAL 
HERNIA. 

By    F.    I).    V.ANDERHOOF,    M.D., 

0>'  August  sth,  I  was  called  to  see  Mrs.  G ,  aged 

fift}'-seven  years,  whose  general  health  was  good,  but 
who  was  inclined  to  be  somewhat  stout.  She  pre- 
sented the  general  or  usual  symptoms  of  strangulated 
hernia,  such  as  tumor  in  the  groin,  tenderness  of  the 
lower  part  of  the  abdomen,  pain,  nausea,  etc.  Gentle 
taxis  was  used  with  no  success,  and  I  then  adminis- 
tered by  hypodermic  injection  one-quarter  grain  of 
morphine  sulphate  into  the  tumor.  After  waiting  an 
hour,  I  again  tried  taxis  but  with  no  better  result, 
and,  concluding  an  operation  was  necessary,  called 
Prof.  D.  M.  Totman,  of  Syracuse,  in  consultation. 
The  patient  was  etherized  and  gentle  taxis  was  again 
tried,  but  we  could  not  reduce  the  mass.  Dr.  Totman 
cut  down  upon  the  tumor  and  readily  found  the  sac, 
which  contained  about  a  half-ounce  of  fluid,  but  none 
of  the  usual  contents  of  hernire.  Upon  careful  exami- 
nation, to  our  great  surprise,  we  discovered  only  the 
appendix  forming  the  contents  of  the  sac.  The  latter 
was  firmly  adherent  to  the  femoral  ring,  and  markedly 
injected  but  not  otherwise  diseased.  The  appendix  was 
slightly  congested  and  adherent  to  the  sac  at  the  ring; 
otherwise  it  was  in  normal  condition.  After  we  had 
broken  up  the  adhesions  and  dilated  the  ring,  it  was 
decided  to  return  the  appendix  to  the  abdominal  cavity. 
The  sac  was  then  sutured  to  the  ring  and  the  wound 
was  closed.  The  patient  made  a  i  ipid  and  unevent- 
ful recover}',  and  now  nearly  two  months  after  the 
operation  is  in  the  enjoyment  of  perfect  health.  It 
was  questioned  at  the  time  what  it  was  best  to  do  with 
the  appendix,  amputate  or  return;  in  the  light  of  sub- 
sequent events  we  are  of  the  opinion  that  the  wiser 
course  was  followed. 


704 


MEDICAL    RECORD. 


[November  13,  1897 


A    PECULIAR    CASE     OF  APPENDICITIS. 
By   II.    S.    JEWETT,    M.D.. 


H.  Z ,  German,  aged  thirty-seven,  grocer,  married, 

si.x  feet  in  iiis  stockings,  weighing  two  hundred  and 
thirt)'  pounds,  had  till  his  final  illness  never  lost  a 
day's  time  from  sickness  since  childhood.  Having 
been  slightly  constipated  for  several  days,  he  took  a 
dose  of  castor  oil  on  retiring,  March  i,  1897.  The  oil 
procured  for  him  four  free  (but  not  water)-)  stools  be- 
tween 8  A.M.  and  noon  of  March  2d.  The  2d  of 
March  being  his  birthday,  the  evening  was  celebrated 
by  a  lunch,  with  beer,  with  his  friends.  To  this 
lunch  he  ascribed  all  his  sickness.  After  going  to 
bed  he  was  restless  and  could  not  sleep.  He  had 
slight  pains,  which  started  in  the  back,  in  the  region 
of  the  kidneys,  and  passed  downward  to  the  scrotum, 
with  desire  to  pass  urine,  and  also  to  defecate.  This 
feeling  caused  him  to  make  frequent  trips  to  the  water- 
closet,  though  he  had  no  stool,  and  passed  but  little 
urine  each  time. 

On  the  morning  of  March  3d  he  took  a  large  table- 
spoonful  of  castor  oil,  which  had  not  acted  on  his 
bowels  when  I  saw  him  at  4  p.m.,  March  3d. 

At  that  time  I  obtained  the  above  history.  He  was 
then  restless,  alternately  lying  down,  getting  up,  and 
walking  about  the  room.  Temperature,  98.8"  F. : 
pulse,  80,  full  and  even;  abdomen  soft  (absolutely  no 
rigidity  of  either  side ;  no  tenderness  on  pressure  (even 
when  deeply  made) ;  no  nausea.  I  prescribed  five 
grains  of  salol  every-  three  hours,  and  ordered  enemata 
of  warm  soapsuds  to  aid  the  oil  already  taken. 

March  4th,  8  a.m.,  the  patient  had  passed  a  bad 
night:  he  was  very  restless,  with  constant  desire  to 
urinate  and  defecate,  though  the  bowels  had  not  yet 
moved.  Temperature.  99°  F. ;  pulse,  84,  full  and 
regular.  No  nausea,  no  tympanites,  no  rigidity  of  ab- 
domen, no  tenderness  on  pressure,  nothing  abnormal 
to  be  felt  per  rectum.  The  tongue  was  dry  and  slightly 
coated  with  brown  fur.  There  was  continuous  thirst 
and  a  constant  desire  to  defecate  and  urinate.  I  or- 
dered five  grains  of  calomel,  to  be  followed  by  Epsom 
salts  in  five  hours  (if  the  calomel  had  not  acted  by 
that  time). 

March  4th,  7  p. ^r.,  temperature,  99°  F. ;  pulse,  84, 
regular  and  of  good  strength.  The  first  dose  of  salts 
was  vomited  as  soon  as  taken;  a  second  dose  (taken 
one  hour  later)  was  retained.  The  bowels  had  moved 
once,  but  the  desire  to  go  to  stool  was  not  relieved. 
The  man  was  very  restless,  moving  about  the  room 
and  trying  to  defecate  or  pass  urine  every  few  minutes. 
1  passed  a  catheter  and  drew  off  three  ounces  of  urine 
of  a  dark  amber  color;  specific  gravity,  1.024;  no  al- 
bumin or  sugar:  indican  above  normal.  I  prescribed 
morphine,  one  eighth  grain,  every  three  hours. 

March  5th,  8  a.m.,  l)r  J.  C.  Reeve,  Sr.,  saw  the  pa- 
tient in  consultation.  The  patient  had  passed  a  very 
restless  night — up  every  few  minutes  to  pass  urine  or 
to  try  to  have  a  stool.  Temperature,  99"  F. ;  pulse 
barely  perceptible  and  very  rapid.  No  pain,  no  tym- 
panites, no  tenderness  over  abdomen,  no  rigidity  of 
abdominal  walls.  Nothing  to  complain  of  but  moder- 
ate, constant  tenesmus  of  bladder  and  rectum.  He 
collapsed  while  on  the  night  stool  (trying  to  defecate) 
at  half-past  nine,  and  died  at  11:45  a.m.,  March  5th. 

Autopsy,  3  P.M.,  March  5th:  The  abdominal  walls 
were  very  fat  (two  and  one-half  inches  thick).  The 
greater  omentum  descended  to  the  pelvis,  and  was 
loaded  with  fat  (being  one  and  one-half  inches  thick). 
The  usual  incision  through  the  linea  alba  was  made, 
and  pus  oozed  out  of  the  lower  angle  of  the  wound  as 
soon  as  the  peritoneum  was  opened.  With  the  excep- 
tion of  the  presence  of  pus,  everj-thing  was  normal 


save  in  the  region  of  the  csecum.  Here  the  intestines 
were  glued  together  by  lymph,  forming  a  pocket  w  hich 
contained  about  one-half  pint  of  pus  and  the  gangre- 
nous appendi.v,  which  had  sloughed  entirely  off  at  one- 
fourth  inch  from  the  caecum.  The  appendix  pointed 
upward  and  to  the  left,  and  was  adherent  to  the  mesen- 
tery of  the  ileum.  The  portion  which  had  sloughed 
off  was  four  inches  long  and  five-eighths  inch  in  di- 
ameter. It  contained  two  faecal  concretions — one  (at 
one  and  one-half  inches  from  the  csecum)  was  three- 
fourths  inch  long  and  three-eighths  inch  in  diameter; 
the  other,  of  nearly  the  same  size,  projected  for  one- 
fourth  its  length  through  the  sloughed-off  tip  of  the 
appendix.  The  bladder  and  rectum  were  normal,  and 
there  were  no  inflammatory  adhesions  to  either,  and 
the  question  in  my  mind  was:  Whence  the  tenesmus  of 
bladder  and  rectum  ? 


A   LARGE    DOSE    OF    SODIUM    SALICYLATE. 

Bv    H.  S.  JEWETT,    .M.D., 

DA\-rON,    OHIO. 

H.  D.   C ,   in  his  eighty-second  year,  had  been 

taking  ten-grain  doses,  t.i.d.,  of  sodium  salicylate  for 
a  slight  rheumatic  affection.  He  bought  three  hun- 
dred and  twenty  grains  and  dissolved  it  in  four  ounces 
of  water.  Of  this  solution  he  took  one  fluid  drachm 
(containing  ten  grains)  three  times  a  day.  One  day, 
after  preparing  a  fresh  bottleful,  he  drank  (in  a  fit  of 
abstraction)  the  whole  amount,  three  hundred  and 
twent}-  grains,  at  one  dose.  The  only  unpleasant  re- 
sults were  excessive  roaring  in  the  ears,  verj-  active 
catharsis,  and  weakness  from  fright,  which  confined 
him  to  his  room  for  a  few  days,  after  which  he  felt 
better,  stronger,  and  more  active  than  he  had  for  sev- 
eral years. 


DEATH    FROM    A.C.E.    MIXTURE. 
By   H.    S.   JEWETT,    M.D., 

DA%-rON,    OHIO. 

R.  H ,  aged  forty-four,  single,  laborer,  was  ad- 
mitted to  St.  Elizabeth's  Hospital,  August  25,  1895, 
witli  compound  fracture  of  the  tibia  and  fibula.  He 
had  been  a  hard  drinker  for  many  years.  A.C.E.  mix- 
ture was  administered  and  the  fracture  was  adjusted 
and  dressed.  The  fragments  having  become  displaced, 
A.C.E.  was  again  administered  on  August  27th,  and 
the  fracture  was  readjusted.  On  August  28th  A.C.E. 
was  again  administered  and  the  ends  of  the  bones 
were  v,  ired  together.  .Mthough  he  was  a  bad  subject, 
these  three  administrations  of  the  anaesthetic  produced 
no  unpleasant  symptoms,  excepting  possibly  slight 
prolongation  of  the  struggling  stage. 

For  the  removal  of  a  sequestrum  at  the  site  of  the 
injury,  A.C.E.  was  again  administered  on  November  7, 
1895.  At  this  time  physical  examination  showed  no 
lesion  of  the  heart,  and  the  urine  contained  no  casts,  al- 
bumin, or  sugar.  After  a  few  whiffs  of  the  ana-stlietic 
and  before  consciousness  was  entirely  lost,  the  patient 
began  to  struggle  violently,  had  a  slight  convulsion, 
and  ceased  breathing.  His  head  was  immediately 
low-ered:  artificial  respiration  (by  Sylvester's  method) 
was  commenced  and  continued  for  forty  minutes. 
While  this  was  being  carried  out,  rhythmic  traction  of 
the  tongue  was  made  and  the  electric  battery  was  used. 
Whiskey,  sti-)-chnine,  and  nitroglycerin  w-ere  also  in- 
jected hypodemiatically.  The  pulse  continued  to  beat 
for  nearly  a  minute  after  respiration  had  ceased.  No 
post-mortem  examination  was  permitted. 


November  13,  1897] 


MEDICAL    RECORD. 


705 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &.  CO.,  43,  45,  &.  47  East  Tenth  Street. 


New  York,  November  13,  1897. 


SHOULD    MINISTERS    PAY    DOCTORS? 

That  medical  men  are  suffering  from  a  variet)'  of 
grievances  is  too  well  known  to  need  much  recapitula- 
tion. There  are  so  many  ways  of  imposing  on  their 
good  nature  that  it  is  difficult  to  particularize.  Not 
only  through  the  agency  of  dispensaries  and  hospitals 
are  they  mulcted  of  their  just  dues,  but  there  are  other 
and  not  less  insinuating  methods  of  abusing  their 
benevolence.  The  statement  has  been  made,  and  is 
probably  near  the  mark,  that  fift}-  per  cent,  of  the  peo- 
ple will  shirk  paying  their  doctor  and  will  lower  them- 
selves to  almost  any  mean  subterfuge  in  order  to  save 
a  few  dollars.  The  belief  would  appear  to  be  wide- 
spread that  physicians  earn  their  fees  easily,  and  they 
are  in  consequence  looked  upon  as  fair  game  by  that 
class  of  the  communit}'  which  likes  to  get  something  for 
nothing.  A  custom  prevails  in  this  countr)-  that  min- 
isters should  be  considered  as  free  from  any  pecuniar}- 
obligation  to  the  doctor  for  seri'ices  rendered.  This 
custom  has  been  in  existence  for  so  long  a  time  that 
the  fact  seems  to  have  been  forgotten  that  this  free 
service  is  only  an  act  of  courtesy  on  the  part  of  the 
physician,  and  not,  as  the  minister  imagines,  by  any 
means  binding.  The  explanation  for  this  state  of 
affairs  is  not  easy  to  give.  In  bygone  times  there  may 
have  been  fai.ly  cogent  reasons  why  the  doctor  should 
thus  favor  the  clergj'man.  Then  it  might  perhaps 
have  been  argued  that  in  many  instances  the  medical 
man  received  a  quid  pro  quo — he  was  repaid  to  a  cer- 
tain extent  by  the  introduction  of  patients.  Times, 
however,  have  changed,  and  that  argument  now  will 
hardly  stand.  Again,  the  relative  financial  positions 
of  the  two  professions  have  greatly  altered.  At  one 
time,  before  acute  competition  had  reduced  his  earn- 
ings, the  doctor  was  both  able  and  willing  to  lend  a 
helping  hand  to  the  poor  minister.  Nowadays  it  may 
be  said  with  truth  that  their  respective  positions  are 
reversed,  and  that  the  minister  is  as  well  able  to  pay 
for  as  the  doctor  is  to  give  his  services.  The  clerg}'- 
man  may  not  be  much  richer,  but  it  is  very  certain  that 
the  doctor  is  a  great  deal  poorer. 

Still,  when  all  has  been  said  and  done,  it  is  not  so 
much  the  custom  itself  as  the  abuse  of  it  that  hurts 
both  the  feelings  and  pocket  of  the  doctor.  For  ex- 
ample, take  a  popular  summer  resort,  to  which  people 
flock  for  a  short  time   and  where  the  resident  prac- 


titioners hope  to  make  their  harvest,  often  indeed 
chiefly  depending  upon  their  earnings  at  this  season  to 
carry  them  through  the  remainder  of  the  year.  Nu- 
merous clerg}'men  with  their  wives  and  families  will 
visit  the  place,  many  of  whom  will  require  medical  at- 
tendance. Surely  in  such  cases  it  is  hard  on  the  un- 
fortunate doctor  that  he  should  be  expected  to  attend 
these  absolute  strangers  as  a  matter  of  obligation.  He 
will  not  greatly  object  to  giving  his  services  to  the 
resident  preachers,  but  that  he  should  not  feel  sore  at 
wasting  his  time  on  people  he  may  never  see  again  is 
rather  too  much  to  look  for  from  poor  human  nature. 
A  line  should  be  drawn  somewhere. 

There  is  also  said  to  be  a  lamentable  lack  of  reci- 
procit}'  about  this  custom  ;  thus  if  a  physician  who  has 
been  attending  a  minister  and  any  one  of  hir  family 
wishes  to  get  married  by  him,  he  will  in  all  likelihood 
be  called  upon  for  a  fee.  This  is  not  exactly  doing 
unto  others  as  ye  would  they  should  do  unto  you. 

In  England  the  custom  of  free  medical  attendance 
exists,  but  to  a  much  more  limited  extent  than  here. 
It  is  there  regarded  as  a  question  of  courtesy  and  not 
of  obligation.  Most  of  the  consultants  in  the  large 
towns  do  not  take  fees  from  clergymen,  simply  because 
they  think  the  latter  cannot  afford  to  pay  and  not  be- 
cause they  consider  themselves  in  c.ny  way  bound  to 
give  them  free  advice.  In  the  country  districts,  how- 
ever, of  Great  Britain,  the  clergyman  pays  the  doctor 
just  as  he  would  his  lawyer  or  his  tradesman.  This 
matter  should  be  placed  in  its  true  light.  It  is  not  ob- 
ligator)' on  the  doctor  to  attend  the  ministar  without 
payment,  nor  is  there  any  unwritten  law  to  that  effect. 
If  he  does  so  it  is  altogether  from  kindness,  and  it  is 
galling  to  him  to  have  the  action  regarded  otherwise. 
Why  should  not  ministers  be  classed  in  the  same  cat- 
egory as  ordinary  individuals?  Those  who  cannot 
afford  to  pay  should  be  attend  d  free  of  harge,  not  as 
claiming  such  attendance  as  a  r!gh:,  but  in  the  exercise 
of  pure  benevolence.  On  the  oth  r  hand,  there  are 
no  reasons  why  those  who  are  able  t  pay  should  not 
do  so.  Perhaps  the  subj  'ct  is  misunderstood  by  them, 
and  the  true  position  of  affairs  is  not  thoroughly  ap- 
preciated. They  imagine  that  free  attendance  is  their 
right.  If  their  minds  were  disabused  of  this  id  a, 
and  if  they  were  convinced  that  by  not  paying  they 
were  in  a  manner  accepting  alms,  with  the  consequent 
loss  of  self-respect,  their  views  might  undergo  a  con- 
siderable alteration. 


THE    NAVY    MEDICAL    SERVICE. 

It  will  surprise  many  of  the  friends  of  the  naval  med- 
ical service  to  learn  that  in  spite  of  the  many  strug- 
gles heretofore  made  for  naval  staff  rank  the  fight 
has  been  virtually  given  up  and  that  the  staff  in  ques- 
tion is  apparently  resigned  to  its  fate.  This  is  the 
more  deplorable,  inasmuch  as  the  engineer  corps,  its 
recognized  partner  in  the  question,  has  gained  its  point, 
as  is  shown  in  the  recent  report  of  the  committee  of 
the  line  and  staff  appointed  to  consider  the  claim.  It 
is  useless  to  recapitulate  what  this  means,  either  in 
the  light  of  disparagement  of  equal  relative  rights  or 


7o6 


MEDICAL    RECORD. 


[November  13,  1897 


of  absolute  justice  to  each.  It  may  be  well,  however, 
in  passing,  to  bear  in  mind  the  many  indignities 
suffered  by  the  medical  service  from  officers  of  the  line 
when  questions  of  authoritative  jurisdiction  have  been 
brought  to  the  level  of  practical  demonstration.  It 
was  not  that  the  medical  officer  was  greedy  of  power, 
but  that  he  desired  proper  recognition  in  the  enforce- 
ment of  regulations  affecting  his  own  particular  work 
with  the  men  temporarily  placed  in  his  charge.  This 
old-time  grievance  has  become  so  much  a  matter  of 
common  knowledge  with  civil  practitioners  that  the 
applications  for  entrance  into  the  navy  have  fallen  off 
to  a  degree  that  threatens  the  future  efficiency  of  its 
medical  service.  As  a  fact  in  point  there  are  sixteen 
vacancies  which  cannot  be  filled,  although  they  have 
e.xisted  for  a  long  time.  Under  existing  circumstances 
it  is  not  likely  that  the  evil  will  be  remedied,  espe- 
cially now  that  it  is  declared  in  a  public  and  official 
manner  that  there  is  virtually  no  hope  for  the  future 
applicant  who  as  a  professional  gentleman  wishes  to 
command  that  respect  for  his  position  which  its  re- 
sponsibility rightly  demands. 

The  real  trouble  in  obtaining  men  is  the  lack  of 
proper  rank  and  quarters  for  them  on  shipboard  during 
the  first  two  or  three  years.  The  assistant  surgeons 
very  naturally  object  to  being  messed  with  cadets  and 
captains'  clerks,  as  they  are  according  to  the  present 
regulations,  and  believe  they  should  be  with  ward- 
room officers.  Until  they  are  treated  better,  the  navy 
will  be  short  of  surgeons,  for  few  men  who  are  capa- 
ble of  earning  a  living  elsewhere  will  submit  to  such 
indignity. 


THE   ANTIFOOTBALL    BILL. 

The  lamentable  death  of  the  Georgia  student  Gam- 
mon as  the  result  of  injuries  received  in  a  game  of 
football  has  occasioned  the  passage  of  a  bill  by  the 
house'of  representatives  of  Georgia,  making  it  a  mis- 
demeanor to  engage  in  the  game  when  matches  have 
been  arranged  or  gate  money  has  been  demanded.  The 
overwhelming  majority  vote  of  the  lower  house  makes 
it  quite  probable  that  the  senate  will  indorse  the  action 
and  the  bill  will  become  a  law.  If  this  be  the  case, 
Georgia  will  set  a  laudable  example  for  every  com- 
monwealth of  the  country.  The  time  certainly  has 
come  when  such  a  general  movement  is  necessary. 
In  view  of  the  great  number  of  serious  accidents  on  the 
football  field  between  college  teams,  it  is  impossible 
any  longer  to  view  the  game  in  the  light  of  innocent 
recreative  amusement  with  harmless  and  healthful 
athletics  as  its  object.  Although  so-called  slugging 
has  been  ruled  out  in  the  new  game,  there  is  still  left 
enough  of  brutal  muscular  force  to  make  the  alleged 
sport  productive  of  the  greatest  variety  of  surgical  in- 
juries to  every  part  of  the  body.  In  fact,  there  is 
hardly  a  game  played  in  which  some  one  of  the  con- 
testants is  not  more  or  less  seriously  hurt.  Only  the 
severer  injuries  are  noted,  while  the  lesser  ones  serve 
as  enlivening  incidents  to  call  forth  the  plaudits  of 
an  excited  audience.  Short  of  actual  death  on  the 
field,  not  much  account  is  taken  of  the  hundreds  of 


young  men  who  are  oftentimes  injured  for  life  as  the 
result  of  the  rough-and-tumble  methods  of  the  match. 
The  trainers  explain  the  number  of  injuries  by  the  lack 
of  requisite  physical  preparation  for  the  contest,  but 
in  reality  the  more  the  footballers  are  trained  the  more 
dangerous  becomes  the  game.  It  is  certainly  time 
we  should  look  the  matter  fairly  in  the  face.  If  we 
wish  to  develop  pluck,  courage,  endurance,  and 
strength,  we  can  do  so  in  more  healthful  and  safer 
ways.  It  is  time  that  the  new  game,  with  mere  weight 
against  weight,  should  be  abolished. 


THE     ESTABLISHMENT    OF     MORE    SMALL 
PARKS. 

The  advisory  committee  appointed  by  Mayor  Strong  to 
consider  the  practicabilit}'  of  creating  small  parks  in 
different  parts  of  this  city  as  playgrounds  for  children, 
has  reported  favorably  by  recommending  that  a  dozen 
or  more  squares  be  devoted  to  the  purpose.  This  is 
an  eminently  wise  recommendation,  and  its  fulfilment 
will  be  of  untold  benefit  to  the  thousands  of  children 
in  the  thickly  settled  districts.  These  breathing- 
spots  will  not  only  conduce  to  the  sanitary  welfare  of 
the  neighborhoods,  but  will  doubtless  have  a  social 
influence  upon  the  parents  and  children  that  can 
hardly  be  estimated.  In  the  latter  connection  the 
reports  of  the  police  captains  are  quite  interesting  in 
proving  that  the  opening  of  the  small  parks  has  con- 
duced markedly  to  the  abolition  of  juvenile  rowdyism, 
such  as  was  formerly  so  intimately  associated  with 
the  ordinary  street  education.  It  is  also  advised  by 
the  committee  that  playgrounds  be  connected  with  the 
public  schools.  This  is  a  most  excellent  and  most 
healthful  measure  in  the  right  direction,  and  will  tend 
to  educate  the  rising  generation  in  those  elements  of 
civilization  which  naturally  evolve  themselves  in 
contented,  healthful,  and  law-abiding  citizenship. 


ONE  MORE  KICK  AT  AN   ABUSED  PROFES- 
SION. 

The  supreme  court  of  Illinois  has  recently  handed 
down  a  decision  to  the  effect  that  any  physician  may 
be  called  from  his  practice  at  any  time  and  forced  to 
give  expert  testimony  in  court  without  compensation 
other  than  the  regular  witness  fee.  The  decision  was 
on  the  appeal  of  Dr.  J.  N.  Dixon,  of  Springfield,  who 
was  fined  for  contempt  of  court  because  he  refused  tc 
give  expert  testimony  without  adequate  compensation. 
According  to  The  Journal oi  Springfield,  in  May,  1895, 
Dr.  Di.xon  was  subpoenaed  as  an  expert  witness  in  the 
trial  of  a  personal-injury  suit  brought  against  the  city. 
The  city  desired  to  show  by  Dr.  Dixon's  testimony 
whether  the  injuries  sustained  would  produce  the  re- 
sult claimed  by  the  plaintiff  in  the  suit.  Dr.  Dixon 
refused  to  testify  in  the  case  unless  he  was  paid  a  fee. 
The  judge  entered  a  ruling  on  the  matter,  deciding 
that  the  physician  was  not  entitled  to  a  special  fee 
and  that  it  was  his  duty  to  give  the  testimony.  Dr. 
Dixon  still  refused  to  testify,  and  the  court  assessed  a 


November  13,  1897] 


MEDICAL    RECORD. 


707 


fine  of  $25  against  him  for  contempt  of  court.  The 
case  was  appealed  by  Dr.  Dixon  to  the  appellate 
coart,  where  the  decision  was  sustained.  The  State 
Medical  Society  took  the  matter  up,  and  by  its  direc- 
tion Dr.  Di.xon  carried  the  case  to  the  supreme  court. 
In  giving  his  decision,  Judge  Creighton  classed  the 
giving  of  testimony  with  jury  service  and  other  pub- 
lic duties.  He  admitted  that  it  is  a  hardship  for  phy- 
sicians, whose  time  is  valuable,  to  be  compelled  to 
attend  upon  trials  for  the  usual  witness  fees,  but  he 
pointed  out  that  other  citizens  are  required  to  make 
similar  sacrifices  for  the  public  good.  He  declared 
that  it  would  be  unjust  discrimination  to  allow  experts 
special  fees,  while  other  men  were  required  to  neglect 
their  business  and  attend  upon  court  for  the  fees  fixed 
by  the  statute. 

This  same  worthy  judge  would  probably  be  very 
indignant  if  he  were  forced  to  sit  on  the  bench  and 
hand  down  absurd  decisions  for  a  couple  of  dollars  a 
day.  But  lawyers  are  not  doctors.  They  make  no 
pretence  of  working  for  the  love  of  God  and  the  good 
of  their  fellow-men ;  they  work  to  make  a  living  and 
are  not  ashamed  to  say  so. 


INEXPERT   TESTIMONY. 

The  editor  of  the  American  Veterinary  Hevietc,  com- 
menting upon  some  remarks  in  these  columns  anent 
the  conflicting  testimony  of  the  alleged  experts  in  the 
Luetgert  trial,  thinks  that  the  trouble  lay  in  the  fact 
that  the  human  anatomists  were  talking  on  a  subject 
that  they  actually  knew  little  or  nothing  about,  namely, 
comparative  or  veterinary  anatomy.  The  writer  evi- 
dently believes  that  there  are  many  veterinary  anato- 
mists in  this  country  who  could  give  the  points  of 
osseous  differentiation  between  a  woman  and  a  hog 
offhand;  indeed,  he  says  so  in  nearly  these  words.  It 
would  perhaps  be  well  if  both  sides  called  in  veteri- 
nary instead  of  human  anatomists  at  the  next  trial. 
It  could  then  possibly  be  seen  whether  or  not  the  hired 
witnesses  in  the  first  trial  had  testified  on  a  subject  of 
which  they  had  no  knowledge,  when  a  man's  life  was 
dependent  upon  the  nature  of  their  testimony. 


THE   ADVERTISEMENTS    THAT   ARE  UNFIT 
TO    PRINT. 

An  esteemed  correspondent  has  called  our  attention  to 
a  misdemeanor  perpetrated  by  the  publishers  of  the 
Aeu'  York  Times,  z.  journal  with  ordinarily  well-sus- 
tained pretensions  to  decency.  The  unlawful  act  was 
the  publication,  in  the  issue  of  October  31st,  of  the 
following  advertisement: 

"  Professional  title  wanted.  To  purchase  the  name, 
and  right  to  use  the  same,  of  a  retired  physician. 
Address,  with  full  particulars,  box  827,  New  York 
City." 

According  to  the  laws  relating  to  the  medical  pro- 
fession, w-hich  were  enacted  by  the  legislature  of  1893 
and  which  were  amended  by  the  legislature  of  1895, 
entitled  "chapter  661  of  the  laws  of  1893,  chapter  25 


of  the  general  laws,"  such  an  advertisement  becomes 
not  only  a  misdemeanor  for  the  person  who  purchases, 
but  for  all  those  who  aid  or  abet  it.  Thus,  chapter 
398  of  the  laws  of  1895,  which  is  an  amendment  to 
section  153,  reads : 

•■  Penalties  and  their  collection.  Any  person  who, 
not  being  then  lawfully  authorized  to  practise  medi- 
cine within  this  State  and  so  registered  according  to 
law,  shall  practise  medicine  within  this  State  without 
lawful  registration  or  in  violation  of  any  provision  of 
this  article;  and  any  person  who  shall  buy,  sell,  or 
fraudulently  obtain  any  medical  diploma,  license, 
record,  or  registration,  or  who  shall  aid  or  abet  such 
buying,  selling,  or  fraudulently  obtaining,  or  who 
shall  practise  medicine  under  cover  of  any  medical 
diploma,  license,  record,  or  registration  illegally  ob- 
tained or  signed  or  issued  unlawfully  or  under  fraud- 
ulent representations  or  mistake  of  fact  in  the  material 
regard;  ...  on  conviction  thereof  shall  be  punished 
by  a  fine  of  not  more  than  S250  or  imprisonment  for 
six  months  for  the  first  offence;  and  on  conviction  of 
any  subsequent  offence,  by  a  fine  of  not  more  than 
$500  or  imprisonment  for  not  less  than  one  year,  or  by 
both  fine  and  imprisonment." 

Very  probably  the  proprietors  of  the  New  York 
Times  did  not  know  of  the  unlawful  nature  of  their 
action  when  they  sold  the  space  for  this  advertise- 
ment, but  they  knew  they  were  aiding  and  abetting  a 
meretricious  quack  and  a  dishonest  rascal — one  who, 
if  he  succeeded  by  their  help  in  his  unlawful  quest, 
would  be  in  a  position  to  disobey  the  laws  of  the  State 
and  to  jeopardize  the  lives  of  those  who  might  be  led 
to  trust  him.  Certainly  the  publication  of  such  an 
advertisement  by  a  journal  which  claims  to  be  reputa- 
ble and  even  superior  in  virtue  to  its  rivals  is  extraor- 
dinary. This  paper  purports  to  have  "all  the  news 
that's  fit  to  print,"  but  its  high  morals  are  evidently 
not  proof  against  the  seductions  of  cash  advertise- 
ments. 


INHIBITION    OF    OSCULATORY    REFLEXES. 

A  YOUNG  physician,  a  member  of  the  house  staff  in 
Bellevue  Hospital,  is  in  considerable  trouble  in  con- 
sequence of  a  heinous  charge  of  forcibly  kissing  one 
of  the  trained  nurses  in  that  institution.  The  authori- 
ties have  promptly  suspended  him  in  order  that  the 
case  may  be  properly  investigated.  So  far  as  the 
facts  go  it  would  seem  to  prove  that  doctors,  espe- 
cially young  ones,  are  intensely  human,  even  if  they  are 
not  strictly  philosophical.  There  is  perhaps  less  ex- 
cuse for  a  professional  man  who  may  be  in  provoking 
contact  with  constant  temptation  to  forget  his  dignity 
than  for  ordinary  mortals.  He  is  supposed  to  have  a 
special  training  in  inhibiting  his  emotional  censes 
and  in  controlling  his  osculatory  and  other  responsive 
reflexes.  But,  psychologically  speaking,  when  toeing 
the  dead  line  of  professional  propriety,  there  is  often 
a  propensity  to  step  beyond  in  a  dangerous  area  of 
culpable  indiscretion.  The  only  excuse  may  be  that 
the  unfortunate  criminal  is  still  young  and  has  a 
great  deal  yet  to  learn.  When  the  positive  pole  of 
temptation  and   the  negative  pole  of  opportunity  are 


7o8 


MEDICAL    RECORD. 


[November  13,  1897 


in  close  proximity,  there  is  always  a  means  of  prevent- 
ing explosions  by  the  interposition  of  a  suitable  non- 
conducting material  of  impervious  unconcern.  Con- 
sequently it  was  all  wrong,  and  very  wrong,  for  the 
young  doctor  to  be  off  his  professional  guard.  It  is 
entirely  inexcusable  for  him  to  plead  the  baby  act  by 
magnifying  any  possible  provocation,  great  as  that 
might  have  been.  The  gauze  cap,  the  spotless  apron, 
the  graceful  carriage,  and  the  demure  demeanor  of  the 
unsuspecting  victim  have  nothing  to  do  with  the  re- 
sult. It  is  sad  to  think  that  the  young  man  should 
commence  a  promising  career  with  such  a  stain  on  his 
professional  escutcheon.  The  constant  menace  of  dan- 
ger should  have  doubled  his  means  of  resistance  to 
folly.  Whatever  may  be  the  outcome  of  this  deplor- 
able case,  the  grand  and  fundamental  principle  of  pro- 
fessional indifference  to  all  amatory  demonstrations 
should  be  rigidly  maintained;  otherwise  all  the  desir- 
able and  well-trained  nurses  may  desert  our  hospitals 
and  leave  our  patients  to  the  care  of  the  shiftless, 
unclean,  and  irresponsible  chore  woman. 


TUBERCULOSIS     IN    THE     KANSAS     STATE 
AGRICULTURAL    COLLEGE    HERD. 

Our  attention  has  been  called  to  a  report  on  tubercu- 
losis in  the  Kansas  State  Agricultural  College  herd, 
which  appeared  in  our  issue  of  September  nth.  This 
report  is  said  to  have  been  partly  incorrect.  A  jour- 
nal containing  a  correct  account  has  been  sent  us  from 
the  college.  We  gather  from  this  that  although  the 
whole  herd  of  cattle  is  affected  with  tuberculosis  and 
the  condition  of  the  hogs  and  sheep  is  suspected,  no 
mention  is  made  of  any  human  being  having  become 
infected.  On  that  point  we  must  have  been  misin- 
formed. We  may  add  that  a  committee  with  unlimited 
authority  has  been  appointed  to  investigate  fully  and 
thoroughly  the  affairs  of  the  college. 


Hexus  of  the  "Smeefe. 

The  Yellow  Fever.— The  weather  in  the  South  has 
until  the  last  few  days  again  been  warm,  but  that 
seems  to  have  had  no  unfavorable  effect  upon  the  prog- 
ress of  the  yellow  fever,  which  is  evidently  waning. 
The  new  cases  are  rapidly  diminishing  in  number, 
although  the  mortality,  as  is  usual  toward  the  close  of 
an  epidemic,  is  increasing  somewhat.  It  is  believed 
that  the  fever  will  have  disappeared  entirely  by  the 
middle  of  this  month,  and  the  New  Orleans  board  of 
health  has  announced  that  it  is  now  perfectly  safe  for 
persons  to  enter  the  city.  Among  the  most  recent 
victims  of  the  fever  is  Dr.  I.  M.  Wright,  of  Biloxi, 
Miss.,  whose  death  was  announced  on  November  8th. 
There  have  been  heavy  frosts  at  Memphis,  and  all 
quarantine  restrictions  have  now  been  raised. 
Throughout  the  South  also  the  shotgun  quarantines 
are  being  abolished,  passenger  and  freight  trains  are 
moving  again,  and  business  is  being  resumed  gener- 
ally. The  millions  of  dollars  that  have  been  lost 
through  this  senseless  fright  are,  however,  lost  for 
good  and  all. 


Ambulance  Surgeon  Tracy,  of  the  New  York  Hos- 
pital, in  responding  to  a  street  accident  "hurry  call" 
one  day  this  week,  found  in  the  injured  man  his  long- 
lost  brother.  In  a  town  of  this  size,  where  there  are 
so  many  other  men  who  it  might  have  been,  the 
incident  is  worthy  of  note. 

Post-Graduate  Medical  School  and  Hospital. — 
The  professorship  of  nervous  and  mental  diseases  in 
the  New  York  Post-Graduate  Medical  School,  made 
vacant  last  summer  by  the  resignation  of  Dr.  Charles 
L.  Dana,  has  been  filled  by  the  election  of  Dr.  Joseph 
Collins. 

New  York  Foundling  Hospital.  —  Dr.  Heniy  C. 
Coe  has  been  appointed  consulting  gynaecologist  to 
the  New  York  Foundling  Hospital,  to  fill  the  vacancy 
occasioned  by  the  death  of  Dr.  Lusk. 

New  Army  Surgeons. — Six  men  have  passed  the 
examination  held  recently  in  Washington  for  appoint- 
ment as  assistant  surgeons,  and  will  soon  be  commis- 
sioned by  the  President.  Seven  vacancies  existed, 
and  over  forty  candidates  appeared  for  them.  The 
young  men  who  will  be  appointed  are  George  Rauch- 
fuss,  of  New  York;  Bernard  S.  Higley,  of  Ohio: 
Henry  Page,  of  Maryland;  Bailey  K.  Ashford,  of 
Washington;  Henry  H.  Weber,  of  Massachusetts;  and 
Jere  B.  Clayton,  of  California.  The  new  assistant 
surgeons  will  be  required  to  take  a  course  of  instruc- 
tion in  the  Army  Medical  School  before  being  as- 
signed to  regiments.  There  is  still  one  vacancy  in 
the  medical  corps,  and  two  more  will  occur  this  month 
by  the  retirement  of  Lieutenant-Colonel  Walters  and 
Major  Corson. 

The  Plague  in  India  is  spreading  rapidly,  and  now 
threatens  all  the  northern  and  central  part  of  the 
peninsula.  Much  apprehension  has  been  caused  by 
its  appearance  at  Hurdwar  on  the  Ganges,  which  is  a 
centre  for  pilgrimages  and  is  frequented  by  great 
crowds  drawn  from  all  parts  of  India. 

Gymnastics  in  the  College  Curriculum. — The  Yale 

faculty  has  instituted  compulsory  gymnasium  work  for 
the  freshman  class.  Dr.  Anderson  will  have  charg  -  of 
the  course,  which  will  consist  of  two  hours  a  week, 
lasting  through  the  first  half  of  the  second  term.  Men 
who  are  in  regular  training  for  the  athletic  teams  and 
those  who  are  physically  disabled  will  be  excused. 
The  class  work  will  consii;t  partly  of  dumbbell  or 
wand  exercises,  and  later  heavy  gymnasticc,  to  which 
especial  attention  will  be  paid. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
November  6,  1897.  October  30th. — Passed  Assistant 
Surgeon  Adrian  R.  Alfred  detached  from  waiting 
orders  at  his  home,  Jeddo,  Mich.,  and  ordered  to  ma- 
rine recruiting  rendezvous,  San  Francisco,  Cal.  No- 
vember 2d. — Surgeon  P.  Fitzsimons  ordered  to  duty 
as  a  member  of  the  board  of  inspection  and  sur%-ey, 
Washington,  D.  C,  November  Sth;  Assistant  Surgeon 
G.  D.  Costigan  detached  from  the  Lancaster  and  or- 
dered to  the  Jiuiiaiia. 


November  13,  1897] 


MEDICAL    RECORD. 


709 


The  Guild  of  St.  Barnabas.— The  annual  meeting 
of  this  association  of  nurses  was  held  a  few  days  ago 
in  Orange,  N.  J.  The  active  membership  of  the  guild, 
composed  entirely  of  hospital  nurses,  now  numbers 
thirteen  hundred. 

The  Craig  Colony  for  Epileptics  at  Sonyea,  Liv- 
ingston County,  N'.  Y.,  closed  its  fourth  fiscal  year, 
September  30,  1897.  There  were  at  that  time  two 
hundred  and  fourteen  patients  in  the  colony,  the  ma- 
jority of  whom  had  been  transferred  from  the  various 
county  houses  throughout  the  State.  New  buildings 
are  in  course  of  construction,  which  when  completed 
will  enable  the  colony  to  accommodate  one  hundred 
and  forty  additional  patients,  making  the  total  popu- 
lation about  three  hundred  and  fifty.  It  is  estimated 
by  State  charit)'  officials  that  this  number  represents 
about  one-third  of  the  total  number  of  epileptics  now 
on  public  charge  throughout  the  State.  A  laboratory 
for  the  use  of  a  pathologist  and  pathological  chemist 
is  being  constructed.  Dr.  Christian  A.  Herter,  of 
New  York,  has  been  appointed  pathological  chemist, 
and  Dr.  Ira  Van  Gieson,  of  New  York,  consulting 
pathologist  to  the  colony.  Dr.  William  P.  Spratling 
continues  as  medical  superintendent  of  the  colony. 
Dr.  Frederick  Peterson,  of  New  York,  has  been  re- 
elected president  of  the  board  of  managers. 

The  New  York  State  Association  of  Railway 
Surgeons. — The  seventh  annual  meeting  of  this  society 
will  be  held  in  the  building  of  the  Academy  of  Medi- 
cine, in  this  city,  on  Tuesday,  November  16,  1S97. 
The  special  topic  for  discussion  will  be  "Traumatic 
Neurasthenia,"  and  several  papers  on  other  subjects 
are  announced  in  the  programme.  The  president  of 
the  association  is  Dr.  J-  Frank  Valentine,  of  Brooklyn, 
and  the  secretary.  Dr.  C.  B.  Herrick,  of  Troy. 

A  New  Swindle. — A  young  man  in  this  cit}-  has 
recently  adopted  a  new  way  of  making  a  living,  which 
has  worked  well  in  a  few  cases,  but  is  not  likely  to 
survive  publicity  for  a  great  length  of  time.  He  de- 
livers a  package  to  a  man  in  his  office,  pretending 
that  it  contains  medicine  ordered  by  the  victim's 
wife,  and  after  collecting  a  moderate  sum,  varying  in 
amount  from  fifty  cents  to  two  or  three  dollars,  departs. 
The  packet  is  inclosed  in  an  American  District  Tele- 
graph Company's  envelope,  and  when  opened  by  the 
mystified  wife  in  the  evening  is  found  to  contain  a  few 
grains  of  corn. 

The  Final  Echo  of  the  Medical  College  Consoli- 
dation Scheme.— On  November  4th  the  regents  of  the 
university  at  .Mbany,  in  accordance  with  the  request 
of  the  New  York  University  and  Bellevue  Medical 
College,  reconsidered  the  ordinance  of  April  8th,  pro- 
viding for  the  consolidation  of  the  two  medical  schools. 
and  the  matter  was  laid  on  the  table. 

Medical  Sufferers  from  Yellow  Fever.  —  Several 
young  practitioners  have  been  stricken  with  the  pre- 
vailing fever.  Fortunately  we  have  no  fatality  to 
record  for  October.  Drs.  J.  Bamett,  M.  J.  Magruder, 
H.  Oliiphant,  Otto  Lerch,  E.   P.  Lowe,   C.   J.   Miller, 


S.  G.  Kreeger  are  among  those  who  have  been  attacked, 
but  we  are  happy  to  state  that  they  have  all  made  good 
recoveries. — New  Orleafis  Medical  and  Surgical  Jour- 
nal. 

Surgeons  for  Inland  and  Coasting  Steamers. — 
The  Newport  (R.  I.)  Medical  Society  has  taken  up  the 
question  of  ship's  surgeons,  and  urges  upon  Congress 
the  passage  of  laws  compelling  passenger  steamers  in 
the  inland  and  coastwise  trade  to  carr)-  surgeons.  The 
committee  states  that  some  of  the  Sound  steamers 
sometimes  carry  as  many  as  a  thousand  passengers  on 
the  boat.  Although  the  trip  lasts,  as  a  rule,  only  nine 
hours,  still  there  are  times  when  the  boats  are  delayed 
for  hours,  and  it  would  be  in  keeping  with  the  human- 
ity of  the  times  to  have  a  physician  on  the  boat.  All 
the  steamboats  on  the  Sound,  on  the  Great  Lakes,  on 
the  long  rivers  where  passengers  are  often  for  days 
without  medical  aid,  practise  the  same  economy.  Our 
seagoing  steamers  running  South,  as  a  rule,  have  no 
physician  on  board.  Some  employ  the  device  of  em- 
ploying the  purser  as  surgeon,  and  when  he  is  pressed, 
owing  to  his  numerous  duties,  appoint  at  times  a  man 
who  is  not  any  more  qualified  than  the  purser  to  act 
as  surgeon's  assistant.  Such  steamers  as  those  run- 
ning from  Philadelphia  to  Portland  carry  often  thirty 
or  forty  passengers  and  a  crew  of  twenty  or  more,  and, 
being  often  out  three  days,  should  have  a  physician 
on  board.  It  is  a  very  common  practice  with  all  the 
transportation  companies  to  rely  upon  travelling  phy- 
sicians to  care  for  sick  seamen  and  passengers.  They 
receive  no  compensation  for  their  services  and  are  not 
even  returned  their  passage  money.  It  is  a  question, 
however,  whether  in  such  a  case  the  company  could 
not  be  compelled  to  compensate  the  physician  for  ser- 
vices rendered  at  the  request  of  the  captain  or  other 
responsible  employee. 

Sir  Alfred  B.  Garrod  cannot  be  called  a  rolling 
stone.  He  recently  celebrated  the  completion  of  his 
fiftieth  year  in  medical  practice,  and  it  then  was  said 
that  he  had  lived  the  half-century  in  the  same  house 
in  Harley  Street,  never  having  experienced  the 
delights  of  house  moving. 

Yellow-Fever  "  Experts."  — Since  the  outbreak  of 
yellow  fever  occurred  in  the  South  last  August,  legions 
of  so-called  "  experts"  have  sprung  into  existence,  and 
have  foisted  themselves  upon  press  correspondents 
and  a  patient  public  to  such  an  extent  that  there  is 
really  a  possibility  that  there  are  now  more  experts 
than  there  are  or  have  been  yellow-fever  patients. 
These  gentlemen  have  been  all  so  antagonistic  in  their 
diagnoses,  and  have  so  freely  expressed  themselves 
pro  and  con  whenever  a  fresh  outbreak  of  fever  v.as 
reported,  that  the  poor  befuddled  public  hardly  knew 
what  to  believe. — Memphis  Medical  Alonthly. 

The  Difficulty  of  Enforcing  Isolation  in  New 
Orleans. — Correspondents  of  the  Italian  papers  from 
New  Orleans  say  that  one  great  cause  of  the  spread  of 
yellow  fever  in  that  city  is  the  obstinacy  with  which 
the  Italian  residents  resist  the  efforts  of  the  health 
authorities  to  isolate  the  sick.  In  many  cases  it  has 
been  necessary  for  the  health  officers  to  go  through  the 


7IO 


MEDICAL    RECORD. 


[November  13,  1897 


Italian  quarter  under  the  protection  of  the  police,  so 
incensed  are  the  ignorant  inhabitants  by  the  enforce- 
ment of  the  necessary  precautions.  In  many  cases  they 
elude  the  vigilance  of  the  inspectors  and  smuggle  the 
sick  from  one  house  to  another,  spreading  the  disease 
in  every  direction. 

Physicians  to  Spare. — A  paragraph  is  going  the 
rounds  of  the  daily  press,  to  the  effect  that  Columbus, 
Ohio,  with  one  hundred  thousand  inhabitants,  has 
thirteen  hundred  physicians,  or  one  to  every  seventy- 
seven  persons. 

In  Favor  of  National  Control  of  Epidemics. — The 

board  of  supervisors  of  Warren  County,  Miss.,  recently 
adopted  unanimously  resolutions  declaring  it  "the 
deliberate  opinion  of  this  board  that  the  entire  subject 
of  quarantine  against  yellow  fever  and  other  infectious 
diseases  of  foreign  origin  ought  to  be  under  the  para- 
mount control  of  the  United  States,  the  experience  of 
the  present  system  and  spread  of  yellow  fever  this  year 
furnishing  conclusive  evidence  that  the  several  inde- 
pendent boards  of  health  of  the  States  bordering  on 
the  Gulf  of  Mexico  cannot  be  safely  relied  upon  to 
prevent  the  introduction  and  spread  of  infectious  and 
contagious  diseases." 

The  American  Electro-Therapeutic  Association — 
At  the  seventh  annual  meeting  of  this  society,  held  at 
Harrisburg,  Pa.,  the  following  officers  were  elected: 
President,  Dr.  Charles  R.  Dickson,  343  Sherbourne 
Street,  Toronto,  Ontario;  First  Vice-President,  Dr. 
Frederic  Schavoir,  8  Atlantic  Street,  Stamford,  Conn. ; 
Second  Vice-President,  Dr.  Caleb  Brown,  Sac  City, 
Iowa;  Treasurer,  Dr.  Richard  J.  Nunn,  1194^  York 
Street,  Savannah,  Ga. ;  Secretary,  Dr.  John  Gerin,  68 
North  Street,  Auburn,  N.  Y.  The  next  meeting  will 
be  held  in  Buffalo,  N.  Y.,  on  September  13,  14,  and 
15,  1898. 

The  Movement  for  the  Repression  of  Tuberculo- 
sis.— On  completing  the  twenty-fifth  year  of  his  reign, 
the  King  of  Sweden  has  given  2,200,000  kroner  to  be 
applied  toward  the  abatement  of  tuberculosis  by  the 
erection  of  sanatoria  and  other  means. 

Brooklyn  Police  Surgeons. — Brooklyn  is  to  have 
four  police  surgeons  at  $3,000  a  year  each  under  the 
new  charter.  The  civil-service  commissioners  have 
named  November  19th  as  the  date  for  the  competitive 
examination  for  the  places.  If  the  same  proportion 
prevails  as  at  the  recent  examination  to  fill  vacancies 
on  the  New  York  board  of  police  surgeons,  there  will 
be  one  hundred  and  sixty-four  competitors. 

Contract  Medical  Practice  Denounced. — The  Som- 
erset County  District  Medical  Society,  at  the  quarterly 
meeting  held  in  Somerville,  N.  J.,  October  28,  1897, 
passed  the  following  resolutions : 

"  Whereas,  The  members  of  this  society  are  fre- 
quently importuned  to  make  contracts  to  attend  private 
families,  the  members  of  various  societies,  lodges, 
etc.,  at  reduced  rates;  therefore  be  it 

"Resolved,  That  it  is  the  expressed  sentiment  of 
this  society  that  it  is  derogatory  lo  the  dignity  of  the 


medical  profession  for  any  regular  physician  to  sub- 
scribe to  any  such  contract; 

"  Resolved,  That  any  member  of  this  district  society 
who  hereafter  makes  any  contract  or  agreement  to 
attend  the  members  of  any  family,  society,  lodge,  or 
other  organization  for  a  fixed  sum  shall  be  considered 
as  violating  the  spirit  of  the  code  of  ethics,  and  such 
violation  shall  be  considered  sufficient  ground  for  ac- 
tion by  this  society  in  accordance  with  section  16  of 
the  bylaws  of  said  society; 

"  Resolved, 'YhsX  this  society  earnestly  recommends 
the  cancellation  of  any  existing  contracts  which  may 
be  opposed  to  the  spirit  of  these  resolutions;  and  be 
it  further 

" .^fj-^/'r^'^.  That  nothing  in  these  resolutions  shall 
be  construed  as  affecting  any  contract  of  a  local  sur- 
geon for  any  railroad  company  or  of  any  township  or 
county  physician,  or  any  position  under  municipal. 
State,  or  national  government." 

An  International  Leprosy  Society. — At  the  recent 
leprosy  congress  in  Berlin,  a  commission  was  ap- 
pointed to  prepare  plans  for  the  formation  of  an  Inter- 
national Leprosy  Society.  Professor  Virchow  is  the 
president  of  the  commission. 

An  Earthly  Paradise  is  what  Tlie  Lancet  calls 
Montagu  Square  in  London,  the  dwellers  on  which 
were  empowered,  by  a  private  act  passed  in  the  reign 
of  George  III.,  to  bring  offenders  before  the  magis- 
trate for  annoying  people  by  selling  newspapers  "and 
noisily  endeavoring  to  attract  attention  that  they  had 
newspapers  for  sale."  Three  boys  were  charged  with 
this  offence,  and  their  respective  mothers  made  to 
enter  into  their  recognizances  in  £.z^  to  bring  them  up 
for  judgment  if  called  upon.  Would  that  New  York- 
ers had  the  privilege  of  the  Montagu  Squarers  of 
damping  the  hideous  tones  of  the  loud-mouthed  e.xtra 
cries! 

Subscriptions  to  Charity  in  England.— During  the 
past  year  there  have  been  public  collections  for  chari- 
table objects  in  England  amounting  to  about  $4,000,- 
000.  Of  this  amount  $2,750,000  was  for  the  Indian 
famine  fund,  about  $1,000,000  for  the  various  jubilee 
funds,  and  the  balance  for  the  Hospital  Sunday  fund 
and  the  Maidstone  and  the  Montserrat  'elief  funds. 

The  Gloucester  Small-Pox  Epidemic. — The  report 
of  the  commission  investigating  the  epidemic  of  small- 
pox, which  served  as  England's  celebration  of  the  Jen- 
ner  centenarj-,  has  been  published,  and  affords  little 
consolation  to  the  antivaccinationists.  According  to 
the  official  figures,  the  unvaccinated  persons  attacked 
stood  to  the  vaccinated  attacked  in  the  proportion  of 
ninety-six  to  four,  while  among  the  entire  non-adult 
population,  those  attacked  and  those  not  attacked, 
there  were  eighty-three  unvaccinated  ones  to  seventeen 
vaccinated. 

Pay  by  the  Patient  and  Not  by  the  Visit.  -In 
Austria,  where  physicians'  fees  are  fixed  by  law  and 
are  therefore  small,  great  complaint  hr.s  been  made 
because,  if  a  physician  happened  to  attend  several 
members  of  one  family  at  the  same  time,  he  could  col- 


November  13,  1897] 


MEDICAL    RECORD. 


711 


lect  only  one  fee.  To  obviate  this  custom,  which  has 
natiirally  caused  physicians  much  loss,  it  has  lately 
been  decided  that  when  there  are  two  or  more  patients 
in  a  family,  the  doctor  can  charge  a  florin  per  patient 
instead  of  per  visit. 

The  Dangers  of  Self-Treatment.— The  postmaster 
of  Denver  died  on  November  ist  from  an  overdose  of 
morphine  pills,  which  he  had  taken  the  evening  before, 
supposing  them  to  be  cathartic  pills. 

The  Cumberland  County  (N.  J.)  Medical  Society. 
— The  semi-annual  meeting  of  this  society  was  held 
at  Bridgeton,  X.  J.,  October  12  th,  with  the  president. 
Dr.  H.  W.  Elmer,  in  the  chair.  A  paper  on  "  Some 
Favorite  Formula"  was  read  by  Dr.  J.  W.  Wade,  of 
Millville,  X  J.  Dr.  Edward  Fogg,  of  Roadstown,  and 
Dr.  L.  H.  Hummel,  of  Greenwich,  were  elected  to  ac- 
tive membership.  Dr.  J.  Chalmers  Da  Costa  and  Dr. 
Dav'd  Riesman,  of  Philadelphia,  were  elected  to  asso- 
ciate membership. 

New  York  Maternity  Hospital. — Dr.  Simon  Marx 
has  been  appointed  to  the  position  of  attending  sur- 
geon to  the  New  York  Matemitv'  Hospital. 

New  York  Obstetrical  Society — At  the  late  meet- 
ing of  the  New  York  Obstetrical  Society  the  following 
fellows  were  elected  officers  for  the  ensuing  year: 
President,  Dr.  W.  Gill  Wylie;  First  Vice-President, 
Dr.  J.  C.  Edgar;  Second  Vice-President,  Dr.  A.  M. 
Jacobus ;  Recording  Secretary,  Dr.  LeRoy_  Brown ;  As- 
sistant Recording  Secretary,  Dr.  George  W.  Jaroan; 
Corresponding  Secretary,  Dr.  E.  B.  Cragin ;  Treasurer, 
Dr.  J.  Lee  Morrill;  Pathologist,  Dr.  George  C.  Free- 
bom. 

Philadelphia  County  Medical  Society. — A  stated 
meeting  of  the  Philadelphia  Count}'  Medical  Society 
was  held  on  October  27th,  the  president.  Dr.  James 
Tyson,  in  the  chair.  Dr.  Herman  B.  Allyn  read  a 
paper  entitled  "  Typhoid  Fever  Occurring  in  a  Tuber- 
culous Subject  and  Complicated  with  Xephritis." 
He  reported  the  case  of  a  man  presenting  symptoms  of 
typhoid  fever,  together  with  a  positive  reaction  to  the 
Widal  test,  in  whose  sputum  tubercle  bacilli  were  re- 
peatedly found.  Recover}'  from  the  t}'phoid  fever  took 
place,  but  death  resulted  in  consequence  of  the  tuber- 
culosis. Upon  post-mortem  examination  pronounced 
tuberculous  lesions  were  found  in  the  lungs,  but  with- 
out any  evidence  immediate  or  remote  of  disease  of 
the  intestines.  Especial  interest  attached  to  the  pos- 
sibility of  concurrence  of  two  distinct  infections. 
Dr.  J.  W.  Croskey  reported  a  case  in  which  a  bit  of 
wood  almost  one  inch  long  and  one-fourth  of  an  inch 
thick  was  removed  from  the  upper  lid,  in  which  it  had 
been  lodged  under  the  retrotarsal  fold  for  a  period  of 
eight  months.  The  conjunctivitis  which  had  been 
present  disappeared  soon  after  the  removal  of  the 
foreign  body. 

Pathological  Society  of  Philadelphia. — A  stated 
meeting  of  the  Pathological  Society  of  Philadelphia 
was  held  on  October  28th,  the  president,  Dr.  \V.  E. 
Hughes,  in  the  chair.     Dr.  John  B.  Roberts  exhibited 


a  specimen  of  internal  strangulation  of  the  small 
bowel  by  a  thread-like  band  arising  from  the  lower 
portion  of  the  ileum  and  attached  to  the  anterior  ab- 
dominal wall.  Dr.  J.  M.  Swan  exhibited  a  specimen 
of  tuberculosis  of  the  kidney,  tubercles  being  distrib- 
uted in  the  course  of  the  blood-vessels  through  medulla 
and  cortex.  The  second  kidney  was  in  a  state  of 
chronic  parench}'matous  inflammation,  but  free  from 
tubercle.  Dr.  Swan  exhibited  also  a  dissecting  an- 
eurism of  the  arch  of  the  aorta.  Dr.  E.  R.  Schreiner 
exhibited  a  huge  malignant  new  growth  of  the  pyloric 
extremity  of  the  stomach,  with  secondary  deposits  in 
the  liver  and  also  a  small  pedunculated  papillomatous 
tumor  of  the  stomach.  Dr.  Riesman  exhibited  a 
brain  displaying  an  abnormally  long  basilar  artery, 
with  anomalous  branches,  and  also  a  brain  presenting 
a  small  translucent  tumor  behind  the  pituitary  body. 
Dr.  J.  H.  Musser  exhibited  a  huge  melanotic  sarcoma 
of  the  liver,  weighing  seventeen  pounds,  from  a  case 
in  which  a  similar  neoplastic  formation  of  the  choroid 
had  necessitated  removal  of  the  eyeball  more  than  a 
year  previously. 

Miss  Susan  J.  Brayton  is  one  of  the  matriculants 
in  the  New  York  Veterinary  College  this  year.  She 
is  the  daughter  of  a  stock  farmer,  and  if  she  takes  the 
full  course  will,  it  is  said,  be  the  first  woman  veteri- 
nary surgeon  in  America. 

Philadelphia  Polyclinic Dr.  H.  Augustus  Wilson 

has  resigned  the  chair  of  general  and  orthopaedic  sur- 
gery in  the  Philadelphia  Polyclinic,  and  has  been 
made  emeritus  professor.  Dr.  J.  P.  Crozer  Griffith  has 
resigned  the  chair  of  clinical  medicine.  Dr.  Charles 
W.  Burr  has  been  elected  professor  of  neuro-pathol- 
og}-;  Dr.  William  G.  Spiller,  professor  of  diseases  of 
the  nervous  system ;  and  Dr.  J.  W.  McConnell,  associ- 
ate in  diseases  of  the  nervous  system. 

An  Apology.  —  Our  esteemed  contemporar}',  the 
Medical  Age,  chides  us  for  commenting  upon  an  article 
which  appeared  in  its  columns  nearly  a  year  ago. 
We  did  not  know  that  the  editor  regarded  the  contents 
of  his  journal  as  of  such  ephemeral  value,  and  we  shall 
endeavor  in  future  not  to  disturb  the  quiet  of  the  bur- 
ied past.  We  should  not  have  offended  in  this  in- 
stance had  not  the  author  kindly  favored  us  with  a 
reprint  of  his  paper. 

Honors  for  Colored  Physicians. — Dr.  W.  B.  Fay- 
erman,  of  Atlantic  Q'ltv,  has  been  elected  a  member  of 
the  Atlantic  Count}'  Medical  Society.  He  is  the  first 
colored  physician  ever  accorded  this  honor.  New- 
Jersey  has  now  three  colored  physicians  members  of 
county  medical  societies — Dr.  Fayerman,  of  Atlantic 
County;  Drs.  Rholerfort  and  Wormley,  of  Essex. 

College  of  Physicians  of  Philadelphia. — A  stated 
meeting  of  the  College  of  Physicians  of  Philadelphia 
was  held  on  November  3d,  the  president.  Dr.  J.  M. 
DaCosta,  in  the  chair.  Dr.  John  Ashhurst,  Jr.,  read  a 
memoir  of  the  late  Dr.  Theodore  G.  Wormley,  and 
Dr.  Arthur  Van  Harlingen  read  a  paper  entitled 
"  Folliculitis  Nuchse  Sclerotisans  (Acne  Keloid),"  also 
exhibiting  a  specimen  of  this  variety  of  growth. 


712 


MEDICAL    RECORD. 


[November  13,  1897 


Bucks  County  (Pa.)  Medical  Society.  —  At  the 
annual  meeting  of  the  Bucks  County  Medical  Society, 
held  at  Doylestown,  Pa.,  on  November  3d,  Dr.  Frank 
R.  Swartzlander,  Jr.,  read  a  paper  on  "The  Serum 
Diagnosis  of  Typhoid  Fever;"  and  Dr.  William  R. 
Cooper,  of  Point  Pleasant,  Pa.,  and  Dr.  J.  H.  Fretz, 
of  Stockton,  N.  J.,  made  clinical  reports.  The  fol- 
lowing officers  were  chosen  for  the  ensuing  year:  Fres- 
idetit.  Dr.  J.  N.  Richards,  Fallsington ;  Vice-President, 
Dr.  C.  D.  Fretz,  Jr.,  Sellersville;  Secretary,  Dr.  A.  T. 
Myers,  Blooming  Glen ;  Treasurer,  Dr.  Frank  Swartz- 
lander, Doylestown;  Board  of  Censors,  Dr.  A.  M. 
Cooper,  Point  Pleasant;  Dr.  William  Stavely,  Lahas- 
ka;  and  Dr.  George  M.  Grim,  Ottsville. 

Obituary  Notes. — Dr.  Joseph  E.  Culver  died  at 
his  home  in  Jersey  City  on  November  ist,  of  pneumo- 
nia, at  the  age  of  seventy-four  years.  He  was  a  grad- 
uate of  the  College  of  Physicians  and  Surgeons  in  this 
city  in  1849.  He  was  one  of  the  founders  of  the 
Hudson  County  Medical  Society,  and  was  a  member 
of  the  Pathological  Society  and  of  the  Neurological 
Society  in  New  York.  Four  sons,  two  of  whom  are 
physicians,  survive  him.— Dr.  James  G.  Sloan,  a 
member  of  the  Pennsylvania  State  legislature,  died  at 
Monongahela  City,  Pa.,  on  November  2d,  at  the  age 
of  fifty-six  years.  He  was  graduated  from  Jefferson 
College  in  1862,  and  a  week  later  he  enlisted  in  com- 
pany G,  Pennsylvania  volunteers,  serving  until  the 
close  of  the  war.  He  then  served  for  four  years  in 
the  land  office  bureau  of  the  interior  department  at 
Washington,  D.  C  ,  and  was  graduated  from  George- 
town Med'orl  College  in  1869.  He  was  elected  a 
member  of  the  Pennsylvania  legislature  in  1896. 

A  Mattei  Cancer  Hospital. — The  late  Count  Mattel, 
who  apparently  r-ally  believed  in  his  "electric"  treat- 
ment of  cancer,  left  directions  in  his  will  for  the  foun- 
dation of  a  hospital  in  which  cancer  sufferers  may  be 
treated  according  to  his  methods. 

Medical  Practice  Regulations  in  Illinois. — The 
State  board  of  health  of  Illinois  has  decided  that  after 
May  I,  1898,  all  non-graduate  applicants  for  license 
to  practise  medicine  and  surgery,  who  are  examined 
in  accordance  with  the  provisions  of  the  medical  prac- 
tice act,  in  addition  to  the  requirements  already  ex- 
acted, must  present  as  evidence  of  a  satisfactory  pre- 
liminary education  either  (i)  a  diploma  or  certificate 
of  graduation  from  a  high  school;  (2)  a  certificate  of 
having  passed  the  matriculation  examination  to  a  rec- 
ognized literary  or  scientific  college;  or  (3)  a  certi- 
ficate of  successful  examination  by  the  faculty  of  any 
reputable  university  or  college  of  arts  or  science  (not 
members  of  a  medical  college  faculty),  by  the  State 
superintendent  of  public  instruction  of  Illinois,  or  by 
the  principal  of  a  high  school  in  Illinois,  in  the  fol- 
lowing branches:  English  grammar,  arithmetic,  ele- 
mentary physics.  United  States  history,  geography, 
and  Latin  (equivalent  to  one  year  in  a  high  school). 
Each  candidate  will  also  be  required  to  present  a  cer- 
tilicate  from  a  medic.il  college  in  good  standing  with 
the  board,  attesting  that  the  applicant  has  (i)  pur- 
sued the  study  of  practical  anatomy  in  said  college  for 
at  least  one  term  and  has  made  dissections  of  the  en- 


tire cadaver;  (2)  taken  at  least  one  full  course  in 
operative  surgery  and  practical  obstetrics;  and  (3) 
personally  attended  six  or  more  cases  of  labor.  Bac- 
teriolog)'  has  been  added  to  the  subjects  of  the  non- 
graduate  examination. 

The  Chewing-Gum  Habit,  we  learn  from  the  Brit- 
ish Medical  Journal,  has  been  taken  up  ii.  England  by 
many  young  women — students,  actresses,  and  others — 
who  have  become  inveterate  chewers.  A  few  days  ago 
an  inquest  was  held  at  Lincoln  on  a  child,  eight  yeafs 
of  age,  who  died  from  the  effects  of  eating  a  pellet  of 
the  substance.  The  symptoms  preceding  death  were 
those  of  gastritis,  and  at  the  post-mortem  examination 
it  was  found  that  the  mucous  membrane  of  the  stomach 
was  inflamed  and  that  there  was  much  local  peritoni- 
tis. The  coroner  pointed  out  that  the  distribution  of 
such  dangerous  stuff  to  young  children  was  a  very  im- 
proper proceeding,  and  the  jury,  in  indorsing  his  re- 
marks, added  that  in  its  opinion  the  sale  should  be 
absolutely  prohibited. 

Tuberculosis  in  Cigars. — According  to  the  news- 
papers. Dr.  J.  C.  Spencer,  bacteriologist  of  the  board 
of  health  of  San  Francisco,  reports  that  he  has  discov- 
ered the  bacilli  of  tuberculosis  in  cigars. 

Bequests  to  Hospitals Under  the  will  of  the  late 

George  M.  Pullman,  thirteen  hospitals  and  charitable 
institutions  of  Chicago  will  receive  $10,000  each. 

Dr.  Marion  Hunter,  niece  of  Sir  William  Hunter, 
has  been  appointed  the  female  member  of  the  British 
medical  corps  sent  out  to  combat  the  plague  in  India. 
She  was  until  recently  the  only  woman  physician  hold- 
ing the  Cambridge  diploma  of  public  health. 

The  Southern  Surgical  and  Gynae  :ological  Assso- 
ciation  held  its  tenth  annual  meeting  at  St.  Louis,  Mo., 
on  November  9,  10,  and  11,  1897. 

Typhoid  Fever  in  a  London  Hospital. — Eighteen 

or  twenty  of  the  nurses  and  ward  helpers  at  University 
College  Hospital,  London,  have  recently  suffered 
from  typhoid  fever.  The  outbreak  was  due  to  a  sin- 
gular piece  of  stupidity  on  the  part  of  the  authorities. 
All  those  attacked  took  the'r  meals  in  a  temporary 
dining-room,  which  had  been  provided  for  them  be- 
cause certain  houses  in  which  they  had  been  previously 
accommodated  were  pulled  down  on  acco-nt  of  the 
rebuilding  of  th.,  hospital.  The  water  wh.ch  '  .d  been 
used  in  this  room  for  drinking,  instead  of  being  taken 
from  the  main,  as  is  usual  throughout  the  hospital, 
was  drawn  from  a  cistern  which  became  contaminated 

Yersin's  Antiplague  Serum — It  is  reported  from 
Bomb.ay  that  Yersin  has  had  much  success  with  his 
antiplague  serum,  the  only  cases  not  amenable  to  treat- 
ment being  those  whi-h  were  seen  too  late,  the  disease 
having  already  become  firmly  established  and  the  pa- 
tient being  practically  moribund. 

Many  Want,  Few  Get. — A  civil-service  examina- 
tion for  appointment  on  the  staff  of  police  surgeons 
was  held  last  week  at  police  headquarters  in  this  city. 
There  were  two  vacancies,  and  the  competitors  num- 
bered eighty-two. 


November  13,  1897] 


MEDICAL    RECORD. 


713 


AMERICAN   PUBLIC  HEALTH  ASSOCIATION. 

Abstract  of  Proceedings  of  the  Twenty-Ffth  Annual 
Meeting,  Held  in  Ptiiladelphia,  October  26,  2j,  28, 
and  2g,  iSgj. 

First  Day — Morning  Session. 

The  association  met  at  Hotel  Walton,  and  was  called 
to  order  by  the  president,  Dr.  Henry  B.  Horlbeck, 
of  Charleston,  S.  C. 

After  the  transaction  of  some  routine  business,  the 
reading  of  reports  and  papers  was  begun. 

Report  of  Committee  on  Steamship  and  Steam- 
boat Sanitation. — This  was  read  by  Dr.  Frederick 
MoxriZAMBERT,  general  superintendent  of  quarantine 
of  the  Dominion  of  Canada,  in  which  he  directed  at- 
tention to  the  bedding  of  passengers — those  portions 
of  it  which  are  not  regularly  laundried,  blankets,  mat- 
tresses, and  pillows,  saying  they  should  be  freely  ex- 
posed to  the  air,  and,  if  possible,  to  the  sunshine  after 
each  trip.  The  somewhat  common  usage  on  inland 
steamboats  of  having  the  dining-room  on  a  deck  below 
the  water  line  was  not  to  be  commended.  Such  a  posi- 
tion rendered  proper  cleanliness  and  ventilation  more 
difficult  and  tended  to  unwholesomeness.  Reference 
was  made  to  the  all-important  matter  of  the  exposure 
of  the  travelling  public  on  steamboats,  as  elsewhere,  to 
the  danger  of  contracting  disease  from  fellow-travel- 
lers suffering  with  consumption,  who  in  their  expec- 
torations scattered  infectious  material  broadcast.  Ob- 
jectionable and  indefensible  as  it  was  at  all  times,  with 
steamboat  saloons  closed  and  artificially  heated,  the 
expectorator's  filthy  habit  became  especially  danger- 
ous to  other  passengers.  The  sputa  drying  on  the 
decks  rose  as  dust  to  be  inhaled,  and  to  add  to  the 
great  list  of  the  victims  of  this  fell  destroyer  of  man- 
kind. All  spittoons  should  contain  water  or  a  dis- 
infectant, which  should  be  frequently  changed.  With 
the  advancing  education  of  the  general  public  in  the 
knowledge  and  belief  in  the  contagiousness  of  con- 
sumption, and  the  methods  to  be  employed  to  limit 
and  prevent  its  spread,  an  ever-increasing  degree  of 
success  might  be  confidently  hoped  for. 

A  Study  of  Yellow  Fever  from  a  Medico-Geo- 
graphical Point  of  View. — Dr.  Eduardo  Liceaga, 
president  of  the  supreme  board  of  health  of  Mexico, 
contributed  this  paper,  which  was  read  by  Dr.  Gihon 
in  the  absence  of  the  author.  The  writer  said  in  part 
that  in  the  port  of  Vera  Cruz,  which,  as  had  already 
been  shown,  could  be  considered  one  of  the  sources  in 
which  the  yellow-fever  germ  obtained  a  spontaneous 
growth,  only  three  cases  of  the  disease  had  ap- 
peared during  a  period  under  study,  and  these  three 
cases  occurred  within  the  month  of  June.  With  re- 
spect to  other  points  on  the  Gulf  coast,  and  especially 
the  ports,  it  could  safely  be  asserted  that  during  the 
period  covered  by  this  report  not  a  single  case  of  yel- 
low fever  had  presented  itself.  Passing  to  the  Pacific 
coast,  and  bearing  in  mind  the  terrible  epidemic  that 
in  the  year  1884  desolated  the  coast,  the  supreme 
board  of  health  of  Mexico  had  taken  especial  care  to 
prevent  the  disease  from  being  imported  from  the 
Central  American  countries,  where  unfortunately  it 
now  prevailed  in  an  epidemic  form.  Difficulties  were 
still  encountered  in  making  an  exact  diagnosis  between 
yellow  fever  and  certain  forms  of  paludic  infection 
that  in  hot  countries  assume  a  very  similar  aspect  and 
the  serious  character  that  is  generally  borne  by  that 
disease,  so  much  so  that  even  persons  who  were  accus- 
tomed to  observe  the  two  affections  were  often  uncertain 
as  to  the  diagnosis.     These  doubts,  the  speaker  hoped, 


would  be  dissipated  in  the  future  by  reason  of  the  dis- 
covery of  the  yellow-fever  microbe  by  Sanarelli.  A 
knowledge  of  the  cause  of  the  disease  would  not  only 
allow  us  to  make  an  exact  diagnosis,  but  would  doubt- 
less facilitate  the  means  for  attacking  it  in  an  effective 
manner. 

D.  Samuel  H.  Durgin,  of  Boston,  spoke  of  the  im- 
portance of  closer  and  more  careful  bacteriological 
work  in  the  study  of  yellow  fever. 

The  Drainage,  Plumbing,  and  Ventilation  of  Pub- 
lic and  Private  Buildings. — A  paper  on  this  subject 
was  read  by  Mr.  J.  W.  Hughes,  of  Montreal.  The 
author  confined  himself  to  the  ventilation  of  the  plumb- 
ing-system of  a  building,  or  more  correctly,  that  part 
of  a  plumbing-system  which  served  for  the  conveyance 
of  the  house  wastes  known  as  sewage,  and  that  were  to 
be  finally  disposed  of,  as  far  as  any  particular  building 
was  concerned,  when  they  reached  the  public  sewer. 
It  was  no  more  possible  to  lay  down  rules  covering 
every  contingency  arising  in  scientific  plumbing  and 
ventilating  than  it  was  to  apply  fixed  rules  to  the 
practice  of  medicine.  The  principles  of  scientific 
medicine  and  plumbing  were  fixed,  but  the  applica- 
tion of  these  principles  called  for  the  intelligence 
acquired  by  education  and  developed  by  practice. 
Much  injury  had  been  done  by  attempting  to  frame 
plumbing-laws  which  would  apply  to  every  case.  If 
the  association  would  make  a  study  of  the  general 
principles  covering  this  question  and  embody  them  in 
a  code  having  its  indorsement,  leaving  the  practical 
application  of  those  principles  to  those  whose  special 
duty  it  was  to  apply  them,  much  good  would  result. 


First  Day — Afternoon  Session. 

Dr.  John  L.  Leal,  health  officer  of  Paterson,  N.  J., 
followed  with  a  paper  on  the  same  subject,  in  which 
he  emphasized  three  points  bearing  upon  the  question 
of  ventilation:  ist.  That  every  building  intended  for 
occupancy  should  have  some  special  means  of  ventila- 
tion. 2d.  That  these  means  should  be  commensurate 
with  the  requirements  of  any  particular  building.  3d. 
That  the  more  simple  and  uncomplicated  the  means 
used,  the  more  successful  was  likely  to  be  their  opera- 
tion. The  objects  of  plumbing  were:  ist,  the  imme- 
diate withdrawal  from  a  building  of  certain  waste 
products  of  life,  the  presence  of  which  would  prove 
detrimental  to  health:  and,  2d,  to  prevent  harm  to  the 
inmates  of  the  said  building  arising  from  these  products 
after  removal,  through  the  means  of  their  removal. 
Not  only  were  we  threatened  by  the  presence  of  these 
substances,  but  we  were  also  threatened  by  certain  dan- 
gers inherent  in  the  best  system  at  our  disposal  for 
ridding  ourselves  of  them. 

Report  of  the  Committee  on  Car  Sanitation. — This 
report,  by  Prof.  S.  H.  Wooderidge,  of  the  Institute  of 
Technology,  Boston,  was  read  by  Dr.  Durgi.n  in  the 
absence  of  the  author.  The  author  stated  that  some- 
thing like  interstate  agitation  and  regulation  were  re- 
quisite to  any  legislative  advancement  in  this  field  of 
hygienic  improvement.  For  this  reason  it  seemed  the 
better  way  that  the  movement  should  originate  within 
or  be  fostered  by  some  strong  railroad  corporation 
which  would  set  the  pace  for  other  railroads  event- 
ually to  put  themselves  in  step  with.  The  writer  de- 
scribed a  new  type  of  improved  parlor  and  sleeping 
car  which  had  been  devised. 


First  Day — Ei'ening  Session. 

To  this  session  the  public  was  invited.  Prayer 
was  offered  by  Rev.  William  N.  McVickar,  D.D.,  of 
Philadelphia. 

Dr.  Benjamin  Lee,  in  the  absence  of  Governor 
Hastings,  welcomed  the  members  and  visitors  on  the 


714 


MEDICAL    RECORD. 


[November  13,  1897 


part  of  the  Commonwealth,  and  Mayor  Warwick  ex- 
tended to  them  the  hospitality  of  the  city.  The  mayor 
referred  feelingly  to  the  life  work  of  the  late  Dr.  Wil- 
liam H.  Ford  in  the  cause  of  municipal  sanitation, 
after  which  the  address  of  President  Horlbeck  was 
delivered. 

Speaking  of  the  progress  made  in  the  study  of  dis- 
ease, President  Horlbeck  said  that  the  theory  based 
upon  the  humors  of  the  blood  had  given  place  to  a 
knowledge  of  the  denizens  of  the  blood,  which  were 
being  recognized  as  surely  as  the  flora  and  fauna  of 
our  fields.  The  microscope  gave  us  the  keynotes  of 
our  temporal  welfare.  He  then  gave  a  history  of  the 
association  from  its  organization  in  1872,  which  he 
said  had  grown  until  there  were  now  one  thousand 
eight  hundred  and  forty-four  names  enrolled  in  its 
membership.  During  its  existence  some  of  the  most 
important  discoveries  in  the  domain  of  medicine  and 
surgery  had  been  made,  and  the  science  of  bacteri- 
ology had  had  its  birth  and  development.  Since  the 
last  annual  meeting  in  Buffalo  the  method  of  diagnos- 
ticating typhoid  fever,  as  discovered  and  described 
by  Widal,  of  Paris,  had  been  elucidated  by  Wyatt 
Johnston,  of  Montreal.  During  the  twenty-five  years 
of  the  life  of  the  association  the  processes  of  taking 
care  of  contagious  diseases  had  entirely  changed.  It 
was  now  an  essential  feature  of  practice  in  all  com- 
munities to  confine  all  such  cases  to  the  individaul 
affected.  He  next  dwelt  upon  the  necessity  for  a  pure 
water  supply,  and  then  passed  on  to  the  consideration 
of  quarantine  methods.  He  recommended  a  govern- 
ment commission  on  yellow  fever.  It  was  estimated 
that  over  ninety-five  per  cent,  of  all  the  yellow  fever 
cases  that  had  reached  our  shores  had  come  from 
Havana.  A  committee  of  the  association  had  been 
appointed  to  bring  the  vital  question  before  the  gov- 
ernments of  this  country  and  to  urge  the  governments 
of  the  countries  interested  to  prompt  action  in  this 
matter.  This  would  seem  to  be  the  occasion  when  not 
only  the  recommendations  of  the  committee  on  yellow 
fever  should  be  carried  out,  but  also  the  association 
should  make  a  demand  on  our  general  government  to 
the  effect  that  a  commission  of  expert  bacteriologists 
be  sent  to  Havana  and  Rio  and  be  kept  there  until 
the  materies  morbi  had  been  discovered,  until  the 
secrets  of  this  dread  disease  had  been  unfolded.  The 
examples  of  other  countries  in  the  solution  of  the 
problems  involved  in  cholera,  tuberculosis,  bubonic 
plague,  and  leprosy  were  noted,  and  the  question  was 
asked,  why  should  we  not  solve  the  problems  of  yellow 
fever?  He  recommended  that  a  committee  from  the 
association  be  appointed  to  wait  upon  the  President 
of  the  United  States  with  a  view  to  carrying  out  this 
idea.  Finally,  reference  was  made  to  the  experiments 
carried  on  by  the  State  board  of  health  of  Massachu- 
setts at  Lawrence,  on  the  utility  of  filtration  of  water 
supply  with  reference  to  the  removal  of  typhoid  germs, 
the  average  result  being  the  removal  of  ninety-eight 
and  a  half  per  cent,  of  the  germs.  A  diminution  of 
sixty  per  cent,  in  typhoid  cases  at  Lawrence  had  been 
the  result  of  sand  filtration. 


Second  Day — Alonting  Session. 

Report  of  the  Committee  on  Pollution  of  Water 
Supplies.— Dr.  Charles  Smart,  of  Washington,  D.  C, 
read  the  report,  which  stated  that  the  committee  had 
been  chiefly  engaged  in  perfecting  the  standard 
methods  of  bacteriological  research.  The  committee 
felt  that  it  should  be  discharged  from  its  duties,  and 
that  a  new  one  should  be  appointed,  which  should  con- 
sist of  a  couple  of  men  who  were  practically  acquainted 
with  municipal  water  supplies,  a  couple  more  who 
knew  effectively  the  chemical  aspects  of  the  subject, 
and,  finally,  a  like  number  who  knew,  as  it  should  be 


known,  the  bacteriolog)'  of  the  subject.  The  com- 
mittee had,  however,  announced  the  bacteriological 
formula;  for  use  in  laboratories.  In  accordance  with 
the  suggestion  the  committee  was  discharged. 

Disinfectants — Prof.  Franklin  C.  Robinson,  of 
Maine,  spoke  on  the  subject  of  disinfectants.  He 
said  he  could  not  help  noting  how  rapidly  the  knowl- 
edge and  use  of  formaldehyde  had  spread.  Only  one 
year  ago  it  was  practically  unknown  in  the  United 
States.  There  was  no  apparatus  for  generating  it  in 
quantity  except  the  one  that  was  exhibited  then.  Now 
probably  most,  if  not  all,  of  the  members  had  used  it. 
He  ventured  to  predict  that  we  were  far  from  knowing 
all  about  it,  and  that  a  year  from  now  greater  progress 
would  be  seen  than  during  the  past  year. 

Dr.  E.  a.  de  Schw-einitz,  of  Washington,  D.  C, 
followed  with  a  paper  on  the  determination  of  the 
amount  of  formaldehyde  yielded  by  the  formaldehyde 
lamp;  and  Prof.  S.  Burrage,  of  Lafayette,  Ind., 
made  some  remarks  on  fumigation  experiments  with 
formaldehyde. 

Diagnosis  of  Small-Pox. — Dr.  Frank  W.  Wright, 
of  New  Haven,  read  this  paper.  He  said  that  an  early 
diagnosis  of  small-pox  was  of  great  importance.  Next 
to  vaccination  this  was  the  most  essential  factor  in 
preventing  the  disease  from  spreading.  If  all  cases 
of  small-pox  were  typical  it  would  not  be  difficult  to 
make  a  correct  diagnosis;  but  in  these  days  of  gen- 
eral vaccination  typical  small-pox  was  seldom  seen,  the 
great  majority  of  the  attacks  being  modified  by  former 
vaccinia  and  commonly  spoken  of  as  varioloid;  but 
we  might  call  them  modified  small-pox.  If  by  chance 
a  health  officer  should  fail  to  recognize  a  case  of 
small-pox  and  the  disease  should  spread,  he  would  be 
subjected  to  verj-  severe  criticism  and  would  probably 
be  removed  from  his  position  in  disgrace.  On  the  other 
hand,  if  he  should  declare  some  disease  that  resem- 
bled modified  small-pox  as  that  disease  and  future 
events  proved  that  a  mistake  had  been  made,  he  would 
be  just  as  severely  criticised,  and  would  probably 
have  to  defend  himself  in  a  suit  for  damages. 

Second  Day — Afternoon  Session. 

The  Barber   Shop   as   a   Menace   to   the   Public 

Health Dr.  A.  Walter  Suiter,  of  Herkimer,  N.  V., 

read  a  paper  with  this  title.  It  seemed  that  the  time 
had  arrived  when  the  attention  of  public  health  au- 
thorities should  be  called  to  that  part  of  hygiene 
which  applied  to  the  barber  shop.  The  first  attempt 
of  modern  times  to  regulate  sanitarily  the  operations 
of  tlie  barber  shop  was  recently  made  in  the  city  of 
Paris.  As  a  public  regulation  and  by  direction  of  the 
sanitary  authorities,  an  order  had  been  promulgated  re- 
quiring that  for  the  protection  of  the  public  specific 
rules  of  asepsis  and  disinfection  shall  be  observed  in 
all  shops.  One  evening,  several  years  ago,  a  sheep- 
ish-looking individual  shuffled  his  way  into  the  au- 
thor's waiting-room  and  requested  a  prescription.  He 
was  observed  to  be  suffering  from  disease  and  pre- 
sented a  most  unattractive  appearance;  his  face  was 
literally  covered  with  eruptions  and  his  mouth  and 
lips  were  ulcerous  in  high  degree  with  mucous  patches. 
The  man's  case  was  disposed  of  and  he  was  gladly 
dismissed.  Having  to  take  an  early  train,  Dr.  Suiter 
shortly  afterward  proceeded  to  the  barber  shop  to  pre- 
pare for  his  toilet.  His  barber's  chair  was  occupied 
and  he  sat  down  to  await  his  call.  As  the  occupant 
was  about  to  arise  he  was  startled  to  obser\e  the  very 
patient  for  whom  he  had  prescribed  an  hour  before. 
It  is  needless  to  say  that  he  took  his  departure.  Then 
and  there  he  resolved  that  his  face  should  never  again 
be  shaved  by  a  barber. 

Meat  Inspection.— Prof.  Leonard  Pearson,  of 
Philadelphia,  discussed  the  subject  of  meat  inspec- 


November  13,  1897] 


MEDICAL    RECORD. 


715 


tion.  Reference  was  first  made  to  the  amount  of  meat 
consmned  by  the  various  peoples  of  the  world  and  to 
the  methods  of  inspection  followed  in  Europe  and  in 
America.  Since  the  bacterial  origin  of  many  diseases 
had  been  demonstrated,  and  the  close  relationship  of 
many  of  the  diseases  of  man  and  animals  had  been 
established,  the  importance  of  rational  meat  inspec- 
tion had  been  greatly  emphasized. 

Dr.  Edward  Jacksox,  of  Philadelpnia,  spoke  of  eye 
strain  from  poor  window  glass,  and  said  the  bad  influ- 
ence of  defective  window  glass  was  intensified  by  the 
eye  having  to  look  through  different  parts,  causing 
different  kinds  of  strain,  with  the  result  that  the  eye 
could  not  adjust  itself  so  as  to  work  to  the  best  ad- 
vantage. Even  if  the  defects  in  the  glass  were  com- 
paratively slight,  at  a  certain  distance  they  would  cause 
serious  strain  similar  to  that  of  astigmatism. 

Dr.  E.  p.  Lachapelle,  of  Montreal,  followed  with 
the  report  of  the  committee  on  transportation  of  dis- 
eased tissue  by  mail,  in  which  he  said  that  the  postal 
authorities  of  Canada  had  lately  given  their  consent 
to  the  use  of  the  mails  for  this  purpose,  this  result 
being  largely  due  to  the  valuable  help  received  from 
the  newly  appointed  deputy  postmaster-general,  who, 
being  a  physician,  was  quite  an  fait  as  to  the  import- 
ance of  the  demand.  As  regarded  the  United  States  it 
might  be  said  that,  since  the  use  of  the  mails  had  been 
granted,  the  State  board  of  health  of  New  Jersey,  at 
least,  which  had  fully  availed  itself  of  the  privilege, 
had  not  detected  any  case  of  infection  traced  to  the 
circulation  through  the  mails. 


Third  Day — Morning  Session. 

Health  Legislation. — The  report  of  the  committee 
on  health  legislation  contained  a  proposed  bill  to  es- 
tablish a  department  of  public  health,  the  latter  to  be 
under  the  control  and  management  of  a  commissioner 
of  public  health,  who  should  be  a  regularly  educated 
physician,  appointed  by  the  President  of  the  United 
States,  and  whose  term  of  office  should  be  six  years. 

Surgeon-Gexeral  George  M.  Sterxberg,  of 
Washington,  spoke  in  regard  to  the  bacillus  of  yellow- 
fever,  with  which,  in  common  with  Sanarelli,  his  name 
is  so  prominently  identified. 

Dr.  J.  E.  Moxjaras,  of  San  Luis  Potosi,  Me.xico, 
spoke  of  the  necessity  for  adopting  an  international 
classification  of  the  professions. 

Dr.  Peter  Bryce,  of  Toronto,  read  a  paper  in  which 
he  emphasized  the  view  that  in  dealing  with  tubercu- 
losis it  was  the  duty  of  the  State  to  do  whatever  could 
be  done  by  the  individual. 

Consumption  as  an  Indoor  Disease. — Dr.  SA^ruEL 
VV.  Abbott,  of  Wakefield,  Mass.,  followed  with  a  paper 
on  this  subject,  saying  that  no  form  of  infection  had 
been  studied  with  greater  interest  during  the  past 
quarter  of  a  century  than  that  of  tuberculosis.  As 
proofs  that  consumption  was  an  indoor  disease,  he  first 
called  attention  to  the  evidence  shown  by  occupations, 
and  secondly,  to  evidence  presented  by  the  conditions 
of  age  and  se.x. 

At  the  close  of  the  morning  session  the  members 
visited  the  Medico-Chirurgical  College  and  Hospital 
of  Philadelphia,  where  they  were  entertained  at  a 
luncheon,  and  were  afforded  an  opportunity  of  in- 
specting the  splendid  new  amphitheatre  and  the  vari- 
ous appointments  of  the  institution. 


districts  of  our  large  cities,  unconsciously  disseminat- 
ing the  germs  of  their  diseases  among  their  own  kin, 
friends,  and  neighbors,  or  who  crowded  the  wards  of 
our  general  hospital  to  the  detriment  and  danger  of  the 
patients  suffering  from  acute  diseases,  had  become  for 
the  sanitarian  one  of  the  vital  issues  of  the  day.  A 
number  of  well-known  sanitarians  were  quoted  as  ex- 
pressing the  belief  that  the  only  solution  of  the  ques- 
tion was  the  erection  of  special  sanatoriums  under  mu- 
nicipal control.  Two  other  papers  were  read  on  the 
subject  of  consumption.  One  dealt  with  bovine  tuber- 
culosis in  its  relation  to  the  public  health,  and  the 
other  with  tuberculosis  and  milk  supply. 

Dr.  Lawrexce  L.  Flick,  of  Philadelphia,  in  dis- 
cussing the  papers,  said  that  no  hope  of  accomplishing 
great  results  could  be  looked  for  until  the  public  was 
educated  on  the  subject  of  the  infectiousness  of  the 
disease.  This  education  was  going  on,  and  in  Phila- 
delphia in  the  last  ten  years  there  had  been  a  reduction 
of  the  disease  by  one-third. 

Dr.  Lydia  Rabinowitsch,  of  Philadelphia,  told  of 
the  experiments  which  she  had  made  in  the  past  two 
years  with  butter  and  milk.  In  milk  she  had  found 
from  twenty  to  thirty  per  cent,  of  tubercle  bacilli.  In 
eighteen  samples  of  butter  from  different  store*  she 
had  not  found  the  bacillus  of  tuberculosis,  but  had 
found  a  micro-organism  which  very  much  resembled  it. 

Dr.  E.  F.  Stewart,  of  East  Orange,  N.  J.,  presented 
a  paper  entitled  "A  Plan  for  Purifying  Water." 

Investigations  of  Water   Supply  by  the  United 

States  Geological  Survey Mr.  F.  H.  Newell,  of 

Washington,  D.  C,  followed  with  a  paper  in  which 
he  said  it  had  been  demonstrated  again  and  again  that 
purification  of  sewage  by  filtration  or  by  irrigation  was 
practicable  and  could  be  conducted  at  reasonable  ex- 
penditure, and  it  was  to  be  hoped  that  the  time  was 
rapidly  approaching  when  public  sentiment  would  be 
aroused  to  the  degree  of  compelling  such  filtration 
whenever  public  health  or  comfort  was  imperilled. 

A  Brief  Review  of  the  Work  of  Sand  Filters  at 
Lawrence,  Mass. — This  was  read  by  H.  W.  Clark, 
chemist  in  charge  of  the  Lawrence  Experiment  Sta- 
tion. In  1887  the  deaths  from  typhoid  fever  at  Law- 
rence were  12  per  10,000;  in  1889,  18.75;  ^"  1890, 
13.33;  in  1891,  12.20,  and  in  1892,  11. 11.  During 
1893  the  filter  was  built,  and  hence  during  a  portion 
of  the  year  filtered  water  was  being  used.  In  1894 
filtered  water  was  in  use  during  the  entire  year,  and 
the  death  rate  from  typhoid  fever  was  5  per  10,000; 
during  1895  it  was  3.07;  during  1869,  1.86;  and  the 
rate  for  the  present  year  promised  to  be  exactly  the 
same  as  for  1896. 


Third  Day — Afternoon  Session. 

Urgent  Need  of  Sanatoria  for  the  Consumptive 
Poor  of  Large  Cities — Dr.  S.  A.  Knopf,  of  New- 
York,  opened  this  session  with  the  reading  of  this 
paper.  The  question  what  to  do  with  the  thousands 
of  tuberculous  patients  who  inhabited  the  tenement 


Fourth  Day — Alorning  Session. 

The  report  of  the  committee  on  disposal  of  garbage 
and  refuse  was  read  by  Mr.  Rudolph  Herixg,  C.E., 
of  New  York.  The  report  stated  that  it  was  inexpedi- 
ent to  make  original  researches,  and  the  work  of  the 
committee  had  been  confined  to  the  collection  of  sta- 
tistics and  the  inspection  of  plants. 

Then  followed  a  report  of  the  committee  on  the 
transportation  and  disposal  of  the  dead,  which  was 
read  by  Dr.  Charles  O.  Probst,  of  Ohio.  Among 
other  things  this  report  favored  the  preparation  of 
bodies  for  shipment  by  licensed  embalmers. 

Dr.  Henry  Mitchell,  of  Asbury  Park,  objected  to 
this  on  the  ground  that  it  sought  to  create  a  special 
class  of  workers,  to  whom  all  the  business  would  be 
restricted. 

Several  other  papers  were  read  and  discussed. 

The  following  officers  were  elected  for  the  ensuing 
year:  President,  Dr.  Charles  A.  Lindsley,  of  New 
Haven,  Conn;  First  Vice-President,  Dr.  Benjamin 
Lee,  of  Philadelphia;   Second  Vice-President,  Dr.  John 


7i6 


MEDICAL    RECORD. 


[November  13,  1897 


C.  Schrader,  of  Iowa  City,  la. ;  Secretary,  Dr.  Charles 
O.  Probst,  of  Columbus,  Ohio;   Treasurer,  Dr.  Henry 

D.  Holton,  of  Brattleboro,  Vt. 

The  association  will  hold  its  next  meeting  in   Ot- 
tawa, Canada,  1898. 


THE  NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,   October  ij,  iSgj. 

T.  Mitchell  Prudden,  M.U.,  in  the  Chair. 

Large  Aneurism  of  the  Middle  Cerebral  Artery — 
Dr.  George  P.  Biggs  presented  an  aneurism  of  the 
middle  cerebral  artery,  of  unusual  size.  It  Iiad  been 
taken  from  a  male,  sixty-five  years  of  age,  a  watchman 
by  occupation.  He  was  found  sitting  in  a  chair,  lean- 
ing far  over  to  the  left  side,  the  left  arm  hanging 
helpless.  He  talked  with  great  difficulty,  and  stated 
that  the  attack  had  begun  with  a  very  marked  vertigo. 
He  had  succeeded  in  reaching  a  chair  before  falling. 
Soon  after  he  was  discovered  he  became  speechless. 
The  breathing  was  very  slow  and  irregular,  and  the 
face  was  flushed.  Both  pupils  were  contracted,  the 
right  one  slightly  more  than  the  left.  The  pulse  was 
64  and  regular.  The  radial  arteries  were  hardened. 
The  urine  had  a  specific  gravity  of  1.013,  and  con- 
tained a  trace  of  albumin  but  no  casts.  The  paralysis 
of  the  left  side  graduall)-  increased  and  extended  to 
the  left  leg.  He  became  comatose,  and  died  on  the 
second  day  after  his  admission  to  the  Hudson  Street 
Hospital.  The  clinical  diagnosis  was  cerebral  hemor- 
rhage. 

On  autopsy,  aside  from  the  lesions  inside  of  the 
cranium,  there  were  marked  congestion  and  cedema  of 
the  lungs,  and  quite  advanced  chronic  diffuse  nephritis. 
The  skull  being  opened,  the  dura  was  found  to  be  e.\- 
tremely  tense.  There  was  a  thin  subdural  clot  over 
the  base  and  over  the  lower  part  of  the  outer  surface 
of  the  right  hemisphere  of  the  cerebrum — in  other 
words,  a  moderate  amount  of  subdural  hemorrhage. 
There  was  a  marked  prominence  of  the  middle  portion 
of  the  right  hemisphere.  Beneath  the  pia  over  the 
right  side,  especially  over  the  region  of  the  right  Syl- 
vian fissure  and  over  the  base  of  the  brain  and  the 
temporo-sphenoidal  lobe,  there  was  a  very  extensive 
hemorrhage.  The  ventricles  were  empty.  The  right 
hemisphere  being  cut  into,  a  very  large  hemorrhage  was 
found  Just  outside  of  the  lateral  ventricle.  It  meas- 
ured about  7  cm.  antero-posteriorly,  5  cm.  vertically, 
and  5  cm.  transversely.  At  first  this  appeared  to  be 
an  ordinary  cerebral  hemorrhage,  which  had  appar- 
ently broken  externally,  the  hemorrhage  having  taken 
place  first  in  large  amount  beneath  the  pia,  and  then 
broken  out,  producing  the  subdural  clot.  There  was, 
however,  a  very  decided  hardness  of  the  middle  cere- 
bral artery  in  this  fissure.  This  was  taken  out,  the 
clot  carefully  removed,  and  the  aneurismal  sac  dis- 
sected out.  This  aneurism  measured  1  cm.  in  length 
and  0.;  5  cm.  in  diameter,  and  was  ovoid  in  shape. 
There  was  a  large  ragged  tear  on  the  superior  surface, 
through  which  the  hemorrhage  had  occurred.  The 
aneurism  was  located  in  the  middle  cerebral,  about 
1. 5  cm.  from  the  origin  of  the  vessels. 

The  points  of  interest  in  the  case  were  the  unusual 
size  ol  '.he  aneurism — larger  than  any  that  the  speaker 
had  previously  seen  upon  a  cerebral  vessel — and  the 
fact  that  on  first  examination  it  had  so  closely  re- 
sembled an  ordinary  cerebral  hemorrhage. 

Tubercle  Bacilli  Found  in  the  Faeces.— Dr.  George 
Biggs  also  presented  microscopical  specimens  from  a 
case  of  ordinary  pulmonary  tuberculosis  of  several 
months'  standing,  in  which  the  attending  physician 
had  found  tubercle  bacilli  some  time  before.     In  the 


past  month  the  patient  had  developed  a  diarrhoea, 
which  had  been  clinically  diagnosticated  as  due  to 
tuberculous  involvement  of  the  intestine.  The  patient 
being  very  anxious  about  it,  it  was  suggested  that  an 
examination  of  the  stools  should  be  made  for  tubercle 
bacilli.  The  examination  showed  the  presence  of  a 
distinct  mass  of  purulent  matter,  and  its  nature  had 
been  verified  under  the  microscope.  When  it  was 
stained,  several  tubercle  bacilli  were  revealed.  The 
idea  of  making  such  an  examination  had  at  first  seemed 
to  him  ridiculous,  but  it  was  interesting  to  note  that  the 
search  had  been  successful.  It  might  be  assumed  by 
some  that  the  mass  was  really  a  mass  of  sputum  that 
had  been  swallowed. 

Malarial  Parasite  of  the  Quartan  Type. — Dr. 
Henry  Heiman  exhibited  under  the  m'croscope  the 
quartan  parasite,  obtained  from  a  patient  in  Little  Rock 
at  his  request.  He  had  been  very  anxious  to  find  the 
quartan  parasite,  but  had  never  been  able  to  do  so  in 
specimens  secured  in  New  York  City.  The  specimen 
presented  exhibited  a  parasite  such  as  he  had  never  seen 
before,  and  the  clinical  history  indicated  the  quartan 
type  of  malaria.  The  patient  was  a  boy  of  eleven  years, 
who  had  suffered  from  malaria  for  a  year  or  two.  At 
first  the  malaria  had  assumed  the  quartan  type,  but  later 
on  the  boy  had  had  chills  every  second  day  or  even 
every  day.  This  might  be  accounted  for  by  supposing 
that  he  had  had  several  infections  of  the  quartan  par- 
asite. In  this  parasite  the  red  cell  was  not  swollen. 
The  pigment  was  located  more  in  the  periphery  of  the 
organism,  but  the  organism  itself  appeared  smaller. 
As  it  was  believed  that  the  spores  were  the  most 
characteristic  and  distinguishing  feature,  it  was 
unfortunate  that  they  were  not  found  in  this  specimen. 
In  the  tertian,  seventeen  to  twenty  spores  were  sup- 
posed to  be  in  one  parasite ;  and  in  the  quartan,  from 
six  to  seven  of  these  spores.  He  had  been  unable  to 
confirm  the  statement  that  the  pigment  was  coarser  in 
the  quartan. 

Adeno-Myomata  of  the  Uterus Dr.  T.  Mitchell 

Pruddex  presented  microscope  slides.  He  said  that 
a  considerable  number  of  cases  had  been  reported  in 
late  years  of  uterine  myomata,  or  fibro-myomata,  in 
which  glands  of  the  uterine  type  were  present,  some- 
times with  cysts.  These  myomata  might  be  either 
subserous,  intraparietal,  or  submucous.  They  were 
sometimes  directly  connected  with,  and  the  gland 
structures  were  evidently  derived  from,  the  uterine 
mucous  membrane.  But  thej-  were  often  so  distant 
and  so  entirely  separated  from  the  mucous  membrane 
as  to  justify  the  conjecture  that  they  were  derived  from 
some  embryonal  abnormality  associated  with  the 
development  of  the  Wolffian  body.  These  tumors  had 
formed  the  subject  of  a  monograph  by  Recklinghau- 
sen, and  had  been  discussed,  willi  a  description  of 
new  cases,  by  Cullen,  in  volume  vi.  of  the  Johns 
Hopkins  Hospital  Reports. 

Dr.  Prudden  brought  for  demonstration  slides  from 
two  hitherto  undescribed  cases.  In  neither  of  these 
cases  was  there  anything  especially  noteworthy  in  the 
clinical  history.  One  was  from  a  private  patient, 
thirty-four  years  of  age,  whose  uterus  had  been  removed 
on  account  of  a  tumor,  about  .3  by  2  cm.  in  diameter, 
in  the  posterior  wall  of  the  cer\ix  uter'..  The  other 
tumor  was  a  polypoid  growth,  about  the  size  of  a  hen's 
egg,  attached  to  the  posterior  wall  of  the  uterus,  dis- 
covered at  the  autopsy  on  a  woman  of  seventy-five, 
who  had  died  without  definite  clinical  diagnosis,  and 
who  was  found  to  have  had  chronic  diffuse  nephri- 
tis, chronic  interstitial  hepatitis,  and  carcinoma  of  the 
left  ovary.  In  both  cases  ^  series  of  sections  had 
been  made,  with  a  view  of  discovering  some  connection 
between  the  glandular  elements  of  the  myomata  and 
the  uterine  mucous  membrane,  but  without  success. 
It  would  be  seen  that  the  bulk  of  the  tumors  consisted 


November  13,  1897] 


MEDICAL    RECORD. 


717 


largely  of  fibrous  and  smooth  muscle  tissue,  the  former 
preponderating.  This  mass  was  moderately  dense  and 
moderately  vascular.  Scattered  irregularly  and  on 
the  whole  sparsely  through  this  fibrous  and  muscle 
mass  were  small  collections  of  gland-like  structures 
resembling  islets  of  uterine  mucous  membrane.  The 
glands  were  follicular  in  type,  were  lined  with  cuboi- 
dal  and  low  cylindrical  epithelium,  and  resembled 
those  of  the  mucous  membrane  of  the  body  of  the 
uterus.  Some  of  the  gland  lumina  were  distended 
with  granular  material  to  form  minute  cysts  lined  with 
flattened  epithelium.  Between  and  surrounding  these 
glands  there  was  a  very  cellular  stroma,  resembling 
that  of  the  mucosa  of  the  uterine  body,  and  merging 
gradually  into  the  surrounding  fibrous  tissue. 

These  specimens  were  presented,  Ur.  Prudden  said, 
not  because  these  tumors  were  very  uncommon,  but 
because  they  were  not  usually  recognized,  and  as  a 
contribution  to  the  statistical  data  of  this  interesting 
growth. 

The  society  then  adjourned. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

Stated  Meeting,  November  4,  i8gy. 

Edward  G.  Janeway,  M.D.,  President. 

The  meeting  was  in  charge  of  the  section  on  genito- 
urinary surgery. 

Sterilization  of  Urethral  Instruments. — Dr.  Ed- 
ward Martin,  of  Philadelphia,  read  a  paper  with  this 
title.  It  was  limited  to  a  consideration  of  the  method 
by  which  catheters  could  be  rendered  surgically  clean, 
as  metal  instruments  were  easily  sterilized  by  flaming 
and  boiling.  Sterilization  immediately  before  use, 
the  author  said,  was  often  impracticable,  and  when  the 
catheter  was  required  the  conditions  were  usually  pe- 
culiarly favorable  to  infection.  The  ideal  conditions 
for  catheterization  would  be  a  clean,  supple,  well- 
lubricated  instrument  of  appropriate  calibre,  passed 
by  sterile  hands  through  a  sterile  urethra  into  a  nor- 
ma! bladder.  In  the  first  place,  the  instrument  should 
be  so  constructed  as  to  be  free  from  blind  pockets  for 
the  collection  of  filth.  The  most  dangerous  part  of 
the  ordinary  catheter  was  the  blind  space  beyond  the 
eye;  hence  only  catheters  provided  with  a  solid  head 
should  be  used.  The  internal  surface  of  the  catheter 
was  rarely  even  approximately  smooth,  and  for  this 
reason  the  difficulty  of  sterilizing  the  interior  was 
enormously  increased.  It  was  worthy  of  note  that  the 
soft-rubber  catheters  were  the  smoothest.  The  me- 
chanical cleansing  of  a  catheter  was  best  accomplished 
by  warm  soapsuds  injected  into  the  catheter  immedi- 
ately after  use.  Aiter  soaking,  the  instrument  should 
be  washed  in  freshly  boiled  w-ater;  the  water  within 
the  instrument  was  then  "swung"  out,  and  the  catheter 
placed  in  an  oven  for  a  few  minutes  to  dry.  All  soft 
instruments  stood  well  this  process  of  mechanical 
cleansing.  Sterilization"  might  be  accomplished  with 
heat  or  with  germicidal  drugs.  Diy  heat  had  been  tried 
by  him,  but  it  had  hopelessly  ruined  the  catheters,  and 
the  same  was  true  of  steam.  Boiling,  however,  acted 
more  satisfactorily,  and  if  not  continued  for  more 
than  five  minutes  the  better-grade  catheters  were  not 
injured  and  vi'ere  rendered  sterile.  The  cheaper  cath- 
eters were  damaged  by  such  boiling,  but  the  rubber 
instruments  seemed  rather  to  be  improved  by  it.  This 
process  of  sterilization  was  adapted  to  the  needs  of 
the  layman,  and  the  catheter  could  be  stored  in  a  ster- 
ile cloth.  Alcohol  and  carbolic  acid  quickly  destroyed 
the  finish  of  a  catheter.  Any  gum  catheter  would  lose 
its  lustre,  even  if  soaked  in  alcohol  for  only  one  min- 
ute.    Antiseptic  soaps  had  seemed  to  open  up  a  \ery 


promising  field,  but  his  experiments  had  shown  them 
to  be  entirely  useless.  Another  easy  method  of  steri- 
lization was  that  by  the  vapor  of  mercury.  The  washed 
catheters  were  placed  in  a  closed  compartment  con- 
taining metallic  mercury,  either  exposed  in  a  shallow 
tray  or  in  a  finely  divided  state  in  a  flannel.  An  ex- 
posure in  this  way  for  fourteen  hours,  it  was  claimed, 
would  completely  sterilize  the  catheters.  However, 
his  experiments  and  those  of  others  had  shown  that 
reliable  sterilization  could  not  be  obtained  unless  the 
exposure  was  about  five  times  as  long.  A  convenient 
and  efficient  method  of  sterilization  was  by  the  use  of 
a  tight  box  with  shelves  for  the  catheters  and  a  com- 
partment containing  paraform  powder.  Culture  ex- 
periments had  proved  the  method  to  be  exceedingly 
satisfactory,  but  an  exposure  of  eighteen  hours  was 
insufficient,  and  in  the  case  of  instruments  of  fine 
calibre  the  results  were  unsatisfactory  even  after 
twenty-four  hours.  Even  unwashed  catheters  of  mod- 
erate calibre  were  rendered  absolutely  sterile  by  an 
exposure  of  forty-eight  hours  in  the  paraform  box. 
The  method  was  simple  and  reliable,  and  provided 
for  the  aseptic  storage  of  the  instruments.  The  vapor 
was  found  to  be  slightly  irritating  to  the  mucous  mem- 
brane of  the  urethra  when  the  instruments  were  used. 
The  fonnaldehyde  process  had  been  found  completely 
satisfactory  for  the  sterilization  of  the  instruments  of 
fine  calibre,  such  as  ureteral  catheters.  The  vapor 
should  be  passed  directly  through  the  catheters.  The 
formaldehyde  was  conveniently  kept  in  a  tube  under 
pressure,  and  by  unscrewing  a  cap  the  vapor  could  be 
injected  in  a  concentrated  form  into  the  catheter.  A 
few  seconds  had  been  found  amply  sufficient  to  steri- 
lize the  interior  of  even  the  fine  catheters.  It  should 
not  be  forgotten  that  the  lubrication  and  the  introduc- 
tion of  a  catheter  were  often  the  means  of  causing 
infection.  It  was  a  good  plan  for  the  operator  to  wear 
sterile  cotton  gloves,  changing  them  for  each  case. 
The  penis  having  been  passed  through  a  hole  in  a 
sterile  towel,  the  meatus  should  be  syringed  out  with 
salt  solution. 

The  Best  Lubricant. — The  lubricant  was  best  kept 
in  a  narrow  jar  deep  enough  to  allow^  of  the  introduc- 
tion of  the  catheter  to  a  depth  of  eight  inches — for 
example,  a  specimen  jar.  Investigation  had  failed  to 
discover  a  thoroughly  satisfactory  aseptic  lubricant. 
The  best  were  albolene  and  a  twenty-three-per-cent. 
solution  of  boroglyceride.  The  former  made  it  more 
difficult  to  clean  the  instrument;  the  latter  was  a  mild 
antiseptic,  decidedly  inhibitory,  and  an  excellent  lu 
bricant,  although  not  .so  good  as  the  albolene.  Ar- 
gonin,  in  the  strength  of  i  to  1,000,  had  been  experi- 
mented with,  and  had  been  found  to  cau.se  but  slight 
irritation.  By  flushing  out  the  inethra  during  cathe- 
terization, the  danger  of  infecting  the  bladder  could 
be  greatly  lessened,  but  there  was  a  distinct  danger 
incident  to  the  use  of  all  irritating  disinfectants — i.e., 
they  were  liable  to  set  up  a  total  urethritis  which 
would  strongly  predispose  to  infection.  The  sterile 
catheter  should  be  introduced  while  sterile  salt  solu- 
tion was  flowing  through  it.  In  cases  of  long-standing 
disease  of  the  bladder,  he  adopted  this  method  and 
entirely  omitted  the  lubricant,  thereby  diminishing  the 
risks  of  infection. 

Self-Catheterism — Patients  who  were  compelled  to 
practi.se  self-catheterism  should  be  furnished  with  soft- 
rubber  catheters  of  a  size  and  shape  of  tip  which 
would  permit  the  easiest  and  least  painful  entrance 
into  the  bladder.  It  would  usually  be  found  that  the 
soft-rubber  coude'e  catheters  fulfilled  these  require- 
ments. Even  the  most  supple  woven  catheter  would 
be  found  rigid  for  half  an  inch  of  its  length,  when 
compared  with  the  .soft-rubber  instrument.  The  rub- 
ber coudee  catheters  had  proved  far  more  satisfactory 
than  any  others  that  he  had  used  in  practice.     'I'hese 


7i8 


MEDICAL    RECORD. 


[November  13,  1897 


catheters  were  not  only  easy  to  pass,  but  were  cheap 
and  were  readily  made  sterile.  The  patient  should 
provide  twice  as  many  catheters  as  were  needed  for 
use  in  the  twenty-four  hours,  .\fter  boiling  the  num- 
ber required  for  one  day,  they  should  be  wrapped  up 
in  a  sterile  fabric.  He  had  had  constructed  a  bamboo 
cane,  in  one  end  of  which  was  a  small  cylindrical 
paraform  box  containing  four  catheters,  and  in  the 
other  end  another  case  for  the  soiled  catheters  and  for 
the  lubricant. 

Clinical  Results  More  Reliable  than  Laboratory 
Reports.  —  Dr.  Samuel  Alexander  said  that  he 
agreed  substantially  with  all  that  had  been  stated  in 
the  paper;  nevertheless  as  a  clinician  he  felt  that 
many  of  the  ideas  there  presented  must  be  character- 
ized as  Utopian.  It  was  a  very  much  simpler  matter 
to  carry  on  a  system  of  thoroughly  sterile  catheterism 
in  hospital  than  in  private  practice.  In  his  service 
at  Bellevue  Hospital  a  large  number  of  methods  had 
been  tried,  and  these  had  been  simplified  as  much  as 
possible.  The  best  grade  of  catlieters  had  been  se- 
lected, but  he  was  not  yet  prepared  to  give  up  the 
woven  catheter,  although  admitting  that  it  was  most 
difficult  to  sterilize.  For  a  time  he  had  had  the  cathe- 
ter washed  in  soapsuds,  then  injected  with  a  five-per- 
cent, solution  of  nitrate  of  silver,  followed  by  a  solu- 
tion of  chloride  of  sodium,  and  afterward  dried  and  put 
away.  The  method  was  exceedingly  dirty  and  stained 
the  hands  very  badly;  moreover,  the  culture  experi- 
ments had  not  been  so  satisfactory  with  this  method 
as  had  been  anticipated.  In  general,  he  would  say 
that  the  clinical  results  had  been  very  much  better 
than  one  would  have  expected  from  the  laboratorj'  re- 
ports, and  he  would  ver)'  much  prefer  to  trust  to  his 
clinical  observations  than  to  the  laboratory  reports  of 
what  his  results  ought  to  be.  Another  method  had 
been  to  throw  the  catheters  into  a  basin  of  boiling 
water  immediately  after  use.  They  were  then  collected 
and  washed  with  soapsuds,  and  those  that  could  be 
boiled  were  treated  in  that  way.  He  had  not  found 
that  boiling  for  five  or  ten  minutes  would  fulfil  the 
laboratory  requirements.  Last  summer  he  had  used 
a  Janet  sterilizer  in  his  office,  in  connection  with  for- 
maldehyde, but  had  found  that  a  much  longer  time 
was  required  to  effect  sterilization  than  had  been 
stated,  if  the  catheters  were  old  ones.  Another  objec- 
tion was  that  a  catheter  must  be  washed  before  use, 
otherwise  much  stinging  pain  would  be  caused  by  the 
gas  clinging  to  the  outside  of  the  catheter.  If  this 
was  done  with  water  that  was  not  absolutely  sterile, 
the  whole  process  would  be  vitiated.  Catheters  that 
could  not  be  boiled  were  immersed  in  very  hot  water, 
after  being  thoroughly  cleansed  with  soap  and  water. 
He  could  in  this  way  get  as  good  results  as  by  using 
the  catlieters  sterilized  by  formaldehyde. 

Just  as  Good  Results  without  Irrigation. — At  one 
time  he  had  advocated  and  practised  the  plan  of  steri- 
lizing the  urethra,  but  he  found  now  that  he  got  just 
as  good  results  when  he  did  not  wash  out  the  urethra 
as  when  he  washed  it  out  before  introducing  instru- 
ments. For  this  reason  he  did  not  now  wash  out  the 
urethra  before  the  introduction  of  the  catheter,  unless 
a  severe  urethritis  was  present.  A  good  deal  de- 
pended upon  cleansing  the  meatus,  yet  simply  wash- 
ing off  the  meatus  was  sufficient  in  an  ordinarily 
clean  person.  He  believed  firmly  that  although  one 
had  absolutely  sterilized  the  catheters,  if  one  did  not 
use  the  instruments  with  proper  skill  and  dexterity, 
the  amount  of  trauma  so  produced  would  be  an  active 
agent  in  carrying  infection  from  the  urethra  into  the 
bladder. 

The  Essentials  for  Aseptic   Catheterism Three 

factors  were  essential  for  aseptic  catheterism,  viz. :  (i) 
as  clean  a  catheter  as  possible;  (2)  the  gentle  use  of 
it;  and  (3)  the  catheter  must  be  of  the  best  grade — 


not  only  smooth,  but  sufficiently  flexible.  New  cathe- 
ters were  likely  to  be  too  stiff  for  proper  use;  they 
should  accordingly  be  frequently  soaked  in  hot  water 
at  first,  and  drawn  through  the  hands  in  order  to  ren- 
der them  sufficiently  supple. 

Catheter  Life.  —  The  method  advocated  by  the 
reader  of  the  paper  for  those  prostatics  who  had  to 
catheterize  themselves  was  a  good  one,  yet  it  was  not 
probable  that  it  could  be  carried  out  in  very  many 
instances.  In  the  beginning  of  catheter  life,  when 
there  was  residual  urine  with  obstruction  and  when 
the  urine  was  clear,  no  pains  should  be  spared  by  the 
surgeon  to  have  the  catheters  absolutely  sterile  and  to 
see  that  the  catheterism  was  performed  at  absolutely 
regular  intervals.  A  person  with  an  enlarged  prostate 
at  the  beginning  of  catheter  life  could  be  passed 
through  what  used  to  be  the  dangerous  period  of  cathe- 
ter fever  without  any  noteworthy  infection  of  the  blad 
der.  But  the  time  would  come  when  that  patient  did 
not  require  such  careful  watching,  when  the  bladder 
was  not  congested,  and  had  ceased  to  be  a  fertile  field 
for  the  growth  of  micro-organisms.  Then  the  absolute 
and  rigid  rules  for  catheter  sterilization  were  not  so 
important  as  at  the  beginning  of  catheter  life. 

Individual  Vulnerability. — Dr.  Willy  Meyer  said 
that  many  were  inclined  to  wonder  at  tlie  number  of 
catheterizations  daily  performed  without  any  serious 
reaction  and  without  the  precautions  advocated  being 
taken.  There  were  certainly  great  individual  differ- 
ences, and  bad  results  occasionally  followed  even  when 
unusual  care  had  been  taken  in  the  catheterism.  It  was 
evident  that  the  virulence  of  the  organisms  and  the 
condition  of  the  patient's  system  at  the  time  exercised 
a  potent  influence.  It  should  be  emphasized,  for  the 
benefit  of  the  general  practitioner,  that  metal  and  rub- 
ber instruments  could  be  sterilized  by  washing  and 
boiling  in  water  for  five  minutes. 

Preifers  Chloride  of  Calcium  and  Formalin  for 
Sterilization. — His  own  practice  had  led  him  to  be- 
lieve that  the  best  method  of  sterilization  for  gum- 
elastic  catheters  was  by  the  use  of  formalin.  The 
instrument  could  be  dried  by  the  aid  of  chloride  of 
calcium,  and  then  could  be  placed  in  a  suitable  recep- 
tacle and  exposed  to  the  formalin.  The  use  of  the 
chloride  of  calcium  he  believed  to  be  an  important 
point.  In  spile  of  tlie  greatest  care  in  sterilizing  the 
instruments  and  the  urethra,  urethral  fever  was  bound 
to  occur  in  a  certain  number  of  cases.  It  was  proba- 
blj'  due  to  infection  with  the  colon  bacilli  in  connec- 
tion with  traumatism.  He  had  observed  this  occa- 
sionally in  his  first  efforts  at  cystoscopy.  Nitze  had 
devised  a  special  sterilizer  for  steaming  die  cystoscope, 
but  in  the  speaker's  hands  its  use  had  resulted  in  seri- 
ously damaging  several  cystoscopes.  It  had  been  found 
that  formalin  vapor  did  not  attack  the  cystoscope ;  hence 
it  was  now  possible  safely  and  efficiently  to  sterilize 
such  instruments.  Since  he  had  adopted  the  plan  of 
flushing  out  the  bladder  repeatedly  after  the  first  pas- 
sage of  instruments  in  patients  suffering  from  prostatic 
enlargement,  he  had  not  obser\'ed  urethral  fevers.  As 
the  ureteral  catheters  could  now  be  properly  sterilized, 
it  was  perfectly  justifiable  to  use  these  instruments, 
but  one  should  be  satisfied  at  first  with  passing  the 
instrument  only  a  short  distance  into  the  ureters. 

The  Flora  of  the  Urethra Dr.  Robert  W.  Tay- 
lor said  that  he  was  afraid  that  the  elaborate  method 
advocated  in  the  paper  was  not  practicable  in  most 
instances;  moreover,  he  was  of  the  opinion  that  fully 
as  good  results  could  be  obtained  by  the  well-known 
clinical  methods  outlined  by  Dr.  Alexander.  It  had 
been  clearlj'  shown  that  a  very  common  inhabitant  of 
the  meatus  and  its  vicinit}'  was  the  colon  bacillus. 
The  first  inch  of  the  urethra  contained  more  microbes 
than  any  other  part,  except  the  bulb.  Several  good 
obser%'ers  insisted  that  the  gonococcus  was,  under  nor- 


November  13,  1897] 


MEDICAL    RECORD. 


719 


mal  conditions,  a  harmless  denizen  of  the  urethra, 
and  that  the  changes  in  the  tissues  incident  to  trauma- 
tism, as  produced  by  sexual  indulgence,  the  passage 
of  instruments,  and  changes  in  the  urethra  from  pros- 
tatic disease,  rendered  this  micro-organism  noxious. 
It  was  true  that  this  was  still  a  mooted  point,  but  it 
was  well  worthy  of  thoughtful  consideration.  The 
speaker  recalled  one  case  of  what  the  patient  called 
"acute  clap,"  whic;h  had  originated  from  the  over- 
zealous  use  of  the  endoscope  by  a  surgeon.  Dr.  Prud- 
den  had  found  in  the  cultures  from  this  case  the  mi- 
crococcus ureae— a  micro-organism  that  had  hitherto 
been  considered  harmless.  He  believed  there  were 
many  saprophytes  in  the  urethra  which  were  usually 
innocuous,  but  v.hich  became  hostile  under  altered  con- 
ditions of  the  mucous  membrane.  Many  a  physician 
was  accused  of  having  infected  a  urethra  with  germs 
from  without,  when  he  had  really  done  it  by  the  use 
of  too  large  instruments  or  by  bungling  manipulations. 
It  should  always  be  remembered  that  a  man  carried 
around  within  himself  the  agents  of  infection  in  the 
urethral  canal  and  perhaps  also  in  the  bladder. 

The  Method  Must  be  Simple.  —  Dr.  L.  Boltox 
B.\xGs  said  that  in  considering  the  relation  of  infection 
to  an  individual  patient  he  had  been  led  to  obser\-e 
that  in  order  to  have  the  physician's  directions  obeyed, 
particularly  in  the  prostatic  cases,  these  directions 
must  be  as  simple  as  possible.  There  was  no  exception 
to  this  rule,  not  even  when  medical  men  were  the  pa- 
tients. Most  men  were  willing  to  wash  their  catheters 
with  hot  soap  and  water,  and  perhaps  even  to  boil 
them,  but  he  had  not  been  satisfied  with  the  results 
obtained  in  this  way.  He  had  been  experimenting 
with  simple  methods  of  sterilizing  catheters  by  the 
use  of  formaldehyde,  but  this  investigation  had  not 
yet  been  completed.  We  should  always  bear  in  mind 
that  there  was  a  certain  individual  vulnerability  to 
infection.  He  had  known  the  most  careless  and  dirty 
men  to  live  to  good  old  age  without  the  urine  having 
been  rendered  more  than  slightly  turbid  in  spite  of 
the  long  and  constant  use  of  the  catheter. 

The  Metallic  Catheter  Responsible  for  Much  In- 
fection.— Dr.  Alex.\nder  J.  C.  Skene  said  that,  while 
he  recognized  the  value  of  the  sterilization  of  instru- 
ments, he  was  sure  that  too  much  stress  had  been  laid 
upon  it,  and  that  quite  a  number  of  surgical  sins  were 
committed  in  the  name  of  sterilization  and  aseptic 
surgery.  He  recalled  the  fact  that  cystitis  had  been 
very  common  in  cases  of  catheterism  before  the  advent 
of  antiseptic  surgery,  and  his  disappointment  on  find- 
ing that  the  number  of  cases  remained  undiminished, 
even  after  antiseptic  surgery  had  come  in  vogue,  just 
so  long  as  the  old-fashioned  metallic  catheter  was  em- 
ployed. These  instruments  had  been  largely  responsi- 
ble, whether  they  were  clean  or  filthy,  for  these  cases 
of  infection,  for  as  soon  as  they  had  been  abandoned 
the  cases  of  cystitis  from  catheter  infection  had  been 
lessened  fully  fifty  per  cent.  Of  course,  the  surgeon 
should  be  exceedingly  careful  about  having  the  hands 
and  the  instruments  clean,  and  this  was  not  difficult  of 
accomplishment  in  practice.  He  had  found  that  if  a 
cystoscope  or  an  endoscope  were  exposed  in  the  oper- 
ating-room to  the  formaldehyde  vapor,  it  would  be 
clean  enough  for  use,  and  he  had  never  seen  any  harm 
from  the  employment  of  these  instruments  when  so 
treated.  It  was  necessarj-  only  thoroughly  to  boil  the 
Jacques  soft-rubber  catheter  for  fifteen  or  twentj-  min- 
utes to  secure  thorough  sterilization.  After  having 
been  sterilized  in  this  way  the  catheter  should  be  put 
in  a  sterilized  tube,  and  the  ends  closed  hermetically 
or  with  rubber  caps.  When  it  was  necessarj'  to  carry 
around  such  instruments,  they  should  be  washed  out 
with  ether  vapor  and  then  immersed  in  a  twenty-per- 
cent, carbolic-acid  solution  just  before  use.  He  used 
the  same  method  when  the  cystoscope  or  endoscope 


had  been  kept  for  a  considerable  time  after  having 
been  sterilized  in  the  manner  already  described,  and 
he  was  perfectly  confident  from  clinical  obser\'ation 
that  such  treatment  effectually  put  the  noxious  germs 
to  sleep.  The  great  difficulty-  he  had  found  was  in 
properly  cleansing  the  urethra  and  also  the  mouths  of 
the  ureters. 

The   After-Cleansing   of    the   Urethra It  had 

always  seemed  to  him  somewhat  pathetic  to  see  a  sur- 
geon take  infinite  pains  in  sterilizing  the  catheter  and 
then  pass  it  in  through  a  canal  teeming  with  germs  of 
all  kinds.  It  was  his  practice  to  fill  the  urethra  with 
some  sterilizing  solution,  and  allow  it  to  remain  there 
for  some  time  before  the  passage  of  the  instrument 
In  catheterizing  the  ureters  he  had  always  taken  the 
pains  to  sponge  off  the  mouths  of  the  ureters  after 
having  flushed  out  the  urethra  and  bladder.  An  addi- 
tional precaution  was  to  flush  out  these  parts  with 
some  sterile  solution  after  the  necessary  manipulations 
had  been  carried  out.  Such  procedures,  he  was  con- 
fident, would  do  more  to  prevent  and  control  infection 
than  the  more  elaborate  methods  directed  entirely  to 
the  sterilization  of  the  instruments.  He  knew  of  no 
germs,  except  possibly  the  tubercle  bacilli  and  the 
gonococci,  that  would  do  any  harm  if  they  remained 
for  a  short  time  in  a  bladder  that  was  entirely  free 
from  abrasion. 

Dr.  Frederic  R.  SrimGis  said  that  the  main  point 
was  cleanliness,  and  that  was,  after  all,  what  was  meant 
in  practice  by  the  term  "sterilization."  When  the 
discharge  was  confined  to  the  deeper  portions  of  the 
canal,  the  first  effort  should  be  to  determine  its  nature 
and  that  of  the  germs  there  present 

Urethral  Irrigation  Important. — Because  we  were 
not  able  absolutely  to  sterilize  the  urethra  was  no  rea- 
son why  we  should  not  carry  out  irrigation  of  the  ure- 
thra. One  of  the  best  means  of  accomplishing  this 
was  to  have  the  patient  urinate.  Failing  that,  irriga- 
tion might  be  employed  either  by  means  of  a  double 
catheter  or  by  filling  the  urethra  with  a  weak  solution 
of  permanganate  of  zinc  or  of  argonin,  by  means  of  a 
fountain  syringe.  In  the  majority  of  instances  irriga- 
tion of  the  urethra,  he  believed,  was  unnecessar}-,  and 
under  all  circumstances  it  was  impossible  thoroughly 
to  sterilize  the  canal.  As  a  lubricant  he  used  borated 
solution  of  glycerin  or  a  borated  solution  of  oil.  The 
oil  was  first  sterilized  by  dry  heat,  and  then  as  much 
boric  acid  was  added  as  the  oil  would  take  up.  Small 
portions  of  this  lubricant  were  kept  in  a  tube  stoppered 
with  cotton,  and  at  the  conclusion  of  the  day's  work 
the  remaining  portion  was  thrown  away. 

Traumatism  Strongly  Predisposes  to  Infection. 
— Dr.  Eugene  Fuller  said  that  the  sterilization  of 
urethral  instruments  was  still  in  its  infancy.  It  was  a 
matter  of  much  importance,  but  in  its  consideration 
we  should  not  overlook  the  large  part  played  by  trau- 
matism in  the  production  of  infection.  This  had  been 
well  illustrated  by  one  of  the  speakers,  who  had  stated 
that  the  number  of  infections  had  been  reduced  fifty 
per  cent,  by  abandoning  the  metal  instrument,  which 
was  only  another  way  of  saying  that  traumatism  had 
been  responsible  for  much  of  the  infection.  It  seemed 
to  him  that  if  the  genital  apparatus  were  perfectly 
healthy — if  there  were  no  seminal  vesiculitis — it  would 
be  very  rare  for  that  tract  to  be  infected  by  an  instru- 
ment, unless  the  latter  was  very  large  or  traumatism 
was  produced.  Traumatism  of  the  deep  urethra  was 
a  very  common  cause  of  infection.  Every  one  was 
familiar  with  those  occasional  cases  of  epididymitis  de- 
veloping even  after  all  the  usual  precautions  had  been 
taken  to  sterilize  the  parts.  The  secret  was  often  to 
be  found  in  the  fact  that  the  instrument  had  been 
forced  through  an  obstructed  deep  urethra.  Such  an 
accident,  from  distention  of  the  deep  urethra,  could  be 
guarded  against  by  previously  ascertaining  the  condi- 


720 


MEDICAL    RECORD 


[November  13.  1897 


tion  of  these  parts  by  a  digital  examination  through 
the  rectum.  There  was  comparative!)'  little  danger  of 
infecting  the  prostate  itself:  the  capsule  was  often 
tumefied  and  inflamed,  but  the  focus  of  infection  was 
primarily  in  the  ejaculator}'  ducts.  Tuberculosis  was 
extremely  likely  to  get  a  foothold  at  the  prostatic 
sinus. 

Gentle    Manipulations    and    Urethral    Irrigation 

Essential Dr.    K.   L.   Keyes  said   that  everj'  one, 

from  the  practical  side,  paid  less  attention  to  the  an- 
tisepsis of  the  instruments  than  to  other  factors,  and 
this  seemed  to  him  just.  We  did  not  usually  interfere 
by  the  introduction  of  instruments  into  the  urethra 
until  the  pool  had  already  been  defiled.  The  avoid- 
ance of  traumatism  and  the  irrigation  of  the  urethra 
after  instrumentation  were  the  two  most  important  ele- 
ments. He  returned  always  with  fondness  and  affec- 
tion to  hot  water  and  ordinary  cleanliness,  but  occa- 
sionally diverged  to  silver,  bichloride,  or  salicylic 
acid.  He  should  probably  continue  to  depend  upon 
these  elements  until  he  was  "gathered  in."  His  re- 
sults had  been  sufficiently  satisfactory  to  make  him 
feel  that  it  was  not  necessary  to  place  too  much  reli- 
ance upon  asepsis,  although  the  work  done  in  this  field 
was  a  commendable  one  and  would  have  a  good  effect 
upon  the  profession  at  large.  It  was  his  practice  to 
irrigate  with  weak  solutions  of  salicylic  acid  or  i  to 
4,000  solution  of  nitrate  of  silver,  particularly  along 
the  urethra  and  in  the  bladder,  after  instrumentation. 
This  washing  out  the  pool  after  it  had  been  stirred 
up  by  the  surgeon  was  a  point  in  the  technique  which 
seemed  to  him  more  important  even  than  the  early 
cleanliness. 

Dr.  Ramon  Guitkr.\s  spoke  of  the  importance  of 
using  only  catheters  of  the  best  grade.  The  best  ones 
were  covered  with  lacquer,  both  externally  and  inter- 
nally; the  second-grade  were  only  covered  externally; 
and  the  third  or  poorest  were  simply  dipped  into  the 
lacquer,  tiuis  leaving  numerous  small  crevices  which 
made  it  almost  impossible  to  sterilize  the  instrument. 
His  own  practice  was  to  scrub  and  flush  out  the  cathe- 
ter immediately  after  use,  then  to  boil  it  for  five  min- 
utes, then  to  dr)'  and  store  in  closed  glass  tubes. 

Dr.  Ferdinand  C.  Valentine  exhibited  an  appa- 
ratus for  sterilizing  the  cystoscope,  in  which  this  in- 
strument could  be  exposed  to  a  temperature  of  240°  C. 
without  injur}^  It  was  his  rule  to  employ  irrigations 
of  the  urethra  and  bladder  after  the  slightest  instru- 
mentation ;  he  could  not  see  how  irrigation  before  the 
introduction  of  the  instrument  would  be  of  any  service 
whatever.  He  asserted  his  belief  that  it  was  in  con- 
sequence of  this  routine  irrigation  that  he  had  not  had 
a  single  case  of  catheter  fever  for  the  past  three  years. 

A  Deadly  Heirloom. — Dr.  Martin,  in  closing  the 
discussion,  said  that  his  purpose  in  presenting  the 
paper  had  been,  not  to  complicate  the  method  of  steri- 
lization, as  the  speakers  seemed  to  think,  but  to  sim- 
plify it.  The  danger  of  using  the  metallic  catheter 
had  been  forcibly  impressed  upon  him  by  an  incident 
in  his  hospital  service.  A  physician  from  the  South 
who  was  suffering  from  retention  of  urine  was  violently 
opposed  to  having  a  metallic  catheter  passed  upon 
him,  and  when  he  was  finally  convinced  that  this  must 
be  done  he  made  his  will  and  prepared  for  the  worst. 
To  his  astonishment  he  survived  the  ordeal,  and  then 
explained  that  in  his  family  there  had  been  a  "  heredi- 
tary" silver  catheter,  that  had  descended  from  his 
grandfather,  and  lliat,  according  to  the  traditions  of 
his  family,  every  one  upon  whom  that  catheter  had 
been  passed  had  dinl  uitliin  two  months. 


Typhoid. — I  believe  the  Woodbridge  treatment  of 
typhoid  fe\er  as  a  specific  is  a  delusion. — Hugh  F. 
Lorimer. 


©orrjespondcuce. 


OUR    LONDON    LETTER. 


(Fr 


■  Special  Correspondent.) 


THE    TYPHOID    EPIDEMIC — HOSPITAI.    REFORM — OB.STET- 

RICAL       society COLLEGES       OF        PHYSICIANS       AND 

SURGEONS — GUILD  OF  ST.  LUKE-j-MEDICAL  COUNCIL 
PROFESSOR  STOCKMAN JUBILEE  MEDALS  —  INE- 
BRIETY—  DEATHS  OF  SURGEON-GENERAL  CORNISH 
AND    MR.  o'gRADY. 

London',  October  22,  1897. 

The  epidemic  at  Maidstone  is  still  prevalent  and  causes 
great  public  anxiety.  It  is  also  the  chief  topic  of  con- 
versation when  doctors  meet.  It  will  perhaps  prove  the 
most  disastrous  epidemic  we  have  seen.  There  was  a 
fall  in  the  number  of  fresh  cases  at  the  end  of  last 
week;  on  Monday  last  they  declined  to  4,  on  Tuesday 
to  6,  but  on  Wednesday  they  rose  again  to  18.  Yes- 
terday there  were  14,  raising  the  total  from  the  begin- 
ning to  1,715  with  106  deaths.  The  medical  officer's 
report  shows  up  to  Wednesday  a  weekly  average  of 
12.2  cases  per  diem  as  against  26.4,  69.4,  and  74.4  for 
the  three  preceding  weeks  respectively.  Many  are  en- 
couraged to  hope  that  this  shows  the  danger  is  subsid- 
ing, but  an  examination  of  the  daily  figures  gives  rise 
to  doubts.  The  number  of  young  lives  sacrificed  is 
large,  about  half  the  deaths  having  been  of  patients  be- 
tween the  age  of  five  and  sixteen.  About  one-third  of 
the  six  thousand  houses  in  the  town  are  without  proper 
water  supply  for  the  closets.  This  and  other  sanitary 
defects  the  corporation  is  determined  to  remedy  as 
rapidly  as  possible. 

The  polluted  water  pipes  were  disinfected  between 
Saturday  and  Monday  under  the  direction  of  Dr.  Sims 
Woodhead,  several  tons  of  chloride  of  lime  being  dis- 
solved and  the  solution  passed  into  the  pipes.  Why 
so  simple  a  plan  could  not  have  been  tried  three 
weeks  earlier  is  as  great  a  mystery  as  why  the  water 
was  not  cut  off  at  first.  The  only  reason  appears  to  be 
that  the  water  company  did  not  like  the  expense.  The 
deaths  of  more  than  one  hundred  persons  and  the  ter- 
rible sufferings  of  the  others  seem  to  have  had  no  effect 
on  the  monopolists,  except  as  producing  a  fear  for  their 
dividends.  The  public  is  indignant,  but  at  present 
pity  is  the  chief  feeling.  The  judgment  of  the  monop- 
olists is  yet  to  come.  The  local  government  board 
has  consented  to  hold  a  public  inquiry  as  soon  as  it 
will  not  interfere  with  the  work  of  attending  to  the 
immediate  needs  of  the  sufferers. 

The  Hospital  Reform  .\ssociation  held  a  confer- 
ence yesterday  at  which  they  had  secured  the  Earl  of 
Stamford  as  president.  His  lordship  quoted  statistics 
showing  the  enormous  increase  of  outpatients,  and 
read  a  letter  from  a  general  practitioner  lamenting  the 
want  of  cohesion  in  the  profession  and  holding  that 
the  position  could  be  commanded  by  union,  just  as  the 
workingmen  have  found  that  combination  alone  can 
make  them  masters  of  a  situation.  Other  speakers 
animadverted  strongly  on  the  fact  that  a  very  large 
proportion  of  these  outpatients  were  not  proper  ob- 
jects of  charitable  relief. 

Mr.  Timothy  Holmes,  who  has  always  taken  an  in- 
terest in  this  question,  held  that  it  is  not  so  much  a 
pecuniar}'  as  a  medical  one.  the  time  of  the  consultant 
being  too  much  taken  up  with  chronic  or  trivial  cases. 
But  the  general  practitioner  will  reply  to  this  only 
that  the  consultants  could  relieve  tiiemselves  if  they 
would,  and  in  so  doing  would  remedy  the  abuse. 

Sir  William  Hroadbent  took  a  different  position, 
remarking  that  to  get  rid  of  abuses  medical  men  must 
have  power  behind  them,  and  this  power  they  had  in  the 
Sunday  and  other  funds,  but  time  would  be  required. 
This  strikes  me  as  ven,-  poor  support  to  the  cause,  for 


November  i  ;.  i5 


MEDICAL    RECORD. 


721 


the  Sunday  fund  has  had  ^  L-i^ri\  long  time  but  has 
never  moved  in  this  or  any  othti  Vay  likely  to  benefit 
the  general  practitioner.  The  mana^-,e;s  of  the  fund 
have  one  lu-tc  noire — the  special  hospitait :  but  if  they 
could  shut  them  all  up  they  would  gladly  transfer  all 
the  patients  to  the  overcrowded  waiting-rooms  of  the 
general  hospitals  and  contribute  to  enlarging  thes. 
How  would  this  benefit  the  general  practitioner  01 
diminish  the  admitted  abuse? 

Sir  H.  Burdett  recommended  the  association  to'.'aii 
until  next  year  to  see  the  result  of  a  new  plan  of  col- 
lection and  distribution.  Then  he  said  many  out 
patients  were  willing  to  subscribe  and  could  do  so  by 
means  of  a  projected  stamp  album.  This  is  much 
like  the  invitation,  "  Open  your  mouth  and  shut  your 
eyes  and  see  what  I  will  send  you."  Tlie  general 
practitioners  are  to  wait  with  open  mouths  while  their 
patients  buy  si.x-penny  albums  and  say  they  are  entitled 
to  the  hospital  care  for  which  they  have  paid! 

.\  resolution  to  appoint  a  committee  was  carried, 
but  most  of  those  present  refrained  from  voting — a 
sad  indication  on  which  the  reformers  may  well 
ponder. 

At  the  Obstetrical  Society  a  paper  by  Mr.  Doran  on 
the  management  of  true  and  false  capsules  in  ovari- 
otomy gave  rise  to  an  interesting  discussion.  Mr. 
Doran  wrote  an  article  last  year  on  the  anatomy  of 
these  capsules,  in  which  he  referred  in  reply  to  an  in- 
quiry as  to  the  precise  anatomical  differences.  When 
a  capsule  should  be  cut  away,  when  it  should  be  let 
fall  into  the  pelvis,  and  when  it  should  be  stitched  to 
the  lower  end  of  the  wound  and  drained,  were  the  main 
points  considered.  The  first  plan  should  be  followed 
if  possible  when  the  capsule  is  healthy,  the  second 
when  no  pedicle  can  be  formed  and  hemorrhage  is 
under  control.  Fixation  must  be  employed  when  there 
is  advanced  inflammatory  change  with  suppuration  of 
the  tumor,  or  when  hemorrhage  is  not  quite  controlled. 
The  question  of  using  iodoform-gauze  stuffing  evoked 
some  different  opinions.  Dr.  Herbert  Spencer  had 
used  it  w-ith  great  satisfaction  for  the  last  four  years, 
and  considered  it  an  excellent  means  of  checking  hem- 
orrhage, averting  sepsis,  and  blocking  out  intestines 
from  torn  capsules  and  infected  areas.  Dr.  Culling- 
worth  (president)  said  he  had  not  had  a  large  experi- 
ence with  gauze  packing.  Its  removal  was  a  formi- 
dable matter  and  produced  so  much  distress,  bodily 
and  mental,  that  he  used  it  only  when  compelled. 
Still  he  recognized  its  immense  value  in  certain  cases, 
e.g.,  in  hemorrhage  from  vessels  to  which  it  was  impos- 
sible to  apply  a  ligature  on  account  of  their  lying  so 
deep  in  the  pelvis.  The  subject  of  iodoform  poison- 
ing was  also  mentioned  by  some  of  the  speakers. 

The  Harveian  oration  was  delivered  at  the  CoUegc 
of  Physicians  on  Monday,  when  a  good  audience  as- 
sembled. The  orator  this  year  was  Sir  W.  Roberts. 
At  the  close  the  Baly  medal  was  presented  to  Professor 
Schafer;  the  first  Weber-Parker  medal  and  prize  were 
awarded  to  Dr.  .\rthur  Ransomc,  and  a  second  medal 
was  given  to  Dr.  Peter  Paterson  of  (Glasgow.  The 
Moxon  medal  was  awarded  to  Sir  S.  Wilks,  the  presi- 
dent. 

.\t  the  meeting  of  the  council  of  the  College  of  Sur- 
geons thanks  were  awarded  to  Mrs.  Gowlland  for  the 
presentation  she  had  made  of  ll)e  beautiful  drawing 
of  her  late  husband;  and  Dr.  Woodhead  reported  the 
results  of  his  recent  visit  to  (Germany  to  compare  the 
methods  of  preparing  diphtheria  antitoxin. 

The  "Guild  of  St.  Luke"  should  be  satisfied  witii 
the  success  of  its  special  service  at  St.  Paul's  Cathe- 
dral, which  was  held  on  Thursday  evening,  when  the 
archbishop  of  York  preached.  In  the  course  of  his 
sermon  he  said  to  the  assembled  doctors :  "  The  most 
ancient  of  the  guilds  were  religious  institutions,  and 
the  medical  profession  has  never  been  lacking  in  con- 


tiibution  to  religious  literature.  Yours  is  a  religious 
calling,  though  not  usually  accounted  as  such." 

The  Guild  of  St.  Luke  is  a  society  of  medical  men 
attached  to  the  church — mostly  the  very  "  high"  church 
T.i.d  much  given  to  ritualistic  practices.  Perhaps  from 
•'cs  prepossessions  in  this  direction  arose  its  desire  for 
a  great  ceremonial  in  the  cathedral.  A  service  was 
•:;  "ranged  for  and  graduates  were  asked  to  come  in  their 
•.  2ademic  robes.  A  large  number  did  so,  and  gowns 
:  no  !:■  •)d.<;  gave  color  and  brilliancy  to  a  scene  such 
as  is  s.  :  ■'.  met  with  in  church,  for  the  congregation 
was  a  laige  .■  .;  even  for  the  cathedral. 

The  niajorii)  ot  Prof.  Victor  Horsley  over  Sir  W. 
Foster  exceeded  ight  hundred.  The  official  return 
of  votes  recorded  is:  Mr.  Horsley,  6,946;  Sir  W. 
Foster,  6.112;    Jr.  Rigby,  197:   Dr.  Diver,  81. 

The  new  "".alendar  of  the  College  of  Surgeons  gives 
the  number  <.f  fellows  as  1,191  against  the  members' 
masses  of  17,3,3^.     The  finances  seem  to  be  flourishing. 

Dr.  Stockmaii  has  had  a  very  warm  reception  at 
Glasgow  as  the  new  professor  of  materia  niedica  at  the 
university.  He  delivered  his  introductory  lecture  on 
the  14th,  when  the  principal  introduced  him,  welcom- 
ing the  bearer  of  so  splendid  a  reputation,  and  Profes- 
sor Gairdner  referred  to  his  great  qualifications  for 
the  chair.  The  students  gave  him  a  good  welcome 
too.  In  his  address  he  paid  a  tribute  to  Professor 
Charteris,  his  lamented  yreclecessor.  Dr.  Stockman's 
friends  in  Edinburgh  invited  him  to  a  dinner  before 
he  left  and  were  equally  er.tnusiastic  as  to  his  merits. 

Dr.  Fred.  St.  George  Mivart  "-  .^  been  appointed 
a  medical  inspector  to  the  locai  government  board  in 
consequence  of  the  lamented  deceuse  of  Dr.  Barry, 
mentioned  in  my  last.  The  new  govc;'-  nent  inspec- 
tor qualified  in  1881,  took  the  F.R.C.S.  v.  Edinburgh 
in  18S5,  and  M.D.  at  Louvain  in  1889. 

The  jubilee  medal  has  been  conferred  on  ',ir  Wil- 
liam H.  Flower,  K.C.B.,  F.R.S.,  president  of  the  Zoo- 
logical Society,  and  Dr.  Hicks,  F.R.S.,  president  of 
the  Geological  Society. 

Surgeon-Major  Poole,  M.D.,  read  a  paper  last  vvtek 
before  the  society  for  the  study  of  inebriety,  in  winch 
much  testimony  was  collected  in  confirmation  of  he 
redity  as  a  chief  cause.  The  president.  Dr.  Norman 
Kerr,  and  several  other  members  repudiated  the  com- 
mon remark  that  "doctor's  orders"  were  mostly  to 
blame.  Dr.  Kerr  said  he  could  trace  such  influence 
in  not  more  than  one-half  of  one  per  cent. 

Surgeon-General  Cornish,  CLE.,  honorary  phy- 
sician to  the  Queen,  died  on  the  19th  inst.,  aged 
seventy  years. 

Mr.  E.  S.  O'Grady  died  of  pneumonia  on  the  iSlh. 
He  was  the  gentleman  who  was  determined  to  bring 
the  conduct  of  tlie  managers  of  the  Mercer's  Hospital 
before  a  court  of  law  and  who  declined  to  allow  them 
to  confiscate  his  rights.  His  courage  and  uprightness 
were  remarkable,  and  his  skill  as  a  surgeon  was  ac- 
knowledged by  all.  What  will  be  the  effect  of  his  un- 
expected death  on  the  Mercer's  scandal  it  is  too  soon 
to  conjecture. 

THE    TREATMENT      Ol       Pl;LMO^AK^•     TC- 
BERCULOSIS. 


Sir:  As  a  country  practitioner  I  would  like  to  ask  the 
editor  or  the  readers  of  the  Medical  Record  for 
information  regarding  the  treatment  of  consumption. 
Professor  Koch  discovered  the  bacillus  and  has  ever 
since  tseen  trying  to  find  something  to  kill  it.  Shirley, 
of  Detroit,  a  few  years  ago,  it  will  be  remembered, 
tried  the  inhalation  of  gas  for  the  same  purpose.  Not 
long  ago  an  article  appeared  in  the  Mkdical  Rkcord 
detailing  a  number  of  patients  "'cured'"  by  intrabron- 
chial  irrigation.     One  of  these  patients  has  just  gone 


722 


MEDICAL    RECORD. 


[November  13,  1897 


to  California  to  see  if  there  is  any  help  for  him  in  the 
bland  climate  of  the  Pacific  slope.  We  country  doc- 
tors must  of  necessity  follow  the  leaders  in  the  large 
cities.  We  cannot  experiment,  but  must  select  the 
best  fruits  of  investigators  in  the  great  medical  centres. 
Now  what  I  would  like  to  know  is:  Are  we  working 
along  sensible  lines?  Are  we  not  pursuing  a  phantom 
when  we  expect  to  kill  the  bacillus  or  wash  it  away? 
These  leaders  tell  us  that  we  drink  in  and  inhale 
bacilli;  yet  they  spend  their  time  "curing"  cases  by 
killing  the  bacilli.  The  next  day  perhaps  their  patient 
inhales  or  drinks  in  a  few  more;  then  of  course  they 
irrigate  or  inflate  or  in  some  other  abstruse  way  cure 
the  patient  some  more,  and  so  on  ad  infiriitum.  Is 
this  common  sense?  It  is  a  prettj-  theory  and  attrac- 
tive— particularly  in  these  hard  times;  but  is  it  pro- 
fessional, is  it  honest?  I  suppose  of  course  that  we  all 
get  these  bacilli  in  one  way  or  another  into  our  sys- 
tems; then  why  do  we  not  all  have  tuberculosis? 
Isn't  it  reasonable  to  believe  that  the  reason  some  of 
us  do  not  have  consumption  is  because  they  (the 
bacilli)  do  not  find  in  us  a  suitable  soil  for  their 
development?  If  this  be  true,  is  it  not  the  most  sen- 
sible plan  to  divert  our  attention  from  the  poor  worn- 
out  bacillus  to  the  man  himself,  and  endeavor  to  place 
him  on  such  a  high  plane  of  health  and  vigor  that 
this  miserable  little  microbe  will  fall  in  the  "battle 
of  the  cells,"  and  save  us  the  trouble  of  tr}'ing  to  kill 
him  by  shooting  at  long  range  with  tuberculin  or  an 
irrigation  tube? 

If  we  can  ever  succeed  in  killing  the  bacillus,  will 
it  "cure"  the  case?     I  would  like  to  know-. 

E.  W.  BoGARDUS,  M.D. 

Poplar  Ridge,  X.  Y.,  October  25,  1897. 


ANESTHESIA  AND  ITS  ADMINISTRATION 
IN  GREAT  BRITAIN  AND  IRELAND,  WITH 
SPECIAL  REFERENCE  TO  ITS  BEING  MADE 
A  SPECIALTY. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  Stimulated  by  your  recent  editorial  on  "  Anaes- 
thesia as  a  Specialty,"  in  order  to  learn  of  the  ways 
and  means  in  Great  Britain  I  addressed  a  series  of 
questions  to  my  esteemed  friend.  Prof.  George  Bell 
Todd,  M.B.,  of  Glasgow,  and  with  his  permission  take 
the  liberty  of  sending  you  his  valuable  communication, 
feeling  certain  that  it  will  be  of  interest  to  many  of 
your  readers.  A.  Ernest  Gallant,  M.D. 

*<  General  Remarks. — Anaesthetists  as  specialists 
are  not  common  in  our  islands:  that  is  to  say,  special- 
ists in  the  sense  that  they  engage  in  that  department 
alone.  Still,  there  are  one  or  two  in  London  and  other 
large  English  cities  who  live  principally  by  this  call- 
ing. 

"  I  cannot  give  you  details  as  to  the  exact  number 
of  men  in  Great  Britain  and  Ireland  who  live  by  this 
specialty  alone.  I  should  be  inclined  to  put  their 
number  at  a  dozen,  at  the  outside. 

"  All  our  chief  hospitals  here  keep  an  anaesthetist — • 
that  is  to  say,  one  or  more  members  of  the  medical 
staff  who  by  past  experience,  are  regarded  by  them 
as  capable  of  administering  anesthetics,  and  who  re- 
ceive, in  alas!  too  many  instances,  an  honorarium  for 
their  work  equal  to  twenty  guineas,  which  is  considered 
by  the  hospital  directors  quite  enough  for  such  respon- 
sible work.  In  smaller  hospitals  it  is  common  to  give 
ten  or  fifteen  guineas  as  a  remuneration,  and  many 
special  hospitals  give  no  remuneration  at  all.  There 
are  two  medical  men  in  Glasgow  who  go  in  for  anaes- 
thesia as  a  specialt)',  but  they  engage  in  private  prac- 


tice as  well.  One  is  the  ansesthetist  at  the  Glasgow 
Royal  Infirmary ;  the  other  is  our  new  anesthetist  at 
the  Samaritan  Hospital.  These  gentlemen  are  fre- 
quently employed  in  dental  operations  at  dentists'^ 
rooms  and  at  the  patients'  own  residences.  In  fact,  I 
may  mention  that  so  strict  are  the  authorities  that  no 
dentist  will  risk  giving  chloroform  or  ether  in  a  big 
operation  without  calling  in  the  patient's  medical 
man  to  give  the  anaesthetic,  or  else  bring  in  an  anes- 
thetist. This  is  certainly  the  most  fruitful  source  of 
income  for  the  latter. 

"  Again,  most  surgeons  in  cities  employ  a  young 
medical  man  of  a  few  years'  standing  to  give  anaes- 
thetics to  their  private  patients.  On  inquiry  one  often 
finds  that  the  young  medical  man  is  his  chief's  assis- 
tant in  the  hospital ;  not  the  house  surgeon,  but  the 
deputy  or  assistant  surgeon,  appointed  to  the  surgical 
wards — more  often  at  the  chief's  request  than  at  the 
option  of  the  governors,  at  least  as  far  as  Edinburgh 
and  Glasgow  are  concerned. 

"  Sometimes,  but  not  verj'  often,  medical  students 
in  their  fifth  year  may  be  taken  out  by  their  teachers 
to  administer  chloroform;  but  these  men  have  com- 
pleted at  least  two  years'  hospital  training,  and  prob- 
ably have  given  anaesthetics  in  the  hospital  under 
their  teacher,  his  assistant,  or  the  house  surgeon. 

"  I  may  remark  here  that  female  medical  practition- 
ers in  this  country  are  peculiarly  unfitted  to  give 
anaesthetics.  That  such  is  the  case  I  know  from  ex- 
perience, and  it  is  well  illustrated  at  the  Woman's  Hos- 
pital, Euston  Road,  London,  which  is  remarkable  for 
the  failures  in  administering  chloroform  correctly. 

"As  to  the  ordinarj-  house  surgeon,  he  may  be  said 
to  be  an  unknown  quantity  so  far  as  the  giving  of  an 
anesthetic  is  concerned.  Nothing  worries  a  surgeon 
more  than  to  experience  the  attempts  of  a  new  house 
surgeon  administering  an  anesthetic,  and  also  the  un- 
certainty of  his  success  until  he  has  gained  the  requi- 
site knowledge,  when  too  often  the  young  man  is  trans- 
ferred to  the  medical  wards  of  the  hospital,  never 
again  to  enter  the  surgical  wards  unless  be  has  the 
good  fortune  to  be  appointed  assistant  to  his  chief, 
which  is  about  one  chance  in  a  hundred. 

"A  ver)"  good  plan  is  that  every  anesthetic  admin- 
istration in  a  hospital  is  noted  in  the  ward  journal,  and 
by  whom  given,  together  with  any  physical  signs,  pul- 
monary or  cardiac,  that  have  been  discovered  before 
the  administration  took  place. 

"No  student  is  allowed  to  administer  chloroform  in 
any  case  before  his  fourth  year,  and  who  has  not  had 
two  years'  hospital  experience.  He  is  usually  picked 
out  by  his  teacher  from  among  the  other  men,  owing 
to  his  aptness. 

"It  is  often  the  case  that  unqualified  assistants  in 
private  practice  administer  chloroform  and  ether  very 
well,  but  these  men  have  been  taught  by  their  employ- 
ers and  have  an  experience  in  some  cases  extending 
over  many  years.  (They  are  chiefly  '  chronics  '  and 
men  who  have  to  work  in  the  struggle  for  existence  to 
keep  themselves  at  their  classes:  this  is  common  with 
Scotch  unqualified  assistants,  who  are  employed  by 
English  medical  men  chiefly  in  large  collier)-  prac- 
tices.) But  this  class  is  dying  out,  as  the  authorities 
insist  on  the  giving  of  anesthetics  by  qualified  men 
alone,  as  often  crops  up  at  coroners'  inquests. 

"The  newly  fledged  practitioner  is  remarkable  for 
his  inability  to  administer  an  anesthetic  correctly. 
This  is  a  common  complaint  among  countn-  practi- 
tioners. 

"  So  far  as  the  medico-legal  aspect  of  the  case  is 
concerned,  the  anesthetist  must  be  a  qualified  regis- 
tered practitioner.  If  he  is  not  qualified  and  regis- 
tered, he  cannot  sue  for  fees  in  the  courts  of  the  land. 
Otherw  ise  he  is  regarded  in  the  eye  of  the  law  as  a 
quack. 


November  13,  1897] 


MEDICAL    RECORD. 


723 


"  In  order  to  give  you  the  exact  details  of  the  num- 
ber of  anaesthetists  at  all  the  hospitals  in  this  country, 
and  the  bylaws  in  force  at  the  various  hospitals  regu- 
lating the  administration  of  anssthetics,  I  should  re- 
quire the  services  of  a  special  commission  to  visit 
each  hospital  and  report. 

"  I  have  endeavored  to  give  you,  I  believe,  a  correct 
and  faithful  statement  of  the  case  as  pertaining  to 
London,  Dublin,  and  Scotch  hospitals,  and  of  that  of 
general  practitioners  here,  so  that  it  cannot  be  said 
that  every  Tom,  Dick,  and  Harry  has  the  opportunity 
or  even  gets  the  chance  of  inflicting  a  nuisance  in  the 
way  of  giving  anaesthetics  inefficiently. 

"  I  might  close  these  general  remarks  by  stating  that 
the  late  Sir  George  H.  B.  McLeod  was  so  particular 
in  giving  chloroform  himself  that  he  commenced  the 
administration  in  ever)-  case,  and  handed  the  further 
work  over  to  his  assistant  until  he  himself  completed 
the  operation.  He  had  some  seventeen  thousand  ad- 
ministrations with  only  three  deaths,  and  these  took 
place  within  the  last  three  years  of  his  life.  I  merely 
mention  this,  as  he  was  my  last  surgical  teacher. 

"  I.  As  to  Previous  Training  and  Experience. — 
The  student  gets  special  lectures  from  his  hospital 
physicians  and  surgeons  on  N^O,,  CHCI,,  and  ether; 
and  combinations,  as  what  is  called  the  A.C.E.  mix- 
ture here  =  i  vol.  alcohol,  2  vols.  CHCT,  3  vols,  ether 
— so  proportioned,  I  believe,  that  they  evaporate 
equally  and  uniformly  at  the  same  temperature  and 
barometric  pressure.  The  student  requires  to  know 
the  use  of  N^O,  and  its  mode  of  administration,  but 
nothing  can  make  up  for  lectures  on  these  modes  of 
anaesthesia  except  the  practical  information  gained  by 
administration. 

"  II.  Physical  Diagnosis. — The  student  is  taught 
to  make  a  searching  physical  examination  of  the  heart, 
blood-vessels,  lungs,  and  kidneys  as  to  the  presence 
of  organic  disease  before  the  patient  is  proposed  to 
be  operated  on.  If  the  patient  is  under  obser\-ation, 
it  is  always  the  rule  to  make  such  an  examination  a 
day  or  t%vo  before  the  proposed  administration  and  not 
immediately  before,  as  is  sometimes  done,  as  it  often 
excites  the  patient  and  affects  the  breathing,  etc.  Just 
lately  we  had  a  case  at  the  Samaritan  Hospital  in  which 
pulsation  in  the  suprasternal  notch  with  some  increase 
of  dulness  at  the  base  of  the  heart  revealed  an  aneu- 
rism of  the  aortic  arch.  This  escaped  the  observation 
of  the  resident,  a  lady  doctor,  till  it  was  pointed  out  to 
her. 

"  The  pulse  is  most  important  to  notice  beforehand, 
as  it  becomes  so  altered  under  chloroform  administra- 
tion. The  student  is  taught  to  know  what  a  dicrotic 
pulse  is  like,  so  that  he  may  be  able  to  look  ahead 
during  the  administration  of  chloroform. 

"III.  Urinalysis. — The  presence  or  absence  of 
albumin  is  carefully  noted;  also  specific  gravity,  re- 
action, etc. 

"  The  presence  of  sugar  in  the  urine  is  an  indication 
that  if  it  is  necessary  to  give  chloroform  the  pulse  and 
breathing  require  particular  attention,  as  often  in  these 
cases  fatal  results  follow.  This  point  is  strongly  im- 
pressed on  students  and  medical  men  also. 

"  Inhalers. — The  practice  generally  followed  here 
is  to  use  an  inhaler  such  as  Clover's  or  Junker's. 
Quite  a  number  of  good  inhalers  are  in  the  market, 
and  a  good  aneesthetist  will  be  able  to  substitute  any 
of  them  he  pleases,  or  even  use  the  towel  or  the  flannel, 
or  linen-covered  cage  which  acts  as  a  respirator.  Our 
method  at  the  Samaritan  Hospital  is,  say,  for  merely 
an  examination  under  chloroform,  to  give  it  on  a 
respirator;  also  for  a  minor  operation;  for  a  major 
or  any  operation  taking  some  time,  the  patient  is  first 
put  under  N„0,,,  and  then  kept  under  ether  or  chloro- 
form, as  the  anaesthetist  may  choose. 

■'  The  student  is  always  shown   the   best   apparatus 


to  use ;  indeed,  he  must  know  them  as  well  as  any 
other  surgical  instruments  he  may  be  shown  at  his 
examinations. 

"  Stimulants  in  every  case  when  necessary  are 
given  by  the  orders  of  the  anaesthetist,  another  medical 
man  administering  brandy  or  whiskey  by  mouth,  or 
brandy  or  ether  hypodermically,  as  the  case  may  be. 

"  Sometimes  the  patient  may  get,  say,  one-half  ounce 
of  brandy  some  little  time  before  being  anaesthetized. 
This  is  very  seldom  the  case,  but  it  is  sometimes  given 
when  there  is  a  weak  pulse.  The  general  rule  is  to 
discourage  the  use  of  stimulants  unless  absolutely 
necessary.  Nitrite  of  amyl  in  a  broken  capsule  is 
sometimes  given  in  threatened  collapse,  to  act  as  a 
stimulant  to  the  heart,  of  course  by  inhalation. 

"  Stimulants  are  always  at  hand  in  the  operating- 
room,  so  as  to  be  ready  for  instant  use  if  necessar}-. 

"Means  of  Resuscitation The  artificial  methods 

of  respiration  are  always  used.  Inversion  of  the  body 
is  strongly  recommended  before  artificial  respiration  is 
commenced.  Inversion  alone  has  saved  a  good  many 
patients.  The  sudden  application  of  a  large  cloth 
dipped  in  boiling  water  to  the  cardiac  region  is  useful ; 
a  hot  towel  removed  from  a  steamer  has  been  very 
useful  with  us  at  the  Samaritan  Hospital.  These 
various  acts  are  performed  on  instruction  by  the  anes- 
thetist himself,  and  not  by  half  a  dozen  men  all  shout- 
ing at  the  same  time. 

"The  Best  Anaesthetic  and  who  Decides. — The 
anaesthetist  states  which  he  purposes  to  use,  and  the 
physician  or  surgeon  usually  concurs ;  at  other  times 
he  may  intend  to  use  chloroform,  and  finding  it  un- 
suitable administer  ether. 

"  Responsibility. — The  surgeon  is  not  responsible; 
the  anaesthetist  is  responsible  for  the  patient  as  long 
as  he  is  under  the  anaesthetic.  It  is  agreed  that  it 
rests  entirely  with  the  anaesthetist. 

"  Fees  in  private  practice  are  usually  handed  over 
to  the  anesthetist  when  the  surgeon  or  physician  gets 
his,  unless  there  is  any  arrangement  for  being  paid 
before  leaving  the  patient's  house,  as  sometimes  pa- 
tients prefer  to  pay  the  anaesthetist  at  once. 

"  Substitutes. — With  us,  usually  myself  or  another 
member  of  our  staff  takes  the  place  of  the  anesthetist 
if  he  be  called  away. 

'■  The  anaesthetist  is  required  to  attend  the  hospital  at 
the  usual  hospital  hour  on  all  operating-days  (with  us, 
9  A.M.,  Wednesdays  and  Saturdays),  whether  he  is 
needed  or  not,  and  at  any  other  time  his  services  are 
necessary.  Of  course  he  knows  exactly  when  to  come, 
as  he  is  on  the  telephone. 

"  The  anesthetist  rarely  asks  the  interne  to  do  his 
work;  in  fact,  internes  here  do  not  care  mucli  about 
that  kind  of  work. 

"The  professional  standing  is  good.  An  anesthe- 
tist usually  takes  up  a  specialty  like  the  throat,  eye,  or 
gynecolog)',  or  the  ear,  as  he  has  no  time  for  general 
practice." 

ECONOMY    IN    HYPODERMIC    NEEDLES. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  Thousands  of  hypodermic-syringe  needles  are 
thrown  away  each  year  as  useless  by  members  of  the 
profession,  which  could  with  a  slight  amount  of  trouble 
be  restored  to  their  original  state.  The  channel  of 
the  needle  becomes  occluded,  owing  to  the  deposition 
of  material  derived  from  the  injection  fluid.  This 
precipitate  is  readily  dissolved  and  removed  by  boil- 
ing the  needles  for  a  period  of  ten  minutes  in  a 
solution  of  sodium  carbonate,  which  not  only  cleanses 
the  needle  internally,  but  restores  the  brightness  of  the 
external   surface  as  well. 

Adolph  G.  Brown,  M.D. 

Red  Bank,  N.  J. 


724 


MEDICAL    RECORD. 


[November  13,  '897 


PUERPERAL   SEPTIC/3<:MIA. 


A    NATIONAL   QUARANTINE   SYSTEM. 


Sir  :  On  reading  the  discussion  held  by  the  New  York 
Academy  of  Medicine,  one  can  but  note  the  difference 
of  opinion  entertained  by  the  various  members  in 
regard  to  puerperal  septicrEmia,  its  source,  and  its 
treatment.  Although  mine  has  been  somewhat  lim- 
ited, yet  I  feel  that  I  have  had  ample  e.xperience  to 
justify  the  following  conclusions:  that  the  source  of 
infection  is  undoubtedly  through  the  uterus,  not  the 
vagina;  that  in  a  large  majority  if  not  in  all  cases  the 
cause  is  principally  the  retention  of  offending  matter 
in  utero. 

The  absorptive  power  of  the  vaginal  mucous  mem- 
brane is  not  great  under  ordinary  conditions.  Now, 
then,  this  offending  matter  is  one  of  two  things— either 
secundine  or  the  necessary  discharge.  This  product 
is  by  retention  so  exposed  to  the  abraded  portion 
of  the  intra-uterine  surface  that  absorption  takes 
place. 

All  the  cases  of  Puerperal  septicaemia  I  have  wit- 
nessed bear  me  out  in  this  conclusion,  and  I  think  if 
a  proper  search  is  made  one  will  rarely  fail  to  find  the 
cause;  and  yet  the  apparent  cause  is  so  slight,  so 
inferior  to  that  found  in  other  cases  that  present  no 
grave  symptoms,  that  we  are  inclined  to  infer  that  sys- 
temic conditions  have  much  to  do  with  and  are  much 
at  fault  for  this  trouble.  I  have  not  found  septicemia 
more  prevalent  in  badly  lacerated  cases:  in  fact,  my 
experience  has  shown  quite  to  the  contrary,  and  con- 
vinces my  mind  that  we  must  look  elsewhere  than  to  lac- 
erations of  either  the  uterus  or  the  vagina  for  a  solution 
of  this  subject.  Just  how  much  is  to  be  attributed  to 
general  systemic  conditions  is  a  question  that  to  my 
mind  demands  a  yet  closer  investigation,  and  until 
further  evidence  has  been  brought  to  light  on  this  part 
of  the  subject  I  shall  continue  to  be  of  the  same  mind 
I  now  am.  I  have  watched  these  cases  closely  and 
earnestly  for  the  past  twenty-five  years,  and  I  feel  that 
so  far  we  are  largely  in  the  dark  as  to  the  nature  and 
cause  of  this  dread  disease.  That  thorough  cleanli- 
ness is  a  step  in  the  right  direction  is  indisputable. 
That  therapeutical  remedies  fail  in  each  and  every 
case  is  also  a  sad  reality.  That  curettage  to  a  de- 
gree that  would  in  the  least  irritate  the  endometrium 
is  ne.xt  to  criminal,  and  anything  further  than  the 
removal  of  retained  morbid  matter  from  the  uterus 
and  its  thorough  cleansing  by  the  gentlest  means  is 
meddlesome  and  to  be  condemned.  I  do  not  believe 
ergot  has  anyinlluence  in  preventing  septic  conditions. 
I  rarely  give  a  dose  nowadays,  and  have  less  trouble 
than  formerly  when  I  believed  I  had  not  done  my  duty 
until  I  iiad  given  at  least  one  drachm  of  fluid  extract 
of  ergot.  I  believe  that,  if  we  eliminate  this  "  general 
systemic  idea,"  in  thorough  cleanliness  of  the  uterus 
we  may  safely  trust  for  our  success.  Proper  food,  with 
favorable  hygienic  surroundings,  is  next  in  importance. 
1  am  convinced  that  with  a  clean  uterus  we  may  rest 
content  that  nature  will  do  the  rest.  To  obtain  this  it 
is  not  essential  that  every  emptied  uterus  should  be 
irrigated  with  any  and  all  kinds  of  .so-called  antiseptics. 
Not  at  all.  In  fact,  very  few  need  anything  of  the 
.sort.  I  rarely  irrigate  a  uterus  after  delivery  at  full 
term ;  I  am  more  chary  regarding  one  that  has  attempted 
to  expel  its  contents  prematurely,  and  on  the  tirst 
unfavorable  symptom  presenting  I  rarelv  fail  to  wash 
that  organ.  One  thorough  wasiiing  is  most  often  sutli- 
tient,  and  I  would  caution  against  frequent  repetition. 
Do  not  repeat  your  irrigation  except  as  indicated  by 
results  obtained,  and  if  this  course  is  followed  pru- 
dently yet  thoroughly  by  the  physician  himself  you 
may  "to  the  dogs  with  your  physic." 

VVii.i.iA.M  .\.  Daviso.n,  M.D. 

lUriH,  Mont. 


Sir  :  Any  olftervant  traveller  through  the  South  just 
at  this  time,  when  yellow  fever  is  so  much  in  evi- 
dence, cannot  but  become  forcibly  impressed  with  the 
necessity  for  a  quarantine  system  that  is  broad  and 
comprehensive  in  its  scope  and  that  can  be  made  to 
extend  beyond  the  range  of  small  towns,  counties,  or 
municipalities.  Petty  jealousies  between  rural  locali- 
ties, quarantine  regulations  widely  at  variance,  and  a 
lack  of  harmony  in  the  construction  and  enforcement 
of  quarantine  methods  have  done  as  much,  during  the 
present  yellow-fever  epidemic  in  the  South,  to  bring 
hardship  and  disaster,  as  the  disease  itself. 

A  recent  tour  through  the  South  convinces  me  that 
this  statement  is  perfectly  true.  The  lack  of  confi- 
dence in  local  regulations,  the  harshness  with  which 
they  conflict  with  the  regulations  of  adjoining  locali- 
ties, the  laxity  of  methods  pursued,  are  all  apparent  to 
the  crudest  observer.  I  was  informed  by  many  railway 
officials  in  the  South  and  by  quarantine  officers  them- 
selves that  the  attempt,  as  it  is  made  by  the  different 
localities,  to  prevent  the  spread  of  the  disease  is  really 
doing  greater  harm  than  the  disease. 

All  epidemics  that  assume  the  scope  and  magnitude 
that  yellow  fever  has  now  assumed  in  the  South  are 
interstate  matters  always,  and  matters  of  vital  import- 
ance not  only  in  so  far  as  lives  are  endangered,  but 
in  jeopardizing  and  destroying  commerce.  The  na- 
tional government  has  jurisdiction  o\er  interstate  com- 
merce. Why  can  it  not  regulate  and  preserve  the 
health  and  comfort  of  the  people,  when  they  stand  en- 
dangered by  so  universal  and  deadly  a  scourge  as  yel- 
low fever,  and  when  local  measures  to  restrict  its 
spread  are  tentative  and  inefficiently  administered? 

A  national  quarantine  system  or  an  interstate  quar- 
antine system  administered  by  the  national  govern- 
ment, if  done  conservatively  and  efficiently,  would 
give  confidence,  destroy  conflicting  regulations  between 
minor  communities,  and  do  much  to  relieve  epidemics 
of  the  present  kind  of  much  of  their  real  harm.  Let 
us  have  a  national  quarantine  system,  and  let  it  exist 
in  fact  as  well  as  in  name. 

William   P.   Spratliki.;,  M.D. 

SoNVEA.  X.   v.,  October  20,  1S07. 


Contagious  Diseases — Weekly    Statement. — Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitarv  liureau,  Health  Department,  for  the 
week  ending  .\o\cniber  6,  1897: 


200 

III 

28 

9 

121 

7 

0 
i8r) 

3 
>3 

M3 

24 

Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. .  . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox 


Eye  Complications  of  Typhoid  include,  according 
to  C.  Stedraan  Bull,  catarrhal  conjunctivitis,  phlyc- 
tenular conjunctivitis  and  keratitis,  loss  of  accommo- 
dation for  dilatation  by  paralysis  of  the  iris  sphincter, 
retinal  hemorrliages.  paralysis  of  the  external  mus- 
cles, neuro-retinitis  or  retrobulbar  neuritis,  ambly- 
opia, iiemianupia,  inflammation  of  the  uveal  tract, 
iritis,  cyclitis,  choroiditis. — I.a  Mui.  Mod. 


Medical  Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


whoie'No°'i4ii.       -^^^  York,    November  20,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rigiual  J^rticXcs. 

WHAT  MUST  WE  DO  TO  BE  SAVED?  BEING 
AN  INQUIRY  INTO  AND  A  BRIEF  SUM- 
MARY OF  THE  CAUSES  LEADING  TO  THE 
HOSPITAL  AND  DISPENSARY  ABUSE  OF 
MEDICAL    CHARITY.' 

By   THOMAS   J.    HILLIS,    M.D., 

There  is  really  after  all  nothing  very  startling  in  the 
title  of  this  paper;  it  simply  means  that  the  profession 
of  which  we  are  a  part  is  threatened  on  all  sides  and 
beset  by  many  dangers. 

It  will  be  my  object  to-day  to  point  out  some  of 
these  dangers,  and  leave  the  task  of  applying  a  rem- 
edy for  another  time,  since  the  few  minutes  allotted 
me  here  admit  only  a  cursory  glance  at  this  wide  field. 

The  medical  press  throughout  the  country  teems 
with  articles  on  hospital  and  dispensary  abuse,  and  a 
wail  of  distress  is  heard  from  one  end  of  the  land  to 
the  other  from  the  rank  and  file  of  our  profession. 
They  say  that  among  the  causes  for  this  distress  and 
discontent  the  abuse  of  charity  in  hospital  and  dis- 
pensary stands  single  and  alone,  conspicuous  in  its 
isolation;  that  these  institutions  have  broken  faith 
with  the  profession  which  created  them  and  made  their 
existence  possible;  that  if  these  abuses  are  allowed  to 
continue,  in  a  short  time  a  practitioner  of  medicine 
will  be  a  rare  curiosity  outside  of  a  hospital  or  dispen- 
sary; that  a  profession  more  ancient  than  the  Golden 
Fleece  or  Roman  Eagle,  and  endowed  with  attributes 
of  mercy  and  honor,  will  perish  from  the  earth,  and 
there  will  remain  only  the  hothouse  plants,  the  clinic 
and  maternity  home,  founded,  fostered,  and  nourished 
by  a  millionaire  whose  memory  is  not  savory,  through 
the  dollars  wrung  from  honest  toil  and  the  millions 
made  through  syndicates  by  the  maladministration  of  a 
government  supposed  to  act  for  the  interests  and  wel- 
fare of  the  people — a  supposition,  however;  an  illu- 
sion and  a  snare. 

before  proceeding  any  farther,  it  might  be  well  to 
inquire  into  the  truth  or  falsity  of  these  charges,  so 
boldly  advanced  by  the  profession,  against  hospital 
and  dispensary. 

These  concerns  are  dealing  only  with  conditions 
that  present  themselves  continually.  These  condi- 
tions are  effects,  not  causes.  These  effects  will  be 
traced  to  their  sources.  It  will  be  the  purpose  of  this 
paper  to  point  out  these  sources  and  fasten  the  respon- 
sibility where  it  belongs.  Then  there  are  causes  for  this 
hospital  and  dispensary  abuse,  and  for  all  the  abuses 
pointed  out  by  the  physician  in  his  calendar  of  perse- 
cution and  oppression.  These  causes  will  be  consid- 
ered, and  in  the  classification  of  causation  the  physi- 
cian himself  will  have  the  honor  or  dishonor  of  holding 
high  place  or  being  first  cause. 

This  paper  will  trace  an  ambitious,  unscrupulous 
young  physician,  from  the  moment  he  leaves  the  class- 
room to  hang  out  his  sign,  proclaiming  to  the  world 
his  calling  and  inviting  that  world's  approbation  and 

'  Read  at  the  fourteenth  annual  meeting  of  the  New  York  state 
Medical  .\ssociation,  October  12,  1897. 


patronage,  through  years  of  toil  and  intrigue,  through 
the  ups  and  downs  of  a  busy,  ceaseless  activity.  It 
will  watch  him  in  his  dealings  with  others,  particu- 
larly his  brother  practitioners.  It  will  see  if  he  ob- 
serves the  golden  rule,  "  Do  unto  others  as  you  would 
like  to  be  done  by,"  and  if  the  word  brother  has  any 
meaning,  as  applied  by  physicians  to  each  other,  and 
whether  it  is  not  hollow  and  delusive. 

By  following  this  physician  through  the  mazes  and 
perple.xities,  the  labyrinths  and  subterraiiean  channels 
in  which  a  professional  life  will  run  for  the  first  fif- 
teen years  of  its  career,  we  shall  not  have  much  trouble 
in  discovering  the  principal  source  from  which  the 
river  of  hospital  and  dispensary  abuse  has  sprung — 
namely,  the  physician  himself.  Though'  ages  have 
rolled  away  since  the  inspired  words  were  uttered, 
they  still  ring  through  the  universe,  at  once  a  com- 
mand, a  warning,  and  a  benediction — "  Physician, 
heal  thyself." 

His  journey  in  Pursuit  of  Success The  young 

physician,  after  receiving  his  diploma,  and  with  the 
benediction  of  his  alma  mater  ringing  in  his  ears, 
starts  out  into  the  active  practice  of  his  profession. 
He  will  not  tarry  in  Jericho  until  his  beard  is  grown, 
or  immure  himself  in  his  cloister  until  the  ink  is  dry 
on  his  diploma.  He  is  charged  with  medical  energy, 
as  a  balloon  is  with  vapor  or  a  battery  with  electric 
force,  and  as  the  exponent  of  the  gospel  of  healing  he 
sallies  forth,  a  veritable  Don  Quixote,  to  heal  the  sick 
and  bind  up  the  wounds  of  the  injured,  though  the 
practical  knowledge  properly  to  apply  his  methods  is  as 
crude  and  visionary  and  as  barren  of  results  as  was  that 
of  the  redoubtable  knight  to  regenerate  and  reorgan- 
ize society.  He  refused  to  listen  to  an  old  physi- 
cian, as  full  of  knowledge  as  he  was  ripe  in  years, 
waving  him  off  with  a  grandiloquent  motion  of  his 
hand  when  he  offered  to  point  him  the  way  on  Ihat 
memorable  morning  he  started  out  on  his  professional 
career.  This  stripling  out  of  school,  now  turning 
himself  loose  on  society,  refused  to  hear  the  advice  of 
a  sage. 

Lord  of  Himself,  a  Heritage  of  Woe .\fter  some 

effort  he  finds  a  desirable  neighborhood  in  which  to 
locate,  and  after  further  effort  he  secures  an  appoint- 
ment on  the  staff  of  a  free  dispensary.  He  joins  a 
medical  society,  and  the  church  in  the  neighborhood; 
he  is  now  honored  as  a  resident. 

The  dispensary,  while  giving  him  experience  which 
he  sadly  needs,  occasionally  supplies  a  patient  whom 
he  can  corral  to  his  office  by  a  little  deception,  quiet 
entreaty,  and  tact.  In  the  church  he  can  get  at  close 
range  to  the  pastor,  and  to  know  the  pastor  well  has 
a  special  significance  for  him,  to  which  assertion  many 
successful  physicians  can  attest.  The  medical  society 
aids  too,  by  imparting  dignity  and  stability,  and,  fur- 
ther, it  lifts  him  high  above  the  quack  and  other  ven- 
dors of  medical  wares.  Having  now  secured  these 
three  objects  so  dear  to  his  heart,  he  has  a  further 
ambition:  he  wishes  to  become  a  lecturer,  with  the 
ultimate  object  of  blos.soming  out  into  a  professor.  So 
he  hires  the  lyceum  attached  to  the  Sunday  school,  for 
a  course  of  lectures  on  longevity  and  hygiene,  under 
the  auspices  of  the  pastor  and  board  of  trustees  of  the 
church.     To  be  honest  in  the  matter,  he  cares  not  a 


726 


MEDICAL    RECORD. 


[November  20,  1897 


rap  about  the  longevity  or  hygiene  of  this  particular 
neighborhood;  it  would  be  to  his  interest  were  the 
sanitary  conditions  to  remain  bad,  and  disease,  en- 
demic and  epidemic,  to  spread  its  wings  over  the  peo- 
ple. Unfortunately,  he  wishes  only  to  exploit  himself, 
and  under  cover  of  a  lecture,  the  subject  of  which  h^ 
knows  little  or  nothing  about,  to  advertise  himself 
among  what  may  now  be  called  his  new  constituency. 
His  lecture  is  commonplace  and  abounds  in  catch- 
words and  well-worn  phrases,  but,  as  the  admission  is 
free,  it  is  heard  by  the  people,  who  are  attracted  more 
by  curiosity  than  by  a  thirst  for  knowledge. 

In  that  town  where  Dr.  Youngblood  located  there 
were  four  other  physicians;  but  it  will  be  observed 
that  he  did  not  visit  any  of  them  for  counsel  or  advice 
on  such  a  momentous  undertaking  as  locating  and 
making'  a  start  in  the  practice  of  his  profession.  He 
did,  however,  visit  a  livery-stable  keeper,  and  a  drug- 
gist, and  the  superintendent  of  a  patent-medicine 
plant.  The  liveryman  thought  there  was  an  opening 
for  a  bright  young  man,  especially  if  he  could  afford 
to  drive;  it  would  impress  his  personality  the  more. 
The  druggist  was  sure  there  was  an  opening,  as  none 
of  the  other  four  doctors  in  the  town  was  very  well 
liked ;  but  he  asked  the  physician  as  a  special  favor  to 
keep  that  to  himself,  as  he  would  not  for  the  world 
have  his  name  mentioned  or  in  any  way  mi.xed  up  in 
the  matter,  since  he  was  only  helping  a  clever  young 
man  to  make  his  way  in  the  world.  The  superinten- 
dent of  the  patent-medicine  plant  was  certain  there 
was  room  for  another  physician,  and  success  was 
already  assured  if  he  would  only  push  certain  new 
remedies  that  his  firm  was  now  placing  on  the  market. 
His  signature  and  photograph  would  be  of  great  value 
to  them ;  besides,  it  would  advertise  him,  it  would  be 
a  ready  avenue  to  the  public  ear,  and  perhaps  to  the 
people's  heart. 

While  he  was  talking  to  the  superintendent,  a  gen- 
tleman stood  by,  who  later  said:  "The  doctors  are 
sleepy  in  this  village;  we  want  a  live  man,  who  could 
easily  make  a  fortune  in  a  very  few  years."  He  did 
not,  however,  say  that  he  him.self  was  a  bankrupt,  who 
defaulted  on  his  obligations,  and  who  was  now  a  fugi- 
tive from  the  vengeance  of  his  creditors. 

While  talking  to  the  postmaster.  Dr.  Youngblood 
fell  in  with  a  new  acquaintance,  who  welcomed  him  to 
town,  spoke  highly  of  his  lecture  at  the  lyceum,  which 
he  declared  he  heard  with  great  pleasure;  in  fact,  his 
wife  and  oldest  daughter  were  delighted  with  it,  and 
wished  particularly  to  know  when  he  would  deliver 
his  next  lecture.  In  their  opinion  the  last  was  a  mas- 
terpiece— plain,  forceful,  and  convincing.  He  also 
made  mention  of  the  several  patients  he  had  sent  to 
him  for  treatment,  as  the  diagnoses  of  their  cases  by 
the  other  physicians  in  the  town  were  doubtful,  and  the 
treatment  was  very  un.satisfactory.  He  added  :  "  We 
are  sadly  in  need  of  young  blood  in  this  town  of  ours — 
and,  doctor,  what  a  singular  coincidence,  your  name 
is  Youngblood  too.  Indeed,  how  peculiar!  A  dead 
streak  of  luck  for  you,  I  assure  you." 

Dr.  Youngblood  knew  later,  but  was  not  now  aware, 
that  he  was  talking  to  a  dead  beat,  who  fleeced  the 
other  four  physicians  in  the  town  for  professional  ser- 
vices rendered,  and  who  found  this  gentlemanly  means 
of  paying  them  for  the  same. 

Now  Dr.  Youngblood  felt  naturally  proud  for  this 
mark  of  respect  from  his  new  townsman,  also  for  the 
kindness  he  showed  him  in  recommending  his  friends 
to  his  professional  care,  and  invited  iiim  to  call  at  his 
office  to  see  him  socially,  and,  if  ever  the  occasion 
arose  requiring  his  professional  attention,  it  would  be 
rendered  gladly  and  with  good  will.  This  young  dis- 
ciple of  .Ksculapius,  now  on  the  high  road  to  success, 
did  not  send  any  of  his  professional  brothers  an  invi- 
tation to  his  lectures  at  the  lyceum,  but  it  was  observed 


that  one  or  two  bald-headed  gentlemen  sat  in  an  in- 
conspicuous corner  of  the  lecture  hall,  and  a  young 
lady  nudged  her  escort,  exclaiming:  "Why,  I  declare, 
there  are  Dr.  White,  and  our  old  physician,  Dr.  Black, 
taking  notes  of  the  lecture."  Sure  enough,  the  gen- 
tlemen were  there,  to  hear  what  new  facts  this  new 
physician  could  impart  regarding  longevity  and  hy- 
giene. As  before  related,  they  were  not  invited  or 
consulted  in  any  manner  in  relation  to  the  lecture  or 
its  management;  in  fact,  so  far  the  young  lecturer  has 
not  seen  fit  even  to  ascertain  the  names  of  his  brother 
practitioners  in  the  town;  he  has,  however,  a  well- 
defined  and  definite  knowledge  that  they  exist.  He 
heard  certain  names  echoing  through  some  sick-rooms 
where  he  was  called  professionally,  but  these  names 
burned  deep  into  his  heart,  as  they  were  mentioned 
with  alYection  and  respect,  and  he  made  a  mental  reso- 
lution that  he  would  never  rest  or  be  satisfied  until  he 
downed  these  patriarchs,  whom  he  regarded  as  old 
fogies  and  only  a  stumbling-block  in  the  road  of  prog- 
ress—  indeed,  a  direct  hindrance  to  the  new  medical 
dispensation. 

Now  Dr.  Youngblood  cares  not  a  mill  for  the  eti- 
quette of  his  profession ;  it  has  no  concern  for  him. 
At  present  he  is  interested  only  in  himself,  and  must 
and  will  build  up  his  practice,  even  though  the  heav- 
ens fall  and  the  earth  trembles  under  his  feet.  Now 
to  accomplish  his  purpose  he  will  break  down  all  the 
barriers  that  have  hedged  in  the  traditions  of  an 
ancient  and  honorable  calling.  He  flings  etiquette 
out  of  the  window;  later  on,  after  he  acquires  success, 
he  may  amuse  himself  by  observing  this  etiquette,  and 
perhaps,  if  pressed  hard,  accept  the  presidency  of  a 
medical  society;  at  present,  however,  he  is  too  busy 
to  bother  himself  with  such  toys. 

In  the  evening  the  young  physician  is  consulted  by 
a  lady  who  has  contracted  a  severe  cold,  which  she 
cannot  shake  off^.  She  has  a  cough  mixture  prescribed 
by  Dr.  Goodman  six  months  previous;  it  helped  her 
then — it  has  failed  now.  She  did  intend  to  see  Dr. 
Goodman  again.  He  has  been  the  physician  of  her 
family  for  twenty  years,  has  led  a  blameless  life,  and  is 
respected  by  all ;  but  a  gentleman  of  her  acquaintance 
persuaded  her  to  consult  Dr.  Youngblood,  who  spoke 
about  a  serum  in  his  lecture  at  the  lyceum  on  Monday 
night,  and  said  that  if  this  serum  was  injected  under 
the  skin  it  would  quickly  destroy  the  bacilli  which 
were  playing  tag  and  having  a  jollification  in  tlie  blood 
current. 

"  You  said  at  the  lyceum  lecture  that  you  saw, 
through  your  powerful  microscope,  these  little  bacilli 
playing  croquet  in  the  lung  tissue  and  having  a  lawn 
party  on  tiie  apex  of  the  right  lung  of  one  affected 
with  tuberculosis.  These  were  dreadful  things  to 
see,  doctor,  and  if  this  was  told  by  any  other  physician 
in  the  town  we  should  say  he  was  afflicted  with  night- 
mare :  but  you,  coming  fresh  from  a  great  college,  carry 
the  latest,  the  very  latest  information,  and  tell  it  with 
an  eloquent  simplicity  that  cannot  fail  to  gain  for  you 
respect  and  popularity." 

Dr.  Youngblood,  charmed  by  tlie  candor  and  good- 
will of  this  lady,  explains  that  after  these  pestiferous 
creatures  have  been  driven  out  the  lung  will  resume  its 
normal  function  and  the  cough  cease  at  once.  He 
makes  an  artful  but  superficial  examination,  and  dis- 
covers the  bacilli  lurking  within,  though  he  does  not 
communicate  this  fact  to  the  young  k\dy  in  words:  hut 
his  look  is  fraught  with  direful  forebodings,  which  he 
tries  to  hiile  by  that  professional  smile,  that  may  mean 
much  or  nothing,  and  is  so  well  known  to  us  all.  He 
gives  an  injection  of  his  tuberculin;  he  says  another 
and  still  another  may  be  necessary,  and  occasionally 
the  little  pests  are  so  well  fortified  within  the  hou.se  of 
clay  tiiat  they  cannot  be  dislodged.  However,  he  is 
sure  that  such  will  not  apply  to  her  case,  as  she  has 


November  20,  1897] 


MEDICAL    RECORD. 


727 


taken  it  in  time;  but  as  a  matter  of  routine  and  pre- 
caution he  gives  her  a  sedative,  and  enjoins  that  she 
shall  take  a  cathartic  pill  every  night  and  avoid 
draughts,  and  dismisses  her,  after  requesting  her 
presence  again  in  two  days  for  further  consultation  and 
instruction.  At  the  appointed  time  she  returns  with 
her  mother,  who  thanks  the  young  physician  for  his 
successful  treatment  of  her  daughter's  case.  The 
cough  is  much  less  frequent  and  by  no  means  so  hard 
as  it  was.  "'  Dr.  Youngblood,"  says  the  patient,  "  I 
believe  your  serum  has  accomplished  its  purpose,  and 
brought  death  to  the  miscreants  that  were  gnawing  at 
my  vitals:  I  am  happy  now,  and  feel  a  load  off  my 
heart,  and  regard  you  as  my  benefactor." 

"  Doctor,"  says  the  young  lady's  mother,  as  she  is 
about  to  retire  with  her  daughter,  "  my  son  was  at  the 
Liberal  Club  on  Saturday  night,  while  you  gave  an  ex- 
hibition of  those  wonderful  and  mysterious  .v-rays,  and 
told  so  graphically,  so  lucidly,  how  you  located  the 
bullet  in  a  veteran's  heart,  which  he  received  while 
protecting  his  country's  honor  and  subduing  strikers 
and  riot.  As  it  happened,  doctor,  he  was  a  colonel  in 
the  national  guard  of  my  own  native  State,  Pennsyl- 
vania. As  you  so  graphically  and  pathetically  de- 
scribed, he  carried  his  wound  for  twenty  long  years — 
how  he  suffered,  and  what  great  skill  and  surgical  tact 
you  displayed  in  locating  and  removing  the  cause  of 
his  trouble!  My  son  further  told  how  you  said  you 
removed  a  dreadful  cancer,  by  a  method  new  and  pecu- 
liarly your  own,  from  the  walls  of  the  stomach  of  a 
lady  from  India,  who  came  the  long  journey  to  have 
the  benefit  of  the  best  talent,  as  the  physicians  of  the 
Orient  had  regarded  her  case  as  altogether  a  hopeless 
one." 

Says  the  lady  with  emphasis  mingled  with  pride: 
"  My  son  is  an  observing  young  man ;  he  related  this 
story  at  the  whist  party  we  had  at  our  house  last  night. 
His  father  is  thinking  seriously  of  making  him  a  phy- 
sician, and  said  you  would  be  an  excellent  preceptor. 
Before  I  go,  I)t.  Youngblood,  let  me  assure  you  of  my 
good  will,  and  you  can  count  in  future  on  the  patron- 
age of  my  family  and  of  every  friend  of  mine  I  am  able 
to  influence.  To  be  sure.  Dr.  Goodman  has  been  our 
medical  adviser  for  twenty  or  more  years.  We  have 
esteemed  him  highly;  his  successes  are  entwined  in 
the  memory  of  our  house,  and  his  failures  we  have 
regarded  as  the  visitations  of  Heaven;  but  I  declare, 
doctor,  you  have  captured  us  completely.  My  daugh- 
ter here  is  in  ecstasies  over  j'our  treatment  of  her  own 
case." 

The  young  physician's  vanity  is  tickled,  and  he  is 
justly  proud  of  his  success.  He  tries  to  hide  this  pride 
from  Dr.  Black,  who  has  not  had  the  pleasure  of  his 
acquaintance,  as  he  lias  not  been  out  much,  because  of 
repeated  attacks  from  his  old  enemy,  the  gout;  but  he 
has  heard  remarks  dropped  here  and  there  about  the 
lyceum  lecturer  and  the  social  confabs  at  the  Liberal 
Club:  but,  as  might  be  expected  from  his  age  and 
experience,  refrained  from  criticising  the  young  phy- 
sician, whose  success  under  legitimate  conditions  he 
would  be  inclined  to  consider  with  a  kindly  feeling, 
though  it  leaked  out  that  he  did  not  have  a  very  ex- 
alted opinion  of  the  subject  matter  of  the  lyceum  lec- 
tures, or,  for  that  matter,  of  the  lecturer  himself. 

A  Consultation  between  Physicians.— Now  it  hap- 
pens in  this  wise.  Dr.  IJlack  is  in  attendance  on  a 
child,  sick  w  ith  a  dangerous  disease  :  the  case  presents 
grave  features.  Dr.  Black,  while  retaining  the  confi- 
dence of  the  family,  requests  a  consultation,  and  mod- 
estly leaves  it  to  themselves  to  choose  who  the  consul- 
tant should  be. 

On  entering  the  sick-room  at  ten  o'clock  next  morn- 
ing, though  the  hour  for  consultation  was  set  for 
10:15,  he  is  surprised  to  have  the  pleasure  of  meeting 
Dr.   Youngblood,  who   at   the   last   moment   has  been 


summoned  over  the  head  of  old  Dr.  White,  whom  Dr. 
Black  was  so  sure  of  meeting  in  the  house  of  Mrs. 
Goodyear.  After  e.xchanging  greetings.  Dr.  Young- 
blood says :  ''  Pardon  me.  Dr.  Black,  I  came  a  few- 
minutes  before  the  appointed  time,  thinking  you  might 
be  here  a  little  earlier  vourself.  As  I  am  an  exceed- 
ingly busy  man,  I  must  utilize  every  spare  moment  of 
my  time."  His  real  reason,  however,  for  coming  early 
is  to  make  an  examination  on  his  own  account,  unham- 
pered by  the  eye  of  Dr.  Black,  and  to  give  and  receive 
some  suggestions  from  the  family,  in  order  more  thor- 
oughly to  familiarize  himself  with  the  case,  and,  if 
possible,  surprise  and  nonplus  Dr.  Black  at  his  skill 
and  aptness  in  diagnosis. 

After  surveying  the  room  with  a  pompous  air,  he 
asks  to  see  the  observation  chart,  and  directs  his  atten- 
tion to  the  nurse  rather  than  to  the  physician:  but  as 
a  matter  of  fact  he  has  already  seen  this  chart  on  the  sly, 
when  he  sent  the  nurse,  as  a  pretext,  to  communicate 
some  fact  to  the  family  in  an  inner  room.  He  wants 
to  know  all  about  the  temperature  curve  and  the  pulse 
wave,  now  affecting  an  air  of  superiority  and  measuring 
the  sick-room  with  an  insolent  stride. 

Dr.  Black,  while  a  careful  obser\'er,  does  not  lay 
quite  so  much  stress  on  the  variations  of  these  waves 
and  curves.  He,  however,  recognizes  that  the  pulse  is 
rapid  and  the  temperature  high ;  but  as  the  alimentary 
tract  is  clear  from  obstruction  and  the  head  compara- 
tively cool,  he  prefers  to  direct  his  attention  to  the 
heart  and  stomach  rather  than  to  the  temperature.  He 
tells  Dr.  Youngblood  that  temperature  in  a  child  has 
not  such  serious  import  as  in  those  of  more  mature 
years;  that  to  strengthen  the  heart  beat  and  to  have  the 
stomach  tolerant  of  food  have  always  been  his  first  and 
most  important  duty.  "  My  professor  at  college,  in 
whom  I  have  the  most  im.pl icit  confidence,"  says  Dr. 
Youngblood,  "  laid  great  stress  on  temperature  in  a 
child.  He  declared  it  acted  first  on  the  nerve  cen- 
tres; secondly  on  the  reflexes,  which  he  said  were  very 
impressionable  and  sensitive  at  this  early  period  of 
life;  and  was  apt  to  develop  spasm,  which  so  con- 
tracted the  respiratory  group  of  muscles  that  it  inter- 
fered with  the  return  circulation,  and  was  sure  to  pro- 
duce cerebral  congestion — a  grave  complication  in 
one  suffering  from  any  form  of  disease." 

The  gentlemen  are  agreed  on  the  nature  of  the  dis- 
ease, but  in  prognosis  and  treatment  stand  wide  apart. 
Dr.  Black,  while  recognizing  the  gravity  of  the  case, 
is  not  absolutely  hopeless  of  the  final  result;  however, 
since  Dr.  Youngblood  is  certain  of  a  favorable  termi- 
nation if  his  line  of  treatment  is  adopted,  there  is  no 
other  course  open  to  Dr.  Black  but  to  retire  from  the 
case,  which  he  does.  This  resolution  is  made  by  Dr. 
Black  while  adjusting  his  overshoes  in  an  anteroom, 
after  hearing  Dr.  Youngblood,  again  on  the  sly — 
though  spoken  in  a  low  whisper — express  a  desire  to 
be  alone  in  the  case  to  the  father  of  the  child,  as  he  was 
waiting  anxiously  at  the  door  of  the  consultation  room 
to  hear  if  the  physicians  had  any  good  news  to  convey 
concerning  the  outcome  of  the  disease  with  which  his 
child  is  now  afflicted. 

It  will  be  granted  Dr.  Black's  ears  are  not  slow  to 
hear,  even  if  his  joints  are  stiff  and  he  carries  a 
weight  of  seventy  years  on  his  shoulders. 

The  two  physicians  part  with  a  cool,  self-contained, 
and  quiet  reserve,  but  they  do  not  part  as  friends — a 
thing  not  observed  by  members  of  the  family,  who  are 
worried  and  buried  in  grief,  and  who  would  be  almost 
inconsolable  were  it  not  for  the  rays  of  hope  kindled 
in  their  hearts  and  the  bright  light  reflected  on  their 
path  by  the  favorable  prognosis  and  kind  words  of  Dr. 
Youngblood. 

Dr.  Youngblood,  now  alone  in  the  case,  is  heroic  in 
his  treatment.  He  blisters,  purges,  applies  the  cold 
pack  and  ice-bags  to  the  head:  he  examines  the  coa' 


72? 


MEDICAL    RECORD. 


[November  20,  it 97 


tar  series  and  gives  full  doses  of  the  very  latest  anti- 
p)'retic,  also  an  analgesic  and  a  cerebral  sedative,  for 
he  has  a  fear  of  the  reflexes.  He,  however,  succeeds 
only  in  robbing  the  child  of  the  little  strength  it 
possessed  under  Dr.  Black's  fostering  care,  for  he 
hourly  grows  weaker.  Next  day  Dr.  Youngblood  looks 
wise  and  serious:  he  does  not  wish  the  family  to 
understand  that  he  is  criticising  the  methods  of  Dr. 
Black,  who  so  recently  had  charge  of  the  case  and  in 
whom  they  were  wont  to  place  such  confidence;  no, 
nothing  of  the  kind — oh!  no,  indeed;  but  he  is  ex- 
tremely sorr)'  he  did  not  have  an  opportunity  to  see 
the  child  one  day  earlier,  just  one  day  earlier.  At 
present  the  system  is  wasted  and  exhausted,  and  can- 
not respond  to  his  new  and  powerful  remedies;  even 
electricit)',  strychnine,  or  nitroglycerin  is  useless  now. 
However,  he  will  try  o.ws^en  :  it  will  relieve  the  par- 
oxysms and  make  his  last  hours  tranquil  and  com- 
posed. 

Next  day  all  is  still — only  the  lamentations  of  a 
distressed  and  sorrowing  mother,  who  between  her 
sobs  tells  a  lady  acquaintance  who  comes  to  offer  her 
such  consolation  as  is  in  her  power:  "Just  think,  !Mrs. 
Green,  my  darling  could  have  been  saved  if  we  had 
called  Dr.  Youngblood  earlier — just  one  day  earlier!" 
Earlier!  just  one  day  earlier!  was  wafted  out  upon  the 
darkness,  and  the  refrain  was  taken  up  by  the  hills  and 
echoed  through  the  vale — "  Earlier!  just  one  day  ear- 
lier!'"— on  that  memorable  summer  niglit  when  Mrs. 
Goodyear  fell  fainting  into  the  arms  of  her  sympathetic 
friend,  Mrs.  Green. 

While  the  family  is  making  preparations  for  the 
funeral.  Dr.  Youngblood  and  Dr.  Black  meet  again. 
It  is  only  a  coincidence,  and  not  expected  by  either 
gentleman.  The  object  of  each  in  his  visit  is  different, 
as  were  their  prognosis  and  treatment  of  the  now  dead 
child.  Dr.  Youngblood  comes  for  the  purpose  of  be- 
ing seen  and  to  advertise  himself  again.  This  occa- 
sion presents  an  excellent  opportunity,  and  he  is  not 
the  man  to  let  an  opportunity  slip.  The  fact  that  he  has 
been  acquainted  with  this  family  only  three  days  counts 
for  nothing  with  him.  He  is  sure  of  a  warm  reception ; 
they  will  be  grateful  for  the  gallant  fight  and  final 
effort  he  has  made  to  save  their  loved  one.  Dr.  Black 
comes  in  obedience  to  the  human  impulses  that  find 
a  home  in  his  breast  and  a  ready  outlet  in  his  kindly 
nature,  to  offer  his  sympathies  to  the  family  he  has 
known  ^so  well  for  twenty-five  years,  in  this  hour  of 
their  tribulation.  Dr.  Black  withdraws,  but  Dr. 
Youngblood,  who  is  now  a  conspicuous  figure  in  the 
house  of  mourning,  remains  and  chats  with  the  pastor, 
who  himself  was  a  physician,  but  abandoned  that  pro- 
fession for  a  holier  if  not  a  less  laborious  calling.  .\ 
theological  student  is  also  present,  who,  feeling  him- 
self too  much  of  a  sinner  to  enter  holy  orders,  asks 
advice  of  Dr.  Youngblood  and  permission  to  be  ac- 
counted as  his  student,  and  solicits  the  honor  of  call- 
ing him  preceptor.  The  divinity  student  is  fearful 
that  there  may  not  be  room  for  another  physician  in  the 
already  crowded  ranks  of  the  profession,  but  Dr. 
Youngblood  allays  his  apprehensions  by  assuring  him 
that  there  is  plenty  of  room  at  the  top  for  the  higher 
order  of  talent — a  qualit)'  he  is  sure  he  possesses — 
and  hopes  it  will  not  be  long  after  his  graduation 
when  he  may  perhaps  climb  to  the  high  altitude  he 
himself  occupies  in  his  profession  and  in  the  public 
eye.  Dr.  Youngblood  talks  on  various  topics,  when 
finally  the  conversation  turns  on  the  practice  of  medi- 
cine, and  the  pastor  and  pliysician  engage  in  an  ani- 
mated if  not  learned  debate  about  disease  germs  in 
general  and  micro-organisms  in  particular — their  hab- 
its, their  haunts,  and  their  influence  on  the  animal 
economy.  Dr.  Youngblood  declares  that  all  diseases 
spring  from  the  same  source  or  cause,  namely,  derange- 
ment of   adjustment   and   co-ordination    in   the  vital 


mechanism.  Dr.  Youngblood  gives  it  as  his  opinion 
that  at  some  time  in  the  future,  a  period  he  thinks  not 
remote,  the  etiology  of  disease  will  be  thoroughly 
mastered,  and  the  catalogue  of  causation  from  measles 
to  cerebro-spinal  meningitis  be  an  open  book;  a 
clear  bright  light  will  then  illuminate  the  whole 
domain  of  medicine;  and  he  hails  with  acclamation 
the  opening  of  this  new  day.  The  problem  of  the  fu- 
ture, he  says,  will  be,  not  to  cure,  but  to  prevent  dis- 
ease, when  the  old  adage  will  have  a  definite  if  not  a 
new  meaning,  that  "an  ounce  of  prevention  is  worth  a 
pound  of  cure."  He  continues:  "The  discoveries 
lately  made  and  the  new  remedies  introduced  are  pass- 
ing through  a  trying  ordeal,  as  have  all  discoveries 
and  inventions  that  have  gone  before — they  are  receiv- 
ing, as  it  were,  their  baptism  of  fire :  but  he  has  no  doubt 
they  will  emerge  in  triumph  from  the  ordeal  of  flame." 
The  microscope,  the  chemical  equation,  and  the  j:-rays 
are  leading  the  vanguard  in  this  era  of  wonders,  and 
pointing  the  way  to  boundless  possibilities  in  the 
realm  of  human  thought  and  achievements. 

"Dr.  Youngblood,"  says  the  clerg\-man,  "you 
astonish  me  by  your  familiarit}'  with  scientific  sub- 
jects. I  can  only  say  that  I  am  overcome  with  the 
magnitude  of  the  situation,  and  recognize  that  we  are 
living  in  a  grand  and  progressive  age."  After  taking 
a  full  breath,  the  clergyman  continues :  "  Dr.  Young- 
blood, if  I  understand  this  new  gospel,  which  you  have 
with  so  much  eloquence  propounded,  the  various  dis- 
eases are  but  the  preponderance  of  one  colony  of  par- 
asites over  another;  the  leucocytes,  always  present 
in  the  blood,  must  be  ever  on  the  vigil  and  always 
prepared  to  give  battle,  in  order  to  save  the  body  intact 
from  the  ravages  of  these  all-devouring  hordes.  The 
leucocytes,  then,  are  at  once  the  scavengers  and  the 
guardians  of  the  public  health.  The  blood  is  the  bat- 
tlefield, and  life  or  death  the  resultant  of  these  con- 
tending forces.  I^id  not  the  Holy  Scripture  point  out 
and  demonstrate  this  fact  long  ago,  when  it  declared, 
'  The  blood  is  the  life  '  ?" 

This  discourse  is  heard  by  many  mourners  who  have 
come  from  distant  parts  to  pay  their  respects  to  the  liv- 
ing and  to  honor  the  dead.  The  pastor  will  be  known 
for  his  learning  as  well  as  his  piety,  and  Dr.  Young- 
blood's  fame  for  scholarship  as  well  as  his  rare  skill 
in  his  profession  will  be  spread  far  and  wide. 

Dr.  Black,  who  retired  to  an  adjacent  room  only  to 
console  the  bereaved  parents,  is  an  unwilling  auditor 
of  this  ill-timed  discussion.  Later,  on  the  porch,  on 
his  way  home,  he  is  approached  by  the  divinity  student, 
who  asks  the  doctor  for  his  opinion  as  to  the  relative 
merits  of  the  discussion  between  his  pastor.  Rev.  Mr. 
Mayflower,  and  Dr.  Youngblood,  his  new  preceptor. 
The  old  physician  draws  himself  up  to  his  full  height 
and  says:  "Sir,  this  occasion  is  too  sad  and  the  time 
inopportune  to  answer  questions  that  do  not  immedi- 
ately concern  the  welfare  of  this  aftlicted  family.  I 
refrain,  sir,  from  commenting  on  the  egotism  and  bad 
taste  of  the  gentleman  who  opened  the  discussion,  or 
on  the  gentleman  who  closed  it,  for  his  lack  of  moral 
perception  and  thoughtlessness  in  desecrating  the 
attributes  of  his  sacred  calling." 

Three  men  are  conspicuous  figures  in  a  large  room, 
where  the  town  squire  holds  court,  one  cold  winter's 
morning  in  December.  There  are  some  whisperings 
going  around  in  regard  to  a  young  woman  and  an  ante- 
mortem  statement.  However,  the  facts  are  not  clear, 
and,  according  to  some  voung  ladv  friends  of  Dr. 
Youngblood,  it  is  an  outrage  to  associate  his  name  in 
any  manner  with  the  case.  These  three  men  are  Dr. 
Youngblood;  his  student,  Mr.  Hopewell,  now  Dr. 
Hopewell;  and  a  young  man,  an  accessory  to  the  act. 
now  the  central  figure  in  what  is  very  likely  to  end  in 
a  tragedv.     This  voung  man  takes  stealthv  but  furtive 


November  20,  1897] 


MEDICAL    RECORD. 


729 


glances  at  the  ancient  squire,  while  his  restless  little 
eyes  roam  around  the  courtroom,  always  to  fall  when 
they  light  on  a  little  old  woman  in  black  in  a  remote 
comer  of  the  room.  She  is  the  mother  of  the  dying 
girl.  There  is  Dr.  MayHower,  reinforced  by  two  dea- 
cons and  a  trustee,  a  contractor — all  have  come  to 
attest  to  Dr.  Youngblood's  piety  and  personal  worth, 
and  the  utter  impossibility  of  either  this  devout  Chris- 
tian or  his  talented  student,  Dr.  Hopewell,  being  guilt)- 
of  a  crime.  They  have  come,  if  necessar)',  to  give  bail 
in  any  amount  to  save  these  gentlemen  the  ignominy 
of  entering  a  cell  or  spending  a  night  in  the  lockup. 

Dr.  Youngblood  in  Jail.  —  Dr.  Youngblood,  in 
jail,  is  not  wanting  in  sympathy  from  without.  The 
sewing-girls  from  the  attics  leave  their  offerings  of 
golden  rod  and  wild  daisies  at  the  jailor's  lodge,  and 
the  more  affluent  ladies  of  his  now  numerous  acquaint- 
ance bring  pressure  in  the  shape  of  a  dollar  on  the 
jailor's  palm,  and  are  thus  able  to  present  Dr.  Young- 
blood f)ersonally  with  an  offering  of  American  Beauty" 
roses;  and  some  of  his  more  enthusiastic  lady  admir- 
ers insist  on  pinning  a  chrysanthemum  on  his  bosom; 
some  others  entivine  delicate  leaves  of  smilax  in  his 
buttonhole. 

.\  lawyer  from  Philadelphia,  Mr.  Sharp,  laughs 
heartily  in  his  office  while  reading,  when  he  declares 
the  indictment  is  full  of  legal  blowholes — that  it  is 
woven  so  clumsily  and  its  texture  is  so  loose  that  a 
flock  of  wild  turkeys  could  fly  through  the  apertures  or 
interstices  it  presents. 

It  appears  it  occurred  in  this  way.  The  district 
attorney's  assistant,  who  was  a  physician  before  he 
read  law  and  entered  the  service  of  the  State,  was  not 
skilled  in  drawing  up  indictments  for  the  criminal 
calendar.  Dr.  Youngblood  escaped  through  a  techni- 
calit}-.  He  pleaded,  "■  Xot  guilty;'"  but  a  flaw  in  the 
indictment  was  the  thunderbolt,  and  Mr.  Sharp  the 
Ajax  who  hurled  it  at  the  prosecution,  though  Deacon 
Primrose,  when  shaking  Dr.  Youngblood  by  the  hand, 
exclaimed.  "  It  was  through  interposition  of  Heaven  !  ' 

The  Founding  of  a  New  Dispensary  to  Commemo- 
rate Dr.  Youngblood's  Escape  from  Jail. — Now  it 
was  said  with  one  voice  by  the  good  people  of  Dr. 
Youngblood's  acquaintance  and  Rev.  Mr.  Mayflower's 
congregation  that  Dr.  Youngblood  must  have  a  jus- 
tification. So  they  set  about  at  once  raising  a  fund 
to  found  another  dispensary.  A  well  to-do  old  lady, 
an  e.\-president  of  the  society  of  King's  Daughters, 
said  she  would  donate  sufficient  to  build  an  amphithe- 
atre; that  it  should  be  known  as  the  Youngblood 
Operating-Room  of  the  Free-to-AU  Dispensarj'. 

Dr.  Youngblood.  smarting  under  the  disgrace  of  his 
late  sojourn  in  jail,  almost  refused  to  be  comforted, 
and  was  quick  to  discern  who  were  instrumental  in 
this  effort  to  cover  him  with  disgrace.  His  heart 
yearned  for  revenge  as  the  names  of  Drs.  Goodman, 
White,  and  Black  flitted  through  his  brain.  He  would 
accept  the  honor  of  being  surgeon-in-chief  to  this 
new  charity  only  conditionally,  and  that  condition  was 
that  the  disp)en.sary  should  be  free  to  all,  as  its  name 
implied.  "Yes,"  he  exclaimed,  "as  free  as  salvation 
or  the  air  we  breathe!''  He  said  he  was  aware  that 
some  physicians  in  the  town  would  prefer  that  a  dis- 
crimination should  be  made,  and  those  able  to  pay  for 
treatment  turned  from  the  door;  but  such  physicians 
only  wanted  to  draw  water  to  their  own  mills,  and 
their  designs  should  be  frustrated  by  making  the  dis- 
pensary a  "  Free-to-AU."  As  this  was  a  free  country, 
the  dispensary  should  be  free  in  fact  as  well  as  in  name. 

Dr.  Youngblood  was  so  determined  in  this  resolu- 
tion that  he  aroused  some  opposition  among  his  friends, 
but  it  died  away  after  he  quoted  the  lines  from  a  well- 
known  author: 

' '  Come  one,  come  all '.  this  rock  shall  fl y 
From  its  firm  base  as  soon  as  I. "' 


It  was  a  matter  of  only  minor  importance  to  Dr. 
Youngblood  when  the  Free-to-AU  Dispensary  was  sued 
for  malpractice,  but  the  suits  were  dismissed  by  Judge 
Youngman  on  the  ground  that  the  dispensarj-  was  a 
charitable  institution  and  not  responsible  for  the  bun- 
gling of  its  surgeons. 

The  lawyer  for  the  plaintiff,  now  a  helpless  cripple 
because  Dr.  Youngblood  and  his  assistant,  Dr.  Hope- 
well, mistook  a  fracture  at  the  hip-joint  for  rheuma- 
tism, could  not  agree  with  the  learned  judge:  he 
thought  every  tub  should  sit  on  its  own  bottom,  and 
that  the  dispensary  should  not  hide  its  surgeons  under 
the  petticoats  of  charit}",  in  order  to  escape  an  obliga- 
tion and  a  responsibility  from  which  a  private  physician 
would  have  to  defend  himself  before  a  jur\-  of  his 
peers. 

It  appears  that  the  old  gentleman,  now  a  cripple, 
was  on  a  free  excursion — though  it  was  said  he  had 
money  in  the  bank — and  while  promenading  the  deck 
of  the  excursion  steamer  slipped  on  an  orange  peel, 
and  suddenly  sat  on  his  right  hip.  Next  day,  at  the 
Free-to-AU  Dispensary  where  he  was  carried,  Dr. 
Hopewell  said  it  was  a  sprain ;  and  as  the  old  man 
was  suffering  from  rheumatics.  Dr.  Youngblood  paid 
no  attention  when  the  patient  said  he  could  not  raise 
his  right  leg  and  that  he  had  a  severe  pain  in  the 
region  of  his  groin. 

The  physicians'  incomes  were  gradually  shrinking, 
as  the  town  was  constantly  growing  poorer  and  the  peo- 
ple were  flocking  to  the  Free-to-AU  Memorial  Dispen- 
sary. Dr.  Youngblood  did  not  mind  this,  for  he  had 
received  a  windfall  from  the  old  lady  who  founded 
the  Youngblood  Operating-Room,  now  just  deceased, 
for  his  skill  in  treatment  and  fidelity  in  watching  over 
her  during  the  last  hours  of  a  well-spent  life. 

It  may  be  noted  the  town  grew  so  poor  that  another 
workhouse  had  to  be  built  and  a  wing  added  to  the 
jail,  and  the  county  again  saddled  with  a  load  of  debt, 
as  people  were  hungry  and  homeless,  suUen,  and  in  a 
fighting  mood.  Xow  the  privation  and  distress  were 
not  brought  about  through  pestilence  or  famine,  or  any 
cataclysm  or  vicissitude  of  fate  or  fortune.  They  were 
the  direct  result  and  logical  sequence  of  the  teachings  of 
three  men  in  the  village.  These  men  were  Rev.  Jona- 
than Mayflower;  an  editor  with  a  past  named  Broad- 
cast, who  led  a  roving  life  imtil  he  settled  in  the  vil- 
lage and  embraced  religion  at  a  street  gathering  of  the 
Salvation  .\rmy :  and  Mr.  Redflame,  an  anarchist,  who 
was  converted  at  a  prayer-meeting  in  Dr.  Mayflower's 
church,  and  who  since  his  conversion  preferred  to 
be  known  as  a  socialist.  These  three  men,  with  the 
able  assistance  of  Dr.  Youngblood  and  his  Free-to-AU 
Dispensary,  were  responsible  for  the  wretchedness  and 
squalor  now  prevailing  and  rampant  in  the  town,  by 
teaching  false  doctrines  and  sowing  the  seeds  of  dis- 
sension and  discontent. 

Mr.  Redflame,  though  ostensibly  a  socialist,  had  a 
penehant  for  lurid  and  turgescent  oratory  that  worked 
the  people  up  to  a  high  pitch  of  excitement.  His 
last  effort  in  the  now  historic  lyceum  was  noted  for 
its  very  extravagant  language.  He  belched  out  defi- 
ance and  hate  as  the  crater  of  Vesuvius  pours  forth  its 
sea  of  flame.  He  so  fired  the  hearts  of  his  five  hun- 
dred stalwart  hearers  that  they  shouted  with  one  voice 
for  free  rent,  free  clothing,  and  free  beer.  This  was 
considered  a  modest  request  by  Mr.  Redflame,  and 
was  not,  after  all,  demanding  too  much,  since  they 
had  already  free  coal  and  free  bread  through  the  kind- 
ness and  industry  of  Mr.  Mayflower,  who  buttonholed 
and  ptersonally  canvassed  every  member  of  his  church 
for  a  donation  for  the  good  work.  Editor  Broadcast 
had  to  do  with  the  ice  and  milk  funds,  for  which  he 
advertised  liberally  in  his  paper,  artfully  slipping  in 
advertisements  as  editorial  matter  and  imposing  on 
his  readers,  who  believed  that  Mr.  Broadcast  was  as 


730 


MEDICAL    RECORD. 


[November  20,  1897 


honest  as  he  claimed  to  be,  and  that  he  had  given 
up  his  bad  practices  since  his  conversion  at  the  street 
meeting  of  the  army. 

Dr.  Youngblood  took  care  of  the  dispensary,  and 
organized  free  excursions;  also  a  gymnasium  with  a 
free-soup  kitchen.  Mr.  Redflame  declared,  in  one  of 
his  passionate  appeals  to  the  people,  who  were  now 
too  lazy  to  work,  that  wealth  was  a  curse  to  the  coun- 
try ;  that  rich  men  should  be  hanged,  their  property 
confiscated,  and  the  proceeds  divided  among  the  poor. 
The  earth,  he  said,  belonged  to  all,  and  the  fulness 
thereof;  that  as  the  earth  was  our  common  mother,  it 
was  our  common  heritage  too.  '"  Earth  to  earth,  and 
dust  to  dust,"  was  the  behest  and  mandate  of  Heaven  ; 
that  all  were  born  free  and  equal,  was  the  dictum  and 
pride  of  this  country  of  his  adoption.  In  conclusion, 
he  said,  with  forceful  if  not  accurate  diction :  "  The 
constitution  further  declares,  '  Ours  shall  be  a  govern- 
ment of  the  people,  by  the  people,  and  for  the  people.'  " 

The  pastor,  who  was  presiding  officer  at  this  meet- 
ing—Mr. Broadcast  and  Dr.  Youngblood  being  vice- 
presidents— thought  Mr.  Redflame  a  little  too  radical 
in  his  views,  and  that  he  went  out  of  the  way  to  abuse 
the  few  rich  men  in  his  church.  He  told  Mr.  Red- 
flame that  if  this  extravagant  language  was  repeated 
it  would  be  instrumental  in  driving  him  from  his  par- 
ish and  from  a  people  whom  he  loved.  He  said  the 
few  wealthy  men  would  go  where  there  was  more  safet}' 
for  their  person  and  property ;  besides,  that  he  had  no 
ambition  to  be  the  pastor  of  a  constituency  of  paupers 
in  his  declining  )'ears;  furthermore,  he  had  a  family 
to  support,  and  their  welfare  was  a  matter  of  much 
concern  to  him.  So  he  cautioned  the  anarchist  to  be 
more  careful  in  his  future  harangues  at  the  lyceum. 

The  Pastor  Suffers  a  Reduction  of  Salary. — 
Rev.  Mr.  Mayflower  is  much  troubled;  he  paces  the 
floor  of  his  study  with  uncertain  step.  He  has  but  just 
returned  from  his  vacation  trip  to  his  annual  haunts, 
the  Berkshire  Hills,  when  a  committee  of  the  trustees 
of  his  church  knock  at  his  study  door.  They  have 
departed;  the  salary  of  the  beloved  pastor  is  reduced 
one-half.  Another  and  more  inflammatorj'  speech  had 
been  delivered  at  the  lyceum  by  Mr.  Redflame,  a  week 
before  the  pastor's  return.  It  was  published  in  the 
Wide-Aitiake  Journal,  Mr.  Broadcast's  paper,  which 
the  sexton,  Mr.  Crowsfoot,  saved  for  the  pastor's  peru- 
sal. The  pastor,  overcome  with  the  fatigue  of  his 
journey  and  the  excitement  of  meeting  the  trustees,  is 
too  greatly  exhausted,  and  requests  Mr.  Crowsfoot  to 
read  the  speech  of  Mr.  Redflame  to  him.  The  sexton 
begins:   "  'Let  the  torch  be  lighted,  lay  waste  their 

lands '"     "Stop!  stop!  enough!"  cries  the  pastor. 

The  sexton,  who  is  absorbed  in  his  subject  and  quite 
deaf,  does  not  notice  Mr.  Mayflower,  and  continues  to 
read:  "' Let  loose  the  dogs  of  war !  let  destruction  and 
ruin,  tornado  and  cyclone,  wipe  them  from  the  face  of 

the  earth '  "     "  Stop !     I  say,  stop !  "  cries  Rev.  Mr. 

Mayflower,  with  gesture  as  well  as  voice,  and  in  anger; 
"  Mr.  Redflame  has  ruined  my  church,  bankrupted  my- 
self, and  leaves  my  little  family  almost  homeless.  I 
repeat,  I  want  no  more  of  him — I  am  through  with 
him  now." 

Rev.  Mr.  Mayflower   now   Conscious   that  Some 

Atonement  Should  be  Made  for  his   Errors Rev. 

Mr.  Mayflower  was  full  of  reminiscences,  recollections 
that  wrung  his  heart.  He  now  recognized  his  mistake, 
and  saw  with  open  e)-es  the  misery  it  had  brought  on 
others.  Around  him  on  every  side  was  disaster,  largely 
the  work  of  his  own  hands.  ''As  ye  sow,  so  shall  ye 
reap" — and  had  he  not,  with  the  help  of  Mr.  Redflame 
and  Mr.  Broadcast,  with  the  aid  and  counsel  of  Dr. 
Youngblood,  sowed  the  wind  of  false  doctrines  of 
social  economics  among  his  flock,  and  was  he  not  now 
reaping  the  whirlwind? 

The  pastor  made  some  effort  to  reconcile  his  con- 


science to  the  altered  situation,  and  in  some  measure 
justify  himself,  in  that  it  was  the  result  of  good  inten- 
tions; but  he  felt  that  was  only  an  excuse- — indeed,  a 
subterfuge  —  since  good  intentions  were  branded  in 
flame  on  lost  souls.  "  The  way  of  the  transgressor  is 
hard,"  and  "  The  wages  of  sin  is  death,"  he  saw  em- 
blazoned on  the  sky  as  he  opened  the  window  to  get 
some  air,  for  he  was  growing  faint;  but  the  sign  in 
the  heavens  was  the  gleam  from  a  burning  church,  and 
that  church  his  own,  and  the  letters  painted  there  were 
only  the  reflex  of  a  guilty  conscience. 

He  then  and  there  wished  to  imitate  his  prototype 
of  the  "  Scarlet  Letter" — the  one  eager  to  make  atone- 
ment for  a  personal  sin;  the  other  for  social  heresies 
that,  while  not  so  intrinsically  heinous,  were  deplora- 
ble, far-reaching,  and  disastrous  in  their  results — by 
going  to  the  lyceum,  and  under  its  shadow  renouncing 
these  social  heresies  and  making  recompense  for  his 
free-dispensary  folly.  But  his  moral  courage  failed; 
he  could  not  summon  a  resolution  strong  enough  to 
support  his  legs  across  the  floor,  much  less  undertake 
the  more  hazardous  journey  to  the  lyceum,  where  he 
had  sat  a  listener  to  the  Culminations  of  Mr.  Red- 
flame and  indorsed  them  by  his  presence. 

It  was  whispered  by  Dame  Rumor  that  Mr.  Red- 
flame might  know  something  about  the  burning  of  the 
church.  This  the  pastor  refused  to  believe,  as  he  had 
given  Mr.  Redflame  communion  that  day.  He  con- 
tinued: "  Mr.  Redflame  led  our  meeting  only  this  eve- 
ning, and  made  a  touching  prayer  for  the  conversion 
of  the  heathen  and  a  speedy  gathering  together  of  the 
nations  in  a  brotherhood  of  love."  The  pastor  re- 
sented the  imputation  on  his  parishioner,  Mr.  Red- 
flame's,  character.  He  said :  "  Human  nature  is  not. 
so  base ;"  but  the  fire  marshal  and  underwriters  fast- 
ened the  crime  on  Mr.  Redflame,  a  jury  convicted 
him,  and  the  judge  sentenced  him  to  imprisonment  for 
life. 

It  appeared  at  the  trial  that  the  motive  which 
prompted  Mr.  Redflame  to  the  crime  was  revenge 
directed  against  the  pastor,  as  he  was  beginning  to 
look  coldly  and  frown  on  his  lecture  projects,  and  on 
the  occasion  of  their  last  meeting  the  pastor  had  told 
him  bluntly  to  leave  off  talking  and  go  to  work — that 
then,  perhaps,  others  in  the  village  would  follow  his 
example.  To  this  Mr.  Redflame  made  no  answer,  but 
the  color  came  to  his  face  and  he  bit  his  lips. 

The  Rev.  Mr.  Mayflower  Angling  for  a  New 
Charge. — Rev.  Mr.  Mayflower  now  rallied  his  shattered 
nerves,  and  made  what  reparation  he  could  in  helping 
to  build  up  the  community  he  was  so  instrumental  in 
tearing  down.  He  asked  it  as  a  special  favor  to  him 
if  Dr.  Youngblood  would  be  more  careful  and  dis- 
criminating in  the  distribution  of  his  charity,  and  cut 
off  his  free-soup  kitchen  attached  to  the  lyceum,  hop- 
ing by  that  means  to  send  the  able-bodied  men  loafing 
there  to  do  an  honest  day's  work.  He  also  counselled 
him  to  hold  out  the  olive  branch  to  the  other  physi- 
cians in  the  town,  as  by  this  means  he  might  be  able 
to  secure  their  co-operation  and  support  in  bringing 
about  the  prosperity  which  was  now  so  much  needed. 
At  this  moment  the  sexton,  Mr.  Crowsfoot,  handed  the 
pastor  a  letter.  It  contained  a  request  from  a  deacon 
in  a  distant  parish  that  he  kindly  occupy  the  pulpit  in 
his  church  the  following  Sabbath,  as  the  loved  pastor 
ministering  there  had  been  called  to  his  higher  reward. 
Rev.  Mr.  Mayflower,  on  the  following  Sunday,  preached 
from  the  pulpit  left  vacant  by  the  sainted  Dr.  Stargaze. 
The  Sunday-school  superintendent,  in  describing  the 
occasion  to  Dr.  Hopewell,  Dr.  Youngblood's  assistant, 
who  had  severed  his  connection  with  the  Free-to-.-Ml 
Dispensary,  and  had  started  a  private  hospital  on  his 
own  account  in  the  town  now  the  scene  of  his  old  pas- 
tor's new  charge,  said :  "  He  took  us  by  storm.  His 
preaching    had   depth   and  solidity;  its  manner  was 


November  20,  1897] 


MEDICAL    RECORD. 


73^ 


shaqa,  direct,  incisive,  with  the  thrill  to  electrify,  the 
force  to  convince.  The  day  he  preached  was  a  dav  of 
Pentecost  indeed,  and  the  people  went  on  their  way 
rejoicing."  Let  us  add,  the  pastor  rejoiced  too,  for 
he  had  a  reasonable  expectation  of  winning  a  rich 
congregation. 

The  Pastor's  Farewell — At  home  in  his  pulpit 
the  following  Sabbath  the  preacher  is  serious,  solemn, 
and  reminiscent.  Grief  is  heavy  at  his  heart  and  his 
eyes  are  suffused  with  tears,  after  the  sermon — a  model 
sermon,  too — which  was  a  review  of  his  labors  in  the 
parish  during  a  pastorate  of  ten  years,  a  labor  of  love, 
but  withal  one  of  disaster  to  his  hearers.  Its  humility- 
and  pathos  made  tears  ramble  down  the  wrinkled  faces 
of  the  deacons,  and  brought  sobs,  subdued  and  plain- 
tive, from  the  ladies  of  the  congregation.  He  told 
eloquently  how  he  wrestled  in  prayer,  how  the  spirit 
of  inspiration  came  upon  him,  how  he  was  directed  to 
accept  the  call  from  the  distant  parish.  The  people 
there  were  crjing  for  spiritual  food,  and  praying  for 
a  shepherd  to  lead  them  and  keep  them  in  the  way ; 
it  was  in  obedience  to  a  divine  mandate  and  the  will 
of  the  Master  that  he  should  labor  in  another  field. 

A  solemn  stillness  fell  on  the  people  gathered  there, 
buoyed  up  by  the  strong  arm  of  Christian  resignation 
and  sustained  by  the  faith  that  was  in  them ;  they 
were  willing  to  let  their  pastor  go.  He  departed,  with 
the  benediction  of  a  congregation,  which  he  had  been 
so  instrumental  in  bringing  to  famine  and  the  poor- 
house,  ringing  in  his  ears,  but  whose  members  yet  were 
kind,  to  fill  the  more  lucrative  pulpit  in  the  distant 
parish. 

Rev.  Mr.  Mayflower  Not  so  Influential  with  Some 
of  His  Old  Congregation. — Notwithstanding  the  in- 
junction of  the  pastor.  Dr.  Black  refused  to  have  any- 
thing to  do  with  Dr.  Yoimgblood.  He  thought  that 
to  have  any  dealings  with  this  man  was  like  com- 
pounding a  felony;  indeed,  it  might  be  just  as  well  to 
say  it,  he  regarded  him  as  a  mountebank  and  charla- 
tan, one  by  no  means  an  ornament  to  his  profession. 
Dr.  Black's  sterling  worth  commanded  respect,  and  he 
now  began  to  be  influential  in  the  reawakened  com- 
munity. He  invited  Dr.  Goodman  to  deliver  an  ad- 
dress before  the  town  council,  and  give  his  views  as 
to  the  course  to  be  pursued  in  order  to  bring  back  the 
prosperity  that  so  long  was  a  stranger  to  this  now  fam- 
ished and  desolate  town. 

Dr.  Goodman's  Address  on  Idleness  and  Industry. 
— "  -Alter  watching  the  course  of  events  for  some  time, 
and  being  a  witness  of  so  much  want  and  sorrow  in  our 
communit}-,  I  have  been  convinced  of  the  fact  that 
charity  has  its  limit,  and  beyond  that  limit  it  loses  its 
sweet  savor  and  gives  out  a  rank  and  unwholesome 
odor. 

"  When  charity  is  dispensed  at  the  expense  of  and 
to  the  detriment  of  others,  it  is  an  oppression  working 
evil  in  two  ways :  the  beneficiary  of  the  charit}-  will 
grow  shiftless  and  lazy,  while  the  donor  will  ultimately 
become  dependent  himself.  His  misapplied  charitj- 
has  poisoned  the  wellspring  of  societ)',  torn  that 
society  in  twain,  sowed  the  seeds  of  privation,  laziness, 
sedition,  and  crime.  It  has  made  fathers  drunkards, 
homes  cheerless,  and  mothers  weep.  It  has,  as  you 
see  by  Dr.  Youngblood's  experiment,  created  an  army 
of  idlers  that  have  voluntarily  thrown  down  their  labor 
to  be  partners  in  the  era  of  good  things  promised  by 
him  and  our  late  pastor,  Rev.  Mr.  Mayflower.  When 
people  obtain  the  necessaries  of  life  for  the  asking, 
what  is  the  use  or  necessity  for  them  to  labor  at  all? 
Now  our  factories  are  closed,  our  fertile  fields  lie 
waste,  our  industries  are  paralyzed.  The  men  to  oper- 
ate these  varied  industries  are  now  in  free-soup  kitch- 
ens, on  free  excursions,  or  hanging  around  the  corridors 
of  free  dispensaries  waiting  to  be  cured  of  imaginary 
ailments. 


••  Dr.  Voungblood,  Mr.  Broadcast,  Rev.  Mr.  May- 
flower, and  the  notorious  Redtlame  labored  to  inau- 
gurate the  workingman's  millennium.  Only  one, 
however,  of  these  men  was  sincere  and  honest  in  his 
purpose,  and  even  he,  when  the  storm  broke  and  the 
bottom  fell  out  of  his  project,  like  a  rodent  on  a 
sinking  ship,  scented  disaster  and  ran  to  cover  by 
taking  shelter  in  the  pulpit  of  a  prosperous  parish. 
He  had  no  scruples  in  leaving  his  old  congregation  in 
midocean  with  a  stormy  sea,  to  pilot  their  way  unaided 
and  alone  to  the  spiritual  shore.  He  left  on  the  pre- 
text that  he  was  called  through  a  dream — an  inspira- 
tion— to  take  charge  of  a  tlock  which  was  hungering 
for  a  spiritual  love  with  which  he  was  abimdantly 
supplied  and  which  he  was  able  to  distribute  and 
bestow  on  all  who  applied  at  his  open  door. 

"The  stimulus  to  labor  is,  first,  hunger;  second,  a 
desire  for  wealth.  We  cannot  attain  to  the  second 
except  we  appreciate  and  recognize  the  value  of  the 
first.  This  will  explain  why  we  have  no  millionaires 
at  the  equator,  and  so  few  in  the  tropics:  there  nature 
is  kind  and  lavish  to  her  children ;  there  fruit  supplies 
abound  without  cultivation ;  there  the  people  have  food 
without  labor. 

■■  This  prodigality  of  nature  takes  away  the  stimulus 
to  industrj- — namely,  hunger;  the  incentive  is  not 
there.  Nature  here  is  the  philanthropist;  and  has  she 
not  brought  forth  and  reared  her  legions  of  degener- 
ates? She  left  them  without  the  stimuli  to  industr)-, 
but  warmed  their  naked  flanks  in  the  rays  of  a  torrid 
sun  and  lulled  them  to  sleep  in  the  shadow  of  eternal 
spring. 

"The  million  that  the  philanthropist  left  last  year 
to  build  a  dispensary  and  found  a  home  for  destitute 
men,  will  prove  a  monument  to  his  folly,  a  thing  to 
mock  his  memor}-,  a  scourge  to  flog  society.  It  will 
enlist  an  army  of  beggars,  and,  basking  in  the  sunshine 
of  this  bequest  and  a  beneficiar}-  of  it,  will  be  found 
the  anarchist  with  his  torch,  the  socialist  with  his  jar- 
gon, and  the  burly  tramp  with  his  bludgeon  and  his 
beer  can.  The  philanthropist,  while  appeasing  their 
hunger,  takes  away  their  stimuli  to  labor;  for  this  they 
will  repay  societ)"  by  goading  it  to  anger  and  then 
stabbing  it  in  the  back.  This  will  be  their  gratitude 
and  the  monument  reared  to  the  philanthropist's  mem- 
ory. As  siuely  as  the  square  of  a  straight  line  is  equal 
to  four  times  the  square  of  its  half,  so  surely  will  a 
charitable  bequest  be  met  by  a  multiple  of  poverty  and 
a  complement  of  crime. 

"  The  abuse  of  charit}'  has  worked  more  mischief  and 
brought  more  miserj-  in  its  wake  than  have  pestilence 
and  famine.  It  has  crowded  our  dispensaries  to  the 
doors,  filled  our  poorhouses  with  wrecks  of  humanity, 
congested  our  prisons,  and  has  always  been  a  highway 
to  revolution  and  the  gibbet.  Without  that  million 
the  lazy  man  might  work;  with  it,  he  will  not,  for 
while  it  lasts  his  incentive  to  labor  will  disappear. 
After  he  has  drank  his  bowl  of  free  soup  and  eaten  the 
bread  of  idleness,  he  will  talk  of  oppression,  and 
whisper  assassination  to  his  fellow-mendicant,  and 
smite  the  hand  which  fed  him.  That  hand  he  declares 
has  forged  the  chain  and  locked  the  shackles  that 
made  him  a  beggar,  a  bondman,  and  a  slave. 

"  From  time  immemorial  the  problem  has  presented 
itself,  how  to  help  the  poor,  and  what  to  do  to  relieve 
their  needs  and  raise  them  to  be  self-supporting  and 
units  of  value  in  the  social  fabric.  With  a  blind  and 
unreasoning  zeal,  Rev.  Mr.  Mayflower  labored  to  solve 
this  problem;  but,  as  you  all  now  see,  his  failure  was 
as  signal  and  complete  as  was  that  of  others  who  went 
before  him. 

"  .\s  you  have  heard,  the  philanthropist  left  a  mil- 
lion to  found  a  dispensary  and  a  home  for  destitute 
men.  The  climax  of  effort  was  reached  when  he 
lounded  this  so-called  charitj' — really,  however,  only 


MEDICAL    RECORD. 


[November  20,  1897 


a  satire  on  charity — a  dispensary,  a  home,  and  a  free 
lunch  for  lazy  men.  He  did  not  trouble  himself  to 
look  below  the  surface  or  investigate  as  to  what  effect 
his  charity  would  have  on  other  enterprises  and  indus- 
tries. His  carelessness  in  this  respect  would  lead  one 
to  the  conclusion  that  there  was  a  motive  for  his 
charity.  Could  it  be  possible  that  he,  like  Dr.  Young- 
blood,  wished  only  to  advertise  himself  ?  If  alive  or  if 
now  dead,  had  he  a  morbid  and  mortuary  ambition  that 
his  name  should  ring  through  the  world,  and  redound  to 
the  interest  of  his  estate  and  the  glory  and  advancement 
of  his  heirs  and  legatees?  The  golden  rule, '  To  have 
a  just  regard  for  the  rights  of  others, '  he  ignored,  or 
if  he  considered  it,  brushed  it  aside  with  contempt,  as 
did  Dr.  Voungblood  the  advice  of  the  sage  who  pointed 
him  the  way  to  honorable  success  the  morning  he 
started  on  his  eventful  career.  The  obsen-ance  of  this 
rule  is  the  guidepost  to  honorable  and  fair  dealings 
among  civilized  communities.  Why  did  the  millionaire 
neglect  to  observe  this  rule?  Let  us  in  charity  draw 
the  veil  over  his  motives,  and  say  he  was  blind,  morally 
blind,  and  that  he  felt  he  had  discharged  his  obliga- 
tion to  society  in  founding  the  dispensary  and  home 
for  destitute  men ;  that  he  had  rejoiced  in  the  good  he 
had  accomplished  and  the  monument  he  had  raised  to 
perpetuate  his  memory.  But  his  work,  as  a  matter  of 
fact,  has  only  begun;  before  him  lie  a  wide  field  and 
boundless  possibilities.  He  lost  his  opportunity  by 
taking  the  advice  of  Rev.  Mr.  Mayflower  and  Dr. 
Youngblood.  In  this  case  it  was  the  blind  leading 
the  blind,  with  the  usual  result — that  both  fell  into  the 
ditch.  Now,  what  should  this  rich  man  have  done 
with  his  wealth  that  he  threw  away  in  founding  this 
dispensary  and  home,  in  order  to  confer  a  lasting  ben- 
efit on  his  less  fortunate  fellow-beings?  He  should 
first  have  acquainted  himself  with  the  significance  and 
import  of  the  word  charity — on  which  one  word  a 
volume  could  be  written ;  second,  he  should  have  in- 
quired into  the  cause  of  the  poverty  and  distress  that  so- 
licited his  bequest,  and,  by  removing  the  cause,  wiped 
out  the  effect.  Here  is  the  rock  on  which  his  project 
foundered;  he  mistook  the  effect  for  the  cause — the 
impact  for  the  power  behind — and  was  as  successful 
in  treatment  as  was  the  quack  who  told  his  patient 
he  had  dropsy,  and  set  about  blistering  his  swollen 
e.xtremities  in  the  hope  of  drawing  off  the  fluid  and 
mitigating  his  sufferings. 

"The  medical  quack  and  the  philanthropic  quack 
stand  on  precisely  the  same  level ;  both  treated  the 
effect  for  the  cause.  The  quack  added  to  the  misery 
of  his  patient  and  hastened  his  death;  the  philanthro- 
pist's bequest  was  a  stumbling-block  in  the  path  of 
progress,  it  robbed  the  people  of  the  stimulus  to  labor, 
and  was  a  direct  hindrance  to  the  advancement  of  the 
human  race.  It  diffused  laziness,  dependence,  and 
crime  on  every  hand,  as  the  sun  diffuses  light  and 
heat. 

'■  In  the  inauguration  of  this  era  of  reform,  what 
part  has  the  rich  man  to  play  with  his  million?  He 
must  make  an  effort  to  develop  the  moral  sense  and 
awaken  a  pride  for  industrious  activity  in  the  recipient 
of  his  charity.  If  the  man  or  the  woman  is  lazy,  the 
philanthropist  must  show  him  or  her  the  necessity  for 
energy  and  activity:  if  they  are  prodigal  and  improvi- 
dent, he  must  impress  them  with  the  advantages  to 
be  derived  from  temperance  and  self-restraint;  if  tliey 
are  illiterate  and  incompetent,  he  must  teach  them  the 
meaning  and  usefulness  of  knowledge  and  the  good 
that  can  be  accomplished  by  being  proficient  in  some- 
thing in  consonance  with  tlieir  intelligence,  tempera- 
ment, and  environments — in  short,  he  must  instruct 
them  in  the  value  of  self-reliance,  dignity,  and  inde- 
pendence; that  each  individual  should  be  self-sustain- 
ing; that  intemperance  and  selfishness  are  barriers  to 
progress,  and  not  compatible  with  the  higher  develop- 


ment of  our  race.  In  proportion  as  this  simple  and 
easily  digested  philosophy  is  disseminated  among  the 
people,  will  poverty  die  out,  and  with  it  the  poor- 
house,  the  jail,  the  free  dispensar}',  and  the  five-cent 
lodging-house;  for  then  the  vexed  social  problem  will 
have  solved  itself." 

Dr.  Youngblood,  who  was  in  the  hall,  left  before  the 
conclusion  of  Dr.  Goodman's  address.  It  was  noticed 
that  he  was  disgruntled  and  perturbed. 

A  Letter  from  the   Pastor Dr.    White,    better 

known  in  church  circles  as  Deacon  White,  read  a  letter 
from  the  old  pastor,  who  still  viewed  his  former  con- 
gregation with  a  fatherly  eye  from  afar. 

"To  Mv   Old   and    Beloved    Flock,  with    Greet- 
ings : 

"  Dear  friends  of  the  past,  whose  memory  is  entwined 
with  sad  recollections,  our  parting  almost  broke  my 
heart;  but,  as  it  was  my  mission  to  go,  I  accepted  the 
call  with  composure  and  resignation,  believing  as  I  do 
that  it  will  not  be  long  before  the  kind  Providence 
that  counts  the  hairs  of  our  heads  and  keeps  us  in  the 
hollow  of  His  hand  will  fill  the  place  so  unworthily 
occupied  by  me  with  one  who  will  carry  on  the  work 
I  left  undone  and  bring  back  some  who  have  wandered 
from  the  fold,  to  eat  the  husks  and  to  drink  the  wine  of 
a  physical  and  temporary  joy,  that  is  shortlived  and 
perishable.  Keep  firm  in  the  faith,  and  hold  fast  to 
that  which  is  good. 

"  Yours,  in  the  hope  and  reward  of  a  kindly  life  and 
a  propitious  future, 

"Jonathan"  Mayflower." 

The  Deacon's  Confession. — The  letter  from  the  old 
pastor  fell  like  a  bomb,  charged  with  spiritual  fire,  on 
this  little  band  of  worshippers,  now  gathered  in  Dr. 
Youngblood's  Memorial  Operating- Room — though  Dr. 
Youngblood  was  absent,  having  run  away  from  the  con- 
sequences of  another  shady  transaction.  They  had 
worshipped  here  since  the  burning  of  the  church  by 
the  anarchist  Redflame. 

Deacon  Bloodgood,  overcome  by  the  whirlwind  of 
joy  that  the  reading  of  the  pastor's  letter  called  forth, 
being  a  good  man,  thought  it  no  disgrace  to  make  a 
few  remarks  about  a  thing  that  hung  to  his  skirts  and 
flapped  its  ugly  wings,  like  a  black  cloud,  over  a  con- 
science otherwise  clear  and  a  life  without  blame,  and 
began : 

"  Fellow-Christians  and  loved  ones,  others  before 
me  have  made  confession  to  their  shortcomings  in  this 
very  operating-room,  made  memorable  by  the  brilliant 
achievements  of  Dr.  Youngblood's  scalpel  and  the  fare- 
well address  of  Rev.  Mr.  ^Mayflower,  and  now  hallowed 
by  the  pathetic  epistle  just  read  with  so  much  eloquence 
by  Brother  White.  An  obligation  was  enjoined  on  all 
Christians  when  the  word  was  spoken,  '  Confess  your 
sins  one  to  another.'  Now  I  must  tell  you  with  shame 
and  humiliation  the  part  I  played  in  bringing  about 
this  reign  of  poverty  and  the  general  hard  times  that 
have  pinched  you  so,  robbing  you  of  the  pleasure  of 
sending  your  annual  donation  this  year  to  the  board  of 
foreign  missions  for  the  conversion  of  the  heathen; 
that  compelled  you  to  cut  down  your  beloved  pastor's 
salary  one-half;  and  that  still  compels  you  to  worship 
in  this  Memorial  Operating-Room.  My  resolution  to 
make  this  confession  became  fi.\ed  when  we  had  to 
build  a  new  wing  to  the  hospital  of  which  your  humble 
Christian  brother  is  trustee;  if  possible,  this  resolution 
became  more  fi.xed  after  hearing  the  address  of  Dr. 
Goodman  before  the  town  council,  of  which  I  am  also 
a  member,  and  the  report  of  the  committee  of  that 
council  that  a  new  jail  was  necessary  and  imperative. 
It  was  conferring  an  honor  on  me,  which  I  do  not  be- 
lieve I  deserved,  when  I  was  made  president  of  the 
board  of  governors  of  the  Free-to-AU  Memorial  Dis- 
pensary, the  walls  of  which  shelter  us  now. 


November  20,  1897] 


MEDICAL    RECORD. 


'To 


■■  As  president  of  the  board  of  governors  of  the  Free- 
to-All,  being  a  hardheaded  business  man  before  I  be- 
came governor  of  our  town  hospital  and  president  of 
the  Memorial,  I  brought  all  the  experience  of  forty 
years'  close  attention  to  business  into  my  new  offices. 
I  saw  around  me  an  opportunity  to  build  up  the  hospi- 
tal and  dispensary,  and  to  accomplish  this  purpose 
utilized  ever\r  force  at  my  command.  Good  doctors 
were  standing  in  line  at  the  hospital  gate,  l>at  in  hand, 
with  credentials,  waiting  a  nod  or  a  beck  from  me, 
that  would  transform  them  into  surgeons  and  visiting 
physicians  at  our  hospital  or  dispensary.  One  of 
them  told  me  that  it  was  the  American  Derby  of  the 
profession,  to  secure  one  of  these  prizes  I  had  at  my 
ready  disposal.  He  said  that,  having  secured  this 
prize,  his  futurity  was  already  a  reality;  he  would  be 
talked  about,  called  into  consultation,  and  lifted  above 
the  heads  of  his  brother  practitioners,  who  after  a  little 
while — though  jealous  now — would  learn  to  respect  and 
esteem  him  themselves. 

"  My  system  of  transacting  business  was  so  complete 
and  perfect  in  detail,  and  the  punishment  for  the  in- 
fraction of  a  bylaw  so  condign  and  swift,  that  insub- 
ordination was  rare  and  never  formidable  at  our  hos- 
pital or  dispensary.  Our  effort  to  discriminate  between 
the  deserving  and  the  impostor  at  our  hospital  gate 
was  an  imposition  and  a  sham.  While  we  pretended 
to  treat  only  the  deserving  and  needy  at  our  hospital 
and  dispensary,  we  waved  to  the  crowds  to  come  on.  We 
wished  to  make  a  show ;  we  had  a  mania  for  increasing 
the  list  of  paupers  and  mendicants  on  our  dispensary 
ledger,  just  as  I  had  the  burning  ambition  to  outsell 
my  neighbor  in  the  leather  business  in  the  Swamp,  years 
ago,  before  I  retired  to  private  life. 

"Fellow-Christians,  it  has  been  said  that  the  evil 
men  do  lives  after  them.  The  evil  I  have  done  lives 
now  before  my  eyes;  I  can  see  it  in  your  hollow 
cheeks  and  haggard  faces,  in  your  poorly  furnished 
homes  and  naked  children.  The  abuse  of  charity,  as 
Dr.  Goodman  so  well  said,  encourages  men  to  idleness 
and  paved  the  way  to  the  poorhouse.  I  can  see  it  all 
now.  To  increase  my  misery  and  fill  the  cup  of  my 
woe,  I  have  still  a  sadder  recollection  to  relate,  and 
I  relate  it  with  fear  and  trembling,  lest  I  should  be 
struck  dead  by  the  righteous  vengeance  of  Heaven  for 
this  traitorous,  cowardly,  and  perfidious  act  of  mine. 

"  In  a  moment  of  weakness,  Satan  whispered  in  my 
ear  that  the  well-dressed  and  respectable  element  that 
crowded  to  my  dispensary  should  have  protection  ;  that 
■  their  interests,  their  lienor,  and  their  presence  demand- 
ed some  mark  of  recognition  from  the  governors  of 
the  hospital  and  the  Free-to-AU  Memorial  Dispensary. 
They  did  not  wish  to  be  branded  as  paupers  or  con- 
sidered as  dependents;  they  were  helping  the  institu- 
tion by  their  names,  and  giving  it  tone  by  their  pres- 
ence; they  were  willing  to  pay  a  dollar  a  month  to 
me,  to  take  the  sting  out  of  charity  and  give  them  a 
true  bill  of  lading  for  the  full  voyage  and  a  cabin  pas- 
sage to  health  and  activity,  while  the  others,  less  for- 
tunate, at  our  dispensary  door,  had  to  take  refuge  in 
the  steerage.  With  shame  and  contrition,  I  here  con- 
fess I  acceded  to  this  dishonorable,  this  outrageous 
demand,  and  gave  these  people — these  paupers — rights 
and  privileges  properly  belonging  to  the  honest  private 
patient  w-ho  consults  a  physician  at  his  office,  and  who 
was  at  one  time — before  the  advent  of  my  nefarious 
scheme  and  dollar-a-month  abomination — willing  and 
eager  to  pay  for  the  same.  This  was  the  unkindest 
cut  of  all,  a  stab  in  the  vitals,  to  the  men  who  have 
made  the  practice  of  medicine  honorable  and  have 
elevated  its  standard  to  a  scientific  calling.  I  closed 
the  doors  to  a  laudable  ambition  in  these  men,  namely, 
to  make  a  respectable  livelihood  and  to  be  factors  in 
the  community  for  which  they  labored  and  amid  which 
they  cast  their  lot. 


"  Yes,  fellow-Christians,  these  honorable  and  com- 
petent practitioners  had  to  close  their  office  doors  be- 
cause we  inveigled  and  allured  their  patients  to  our 
dollar-a-month  banquet ;  but  our  charity  was  a  charnel- 
house,  and  our  banquet  the  banquet  of  death  to  the 
community,  and  a  spot  that  will  not  wash  out  on  tliis 
conscience  of  mine.  True,  some  governors  of  the 
hospital  and  dispensary  opposed  me  in  my  action; 
but,  as  the  contest  was  close,  my  vote  was  affirmative 
and  decisive. 

"The  practitioner  fought  manfully  for  his  rights  at 
first,  but  it  was  the  battle  of  the  many  with  one ;  it 
was  his  little  office  against  our  organized  opposition. 
He  succumbed  in  the  unequal  stmggle.  It  is  written: 
'  The  race  is  not  given  to  the  swift,  nor  the  battle  to 
the  strong.'  This  is  demonstrated  by  the  poverty  now 
prevailing,  and  further  demonstrated  by  the  sign  in 
the  heavens  seen  by  our  late  pastor,  Mr.  Mayflower, 
in  the  reflection  of  his  conscience  and  the  burning  of 
his  church.  I  told  my  brother  governors  at  our  meet- 
ing yesterday  that  this  abomination  should  cease — that 
charity  was  beautiful,  but  masquerading  in  her  garb 
was  a  crime  that  would  not  go  unpunished.  I  pointed 
out  the  deplorable  condition  of  the  industries,  the 
army  of  idlers  in  the  street,  and  the  destitution  we 
had  brought  home  to  the  legitimate  practice  of  medi- 
cine. 

"These  injustices  were  kindled  into  life  by  our 
abuse  of  sweet  charity,  and  fanned  into  flame  by  the 
dollar-a-month  monstrosity  and  abomination.  This 
hybrid  monster,  with  the  face  of  charity  but  the  body 
of  a  misshapen  and  hideous  demon,  is  sapping  the 
lifeblood  out  of  the  community  to-day.  It  is  a  stench 
in  the  nostrils  of  honest  manhood,  and,  I  repeat, 
an  abomination,  a  crime.  True,  it  has  put  a  few  dol- 
lars in  our  colfers,  but  it  is  the  price  of  our  treason 
and  the  blood  of  an  honorable  and  deser\-ing  profes- 
sion. 

"  Brother  governors,  we  tried  to  accomplish  an  im- 
possible feat  in  our  effort  to  unite  charity  with  manly 
independence.  They  spurned  each  other.  Charity  is 
lowly  and  vaunteth  not  herself.  She  seeks  poverty  in 
the  slums  and  byways,  and  teaches  it  the  language  of 
independence  and  the  lesson  of  stalwart  manhood. 

"  '  .She  takes  the  fihh-stained  lyre 
From  pauper  and  from  slave, 
To  teach  the  languid  wires 

The  sounds  that  manhood  gave.' 

"She  lifts  it  from  its  lowly  habitation  and  starts  it 
on  its  journey  with  the  force  and  impetus  that  commend 
it  to  success." 

The  governor  continued  :  "  While  charity  may  asso- 
ciate with  poverty  and  squalor,  they  will  not  assimi- 
late; they  have  nothing  in  common;  their  relative 
characters  and  features  are  as  different  as  day  is  from 
night,  light  from  darkness,  beauty  from  a  shapeless 
mass  of  ragged  rocks. 

"The  complement  of  their  social  equation  is  the 
monster  we  have  conjured  into  life  —  namely,  the 
dollar-a-month  dispensary  fraud,  that  I  feel,  as  you  all 
can  read,  branded  on  my  forehead  now.  By  this  fraud 
we  have  inoculated  charity  with  a  virus  and  defiled 
her  by  its  touch — tlie  beautiful  goddess  we  ha\e  thrown 
into  a  sew'er,  to  be  transformed  by  the  slush  into  a 
monument  to  our  perfidity  and  treason.  I  repeat, 
fellow-Christians,  I  cannot  justify  myself  before  you 
or  hide  behind  a  legal  opinion  of  Justice  Youngman. 
I  want  to  bear  the  full  burden  of  my  shame,  and  as 
such  make  some  atonement  for  my  crime." 

The  deacon,  overcome  by  exhaustion  from  the  ex- 
penditure of  ph)'sical  energy  and  mental  excitement 
that  his  confession  had  occasioned  him,  for  he  was  an 
old  man,  sank  into  his  chair,  crushed,  defeated,  and 
covered  with  humiliation. 


734 


MEDICAL    RECORD. 


[November  20,  1897 


A  hungry  physician,  also  a  member  of  the  little 
congregation,  was  an  interested  listener  to  the  deacon's 
confession,  and  with  more  zeal  than  discretion,  and 
without  the  consciousness  of  doing  an  injury  or  injus- 
tice to  any  one,  recited  the  lines: 


"  The  desolator  desolate, 
The  victor  overthrown. 
The  arbiter  of  others'  fate 
Now  suppliant  for  his  own." 

The  good  deacon,  with  his  face  buried  in  his  hands 
and  happily  unconscious  of  what  was  transpiring 
around  him — his  thoughts  turned  inward  on  themselves 
— was  automatically  chanting : 

"  Roclc  of  ages,  cleft  for  nie. 
Let  me  hide  myself  in  Thee." 

Dr.  White's  Temptation. — It  can  be  seen  that  from 
the  abuse  of  hospital  charity,  and  the  hard  times  and 
financial  stress  prevailing,  the  honest  physician  was 
a  sufferer.  One  of  these  sufferers  was  Dr.  White,  who 
though  old  had  yet  some  vigor  in  him,  enough  to  resist 
temptation  and  fight  the  battle  for  the  profession  in 
which  he  took  such  pride  and  of  which  he  was  glad  to 
be  accounted  a  member.  No  patients  were  coming  to 
Dr.  White's  office,  and  he  had  few  outside  calls.  The 
popular  tide  was  running  high,  and  it  set  toward  the 
Free-to-AU  Memorial  Dispensary;  it  threatened  to 
swamp  and  carry  the  old  physician  in  its  path. 

One  day,  at  the  springtide  of  its  flow,  the  old  physi- 
cian was  jostled,  elbowed,  and  trampled  on  in  this  mad 
rush  of  the  human  tide  to  the  Free-to-All  Memorial 
Dispensary  and  soup-kitchen  annex.  This  old  man's 
little  store  was  fast  disappearing,  like  snow  under  the 
rays  of  a  hot  sun.  Starvation  stared  him  in  the  face. 
Just  like  his  old  pastor.  Rev.  Mr.  Mayflower,  he  cared 
not  for  himself ;  it  was  for  his  family — they  were  all  to 
him. 

At  midnight  Dr.  White  was  aroused  from  a  broken 
slumber  by  another  physician,  whom  he  was  rather  sur- 
prised to  see  and  at  such  an  unusual  hour,  for  he  had 
only  the  most  casual  acquaintance  with  him,  and  gave 
this  acquaintanceship  the  most  formal  acknowledg- 
ment to  the  physician  living  so  near  his  door.  This 
visitor  was  a  successful  quack,  whose  heart  was  touched 
by  the  woes  and  poverty  he  saw  reflected  in  Mrs. 
White's  face  as  he  passed  her  on  the  street  the  other 
day.  He  came  at  midnight,  as  if  he  hoped  the  dark- 
ness would  hide  and  shelter  him  in  the  commission  of 
a  dishonorable  act.  He  came  to  tempt  Dr.  White.  Dr. 
Dash  was  affluent,  and  the  partner  in  business  or  crime 
of  Dr.  Bounce,  the  hustler  in  their  symptom-blank, 
flimflam,  and  tricky  advertising  schemes.  He  had 
houses  and  lands,  blooded  stock,  and  a  magnificent 
town  residence;  his  business  offices  on  the  thorough- 
fare— for  privacy  would  be  fatal  to  him — were  fitted 
up  in  gorgeous  style.  He  also  had  a  pew,  but  not  in 
Rev.  Mr.  Mayflower's  old  church.  He  gave  liberally 
to  foreign  missions,  paid  tribute  to  the  political  bosses 
to  nominate  a  political  king  to  reign  over  him  and 
protect  his  interests.  He  was  the  right-hand  man  of 
the  pastor,  and  chairman  of  the  board  of  trustees  of 
his  church. 

He  told  Dr.  White  that  lie  understood  his  poverty 
and  the  source  from  which  it  came,  that  he  saw  a  way 
of  deliverance  for  him,  that  he  would  lead  him  into 
tiiat  way,  and  once  there  he  could  take  care  of  him- 
self in  the  journey  to  prosperity. 

Slipping  into  the  doctor's  hand  a  check  for  $50,  he 
requested  him  to  get  out  of  bed,  as  he  wished  a  further 
inter\'iew  in  the  parlor. 

"  '  Come  into  my  parlor,'  said  Iho  spider  to  tlie  lly. " 

Dr.  White's  eyes  blinked  and  snapped  when  on  tlie 
threshold  of  the  door.     It  was  from  the  flash  of  the  dia- 


mond displayed  in  the  immaculate  bo.som,  and  the 
electric  apparatus  attached  to  the  kodak  of  Dr.  Dash. 
With  kodak  ready,  he  said  he  wanted  two  pictures  of 
Dr.  White,  one  before  and  one  after  treatment.  He 
wanted  them  for  the  IVide-Awake  Journal  next  morn- 
ing. He  said  it  was  a  kind  of  reversal  of  custom,  as 
in  the  first  snap  he  wished  him  to  look  just  as  he  was, 
woebegone  and  careworn.  In  the  second  shot  he  was 
to  look  pleasant,  as  if  his  sufferings  were  over  and  he 
saw  new  light. 

Dr.  White  was  about  to  expostulate,  when  shut  off 
by  his  visitor:  "  Only  )'our  consent.  Dr.  White,  merely 
your  consent:  I  do  the  rest.  It  is  to  say  over  your 
own  signature  how  you  were  cured  of  a  long-standing 
deafness  and  a  defective  sight,  after  all  other  means 
failed  to  give  relief;  to  tell  of  the  days  of  agony  and 
nights  of  misery  you  were  compelled  to  endure,  when 
noises,  like  the  roaring  of  many  waters  and  sounds 
like  the  belching  of  a  locomotive,  swept  like  a  blast- 
furnace through  your  tortured  brain.  It  is  to  tell  how 
the  celebrated  Professor  Long  was  puzzled,  baffled,  to 
understand  the  cause  or  apply  a  remedy  to  your  dis- 
ease; to  say  that  the  famous  Professor  Short  was 
equally  helpless;  and  how  both  failed  to  mitigate 
your  tortures  or  give  any  relief;  to  tell  in  song  and 
story  how  the  combined  talents  of  your  great  medical 
lights  failed  and  paled,  like  the  light  of  a  tallow  can- 
dle in  the  blaze  of  the  midday  sun,  when  pitted  against 
the  skill  and  inimitable  art  of  the  celebrated  special- 
ists, Drs.  Dash  and  Bounce,  with  offices  on  the  Bou- 
levard. Doctor,  do  not  hesitate  or  throw  away  a 
golden  opportunity.  I  assure  you.  Dr.  White,  the 
practice  of  medicine  is  a  business  like  any  other,  the 
object  of  which  is  to  make  money;  if  it  fails  in  this 
respect,  it  fails  altogether."  He  told  the  doctor  that 
medical  etiquette  did  not  pay  rent,  and  that  hunger 
could  not  be  appeased  by  membership  in  a  medical 
society  or  even  by  being  a  fellow  of  an  academy. 

He  continued:  "  Fine  feathers  make  fine  birds,  but 
the  most  beautiful  and  graceful  of  these  birds — namely, 
the  peacock,  which  is  also  known  as  a  proud  bird;  in 
fact,  symbolical  of  pride  and  vanity — if  shorn  of  his 
plumage  and  plucked  of  his  feathers,  would  make  a 
rather  poor  Thanksgiving  dinner.  The  turkey  is  my 
symbol ;  you  can  have  the  peacock  as  yours.  To  be 
sure,  the  turkey  is  not  handsome,  but  is  withal  heavy 
and  substantial,  and  has  a  fragrant  odor  for  a  hungry 
palate." 

Continuing,  he  declared:  "The  peacock  is  all  show 
and  no  reality,  the  turkey  is  clumsy  but  juicy;  the 
one  appeals  to  the  eye,  the  other  to  the  stomach.  I 
repeat,  you  keep  your  fine  bird ;  I  am  satisfied  with 
mine.  Dr.  White,  let  me  tell  you,  all  the  medical 
etiquette  in  the  universe  is  not  so  potent  to  drive  a 
creditor  from  your  door  as  a  ten-dollar  bill. 

"  The  quacks  are  not  skilled  in  the  amenities  and 
folklore  of  your  nonsensical  societies;  your  bylaws 
are  feeble  to  punish  the  guilty,  and  helpless  to  protect 
the  innocent.  You  are  held  together  by  a  rope  of  sand, 
an  illusion,  an  ignis fatiitis.  The  philosophy  of  your 
boasted  societies  is  largely  metaphorical  and  founded 
on  a  misconception  of  human  nature,  which  any  of 
you  thirty  or  more  years  in  active  practice  have  found 
out  to  your  cost. 

"This  is  why  I  left  the  fold  and  took  to  the  road  as 
a  medical  pirate  and  brigand,  where  your  sympathies 
and  all  your  energies  should  have  been  enlisted. 
You  were  only  disinterested  spectators,  and  left  me  to 
fight  the  battle  alone,  to  be  crushed  and  defeated,  while 
my  cause  was  a  just  and  holy  one.  Like  a  high- 
spirited  and  honest  woman  driven  to  the  street,  1  was 
driven  from  the  fold.  Your  societies  talk  loudly  and 
learnedly  about  the  public  health,  and  your  efforts  to 
advance  and  elevate  the  public  morals.  When  it  fails 
to  protect  those  of  its  own  household,  how  can  it  hope 


November  20,  1897] 


MEDICAL    RECORD. 


735 


to  be  successful  in  a  wider  field?  This  is  why,  dear 
doctor,  you  cannot  impress  your  individuality  on  the 
public  mind  or  manners,  and  why  you  are  now  and 
always  will  be,  till  the  coming  of  the  millennium, 
negative  and  feeble  in  affairs  of  finance  and  state.  I 
have  further  discovered  that  the  members  of  your  so- 
cieties are  interested  in  their  individual  interests, 
rather  than  in  the  welfare  of  the  societies  as  a  whole. 
I  repeat.  Dr.  White,  any  body  of  men  calling  themselves 
a  society  in  the  arts  and  trades,  so  regardless  of  the 
welfare  and  interests  of  its  members,  could  not  hold 
together  half  a  year.  But  enough  on  what  has  no 
interest  for  me.  What  occupies  my  attention  now, 
since  I  left  your  society,  is  making  money  and  watch- 
ing the  district  attorney,  by  being  careful  not  to  step 
over  the  danger  line  into  the  domain  of  criminality: 
however,  it  is  only  fair  to  say  that  that  functionary  has 
given  me  very  little  trouble.  He  acts  with  regard  to 
me  as  if  he  were  under  some  mesmeric  spell  or  other 
occult  influence,  or  a  resident  or  guardian  of  the  inter- 
ests of  some  other  planet  than  ours. 

"  The  reason  may  be  this :  looked  at  in  a  commercial 
sense  and  latter-day  light,  mine  is  a  legitimate  busi- 
ness, just  like  the  grocery,  the  drygoods,  or  the  furni- 
ture trade.  The  grocer,  the  drygoods  man,  and  the 
furniture  man  cry  fraud  on  each  other.  The  grocer 
says  his  brother  in  trade  adulterates  his  food  supplies, 
and  that  his  brother  is  a  fraud  and  a  cheat;  the  same 
cry  is  raised  by  the  drygoods  man  and  the  furniture 
man  against  each  other — that  he  is  procuring  money 
under  false  pretences.  They  lie  in  advertising  their 
wares;  I  lie  in  advertising  mine.  It  used  to  be  that 
all  was  fair  in  love  and  war,  but  now  business  has  a 
place  on  this  black  list  of  social  piracy  that  has  thrust 
itself  through  the  public  conscience,  and  choked  that 
conscience  into  silence  with  its  glamour  and  its  gallan- 
try. The  district  attorney  thinks  so  too,  since  he  has 
not  to  my  knowledge  prosecuted  any  of  these  fraudu- 
lent concerns,  though  like  myself  they  are  breaking 
the  law  every  day  in  dishonest  practices.  I  have  not 
even  heard  the  voice  of  the  press,  the  boasted  guardian 
of  the  public  weal  and  honor,  though  waiting  to  hear 
that  voice  long.  I  suppose  it  is  stifled,  hushed, 
drowned,  by  the  flood  of  advertisements  these  fraudu- 
lent business  concerns  turn  into  the  feed  trough  of  that 
press.  That  is  the  reason  it  is  mum  about  my  own 
fraudulent  advertisements  on  diseases  I  have  not  cured 
and  about  a  public  I  have  fooled.  My  advertising 
roll  of  bills  has  a  sedative  influence  on  its  belli- 
cose and  caustic  pens.  The  press  does  not  care  a  rap 
for  you,  Dr.  White,  or  your  societies,  since  you  send 
no  advertising  grist  to  their  mills." 

Dr.  White,  his  face  already  pale,  grew  paler.  He 
summoned  the  remnant  of  the  little  force  that  slum- 
bered within  him,  and,  rising  from  his  chair,  he  began  : 

"  Dr.  Dash,  if  your  visit  to  me  to-night  was  one  of 
a  single  purpose — that  purpose  to  do  good  without 
hop)e  of  reward — my  pride,  my  manhood  would  rebel 
and  cry  out  against  being  the  recipient  of  charity  from 
any  one,  much  less  from  you,  sir,  coming  here  for  the 
purpose  of  advancing  your  own  interests,  masked  by 
the  plea  of  benefiting  a  fellow-man  in  distress.  Your 
proposition  I  scorn;  it  is  monstrous;  it  outrages  every 
manly  and  honorable  impulse  that  my  nature  is  capa- 
ble of  conceiving.  I  refuse,  sir,  to  accede  to  your  re- 
quest, and  hand  back  what  you  considered  would  be 
the  price  of  my  shame.  I  have  been  honored  in  peace 
and  in  war.  Here  are  the  emblems  of  this  appreciation 
and  honor;  here  the  medals  and  tokens  I  have  loved 
so  long  and  well,  which  you  see  adorn  this  threadbare 
coat  of  mine,  and  which  will  go  down  to  the  grave 
unsullied  and  untarnished  by  any  barter  for  lucre. 
They  stand  for  worth  and  sturdy  manhood,  for  an 
honest  cause  and  a  noble  profession.  Go,  Dr.  Dash; 
I  refuse  to  be  tempted.     My  family  will  be  protected 


when    I    am  gone.     Shipwreck    and    starvation    may 
come;  but  disgrace,  never.     Welcome — 

"  ■  Death,  the  old  man's  friend, 
The  kindest  and  the  best.'  " 

The  Summary  of  Causes  Leading  to  the  Abuse 
of  Charity.  — In  the  foregoing  sketch  a  few  of  the 
leading  causes  for  the  abuse  of  medical  charity  are 
given;  there  are  other  causes,  but,  since  brevity  and 
time  are  precious,  they  will  not  be  touched  on  here. 
However,  no  suffering  or  hardship  will  be  entailed  on 
account  of  this  omission,  since  they  are  mostly  auxili  • 
ar}'  and  offshoots  of  the  original  and  principal  griev- 
ance cited  in  this  article  by  example  and  illustration 
— which  method  to  the  writer's  mind  is  the  best  possi- 
ble way  to  present  a  truth.  By  this  means  a  fact  is 
made  more  palatable,  and  an  impression  is  produced 
far  more  enduring  than  by  the  old  method  of  generali- 
zation and  moralizing — reaching  conclusions  by  com- 
parison, deduction,  and  inference.  The  one  entertains 
while  it  instructs:  the  other,  by  its  monotony  and 
infinity  of  detail,  obscures  and  buries  in  a  grave  of 
verbose  redundancy  the  main  facts  sought  to  be  im- 
pressed. 

Dr.  Youngblood  is  the  incarnation  of  the  pernicious 
activity  and  commonplace  audacity  with  which  the 
medical  profession  is  to-day  honeycombed,  under- 
mined, and  disgraced.  The  V'oungbloods  have  made 
our  calling  the  jest  of  the  people ;  they  have  so  injected 
the  element  of  fakir  and  three-card-monte  man  into 
the  current  of  medical  thought  that  the  honest  and 
intelligent  practitioner  blushes  while  contemplating 
the  future  of  his  profession.  These  Youngbloods 
have  divided,  demoralized,  and  prostituted  our  profes- 
sion to  their  own  selfish  ends,  so  that  it  is  an  easy 
prey  for  the  wily  hospital  governor  to  feed  on  or  the 
philosopher  to  base  a  truth  or  point  a  moral  with. 

Mr.  Broadcast  is  the  soul  and  embodiment  of  the 
unscrupulous,  dishonorable  editor,  who  will  stoop  to 
anything  to  further  and  advance  his  individual  inter- 
ests. While  one  sheet  of  his  journal  is  devoted  to 
editorials  eulogizing  fair  business  dealings,  the  other 
side  is  full  of  fraudulent  advertisements;  with  one 
hand  he  smites  the  usurer  and  locks  the  embezzler  in 
a  cell,  while  with  the  other  he  receives  the  reward  of 
conspiracy  and  cunning  from  his  partnership  with  the 
dishonest  business  man,  the  impostor,  and  the  quack. 

The  Rev.  Mr.  Mayflower  is  a  type  of  the  clergymen 
who  are  preaching  from  their  pulpits  and  proclaiming 
from  the  lecture  platform  their  sympathy  w  ith  the  poor, 
and  the  efforts  they  are  making  to  advance  the  inter- 
ests and  better  the  condition  of  tlie  laboring  classes. 
These  clergymen  are  loud  in  their  condemnation  of  any 
scheme  to  improve  the  condition  of  the  general  prac- 
titioner, who  they  say  has  no  grievance,  and  whose 
business  it  is  night  or  day  to  answer  the  call  of  all 
who  may  apply  at  his  doorbell,  without  being  inquisi- 
tive as  to  whether  he  will  receive  a  compensation  for 
his  services.  These  reverend  gentlemen  claim  that 
the  physician  has  no  moral  right  to  ask  for  a  reward 
for  his  labor.  "  This  should  be  left  to  the  generosity 
or  judgment  of  the  patient,"  say  these  obliging  gentle- 
men. By  preaching  such  doctrines  and  emphasizing 
these  absurd  assertions  in  private  and  public,  they 
have  inflicted  a  hardship  on  the  medical  profession, 
and  largely  contribute  to  make  the  poor  poorer  and  the 
discontented  more  discontent.  They,  more  than  any 
other  cause,  have  helped  to  fill  the  waiting-rooms  of 
the  hospitals  and  dispensaries  with  medical  paupers; 
and,  worse  yet,  tliey  put  seditious  words  in  their  mouths 
and  revolutionary  ideas  in  their  heads  about  the  rights 
of  the  poor  and  the  duty  of  the  government. 

The  anarchist,  strange  to  say,  is  largely  the  product 
of  the  social  teachings  of  the  Mayflower  brand  of  cler- 
gyman, who  is  careful  to  run  away  from  trouble  him* 


736 


MEDICAL    RECORD. 


[November  20,  1897 


self  and  better  his  condition  whenever  an  opportunity 
offers.  He  is  perfectly  willing  to  leave  his  old  flock 
to  shift  for  itself,  to  hope  and  pray  as  best  it  can. 

Dr.  Dash  is  a  sample  of  that  moral  reptile  known 
as  the  advertising  quack.  The  effrontery  of  this  man 
is  remarkable.  By  organized  fraud  and  misrepresen- 
tation he  reaps  his  harvest  of  dollars  and  flourishes 
like  a  green  bay  tree,  notwithstanding  that  the  search- 
light of  an  aroused  public  opinion  is  directed  on  his 
methods.  He  still  reposes  with  a  beautiful  serenity 
in  the  confidence  of  his  victims,  and,  like  the  surgeon 
of  the  Free-to- All  Dispensary,  hides  behind  the  fog  of 
legal  technicalities  placed  on  the  track  of  justice  by 
Mr.  .Sharp,  his  attorney. 

The  pernicious  influence  of  the  Voungbloods,  May- 
flowers, Broadcast.s,  Redflames,  and  Dashes  must  be 
destroyed  before  any  diminution  in  charity  abuse  is 
possible.  The  combined  influence  of  these  men  is 
the  moral  Saint  Lawrence  feeding  the  gulf  of  charity. 
Behind  this  gulf  is  a  perverted  public  sentiment,  fed 
by  millionaires  and  some  well-meaning  philanthro- 
pists—as the  teeming  waters  of  the  St.  Lawrence  are 
fed  by  the  great  chain  of  North  American  lakes. 

The  hospital  governor  is  only  a  condition,  a  mere 
incident  in  this  Niagara  of  charity,  a  sort  of  caretaker 
at  the  falls,  so  to  speak.  The  poor,  helpless  man  is 
as  unable  to  shoot  these  rapids  as  was  Dr.  Goodman 
or  the  Rev.  Mr.  Mayflower;  indeed,  he  must  use  ex- 
treme caution  that  he  is  not  drawn  into  the  vortex  and 
swallowed  in  the  maelstrom  of  the  seething  waters  of 
the  abyss  below.  He  is  ultimately  in  as  much  danger 
for  his  life  as  was  old  Dr.  White  in  being  swept  away 
by  the  human  tide  that  rushed  through  the  thorough- 
fare to  the  Free-to- All  Dispensary. 

The  hospital  and  its  adopted  child,  the  dispensary, 
will  collapse,  shrinking  to  their  normal  proportions^ 
when  rich  men  are  convinced  that  it  is  not  to  their 
interest  to  contribute  further  to  the  maintenance  of 
these  institutions.  Rich  men  as  a  rule  are  selfish.  It 
is  the  lack  of  generosity  and  kindness  in  their  natures, 
as  much  if  not  more  than  business  ability,  that  con- 
tributes so  largely  to  their  success.  In  order  to 
acquire  their  wealth,  what  human  wrecks  are  strew^n  in 
their  wake!  what  a  cyclone  of  misery  has  been  the 
companion  of  their  triumphal  march! 

"  .Vh  !  that  some  warning  vision  there, 
Some  voice  that  might  have  spoken." 

The  millionaire  treads  on  broken  hearts,  lacerated 
feelings,  and  blighted  pledges— all  offered  as  a  sacri- 
fice on  the  altar  of  mammon.  While  treading  on  the 
graves  of  his  victims  and  in  possession  of  the  millions 
his  soul  craved  for,  he  suddenly  experiences  a  revolu- 
tion of  feeling  and  has  a  religious  spasm,  the  reflex  of 
a  troubled  conscience,  which  impels  him  to  build  a 
chapel,  found  a  hospital,  or  endow  a  dispensary.  He 
is  as  selfish  in  his  new  enterprise  as  he  was  in  the 
accumulation  of  his  millions,  and  persistently  refuses 
to  take  those  into  his  confidence  who  could  show  him 
how  to  make  his  bequest  of  the  greatest  good  to  the 
greatest  number  of  human  beings,  and  very  probably, 
like  Dr.  Youngblood,  wishes  to  advertise  himself  while 
playing  the  role  of  philanthropist  and  humanitarian 

Conclusions.  -The  problem  of  the  hour,  then,  is  to 
convince  rich  men  that  their  interests  are  assailed  and 
their  future  is  imperilled  by  the  countenance  and  aid 
they  are  giving  to  indiscriminate  charity;  that  tliis  so- 
called  charity  is  a  two-edged  sword,  and  will  cut  both 
ways.  This  cannot  be  done  by  the  gatliering  of  a  few 
well-meaning  gentlemen  at  a  hall  on  Madison  Avenue 
or  by  the  protest  of  a  State  medical  society  at  its  an- 
nual meeting.  However  honest  in  purpose,  they  suc- 
ceed only  in  making  themselves  look  ridiculous  and  a 
plaything  of  the  great  public,  which  is  looking  through 
the  fence  across  the  way.     The  efforts  of  these  gentle- 


men very  much  resemble  that  of  the  famous  old  lady 
m  her  heroic  endeavor  to  hurl  back  and  stem  the  rising 
tide  with  her  broom,  or  the  fisherman  to  drain  the 
ocean  with  an  oystershell.  The  public  will  say  that 
we  are  interested  parties  in  the  matter,  and  not  likely 
to  give  a  disinterested  opinion;  that  our  meetings  of 
protest  are  made  up  largely  of  two  classes,  the  big 
fellows  and  the  little  fellows— namely,  those  who  are 
able  and  those  who  are  not  able  to  make  a  living  at 
practice;  that  the  big  fellows  are  helping  the  little 
fellows  to  climb  the  apple  tree;  that  it  is  a  contest 
where  there  is  only  a  plaintiff  in  the  suit  and  no  action 
at  law. 

Some  good  has  been  accomplished,  however,  and  in 
the  right  direction,  by  a  few  writers  in  the  medical 
press,  notably  by  that  well-known  and  long-time  cham- 
pion of  the  general  practitioner.  Dr.  George  F.  Shradv 
of  New  York.  The  Titanic  blows  of  this  sturdy  yeo- 
man through  the  editorial  columns  of  the  .Medical 
Record,  resound  through  the  medical  world;  the 
echoes  of  these  blows  have  awakened  the  millionaire 
and  philanthropist  to  hear  that  their  interests  and 
their  future  largely  depend  on  the  manner  and  method 
with  which  they  handle  this  new  danger,  how  to  control 
and  regulate  the  problem  of  charity. 

Is  it  any  wonder,  then,  as  the  poor  physicians  survey 
the  field  and  recognize  the  overwhelming  odds  against 
them— the  forces  with  which  they  are  to  compete,  the 
crowd  outside  and  the  many  in  their  own  ranks— that 
they  grow  despondent,  and  e.xclaim  in  their  anguish  of 
soul,  "What  must  we  do  to  be  saved?" 

51  Charlton  Street. 


STOMACH  DISTURBANCES  CAUSED  BY 
HERNIA  OF  THE  LINEA  ALBA  IN  THE 
EPIGASTRIUM.' 

By  CHARLES   D.    .\.A.RON.    M.D., 

DETROIT,   MICH., 
INSTRUCTOR   IN   MATERIA   MEDICA   IN  THE  DETROIT  COLLEGE    OF   MEDICINE. 

I  WISH  to  report  an  interesting  case  that  has  come  un- 
der my  notice.  It  is  a  case  of  subperitoneal  fatty  her- 
nia of  the  linea  alba.  The  practitioner  does  not  expect 
a  hernia  in  the  neighborhood  of  the  epigastrium,  for 
it  is  well  known  that  that  is  quite  rare.  Still  it  is  of 
the  utmost  importance  to  those  of  us  who  are  giving 
especial  attention  to  diseases  of  the  digestive  tract  to 
bear  in  mind  tliat  hernia  in  the  epigastrium  does  occur 
more  often  than  supposed.  These  hernia;  are  obscure 
because  usually  they  are  small  and  elude  detection. 
The  case  I  refer  to  will  illustrate  how  a  small  subperi- 
toneal fatty  hernia  will  give  all  the  symptoms  of  gas- 
tric disturbance. 

April    13,    1892,    Mr.    D ,    a   cigarmaker,   aged 

forty-nine,  consulted  me  for  what  he  called  gastric 
catarrh.  He  gave  the  following  history :  He  enjoyed 
good  health  until  four  years  before  he  consulted  me. 
While  eating  his  dinner  he  was  suddenly  taken  with 
nausea  and  vomiting.  Ever  since  he  has'  suftered  in 
various  ways,  and  has  given  such  symptoms  as  to  lead 
his  physician  to  believe  he  was  suffering  from  a  stom- 
ach disorder.  Sometimes  he  feels  comparatively  well, 
and  at  other  times  his  trouble  is  aggravated.  He  com- 
plains of  pain  in  the  epigastrium.  When  I  saw  him 
first  he  had  a  thickly  coated  tongue,  complained  of 
headache  and  loss  of  appetite.  He  had  lost  twenty- 
eight  pounds  in  four  months,  and  was  unable  to  retain 
food  in  his  stomach.  He  vomited  milk  and  soup  just 
as  he  did  meat  and  potatoes,  and  suffered  with  consti- 
pation.    The  urine  was  normal. 

Upon  physical  examination   I  found  the  stomach  in 
normal  position  and  was  unable  to  discover  any  or- 

'  Read  before  the  annual  meeting  of  the  Northern  Tri-State 
.Medical  .Vssociation  at  Detroit,  Mich.,  July  15  and  16,  1897. 


November  20,  1897] 


MEDICAL    RECORD. 


737 


ganic  disturbance  except  midway  between  the  xiphoid 
appendix  and  the  umbilicus.  Here  in  the  median  line, 
by  palpation,  I  felt  a  lobulated  mass,  which  was  flat- 
tened and  not  larger  than  a  small  chestnut.  It  was 
slightly  movable,  and  felt  soft  and  bogg)-.  My  patient 
knew  nothing  of  the  existence  of  this  small  enlarge- 
ment. I  paid  little  attention  to  this  protuberance,  but 
my  patient  began  to  get  weaker,  and  all  treatment 
which  apparently  seemed  rational  was  without  results. 
He  would  vomit  upon  the  slightest  provocation,  and 
suffer  severe  pain,  extending  to  the  back,  after  anv  food 
had  entered  his  stomach.  I  concluded  that  the  trouble 
was  a  reflex  ner\ous  disturbance,  and  the  mass  in  the 
linea  alba  was  the  cause  of  it.  Upon  examination  I 
could  not  get  the  t}-pical  signs  of  hernia — fulness  on 
coughing,  etc.  Unable  to  find  much  literature  on  the 
subject,  I  called  in  Dr.  T.  A.  McGraw,  and  we  agreed 
upon  a  diagnosis  of  hernia  in  the  linea  alba. 

-April  2  I,  1892,  the.patient  entered  Harper  Hospital. 

April  22d,  I  assisted  Dr.  McGraw  in  the  operation. 
A  one-inch  vertical  incision  was  made  over  the  protu- 
berance, passing  through  skin  and  subcutaneous  tissue. 
We  immediately  came  upon  the  tumor,  which  consisted 
of  a  lobulated  mass  of  fat.  It  was  covered  by  a  layer 
of  thin  connective  tissue,  which  continued  from  the 
base  of  the  tumor  as  a  pedicle.  On  lifting  the  tumor 
a  minute  opening  was  obser\-ed  in  the  linea  alba, 
through  which  the  pedicle  passed.  Care  being  taken 
that  no  part  of  the  neck  was  caught  in  the  ring,  the 
pedicle  was  ligated  as  deep  as  possible.  The  stump 
retracted  within  the  opening  in  the  linea  alba.  The 
pedicle  extended  through  the  linea  alba  and  a  part  of 
the  peritoneum  adhered  to  the  tumor,  as  is  usual  in 
these  cases.  The  ring  was  hardly  larger  than  the  di- 
ameter of  a  match.  The  edges  were  denuded  and  the 
aperture  was  sutured.  Union  took  place  by  first  in- 
tention. The  mass  was  not  larger  than  a  flattened 
chestnut  and  was  lobulated.  Our  diagnosis  was  a 
subperitoneal  fattv"  hernia  of  the  linea  alba.  The  pa- 
tient made  a  rapid  recover}-.  His  diet  was  at  first 
fluids  and  gradually  solids.  All  symptoms  entirely 
disappeared,  and  he  was  able  to  resume  work  six  weeks 
after  the  operation.  This  he  had  been  unable  to  do 
for  two  j'ears  previously. 

The  patient  left  the  hospital,  March  5,  1892,  four- 
teen days  from  the  time  of  the  operation.  It  is  now 
five  years  since  then,  and  he  has  had  no  return  of  his 
trouble. 

During  my  stay  in  Berlin  I  had  the  pleasure  of  see- 
ing three  such  cases  at  the  Augusta  Hospital  Poly- 
clinic. Dr.  Leopold  Kuttner,  assistant  to  Prof.  C.  A. 
Ewald,  was  kind  enough  to  demonstrate  the  cases  to 
me.  Since  then  he  has  reported  several  cases  in  an 
elaborate  paper.'  These  cases  had  been  sent  to  the 
Augusta  Hospital  Polyclinic  by  physicians  as  stub- 
born cases  of  gastric  catarrh.  They  had  evidently 
failed  to  make  an  adequate  diagnosis. 

There  was  at  one  time  a  disposition  to  consider 
ever)'  kind  of  dyspeptic  difficulties,  excluding  catarrh, 
ulcer,  and  cancer,  as  a  neurosis  of  the  stomach.  We 
are  gradually  coming  to  know  that  gastric  neuroses 
cover  a  number  of  various  symptoms,  each  of  which 
upon  a  careful  examination  may  have  a  respectively 
different  cause.  Still  we  must  confess  that  at  times  it 
is  difficult  to  differentiate  between  a  functional  and 
organic  disease,  with  regard  to  stomach  affections. 

Lindner,"  in  an  exhaustive  work  on  abdominal  her- 
nia, points  out  the  fact  that  patients  often  complain  of 
gastric  disturbances,  undefined  pains,  etc.,  while  upon 
more  careful  examination  small  hemise  are  found  to 

'  L.  Kuttner:  "Ueber  Verdaunngsstorungen,  venirsacht  durch 
verschiedene  Bruchformen.  besonders  durch  }Iemien  der  Linea 
alba.  Mittheilungen  ausden  Grenzgebieten  der  Medizinund  der 
Chirurgie."     Erster  Band.  iSg6. 

■  Lindner:  Berliner  Klinik,  iSgi,  Ileft  49. 


be  present.  At  times  these  hemiEe  are  hardly  larger 
than  a  pea.  If  careful  palpation  is  omitted,  such  pa- 
tients are  usually  treated  for  gastric  catarrh,  intestinal 
catarrh,  etc.,  and,  to  the  surprise  of  the  physician  and 
patient,  all  means  apparently  rational  are  without  re- 
sults, until  a  cautious  and  practical  examination  rec- 
ognizes the  cause  to  be  a  hernia  of  the  linea  alba. 
Lothrop'  says  that,  owing  to  the  great  density  ot  the 
linea  alba,  the  rupture  in  hernia  epigastrica  generally 
starts  to  one  side  of  the  median  line.  When  once 
there  is  a  small  rent  in  the  fascia,  the  abdominal 
pressure  forces  a  small  portion  of  the  pliable  subperi- 
toneal fat  through  the  slit,  both  of  which  slowly  en- 
large. Later  a  portion  of  the  peritoneum  is  dragged 
after  the  fat,  and  thus  we  have  the  beginning  of  the 
hernial  sac,  the  outer  surface  of  which  may  be  covered 
with  a  layer  of  fat.  He  says  that  when  once  this  peri- 
toneal pouch  has  been  formed,  the  entrance  of  omen- 
tum OS  gut  is  easily  understood. 

Statistics  show  that  hernia  epigastrica  is  more  prev- 
alent in  men  than  in  women.  At  one  time  it  was 
supposed  that  all  cases  of  hernia  in  this  region  con- 
tained a  part  of  the  stomach.  This  we  know  now  not 
to  be  true.  They  may  contain  subperitoneal  fat,  peri- 
toneum, omentum,  large  intestine,  small  intestine,  all 
together  or  any  one  of  these  singly.  At  times  it  is 
impossible  to  ascertain  whether  the  omentum  is  in  the 
sac  or  not,  but  when  the  hernia  is  of  any  considerable 
size  the  omentum  is  usually  present.  Litten  has  given 
us  a  method  by  which  we  can  differentiate  the  subperi- 
toneal lipoma  from  hernia  containing  omentum,  etc. 
He  places  his  hand  over  the  hernia,  telling  the  patient 
to  cough  at  the  same  time.  '  If  the  sac  contains  omen- 
tum and  intestine,  we  get  the  impression  as  if  water 
were  being  squirted  against  the  hand  or  shot  thrown 
against  it ;  if  not,  he  decides  that  there  is  a  subperi- 
toneal fatty  hernia. 

Hernia  of  the  linea  alba  occurs  usually  in  the  up- 
per part  of  the  abdomen.  It  is  found  mainly  between 
the  tip  of  the  xiphoid  appendix  and  the  umbilicus. 
Rarely  do  we  see  these  hemia  below  the  navel. 
Above  I  said  that  the  male  sex  seems  to  suffer  more 
frequently  with  these  herniae  than  the  female.  I  be- 
lieve that  the  cause  of  this  lies  in  the  fact  that  hernia 
epigastrica  has  often  been  mistaken  for  hernia  ventra- 
lis;  this  led  to  the  notion  that  it  occurs  in  women 
more  often  than  in  men.  The  size  and  form  of  these 
hernia;  are  variable,  and  range  from  those  of  a  bean  to 
those  of  an  egg.  The  form  depends  on  the  size — the 
small  ones  are  usually  round,  while  larger  ones  hang 
down  like  a  bag. 

The  symptoms  of  fat  and  intestinal  hernia  may  for 
a  long  time  be  latent,  and  such  abnormalities  may 
often  be  found  without  symptoms.  Symptoms  may 
manifest  themselves  suddenly.  Pain  may  show  itself 
in  paro.xysms,  after  the  taking  of  food,  coughing,  etc., 
and  may  encircle  the  body  and  run  down  the  legs. 
Patients  complain  of  pain  on  bending,  and  vomiting  is 
a  common  occurrence.  Pains  seem  to  be  greater  after 
taking  solid  foods  than  after  a  fluid  diet.  There  are 
several  varieties  of  typical  symptoms;  loss  of  appetite, 
nausea,  flatulence,  constipation  may  occur  in  light 
cases.  Along  with  these  symptoms  which  point  to 
disease  of  the  digestive  organs,  the  disease  may  as- 
sume the  form  which  resembles  hysteria,  neurasthenia, 
and  melancholia. 

Most  convincing  in  the  diagnosis  of  hernia  epigas- 
trica is  the  evidence  of  a  tumor  by  palpation,  which  is 
less  difficult  the  larger  the  protuberance.  Important 
is  the  sensitiveness  to  pressure.  This  point  is  diag- 
nostically  valuable  if  the  hernia  is  small.  The  chem- 
ical and  microscopical  analysis  of  the  stomach  con- 
tents usually  shows  that  gastric  functions  are  normal. 

'  Lothrop:  The  Boston  Medical  and  Surgical  Journal,  March 
4,  1897,  p.  201. 


738 


MEDICAL    RECORD. 


[November  20,  1897 


The  symptoms  of  true  intestinal  hernia  of  the  epigas- 
trium resemble  those  of  subperitoneal  lipoma  so  much 
that  a  complete  distinction  between  them  is  at  times 
difficult  to  make.  However  that  may  be,  from  the 
viewpoint  of  the  practitioner  this  differentiation  is  of 
no  material  importance,  since  operative  measures  are 
equally  necessary  in  both  cases. 


THE   DIAGNOSIS    OF   CHOREA    IN    ADULTS. 

By   W.    MOSER,    M.IX. 
brooklyn,  n.  v. 

That  chorea  is  not  infrequently  seen  in  childhood  is 
universally  conceded.  In  adults,  however,  it  has  been 
hitherto  regarded  as  comparatively  rare.  Recently 
KrafTt-Ebing  informs  us  that  chorea  in  adults  is  not 
so  infrequent  as  is  generally  believed,  and  that  it  has 
in  them  a  different  significance  than  in  children.  In 
extreme  old  age  it  is  certainly  not  a  common  disease. 
I  have  seen  three  cases  of  chorea  in  adults  since  the 
publication  of  Krafft-Ebing's  article,  and  this  I  do 
not  regard  as  a  mere  coincidence,  but  rather  as  con- 
firmatory evidence  that  the  disease  is  not  so  rare  in 
adults.  It  may  be  questioned  whether  in  adults  we 
are  dealing  with  the  same  disease  as  occurs  in  chil- 
dren. Choreiform  movements  in  adults  may  be  a  symp- 
tom of  organic  cerebral  disease,  as  in  prehemiplegic 
or  posthemiplegic  chorea  (Weir  Mitchell,  Charcot). 
Choreiform  movements  may  occur  during  pregnancy. 
They  are  rare,  however,  and  the  high  mortality  leads 
me  to  believe  that  we  are  confounding  organic  cerebral 
lesions  with  true  chorea  or  choreiform  movements  as 
we  see  them  in  children. 

Chorea  proper  usually  gives  a  favorable  termination, 
although  I  have  seen  two  fatal  cases  in  children.  No 
autopsy  was  made.  Chorea  may  be  associated  with 
hysteria,  as  in  the  electrical  or  rhythmical  chorea 
of  French  writers,  and  there  are  also  the  chorei- 
form movements  occurring  in  alcoholic  subjects  (al- 
coholic chorea).  These  cases  are  not  properly  chorea, 
nor  are  they  influenced,  as  is  the  large  majority  of 
cases  of  true  chorea,  by  the  administration  of  arsenic. 
The  form  of  the  disease  known  as  Huntington's  chorea, 
while  it  has  features  in  common  with  chorea  proper,  still 
has  some  important  differences.  It  is  seldom  seen  be- 
fore middle  life.  It  occurs  more  frequently  in  males 
than  in  females,  develops  gradually,  and  late  in  the  dis- 
ease the  mind  becomes  affected.  It  does  not  improve 
under  arsenical  treatment.  Choreiform  movements  may 
be  local,  i.e.,  confined  to  one  member,  as  an  arm,  and  if 
they  do  not  soon  yield  to  the  administration  of  arsenic 
it  is  to  be  feared  that  they  may  be  the  precursor  of 
cerebral  hemorrhage.  When  choreiform  movements 
follow  a  cerebral  hemorrhage,  they  are  known  as  post- 
paralytic chorea.  The  symptom  known  as  athetosis 
(Hammond)  is  a  form  of  local  chorea,  and  signifies 
organic  brain  lesion,  usually  cerebral  hemorrhage  or 
sclerosis,  and,  as  Wood  truly  says,  it  is  "  only  one  of 
an  innumerable  variety  of  posthemiplegic  spasms, 
and  is  never  exactly  the  same  in  two  cases."  The 
condition  known  as  hemiataxia '"  may  be  considered 
simply  as  a  very  mild  form  of  postparalytic  chorea" 
(Wood).  In  reviewing  the  different  forms  of  chorea 
just  mentioned,  it  becomes  apparent  that  we  cannot 
always  be  dealing  with  a  disease  f'cr  sf,  or  a  disease 
identical  with  the  functional  chorea  or  chorea  minor 
of  children.  But  it  is  the  chorea  minor  of  adults 
which  forms  the  subject  of  this  article,  and  like  the 
disease  in  childhood  it  frequently  presents  the  follow- 
ing peculiarities: 

I.  Great  emotional  disturbance,  such  as  fright,  acts 
as  a  cause,  and  did  so  in  one  of  the  three  cases  men- 
tioned, that  of  a  young  lady  of  nineteen  years. 


2.  Its  association  with  rheumatism  or  a  rheumatic 
history.  In  one  of  my  cases  a  lady,  aged  thirty-two 
years,  gives  a  rheumatic  history. 

3.  Its  association  with  endocardial  lesions. 

4.  Last,  but  not  least,  it  is  usually  improved  by 
the  administration  of  arsenic,  while  choreiform  move- 
ments of  organic  cerebral  origin  are  not.  Nor  is  hys- 
terical chorea  improved  under  arsenic.  The  same 
might  be  said  of  paramyoclonus  multiplex,  with  which 
the  disease  in  question  might  be  confounded. 

I  regard  arsenic  in  chorea  minor  as  a  specific,  like 
quinine  in  malaria  or  mercury  in  syphilis.  Hence  in 
a  given  case  of  chorea,  especially  if  it  be  localized,  as 
in  an  arm,  and  no  improvement  takes  place,  there 
arises  a  suspicion  in  my  mind  that  it  depends  upon 
serious  cerebral  lesion  and  may  possibly  be  the  pre- 
cursor of  cerebral  hemorrhage. 


FORWARD    DISLOCATION    OF    THE    FORE- 
ARM. 

Lv    HENRY    D.    FULTON,    M.D.. 

PITTSBCRG,   PA. 

The  forward  dislocation  of  both  bones  of  the  forearm 
at  the  elbow  is  of  such  infrequent  occurrence  that  the 
following  report  of  such  a  case  may  be  of  interest. 
The  case  presented  two  points  of  special  interest: 
first,  it  was  unattended  by  fracture  of  the  olecranon, 
and  secondly,  the  displacement  occurred  when  the 
forearm  was  in  a  position  of  complete  extension.  The 
case  was  seen  in  consultation  with  Dr.  F.  G.  Gardiner 
of  this  city. 

The  subject  was  a  man  of  middle  age,  muscular  in 
build,  and  at  the  time  of  the  accident  intoxicated  to  a 
moderate  degree.  The  history  which  he  gave,  and 
which  was  corroborated  by  a  friend  with  him  at  the 
time,  was  that  while  he  was  about  to  step  from  a 
freight  car,  and  while  still  holding  securely  to  the 
iron  support  at  the  end  of  the  car,  used  by  trainmen 
in  getting  on  or  alighting  from  a  car,  the  step  turned, 
throwing  his  foot  off,  the  entire  weight  of  his  body 
being  for  an  instant  sustained  by  one  arm.  \vhen  the 
luxation  occurred  at  the  elbow.  As  above  stated,  there 
was  no  fracture  of  the  olecranon,  which  has  compli- 
cated six  of  the  twenty  cases  of  this  dislocation  which 
have  so  far  been  reported  ("  American  Text-book  of 
Surgery,"  page  439).  The  end  of  the  humerus  formed 
a  large  prominence  posteriorly,  causing  a  marked  and 
sufficiently  characteristic  deformity.  The  radius  and 
ulna  were  completely  displaced  upward  upon  the  an- 
terior surface  of  the  humerus.  Efforts  to  effect  reduc- 
tion without  anaesthesia  were  unsuccessful,  .\fter  the 
patient  was  thoroughly  anesthetized  the  parts  were 
restored  by  our  combined  efforts  to  their  natural  rela- 
tion. The  reduction  was  somewhat  difficult  and  was 
obtained  by  making  extension  by  pulling  on  the  hand 
and  wrist  while  the  forearm  was  maintained  in  a  ffexed 
position  at  right  angles  with  the  elbow. 

Hamilton  states,  in  his  work  on  "  Fractures  and 
Dislocations,"  that  Sir  Astley  Cooper  and  others  de- 
nied that  this  dislocation  could  occur  without  fracture 
of  the  olecranon,  but  that  the  possibility  of  its  occur- 
rence is  now-  well  established.  The  last  edition  of 
Gross'  ''  Surgery"  mentions  that  there  have  been  ten 
instances  recorded  of  this  dislocation  without  fracture 
of  the  olecranon,  and  later  works  cite  fourteen  cases 
so  far  authenticated.  In  previous  cases  of  this  rare 
dislocation  which  have  been  reported,  the  mode  of 
production  has  invariably  been  stated  to  have  been 
some  force  or  a  blow  on  the  olecranon  process  of  the 
ulna  when  the  forearm  was  in  a  flexed  position.  The 
history  of  this  case  is  perfectly  clear  on  the  point  that 
the  displacement  occurred  when  the  forearm  was  in 
extension. 


November  20,  1897] 


MEDICAL    RECORD. 


739 


progress  of  I^XctUcal  J«cicnjce. 

The  Treatment  of  Trifacial  Neuralgia  by  Liga- 
tion of  the  Common  Carotid  Artery. — From  a  survey 
of  the  literature,  together  with  experimental  observa- 
tions upon  dogs,  Ricketts  (Journal  of  the  American 
Medical  Association,  October  16,  1897,  p.  772)  con- 
cludes that  ligation  of  the  common  carotid  arter}',  in 
the  absence  of  pathologic  conditions,  is  attended  by 
but  little  danger.  It  is  safer,  more  certain,  and  at- 
tended with  fewer  serious  consequences  than  any  of 
the  intracranial  operations  for  the  relief  of  trifacial 
neuralgia.  The  cause  of  this  condition  seems  to  be 
either  congestion  or  anaemia;  when  congestion,  liga- 
tion is  the  more  certain  to  bring  relief.  The  close 
proximity  of  the  ganglion  to  the  bone  upon  which  it 
rests  and  the  weight  of  the  brain  upon  it,  together  with 
localized  meningitis,  seem  to  explain  in  some  degree 
the  occurrence  of  anaemia  and  congestion  of  the  gan- 
glion. The  cellular  structure  of  the  ganglion  is  not 
changed  by  ligation  of  the  carotid  artery,  so  that  no 
such  alteration  can  be  assigned  as  the  cause  of  relief 
from  pain.  As  the  size  of  the  blood-vessels  on  the 
side  ligated  does  not  seem  to  be  diminished  at  the  end 
of  eight  weeks,  the  cause  of  relief  lies  evidently  in 
the  fact  that  the  blood  pressure  is  much  lessened, 
inasmuch  as  lowering  of  arterial  tension  in  any  con- 
gested area  affords  relief.  However  uncertain  the 
cause  of  the  pain  or  of  its  relief,  ligation  of  the  com- 
mon carotid  artery  must  be  recognized  as  an  estab- 
lished operation  in  the  treatment  of  trifacial  neuralgia. 

Ichthyol  in  Variola. — Dr.  Kolbassenko  {Le  Scalpel, 
October  3,  1897)  reports  that  he  has  employed  ichthyol 
in  eighteen  cases  of  variola,  only  two  of  which  were 
fatal ;  these  two  cases  were  in  a  very  serious  condition 
when  he  undertook  the  treatment.  From  the  time  of 
appearance  of  the  variola  papules  to  the  disappearance 
of  the  pustules,  the  following  pomade  is  to  be  applied 
three  times  daily  over  the  entire  surface  of  the  body: 
ichthyol,  10;  oil  of  sweet  almonds,  60:  lanolin,  20. 
For  economy  in  hospital  practice  vaseline  may  be 
substituted  for  oil  of  sweet  almonds.  During  the  stage 
of  the  prodromic  fever  until  the  appearance  of  the 
papule,  i.e.,  from  the  time  variola  is  suspected,  the 
author  applies  all  over  the  body  a  liniment  containing 
equal  parts  of  essence  of  eucalyptus,  of  ether,  and  of 
lanolin.  This  treatment  has  the  advantage  of  sup- 
pressing, so  to  speak,  the  itching  in  the  state  of  erup- 
tion; of  diminishing  fever  in  the  state  of  suppuration 
(the  temperature  will  not  rise  above  39.5°  C.) ;  of  di- 
minishing the  suppuration  itself,  and  of  shortening  by 
one-half  the  desquamative  stage. 

The  Virulence  of  the  Bacilli  of  Loeffler  in  Connec- 
tion with  the  Clinical  Forms  of  Diphtheritic  An- 
gina.— Dr.  G.  H.  Lemoine  writes,  in  Le  Bull.  Med., 
No.  51,  June,  1897,  that  in  thirty-seven  cases  of  pseudo- 
membranous angina  with  the  bacilli  of  Loeffler,  the 
bacilli  extracted  from  the  false  membrane  were  found 
pathogenic.  Twenty-nine  of  these  anginas  had  the 
■clinical  features  of  diphtheria;  on  the  other  hand,  the 
remaining  four  were  benign  and  the  bacilli  were  de- 
void of  virulence.  In  the  cases  in  which  the  bacilli 
were  virulent,  long  and  moderate  forms  were  found, 
except  in  four  cases,  in  which  the  short  form  existed 
and  the  bacilli  were  of  attenuated  virulence.  One  can 
say  that  generally  there  is  an  agreement  between  the 
results  of  bacteriological  and  those  of  clinical  exami- 
nation as  to  the  nature  of  diphtheritic  angina.  It  is  the 
same  if  one  wishes  to  base  the  gravity  of  the  affection 
in  man  on  the  bacteriological  examination,  since  ani- 
nials  are  chosen  that  are  excessively  sensitive  to  the 
bacilli   of    Loeffler.     In   three  serious   cases   of   true 


diphtheria  the  Loeffler  bacilli  showed  themselves 
attenuated,  but  bacteriological  st\idy  shows  considera- 
ble virulence  of  the  coli  bacilli  and  the  streptococcus. 
The  greater  or  less  resistance  of  the  organism  ought  to 
be  taken  into  account.  In  practice  one  cannot  rely 
exclusively  on  bacteriology  to  yield  the  diagnosis  of 
diphtheritic  angina.  The  exclusive  presence  of  the 
bacilli  in  the  short  form  ought  to  lead  us  to  reserve 
our  decision.  The  long  and  medium  bacilli  appear 
to  be  characteristic  of  diphtheria.  But  in  every  case 
it  is  necessary  to  take  into  account  the  number  of  ele- 
ments found;  not  only  the  number  of  colonies  devel- 
oped on  the  Senion's  tube,  but  also  the  quantity  of 
bacilli  entering  into  the  constitution  of  the  false  mem- 
brane. An  examination  of  the  false  membrane,  de- 
tached with  forceps  and  washed  in  sterilized  water, 
has  given  conclusive  results  in  cases  reported  by  the 
author;  and  in  a  patient  who  died  of  strepto-diphthe- 
ria,  he  was  also  able  to  affirm  the  association  of  the 
streptococcus.  The  clinic  remains  at  the  foundation 
of  the  diagnosis  of  diphtheritic  angina;  it  alone  in-' 
dicates  the  time  of  intervention;  bacteriology  will 
indicate  the  manner  of  intervention. 

Acetonuria,  Diacetonuria,  and  Butyric  Acid  in  the 
Gastro-Intestinal  Troubles  of  Infants  and  Young 
Children. — Dr.  P.  Vergely  i^Archires  Cliniqucs  de  Bor- 
deaux, September,  1897)  draws  the  following  conclu- 
sions from  his  study  of  this  subject:  1.  The  presence 
of  acetone,  diacetic  acid,  and  oxybutyria  acid  in  the 
urine  of  infants  affected  with  digestive  troubles  is 
quite  frequent.  2.  These  digestive  troubles  have  par- 
ticular physiognomy  due  to  the  formation  of  these 
substances  in  the  digestive  tract.  3.  The  presence  of 
o.xybutyric  acid,  of  diacetic  acid,  and  of  acetone  in 
young  subjects,  when  the  kidneys,  the  liver,  the  lungs, 
and  the  nervous  system  are  free  from  serious  lesions, 
gives  a  favorable  prognosis.  4.  It  is  possible  that 
o.xybutyric  acid,  diacetic  acid,  and  acetone  are  formed 
in  the  digestive  tract  by  the  action  of  micro-organisms 
or  of  albuminoids  and  sugars  of  the  alimentary  mass; 
that  with  these  harmless  materials  introduced  into  the 
blood  with  albuminoids  and  with  fat  by  the  fact  of 
autophag)'  may  be  the  point  of  departure  for  the  for- 
mation of  acetonuric  products.  5.  The  meat  diet 
ought  to  be  proscribed  and  carbohydrates  ought  to 
furnish  the  nourishment  during  the  acute  period.  One 
should  have  recourse  to  different  evacuants,  purgatives, 
and  emetics,  and  these  should  be  followed  with  alka- 
lines,  glycerin,  hypophosphites,  and  soda — at  least  in 
non-diabetic  subjects. 

Spleno-Pneumonia  in  Typhoid  Fever. — Drs.  Auche 
and  Carriere,  in  the  Archives  Cliniqucs  de  Bordeaux, 
September,  1897,  draw  tlie  following  conclusions  from 
their  article  on  the  above  subject :  i.  Spleno-pneumo- 
nia  ought  to  be  classed  among  the  number  of  compli- 
cations possible  in  typhoid  fever;  but  it  is  very  rare, 
two  cases  only  having  been  reported  up  to  the  present 
time.  2.  This  complication  comes  at  an  advanced 
period  of  dothinenteritis.  Its  first  symptoms  have  been 
noticed  on  the  seventeenth  or  eighteenth  day  after  the 
beginning  of  the  fever  in  Dr.  Bouicli's  case;  during 
the  convalescence  from  a  slight  relapse  in  the  writers' 
personal  observation.  Its  progress  may  be  rapid  and 
its  termination  speedily  fatal,  or  it  may  follow  a  slow 
evolution  and  present  the  ordinary  prognostication  of 
the  disease  of  Grancher.  4.  Its  anatomical  substra- 
tum consists  in  a  pulmonarj'  congestion,  as  shown  in 
the  macroscopical  and  microscopical  examination  of 
Bouicli's  case.  5.  As  to  the  patholog},  in  the  authors' 
case  it  was  as  obscure  as  it  is  in  such  instances  gener- 
ally. "  It  seems  from  the  result  of  our  studies  that  the 
bacilli  of  Eberth  ought  not  to  be  incriminated  and  re- 
garded as  the  direct  cause  of  this  complication.     It  is 


740 


MEDICAL    RECORD. 


[November  20,  1897 


necessary  to  look  for  the  pathological  element  in  the 
white  staphylococci,  which  we  have  cultivated. 
Their  feeble  degree  of  virulence,  their  existence  in  a 
state  of  purity  in  our  best  cultures,  make  us  believe 
this.  Staphylococci  are  so  widely  scattered,  one  being 
able  to  find  them  particularly  in  the  surface  of  the 
skin  even  after  the  strictest  antiseptic  precautions,  that 
we  cannot  feel  justified  in  implicating  them." 

Experiments  with  Koch's  New  Tuberculin.— In  a 
review  of  the  recent  work  with  this  remedy,  Maere  has 
reported  {Le  Scalpel,  October  3,  1897)  seven  cases  of 
lupus  treated  by   injections    of   the    new  tuberculin. 
Doutrelepont  {Deutsche  med.   Woch.)  has  used  it  in  fif- 
teen cases  of  lupus,  the  greater  part  of  which  presented 
tuberculous  ganglia.     He  considers  the  new  tuberculin 
superior  to  the  old,  and  is  of  the  opinion,  as  far  as  he 
can  judge  at  present,  that   it  constitutes  a  valuable 
therapeutical  agent.     He  has  been  struck,  as  has  also 
M.  Bussenius,  with  the  fact  that  its  action  varies  with 
■  the  length  of  time  that  it  has  been  bottled.     It  seems 
imprudent  to  him  to  follow  the  directions  of  Koch  for 
increasing  the  dosage.     The  amount  must  be  increased 
more  slowly  if  fever  is  to  be  avoided;  such  fever  may 
be  only  temporary,  but  it  affects  the  general   state  of 
the  patient.     These  fevers  have  caused  the  patient  to 
lose  in  weight,  while  generally  there  is  an  increase  in 
weight  during  treatment.     Locally  the  ulcers  of  lupus 
are  rapidly  cicatricized,  the  projecting   parts  do  not 
give  way,  the  nodules  are  replaced   by  cicatricial  tis- 
sue.     The  ganglia  have  diminished   in  volume,  but 
some  suppurate  and  have  to  be  incised.     Baudach  re- 
ports having  made  two  hundred  and  eighty-five  injec- 
tions in  twenty  patients.     He  has  not  observed  a  single 
abscess,  though  De  la  Camp  and  Rumpf,  of  Hamburg, 
say  they  have  often  observed  at  the  point  of  injection 
painful    infiltrations,    yielding  to     treatment    slowdy. 
Five  of  Baudach's  patients  have  followed  the  treatment 
to  the  end ;  this  has  required  from  sixty-four  to  sev- 
enty  days.     One    patient   withdrew  from    treatment; 
thirteen  others  are  still  under  treatment.     The  injec- 
tions seem  to  give  good  results.     They  sufficed  in  one 
case  to  close  a  rectal  fistula.     This  treatment  should 
not  interfere  with  hygienic  measures  and  an  outdoor 
life.     Spengler,  the  former  assistant  of    Koch,   is   a 
firm  believer  in  the  new  product,  and  declares  that  it 
causes  less  reaction  than  the  old ;  tiie  cough  diminishes 
under  its  influence,  as  well  as  expectoration.     Ulcer- 
ations of  the  larynx    heal    more   rapidly   than    when 
touched  with  lactic  acid.     In  one  case  of  mi.xed  infec- 
tion with  fever  it  was  harmful  and  had  to  be  discon- 
tinued.    Splengler  is  very  careful   in   applving  this 
treatment  to  patients,  using   it   only  with   tuberculous 
patients  whose  temperature  does  not  exceed  37.5'  C, 
or  a  temperature  under  the  tongue  of  37.2"  C.      It  is 
necessary  that  expectoration  should  show  the  absence 
of  all  secondary  infection;  such  infection  maybe  pos- 
sible even   in   the  absence  of  fever.     He  makes  the 
injections  in  the  posterior  side  of  the  forearm.     When 
the  doses  are  raised  from  five  to  twenty  milligrams  the 
injections  are  no  longer  made  every  two  davs,  but  at 
intervals  of  from  five  to  eight  days,  in  order'  to  avoid 
the  accumulation  of  the  tuberculous  toxins  in  the  sys- 
tem.    From  the  outset  it  secures  against  attacks'of 
fever.     He  advises  very  sensitive  patients  to  replace 
the  injections  by  rubbings  with  tiie  remedy.     On  the 
other  side,  Jez  (  Wiener  mcci.   Woch.),  after  treating  six 
patients,  contests  all  immunizing  and  curative  power 
of  the  tuberculin.     He  notes  violent  attacks  of  fever, 
aggravation  of  all  symptoms,  an  increase  of  the  rSles 
and  of  the  number  of  bacilli  in  the  sputum.     K.  Mul- 
ler  opposes  the  use  of  tuberculin   in  case  there  are 
tuberculous  complications  of  the  ear.      One  woman, 
who  had  lupus  and  tuberculous  otitis  of  the  left  ear,' 
had  during  injections  an  attack  of  miliarv  tuberculosis 


in  the  right  ear.     Two  English  clinicians  report,  in  the 
British  Medical  Journal,  that    they  have   treated  six 
cases  of  lupus  by  the  new  method,  and  confirm  the 
assertions  of  Koch  as  to  the  local  action  of  the  remedy. 
They  note  a  diminution  of  congestion  in  the  parts  sur- 
rounding the  lupus;  the  development  of  a  depression 
in  the  centre  of  the  nodule,  with  consecutive  desqua- 
mation:    the  healing  of   the    ulcerated  surface:    the 
gradual  disappearance  of  the  oedema  of  the  lips,  ears, 
etc.     In  two  cases  the  lupus  nodules  have  disappeared  ; 
in  two  other  cases  the  nodules  shrivelled  up.     In  a 
particularly  tenacious  case  the  process  was  partially 
checked  from  the  beginning  of  treatment.     It  is  only 
at  the  time  that  large  doses   have  been  injected  that 
marked  febrile  disturbances  have  been  observed,  with 
turgescence  and  inflammation  of  the  local  lesion,  but 
these  attacks  have  quickly  yielded.     \\'ithout  commit- 
ting themselves  on  the  question  of  a   possible   cure, 
these  authorities  believe  that  they  can  recommend  the 
method,  at  least  in  cases  of  common   lupus  when  the 
general  condition   is  still  good.     It  is  interesting,  a 
propos  of  the  widely  differing  results  that  tuberculin 
treatment  has  given,  to  mention  the  information  col- 
lected by  Dr.  Rembold,  of  Stuttgart.     He  treated,  from 
1890  to  1891,  with  the  old  tuberculin,  82  cases.     After 
six  years  he  has  attempted  to  ascertain  what  has  be- 
come of  these  patients,  but  has  been  able  to  trace  only 
70.     Of  these  70,  27  only  had  a  mixed  infection,  the 
importance  of  which  was  then  ignored.     They  are  all 
dead  (23  died  the  first  year,  2   the  second,  and  2   the 
third).      These  figures  show  that  patients   belonging 
to  this  categorj'  cannot  hope  for  much  from  tuberculin. 
The  remaining  43  are  divided  into  three  groups.      Se- 
rious cases,  12  :   10  died,  2  better  and  living.     Moder- 
ately severe  cases,   15;  7  died,  8    living  and  better. 
Mild  cases,  16;   i  died,  3  living  and  better,  12  cured. 
Out  of  the  43  cases,  18  dead,  12  better,  and  13  cured. 


Treatment  of  Wounds  by  the  Aseptic  Cage To 

avoid  the  drawbacks  of  the  present  methods  of  dress- 
ing in  extensive  burns  or  granulating  surface  wounds 
generally.    Dr.  J.  R.   Benson   has  for  some  time  em- 
ployed a  method  of  treatment  which  consists  in  apply- 
ing no  dressing  of  any  kind  to  the  wound,  but  leaving 
it  exposed  to  the  air  under  a  kind  of  cage   covered 
with  dry  dressing.     This  cage  may  be  applied  with 
ease  to  any  part  of  the  body.     Dr.  Benson  proceeds  in 
this  manner:  A  piece  of  tin  of  sufficient  thickness  is 
cut  so  as  to  form  a  splint  for  the  part  to  rest  on,  with 
a  number  of  long  processes  projecting  at  the  sides. 
These  processes  are  bent  over  the  wound,  leaving  a 
space  between  them  and  the  latter,  forming  a  cage. 
The  cage  is  attached   by  strapping  above  and  below 
the  wound,  and  the  whole  is  covered  with  a  dr)-  asep- 
tic towel.     In  large  body  wounds  ordinary  wire  cradles 
will  answer  the  purpose ;  if  the  wound  'is  small,  two 
pieces  of  glass  tubing  may  be  strapped  to  the  skin  and 
gauze  stretched  over  them.     The  gauze  and  towel  are 
removed  from   time  to  time,  and  the  wound  is  washed 
with  a  weak  aseptic  lotion.     In  cases  of  skin  grafting 
Dr.  Benson  covers  the  grafts  with  protective  and  pres*^ 
sure  is  applied  in  the  ordinary  wav.     About  six  hours 
later  the  wound  is  undressed'  and'  the  cage  applied. 
Care  should  be  taken  not  to  remove  the  protective  too 
soon  and  not  to  let  it  remain  too  long.     In  the  fonner 
case  serum  is  poured  out  between  the  wound  and  the 
grafts,  preventing  them  from  adhering;  while  in   the 
latter  case  the  transplanted  grafts  become  adherent  to 
the  protecti\e  and  may  be  dragged  off  with  it.     The 
wound  is  douched  once  or  twice  a  day  w  idi  a  1  to  2,000 
mercuric-chloride    solution.     Skin    grafting    in    this 
manner   becomes  a  fairly  easy  operation,  the  results 
being    certain    and    in\ariabrv    successful.  —  J/<',//ra/ 
Week. 


November  20,  1897] 


MEDICAL    RECORD. 


741 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE    F.    SHRADY,  A.M.,  M.D.,   Editor. 

Publishers 
WM.  WOOD  &  CO.,   43,  45,  &  47  East  Tenth  Street. 


New  York,  November  20,  1897. 

THE  CONDITIONS  OF   MODERN   NAVAL 
WARFARE. 

In  the  late  war  between  China  and  Japan,  naval  war- 
fare on  a  large  scale  and  under  modem  conditions  was 
for  the  first  time  fairly  exemplified.  Without  doubt,  if 
the  Japanese  had  met  f  oemen  more  worth}-  of  their  steel, 
the  lesson  taught  from  a  medical  and  surgical  point  of 
view  would  have  been  even  more  instructive.  How- 
ever, quite  enough  facts  have  been  gathered  to  de- 
monstrate plainly  that  a  complete  revolution  has  been 
effected  in  the  methods  of  naval  warfare.  Not  only  has 
it  been  shown,  as  might  have  been  anticipated  from 
the  nature  of  the  new  conditions,  that  the  wounds  re- 
ceived were  of  a  more  fearful  and  generally  of  a  differ- 
ent character,  but  it  also  has  been  clearly  shown  that 
the  shock  to  the  nervous  system  from  the  noise  and 
vibration  was  terrible — in  some  instances,  indeed,  fatal. 
Dr.  S.  Suzuki,  fleet  surgeon  in  the  imperial  Japanese 
navy,  read  before  the  International  Congress  at  Mos- 
cow a  paper  treating  of  the  wounded  in  naval  battles 
between  Japan  and  China,  together  with  some  notes  on 
the  sanitary  conditions  of  the  navy  during  the  war. 
This  paper  has  just  been  published  in  pamphlet  form. 
Many  interesting  details  are  given.  The  principal 
seat  of  injuries  appears  to  have  been  the  head,  while 
the  hurts  causing  the  largest  number  of  deaths  were 
those  affecting  larger  parts  of  the  body.  This  was  a 
natural  result,  because  in  the  majority  of  these  cases 
at  least  one-third  of  the  body  was  burned  and  in  some 
wholly  destroyed.  It  is  pointed  out  that  in  sea  fights 
most  of  the  wounds  are  in  the  head,  and  in  land  fights 
in  both  extremities.  The  explanation  is  that  in  land 
fights  soldiers  as  a  rule  are  injured  only  by  shells  and 
bullets,  whereas  in  sea  battles  all  materials  around 
the  combatants,  as  ship  planks  and  rigging,  etc.,  being 
blown  to  pieces  by  the  bursting  of  shells,  increase  the 
causes  of  injury.  The  antiseptic  treatment,  which  was 
of  course  pursued,  seems  to  have  been  attended  with 
most  satisfactor}-  results.  No  infectious  diseases  of 
wounds  occurred,  with  the  exception  of  one  fatal  case 
of  erysipelas.  There  was  one  case  of  bums  leaving 
remarkable  keloid  scars.  The  sanitarj-  condition  of 
the  Japanese  na\7  was  throughout  the  war  excellent. 
Venereal  disease  and  its  sequels  supplied  37.69  per 
cent,  of  the  total  number  of  cases  of  disease.  Dis- 
eases of  the  respiratory  system    numbered  9.01    per 


cent.;  diseases  of  the  digestive  system,  10.09  P^r 
cent.;  and  skin  diseases,  8.91  per  cent.  There  were 
167  cases  of  malarial  fever,  4.79  per  cent,  of  which 
were  fatal.  But  3  cases  of  cholera  occurred  in  the 
Japanese  na\-}'.  Of  the  43  cases  of  kak'ke,  3  were  fatal, 
the  ratio  of  cases  per  100  of  force  being  0.21.  Of  the 
total  number  of  persons  dying  at  sea  during  the  war, 
150  were  killed  in  action  and  177  died  of  disease. 


TYPHOID  FEVER  IN   RELATION  TO  WATER. 

It  is  somewhat  of  a  coincidence  that  Dr.  Hart's  sum- 
mary report  of  typhoid-fever  outbreaks  in  Great  Britain 
should  have  been  published  at  the  time  when  one  of 
the  most  widespread  and  virulent  epidemics  of  that 
disease  which  has  ever  occurred  in  England  was  rag- 
ing at  Maidstone.  It  is  now  some  si.xteen  years  ago 
since  any  report  on  water-bome  t)-phoid  was  made  in 
Great  Britain.  The  subject  matter  of  that  report  was 
also  collected  and  published  by  Dr.  Hart.  In  the 
present  summar)'  the  question  of  typhoid  fever  in  rela- 
tion to  water  is  treated  in  all  its  aspects,  and  many  de- 
tails are  given  of  epidemics  in  all  parts  of  the  United 
Kingdom.  Referring  to  the  change  that  has  come 
over  the  minds  of  the  people  in  regard  to  the  dangers 
lurking  in  water,  the  author  says:  "The  time  is  not 
long  since,  however,  in  which  much  scepticism  existed 
in  this  countrj-  as  to  the  bad  effect  on  health  of  even 
considerable  amounts  of  organic  impurit)';  but  in  the 
inter\'al  the  theorj-  previously  held  by  the  majoritj'  of 
medical  sanitarians  has  received  the  added  weight  of 
exact  experimental  research  and  proof.  It  no  longer 
remains  a  mere  theory,  but  is  now  an  accepted  fact, 
the  remaining  difficulty  being  to  make  people  see  that 
the  existence  of  disease-provoking  properties  in  their 
neighborhood  in  relation  to  their  drinking-water  is 
such  as  needs  removal,  when  such  removal  entails  ex- 
penditure of  money."  These  words  apply  with  as 
much  force  to  the  people  of  America  as  to  those  of 
England. 

Dr.  Hart  is  in  accord  with  the  majority  of  experts 
in  trusting  to  filtration  as  the  most  efficient  method  of 
purifying  water,  but  he  is  not  in  accord  with  the  modes 
of  filtering  in  general  use  in  Great  Britain.  On  this 
subject  he  says:  "In  the  matter  of  filtration  I  am 
much  afraid  we  come  verj-  far  short  of  that  point  of 
perfection  to  which  it  were  well  that  we  should  attain. 
The  theory  now  advanced  conceming  the  filtering  of 
drinking-water,  which  eats  at  the  ver\-  heart  of  our 
preconceived  notions  as  to  the  treatment  to  which  our 
filter  beds  should  be  subjected,  has  also  brought  with 
it  the  statement  of  the  only  position  which  it  is  safe 
to  adopt,  if  we  are  to  be  free  from  the  danger  of  recur- 
ring outbreaks  of  typhoid  fever  by  reason  of  our  water 
supply  becoming  polluted  in  a  manner  not  to  be  ren- 
dered harmless  by  our  prevailing  methods  of  filtration. 
To  such  of  my  readprs  as  have  not  studied  the  paper 
of  Prof.  R.  Koch  on  '  Water  Filtration  and  Cholera,' 
I  would  say,  do  so;  and  I  would  further  lay  stress  on 
the  rules  which  are  therein  laid  down  for  the  frequent 
and  regular  bacteriological  examination  of  water  from 
each  separate  filtering-basin  and  before  the  water  has 


742 


MEDICAL    RECORD. 


[November  20,  1897 


been  allowed  to  pass  into  the  general  storage  reser- 
voir, as  also  to  the  rule  as  to  the  construction  of  the 
filter  beds  in  such  manner  that  improperly  filtered 
water  can  be  at  once  removed,  not  being  allowed  to 
mix  with  the  other  water  to  be  delivered  to  the  distrib- 
uting mains." 

The  pamphlet  throughout  is  well  worth  a  study  by 
those  interested  in  public  hygiene. 


COMPARATIVE  POSITION  OF  THE  ORDI- 
N.\RV  GENERAL  PRACTITIONER  HERE 
AND    IN    ENGLAND. 

Competition,  associated  with  other  causes,  has  for 
some  time  past  pressed  very  heavily  upon  medical 
men  in  this  country.  Their  average  income  is  smaller 
and  their  future  chances  are  not  nearly  so  bright  as 
they  were  but  a  few  years  ago.  The  reduction  in  the 
earnings  of  doctors  is  not  confined  to  the  United 
States,  but  is  a  worldwide  evil.  These  remarks  ap- 
ply to  the  rank  and  file  of  the  medical  profession 
only,  and  not  to  the  specialists  who  in  every  land 
may  be  said  to  form  a  separate  class.  In  Great  Brit- 
ain, indeed,  the  position  of  the  general  practitioner 
has  become  so  precarious  that  an  absolute  dread  as  to 
the  ultimate  result  is  pervading  its  ranks,  and  reme- 
dies are  being  suggested  and  sought  for  on  all  sides. 
Thus  from  a  contemplation  of  the  state  of  affairs  in 
the  old  world,  the  doctors  here  may  e.\tract  some 
grains  of  comfort.  It  is  always  consoling  to  the  or- 
dinary individual  to  know  that  there  are  others  in  a 
worse  plight  than  himself.  In  the  first  place,  the  ex- 
pense of  a  medical  education  in  Great  Britain  aver- 
ages more  than  in  America.  To  obtain  a  degree  or 
qualification  in  any  medical  school  in  England,  Scot- 
land, or  Ireland,  a  course  of  study  covering  a  period 
of  at  least  five  years  is  compulsory  and  entails  an  ex- 
penditure of  a  no  less  sum  than  $3,000.  The  Laiurt 
and  British  Medical  Journal  put  the  cost  at  a  much 
higher  figure.  When,  after  these  years  of  work  and 
anxiety  and  after  spending  this  amount  of  money,  the 
student  succeeds  in  obtaining  his  license  to  practise, 
what  are  his  prospects?  If  he  possesses  money,  all 
v.'ell  and  good.  At  any  rate  he  can  make  a  fair 
start,  but  if  he  has  no  means,  what  then  ?  At  the 
outset  he  may  be  fortunate  enough  to  earn  an  in- 
come of  from  $250  to  $400  a  year  as  an  indoor  assis- 
tant to  a  practitioner;  as  a  ship's  surgeon  he  may  be 
paid  as  much  as  $40  a  month ;  a  parish  appointment 
may  afford  him  perhaps  $250  yearly;  or,  lastly,  if  he 
will  consent  to  pocket  his  pride  and  lose  much  of  his 
self-respect,  he  may  open  in  the  poor  suburbs  of  Lon- 
don or  in  the  slums  of  one  or  other  of  the  large  towns, 
what  the  inhabitants  of  these  districts  briefly  term  the 
doctor's  shop,  and  tliere  retail  medicine  and  advice  for 
twelve  cents  and  pay  a  visit  for  twenty-four  cents. 
Again,  take  the  case  of  a  young  man  in  Great  Britain, 
who  either  through  interest  or  the  possession  of  capi- 
tal is  able  to  commence  life  as  a  general  practitioner 
under  more  favorable  auspices,  and  compare  his 
chances  with  those  of  the  beginner  here.      It  is  stated  in 


the  British  Medical  Journal  on  well-informed  authority 
that  the  average  income  of  a  doctor  in  Great  Britain 
does  not  exceed  $1,000,  so  it  may  be  taken  for  granted 
that  the  average  yearly  earnings  of  those  starting  prac- 
tice is  very  considerably  less  than  this  sum.  On 
equally  authentic  authority  it  is  asserted  that  the 
average  income  of  a  medical  man  here  after  about  five 
years'  practice  varies  from  $800  to  $1,500,  and  that 
the  income  of  a  practitioner  of  twenty  years'  standing 
can  be  estimated  at  not  less  than  $2,000.  But  this  is 
not  all  the  advantage  the  doctors  on  this  side  possess. 
It  is  when  we  review  the  fees  in  detail  that  the  great 
difference  in  the  pecuniary  position  of  medical  men  here 
and  in  that  of  their  brother  practitioners  in  England  is 
most  clearly  appreciated.  Incomes  in  this  country 
may  be  estimated  at  nearly  double  that  on  the  other 
side,  while  fees  average  nearly  four  times  as  much. 
Reference  has  already  been  made  to  some  of  the  fees  in 
the  poorer  districts  of  the  large  towns  in  England.  It 
may  be  added  that  in  the  gricultural  parts  of  the 
country  they  are  not  much  higher,  besides  being  more 
difficult  to  collect.  Here  no  self-respecting  doctor 
will  take  a  fee  of  under  half  a  dollar  for  an  office 
visit,  or  less  than  a  dollar  for  an  outside  visit.  For 
midwifery  he  will  expect  at  least  $15  (the  average  in 
Great  Britain  is  about  $5).  In  England  a  doctor  has 
to  do  more  than  twice  the  amount  of  work  in  order  to 
earn  the  same  income.  Finally  there  can  be  no  doubt 
that  the  ordinary  working  member  of  the  medical  pro- 
fession in  this  country  is  in  a  comparatively  better 
position,  in  addition  to  having  a  brighter  outlook  than 
one  of  the  same  class  in  England.  Into  the  question 
of  causes  in  both  countries  there  is  no  need  to  enter. 


WHAT    THE   "MEDICAL   RECORD"  DOES. 

The  Buffalo  Medical  Journal,  in  an  editorial  in  its 
issue  of  October  last,  referring  to  the  late  Moscow 
congress,  says:  "The  Medical  Record  has  published 
a  full  cabled  synopsis  of  the  proceedings,  which  is  a 
marked  instance  of  journalistic  enterprise  as  well  as 
lavish  expenditure." 

So  far  as  we  know  this  is  the  only  reference  which 
has  been  made  in  any  American  medical  journal  to 
what  has  been  the  most  difficult  and  expensive  attempt 
on  our  part  to  supply  our  readers  with  the  news  of  the 
dz.y,  pari  passu  with  its  occurrence. 

Remarkable  as  is  the  occasion,  it  is  perhaps  not  to 
be  wondered  at,  since  any  such  reference  would  only 
go  to  show  the  lack  of  the  same  enterprise  and  ex- 
penditure on  the  part  of  any  metropolitan  journal  so 
noticing  it.  We  refer  to  it  here  simply  to  impress 
upon  our  readers  the  fact  that  the  Medical  Record 
never  spares  expense  in  providing  material  and  news 
which  the  wide-awake  members  of  the  medical  profes- 
sion should  have  to  keep  themselves  in  the  front  rank 
of  scientific  progress.  Its  corps  of  regular  correspond- 
ents all  over  the  world  is,  unquestionably  we  presume, 
the  largest  and  most  complete  of  any.  We  think  it 
will  hardly  be  considered  egotism  for  us  to  say  that  it 
is  the  one  journal  which  is  indispensable  to  all  who 


November  20,  1897] 


MEDICAL    RECORD. 


743 


desire  to  be  informed  promptly  of  the  progress  of 
medical  science  and  of  medical  news.  While  we 
make  this  claim  for  the  Medic.\l  Record,  we  must 
reiterate  what  we  have  repeatedly  said  in  these  col- 
umns before — that  no  medical  man  who  can  afford  it 
should  neglect  also  to  subscribe  for  and  do  what  he 
can  to  support  and  encourage  his  local  medical  jour- 
nal. With  that  and  the  Medical  Record  coming 
regularly  to  his  table,  he  could  be  no  better  equipped 
if  he  subscribed  to  a  dozen  other  journals,  so  far  as 
periodical  literature  pertaining  to  his  profession  is 
concerned. 


A   SIGN   OF    PROGRESS   IX   AMERICAN   PSY- 
CHIATRY. 

The  recent  appointment  of  William  Krohn,  Ph.D.,  a 
psychologist,  to  a  position  on  the  staff  of  the  Eastern 
Illinois  Hospital  for  the  Insane,  is  of  sufficient  import- 
ance to  deserve  more  than  passing  notice.  Time 
was,  and  that  not  far  removed,  when  the  appointment 
of  a  professional  psychologist,  not  a  physician,  to  a 
salaried  position  in  an  insane  asylum  would  have  been 
looked  upon  as  an  unwarrantable  procedure,  an  unjus- 
tifiable expenditure  of  public  funds,  and  an  encroach- 
ment upon  the  rights  of  the  physician.  Happily 
neither  physicians  nor  the  lait\-  take  such  a  biassed 
view  to-day.  It  may  confidently  be  predicted  that  the 
advent  of  the  psychologist  to  the  asylum  will  be  fol- 
lowed in  time  by  a  better  understanding  of  morbid 
mental  processes.  Moreover,  the  benefit  that  should 
result  from  the  co-operation  and  intelligent  collusion 
of  the  physician  and  psychologist  will  be  reaped  not 
alone  by  the  participants,  but  by  the  patient,  for  it  has 
already  been  shown  that  occasionally  the  outbreak  of 
an  attack  of  insanit}'  is  heralded  by  phenomena  that 
can  be  interpreted  and  given  their  proper  significance 
only  through  psychological  tests.  The  possibilit)'  of 
studying  the  association  of  mental  conditions  with 
different  pathological  states,  and  the  genesis  of  the 
former  as  indicative  and  dependent  upon  the  latter, 
may  eventually  suggest  to  physicians  some  means  for 
the  alleviation  of  the  conditions  thus  heralded  before 
they  have  progressed  to  a  stage  that  makes  recovery 
impossible.  Naturally  such  study  can  be  made  by  the 
physician  if  he  has  received  training  in  the  theorj- and 
practical  applications  of  psychology,  but  unfortunately 
such  training  is  uncommon.  In  some  countries  of 
Europe,  particularly  in  Germany,  a  few  psychiatrists 
have  had  adequate  preliminar)- training  in  psychology, 
and  this  training  has  been  reflected  in  the  character 
and  worth  of  their  real  contributions  to  psychiatry. 
Such  work  has  been  done,  for  example,  by  Krapelin, 
the  director  of  the  Psychiatry  Clinic  in  Heidelberg,  a 
pupil  of  Wundt;  by  Triiper,  of  Jena,  also  a  pupil  of 
the  same  master;  while  in  our  own  country  the  prom- 
ising work  that  has  been  begun  by  Hoch,  of  the  Mc- 
Lean Asylum,  and  Meyer,  of  the  Worcester  Asylum, 
both  young  men  trained  in  psycholog}'  as  well  as  in 
medicine,  is  worthy  of  mention.  We  do  not,  of  course, 
contend  that  it  is  necessary  to  be  a  professed  psychol- 
ogist before  undertaking  the  work  of  a  psychiater,  for 


we  are  deeply  cognizant  of  the  fact  that  the  latter  may 
evolute  into  the  best  type  of  the  former.  In  support 
of  the  statement  we  may  cite  the  brilliant  work  that 
has  been  done  in  psychologj-  by  Ziehen,  of  Jena,  who 
represents  the  psychiatrist  in  psycholog)' :  but  as  a 
rule  it  will  be  found  that  better  results  may  be  ex- 
pected if  the  training  in  psychology  follows  the  training 
in  medicine,  than  vice  versa. 

One  cannot  be  cognizant  of  current  opinion  among 
medical  men,  particularly  among  those  who  are  work- 
ing on  the  problem  of  disordered  mental  processes, 
without  being  strongly  impressed  with  the  emphasis 
that  is  being  placed  on  the  importance  of  bearing  gen- 
eral psychological  facts  and  principles  upon  the  diag- 
nosis and  treatment  of  diseased  states  of  the  mind. 
Despite  this  recognition  on  the  part  of  physicians,  the 
extension  of  psychology-  into  the  domains  of  medicine 
has  been  brought  about  by  the  psychologist,  the  one 
important  exception  being  that  of  Ziehen,  referred  to 
above,  and  perhaps  also  of  Morselli.  If  it  be  granted 
that  the  study  of  psycholog)-  and  its  application  mav 
be  of  service  to  mental  medicine,  we  may  naturallv 
look  for  its  inclusion  in  the  curricula  of  the  more  ad- 
vanced medical  schools.  Indeed,  it  has  already  been 
made  an  optional  subject  for  fourth-year  medical  stu- 
dents in  the  University  of  Pennsylvania.  We  may 
likewise  expect  to  see  an  affiliation  of  the  professed 
psychologist  with  institutions  for  defectives  and  the 
insane,  and  the  appointment  of  Dr.  Krohn  we  consider 
a  step  in  the  right  direction,  as  was  the  appointment 
of  Dr.  Lightner  Witmer,  professor  of  psychology  in 
the  Universit)-  of  Pennsylvania,  a  few  years  ago,  to 
the  position  of  consulting  psychologist  to  the  Pennsvl- 
vania  Institute  for  Feeble-Minded  Children,  at  Elwyn. 
Such  appointments  indicate  a  distinct  advance  in  the 
working  correlation  of  psychology  and  mental  pathol- 
og)-,  and  as  such  they  deserve  the  attention  and  emu- 
lation of  managing  boards  of  other  institutions  and  of 
State  commissioners  of  lunacv. 


THE   VENOM    OF    SNAKES    AND    ITS    ANTI- 
TOXIN. 

Fro.m  very  early  times  medical  science  has  been 
searching  to  discover  a  counteracting  agent  to  the 
venom  of  snakes.  In  India  it  is  estimated  that  on 
the  average  more  than  twent)'  thousand  persons  die  an- 
nually from  the  bite  of  the  hooded  serpent.  Up  to 
last  year  all  these  efforts  to  find  an  antidote  had  been 
in  vain,  when  almost  simultaneously  Calmette  at  the 
Pasteur  Institute  and  Fraser  in  Edinburgh  claimed 
to  have  discovered  an  efficacious  antitoxin.  Many 
nations  and  races  low  down  in  the  scale  of  civiliza- 
tion have  been  for  ages  in  possession  of  the  knowl- 
edge whereby  they  could  render  themselves  immune 
to  snake  poison.  The  negroes  of  the  Guinea  coast,  some 
Kaffirs  in  South  Africa,  and  the  fakirs  of  India  are 
among  those  who  know  of  this  safeguard.  The  method 
practised  by  these  people  is  either  to  eat  the  snake  or 
to  inoculate  themselves  with  the  venom  itself.  Differ- 
ent animals  are  affected  in  different  degrees  by  snake 
poison.     Calmette  and   Fraser  first  ascertained  bv  a 


744 


MEDICAL    RECORD. 


[November  20,  1897 


series  of  experiments  on  various  animals  the  minimum 
fatal  dose.  This  was  found  to  be  exactly  in  proportion 
to  the  body  weight  of  the  animal.  After  this  point  had 
been  settled,  the  attempt  was  made  to  secure  immunity 
for  these  animals  against  poison.  This  was  effected 
by  gradually  increasing  the  dose,  until  finally  the 
original  fatal  dose  had  been  largely  exceeded.  C'al- 
mette  by  this  method  rendered  animals  proof  against 
sixty  times  their  normal  minimum  dose,  while  Fraser 
made  a  rabbit  able  to  withstand  fifty  times  the  ordinar- 
ily fatal  dose.  As  yet  direct  experiments  on  man  have 
been  too  f^w  clearly  to  demonstrate  his  susceptibility 
to  snake  venom,  but  it  has  been  conjectured  that  his 
omnivorous  character  would  place  his  susceptibility 
between  that  of  a  cat  and  that  of  a  rabbit.  Hence  to 
kill  a  man  of  ordinary  weight,  from  2.16  to  2.31  grains 
of  venom  would  be  necessary.  In  India  and  elsewhere 
Calmette's  method  has  been  tested  with  successful  re- 
sults in  a  few  cases  of  snake  poisoning.  One  authen- 
ticated case  of  a  human  subject  occurred  at  Saigon, 
where  an  assistant  in  the  laboratory  was  bitten  in  the 
hand.  The  hand  and  forearm  were  quickly  paralyzed, 
and  the  serum  was  not  injected  until  one  hour  after  the 
bite;  nevertheless  the  man  after  passing  a  bad  even- 
ing recovered  during  the  night.  The  methods  of  Cal- 
mette  and  Fraser  differ.  Calmette  advocates  injection 
while  Fraser  believes  in  swallowing  the  venom.  Weir 
Mitchell  supplied  Fraser  with  the  venom  of  three  spe- 
cies of  rattlesnakes  (Crotalus  horridus,  adamanteus, 
and  durissus)  and  also  with  a  specimen  of  the  copper- 
head. Experiments  have  thus  been  made  with  the 
venom  of  the  most  deadly  poisonous  serpents  of  Asia, 
America,  and  Australia.  However,  before  a  definite 
opinion  can  be  given  as  to  the  orrhotherapy  of 
snake  bites,  further  experiments  and  evidence  will  be 
required. 


a  piece  of  useless  barbarity.  Cycling  he  condemns 
and  opines  that  the  physical  advantages  attending  this 
modern  mode  of  locomotion  are  apt  to  be  too  dearly 
bought. 


PRINCE    BISMARCK'S    DOCTOR    AND    MEDI- 
CAL   PRACTICE. 

Dr.  Schweninger,  the  medical  attendant  of  Prince 
Bismarck,  has  lately  been  giving  his  views  on  "medi- 
cal men  and  medical  practice,"  and  from  his  position 
these  views  naturally  arouse  much  more  interest  among 
the  laity  than  they  deserve  by  reason  of  either  origi- 
nality or  soundness. 

He  is  not  by  any  means  a  believer  in  up-to-date 
medicine.  In  regard  to  the  present-day  doctor,  he  ob- 
served that  he  is  surgeon,  bacteriologist,  electrician, 
anatomist,  microscopist,  physicist  or  physiologist,  but 
is  very  little  of  the  physician.  He  looks  upon  mod- 
ern pharmacy  with  great  contempt,  and  he  extends 
this  contempt  to  the  medical  men  who,  from  mis- 
guided enthusiasm  or  mere  self-interest,  assist  the 
pharmaceutical  specialist  in  making  a  fortune  at  the 
expense  of  gullible  humanity.  As  to  the  new  dis- 
coveries of  medical  science  he  contends  that  they  are 
either  useless  "  Aborigine"  or  old  remedies  long  since 
tried  and  abandoned.  The  corset  in  the  woman  and 
the  silk  hat  in  the  man  he  believes  to  be  the  two  great 
sources  of  ill  health.  Vaccination  he  believes  in  to  a 
certain  extent,  but  regards  compulsory  vaccination  as 


ICcxus  0f  the  ^meefe. 

An  Italian  Sewer  in  the  Fifth  Avenue  Water 
Pipes — The  Medical  Times  of  this  city  calls  the  at- 
tention of  the  health  board  to  the  fact  that  the  large 
water  pipes  which  are  being  laid  in  Fifth  Avenue 
have  been  used  by  the  workmen  as  a  urinal,  if  not 
worse,  during  the  protracted  time  during  which  this 
work  has  been  going  on,  thus  defiling  the  water  sup- 
ply to  the  level  of  a  common  sewer.  The  writer  says 
that  from  the  window  of  his  sanctum  he  has  seen  this 
done,  and  can  thus  substantiate  the  truth  of  the  state- 
ment from  personal  knowledge. 

The  Harlem  Medical  Association.— The  regular 
meetings  of  this  society  will  be  held  hereafter  at 
Arthur  Hall,  Lenox  Avenue  between  One  Hundred  and 
Twenty-sixth  and  One  Hundred  and  Twenty-seventh 
streets,  on  the  second  Monday  of  each  month,  except 
July,  August,  and  September. 

The  Chicago   Pathological   Society The  annual 

address  before  the  Chicago  Pathological  Society  will 
be  delivered  on  the  evening  of  Friday,  December  3d, 
by  George  M.  Sternberg,  M.D.,  surgeon -general  of  the 
United  States  army.  The  subject  of  the  address  will 
be  "Yellow  Fever;   Its  Etiology  and  Pathology." 

Laying  the  Cornerstone  of  the  New  Bellevue 
College. — On  Saturday  afternoon  last,  the  comer- 
stone  of  the  new  building  of  the  Bellevue  Hospital 
Medical  College  was  laid  with  appropriate  ceremonies. 
Mr.  D.  O.  Mills,  president  of  the  board  of  trustees, 
presided.  The  Rev.  Dr.  Roderick  Terry  delivered  a 
prayer  and  then  Dr.  Austin  Flint  introduced  Dr.  Lewis 
A.  Sayre,  who  laid  the  cornerstone,  and  in  his  address 
described  the  founding  of  the  college  and  reviewed 
briefly  its  later  history.  The  remaining  exercises 
were  held  in  the  lecture  room  of  the  Carnegie  Labora- 
tory. Addresses  were  delivered  by  Dr.  Landon  Car- 
ter Gray,  representing  the  alumni,  the  Rev.  Dr.  Rod- 
erick Terry,  D.D.,  of  the  board  of  trustees,  and  Dr. 
John  S.  Billings,  representing  the  medical  profession. 
The  cornerstone  contains  among  other  things  a  small 
vial  of  diphtlieria  antitoxin  and  a  tube  containing 
spores  of  the  bacillus  aerogenes  capsulatus,  which  we 
trust  may  not  lead  to  a  gangrene  of  this  venerable 
teaching-institution.  The  new  building,  which  will 
occupy  the  southwest  corner  of  Twenty-sixth  Street 
and  First  Avenue,  adjoining  the  Carnegie  Laboratory, 
will  be  six  stories  high  and  seventy-five  by  one  hun- 
dred feet  in  dimensions.  It  will  be  constructed  of 
brick  and  gray  stone,  and  will  be  fireproof.  Accord- 
ing to  present  e.\pectations,  the  building  will  be  com- 
pleted by  the  time  the  next  college  year  begins. 

Dr.  Laporte's  Condemnation. — Subscriptions  are 
being  solicited  among  physicians  by  several  of  the 
journals  in  France,  not  only  to  secure  a  fund  for  Dr. 


November  20,    1897] 


MEDICAL    RECORD. 


745 


Laporte,  recenth'  condemned  for  malpractice,  but  also 
to  raise  the  amount  necessar)-  for  having  the  case  re- 
opened in  the  courts.  The  Societe  de  Me'decine, 
which  is  the  oldest  medical  bodj'  in  France,  has 
passed  resolutions  of  sympathy  for  the  unfortunate 
physician,  and  of  condemnation  of  the  injustice  done 
him  by  the  court,  recommending  that  a  new  trial  be 
sought. 

The  Late  Dr.  William  Thurman.— The  West  End 
Medical  Societ}',  at  its  regular  meeting  held  on  the  7th 
inst,  upon  recommendation  of  a  committee  consisting 
of  Drs.  Edward  J.  Ware  and  Charles  A.  Kinch,  adopted 
the  following  minute:  "The  West  End  Medical  Soci- 
ety records  with  sorrow  the  death  of  an  associate  mem- 
ber, Dr.  William  Thurman,  and  oflfers  the  following 
testimonial  of  our  regard  and  appreciation  of  his 
noble  qualities.  He  was  a  conscientious  and  success- 
ful physician,  and  well  informed  in  all  the  depart- 
ments of  medicine.  He  preferred  family  practice  and 
was  especially  interested  in  the  little  children.  He 
was  generous  to  the  younger  members  of  the  profes- 
sion. He  was  interested  in  many  charities  and  freely 
gave  his  time,  money,  and  professional  talents  to  their 
advancement." 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  na\7  for  the  week  ending 
November  13,  1897.  November  8th. — Surgeon  James 
R.  Waggener  relieved  from  the  Marion  and  ordered  to 
resume  duties  at  Mare  Island  navy  )'ard.  Surgeon  C. 
Biddle  detached  from  duty  at  the  navy  department, 
i2th  inst.,  and  ordered  to  the  Newport,  13th  inst. 
Passed  Assistant  Surgeon  C.  H.  T.  Lowndes  detached 
from  the  Washington  navy  yard,  12th  inst.,  and  ordered 
to  the  Newport,  13th  inst.  Surgeon  J.  E.  Gardner, 
detached  from  the  Dolphin  and  ordered  home  on  wait- 
ing orders. 

College  of  Physicians  of  Philadelphia — A  stated 
meeting  of  the  section  on  general  medicine  of  the 
College  of  Physicians  of  Philadelphia  was  held  on 
November  8th,  the  president  of  the  college,  Dr.  J.  M. 
DaCosta,  in  the  chair.  Dr.  F.  A.  Packard  discussed 
methods  of  prescribing  diet  in  private  practice,  and 
exhibited  an  elaborate  diet  sheet  permitting  the  indi- 
cation of  foods  that  are  to  be  avoided  as  well  as  those 
that  may  be  taken  either  in  moderation  or  freely.  Dr. 
Hermann  B.  Allyn  reported  a  case  of  locomotor  ataxia 
with  perforating  ulcer  of  the  toe,  and  exhibited  the 
patient.  Dr.  J.  A.  Scott  exhibited  the  brain,  the  kid- 
neys, and  the  heart  from  a  case  in  which  death  had 
resulted  from  a  copious  extravasation  of  blood  into 
the  basal  ganglia  of  the  right  hemisphere,  rupturing 
into  the  lateral  ventricle,  and  extending  into  that  of 
the  opposite  side.  The  heart,  although  free  from 
gross  valvular  and  endocardial  or  myocardial  change, 
was  immensely  enlarged;  and  the  kidneys,  small  and 
white,  were  in  a  state  of  parenchymatous  inflammation. 

Philadelphia  County  Medical  Society. — A  stated 
meeting  of  the  Philadelphia  County  Medical  Society 
was  held  on  November  loth,  the  president,  Dr.  James 
Tvson,  in   the   chair.     Dr.  George   E.  de   Schweinitz 


reported  a  case  of  abscess  of  the  orbit  resulting  from 
suppurating  ethmoiditis,  in  which  recovery  from  both 
primary  and  secondary  conditions  followed  evacuation 
of  the  pus  accumulation  and  drainage.  Dr.  Louis  T. 
Lautenbach  read  a  paper  entitled  "  Philadelphia's  Gas- 
Supply  in  its  Relation  to  Public  Health — A  Compar- 
ison of  the  Injurious  Qualities  of  Coal  Gas  and  Water 
Gas."  He  pointed  out  that  water  gas  is  much  the 
more  poisonous  by  reason  of  the  larger  quantity  of 
carbon  monoxide  it  contains,  while  on  the  other  hand 
coal  gas  is  the  more  explosive  from  the  larger  propor- 
tion of  marsh  gas  contained.  Dr.  Philip  Fischelis 
read  a  paper  entitled  "The  Use  of  Electrolysis  and 
the  Galvano-Cautery  in  the  Treatment  of  Diseases  of 
the  Nose  and  Throat."  Dr.  Joseph  Gibb  read  a  paper 
on  "The  Differential  Diagnosis  of  Ulcerative  Dis- 
eases of  the  Lar\'nx  and  Pharynx."  Dr.  G.  Betton 
Massey  made  a  demonstration  of  an  original  process 
by  which  nascent  mercuric  salts  are  cataphorically  con- 
veyed into  the  body,  and  presented  a  patient  in  whom 
a  large  swelling  of  the  upper  jaw  had  been  dissipated 
by  means  of  the  procedure,  which  consists  in  the  pas- 
sage of  a  current  of  from  three  hundred  to  one  thou- 
sand milliamperes  or  more  through  a  gold  electrode 
with  an  amalgam  coating  of  mercury. 

Is  Medicine  a  Trade  or  Business  ? — An  English 
contemporary  says  that  in  the  lease  of  many  London 
houses  there  is  a  provision  forbidding  the  carrying  on 
of  any  trade  or  business,  and  it  has  been  decided  by 
the  courts  that  the  business  of  treating  the  sick  is  one 
of  the  forbidden  trades. 

Pathological  Society  of  Philadelphia. — A  stated 
meeting  of  the  Pathological  Society  of  Philadelphia 
was  held  on  November  1 1  th,  Dr.  A.  C.  Abbott  in  the 
chair.  Dr.  Joseph  Sailer  exhibited  a  heart,  the  seat 
of  old  pericarditis,  presenting  an  aneurism  close  to 
the  apex  of  the  left  ventricle,  which  had  ruptured,  and 
a  second  aneurism  projecting  from  the  posterior  aspect 
of  the  ventricle.  Histologic  examination  disclosed 
the  existence  of  myocarditis,  which,  together  with  the 
aneurismal  formation,  was  attributed  to  the  antecedent 
pericarditis.  Dr.  Sailer  exhibited  also  lungs  from  a 
case  of  purulent  pneumonia,  with  metastatic  abscesses 
in  the  kidneys.  Dr.  Judson  Daland  exhibited  an 
appendix  vermiform  is  containing  a  pin  and  success- 
fully removed  by  operation.  Dr.  J.  D.  Steele  pre- 
sented a  review  of  the  literature  of  Koch's  tuberculin. 
He  also  exhibited  a  specimen  of  hemorrhage  into  the 
lateral  ventricle,  with  enlargement  of  the  heart  and 
chronic  parenchymatous  nephritis.  Dr.  J.  H.  McKee 
exhibited  a  rabbit  presenting  an  umbilical  hernia  con- 
taining what  was  supposed  to  be  a  diseased  vermiform 
appendix,  but  upon  more  careful  examination  proving 
to  be  a  remnant  of  the  round  ligament  of  the  liver. 
Dr.  D.  Riesman  exhibited  a  specimen  of  carcinoma  of 
the  stomach  with  ulceration  and  metastasis  to  the 
liver;  and  also  gangrenous  lungs. 

Philadelphia  Pediatric  Society. — A  stated  meeting 
of  the  Philadelphia  Pediatric  Society  was  held  on 
November  glh,  the  president,  Dr.  J.  P.  Crozer  Griffith, 
in  the  chair.     Dr.  J.  H.  Jopson  demonstrated  a  case 


746 


MEDICAL    RECORD. 


[November  20,  1897 


•of  congenital  hereditary  oedema  in  a  child,  five  years 
old,  that  had  been  under  observation  from  birth,  and 
whose  brother  presented  a  like  condition.  According 
to  the  historj',  the  father  had  suffered  similarly  in 
childhood.  The  patient  presented  exhibited  a  firm 
swelling  of  both  legs  and,  in  less  degree,  also  of  the 
thighs,  with  a  large  pad  of  cedematous  tissue  on  the 
dorsum  of  each  foot.  The  mental  state  was  good  and 
there  were  no  other  abnormal  manifestations.  It  was 
generally  agreed  that  the  condition  was  a  develop- 
mental or  embryologic  one,  and  it  was  suggested  that 
thyroid  extract  might  prove  useful  in  treatment.  Dr. 
F.  A.  Packard  read  a  paper  upon  the  treatment  of  in- 
tussusception from  the  medical  .s:andpoint,  relating 
the  history  of  a  case  in  which  operation  was  required 
and  terminated  fatally.  He  pointed  out  the  rarity  of 
the  disorder,  and  expressed  a  caution  with  regard  to 
the  avoidance  of  too  great  pressure  in  attempts  at  re- 
duction by  hydrostatic  means.  Any  other  means  than 
surgical  intervention,  to  be  successful,  must  be  insti- 
tuted early,  as  swelling,  adhesion,  and  ulceration  are 
lik-^ly  to  have  taken  place  in  the  course  of  two  or  three 
■days.  Dr.  Edward  Martin  discussed  the  subject  from 
the  surgical  point  of  view,  agreeing  essentially  with 
the  propositions  made  by  Dr.  Packard.  Dr.  R.  G.  Le 
Conte  read  a  paper  on  "  Intussusceptions  of  the  Post- 
mortem Typ^  Observed  during  Coeliotomy,"  reporting 
a  case  in  \  hich  this  condition  was  found. 

The  oilent  Profession A  writer  in  the   Chemist 

■and  Druggist  falls  foul  of  The  Times  for  venturing  to 
assert  -.lat  che  profession  as  a  body  is  not  esteemed  as 
il  should  be  probably,  adds  The  Times  writer,  because 
the  medical  profession  as  a  body  has  taken  no  pains 
to  establish  and  defend  its  position.  This  is  not  the 
opinion  of  the  editor  of  the  Chemist  and  Druggist,  who 
roundly  declares  that  "  if  there  is  one  class  of  men 
who  more  thin  another  is  everlastingl/  clamoring  for 
more  recognition,  more  rights,  and  more  privilege:,  it 
is  th-jse  doctoi .."  If  adds  this  genial  critic,  their 
wisdom  is  no^  morj  conspicuous  than  their  silence,  it 
does  n  t  amount  to  much.  With  respect  to  the  charge 
of  silence,  we  are  told  that  "the  silent-suffering,  self- 
sacrificing;  profession  is  almost  as  successful  a  feat  of 
imagination'  as  the  large  profit  alleged  to  be  made  by 
druggists  on  the  sale  of  nostrums. — The  Medical  Press. 

The  Clinical  Society  of  Elizabeth  (N.  J.)  will 
hold  a  series  of  special  meetings  during  the  coming 
winter,  at  which  the  e  will  be  lectures  on  various  top- 
ics delivered  by  inviuition  by  out-of-town  physicians. 
The  fi  St  lecture  of  the  series  was  delivered  on  Octo- 
ber 28th,  by  Dr.  R.  T.  Morris,  of  this  city,  the  subject 
being  "Appendicitis." 

Villag :  Writer  Supply  in  England. — A  writer  in 
the  Wi':tmi?tstcr  Gazette,  referring  to  the  Maidstone 
typhoid-fever  epidemic,  says  that  very  few  villages  in 
Englai.d  have  pure  water,  and  to  anybody  who  is 
acquainted  w'th  the  facts  it  is  not  much  wonder  that 
typhoid  and  diphtheria  are  fairly  constant  items  of 
village  life.  Many  villages  depend  upon  rivers  for 
the'r  supply,  which  the  cottagers  dip  up  in  buckets  as 
they  want  it,  with  all  the  possible  contamination  from 


other  villages  and  land  drainage  up  stream.  Open 
wells  and  pits,  choked  with  dv;i»d  leaves  and  decaying 
vegetable  matter,  are  frequent,  and  where  there  are 
covered  wells  and  pumps  they  are  often  foul  with  the 
percolation  of  old  cesspools  and  dv;ad  wells  in  their 
neighborhood.  In  Diss  the  supply  comes  from  pits, 
and  the  surveyor  reported  that  the  water  was  only  six 
inches  deep  and  in  a  very  b  .d  srte,  with  a  foot  of  foul 
mud  under  it.  It  was  suggested  that  the  mud  should 
be  dredged  up  and  the  rainfall  left  to  fill  the  pits 
again.  The  medical  officer  pointed  out  that  the  water 
in  any  case  was  utterly  unfit  for  drinking-purposes, 
as  it  was  contaminated  by  field  drainage. 

Starvation  and  Death  in  the  Klondike The  tales 

brought  by  returning  miners  are  of  terrible  suffering 
and  privation  endured  by  the  gold  seekers  who  have 
gone  to  Alaska  this  year,  and  they  give  every  reason 
to  fear  that  the  misery  of  this  coming  winter  will 
beggar  description.  The  members  of  a  party  that  re- 
turned two  weeks  ago  to  Victoria  gave  a  moving  ac- 
count of  their  return  over  the  mountain  trail  from 
Dawson  City.  During  the  trip  they  were  reduced  to 
boiling  and  eating  pieces  of  raw  hide  and  their  boot 
tops.  At  one  time  they  had  nothing  for  three  days, 
when  an  owl  was  killed,  and  on  this  they  subsisted  for 
three  days  longer.  When  they  reached  Dalton's  cabin 
two  of  the  party  were  mad  from  hunger.  The  leader 
of  the  party  said  that  when  he  left  Dawson  Cit)'  four 
hundred  persons  had  purchased  tickets  for  St.  Michael, 
intending  to  go  down  on  the  steamers,  which  will, 
however,  not  get  up  until  spring  releases  the  river  ice. 
To  add  to  the  misery  of  their  position,  everj'  day  sees 
new  arrivals.  Now  that  they  are  there  they  find  curses 
their  welcome,  and  would  give  anything  to  escape. 
The  supply  of  food  is  insufficient  for  those  already 
there,  and  the  only  escape  of  many  from  star\'ation  is 
through  typhoid  fever,  which  is  reducing  thair  number 
at  the  rate  of  five  or  six  a  day,  and  so  leaving  a  smaller 
number  of  consumers  of  the  lessening  food  supply. 

The  German  Conquest  of  Moscow. —  An    English 

member  of  the  Twelfth  International  Medical  Congress 
writes  (The  Practitioner):  "The  congress  was  over- 
spread by  hordes  of  Austro-Germans.  They  waited 
in  rows  outside  the  doors  before  any  reception,  and 
then  made  a  football  rush  for  the  buffet,  wh'^re  they 
remained  in  rows  six  deep  for  the  remainder  of  the 
evening,  on  they' j'  ^"'^ij'y  ■'"''■f''''  principle,  not  stirring 
even  to  let  a  lady  get  an  ice.  They  were  well  organ- 
ized; for  months  beforehand  committees  had  been  at 
work  in  Berlin  and  Vienna,  the  meetings  being  pre- 
sided over  by  such  men  as  Virchow  and  Politzer. 
The  Teuton,  therefore,  was  very  much  in  evidence 
in  every  part  of  the  congress,  entirely  owing  to  his 
own  strategical  forethought  and  disciplined  '  pushful- 
ness.'  Nearly  every  German  professor  whose  name  is 
known  outside  his  own  lecture  room  was  there.  Like 
the  old  Highland  chiefs  when  they  went  forth  in  state, 
each  leader  of  German  medicine  came  to  Moscow  '  with 
his  tail  on,'  each  one  bringing  with  him  a  posse  of 
admiring  and  dutiful  retainers,  who  acted  as  a  claque. 
The  French  were  simply  swallowed  up  in  the  whirl- 
pool of  triumphant  Teutonism." 


November  20,  1897] 


MEDICAL    RECORD. 


747 


The  Prince  of  Wales'  Hospital  Fund — The  re- 
ceipts of  this  fund,  up  to  date,  amount  to  about  _;^i8o,- 
000,  which  is  a  g'  odly  sum,  bi.t  very  far  below  that 
which  was  aimed  at  by  those  wh  put  His  Royal  High- 
ness in  motion.  To  have  realized  their  anticipations 
at  least  a  million  was  wanted,  but  there  is  no  hope 
that  anything  approaching  that  amount  will  come  in. 
There  are,  in  fac',  abundant  evidences  that  the  Lon- 
don hospit;.l  system,  as  a  means  of  relief  of  the  poor, 
is  on  its  last  legs,  and  we  may  hope  that  these  costly 
institutions  will,  sooner  or  lat'^'",  find  it  necessary  to 
make  both  ends  meet  by  the  wholesome  process  of 
retrenchment  rather  than  the  oft-repeated  process  of 
unblushing  begging. — Medical  Press. 

"  Virchow's  Archiv." — This  much  quoted  periodi- 
cal celebrates  with  the  appearance  of  volume  cl. 
the  completion  of  its  fiftieth  year  of  publication,  it 
having  been  established  in  1847. 

A  Decorated  Surgeon. — Sir  William  MacCormac 
is  said  to  be  the  most  highly  decorated  member  of  his 
profession  in  Great  Britain.  He  has  the  Order  of 
Medjidie,  the  Crown  of  Prussia,  the  Ritter  Kreuz  of 
Bavaria,  Dannebrog,  Crown  of  Italy,  Cross  of  tlie 
Takovo  of  Servia,  Order  of  Merit  of  Spain  and  Portu- 
gal, and  the  Star  of  Sweden.  He  is  also  Knight  of 
Grace  of  the  Order  of  St.  John  of  Jerusalem. 

<<  The  Journal  of  the  Boston  Society  of  the  Med- 
ical Sciences"  has  been  enlarged  to  octavo  size,  and 
•will  hereafter  not  be  sent  gratis  to  would-be  readers. 
It  will  contain  abstracts  of  experimental  work  carried 
on  in  th  medical  school  of  Harvard  Universit)',  the 
experimental  laboratories  of  the  Massachusetts  Gen- 
eral and  the  Boston  City  hospitals,  and  the  physio- 
logical and  biological  departments  of  the  Massachu- 
setts Institut-i  of  Technology  and  Clark  University. 
It  w'll  bu  published  ten  times  a  year,  from  October  to 
June,  promptly  after  each  meeting  of  the  Boston  Soci- 
ety of  the  Medical  Sciences,  of  which  it  will  contain 
full  reports. 

To  Study  Yellow  Fever  in  Cuba.— A  Washing- 
ton dispat  h  states  that  the  President  has  detailed 
passed  Assistant  Surgeon  Eugene  Wasdin  and  passed 
Assistant  Surgeon  H.  D.  Geddings,  United  States 
Marine  Hospital  service,  for  special  duty  at  Havana, 
Cub',  for  the  purpose  of  making  bacteriologic.il  in- 
vestigations into  the  cause  and  nature  of  yellow  fever. 
These  officers  have  been  engaged  for  some  time  in 
laboratory  work  in  New  Orleans,  but  as  the  yellow 
fever  is  dying  out  in  the  South  it  is  deemed  best  that 
they  should  continue  the  investigation  at  a  place  where 
proper  material  may  be  obtained. 

The  Disinfection  of  Books. —  At  a  recent  meeting 
of  the  New  Y -rk  Library  Club,  Dr.  John  S.  Billings 
described  the  method  of  disinfection  of  books  by  for- 
malin vapor.  In  some  experiments  made  recently  at 
the  laboratory  of  the  University  of  Pennsylvania,  a 
saucer  of  formalin,  a  book  which  had  been  infected 
with  the  bacteria  of  diphtheria,  another  with  scarlet 
fever,  and  another  with  erysipelas,  were  placed  under 
a  bell   jar.     The  experiment  showed  that  one  cubic 


centimetre  of  formalin  to  three  hundred  cubic  centi- 
metres of  space  would  thoroughly  disinfect  any  book 
in  fifteen  minutes. 

Dr.  Frederick  G.  Novy,  of  Ann  Arbor,  has  been 
appointed  a  member  of  the  Michigan  State  Board  of 
health  to  fill  the  vacancy  created  by  the  resignation  of 
Dr.  G.  H.  Granger.  Dr.  N  vy  is  well  known  for  his 
excellent  work  in  physiological  chemistry,  much  of 
which  has  been  done  in  collaboration  with  Dr. 
Vaughan,  also  of  Ann  Arbor. 

A  Russian  Leprosy  Congress. — Russian  physicians 
are  agitating  the  question  nf  holding  a  national  con- 
ference on  leprosy  in  St.  Petersburg.  The  conference 
will  probably  be  held  early  in  1898,  but  the  precise 
date  is  not  yet  determined  upon. 

Dr.  Richard  K.  Macalester  has  been  appointed 
neurologist  to  the  Columbus  Hospital  of  this  city. 

The    "Right   Lungs"   and   the    "Left,  Lungs " 

are  the  names  of  two  quoit  teams  organized  among 
the  consumptive  patients  of  the  Cincinnati  Branch 
Hospital. 

The  Ninth  International  Congress  of  Hygiene 
and  Demography  will  be  held  in  Madrid  in  April, 
1898.  The  following  are  the  sections  in  the  depart- 
ment of  hygiene :  I.  Microbiology  applied  to  hygiene. 
2.  Prophylaxis  of  communicable  diseases.  3.  Medi- 
cal climatology  and  topography.  4.  Urban  hygiene. 
5.  Hygiene  of  alimentation.  6.  Hygiene  of  child- 
hood and  school  life.  7.  Hygiene  of  exercise  and  of 
labor.  8.  Military  and  naval  hygiene.  9.  Civil  and 
military  veterinary  hygiene.  10.  Sanitary  architec- 
ture and  engineering.  In  the  d  partment  of  demog- 
raphy there  will  be  three  sections:  i.  The  tv^chnique 
of  demographic  statistics.  2.  Statistical  results  and 
their  applications  to  demography.  3.  Dynamic  de- 
mography. 

Hospital  Stamps. — --The  issue  of  a  special  stamp  to 
be  sold  in  aid  of  the  Prince  of  Wales'  Hospital  Fund 
was  so  successful  in  its  recul  ;s  t'lis  y  ar  that  it  has 
been  decided  to  make  it  an  annual  institution.  Phi- 
latelists throughout  the  world  will  have  therefore  to 
decide  that  these  stamps  are  not  worth  collecting,  or 
else  submit  to  an  annual  tax  for  the  benefit  of  the 
London  hospitals. 

Indigent  Consumptives  in  the  Orange  Free  State. 
— The  president  of  the  Bloemfontein  Ben  jvolent  Soci- 
ety has  written  to  the  London  Thnes,  urgin  -  English 
medical  practitioners  not  10  send  impecunious  con- 
sumptives to  the  Orange  Free  State.  Bloemfontein, 
he  says,  has  a  high  and  well-deserved  reputation  as  a 
health  resort  for  consumptives,  but  it  is  not  a  place  in 
which  invalids  can  hope  to  gain  a  livelihood.  The 
population  is  under  seven  thousand,  and  quite  three 
thousand  out  of  that  total  are  blacks.  The  trade  of 
the  town  is  not  large,  and  living  is  very  expensive. 
Phthisical  persons  are  constantly  arriving  there,  hop- 
ing to  find  some  means  of  making  a  living,  but  find 
none,  and  soon  see  themselves  reduced  to  living  upon 
the  bounty  of  the  charitable.  Similar  ccm.plaints  are 
heard  from  time  to  time  in  certain  parts  of  our  own 


748 


MEDICAL    RECORD. 


[November  20,  1897 


countr}-.  Next  to  sending  a  person  in  the  last  stage 
of  pulmonary  tuberculosis  to  die  among  strangers  far 
from  his  home,  the  practice  of  sending  those  in  the 
early  stages  to  a  new  place  without  their  previously 
being  assured  of  a  means  of  support  is  most  repre- 
hensible and  cruel. 

Association  of  Assistant  Physicians  of  Hospitals 
for  the  Insane. — At  the  annual  meeting  of  this  soci- 
et)',  held  recently  at  Mendota,  Wis.,  the  following 
papers  were  presented :  "  Imbecility  an  Element  in 
Insanity,"  Dr.  R.  M.  Phelps;  "A  Case  of  Pure  Co- 
cainism,"  Dr.  George  Boody;  "The  Early  Diagnosis 
of  Paretic  Dementia,"  Dr.  V.  Podstaka;  "A  Report 
of  a  Case  of  Tubercles  of  Brain,  with  Clinical  His- 
tory and  Presentation  of  Gross  and  Microscopic  Speci- 
mens," Dr.  A.  F.  Lemke;  "Staff  Meetings  in  Hos- 
pitals for  the  Insane,"  Dr.  Irwin  H.  Neff;  "Report  of 
the  Ophthalmologist  at  Willard  State  Hospital,  for 
One  Year,"  Dr.  S.  F.  Mellen;  "Some  Notes  on 
Twenty-five  Cases  of  Paresis,"  Dr.  Samuel  Dodds; 
"  Alcohol  as  a  Factor  in  Producing  Insanity,"  Dr.  M. 
C.  Mackin;  "A  Classification  Based  on  Clinical 
Lines,  Combined  with  a  Tabulation  of  Clinical  Data," 
Dr.  R.  M.  Phelps;  "The  Advantages  of  Cottages  in 
the  Treatment  of  Certain  Cases,"  Dr.  Samuel  Dodds; 
"  Report  of  an  Autopsy,  with  Exhibition  of  Photo- 
graphs," Dr.  George  Boody;  "A  Syphilitic  Case,  with 
Post- Mortem,"  Dr.  Irwin  H.  Neff;  "Relation  of  Lab- 
oratory Methods  in  Psychology  to  Asylums,"  Prof.  W. 
O.  Krohn,  of  Kankakee  Hospital. 

Public  Charities  in  W-ishington. — The  district 
commissioners  will  ask  congress  to  appropriate  S134,- 
500  for  the  maintenance  of  the  public  hospitals  and 
dispensaries  in  Washington.  The  largest  item  in  the 
appropriation  asked  for  is  one  of  $57,500  for  the 
Freedman's  Hospital  and  Asylum. 

Beriberi  in  the  Isthmus. —  Several  hundred  negroes 
were  recently  imported  from  Sierra  Leone  to  work  on 
the  Panama  Canal,  to  take  the  places  of  the  Jamaicans, 
whose  work  had  not  been  satisfactory.  Soon  after  the 
arrival  of  the  Africans,  beriberi  broke  out  and  nearly 
one  hundred  of  them  have  died  of  the  disease. 

New  City  Lungs. — The  committee  on  small  parks, 
appointed  by  Mayor  Strong  in  June  to  advise  con- 
cerning the  creation  of  small  parks  in  the  citj'  below 
Fifty-ninth  Street,  recently  made  a  report.  A  number 
of  sites  were  recommended,  and  it  is  estimated  that 
all  the  proposed  parks  can  be  opened  within  four 
years,  at  a  cost  of  about  $3,500,000. 

A  Medical  Counterfeiter. — A  physician  of  Haral- 
son County,  Ga.,  was  recently  arrested  on  a  charge  of 
counterfeiting.  His  specialty  was  the  manufacture  of 
$10  gold  pieces. 

Smugglers  of  Drugs A  young  man  in  Rhode  Isl- 
and, the  owner  of  a  yacht,  was  recently  punished  for 
an  attempt  at  smuggling.  He  took  his  yacht  to  Hali- 
fax, Nova  Scotia,  last  summer,  and  while  there  pur- 
chased some  $2,000  worth  of  sulphonal  and  phenace- 
tin.  These  he  brought  to  this  countrj-,  and  then  found 
he  could  not  dispose  of  them  without  detection.     He 


finally  became  apprehensive  that  the  authorities  would 
find  him  out,  so  he  went  to  the  customs  officer  and 
confessed  to  having  the  drugs.  These  were  confis- 
cated, and  the  young  man  now  has  concluded  that 
crime  doesn't  pay. 

A  Physician  Accused  of  Grave  Robbery — A  phy- 
sician of  Chillicothe,  Ohio,  was  arrested  recently, 
charged  with  complicity  in  grave  robbery.  He  is  ac- 
cused of  having  directed  two  medical  students  to  a 
cemetery  where  a  body  they  wanted  to  steal  had  been 
buried,  and  then  of  carr}-ing  the  disinterred  body  in 
his  own  trunk  to  the  medical  college  in  Columbus. 

Newspaper  Medicine The  people  of  Omaha  are 

itching,  if  we  may  believe  the  reports  telegraphed  to 
the  daily  papers  of  this  city,  and  the  physicians  are 
said  to  be  puzzled  as  to  the  nature  of  the  affection. 
According  to  the  dispatches,  this  "  disease  develops  in 
small  eruptions  which  cover  the  body.  The  eruptions 
are  highly  inflamed  and  finally  scale  off  like  scurvy." 
We  may  well  believe  that  eruptions  which  "  scale  off 
like  scurvy"  puzzle  the  physicians,  who  state  that 
"  the  disease  is  caused  by  some  germ  that  settles  on 
the  skin,"  but  "this  is  all  they  can  say  about  it." 

Poisonous   Bullets  in  Cuba In   defiance   of  the 

laws  that  govern  civilized  warfare,  the  Spaniards  in 
Cuba,  so  the  Daily  Chronicle's  special  correspondent 
asserts,  have  been  using  brass-tipped  cartridges 
throughout  the  Cuban  war.  These  bullets  become 
coated  with  verdigris,  and  when  fired  from  a  rifle 
the  brass  spreads  out  raggedly  at  the  base,  so  that  it 
creates  a  deadly  wound.  With  a  limited  medical  staff 
and  an  absence  of  antiseptics,  such  wounds  lead  to 
gangrene  and  death.  In  short,  the  bullets  are,  to  all 
intents  and  purposes,  poisonous,  and  contravene  the 
Geneva  convention.  The  recent  capture  of  a  train 
has  placed  a  large  quantity  of  this  deadly  ammunition 
in  the  hands  of  the  insurgents,  who  are  now  enabled 
to  hoist  the  Spaniards  with  their  own  petard.  The 
nickel-covered  bullet  used  by  our  own  troops  in  the 
present  Indian  frontier  war  has  caused  such  terrible 
wounds  as  to  have  suggested  to  certain  unfriendly 
nations  that  we  have  adopted  explosive  bullets.  The 
effect,  however,  is  simply  due  to  the  ripping  open  of 
the  nickel  jacket  on  contact.  In  the  case  of  the 
Spaniards  no  attempt  is  made  by  General  Weyler  to 
cloak  the  fact  that  he  is  waging  a  war  of  extermina- 
tion, and  that,  in  characteristic  Spanish  fashion,  he 
considers  any  means  justified  that  may  conduce  to  that 
end. — Medical  Press. 

The  Last  Slap  at  the  Expert  Witness.— Experts 
are  having  a  hard  time  now.  Some  can  get  no  pay 
for  their  testimony,  others  are  accused  of  ignorance, 
and  others  again  of  venality,  but  it  was  reser\-ed  for  a 
St.  Louis  judge  to  recognize  a  "  professor"  of  phre- 
nology as  an  expert  in  insanity.  He  testified  that  the 
defendant  in  a  murder  trial  was  insane,  and,  upon 
being  questioned  as  to  the  reasons  for  his  conclusion, 
said  that  his  opinion  was  based  solely  upon  a  phreno- 
logical examination  made  by  passing  his  hands  over 
the  man's  head. 


November  20,  1897] 


MEDICAL    RECORD. 


749 


A  Jumble  of  Misinformation. — Under  the  caption 
"A  Caution  against  American  Medical  Qualifica- 
tions," our  esteemed  contemporary,  the  Medical  Press, 
says :  "  It  is  understood  that  the  American  Association 
of  Medical  Colleges,  which  has  been  heretofore  re- 
garded as  the  select  circle  among  the  numerous 
diploma-granting  institutions  of  the  new  world,  has 
agreed  to  recognize  the  studies  pursued  in  homoe- 
opathic and  eclectic  colleges  for  four  years  of  the 
necessary  period.  This  means  practically  an  abroga- 
tion of  the  education  test  altogether,  the  merits  of  the 
candidate  being  henceforth  determined  by  an  exami- 
nation of  which  no  one  knows  the  standard."  The 
crass  ignorance  of  foreigners  concerning  American 
institutions  would  be  a  matter  of  small  concern  to  us 
if  they  did  not  presume  to  draw  conclusions  from 
their  false  premises. 

Fining  a  Corpse. — A  coroner  in  Kansas  recently 
fined  a  corpse  twenty-five  dollars  for  carrying  a  con- 
cealed weapon.     The  latter  was  duly  confiscated. 

Obituary  Notes. — Dr.  James  Carey  Thomas  died 
at  Baltimore  on  November  9th,  at  the  age  of  sixty-four 
years.  He  was  graduated  from  Haverford  College 
and  later  from  the  medical  school  of  the  Universit}- 
of  Maryland  in  the  class  of  1854.  He  was  a  trustee 
of  Johns  Hopkins  University.  He  was  a  widely 
known  member  of  the  Society  of  Friends. — Dr.  E.  A. 
Frampton,  of  New  Plymouth,  Ohio,  died  September 
14th,  of  pulmonary  trouble,  aged  almost  fifty-nine 
years.  He  was  a  great  sufiferer  for  many  years.  He 
was  graduated  in  medicine  in  1869. — Dr.  George 
Allen,  superintendent  of  the  State  Hospital  at  Col- 
lins, N.  Y.,  died  in  Gowanda  on  November  14th,  of 
chronic  nephritis,  at  the  age  of  forty-four  years. 

The  Yellow-Fever  Visitation  is  practically  at  an 
end,  although  there  are  still  a  few  cases  reported  daily 
in  New  Orleans.  The  United  States  Marine  Hospital 
service  will  stop  the  disinfection  of  freight  in  a  few 
days.  Had  it  not  been  for  this  service  all  business, 
travel,  and  even  the  mails  would  have  been  stopped 
in  the  South  and  Southwest.  The  fever  has  finally 
been  rooted  out  of  the  Jewish  Home,  Poydras  Asylum, 
Orphans'  Home,  and  other  asylums  which  it  invaded 
notwithstanding  the  effort  to  keep  it  out.  All  quaran- 
tine guards  have  been  removed  from  houses,  but  the 
yellow-fever  flags  will  be  still  kept  up. 


HARRISON    ALLEN,    M.D. 


Dr.  Harrisox  .A.llen,  emeritus  professor  of  compara- 
tive anatomy  in  the  medical  school  of  the  University 
of  Pennsylvania,  died  suddenly  at  his  home  in  Phila- 
delphia, on  Sunday,  November  14th,  in  an  attack  of 
angina  pectoris.  Dr.  Allen  was  born  in  Philadelphia 
in  1841;  was  graduated  in  medicine  from  the  Univer- 
sity of  Pennsylvania  in  1861,  and  then  passed  a  year 
as  interne  at  the  Blockley  Almshouse.  He  entered 
the  army  upon  completing  his  service  at  the  Blockley, 
and  was  retired  as  surgeon  with  the  brevet  rank  of 
major  at  the  close  of  the  war.     In  1865  he  was  called 


to  the  chair  of  comparative  anatomy  and  zoology  in  the 
medical  school  of  the  University  of  Pennsylvania", 
which  he  held  for  thirty  years.  He  was  the  author  of 
numerous  monographs,  papers,  and  books  on  medical 
subjects.  At  the  Columbian  exposition  he  was  one  of 
the  judges  on  anthropology.  He  was  a  member  of  the 
Academy  of  Natural  Sciences,  the  Natural  History 
Society  of  Boston,  the  Pathological  Society  of  Phila- 
delphia, the  Biological  Society  of  Washington,  the 
Philadelphia  Count}'  Medical  Society,  the  American 
Laryngological  Association,  the  Neurological  Society 
of  Philadelphia,  the  Historical  Society  of  Texas,  and 
the  American  Association  of  Anatomy,  of  which  he 
was  one  of  the  founders.  He  was  visiting  surgeon  to 
the  Philadelphia  Hospital  from  1874  to  1878,  and 
was  assistant  surgeon  to  Will's  Eye  Hospital,  1860- 
70,  and  St.  Joseph's  Hospital,  1870-78.  He  was  also 
professor  of  anatomy  at  the  Philadelphia  Dental  Col- 
lege, 1866-78. 


THOMAS    WILLIAM    EVANS,    M.D.,    D.D.S., 


Dr.  T.  W.  Evans,  the  "  American  dentist"  of  Paris, 
died  at  his  home  in  that  city,  on  Sunday,  November 
14th,  of  angina  pectoris.  He  was  born  in  Philadel- 
phia about  seventy-four  years  ago,  the  exact  date  being 
uncertain,  as  one  of  his  peculiarities  was  a  reticence 
concerning  his  age  and  he  would  never  admit  that  he 
was  growing  old.  He  began  life  as  a  goldsmith's  ap- 
prentice, and  it  v,as  while  making  plates  for  artificial 
teeth  that  he  first  conceived  the  idea  of  adopting  den- 
tistry as  a  profession.  .  He  entered  the  Jefterson  Med- 
ical College  and  took  an  M.D.  degree  there  and  then 
studied  dental  science.  He  went  to  Paris  in  1846  to 
attend  a  conference  as  a  representative  of  American 
dental  surgery,  and  resolved  to  remain  in  that  city, 
where  he  speedily  achieved  a  great  reputation.  The 
president  of  the  French  Republic,  afterward  the  Em- 
peror Napoleon  III.,  was  among  his  earliest  friends 
and  patrons,  and  through  his  recommendation  Dr. 
Evans  soon  numbered  most  of  the  crowned  heads  of 
Europe  among  his  clientele.  He  was  instrumental  in 
getting  an  introduction  to  a  court  ball  for  the  Duchess 
of  Montijo,  who  there  met  the  Emperor  and  later  be- 
came the  Empress  Euge'nie.  He  again  rendered  a 
great  service  to  the  same  lady  by  conveying  her  se- 
cretly out  of  Paris  during  the  siege,  and  seeing  her 
safely  landed  in  I'lngland.  Dr.  Evans  accumulated  a 
large  fortune  by  the  practice  of  his  profession  and 
successful  real-estate  speculations,  and  he  announced, 
when  on  a  visit  to  this  country  a  few  months  ago,  that 
he  intended  to  devote  a  large  part  of  it  to  the  founda- 
tion of  a  college  of  dentistry.  His  wife  died  some 
time  ago  and  he  left  no  children.  Although  the 
greater  part  of  his  life  was  spent  in  Paris,  Dr.  Evans 
always  remained  a  patriotic  -American,  and  left  direc- 
tions that  he  should  be  buried  on  .American  soil.  He 
came  to  the  United  States  during  the  war  of  the  rebel- 
lion, organized  the  National  .Sanitary  Commission, 
made  an  investigation  of  the  conditions  here,  and  was 
instrumental  in  preventing  Napoleon  from  granting 
recognition  to  the  South.  Dr.  Evans  assisted  many 
struggling  students  in  life  and  buried  some  poor  ones 
or  their  wives  when  death  came.  He  established  the 
Lafayette  Home  in  Paris  for  unchaperoned  .American 
young  women  who  went  to  Paris  to  study.  .Although 
designed  for  his  countrywomen  particularly,  the  privi- 
leges of  the  home  were  extended  to  some  other  stu- 
dents. Altogether  about  one  hundred  could  be  ac- 
commodated in  the  home,  and  the  demand  was  such 
that  he  caused  the  erection  of  another  building,  the 
opening  of  which  was  to  have  been  celebrated  on 
Christmas  Day. 


750 


MEDICAL    RECORD. 


[November  20,  1897 


Sacicttj  'Reports. 

NEW    YORK    NEUROLOGICAL    SOCIETY. 

Stated  Meeting,  NoTctnber  2,  i8gj. 

C.  A.  Herter,  M.D.,  IN  THE  Chair. 

Thomsen's  Disease. ^ — Dr.  George  W.  Jacoby  exhib- 
ited a  typical  case  of  Thomsen's  disease.  The  patient, 
a  young  man,  had  been  referred  to  him  by  Dr.  Schwinn, 
of  West  Virginia,  with  a  correct  diagnosis.  The  pa- 
tient was  twenty-eight  years  of  age,  and  had  lived  in 
this  country  since  1884.  There  was  nothing  in  the 
family  history  bearing  upon  the  condition  especially, 
except  that  a  distant  cousin  was  said  to  have  walked 
stiffly  and  in  a  peculiar  manner  for  fifteen  years.  The 
patient  himself  had  always  been  delicate,  but  had  been 
as  active  as  other  boys.  He  had  had  typhoid  fever  in 
1889,  and  on  recovering  from  this  had  first  noticed  a 
cramp  in  the  legs.  After  a  little  it  was  found  that  he 
could  not  execute  movements  as  quickly  as  before.  In 
1893  he  first  sought  treatment.  For  the  past  year  or 
two  his  arms  and  hands  had  also  been  affected.  The 
condition  varied  considerably  at  different  times,  but 
was  apparently  not  affected  by  meteorological  changes. 
The  examination  showed  quick  reaction  of  the  eye 
muscles,  with  spasm  of  the  external  rectus;  cramp  of 
the  masseter  muscles  on  bringing  the  jaws  together 
forcibly;  no  involvement  of  the  pterygoids.  All  the 
muscles  of  the  upper  extremity  and  of  the  thorax  were 
involved;  indeed,  nearly  all  the  muscles  of  the  body. 
The  contraction  of  the  muscles  was  decidedly  tetanic, 
and  was  ver)-  marked  at  first ;  but  on  repeated  tests  it 
gradually  subsided.  The  electrical  examination 
showed  marked  myotonic  reaction,  and  also  a  wave- 
like appearance;  but  he  could  not  make  up  his  mind 
that  this  latter  phenomenon  consisted  of  a  series  of 
waves,  such  as  are  observed  in  water.  A  piece  of 
muscle  had  been  excised  from  the  biceps  and  also 
one  from  the  quadriceps,  but  they  had  not  yet  been  mi- 
nutely examined.  The  case  was  quite  characteristic  on 
account  of  the  marked  variations  occurring  from  time 
to  time.  The  speaker  said  that  in  an  article  published 
by  him  ten  or  more  years  ago,  he  had  taken  the  stand 
that  these  cases  were  probably  of  myopathic  origin, 
due  to  ^ome  congenital  defect  in  development;  but  in 
the  light  of  modern  investigation  he  was  now  disposed 
to  believe  that  some  central  cause  was  at  work — that 
there  was  a  functional  hereditary  derangement  of  the 
central  nervous  system — a  condition  of  lessened  resist- 
ance in  the  cells.  This  did  not  seem  to  him  a  strange 
assumption,  when  one  considered  the  well-known  idio- 
syncrasies exhibited  to  various  toxic  influences.  On 
the  theory  that  some  kind  of  toxaemia  was  at  the  foun- 
dation of  this  disease,  he  thought  the  observed  phe- 
nomena could  be  explained — at  least,  in  this  direction 
seemed  to  lie  the  possibility  of  solving  the  pathogeny 
of  this  class  of  cases.  This  patient  had  not  been 
affected  by  the  disease  until  eighteen  years  of  age; 
hence  there  was  no  propriety  in  calling  such  a  case 
"myotonia  congenita."  He  would  divide  these  cases 
into  three  classes,  viz.:  (i)  myotonia  congenita,  (2) 
myotonia  acquisita,  and  (3)  myotonia  transitoria. 

Dr.  Frederick  Peterson  asked  wiiy  a  theory  of 
causation  might  not  be  founded  upon  chemical  changes 
in  the  muscles.  Changes  in  the  structure  of  the  mus- 
cles, he  said,  were  known  to  arise ;  for  instance,  in 
connectioii  with  typhoid  fever. 

Dr.  Herter  thought  that  we  must  look  to  toxic 
agents  as  furnishing  at  least  a  clew  to  the  causation  of 
such  conditions.  The  peculiar  susceptibility  to  cer- 
tain types  of  poi-sons,  seen,  for  instance,  in  epilepsy, 
must  be  referred  to  peculiarities  of  the  central  nervous 


system.  He  would  agree  with  Dr.  Peterson  that  these 
cases  did  not  seem  to  be  of  central  origin,  and  that  it 
was  more  probable  that  they  arose  from  chemical 
changes  in  the  muscles.  To  study  this  subject  suc- 
cessfully, it  would  be  necessary  to  inquire  into  the 
condition  of  the  secretions  and  excretions  at  the  time 
of  the  onset  of  the  disease  and  not  after  it  had  become 
chronic. 

Pachymeningitis  Hemorrhagica  Interna  in  Chil- 
dren.— Dr.  C.  A.  Herter  said  that  internal  hemorrha- 
gic pachymeningitis  was  usually  considered  to  be  a 
very  rare  condition  in  children,  yet  one  German 
observer  had  found  it  in  about  seventeen  per  cent,  of 
his  autopsies.     The  following  cases  were  reported : 

Case  I.- — A  female  child,  five  and  one-half  months 
old,  was  admitted  to  the  Babies'  Hospital  on  May  15, 
1897,  vi'ith  an  entirely  negative  family  history.  The 
child's  illness  had  begun  one  month  previously,  with 
persistent  vomiting.  The  head  was  of  normal  shape 
and  the  fontanelles  were  not  bulging.  There  was  a 
soft  spot  over  one  parietal  bone.  The  child  had  no 
teeth.  On  the  fifth  day  after  admission  tremor  and 
nystagmus  developed.  Nine  days  after  admission 
there  was  a  general  convulsion,  in  which  the  mouth 
deviated  to  the  left.  Cyanosis  was  a  feature  of  the 
convulsion.  A  second  one  occurred  in  ten  hours, 
.-^fter  these  seizures  the  fontanelles  were  sunken.  The 
child  now  became  semicomatose,  and  died  after  a  few 
days. 

The  autopsy  showed  the  presence  of  hemorrhagic 
pachymeningitis,  fibrino-purulent  pleurisy,  pulmonary- 
congestion,  fatty  liver,  and  nephritis.  Along  the  su- 
perior longitudinal  fissure,  over  the  entire  base  and 
over  the  island  of  Reil  on  both  sides,  w-as  a  membrane 
covering  the  pia.  The  ventricles  were  normal  in  size 
and  contained  about  one  drachm  of  hemorrhagic  fluid. 
There  was  fluid  blood  in  all  the  sinuses.  The  cervi- 
cal cord  showed  the  same  conditions.  L'nder  the  mi- 
croscope the  right  occipital  region  showed  the  pia  at- 
tached to  the  cortex  in  many  places,  and  there  was  a 
splitting  up  of  the  membrane  overlying  the  cortex  into 
two  or  more  layers.  The  inner  layer  was  infiltrated 
with  small  round  cells.  The  outer  membranous  layers 
consisted  of  small  round  cells,  fibroblasts,  and  con- 
nective-tissue fibres.  The  island  of  Reil  showed  the 
same  condition,  but  much  more  marked,  and  about  the 
same  condition  was  present  over  the  cerebellum.  In 
the  spinal  cord  there  were  only  slight  traces  of  hemor- 
rhage. 

Case  II.  —  Female  infant,  colored,  twenty-two 
months  old.  The  child  had  been  nursed  for  seven 
months.  It  had  never  walked  or  stood  alone,  and  was 
markedly  rachitic.  The  first  two  months  in  the  hos- 
pital were  marked  by  slight  loss  in  weight  and  consid- 
erable prostration.  In  October,  1897,  the  child  was 
readmitted,  with  the  statement  that  she  had  been  well 
up  to  three  days  before,  at  which  time  she  had  had 
four  convulsions,  followed  by  three  more  the  next  day. 
The  general  condition  was  very  bad.  The  hands  and 
feet  were  in  a  position  of  persistent  flexor  contraction, 
characteristic  of  tetany.  The  knee  jerks  were  unob- 
tainable :  tlie  fontanelles  were  bulging.  There  was 
slight  but  var}^ing  rigidity  of  the  muscles  at  the  back 
of  the  neck.  Hloody  mucous  diarrhcta  was  present, 
and  the  child  died  comatose. 

The  autop.sy  showed  pachymeningitis  hemorrhagica 
interna,  broncho-pneumonia,  and  acute  and  chronic 
ulcerative  colitis.  Over  the  right  side  of  the  brain 
was  a  recent  blood  clot,  covering  the  entire  hemisphere, 
and  over  the  left  occipital  lobe  the  inner  surface 
of  the  dura  was  covered  with  a  membrane  extending 
from  the  superior  longitudinal  fissure  on  either  side. 
The  pia  was  congested.  The  ventricles  and  brain 
substance  were  apparently  normal.  .\11  the  sinuses 
were  filled  with  recent  clots.     The  microscopical  ex- 


November  20,  1897] 


MEDICAL    RFXORD. 


75  r 


amination  showed  thickening  of  the  pia  over  the  right 
temporo-sphenoidal  lobe,  and  the  vessels  of  the  pia 
were  thickened.  There  was  also  a  thick  membrane 
splitting  up  into  layers,  as  in  the  other  case.  There 
were  numerous  small  blood-vessels,  and  hemorrhages 
had  occurred  into  the  meshes  of  the  membrane.  In 
places  there  were  aggregations  of  small  round  cells 
undergoing  fragmentation.  They  were  found  chiefly 
in  the  superficial  layers  of  the  membrane.  In  the 
dura  the  fibres  were  separated  from  each  other  by  se- 
rous infiltration,  and  the  dura  was  covered  with  a 
membrane  similar  to  that  already  described.  In 
places  there  was  very  extensive  pachymeningitis. 

It  was  at  about  five  months  of  age,  the  speaker  said, 
that  this  disease  was  especially  frequent.  The  ma- 
jority of  these  infants  were  badly  nourished,  many  of 
them  being  subjects  of  rachitis  or  of  chronic  colitis. 
The  new  membrane  must  be  regarded  as  originating 
from  proliferation  of  the  dural  endothelial  cells.  In 
some  cases  there  was  little  inclination  to  hemorrhage. 
The  membrane  was  very  variable  in  thickness;  some- 
times it  reached  a  thickness  of  two  or  three  lines.  It 
was  especially  prone  to  occur  in  the  basal  fossa;. 
There  seemed  no  good  reason  for  thinking  that  the 
locality  of  the  pigmentation  indicated  that  the  layer  of 
blood  originated  from  the  inner  surface  of  the  dura. 
On  the  other  hand,  there  was  no  conclusive  proof  of 
the  old  notion  that  the  disease  was  of  inflammator}- 
origin.  It  was  so  common  to  find  severe  into.xications 
without  such  lesions  that  the  intoxication  theory  did 
not  seem  to  him  tenable.  It  was  apparently  impossi- 
ble to  recognize  the  condition  until  the  hemorrhage 
occurred,  and  even  then  it  was  extremely  difficult  to 
make  a  positive  diagnosis.  Slight  cerebral  symptoms 
were  probably  masked  in  these  very  young  and  usually 
marantic  children.  The  hemorrhage  was  probably 
more  often  unilateral,  and  the  usual  symptoms  pres- 
ent were  rigidity,  hemorrhage,  and  coma.  Paralysis 
was  rarely  noted.  The  pyrexia  was  usually  less  than 
in  meningitis,  but  these  cases  w'ere  so  commonly  com- 
plicated with  other  diseases  that  the  range  of  temper- 
ature was  very  variable.  He  did  not  think  there  was 
any  symptom  or  combination  of  symptoms  in  hemor- 
rhagic internal  pachymeningitis  which  might  not  be 
encountered  in  any  acute  infection  without  any  cerebral 
affection  being  present;  but  whenever  unilateral  rigid- 
ity and  convulsions,  with  deepening  stupor,  were  pres- 
ent in  a  cachectic  or  rachitic  child  under  one  year  of 
age,  we  should  think  of  that  diagnosis.  It  was  proba- 
ble that  relatively  slight  traumatisms  of  the  head  might 
occasion  rupture  of  vessels  in  the  highly  vascular 
membrane.  This  gave  these  cases  a  certain  medico- 
legal importance. 

Dr.  Peterson'  remarked  that  the  condition  was 
interesting  to  him  because  of  the  possibility  of  its 
being  found  occasionally  in  infantile  cerebral  palsy. 

Dr.  Herter  said  that  he  was  inclined  to  think  that 
these  membranes  were  considerably  more  frequent  than 
one  would  suppose  from  the  literature.  It  was  quite 
possible  to  overlook  the  presence  of  the  membrane  if 
it  were  not  decidedly  vascular. 

The  Pathology  and  Morbid  Anatomy  of  Hunting- 
ton's Chorea,  with  Remarks  on  the  Development 
and  Treatment  of  the  Disease. — Dr.  Jo.seph  C'ollins 
said  that  the  neurologist  frequently  encountered  knotty 
problems,  and  among  these  none  had  the  secret  of  its 
genesis  more  carefully  concealed  than  the  hereditary 
degenerative  diseases.  The  pathogenesis  of  the  acute 
inflammatory  diseases  of  the  nervous  system  was  an 
open  book,  but  the  degenerative  diseases  were  discour- 
agingly  slow  in  yielding  the  mystery  of  their  being. 
This  was  especially  true  of  such  degenerative  diseases 
as  the  hereditary  ataxias,  choreas,  and  dystrophies. 
The  status  of  the  original  lesion  could  not  always  be 
inferred  from  a  consideration  of  the  lesion  found  at 


the  time  of  death,  and  this  was  particularly  true  if  the 
disease  had  existed  a  great  number  of  years.  No  one 
could  do  much  laboratory  work  on  the  central  nervous 
system  of  individuals  who  had  succumbed  to  degener- 
ative nervous  diseases  of  long  duration,  without  hav- 
ing forced  upon  him  the  fact  that  there  are  certain 
abnormalities  of  the  circulatory  system — varying  de- 
grees of  degeneration  of  vessels,  change  in  the  size  of 
the  lymph  spaces,-and  relative  disproportion  of  glia 
tissue  to  the  parenchyma — which  occur  with  all  degen- 
erative diseases,  considered  entirely  apart  from  their 
causation.  He  felt  convinced  that  such  changes  were 
very  often  secondary,  and  had  no  other  significance 
than  as  evidences  of  protracted  disturbance  of  nutri- 
tion, and  that  this  nutritional  depravity  was  the  result 
of  the  existence  of  the  original  lesion.  There  was 
nothing  more  certain  than  the  occurrence  of  glia  pro- 
liferation in  all  slowly  progressing  destructive  lesions 
of  the  ner\'ous  system,  but  nothing  could  be  more  mis- 
leading than  to  consider  this  glia  overgrowth  to  be 
primary  and  the  changes  in  the  parenchyma  secondary. 

Huntington's  chorea.  Dr.  Collins  said,  was  a  com- 
paratively rare  disease  and  of  rather  recent  recogni- 
tion ;  hence  the  reports  made  upon  its  pathology  had 
not  been  unifonn.  The  discrepancies  were  apparently 
the  resultant  of  the  varying  points  of  view  of  different 
observers.  In  studying  the  nervous  system  in  cases 
of  Huntington's  chorea,  it  was  scarcely  justifiable  to 
maintain  that  all  the  morbid  conditions  were  inherent 
to  the  disease,  for,  as  has  been  said,  many  of  them 
might  be  the  consequence  of  prolonged  interference 
with  nutrition.  Although  the  present  study  of  the 
patholog)^  of  the  disease  was  upon  an  individual  who 
had  had  the  disease  for  a  considerable  time,  it  was 
compared  with  a  case  of  much  shorter  duration  reported 
by  Dr.  C.  L.  Dana.  A  study  of  these  two  cases,  he  felt 
confident,  would  go  far  toward  establishing  the  morbid 
anatomy  and  hinting  at  the  pathogenesis. 

His  patient  was  a  man,  fifty-five  years  of  age,  who 
had  married  in  early  manhood,  and  who  was  the  father 
of  three  children — all  of  them  giving  evidence  of 
neuropathic  inheritance.  The  known  duration  of  the 
disease  in  his  case  was  ten  years.  At  the  beginning 
the  hands  only  were  aftected,  but  in  the  last  years  the 
lower  extremities  were  also  involved.  The  mind 
remained  in  fairly  good  condition  up  to  about  three 
years  before  his  death,  when  he  began  to  have  suspi- 
cions about  his  relatives  and  friends,  and  became 
forgetful  and  suicidal.  His  speech  was  so  imperfect 
that  in  the  last  years  of  his  life  he  was  understood  with 
difficulty.  Dr.  Collins  had  seen  him  for  the  first  time 
a  few  days  before  his  death.  He  then  had  a  tempera- 
ture of  105^  F.,  and  it  remained  at  about  this  point 
until  the  end.  The  movements  were  ver}'  severe  and 
incessant,  except  during  sound  sleep,  although  even 
then  they  frequently  awakened  him.  He  was  quite 
conscious,  but  made  no  response  to  questions.  The 
cause  of  death  seemed  to  be  exhaustion  and  high 
temperature.  The  disease  was  traceable  to  the  mater- 
nal grandfather — an  Irishman — who  had  three  chil- 
dren, two  of  whom  were  affected  with  the  disease. 
One  of  these  was  the  mother  of  this  patient,  and  of 
her  seven  children  five  were  afflicted  with  the  disease. 
The  other  daughter  had  two  children,  one  of  whom 
became  choreic.  In  three  generations  there  had  been 
no  less  than  nine  affected,  and,  when  it  was  considered 
that  many  of  these  children  died  in  infancy,  the  num- 
ber of  cases  that  had  developed  was  surprisingly  great. 

At  the  autopsy,  on  opening  the  skull,  the  dura  was 
considerably  adherent,  the  diploe  dense,  and  the  Pac- 
chionian depressions  were  marked.  The  brain  had  a 
wet  appearance,  as  did  also  the  cord.  The  pia  was  not 
adherent  to  the  brain.  The  convolutions  of  the  ante- 
rior pole  of  the  brain  were  very  small,  and  the  entire 
encephalon  weighed  forty-three  and  one-half  ounces. 


■52 


MEDICAL    RECORD. 


[November  20.  1897 


The  dura  was  intimatel)'  adherent  to  the  spinal  column. 
The  principal  fissures  were  somewhat  wider  and  shal- 
lower and  shorter  than  in  the  normal  brain,  but  there 
was  nothing  pointing  to  defective  convolutions.  The 
average  thickness  of  the  gray  matter  was  uniformly 
less  than  in  the  normal  brain  cortex,  but  this  thinness 
could  not  be  attributed  here  to  age.  An  examination 
of  the  pons  and  medulla  oblongata  did  not  show  any 
marked  variations  from  the  normal,  but  the  changes 
were  more  noticeable  lower  down.  Microscopical 
changes  were  not  confined  exclusively  to  the  Rolandic 
region,  but  the  process  here  was  more  advanced.  The 
specimens  were  stained  by  various  methods  and  care- 
fully examined.  The  macroscopical  changes  were 
briefly  as  follows:  i.  Thinness  and  atrophy  of  the 
cortex.  2.  The  mottled,  streaked  appearance  and 
cribriform  state  on  cross-section  of  the  brain  in  the 
fresh  state,  due  to  diminution  in  number  and  in  health 
of  the  ganglion  cells,  and  to  the  increased  perivascular 
and  pericellular  spaces  and  increased  patency  of 
blood-vessels.  The  microscopical  changes  were:  i. 
A  decay  or  slowly  progressive  degeneration  of  the 
ganglion  cells  of  the  cortex  throughout  the  brain, 
especially  of  the  two  deepest  layers,  the  layers  of  large 
pyramids  and  polymorphous  cells.  This  cell  death 
was  particularly  evident  in  the  Rolandic  region,  very 
much  less  so  in  the  anterior  pole  of  the  brain,  and 
incomparably  less  in  the  posterior  pole.  2.  Increase 
of  glia  tissue,  but  not  sufficiently  prominent  to  consti- 
tute sclerosis,  the  conspicuous  increase  being  about 
blood-vessels  and  ganglion  cells.  3.  Enlargement  of 
the  pericellular  spaces  and  distention  of  the  pericellu- 
lar spaces.  4.  Slightly  diseased  blood-vessels,  con- 
sisting principally  of  a  proliferation  of  the  nuclei  of 
the  adventitia  and  a  thickening  of  the  intima.  This 
involvement  of  the  vessels  was  not  regular  or  symmet- 
rical, but  showed  itself  in  certain  sections  of  vessels 
only.  5.  Relative  paucity  of  the  meduUated  fibres  of 
the  cortex.  In  short,  it  might  be  said  that  the  lesion 
was  a  chronic  parench3Tnatous  degeneration  of  the 
cortex,  with  consecutive  and  secondary  changes  in  the 
interstices,  the  brunt  of  the  disease  having  been  borne 
by  the  motor  regions.  There  was,  in  consequence,  a 
degeneration  of  the  pyramidal  tracts  in  the  spinal  cord. 
In  Dr.  Dana's  case  the  central  convolutions  suffered 
most,  and  the  process  occurred  in  patches  throughout 
the  affected  cortex.  There  was  nothing  to  justify  the 
opinion  that  it  was  an  inflammation:  the  process  was 
evidently  one  of  degeneration. 

In  connection  with  the  treatment.  Dr.  Collins  said 
that  he  desired  to  emphasize  the  necessity  for  delaying 
the  advent  of  the  disease  in  those  v.ho  had  a  hereditary 
tendency  to  it,  and  also  to  emphasize  the  folly  of 
tenotomy  of  the  eye  muscles — a  method  of  treatment 
now  being  carried  out  upon  one  of  these  unfortunate 
individuals  in  this  city,  with  a  promise  of  a  cure.  If 
we  wished  to  influence  the  course  of  hereditary  chorea 
after  it  had  once  become  manifest,  it  would  be  neces- 
sary to  administer  in  the  largest  possible  doses  con- 
sistent with  life  whatever  drug  was  selected,  and  to 
maintain  this  medication  for  a  long  time. 

Dr.  OiN'fK  said  that  he  had  been  present  at  the 
autopsy  in  the  case  reported  in  the  paper,  and  had 
been  especially  impressed  with  the  general  narrowing 
of  the  gyri — a  general  atrophy.  On  section,  the  mot- 
tled appearance  of  the  cortex  had  been  most  striking, 
but  the  cribriform  appearance  produced  by  the  enlarge- 
ment of  the  perivascular  spaces  was  also  worthy  of 
note.  The  general  apix;arance  of  the  brain  resembled 
very  closely  that  of  a  brain  from  a  case  of  general 
paresis.  The  microscope  confirmed  the  macroscopical 
appearances,  although  the  changes  were  not  so  marked 
as  one  would  have  expected  from  tiie  gross  appearance. 
The  cell  changes  were  of  the  atrophic  order.  The 
characteristic  feature  was  the  accumulation  of  neuroglia 


cells  in  the  pericellular  and  perivascular  spaces.  HLs 
impression  was  that  this  accumulation  was  due  to  a 
secondary  process  folPowing  atrophy  of  the  cells.  The 
disease  was  evidently  a  degenerative  one,  originating 
in  the  parenchyma  of  the  brain,  and  not  in  the  inter- 
stitial tissue. 


NEW     YORK 


MEDICO  -  CHIRURGICAL 
.SOCIETY. 


Adjourned  Meeting,  J^ovember  S,  iSgj. 
].  Blake  White,  M.D.,  President. 

A  Plea  for  Rational  Therapeutics  in  Diphtheria. — 

Dr.  a.  E.  Bieser  read  a  paper  with  this  title.  He  said 
that  a  proper  working  hypothesis  could  not  be  based 
on  either  bacteriology,  pathology,  or  etiology  alone, 
but  upon  a  sensible  combination  of  all  three;  and 
until  such  a  hypothesis  was  formulated  no  investiga- 
tion of  diphtheria  could  be  said  to  be  exactly  scien- 
tific. The  diphtheria  bacillus  might  be  the  specific 
cause  of  what  was  known  as  Klebs-Loettler  infection, 
but  it  certainly  was  not  the  cause  of  the  physiological 
inflammation  of  the  throat  which  furnished  that  point 
of  least  resistance  which  was  absolutely  necessary  for 
the  development  of  the  bacillus  and  its  toxin. 

The  Specific  Nature  of  Diphtheria. — In  the  first 
place  the  Klebs-Loeffler  bacilli  did  not  affect  the 
healthy  throat,  because  of  the  absence  of  a  nidus  of 
development,  whatever  that  might  be.  That  a  perver- 
sion of  nonnal  physiology  was  necessary  to  start  up 
the  Klebs-Loeffler  bacillus  was  generally  admitted: 
hence  this  bacillus  could  not  cause  the  disease,  and 
it  was  perfectly  reasonable  to  believe  that  any  treat- 
ment that  restored  or  partially  restored  tlie  perverted 
function  might  do  as  much  good  as  a  specific  plan  of 
medication,  such  as  that  with  antitoxin.  It  was  known 
that  healthy  secretions  were  capable  of  disposing  of 
even  pathogenic  bacteria,  and  bacteriologists  admitted 
that  the  healthy  throat  was  in  itself  a  barrier  against 
the  invasion  of  the  Klebs-Loeffler  bacillus.  If  this 
was  true,  our  effort  should  not  be  to  get  rid  of  the 
disease  by  the  use  of  diphtheria  antitoxin  and  germi- 
cides, but  by  stimulating  the  normal  secretions  and 
so  favoring  the  removal  of  the  pathogenic  germs. 
Numerous  cases  of  clinical  diphtheria  had  been  re- 
ported by  competent  observers  in  which  Klebs-Loef- 
fler bacilli  were  absent — cases  v.-hich  were  diphtheritic 
in  every  respect,  even  to  the  extent  of  causing  paral- 
ysis and  death.  Indeed,  Loeffler  himself  had  stated 
that  there  could  be  true  clinical  diphtheria  without 
the  presence  of  Klebs-Loeffler  bacilli.  Jacobi,  in 
1895,  had  stated  that  he  doubted  if  there  might  not  be 
such  a  thing  as  a  streptococcus  diphtheria,  and  Bow- 
ker  in  the  same  year  had  said  that  the  streptococcus 
infection  associated  with  diphtheria  was  just  as  viru- 
lent as  the  infection  with  the  Klebs-Loeffler  bacilli. 
It  had  seemed  to  him  that,  just  as  in  tuberculosis,  we 
had  a  distinct  disease  to  treat  independently  of  the 
bacillary  or  non-bacillary  infections  which  modify  the 
progress  of  the  disease,  so  in  diphtheria,  independently 
of  specific  infection,  there  was  a  distinct  physiological 
disturbance  antedating,  as  well  as  following,  the  in- 
fection. If  the  specific  hypothesis  were  not  in  accord 
with  all  the  facts,  how  could  a  specific  plan  of  medica- 
tion, based  upon  such  a  hypothesis,  meet  all  the  re- 
quirements of  the  bedside  treatment  of  diphtlieria? 
Antitoxin  might  overcome  the  specific  toxaemia,  but  it 
was  not  inconceivable  that  at  tlie  same  time  the  physi- 
ological processes  might  be  so  interfered  with  as  in 
itself  to  constitute  a  danger.  A  case  was  cited  in 
which  the  patient  was  treated  with  antitoxin  and  re- 
covered from  the  diphtheria,  but  died  of  nephritis 
originating,  as  it  seemed  to  him,  from  the  introduc- 
tion of  the  specific  remedy  into  the  system. 


November  20,  1897] 


MEDICAL    RECORD. 


753 


A  Dual  Working  Hypothesis. — He  based  his  treat- 
ment upon  a  dual  hypothesis,  as  opposed  to  the 
specitic  or  bacteriological  one.  This  hypothesis 
comprised  two  entirely  different  parts,  viz.:  (i)  the 
numerous  and  varied  perversions  of  physiological 
functions,  called  "the  disease;"  and  (2)  the  Klebs- 
Loeffler  infection  and  the  other  infections.  It  was 
important  to  remember  that  about  the  time  the  phy- 
sician was  called  in  to  treat  diphtheria  it  might  be 
something  more  than  a  Klebs-Loeffler  infection — the 
lungs,  kidneys,  and  blood  might  be  already  infected 
with  streptococci.  In  addition  to  the  pathological 
lesion  in  the  throat,  the  kidneys  might  be  the  seat  of 
cloudy  swelling  or  fatty  metamorphosis,  and  the  dis- 
turbances of  the  vital  functions  might  be  so  great  that 
all  the  antitoxin  in  the  world  would  not  cure  the  dis- 
ease, though  it  might  cure  the  Klebs-Loeffler  infection. 

Treatment. — He  was  not  one  of  those  who  believed 
that  when  one  had  injected  antito.xin  diphtheria  had 
been  treated  and  that  there  was  nothing  else  to  be 
done.  In  some  cases  of  diphtheria,  especially  in 
mixed  infections,  and  when  the  renal  function  was 
already  impaired,  it  would  be  far  better  if  the  injec- 
tion of  antitoxin  was  entirely  dispensed  with.  The 
particular  patient  must  be  treated  rather  than  the  in- 
fection. As  healthy  secretions  inhibited  bacterial  in- 
vasion, our  effort  should  be  to  stimulate  this  action  of 
the  secretions.  Three  remedies  seemed  to  act  in  this 
way,  viz.:  (i)  ipecac;  (2)  iron;  and  (3)  mercury. 
Ipecac  increased  the  activity  of  the  secretions,  and 
iron  removed  the  congestion  in  the  throat  and  so 
favored  normal  secretion ;  but  his  sheet  anchor  was 
mercury.  In  his  experience,  this  drug,  in  combina- 
tion with  whiskey  and  iron,  had  cured  any  Klebs- 
Loeffler  toxaemia  that  the  antitoxin  could  cure,  pro- 
vided it  was  given  early  enough  and  in  sufficient  doses. 
He  did  not  give  it  as  a  germicide,  but  because  it  was 
one  of  the  best  glandular  stimulants  of  the  epithelial 
structures  at  our  command.  It  was  also  a  powerful 
hepatic  stimulant,  and  a  most  excellent  diuretic.  In 
his  hands,  it  had  yielded  better  results  in  the  same 
class  of  cases  than  had  antitoxin.  In  cases  of  mixed 
infection,  in  which  after  the  antitoxin  injection  the 
renal  function  had  been  entirely  in  abeyance,  or  this 
already  impaired  renal  function  had  been  still  further 
interfered  with,  this  treatment  had  caused  a  free  action 
of  the  kidneys,  in  marked  contrast  to  what  was  ob- 
served in  cases  in  which  antitoxin  alone  had  been 
used. 

Author's  Statistics Of  2;^  cases  treated  in  tene- 
ment practice  without  antitoxin,  the  Klebs-Loettler 
bacilli  were  found  in  80  per  cent.,  and  all  but  two 
were  fatal.  The  two  fatal  cases  had  not  been  .seen 
until  the  disease  had  lasted  for  a  number  of  days,  and 
they  terminated  in  from  seven  to  fourteen  days  later. 
He  had  treated  in  private  practice  a  total  of  1 1 5  cases 
of  diphtheria,  with  6  deaths,  or  a  mortality  of  about  5 
per  cent.  Of  the%e  115,  104  were  non-laryngeal,  and 
of  these  3  were  fatal,  giving  a  mortality  of  3  per  cent. 
There  were  ii  cases  of  laryngeal  diphtheria,  with  3 
deaths,  or  a  mortality  of  27  per  cent.  Of  the  115,  70 
cases  should  have  recovered  under  any  rational  treat- 
ment, as  the  croupous  inflammation  was  not  accom- 
panied by  a  deep  ulcerative  process.  Twenty-nine 
cases  were  severe,  a  deep  ulcer  being  left  after  the 
membrane  had  come  off.  Five  were  septic  naso- 
pharyngeal diphtherias.  The  eleven  laryngeal  cases 
required  intubation.  The  cases  reported  were  all 
clinical  diphtheria,  yet  under  his  treatment  the  mor- 
tality had  been  only  5  per  cent,  without  antitoxin. 
His  results  corresponded  well  with  those  of  Dr.  Jacobi 
and  Dr.  Fruitnight.  His  treatment  consisted  in  giv- 
ing one-fort)'-eighth  to  one-thirty-second  of  a  grain  of 
bichloride  of  mercury  every  hour,  day  and  night,  for 
forty-eight  hours,  and  then  every  two  or  three  hours 


for  two  or  three  days  more.  Five  minims  of  the  tinc- 
ture of  the  chloride  of  iron  was  given  in  the  same  way 
as  the  bichloride,  only  fifteen  minutes  later,  and  con- 
tinued somewhat  longer.  By  the  fourth  day  the  de- 
sired effect  from  the  bichloride  of  meicury  would  be 
produced,  i.e.,  very  slight  salivation.  Half  an  hour 
after  the  ingestion  of  the  iron,  two  drachms  of  whis- 
key was  given,  diluted  with  water,  and  this  was  also 
kept  up  hourly.  With  this  tripod  of  drugs  he  had  suc- 
ceeded in  saving  ninety-seven  per  cent,  of  the  laryn- 
geal and  seventy -two  per  cent,  of  the  pharyngeal  cases. 
In  the  laryngeal  cases  it  had  been  his  practice  to  give 
forty  grains  of  calomel  by  sublimation,  every  two  or 
three  hours.  This  he  considered  to  be  the  treatment 
of  the  disturbance  of  throat  physiology. 

Gives  Mercury  and  Whiskey  up  to  the  Physi- 
ological Effect. —  As  regards  the  treatment  of  the  other 
conditions  present,  of  course  absolute  rest  must  be 
insisted  upon.  Half  an  ounce  to  four  ounces  of  whis- 
key should  be  given  daily,  the  dose  being  doubled  even 
if  the  pulse  remained  weak.  The  whiskey  must  be  given 
until  the  physiological  effect  was  obtained — flushing 
of  the  cheeks,  odor  of  alcohol  on  the  breath,  and  the 
desired  effect  on  the  pulse — no  matter  what  the  dose, 
but  it  must  be  given  well  diluted  with  water  or  milk 
to  prevent  its  emetic  action.  Children  stand  large 
doses  of  alcohol,  as  they  do  mercurv,  in  diphtheria. 
In  older  children  affected  with  nasal  diphtheria  it 
might  be  wise  to  irrigate  the  throat  with  decinormal  salt 
solution,  but  in  younger  children,  who  would  always 
resist,  such  treatment  did  more  harm  than  good.  The 
abstinence  from  injudicious  local  treatment  of  the  nose 
and  throat  had  had  a  great  influence  in  diminishing 
the  absolute  death  rate  from  diphtheria  in  regions 
where  antitoxin  was  now  employed.  Such  abstinence 
would  reduce  the  absolute  mortality  from  diphtheria 
anywhere,  irrespective  of  the  use  of  diphtheria  anti- 
toxin. In  order  to  combat  the  Klebs-Loeffler  infec- 
tion, if  the  case  was  seen  early  enough,  antitoxin 
might  be  administered,  but  if  not  seen  until  the  sixth 
or  seventh  day,  and  especially  if  there  was  marked 
sepsis  or  marked  impairment  of  the  renal  function,  he 
would  not  use  it.  These  cases  usually  had  suppres- 
sion of  urine,  and  terminated  fatally,  although  per- 
haps this  was  not  due  to  the  antitoxin.  In  five  cases 
of  badly  septic  nasopharyngeal  diphtheria  the  treat- 
ment above  outlined  saved  two,  although  both  had 
been  declared  by  consultants  to  be  hopeless.  In  the 
one  hundred  and  fifteen  cases  there  was  not  a  sin- 
gle instance  of  mercurial  poisoning;  on  the  contrary, 
he  had  had  the  greatest  difficulty  in  salivating  these 
children.  The  most  that  he  could  do  was  slightly  to 
increase  the  salivary  secretion  after  two  or  three  days, 
and  this  increase  would  disappear  in  twenty-four  hours 
or  so.  There  was  no  swelling,  tenderness  of  the  gums, 
or  loosening  of  the  teeth. 

Proof  of  Specific  Nature  of  Diphtheria. — Dr.  VVil- 
LiA.M  H.  Tho.msox  said  that  the  paper  was  an  illustra- 
tion of  how  endless  might  be  the  discussions  brought 
out  by  this  subject  of  diphtheria.  The  word  "spe- 
cific" as  applied  to  disease  could  be  used  correctly 
only  in  infections.  It  was  difficult  to  think  of  a  spe- 
cific disease  that  was  not  an  infection.  He  had  been 
deeply  interested  in  the  specific  nature  of  infectious 
disea.ses  from  the  very  beginning  of  his  medical  ca- 
reer, and  the  second  medical  paper  that  he  had  pub- 
lished had  been  on  "  The  Distinction  between  a  Virus 
and  a  Poison."  In  this  he  had  directed  attention  to 
the  fact  that  the  action  of  a  poison  necessarily  de- 
pended upon  quantity,  whereas  with  a  virus,  although 
quantity  was  not  an  essential  element,  a  certain  time, 
called  the  period  of  incubation,  or,  better,  "germina- 
tion," was  required  for  the  development  of  the  char- 
acteristic symptoms.  Another  element  of  infection 
was  reproduction — a  process  which  could  not  be  ex- 


754 


MEDICAL    RECORD. 


[November  20,  1897 


plained  either  physically  or  chemically — and  which 
was  observed  only  in  the  animal  kingdom.  At  the 
time  that  he  had  presented  to  the  County  Medical  So- 
ciety the  communication  referred  to,  it  had  been  met 
with  a  howl  of  derision,  and  for  years  he  had  been 
ridiculed  for  teaching  that  these  communicable  dis- 
eases were  dependent  upon  organic  agents.  His  es- 
pecial reason  for  believing  this  doctrine  was  their 
markedly  specific  character. 

The  Characteristic  Pathological  Lesions  of  Diph- 
theria.— By  "  specific'"  was  meant  that  a  disease  which 
was  communicable  could,  in  an  infected  subject,  pro- 
duce e.xactly  the  same  disease  in  its  clinical  features 
in  a  healthy  subject  when  communicated  to  him,  and 
that  the  pathological  changes  would  be  identical.  He 
did  not  think  any  one  now  would  question  that  this  was 
true  of  diphtheria.  From  the  diphtheritic  membrane 
a  poison  could  be  isolated  which,  when  injected  into 
animals,  produced  identical  changes  of  a  most  char- 
acteristic and  specific  kind.  These  changes  consisted 
in  a  ver)'  peculiar  and  specific  form  of  fatty  degenera- 
tion of  the  heart,  and  a  peculiar  change  in  the  skeletal 
muscles,  not  at  all  resembling  the  fatty  change  ob- 
served in  other  diseased  conditions  of  the  skeletal 
muscles.  Perhaps  the  most  notable  and  characteristic 
changes  were  those  occurring  in  the  nervous  system — 
a  true  solution  of  the  axis  cylinder,  beginning  in  the 
medulla  and  ending  in  a  breaking  of  the  a.xis  cylin- 
der, with  a  typical  Wallerian  degeneration  in  the  parts 
beyond.  This  degeneration  was  certainly  specific,  and 
was  produced  by  the  poison  isolated  from  the  diph- 
theritic membrane.  Again,  there  were  some  peculiar 
hyaline  changes  occurring  in  small  spots  in  the  sub- 
stance of  the  liver,  and  without  any  nephritis  whatever 
there  v.-ere  similar  and  characteristic  changes  occur- 
ring in  the  parenchyma  of  the  kidneys.  These  changes 
were,  therefore,  all  specific.  This  being  the  case,  we 
must  admit  that  there  is  such  a  thing  as  specific  diph- 
theria, due  to  a  specific  agent,  namely,  a  bacterium 
which,  outside  of  the  body,  upon  plates  and  liquid 
cultures,  could  be  propagated  and  made  to  produce 
the  same  specific  results.  If  he  had  understood  the 
paper  correctly,  the  position  taken  by  the  author  was 
that  something  besides  the  presence  of  the  specific 
bacillus  was  necessary  before  we  could  have  the  dis- 
ease diphtheria.  He  did  not  think  any  one  would 
oppose  such  a  statement.  Wherever  we  had  a  seed, 
we  di4  not  necessarily  have  a  crop,  but  when  we  had 
the  crop  we  had  the  seed;  in  addition  to  the  seed  we 
must  have  the  soil,  otherwise  we  could  not  get  the 
crop.  Such  a  principle  was  exemplified  in  numerous 
instances  throughout  all  nature — indeed,  this  was  a 
strong  argument  against  these  diseases  being  due  to 
ordinary  poisons,  for  surely  if  such  a  poison  was  ad- 
ministered there  would  be  a  definite  relation  between 
the  size  of  the  dose  and  the  result.  Again,  he  had 
never  seen  a  turnip  turn  into  a  potato,  or  vice  versa, 
but  he  had  seen  fields  in  which,  along  with  the  pota- 
toes or  turnips,  there  were  all  sorts  of  weeds.  In  every 
one  of  the  infections  we  sooner  or  later  got  multiple 
infections,  and  tlie  disorders  dependent  upon  them. 
There  was,  therefore,  nothing  remarkable  about  true 
septicaemia  developing  in  conjunction  with  diphtheria; 
it  was  no  argument  against  the  specific  nature  of  diph- 
theria. In  pneumonia,  for  example,  we  had  not  only 
a  specific  infection  but  an  invasion  with  a  host  of 
micro-organisms.  All  this  simply  meant  that  we  must 
be  constantly  on  the  lookout  for  infections  or  compli- 
cations other  than  the  specific  one  first  demanding  our 
attention.  It  was  for  this  reason  that  the  skilful  phy- 
sician was  he  who  could  recognize  not  only  the  special 
action  but  also  these  collateral  and  frequently  fatal 
complications  arising  from  other  causes. 

Diphtheria  Antitoxin. — He  believed  there  was  a 
true  specific  remedy  for  the  specific  infection  of  diph- 


theria, but  his  recognition  of  this  served  only  to  per- 
pare  him  for  all  sorts  of  failures.  One  might  just  as 
well  say  that  water  had  no  specific  power  to  put  out 
fire,  because  houses  sometimes  burn  down  during  a 
heavy  downpour  of  rain.  He  had  understood  the 
reader  of  the  paper  to  say  that  there  were  a  number  of 
cases  of  clinical  diphtheria  without  the  presence  of 
the  specific  diphtheria  bacillus.  Certainly,  it  was 
well  known  that  membranous  exudation  was  a  feature 
of  various  diseased  conditions  besides  true  diphtheria, 
and  it  was  just  for  this  reason  that  so  much  stress  was 
laid  upon  the  necessity  for  establishing  the  diagnosis 
of  diphtheria  by  bacteriological  examination.  But  he 
would  take  issue  with  the  reader  of  the  paper  on  the 
statement  that  the  changes  in  the  nervous  system,  char- 
acteristic of  diphtheria,  could  occur  in  cases  in  which 
there  had  been  no  infection  with  the  Klebs-Loeffler 
bacilli.  There  were  cases  of  neuritis  occurring  with 
other  infections,  but  these  were  not  at  all  like  the 
acute  process  of  nerve  degeneration  found  in  cases  of 
infection  with  Klebs-Loeffler  bacilli. 

Dr.  Dillon  Brown  said  that  he  certainly  could  not 
accept  the  conclusions  drawn  by  the  reader  of  the 
paper,  although  many  of  the  facts  stated  were  so  well 
known  and  so  generally  accepted  as  to  be  considered 
almost  elementary.  The  result  obtained  by  Dr.  Bies- 
ser  in  ordinary  nasal  diphtheria  represented  about  the 
usual  results  that  had  been  obtained  by  practitioners 
under  this  line  of  treatment  before  the  introduction  of 
antitoxin,  and  if  Dr.  Bieser  had  used  antitoxin  in 
proper  doses  in  these  cases  it  was  probable  that  his 
results  would  have  been  much  better.  Dr.  Brown  said 
that  in  the  laryngeal  cases  Dr.  Bieser  had  certainly 
had  better  results  than  he  had  obtained  with  the  same 
line  of  treatment,  but  such  a  very  small  number  of 
cases  was  of  very  little  account  as  indicating  the  value 
of  any  plan  of  treatment.  His  own  experience  com- 
prised considerably  more  than  one  thousand  cases,  and 
if  the  results  were  divided  up  into  hundreds,  according 
to  the  different  methods  of  treatment  adopted,  the  re- 
sults would  vary  more  than  fifteen  or  twenty  per  cent. 
Previous  to  antitoxin,  and  with  the  internal  use  of 
mercury,  either  in  the  form  of  bichloride  or  calomel, 
his  results  had  not  been  nearly  so  good  as  those  of 
Dr.  Bieser — only  forty  to  forty-five  per  cent.  Since 
the  use  of  antitoxin  they  had  been  very  much  belter. 

Mercury  Rarely  Causes  Salivation  in  Children. 
• — It  was  not  surprising  that  the  reader  of  the  paper 
should  not  have  produced  salivation  by  such  large 
doses  of  mercury,  for  children  were  not  easily  affected 
in  this  way  by  mercury;  instead,  this  drug  usually 
made  them  intensely  anemic  and  caused  extreme  pros- 
tration. In  his  own  experience  he  had  rarely  seen 
salivation,  but  he  had  observed  under  this  treatment 
intense  anaemia  and  great  prostration.  In  conclusion, 
he  would  enter  his  protest  against  a  line  of  treatment 
like  that  advocated  in  the  paper,  which  kept  a  baby 
awake  day  and  night  for  forty-eight  hours.  Remark- 
ably good  results  would  have  to  be  shown  to  justify 
such  a  course. 

Faith  in  Antitoxin  Still  Weak. — Dr.  William 
Henry  Porter  said  that  he  was  very  decidedly  in 
accord  with  Dr.  Thomson  in  his  assertion  that  diph- 
theria is  a  specific  disease,  and  that  it  has  a  specific 
poison,  producing  specific  changes.  He  had  not  yet 
been  able  to  acquire  so  large  a  faith  in  tlie  antitoxin 
treatment  of  diphtheria  as  some  had  done.  In  follow- 
ing the  discussion  it  had  occurred  to  him  that  the 
probability  was  that  if  antitoxin  was  the  specific  it 
was  claimed  to  be  it  was  only  for  a  particular  kind  of 
infection;  and,  although  it  might  bean  agent  for  good 
in  that  particular  instance,  it  might  be  very  harmful 
to  an  individual  in  health  or  one  with  a  mi.xed  infec- 
tion. He  thought  he  had  seen  very  unpleasant  results 
from  the   use  of  antitoxin   in  cases  which  were  not 


November  20,  1897] 


MEDICAL    RECORD. 


755 


diphtheria,  or  which  were  very  mild  examples  of  this 
disease.  It  was  for  this  reason  that  he  felt  still  some- 
what doubtful  as  to  how  great  a  specific  antitoxin  was 
for  diphtheria.  He  had  no  doubt  that  antitoxin  was  a 
chemical  compound  in  the  same  sense  that  strychnine, 
atropine,  morphine,  etc.,  were,  and  it  might,  when  in- 
troduced into  the  system,  by  its  very  toxicitj'  stimulate 
the  protoplasm  into  increased  activitj-,  but  the  ques- 
tion in  his  mind  was  whether  it  could  do  this  with 
absolute  safetj'. 

Bromine  the  Best  Local  Application. — Dr.  W.  H. 
McEnroe  said  that  he  knew  of  nothing  better  than 
Smith's  solution  of  bromine  for  the  destruction  of  the 
horrible  odor  caused  by  decaying  diphtheritic  mem- 
brane in  the  throat.  This  remedy  could  also  be  given 
internally.  He  had  never  lost  a  case  of  diphtheria 
treated  in  this  way.  He  relied  upon  iron  in  this  dis- 
ease, simply  as  a  cardiac  stimulant,  and  when  it  was 
given  in  drachm  doses  with  sufficient  frequency  it 
■would  sometimes  cause  a  return  of  the  first  sound  of 
the  heart.  He  had  not  used  antitoxin  very  exten- 
sively, but  from  the  testimony  of  others  he  w  as  con- 
vinced that  it  approached  very  closely  to  a  real  specific. 

Immunization. — Dr.  S.  A.  Knopf  said  that  nothing 
had  been  said  in  this  discussion  about  the  use  of  anti- 
toxin as  a  prophylactic.  In  a  recently  published  re- 
port of  a  severe  epidemic  of  diphtheria  in  Bologna, 
isolation,  disinfection,  and  closure  of  the  schools  had 
failed  to  stop  the  epidemic.  Preventive  inoculations 
of  antitoxin  had  then  been  used  on  a  large  scale,  four- 
fifths  of  the  children  between  the  ages  of  one  and 
twelve  being  subjected  to  the  treatment.  At  once  new- 
cases  failed  to  develop,  and  the  epidemic  was  quickly 
brought  to  an  end.  While  in  Paris  he  had  watched 
with  intense  interest  the  first  experience  with  diph- 
theria antitoxin.  From  his  notes  made  at  that  time 
he  found  that,  whereas  the  mortality  from  diphtheria 
in  one  hospital  for  the  period  from  1890  to  1894  had 
been  seventy-three  per  cent.,  it  fell  to  fort3--nine  per 
cent,  in  the  first  few  months  after  the  introduction  of 
the  antitoxin  treatment.  This  should  convince  any 
one  that  it  is  really  a  specific  in  the  treatment  of 
diphtheria. 

Dr.  William  Vissman  said  that  he  heartily  agreed 
with  Dr.  Thomson  as  to  the  very  great  raritj'  of  a  pure 
infection  of  any  sort,  and  he  also  believed  that  if  anti- 
toxin was  mixed  with  the  toxins  of  diphtheria  and 
injected  into  an  animal  the  animal  would  not  die 
from  a  large  dose  of  the  to.xins  of  diphtheria.  He 
would  also  grant  that  if  a  certain  quantity  of  diphthe- 
ria antitoxin  was  introduced  into  a  lower  animal,  and 
after  twelve  hours  the  toxins  of  diphtheria  were  intro- 
duced, the  animal  would  probably  recover.  If,  how- 
ever, a  fatal  dose  of  toxin  was  introduced,  and  then 
after  twelve  hours  the  antitoxin  was  given,  the  animal 
would  not  always  recover.  In  other  words,  the  diph- 
theria antitoxin  seemed  to  be  an  antidote  for  the  spe- 
cific toxins  of  the  Klebs-Loeffler  bacillus. 

Impossible  to  Make  a  Reliable  Bacteriological 
Diagnosis  of  Diphtheria  in  Twenty-Four  Hours.  — It 
was  customary  now  to  make  diagnoses  of  diphtheria  in 
twenty-four  hours  by  a  bacteriological  examination,  yet 
in  the  first  few  hours  the  Klebs-Loeffier  bacillus  looked 
exactly  like  the  xerosis  bacillus — an  absolutely  harm- 
less organism.  Then  there  was  an  organism  called 
the  pseudo-diphtheria  bacillus,  which  resembled  it  in 
every  way,  except  that  it  was  not  toxic.  We  might 
take  the  diphtheria  bacillus  in  its  most  virulent  form, 
and  put  it  in  an  incubator  and  grow  it  at  about  45-  C; 
this  would  make  an  excellent  demonstration  of  diph- 
theria in  the  laboratory,  but  it  would  be  found  to  have 
lost  its  virulence  at  that  temperature.  We  knew  of 
no  method  by  which  this  virulence  could  be  reproduced. 
It  could  not  be  said  that  one  had  diphtheria  unless 
there  was  present  a  diphtheritic  lesion  in  the  throat; 


the  simple  presence  of  the  diphtheria  bacillus  in  the 
throat  did  not  constitute  clinical  diphtheria.  Consid- 
ering the  many  obstacles  to  be  overcome  in  connection 
with  the  determination  of  the  virulence  and  the  estab- 
lishment of  the  identity  of  the  diphtheria  bacillus,  he 
did  not  hesitate  to  assert  that  a  bacteriological  diag- 
nosis of  virulent  diphtheria  in  the  human  throat  could 
not  be  made  in  twent}'-four  hours.  It  should  be  re- 
membered also  that  about  four  hundred  different  or- 
ganisms had  been  isolated  from  the  throats  of  healthy 
persons,  and  that  many  organisms  from  the  mouth,  if 
cultivated  in  bouillon,  would  produce  death  in  the 
lower  animals  in  a  short  time,  although  perhaps  not 
quite  so  quickly  as  the  diphtheria  bacillus.  UTien 
one  said  that  an  organism  was  the  cause  of  a  disease, 
one  must  find  that  organism  in  every  case  of  the  dis- 
ease; one  must  obtain  a  pure  culture  of  this  organism 
and  with  it  reproduce  the  disease.  Now  the  only 
thing  that  had  been  done  so  far  with  the  diphtheria 
bacillus  was  to  obtain  it  in  pure  culture. 

Diphtheria  in  the  Lower   Animals The  lesions 

found  in  human  beings  suffering  from  diphtheria  were 
not  the  same  as  in  the  lower  animals.  If  diphtheria 
bacilli  were  placed  on  the  mucous  membrane  of  one 
of  the  lower  animals,  there  would  be  few  if  any  symp- 
toms ;  but  if  the  mucous  membrane  was  denuded  and 
the  bacilli  were  then  applied  to  it,  a  false  membrane 
would  be  formed,  but  it  would  not  extend  beyond  the 
denuded  surface.  Sometimes  by  the  injection  of  the 
diphtheria  bacilli  the  membrane  would  be  made  to 
spread  farther.  If  these  animals  lived  long  enough, 
they  would  suffer  from  paralyses,  and  this  would 
occur  even  when  they  were  inoculated  with  almost 
any  other  organism.  If  the  diphtheria  bacillus  was 
injected  into  the  subcutaneous  tissue,  the  animal 
would  die;  if  the  fatal  termination  was  postponed 
for  some  time,  there  would  be  first  an  infiltration 
at  the  site  of  the  injection,  and  then  a  slight  hydrops 
of  the  pericardium,  pleura,  and  peritoneum.  These 
were  not  characteristic  of  diphtheria  in  the  human 
being.  It  would  also  be  found  that  there  was  cloudy 
swelling  of  the  muscles,  kidneys,  liver,  and  other 
organs;  but  the  same  was  true  of  almost  any  infec- 
tious disease.  If  the  animal  lived  sufficiently  long, 
necrosis  would  occur  at  the  site  of  the  injection,  but 
no  one  had  yet  been  willing  to  place  himself  on  record 
as  saying  that  the  bacilli  so  introduced  in  the  lower 
animals  had  increased  at  all  in  number.  Dr.  Viss- 
man said  that  he  did  not  think  that  the  diphtheria  pro- 
duced in  the  lower  animals  was  exactly  the  same  dis- 
ease as  that  found  in  the  human  being.  Kittens,  young 
chickens,  and  dogs  sometimes  die  of  a  disease  present- 
ing the  usual  clinical  features  of  diphtheria — e.g., 
diphtheritic  membrane  and  paralyses — but  the  bacil- 
lus present  here  and  capable  of  reproducing  the  dis- 
ease was  unlike  the  diphtheria  bacillus.  In  diphthe- 
ritic inflammations  of  the  conjunctiva  we  rarely  found 
diphtheria  bacilli,  and  the  same  was  true  in  most  cases 
of  diphtheritic  otitis.  If  a  person  had  a  slight  ulcera- 
tion in  the  throat,  and  a  twent)--four-hour  diagnosis 
showed  diphtheria  bacilli,  the  conclusion  would  be 
that  the  case  was  one  of  true  diphtheria.  It  was  on 
such  diagnoses  that  many  cases  were  reported  as  hav- 
ing been  cured  of  diphtheria  by  the  use  of  antitoxin. 

Effects  of  Micro-Organlsms  on  One  Another. — Dr. 
Vissman  next  considered  the  effects  of  the  micro- 
organisms on  one  another.  He  said  that  if  the  bacillus 
butyricus,  a  strictly  anaerobic  organism,  was  used  to 
inoculate  a  tube,  and  at  the  same  time  the  bacillus 
prodigiosus  was  added,  it  would  be  found  that  the 
bacillus  butj-ricus  would  grow  perfectly  in  the  pres- 
ence of  the  atmosphere.  Similarly  the  bacillus  of 
tetanus  would  not  grow  in  the  presence  of  the  atmos- 
phere unless  the  bouillon  were  at  the  same  time  inoc- 
ulated with  the  diphtheria  bacillus.     Again,  the  diph- 


756 


MEDICAL    RECORD. 


[November  20,  1897 


theria  toxin  became  less  virulent  when  mixed  with 
the  staphylococcus  pyogenes  aureus,  and  very  much 
more  virulent  when  mixed  with  the  streptococcus. 
Clinically,  he  said,  it  would  be  found  that  diphtheria 
was  never  a  pure  infection  with  the  Klebs-Loeffler 
bacillus;  it  was  most  commonly  contaminated  with 
the  streptococcus,  which,  as  had  been  said,  tended 
greatly  to  increase  the  virulence  of  the  diphtheria 
bacilli. 

In  conclusion,  he  suggested  that  in  the  use  of  diph- 
theria antitoxin  it  was  well  not  to  lose  sight  of  the 
effect  of  the  injection  of  heterogeneous  serum  into  the 
human  system. 

Antitoxin  Treatment  Not  Free  from  Danger.— Dr. 
George  Bieser  said  that  at  first  he  had  been  enthusi- 
astically in  favor  of  diphtheria  antitoxin,  but  he  had 
soon  learned  that  his  patients  developed  acute  suppres- 
sion of  urine  shortly  after  the  administration  of  this 
remedy.  This  dangerous  complication  had  developed 
in  mild,  ordinary  cases  of  diphtheria,  which,  accord- 
ing to  his  past  experience,  should  have  recovered  under 
very  simple  treatment.  Recently  he  had  used  simple 
remedies,  like  benzoate  of  sodium  and  bromide  of 
potassium,  and  just  such  cases  had  recovered.  In  the 
severer  cases  of  diphtheria  he  had  found  the  antitoxin 
of  no  value  at  all — in  fact,  the  children  had  become 
much  worse  after  its  use.  He  thought  the  cases 
treated  very  recently  here  were  not  nearly  so  severe  as 
those  seen  a  few  years  ago.  He  saw  no  reason  why 
we  should  run  the  risk  of  injecting  a  remedy  of  un- 
known properties  in  the  mild  cases,  that  usually  recov- 
ered under  simple  and  absolutely  safe  treatment. 

Dr.  Cook  said  that  he  had  heard  it  claimed  that 
diphtheria  antitoxin  produced  its  results  by  introduc- 
ing into  the  system  a  substance  which  nature  would 
produce,  provided  the  individual  lived  long  enough. 
If  this  was  the  correct  theory  of  its  action,  he  would 
raise  the  question:  "Is  it  rational  to  introduce  into 
the  system  at  one  time  such  large  quantities  of  a  sub- 
stance that  nature  would  only  produce  slowly  and  in 
small  quantity?" 

Dr.  a.  E.  Bieser,  in  closing  the  discussion,  said 
he  had  endeavored  to  make  it  understood  that  he 
believed  the  clinical  disease  diphtheria  was  due  to 
a  combination  of  germs,  although  undoubtedly  one 
form  was  due  to  the  Klebs-Loeffler  bacillus.  When 
there  were  present  marked  prostration,  irregular  tem- 
perature, croupous  inflammation,  and  necrosis,  the  case 
was  one  of  clinical  diphtheria,  no  matter  what  the  germ 
causing  it.  The  point  he  had  made  was  that  diphthe- 
ria antitoxin  was  good  for  nothing  else  but  pure  Klebs- 
Loeffler  infection,  and  that  death  was  very  commonly 
due  to  other  germ  infections.  When  a  person  died 
from  a  large  dose  of  morphine,  he  died  from  the  poi- 
son morphine,  and  not  of  the  morphine  disease,  and 
so  it  might  be  claimed  that  permanganate  of  potassium 
would  be  useful  for  the  morphine  poisoning,  but  it 
would  be  of  no  advantage  for  the  morphine  disease. 
If  in  actual  practice  diphtheria  was  the  diphtheria  of 
the  laboratory — a  pure  Klebs-Loeffler  infection — then 
the  statistics  should  show  this;  but  Friinkel  and  man)' 
other  authorities  admitted  that  it  rarely  was  such  an 
infection.  He  had  counted  up  the  number  of  deaths 
occurring  weekly  in  1895,  i8g6,  and  1897.  Coming 
to  the  first  week  of  November  in  each  of  these  years, 
it  would  be  found  that  in'iSgs,  when  antitoxin  had 
been  very  little  used,  8,270  cases  had  been  reported 
(taken  from  the  Medic.m.  Record),  with  1,390  deaths: 
that  in  1896,  9,550  cases  had  been  reported,  with  1,366 
deaths — an  increase  of  over  a  thousand  cases ;  and  that 
in  1897,  9,550  cases  had  been  reported — 200  less  than 
in  1896 — and  1,408  deaths.  There  were  three  potent 
reasons  why,  independently  of  treatment,  the  gross 
mortality  of  diphtheria  should  fall  anywhere,  viz. :  (i) 
A  definite  set  of  cases,  diagnosticated  by  the  finding 


of  the  Klebs-Loeffler  bacillus,  received  a  definite  dose 
of  antitoxin,  and  these  cases  treated  in  a  definite  way 
were  compared  with  indefinite  cases  in  which  the 
diagnosis  was  uncertain,  and  which  had  been  treated 
indifferently;  (2)  the  abstinence  from  injudicious  lo- 
cal treatment  would  reduce  the  gross  mortality:  and 
(3)  the  undoubted  increase  in  the  number  of  mild 
cases  reported,  thus  increasing  the  chances  of  a  better 
percentage  of  mortality. 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 
DEATH  OF  PRINCESS  MARY,  DUCHESS  OF  TECK — TYPHOID 

OUTBREAKS,  MAIDSTONE,    LYNN,    BELFAST,    CLIFTON 

COUNCILLORS     NEW    AND     OLD,    PROFESSOR     HORSLEV,  . 

DR.    GLOVER  ■ —  PATHOLOGICAL    SOCIETY PROFESSOR 

COATS PROFESSOR     MACEWEN — DEATH    OF    DR.    BELL 

FLETCHER. 

London*,  October  29,  1897. 

The  bereavement  of  the  ro3"al  family,  of  which  you 
will  have  heard,  is  shared  by  the  nation,  and  mourn- 
ing will  be  generally  put  on  for  the  Duchess  of  Teck. 
Her  royal  highness  was  a  great  favorite  with  the  pub- 
lic, and  the  medical  profession  will  be  specially  sym- 
pathetic on  account  of  the  active  part  she  took  in 
promoting  charities.  There  was  much  an.xiety  about 
her  in  April  when  Mr.  Herbert  AUingham  operated 
for  umbilical  hernia.  She  recovered  well  and  re- 
ceived an  enthusiastic  welcome  at  the  jubilee.  On 
Tuesday  signs  of  a  fresh  obstruction  occurred,  and 
operation  showed  this  near  the  old  sac.  The  opera- 
tion was  successful,  but  the  patient  sank  two  hours 
later  from  heart  failure.  The  duchess  had  had  car- 
diac trouble  for  several  years. 

Mr.  Herbert  AUingham,  F.R.C.S.,  is  the  son  of  Mr. 
William  AUingham,  and  has  followed  his  father's 
specialty  and  assisted  in  the  last  edition  of  his  work 
on  "  Diseases  of  the  Rectum."  He  has  written  a 
work  himself  on  colotomy,  which  has  been  well  re- 
ceived, and  at  the  last  vacancj'  was  elected  assistant 
surgeon  to  St.  George's  Hospital. 

Typhoid  fever  is  still  the  most  prominent  medical 
topic,  fresh  outbreaks  having  increased  the  public 
alarm.  The  number  of  notifications  has  diminished 
during  the  week.  Yesterday  there  were  9,  and  that 
number  has  not  been  exceeded  since  the  21st.  On  the 
25th  there  was  only  i,  but  the  next  da)-  there  were  8. 
LTp  to  last  night  the  total  number  attacked  reached  1,757 
and  the  deaths  1 16.  Some  of  the  later  cases  are  con- 
sidered to  be  caused  by  direct  infection  from  the  sick, 
and  it  is  asserted  that  in  some  parts  the  drains  are  so 
arranged  as  to  be  a  danger.  The  fact  that  one-third 
of  the  houses  have  not  an  efficient  water  supply  is 
quite  as  important.  Dr.  Washbourn's  bacteriological 
examination  enables  him  to  state  that  the  Tutsham 
spring  was  undoubtedly  polluted,  and  there  is  a  strong 
suspicion  as  to  some  other  springs  which  it  would  be 
well  to  have  him  investigate. 

The  epidemic  at  Belfast  is  reported  to  be  of  mild 
type,  but  the  number  of  cases  is  serious  and  points  to 
a  wide  distribution.  Water  again  is  supposed  to  be 
the  medium  of  the  poison.  There  were  142  cases 
under  treatment  in  the  workhouse  last  week,  and  26 
fresh  cases  have  been  admitted.  Altogether  more  than 
350  cases  are  reported  to  have  occurred  in  the  city 
during  the  last  month. 

There  is  another  serious  epidemic  at  King's  Lynn, 
Norfolk,  which  at  the  last  census  had  a  population  of 
18,360.  Yesterday  there  were  25  new  cases,  bringing 
the  total  up  to  235.     Only  4  deaths  have  been  reported 


November  20,  1897] 


MEDICAL    RECORD. 


757 


at  present,  but  more  will  doubtless  follow,  though  the 
type  is  said  to  be  mild. 

Here,  too,  the  w.iter  supply  is  impugned,  and  if  all 
I  hear  about  it  is  true  the  ep.demic  is  considerably 
overdue.  New  works  are  in  progress  to  obtain  a  purer 
supply,  but  months  must  lapse  before  the  completion. 
The  delay  is  said  to  have  been  due  to  opposition  to 
the  scheme  from  some  of  the  rate  payers,  but  for  which 
the  new  supply  would  have  been  in  use  by  this  time. 

Yet  another  outbreak — Clifton  near  Bristol,  25  cases 
occurring  in  the  week.  In  Clifton  College  there  are, 
I  hear  to-day,  ^o  scholars  and  one  of  the  masters  down 
with  t}phoid.  The  outbreak  is  thought  to  be  traceable 
to  the  milk  supply. 

The  outbreak  at  University  College  Hospital  was 
stopped  at  once,  but  one  nurse  lias  succumbed  to  the 
disease.  As  soon  as  inspection  was  made,  a  part  of 
the  water  was  suspected  and  immediately  cut  off. 
Further  examination  showed  how  correct  was  the  sus- 
picion. If  the  same  measures  had  been  taken  at 
Maidstone,  how  many  lives  would  have  been  saved! 

Much  was  made  during  the  election  of  the  fact  that 
the  new  member,  being  elected  for  five  years,  would 
necessitate  an  additional  election  with  all  the  expense 
in  the  future.  I  had  intended  to  ask  the  successful 
candidate  whether  he  would  not  obviate  this  by  re- 
signing when  the  other  members  had  to  be  elected. 
It  is  the  greater  pleasure  to  find  that  Mr.  Victor  Hors- 
ley  has  anticipated  my  suggestion,  and  in  thanking  the 
constituenc)'  for  the  honor  done  him  announced  his 
intention  of  resigning  at  the  end  of  the  term  of  his 
fellow-representatives. 

Dr.  Glover  has  incurred  the  wrath  of  the  "  Corporate 
and  Medical  Reform  Committee.''  Instead  of  answer- 
ing the  series  of  questions  sent  to  candidates  and  also 
to  him.  Dr.  Glover  wrote  a  letter  which  is  a  scathing 
criticism  of  the  gentlemen  who  assumed  the  right  to 
ask  questions  of  the  direct  representatives.  Dr.  Glover 
has  no  sympathy  with  noisy  agitators  and  delivers 
some  home  truths.  Nevertheless,  I  doubt  his  wisdom 
in  this  case,  for  it  may  be  held  that  every  constituent 
has  a  right  to  heckle  his  member,  and  there  is  some- 
thing to  be  said  in  favor  of  the  views  put  forward  by 
this  last  self-appointed  committee.  Dr.  Glover  is  a 
strong  man,  a  general  practitioner  of  the  highest  grade, 
supported  on  this  ground  by  general  practitioners  and 
consultants  too.  He  is  also  an  able  penman,  a  con- 
stant contributor  to  TAf  Lancet.  He  belongs  to  a  fam- 
ily of  able  men — one  of  his  brothers  is  a  distinguished 
divine. 

At  the  opening  meeting  of  the  Pathological  Societ)' 
the  president  (Dr.  Payne)  remarked  in  his  address 
that  some  criticism  had  been  of  late  offered  on  the 
name  of  the  society,  but  he  held  that  the  founders 
had  no  choice  in  the  matter  and  no  one  could  expect 
an  alteration  at  this  date.  He  thought  the  associa- 
tion of  the  idea  of  morbid  anatomy  with  the  term 
pathology  regrettab'°  as  giving  an  incomplete  view. 
He  defended  the  rul;  of  the  society,  that  except  in 
special  cases  communications  could  not  be  received 
unless  accompanied  by  a  material  specimen  of  some 
sort.  The  study  of  disease  rests  on  a  double  founda- 
tion— anatomical  and  functional  change — and  the  so- 
ciet}- belongs  lo  the  anatomical  investigators.  Syden- 
ham and  Locke  neglected  the  anatomical  side  of 
pathologv',  but  had  they  lived  at  the  present  time  they 
would  probably  have  held  different  views.  The  term 
morbid  anatomy  should  not  be  restricted  to  post-mor- 
tem examinations  but  should  include  the  investigation 
of  all  material  change  of  organs  and  tissue  by  all 
available  means.  He  held  it  to  be  a  mistake  to  call 
everything  clinical  if  observed  during  life,  for  even 
physical  diagnosis  is  related  to  patholog)-,  signs  be- 
coming significant  only  when  connected  with  known 
changes.     Dr.  Payne  hoped  the   society   would   con- 


tinue to  bring  the  results  of  pathological  research  into 
relation  with  practical  medicine,  reporting  them  in  a 
manner  intelligible  to  all  interested  in  the  subject, 
even  those  not  engaged  in  research. 

Professor  Coats,  of  Glasgow,  has  been  granted  leave 
of  absence  to  spend  the  winter  in  New  Zealand,  in  the 
hope  of  restoring  his  impaired  health. 

A  difficulty  has  arisen  between  Dr.  Macewen  and 
the  manager  of  the  Western  Infirmary.  I  should  hope 
Scotch  intelligence  and  fair  play  will  be  equal  to 
solving  it. 

The  suicixles  of  two  practitioners  have  occurred 
during  the  week.  Prussic  acid  was  the  agent  in  both 
cases.  One  gentleman  seems  to  have  been  driven  to 
insanity  by  anxietj-  about  his  patients.  He  had  been 
in  the  habit  of  taking  narcotics.  The  other  was  con- 
fronted with  a  threat  of  having  some  charge  brought 
against  him. 

The  mortality  from  diphtheria  is  again  increasing 
here. 

Dr.  Bell  Fletcher,  F.R.C.P.,  died  on  the  21st,  aged 
ninety-one  years.  For  many  years  he  was  the  most 
busy  consultant  of  the  Midlands.  He  retired  only 
about  a  dozen  years  ago,  shortly  before  which  I  was 
chatting  with  him.  He  was  aged  then,  and  I  hardly 
expected  he  would  reach  ninety.  It  is  twenty  years 
since  he  was  made  consulting  physician  to  the  Bir- 
mingham Hospital,  after  thirty  years  of  active  ser\'ice. 
He  took  great  interest  in  the  other  Birmingham  chari- 
ties and  societies,  supporting  tliem  by  his  work  and 
his  purse.  He  became  a  fellow  of  the  London  Col- 
lege of  Physicians  as  long  ago  as  1848. 


OUR    PARIS    LETTER. 

I  From  our  Special  Correspondent.) 

VERDICT      IX       THE      TRIAL     OF       DR.      LAPORTE  THE 

BOUCIC.4UT  HOSPITAL — THE  CONTAGIOUSNESS  OF 
LEPROSY — THE  FACULTY  OF  MEDICINE'S  NEW 
SCHEDULE  OF  STUDIES — PARIS  CABS — IMMUNIZING  A 
HORSE  BY  MEANS    OF   A   TYPHIC    BACILLARY  CULTURE. 

Paris,  October  29,  1897. 

The  trial  of  Dr.  Laporte,  which  has  been  one  of  the 
great  causes  dlil'irs  at  Paris,  and  has  engaged  lay  as 
well  as  professional  attention  for  many  weeks  past, 
has  terminated.  The  verdict  of  the  tribunal  was  three 
months'  imprisonment,  waiving  execution  of  the  pen- 
alty. Thus  the  doctor,  while  not  going  actually  to 
prison,  remains  all  the  same  condemned.  The  cir- 
cumstances were  sufficient  to  justify  an  absolute  ac- 
quittal. In  the  future,  physicians  "  caught'"  in  remote 
districts  in  urgency  cases,  and  without  the  necessary 
instruments  to  perform  craniotomy  prescribed  in  stand- 
ard works  on  obstetrics,  may  hesitate  to  interfere. 
Mother  and  child  might  thus  both  be  sacrificed.  The 
case  has  aroused  the  old  quarrel — with  which  you  in 
New  York  are  also  familiar — between  lawyers  and 
doctors.  .V  subscription  has  been  started  in  favor  of 
Dr.  Laporte  by  the  medical  profession,  which  is  likely 
to  realize  something  handsome. 

Madame  Boucicaut,  the  Parisian  benefactress,  who 
died  some  years  ago,  bequeathed  to  the  Assistance 
Publique  large  sums  to  found  a  hospital.  It  was 
expected  that  the  great  hospital  of  the  Rue  de  la  Con- 
vention would  be  ready  for  inauguration  three  months 
ago.  The  construction  and  arrangements  were  at  that 
time  not  sufficiently  advanced,  and  a  delay  was  de- 
manded until  October  15th.  It  is  to  be  hoped  that 
this  munificent  gift  will  be  entirely  available  and 
ready  for  occupancy  before  the  cold  weather  which  is 
coming  falls  too  heavily  upon  the  sick  poor. 

The  contagiousness  of  lepro.sy  is  just  now  being  dis- 
cussed by  Paris  physicians,   who   seem  to  be   prett)' 


758 


MEDICAL    RECORD. 


[November  20,  1897 


united  in  their  opinions  on  the  subject.  Dr.  Lesnier, 
an  authority  of  the  first  order  on  skin  diseases,  thinks 
that  leprosy  is  not  always  nor  everywhere  equally  con- 
tagious. There  are  also  many  eminent  observers  who 
have  concluded  that  the  disease  is  not  contagious  at 
all.  This  is  undoubtedly  true  under  certain  con- 
ditions of  locality  and  climate.  But  in  a  disease  like 
leprosy  we  must  judge  of  the  universal  field  compris- 
ing different  parts  of  the  globe,  and  what  takes  place 
in  leprous  districts  as  a  whole,  and  not  in  one  place, 
city,  or  special  country.  It  will  thus  be  seen  that 
the  contagiousness  of  leprosy  is  a  fact  that  it  is  im- 
possible to  deny.  Dr.  Hansen,  who  is  one  of  the  most 
expert  on  leprosy,  is  a  decided  partisan  of  contagion. 

The  Faculty  of  Medicine  has  issued  its  schedule  of 
studies  and  practical  work  for  the  academic  year 
1897-98.  The  lectures  and  different  courses  begin 
on  Monday,  November  ist.  As  it  may  be  interesting 
and  even  profitable  to  the  deans  of  medical  schools, 
colleges,  and  universities  in  the  United  States  to 
know  exactly  how  medicine  is  taught  in  the  great 
ficole  de  Medecine  de  Paris,  I  give  the  following 
summaiy,  noting  in  the  first  place  that  the  general 
course  of  study  has  been  lengthened  from  four  years 
to  five,  by  decree  of  July  31,  1895: 

First  year — Anatomy,  histology,  physiology,  bio- 
logical chemistry,  elementary  general  pathology 
(propaedeutics) ;  obligatory  practical  work  :  biological 
chemistry,  dissection. 

Second  year — Anatomy,  histology,  external  pathol- 
ogy, medical  and  surgical  clinic;  obligatory  practical 
work:  hospital  stage,  dissection. 

Third  year — Internal  pathology,  external  pathology, 
operative  medicine,  obstetrics  (accouchements),  path- 
ological anatomy,  natural  medical  history  (parasi- 
tology), medical  and  surgical  clinic;  obligatory  prac- 
tical work:  hospital  stage,  pathological  anatomy, 
parasitology  (animal  and  vegetable  parasites). 

Fourth  year — Therapeutics,  hygiene,  legal  medicine, 
pharmacology,  botanical  materia  medica,  medical  and 
surgical  clinic,  special  clinic,  obstetrical  clinic,  chem- 
istry and  physics  applied  to  hygiene  and  therapeutics, 
history  of  medicine  and  surgery;  obligatory  practical 
work:  special  hospital  stage:  elective  practical  work: 
botanical  materia  medica,  chemical  materia  medica, 
pharmaceutical  materia  medica,  bacteriology,  etc. 

Fifth  year — Elective  practical  work:  botanical  ma- 
teria mgdica,  chemical  materia  medica,  pharmaceutical 
materia  medica,  bacteriology,  etc, 

Several  of  the  Paris  cab  companies  are  still  send- 
ing out  open  carriages,  although  the  weather  is  much 
colder  and  winter  is  approaching;  in  thus  disregard- 
ing the  public  health,  they  are  exposing  their  occu- 
pants to  severe  colds,  bronchitis  as  well  as  pneumonia, 
and  furnishing  cases  for  the  doctors. 

Dr.  Van  de  Velde  reported  at  the  last  meeting  of 
the  Biological  Society  that  at  Louvain  they  have  been 
for  two  years  past  immunizing  a  horse  by  means  of 
cultures  of  a  single  variety  of  the  bacilli  of  typhoid 
fever. 


Compression  of  the  Sciatic  Nerve. — Dr.  .Vrullani 

(Ga-:.  i/.  Os/>.  c  ,■/.  Clin.,  February  28th)  has  improved 
upon  digital  compression  for  sciatica  by  substituting 
a  doul)le-pad  apparatus  for  the  fingers.  He  has  ap- 
plied it  to  forty  patients:  two  were  improved,  six  were 
unimproved,  and  thirty-two  were  cured.  He  recom- 
mends compression  of  the  popliteal  cavity  besides  the 
point  where  the  sciatic  nerve  emerges  in  the  thigh. 
The  general  condition  of  the  patient  and  the  location 
of  the  pain  are  better  criteria  for  the  success  of  tin- 
measure  than  electric  tests  or  the  duration  of  the 
affection. 


J-uvgical  ^xtggcstions. 

The  Treatment  of  Deep-Seated  Thoracic  Aneu- 
risms.—  Dr.  Clarke,  in  the  Clinical  Journal,  December 
9,  1896,  says  that  the  most  essential  points  in  the 
treatment  are  rest  and  restriction  of  the  amount  of 
fluid  taken.  The  diet  should  be  light  and  easy  of  di- 
gestion, the  amount  taken  at  each  meal  being  small. 
It  is  difficult  to  get  patients  to  remain  on  the  rigid 
Tufnell  diet.  The  amount  of  fluid  taken  can  gradually 
be  reduced  to  a  pint  in  twenty-four  hours  without  great 
discomfort  to  the  patient  at  rest.  Rest  should  be  ab- 
solute in  the  recumbent  posture.  This  treatment 
should  be  carried  out  for  at  least  three  or  four  months, 
when  if  the  patient  shows  decided  improvement  he  may 
be  allowed  to  sit  up  in  bed  and  then  gradually  to  move 
about.  Dr.  George  Balfour  recommends  iodide  of  po- 
tassium as  the  most  valuable  medicine,  although  its 
exact  mode  of  action  is  uncertain.  It  is  administered 
every  eight  hours  at  first,  in  a  dose  of  seven  or  eigiit 
grains,  and  gradually  increased  so  long  as  there  is  no 
acceleration  of  the  pulse,  until  fifteen  or  twenty  or 
twenty-five  grains  are  given  at  each  dose.  Dr.  Clarke 
cites  two  cases  of  aneurism  of  the  transverse  aorta 
cured  in  this  way. 

Local  Anaesthetic — For  a  five-minute  effect  apply: 

i^  Chloroform 10 

Ether 15 

Menthol i 

— Le  Ger.ant  and  Pierre. 

Indications  for  Hysterectomy — Hysterectomy  is 
advisable  in  the  vast  majority  of  cases  of  fibroid  tu- 
mors of  the  uterus:  i.  In  all  cases  in  which  there  are 
urgent  symptoms  from  pressure,  or  in  which  there  are 
urgent  subjective  symptoms  referable  to  the  uterus. 
2.  In  all  fibrocystic,  (edematous,  and  myomatous  tu- 
mors. 3.  In  all  tumors  of  intraligamentous  or  sub- 
peritoneal growth.  4.  In  all  large  tumors  which  have 
Ijecome  decidual  abdominal. — Penrose. 

To  prevent  ankylosis  after  phlegmon  of  the  hand. 
begin  active  and  passive  motion  from  the  beginning 
of  the  process  of  repair.  Joints  are  to  be  manipulated 
for  several  minutes  at  a  time  for  two  or  three  hours  a 
day. 

Open  Tendon  Injuries.  —  Dr.  Carl  S.  Haegler 
{Beitr.  ziir  klin.  Cliir.,  xvi.,  No.  2)  reports  one  hun- 
dred cases  treated  at  the  surgical  clinic  of  Professor 
Socin.  The  preparation  for  operation  is  as  follows: 
The  parts  are  thoroughly  cleansed  and  disinfected  by 
sublimate  solution,  1  to  5,000.  .\n  elastic  bandage 
is  applied  centrifugally  to  the  uplifted  arm,  and  left 
in  place  until  the  dressing  of  the  wound.  The  hand 
of  the  assistant  is  not  so  efficient  as  these  bandages. 
The  bloodless  method  is  not  used.  Operations  are 
performed  without  general  anaesthesia,  except  in  the 
cases  of  children.  The  bandage  dulls  the  pain, 
which  at  most  is  not  great.  In  suturing  the  skin  or 
enlarging  the  wound  cocaine  is  sometimes  used. 
The  search  for  tendon  ends  is  sometimes  difficult. 
Sharp  hooks  should  not  be  used.  When  single  ten- 
dons of  the  flexor  communis  digitorum  are  divided, 
Filiget  recommends  hyperextension  of  the  adjoining 
finger  as  very  successful  in  causing  tiie  tendon  end  to- 
appear  in  the  wound.  When  it  is  necessar}*  to  make 
an  incision,  an  enlargment  of  the  original  wound  is 
best.  Starting  from  one  angle  of  the  original  cross- 
wound,  an  incision  is  made  jwrallel  and  to  one  side  of 
the  injured  tendon:  turning  back  this  flap  gives  ample 
room  to  find  the  tendon.  By  this  incision  adhesion  of 
the  tendon  sheath  to  the  skin  cicatrix  is  avoided  as 
much  as  possible.     After  the  ends  are  approximated 


November  20,  1897] 


MEDICAL    RECORD. 


759 


comes  the  question  of  suture.  An  ideal  operation 
must  complete!)-  approximate  the  divided  ends,  the 
ends  must  be  in  accurate  apposition,  nutrition  must  be 
disturbed  to  the  least  extent,  the  operation  must  be 
simple  and  quickly  performed.  A  simple  method 
nearly  related  to  that  of  Schwarz  has  been  used  in  the 
great  majority  of  cases.  Through  the  proximal  end  a 
thread  is  passed  which  serves  as  a  tractor,  and  with 
the  same  needle  the  distal  end  is  pierced.  To  avoid  a 
change  of  position  on  the  part  of  the  surgeon,  and  on 
account  of  the  unusual  direction  in  which  the  needle 
must  be  passed,  the  distal  end  is  grasped  with  a  toothed 
forceps  and  twisted  180  degrees  on  its  long  axis,  and 
after  the  needle  is  passed  allowed  to  return  to  its  nor- 
mal position.  In  order  to  bring,  the  edges  into  close 
apposition,  one  or  two  sutures  are  introduced,  crossing 
over  the  first  suture  at  right  angles  and  piercing  each 
end  beyond  it.  Dry  sterilized  catgut  as  a  suturing 
material  has  given  the  most  favorable  results.  After 
suturing  the  wound  is  wiped  out  dry,  thoroughly  disin- 
fected, and  in  the  majority  of  cases  the  skin  sutured. 
The  wound  is  never  drained;  a  gauze  dressing  is  ap- 
plied and  the  hand  and  wrist  are  immobilized  by  a 
zinc  splint  and  starch  bandage.  The  patient  should  be 
seen  daily  and  closely  watched  for  any  sign  of  trouble. 
Phlegmonous  inflammation  ensued  in  eleven  cases. 
Even  though  union  be  prevented  by  suppuration  in 
wounds  of  the  extensors  over  the  hand  and  fingers, 
function  may  be  in  some  measure  restored  by  continu- 
ous fixation  of  the  injured  finger  in  an  extended  posi- 
tion. As  a  general  rule,  mechanical  treatment  should 
be  begun  in  the  third  week  in  injuries  of  the  extensors; 
in  flexor  injuries,  during  the  fourth  or  fifth  week. 
Every  case  must  be  treated  on  its  own  merits.  The 
time  of  beginning  must  depend  on  the  extent  of  the  in- 
jury, the  course  of  healing,  the  age  and  intelligence  of 
the  patient.  Massage  of  the  forearm  should  commence 
after  the  first  dressing,  viz.,  in  from  ten  to  fourteen 
days.  The  splint,  which  should  reach  to  the  elbow, 
is  now  removed  and  replaced  by  a  shorter  one,  and  the 
forearm  is  daily  massaged.  An  elastic  cord,  one  end 
of  which  is  fastened  to  the  wall  or  table  while  the 
other  end  is  grasped  by  the  patient,  is  a  device  which 
has  given  good  results.  Later  a  faradic  current  is  ap- 
plied. Of  the  one  hundred  cases  thirty-five  were  of 
flexor  injuries,  and  in  sixteen  of  these,  or  forty-six  per 
cent.,  the  treatment  gave  a  good  functional  result.  In 
eleven  instances  function  was  restored  from  one-half  up 
to  three-fourths  of  the  normal.  In  eight  cases  there  was 
almost  total  loss  of  function,  due  mostly  to  phlegmo- 
nous inflammation.  In  some  tliere  were  firm  adhesions. 
Some  of  the  cases  could  not  be  followed  up.  Tlie 
prognosis  differs  greatly  according  to  the  situation  of 
the  injury.  In  the  lower  third  of  the  arm  there  is 
often  an  extensive  injury  to  the  neighboring  muscles 
and  consequent  adhesion  of  the  tendon  cicatrix.  Atro- 
phy of  the  muscles  intensifies  the  bad  results.  Mas- 
sage must  be  begun  very  early.  Injuries  over  the 
wrist-joint  are  to  be  dreaded  for  the  frequent  serious 
complications  due  to  the  anatomical  relations.  Excel- 
lent results  were  obtained  in  a  few  of  these  cases.  In 
injuries  over  the  metacarpus  the  prognosis  is  bad.  In 
phalangeal  injuries  tlie  prognosis  is  not  good,  though 
function  is  not  always  destroyed.  Prognosis  in  divi- 
sion of  the  flexor  profundus  over  the  last  phalanx  is 
absolutely  bad.  The  prognosis  in  injuries  of  the  ex- 
tensors is  very  favorable.  The  search  for  tendon 
ends  is  not  difficult,  and,  as  the  tendons  do  not  glide 
in  tubular  sheaths  like  the  flexors,  the  function  is  not 
so  much  affected  by  adhesions.  .Sixty-five  cases  were 
treated,  and  fifty,  or  seventy-seven  per  cent.,  yielded 
a  perfect  result.  Simultaneous  oi^ening  of  the  joint 
occurred  in  thirty-seven  per  cent,  of  tiie  cases,  but  this 
complication  did  not  prevent  healing  and  restoration 
of  function. 


Contagious  Diseases— Weekly  Statement.— Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  November  13,  1897  ; 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. .  . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox 


iqs 

8q 

iS 

9 

124 

II 

0 

3 

iSi 

10 

"5 

20 

6 

4 

19 

0 

A  Delicate  Instrument.— A  microtome  for  making 
sections  of  the  entire  human  brain  is  being  constructed 
on  the  pattern  of  the  "automatic  precision  microtome" 
recently  brought  out.  The  manufacturers  expect  that 
the  new  instrument  will  make  large  sections  of  greater 
thinness  and  accuracy  than  it  has  been  possible  to 
obtain  hitherto. 

Hot  Weather  and  Crime.— A  curious  investigation 
has  been  undertaken  by  the  officers  of  the  weather  bu- 
reau in  the  United  States.  Col.  Willis  Moore  origi- 
nated the  investigation,  believing  that  there  is  a  close 
connection  between  the  condition  of  the  atmosphere 
and  the  physical  and  moral  welfare  of  the  people. 
The  results  of  these  investigations  are  as  follows: 
Taking  in  the  whole  country  during  January,  Febru- 
ary, and  March,  there  were  in  even  numbers  1,200  sui- 
cides reported  in  the  United  States;  while  in  July, 
August,  and  September  there  were  1,600.  In  the  same 
period  there  were  1,700  murders  in  the  cold  term,  as 
compared  with  2,500  in  the  three  hot  months.  There 
were  50  persons  hanged  or  lynched  in  the  three  cold 
months,  and  113  hanged  or  lynched  in  the  three  hot 
months.  The  investigation  is  said  to  have  been  in- 
stituted with  the  idea  of  issuing  in  the  near  future 
warning  of  the  approaches  of  crime  waves. — Sa/u- 
tarian. 

Chief  Nervous  Affections  of  Alcoholism. — Alco- 
holic coma,  delirium  tremens  with  visual  hallucina- 
tions, restlessness,  fear,  tremor,  and  failure  of  sleep 
and  appetite,  acute  traumatic  delirium  occurring  after 
wounds,  mania  a  potii  without  tremor  but  with  raving 
and  violence,  multiple  neuritis  with  loss  of  knee- 
jerks  and  tenderness  over  the  calves  and  nerve  trunks, 
chronic  insanity,  showing  in  different  cases  either 
physical,  mental,  or  moral  degeneration  especially 
prominently. — SnoRr. 

Typhoid. — Dr.  Hare  has  recently  published  a  sta- 
tistical review  of  all  the  cases  (one  thousand  nine 
hundred  and  two)  treated  during  the  past  ten  years  by 
the  Brand  method  in  the  hospital  of  Brisbane,  Aus- 
tralia. The  mortality  has  been  7.5  percent.;  for  the 
five  years  preceding  the  introduction  of  tlie  method  it 
was  14.8  per  cent. — La  Med.  Mod.,  May  29,  1897. 

X-Rays  Applied  to  the  Stomach MM.  Koux  and 

Halthazard  have  applied  the  .v-rays  to  a  man  after  the 
ingestion  of  a  certain  quantity  of  bismuth.  Experi- 
ments made  successively  on  frogs  and  dogs  have 
clearly  shown  the  form  of  the  stomach  at  the  time  of 
digestion.  They  have  seen  that  the  stomach  of  man, 
like  that  of  the  frog  and  dog,  presents  two  distinct 
parts.  The  larger  serves  as  the  reservoir  for  tlie  food 
ingested;  the  smaller,  which  is  the  prepyloric  portion 
of  the  stomach,  is  the  only  part  that  undergoes  any 
movement.     These  movements  are  violent  and   peri- 


76o 


MEDICAL    RECORD. 


[November  20,  1897 


staltic,  contrary  to  the  opinions  advanced  by  Hofmeis- 
ter  and  Schutz ;  it  forces  little  by  little  into  the  duo- 
denum the  matter  that  has  accumulated  in  the  stomach. 
— Sanitarian. 

Scurvy The  experience  of   Xansen's  expedition 

has  given  rise  to  discussion  on  the  causation  of  scurvy. 
Torup  believed  that  it  is  due  to  ptomains  generated  in 
badly  preserved  foods,  and  great  care  was  taken  in 
selecting  the  preserved  foods  on  which  Nansen's  party 
lived,  with  complete  success.  A.  E.  Wright  shows 
that  the  herbivora  have  no  protection  against  acid 
administration  in  their  food,  and  quickly  die  if  it  is 
given  artificially.  In  the  carnivora  there  is  a  provision 
for  neutralizing  acid  by  the  waste  ammonia  of  the 
body.  In  the  human  being  this  is  less  perfect,  and  if 
all  vegetable  food  is  cut  off  we  should  get  an  acid 
intoxication.  But  Nansen  has  shown  that  fresh  blood 
and  raw  fiesh  are  an  antidote,  and  Wright  says  that 
this  is  easily  explicable,  because  blood  is  not  only 
alkaline,  but  it  produces  salts  akin  to  those  obtained 
from  lemon  juice.  However,  as  the  explorers  were 
often  without  fresh  blood  and  flesh  much  of  their  time, 
the  immunity  may  have  been  after  all  due  to  the  care- 
fully preserved  foods  which  they  consumed. 

Tobacco  Smoking  and  Genius In  his  work  enti- 
tled "  Introduction  a  la  Medecine  de  I'Esprit,"  M. 
Maurice  de  Fleury  devotes  a  chapter  to  tobacco  smok- 
ing from  the  point  of  view  of  men  of  letters.  In  the 
first  place  Balzac  professed  a  fanatical  aversion  to  to- 
bacco in  all  its  forms.  In  his  books  he  invariably 
covers  with  contempt  the  characters  whom  he  portrays 
as  smokers.  Next  Victor  Hugo;  he  likewise  was  no 
smoker.  One  evening  at  his  house  one  of  the  guests 
was  vaunting  the  beneficent  effects  of  a  cigarette  on  a 
creative  imagination.  The  great  poet  at  once  rose  in 
revolt.  "  Believe  me,"  said  he,  "  tobacco  is  more  hurt- 
ful to  you  than  beneficial.  It  changes  thought  into 
reverie."  Finally,  Zola  says:  "I  have  no  definite 
opinion  on  the  question.  Personally  I  gave  up  smok- 
ing ten  or  twelve  years  ago  on  the  advice  of  my  medi- 
cal attendant,  when  I  believed  myself  to  be  affected 
with  heart  disease.  But  to  suppose  that  tobacco  exer- 
cises an  influence  on  French  literature  raises  a  ques- 
tion of  such  magnitude  that  the  most  rigid  scientific 
proof  alone  could  dispose  of  it.  I  have  known  great 
writers  who  smoked  without  stint,  but  their  intellects 
were  riot  one  whit  less  acute.  If  genius  be  neurosis, 
then  why  seek  to  cure  it?  Perfection  is  such  a  very 
tiresome  thing  that  I  very  often  regret  having  broken 
myself  of  the  tobacco  habit." — Lancet. 

Health  Reports. — The  following  statistics  concern- 
ing yellow  fever,  small-pox,  and  cholera  have  been 
received  in  the  office  of  the  supervising  surgeon-gen- 
eral of  the  United  States  Marine  Hospital  service, 
lUiring  the  week  ended  November  13,  1897  : 

Yellow  Fever— United  States. 

Cases.   Deaths. 

.\  lahaina,  Flomaton November  3d  65 

tJrcensboro November  2d i  i 

Mobile November  6th  to  1 2th     29  6 

.\Iontgomery November  6th  to  loth 6  i 

Selma November  loth i 

Whistler November  6th  to  12th  ...       .  16  2 

Louisiana,  Baton  Rouge  . . .  November  nth i 

New  Orleans  . . .  November  «h  to  12th 84  36 

Mississippi,  Biloxi November  5th  to  1  ilh 11  1 

Clinton November  i2th 2 

Edwards November  8th  and  12th  6 

Pascagoula November  8th  and  loth i 

.Scranton November  8th  and  loth 4  1 

(Memphis November  4th  to  7th 5  ; 


Yellow  Feve 


-Fore 


S.MALL-Pox— Foreign. 

Bohemia,  Prague October  i6th  to  23d i 

China,  Hong  Kong .September  26th  to  October  2d  .     i 

Cuba,  .Sagua  la  Grande October  23d  to  30th 46 

Japan,  Fukushima  Ken October  1st  to  10th,    .-- 4 

Kagoshima  Ken October  ist  to  loth 1 

Miyagi  Ken October  ist  to  joth 2 

Nagasaki  Ken October  ist  to  loth 

The  Hokkaido October  ist  to  loth 7 

Scotland,  Edinburgh October  i6th  to  23d 

Glasgow October  i6th  to  23d 4 

U.S.  of  Colombia,  Cartagena. October  5th  to  12th 7 

Cholera — Foreign. 

India,  Madras September  25th  to  October  ist.    . . 

Japan,  Tokio  Fu October  ist  to  loth 3 


Cuba,  Ouantanamo. September  ist  to -toth .. 

Matanzas October  20th  to  November  3d..  . . 

Sagua  la  (irande.. .  - .  October  23d  to  30th 49 

Jamaica,  Buff  Bay October  i6th  to  23d. i 

Kingston July  2.3d  to  October  a3d .ti6  j 

IManchester July  23d  to  October  23d 9 

Port  Antonio July  23d  to  October  23d,   ...        4 

.St   Elizabeth July  23d  to  October  23d i 

Nicaragua,  Leon October  ist 

Port  Rico,  Cape  Haytien. . . .  November  6th Yellow  fcvt 

r»*  ported. 


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Wounds  in  War.  By  Surg. -Col.  W.  F.  Stevenson.  Svo, 
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^mtntcv  Bcaltli  ^csovts. 

Intelligent  people  everywhere  recognize  the  import- 
ance of  pure  air  and  sunshine  as  the  essential  means 
of  acquiring  a  healthy  constitution  and  maintaining  it, 
and  as  indispensable  for  restoring  it  when  from  any 
cause  it  has  become  impaired.  But  it  is  only  just 
now,  as  it  were,  that  people  have  begun  to  learn  the 
twofold  eftect  of  a  bountiful  supply  of  pure  air  and 
sunshine;  that,  while  these  agents  are  essential  to  the 
procurement  and  maintenance  of  human  health,  they 
are  inimical  to  microbic  life,  and  to  none  more  so 
than  to  the  tubercle  bacillus;  and  conversely,  that 
climatic  or  any  other  conditions  restricting  the  need- 
ful supply  of  pure  air  and  sunshine  are  promotive  of 
microbic  life,  and  of  none  more  so  than  of  the  tubercle 
bacillus. 

Nevertheless,  the  rigor  of  the  winter  climate  in  the 
greater  part  of  the  northern  United  States,  where  pul- 
monary consumption  extensively  prevails,  is  such  as 
frequently  to  render  the  maintenance  of  the  primary 
conditions  essential  to  health  impracticable  for  those 
who  most  need  them — those  who  are  afflicted  with  or 
predisposed  to  consumption. 

Although  the  benefit  to  be  expected  from  a  change 
of  climate  under  the  circumstances  indicated  is  by  no 
means  limited  to  persons  so  afflicted  or  so  predisposed, 
the  best  test  of  the  benefit  to  be  expected  from  a 
health  resort  is  the  observed  relation  that  it  holds  to 
consumption  and  its  favoring  conditions,  as  compared 
with  the  locality  to  be  abandoned.  This  test  is  justi- 
fied by  the  fact  that  consumption  is  less  amenable  to 
mere  medical  treatment  than  any  other  disease,  and 
by  the  excess  of  the  mortality  caused  by  it  over  that 
of  any  other  disease  in  districts  where  it  prevails. 
Moreover,  places  relatively  exempt  from  consumption 
are  ordinarily  correspondingly  exempt  from  other  dis- 
eases propagated  by  bacteria,  and  via'  versa. 

But  every  observant  physician  knows  that  the  cure 
of  consumption  by  ciiange  of  climate  depends  upon  the 
promptitude  with  which  the  change  is  made— that  it 
should  be  made  at  the  earliest  possible  period  after 
the  incipient  symptoms  have  been  discovered,  when 
the  constitution  is  otherwise  sound  and  the  physiolog- 
ical functions  are  regular.  In  such  cases  a  cure  is 
frequently  etTected  by  a  judicious  change  of  climate, 
and  in  those  predisposed  to  consumption,  before  it 
has  been  developed  by  unfavorable  conditions  and  ex- 
posure, resort  to  some  place  where  there  are  a  large 
preponderance  of  sunshiny  days  and  a  temperature 
that  will  admit  of  much  outdoor  exposure,  where  it  is 
neither  too  cold  nor  oppressively  warm,  where  the 
food  is  wholesome  and  the  water  pure,  where  commo- 
dious and  well-ventilated  bedrooms  and  healthful  sur- 
roundings are  obtainable,  the  disease  is  preventable. 

Such  resorts,  approximately,  it  is  the  purpose  of  this 
paper  to  designate. 

Ocean  a.nd   Hicn-Ai/rrrunK   Resokis. 

Recent  knowledge  of  microbic  life,  as  related  to  the 
purity  of  the  atmosphere,  justifies  the  inference  that 
the  benefit  to  consumptives  derived  from  sea  voyages 


or  from  resort  to  high  altitudes  is  independent  alike 
of  the  extreme  density  and  moisture  of  the  ocean  atmos- 
phere in  the  one  case,  and  of  the  rarefaction  and  dry- 
ness of  the  air  in  the  other.  In  both  cases  the  air  is 
inimical  to  tubercle  bacilli,  as  it  is  also  inimical  to 
other  bacilli — indeed,  to  all  microbic  life.  And,  bar- 
ring the  preventable  conditions  of  a  foul  bilge  and  in- 
adequate ventilation  of  staterooms  and  other  sleeping- 
quarters  on  board  ship:  close  bedrooms,  defective 
house  drainage,  unhealthful  surroundings,  and  dust — 
barring  these  conditions  respectively,  ocean  atmos- 
phere and  high  altitude  are  alike  propitious  and  com- 
mendable to  persons  afflicted  with  or  predisposed  to 
pulmonary  consumption. 

Ocean  air,  however,  it  should  be  understood,  is  not 
the  air  of  the  seacoast,  but  of  the  open  sea,  suffi- 
ciently distant  from  the  land  to  be  free  from  all  con- 
tamination. It  is  more  equable  and,  in  correspond- 
ing latitudes,  excepting  the  tropics,  warmer  than  over 
the  land;  and  within  the  tropics,  though  warm,  is 
never  sultry,  as  it  is  at  the  same  degree  of  temperature 
on  the  land,  nor  is  the  temperature  so  high.  In  the 
tropics,  the  range  of  the  thermometer  at  sea  is  from 
72°  to  84"  F.,  and  rarely  as  high  as  86°  F.  at  midday. 
The  mean  relative  humidity  is  about  73.5  per  cent. 
(100  representing  complete  saturation).  The  humid- 
ity is  usually  a  little  greater  in  the  night  than  during 
the  day,  but  commonly  is  less  at  all  times  than  that  of 
the  air  of  seacoast  places. 

Besides  the  excess  of  moisture,  as  compared  with 
that  of  the  land  distant  from  the  seacoast,  the  ocean 
air  always  contains  some  sea  salt,  although,  excepting 
in  the  trade  winds  or  in  gales,  in  infinitesimal  quan- 
tity ;  never  in  such  excess  even  in  the  trade  winds 
or  gales  as  to  be  otherwise  than  a  healthful  stimulus 
to  respiration.  It  also  possesses  properties  beneficial 
to  certain  specific  diseases. 

The  special  advantages  of  an  ocean  atmosphere  are : 

1.  Its  entire  freedom  from  the  dust  common  to  do- 
mestic conditions — particles  of  tissue  wastes  of  all 
sorts,  hair,  straw,  feathers,  cobwebs,  insects,  dried 
sputa,  etc. ;  from  traffic  dust — the  wear  of  travel  and 
friction;  from  all  insoluble  and  irritating  grit  wafted 
from  paved  streets,  houses,  walls,  dusty  roads,  or  sandy 
plains.  It  is  air,  in  short,  that  contains  a  maximum 
of  the  elements  essential  to  life  and  health,  and  a 
minimum  only  or  none  at  all  of  the  deleterious  sub- 
stances always  floating,  in  greater  or  lesser  degree,  in 
the  lower  stratum  of  the  atmosphere  over  the  land. 

2.  Complete  change  of  scene  and  rest;  relief  from 
all  sources  of  excitement  and  worry — newspapers,  tel- 
egrams, messenger  boys,  letters,  expectations,  and  all 
sorts  of  inde.scribable  turmoil.  And  the  passing 
breeze  is  not  from  just  over  the  marsh  or  stagnant 
pond,  nor  is  it  from  the  malodorous  tenement-house 
district;  it  bears  no  foul  emanations  and  no  disease 
germs.  F.very  breath  of  it  is  brand  new,  and  when 
exhaled  it  never  hovers  round  to  taint  the  next  inspi- 
ration, but  is  wafted  away  and  speedily  transformed 
into  the  pure  elements  of  the  atmosphere. 

Thus  inhaled  throughout  the  day,  the  pure  soft  air 
soothes  the  nerves,  invigorates  the  functions,  promotes 
sleepiness,  and  welcomes  repose.  Sound  slumber  su- 
pervenes, and  with  no  business  appointments  to  be  met 


762 


abundant  time  is  taken  for  breakfast,  dinner,  and 
supper — with  an  invigorated  appetite  and  improved 
digestion. 

I  he  invalids  to  whom  an  ocean  atmosphere  is  most 
commendable  are  pointed  out  by  that  which  is  just 
above  stated — consumptives  in  the  incipient  stage 
and  persons  predisposed  to  consumption ;  persons  of 
scrofulous  diathesis:  persons  afflicted  with  nervous 
complaints — not  organic  ner\ous  diseases,  but  the  easily 
recognized  conditions  of  o\erwork  though  often  unde- 
finable,  the  result  of  physical  or  mental  nervous  strain, 
anxiety,  worry,  irritability,  debility,  nenous  break- 
down, insomnia;  and  persons  afflicted  with  chronic 
nephritis. 

But  firstly  of— 

IXL.AXD    AXD    SeaCOAST    ReSORTS. 

U'iiiter  resorts — resorts  for  invalids  that  will  per- 
mit the  utmost  outdoor  exposure — are  not  to  be  found 
north  of  or  even  in  the  vicinity  of  New  York  City. 
It  may  be  remarked,  however,  in  relation  to  the  con- 
stant danger  of  nervous  or  physical  breakdown  of  those 
who  are  too  intensely  engaged  in  the  struggle  for  pre- 
eminence in  cit)-  occupations,  that  the  difference  in 
the  temperature  of  the  atmosphere,  or  mere  change  of 
place,  is  of  much  less  significance  to  them  than  rest— 
rest,  though  it  may  be  but  for  a  week  or  two,  or  for 
even  a  few  days  at  a  time,  with  such  a  total  relin- 
quishment of  their  occupations  and  under  such  condi- 
tions as  will  admit  of  recuperation. 

Lakewood,  N.  J.,  about  two  hours  from  New  York, 
situated  on  a  sandy  soil,  seventy  feet  above  sea  level, 
in  the  midst  of  a  pine-woods  region,  is  an  admirably 
appointed  resort  for  rest  and  recuperation,  with  abun- 
dant hotel  accommodations  at  moderate  rates. 

Atlantic  City,  ninety  minutes  from  Philadelphia 
and  four  hours  from  New  York  by  railroad,  besides 
being  a  deservedly  popular  summer  resort,  possesses 
some  unusual  advantages  as  a  winter  resort,  consider- 
ing its  latitude.  The  trend  of  the  coast  at  this  point 
is  such  as  to  bring  it  almost  directly  in  the  face  of  the 
westerly  and  northwesterly  winds,  which  considerably 
modify  the  temperature  of  the  ocean  atmosphere. 
According  to  the  records  of  the  United  States  signal 
station  at  Atlantic  City,  as  published  several  years 
ago,  the  average  mean  temperature  for  December, 
Januar),  February,  and  March  for  a  number  of  years 
was  35.8°  F;  The  prevailing  winds  in  winter  are  from 
the  west  and  northwest.  Several  hotels  are  kept  open 
during  the  winter,  at  moderate  rates. 

Old  Point  Comfort,  with  its  delightful  Hotel  Cham- 
berlain, is  the  favorite  winter  resort  for  those  not  car- 
ing for  a  more  southern  climate.  The  hotel  is  admi- 
rably equipped  with  every  appurtenance  promotive  of 
comfort  and  pleasure  — open-air  pavilions  over  the 
water,  verandas  inclosed  in  glass,  enabling  invalids 
to  enjoy  the  sunshine  and  water  view  without  exposure: 
in  short,  everything  calculated  to  make  a  sojourn  here 
pleasant.  As  a  place  of  rest  for  the  overworked  and 
those  suflfering  from  insomnia  and  worn,-,  Old  I'oint 
Comfort  with  all  its  attractions  is  commendable. 

Virginia  Beach,  thirty  miles  from  Old  Point  Com- 
fort and  si.v  miles  south  of  Cape  Henry,  comprehends 
similar  conditions  and  advantages,  with  the  ;iddition 
of  pine  woods,  which  e.vercise  a  modifying  influence 
on  the  climate.  And  here  it  may  be  remarked  of  pine 
forests  generally  that  they  add  to'the  salubrity  of  their 
region.  Kven  the  great  Dismal  Swamp  forests  of  \'ir- 
ginia  and  North  Carolina  are  known  to  be  healthful 
in  the  interior,  while  on  its  borders  or  in  portions 
where  the  trees  are  felled  it  is.  like  the  .seacoast.  com- 
monly insalubrious.  Humid  air  charged  with  mias- 
matic emanations  is  deprived  of  them  in  passing 
through  a  pine  forest.  .At  Virginia  Beach  the  Prin- 
cess Anne  Hotel,  with  every  modern  convenience,  is 


MEDICAL    RECORD.  [November  2-j,  iZc^-j 

situated  within  a  few  yards  of  the  ocean  while  at  the 
rear  of  the  hotel  is  the  dense  pine  forests. 

Old  Point  Comfort  and  ^'irginia  Beach,  as  well  as 
Norfolk,  are  accessible  from  New  York  bv  the  Old 
Dominion  Steamship  Companv's  line.  Fares  from 
New  York  to  Old  Point,  S8 ;  round  trip,  S13.  The 
same  to  Norfolk.  To  Virginia  Beach,  S8.50:  round 
t"P,  $i3-5°-  Hotel  rates,  S3  to  $5  per  dav.  The  Old 
Dominion  line  dispatches  one  of  its  com'fortable  and 
commodious  ocean-going  steamers  every  week  day  for 
these  Virginia  ports,  and  the  night  at  sea  generally 
proves  a  delightful  break  in  the  journey. 

"  The  Warm  Springs  Valley  "  of  Virginia  derives 
Its  popular  name  from  the  numerous  supplies  of  thermal 
mineral  waters  which  it  affords.  It  is  a  valley  of  about 
two  miles  in  average  breadth  and  nearlv  thirtv  miles  in 
length,  parallel  with  the  main  Alleghany  d'ivide,  be- 
tween towering  mountains,  from  the  crest  of  which, 
four  thousand  feet  above  sea  level,  the  intervening' 
stretches  of  country  present  a  mar\ellous  panorama  of 
mountain  scenery. 

The  altitude  of  the  valley  (about  eighteen  hundred 
feetj  and  its  protection  by  the  surrounding  mountains 
from  wind  storms  and  sudden  changes,  combine  to 
produce  a  temperature  relatively  mild  for  the  winter  in 
this  latitude,  and  delightful  for  the  rest  of  the  vear. 
Moreover,  there  are  at  short  distances  apart  many  gaps 
through  the  mountains,  extending  quite  to  the  foot  of 
the  ridge,  and  these  present  picturesque  gorges,  some 
with  narrow  roads,  but  many  with  creeks  winding 
their  way  to  Jackson  River,  a' tributary  of  the  James. 
This  somewhat  peculiar  topographical' feature  insures 
excellent  drainage  of  the  soil  and  atmospheric  circu- 
lation, an  exceptional  advantage  not  often  found  in 
narrow  valleys  hemmed  in  by  lofty  mountains,  which 
exclude  the  sun's  rays  for  a  considerable  portion  of 
the  day. 

The  Hot  Springs  lie  at  the  head  of  one  of  these 
intersecting  gorges,  and  Cedar  Creek,  which  is  formed 
by  the  united  body  of  their  waters,  rushes  down  the 
steep  declivity  of  the  gorges,  so  as  to  clear  the  main 
valley  within  a  few  feet  from  their  sources.  Twelve 
or  fifteen  miles  from  Hot  Springs  the  vallev  terminates 
abruptly  by  merging  into  that  of  Jackson  River,  but 
at  an  elevation  of  about  two  hundred  feet  above  the 
river:  and  just  here  the  Falling  Springs  Creek,  de- 
scending from  the  Warm  Springs  Mountain  on  the 
east,  crosses  the  road,  and  thus  presents  the  picturesque 
spectacle  of  an  unbroken  fall  from  the  top  of  the  preci- 
pice to  the  valley  beneath.  This  miniature  cataract, 
miniature  as  to  breadth  and  volume  of  water,  is  half 
as  high  again  as  that  of  Niagara,  and  was  considered 
by  Mr.  Jefferson  worthy  of  description  in  his  "Notes 
of  Virginia." 

The  waters  of  these  springs— Hot  and  Warm  Springs 
(Bath  County)— have  been  analyzed  by  several  dis- 
tinguished chemists,  with  nearly  identical  results. 
They  are  classifiable  chiefly  as  alkaline-calcic.  The 
Boiler  Spring,  in  particular,  has  been  not  inaptly  com- 
pared with  the  springs  at  Aix-les-Bains,  in  France, 
though  it  has  a  slightly  higher  temperature— Boiler 
Spring,  temperature,  108'  F. ;  Aix-les-Bains,  103'  F. 

Grains 

Magnesium  sulphate 8.476 

M.ignesium  carbonate -!oi8 

Calcium  sulphate 1.805 

Calcium  carbonate 23.076 

-Soilium  sulphate 3!  684 

Pot.assiuni  chloride \%t\ 

Silica ;;.;:::;;;:::;;:;;  u^^, 

'•■'"a' 42-614 

Carbonic  acid  is  given  off  freely,  hut  is  not  here 
measured. 

The   hotel    accommodations   and   the   facilities  for 


November  27,  1897] 


MEDICAL    RECORD. 


76: 


using  the  waters  are  abundant  and  excellent,  and  at 
moderate  rates. 

A  branch  railway,  twent)'-five  miles  in  length,  has 
recently  been  built  from  Covington,  Va.,  to  the  Hot 
Springs,  and  direct  connection  is  made  with  through 
trains  east  and  west  bound  on  the  main  line  of  the 
Chesapeake  and  Ohio.  The  Warm  Springs  Valley 
can  now  be  reached  by  rail  in  fourteen  hours  from 
New  York,  twelve  hours  from  Philadelphia,  nine  hours 
from  Baltimore,  eight  hours  from  Washington  and 
Richmond,  ten  hours  from  Norfolk,  and  twelve  hours 
from  Cincinnati.  Arrangements  can  be  made  when 
desired  to  run  through  cars  from  any  of  the  cities 
named,  or  from  points  beyond,  direct  to  the  Hot 
Springs. 

Especial  attention  is  invited  to  the  fact  that  the 
Hot  and  Warm  Springs  Valley  lies  midway  between 
New  York  and  Cincinnati,  and  is  reached  in  one 
night's  ride  from  either  point. 

For  many  persons  a  most  restful  change  from  the 
monotony  of  daily  life  may  be  obtained  by  a  trip  on 
one  of  the  many  stanch  and  beautiful  steamships  of 
the  Atlantic  coastwise  routes,  or  the  trip  may  be  ex- 
tended to  such  nearby  places  as  Bermuda,  the  Bahama 
Islands,  Jamaica,  or  still  farther  to  the  Windward  Isl- 
ands, the  most  eastwardly  of  the  West  India  group. 

A  trip  to  Cuba  just  now  naturally  does  not  present 
much  attraction.  We  have  already  referred  to  the 
steamers  of  the  Old  Dominion  Steamship  Line  to  Nor- 
folk. In  addition  to  these  there  are  steamers  running 
regularly  every  week  and  oftener  to  Charleston,  to  Sa- 
vannah, and  to  Jacksonville,  Fla. 

The  Bermudas  are  within  fortj'-eight  hours  of  New 
York,  in  the  same  latitude,  32°  45'  N.,  as  Charleston, 
S.  C..  and  six  hundred  miles  east  of  that  city.  There 
are  three  hundred  and  sixty-five  islands  in  the  group, 
counting  some  ver}-  small  islets,  all  formed  by  the  ir- 
regular crests  of  a  bank  of  coral  and  separated  by  nar- 
row channels.  The  most  of  them  are  covered  with  semi- 
tropical  vegetation,  and  some  of  them  are  remarkably 
beautiful  and  picturesque.  Only  about  twenty  of  them 
are  occupied  as  dwelling-places,  but  all  are  delightful 
points  for  boating  and  fishing.  Bermuda,  the  princi- 
pal member  of  the  group,  is  sixteen  miles  long  by  one 
and  one-half  miles  wide.  Hamilton,  the  chief  town, 
has  about  eight  thousand  inhabitants,  and  several  ex- 
cellent hotels,  at  from  S2  to  $4  a  day,  or  Si 2  to  $21  a 
week;  and  a  number  of  good  boarding-houses,  at  Sio 
to  Si 2  a  week.  St.  George,  on  an  island  of  the  same 
name  and  next  in  importance  to  Bermuda,  approxi- 
mates Hamilton  in  the  excellence  of  its  hotels  and 
boarding-houses,  and  at  similar  rates.  St.  David's, 
Somerset,  and  Ireland  are  also  important  islands,  and 
are  alike  enjoyable  for  the  beauty  of  the  scener>'  and 
the  excellence  of  the  roads.  There  are  no  mountains 
to  climb  and  no  rivers  to  cross  in  Bermuda — the  great- 
est altitude  being  but  about  two  hundred  feet  above 
sea  level ;  but  there  are  many  rocky  towers  and  preci- 
pitous roadbanks  and  as  many  deep  cuttings  needful 
to  reach  the  beautifully  level  roadbed — hard  and  gen- 
erally without  dust.  There  is  no  end  to  these  roads 
(altogether  they  are  said  to  be  nearly  two  hundred 
miles  in  length),  at  one  instant  winding  through 
artificial  gorges  whose  banks  are  overhung  by  a  pro- 
fusion of  trailing  plants,  maiden-hair  ferns,  and  fra- 
grant flowers,  and  at  the  next,  with  glimpses  of  the  sea 
and  the  islets  scattered  round  flashing  into  view,  re- 
vealing new  pictures  in  the  ever-changing  beauty  of 
the  scene. 

These  islands  are  reached  by  the  steamers  of  the 
Quebec  Steamship  Line. 

Nassau,  the  capital  of  the  Bahamas — the  most  north- 
ern of  the  West  India  Islands — situated  on  an  eleva- 
tion about  seventy-five  feet  above  sea  level,  in  lati- 
tude 25"  5'  N.,  has  been  long  and  justly  regarded  as 


a  congenial  winter  resort  for  consumptives,  for  those 
affected  with  nervous  disorders  and  breakdowns,  and 
for  invalids  with  Bright's  disease.  The  streets  are  of 
the  natural  limestone  rock,  and  there  are  several  inter- 
esting drives  about  the  island.  There  are  a  tropical 
profusion  of  flowers  and  trees,  a  public  library,  muse- 
ums, and  several  churches.  The  Royal  Victoria  Hotel 
is  open  during  the  winter  and  has  an  excellent  repu- 
tation;  $2.50  to  $4  a  day.  Harbor  Island,  a  few  miles 
distant  from  Nassau,  is  also  a  place  of  good  repute, 
but  the  writer  has  no  knowledge  of  its  hotel  accommo- 
dations. The  mean  winter  temperature  of  Nassau  is 
about  70°  P.;  the  range  is  from  64°  to  82°  F.  It  is 
accessible  by  means  of  the  Ward  Line,  113  Wall 
Street,  New  York.  As  the  fleet  of  this  line  is  large,  it 
makes  weekly  sailings  and  excursions  to  Nassau 
for  S50,  to  Mexico  for  Si 00,  to  Cuba  for  S6o.  An- 
other excursion  of  twenty-two  days  to  Nassau  and  to 
the  south  side  of  Cuba  is  oft'ered  by  this  company,  the 
entire  cost  being  Si 00,  including  board  while  in 
port. 

Jamaica  is  the  largest  of  the  British  West  India 
Islands,  comprehending  an  area  of  forty-four  hundred 
and  forty-two  square  miles,  and  a  population  of  about 
six  hundred  thousand.  The  general  appearance  of 
the  island  is  exceedingly  beautiful,  but  not  all  of  it 
is  healthful.  The  Blue  Slountains  extend  through  its 
entire  length;  indeed,  the  whole  island  is  wellnigh 
comprehended  in  them,  for,  on  all  sides  from  the 
water's  edge  up,  the  ascent  is  in  ridges  and  hills  of 
continuously  increasing  altitudes,  intersected  by  vales 
and  streams  with  more  or  less  abrupt  precipices  and 
overhanging  cliffs — all  covered  with  richest  tropical 
groves  and  undergrowth,  exhibiting  tlie  most  romantic 
scenery,  and  culminating  at  a  height  of  seventv-three 
hundred  feet  above  sea  level,  yet  never  capped  with 
snow. 

Between  the  mountain  ranges  and  ridges  there  are 
extensive  plains  and  spacious  savannas,  whose  water- 
logged soil,  like  that  along  a  considerable  portion  of 
the  extensive  coast  line  of  over  five  hundred  miles,  is 
more  or  less  productive  of  malarial  fevers.  But  these 
localities  are  easily  avoided,  as  they  should  be,  by 
resort  to  some  of  the  many  healthful  localities  on  the 
mountain  slope,  at  an  altitude  of  twenty-five  hundred 
feet  and  upward,  entirely  exempt  from  malarial  dis- 
eases. At  this  altitude  (twenty-five  hundred  feet)  the 
winter  range  of  temperature  is  from  55  to  65  F.  It 
is  about  one  degree  lower  for  every  three  hundred  and 
forty-five  feet  increase  of  altitude.  Mineral  springs 
have  been  discovered  in  several  localities  in  the  island; 
with  but  one  exception  there  is  no  published  analysis 
of  the  waters,  and  this  is  of  the  ''sulphurous  sodic- 
calcic  thermal  springs,"  near  the  village  of  Bath, 
about  twenty  miles  from  Kingston,  reached  by  an  ex- 
cellent road  through  beautiful  scener}-.  The  waters 
are  said  to  resemble  those  of  Bath  in  England,  and  to 
be  of  much  value  in  the  treatment  of  rheumatism  and 
gout.  The  published  analysis  gives  the  following 
chemical  constituents  in  one  gallon  of  the  water: 

Chloride  of  sodium 13.84 

Chloride  of  potassium 0.32 

Sulphate  of  calcium 5.01 

Sulphate  of  sodium 6.37 

Carbonate  of  sodium 1.69 

Silica 2. 72 

0.\ide  of  sodium  combined  with  silica i.oo 

Organic  matter o.gt) 

The  springs  are  situated  in  a  deep  ravine  about  one 
and  one-half  miles  from  the  village,  accessible  by  a 
good  road,  where  bathhouses  have  been  constructed 
for  those  who  wish  to  use  the  waters.  The  island  is 
intersected  by  splendid  macadamized  roads,  besides 
railways,  and,  considering  the  large  number  of  acces- 
sible and   well-appointed   localities,  with  good   hotels 


764 


MEDICAL    RECORD. 


[November  27,  1897 


at  $3  to  S4  a  day,  at  various  altitudes  and  with  liealth- 
ful  surroundings,  it  is,  taken  altogetlier,  a  winter  re- 
sort of  exceptional  excellence.  On  account  of  the 
rainfall,  however,  which  is  great  at  other  seasons,  the 
preferable  period  for  enjoying  tlie  climate  of  Jamaica 
is  precisely  that  which  is  the  most  convenient  for 
rounding  out  this  winter  voyage — January  to  March, 
the  relatively  dry  season. 

This  island  is  reached  by  steamers  of  the  Quebec 
Steamship  Company,  and  also  by  the  Atlas  Line  from 
New  York. 

For  those  who  have  the  time  and  inclination,  a  trip 
by  the  steamers  of  the  Quebec  Steamship  Company  to 
the  Windward  Islands  is  extremely  delightful.  The 
first  stop  of  this  line  is  at  .Santa  Cruz.  Next  comes 
the  Island  of  St.  Thomas.  These  two  islands  are  un- 
der the  Danish  government.     "  English  spoken." 

Then  comes  St.  Kitts,  an  English  island  of  great 
beauty  and  fertility,  with  good  hotel  accommodations. 
Sixty  miles  east  the  steamer  touches  Antigua,  also 
under  the  English  government.  Then  come  Guada- 
lupe, Dominica,  and  Martinique.  Santa  Lucia  comes 
•next,  and  then  Barbadoes,  the  most  eastward  of  the 
Windward  Islands,  in  latitude  13°  10'  N.,  and  longi- 
tude 59  32'  \V.  Steamers  of  this  line  often  touch 
at  other  smaller  islands.  The  rates  of  passage  in- 
clude living  on  the  steamer  from  the  time  one  leaves 
New  York  until  he  returns. 

Still  another  but  shorter  voyage  is  by  the  vessels  of 
the  Red  "  D"  Line  to  Cura^;oa  and  Caracas,  both  in- 
teresting and  healthful  winter  resorts.  Curacoa  is  a 
Dutch  island,  in  latitude  12"  20'  N.,  about  fifty 
miles  from  the  coast  of  Venezuela,  with  a  climate  very 
similar  to  that  of  Barbadoes.  Caracas,  the  capital  of 
Venezuela,  is  in  latitude  10  30'  N.  The  city  is  ad- 
mirably laid  out,  radiating  from  a  beautiful  park  in 
the  centre  of  the  town  and  following  the  cardinal 
points  of  the  compass.  There  are  many  fine  buildings 
and  magnificent  suburbs,  intersected  by  good  roads. 

The  winter  climate  is  agreeably  cool  and  equable. 
The  thermometer  averages  about  65°  F.  during  the 
night,  and  in  the  early  morning  ranges  from  50'  to  55  ' 
F. ;  it  rarely  rises  to  75"  F.  at  midday.  Few  climates 
present  such  favorable  conditions  in  altitude  and  tem- 
perature. 

There  are  several  excellent  hotels,  at  from  S2.50  to  S4 
a  day,  where  English-speaking  servants  are  employed. 
Carriage'  hire  is  regulated  by  tariff — thirtj'  cents  for 
each  person  to  any  part  of  the  city.  Street-car  routes 
from  the  railway  stations  pass  all  of  the  hotels. 

Rates  of  passage:  New  York  to  La  Guayra.  j8o: 
to  Cura(;oa,  $70:   round  trip,  $144. 

The    Carolinas. 

The  middle  section  of  North  Carolina  ranges  from 
six  hundred  to  fifteen  hundred  feet  above  sea  level. 
It  is,  for  the  most  part,  covered  with  pitch  pine,  and  is 
remarkably  healthful.  The  mean  winter  temperature 
is  from  40°  to  45°  F.,  and  the  relative  humidity  69 
per  cent. 

Southern  Pines,  seventy  miles  beyond  Raleigh,  on 
the  Seaboard  Air  Line,  from  Norfolk,  is  situated  at  an 
elevation  of  about  six  hundred  feet  above  sea  level,  in 
the  midst  of  the  pine-wood  region.  The  average  win- 
ter temperature  is  44°  F.,  and  the  atmosphere  relatively 
dry.  It  is  a  new  resort  and  yet  in  process  of  improve- 
ment. The  Piney  Woods  Inn  is  the  principal  place 
at  which  to  stop. 

Pinehurst,  six  miles  west  of  Southern  Pines  (con- 
necting by  electric  cars),  possesses  the  same  advantages 
of  local  and  climatic  conditions,  with  more  advanced 
improvement  round  about,  and  hotel  accommodations 
about  the  same.  There  are  excellent  roads,  reason- 
able carriage  rates,  and  interesting  forest  drives  all 
about  both  these  places. 


Asheville,  a  charmingly  situated  city,  twent\-two 
hundred  and  fifty  feet  above  sea  level,  enjoys  an  ad- 
mirably pure  atmosphere,  though  it  is  rather  cold  for 
very  sensitive  invalids.  Mean  winter  temperature, 
37.8°  F. ;  relative  humidity,  69.3  per  cent.  It  pos- 
sesses all  the  advantages  of  the  most  highly  favored 
winter  resorts  of  southern  Blurope,  besides  the  addi- 
tional advantage  of  freedom  from  the  sudden  changes 
of  temperature  common  to  those  resorts.  Hotels  are 
commodious  and  excellent,  at  from  $3  to  §5  a  day. 
The  drives  and  scenery  are  superb.  Asheville  is 
reached  by  six  routes  of  travel,  and  each  of  them  has 
features  interesting  to  tourists. 

First,  r/(7  the  western  North  Carolina  division  of  the 
Richmond  and  Danville  Railroad,  seventy-nine  miles 
from  SaVishmy,  j\/i>rj^a>i/o»  (Hunt  House)  is  a  popular 
resort,  eleven  hundred  feet  above  sea  level,  with 
charming  scenery.  Twenty-five  miles  farther  on  is 
Linville  Gorge,  where  the  Linville  River  bursts  through 
the  Linville  Mountains.  The  gorge  is  fifteen  miles 
in  length,  and  the  heights  which  overshadow  it  are 
not  less  than  two  thousand  feet.  The  river  plunges 
over  a  precipice  one  hundred  feet  high  and  one 
hundred  and  fifty  feet  broad,  and  then  rushes  for- 
ward over  a  bed  of  rock.  Cliffs  worn  by  the  ceaseless 
action  of  the  water  into  the  most  fantastic  shapes 
hang  over  it,  detached  masses  strew  the  channel,  and 
the  tumult  of  its  fretted  waters  ceases  only  when  pauses 
now  and  then  occur  in  crystal  pools  of  placid  gentle- 
ness. The  route  continues  exceedingly  picturesque 
until  it  pierces  the  Blue  Ridge  by  the  Swannanoa  Tun- 
nel, eighteen  hundred  feet  long  and  twenty-seven  hun- 
dred feet  above  sea  level,  and  then  gradually  descends 
into  the  elevated  basin  in  which  Asheville  lies,  along 
the  bank  of  the  Swannanoa,  one  of  the  loveliest  of 
North  Carolina  rivers. 

Second :  From  Spartanburg,  S.  C,  seventy  miles 
by  the  Asheville  and  Spartanburg  branch  of  the  Rich- 
mond and  Danville  Railroad. 

Third:  From  Charlotte,  N.  C.,by  railway  to  States- 
ville  on  the  Western  North  Carolina  Railway;  or  to 
Shelby,  on  the  Shelby  division  of  the  South  Carolina 
Railway,  and  thence  to  Lincolnton  and  Hickory,  on 
the  Western  North  Carolina  Railroad.  This  route  is 
through  the  famous  Hickory  A'//f  Gap,  the  scener}'  of 
which  has  been  declared  by  some  European  travellers  to 
be  equal  in  beauty  and  grandeur  to  that  of  any  pass  in 
the  Alps.  The  entire  length  of  the  Gap  is  about  nine 
miles,  the  last  five  being  watered  by  the  Rocky  Broad 
River.  The  gateway  of  the  gorge  on  the  eastern  side 
is  about  one-half  mile  wide,  and  from  this  point  the 
road  winds  upward  along  a  narrow  pass,  hemmed  in 
on  all  sides  by  stately  heights.  From  the  summit  of 
the  Gap  there  is  a  magnificent  view  in  all  directions. 

Fourth — for  those  who  would  prefer  to  journey  with 
less  speed  than  by  the  railroad,  for  the  sake  of  the  great- 
er enjoyment  of  the  scenery  :  By  stage  from  Greenville, 
S.  C,  via  Saluda  Gap,  Flat  Rock,  and  Hendersonville, 
to  Asheville,  sixty  miles.  Flat  Rock,  once  the  most 
frequented  of  Carolina  resorts,  has  been  somewhat 
shorn  of  its  glories  during  recent  years,  but  the  lovely 
valley  of  its  site  still  remains  and  yot  contains  some 
noble  mansions,  surrounded  by  gardens  filled  with  the 
rarest  and  most  beautiful  shrubbery  and  flowers. 

Fifth,  also  by  stage  from  Greenville,  via  Ime's  Gap 
and  Caesar's  Head  to  Asheville,  about  seventy-five 
miles.  Ctesars  Head  is  a  bold  and  beautiful  head- 
land, and  will  well  repay  a  visit  in  passing.  And  just 
Ijeyond  is  Cashier's  Valley,  famous  for  its  salubrious 
climate.  It  is  more  of  a  tableland  than  a  valley,  lying 
on  the  side  of  the  Blue  Ridge,  about  thirt}-five  hun- 
dred feet  above  sea  level,  and  hemmed  in  on  all  sides 
by  higher  peaks,  the  highest  of  which  is  Chimney 
Top.  On  the  southwestern  edge  of  the  valley  is  While 
Side  Mountain,  one  of  the  most  striking  peaks  in  North 


Xovember  27,  1897] 


MEDICAL    RECORD. 


765 


Carolina,  rising  to  the  height  of  more  than  tive  thou- 
sand feet  above  sea  level,  its  southern  face  being  an 
immense  precipice  of  white  rock  two  miles  long,  and 
so  curved  as  to  form  part  of  the  arc  of  a  circle,  with 
many  cave-like  recesses  with  wildly  picturesque  es- 
carpments around.  The  largest  of  these  recesses  is 
known  as  the  DeviFs  Supreme  Court  House ;  and,  ac- 
cording  to  Cherokee  tradition,  the  prince  of  the  pow- 
ers of  darkness  will  on  the  day  of  doom  erect  his  throne 
here  and  \.x\  all  the  spirits  who  fall  under  his  jurisdic- 
tion. The  approach  to  it  is  by  a  long,  narrow,  and 
dangerous  ledge,  upon  which  only  the  most  coolheaded 
should  venture  to  tread.  The  ascent  to  the  summit  of 
the  mountain  can  be  made  partly  on  horseback.  The 
view  from  the  summit  is  of  surpassing  grandeur.  '"To 
the  northeast,  as  far  as  the  eye  can  reach,  rise  a  multi- 
tude of  sharply  defined  blue  and  purple  peaks,  the 
valleys  between  them,  vast  and  filled  with  frightful 
ravines,  seeming  the  merest  gullies  on  the  earth's  sur- 
face. Farther  off  than  this  line  of  peaks  rise  the  dim 
outlines  of  the  Balsam  and  Smoky  ranges.  .  In  the 
distant  southwest,  looking  across  into  Georgia,  we  can 
descrj-  Mount  Yonah,  lonely  and  superb,  with  a  cloud 
reef  abou*  its  brow.  Sixt)-  miles  away,  in  South  Caro- 
lina, a  flash  of  simlight  reveals  the  roofs  of  the  Ger- 
man settlement  of  Walhalla;  and  on  the  southeast, 
beyond  the  precipices  and  ragged  projections,  towers 
Chimney  Top  Mountain,  while  the  Hog  Back  bends 
its  ugly  form  against  the  sky  and  Cold  Mountain 
rises  on  the  left.  Turning  to  the  north  we  behold 
Yellow  Mountain,  with  its  square  sides,  and  Short 
Off.  Beyond  and  beyond,  peaks  and  peaks,  and  ra- 
vines and  ravines!  It  is  like  looking  down  on  the 
world  from  a  balloon." 

Sixth  :  From  the  northwest  or  southwest,  by  the  East 
Tennessee,  Virginia,  and  Georgia  Railway  to  Morris- 
town,  Tenn. ;  thence  by  its  North  Carolina  division  to 
Wolf  Creek:  thence  by  the  Paint  Rock  branch  of  the 
Western  North  Carolina  division  of  the  Richmond  and 
Danville  Railroad,  which  traverses  the  valley  of  the 
French  Broad  to  Asheville  amid  magnificent  scenerj'. 

The  Warm  and  Hot  Springs  of  North  Carolina 
have  been  long  known  as  among  the  most  noted  min- 
eral waters  of  the  Southern  States.  They  are  situated 
in  Buncombe  County  on  the  western  bank  of  the 
French  Broad  River,  about  fort}'  miles  from  Asheville, 
and  are  accessible  by  railway. 

The  waters  vary  in  temperature  from  94"  to  104"  F. 
An  analysis  of  three  quarts  of  the  water  by  Prof.  E.  D. 
Smith  (Siniman's  Journal,  vol.  viii.)  gives  the  follow- 
ing constituents: 

Muriates  of  calcium  and  magnesium grs.  4 

Sulphate  of  magnesium "  6 

Sulphate  of  calcium "  14.5 

Insoluble  residue "  2.3 

Loss "  I 

Total grs.  2S 

Equal  to  4.66  grains  of  solids  in  a  pint. 

The  wTiter  is  unable  to  find  any  later  analysis,  but 
they  are  advertised  to  contain  '"  carbon  dioxide,  free 
hydrogen  sulphide,  carbonic  acid,  sulphuric  acid,  in 
combination  with  calcium  and  a  trace  of  magnesia." 
The  waters  are  chiefly  used  in  the  form  of  baths 
(though  sometimes  they  are  drunk),  for  which  there  are 
excellent  facilities.  They  are  of  creditable  repute  in 
the  treatment  of  rheumatism,  rheumatic  gout,  liver  and 
kidney  complaints,  and  cutaneous  diseases.  The 
locality  is  eminently  healthful  and  the  scenery  beau- 
tiful. 

Summerville,  S.  C,  twenty-two  miles  from  Charles- 
ton on  the  South  Carolina  Railroad,  has  long  been  a 
favorite  winter  resort  for  those  who  would  escape  the 
damp  and  chilly  winds  that  sweep  down  the  coast  It 
is  situated  on  a  ridge  extending  across  the  peninsula 


between  the  Cooper  and  Astley  rivers  and  covered  with 
pine  woods.  The  air  is  sou  and  balmv,  with  a  winter 
temperature  of  about  60'  F.,  seldom  rising  to  70'  and 
rarely  falling  below  55. 

The  Fine  Forest  Inn  is  a  commodious  and  well- 
fumished  hotel,  with  large  and  well-ventilated  bed, 
bath,  and  toilet  rooms  on  every  floor.  Its  rates  are 
from  $3  to  $5  a  day,  S17.50  to  I30  a  week.  It  has 
excellent  stables,  with  or  without  the  ser\-ices  of  ex- 
perienced drivers.  There  are  several  good  boarding- 
houses  with  prices  ranging  from  $7  to  Sio  a  week. 
The  roads  are  good,  and  there  are  many  places  of  his- 
torical interest  in  the  vicinit}-. 

Aiken  is  of  extensive  repute  for  its  healthfulness, 
and  few  places  are  more  favorably  known.  It  is  an 
expanded  village  of  about  three  thousand  inhabitants, 
situated  on  a  tableland  with  an  excellent  watershed, 
between  the  Savannah  and  Edisto  rivers  (but  at  a  con- 
siderable distance  from  either'),  at  an  elevation  of  five 
hundred  and  sixty-five  feet  above  sea  level.  The  soil 
is  sandy  and  much  of  the  country  round  about  is  cov- 
ered -with  loft)-  pine  trees.  It  is  to  this  thrifty  growth 
and  the  well-drained  sandy  soil  that  the  healthfulness 
of  the  region  is  attributable. 

The  latitude  of  Aiken  is  ■^■y  Z~  ^■-  longitude,  81' 
34'  W.  Mean  winter  temperature,  50'  F. :  range, 
twelve  degrees.  Mean  relative  humidity,  60.65. 
Rainfall,  7.16  inches. 

The  streets  are  wide  and  well  shaded,  the  roads 
good,  and  the  drives  round  about  interesting.  There 
are  stables  well  stocked  for  both  saddle  and  carriage 
riding,  and  it  has  relatively  few  days  when  outdoor 
exercise  is  not  enjoyable. 

Of  the  hotels,  the  Highlana  Fark  Hotel  is  one  of 
the  most  elaborate  and  best  equipped  in  the  countr}-. 
The  grounds  embrace,  besides  fiftj-  acres  of  green  lawn 
smmediately  surrounding  the  house,  thickly  inter- 
ipersed  with  shade  trees  and  ornamental  shrubber}-,  a 
pine-woods  park  of  three  hundred  and  fift\-  acres, 
beautifully  laid  out  in  walks  and  drives,  with  here 
and  there  a  rustic  seat,  and  in  the  centre  of  the  park  a 
glass-inclosed  pavilion. 

There  are  several  other  good  hotels  with  prices  from 
$2.50  to  $5  a  day,  and  many  excellent  boarding-houses 
at  from  $10  to  $15  a  week.  There  are  five  churches 
for  whites,  and  four  for  colored  people.  A  polo  club 
and  other  attractions  contribute  to  social  enjyment. 

Aiken  is  accessible  :  From  New  York,  Philadelphia, 
and  Washington,  via  the  Atlantic  Coast  Line,  direct  to 
Aiken,  leaving  New  York  at  9:25  A.Nr.,  arriving  at 
Aiken  at  7:28  next  morning,  with  through  sleeper. 
Also  via  the  Clyde  Line  of  steamers  to  Charleston,  and 
thence  by  the  South  Carolina  and  Georgia  Railway. 

From  Chicago,  the  West,  and  Northwest  via  the 
various  routes  to  Atlanta,  Ga. :  thence  by  the  Georgia 
Railroad,  connecting  at  .\ugusta  with  the  South  Caro- 
lina and  Georgia  Railway. 

From  Thomasville  or  Florida  to  Savannah,  thence 
by  the  Georgia  Railroad  through  Augusta,  or  the  At- 
lantic Coast  Line  through  Charleston.  Or  via  Den- 
mark, by  the  Florida  Central  and  Peninsular,  and 
thence  by  the  South  Carolina  and  Georgia  Railway  to 
.\iken. 

The  Southern  Railway,  the  "  New  Short  Line"  from 
the  North,  East,  and  West  has  a  direct  passenger  route 
to  healthful  .Aiken,  and  runs  Pullman  vestibule  trains 
and  superb  hotel  dining-cars.  A  train  leaves  New 
York  at  12  :3o  noon,  arriving  at  Aiken  at  10:55  .a.m.; 
also  at  4:25  P.M.,  arriving  at  5  p.m. 

Camden  is  an  attractive  and  healthful  place,  situated 
in  a  salubrious  region  in  the  central  part  of  the  State, 
known  as  the  "Sand  Hills,"  about  four  hundred  feet 
above  sea  level.  The  climatic  and  local  conditions 
are  strikingly  similar  to  those  of  Aiken.  There  are 
good  hotel  accommodations.     Camden  can  be  reached. 


766 


MEDICAL    RECORD. 


[November  27,  1897 


from  New  York  by  way  of  the  Atlantic  Coast  Line  to 
Charleston,  and  thence  in  five  hours  by  the  Charleston, 
Cincinnati,  and  Chicago  Railroad. 

Columbia,  the  capital  of  South  Carolina,  a  city  of 
about  fifteen  thousand  inhabitants,  is  situated  at  an 
altitude  of  three  hundred  feet  above  sea  level  on  the 
bluffs  of  the  Congaree  River,  a  few  miles  below  the 
beautiful  falls  of  that  river,  on  a  sandy  soil,  with  ex- 
tensive pine  forests  in  the  vicinity.  There  are  many 
handsome  residences  and  imposing  public  buildings, 
with  beautifully  shaded  streets  and  channing  flower 
gardens.  In  the  suburbs  are  handsome  parks  and 
pleasure  grounds,  good  roads,  and  pleasant  drives 
round  about.  The  winter  climate  is  similar  to  that  of 
Summerville. 

There  are  several  good  hotels,  at  from  $2.50  to  S3 
a  day.  It  is  reached  by  the  Richmond  and  Danville 
Railroad  direct,  or  :  ia  steamer  to  Charleston,  thence 
by  the  South  Carolina  Railroad. 

Spartanburg,  in  the  northern  part  of  the  State,  two 
hundred  and  twenty-three  miles  from  Charleston,  and 
ninety-three  from  Columbia  by  the  Greenville  and 
Columbia  and  Spartanburg  and  Union  railways,  is 
pleasantly  situated  in  the  mineral  region,  famous  for 
its  gold  and  iron  mines  and  7>uneral  umtcrs,  and  yet 
more  famous  for  the  memorable  battle  ground  of  the 
Cowpens,  in  the  vicinit}',  where  on  January  17,  1781, 
occurred  the  defeat  of  the  British  under  Tarleton. 

Glenns  Springs  here  are  strongly  impregnated  with 
sulphur  and  contain  sulphate  of  magnesium,  with  sul- 
phate, bicarbonate,  and  chloride  of  calcium.  The 
waters  are  considered  efficacious  in  certain  forms  of 
rheumatism,  scrofula,  and  dyspeptic  complaints.  Lime- 
stone .S/''''",^'' is  chalybeate,  and  possesses  valuable  tonic 
properties. 

Spartanburg  is  situated  on  high  ground  with  health- 
ful surroundings.  The  temperature  here  is  somewhat 
lower  than  at  Aiken,  and  the  springs  are  a  summer  re- 
sort for  Charlestonians  to  some  e.xtent;  but  they  are  also 
good  as  a  winter  resort,  particularly  for  Northern  peo- 
ple who  would  avail  themselves  of  the  benefit  of  such 
waters  under  congenial  climatic  conditions.  There 
are  good  hotel  and  boarding-house  accommodations. 

Chick's  Springs,  Greenville,  ninety-three  miles 
nearer  Charleston,  at  the  foot  of  Saluda  Mountain,  on 
the  Ennoree  River,  are  also  favorably  situated  as  re- 
gards climate.  There  are  two  springs :  the  waters  of 
one  are^slightly  sulphurous  and  of  excellent  repute  in 
the  treatment  of  hepatic  affections;  the  other  is  mildly 
chalybeate  and  commendable  to  anasmics.  The  region 
is  eminently  salubrious,  and  at  Greenville  there  are 
excellent  accommodations  for  visitors. 

Georgi.'^. 

The  Pine  Forests  of  Georgia  are  a  continuation 
from  the  Carolinas,  but  of  even  greater  extent.  They 
reach  from  one  erd  of  the  State  to  the  other,  along 
the  eastern  and  middle  section,  and  save  for  a  district 
extending  seventy  miles  or  so  inland  from  the  coast 
are  everywhere  healthful. 

Savannah,  however,  though  only  eighteen  miles 
from  the  mouth  of  the  river  of  the  same  name  and  but 
forty  feet  above  the  level  of  the  sea,  is  a  delightful 
winter  resort.  Its  beautiful  parks,  magnificent  live 
oaks,  evergreen  shrubber}',  and  beautiful  flower  gar- 
dens add  enchantment  to  the  soft,  mild  climate.  It  is 
in  latitude  32  5'  N. ;  longitude,  81  '  5  W.  The  mean 
winter  temperature,  54.5°  F.,  is  but  slightly  variable, 
and,  with  prevailing  westwardly  winds  and  little  rain, 
makes  congenial  weather.  The  attractions  round 
about,  good  roads  and  every  accommodation  desir- 
able for  their  use,  are  well  calculated  to  promote 
health.  The  scope  of  this  paper  will  not  permit  much 
detail,  even  of  the  most  interesting  objects,  but  one 
can   hardly  forbear   particularizing  the  rare  specta- 


cle of  the  great  live  oaks  which  shade  Bonaventure 
Cemetery,  to  be  seen  nowhere  else  in  such  magnifi- 
cence. More  than  a  hundred  years  ago  these  grounds 
were  laid  out  in  broad  avenues  and  planted  with  native 
live  oaks  scattered  through  the  extensive  lawns  that 
surrounded  the  mansion  of  the  Tatnalls,  and  these 
trees  have  been  growing  ever  since.  They  stand  in 
great  columns  on  either  side  of  the  walks,  while  their 
far-reaching  branches  interlace  overhead,  like  the 
fretted  roof  of  some  vast  cathedral.  The  deep  shade 
of  their  ever-green  foliage  shutting  out  the  sky  above, 
and  the  long  gray-moss  drapery  depending  from  the 
leafy  canopy,  at  times  silent,  at  times  gently  swaying 
in  the  breeze,  give  to  the  scene  a  weird  and  strangely 
sombre  aspect,  at  once  picturesque  and  solemn.  A 
more  beautiful  or  more  significant  and  appropriate 
monument  to  the  dead  than  the  shades  of  these  forest 
aisles  cannot  be  imagined.  There  are  many  beauti- 
ful and  several  historical  monuments  of  interest. 

Hotels  are  abundant  and  excellent,  at  from  $2.50  to 
S4  a  day. 

Steamers  run  from  Boston,  Philadelphia,  and  Balti- 
more to  Savannah.  By  railway  it  may  be  reached  by 
the  Atlantic  Coast  Line  via  Richmond,  Wilmington, 
and  Charleston;  or  by  the  Richmond  and  Danville 
Railroad  to  Columbus,  and  thence  by  the  South  Bound 
Railroad;  from  Cincinnati,  St.  Louis,  and  Memphis, 
by  the  Louisville  and  Nashville  Railroad,  and  branches 
via  Chattanooga  and  Atlanta,  and  by  the  Central 
Railroad  of  Georgia;  from  New  Orleans  by  the 
Louisville  and  Nashville  Railroad  and  the  Savannah, 
Florida,  and  A\'estern  Railroad. 

Augusta,  a  handsomely  laid  out  and  beautiful  city, 
is  situated  at  the  head  of  steamboat  navigation  on  the 
Savannah  River,  one  hundred  and  thirty  miles  from  its 
mouth,  at  an  elevation  of  one  hundred  and  eighty-five 
feet  above  sea  level.  The  sanitary  administration  of 
the  city  is  of  exceptional  excellence.  The  climate  is 
similar  to  that  of  Aiken,  from  which  it  is  only  seven- 
teen miles  distant.  There  are  good  roads  and  beauti- 
ful scenery  round  about,  and,  taken  altogether,  as  a 
winter  resort  for  persons  predisposed  to  or  affected 
by  consumption,  Augusta  possesses  many  advantages. 
The  hotel  accommodations  are  ample  and  excellent, 
and  rates  are  moderate. 

Augusta  is  accessible  by  way  of  the  Savannah  River 
and  by  the  Central  Railroad  of  Georgia;  from  the 
North  by  the  Piedmont  Air  Line  via  Washington, 
Danville,  and  Charlotte,  or  by  the  Atlantic  Coast 
Line  via  Washington,  Richmond,  Wilmington,  and 
Columbia. 

Thomasville,  a  town  of  about  six  thousand  inhabi- 
tants, is  situated  on  the  Savannah,  Florida,  and  West- 
em,  and  the  Altantic  and  Gulf  railroads,  two  hundred 
miles  southwest  of  Savannah,  twelve  miles  from  the 
Florida  State  line,  in  the  midst  of  the  long- leaf  pine 
region,  at  an  altitude  of  three  hundred  and  thirty  feet 
above  sea  level.  The  average  winter  temperature  is 
55°  F.  The  streets  are  broad  and  well  shaded,  and 
the  walks  pleasant.  It  is  a  churchly  community- — Epis- 
copal, Methodist,  Baptist,  Presbyterian,  Roman  Cath- 
olic, and  Jewish  denominations  being  represented. 
The  excellent  drives  through  the  pine  woods  and  the 
scenery  round  about,  with  the  prevailing  sunshiny 
weather,  are  important  among  the  advantages  of  this 
deser\-edly  noted  resort. 

There  are  three  good  hotels  and  a  number  of  excel- 
lent boarding-houses  at  moderate  rates. 

Florid.a. 

Those  who  would  measure  climate  at  the  level  of 
the  sea  by  the  meridian  only  will  wholly  fail  to  form 
a  correct  conclusion  with  regard  to  Florida.  North- 
ern Mexico,  the  peninsula  of  California,  the  Desert  of 
Sahara,  Central  Arabia,  Northern  Hindostan,  Northern 


MEDICAL    RECORD. 


November  27,  1S97] 

Burniah,  Southern  China,  and  numerous  other  regions 
less  known  and  some  of  them  insular-like,  and  in  the 
same  latitude  as  Florida,  have  climates  more  or  less 
similar  to  each  other,  but  all  of  them  are  strikingly 
different  from  that  of  Florida;  and  for  the  reason 
doubtless  that  none  of  those  localities  is  bounded  by 
an  immense  body  of  warm  water  on  one  side  and  a 
swiftly  flowing  ocean  current  on  the  other,  and  the 
peninsula  between  covered  for  the  most  part  by  a  pine 
forest— a  combination  of  intluences  conducive  to 
healthfulness  not  found  to  anything  like  the  same  ex- 
tent in  any  other  region  of  the  same  latitude  lying 
near  the  level  of  the  sea,  Florida's  greatest  altitude 
being  nowhere  more  than  three  hundred  feet. 

Florida  lies  between  the  parallelsof  24"  30'  and  31' 
north  latitude,  and  87  30'  west  longitude.  The  mean 
winter  temperature  is  about  60°  F. ;  mean  relative  hu- 
midity, 72.7.  Average  number  of  rainy  days  during 
the  five  months,  November  to  March  inclusive,  for  a 
series  of  years  at  Jacksonville  (Signal  Ser^-ice  records), 
37.4.  The  drv-est  month  is  November,  immediately 
following  the  wettest  part  of  the  rainy  season.  The 
winter  weather  altogether  throughout  the  State  is  gen- 
erally such  as  to  allow  outdoor  exposure  some  por- 
tion of  every  day,  and  the  preponderance  of  sunshiny 
days,  with  an  almost  constant  gentle  breeze  from  over 
the  sea  and  through  the  pines,  permits  the  fullest 
open-air  enjoyment;  and  so  generally  do  these  con- 
ditions prevail  the  tourist  can  hardly  go  amiss  with 
regard  to  his  outdoor  programme.  But  here,  as  indeed 
everywhere  else— however  good  the  promises  and 
beautiful  the  premises— the  tourist  should  ahuays  be 
alert  as  to  the  conditions  of  his  sleeping-quaners 
and  their  immediate  surroundings. 

Jacksonville   is  the  gateway  at  which  the  steam- 
ships, steamboats,  and  railways  enter,  the  latter  radi- 
ating thence  throughout  the  State.     It  is  a  beautiful 
city  of   thirty  thousand   inhabitants,  wide   and  well- 
shaded   streets,   and   handsome    parks.     There    are  a 
half-dozen  or  more  excellent  hotels.     The  St.  fames 
facing  St.  James  Park,  the  most  elevated  grounds  of 
the  city,  has  accommodations  for  five  hundred  guests, 
and  is' provided  with  all  the  comforts    and    conven- 
iences which  characterize  a  hotel  of  the  first  class 
The   rates    are   S4    a    dav,  with    special   weekly    and 
family  rates.     The  Everett  and  the  Windsor  hotels  are 
also  beautifully  situated,  and  of  like  proportions  with 
the  St.  James  and  at  the  same  rates.     The  new  Duval, 
the  Carlton,  St.  John's  House,  the  Grand  View,  Tre- 
mont  House,  the  Travellers',  and  Hotel   Placide  of- 
fer good    accommodations    at   from  $2  to  $3   a  day. 
There  are  also  manv  good  boarding-houses  at   from 
$8    to    $14   a  week.      From   New   York,  Jacksonville 
is  most  comfortably  reached   by  the    Clyde   Steam- 
ship   Company's   ships,  5    Bowling   Green,  the    pas- 
sage costing  S25  ;  e.tcursion,  $43-3°-      ^y  rail  the  At- 
lantic Coast   Line,  via  Washington,  Charleston,  and 
Savannah,    runs   vestibuled    trains    with    buffet   and 
sleeping  cars  through  in  twenty-eight  hours,  without 
change,  the  fare  being  $29.15. 

St.  Augustine,  the  oldest  European  settlement  in 
the  United  States,  is  situated  on  the  .Ulantic  coast  on 
a  narrow  sand  beach  bet^veen  Matanzas  River  on  the 
east  and  the  St.  Bastian  on  the  south  and  west,  about 
forty  miles  s(  uth  of  the  mouth  of  the  St.  John's  River. 
The  harbor  of  St.  Augustine  is  protected  by  --^nasta- 
sia  Island,  which  lies  between  it  and  the  ocean.  The 
beach  for  miles  around  is  covered  with  a  tangled 
growth  of  palmetto  and  semitropical  shrubs.  1  he 
streets  of  the  town  are  narrow,  and  seem  to  have  shaped 
their  course  by  crooked  paths  that  wound  their  way 
through  the  tangled  vegetation  three  centuries  ago, 
when  the  town  was  founding,  such  paths  being  more 
easily  followed.  The  streets  are  paved  with  shell 
and  many  of  the  old  houses  are  constructed  of  shell 


767 


stone  (coquina),  quarried  on  Anastasia  Island.  The 
whole  aspect  of  the  town  is  siii  generis.  Like  Topsy, 
it  •■  just  growed,"  and  it  has  continued  to  grow  in 
conformity  with  its  planless  beginning,  more  than 
half  a  century  before  the  landing  of  the  Pilgrims  at 
Plymouth;  but  though  founded  on  the  sand  it  still 
endures. 

The  prevailing  '•  style"  of  architecture  is  quaint 
and  ancient;  the  verandas  jut  out  from  either  side  and 
almost  touch  across  the  streets.  It  is  a  surviving 
remnant  of  old  Spain,  and  the  objects  to  be  seen 
round  about  are,  many  of  them,  Spanish  in  character 
and  deeply  interesting.  Many  important  recent  im- 
provements have  been  made,  however,  and  the  current 
life  here,  which  used  to  be  described  as  indolent  and 
lazy,  is  accumulating  force,  and  thrift  is  following. 

The  winter  climate  is  remarkably  equable  and 
agreeable,  the  mean  temperature  being  about  58.8°  F. 
The  Fonee  de  Leon  Hotel  is  a  building  of  magnificent 
proportions,  replete  with  all  modern  conveniences  and 
adorned  with  beautiful  gardens  of  flowers  and  ever- 
greens. It  has  accommodations  for  seven  hundred 
guests  at  from  $5.00  a  day  and  upward.  The  Cor- 
dova, across  the  street,  is  run  as  an  annex  for  the  over- 
flow of  the  Fonee  de  Leon.  The  Alcazar,  San  Mareo, 
Magnolia,  and  St.  George  are  comfortable  hotels,  with 
modern  appointments,  at  from  §2.50  to  $4  a  day,  with 
special  weekly  rates. 

There  are  at  least  a  dozen  other  houses  where  guests 
are  well  taken  care  of  at  from  $1.50  to  $2.50  a  day, 
and  weekly  at  from  $8  to  $15. 

Ormond,  on  the  Halifax  River,  situated  fifty  miles 
down  the   coast  from   St.   Augustine,  on  the   line    of 
the  Florida  East  Coast  Railway,  and  eighteen  miles 
north  of  Mosquito  Inlet,  occupies  both  banks  of  the 
river,  and  fronts  one  of  the  finest  sections  of  beach 
on  the  Atlantic  coast.     Hotel  Ormond,  on  the  bank  of 
the  river,  is  beautifully  situated,  and  equipped  with  all 
modern  conveniences.     Here  can  be  obtained,  at  rea- 
sonable prices,  launches  and  row  boats,  fishing  and 
hunting  outfits— everything  promotive  of  the  health  and 
pleasure  of  the  guests.     Hotel  rates  are   from   $4-50 
to    $5    a    day;    $23   to    $28    a  week.     Hold    Coquiiia 
is  also  beautifully  situated,  upon   a  bluff    overlook- 
ino-  the  ocean,  from  which  it  is  distant  about  three 
hundred  feet.     Among  other  features  it  has  a  glass- 
inclosed    apartment    which    affords    the    famous    .sea- 
side sun    baths  that  are  so  highly  recommended  by 
some  physicians;  and  also  at  all  times  an   attractive 
view  of  ocean  and  beach.     Surf  bathing  begins  here 
about  the  ist  of  February,  and  for  this  it  surpasses 
any  other  place  on  the  coast.     A  horse-car  line   from 
the  railroad  station  to  Hotel  Coquina  on  the  ocean 
shore   passes    near   all    hotels    and   boarding-houses. 
Rates  are  $3  a  day,  with  special  weekly  rates.     The 
Bosarve,  The   Sunnyside,  and  The  Granada   furnish 
accommodations  at  from   $7   to   $15   a  week.      From 
Hotel  Ormond  dock  launches  ply  their  way   up  the 
river  a  distance  of  five  miles,  to  the  mouth  of  the 
Tomok-1,  in  view  of  beautiful  rolling  lands  devoted  to 
the  cultivation  of  oranges  and  early  vegetables.     As 
one  ascends  the  river,  the  scenery  increases  in  beauty, 
amid  the  rare  double-headed  palmettoes  and  pine  for- 
ests.    The  route  is  very  circuitous,  and  occasionally 
alligators  may  be  seen.     The  climate  is  enjoyable. 

From  Jacksonville  all  points  in  South  Florida  are 
accessible.  For  St.  John's  River  steamers  leave 
daily  except  Saturdays,  and  for  Sanford,  one  hundred 
and  ninety-three  miles  south,  stopping  at  intermediate 
landings.  The  banks  of  the  St.  John's  are  lined  with 
luxuriant  tropical  vegetation,  handsome  shade  trees, 
orange  groves,  and  many  picturesque  villas  and  vil- 
lages. _ 

Mandarin,  a  small  village  on  the  east  bank  of  bt 
John's,  is  one  of  the  oldest  settlements  in  the  State. 


768 


MEDICAL    RECORD. 


[November  27,  1897 


Near  the  landing,  almost  hidden  among  live  oaks  and 
orange  trees,  stands  the  whilom  home  of  the  celebrated 
authoress  of  "Uncle  Tom's  Cabin;"  and  directly 
across  the  river  from  this  place  shines  the  white  fence 
of  Orange  Park.  Hibernia,  New  Switzerland,  and 
Remington  Park  are  passed,  and  the  next  landing- 
place  is  Magnolia,  a  popular  resort.  The  Magnolia 
Springs  Hotel  is  replete  with  all  the  modern  improve- 
ments. The  rates  are  from  $3  to  $5  a  day;  special 
weekly  and  family  rates.  Two  miles  beyond,  and 
thirty  miles  from  Jacksonville,  is  Green  Cove  Springs, 
which  furnish  sulphuretted  water  with  a  temperature 
of  78^  F.,  gushing  forth  at  the  rate  of  three  thousand 
gallons  per  minute.  This  spring  has  been  recently 
improved,  fitted  up  with  plunge  and  swimming  baths, 
and  other  improvements  are  in  process;  among  which 
will  be  pools  inclosed  with  glass,  and  all  kinds  of 
bathing-facilities.  The  Clarendon  Hotel,  which 
fronts  the  Spring  Park,  has  accommodations  for  two 
hundred  guests,  and  is  said  to  be  first-class  in  all  its 
appointments.  There  are  hot  sulphur  baths  of  the 
spring  water  in  the  hotel.  Here  also  are  the  Hotel  St. 
Elmo,  the  Oakland,  St.  Clair,  and  Green  Cove  Springs 
hotels,  with  accommodations  at  from  $2.50  to  $3  a 
day,  and  special  rates  by  the  week.  Eighteen  miles 
farther  on  is  Palatka,  a  town  of  five  thousand  in- 
habitants, seventy-five  miles  from  Jacksonville,  oc- 
cupying a  fine,  high  plateau,  with  a  wide-reaching 
view  up  and  down  the  river.  It  has  long  been  among 
the  most  favorite  winter  resorts  in  the  State,  and  is 
well  provided  with  good  hotels  at  from  $2  to  $4 
a  day.  Excellent  boarding-houses  are  numerous  at 
reasonable  rates,  and  there  is  a  great  variety  of  social 
amusements.  Palatka  is  the  starting-point  for  the  trip 
up  the  Ocklawaha  River,  the  most  tropical  stream  in 
North  America.  The  journey  is  made  in  new  and  very 
comfortable  boats  for  enjoying  the  scenery.  Here,  too, 
there  is  railway  connection  with  Gainesville  and  Ocala 
via  the  Florida  Southern  Railroad  for  the  Indian  River. 
Moreover,  Palatka  is  the  usual  and  best  point  of  de- 
parture for  the  hunting  and  fishing  grounds  of  the 
upper  St.  John's  and  the  Indian  River  region,  and  those 
who  are  not  provided  with  hunting  and  fishing  equip- 
ments can  obtain  them  here. 

The  upper  St.  John's  from  Palatka  southward  in- 
creases in  picturesque  scenery  with  each  succeeding 
hour.  Instead  of  being  a  broad  estuary,  the  river 
now  becomes  narrow  and  tortuous,  and  at  night,  when 
illuminated  by  the  powerful  searchlight  of  the  steamer, 
to  the  traveller's  first  view  it  is  a  picture  from  fairy- 
land. Yet,  narrow  as  it  is,  every  few  miles  it  ex- 
pands into  lakes,  some  of  which  are  large  bodies  of 
shallow  water  teeming  with  ducks  and  other  wild  fowl. 
Lake  George,  four  miles  wide  and  eighteen  miles  long, 
is  the  most  beautiful  sheet  of  water  in  the  State,  con- 
sidered by  many  tourists  equal  in  picturesqueness  to 
its  namesake  in  the  State  of  New  York.  It  is  dotted 
with  many  lovely  islands,  like  its  namesake,  but  these, 
instead  of  being  covered  with  groves  of  timber  trees 
and  bush,  are  for  the  most  part  the  sites  of  orange 
groves.  All  along,  the  shores  and  clumps  of  tropi- 
cal bush  are  alive  with  the  sweet  songs  of  South- 
ern birds;  and  here  and  there,  in  striking  contra.st 
with  anything  that  is  ever  seen  along  the  lake  shores 
of  the  North,  cranes  and  fiamingoes  are  seen  stalking 
the  water's  edge,  picking  choice  morsels  from  the  rip- 
ple; while  off  shore  great  boat-like  pelicans  are  cruis- 
ing about  and  loading  their  pouches  with  delicate  fish 
for  the  little  ones  at  home.  The  next  point  of  interest 
is  Beresford,  the  landing-place  for  the  nourishing  dis- 
trict about  Deland,  Lake  Helen,  Orange  City,  etc.  A 
few  miles  farther  up  the  narrow  and  lazy  .stream  brings 
the  steamer  to  Lake  Monroe  and  the  conclusion  of  the 
voyage — the  head  of  steamboat  navigation— at  Sanford 
and  Enterprise. 


Sanford  is  the  metropolis  of  South  Florida.  It  is 
the  terminus  of  seven  railroads,  with  a  daily  mail 
service  north,  south,  east,  and  west.  Its  late  rapid 
growth  has  exceeded  all  expectations  and  greatly  in- 
spired energy  in  public  improvements.  The  sanitarj* 
condition  is  reported  to  be  the  best  in  the  State.  It 
has  excellent  water  works,  a  good  fire  department, 
and  other  public  works,  fine  churches,  and  social 
clubs.  There  are  many  fine  orange  groves  in  the 
vicinity  and  pleasant  scenery  abounds.  Hunting  and 
fishing  are  fruitful,  and  accommodations  for  tour- 
ists unlimited.  The  Sanford  House  has  long  been  fa- 
mous, and  there  are,  besides,  San  Leon  Hotel,  Sirvine 
Hotel,  and  other  good  houses,  at  from  $2  to  $4  a  day 
and  reduced  rates  by  the  week,  and  many  good  board- 
ing-houses at  lower  rates. 

Enterprise  is  on  the  opposite  side  of  the  lake  from 
Sanford.  Brock  House  here  is  famous  among  tourists 
who  have  been  privileged  to  enjoy  it.  It  is  beautifully 
situated  on  the  north  shore  of  Lake  Monroe,  and  is 
provided  with  all  modern  improvements,  gas,  electric 
bells,  baths,  open  fires,  telegraph  office,  and  is,  in 
short,  one  of  the  most  homelike  and  comfortable  hotels 
in  the  south.  Rates,  $3-50  to  $4  a  day;  weekly, 
$17.50  and  upward;  special  rates  to  families. 

The  Indian  River  section  is  yearly  becoming  more 
and  more  attractive.  The  "  river"  itself  is  a  long  la- 
goon or  arm  of  the  sea,  beginning  near  the  lower  end 
of  Hillsborough  Lagoon  and  extending  along  the  east 
side  of  the  peninsula  for  nearly  one  hundred  and  fifty 
miles.  It  is  separated  from  the  Atlantic  by  a  narrow 
strip  of  land,  through  which  it  communicates  with  the 
open  water  by  the  Indian  River  Inlet  and  by  Jupiter 
Inlet;  and  for  more  than  thirty  miles  of  its  northern 
course  it  flows  parallel  with  the  St.  John's  River,  at 
an  average  distance  of  about  ten  miles. 

The  favorite  route  to  Indian  River  is  by  the  Clyde 
St.  John's  River  Line  via  Sanford  or  Enterprise  to 
Titusville,  thirty-seven  miles.  It  is  also  accessible  by 
the  Jacksonville,  St.  Augustine,  and  Indian  River  Rail- 
road, which  runs  one  hundred  and  fifty-eight  miles  to 
Titusville.  Here  connections  are  made  with  the  Flori- 
da East  Coast  Railway. 

Titusville  is  a  thriving  town  of  about  two  thousand 
five  hundred  inhabitants,  and  is  noted  for  its  beautiful 
vegetable  and  fruit  farms  and  its  orange  groves.  Mer- 
ritt's  Island,  almost  opposite  Titusville,  is  a  long  tri- 
angular island,  comprising  about  fifty-eight  thousand 
acres,  mostly  pine  land,  but  noted  for  its  pineapple 
plantations.  The  portion  of  the  Indian  River  on  the 
east  side  of  the  island  is  called  Banana  River,  and  is 
a  great  resort  for  fishermen. 

Rockledge  is  a  beautifully  situated  town  on  the  west 
bank  of  the  river,  the  trade  centre  for  the  superior 
quality  of  the  oranges  cultivated  in  its  vicinity.  Fish- 
ing and  duck-shooting  afford  abundant  recreation  and 
amusement  to  sportsmen.  Hotel  Indian  River  here 
keeps  sail  and  row  boats  and  steam  launches  for  the 
benefit  of  its  guests:  and  daily  excursions  are  made 
to  Fairyland,  City  Point,  Tropic,  and  other  places 
of  interest.  Hotel  rates,  $4  and  $5  a  day;  $22.50  to 
$25  and  upward  a  week.  The  New  Rockledge  Hotel 
and  The  Plaza  are  good  hotels,  though  less  elaborate 
than  the  Hotel  Indian  River — at  $2.50  and  $3.50  a  day. 

Jupiter,  at  the  mouth  of  Indian  River,  on  Jupiter 
Inlet,  the  landing-place  of  the  Indian  River  Steamboat 
Company,  is  an  excellent  winter  resort  for  fishing  and 
hunting.  The  climate  is  equable  and  enjoyable,  the 
temperature  ranging  from  58°  to  62^  F.  Carlin  House 
and  Miller  House  furnish  accommodations  at  $2  a 
day,  or  ?io  a  week. 

JPalm  Beach,  on  the  eastern  shore  of  Lake  Worth, 
the  terminus  of  the  Jacksonville,  St.  Augustine,  and 
Indian  River  Railroad,  has  recently  been  made  one  of 
the  most  attractive  winter  resorts  of  Southern  Florida, 


November  27,  1897] 


MEDICAL    RECORD. 


769 


famed  for  its  fishing  and  hunting  advantages.  It  may 
be  reached  also  rviz  steamers  of  the  Indian  River  Steam- 
boat Company  to  Jupiter,  thence  by  the  Jacksonville 
and  Lake  Worth  Railroad,  and  steamers  on  Lake  Worth. 
The  town  is  situated  between  the  ocean  and  Lake  Worth. 
The  region  around  abounds  in  tropical  fruits  and 
flowers.  The  Royal  Poinciana  rivals  the  Ponce  De 
Leon  of  St.  Augustine  in  magnificence,  elegance,  and 
equipment.  It  has  accommodations  for  one  thou- 
sand guests.  Rates,  $5  a  day  and  upward;  special 
rates  for  the  season.  Cocoanut  Grove  House,  Lake 
Worth  Hotel,  and  Oak  Lawn  House  are  good  hotels  at 
from  S2.50  to  S4  a  day,  and  special  weekly  rates;  and 
there  are  boarding-houses  at  from  Sio  to  S15  a  week. 

Miami,  on  Biscayne  Bay,  is  the  terminus  of  the  Flor- 
ida East  Coast  Railway,  which  skirts  the  east  coast  of 
Florida  from  Jacksonville  south,  and  is  the  most 
southern  of  the  well-equipped  east-coast  winter  resorts. 
Semiweekly  trips  are  made  here  by  the  Miami-Xas- 
sau  Steamship  Line  during  January;  triweekly  during 
February  and  March;  and  semiweekly  during  April, 
imtil  the  service  terminates.  The  winter  temperature 
here  is  equable  and  about  64°  F.  The  vegetation  is 
strikingly  tropical,  and  the  two  excellent  hotels.  Hotel 
Royal  Palm  and  Hotel  Biscayne,  display  it  to  ad- 
mirable advantage  in  their  beautifully  laid  out  and 
ornamented  grounds.  Biscayne  Bay  is  a  large  sheet 
of  salt  water,  so  clear  that  its  garden- like  bottom  and 
numberless  fish  can  be  plainly  seen  to  a  depth  of 
twenty-five  feet  and  more.  It  is  separated  from  the 
ocean  by  the  picturesque  Florida  Keys.  There  is 
open-air  bathing  in  the  bathing-pool  in  front  of  the 
Royal  Palm  at  all  times.  Boating  and  canoeing  on 
the  rivers  and  into  the  Everglades,  with  steam-launch 
and  sailboat  excursions,  are  other  attractions.  Hotel 
rates,  $3  a  day  and  upward. 

Winter  Park,  managed  under  the  auspices  of  the 
Plant  Railroad  System,  is  situated  at  an  altitude  of 
over  a  hundred  feet  above  sea  level,  in  the  midst  of  the 
lake  and  pine-forest  region  ;  about  forty  miles  from  the 
Atlantic  coast,  and  eighty  miles  from  the  Gulf  of  Mex- 
ico, one  hundred  and  thirty-three  miles  south  of  Jack- 
sonville, and  one  hundred  miles  north  of  Tampa.  The 
situation  affords  an  excellent  watershed  and  good  soil 
drainage.  The  water  of  the  lakes  round  about  is  said 
to  flow  from  one  to  another.  The  average  winter  tem- 
perature is  about  62'  F. ;  the  winter  rainfall  is  slight, 
and  the  air  relatively  dry.  The  Seminole  Hotel 
is  an  elegant  establishment,  equipped  with  all  mod- 
em improvements;  53  to  S4  a  day.  The  bicycle  and 
other  roads  are  excellent,  and  the  outdoor  attractions 
enjoyable.  Oaila  is  a  flourishing  business  town  of  five 
thousand  inhabitants,  situated  on  the  central  ridge, 
about  midway  between  Jacksonville  and  Tampa,  on 
the  Plant  Railroad  route  to  Key  West.  The  high  dry 
land  is  entirely  free  from  malaria,  and  the  refreshing 
breezes  through  the  pines  from  the  ocean  and  the  Gulf 
combine  to  produce  a  mild  and  healthful  climate — 
particularly  commendable  to  consumptives,  as  is  also 
Winter  Park.  The  mean  winter  temperature  is  about 
62  "  F.,  equable,  and  the  air  relatively  dry — the  rainfall 
during  the  winter  months  being  small.  The  roads  are 
good  and  the  outings  attractive.  The  Ocala  House  is 
commodious  and  well  equipped  with  all  modern  ap- 
pliances; rates,  S3  to  $4  a  day. 

Tampa  Bay  Hotel  at  Tampa,  conducted  by  the 
Plant  System,  is  an  eminently  luxurious  house,  with 
everything  calculated  to  promote  the  enjoyment  of 
the  tourist.  It  is  a  fireproof  structure,  built  upon 
the  Tampa  peninsula,  open  to  the  mild  and  equable 
climate  of  the  Gutf,  with  spacious  grounds  orna- 
mented with  tropical  verdure  and  flowers.  The  Ca- 
sino, which  adjoins  the  hotel  park,  fifty  feet  distant 
and  midway  between  one  of  the  hotel  entrances  and 
Hillsborough  Bay,  is  a  handsome  addition  to  the  means 


of  enjoyment,  provided  as  it  is  with  a  swimming-pool, 
fiftj-  by  seventy  feet,  with  a  depth  of  water  varying 
from  three  to  ten  feet,  surrounded  by  dressing-rooms, 
each  with  an  outside  window.  A  competent  instruc- 
tor in  swimming,  as  well  as  ladies'  maids,  is  in  at- 
tendance during  the  season.  The  Theatrical  Audi- 
torium, one  hundred  and  fifty-seven  by  eighty-eight 
feet  floor  space,  with  a  seating  capacity  for  an  audi- 
ence of  two  thousand,  furnished  with  handsome  opera 
chairs,  is  another  Casino  feature ;  and  for  this  the  pro- 
prietor announces  that  "  a  large  number  of  the  best 
theatrical  companies  are  engaged  and  will  appear  at 
intervals  during  the  season.'' 

Alabam.a. 

The  winter  climate  of  northern  Alabama  is  both 
delightful  and  healthful.  The  temperature  rarely  falls 
so  low-  as  32""  F.,  the  average  temperature  being  about 
50°  F.  Huntsville  and  Florence,  on  the  Tennessee 
River,  are  justly  favorite  health  resorts,  with  excellent 
accommodations  at  moderate  prices. 

Mobile,  situated  on  a  sandy  soil  on  the  western 
shore  of  Mobile  Bay,  with  a  thrifty  growth  of  pine 
woods  roundabout,  through  and  by  which  the  warm 
Gulf  breeze  is  sifted  of  its  excess  of  moisture,  is 
also  an  excellent  winter  resort  for  people  with  ten- 
der lungs,  and  the  better  now  by  reason  of  the 
energetic  sanitary  measures  recently  practised  on  ac- 
count of  the  fever,  from  which  there  is  no  longer  any 
danger.  Besides,  on  the  eastern  shore  of  the  bay,  from 
fifteen  to  twenty  miles  nearer  the  Gulf,  Alabama  City, 
Williamsburg,  and  Point  Clear  are  well-appointed 
places,  with  good  hotel  accommodations,  bathing  and 
boating  facilities,  with  cottages  and  orange  groves 
roundabout,  available  for  invalids  or  for  pleasure 
seekers  who  would  long  sojourn  and  enjoy  the  attrac- 
tions of  fishing  and  hunting.  The  waters,  fields,  and 
forests  are  all  alive  with  game. 

Mississippi. 

The  bluff  shore  of  the  Gulf  and  Mississippi  Sound, 
along  which  are  situated  Pass  Christian,  Ocean 
Springs,  Bay  St.  Louis,  Biloxi,  Pascagoula,  several 
smaller  towns,  and  numerous  villas,  has  long  been 
deser\-edly  noted  for  its  healthfulness  and  is  a  favorite 
winter  resort  for  invalids  who  would  enjoy  the  warm 
and  soft  Gulf  winds.  Though  these  winds  are  some- 
times loaded  with  moisture,  the  moisture  is  always 
clean  and  never  liable  to  make  people  sick,  like  that 
which  hovers  over  low  and  undrained  soil.  Their 
salutary  eff'ects  on  some  of  the  more  chronic  forms  of 
tuberculosis,  particularly  in  aged  persons,  in  nervous 
derangements  and  insomnia,  are  well  attested  by  nu- 
merous cases.  But  it  appears  to  have  been  the  great 
misfortune  of  this  locality  recently  that  the  authorities 
have  neglected  needful  sanitary  measures,  insomuch 
as  to  have  allowed  opportunity  for  the  epidemics  of 
dengue  and  yellow  fever.  It  may  be  said,  however,  as 
of  Mobile  and  of  New  Orleans,  that  the  condition  has 
been  greatly  improved  by  reason  of  the  energetic  sani- 
tary measures  that  have  since  been  practised.  There 
are  good  hotel  and  boarding-house  accommodations 
in  all  the  localities  named,  and  other  facilities  for 
enjoyment. 

LOI'ISIAN.A. 

The  northern  and  western  sections  of  this  State  are 
generally  healthful  at  all  seasons;  and  the  mild  winter 
climate,  which  allows  daily  outdoor  exposure,  has  long 
been  recognized  as  being  particularly  beneficial  to  per- 
sons affected  with  or  predisposed  to  pulmonar3'diseases. 

New  Orleans  is  one  of  the  most  enjoyable  winter 
resorts  in  the  country,  and  the  more  so  by  reason 
of  the  enforcement  of  sanitation  on  account  of  the 
fever.     There  is  no  day  so  cold  and  but  very  rarely 


770 


MEDICAL    RECORD. 


[November  27,  1897 


one  so  wet  as  to  prevent  open-air  exposure,  and 
there  is  no  end  to  the  attractions  in  and  round 
about  the  city.  Many  of  the  old  relics  of  Span- 
ish and  French  rule  still  exist.  Its  French  quarter 
and  market  are  unique  as  objects  of  interest.  Old 
Spanish  Fort,  on  Lake  Ponchartrain,  five  miles  dis- 
tant by  electric  cars,  the  originally  undertaken  site  of 
the  city — and  now  to  New  Orleans  what  Coney  Island 
is  to  New  York — is  a  daily  novelty.  Other  places  in 
the  suburbs  are  the  battleground  of  the  famous  victory 
of  General  Jackson  over  the  British  forces,  January  8, 
1815,  and  the  still  unfinished  monument  commemor- 
ative of  the  victory;  Carolton,  Gretna,  Algiers,  and 
many  other  localities  of  interest  but  a  few  miles  distant, 
all  accessible  by  excellent  carriage  roads,  surface  cars, 
or  steamboat  excursions.  New  Orleans  has  been  so 
long  famous  for  its  opera,  theatres,  and,  above  all,  for 
its  "  Mardi  Gras,"  on  Shrove  Tuesday,  when  Rex,  King 
of  the  Carnival,  arrives,  that  to  undertake  a  description 
of  these  enjoyments  would  be  wholly  superfluous  as 
well  as  altogether  inadequate.  They  should  be  seen 
and  shared  to  be  duly  appreciated. 

Arkansas  Hot  Springs. 

These  are  situated  in  the  town  of  Hot  Springs, 
Ark.,  latitude  34"  5'  N.,  in  the  midst  of  a  wild  ind 
picturesque  mountain  region,  one  thousand  five  hun- 
dred feet  above  the  sea  level,  forty-five  miles  south- 
west of  Little  Rock,  and  six  miles  north  of  Wachita 
River.  The  town  lies,  principally,  in  the  narrow  val- 
ley of  Hot  Springs  Creek,  running  north  and  south 
between  the  Ozark  Mountains.  It  is  embowered  in 
trees  and  presents  a  very  picturesque  appearance.  In 
the  middle  of  the  day  it  is  sometimes  very  warm,  even 
in  winter,  and  the  nights  are  cool ;  but  the  average  win- 
ter temperature  is  about  50  '  F.  The  springs  are  in 
number  seventy-one.  They  are  chiefly  chalybeate  and 
sulphuretted.  They  vary  in  temperature  from  76^  to 
157°  F.,  and  many  of  them  have  been  improved.  The 
waters  are  used  internally  and  to  a  considerable  ex- 
tent e.xternally;  there  is  a  large  number  of  bathing- 
houses  with  vapor,  douche,  and  plunge  baths  at  various 
temperatures.  The  amount  of  hot  water  flowing  from 
the  springs  into  the  creek  renders  it  sufficiently  warm 
for  bathing  in  midwinter;  the  discharge  into  the 
creek  is  about  five  hundred  and  fifty  gallons  a  min- 
ute. Their  chief  reputation  rests  upon  their  efficacy  in 
the  treatment  of  rheumatic  and  gouty  affections,  syphi- 
litic arid  mercurial  diseases,  and  certain  forms  of 
skin  diseases.  It  is  not  a  good  resort  for  consump- 
tives. Hotels  are  numerous  and  adequate,  at  from 
$2  to  Js  a  day,  and  $8  to  $15  a  week.  Rates  of 
travel:  from  New  York,  over  the  trunk  lines,  $32.40 
to  $35.40;  from  St.  Louis  by  the  St.  Louis,  Iron 
Mountain  and  Southern  Railroad  to  Malvern,  and 
thence  by  a  branch  road  to  the  Springs  (distance,  four 
hundred  and  thirteen  miles;  time,  about  fifteen  hours), 
excursion  tickets,  good  for  ninety  days,  $22.50. 

"Dry,  warm  air  is  found  in  southwestern  Texas, 
and  the  southern  portions  of  New  Mexico  and  Ari- 
zona." This  was  the  deduction  of  Gen.  A.  VV.  Greely, 
chief  signal  officer,  from  a  map  illustrative  of  an 
article  under  the  caption  of  "Where  Shall  We  Spend 
our  Winter?"  contributed  by  him  to  Scy/V/wr's  Maga- 
zine, for  November,  1888. 

Texas. 
San  Antonio,  a  city  of  over  fifty  thousand  inliabi- 
tants,  situated  at  an  elevation  of  six  hundred  feet 
above  sea  level,  between,  or  rather  on,  by  reason  of  the 
recent  expansion  of  the  city,  two  rivers,  the  San  An- 
tonio and  the  San  Pedro,  latitude  29°  30'  N.,  possesses 
a  mild,  dry,  and  equable  winter  climate,  commendable 
to  consumptives.  It  is,  however,  subject  to  occasional 
high  winds  and  dust,  which  should    be  avoided.     It 


is  a  progressive  city,  and  enjoyable  because  of  its  ex- 
cellent hotels,  churches,  opera  house,  and  other  social 
attractions;  a  large  preponderance  of  sunshiny  days, 
good  roads  round  about,  and  conditions  inviting  to 
outdoor  life.  It  is  two  hundred  and  ten  miles  west  of 
Houston  by  the  Galveston,  Harrisburg,  and  San  An- 
tonio Railroad,  of  the  Southern  Pacific  system;  one 
hundred  and  thirty-five  miles  from  the  Gulf  of  Mexico 
by  the  San  Antonio  and  Aransas  Pass  Railroad; 
eighty-two  miles  from  Austin  by  the  International 
and  Great  Northern  Railroad,  and  one  hundred  and 
fifty  miles  by  rail  from  the  Rio  Grande  at  Laredo. 

Boerne,  a  small  town  thirty  miles  northwest  of  San 
Antonio,  on  the  San  Antonio  and  Aransas  Pass  Rail- 
road, at  an  elevation  of  one  thousand  five  hundred  and 
fifty  feet  above  sea  level,  has  a  climate  very  similar  to 
that  of  San  Antonio;  average  winter  temperature,  62.7° 
F. ;  mean  relative  humidity,  69.  Severe  "northers" 
sometimes  occur  during  the  winter,  when  there  is  a 
fall  in  the  temperature  of  from  five  to  twenty  degrees, 
for  a  few  hours,  or  for  a  day  or  two.  There  are  no 
hotels  of  consequence  here,  but  there  are  good  board- 
ing-houses at  from  $20  to  40  a  month;  and  com- 
monly, plainly  furnished  houses  may  be  rented  at 
from  $10  to  $20  a  month.  There  are  very  tew  days 
during  the  winter  which  are  prohibitive  of  outings. 
The  roads  are  good,  and  there  are  many  attractions  in 
the  way  of  driving,  hunting,  and  fishing. 

El  Paso,  a  city  of  eleven  thousand  inhabitants,  situ- 
ated at  an  altitude  of  three  thousand  seven  hundred  and 
sixty-four  feet  above  sea-level,  in  the  extreme  north- 
western corner  of  the  State,  in  latitude  30"  47'  N.,  has 
a  mean  winter  temperature  of  about  46^  F.,  but  there  is 
great  variation  in  the  day  and  night  temperatures;  at 
midday  the  temperature  often  rises  to  60  F.  and  at 
night  sinks  to  freezing.  The  winds  are  moderate  and 
the  atmosphere  is  cloudless.  Mean  winter  rainfall, 
0.65  inches;  mean  relative  humidity,  56  per  cent. 
There  are  several  good  hotels  here  and  pleasant  social 
attractions.  Wheeling  and  driving  on  good  roads, 
and  mountain  climbing  are  the  out-door  attractions. 

New  Mexico. 

Las  Cruces,  a  small  town  situated  at  an  altitude  of 
three  thousand  eight  hundred  feet  above  sea  level,  in 
the  southern  portion  of  the  State,  on  the  line  of  the 
Atchison,  Topeka,  and  Santa  Fe  Railroad,  has  an  aver- 
age winter  temperature  of  about  43  ^  F.,  and  a  relatively 
dry  atmosphere,  with  a  large  proportion  of  sunshiny 
days  that  admit  daily  outings.  The  attractions  are 
interesting  drives,  shooting,  and  Mexican  curios. 
There  are  no  hotels  of  note  here,  but  there  are  good 
boarding-houses,  among  them  those  of  F.  C.  Baker,  R. 
C.  Halton,  J.  R.  Schmidt,  K.  Livingston. 

Arizona. 

Phoenix,  situated  at  an  altitude  of  one  thousand  two 
hundred  feet  abo\e  sea  level,  in  the  Salt  River  Valley, 
with  a  branch  connection  with  the  Atchison,  Topeka, 
and  Santa  Fd  Railway,  occupies  about  the  same 
parallel  of  latitude  as  San  Antonio,  and  possesses 
a  similar  climate,  with  the  additional  advantage  of 
greater  altitude,  but  greater  liability  to  dust.  The 
valley  is  about  sixty  miles  long  by  twenty  wide,  pro- 
tected by  high  mountains.  The  average  winter  tem- 
perature is  about  60°  F.,  and  the  atmosphere  exception- 
ally dry.  PhcKnix  is  reported  to  be  well  equipped  for 
the  entertainment  of  visitors. 

California. 

The  improved  health  resorts  ^)f  California  are  al- 
most wholly  confined  to  the  seacoast;  and  the  winter 
resorts  in  Southern  California  are  only  those  between 
Monterey  and  San  Diego. 

Monterey,  situated  on  the  southern  extremit\-  of  a 


November  27,    1897J  MEDICAL    RECORD.  77' 

K,v  nf   the  same  name   seventy-eight  miles  south  of  side,  and  surrounded  by  shade  trees,  a  beautiful  lawn, 

Sa     Francisco  by  wa  er',  and  two  hfurs  distant  by  rail.  and  rare  tropical  plants  and  flowers.     The  surround- 

S  tv^de  5°  ,7    X     has  an  equable  mean  winter'  tem-  ings  make  one  feel  that  there  are  plenty  of  room  and 

ne  a  ure  of  .^ °  F  •  the  atmosphere  is  humid.  comfort  everywhere.     There  are  bathrooms  convenient 

'     rte  nenins'ula  on  which  the  town  lies  affords  views  to  the  hotel,  where  hot  and  cold  baths  are  served.  _ 

of  the  b^aTand  the  ocean  and  beautiful  scener)^  round  Good  hunting  and  fishmg  as  well  as  romantic  drives, 

lout       lh.X'f  M  Monte  is  one  of  the  largest  and  add  to  the  reputation  of  the  springs.     Board,  $2.50  a 

^'  lanTa  Cruz'  across  the  bay,  opposite  Monterey,  and      coast  is  found  to  disagree,  relief   may  be  obtained  by 

rf  ,t  to'r  The^e  t;  goS  b..hhouse,  and  ev„y-  farther  i„.o  tb.cat.ons  of  the  mounlam  ,,de  .here  ,h. 

rLl^e^a,,  .„  .he  co£„  a,,d  ^^^  i;i;=a"US  ^^fZ.  /e"™"  l^pS',,':; 

ers.     It  IS  a  beautiful  town   f^^/^  ^^^^   'rS///./.-/  desirable  localities  for  consumptives  than  does  .Santa 

Ss^vS  Sity.     It    's  t^sU;^rethfd  from'all'  Barbara.     The  hotel  accommodations  are  adequate  and 

points  by  horse   cars   and  f  ^^^^/^.^^^  .^.^^^^^I'.fi;-.  'Tlo'em^er,  about  six  miles  northeast  of  the  town  are 

boring  localities,  and  the  Southern   1  acific  Rail.a)  Mo  eo                     ^^^                 picturesquely  located 

station  IS  only  a  short  distance  off.     The  rates  are  '^^^_^  ^^^^^^^^  ^^  fourteen  hundred  and  fifty  feet  above 

moderate.         ^     .,        „    ,^„      r  ^,       p._:fi-    „  jo.vn  sea  level,  amid  the  forest-covered  mountains.      There 

valley  of    Santa  Clara,    one    iiour   ana  .'•'^^'"•>  Seven   of  the  principal  ones  are  used  for 

wide.     To  the  east  are  the  hills  of  the  Coast  Range,      tion^     V„_p,e-    ^j^.,,  ^Hes  south  of  Santa  Barbara,  a 

;s.s  ^/rns;::Snr\s^^M  I  ^^:l£^:^:^:^:^ 

town,      ne  Hotel  Veudome  is  a  commodious  and  we  U  -PPjy  °^  P"-  %}^^  ^^^^  ^^,„;,,  temperature  is  about 

furnished  house,  only  a  few  minutes   walk  from  the  a'^';  "^f  ™;  ,  y^^    ^  The  percentages  of 

Southern    Pacific    Railway    depot.     The    ^t      ^  ,        fj^^shiny  day!,  afd  the  nu'mber  of^lear 

pass  the  door  at  short  intervals.    ^J^^^^^^^^^^^  ^^X:  winter,  as  recorded,  are,  respectively,  34,  66 

facility  for  the  enjoyment  of  the  magnihcent  scenery  a  )  ^^^^  delightful  climate,  excellent  roads,  and 

with  which  the  town  is  surrounded  heautiful  scenery  all  lend  their  attraction  to  open-air 

Pacific  Congress  5/.  «.^.-so-called  because  o^  the  be^itfful    ceneiy  a  ^^^^^^^^  ^^         ^^^^  ^^^ 

tTi  T-t  ^:itlairL^r?eV.ve.;?°oi^^n?o;i  SCre  abundantly  adequate   and  well   equipped. 

;r  s'lia,  at  an  elevation  of  seven  hundred  feet  and  te  rates  - -d.ate.^  ^^^^  „^  ^,^  ,,^..,.,  ,,,,,, 

above  sea  level,  amid  picturesque  scenery.    The  chem.-  ^f^J^ff^'^^^         li„,  „f   the   Southern   California 

cal  elements  of  the  waters,  as  show^  by  analysis  made  Mo miUuns    on  ^' -   "-^^^^^^^   ^^   ^os   Angeles    and 

by  Dr.  VVinslow  Anderson,  are  as  follows:  fi,^  hvmdred  feet  higher,  possesses  a  delightful  cli- 

che Pacific  Congress  water  contains  304.07  grams      ^^^  hundred  ^eet^^^..^^^  ,^P  ^^^^^  ^^  ^^^^^^ ^.^  ^^^^ 

of  solid  matter  to  the  gallon,  consisting  of:            ^  ^and  i"habitanl.s,  has  steam  and  surface  railroad  con- 
Sodium  chloride "5-7  nections  for  many  miles  round,  and  excellent  roads 

Indium  suSatT .■;:;:;::;::;;;:;::■.■■::     i^.^,  besides  •,    which,  with   the  beauty  of  the  scenery  and 

Potassium  carbonate. 2.06  ^^^^  objects  of  interest  round  about,  are  constant  in- 

Magnesium  carbonate 26.34  centives  to   open-air  enjoyment.      1  he   J\ny/>io/hi  und 

Magnesium  sulphate 4.  9  Carkton  are  both  good  hotels  at  moderate  rates. 

Ai«rnV'         '" :;:::::::'.■.'.:  ■.      4.50  San  Bernardino,  a  delightful    inland  resort,  with 

^Hca      ■.■.'.■.■.'.'.'.■".'.■.■.■.■. 3.98  about  five  thousand  inhabitants,  lies  in  a  picturesque 

"ZTZ  valley  about  sixty  miles  east  of  Los  Angeles,  in  the 

^     ■l"^''^'  ■  ■  ■ Lee.'  mountains.     It  is  reached  from  Los  Angeles  by  the 

GLfe^-fr^ec^bonicacid:::;:::::::::::::::.     44.. 7  southern    California   Railroad   in   two    hours.        t    IS 
The  springs  have  been  improved,  and  have  the  ad-      embowered   -^^J^^^.^^l^:^^^'^^^^^^^ 

vantage  'of  §eing  a  popular  winter  as  well  as  summer      ^^^^o.cesj^of  Cahfo^^^^  al  ^^^  ^.^  .^  ^P^^  ^^.^^ 

resort.  .  ■     u     t  i;.,^.       firm   tint  of  nlares  on  the  coast,  and    in    so    far  is 


772 


MEDICAL    RECORD. 


[November  27,  1897 


the  scenery  are  a  perpetual  inducement  to  open-air  life. 
There  are  several  excellent  hotels  at  moderate  rates. 

San  Diego,  situated  on  the  bay  of  the  same  name, 
four  hundred  and  sixty  miles  southeast  of  San  Fran- 
cisco and  fifteen  miles  north  of  the  Mexican  border, 
latitude  32°  44'  N.,  is  a  city  of  about  twent}'  thousand 
inhabitants,  and,  next  to  that  of  San  Francisco,  has 
the  best  harbor  on  the  California  coast.  The  town  is 
more  than  one  hundred  years  old,  but  it  is  only  during 
recent  years  that  the  sanitary  works  have  been  such  as 
to  render  the  town  attractive  as  a  winter  resort,  and 
recently  much  progress  has  been  made.  The  soil  in 
the  higher  portions  of  the  town  is  sandy;  the  mesas 
or  tablelands  ascend  from  the  bay  until  they  reach 
the  mountains,  about  forty  miles  distant.  Hence  the 
natural  facilities  for  drainage  are  good,  excepting  for 
some  low  and  marshy  ground  around  the  shores  of  the 
southern  end  of  the  bay,  and  have  been  turned  to  ad- 
vantage. Some  forty  to  fifty  miles  of  sewerage  pipes 
have  been  laid,  and  a  pure  water  supply,  brought  from 
the  mountains,  has  been  introduced  within  the  last  ten 
years.  The  best  residential  portion  of  the  town  is 
Florence  Heights,  one  hundred  and  eighty  feet  above 
sea  level,  where  there  are  many  beautiful  houses  with 
charming  grounds. 

The  climate  is  remarkably  equable  and  dry  for  a 
seacoast  place,  the  annual  range  of  temperature  being 
but  fifteen  degrees;  the  mean  winter  temperature  is 
about  54°  F.,  from  which  it  rarely  varies  more  than 
five  degrees.  Relative  humidity,  73  per  cent.  Frost 
is  unknown  here  and  the  lowest  temperature  on  record 
is  40°  F.  The  average  annual  rainfall  is  ten  inches — 
about  one-third  of  it  during  the  winter  months.  The 
breeze  is  almost  constant  but  moderate,  and  a  fog  ex- 
ceedingly rare. 

Directly  opposite  San  Diego,  across  the  bay,  one 
mile  distant  and  with  steam-ferry  connection,  is  Coro- 
nado  Beach,  a  crescent-shaped  tongue  of  hard  sand, 
six  miles  long,  which  separates  the  bay  from  the  ocean, 
bearing  some  resemblance  to  Cape  May. 

These — San  Diego  and  Coronado — are  "  Our  Italy," 
of  which  Charles  Dudley  Warner  wrote  so  admiringly, 
after  spending  a  part  of  the  winter  there  in  1889-90. 
"It  lies  there,  our  Mediterranean  region,  on  a  blue 
ocean  protected  by  barriers  of  granite  from  the  North- 
ern influences,  an  infinite  variety  of  plain,  canon,  hills 
valleys,  seacoast — our  new  Italy,  without  malaria  and 
with  every  sort  of  fruit  which  we  desire,  except  the 
tropical,  which  will  be  grown  in  perfection  when  our 
knowledge  equals  our  ambition  ;  and  if  you  cannot 
find  a  winter  home  there,  or  pass  some  contented 
weeks  in  the  months  of  Northern  inclemency,  you  are 
weighing  social  advantages  against  those  of  the  least 
objectionable  climate  within  the  Union.  It  is  not  yet 
proved  that  this  equability  and  the  daily  outdoor  life 
possible  there  will  change  character,  but  they  are  likely 
to  improve  the  disposition  and  soften  the  asperities 
of  common  life.  At  any  rate,  there  is  a  land  where, 
from  November  to  April,  one  has  not  to  make  a  con- 
tinual fight  with  the  elements  to  keep  alive." 

The  Hotel  del  Coronado,  on  Coronado  ISeach,  is  one 
of  the  most  commodious  and  luxuriously  equipped 
hotels  in  the  Union.  It  covers  seven  and  one-half 
acres,  surrounded  by  a  park  of  ornamental  trees  and 
flowers  of  unsurpassable  beauty.  Its  chief  rivals  are 
the  Horton  House,  Florence  Hotel,  and  Brewster  House  ; 
and  St.  James  Hotel,  at  San  Diego,  on  the  other  side 
of  the  bay,  though  less  elaborate,  is  of  equal  elegance 
with  the  Coronado.     The  rates  are  from  $3  to  $5  a  day. 

Of  attractions  to  outdoor  life  there  is  no  end  in 
the  beautiful  scenery  and  places  of  interest,  accessible 
by  wheel  or  carriage  on  good  roads,  .steam  and  surface 
cars,  and  steamboat  excursions — so  versatile  and  so 
interesting  as  to  be  a  constant  inducement  to  health- 
ful recreation  in  the  open  air. 


San  Diego  is  the  western  terminus  of  the  Atchison, 
Topeka,  and  Santa  Fe  system.  Its  connection  with 
San  Francisco  is  by  steamer  or  the  Southern  Pacific 
via  Los  Angeles. 

Through  tickets  are  on  sale  at  San  Francisco,  Oak- 
land, Alameda,  and  San  Jose',  reading  to  Lompoe, 
Santa  Barbara,  and  Los  Angeles,  and  other  points; 
also  at  Los  Angeles,  Sant  Barbara,  and  Lompoe, 
reading  in  the  opposite  direction.  The  rates  are  as 
follows:  Between  San  Francisco  and  Lompoe,  $io.go; 
between  San  Francisco  and  Santa  Barbara,  $15:  be- 
tween San  Francisco  and  Los  Angeles,  $18.35.  ^^' 
tween  San  Jose'  and  Lompoe,  $9.65  ;  between  San  Josd 
and  Santa  Barbara,  S15;  between  San  Jose  and  Los 
Angeles,  S18.35. 

The  Sandwich  Islands. 

With  the  geography  of  these  islands  in  detail  the 
tourist  is  supposed  to  have  made  himself  acquainted 
from  other  sources.  They  lie  in  latitude  21°  18'  N., 
and  longitude  157°  55'  W.,  twenty -one  hundred  miles 
from  San  Francisco.  The  Ocean  Steamship  Com- 
pany's steamers  make  the  voyage  fortnightly;  also 
those  of  the  Pacific  Mail  Steamship  Company,  and  the 
Occidental  and  Oriental  Steamship  Company.  The 
usual  time  from  San  Francisco  to  Honolulu  is  six 
days.  Fare,  S75:  round  trip,  good  for  four  months. 
$125. 

Though  these  islands  are  on  the  verge  of  the  tropics 
and  over  two  thousand  miles  distant  from  other  land, 
the  climate  is  virtually  an  exaggeration  of  that  of  the 
seacoast  rather  than  oceanic.  This  is  probably  due 
to  the  nature  and  conformation  of  the  soil,  the  enormous 
amount  of  vegetable  debris,  and  the  great  rainfall. 

There  are  twelve  islands  in  the  group,  all  of  vol- 
canic origin,  differing  in  altitude  from  ocean  level 
to  fourteen  thousand  feet  above.  Besides  the  two 
peaks  of  the  principal  island,  Hawaii,  Mauna  Kea  and 
Mauna  Loa,  each  of  which  is  fourteen  thousand  feet 
high  and  one  of  them  covered  with  perpetual  snow,  this 
island  is  traversed  by  many  other  rugged  and  craggj' 
peaks  and  ridges,  and  presents  a  magnified  view,  as  it 
were,  of  the  same  characteristics  more  or  less  common 
to  the  other  islands  of  the  group.  Several  of  them,  or 
at  least  large  portions  of  several  of  them — particularly 
on  the  windward  sides — are  covered  with  dense  for- 
ests. The  rough  crevices  and  culs-de-sac  are  liter- 
ally stuffed  with  the  debris.  The  annual  rainfall  is 
from  one  hundred  and  forty  to  one  hundred  and  fifty 
inches,  and  in  consequence  of  the  obstructed  surface 
drainage  and  the  high  temperature  the  accumulated 
debris  is  kept  in  a  state  of  constant  decay  and  the  cli- 
mate rendered  malarious.  Moreover,  by  reason  of 
the  elevated  peaks  and  ridges  and  the  thick  forests 
on  the  windward  sides  of  the  islands,  the  circulation 
of  the  air  is  impeded  and  the  benefit  which  otherwise 
would  be  derivable  from  the  prevailing  trade  wind 
from  the  northeast  is  lacking.  Hence  the  winter  tem- 
perature of  these  islands,  according  to  the  records,  in- 
stead of  being  oceanic  and  equable  at  about  80^  F., 
is  about  70°  F.  and  variable — the  diurnal  variation  in 
winter  being  from  ten  to  fifteen  degrees,  and  the 
annual  range  from  53"  to  90"  F.  The  sea  voyage 
from  San  Francisco  is  commendable,  but  as  a  health 
resort  Hawaii  does  not  compare  favorably  with  those 
on  the  seacoast  of  Southern  California. 


Intussusception — Under  ana?sthesia  a  rectal  tip  was 
inserted,  which  controlled  any  escape  of  water  from 
the  rectum,  and  through  it  over  two  gallons  of  water 
was  introduced  into  the  bowel.  There  was  a  sudden 
violent  gush  of  water  from  the  patient's  mouth,  show- 
ing that  the  obstruction  was  overcome, — Pynchok, 
Matheii'^s  Aledical  Quarterly,  January. 


November  27,  1897] 


MEDICAL    RECORD. 


11: 


©riginal  |irticUs. 

NASSAU    AND    THE    BAHAMA    ISLANDS. 
By   OLIVER    T.    D.    HUGHES,   Ph.D.,    M.D., 

MERIDEN,   CONN., 

EX-nCE-PRES!DEST,  COXSECTICUT  MEDICAL  SOCIETY  ;  LATE  PRESIDENT,  NEW- 
HAVEN  COUNTY  MEDICAL  ASSOCI.-VTION  ;  .ME.MBER,  AMERICAN  MEDICAL 
ASS0CI.\TION. 

How  often  we  tell  a  patient  that  a  change  of  climate 
is  necessary — is,  in  fact,  imperative  to  save  life — and 
then  deliberately  send  him  to  some  place  which  is  in 
every  way  unfitted  for  his  diseased  condition !  Now, 
after  a  thorough  acquaintance  with  Nassau  and  the 
Bahama  Islands  since  1875 — that  is  to  say,  some  two- 
and-twenty  years — I  think  I  can  with  some  knowledge 
and  authority  speak  for  what  Nassau  can  do  for  a  cer- 
tain class  of  cases;  or,  in  other  words,  what  special 
diseases  may  be  and  are  benefited  by  a  longer  or 
shorter  sojourn  there. 

I  might  say,  at  the  start,  that  I  am  no  great  believer 
in  sending  patients  in  artuulo  mortis  to  any  place  but 
their  own  home.  Such  patients  will  not  improve  any- 
where; let  them  die  in  peace  and  comfort,  at  home 
among  their  friends  and  relatives. 

The  Bahama  Islands  lie  a  few  hours'  sail  from  the 
eastern  shore  of  Florida,  with  the  Gulf  Stream  wind- 
ing its  way  among  them,  keeping  up  a  dry,  pleasant 
heat,  which  never  becomes  oppressive,  owing  to  the 
ever-blowing  trade  winds — the  average  winter  temper- 
.  ature  being  between  70^  and  80°  F.  during  the  day, 
and  at  night  everything  is  cool,  with  no  mosquitoes  or 
other  members  of  the  flying  world  to  disturb  pleasant 
or  healthful  dreams.  Doors  and  windows  nobody 
shuts  either  by  day  or  night,  as  the  air  will  do  good, 
"and  thieves  do  not  break  through  nor  steal." 

But  to  come  down  to  the  cases  benefited  by  resi- 
dence in  this  group  of  islands: 

I  St.  All  cases  of  acute  or  semi -acute  affections  of 
the  lungs. 

2d.  All  cases  of  nervous  afflictions,  including  most 
especially  those  of  a  diabetic  character. 

3d.  Rheumatic  cases  in  all  their  chronic  and  semi- 
chronic  conditions. 

4th.  All  classes  of  patients  recovering  from  severe 
forms  of  any  of  the  acute  diseases. 

5th.  It  is  the  only  place  in  the  world  for  a  tired-out 
professional  or  business  man  to  take  it  easy,  and  really 
do  nothing  but  enjoy  himself  quietly  and  give  nature 
a  chance  to  build  up  and  once  more  make  a  man  able 
to  do  man's  work. 

6th.  That  class  of  stomach  troubles  found  so  often 
among  business  or  professional  men  and  women  who 
bolt  their  meals  and  then  rush  off  to  work  again ;  tliat 
class  of  cases  in  women  who  are  so  constipated  that 
they  never  have  a  natural  movement  of  the  bowels. 

In  the  first  class  mentioned  — affections  of  the  lungs 
— so  long  as  they  are  not  in  the  last  stages,  where  can 
you  find  such  a  perfectly  dry  sea  air,  thoroughly  load- 
ed by  nature  with  everything  necessary  to  repair 
broken-down  tissue  and  build  it  up  anew,  sound  and 
healthful?  The  wife  of  one  of  America's  greatest 
painters  was  kept  alive  for  over  twenty  years  by  being 
brought  down  every  winter.  A  great  many  times  I 
have  seen  her  carried  aboard  the  steamer  at  New  York 
on  a  Thursday  afternoon,  and  on  the  next  Monday 
morning  seen  her  walk  ashore  at  Nassau  almost  a  new 
per.son. 

Another  case:  the  beautiful  wife  of  a  prominent 
New  York  lawyer,  who  if  she  stays  in  New  York  ('it)- 
during  the  winter  at  once  develops  a  well-marked 
bronchitis  which  more  than  once  has  nearly  carried 
lier  off,  finds  instant  relief  in  the  fair  Isle  of  Irme. 

A  medical  friend   of   mine,   now  enjoying  a   large 


practice  in  one  of  our  Southern  cities,  came  to  me 
some  years  ago  for  advice  as  to  what  he  should  do. 
On  e.xamination  I  found  his  right  lung  very  much 
broken  down.  He  had  previously  seen  nearly  every 
prominent  lung  specialist  in  the  country,  and  had  been 
advised  to  go  from  -Maine  to  California.  He  had 
done  so,  with  the  result  that  he  had  gotten  steadily 
worse — to  say  nothing  of  a  pocketbook  nearly  empty. 
He  wanted  advice  as  to  what  to  do.  His  stomach 
had  arrived  at  that  point  where  food  and  medicine 
were  almost  rejected  before  being  swallowed.  I  ad- 
vised him  to  go  and  live  on  one  of  the  out-islands  of 
the  Bahama  group,  to  leave  all  medicine  alone,  and 
to  feed  on  the  flesh  of  the  green  turtle,  with  plenty  of 
baked  plantains  in  place  of  bread,  and  some  good  rye 
whiskey  to  take  the  place  of  all  opiates.  He  did  as  I 
advised,  lived  strictly  as  ordered,  was  outdoors  all  day 
long,  even  sleeping  at  night  with  only  a  shed  over 
him,  bathing  every  day  in  the  warm  salt  water.  He 
gradually  improved,  until  after  living  thus  for  eigh- 
teen months  he  came  back  to  the  United  States  a  well 
man,  hearty  and  able  to  do  a  good  day's  w  ork,  to  enjoy 
three  square  meals  a  day  without  distressing  his  di- 
gestion in  any  way.  He  had  been  cod-liver  oiled 
almost  to  death  before  starting  for  the  Bahamas — with 
what  result?  His  lungs  steadily  getting  worse  and  his 
digestion  ruined.  Now  mark  the  difference.  Under 
a  good  liberal  diet  of  fresh  turtle  flesh — which  con- 
tains ten  to  one  more  nourishment  and  tonic  proper- 
ties than  any  bad-smelling  and  worse-tasting  cod's- 
liver  product — he  picks  up,  is  able  to  enjoy  his  food, 
and  nature  gets  a  chance  to  repair  his  diseased  lung 
tissue.  Oh!  when  will  we  learn  to  appreciate  nature's 
rare  gifts  and  to  keep  from  doing  harm  just  from  force 
of  habit  and  because  our  grandfathers  blundered  at  the 
start  1  1  can  recall  a  great  many  other  cases,  but  I 
think  the  above  are  enough. 

In  the  second  class— nervous  affections — the  cli- 
mate seems  to  have  a  soothing,  quieting  effect,  which, 
combined  with  the  complete  change  in  the  ways  and 
manners  of  life,  helps  to  take  the  patients'  thoughts 
away  from  themselves  and  thus  improve  their  nervous 
system. 

For  the  diabetic,  where  can  he  find  a  place  so  well 
suited  for  him?  As  near  the  sea  level  as  he  can  get 
without  walking  directly  into  the  sea:  a  climate  such 
that  he  can  be  outdoors  day  and  night :  with  the  greatest 
variety  of  fish  diet,  with  acid  fruits  in  profusion,  with 
the  skin-baked  banana  food,  as  near  a  non-starchy 
substitute  for  flour  as  can  be  found. 

Thirdly,  that  class  of  chronic  rheumatic  cases  so 
often  found  in  our  Northern  cities  and  villages.  The 
crippled  fingers  and  feet  seem  to  improve  and  grow 
limber  once  more  under  the  influence  of  the  life-giving 
air  and  warm  salt-water  baths. 

Fourthly,  any  one  who  has  been  flat  on  his  back, 
after  a  severe  attack  of  any  kind  of  acute  sickness 
during  a  Northern  ice-bound  winter,  improves  rapidlv. 
What  with  the  complete  change  of  climate,  food,  hab- 
its of  life,  etc.,  two  weeks  out  there  will  do  more  good 
than  three  months  of  tonics. 

Fifthly,  how  often  we  are  called  to  see  a  business 
man  who  is  said  to  be  suffering  from  "malaria,'"  or 
"nervous  prostration,"  or  some  other  thing  which 
means  the  same — "  nothing."  Why  not  use  good,  plain 
Anglo-Saxon  and  say  that  he  is  "played  out'"  from 
overwork  or  something  else?  To  this  class  a  two  or 
four  weeks'  trip  to  these  beautiful  isles,  with  their 
easy-going,  happy-go-lucky  ways,  brings  new  life. 
One  is  able  to  see  the  funny  side  of  life  once  more,  to 
laugh,  be  merry,  and  grow  fat  and  be  happy.  Can 
medicine  alone  do  this?      I  think  not. 

Si.xthly,  we  come  to  the  man  and  woman  who  have 
arrived  at  that  stage  of  life  on  earth  when  the  pleas- 
ures 01  the  table  are  a  thing  of  the  past,  who  can  only 


774 


MEDICAL    RECORD. 


[November  27,  1897 


groan  and  look  sour  when  they  see  anybody  else  enjoy 
a  good  meal,  who  travel  around  with  a  large  and  well- 
assorted  case  of  every  drug  in  the  materia  medica — to 
say  nothing  of  half  a  dozen  bottles  of  So-and-So's 
digestive  fluids.  To  these  people — who  know  more  or 
think  they  do  than  all  the  medical  profession  in  the 
world  —  I  say  :  Throw  away  your  patent  medicines,  go 
to  "  those  blessed  islands"  of  Columbus,  drink  of  na- 
ture's greatest  remedy — "  pineapple  juice,"  fresh  and 
sweet — live  temperately,  avoid  highly  spiced  foods, 
and  be  cured. 

Just  one  word  concerning  the  constipated  woman, 
who  has  to  take  "  physic"  every  day  of  her  life.  Try  on 
her  the  effect  of  a  trip  to  Nassau,  and,  instead  of  the 
usual  amount  of  cathartic  medication,  just  let  her  drink 
a  quart  of  fresh  pineapple  juice  during  the  day. 

The  people  and  government  officials  of  Nassau  will 
be  found  obliging  and  willing  to  ser\e  strangers  in 
every  way.  There  is  no  formality:  hospitality 
abounds  on  every  hand,  from  the  rich  Nassau  mer- 
chant to  the  poor  humble  "  colored  brother'"  at  Grants- 
town.  No  pen  can  describe  the  quaint  sights  or  funny 
sayings  to  be  seen  and  heard  among  these  primitive 
descendants  of  captured  blacks  liberated  from  Congo 
slave  ships.  I  have  never  yet  seen  a  person  who  has 
once  been  to  these  islands  but  wishes  to  return  once 
more  to  them  for  just  one  more  happy  stay  among 
these  contented,  happy  islanders. 

Living  is  cheap  comparatively;  the  hotels  and 
boarding-places  are  clean,  neat,  and  pleasant.  Out- 
side expenses  need  not  amount  to  very  much. 

How  to  get  there  is  simple  and  easy.  Take  one  of 
the  handsome  and  well-equipped  steamships  of  the 
New  York  and  Cuba  Mail  Steamship  Company  (James 
E.  Ward  &  Co.,  113  Wall  Street,  New  York,  agents), 
some  cold,  sleety,  disagreeable  Thursday  afternoon 
this  winter,  from  Pier  17,  East  River,  and  after  a  pleas- 
ant life-giving  sea  voyage  of  four  days — during  which 
you  have  been  fed  like  a  nabob  and  lodged  like  a  lord 
— you  are  landed  at  Nassau  the  following  Monday 
morning;  or,  if  you  are  a  poor  sailor,  go  rw  a  "  Florida 
special"  to  Miami,  and  take  the  Flagler  Line  steamer 
direct  to  Nassau.  But  whichever  way  you  go,  when 
you  start  to  come  back  you  will  leave  good,  quaint, 
old  Nassau  with  many  regrets. 

One  word  in  closing  for  the  medical  profession  as 
found -in  Nassau.  Without  any  e.xception,  they  are 
well-read,  busy,  good  fellows,  always  glad  to  welcome 
a  visiting  professional  brother  and  to  do  anything  to 
make  his  stay  among  them  pleasant  in  every  way. 


THE  ASHEVILLE  PLATEAU  IN   THE  MOUN- 
TAINS  OF   WESTERN    NORTH   CAROLINA. 

By   S.    WESTRAY    BATTLE,    M.D..    L.S.N.. 

ASHEVILLE,   N.    C. 

H.wiNG  received  so  many  inquiries  for  a  brief  outline 
of  the  climatic  conditions  which  prevail  upon  what  I 
have  chosen  to  call  the  Asheville  plateau,  a  summary 
of  the  advantages  of  the  region  may  not  be  out  of 
place. 

It  is  a  common  thing  in  this  life  that  the  harder  a 
thing  is  to  acquire  the  more  desirable  it  becomes.  The 
same  proposition  obtains  in  the  matter  of  climate:  the 
more  inaccessible  a  place,  the  more  virtues  it  possesses. 
It  seems  to  me  that  the  profession  has  not  given  to  this 
region  the  attention  it  merits — a  most  desirable  and 
beautiful  section  of  country,  in  close  touch  with  the 
East  and  North,  and  most  accessible  from  all  points 
South  and  West. 

Nestled  in  the  heart  of  the  .Mleghanies,  cradled  by 
the  Blue  Ridge  and  Creat  Smokies,  stretches  the 
.-Vsheville  plateau,  the  great  sanatorium  of  Western 
North  Carolina  and  Eastern  United  States.     It  enjoys 


a  climate  sui generis,  representing  the  golden  mean  of 
altitude  and  latitude  and  the  several  meteorological 
conditions  which  go  to  make  up  a  wholesome  and  fas- 
cinating resort.  Nowhere  east  of  the  Rocky  Moun- 
tains is  to  be  found  anything  approaching  it  for 
fall  and  winter,  spring  and  summer — an  all-the-year- 
round  retreat.  It  is  cool  in  summer,  yet  the  winters, 
shorn  of  their  harslmess  by  reason  of  its  southern  lat- 
itude, induce  almost  daily  outdoor  exercise  in  the 
way  of  shooting,  riding,  driving,  or  short  mountain 
excursions  on  foot.  For  lovers  of  golf  it  is  ideal :  and 
at  Asheville,  the  centre  of  the  plateau,  are  united  the 
comforts  of  a  city  with  the  delights  of  the  country. 

The  plateau  is  an  elevated  tableland,  somewhat  tri- 
angular in  shape,  embracing  some  six  thousand  square 
miles  of  Western  North  Carolina,  with  a  general  ele- 
vation of  two  thousand  feet  above  the  sea  level,  though 
altitudes  up  to  six  thousand  feet  may  be  had  for  the 
climbing  any  day  in  the  year.  Hills,  valleys,  rivers, 
and  forests  so  diversify  this  intramontane  expanse  as 
to  make  it  lovely  and  restful  to  the  eye,  beyond  the 
power  of  my  pen  to  portray. 

The  temperature  is  indicated  by  the  following  table : 
Mean  temperature  of  spring,  53.49^  F. :  summer, 
70.72°  F. ;  autumn,  53.48^  F. ;  winter,  38.87'  F. ;  for 
the  year,  54.14°  F. ;  with  a  mean  relative  humidity  of 
65  per  cent. 

There  can  hardly  be  room  for  controversy  that  right 
here  we  are  enjoying  the  golden  mean  of  American 
climate.  With  medium  altitude,  dry,  tonic,  invigorat- 
ing, and  ozoniferous  atmosphere,  the  region  cannot 
fail  to  grow  in  popularity  as  meeting  the  indications  . 
in  the  cases  of  a  large  majority  of  health  seekers,  more 
especially  those  looking  for  the  all-tJie-year-round 
residence:  and  it  has  occurred  to  the  writer  that  it 
should  particularly  appeal  to  the  retired  of  the  army 
and  the  navy,  and  to  him  of  modest  independence, 
who  wants  to  enjoy  his  otiiini  cum  dig.  away  from  the 
busy  whirl  of  the  city  and  carking  care.  Nor  is  it 
amiss  to  mention  that  the  finest  private  residence  in 
America  has  been  built  here.  With  good  roads  and 
inviting  inns,  the  shadows  of  which  are  now  upon  us, 
its  attractions  will  vie  with  the  now  popular  mountain 
regions  of  Europe. 

In  regard  to  the  merits  of  the  climate,  or  the  clima- 
totherapy  of  the  plateau,  let  me  briefly  sum  up  its  ad- 
vantages without  bestowing  indiscreet  or  overzealous 
praise.  It  is  pre-eminently  a  suitable  one  for  the 
early  stages  of  pulmonary  phthisis,  especially  for  such 
subjects  as  can  and  will  get  out  in  the  air,  and  are 
determined  to  take  the  benefit  of  the  dry,  tonic,  invig- 
orating, bracing  qualities  thereof,  and  keep  good 
hours.  Conditions  which  seem  to  favor  germ  propaga- 
tion and  prolong  the  species  of  the  genus  bacterium 
do  not  exist  here.  Wounds  heal  kindly  and  operative 
procedures  of  the  gravest  character  are  rarely  followed 
by  septic  infection. 

The  mortality  from  pulmonary  phthisis  is  not  large 
in  any  part  of  Nortii  Carolina,  being,  according  to  the 
mortality  tables  of  the  tenth  census  (18S0),  13.4  for 
every  10,000  of  population  throughout  the  State.  But 
it  is  interesting  to  note  that  the  mountain  counties 
show  a  mortality  of  only  10.6  in  every  10,000  of  pop- 
ulation, as  against  16.1  for  every  10,000  of  population 
of  all  the  other  counties  of  the  State  in  the  aggregate; 
or  in  other  words,  in  a  State  where  pulmonary  phthisis 
does  not  figure  prominently  in  the  mortality  tables  the 
death  rate  is  still  fifty  per  cent,  less  in  the  mountain 
section  than  in  the  other  lower-lying  portions  of  the 
State. 

Among  other  conditions  indicating  the  advisability 
of  a  sojourn  in  this  region  may  be  mentioned  asthma, 
hay  fever,  convalescence  from  malarial  and  other 
fevers  (there  are  no  lakes  or  sw;>mps,  and  malaria  is 
unknown),  nervous  prostration,   and  exhaustion   from 


November  27,  1897] 


MEDICAL    RECORD. 


775 


overwork  or  long-continued  summer  heat;  as  also 
chronic  congestion  of  the  internal  organs  by  reason  of 
diminished  atmospheric  densitj-  causing  a  determina- 
tion of  blood  to  the  surface — hence  arises  one  of  the 
benefits  of  altitude  in  incipient  phthisis.  Nervous 
energy  and  muscular  vigor  are  usually  increased,  and 
the  nutrition  of  the  body  and  the  general  condition  of 
the  blood  improved  by  a  sojourn  at  moderate  elevation ; 
above  six  thousand  feet  the  appetite  for  food  is  dimin- 
ished and  the  digestive  organs  are  frequently  disor- 
dered, whereas  a  medium  altitude  usually  increases 
the  desire  for  food  and  quickens  digestion.  By  rea- 
son of  its  medium  altitude  contraindications  to  a 
residence  upon  the  plateau  are  few,  though  organic  dis- 
ease of  the  heart,  in  which  the  circulation  is  much  dis- 
turbed, must  not  be  lost  sight  of.  Of  course  those  who 
are  in  advanced  phthisis,  and  are  too  feeble  to  breathe 
the  outdoor  air  anS  take  some  sort  of  outdoor  e.xer- 
cise,  are  better  off  at  home  with  their  friends,  sur- 
rounded by  comforts  that  cannot  be  supplied  else- 
where. 

Since  the  above  was  wTitten,  Surgeon  John  \V.  Ross, 
who  retired  from  active  service  in  the  United  States 
navy  in  1894  on  account  of  retinitis,  has  returned 
from  a  visit  of  inspe-Jtion  and  careful  study  of  certain 
of  the  veteran  tuberculous  sanatoria  in  Germany,  par- 
ticularly those  at  Falkenstein  in  the  Taunus,  and 
Reiboldsgriin  in  Saxony,  where  such  admirable  re- 
sults have  been  and  are  still  being  obtained;  as  well 
as  the  more  recently  established  institutions  at  Rup- 
pertshain  and  .-Vlbertsberg  for  the  cure  of  the  poor 
afflicted  with  phthisis.  Dr.  Ross  returns  convinced 
that  the  climatic  conditions  of  the  Asheville  plateau 
are  the  most  favorable,  all  the  year  round,  that  he  has 
ever  experienced  for  the  cure  of  patients  afflicted  with 
tuberculosis:  and  that  a  properly  constructed, 
equipped,  and  conducted  sanatorium  here  would  give 
better  results  than  those  obtained  in  Germany. 

The  doctor's  opinion  is  of  value,  for  while  in  ac- 
tive service  in  the  navy  and  since  his  retirement  he 
has  given  special  attention  to  the  study  of  pulmonary- 
tuberculosis  with  special  reference  to  its  climatic  and 
hygienic  treatment,  having  visited  many  of  the  best 
and  most  popular  consumptive  resorts  in  the  United 
States,  South  America,  and  Sandw  ich  Islands,  besides 
those  of  the  Old  World:  nor  has  this  conclusion  been 
reached  hastily,  as  he  had  occasion  to  spend  months 
here  several  years  ago. 


THE  URGENT  NEED  OF  SANATORIUMS  FOR 
THE  CONSUMPTIVE  POOR  OF  OUR  LARGE 
CITIES.* 

By   S.   a.    KNOPF.    M.D.    (Paris  axd  Bell.    N.    V.), 

PHVSICIAK  TO  THE  LfSG  DEPARTMENT  OF  THE  NEW  YORK  THROAT  AND 
NOSE  HOSPITAL  ;  FORMERLV  ASSISTANT  PHVSICIA.N-  TO  PROFESSOR  DETT- 
VTEILBR,  FALKENSTEIN  SANATORIfM,  GERMANY  ;  FELLOW  OF  THE  AMER- 
ICAN ACADEMY  OF  MEDICINE  ;  FELLOW  OF  THE  NEW  YORK  ACADEMY 
OF   MEDICINE,    ETC. 

The  question  what  to  do  with  the  thousands  of  tuber- 
culous patients  who  inhabit  the  tenement  districts  of 
our  large  cities,  unconsciously  disseminating  the 
germs  of  their  diseases  among  their  own  kin,  friends, 
and  neighbors,  or  who  crowd  the  wards  of  our  general 
hospitals  to  the  detriment  and  danger  of  the  patients 
suffering  from  acute  diseases,  has  become  for  the  san- 
itarian one  of  the  vital  issues  of  the  day. 

In  Europe  such  men  as  von  Leyden.  of  Kerlin:'  von 
Schroetter,  of  Vienna;"  Grancher'  and  Letulle,  of  Par- 
is;' Weber,  of  London;^  and  in  this  country  Biggs 
and  Prudden,  of  New  York;'  Bowditch '  and  Otis," 
of  Boston;   Flick,"  Hinsdale,""  and  Lee,"  of  Philadel- 

*  Read  at  the  twenty-fifth  annual  meeting  of  the  .\merican  Pub- 
lic Health  .Association,  held  in  Philadelphia.  Pa..  October  26-29. 
1897. 


phia;  Hamilton,  of  Chicago;'"  and  many  others"  be- 
lieve the  only  solution  to  be  the  erection  of  special 
sanatoriums,*  preferably  under  mimicipal  control.  I 
myself  have  pleaded  for  sanatoriums  for  the  consiunp- 
tive  poor  on  previous  occasions,"  and  I  now  renew  my 
plea  before  you,  wishing  to  show  again  the  virgent 
ueed  for  such  institutions. 

In  Europe  the  pleadings  of  the  profession  for  estab- 
lishments of  this  kind  have  not  been  in  vain;  Ger- 
many alone  can  boast  of  over  thirty  sanatoriimis  for 
the  consiunptive  poor,  already  in  working  order  or  in 
the  course  of  construction,  most  of  them  under  muni- 
cipal control."  In  the  United  States  there  are  only 
two  or  three,  partly  supported  by  private  charity,  and 
not  one  institution  which  we  may  justly  call  a  muni- 
cipal sanatorium  for  the  consumptive  poor.  Only  re- 
cently we  of  New  York  and  you  of  Pennsylvania  have 
had  the  painful  experience  of  seeing  the  chief  officers 
of  our  respective  States  veto  appropriations  intended 
to  create  institutions  which  might  have  become  the 
nucleus  of  more  efficient  work  than  has  ever  yet  been 
accomplished  in  the  L'nited  States  in  the  extermina- 
tion of  this  dread  disease. + 

Far  be  it  from  me  to  criticise  the  action  of  these 
distinguished  governors,  who  thought  to  serve  their 
State  best  by  vetoing  an  appropriation  which  seemed 
to  them  unnecessary. 

To  convince  them  of  their  error,  to  convince  the 
many  of  our  fellow-practitioners  who  also  deny  as  yet 
the  need  of  special  institutions  for  the  consimiptive 
poor,  to  show  to  the  philanthropist  a  most  practical 
and  noble  way  to  do  good,  not  only  to  the  consumptive 
individual  but  indirectly  to  the  whole  community — I 
will  ask  them  all  to  accompany  me  for  a  moment  on  a 
little  excursion  to  the  crowded  tenement  district  of  one 
of  our  large  cities.  Let  them  visit  there  with  me  some 
of  the  consumptive  poor  who  live  in  these  houses,  in 
all  the  various  stages  of  the  disease,  from  the  incipient 
case  of  pulmonar)-  tuberculosis  to  the  last  hectic  stage 
of  consumption,  with  all  its  pitiful  manifestations  of 
the  slow  ebbing  away  of  human  life. 

Let  us  leave  our  comfortable  homes,  and  enter  the 
narrow  streets  of  those  districts,  crowded  with  human- 
ity. We  make  our  way  into  a  house  through  the  little 
world  in  rags  playing  on  the  sidewalks.  The  hallways 
are  dark,  and  the  odor  indicative  of  crowded  and  un- 
clean rooms  greets  us.  We  ascend  one  or  many  flights 
of  stairs,  in  the  rear  or  in  the  front — it  makes  little 
difference.  There  lives  Mr.  So-and-So,  with  his  wife 
and  several  children.  They  occupy  two  rooms,  rarely 
three:  but  only  one  receives  direct  light  and  air.  And 
in  these  few  rooms  live,  cook,  eat,  sleep,  and  often 
work  from  eight  to  ten  human  beings. 

We  inquire  after  the  patient,  and  find  him  lying  on 
a  couch  or  bed  in  a  dark  bedroom.  We  e.xamine  him, 
and  find  him  suffering  from  pulmonary  tuberculosis  in 
the  last  stages.  On  examining  the  other  members  of 
the  family,  we  find  one  or  two  of  them  already 
'■  touched"  by  the  deadly  germ. 

In  an  audience  of  sanitarians  there  is  no  need  to 
explain  how  the  other  members  of  the  family  have 
been  infected.      But  I    invited  to  my  excursion  some 

*  Contrary  to  the  custom  of  many  English-speaking  people, 
especially  in  the  United  States,  I  call  these  establishments  sana- 
toriums and  not  sanitarhims.  The  former,  from  sanart.  to 
heal,  gives  a  better  equivalent  to  the  German  "  Heilanstalt,"  the 
word  used  by  the  originator  of  this  system  (Brehmer).  Secondly, 
the  word  sanitarium,  from  saiiilas.  health,  is  usually  employed  to 
designate  a  place  considered  simply  as  especially  healthy,  a  fa- 
vorite resort  for  convalescent  patients. 

+  .\  decidedly  different  view  must  have  been  taken  by  the  chief 
of  a  European  .State.  -At  the  recent  twenty-fifth  anniversary  of 
King  Oscar's  accession  to  the  throne  of  Sweden,  a  deputation 
presented  him  «-ith  the  sum  of  220,000  crowns,  which  amount 
had  been  raised  among  the  people.  He  accepted  the  gift,  but 
decided  that  the  entire  sum  should  be  devoted  to  combat  tuber- 
culous diseases. 


7/6 


MEDICAL    RFX.ORD. 


[November  27,  1897 


distinguished  laymen,  and  to  them  I  must  briefly  ex- 
plain how  one  tuberculous  individual  is  capable  of 
transmitting  his  disease  to  whole  families. 

A  consumptive  expectorates  at  times  as  many  as 
seven  billions  of  bacilli  in  twenty-four  hours.  If  the 
sputum  containing  these  germs  is  not  properly  dis- 
posed of;  if  it  has  had  a  chance  to  dry  on  the  floor,  in 
a  handkerchief,  on  the  clothing,  linen,  or  the  beard  of 
the  patient — it  will  sooner  or  later  become  pulverized 
and  be  inhaled  as  dust  by  the  other  members  of  the 
family.  If  these  are  vigorous  and  well  nourished  they 
need  not  fear  a  contamination,  for  in  health  our  nasal 
mucous  membrane  has  a  most  marked  bactericidal 
function.  But,  alas!  very  many  of  the  inhabitants 
of  these  tenement  districts  are  underfed,  and  their 
unhygienic  surroundings  are  ill  adapted  to  increase 
their  power  of  resistance  to  disease.  It  seems  also 
not  improbable  that  at  times  the  bacilli  floating  on 
particles  of  dust  in  the  air  are  deposited  on  the  food, 
and  thus  the  germs  are  ingested. 

Numerous  experimenters,  such  as  Falk,"'  Wesener,'" 
Straus,  and  Wurtz,"  have  shown  that  the  gastric  juice 
has  little  power  to  destroy  the  bacillus  of  tuberculosis, 
and  thus  if  the  blood,  which  in  health  is  phagocytic, 
is  of  poor  quality,  its  corpuscles  will  not  be  able  to 
swallow  the  ingested  bacilli.  If  the  victim  be  a  child, 
these  will  find  the  best  medium  for  multiplication  in 
the  delicate  intestinal  epithelium.  If  it  be  an  adult, 
the  bacillus  will  find  an  easy  abiding-place  in  the 
apices  of  the  lungs  through  the  lymphatic  and  circu- 
latory systems. 

The  weakest  members  of  the  family  soonest  fall 
victims  to  the  disease.  Fresh  pure  air  and  good 
healthy  food,  which  are  after  all  the  best  microbe 
killers,  are  lacking  in  the  homes  of  most  of  these  un- 
fortunates, and  thus  the  propagation  of  tuberculosis  is 
most  terrible,  in  the  tenement  districts. 

Compassion  moves  us,  and  through  our  efforts  we 
procure  a  bed  in  one  of  the  general  municipal  hospi- 
tals for  the  unfortunate  sufferer.  (Most  of  our  hos- 
pitals supported  by  private  charity  refuse  admission 
to  consumptives.)  He  bids  good-by  to  his  loved 
ones.  He  is  taken  in  an  ambulance  to  the  nearest 
municipal  hospital.  There  are  no  special  wards  for 
consumptives,  and  the  patient  is  placed  in  one  of  the 
general  wards.  His  neighbor  to  the  right  may  have 
typhoid  fever;  the  one  to  the  left  a  pleurisy  u /r/'gort' : 
opposite  him  may  be  a  rheumatic  or  a  fellow-consump- 
tive. If  the  physician  in  charge  is  in  favor  of  medi- 
cation, the  patient  will  receive  the  latest  remedies 
well  spoken  of  in  the  treatment  of  tuberculosis.  If 
the  doctor  is  sceptical  as  to  the  value  of  medication  in 
this  disease,  the  patient  may  or  may  not  receive  the 
special  diet,  and  the  rest  is  left  to  nature.  In  the 
morning,  before  the  arrival  of  the  visiting  physician, 
the  poor  consumptive  inhales  the  dust,  and  with  it 
countless  numbers  of  pathogenic  micobes,  raised  by 
the  attendant  sweeping  the  ward  with  an  ordinary 
broom  instead  of  wiping  the  floor  with  a  moist  mop. 
If  the  patient  has  not  yet  his  mi.xed  infection,  he  will 
soon  get  it.  The  consumptive  in  our  general  hospitals 
is  almost  as  much  deprived  of  fresh  pure  air  as  he  has 
been  in  his  home.  Should  he,  day  or  night,  ask  to 
have  a  window  open,  his  rheumatic  neighbor  would 
very  strenuously  object,  for  he  could  not  stand  the 
draught.  Respiratory  exercises  are  but  rarely  recom- 
mended, for  the  physician  knows  that  they  are  useless 
in  the  ordinary  hospital  atmosphere.  .\t  meal  times 
the  consumptive  patient  eats  but  little.  The  frequent 
anorexia  he  cnnnot  overcome,  and  even  tlie  special  diet 
does  not  tempt  him.  The  aerotherapeutic  and  hydro- 
therapeutic  measures,  so  largely  and  beneficially  re- 
sorted to  in  sanatoriums  and  special  hospitals  to  over- 
come the  loss  of  appetite,  cannot  be  carried  out  in  a 
general  hospital.     At  night  tlie  patient  sleeps  but  lit- 


tle. He  is  kept  awake  either  by  his  own  cough  or  by 
that  of  his  neighbor.  The  stuffy  night  atmosphere  of 
the  waid  furthers  still  more  his  hyperidrosis.  Thus 
he  passes  weeks,  sometimes  months,  until  a  fatal  ter- 
mination ends  his  sufferings. 

We  must  leave  our  consumptive  friend  to  his  fate  in 
the  hospital,  and  return  once  more  to  his  family  at 
home.  There  we  find  most  likely  that  they  are  in 
want,  their  supporter  having  been  sick  for  months.  In 
the  majority  of  cases  such  a  family  is  bound  to  become 
a  public  charge  in  the  end. 

This  is  the  average  condition  of  the  consumptive 
poor  in  our  large  cities,  and  the  general  practitioners 
present  will  find  that  the  picture  I  have  drawn  of* the 
life  of  the  tuberculous  patient  without  means,  at  home 
and  in  the  general  hospital,  has.  not  been  a  fictitious 
one. 

How  can  it  be  changed  ?  There  are  in  New  York 
about  ten  thousand  consumptives  without  means,  and 
all  other  large  cities  of  the  union  have  an  equal  pro- 
portion. 

What  can  the  creation  of  sanatoriums  do,  in  face 
of  such  appalling  numbers.'  Seemingly  little  at  the 
beginning,  but  much  good  in  the  long  run. 

Would  the  maintenance  of  a  consumptive  patient  in 
a  sanatorium  or  special  hospital  in  or  near  a  large  city 
be  more  expensive  than  in  a  general  hospital.'  I  will 
answer  this  question  by  a  few  recent  statistics  which 
I  have  gathered  for  this  purpose. 

According  to  the  last  annual  report  of  the  board  of 
commissioners  of  charity  and  correction  of  the  city  of 
New  York,  the  highest  daily  expense  per  patient  (in 
Fordham  Hospital)  was  S2.06,  the  lowest  daily  expense 
per  patient  (in  the  City  Hospital)  was  thirty-three 
cents,  and  the  average  expense  per  day  per  patient  for 
all  the  municipal  hospitals  of  New  York  is  Si.  16. 
The  daily  average  expense  in  the  most  luxurious  and 
most  modernly  equipped  sanatorium  for  consumptives, 
the  Loomis  Sanatorium,  under  the  able  direction  of 
Dr.  Stubbert,  is  $1.43.  The  Adirondack  Cottage  San- 
atorium, which,  through  the  untiring  effort  of  its  dis- 
tinguished director,  Dr.  Trudeau,  has  done  so  much 
good  already  and  has  saved  so  many  lives,  expends 
for  each  of  its  patient  Si  per  day.  While  in  these 
two  institutions  patients  with  only  incipient  phthisis 
are  admitted,  at  the  Chestnut  Hill  (Philadelphia) 
Hospital  for  the  Consumptive  Poor,  with  Dr.  J.  Solis 
Cohen,  the  distinguished  laryngologist,  as  visiting 
physician,  and  Dr.  Bacon  as  house  physician,  con- 
sumptives are  admitted  even  in  the  very  advanced 
stages.  Still  this  institution  was  able  to  obtain  very 
satisfactory  results  indeed,  as  is  shown  by  the  latest 
report:  Discharged  as  cured,  8  per  cent.;  improved, 
iiyi  percent.;  unimproved,  6-.;  percent.;  died,  17'.; 
per  cent. ;  and  the  average  daily  expense  was  only 
between  thirty  and  forty  cents. 

The  value  of  isolation  may  best  be  shown  by  the 
work  of  St.  Joseph  Hospital  for  Consumptives  of  New 
York,  where  the  most  of  the  patients  admitted  are  in 
the  last  stage  of  the  disease.  Dr.  Cauldwell,  the  phy- 
sician-in-chief, very  kindly  gave  me  the  following  in- 
formation: This  institution  receives  annually  fifteen 
hundred  consumptives,  at  an  average  daily  expense  of 
about  fifty  cents  per  patient.  Dr.  Cauldwell  does  not 
claim  to  be  able  to  do  more  than  care  for  them  under 
existing  circumstances,  although  a  goodly  number  are 
discharged  able  to  work  again.  But,  leaving  aside  the 
curative  results,  St.  Joseph  Hospital,  by  taking  care  of 
fifteen  hundred  patients  coming  from  among  the  poor- 
est classes,  suppresses  annually  fifteen  hundred  foci 
of  infection.  How  many  lives  may  not  thus  be  saved 
indirectly? 

Of  course  at  Liberty,  Saranac  Lake,  and  Sharon,  in 
view  of  the  fact  that  these  institutions  are  intended 
only    for    incipient    cases,    the    curative    results    are 


November  27,  1897] 


MEDICAL    RECORD. 


m 


much  more  favorable.  Thus  Dr.  Trudeau  could  report 
from  thirty  to  thirty-five  per  cent,  of  cures  with  an 
average  stay  of  eleven  months  ten  days.  This  shows, 
as  Dr.  Trudeau  well  remarked  in  a  recent  letter  to  me, 
the  very  great  importance  of  early  diagnosis. 

At  the  Liberty  Sanatorium,  of  the  patients  who  re- 
mained over  three  months  in  the  institution  fifty  per 
cent,  were  improved,  and  about  twenty-five  per  cent. 
cured.  With  those  who  stayed  a  shorter  period  the 
results  were  less  favorable. 

Dr.  Vincent  Y.  Bowditch,  of  the  Sharon  Sanatorium, 
near  Boston,  reports  twenty-five  per  cent,  of  "arrested 
cases"  and  a  much  larger  percentage  of  improvements. 
Such  results  are  remarkable  indeed,  considering  that 
this  latter  institution  is  situated  but  a  few  miles  from 
a  large  city  and  does  not  claim  any  special  climatic 
advantages. 

But  aside  from  the  considerable  number  of  cures 
which  can  be  eft'ected  in  a  sanatorium  for  consump- 
tives, especially  when  the  hygienic  and  dietetic  treat- 
ment under  constant  medical  supervision  is  strictly 
adhered  to,  there  are  other  saniiary  advantages  of  in- 
estimable value  which  a  community  would  derive  from 
the  creation  of  one  or  several  sanatoriums  for  the  con- 
sumptive poor.  In  a  perfectly  conducted  sanatorium, 
where  the  curable  cases  are  cured,  and  the  hopeless  cases 
cared  for  so  that  it  is  impossible  for  them  to  propagate 
the  disease,  all  patients  receive  a  hygienic  education  so 
that  they  may  understand  why  they  should  e.xpectorate 
only  in  a  proper  receptacle,  why  they  should  be  careful 
with  all  other  secretions,  what  they  should  do  or  not  do 
to  avoid  new  colds,  why  it  would  be  unwise  for  them 
to  marry  as  long  as  they  are  not  perfectly  cured,  etc. 
When  the  patient  who  has  passed  through  such  a  sana- 
torium returns  to  his  home  cured  or  only  improved,  he 
will  become  an  educational  factor  in  public  hygiene. 
He  will  not  only  have  learned  to  avoid  the  causes  whicli 
may  aggravate  his  condition,  but  he  will  still  use  his 
pocket  spittoon  and  tell  his  friends  that  he  uses  it  to 
protect  them  from  any  possibility  of  getting  the  disease 
through  him,  and  at  the  same  time  he  will  know  that 
through  such  precaution  he  also  protects  himself  from 
reinfection. 

By  excluding  all  consumptive  cases  from  our  general 
hospitals  and  directing  them  to  special  inslitutions,  we 
shall  protect  a  patient  with  a  pleurisy  a  frigore  from 
the  likelihood  of  developing  a  pleurisy  of  tuberculous 
nature.  We  shall  protect  the  typhoid-fever  patient, 
with  his  greatly  reduced  power  of  resistance,  from  be- 
coming the  prey  of  the  bacillus  of  tuberculosis,  which 
up  to  now  has  been  an  almost  constant  sojourner  in  our 
general  hospitals,  thanks  to  the  lack  of  special  estab- 
lishments where  patients  afflicted  with  tuberculous 
diseases  should  have  been  cared  for. 

That  there  is  never  any  danger  from  even  the  multi- 
ple creation  of  sanatoriums  in  the  same  locality,  I 
have  endeavored  to  demonstrate  in  several  of  my  pre- 
vious writings,  by  citing  the  statistics  concerning  the 
mortality  from  tuberculosis  before  and  after  the  estab- 
lishment of  sanatoriums  for  consumptives  in  certain 
villages  in  Germany.  These  statistics  were  obtained 
from  the  official  documents  in  these  respective  com- 
munities. In  Goerbersdorf  they  co\er  a  period  of  one 
hundred  years;   in  Falkenstein  a  period  of  forty  years. 

Those  desiring  to  read  them  in  detail  I  must  refer 
to  my  article  in  the  New  York  Medkai,  Record  of 
October  3,  1896,  entitled  "Are  Sanatoriums  for  Con- 
sumptives a  Danger  to  the  Neighborhood.'" 

Here  I  can  only  summarize  by  saving  that  in  these 
two  villages,  wiiere  five  of  the  largest  German  sanato- 
riums are  situated  ((ioerbersdorf  and  Falkenstein),  the 
mortality  from  tuberculosis  has  actually  decreased 
among  the  village  people,  being  now  one-third  less 
than  before  the  establishment  of  those  institutions. 
This,  no  doubt,  is  due  to  the  example  set  by  the   in- 


mates of  the  sanatoriums,  and  it  is  also  the  best  proof 
that  well-conducted  sanatoriums  for  consumptives  are 
not  centres  of  infection,  but,  on  the  contrary,  places- 
where  one  is  safest  from  contagion.  Still  more,  I 
venture  to  say  that  properly  conducted  sanatoriums  for 
consumptives  not  only  serve  as  hygienic  educators  of 
individuls,  but  as  educators  of  communities  as  well. 

From  what  has  been  said,  it  is  evident  that  there  can 
be  no  objection  to  the  establishment  of  municipal 
sanatoriums  or  special  hospitals  for  consumptives. 
The  sanitary  advantages  derived  therefrom  for  all 
communities,  large  or  small,  have  been  clearly  demon- 
strated. It  would  remain  only  to  show  that  through 
the  multiple  creation  of  such  institutions  the  common- 
wealth would  be  the  financial  gainer  as  well,  and  that 
these  establishments  would  not  further  the  abuse  of 
medical  charity  from  which  we  all  suffer  at  the  present 
time. 

When  the  worthy  but  poor  consumptive  is  taken  in 
time  to  an  institution  where  his  chances  of  recovery 
are  still  good,  he  will  have  little  chance  to  infect  the 
other  members  of  the  family,  and  he  is  likely  to  return, 
after  a  relatively  short  sojourn,  restored  to  health  and 
hygienically  educated,  ready  to  become  again  a  bread- 
winner and  supporter  of  his  family.  Now  the  mainte- 
nance of  this  patient  in  a  municipal  sanatorium  for 
from  three  to  six  months  or  even  longer,  during  the 
earlier  stage  of  the  disease,  will  cost  the  common- 
wealth no  more  than  if  he  had  been  taken  to  the  gen- 
eral hospital  for  perhaps  the  same  period  of  time,  but 
in  a  much  farther  advanced  and  more  hopeless  state  of 
his  disease.  If  the  family  were  absolutely  destitute 
the  members  would  have  to  be  supported  by  the  muni- 
cipality, whether  the  head  of  the  family  were  in  the 
sanatorium  or  general  hospital.  But  since,  when 
treated  in  time  and  in  a  special  institution,  he  has 
twenty-five  to  thirty-five  more  chances  of  getting  well, 
the  likelihood  of  the  community  being  obliged  to  sup- 
port a  widow  and  several  orphans  has  thus  also  been 
reduced  by  nearly  one-third. 

Now  let  me  develop  to  you  a  little  ideal  plan  of 
how  to  proceed  to  select  the  proper  cases  for  treatment 
in  such  institutions,  how  to  avoid  unnecessary  expen- 
diture on  the  part  of  city  governments,  and,  lastly,  how 
to  avoid  admitting  to  free  treatment  patients  able  to 
pay. 

A  large  city  desiring  to  treat  its  worthy  consump- 
tive poor  must  have  a  series  of  institutions. 

(i)  There  should  be  a  centrally  located  reception 
hospital. 

(2)  A  city  sanatorium,  located  in  the  outskirts  and 
if  possible  in  a  somewhat  elevated  region,  where  the 
atmosphere  is  known  to  be  pure.  Here  all  patients- 
should  pass  through  a  preparatory  sojourn  before  be- 
ing sent  to  the  mountain  sanatorium.  The  more  ad- 
vanced cases  would  all  be  retained  here. 

(3)  A  mountain  sanatorium  at  no  greater  distance 
from  the  city  than  three  or  five  hours  by  rail,  at  an 
altitude  if  possible  of  between  one  thousand  and  two 
thousand  feet,  on  porous  ground,  with  southern  expo- 
sure, and  as  nearly  as  possible  protected  againt  the 
coldest  winds,  preferably  surrounded  by  a  pine  forest. 
To  this  place  the  selected  incipient  and  the  improved 
cases  from  the  city  sanatorium  should  be  sent  to  com- 
plete their  cure. 

The  central  reception  hospital  receives  all  patients 
applying  for  admission  or  sent  there  by  physicians 
or  the  sanitary  inspectors.  The  patient  is  not  sent  to 
either  the  city  or  mountain  sanatorium  immediately 
after  an  examination.  He  has  to  remain  in  the  recep- 
tion hospital  for  a  few  days,  to  rest  and  receive  some 
instructions  as  to  his  conduct  in  the  city  or  mountain, 
sanatorium.  To  lessen  expense  of  the  various  institu- 
tions, he  is  expected  to  aid  about  the  house  wherever 
he  may  be  and  work  as  the  doctor  decrees.     No  one 


778 


MEDICAL    RECORD. 


[November  27,  1897 


else  should  have  a  voice  in  this  matter.  In  the  mean 
time  proper  inquiries  are  made,  first  of  the  patient's 
former  physician,  and  then  of  the  most  reliable  source, 
as  to  his  financial  standing.  If  the  patient  is  able 
to  pay  something,  he  should  not  be  refused  admis- 
sion, but  this  money  should  be  used  to  help  give  the 
physician  a  salary  for  his  service,  to  which  he  is  as 
much  entitled  as  the  superintendent.  For  we  must 
bear  in  mind  that  it  is  the  constant  medical  supervi- 
sion of  the  consumptive  in  a  sanatorium  which  is  the 
all-important  factor  in  the  hygienic  and  dietetic  treat- 
ment. And  I  wish  to  state  right  here  that  I  strongly 
disapprove  of  so-called  homes  for  consumptives. 
These  places  are  mostly  always  without  a  house  phy- 
sician, and  as  a  consequence  the  hygienic  and  prophy- 
lactic measures  are  rarely  carried  out  to  the  extent  of 
making  infection  impossible. 

The  creation  of  municipal  sanatoriums  for  consump- 
tives requires  a  large  staff  of  experienced  physicians, 
who  would  have  to  devote  a  great  deal  of  their  time  to 
such  service.  As  I  have  demonstrated,  the  common- 
wealth would  be  the  gainer  thereby  financially.  It 
would  be  a  great  injustice  should  the  physician  alone 
be  the  loser. 

The  well-to-do  or  wealthy  citizen  can  receive  the 
'lygienic  and  dietetic  treatment  in  his  private  home  or 
in  a  private  institution.  For  the  consumptive  poor 
and  those  able  to  pay  a  moderate  price,  we  need  a 
large  number  of  institutions  under  city-government 
control. 

Our  prophylactic  measures,  no  matter  how  strict, 
will  not  suffice  to  do  away  with  the  centres  of  infection 
daily  created  anew  in  our  tenement  districts.  To  pre- 
vent the  hopeless  cases  from  communicating  the  dis- 
ease to  the  large  number  of  susceptible  individuals 
with  whom  they  will  come  in  contact,  to  give  the  tuber- 
culous patient  yet  in  the  early  stages  of  the  disease, 
but  with  little  or  no  means,  the  best  possible  chance 
of  becoming  a  well  man  and  a  useful  citizen,  we  need 
municipal  sanatoriums.  Let  physicians,  statesmen, 
and  philanthropists  unite  to  further  the  creation  of 
such  institutions,  for  through  them  I  think  we  shall  not 
only  alleviate  much  suffering,  but  may  solve  one  of 
the  most  important  and  difficult  problems  in  medical 
and  social  science. 

955    MaD.SON-    AVENIE. 

REFERENXES. 

1.  Von  Leyden  :  Ueber  die  Versorgung;  der  Lungenkranken 
seitens  der  grossen  Stadte  ( How  to  Take  Care  of  Tuberculous 
Patients  by  the  Large  Cities) .  Communication  to  the  Eighth 
International  Congress  of  Hygiene  and  Demography.  .Also ; 
Ueber  die  .\ufgabe  des  Berlin-Brandenburger  Heilstatten-Ver- 
eins  fiir  Lungenkranke.      Hygienische  Rundschau,  July  i,  i8g6. 

2.  Von  Schroetter  :  Ueber  den  gegenwartigen  Stand  der  Frage 
■der  Errichtung  eigener  Ileilst.itten  fiir  Tuberculose. 

3.  Oranchcr  :   Maladies  de  r.-\ppareil  Respiratoire. 

4.  l.etulle  ;   Tresse  Medicale,  August  ii,  1894. 

5.  Weber  :  Croonian  Lectures  on  the  Hygienic  and  Climatic 
Treatment  of  Chronic  Pulmonary  Phthisis. 

6.  Biggs  and  Prudden  :  Communication  to  the  Hon.  C.  G. 
Wilson,  president  of  the  board  of  health,  January  11,  iSgy. 
New  York  Medical  Journal.  Januar)'  27,  1S97. 

7.  Bowditch  :  Treatment  of  Phthisis  in  Sanitaria  near  our 
Homes.  Annual  Meeting  of  the  Massachusetts  Medical  Society, 
June,  1S96. 

8.  Otis :  The  .Sanatorium  or  Closed  Treatment  of  Phthisis. 
New  V'ork  Medical  Journal,  June  13,  1896. 

g.  Flick  :  Special  Hospitals  for  the  Treatment  of  Tuberculo- 
sis.    Times  and  Register,  March  i;,  1890. 

10.  Hinsdale  ;  Recent  Measures  for  the  Prevention  and 
Treatment  of   Tuberculosis.     The  Medical   News,  .\ugust,  1S94. 

11.  Pienjamin  Lee:  Present  .\ttitude  of  Sanitarians  and 
lioards  of  Health  toward  I'ulmonary  Consumption.  Paper  read 
before  the  section  of  State  medicine  of  the  American  .Meilical 
Association,  June  3,  1S97. 

12.  Hamilton  ;  The  Prevention  of  Tuberculosis.  Journal  of 
the  .'\merican  Medical  Association,  June  12,  1897. 

13.  Mannheimer  :  Deutsche  medicinische  Wochenschrift,  May, 
1897.  Rose  :  Gaillard's  Medical  Journal,  New  York,  1895,  vol. 
1.x. 

14.  Knopf,  S.  A.:   Les  Sanatoria,  etc.     These  de  Paris,  June, 


1895.  New  York  Medical  Journal,  October  5  and  12,  1895. 
Fourth  Annual  State  .Sanitary  Convention  of  California.  April, 
1S96.     Medical  Record,  February  13,  1S96. 

15.  Liebe  :  Der  Stand  der  Bewegung  fiir  Volksheilanstalten 
fiir  unbemittelte  Lungenkranke  im  Fruehjahre,  1696.  Hygie- 
nische Rundschau,  Nos.  13  and  14,  July,  1S96. 

16.  Falk  ;  Ueber  das  Verhalten  von  Infectionsstofien  im  Ver- 
dauungskanaie.      Virchow's  Arch  ,  1883,  Bd.  93,  p.  Oo. 

17.  Wesener  :  Beitrage  zur  Lehre  von  der  Futterungstubercu- 
lose.      Freiburg,  Bd    1S85,  pp.  55  to  60. 

18.  Straus;  La  Tuberculose  et  son  Bacille,  Paris,  1895,  pp. 
210,  212. 


TUBERCULOSIS— THE  PINE  BELT  OF  SOUTH 
ALABAMA    VERSUS    HIGH    ALTITUDES. 

By    KIETH    FONDE,    M.D., 

CITRONELLE,    ALA. 

Is  it  not  a  fact  that  most  physicians  treating  tubercu- 
losis to-day  are  sending  the  vast  majority  of  their 
patients  to  the  high  altitudes,  without  remembering 
the  long  list  of  contraindications.''  The  fact  that 
physicians  of  the  mountains  have  furnished  in  this 
country  almost  all  the  literature  on  the  subject  of  cli- 
matology is  perhaps  responsible  for  this.  It  is  true, 
I  think,  that  in  any  series  of  unselected  cases  a  large 
majority  would  show  positive  contraindications  to 
high  altitudes.  While  I  do  not  deny  that  high  alti- 
tudes have  a  well-deserved  place  in  therapeutics,  it  is 
only  for  a  certain,  or,  I  should  say,  one  class  of  tuber- 
culous patients.  The  writer  believes,  and  proposes  to 
offer  some  evidence  to  show,  that  sea  air,  if  at  suffi- 
cient elevation  (three  hundred  to  five  hundred  feet) 
and  far  enough  inland  (thirty  to  seventy-five  miles, 
these  figures  being  arbitrarily  chosen),  and  preferably 
in  a  pine  forest,  with  sandy  soil  and  hills  to  insure 
perfect  drainage,  is  far  more  beneficial  to  the  majority 
of  cases  of  tuberculosis  than  is  the  inland  mountain 
air.  As  a  type  of  such  a  location  I  select  Citronelle, 
Ala.,  thirty-three  miles  north  of  Mobile,  on  the  Mobile 
and  Ohio  Railroad,  at  an  altitude  of  three  hundred 
and  sixty  feet  above  the  sea,  the  highest  point  within 
this  distance  of  the  coast  between  Boston  and  Galves- 
ton. Most  parts  of  Florida  are  too  low  and  moist; 
the  deep  sands  make  exercise  unpleasant,  and  the  glare 
and  mosquitoes  are  disagreeable.  Moreover,  cottages 
are  preferable  to  most  of  the  hotels  and  large  build- 
ings. One  patient  then  does  not  annoy  others  by 
coughing,  etc.  Patients  are  more  separated,  and  the 
rooms  of  cottages  are  less  likely  to  lack  sunshine  and 
ventilation  than  are  those  of  large  buildings.  Citron- 
elle, however,  has  the  advantages  of  excellent  waters, 
chalybeate  and  freestone  from  bold  springs,  and  of 
being  surrounded  on  all  sides  by  high  pine  forests, 
and  also  of  being  easy  of  access  from  the  north  and 
east.  .V  comparison  of  the  available  official  reports, 
kindly  furnished  me  by  Dr.  J.  G.  Michael,  of  Citron- 
elle, observer  of  the  United  States  weather  bureau, 
shows  that  for  each  of  the  months  of  December,  Janu- 
ary, February,  and  March,  from  December,  1888,  to 
March,  1894,  inclusive,  at  Citronelle  the  minimum 
temperature  averages  fifteen  degrees  higher  than  at 
-Asheville,  N.  C.  The  average  maximum  for  the  same 
{■)eriod  shows  seven  degres  warmer  at  Citronelle. 

If  we  hear  in  mind  that  "  chronic  ulcerative  phthisis 
includes  the  great  majority  of  all  cases  of  pulmonary 
tuberculosis,  .  .  .  and  that  a  majority  of  all  cases  of 
pulmonary  tuberculosis  are  combined  infections," 
and  the  great  importance  of  secondary  infection,  as 
emphasized  by  Prudden,'  and  that  these  cases  are  not 
suited  to  high  altitudes,  we  shall  use  more  discretion, 
jirolong  manv  lives,  and  gain  a  better  record  in  the 
treatment  of  this  disease.  In  Hayem's  "  Physical  and 
Natural  Therapeutics"  (Paris),  edited  bj  Prof.  H.  A. 

'  New  York  Med.  Jour.,  1894,  ii.  Osier's  "  Pr.ictlceof  Medi- 
cine," 1S96,  2d  edition. 


November  27,  1897] 


MEDICAL    RFXORD. 


779 


Hare,  1895,  we  find  the  many  contraindications  to 
high  altitudes  laid  down  by  very  high  authority,  and 
at  the  same  time  we  learn  something  of  sea  air  and 
coast  climates'  as  follows:  "The  regularity  in  direc- 
tion and  time  of  the  wind,  the  state  of  barometric  pres- 
sure, the  great  intensity  of  the  sunlight,  the  high  pro- 
portion of  ozone,  the  absence  of  dust,  and  the  presence 
in  the  air  of  small  particles  of  sodium  chloride  and 
traces  of  iodine  and  bromine.  The  physiological 
action  of  sea  air  has  been  investigated  by  a  number 
of  authoritities,  especially  by  Beneke.  It  has  been 
found  to  influence  strongly  the  general  nutrition,  even 
in  a  more  marked  degree  than  sea  baths.  The  surface 
of  the  body  is  cooled  more  quickly  on  the  seacoast 
than  in  inland  stations;  the  nutritive  processes  are 
active;  the  quantity  of  urine,  the  excretion  of  urea 
and  of  sulphuric  acid  are  greatly  increased,  while  that 
of  phosphoric  and  uric  acid  is  diminished.  The  body 
weight  is  also  augmented.  There  is  generally  a  fall 
in  the  number  of  respirations  and  pulsations;  sleep 
improves,  and  the  nervous  system  is  slightly  stimu- 
lated. The  last  effect  may,  however,  be  so  marked 
that  in  impressionable  persons  it  causes  insomnia." 

Let  us  see  what  further  evidence  there  is  at  hand  to 
support  the  proposition  that  the  Southern  coast  cli- 
mates do  not  obtain  the  medical  patronage  they 
deserve. 

Dr.  Solly,  the  able  representative  of  the  high-alti- 
tude advocates,"  says:  "Cold  dry  winds  simply  stim- 
ulate or  else  irritate  the  patient  and  hence  improve 
relaxed  catarrhal  conditions,  but  make  those  which 
are  inflammatorv- worse."  On  this  point  Hayem  says: 
'"A  cold  dry  climate  diminishes  the  cutaneous  evapo- 
ration and  increases  the  loss  of  heat;  it  predisposes 
to  catarrhal,  rheumatic,  and  renal  affections."  Dr. 
Solly  proceeds:  "Warm  moist  winds  act  as  a  tonic 
or  increase  irritability.^  Apparently,  humidity  of  the 
air,  apart  from  other  factors,  does  not  in  itself  produce 
phthisis.  The  comparative  immunity  from  consump- 
tion among  the  men  of  the  British  navy  contrasted 
with  those  of  the  army,  and  the  rarity  of  the  disease 
in  many  islands,  show  this."  Yet  Dr.  Solly  collected 
a  series  of  seven  thousand  seven  hundred  and  ninet}"- 
five  cases  which  he  analyzed,  and  this  led  him  to  state 
that  "  an  almost  steady  rise  in  the  percentage  of  im- 
provement toward  the  highlands"  occurs.  He  says, 
however,  of  these  cases :  "  It  must,  of  course,  be  ad- 
mitted that  the  material  of  which  the  cases  are  com- 
posed is  too  variable  in  quality  to  allow  of  any  close 
comparison  of  results,  but,  as  the  number  of  cases  and 
of  reporters  is  so  great,  the  law  of  average  comes  in 
to  help  us."  And  he  closes  the  subject*  by  saying: 
"With  regard  to  the  elevation,  high  altitudes  are  of 
benefit  to  the  majority  of  cases  of  phthisis,  particularly 
those  of  a  tuberculous  type." 

Ingals'  says:  "There  is  no  climate  to  which  con- 
sumptives may  be  sent  indiscriminately,  but  suitable 
places  should  be  selected  for  each  patient.  Some 
patients  do  better  in  cold  weather,  but  the  majority 
are  better  in  summer.  It  will  be  found  that  those 
who  feel  best  in  winter  are  likely  to  be  benefited  by 
a  comparatively  cool  climate,  the  others  in  a  warm 
climate." 

Without  making  further  quotations  I  will  venture 
the  assertion  that  those  subjects  of  pulmonary  tuber- 
culosis or  chronic  bronchitis,  who  are  expectorating 
tough  tenacious  matter,  especially  those  of  irritable 
.  or  of  nervous  temperament,  will  stand  a  far  better  chance 
of  clearing  their  lungs  of  this  infectious  material  in  a 

1  Pp.  56.  57- 

'  "  System  of  Practical  Therapeutics,"  edited  by  11.  A.  Hare, 
vol.  iv.,  l8g7,  p.  68. 

2  Ibid.,  pp.  8-.  Mbid.,  p.Ti. 

^  "  diseases  of  the  Chest  and  Nasal  Cavities,"  1895,  pp. 
174.  175- 


climate  virtually  of  pure  sea  air  with  its  ozone  and 
moisture.  The  latter,  if  not  in  excess,  is  more  bene- 
ficial in  these  cases  than  the  very  dry  atmosphere 
that  tends  to  render  the  sputum  more  tough  and 
tenacious,  and  more  difficult  to  expectorate,  the 
consequence  being  that  many  germs  are  retained 
that  would  be  thrown  off.  The  effect  of  moisture,  I 
think,  is  demonstrated  by  the  use  of  vapor  inhalations 
under  compressed  air.  Dr.  Solly  acknowledges  the 
value  of  such  inhalations: 

■'  It  is  probable  that  the  chief  benefit  is  derived  from 
the  cleansing  and  stimulating  of  the  bronchial  tubes 
and  from  the  deep-breathing  exercises."  This  treat- 
ment, he  continues,  "  should  be  carried  out  every  day 
until  the  cough  and  expectoration  become  moderate." 
I  believe  it  should  be  continued  until  there  is  no 
purulent  expectoration,  but  Dr.  Solly  says;  "It  is 
probable  that  at  sea  level  inhalations  are  more  efficient 
when  given  in  connection  with  treatment  in  the  pneu- 
matic cabinet." 

In  the  treatment  of  secondary  infections  I  prefer  a 
McBride  inhaler  to  the  Globe.  If  the  rubber  tubing 
be  made  to  fit  closely,  the  vapor  is  inhaled  under  some 
pressure.  A  separate  glass  mouthpiece  can  be  used 
for  each  patient,  and  these  kept  sterilized  in  separate 
glasses.  The  instrument  can  be  thoroughly  cleaned. 
If  care  is  used  in  turning  on  air  from  the  tank,  a  more 
or  less  perfect  "  aerial  lavage"  '  is  obtained,  and  I 
prefer  a  watery  vapor  like  the  following  to  balsamic 
vapor  for  most  cases;  the  watery  vapor  liquefies  the 
expectoration,  so  that  coughing  brings  the  matter  up 
without  great  effort,  and  the  lung  is  cleaned  better :  Car- 
bolic acid,  two  to  three  per  cent. ;  benzoate  of  sodium, 
five  to  ten  percent.;  oil  of  eucalyptus  or  oil  of  cinna- 
mon, one  part  to  three  or  five  hundred  parts:  glycerin, 
about  ten  per  cent.  In  some  cases  lime  water,  fifty  to 
seventy-five  per  cent.,  can  be  used  instead  of  the  ben- 
zoate. The  decided  alkaline  reaction  aids  the  solu- 
tion of  mucus,  and  the  essential  oils  stimulate  the 
glands  of  the  bronchial  membrane  besides  being  meas- 
urably germicidal.  This  vapor  is  pleasant  to  inhale, 
and  if  the  oils  are  alternated  the  patient  does  not  tire  of 
the  taste.  These  drugs  of  course  have  been  each  used 
before,  but,  so  far  as  I  know,  not  in  combination. 
Again,  I  think  that  in  all  incipient  cases,  and  in  those 
beginning  to  expectorate  purulent  matter,  we  should 
see  that  the  tooth  brush  with  an  appropriate  mouth 
wash  is  regularly  used  before  each  meal,  for  who 
can  say  how  long  a  tuberculous  focus  may  remain 
local? 

In  this  way  we  may  delay  infection  of  the  intestinal 
canal,  for  "  in  adults  the  lungs  usually  contain  tuber- 
cle when  it  is  present  in  the  body  (Louis'  law)."  A 
pure  tuberculous  infection,  as  a  rule,  is  slow  in  its 
progress,  and  if  those  who  come  to  you  for  their  per- 
sistent cough,  or  after  their  first  hemorrhage,  were 
immediately  removed  from  the  impure  atmosphere  of 
a  city  (or  from  their  trade)  and  their  secondary  infec- 
tion, present  in  the  vast  majority  of  cases,  carefully 
treated,  you  would  prolong  such  lives  and  give  them  a 
far  better  opportunity  of  obtaining  an  arrest  of  the 
disease.  You  send  such  a  patient  more  often  to  Ihe 
cold  dry  atmosphere  of  the  high  altitude;  he  is  usually 
restless,  with  rapid  pulse  and  respiration,  more  or  less 
fever,  uncertain  of  rest  after  his  arrival,  and  has  an 
opiate  cough  mixture  to  help  retain  the  germs  he  might 
otherwise  throw  off.  I  would  suggest  a  different  course, 
viz.:  send  him  to  an  appropriately  sedative  climate, 
where  he  can  go  out  almost  every  day  of  the  year,  and 
you  have  done  the  best.  In  selecting  the  point  to 
which  your  patient  shall  go,  the  cold  raw  winds  of 
the  Atlantic  coast  region  must  not  be  lost  sight  of.  It 
is  for  this  reason  that  I  have  preferred  the  Pine  Belt 
of  Alabama. 

'  Duiardin-Eeaumetz. 


ySo 


MEDICAL    RECORD. 


[Nov 


emDer  2: 


1897 


LOOKOUT    MOUNTAIN    Ab    A    HEALTH 
RESORT. 

Bv    \V.    A.    DEITRICH,    M  D. 

During  the  spring  of  1888,  while  practising  my  pro- 
fession in  northern  Indiana,  it  was  my  misfortune  to 
■contract  pulmonary  tuberculosis,  for  which  I  consulted 
the  late  Dr.  Joseph  P.  Ross,  of  Chicago,  and  through 
his  advice  I  sought  a  residence  on  Lookout  Mountain. 
A  full  description  of  my  case  was  published  in  the 
Journal  of  the  Atiiericaii  Aledical  Association  of  August 
16,  1890,  but  suffice  it  to  say  that  I  have  entirely  re- 
covered my  health. 

Lookout  Mountain  has  been  known  in  history  ever 
since  Hooker  fought  his  famous  '"  battle  above  the 
clouds,"  but  further  than  this  scarcely  anything  has 
ever  been  said  of  it,  and  little  is  known  of  it  as  a 
health  resort  by  our  Northern  brethren.  The  moun- 
tain rises  abruptly  from  the  Tennessee  River  until  it 
attains  a  height  of  seventeen  hundred  feet  above 
the  river,  and  twenty-two  hundred  and  eighty  feet 
above  sea  level.  Lookout  stands  alone  in  its  majestic 
beauty,  being  separated  from  all  other  mountain  ranges 
by  a  wide  and  fertile  valley.  The  top,  or  plateau,  is 
an  undulating  surface,  beginning  at  a  point  at  its 
northern  extremit)-  and  gradually  widening  out  as  it 
runs  southward  until  it  reaches  a  width  of  a  mile  or 
more.  It  e-xtends  across  the  line  into  Georgia,  but  it 
is  only  of  that  portion  of  the  mountain  lying  within 
the  borders  of  Tennessee  that  I  shall  speak,  as  it  is 
the  only  part  that  is  of  easy  access.  The  greater  part 
of  this  plateau  comes  to  an  abrupt  end,  where  the  rock 
seems  to  have  broken  off  precipitately  and  left  a  per- 
pendicular bluff  several  hundred  feet  high.  The  soil 
is  light  and  sandy,  absorbing  moisture  so  rapidly  that 
within  a  few  hours  after  a  rain  a  person  can  go  out 
walking  without  fear  of  getting  damp  feet.  A  large 
part  of  this  plateau  was  cultivated  previous  to  our 
civil  war,  but  since  then  it  has  grown  up  in  primitive 
forests  of  pine  and  oak,  with  the  former  predominating. 

It  is  impossible  to  give  a  pen  picture  of  this  grand 
old  mountain  by  which  any  effort  of  the  imag'i  ation 
can  form  an  idea  as  to  its  beauty  and  grandeui.  To 
say  the  view  from  its  top  is  grand  would  not  e.\press 
it.  It  is  not  only  grand,  magnificent,  sublime,  but 
also  very  entrancing.  The  scenery  is  varied  from 
every  point  of  observation,  and  to  the  lover  of  nature 
are  presented  views  of  which  he  will  never  weary,  and 
this  of  itself  will  urge  invalids  on  to  keep  out  of 
doors  and  ramble  from  place  to  place.  From  its  lofty 
summit  seven  different  States  can  be  seen,  and  with 
the  city  of  Chattanooga  lying  at  its  base,  with  its  fifty 
thousand  souls,  and  ten  different  trunk  railroads  cen- 
tring there,  it  affords  a  scene  not  to  be  found  else- 
where. Its  beaut)-  can  be  appreciated  only  by  the  eye 
of  the  beholder. 

Unfortunately  the  meteorological  records  (except  its 
temperature)  have  never  been  taken  until  within  the 
last  )ear,  but,  comparing  what  we  have  with  the  obser- 
vations taken  in  the  city  of  Chattanooga,  we  can  form 
a  fairly  good  estimate.  The  mean  annual  temperature 
is  54  F.,  with  a  mean  annual  range  of  seventeen  de- 
grees. During  the  winter  the  temperature  seldom  falls 
below  freezing,  and  only  once  during  the  past  five 
years  has  it  fallen  as  low  as  2'  F.,  and  that  last 
winter,  while  only  fifty  miles  north  of  us  it  regis- 
tered —  12"  F.  During  the  summer  the  temperature  has 
risen  above  88'  F.  only  five  times,  and  that  occurred 
the  past  summer.  The  snowfall  has  been  almost  ////, 
with  the  exception  of  once  last  winter,  when  there  was 
a  fall  of  about  nine  inches.  The  average  number  of 
clear  and  fair  days  during  the  entire  year  is  twenty- 
four  in  each  month.  It  is  impossible  to  give  the  rain- 
fall, as  no  exact  data  have  been  kept  of  it.  The  aver- 
age relative  humidity  can  only  be  estimated,  from  that 


of  Chattanooga.  The  United  States  weather  observer 
there  says  it  is  at  least  5  per  cent,  less  than  that  of  the 
city,  and,  as  it  is  71  per  cent,  in  Chattanooga,  that  of 
the  mountain  must  be  66  per  cent,  or  less.  The  air  is 
relieved  of  a  great  deal  of  its  moisture  as  it  is  wafted 
across  the  mountain  ranges  surrounding  Lookout  on 
all  sides,  thus  giving  us  a  dry  atmosphere.  It  is  free 
from  all  micro-organisms  and  impurities,  and  there  is 
nothing  here  to  contaminate  it.  Sunshine  is  abundant, 
and  gentle  breezes  are  always  blowing:  sultry  days 
and  wind  storms  are  unknown.  The  air  is  invigorat- 
ing, it  having  neither  the  debilitating  heat  of  the 
Southern  clime  nor  the  severe  storms  and  cold  of  the 
Northern  to  affect  us. 

Dr.  Wight,  after  a  thorough  investigation,  states 
that  consumption  has  never  been  known  to  occur 
among  the  natives  of  the  mountain.  Malaria  seldom 
if  ever  occurs :  at  least  I  have  never  seen  an  original 
case  of  malaria  or  consumption  during  my  five  years' 
residence  here;  but,  on  the  contrary,  I  have  carefully 
watched  the  progress  of  a  great  many  consumptives 
who  came  to  Lookout  with  the  hope  of  improving 
their  health,  and  if  possible  receiving  a  cure.  With 
very  few  exceptions,  those  who  sought  a  residence 
here  were  either  benefited  or  cured.  The  most  of  those 
who  received  no  relief  were  so  far  advanced  with  their 
disease  that  it  was  utterly  impossible  for  them  to  be 
benefited  anywhere.  Those  with  an  acute  affection 
naturally  found  the  quickest  relief,  while  those  with 
the  so-called  fibroid  phthisis  improved  slowly ;  but  with 
proper  care,  diet,  and  exercise,  every  one  (unless  too 
far  advanced)  would  find  almost  immediate  relief,  and 
if  they  remained  long  enough  a  cure  would  result  in 
the  great  majority  of  cases.  Consumptives,  after 
visiting  some  of  the  other  health  resorts,  such  as  Cali- 
fornia, Colorado,  Texas,  and  Florida,  and  receiving 
no  benefit,  have  come  to  grand  old  Lookout,  and  their 
improvement  has  soon  became  apparent.  I  recall,  for 
instance,  the  case  of  a  young  gentleman,  a  professional 
brother,  with  phthisis,  who  had  spent  some  time  in 
Colorado  and  New  Mexico  seeking  relief,  but,  failing 
to  find  it,  had  returned  home,  as  he  thought,  to  die. 
While  at  home  he  was  advised  by  Dr.  Ross  to  try  this 
place.  He  did  so,  arriving  here  about  January,  1889, 
and  remaining  until  the  following  August,  when  he 
again  returned  home,  'to  all  outward  appearances  a 
healthy  man,  but  still  having  a  slight  induration  in 
the  lung.  He  then  went  to  California  to  practise  his 
profession,  but,  after  residing  there  a  year  or  two,  his 
trouble  had  increased  so  far  that  he  died.  I  could 
cite  numerous  other  cases  like  this:  some  patients 
remained  long  enough  to  receive  a  complete  cure: 
others,  after  receiving  a  partial  cure,  would  return 
home,  thinking  they  could  not  remain  away  from  bus- 
iness any  longer.  The  one  great  trouble  with  con- 
sumptives going  to  a  health  resort  is  that  they  will 
not  remain  long  enough :  as  soon  as  they  are  on  the 
fair  road  to  recover)-  they  become  anxious  to  return  to 
their  families,  friends,  and  business.  When  invalids 
are  sent  away  from  home  and  relatives  to  seek  a  new- 
clime,  they  should  be  instructed  to  remain  (providing 
they  improve)  until  their  attending  physicians  say 
their  health  is  entirely  restored. 

Other  diseases  that  are  benefited  by  a  residence  on 
Lookout  are  insomnia,  nervous  prostration,  asthma, 
bronchitis,  and  the  enteritis  of  infants.  Children  are 
frequently  brougiit  to  the  mountain  during  the  sum- 
mer months  with  cholera  infantum,  so  sick  that  phy- 
sicians say  they  could  not  possibly  live  more  than  a 
day  or  two  in  the  city :  yet,  as  if  by  magic,  tliey  com- 
mence to  improve  ahnost  immediately  after  reaching 
its  sununit,  and  that  with  ver)-  little  medicine.  Only 
a  few  weeks  ago  Dr.  Bowen,  of  Paris,  Ky.,  brought  his 
baby  suft'ering  from  enteritis  to  the  mountain,  carr)ing 
it  upon  a  pillow,  and  not  thinking  that  it  could  pos- 


N  ovember 


1897] 


MEDICAL    RECORD. 


781 


sibly  live.  The  child  soon  began  to  brighten  up  and 
feel  better,  and  a  few  days  ago  they  left  the  mountain 
with  a  healthy  baby,  and  feeling  ven-  enthusiastic  con- 
cerning the  climate  of  this  place. 

Lookout  Mountain  is  accessible  by  rail  from  every 
point  of  the  compass.  It  has  an  incline  and  standard- 
gauge  railway  connecting  it  with  Chattanooga,  thus 
giving  quick  and  easy  access  to  that  thriving  cir\-. 
Dr.  J.  A.  Robinson,  of  Chicago,  says:  "The  ideal  re- 
quirement for  the  treatment  of  consumptives  is  a  com- 
bination of  all  the  requisites  of  a  perfect  climate,  and 
also  the  opportunity  to  enjoy  citj-  life  with  its  atten- 
dant evidences  of  civilization."'  He  further  says  that 
the  only  locality  where  there  is  a  possibility  of  such  a 
combination  is  Lookout  Mountain,  Tenn. 

It  is  an  all-the-year  climatic  resort,  and  has  the  ad- 
vantage over  the  other  resorts  in  being  within  easy 
reach  of  all  Xorthem  and  Eastern  cities.  The  water 
supply  is  abundant,  and  as  pure  as  can  be  found,  con- 
sisting entirely  of  moimtain  spring  water,  either  free- 
stone or  chalybeate. 

The  facilities  for  entertaining  invalids  and  tourists 
are  now  ever}-thing  that  could  be  desired  by  the  most 
fastidious  tastes. 


SOME   MISCONCEPTIONS    OF    NEW    MEXICO 
CORRECTED. 


Bv   WILLIAM    CURTISS   BAILEV,    A.M.,    M.D., 


The  peculiar  location  of  Las  Vegas  Hot  Springs,  and 
the  conditions  prevailing  here,  are  not  always  clearly 
understood  by  the  profession.  Situated  in  the  north- 
em  portion  of  New  Mexico,  it  becomes  a  part  of  the 
tablelands  of  that  territory.  A  study  of  its  climate 
and  general  surroundings  necessarily  includes  a  study 
•of  the  climate  and  topography  of  New  Mexico,  yet  it 
has  conditions  distinctly  its  own. 

Nestled  in  a  little  valley  at  the  entrance  of  a  cafion, 
•which  at  this  point  is  broadened,  Las  Vegas  Hot 
Springs  is  surrounded  four-fifths  of  a  circuit  by  foot- 
hills of  the  Rockies,  sufficiently  high  to  protect  it 
from  severe  winds  and  modify  its  temperature.  It  is 
watered  by  a  brisk  mountain  stream  of  considerable 
volume,  named  the  Gallinas  River,  which  originates 
as  a  series  of  springs  a  few  miles  up  a  canon  of  the 
same  name.  In  the  immediate  vicinity  of  Las  Vegas 
Hot  Springs  are  thirt}'  or  more  thermal  springs,  varj^- 
ing  in  temperature  from  wann  to  144'  F.  An  analy- 
sis shows  that  saline  elements  mainly  predominate, 
although  in  some  lithia  is  found,  in  others  sulphur,  in 
others  iron,  and  in  all  free  carbonic-acid  gas  exists  in 
abundance.  In  the  same  field  with  the  spring  is  lo- 
cated a  natural  peat  bed,  of  no  inconsiderable  value  as 
a  medicinal  agent.  Las  Vegas  Hot  Springs  is  six 
miles  from  any  considerable  centre  of  population. 
The  hills  and  mountains  encircling  it  are  covered  with 
trees  and  verdure,  the  principal  trees  being  pifion, 
pine,  and  cedar.  The  soil,  thus  held  down  by  roots 
■of  various  kinds,  is  not  readily  disturbed  by  winds: 
hence  no  sandstorms  occur  at  this  plr.ce.  Besides  its 
location  at  the  entrance  of  a  canon.  Las  Vegas  Hot 
Springs  is  situated  upon  the  northern  slope  of  the 
■Canadian  Valley.  This  valley  is  protected  on  the 
west  by  the  true  range  of  the  Rockies,  which  extend 
north  and  south  through  the  centre  of  the  territor}'.  A 
spur  of  the  Rockies,  projecting  at  right  angles  from 
the  main  range  along  the  New  Mexico  and  Colorado 
line,  marks  the  northern  protection.  These  two  ranges 
form  a  barrier  against  most  storms  arising  in  the 
Great  Northwest,  and  modify  the  extremes  of  climate 
in  the  valley  to  a  considerable  degree. 


The  latitude  of  Las  Vegas  Hot  Springs  is  an  inter- 
esting one.  It  is  the  same  as  is  found  in  the  northern 
part  of  Africa  and  Arabia,  portions  of  the  world  known 
to  be  the  driest.  Its  longitude  bisects  that  drv  area 
which,  beginning  in  the  northern  part  of  Texas,  extends 
in  a  northerly  direction  through  New  Mexico  and  into 
Colorado.  Instead  of  the  extreme  heat  supposed  to 
prevail  in  northern  New  Mexico,  because  of  its  south- 
em  latitude,  it  is  a  fact  that  the  weather  is  decidedly 
cool  and  bracing  during  the  summer  months.  Op- 
pressive days  are  never  known.  This  is  explained 
by  the  height  above  sea  level,  the  altitude  being  6,767 
feet.  While  the  altitude  modifies  the  extremes  of 
summer,  the  protection  afforded  by  the  Rockies  on 
the  west  and  the  eastern  spur  along  the  Colorado  bor- 
der on  the  north  modifies  equally  well  the  extremes  of 
winter. 

A  study  of  the  great  storm  centres  is  essential  to  an 
appreciation  of  the  difference  between  the  area  of 
great  precipitation  and  the  high  tablelands  of  New- 
Mexico.  Such  study  is  essential  in  order  to  under- 
stand why  these  high  tablelands  have  attracted  the 
attention  of  the  profession  as  a  refuge  for  people 
seeking  health.  Such  study  will  convey  a  clearer  idea 
than  generally  prevails  of  what  is  actually  found  upon 
obser\-ation. 

In  the  eastern  section  of  the  L'nited  States  the  area 
of  the  greatest  precipitation  is  found  around  the  great 
lakes  and  certain  portions  of  New  England.  The 
precipitation  lessens  somewhat  as  one  approaches  the 
Atlantic  coast.  It  lessens  to  a  greater  degree  and 
with  considerable  uniformity  as  one  travels  westward 
from  the  section  above  mentioned.  After  one  has 
passed  the  Mississippi,  the  rainfall  is  found  to  de- 
crease with  rapidity,  especialh-  after  that  portion  of 
the  country  is  reached  where  there  is  considerable 
elevation  above  sea  level.  In  eastern  Kansas,  for 
example,  the  annual  rainfall  is  recorded  as  thirty 
inches;  western  Kansas,  as  twenty  inches.  Passing 
west  from  this  State  the  elevation  is  noticeably  rapid, 
and  the  annual  rainfall  is  soon  found  to  be  only  fif- 
teen inches.  When  one  has  reached  Las  Vegas  Hot 
Springs  the  annual  precipitation  is  reduced  to  12.7 
inches.  If  one  draw  a  line  in  a  northerly  and  south- 
erly direction  along  the  western  boundary  of  this  great 
area  of  precipitation,  which  line  shall  represent  a 
monthly  rainfall  of  one  inch  or  more,  such  line  will  be 
seen  to  varv-  in  location  and  contour  according  to  the 
month  for  which  it  is  drawn.  For  example,  in  January 
it  will  be  found  on  the  average  between- longitude  95^ 
and  100'  W.  All  of  that  section  of  the  United  States 
east  of  this  line,  to  the  Atlantic  coast  inclusive,  has  an 
average  monthly  precipitation  of  from  one  to  six  inches 
or  more.  West  of  this  line  to  the  western  slope  of  the 
Rockies,  the  monthly  precipitation  does  not  average 
one  inch.  In  February  the  line  has  travelled  a  little 
west,  on  an  average  about  two  or  three  degrees.  In 
March  it  has  reached  longitude  loo'  W.  In  April, 
in  its  northerly  portion,  it  has  covered  Colorado,  and 
has  met  with  the  Pacific  storm  centre:  but  New  Mex- 
ico is  still  exempt,  e.xcept  in  its  northeastern  comer. 
By  June  New  Mexico  is  mainly  covered.  The  precipi- 
tation in  New  Mexico  from  this  time  until  September 
has  considerably  increased.  The  storm  line  now  must 
be  drawn  along  the  western  border  of  Arizona,  and  the 
average  precipitation  in  New  Mexico  has  become  two 
or  three  inches.  By  September  the  storm  line  begins 
to  recede.  By  October  it  has  reached  the  eastern  por- 
tion of  New  Mexico.  By  December  it  is  nearly  back 
to  the  eastern  extremity.  It  is  thus  observed  that 
while  all  portions  of  the  United  States  east  of  longi- 
tude 97'  W.  have  a  continuous  monthly  average  of 
more  than  one  inch.  New  Mexico  is  exempt  during  this 
portion  of  the  year.  But  while  it  is  true  that  New- 
Mexico  is  thus  exempt,  there  is  no  month   in  which 


782 


MEDICAL    RECORD. 


[Xovember  27,  1897 


some  precipitation  is  not  recorded;  there  is  no  month 
in  which  there  are  no  stormy  days;  there  is  no  month 
in  which  there  is  not  danger  from  exposure.  The  ad- 
vantage is  found  in  the  difference  in  amount  of  precip- 
itation, which  gives  New  Mexico  a  far  greater  number 
of  days  of  sunshine  per  year,  with  a  minimum  number 
of  stormy  days,  together  with  all  the  benefits  which 
naturally  follow  from  such  excess  of  sunshine  and 
such  diminution  of  precipitation. 

The  directions  not  infrequently  given  by  physicians 
.0  patients  sent  to  this  territory  are  something  like 
this:  "Go  to  the  tablelands  of  New  Mexico,  where 
are  dr}'ness,  altitude,  and  excess  of  sunshine.  Select 
a  home,  on  ranch  or  in  town,  where  you  may  obtain 
wholesome  food.  Live  out  of  doors  all  you  can. 
Seek  medical  advice  when  required.  Depend  upon 
climate  and  exercise  to  restore  you  to  health."  This 
is  wholesale  advice  prescribed  in  a  wholesale  way, 
with  evident  unfamiliarity  with  the  general  results  ac- 
cruing therefrom.  Patients  should  be  more  carefully 
selected  to  whom  such  advice  is  given.  The  prescrip- 
tion should  be  more  explicit,  and  warnings  more  fre- 
quent. It  should  not  be  expected  that  invalids  w-hose 
constitution  is  impaired  by  disease;  whose  vitality 
is  reduced  below  the  normal;  who  are  surrounded 
with  home  comforts  and  luxuries;  who  have  been 
more  or  less  under  close  medical  supervision:  who 
are,  as  a  rule,  unfamiliar  with  the  favorable  or  unfa- 
vorable conditions  affecting  the  disease  which  com- 
pels their  absence:  who,  since  they  are  invalids,  are 
in  no  wise  proper  persons  to  direct  their  own  case — 
can  safely  exchange  home  life  for  ranch  life,  to  "rough 
it"  as  best  they  may. 

It  is  interesting  and  instructive  to  pass  thro-jgh  any 
of  the  trains  bound  west,  especially  during  the  winter 
months,  and  note  the  type  of  people  seeking  healtii, 
particularly  those  of  a  tuberculous  character.  It  is  not 
an  infrequent  occurrence  that  some  of  these  fail  to 
reach  their  destination  alive.  It  is  not  unusual  to  find 
some  so  far  advanced  in  the  disease  as  to  be  unable  to 
sit  up  during  the  journey.  Others,  less  advanced,  may 
walk  about,  but  display  evidences  of  streptococcus 
fever.  Others,  again,  can  scarcely  be  recognized 
among  the  well.  If  we  follow  these  people  from  the 
train,  and  obser\-e  their  attempts  to  regain  health,  we 
find  that  on  an  average  fifty-three  per  cent.  fail. 
Nearly  all  advanced  to  the  third  stage  of  the  disease, 
that  stage  which  Koch  says  has  ceased  to  be  tubercu- 
losis, but  is  pus  fever,  die  within  a  brief  period  after 
arrival  here.  Among  those  less  advanced,  imbued 
with  the  spirit  of  exercise,  the  result  is  fatal  in  a  con- 
siderable proportion.  It  is  an  error  to  presume  that 
patients  unfitted  to  conduct  their  own  case  at  home 
without  medical  supervision  can  do  so  in  New  Mex- 
ico. It  is  an  error  to  presume  that  invalids  who 
have  made  no  special  study  of  climatotherapy  shall 
know  how  intelligently  to  obtain  favorable  results, 
because  removed  to  a  location  possessing  improved 
climatic  conditions.  It  is  an  error  to  presume  that 
any  of  nature's  remedies  are  exempt  from  the  gener- 
ally recognized  law  that  intelligence  and  experience 
shall  direct  their  use.  Whereas  it  is  true  that  in  the 
tablelands  of  New  Mexico  are  found  excess  of  sun- 
shine, increased  dryness,  higher  altitude,  a  minimum 
of  precipitation,  and  less  variation  of  temperature  than 
in  other  sections  of  the  continent,  yet  it  is  not  all  sun- 
shine. There  are  cloudy  and  there  are  stormy  davs. 
There  are  days  that  have  considerable  wind.  There 
are  times  when  it  is  dangerous  to  expose  one's  .self. 
There  is  an  intelligent  way  to  take  advantage  of  the 
conditions  prevalent  here,  and  there  is  an  erroneous 
way.  There  is,  perhaps,  no  section  possessing  so 
great  a  union  of  nature's  forces  favoring  restoration  to 
health,  yet  caution  must  be  exercised  if  proper  advan- 
tage be  taken  of  it. 


MEXICO— ITS    CLIMATE   AND    HEALTH 
RESORTS. 

By   H.    S.    .squires,    M.D.. 

CHIEF   <lKGEOS.    MEXICO  CENTRAL  RAILWAY. 

The  ordinarv'  observer,  looking  at  a  map  of  the  re- 
public of  Mexico  and  noting  that  the  tropic  of  Can- 
cer passes  almost  through  the  centre,  probably  infers 
that  the  climate  is  warm  in  the  winter  and  insufferably 
hot  in  the  summer  months.  He  does  not  know,  or 
fails  to  consider,  that  the  principal  cities  are  located 
on  a  plateau  which  varies  from  thirty-five  hundred  to 
eight  thousand  feet  in  elevation,  and  that  this  eleva- 
tion so  modifies  the  climate  that  his  inference  is  wrong 
in  nearly  ever)-  particular.  The  fact  is  that  from  the 
snow-capped  mountains  which  overshadow  Mexico 
City  to  either  coast,  every  variety  of  climate  is  to  be 
found. 

But  to  the  physician  seeking  a  place  for  his  patients 
and  for  tourists  and  invalids  the  climate  of  the  plateau 
from  El  Paso,  Tex.,  to  Mexico  City  will  be  of  particu- 
lar interest.  After  the  Rio  Grande  is  passed,  the  first 
city  of  any  importance  and  one  whose  climate  may  be 
taken  as  a  type  of  the  first  and  lower  plateau,  is  Chi- 
huahua. It  is  at  an  elevation  of  about  forty-five  hun- 
dred feet  above  the  sea.  Here  the  different  seasons 
are  more  marked  than  they  are  farther  south.  The 
coldest  months  are  from  November  to  Februarj-,  and 
during  this  season  the  cold  is  sufficient  at  night  to 
make  a  grate  fire  comfortable,  but  during  the  day  the 
air  is  bracing  and  warm  enough  to  make  it  pleasant 
to  sit  out  of  doors  without  extra  wraps. 

The  summer  climate  of  Chihuahua  is  very  agree- 
able, and  often,  when  the  heat  is  oppressive  on  leaving 
El  Paso,  one  finds  on  his  arrival  at  Chihuahua  that, 
although  he  is  two  hundred  and  twent}"-five  miles  far- 
ther south,  the  increase  in  altitude  of  one  thousand 
feet  can  be  appreciated  by  the  cool  bracing  air.  As- 
one  goes  farther  south  from  Chihuahua  to  Mapimi, 
Lerdo,  and  Torreon,  the  cold  of  the  winter  months 
grows  less  and  the  climate  becomes  more  equable  all 
the  year  until  as  he  continues  south  he  reaches  Zacate- 
cas.  at  an  elevation  of  eight  thousand  feet,  which 
place  may  be  said  to  be  the  gateway  to  the  higher 
plateau,  whose  elevation  ranges  from  five  to  eight 
thousand  feet,  and  on  which  are  located  the  cities  of 
Aguas-Calientes,  San  Luis  Potosi,  Leon,  Lagos,  Silao, 
Queretaro,  Guadalajara,  and  Mexico  City.  And  on 
this  plateau  the  health  and  pleasure  seeker  finds  the 
ideal  climate,  both  winter  and  summer. 

December  and  January  are  the  coldest  months. 
Even  then  the  thermometer  rarely  re;iches  the  freez- 
ing-point. Stoves  are  unnecessary,  although  all  the 
new  hotels  are  supplied  with  means  of  heating  the 
rooms,  as  invalids  sometimes  find  it  chilly  at  night 
from  the  light  air  of  this  altitude.  But  the  most  deli- 
cate constitution  would  not  need  artificial  heat  after 
nine  o'clock  in  the  morning,  for  by  that  time  the  sun 
is  well  up,  and  the  last  particle  of  chilliness  is  out  of 
the  air.  The  days  are  delightful.  The  blue  cloud- 
less sky  day  after  day  becomes  almost  monotonous. 
Every  day  is  clear  and  bright,  and  although  one  knows 
that  at  this  season  snow  and  cold  are  holding  the 
greater  part  of  the  people  of  the  I'nited  States  wiiliin 
doors  it  is  hard  to  realize  it,  for  here  the  public  gar- 
dens (and  every  Mexican  town  has  two  or  three)  and 
flowers  are  in  bloom  and  the  natives  are  practically 
living  out  of  doors. 

If  possible  the  summer  climate  on  this  plateau  is 
superior  to  that  of  the  winter.  As  a  rule  the  rains 
begin  in  June  and  continue  until  October.  When  one 
speaks  of  the  rainy  season  it  seems  to  convey  to  the 
uninitiated  the  idea  of  one  continual  rain  storm  day 
and  night  for  months.     Such  is  not  the  case,  for  it 


November  27,  1897] 


MEDICAL    RECORD. 


7^Z 


rarely  rains  more  than  two  hours  a  day  and  for  the  re- 
mainder of  the  day  it  is  clear  and  cloudless. 

A  day  in  Mexico  during  the  rainy  season  might  be 
described  like  this:  One  is  awakened  in  the  morning 
•by  the  sunshine  pouring  into  his  room.  The  birds  in 
the  patio  of  the  hotel  as  well  as  those  in  the  gardens 
are  singing.  The  fragrance  of  the  moist  ground  and 
flowers  comes  into  the  open  window  with  the  sunshine, 
and  aside  from  the  clear  moist  air  one  would  not  real- 
ize that  it  had  rained  the  day  before  and  that  this  was 
a  morning  in  the  height  of  the  rainy  season.  It  seems 
too  beautiful  to  remain  longer  in  the  house,  and  one  is 
soon  up  and  out  into  the  bright  sunlight.  The  sky  is 
cloudless  e.xcept  for  a  little  bunch  of  clouds  near  the 
horizon,  and  as  the  day  wears  on  this  grows  larger, 
until  by  three  or  four  o'clock  in  the  afternoon  the  sun 
is  hidden  and  the  rain  commences.  Shower  follows 
shower  for  two  or  three  hours,  and  then  the  clouds 
disappear,  and  by  seven  in  the  evening  the  streets  are 
dr}-,  the  moon  shines  out,  and  then  the  population  of 
the  town  comes  to  take  a  walk  and  sit  on  the  plaza, 
and  listen  to  the  music.  One  can  stay  there  until 
midnight  if  he  chooses,  without  fear  of  cold  or  catarrh. 

At  this  season  of  the  year  the  vegetation  is  lu.xuri- 
ant.  The  fields  are  green,  the  trees  are  dense  with 
foliage,  and  every  bush  that  bears  a  flower  is  in  full 
bloom.  The  heat  even  at  midday  during  the  summer 
months  is  not  oppressive  and  the  nights  are  always 
cool,  so  cool  in  fact  that  one  must  sleep  under  at  least 
one  blanket. 

The  monthly  summarj-  of  the  Meteorological  Ob- 
rservaton,-  in  Mexico  for  July  shows  what  the  climate 
actually  is: 

Temperature  of  the  Air  (Fahr.  ). 

Monthly  mean  in  shade 62.96  degrees. 

"      "  sun 63.14  " 

Maximum  in  shade 77.l8  " 

"  sun 88.34 

Minimum  in  shade 53-6o  " 

■ '  open  air 46.40  ' ' 

Total  range  in  shade 23.58  " 

"         '■       "   open  air 41-94 

"While  the  inhabitants  of  New  York,  Chicago,  and 
other  cities  of  the  temp:rate  zone  are  dying  of  heat 
stroke,  this  is  July  weather  in  Mexico  City. 

When  this  fact  becomes  impressed  on  the  travelling 
public,  Mexico  must  become  one  of  the  great  summer 
resorts,  as  it  is  now  a  popular  winter  resort.  Aside 
from  the  climate  of  Mexico  there  are  certain  hot 
springs  which  for  ages  have  been  looked  upon  as  cur- 
ative in  certain  diseases,  and  the  experience  of  the 
past  few  years  has  demonstrated  beyond  a  doubt  that 
they  have  all  the  virtues  which  have  been  credited  to 
them. 

As  one  comes  into  the  country  from  El  Paso  the 
first  of  these  hot  springs  is  located  at  Santa  Rosalia, 
a  town  of  about  eight  thousand  inhabitants,  three  hun- 
dred and  twentj'-five  miles  south  of  El  Paso.  The 
town  is  a  short  distance  from  the  railway  station  and 
the  baths  are  about  two  miles  back  to  the  west  of  it. 
Coaches  are  at  the  station  to  meet  all  trains  to  carrj- 
passengers  either  to  the  town  or  baths,  where  the  hotel 
accommodations  are  good.  The  waters  at  the  springs 
are  highly  charged  with  sulphur,  as  the  following 
.analysis  will  show: 

.\NALVsis  OF  Santa  Rosalia  Springs. 

Grains  in 
Imperial  Gallon. 

Chlorine 20S4 

Sulphur,  hydrogen  sulphide .0274 

"         hyposulphite OOI4 

Sulphuric-acid  anhydrite 1I.53Q5 

Carbonic  acid 7700 

Oxide  of  sodium    9401 

"  potassium 0399 

"      "  magnesium 1.5524 

"      "  calcium   (lime) 5.1629 


Chloride  of  potassium 0644 

"       "    sodium 2961 

Carbonate  of  sodium 1.3335 

Sulphate  of  magnesium 4.6875 

"    calcium 13.323S 

The  diseases  most  benefited  by  these  waters  are  acute 
rheumatism,  chronic  arthritis,  gout,  specific  blood  dis- 
eases, and  chronic  malarial  poisoning.  In  this  latter 
very  marked  benefits  have  been  derived.  Those  who 
have  lived  on  the  coast  and  who  suffer  from  repeated 
attacks  of  malaria,  even  after  having  left  the  malarial 
district,  find  that  after  a  two-weeks'  course  of  baths  the 
germs  are  entirely  eliminated  from  the  blood. 

Aguas-Calientes,  as  its  name  implies  (hot  water),  is 
one  of  the  best-known  resorts  in  Mexico.  The  city 
has  between  thirty  and  forty  thousand  inhabitants. 
The  climate  is  fine  all  the  year.  The  hotels  are  ex- 
ceptionally good.  The  plaza  and  the  garden  of  San 
Marcus  are  both  beautiful.  Horse  cars  run  from  the 
main  plaza  to  the  baths  and  to  the  river,  about  a  mile 
in  the  opposite  direction  to  the  west,  and  to  the 
big  silver  smelter,  offering  easy  facilities  for  seeing 
the  town  and  enjoying  outdoor  exercise.  The  hot 
baths  are  the  great  attraction,  and  are  patronized  by 
sick  and  well  alike.  The  springs  are  east  of  the 
town,  about  a  mile  from  the  main  plaza.  Here  the 
hot  water  bubbles  up  through  the  sand  in  the  bottom 
of  the  bathing-tanks,  supplying  an  abundance  of  clean 
water.  Some  of  these  tanks  are  roofed  over,  allowinj' 
the  full  amount  of  heat  to  be  retained,  while  others 
are  open  and  the  water  is  cooler.  The  bath  named  San 
Ramon  is  the  hottest,  and  is  considered  of  superior 
qualit)-  to  the  others.  Midway  between  the  plaza  and 
the  springs  are  other  bathhouses.  The  water  supply- 
ing these  baths  is  brought  in  solid  masonry-covered 
ditches  from  the  hot  springs  above,  and  the  water  is 
practically  the  same  in  all.  In  these  one  finds  solid 
masonr)-  tubs,  shower  baths,  and  a  large  swimming- 
tank. 

The  analysis  of  the  water  is :  Temperature,  30'  to  40° 
C:  without  reaction  to  litmus,  except  the  bath  San 
Ramon,  which  is  slightly  acid  and  has  a  small  amount 
of  sulphur.  The  following  table  shows  the  amount  of 
solids  in  grams  to  the  litre: 

Sulphide  of  sodium 020 

Sulphate  of  sodium 030 

"   calcium 070 

Carbonate  of  calcium 030 

Chloride  of  sodium 018 

-Acetate  of  potassium 005 

Sulphate  of  magnesium 008 

Residue 005 

These  waters  are  recommended  for  rheumatism,  skin 
and  nervous  diseases.  To  the  south  from  Aguas-Cali- 
entes the  elevation  of  the  plateau  is  lower  and  the 
cities  of  Lagos,  Leon,  Silao,  and  Queretaro  are  con- 
siderably warmer:  they  are  all  of  interest  and  all 
have  fine  climates.  Near  Silao  there  are  very  fine 
sulphur  springs,  one  four  and  the  other  twelve  miles 
from  the  city.  The  water  is  very  hot  and  highly 
charged  with  sulphur,  and  I  judge  that  the  analysis 
would  show  a  great  similarity  to  that  of  Santa  Rosalia, 
although  no  analysis  has  been  made  that  I  am  aware 
of.  The  same  class  of  diseases  which  find  relief  at 
Santa  Rosalia  are  also  benefited  by  these  waters. 

The  whole  State  of  Jalisco  is  dotted  over  with  hot 
springs,  but  those  near  Guadalajara  are  of  principal 
interest.  The  city  of  Guadalajara  is  situated  a  half- 
day's  ride  from  the  main  line  of  the  Mexican  Cen- 
tral Railway,  at  an  elevation  of  five  thousand  feet. 
There  are  several  lakes  near  the  city,  and  the  river 
into  which  Lake  Chapala,  the  largest  of  these,  empties 
passes  but  a  few  miles  from  the  city.  On  this  are  the 
falls  of  Juanactlan,  which,  besides  being  a  great  nat- 
ural curiosity,  furnish  pwwer  in  abundance  for  the  elec- 


784 


MEDICAL    RECORD. 


[November  27,  1897 


trie  lights  and  water:  the  result  is  that  Guadalajara  is 
one  of  the  best-lighted  and  cleanest  cities  in  Mexico. 
The  buildings  are  all  fine  and  the  gardens  remarkably 
beautiful,  and  the  climate  is  so  modified  by  the  pro.\- 
imity  of  the  lakes  that  it  is  undoubtedly  the  finest  in 
the  republic.  A  short  distance  from  Guadalajara  is 
Chapala,  which  is  the  watering-place  of  Mexico.  Here 
wealthy  residents  of  Mexico  City  and  Guadalajara 
have  their  summer  home,  where  they  can  enjoy  the 
close  proximity  of  the  lake.  A  new  modern  hotel  is 
in  course  of  construction,  and  when  finished  will  afford 
increased  inducements  to  pleasure  or  health  seekers. 
Horses  and  boats  can  be  rented  for  pleasure  trips. 
Here  are  found  hot  sulphur  and  iron  springs,  the 
waters  being  used  both  for  drinking  and  bathing. 

Near  Mexico  City  are  the  noted  springs  of  Guada- 
lupe and  The  Pefion.  Quoting  from  a  recent  report 
of  these:  "In  the  city  of  Guadalupe  Hidalgo,  four 
kilometres  north  of  the  City  of  Mexico,  exists  the 
famous  '  Well,'  whose  waters  are  taken  for  every  class 
of  disease  and  to  which  are  attributed  miraculous 
therapeutic  qualities,  not  only  from  their  composition 
but  from  the  special  virtues  ceded  to  it  by  the  Virgin 
of  Guadalupe."  The  analysis  of  the  water,  as  made 
by  Prof.  Leopold  Rio  de  la  Loza,  is  as  follows: 

Temperature 21.5°  C. 

Density i. 001 34 

Chemical  Composition. 

Air 8.73 

Carbonic  acid 234-9° 

Nitrogen 8.00 

Total  c.c.  per  litre 251.63 

Solids. 

In  Solution.  Undissolved. 

Sulphate  of  calcium Trace. 

Carbonate  of  calcium 00557  -29/51 

"          "  magnesium 00557  .02086 

"           "  sodium 19275  .06035 

Chloride  of  potassium 10790  .06035 

"  sodium 107QO  .01000 

"       "  magnesium 02825  .01000 

Silicate  of  sodium 06771  .01321 

■'    potassium 03230  .00372 

Iodide  of  potassium Tjace.  .00372 

"    sodium 07468  .00372 

Silica 07468  .00372 

Aluminium   06541  .00364 

Iron 06541  .00102 

Magnesia 06540  Trace. 

Organic  matters 02907  . 1 5978 

Bituminous  matters 02907  .01800 

Total  grams  per  litre 60264         .72618     

Total 1.32SS2 

Near  the  well,  which  is  used  for  drinking  only,  are 
baths  which  are  fed  by  artesian  springs  and  whose 
composition  is  similar  to  that  of  the  well.  Pilgri- 
mages are  made  from  all  over  the  republic  every  year 
to  these  springs,  and  the  cures  reported  are  indeed 
marvellous. 

-About  four  kilometres  northeast  of  Mexico  City  are 
The  Pefion  baths.  From  the  time  of  the  Aztecs  these 
baths  have  been  renowned.  Illustrious  men  from  all 
parts  of  the  world  have  analyzed  them  and  decided 
that  they  compare  favorably  with  Kissingen,  Wies- 
baden, Wildbad,  and  Kms.  Recently  a  hotel  has  been 
built  with  modern  conveniences  and  bathhouses  com- 
plete in  every  particular,  .so  that  parties  now  wishing 
to  take  advantage  of  these  springs  can  do  so  with  every 
comfort.  The  analyses  of  the  different  springs  vary 
some  in  detail,  but  one  is  a  fair  type  of  all.  The 
physical  characteristics  are  boiling  water  with  evolu- 
tion of  gas,  without  odor  or  color;  to  the  taste,  slightly 
sharp  and  salt:  to  the  touch,  slightly  oily. 

Temperature 46'  C. 

nensity 1.00263  at  iS°  C. 

Reaction,  slightly  acid. 


Quantity  of  lixed  matter  obtained  from  evapor- 
ation of  one  litre  of  water 2.23  gm. 

Chemical  Co.mpositiox. 

Nitrogen 68  gm,         ■ 

Oxygen 6    " 

Carbonic  acid 26    " 

100  gm. 
Solids. 

Sulphate  of  calcium 0S64  gm. 

Phosphate  of  calcium 0058    " 

Bicarbonate  of  calcium 2385     " 

"  "  magnesium 7892    " 

"  "  sodium 2002    " 

"  "  potassium 1250    " 

"  "  iron ooii     " 

Chloride  of  sodium 9875     " 

Silica 1620    " 

-■Muminiura 0599    " 

Manganese,  lithia,  boric  acid,  and  iodine..      Trace. 

2.6556  gm. 

Having  given  a  general  idea  of  the  climate  and  re- 
sorts of  Mexico,  I  will  close  with  a  brief  resume  of  the 
diseases  which  are  most  benefited  by  a  visit  or  resi- 
dence here. 

Patients  with  organic  heart  trouble  and  those  who- 
suffer  from  advanced  pulmonary  disease  should  under 
no  circumstance  come  to  Mexico. 

Those  with  incipient  phthisis  may  get  some  relief, 
and  the  locality  best  suited  to  them  is  on  the  lower 
plateau  from  Chihuahua  south  to  Torreon,  or  at  Gua- 
dalajara. Many  who  seem  to  be  in  good  physical  con- 
dition but  in  whom  the  bacillus  tuberculosis  has  been 
demonstrated  in  the  sputum,  will  get  but  little  relief 
in  this  climate.  The  air  is  so  rare  that  for  the  first 
few  days  they  feel  better.  They  are  stimulated  and 
feel  that  they  have  reached  exactly  the  suitable  cli- 
mate; but  after  this  first  sensation  wears  off  the  action 
of  the  heart  becomes  affected  with  the  increased  work, 
the  lungs  become  congested,  and  the  patient  fails 
rapidly.  Many  people  who  have  a  family  history  of 
consumption,  but  in  whom  as  yet  the  disease  has  not 
developed,  find  that  a  residence  here  improves  their 
general  health  and  the  tendency  to  the  disease  dis- 
appears. 

Asthmatics  as  a  rule  find  relief  in  this  climate. 

Sufferers  from  Rright's  disease,  uncomplicated  with 
cardiac  disease,  are  much  improved.  In  these  cases 
pulque  has  been  tried  quite  extensively.  It  is  a  mild 
laxative  and  diuretic.  Much  has  been  said  for  and 
against  its  use.  To  gorge  one's  self  with  pulque,  as 
many  of  the  lower  classes  do,  practically  live  on  it, 
could  not  fail  to  bring  about  disease  of  the  kidneys 
and  liver,  but  a  glass  of  pulque,  taken  two  or  three 
times  a  day,  has  proved  to  me  beyond  a  doubt  to  be  of 
great  therapeutic  value. 

Many  cases  of  nervous  prostration  and  insomnia 
have  been  completely  cured.  The  warm  baths,  the 
outdoor  life,  with  a  moderate  amount  of  pulque  at 
dinner  and  at  bedtime,  will  quiet  the  nerves  and  bring 
on  a  natural  refreshing  sleep,  devoid  of  all  bad  after- 
effects. 

Phj'sicians  recommending  patients  to  visit  Mexico- 
should  bear  in  mind  that  the  change  from  the  sea  le\el 
to  an  altitude  ot  from  five  to  eight  thousand  feet  should 
be  made  as  gradually  as  possible,  and  that  for  several 
days  after  the  high  altitude  is  reached  exercise  of  a 
violent  nature,  long  walks,  or  horseback  riding  should 
be  deferred  until  the  constitution  has  become  accus- 
tomed to  the  change  and  the  circulation  becomes 
equalized  under  the  new  conditions. 


The  Medical  Society  of  the  County  of  New  York, 
has  framed  a  bill  against  the  abuse  of  medical  charities. 


November  27,  1897] 


MEDICAL    RECORD. 


785 


^hcrapfcutic  Mints. 

To  Avoid  lodism  in  Giving  Iodide  of  Potassium. — 

1}  Pot.  iod 50 

Ammon.  ferrocitr 4 

Tr.  nuc.  vom S 

Aq.  dest 3° 

Tinct.  cinch 60 

M.     S.   Teaspoonful  in  half  a  glass  of  water  after  each  meal. 

— Spenxer. 

Infantile  Diarrhoea. — To  make  up  for  the  liquid 
lost  in  purging,  especially  in  the  algid  t)'pe,  inject 
subcutaneously  thirty  cubic  centimetres  of  the  follow- 
ing, from  three  to  six  times  daily : 

1}  Sod.  chl 7  gm. 

Aq.  dest.  steril 1  litre. 

Or  Hayem's  artificial  serum: 

^  Sod.  sulph 10  gm. 

Sod.  chlor 5  gm . 

Aq.  dest.  steril I  litre 

— Les.^ge. 

Reichmann's  Disease Contrar}-  to  the  opinion  of 

Hayem  that  gastro-succorrhara,  or  the  presence  of  large 
quantities  of  fluid  in  the  stomach  during  fasting,  can 
be  cured  only  by  surgical  treatment,  Robin  claims 
good  results  from  purelv  medical  measures. — Za  Jie7\ 
Med.,  May  26th. 

When  Quinine  Cannot  be  Given  by  the  Mouth 
it  may  be  administered  in  suppositories  in  half-gram 
or  gram  doses. — J.  Duxbar-Brunton. 

In  Bronchial  Asthma. — 

IJ  Tr.  opii  croc 5 

-Eth.   sulph 10 

M.     S.  Gtt.  1.  ever)-  half-hour  until  the  attack  is  quieted. 

— Clvmer. 
Nephritic  Colic. — 

1}  Morph.  hydrochl 0.20  cgm. 

.\trop.  sulph.  (neutr.) 0.005  mgm. 

Aq.  laurocerasi 20  gm. 

M.     S.  A  Pravaz  sjringeful  or  one  cubic  centimetre  con- 
taining a  centigram  (gr.  \)  of  morphine. 

This  should  be  the  maximmn  initial  dose  when  the 
patient's  susceptibilit}'  is  not  known. — M-*BBOt".\. 

Coryza. — A  generous  pinch  of  the  following  mix- 
ture is  to  be  snuffed  into  the  nostrils  at  the  very  onset 
of  symptoms  and  repeated  five  or  six  times  at  inter- 
vals of  an  hour.     The  powder  must  be  freshly  prepared. 

K  Pulv.  ac.  boric 3  gm. 

Menthol 0.30  cgm. 

— Gas.  de  Hop,  June  29th. 

Benzoate  of  Bismuth. — Benzoic  acid,  being  twice 
as  soluble  and  seven  times  as  antiseptic  as  salicylic 
acid,  being  readily  eliminated  and  non-caustic,  should 
cause  the  benzoate  of  bismuth  to  be  preferred  to  the 
salicylate. — Pierre  Vigier. 

In  Soft  Chancre,  syphilitic  ulceration,  ulcerating 
lupus,  intertrigo,  etc.,  europhen  gives  excellent  re- 
sults and  is  preferable  to  iodoform  on  account  of  the 

odor. FofRNIER. 

Puerperal  Fever.— Salt  injections  diminish  the 
gravity  of  the  situation,  give  hope  to  the  patient  and 
opportunity  to  the  physician  to  seek  other  means  of 
relief.     When  large  injections  are  desirable: 

"S,  Sodii  chloridi 7  to  10  gm. 

.\q.  dest.  ster i  litre. 

The  injection  can  be  made  into  regions  rich  in  cel- 


lular tissue,  such  as  the  hips,  buttocks,  or  lumbar 
region,  or  the  solution  can  be  injected  directly  into  a 
vein. — Laskixe. 

Gastritis. — In  the  hyperpeptic  form  with  abundant 
secretion  without  dilatation,  prescribe  a  course  of 
Carlsbad  water  unless  there  be  heart  disease  or  phthi- 
sis or  the  subject  be  feeble  or  aged.  A  fonnula  for  an 
artificial  Carlsbad,  for  home  use,  is  the  following: 

'B,  Sod.  sulphat 2. ;  to  3  gm. 

Sod.  bicarb 2  to  2. 5  gm. 

Sod.  chlor i  gm. 

Aq.  dest i  litre. 

Sterilize  or  consume  while  fresh. — M.  G.  H.wem. 
Amenorrhoea. — 

B  Pulv.  calumb.e, 

Pulv.  saffron aa  I  gm. 

Ferri  redacti 0.50  cgm. 

.■Vices  pulv o.  30  cgm. 

M.   ft.  chart.  Xo.  x.     One  or  two  in  honey  or  preserves  after 
the  evening  meal. 

— Dauchez. 
Gastro-Enteritis  of  Infants. — 

R  Benzo-naphthol o.  50 

Bism.  salicylat i 

Divide  into  three  packages,  to  be  taken  during  the 
twentV'-four  hours  on  an  empt}'  stomach.  Over  one 
year  of  age,  one  gram  of  the  first  and  a  gram  and  a 
half  of  the  second  are  advised. — Carriere. 

Cardiopathy  with  Vascular  Calcification, — In  a 
study  of  the  administration  and  elimination  of  the  lime 
salts,  Dr.  Rumpf  (Berlin  Congress,  June  12th)  believes 
his  studies  have  taught  him:  ist.  That  if  we  furnish 
lime  salts  in  abundance  to  the  organism,  the  latter 
takes  up  a  notable  quantity.  2d.  That  in  cases  of  calci- 
fication of  the  vessels  the  quantit}-  of  lime  eliipinated 
may  be  inferior  to  that  which  is  introduced.  3d.  That 
the  blood  contains  a  quantit}-  of  lime  salts  which 
varies  according  as  the  subject  is  normal  or  patho- 
logical. 

Laxative  in  Hepatic  Subjects. — 

1$  .\loes  Socoir o.  05  cgm. 

Ext.  rhei, 
Ext.  cascan«, 

Podophylli aa  0.02  cgm. 

Ext.  hyoscyami, 

Ext.  bellad aa  o.oi  cgm. 

S.   For  one  pill  to  be  taken  at  the  beginning  of  the  evening 
meal. 

— Valentix. 
Pulmonary  Tuberculosis. — 

R  StrjchninK  sulph gr-  ss. 

Atropine  sulph gr.  )^ 

Cinchonidin;^  sulph 3  ij. 

Ext.  gentianse 3  ss. 

M.    bene.     Fiat    massa  et   in  pilulas   No.    Ix.    dividenda. 
S.   One  pill  night  and  morning. 

Or: 

R  Ferri  et  quinina;  citratis 3  i. 

Strychninae  sulphatis gr.  \ 

Aquoe  purae §  i. 

SvT.  acidi  citrici q.s.  ad    3  iv. 

M.  fiat   solutio.      S.    '.  i.   in   wineglassful   of  water    after 
meals. 

— J.  Hobart  Egbert. 

Tuberculosis  with  Syphilis  of  the    Larynx In 

a  report  of  fifty  of  the  cases  studied  during  the  past 
year,  the  following  clinical  facts  have  been  brought  out : 
I.  Tuberculous  and  syphilitic  ulcerations  are  found 
side  by  side  in  the  larynx.  2.  The  presence  of  a 
syphilitic  ulcer  by  the  side  of  a  tuberculous  ulcer  in 
the  anatomy  exercises  a  moderating  influence  upon  the 
tuberculous  deposit,  if  the  syphilis  be  treated,  and 
prolongs  the  life  of  the  patient.  3.  Do  not  rely  upon 
the  report  of  the  microscope  in  all  these   cases,  as  the 


786  MEDICAL 

tubercle  bacilli  will  be  found  if  there  be  a  phthisis, 
but  the  syphilitic  element,  if  present,  may  he  over- 
looked. 4.  In  the  case  of  a  mixed  sore,  the  syphilit- 
ic ulcer  will  generally  progress  more  quickly  than  the 
tuberculous,  but  can  be  easily  controlled  if  the  right 
diagnosis  is  rendered. — E.  Harrison  Griffin,  Laryn- 
goscope, April. 

Neuralgia. — 

I^  Menthol, 

Guaiacol aa    3  '• 

Alcohol,  absolute 3  xviij. 

M.     S.    3  i.  of  this  mixture   to  be  rubbed  lightly  into  the 
affected  part  two  or  three  times  a  day. 

— Sabbatini. 
Uraemic  Headache — 

I^  Potass,  citrat 3  ij. 

Spts.   juniperi 3  vi. 

.(Either,  nitr 3  ij-. 

Inf.  scoparii 3  vi. 

M.     S.  A  wineglassful  t.i.d. 

—Day. 
Epilepsy — 

1}  Amnion,  bromid 3  vi. 

Antipyrin 3  i- 

Liq.  potass,  arsen 3  i- 

Aq.  menth.  pip ;  vi. 

M.     S.    I  ss.  in  water  night  and  morning. 

— Wood. 
Hysteria. — 

I?  Acid .  arsen gr.  ss. 

Ferri  sulph. , 

Ext.  sumbul aa  gr.  .x.k. 

AsafoJtida; g^.  xl. 

M.  ft.  pil.  No.  XX.     S.   One  t.i.d.  p.c. 

GOODELL. 

Neuralgia. — 

1}  Aconitina; gr.  iv. 

Veratrinae gr.  xv. 

Glycerini 3  ij. 

Cerati 3  vi. 

M.     S.    To  be  rubbed  over  the  painful  parts. 

Do  not  apply  to  any  abraded  surface. — Da  Costa. 
Or: 

"B,  Quininje  sulph 3  i. 

Morphin.  sulph.. 

Acid,  arsen aa  gr.  iss. 

Ext.  aconiti g^.  xv. 

Strych.  sulph gr.  i. 

M.  ft.  pil.  No.  XXX.     S.  One  thrice  daily, 

— S.  D.  Gross. 
Diabetes  Mellitus. — 

"S,  Sodii  salicylat 3  iij. 

Liq.  potass,  arsen 3  i. 

Glycerini 5  i. 

Aq.  cinnamomi ad  |  iij. 

M.     S.    3i.-§ss.  t.i.d. 

—J.  C.  Wilson. 
Diabetes  Insipidus. — 

1}  Pulv.  opii gr.  iv. 

Acidi  gallici 3  i j . 

M.  ft.  chart.  No.  xii.     S.  One,  three  or  four  times  daily. 
— H.  C.  Wood. 
Tuberculous  Meningitis. — 

1{  Moschi gr.  iij. 

Camphora;  gr.  xv. 

Chloral,  hydrat gr.  viiss. 

Vitelli  ovi No.  i. 

Aq.  dest 3  iv. 

IVI.     S.   Wash  out  the  rectum  with  simple  enema  and  inject 
two  ounces. 

— Simon. 
Pleuritis — In  the  acute  stage: 

"S,  Potass,  acetatis gr.  xv. 

Tr.  aconiti  rad gtt.  ij. 

Codeinjc  sulph gr.  ^. 

Spt.  Mindereri 3  ij. 

M.     S.  This  mixture  to  be  given  every  three  hours. 

When  the  pleuritis  is  of  the  rheumatic  tj'pe,  add  ten 
grains  of  salicylate  of  sodium  to  the  mi.xture  given 
above.     To  get  rid  of  an  effusion  of  serum,  withhold 


RECORD. 


[November  27,  1897 


liquids  as  much  as  possible  and  give  saline  purgatives 
and  diuretics;  the  blood  being  thus  deprived  of  its 
water)'  elements  will  frequently  take  up  the  effusion 
from  the  pleura.  If  it  does  not  do  so,  the  aspirator 
should  be  used  and  from  ten  to  twelve  ounces  of  liquid 
withdrawn;  the  remainder  will  usually  promptly  dis- 
appear. The  character  of  the  fluid  in  the  pleural  sac 
may  easily  be  determined  by  withdrawing  some  with  a 
hypodermic  syringe.  When  pus  is  found  neither  the 
aspirator  nor  the  trocar  and  cannula  should  be  used, 
but  a  free  incision  should  be  made  in  the  seventh  or 
eighth  intercostal  space  on  a  line  with  the  posterior 
axillary  fold ;  the  pus  and  fibrinous  clots  can  thus  be 
thoroughly  evacuated,  after  which  a  drainage  tube 
guarded  with  a  safety  pin  should  be  introduced  and  a 
dressing  of  sterile  gauze  and  cotton  applied.  The 
tube  may  be  shortened  from  time  to  time,  and  when  the 
discharge  is  thin  or  serous  may  be  withdrawn.  The 
initial  operation  as  well  as  all  subsequent  dressings 
must  be  done  with  strict  aseptic  methods;  the  danger 
of  acute  infection  is  great.  It  is  necessary  to  excise 
a  portion  of  rib  when  drainage  cannot  properly  be  se- 
cured by  thoracotomy.  This  allows  thorough  explora- 
tion, pockets  of  pus  can  be  broken  up,  drainage  will 
be  perfect.  Irrigation  of  the  pleural  sac  I  believe  is 
harmful ;  it  irritates  and  delicate  adhesions  are  broken 
up. — E.  H.  James. 

Diphtheria. — 

I{  Hydrarg.  chlor.  mit gr.  i. 

Sodii  bicarb gp-.  xxiv. 

Pulv.  aromat gfr.  vi. 

M.   ft.  chart  No.  xii.     S.   One  powder  every  two  hours. 

— Starr. 
Or: 

If  Menthol 3  iiss. 

Toluol q.s.  ad   3  x. 

Solve  et  adde: 

.\lcohol  abs 3  ij- 

Liq.  ferri  chloridi 3  i. 

M.     S.   Apply  with  a  cotton  swab. 

— LOEFFLER. 

Gout 

I(  Vini  sera,   colchici §  ss. 

Potass,  iodidi 3  ij. 

Liq.   potass |  iss. 

Tr.  zingiberis |  ij. 

JSL     S.    3  >•  twice  daily  in  warm  water. 

— Hodgson. 
Or: 

I{  Lithii  benzoat 3  ij. 

Aq.  cinnamomi §  iiss. 

M.     S.    3  i.  in  a  wineglass  of  water  every  four  hours. 

— Jaccoud. 
Chronic  Bronchitis. — 

I{  Apomorph.   liydrochlor gr.  ss. 

Syr.  pruni  virg §  ij. 

Syr.  picis  liquidce §  iv. 

M .     S.   Tablespoonful  three  times  a  day. 

— MuRRELL. 
Or: 

If  .\cid.  carbol gr.  xxv. 

Tr.  opii  campli 3  iij. 

^L     S.   .\  drachm  added  to  one-half  pint  of  hot  water  in  the 
inhaler;  use  three  times  a  day. 

— N.  S.  Davis. 

Typhoid  Fever. — The  whole  question  of  the  treat- 
ment of  typhoid  fever  might  be  summed  up  as  follows: 
Keep  the  bowels  thoroughly  open.  Keep  the  alimen- 
tary canal  as  aseptic  as  possible.  Give  good  nourish- 
ing food — that  which  the  patient  will  readily  assimi- 
late. Give  plenty  of  water  by  both  the  mouth  and 
the  rectum.  Use  the  best  intestinal  antiseptic  known. 
Never  give  opium.  Never  give  phenacetin  or  acet- 
anilid.  Give  strychnine  as  indicated.  If  this  plan 
is  followed  you  will  rarely  have  a  death  from  typhoid 
fever. — Dr.  McCormick.  Journal  of  the  American 
Aledical  Association,  July  10th. 


November  27,  1897] 


MEDICAL    RECORD. 


787 


^itroicat  Suggestions. 

Sudden  Death  in  the  Puerperium. — i.  Puhnonar}- 
embolism  is  the  cause  of  death  in  most  of  these  cases. 
2.  It  is  rare,  but  so  shocks  a  communit)^  when  it  occurs 
that  it  is  advisable  to  take  every  precaution  to  guard 
against  it.  3.  Phlebitis,  varicose  veins,  prolonged 
labor,  hemorrhage,  anaemia,  sepsis,  cancer,  syphilis, 
etc.,  predispose  to  its  production.  4.  In  the  presence 
of  peripheral  thrombosis,  etc.,  absolute  rest  must  be 
enjoined,  especially  between  the  second  and  third 
weeks  of  the  puerperium,  as  this  is  the  disintegrating 
period  of  the  clots.  The  danger  should  also  be  ex- 
plicitly pointed  out  to  both  patient  and  attendants, 
thus  insuring  to  some  extent  a  healthy  co-operation. 
5.  The  extreme  changes  in  the  blood  usually  ascribed 
to  pregnancy  and  the  puerperium  are  erroneous,  and 
not  corroborated  by  modern  investigation.  6.  Sudden 
death  from  air  embolism  in  the  puerperium  is  doubt- 
ful from  physiological,  pathological,  and  rational 
standpoints.  7.  Shock  is  both  a  direct  and  indirect 
cause  of  death  in  the  puerperium,  and  should  be 
guarded  against.  8.  Organic  heart  affections,  kidney 
trouble,  etc.,  are  capable  of  producing  death  at  any 
time,  and  should  not  be  overlooked  in  the  puerperium. 
■ — Galt.max. 

Operative  Treatment  of  Cancer  of  the  Rectum. — 
In  a  very  exhaustive  paper  on  the  operative  treatment 
of  cancer  of  the  rectum,  published  in  the  Annals  of 
Surgery,  April  number.  Dr.  Edward  H.  Taylor,  of  Dub- 
lin, summarizes  his  most  important  points  as  follows: 

1.  Great  care  should  be  exercised  in  the  selection  of 
cases  for  operation.  Cancers  which  have  exceeded 
the  limits  of  the  bowel  and  have  acquired  adhe- 
sions   to   neighboring  parts  do  better  if   left    alone. 

2.  The  preparatory  treatment  deserves  our  utmost  at- 
tention, having  as  its  object  the  improvement  of  the 
patient's  general  condition,  and  as  great  a  degree  of 
intestinal  asepsis  as  it  is  possible  to  obtain.  3.  Free 
purgation,  intestinal  antiseptics,  and  rectal  irrigation 
cannot  have  a  really  useful  effect  so  long  as  there  ex- 
ists an  ulcerating  cancerous  surface  swarming  with 
virulent  micro-organisms.  The  use  of  the  curette 
whenever  possible,  followed  by  irrigation,  should  ac- 
company the  other  measures.  4.  A  preliminary  colot- 
omy  can  scarcely  be  recommended  as  a  matter  of 
routine.  It  appears  to  be  chiefly  indicated  when 
attempts  to  empty  the  intestine  and  cleanse  it  have 
been  either  impossible  or  attended  with  difficulty. 
5.  We  should  consider  a  certain  number  of  types  of 
rectal  cancer,  both  as  regards  their  site  and  extent, 
with  a  view  to  determine  the  methods  best  suited  for 
their  removal.  6.  Three  cardinal  rules  may  be  sug- 
gested as  applicable  to  all  cases:  (a)  Control  bleeding 
as  much  as  possible,  {p)  Let  the  principles  of  aseptic 
surgery  be  as  strictly  observed  as  the  field  of  operation 
will  admit,  {c)  Avoid  rough  manipulations  in  the 
separation  of  the  diseased  tissues;  let  it  be  effected  for 
the  most  part  by  a  process  of  careful  dissection.  7. 
The  perineal  operation  is  best  employed  for  ano-rectal 
cancers;  that  is,  for  cancers  which  involve  the  sphinc- 
teric  zone  and  e.xtend  for  some  distance  above  it.  8. 
If  possible  the  rectum  should  not  be  .split  in  its  re- 
moval, nor  should  the  finger  be  introduced  to  serve  as 
a  guide  in  its  separation.  Elastic  ligatures  should  be 
applied  and  sterilized  gauze  placed  beneath  before  it 
is  cut.  9.  Cancers  situated  in  the  suprasphincteric 
region  are  better  removed  by  the  sacral  method.  As 
contrasted  with  the  perineal,  it  gives  more  room, 
bleeding  is  more  easily  controlled,  separation  of  the 
disease  is  more  readily  effected,  and  it  gives  the  best 
functional  results.  10.  Temporary  sacral  resection 
should  n:)t  be  entirely  disregarded,  owing  to  its  mani- 


fest advantages  over  the  more  extensive  mutilation  of 
Kraske  and  Bardenheuer.  11.  If,  when  the  cancer  is 
excised,  it  is  found  that  the  upper  healthy  segment 
descends  easily,  it  is  worth  while  making  an  attempt  to 
suture  it  to  the  anal  margin,  having  previously  removed 
the  mucous  membrane  from  the  lower  segment.  12.  In 
cases  in  which  the  ends  of  the  bowel  have  been  united 
after  removal  of  the  cancerous  segment,  it  is  well  not 
to  close  the  sacral  wound  completely,  for  fear  of  acci- 
dents. 13.  For  cancers  situated  high  up,  as  well  as 
for  those  of  wide  extent  in  the  rectum,  the  formation 
of  a  sacral  anus  is  often  the  only  means  at  our  dis- 
posal. 14.  In  such  cases  it  appears  advisable  to  fol- 
low the  advice  of  Gersuny,  and  give  the  bowel  a  tw^ist 
on  its  long  axis  before  attaching  it  to  the  skin,  the 
object  being  to  establish  a  modified  sphincteric  ap- 
paratus. 15.  The  perineo-abdominal  and  sacro- 
abdominal  operations  are  grave;  they  involve  serious 
risks,  and  can  be  required  only  in  very  exceptional 
cases.  However,  we  must  encourage  attempts  which 
help  to  extend  more  widely  the  indications  for  com- 
plete removal  of  the  disease  and  such  as  are  suitable 
for  those  desperate  cases  in  which  the  palliative  treat- 
ment afforded  by  an  artificial  anus  has  hitherto  been 
our  only  resource. 

Intestinal  Anastomosis. — Dr.  T.  Myles  {The  Med- 
ical Press  and  Circular,  April  7,  p.  350)  draws  atten- 
tion to  a  fact  that  is  too  often  lost  sight  of.  The  in- 
testinal canal  is  a  tube  of  living  tissue,  not  merely  a 
passive  channel :  its  contents  are  propelled  through  it 
by  muscular  action,  and  it  is  not  sufficient  for  us 
merely  to  be  able  to  seal  up  an  aperture  in  its  wall. 
We  want  much  more  than  this;  we  want  to  preserve  or 
retain  its  normal  peristaltic  action,  and  to  attain  this 
object  should  be  our  ideal.  Imagine  what  happens  as 
the  result  of  almost  every  method  yet  devised  in  an 
end-to-end  anastomosis.  The  living  contractile  mus- 
cular wall  at  one  spot  is  replaced  by  an  inert  cicatrix, 
in  which  the  longitudinal  muscular  fibres  end.  Such 
cicatrix  may  be  only  a  few  lines  in  length  or  it  may 
be  more,  but  it  exists,  and  exists  as  an  obstruction,  the 
contents  of  the  bowel  being  forced  through  it  by  me- 
chanical pressure  from  above,  not,  as  it  should  be,  by 
the  contraction  of  its  wall.  Moreover,  the  expansile 
character  of  the  gut  is  lost  here  also,  the  bowel  at  the 
seat  of  union  cannot  enlarge  like  the  rest  of  the  gut, 
and  with  a  sudden  constriction  of  the  lumen  and  an 
inert  area  of  bowel  we  have  all  the  requisites  for  the 
production  of  an  intussusception.  Until  we  can  re- 
store the  direct  continuity  of  the  muscular  fibres  (and 
this  seems  almost  hopeless  at  present)  we  have  not 
attained  our  ideal.  Nevertheless,  the  more  nearly  we 
approach  this  condition — or,  in  other  words,  the 
smaller  the  cicatrix  consistent  with  safety — the  better 
and  safer  will  be  our  results.  It  is  for  this  reason  I 
give  my  personal  adhesion  to  the  simple  unaided  suture 
in  the  great  majority  of  cases.  Whenever  it  is  prac- 
ticable, I  believe  it  will  give  better  results  than  any 
other  method.     But  it  is  not  always  practicable. 

Hypodermic  Treatment  of  Syphilis. — 

If  Hydrarg.  bichlorid. , 

Ammon.   chlorid aa  3i. 

Sod.  chlorid gr.  Ixij. 

Aqua;  dest gr.  xx. 

Mix  and  filter.     Add  white  of  one  egg  dissolved  in  distilled 
water,   '%  ivss.     S.   v\  xx.  subcutaneously. 

This  is  the  equivalent  of  one-sixth  grain  of  bichloride. 
Objections  raised  against  this  method  are :  Unneces- 
sary pain,  subcutaneous  infiltration,  large  indurated 
and  painful  swelling,  inflammation,  abscesses,  stoma- 
titis, ptyalism,  disturbances  of  circulation  and  respi- 
ration. The  advantages  claimed  are:  i,  Accuracy  of 
dose;  2,  exactness  in  intervals  between  doses;  3,  ra- 
pidity of  action  of  medicine;  4,  small  amount  of  mer- 


788 


MEDICAL    RECORD. 


[November  27,  1897 


cury  and  the  short  time  needed  to  effect  a  cure;  5,  the 
constant,  never-ceasing  effect  of  the  mercur)'  day  and 
night:  6,  the  personal  super\'ision  of  the  physician; 
7,  the  certainty  of  the  patient's  getting  the  right  medi- 
cine, of  its  being  properly  administered  at  regular 
stated  intervals,  and  of  his  inability  to  get  your  pre- 
scription refilled  or  to  give  your  knowledge  to  a  friend 
or  sell  it  to  some  charlatan;  8,  profit  to  the  physician 
and  economy  to  the  patient  on  account  of  the  saving 
of  the  drug  bill  of  four  years.  The  doctor  with  this 
method  is  sure  of  two  ver)'  important  things,  his  fee 
and  his  patient's  gratitude  for  his  speedy  cure — quick 
delivery,  so  to  speak;  9,  absence  of  gastro-intestinal 
disturbances:  10,  last,  though  not  least,  quick  diag- 
nosis in  questionable  cases. — Dr.  Dabney,  JVew  Or- 
/earis  Medical  and  Surgkaljournal,  April,  1897. 

Erysipelas. — 

I?  Tannin 2  parts. 

Camphor 3       " 

Sulphuric  ether 15 

Paint  the  erysipelatous  area  everj'  hour  or  two,  pro- 
ceeding from  the  healthy  skin  toward  the  centre  of 
the  patch.  There  is  some  burning  at  first,  due  to  the 
evaporation  of  the  ether.  In  a  short  time  a  crust 
forms,  the  swelling  goes  down,  and  in  a  few  days  the 
cure  is  complete. — Gaz.  degli  Osped. 

When  Shall  We  Use  the  Forceps?— i.  The  indi- 
cation for  the  use  of  forceps  rarely  or  never  arises 
during  the  first  stage  of  labor,  before  the  membranes 
have  been  ruptured.  2.  It  may  be  necessary  to  em- 
ploy the  forceps  during  the  first  stage,  when  the  waters 
have  escaped  on  account  of  the  increasing  exhaustion 
of  mother  or  child.  3.  It  is  proper  during  the  first 
stage  of  labor  to  apply  the  forceps  for  accidents,  when- 
ever they  may  arise,  notably  in  certain  cases  of  con- 
vulsions, placenta  previa,  and  prolapse  of  the  cord. 
4.  In  the  second  stage  it  is  proper  to  apply  the  forceps 
one-half  hour  after  the  head  ceases  to  advance,  when 
there  is  no  disproportion  between  the  passage  and 
passenger.  5.  When,  however,  there  is  a  tight  fit  be- 
tween the  child  and  the  birth  canal,  the  use  of  the  for- 
ceps may  be  delayed.  This  delay  should  rarely  ex- 
ceed two  hours  after  the  head  ceases  to  advance.  6. 
If  the  head  is  engaged,  and  neither  advances  with  the 
pain  noj  recedes  after  the  pain,  the  forceps  should  be 
applied  promptly. — Dr.  Park,  American  Gynecological 
and  Obstetrical  Journal,  February,  1897. 

Hydatid  Cysts. — According  to  .\ustralian  writers, 
the  aspiration  of  hydatid  cysts  is  directly  fatal  in  at 
least  eighteen  per  cent.  Of  the  rest,  at  least  fifty  per 
cent,  are  not  cured.  Owing  to  improvements  in  the 
methods  of  operation,  the  treatment  by  incision  is 
most  successful  in  all  early  and  uncomplicated  cases. 
Only  a  small  wound  is  required,  through  which  the 
parasitic  cyst  is  most  easily  removed,  and  the  thin- 
walled  adventitous  cyst  falls  together  and  is  united 
without  drainage  whenever  possible.  The  longer  the 
hydatid  cyst  remains,  the  more  adherent  becomes  the 
parasitic  cyst  and  the  thicker  the  wall  of  the  adventi- 
tious cyst,  so  that  the  former  is  removed  w  idi  difficulty, 
the  latter  does  not  collapse  readily,  and  hence  pro- 
longed drainage  is  necessary  with  all  its  attendant 
troubles.  The  suppuration  or  rupture  of  the  hydatid 
immediately  puts  the  patient's  life  in  grave  danger. 
— -Spenxer,  TIic  Hospital,  April  17th,  p.  43. 

Fatty  Embolism.  —  Dr.  Groube  ( La  Settimana 
Medica,  No.  22,  1896)  concludes:  i.  Though  rare, 
cerebral  fatty  embolism  may  assume  a  dangerous 
grade,  and  should  be  considered  in  grave  traumatism 
of  the  bones  and  soft  parts.  2.  The  urine  should  be 
examined  daily  for  three  weeks  for  the  presence  of 


fat.  3.  The  quantity  found  in  the  urinarj-  secretion 
will  be  a  relative  guide,  inversely,  as  to  the  quantity 
circulating  in  the  blood,  for  probabl)"  these  two  stand 
in  inverse  order.  A  slight  quantit}'  in  the  urine  with 
increase  of  dyspnoea  indicates  a  retention  of  fat  in  the 
blood  and  imminent  danger.  4.  The  dyspnoea  and 
lowering  of  temperature  merit  special  attention.  5. 
Absolute  rest  of  the  injured  part  is  necessary  and 
rational;  in  complicated  fractures  change  the  dress- 
ings only  when  absolutely  necessary.  Massage  is 
contraindicated.  In  contusions  of  the  soft  parts  mas- 
sage is  allowable  only  later  when  the  blood  does  not 
show  a  tendency  to  be  absorbed.  6.  Contusions  often 
give  rise  to  large  cavities  filled  with  fluid  blood  and 
fat.  In  these  cases  opening  the  cavity  hastens  heal- 
ing and  is  devoid  of  danger.  7.  If  amputation  be 
considered,  the  danger  of  fatty  embolism  should  be 
kept  in  mind.  8.  As  to  treatment,  the  kidneys  and 
heart  should  be  stimulated ;  for  the  latter  digitalis 
being  especially  useful. 

Diseases  of  the  Gall  Bladder  and  Bile  Ducts. — 

Dr.  A.  \V.  Mayo  Robson  {Medical  Press  and  Circular, 
April  7th),  speaking  on  the  above  subject,  said :  "  The 
presence  of  healthy  bile  in  the  peritoneum,  such  as 
might  occur  from  an  injury  such  as  a  stab,  a  bullet 
wound,  or  a  blow,  in  a  healthy  individual  may  be  tol- 
erated for  some  time  without  serious  damage,  as  in  a 
case  recorded  by  Thiersch,  who  successfully  removed 
over  forty  pints  of  bile  from  the  abdominal  cavity- 
after  the  gall  bladder  had  been  ruptured  by  a  blow. 
The  experiments  of  Schuppel  and  Bosbrom  apparently 
prove  that  the  peritoneum  can  absorb  extravasated  bile 
without  serious  trouble,  and  there  have  also  been  sev- 
eral cases  reported  in  which  extravasated  bile  has  been 
successfully  evacuated,  either  by  tapping  or  by  inci- 
sion and  drainage.  Such  a  fortunate  result  cannot, 
however,  always  be  looked  for,  as  is  shown  by  the 
specimens  in  some  of  the  college  and  hospital  mu- 
seums. In  all  the  cases  in  which  the  historj-  is  ap- 
pended, the  fact  of  the  long  survival  after  so  serious 
an  accident  is  at  once  borne  home,  and  the  lesson  is 
manifest  that  operations  would  in  each  case  have  given 
good  hopes  of  success.  Mr.  Lane  has  also  published 
a  case  of  rupture  of  the  gall  bladder  in  which  the  pa- 
tient recovered  after  having  a  considerable  amount  of 
bile  free  in  the  peritoneal  cavity  for  five  weeks.  This 
case  confirms  the  views  previously  held,  that  when 
surgeons  are  dealing  with  the  bile  passages  the  en- 
trance of  a  little  bile  into  the  peritoneum  need  not 
cause  anxietj'  if  only  the  bile  be  healthy." 

Mustard  as  an  Antiseptic. — One  never  goes  into 
a  house,  or  at  least  a  locality,  in  which  mustard  cannot 
easily  be  procured,  and  my  custom  is  thoroughly  to 
rub  and  scrub  my  hands  with  a  mixture  of  green  or 
other  soap,  corn  meal,  and  mustard  flour,  for  about 
five  minutes.  After  rubbing  thoroughly  into  all  the 
crevices  and  creases  of  the  hands  and  nails  by  aid  of 
a  nailbrush,  one  may  be  absolutely  certain  that  his 
hands  are  sterilized,  no  matter  what  he  may  have  been 
doing  previously.  I  have  no  hesitation  in  proceeding 
from  an  autopsy  to  the  operating-room,  if  I  may  thus 
protect  my  hands.  Used  as  indicated,  the  mustard 
leaves  no  unpleasant  sensation:  and  one  may  feel  that 
by  the  time  it  produces  unpleasant  tingling  or  rube- 
faction  of  the  skin  its  essential  oil  has  done  its  desired 
work  as  an  antiseptic.  I  have  discarded  all  other 
means  of  preparing  the  hands,  and  in  several  years'  use 
of  mustard  in  this  way  have  never  been  disappointed 
or  had  the  slightest  reason  to  question  its  effective- 
ness. I  might  add  also  that  it  is  an  admirable  de- 
odorizing agent,  and  will  take  away  from  the  hands 
all  offensive  odor  of  dead  or  dying  tissues  and  all  red- 
olence of  iodoform. — Dr.  Roswell  Park,  Buffalo 
Medical  Journal. 


November  27,  1897] 


MEDICAL    RECORD. 


789 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   r.   SHRADY,  A.M.,  M.D.,  Editor. 

Publisher^ 
WM.  WOOD  &  CO..  43   45,  &  47  East  Tenth  Street. 


New  York,  November  27,  1897. 


PHTHISIS  AND  RACIAL  DETERIORATION. 
The  theor)'  of  the  relationship  of  phthisis  to  insanity 
is  no  new  one,  although  now  that  most  of  the  ills  to 
■which  man  is  subject  are  put  down  to  heredit}-,  more 
notice  is  taken  of  the  matter  than  formerly.  Clouston 
obser\ed,  as  long  ago  as  1863,  the  hereditary  kinship 
of  insanit)-  and  tuberculosis,  as  did  also  McKinnon 
and  Van  der  Kolk.  The  belief  that  consumption  is  a 
form  of  neurosis  is  gaining  ground  and  is  held  by 
many  of  those  best  able  to  speak  with  authorit}';  at  all 
events,  it  is  on  all  sides  conceded  that  persons  of  a 
neurotic  tendency  are  much  more  liable  to  become 
infected  with  the  phthisical  taint  than  those  who  are 
in  a  state  of  sound  bodily  health.  This  question  is 
tiow  being  regarded  and  discussed  from  every  point  of 
view.  Mr.  Lawrence  Irwell,  a  member  of  the  neo- 
Darwinian  school  of  biolog}-,  has  lately  published  in 
pamphlet  form  a  paper  on  "  Racial  Deterioration  and 
the  Relation  between  Phthisis  and  Insanity,"  -which 
he  read  at  the  meeting  of  the  American  Health  Asso- 
ciation in  1896.  In  this  paper  most  of  the  up-to-date 
views  in  connection  with  consumption  are  set  forth, 
and  many  of  the  most  prominent  experts  on  the  subject 
are  cited  in  support  of  the  opinions  expressed.  The 
term  diathesis  is  well  defined  as  "an  exaggerated 
temperament,  signif)-ing  a  proclivitj'  toward  some  par- 
ticular disorder."  The  first  point  touched  upon  is  the 
risk  attending  the  marriage  of  persons  of  phthisical 
tendencies.  That  this  is  a  real  and  growing  danger  is 
a  fact  only  too  self-evident,  and  that  there  is  need  of 
much  more  caution  than  is  at  the  present  time  ob- 
serv-ed  in  choosing  a  husband  or  wife  from  the  physi- 
ological standpoint  is  as  equally  evident.  But  the 
spread  of  consumption  is  not  the  sole  danger  to  be 
dreaded  in  such  marriages.  It  has  been  proved  that 
marriage  into  a  family  tainted  with  tuberculosis  is 
often  productive  not  only  of  phthisical  but  also  of 
mentally  deficient  offspring.  The  blend  of  neurotic 
and  tuberculous  heredit\-  appears  to  be  specially  harm- 
ful. Statistics  collected  in  various  parts  of  the  world 
show  that  a  phthisical  family  history  is  a  preponder- 
ating factor  in  the  etiologj-  of  idiocy  and  imbecility 
(being  found  in  28.31  per  cent,  of  the  cases  tabulated 
by  Shuttleworth  and  Beach).  Naturally  an  increase 
of  suicide  moves  hand  in  hand  with  an  increase  of 
insanity.  It  has  been  remarked  that  the  farther  a 
race  advances  in  civilization,  the  more  are  its  mem- 


bers given  to  self-destruction.  In  the  historj-  of  the 
ancient  world  the  suicidal  mania  was  most  rampant 
when  civilization  was  at  its  acme.  In  Rome  at  one 
period  suicide  was  almost  an  epidemic.  Nations  ad- 
vance and  deteriorate  at  one  and  the  same  time. 
Among  the  primitive  races  suicide  is  almost  unknown. 
One  of  the  saddest  and  most  impressive  signs  of  the 
time  is  the  growing  prevalence  of  self-destruction 
among  the  young.  Child  suicide  is  increasing  both 
in  this  country  and  in  most  of  the  countries  of  the  old 
world.  Recently  the  number  of  youthful  suicides  in 
England  alone  has  averaged  over  ten  annually,  and  in 
America  this  average  is  very  considerably  higher. 

In  connection  with  suicide  there  are  some  curious 
points  to  be  obsened.  One  of  these  is  that  every- 
where self-destruction  is  more  common  with  men  than 
with  women.  This  may  be  explained  partly  by  the 
fact  that  up  to  the  present  day  woman  has  taken  a 
less  harassing  share  in  the  fight  for  existence,  partly 
by  the  purer  life  which  she  usually  leads,  and  partly 
by  her  natural  repugnance  to  mutilation  of  the  body. 
Another  somewhat  peculiar  point  is  the  time  of  the 
3-ear  in  which  the  tendency  to  self-destruction  is  most 
marked.  One  would  imagine  that  in  the  dreary  months 
of  winter  and  early  spring,  when  all  the  surroundings 
are  of  a  depressing  character,  to  a  person  in  an  over- 
strung mental  condition  such  a  time  would  appear 
most  fitting  for  ending  life.  However,  this  is  not  the 
case,  and  statistics  demonstrate  that  suicides  are  most 
numerous  in  the  months  of  May  and  June. 

WTiile  allowing  that  heredity  plays  a  very  prominent 
part  in  disseminating  the  seeds  of  tuberculosis  and 
insanit)',  it  should  not  be  forgotten  that  environment 
exerts  no  small  degree  of  influence  toward  bringing 
about  the  same  results.  Unfavorable  environment 
also  tends  to  originate  and  call  into  activity  latent 
forms  of  neurosis  and  produces  mental  as  well  as 
physical  degeneracy.  This  truth  is  exemplified  in  the 
case  of  dwellers  in  the  Alpine  valleys,  who  have  de- 
teriorated from  a  stout  and  healthy  race  into  cretins, 
both  mentally  and  physically  deficient.  Therefore 
individuals  predisposed  by  inheritance  to  neurosis 
should  live  amid  bright  and  healthy  surroundings  and 
in  as  cheerful  a  mental  atmosphere  as  possible.  By 
these  means  the  development  of  the  taint  may  be  kept 
in  check.  This  treatment  is,  however,  after  all,  but 
a  palliative  one,  and  it  is  argued  that  steps  should  be 
taken  to  strike  at  the  root  of  the  evil  and  endeavor  to 
stamp  it  out.  The  only  feasible  remedy  as  yet  sug- 
gested is  that  the  question  of  marriage  should  be  re- 
garded in  a  much  more  serious  light,  and  that  parents 
should  consult  a  physician  before  allowing  their  chil- 
dren to  wed.  Consumption  is  a  matter  of  more  than 
national — it  is  of  universal  import,  and  if  any  worka- 
ble plan  can  be  devised  to  eradicate  its  sources  or 
even  to  lessen  its  dangers,  such  a  plan  should  he 
adopted.  Possibly  in  the  course  of  time  it  will  be 
found  necessar}'  in  the  interests  of  the  health  of  the 
community  at  large  to  enforce  laws  restricting  the  re- 
production of  morbid  taints.  The  time  is  not  yet  ripe, 
and  until  it  arrives  the  only  path  to  pursue  is  to  edu- 
cate the  public  in  regard  to  the  gravity  of  the  situa- 
tion. 


790 


MEDICAL    RECORD. 


[November  27,  1897 


THE  EFFECT  OF  SMOKING  ON  THE  HEALTH 
OF   THE    YOUNG. 

In  the  Journal  of  the  Russian  National  Health  Society 
for  September  last,  Dr.  Mendelssohn  contributes  an 
account  of  the  results  of  some  observations  made  by 
him  a  few  years  ago,  in  regard  to  the  effect  of  smok- 
ing on  the  health  of  students.  In  view  of  the  great 
interest  taken  now  by  medical  men  in  the  question, 
these  deductions  should  prove  instructive.  In  1890 
a  circular  was  sent  to  every  student  of  the  Army 
Medical  Academy  in  St.  Petersburg  and  in  the  Tech- 
nological Institute,  containing  several  questions  which 
the  students  were  asked  to  answer,  and  1,071  replies 
were  received.  Among  the  medical  students  54.66 
were  found  to  be  habitual  smokers,  and  among  techno- 
logical students  only  47.18.  Judging  from  these 
statistics,  smoking  appears  to  be  very  common  among 
the  young  in  Russia.  Two  began  the  habit  at  the 
e-xtremely  tender  age  of  six,  3  at  the  age  of  nine,  1 1 
at  the  age  of  ten,  5  at  the  age  of  eleven,  27  at  the 
age  of  twelve,  and  so  on,  the  maximum  being  reached 
at  the  age  of  seventeen.  The  average  number  of 
cigarettes  smoked  daily  by  a  medical  student  was 
19.64,  and  by  a  technological  student  22.88.  (The 
fact  should  be  borne  in  mind  that  Russian  cigarettes 
are  very  small.) 

The  tabulated  figures  relating  to  the  effect  of  smok- 
ing on  the  health  are  very  interesting,  and  if  accurate 
go  further  to  emphasize  the  fact  that  smoking  is  det- 
rimental to  the  health  of  the  young.  Of  the  smokers 
16.09  per  cent,  were  found  to  have  some  affection  of 
the  respiratory  tract,  while  only  10.69  "^^  ^^^  r^an- 
smokers  were  thus  affected.  In  respect  to  diseases  of 
the  alimentary  tract,  the  figures  were  respectively 
11.88  and  9.92  per  cent.;  and  of  both  tracts  com- 
bined, 8.77  and  3.22  per  cent.  Turning  to  the  effect 
of  the  age  at  which  the  habit  was  begun,  it  was  found 
that  those  who  had  acquired  the  habit  before  the  age 
of  sixteen  years  gave  higher  percentages  of  illness 
than  those  who  began  at  or  after  that  age.  Another 
table  illustrates  the  harmfulness  of  inhaling  the  smoke. 

It  has  long  been  agreed  that  with  the  j-oung  smoking 
is  not  conducive  to  good  health.  To  the  ordinary 
adult  it  is  probable  that  smoking  in  moderation  is  by 
no  means  hurtful ;  in  fact,  many  distinguished  medi- 
cal men  have  held  that  to  some  persons  it  is  even 
beneficial. 


CONSUMPTION   IN   ITS   RELATION    TO   THE 
WAGE-EARNING    PERIOD   OF    LIFE. 

The  prevention  of  tuberculosis  is  a  question  of  so 
surpassing  an  importance  that  any  information  bearing 
on  the  subject  is  always  eagerly  listened  to.  Accord- 
ing to  the  vital  statistics  of  the  State  of  Massachusetts, 
the  death  rate  in  regard  to  the  age  of  the  victims  to 
consumption  has  within  recent  years  completely 
altered.  Up  to  about  fifteen  years  ago  the  highest 
death  rate  from  tuberculosis  was  found  among  those 
between  the  ages  of  seventy  and  eight}'.  At  the  pres- 
ent time  the  highest  death  rate  from  consumption  at 
any  age  is  that  which  prevails  at  the  age  period  twenty 


to  thirty.  The  figures  for  the  twenty-five  years  1863- 
87  were:  at  the  age  period  twenty-five  to  thirt}' — 49.4 
per  10,000  of  the  living  at  that  age,  and  62.1  of  the 
living  at  the  age  seventy  to  eighty.  This  excess  at  ad- 
vanced ages  has  disappeared  in  recent  years.  It  would 
be  interesting  to  learn  whether  the  statistics  from  the 
various  civilized  countries  of  the  world  would  afford 
the  same  results  as  those  of  Massachusetts.  If  so, 
the  situation  is  indeed  a  serious  one.  Some  comfort, 
however,  can  be  extracted  from  the  fact  that  not  only 
in  Massachusetts,  but  in  America  generally  and  in 
Europe,  the  death  rate  from  consumption  at  all  ages 
has  decreased  and  is  still  decreasing. 


THE   DISCOVERER    OF    ANESTHESIA. 

Once  again  the  question  as  to  who  discovered  anaes- 
thesia has  cropped  up.  It  is  not  likely  now  that  the 
disputed  point  will  ever  be  really  decided  to  the  satis- 
faction of  every  one,  although  the  mass  of  evidence 
would  appear  to  be  in  favor  of  Morton's  claim.  In 
the  last  number  of  The  Johns  Hopkins  Hospital  Bulletin 
is  published  a  portion  of  a  paper  read  by  Dr.  Hugh 
Young,  in  support  of  the  contention  that  Dr.  Crawford 
Long  was  the  true  discoverer.  Dr.  Young  certainly 
presents  a  strong  case  for  Dr.  Long,  and  provides  some 
very  interesting  reading.  It  is  explained  that  the  rea- 
son why  Dr.  Long  did  not  put  his  claims  forward  more 
energetically  was  on  account  of  his  modest  and  retir- 
ing disposition.  The  irony  of  fate  was  never  more 
plainly  exemplified  than  in  the  lives  and  deaths  of  the 
three  claimants  to  the  honor  of  the  discover}'  which  of 
all  others  was  surely  of  the  greatest  benefit  to  man- 
kind. 


CLINICAL    STUDY    IN    MOSCOW. 

All  the  visitors  to  the  International  Congress  in 
Moscow  appear  to  have  been  greatly  impressed  by 
the  facilities  for  pursuing  clinical  obser\-ation  to  be 
found  in  that  city.  The  hospital  there  is  said  to  be 
the  most  perfect  in  the  world.  It  is  situated  at  some 
distance  from  the  town  and  consists  of  a  dozen  blocks, 
each  one  of  which  is  devoted  to  a  special  branch  of 
medicine  or  surgery.  The  erection  of  this  building 
was  partly  due  to  private  munificence.  The  govern- 
ment and  municipalit}'  supplemented  this  gift  with  a 
grant. 

THE   ARTICLES    ON    HEALTH    RESORTS. 

The  articles  on  health  resorts  printed  semi-annu- 
ally in  this  journal  make  no  pretension  to  com- 
pleteness; they  are  suggestive  only,  and  are  intended 
simply  as  pointers  for  physicians  who  may  need  hints 
in  this  direction  for  their  own  use  or  for  the  use  of 
their  patients.  That  these  articles  have  been  appre- 
ciated has  been  amply  demonstrated  to  us,  since  they 
w'ere  begun  in  June,  1896,  by  the  very  numerous  com- 
munications we  have  received  from  members  of  the 
profession  in  all  parts  of  the  country  requesting  further 
information.     The  transportation    department  of   the 


November  27,  1897] 


MEDICAL   RECORD. 


791 


Medical  Record,  inaugurated  at  the  same  time,  has 
been  the  means  of  aiding  hundreds  of  physicians  since 
that  time  in  carrying  out  their  plans  for  travel  and  so- 
journ. Circulars,  booklets,  and  timetables  of  all  lines 
and  places  are  on  application  sent  without  charge  to 
any  subscriber  to  the  Medical  Record. 


Ofle  Way  to  Prevent  the  Abuse  of  Medical  Char- 
ity.— The  New  York  Cancer  Hospital  (One  Hundred 
and  Sixth  Street  and  Central  Park,  West)  will  hereaf- 
ter send  the  following  notice  to  the  physician  of  every 
patient  who  applies  for  treatment  at  that  institution : 

"  New  York  Canxer  Hospital,  | 
"  1 06th  Street  and  Central  Park,  West,  j 


" JJ.IJ. 

"  Dear  Doctor  :  M 

has  applied  to  enter  this  hospital.     We  understand 

that has  recently  been  under  your  care; 

kindly  let    us  know   if    you  consider 

a  proper  case  for  free  medical  treatment. 

"An  answer  will  oblige, 

"  Yours  very  truly, 


■■  Superintendent." 
This  is  an  example  worthily  set  for  every  other  hospi- 
tal in  this  or  any  other  city. 

Society  for  Medical  Progress. — The  following  offi- 
cers were  elected  for  the  ensuing  year:  President,  Dr. 
Louis  Fischer;  First  Viee- President,  Dr.  M.  T.  Sime; 
Second  Vice-President,  Dr.  Thomas  Buckley ;  Treasurer, 
Dr.  Harold  Lesser;  Secretary,  Dr.  F.  P.  Lowenstein. 

Bayonne  Hospital,  N.  J. — Dr.  Charles  W.  Allen 
has  been  appointed  consulting  dermatologist  to  the 
above  institution. 

Dr.  Martin  Roche,  president  of  the  Pennsylvania 
College  of  Pharmacy  and  of  the  Polytechnic  Univer- 
sity, died  at  Philadelphia  on  November  15th,  in  con- 
sequence of  an  apoplectic  attack,  at  the  age  of  seventy- 
one  years.  He  began  the  study  of  medicine  at  the 
naval  hospital  in  Portsmouth,  Va.,  and  was  graduated 
from  the  medical  department  of  the  University  of 
Pennsylvania  in  1852. 

Northern  Medical  Association  of  Philadelphia — 
A  stated  meeting  of  the  Northern  Medical  .Association 
was  held  on  November  12th.  An  informal  discussion 
was  held  on  the  subject  of  "  The  Ethical  Standard  of 
Membership  in  the  Northern  Medical  Association," 
in  the  course  of  which  reference  was  made  to  the  par- 
ticipation by  members  in  benefit  and  other  public 
associations.  Dr.  I.  P.  Stritmatter  presented  a  num- 
ber of  specimens,  illustrative  of  the  treatment  of  endo- 
metritis by  means  of  irrigation  with  solutions  of  mer- 
curic chloride  and  the  employment  of  the  stem  pessary. 
Dr.  Samuel  Wolfe  read  a  paper  entitled  "  Physiologi- 
cal and   Pathological    Observations  Connected  with 


Disease  and  Injury^  of  the  Cer\-ical  Cord,"  relating  two 
cases  in  which  death  resulted  from  fracture  of  cer\-ical 
vertebrae. 

Health  Protective  Hospital  for  Contagious  Dis- 
eases in  Philadelphia. — The  agitation  that  has  been 
going  on  in  Philadelphia  for  the  last  three  years  has 
finally  culminated  in  the  purchase  of  a  site  for  a  pay 
hospital  for  the  treatment  of  contagious  diseases,  in 
contiguity  with  the  Municipal  Hospital.  A  consider- 
able sum  of  money  has  already  been  collected,  and  a 
corporation,  including  representatives  of  the  Women's 
Health  Protective  Association  and  the  Philadelphia 
County  Medical  Society-,  formed,  which  held  its  first 
meeting  on  November  15th.  The  object  of  the  new 
institution  is  to  furnish  accommodation  for  those  at- 
tacked with  contagious  diseases  in  boarding-houses, 
hotels,  or  apartment  houses,  or  in  their  own  homes, 
and  who  will  desire  some  such  means  of  isolation,  for 
which  they  will  be  glad  to  pay. 

Dr.  C.  B.  Meding,  of  this  city,  has  been  elected 
executive  surgeon  of  the  Harlem  Eye,  Ear,  and  Throat 
Infirmary,  in  place  of  Dr.  R.  E.  Swinburne,  deceased. 

"  The  American  Practitioner  and  News,"  of  Lou- 
isville, will  be  changed  at  the  beginning  of  the  year 
from  a  biv.eekly  to  a  semimonthly. 

The  Spitting-Nuisance  in  Germany. — The  spit- 
ting-nuisance, which  in  Germany  is  almost  as  bad  as 
in  our  own  land,  has  begun  to  receive  attention  from 
medical  men.  At  a  recent  meeting  of  the  German 
Public  Health  Association  there  was  a  discussion  on 
the  spread  of  infectious  diseases  at  health  resorts  and 
on  railways,  and  it  was  generally  agreed  that  one  of 
the  most  eftective  means  of  spreading  disease  was  the 
habit  of  promiscuous  expectoration  on  the  floors  of 
railway  carriages  and  in  public  streets.  Professor 
Esmarch  recommended  that  the  government  be  re- 
quested to  forbid  the  practice. 

American  Dentists  in  Italy. — The  Italian  govern- 
ment has  apparently  had  enough  of  tourists,  for  it  is 
doing  its  best  to  keep  them  away  by  its  crusade  against 
non-Italian  physicians  and  dentists.  Recently,  ac- 
cording to  the  Rome  correspondent  of  T/ie  Lancet,  a 
circular  has  been  addressed  by  the  minister  of  the  in- 
terior to  the  prefects  throughout  the  kingdom.  It  is 
neither  more  nor  less  than  a  mandate  charging  these 
functionaries  to  invite  all  non-Italian  dentists  to  fur- 
nish proof  that  in  addition  to  their  home  qualifications 
they  possess  one  from  a  recognized  qualifying  body  in 
Italy,  failing  which  these  gentlemen  are  to  be  held  as 
practising  illegally,  are  therefore  to  be  called  upon  to 
desist  from  practice,  and  in  the  event  of  their  being 
contumacious  to  be  denounced  to  the  judiciary 
authority. 

Vaccination  against  Typhoid  Fever. — The  exper- 
iments recently  made  at  Maidstone  in  antityphoid  in- 
oculation were  unsatisfactory,  as  they  were  begun  at 
a  time  when  the  epidemic  was  waning.  Now  Professor 
Wright,  of  Netley,  proposes,  with  the  permission  of 
the  military  authorities,  to  inoculate  all  the   British 


792 


MEDICAL    RECORD. 


[November  27,  1897 


troops,  especially  those  sent  to  India,  in  order  to 
render  tiiem  immune  to  the  typhoid  fever  which  al- 
ways prevails  there  to  such  an  alarming  extent. 

The  Tri-State  Medical  Association. — The  annual 
meeting  of  this  society  was  postponed  by  reason  of 
the  yellow  fever,  to  Wednesday  and  Thursday,  De- 
cember 15th  and  i6th.  The  meeting  will  be  held  in 
Memphis. 

Dr.  John  N.  Mackenzie,  of  Baltimore,  has  resigned 
the  chair  of  laryngology  in  the  University  of  Mary- 
land. 

Typewritten  Prescriptions.— Mr.  Labouchere  pro- 
poses, in  Truth,  that  a  law  be  passed  making  it  obli- 
gatory to  typewrite  all  prescriptions,  so  that  they  may 
be  filled  with  safety  and  accuracy.  He  says  that  he  is 
led  to  make  this  suggestion  by  the  confession  of  a 
druggist,  who  said  that  he  always  did  the  best  he 
could  with  an  illegible  prescription,  and  when  he 
could  not  read  it  at  all  put  up  what  he  thought  best. 

A  Ruling  on  a  Question  of  Ethics. — At  a  recent 
meeting  of  the  Medical  Society  of  Santa  Clara  County 
(Cal.)  a  resolution  was  adopted  to  the  effect  that  the 
code  of  ethics  does  not  preclude  the  members  of  the 
society  "  from  freely  rendering  most  prompt  and  effi- 
cient assistance  to  the  sick,  the  injured,  or  the  suffer- 
ing, and  obtaining  the  history  of  such  cases  from  all 
available  sources,  whether  previously  attended  by 
homcEopathic  or  eclectic  practitioners,  or  unlicensed 
fraudulent  pretenders — the  right  to  change  physicians 
being  unquestionable;  or  from  receiving  in  emergen- 
cies needed  assistance  and  advice  from  persons,  what- 
ever their  titles  or  pretensions;  nor  do  such  codes  of 
ethics  preclude  regular  physicians  from  seeing  or  vis- 
iting the  sick  or  injured  while  attended  by  homoeopaths 
or  eclectics  or  unlicensed  persons,  and  freely  stating 
their  opinions  about  diagnosis  and  treatment,  and  do- 
ing all  else  required  by  humanity  and  friendship;  but 
they  do  preclude  their  representing  or  regarding  such 
visits  and  attendance  as  professional  consultations  or 
agreements,  or  personally  receiving  professional  pay 
therefor,  as  lowering  the  character  and  standing  of  the 
medical  profession  and  misleading  the  sick  and  their 
friends  and  the  community." 

Dr.  Howard  A.  Kelly.— A  reception  was  tendered 
to  Dr.  Howard  A.  Kelly,  of  the  Johns  Hopkins  Uni- 
versity, Baltimore,  by  the  Medical  Club  of  Philadel- 
phia in  the  parlors  of  The  Aldine  one  evening  last 
week. 

Insuring  Students  against  Mishap.— An  arrange- 
ment has  been  made  by  the  authorities  of  Heidelberg 
University  with  an  accident  insurance  company, 
whereby  a  student  who  may  be  disabled  by  an  accident 
in  the  chemical  and  physical  laboratories  receives 
$500,  or  a  proportionate  sum  if  the  accident  causes 
temporary  disability  only. 

A    Cystoscopic    Controversy Drs.    Casper  and 

Nitze  quarrelled  so  long  and  so  loud  over  tlie  question 
of  priority  in  the  invention  of  a  cystoscope,  which  the 
former  had  exhibited  as  of  his  own  devising,  that  they 


finally  appealed  to  the  law.  Many  of  the  prominent 
surgeons  of  Berlin  were  called  as  experts,  and  differed 
as  widely  in  their  sworn  testimony  as  if  they  were  ex- 
pert witnesses  in  a  murder  case.  Finally  Casper  won 
the  suit,  and  Nitze  was  adjudged  to  have  no  well- 
founded  claim  to  priority.  He  not  only  lost  his  case, 
but  had  to  pay  a  fine  for  saying  what  was  not. 

Dr.  Guiteras,  who  was  sent  to  Texas  by  the  Marine 
Hospital  service  to  investigate  certain  cases  of  sup- 
posed yellow  fever,  has  been  the  object  of  much  in- 
temperate abuse  by  certain  medical  men  in  that  State 
because  he  diagnosed  the  cases  as  yellow  fever. 

The  Temerity  of  Old  Age — A  man  aged  one 
hundred  years  and  one  month  was  married  in  St. 
Joseph,  Mo.,  on  November  i8th,  to  a  widow  aged 
seventy-seven  years.  Both  bride  and  groom  are  said 
to  have  been  in  excellent  health  up  to  that  time. 

Suicide  of  a  Physician A   medical    practitioner 

in  Birkenhead,  England,  was  recently  sentenced  in  a 
Liverpool  police  court  to  two  months'  imprisonment 
for  neglecting  to  comply  with  a  maintenance  order 
obtained  by  his  wife.  Before  the  judge  had  finished 
speaking  the  man  swallowed  an  ounce  of  hydrocyanic 
acid  with  a  promptly  fatal  result. 

Football  in  Georgia. — The  Georgia  senate  passed 
the  anti-football  bill  on  November  i8th  by  a  vote  of 
thirty-one  to  four.  The  prohibitive  bill  had  already 
passed  the  house  by  a  vote  of  ninet)'-six  to  two.  It 
is  currently  believed  that  the  governor  is  opposed  to 
the  bill,  but  his  veto  would  be  ineffective  against  such 
numbers.  The  bill  prohibits  the  playing  of  a  game 
of  football  in  any  place  in  the  State  where  admission 
is  charged. 

Perils  from  Electricity. — A  man  was  killed  in 
Philadelphia  last  week  by  a  shock  of  electricity  while 
he  was  looking  in  a  shop  window.  It  was  raining  and 
he  was  holding  an  umbrella  with  a  steel  rod  in  it  over 
his  head.  Above  him  was  an  electric  arc  light.  The 
end  of  the  umbrella  rod  touched  the  iron  frame  of  the 
lamp  and  a  current  of  electricity  passed  through  his 
body  to  the  iron  covering  of  a  coal  shaft  in  the  side- 
walk, killing  him  instantly.  A  man  was  killed  in  a 
similar  way  on  Eighth  Avenue  in  this  city  about  three 
years  ago. 

Alleged  Spread  of  Diphtheria  by  Means  of  Pen- 
cils.— An  inquiry  has  just  been  concluded  in  Indian- 
apolis concerning  an  unusual  increase  in  diphtheria 
among  public-school  children  since  the  opening  of  the 
fall  session.  As  a  result  of  this  inquiry  the  sanitary 
authorities  have  concluded  that  the  disease  has  spread 
through  the  distribution  of  lead  pencils  and  penhold- 
ers. Under  the  system  in  vogue  in  the  schools  each 
child  is  required  to  take  its  pencil  and  penholder  to 
the  teacher's  desk  in  the  afternoon.  These  are  placed 
in  a  box,  and  the  next  day  are  redistributed.  It  is 
proposed  to  sterilize  the  pencils  hereafter  previous  to 
their  distribution  each  morning. 

Repressing  Flirtation. —  .V  telegram  from  Louis- 
ville to  the  daily  papers  says  that  it  has  been  found 


November  27,  1897] 


MEDICAL    RECORD. 


793 


necessary  to  place  two  policemen  on  guard  before  the 
Louisville  School  of  Medicine  every  day  at  the  time 
the  girls'  fiigh  school  is  dismissed,  in  order  to  prevent 
the  medical  students  from  flirting  with  the  young 
women  of  the  high  school,  which  adjoins  the  medical 
college.  The  students  deny  that  they  have  ever  so 
much  as  glanced  at  the  high-school  girls,  and  say  that 
the  charge  was  brought  merely  to  induce  the  city  au- 
thorities to  build  a  new  schoolhouse  in  another  locality. 

The  Lane  Lectures The  announcement  is  made 

that  the  third  course  of  Lane  lectures  before  the  stu 
dents  of  Cooper  Medical  College  of  San  Francisco 
will  be  delivered  'by  Dr.  T.  Clifford  Allbutt,  of  Cam- 
bridge, England.  The  subject  of  the  course  will  be 
the  diseases  of  the  heart. 

Damages  for  Injuries  Resulting  in  Death.— About 
two  years  ago  a  constitutional  amendment  was  passed 
in  this  State,  providing  that  the  amount  of  damages 
recoverable  for  injuries  (railway  or  other)  resulting  in 
death  should  not  be  subject  to  any  statutory  limitation. 
It  was  formerly  limited  to  $5,000.  One  of  the  results 
of  this  amendment  was  seen  recently  in  a  verdict  of 
$30,000  damages  against  the  New  York,  New  Haven, 
and  Hartford  Railroad  Company  for  injuries  which 
resulted  in  the  death  of  Dr.  Mixsell. 

Police  Surgeoncies  in  Brooklyn. — Two  hundred 
and  seven  medical  men,  young  and  old,  veterans  and 
recent  graduates,  came  up  for  examination  last  week 
for  appointment  on  the  board  of  police  surgeons. 
The  salary  of  a  police  surgeon  will  be  $3,000  a  year. 
There  will  be  tsvo  hundred  and  three  disappointed 
ones,  as  there  were  but  four  vacancies  to  be  filled. 

Objections  to  the  Providence  Hospital — A  resi- 
dent of  Washington  has  brought  suit  in  the  district 
court  for  an  injunction  to  restrain  Treasurer  Roberts 
from  paying  any  money  to  the  Providence  Hospital, 
upon  an  agreement  between  the  surgeon-general  of  the 
army  and  the  directors  of  the  hospital.  This  agree- 
ment provided  for  the  support  and  medical  treatment 
of  ninety-five  medical  and  surgical  patients  who  are 
destitute.  There  is  also  another  agreement  between 
the  district  commissioners  and  the  directors  of  the 
hospital,  wherein  it  is  provided  that  the  commission- 
ers "will  erect  on  the  grounds  of  the  hospital  an  iso- 
lated building  or  ward  for  the  treatment  of  minor 
contagious  diseases."  The  petitioner  alleges  that  the 
hospital  is  a  Catholic  institution,  that  the  contract 
referred  to  is  unauthorized  by  law,  and  that  the  ap- 
propriation of  funds  of  the  United  States  for  the  use 
and  support  of  religious  societies  is  unconstitutional. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
November  20,  1897.  November  17th. — Surgeon  C.  G. 
Herndon  detached  from  the  bureau  of  medicine  and 
surgery  and  placed  on  waiting  orders;  Assistant  Sur- 
geon J.  C.  Thompson  detached  from  the  naval  labora- 
tory, Brooklyn,  and  ordered  to  the  naval  hospital, 
Mai-e  Island,  Cal.;  Assistant  Surgeon  W.  B.  Grove 
detached  from  the  naval   hospital.  Mare  Island,  Cal., 


on  reporting  of  relief,  and  ordered  to  the  Oregon. 
November  19th. — Passed  Assistant  Surgeon  T.  B.  Bai- 
ley detached  from  the  Yorktown  and  ordered  home 
with  two  months'  leave. 

Work  of  the  Food  Inspectors. — During  the  past 
summer  the  food  inspectors  of  the  New  York  board  of 
health  seized  and  destroyed  2,578,448  pounds  of  fruit, 
meat,  fish,  and  other  food  stuffs.  Of  these  there  were 
1,012,145  pounds  of  bananas,  39,905  pounds  of  apples, 
2,120  pounds  of  eggs,  320,105  pounds  of  watermelons, 
50  pounds  of  onions,  275,285  pounds  of  fish,  437,850 
pounds  of  meat,  7,730  pounds  of  cucumbers,  and  1,850 
pounds  of  pickles. 

No  More  Forced  Charity  for  Private  Institutions. 

— The  board  of  estimate  has  been  informed  by  Cor- 
poration Counsel  Scott  that  chapter  754  of  the  laws  of 
1895  rendered  discretionary  all  mandatory  laws,  passed 
prior  to  that  time,  compelling  the  board  to  insert  cer- 
tain estimates  in  the  annual  budget  to  provide  money 
for  private  charitable,  correctional,  and  reformatory 
institutions.  Hitherto  these  institutions  have  de- 
manded certain  sums  as  a  matter  of  right  under  the 
provisions  of  these  laws.  The  corporation  counsel 
says  that  the  board  of  estimate  may  now  consider  the 
applications  for  relief  from  the  institutions  on  their 
merits,  and  appropriate  such  sums  as  in  its  judgment 
it  deems  just.  Comptroller  Fitch  was  directed  to 
notify  the  heads  of  the  institutions  interested  of  the 
opinion  of  the  corporation  counsel,  and  advise  them 
that  they  must  press  their  claims  on  their  merits  upon 
the  consideration  of  the  final  estimates.  The  aggre- 
gate amount  which  the  city  has  been  compelled  to 
raise  annually  by  these  mandatory  laws  has  been  in 
the  neighborhood  of  $1,000,000.  A  committee  has 
been  appointed  from  the  County  Medical  Society  to 
look  after  the  matter. 

The  Health  Board  and  the  County  Society.—"  It 

may  well  be  asked  by  what  right  in  law  or  equity  does 
the  health  department  or  its  physicians  presume  to 
treat  disease  in  public  institutions  or  elsewhere,  and 
in  some  instances  attempt  to  dictate  or  to  discredit  the 
diagnosis  of  the  condition  or  the  treatment  of  patients 
under  the  care  of  a  licensed  practitioner,  not  only  in 
private  life,  but  in  public  institutions  also.  If  the 
afflicted  persons  are  poor  and  in  need  of  hospital  care, 
they  should  be  treated  like  other  poor  patients,  by  the 
physicians  of  the  various  public  institutions  under  the 
care  of  the  commissioners  of  charities.  If  they  are 
well-to-do,  then  they  should  be  treated  at  home  by  the 
private  practitioner,  or  in  a  secluded  public  or  private 
hospital  if  need  be,  and  pay  for  the  services  rendered." 
— Dr.  A.  M.  Jacobus^  in  Annual  Address  before  the  So- 
ciety. 

Election  of  Officers  of  the  Woman's  Hospital  So- 
ciety.— The  following  officers  have  been  elected  by 
the  Woman's  Hospital  Society  to  serve  for  the  ensuing 
year:  President^  Dr.  Paul  F.  Mund(f;  Vice-President, 
Dr.  Leroy  Broun ;  Secretary  and  Treasurer,  Dr.  James 
N.  West;  Executive  Committee,  Drs.  Nathan  C.  Boze- 
man,  E.  L.  H.  McGinnis,  J,  Dougal  Bissel,  and 
George  H.  Mallett. 


794 


MEDICAL    RECORD. 


[November  27,  1897 


©linicat  gepartmjcnt. 

SERUM    IN    TUBERCULOSIS. 
By  CHARLES  C.   BROWNING,    M.D., 

HIGHLAND,   MESSINA  P.    O.,    CAL. 

A  BRIEF  report  of  cases  treated  by  me  with  tubercle 
antitoxin  is  submitted.  Since  May,  1895,  I  have 
treated  ten  patients,  with  the  following  results,  to  wit : 
t\vo  deaths,  four  recoveries,  and  four  under  treatment. 

The  two  who  died  commenced  treatment  when  the 
disease  was  far  advanced,  but  obtained  so  much  relief 
from  the  distressing  symptoms  incident  to  this  stage  of 
the  disease  that  the  treatment  was  continued  to  the 
end.  When  the  serum  was  discontinued  for  a  short 
time,  these  symptoms  returned,  to  be  relieved  when 
the  serum  was  resumed. 

Of  the  four  patients  reported  cured,  all  are  still 
under  observation.  Three  are  adults,  and  were  suffer- 
ing from  pulmonary  tuberculosis  in  the  second  stage. 
There  have  been  no  symptoms  of  the  disease  for  pe- 
riods varying  from  eighteen  months  to  two  years,  the 
time  since  treatment  was  discontinued  in  the  several 
■cases.  The  fourth  case  was  that  of  a  child,  five  years 
of  age,  who  had  suffered  from  Pott's  disease  of  the 
spine  and  was  suffering  at  the  time  of  the  beginning  of 
treatment  with  hip-joint  disease.  The  serum  was  ad- 
ministered for  four  months,  per  rectum,  with  results 
which  were  alike  surprising  and  satisfactor}\  There 
is  no  indication  of  a  return,  although  six  months  have 
elapsed. 

Of  the  four  patients  under  treatment,  all  have  im- 
proved. Two  are  far  advanced  and  will  probably  ob- 
tain only  temporary  relief.  The  other  two  are  pro- 
gressing rapidly,  with  good  prospect  for  final  recovery. 
One  of  the  latter  is  taking  the  serum  per  rectum. 

The  diagnosis  in  all  these  cases  was  verified  by  the 
microscope. 


REPORT  OF  OPERATIONS  IN  THREE  CASES 
OF  UMBILICAL  HERNIA  IN  ELDERLY 
WOMEN. 

By   PATRICK  C.V.SSIDV,    M.D., 

VISITING  SURGEON  TO  THE  W.  W.    BACKUS   HOSPITAL,  NORWICH,   CONN. 

In  comparison  with  the  number  of  operations  for  in- 
guinal and  femoral  hernias,  the  reported  operations 
upon  umbilical  hernise  are  small  in  number;  in  fact, 
surprisingly  small.  This  rarity  of  such  operations  is 
not  in  all  probability  due  to  the  great  comparative 
rarity  of  umbilical  hernia,  but  to  the  fact  that  in  a 
majority  of  cases  trusses  and  other  appliances  act  very 
well  in  keeping  back  the  hernial  contents.  On  this 
account  the  individual  is  not  troubled  by  the  hernia; 
therefore  the  surgeon  is  not  called  upon  for  interfer- 
ence. To  tell  the  truth,  a  great  many  per.sons  having 
hernia;  which  give  them  at  times  great  trouble  do  not 
even  then  consult  a  surgeon,  but  prefer  to  liurry  to  the 
instrument  maker  and  have  a  truss  fitted.  Of  course, 
in  cases  of  enormous  hernia  or  strangulation,  the  sur- 
geon is  consulted  and  operation  is  often  advised.  The 
three  cases  to  be  reported  bear  out  my  statements.  In 
one  of  these  cases  the  hernia  had  been  of  only  one  year's 
standing,  but  in  the  other  two  cases  several  years  had 
elapsed  since  the  beginning  of  the  trouble.  These 
cases  also  testify  as  to  tlie  rarity  of  this  form  of  her- 
nia, for  they  are  the  only  cases  of  umbilical  hernia 
which  have  been  operated  upon  in  this  hospital  during 
its  four  years  of  existence. 

Case  I. — Mrs.  G ,  aged  sixty-three,  is  a  farmer's 

wife,  living  in  Ledyard.  For  twenty  years  she  had 
an  umbilical  hernia.  During  these  years  she  had 
worn    trusses    of    various    forms   with    poor    results. 


Yet,  in  spite  of  the  fact  of  hernia,  she  had  borne  eight 
children.  She  reported  that  the  hernia  had  been 
"strangulated"  twice,  and  for  two  weeks  before  com- 
ing to  the  hospital  she  had  suffered  almost  intolerable 
pain  and  much  inconvenience  otherwise.  On  account 
of  this  great  pain  she  decided  to  come  to  the  hospital. 
Upon  examination  the  ring  was  found  to  be  about  one 
inch  in  diameter  and  the  abdominal  walls  were  ver}-  lax. 
She  was  operated  upon  May  17,  1897.  After  the  sac  had 
been  exposed,  it  was  opened  and  was  found  to  be  filled 
with  omentum.  This  was  ligated  and  cut  off.  The 
sac,  being  adherent  everywhere  to  the  ring,  was  cut  ofif 
at  a  short  distance,  about  0.5  cm.,  from  the  ring.  The 
ring  was  closed  by  a  row  of  chroniicized  catgut  sutures 
in  such  a  way  as  to  bring  the  serous  surfaces  of  the 
sac  together.  The  bellies  of  the  rectus  were  dissected 
for,  and  after  being  found  were  brought  together  with 
the  fascia  in  apposition  above  the  ring  and  stitched 
with  the  gut  sutures.  Next  the  skin  incision  w  as  closed 
with  interrupted  silk  sutures.  The  patient  made  an 
uninterrupted  recover}-,  the  wound  healing  by  first  in- 
tention. She  has  been,  since  her  discharge,  attending 
to  her  duties  as  housewife  on  a  farm. 

Case  II.- — Mrs.  McB ,  aged  forty-nine,  residing 

in  Wauregan,  has  had  several  children.  During  the 
past  five  years  she  has  had  an  umbilical  hernia.  This 
had  never  given  her  any  trouble  until  May  17,  1897, 
four  days  before  coming  to  the  hospital.  On  this  day, 
after  a  fit  of  coughing,  the  tumor  became  much  en- 
larged and  caused  pain.  There  was  vomiting  but  no 
constipation.  She  was  admitted  to  the  hospital,  May 
21,  1897.  On  examination  an  irreducible  hernia  was 
found  at  the  umbilicus.  The  percussion  note  was  dull 
over  the  tumor.  It  was  decided  to  operate.  At  oper- 
ation, after  cutting  down  on  the  sac,  this  was  found  to 
be  adherent  to  the  ring  and  was  cut  away  at  a  short 
distance  from  the  ring.  The  contents  of  the  sac  con- 
sisted chiefly  of  omentum,  but  there  was  also  included 
a  portion  of  intestine,  making  a  partial  enterocele.  A 
large  portion  of  the  omentum  was  ligated  and  cut  off, 
and  the  residue  of  the  hernial  contents  was  returned  to 
the  abdomen.  The  wound  was  closed  in  the  manner 
described.  A  rapid  recovery  followed,  the  wound 
healing  by  first  intention. 

Case  III. — Mrs.  W— — ,  aged  sixty,  resides  in 
Norwich.  She  had  been  troubled  by  an  umbilical  her- 
nia for  about  a  year.  Occasionally,  she  said,  it  would 
become  "  strangulated."  On  these  occasions  she  got 
relief  by  assuming  a  recumbent  position  and  applying 
heat  to  the  tumor.  It  would  at  times  diminish  in 
size,  but  never  disappeared.  On  the  evening  of  March 
23,  1897,  she  was  taken  with  a  severe  attack  of  vomit- 
ing, coincident  with  which  the  tumor  became  full, 
hard,  and  painful  to  the  touch.  Dr.  L.  S.  Paddock 
was  called  in.  He  attempted  taxis,  but  failed  to 
reduce  and  had  her  removed  to  the  hospital  at  once. 
She  arrived  there  at  4  a..m.,  and  sodium  bromide  was 
given  and  ice  applications  were  tried.  She  had  no 
pyrexia.  -\t  the  operation  an  incision  was  made 
in  the  middle  line,  over  what  appeared  from  percus- 
sion to  be  omentum.  The  sac,  after  it  was  opened, 
was  found  to  be  chiefly  filled  with  omentum,  which 
was  adherent  to  the  abdominal  walls.  After  dissect- 
ing through  tliis,  several  knuckles  of  congested  and 
gangrenous-looking  colon  were  found.  The  ring, 
which  was  tense  and  constricted,  was  enlarged  by 
incision.  This  enla-gement  was  followed  by  recov- 
er)' of  circulation  in  the  gre.iter  part  of  the  intes- 
tine and  the  disappearance  of  the  adema  of  the  whole 
mass.  The  tenseness  was  also  relieved.  The  inci- 
sion was  now  enlarged  and  tlie  sac  opened  in  all 
directions.  Tiie  sac  was  cut  off  as  in  the  other  two 
operations.  The  intestines  were  washed  in  saline  so- 
lution and  then  returned  to  the  abdominal  cavity.  The 
sutures   inclosing  the   incision  were  made  as  in   the 


November  27,  1897] 


MEDICAL    RECORD. 


795 


other  operations,  but  in  this  case  a  gauze  drain  was 
introduced.  The  patient  rallied  nicely  from  the  anaes- 
thetic, but  the  pulse  was  very  weak.  Stimulants  were 
freely  administered,  but  her  condition  grew  gradually 
worse  and  she  died  at  4  a.m.  of  the  morning  after.  At 
the  necropsy  the  small  intestine  was  found  to  be  filled 
with  blood  from  internal  oozing.  During  the  last  few 
hours  of  life  several  ounces  of  blood  were  passed  per 
rectum. 

Of  course,  too  short  a  time  has  elapsed  since  opera- 
tion in  Cases  I.  and  II.  to  give  good  grounds  for 
claiming  a  cure,  but  up  to  the  present  the  patients 
have  been  able  to  attend  to  their  duties,  which  are  by 
no  means  light,  without  any  recurrence  and  with  no 
discomfort. 


ONE-SIDED     SPASTIC     SPINAL     PARALYSIS 
(PRIMARY    LATERAL    SCLEROSIS). 

By   HAROLD   N.    MOVER,    M.D., 

CHICAGO. 

It  is  hardly  necessary  to  discuss  the  question  as  to 
whether  there  can  be  a  primary  lateral  sclerosis. 
Some  authors,  notably  Oppenheim,  are  of  the  opinion 
that  it  may  occur,  while  Dana  discards  the  term  alto- 
gether. Our  recent  acquisitions  regarding  the  neuron 
have  altered  our  conception  of  the  system  diseases 
of  the  cord  and  their  relation  to  the  brain.  Regard- 
ing the  nerve  cell  and  fibres  as  practically  the  same 
structure  in  a  pathological  sense,  there  can,  I  think, 
be  little  doubt  that  motor  fibres  may  degenerate  at  the 
beginning  in  the  cortex,  or  the  degeneration  may  have 
its  beginning  at  any  point  along  the  course  of  the 
fibres.  Without  doubt  there  are  well-marked  cases 
that  can  be  explained  by  no  other  hypothesis  than  that 
of  primary  involvement  of  the  crossed  pyramidal  tracts. 
Oppenheim  and  Dana  claim  that  no  case  of  this  kind 
has  yet  come  to  autopsy.  In  view  of  these  uncertain- 
ties, I  have  concluded  to  retain  the  older  designation 
of  spastic  spinal  paralysis. 

The  patient  was  a  male,  thirty-eight  years  of  age,  a 
farmer  by  occupation,  and  had  always  resided  in  the 
country.  The  family  history  was  e.xcellent,  presenting 
no  cases  of  nervous  trouble  or  tuberculosis.  The  pa- 
tient had  always  had  excellent  health,  and  denied  all 
venereal  infection.  Four  years  before  coming  under 
observation  he  had  a  severe  attack  of  influenza  in  the 
early  spring  months.  From  this  illness  he  made  a 
slow  convalescence,  and  as  the  season  advanced  and 
the  weather  became  warmer  he  noticed  that  the  left 
side  of  his  face  did  not  sweat  as  did  the  right  side. 
He  is  not  positive  that  the  dryness  of  the  surface  in- 
cluded the  entire  left  half  of  the  body,  but  does  recol- 
lect that  the  left  hand  was  always  drier  than  the 
right.  During  the  summer  this  symptom  gradually 
disappeared.  As  autumn  approached  he  observed  an 
increasing  weakness  of  the  left  arm  and  leg.  He  is 
not  positive,  but  thinks  this  loss  of  strength  began 
first  in  the  arm.  With  this  weakness  there  was  an  in- 
creasing stiffness  of  the  left  leg  and  arm.  The  paral- 
ysis has  gradually  increased  ever  since  it  began, 
though  the  progress  of  the  disorder  was  more  marked 
during  the  first  two  years. 

As  the  patient  enters  the  room  his  walk  is  distinctly 
of  a  hemiplegic  type,  and  at  first  glance  a  diagnosis 
of  cerebral  hemorrhage  would  be  made.  On  interro- 
gating the  patient  it  was  learned  that  the  disease  came 
on  gradually,  that  at  no  time  was  there  "a  stroke"  or 
impairment  of  consciousness.  The  side  of  the  face  is 
not  involved  and  there  is  no  disturbance  of  speech,  nor 
are  the  eyes  involved. 

The  muscular  system  is  well  developed  and  he  has 
€very  appearance  of  being  in  perfect  health.  He 
stands  with  eves  closed  and  feet  close  togetlier,  with- 


out swaying.  In  neither  hand  is  there  inco-ordination. 
The  knee  jerk  is  greatly  increased  on  the  left  side, 
as  is  the  elbow  jerk.  Myotatic  irritability  is  exagger- 
ated. A  slight  tap  on  the  quadriceps  is  sufficient  to 
throw  the  left  leg  nearly  straight.  There  is  no  dis- 
tinct quadriceps  clonus.  Ankle  clonus  is  marked 
and  will  continue  for  several  minutes.  On  the  right 
side  there  is  an  increase  in  the  knee  jerk,  though 
no  ankle  clonus  is  present.  The  patient  says  that 
in  walking  the  ankle  jerk  often  occurs  in  the  left  foot, 
and  it  is  necessary  for  him  to  stop  and  press  the  foot 
firmly  to  the  ground.  It  is  apparent  that  the  right 
side  is  involved  to  a  slight  extent,  but  it  is  not  suffi- 
cient to  attract  the  attention  of  the  patient.  Move- 
ments of  the  right  arm  and  leg  are  clumsy  and  diffi- 
cult of  execution.  The  grasp  of  the  left  hand  is  nearly 
abolished ;  that  of  the  right  is  especially  strong  and 
vigorous.     The  superficial  reflexes  are  not  altered. 

Electrical  reactions  are  normal  on  the  paralyzed 
side.  As  compared  with  the  opposite  side,  the  same 
amount  of  current  is  required.  There  is  no  tendency 
to  polar  inversion.  Sensation  is  not  altered  or  dimin- 
ished anywhere,  nor  are  there  any  trophic  disturbances. 
The  muscles  are  everywhere  as  full  and  rounded  on 
the  paralyzed  as  on  the  healthy  side.  The  pupils  and 
eyegrounds  are  normal.  The  visual  fields  for  white 
and  colors  are  normal  in  both  eyes.  All  of  the  cranial 
nerves  are  intact  and  there  is  no  increase  in  the  jaw 
jerk.  Speech  is  not  disturbed.  The  functions  of  the 
bladder  and  rectum  are  normal.  There  is  no  impair- 
nrent  of  the  sexual  centre. 

This  is  the  first  case  that  has  come  under  my  per- 
sonal observation  in  which  primary  lateral  sclerosis 
was  practically  limited  to  one  side.  I  say  practi- 
cally limited,  for  it  is  apparent  that  there  is  a  very 
slight  involvement  of  the  right  side,  though  it  is  not 
sufficient  to  attract  the  attention  of  the  patient.  I 
regard  this  unilateral  grouping  of  the  symptoms  in 
this  disorder  as  exceedingly  rare,  and  one  to  which 
many  late  writers  do  not  refer.  Bastian  ("  Paralyses, 
Cerebral,  Bulbar,  and  Spinal,"  1886)  states  that  in 
rare  cases  the  disease  is  limited  to  one  side  of  the 
body,  beginning,  for  instance,  in  one  leg  and  then  ex- 
tending to  the  arm  on  the  same  side,  so  as  to  present 
a  kind  of  hemiplegic  distribution.  In  equally  rare 
cases  the  upper  extremities  may  be  affected  first,  the 
disease  later  involving  the  trunk  and  legs. 

Recently  Dr.  Charles  K.  Mills  described  to  me  a 
similar  case  which  had  come  under  his  observation 
but  had  never  been  published.  In  this  case  the  dis- 
ease was  of  a  distinctly  "  hemiplegic"  type. 


A   CASE   OF    COMPLETE    SPONTANEOUS 
VERSION. 


By    K.    N.    DALEY,    M.D.. 


BOSTON,    MASS. 


On  May  27th,  I  was  called  to  attend  Mrs.  C ,  a 

secundipara,  aged  about  twenty-eight  years.  No  word 
having  been  left  at  the  office  as  to  the  nature  of  the 
case,  it  was  some  few  hours  after  I  was  summoned  that 
the  visit  was  made.  The  patient's  house  was  reached 
at  about  2  p.m.,  and  it  was  learned  that  she  had  been 
in  labor  since  early  the  previous  evening.  While 
cleaning  up  1  had  occasion  to  observe  the  character 
and  duration  of  her  pains,  which  at  this  time  were  re- 
curring at  about  five-minute  intervals.  It  seemed  to 
me  that  she  had  not  reached  the  second  stage,  and  an 
examination  made  shortly  after  confirmed  the  infer- 
ence, the  OS  being  of  but  the  size  of  a  five-cent  piece; 
head  presenting.  'I'he  result  of  examination  was  made 
known  to  the  patient,  and  she  was  encouraged  and  in- 
structed how  to  work  witli  her  pains. 


796 


MEDICAL    RECORD. 


[November  27,  1897 


Soon  the  case  seemed  to  progress  nicely,  the  pains 
increasing  in  frequency  and  intensity.  After  an  inter- 
val of  an  hour  or  more  a  second  examination  was 
made.  I  was  somewhat  surprised  to  find  tliat  there 
was  scarcely  any  perceptible  change  in  the  ^i/e  of  the 
OS,  which  was  exceedingly  rigid  and  felt  like  a  tense 
ring  of  cartilage.  However,  the  pains  being  strong, 
regular,  and  frequent,  she  was  allowed  to  continue  for 
another  couple  of  hours,  in  the  hope  that  with  the  in- 
creasing force  and  frequency  of  the  contractions  dila- 
tation would  eventually  ensue.  At  the  third  exami- 
nation (made  about  two  hours  after  the  second)  the  os 
had  increased  to  about  the  size  of  a  silver  dollar,  but 
still  presented  the  tense,  rigid  character.  Position  was 
made  out,  it  being  a  normal  O.L.A. 

Moral  suasion  was  again  resorted  to,  but  by  this 
time  the  patient  had  begun  to  tire  and  grow  weak. 
Vomiting  soon  supervened  and  it  required  constant 
effort  to  keep  her  mind  on  her  work.  The  pains  also 
now  lost  their  frequency,  but  seemed  to  make  up  for 
this  loss  by  increased  intensity,  with,  however,  but 
little  effect  on  the  size  of  the  os. 

Manual  dilatation  was  tried,  but  owing  to  the  car- 
tilaginous character  of  the  os  but  little  headway  was 
made.  There  were  now  signs  of  complete  inertia, 
and  it  was  decided  to  etherize,  apply  forceps  after 

complete  dilatation,  and  then  deliver.     Mr.  C was 

dispatched  for  ether,  the  writer  meanwhile  continuing 
the  dilatation.  Just  at  this  time  the  membranes  were 
accidentally  ruptured  and  quite  a  rush  of  waters  came 
down,  but  version  did  not  occur  immediately,  for  the 
head  could  easily  be  felt  with  the  dilating  hand  for 

some  few  minutes  later,  when  Mr.  C returned  with 

the  ether. 

Dilatation  was  suspended  at  this  point.  The  head 
was  presenting,  position  O.L.A.,  head  not  engaged. 
This  was  the  position  just  previous  to  etherization,  the 
OS  just  admitting  the  hand.  Ether  was  given  and  soon 
the  woman  was  completely  under  its  effects. 

The  cone  was  now  intrusted  to  an  attendant,  it  being 
my  intention  to  complete  the  dilatation  and  deliver  as 
soon  as  possible.  The  interval  between  my  last  ex- 
amination and  this  moment  could  certainly  not  have 
been  more  than  fifteen  minutes,  yet  on  introducing  the 
hand  to  enlarge  the  os  still  more  I  was  completely 
dumfounded  to  find  not  the  head  but  the  breast.  At 
first  L could  scarcely  believe  my  own  senses,  but  yet 
there  it  was!  I  had  informed  the  attendants  of  my 
intention,  and  in  fact  had  my  forceps  by  my  side  in 
lysol  solution,  all  ready  for  instant  application. 

There  was  now  but  one  thing  to  do — complete  the 
dilatation,  go  up  for  a  foot  and  bring  it  down,  which 
was  soon  accomplished,  and  after  some  further  slight 
difficulty  delivery  was  happily  completed. 

Such  cases  are  explained  by  Lusk  thus:  The  amni- 
otic fluid  having  escaped,  the  foetus  is  seized  by  the 
uterine  muscular  walls,  which  now  labor  under  a  me- 
chanical disadvantage.  The  pains  force  the  head  into 
contact  with  the  os  internum.  There  is  absence  of  a 
distending  bag  of  waters;  the  contractions  at  the  fun- 
dus become  more  jX)werful,  the  os  refuses  to  dilate, 
the  presenting  part  is  displaced  laterally,  and  the  part 
previously  occupying  the  fundus  is  forced  into  the 
pelvis. 


Laryngismus  Stridulus. — 

I{  Pot.  cit gm.  7 

Sydenham's  laudanum git.  20 

Pulv.  ipecac, 

Syr.  simp aa    gra.  15 

Aq q.s.  ad  gm.  120 

M.     S.   For  a  child  a  tablespoonfui  every  two  hours. 

— Douglas. 


dJorrjespoutlettce. 

OUR    LONDON    LETTER. 


CFr 


r  Special  Correspondent. ) 


TYPHOID    EPIDEMICS OPHTHALMIA    AND  SCHOOLS DR. 

BARNARDO DR.  SIMS  WOODHEAD — CLINICAL  SOCIETY 

nurses'     disputes DEATHS     OF     DR.     HAUGHTON, 

SIR    WILLIAM     MACKINNON,     AND     SIR     RUTHERFORD 
ALCOCK. 

I.O.N  DON,  November  5,   1897. 

The  typhoid  scourge  continues.  At  Maidstone  the 
medical  officer  of  health  reported  on  Wednesday  35 
new  cases  for  the  week,  an  average  of  5  a  day.  The 
next  day  there  were  lo,  bringing  the  total  up  to  1,795. 
He  did  not  consider  any  well  in  Maidstone  safe,  and 
the  conduit  water  was  in  constant  danger  of  pollution. 
The  corporation  has  spent  about  ^6,000  in  temporary 
hospitals,  laundries,  nursing,  and  such  like.  More 
than  ^6,000  has  been  subscribed  to  help  the  sick  and 
the  orphans. 

At  Lynn  also  the  epidemic  is  unchecked.  On 
Wednesday  17  fresh  cases  raised  the  total  to  316 
with  12  deaths.  Yesterday  14  new  cases  were  added. 
At  Clifton  the  number  of  cases  had  risen  yesterday  to 
T20,  and  it  was  said  all  had  been  traced  to  one  milk 
supply  from  a  distant  farm. 

Dr.  Sydney  Stephenson,  who,  as  I  informed  you,  was 
appointed  to  examine  the  school  children  as  to  the 
prevalence  of  ophthalmia,  has  completed  his  report, 
which  is  now  printed  as  an  appendix  to  the  annual  re- 
port of  the  local  government  board.  Among  1,702 
children  examined,  he  found  973  cases  of  chronic  tra- 
choma, but  acute  ophthalmia  was  rare  except  among 
pauper  children.  Dr.  Stephenson  says  trachoma  is 
certainly  more  common  in  poor-law  institutions  than 
in  outside  schools,  but  the  difference  is  not  so  great 
as  many  supposed.  Actual  injurj-  to  eyes  or  to  sight 
from  trachoma  occurred  in  439  eyes  in  277  children, 
and  this  he  says  is  "due  to  a  malady  that  is  preventable 
and  ought  to  be  prevented."  During  the  last  twenty 
years  great  improvement  has  been  effected  in  the  oph- 
thalmic condition  of  the  children.  In  1874  Mr.  Net- 
tleship  found  in  8,798  children  trachoma  affecting  42 
per  cent.  Now  Dr.  Stephenson  finds  the  percentage 
reduced  to  4.91.  Similar  improvement  is  noted  in 
other  respects.  Dr.  Stephenson  traces  the  primary 
cause  of  trachoma  in  the  schools  to  importation  of 
diseased  children,  and  asserts  that  aggregation  cannot 
be  shown  to  exert  an  appreciable  effect  on  its  spread. 
The  remedies  propounded  are  structural  adaptations 
and  careful  administration  and  supervision,  particu- 
larly in  regard  to  washing-arrangements  and  other 
sources  of  infection,  together  with  probation  of  thirty 
days  for  new  comers  and  frequent  skilled  inspection; 
medical  officers  to  be  specially  trained  to  examine 
and  record  the  condition  of  the  eyes  of  every  new 
comer,  .and  a  central  hospital  to  intercept  diseased 
children  and  detain  them  until  cured.  Seaside  sana- 
toria and  other  provisions  are  also  recommended. 

I  am  sorry  to  see  that  Dr.  Barnardo's  homes  do  not 
come  out  well  as  to  the  prevalence  of  trachoma.  In 
one  of  them  5.51  per  cent,  were  affected.  Of  course 
the  class  of  cases  in  these  institutions  must  be  taken 
into  consideration  as  specially  difficult  to  deal  with,  but 
I  should  think  that  Dr.  Barnardo  will  carefully  study 
this  report  and  direct  his  best  efforts  to  the  matter. 
Probably  most  of  your  readers  are  acquainted  with  the 
great  good  he  has  accomplished.  Dr.  Barnardo  was  a 
student  of  the  London  Hospital.  He  gave  up  the  pro- 
fession for  the  purpose  of  rescuing  the  children  who 
were  destitute  and  outcasts.  The  work  grew  rapidly, 
and  has  attained  such  dimensions  that  he  is  now  able 
to  offer  to  receive  and  provide  for  the  one  hundred  or 


November  27,  1897] 


MEDICAL    RECORD. 


79; 


more  orphans  of  the  Maidstone  epidemic.  He  found 
himself  early  in  his  work  rather  hampered  by  not  being 
qualified.  He  therefore  took  his  diplomas,  and  he  has 
been  fellow  of  the  Edinburgh  College  of  Surgeons 
since  1879. 

When  Sir  B.  W.  Richardson  died  many  people  won- 
dered whether  another  medical  man  could  be  found  to 
follow  up  his  temperance  work.  His  successor  as 
president  of  the  Medical  Temperance  Association  is 
Dr.  Sims  Woodhead,  whose  scientific  reputation  you 
are  well  acquainted  with.  Last  week  a  complimen- 
tary breakfast  was  given  to  Dr.  Woodhead  in  Dublin, 
by  the  several  Irish  societies  engaged  in  temperance 
work.  The  College  of  Surgeons  lent  its  hall  for  the 
occasion,  and  Sir  William  Thompson  presided  and  said 
he  was  very  glad  to  take  part  in  the  proceedings,  and 
as  president  of  the  college  he  assured  a  gratified  audi- 
ence that  the  council  had  willingly  given  what  facility- 
it  could  to  honor  their  distinguished  guest. 

There  was  an  interesting  show  at  the  last  meeting 
of  the  Clinical  Society,  and  next  week  there  is  to  be  a 
series  of  cases  of  forcible  rectification  of  cur\-ature  of 
the  spine,  as  practised  by  Dr.  Calot.  The  cases  ate  to 
be  brought  forward  by  Mr.  Tubby  and  Mr.  Robert 
Jones.  It  is  anticipated  that  M.  Calot  will  be  present 
and  defend  his  method,  which  will  no  doubt  be  criti- 
cally discussed. 

The  Royal  British  Nurses'  Association  has  its 
troubles,  and  is  hardly  a  bed  of  roses  for  those  doc- 
tors who  have  devoted  much  time  and  energy  to  its 
assistance.  Last  week  there  was  a  meeting  of  its 
"  members'  rights  defence  committee"  at  St.  Mar- 
tin's Hall,  convened  by  certain  malcontents  for  the 
purpose  of  condemning  the  management  and  demand- 
ing a  public  inquiry  into  the  grave  charges  made 
against  the  managers.  Mrs.  Bedford  Fenwick  moved 
a  resolution  to  the  effect  that,  "in  view  of  the  great 
public  and  professional  interests  involved,  inquiry  is 
imperatively  needed,"  and  calling  on  Parliament  to 
appoint  a  select  committee  next  session.  In  support 
of  this  she  accused  five  medical  men  of  controlling 
the  association  and  mismanaging  the  finances.  The 
meeting  was  not  a  large  one — perhaps  over  a  hundred 
persons  were  present,  but  they  were  not  all  nurses:  in 
fact  the  uniform  was  not  at  all  conspicuous.  Two  of 
the  speakers  who  followed  said  they  were  not  nurses 
or  members,  but  came  to  support  Mrs.  Fenwick,  in 
whom  a  subsequent  speaker  said  she  knew  many 
nurses  had  confidence.  A  late  secretary  remarked  on 
the  few  nurses  present,  and  said  Mrs.  Bedford  Fenwick 
did  not  represent  either  the  association  or  the  nurses 
and  had  called  this  meeting  only  because  she  had  been 
omitted  from  the  council.  Hereupon  storms  of  hisses 
and  applause  conspired  to  interrupt  the  proceedings, 
and  the  resolution  was  declared  to  be  carried.  Sir  C. 
Browne,  Dr.  Bezley  Thome,  and  Messrs.  Pick,  Lang- 
ton,  and  Fardon  are  the  gentlemen  who  are  accused  of 
mismanagement  by  Mrs.  Bedford  Fenwick  and  her 
husband,  but  what  the  association  would  gain  by  trans- 
ferring to  the  latter  the  confidence  felt  in  the  former 
requires  explanation. 

The  foremost  professor  of  Dublin  University,  the 
Rev.  Samuel  Haughton,  AE.D.,  D.D.,  died  on  Sunday, 
and  will  be  missed  by  an  immense  number  of  gradu- 
ates who  can  hardly  realize  Trinity  College  without 
Haughton  as  the  most  prominent  figure.  He  entered 
the  university  in  1839,  and  crowned  his  brilliant  stu- 
dent career  by  winning  the  fellowship  the  very  year 
he  took  his  B.\.  (1844).  Ever  since  he  has  been 
closely  connected,  I  may  say  identified  with  the  uni- 
versity, in  which  he  has  held  every-  important  office. 
He  took  the  M.D.  in  1862  in  order  to  qualify  himself 
for  the  registrarship  of  the  School  of  Physic,  and  no 
sooner  was  he  installed  than  he  began  a  series  of  re- 
forms which  gave  new  life  to  the  school  and  in  fact 


set  the  tone  of  medical  education  in  Dublin.  He  was 
a  great  mathematician,  a  naturalist  of  a  high  order, 
and  possessed  most  remarkable  mental  gifts,  so  that 
any  subject  to  which  he  gave  attention  was  at  once 
mastered  by  him  and  not  seldom  advanced.  With  all 
this  he  was  an  eloquent  exponent  of  science,  a  public 
speaker  of  such  power  as  always  to  attract  an  audience 
and  always  please — a  bom  orator  in  fact,  with  a  full 
dash  of  rare  Irish  humor.  For  several  years  he  repre- 
sented his  tmiversity  in  the  General  Medical  Council, 
where  his  wit  and  humor  enlivened  the  usual  deadly 
didl  proceedings,  and  where  if  he  met  his  equals  in 
intellect  there  were  certainly  none  who  excelled  him. 
Honorary  degrees  of  Oxford,  Cambridge,  Edinburgh, 
and  foreign  universities  were  conferred  upon  him. 
Among  his  works  his  "  Principles  of  Animal  Mechan- 
ics," published  in  1873,  is  perhaps  best  known  to  the 
profession. 

Sir  William  Mackinnon,  K.C.B.,  formerly  director- 
general  of  the  army  medical  department,  died  on  the 
28th  ult,  aged  sixty-seven  years.  He  was  F.R.C.S. 
Edin.,  1873,  licentiate  of  1851.  The  Irish  College 
conferred  upon  him  an  honorary  fellowship.  Sir  Wil- 
liam Russell  in  TA^  Times  says :  "  He  was  one  of  the 
best  and  bravest  soldiers  that  ever  wore  the  uniform 
of  the  Queen,  but  it  conveyed  no  idea  of  the  man  him- 
self, who  was  an  embodiment  of  some  of  the  finest 
traits  of  the  Celtic  Highlanders." 

Sir  Rutherford  Alcock,  K.C.B.,  D.C.L.,  F.R.C.S., 
died  on  Wednesday  morning,  aged  eighty-eight  years. 
He  had  left  the  profession  so  long  ago  and  had  become 
so  notable  in  the  diplomatic  service  that  many  were 
unaware  that  he  ever  belonged  to  us.  He  was  on  the 
medical  staff  of  the  British  forces  in  the  peninsula, 
and  received  honors  and  decorations  from  Spain  and 
Portugal.  Afterward  he  was  consul  in  China,  and 
subsequently  plenipotentiary  to  Japan  and  our  first 
minister  to  that  coimtry.  Still  later  (i865>  he  had 
the  same  position  at  Pekin,  and  six  years  later  retired. 
He  had  been  president  of  the  Royal  Geographical  So- 
ciety. He  took  an  interest  in  hospital  work,  in  the 
course  of  which  I  came  into  contact  with  him.  His 
help  was  specially  valuable  and  highly  appreciated  at 
the  Westminster  Hospital.  He  published  "  Notes  on 
the  Medical  History  of  the  British  Legion  in  Spain" 
and  other  works,  among  which  I  may  mention  those 
on  "Japanese  Art  and  Industries,'"  and  a  Japanese 
grammar  and  dialogues  in  that  language. 


OUR    BERLIN    LETTER. 

rFrom  OUT  Special  Correspoodenc) 

THE    LEPRA    COXFEREXCE SOME    NEW    D.ATA    CONXERX- 

ING     THE    LU.MBAR     PUXCTfRE PARASITIC    SK.IX    DIS- 
EASES. 

Beri-in,  October  30,  1S07. 

The  International  Lepra  Conference  began  its  sittings 
on  the  nth  of  October  at  the  imperial  health  depart- 
ment's building  in  Berlin.  About  one  hundred  and 
fifty-  physicians  and  representatives  of  almost  ail  cul- 
tured nations  were  present.  V"irchow  was  chosen 
president;  and  Lassar  (Berlin),  Hansen  (^Norway), 
and  Ehlers  (Denmark)  were  named  as  an  advisory 
committee.  The  session  was  addressed  by  Minister 
Posadowsky,  who  said  that  the  government  took  a  deep 
interest  in  this  much-contended  question. 

Of  the  many  congresses  held  this  summer  in  Berlin, 
the  lepra  conference  awakens  perhaps  the  most  inter- 
est, because  of  the  practical  results  for  our  battle  with 
this  horrible  scourge  which  will  result  from  the  con- 
ference of  so  many  authorities.  Hence  the  deep  in- 
terest of  all  governments.  We  Germans  are  con- 
cerned in  preventing  that    little  epidemic  which,  as 


MEDICAL    RECORD. 


[November  27,  1897 


mentioned  in  a  previous  letter,  exists  in  the  eastern 
part  of  Prussia,  from  spreading  over  the  entire  empire. 
The  government  has  ordered  the  building  of  a  lepra 
home,  and  that  all  sufferers  be  brought  to  this  isolation 
station  and  there  treated  in  the  most  humane  manner. 
Without  these  precautions,  Armauer  Hansen,  the  cele- 
brated discoverer  of  the  lepra  bacillus,  declares  noth- 
ing can  be  attained. 

Representing  France,  Besnier  (Paris)  spoke  of  the 
danger  of  the  spread  of  the  pest  through  the  nasal  se- 
cretion, for  multitudes  of  bacilli  are  to  be  found  in 
this  secretion,  and  it  is  to  be  easily  understood  how 
dangerous  an  unclean  person  is  for  his  neighors.  In 
agreement  with  this  fact,  we  often  find  the  first  mani- 
festations of  leprosy  on  the  nose,  or  rather  some  part 
of  the  face. 

Armauer  Hansen  (Norway)  pleaded  for  a  humane 
but  strict  isolation  of  the  lepers.  The  majority  must 
not  be  placed  in  danger  because  of  the  benefit  thereby 
resulting  to  the  minority ;  and  even  the  greatest  pity 
we  may  feel  toward  these  unfortunates  must  not  influ- 
ence us  to  endanger  the  welfare  of  an  entire  nation. 
The  speaker  then  showed  how  the  extra  expenditures 
for  the  care  and  provision  of  lepra  cases  had  repaid, 
for  under  this  system  the  number  of  cases  diminished 
year  by  year. 

England's  delegate  advocated  the  theory  that  in  the 
habitual  eating  of  fish  was  to  be  found  the  main  factor 
in  the  etiology  of  leprosy;  an  opinion  not  shared, 
however,  any  longer  by  other  lepra  authorities. 

A  number  of  other  purely  scientific  questions  and 
problems  took  up  the  time  of  the  conferrees.  A  most 
friendly  spirit  prevailed  all  the  time. 

The  Perlin  Dermatological  Societ)'  held  a  festive 
session  at  the  Langenbeck-Haus,  in  honor  of  the  con- 
ference. The  hall  was  prettily  decorated,  and  every 
seat  taken.  In  the  front  rows,  in  addition  to  the  dele- 
gates, were  among  others  of  prominence  the  Kultus 
Minister  Bosse,  Professors  Virchow,  Jolly,  and  v.  Berg- 
mann.  Professor  Lassar  opened  the  session  with  an  ad- 
dress of  welcome  in  the  German,  French,  and  English 
languages,  closing  with  a  German  cheer  for  the  Em- 
peror. He  followed  with  a  paper  on  "Venereal  Dis- 
eases and  Public  Health."  This  concluded,  he 
ascended  the  platform  and  announced  that  the  Derma- 
tological Society  had  elected  Rudolph  Virchow  an 
honorary  member  of  that  body.  Here  followed  pro- 
jected pictures  on  the  screen,  illustrating  many  cases 
of  interest  of  leprosy  and  lupus.  This  closed  the 
session,  which  was  followed  by  a  supper. 

At  the  close  of  the  conference  the  members  and  del- 
egates were  invited  to  a  banquet  given  by  the  Kaiser. 
A  special  train  brought  them  to  Wild  Park,  where  the 
royal  coaches  conveyed  them  to  the  New  Palace.  The 
Kaiser  presided  at  the  table.  His  wife  and  all  the 
children  were  present.  He  conversed  frequently, 
especially  with  Virchow;  likewise  the  Empress.  Min- 
ister Bosse  and  Professor  Lassar  introduced  the 
gentlemen.  The  Emperor  passed  from  one  foreign 
delegate  to  the  other,  saying  a  word  or  two  to  each 
one.  He  assured  them  that  his  interest  in  the  ques- 
tion had  led  him  to  become  well  acquainted  with  it. 
Meanwhile  refreshments  were  served,  and  every  body 
felt  at  ease;  time  passed  quickly,  so  that  the  original 
time  set  (one  hour)  was  long  passed  wlien  the  imperial 
couple  withdrew.     Thus  closed  the  conference. 

At  the  first  autumnal  session  of  the  Verein  fiir  in- 
nere  Medicin,  v.  Leydcn,  addressing  tire  meeting,  paid 
his  respects  to  three  great  men  who  had  passed  away 
during  the  vacation.  Fresenius,  Heidenhain,  and 
Oertel  are  men  whose  fame  extends  farther  than  do 
Germany's  borders;  the  entire  world  recognizes  their 
merit  and  labors,  v.  Leyden  also  spoke  of  the  active 
interest  of  Germany  in  the  international  congress  at 
Moscow.     He  believed  the  Cerman   scientists  could 


with  complacency  regard  the  laurels  they  had  plucked 
there. 

Stadelman  spoke  about  the  lumbar  puncture  and  his 
experience  with  one  hundred  cases.  These  included 
meningitis  tuberculosa,  meningitis  purulenta,  absces- 
sus  cerebri,  brain  tumors,  and  cerebral  hemorrhages, 
etc.  He  summed  up  as  follows:  For  diagnostic  pur- 
poses, a  positive  result  only  is  to  be  considered;  a 
negative  one  is  of  no  value.  As  regards  therapy,  lum- 
bar puncture  is  of  no  benefit;  on  the  contrary,  its  em- 
ployment is  often  contraindicated,  especially  in  cere- 
bral hemorrhage,  as  it  tends  to  make  the  condition 
worse. 

At  the  first  meeting  of  the  Berliner  medicinische 
Gesellschaft,  Blascko  presented  a  case  of  leprosy. 

An  improvement  of  the  Roentgen  photography  was 
reported  by  Levy-Dorn.  It  consists  in  the  placing  of 
a  fluorescing  screen  made  up  of  a  layer  of  fine  gran- 
ules of  tungstate  of  calcium.  By  means  of  this  im- 
provement the  exposure  is  diminished  and  at  the  same 
time  the  pictures  are  made  sharper. 

The  greatest  interest  was  awakened  by  the  reading 
of  Buschke's  article,  "  Yeast  Fungi  of  the  Human  Skin 
and  the  Disorders  Caused  by  Pathogenic  Fungi." 
Buschke  observed  a  woman  with  ulcerating  tumors  of 
the  skin.  He  discovered,  by  means  of  cultures  and 
inoculation,  the  cause  to  be  a  yeast  fungus.  This  is 
the  first  case  of  blastomycosis  positively  recognized  in 
man.  This  case  led  Buschke  to  further  investigation, 
to  ascertain  if  variola,  syphilis,  and  carcinoma  were 
not  caused  by  fungi.  There  are  yeast  plants  which 
grow  upon  the  exterior  and  penetrate  into  the  tissues 
and  blood.  This  variety  Buschke  studied  experimen- 
tally. A  yeast  plant  obtained  from  a  cervical  discharge 
was  cultivated.  If  from  this  culture  a  portion  was 
brought  into  the  conjunctiva  of  animals,  sarcoma- 
like swellings  were  produced  and  then  imiversal  blas- 
tomycosis. On  the  other  hand,  Buschke  could  not 
produce  any  blastomycosis  from  malignant  growths  of 
man.  The  peculiar  round  bodies  seen  and  described 
by  some  authors  in  this  condition  (blastomycosis)  are 
certainly  not  yeast  growths.  Buschke's  investigations 
have  yielded  a  negative  result  as  regards  the  etiology 
of  carcinoma;  still  they  open  to  our  view  a  new  per- 
spective of  the  pathological  new  growths. 


ONE   OF   THE   CAUSES    OF   THE   ABUSE   OF 
CHARITY    AT    OUR    DISPENSARIES. 


Sir  :  Much  as  has  been  said  and  written  on  the  sub- 
ject of  the  abuse  of  charity  at  our  dispensaries,  one 
very  important  factor  in  its  causation  has  been  quite 
overlooked.  I  refer  to  the  part  the  family  physician 
has  taken  in  the  past,  and  is  still  taking,  in  greatly 
increasing  the  number  of  persons  who  apply  for 
gratuitous  treatment.  Most  of  our  dispensaries  are 
devoted  to  the  specialties.  The  family  physician  has, 
for  instance,  a  patient  who,  he  thinks,  should  be  treated 
by  a  specialist.  The  patient,  although  in  moderate 
circumstances,  is  able  and  in  many  cases  perfectly 
willing  to  pay  for  treatment.  Instead  of  being  sent 
by  the  family  physician  to  the  office  of  a  specialist 
with  a  note  asking  consideration  for  the  patient  in  the 
matter  of  fee,  he  is  told  to  go  to  a  dispensary  (the 
physician  generally  designating  the  one  on  which  he 
confers  the  privilege)  and  receive  free  treatment. 

I  have  been  engaged  in  dispensary  practice  in  New 
York  for  twenty-five  years,  and  I  do  not  hesitate  to 
assert  that  in  my  opinion  the  family  physician  is 
largely  responsible  for  the  abuse  which  is  now  acting 
as  a  boomerang  against  himself. 

It  is  not  an  uncommon  occurrence  at  mv  clinic  to 


November  27,  1897] 


MEDICAL    RECORD. 


799 


have  well-dressed  persons  apply  for  treatment.  After 
ascertaining  residence,  occupation,  etc.,  I  inquire :  "  Do 
your  circumstances  compel  you  to  apply  for  treatment 
at  this  place,  which  is  intended  for  the  poor  only?" 
The  answer  almost  invariably  is:  "I  am  able  to  pay 
something,  but  my  family  physician  told  me  to  come 
here  and  I  would  receive  free  treatment."  Sometimes 
they  coolly  inform  me  that  they  have  been  sent  to  the 
dispensarj'  for  opinion  only,  and  that  the  family  phy- 
sician merely  wanted  to  feel  assured  that  his  own  diag- 
nosis was  correct.  It  goes  without  saying  that  such 
cases  are  refused  treatment  at  my  clinic.  Xew  York 
has  no  lack  of  specialists,  many  of  whom  are  young 
men  who  would  gladly,  if  such  cases  were  referred  to 
them  at  their  offices,  give  them  treatment  at  prices 
they  could  well  afford  to  pay.  If  this  were  done,  the 
clinics  at  many  of  our  dispensaries  would  soon  rapidly 
decrease  in  the  number  of  unworthy  persons  applying 
for  treatment.  Clinton  Wagner,  M.D. 

19  E.\ST  Thirty-Eighth  'Street. 


EPISTAXIS    IN    TVPHOID    FEVER. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  Some  recent  remarks  in  the  Medical  Record 
upon  certain  symptoms  in  tj'phoid  fever  lead  me  to 
call  attention  to  an  important  symptom,  clinically  and 
practically,  to  wit,  epista.xis. 

About  ten  years  ago  I  obser\-ed  that  in  this  disease 
perforation  of  the  nasal  septum  near  its  facial  border 
sometimes  occurs.  This  led  to  the  examination  of 
every  case  of  hemorrhage,  and  uniformly  it  was  dis- 
covered to  be  from  the  same  point,  situated  about  one- 
quarter  or  one-third  of  an  inch  from  the  outer  margin  of 
the  septum  on  one  or  both  sides.  Observance  of  this 
fact  will  give  the  attendant  immediate  control  of  the 
hemorrhage  by  placing  and  holding  the  finger  over  the 
bleeding  point.  A  few  moments'  pressure  over  the 
alas,  continued,  will  often  be  sufficient.  While  I  have 
not  verified  it,  my  impression  is  that  hemorrhages 
occurring  in  low  states  of  the  system  are  from  the 
same  region.  R.   \V.  Erwin,  M.D. 

B.w  Citv,  Mich.,   November  6,   1897. 


A   NEW  OPERATION   FOR   MALIGNANT  DIS- 
EASE  OF   THE   TESTICLE. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  referring  to  Dr.  J.  Coplin  Stinson's  article 
with  the  above  title  in  the  Medical  Record  of  Octo- 
ber 30,  1897,  I  would  suggest  that  many  practitioners 
have  seen  many  cases  of  large  and  painless  induration 
of  the  testicle  and  scrotum  disappear  quite  readily 
under  the  proper  administration  of  the  iodides,  or 
iodides  and  mercury.  A  painless  carcinoma  is  so 
rare  that  it  may  be  said  practically  not  to  exist  at  all. 

As  Dr.  Stinson  did  not  do  the  entire  radical  opera- 
tion suggested,  owing  to  the  fact  that  the  inguinal 
glands  had  been  previously  removed,  it  opens  a  doubt 
as  to  the  mortality  rate  being  "about  «//.'"  It  short- 
ened and  simplified  his  one  operation  to  leave  out  the 
extensive  dissection  necessary  to  remove  the  inguinal 
glands.  Dr.  Stinson's  operation  is  novel,  but  the 
principle  of  removing  all  possible  source  of  infection 
when  operating  for  malignant  disease  in  any  part  of 
the  body  accessible  to  operation  is  just  as  old  as  ever. 

Dr.  Stinson  does  not  state  whether  or  not  a  micro- 
scopic confirmation  of  the  diagnosis  was  made  by  pre- 
paring slides  from  the  tissues  removed. 

E.  H.  Smith,  M.D. 

Santa  Clar.\,  Cal. 


Contagious  Diseases — Weekly    Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitarj-  Bureau,  Health  Department,  for  the 
week  ending  November  20,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis. . . 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-po.x 


246 

93 

21 

4 

153 

10 

0 

3 

25S 

16 

151 

19 

4 

4 

Opium  Eating  among  the  Kaffirs. — It  is  reported 
that  opium  eating  has  become  a  habit  with  the  Kaffirs. 
The  Chinese  are  said  to  be  the  chief  purveyors,  though 
the  trade  is  by  no  means  restricted  to  them. — Hospital. 

The  Alleged  Heredity  of  Consumption.— There  is 

no  doctrine  more  firmly  impressed  on  the  mind  of  the 
average  director  of  a  life  insurance  companv  than  the 
hereditary'  transmission  of  consumption.  Yet,  like  all 
cherished  beliefs,  this  doctrine  is  being  attacked  on 
all  sides,  and  if  it  is  to  remain  as  one  of  the  funda- 
mental principles  of  life  insurance,  fresh  statistics 
must  be  collected,  so  as  to  confute  the  statements  con- 
fidently made  by  its  opponents.  There  can  be  little 
doubt  that  in  many  of  the  so-called  cases  of  trans- 
mitted phthisis  the  patient  acquired  the  disease  by 
contagion,  his  powers  of  resistance  to  the  bacillus  be- 
ing enfeebled  by  the  same  conditions  of  environment 
as  led  to  his  father  or  mother  being  aff'ected.  In  or- 
der therefore  to  prove  that  consumption  is  inherited,  it 
will  be  necessar)-  to  show  that  the  children  of  con- 
sumptive parents,  when  removed  from  the  influence  of 
the  parental  environment,  succumb  to  the  disease  to  a 
greater  extent  than  do  the  general  population. — British 
Medical  Journal. 

Self-Sacrifice. — A  recent  issue  of  a  Western  eclec- 
tic journal  contains  a  page  of  editorial  notes.  The 
first  note  is  headed  "  Be  Good  to  Yourself."  Further 
down  the  page  is  another,  entitled  "  Consultations." 
It  reads:  "Our  physicians  are  isolated,  and  find  it 
difficult  to  get  aid  in  consultations  and  surgical  oper- 
ations; but  we  are  determined  to  give  all  the  assist- 
ance in  that  direction  that  is  possible.  We  travel  a 
good  deal  by  rail  for  consultations,  and  sometimes  re- 
muneration is  hardly  what  v.e  would  have  made  by 
staying  at  home;  nevertheless  we  are  desirous  of  giv- 
ing strength  to  our  cause." 

Even  in  Old  Roman  Days ! — 

Wise  Arruns,  asked  "  How  long  will  Caius  live?" 
Replied,  "  Tliree  days  the  fatal  sisters  give  ; " 
And  Arruns  knew  the  prophet's  art.      But  lo  ! 
Stronger  than  gods  above  or  gods  below, 
Euschemon  comes  ;  his  healing  arts  he  tries, 
And  in  a  single  day  poor  Caius  dies. 

—  Spectator,  August  28,  1897. 

Astigmatism  in  German  Schools. — In  the  major- 
ity of  instances  of  weak-sightedness,  as  well  as  in 
structural  disease,  and  in  some  instances  of  accommo- 
dation error,  the  origin  has  been  in  astigmatism  which 
has  passed  unnoticed.  In  examinations  of  twelve 
hundred  eyes,  over  sixt}'  per  cent,  were  found  more  or 
less  astigmatic,  while  one  hundred  and  five  were  my- 
opic and  one  hundred  and  eighty-eight  hypermetropic. 
— Steiger,  Correspondenzblatt  fiir  Schweizer  Aerzte, 
May  15,  1897. 


8oo 


MEDICAL    RECORD. 


[November  27,  1897 


Appendicitis  has  been  simulated  and  operation  per- 
formed in  a  case  observed  by  Picque  {Le  Bn'..  MM.), 
in  which  a  pus  collection  in  the  diverticulum  of 
Meckel  had  been  the  origin  of  the  symptoms. 

Infantile  and  Hereditary   Multiple   Sclerosis — 

Eichhorst  {Vircliow's  Anhiv,  Bd.  146,  Hft.  1-3) 
claims  that  previously  reported  instances  of  infantile 
multiple  sclerosis  will  not  bear  the  closest  critical 
scrutiny,  and  that  most  of  them  are  to  be  regarded  as 
diffuse  sclerosis  of  the  brain.  He  relates  two  instances 
of  multiple  sclerosis  in  mother  and  son  confirmed  by 
autopsy,  the  son  having  died  at  the  age  of  eight  years. 
Anatomical  changes  were  found  in  both  instances  only 
in  the  spinal  cord,  although  nystagmus,  disturbances 
of  speech,  and  pronounced  psychical  changes  were 
present.  This  is,  however,  not  so  much  to  be  won- 
dered at,  since  the  typical  picture  of  multiple  sclero- 
sis may  be  present  without  organic  lesion. 

Quackery. — To  gain  some  idea  of  the  profits  of 
quackery,  consider  the  fact  that  in  one  year,  1890,  the 
manufactories  of  patent  medicines  in  the  United  States 
sold  their  products  for  $32,622,123.  Now  if  the  re- 
tailers doubled  the  price  to  consumers,  as  is  more  than 
probable,  then  the  people  of  this  country  paid  for  their 
patent  medicines,  which  very  surely  do  much  more 
harm  than  good,  money  enough  to  have  paid  every  one 
of  the  104,805  "  physicians  and  surgeons"  of  the  Unit- 
ed States  an  annual  income  exceeding  $600. — Dr. 
Chaill6,  New  Orleans  Medical  and  Surgical  Joiir/ial, 
May,  1897. 

To  Determine  Age  of  Foetus  in  Miscarriages. — 

Dr.  Lambinon  gives  the  following  figures,  obtained 
at  the  Liege  Maternity,  bearing  upon  the  weight  of 
the  placenta  in  cases  of  miscarriage.  The  average 
weight  of  the  placenta  at  6  weeks  was  20  gr. ;  at  go 
days,  67  gr.;  120  days,  iii  gr. ;  165  days,  262  gr. ; 
and  at  235  days,  330  gr. 

The  Prevention  of  Tuberculosis. — At  the  Twelfth 
International  Medical  Congress,  held  in  Moscow,  Dr. 
V.  C.  Vaughan  concluded  a  paper  with  the  following 
propositions:  All  milkmen  should  be  provided  with  a 
license  from  the  municipality;  such  a  license  not  be- 
ing granted  until  the  cattle  have  been  inspected  by  a 
competent  veterinarian,  who  should  apply  the  tubercu- 
lin test' in  every  instance,  and  any  animal  foiHid  suffer- 
ing from  tuberculosis  should  be  immediately  de- 
stroyed. Cattle  killed  for  food  should  also  be  subject 
to  skilled  inspection.  The  disinfection  of  sputum 
from  consumptive  individuals  is  absolutely  necessary, 
and  such  persons  should  not  be  allowed  to  expectorate 
in  the  streets  or  public  vehicles.  Houses  and  rooms 
which  have  been  inhabited  by  consumptives  should  be 
disinfected.  The  government  should  construct,  equip, 
and  maintain  hospitals  for  paupers  suffering  from  tu- 
berculosis; sucli  hospitals  should  be  divided  into  two 
classes — one  for  incurables  and  the  other  for  those 
who  may  recover.  Tuberculosis  in  its  early  stage  is  a 
comparatively  curable  disease;  therefore  persons  yet 
in  this  stage  should  be  examined  once  or  twice  a  year 
by  a  physician,  and  the  government  should  furnish 
physicians  to  make  such  examinations  for 'the  poor. 

Anti-Football.  —  The  most  weighty  deliverance 
that  this  fall's  discussion  of  football  has  called  forth 
is  the  article  from  the  Medical  Rkcord,  which  we 
reprint  in  "The  Revolt  against  Football"  column. 
The  Medical  Record  is  a  conservative  medical  jour- 
nal of  the  highest  standing,  which  speaks  with  author- 
ity on  the  subject  of  physical  training,  and  its  words 
must  have  great  influence  with  people  who  keep  their 
heads  steady  in  the  whirl  of  excitement  that  comes 
with  the  ending  of  the  season.  The  Medical  Record 
holds  that  the  game  as  now  played  ought  not  to  be 


allowed,  on  the  ground  that  it  can  no  longer  be  viewed 
in  the  light  of  innocent  recreative  amusement,  with 
harmless  and  healthful  athletics  as  .its  object;  but 
that,  even  with  "  slugging"  ruled  out,  it  is  "  productive 
of  the  greatest  variety  of  surgical  injuries  to  every  part 
of  the  body,"  and  that  the  effect  of  such  injuries  is 
lifelong  in  a  large  proportion  of  cases.  This  is  a 
phase  of  the  subject  which  is  seldom  regarded,  except 
by  the  medical  profession.  Unless  a  player  is  so 
badly  hurt  that  he  cannot  enter  the  field  again  during 
the  season,  the  injury  is  generally  dismissed  by  both 
the  young  man  himself  and  the  public  as  a  mere  trifle, 
while  really  he  may  suffer  the  effects  always,  and  more 
severely  as  he  passes  on  from  middle  life  into  old  age. 
— New  York  Evening  Post. 

Health  Reports. — The  following  statistics  concern- 
ing yellow  fever  and  small-pox  have  been  received 
in  the  office  of  the  supervising  surgeon-general  of  the 
United  States  Marine  Hospital  service,  during  the 
week  ended  November  20,  1897: 

Yellow  Fe\er — United  States. 

Cases.  Deaths. 

Alabama,  Flomaton November  1 7th i 

Mobile November  13th  to  19th 13-  i 

l.x)uisiana,  New  Orleans November  14th  to  19th 49  12 

Mississippi,  Bilo.xi November  14th  to  rgth 6  i 

Clinton  November  13th  to  igth 3 

Edwards November  j 3th  to  19th. ..... ..     5  i 

Scranton November  13th  to  19th 11  i 

Yellow  Fever— Foreign. 


Cuba,  Manzanillo October  17th  to  31st  . . 

Matanzas November  3d  to  loth  . 

Jamaica,  Port  au  Prince     ....  November  loth 


Small-Pox — United  States. 
Georgia,  .Atlanta November  14th  to  17th 26 


Wiiile  the  Medical  RECORn  is  pleased  to  receive  all  new  publi- 
cations which  may  be  sctit  to  it^  and  an  acknowledgement  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  iinder standing  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  ivill  not  be 
of  interest  to  its  readers. 

Handbook  of  Therapeutics.  By  Dr.  S.  Ringer  and  Dr. 
H.  Sainsbury.  Thirteenth  Edition.  Svo,  746  pages.  William 
Wood  and  Company,  New  York. 

OrHTHALMOLoiucAL  Therapeitics.  By  Dr.  Landolt  and 
Dr.  Gygax.  i2mo,  138  pages.  J.  B.  Lippincott  Company, 
Philadelphia.      Price,  $i.oo. 

The  Principles  of  Bacterioloijy.  By  Dr.  A.  C.  Abbott. 
Fourth  Edition.  Svo,  543  pages.  Illustrated.  Lea  Brothers  & 
Co. ,  New  York. 

Handbook  of  Materia  Medica  ;  Pharmacy  and  Thera- 
peutics. By  Dr.  Samuel  Potter.  Svo,  900  pages.  P.  Blakis- 
ton,  Son&Co.,  Philadelphia.     Price,  $4.50. 

Pk.\ctical  Therapeutics.  By  Dr.  H.  A.  Hare.  Si.xth 
Edition.     Svo,  75S  pages.     Lea  Brothers  &  Co.,  New  York. 

Diseases  of  Women.  By  Dr.  H.  J.  Garrigues.  Second 
Edition.  Svo,  728  pages.  Illustrated.  W.  B.  Saunders,  Phil- 
adelphia.     Price,  $4.00.  net. 

Practice  of  Midwifery.  By  H.  Brown.  L.R.C.P., 
L.R.C.S.  i2mo,  103  pages.  J.  and  .\.  Churcliill,  London. 
Price,  fli.oo. 

Clinical  Methods.  By  Dr.  R.  Hutchison  and  H.  Rainy, 
M.A.      i2mo,    552    pages.      Illustrated,      l.ea    Brothers   &    Co., 

Philadelphia. 

Mastoid  .-Vhscesses.  By  Dr.  A.  Broca  and  Dr.  F.  Lubet- 
Barbon.  Translated  by  Dr.  H.  J.  Curtis.  lamo.  26S  pages. 
Illustrated.     11.  K.  Lewis,  London.     Price,  6s. 

Surgical  P.vihology.  By  J.  J.  Clarke,  M.B.  Svo,  440 
pages.  Illustrated.  Longmans,  Green  &  Co.,  New  York. 
Price,  $3.00. 

Dlseases  of  the  Skin.  By  Dr.  J.  V.  Shoem.iker.  Third 
Edition.  Svo,  894  pages.  Illustrated.  D.  -Appleton  and  Com- 
pany, New  York. 

Skin  Diseases  of  Children.  By  Dr.  George  H.  ¥ox. 
Svo,  190  pages.  Illustrated.  William  Wood  and  Company, 
New  York. 


Medical  Record 

A  Weekly  Journal  of  Medicine  and  Surgery 


Vol.  52,  No.  23. 
Whole  No.  1413. 


New  York,    December  4,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rigtuaX  lirticXes. 

ACUTE   SEROUS    MENINGITIS    (ALCOHOLIC 
MENINGITIS,  WET-BRAIN).' 

By   CHARLES    L.    DANA.    M.D.. 


The  description  I  am  about  to  give  of  so-called  alco- 
holic meningitis  is  based  upon  twenty  cases  observed 
during  life  and  examined  after  death  macroscopically 
and  in  most  cases  microscopically.  The  observations 
were  controlled  by  clinical  and  autopsical  studies  of  a 
case  each  of  pernicious  anemia,  suicide,  purulent 
meningitis,  cerebral  tumor,  uraemia,  cancer  of  the  py- 
lorus, and  morphine  poisoning.  Most  of  these  patients 
died  in  terminal  conditions  suggestive  of  the  last  days 
of  alcoholics.  I  have  also  had  careful  notes  taken 
by  Dr.  A.  J.  Brown,  Dr.  Gardner,  and  Dr.  Daley,  of 
cases  of  ''  alcoholic  meningitis"  which  ended  in  recov- 
ery. Out  of  this  material  I  have  constructed  a  picture 
of  what  is  known  in  the  hospitals  as  "wet-brain,"  or 
"  alcoholic  meningitis,"  and  what  I  have  termed  serous 
meningitis.  This  term  is  not  strictly  correct,  as  I 
shall  show;  for  the  process  is  not  so  much  an  inflam- 
mation as  it  is  a  to.\a;mia  leading  to  congestion,  then 
to  an  oedema  both  of  the  brain  and  its  membranes, 
with  a  moderate  serous  effusion  into  the  ventricles  and 
decided  disorganization  of  tlie  brain  elements.  But 
the  clinical  picture  is  strikingly  like  that  of  true 
meningitis. 

Etiology. — The  disease  occurs  oftenest  in  men  sim- 
ply because  of  the  more  frequent  indulgence  of  the 
male  se.x  in  alcohol.  It  rarely  develops  until  a  person 
has  been  drinking  eight  or  ten  years,  and  consequently 
affects  people  oftenest  between  the  ages  of  thirty  and 
forty.  The  e.xciting  cause  is  commonly  alcohol,  and 
in  this  country  whiskey  or  what  are  known  as  "hard 
drinks,"  but  beer  and  ale  will  accomplish  tlie  same 
result.  I  have  rarely  seen  the  disease  in  wine  drink- 
ers. The  persistent  use  of  morphine,  cocaine,  and 
chloral  may  lead  to  much  the  same  condition.  The 
patients  often  have  some  tuberculosis,  or  sclerotic 
changes  in  the  arteries,  and  perhaps  cirrhotic  liver 
and  kidneys.  The  exciting  cause  is  usually  a  continu- 
ous drinking-bout  of  two  or  three  weeks,  ending  in 
delirium  tremens.  The  delirium  tremens,  however,  is 
not  by  any  means  always  present.  The  patient  may 
pass  directly  from  a  condition  of  prolonged  intoxica- 
tion into  the  condition  of  alcoholic  meningitis  or 
"  wet-brain." 

Symptoms. — In  case  delirium  tremens  has  occurred, 
the  patient  after  two  or  three  days  of  prolonged  deliri- 
ous excitement  gradually  sinks  into  a  semicoma. 
This  is  accompanied  by  a  muttering  delirium.  The 
patient  is  sufficiently  conscious  to  have  flitting  delu- 
sions and  hallucinations  of  sight  and  hearing.  At  this 
time  he  is  able  to  drink  and  take  food;  the  pulse  is 
rather  rapid,  the  temperature  is  usually  normal  or  may 


1897 


Read  at  the  meeting  of  the  Practitioners'  Society,  October  15, 


be  raised  one-half  or  one  degree.  The  skin  is  hyper- 
ffisthetic,  and  pressure  upon  the  muscles  of  the  arms 
or  legs  or  abdomen  causes  pain.  The  patient  rarely 
complains  of  headache,  as  in  acute  meningitis,  and  he 
has  no  explosive  vomiting.  The  pupils  are  usually 
rather  small.  Often  at  this  time  conjunctivitis  and 
keratitis  appear. 

After  a  few  days  the  patient's  stupor  becomes  deeper 
and  he  can  be  aroused  only  with  difficulty.  The  arms 
and  legs  are  now  somewhat  stiff,  the  reflexes  are  exag- 
gerated, the  neck  is  stiff  and  slightly  retracted,  and  at- 
tempts to  move  the  head  bring  out  expressions  of  pain. 
Indeed,  the  stiffness  is  in  a  measure  voluntary,  the 
patient  resisting  directly  attempts  to  move  and  bend 
the  limbs.  There  are  no  jerking,  jumping,  or  con- 
vulsive movements.  The  abdomen  is  retracted  and 
the  skin  and  muscles  are  still  \ery  hyperfesthetic. 
The  lids  are  nearly  closed;  the  pupils  are  small 
and  do  not  react  well  to  light.  The  tongue  is 
coated  and  usually  dry,  and  urine  and  fasces  may  be 
passed  involuntarily.  The  patient  may  linger  this 
way  for  several  days  more.  The  pulse  becomes  rapid 
and  feeble,  the  extremities  are  stiff  and  cold.  The 
skin  is  dry  and  loses  its  elasticity,  so  that  when  pulled 
up  between  the  fingers  it  stays  in  folds.  "  Putty  skin" 
is  a  good  name  for  this.  The  coma  deepens,  the  tem- 
perature may  rise  to  103°  or  104°  F.,  and  symptoms 
of  pneumonia  may  appear  as  the  scene  closes,  the 
duration  of  the  attack  being  about  ten  days.  On  the 
other  hand,  in  some  cases  the  patient  does  not  pass 
into  the  worst  stage,  the  mind  becomes  clearer,  the 
hyperesthesia  lessens,  food  is  taken  better,  and  the 
bowels  are  moved  voluntarily.  Improvement  contin- 
ues, and  in  three  or  four  weeks  the  convalescence 
begins. 

Some  special  clinical  observations  were  made  forme 
by  Dr.  A.  J.  Brown.  In  ten  cases  the  blood  was  ex- 
amined. He  found  in  all  a  diminution  of  red  blood 
cells,  the  average  being  about  four  million  per  cubic 
millimetre.  The  haemoglobin  was  also  diminished, 
the  average  being  seventy  per  cent.  Evidence  of 
degeneration  of  the  red  blood  cells  and  of  poikilocytosis 
and  leucocytosis  was  often  noted. 

Tlie  lurine  noted  in  two  cases  showed  excess  of  urea 
and  earthy  phosphates.  Albumin  was  found  once,  and 
this  was  due  to  an  old  nephritis. 

Electrical  tests  of  the  muscles  showed  uniformly  a 
lessened  irritability  to  the  faradic  current.  The  deep 
and  superficial  reflexes  were  usually  exaggerated  until 
the  latest  stage,  when  they  were  diminished. 

Careful  examination  of  the  eyes  was  made  in  a 
number  of  cases  by  Dr.  A.  E.  Davis,  who  reported  his 
results  in  The  Fost-Giadnatc.  He  never  found  optic 
neuritis;  in  the  early  stages  there  was  congestion  of 
the  fundus. 

Pathological  Anatomy. — Besides  autopsies  made 
under  my  own  direction,  I  have  a  number  of  careful 
reports  from  Dr.  H.  Brooks,  of  the  Carnegie  Labora- 
tory. 

In  cases  of  short  duration  in  which  the  delirium  has 
hardly  abated  or  in  which  a  pneumonic  fever  has  com- 
plicated the  course,  the  meninges  are  congested;  but 
in  the  typical  prolonged  cases  this  congestion  is  only 
moderate.      The  dura  is  often  thickened ;   rarely  it  is 


802 


MEDICAL    RECORD. 


[December  4,  1897 


adherent  in  places  tolhe  pia.  The  pia  is  thickened  and 
opaque  just  about  in  proportion  to  the  age  of  the  patient 
and  duration  of  the  alcoholic  habits.  It  sometimes 
shows  hemorrhagic  patches.  There  is  considerable 
serous  fluid  in  the  subdural  sac  and  inthe  subarach- 
noid spaces.  The  ventricles  are  usually  found  dilated 
and  contain  an  excess  of  fluid,  but  are  not  often  extreme- 


-Male,    Thirty  four 
;ral  convolution.     X  ^ 

ly  distended.  The  brain  when  cut  into  is  rather  pale, 
soft,  and  shows  punctate  hemorrhages,  especially  in 
the  deeper  parts  and  in  the  pons.  Occasionally  one 
finds  points  of  hemorrhagic  softening,  similar  to  those 
described  as  hemorrhagic  encephalitis. 

Microscopic  examination  shows  in  the  uncompli- 
cated cases  that  there  is  no  true  inflammatory  process. 
There  is  often  congestion,  but  not  always;  tlie  com- 
moner condition  is  an  cedema  of  the  brain  tissue,  the 
perivascular  and  pericellular  spaces  being  dilated. 
The  nerve  cells  show  conditions  of  degeneration  such 
as  one  might  expect  if  they  were  attacked  by  an  irri- 
tative and  destructive  agent,  which  agent  had  not 
markedly  affected  the  vascular  conditions  of  the  part. 
The  cortex  may  even  be  somewhat  pale,  and  often 
shows  the  evidence  of  oedema  in  the  dilated  perivas- 
cular and  pericellular  spaces.  The  cell  bodies  them- 
selves show,  in  very  acute  and  febrile  cases,  a  great 
degree  of  pigmentation,  and  in  some  cases  the  masses 
of  pigment  occupy  more  than  half  of  the  body  of  the 
cell.  In  the  pyramids  these  deposits  are  usually  at 
the  ba.se,  in  the  region  of  the  axis-cylinder  process;  in 
some  of  the  spindle-shaped  cells  of  the  deeper  layers  the 
pigment  is  seen  deposited  between  the  nucleus  and  the 
apex  of  the  cell.  Hut  in  the  ordinary  types  of  wet-brain 
I  found  but  little  abnormal  pigmentation.  The  cyto- 
plasm shows  a  loss  of  the  distinct  chromophilic  mark- 
ings, and  looks  as  though  these  bodies  had  been  broken 
up  into  granular  masses.  The  body  of  the  cell  some- 
times looks  as  though  it  were  made  up  of  minute 
fatty  granules.  Sometimes  the  granular  masses  have 
dropped  out  of  the  cell  into  the  perivascular  space. 
'I'he  pigmentary  changes  are  always  most  striking  in 
the  large  cells.  The  changes  are  by  no  means  uni- 
form, but  appear  to  affect  certain  areas,  and  are  much 
oftener  seen  in  a  typical  fashion  in  the  cortex  of  the 
central  convolutions  than  in  the  occipital  or  frontal 
lobes.  The  cell  processes  are  still  fairly  perfect,  at 
least  many  of  them,  and  at  times  the  chromophilic 
granules  can  be  well  .seen  at  the  roots  of  the  cell  proc- 
esses, especially  the  axis-cylinder  and  the  apical  proc- 
ess, though  the  cell  body  may  be  in  a  very  damaged 
condition.     Nothing    is    so    striking    throughout    the 


whole  of  the  brain  cortex  as  tiie  preservation  and  great 
integrity  of  the  nuclei  and  nucleoli.  In  the  smaller 
pyramids,  in  which  the  body  subtance  is  relatively 
less  in  amount,  these  nuclei  are  often  stripped  almost 
entirely  of  the  surrounding  cytoplasm  ;  but  the  nucleus 
itself  usually  remains  unchanged  in  form  and  size. 
The  chromatic  network  is  not  easily  made  rat,  how- 
ever. The  nucleolus  loses  its  sharp  outline,  and 
shows  ragged  edges,  becoming  star  shaped,  and  some- 
times being  thinned  out  into  a  line.  As  the  cell  body 
degenerates  and  is  dropped  off,  the  nucleus  becomes 
more  and  more  nearly  free,  and  the  nucleolus  can  be 
seen  approaching  the  line  near  the  periphery  of  the 
nucleus.  A  vacuole  is  sometimes  seen  in  the  nucleo- 
lus, but  never  in  the  cell  body  in  good  sp>ecimens.  It 
is  a  pretty  well-established  fact  that  in  the  nucleus,  with 
its  nuclein  or  nucleic-acid  compounds,  takes  place  the 
constructive  metabolism  of  the  cell.  When  this  part 
is  destroyed,  the  cell  may  live  for  some  time,  but  it 
cannot  regenerate  or  longer  perform  its  functions. 
On  the  other  hand,  if  the  nucleus  still  remains  intact, 
the  capacity  of  the  cell  to  throw  out  a  new  body  and 
reconstruct  itself  is  still  present. 

In  the  brains  of  alcoholics  which  I  have  examined, 
there  is  throughout  the  transverse  section  a  striking 
integrity  of  the  nucleus,  and  I  attribute  to  this  the  fact 
that,  despite  the  most  severe  intoxication  with  alcohol 
poisons,  the  individual  may  still  recover  perfectly  his 
former  mental  powers. 

The  smaller  blood-vessels  sometimes  show  thick- 
ened walls  and  the  evidence  of  a  general  arterial  scle- 
rosis. 

Pathology. — Persons  suffering  from  acute  alcohol- 
ism, and  who  have  afterward  died  in  that  condition, 
have  come  to  the  hospital  with  this  history:  First,  that 
they  have  been  hard  drinkers  for  a  good  many  years, 
or  else  moderate  drinkers  with  periodical  sprees :  next, 
that  they  have  been  drinking  ver}'  hard  for  two  or  three 
weeks  previous  to  admission;  third,  that  they  have 
practically  eaten  nothing  for  a  number  of  days,  having 
sustained  life  by  copious  libations  of  beer  and  whis- 
key, intermixed  with  gin,  a   little  beef  tea,  milk,  and 


■|(..  2.— Male,   Forty-sij 
X  t\i  in.     Pericellular  dilatatit 


vichy,  and  occasionally  some  soft  food.  Finally, 
these  patients,  for  .some  days  before  death,  are  lying  in 
a  condition  of  coma,  with  a  little  fever,  or  else  are  ir» 
active  delirium,  with  a  considerable  degree  of  fever. 

The  conclusion  that  I  draw  from  these  conditions  is 
that  death  in  such  cases  is  not  caused  in  any  large 
degree  by  direct  poison  from  alcohol,  but  is  due  much 


December  4,  1897] 


MEDICAL    RFXORD. 


803 


more  to  e:  haustion  and  starvation,  which  probably 
lead  to  the  development  of  leucomains  or  toxic  prod- 
ucts of  some  sort,  the  result  of  the  disturbed  metab- 
olism. The  pictures,  therefore,  of  cell  degeneration 
in  persons  who  die  of  acute  alcoholism  do  not  repre- 
sent the  same  things  that  one  would  get  in  producing 
acute  and  excessive  alcoholic  poisoning  in  animals  by 
the  injection  of  massive  doses  of  the  drug. 

It  is  probable  that  the  injured  cells,  losing  their 
vitality,  throw  off  products  of  acute  degeneration. 
These  morbid  chemical  products  lead  to  a  vascular  re- 
laxation or  other  morbid  state  of  vessel  walls;  serum 
is  poured  out  for  the  purpose  of  dissolving  and  carry- 
ing away  the  products  of  cell  degeneration.  This 
process  is  a  serous  exudation,  which,  being  a  reaction  to 
an  irritant,  is  protective  to  the  organism,  and  may  there- 


t%^'.' 


Fig.  3. — Male,  Forty.  Delirium  tremens,  followed  by  "  meningitis,"  four 
days.  Cells  of  three  layers  of  mid-central  convolutions.  X  ^j  in.  Granu- 
lar degeneration  of  cell  bodies,  pericellular  infiltration,  arterlo-sclcrosis. 

fore  be  classed  as  inflammatory,  using  that  word  in  its 
broadest  sense.  If  this  serous  exudate  could  be  rapidly 
withdrawn,  .so  much  poison  would  be  taken  from  the 
system,  and  the  parts  would  heal  just  as  wlien  the  pleu- 
ral effusion  is  removed.  This  furnishes  a  certain  ra- 
tional basis  for  the  treatment  to  be  referred  to  later. 

Diagnosis — The  diagnosis  of  the  disease  is  to  be 
made  from  ordinary  suppurative  meningitis,  from  acute 
serous  meningitis  due  to  infection,  and  from  acute 
encephalitis.  In  most  cases  the  history  of  the  patient 
is  quite  sufficient  to   establish    the   diagnosis.      The 


symptoms  of  themselves  are  almost  identical  with  those 
of  ordinary  acute  suppurative  meningitis.  The  only 
distinctions  which  I  have  been  able  to  observe  are 
that  in  suppurative  meningitis  there  is  more  fever, 
there  is  less  of  the  low  delirium,  hallucinations  are 
rare,  and  there  is  an  earlier  and  more  proiound  coma. 
In  other  words,  it  is  an  acuter  and  more  severe  mal- 
ady than  alcoholic  meningitis.  The  absence  of  con- 
vulsions and  paralysis  and  the  presence  of  hyperses- 
thesia,  rigidity,  and  contracted  pupils,  as  well  as  the 
absence  of  pyre.xia,  are  usually  sufficient  to  distinguish 
the  disorder  from  encephalitis  or  encephalitis  compli- 
cated by  alcoholic  meningitis. 

Prognosis. — The  prognosis  is  bad  when  the  disease 
has  become  well  developed  with  fever  and  when  de- 
cided coma  and  rigidity  have  set  in.  Most  cases 
not  seriously  complicated  with  other  diseases  get  well. 
A  prognostic  criterium  which  I  have  long  used  and 
which  is  fairly  accurate  is  this:  if  the  patient  has  not 
a  stiff"  neck  he  will  get  well,  but  when  stiff  neck  comes 
on  the  patient  dies  in  the  majority  of  cases. 

Treatment — The  treatment  of  the  disorder  should 
be  instituted  at  the  very  beginning.  If  there  are  still 
^ny  relics  of  the  debauch,  as  shown  in  the  condition 
of  the  stomach  or  intestinal  tract,  the  stomach  should 
be  washed  out,  and  at  all  events  a  thorough  purge 
should  be  given.  The  patient  should  then  be  fed 
most  liberally  with  hot  milk  given  every  two  hours; 
beef  tea  and  an  egg  beaten  up  in  milk  may  also 
be  given,  and  the  condition  of  practical  starvation 
should  always  be  borne  in  mind.  Stimulants  in 
the  shape  of  whiskey  should  not  be  administered 
if  it  is  possible  to  avoid  them,  but  strychnine  in 
doses  of  one-sixtieth  of  a  grain  every  two  hours  is 
often  useful.  An  ice  cap  should  be  applied  to  the 
head,  and  at  times  leeches  or  large  blisters  seem  to  be 
useful  applied  to  the  back  of  the  neck.  The  patient, 
however,  should  not  be  much  depleted.  When  he  be- 
comes comatose  it  means  that  the  ventricles  and 
arachnoid  cavities  are  becoming  filled  with  water. 
At  this  time  tapping  the  spinal  cord  may  be  tried. 
I  have  done  this  in  about  fifteen  cases,  and  have  at 
times  removed  two  or  three  ounces  of  fluid  with  some 
amelioration  of  the  symptoms  and  never  any  bad  re- 
sults. In  one  case  the  patient  improved  at  once,  and 
finally  recovered.  In  the  others  improvement  was 
only  temporary. 


REPORT  OF  THE  PROGRESS  MADE  IN  THE 
TREATMENT  OF  LARYNGEAL  TUBERCU- 
LOSIS SINCE  THE  LAST  INTERNATIONAL 
CONGRESS.* 


15  V 


\V.    GLEITSMANN,    M.D., 

NEW   YORK   CITY, 


VICE-PRESIDRNT  OF  THE  LARYNGOLOGICAL  SECTION  OF  THE  INTERNATIONAL 
MEDICAL  CONGRESS  ;  1'ROFE.SSOR  OF  LARYNGOLOGY  AND  RHINOLOGY,  NEW 
YORK  POLYCLINIC  ;  CHAIRMAN  OF  THE  SECTION  OF  LARYNGOLOGY  OF  THE 
NEW  YORK  ACADEMY  OF  MEDICINE  ;  LARVNGOLOGIST  TO  THE  GERMAN 
HOSPITAL   AND   DISPENSARY,   ETC. 

When  I  was  honored  by  the  committee  of  our  section 
with  th^  request  to  open  jointly  with  Dr.  Ruault  the 
discussion  on  the  progress  in  the  treatment  of  laryn- 
geal tuberculosis,  I  was  of  the  opinion  that  it  would 
facilitate  our  work  and  enhance  tiie  value  of  our  con- 
tribution, if,  with  the  magnitude  of  the  subject  before 
us,  a  division  of  the  different  topics  could  be  arranged, 
as  in  this  case  each  of  us  could  devote  himself  en- 
tirely to  the  task  assumed,  and  unavoidable  repetitions 
would  be  obviated.  As  Dr.  Ruault  has  expressed  the 
desire  to  treat  the  subject  in   its  entirety,  I  apologize 

*  Taper  read  by  invitation  to  open  tlie  stated  discussion  on 
laryngeal  tuberculosis  in  the  section  on  laryngology  and  rhi- 
nology  of  the  Twelfth  International  Medical  Congress,  Moscow, 
August  20,  1897. 


8o4 


MEDICAL    RFXORD. 


[December  4,  1897 


beforehand  if  I  should  tread  upon  ground  already 
covered  in  his  discourse. 

It  is  my  intention  to  give  in  this  report  a  critical 
review  of  the  development  of  the  treatment  of  laryn- 
geal tuberculosis,  to  mention  in  this  connection  the 
remedial  agents  introduced  since  the  last  international 
congress,  and  to  conclude  with  remarks  on  the  surgi- 
cal treatment,  to  which  I  have  paid  attention  for  sev- 
eral years.  In  this  manner  I  hope  to  keep  my  paper 
within  reasonable  limits,  to  avoid  repeating  what  has 
already  been  said,  and  to  be  able  to  present  one  or 
two  new  contributions  to  the  treatment,  which  I  shall 
submit  to  your  consideration  and  criticism. 

The  time  is  certainly  within  the  memory  of  several 
of  us  when  laryngeal  tuberculosis  was  considered  a 
noli  me  tangcrc,  and  was  best  left  alone.  Fortunately 
this  period  has  passed  by,  never  to  return,  although 
the  results  obtained  and  our  power  to  effect  a  cure 
are  still  more  limited  than  the  exertion  and  the  devo- 
tion of  many  of  our  best  men  to  this  special  subject 
would  merit.  But  if  our  earnest  efforts  fail  some- 
times, we  must  not  forget,  as  Semon'  very  appropri- 
ately says,  when  speaking  of  the  prognosis  of  laryngeal 
tuberculosis,  that  it  is  merely  a  local  manifestation  of 
a  general  infectious  process,  and  that  we  cannot  prom- 
ise to  cure  the  latter,  even  when  successful  in  arresting 
for  a  time  the  laryngeal  complication.  On  the  other 
hand,  we  have  learned  ;  and  we  feel  justified  to  subject 
to  treatment,  and  if  necessary  to  use  energetic  means, 
patients  in  whom  we  know  beforehand  that  a  cure  is 
impossible,  but  whose  sufferings  we  feel  called  upon 
to  relieve.  The  fact  that  we  are  now  able  to  give  relief, 
even  when  we  cannot  cure,  is  certainly  in  a  great 
measure  due  to  our  modern  methods  of  treating  laryn- 
geal tuberculosis.  When  I  make  this  statement  I  do 
not  mean  to  underrate  in  the  least  the  brilliant  results, 
obtained  by  many  of  us,  which  terminated  in  a  perma- 
nent cure  of  the  laryn.\  in  a  number  of  cases  by  em- 
ployment of  different  means.  But  tiie  proportion  of 
■cases  cured  to  the  vast  number  of  sufferers  is  very 
small,  and  many  whose  larynges  ultimately  healed  suc- 
cumbed to  the  concomitant  pulmonary  disease.  Let 
us  hope  that  the  efforts  made  now  in  all  parts  of  the 
globe  to  master  the  latter  may  before  long  be  crowned 
with  success,  when  we  can  expect  that  the  number  of 
hopeless  laryngeal  cases  will  decrease  and  our  work  be 
less  subjected  to  criticism  than  it  is  at  the  present  time. 

The  tfeatment  of  laryngeal  tuberculosis  can  in  my 
opinion  be  very  properly  divided  into  three  chapters: 
the  medicinal,  the  local,  and  the  surgical,  although  a 
combination  of  two  or  of  all  three  methods  is  often  ad- 
visable and  necessary. 

As  to  the  employment  of  medicinal  agents.  I  always 
endeavored  to  improve  the  general  and  the  pulmonary 
conditions,  thereby  inliuencing  favorably  the  laryn- 
geal lesion.  I  cannot  share  the  absolute  negation  of 
the  utility  of  the  creosote  preparations,  as  stated  by 
Stoerk,-'  but  prefer  to  give  the  carbonate  combina- 
tions. I  have  seen  improvement  follow  after  the  use 
of  carbonate  of  guaiacol  and,  still  more,  benzozol, 
especially  at  the  beginning  of  the  disease.  Leav- 
ing the  other  well-known  drugs  out  of  consider- 
ation, I  have  also  tried  to  treat  a  number  of  my  pa- 
tients with  injections  of  tuberculin  and  its  products, 
and  with  serum.  The  tuberculin  injections  made 
years  ago  did  not  satisfy  me,  although  I  am  not  pre- 
pared to  deny  their  value  in  pulmonary  affections  if 
properly  used.  I  have  no  experience  with  Maragliano's 
serum,  and  the  new  tuberculin  of  Koch  is  of  too  recent 
a  date  to  allow  of  any  report  on  its  definite  value. 

Under  local  or  topical  treatment  I  understand  atom- 
ization,  inhalation,  insuftlation,  injections,  anil  pig- 
ments. The  three  agents  named  first  will  always 
retain  their  place  in  the  therapeutics  of  laryngeal  tu- 
berculosis;   and  inhalations    and    insuftlations    have 


been  for  some  time  and  are  even  now  employed  as 
curative  agents,  although  Hajeck'  says  that  he  has 
never  seen  an  ulcer  of  undoubted  tuberculous  nature 
heal  from  the  application  of  antiseptics  alone.  You 
will  spare  me  their  enumeration,  the  more  so  because 
I  have  no  new  drug  to  add  to  the  list.  Rosenberg's 
injections  of  menthol  in  olive  oil  are  known  to  all  of 
us.  Recently  Botey.'  who  began  experimenting  as 
early  as  1890,  claims  to  have  seen  improvement  from 
tracheal  injections  of  creosote  and  guaiacol  in  laryn- 
geal and  pulmonary  tuberculosis.  He  injects  a  one 
to  two  per  cent,  solution  in  olive  oil,  with  a  suitable 
syringe,  in  doses  gradually  increasing  from  three  to 
twenty  grams.  His  statement  of  the  results  obtained 
is  as  follows,  viz. :  That  in  more  than  half  the  number 
of  patients  the  pulmonary  symptoms  had  remained 
stationary,  the  expectoration  and  the  cough  had  les- 
sened, and  the  general  nutrition  had  improved.  About 
half  the  number  of  patients  he  claims  to  have  cured 
by  two  months'  treatment.  Similar  data  are  given  by 
Barton,''  who  gave  intratracheal  injections  of  ben- 
zoinol,  europhen,  and  menthol  to  ten  patients,  three  of 
whom  had  pulmonary  ])hthisis,  with  considerable  im- 
provement. I  have  also  used  these  injections,  with 
agreeable  results,  in  chronic  bronchitis  and  tracheitis, 
but  confined  myself  to  atomization  of  these  compounds 
in  laryngeal  tuberculosis,  considering  these  remedies 
less  effective  for  a  cure  than  for  an  amelioration  of 
distressing  symptoms,  which  purpose  they  fulfilled. 

Of  all  the  remedies  applied  locally  in  the  larynx, 
and  we  might  almost  say  of  all  the  means  employed 
in  the  treatment  of  laryngeal  tuberculosis,  none  enjoys 
such  universal  consensus  of  opinions  as  to  its  efficacy 
as  the  application  of  lactic  acid,  introduced  by  Krause 
in  1885;  and  it  is  gratifying  to  note  that  there  is  an 
equal  harmony  in  regard  to  the  manner  of  its  applica- 
tion, as  well  as  to  the  indications  for  it.  Scepticism 
is  for  once  subdued,  and  as  much  as  one  may  feel  dis- 
appointed in  the  value  of  a  remedy,  and  criticise  its 
indications,  which  has  proved  useful  in  another's  hand, 
Krause's  discovery  has,  to  my  knowledge,  no  opponents 
at  present. 

Similar  results  have  been  observed  from  the  use  of 
sulphoricinate  of  phenol,  which  has  found  an  ardent 
advocate  in  my  honorable  confrere,  Dr.  Ruault,'  whose 
report,  based  on  extensive  and  painstaking  studies,  is 
before  you.  I  have  nothing  to  add  to  his  remark,  ex- 
cept that  his  statements  are  supported  by  others,  among 
them  Heryng,"  who  also  found  that  it  promotes  not 
only  healing  of  tuberculous  ulcerations,  but  also  ab- 
sorption of  infiltrations. 

Another  remedy,  which  has  been  tested  by  a  number 
of  colleagues,  has  been  recommended  by  Simanowsky'' 
and  Spengler,°of  St.  Petersburg,  viz.,  parachlorphenol. 
The  former  says  that  superficial  nodules  and  ulcera- 
tions disappear  quickly  after  a  few  applications,  and 
that  deeper  ulcers  and  large  infiltrations  require  treat- 
ment of  several  months.  The  solutions  he  employs 
are  from  five  to  twenty  per  cent,  parachlorphenol  in 
glycerin,  and  he  claims  that  they  exert  their  beneficial 
inlluence  by  penetrating  into  the  depth  of  the  tissues 
themsehes.  His  views  are  corroborated  by  Spengler, 
Zinn,"'  Heddericli,"  and  others.  Zinn  praises  the  rem- 
edy very  highly  and  considers  it  an  important  addition 
to  our  therapeutic  means.  It  has  also  a  long-lasting 
an.Tjsthetic  effect  after  the  first  pain  from  the  applica- 
tioii  has  subsided.  In  the  discussion  following  Hed- 
derich's  paper,  divergent  views  were  brought  forward 
l>y  Lublinski  and  Seifert,  who  found  the  remedy  too 
painful  and  of  no  better  effect  than  creosote  or  chloride 
of  zinc.  From  a  limited  experience  I  can  testify  to 
the  efficiency  of  parachlorphenol,  but  in  a  few  cases 
the  infiltrations  would  not  yield  and  1  had  to  have 
recurrence  to  curettage. 

In  a  paper  read  before  the  American  Laryngologi- 


December  4,  1897] 


MEDICAL    RECORD. 


805 


cal  Association  at  Washington,  last  May,  Dr.  Mur- 
ray spoke  of  a  new  preparation,  called  enzymol,  as 
a  most  valuable  auxiliary  to  the  curette  and  lactic 
acid.  In  his  remarks  he  said  that  it  was  non-irritat- 
ing, and  possessed  in  a  high  degree  the  quality  of 
digesting  necrosed  tissue.  He  applied  it  to  a  large 
ulcer  upon  the  ventricular  band,  and  in  t\vent)--four 
hours  the  detritus  with  which  the  ulceration  was  cov- 
ered had  entirely  disappeared,  leaving  a  perfectly 
clean  surface,  upon  the  face  of  which  were  two  nodu- 
lar projections,  apparently  tuberculous  deposits  which 
had  not  yet  undergone  the  process  of  ulceration. 

The  last  part  of  our  subject,  the  surgical  treatment, 
IS  the  most  modern  and  radical  measure,  and  conse- 
quently more  a  subject  for  criticism  than  are  the  previ- 
ous ones.  It  comprises  different  procedures,  viz.:  i, 
Incision;  2,  curettage;  3,  submucous  injections;  4, 
electrolysis;  5,  galvano-cautery ;  6,  larj'ngotomy ;  7, 
lar}'ngectomy ;  8,  tracheotomy;  and  g,  intubation. 
The  endolaryngeal  measures,  and  of  these  the  curet- 
tage, are  naturally  of  the  greatest  interest  to  us,  and  al- 
though with  one  exception — which  will  be  stated  later 
on — no  important  new  discoveries  have  been  reported, 
as  far  as  my  knowledge  goes  the  number  of  opponents 
has  lessened,  the  indications  are  more  clearly  defined, 
and  a  better  judgment  as  to  the  results  obtainable  pre- 
vails. 

Curettage,  which  was  favorably  spoken  of  by  fifteen 
members  of  the  laryngological  section  of  the  Interna- 
tional Congress  at  Rome,  has  since  made  many  con- 
verts, and  it  is  a  source  of  great  pleasure  for  me  to  be 
able  to  say  that  it  has  also  been  more  frequently  em- 
ployed in  the  United  States  within  the  last  few  years. 
Two  years  ago  a  general  discussion  on  laryngeal  tu- 
berculosis took  place  at  the  meeting  of  the  American 
Larj'ngological  Association  in  May,'"'  when  the  reader 
was  assigned  to  speak  about  the  surgical  treatment; 
and  later,  in  July,  he  w-as  allow'ed  to  contribute  his 
mite  on  the  same  subject  before  the  British  Laryngo- 
logical Association,"  after  listening  to  the  excellent 
essays  of  Krause  and  Heryng.  From  this  time  dates 
the  greater  familiarity  of  the  American  profession 
with  surgical  treatment,  and  although  its  adoption  is 
but  slowly  progressing,  I  know,  from  personal  and 
other  communications  w-ith  medical  men  and  instru- 
ment makers  who  supply  the  instruments  in  increasing 
numbers,  that  curettage  has  taken  a  hrm  foothold  also 
in  the  Western  hemisphere. 

The  reasons  why  curettage  is  slow  to  find  general 
recognition  in  suitable  cases  are  in  my  opinion  two- 
fold: I  St,  we  are  only  too  often  confronted  with  the 
impossibility  of  eliminating  the  almost  always  concom- 
itant pulmonary  disease  to  which  ultimately  the  major- 
ity of  sufferers  succumb;  2d,  the  difficulty  of  removing 
all  the  tissue  which  is  diseased  and  of  preventing  re- 
lapses. 

As  to  the  first  objection,  the  laryngologist  is  in  the 
same  position  as  the  surgeon  in  similar  cases.  The 
latter  does  not  hesitate  now  to  excise  a  tuberculous 
articulation  without  hoping  to  cure  thereby  the  tuber- 
culous diathesis,  but  he  removes  by  his  operation  a 
constantly  threatening  focus  of  infection.  He  makes 
gastrotomy  in  cancer  of  the  pylorus  without  expecting 
to  influence  the  malignant  growth,  but  with  the  assur- 
ance that  by  the  introduction  of  nourishment  the  tor- 
tures of  starvation  will  be  avoided  and  the  patient's 
life  prolonged.  Operations  with  such  an  object  in 
view  are  not  only  justifiable,  but  also  imperative  for 
the  surgeon  as  well  as  for  the  laryngologist. 

The  second  objection,  as  to  the  difficulty  of  remov- 
ing all  the  diseased  tissue,  cannot  be  sustained  if  the 
cases  are  properly  selected.  It  is  true  that  we  often 
labor  under  the  disadvantage  of  not  being  able  to 
excise  the  tuberculous  infiltrations  until  we  reach 
healthy  tissue.     But  I  believe  that  Pieniazek."  in  his 


excellent  monograph  on  laryngotomy,  goes  too  far 
when  he  limits  curettage,  ist,  to  cases  in  which  there 
are  no  or  only  small  infiltrations  of  the  lungs;  2d,  to 
those  in  which  the  laryngeal  lesions  are  so  circumscript 
that  they  can  be  easily  and  thoroughly  removed,  at 
the  same  time  a  part  of  the  neighboring  healthy  tissue 
being  taken  away.  We  know  that  one  curettage  is 
seldom  sufficient  in  a  given  case,  and  we  should  feel 
encouraged  by  the  successful  efforts  of  Hajeck,"  who 
ultimately  cured  the  larynx  of  a  patient  after  having 
operated  endolaryngeally  twelve  times  before  the  gran- 
ulations of  the  vocal  cords  and  intra-arytenoid  region 
were  completely  removed.  In  his  paper  he  also  em- 
phasizes a  point  to  which  I  attribute  great  importance, 
viz.,  to  individualize  and  to  discriminate  in  each  par- 
ticular case  before  curettage  is  decided  upon.  Some 
patients,  he  says,  bear  cocaine  badly,  lose  their  appe- 
tite; with  others  it  is  followed  by  fever  and  general 
depression.  Rethi"'  is  of  the  same  opinion;  he  writes 
about  a  patient  with  a  moderate  infiltration  of  the 
intra-aiytenoid  fold  and  right  vocal  band,  who  became 
aphonic  two  days  after  curettage;  severe  dysphagia  set 
in,  the  wound  did  not  heal,  and  perichondritis  devel- 
oped with  subsequent  exitus.  I  had  a  similar  case  this 
spring,  in  which  I  considered  curettage  eminently  in 
place,  and  in  which  it  was  also  indicated  on  account 
of  dysphagia.  The  excision  of  the  intra-arytenoid 
region  was  easily  accomplished,  but  the  wound  cov- 
ered itself  with  a  tenacious  grayish  deposit,  which 
would  not  yield  to  local  applications;  the  suft'erings 
of  the  patient  were  increased  rather  than  lessened,  and 
his  death  was  possibly  accelerated  by  the  well-meant 
operative  interference.  It  is  extremely  doubtful  if  we 
shall  ever  be  able  to  foretell  in  each  individual  case 
the  accidents  that  may  befall  a  patient  whom  we  con- 
scientiously believed  a  fit  subject  for  curettage;  but 
by  following  the  indications  to  be  stated  we  shall  be 
guarded  in  the  majority  of  cases  against  mishaps  which 
may  otherwise  occur. 

As  to  relapses,  we  shall  not  be  able  to  forestall  them 
by  curettage,  but,  if  it  is  rightly  adopted  and  properly 
executed,  they  will  not  be  more  but  rather  less  fre- 
quent than  with  other  methods  of  treatment.  We  have 
at  present  no  remedy  which  is  an  absolute  safeguard 
against  relapses  in  so  treacherous  and  misleading  a 
disease;  but  we  are  entitled  to  hope  that  the  remedies 
which  have  promoted  absorption  of  tuberculous  infil- 
tration so  successfully  without  operative  interference 
will  also  materially  assist  in  the  elimination  of  dis- 
eased tissue  unavoidably  left  after  curettage,  as  well 
as  prevent  too  frequent  relapses. 

I  crave  your  indulgence  for  the  lengthy  remarks 
just  made,  which  contain  nothing  new  to  a  body  of 
men  such  as  I  have  the  honcr  to  address.  But  curet- 
tage has  more  adversaries  at  large  than  we  may  per- 
haps believe,  and  I  thought  it  only  right  that  a  positive 
declaration  of  its  propriety  and  utility  should  be  made 
on  this  occasion,  which,  with  the  discussion  following, 
will  have  more  weight  and  find  more  recognition  than 
when  made  in  a  smaller  circle. 

Through  the  efforts  of  many  of  our  best  men,  whose 
number  is  too  large  to  permit  naming  them,  the  in- 
dications for  curettage  are  now  more  clearly  defined 
than  they  used  to  be.  Theodor  Heryng,  your  country- 
man, whom  we  can  well  call  the  father  of  surgical 
treatment,  and  who  by  his  numerous  publications  and 
indefatigable  efforts  has  probably  contributed  more 
than  any  of  us  to  destroy  the  fallacy  of  the  incurability 
of  lar)'ngeal  tuberculosis,  has  in  two  recent  publica- 
tions" written  fully  about  the  indications  and  con- 
traindications for  curettage,  the  precaution  we  have 
to  u.se  in  its  execution,  and  the  results  we  are  entitled 
to  expect.  His  views  are  the  same  as  I  expressed  in 
my  paper  heretofore  mentioned,  with  the  only  excep- 
tion that  I  do  approve  of  curettage  as  a  measure  for 


8o6 


MEDICAL    RECORD. 


[December  4,  1897 


relief  in  advanced  phthisis,  when  the  dysphagia  is  so 
severe  as  to  prevent  the  patient  from  taking  nourish- 
ment— a  view  which  also  Krause  corroborated  in  his 
remark  before  the  British  Lar}'ngological  Association, 
1895,  giving  at  the  same  time  a  very  good  illustration 
of  its  benefit  in  a  case  of  this  nature.  I  therefore 
consider  curettage  indicated : 

1.  In  cases  of  primary  tuberculous  affections  with- 
out pulmonary  complications,  in  one  of  which  at  least 
I  prevented  the  infection  from  extending  to  the  lower 
air  passages  and  restored  the  patient  to  health  after 
a  severe  and  prolonged  struggle,  over  eight  years  ago." 

2.  In  cases  with  circumscribed  ulcerations  and 
infiltrations  of  the  larynx. 

3.  In  cases  with  dense  hard  infiltrations  of  the 
arytenoid  region  of  the  posterior  wall,  also  of  the  ven- 
tricular bands,  tuberculous  tumors  of  the  epiglottis. 

4.  In  the  incipient  stage  of  pulmonary  disease  with 
but  little  fever  and  no  hectic  symptoms. 

5.  In  advanced  pulmonary  disease  with  distressing 
dysphagia  resulting  from  infiltration  of  the  arytenoids, 
as  the  quickest  means  of  giving  relief. 

As  the  last  indication  noted  may  possibly  incur 
more  opposition  than  the  others,  I  feel  constrained  to 
state  that  it  was  always  a  great  source  of  satisfaction 
to  me  when  I  was  able  to  relieve  a  sufferer,  though  I 
knew  his  days  were  numbered,  from  the  tortures  he 
had  to  endure.  In  such  cases  I  know  of  no  procedure 
which  acts  so  rapidly  and  so  effectually  as  curettage, 
and  it  is  surprising  how  well  such  patients  bear  the 
operation  and  how-  quickly  the  wound  heals,  even  in 
an  advanced  stage  of  the  disease. 

The  contraindications  for  curettage  are: 

1.  Advanced  pulmonary  disease  and  hectic. 

2.  Disseminated  tuberculosis  of  the  larynx. 

3.  E.xtensive  infiltrations  producing  severe  stenosis, 
when  tracheotomy  is  indicated,  or  laryngotomy  can  be 
taken  into  consideration. 

I  fully  agree  with  Heryng  not  to  advise  the  opera- 
tion in  timid,  disti'ustful  patients  lacking  the  neces- 
sary nerve  power,  and,  like  him,  prefer  to  operate  on 
the  patient  in  a  ho.spital,  where  he  is  under  absolute 
control  and  the  after-treatment  can  be  carried  out  more 
satisfactorily. 

The  technique  of  the  operation  has  been  greatly  fa- 
cilitated by  Heryng's  rotary  double  curette,  which, 
although  published  before  the  last  international  con- 
gress," ought  not  to  be  left  unmentioned  in  a  treatise 
on  this  subject.  Dr.  Gougenheim  constructed  an  in- 
strument which  he  called  " cwporfe  pil-ce"  which, 
being  larger  than  Krau.se's  curettes,  enables  him  to 
remove  a  greater  amount  of  tissue.  The  instrument 
is  mentioned  in  his  report  at  the  last  congress. 

Two  years  ago,  at  London,  Heryng  spoke  at  length 
about  the  details  of  the  technique  of  curettage,  and 
.showed  elaborate  drawings,  which  by  his  permission 
I  present  to  the  section.  They  are  so  well  executed 
and  so  plain  in  their  conception  that  I  deem  further 
remarks  unnecessary. 

Of  the  other  surgical  measures  there  are  only  a  few 
about  which  I  shall  make  some  comment.  Submucous 
injections  of  lactic  acid  gave  me  satisfactoiy  results 
in  a  number  of  cases  in  which  curettage  was  either 
objected  to  or  considered  inappropriate.  Only  two 
months  ago  I  was  spared,  in  all  probability,  a  disa- 
greeable experience  by  a  submucous  injection  while 
preparing  a  patient  for  curettage.  I  intended  to  use 
the  double  curette  and  to  excise  both  arytenoid  regions, 
of  which  the  right  one  was  slightly  ulcerated  and  felt 
softer  to  the  touch  of  the  cotton  carrier  when  applying 
cocaine  than  the  left  one.  As  a  number  of  applica- 
tions did  not  produce  the  desired  local  anaesthesia,  I 
injected  cocaine  with  a  laryngeal  syringe  into  the 
right  arytenoid  swelling,  when  a  continuous  and  pro- 
longed   hemorrhage    followed.     I    naturally    desisted 


from  curettage,  and  injected  in  both  sides  a  fifty-per- 
cent, solution  of  lactic  acid.  The  result  was  that  the 
hard  dense  left  portion  sloughed  away  almost  com- 
pletely after  a  week,  leaving  a  healthy  surface,  and  the 
right  arytenoid  meanwhile  became  smaller  and  firmer 
and  allowed  curettage  without  any  untoward  accident, 
greatly  to  the  relief  of  the  patient,  who  had  not  swal- 
lowed solid  food  for  several  weeks  previously. 

Dr.  Chappell,  of  New  York,  has  used  the  creosote 
treatment  in  his  clinic  during  the  last  two  years  in  the 
form  of  sprays,  pigments,  and  submucous  injections. 
For  the  latter  he  uses  wintergreen  and  castor  oil  as  a 
vehicle,  in  the  proportion  of  one  drachm  of  creosote 
to  the  ounce,  which  he  injects  with  an  automatic 
syringe  devised  by  himself,  and  which  I  present  for 
your  inspection.  His  results  are  embodied  in  two 
reports,'""  which  he  supplemented  by  a  verbal  commu- 
nication as  follows:  Of  the  first  series  of  seven  pa- 
tients, four  are  alive;  of  the  second  series  of  thirty- 
two  patients,  eight  are  alive;  including  the  four  of  the 
first  series,  ten  had  relapses,  five  died,  and  nine  were 
lost  sight  of.  Of  twelve  patients  seen  after  publica- 
tion of  his  reports,  one  had  a  considerable  ulceration 
of  the  larynx  which  healed  entirely,  five  showed  marked 
improvement,  of  two  he  has  no  further  information, 
and  five  lost  the  improvement  previously  gained.  As 
I  have  not  practised  the  local  creosote  treatment,  I 
have  no  personal  experience  and  must  confine  myself 
to  reporting  what  has  been  communicated  to  me. 

To  the  subject  of  electrolysis  belongs  cataphoresis, 
which  I  have  to  offer  as  a  new  contribution  to  the 
treatment  of  laryngeal  tuberculosis,  by  Dr.  Scheppe- 
grell,"'  of  New  Orleans.  Last  May,  after  having  tried 
several  substances,  he  finally  decided  to  use  electrodes 
made  of  chemically  pure  copper,  finding  that  the  oxy- 
chloride  of  copper  is  a  salt  possessing  marked  germi- 
cidal properties,  while  exerting  at  the  same  time  a 
stimulating  effect  on  the  pathological  tissues.  A  five- 
per-cent.  spray  of  cocaine  is  sufficient  for  local  anaes- 
thesia, the  current  must  be  weak  (rarely  over  five 
niilliamperes),  and  the  copper  electrode  is  to  be  con- 
nected with  the  positive  pole,  the  negative  pole  with 
a  large  dispersing  electrode  to  the  neck.  The  appli- 
cations are  made,  as  a  rule,  every  second  day.  To 
obviate  laceration  of  the  tissues  during  movements  of 
the  larynx  and  to  prevent  infections  by  punctures  made 
by  needles,  he  constructed  spherical  electrodes,  which 
he  found  efficient  for  cataphoresis,  and  when  properly 
applied  to  occasion  no  pain,  irritation,  or  reaction. 
I  brought  the  instruments  with  me,  and  offer  them  to 
you  for  inspection.  Scheppegrell  found  autoscopy  a 
valuable  help  when  applying  cataphoresis,  and  claims 
for  the  latter : 

1.  That  there  is  no  real  destruction  of  the  tissues 
or  lacerations  of  the  surfaces. 

2.  That  there  is  absolutely  no  reaction,  no  hemor- 
rhage. 

3.  That  this  method  does  not  demand  the  high  de- 
gree of  skill  required  for  curettage,  and  is  especially 
simple  when  used  with  the  autoscope. 

4.  That  it  is  applicable  in  all  cases  of  laryngeal 
tuberculosis. 

Scheppegrell  gave  in  his  paper  the  history  of  three 
patients  treated  with  cupric  cataphoresis,  to  which 
he  added  four  more  cases  in  a  letter  to  the  writer, 
dated  June  ist.  All  his  patients  had  pulmonary  com- 
plication. In  three  cases  the  treatment  had  to  be 
discontinued  on  account  of  tlie  advanced  stage  and 
weak.iess  of  the  p.itient.  In  two  recent  cases  the 
ulcer ition  and  infiltration  of  the  arytenoid  region 
subsided  and  the  dysphagia  was  relieved.  The  first 
patient  he  treated  was  similarly  affected,  but  after  seven 
applications  he  was  so  much  improved  that  he  w'ent 
into  the  country,  from  which  he  returned  after  six 
weeks  with  his  pulmonary  trouble  aggravated,  but  with 


December  4,  1897] 


MEDICAL    RECORD. 


807 


no  recurrence  of  laryngeal  ulceration.  His  third  pa- 
tient suffered  for  seven  months  from  tuberculous  laryn- 
gitis, and  had,  in  addition  to  ulceration  and  infiltra- 
tion of  the  arytenoid  region,  also  tumefaction  of  the 
epiglottis.  After  eleven  applications  the  ulcerations 
had  entirely  healed,  enabling  the  patient  to  take  solid 
food  without  pain,  and  eight  weeks  later,  with  biweekly 
applications,  the  infiltrations  also  had  disappeared. 
The  improvement  was  lasting,  and  was  verified  six 
months  later,  when  the  larynx  showed  no  return  of  the 
previous  disease. 

The  number  of  cases  is  too  limited  and  the  time  of 
observation  too  short  to  allow  a  definite  opinion  of 
the  value  of  this  method.  But  its  application  is  sim- 
ple and  the  results  are  sufficiently  encouraging  to 
merit  further  investigation  and  trial. 

Larygotomy  and  tracheotomy  in  laryngeal  tubercu- 
losis have  been  the  subject  of  two  essays  which  de- 
serve a  passing  notice.  Crepon"-  has  collected  seven- 
teen cases  of  laryngotomy  from  the  literature,  to  which 
two  have  to  be  added,  published  by  Lohoft',"  and  two 
performed  by  Pieniazek.'  Four  of  Crepon's  patients 
became  worse  after  the  operation;  four  were  tempo- 
rarily relieved  from  their  sufferings  but  ultimately 
died  from  the  pulmonary  disease ;  seven  experienced 
remarkable  improvement  of  their  ailment  and  also  of 
their  general  condition;  one  patient,  operated  upon 
by  Hopmann,  was  still  able,  after  eleven  years,  to 
preach  in  a  loud  although  somewhat  hoarse  voice.  In 
one  of  the  two  cases  reported  by  Lohoff  the  patient 
died  immediately  after  the  operation;  the  other,  with 
infiltration  of  both  lungs,  was  in  fair  health  three 
years  after  the  operation.  Of  Pieniazek's  patients  one 
died  five  days  after,  the  other  eighteen  months  after  the 
operation.  The  latter  considers  laryngotomy  indicated 
when  the  lesions  are  localized  in  the  region  of  the 
glottis,  therefore  in  affections  of  the  vocal  cords,  of 
the  arytenoid  regions,  and  especially  of  the  subglottic 
space.  As  he  says  that  laryngotomy  ought  to  be  made 
only  in  a  relatively  good  condition  of  the  lungs,  the 
number  of  suitable  cases  will  naturally  remain  small, 
as  we  see  unfortunately  a  well-developed  pulmonary 
disease  in  the  majority  of  our  patients. 

In  his  treatise  on  tracheotomy  Lohoff  does  not  con- 
sider it  a  curative  measure,  nor  does  he  approve  of  it 
being  made  only  as  a  last  resource.  He  coincides 
with  the  generally  accepted  view  that  it  is  indicated 
in  stenosis  and  dyspncea,  but  in  such  cases  without 
reference  to  the  pulmonary  condition. 

If,  in  conclusion,  we  allow  all  that  has  been  said  to 
pass  in  review  before  our  mind,  we  are  compelled  to 
acknowledge  that  during  the  last  few  years  not  only 
satisfactory  progress  in  the  treatment  of  laryngeal 
tuberculosis  has  been  made,  but  also  that  in  many 
directions  diligent  efforts  are  being  made  to  overcome 
our  deficiencies  and  to  improve  our  methods.  But  let 
us  at  the  same  time  keep  in  mind  the  well-meant  words 
of  Kuttner,  viz.,  that  by  laryngotomy  we  can  very  well 
recognize  laryngeal  tuberculosis  in  its  initial  stage, 
but  that  we  seldom  see  a  patient  at  the  commence- 
ment of  the  disease.  When  the  necessity  of  an  early 
interference  shall  be  more  fully  accepted,  when  the 
better  results  obtained  at  this  stage  shall  be  more  gen- 
erally recognized,  then  also  the  laryngologist  will  find 
his  task  easier,  and  earn  with  greater  satisfaction  to 
himself  the  well-deserved  rewards  for  his  labors. 

REFERENCES. 

1.  Semon,  F.:  A  Clinical  Lecture  on  Laryngeal  Tubercu- 
losis.     Clinical  Journal,  January  3  and  10,  1894. 

2.  Stoerk;  Ueber  die  Kreosottherapie  bei  Tuberculose  des 
Kehlkopfs  und  der  Lungen.  Archiv  fUr  Laryngologie,  Bd.  i., 
Heft  2,  p.  208. 

3.  Hajeck,  M.:  Die  locale  Behandlung  der  Kehlkopftuber- 
culose.  Centralbl.  fur  die  gesammte  Therapie,  Wien,  1895, 
vol.  .\iii. ,  p.  127. 


4.  Botey,  R.:  Les  Injections  Tracheales  de  Creosote  et  de 
Guaiacol  dans  la  Tuberculose  Laryngo-Pulmonaire.  Anal,  des 
Mai.  d.  Oreilles,  Janvier,  1897.  p.  26. 

5.  Barton :  Diseases  of  the  Trachea,  Bronchi,  and  Lungs 
Treated  by  Intratracheal  Injections.  Medical  Record,  August 
I,  1896. 

6.  Ruauk  :  Le  Phenol  Sulforicine  dans  la  Tuberculose  Laryn 
gee.      Paris,  G.  Masson,  1895. 

7.  Heryng  :  Ueber  Phenolum  sulforicinicum  und  seine  An, 
wendung  bei  tuberculosen  und  chronischen  Erkrankungen  des 
Rachens,  des  Kehlkopfs  und  der  Nase.  Therapeut.  Monats- 
hefte,  November  3,  5,  7,  1S96. 

8.  Simanowsky  :  Ueber  die  Behandlung  phthisischer  und  an- 
derer  Erkrankungen  der  obern  Luftwege  mit  Ortho-  und  Para- 
chlorphenol.     Therapeut.  Monatshefte,  No.  8,  1894. 

9.  Spengler  :  Archives  des  Sciences  Biologiques,  St.  Peters- 
burg, torn,  iv.,  vol.  i.,  May,  1895. 

10.  Zinn  ;  Ueber  die  Behandlung  tubercul.  Kehlkopfserkran- 
kungen  mit  Parachlorphenol.  Charite-Annalen,  Berlin,  1896, 
p.  204. 

n.  Hedderich  :  Klinische  Erfahrungen  iiber  Paramonochlor- 
phenol  bei  Larynxphthise.  Munch,  med.  Wochensch.,  i8g6, 
p.  749- 

12.  Gleitsmann  :  Transactions  of  the  American  Laryngologi- 
cal  Association,  1895,  p.  132. 

13.  Gleitsmann  :  Transactions  of  the  British  Laryngological, 
Rhinological,  and  Otological  .\ssociation,  1895,  pp.  71-8S. 

14.  Pieniazek  ;  Ueber  die  Laryngofissur  auf  Grundlage  eigener 
Erfahrung.      Deut.  Zeitschrift  fiir  Chirurgie,  vol.  xxxvi.,  p.  342. 

15.  Hajeck  ;   L.c. 

16.  Rethi,  L.:  Bemerkungen  zur  chirurgischen  Behandlung 
der  Kehlkopftuberculose.  Wiener  klinische  Wochenschrift, 
1S95,  p.  738. 

17.  Heryng:  Result  of  the  Surgical  Treatment  of  Laryngeal 
Phthisis,  Based  on  Two  Hundred  and  Fifty-two  Cases.  Journal 
of  Laryngology,  August  and  September,  1893  ;  April,  May,  and 
August,  1S94.  Also;  Fernere  Beitrage  zur  chirurgischen  Be- 
handlung der  Larynxphthise.  Klinische  Zeit-  und  Streitfragen, 
Wien,  1894,  Band  viii..  Heft  2. 

1 8.  Gleitsmann  :  Ein  Fall  von  geheilter  primarer  Pharynx- 
tuberculose.  Verhandl.  des  loten  Internal.  Congresses,  Band 
4,  .Vbtheilung  12,  p.  151. 

19.  Heryng  ;  Eine  drehbare  Universalcurette  fUr  endolaryn- 
geale  Operationen.      Therapeutische  Monatshefte,  July,   1S93. 

20.  Chappell :  The  Treatment  of  Laryngeal  Tuberculosis  by 
the  Application  and  Submucous  Injection  of  Creosote.  New 
Vork  Med.  Jour.,  March  30,  1895.  Also:  Observations  on  the 
Creosote  Treatment  of  Tuberculosis  of  the  Upper  Air  Passages. 
Ibid.,  May  9,  1896. 

21.  Scheppegrell,  W.:  The  Treatment  of  Laryngeal  Tuber- 
culosis with  Cupric  Interstitial  Cataphoresis,  with  Report  of 
Cases.     Medical  Record,  May  29,  1897. 

22.  Crepon,  Ernst  ;  Die  Behandlung  der  Larynxtuberculose 
durch  Laryngofissur.     Marburg,  1S94. 

23.  Lohoff,  B. ;  Ueber  Tracheotomie  bei  Larynxtuberculose. 
Wurzburg,  Scheiner,  1894. 

24.  Pieniazek  :   L.c. 


ON     THE     MICROSCOPICAL     EXAMINATION 
OF    BACTERIA,    ETC. 

By  HENRY  G.    PIFFARD,    M.D., 

PROFESSOR   OF  DERMATOLOGY,    NEW  YORK  UNIVERSITY. 

DtJRiNG  a  conversation  recently  held  with  one  of  our 
most  eminent  bacteriologists  he  expressed  himself 
substantially  as  follows:  "Bacterial  investigation  has 
about  reached  its  limit.  We  may  discover  more  spe- 
cies and  doubtless  will,  but  I  do  not  see  how  we  are 
to  find  out  anything  more  about  those  known  at  pres- 
ent, unless  some  one  will  discover  or  invent  new  or 
improved  methods  of  investigation." 

In  the  systematic  examination  of  bacteria  as  usually 
conducted  at  the  present  day,  it  must  be  admitted  that 
the  culture  tube  and  the  plate  take  precedence  over 
the  microscope.  Prepare  a  slide  in  the  ordinary  way 
and  submit  it  to  a  professed  bacteriologist,  and  he  will 
tell  you  at  a  glance  through  the  microscope  whether  it  is 
a  coccus,  a  bacillus,  a  merista,  a  sarcina,  or  a  — thrix. 
He  will  also  tell  if  it  is  a  streptococcus,  or  a  staphy- 
lococcus, or  a  diplococcus,  but  beyond  that  he  will 
hardly  venture,  except  in  the  ca.se  of  a  limited  num- 
ber of  micro-organisms  with  specially  characteristic 
morphological  peculiarities.  If  you  press  him  for  a 
diagnosis  he  will  say:  "Give  me  some  of  the  fresh 
material  and  let  me  make  plates  and  tubes,  and  I  can 


8o8 


MEDICAL    RECORD. 


[December  4,  1897 


then  tell  you  what  it  is;"  and  his  diagnosis  will  be 
based  more  on  the  macroscopical  appearance  of  the 
cultures  than  on  the  microscopical  appearance  of  the 
organism.  Occasionally  differential  staining  and  de- 
colorizing methods  will  assist  the  observer  in  arriving 
at  a  decision  as  to  the  particular  species  under  exami- 
nation. 

While  the  bacteriologists  have  exhibited  the  most 
persevering  efforts  in  perfecting  some  of  the  details  of 
their  art,  and  great  ingenuity  in  devising  apparatus 
and  other  aids  in  their  work,  they  appear  in  the  main 
to  have  neglected  one  important  side  of  the  question 
■ — namely,  the  optical  one. 

The  usual  routine  as  practised  in  college  and  other 
public  laboratories  is  to  make  the  smear  on  the  cover 
glass  (sometimes  wrongly  on  the  slide),  fix  and  stain 
it,  and  then  examine  the  mount  in  water,  cedar-oil,  or 
balsam,  using  for  the  purpose  a  Jj"  homogeneous  im- 
mersion objective  and  an  Abbd  condenser,  with  day- 
light illumination.  If  asked  why  they  do  not  adopt 
better  methods,  some  will  reply  that  they  did  not  know 
there  was  any  better  way.  "  This  is  tlie  way  the  books 
tell  you,  and  this  is  the  way  they  do  it  in  Germany." 
Others  will  say:  "Oh,  life's  too  short;  haven't  time  to 
learn  better  methods,  even  if  there  are  any.  All  I  care 
about  is  to  be  able  to  tell  a  tubercle  or  some  other 
bacillus  when  I  see  it,  and  I  can  do  that  now."  Ex- 
ceptionally there  are  men  who  would  do  better  if  they 
knew  how,  but  whose  lack  of  familiarity  with  the  ele- 
mentary principles  underlying  the  microscopic  art 
stands  in  their  way. 

To-day  there  are  twenty-five  men  using  the  micro- 
scope where  there  was  one  twenty-five  years  ago,  yet 
the  average  skill  in  microscopy  possessed  by  the 
present-day  workers  is  decidedly  below  that  of  their 
predecessors.  That  is  to  say,  in  former  times  there 
was  a  much  larger  proportion  of  workers  who  thor- 
oughly understood  the  capacity  and  possibilities  of 
the  instrument  than  we  find  to-day.  The  mere  fact 
that  a  man  works  six  or  eight  hours  daily  with  the 
microscope  does  not  necessarily  imply  that  he  is  a 
skilful  microscopist,  and  when  the  work  is  of  routine 
character  and  of  limited  scope  it  tends  to  retard  rather 
than  to  advance  the  acquirement  of  special  skill  in  the 
use  of  the  instrument.  A  man  may  drive  a  garbage 
cart  for  ten  years,  going  daily  over  the  same  route, 
but  though  he  may  be  able  to  guide  his  horse  through 
the  street  without  collision  or  other  accident  there  is 
little  in  his  occupation  that  tends  to  make  him  a  skil- 
ful horseman,  in  the  proper  acceptation  of  this  term. 

Before  the  invention  of  the  homogeneous  immersion 
lens,  the  value  of  wide  angle  and  high  aperture  was 
fully  appreciated  by  intelligent  and  observant  work- 
ers, although  the  exact  relationship  of  aperture  to  per- 
formance was  not  properly  understood  until  made  clea'- 
through  the  labors  and  researches  of  Abbe. 

In  the  construction  of  dry  lenses  of  wide  angle, 
America  twenty-five  years  ago  stood  in  the  van,  witli 
Charles  A.  Spencer  as  its  leading  exponent.  On 
nearly  a  par  with  him  were  Robert  Tolles  and  Wil- 
liam Wales.  In  water-immersion  len.ses,  England, 
represented  by  the  firm  of  Powell  &  Lealand,  was  in 
the  lead.  The  American  makers  were  close  seconds, 
and  Hartnack  in  Paris  stood  next.  The  German  ob- 
jectives were  but  little  esteemed,  and  at  even  the  pres- 
ent day,  so  far  as  dry  lenses  are  concerned,  they  do 
not  compare  favorably  with  the  best  American  and 
English  work. 

Before  the  invention  of  the  homogeneous  immersion 
lens,  workers  with  wide-angle  dry  and  water-immer- 
sion objectives  found  it  necessary  to  possess  and  em- 
ploy a  certain  degree  of  skill  in  the  management  of 
their  tqols,  and  microscopy  was  tridy  an  art  requiring 
the  exercise  of  the  intellectual  faculties  as  well  as 
mere   manual   manipulation.     The    invention    of   the 


homogeneous  or  oil-immersion  objective  and  the  Abb^ 
condenser  have  changed  all  this,  and  microscopy  as 
generally  practised  at  the  present  day  is  little  more 
than  a  purely  mechanical  operation;  and  we  need  not 
therefore  be  surprised  that  there  are  large  numbers  of 
men  using  the  instrument  daily  who  have  not  the  re- 
motest conception  of  the  true  capacities  of  the  instru- 
ment or  of  the  proper  means  of  developing  them  to  the 
utmost.  Place  a  high-grade  dry  lens  (say,  one  of  4  or 
3  mm.  equivalent  focus,  and  a  numerical  aperture 
above  0.90)  in  the  hands  of  one  of  these  men  and  he 
is  absolutely  helpless.  He  may  by  the  veriest  chance 
obtain  a  correct  image  of  the  object  under  examina- 
tions, but  the  proljabilities  of  his  doing  so  are  very 
slight  indeed. 

Three  or  four  years  ago  a  gentleman  who  was  an 
instructor  in  pathological  histology  in  one  of  the  lab- 
oratories of  this  city  brought  me  a  photomicrograph, 
saying  that  it  did  not  suit  him,  but  he  did  not  know 
what  the  matter  was.  A  glance  at  the  picture  revealed 
an  intensely  undercorrected  image,  and  I  told  my 
friend  that  he  had  been  using  a  very  poor  lens. 
"Why,"  said  he,  "that  cannot  be.  I  used  a  Zeiss  4 
mm.  apochromatic,  and  the  object  was  carefully- 
mounted  with  a  very  thin  cover."  I  then  asked :  "  What 
was  the  position  of  the  screw  collar?'"  He  did  not 
qurte  understand  my  question,  but  after  some  explana- 
tion admitted  that  he  did  not  know  what  the  adjust- 
able collar  was  for,  or  how  to  use  it,  but  that  he 
always  screwed  it  up  tight  and  used  it  that  way.  In 
his  ordinary  work  he  always  used  the  shortest  possible 
tube  length,  as  it  didn't  make  him  stretch  his  neck  up 
so  far  to  look  into  it,  "  except  when  I  want  to  magnify 
a  little  more,  and  then  I  pull  it  out  farther."  There 
are  just  three  ways  in  which  one  may  obtain  an  under- 
corrected  and  untruthful  image  with  a  well-made 
high-grade  dry  lens.  These  are  using  too  short  a 
tube  length,  using  too  thin  a  cover  glass,  and  bringing 
the  middle  and  posterior  systems  of  the  objective  into 
too  close  approximation. 

Now  in  the  particular  instance  here  stated,  the  oper- 
ator had  succeeded  in  producing  undercorrection  in 
all  three  ways,  and  in  fact  had  almost  exhausted  the 
possibilities  in  this  direction  in  the  falsification  of 
the  image.' 

How  many  microscopical  workers  are  there  at  the 
present  day  who  take  the  pains  to  use  cover  glasses 
corresponding  in  thickness  to  the  corrections  of  the 
objectives?  How  many  adjust  the  tube  length  prop- 
erly; and  how  many,  if  they  happen  to  possess  an 
adjustable  objective,  know  how  to  use  it? 

Reverting  to  our  first  paragraph  in  reference  to  new 
and  improved  methods  of  investigation,  we  may  well 
ask  when  will  such  methods  be  discovered?  Possibly 
to-morrow — perhaps  not  for  years.  In  the  mean  time 
would  it  not  be  well  to  utilize  all  means  now  known 
to  science,  whereby  better  images  may  be  obtained 
tlian  those  now  commonly  displayed? 

If  we  desire  to  accomplish  this  we  must  consider: 
(i)  the  illumination  ;  (2)  tiie  condenser;  (3)  the  ob- 
jective; (4)  the  slide  and  cover;  (5)  the  mounting 
medium;  (6)  the  method  of  mounting  and  staining; 
(7)  the  immersion  medium.  To  obtain  the  very  best 
results  the  microscopical  worker  must  avail  himself 
of  each  and  every  aid  that  will  contribute  its  factor 
toward  the  perfection  of  the  image  and  consequent 
accuracy  of  delineation. 

Illumination — liefore  the  invention  of  the  Abb^ 
condenser  and  at  a  time  when  achromatic  condensers 
were  few  and  far  between,  the  concaxe  mirror  was  the 
only  available  means  of  condensing  the  light  on  the 
object  under  examination.  The  curvature  of  the  mir- 
ror was  usually  such  that  parallel    light  was  focussed 

'  I'or  fiirtliLT information  concerning  undercorrection,  sec  Medi- 
cal Rfaoru.  October  17,  1S96.  p.  545. 


December  4,    1897] 


M 


EDICAL    RECORD 


on  the  object,  the  mirror  being  permitted  to  move  up 
and  down  on  the  bar,  to  allow  for  variations  in  the 
thickness  of  the  slide  on  which  an  object  was  mounted. 
If  daylight  was  used,  the  light  reflected  from  a  white 
cloud  gave  much  finer  results  than  light  coming  from 
a  pure  blue  unclouded  sky.  The  difference  is  so  no- 
ticeable that  some  microscopists  sought  to  imitate  the 
cloud  lighting  by  having  mirrors  made  from  plaster 
of  Paris  or  porcelain,  to  be  used  with  a  blue  sky.  If 
artificial  light  is  used,  it  is  necessary  to  have  either  a 
mirror  of  shorter  focus  or  to  use  a  bull's  eye  between 
the  lamp  and  the  mirror;  otiierwise  the  light  will  be 
focussed  considerably  above  the  object  and  false  dif- 
fraction lines  may  be  more  or  less  evident. 

The  Abbe  condenser  now  in  almost  universal  use  is 
certainly  an  immense  improvement  over  the  simple 
mirror,  and  this  with  ordinary  daylight  constitutes  the 
customary  laboratory  illumination.  Good  daylight, 
especially  the  white-cloud  sort,  leaves  little  to  be  de- 
sired for  low  and  medium  powers,  but  the  variability 
of  daylight  on  different  days  and  at  different  hours 
of  the  day  is  a  serious  objection  to  its  use  with 
high  powers,  if  we  seek  to  obtain  the  best  optical  re- 
sults. For  the  finest  work  one  should  discard  daylight 
and  the  "  Abb^,"  and  use  artificial  light  with  an  achro- 
matic condenser.  For  ordinary  work  I  know  of  noth- 
ing better  or  more  convenient  than  an  incandescent 
electric  lamp  with  frosted  bulb,  giving  a  pure  white 
yet  soft  light  agreeable  to  the  eye,  and  strongly  imi- 
tating in  its  effects  good  white-cloud  illumination. 
Gas  and  oil  lamps  of  the  Argand  type  of  construction 
are  extremely  undesirable,  as  they  give  a  large  amount 
of  diffuse  light,  accompanied  at  the  same  time  by  an 
uncomfortable  degree  of  heat.  The  VVelsbach  and 
similar  mantle  lamps  are  still  more  objectionable. 
With  lamps  of  this  character  it  is  not  possible  to  ob- 
tain the  finest  resolutions  of  delicate  structures,  and 
all  of  them  should  be  discarded  as  sources  of  illumi- 
nation for  the  microscope.  If  kerosene  oil  is  em- 
ployed, the  best  lamp,  especially  for  high-power  work, 
is  one  with  half-inch  wick  mounted  in  the  focus  of  a 
bull's-eye  lens,  and  with  the  narrow  edge  of  the  flame 
presented  to  the  microscope.  The  lamp  should  be 
mounted  so  that  it  may  be  raised  or  lowered  and  tilted 
when  necessary.  Still  better  is  the  electric  lamp  with 
short  straight  filament,  described  by  me  some  years 
ago.'  With  such  lamps  results  can  be  obtained  greatly 
superior  to  any  possible  witli  daylight.  Acetylene 
gas,  however,  gives  promise  of  proving  an  almost  ideal 
source  of  illumination,  and  will  doubtless  come  into 
extensive  use  as  soon  as  a  lamp  is  made  with  good 
mechanical  features,  and  we  can  be  reasonably  sure 
that  the  lamp  will  not  explode  at  some  inopportune 
moment. 

The  character  of  the  substage  condenser  is  of  the 
utmost  importance.  The  chromatic  or  "  Abbe"  con- 
denser is  a  cheap  makeshift.  It  is  certainly  better 
than  no  condenser  at  all,  and  with  daylight  answers 
reasonably  well.  These  condensers  are  made  by  every 
optician,  and  as  they  consist  of  either  two  or  three 
simple  crown-glass  lenses  there  should  be  little  differ- 
ence in  the  products  of  the  different  factories.  There 
is,  however,  a  good  deal  of  difference.  The  N.  A.  1.20 
and  N.  A.  1.40  of  Zeiss  are  the  best  I  have  ever  used. 
The  N.  A.  1.20  of  Leitz  is  good,  but  I  cannot  say  as 
much  of  the  N.  A.  1.40  of  the  same  make. 

.\  well-corrected  achromatic  condenser,  however,  is 
to  be  greatly  preferred  to  an  "  .\bb^."  At  least  two 
of  these  should  be  at  the  command  of  the  microscopist 
— that  is,  one  of  N.  A.  i  for  low  and  medium  power 
work,  and  one  of  N.  A.  1.30  or  1.40  for  use  with  im- 
mersion lenses.  The  N.  A.  i  achromatic  will  give  a 
larger    aplanatic  cone    of    light  than  the  N.  A.  1.20 

'  New  York  Medical  Journal,  July  16,  1892;  Medical  Kf.cord, 
May  4,  1895. 


"Abbe',"  and  is  for  this  and  other  reasons  to  be  pre- 
ferred. The  N.  A.  1.30  or  1.40  achromatic  will  fill 
the  most  exacting  demands  of  the  best  modern  objec- 
tives. It  should  be  understood,  of  course,  that  the 
apertures  referred  to  exist  only  when  the  condenser  is 
in  oil-immersion  contact  with  the  lower  surface  on  the 
slide.  If  used  dry,  the  aperture  is  very  much  less  and 
the  results  are  not  so  good. 

In  bacteriological  work  the  oil-immersion  lens  is 
almost  universally  employed,  and  one  with  a  numeri- 
cal aperture  of  1.30  is  perhaps  the  favorite.  For 
purely  clinical  and  diagnostic  work  an  immersion  lens 
is  in  most  instances  unnecessary,  as  the  characteristic 
features  of  even  the  tubercle  bacillus  can  be  readily 
made  out  with  a  high-grade  dry  lens  of  one-eighth  or 
one-tenth  inch  equivalent  focus.  No  lens  of  the  focus 
referred  to  with  an  N.  A.  lens  less  than  .90  should  be 
ranked  as  high  grade,  and  should  always  be  furnished 
in  an  adjustable  mount.  The  greater  the  numerical 
aperture,  the  more  sensitive  is  the  lens  to  cover-glass 
thickness.  Lenses  of  this  description  are  not  in  very 
common  use,  and  for  two  reasons.  In  the  first  place 
they  are  expensive,  and  secondly  the  great  majority  of 
microscopical  workers  do  not  know  how  to  correct  a 
lens  for  cover-glass  thickness  and  will  not  take  the 
trouble  to  learn.  If  they  happen  to  possess  an  adjust- 
able lens  they  use  it  with  covers  of  varying  thickness, 
at  perhaps  either  the  open  or  closed  point;  are  dis- 
satisfied with  the  result,  and  continue  their  work  with 
the  cheap  but  inferior  German  lenses. 

Bausch  &  Lomb  make  an  excellent  dry  J"  adjusta- 
ble objective  with  an  aperture  of  .92.  The  price 
seems  very  high  in  comparison  with  a  Leitz  of  the 
same  focus  with  an  aperture  of  .85.  Those  who  count 
the  cost  will  buy  the  latter,  while  those  who  desire  a 
distinctly  superior  performance  and  possess  the  skill 
to  manipulate  the  lens,  will  doubtless  prefer  the  former. 
With  such  a  lens  nine-tenths  of  routine  bacteriologi- 
cal work  can  be  done  in  a  very  satisfactory  manner. 
It  should  be  remembered,  however,  that  with  the  high 
aperture  of  this  lens  the  working-distance  is  neces- 
sarily small.  Bacteriological  mounts  may  be  made 
on  covers  not  exceeding  .17  mm.,  but  for  histological 
sections  thinner  covers  should  be  used.  The  objective 
referred  to  is  corrected  for  a  tube  length  of  216  mm., 
which  is  a  desirable  mean  between  the  inconveniently 
long  English  (250  mm.)  and  the  unnecessarily  short 
German  (Leitz,  170  mm.;  Zeiss,  160  mm.)  tubes. 

For  research  work  immersion  lenses  of  the  highest 
possible  aperture  should  be  employed.  Zeiss,  and 
Powell  &  Lealand  offer  objectives  of  N.  A.  1.40,  but 
in  both  of  these  instances  the  front  lens  is  not  very 
securely  fastened  in  the  mount.  Bausch  &  Lomb  and 
Spencer  quote  lenses  with  N.  A.  1.42,  and  repeated 
measurements  have  shown  me  that  the  claimed  aper- 
ture is  fully  realized,  and  I  have  never  known  of  the 
displacement  of  the  front  lens  in  either  of  these  makes. 
Powell  &  Lealand  also  construct  an  oil-immersion  ob- 
jective with  an  aperture  of  1.50,  and  Zeiss  a  mono- 
bromide  immersion  with  an  aperture  of  1.63,  but  this 
latter  requires  special  flint-glass  slides  and  cover 
glasses,  which  are  expensive,  costing  two  marks  apiece 
for  the  slides  and  one  mark  for  the  covers.  Some  ad- 
justable oil  immersions  will  also  work  with  mono- 
bromide,  giving  thereby  increased  aperture  and  im- 
proved performance. 

Slides  and  covers  to  be  used  in  connection  with 
bacteriological  technique  should  be  the  same  that  I 
have  elsewhere'  recommended  for  use  in  the  examina- 
tion of  blood. 

The  medium  usually  employed  for  permanent  mounts 
is  Canada  balsam,  while  for  mere  temporary  examina- 
tions water  and  cedar  (immersion)  oil  are  frequently 
made  use  of. 

'  -Medical  Record,  October  17,  i8g6. 


8io 


MEDICAL    RECORD. 


[December  4,  1897 


When  deeply  stained,  bacteria  may  be  regarded  as 
opaque  bodies  and  consequently  without  refractive 
index,  and  their  form  becomes  manifest  through  con- 
trast with  the  refractive  medium  that  surrounds  them, 
be  the  same  air,  water,  oil,  or  what  not.  Now  in  a 
general  way  the  greater  this  contrast  the  more  dis- 
tinctly the  morphology  of  the  micro-organism  is  dis- 
played. Water  has  an  index  of  1.33,  while  cedar  oil 
and  the  xylol  and  benzol  solutions  of  balsam  have  an 
index  of  about  1.52.  Consequently  the  visibility  of 
bacteria  in  either  of  these  latter  is  greater  than  in 
water.  The  oil  of  cinnamon  (cassia),  however,  has 
an  index  of  1.59  and  is  consequently  better  than  either 
of  the  media  mentioned.  "  Naphthalin-ambar"  '  with 
an  index  of  1.625  gives  us  ten  points'  gain  over  balsam 
and  is  well  suited  for  permanent  mounts,  while  the 
pure  monobromide  of  naphthalin  (index  1.65)  dis- 
plays them  still  more  finely.  Mounts  may  also  be 
made  with  a  medium  of  still  higher  refractive  index, 
namely,  the  iodide  of  methyl  (n=i.72).  There  are 
two  inconveniences  connected  with  the  use  of  this  sub- 
stance. In  the  first  place  it  is  extremely  volatile  and 
the  cover  must  be  instantly  sealed  to  the  slide,  best 
done  with  Bell's  cement;  and,  secondly,  it  rapidly  ex- 
tracts some  of  the  basic  stains  from  the  bacteria  and 
diffuses  them  through  the  medium. 

It  must  not  be  supposed,  however,  that  the  media  of 
high  index  are  alone  useful  in  the  examination  of  bac- 
teria, as  many  peculiarities  and  points  of  structure  are 
more  readily  seen  in  media  of  comparatively  low  index, 
like  water  (n=i.33).  For  instance,  take  a  living  and 
sporulating  culture  of  anthrax  and  prepare  a  cover 
film  in  the  usual  way,  fix  by  heat,  stain  if  you  please 
with  fuchsin,  and  mount  in  balsam  or  some  similar 
medium ;  then  make  another  mount  in  water  or  serum 
without  fixation  or  stain,  and  compare  the  two.  In  the 
latter  case  we  are  enabled  to  see  the  bacteria  in  nearly 
or  quite  the  condition  that  they  exist  in  nature,  but  in 
the  fixed  and  stained  preparation  we  look  only  on  thin 
shrivelled  corpses.  We  think  the  microscopist  would 
hardly  seek  to  solve  problems  in  human  biology  by 
the  study  of  the  tissues  of  an  Egyptian  mummy,  and 
yet  this  is  practically  what  they  are  doing  when  they 
confine  these  studies  to  the  dried  and  stained  bacterial 
filaments.  My  own  studies  in  the  realm  of  bacteri- 
ology have  been  too  limited  to  permit  me  to  dogma- 
tize on  this  subject,  but  researches  in  a  closely  allied 
field  among  the  moulds  and  other  fungi,  and  the  lower 
chlordphyllous  algae,  desmids,  and  living  diatoms  have 
demonstrated  the  advantages  to  be  derived  from  the 
study  of  these  organisms  under  conditions  of  least  pos- 
sible morphological  distortion.  For  instance,  make  a 
cover-glass  preparation  of  the  common  Oidium  lactis, 
dry,  fix  by  heat,  stain,  and  mount  in  a  balsamic  me- 
dium. Prepare  another  cover  glass,  and  without  dry- 
ing, fixing,  or  staining  mount  immediately  in  glycer- 
in jelly,  or  a  ten-per-cent.  solution  of  lysol.  Examine 
both  mounts  with  a  good  objective  and  note  the  re- 
markable difference  in  the  appearance.  The  spores 
of  lycopodium  mounted  in  one  medium  show  the  sur- 
face reticulations  distinctly,  while  the  interior  is 
translucent  and  apparently  structureless.  In  another 
medium  the  reticulations  may  be  invisible,  while  the 
interior  contents  (oil  globules,  etc.)  constitute  the 
prominent  features  of  the  picture.  Take  a  little  starch 
of  almost  any  sort  and  mount  in  balsam,  and  compare 
it  with  some  mounted  in  glycerin  jelly  or  lysol  solu- 
tion. Do  the  same  with  the  spores  of  some  of  the 
hyhienomycetes.     In  the  balsam  mounts  one  will  find 

'  The  preparation  of  this  w.is  described  by  me  in  this  Journal, 
May  4,  1S95.  It  may  be  obtained  ready  for  use  from  Eimer  & 
Amend,  of  this  city,  or  the  purified  gum  may  be  had  from  Paul 
Rousseau  &  Cie,  17  Rue  Soufflot,  I'aris.  The  gum  tlius  obtained 
should  be  mixed  with  the  requisite  amount  of  monobromide  of 
naphthalin,  so  that  the  resulting  solution  shall  have  the  required 
indes. 


very  little  clew  to  the  intimate  structure  of  these  sev- 
eral bodies,  while  the  other  mounts  will  exhibit  details 
invisible  in  the  former.  Why,  then,  should  not  these 
various  methods  find  a  wider  application  in  bacteri- 
ology than  now  appears  to  be  the  case? 

If  then  bacteriology,  as  suggested,  has  nearly  reached 
the  end  of  its  tether  with  its  customary  methods,  would 
it  not  be  well  for  the  students  of  this  branch  to  avail 
themselves  of  methods  found  useful  in  other  depart- 
ments of  natural  science,  and  especially  develop  their 
microscopical  technique  to  the  utmost? 

256  West  Fifty-Seventh  Street. 


"  IN  THOSE   DAYS  THERE  WERE    DEVILS."  ' 
By   JAMES   WEIR,   Jr.,    M.D., 

OWE.NSBORO,   KY. 

There  are  many  a  romance  and  thrilling  tale  hidden 
amid  the  du.sty  tomes  of  mediaeval  medicine.  Espe- 
cially is  this  true  of  those  old  works  which  treat  of 
demoniacal  possession  and  obsession,  of  trance,  ec- 
stasy, and  the  thousand  and  one  manifestations  of 
hysteria  then  characterized  as  visible  presentments 
of  the  devil  himself  in  propria  persona.  In  the  tale 
of  Urban  Grandier,  in  "  Crimes  Celebres,"  Alexander 
Dumas  has  simply  related  an  historical  episode,  con- 
fining himself  closely  to  absolute  fact.  Laigue-Gen- 
til  gives  the  medical  points  of  this  strange  story,  and 
from  these  two  authors  the  following  paraphrase  is  de- 
rived. 

Even  in  early  youth  Urban  Grandier  was  distin- 
guished by  a  mental  acuteness  and  activity  that  far 
transcended  the  mediocre  and  groping  psychical  efforts 
of  his  companions.  The  boy's  high  intellectuality 
soon  attracted  the  notice  of  his  uncle,  Claude  Gran- 
dier, a  scientist  of  considerable  note  in  his  day,  who 
undertook  his  early  education.  After  several  years' 
study  with  his  uncle.  Urban  was  enrolled  at  the  age 
of  twelve  in  the  Jesuits'  College  at  Bordeaux.  His 
teachers  soon  discovered  marked  oratorical  talent  in 
the  youthful  student,  whereupon  he  was  made  to  preach 
and  declaim,  his  style  being  carefully  watched,  criti- 
cised, and  corrected.  As  soon  as  he  arrived  at  a  suit- 
able age  the  college  authorities  made  him  curate  of 
St.  Peter's  Church  in  the  town  of  Loudun ;  soon  after 
this  he  was  given  the  stipend  of  a  prebendary  in  the 
college  of  Sainte-Croix.  Contemporaneous  writers 
describe  him  as  being  about  thirty  years  old  (1631), 
"tall  and  well  proportioned,  his  air  noble,  and  his 
countenance  very  handsome,  although  its  expression 
was  a  little  haughty."  He  was  by  far  the  most  learned 
man  in  that  section  of  the  country,  a  finished  orator, 
a  courtly,  refined,  and  agreeable  gentleman.  He  was 
free  from  all  the  vices  of  that  age,  and  the  only  fault 
that  could  be  found  in  him  by  his  enemies  (and  he 
soon  made  a  host  of  very  formidable  and  powerful 
ones)  was  an  inordinate  fondness  for  the  society  of 
women. 

By  his  wit,  his  learning,  his  oratory,  and  his  pleas- 
ing personalit}-,  he  soon  filled  his  church  to  overflow- 
ing with  zealous  and  admiring  communicants.  But, 
just  in  proportion  as  St.  Peter's  became  crowded,  the 
congregations  of  the  other  churches  and  the  perquisites 
of  the  priests  in  charge  of  them  dwindled  away.  This, 
of  course,  aroused  jealousy,  and  jealousy  soon  turned 
into  downright,  deadly  hatred. 

Urban  was  gentle,  affable,  agreeable,  and  affection- 
ate when  among  his  friends,  but  when  among  his  ene- 
mies, especially  when  he  had  right  on  his  side,  he  was 

'  The  notes  for  this  paraphrase  of  Dumas'  story  were  made 
and  the  MS.  was  partly  written  in  the  winter  of  1SS9  ;  it  was  not 
completed,  however,  until  the  summer  of  iSg6.  Recently  a 
translation  of  "  Crimes  Celibres  "  has  appeared,  in  which  the  stor>' 
is  told  in  full.  This  paper  was  sent  to  the  Medical  Record 
during  the  summer  of  1896. 


December  4,  1897] 


MEDICAL    RECORD. 


811 


stern,  haughty,  and  absolutely  inflexible.  Soon  after 
he  was  given  the  prebend  in  the  college  of  Sainte- 
Croi.x,  he  sued  that  chapter  for  the  possession  of  a 
house  and  won  his  suit.  He  immediately  pressed  the 
judgment  given  him  in  this  suit  to  a  fulfilment,  thereby 
incurring  the  bitter  enmity  of  Mignon,  a  canon  of 
Sainte  Croix  and  director  of  the  Ursuline  convent. 
This  priest  was  an  arrant  hypocrite,  a  detestable  liar 
and  falsifier,  and  was,  as  we  shall  soon  see,  the  head 
and  centre  of  the  miserable  band  of  plotting  priests, 
nuns,  officials,  and  riffraff  that  brought  the  brave  and 
honorable  Grandier  to  a  horrible  torture  and  to  a  still 
more  horrible  and  painful  death. 

About  the  time  of  Urban 's  victory  over  the  chapter 
of  Sainte-Croix,  Julia  Trinquant,  the  beautiful  daugh- 
ter of  \h.& procureur  die  roi,  fell  sick  with  some  linger- 
ing disease,  and  Martha  Pelletier,  one  of  her  girl 
friends,  left  her  own  home  and  went  to  that  of  Julia 
in  order  to  nurse  her  sick  friend.  During  the  course 
of  Mile.  Trinquant's  illness,  a  child  was  born  to  Mile. 
Pelletier,  but  the  people  of  the  town,  influenced  by 
the  atrocious  calumniator,  Mignon,  ascribed  maternity 
not  to  Martha,  the  real  mother  of  the  child,  but  to 
Julia,  the  fair  and  innocent  daughter  of  the  procureur 
du  rot.  The  father  of  the  child  was  declared  to  be 
Urban  Grandier.  Trinquant,  by  virtue  of  his  office, 
had  Martha  arrested ;  she  was  brought  before  him  and 
questioned,  but  she  swore  over  and  over  again  that  the 
child  was  her  own.  She  also  declared  that  Urban 
Grandier  was  not  the  father  of  her  child.  The  public 
was  not  convinced,  however,  but  still  believed  that 
Mile.  Pelletier  had  assumed  the  guilt  of  Mile.  Trin- 
quant for  a  monetary  consideration,  and  that  Urban 
was  the  father  of  the  child. 

M.  Barot,  a  rich  and  influential  citizen  of  Loudun, 
and  Mignon's  uncle,  had  had  a  furious  quarrel  with 
Grandier,  in  which  he  came  out  badly  worsted.  This 
made  him  an  implacable  foe,  and  one,  too,  on  account 
of  his  wealth  and  position,  to  be  feared.  This  man 
invited  Trinquant,  Mignon,  and  a  priest  named  Meu- 
nier  (from  whom  Urban  had  won  a  lawsuit)  to  meet 
him  and  to  join  him  in  a  cabal  against  their  mutual 
enemy ;  M.  Menuau,  avocat  du  rot,  who  was  jealous 
of  Grandier,  also  came  to  this  meeting.  Having  failed 
to  incriminate  Urban  and  Julia  Trinquant  through 
Martha  Pelletier,  they  set  themselves  to  evolve  an- 
other plot.  But  Father  Grandier  lived  so  honestly 
and  uprightly  that  they  could  find  no  fault  on  which 
to  base  an  accusation. 

I  have  stated  above  that  he  was  exceedingly  fond  of 
female  society,  though,  as  we  have  now  every  reason  for 
believing,  this  penchant  was  entirely  innocent.  His 
enemies,  however,  started  the  report  that  he  was  con- 
ducting a  liaison  with  a  young  lady  of  Loudun,  and 
that  in  order  to  overcome  her  scruples  he  had  married 
her,  having  performed  the  double  office  of  priest  and 
husband.  Such  was  the  silly  tale  inaugurated  by  this 
unscrupulous  cabal,  and  which,  as  they  thought, 
would  bring  their  haughty  enemy  to  terms.  But 
Grandier,  secure  in  his  innocence,  treated  their  accu- 
sations with  contemptuous  indifference.  Upon  a  cer- 
tain occasion,  however,  his  anger  got  the  better  of  his 
pride,  and  he  bitterly  reproached  one  Duthibaut,  who 
had  persistently  circulated  the  story  of  his  marriage 
with  the  young  lady.  This  man,  stung  by  and  writh- 
ing beneath  the  smart  of  Urban's  matchless  invective, 
raised  his  cane  and  struck  him.  This  scene  occurred 
in  the  Church  of  Sainte-Croix  while  the  priest  was 
still  dressed  in  the  holy  robes  of  his  office,  constitut- 
ing, necessarily,  a  sacrilege  of  the  gravest  moment. 
Urban  proceeded  against  Uuthibaut,  who,  by  tiie  way, 
was  rich  and  influential,  with  his  usual  promptness. 
He  complained  to  the  king,  Louis  XHL,  who  at  once 
brought  the  matter  before  parliament. 

While  Urban  was  in  Paris   prosecuting  Duthibaut 


for  sacrilege,  the  cabal  in  Loudun  was  busily  prepar- 
ing a  bomb  in  the  shape  of  an  accusation  that  was  to 
be  placed  in  the  hands  of  his  superior,  the  bishop  of 
Poitiers.  Two  men  were  found  who,  for  money,  swore 
that  he  had  debauched  women  and  girls,  and  that  he 
had  converted  St.  Peter's  Church  into  a  maison  dcjoie, 
and  that  he  never  read  his  breviary.  The  bishop,  who 
was  Grandier's  enemy  also  (the  latter  having  granted 
a  dispensation  of  marriage,  which  was  a  prerogative 
of  the  former,  hence  his  enmity),  issued  a  writ  of  arrest 
and  summons  for  Urban  to  appear  before  him.  The 
summons,  with  a  copy  of  the  accusation  was  given  to 
Duthibaut,  who  hurried  to  Paris  and  placed  them  be- 
fore parliament.  This  body  then  decided  that  the 
priest  must  stand  his  trial  before  his  religious  su- 
perior before  they  could  proceed  further  with  the  case 
against  Duthibaut.  Grandier's  high  courage  did  not 
desert  him;  he  travelled  back  to  Loudun  with  all 
speed.  As  soon,  however,  as  he  arrived  there  and 
before  he  could  make  any  efforts  toward  preparing  his 
defence,  he  was  seized  and  thrown  into  one  of  the 
noisome  dungeons  of  the  bishop's  prison.  Here  he 
remained  closely  confined  for  two  months.  He  was 
then  brought  out  for  trial,  and,  notwithstanding  the 
fact  that  the  charges  were  mere  assertions  as  in  the  case 
of  the  young  lady  to  whom  he  was  reported  to  be  al- 
ready married,  no  names  were  given  to  the  women  and 
girls  whom  he  was  accused  of  debauching),  he  was 
found  guilty  and  sentenced  to  live  on  bread  and  water 
for  three  months,  and  debarred  the  practice  of  his  priest- 
ly functions  in  the  diocese  of  Poitiers  for  five  years, 
and  in  Loudun  forever.  Grandier  appealed  from  this 
sentence  to  the  archbishop  of  Bordeaux;  his  accusers, 
thinking  completely  to  annihilate  him,  then  also  ap- 
pealed, carrying  their  appeal  to  parliament.  It  was 
decided,  however,  that,  owing  to  the  great  expense  in- 
cident to  the  transportation  and  maintenance  of  so 
many  witnesses,  the  case  should  be  tried  by  the  civil 
court  of  Poitiers.  In  this  just  and  impartial  court  the 
false  witnesses  were  soon  entrapped  into  making  con- 
tradictory statements,  whereupon  they  lost  courage  and 
confessed  that  their  evidence  against  Urban  was  false. 
He  was  consequently,  on  May  25,  1631,  declared  not 
guilty  by  the  court.  He  had  yet  to  stand  his  trial  be- 
fore the  archbishop  of  Bordeaux,  who  was  then  at  Saint- 
Jouin-de-Marmes.  He  hurried  thither  and  asked  for 
an  immediate  trial,  which  was  granted,  and,  in  a  few 
days  he  returned  to  Loudun  in  triumph — he  had  been 
acquitted  on  every  count  of  the  indictment. 

We  may  take  it  for  granted  that  a  man  of  Grandier's 
temperament  did  not  let  matters  rest  here — nor  did  he. 
He  at  once  entered  proceedings  against  Mignon,  Trin- 
quant, Barot,  Meunier,  and  Menuau  for  conspiracy. 
Meanwhile  he  had  vigorously  conducted  the  prosecu- 
tion of  Duthibaut  (the  man  who  had  struck  him  with 
a  cane  in  the  Church  of  Sainte-Croix),  and  had  gotten 
a  judgment  again.st  him.  Duthibaut  was  fined,  repri- 
manded, and  forced  to  pay  a  sum  of  money  to  the 
priest  whom  he  had  insulted.  The  cabal  found  them- 
selves in  hard  case — from  accusers  they  had  become 
the  accused,  from  prosecutors  they  had  become  the 
prosecuted.  It  behooved  them  to  bestir  themselves 
and  crush  their  enemy,  otherwise  they  were  lost. 
They  met  again,  Duthibaut  having  been  added  to 
their  number,  this  time  at  a  house  belonging  to  Trin- 
quant in  the  village  of  Pindardine;  there  they  formed 
a  new  plot  which,  for  utter  wickedness,  is  without  par- 
allel in  the  history  of  mankind. 

Some  time  before  the  events  just  related  had  trans- 
pired, the  mother  superior  of  the  Ursuline  convent 
had  asked  Grandier  to  become  the  spiritual  director 
of  her  household.  He,  owing  to  his  multitudinous 
engagements,  had  refused,  thereby  incurring  the  en- 
mity of  the  nuns,  who  considered  themselves  scorned 
and   despised.     Better  had   it  been  for  him  had  he 


8l2 


MEDICAL    RECORD. 


[December  4,  1897 


thrust  his  right  hand  into  fire  and  burned  it  to  a 
cinder  than  to  have  used  it  in  penning  a  refusal  to 
these  women!  For,  by  these  weak  women  and  girls 
■was  he  to  be  dragged  down  and  utterly  destroyed. 

Several  days  after  the  meeting  of  the  conspirators 
at  the  house  of  Trinquant  in  the  village  of  Pindar- 
dine,  it  was  whispered  in  Loudun  that  two  nuns  in 
the  Ursuline  convent  had  been  possessed  by  devils, 
and  that  these  devils  had  been  enabled  to  penetrate 
into  the  bodies  of  these  holy  women  solely  through 
the  magic  of  Urban  Grandier,  a  priest  of  Holy  Alother 
Church.  "Horrible!  a  priest  and  trafficking  with  dev- 
ils. Send  for  the  e.xecutioner !  Send  for  the  stake! 
Burn  him!  burn  him!"  Thus  the  superstitious  and 
the  ignorant.  Fortunately  for  Urban,  as  well  as  for 
us,  even  in  those  days  there  were  some  people  who 
•did  not  believe  in  diabolical  possession,  and  the  sen- 
eschal of  the  town  of  Loudun  was  one  of  those  people. 
Mignon,  who  had  been  appointed  spiritual  director  of 
the  convent  after  Grandier's  refusal,  sent  for  the  curate 
of  Saint-Jacques  of  Chinon,  Father  Barre,  whom  he 
desired  to  assist  him  in  exorcising  the  devils.  The 
seneschal  of  the  district,  Guillaume  Cerisay  de  la 
Gueriniere,  and  the  civil  lieutenant,  Louis  Chauvat, 
requested  that  they  might  be  present  at  the  exorcism. 
When  the  two  officers  of  the  law  arrived  at  the  convent 
they  were  met  by  Mignon,  who  told  them  a  wonderful 
tale  of  spectres,  goblins,  and  devils.  He  informed 
them  that  the  two  possessed  nuns  were  asleep,  but 
that  if  they  would  come  back  at  some  future  time  they 
could  see  these  wonderful  performances  and  judge  for 
themselves.  Here  I  will  quote  from  Dumas'  "  Cele- 
brated Crimes"  the  following  passage:  "The  two 
magistrates  were  taking  tlieir  leave,  when  a  nun  hastily 
announced  to  them  that  the  two  possessed  sisters  were 
again  tormented  by  their  persecutors;  they  went  up 
with  Mignon  and  the  curate  of  Venier  into  a  room  at 
the  top  of  the  house,  furnished  with  seven  small  beds, 
only  two  of  which  were  occupied,  the  one  by  the  ab- 
bess and  the  other  by  the  lay  sister.  .  .  .  The  two 
magistrates  had  no  sooner  entered  the  room  than  the 
abbess  was  seized  with  violent  convulsions,  making 
the  strangest  contortions,  and  uttering  cries  in  exact 
imitation  of  those  of  a  sucking  pig."  .  .  .  Mignon 
told  the  seneschal  and  the  civil  lieutenant  that  the  ab- 
bess herself  did  not  understand  Latin,  but  that  the 
devil  inhabiting  was  a  good  classical  scholar  and 
spoke  g6od  Latin ;  he  would,  therefore,  interrogate 
her  in  that  language.  After  exorcising  her  he  began 
the  interrogation. 

Q.  "  Propter  giMtn  causanl  ingressus  cs  in  corpus  Iiujiis 
virginis  ?"  (Why  have  you  entered  the  body  of  this 
young  maiden  ?) 

A.  "  Causa  animositatis."    (On  account  of  enmity.) 

Q.  "  Per  quod  pacfumf"     (By  what  compact?) 

A.  "  Per  /lores."     (Flowers.) 

Q.  "Qualesr   (What  flowers?) 

A.  "Rosas."     (Roses.) 

Q.  "  Quis  misit?"     (Who  sent  you?) 

At  this  question  the  two  magistrates  observed  the 
movement  of  hesitation  in  the  abbess;  twice  she 
opened  her  mouth  to  answer,  without  uttering  a  sound; 
the  third  time  .she  replied  in  a  faint  voice: 

A.  "  Urhanus."     (Urban.) 

Q.  "  Die  cognomen  I"     (What  is  his  surname?) 

Here,  again,  the  possessed  woman  appeared  in  a 
state  of  hesitation,  but,  as  if  .compelled  by  the  power 
of  the  exorcist,  she  answered: 

A.  "  Grandier."      (Grandier.) 

Q.  "  Die  qualitakmV'     (What  is  his  profession  ?) 

A.  "  Saccrdos."     (A  priest.) 

Q.  "  Cujus  ecclcsiieV     (Of  what  church?) 

A.  "  Sancfi  Petri."      (Of  Saint  Peter.) 

Q.  "  Quic  persona  attulit flares  V  (What  person  has 
brought  the  flowers?) 


A.  "'  Diabolica."     (A  person  sent  by  the  devil.) 

In  this  interrogation  the  devil  used  correct  Latin, 
for  he  had  been  well  drilled;  we  will  see,  however, 
that  in  another  interrogation  he  used  Latin  bad 
enough  to  have  shamed  a  ten  years'  old  seminarian. 
These  exorcisms  and  interrogatories  continued  at  in- 
tervals for  several  weeks,  when  it  was  announced  by 
Barre',  and  confirmed  by  the  abbess,  that  instead  of 
one  devil  there  were  no  less  than  seven  in  her  body. 
These  devils  were  named  Asmodeus,  Be'herit,  Cer- 
berus, Earas,  Elimi,  etc. 

It  is  not  to  be  supposed  that  Grandier  was  in 
ignorance  of  these  performances;  he  was  fully 
aware  of  his  danger,  and  felt  alarmed  for  the  first  time 
in  all  his  life.  He  remembered  Ganfredi,  who 
had  been  executed  only  a  few  years  before  for  deal- 
ing in  sorcery  and  witchcraft.  The  seneschal  was 
an  upright,  honorable  man,  and  felt  convinced  all 
along  that  there  was  a  conspiracy  between  nuns  and 
priests  for  the  overthrow  of  Urban.  To  him,  then, 
this  unfortunate  man  appealed;  he  demanded  that 
the  two  nuns  be  separated,  and  that  other  exorcists 
and  physicians  be  appointed.  This  the  seneschal  en- 
deavored to  do,  but,  much  to  his  surprise,  was  even 
himself  refused  admittance  to  the  convent.  Grandier 
appealed  to  the  arclibishop  of  Bordeaux,  who  at  once 
appointed  a  commission,  composed  of  Sieur  Barre', 
Father  I'Escaye,  and  Father  Gau,  men  in  whom  he 
had  the  utmost  confidence.  As  soon  as  this  commis- 
sion took  charge  of  the  possessed  women,  the  devils 
left  them  and  did  not  return  while  they  remained  at 
the  convent.  The  archbishop  had  previously  sent  his 
own  physician  to  examine  the  nuns;  the  devils  had 
remained  quiet  during  his  visit,  and  so  he  had  nothing 
to  report.  But  fate,  in  the  shape  of  Cardinal  Riche- 
lieu, far  away  in  Paris,  was  reaching  out  eager  hands 
toward  the  unfortunate  Grandier.  M.  Laubordement 
was  sent  by  Richelieu  to  Loudun  with  orders  to  de- 
molish its  castle.  This  man  was  introduced  to  Mig- 
non, Trinquant,  Barrt;,  and  others  of  the  cabal,  who 
became  quite  intimate  with  him.  The  commission  of 
the  archbishop  of  Bordeaux  having  been  withdrawn 
about  this  time,  the  devils  returned  in  full  force.  M. 
Laubordement  was  present  at  the  exorcisms  (for  as 
soon  as  one  devil  was  compelled  to  take  his  departure 
another  devil  took  his  place)  and  was  apparently  fully 
convinced  of  the  genuine  character  of  the  manifesta- 
tions. But  this  man  had  joined  the  conspirators,  for 
he  was  a  relative  of  the  abbess  and  was  deeply  in- 
censed at  the  archbishop's  action  in  appointing  a  com- 
mission to  judge  as  to  the  genuineness  of  the  diaboli- 
cal phenomena. 

He  returned  to  Paris  and  sought  the  all-powerful 
duke.  No  sooner  had  Richelieu  heard  the  name  of 
Urban  Grandier  and  the  charges  against  him,  than  he 
smiled  in  grim  satisfaction.  When  the  cardinal  was 
prior  of  Coussay  he  had  had  a  quarrel  with  Urban  and 
had  been  badly  worsted ;  here,  then,  was  his  enemy 
betrayed  into  his  hands.  A  writ  for  Grandier's  arrest 
was  at  once  made  out  and  signed  by  die  king;  this 
was  given  to  Laubordement,  who  returned  at  once  to 
Loudun,  where  his  unfortunate  \ictim  was  arrested  and 
thrown  into  prison.  The  exorcisms  and  interrogations 
and  diabolical  manifestations  continued;  a  host  of 
devils  descended  one  night,  and  the  next  morning 
eleven  more  young  girls,  inmates  of  the  convent,  were 
howling  and  whooping  like  demons.  Asmodeus  and 
Cerberus  and  Bchorit  and  Earas  and  the  remainder  of 
the  seven  devils,  however,  .still  continued  faithful  to 
their  first  love,  the  abbess.  Jeanne  de  ISelfield.  Their 
Latin  became  incorrect,  iiowever,  just  as  soon  as  the 
interrogations  became  frequent  and  lengtliy.  One 
more  quotation  to  prove  this: 

"  Mass  being  concluded,  Barre  approached  her  to 
offer  her  the  communion  and  to  exorcise  her;  and, 


December  4.  1897] 


MEDICAL    RECORD. 


813 


holding  the   holy  sacrament  in  his  hand,  he  said  to 
her: 

''"' Adora  Deiim  tuu»i,  crcatoriuii  tuuvi.' "  (Adore 
your  God,  your  Creator.) 

The  abbess  remained  silent  for  a  brief  space,  as  if 
she  found  much  difficult}'  in  expressing  this  declara- 
tion of  love:  at  last  she  said: 
" '  Adoro  tc. '       (I  adore  thee.) 
"'  Quam  adoras  l '     (Whom  do  you  adore?) 
'"■/esiis  Christus'   (Jesus  Christ),  replied  the  nun, 
who  was  not  aware  that  the  verb  adoro  governs  the 
accusative    case.  .  .  .   Daniel  Douin,  the   assessor  of 
the  provostship,  could  not  refrain  from  saying  aloud: 
'  Here   have  we    a    devil  who    is    not    strong    in   the 
verbs  acti\e.' " 

This  miserable  chicanery  was  kept  up  for  months, 
the  unfortunate  Grandier  fighting  against  it  as  well  as 
he  could  from  the  depths  of  his  dungeon.  The  senes- 
chal, and  his  brother  magistrates  also,  did  what  they 
could.  Time  and  again  did  they  expose  the  shallow 
artifices  and  subterfuges  of  Mignon  and  Father  Lac- 
tance  (another  priest  who  had  joined  the  conspirators) 
but  all  in  vain — the  case  had  been  prejudged,  the 
sentence  had  already  been  formulated.  Even  when 
Sister  Claire,  weeping  in  bitter  sorrow  at  the  part 
she  had  played  in  bringing  a  good  man  to  his  death, 
confessed  to  Father  Lactance  before  a  crowded 
church  that  she  had  given  false  evidence  and  that  she 
had  feigned  diabolical  possession,  the  priest  only 
laughed  in  her  face,  and  cried  out  that  it  was  the 
devil  speaking  and  not  the  good  sister.  She  was  hur- 
ried back  to  the  convent,  never  again  to  emerge  there- 
from. "A  still  stranger  scene  took  place  upon  the 
day  after.  While  M.  Laubordement  was  questioning 
a  nun,  the  superior  came  down  into  the  court  with 
naked  feet,  and  a  rope  round  her  neck,  in  the  midst 
of  a  frightful  storm,"  and  stood  waiting  for  him. 
When  he  appeared,  "  Sister  Jeanne  des  Anges  (Jeanne 
de  Belfield,  the  abbess),  kneeling  down  before  him, 
declared  that  she  had  not  power  to  play  the  horrible 
part  which  had  been  taught  her  any  longer,  and  before 
God  and  man  she  declared  Urban  Grandier  innocent." 
M.  Laubordement,  like  Father  Lactance,  only  laughed, 
and  said  that  it  was  the  devil  speaking  with  her 
tongue.  Sisters  Jeanne  and  Claire  were  the  nuns  first 
corrupted  by  Mignon  and  his  ally,  who,  together  with 
the  other  conspirators,  were  the  only  visible  and  real 
devils  in  this  infamous  drama  of  crime.  After  a  far- 
cical trial,  Grandier  was  condemned  to  the  torture  of 
the  boot,  and  finally  to  be  burned  alive  in  the  "public 
place  of  Sainte-Croix."  On  the  18th  of  August,  1634, 
he  was  taken  to  the  torture  chamber  by  Laubordement 
and  Father  Lactance.  The  executioner  was  dismissed, 
and  then  these  two  gentle  followers  of  the  merciful 
Christ  proceeded  with  their  own  hands  to  apply  the 
boot  to  their  victim's  legs  and  to  crush  them  into  a 
bloody,  formless  mass  of  bone,  flesh,  nerve,  and  liga- 
ment. After  some  further  torture,  during  which  they 
continually  commanded  Urban  to  confess  (he  replying 
that  he  was  innocent  and  could  not  imperil  the  safety 
of  his  soul  by  the  utterance  of  a  lie  in  order  to  save 
his  body  from  torture),  they  placed  him  on  a  cart 
and  hauled  him  to  the  public  place  of  Sainte-Croix. 
He,  being  unable  to  stand  on  account  of  his  crushed 
limbs,  was  then  fastened  to  the  stake  with  a  chain, 
which  was  passed  around  his  middle.  The  fagots 
were  fired,  and,  after  calling  aloud  the  name  of  Jesus 
three  times,  amid  flame  and  smoke  the  spirit  of  this 
good  priest  left  its  earthly  tenement  and  ascended  to 
its  Maker.  Thus  died  Urban  Grandier,  the  victim  of 
one  of  the  foulest  plots  that  ever  disgraced  humanity. 
That  it  was  a  plot,  the  testimony  of  the  abbess  and 
Sister  Claire  most  positively  declares  and  affirms. 
Verily,  there  were  devils  in  those  days. 

*'  Waveland." 


THE  HAND  AS  A  PROPAGATOR  OF  MI- 
CROBIC  DISEASE  —  A  MEDICO-SOCIAL 
QUESTION. 

By    NATHAN    BREITER,    M.D., 

NEW   YORK, 

VISITING    PHYSICIAN    TO   THE  GOOD    SAMARITAN   DISPENSABV. 

A  FEW  weeks  ago  I  happened  to  meet  a  chance  ac- 
quaintance, and,  of  course,  the  usual  mode  of  greeting 
manifested  by  the  shake  of  the  hand  was  resorted  to. 
I  at  once  perceived  something  rough  and  oily  about 
his  hand,  but,  not  wishing  to  discuss  the  matter,  I  said 
nothing  relative  thereto,  and  the  circumstance  very 
soon  faded  from  my  mind.  A  few  days  subsequent  to 
that  time  the  same  person  presented  himself  as  a  pa- 
tient at  my  office,  and,  forgetting  my  former  impres- 
sion, he  shook  hands  again,  whereupon  I  noticed  the 
same  condition  as  before.  An  examination  revealed 
the  fact  that  he  had  had  a  hard  chancre  about  six 
months  prior  to  his  call,  and  that  at  the  time  of  his 
call  he  was  sufl'ering  from  an  extensive  syphilide  which 
partly  involved  the  hands.  On  the  discovery  of  this 
fact  it  at  once  occurred  to  me  that  I  had  not  washed 
my  hands  until  several  hours  had  elapsea  after  our 
former  friendly  greeting.  I  felt  like  shaking  my  han(J 
off  or  shaking  the  custom  out  of  existence.  An  effort 
in  the  latter  direction  seemed  more  feasible.  I  stud- 
ied the  question — the  medico-social  question — its 
cause,  effects,  and  treatment. 

Cause. — In  view  of  the  fact  that  most  of  the  cus- 
toms have  had  a  somewhat  similar  origin,  some  more, 
others  less  rational,  most  began  in  the  impulsiveness 
occasioned  by  circumstances,  varying  as  to  time  and 
place,  and  founded  in  extensiveness  on  mimicry,  a 
consideration  of  the  one  seemingly  most  grave  at  the 
present  time  will  also  reflect  upon  and  give  credence 
to  others  still  extant. 

In  Leopold  Wagner's  "  Manners,  Customs,  and  Ob- 
servances," we  find  the  following:  "The  custom  of 
shaking  hands  originated  in  the  ancient  and  universal 
practice  of  grasping  the  weapon  hand  during  a  truce 
as  a  precaution  against  treachery.  But  it  will  be 
asked,  how  came  it  that  the  chance  meeting  of  friends 
was  signalized  by  a  shaking  of  hands?  To  this  it 
may  be  answered  that,  just  as  the  warrior  clutches  the 
weapon  hand  to  prevent  mischief,  so  he  freely  extends 
his  own  weapon  hand  to  a  friend  as  a  sign  that  he  has 
no  thought  of  standing  on  the  defensive."  He  also 
states  that  the  exertion  caused  by  this  very  vigorous 
grasp  caused  the  hand  to  shake.  Now,  here  we  cer- 
tainly have  a  rational  condition  of  things  born  of 
necessity  and  practised  intelligibly.  As  time  rolled 
on,  necessity  became  a  negative  factor;  the  spirit 
which  actuated  the  original  grasp  gone,  the  vigorous 
symbolification  became  less  marked,  and  soon  the 
natural  shake  which  was  consequent  upon  enervation 
was  substituted  by  the  artificial  one  consequent  upon 
de\'ice.  But  still  the  practice  continued,  modified 
here  and  there  by  the  whims  of  successive  genera- 
tions, mostly  performed  with  indifference,  occasionally 
with  some  degree  of  pleasure,  in  no  case  with  any  ap- 
parent detriment.  And  so,  by  continuous  application 
a  feeling  was  engendered,  cultivated,  and  propagated 
to  posterity,  becoming  a  habit  akin  to  a  natural 
law.  So  we  see  that  from  a  comparatively  dark  and 
illiterate  period  a  custom  having  a  rational  origin, 
which  rationale  dwindled  into  nothingness  during  its 
spread  and  migration  through  successive  centuries, 
was  ushered  into  our  glorious  civilization,  unneces- 
sary in  it  essence,  devoid  of  all  intelligence,  and  posi- 
tively injurious  to  public  health.  Unconsciousness 
is  blameless  in  inactivity.  The  microscope  and  bac- 
teriology have  opened  our  eyes.  Now  torpidity  where 
danger  lurks  becomes  a  crime. 

Effects. — I  have  in  a  very  limited  way  resorted  to  a 


8i4 


MEDICAL    RECORD. 


[December  4,  1897 


series  of  experiments  relative  to  the  bacteriological 
condition  of  the  skin  of  the  hand,  but  as  my  results 
are  but  shadows  of  already  established  facts,  and  as  the 
purpose  of  this  paper  is  only  to  expound  the  disastrous 
relationship  between  known  contagious  and  infectious 
diseases  and  a  social  custom,  I  shall  at  once  proceed 
with  my  delineation  of  effects. 

Prof.  W.  H.  Welch,  in  his  article  on  "  General  Bac- 
teriology of  Surgical  Infections,"  in  Dennis'  "  System 
of  Surgery,"  says:  "As  the  skin  is  exposed  to  con- 
tamination from  the  air  and  all  sorts  of  sources,  it  is 
evident  that  there  is  scarcely  any  limit  to  the  number 
of  species  of  bacteria  which  may  possibly  be  found  on 
the  skin."  Also  "  the  kind  and  the  number  of  bacteria 
found  upon  exposed  parts  of  the  skin  vary  considerably 
according  to  the  habits  and  the  occupation  of  the  indi- 
vidual." That  the  surface  of  the  human  body  is  a 
very  hotbed  for  the  propagation  of  a  great  variety  of 
micro-organisms,  Fiirbinger,  Mittman,  Bizzozero,  Mag- 
giora,  Welch,  and  many  others  have  elucidated  most 
conclusively.  It  is  certainly  beyond  the  shadow  of  a 
doubt  that  in  the  presence  of  a  predisposing  factor, 
and  sometimes  even  without,  the  microbic  diseases  are 
ushered  into  existence  by  their  individual  prototj-pes, 
this  being  essentially  brought  about  by  contact  in  some 
"way  of  the  two  contingent  forces.  Modern  surgery 
is  founded  on  this  principle.  The  carefulness  with 
which  we  prepare  our  hands  and  surgical  instruments 
before  and  after  a  surgical  operation  well  e.xemplifies 
the  importance  of  a  familiarity  with  its  dangers  in 
every  sense.  We  recognize  the  fact  that  many  of  our 
microbic  diseases,  especially  those  of  the  exanthematic 
type,  eliminate  their  toxic  element  very  largely  through 
the  medium  of  the  skin,  which  undergoes  extensive  ex- 
foliation disseminating  the  poison  far  and  wide.  These 
conditions  are  recognized.  Isolation  is  resorted  to 
and  enforced  most  rigorously,  thereby  checking  the 
spread  of  the  disease,  and  then  disinfectants,  lavishly 
applied,  cause  the  destruction  of  the  offending  armies. 
In  the  era  of  scientific  prophylaxis  consequent  upon 
the  introduction  of  the  microscope,  bacteriolog}',  and 
antiseptics,  we  find  a  steady  decline  of  epidemics 
either  developing  in  the  outer  world  or  in  our  hospital 
wards.  The  aphorism,  "An  ounce  of  prevention  is 
better  than  a  pound  of  cure,'"  is  well  exemplified  in 
every  department  of  medicine.  Yet,  accidental  inocu- 
lations of  tuberculosis,  syphilis,  small-pox  or  vaccinia, 
and  the  like,  still  exist,  and  are  but  demonstrations  of 
either  an  unavoidable  cause — which,  by  the  way,  di- 
vests it  of  its  purely  accidental  origin — or  a  faulty 
observance  of  established  data.  Medical  literature  is 
by  no  means  devoid  of  classical  descriptions  of  micro- 
bic disease  consequent  upon  ritual  observances.  How- 
ever, as  far  as  such  customs  (and  they  are  in  a  sense 
customs)  are  concerned,  aside  from  using  the  modern 
methods  of  surgical  cleanliness,  little  if  anything  can 
be  done.  They  are  deep  rooted.  Martyrs  to  religion 
have  come  and  gone.  Martyrs  still  exist,  and  mart}'rs 
are  still  to  come.  Many  changes  as  to  wearing-ap- 
parel, so  far  as  they  affect  our  physical  well  being, 
have  been  brought  about  by  medical  agitation.  It 
may  be  difficult  in  the  beginning  for  the  general  pub- 
lic to  conceive  the  cause,  but  it  does  gradually  fall  in 
line,  whether  through  actual  conception  or  mimicry 
makes  no  difference;  it  follows,  and  because  it  fol- 
lows it  should  be  properly  led. 

The  corset,  with  it  barbaric  origin  of  metal  breast- 
plate, has  gone  through  its  evolutionary  stages,  doing 
its  systematic  harm  and  furnishing  material  for  the 
contention  of  the  gynaecologist;  and  because  of  this 
contention,  in  lieu  of  its  eradication,  it  has  met  with 
improvements  so  as  best  to  conform  with  woman's 
physical  well-being.  I  say  "woman's"  because  soci- 
ety is  so  constituted  as  to  make  woman's  appearance  a 
factor — and  that  largely^ — in  her  entire  makeup.     One 


more  instance :  During  the  early  part  of  the  tenth  cen- 
tury the  barbaric  custom  of  wearing  earrings  was  dis- 
carded, to  be  brought  to  light  again  in  the  time  of 
Queen  Elizabeth.  Prince  Henry  HI.,  of  France,  being 
of  effeminate  nature  and  anxious  to  ape  the  opposite 
sex,  adorned  his  already  girlish  person  with  precious 
ornaments  dangling  from  his  ears.  His  courtiers  and 
chevaliers  followed;  the  public  followed.  It  became 
a  general  custom  almost  throughout  the  civilized  world. 
Our  immortal  Shakespeare  was  not  insensible  to  the 
remnant  (ear  strings)  of  this  new  device.  But,  fortu- 
nately, perhaps  through  mans  superior  strength,  this 
superstructure,  founded  upon  imbecilit)',  met  with  a 
speedy  dissolution.  It  remains  for  the  weaker  sex  to 
follow.  Instances  of  infectious  skin  diseases  or  in- 
fectious constitutional  diseases  of  the  most  grave  na- 
ture are  not  unheard  of  consequences  of  this  absurd 
custom.  They  may  not  be  proportionally  large  in 
number,  but  they  are  real,  and  such  realit}',  however 
small,  with  an  avoidable  cause,  must,  of  necessity,  be 
a  reproach  to  our  boasted  civilization. 

Now  what  can  we  say  of  the  hand — the  subject 
proper  of  this  paper?  The  hand,  in  order  to  serve 
the  manifold  purposes  of  its  existence,  is  forced  to 
contend  with  circumstances  which,  by  no  means,  add 
either  to  its  cleanliness  or  to  its  freedom  from  courting 
disease.  The  importance  of  this  essentially  mournful 
condition  has  manifested  itself  in  many  instances  in 
a  very  palpable  and  painful  way.  Diseases  most 
dreadful  in  their  nature  and  origin  have  forced  them- 
selves upon  us,  giving  us  the  stigma  of  malefaction 
and  our  progeny  the  heritage  of  shame.  The  intro- 
spective and  practical  mind  will  readily  conceive  the 
revulsiveness  of  feeling  engendered  in  our  friends  and 
acquaintances  when  deteriorating  conditions,  avoid- 
able or  unavoidable,  associate  themselves  with  our 
well  being.  Society  attempts  to  shut  the  gates  upon 
us,  physicians  clamor  for  social  ostracism,  and  both 
with  justice.  Should  any  stone  be  left  unturned  in 
our  endeavor  to  give  ourselves  and  posterity  the  best 
possible  phase  of  a  future  existence? 

In  my  limited  series  of  experiments  I  have  found — 
as  more  accurate  observers  have  before  me — among 
patients  with  gonorrhceal  urethritis  that  the  filth  col- 
lected from  the  surface  of  the  hand  showed  the  pres- 
ence of  the  gonococcus  of  Neisser ;  among  tuberculous 
cases  the  presence  of  tubercle  bacilli;  among  diph- 
theria cases  suspicious  Klebs-Loeffler  bacilli;  and, 
doubtless,  every  disease  of  a  microbic  nature  has  an 
infinite  number  of  its  treacherous  and  devouring  proto- 
types in  this  cordial  member  of  greeting,  ready  to 
attack  the  new  and  unsuspecting.  The  presence  of 
most  of  the  known  types  of  bacteria  have  been  found 
upon  the  normal  hand  as  well,  and  it  requires  no  great 
stretch  of  the  imagination  reasonably  to  conclude  that 
these  micro-organisms  can  be  present.  The  clinical 
demonstration  supporting  these  conditions  is  as  old  as 
the  knowledge  of  the  causative  relation  between  mi- 
crobe and  disease.  Instances  of  auto-infection,  both  of 
the  original  and  reinfection  kind,  are  within  the  experi- 
ence of  every  physician.  The  large  number  of  cases  of 
infectious  and  gonorrhceal  conjunctivitis  with  or  with- 
out gonorrhreal  urethritis,  tuberculosis — local  or  gen- 
eral— infectious  skin  diseases,  primary  syphilis,  ery- 
sipelas, sepses  of  any  kind,  or  any  of  the  transmissible 
diseases  includes  with  its  causative  relations,  as  a 
factor,  the  hand.  Medical  literature  is  not  lacking  in 
evidence  of  this  fact.  Frequent  ablutions  may  mod- 
erate the  extent  of  but  do  not  eradicate  the  evil. 
In  this  connection  I  may  here  state  that  an  incident 
which  occurred  to  me  a  few  weeks  ago  struck  the  mark 
most  forcibly.  Two  male  friends  consulted  me  about 
their  respective  troubles.  One  had  a  typical  gonor- 
rhteal  urethritis,  the  other  a  typical  gonorrhceal  con- 
junctivitis without  apparent  cause.     The  gonococcus 


December  4,  1897] 


MEDICAL    RECORD. 


815 


of  Neisser  was  found  in  both  cases.  No  interchange 
■  of  towels  had  taken  place.  The  only  contact  between 
them  was  the  customary  handshake  on  meeting  and 
parting.  In  the  absence  of  a  more  probable  cause  for 
the  conjunctivitis  the  hand  is  certainly  a  plausible  one. 
I  recall  another  instance  which  occurred  with  me  about 
six  years  ago,  while  practising  medicine  in  the  city 
of  Chicago.  A  friend  of  mine,  with  whom  I  had  been 
in  the  habit  of  shaking  hands,  consulted  me  about  a 
"pimple,"  as  he  called  it,  on  his  right  index  finger. 
I  suspected  nothing  out  of  the  ordinary  and  paid  little 
attention  to  it.  The  pimple  persisted  in  its  sluggish 
existence  and  soon  assumed  a  suspicious  aspect.  I 
then  questioned  him  closely,  and  found  that  he  had 
been  indulging  in  digital  exploration  of  a  female's 
genital  organs.  Secondary  symptoms  later  on  con- 
firmed the  suspicion;  yet  this  man  certainly  exercised 
no  compunction  in  extending  in  friendly  greeting  his 
filthy  member.  Many  victims  of  scarlet  fever,  both  in 
the  early  and  desquamative  stages,  especially  the  lat- 
ter, are  walking  the  streets  of  every  large  city  ready  to 
engraft  upon  the  moist  hand  of  any  chance  acquaint- 
ance the  prolific  virus  of  the  disease.  The  same  may 
be  said  of  persons  with  pulmonary  tuberculosis,  whose 
hands  and  handkerchiefs,  through  incessant  wiping  of 
the  mouth,  are  foul  and  saturated  with  the  bacteria- 
laden  expectoration  of  the  disease.  A  skin  specialist 
of  large  experience  tells  me  that  he  has  seen  among 
laymen  many  cases  of  primary  syphilis  of  the  hand, 
without  any  recognized  source  of  infection.  Also  that 
he  has  had  cases  coming  to  him  with  the  secondary 
roseola  eruption  which  he  traced  to  an  untreated  small 
and  sluggish  ulcer  on  the  hand,  these  patients  having 
been  unaware  of  the  nature  of  their  disease.  Tuber- 
culosis of  the  hand,  the  lesion  small  or  large  in  area, 
often  painless,  and  unrecognized  as  such  for  a  long 
while,  and  perhaps  untreated,  is  by  no  means  an  in- 
frequent occurrence.  Scabies,  as  we  know,  has  a  marked 
predilection  for  the  hand.  The  germs  of  favus  and 
ringworm  find  their  nidus  there.  Need  I  mention 
others.'  Now,  whether  these  conditions  are  the  result 
of  hand-to-hand  contact  or  not  does  not  matter.  The 
conditions  themselves  are  dangerous  elements,  and  it 
is  the  consideration  of  such  factors  in  the  causation  of 
disease  that  we  are  studying. 

Most  of  us  are  familiar,  either  through  reading  or 
experience,  with  the  classical  finger  chancre  of  mid- 
Avives,  dentists,  physicians,  surgeons,  and  nurses.  We 
recognize  that  contact,  and  more  likely  in  the  presence 
of  an  abrasion,  with  the  contaminated  source  has 
caused  it  there;  we  also  recognize  that  laymen,  in 
consequence  of  digital  fondling  of  the  female  genital 
organs,  are  not  exempt.  Now  as  syphilis  is  most  in- 
fectious during  its  primary  and  secondary  stages,  and 
as  in  the  latter  stage  its  diffusion  may  extend  over  the 
entire  surface  of  the  body — (and  even  in  the  former, 
though  the  lesion  is  hidden,  the  hand  may  still  have 
its  share  of  the  virus  through  repeated  fondling  of  the 
affected  part) — are  we  not  forced  to  recognize  that 
surface  contact,  hand  to  hand,  as  well  as  by  any  other 
parts,  is  dangerous?  Of  course  the  mucous  membrane 
serves  as  a  better  pabulum  for  the  invasion  and  de- 
velopment of  micro-organisms,  but  the  skin  is  not 
absolutely  negative  in  that  respect,  and,  if  it  were,  it 
would  make  little  difference,  as  the  two,  skin  and  mu- 
cous membrane,  are  very  often  in  close  apposition  with 
each  other.  We  know  that  the  hand  has  carried  bac- 
teria to  the  mouth,  disseminating  contagion  in  that  way. 
Typhoid  fever,  Asiatic  cholera,  diphtheria,  and  other 
diseases  are  known  to  have  been  produced  that  way. 
Why  search  through  medical  libraries  for  similar  and 
perhaps  more  conclusive  evidence?  The  subject  has 
passed  the  stage  of  novelty.  So  while  we  professional 
people  are,  by  reason  of  our  profession,  forced  to  in- 
vite and  then  to  battle  (for  we  have  antiseptics)  with 


these  enemies,  there  is  no  reason  why  we  should  un- 
necessarily and  under  the  cloak  of  custom  invite  them 
and  then  leave  them  to  do  their  harm.  No  antiseptics 
are  ever  thought  of  after  the  latter  procedure,  and  it  is 
this  latter  procedure  which  is  practised  by  everybody 
throughout  the  civilized  world. 

Cleanliness  is  godliness.  Filth  is  Satan's  armor  of 
defence.  Medical  cogitation  and  agitation  have  caused 
rapid  strides  in  the  advancement  of  the  science  of  san- 
itation. We  grope  no  more  in  the  dark.  The  ideal, 
illuminated  with  the  light  of  this  century's  inventions 
and  discoveries,  stands  unveiled.  Should  we  hesitate 
because  there  may  be  some  obstacle  in  our  path,  or 
because  the  subject  smacks  more  of  the  social  than  of 
the  medical  aspect,  or  should  we  systematically  go  to 
work  and  cause  its  extermination? 

Treatment. — How  shall  we  go  about  it  and  with 
what  prospect  of  success?  Customs  and  ceremonies 
of  all  denominations  are  prevalent  among  all  nations 
both  in  civilized  and  savage  life.  The  atrociousness 
of  their  character  in  the  latter  sphere  passes  the  bound 
of  human  imagination  in  the  former.  Murder  and 
rapine  in  its  widest  and  most  brutal  sense  have  for 
their  cloak  and  protection  established  customs;  and 
an  omission  of  such,  where  it  is  expected,  is  a  sacri- 
lege to  established  law  and  order.  In  their  savage 
ignorance  they  are  unconscious  of  the  enormity  of 
their  crimes.  But  we  of  the  civilized  world,  and  with 
a  nineteenth-century  enlightenment,  can  understand 
and  look  upon  them  with  horror.  We  have  by  far 
surpassed  their  developmental  stage  and  look  forward 
to  a  grander  one  than  our  own,  where  harmful  relics, 
now  extant,  will  be  entirely  relegated  to  the  past. 
Now  can  we  help  the  natural  evolution  of  this  phase 
of  sociology  along?  History  repeats  itself.  Let  us 
look  to  history  for  information. 

In  the  reign  of  Alexander  the  Great,  when  his  Maj- 
esty was  afflicted  with  wryneck,  all  his  courtiers  and 
generals  considered  it  the  correct  thing  to  carry  their 
heads  on  one  side.  Soon  the  public  followed.  This, 
of  course,  spread  like  wildfire.  However,  the  king 
recovered  from  his  malady;  his  courtiers  and  generals 
recovered;  the  public  recovered.  The  people  at  that 
time  wanted  a  guide  whom  they  could  ape  or  follow. 
Not  more  than  twenty  years  ago  the  Princess  of  Wales 
sustained  an  injury  to  her  knee  which  caused  her  to 
limp.  "My  ladies"  at  court  limped;  the  public  limped 
— all  England  limped.  In  the  course  of  time  the 
princess  recovered.  "My  ladies"  at  court  recovered; 
all  England  recovered.  So  we  see  that  the  people 
now  also  want  a  guide,  some  one  to  ape  or  to  follow. 
The  imitative  faculty  whi:h  is  part  of  our  mental 
makeup  existed  during  the  time  of  Alexander  the 
Great;  it  exists  to-day.  Many  customs  and  costumes 
are  repeatedly  introduced  and  as  many  repeatedly  for- 
gotten ;  none  in  itself  essential  to  our  well-being,  or  not 
to  be  replaced.  Those  of  medical  consequence  were 
discussed  by  physicians,  and  the  mere  discussion  of 
them  by  physicians  either  gave  them  the  stamp  of  ap- 
proval or  modified  them  so  as  to  minimize  their  dan- 
ger, or  caused  their  total  abandonment.  New  cus- 
toms, social  or  otherwise,  are,  as  a  rule,  in  conformity 
with  the  advancement  of  the  age  which  gives  them 
birth,  and  either  meet  with  corresponding  changes  as 
time  goes  on,  or,  in  the  event  of  their  quiescence  and 
relative  regression,  assume  anomalous  or  destructive 
phases  which  justify  an  interference.  The  first  step 
in  the  progress  of  interference,  when  a  medico-social 
question  is  at  issue,  is  its  discussion  by  physicians, 
and  this  unconfined  to  /Ksculapian  walls.  The  next 
step  is  its  discussion  by  the  public.  Our  object  is  to 
start  the  wheel  a-turning — reason  and  mimicry  will 
do  the  rest.  A  simplification  of  matters  in  a  delicate 
and  unalarming  way  before  the  public  eye,  through 
the  medium  of  the  daily  newspapers,  would  be  a  de- 


8i6 


MEDICAL    RECORD. 


[December  4,  1897 


sideratum  here.  The  intelligence  of  the  present  age 
would  at  once  grasp  at  the  judiciousness  of  the  pro- 
ject, and  if  it  did  not  the  intellect  of  social  leaders 
would — the  public  later;  and  very  soon  the  custom 
would  become  extinct,  and  so  much  would  have  been 
done  toward  disarming  society  of  a  universal  custom 
which  to-day  has  no  rational  significance,  and  which 
can  and  necessarily  must  perpetuate  among  us  and 
among  future  generations  irremediable  disease. 

Some  may  look  upon  this  subject  with  derision; 
nevertheless  the  truth  is  this — no  matter  how  small 
the  percentage  of  evil  consequencees  accruing  from 
this  universal  hand-shaking,  the  total  number,  in  view 
of  its  extensiveness,  must  necessarily  be  great.  The 
subject  is  deserving  of  serious  consideration.  Con- 
scientious physicians  and  surgeons  will  accord  it. 

172  East  Seve.ntv-Second  Street. 


progress  of  Medical  Science. 

A  Method  of  Producing  Immunity  to  Infection 
with  Tuberculosis. — Paterson  {Lancet,  October  30, 
1S97,  p.  1,106)  found  that  while  rabbits  and  guinea- 
pigs  inoculated  with  the  bacillus  of  mammalian  tuber- 
culosis by  way  of  the  peritoneal  cavity,  the  anterior 
chamber  of  the  eye,  the  veins,  and  the  subcutaneous 
tissues,  died  from  tuberculosis  after  the  lapse  of  vary- 
ing periods,  invariably  negative  results  were  obtained 
from  injections  of  the  same  organism  into  birds.  On 
the  other  hand,  birds  treated  with  virulent  avian  tuber- 
cle bacilli  showed  after  the  lapse  of  a  given  time  nu- 
merous tubercles  in  the  viscera.  Although  it  would 
thus  appear  that  birds  are  not  susceptible  to  infection 
with  the  bacilli  of  mammalian  tulaerculosis,  human 
beings  have  proved  susceptible  to  infection  witii  the 
bacilli  of  tiie  tuberculosis  of  fowl,  and  individuals  so 
infected  are  in  turn  capable  of  transmitting  the  infec- 
tion to  birds.  It  was  further  found  that  pus  from  an 
abscess  in  a  man  proved  capable  of  inducing  tuber- 
cles in  rabbits.  While  tubercle  bacilli  could  not  be 
detected  in  the  pus,  cultures  from  the  tubercles  showed 
the  characteristic  appearances  of  avian  tubercle  bacilli. 
Rabbits  first  inoculated  with  sterilized  watery  suspen- 
sions of  avian  tubercle  bacilli  and  subsequently 
treated  with  suspensions  of  virulent  mammalian  tuber- 
cle bacilli,  remained  well,  only  local  lesions  develop- 
ing. Fowl  treated  with  increasing  doses  of  sterilized 
watery  suspensions  of  avian  tubercle  bacilli  withstood 
the  larger  doses  without  apparent  detriment  to  healtii. 
The  blood  serum  of  such  animals  displayed  a  bacteri- 
cidal effect  on  mammalian  tubercle  bacilli,  but  not 
upon  avian  tubercle  bacilli.  Injection  of  the  serum 
into  rabbits  and  guinea-pigs  was  followed  by  the  de- 
velopment of  local  swelling  and  loss  of  weight.  Rab- 
bits inoculated  with  mammalian  tubercle  bacilli  and 
treated  with  the  serum  displayed  a  marked  local 
reaction  and  only  local  lesions.  In  animals  first 
treated  with  the  serum  and  afterward  inoculated  with 
virulent  mammalian  tubercle  bacilli,  only  local  lesions 
developed.  Injection  of  the  serum  into  a  man  gave 
rise  to  marked  local  and  constitutional  reaction.  Tiie 
opinion  is  expressed  that  if  such  susceptible  animals 
as  guinea-pigs  can  be  rendered  immune,  as  much  may 
be  expected  of  man  also.  It  is  uncertain  how  long 
the  immunity  thus  conferred  lasts,  but  under  the  least 
favorable  conditions  it  can  be  renewed  from  time  to 
time. 

The  Employment  of  Saccharomyces  in  the  Treat- 
ment of  Tuberculosis  and  Carcinoma.  —  Manders 
(British  Medical  foiinia/.  No.  1,917,  p.  802)  details 
the  method  devised  by  Backer  in  the  treatment  of  tu- 
berculosis and  carcinoma.      It  had  been  obser\'ed  that 


the  saccharomyces  possess  under  certain  conditions 
phagocytic  powers  similar  to  those  of  leucocytes.  A 
pure  culture  of  saccharomyces  cerevisiffi  was  injected 
with  aseptic  precautions  into  a  healthy  guinea-pig,  and 
produced  little  or  no  effect.  Next,  a  healthy  animal 
was  injected  with  the  pure  culture  mixed  with  a  pro- 
portion of  fermentable  matter  previously  sterilized, 
and  it  was  found  that  the  yeast  cells  underwent  multi- 
plication and  carried  out  the  function  of  fermentation 
within  the  system  of  the  animal.  Then  a  guinea-pig 
was  inoculated  in  the  ear  with  diphtheria,  and  an  in- 
jection of  the  mixture  of  pure  culture  with  sterilized  fer- 
mentable matter  was  administered  subsequently,  with 
recovery  of  the  animal.  Similar  experiments  were 
made  with  guinea-pigs  rendered  artificially  tubercu- 
lous, and  the  results  were  so  encouraging  that  obser- 
vations upon  human  beings  were  next  resorted  to.  It 
having  been  shown  that  the  injections  were  not  attended 
by  harmful  results,  a  number  of  cases  of  tuberculo- 
sis were  subjected  to  the  treatment,  with  most  satis- 
factory results.  Similarly  good  results  are  stated  to 
have  occurred  in  cases  of  carcinoma. 

The  Treatment  of  Diphtheria  with  Antitoxic  Se- 
rum.— Clubbe  {British  Medical  Journal,  October  23, 
1897,  p.  1,177)  has  reported  two  parallel  series  of  cases 
of  diphtheria,  each  to  the  number  of  300,  one  of  which 
w'as  treated  with  and  the  other  without  antitoxic  serum, 
at  the  diphtheria  branch  of  the  Sydney  Children's 
Hospital.  In  all  the  diagnosis  was  confirmed  by  the 
presence  of  Klebs-LoetVler  bacilli.  The  report  is 
especially  interesting  because  the  cases  were  all 
treated  in  the  same  hospital  and  by  the  same  physician, 
and  because  the  general  management  was  in  all  essen- 
tially the  same.  Of  the  300  cases  treated  without 
serum,  169  were  in  females  and  131  in  males.  Of  this 
number  142  recovered  and  158  died — a  mortality  of 
52.7  per  cent.;  loi  were  cases  of  simple  diphtheria, 
with  recovery  in  78  and  death  in  23 — a  mortality  of 
22.7  per  cent. ;  199  required  .tracheotomy,  with  recov- 
ery in  64  and  death  in  135 — a  mortality  of  67.8  per 
cent.  Of  the  ca.ses  treated  with  serum,  158  were  in 
females  and  142  in  males.  Of  this  number  recover)- 
ensued  in  240  and  death  in  60 — a  mortality  of  20  per 
cent.;  171  were  cases  of  simple  diphtheria,  with  re- 
covery in  160  and  death  in  11 — a  mortality  of  6.4  per 
cent.  Tracheotomy  was  required  in  129  cases,  with 
recovery  in  80  and  death  in  49 — a  mortality  of  37.9 
per  cent.  After  the  preceding  report  had  been  made, 
an  additional  100  cases  were  treated  with  serum,  with 
recovery  in  81  and  death  in  19. 

Pulmonary  Tuberculosis  and  Childbearing. — In  a 
paper  read  before  the  Obstetrical  Society  of  Boston, 
Townsend  (Boston  Medical  and  Surgical  Journal,  Oc- 
tober 14,  1897,  p.  391)  reaches  the  following  conclu- 
sions: 1.  Conception  may  take  place  even  in  advanced 
pulmonary  tuberculosis.  2.  The  disease  is  generally 
held  in  abeyance  during  pregnancy,  although  it  may 
advance  or  even  originate  at  this  time.  3.  Labor  is 
short  and  easy  in  proportion  to  the  severity  of  the  dis- 
ease. 4.  During  the  puerperium  a  rapid  advance, 
leading  in  .some  cases  to  speedy  death,  occurs;  or  tlie 
disease  may  originate  at  this  time.  In  either  case  the 
temperature  chart  suggests  puerperal  sepsis.  5.  Pre- 
mature labor  is  more  common  the  more  advanced  the 
disease,  although  pregnancy  often  goes  on  to  full  term 
even  in  advanced  cases.  6.  The  average  weight  of 
full-term  children,  as  well  as  their  general  condition 
at  birth,  is  not  markedly  below  that  of  children  of 
healthy  mothers,  except  in  the  rare  instances  of 
congenital  tuberculosis. 

Hemorrhoids. — Tincture  of  horse  chestnut  in  doses 
of  from  twentv  to  thirty  drops,  twice  daiiv. — Akt.\ult. 


December  4,  1897] 


MEDICAL    RECORD. 


817 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &  CO.,  43,  45,  &  47  East  Tenth  Street. 


New  York,  December  4,  1897. 


THE      PHYSICAL     DEGENERACY     OF     THE 
NEGRO. 

The  race  problem  in  the  South  seems  destined  to  be 
settled  according  to  natural  laws  unless  something  is 
done,  and  done  soon,  to  save  the  negro  from  the  results 
of  his  own  vices  and  neglect  of  elementary  hygienic 
laws.  The  testimony  of  those  who  have  studied  this 
subject  is  all  but  unanimous,  and  it  has  received  ad- 
ditional confirmation  through  the  investigations  of  Dr. 
R.  H.  Johnson,  of  Brunswick,  Ga.,  himself  a  colored 
physician.  The  figures  which  he  has  gathered  from 
a  study  of  the  vital  statistics  of  nearly  three  hundred 
towns  in  the  Southern  States  show  that  the  death  rate 
of  negroes  is  double  that  of  whites  in  the  same  com- 
munities, and  not  only  this,  but  the  birth  rate  is  also 
smaller  among  the  colored  than  among  the  white  pop- 
ulation. Furthermore,  the  day  of  the  stalwart  negro 
is  passing,  if  not  already  gone,  and  the  members  of 
the  younger  generation  of  the  race  make  a  poor  show- 
ing, as  regards  their  size  and  physical  constitution, 
when  compared  with  their  grandfathers  and  grand- 
mothers. 

Dr.  Johnson  attributes  this  degeneracy  of  his  race 
— rightly,  we  believe — to  the  carelessness,  want  of 
forethought,  and  dissipation  so  unfortunately  charac- 
teristic of  a  large  portion  of  the  colored  population  in 
the  South  since  the  civil  war.  "  In  antebellum  days," 
says  Dr.  Johnson,  "  the  negro  seemed  to  be  an  immune 
to  consumption,  and  many  great  medical  writers  and 
teachers  boast  of  never  having  seen  such  among  the 
negroes.  Enforced  temperate  living  and  sanitary  pre- 
cautions made  the  black  man  a  physical  giant,  but  the 
giants  are  disappearing,  and  in  their  places  is  coming 
on  a  race  of  smaller  stature  and  decreased  vitality." 

In  the  days  of  slavery  the  colored  man  was  property 
and  was  looked  after  with  all  the  care  which  men  are 
accustomed  to  give  to  the  safe-keeping  of  their  pos- 
sessions. Their  health  was  carefully  attended  to  by 
the  plantation  physician,  they  were  decently  housed, 
well  fed,  forced  to  live  temperately,  and  to  go  to  bed 
in  proper  season.  But  the  fortunes  of  war,  while 
giving  them  liberty,  gave  them  also  license  to  indulge 
in  all  the  enervating  and  physically  degrading  vices 
of  the  higher  race  at  a  time  when  they  had  not  learned 
the  necessity  of  self-restraint  and  of  regard  for  the 
laws  of  health. 


That  this  is  the  true  reason  of  the  colored  man's 
physical  deterioration  is  further  shown  by  what  Sur- 
geon-General Sternberg  has  to  say,  in  his  recently 
issued  annual  report  concerning  the  health  of  the  col- 
ored soldiers.  "Great  improvement,"  he  says,  "has 
taken  place  in  the  past  few  years  in  the  sanitary  con- 
dition of  the  colored  troops.  The  white  troops  have 
participated  in  the  improvement,  although  their  rates 
have  not  fallen  so  rapidly  as  those  of  the  colored  men. 
During  the  past  year  the  total  hospital  admission  rate 
for  all  causes  among  the  colored  troops  was  868.88  per 
1,000  of  strength,  as  compared  with  1,132.49  among 
the  whites,  and  as  compared  with  915.88  among 
themselves  in  the  previous  year,  and  with  1,368.64, 
their  own  annual  average  for  the  previous  decade,  the 
annual  average  of  the  white  troops  having  been 
1,284.95.  T^^^  non-efficiency  from  all  causes  among 
the  colored  troops  during  the  year  was  25.75  per  1,000 
of  strength,  as  compared  with  34.72  among  the  white 
troops.  The  colored  soldier  lost  9.42  days  from  dis- 
ability during  the  year;  the  white  soldier,  12.71 ;  and 
the  average  time  of  treatment  of  each  case  was,  among 
the  colored  troops,  10.84  days;  among  the  white,  11.22 
days.  The  causes  of  disability  from  which  the  colored 
men  suffered  less  than  the  white  troops  were  malarial 
fevers,  venereal  diseases,  alcoholism,  diarrhoea,  and 
injuries ;  those  from  which  they  suffered  more  were 
neuralgia,  rheumatism  and  myalgia,  tonsillitis,  colic 
and  constipation,  conjunctivitis,  and  pneumonia." 

These  figures  contain  much  to  encourage  those  who 
have  the  future  of  our  colored  brothers  at  heart  and 
who  have  looked  with  sorrow  upon  their  downward 
progress  since  the  day  of  their  emancipation.  The 
figures  show,  indeed,  that  the  race  is  capable  of  regen- 
eration, since  even  now  its  members  living  under  the 
sanitary  and  moral  restraint  of  army  discipline  are 
found  to  be  superior  to  their  white  comrades  living 
under  the  same  conditions.  The  proof  exists  that  the 
colored  race  may  yet  be  brought  back  to  its  former 
high  sanitary  condition,  but  the  problem  remains  how 
to  lift  it  up  from  the  abyss  of  misery  and  how  to  avert 
its  threatened  extinction.  Here  is  a  task  for  the  col- 
ored members  of  our  profession,  which  they  can  ac- 
complish far  better  than  their  white  confreres  and 
which  calls  for  their  best  thought  and  self-sacrificing 
devotion. 

MALE    NURSING    IN    ENGLAND. 

The  Hamilton  Association  for  providing  trained  male 
nurses  was  started  twelve  years  ago,  as  some  of  our 
readers  may  recollect  (see  MtDiCAL  Record,  June  6, 
1885),  and  the  twelfth  annual  report  is  now  before  us. 
From  this  we  learn  that  even  after  so  long  a  trial  the 
association  is  not  yet  self-supporting,  although  many 
hundreds  of  pounds  w-ere  given  by  the  benevolent 
foundress — the  late  Miss  Jane  Hamilton,  who  at  her 
decease  left  a  further  sum  of  money  to  continue  the 
work.  From  the  first  the  association  secured  the  sup- 
port of  the  leaders  of  the  English  profession,  some  of 
whom  have  served  on  the  committee  of  management. 
Nevertheless,  the  large  general  hospitals  of  London 
have  hitherto  given  only  a  very  one-sided  support  to 


8i8 


MEDICAL    RECORD. 


[December  4,  1897 


the  movement,  although  the  association  supplied  them 
for  years  with  men  nurses  for  emergencies,  and  that  at 
a  rate  which  entailed  a  loss  to  the  funds  in  every  case. 
Miss  Hamilton  was  desirous  of  establishing  a  training- 
school  at  one  of  these  hospitals  and  would  have  en- 
dowed it,  but  none  of  them  seems  to  have  been  willing 
to  give  up  a  men's  ward  to  nursing  by  men.  This 
seems  a  very  strange  circumstance  to  us  in  this  city, 
where  the  training-schools  for  male  nurses  have  from 
their  inception  been  located  in  the  large  general  hos- 
pitals, and  we  can  only  suggest  as  an  explanation  that 
the  nursing  of  the  English  hospitals  is  in  the  hands 
of  some  narrow-minded  women,  who  oppose  any  en- 
croachment on  what  they  consider  their  natural  do- 
main. If  so,  it  seems  a  pity  that  some  hospital  com- 
mittee has  not  the  courage  to  override  the  foolish 
jealousy  of  its  matron  or  nursing  superintendent. 

That  there  is  a  need  for  male  nursing  in  London, 
and  that  some  women  recognize  the  need,  were  well 
shown  early  in  the  3'ear  by  an  article  in  the  Ninefeeni/i 
C'/ifitry,  from  the  pen  of  Lady  Priestley,  who  empha- 
sized the  widespread  feeling  that  women  are  not  suita- 
ble for  nursing  all  cases,  and  urged  the  more  general 
employment  of  male  nurses.  Lady  Priestley  seems, 
however,  to  have  been  strangely  oblivious  to  the  fact 
that  the  Hamilton  Association,  established  and  en- 
dowed for  this  end  by  one  of  her  own  sex,  had  for  years 
been  carr}'ing  out  her  ideas  at  her  very  door.  Perhaps 
her  position  as  the  wife  of  a  distinguished  obstetrician 
may  be  the  reason  why  her  attention  had  not  been 
drawn  to  the  existence  of  the  Hamilton  Association, 
which  is,  we  believe,  the  pioneer  of  male-nursing 
associations. 


TREATMENT    OF    OZ^.NA. 

In  a  paper  lately  read  at  the  Congress  of  the  French 
Society  of  Otology,  Laryngology,  and  Rhinology,  by 
Dr.  E.  I.  Moure,  of  Bordeaux,  the  treatment  of  ozajna 
was  very  fully  discussed  and  some  new  lights  are  thrown 
upon  a  subject  concerning  which  there  is  much  yet  to 
be  learned.  The  bacteriological  aspect  of  the  disease 
is  touched  upon,  and  the  various  forms  of  treatment 
in  vogue  are  cited.  The  author  strongly  deprecates 
operation  as  a  remedy,  and  after  briefly  referring  to 
treatment  o£  ozisna  by  the  introduction  of  bougies, 
snuffing,  inhaling  hot  vapor,  the  use  of  ointment,  mas- 
sage, cauterization,  he  dwells  at  some  length  on  inter- 
stitial electrolysis.  Monopolar  electricity  was  intro- 
duced as  a  remedy  by  Dr.  Garrigon-Desarenbs  in 
1884,  who  used  it  superficially.  In  1895  Dr.  Cheval, 
of  Brussels,  tried  bipolar  interstitial  electrolysis,  and 
claims  great  success  from  this  mode  of  treatment.  Dr. 
liayer,  of  Brussels,  and  M.  Rethi,  of  Vienna,  agree 
with  these  conclusions. 

Dr.  Moure,  however,  dissents  from  these  views. 
He  gave  interstitial  electrolysis  a  fair  trial,  and  while 
allowing  that  the  immediate  effects  appeared  very  sat- 
isf.ictory,  he  found  that  this  amelioration  was  but  tem- 
porary. The  treatment  recommended  by  Dr.  Moure  is 
as  follows:  He  first  inquires  of  the  patient  whether 
he  wishes  to  undergo  a  partial   or  regular  course  of 


treatment.  If  partial,  the  nasal  cavities  are  first 
cleared  by  means  of  cotton  wool  soaked  in  carbolic  gly- 
cerin; after  this  the  nasal  and  post-nasal  cavities  are 
irrigated  with  some  antiseptic  wash.  If,  on  the  con- 
trary, the  patient  wishes  to  undergo  a  regular  course 
of  treatment,  in  the  first  instance  the  nasal  cavities  are 
douched  with  a  solution  of  boric  acid;  when  this  has 
been  continued  for  a  few  weeks,  the  nasal  mucous 
membrane  is-  massaged  with  antiseptic  cotton  wool; 
nitrate  of  silver  is  then  made  use  of;  and,  finally,  an 
alkaline  injection  clears  away  any  excess  of  nitrate  of 
silver  that  may  be  contained  in  the  interior  of  the  nose. 
By  these  means  it  is  contended  that  a  definite  cure 
may  be  obtained. 

There  are,  however,  many  medical  men  who  will 
prefer  to  try  a  more  heroic  form  of  treatment  for  the 
cure  of  ozffina  than  the  foregoing.  Dr.  Mackenzie,  of 
Edinburgh,  says  that  ozaena  is  a  disease  of  the  mucous 
membrane,  and  that  the  atrophy  or  shrinkage  which  is 
a  characteristic  of  it  is  due  to  pressure  of  the  hard- 
ened pus  (crusts)  upon  that  membrane — a  condition 
which  is  somewhat  analogous  to  that  met  with  in  the 
skin  in  certain  forms  of  eczema.  He  has  endeavored 
by  curetting  to  supplant  the  diseased  membrane  by 
new  tissue,  and  claims  to  have  met  with  great  success 
from  this  treatment.  .After  curetting,  he  uses  oily  ap- 
plications, such  as  a  mixture  of  ichthyol  and  olive  oil, 
which  he  finds  soothing  and  beneficial. 


THE     SLAUGHTER    HOUSE     IN     RELATION 
TO    DISEASE. 

The  growing  danger  of  slaughter  houses  as  a  factor  in 
spreading  disease  is  at  last  being  appreciated  in  its 
true  bearings,  and  steps  are  being  everywhere  taken 
thoroughly  to  investigate  the  matter  and  to  correct  as 
far  as  possible  the  evils  of  the  present  system.  There 
is  much  to  be  done,  but  as  soon  as  the  general  public 
understands  the  nature  of  the  perils  to  which  it  is 
subjected,  owing  to  the  unsanitary  conditions  under 
which  slaughter  houses  are  generally  maintained,  just 
so  soon  will  they  insist  that  remedial  measures  be 
taken.  The  most  effective  way  to  impress  people  with 
a  sense  of  their  danger  is  by  pointing  out  to  them  that 
these  unsanitary  conditions  are  one  of  its  sources,  and 
to  prove  to  them  that  unless  radical  remedies  be  put 
into  force  infectious  diseases  may  increase  to  an  almost 
unlimited  extent. 

Ch.  Wardell  Stiles,  Ph.D.,  in  a  paper  published  in 
1896,  presents  in  a  clear  manner  the  subject  of  country 
slaughter  houses  as  a  factor  in  spreading  disease. 
In  the  course  of  his  remarks  he  says:  "The  first  mat- 
ter to  notice  in  connection  with  this  subject  is  that 
every  slaughter  house  it,  from  the  verj'  nature  of 
things,  a  centre  of  disease,  and  naturally  the  poorer  the 
condition  of  the  premises  the  more  dangerous  they 
are.  These  facts  will  appear  clear  if  one  considers 
what  takes  place  at  one  of  these  houses.  Even  if  only 
a  few  animals  are  slaughtered  each  week,  the  total 
number  may  amount  to  several  hundreds  during  the 
year.  Some  of  the  animals  are  surely  diseased.  At 
least  one  of  tlie  hogs  has  trichinosis,  and  when   the 


December  4,  1897] 


MEDICAL    RECORD. 


819 


offal  of  this  trichinous  hog  is  fed  to  hogs  which  are 
raised  upon  the  grounds  the  latter  cannot  escape  in- 
fection with  trichinae.  But  that  is  not  all.  The 
slaughter  houses  are  often  overrun  with  rats ;  the  rats 
feed  on  the  offal,  and  when  feeding  on  the  offal  of  a 
trichinous  hog  they  likewise  cannot  escape  infection 
with  trichinae.  Rats  act  as  direct  transmitters  of  tri- 
chinosis to  hogs."  Dr.  Stiles  gives  many  more  in- 
structive details,  but  which  we  have  not  the  space 
to  quote.  He  summarizes  thus:  "Every  slaughter- 
house is  a  centre  of  disease  for  the  surrounding  coun- 
try', spreading  trichinosis,  echinococcus  disease,  gid, 
wireworm,  and  other  troubles  caused  by  animal  para- 
sites, and  tuberculosis,  hog  cholera,  swine  plague,  and 
other  bacterial  diseases.  The  important  factors  con- 
cerned in  spreading  these  diseases  are  offal  feeding, 
drainage,  rats,  and  dogs."  Two  of  the  remedies  sug- 
gested are  as  follows:  "First,  by  a  reduction  in  the 
number  of  premises  on  which  slaughtering  is  allowed, 
on  which  account  it  is  urged  as  all-important  that 
there  be  a  segregation  of  the  slaughter  houses,  so  that 
all  the  butchers  of  any  given  town  will  be  compelled 
to  do  all  their  killing  in  a  common,  inclosed,  and  re- 
stricted area.  In  abandoning  slaughter  houses  care 
should  be  taken  to  destroy  the  rats,  in  order  to  prevent 
the  spread  of  infection.  Second,  by  regulating  the 
factors  concerned  in  spreading  the  diseases:  {u)  offal 
feeding  should  be  abolished;  (d)  drainage  should  be 
improved ;  (;)  rats  should  be  destroyed ;  and  [it)  dogs 
should  be  excluded  from  the  slaughter  houses." 

This  question  of  slaughter  houses  is  attracting  much 
attention  in  Europe,  though  chiefly  in  connection  with 
tuberculosis,  and  some  of  the  countries  there  have 
adopted  stringent  regulations  controlling  their  man- 
agement. The  system  in  vogue  in  Denmark  is  said 
to  be  the  most  perfect.  In  Copenhagen  every  animal 
is  after  slaughter  branded  upon  various  parts  of  the 
carcass,  and  the  brand  is  exposed  in  the  butchers'  shops 
to  the  public,  which  in  consequence  recognizes  that  the 
meat  has  been  passed  by  the  official  inspectors  as  fit 
for  human  food.  In  England  the  question  has  only 
lately  been  seriously  taken  up.  A  royal  commission 
has  been  appointed,  members  of  which  are  at  the  pres- 
ent time  visiting  some  of  the  principal  towns  in  the 
kingdom  for  the  purpose  of  collecting  evidence.  In 
France  carcasses  are  seized  when  there  are  any  visible 
signs  of  tuberculosis. 

From  abattoir  statistics  it  is  shown  that  in  Berlin  12 
per  cent,  of  the  cattle  slaughtered  are  tuberculous;  in 
Dresden,  14.4  per  cent.;  in  Upper  Silesia,  9.5  per 
cent;  in  Durham,  18.7  per  cent.;  and  in  Mid-Lothian 
(a  district  in  Scotland  in  which  Edinburgh  is  located), 
20  per  cent.  Of  those  slaughtered  in  London,  25  per 
cent,  are  diseased;  and  in  New  York,  about  20  per 
cent.  There  can  be  no  room  for  doubt  that  the  sooner 
the  task  of  putting  all  slaughter  houses  into  a  proper 
sanitary  state  is  effectively  carried  out,  the  better  will 
it  be  for  the  public  health. 

The  New  Hospital  for  Scarlet  Fever  and  Diph- 
theria is  to  be  opened  for  patients  toward  the  end  of 
the  month  of  December. 


THE   ACADEMY    OF    MEDICINE    AND    THE 
NEWSPAPERS. 

The  time  to  arrest  an  evil  is  at  its  inception,  and  for 
that  reason  we  take  occasion  just  now  to  utter  a  word 
of  reproof  to  the  officers  of  the  New  York  Academy  of 
Medicine.  Through  the  negligence  or  the  connivance 
of  certain  persons  connected  with  this  society,  reports 
of  the  meetings  of  the  general  body  and  of  individual 
sections  have  appeared  in  the  daily  papers  with  star- 
tling frequency  and  regularity  this  autumn.  Reporters 
are  not  detailed  to  report  medical  meetings  unless 
word  is  sent  to  the  editors  that  the  proceedings  are  to 
be  of  interest  to  the  general  public.  The  report  of 
the  annual  meeting  of  the  academy,  with  a  full  ab- 
stract of  the  anniversar)'  address,  is  proper  enough,  for 
the  occasion  is  intentionally  made  one  of  interest  to 
the  laity;  but  for  reports  of  section  meetings  there  can 
be  no  excuse  whatever,  except  that  of  a  desire  to  ad- 
vertise boldly  and  baldly.  The  latest  offence  has 
been  committed  by  the  section  on  neurology  and 
psychiatry. 


'^cws  of  ttxc  'WictU. 

Care  of   Consumptives  by  the  Board  of  Health 

The  board  of  estimate  and  apportionment  of  New 
York  has  been  asked  by  the  health  board  to  appropri- 
ate $60,000  for  the  care  of  tuberculous  patients  in 
Seton  Hospital  at  Kingsbridge.  It  is  said  that  the 
board  can  make  arrangements  with  the  authorities  of 
this  hospital  for  the  care  of  consumptives  at  %  per- 
capita  rate  of  $1  a  day.  The  argument  is  made  that 
most  of  the  hospitals  are  forced  by  want  of  room  to 
refuse  many  applicants  suffering  from  tuberculosis, 
and  those  that  do  accept  patients  of  this  class  dis- 
charge them  as  soon  as  they  are  sufficiently  improved 
to  be  able  to  get  about,  in  order  to  make  room  for 
more  desperate  cases.  For  this  reason,  it  is  alleged, 
few  hospital  patients  are  ever  cured,  as  they  might  be  if 
cared  for  a  sufficiently  long  period.  But  why  should 
the  health  board  take  this  matter  in  hand?  It  was  not 
created  to  treat  disease,  but  to  prevent  it.  Why  not 
leave  the  management  of  such  hospitals  to  the  De- 
partment of  Charities,  where  it  rightly  belongs.^ 

Typhoid  in  Paterson. — Typhoid  fever  has  again 
broken  out  in  Paterson,  N.  J.,  twenty-seven  cases  hav- 
ing recently  been  reported  to  the  board  of  health,  and 
fears  are  entertained  that  there  may  be  an  epidemic. 
Eleven  of  the  cases  are  among  the  inmates  of  the 
Paterson  Orphan  Asylum. 

An  Impetuous  Student. — A  student  from  New 
York  in  a  Chicago  medical  college  was  recently  ar- 
rested for  resorting  to  western  methods  to  enforce  his 
ideas  of  the  proper  treatment  of  a  young  woman  by  a 
fellow-student.  He  was  walking  with  the  lady  when 
he  met  one  of  his  classmates  who  had  spoken  of  her 
without  proper  respect,  and  whipping  out  a  revolver 
made  the  offender  drop  in  his  tracks  in  the  mud  of 
Chicago  and  apologize  then  and  there. 


820 


MEDICAL    RECORD. 


[December  4,  1897 


New  York  Skin  and  Cancer  Hospital. — Dr.  Paul 
F.  Mundd  has  been  elected  consulting  gynaecologist 
to  the  New  York  Skin  and  Cancer  Hospital,  to  suc- 
ceed the  late  Dr.  William  T.  Lusk. 

Police  Surgeon  Examination. — At  the  recent  ex- 
amination for  the  position  of  police  surgeon  somewhat 
over  eighty  applicants  presented  thamselves.  Only 
four  succeeded  in  reaching  a  percentage  of  70  or  over 
on  the  answers  to  the  questions  in  medicine,  surgery, 
physiology,  and  materia  medica.  The  first  man  on 
the  eligible  list  reached  94  per  cent.;  the  second,  90 
per  cent.;  the  third,  80  per  cent. ;  and  the  fourth,  77.6 
percent.  The  examination  for  merit  also  included  an 
exercise  in  spelling  and  one  in  letter  writing.  The 
award  for  fitness,  which  counts  50  per  cent,  of  the 
grand  total,  is  based  upon  the  general  experience  and 
standing  of  the  candidates.  The  medical  questions 
were  fair  ones,  and  the  whole  examination  was  con- 
ducted in  a  thoroughly  business-like  and  straightfor- 
ward manner. 

Reception  to  a  Physician. — A  reception  and  ban- 
quet were  tendered  on  November  24th  to  Dr.  A.  H. 
Halberstadt,  of  Pottsville,  Pa.,  the  oldest  practising 
physician  of  Schuylkill  County,  by  some  fifty  of  his 
professional  friends  from  all  parts  of  the  surrounding 
country.  On  behalf  of  his  friends.  Dr.  W.  H.  Robin- 
son, of  Pottsville,  presented  a  gold-headed  ebony  cane. 
Dr.  R.  S.  Christman,  of  Pottsville,  delivered  a  wel- 
coming address.  Dr.  F.  W.  Boyer,  of  Pottsville,  spoke 
upon  "The  Social  Side  of  the  Doctor's  Life."  The 
additional  toasts  were:  Dr.  David  Taggert,  of  Frack- 
ville,  "The  Ladies;"  Dr.  J.  E.  Merkle,  of  Hecksher- 
ville,  "The  Doctor  in  Politics;"  Dr.  C.  B.  Miller,  of 
Pottsville,  "Medical  Treatment;"  Dr.  G.  H.  Halber- 
stadt, "  Surgery." 

Philadelphia  County  Medical  Society.— A  stated 
meeting  of  the  Philadelphia  County  Medical  Society 
was  held  on  November  24th,  the  president.  Dr.  James 
Tyson,  in  the  chair.  Dr.  T.  B.  Schneideman  reported 
a  case  of  sympathetic  ophthalmia  following  traumatism, 
in  which  recovery  followed  enucleation  of  the  exciting 
eye.  Dr.  Orville  Horwitz  read  a  paper  in  which  he 
pointed  out  that  the  administration  of  methylene  blue 
might  serve  a  useful  diagnostic  purpose  in  distinguish- 
ing between  fistulae  as  connected  with  the  genito-uri- 
nary  tract  and  especially  with  the  kidney  or  with  other 
viscera.  He  reported  a  case  in  which  the  dressings 
covering  a  fistulous  opening  were  stained  blue  follow- 
ing the  administration  of  methylene  blue,  and  he  ex- 
hibited the  deeply  stained  urine.  He  suggested  fur- 
ther the  possibility  of  facilitating  skiagraphy  of  the 
kidney  by  the  use  of  the  drug.  Dr.  Judson  Daland 
presented  a  communication  detailing  observations 
tending  to  show  the  inutility  of  tincture  of  digitalis 
administered  in  the  form  of  tablets. 

The  Pittsburg  Academy  of  Medicine.— The  tenth 
annual  meeting  of  this  society  was  held  on  Thursday 
evening,  December  2d,  at  the  Hotel  Henry.  The 
annual  address  was  d  livered  by  Dr.  George  M.  Stern- 
berg, Surgeon-General,  U.  S.  A.,  the  subject  being 
"The  Relations  of  Man  and  Microbe." 


Philadelphia  Neurological  Society.  —  A  stated 
meeting  of  the  Philadelphia  Neurological  Society  was 
held  on  November  22d,  the  president.  Dr.  C.  VV.  Burr, 
in  the  chair.  Dr.  W.  G.  Spiller  reported  two  cases  of 
posterior  spinal  sclerosis,  in  which  the  other  symptoms 
remained  in  abeyance  on  the  development  of  blindness 
and  atrophy  of  the  optic  nerve,  and  he  exhibited  one 
of  the  patients.  Neither  of  the  cases  presented  note- 
worthy derangement  of  motility  or  co-ordination,  and 
for  this  reason  Dr.  Spiller  objected  to  the  use  of  the 
term  locomotor  ataxia.  Dr.  Spiller  also  exhibited  a 
microscopic  section  showing  a  neuromuscular  bundle 
containing  nerve  fibres  from  a  case  of  muscular  dys- 
trophy; and  one  of  the  optic  nerve  showing  hemi- 
atrophy from  a  case  of  acromegaly.  Dr.  F.  A.  Packard 
exhibited  two  brothers  presenting  progressive  mus- 
cular dystrophy,  with  mental  deficiency  and  possible 
enlargement  of  the  thyroid  gland.  Dr.  William  Osier 
read  a  paper  on  paralysis  of  the  hypoglossal  nerve, 
reporting  a  case  presenting  hemiatrophy  of  the  tongue, 
with  paralysis  of  one  side  of  the  larynx  and  pharynx 
in  conjunction  with  a  tumor  in  the  parotid  region  of 
the  same  side.  Dr.  C.  W.  Burr  exhibited  a  brain 
presenting  a  large  excavation  in  the  motor  area  of 
either  hemisphere  near  the  longitudinal  fissure,  from  a 
case  in  which  during  life  there  had  been  profound 
mental  impairment  and  frequent  epileptic  seizures. 
Dr.  G.  M.  Purves  exhibited,  for  Dr.  C.  K.  Mills, 
brains  from  two  cases  of  intraventricular  hemorrhage, 
and  Dr.  Mills  made  some  remarks  on  the  methods  of 
dividing  the  brain  at  post-mortem  examinations.  Dr. 
J.  P.  Arnold  reported  a  case  of  brain  tumor  situated 
on  the  median  aspect  of  the  left  hemisphere,  present- 
ing during  life  right  hemiplegia  of  progressive  type, 
with  optic  atrophy,  but  without  convulsions. 

The  Late  Dr.  Charles  A.  Avery. — At  a  stated 
meeting  of  the  Medical  Society  of  the  County  of  New 
York,  held  at  the  New  York  Academy  of  Medicine,  17 
West  Forty-third  Street,  on  Mond  y,  November  22, 
1897,  the  following  resolutions  were  adopted: 

"  Whereas,  Dr.  Charles  H.  Avery,  our  esteemed  and 
honored  secretary,  has  been  removed  by  death,  which 
occurred  November  2,  1897; 

"Resolved,  That  we  hereby  express  our  deep  sense 
of  the  loss  which  our  societ)'  has  sustained  in  his 
decease ; 

"Resolved,  That  we  desire  to  bear  testimony  to  the 
sterling  integrity  of  his  character,  to  his  genial  social 
qualities,  and  to  his  devotion  to  the  interests  of  this 
society  which  he  has  so  long  faithfully  and  efficiently 
served  in  the  capacity  of  secretary; 

"  Resolved,  That  a  cojjy  of  these  resolutions  be 
transmitted  to  the  medical  journals  of  this  city,  and 
that  an  engrossed  copy  be  sent  to  the  family  of  our 
deceased  associate. 

"John  S.  Warren,  M.D., 
"William  E.  Bullard,  M.D., 

"  Committee." 

Obituary  Notes.— Dr.  George  H.  Horn,  for  many 
years  secretary  of'the  American  Philosophical  Society, 
died  on  November  25th,  at  the  age  of  fifty-eight  years. 
He  was  one  of  the  leadinjr  entomologists  of  the  LTnited 


December  4,  1897] 


MEDICAL    RECORD. 


821 


States  and  an  active  member  of  the  Academy  of  Natu- 
ral Sciences.  He  was  graduated  from  the  Central 
High  School  of  Philadelphia  and  from  the  medical 
department  of  the  University  of  Pennsylvania. — Dr. 
J.  E.  Whiteside,  of  Philadelphia,  died  at  Atlantic 
City  on  November  25th,  at  the  age  of  seventy-four 
years.  He  was  graduated  from  the  Pennsylvania  Col- 
lege at  Gettysburg  in  1844,  and  was  engaged  in  the 
practice  of  medicine  for  fifty-three  years. 

Western  Surgical  and  Gynaecological  Association. 

— The  seventh  annual  convention  of  this  association 
will  be  held  at  Denver,  Col.,  December  28  and  29, 
1897. 

American  Association  for  the  Study  and  Cure  of 
Inebriety. — The  twenty-seventh  annual  meeting  of 
this  association  will  be  held  December  8,  1897,  in  the 
hall  of  the  Washingtonian  Home,  41  Waltham  Street, 
Boston,  Mass.  Several  interesting  papers  are  an- 
nounced. The  annual  address  will  be  delivered  by 
Dr.  Ira  Van  Gieson,  of  New  York,  "  On  Some  Recent 
Researches  on  the  Action  of  Alcohol  on  Brain  Cells." 
Dr.  Mason  is  president  of  the  association,  and  Dr. 
T.  D.  Crothers,  of  Hartford,  secretary. 

The    New   Jersey    Sanitary  Association.  —  The 

twenty-third  annual  meeting  of  this  association  will  be 
held  at  Lakewood,  N.  J.,  on  Friday  and  Saturday,  De- 
cember 10  and  II,  1897.  The  sanitary  association  is 
composed  of  professors  and  teachers  in  New  Jersey 
colleges  and  schools,  municipal  officers,  health  officers, 
lawyers,  physicians,  clergymen,  civil  engineers,  sani- 
tary engineers,  architects,  plumbers,  and  other  citizens 
of  the  State,  interested  in  sanitation  as  related  to 
homes,  schools,  and  municipalities.  The  objects  of 
the  annual  meeting  are  the  presentation  of  facts,  the 
comparison  of  views,  and  the  discussion  of  the  meth- 
ods relating  to  the  prevention  of  sickness  and  of 
untimely  deaths. 

Rounding  up  Connecticut  Doctors. — The  police 
court  in  New  Britain,  Conn.,  presented  a  brilliant 
appearance  a  week  before  Thanksgiving,  the  usual 
motley  group  of  drunk  and  disorderlies  being  replaced 
by  a  batch  of  nine  physicians,  all  charged  with  neglect 
in  making  proper  returns  of  certificates  of  birth.  The 
Hartford  County  health  officer  was  the  prosecutor,  and 
he  had  resorted  to  this  means  of  reminding  the  delin- 
quents of  their  duty  after  his  letters  of  remonstrance 
had  failed  to  have  the  desired  effect.  Each  nf  the 
accused  acknowledged  his  fault  and  was  promptly 
fined  $10  and  costs,  the  latter  bringing  the  total  up  to 
$19.07. 

Kipling's  Compliments  to  the  Doctors. — Rudyard 
Kipling  was  a  guest  at  the  annual  dinner  of  the  Har- 
veian  Society  of  London,  at  the  Caf^  Monico,  on  No- 
vember 25th,  and  replied  to  the  toast  of  "The  Visi- 
tors." He  said  he  had  come  so  near  being  a  doctor  in 
his  youth  as  to  be  allowed  to  play  In  the  neigliborhood 
of  St.  Mary's  Hospital.  Hut  later  he  had  been  thrown 
much  in  the  company  of  medical  men  in  all  parts  of 
the  world,  and  he  admired  them.      He  had   seen   them 


going  to  certain  death  with  no  hope  of  reward,  because 
it  was  "  business."  He  had  also  seen  them  handling 
cholera  and  small-pox,  and  when  dying  therefrom 
wiring  for  a  substitute.  He  had  seen  them  in  Ver- 
mont manage  a  practice  twenty  miles  in  each  direction, 
driving  horses  through  eight  feet  of  snow  to  attend  an 
operation  ten  miles  away,  and  digging  their  horses  out 
of  the  snow  and  proceeding.  It  was  one  of  the  proud- 
est things  of  his  life,  he  said,  to  have  been  associated 
with  "  real  fighting  men  of  this  class." 

Dr.  Alfredo  A.  Kathnack,  recently  lecturer  on 
pathology  at  St.  Bartholomew's  Hospital,  has  been 
elected  to  the  professorship  in  that  subject  at  Cam- 
bridge University,  in  succession  to  the  late  Dr.  C.  S. 
Roy. 

Intemperate  Antiprohibitionists Dr.  August  Fo- 

rel,  professor  of  psychiatry  in  the  University  of  Zu- 
rich and  director  of  the  State  Asylum  for  the  Insane, 
has  resigned  on  account  of  the  attacks  made  upon  him 
by  the  press  by  reason  of  his  strong  opposition  to  the 
use  of  alcohol.  The  prohibitionists  have  for  so  long 
enjoyed  almost  a  monopoly  in  illiberality  that  it  must 
come  somewhat  as  a  shock  to  find  such  fanaticism 
exhibited  on  the  other  side. 

A  Difference  of  Opinion — At  an  inquest  held  a 
short  time  ago  in  England  on  the  body  of  a  lad,  sixteen 
years  old,  the  jury  found  that  the  boy  died  from  syn- 
cope, due  to  nicotine  poisoning,  caused  by  the  exces- 
sive smoking  of'  cigarettes.  The  coroner  said  there 
seemed  to  be  quite  an  epidemic  of  such  cases,  and  it 
w-as  time  the  attention  of  parents  was  called  to  the 
danger  of  their  children  smoking  at  so  early  an  age. 
In  commenting  upon  this  verdict.  The  Laticet  agrees 
with  the  coroner  and  suggests  an  analysis  of  the  to- 
bacco which  caused  the  boy's  death.  On  the  otker 
hand,  the  editor  of  the  British  Mcdicaljounial,  while 
disclaiming  any  approval  of  indulgence  in  the  cigar- 
ette habit  by  children,  questions  the  accuracy  of  the 
verdict,  and  says  that  the  coroner  overstated  the  case 
when  he  asserted  that  there  had  been  many  deatks 
recently  from  this  cause. 

English-Speaking  Practitioners  in  Italy. — At  the 
last  general  medical  congress  held  here  it  was  unan- 
imously voted  that  foreign  medical  practitioners  pro- 
fessionally engaged  in  Italy  should  undergo  a  state 
examination  or  qualify  at  one  or  other  of  the  Italian 
schools  in  order  to  legalize  their  practice.  In  con- 
sequence of  this  step  a  deputation  of  the  English- 
speaking  practitioners  has  just  waited  on  Signor 
Serena,  under  secretary  of  state  for  the  home  depart- 
ment, to  protest  against  such  action.  His  excellency 
announced  in  reply  that  arrangements  in  the  direction 
proposed  by  the  Italian  Medical  Congress  had  not  yet 
been  taken,  but  that  in  any  case  the  government  before 
giving  legal  effect  to  the  innovation  contempJated  by 
the  congress  would  put  itself  in  diplomatic  communi- 
cation with  the  governments  of  the  other  powers,  with 
a  view  to  obtaining  for  Italian  practitioners  in  those 
countries  the  same  privileges  enjoyed  in  Italy  by  for- 
eigners. The  matter  will  probably  rest  there. — The 
Lancet. 


822 


MEDICAL    RECORD 


[December  4,  1897 


^ctjiewjs  and  Notices. 

Chirurgie  des  Voies  Urixaires  :  Etudes  Cliniques. 
Par  le  Dr.  E.  Lou.meau,  Professeur  Libre  de  Clinique  des 
Maladies  des  Voies  Urinaires.  2me  Volume.  Avec 
Planches  hors  Texte.  Bordeaux :  Feret  et  Fils,  Libraires- 
Editeurs.      1897. 

This  is  the  second  volume  based  upon  the  author's  personal 
observation  of  cases,  to  which  he  has  added  such  commen- 
taries as  have  seemed  necessar)'.  Much  of  the  matter  has 
already  been  published  in  periodical  literature  or  as  commu- 
nications to  societies.  A  similar  volume  with  the  same  title 
was  published  by  the  author  some  three  years  ago. 

Die  Hefex  als  Kr-ankheitserreger.     Von  Dr.  Otto 
Busse,    Privatdocent   fiir  Pathologic   imd   pathologische 
Anatomie   in   Greifswald.     Berlin:    August    Hirschwald. 
.      1897. 

This  short  brochure,  containing  two  colored  plates  and  a 
number  of  other  illustrations,  represents  the  results  of  a 
careful  experimental  study  of  the  yeast  family  of  plants 
(blastomycetes,  etc.)  in  the  production  of  disease  processes. 

Cystitis  und  Urininfektion.  Klinische,  experimen- 
telle  und  bakteriologische  Studier.,  von  Dr.  Med.  Max 
Melchior,  Privatdocent  an  der  Universitat  in  Kopenha- 
gen,  Fr.  Chef  des  Laboratoriimis  und  Secimdarchirurg  am 
Koniglichen  Friedrichs-Hospital.  Berlin :  Verlag  von  S. 
Karger.      1897. 

This  unbound  volume  of  two  hundred  and  thirty-eight 
pages  without  illustrations  is  a  praiseworthy /-^ww^  of  present 
knowledge  concerning  urinary  infections  and  the  results  of 
bacteriological  experimentation  in  cystitis,  urethral  fever,  etc. 

Technik  und  praktische  Bedeutung  der  Asepsis 
bet  der  Behandlung  der  Harnleiden.     Von  Dr. 
Robert  Kutner,  Berlin.     Berlin :    August  Hirschwald. 
1897. 
The  author  has  included  in  forty-two  pamphlet  pages  many 
useful  hints  on   the  aseptic  treatment   of   urinary  derange- 
ments.    There  are  eight  illustrations. 

Festschrift  Eduard  Hagexbach-Burckhardt,  Pro- 
fessor der  Kinderheilkunde  und  Director  des  Kinderspitals 
in  Basel,  zu  seinem  25jahrigen  Professoren-Jubilaum. 
Gewidmet  von  seinen  Schiilem.  Basel  und  Leipzig :  Carl 
Sallmann.      1897. 

This  jubilee  production  by  the  author's  pupils  contains  a 
number  of  well-written  and  interesting  theses ;  one  on  con- 
genital malformations  is  well  illustrated  by  two  plates  con- 
taining many  interesting  specimens. 

Specielle  Diatetik  ukd  Hygiene  des  Lungen-  und 
Kehlkopf-Schwindsuchtigen.  Von  Dr.  Felix 
BlumenfeLD,  Wiesbaden.  Berlin:  'Verlag  von  Au- 
gust Hirschwald.      1897. 

Many  useful  hints  in  the  management  of  consumptive 
patients  will  be  found  to  repay  the  reader.  There  are  about 
one  hundred  pages  of  text. 

A  Pictorial  Atlas  of  Skin  Diseases  and  Syphi- 
litic Affections.  In  Photo-Lithochromes  from  Models 
in  the  Museum  of  the  St.  Louis  Hospital,  Paris.  With 
Explanatoiy  Woodcuts  and  Texts  by  Ernest  Besnier, 
A.  FOURNIER,  Tenneson,  Hallopeau,  Du  Castel, 
Henri  Feulard,  L.  Jacquet.  Part  XI.  Edited  and 
annotated  by  J.  J.  Pringle,  M.B.,  F.R.C.P.  London: 
The  Rebman  Publishing  Company,  Ltd.  Philadelphia: 
W.  B.  Saunders.     1897. 

The  first  plate  presents  the  interesting  conditions  of  hydroic 
erythema  of  the  hands  and  lips,  for  which  the  text  has  been 
written  by  Du  Castel.  The  next  plate,  representing  the 
pigmented  syphilide,  has  nothing  special  to  commend  it,  and 
one  is  at  a  loss  (unless  thoroughly  familiar  with  the  subject) 
to  guess  from  what  portion  of  the  anatomy  the  picture  is 
taken.  Whenever  a  question  of  anatomical  location  could 
arise  it  would  be  much  better  if  the  region  from  which  the 
model  was  made  were  indicated  on  the  plate.     The  other. 


representing  moUuscum  contagiosum,  the  text  of  which 
is  written  by  Baudouin,  is  of  special  value  in  differentia- 
tion of  these  lesions  from  a  syphilide.  Plate  44,  showing 
nsevi  of  the  leg,  described  by  Gaucher,  is  of  interest  more 
as  a  curiosity  than  because  of  its  great  practical  importance. 
The  pigmentation  from  pediculosis  is  strikingly  portrayed  in 
a  typical  picture  of  the  back. 

Rheumatism  and  its  Treatment  by  the  Use  of  the 
Percusso  Punctator.  By  J.  Brindley  James, 
M.R.C.S.  Eng.,  Licentiate  of  the  Royal  College  of  Phy- 
sicians of  Ireland ;  Associate  of  King's  College,  Lon- 
don ;  Author  of  ' '  Replies  to  Questions  in  Therapeutics. " 
Second  edition.  The  Rebman  Publishing  Company,  Ltd. 
London.      1 897. 

This  is  a  second  edition  of  a  verj-  brief  account  oi  the 
author's  invention  for  making  acupuncture  over  the  seat  of 
painful  affections.  The  first  appeared  some  ten  years  ago. 
He  also  employs  injections  of  sulphuric  ether,  dry  cup- 
ping, and  internal  medication. 

International  Clinics:  A  Quarterly  of  Clinical  Lec- 
tures on  Medicine,  Neurology,  Surgery,  Gynaecology,  Ob- 
stetrics, Ophthalmology,  Lar\-ngology,  Pharyngology, 
Rhinology,  Otology,  and  Dermatology,  and  Specially  Pre- 
pared Articles  on  "Treatment.  By  Professors  and  Lectur- 
ers in  the  Leading  Medical  Colleges  of  the  L'nited  States, 
Germany,  Austria,  France,  Great  Britain,  and  Canada. 
Edited  by  Judson  Daland,  M.D.  (University  of  Penn- 
sylvania), Philadelphia,  Instructor  in  Clinical  Medicine, 
and  Lecturer  on  Physical  Diagnosis  in  the  University  of 
Pennsylvania,  Assistant  Physician  to  the  Hospital  of 
the  University  of  Pennsylvania;  J.  Mitchell  Bruce, 
M.D.,  F.R.C.P.,  London,  England,  Physician  to  and 
Lecturer  on  the  Principles  and  Practice  of  Medicine  in 
the  Charing  Cross  Hospital ;  David  W.  Finlav,  M.D., 
F.R.C.P.,  Aberdeen,  Scotland,  Professor  of  Practice  of 
Medicine  in  the  University  of  Aberdeen ;  Physician  to  and 
Lecturer  on  Clinical  Medicine  in  the  Aberdeen  Royal  In- 
firmary. Volume  XL,  Seventh  Series.  Philadelphia:  J. 
B.  Lippincott  Company.      1897. 

The  volume  at  hand  is  quite  up  to  the  average  of  this  well- 
edited  series  of  monographs  and  lectures. 

The  contributors  are  as  usual  chosen  with  deliberate  care. 
The  lectures  are  conveniently  classified  under  therapeu- 
tics, medicine,  neurology,  surger\',  etc.  The  first,  by  Ed- 
ward Jackson,  is  a  verj'  short  chapter  on  the  treatment  of 
presbyopia.  Indeed  most  of  the  chapters  are  short  and  cor- 
respondingly attractive.  This  also  makes  it  possible  to  in- 
clude in  the  volume  the  writings  of  many  more  authors  than 
is  possible  when  long-drawn-out  discourses  are  accepted. 
Not  only  is  the  quality  of  the  writings  being  maintained,  but 
the  general  make-up  of  the  book  is  very  satisfactory. 

The  illustrations  are  not  so  numerous  nor  are  they  so  good 
as  in  many  former  volumes  of  the  series. 

Journal  of  the  Military  Service  Institutions  of 
the  United  States.  Vol.  XX.,  No.  LXXXVI. 
March,  1897. 

This  is  a  bimonthly  publication  edited  by  James  C.  Bush. 
The  present  number  contains  interesting  articles  on  proper 
military  institutions,  by  Wagner,  Foote,  and  Steele.  It  of- 
fers besides  much  that  is  of  interest  to  militarj'  men. 

The  Origin  of  Disease,  Especially  of  Disease  Re- 
sulting from  Intrinsic  as  Opposed  to  Extrin- 
sic Causes.  By  Arthur  V.  Meigs,  M.D.,  Physician 
to  the  Pennsylvania  Hospital.  8vo,  pp.  229.  Philadel- 
phia:    J.  B.  Lippincott  Company.      1897. 

This  well-written  and  logically  suggestive  work  is  upon  a 
topic  of  wide  interest  to  every-  thoughtful  reader,  and  gives 
much  food  for  the  earnest  study  and  careful  differentiation  of 
long-accepted  facts.  The  courage  evinced  by  the  author  in 
combating  many  of  the  time-worn  tlieories  regarding  the 
intrinsic  and  extrinsic  origins  of  disease  will  be  duly  appreci- 
ated by  all  who  may  be  interested  in  a  very  broad  subject 
treated  in  a  philosophical  manner  from  a  conscientiously 
comprehensive  praint  of  view.  The  wTiter  follows  a  very 
consistent  line  of  argimient,  which  tends  to  prove  that  in  all 
human  beings  there  is  a  latent  tendency  to  disease  that  re- 
sembles in  a  striking  way  the  ordinary  physical  changes  of 
progressive  decay.     The  latter  is  made  manifest  more  par- 


December  4,  1897] 


MEDICAL    RECORD. 


82- 


ticularly  in  the  study  of  the  varied  conditions  associated  with 
fibrosis  in  the  different  tissues  of  the  vital  organs.  The  facts 
bearing  on  this  view  are  adduced  from  the  study  of  a  large 
number  of  microscopical  lesions  of  the  vessels  and  parenchy- 
mata  of  the  organs  in  question.  It  is  the  careful  consideration 
of  these  data  that  leads  to  the  almost  inevitable  conclusion 
that  no  one  organ  is  a  leading  factor,  but  rather  that  each  is 
a  part  of  a  whole,  in  a  general  degenerative  process.  The 
views  on  the  duality  of  phthisis,  and  the  differences  between 
inflammatory  and  strictly  tuberculous  degenerations,  are  par- 
ticularly interesting  in  view  of  the  generally  accepted  beliefs  to 
the  contrary.  The  same  may  be  said  from  the  standpoint  of 
novelty  regarding  the  multiple  character  of  Bright's  disease, 
and  the  ingenious  disproof  of  the  tenability  of  compensatory 
cardiac  hypertrophy  in  vah-ular  affections.  Altogether  the 
volume  deals  very  exhaustively  \\-ith  the  subject  in  hand,  and 
is  an  efficient  aid  to  every  one  who  may  wish  to  reconcile 
the  facts  of  clinical  experience  with  the  actual  demonstration 
of  associated  pathological  lesions. 

The  Surgical  Peculiarities  of  the  American 
Negro.  A  Statistical  Inquirj'  Based  upon  the  Records 
of  the  Charity  Hospital  of  New  Orleans,  La.,  Decennium 
1884-94.  By  Rudolph  Matas,  M.D.,  Professor  of 
Surgery,  Medical  Department,  Tulane  University-  of 
Louisiana;  Visiting  Surgeon  to  the  Charity  Hospital  of 
New  Orleans. 

This  brochure  of  one  hundred  and  thirty  pages,  reprinted 
from  the  transactions  of  the  American  Surgical  Association 
for  1896,  deals  with  a  great  variety'  of  interesting  conditions, 
which  the  author  has  carefully  worked  up  from  several  differ- 
ent standpoints.  The  diseases  of  the  skin  have  been  made  the 
subject  of  a  special  study  by  Dr.  Dyer,  also  of  New  Orleans 
Charity  Hospital,  which  is  added  as  an  appendix.  Data 
from  various  sources  have  been  incorporated,  and  quite  a 
lengthy  bibliography  closes  the  volume. 

Report  of  the  Passaic  Valley  Sewerage  Commis- 
.sioN  UPON  the  General  System  of  Sewage  Dis- 
posal for  the  Valley  of  the  Passaic  River, 
AND  Prevention  of  the  Pollution  Thereof. 
Newark,  \.  J.,  February,  1897. 

This  report  contains  valuable  data  and  a  large  map  of  the 
district  in  question.  In  a  brochure  of  one  hundred  and  thirty 
pages,  the  author  has  collected  much  interesting  data  bear- 
ing upon  the  question  in  hand. 

Practical  Notes  on  Urinary  Analysis.  By  Wil- 
liam B.  Canfield,  A.m.,  M.D.,  Lecturer  on  Clinical 
Medicine,  University  of  Maryland;  Visiting  Physician  to 
the  Union  Protestant  Infirmar)',  Bay  View  Hospital. 
Second  Revised  Edition.     Detroit :  George  S.  Davis. 

The  present  edition  of  Dr.  Canfield's  hundred-page  bro- 
chure has  been  revised  so  as  to  cover  the  ground  and  include 
the  more  recent  methods  of  urinary  analysis. 

Lectures  on  Appendicitis  and  Notes  on  Other 
SuBjEcrs.  By  Robert  T.  Morris,  A.M.,  M.D., 
Fellow  of  the  New  York  Academy  of  Medicine ;  Ameri- 
can Association  of  Obstetricans  and  Gynaecologists; 
American  Medical  Association.  Second  Edition,  Revised 
and  Enlarged.  With  Illustrations  by  Henry  Mac- 
Donald,  M.D.  New  York  and  London:  G.  P.  Put- 
nam's Sons. 

The  present  volume  has  been  somewhat  increased  in  size 
and  modified  in  text.  The  work  is  practically  a  collection  of 
lectures  embracing  the  author's  views  upon  the  very  impor- 
tant and  interesting  subject. 

There  are  added  (under  the  heading  of  "Notes")  a  series  of 
short  articles  upon  important  surgical  topics,  which  equal  in 
space  covered,  illustrations,  and  general  interest  the  lectures 
proper. 

Hand-Book  for  Hospitals.  By  Abbv  Howland 
Woolsev,  Member  of  Committee  on  Hospitals  of  the 
State  Charities  Aid  .A.ssociation.  Third  Edition.  New 
York  and  London :  G.  P.  Putnam's  Sons. 

This  is  No.  32  of  the  New  York  State  Charities  Aid  Asso- 
•ciation  Series.  A  special  committee  on  revision  of  this  hand- 
book, consisting   of   Drs.    Hitchcock,  Wheelock,    and   Gill 


Wylie,  has  collected  a  mass  of  special  information  here 
embodied,  which  will  be  foimd  of  great  use  to  charity  com- 
missioners, superintendents  of  poor,  and  those  engaged  in  the 
management  of  hospitals,  asylums,  and  institutions  in  gen- 
eral. It  embraces  information  on  water  supply,  drainage, 
housekeeping,  nursing-services,  disinfection,  etc. 

Address  on  Immunity  to  Disease.  By  W.  B.  Ran- 
som, M.D.,  M.A.,  M.R.C.P.,  Physician  to  the  General 
Hospital,  Nottingham.  London :  John  Bale  &  Sons. 
"This  is  the  presidential  address  delivered  before  the  Not- 
tingham Medico-Chirurgical  Societj'.  It  deals  in  an  excep- 
tional manner  with  a  very  interesting  question. 

A  Clinical,  Pathological,  and  Experimental 
Study  of  Fracture  of  the  Lower  End  of  the 
Radius,  with  Displacement  of  the  Carpal 
Fragment  toward  the  Flexor  or  Anterior 
Surface  of  the  Wrist.  By  John  B.  Roberts, 
A.M.,  M.D.,  Professor  of  Anatomy  and  Surgery  in  Phila- 
delphia Potyclinic ;  Professor  of  Surgery  in  the  Woman's 
Medical  College  of  Pennsylvania.  With  33  illustrations. 
Philadelphia:  P.  Blakiston,  Son  &  Co.      1897. 

This  little  work  of  seventy-sLx  pages  deals  with  specimen 
cases,  experimental  obser\^ations,  causes  and  mechanism, 
symptoms,  diagnosis,  and  treatment  of  the  injury  described. 

Proceedings  of  the  Nebraska  State  Medical  So- 
ciety. Twenty-ninth  Annual  Session,  1897.  Published 
by  the  Society. 

Three  hundred  and  seventy  three  pages  of  well-prepared, 
well-printed,  and  well-bound  papers,  with  frontispiece  picture 
of  President  Haldeman. 

.A.NNUAL  Report  of  the  State  Board  of  Charities 
for  the  Year  1896.  Transmitted  to  the  Legislature 
February  25,  1897.  Albany  and  New  York :  Wynkoop- 
Hallenbeck-Crawford  Company.      1896. 

This  is  the  usual  senate  report,  and  it  contains  much  of  sta- 
tistical interest. 

The  American  Academy  of  Railroad  Surgeons. 
Report  of  the  Third  Annual  Meeting  held  at  Chicago,  III., 
September  23,  24,  and  25,  1896.  Edited  by  R.  Harvey 
Reed,  .M.D.,  Columbus,  Ohio.  Chicago:  American 
Medical  Association  Press.      1897. 

Besides  the  usual  number  of  surgical  papers,  this  volimie 
contains  good  pictures  of  Dr.  J.  E.  Owens,  of  Chicago,  as 
a  frontispiece,  and  of  Drs.  Hamden,  of  Waverly ;  Dooley,  of 
Buffalo;  and  Peck,  of  Utica,  New  York,  which  make  the 
volume  the  more  worth  keeping. 

A  Manual  of  Legal  Medicine  for  the  Use  of 
Practitioners  and  Students  of  Medicine  and 
Law.  By  Justin  Herold,  A.M.,  M.D.,  formerly 
coroner's  physician  of  New  York  City  and  County,  etc. 
8vo,  pp.  678.  Philadelphia:  J.  B.  Lippincott  Company. 
1898. 

The  wide  and  varied  practical  experience  of  the  author  as 
coroner  has  well  qualified  him  for  the  task  of  presenting,  in 
a  condensed  form,  the  fundamental  principles  of  medical 
jurisprudence,  and  an  abundant  evidence  of  the  fact  is  the 
general  character  of  the  work  itself.  No  attempt  has  been 
made  to  write  an  exhaustive  treatise,  but  the  skill  shown  in 
the  selection  of  essential  salient  points  of  the  varied  topics 
considered  amply  compensates  for  that  illustrative  detail  ex- 
pected in  more  elaborate  works.  The  g  -eral  field  is  well 
covered  and  the  arrangement  is  consistently  systematic.  The 
work  is  divided  in  two  parts,  the  first  treating  of  toxicology, 
and  the  second  of  forensic  medicine  proper.  The  classifica- 
tion of  drug  poisons  is  complete  enough  for  practical  pur- 
poses and  the  chemical  tests  for  their  detection  are  clearly 
presented.  The  toxic  phenomena  are  well  described  and  the 
points  of  diagnosis  are  well  considered.  In  part  second,  the 
more  important  portion  of  the  volume  for  practitioners,  there 
is  a  full  exposition  of  the  facts  connected  with  wounds  as  vari- 
ous causes  of  death  in  murder  and  suicide  cases,  and  of  the 
legal  relations  of  supposed  accidents  with  suspected  murder. 
In  this  connection  the  pathological  conditions  of  drowning 
are  very  lucidly  described,  and  ihf  differences  between  ante- 
mortem  and  post-mortem  immersion  are  properly  explained. 


824 


MEDICAL    RECORD. 


[December  4,  1897 


Due  attention  is  also  given  to  malpractice  cases,  to  matters  of 
contributory  negligence  connected  tlierewith,  and  to  the  rela- 
tions of  death  in  criminal  cases  with  negligence  or  want  of  skill 
in  the  practitioner.  Deaths  by  electricity  also  form  a  ver\- 
interesting  portion  of  the  book.  The  appendix  contains  a 
medico-legal  description  of  several  recent  leading  criminal 
cases,  notably  those  of  Carlisle  Harris,  Meyer,  Holmes,  and 
Robert  W.  Buchanan. 

Appendicitis  and  its  Surgical  Treatment,  with 
A  Report  of  Seventv-Five  Operated  Cases.  By 
Herman  Mynter,  M.D.,  Professor  of  Operative  and 
Clinical  Surgery  in  Niagara  University,  Buffalo,  N.  Y. 
8vo,  pp.  302.  Philadelphia:  J.  B.  Lippincott  Company. 
1897. 

This  volume  on  the  absorbing  topic  of  appendicitis  is  a  verj- 
careful  and  quite  exhaustive  study  of  the  subject,  ostensibly 
from  the  surgeon's  point  of  view.  One  of  the  chief  charac- 
teristics of  the  volume  is  its  carefully  prepared  bibliography, 
showing  painstaking  accuracy  in  the  numerous  quotations 
from  authorities.  The  author  accepts  the  view  of  the  bac- 
terial origin  of  the  disease  and  the  marked  predisposing 
influences  of  malpositions  as  the  direct  results  of  initiatory- 
inflammatory  attacks.  The  medical  treatment  is  viewed 
quite  impartially  and  gives  greater  strength  to  the  argu- 
ments in  favor  of  radical  surgical  measures.  The  well- 
written  reports  of  seventy-five  operative  cases  fully  attest 
the  soundness  of  the  author's  views  as  to  early  interference. 

A  System  of  Practical  Medicine  by  American  Au- 
thors. Edited  by  Alfred  Lee  Loomis,  M.D.,  LL.D., 
Late  Professor  of  Medicine  in  the  New  York  University, 
and  William  Oilman  Thompson,  ^LD.,  Professor  of 
Materia  Medica,  Therapeutics,  and  Clinical  Medicine  in 
the  New  York  L'niversitj',  Physician  to  the  Presbyterian 
and  Bellevue  Hospitals,  New  York.  \'olume  H.  Dis- 
eases of  the  Respirator)'  System  and  the  Mediastinum, 
Diseases  of  the  Blood,  Diseases  of  the  Kidneys,  Dis- 
eases of  the  Bladder  and  Prostate  Gland.  Illustrated. 
New  York  and  Philadelphia:  Lea  Brothers  &  Co.      1897. 

The  contributors  to  this  second  volume  include  besides  the 
late  Dr.  Alfred  Loomis  and  Dr.  Henry  P.  Loomis,  such  names 
as  Solly,  Tyson,  Whittaker,  Fitz,  Coleman,  Mason,  and  a 
number  of  others.  The  general  scope  and  make-up  of  the 
work  quite  come  up  to  the  standard  promised  in  Volume 
I.  The  pulmonar\'  diseases  have  come  in  for  a  large  share 
of  careful  consideration,  and  are  treated  of,  in  part  at 
least,  in  a  masterly  way.  The  contribution  from  Loomis 
himself  upon  endocarditis,  though  not  especially  long,  elu- 
cidates the  subject  in  a  very  complete  and  satisfactory- 
manner.  Next  to  the  diseases  of  the  lungs  come  those 
of  the  kidneys,  so  far  as  space  occupied  and  careful  prepa- 
ration are  concerned.  The  blood,  in  its  various  pathologi- 
cal changes,  has  received  a  large  amount  of  attention  at 
the  hands  of  Shattuck  and  Cabot,  making  a  very  interest- 
ing and  instructive  chapter  illustrated  with  no  less  than 
three  colored  plates  besides  the  woodcuts.  The  illus- 
trations throughout  the  work  are  numerous  and  excellent. 
No  chapters  can  be  picked  out  as  presenting  evidences  of 
greater  care  and  preparation  than  others ;  still  upon  a  cur- 
sory review  those  upon  the  physical  signs  of  pulmonary-  dis- 
eases, hay  fever,  asthma,  heart  disease,  endocarditis,  and  the 
non-tuberculous  diseases  of  the  pleura  appear  to  have  been 
prepared  for  the  reader  with  conscientious  consideration. 

A  System  of  Practical  Therapeutics.  Edited  by 
Hobart  Amorv  Hare,  M.D..  Professor  of  Therapeu- 
tics and  .Materia  Medica  in  the  Jefferson  Medical  College 
of  Philadelphia,  Physician  to  the  Jefferson  Medical  Col- 
lege Hospital.  Volume  I\'.  With  Illustrations.  Phila- 
delphia and  New  York:  Lea  Brothers  &  Co.      1897. 

This  fourth  volume  covers  the  field  of  hydrotherapy,  cliriiate. 
infections,  diseases  of  the  respiratory,  digestive,  genito-uri- 
nary,  cutaneous,  and  nervous  systems,  and  diseases  of  the 
eye  and  ear. 

We  believe  that  the  editor  of  this  system  has  been  gov- 
erned by  wisdom  in  urging  his  authors  to  include  in  their 
special  departments  illustrative  prescriptions  with  dosage  and 
directions  for  the  requirements  of  g^ven  conditions.  He 
very  justly  says :  •  •  The  practising  physician  wishes  to  know 
how  the  author  himself  would  use  the  remedies  he  com- 
mends, if  he  were  at  the  bedside."     In  spite  of  this  policy 


the  prescriptions  are  not  profuse,  even  in  the  editor's  ow-n 
chapters,  one  of  which,  dealing  with  scarlet  fever  and  measles, 
is  strikingly  brief.  Diseases  of  the  blood  are  more  briefly 
considered  than  is  customary  to-day  in  the  larger  w-orks  on 
medicine. 

We  must  not  forget,  however,  that  we  have  before  us  a 
system  of  therapeutics,  and  not  a  treatise  upon  general  medi- 
cine. Taken  altogether,  this  volume  is  of  equal  excellence 
with  those  already  published,  and,  although  the  illiastrations 
are  few,  the  text  is  for  the  most  part  presented  in  a  very 
readable  manner.  The  list  of  contributors  contains  many  of 
the  best-known  .American  names. 

Anomalies  and  Curiosities  of  Medicine.  An  En- 
cyclopsedic  Collection  of  Rare  and  Extraordinarj'  Cases, 
and  of  the  Most  Striking  Instances  of  .'Vbnormalit)-  in  All 
Branches  of  Medicine  and  Surgery,  Derived  from  an  Ex- 
haustive Research  of  Medical  Literature  from  its  Origin 
to  the  Present  Day,  Abstracted,  Classified,  Annotated,  and 
Indexed.  By  George  M.  Gould,  .A.M.,  M.D.,  and 
Walter  L.  Pyle,  A.M.,  M.D.  Philadelphia:  W.  B. 
Saunders.     1897. 

It  is  with  somewhat  of  a  "dime-museum  "  feeling  that  one 
opens  this  volume  of  human  freaks,  and  one  is  likely  to 
ask  himself  at  the  threshold  whether  or  not  he  is  • '  glad  he 
came."  A  fascination,  however,  leads  him  from  one  anom- 
aly to  another,  until  he  finds  himself  studying  monstrosities, 
deformities,  congenital  and  acquired,  of  every  variety  of 
which  mortal  has  ever  dreamed,  and  many  which  could 
scarcely  enter  the  imagination  in  the  wildest  delirium.  It  is 
a  large  volume,  and,  while  by  no  means  exhausting  the  ex- 
tensive subject,  it  contains  a  classified  collection  of  a  large 
number  of  rare  and  remarkable  specimens  illustrating  what 
de\-iations  from  the  normal  human  nature  is  capable  of.  As 
an  epitome  of  the  literature  of  medical  freakdom  the  work 
will  fill  a  place  as  a  book  of  reference,  especially  if  in  future 
editions  certain  chapters  are  supplemented  so  as  more  per- 
fectly to  cover  the  field.  Sexual  peculiarities  take  up  a  large 
space,  while  pathological  gro\\-ths  attaining  unusual  propor- 
tions are  included  among  the  curiosities,  along  with  joined 
twins,  triple  monsters,  homed  men.  and  bearded  ladies.  The 
index  is  quite  long  but  lacking  in  many  particulars,  and 
should  be  supplied  with  cross-references.  A  partial  bibli- 
ography, ranging  from  Nos.  100  to  847,  is  arranged  so  as  to 
save  footnote  space.  Too  many  of  the  interesting  condi- 
tions depicted  and  described  are  not  entered  in  this  list.  The 
illustrations  are  numerous  and  naturally  supply  the  chief 
charm  of  the  w-ork,  which  will  interest  natures  of  a  morbidly 
curious  trend  no  less  than  those  scientificallv  inclined. 


Painful  Cystitis  in  'Women  Treated  by  Vesical 
Curetting. — Camero  claims  that  the  lesions  of  cys- 
titis are  more  frequently  localized  about  the  neck  of 
the  bladder  and  of  the  trigonuni.  In  e.vtreme  cases  we 
have  an  interstitial  cystitis  which  seems  to  be  beyond 
therapeutic  measures.  It  has  been  observ-ed  that  even 
when  the  pain  was  intense  the  mucous  membrane  was 
not  deeply  involved.  In  such  cases  vesical  curetting 
is  productive  of  good.  The  operation  should  be  pre- 
ceded by  thorough  lavage  of  the  bladder,  with  a  solu- 
tion of  boric  acid  to  which  is  added  one  per  cent,  of  a 
solution  of  bichloride  of  mercury  of  the  strength  of  1 
to  1,000.  The  doctor  concludes  his  article  as  fol- 
lows: "1.  Painful  cystitis  is  particularly  frequent  in 
women.  2.  The  measures  to  be  resorted  to  should 
consist  of  the  treatment  of  the  uterus  and  its  adnexa 
and  general  treatment.  3.  The  local  treatment  of  cys- 
titis, although  easy  in  light  cases,  becomes  insufficient 
in  pronounced  cases.  4.  Surgical  treatment  becomes 
necessary  in  cases  in  which  the  pain  is  intense.  5. 
Cystotomy,  particularly  colpo-cystotomy,  should  be 
reserved  for  very  serious  cases.  6.  Very-  often  recov- 
ery or  a  step  toward  recovery  by  means  of  local  topi- 
cal treatment  may  be  obtained  by  curetting  the 
bladder  through  the  urethra.  7.  This  operation  is 
simple  and  easy;  it  does  not  require  any  complemen- 
tal  operation,  and  it  gives  excellent  results." — Ga- 
seitc  hi-bdomadaire  df  Mcdecitit  et  dc  Chirurzie. 


December  4,  1897] 


MEDICAL    RECORD. 


82s 


Jiociety  Reports. 

THE  PRACTITIONERS'  SOCIETY  OF  NEW 
YORK. 

Regular    Meeting.    Held    on  Friday  Evening,   October 
IS.  iSgj. 

"^'.    GiLMAX    THOiiPsox,  M.D.,  President,    in    the 
Chair. 

A  Case  of  Pulmonary  Tuberculosis  Complicated  by 
Pneumo-Hydrothorax,  with  Some  Unusual  Features. 
— The  patient,  presented  by  Dr.  A.  A.  Smith,  was  a 
man  thirt}--five  years  old,  a  gripman  by  occupation, 
who  first  came  to  Bellevue  Hospital  in  Januar}-,  1897. 
During  the  previous  summer  he  had  been  ill  enough 
for  the  railway  company  to  grant  him  a  vacation,  and 
when  he  returned  to  his  work  his  condition  was  unim- 
proved ;  he  suffered  from  cough,  shortness  of  breath, 
a  certain  amount  of  fever,  and  on  one  occasion  he  ex- 
pectorated a  small  quantity  of  blood.  About  two 
weeks  before  he  entered  the  hospital  he  had  had 
a  violent  attack  of  coughing,  with  moderately  severe 
pains  which  he  referred  to  the  lower  axillarj-  region. 
At  no  time  had  he  had  any  severe  pain  higher  up  in 
the  thorax. 

Upon  his  admission  to  the  hospital  the  physical 
examination  revealed  a  rather  curious  condition. 
There  were  evidences  of  consolidation  of  the  right 
lung  with  marked  thickening  of  the  pleura  over  the 
upper  thoracic  region,  extending  down  to  the  inferior 
angle  of  the  scapula;  below  that  there  was  a  very 
marked  t}'mpanitic  percussion  sound,  and  over  that 
area  there  was  an  entire  absence  of  vocal  fremitus  with 
distinct  amphoric  breathing.  The  diagnosis  of  pul- 
monary tuberculosis  complicated  by  pneumothorax 
was  made.  Within  fortj'-eight  hours  succussion 
sounds  were  heard,  with  distinct  evidence  of  a  pneumo- 
hydrothorax.  There  was  marked  dyspnoea,  which  was 
relieved  by  the  withdrawal  of  a  portion  of  the  fluid  by 
aspiration.  In  the  course  of  a  few  days  the  cavity 
refilled  and  was  again  aspirated.  Subsequent  to  this 
the  symptoms  of  pneumo-hydrothorax  entirely  disap- 
peared and  he  improved  rapidly  during  the  past  sum- 
mer, gaining  nine  pounds  in  weight.  In  September, 
however,  his  pulmonary  symptoms  became  more  acute, 
and  he  developed  a  laryngitis  which  was  tuberculous  in 
character:  another  serous  effusion  also  took  place,  and 
a  large  quantity  of  fluid  was  withdrawn. 

Dr.  Smith  said  the  point  of  special  interest  in  con- 
nection with  the  case  was  the  improvement  that  oc- 
curred subsequent  to  the  attack  of  pneumo-hydrothorax. 
.^t  the  present  time  the  physical  signs  were  those  of 
consolidation  at  the  apex  of  the  right  lung,  with  marked 
thickening  of  the  pleura,  extending  from  about  the 
middle  of  the  scapula  to  the  base  of  the  lung.  No 
tubercle  bacilli  had  been  found  in  the  fluid  withdrawn 
from  the  chest,  although  they  were  found  in  the  sputa. 

Acute  Serous  Meningitis. —  Dr.  C.  L.  Dana  read  a 
paper  on  this  subject  (see  page  801). 

Dr.  G.  L.  Peabodv  said  this  condition  of  "  wet- 
brain,"  so  called,  was  one  with  which  all  who  had 
had  much  pathological  experience  in  hospital  practice 
were  thoroughly  familiar.  The  speaker  confessed  that 
he  had  never  ascribed  to  it  the  importance  attached  to 
it  by  Dr.  Dana,  nor  had  he  ever  regarded  it,  strictly 
speaking,  as  an  inflammatory  process — of  which,  in 
fact.  Dr.  Dana  had  fonnd  no  evidence.  Dr.  Peabody 
said  he  had  always  looked  upon  this  condition  as  a 
part  of  the  general  atrophic  changes  which  occurred  in 
the  organs  of  alcoholic  patients.  We  knew  that  in 
this  class  of  cases  atrophic  changes  took  place  in  the 
more  imjxirtant  glandular  structures,  particularly  in 


the  stomach,  liver,  and  kidneys,  and  even  the  obesity 
produced  by  alcohol  was  now  regarded  as  an  evidence 
of  malnutrition — it  was  really  an  atrophic  condition. 
It  would  be  fairer,  the  speaker  thought,  to  infer  that 
the  serous  exudates  described  by  Dr.  Dana  were  the 
result  of  an  antecedent  atrophy  of  the  brain  tissues. 
There  was  an  exudation  of  serum  to  take  the  place  of 
the  brain  tissue  which  had  been  lost  by  the  atrophic 
process.  In  conclusion.  Dr.  Peabod)-  said  that  he  did 
not  wish  to  be  understood  as  denying  the  conclusions 
set  forth  by  Dr.  Dana.  Because  of  the  absence  of  so 
many  of  the  usual  typical  symptoms  of  meningitis, 
however,  and,  further,  because  of  the  fact  that  many 
alcoholic  patients  who  died  had  an  abnomally  dry 
brain  rather  than  a  wet  one,  he  had  been  led  to  the  be- 
lief that  the  condition  referred  to  was  the  result  of 
atrophic  changes  rather  than  an  inflammation. 

Dr.  D.\xa,  in  reply  to  a  question  as  to  how  he 
tapped  the  spinal  cord,  said  he  had  followed  the  meth- 
od described  by  Quincke.  The  patient  was  placed  on 
his  side,  with  the  head  elevated  and  the  trunk  well 
fle.xed,  and  then  a  needle,  about  five  inches  long,  was 
passed  in  between  the  second  and  third  liunbar  verte- 
bras directly  between  the  spines  in  children,  and  about 
one-fourth  of  an  inch  to  one  side  in  adults.  Dr.  Dana 
said  that  the  operation,  while  it  required  a  little  skill, 
was  comparatively  simple,  and  the  needle  usually  at  the 
first  attempt  slipped  right  in,  and  its  insertion  was  gen- 
erally followed  by  a  spiut  of  fluid,  which  was  permitted 
to  run  until  three  or  four  drachms,  sometimes  only  one 
drachm,  and  sometimes  even  one  ounce  or  more  had 
escaped. 

Dr.  Beverley  Robinson  spoke  of  two  cases  at  St. 
Luke's  Hospital,  in  which  tapping  the  spinal  cord  had 
been  resorted  to.  The  first  case  was  one  of  obscure 
spinal  trouble.  The  patient  was  going  from  bad  to 
worse,  and  it  was  finally  decided  to  tap  the  cord.  This 
was  done,  but  no  fluid  followed  the  insertion  of  the 
needle.  The  case  went  on  to  a  fatal  termination,  the 
patient  apparently  not  having  received  any  benefit 
from  the  operation.  The  second  case  was  one  of  cere- 
bro-spinal  meningitis.  The  lower  portion  of  the  cord 
was  tapped,  and  about  four  ounces  of  purulent  fluid 
was  withdrawn.  Xo  bacteriological  examination  was 
made.  In  that  case  the  patient  died  during  the  tapping. 
Dr.  Robinson  said  that  in  view  of  his  experience  with 
this  operation,  he  should  not  care  to  resort  to  it  again 
unless  the  conditions  demanding  it  were  very  urgent. 

Dr.  Y.  p.  Gibney  said  he  had  performed  tapping  of 
the  cord  in  cases  of  tuberculous  meningitis  with  neg- 
ative results.  While  he  had  never  seen  death  occur 
during  the  operation,  as  in  Dr.  Robinson's  case,  or 
any  harmful  effects  follow  its  performance,  he  had 
been  rather  impressed  with  the  inutility  of  the  meas- 
ure in  tuberculous  meningitis.  In  cases  like  those 
described  by  Dr.  Dana,  he  could  understand  the  need 
of  such  a  procedure,  especially  as  he  saw  no  particu- 
lar objection  to  the  operation.  It  was  well  known  that 
a  spina  bifida  could  be  tapped,  and  unless  too  much  of 
the  fluid  was  removed  no  ill  effects  would  follow. 

Dr.  Adami,  of  Montreal,  was  inclined  to  agree  with 
Dr.  Peabody  that  the  condition  described  so  fully  by 
Dr.  Dana  might  in  the  main  be  of  the  nature  of  a  hy- 
drops ex  vacuo,  secondary  to  atrophic  changes  in  the 
cortex.  The  alterations  in  the  cells  described  and 
illustrated  might  well  be  atrophic  in  character,  and 
had  there  been  an  active  pouring  out  of  fluid,  such  as 
occurred  in  meningitis,  he  would  not  have  anticipated 
such  great  variations  in  the  amount  of  fluid  secured  by 
lumbar  tapping.  Judging  from  these  great  variations, 
it  would  appear  rather  that  in  this  condition  of  the 
"wet-brain"  of  alcoholism  there  might  be  two  factors 
in  action  to  different  extents  at  different  stages  or  in 
different  individuals — a  passive  pouring  out  of  fluid 
to  compensate  for  toxic  atrophy  of  the  brain  substance. 


826 


MEDICAL    RECORD. 


[December  4,  1897 


and  an  active  pouring  out,  obscurely  inflammatory  in 
character,  as  suggested  by  Dr.  Dana. 

Dr.  H.  M.  Biggs  said  that  while  in  Berlin,  in  the 
summer  of  1896,  he  was  informed  by  Professor  Koch 
that  at  the  Hospital  for  Infectious  Diseases  lumbar 
tapping  was  resorted  to  almo.st  as  a  routine  measure 
in  differentiating  between  cerebro-spinal  and  other 
types  of  meningitis.  In  regard  to  the  pathology  of  the 
condition  described  by  Dr.  Dana,  the  speaker  said 
that  while  in  the  main  he  agreed  with  Dr.  Peabody,  that 
the  process  was  secondary  to  an  atrophy,  still  he 
thought  the  atrophy  was  not  the  only  factor  in  its  pro- 
duction. In  addition  to  the  increase  of  cerebro-spinal 
fluid  secondary  to  the  atrophy  in  the  brain  tissue,  there 
was  probably  a  further  increase  in  the  quantity  of  the 
fluid,  due  to  the  direct  influence  of  the  acute  alcohol- 
ism. This  seemed  to  the  speaker  probable,  as  it  was 
not  usual  to  see  in  autopsies  on  alcoholic  subjects 
who  had  died  suddenly  or  from  the  direct  result  of 
some  other  condition  than  acute  alcoholism  such  a 
very  great  increase  in  cerebro-spinal  fluid  as  was  com- 
monly found  in  chronic  alcoholism  with  an  acute 
alcoholism  supervening  and  causing  death. 

Dr.  a.  a.  Smith  inquired  whether  Dr.  Dana  had 
found  any  connection  between  the  condition  described 
and  changes  in  the  kidneys. 

Dr.  Dana  replied  that  he  had  found  no  such  con- 
nection. In  a  number  of  the  cases  no  evidences  of 
nephritis  had  been  found  post  mortem,  and  in  those 
cases  the  condition  of  the  brain  was  essentially  the 
same  as  in  those  in  which  kidney  lesions  did  exist.  He 
was  inclined  to  believe,  however,  that  general  arterial 
sclerosis  accompanying  chronic  nephritis  would  be 
apt  to  accelerate  this  condition  of  "  wet-brain"  and 
render  it  more  serious. 

Dr.  Thompson  said  that  Dr.  Dana  had  certainly 
given  a  very  graphic  clinical  picture  of  this  condition. 
He  fully  indorsed  the  view  expressed  by  the  writer 
that  in  tlie  treatment  of  these  patients  food  was  of  more 
importance  than  were  stimulants.  After  lavage  of  the 
stomach  the  food  could  be  introduced  through  the  tube, 
with  rectal  alimentation  in  addition. 

Dr.  Dana,  in  closing  the  discussion,  said  he  did  not 
regard  this  condition  as  an  inflammation,  in  the  ordi- 
nary sense  of  the  word,  yet  he  thought  it  might  be 
looked  upon  as  an  inflammation  in  the  broadest  defi- 
nition of  that  word.  The  serous  effusion  was  the  result 
of  a  reaction  of  the  cells  to  an  irritant,  and  it  was 
poured  out  in  order  to  wash  away  the  poisons  resulting 
from  cell  degeneration.  The  speaker  said  he  used  the 
term  meningitis  because  the  clinical  picture  was  very 
similar  to  one  of  meningitis.  Often,  at  the  post-mor- 
tem in  these  cases,  a  purulent  meningitis  was  found 
which  had  not  been  recognized  during  life,  because 
the  symptoms  corresponded  simply  to  "wet-brain." 
In  regard  to  the  view  expressed  that  the  process  was  an 
cedema  and  the  result  of  atrophy,  he  thought  there  was 
considerable  truth  in  it,  especially  in  the  older  cases; 
but  this  view  could  not  hold  good  in  the  majority  of 
cases,  because  the  majority  of  these  patients  got  well. 
They  went  through  this  process,  showed  all  these  symp- 
toms, and  then  recovered  entirely,  with  no  evidences 
of  brain  atrophy  afterward.  Taking  a  general  view  of 
these  cases.  Dr.  Dana  said  he  was  inclined  to  believe 
that  the  process  was  one  which  was  more  perhaps  in 
the  nature  of  a  toxxmia  than  of  an  inflammation,  and 
that  there  was  some  active  change  in  the  brain  cells 
due  to  this  toxic  agent.  In  the  fatal  case  narrated  by 
Dr.  Robinson  the  quantity  of  fluid  removed — namely, 
four  ounces — appeared  to  him  to  be  rather  large. 

The   Clinical    Value   of    the   Widal   Test The 

author,  Dr.  W.  Gilman  Thompson,  stated  that  at  the 
meeting  of  the  British  Medical  Association  he  had 
reported  five  hundred  and  three  cases  in  which  the 
Widal  test  had  been  employed,  and  from  that  series  he 


had  drawn  some  conclusions  as  to  its  value.  Since 
then  he  had  added  to  the  above  list  fifty-one  cases 
he  had  had  in  his  own  service  at  the  Bellevue  and 
Presbyterian  Hospitals.  The  total  number  of  cases, 
therefore,  on  which  he  was  now  prepared  to  report  was 
five  hundred  and  fifty-four;  this  did  not  include  re- 
peated tests  made  on  the  same  patient.  The  tests  were 
made  by  experienced  bacteriologists  connected  with 
the  board  of  health  and  with  five  different  hospitals. 
In  the  majority  of  the  cases  those  who  made  the  tests 
had  not  seen  the  patients  and  knew  nothing  whatever 
about  them.  In  one  hundred  and  eighty-two  of  the 
cases  there  were  undoubted  clinical  evidences  of  ty- 
phoid fever;  in  the  remainder  the  test  was  made  as  a 
matter  of  routine.  The  test  gave  rise  to  very  curious 
results  in  certain  cases.  In  one  instance,  for  example, 
four  tests  were  made  during  the  course  of  the  fever 
without  getting  any  result,  but  a  distinct  reaction  was 
obtained  during  convalescence.  In  two  other  cases 
the  reaction  occurred  only  during  the  relapses.  In 
the  one  hundred  and  eighty-two  cases  which  were  diag- 
nosed clinically  as  typhoid  fever  the  test  gave  a  posi- 
tive reaction.  In  six  cases  of  undoubted  typhoid  the 
test  failed  absolutely.  In  a  number  of  cases  of  mala- 
ria, pneumonia,  and  other  diseases,  positive  reactions 
were  also  obtained,  rendering  the  test  somewhat  unre- 
liable from  the  clinical  standpoint. 

Dr.  H.  M.  Biggs  showed  some  cultures  of  the  ba- 
cillus typhosus  which  had  been  prepared  by  a  new 
method  devised  by  Dr.  Philip  H.  Hiss,  assistant 
bacteriologist  in  the  health  department.  As  was  well 
known,  Dr.  Biggs  said,  there  had  always  been  great 
difficulty  in  the  isolation  and  identification  of  the 
typhoid  bacilli  in  the  fasces,  and  their  difterentiation 
from  other  bacilli  of  the  "colon  group" — at  least,  in 
their  rapid  and  certain  identification.  Various  meth- 
ods had  been  devised  to  obviate  this,  none  of  which 
had  been  accurate  or  satisfactory  in  all  respects;  they 
involved  either  too  much  uncertainty  or  too  much  time 
and  labor  to  be  of  practical  value  in  a  diagnostic 
sense.  Dr.  Hiss,  he  said,  after  a  long  series  of  experi- 
ments, had  succeeded  in  finding  two  media  which 
seemed  to  overcome  the  obstacles  heretofore  met  with. 
He  then  gave  the  following  abstract  from  a  paper  "On 
a  Method  of  Isolating  and  Identifying  the  Bacillus 
Typhosus,"  which  will  shortly  appear  in  the  /ourrtal 
oj  Experimental  Medicine  : 

"Two  media  have  been  devised.  One  for  the 
differentiation  of  the  bacillus  typhosus  from  the  va- 
rious members  of  the  '  colon  group '  by  tube  culture, 
and  one  for  the  differentiation  of  the  colonies  of  the 
bacillus  typhosus  from  those  of  the  '  colon  group '  by 
plate  culture. 

"  The  tube  medium  contains  agar,  5  gm. ;  gelatin, 
80  gm. ;  NaCl,  5  gm. ;  extract  of  beef  (Liebig's),  5 
gm.;  and  glucose,  10  gm.  to  the  litre;  and  has  a  reac- 
tion indicating  1.5  per  cent,  of  normal  acid,  phenol- 
phthalein  being  the  indicator. 

"In  this  medium  the  growth  of  the  typhoid  bacillus 
produces  a  uniform  clouding,  at  37°  C.,  within  eigh- 
teen hours.  The  colon  cultures  do  not  give  the  uni- 
form clouding,  and  present  several  appearances,  de- 
pendent upon  difterences  in  their  motility.  [Tubes 
were  shown.] 

"The  plating  medium  contains  agar,  10  gm.;  gela- 
tin, 25  gm. ;  NaCl,  5  gm. ;  beef  extract,  5  gm.;  glu- 
cose, 10  gni.  to  the  litre;  and  reacts  two  per  cent,  acid 
to  phenolphthalein. 

"The  colonics  of  the  bacillus  typhosus  in  plate  cul- 
tures made  with  this  medium  give  rise  to  fringing 
threads  and  outgrowths,  and  are  small.  The  colon 
colonies  are  larger  and  do  not  form  threads. 

"Tiiese  colonies  develop  within  eighteen  hours,  and 
the  tube  medium  may  then  be  inoculated  from  them. 
This  in  its  turn  gives  its  characteristic  appearance  in 


December  4,  1897] 


MEDICAL    RECORD. 


827 


eighteen  hours,  the  whole  process  taking  about  thirtj'- 
six  hours,  at  37°  C. 

"Tlie  bacillus  typhosus,  alone  of  all  the  organisms 
investigated  during  these  experiments,  has  displayed 
the  power  of  giving  rise  both  to  the  thread-forming 
colonies  in  the  plating  medium,  and  to  the  uniform 
clouding  of  the  tube  medium  when  exposed  to  a  tem- 
perature of  37°  C;  hence  these  two  characters  in 
combination  have  proved  of  great  value  in  the  isola- 
tion and  identification  of  the  bacillus  typhosus,  and 
will  apparently  prove  diagnostic. 

"The  practical  application  of  these  media  has  led 
to  the  ready  detection  and  isolation  of  the  bacillus  ty- 
phosus from  the  stools  and  urine  of  patients  suffering 
from  typhoid  fever." 

The  value  of  this  method  was  carefully  tested  on 
the  fasces  from  a  series  of  cases  in  the  New'  York  Hos- 
pital. There  were  twenty-six  cases,  of  which  nine 
were  proven,  both  clinically  and  bacteriologically,  to 
be  not  typhoid.  Of  the  remaining  seventeen,  fourteen 
were  in  the  febrile  stage  and  three  convalescent.  The 
three  convalescent  cases  were  all  negative.  In  thir- 
teen of  the  fourteen  cases  in  the  febrile  stage,  typhoid 
bacilli  were  isolated  from  the  stools. 

The  speaker  said,  in  regard  to  the  results  in  cases 
from  other  hospitals,  that  they  were  not  so  good  as 
the  investigators  hoped  to  obtain  in  the  future,  because 
in  many  instances  the  stools  were  not  received  in  a 
proper  condition.  In  one  instance  the  stool  had  been 
sterilizd  with  bichloride  of  mercury,  and  many  of  them 
had  stood  for  from  forty-eight  to  seventy-two  hours. 
Of  course  the  results  in  such  cases  could  not  be  satis- 
factory. He  had  been  informed  by  Dr.  Hiss  that  it  re- 
quired on  the  average  about  one  hour  per  case  to  make 
such  an  e.xamination  of  the  faeces,  which,  as  compared 
with  any  other  method  for  the  separation  of  the  ty- 
phoid bacillus,  was  an  immense  saving  Of  time. 

The  health  department,  he  said,  had  decided  to  add 
this  method  to  the  Widal  test  for  the  diagnosis  of  ty- 
phoid fever,  and  circulars  of  information  had  been 
issued.  [A  copy  of  the  circular  is  printed  in  connec- 
tion with  this  report.]  In  any  case  of  suspected  ty- 
phoid the  health  board  would  examine  the  stools  or 
urine  if  the  attending  physician  desired  it.  In  a  con- 
siderable number  of  cases  of  typhoid  fever  the  bacilli 
were  found  in  the  urine,  in  how  large  a  number  was  not 
known,  but  they  were  certainly  present  in  a  consider- 
able proportion  of  cases.  It  was  not  known  how  early 
the  bacilli  appeared  in  the  stools  or  how  long  they 
remained.  In  most  of  the  cases  which  had  been  ex- 
amined the  disease  was  fairly  well  advanced.  The 
sixth  day  was  the  earliest  period  at  which  the  bacilli 
were  found  in  the  faeces,  and  it  was  the  only  case 
which  was  examined  so  early.  In  other  cases  the  ba- 
cilli were  found  on  the  eleventh,  twelfth,  and  thirteenth 
days,  respectively,  while  in  others  they  were  found  still 
later.  In  none  of  the  cases  did  the  bacilli  persist 
during  convalescence.  In  most  of  the  cases  when 
the  temperature  was  normal  the  results  were  negative. 

Dr.  Biggs  said  that  the  conception  of  what  typhoid 
fever  is  must  be  somewhat  revised,  or  at  least  that  term 
must  be  confined  to  that  form  of  typhoid  infection  in 
which  abdominal  symptoms  and  lesions  were  present 
in  the  small  intestines.  Unquestionably  cases  of  ty- 
phoid infection  occurred  in  which  tliere  were  no  such 
lesions  in  the  small  intestines,  and  in  which  the  usual 
manifestations  of  typhoid  fever  were  absent. 

Dr.  Biggs  took  strong  exceptions  to  the  conclusions 
of  Dr.  Thompson.  He  thought  that  Dr.  Thompson's 
description  of  the  test  was  not  sharply  enough  defined. 
The  Widal  test,  when  it  was  first  described,  was 
thought  to  be  specific  and  qualitative.  Soon  after- 
ward it  was  found  to  be  simply  quantitative.  Merely 
to  say  that  the  reaction  was  obtained  had  little  or  no 
force,  unless  we  could  also  say  under  what  conditions 


it  was  obtained.  At  the  laboratory  of  the  health  de- 
partment the  experience  now  probably  covered  between 
four  hundred  and  five  hundred  cases  of  typhoid  fever, 
and  in  no  instance  when  the  reaction  was  produced  in 
the  dilution  of  i  to  20  had  the  final  results  shown  that  a 
typhoid  infection  did  not  exist.  When  a  definite  re- 
action was  produced  in  a  dilution  of  i  to  20,  the  reac- 
tion taking  place  within  a  time  limit  of  ten  minutes, 
it  seemed  perfectly  safe  to  assume  that  we  had  to  deal 
with  a  typhoid  infection.  On  the  other  hand,  there 
was  a  considerable  number  of  cases  of  undoubted  ty- 
phoid infection  in  which  the  reaction  was  absent. 
Negative  results  therefore  did  not  exclude  a  typhoid 
infection.  The  reaction  might  be  absent  throughout 
the  entire  course  of  the  disease,  or  it  might  appear  very 
late  or  even  during  a  relapse,  so  that  the  absence  of 
such  reaction  did  not  exclude  the  existence  of  typhoid, 
but  the  presence  of  the  reaction  under  definite  condi- 
tions entirely  justified  the  assumption  that  the  case  was 
one  of  t}'phoid  infection. 

"  Circular  of  Information  Regarding  the  Separa- 
tion for  Diagnostic  Purposes  by  a  New  Method  of 
the  Typhoid  Bacilli  from  the  Stools  and  Urine  in 
Cases  of  Typhoid  Fever. — The  examination  of  speci- 
mens of  blood  from  cases  of  suspected  typhoid  fever 
for  the  Widal  reaction  has  been  of  great  assistance  in 
diagnosis.  Occasionally,  however,  the  agglutinating 
substances  do  not  develop  in  the  blood  at  any  time,  or 
only  very  late  in  the  course  of  the  disease,  or  an  ear- 
lier infection  cannot  be  excluded,  owing  to  the  lack  of 
a  reliable  previous  history.  In  these  instances  the 
Widal  test  fails  to  give  the  information  desired. 

"  Bacteriologists  have  long  sought  for  a  rapid  and 
certain  method  of  obtaining  and  identifying  in  pure 
culture  the  typhoid  bacillus  from  the  stools  and  urine 
in  cases  of  typhoid  fever;  but  hitherto  without  satisfac- 
tory results.  Dr.  Hiss,  assistant  bacteriologist  to  the 
health  department,  has  devised  a  method  by  which  it 
is  believed  it  will  now  be  possible  to  recover  and 
identify  the  typhoid  bacilli  within  less  than  forty- 
eight  hours,  from  specimens  of  fasces  and  urine  con- 
taining them.  The  health  department  desires  thor- 
oughly to  test  this  method,  and  is  prepared  to 
undertake  these  examinations  if  proper  specimens  are 
furnished. 

"  While  definite  knowledge  is  lacking  as  to  the 
number  of  typhoid  bacilli  usually  present  in  the  stools 
of  typhoid  patients,  and  as  to  the  time  of  their  appear- 
ance and  disappearance,  it  is  believed  that  they  are 
generally  present  in  the  discharges,  not  only  during 
the  height  of  the  disease,  but  also,  though  to  a  less 
extent,  at  its  commencement  and  for  a  considerable 
time  during  convalescence.  The  appearance  of  the 
bacilli  in  the  urine  is  usually  later  than  in  the  fseces. 
The  experience  thus  far  obtained  seems  to  indicate 
that  the  bacilli  may  be  obtained  from  about  fifty  per 
cent,  of  all  cases  on  the  first  examination,  and  from 
about  ninety  per  cent,  after  repeated  examinations. 
The  health  board  hopes  that  these  examinations  will 
prove  of  value,  not  only  for  diagnostic  purposes,  but 
also  in  solving  important  sanitary  questions  relating 
to  the  presence  in  and  time  of  disappearance  of  the 
bacilli  from  the  stools  during  convalescence. 

"  Physicians  are  requested  to  send  specimens  of  in- 
testinal discharges  and  urine  from  well-defined  cases 
of  typhoid  fever,  and  also  from  all  doubtful  cases  in 
which  the  Widal  test  has  failed  to  give  definite 
information. 

"  It  must  be  understood  that  as  yet  these  investi- 
gations are  largely  experimental,  but  that  when  the 
typhoid  bacilli  are  i-solated  in  culture  an  absolute 
diagnosis  of  typhoid  infection  is  obtained. 

*'  Directions  for  Preparing  Specimens  of  Faeces  or 

Urine  for  Examination Care    should   be  taken  to 

send,  if  possible,  a  specimen  obtained  from  a  natural 


828 


MEDICAL    RECORD. 


[December  4,  1897 


movement  or  one  following  a  simple  enema.  No  dis- 
infectants, of  course,  should  be  employed.  If  the 
movement  is  formed,  the  portion  from  the  part  last 
passed — that  is,  the  portion  coming  from  highest  up  in 
the  intestine — should  be  selected.  In  cases  compli- 
cated by  colitis,  care  should  be  observed  to  avoid,  if 
possible,  the  selection  of  a  specimen  composed  largely 
of  mucus. 

"The  specimen  is  collected  by  seizing  a  small  por- 
tion of  the  discharges  between  the  two  slips  of  wood 
accompanying  the  outfit,  and  placing  this  in  a  bottle. 
The  top  of  the  bottle  is  replaced  and  the  specimen 
returned  to  a  culture  station  or  to  the  laboratory. 

"  Specimens  of  urine  should  be  received  directly  into 
the  bottle  accompanying  the  outfit,  or  should  be  col- 
lected in  an  absolutely  clean  vessel  and  immediately 
transferred  to  this  bottle,  which  is  then  returned  to  a 
culture  station  or  to  the  laboratory. 

"The  necessary  outfits,  with  directions  and  blanks, 
may  be  obtained  at  the  various  health-department  de- 
pots, where  diphtheria  culture  tubes,  antitoxin,  and 
other  products  are  supplied.  The  accompanying  blank 
should  be  fully  filled  out  in  every  case." 


SOUTHERN  SURGICAL   AND  GYNECOLOGI- 
CAL ASSOCIATION. 

Tenth  Annual  Meeting,  Held  at  St.  Louis,  November  g, 
10,  and  II,  i&gj. 

Georoe  Ben  Johnston,  M.D.,  President. 

First  Day,  Morning  Session. 

The  meeting  was  held  at  the  Southern  Hotel. 

Gall  Stones  in  their  Relation  to  Cancer  of  the 
Gall  Tract. — Dr.  A.  L.  Reed,  of  Cincinnati,  read 
the  paper,  which  was  based  upon  a  report  of  four 
cases  in  which  distinct  gall-stone  history  had  pre- 
ceded the  history  of  malignant  disease.  The  diag- 
nosis had  been  confirmed  in  all  of  them  by  exploratory 
incision,  and  in  two  of  them  by  autopsy. 

Case  I. — -Woman,  aged  fifty-two.  Had  hepatic 
colic  during  five  years  preceding,  associated  with  all 
of  the  usual  gall-stone  symptoms.  During  the  preced- 
ing thirteen  months  pain  in  the  right  hypochondriac 
region'  had  been  constant.  Within  the  preceding  six 
weeks  persistent  jaundice  had  developed.  Globular 
tumefaction  was  felt  below  the  costal  margin.  Ex- 
ploratory incision  revealed  primary  carcinoma  of  gall 
bladder  and  gall  tract  with  secondary  development  in 
the  liver.     Diagnosis  confirmed  by  autopsy. 

Case  II. — Male,  aged  sixty.  Had  gall  stones  for 
twenty  years  •,  confirmed  by  their  frequent  passage  per 
vias  7iatiirales.  Patient  had  undergone  rapid  emacia- 
tion, and  during  the  preceding  month  pain  had  become 
constant.  More  latterly  he  became  pronouncedly 
jaundiced.  No  physical  symptoms  could  be  detected. 
Exploratory  incision  revealed  carcinoma  of  the  gall 
bladder  and  gall  ducts,  witli  secondary  nodules  in  the 
liver.  A  calculus  was  found  in  the  common  duct  and 
disintegrated  by  needle  puncture.  Primary  recovery 
with  amelioration  of  all  symptoms,  followed  by  death 
four  months  later.     No  autopsy. 

Case  III. — Woman,  aged  forty-five.  Had  had  he- 
patic colic  for  several  years.  During  the  preceding 
six  months  she  hail  been  profoundly  jaundiced.  Lost 
flesh  rapidly.  Examination  of  the  blood  revealed 
marked  chohrjuiia.  There  were  no  physical  symptoms 
in  the  right  hypogastrium.  Exploratory  incision  re- 
vealed induration  about  the  head  of  the  gall  bladder 
and  common  du  t,  to  both  of  which  the  duodenum  was 
firmly  attached  for  a  distance  of  several  inches.  Cal- 
culus could  be  fell  within  the  common  duct  just  within 


its  orifice.  This  could  not  be  dislodged  by  prudent 
pressure  or  disintegrated  by  needle.  It  was  delivered 
by  incision  through  the  duodenum.  Patient  never 
rallied,  but  died  within  thirty-six  hours  after  the 
operation.     No  autopsy. 

Case  IV. — Man,  aged  fifty-two,  constant  drinker. 
Had  severe  attacks  of  hepatic  pain  during  preceding 
fifteen  years.  Last  attack  was  persistent  and  contin- 
ued for  over  six  weeks.  In  addition  to  the  usual 
symptoms  he  had  a  vacillating  temperature  and  sweats. 
Operation  revealed  empyema  of  the  gall  bladder  with 
induration  at  its  ductile  end.  The  gall  bladder  was 
stitched  to  the  abdominal  incision  and  drained. 
Death  a  week  later.  Autopsy  revealed  carcinoma  of 
the  ducts  at  their  juncture.  Numerous  small  calculi 
were  found  in  the  hepatic  duct  well  up  in  its  main 
trunk  and  in  a  number  of  its  twigs.  Multiple  ab- 
scesses were  found  in  the  liver  substance. 

These  cases,  the  author  said,  had  a  suggestive  sig- 
nificance and  pointed  to  an  etiological  relationship. 
This  was  explained  by  the  result  of  persistent  irritation 
of  the  foreign  bodies  upon  the  mucous  surfaces,  in- 
ducing hypertrophy,  cell  proliferation,  and,  in  the 
event  of  the  existence  of  original  tendencies  to  cancer 
of  ante-natal  origin,  they  induced  rapid  development 
of  the  malignant  neoplasm. 

Dr.  Edwin  Ricicetts,  of  Cincinnati,  reported  two 
interesting  cases  of  cancer  which  he  believed  were 
due  to  gall  stones.  He  said  Courvoisier  had  found 
malignancy  in  seventy  or  eighty-four  cases  of  gall 
stone;  while  Bradrowski  had  found  forty  cases  of 
cancer. 

Dr.  Joseph  Eastman,  of  Indianapolis,  reported  a 
case  which  had  come  under  his  observation  within  the 
last  two  weeks,  which  confirmed  the  remarks  of  the  es- 
sayist. He  believed  that  cancer  of  the  gall  bladder 
and  gall  ducts,  as  in  the  uterine  cervix,  was  often  the 
outgrowth  of  prolonged  localized  irritation. 

Dr.  James  T.  Jelks,  of  Hot  Springs,  had  seen 
cancer  of  the  uterus  unmistakably  produced  by  gall- 
stone infection ;  hence  the  deductions  of  the  paper,  to 
urge  operative  interference  in  all  cases  to  prevent  car- 
cinoma of  the  liver,  were  prudent. 

Dr.  Rufus  B.  Hall,  of  Cincinnati,  expressed  him- 
self as  being  firmly  convinced  that  the  deductions 
drawn  from  the  paper  would  be  sustained  by  future 
work  in  this  direction.  Nine  cases  tabulated  by  him 
confirmed  the  deductions  of  the  essayist.  He  cited 
one  case. 

Dr.  a.  M.  Cartledge,  of  Louisville,  said  that  in 
many  cases  presenting  a  history  of  the  passage  of  gall 
stones  the  patient  may  have  had  beginning  carcinoma 
of  the  ducts  for  two  or  three  years  previously.  He 
indorsed  the  views  of  the  essayist  relative  to  operative 
interference  in  cases  of  gall  stones. 

Dr.  L.  McLane  Tiffany,  of  Baltimore,  thought  the 
causative  relation  between  ga.l  stones  and  cancer  was 
not  yet  w-ell  established;  but  that  cancer  was  accom- 
panied by  gall  stones  and  found  frequently  to  exist 
was  well  known. 

Dr.  Thaddeus  A.  Reamy,  of  Cincinnati,  took  a 
more  conservative  ground,  and  thought  the  association 
ought  not  to  go  on  record  to  the  effect  that  because 
gall  stones  are  associated  with  cancer  the  abdomen  of 
every  man  or  woman  having  gall  stones  must  be  cut 
open  lest  he  or  she,  as  the  case  might  be,  might  have 
cancer. 

Dr.  Reed  re-emphasized  the  significance  of  the  per- 
sistent coincidence  of  cancer  in  long-standing  gall- 
stone cases.  His  own  brief  experience  embraced  cases 
in  which  there  had  been  long-standing  antecedent  gall- 
stone history. 

Disposal  of  the  Stump  in  Appendicitis  Opera- 
tions was  the  title  of  a  paper  by  Dr.  W.  D.  Hag- 
gard, Jr.,  of  Nashville,  Tenn.     The  author  considered 


December  4,  1897] 


MEDICAL    RECORD. 


829 


appendicitis  pre-eminently  a  surgical  affection.  Sur- 
gical isolation  of  the  infected  appendix  was  as  essen- 
tial as  the  hygienic  isolation  of  any  of  the  infectious 
diseases.  The  more  imperative  and  explicit  operative 
indications  were  specitied.  The  various  methods  of 
disposing  of  the  stump  by  invagination  were  discussed, 
and  the  modification  and  technique  employed  by  A' an 
Hook,  Dawbarn,  McBurney,  Murphy,  and  Morris  were 
described.  The  ideal  of  all  surgery  was  completeness : 
applied  to  the  surgery  of  the  appendix,  it  was  total 
extirpation  of  the  organ.  He  then  described  the 
following  method  practised  by  Deaver  in  suitable 
cases :  After  the  appendix  and  meso-appendix  are  freed 
from  adhesions,  the  ctecum  is  stripped  of  its  contents 
and  grasped  between  the  fingers  and  thumb  of  the  left 
hand,  the  appendix  being  held  by  forceps  and  cut  off 
flush  with  the  colon.  The  resulting  peritoneal  wound 
is  united  by  continuous  Lembert  sutures,  while  the 
caicum  is  still  held  securely  with  the  left  hand  just 
as  in  a  gun-shot  or  stab  wound  of  the  intestine. 
Sutures  may  be  disposed  in  two  layers,  the  first 
uniting  the  edges  of  the  wound  and  the  second  ap- 
proximating the  peritoneal  covering  to  the  crecum  over 
it.  This  method  is  not  applicable  in  cases  in  which 
the  caecum  is  bound  down  by  adhesions  preventing  its 
delivery  in  the  incision.  It  is  necessary  to  prevent 
the  escape  of  colon  contents  by  accurate  suturing  of 
the  cut  ends. 

Total  excision  of  the  appendix  with  closure  of  the 
hole  in  the  head  of  the  colon  does  away,  first,  with  sub- 
sequent perforation  of  the  stump  under  the  ligature 
from  infection  in  its  own  cavity;  second,  abscess  of 
the  wall  of  the  c»cum  from  invagination  of  the  in- 
fected stump;  third,  continuance  of  infected  proc- 
ess from  stricture  in  the  stump  between  the  distal  liga- 
ture and  the  proximal  opening  of  the  appendix  into  the 
ccecum;  fourth,  imperfect  invagination  with  incomplete 
drainage  of  the  stump  on  account  of  the  ccecal  w-all  being 
thickened  and  stiffened  with  inflammatorj'  exudate. 

The  author  has  employed  this  method  with  entire 
satisfaction  in  five  cases. 

Report  of  Four  Cases  of  Abscess  of  the  Uterus. 
— This  paper  v.as  by  Dr.  Georce  H.  Noble,  of  At- 
lanta, Ga.  The  first  case  was  one  of  puerperal  origin, 
the  operation  being  done  at  the  end  of  the  second  week. 
There  were  a  pus  tube  and  abscess  of  the  left  ovary. 
The  appendages  on  the  right  side  were  normal.  After 
extensive  adhesions  of  unilateral  disease  had  been 
separated,  an  abscess  of  the  fundus  uteri  about  the  size 
of  an  ordinary  lemon  was  discoverd,  which  was  excised, 
curetted,  and  cauterized  witli  carbolic  acid.  The  cavity 
extended  from  the  median  line  to  the  stump  of  the  ap- 
pendages on  the  left,  which  was  turned  into  it  and 
fastened  with  sutures  to  prevent  the  formation  of  a  dead 
space.  A  glass  drain  was  dropped  into  Douglas'  pouch 
after  the  abdominal  cavity  had  been  flushed.  The 
woman  made  an  uneventful  recovery  and  had  been  well 
for  two  years  without  any  pelvic  disturbance.  Three 
other  similar  cases  were  reported  in  delail  by  the  author. 
The  four  cases  showed  what  any  surgeon  would  some- 
times do  for  an  aseptic  uterus  when  given  a  chance. 
They  also  supported  the  view  that  it  was  not  always 
necessary  to  extirpate  the  uterus  in  suppurative  in- 
flammation of  its  parenchyma,  and  that  such  opera- 
tions should  be  confined  to  cases  in  which  the  uterus 
was  thoroughly  septic  or  riddled  with  abscesses. 

Dr.  a.  M.  Cartled<;e  said  the  results  following 
the  method  pursued  by  the  essayist  were  better  than 
those  of  hysterectomy  for  infected  uterus  complicating 
childbirth  or  abortion. 

Dr.  J.  Wesi.kv  Udvkk  was  pleased  with  the  ad- 
vanced position  taken  by  the  author  of  the  paper. 
Gynaecologists  had  to  fear,  however,  the  future  useful- 
ness of  the  uterus  if  they  followed  this  method.  It 
might  tend  to  the  production  of  rupture  of  the  organ. 


Dr.  James  T.  Crofford  said  that  in  cases  of  abscess 
of  the  uterine  wall  originating  from  the  mucous  mem- 
brane, if  the  cervix  was  kept  dilated  and  the  uterus, 
freed  of  everything  with  a  curette,  was  thoroughly 
cleansed  and  packed  with  gauze,  these  abscesses  would 
open  into  the  endometrium,  followed  by  relief  in  the 
majority  of  cases. 

Dr.  Richard  Douglas  said  that  he  treated  cases  of 
infection  following  abortion  or  full-term  labor  by  the 
Carossa  method  with  decided  benefit. 

Dr.  W.  E.  B.  Davis  said  that  uterine  abscesses 
following  either  abortion  or  the  puerperal  state  could 
be  treated  successfully  by  incision  and  drainage  in  a 
good  proportion  of  cases,  even  though  the  abscesses 
might  extend  beyond  the  uterus.  Illustrative  cases  in 
which  this  treatment  was  resorted  to  were  cited. 

Dr.  T-  G.  Earnest  favored  an  exploratory  incision 
to  ascertain  whether  or  not  the  patient  was  a  fit  subject 
for  the  method  of  treatment  pursued  by  Dr.  Noble. 
In  the  event  the  case  was  not  suitable  for  the  applica- 
tion of  this  method,  very  little  damage  was  done  by 
such  an  incision. 

Dr.  R.  M.  Cunningham  said  it  was  e.xtremely  dif- 
ficult in  general  surgery  to  get  primary  union  after 
curetting  and  disinfecting  abscesses,  in  that  it  was 
difficult  to  destroy  the  staphylococcus,  and  more  par- 
ticularly the  streptococcus,  which  perhaps  e.xtended 
beyond  the  abscess  wall  and  continued  its  infective 
influence. 

Dr.  Noble,  in  closing,  emphasized  the  "point  that 
the  uterus  was  the  seat  of  infection,  and  not  the  appen- 
dages. Only  in  cases  in  which  there  were  one  or  two 
or  possibly  three  abscesses  was  this  method  of  treat- 
ment applicable. 

A  Study  of  Retroperitoneal  Neoplasms  and  Sup- 
purations, with  Special  Reference  to  Diagnosis. — 
Dr.  Richard  Douglas,  of  Nashville,  Tenn.,  the  au- 
thor, accepted  the  definition  of  Mr.  Lockwood  for  retro- 
peritoneal neoplasm,  namely,  a  solid  or  cystic  tumor 
growing  behind  the  peritoneum  into  the  fold  and  not 
connected  with  any  of  the  great  retroperitoneal  organs. 
The  author  then  dwelt  at  length  upon  the  pathology 
of  these  neoplasms  and  their  causation,  and  then 
passed  on  to  consider  retroperitoneal  cysts,  and  cysts 
of  the  pancreas.  While  not  an  advocate  of  the  use  of 
the  aspirator  in  intra-abdominal  diagnosis,  yet  under 
proper  conditions  the  author  thought  this  instrument 
would  reveal  valuable  evidence,  not  only  as  to  whether 
the  growth  was  solid  or  cystic,  but  as  to  its  nature.  In 
retroperitoneal  sarcoma  aspiration  revealed  only  a  little 
blood  or  blood  serum  in  the  needle.  This  sign  en- 
abled Weir  and  Hull  correctly  to  diagnosticate  a  case 
reported  by  Devlin. 

Tubal  and  Ovarian  Hemorrhage  Resembling  Rup- 
tured Ectopic  Pregnancy.—  This  paper  was  read  by 
Dr.  J.  Wesley  Bovee,  of  Washington,  D.  C.  The  author 
said  that  a  few  years  back  pelvic  haematocele  was  a 
condition  that  every  practitioner  met  occasionally,  and 
many  were  the  supposed  causes  of  it.  When  the  sub- 
ject of  ruptured  tubal  pregnancy  was  so  universally 
taken  up,  some  of  the  most  aggressive  investigators 
told  us  to  search  in  every  case  of  pelvic  ha;matocele 
and  we  w^ould  find  a  ruptured  ectopic  pregnancy.  This 
dictum,  though  not  indorsed  by  all  observers,  found  a 
ready  following,  and  to  this  time  the  majority  of  stu- 
dents of  diseases  of  the  female  pelvic  organs  had 
accepted  it.  Many  cases  had  been  reported  in  which 
a  presumptive  diagnosis  of  ruptured  tubal  pregnancy 
had  been  made — cases  in  which  such  symptoms  as 
shock,  sharp  pain,  irregularity  of  menstruation  even  to 
amenorrhcea,  small  tumor  in  the  pelvis  were  present 
and  some  in  which  even  death  resulted,  aixl  yet  autopsy 
had  revealed  no  pregnancy,  but  instead  hemorrhage 
from  a  Fallopian  tube  or  an  ovary,  or  both.  The 
speaker  offered,  as   he   thought,   conclusive  evidence 


8.-,o 


MEDICAL    RECORD. 


[December  4,  1897 


against  the  positive  statements  that  had  gone  out,  that 
this  condition  would  always  be  found  in  these  hemor- 
rhages. There  were  many  instances  in  which  women 
were  deeply  wronged  by  these  diagnoses.  Oftentimes 
the  hemorrhages  have  occurred  in  virgins  at  a  very 
young  age  and  in  widows  above  reproach.  These  hem- 
orrhages result  from  ectopic  pregnancy;  from  malig- 
nant disease  of  the  uterus,  appendages,  or  rectum ;  from 
varicose  veins  in  the  broad  ligaments;  from  disease  of 
the  appendix;  from  inflammatory  disease  of  the  tubes 
and  ovaries,  and  from  many  other  causes.  The  author's 
remarks  were  restricted  to  disease  of  the  appendages, 
and  he  cited  a  case  in  detail  to  exemplify  them. 

First  Day — Afternoon  Session. 

Extra-Uterine  Pregnancy  Operated  on  at  the 
Seventh  Month. — Dr.  J.  G.  Earnest,  of  Atlanta,  Ga., 
reported  an  interesting  case.  The  patient  was  thirty- 
six  years  of  age,  and  the  mother  of  several  chil- 
dren. She  came  under  his  care  September  19,  1897. 
Five  months  previous  he  had  been  called  to  see  her 
on  account  of  profound  collapse  which  threatened 
life.  A  history  of  irregular  uterine  hemorrhages  was 
elicited  and  a  diagnosis  of  ruptured  tubal  pregnancy 
on  the  left  side  was  made.  Operation  was  deferred  at 
this  time,  for  the  reason  that  it  was  feared  the  patient 
would  die  under  the  anesthetic.  Nothing  further  was 
heard  from  patient  until  the  date  mentioned,  when  the 
abdomen  was  found  distended  by  a  tumor  on  the  left 
side  and  in  the  centre  as  high  as  the  umbilicus.  On 
the  right  side  was  another  apparently  distinct  cyst 
filling  that  side  of  the  pelvis  and  extending  well  up 
into  the  abdomen.  On  opening  the  abdomen  a  large 
tumor  occupying  the  centre  and  left  side  presented  a 
surface  somewhat  irregular,  very  dark  in  color,  and 
traversed  in  every  direction  by  large  blood-vessels  on 
the  surface.  The  enlarged  uterus  was  inclosed  in  this 
mass.  The  tumor  of  the  right  side  was  about  the  size 
of  an  adult  head,  about  one-quarter  of  an  inch  thick, 
and  seemed  to  be  distinct  from  the  large  one,  the  di- 
viding line  dipping  down  between  them  about  half  the 
diameter  of  the  tumor.  To  the  larger  mass  were  at- 
tached several  coils  of  intestine,  which  were  dark  and 
changed  in  texture  at  the  points  of  contact.  The  cyst 
on  the  right  side  peeled  out  without  much  hemorrhage, 
but  wi,th  the  work  of  peeling  off  the  placenta  from  the 
pelvic  and  abdominal  wall  began  the  flow  of  blood 
so  appalling.  The  task  being  pushed  as  rapidly  as 
possible,  the  mass  was  loosened  and  iodoform  gauze 
quickly  packed  behind  it.  The  cyst  was  still  un- 
broken and  had  the  appearance  when  lifted  up  of  being 
a  fibrocystic  tumor  of  the  uterus.  The  author  con- 
cluded to  remove  the  uterus  and  drain  through  the 
vagina.  As  the  uterine  arteries  could  not  be  reached, 
a  wire  attached  to  a  serre-nceud  was  thrown  around  the 
uterine  body,  tigiUened,  and  the  mass  cut  away.  The 
patient  was  now  in  such  a  critical  condition  that  the 
author  abandoned  draining  through  the  vagina.  He 
tied  the  uterine  and  ovarian  arteries,  and  packed  the 
cavity  with  iodoform  gauze,  which  was  brought  out  at 
the  lower  angle  of  the  wound,  and  closed  the  abdomen 
with  silkworm  gut.  The  gauze  was  removed  on  the 
sixth  day.  On  the  eighth  day  frecal  matter  passed 
from  the  drainage  tract.  From  this  time  until  she 
left  the  hospital,  October  30th,  most  of  the  fasces 
passed  by  the  fistula.  Five  days  later  she  was  having 
free  rectal  evacuations  with  a  corresponding  falling  off 
of  the  fai'cal  discharge  from  the  fistula.  The  speaker 
said  that  if  the  fistula  failed  to  close  spontaneously  it 
would  be  closed  by  operation.  The  large  tumor  was 
covered  entirely  by  an  enormously  expanded  placenta 
beginning  in  the  bottom  of  the  pelvis,  firmlv  attached  to 
the  pelvic  and  a  portion  of  the  abdominal  wall,  its  villi 
reaching  well  down  into  the  tissues.     From  the  top  it 


was  deflected  from  the  abdominal  parietes  over  beyond 
the  centre,  everting  the  body  of  the  uterus.  In  the  cyst 
thus  formed  was  found  a  fcetus  of  about  seven  months. 

Cystic  Disease  of  the  Mamma. — Dr.  L.  McLane 
TiKFANV,  of  Baltimore,  read  the  paper.  He  said  the 
occurrence  of  cysts  as  a  confusing  element  in  the 
course  of  solid  tumors  of  the  breast  was  not  so  uncom- 
mon and  might  greatly  resemble  the  subject  dealt 
v.'ith  in  his  paper;  yet  the  clinical  history  and  anatomy 
of  cystic  adenomata  were  sufficiently  clear  and  the 
prognosis  was  suffrciently  important  to  justify  careful 
study.  In  most  cases  an  accurate  diagnosis  could  be 
reached  before  operation.  Dr.  Tiffany  reported  eleven 
cases  that  showed  many  symptoms  in  common. 

Cystic  Fibro-Adenoma  of  the  Breast. — The  speaker 
had  examined  three  of  these  tumors,  and,  as  they  agreed 
so  closely  both  in  microscopic  and  macroscopic  ap- 
pearances, a  description  of  one  would  answer  for  all. 
Macroscopically  the  breast  is  full  and  hard  with  nu- 
merous small  nodules,  to  be  felt  under  the  skin,  but 
not  adherent  to  it.  These  nodules  vary  in  size  from 
that  of  a  pea  to  that  of  a  walnut.  Some  of  them  feel 
as  though  they  contain  fluid.  When  the  breast  is  cut 
through,  normal  glandular  tissue  is  seen  to  be  re- 
placed by  a  hard,  dense  white  tissue  with  innumerable 
cysts  containing  either  glazy  sticky  fluid  or  a  cheesy 
material.  The  fluid  varies  in  color.  In  some  cases 
it  is  white  and  transparent;  in  others  green,  red,  yel- 
low, or  a  dirty  brown.  Microscopically  sections  were 
taken  from  various  parts  of  the  tumor,  hardened  in  a 
ten-per-cent.  solution  of  formalin  for  twenty-four  hours 
and  in  alcohol.  They  were  embedded  in  celloidin  and 
stained  by  the  ordinary  method  with  hfematoxylon  and 
eosin.  Under  the  microscope  the  sections  presented  the 
following  appearance :  There  is  a  mass  of  white  fibrous 
tissue  including  cysts,  fat,  and  tubules.  The  tubules 
are  lined  by  several  rows  of  cuboidal  epithelial  cells 
and  are  massed  in  discrete  areas  presenting  somewhat 
the  appearance  of  an  intracanalicular  growth.  In 
some  localities  the  tubules  are  seen  to  be  much  di- 
lated in  parts,  completely  filled  with  cells,  while  out- 
side they  are  surrounded  by  a  well-marked  area  of 
round-cell  infiltration.  Here  and  there  in  the  tubules 
are  to  be  seen  loose  desquamated  cells,  which  are 
granular  and  swollen,  presenting  somewhat  the  ap- 
pearance of  the  cells  of  sebaceous  glands.  These 
cells  have  very  deep-staining  nuclei,  and  when  seen 
in  the  smaller  tubules  are  deeply  pigmented,  of  a 
brownish  color,  as  though  blood  stained,  and,  as  here 
and  there  one  can  find  the  remains  of  red  blood  cor- 
puscles, tliis  is  probably  the  case.  Many  of  the  ducts 
are  lined  by  papillary  ingrowths  made  up  of  cylindri- 
cal cells  which  take  eosin  well.  The  tubules  present 
all  stages  of  dilatation  up  to  large  cysts;  many  of  the 
cysts  are  lined  by  several  layers  of  cells  resembling 
pavement  epithelium.  The  fibrous  tissue  which  is  so 
abundant  is  rather  wavy,  not  very  cellular,  and  well 
supplied  with  blood-vessels.  It  stains  very  faintly 
with  eosin.  The  diagnosis  of  benign  cystic  fibro- 
adenoma is  perfectly  clear. 

The  X-Ray  and  its  Application  to  Surgery. — 
Dr.  -V.  V.  L.  Rrokaw,  of  St.  Louis,  Mo.,  made  some 
remarks  on  this  subject,  and  exhibited  two  hundred 
radiographs.  He  showed  excellent  radiographs  of  the 
heart,  the  thorax,  fractures  of  the  dorso-lumbar  verte- 
brae, the  pelvis,  and  fractures  and  lesions  of  the  long 
bones.  Of  the  many  hundred  exposures  he  had  made, 
he  had  yet  to  see  harmful  effects  following  the  use  of 
the  .v-ray,  such  as  cutaneous  burns,  loss  of  hair,  and 
lesions  of  varying  intensity. 


Second  Day — Morning  Session. 

Chronic  Proctitis — Dr.  D.  F.  Talley,  of  Birming- 
ham, .\la.,  read  a   paper  on  this  subject.     He  dealt 


December  4,  1897] 


MEDICAL    RECORD. 


831 


■with  two  varieties  of  non-specific  chronic  proctitis. 
First,  those  cases  in  which  a  diffuse,  persistent  inflam- 
mation, superficial  ulceration,  and  papillomatous  vege- 
tation were  the  prominent  features.  Second,  those  in 
which  the  submucous  tissues  were  principally  involved 
in  tiie  hypertrophic  process,  causing  a  proliferative 
stenosing  proctitis.  The  main  symptoms  of  these  two 
forms  of  proctitis  were  described.  Rest  in  the  re- 
cumbent position  was  recommended  as  being  of  para- 
mount importance  in  the  treatment  of  the  first  form  of 
the  disease.  The  diet  should  be  of  a  liquid  character, 
bland  and  nutritious.  The  sphincter  muscle  should 
be  divulsed  when  the  trouble  is  low  in  the  rectum. 
In  the  absence  of  ulceration,  when  there  was  a  diffuse 
chronic  inflammation,  the  mucous  membrane  should 
be  mopped  with  silver  or  copper  of  the  strength  of 
thirty  grains  to  the  ounce.  The  after-treatment  con- 
sisted in  putting  the  patient  to  bed,  washing  the  rectum 
daily  with  warm  boric-acid  solution,  and  the  use  of 
suppositories  of  iodoform  and  boric  acid.  In  chronic 
cases  in  which  the  ulcers  were  extremely  indolent,  the 
solid  stick  of  silver  or  crystal  of  copper  might  be  used. 
In  these  cases  it  was  necessary  to  make  repeated  appli- 
cations before  the  ulcers  became  healthy  and  began  to 
heal. 

The  Sources  and  Diagnosis  of  Pyuria.  —  Dr. 
Howard  A.  Kelly,  of  Baltimore,  read  this  paper. 
He  began  by  stating  that  if  he  were  asked  what  sub- 
ject in  the  entire  range  of  medicine  and  surgery  he 
considered  it  most  important  to  bring  prominently  be- 
fore the  profession  at  present  he  would  probably  reply. 
Pyuria.  The  subject  is  important  on  account  of  the 
great  number  of  undetermined  cases  under  treatment, 
and  on  account  of  the  progressive  nature  of  some  forms 
of  the  disease,  as  well  as  on  account  of  the  facility 
with  which  the  diagnosis  can  now  be  made  with  better 
means  of  investigation.  Pyuria,  of  course,  signifies 
merely  the  presence  of  pus  in  the  urine;  this  may  be 
in  large  or  in  small  quantities,  and  may  proceed  from 
any  part  of  the  urinary  tract  from  the  external  urethral 
orifice  up  to  the  corte.x  of  the  kidneys.  The  investi- 
gation of  a  pyuria  is  an  analytical  one — taking  the 
symptom  and  trying  to  trace  its  origin.  The  best  way 
to  investigate  a  pyuria  is  to  begin  by  making  an  ex- 
amination of  the  urinary  tract,  following  an  anatomi- 
cal order,  proceeding  from  below  upward.  The  his- 
tory of  the  case,  the  microscopical  and  bacteriological 
and  chemical  examinations  of  the  urine  must  be  care- 
fully made,  and  all  facts  ascertainable  by  palpation 
must  be  elicited  first.  The  direct  investigation  then 
proceeds  in  an  orderly  manner,  beginning  with  the 
external  urethral  orifice,  where  Skene's  glands  may  be 
di,stended  with  a  drop  or  two  of  pus;  the  urethra  may 
be  in  a  state  of  intense  inflammation  and  even  ulcer- 
ation, affording  suflicient  pus  to  yield  a  decided  sedi- 
ment in  the  urine.  Sometimes  a  suburethral  abscess 
may  pass  unnoticed  for  many  months,  in  spite  of  the 
fact  that  it  contains  from  a  teaspoonful  to  a  tablespoon- 
ful  of  pus.  The  vesical  sources  of  pyuria  are  from  a 
cystitis,  including  a  trigonitis  or  inflammation  of  the 
trigonum;  foreign  bodies,  creating  a  cystitis;  ulcers, 
associated  with  a  cystitis  or  tuberculous  in  their  nature. 
These  affections  will  all  be  readily  recognized  by 
making  a  cystoscopic  examination  of  the  patient  in 
the  knee-breast  position,  through  a  simple  cylindrical 
speculum.  By  this  examination  the  cystitis  will  often 
be  found  to  be  well  localized  and  in  patches,  which 
may  be  readily  treated  by  direct  topical  applications; 
upon  removing  a  foreign  body,  the  cause  of  a  cystitis, 
the  pyuria  disappears.  Ulcers  seen  through  the  cys- 
toscope  may  be  treated  with  strong  solutions  of  nitrate 
of  silver,  curetted,  or  cauterized.  There  are  also  a 
number  of  extra  sources  of  pyuria,  and  these  arise  most 
frequently  from  tubal  and  ovarian  abscesses  breaking 
into  the  bladder,  across  the  base  of  a  broad  ligament. 


If  the  pyuria  does  not  come  from  the  lower  urinary 
tract  it  must  then  come  from  one  of  the  ureters  or  kid- 
neys; a  telltale  blush  around  a  ureteral  orifice  often 
marks  the  side  from  which  the  pus  issues.  The  author 
has  found  pyurias  from  the  upper  urinary  tract  proceed- 
ing from  strictures  of  the  ureter  with  a  gonorrhoeal,  tu- 
berculous, or  other  infection.  The  site  of  the  stricture 
and  the  source  of  the  pyuria  may  be  readily  located  in 
these  cases  by  passing  a  ureteral  catheter — a  metal  one 
for  the  low  strictures,  or  a  flexible  one  for  those  above 
the  pelvic  brim.  Renal  pyurias  are,  after  all,  the  com- 
monest of  all,  and  the  author  finds  that  these  are 
most  frequently  caused  either  by  a  calculus  in  the 
pelvis  of  the  kidney,  or  by  a  tuberculous  pyelitis,  or  by 
a  hydronephrosis  which  has  become  infected.  Such 
pyurias  are  often  the  occasion  of  large  amounts  of 
pus  in  the  urine,  appearing  either  continuously  or  in- 
termittently. Bypassing  a  renal  catheter  well  up  into 
the  pelvis  of  the  kidney,  the  pus  may  be  evacuated  and 
the  pelvis  washed  out.  If  the  pus  is  too  thick  to  flow 
through  the  catheter,  it  may  be  thinned  out  by  inject- 
ing a  little  fluid.  By  making  an  orderly  investigation 
of  this  sort  the  pus  is  traced  to  its  origin,  and  the 
source  of  the  disease  is  discovered  and  treated  and  the 
cause  eliminated,  if  possible,  just  as  we  would  seek 
to  investigate  the  source  of  the  contamination  of  a 
body  of  water  by  taking  a  boat  and  travelling  up  the 
muddy  stream  until  we  had  located  the  point  at  which 
it  entered  the  main  body  and  until  we  found  that  above 
this  point  the  water  was  free  from  contamination. 
The  methods  proposed  are  safe  in  careful,  practised 
hands. 

The  Early  Diagnosis  and  Treatment  of  Cancer 
of  the  Uterus.— Dr.  WillL'\m  H.  Myers,  of  Fort 
Wayne,  Ind.,  followed  with  a  paper  on  this  subject, 
in  which  he  first  dwelt  upon  the  various  theories  re- 
specting the  nature  of  cancer,  the  last  theory  being 
that  the  disease  was  in  its  origin  purely  local.  The 
author  dealt  with  the  elements  of  diagnosis,  and  gave 
statistical  results  following  operations  by  dift'erent  in- 
vestigators of  this  disease.  He  considered  the  value  of 
the  microscope  as  an  aid  in  the  clinical  diagnosis  of 
cancer  to  have  been  overestimated,  and  cited  several 
high  authorities  in  support  of  his  view.  He  closed 
by  saying  that  the  knife  had  become  the  emblem  of 
gynjEcological  treatment.  It  had  supplanted  the  cu- 
rette, intra-uterine  injections,  caustic  applications,  the 
quaint  conceits  of  the  monkish  craft,  and  the  brutal 
records  of  the  "cancer  cure."  The  knife  had  become, 
in  a  surgical  sense,  the  specific  therapy  of  this  par- 
ticular disease. 


Second  Day — Afternoon  Session. 

A  Case  of  Tetanus  following  a  Surgical  Opera- 
tion.—Dr.  F.  D.  Thompson,  of  Fort  Worth,  Tex., 
reported  the  case.  The  patient,  a  male,  was  twenty- 
one  years  of  age,  American,  with  good  family  history, 
for  whom  a  radical  operation  was  performed  for  exten- 
sive varicocele.  Thorough  asepsis  was  carried  out. 
The  result  of  the  operation  was  excellent;  yet  on  the 
morning  of  the  ninth  day  after  operative  interference 
the  patient  could  not  open  his  mouth  very  well,  and 
there  was  more  or  less  stiffness  about  the  muscles  of 
the  neck.  A  diagnosis  of  incipient  tetanus  was  made, 
and  the  patient  died  in  less  than  three  days  after  the 
first  appearance  of  the  tetanic  symptoms.  The  speaker 
could  not  account  for  the  infection  of  this  patient  with 
the  bacillus  tetani. 

At  this  juncture  the  president.  Dr.  George  Ben 
Johnston,  delivered  his  address.  He  selected  for 
his  subject — 

The  Prevalence  of  Specialism,  and  Who  Shall  be 
Specialists? — The  tendency  of  the  times  was  toward 
specialism  in  medicine.     Specialism  was  desirable  be- 


832 


MEDICAL    RECORD. 


[December  4,  1897 


cause  it  gave  to  the  profession  and  the  people  the  most 
intelligent  consultants  and  the  most  skilled  attend- 
ants the  art  of  medicine  could  supply.  He  divided 
specialists  into  two  kinds,  the  true  and  the  pseudo- 
specialist.  The  former  he  defined  as  one  speciall}' 
distinguished  for  learning  and  skill  in  a  given  pur- 
suit; the  latter  as  one  having  merely  a  special  occu- 
pation. He  made  very  clear  the  difference  between 
these  varieties,  for  one  reached  the  distinction  of  a 
specialist  by  reason  of  his  training,  experience,  skill, 
and  wisdom,  whereas  the  other  was  made  a  specialist 
by  the  possession  of  a  diploma,  a  doorplate  and  a 
"  kit"  of  special  instruments.  The  professional  quali- 
ties of  the  true  specialist  he  likened  to  a  massive 
pyramid,  the  finished  capstone  of  which  constituted 
the  specialty.  This  pyramid  of  experience,  learning, 
and  skill  was  a  stable  edifice,  a  pillar  of  strength 
which  could  not  topple  or  reel.  In  the  case  of  the 
pseudo-specialist  this  pyramid  of  learning  was  in- 
verted. There  was  no  base  of  a  knowledge  of  detail, 
of  general  information,  of  professional  attainments. 
The  structure  had  no  foundation  in  fact.  It  began 
with  the  specialty,  and  its  growth  spread  as  it  as- 
cended, overshadowing  what  was  below,  thus  rendering 
it  an  unstable,  top-heavy  structure.  The  public  had 
been  improperly  educated  to  the  idea  of  specialism. 
In  the  public  eye  all  specialists  stood  upon  the  same 
footing,  possessing  all  the  needful  requirements  to 
give  the  best  service.  The  profession  had  misled  the 
public  and  was  responsible  for  this  lack  of  discrimi- 
nation on  its  part.  Medical  colleges  should  vigor- 
ously discourage  the  practice  of  recent  graduates  be- 
coming specialists.  Teachers  should  point  out  to 
them  the  error  they  were  about  to  commit.  They  should 
counsel  them.  Colleges  should  recognize  only  the 
real  specialists.  Reform  in  the  present  system  of 
specialism  must  be  accomplished  through  the  instru- 
mentality of  medical  colleges  and  societies,  and  when 
they  took  the  matter  properly  in  hand  the  general  pro- 
fession and  public  would  lend  cordial  support  and  the 
evil  would  perish. 

Ovariotomy  in  the  Aged. — Dr.  A.  M.  Cartledge, 
of  Louisville,  Ky.,  read  this  paper.  The  patient  upon 
whom  the  operation  was  performed  was  bom  October 
29,  18 16.  Eighteen  months  before  the  speaker  saw 
her  an  abdominal  enlargement  was  noticed,  followed 
shortly  after  by  pressure  symptoms.  Latterly  the  gas- 
tric and  digestive  disturbances  from  pressure  had  been 
very  troublesome.  Emaciation  and  ovarian  e.xpression 
were  appreciable,  but  not  marked.  E.xamination  re- 
vealed the  abdomen  well  filled  with  an  encysted  growth, 
which  was  diagnosticated  as  ovarian.  Naturally  the 
great  age  of  the  patient,  eighty  years  seven  months 
and  fifteen  days,  made  the  decision  as  to  operation  a 
debatable  one.  However,  an  operation  was  deemed 
justifiable,  urged,  and  consented  to,  and  was  done  May 
12,  1897.  The  ovarian  cyst  originated  from  the  right 
ovary,  was  multilocular,  and  weighed  about  forty 
pounds  with  fluid  and  omentum.  The  operation  was 
done  in  fourteen  minutes.  The  patient  sat  up  fourteen 
days  after  the  operation,  and  left  the  infirmarj'  on  the 
seventeenth  day  thereafter.  The  author  had  operated 
seven  times  on  women  over  sixty  years. 

Operative  Treatment  for  Enlarged  Prostate.— Dr. 
H.  II.  (Irani-,  of  Louisville,  who  contributed  the  pa- 
per, drew  the  following  conclusions:  (i)  That  in  ma- 
lignant disease  any  operative  step  except  palliative 
sujirapubic  drainage,  even  if  based  on  an  error  in 
diagnosis,  is  a  serious  mistake;  (2)  that  in  mvomas, 
fibromas,  and  adenomas  it  is  yet  uncertain  that  good 
results  will  follow  castration;  and,  furthermore,  that 
such  conditions  render  enucleation  by  the  .Alexander 
method  very  diflicult  and  perhaps  impracticable. 
Hence  when  interference  resists  catheterization  and 
is   not   remedied  by  the  permanent  catheter,  as  sug- 


gested by  Kane,  suprapubic  section  with  removal  of 
the  projecting  portion,  if  practicable,  or  the  perma- 
nent fistula  of  McGuire,  is  the  wisest  course.  (3)  In 
conditions  including  stone  in  the  bladder,  suppuration 
in  the  gland,  and  the  suspicion  of  intravesical  growths, 
exploration  by  the  suprapubic  method  offers  the  best 
insight  into  the  nature  of  the  lesion,  as  well  as  the 
most  hopeful  prospect  of  relief.  (4)  Inasmuch  as 
castration  is  unsatisfactory,  and  is  less  acceptable  to 
men  under  sixty-five  years  of  age  than  later,  it  ap- 
pears that  in  the  commonest  form  of  enlargement,  the 
chronic  parenchymatous,  to  which  the  operation  of 
Alexander  is  especially  appropriate,  will  be  best 
treated  by  this  method,  provided  it  appears  practicable 
or  necessary  after  section,  which,  if  it  bears  out  the 
promise  of  the  present,  will  surely  take  a  high  place 
in  the  future,  as  the  objections  to  it  are  almost  nil, 
aside  from  the  seeming  gravity  of  the  step. 

Dr.  James  A.  GoncANS,  of  Alexander  City,  Ala., 
followed  with  remarks  on  empyema,  and  reported 
twentv  cases. 


Third  Day — Morning  Session. 

Improved  Technique  in  Operation  for  Intraliga- 
mentous Cyst. — Dr.  Rufus  B.  Hall,  of  Cincinnati, 
after  reviewing  the  literature  on  the  subject,  said  he 
believed  the  mortality  from  operation  for  intraliga- 
mentous cyst  was  much  higher  than  the  statistics 
would  lead  one  to  believe.  A  large  per  cent,  of  the 
deaths  were  due  to  hemorrhage,  either  on  the  table  or 
within  a  few  hours  after  the  patients  were  put  to  bed. 
He  thought  the  operation  proposed  by  him  would  save 
many  lives,  as  it  was  practically  bloodless.  It  was 
applicable  to  those  cases  in  which  the  adhesions  were 
very  firm  and  the  cyst  could  not  be  easily  stripped 
from  the  pelvic  floor.  The  operation  he  proposed  is 
as  follows:  First  tap  the  cyst  and  empty  it.  Ligate 
the  ovarian  artery  on  the  tumor  side  at  the  pelvic  bor- 
der; ligate  the  ovarian  artery  on  the  opposite  side, 
outside  the  healthy  ovar)-;  divide  the  broad  ligament. 
Divide  the  peritoneum  above  the  top  of  the  bladder 
and  push  the  bladder  down.  Ligate  the  uterine  artery 
on  the  healthy  side.  Cut  across  the  cervix  and  clamp 
or  ligate  the  uterine  artery  on  the  tumor  side.  The 
blood  supply  is  then  cut  off  and  the  patient  has  not 
lost  a  drachm  of  blood.  The  capsule  of  the  tumor  can 
now  be  divided  above  the  top  of  the  bladder  and  at  a 
suitable  point  behind,  and  the  tumor  enucleated  from 
below  upward  w'ith  vet}-  much  greater  ease  than  from 
above  downward,  and  with  corresponding  safety  to  the 
ureter,  the  rectum,  and  the  iliac  vessels.  Close  the 
peritoneum  over  the  pelvic  floor  with  a  running  suture 
of  catgut.  This  method  brings  even,'  part  of  the  field 
of  operation  into  view.  The  ureter  can  be  seen,  rec- 
ognized, and  pushed  aside.  The  adhesions  are  sepa- 
rated along  the  line  of  cleavage  instead  of  against  it, 
as  in  the  old  method.  Then  followed  tlie  presentation 
of  a  specimen  and  the  report  of  a  case  illustrating  the 
operation  and  the  class  of  cases  to  which  it  is  espe- 
cially applicable. 

Dr.  H.  Tuholske,  of  St.  Louis,  read  a  lengthy  and 
exhaustive  paper  on  personal  observations  in  abdomi- 
nal surgery,  in  which  he  covered  nearly  every  patho- 
logical condition  known  to  the  abdominal  surgeon. 

Symphyseotomy  as  Compared  with  Other  Ob- 
stetric Operations. —  This  paper  was  read  by  Dr. 
Georce  J.  Kngelmaxx,  of  St.  Louis.  The  author  il- 
lustrated his  remarks  by  diagrammatic  sketches.  Sym- 
physeotomy was  not  so  attractive  an  operation  as  was 
(.'a-sarean  section  or  the  Porro  operation,  yet  it  was  very 
successful  as  compared  with  the  results  of  Csesarean 
section.  It  was  a  successful  all-around  operation  for 
the  cit)-  and  country.  The  mortality  statistics  of  the 
different  operations  were  given  and  compared.     There 


December  4,  1897] 


MEDICAL    RECORD. 


had  been  no  trouble  in  union  of  the  pubic  bone  after 
symphyseotomy.  Quite  a  number  of  women  had  been 
delivered  by  a  second  symphyseotomy.  There  was  no 
trouble  in  the  locomotion  of  women  so  operated  upon. 
A  number  of  cases  were  on  record  of  normal  labors  hav- 
ing followed  symphyseotomy.  The  first  symphyseot- 
omy done  in  this  country  was  by  Dr.  Williams,  of 
Dennison,  Tex.  Dr.  Engelmann  showed  what  had 
been  accomplished  by  symphyseotomy,  and  said  that 
surgeons  must  be  guided  in  a  measure  by  that. 

Plaster  of  Paris  as  a  Universal  Fracture  Dress- 
ing was  the  title  of  a  paper  by  Dr.  John  B.  S.  Davis, 
of  Birmingham,  Ala.  The  author  said  that  less  than 
three  per  cent,  of  the  physicians  who  used  plaster  of 
Paris  as  a  primary  dressing  cut  the  plaster  at  the  time 
of  applying  it.  The  object  of  incising  the  plaster  of 
Paris  was  to  allow  it  to  yield  and  at  the  same  time  fit 
the  contour  of  the  limb.  For  fractures  of  the  shaft  of 
the  humerus,  as  elsewhere,  he  believed  plaster  of  Paris 
was  the  best  dressing. 

The  following  officers  were  elected  for  the  ensuing 
year:  President,  Dr.  Richard  Douglas,  Nashville, 
Tenn. ;  Vice-Presidents,  Dr.  H.  H.  Mudd,  of  St.  Louis, 
Mo.,  and  Dr.  James  A.  Goggans,  Alexander  City,  Ala. ; 
Secretary,  Dr.  W.  E.  B.  Davis,  Birmingham.  Ala; 
Treasurer,  Dr.   A.  M.  Cartledge,  Louisville,  Ky. 

Place  of  next  meeting,  Memphis,  Tenn.  Time,  sec- 
ond Tuesday  in  November,  1898. 


NEW    YORK   AC.\DEMY    OF    MEDICINE. 

Anniversary  Meeting,  November  i8,  i8gj. 

Edward  G.  Janeway,   M.D.,  President. 

Sanitary  Science,  the  Medical  Profession,  and  the 
Public  — Dr.  Herman  M.  Biggs  delivered  the  an- 
niversary discourse,  which  was  on  the  above  topic. 
He  said  that  while  much  had  been  done  to  reduce  the 
mortality  from  preventable  disease,  fully  one-third 
was  still.due  to  this  cause.  The  importance  of  proper 
sanitation  was  well  shown  in  1892,  by  the  deadening 
effect  on  commerce  resulting  from  a  knowledge  that  a 
few  cases  of  Asiatic  cholera  had  reached  this  harbor 
and  that  half  a  dozen  cases  had  gotten  into  this  city. 
Another  example,  fresh  in  our  minds,  was  the  yellow- 
fever  epidemic  in  the  South.  An  expenditure  of  one- 
tenth  of  the  sum  lost  through  the  influence  of  this  in- 
significant epidemic  on  the  business  of  the  country 
would  be  ample  to  render  the  introduction  of  yellow- 
fever  in  the  future  wellnigh  impossible.  With  all  its 
terrors  in  the  time  preceding  vaccination,  smallpox 
was  scarcely  to  be  so  much  dreaded  as  was  tubercu- 
losis to-day.  Tuberculosis  is  not  dramatic  in  appear- 
ance or  in  course,  and  it  is  so  familiar  to  all  of  us 
that  but  little  attention  is  paid  to  it.  It  is  on  this 
account  that  its  ravages  still  continue,  yet  no  disease 
is  better  understood  and  none  is  more  preventable  by 
simple  measures.  After  a  careful  and  prolonged  study 
of  the  subject,  it  was  his  deliberate  conviction  that 
the  time  was  not  far  distant  when,  by  proper  sanitary 
supervision,  the  deaths  from  tuberculosis  would  be 
reduced  to  one-third  the  present  rate.  About  two 
hundred  years  ago,  of  every  thousand  persons  in  the 
population  of  England,  fifty  to  eighty  died  each  year, 
and  the  average  duration  of  life  of  each  person  born 
was  not  more  than  fifteen  or  eighteen  years.  How 
different  from  the  present  death-rate  of  seventeen  per 
thousand!  In  contagious  diseases  we  were  as  yet  un- 
able to  adopt  measures  which  would  prevent  a  suscep- 
tible individual  from  contracting  these  diseases,  but 
simple  precautions  would  rob  the  communicable  dis- 
eases of  their  terrors.  Diphtheria  had  been  increas- 
ing gradually  in  our  large  cities  until  the  introduction 


of  diphtheria  antitoxin  in  1894.  Since  then  it  had 
steadily  diminished,  until  in  Berlin  the  mortality  had 
been  reduced  to  one-fourth.  Whooping-cough  de- 
stroyed annually  in  New  York  City  unnecessarily 
many  hundred  lives — more  than  were  sacrificed  by 
smallpox  and  cholera  together.  Great  difficult)-  was 
experienced  in  controlling  diseases  of  this  kind  in  the 
tenement  districts.  Dr.  Hill,  of  Birmingham,  had 
shown  in  a  very  striking  way  how  the  ravages  of  scar- 
latina might  be  controlled  by  compulsorj-  notification, 
and  by  the  removal  of  such  patients  to  the  hospital. 
There  had  been  many  theoretical  objections  to  this 
plan,  but  they  had  all  been  refuted  by  practical  ex- 
perience. Many  of  the  victories  of  sanitary  science. 
Dr.  Biggs  said,  had  been  won  through  preaching  and 
practising  the  gospel  of  cleanliness.  The  average 
annual  death  rate  for  the  ten-year  period  ending  1893 
was  about  twenty-six  per  one  thousand  of  population, 
yet  in  the  present  year  the  death  rate  was  a  fraction 
over  nineteen — a  reduction  of  over  twenty-five  per 
cent.  This  was  due  to  no  special  innovations,  such 
as  the  introduction  of  an  improved  water  supply,  but 
to  attention  to  many  small  matters  and  to  the  educa- 
tion of  the  people.  Still  it  should  not  be  believed  that 
the  limit  had  yet  been  reached;  there  was  no  inherent 
reason  why  the  death  rate  in  this  city  should  not  be 
reduced  to  fourteen  per  thousand,  or  even  less,  and 
the  average  duration  of  human  life  should  be  increased 
to  fifty  years  or  more. 

The  work  done  by  the  New  York  board  of  health 
was  next  considered  more  in  detail.  The  speaker 
said  that  the  health  board  had  assumed  that  it  was  its 
duty  to  give  such  specific  and  general  information 
regarding  infectious  diseases  as  could  be  furnished  by 
a  thoroughly  equipped  bacteriological  laboratory.  The 
board  of  health  of  New  York  had  been  the  first  to  set 
this  example,  and,  while  it  had  been  followed  in  many 
other  cities,  in  no  other  place  had  the  broad  principle 
upon  which  this  practice  was  founded  been  so  liberally 
and  consistently  carried  out.  Medical  practitioners 
sometimes  forgot  that  the  health  board  legislated  for 
the  whole  citj-,  and  not  for  special  sections  or  dis- 
tricts of  the  cit}',  and  that  special  legislation  was  gen- 
erally objectionable.  Much  greater  liberty  was  allowed 
in  private  houses  than  in  tenements,  because  of  the 
greatly  diminished  risk.  It  had  always  been  the  pol- 
icy of  the  health  officers  not  to  interfere  in  private 
houses  in  matters  that  concerned  the  members  of  the 
family  only,  and  which  did  not  affect  the  outside 
public.  The  greatest  cause  of  misunderstanding  and 
complaint  arose  from  the  fact  that,  with  but  rare  ex- 
ceptions, physicians  could  not  be  induced  carefully  to 
read  the  circulars  issued  by  the  health  department. 
He  felt  that,  as  a  whole,  the  work  of  the  health  de- 
partment in  recent  years  had  deserved  and  had  re- 
ceived the  commendation  of  the  medical  profession  of 
the  city.  The  interests  of  the  individual  and  of  the 
community  were  often  apparently  divergent,  as  in  the 
restriction  of  noxious  trades  and  the  regulations  af- 
fecting tenement  houses.  The  primary  object  of  the 
sanitary  authorities  was  to  secure  for  all  proper  air, 
light,  water,  and  wholesome  f^od.  No  other  city  in 
the  world  had  a  better  and  more  wholesome  water  sup- 
ply. It  was  true  that  at  certain  seasons  of  the  year  the 
water  was  impleasant  to  the  eye  and  to  the  taste,  but 
this  was  due  to  suspended  vegetable  matter,  which  had 
not  yet  been  shown  to  be  deleterious  to  health.  The 
greatest  value  of  the  system  of  compulsory  notification 
of  contagious  diseases  is  that  it  allows  the  sanitary 
authorites  to  devise  and  carry  out  a  scientific  system 
of  control.  It  did  not  seem  to  be  very  generally  un- 
derstood, even  in  the  medical  profession,  that  differ- 
ent diseases  required  different  methods  of  control. 
The  knowledge  required  for  the  intelligent  discharge 
of  the  duties  of  a  public-health  officer  must  be  broad, 


834 


MEDICAL    RECORD. 


[December  4,  1897 


exact,  and  entirely  different  from  that  obtainable  in 
any  existing  institution.  There  are  no  men  to  be 
found  in  this  country  with  an  extensive  knowledge  of 
public  medicine — not  even  in  the  large  cities.  The 
"■reat  sanitary  need  of  the  time  is  the  establishment  of 
training  schools  in  public  health,  and  that  health  offi- 
cers should  have  diplomas  representing  the  possession 
of  an  adequate  knowledge  of  public  medicine.  The 
tenure  of  office  should  be  longer  and  more  secure,  and 
the  compensation  should  be  large.  In  addition  to 
this,  there  should  be  a  national  supervision,  exercised 
by  a  properly  constituted  national  board  of  health,  the 
powers  of  which  should  be  similar  to  those  of  the  local 
government  board  of  Great  Britain.  By  such  means 
we  could  hope  in  time  to  obtain  more  nearly  ideal 
conditions  throughout  the  whole  countr)'. 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 
A    DEBATE    ON    TYPHOID — PROGRESS    OF    THE    EPIDEMICS 

—  BILHARZIA     H^MATOBIOM SIR      HENRY     BURDETT, 

HIS       SPEECH       ON       HOSPITALS,       HIS       CAREER MR. 

HORSLEY JUBILEE    HOSPITAL    AND    "TRUTH." 

London,  November  12.  1897. 

The  Royal  Medical  and  Chirurgical  Society's  next 
meeting  is  to  be  devoted  to  a  discussion  on  the  pre- 
vention of  typhoid  fever.  This  is  very  opportune,  con- 
sidering the  serious  epidemics  which  have  recently 
occurred.  The  discussion  is  to  be  opened  by  Dr. 
Vivian  I'oore,  and  it  may  be  anticipated  that  some  of 
our  leading  authorities  will  join  in  it.  If  no  new  ad- 
vance be  made  known,  our  present  knowledge  will  at 
lejst  be  epitomized  and  a  stimulus  given  to  further 
efforts.  I  must  add  that  the  meeting  will  not  be  con- 
fined to  fellows  of  the  society,  but  visitors  are  cordially 
invited  and  will  be  introduced  by  the  secretaries  on 
the  evening  of  the  debate,  which  is  fixed  for  the  23d 
of  this  month.  As  to  the  recent  outbreaks  a  few  facts 
of  the  week  may  be  added. 

Maidstone  is  still  exciting  the  sympathy  of  the  na- 
tion on  account  of  its  affliction,  and  large  sums  are 
being  subscribed.  It  is  hoped,  however,  that  the 
worsf  has  passed.  At  a  meeting  of  the  guardians  yes- 
terday it  was  decided  to  close  the  relief  stations  on 
Sunday  next,  except  the  central  one.  Four  or  five 
fresh  cases  of  typhoid  have  occuneJ  daily  this  week, 
bringing  the  total  up  to  1,828  with  129  deaths.  It  was 
reported  further  that  diphtheria  had  been  imported 
into  one  district,  28  cases  having  occurred. 

At  King's  Lynn  there  has  been  a  fall  in  the  typhoid 
cases  since  Tuesday,  from  14  to  15  daily  down  to  4  or 
5.  Yesterday  the  M.  O.  H.  reported  5  as  occurring  in 
the  previous  twenty-four  hours,  making  a  total  of  380, 
with  26  deaths.  It  is  said,  however,  that  the  disease 
has  spread  beyond  the  town  limits.  Dr.  St.  George 
Mivart,  the  recently  appointed  government  inspector, 
has  been  down  to  advise  the  authorities. 

Tlie  Clifton  outbreak  has  been  traced  to  a  definite 
cause,  and  the  liristol  town  council  has  been  informed 
that  there  is  no  extension,  but  seven  deaths  have  al- 
ready occurred.  From  Belfast  I  hear  of  three  more 
deaths  in  dangerous  proximity  to  the  water  reservoirs. 

.\l  the  Pathological  Society  meeting  Mr.  {'.  G.  Selig- 
maiui  exhibited  some  live  o\a  of  Bilharzia  iiivmato- 
bium  which  he  had  obtained  from  the  urine  of  a  soldier 
recently  returned  from  Ma.-.nonaland.  These  ova,  he 
said,  were  constantly  passed  from  both  the  bladder 
and  rectum.  Those  fr(Mn  the  bladder  had  terminal 
spines  only,  Init  those  from  tiie  rectum  had  also  lateral 
spines.     He  found  the  ov.i  could  be  hatched  in  urine 


(a  surprise  for  those  who  have  pooh-poohed  the  fact), 
though  not  so  quickly  as  in  water  of  the  same  tempera- 
ture. It  is  very  interesting  to  watch  the  hatching  and 
the  amoeba-like  changes  in  the  shape  of  the  embrj-o. 

Sir  Henry  Kurdett  has  incurred  the  anger  of  many 
general  practitioners  by  his  speech  at  the  meeting  on 
hospital  reform,  in  which  he  attributed  a  degree  of 
incompetency  to  some  of  their  body.  Called  to  ac- 
count for  this  by  a  subsequent  speaker,  he  explained 
that  he  meant  only  that  many  would  be  greatly  helped 
if  they  went  to  hospitals  and  attended  post-graduate 
classes.  This  explanation  does  not  amount  to  a  re- 
pudiation of  the  sense  in  which  his  words  were  under- 
stood, and  7'/ic-  Lancet,  very  naturally,  defended  the 
general  practitioners  from  the  insinuations  of  a  non- 
medical man.  Sir  Henry  retorts  that  he  has  passed 
all  but  the  final,  and  if  need  be  to  defend  his  position 
he  may  devote  a  few  months  to  passing  and  then  chal- 
lenge the  editor  to  stand  against  him  as  candidate  for 
the  General  Medical  Council.  This  would  be  amusing 
as  a  novel  sort  of  controversy  on  hospital  abuse,  and 
no  one  doubts  but  Sir  Henry's  energy  would  carry  him 
far.  Moreover,  he  is  just  retiring  from  the  position 
he  has  so  long  held  on  the  Stock  Exchange,  where,  as 
secretary  of  the  share  and  loan  department,  he  has  for 
years  been  a  most  important  and  hard-working  person. 
That  post  was  gained  by  his  success  in  reorganizing 
the  financial  affairs  of  the  Dreadnought  Hospital,  so- 
that  his  whole  life  has  been  connected  with  hospital 
affairs,  in  which  he  has  always  displayed  the  keenest 
interest.  I  lately  mentioned  his  "  Hospitals  and 
Charities,"  which  occupies  almost  an  official  posi- 
tion. He  is  on  the  councils  of  the  Prince  of  Wales' 
Fund,  the  Sunday  Fund,  and  a  number  of  hospitals. 
It  is  chiefly  for  his  work  of  this  kind  that  he  received 
his  K.C.B.  He  is  the  editor  and  proprietor  of  The 
Hospital,  a  journal  devoted  to  management  and  nurs- 
ing. He  founded  the  Royal  Nurses'  Pension  Fund, 
which  is  a  very  important  organization,  and  has  a 
finger  in  the  pie  of  charities  and  hospitals  too  numer- 
ous to  mention.  It  is  easy,  therefore,  to  see  that,  what- 
ever his  views,  he  is  a  man  to  be  reckoned  with.  His 
knowledge  of  every  sort  of  finance  is  in  itself  a  power. 
He  is  no  doubt  conscious  of  this  and  perhaps  a  little 
too  ready  to  force  his  opinions  on  others,  but  I  think 
he  is  a  good  friend  to  hospitals  and  by  no  means  un- 
aware of  the  difficulties  of  professional  life.  Zeal  and 
hasty  speech  often  go  together,  and  there  may  be  no 
permanent  cause  of  offence  because  Sir  Henrj's  ear- 
nestness and  self-consciousness  led  him  to  assert  him- 
self— and  incidentally  depreciate  the  qualified  G.  P. 
I  do  not  suppose  offence  was  intended,  but  the  speech 
was  unfortimate,  and  accentuates  the  objections  which 
many  feel  to  some  of  his  views  on  hospital  manage- 
ment.    He  is  now  about  to  publish  a  nursing-directory. 

Professor  Horsley's  election  to  the  medical  council 
necessitated  his  resignation  of  the  presidency  of  the 
Defence  Union,  since  that  body  prosecutes  before  the 
council  where  Mr.  Horsley  will  exercise  judicial 
functions.  One  of  the  vice-presidents  of  the  union. 
Dr.  \V.  S.  \.  Griffith,  succeeds  Mr.  Horsley,  no  easy 
task,  and  I  hope  he  may  be  as  succixssful. 

Mr.  Horsley  has  just  been  appointed  by  the  crown 
as  the  successor  of  the  late  Mr.  Walter  Rivington  in 
the  senate  of  the  Iniversity  of  London. 

The  war  waged  by  Tnitli  against  the  Jubilee  Hos- 
pital is  concluded,  .Mr.  Laiiouchere  having  laid  down 
his  arms.  It  is  rather  an  unexpected  move  for  his 
paper,  but  since  lie  so  discredited  iiimself  before  the 
.\frican  committee  people  are  pa)  ing  less  attention  to 
his  Truth.  The  Jubilee  Hospital  does  not  gain  the 
confidence  of  the  profession.  It  is  regarded  as  an  un- 
necessary institution,  and  its  very  position  shows  that 
the  neighborhood  is  not  one  from  which  patients  should 
come. 


December  4.  1897] 


MEDICAL    RECORD. 


835 


THE   TREATMENT   OF    SYMPTOMS. 


Editor  ( 


Medical  Reco 


Sir  :  Dr.  Seth  Mereness,  in  the  Medical  Record  of 
October  i6th,  says  that  every  physician  knows  that 
danger  to  life  is  not  at  all  proportionate  to  severity  of 
symptoms.  I  will  assert  that  a  large  majoritj-  of 
deaths,  except  sudden  deaths,  are  preceded  by  severe 
symptoms.  I  believe  that  every  physician  knows  that 
a  case  of  pneumonia  with  severe  symptoms  has  a 
worse  prognosis  than  one  with  mild  symptoms.  A 
mild  case  of  pneumonia  will  destroy  life  in  the  aged, 
but  it  is  loss  of  vitality  more  than  the  pneumonia  that 
kills.  If,  as  he  says,  it  has  never  been  demonstrated 
that  combating  symptoms  ever  contributed  to  or  ef- 
fected a  cure,  then  nothing  has  ever  been  demon- 
strated, human  experience  is  without  value,  and  cause 
has  no  relation  to  effect. 

I  have  seen  the  mortality  of  typhoid  fever  reduced 
to  two  per  cent,  by  the  judicious  use  of  cathartics,  an- 
tiseptics, and  antipyretics.  Baths  may  do  as  well,  but 
the  same  objections  must  hold  with  this  writer,  for 
they  combat  symptoms — are  given  for  that  purpose,  as 
the  prognosis  is  improved  thereby.  Baths,  however, 
cannot  be  used  with  the  necessary  thoroughness  in 
private  practice. 

While  the  article  contains  much  that  is  instructive, 
such  doctrine  here  alluded  to  violates  all  the  teaching 
I  have  ever  seen  in  the  Medical  Record  and  contra- 
dicts the  opinions  of  thousands  of  the  most  intelligent 
men  of  the  age.  I  am  certain  that  the  relief  of  symp- 
toms, whether  by  hygiene,  hydrotherapy,  drugs,  or  any 
other  agency,  generally  effects  improvement  and  tends 
to  a  cure.  I  am  certain,  too,  that  in  hopeless  cases 
the  relief  of  symptom,  by  whatever  means,  gives  great 
comfort,  reduces  suffering,  and  in  many  instances  pro- 
longs life.  O.  S.  Ensign,  M.D. 


'•WHAT    MUST    WE    DO    TO    BE    SAVED?" 

To  THE  Editor  of  the  Medical  Record. 

Sir:  From  the  standpoint  of  a  poor  country  physician. 
Dr.  Hillis  has  greatly  weakened  what  otherwise  would 
have  been  an  admirable  paper — "What  Must  We  Do 
to  be  Saved  ?" — by  an  uncalled-for  and  an  unjustifiable 
attack  on  the  government  of  the  Cnited  States  and  by 
an  equally  unjustifiable  attack  on  the  rich.  The  lat- 
ter, though  embodied  in  a  bit  of  beautiful  rhetoric,  is 
so  grossly  misleading  that  it  should  not  be  allowed  to 
pass  without  a  protest.  F.  Powers,   M.D. 


A    MEDICAL 


MISSIONARY 
CEYLON. 


WANTED    IX 


To  THE  Editor  of  the  Medical  Recofmi. 

SiK  :  In  connection  with  the  Woman's  Medical  Mis- 
sion in  Jaffua,  Ceylon,  there  is  an  opening  for  a  lady 
doctor  to  be  the  associate  of  Dr.  Isabella  Curr,  who 
went  to  Ceylon  last  year. 

The  five  large  new  buildings  of  the  Woman's  Medi- 
cal Mission,  viz.,  the  mission  house,  the  nurses' 
training-school,  the  medical  and  surgical  wards, 
and  the  dispensary,  together  with  the  necessan,-  out- 
buildings, are  completed  and  ready  for  use. 

The  wards  provide  accommodation  for  forty  in- 
patients. The  training-school  will  accommodate  eigh- 
teen nurses  and  a  matron. 

Rev.  T.  B.  Scott,  M.D.,  and  Mrs.  T.  B.  Scott,  M.D., 
who  are  in  charge  of  the  general  medical  mission  near 
by,  will  act  as  consulting  physicians. 

A  pxjpulation  of  three  hundred  thousand  people  in 
this  province  is  accessible.  The  climate  is  healthful. 
The  outlook  for  the  work  is  promising.      Ten  families 


of  x\merican  and  British  missionaries  reside  in  the 
province.  There  are  three  thousand  native  Christians, 
members  of  mission  churches,  and  fifteen  thousand 
children  and  youths  in  mission  schools. 

As  the  training  of  educated  Christian  young  women 
as  nurses  will  be  an  important  feature  of  the  work,  we 
are  desirious  of  finding,  to  fill  this  vacancy,  a  medical 
lady  who  has  had  a  nurse's  training,  or  one  who  would 
be  willing,  before  going  out,  to  take  some  special  in- 
struction in  nursing.  She  should  be  possessed  of  a 
true  missionar}-  spirit.  We  should  be  glad  to  hear 
from  any  one  who  is  fully  qualified,  or  who  is  about 
to  graduate  the  coming  spring. 

Mary  and  Margaret  W.  Leitch. 


THE    IMPROVEMENT    OF    GENERAL    AN^S- 
THESI.A. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  Since  my  return  to  the  city  on  September  15, 
1897,  the  time  of  commencing  my  fall  service  at  the 
German  Hospital,  I  have  in  all  operations  requiring 
general  narcosis  made  use  of  the  ansesthetic  mixture 
proposed  by  Dr.  C.  L.  Schleich,  of  Berlin,  in  1895, 
and  strongly  recommended  by  him  again  this  year.  I 
have  availed  myself  of  the  advantages  of  this  mixture 
also  in  all  my  private  operations  done  during  this 
period. 

I  have  been  personally  so  favorably  impressed  with 
the  working  of  the  new  mixture,  as  have  also  been  the 
members  of  the  house  staff  of  the  German  Hospital 
and  all  those  colleagues  who  witnessed  ray  operations 
in  hospital  and  private  practice,  that  I  almost  feel  it 
my  dut\-  to  give  this  preliminary  report,  which  is  based 
on  very  nearly  one  hundred  cases  of  my  own — cer- 
tainly a  sufficiently  large  number  to  permit  draw- 
ing conclusions.  More  patients  than  the  compara- 
tively few  coming  under  the  care  of  a  single  man 
should  derive  the  benefits  of  this  anaesthetic  as  soon 
as  possible.  I  am  convinced  that  whoever  has  tried 
Schleich's  anaesthetic  mixture  will  not  return  to  the 
ordinary  ether  or  chloroform  narcosis. 

Schleich  seems  to  have  solved  the  problem  of  mak- 
ing general  anaesthesia  a  safe  procedure — as  far  as 
this  ever  can  be  done — by  experimenting  on  a  physi- 
cal, not  on  a  chemical  basis:  viz.,  by  adapting  the 
boiling-point  of  the  narcotic  to  the  temperature  of  the 
body. 

He  uses  a  mixture  of  three  drugs,  viz.,  chloroform, 
ether,  and  petroleum  ether  (benzin),  the  latter  of  the 
boiling-point  of  60  -65    C.  (i4o''-i48'  F.).^ 

Formula  I.  Boiling-point  =  100.4°  F.  (38^  C). — 
Chloroform,  45  c.c.—  iyi  oz. ;  petroleum  ether,  15 
c.c.  =  ,'j  oz. ;  sulphuric  ether,  180  c.c.  =  o  oz.  It  is 
used  for  narcosis  in  operations  of  short  duration. 

Formula  II.  Boiling-point  =  104'  F.  (40'  C). — 
Chloroform,  45  c.c.  =  i'^  oz. ;  petroleum  ether,  15 
c.c.  =  '-  oz. ;  sulphuric  ether,  150  c.c.  =  5  oz.  It  is 
used  for  operations  lasting  a  little  longer. 

Formula  III.  Boiling-point  =  107.6'  F.  (42"  C). — 
Chloroform,  30  c.c.  =  1  oz. ;  petroleum  ether,  15  c.c. 
=  'j  oz. ;  sulphuric  ether,  80  c.c.  =  2-.;  oz.  It  is 
used  for  major  operations. 

The  measurement  is  made  by  volume,  not  by  weight. 
In  a  chemical  sense  it  is  a  real  solution.  Petroleum 
ether  of  the  required  boiling-point,  140^-148"  F., 
can  be  iiad  of  any  first-class  chemist.  Personally  I 
obtained  my  specimens  from  Charles  Cooper  &  Co., 
of  this  city.  I  have  induced  a  number  of  druggists 
throughout  the  city  to  keep  a  stock  of  this  ether. 

Schleich  recommends  a  special  mask  for  the  admin- 
istration of  his  mi.xture.  I'p  to  date  I  have  used,  to 
my  entire  satisfaction,  the  ordinary  ether  mask  (paper 


836 


MEDICAL    RECORD. 


[December  4,  1897 


and  towel)  ;  often  also  that  used  for  chloroform  anes- 
thesia. A  few  days  ago  1  received  Schleich's  mask 
from  Berlin,  and  shall  now  test  the  merits  claimed  for 
the  same. 

The  improvement  of  the  anaesthesia  with  the  help  of 
this  mi.xture  is  very  great  in  my  opinion.  I  shall  here 
mention  only  a  few  points: 

We  miss  the  frequently  occurring  cyanosis,  the  sali- 
vation, the  accumulation  of  mucus  in  the  trachea  dur- 
ing the  administration  of  the  anesthetic  (^ether) ;  we 
do  not  meet  with  bronchitis  or  broncho-pneumonia 
afterward.  As  compared  with  chloroform,  the  influ- 
ence of  the  mi.xture  upon  the  heart's  action  is  by  far 
less  marked;  we  have  given  it  repeatedly  in  cases  of 
heart  disease.  There  are  a  great  many  other  advan- 
tages, to  enumerate  which  here  would  lead  me  too  far. 
In  a  paper  to  be  read  before  the  next  meeting  of  the 
New  York  County  Medical  Society,  on  December 
27th,  I  shall  give  a  detailed  report  of  my  experience. 
Willy  Meyer,  M.D. 

November  26,  1807. 


FINES    FOR    ILLEGAL    PRACTICES. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  The  New  York  Sun  of  November  17,  1897,  no- 
ticing the  fine  of  Si  50  imposed  on  Finney,  a  druggist, 
for  illegally  practising  medicine,  said:  "This  is  the 
heaviest  fine  yet  imposed  in  special  sessions  for  this 
offence." 

In  making  this  statement  The  Su»  was  misinformed. 
The  heaviest  fine  imposed  since  the  County  Society 
began  to  inforce  the  medical  law  in  188 1  was  that  of 
$500,  inflicted  on  January  9,  1889,  in  special  sessions, 
upon  one  Bourquteet,  "  private  physician  to  the  Bey 
of  Tunis,"  for  a  first  offence.  That  same  court  also 
imposed  fines  of  S250  upon  Brown,  August  12,  1887; 
Sirosser,  June  4,  1891;  Goldsmith,  October  31,  1892; 
and  De  Samora,  December  8,  1892  ;  also  fines  of  S^oo 
upon  Eckardt  twice;  Kraft,  Tochterman,  Montague, 
L'tzsinger,  Michael,  Morrel,  La  Roche,  St.  Leon,  and 
Raffel;  also  fines  of  S150  upon  Weinstein,  Guggen- 
heim, Libertino,  Hamecher,  Pool,  Koehler,  and  Rosa. 
Thus  there  have  been  twenty-three  cases  in  which  a 
fine  of  S150  or  more  has  been  imposed  by  that  court. 

The  court  of  special  sessions  also  imposed  on  Octo- 
ber 4,  1897,  prior  to  Finney's  case,  a  fine  of  Si 50  for 
the  illegal  practice  of  dentistry  by  one  Diaz  in  the 
"Boston  Dental  Parlors,"  and  in  so  doing  e.xpressed 
approval  of  the  dental  law  and  the  judicious  manner 
in  which  the  State  Dental  Society  sought  to  have  it 
inforced.  This  the  Medic.\l  Record  noted,  I  think, 
at  the  tin^e. 

The  largest  fines  inflicted  under  the  dental  act  have 
been  two  of  S500  each  upon  the  notorious  Kahn  and 
Jordan,  whom  the  State  Dental  Society  caused  to  be 
convicted  in  1896  for  unlawfully  affixing  the  letters 
M.D.  to  their  names. 

All  of  the  above  fines,  except  those  in  the  dental 
cases,  were  imposed  prior  to  December  15,  1893:  and 
it  may  therefore  be  possible  that  no  fine  of  Si 50  has 
been  imposed  in  special  sessions  since  then. 

The  last  report  of  counsel  published  by  the  County 
Society,  that  of  1896,  shows  by  a  tabulation  that  since 
December  15,  1893,  five  fines  of  $250  and  one  of  S150 
have  been  imposed,  but  in  what  court  does  not  appear: 
however,  from  what  is  said  of  the  court  of  special  ses- 
sions in  the  body  of  that  report,  and  the  further  fact 
that  'J7ii:  Sun  presumably  derived  its  statement  from 
some  one  it  supposed  was  authority,  one  may  fairly 
assume  that  those  fines  were  imposed  in  general  ses- 
sions. 

It  is  a  curious  result  of  the  various  amendments  of 
the  laws  that— dentistry  and  the  practice  of  medicine 
being  both  regulated  by  chapter  5  of  the  general  laws, 


and  the  former  being  a  specialt)'  of  the  latter — the 
misdemeanor  of  unlawful  dental  practice  must  be 
punished  by  a  fine  of  not  less  than  $50,  and  may  be 
punished  by  a  fine  of  S500;  while  the  offence  of  unli- 
censed medical  practice  cannot  be  punished  by  a  fine 
of  more  than  §250,  and  may  be  punished  by  as  small 
a  fine  as  the  court  sees  fit  to  impose,  which  in  one  in- 
stance was  $10  and  in  three  cases  $25.  Thus  for  pur- 
poses of  punishment,  assuming  dentistry  to  be  a  spe- 
cialty of  medicine,  the  part  is  greater  than  the  whole 
— Aristotle  to  the  contrary  notwithstanding. 

W.    A.    FURRIXGTOX,  M.D. 


"SHOULD    MINISTERS    PAY    DOCTORS? 


Medical  Record. 


Sir:  In  answer  to  the  query,  '"  Should  Ministers  Pay 
Doctors?"  I  say,  "Ay,  verily."  For  twent}--five  years 
your  humble  ser\'ant  has  been  pouring  physic  down 
and  pumping  other  medicines  up  into  the  ministers, 
their  wives,  and  other  members  of  the  family,  free  of 
charge  and  sometimes  without  even  a  thank  you.  Why 
should  we  do  it?  Are  not  the  ministers  as  well  paid, 
as  well  fed  and  clothed — house  rent  very  little,  and 
often  free?  When  they  travel,  'tis  either  D.H.  or 
half-fare. 

Don't  we  pay  them  when  they  marry  us?  Don't  we 
tip  them  when  they  baptize  our  children?  Don't 
we  give  them  a  few  ducats  when  we  die? 

They  do  not  have  the  expense  of  keeping  a  horse  or 
two,  nor  of  the  wear  and  tear  of  carriages,  cutters,  har- 
ness, etc.  No  getting  up  "■  o'  nights"  for  a  drive  of 
forty  miles  in  the  country,  with  the  wind  howling  at  a 
speed  of  forty  miles  an  hour  and  the  mercury  forty 
below  zero — furnish  the  medicine  free — all  for  the 
love  of  your  fellow-man.  Not  a  cent  in  sight,  but  we 
must  go — Iwn  gr,',  mal gn'^ or  we  are  heartless,  cold- 
blooded, cruel. 

Ministers  sometimes  show  their  gratitude,  as  when 
I  attended  one  through  a  severe  sickness,  and  during 
his  convalescence  he  advised  one  of  my  good  pay  pa- 
tients to  try  a  rival  MiD. ;  said  he  would  "  get  him  on 
his  legs  quicker."  This  minister,  however,  was  an 
exceptionally  mean  one.  As  a  rule,  they  are  jolly 
good  fellows;  but  I  say,  let  them  pay  and  then  they 
will  better  appreciate  us.  H.  R.  Pdrter,  M.D. 

Bismarck,  X.  D..  November  17,  iSg?. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deatlis  from  contagious  diseases  reported 
to  the  Sanitar)-  Bureau,  Health  Department,  for  the 
week  ending  November  27,  1897  : 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 

l.arj'ngeal  diphtheria  (croup) 
Chicken-pox , 


162 
26 
127 
o 
239 
193 


Bacteria    in    Ink Septicemia   following    a    pen 

scratch  is  explained  by  Marpmann,  of  Leipzig,  on  the 
theory  of  the  constant  presence  in  most  inks  of  sapro- 
phytes, bacteria,  and  micrococci.  .\  bacillus  was  cul- 
tivated and  found  fatal  to  mice. 


Medical  Record 

A  IVeekly  yoiirnal  of  Medicine  and  Surgery 


Vol.  52,  No.  24. 
Whole  No.  1414. 


New  York,    December    ii,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc 


©vigiual  Articles. 

A  MODIFIED  IXCISIOX  AT  THE  OUTER 
BORDER  OF  THE  RECTUS  MUSCLE  FOR 
APPENDICITIS. 

By   FRED.    KAMMERER,    M.D., 

NEW  VORK. 

At  the  meeting  of  the  Xew  York  Surgical  Societ\-  on 
March  24,  1S97,'  I  showed  two  patients  upon  whom  I 
had  ojDerated  for  appendicitis  in  the  declining  stage 
of  an  acute  attack  by  a  method  the  principle  of  which 
as  applied  to  appendicectomy  was,  I  think,  new. 
Since  then  I  have  had  occasion  to  operate  in  only 
two  other  cases,  both  during  the  internal,  by  the 
same  method. 

There  can  be  no  question  that  even  very  small  in- 
cisions, carried  in  one  plane  through  the  entire  abdom- 
inal wall,  will  occasionally  lead  to  the  formation  of 
hernia  later  on.  The  size  of  the  incision  through  the 
skin  is  irrelevant  in  this  respect  The  damage  to  the 
muscular  tissues  and  fasciae  is  responsible  for  the 
later  development  of  a  hernia,  and  it  is  well  to  re- 
member in  this  connection  that  a  good  deal  of  damage 
can  be  done  to  the  same  even  through  a  skin  incision 
of  only  one  or  two  inches.  Hernia;  were  of  frequent 
occurrence  after  operations  for  appendicitis  when  the 
old  incision  at  the  outer  border  of  the  rectus  muscle 
was  universally  practised,  before  McBurney  pub- 
lished his  method  of  intermuscular  separations.  My 
own  experience  with  this  method  is  limited  to  a  few 
cases,  but  we  may  gather  from  the  reports  of  others 
that  it  has  taught  us  to  avoid  herniae  with  almost  abso- 
lute certainty.  To-day  I  believe  that  the  same  asser- 
tion can  be  made  of  the  modified  incision  at  the 
outer  border  of  the  rectus  which  I  demonstrated  at  the 
meeting  above  referred  to.  I  have  now  operated  six 
times  according  to  this  plan.  Two  of  the  patients 
were  operated  upon  in  the  summer  of  1895.  In  one 
case  suppuration  occurcd,  and  although,  after  some 
delay,  the  patient  was  discharged  with  his  wound 
closed,  the  integrit)'  of  the  abdominal  wall  may  have 
become  impaired.  In  the  other  case  the  wound  healed 
by  first  intention,  but  I  have  not  been  able  at  present, 
after  a  lapse  of  two  years,  to  find  the  patient  again, 
although  I  have  made  diligent  search  for  him.  The 
other  four  cases  have  come  under  my  obser\-ation  this 
year,  and  seem  to  hold  out  promise  of  permanent  res- 
toration of  the  abdominal  wall  with  ver\-  little  dis- 
figuration. The  method  and  the  cases  are  the  fol- 
lowing: 

Method — Before  administering  the  anaesthetic  the 
patient  is  requested  to  raise  his  body  from  the  operat- 
ing-table: in  other  words,  to  contract  his  recti  muscles, 
so  that  the  outer  border  of  the  right  rectus  may  be 
accurately  determined.  I  have  found  a  ven,-  marked 
difference  in  the  width  of  this  muscle  in  different  in- 
dividuals, and  in  making  only  a  small  incision  in  the 
skin  it  is  essential  to  locate  the  outer  border  at  the 
correct  place.  The  incision  should  be  about  two 
inches  in  length,  and  the  line  drawn  from  the  superior 
anterior  spine  to  the  umbilicus  should  divide  it  in 
'  Annals  of  Surgerj-,  August,  iSgj,  vol.  .\xvi. 


such  a  way  that  somewhat  more  of  it  lies  below  than 
above  that  line.  The  skin,  subcutaneous  fat,  and  apo- 
neurosis of  the  external  oblique  are  divided.  The  an- 
terior sheath  of  the  rectus  muscle  is  now  opened,  the 
operator  cutting  in  the  same  direction  a  little  to  the  in- 
side of  the  right  linea  semilunaris  and  exposing  the  up- 
f>er  and  outer  border  of  the  rectus  muscle  itself.  It  is 
important  not  to  place  this  incision  too  far  in  an  out- 
ward direction,  in  order  not  to  incise  the  linea  semi- 
lunaris and  thus  impair  the  strength  of  the  abdom- 
inal wall.  The  rectus  muscle  is  now  drawn  toward 
the  median  line  and  dissected  away  from  its  pos- 
terior sheath  for  about  one  inch  or  a  little  less.  In 
doing  this  we  come  in  contact  with  the  epigastric 
vessels  and  a  branch  of  the  ileo-hypogastric  nene, 
which  latter  perforates  the  sheath  and  passes  into 
the  rectus  muscle,  general!}'  in  the  upper  half  of 
the  incision.  Ligation  and  division  of  the  vessels 
may  be  practised,  if  the  latter  are  at  all  in  the 
way.  I  do  not  see  any  disadvantage  in  such  a  course, 
as  we  often  ligate  vessels  of  the  same  size  in  other 
operations  without  the  slightest  hesitation.  Section 
of  the  branch  of  the  ileo-hypogastric  nerve  is,  how- 
ever, a  more  serious  matter.  In  the  first  two  cases 
reported  'below  I  divided  the  ner%-e.  The  result  of 
this  was  atrophy  of  that  part  of  the  rectus  muscle 
which  is  supplied  by  it.  Five  or  six  weeks  after  the 
operation  a  verj-  marked  wasting  of  the  muscle  was 
apparent  when  the  patients  called  into  action  both 
their  recti.  The  atrophy  was  confined  to  only  a  small 
part  of  the  rhuscle,  lying  ver\"  likely  between  the  two 
nearest  tendinous  intersections  of  the  latter,  imme- 
diately below  and  to  the  right  of  the  umbilicus.  Xo 
other  portions  of  the  muscle  were  involved,  they  being 
evidently  supplied  by  other  branches,  such  as  the 
anterior  branches  of  the  lower  intercostal  ner^-es.  In 
my  last  two  cases  I  have,  therefore,  avoided  section  of 
the  nerve.  This  is  easily  accomplished  by  hooking  it 
with  a  blunt  cun-ed  retractor  and  pulling  it  into  the 
upper  angle  of  the  incision.  The  dissection  of  the 
muscle  from  its  posterior  sheath  is  the  work  of  a  few 
moments,  and  is  more  easily  accomplished  when  the 
abdominal  walls  are  tense  than  when  we  are  dealing 
with  la.x  and  flabby  abdominal  muscles.  The  rectus 
muscle  is  now  drawn  well  toward  the  median  line  by 
the  aid  of  two  sharp  retractors,  and  an  incision  (C)  is 
carried  through  the  posterior  sheath,  the  transverse 
fascia,  and  the  peritoneum,  parallel  to  the  original  in- 
cision and  a  little  shorter  than  the  same  (about  one 
and  a  half  inches  long).  The  cut  edge  of  the  peri- 
toneum toward  the  median  line  is  secured  by  the 
application  of  one  or  two  artery  clamps.  The  flap  of 
peritoneum,  fascia,  and  sheath  (^),  on  the  outside 
edge  of  the  peritoneal  incision,  is  relieved  of  all  ten- 
sion as  soon  as  the  abdominal  cavity  is  opened,  and 
when  a  blunt  retractor  is  inserted  into  tl|e  incision 
and  traction  made  in  an  outvvard  direction,  to  expwse 
the  region  of  the  appendix,  it  offers  ven,-  little,  if  any. 
additional  resistance  to  that  of  the  entire  abdominal 
wall  at  the  site  of  the  original  incision  through  the 
skin  {B).  This  is  a  f)oint  I  wish  to  emphasize,  as  the 
discussion,  following  the  presentation  of  my  patients 
at  the  meeting  I  have  previously  referred  to,  made  it 
apparent  that  some  of  the  gentlemen  present  were  in- 


MEDICAL    RECORD. 


[December  ii,  1897 


clined  to  the  belief  that  the  site  of  the  incision  might 
be  too  near  the  median  line.  As  already  stated,  I 
cannot  find  that  this  overhanging  flap  of  sheath,  fascia, 
and  peritoneum  (A)  offers  any  further  obstacle  to  ex- 
posure of  the  region  of  the  appendix  than  is  met  with 
when  the  incision  is  carried  at  the  outer  border  of 
the  rectus  straight  into  the  abdominal  cavity.  The 
question  is  simply  whether  or  not  the  outer  border  of 
the  rectus  is  a  convenient  location  for  entering  the 
abdomen  and  searching  for  the  appendix.  I  believe 
it  is  as  good  as  any.  No  particular  location  can  be 
the  best  in  everj-  case. 

After  the  appendix  has  been  found  and  removed, 
the  incision  through  the  posterior  sheath,  fascia,  and 
peritoneum  is  closed  by  a  running  catgut  suture  (I 
use  formalin  catgut),  to  accomplish  which  the  rectus 
must  be  drawn  well  aside.  Thereupon  the  latter  is 
released  from  the  retractors  and,  falling  into  place,  is 
fastened  by  a  few  thin  catgut  sutures  at  its  outer  edge 


-4,  Layer  of  posterior  sheath  of  rectus,  transversalis  fascia,  and  peritoneum. 

B,  Incision  through  the  skin. 

C,  Incision  through  posterior  sheath  of  rectus,  fascia,  and  peritoneum. 
Z>,  Semilunar  fold  of  Douglas. 

in  its  original  situation.  The  incision  in  the  anterior 
sheath  of  the  muscle  is  now  closed  *by  individual  su- 
tures of  catgut,  and  finally  the  aponeurosis  of  the  ex- 
ternal oblique  and  the  skin  are  dealt  with  in  the  same 
manner,  separately. 

Cases.' — I  omit  the  first  two  cases,  operated  upon 
during  the  summer  of  1895,  as  I  have  not  been  able  to 
hunt  up  the  patients  this  year,  when  I  again  took  up 
the  operation.  I  shall  say,  however,  that  I  experi- 
enced no  difficulty  in  finding  and  removing  the  appen- 
dix through  the  incision. 

Case  I. — G.  H ,  male,   aged  twenty-two  years. 

First  attack.  Seen  at  the  expiration  of  a  week,  with 
some  resistance  and  pain  on  pressure  still  present  in 
right  iliac  fossa;  also  a  distinct  infiltration  on  deep 
pressure. 

Operation  on  January  20,  1897:  .\ppendix  bound 
down  by  adhesions,  pointing  in  an  upward  and  back- 
ward direction,  its  tip  lying  near  posterior  brim  of 
pelvis,  .\dhesions  broken  up  and  appendix  removed; 
small  perforation  found  at  tip.  On  section,  extended 
gangrene  of  mucosa;  two  fa-cal  concretions  in  appen- 
dix.    Suture  as  above  de.scribed:  primar)-  union. 

Case    II. — J.  8 ,  male,    aged    forty-t\vo   vears. 

Recurrent  appendicitis  for  past  ten  years;    last  attack 


about  a  week  previous ;  ver)'  distinct  induration  in  iliac 
region  about  one-fourth  of  an  inch  wide  and  one  and 
one-half  inches  long,  at  outer  border  of  rectus. 

Operation  on  February  3,  1897:  Appendix  found 
lying  verj-  superficially,  corresponding  to  infiltration 
felt  before  opening  of  abdominal  cavity;  easily  re- 
moved; much  swollen,  not  perforated,  and  containing 
no  concretions;  beginning  gangrene  of  mucosa  well 
marked  at  tip  of  appendix.     Suture;  primary  union. 

In  the  above  two  cases  marked  partial  atrophy  of 
the  rectus  muscle  developed,  as  the  result  of  section  of 
the  ileo-hypogastric  branch.  In  the  second  case  re- 
ported, which  I  had  occasion  to  examine  during  Sep- 
tember, I  have,  however,  found  complete  restitution  to 
normal  size  and  activit)-,  although  no  examination 
was  made  with  electric  currents.  No  hernia  has  de- 
veloped from  this  partial  temporary  paralysis.  Nev- 
ertheless, I  think  it  wiser  to  avoid  its  occurrence,  as 
in  the  following  two  cases : 

Case  III. — M.  S ,  female,  married,  aged  twent)'- 

seven  years.  Man}-  attacks  lately ;  last  attack  a  few 
days  ago,  lasting  only  a  day  or  two  with  tenderness  at 
McBurney's  point.  At  time  of  operation  no  phys- 
ical signs,  but  slight  pain  on  deep  pressure. 

Operation,  end  of  March,  1897:  Usual  incision; 
rectus  muscle  very  broad,  its  outer  border  only  one 
inch  from  superior  anterior  spine :  some  difficulty 
experienced  in  dissecting  away  the  posterior  sur- 
face of  the  muscle  from  its  sheath,  owing  to  great 
laxity  of  muscular  tissue.  The  incision,  in  this  in- 
stance, having  been  unintentionally  placed  at  a  higher 
level,  the  branch  of  the  ileo-hypogastric  was  found  in 
the  lower  half  of  the  incision,  and  it  was  therefore 
drawn  into  the  lower  angle  of  the  wound  by  a  blunt 
retractor  and  not  divided.  Ligation  of  epigastric  ves- 
sels unnecessar)- ;  appendix  three  and  one-half  inches 
long,  buried  among  intestines,  slightly  adherent,. 
easily  found  and  removed;  its  walls  very  much  thick- 
ened; no  perforation.     Suture;  primary  union. 

September  20,  1897:  No  indication  of  hernia:  at 
cicatrix  skin  freely  movable  over  subcutaneous  tissues. 

Case  IV. — R.  J ,  male,  aged   seventeen   years. 

About  a  dozen  attacks  during  1897,  mostly  mild  in 
character,  but  a  few  accompanied  by  pain  and  high 
temperatures,  necessitating  rest  in  bed  for  several 
weeks;  slight  sensitiveness  at  McBurney's  point  on 
deep  pressure ;  no  physical  signs. 

Operation,  September  10,  1897  :  Incision  two  inches 
long;  muscle  easily  separated  from  sheath;  ner\'e 
branch,  across  upper  part  of  wound,  easily  held  out 
of  harm's  way  by  retractor;  apjjendix  on  inner  side 
of.  colon,  kinked  and  firmly  adherent  to  its  own 
mesenter}-;  blunt  separation  of  adhesions  somewhat 
difficult  during  removal  of  appendix;  end  of  ap- 
pendix obliterated  for  about  three-fourths  of  an  inch,, 
the  remaining  portion,  to  its  base,  much  distended 
and  filled  with  pus  and  two  facal  concretions;  a 
tight  stricture  found  at  the  base.  Suture  as  usual; 
primar)-  union. 

Further  Remarks — In  a  number  of  dissections 
upon  the  cadaver  I  have  found  the  semilunar  fold  of 
Douglas,  which  marks  the  inferior  termination  of  the 
posterior  sheath  of  the  rectus  muscle,  at  a  dis- 
tance of  about  one  inch  from  the  nearest  point  of 
the  line  drawn  from  the  superior  anterior  spine  to 
the  umbilicus.  (I  have  tried  to  demonstrate  this- 
in  the  figure,  although  at  the  operation  the  rectus  is 
never  displaced  to  such  an  extent  as  to  disclose 
the  semilunar  fold.)  It  is  very  easy  after  removal 
of  the  rectus,  with  the  abdomen  unopened,  to  de- 
monstrate the  weakness  of  what  remains  of  the  ab- 
dominal wall  between  the  semilunar  fold  and  the 
symphysis  by  pressure  upon  the  abdomen,  which  will 
cause  a  bulging  of  the  intestines  at  that  point.  But 
even  with  due  regard  for  these  anatomical  facts,  I  do- 


December  ii,  1897] 


MEDICAL    RECORD. 


839 


not  think  that  an  incision  carried  beyond  the  semi- 
unar  fold  can  lead  to  the  formation  of  hernia,  if  pri- 
mary union  is  obtained  and  the  rectus  abdominis 
fully  covers  the  sutured  incision  into  the  posterior 
sheath.  On  the  other  hand,  there  is  no  necessity  for 
carrying  the  incision  lower  than  the  semilunar  fold. 

The  modification  of  the  incision  at  the  outer  border 
of  the  rectus  is  suited  for  cases  during  the  interval. 
Although  the  first  case  reported  was  operated  upon  by 
this  method,  when  the  products  of  acute  inflammation 
and  perhaps  the  infectious  agents  themselves  were  still 
present  in  the  tissues,  and  the  case  did  well,  I  think 
it  might  have  been  wise  to  establish  drainage,  if  only 
for  a  short  period.  But  in  that  event  f  should  have 
employed  McBumey's  incision  for  suppurative  cases, 
an  inch  to  the  inside  of  the  anterior  superior  spine. 
When  suppuration  is  well  established,  I  feel  as  if  I 
would  rather  err  on  the  safe  side.  In  many  such  cases 
at  the  critical  moment  we  need  as  large  an  opening  as 
w'e  can  get  for  efficient  drainage.  I  venture  to  believe 
that  we  all  are,  now  and  then,  agreeably  or  disagreea- 
bly surprised  at  the  condition  of  affairs  revealed  after 
abdominal  section  in  cases  of  acute  appendicitis. 
With  this  uncertainty  I  should  hesitate  to  employ  any 
other  than  a  free  incision  in  suppurative  cases,  al- 
though we  have  lately  heard  of  splendid  results  even 
in  such  cases  by  McBumey's  blunt  dissection. 

Some  points  in  favor  of  the  modified  incision  at  the 
border  of  the  rectus  are  the  simplicity  of  the  procedure, 
the  possibility  of  doing  the  operation  with  one  assist- 
ant, the  technical  advantage  when  operating  on  per- 
sons with  well-developed  abdominal  muscles.  I  have 
practised  the  method  without  any  blunt  dissection,  if 
that  be  worth  mentioning. 

Note. — A  few  days  before  receiving  the  proofsheets  of  this 
article,  my  attention  was  called  to  a  short  communication  by 
Ad.  Jalaguier,  surgeon  to  the  Hopital  Trousseau,  in  Paris, 
in  which  the  author  describes  an  operation  very  similar  to  the 
one  I  have  just  described.  He  further  states  that  he  has  em- 
ployed the  same  in  some  twelve  cases  with  very  satisfactory  re- 
sults. Whether  or  not  his  first  operation  was  done  before  my 
own  (summer,  1895)  I  cannot  say,  as  he  gives  no  details  of  his 
cases.  Even  if  we  have  both  employed  the  method  indepen- 
dently of  one  another,  I  regret  that  I  have  been  guilty  of  an  over- 
sight in  reference  to  Jalaguier's  publication.  He  divides  the  skin 
and  the  aponeurosis  of  the  e.xternal  oblique  at  the  outer  border  of 
the  rectus,  and  then  dissects  the  aponeurosis  on  the  inner  side  of 
this  incision  for  some  distance  from  the  anterior  sheath  of  the 
muscle.  The  latter  (the  sheath)  is  then  divided  about  one  centi- 
metre to  the  inside  of  the  border  of  the  rectus,  e.xposing  the 
muscle.  I  have  not  insisted  on  this  point,  but  simply  divide  the 
anterior  sheath  somewhat  to  the  inside  of  the  right  linea  semi- 
lunaris. In  all  other  particulars  the  methods  are  exactly  alike. 
.■\s  all  the  layers  are  finally  sutured  separately,  the  planes  in 
which  the  lines  of  suture  lie  in  Jalaguier's  operation  are  more  dis- 
tant from  one  another  than  in  mine.  I  think,  however,  that  the 
main  support  is  given  to  the  abdominal  wall  by  a  firm  union  of 
the  rectus  muscle  with  the  sutured  incision  in  the  posterior 
sheath.  Jalaguier  merely  mentions  the  nerve  branch  passing  with- 
in the  line  of  incision  into  the  rectus,  and  I  assume  that  he  has  al- 
ways been  able  to  avoid  cutting  it.  It  is  certainly  entitled  to  the 
full  attention  of  the  surgeon.  He  has  recommended  the  opera- 
tion more  especially  in  children  with  thin  and  pliant  abdominal 
walls,  and  he  prefers  "/'7«rjV/i>//<7Hr:V«;//'  in  adults  with  well-de- 
veloped and  rigid  muscles.  I  rather  like  to  operate  by  the  method 
on  patients  with  a  well-marked  rectus  abdominis  muscle. 


Phimosis  as  a  Factor  in  the  Causation  of  Her- 
nia.—  It  is  said  that  inguinal  hernia  often  arises  in 
consequence  of  the  straining  efforts  of  the  child. 
This  may  be  true  in  some  infants  who  have  a  patent 
processus  vaginalis,  but  it  certainly  does  not  very*  often 
occur  when  these  peritoneal  prolongations  have  become 
obliterated:  and,  moreover,  itiniust  be  freely  admitted 
that  a  very  large  number  of  cases  of  aggravated  phi- 
mosis are  not  the  subjects  of  hernia.  Thus,  although 
the  condition  may  play  a  part  in  the  production  of 
hernia,  it  is  probably  but  rarely  the  sole  factor. — 
EccLES,  The  Ifospital,  April  24th. 


THE  CLINICAL  VALUE  AND  CHEMICAL 
RESULTS  OF  USING  PROFESSOR  GAERT- 
NER'S    MOTHER    MILK   IN    CHILDREN. 

By   LOUIS   FISCHER,    M.D., 


professor  of  dise.ase 
medicine;  atte.se 
german  poliklini 
messiah  home  for  ch 
children,  to  the  uni' 


OF  CHILDREN  IN  NEW  YORK  CLINICAL  SCHOOL  OP 
:g  PHYSICIAN  TO  THE  CHILDREN'S  DEPARTMENT  OF 
TO  THE   WEST  SIDE   GERMAN     DISPENSARY,   TO   THE 

rniLDREN  ;  consvlting  physician,  department  of 

NITED    HEBREW   CHARITIES, 

AND 

HERMAN    POOLE,    F.C.S.. 

DiTRixG  the  last  two  years  a  new  infant  food  has  been 
given  great  prominence  in  European  medical  litera- 
ture. This  new  factor  in  the  problem  of  infant  feed- 
ing is  the  mother  milk  of  Professor  Gaertner,  of  the 
University  of  Vienna.  Its  debut  before  the  profession 
was  made  in  an  article  by  Gaertner  in  the  Therapcii- 
tisclie  Wochenschrijt,  May  5,  1895.  A  few  months 
before,  January,  1895,  Gaertner,  in  an  address  before 
the  Vienna  Scientific  Societ)-,  explained  the  mode  of 
preparation  and  the  results  obtained  with  his  new 
modification  of  cow's  milk,  for  such  the  mother  milk 
of  Gaertner  really  is.  Professor  Gaertner,  in  the 
preparation  of  his  food,  has  aimed  to  overcome  what 
has  been  the  great  difficulty  in  infant  feeding — namel)', 
to  reduce  the  excess  of  casein  by  a  scientific  process 
without  the  addition  of  chemicals. 

To  achieve  this  result  he  employs  a  machine  called 
a  separator  or  Pfanhauser  centrifuge,  which  makes  four 
thousand  or  eight  thousand  revolutions  per  minute. 
The  apparatus  consists  essentially  of  a  drum  of  steel, 
which  revolves  on  its  axis.  This  drum  is  filled  with 
equal  parts  of  fresh  cow's  milk  and  sterilized  water. 
The  mixture  contains  approximately  the  same  amount 
of  casein  as  human  milk,  for  cow's  milk  undiluted 
contains  about  twice  as  much  casein  as  human  milk. 
The  mixture  is  next  poured  into  the  centrifuge  and 
the  speed  of  the  drum  is  carefully  regulated,  so  as  to 
separate  the  mixture  contained  therein  into  (i)  a 
creamy  (fatty)  milk,  and  (2)  a  skimmed  milk.  The 
two  portions  so  separated  are  then  led  oft'  separately 
by  suitable  openings  in  the  centrifuge. 

The  analysis  of  each  of  these  portions  shows  that 
the  creamy  milk  has  the  same  quantity  of  fat  as  is 
found  in  human  milk,  while  about  two  per  cent,  of  the 
casein  is  contained  in  the  skim  milk,  and  the  remain- 
der, about  1.7  per  cent.,  remains  in  the  creamy  milk. 
The  chemical  composition  of  fat  milk  is  shown  in  the 
following  table: 

Proteid.  Fat.  Sugar.  Ash. 

Eat  milk 1.76  3-3.5  2.5  0.35 

Human  milk 1.03  3.5  7.03  0.21 

Cow's  milk  diluted  with  one- 
half  water 1.76  1.6  2.;  0.35 

If,  now,  three  or  four  grams  of  milk  sugar  be  aidded 
to  every-  one  hundred  cubic  centimetres  of  fat  milk, 
the  percentage  of  sugar  is  brought  up  to  the  level  of 
sugar  in  human  milk.  This  addition  is  made  before 
sterilizing.  The  fat  milk  has  the  advantage  over  the 
diluted  milk  of  having  ''a  higher  percentage  of  fat," 
and  also  it  curdles  more  slowly  than  diluted  milk  and 
the  curd  forms  a  more  fiocculent  precipitate. 

-According  to  Escherich  the  following  amounts 
should  be  used  at  different  ages  of  infancy,  feeding 
every  two  to  four  hours : 

Infants  under  two  weeks,  500C.C.  (17^-^  3  )  in  nine  feedings, 

three  to  four' "  7500.0.(263)       "eight      " 

four  to  eight    "  1,0000.0.(353)       "      "         " 

three  to  four  months,  1, 250c. c.  (42  3  )       "      "         " 
five  to  six  "         1,5000.0.(503)       "seven     " 

Escherich  gi\es  in  detail  his  experience  in  feeding 
with  fat  milk  fifty  infants  in  a  hospital,  including 
rickety  and  tuberculous  children.  He  has  certainly 
met  with  marked  success.     Some  cases    have    been 


840 


MEDICAL    RECORD. 


[December  ii,  1897 


under  observation  for  six  months.  His  article  is  pub- 
lished in  extenso  in  Mitteihmgen  dcs  Vereins  der  Aerzte 
in  Steiermark,  No.  i,  1895. 

Baginsky'  mentions  Gaertner  milk  as  a  new  form 
of  food  introduced.  In  our  country  Jacobi'  states  that 
Gaertner  milk  is  applicable  to  the  majority  of  infants 
who  require  cow's  milk  appropriately  prepared. 

During  the  last  summer  I  proposed  to  test  the  effi- 
xacy  of  Gaertner  milk.  With  this  view  I  have  sub- 
jected the  milk  to  a  very  rigid  test,  inasmuch  as  the 
time  chosen,  from  June  to  October,  was  the  heated 
term,  which  is  the  worst  for  milk  digestion,  and  the 
hygienic  conditions  of  the  infants  were  those  found  in 
the  average  tenement  house,  too  well  known  to  need 
description. 

The  guides  for  ascertaining  the  degree  of  assimila- 
tion were  the  following  factors: 

1.  The  child's  general  condition,  as  manifested  by 
its  appearance,  appetite,  and  sleep. 

2.  The  presence  or  absence  of  gastro-enteric  dis- 
turbances, such  as  vomiting,  colic,  restlessness. 

3.  The  condition  of  the  stools,  constipation  or  di- 
arrhoea, the  number  of  stools  in  twenty-four  hours. 

4.  The  gain  in  weight;  weekly  observations. 

The  nurses  or  mothers  were  instructed  to  note  the 
amount  of  food  taken  and  the  number  of  stools  in 
twenty-four  hours. 

We  submitted  the  stools  passed  in  twenty-four  hours 
to  Mr.  Herman  Poole,  our  chemist,  wliose  chemical 
report  is  appended.  Thus  we  have  tried  to  ascertain 
how  much  proteids,  fat,  sugar,  and  salts  were  taken, 
how  much  absorbed,  and  how  much  was  voided  in  the 
iaeces  without  having  taken  part  in  metabolism. 

The  following  cases  will  serve  to  illustrate  the 
method  pursued  in  attempting  to  solve  the  problem 
before  us  and  the  results  obtained  as  regards  the  effi- 
cacy of  the  milk: 

Case  I. — Dorothy  Shattuck,  a  prematurely  born 
child,  the  labor  having  occurred  in  the  middle  of  the 
■eighth  month  of  gestation.  For  three  weeks  after 
Isirth  the  child's  mother  fed  her  on  Borden's  "  Eagle 
brand"  condensed  milk,  and  then,  being  discouraged 
with  the  results,  gave  the  child  to  the  care  of  Mrs. 
Turnure,  who  brought  her  to  the  clinic.  For  the  past 
\veek  she  had  fed  the  child  on  malted  milk  and  a  mix- 
ture of  milk,  cream,  and  barley  water.  June  16,  1897, 
the' little  patient  first  came  to  us  at  the  German  Poli- 
klinik.  She  stated  that  the  child  had  been  getting 
worse,  was  extremely  irritable,  slept  badly,  had  had 
persistent  vomiting  and  diarrhoea,  with  si.x  and  more 
■watery  stools  daily.     It  also  had  a  hacking  cough. 

Status  praisens:  An  e.xtremely  emaciated  child, 
twelve  weeks  old,  weighing  6  lbs.  and  12  oz.  The 
head  is  of  normal  shape;  the  face  has  a  peculiar,  senile 
expression  ;  the  fontanelles  are  open,  but  do  not  bulge. 
The  scalp  is  of  a  reddish  color,  with  here  and  there  a 
furuncle.  The  face  has  a  sallow,  earthy  color;  the 
•eyes  are  kept  closed  most  of  the  time.  The  thorax  is 
not  deformed;  the  ribs  are  not  beaded;  the  thoracic 
skeleton  is  sharply  outlined;  the  skin  is  dry,  yellow- 
ish. The  upper  extremities  show  thick  epiphyses: 
thin,  flabby,  bluish  skin;  cold,  weak  hands;  and  thin, 
atrophic  long  bones.  The  reflexes  are  diminished,  the 
grasp  is  weak.  The  abdomen  is  full  and  pendulous, 
the  abdominal  walls  are  very  thin,  the  intestines  are 
<listended  with  gas.  The  skin  in  the  groins  is  flabby; 
there  are  no  dilated  veins  and  no  hernia;.  The  but- 
tocks and  genitals  are  covered  with  an  erythematous 
rash  (intertrigo) ;  the  anal  reflex  is  normal ;  rectal 
temperature,  99°  F.  The  lower  limbs  are  similar  to  the 
■npper — thin  bones,  thick  epiphyses,  atrophic  muscles, 
bluish  dry  skin.  The  scapula^  project  behind;  the 
spine  is  not  deformed;    the  whole  appearance  is  one 

'  "  Lehrbuch  der  Kinderkrankheiten."  fifth  edition,  pp.  35-36. 
^  "  Therapeutics  of  Infancy  and  Childhood,"  p.  joS. 


of  extreme  atroph)'.  The  tongue  has  a  white  coating; 
gums  normal ;  foetor  ex  ore.  There  are  swollen  glands 
in  the  inguinal  region  and  furuncles  on  the  thighs. 
The  child  drinks  w  ater  with  avidity ;  a  peculiar,  lactic- 
acid  smell  is  exhaled  from  the  body. 

Diagnosis:  Athrepsia,  catarrhus  gastro-entericus, 
rachitis. 

Treatment:  {a)  Hygienic:  Daily  baths;  cleanli- 
ness in  the  mouth,  clothing,  bottles,  nipples. 

{b)  Dietetic:  The  sole  diet,  Gaertner's  mother  milk. 
Three  cans  (one-third  litre  in  each)  in  twenty-four 
hours;  beginning  with  a  few  ounces  at  a  time,  and 
increasing  the  dose  gradually  until  eight  ounces  are 
given  at  one  meal,  of  which  there  should  be  six  in 
twenty-four  hours,  i.e.,  every  three  hours  in  the  day- 
time and  at  longer  inter\-als  at  night. 

(c)  Medicinal:  None. 

An  irrigation  with  hot  water  was  used  to  wash  out 
the  colon  and  rectum  before  the  diet  was  begun. 

June  23d,  the  child  took  the  milk  at  first  reluctantly ; 
the  first  doses  were  vomited  at  once.  The  nurse  per- 
sisted, however,  and  her  efforts  were  rewarded,  for  in 
a  few  hours  the  baby  began  to  take  the  milk  in  larger 
quantities  and  to  retain  it  well.  The  vomiting  and 
diarrhoea  stopped — three  stools  daily.  The  child  was 
quiet,  and  slept  twelve  to  sixteen  hours  out  of  t^venty- 
four.     Looked  cleaner  and  brighter. 

June  26th,  the  general  condition  is  the  same;  bowels 
regular,  tongue  clean,  complexion  more  natural. 

On  July  14th  the  weight  was  8  lbs.  and  3  oz.,  a 
gain  of  I  lb.  and  10  oz.  in  two  weeks;  26  oz.  in  fifteen 
days,  equals  i-.;  oz.  daily  gain.  The  milk  was  con- 
tinued in  the  same  quantities;  a  fresh  supply  was 
furnished  at  the  clinic  on  every  visit.  The  child  was 
seen  two  or  three  times  every  week. 

July  29th,  weight,  8  lbs.  and  10  oz.  Gained  7  oz. 
in  fifteen  days,  or  Yz  oz.  daily  out  of  the  48  oz.  of  milk 
consumed. 

August  4th,  had  an  attack  of  vomiting  and  diar- 
rhoea, which  was  relieved  by  one  dose  of  castor  oil. 
There  are  three  or  four  stools  daily. 

August  7th,  milk  continued  as  usual.  The  child 
looks  bright;  face  smooth  and  of  a  natural  color. 
Sleeps  well,  appetite  good. 

.\ugust  14th,  for  the  last  two  days  there  is  vomiting 
following  an  attack  of  cough.  Child  takes  her  food 
well;  mucous  rales  on  both  sides  of  the  chest;  tem- 
perature, 101"  F. :  diagnosis  of  bronchitis.  A  tea- 
spoonful  every  three  hours  of  mistura  glycyrrhizre 
composita,  to  which  some  belladonna  had  been  added, 
relieved  the  cough. 

September  4th,  the  child  has  a  normal  temperature, 
cough  is  stopped,  general  condition  is  good,  digestive 
organs  are  in  good  order. 

The  child  was  not  seen  until  September  20th. 
Weight,  10  lbs.  and  14  oz.  The  child  is  still  taking 
the  milk,  and  appears  to  enjoy  very  good  health. 

C.\SE  II. — Abraham  Friedman,  one  year  old,  was 
fed  at  the  breast  for  the  first  seven  weeks  of  his  life. 
Since  then  he  had  been  receiving  condensed  milk. 
On  July  3d  was  first  seen  at  the  German  Poliklinik, 
with  the  history  of  diarrhoea,  twelve  greenish  stools 
a  day,  vomiting  once  or  twice  daily. 

On  examination,  a  pale,  bloated  child:  skin  flabby, 
smooth,  and  dr\^;  fontanelles  oj)en,  dentition  retarded, 
ribs  beaded,  abdomen  pendulous,  limbs  weak,  and 
bones  very  thin.     Weight,  17  lbs.  10  oz. 

Diagnosis:  Gastro-enteritis,  rachitis. 

Treatment :  An  irrigation  of  colon  and  rectum  with 
a  decinormal  saline  solution;  five  grains  of  beta- 
naphthol  bismuth  every  three  hours. 

Diet:  Gaertner  milk,  three  or  four  cans  daily,  at 
intervals  of  three  hours. 

On  July  7ih  the  general  condition  is  better,  no 
vomiting,  two  or  three  stools  a  dav. 


December  ii,  1897] 


MEDICAL    RECORD. 


July  14th,  the  condition  remains  the  same. 

July  29th,  no  diarrhoea,  no  vomiting;  has  two  stools 
a  day. 

August  7th,  the  child's  weight  is  20  lbs.  and  10  oz. 

September  3d,  the  child  receives,  in  addition  to  the 
mother  milk,  soup  and  rice.  The  general  appearance 
is  better;  two  stools  daily  of  a  brownish-yellow  color. 
The  child  was  discharged  cured. 

Case  III. — Abraham  Bassick,  seven  months  old, 
first  seen  at  the  dispensary  July  21st.  Previous  his- 
tory: Born  at  term;  for  the  first  three  days  after  birth 
he  received  the  breast,  and  then  he  was  fed  on  con- 
densed milk.  The  child  has  an  erythema  intertrigo 
and  lichen  tropicus.  Now  suffers  with  diarrhoea, 
vomiting,  and  colic.  Child  is  considerably  emaci- 
ated, and  weighs  8  lbs.  and  14  oz.,  including  his 
clothes. 

Diagnosis:  Athrepsia  infantum. 

Prognosis  doubtful. 

Treatment  same  as  in  Case  I.  Feeding:  Number 
of  cans  daily,  three;  number  of  meals  per  day,  six;  at 
night,  two. 

Clinical  results:  The  child  increased  in  weight; 
the  condition  of  the  gastro-intestinal  tract  seemed  to 
improve  while  he  was  taking  this  form  of  food ;  there 
were  no  vomiting  and  diarrhoea  for  the  first  three  days 
after  the  commencement  of  the  feeding.  The  child 
was  infected  with  measles  on  August  gth,  and  was 
removed  from  our  observation.  The  child  died  of 
pneumonia,  August  i6th. 

Case  lY. — Grace  Bliss,  two  months  old,  was  first 
seen  August  14th.  Mother  had  a  number  of  miscar- 
riages and  lost  several  children;  has  had  several 
stillborn  children,  some  covered  with  an  eruption. 
The  present  child  was  born  at  term,  weight  not  known ; 
has  been  nourished  at  the  breast  until  to-day.  For 
the  past  two  weeks  the  child  has  been  restless,  cries 
a  good  deal;  coughs,  has  coryza;  also  has  eructa- 
tions and  passes  a  great  deal  of  wind;  three  or  four 
greenish  slimy  stools  a  day. 

The  examination  shows  a  large,  square  head,  thick 
epiphyses,  distended  abdomen,  beaded  ribs,  flabby 
skin.  There  are  no  eruptions,  and  their  existence  pre- 
viously is  denied.  The  temperature  is  normal;  no 
enlarged  glands.  Weight  to-day,  1 1  lbs. ;  the  child 
has  been  losing  weight  gradually. 

Diagnosis:    Athrepsia,   rachitis,   lues    congenitalis. 

Treatment:  The  breast  feeding  is  to  be  alternated 
with  Gaertner  milk,  one  to  one  and  one-half  cans 
daily. 

The  child  was  seen  every  other  day  until  August 
28th.  General  condition  good,  takes  the  milk  readily, 
there  is  much  less  colic,  the  child  seems  more  con- 
tented and  more  quiet;  stools  are  yellowish  and  ap- 
pear more  nomial  in  consistence. 

On  September  ist  the  child's  weight  was  11  lbs.  and 
II  oz.,  a  gain  of  11  oz.  in  two  weeks.  The  child  has 
been  watched  during  the  month  of  September,  and  has 
received  small  doses  of  calomel — one-tenth  grain  three 
times  a  day  for  its  lues — besides  a  bichloride  bath,  i 
to  10,000,  every  third  or  fourth  night. 

V\'e  consider  this  case  very  much  improved. 

Case  V.  —  Mary  Burghardt,  a  premature  child,  born 
at  the  eighth  month  of  utero-gestation.  Mother  reports 
that  it  weighed  al)out  two  pounds  (s/r).  It  was  first  seen 
on  the  I  St  of  August.  During  the  first  week  of  life 
the  child  appeared  fairly  well,  slept  quietly,  and  took 
the  breast  without  any  signs  of  discomfort.  The 
child  is  now  eleven  days  old;  we  are  told  that  it 
coughs,  moans,  and  cries  when  touched.  There  are 
frequent,  soft  stools.  The  child  is  about  one  and  one- 
half  feet  long,  and  weighs  three  lbs.  The  mother  states 
that  she  has  lost  several  children  in  their  infancy  and 
had  several  miscarriages. 

Examination:  The  head  is  of  normal   shape,  with 


the  soft  bones  and  open  fontanelles  at  this  age.  The 
face  has  a  senile  expression,  but  the  skin  is  of  normal 
color.  There  is  no  eruption  ;  there  are  no  beaded  ribs. 
The  upper  extremities  are  very  thin,  the  hands  cold,, 
the  feet  cold.  The  veins  are  enlarged;  the  abdomen 
is  distended,  tympanitic  on  percussion.  The  mother 
states  that  the  skin  of  the  lower  half  of  the  body  came 
off  in  large  scales  a  few  days  after  birth.  The  skin  is- 
dry  and  slirimken.  Temperature,  101.6"  F. ;  pulse, 
138. 

Treatment :  Irrigation ;  calomel,  one-tenth  grain 
t.i.d.     Gaertner  milk,  two  ounces  every  three  hours. 

The  diagnosis  of  the  case  was  congenital  syphilis- 
and  athrepsia  infantum. 

The  child  was  reported  considerably  improved,  but 
it  was  thought  advisable  not  to  increase  the  quantity 
of  milk  until  the  28th  of  August,  when  the  child  re- 
ceived one-half  ounce  more  at  each  feeding.  The 
child  was  watched  during  the  month  of  September^ 
and  is  considerably  improved  to-day.  Weight,  4  lbs. 
and  9  oz.  on  September  25th. 

Owing  to  the  coolness  of  the  limbs,  inunctions  of 
oil  were  given  every  day  following  the  bath,  and  the 
child's  body  was  wrapped  in  cotton  wool. 

Besides  the  above  cases  we  have  had  fifteen  patients 
to  whom  Gaertner  milk  was  given  since  the  beginning 
of  June  last.  In  some  cases  it  was  necessary  to  add 
sugar  to  the  milk,  as  many  children  objected  to  the 
taste.  In  one  case  (Case  III.)  no  deductions  can  be 
made,  owing  to  the  child's  infection  with  measles  and 
pneumonia  resulting  fatally. 

Cases  I.  and  V.  serve  as  splendid  illustrations  for 
the  proper  determination  of  the  value  of  this  food,  as 
both  were  syphilitic  and  prematurely  born  children. 
The  other  two  children  (Cases  II.  and  IV.),  although 
much  stronger  at  the  commencement  of  the  treatment, 
improved  very  rapidly.  We  sometimes  diluted  the 
Gaertner  milk  with  equal  parts  of  barley  or  rice  water, 
and  if  this  latter  mixture  was  not  retained,  then  the 
Gaertner  milk  was  discontinued.  In  the  above  cases 
the  milk  was  borne  very  well,  and  is  continued  up  to 
the  present  day.  Although  our  experience  is  not  so- 
large  as  that  of  Professor  Escherich,  we  feel  that  we 
can  indorse  both  his  statements  and  those  of  Professor 
Gaertner. 

The  assimilation  of  this  form  of  food,  judging  from, 
the  stools,  is  equal  to  that  of  any  other  modified  milk. 
The  German  journals  assert  that  rickets  and  scurvy- 
can  be  prevented  by  using  this  milk.  As  our  observa- 
tions have  not  been  carried  on  long  enough,  we  cannot 
yet  corroborate  this. 

As  we  frequently  notice  that  some  children  show  a 
distinct  idiosyncrasy  when  given  milk,  so  it  was  in 
one  case  in  which  neither  cow's  milk,  nor  modified 
milk,  nor  breast  milk,  nor  Gaertner  milk  was  tolerated. 
That  child  fared  best  on  malted  milk,  properly 
diluted. 

Conclusions. — The  small  amount  of  proteid  matter 
contained  in  the  milk  appeared  to  be  very  easily 
assimilated  in  the  cases  above  mentioned.  Case  I.  is 
a  splendid  illustration  of  a  tolerance  of  this  form  of 
feeding,  when  neither  cow's  milk,  condensed  milk» 
nor  malted  milk  was  retained.  We  felt  greatly 
encouraged,  especially  in  the  very  hot  July  days,  tc> 
find  this  baby  gaining  in  weight,  for  it  must  be 
remembered  that  this  child,  in  our  city  with  poor 
hygienic  surroundings,  gained,  from  the  end  of  June 
to  the  14th  of  July,  26  oz.  in  fifteen  days. 

Case  II.,  suftering  from  summer  complaint  about 
the  same  time,  early  in  July,  made  very  rapid  progress, 
and  while  it  could  not  digest  a  dilution  of  one-third 
milk  and  two-thirds  barley  water  without  passing  six 
or  eight  stools  a  day,  fared  very  well  on  the  Gaertner 
milk. 

Case  III.   was   under  observation   from    July   21st 


842 


MEDICAL    RECORD. 


[December  ii,  1897 


until  August  9th,  and,  although  progressing  favorably, 
unfortunately  contracted  measles  and  died. 

Case  IV.,  an  emaciated  child,  had  been  receiving 
breast  milk  which  did  not  satisfy  it.  It  frequently 
nursed  from  thirty  to  thirtv'-five  minutes  at  the  breast. 
The  child's  mother  insisted  on  nursing  it,  and  thus  we 
gave  mixed  feeding,  alternating  the  breast  milk  with 
the  Gaertner  milk.  Thus  the  child  has  received  from 
two  to  three  cans  of  milk  per  day,  without  showing 
any  evidences  of  colic,  and  without  having  gastric  or 
enteric  disturbances.  The  treatment  has  been  con- 
tinued for  over  two  months. 

Case  v.,  the  prematurely  born  child  with  congenital 
syphilis,  was  certainly  one  which  was  well  adapted 
for  the  trial  of  this  form  of  feeding.  When  she  was  first 
seen  there  were  thick,  cheesy  stools,  which,  after  the 
gastro-intestinal  tract  had  been  cleaned  and  feeding 
changed,  showed  an  entire  cessation  of  the  colicky 
symptoms.  When  commencing  this  treatment,  the 
child  having  previously  fed  on  cow's  milk,  I  ordered 
all  milk  to  be  stopped,  and  fed  the  child  on  barley 
water  and  rice  water  for  three  days,  after  which  I  gave 
Gaertner  milk,  one  ounce  every  three  hours  on  the 
first  day,  two  ounces  ever)'  three  hours  on  the  second 
day,  three  ounces  ever)'  three  hours  on  the  third  day. 
Considering  the  syphilitic  condition  and  the  fact  that 
it  was  a  premature  child,  the  increase  of  3  lbs.  and  7 
oz.  from  August  nth  until  -September  25th,  during 
a  period  of  six  weeks,  speaks  for  itself. 

In  conclusion  I  desire  to  thank  George  Saxe  (M.S. 
at  the  Columbian  Universit)-),  and  Dr.  McConville, 
Dr.  De  Hart,  and  Dr.  Emil  Joel  for  kind  and  valued 
assistance. 

CHEMICAL    REPORT,    BY    HERM.-^X    POOLE,    F.C.S. 

The  chemical  examinations  were  made  with  the  idea 
of  working  out  some  connection  between  the  substances 
ingested  and  those  excreted.  To  this  end  the  milk  fed 
was  analyzed  and  from  this  the  quantit)'  of  each  con- 
stituent fed  to  the  child  daily  was  determined.  The 
faces  were  also  examined  so  as  to  ascertain  the  quan- 
tity of  undigested  fat  and  casein  voided.  The  results 
of  both  sets  of  analyses  are  given  below,  the  faeces  ex- 
aminations being  tabulated  and  plotted  for  the  better 
elucidation  of  the  facts. 

The  Milk. — The  milk  used  in  feeding  the  children 
contained  the  following:  Fat,  3.05  per  cent. ;  casein, 
2.09  per  cent;  milk  sugar,  6  per  cent.  Specific  grav- 
ity, 1.0275.     Reaction,  faintly  alkaline. 

When  cold  part  of  the  fat  separates  out,  forming  a 
layer  on  the  top  of  the  liquid.  On  being  wanned  and 
thoroughly  shaken,  this  is  completely  emulsified  and 
distributed  through  the  fluid.  Its  appearance  is  that 
of  a  good,  rich  milk,  in  taste  a  little  sweeter  than  ordi- 
nary cow's  milk;  and  it  is  more  liquid  and  mobile. 

Each  can  contained  "i  of  a  litre  or  20.34  cubic 
inches,  and  weighing  nearly  9^^  ounces.  Of  this  there 
was:  Fat,  0.289  o^-i  casein,  0.198  oz.;  milk  sugar, 
0.569  oz.;  total,  1.056  oz. 

Each  child  consumed  from  three  to  four  cans  of  the 
milk  per  day  and  hence  used:  0.867  to  1.156  oz.  of 
fat;  0.594  to  0.792  oz.  of  casein;  1.707  to  2.276  oz. 
of  milk  sugar. 

The  milk  was  perfectly  sterilized,  a  can  remaining 
open  for  five  days  without  thickening  or  showing  acid- 
ity. The  can  analyzed  had  a  shot  of  solder  in  it, 
which  was  perfectly  bright,  showing  no  chemical  action 
and  consequently  no  solution  of  lead. 

The  Faeces. — The  chemical  examination  of  the 
fasces  was  made  with  a  view  of  obtaining,  as  nearly  as 
possible,  the  percentage  of  undigested  fat  and  casein. 
To  this  end  the  nurses  were  instructed  to  deliver  at  the 
laboratory  three  times  a  week  the  napkins  used  dur- 
ing the  previous  twenty-four  hours.  They  were  put 
into  cigar  boxes  and  kept  in  them  until  examined, 


which  was  on  the  day  of  receiving  them.  In  some 
cases  they  were  in  very  good  condition,  but  many 
times  they  were  dry  and  hard,  the  deposit  adher- 
ing so  firmly  to  the  cloth  that  it  was  almost  impossi- 
ble to  remove  sufficient  for  analysis  and  have  it  free 
from  adhering  cotton  fibre.  This  was  especially  the 
case  when  cotton  flannel  was  used,  as  was  frequently 
done. 

In  all  cases  except  No.  i  (Shattuck)  the  weight  of 
the  fasces  given  is  below  that  actually  voided;  in  case 
No.  2  as  much  as  twenty-five  per  cent,  can  be  added 
to  the  amount  given;  with  Nos.  3  and  4  at  least  fifty 
per  cent.,  and  on  some  days  the  amount  obtained  for 
analysis  was  not  one-half  of  that  actually  voided. 

The  amount  of  moisture  was  of  course  much  influ- 
enced by  that  of  the  liquid  excretion,  which  naturally 
varied  considerably.  Still,  to  avoid  necessity  of  labo- 
rious analysis,  the  hypothesis  was  adopted  that  the 
amount  of  moisture  aljsorbed  from  the  faeces  by  the 
cloth  was  equal  to  that  added  by  the  liquid  excretion. 
In  some  cases  I  think  this  was  correct;  in  others  it  is 
doubtful,  especially  when  the  faeces  as  voided  were 
ver)'  thin  and  the  napkin  had  evidently  been  kept  long 
enough  to  become  dry.  This  was  a  matter  ver)-  hard 
to  regulate,  and  must  be  accepted  as  found. 

The  physical  appearance  did  not  vary  very  much  in 
individual  cases,  except  in  times  of  intestinal  disturb- 
ance. After  a  few  days  the  cloths  of  Case  I.  would 
have  the  faeces  in  a  single  mass,  and  of  such  consist- 
ence that  over  ninety  per  cent,  of  it  could  be  easily 
removed.  While  the  child  was  suffering  from  an 
attack  of  the  diarrhoea,  as  shown  by  a  rise  in  the 
curve,  of  course  such  a  condition  could  not  be  ex- 
pected. There  was  a  decided  improvement  in  the 
color  in  each  case,  it  changing  from  a  dead  clayey 
appearance  to  a  more  or  less  decided  yellow,  with  oc- 
casionally a  greenish  tinge.  When  dry,  as  was  some- 
times the  case,  the  color  was  uniformly  brown  or  dark 
brown. 

In  most  cases  the  faeces  at  first  were  very  thin  and 
spread  all  over  the  cloth,  but  with  those  continued  for 
a  time  this  character  changed  to  becoming  firmer  and 
more  collected  in  one  place.  Some  of  the  cases  were 
so  poorly  taken  care  of  that  no  mention  need  be  made 
of  the  condition,  it  beingihardlypossible  to  obtain  a 
sufficient  quantity  for  satisfactor)'  examination. 

With  one  exception  the  smell  was  uniformly  very 
faint  and  not  of  an  offensive  character.  The  excep- 
tion is  the  case  of  the  Bassick  child,  which  was  fed  with 
egg  albumen  in  addition  to  the  milk.  One  of  the 
other  cases  showed  a  faint  skatol  odor  twice,  but  in 
none  of  the  others  was  it  noticed  and  in  this  case  there 
was  not  sufficient  skatol  to  admit  of  separation.  On 
many  days  the  lactic-acid  odor  was  not  perceptible, 
although  litmus  paper  showed  a  faint  acidity. 

The  reaction  was  almost  uniformly  acid,  not  strong 
at  any  time,  and  not  measurable  except  in  very  few 
instances,  and  in  these  only  to  a  vety  small  fraction 
of  a  per  cent.  (0.005)  ^^  determined  with  decinor- 
mal  ammonia  solution.  On  some  days  no  change  in 
moistened  test  paper  could  be  obser\-ed  after  fifteen 
minutes.  No  decided  alkaline  reaction  was  found  ex- 
cept once,  and  this  was  in  a  dried  sample,  the  reac- 
tion of  which  may  have  been  influenced  by  the  urine 
present. 

The  quantity  in  the  same  case  did  not  vary  vety 
much.  When  a  vety  large  figure  is  given  there  was 
evidently  an  accumulation  of  two  days,  as  was  shown 
by  the  physical  character.  As  mentioned  above,  in 
some  cases  I  was  not  able  to  remove  more  than  half 
of  the  total,  and  of  course  tlie  amounts  given  do  not 
fairly  represent  the  quantity.  This  is  true  with  all 
cases  except  Case  I.,  which  will  average  within  ten 
per  cent,  of  the  total  voided.  It  is  impossible  to  im- 
press the  kind  of  people  from  whom  these  were  ob- 


December  ii,  1897] 


MEDICAL    RECORD. 


843 


tained  with  any  idea  of  care  in  this  regard,  and  the 
cloths  brought  to  me  show  it. 

Remarks  analogous  to  those  made  regarding  the 
amount  of  excretion  apply  as  well  to  the  water  con- 
tained. Still  a  fair  average  can  be  found  and  will 
probably  be  near  the  correct  one.  In  most  cases  I 
was  obliged  to  put  all  together,  wet  and  dry,  to  have 
sufficient  for  analysis,  and  this  at  times  caused  an  ab- 
normal number  to  appear  as  the  water  content.  This 
is  notably  the  case  with  the  Bassick  child,  in  which  the 
water  content  dropped  on  one  day  to  twent)-  per  cent., 
the  cloths  being  practically  dry.  It  was  also  noticed 
in  regard  to  this  one  that  in  this  instance  the  ordi- 
nary strong  smell  was  absent. 

In  each  case  the  quantity  of  fat  and  casein  decreased 
after  the  milk  was  used,  and  remained  at  a  lower  percen- 
tage. This  does  not  apply  to  the  Bassick  case,  and  in 
fact  this  case  was  amenable  to  no  law  but  that  of  uni- 
form filth.  Whenever  a  temporary  sickness  occurred 
the  percentages  would  rise,  and  with  the  Shattuck  child 
this  rise  also  occurred  nearly  simultaneously  with  her 
being  taken  to  Staten  Island,  where,  although  she  was 
reported  in  good  health,  the  percentages  kept  higher 
than  when  she  was  in  the  cit}%  and  on  her  return  to  the 
city  they  fell  again.  Still,  in  none  of  these  cases  of 
rise  in  percentage  did  it  reach  that  point  which  was 
attained  at  the  beginning  of  the  experiments.  No 
notice  is  taken  in  these  results  of  the  quantity  of  fat 
which  exists  in  the  faeces  combined  with  calcium, 
iron,  alumina,  etc.,  as  insoluble  soaps.  These  have 
undergone  some  change  in  the  system,  and  only  the 
undigested  or  unchanged  fats  which  were  soluble  in 
ether  were  determined. 

The  methods  used  for  determining  the  fat  and  casein 
were  those  mentioned  in  my  paper  read   before  the 


American  Chemical  Society  at  Detroit  in  1897.  The 
faeces  were  dried  at  90  F.,  then  at  110°  C,  and  the 
ether  extract  taken.  This  ether  extract  containing 
also  cholesterin  with  fat  was  saponified  with  alcoholic 
potassa  and  the  cholesterin  taken  up  with  ether.  The 
fat-acid  soap  was  then  decomposed  by  hydrochloric 
acid  and  the  fat  determined.  The  residue  from  the 
ether  extraction  was  then  treated  with  water  and  with 
alcohol.  The  residue  thus  obtained  containing  the 
undigested  casein  and  the  epithelial  cells  from  the 
intestinal  tract  was  digested  with  diluted  hydrochloric 
acid  for  ten  to  twelve  hours,  and  this  solution  used  to 
determine  the  nitrogen  by  the  Kjeldahl  method.  Ca- 
sein was  considered  as  being  fifteen  per  cent,  nitrogen. 

Of  course  these  methods  may  be  open  to  objections, 
but  I  know  of  no  better  ones,  and  after  trying  several 
others  decided  that  they  would  suit  the  investigation 
and  its  requirements  the  best,  and  I  actually  believe 
that  the  true  state  of  affairs  has  been  shown  better  than  it 
would  have  been  by  any  of  the  methods  previously  used. 

The  following  tables  show  the  results  of  the  exami- 
nation, giving  the  date  of  receiving  the  faeces,  the 
general  appearance,  consistence,  reaction,  quantity  in 
grams  that  could  be  removed  from  the  cloth,  and  the 
percentages  of  water,  fat,  and  casein  obtained  by 
the  methods  given  above.  The  percentages  of  choles- 
terin are  not  given,  although  they  were  of  course  ob- 
tained. They  did  not  run  in  a  uniform  proportion  to 
the  fat,  being  at  times  very  much  larger  than  at  others. 

Discussion  of  the  Curves. — The  curves  are  made 
by  using  the  days  of  the  month  as  abscissas  and  the 
percentages  as  ordinates.  The  zero  point  at  the  inter- 
section of  the  axes  is  then  the  date  of  the  commence- 
ment of  the  experiment  on  the  line  of  the  abscissas 
and  Q  per  cent,  on  the  line  of  the  ordinates. 


CASE    I.— DOROTHY   SHATTUCK. 


Date — 1897. 

June  2Sth 

June  30th 

July  3d 

July  6th 

July  8th 

July  loth 

July  I2th 

July  14th 

July  i6th , 

July  i8th 

July  20th 

July  23d 

July  30th 

August  6th .... 
.August  13th. . . 
August  23d  .  . . 
August  27th. . . 
.\ugust  29tb. . . 


Appearance. 

Clayey  

Clayey  

Yellowish 

Slight  yellowish 

Yellowish  

Yellow 

Yellow 

Yellow 

Yellow 

Yellow 

Yellow-brown 

Three  yellow,  one  brown 

Yellowish 

Yellow-green 

Yellow 

Yellow-green  and  dark  . . 

Yellow 

Yellow-green  


Consistence,  etc 


Reaction. 


Thin 

Soft 

Soft 

Soft 

Lumpy 

Lumps 

Lumps 

Lumps 

Lump  part  quite  dry. 

Lumps 

Lumps 

Three  soft,  one  dr)-. . 

Lumpy 

Soft..' 

Soft 

Mixed 

Soft 

Soft 


Acid 

Acid 

Acid 

Acid 

Faint  acid 

Nearly  neutral  . 

Neutral 

Neutral 

Faint  acid 

Faint  acid 

Faint  acid 

Very  faint  acid  . 

Neutral 

Acid 

Neutral 

Neutral 

Very  faint  acid  . 
Very  faint  acid . 

Average. . . . 


26 

30 

29 

10.8 

33-7 

38.6 

62.5 

42.6 

I5.S 

51.8 

33 

21 

18.4 

12.7 

29 

23.4 


27.96        67.2 


67.7 

73-3 

76.1 

68.8 

69.9 

65 

63 

55 

71-5 

63.2 

51.2 

61.2 

75 

70.6 

69 

69.26 

63 


5.66 

4.72 

3.8 

2.25 

2.25 

3.8 

3-24 

2.99 

3-49 

2.46 

2.5 

2.23 

2.5 

2.92 

3-99 
3.66 
3-4 
3-65 


3.25 


1.06 

1.06 

1.16 

1.2 

1. 12 

1.06 

1.08 

1.09 

1.29 

1.05 

1. 12 

0.79 

1.85 

1-5 

3 

2. 9 

2.45 

1.92 


1.48 


CASE   IL— ABRAHAM 

FRIEDMAN. 

Date— 1897. 

Appearance. 

Consistence,  etc          |              Reaction. 

Quantity, 
Grams. 

Water, 
Per  cent. 

Fat, 
Per  cent. 

Casein, 
Per  cent. 

Thin 

Acid 

9.8 
3.2 
7-7 

33-44 

19.36 
6.6 

12.6 
8.76 

10.56 
9.32 
3.12 

17-13 

77-95 

60 

72.83 

65.14 

70.2 

65.66 

69.18 

74.89 

75-18 

76.24 

79-69 

71.84 

7.66 
5.18 
4.01 
3-09 
3-15 

3 

3.29 

2.83 

3.25 

3-43 

4-49 

3-43 

2.92 

Smeary,  yellowish 

Thin 

Faint  acid 

Faint  acid 

Faint  acid 

Faint  acid 

Neutral 

3.06 

Thin 

2.05 

Soft,  strong  smell . . . 
Soft 

203 

Two  yellow,  one  brown  .  . 

1.08 

Soft 

1-54 

Soft 

Acid 

1.86 

August  6th 

Yellow,  green,  and  brown. 

Soft 

Faint  acid 

Acid 

1.25 

Soft,  strong  smell . . . 
Thin 

1-79 

Faint  acid 

Faint  acid 

Faint  acid 

Average 

2.03 

August  i6th 

Pasty 

2.42 

11-92         71-57 

3.83 

1.64 

844 


MEDICAL    RECORD. 

CASE   III.— ABRAHAM   BASSICK. 


[December  ii,  1897 


Date— 1897. 

Appearance. 

Consistence,  etc. 

Reaction. 

Quantity, 
Grams. 

Water, 
Per  cent. 

Fat, 
Percent. 

Casein. 
Per  cent. 

July  20th 

July  23d 

July  28th 

July  30th 

August  2d  ... . 
August  6th. .  . . 

Too  small  quantit)-  for  e.^Lami- 
nation. 

Yellow-brown 

Brown 

Soft,  strong  smell 

Dried 

Acid 

No  reaction 

Faint  acid 

Faint  acid 

Faint  acid 

.\verage 

4-83 

5-4 

5.3 

7.5 

6.33 

78.4 
20.53 
75-45 

55-5 
55.78 

4.28 

4.7 

3-48 

4 

4.23 

3-54 
4-5 

Thin     

3 

Yellow  and  brown 

All  dark  but  one  yellowish . .  . 

Slimy,  strong  smell 

Hard,  but  one  thin  and 
strong  smell. 

2.53 
2.79 

5.87 

57.13 

4.14 

3.2- 

CASE   IV.— GRACE   BLISS. 


Date— 1897. 

August  iSth  . . 
August  23d. . . 
August  27th.. . 


Appe; 

Yellow 

Yellow-green. .  . . 
Yellow 


Soft-dried Yerj-  faint  acid  .      3. 75 

Finn Verj-  faint  acid. .  j     3.95 

Dried  lumps. ...   Very  faint  acid..      4.25 


53-25 
46.55 

55 


21.06 
22.45 
18.36 


4.02 
4.07 
3.63 


The  Shattuck  curves :  The  curve  of  the  casein  per- 
centage runs  very  even  until  the  latter  part  of  July, 
the  time  when  the  child  was  taken  out  into  the  coun- 
tr)'.  \Vhile  she  was  there  her  health  was  reported  good 
except  at  the  middle  of  August,  when  she  had  an  at- 
tack of  diarrhoea,  which  lasted  some  time.  This  is 
plainly  shown  on  the  curve,  both  casein  and  fat  lines 
responding  to  the  conditions.  Why  the  curves  rose 
about  July  29th  is  not  e.xplained.  The  fat  curve  made 
a  decided  downward  movement  from  the  beginning, 
and  except  for  the  fluctuations  due  to  intestinal  troubles 
remained  low;  in  all  cases  it  remained  lower  than  it 
was  at  its  inception.  This  cuR'e,  like  that  of  the  casein, 
tends  upward  about  July  29th,  and  does  not  return  to 
its  former  low  figures. 

The  Friedman  ciu^'es:  With  these  curves,  as  with 
the  Shattuck  ones,  the  effect  of  the  feeding  is  shown 
by  a  downward  movement.  The  two  lines  run  closer 
together  than  in  the  Shattuck  case,  and  both  respond 


DIABETES  MELLITUS  AND  ITS  TREATMENT: 
REMARKS  BASED  ON  CLINICAL  EXPERI- 
ENCE.' 

Bv    HENRY    S.    STARK,    A.M.,    M.D., 

In'  contemplating  the  character  and  nature  of  diabetes 
mellitus,  we  are  once  more  confronted  with  the  almost 
legendary  bugbear  that,  despite  all  the  boasted  prog- 
ress of  the  medical  sciences  in  our  own  times,  there 
are  still  more  medical  mysteries  in  heaven  and  earth 
than  were  ever  dreamt  of  by  medical  philosophers. 
That  this  disease  is  one  of  the  most  conspicuous  ex- 
amples in  illustration  of  this  text  becomes  painfully 
apparent  when  we  recall  the  slight  progress  made  in 
our  knowledge  of  it.  Pathology  has  been  practically 
a  dead  letter,  bacteriology  has  revealed  nothing  char- 
acteristic or  constant,  while  recent  elaborate  studies 
of  himian  blood  have  borne  no  fruit  whatever.     Dia- 


85 

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to  the  diarrhoea  which  commenced  August  ist  and  was 
at  its  height  at  about  the  17th.  The  fat  cur\'e  seemed 
to  respond  more  quickly  to  changes  in  the  intestinal 
tract  than  did  that  of  the  casein,  and  at  limes  no  change 
in  the  casein  could  be  determined  when  a  marked  one 
in  the  fat  was  evident.  At  other  times,  however,  from 
some  cause,  the  casein  showed  a  change  not  to  be 
noticed  in  the  fat. 

The  curves  of  the  other  cases  are  not  plotted,  as  they 
were  soon  discontinued,  and  the  data  obtained  were  not 
considered  sufficient. 


What  Constitutes  a  Maid. — The  supreme  court  of 
Vermont  has  decided,  in  an  action  of  indictment  for 
adultery,  that  a  maiden  is  "a  young  unmarried  female, 
not  necessarilv  a  virgin.'" 


betes,  therefore,  has  to  this  day  no  definite  status  as 
a  pathological  entity,  being  known  rather  as  a  symp- 
tomatic complex  or  clinical  picture,  much  the  same  as 
exophthalmic  goitre  and  certain  other  medical  non- 
descripts are.  It  is  generally  admitted  that,  in  order 
to  establish  the  identity  of  a  particular  disease,  it 
becomes  necessary  to  show  that  the  disease  in  question 
is  produced  by  a  special  cause  manifesting  itself  by 
distinct  pathological  conditions;  and,  further,  it  must 
be  shown  that  the  particular  disease  is  characterized 
by  distinctive  features  pertaining  to  its  symptomatol- 
ogy and  clinical  picture  not  common  to  other  affections. 
I  scarcely  believe  that  diabetes  mellitus  comes  within 
the  pale  of  these  conditions,  and  on  that  account  its 
place  in  our  nosology  is  still  in  question.     True,  there 

'  Read   at  the  meeting  of  the    section  on  general  medicine; 
New  York  .\cademy  of  Medicine,  November  16,  1897. 


December  ii,  1897] 


MEDICAL    RECORD. 


845 


are  extant  various  theories  of  its  origin  and  of  the 
nature  of  the  lesion ;  of  these  some  are  radically  di- 
vergent, while  all  are  based  on  assumption  rather  than 
on  the  results  of  post-mortem  examinations,  and  it  is 
just  on  this  account  that  our  knowledge  is  too  pre- 
sumptive and  too  ambiguous  to  be  construed  in  any 
one  constant  way.  We  cannot  therefore  be  expected 
to  accept  as  incontrovertible  truths  facts  which  only 
hold  true  at  the  bedside  or  on  the  vivisectionist's 
table,  but  which  lose  their  significance  in  the  post- 
mortem room. 

Among  the  various  organs  to  which  was  referred  the 
lesion  of  diabetes  mellitus,  the  most  prominent  are  the 
liver,  the  pancreas,  and  the  medulla  oblongata. 
Authorities  accordingly  speak  of  hepatic,  pancreatic, 
and  cerebral  diabetes,  respectively.  As  far  as  the 
importance  of  this  classification  is  concerned  for  clini- 
cal and  therapeutical  purposes,  I  have  found  that  I 
could  in  most  instances  discard  it  without  detriment 
to  the  health  of  my  patients;  in  point  of  fact,  I  am 
frank  to  confess  my  inability  in  most  instances  to 
differentiate  between  these  varieties.  The  discrimi- 
nation from  a  therapeutical  standpoint  is  scarcely  nec- 
essary, for  viewed  in  this  light  the  disease  has  always 
been  a  puzzle.  The  very  fact  that  such  divers  and 
ofttimes  diverse  drugs  have  been  recommended  for  the 
cure  of  it  is  the  very  best  evidence  to  prove  how 
inefficient  they  all  are.  This  postulate  holds  true  for 
many  other  affections,  while  the  converse  of  this  prop- 
osition, to  my  mind  at  least,  is  just  as  true — that, 
whenever  any  one  drug  is  recommended  for  the  cure 
of  a  host  of  alfections,  a  catholicon  as  it  were,  the 
presumption  is  strongly  in  favor  of  the  claim  that  it 
is  next  to  useless  in  most  of  them. 

The  first  factor  in  diabetes  mellitus  is  to  establish 
the  existence  of  the  disease;  this,  in  view  of  its  unas- 
certained patholog)',  is  not  so  easy  as  would  appear  on 
first  thought,  for  I  know  of  no  disease  in  which  it  is 
so  difficult  to  determine  where  physiology  ceases  and 
where  pathology  begins.  Acute  or  chronic  glycosurias 
are  not,  per  se,  sutficient  evidence  to  warrant  a  diagno- 
sis of  diabetes,  for  we  know  that  both  forms  of  sac- 
charine urine  may  occur  under  conditions  which  are 
compatible  with  the  enjoyment  of  good  health.  We 
may  have  a  normal  or  a  pathological  glycosuria  of 
transient  duration ;  thus  also  a  normal  or  physiological 
glycosuria  may  follow  an  overindugence  in  carbohy- 
drates, or  may  even  follow  unusual  muscular  fatigue; 
in  the  same  way  also  a  temporary  pathological  glyco- 
suria may  be  artificially  induced  by  the  exhibibtion  of 
certain  drugs,  most  of  which  are  too  familiar  to  require 
enumeration;  thus  also  this  condition  may  be  pro- 
duced by  lesions  of  the  brain,  spinal  cord,  or  ner\'es. 
And  yet  not  one  of  these  conditions  constitutes  diabetes 
mellitus.  Therefore  the  question  arises:  When  can  a 
person  be  said  to  be  suffering  from  diabetes.'  I  be- 
lieve from  my  personal  experience  of  numerous  cases 
that  two  or  more  pathological  phenomena  must  obtain 
before  a  positive  conclusion  is  warranted ;  namely, 
chronic  glycosuria,  polyuria,  and  polydipsia,  and  a 
general  deterioration  in  health  depending  upon  these 
phenomena.  Whenever  this  triad  of  symptoms  is 
present,  a  diagnosis  is  justifiable. 

From  a  therapeutic  standpoint  this  distinction  is  of 
considerable  importance,  for  there  comes  a  time  in 
the  course  of  all  chronic  glycosurias  when  we  must 
pass  judgment  on  the  case  in  order  to  adopt  suitable 
remedial  measures.  I  do  not  think  the  criterion  sug- 
gested by  me  is  tCo  far-fetched,  although  I  can  readily 
understand  that  some  practitioners,  particularly  life- 
insurance  examiners,  would  take  exception  to  it.  The 
point,  however,  to  be  emphasized  is  that  neither  acute 
nor  chronic  glycosuria  without  a  depreciation  of  the 
general  health  ought  to  be  considered  diabetes  melli- 
tus.    The  presence  of  sugar  in  the  urine,  just  as  the 


presence  of  albumin,  has  a  certain  diagnostic  value, 
whose  importance  is  in  direct  ratio  to  the  changes  in 
the  general  state  of  the  patient's  health. 

While  on  the  question  of  diagnosis  I  wish  to  allude 
to  certain  signs  and  symptoms  which  are  not  usuall)' 
mentioned  as  such  in  the  more  familiar  text-books, 
and  whose  presence,  singl}-  or  in  combination,  ought 
always  to  arouse  suspicion  of  this  disease.  Among 
these  evidences  of  the  affection  may  be  mentioned  the 
following:  Periodic  attacks  of  headache  in  obese  sub- 
jects over  thirty-five  years  of  age;  extreme  fatigue 
after  a  short  but  violent  exertion,  and  prolonged  fatigue 
of  twenty-four  to  forty-eight  hours  after  a  slight  exer- 
tion, both  forms  occurring  in  adults;  slowly  failing 
vision  in  the  aged  or  quickly  failing  vision  in  the 
young;  certain  signs  and  symptoms  referable  to  the 
mouth,  such  as  unusual  redness  of  the  buccal  mucous 
membrane  combined  with  acid  saliva  and  decaying 
teeth.  This  is  a  combination  we  frequently  encounter 
in  middle-aged  women.  Two  varieties  of  symptoms 
referable  to  the  heart  and  its  functions;  one  set  of 
cases  simulating  an  attack  of  angina  pectoris,  e.g.,  pain 
in  the  left  precordial  region,  radiating  up  to  the 
shoulder  and  down  the  arm,  accompanied  by  dyspnoea 
and  cardiac  oppression ;  a  second  set  of  cases  which 
present  the  physical  signs  of  cardiac  hypertrophy  or 
of  arterio-sclerosis.  This  latter  set  of  cases  may  be 
met  with  not  infrequently  in  obese  male  subjects,  with 
florid  expressions  and  with  otherwise  healthy  appear- 
ances. In  reference  to  these  cardiac  symptoms,  it  is 
necessarv-  to  state  that  I  do  not  claim  an  etiological  or 
a  pathological  relationship  betw-een  diabetes  and  heart 
disease,  nor  do  I  claim  that  the  inroads  of  the  disease 
exhibit  a  special  predilection  for  the  heart.  I  am 
merely  reverting  to  these  symptoms  and  organic 
changes  as  frequent  coincidences  and  as  sequelas  in 
the  course  of  diabetes,  when  perhaps  there  may  be  no 
other  palpable  deviation  from  sound  health.  Still 
another  train  of  symptoms  which  has  aroused  my  sus- 
picion of  diabetes  mellitus  was  referable  to  the  ner- 
vous system.  This  set  was  characterized  by  marked 
ner\-ousness.  The  patient,  usually  an  old  man,  would 
be  possessed  of  an  ungovernable  temper,  which  was 
aroused  under  the  slightest  pretext;  generally  he  would 
have  a  morose  expression,  would  be  impatient  and 
easily  irritated.  This  set  of  peculiarities  is  so  famil- 
iar, and  forms  such  a  classical  picture,  to  German 
practitioners  and  even  to  the  laity,  that  whenever  met 
with  in  an  old  man  he  would  be  at  once  labelled  by 
the  knowing  ones  as  a  person  w  ho  probably  was  a  vic- 
tim of  diabetes.  Other  symptoms  which  should  put 
the  clinician  on  his  guard  are  unusual  pallor,  premature 
grayness,  slow  healing  of  wounds,  and  premature 
sexual  weakness. 

A  propcs  of  the  question  of  diagnosis,  I  wish  here 
to  allude  to  a  possible  vagarj'  or  anomaly  of  diabetes, 
a  condition  which  I  might  be  permitted  to  style 
"aglycosuric  diabetes"  —  that  is,  diabetes  mellitus 
without  the  presence  of  glucose  in  the  urine.  To 
illustrate:  I  have  at  present  under  treatment  a  woman, 
aged  forty-five  years,  who  furnishes  all  the  classical 
symptoms  of  diabetes  mellitus — namely,  marked  ema- 
ciation, a  general  ner\-ous  and  mental  depression, 
polyuria,  a  ravenous  appetite,  an  uncontrollable  pru- 
ritus vulvae;  her  urine  is  always  of  high  color  and 
specific  gravity,  but  never  shows  any  trace  of  glucose. 
This  patient  is  under  my  observation  for  nearly  five 
\-ears,  during  which  time  any  number  of  tests  and  of 
all  kinds  were  made  by  myself  and  others,  and  yet 
there  never  was  detected  even  a  trace  of  sugar  in  her 
urine.  The  clinical  history  and  the  character  of  the 
urine  would  enable  us  to  exclude  diabetes  insipidus. 
Here,  then,  is  a  type  of  disease  which  has  not  yet  been 
recognized  in  our  nosology.  The  clinical  picture 
conforms  most   perfectly  with  diabetes  mellitus,  and 


846 


MEDICAL    RECORD. 


[December  1 1,  1897 


yet  the  urine  never  reacts  affirmatively.  I  have  seen 
a  few  of  such  cases,  and  it  is  my  invariable  custom  to 
look  upon  them  as  diabetes  mellitus  and  to  adopt 
treatment  accordingly. 

Before  touching  upon  the  treatment  of  this  disease, 
I  wish  to  make  certain  observations  regarding  its 
prophylaxis.  For  while  we  cannot  in  most  instances 
radically  eradicate  the  disease,  we  can  in  a  minority 
of  cases  prevent  its  appearance  in  a  number  of  sub- 
jects whose  physiological  demeanor  and  whose  physi- 
cal condition  plainly  indicate  that  they  are  candidates 
for  this  disease.  My  experience  has  taught  me  one  or 
two  points  of  practical  importance  which  I  shall  in- 
corporate in  these  remarks. 

First  and  foremost,  when  confronted  with  obese 
male  subjects  over  forty  years  of  age,  physicians 
should  always  insist  upon  and  impress  their  clieiitele 
with  the  importance  of  suitable  muscular  exercise. 
From  general  inclination  such  subjects  are  averse  to 
any  such  indulgence,  for  obesity  and  exercise  seem  to 
be  diametrically  opposed,  while  obesity  and  laziness 
are  synonymous.  Obesity  and  diabetes  are  ofttimes 
concomitants.  If  such  subjects  are  of  the  Hebrew 
faith  this  injunction  applies  with  double  force,  for  it 
is  only  too  well  known  that  this  race  is  peculiarly  and 
unaccountably  susceptible  to  this  affection.  That  the 
muscular  system  is  largely  involved  in  the  glycosuric 
function  is  now  well  established  on  a  physiological 
basis,  for  it  appears  that  this  system  serves  as  a  gly- 
cogen reservoir  just  as  the  liver  does;  and  that  under 
certain  abnormal  conditions  the  quantity  stored  up  is 
not  consumed,  but  rather  finds  its  way  into  the  circu- 
lation and  thence  into  the  urine.  There  is  a  set  of 
benign  cases  in  which  the  symptoms  have  been  made 
to  disappear  by  simply  getting  the  patient  to  take  suit- 
able muscular  exercise.  This  exercise  must  not  be 
carried  to  the  point  of  fatigue,  but  must  be  taken  in 
moderation  and  in  accordance  with  fixed  regula- 
tions. 

Another  point  of  practical  importance  is  that  the 
older  members  of  a  family  in  which  the  diabetic  dys- 
crasia  prevails  should  religiously  eschew  foodstuffs 
rich  in  carbohydrates,  while  the  younger  members 
should  indulge  in  such  articles  in  moderation.  Hered- 
ity is  now  known  to  play  an  important  role  in  the  eti- 
ology of  this  trouble.  I  have  seen  any  number  of 
cases  in  which  this  causative  factor  was  pronounced. 
Thus  I  have  seen  three  sisters  affected,  three  bro- 
thers, father  and  two  sons,  grandfather  and  grandson. 
Strangely  and  probably  only  coincidentally,  I  have 
twice  observed  the  disease  occurring  in  husband  and 
wife. 

Third  precaution — corpulent  individuals  suffering 
from  gout  should  positively  abstain  from  sugar  and 
starches,  on  account  of  their  greater  liability  to  the 
disease.  It  would  appear  from  the  foregoing  prophy- 
lactic measures  that  obesity  is  one  of  the  principal 
events  in  the  history  of  diabetes.  That  is  precisely 
the  experience  of  most  clinicians. 

Still  another  precaution  is  that  all  persons  who  by 
reason  of  their  occupation  or  inclination  lead  an  in- 
door, sedentary  life,  but  whose  minds  are  sedulously 
occupied,  should  be  warned  against  their  predisposi- 
tion. Prolonged  mental  strain  or  exhausting  intellec- 
tual occupations  are  important  factors  in  the  etiology 
of  this  disease.  We  constantly  meet  with  cases  of 
glycosuria  in  which  no  other  causative  factor  can  be 
discovered. 

The  medicinal  treatment  of  this  disease  would  fur- 
nish a  splendid  text  for  a  sermon  on  therapeutics.  I 
believe  every  drug  mentioned  in  or  out  of  the  pharma- 
copoeia has  at  one  lime  held  sway.  With  the  excep- 
tion of  opium  and  its  alkaloids,  all  have  lost  their  hold 
on  the  professional  mind.  Probably  eighty  per  cent, 
of  physicians  are  to-day  employing  morphine,  opium, 


or  codeine  in  the  treatment  of  diabetes.  As  long  as 
pathology  is  helpless  satisfactorily  to  account  for  the 
disease,  so  long  will  its  treatment  by  drugs  be  empiri- 
cal and  conjectural.  I  have  employed  almost  every 
drug  advocated,  and  have  finally  discarded  all  save 
opium  and  its  alkaloids. 

At  the  Eleventh  International  Medical  Congress, 
held  in  1894,  at  Rome,  Monin,  of  Paris,  in  an  article 
on  the  treatment  of  diabetes,  strongly  advised  the  use 
of  permanganate  of  potassium  in  the  treatment  of  the 
rheumatic  and  hepatic  varieties,  claiming  for  this  salt 
that  it  "  invigorates  the  vital  forces,  reduces  thirst, 
causes  a  remarkable  diminution  of  sugar  in  the  urine, 
but  an  increase  in  the  number  of  red  globules,  and  if 
hepatic  congestion  be  present  the  liver  is  reduced  in 
size  in  twent)'  days."  He  prescribed  ten  drops  of  a 
five-per-cent.  aqueous  solution  tcr  in  die,  and  also  ad- 
vised a  hot  eight-per-cent.  infusion  of  malt  at  meal- 
times. Immediately  following  the  publication  of 
these  facts,  I  also  began  the  use  of  this  salt  in  the 
treatment  of  diabetes.  I  did  not,  however,  restrict 
myself  to  the  rheumatic  and  hepatic  varieties,  but 
employed  the  drug  indiscriminately  in  all  types.  I 
have  up  to  date  treated  about  fifty  cases  of  diabetes 
with  the  above  solution,  and  with  a  stronger  solution. 
Many  of  these  cases  remained  under  my  personal 
supervision  for  several  months,  and  some  for  several 
)-ears.  In  connection  with  the  exhibition  of  the  drug, 
a  moderate  antidiabetic  diet  was  insisted  upon.  I  am 
now  in  a  position  to  state,  as  the  result  of  my  experi- 
ence with  this  drug,  that  with  the  exception  of  a  very 
few  cases  I  do  not  believe  my  patients  were  at  all 
benefited  by  this  mode  of  treatment,  and,  further,  that 
I  never  obtained  the  favorable  results  described  by 
Monin.  In  most  cases  a  mild  drug  gastritis  super- 
vened, rendering  its  further  employment  undesirable. 
In  a  few  cases  the  drug  was  discontinued  on  the  ap- 
peal of  the  patient.  I  have  now  relegated  the  salt  to 
an  oblivion,  as  far  as  the  treatment  of  diabetes  is 
concerned,  having  satisfied  myself  of  its  inefficiency. 
I  believe  there  is  no  published  record  in  American 
medical  literature  of  the  use  of  permanganate  of  po- 
tassium in  the  treatment  of  diabetes. 

I  know  of  no  disease  in  the  treatment  of  which  the 
personal  equation  enters  so  largely  as  in  the  disease 
in  question,  and  just  on  that  account  the  treatment  to 
be  followed  in  a  given  case  should  be  determined  by 
individual  needs  rather  than  by  general  considerations. 
Idiosyncrasy  is  an  important  factor.  Discretion  and 
good  judgment  on  the  physician's  part  are  ofttimes 
more  sen-iceable  than  drugs.  A  blind  indiscriminate 
resort  to  drugs,  in  connection  with  a  sudden  stoppage 
of  all  foods  containing  sugars  and  starches,  has  often 
resulted  in  more  harm  than  benefit.  It  appears  to  me 
that  it  is  unwise  to  cut  off  suddenly  and  entirely  all 
such  articles  of  food,  just  as  it  is  suddenly  to  stop  the 
use  of  opium  or  alcohol  in  persons  who  are  addicted 
to  their  uses.  Such  drastic  measures  act  as  a  shock 
to  the  system,  from  which  it  naturally  recoils.  If  the 
disease  is  at  all  amenable  to  treatment,  it  must  be 
attacked  by  siege  rather  than  by  assault.  The  physi- 
cian who  studies  the  stereotyped  recommendations  of 
the  text-books  will  not  meet  with  half  the  success  that 
the  physician  will  who  studies  his  patient.  While  I 
am  ready  to  admit  that  I  cannot  point  to  any  patho- 
logical evidence  in  corroboration  of  these  facts,  yet  I 
can  submit  clinical  evidence  in  substantiation.  From 
a  physiological  standpoint  these  facts  are  almost  axi- 
omatic. Physiology  teaches  that  sirgar  is  a  constant 
ingredient  of  the  human  economy,  and  that,  deprived 
of  all  natural  supplies,  the  system  craves  for  it  as  it 
would  for  salt,  but  not  so  markedly.  It  is  reasonable 
to  assume  that  nature  would  not  have  supplied  sugar 
to  the  body  if  she  did  not  intend  it  to  fulfil  some  useful 
function.     The  elimination  of  glucose  from  the  urine 


December  ii,  1897] 


MEDICAL    RECORD. 


847 


is  not  in  itself  an  element  of  danger.  Sugar  can  be 
demonstrated  in  the  blood  and  urine  of  diabetics  for 
da3's  after  all  carbohydrates  have  been  suspended, 
showing  almost  conclusively  that  even  with  an  exclu- 
sively nitrogenous  diet  there  is  an  invariable  supply  of 
sugar  in  the  economy,  and  that  the  source  of  supply  is 
the  ingested  proteids  themselves — that  is,  the  albumin 
derived  from  animal  food.  Since,  then,  it  is  known 
that  even  albumin  may  be  and  is  partially  converted 
into  sugar,  those  physicians  who  advocate  total  absti- 
nence from  carbohydrates  might  just  as  consistently 
advocate  a  total  abstinence  from  nitrogenous  or 
animal  food,  on  the  same  principle. 

There  is  a  set  of  cases  in  which  the  abrupt  suspen- 
sion of  carbohydrates  is  a  positive  danger.  I  refer  to 
those  diabetics  in  whom  a  rapid  emaciation,  depending 
upon  a  gradual  disappearance  of  the  fat  of  all  tissues 
and  organs,  is  the  most  pronounced  symptom.  In 
consequence  of  the  absorption  of  the  fat  of  the  body, 
there  is  a  gradual  loss  of  strength  and  flesh.  Now,  in 
view  of  the  physiological  fact  that  the  ingested  carbo- 
hydrates are  partially  converted  in  the  human  economy 
into  fat,  just  what  the  system  most  requires  now,  the 
logical  sequence  would  be  to  make  up  for  this  loss  by 
administering  foods  that  contain  starches  and  sugars. 
This  clinical  e.xperiment  I  have  tried  time  and  time 
again,  and  I  verily  believe  with  good  results.  I  there- 
fore allow  moderate  quantities  of  carbohydrated  food- 
stuffs in  these  selected  cases,  and  I  have  reason  to 
believe  that  I  have  tided  more  than  one  rapidly  ema- 
ciating diabetic  over  a  critical  period.  In  these  cases 
also  I  do  not  entirely  forbid  malt  or  spirituous  bever- 
ages; on  the  contrary,  I  advise  and  allow  their  use  in 
moderation.  It  seems  unreasonable  to  withhold  alco- 
holic stimulants  entirely  from  persons  who  are  accus- 
tomed or  possibly  addicted  to  their  uses,  and  who  are 
daily  losing  strength  and  flesh  by  reason  of  such 
privations.  There  are  certain  diabetics,  and  I  have 
several  in  mind  at  this  time  of  writing,  who  indulged 
in  alcoholic  stimulants,  contrary  to  my  orders,  and 
who  were  never  the  worse  for  it.  The  best  guide  for 
gauging  the  quantity  of  carbohydrated  food  that  is 
permissible  in  a  given  case  of  diabetes  is  furnished 
by  a  weekly  comparison  of  the  body  weight  of  the 
patient  with  the  quantity  of  glucose  eliminated. 
Thus  if  the  patient's  weight  remains  stationary  or 
increases,  while  the  quantity  of  sugar  excreted  remains 
fixed  or  nearly  so,  the  amylaceous  food  is  doing  no 
harm;  conversely,  if  the  weight  steadily  decreases 
while  the  glucose  increases,  the  carbohydrates  are 
severely  contraindicated.  There  is  a  set  of  cases, 
usually  severe,  in  which  the  urine  always  reacts  affir- 
matively to  the  yeast  test,  despite  an  exclusively  nitro- 
genous diet.  Here  again  the  course  to  be  pursued  as 
far  as  the  dietary  is  concerned  should  be  a  compromise 
one;  that  is,  the  three  classes  of  food — carbohydrates, 
proteids,  and  fat — should  be  included  in  proportions 
compatible  with  the  conditions.  Some  dry  acid  wine, 
such  as  Moselle,  or  white  and  red  Rhine  wines,  or  a 
light  red  wine  such  as  claret,  is  permissible  and  even 
indicated.  These  wines  contain  a  minimum  of  sugar, 
while  their  fermentation  has  been  completed  before 
bottling. 

It  is  always  important  in  the  intelligent  treatment 
of  this  disease  to  ascertain  the  quantity  of  urea  elimi- 
nated \\-ith  the  urine;  for  this  knowledge  furnishes  a 
clew  regarding  the  rapidity  and  degree  in  relative 
terms  of  tissue  destruction  or  of  retrograde  metamor- 
phosis. The  ratio  between  the  ingested  nitrogenous 
food  and  urea  eliminated,  while  in  no  instance  a  fixed 
quantity,  nevertheless  operates  in  accordance  with  the 
fixed  laws  of  metabolism.  It  is  evident  that,  armed 
with  a  knowledge  of  the  rate  of  urea  excreted,  the 
physician  is  in  a  position  to  direct  the  patient  regard- 
ing the  quantity  and  the  quality  of  his  food.     With  a 


knowledge  of  such  a  ratio,  we  have  also  a  guide  to 
maintain  a  nitrogenous  equilibrium,  a  physiological 
state  which  in  all  diabetics  ought  to  be  a  matter  of 
solicitude,  for  by  watching  this  standard  we  can  at 
times  avert  the  coma  or  uraemia  that  may  be  attributed 
in  certain  instances  to  the  enforced  conditions  of  diet; 
that  is,  to  the  unusually  large  quantities  of  proteid 
foods.  It  is  right  here  that  the  personal  equation  in 
a  given  case  of  diabetes  enters,  and  it  demonstrates 
how  true  the  statement  is  that  each  case  is  a  problem 
by  itself.  It  must  be  apparent  that  to  treat  a  case  of 
diabetes  conscientiously  and  intelligently  we  must 
have  a  knowledge  of  the  quantity  of  urea  eliminated 
in  the  urine.  The  urine  should  be  tested  for  urea 
once  or  twice  every  month.  There  are  several  meth- 
ods in  vogue.  The  apparatus  and  method  devised  by 
Doremus  are  sufficiently  correct  for  all  clinical  pur- 
poses. This  method  is  based  upon  the  chemical  fact 
that  hypobromite  of  sodium  decomposes  urea  into 
water,  nitrogen,  and  carbonic  acid.  A  graduated 
scale  on  the  areometer  indicates,  approximately  only, 
the  quantity  of  urea  in  a  given  quantity  of  urine. 
The  weekly  or  fortnightly  variations  can  thus  be 
rapidly  estimated. 

Considering  the  valuable  data  to  be  derived  from  a 
knowledge  of  the  comparative  quantities  of  urea  elim- 
inated, it  is  no  exaggeration  to  claim  that  its  determi- 
nation is  paramount  only  to  a  knowledge  of  the  quanti- 
ties of  glucose  eliminated.  At  times  it  is  the  only 
clew  which  heralds  an  attack  of  uraemia  or  of  coma, 
and  oftener  it  is  the  only  available  method  to  deter- 
mine whether  the  economy  is  surcharged  or  overbur- 
dened with  the  nitrogenous  elements  of  an  exacting, 
artificial  diet.  In  this  connection  it  is  well  to  remem- 
ber the  fact  that  diabetic  urine  contains  an  excess  of 
urea,  a  phenomenon  by  no  means  strange  when  we 
take  into  account  the  proteid  character  of  the  alimen- 
tation; and  secondly,  the  rapid  tissue  destruction, 
muscular,  adipose,  and  otherwise,  that  is  an  invariable 
accompaniment  of  this  disease. 

From  what  has  been  said  about  urea,  it  may  be 
reasonably  inferred  that  a  like  claim  will  be  made 
regarding  the  presence  of  albumin  in  the  urine  of 
diabetics.  Albumin  is  present  in  about  one-third  of 
all  cases  of  diabetes.  If  present,  its  quantity  should 
be  determined  for  precisely  the  same  reasons  as  have 
been  stated  above  for  urea.  For  the  quantitative  test 
I  usually  employ  Eschbach's  albuminometer.  An 
albuminuria  in  a  diabetic  does  not  necessarily  indi- 
cate renal  disease,  but  when  it  does  the  question  of 
alimentation  will  tax  the  practitioner's  ingenuity  to 
the  utmost,  for  it  is  known  that  the  diet  indicated  in 
diabetes  is  contraindicated  in  nephritis.  Here,  then, 
is  a  set  of  conditions  or  rather  complications  which 
will  require  careful  discrimination.  In  this  set  of 
cases  the  safest  plan  of  operation  will  be  to  gauge  and 
compare  the  quantities  of  glucose,  urea,  and  albumin, 
in  order  to  arrive  at  a  working  hypothesis,  and  in  this 
manner  to  find  and  to  maintain  an  equilibrium  that 
best  suits  the  exigencies  of  the  case. 

There  are  certain  points  in  the  treatment  of  this 
disease  which  have  been  so  well  established  by  time 
and  experience,  concerning  which  there  is  such  wide- 
spread unanimity  of  opinion,  that  they  are  equivalent 
to  truisms,  and  on  that  account  I  purposely  refrain 
from  mentioning  them  in  this  paper. 

In  a  bird's-eye  view  of  this  pajjer,  two  propositions 
will  stand  out  from  all  others  as  the  most  important — 
to  wit,  that  the  new  and  the  abnormal  ingredients  of 
the  urine  should  be  measured,  the  results  being  re- 
served for  future  reference  as  an  aid  to  the  dietetic 
treatment;  and  secondly,  that  an  exclusively  nitroge- 
nous diet  will  often  prove  to  be  a  menace  rather  than 
a  benefit  to  health. 

151  East  Seventy-Second  Street. 


MEDICAL    RECORD. 


[December  ii,  1897 


PAIN,      OPIUM,      AND       APPENDICITIS. —  A 
PROTEST   AND  A   PLEA. 

By   ADOLPH    RUPP,   M.D., 


Even  fifteen  and  twenU'  years  ago  one  met  surgeons 
Avho  had  no  great  affection  for  opium  in  the  treatment 
•of  peritonitis;  but  to-day  may  be  one-half  or  more  of 
the  surgeons  give  it  a  distressingly  cold  shoulder. 
Physicians,  on  the  other  hand,  are  as  a  rule  as  fond  of 
this  magnificent  drug  and  its  derivatives  as  ever;  and 
I  think,  speaking  as  a  general  practitioner,  justly  so. 

This  difference  of  faith  and  practice  is  conditioned 
by  professional  habits  and  experience,  besides  social 
■circumstances  which  affect  both  classes  somewhat 
differently.  Pain  no  doubt  has  a  religious  and  meta- 
physical aspect  which  may  be  consoling  enough  to 
some  from  a  theoretical,  or  a  devotional,  or  an  aca- 
demic point  of  view,  but  when  it  affects  the  flesh  and 
l)owels  of  men,  women,  and  children,  metaphysics  is 
thrown  to  the  winds  and  a  physician,  usually  not  a  sur- 
geon, is  called  in  to  put  a  stop  to  it  as  speedily  as 
possible,  and  by  means  less  excruciating  and  appalling 
than  the  pain  itself.  To  accomplish  this  end,  opium 
in  some  form  is  applied.  Afterward  the  surgeon  may 
be  needed.  The  physician  prepares  the  way  for  him, 
and  makes  his  exit  easy. 

Of  late,  surgeons  have  claimed  appendicitis  to  be  a 
surgical  disease;  but  general  experience  and  statistics 
do  not  altogether  justify  the  claim.  In  only  a  small 
percentage  of  cases  the  surgeon's  ser\'ices  are  needed, 
but  in  ever)'  case  that  comes  under  medical  care  the 
possibilit\-of  the  surgeon's  help  is  never  to  be  left  out 
of  consideration — and  only  in  these  senses  is  appen- 
dicitis a  surgical  di-sease. 

To  the  writer  it  seems  that  surgeons  are  somewhat 
paradoxical  concerning  the  administration  of  opium 
and  its  derivatives  for  the  relief  of  pain.  They  claim 
that  opium  masks  the  disease — in  what  way  it  is  not 
always  easy  to  get  definite  ideas  or  indications  from 
them.  Physicians  know  from  experience,  and  many 
surgeons  agree  with  them,  that  the  severity  of  the 
pain  is  not  indicative  of  the  gravit)'  of  any  particular 
case  of  appendicular  inflammation.  Very  painful  ap- 
pendicular trouble  may  be  and  is  often  recovered  from 
within  a  week's  time,  and,  again,  this  disease  has 
killed  a  patient  within  forty-eight  hours  without  hav- 
ing given  rise  to  much  e.xtraordinary  pain.  Further- 
more, the  location  of  the  pain  is  not  by  any  means 
definitely  fixed.  All  that  the  symptom  pain  does 
for  us  definitely  in  the  way  of  diagnosis  is  to  direct 
«ur  attention  to  the  abdomen  for  the  source  of  trouble. 
Pain  as  such  is  of  only  minor  importance  in  arriving 
at  a  diagnosis  of  appendicitis.  Such  being  the  case, 
why  not  then  relieve  the  patient  from  pain?  Does 
opium  mask  the  other  symptoms  and  signs  of  appen- 
dicitis or  those  that  indicate  its  progress  for  better  or 
worse?  A  practical  experience  in  hospital  and  pri- 
vate practice  of  twenty  years'  duration  urges  the 
writer  to  answer  positively,  No!  Over  and  over 
again  he  has  found  in  cases  of  appendicitis  and  other 
forms  of  peritonitis  that  patients  complain  of  pain  on 
movement,  or  when  the  affected  regions  have  been  pal- 
pated or  manipulated,  while  they  were  tolerably  com- 
fortable under  varying  doses  of  opium.  Furthermore, 
opium,  far  from  interfering  with  the  functions  of  diag- 
nosis in  these  diseases,  also  has  an  indirect  curative 
effect  by  more  or  less  controlling  the  local  inflamma- 
tion, by  reducing  circulatory  pressure  and  diminishing 
intestinal  j^eristalsis. 

To  conclude:  It  has  not  been  the  object  of  this 
paper  to  antagonize  the  surgeon  and  his  due  share  in 
the  management  of  appendicitis,  but  simply  to  insist 
on  two  facts;  namely,  that  pain  as  such  and  as  a 
symptom  of  appendicitis  is  of  but  subordinate  import- 


ance as  a  factor  in  diagnosis,  but  often  of  pressing  and 
paramount  importance  respecting  therapeutical  indi- 
cations which'are  best  carried  out  by  the  judicious 
administration  of  opium  or  its  derivatives,  oftentimes 
in  large  and  generous  doses.  Opium  can  do  no  harm 
to  the  patient  suffering  from  pain  in  the  course  of 
appendicitis,  unless  the  calm  and  comfort  which  it 
brings  benumbs  the  diagnostic  capabilities  of  the 
managing  doctor.  The  man  who  cannot  diagnosticate 
a  case  of  appendicitis  and  differentiate  it  from  other 
acute  intra-abdominal  affections  of  a  suppurative  and 
non-suppurative  character  which  are  initiated  with  and 
accompanied  by  pain  as  a  matter  of  course,  ought  not 
to  treat  any  case  of  abdominal  pain  unassisted.  An 
incompetent  diagnostician  will  make  havoc  with  even 
a  consulting  surgeon,  as  well  with  opium  as  with  any 
other  remedy.  Thus  when  opium  does  harm  to  a 
patient  suffering  from  appendicitis,  the  harm  should 
be  attributed  to  a  bad  diagnosis,  and  not  to  the  opium; 
and,  finally,  it  should  not  be  overlooked  that  pain  as 
such  does  not  settle  the  question  for  operation  or 
diagnosis,  and  that  opium  is  the  only  remedy  that  can 
kill  a  killing  pain. 

406  West  THiK-n--FoLRTn  Street. 


ELECTRIC  TREATMENT  IN  GOUT  AND  THE 
URIC-ACID    DIATHESIS." 


By    ROBERT   XEWMAX,    M.D., 


From  careful  observation  and  experience  the  author 
asserts  that  gout  and  kindred  diseases  can  always  be 
checked,  relapses  prevented,  and  in  man)'  cases  cured, 
by  the  judicious  application  of  electricity,  particularly 
with  the  static  current. 

To  this  association  three  papers  have  been  contrib- 
uted, bearing  on  the  subject  under  consideration.  The 
first  was  read  in  i8gi,  at  the  first  annual  meeting,  by 
Dr.  W.  F.  Robinson,  on  "  Electricit)-  in  the  Treatment 
of  Rheumatism."  He  recommended  the  galvanic  cur- 
rent in  affections  of  one  or  two  joints,  and  static  elec- 
tricity if  the  rheumatism  is  generally  diffused  in  the 
body,  in  which  case  he  gives  the  static  sparks.  Ap- 
plications may  be  made  on  alternate  days,  lasting  ten 
minutes. 

.At  the  same  meeting  Dr.  Margaret  A.  Cleaves  read 
a  paper  on  "  The  Uses  of  the  Galvanic  Current  in  Ar- 
ticular Inflammatory  E.xudations."  The  treatment  was 
by  the  galvanic  current,  constant  or  interrupted.  In 
one  case  after  thirteen  sciir/irs  it  was  followed  by  fara- 
dization. The  point  taken  is  the  use  of  electricity 
during  an  acute  stage  instead  of  waiting  for  the  chronic 
state.  The  argument  is  that  electricity  can  be  used 
in  an  acute  stage,  that  there  is  no  danger  of  developing 
more  acute  inflammation.  By  waiting  for  the  advanced 
stage  the  case  is  made  more  difficult  to  handle,  thick- 
enings of  the  articular  tissues,  contractions  of  limbs, 
exudations,  impairment  of  movement,  even  ankylosis 
being  met  with.  Such  teachings  are  more  modern, 
very  rational,  and  deserve  much  consideration  in  the 
use  of  electro-therapeutics. 

At  the  sixth  annual  meeting  at  Boston  in  1896,  Dr. 
J.  Griffith  Davis  contributed  a  very  practical  essay. 
"  Uric  Acid — The  Role  of  Electricity  in  Its  Treat- 
ment." .\dvanced  grave  cases  with  complications 
were  cured  with  the  faradic  current,  but  from  later 
obser\-ations  the  good  results  of  the  static  sparks  were 
acknowledged.     Dr.  Rockwell '  says  that  the  galvanic 

'  Read  at  the  seventh  annual  meeting  of  the  .-Vmerican  Electro- 
Therapeutic  .\ssociation,  in  Harrisburg,  September  21,  1S97. 
*  Rockwell,  E.:    "International  System  of  Electro-Therapy." 

P-  33- 


December  ii,  1897] 


MEDICAL    RECORD. 


849 


current  in  the  treatment  of  gout  and  rheumatism  should 
be  selected  on  theoretical  grounds,  but  from  his  own 
experience  he  is  in  favor  of  faradization,  and  the 
higher  its  tension  the  greater  appears  to  be  its  anal- 
gesic properties.  For  this  reason  the  static  induction 
current,  the  tension  of  which  is  enormous,  is  often 
ser\-iceable. 

Cataphoresis  can  be  used  to  introduce  therapeutic 
substances  into  the  system  by  electricity,  in  which 
case  it  is  difficult  to  say  whether  the  medicine  or  the 
electricit)-  gives  a  benefit.  Edison'  has  made  experi- 
ments with  cataphoresis  in  gouty  concretidhs  as  fol- 
lows: A  galvanic  current  of  twent)- milliamperes  was 
passed  through  a  jar  containing  an  aqueous  five-per- 
cent, solution  of  lithium  chloride,  in  which  the  patient 
immersed  his  hand  up  to  the  wrist.  The  other  hand 
was  similarly  immersed  in  a  solution  of  common  salt. 
The  current  was  given  four  hours  a  day  for  six  con- 
secutive days.  The  size  of  one  of  the  joints  was 
diminished  and  pain  relieved. 

The  writer  has  tried  this  treatment  but  found  it  too 
heroic,  painful,  troublesome,  requiring  too  much  time, 
with  results  not  in  proportion  to  the  process.  Be- 
sides, patients  as  a  rule  will  not  submit  to  four  hours' 
daily  treatment. 

As  a  rule  galvanism  has  been  recommended  in  these 
diseases  by  former  authors.  Professor  Senator"  (Ber- 
lin) suggests  the  descending  galvanic  current  in  rheu- 
matism ;  Remak'  uses  strong  galvanism.  The  papers 
mentioned  are  rational ;  they  are  wTitten  with  an  hon- 
est purpose,  with  close  obser\'ation  of  results,  and  must 
be  accepted  as  reliable.  There  is  no  contradiction  even 
if  different  currents  of  electricity  have  been  used  and 
reported  successful.  There  is  only  one  electricity, 
which  is  always  mingled  with  some  magnetic  power; 
but  there  are  different  currents,  instruments,  and  w^ays 
to  apply  it  as  an  electro-therapeutic  measure;  which 
to  choose,  in  the  particular  case,  is  the  art  of  the  phy- 
sician. Each  author  mentioned  has  good  reason  for 
applying  the  current  indicated  according  to  the  dis- 
ease, its  stage,  symptoms,  indications,  and  complica- 
tions, and  the  patient  himself.  The  writer  would 
select  the  galvanic  current  in  cases  as  mentioned  by 
Dr.  Cleaves  and  others.  The  static  and  faradic  cur- 
rents belong  to  the  same  class,  only  one  has  a  higher 
tension,  and  as  such  should  be  selected  in  appro- 
priate cases.  The  writer  is  familiar  with  the  won- 
derful power  of  faradization  in  absorption  of  fluid  in 
anasarca,  as  Dr.  Davis  has  used  it.  The  reasons  for 
selecting  a  particular  method  or  current  will  be  given 
later,  after  a  general  consideration  about  uric  acid. 

Uric  Acid. — The  literature  on  uric  acid  in  disease 
is  very  abundant,  and  theories  and  practice  of  differ- 
ent writers  vary  greatly,  so  that  mooted  questions 
arise,  and  therefore  also  arise  doubts  about  the  present 
status  of  many  diseases  and  their  treatment.  In  many 
ways  acknowledged  authorities  make  just  opposite 
statements.  The  writer  knows  his  shortcomings  and  his 
inability  to  settle  such  questions,  and  will  not  attempt 
to  make  positive  statements.  He  also  finds  that  his 
experiments  and  the  tables  thereof  are  not  of  any  prac- 
tical value.  Hence  he  offers  only  observations  and 
references  which  will  show  the  diversity  of  views. 

Excretion  of  Uric  Acid According  to   Professor 

Wormley  the  normal  standard  of  excretion  of  uric  acid 
is  eleven  grains  daily.  In  contradiction  our  modern 
physiologists  state  that  uric  acid  seldom,  if  ever,  ex- 
ists in  a  free  state  in  normal  urine.'  In  normal  urine 
uric  acid  is  combined  with  sodium,  ammonium,  potas- 
sium, calcium,  and  magnesium.  Therefore  the  pres- 
ence of  uric  acid   in  the  urine  manifests  a  constitu- 

'  N'ew  York  Medical  RECORn,  November  15,  iSgo.  p.  549. 
'■' Ziemssen  :  "  Patholog)-  and  Therapy,"  vol.  -xiii. 
'  Remak  :  "  Galvano-Therapie,"  Berlin,  1S5S,  p.  413. 
■•Flint's  "  Physiolog), "  p.  416. 


tional  disease,  in  which  one  or  several  organs  are 
involved,  as  the  liver,  assimilation  in  general,  stomack 
and  bowels  in  particular,  the  blood,  kidneys,  ureter,, 
bladder,  urethra,  etc.  As  a  rule  we  are  told  that  the 
retention  of  uric  acid  in  the  system  is  the  cause  of  dis- 
ease, while  some  may  state  that  the  uric  acid  is  a  con- 
sequence of  the  disease. 

The  quantity  of  uric  acid  in  the  system  cannot  be 
known,  because,  if  the  urine  contains  a  large  percent- 
age of  uric  acid,  that  does  not  indicate  the  degree  of 
excess  in  the  system,  nor  does  a  clear  urine  with  little 
or  no  uric  acid  prove  the  absence  of  uric  acid  from  the 
system. 

The  reaction  of  urine  with  uric  acid  is  generally  con- 
sidered acid,  and  a  consequence  of  faulty  diet,  but  it 
has  been  also  observed  that  during  an  abundance  of 
uric-acid  excretion  the  reaction  is  decidedly  alkaline. 
One  observer  found  a  uric-acid  diathesis  from  the 
drinking  of  alkaline  water.' 

The  cause  of  uric  acid  and  accompanying  gout  is 
generally  traced  to  overfeeding  and  a  consequent  ple- 
thora, which,  however,  do  not  explain  the  extreme 
aneemia  and  weakness  observed  in  many  cases. 

The  presence  of  uric  acid  is  found  in  many  diseases, 
of  which  the  following  may  be  mentioned :  angina, 
bronchitis,  catarrh,  mitral  stenosis  of  the  heart,  dys- 
pepsia, diseases  of  the  liver  and  bowels,  nephritis, 
anasarca,  headaches  and  hyperaemia  of  the  brain,  lead 
poisoning,  genito-urinar)^  inflammations,^  neurasthe- 
nia,' rlieumatism,  gout,  atheroma  in  arterioles.'  The 
following  are  some  of  the  conclusions  of  Dr.  Pearce's 
paper : 

"  That  disturbed  metabolism  is  the  cause  sui generis  of 
a  number  of  symptoms  in  many  constitutional  diseases, 

"That  finding,  as  we  have  found,  such  variations  in 
the  quantitative  findings  of  uric  acid  in  the  same  case 
under  apparently  similar  symptomatology,  and  with 
much  variation  in  diet,  exercise,  etc.,  we  must  assume 
that  the  cause  in  many  cases  is  not  dietarv'  indiscre- 
tions or  idiosyncrasy. 

"That  certain  persistent  occipital  headaches,  not  re- 
lieved by  proper  glasses  or  eye  treatment,  may  be  due 
to  uric  acid  deposited  in  the  meninges." 

At  the  last  meeting  of  the  American  Medical  Asso- 
ciation in  June,  1897,  at  Philadelphia,  in  a  discussion 
on  gout.  Dr.  H.  C.  Wood  made  some  remarks  that  de- 
ser\-e  mention.  "  He  wished  it  clearly  understood,  in 
the  first  place,  that  all  our  scientific  knowledge  of  gout 
at  present  amounted  to  little  more  than  a  mass  of 
trundling  expectation  upon  which  hereafter  was  to  be 
built  some  true  knowledge." 

The  field  of  uric  acid  in  disease  is  so  wide,  and  our 
knowledge  about  it  so  indefinite,  that  it  prompts  the 
writer  to  abandon  the  larger  field  and  confine  himself 
to  gout  and  its  electric  treatment,  giving  good  reasons 
for  the  selection  of  the  proper  current. 

Gout  may  be  acquired,  and  acute  or  chronic;  of  the 
latter,  gout  as  an  inherited  disease  will  be  particu- 
larly considered  in  this  paper. 

The  Theory  of  Gout. — There  are  dilTerent  theories 
about  the  cause  and  progress  of  gout  and  its  treatment- 
The  following  appear  worthy  of  note: 

Gout  is  a  constitutional  disease.  During  painful 
attacks  there  is  a  retention  of  uric  acid  and  its  salts 
in  the  system  and  in  the  blood.  The  diathesis  being 
present,  faulty  digestion  causes  an  attack.  The  man- 
ner of   the  production  of  uric   acid  is  not  sufficiently 

'  Dr.  \V.  W.  Reed,  Fowler,  Col.,  Journal  of  the  American 
Medical  Association,  August  28,  iSgy. 

-  "  I'he  Relation  of  Uric-.\cid  Excess  to  Genito-Urinar)' In- 
flammations," by  Bransford  Lewis,  M.D.,  Journal  of  Cutaneous 
and  Genito-Urinary  Diseases,  July,  iSgy. 

'"The  Role  of  Uric  Acid  in  Neurasthenia,"  by  F.  Savary 
Pearce,  M.D.,  Virginia  Medical  Semi-Monthly,  June  25,  1897. 

■*  Dr.  N.  S.  Da\-is,  Jr.,  meeting  of  the  .American  Medical  Asso- 
ciation, June  4,  1S97. 


850 


MEDICAL    RECORD. 


[December  ii,  1897 


known.  The  spleen  is  probably  a  factor  in  its  causa- 
tion.' 

The  theory  of  Garrod '  is  that  the  kidneys  are  dis- 
eased. An  acute  relapse  of  gout  is  caused  by  the  irri- 
tation in  the  tissues  pregnant  with  retained  uric  acid. 
Prognosis  in  chronic  gout  is  that  generally  it  ends 
with  death,  either  after  long  sufferings  through  com- 
plications or  suddenly,  as  in  apoplexy  or  angina 
pectoris. 

Professor  Senator  says  that  treatment  effects  ameli- 
oration and  cessation  of  attacks,  but  no  permanent 
cure ;  relapses  appear  at  locus  mi?ioris  resistentice. 

Treatment  consists  in  medicines,  diet,  exercise, 
mineral  water,  and  electricity. 

1.  Medicines  have  been  recommended  in  great  va- 
riety and  combinations.  Some  benefit  typical  cases 
and  may  not  help  others.  Sometimes  all  are  unsatis- 
factory, and  one  remedy  which  always  has  cured  one 
patient  may  suddenly  prove  useless  for  the  same  in- 
dividual. Ebstein  says  alkaline  remedies  are  to  be 
used,  not  abused.  In  some  cases,  however,  alkalines 
aggravate  and  acids  may  benefit.  Therapeutics  of  all 
kinds  and  forms  have  been  used,  but  to  enumerate 
them  here  would  be  useless. 

2.  .\  specific  diet  ought  to  be  good,  but  the  state- 
ments of  authorities  are  very  contradictory'.  Some 
order  a  vegetable  diet  or  milk,  and  no  meat;  others  say 
meat  only.  Dr.  Senator  recommends  a  mixed  diet  with 
avoidance  of  fat.  One  patient  did  not  improve  on 
vegetables;  was  told  to  eat  less  of  vegetables,  more 
of  meat,  and  improved  at  once.  Almost  all  physicians 
prohibit  coffee,  tea,  and  alcoholic  liquors,  which  ap- 
pears to  be  rational,  but  in  practice  we  find  that  pa- 
tients need  whiskey  as  a  diuretic,  and  grow  worse  and 
weak  if  the  whiskey  is  omitted.     My  friend.  Dr.  A.  T. 

E ,  says  he  has  attacks  of  gout,  and  cures  himself 

by  drinking  champagne,  while  other  patients  provoke 
an  attack  by  drinking  champagne.  Dr.  Armstrong'  in 
the  Journal  of  the  Ainerican  Medical  Association,  May  i, 
1897,  states  that  he  gives  only  red  meat  and  hot  water. 

3.  Exercise,  active  or  passive,  is  perhaps  one  of  the 
best  remedial  agents,  because  it  regulates  the  circula- 
tion, stirs  up  the  action  of  the  different  organs  to  a 
normal  state,  and  thereby  eliminates  the  effete  material 
from  the  body.  Bicycle  riding  is  undoubtedly  good 
exercise. 

4.  'Mineral  waters,  drunk  at  the  spring,  have  done 
good  for  various  reasons,  of  which  one  is  the  execu- 
tion of  all  strict  orders  from  the  physician  at  the 
spring.  Carlsbad  is  the  principal  place  where  pa- 
tients are  sent.  However,  many  sufferers  get  well 
from  electric  treatment  without  ever  being  at  Carls- 
bad. The  writer  knows  also  of  some  cases  which  were 
benefited  by  drinking  imported  Teplitz  water,  which 
is  pleasant  to  the  taste  and  acts  on  the  mucous  lining, 
and  particularly  on  the  kidneys,  as  a  valuable  diuretic. 

Electricity,  sometimes  in  combination  with  but  often 
without  the  aid  of  any  other  remedy,  has  positively 
cured  rheumatism  and  gout.  Different  instruments 
and  currents  may  be  used  with  success,  as  indicated 
in  the  papers  mentioned  before.  In  some  cases  it  will 
be  well  to  vary  the  mode  of  application.  Gout  may 
be  acute  and  acquired,  01  hereditary.  In  the  first 
form  a  positive  cure  can  be  promised  in  almost  every 
case.  The  chronic  form  is  more  difficult  to  cure,  and 
the  treatment  must  be  continued  over  a  longer  period 
and  new  attacks  guarded  against  by  the  early  applica- 
tion of  electricity.  If  some  cases  of  chronic  gout  are 
not  cured,  at  least  the  single  attacks  are,  and  relapses 

'  Kanke,  II.:  "  Ueobachtungen  tlber  llarns.aure,"  Monchen, 
1S58. 

'  "  The  Nature  and  Treatment  of  Gout  and  Rheumatic  Gout," 
by  Alfred  Haring  Garrod,  K.R.S.,  M.I).,  London,   1859. 

•'  "  The  Value  of  an  Kxclusively  Meat  Diet  in  Chronic  Gout," 
lournal  of  the  American  Medical  .Vssociation,  August  14,  1S9J. 


can  be  prevented  by  attention  and  proper  treatment  in 
time,  when  the  system  manifests  any  abnormality. 
This  rule  has  particular  reference  to  the  treatment  of 
hereditary  gout  with  the  static  current,  and  to  give 
evidence  of  this  is  the  particular  purpose  of  this  paper. 

Static  Electricity — First  it  must  be  shown  what 
qualities  the  static  current  possesses  which  make  it 
desirable  to  choose  it  in  these  affections,  and  what 
effect  it  may  have  in  mastering  and  correcting  the 
irregularities  in  the  system. 

Static  electricity  has  the  same  properties  which 
are  attributed  to  general  electricity.  It  has  a  high- 
potential,  high-frequency  current.  The  physiological 
effects  of  high-frequency,  high-potential  currents  are 
so  well  described  by  Dr.  W.  J.  Morton,  who  is  the 
pioneer  in  the  therapeutic  use  of  static  electricity,  and 
his  writings  have  been  so  often  quoted,  that  the  writer 
can  well  omit  repeating  and  referring  to  them. 

We  use  static  electricity  in  different  ways — as  mas- 
sage, as  an  induced  current,  in  which  shape  it  takes 
the  place  of  faradization,  but  generally  as  a  spark  or 
breeze  in  different  varieties.  As  a  rule  the  patient  is 
placed  on  an  insulated  platform,  with  which  the  posi- 
tive pole  of  the  machine  is  connected.  The  electricity 
is  thereby  concentrated  in  the  platform,  and  the  patient 
becomes  the  end  of  the  positive  electrode,  in  which 
the  electricity  accumulates.  The  other  electrode  con- 
nected with  the  negative  pole  is  managed  by  the  opera- 
tor and  brought  near  the  patient's  body.  Sparks  or 
breezes,  as  the  case  may  be,  are  given,  or,  more  cor- 
rectly, taken  from  the  patient.  For  any  particular 
reason  the  poles  may  be  reversed  if  the  operator  sees 
any  indication. 

The  curative  power  of  the  static  application  has 
been  tried  fully  as  follows: 

1.  Static  electricity  is  generally  diffused  in  the 
body,  and  penetrates  deeply  through  tissues  and  joints. 

2.  It  acts  as  a  general  tonic. 

3.  The  breeze  allays  any  pain,  in  most  instances 
in  five  minutes.  In  very  painful  affections  of  the 
joints  it  needs  several  applications  before  the  pain 
and  infiltration  are  removed;  but  when  an  attack  is  in 
progress,  after  three  applications  in  a  single  day  free- 
dom of  motion  and  cessation  of  pain  should  be  ex- 
pected. 

4.  Headaches  and  confusion  of  the  brain  and  the 
uneasiness  of  the  mental  forces  are  removed  by  the 
breeze. 

5.  It  equalizes  the  temperature  and  restores  it  to  a 
normal  degree,  no  matter  if  the  temperature  has  fallen 
or  been  raised  through  the  disease.  (Dr.  Cleaves  has 
made  valuable  observations  on  this  point.) 

6.  The  circulation  is  equalized;  one  distressing 
symptom  in  gout  is  the  feet  being  so  cold,  like  ice — a 
feeling  as  if  they  do  not  belong  to  one's  body,  numb, 
so  that  locomotion  is  almost  impossible.  The  sparks 
will  equalize  the  blood  circulation,  and  thereby  re- 
move that  distressing  symptom. 

7.  The  animal  heat  is  favored,  the  action  of  the 
skin  restored,  and  even  diaphoresis  evoked. 

8.  It  stimulates  the  organs  to  a  better  secretion. 
The  liver,  bowels,  kidneys,  etc.,  which  were  sluggish 
or  were  interrupted  in  their  actions,  will  resume  their 
function. 

9.  It  favors  the  excretions  of  effete  material,  puri- 
fying the  system  of  uric  acid,  etc. 

10.  It  removes  nervous  debility. 

1 1.  There  is  an  absorption  of  infiammatory  products, 
in  joints  as  well  as  of  fluids,  as  we  find  in  anasarca. 

12.  It  replaces  exercise  and  acts  as  passive  motion. 
Tliese  effects  are  well  established,  and  have  been 

observed  by  many  authors,  as  well  as  by  the  writer  on 
himself  und  on  oilier  patients. 

Analysis  for  Uric  Acid  (after  no  treatment  and  after 
electric  treatment). — The  following  analyses  by  Mr. 


December  ii,  1897] 


MEDICAL    RECORD. 


851 


Murray,  a  practical  chemist,  of  the  urine  of  a  patient 
having  hereditary  gout  are  submitted  to  show  the  rela- 
tive excretion  of  uric  acid  at  different  periods  of  treat- 
ment. One  pint  of  the  quantity  voided  during  the  last 
twenty-four  hours  was  submitted  for  analysis  in  each 
instance.     The  result  was  as  follows : 

Specimen  I. — No  treatment.  September  g,  1897, 
two  weeks  after  a  slight  gout  attack.  During  these 
two  weeks  the  patient  had  not  had  any  treatment. 
After  a  hot  day  forty-six  ounces  was  passed  in  twenty- 
four  hours,  of  which  one  pint  was  submitted  for  anal- 
ysis, with  the  following  result: 

Total  quantity  for  twenty-four  hours,  1,305  c.c.= 
46  oz.  Color,  pale,  cloudy.  Odor,  urinous.  Re- 
action, strongly  alkaline (ammoniacal).  Specific  grav- 
ity, 1.020  at  15°  C. 

Deposit,  quantity,  and  general  appearance:  Abun- 
dant, light,  flocculent  Phosphates  present,  albumin 
present.  Uric  acid,  0.334  gm.  =  5  gr.  for  twenty-four 
hours.  Microscopical  examination — triple  crystals 
and  amorphous  phosphates. 

Specimen  II. — After  three  days'  electric  treatment. 
An  attack  of  gout  beginning;  liver  sluggish;  tongue, 
thick  white  furred;  left  foot  very  oedematous  and 
painful;  impossible  to  wear  a  boot;  general  uneasi- 
ness. Static  sparks  were  given  for  three  days,  every 
day  for  ten  minutes,  which  treatment  prevented  a  seri- 
ous sickness,  and  cured.  Treatment  was  given  on 
September  12th,  13th,  and  14th.  No  medicine,  no 
particular  diet  September  15th,  one  pint  for  analysis 
of  fifty-nine  ounces  of  urine  passed  in  twenty-four 
hours.     Report  received  as  follows.  No.  143: 

"The  Merck  Analytic  Laboratories,) 
"New  York,  September  17,  1897.        ) 

"Physical  and  chemical  character:  Total  quantity 
for  twenty -four  hours,  1,745  c.c.  =  59  oz.  Color,  pale; 
odor,  strong.  Reaction,  acid.  Specific  gravity,  1.020 
at  15^  C. 

"Deposit,  quantity,  and  general  appearance:  Small 
phosphatic  deposits  present.  Albumin  present,  after 
persistent  and  careful  tests.  Uric  acid,  0.1360 
gm.  =  2.o9  gr.  for  twenty-four  hours.  Microscopical 
examinations  show  nothing  particularly  pathological." 

On  comparison  of  the  two  specimens  we  find  that 
after  the  treatment  by  the  static  electricity  for  only 
three  days  and  during  a  gouty  attack,  the  patient  was 
cured,  the  attack  abated,  the  urine  became  acid,  phos- 
phatic deposits  and  albumin  were  less,  and  the  excre- 
tion of  uric  acid  was  reduced  considerably;  while  the 
fir.st  specimen,  taken  when  the  patient  was  apparently 
well,  without  any  electrical  treatment,  showed  more 
pathological  changes  of  a  grave  character,  in  which 
the  larger  amount  of  uric  acid  is  the  most  important 
point.  To  recapitulate,  the  uric  acid  in  the  two  cases 
was:  without  treatment,  excretion  of  uric  acid,  0.334 
gm.  for  twenty-four  hours;  after  three  days'  electric 
treatment,  excretion  of  uric  acid,  0.1360  gm.  for  twenty- 
four  hours. 

Hereditary  Gout. — While  it  is  admitted  that  gout 
is  a  diathetic  disease,  such  diathesis  may  be  entirely 
congenital  and  inherited,  in  which  case  the  afflicted 
are  not  able  to  acquire  or  prevent  the  disease.  The 
statistics  of  Scudamore  prove  the  statement,  as  in  his 
observations  of  five  hundred  and  twenty-three  cases  of 
gout  he  traced  three  hundred  and  nine  to  inheritance, 
the  disease  having  existed  in  one  or  two  of  previous 
generations.  Even  Garrod  states  fifty  per  cent,  as 
hereditary.  The  writer  has  authentic  assurance  of  in- 
heritance and  will  state  only  one  family  history,  and 
from  his  own  observation.  The  disease  ran  through 
three  generations,  in  two  continents,  and  the  observa- 
tions begin  with  the  grandmother,  who  died  in  1836  in 
Germany.    She  had  been  married  twice,  had  four  daugh- 


ters, two  by  each  husband.  All  four  daughters  married ; 
all  had  gout  and  died  from  complications:  one  of  apo- 
plexy in  1838,  one  of  angina  in  1840,  and  the  last 
had  severe  attacks  and  died  of  anasarca  in  1875,  at  the 
age  of  sixty-nine  years.  Some  of  the  male  cousins  of 
the  old  lady  suffered  also  with  gout.  The  children  of 
the  daughters  of  the  third  generation  all  suffered  with 
gout.  One  widower  married  again  and  his  second  wife 
had  three  children,  which  are  well  and  still  alive, 
while  the  three  children  of  the  first  (gout}')  wife  all 
died  in  consequence  of  complications  of  gout;  the  last 
son  in  1888.  Two  children  of  the  daughter  who  died 
in  1875  went  to  America,  had  severe  attacks  of  gout, 
and  the  daughter,  a  widow,  died  with  meningitis  in 
188S,  while  her  brother  succumbed  to  heart  failure 
in  1886,  both  with  complications  of  gout  and  during 
attacks.  The  children  of  the  other  two  daughters  were 
reported  dead,  except  two  males,  who  in  1890  led  a 
miserable  existence  in  Germany  and  had  gouty  spells 
with  deformities  of  the  joints.  The  sufferers  in  this 
family  were  mostly  females,  none  of  whom  have  been  re- 
ported as  high  livers;  none  drank  liquors  or  beer;  of 
some  the  writer  knows  positively  that  they  never  drank, 
and  others  may  have  drunk  a  glass  of  wine  on  particular 
occasions  like  birthdays.  This  history  has  been  men- 
tioned to  show  (i)  that  the  gout  was  inherited,  that  (2) 
it  could  not  have  been  caused  from  faults  in  diet  or 
drinking  liquors,  and  (3)  that  it  occurred  mostly  in 
females,  against  the  reported  statistics  which  show  a 
very  small  precentage  of  females  having  gout. 

The  clinical  history  of  chronic  gout  has  been  often 
and  well  described  by  many  authors;  hence  only  some 
symptoms  will  be  mentioned  here,  for  the  purpose  of 
showing  the  indications  for  making  static  applications. 
After  the  patient  has  had  experience  for  years,  he  may 
anticipate  each  new  attack  and  watch  for  the  same. 
It  generally  begins  with  some  dyspeptic  symptoms: 
the  appetite  is  failing,  the  liver  is  sluggish,  the  bowels 
are  constipated:  gases  in  the  bowels  annoy;  there  are 
headache,  general  depression,  failing  of  mental  bright- 
ness, no  inclination  to  move  about,  a  slight  rise  of 
temperature,  a  beginning  of  stiffness  in  the  joints, 
pain  and  swelling  of  the  metatarso-phalangeal  joint  of 
the  great  toe,  insomnia,  general  restlessness,  pruritus, 
cloudy  urine  with  excess  of  uric  acid.  If  only  some 
of  these  symptoms  are  observed,  static  electricity  is 
indicated,  as  sparks;  and  in  most  cases  this  treatment 
is  so  successful  that  amelioration  is  produced  at  once, 
and  after  several  applications  the  patient  is  cured  of 
that  attack  and  restored  to  his  usual  health.  Medi- 
cine is  not  necessary.  If  the  right  time  has  passed 
over  and  the  symptoms  progress  with  severe  pain  in 
one  or  more  joints,  with  oedema,  so  that  walking  is 
impossible,  the  static  applications  must  be  oftener 
made,  about  three  times  a  day  to  the  swollen  joints. 
The  breeze  may  be  applied,  or  an  electrode  used  in 
massage;  breeze  to  the  head  is  very  beneficial  and 
agreeable.  If  the  disease  is  neglected,  the  next  step 
in  its  progress  is  increased  pain,  more  joints  are 
affected,  the  veins  are  enlarged,  more  uric  acid  is  re- 
tained in  the  system,  and  nephritic  colic  ensues.  Cys- 
titis or  even  urethritis  and  immobility  are  increased; 
there  are  delirium,  excruciating  pains,  etc.  These 
complications  may  cause  death. 

If  the  static  electricity  is  applied  at  the  right  time 
with  care  and  attention,  every  attack  can  be  allayed 
or  even  prevented,  so  that  the  patient  is  kept  com- 
fortable and  in  apparent  good  health.  This  electricity 
will  do  the  work  without  any  other  measures,  but  ad- 
juvants are  not  contraindicated  and  may  be  used.  In 
all  cases  under  his  observation  the  writer  has  suc- 
ceeded perfectly,  as  stated.  As  an  illustration  he  will 
report  now  phases  of  his  own  case : 

Case  of  Hereditary  Gout. — Medicine  failed,  static 
electricitv  succeeded.     R.  N has  inherited  gout 


852 


MEDICAL    RECORD. 


[December  ii,  1897 


from  his  grandmother.  He  has  had  attacks  for  twenty 
jears,  which  became  in  time  more  severe  and  frequent. 
He  has  had  the  usual  symptoms,  excruciating  pains, 
with  all  the  sufferings  described  in  text-books.  Often 
he  could  not  move  about  at  all,  or,  if  a  little  better,  loco- 
moted  in  agonies  on  crutches.  Some  attacks  were  ag- 
gravated with  colic,  during  which  kind  friends  watched 
for  an  opportunity  to  perform  laparotomy  for  suspected 
appendicitis.  Medicines  allayed  pain  sometimes,  at 
others  the  same  remedies  as  well  as  different  ones  failed. 
The  climax  came  in  September,  1892,  when  it  seemed 
that  in  addition  acute  articular  rheumatism  compli- 
cated the  case  so  much  that  the  pain  was  constant  and 
excruciating  in  the  joints  affected,  that  any  motion  or 
a  turning  in  bed  was  an  absolute  impossibility.  The 
case  was  then  treated  by  a  physician  of  the  highest 
standing  and  reputation,  a  professor  in  the  largest  col- 
lege of  New  York,  a  man  of  ample  means,  a  gentleman 
in  every  sense  of  the  word,  whose  attention — a  work' 
of  love — could  not  be  exceeded  by  any  one,  and  whose 
kindness  never  w  ill  be  forgotten.  The  treatment  con- 
sisted in  medicine,  pushed  for  many  weeks,  and  gave 
no  relief  or  benefit.  The  prognosis  was  bad,  and 
ended  in  the  forecast  that  even  if  the  patient  recov- 
ered from  the  present  condition  it  would  be  impossible 
for  him  to  exist  without  spending  four  or  six  weeks 
every  year  in  Carlsbad.  The  patient  could  not  take 
more  medicine,  grew  very  weak,  in  which  state  he 
was  seen  by  several  members  of  this  association,  who 
never  expected  to  see  him  alive  again — in  fact  he 
was  once  declared  dead.  At  a  critical  moment  Dr. 
Nunn  and  our  lamented  member.  Dr.  Hutchinson,  sug- 
gested whiskey  and  beef  juice  to  sustain  life,  which 
resulted  in  marked  benefit.  Improvement  followed 
through  time  and  sustaining  measures,  but  the  patient 
remained  in  a  low  state,  crippled,  and  obliged  most 
of  the  time  to  move  about  on  crutches.  In  the  begin- 
ning of  1893,  friends  recommended  static  electricity, 
and  the  first  applications  were  given  kindly  by  Dr. 
Margaret  A.  Cleaves  three  times  a  week,  so  that  in 
due  time  the  patient  could  walk  well  without  any  sup- 
port, without  pain.  In  the  spring  he  met  in  a  car  his 
former  medical  attendant,  who  was  surprised  to  see 
him  looking  so  well,  and  would  not  believe  that  static 
electricity,  without  any  medicine,  had  made  the  im- 
provement. The  static  applications  have  been  con- 
tinued 'at  home,  whenever  required.  Sometimes  on 
purpose  treatment  was  delayed  until  a  new  attack  had 
been  so  far  advanced  that  the  joint  of  the  great  toe  was 
swollen,  and  the  pain  increased  to  such  a  degree  that 
when  he  arose  in  the  morning  it  was  impossible  for  him 
to  use  the  limb  for  walking,  and  locomotion  had  to  be 
made  with  a  crutch  downstairs  to  the  office,  where  static 
electricity  was  applied.  The  first  seance  ameliorated 
the  bad  symptoms,  the  second  application  made  the 
state  comfortable,  and  the  third — all  in  the  same  day 
— cured  the  attack.  No  extra  diet  was  enforced  (whis- 
key moderately  used  acted  as  a  diuretic  and  benefited 
much).  Occasionally  alkalies  were  added,  which  never 
benefited  and  sometimes  even  increased  the  excretion 
of  uric  acid  and  the  general  irritability.  Through  the 
static-electricity  treatment  the  patient  has  been  kept 
well,  so  as  to  enjoy  life  without  any  serious  sickness 
for  nearly  five  years.  The  hereditary  gout  is  not 
eradicated,  but  all  acute  attacks  have  been  warded  off 
by  the  timely  use  of  the  static  machine.  The  treat- 
ment consisted  in  sparks  and  breezes  as  indicated. 

Conclusions. — 1.  There  is  a  variety  of  causes  and 
symptoms  of  gout. 

2.  The  diit  and  treatment,  etc.,  cannot  l)e  stated  as 
a  routine  for  all  cases  alike. 

3.  It  is  wrong  to  treat  the  disease;  the  patient  must 
be  treated  as  an  individual,  according  to  indications. 

4.  There  are  some  points  in  gout  and  the  uric-acid 
diathesis  which  are  not  understood  at  present. 


5.  Hereditary  gout  exists,  and  will  manifest  itself 
in  individuals  without  their  own  fault. 

6.  Hereditary  gout  as  a  diathesis  cannot  be  eradi- 
cated by  any  treatment,  nor  is  it  the  consequence  of 
overfeeding  or  the  use  of  fermented  liquors,  for  the 
reason  that  it  has  been  observed  in  females  who  dieted 
and  never  drank  liquors  or  beer. 

7.  Static  electricity  is  the  best  treatment  in  heredi- 
tary gout,  and  will  prevent  attacks,  if  used  judiciously 
at  the  right  time,  and  thereby  keep  the  patient  com- 
fortable and  apparently  well. 

8.  Static  electricity  and  other  electric  currents  will 
cure  many  of  the  other  varieties  of  rheumatism  and 
gout. 

64  West  Thirty-Sixth  Stkeei. 


progress  of  fjKtctUcaX  J>cicncc. 

Streptococci  of  Erysipelas — At  the  last  meeting  of 
the  Socie'te'  de  Biologic,  Dr.  Lemoine  reported  that  he 
had  isolated  from  four  cases  of  erysipelas  four  strep- 
tococci, all  of  which  proved  inoffensive  to  rabbits  vac- 
cinated with  Marmorek  serum,  although  they  were 
rapidly  fatal  to  others.  The  streptococcus  of  er)'sipe- 
las  is  therefore  not  always  specifically  different  from 
that  of  Marmorek. — Le  Bill.  Med.,  October  31st. 

Blastomyces  in  Epithelioma. — In  a  study  of  blas- 
tomyces  found  present  in  certain  epitheliomata,  Binaghi 
{Zeit.fiir  U\x.  mid  Jiifeet.,  vol.  xxiii.,  fas.  2)  concludes, 
from  the  constant  presence  of  parasitic  forms  of  char- 
acteristic feature  readily  distinguished  by  coloring 
stains  and  other  chemical  substances,  that  they  are  to 
be  regarded  as  specific  blastomyces.  They  are  not 
found  in  other  tissues,  either  normal  or  pathological. 
That  they  are  not  accidentally  present,  but  are  causa- 
tive agents  of  the  disease,  is  to  be  inferred  from  their 
regular  disposition  and  the  relation  which  they  bear 
to  the  cells  of  the  new  growth. 

Diagnostic  and  Therapeutic  Utility  of  Lumbar 
Puncture.  —  Monti  {Anhiv  fi'ir  Kinderheilkunde,  Ii. 
xxiv.,  H.  I  and  2,  p.  94)  reports  the  results  noted  in 
twenty-one  cases — fifteen  of  tuberculous  basilar  men- 
ingitis, five  of  acute  epidemic  cerebro-spinal  menin- 
gitis, and  one  of  acute  hydrocephalus  secondary  to 
cerebro-spinal  meningitis — in  which  lumbar  puncture 
was  employed  for  diagnostic  and  therapeutic  purposes. 
In  the  cases  of  tuberculous  meningitis  he  found  punc- 
ture to  be  entirely  without  diagnostic  or  therapeutic 
value.  In  cases  of  acute  cerebro-spinal  meningitis, 
examination  of  the  fluid  obtained  by  puncture  afforded 
certain  reliable  indications  as  to  the  nature  of  the 
disease.  In  cases,  however,  in  which  the  acute  stage 
has  already  been  passed  and  only  symptoms  of  hydro- 
cephalus are  present,  examination  of  the  cerebro-spinal 
fluid  yields  no  reliable  diagnostic  information.  Fre- 
quent repetition  of  the  puncture  in  cases  of  cerebro- 
spinal meningitis,  with  evacuation  of  sutficient  quan- 
tities of  fluid,  is  not  without  favorable  influence  upon 
recovery,  at  least  in  some  cases  and  at  an  early  stage. 
The  evidence,  however,  is  considered  not  yet  con- 
clusive. Stadelmann  {^Deutsche  medicinisehe  Woe/ien- 
se/irift,  November  iS,  1897,  p.  745),  from  observations 
in  a  considerable  number  of  cases  of  tuberculous 
meningitis,  purulent  meningitis,  cerebral  abscess,  cer- 
ebral tumor,  cerebral  hemorrhage,  embolism,  and 
thrombosis,  arrives  at  the  conclusion  that  lumbar 
puncture  is  without  tlierapeutic  value.  In  diagnosis 
it  is  of  significance  only  when  it  yields  a  positive  re- 
sult, while  no  conclusion  is  to  be  drawn  from  negative 
findings.  Meningitis  is  to  be  diagnosticated  only 
when  bacteria  are  found  in  the  turbid  fluid  removed 
by  puncture. 


December  ii,  1897] 


MEDICAL    RECORD. 


853 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.   SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &  CO.,  43,  45,  &  47  East  Tenth  Street. 


New  York,  December  11,  1897. 


TYPHOID    FEVER    FROM    INFECTED    MILK. 

The  typhoid  epidemic  at  Paterson,  N.  J.,  wliich  has 
been  traced  to  one  source  of  milk  supply,  affords  an 
exceedingly  apt  illustration  of  the  real  dangers  which 
await  innocent  and  unsuspecting  consumers  of  a  widely 
used  and  very  essential  article  of  food. 

While  the  health  officer  of  Paterson  deser\'es  much 
praise  for  the  prompt  and  efficient  manner  in  which  he 
traced  the  source  of  infection,  it  is  ne%'ertheless  a  great 
pity  that  there  was  any  occasion  to  demand  his  skilled 
services.  In  the  instance  in  question  the  same  old 
story  of  origin  is  told,  in  somewhat  different  form,  it 
is  true,  but  with  the  same  moral  at  the  end.  A  certain 
dairyman,  acting  as  a  distributing  agent  for  a  number 
of  neighboring  small  dealers,  used  the  water  of  an 
infected  pond  for  cleansing  his  cans.  Within  twelve 
feet  of  the  place  of  washing  there  was  a  pipe  which 
carried  the  drainage  from  an  outhouse  infected  by 
t}-phoid  discharges  from  his  sons,  who  during  the  pre- 
liminary stages  of  the  disease  also  worked  in  the  dair}-. 
This  milk  was  distributed  to  such  a  widely  extended 
district  that  it  is  as  yet  impossible  to  learn  the  actual 
amount  of  damage  that  has  been  done,  for,  generally 
speaking,  no  one  can  tell  whence  his  milk  may  come 
or  through  how  many  polluted  hands  and  foul  washings 
it  may  pass  before  it  reaches  his  table. 

We  have  still  in  our  mind  similar  relations  of  cause 
and  effect  in  connection  with  other  epidemics  of  ty- 
phoid from  milk  infection,  notably  those  in  Bay  Head 
and  Montclair,  N.  J.,  in  1894,  and  in  Stamford,  Conn., 
in  1895.  In  all  these  the  origin  of  the  disease  was 
traced  directly  to  typhoid  bacilli  conveyed  in  milk 
contaminated  by  dealers  having  typhoid  fever  in  their 
families.  In  the  Bay  Head  epidemic  a  cowherd,  while 
suffering  from  walking  tj'phoid,  did  all  the  milking 
for  a  dairy  and  infected  the  milk  with  his  unclean 
hands.  The  epidemic  in  Montclair  started  from  a 
baker  who,  while  caring  for  a  case  of  typhoid  fever, 
repeatedly  washed  his  infected  hands  and  allow-ed  the 
drainage  to  enter  a  well,  the  water  of  which  was  used 
for  washing  cans  in  which  ice  cream  was  made.  In 
the  case  of  the  Stamford  epidemic,  which  was  remark- 
able for  the  number  of  persons  stricken,  the  disease 
was  spread  by  a  camp  of  Italians  who  infected  a  well 
in  its  immediate  vicinity.     The  water  from  the  latter 


was  used  by  one  milk  dealer  for  washing  his  cans,  and 
to  this  particular  source  were  traced  fully  three  hun- 
dred and  si.^ty  of  the  reported  cases. 

These  instances  of  the  spread  of  the  fever  by  milk 
prove  what  can  be  done  by  competent  investigation 
and  systematic  examination  of  the  circumstances  con- 
nected with  its  spread;  but  how  many  similar  cases 
are  there  in  which  no  such  pains  are  taken  and  in 
which  the  origin  of  the  disease  is  simply  unexplained? 
Notwithstanding  what  may  be  said  to  the  contrary,  it 
is  still  a  generally  accepted  fact  by  the  profession  that 
t}-phoid  fever  never  originates  de  ttovo.  It  is  safe  to 
say  that,  whenever  sufficient  pains  are  taken,  the  dis- 
ease can  always  be  traced  to  a  given  point  of  trans- 
mitted infection. 

This  fact,  it  seems  to  us,  cannot  be  too  forcibly  im- 
pressed upon  the  medical  man  whenever  he  is  called 
to  a  new  case.  If  he  has  not  the  time  or  opportunity 
to  trace  the  particular  invasion  to  its  source,  his 
bounden  duty  is  in  the  direction  of  making  an  imme- 
diate report  of  the  existence  of  the  fever  to  the  district 
health  authorities.  It  is  quite  true  that  the  attending 
physician  can  give  all  the  necessary  sanitarj-  direc- 
tions which  may  guard  against  the  spread  of  the 
disease,  but  in  matters  concerning  the  health  of  a 
neighborhood  exposed  to  a  common  contamination  he 
is  virtually  powerless  to  act,  save  by  suggestion  and 
advice.  If  the  physician  who  attended  the  fever  cases 
at  the  dairy  in  question  had  done  his  full  duty,  how 
much  sickness  and  perhaps  death  would  have  been 
avoided,  and  how  many  victims  of  his  culpable  neglect 
might  have  been  spared  their  present  suffering! 


DEFECTIVE   MEDICAL    EDUCATION. 

The  epidemic  of  yellow  fever  in  the  South  may  turn 
out,  after  all,  to  be  not  altogether  an  unmixed  evil. 
If  by  its  means  more  attention  should  be  paid  to 
the  study  of  bacteriology  and  the  etiology  of  yellow- 
fever  itself  should  be  made  clear,  then  it  may  be  said 
that  the  good  it  will  have  done  will  ouUveigh  the  evil. 
The  Hospital  of  October  9th  has  an  editorial  referring 
to  a  speech  made  by  the  dean  of  St.  George's  Hospital 
at  the  opening  of  the  winter  session  of  the  medical 
school.  In  this  speech  some  of  the  defects  in  the  sys- 
tem of  modern  medical  education  are  pointed  out,  and 
particularly  the  want  of  knowledge  in  Great  Britain  in 
regard  to  tropical  diseases.  These  remarks  of  Dr. 
Manson  were  full  of  truth,  and  apply  in  a  lesser  de- 
gree to  the  course  of  study  in  use  in  this  countrj-. 
There  is  no  doubt  that  America  is  far  ahead  of  England 
in  matters  bacteriological,  but  here,  as  there,  the  young 
medical  men  who  are  turned  out  by  the  thousands 
yearly  are  hardly  so  thoroughly  equipped  in  practical 
medical  knowledge  as  they  might  be.  Dr.  Manson 
.shows  that  the  curriculum  is  decided  by  the  examina- 
tions, and  that  a  student  will  not  trouble  himself  con- 
cerning any  subjects  outside  the  scope  of  these  exami- 
nations. Therefore  (as  doubtless  not  infrequently 
happens)  when  he  becomes  the  proud  possessor  of  a 
license  to  practise,  he  may  and  probably  will  be  com- 
pletely ignorant  of  many  diseases.     In  both  countries 


854 


MEDICAL    RECORD. 


[December  ii,  1897 


a  large  proportion  of  medical  men  will  practise  in  hot 
climates,  and  their  training  is  too  often  not  of  a  nature 
to  fit  them  for  tropical  practice.  Without  ■\  doubt  the 
curriculum  in  England  is  not  calculated  to  do  so. 

According  to  T/ie  Hospital,  the  fact  is  notorious  that 
men  newly  qualified,  and  who  should  be  conversant 
with  the  latest  improvements  and  developments  in 
medical  science,  display  a  total  lack  of  this  knowledge. 


SHALL   THERE    BE    A    MEDICAL    COMMIS- 
SIONER  OF   CHARITIES? 

With  the  approaching  change  in  our  municipal  gov- 
ernment, there  comes  into  existence  a  new  and  greatly 
enlarged  department  of  charities.  Henceforth  the 
public  charities  of  the  counties  of  New  York,  Kings, 
Richmond,  and  a  part  of  Queens  are  to  be  combined 
under  a  single  commissioner,  having  its  central  office 
in  New  York.  The  occasion  seems  to  us  fraught  with 
the  deepest  interest  to  the  medical  profession  and  to  the 
public.  Already  the  question  is  being  very  earnestly 
and  thoughtfully  discussed,  both  in  the  profession 
and  by  workers  in  charities:  Why  should  there  not  be 
henceforth  a  thoroughly  qualified  medical  commis- 
sioner in  this  governing  body?  The  reasons  given  in 
favor  of  that  proposition  are,  in  our  opinion,  not  only 
unanswerable,  but  so  imperative  that  the  profession 
ought  to  bring  them  to  bear  upon  the  appointing  power 
with  all  the  force  necessary  to  their  full  recognition. 

Let  us  consider  the  special  functions  of  this  depart- 
ment of  charities.  First,  the  institutions  under  its 
management  are  hospitals,  dispensaries,  and  asylums. 
The  New  York  division  alone  contains  four  dispensa- 
ries, treating  over  one  hundred  thousand  yearly,  and 
sixteen  hospitals,  three  of  which  are  the  largest  in  the 
United  States.  In  New  York  and  Kings  new  hospi- 
tals are  constantly  being  both  planned  and  constructed, 
and  the  creation  of  these  institutions  is  to  continue 
from  year  to  year  as  the  wants  of  the  sick  poor  demand. 
It  follows  that  the  duties  of  the  commission  will  be 
chiefly  devoted  to  the  work  of  hospital  construction 
and  management,  while  it  may  safely  be  stated  that 
the  current  every-day  duties  of  the  commissioner  of 
the  boroughs  of  Manhattan  and  the  Bron-X  will  be  nine- 
tenths  of  a  purely  medical  character.  Second,  an  ex- 
amination of  the  public  charities  of  New  York  proves 
the  folly  of  committing  the  establishment  and  manage- 
ment of  these  institutions  entirely  to  unskilled  lay- 
men. For  fifty  years  the  department  has  developed 
without  the  slightest  regard  to  scientific  methods. 
With  the  most  beautiful  and  healthful  sites  for  the  de- 
velopment of  a  great  system  of  public  charities,  the 
finest  in  the  world,  New  York  has  to-day  to  show  for 
the  millions  of  money  expended  on  this  department  a 
large  number  of  uncouth,  ill-placed,  and  worse-con- 
structed buildings,  scattered  indiscriminately  over  the 
islands  of  the  East  River.  Third,  if  we  examine  these 
institutions,  we  find  the  most  crude  and  inefficient 
methods  of  organization  and  an  almost  total  lack  of 
useful  classification  of  their  inmates.  Here  is  a  pop- 
ulation of  seventy-five  hundred  people,  representing 
every  phase  of  destitution,  without  the  slightest  effort 


being  made  to  study  the  conditions  which  brought 
them  to  this  estate,  and  without  a  suggestion  or  even 
a  thought  of  applying  those  remedial  measures  which 
would  enable  them  to  become  self-supporting. 

We  believe  that  if  a  thoroughly  competent  medical 
man  had  been  in  that  commission  for  the  last  quarter 
of  a  century,  we  should  to-day  have  a  department  of 
public  charities  unrivalled  in  this  or  any  other  coun- 
try. Our  profession  has  been  far  too  negligent  of  its 
duty  to  the  public  interest  in  allowing  this  department 
to  develop  from  year  to  year  under  the  blighting  influ- 
ences of  political  partisanship,  without  even  raising  its 
voice  in  protest.  Shall  we  allow  the  present  oppor- 
tunity, when  the  combined  charities  of  the  greater 
city  are  to  come  under  the  control  of  an  entirely  new- 
commission,  to  pass  without  an  effort  being  made  to 
secure  the  appointment  of  at  least  one  medical  com- 
missioner? It  must  be  assumed  that  the  incoming 
political  party  is  desirous  of  giving  to  the  new  cit)'  a 
popular  administration  of  the  several  departments, 
and  to  this  end  will  adopt  any  reasonable  departure 
from  old  methods.  From  every  point  of  view  it  is 
apparent  that  a  medical  commissioner,  especially  for 
the  boroughs  of  Manhattan  and  the  Bronx,  whose 
public  charities  consist  entirely  of  hospitals  and  asy- 
lums, is  not  only  desirable  but  absolutely  necessary 
for  their  efficient  management  and  future  proper 
development. 

PUBLIC   MONEY   FOR  PRIVATE  CHARITIES. 

The  annual  protest  of  the  large  majority  of  the  medi- 
cal profession  of  this  city  against  the  appropriation  of 
public  money  for  private  charities  has  again  been 
fruitless  of  the  desired  results.  The  Medical  League, 
the  Medical  Society  of  the  County,  and  the  County 
Medical  Association,  through  their  representatives, 
made  a  vigorous  fight  before  the  board  of  estimate 
and  apportionment  on  Wednesday  of  this  week,  and 
brought  to  the  surface  of  public  discussion  many  of 
the  vital  questions  which  lie  at  the  root  of  the  pres- 
ent abominable  and  outrageous  methods  of  dispensing 
medical  charity.  In  spite  of  the  forcible  argimients 
to  the  contrary,  the  board  in  question  voted  the  sum 
of  $1,312,420  for  the  very  questionable  purposes 
named.    * 

It  was  very  justly  claimed  by  the  opposers  of  the 
measures  that  in  most  of  the  cases  in  which  claims  were 
made  the  different  institutions  were  distinctly  private 
enterprises  that  throve  by  the  annual  begging,  and 
gave  no  adequate  returns  in  really  charitable  work 
for  the  donations  received.  Some  of  these,  it  was 
urged,  either  had  large  annual  incomes  of  their  own, 
were  managed  wholly  in  the  interests  of  medical 
schools,  or  were  carried  on  for  the  benefit  of  close 
corporations,  which  seemingly  were  above  all  the 
usual  liabilities  of  strict  business  accountabilit}\  All 
of  which  is  strictly  true,  with  great  shame  be  it  said. 

While  it  is  fair  to  say  that  there  are  several  really 
charitable  institutions  in  this  city  that  deserve  help 
from  the  public,  the  number  is  so  exceedingly  small, 
as  compared  to  that  of  the  unworthy  ones  seeking 
such  aid,  that  one-tentli  of  the  amount  of  theappropri- 


December  ii,  1897] 


MEDICAL    RECORD. 


855 


ation  would  be  all  that  would  be  actually  and  legiti- 
mately needed.  Our  good  mayor  whose  charming  weak- 
ness and  genial  flexibility  are  so  charitably  excused 
by  his  friends,  voted  for  the  full  appropriation.  Prob- 
ably in  the  excitement  of  the  moment,  with  his  usually 
irresistible  propensity  to  do  something  startlingly 
inconsistent,  he  forgot  the  little  speech  he  made  at  a 
recent  doctors'  dinner,  in  which  he  declared,  as  sol- 
emnly as  was  possible  for  the  occasion,  that  one  of  the 
greatest  abuses  of  charit}-  was  the  appropriation  of 
public  money  for  private  purposes. 


WANTED,    A    SANITARY    CLEARING-HOUSE. 

The  usual  crop  of  tj-phoid  cases  is  attributed  by  Dr. 
Edmund  Glynn  to  the  holidays.  The  British  Medital 
Journal,  referring  to  this,  says  that  "it  is  almost  a 
pity  that  there  is  not  in  England  some  sort  of  sanitarj- 
clearing-house  to  deal  with  accidents  of  this  kind. 
Surely  the  origin  of  t}'phoid  contracted  at  a  watering- 
place  ought  to  be  investigated.  There  is  a  sort  of 
conspiracy  of  silence  on  the  part  of  the  sanitary  au- 
thorities of  many  watering-places  which  augurs  an 
evil  conscience  on  their  part"  While  we  are  far  from 
saying  that  the  citj'  health  officer  is  always  right  in 
looking  abroad  rather  than  at  home  for  the  origin  of 
his  typhoid  cases,  we  think  it  might  be  not  amiss  if 
medical  men  when  asked  to  recommend  a  health  re- 
sort would  give  the  preference  to  such  as  are  least 
guilty  of  this  policy  of  concealment. 


^cius  of  the  SSlceU. 

Associated  Health  Authorities.  —  At  the  annual 
session  of  the  Associated  Health  Authorities,  held  at 
Woodbur}-,  N.  J.,  on  November  29th,  Dr.  Henry 
Mitchell,  New  Jersey,  secretary  of  the  State  board  of 
health,  delivered  an  address  on  "  Boards  of  Health." 
Dr.  M.  P.  Ravenel,  of  the  Universit}'  of  Pennsylvania, 
read  a  paper  on  "  Tuberculosis  and  Milk  Supply." 
Dr.  T.  B.  Rodgers  read  a  paper  on  "  The  Relation  of 
Contagious  Diseases  of  Animals  to  the  Public  Health." 

The  Plague  in  India. — The  epidemic  of  the  plague 
shows  no  sign  of  abatement  at  Poonah,  Sural,  and 
elsewhere  in  the  Bombay  presidency.  It  has  extended 
to  Belgaum  and  Ahmednagur.  At  the  latter  place  two- 
thirds  of  the  inhabitants  have  already  sought  safetj'  in 
flight.  The  health  authorities  of  Bombay  reported 
that  there  were  twentj^-si.x  new  cases  of  the  plague,  and 
ten  deaths  in  that  citj-  on  November  23d. 

Sickness  and  Death  in  Havana. — It  is  stated  in 
the  latest  issue  of  the  public-health  reports  of  the 
Marine  Hospital  sen-ice  that  there  were  six  hundred 
and  nine  deaths  in  Havana  during  the  preceding  week, 
equivalent  to  an  annual  rate  of  158.3  per  1,000.  This 
estimate  is  only  approximate,  and  it  is  believed  that 
many  deaths,  ten  per  cent,  or  more,  are  not  reported. 
According  to  this  report  there  are  about  three  hundred 
cases  of  yellow  fever  in  that  city.  There  were  twenty- 
four  deaths  from  that  cause  during  the  week,  but  two 
of  that  number  occurring  among  the  civilians,  the  oth- 


ers in  military  hospitals.  The  deaths  from  enteric, 
malarial,  and  the  so-called  pernicious  fevers  show  a 
marked  increase  over  the  preceding  week.  The  deaths 
from  intestinal  diseases  are  about  one-third  of  the  total 
deaths,  but  nearly  half  of  those  occurring  from  enteritis 
are  from  star\'ation  pure  and  simple. 

YeUow  Palms  in  Typhoid  Fever.  —  A  writer  in 
The  Lancet  says  that  he  has  remarked  in  cases  of 
typhoid  fever  a  yellow  discoloration  of  the  palms  of 
the  hands,  which  is  usually  noticeable  in  the  second 
week  and  gets  darker  till  the  crisis,  then  gradually 
disappears  as  the  temperatiu-e  regains  the  normal.  He 
asks  whether  this  is  a  pathognomonic  symptom  of  the 
disease,  or  whether  it  has  been  merely  a  chance  occur- 
rence in  his  cases. 

A  Life  of  Pasteur. — It  is  announced  that  M.  Val- 
lerj-  Radot,  the  son-in-law  of  M.  Pasteur,  has  nearly 
finished  the  biography  he  has  been  busy  on  for  some 
time  past  It  relates  the  storj-  of  M.  Pastetir's  life, 
and  includes  extracts  from  his  letters. 

A  Tragedy  and  a  Fortunate  Escape. — Last  Sat- 
urday Thomas  Button  bought  a  can  of  sauerkraut. 
His  wife  oi>ened  it  and  put  the  kraut  on  the  table  for 
dinner,  raw.  In  the  can  was  a  piece  of  meat  which 
was  thrown  to  a  small  house  dog,  and  he  ate  it  Mr. 
Button  did  not  eat  of  kraut,  but  his  wife  did,  and 
shortly  after  she  vomited  violently  a  number  of  times, 
and  about  half  an  hour  after  the  meat  was  given  to  the 
dog  he  was  found  under  the  bed  dead.  Mrs.  Button 
thinks  a  cup  of  hot  coffee  was  all  that  saved  her  life. 
— Altoona  Journal. 

The  American  Society  of  Naturalists.  —  The 
American  Society-  of  Naturalists  and  the  affiliated  so- 
cieties will  meet  at  Ithaca,  N.  Y  ,  on  December  28th, 
29th,  and  30th.  The  other  societies  meeting  with  the 
naturalists  are:  the  Association  of  American  Anato- 
mists, the  Association  for  Botanical  Morpholog)-  and 
Physiolog}-,  the  American  Morphological  Societ}-,  the 
American  Physiological  Societ}-,  the  American  Psy- 
chological Association,  Section  H  (anthropology)  of 
the  American  Association  for  the  Advancement  of 
Science. 

Medical  Periodicals  in  the  United  States.  —  We 
find,  from  a  newspaper  directory  recently  issued,  that 
the  medical  profession  of  that  country  supports 
directly  or  indirectly  275  periodicals,  of  which  10  are 
issued  weekly,  11  fortnightly,  225  monthly,  6  bi- 
monthly, and  23  quarterly,  with  a  combined  yearly 
circulation  of  16,017,200  copies.  Estimating  that 
there  are  in  round  numbers  120,000  medical  men  of 
all  schools  north  of  the  Gulf  of  Mexico,  of  whom 
probably  not  over  80,000  subscribe  to  a  medical  jour- 
nal of  any  kind,  this  vast  amount  of  literature  seems 
an  enormous  burden  to  carry. — Health,  November 
13,  1897. 

A  New  Psediatric  Journal. — Dr.  Jules  Comby,  of 
Paris,  formerly  editor  of  the  Rcziie  lie  Medecine  Infan- 
tile, which  ceased  publication  about  a  year  ago,  is 
about  to  establish  a  new  journal,  entitled  Archives  de 
Medecine   ites   Enjants.      The    new    archives    will    be 


856 


MEDICAL    RECORD. 


[December  ii,  1897 


published  by  Drs.  Lannelongue,  Grancher,  Hutiner, 
Sevestre,  Moizard,  Brun,  and  Marfan,  under  the  edito- 
rial supervision  of  Dr.  Comby.  The  journal  will 
appear  monthly,  beginning  with  January,  1898. 

"  The  Philadelphia  Medical  Journal."— The  Phil- 
adelphia Medical  Publishing  Company  has  been 
incorporated  under  the  laws  of  Pennsylvania,  for  the 
purpose  of  publishing  a  weekly  medical  journal  to  be 
known  as  The  Philadelphia  Medic-al  Journal.  The  man- 
agement of  the  organization  has  been  intrusted  to  a 
board  of  trustees,  including  representatives  of  leading 
medical  schools  and  other  public-spirited  individuals. 
Dr.  George  M.  Gould  has  been  chosen  editor,  and  it 
is  expected  that  the  first  number  of  the  new  publica- 
tion will  appear  January  i,  1898. 

Physicians  in  Columbus.  —  An  item  is  on  its 
rounds  through  the  papers,  medical  and  lay,  to  the 
effect  that  there  are  thirteen  hundred  physicians  in 
Columbus,  Ohio,  or  one  to  every  seventy-seven  peo- 
ple. The  Columbus  Mcdicaljounial  corrects  this,  say- 
ing that  there  are  only  three  hundred  physicians,  or 
one  to  every  four  hundred  and  sixteen  people.  So 
there  is  still  room  for  one  more  in  that  pleasant  and 
healthful  city. 

Obituary  Notes. — Dr.  Julius  A.  Skilton  died  on 
November  20th,  at  his  home  in  Brooklyn.  He  was 
a  surgeon  during  the  civil  war,  and  was  later  a  war 
correspondent  in  Mexico  during  and  after  Maximil- 
ian's defeat.  He  was  for  some  time  consul-general  in 
Mexico  City,  and  finally  made  his  home  in  Brooklyn. 
He  had  not  practised  medicine  for  a  long  time. — Dr. 
George  H.  Horn,  of  Philadelphia,  who  had  been  for 
many  years  secretary  and  librarian  of  the  American 
Philosophical  Society,  died  on  November  25th,  aged 
fifty-eight  years.  He  was  graduated  in  medicine  from 
the  University  of  Pennsylvania,  and  was  an  honorary 
member  of  a  number  of  European  scientific  societies. 
He  was  president  of  the  American  Entomological  So- 
ciety, and  next  to  the  late  Dr.  John  Labonte  he  was 
looked  upon  as  the  leading  entomologist  in  America. 
He  was  active  in  the  Academy  of  Natural  Sciences, 
and  for  some  time  served  as  its  corresponding  secre- 
tary. His  death  was  the  result  of  apoplexy,  from  which 
he  suffered  a  first  attack  about  a  year  ago. — Dr.  R. 
N.  Short  died  suddenly  at  Mechanicsburg,  Pa.,  on 
December  ist,  of  heart  disease,  at  the  age  of  sixty-six 
years. — Dr.  E.  L.  Welling  died  at  Pennington,  N. 
J.,  on  November  29th,  of  heart  disease.  He  was  a 
graduate  of  Princeton  University  and  of  the  medical 
department  of  the  University  of  Pennsylvania.  He 
was  secretary  of  the  Third  Corps  Union,  which  was 
originally  organized  for  the  relief  of  wounded  soldiers, 
but  after  the  war  became  entirely  social.  He  was  for 
many  years  chief  surgeon  of  the  New  Jersey  national 
guard.  In  1896  he  became  chief  surgeon  of  the  Sol- 
diers' National  Home,  at  Hampton,  Va.,  which  posi- 
tion he  held  for  about  a  year,  resigning  on  account  of 
illness. — Dr.  Martin  Van  Winkle,  of  Little  Falls, 
N.  J.,  died  on  November  29th,  of  apoplexy,  at  the  age 
of  seventy-three  years. — Dr.  Alexander  W.  Stein 
died  at  his  home  in  this  cit}',  on  December  6th,  at  the 


age  of  fifty-seven.  He  was  bom  in  Hungary,  but  was 
brought  to' this  country  by  his  father  when  four  years 
old.  He  was  a  graduate  of  the  New  York  University 
Medical  School  in  the  class  of  1864.  He  was  visiting 
surgeon  to  the  City  Hospital,  professor  of  physiology 
at  the  New  York  College  of  Dentistry,  and  a  member 
of  the  County  Medical  Society  and  the  Academy  of 
Medicine. — Dr.  William  N.  Gilchrist  died  at  the 
Windsor  Hotel,  on  December  3d.  He  was  bom  in 
Kortright,  N.  Y.,  in  1823,  and  after  being  graduated 
from  the  Vermont  Medical  College,  came  to  this  city 
in  1847,  practising  his  profession  until  he  retired, 
about  fifteen  years  ago. — Dr.  James  Olmstead  died  at 
the  Hotel  Grenoble,  in  this  city,  on  December  4th,  at 
the  age  of  fort}'-eight  years.  He  was  graduated  from 
the  Yale  Medical  College  in  1874.  For  the  past 
eleven  years  he  filled  the  post  of  superintendent  of  the 
Connecticut  State  Hospital  for  the  Insane  at  Middle- 
town. — Dr.  Harrison  Willis,  a  prominent  homur- 
opathic  physician  of  Brooklyn,  died  in  that  city  on 
December  2d,  at  the  age  of  sixty-one  years.  He  was 
a  graduate  of  the  Cleveland  Homoeopathic  Medical 
College  in  1864. 

The  Late  Dr.  Harrison  Allen. — At  a  meeting  of 
the  Philadelphia  Neurological  Society,  held  on  the  22d 
of  November,  the  following  action  was  taken: 

"  Whereas,  The  Philadelphia  Neurological  Society 
has  heard  with  great  regret  of  the  death  of  Dr.  Harri- 
son Allen,  it  desires  to  offer  its  sympathy  to  his  family 
and  to  give  expression  to  its  sense  of  the  great  loss 
which  has  been  sustained  by  science  and  the  medical 
profession. 

'■  Dr.  Allen  was  deeply  interested  in  neurology,  not 
only  as  a  human  and  comparative  anatomist,  but  also 
in  various  practical  directions,  as  indicated  by  his 
valuable  contributions  to  this  society  and  other 
medical  bodies. 

"  Charles  W.  Burr,  M.D.,  President. 
"William  G.  Spiller,  M.D.,  Secretary." 

The  Marine  Hospital  Service — In  the  report  of 
Surgeon-General  Wyman,  of  the  Marine  Hospital  ser- 
vice, recently  forwarded  to  the  secretary  of  the  treasury, 
it  is  stated  that,  during  the  fiscal  year  ending  June  30, 
1897,  there  were  54,477  patients  treated  at  the  hospi- 
tals and  dispensaries  under  charge  of  the  surgeons  in 
the  service.  This  was  673  in  e.xcess  of  the  number 
treated  there  the  previous  year;  but  the  total  expendi- 
tures from  the  Marine  Hospital  fund  (?538,356)  were 
$21,000  less  than  those  of  last  year.  Naturally  a  con- 
siderable portion  of  the  report  is  devoted  to  a  consid- 
eration of  the  recent  visitation  of  yellow  fever  in  the 
South.  Up  to  November  loth  the  number  of  cases 
officially  reported  was  4,198,  with  423  deaths.  New 
Orleanshad  1,722  cases  and  244  deaths.  Thesurgeon- 
general  says  that  there  is  little  doubt  that  the  work 
which  was  done  by  the  Marine  Hospital  experts  had 
a  marked  effect  in  controlling  the  spread  of  the  disease 
and  preventing  a  much  more  extensive  epidemic. 
How  the  disease  gained  ^..'-Mission  to  this  country  has 
not  yet  been  satisfactorily  determined.  The  report 
gives  a  description  of  the  national  quarantine  stations. 


December  ii,  1897] 


MEDICAL    RECORD. 


857 


and  an  account  of  the  measures  taken  to  enforce  the 
national  regulations  at  certain  points  where  the  pre- 
cautions taken  by  the  local  authorities  were  inade- 
quate. An  effort  was  made  more  than  a  year  ago  to 
supplant  the  national  quarantine  station  on  Ship 
Island  by  a  State  quarantine  on  a  neighboring  island 
nearer  the  shore,  but  it  failed.  The  report  states  that 
attempts  have  been  made  by  certain  parties  to  excite 
concern  respecting  the  Ship  Island  station  on  account 
of  its  alleged  proximit)-  to  the  shore.  It  has,  the  report 
says,  been  stated  that  the  island  is  five  miles  out, 
whereas  it  is  really  twelve.  Dr.  Wyraan  repeats  his 
recommendation  for  the  enactment  of  a  national  quar- 
antine law,  but  says  that  if  a  new  law  cannot  be 
passed  the  strengthening  of  the  present  law  is  a  matter 
of  urgency,  so  that  effective  measures  may  be  taken  to 
prevent  interference  with  interstate  commerce,  while 
also  preventing  the  spread  of  disease. 

Appointments  at  Manhattan  Hospital.  —  Dr. 
Charles  E.  Norris  has  been  promoted  from  the  position 
of  medical  interne  at  the  Manhattan  State  Hospital  to 
that  of  junior  physician.  Other  changes  in  the  medi- 
cal staff  of  this  institutidh  include  the  appointments 
of  Dr.  John  H.  Crosby  as  junior  physician,  and  of  Dr. 
Er^-ing  Halley  and  Dr.  David  E.  Marshall  as  medical 
internes. 

An  Epidemic  of  Measles. — The  newspapers  report 
that  a  verj'  extensive  epidemic  of  measles  is  prevailing 
in  Springfield,  Ohio.  On  the  first  day  of  this  month 
one  hundred  and  fiftj'-one  new  cases  of  the  disease 
were  reported,  and  one  hundred  and  thirty-nine  cases 
the  following  day,  making  a  total  of  eight  hundred 
cases  up  to  that  date.  The  character  of  the  disease  is 
in  general  mild  and  the  mortality  rate  is  comparatively 
low. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
ger}-,  Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
December  4,  1897.  November  29th. — Passed  Assis- 
tant Surgeon  S.  S.  White  detached  from  the  Concord 
and  ordered  to  the  Wheeling. 

A  Russian  Society  of  Ophthalmology. — The  Rus- 
sian minister  of  the  interior  has  connrmed  the  consti- 
tution of  a  new  medical  society,  to  be  called  the  St. 
Petersburg  Ophthalmological  Society.  Dr.  Dobrovol- 
ski  has  been  elected  president  of  the  new  society ;  Dr. 
Belliaminov,  vice-president;  and  Drs.  Gagarin  and 
Sergiev,  secretaries. 

An  Association  for  the  Spread  of  Skin  Diseases 
is  what  the  French  army  might  be  called,  if  the  story 
told  of  the  wretched  condition  of  the  reserves  in 
France  is  true.  It  is  said  that  epidemics  of  skin  dis- 
eases constantly  appear  among  them,  and  these  are 
traced  to  the  clothing  with  which  they  are  supplied, 
and  which  is  described  as  frequently  filthy  and  tat- 
tered in  condition.  The  reser\'e  force  numbers  about 
one  hundred  thousand  men. 

Dr.  Conrad  Diehl,  a  practising  physician  of  Buffalo, 
N.  Y.,  was  chosen  mayor  of  the  city  at  the  recent  elec- 


tions. The  Buffalo  Medical /onmal  says  that  his  ma- 
jority was  so  considerable  as  to  speak  strongly  of  his 
personal  popularit}-. 

The  Massachusetts  State  Hospital  for  Consump- 
tives, recently  built  under  authorization  of  an  act  of 
legislature  passed  in  1895,  will  be  ready  for  the  recep- 
tion of  patients  early  in  the  year.  The  buildings 
consist  of  an  administration  building  in  the  centre  of 
a  group  of  low,  one-storj-  wooden  buildings,  arranged 
upon  the  arc  of  a  circle,  and  alternately  long  and 
short,  in  order  that  free  access  may  be  given  to  the 
sunlight.  The  buildings  on  one  side  of  the  group  are 
for  men,  and  the  others  are  for  women.  Each  long 
building  has  seven  private  wards,  nine  by  twelve  feet, 
with  open  fireplaces ;  also  a  general  ward,  twenty-five 
by  ninetj-  feet,  with  accommodations  for  twent)--two 
patients,  each  such  ward  having  large  brick  fireplaces 
and  a  ventilating  shaft.  There  is  also  a  "  sun  room," 
composed  wholly  of  glass,  twelve  by  twenty-seven 
feet.  This  is  surrounded  by  a  wide  veranda.  In  the 
small  buildings  the  general  wards  have  only  ten  beds 
each.  These  wards  also  have  their  sun  rooms.  The 
hospital  is  located  at  Rutland,  Worcester  Count}', 
which  lies  at  an  elevation  of  about  twelve  hundred 
feet  above  the  level  of  the  sea.  Unfortunately  the 
institution  will  have  accommodations  for  only  about 
one  hundred  and  fifty  patients. 

A  New  Adulteration The  department  of  agricul- 
ture has  discovered  that  many  creameries  are  using  an 
emulsion  of  cottonseed  oil,  which,  added  to  the  cream, 
increases  the  butter  product  per  gallon  of  milk,  with 
small  chance  of  detection  and  a  large  increase  of 
profit. 

A  Students'  Hospital  at  Cornell  University. — The 
residence  in  Ithaca  of  the  late  Henry  W.  Sage  has 
been  presented  by  William  H.  Sage,  of  Ithaca,  and 
Dean  Sage,  of  Albany,  to  Cornell  Universit}%  for  a 
students'  hospital,  and,  besides  equipping  it,  the  do- 
nors will  endow  it  with  $100,000.  The  house  is  located 
on  a  plateau,  half-way  between  the  city  and  the  cam- 
pus, standing  well  above  surrounding  houses,  yet  easi- 
ly accessible  by  street  cars.  All  necessary  additions 
and  alterations  will  be  made.  The  total  amount  of 
the  gift,  it  is  believed,  will  exceed  $200,000. 

College  of  Physicians  of  Philadelphia — A  stated 
meeting  of  the  College  of  Physicians  of  Philadelphia 
was  held  on  December  i,  1897,  the  president.  Dr.  J. 
M.  DaCosta,  in  the  chair.  Dr.  John  B.  Deaver  read  a 
paper  entitled  ".v-Ray  Pathology  of  Fractures  about 
the  Elbow,"  illustrated  by  stereopticon  views.  Dr. 
William  S.  Forbes  showed  skiagraphs  from  a  case  of 
anterior  dislocation  of  the  head  of  the  radius,  and  Dr. 
J.  K.  Voung  exhibited  a  case  of  fracture  of  both  bones 
of  the  forearm  near  the  elbow,  with  good  movement  at 
this  joint.  Dr.  F.  Savar}-  Pearce  read  a  paper  entitled 
"A  Study  of  the  Blind."  The  president  delivered 
his  annual  address;  the  secretary,  the  treasurer,  chair- 
men of  committees,  and  clerks  of  sections  made  annual 
reports;  and  nominations  were  made  for  officers  and 
members  of  elective  committees  for  1898. 


MEDICAL    RECORD. 


[December  ii,  1897 


NEW   YORK   ACADEMY    OF    MEDICINE. 

Stated  Meeting,  December  2,  iSgj. 

Edward  G.  Janeway,  M.D.,  President. 

nominations. —  Vice-Fresidetit,  Drs.  O.  B.  Douglas  and 
W.  H.  Katzenbach;  Recording  Secretary,  Dr.  Louis 
Faugferes  Bishop;  Corresponding  Secretary,  Dr.  M.  Al- 
len Starr;  Treasurer,  Dr.  Henry  E.  Crampton ;  Trus- 
tee, Dr.  A.  M.  Jacobus;  Chairman  oj  Co7n?nittee  on  Ad- 
missions, Drs.  Henry  Ling  Taylor  and  Gorham  Bacon ; 
Co?nmittee  on  Library,  Drs.  Joseph  Collins  and  Edward 
D.  Fisher. 

Suppurative  Otitis  Media,  its  Complications  and 
Treatment. — Dr.  Gorham  BacoxN  presented  a  paper 
on  this  subject.  He  said  that  suppurative  otitis  media 
was  caused  by  cold,  influenza,  exanthematous  diseases, 
diphtheria,  typhus  and  typhoid  fever,  bronchitis,  cere- 
bro-spinal  meningitis,  pneumonia,  tuberculosis,  the 
puerperal  state,  syphilis,  sea  bathing,  injuries  to  the 
<lrumhead,  and  the  snuffing  up  of  solutions  for  nasal 
catarrh.  Dentition  played  an  important  role  in  its  de- 
velopment, as  did  also  adenoid  growths  and  enlarged 
tonsils.  Scarlet  fever,  diphtheria,  measles,  and  influ- 
enza were  responsible  for  most  of  the  cases,  so  that  it  was 
of  the  greatest  importance  that  the  ear  should  be  care- 
fully examined,  and,  if  need  be,  treated  in  connection 
with  these  disorders.  In  children  the  temperature  was 
apt  to  be  very  high,  and  the  attack  might  be  ushered  in 
by  a  convulsion  or  by  severe  vomiting.  When  the  pain 
persisted  after  the  ear  had  begun  to  discharge,  it  was 
probable  that  the  periosteum  of  the  external  ear  was  in- 
volved or  that  the  mastoid  was  implicated.  The  most 
frequent  seat  of  perforation  was  the  lower  anterior  or 
posterior  quadrant.  Acute  purulent  otitis  media  might 
terminate  in  recovery,  with  or  without  permanent  loss 
of  hearing,  or  the  disease  might  become  chronic. 

In  the  acute  inflammatory  stage  Dr.  Bacon  said 
it  was  important  to  apply  the  artificial  leech  at 
once,  close  to  the  tragus,  and  endeavor  to  abort  the 
disease.  If  the  drumhead  bulged,  a  free  incision 
should  be  made  into  it.  This  should  be  done  only 
under  the  guidance  of  the  eye  and  with  the  aid  of  good 
illumination.  If  the  free  incision  was  not  made  and 
proper  drainage  not  established,  there  would  be  great 
danger  of  the  otitis  media  becoming  chronic.  If  the 
■disease  became  chronic — th  t  is,  in  Shrapnell's  mem- 
brane— the  cavity  should  be  enlarged  and  the  endeavor 
made  to  wash  out  the  secretion  with  a  syringe.  Gran- 
ulations should  be  destroyed  by  the  application  of 
chromic  acid  or  by  the  use  of  the  curette.  If  this 
treatment  failed,  a  cure  could  be  effected  in  many  cases 
by  excision  of  the  ossicles  and  curetting  the  attic. 
Some  of  the  results  of  chronic  otitis  media  were  the 
formation  of  granulations  and  polypi,  caries  of  the 
ossicula  and  temporal  bone,  mastoid  disease,  suppura- 
tive meningitis,  cerebral  abscess,  pya'mia,  and  septi- 
caemia. In  cases  of  acute  otitis  media,  if  the  temper- 
ature remained  high  after  the  incision  of  the  drum  mem- 
brane and  the  opening  of  the  mastoid  cells,  one  should 
think  of  a  complicating  pneumonia  or  perhaps  of  a 
sinus  thrombosis.  In  cases  of  acute  mastoid  disease 
the  operation  should  not  be  deferred  until  redness  and 
(jedema  of  the  tissues  over  the  mastoid  appeared  and 
the  auricle  stood  out  prominently  from  the  head.  In 
making  the  diagnosis  the  two  mastoid  processes  should 
be  compared,  as  in  some  persons  pressure  on  an  unin- 
flamed  mastoid  process  would  cause  pain.  In  the  first 
stage  of  mastoid  inflammation,  secondary  to  acute 
suppurative  otitis  media,  after  incision  the  artificial 
leech  should  be  applied,  and  also  the  Leiter  cold  coil, 
but  tlie  latter  should  not  be  left  on  for  more  than 


forty-eight  hours,  for  if  the  symptoms  had  not  subsided 
by  that  time  immediate  operation  was  indicated.  The 
incision  should  be  made  close  to  the  auricle,  from  the 
tip  to  the  upper  border  of  the  pinna.  This  incision 
could  be  enlarged  in  both  directions  if  complications 
existed.  When  pus  was  found  in  the  antrum  and 
upper  part  of  the  mastoid,  it  should  be  remembered 
that  the  tip  might  contain  pus,  and  if  this  was  not 
liberated  it  might  burrow  down  into  the  tissues  of  the 
neck,  and  give  rise  to  septiceemia.  When  caries  of 
the  tympanic  roof  took  place,  a  collection  of  pus  was 
frequently  found  in  the  temporo-sphenoidal  lobe. 

Symptoms  of  Cerebral  Abscess. — Cerebral  abscess 
almost  always  occurred  in  connection  with  chronic 
purulent  otitis  media.  The  first  stage  of  abscess  was 
usually  marked  by  irritability,  pain,  nausea,  and  vom- 
iting, with  a  diminution  or  cessation  of  the  discharge. 
A  symptom  of  importance  was  a  sudden  change  in  the 
disposition  or  temperament  of  the  patient.  When  pus 
had  formed  in  the  brain,  there  would  be  usually  a 
distinct  lowering  of  the  pulse  rate  and  a  subnormal  or 
but  slightly  elevated  temperature.  When  aphasia 
developed  in  such  a  case,  it  was  an  important  diagnos- 
tic sign  of  abscess  of  the  temporo-sphenoidal  lobe. 
Inflammation  of  the  optic  ner^-e  was  also  sometimes 
present.  In  cerebellar  abscess  the  most  characteristic 
symptoms  were  severe  headache,  nausea  and  vomiting, 
vertigo,  and  facial  paralysis.  The  external  auditory 
canal  should  always  be  carefully  examined  in  every 
case  of  suspected  cerebral  abscess.  When  thrombosis 
of  the  lateral  sinus  was  present  there  would  be  severe 
headache,  high  temperature  with  decided  fluctuations, 
nausea  and  vomiting,  overdistention  of  the  superficial 
veins  in  the  mastoid  region,  and  swelling  of  the  tis- 
sues around  the  tip  of  the  mastoid  would  sometimes  be 
observed.  If  the  jugular  vein  became  involved  there 
would  be  hardness  and  tenderness  along  this  vein. 

Begin  Operating  at  the  Antrum.  ■ —  It  seemed  to 
the  speaker  important  that  the  opening  of  the  antrum 
should  be  made  the  starting-point  of  the  operation. 
If  caries  of  the  tympanic  roof  was  detected,  the  open- 
ing should  be  enlarged  so  as  to  admit  of  thorough 
inspection  of  the  dura.  Sometimes  a  thrombosis  would 
be  found  in  a  sinus,  even  though  an  exploring  needle 
had  withdrawn  fluid  blood.  If  the  sjTnptoms  indicated 
abscess  of  the  cerebellum  the  sinus  should  be  exposed 
first.  The  question  of  ligating  the  internal  jugular 
vein  in  cases  of  thrombosis  here  was  still  a  mooted 
question.  Personally  he  did  not  think  this  was  neces- 
sary. Pressure  should  b"?  made  on  the  neck  from 
below  upward  along  the  course  of  the  internal  jugular 
vein,  in  order  to  remove  the  thrombi  in  the  end  of  the 
lateral  sinus.  If  the  flow  of  blood  could  not  be  re- 
established from  the  lower  end  of  the  sinus,  it  became 
necessary  to  ligate  the  internal  jugular  vein,  especially 
if  there  was  tenderness  or  induration  along  the  vein. 
He  had  never  seen  any  bad  results  from  exploring  the 
different  parts  of  the  brain,  if  care  was  exercised  and 
the  operation  was  done  under  strict  asepsis.  Rapidity 
of  operating  was  of  considerable  importance.  After 
evacuating  the  pus  from  a  brain  abscess,  great  care 
should  be  exercised  in  syringing  the  cavity.  Boric 
acid  should  be  used,  and  afterward  a  loose  packing  of 
iodoform  gauze.  This  was  preferable,  in  his  opinion, 
to  the  use  of  drainage  tubes. 

Dr.  M.  .'Vixen  Starr  said  that  most  of  the  cerebral 
complications  w-ere  observed  in  connection  with 
chronic  cases  of  suppurative  otitis  media.  One  should 
be  chary,  however,  about  making  a  diagnosis  of  brain 
abscess  in  these  cases  on  the  first  appearance  of  cere- 
bral svmptoins;  it  was  better  to  watch  the  case  for  two 
or  three  days  before  deciding,  as  not  infrequently 
apparently  serious  cerebral  symptoms  would  gradually 
disappear  as  a  free  discharge  from  die  ear  was  estab- 
lished. 


December  ii,  1897] 


MEDICAL    RECORD. 


859 


Diagnosis  of  Cerebral  Abscess. — The  diagnosis  of 
cerebral  abscess  was  a  most  difficult  one  to  make,  and 
one  could  not  rely  implicitly  on  any  one  of  the  symp- 
toms, but  must  decide  after  a  careful  study  of  a  num- 
ber of  the  symptoms.  Although  almost  all  observers 
agreed  that  subnormal  temperature  is  the  rule  in  brain 
abscess,  he  had  seen  with  Dr.  Bacon  a  case  in  which 
the  temperature  reached  to  105°  or  106^  F.,  and  was 
so  irregular  as  to  suggest  pyaemia  and  thrombosis  of 
the  lateral  sinus.  Again,  much  stress  was  laid  upon 
the  presence  of  a  cerebellar  gait,  yet  this  was  often  the 
result  of  irritation  of  the  auditory  nerve  or  of  irritation 
of  the  semicircular  canals.  Optic  neuritis  was  some- 
times present,  but  not  often,  probably  because  there 
was  no  time  for  it  to  develop. 

Locating  the  Abscess ;  Visual  Aphasia. — Above 
and  back  of  the  ear  was  the  region  of  the  brain  concerned 
in  the  storage  of  the  memories  of  the  sounds  of  words. 
If  this  part  of  the  brain  was  injured,  the  person  became 
unable  to  understand  what  was  said  to  him.  Again, 
everything  that  we  called  to  mind  by  our  visual  sense 
employed  the  function  of  the  occipital  lobe  of  the  brain 
— the  visual  centres.  The  connection  between  the 
hearing  centres  in  the  temporal  lobe  and  the  visual 
centres  in  the  occipital  lobe  was  made  by  a  long  tract 
lying  under  the  cortex  of  the  brain — a  distinct  associ- 
ation tract.  When  this  tract  was  destroyed,  as  it  often 
was,  in  abscess  of  the  temporal  lobe,  if  one  asked  such  an 
individual  what  some  object  was  that  was  held  up  be- 
fore him,  he  recognized  the  object  but  could  not  call  it 
to  mind  and  name  it,  because  of  the  destruction  of  this 
association  tract.  Dr.  Starr  said  that  this  peculiar 
lack  of  association  was  an  important  symptom  to  elicit 
in  cases  of  suspected  abscess  of  the  temporal  lobe,  yet 
it  was  not  commonly  mentioned  in  text-books. 

Dr.  R.  F.  Weir  gave  reminiscences  of  the  earlier 
days  of  his  experience  in  the  New  York  Eye  and  Ear 
Infirmary.  He  had  operated  upon  nine  patients  in  cases 
of  cerebral  abscess  of  otitic  origin,  five  being  extradural 
and  four  cases  of  sinus  thrombosis.  Of  the  former  only 
two  recovered,  and  of  the  latter  only  one  recovered.  It 
was  worthy  of  note  that  all  the  recoveries  occurred  in 
private  practice,  and  this  was  probably  to  be  explained 
by  the  fact  that  hospital  cases  usually  came  under  ob- 
servation too  late.  One  of  the  earliest  and  most  suc- 
cessful operators  in  this  class  of  cases  was  Schede. 
Personally  his  enthusiasm  regarding  the  surgery  of  tu- 
mors of  the  brain  and  of  epilepsy  had  cooled  off  to  an 
extraordinary  degree,  because  such  operations  at  best 
were  usually  only  of  very  temporarj'  benefit.  In  former 
(lays  sinus  thrombosis  terrified  the  surgeon ;  now  it 
was  even  more  satisfactory  to  treat  than  the  ordinary 
cerebral  abscess,  because  its  symptoms  were  usually 
recognized  quite  promptly  and  the  cases  were  treated 
with  facility  by  those  who,  by  observation  and  some 
experience,  had  acquired  the  necessary  boldness.  Al- 
though sinus  hemorrhage  was  alarming  to  witness,  we 
had  learned  that  it  was  more  easily  controlled  than 
that  from  any  of  the  large  veins. 

Cold  Applications  Dangerously  Misleading.— Dr. 
A.  H.  Buck  said  that  he  could  not  agree  with  Dr. 
Bacon  regarding  the  advisability  of  using  the  Leiter 
cold  coil  in  the  treatment  of  acute  otitis  media.  In 
this  early  stage  one  must  choose  between  hot  and  cold 
applications.  In  his  opinion,  both  of  these  agents 
were  vasomotor  stimulants,  and  they  relieved  the  pain 
through  this  vasomotor  action  by  diminishing  the 
pressure  on  the  sensory  nerve  fibres  of  the  inflamed 
part.  Heat  had  no  power  to  benumb  sensation,  while 
cold  would  do  so  when  carried  beyond  a  certain  point. 
This  very  application  of  cold,  therefore,  served  to  mis- 
lead us,  for  it  was  largely  by  the  persistence  of  pain 
that  we  were  informed  of  the  necessity  of  going  further 
and  operating.  It  was  probably  for  this  very  reason 
that  the  reader  of  the  paper  had  advised  that  the  cold 


should  not  be  applied  longer  than  forty-eight  hours. 
The  application  of  ice  appeared  to  be  getting  very 
popular  in  this  countr}',  and  for  this  reason  he  felt 
called  upon  to  emphasize  the  fact  that  it  was  a  very 
deceptive  agent. 

Dr.  H.  Knapp  reported  several  cases  bearing  upon 
the  subject  under  discussion.  In  one  of  these  a  sub- 
sequent post-mortem  examination  afforded  proof  of  the 
fact  that  explorator)'  punctures  might  be  made  freely 
without  giving  rise  to  any  irritation  or  bad  results.  A 
colored  plate  was  exhibited  from  another  case,  in 
which  an  abscess  almost  completely  filled  the  temporo- 
sphenoidal  lobe,  and  was  surrounded  by  a  small  zone 
of  softening  and  redness,  yet  all  the  rest  of  the  brain 
was  healthy.  He  felt  confident  that  if  this  abscess 
had  been  operated  upon  a  week  earlier,  the  patient 
would  have  recovered. 

There  was  a  tract  a  little  deeper  than  the  one  re- 
ferred to  by  Dr.  Starr,  which  had  been  found  to  be 
implicated  in  only  eight  or  ten  cases  of  brain  abscess. 
Dr.  Weir  had  stated  that  acute  ear  disease  only  excep- 
tionally gave  rise  to  cerebral  abscess,  yet  according  to 
recent  statistics  nine  per  cent,  were  due  to  acute  otitis 
media — not  only  the  extradural  abscesses,  which  were 
very  common,  but  the  real  cerebral  or  cerebellar  ab- 
scesses. These  statistics  had  probably  been  largely 
influenced  by  the  prevalence  in  recent  years  of  epi- 
demic influenza. 

Compact  Bony  Mastoids  Specially  Troublesome. 
— Mastoid  processes  having  a  structure  of  compact 
bone  often  gave  rise  to  most  perplexing  symptoms. 
In  these  cases  there  would  usually  be  pain,  not  only  in 
the  mastoid  region,  but  also  in  the  occipital  region, 
and  often  little  or  no  discharge.  Moreover,  this  pain 
would  be  quite  variable,  ceasing  at  times  altogether. 
Pain  on  pressure  was  of  special  significance  in  local- 
izing the  inflammatory  focus.  Even  at  operation  these 
compact  mastoids  gave  a  good  deal  of  trouble,  because 
even  if  one  found  the  usual  "bead  of  pus"  this  fre- 
quently would  not  lead  the  operator  to  the  main  collec- 
tion of  pus.  In  these  cases  of  compact  mastoids  it 
would  be  found  very  much  easier  to  trephine  in  the 
ordinary  way,  above  and  behind  the  ear,  into  the  cra- 
nium, and  from  there  explore  the  middle  cranial  fossa. 

Dr.  Robert  Abbe  said  that  the  discussion  had 
shown  most  clearly  the  great  risk  of  allowing  a  ;  uru- 
lent  otitis  to  goon  after  the  onset  of  serious  sympti  ms. 
Hemorrhage,  sinus  pyaemia,  and  cerebral  abscess  were 
the  great  dangers  to  be  feared.  If  the  mastoid  was 
operated  upon  quite  early,  the  involvement  of  the  sinus 
would  be  exceedingly  slight.  If,  however,  the  opera- 
tion was  deferred,  the  signs  and  symptoms  of  sinus 
pyaemia  would  soon  make  their  appearance — tender- 
ness and  induration  along  the  jugular  vein.  Many  of 
these  cases,  operated  upon  at  such  a  late  stage,  would 
inevitably  terminate  fatally,  even  after  the  most  radi- 
cal operation.  When  the  cases  had  gone  on  to  the 
formation  of  a  cerebral  abscess,  surgery  held  out  com- 
paratively little  prospect  of  recovery. 

Dr.  Edward  D.  Fisher  said  he  thought  the  question 
of  temperature  was  important  in  making  the  diagnosis 
in  these  cases  of  meningitis  and  cerebral  abscess. 
The  hebetude  present  in  cases  of  cerebral  abscess  was 
a  distinctive  feature,  and  optic  neuritis  was  not  un- 
commonly present.  In  some  cases  there  were  but  few 
symptoms  during  life,  and  the  diagnosis  would  be 
made  only  at  the  post-mortem  examination.  The 
speaker  then  referred  to  a  case  of  chronic  otitis  media 
which  had  been  operated  upon,  and  a  fruitless  search 
made  for  pus.  The  patient  recovered  well  from  the 
operation,  and  afterward  had  four,  or  five  attacks  of 
coma  lasting  for  a  few  hours,  preceded  by  headache, 
dizziness,  and  symptoms  pointing  toward  a  cerebellar 
abscess.  There  had  been  no  optic  neuritis  and  no 
elevation  of  temperature.     It  was  probable  that  in  this 


86o 


MEDICAL    RECORD. 


[December  ii,  1897 


case  there  was  some  disease  affecting  the  semicircular 
canals. 

Dr.  E.  B.  Dench  referred  to  the  value  of  local 
blood  letting  in  the  very  early  stages  of  an  acute 
catarrhal  otitis  media.  When  there  was  a  true  cellu- 
litis present,  however,  he  thought  time  should  not  be 
wasted  in  tr}-ing  local  depletion.  The  incision  into 
the  drum  membrane  should  be  early  and  free,  but  he 
did  not  favor  the  use  of  a  gauze  drain  afterward.  Of 
seventy-two  patients  upon  whom  he  had  operated  by 
the  removal  of  carious  ossicula  and  curettage  of  the 
tympanic  cavity,  forty-four  were  cured;  in  nineteen 
the  discharge  had  greatly  diminished;  the  result 
was  unknown  in  eight;  and  one  had  been  recently 
operated  upon  and  was  still  under  treatment.  The 
Stacke  operation  had  been  done  in  twelve  instances, 
eight  patients  being  cured  and  four  improved.  Out  of 
one  hundred  and  si.xtj-four  operations  he  had  had  but 
ten  fatalities.  His  experience  with  epidural  abscess 
consisted  of  si.\  cases,  all  of  which  had  terminated  in 
recovery. 

Rapid  Operating  Important. — If  an  intracranial 
complication  was  suspected,  time  was  an  important 
element  in  the  operation;  therefore  if  there  was  not 
free  drainage  from  the  e.xternal  auditory  meatus  he 
believed  in  entering  the  cranial  cavity  at  once  through 
an  incision  so  extensive  as  to  allow  exploration  of  the 
cerebellar  fossa,  the  middle  and  posterior  cranial  fos- 
sa?, and  the  lateral  sinus,  as  well  as  to  enter  the  an- 
trum, if  this  was  necessary.  One  should  not  under- 
take a  mastoid  operation  without  the  strictest  aseptic 
precautions.  Personally,  he  never  began  such  an  oper- 
ation without  expecting  to  open  the  cranial  cavity  or 
explore  the  sinus. 

Occasional  Absence  of   Pain Dr.   J.    A.    Booth 

said  that  he  did  not  think  optic  neuritis  was  a  fre- 
quent symptom  of  abscess  of  the  brain,  except  in  cases 
of  abscesses  of  the  cerebellum.  In  two  mastoid  cases 
that  had  come  under  his  observation  the  pain  had  been 
absent,  although  it  was  usually  a  prominent  feature. 
It  had  been  claimed  that  this  exceptional  absence  of 
pain  was  due  to  the  development  of  a  special  toxin 
having  anesthetic  properties. 

Prevention  of  these  Dangerous  Complications. — 
Dk.  F..  Gruening  said  that  if  the  general  practitioner 
would  promptly  and  properly  incise  the  drum  mem- 
brane there  would  be  no  brain  abscesses  or  sinus 
thromboses  to  treat;  but,  in  order  that  general  prac- 
titioners should  be  able  to  do  this,  they  should  receive 
in  their  student  days  better  instruction  regarding  the 
examination  and  local  treatment  of  the  ear. 

Dr.  B.\con,  in  closing,  said,  regarding  the  use  of 
hot  and  cold  applications,  that  he  had  never  had  any 
satisfactory  results  from  the  former.  The  reason  he 
had  advised  stopping  the  use  of  the  cold  coil  after 
forty-eight  hours  was  that  this  application  did  cer- 
tainly mask  the  symptoms  to  some  extent.  It  was  his 
practice  to  remove  the  coil  at  the  end  of  forty-eight 
hours,  and  watch  both  the  temperature  and  the  pain 
for  a  few  hours,  and  examine  the  ear  carefully.  In 
regard  to  the  question  of  abscesses  returning,  he  said 
that  he  felt  that  there  was  always  this  possibility  un- 
less every  portion  of  diseased  tissue  was  removed  at 
the  operation. 

Dr.  Bacon  then  exhibited  two  brains,  one  showing 
a  cerebellar  abscess  and  the  other  a  temporo-sphe- 
noidal  abscess  with  carious  bone. 

National  Bureau  of  Health. — Dr.  A.  Jacobi,  on 
behalf  of  the  old  committee,  reported  that,  as  its  sphere 
appeared  to  be  too  restricted  to  meet  the  present  ne- 
cessities of  the  country,  the  committee  recommended 
the  appointment  of  a  new  one  which  could  more  ef- 
fectually deal  with  the  urgent  and  complex  sanitary 
problems  of  the  present  time. 

Tlie  old  committee  was  discharged,  and,  on  motion 


of  Dr.  Jacobi,  the  president  was  requested  to  appoint 
a  committee  of  five,  of  whom  he  should  be  one,  to 
consider  questions  of  public  health  and  h}'giene,  par- 
ticularly with  regard  to  the  better  control  of  infectious 
diseases,  and  to  prepare  a  bill  to  be  presented  to  the 
United  States  Congress,  either  independently  or  in 
conjunction  with  commercial  bodies. 


SECTION   ON   GENERAL   MEDICINE. 

Stated  Meeting,  JSlovember  16,  i8gj. 

Louis  FAUC.iiRES  Bishop,  M.D.,  Chairm.an. 

Studies  in  the  Isolation  of  the  Bacillus  Typhosus 
as  a  Means  of  the  Diagnosis  of  Typhoid  Fever 

Dr.  Philip  Hanson  Hiss,  Jr.,  read  a  paper  with  this 
title.  He  said  that  recent  experiments  on  animals 
whose  resistance  had  been  reduced  by  exposure  to  nox- 
ious gases  showed  that  under  such  circumstances  they 
could  be  successfully  inoculated  with  cultures  of  the 
typhoid  bacillus,  and  certain  phenomena  resembling 
typhoid  fever  thereby  produced.  Up  to  about  1890 
the  characters  of  the  typhoid-bacillus  growth  and  the 
other  means  of  differentiating  this  bacillus  from  the 
colon  bacilli  were  few  and  indefinite,  and,  as  the  means 
of  differentiating  the  typhoid  organism  from  these 
other  colon  bacilli  became  more  accurate,  the  difficulty 
of  isolating  the  bacillus  t}'phosus  from  the  faces  was 
greatly  increased,  and  the  opinion  gained  ground  that 
the  typhoid  bacilli  were  not  found  in  the  stools.  In 
the  various  bacteriological  studies  of  typhoid  fever 
attempts  had  been  made  to  separate  the  specilic  bacilli 
from  the  faeces,  urine,  and  perspiration,  and  from  blood 
obtained  by  puncture  of  the  spleen.  The  last  proce- 
dure proved  too  dangerous  for  general  adoption.  The 
examination  of  the  urine  gave  better  results  than  the 
blood.  Neumann  had  found  the  t}phoid  organism  in 
eleven  out  of  forty -six  cases,  and  another  obser\-er  had 
found  the  bacillus  in  one  case  as  early  as  the  third 
day  of  the  disease.  There  was  some  reason  for  believ- 
ing that  the  bacilli  were  found  only  in  those  specimens 
of  typhoid  urine  which  contained  albumin.  The 
examination  of  t}-phoid  urine,  nevertheless,  had  been 
shown  to  be  a  practical  and  important  procedure. 
According  to  the  best  modern  observers,  the  tj'phoid 
organism  could  be  recognized  ordinarily  in  from  forty- 
eight  to  seventy-two  hours.  The  colonies  were  much 
smaller  and  of  a  brighter  color  than  those  of  the  colon 
bacilli.  In  April,  1896,  Dr.  Hiss  said,  he  had  begun 
some  investigations  on  the  behavior  of  various  bacteria 
with  certain  solid  media,  and  particularly  of  the  ba- 
cillus typhosus.  Two  media  were  devised — one  for 
the  differentiation  of  the  colonies  of  typhoid  bacilli 
from  the  colon  group  by  plate  cultures,  and  the  other 
for  tube  cultures.  These  media  were  composed  of 
agar,  gelatin,  sodium  chloride,  meat  extract,  and  glu- 
cose, in  varying  proportions,  acidulated  slightly  with 
hydrochloric  acid.  On  the  plate  cultures  the  bacillus 
typhosus  develof)ed  into  small  colonies,  with  irregular 
outgrowths  and  with  fringing  threads.  The  colon  col- 
onies, on  the  other  hand,  were  much  larger  and  darker, 
and  as  a  rule  did  not  form  threads.  After  inoculating 
these  culture  media  with  the  specimen  of  fa;ces,  the 
cultures  were  kept, in  an  incubator  at  a  temperature  of 
37°  C  The  organisms  isolated  in  this  manner  had 
been  subjected  to  the  usual  tests  for  recognizing  the 
bacillus  typhosus,  and  definite  and  positive  proof  of 
their  identity  had  been  obtained  by  several  observers. 
Seventy-eight  cases  had  been  investigated  in  this  way. 
Forty-tiiree  were  reported  as  clinical  typhoid,  of  which 
thirty-seven  were  in  the  febrile  sLige  and  six  were 
convalescent.  In  a  number  of  instances  only  one 
stool  had  been  examined,  and  the  case  not  further  fol- 
lowed, but  even  then  66.6  per  cent,  of  the  cases  had 
given  positive  results  in  the  febrile  stage.     But  the 


December  1 1,  1897] 


MEDICAL    RECORD. 


861 


most  interesting  results  had  been  obtained  in  a  series 
of  cases  from  the  New  York  Hospital.  Of  these 
twenty-six  cases,  twenty-one  were  in  the  febrile  stage 
and  five  were  convalescent.  Of  the  febrile  cases  nine- 
teen were  thoroughly  investigated,  and  in  seventeen, 
or  89.5  per  cent.,  the  typhoid  bacilli  were  found  in 
great  numbers.  In  the  other  two  the  plates  were  not 
satisfactory  and  death  occurred  early.  The  bacilli 
were  isolated  as  early  as  the  si.xth  day,  and  as  late  as 
the  thirtieth  day,  and  in  a  case  of  relapse  on  the  fort)'- 
seventh  day  of  the  disease.  The  bacilli  seemed  to  be 
more  numerous  in  the  stools  after  the  tenth  or  twelfth 
day.  In  one  non-febrile  case  the  bacilli  were  found 
on  the  tenth  day  of  the  disease,  and  after  three  exam- 
inations with  the  Widal  serum  test  had  given  a  nega- 
tive result.  The  fact  that  the  specific  bacilli  were 
present  in  the  blood,  the  spleen,  and  the  urine,  and 
often  early  in  the  disease,  seemed  to  indicate  that  the 
bacilli  occurred  more  generally  throughout  the  body 
than  had  been  heretofore  supposed,  and  that  they 
probably  did  not  reappear  in  the  intestinal  tract  in 
great  numbers  until  about  the  time  of  the  breaking 
down  of  the  intestinal  lesions.  The  bacilli  disap- 
peared rapidly  from  the  stools  after  the  fall  of  the  tem- 
perature, and  when  they  persisted  there  seemed  to  be  a 
special  liabilit)-  to  relapse. 

Compared  with  Widal's  Test.  —  Comparing  this 
method  of  examination  with  the  Widal  test,  it  would 
be  found  to  possess  the  advantage  over  the  serum  test 
of  positively  demonstrating  the  typhoid-fever  infection 
in  a  large  proportion  of  cases,  whereas  the  serum 
reaction  might  indicate  past  or  present  infection,  and 
even  then  was  not  always  to  be  relied  on. 

Dr.  Willia.m  H.  Park  said  that  he  had  had  a  fair 
experience  with  the  different  methods  of  isolating  the 
typhoid  bacilli,  and  he  was  positive  that  of  those  hith- 
erto devised  this  method  of  Dr.  Hiss  was  by  far  the 
best.  Eisner's  method  was  often  ditlicult  of  applica- 
tion, especially  in  warm  weather,  and  one  could  not 
hope  to  find  the  colonies  under  forty-eight  hours.  By 
the  method  described  in  this  paper  the  bacilli  pre- 
sented as  a  rule  a  characteristic  appearance,  not  only 
as  to  their  general  size,  but  because  of  the  presence  of 
the  characteristic  threads.  Of  course,  some  other  ba- 
cilli undoubtedly  made  threads,  and  it  was  possible 
for  even  an  expert  to  be  occasionally  deceived.  The 
tube  medium  seemed  to  him  far  ahead  of  anything  of 
the  kind  that  he  had  before  seen.  All  of  the  bacilli 
so  far  tested  by  Dr.  Hiss  with  this  medium  had  been 
absolutely  differentiated,  the  one  from  the  other,  but 
he  had  noticed  that  unless  the  media  were  prepared 
very  carefully  this  differentiation  would  not  occur. 
As  to  the  practical  value  to  the  physician,  the  speaker 
said  that  one  could  not  hope  to  get  positive  results  in 
much  more  than  fifty  per  cent,  of  the  cases,  although 
a  larger  percentage  had  been  obtained  from  hospital 
practice,  where  more  attention  was  paid  to  the  collec- 
tion of  the  stools  for  examination.  Like  the  sputum 
examination  in  phthisis,  if  the  bacilli  were  found,  it 
was  helpful;  if  not  found,  the  examination  was  of  no 
value.  The  same  was  true  of  the  Widal  reaction.  It 
was  probable,  therefore,  that  the  method  would  not  be 
used  in  a  routine  way,  but  only  in  certain  doubtful 
and  puzzling  cases.  It  was  in  this  way  that  the  Widal 
reaction  had  demonstrated  that  certain  types  of  fever 
formerly  considered  to  be  typhoid  were  really  not  ty- 
phoid fever. 

The  Necessary  Apparatus  Obtainable  at  the 
Health-Board  Stations. — Two  small  bottles  had  been 
devised — one  for  urine,  and  one  for  fx'ces — and  these 
were  to  be  kept  at  the  various  board-of-health  stations 
throughout  the  city  for  the  convenience  of  physicians. 
The  faeces  were  collected  by  means  of  a  glass  pipette 
furnished  with  the  rest  of  the  apparatus. 

T3rphoid  Fever  Located  in  the  Kidney. — Dr.  W. 


GilMjVX  Thompson  said  that  in  one  recent  case  at  the 
Presbyterian  Hospital  the  value  of  the  test  had  been 
demonstrated  very  conclusively.  The  patient  had  had 
some  fever  and  a  tumor  of  the  kidney,  which  was  sup- 
posed to  be  a  collection  of  pus.  It  was  not  thought  at 
the  time  that  the  case  was  one  of  typhoid  fever,  but 
the  diagnosis  had  been  made  by  the  Hiss  method.  It 
was  one  of  those  rare  cases  of  typhoid  fever  located  in 
the  kidney.  The  patient  made  an  excellent  recovery, 
and  the  tumor  disappeared  without  operation  or  special 
treatment. 

Dr.  T.  M.  Cheesmax  said  that  he  felt  that  the  Hiss 
method  was  a  radical  departure  from  all  previous  ones, 
as  hitherto  the  effort  had  been  to  inhibit  the  growth  of 
other  micro-organisms.  On  the  other  hand,  the  exper- 
iments of  Dr.  Hiss  were  made  with  the  idea  of  obtain- 
ing a  medium  which  would  enable  the  typhoid  bacillus 
to  grow  at  its  maximum.  He  had  himself  examined 
the  typhoid  stools  in  a  great  many  instances  in  an 
effort  to  obtain  the  typhoid  bacillus,  and  he  had  been 
uniformly  unsuccessful  by  the  older  methods.  He  had 
examined  the  urine  in  half  a  dozen  instances,  and  had 
been  successful  only  once.  He  had  also  examined  the 
typhoid  spots,  and  in  no  case  had  been  able  to  dis- 
cover the  presence  of  the  specific  bacillus.  He  had 
examined  the  blood  from  finger  puncture  in  twenty- 
five  cases  without  once  finding  the  bacillus.  Eisner's 
method  had  given  him  no  better  results,  and  he  had 
found  that  at  the  end  of  forty-eight  hours  other  micro- 
organisms were  very  liable  to  appear  and  to  simulate 
what  Eisner  had  described  as  the  typhoid  colony. 
He  felt,  therefore,  that  Dr.  Hiss  had  done  much  by 
his  studies  to  elucidate  this  difficult  problem  of  isolat- 
ing the  bacillus  typhosus,  yet  there  was  certainly  a 
great  deal  more  to  learn. 

Dr.  Hiss,  in  closing  the  discussion,  said  that  the 
percentage  of  positive  results  in  the  examination  of 
only  one  stool  was  about  fifty.  In  one  case  at  the 
New  York  Hospital  he  had  made  four  examinations  of 
the  stools  with  negative  results,  yet  subsequently  the 
urine  had  been  found  to  contain  the  bacilli. 

Typhoid  Fever  in  the  Aged. — Dr.  Morris  Manges 
read  a  paper  on  this  subject.  Many  recent  text-books, 
he  said,  made  the  statement  that  typhoid  fever  is  very 
rare  after  the  fortieth  year.  Flint,  in  the  last  edition 
of  his  te.xt-book,  had  stated  that  the  susceptibility  to 
typhoid  infection  was  not  great  after  the  fiftieth  year, 
and  still  less  after  sixty  years  of  age,  but  he  had  seen 
several  cases  occurring  about  this  period  of  life. 
Other  authors  had  stated  that  the  apparent  immunity 
from  typhoid  fever  in  later  life  was  probably  due  to 
the  fact  that  the  individuals  had  been  previously  ren- 
dered immune  by  an  attack  of  typhoid  fever. 

Frequency Dr.  Osier  had  informed  him  that  out 

of  three  hundred  and  eighty-nine  cases  at  the  Johns 
Hopkins  Hospital  up  to  May  15,  1895,  five  patients, 
or  1.3  per  cent.,  were  between  sixty  and  seventy  years 
of  age.  Dr.  Manges  said  that  in  the  present  year  five 
patients,  all  over  fifty  years  of  age,  had  come  under  his 
own  observation.  Two  of  these  had  been  at  the  Mount 
Sinai  Hospital — one  a  man  of  sixty-three,  and  the 
other  a  woman  of  seventy-two.  The  third  was  a 
man  of  sixty-two,  and  the  two  others  were  sixty-five 
years  of  age.  Three  of  the  cases  were  typical  in  every 
way,  but  two  presented  the  appearance  of  a  pneumo- 
nia. These  senile  cases  were  often  marked  by  an  in- 
sidious onset  and  rapidly  increasing  depression  of  the 
vital  forces.  Through  the  kindness  of  Dr.  Tracy,  of 
the  board  of  health,  he  was  able  to  present  the  follow- 
ing figures:  Of  3,644  persons  reported  dead  of  ty- 
phoid fever,  610  were  over  forty-five  years  of  age,  414 
between  forty-five  and  sixty-five,  and  96  were  sixty- 
five  or  over — in  other  words,  14  per  cent,  were  forty- 
five  and  over,  11.3  per  cent,  were  between  forty-five 
and  si.xty-five,  and  2.6  per  cent,  were  sixty-five   and 


862 


MEDICAL    RECORD. 


[December  ii,  1897 


over.  It  should  be  remembered  also  that  these  figures 
were  collated  from  the  deaths  from  this  disease.  Ac- 
cording to  a  table  prepared  for  him  by  Dr.  VV.  H.  Park, 
from  cases  brought  to  his  notice  in  connection  with 
the  examinations  for  the  Widal  reaction,  of  124  per- 
sons of  whom  the  ages  were  given,  118  were  fort}^-five 
years  old  and  under,  and  6  were  between  fortj-five 
and  sixty-five. 

Symptomatology.— The  symptomatology  was  quite 
varied  in  the  aged.  The  onset  was  often  like  that  of 
some  simple  digestive  disturbance;  epistaxis  was  in- 
frequent; the  fever  was  not  marked,  and  was  ver}^ 
irregular;  the  roseola  was  often  absent,  and  if  present 
was  exceedingly  scanty  and  atypical;  the  abdominal 
symptoms  were  not  pronounced ;  enlargement  of  the 
spleen  was  slight  or  wanting;  severe  intestinal  hemor- 
rhages were  common.  On  the  other  hand,  the  pul- 
monar}'  symptoms  were  always  pronounced — conges- 
tion, hypostasis,  and  pneumonia  being  very  common, 
and  often  leading  to  a  faulty  diagnosis.  In  a  case 
cited  by  Dr.  Osier  the  evening  temperature  at  one 
time  was  only  97.5"  F. ;  there  were  hemorrhages  scat- 
tered under  the  skin ;  and  the  urine  contained  a  mod- 
erate quantity  of  albumin,  with  granular  and  hyaline 
casts.  For  a  few  days  the  temperature  was  normal  or 
subnormal  in  the  morning,  and  rose  to  100°  or  101° 
F.  in  the  evening.  The  ecchymosis  increased,  and 
then  pulmonary  symptoms  appeared.  The  case  was 
thought  to  be  one  of  pneumonia  occurring  in  a  debili- 
tated and  aged  subject,  but  at  the  autopsy,  made  by 
Dr.  Welch,  the  anatomical  diagnosis  was  typhoid  fever, 
recent  croupous  pneumonia,  and  enlargement  of  the 
spleen.  In  this  case  there  were  no  clinical  features 
in  any  way  characteristic  of  typhoid  fever,  and  the 
typhoid  state  was  thought  to  be  secondary  to  the  pneu- 
monia. The  extensive  cutaneous  hemorrhages  were 
such  as  were  frequently  seen  in  the  protracted  cachexia 
of  old  people.  In  these  old  people  nephritis  fre- 
quently occurred,  and  asthenia  was  alw-ays  a  marked 
feature,  the  patient  looking  more  seriously  ill  than  the 
symptoms  and  signs  would  seem  to  indicate.  The 
duration  was  very  irregular,  and  convalescence  verj- 
protracted.     Death  frequently  resulted  from  syncope. 

Author's  Cases. — The  speaker  then  briefly  referred 
to  the  five  cases  that  had  come  under  his  observation. 
The  first  patient  was  seventy-two  years  of  age,  and 
complained  chiefly  of  some  abdominal  distress,  with 
pain  over  the  thorax  and  on  swallowing.  There  were 
pneumonia  at  the  right  base,  slight  enlargement  of 
spleen,  and  some  albuminuria.  The  case  resembled  a 
senile  pneumonia,  and  death  occurred  with  pulmonary 
oedema.  Cultures  made  post  mortem  from  the  spleen 
and  from  the  blood  of  the  inferior  vena  cava  gave  pure 
growths  of  t}'phoid  bacilli.  The  second  patient,  sixty- 
three  years  of  age,  had  complained  of  chills,  fever, 
headache,  and  sweating  for  some  time  prior  to  admis- 
sion. There  was  no  eruption  or  enlargement  of  the 
spleen,  and  the  temperature  range  was  anything  but 
characteristic  of  typhoid  fever.  The  fever  assumed 
after  a  time  a  hectic  type,  which  seemed  to  indicate  a 
septic  process.  The  Widal  reaction  was  negative,  but 
puncture  of  the  spleen  after  death  gave  pure  cultures  of 
typhoid  bacilli.  The  next  patient  was  sixt)'-two  years 
of  age.  When  seventeen  years  old  he  had  had  a  typi- 
cal attack  of  typhoid  fever,  with  a  brisk  intestinal 
hemorrhage  in  the  third  week.  He  presented  a  t}-pical 
range  of  temperature  in  this  second  illness.  In  the 
next  patient  it  had  been  found  difficult  to  make  the 
diagnosis  until  the  Widal  reaction  had  been  obtained 
on  the  seventh  day.  He  had  some  bronchitis  and  a 
scanty  roseola,  associated  with  slight  splenic  enlarge- 
ment. The  last  case  ran  the  ordinary  course  of  a  mild 
typhoid.  The  patient  stated  that  he  had  been  ill  for 
over  three  weeks  before  admission,  with  headache, 
slight  cough,  and  great  dryness  of  the  mouth.     The 


liver  and  spleen  were  slightly  enlarged,  and  the  ab- 
domen was  somewhat  tympanitic,  but  there  was  no 
eruption.  The  Widal  reaction  was  negative  at  the 
first  examination,  but  was  positive  two  days  later,  and 
continued  throughout  the  active  stage  of  the  disease. 

Treatment. — The  indications  were  to  combat  the 
adynamia  by  tonic  treatment,  to  guard  against  pul- 
monary complications,  and  to  watch  the  right  side  of 
the  heart.  Baths  were  to  be  avoided,  because  of  the 
atheromatous  condition  of  the  blood-vessels.  Cold 
enemata  or  tepid  baths  might  be  resorted  to. 

Watch  the  Pulmonary  Second  Sound — Dr.  An- 
drew H.  Smith  said  that  it  was  only  in  recent  years 
that  the  profession  had  come  to  realize  that  t)-phoid 
fever  could  occur  late  in  life.  Disease  processes  were 
not  easily  taken  on  in  proportion  as  the  other  proc- 
esses were  sluggish,  and  this  probably  explained  the 
comparative  infrequency  of  typhoid  fever  in  old  age. 
The  condition  which  existed  as  a  part  of  senility  was 
not  like  the  diminished  resistance  observed  in  younger 
persons.  All  the  clinical  symptoms  were  as  a  rule 
less  pronounced  than  in  younger  subjects.  For  exam- 
ple, there  was  less  headache  in  the  typhoid  fever  of 
the  aged ;  so  with  the  epistaxis  and  with  the  tj-phoid 
eruption.  The  feebleness  of  the  circulation  in  older 
persons  also  gave  rise  to  certain  special  features. 
Thus  the  bronchitis  so  commonly  observed  in  younger 
persons  would  take  on  the  form  of  broncho-pneumonia 
in  the  aged.  The  feeble  action  of  the  heart  naturally 
predisposed  to  lung  disorder.  It  was  important  for 
the  physician,  therefore,  to  know  the  amount  of  accen- 
tuation of  the  pulmonary  second  sound,  as  indicative 
of  the  condition  of  the  right  heart,  and  also  of  the  ob- 
struction in  the  pulmonarj'  circulation.  It  was  always 
comforting  in  these  cases  to  find  a  good  pulmonary 
second  sound.  In  these  aged  individuals,  as  a  result 
of  the  feeble  circulation  there  was  a  greater  tendency 
to  thrombosis  and  gangrene.  Thrombosis  of  the  iliac 
vein  was  not  uncommon,  and  a  certain  proportion  of 
these  patients  presented  gangrene  of  the  lower  extrem- 
ities. He  would  feel  unwilling  to  subject  these  old 
people  to  a  cold  bath,  although  cool  enemata  and  tepid 
bathing  might  be  very  well  borne.  We  should  watch 
particularly  for  cold  e.xtremities  and  everything  indi- 
cating impending  failure  of  the  circulation.  Alco- 
holic stimulants  were  indicated  in  these  subjects  more 
than  in  younger  ones.  The  fact  that  the  liver  and 
spleen  were  not  likely  to  be  so  greatly  engorged  con- 
stituted another  evidence  of  the  sluggish  disease 
action  to  which  he  had  already  alluded. 

Dr.  W.  Oilman  Tho.mpson  said  that  he  had  looked 
over  the  records  of  typhoid  fever  cases  at  the  Presby- 
terian Hospital  for  the  last  ten  years.  Of  these  four 
or  five  hundred  patients,  only  seventeen  were  over 
forty-five  years  of  age,  only  six  over  fifty,  and  only 
two  past  sixty  years  of  age.  These  two  latter  were 
interesting  as  demonstrating  the  possibility  of  a  very 
typical  attack  at  this  advanced  age.  It  had  occurred 
to  him  that  the  atypical  condition  in  some  of  the  cases 
described  might  possibly  be  due  to  a  previous  attack 
of  enteric  fever.  The  patients  to  w  hom  he  had  referred 
were  si.\ty-seven  and  sixty-nine  years  of  age  respec- 
tively, and  both  had  derived  the  disease  from  a  com- 
mon source,  yet  these  individuals  did  not  give  evi- 
dence of  extreme  senility. 

Dr.  Willi.am  H.  Thomson  said  that  last  October 
he  had  observed  at  the  Roosevelt  Hospital  a  case  of 
typhoid  fever  in  a  person  sixty-two  years  of  age :  its 
course  had  been  perfectly  typical,  and  had  been  com- 
plicated with  pneumonia,  but  the  patient  had  recov- 
ered. 

Dr.  Manges,  in  closing  the  discussion,  said  that  the 
text-books  would  lead  us  to  suppose  that  the  reaction 
of  these  patients  to  the  disease  was  a  sluggish  one,  but 
in  practice  this  was  not  the  case;  the  reaction  to  the 


December  ii,  1897] 


MEDICAL    RECORD. 


863 


fever  in  the  typical  cases  was  as  obvious  as  in  younger 
persons.  In  the  atypical  cases  only  was  this  sluggish 
reaction  noted.  The  pulmonary  disorder  would  be 
most  likely  to  attract  attention.  It  was  probable  that 
partial  immunity  was  conferred  by  a  previous  attack 
of  the  disease  earlier  in  life,  yet  one  of  his  patients 
had  had  a  prolonged  attack  of  typhoid  fever  when 
seventeen  years  of  age,  and  had  lost  the  immunity 
conferred  by  it  to  such  an  extent  that  his  attack  late 
in  life  was  a  typical  one. 

Diabetes  Mellitus  and  Its  Treatment ;  Remarks 
Based  on  Clinical  Experience. — Dr.  Henry  S.  St.^rk 
read  this  paper  (see  page  844). 

Diabetes  is  Physiology  Perverted. — Dr.  Willia.m 
H.  Thomson  said  that  he  looked  upon  diabetes  as  a 
unique  disease,  because  it  was  the  disease  which  de- 
parted from  the  great  principle  that  "  pathology  is 
physiology  under  difficulties."  Diabetes,  instead  of 
being  "  physiology  under  difficulties,"  was  '"  physiolog)' 
itself  perverted."  It  was  a  disease  in  which  bread, 
instead  of  being  the  staff  of  life,  became  itself  the 
direct  means  of  crippling,  if  not  destroying  life.  The 
only  other  disease  approaching  diabetes  in  this  respect 
was  Graves'  disease,  because  here  butcher's  meat  was 
as  poisonous  as  saccharine  food  was  to  the  diabetic. 
For  years  the  liver  had  been  e.xamined  again  and  again 
in  all  cases  of  diabetes  to  discover  some  pathological 
change,  and  of  late  years  the  pancreas  had  come  for- 
ward in  this  connection,  but  in  a  most  tantalizing  way. 
There  were  unquestionably  some  cases  of  diabetes  in 
which  the  destructive  change  had  occurred  in  the 
pancreas,  yet  in  others  there  would  be  typical  and  even 
fatal  diabetes  without  any  pathological  change  being 
demonstrable  in  the  pancreas.  Traumatisms  to  the 
spine  and  cerebral  traumatism  had  been  known  over 
and  over  again  to  be  the  beginning  of  a  history  of  dia- 
betes, and  injuries  to  the  abdomen,  particularly  blows 
over  the  liver,  had  been  known  to  give  rise  to  a  typical 
and  even  fatal  traumatic  diabetes.  The  fact  that  the 
carbohydrates  were  absolutely  necessary  as  fuel  for 
muscular  function,  Dr.  Thomson  said,  was  one  of  the 
greatest  discoveries  of  modem  physiology.  The  dis- 
covery that  there  was  a  difference  bet\veen  the  thermo- 
genic functions  of  muscles  and  their  contractile  func- 
tions, and  that  the  thermogenic  function  was  the 
important  one,  at  once  showed  that  it  was  the  o.xidation 
of  the  carbohydrates,  mainly  in  the  muscular  system, 
that  kept  up  the  animal  heat.  The  question  then  arose : 
May  there  not  be  some  fault  in  that  system  which 
will  account  for  the  symptoms  of  glycosuria?  This 
singular  disease,  diabetes,  demonstrated  to  us  more 
conclusively  than  anything  else  the  imperfections  in 
our  knowledge  of  physiology.  The  reader  of  the  paper 
had  spoken  of  glycosuria  as  though  it  were  not  dia- 
betes, and  of  albuminuria  as  though  it  were  not 
Bright's  disease.  He  did  not  believe  in  physiological 
albuminuria  or  glycosuria,  for  he  had  repeatedly  noted, 
in  records  extending  over  many  years  in  private  prac- 
tice, that  a  very  slight  glycosuria  or  albuminuria  had 
eventually  developed  into  diabetes  and  Bright's  dis- 
ease respectively.  Glycosuria  was  the  first  step  toward 
diabetes,  and  the  degree  of  severity  varied  very  greatly 
in  different  individuals.  Our  clinical  experience 
taught  us  that  there  was  a  very  great  difference  in  the 
disease  depending  upon  certain  factors.  Foremost 
among  these  he  would  put  age.  The  younger  the  per- 
son, the  worse  the  prognosis.  The  only  cases  in  which 
he  was  not  very  much  disturbed  by  finding  glycosuria 
were  those  of  silvery-headed  men  and  women.  Those 
who  became  diabetic  under  twenty  years  of  age  usu- 
ally exhibited  a  very  uncontrollable  form  of  the  dis- 
ease. He  was  firmly  of  the  opinion  that  it  was  not  the 
sugar  that  caused  the  fatal  explosions  of  diabetes  any 
more  than  it  was  the  urea  in  Bright's  di-sease  that  gave 
rise  to   the  symptoms    of   uraemia,    but    that   certain 


changes  occurred  in  the  sugar  and  allied  bodies  through 
the  operation  of  toxins.  These  toxins  were  responsi- 
ble for  the  development  of  acetonuria.  He  was  always 
alarmed  when  a  diabetic  patient  had  a  sweetish  breath. 
Another  important  and  closely  related  clinical  fact 
was  the  disappearance  of  the  urinary  pigments.  We 
had  much  yet  to  learn  regarding  the  significance  of  pale 
urine  in  both  diabetes  and  Bright's  disease. 

Opiates  Should  be  the  Last  Resort. — He  had 
always  maintained  that  opium  should  be  the  verj'  last 
resort  in  diabetes  instead  of  being  the  sheet  anchor,  as 
many  physicians  seemed  to  believe.  The  preparations 
of  opium  should  be  used  in  diabetes,  not  as  curative 
agents,  but  rather  as  a  means  of  smoothing  the  path 
to  the  grave.  His  treatment  of  diabetes  consisted  in 
the  systematic  use  of  intestinal  antiseptics,  and  he 
was  especially  strenuous  on  this  point  if  he  feared  the 
super\-ention  of  coma.  He  also  believed  in  the  ad- 
ministration of  arsenic,  cod-liver  oil,  and  iron,  and 
sometimes  of  phosphorus  and  alkalies.  He  main- 
tained that  these  agents  were  curative  in  a  certain 
proportion  of  cases,  particularly  in  those  developing 
after  forty  years  of  age.  He  was  always  pleased  to 
learn  that  a  diabetic  patient  was  gouty,  because  this 
materially  improved  the  prognosis. 

Diet  Should  Not  be  too  Exclusive. — He  was,  how- 
e\er,  in  hearty  accord  with  the  reader  of  the  paper 
regarding  the  matter  of  diet.  If  under  a  diet  contain- 
ing carbohydrates  we  found  that  the  patient  was  not 
losing  weight  or  developing  special  diabetic  symptoms, 
no  matter  if  the  sugar  still  persisted,  we  were  justified 
in  keeping  up  such  a  diet.  He  had  seen  harm  done 
by  a  too  rigid  e.xclusion  of  carbohydrates  from  the  diet 
of  diabetics.  Bread  could  be  taken  in  the  form  of 
vety  thin  slices,  so  thoroughly  browned  as  to  be  more 
than  toasted.  In  his  experience  potatoes  had  not  been 
nearly  so  injurious  to  diabetics  as  the  cereals.  He 
would  much  rather  have  a  diabetic  take  a  moderate 
amount  of  potato  than  the  special  diabetic  breads. 
The  question  of  prognosis  should  be  determined  by 
an  experiment  to  ascertain  the  extent  to  which  the 
sugar  diminishes  under  a  rigid  exclusion  of  carbohy- 
drates for  a  period  of  three  days.  If  the  proportion  of 
sugar  remained  relatively  high,  the  prognosis  was  cer- 
tainly far  more  serious  than  when  the  reduction  in  the 
quantity  was  more  prompt. 

Premonitory  Symptoms  of  Diabetes. — Regarding 
the  early  symptoms  of  diabetes,  the  speaker  said  that 
the  great  majority  of  diabetics  had  sugar  in  the  urine 
only  intermittently  at  the  outset.  For  this  reason  the 
urine  should  be  repeatedly  examined  if  a  patient  e.xhib- 
ited  a  decided  form  of  nervous  dyspepsia,  or  a  condi- 
tion of  nerv-ousness  formerly  unknown  to  the  individ- 
ual, or  a  tendency  to  pharyngeal  catarrh,  or  when  there 
was  a  tendency  to  cramps  in  the  calves  of  the  legs  in 
the  early  morning.  This  last  symptom  was  also  com- 
mon in  gout  and  in  chronic  endarteritis,  but  when  these 
conditions  could  be  excluded  the  symptom  was  one 
strongly  presumptive  of  diabetes.  Under  such  cir- 
cumstances the  physician  should  examine  both  the 
morning  and  evening  urine  for  several  days. 

Take  Warning  from  a  Family  History  of  Gout 
or  Obesity. — Dr.  Walter  Mendelson  said  that  we 
had  had  impressed  upon  us  the  fact  that  diabetes  was 
really  the  symptom  complex  arising  from  several 
causes.  Clinically  we  could  distinguish  two  varieties 
— those  cases  which  were  very  amenable  to  treatment, 
and  those  which  progressed  more  or  less  rapidly  in 
spite  of  all  treatment.  In  glycosurics  one  would  usu- 
ally find  a  histoty  of  obesity  or  gout  in  the  patient  or 
in  other  members  of  the  immediate  family.  This  in- 
dicated a  general  state  of  faulty  metabolism.  The 
reader  of  the  paper  had  very  rightly  insisted  upon  the 
fact  that  when  there  was  such  a  family  history  special 
care  should  be  taken  regarding  diet  and  exercise  in 


864 


MEDICAL    RECORD. 


[December  ii,  1897 


early  life.  After  one  had  once  become  quite  obese, 
it  was  very  hard  to  get  rid  of  the  condition.  He 
agreed  with  Dr.  Thomson  that  a  person  who  exhibited 
transient  glycosuria  was  always  in  a  condition  to 
develop  true  diabetes  on  very  slight  provocation. 

The  Body  Weight  a  Guide  in  the  Treatment.— 
In  the  treatment  we  should  never  aim  to  cut  off  the 
carbohydrates  entirely;  this  might  be  an  ideal  treat- 
ment, but  we  should  ever  keep  in  mind  that  the  patient 
is  not  a  chemical  laboratory.  Instead  of  estimating 
the  urea,  one  could  be  guided  in  the  treatment  by 
weighing  the  patient.  He  had  obseri-ed  no  strikingly 
good  results  from  the  administration  of  such  drugs  as 
codeine.  A  sustaining  treatment  was,  however,  of 
importance,  and  for  this  reason  he  was  in  the  habit  of 
prescribing  plenty  of  butter — it  was  usually  more 
agreeable  to  the  patient  than  cod-liver  oil.  Another 
important  point  in  the  management  of  these  cases  was 
to  shield  the  patient  from  undue  mental  or  physical 
strain. 

Alkalies  Most  Valuable. — Dr.  Max  Einhorn  was 
disposed  to  make  a  distinction  between  transient  gly- 
cosuria and  diabetes — in  other  words,  sugar  might 
appear  in  the  urine  from  slight  causes,  and  yet  not 
give  rise  to  actual  disease.  For  e.xample,  the  inges- 
tion of  an  unusual  quantitj-  of  sugar  sometimes  causes 
glycosuria.  The  severity  of  the  aft'ection  could  be 
fairly  well  gauged  by  the  quantity  of  sugar  excreted 
in  the  twenty-four  hours.  Severe  cases  might  be 
found  even  at  an  advanced  age.  While  there  were 
apparently  no  specifics  for  this  disease,  the  prevailing 
opinion  seemed  to  be  in  favor  of  the  administration  of 
some  preparation  of  opium  in  those  cases  in  which 
sugar  was  e.xcreted  in  large  quantity  and  was  not  con- 
trolled by  the  dietetic  treatment.  Of  all  the  recog- 
nized remedies  for  diabetes,  it  seemed  to  him  that  the 
alkalies  were  probably  the  most  valuable.  It  was 
generally  admitted  that  diabetic  coma  could  sometimes 
be  averted  by  the  free  use  of  alkalies.  He  did  not 
think  it  was  harmful  to  exclude  starchy  foods  for  a 
short  time,  but  as  a  rule  these  foodstuffs  should  not  be 
entirely  prohibited.  In  his  experience  the  cereals  were 
better  than  potatoes,  because  they  contain  both  albu- 
minoid and  starchy  food;  even  untoasted  bread  had 
been  well  borne.  The  main  point  was  not  to  allow  too 
large  a  quantity  of  starchy  food  at  any  one  time. 
Vegetables  should  be  given  freely,  especially  lettuce. 

Phosphatic  Diabetes. — Dr.  Andrew  H.  Smith 
asked  the  reader  of  the  paper  whether,  in  those  cases  in 
which  he  had  found  no  sugar  and  the  urine  was  of  high 
specific  gravity,  he  had  thought  of  the  presence  of  a 
large  quantity  of  phosphates.  There  was  a  variety  of 
diabetes  in  which  there  was  no  sugar,  but  a  large 
quantity  of  water  was  voided  and  a  great  excess  of 
phosphates.  It  was  so  well  known  that  diabetes  fre- 
quently had  its  origin  in  great  mental  shock,  or  in  a 
condition  of  prolonged  mental  strain,  that  we  should 
give  this  very  serious  consideration.  He  had  known 
bank  presidents  and  others  in  responsible  positions  to 
be  very  markedly  diabetic.  When  there  was  a  well- 
grounded  suspicion  of  diabetic  inheritance,  the 
younger  members  of  the  family  should  not  be  encour- 
aged to  select  vocations  in  which  there  was  likely  to 
be  much  mental  strain. 

Locomotive  Engineers  Peculiarly  Liable  to  Dia- 
betes— Dr.  Smith  said  tiiat,  having  learned  tliat  loco- 
motive engineers  very  frequently  became  diabetic,  he 
had  applied  to  the  actuary  of  the  Brotherhood  of  Loco- 
motive Engineers  for  statistics,  and  had  learned  from 
this  otiicir.l  that  lliis  disease  was  three  times  more  fre- 
quent in  those  following  this  occupation.  This  was 
not  surprising  when  one  retlected  upon  the  constant 
strain  under  which  the  work  of  a  locomotive  engineer 
is  done.  He  called  to  mind  the  case  of  a  gentleman 
who  became  diabetic  from  the  moment  of  a  severe 


fright  occasioned  by  a  runaway  accident.  The  worst 
thing  we  could  do  was  to  allow  a  diabetic  patient  to 
watch  his  urine  and  keep  a  record  of  its  changes,  as 
this  furnished  a  constant  additional  shock  to  the 
ner\'ous  system. 

Dr.  Stark,  in  closing  the  discussion,  said  that  his 
experience  would  not  warrant  his  becoming  alarmed 
if  the  urine  contained  some  sugar  after  considerable 
horseback  or  bicycle  riding,  and  particularly  if  the 
next  day  there  was  no  longer  any  sugar  in  the  urine. 
He  was  not  familiar  with  the  subject  of  phosphatic 
diabetes  referred  to  by  Dr.  Smith.  In  the  case  that 
he  had  cited  in  the  paper  the  urine  had  been  con- 
stantly acid  in  reaction  and  free  from  sugar,  nor  did 
it  present  the  characteristics  of  phosphatic  urine. 


SECTION    ON    GENERAL   SURGERY. 

Monday  Evening,  November  8,  i8gj. 

W.  W.  Van  Arsdale,  M.D.,  Chairman. 

The  Lorenz  Method   in   Congenital  Dislocations. — 

Dr.  Royal  Whitman  presented  cases  of  congenital 
dislocations  treated  by  the  Lorenz  method.  Dr. 
Whitman  said  that  double  congenital  dislocations 
caused  great  lordosis  and  wabbling  gait.  Single  con- 
genital dislocation  caused  lordosis  and  wabbling  gait, 
but  not  so  great  as  the  double.  He  presented  several 
illustrations  of  the  condition  in  this  deformity.  There 
had  been  practically  no  cures  in  this  country-  until 
recent  years.  Lorenz  and  others  found  that  the  true 
resistance  lay  in  the  anterior  fibres  of  the  muscles 
drawing  the  head  of  the  femur  up  and  back,  and  to 
restore  the  normal  condition  it  was  necessary  to  over- 
come this  resistance.  This  was  done  by  extension  by 
means  of  weights,  by  extreme  abduction  and  retention. 
The  head  of  the  femur,  having  been  drawn  down  over 
the  rim  of  the  acetabulum,  it  was  pushed  forward  to 
dilate  the  capsule,  fixed,  and  thus  the  child  was  allowed 
to  walk.  The  first  case  was  that  of  a  child  with  dou- 
ble congenital  dislocation,  whose  left  leg  had  been 
replaced  with  great  force,  but  it  had  been  necessary  so 
to  bandage  the  limb  that  it  was  not  convenient  for  the 
child  to  walk,  and  so  that  portion  of  the  treatment  had 
been  omitted.  The  fifth  case  was  one  that  was  seven 
years  old,  and  it  had  required  a  weight  of  twenty-five 
to  thirty-five  pounds  for  four  weeks  before  the  opera- 
tion, and  when  the  bone  went  back  it  was  with  a 
tremendous  jar. 

Conservative  Surgery  on  the  Arm. — Dr.  Robert 
T.  Morris  presented  two  cases.  Dr.  Marablat,  of 
Elizabeth,  had  operated  on  the  first  patient  presented. 
The  man  had  been  shot  in  the  elbow  by  a  tow  wad 
discharged  from  a  shotgun  at  close  range.  A  four- 
inch  incision  was  made  and  the  damaged  structures 
were  removed,  embracing  the  olecranon,  a  sharp  piece 
of  the  ulna,  and  the  end  of  the  humerus.  The  radius 
remained  principally  intact.  As  a  result  of  the  oper- 
ation the  arm  was  shorter  than  the  other,  but  the  man 
had  good  use  of  it  and  the  movements  were  good. 
The  second  case  was  that  of  a  man  whose  arm  had  been 
run  between  a  wheel  and  a  belt,  destroying  all  the 
structure  about  midway  between  the  wrist  and  the  el- 
bow, except  a  strip  of  skin  and  the  ulnar  artery.  The 
radius  and  ulna  were  resected,  all  the  parts  sutured, 
and  now  the  patient  had  good  sensation,  could  use  the 
arm  at  ordinary  work,  could  play  the  violin,  and  had 
a  good  grip  in  the  hand.  Dr.  Alorris  spoke  of  a  case 
in  which  he  grafted  three  fingers  on  to  a  young  wo- 
man's hand,  and  the  operation  was  successful.  After 
a  short  time  the  patient  had  good  sensation  in  the 
grafted  fingers,  but  from  sensitiveness,  feeling  she  was 
an  object  of  curiosity,  she  asked  him  to  amputate  the 
fingers.     He  did  so,  and    preser\-ed    them,   and  was 


December  ii,    1897] 


MEDICAL    RECORD. 


865 


anxious  to  have  an  expert  dissect  tlieni  and  find  «  here 
the  ner^-e  supply  was  derived  from. 

Simple  Fracture  of  the  Clavicle  Treated  by  Im- 
mediate Suture. — Dr.  E.  !M.  Foote  presented  a  case 
of  this  nature.  The  patient  was  a  boy  who  had  his 
clavicle  broken  by  a  piece  of  machinery  with  no  in- 
jury to  the  soft  parts  of  importance.  He  was  seen  two 
days  after  the  accident.  The  fracture  could  not  be  re- 
duced, and  four  days  after  the  injury  an  incision  was 
made  ;  the  bones  were  exposed,  but  even  then  they  could 
not  be  brought  into  position.  The  bones  were  drilled, 
then  brought  together,  and  sutured  with  kangaroo  su- 
ture. The  periosteum  had  been  torn  from  a  small  part 
of  the  end  of  one  fragment;  this  suppurated  a  little, 
but  recovered,  and  now  the  union  was  strong.  Dr. 
Foote  said  the  operation  was  not  a  common  one  in 
this  country.  Spencer  reported  a  few  cases,  and  one 
case  was  reported  in  the  Annals  of  Surgery  last  year, 
but  in  Europe  a  number  of  cases  had  been  reported. 
The  results  were  good.  Many  cases  of  broken  clavicle 
healed  w  ithout  any  treatment,  but  this  method  might 
be  employed  with  good  results  in  cases  in  which  the 
fracture  was  irreducible  or  would  not  stay  reduced,  or 
in  which  there  was  interposition  of  muscle  between  the 
fragments,  compound  fracture,  or  hematoma.  It  might 
be  employed  as  a  secondary  operation  in  case  of  pres- 
sure upon  a  nerve.  Most  operators  had  used  silver 
wire  and  some  silk,  but  there  was  no  special  reason  why 
an  absorbable  suture  should  not  be  used. 

Amputation  of  the  Hip. — Dr.  A.  M,  Phelps  pre- 
sented the  case.  The  patient  was  a  young  woman. 
An  aunt  had  tuberculosis  and  a  paternal  uncle  died  of 
phthisis.  Her  illness  began  three  years  ago.  She 
had  abscess  of  the  left  hip,  which  was  enormously 
large.  The  veins  of  the  abdomen  were  enlarged,  the 
lungs  showed  crepitant  rales  on  the  right  side,  the 
patient  was  extremely  anajmic,  and  it  seemed  that 
operation  in  her  condition  was  dangerous.  Her  liver 
was  enlarged,  the  urine  contained  casts  and  pus,  and 
all  indications  pointed  to  amyloid  degeneration  of 
the  liver  and  kidneys.  On  account  of  the  extreme 
anaemia  the  blood  was  forced  from  the  extremities 
into  the  trunk,  and  a  bloodless  operation  was  per- 
formed, with  the  exception  that  the  parts  were  so  soft 
and  destroyed  by  the  disease  that  the  obturator  artery 
could  be  only  partially  controlled.  When  the  joint 
was  cut  down  on,  it  was  found  that  the  disease  had 
amputated  the  head  of  the  femur.  The  specimen 
presented  showed  that  the  bone  was  very  much  de- 
stroyed, contained  sequestra,  and  had  been  amputated 
by  the  disease  process.  The  patient  was  as  well 
after  anajsthesia  as  before,  but  the  ligaments  on  the 
extremities  could  be  removed  only  one  at  a  time  or 
the  patient  would  faint.  By  putting  on  flannel  ban- 
dages and  drawing  tight  and  removing  from  one  extrem- 
ity at  a  time,  the  last  one  was  removed  at  the  end  of 
twenty-four  hours.  After  the  operation  the  albumin 
began  to  disappear  from  the  urine,  the  liver  to  dimin- 
ish in  size,  the  veins  to  become  less  prominent,  and 
at  the  present  time  the  patient  was  in  good  condition. 
The  case  was  interesting  on  account  of  the  bloodless 
operation,  the  effect  of  the  operation  upon  the  casts 
and  pus  in  the  urine,  and  the  decrease  in  size  of  the 
liver,  suggesting  the  possible  effect  of  operation  upon 
amyloid  conditions.  Dr.  Phelps  thought  it  was  im- 
portant in  major  operations,  when  there  was  danger 
from  I0.SS  of  blood,  to  drive  the  blood  into  the  trunk. 
He  thought  the  bloodless  operation  had  reduced  the 
mortality  from  ver\'  great  to  less  than  twenty  per  cent. 

Operation  for  Hernia Dr.  Sa.muel  Lloyd  pre- 
sented a  man  ujjon  whom  he  had  operated  for  hernia, 
and  presented  photographs  taken  before  the  operation. 
These  showed  the  hernia  to  be  immense.  It  had  been 
down  for  twenty  years,  and  was  so  large  that  the  man 
could  hardly  get  about.     At  the  operation  it  became 


necessary  to  invert  the  patient,  on  account  of  the  press- 
ing out  of  the  colon  and  coils  of  small  intestine. 
The  man  had  not  suffered  any  trouble  on  that  side 
since  the  operation,  but  it  was  interesting  to  note  that 
six  months  later  there  appeared  a  hernia  on  the  oppo- 
site side,  which  showed  that  the  side  on  which  the 
operation  had  been  made  was  quite  strong. 

Amputation  of  the  Breast. — Dr.  Howard  Lilien- 
THAL  presented  a  case  which  he  thought  was  interest- 
ing from  a  diagnostic  point.  The  case  was  that  of  a 
woman  who  had  nursed  a  child,  and  three  months  after 
weaning  had  a  swelling  of  the  breast.  He  had  ampu- 
tated the  breast,  because  he  thought  it  was  all  affected. 
Examination  confirmed  the  diagnosis  of  tuberculosis. 
No  other  organ  was  affected.  The  opening  was  very 
slow  in  healing,  one  place  remaining  open  for  four- 
teen months. 

Carcinoma  of  the  Breast. — Dr.  Percy  R.  Bolton 
showed  a  woman  in  whom  both  breasts  were  aft'ected 
by  carcinoma.  Dr.  Tuttle  had  removed  one,  leaving 
the  pectoral  muscles,  and  he  had  later  removed  the 
other  and  had  also  removed  the  corresponding  pecto- 
ral muscle.  It  was  not  easy  to  detect  any  difference 
in  the  strength  of  the  two  sides. 

Dr.  Charles  X.  Dowd  presented  a  case  to  show 
the  good  result  obtained  in  removing  both  pectoral 
muscles  in  operation  for  carcinoma  of  the  breast. 
The  statement  had  been  made  that  the  arm  was  weak 
after  removal  of  the  pectoral  muscles,  but  this  was  not 
true  in  the  case  presented,  for  the  woman  worked  right 
along  and  suffered  no  inconvenience — in  fact,  did  not 
notice  any  difference  in  that  side. 

Dr.  Morris,  in  discussing  the  case  of  fracture  of 
the  clavicle  presented  by  Dr.  Foote,  said  that  by  mak- 
ing a  very  small  incision  it  was  possible  to  drill  a  hole 
in  one  of  the  bones,  and,  making  a  groove  in  the  other, 
fasten  them  by  means  of  a  trowel  pin  and  get  nice 
union.  He  wished  to  congratulate  Dr.  Lloyd  on  the 
good  result  in  such  a  large  hernia. 

Dr.  J.  P.  Tuttle  said  he  was  much  interested  in 
Dr.  Lloyd's  case,  and  wished  to  ask  if  he  found  any 
plates  of  cartilage  in  the  scrotum.  He  then  presented 
a  specimen  of  a  large  cartilaginous  plate  which  he  had 
found  in  tlie  scrotum  in  connection  with  a  large  her- 
nia. It  was  situated  between  the  gut  and  the  sac,  and 
the  gut  had  to  be  dissected  oft'  from  it. 

Dr.  a.  Ernst  Gallant  said  he  would  like  to  men- 
tion the  case  of  a  woman  who  had  a  hernia  larger  than 
the  one  in  the  case  presented.  The  woman  was  sixty- 
two  years  old,  and  had  been  working  since  the  opera- 
tion, two  years  ago.  He  had  found  her  suffering  with 
distention  of  the  bowels  after  operation,  and  the  nurse 
using  enema  and  other  means  to  get  the  bowels  to 
move.  The  house  surgeon  was  going  to  operate  to  re- 
lieve the  condition,  when  the  speaker  relieved  the  case 
by  means  of  massage.  Beginning  at  the  ileo-catcal 
region,  he  massaged  the  abdomen  in  the  direction  of 
the  colon,  and  in  a  short  time  the  bowels  were  relieved 
and  the  patient's  suffering  ended.  In  conneLtion  with 
the  case  presented  by  Dr.  Phelps,  he  mentioned  hav- 
ing seen  an  operation  in  the  Royal  Infirmary,  Edin- 
burgh, in  which  it  was  not  possible  to  control  the 
hemorrhage  except  by  pressure  upon  the  abdominal 
aorta,  but  this  procedure  worked  admirably. 

A  Report  of  Thirty-Two  Cases  of  Cancer  of  the 
Breast. — Dr.  Charles  N.  Dowd  read  a  paper  on  this 
subject.  The  purposes  of  the  paper  were  two:  ist, 
To  investigate  the  benefits  to  be  derived  from  the 
operation;  and  2d,  to  illustrate  the  technique.  It 
could  be  safely  stated  that  the  mortality  was  less  than 
twenty-five  per  cent.,  and  the  benefits  to  be  derived 
from  the  operation  were  great,  as  the  patient  was  re- 
lieved from  the  severe  suffering  and  had  the  hope  that 
there  would  be  no  recurrence  of  the  disease.  He  had 
operated  on  twenty-nine  patients  since   1893.     Only 


866 


MEDICAL    RECORD. 


[December  ii,  1897 


six  of  these  had  been  operated  on  three  years  ago.  Of 
these  four  were  alive  and  two  died  of  metastasis  of  the 
lung.  These  patients  were  operated  on  by  V'olkmann's 
method.  Of  the  remaining  patients  of  the  series,  fifty- 
two  per  cent,  were  now  alive,  and  most  of  the  deaths 
were  from  metastasis.  The  most  interesting  question 
was  how  extensively  the  tissues  should  be  removed  in 
these  operations.  Halsted  and  Willy  Meyer  had  ad- 
vocated the  removal  of  the  pectoral  muscles,  and  since 
that  time  this  operation  had  been  extensively  used.  It 
had  been  urged  against  this  operation  that  it  was  a 
mutilation  of  the  patient,  and  that  there  was  a  loss  of 
povi'er  in  the  arm.  He  had  operated  on  twenty-six  pa- 
tients by  this  method,  and  all  had  good  use  of  the  arm, 
although  there  might  be  a  slight  loss  in  adduction, 
though  imperceptible  to  the  patient.  The  other  mus- 
cles acted  to  make  up  for  the  loss  of  the  pectoral 
muscles.  Sometimes  there  was  oedema  from  removal 
of  the  longer  veins,  but  this  was  temporary.  It  was 
said  too  that  there  was  increase  of  danger,  but  this 
was  unimportant.  He  had  but  one  death,  and  that 
was  in  a  woman  seventy-three  years  of  age  and  ver}' 
weak.  Some  surgeons  advised  the  removal  of  the 
pectoral  muscles  in  the  far-advanced  cases  and  leaving 
them  in  the  more  recent  ones,  but  this  seemed  to  him 
unadvisable,  for  the  greater  the  hope  of  saving  the  case 
the  more  thorough  the  operation  should  be,  if  any  dif- 
erence  was  made.  Some  argued  that  the  glands  from 
the  posterior  triangle  should  be  removed.  One  could 
not  well  argue  against  this,  but  it  was  an  important 
question.  As  to  the  removal  of  the  skin,  the  operation 
should  be  to  remove  diseased  tissue  and  not  to  make 
flaps  for  plastic  operations.  The  method  of  dressing 
was  of  great  help  in  healing  the  wound.  The  stretch- 
ing apart  could  be  relieved  by  putting  on  a  rubber 
bandage  and  drawing  the  parts  toward  each  other  from 
the  sides.  If  there  was  trouble  in  covering  the 
wound,  skin  grafting  was  the  best.  It  seemed  a  mat- 
ter of  importance  to  leave  the  subscapular  nerve. 
Cases  of  local  or  recent  recurrence  were  ones  which 
showed  the  necessity  for  the  most  of  the  technique. 
Patients  who  had  suffered  very  severely  were  much 
relieved  by  the  clearing  out  of  the  cancer  and  by 
proper  dressing,  and  became  comfortable,  usually 
getting  out  of  bed  about  the  sixth  day  and  leaving  the 
hospital  in  twenty-one  days. 

In'discussing  Dr.  Dowd's  paper.  Dr.  Bolton  said 
he  hoped  to  hear  some  evidence  in  favor  of  the  Hal- 
sted operation  over  other  operations.  He  had  heard 
that  patients  lost  the  use  of  the  arm  to  some  extent 
when  the  pectorals  were  removed.  He  thought  recur- 
rence came  oftener  from  the  skin  than  from  any  other 
portion,  which  showed  that  the  superficial  lymphatics 
were  most  involved. 

Dr.  Meyer  said  he  was  much  interested  in  the 
paper.  He  had  advocated  primarily  cutting  the  ten- 
don of  the  pectoralis  major,  and  then  the  minor,  and 
turning  these  muscles  down  and  dissecting.  Halsted's 
method  meant  cutting  the  muscles  from  the  sternal 
end  and  splitting  and  working  toward  the  attachment 
to  the  humerus.  He  thought  the  two  methods  were 
quite  different.  Halsted  took  three  or  four  hours  for  an 
operation.  He  thought  it  best  to  remove  both  pecto- 
ral muscles.  He  had  had  nineteen  or  twenty  cases, 
and  had  never  seen  one  in  which  it  was  necessary  to 
use  a  saline  solution  for  intravenous  injection.  The 
assistant  should  not  draw  the  muscle  hard.  In  refer- 
ence to  Dr.  Bolton's  question  as  to  the  result  upon  the 
strength  of  the  arm,  he  thought  in  every  instance  the 
result  was  better  when  the  nnuscles  were  removed. 
Patients  were  not  troubled  with  cedema  and  could  soon 
move  the  arms.  He  thought  the  pectorals  should  be 
removed,  especially  as  there  were  sometimes  infected 
glands  below  the  pectoralis  minor. 

Dr.  Lilienthal  said  he  was  in  favor  of  this  opera- 


tion, but  the  removal  of  the  pectoral  muscles  must  be 
accompanied  by  some  loss  of  power;  nevertheless,  the 
loss  was  not  so  great  but  it  was  counterbalanced  by 
the  increased  thoroughness  of  the  removal  of  tissue 
that  might  cause  future  trouble.  He  would  suggest 
to  Dr.  Dowd  the  use  of  zinc  plaster  instead  of  rubber, 
as  the  latter  was  more  likely  to  cause  irritation  and 
produce  sores. 

Dr.  Morris  said  the  coraco-brachialis  and  deltoid 
carried  on  the  work  when  the  pectoral  muscles  were 
removed.  In  some  very  fat  pat'ents,  when  there 
was  a  deep  hole  it  could  be  filled  in  with  clots 
of  blood,  but  these  must  be  saved  in  saline  solution 
while  the  operation  was  going  on.  In  cases  in  which 
there  was  suffering  from  oedema,  alternate  dipping  in 
cold  and  hot  water  would  give  relief.  Some  of  his 
patients  suffered  from  neuralgia,  but  authors  did  not 
say  much  about  that  condition. 

Dr.  S.\muel  Lloyd  thought  there  was  little  doubt 
that  the  complete  operation  was  the  best.  He  favored 
beginning  in  the  axilla,  cutting  the  tendons  of  the 
muscles  first,  and  cleaning  the  axilla  without  drawing 
on  the  muscles.  This  also  avoided  working  in  can- 
cerous tissue  toward  the  lymphatics  of  the  axilla.  It 
seemed  important  to  him  not  to  make  tension  across 
the  axilla.  He  preferred  to  make  flaps  from  contigu- 
ous skin. 

The  chairman  called  for  Dr.  H.  A.  Ochsner,  of 
Chicago,  who  said  he  had  come  for  the  purpose  of 
being  instructed,  and  he  had  been.  The  profession  of 
his  city  felt  jealous  of  the  New  Yorkers,  because  they 
had  such  a  handsome  library,  elegant  meeting-place, 
and  brilliant  organization. 

The  chairman  also  called  for  Dr.  \V.  J.  Mays,  of 
Rochester,  Minn.,  who  said  he  did  not  come  to  make 
remarks  upon  the  valuable  papers.  In  the  operation 
leaving  the  pectorals  there  seemed  to  be  more  pain 
from  contraction  than  in  the  Meyer  operation.  The 
paper  showed  that  the  best  result  could  be  expected 
when  the  operation  was  performed  in  the  early  stages. 

Dr.  Dowd  said  he  had  not  used  blood  clots  in  fill- 
ing in  the  wounds.  As  to  resulting  neuralgia,  he  had 
seen  a  good  many  cases  of  it,  but  they  did  not  last  very 
long^ — some  perhaps  for  a  few  months,  none  ever  more 
than  a  year. 

Bottini's  Method  for  the  Galvano-Caustic  Radical 
Treatment  of  Hypertrophy  of  the  Prostate,  with 
Demonstration  of  Instruments. — Dr.  ^^■ILLv  Meyer 
read  a  paper  on  this  subject.  He  said  the  surgeon 
found  it  difficult  to  advise  the  best  method  of  radical 
operation  for  hypertrophy  of  the  prostate  gland,  for 
there  were  many  operations  and  the  difficult}"  was  in 
selecting  the  better  one.  This  was  especially  so  if 
the  patient  was  over  fifty  years  of  age  and  refused  to 
have  the  testicles  removed  or  the  vasa  deferentia  re- 
sected. Whether  prostatectomy  should  be  tried,  or  an 
effort  made  to  influence  the  size  by  ligating  the  internal 
iliac  arteries,  or  to  establish  suprapubic  fistula  with  per- 
manent drainage  of  the  bladder,  was  a  question.  He 
had  seen  patients  get  along  very  well  with  a  suprapubic 
fistula,  but  others  suffered  a  great  deal.  We  were  in- 
debted to  Dr.  A.  Freudenberg,  of  Berlin,  for  calling  at- 
tention to  Bottini's  galvano-caustic  radical  operation. 
It  was  strange  that  so  excellent  an  operation  should  be 
used  by  only  one  man  for  twenty-two  years,  and  that  man 
the  author  of  it,  when  the  operation  had  been  presented 
to  the  profession  by  the  author.  It  was  probably  due 
to  the  fact  that  the  instrument  was  made  in  Italy, 
and  Bottini  was  ever  expecting  to  make  improvements. 
Now  the  instrument  was  made  by  W.  A.  Hirschmann, 
of  Berlin,  and  its  manufacture  could  be  relied  upon. 
Bottini  first  operated  in  1875,  using  what  is  called  the 
"  cauterizzator"  and  incisor,  in  the  shape  of  a  catheter 
of  medium  calibre,  with  short  beak,  carrying  a  porcelain 
disc  on  a  platinum  plate  about  three-fourths  of  an  inch 


December  ii,  1897] 


MEDICAL    RECORD. 


867 


long.  With  this  plate,  made  redhot  with  the  electric  cur- 
rent, he  cauterized  the  prostate  thoroughly  at  different 
spots,  and  if  necessary  repeatedly.  When  the  eschar 
•was  pushed  off,  improvement  began.  Sometimes  it 
was  thirty  days  before  the  patient  felt  the  change. 
Two  years  later  he  published  five  successful  cases. 
Then  he  used  only  the  incisor,  which  removed  the 
mechanical  obstruction  to  tlie  outflow  of  the  urine  by 
slowly  burning  a  groove  or  grooves  through  the  same 
and  not  by  superficial  destruction.  Dr.  Meyer  pre- 
sented this  instrument  to  the  society.  It  was  made 
■with  a  male  and  female  arm ;  the  shank  contained  a 
platinum  knife,  about  five-eighths  of  an  inch  long, 
which  left  the  groove  of  the  female  arm  on  turning 
an  Archimedean  screw  at  the  outer  end  of  the  instru- 
ment. A  scale  attached  regulated  the  length  of  the 
groove  to  be  cut.  There  was  also  a  cooling  apparatus 
which  prevented  injury  to  the  bladder  or  urethra.  The 
operation  should  be  preceded  by  cystoscopic  examina- 
tion. This  would  exclude  the  possibility  of  vesical  cal- 
culi, and  then  it  was  possible  to  diagnose  the  presence 
of  a  median  lobe  to  the  prostate.  Dr.  Meyer  said  he 
had  done  this,  as  operation  afterward  confirmed  the 
diagnosis,  and  he  mentioned  it  because  Dr.  Fuller 
maintained  in  the  section  ongenito-urinary  surgery  that 
it  was  not  possible.  The  technique  of  Bottini's  method 
was  simple.  The  bladder  was  emptied  and  irrigated; 
the  posterior  urethra  locally  anesthetized  w-ith  cocaine 
by  injecting  one  and  one-half  drachms  of  a  one  or  two 
per  cent,  solution  directly  into  the  posterior  urethra  or 
into  the  anterior,  and  gentle  massage  applied  over  the 
perineum.  Five  minutes  later  the  operation  could  be 
performed.  The  bladder  must  be  thoroughly  emptied 
before  introducing  the  cautery,  for  the  cautery-  is  then 
much  more  effective.  It  would  be  found  in  many  cases 
that  the  gland  surrounded  the  internal  urethral  orifice 
like  a  collar.  Having  tested  the  instrument  to  see  if  it 
is  perfect  in  all  respects  and  the  cooling  apparatus  all 
right,  Bottini  burns  three  grooves — the  first  toward  the 
symphysis,  another  just  opposite  directly  back  toward 
the  rectum,  and  one  through  the  lateral  lobe  that  is  the 
larger.  Dr.  Meyer  described  the  operation  in  detail. 
The  operation  lasts,  according  to  the  number  and 
length  of  the  grooves  cut,  about  five  minutes.  The 
patient  su.ffers  but  little  inconvenience  during  or  after 
the  operation.  It  had  been  performed  without  co- 
caine, and  the  patient  said  he  preferred  it  to  examina- 
tion with  the  stone  searcher.  Soon  after  the  operation 
the  patient  generally  complains  of  a  burning  sensation 
on  passing  water.  Most  of  them  remain  permanently 
out  of  bed,  the  general  reaction  being  almost  nil.  If 
the  bladder  has  been  carefully  irrigated  there  is  no 
rise  in  temperature.  In  eighty  cases  Bottini  had  not 
seen  a  serious  hemorrhage,  and  advises  against  the 
permanent  catheter.  The  effect  is  often  immediate. 
Even  patients  eighty  years  old,  slaves  to  the  catheter, 
commence  to  void  the  contents  spontaneously  a  short 
time  after  operation.  Dr.  Meyer  mentioned  some  of 
the  theoretical  objections  to  the  operation,  but  expe- 
rience had  proven  these  unimportant.  A  careful  ob- 
server had  never  seen  a  recurrence  in  twenty-two 
years.  The  writer  gave  a  short  rtfsuj/u'  oi  the  opera- 
tions performed  by  different  physicians  and  their 
results.  He  thought  the  operation  should  be  given  a 
fair  trial,  and  if  it  should  really  prove  to  be  of  such 
great  value  in  the  greater  number  of  cases  of  this 
dreadful  disease,  it  would  become  a  duty  to  place  it 
first  among  the  radical  operations  for  hypertrophy  of 
the  prostate  gland. 

Dr.  Alexander  discussed  Dr.  Meyer's  paper  at 
length.  He  thought  there  was  doubt  as  to  the  exten- 
sive use  of  an  instrument  with  which  it  was  necessary 
to  work  in  the  dark.  All  his  remarks  were  necessarily 
theoretical,  for  he  had  not  had  any  experience  with 
the  instrument.     He  believed  that  there  were  many 


cases  in  which  it  was  not  so  much  a  question  of  oper- 
ation as  scientific  surgical  catheterization. 

Dr.  Meyer  said  there  had  been  reported  only  two 
accidents.  These  were  hemorrhage.  With  the  per- 
fection of  the  instrument  as  it  was  now  made  there 
was  apparently  no  danger  in  the  operation. 


THE    MEDICAL    SOCIETY  OF   THE    COUNTY 
OF   NEW   YORK. 

Stated  Meeting,  November  22,  iSg^. 
Arthur  M.  Jacobus,  M.D.,  President. 

Address  of  the  President-Elect. — Dr.  A.  M.  Jacobus 
delivered  this  address,  and,  in  doing  so,  presented  an 
outline  of  what  should  be  the  work  of  the  society  for 
the  new  year.  He  said  that  he  was  heartily  in  favor 
of  the  dispensary  bill  of  last  year,  if  slightly  changed, 
and  believed  that  if  physicians,  like  the  members  of 
other  professions,  would  get  together  and  stand  by  one 
another  the  result  would  be  sure.  But  the  desired 
reform  could  be  secured  only  by  legal  enactment. 

Regulations  for  Midwives — As  the  Society  of  Med- 
ical Jurisprudence  at  the  meeting  this  month  had  ap- 
pointed a  committee  to  investigate  this  matter,  he  sug- 
gested that  the  committee  on  legislation  of  the  County 
Medical  Society  should  confer  with  this  committee, 
and  report  back  to  the  society. 

Public  Hygiene — Touching  upon  other  matters 
relating  to  public  health,  the  speaker  suggested  the 
establishment  of  water-closets  at  drug  stores  or  other 
places,  at  suitable  intervals  throughout  the  city;  the 
advisability  of  carefully  looking  into  the  claim  that 
the  asphalt  pavements  were  injurious  to  health  by  forc- 
ing noxious  gases  into  houses;  and  the  sanitary  aspect 
of  the  long  school  hours  for  young  children,  with  desks 
not  adjustable  to  the  varying  heights  of  the  little 
pupils. 

A  Fighting  Society. — In  reviewing  some  of  the 
past  work  of  the  society,  the  speaker  said  that  certain 
persons  had  referred  slightingly  to  the  County  Medical 
Society,  dubbing  it  "  a  fighting  society."  As  the  soci- 
ety had  fought  persistently  for  the  honor  of  the  medical 
profession  and  for  the  public  good,  by  endeavoring  to 
suppress  quackery,  this  assertion  should  be  taken  as  a 
compliment;  a  society  that  did  not  have  some  of  this 
kind  of  fighting-blood  in  it  was  not  of  much  account. 

The  society  began  a  series  of  prosecutions  in  1880, 
shortly  after  the  passage  of  the  law  against  irregular 
medical  practitioners.  Since  1880,  the  counsel  fees 
and  other  costs  of  these  prosecutions  had  amounted  to 
$36,567.39;  the  fines  imposed  amounted  to  $21,585, 
and  the  fines  collected  to  $14,160.  This  left  a  large 
annual  deficit  in  this  account.  Why  the  profession 
should  be  made  to  bear  the  cost  of  prosecuting  irregu- 
lar practitioners  of  medicine  was  hard  to  understand, 
but  he  has  been  informed  that  if  this  work  were 
dropped  by  the  society,  it  would  not  be  taken  up  by 
the  public  prosecutor. 

More  Members  Needed. — Unless  more  money  was 
at  their  disposal,  this  good  work  must  cease.  The 
necessary  funds  could  be  procured  only  by  increasing 
the  annual  dues  or  adding  five  hundred  members.  He 
was  in  favor  of  holding  out  the  olive  branch  to  those 
of  special  schools,  providing  they  would  abrogate  their 
sectarian  principles,  as  many  of  them  had  already 
done.  The  society  should  also  welcome  the  return  of 
those  who  left  the  society  many  years  ago  because  of 
a  wrangle  over  the  phrasing  of  a  series  of  bylaws. 

Standing  Committees. — The  following  committees 
were  then  appointed  :  Committee  on  Ethics — Drs.  Rob- 
ert A.  Murray,  Chairman ;  William  Balser,  Malcolm 
McLean,  Robert  Milbank,  and  J.  Lee  Morrill.     Com- 


868 


MEDICAL    RECORD. 


[December  ii,  1897 


mittee  on  Hygiene — Drs.  J.  Henry  Fruitnight,  Chair- 
man; E.  S.  Bullock,  Augustus  Caille,  Grace  Peckham 
Murray,  and  Bernard  Sachs.  Committee  on  Legislation 
— Drs.  Ale.xander  Hadden,  Chairtnan  ;  James  H.  Bur- 
tenshaw,  Thomas  J.  Hillis,  John  B.  Huber,  Maurice  J. 
Lewi,  Charles  E.  Lockwood,  Evarts  M.  Morrell, 
Thomas  E.  Satterthwaite,  George  F.  Shrady,  Theodore 
K.  Tuthill,  Simon  J.  Walsh,  and  Wickes  Washburne. 
Committee  on  Prize  Essays — Drs.  Simon  Marx,  Chair- 
man; Robert  H.  M.  Dawbarn  and  George  C.  Free- 
bom.  Auditing  Committee — Drs.  Robert  Campbell, 
Chairman  ;  and  Hobart  Cheesman. 

A  Special  Committee. — On  motion  of  Dr.  Satter- 
THWAITE,  the  following  were  appointed  on  a  committee 
to  consider  the  relations  of  the  board  of  health  to  the 
medical  profession :  Drs.  T.  E.  Satterthwaite,  Alexan- 
der Hadden,  A.  Jacobi,  H.  G.  Piffard,  and  Andrew  H. 
Smith. 

On  motion  of  Dr.  Piffard,  the  question  of  regulat- 
ing midwives  was  referred  to  the  committee  on  legis- 
lation, and  the  other  matters  alluded  to  in  the  presi- 
dent's address  were  referred  to  the  committee  on 
hygiene. 

(Resolutions  on  the  death  of  Dr.  Avery  were  then 
adopted,  and  ordered  sent  to  the  medical  journals.) 

Prize  Essay :  A  Contribution  to  the  Pathogenesis 
and  Etiology  of  Diabetes  Mellitus. — Dr.  Heinrich 
Ster.v  was  the  author  of  this  essay.  The  essay  will 
appear  in  full  in  a  future  issue  of  The  Medical 
Record. 


NEW    YORK    COUNTY    MEDICAL    ASSOCI.\- 
TION. 

Stated  Meeting,  November  75,  i8gj. 

].    Blake    White,    M.D.,    Vice-President,    in    the 
Chair. 

A  Study  of  the  Nares  and  Pharynx  in  a  Case  of 
Haemophilia. — Dr.  Seymour  Oppenheimer  read  a 
paper  with  this  title.  He  said  that  the  case  to  be 
reported  presented  a  peculiar  symptom  group  which 
rendered  the  classification  exceedingly  difficult. 

The  patient  was  a  woman,  thirt)'-two  years  of  age, 
whom  he  had  first  seen  in  December,  1896.  A  younger 
brother  had  suffered  from  frequent  and  copious  nasal 
hemorrhages  during  childhood,  and  had  been  acciden- 
tally killed  before  reaching  adult  life.  The  patient 
herself  had  been  married  eleven  years,  and  had  one 
boy,  who  was  in  good  physical  condition.  She  had 
enjoyed  good  health  up  to  five  years  ago,  when  she  had 
had  "  rheumatism  of  tlie  heart."'  Four  years  ago  it  was 
noticed  that  the  thyroid  gland  was  increasing  in  size, 
but  it  gave  no  particular  trouble,  and  medical  advice 
was  not  sought.  Later  on  she  developed  exophthal- 
mos, together  with  almost  all  of  the  usual  symptoms 
of  exophthalmic  goitre.  In  July,  1896,  she  first  no- 
ticed a  few  small  dark  spots  on  her  thighs.  These 
disappeared  in  a  few  weeks.  She  then  became  verj' 
nervous  and  complained  of  frontal  headache,  which 
was  relieved  by  the  occurrence  of  profuse  epistaxis. 
She  next  had  an  attack  of  angina  pectoris,  which  was 
followed  by  some  indigestion.  These  attacks  were 
repeated  at  intervals,  and  the  same  succession  of  phe- 
nomena was  usually  observed.  The  purpuric  eruption 
usually  recurred  about  once  in  two  weeks.  Sometimes 
the  epistaxis  and  purpura,  esiJecially  the  former,  would 
replace  the  menstrual  flow.  All  of  these  attacks  came 
on  without  apparent  exciting  cause.  A  number  of 
times  the  epistaxis  began  in  the  night,  while  she  was 
asleep.  The  attacks  of  epistaxis  were  prolonged,  and 
in  one  instance  lasted  for  ten  hours.  The  purpuric 
spots  were  not  elevated  above  the  skin,  and  were  at 
first  of  a  pink  or  red  color,  gradually  becoming  black. 


then  yellow,  and  finally  fading  away.  The  eruption 
was  most  abundant  on  the  inner  surface  of  the  thighs. 

When  she  was  first  seen  by  the  speaker  her  appear- 
ance was  that  of  a  chlorotic  patient,  and  she  then  had 
some  purpuric  spots  on  her  body.  The  turbinated  bod- 
ies were  found  sclerosed,  particularly  the  middle  turbi- 
nate. After  the  nose  was  cleansed  a  minute  ulceration 
was  seen  on  the  left  side  of  the  septum,  over  the  situa- 
tion of  the  anterior  septal  arterj'.  The  mucous  mem- 
brane of  the  septum  was  congested  and  macerated,  and 
the  septum  was  thickened.  On  removing  the  blood 
coagula,  it  was  seen  that  the  tissues  beneath  were  the 
seat  of  a  general  sclerosis.  There  w'ere  at  this  time  no 
petechial  spots  on  these  tissues.  As  a  rule,  the  blood 
would  ooze  from  the  nose,  instead  of  escaping  in  a 
stream.  In  subsequent  attacks  of  epistaxis  it  was  found 
that  the  blood  seemed  to  ooze  from  the  inferior  and 
middle  turbinated  bodies,  and  from  the  septum,  par- 
ticularly from  the  areas  covered  with  cavernous  tissue. 
The  bleeding  did  not  come  from  one  or  two  points,  but 
was  comparable  to  perspiration  in  the  manner  of  its 
escape.  The  hsmoglobin  percentage  was  fift}-eight 
As  she  was  a  poor  woman,  she  could  not  be  kept  in 
bed  and  perfectly  quiet.  The  only  drugs  that  seemed 
to  be  of  any  avail  were  inunctions  of  the  biniodide  of 
mercury  and  tincture  of  belladonna,  pushed  up  to 
twent}-  minims  at  a  dose.  In  Januar)'  the  petechial 
eruption  appeared  for  the  first  time  on  the  posterior 
pharyngeal  wall.  She  steadily  improved  during  the 
spring,  the  attacks  of  epistaxis  and  the  purpuric  erup- 
tions becoming  less  and  less  frequent. 

The  diagnosis  seemed  to  lie  between  exophthalmic 
goitre,  purpura  hasmorrhagica,  peliosis  rheumatica,  and 
hamophilia,  although  practically  it  was  between  h<e- 
mophilia  and  purpura  hasmorrhagica.  In  the  latter 
the  bleeding  from  the  mucous  membrane,  the  speaker 
said,  was  usually  very  severe,  and  was  seen  in  young 
and  delicate  persons.  This  patient  was  an  adult  who 
had  been  strong  and  well  developed  previous  to  the 
eruption  and  the  epistaxis.  She  appeared  ancemic  only 
when  the  attacks  of  epistaxis  were  very  frequent,  and 
the  blood  count  rapidly  returned  to  the  normal.  The 
oozing  from  the  erectile  tissue  seemed  to  indicate  a 
marked  constitutional  dyscrasia,  and  it  was  specially 
worthy  of  note  in  this  case,  because  hemorrhage  in 
cases  of  nasal  sclerosis  was  quite  rare.  Before  the  oc- 
currence of  the  hemorrhage  there  would  be  a  feeling  of 
fulness  in  the  head,  and  especially  over  the  bridge  of 
the  nose.  On  several  occasions  the  nasal  cavities  were 
inspected  shortly  before  an  attack  of  epistaxis,  and  it 
was  then  found  that  the  tissues  became  more  and  more 
turgid  until  the  onset  of  the  hemorrhage.  The  blood 
was  watery,  coagulated  very  slowly,  and  contained  a 
small  jjercentage  of  coloring  matter  and  a  large  num- 
ber of  red  cells.  When  epistaxis  was  the  result  of  a 
constitutional  vice  it  was  likely  to  be  bilateral,  in  con- 
tradistinction to  the  unilateral  hemorrhage  so  com- 
monly observed  when  the  cause  was  traumatic. 

Nosebleed  in  General.— Referring  to  epistaxis  in 
general,  the  speaker  said  that  shortly  before  an  attack 
of  nosebleed  there  was  not  uncommonly  a  peculiar 
pruritus,  involving  especially  the  anterior  nares. 
This  itching  was  peculiar,  in  tliat  the  scratching  did 
not  afiord  relief,  and  tlie  pruritus  was  constant  and 
resisted  all  the  usual  remedial  measures.  In  a  few 
cases  it  had  seemed  to  him  to  be  coincident  with  an 
e.vcess  of  uric  acid  in  the  system.  In  the  control  of  a 
severe  attack  of  epistaxis  he  had  found  it  convenient 
to  cleanse  the  nose  with  a  spray  of  peroxide  of  hydro- 
gen under  fifteen  pounds'  air  pressure,  and  then  astrin- 
gents or  the  cautery  could  be  easily  applied  if  the 
source  of  the  bleeding  was  found  to  be  located  ante- 
riorly. It  had  seemed  to  him  that  in  a  general  way 
the  character  of  the  bleeding  indicated  its  source. 
Thus  if  the  blood  were  bright  red,  not  clotted,  and 


December  1 1,  1897] 


MEDICAL    RECORD. 


869 


flowed  in  a  steady  stream,  the  anterior  septal  artery 
was  probably  the  'source  of  the  hemorrhage.  If  the 
hemorrhage  occurred  in  drops,  it  was  probably  from 
the  septal  or  turbinal  tissues.  If  the  blood  seemed  to 
flow  more  into  the  pharynx,  it  would  usually  be  found 
to  come  from  the  extreme  posterior  end  of  the  middle 
turbinated  body.  Hemorrhage  from  the  phar)-ngeal 
mucosa  was  most  commonly  due  to  such  traumatism  as 
the  lodgment  of  foreign  bodies. 

Dr.  F.  J.  QuiNLAX  thought  that  many  even  alarming 
hemorrhages  from   the   nose  were  purely  local,   and 
hence,  instead  of  blindly  packing  the  nasal  passages 
with  tampons,  the   parts   should  be   inspected  under 
suitable  illumination,   and,  if  possible,  the  bleeding 
point  discovered  and  the  hemorrhage  controlled.     He 
believed,  with  the  reader  of  the  paper,  that  many  cases 
of  epistaxis  were  due  to  reflex  or  constitutional  causes, 
and  sometimes  to  vicious  habits.     He  had  known  it  to 
be  associated  with  masturbation  and  other  conditions 
of  genital  irritation.     Accompanying  such  irritation  it 
would    often    be    found  that  the    nasal    tissues    were 
unduly  engorged.     Again,  adenoid  vegetations  consti- 
tuted an  important  factor  in  the  etiology  of  the  epis- 
ta.\es  of  childhood.     The  part  played  by  atrophic  rhi- 
nitis had  not  been  especially  emphasized  in  the  paper. 
It  was  almost  instinctive  for  ever)-  person  to  make  an 
effort  to  remove  anything  causing  obstruction  in  the 
nasal  passages,   and   therefore    violent   blowing   and 
picking  of  the  nose  were  often  the  exciting  causes  of 
nose  bleed.      In  tiiese  cases  there  was  frequently  an 
atheromatous  condition  of  the  vessels  which  predis- 
posed to  hemorrhage.      Another  source  of  hemorthage 
was  an  engorgement  of  the  large  plexus  of  vessels  at 
the  base  of  the  tongue — that  condition  which  Lennox 
Browne  had  denominated  "  throat  piles."     This  plexus 
was  frequently  impinged  upon  by  the  epiglottis  and 
the  circumvallate  papilla  at  each  act  of  deglutition. 
Again,  the  posterior  tips  of  the  turbinated  bodies  not 
infrequently  became  varicose.     When  this  condition 
was   marked,  he    thought  one   should   hesitate   about 
using  a  galvano-cauter)-  or  any  escharotic  which  might 
break  down  the  already  partially  disorganized  vascu- 
lar condition  of  the  parts.     The  three  cases  of  haemo- 
philia that  he  had  seen   had  been  traceable  to   some 
organic  condition — in  one  case  to  incipient  Bright's 
disease,  in  another  to  cirrhosis  of  the  liver,  and  in  the 
third  to  malignant  disease.      He  had  never  seen  a  case 
of  pure  and  simple  hemophilia.     There  was  no  better 
agent  for  causing  a  shrinkage  of  the  tissues  in  the  nose 
than  cocaine.     This  application  would,  therefore,  not 
onlv  produce  anaesthesia,  but  would  diminish  the  hem- 
orrhage and  clear  the  field  for  observation.     After  this 
had  been  done,  it  would  be  found  in  probably  eighty- 
five  per  cent,  of  all  cases  of  epistaxis  that  the  source 
of  the  hemorrhage  was  the  little  tubercle  of  the  sep- 
tum, almost  on  the  floor  of  the  nose,  and  that  it  could 
be  easily  controlled  by  pressure  with  a  small  pledget 
of  cotton  or  by  touching  with  a  cr}-stal  of  ch-omic  acid 
or  with  nitrate  of  silver  on  the  end  of  a  probe.     The 
application  of  the  galvano-cauter)-  was  sometimes  dan- 
gerous, because  it  broke  down  the  already  weakened 
blood-vessels.     A    great  cause    of  epistaxis  was   an 
irtegularit>-  of  the  nasal  septum  and  the  consequent 
obstruction  to  the  return  of  venous  blood. 

Ur.  T.  I-  CoNCA.XNON  said  that  he  had  treated  over 
one  hundred  cases  of  epistaxis,  and  believed  that  over 
seventy-five  per  cent,  of  them  had  originated  from  the 
septum.  But  the  hemorrhage  usually  came  from  a 
number  of  small  openings  scattered  over  the  septum, 
so  that  the  application  of  a  crystal  of  nitrate  of  silver 
or  of  chromic  acid  would  not  be  suflicient.  The  cau- 
ter\-  was  in  his  hands  the  most  successful  application. 
Some  of  the  worst  cases  of  bleeding  he  had  ever  met 
with  had  occurred  in  women  at  the  climacteric  period, 
and  the  bleeding  seemed  to  come  from  the  middle  tur- 


binate in  most  instances.  The  application  of  a  ten- 
per-cent  solution  of  cocaine  would  shrink  up  the  parts 
sufficientlv  to  enable  the  physician  readily  to  find  and 
control  the  bleeding  point.  It  would  be  noticed  some- 
times that  there  was  an  alternate  congestion  of  the  tur- 
binates. The  books  stated  that  this  was  a  symptom  of 
catarrh,  but  his  experience  had  led  him  to  believe  that 
it  was  a  perfectly  normal  condition. 

Dr.  George  Tucker  Harrison  said  that  probably 
more  cases  of  epistaxis  were  seen  by  general  practi- 
tioners than  by  specialists.  In  the  worst  cases  that  he 
had  met  with  he  had  invariably  succeeded  in  control- 
ling the  bleeding  by  packing  the  nares  with  iodoform 
gauze.     It  was  infinitely  better  than  cotton. 

Successful  Operation'  on  an  Enormous  Inguinal 
Hernia. — Dr.  A.  Erxest  Gallant  reported  a  case  of 
int'uinal  hernia  of  enormous  size  upon  which  he  had 
operated.  He  said  that  these  cases  had  formerly  been 
considered  inoperable,  but  two  successful  cases  of  this 
kind  had  been  reported  in  this  city  during  the  past 
year. 

In  April,  1895,  a  woman  of  si.xtj-two  years  had  come 
under  his  care.  She  stated  that  twent}-six  years  ago 
she  had  felt  a  snap  and  that  something  seemed  to  give 
way  in  the  left  groin.  A  small  protruding  mass  was 
noticed,  and  this  mass  increased  in  size  with  the  birth 
of  each  of  her  four  children.  On  several  occasions 
the  hernia  had  become  incarcerated,  and  at  the  time 
of  her  admission  to  the  Lebanon  Hospital  she  was 
almost  bedridden.  A  photograph  was  presented  show- 
ing the  condition  of  the  patient  before  operation.  The 
hernial  mass  extended  half-way  down  to  the  knees. 

A  large  incision  was  made,  extending  up  on  to  the 
groin.  The  hernia  was  made  up  of  two-thirds  of  the 
transverse  colon,  all  of  the  descending  colon,  and 
considerable  omentum.  The  wall  of  tlie  sac  was  quite 
thin.  The  reduction  was  ver}^  difficult,  the  hernia  be- 
ing of  such  long  standing  and  the  abdomen  quite  flat. 
SLxteen  inches  of  the  small  intestine  was  dissected 
with  some  difficult}-  from  the  lower  part  of  the  sac. 
Owing  to  the  thickness  of  the  ring  it  did  not  seem 
probable  that  the  ordinarj-  Bassini  operation  would  be 
successful,  and  he  had  accordingly  stitched  the  inter- 
nal oblique,  transversalis,  and  peritoneum  to  the  inside 
of  the  abdomen,  just  at  the  angle  of  Poupart's  liga- 
ment, and  had  then  stitched  the  layers  of  Poupart's 
ligament  to  the  external  oblique  and  the  fascia  above, 
and  had  closed  the  skin.  The  skin  incision  reached 
down  to  the  lower  part  of  the  labium  majus  and  up  for 
a  distance  of  twelve  inches. 

Dangerous  Distention  of  Bowel  Relieved  by  Mas- 
sage.— The  patient  rallied  fairly  well  from  the  opera- 
tion, but  on  the  second  day  there  was  considerable 
distention  of  the  bowel.  She  was  given  a  saturated 
solution  of  Epsom  salts  at  short  internals,  and  also 
enemata,  but  without  result,  and  on  the  third  morning 
he  had  been  notified  that  the  patient  was  suffering  from 
intestinal  obstruction  and  that  an  operation  seemed  to 
be  demanded.  The  speaker  said  that  in  July,  1896, 
he  had  published  a  plan  of  treating  cases  of  intestinal 
distention,  which  consisted  in  removing  the  dressings 
and  applying  systematic  massage  over  the  colon.  This 
procedure  was  tried  in  the  case  under  consideration, 
and  in  a  few  minutes  a  gurgling  in  the  bowel  was 
heard.  The  pain  rapidly  diminished,  so  that  the  mas- 
sage could  be  carried  on  with  more  pressure.  .A.fter 
about  fifteen  minutes  there  was  a  sudden  e.xplosion  of 
gas,  and  from  that  time  on  the  patient  steadily  conva- 
lesced. After  leaving  the  hospital  this  woman  was 
able  to  do  washing  and  ironing,  and  attend  to  her 
household.  He  had  seen  her  last  in  March,  1897,  and 
she  had  then  been  in  excellent  condition.  The  result 
seemed  to  him  specially  satisfactory  in  view  of  the  fact 
that  this  woman  had  been  an  invalid  and  bedridden 
for  manv  vears.     He  believed  the  good  result  to  have 


870 


MEDICAL    RECORD. 


[December  11,  1897 


been  due  to  the  method  of  suture  and  also  to  the  sim- 
ple and  ready  method  by  which  the  great  distention  of 
the  intestine  had  been  relieved  without  further  opera- 
tive interference.  Dr.  Gallant  said  that  about  six 
weeks  ago  he  had  done  a  hysterectomy,  and  had  had  to 
remove  two  inches  of  the  abdominal  wall  because  of 
extensive  cicatricial  tissue.  Within  forty-eight  hours 
the  patient  began  to  suffer  a  great  deal  from  abdominal 
distention.  She  was  subjected  to  this  massage  for  fif- 
teen minutes,  with  marked  relief  and  benefit.  The 
first  case  in  which  he  had  tried  this  method  had  been 
one  in  which  the  distention  had  existed  for  five  days. 
After  twenty  minutes'  rubbing  the  gas  had  been  passed 
freely,  and  the  patient  had  gone  on  to  recovery.  In 
addition  to  performing  massage  in  this  manner,  the 
patient  should  be  turned  on  one  side  to  favor  the  es- 
cape of  the  confined  gas.  Cathartics  did  not  meet  the 
indications  in  these  serious  cases,  but  this  simple 
method  would  be  found  both  safe  and  effective. 

Useful  Genito-Urinary  Instruments. — Dr.  Ferdi- 
nand C.  Valentine  exhibited  a  number  of  genito- 
urinary instruments,  which  he  said  would  be  found  as 
serviceable  to  the  general  practitioner  as  to  the  spe- 
cialist. The  first  one  was  a  convenient  modilicalion  of 
the  Guyon  syringe.  The  second  was  a  P'rench  urinal, 
so  constructed  that  the  distal  end  of  a  retained  cathe- 
ter was  kept  constantly  immersed  in  an  antiseptic  solu- 
tion, and  the  urine  overflowed  from  time  to  time  into 
a  larger  compartment.  The  third  instrument  was  a 
modification  of  his  own  apparatus  for  irrigating  the 
urethra  and  bladder.  He  had  found  it  more  conven- 
ient to  substitute  a  metallic, shield  for  the  glass  one. 
The  soft-rubber  tubing  from  the  reservoir  now  passed 
through  a  split  metallic  tube,  and  by  simply  sliding  a 
ring  back  and  forth  this  split  tube  was  made  to 
expand  and  contract,  and  by  pressure  on  the  inclosed 
rubber  tubing  it  perfectly  and  delicately  controlled  the 
flow  of  fluid  through  the  latter.  This  modification 
had  been  found  a  very  decided  improvement  on  the 
older  form  of  stopcock  used  with  this  apparatus. 


©orrespDudcnce. 


OUR   LONDON    LETTER. 

J  CErom  our  Special  Correspondent.) 

ROYAL  COLLEGE  OF  SURGEONS,  ANNUAL  MEETING — AN- 
OI'HER  UNIVERSITY  SCHEME— M.  CALOT  AT  THE  CLIN- 
ICAL SOCIETY,  HIS  TREATMENT  OF  POTT's  DISEASE — 
MEDICAL  SOCIETY,  CRETINISM,  COLEY's  INJECTIONS — 
JUBILEE    OF     AN/ESTHESIA — THE    TYPHOID     EPIDEMICS 

THE      LATE      SURGEON      o'GRADY — DEATH      OF      DR. 

CAGNEY — ROENTGEN    SOCIETY. 


No 


nbcr 


1S97. 


Sir  William  MacCormac,  as  president,  took  the 
chair  at  the  annual  meeting  of  fellows  and  members  of 
the  Royal  College  of  Surgeons  yesterday  afternoon. 
He  pointed  out  some  of  the  more  important  items 
in  the  report  of  the  council,  most  of  which  have 
been  mentioned  in  this  correspondence  as  the  mat- 
ters to  which  they  had  reference  occurred.  He  also 
defended  the  statement  issued  on  the  occasion  of  the 
plebiscite  of  fellows  as  to  the  representation  of  mem- 
bers. This  question  was  now  brought  before  the  meet- 
ing in  distinct  resolutions,  on  which  the  speeches  re- 
sembled many  that  have  gone  before.  By  tw'enty-three 
to  two  a  resolution  was  carried  to  the  effect  that  the 
recent  vote  of  fellows  cannot  be  regarded  as  a  final 
expression  of  opinion.  Then  by  thirty-seven  to  one 
tiie  meeting  repudiated  the  claim  of  the  council  to 
represent  the  members  as  well  as  fellows,  .md  demanded 
the  franchise  for  members. 

The  meeting  then  considered  the  iiuestion  of  medi- 


cal-aid societies,  on  which  the  sister  college  in  Dublia 
has  recently  issued  a  statement  against  those  who  ac- 
cept office  under  disgraceful  conditions.  Whether  the 
corporations  generally  will  follow  remains  to  be  seen. 

A  movement  has  been  going  on  for  some  time  to 
organize  a  teaching  university,  and  a  fresh  scheme  is- 
about  to  be  launched.  It  is  a  federation  similar  to 
that  which  failed  to  secure  the  indorsement  of  Parlia- 
ment. It  would  leave  the  University  of  London  as  it 
is,  and  be  itself  a  teaching  one  only.  It  is  proposed  to 
call  it  the  University  of  Westminster.  The  weak  point 
appears  to  me  to  include  a  faculty  of  theology.  It  may 
not  be  easy  to  get  the  government  to  adopt  so  risky  a 
proposal. 

Dr.  Calot  met  with  a  reception  by  the  Clinical  Soci- 
ety which  ought  to  disperse  any  doubts  he  may  have- 
entertained  as  to  the  cordiality  of  English  professional 
feeling.  There  was  a  good  audience  to  welcome  the 
pioneer  of  the  revival  of  a  mode  of  treatment  of  Pott's- 
disease  by  immediate  reduction  of  the  deformity,  and 
even  those  who  had  most  misgivings  as  to  the  value  of 
the  method  were  as  hearty  in  their  reception  as  those 
who  were  quite  convinced.  Messrs.  Jones,  Tubby,  and 
Murray  all  had  cases  to  relate,  but  as  the  discussion, 
was  adjourned  I  will  postpone  any  consideration  of 
this  to  make  room  for  some  of  M.  Calot's  remarks,, 
who  spoke  in  French  and  was  listened  to  with  close: 
attention. 

He  said  that  in  treating  Pott's  disease  the  sole  object 
he  had  was  to  correct  the  deformity.  To  attack  the  palsy 
or  congestive  abscess  is  to  change  a  disease  which  has- 
ninety-five  per  cent,  of  cures  to  one  with  ninety-five 
per  cent,  of  deaths.  The  prudent  surgeon's  attitude 
was  that  observed  in  knee  or  hip  disease.  Hitherto 
the  results  of  immediate  reduction  had  been  very  favor- 
able and  he  looked  for  further  improvement  in  the  fu- 
ture. Out  of  six  hundred  cases,  of  which  notes  had 
been  furnished  him  from  various  countries,  the  fatality 
of  one  per  cent,  might  compare  well  with  other  recog- 
nized operations.  If,  besides,  he  had  met  with  three 
cases  of  paralysis  following  operation,  it  should  be  re- 
membered that  in  Pott's  disease  paralytic  complica- 
tions occur  in  about  one  in  five  cases.  Further,  he  had 
eight  cases  in  which  paralysis  was  relieved  by  his- 
operation.  The  following  cases  were  not  suitable  for 
the  treatment:  children  in  an  advanced  state  of  ca- 
chexia, those  suffering  from  cough,  those  w  ith  conges- 
tive abscesses  or  with  fistula,  and  those  w  ith  hunchback 
of  long  standing  which  resist  traction  of  from  fifty  to- 
eighty  kilograms. 

M.  Calot  then  detailed  the  treatment  he  adopts  in 
cases  of  long-standing  ankylosed  deformity.  Though 
it  is  possible,  he  liolds,  to  reduce  them  by  traction,  it 
is  more  surgical  to  lay  bare  the  adhesions  and  proceed 
to  break  them  down  by  a  plan  varying  with  their  posi- 
tion. Remote  accidents,  M.  Calot  said,  are  less  to  be 
feared  than  after-operations  on  the  knee.  When  there 
is  default  of  union,  the  latter  can  be  brought  about 
artificially  by  denuding  the  lamina;  at  the  parts  where 
they  are  in  contact,  and  placing  periosteum  over  the 
point  of  desired  junction.  He  had  provoked  artificial 
union  on  ten  occasions  and  was  half  inclined  to  recom- 
mend it  as  a  routine  procedure.  The  plaster  appa- 
ratus he  uses  was  then  described.  It  is  left  on  fron\ 
three  to  five  months  if  the  child  is  doing  well,  and  may 
have  to  be  renewed  once  or  even  twice.  The  ultimate 
duration  of  treatment  varies.  In  acute  cases  it  is  the 
duration  of  Pott's  disease  itself,  one  or  two  years;  \n 
curvature  representing  a  past  Pott's  disease  it  might 
not  be  more  than  from  four  to  eight  months. 

At  the  Medical  Society's  meeting  Dr.  Colman  showed 
a  girl  of  nine  and  a  half  years  as  an  example  of  partial 
cretinism.  She  was  just  tliree  feet  high  and  weighed 
only  two  stones  two  pounds.  Stunted  growth,  absence 
of  anv  accessible  thvroid,  fat  mases  in  the  anterior  tri- 


December  ii,  1897] 


MEDICAL    RECORD. 


871 


angles  of  the  neck,  thick  lips,  and  pufify  eyelids  were 
the  signs  of  cretinism.  Lordosis  and  prominent  ab- 
domen were  also  observed  when  the  girl  came  under 
notice  last  June.  There  was,  however,  entire  absence 
of  the  usual  nervous  symptoms,  and  the  girl  was  intel- 
ligent, bright  looking,  and  had  reached  the  second 
standard  at  school.  She  was  put  on  three  grains  of 
dried  thyroid  e.xtract,  and  in  the  four  months  has  grown 
two  and  a  half  inches,  and  her  appearance  has  become 
less  characteristic.  Dr.  Colman  suggested  there  might 
be  an  accessory  thyroid  wliich  sufficed  for  the  nutrition 
of  the  brain  but  not  for  the  body.  The  president  re- 
marked that  there  might  be  other  cases  of  partial  cre- 
tinism which  it  would  be  well  to  observe  and  treat 
with  thyroid. 

Dr.  Carr  showed  a  girl  who  had  lost  what  he  de- 
scribed as  the  typical  cretinoid  appearance  which  she 
presented  in  February,  1896,  when  she  was  five  years 
old.  Treated  with  thyroid  she  now  presents  a  healthy 
aspect,  goes  to  school,  and  gets  on  there.  Her  weight 
has  increased  from  twenty-four  and  a  half  to  thirty- 
seven  pounds,  and  her  height  from  thirty  to  thirty- 
seven  and  a  half  inches. 

At  the  same  meeting  Mr.  Mansell  MouUin  showed 
two  cases  in  which  inoperable  tumors  had,  he  said, 
almost  disappeared  after  repeated  injections  of  Coley's 
fluid.  One  tumor  was  in  the  groin,  the  other  in  the 
abdomen.  They  were  considered  sarcomatous,  but 
there  was  no  proof  of  their  nature.  They  were  cer- 
tainly not  gummata.  If  they  had  been  inflammatory, 
they  would  almost  certainly  have  suppurated.  Mr. 
Cheyne  remarked  that  the  treatment  seemed  only  to 
benefit  spindle-celled  sarcomata.  Dr.  Colman  said  he 
had  examined  two  tumors  post  mortem,  one  ten  days 
after  Coley's  injections,  the  other  ten  months  after. 
In  the  first  he  found  a  ca\ity  containing  two  drachms 
of  yellow  fluid,  composed  of  broken-down  cells;  in  the 
older  case  an  ordinary  cicatrix  at  the  site  of  injec- 
tion. 

The  Society  of  Anesthetists  held  a  conversazione  last 
night  to  commemorate  the  jubilee  of  the  introduction 
of  ana-sthesia.  A  number  of  interesting  exhibits  con- 
nected with  the  subject  were  shown,  among  which  per- 
haps the  most  noteworthy  were  those  of  Mr.  George 
Foy,  of  Dublin,  whose  '"History  of  Anaesthetics"  will 
be  familiar  to  some  readers. 

The  epidemics  of  typhoid,  although  diminishing,  are 
still  occupying  our  serious  attention.  In  Maidstone 
the  number  of  cases  notified  has  reached  1,848,  with 
some  130  deaths.  At  Lynn  the  medical  officer  of 
health  reports  that  there  has  been  exaggeration  in  the 
papers,  and  there  is  an  abatement  of  the  epidemic,  only 
one  death  having  taken  place  this  week.  But  the  total 
cases  have  reached  406,  a  large  number  out  of  a  popu- 
lation under  19,000,  and  another  death  occurred  yes- 
terday, being  the  thirty-fifth.  The  Belfast  report  is  13 
new  cases  for  the  week.  At  Clifton  the  plague  seems 
stayed,  but  has  affected  200  people  and  killed  15. 
Smaller  outbreaks  are  reported  in  other  directions, 
which  it  is  hoped  may  be  circumscribed. 

Sir  George  Duffey,  president  of  the  Royal  College 
of  Physicians,  Dublin,  took  the  chair  at  an  influential 
meeting,  at  which  it  was  resolved  to  raise  a  memorial 
to  the  late  Surgeon  O'Grady. 

James  Cagney,  M.D.,  A.M.,  etc.,  physician  to  the 
Hospital  for  Epilepsy  and  Paralysis,  and  electro-ther- 
apeutist to  St.  Mary's  Hospital,  expired  yesterday 
morning  from  cardiac  failure,  in  the  course  of  an  at- 
tack of  typhoid.  He  held  a  number  of  other  appoint- 
ments, had  contributed  numerous  papers  to  societies  and 
journals,  and  translated  Erb's  "  Electro-Therapeutics." 

The  Roentgen  Society  has  had  a  successful  coiiver- 
sazione,  when  Prof.  Sylvanus  Thompson,  F.R.S.,  pre- 
sided and  spoke  of  the  value  of  the  rays  in  medical 
work.      He  also  commended  the  secretary.  Dr.  David 


Walsh,  and  spoke  of  his  book  just  issued  on  the  sub- 
ject in  appreciative  terms.  Dr.  Walsh  is  an  enthusiast 
in  the  new  science  and  physician  to  the  Western  Skin 
Hospital. 


OUR    PARIS    LETTER. 


CFr. 


■  .Special  Correspondent). 


MEDICAL     PARIS     IN     FULL      SWING REACTION     CAUSED 

BY  TOO  STRINGENT  LAWS — RE-AD.MISSION  OF  FOREIGN 
STUDENTS HIGH  MORTALITY  RATE  FROM  TUBERCU- 
LOSIS IN  THE  FRENCH  ARMY^DEATH  OF  DR.  EVANS 
— DECREASE   OF   CRIME,    ETC. 

Paris,  November  20,    1897. 

Medical  Paris  is  again  in  full  swing,  the  Place  de 
r  .cole  de  Me'decine  is  once  more  crowded  with  stu- 
dents hurrying  to  and  fro  to  the  various  lectures,  and 
one  meets  at  ever)'  turn  the  carriages  of  professors  and 
general  practitioners  dashing  through  the  city  to  visits 
or  consultations,  or  on  their  way  to  their  services  at 
the  hospitals. 

The  reaction  of  the  excessive  and  almost  draconiarv 
laws,  regarding  the  matriculation  of  foreign  students 
at  the  Faculty  of  Medicine  of  Paris,  has  begun.  It 
will  be  remembered  that  some  years  ago  a  too  great 
number  of  foreign  students  matriculated  at  the  faculty,, 
and  from  this  resulted  an  overcrowding  to  such  an 
extent  that  the  general  council  of  the  faculties  was 
obliged  to  have  recourse  to  certain  measures;  among 
others,  that  of  sending  provisorily  a  considerable  num- 
ber of  the  foreign  students  to  medical  faculties  in  the 
provinces.  The  general  council  of  the  faculties  seems 
to  have  become  convinced  of  the  apparent  harshness 
of  this  measure,  and  to  have  relented,  for  the  necessary 
dispositions  have  been  taken  to  re-establish  the  old 
order  of  things.  The  council  of  the  University  of 
Paris  has  decided  that  from  the  present  academic 
year  foreign  students  may  be  matriculated  as  in  the 
past  at  the  Faculty  of  Medicine  of  Paris.  This  is  in 
my  opinion  a  wise  measure,  and  should  be  followed 
up  by  a  relaxation  of  the  restrictions  affecting  those 
who  are  already  physicians  and  desire  to  practise  in 
France — a  free  and  republican  country. 

The  tables  of  medical  statistics  of  the  French  army 
for  the  year  1895,  published  by  the  minister  of  war, 
show  that  the  general  mortality  of  the  army  is  augment- 
ing every  year;  from  6.19  per  thousand  in  1893  to- 
6.26  per  thousand  in  1894,  it  reaches  6.86  per  thou- 
sand in  1895.  It  is  to  the  mortality  from  grippe 
that  this  augmentation  in  the  total  number  of  deaths^ 
is  partly  due.  Every  year  since  the  pandemic  of 
1889-90,  the  army  has  had  to  pass  through  an  epi- 
demic of  grippe;  but,  while  the  mortality  from  that 
disease  was  50  per  thousand  in  1890,  it  attained  130 
per  thousand  in  1895  —  tliat  is  to  say,  a  figure  almost 
three  times  as  high. 

But  what  gives  most  cause  for  reflection  and  alarm 
is  that  the  number  of  deaths  from  tuberculosis  is  con- 
tinually augmenting;  for  instance,  162  per  thousand 
in  1893  and  1894,  against  165  per  thousand  in  1895; 
from  the  tables  of  statistics  the  annual  total  mortality 
rate  of  the  French  army  from  tuberculosis  may  be 
fixed  at  10  per  thousand.  This  is  doubtless  due  to 
a  variety  of  causes,  such  as  probable  bad  hygiene  in 
barracks,  the  exposure  of  a  soldier's  life  even  in  time 
of  peace,  heredity,  overwork,  etc.  Neverthfiess,  taking 
into  consideration  the  fact  that  an  outdoor  life  is  gen- 
erally conducive  to  health,  especially  when  coupled 
with  exercise  such  as  is  had  in  military  service,  this- 
high  mortality  from  tuberculosis  is,  to  say  the  least,  re- 
markable, and  no  wonder  tiiat  it  is  attracting  profes- 
sional attention.  There  are  many  pros  and  cons  in  the- 
case,  and  it  is  impossible  in  the  sliort  space  of  one  letter 
to  go  at  all  into  the  etiology.     I  am  satisfied,  however,. 


872 


MEDICAL    RECORD. 


[December  1 1,  1897 


that,  speaking  generally,  besides  all  the  causes  which 
favor  the  development  of  the  bacillus  of  Koch,  ab- 
sinthe drinking  and  the  almost  universal  habit  of 
cigarette  smoking — which,  be  it  said  en  passant,  is  the 
very  worst  form  of  using  tobacco— play  a  greater  role 
than  is  usually  admitted,  not  only  in  favoring  the 
development  of  phthisis,  but  often  as  a  direct  causal 
factor. 

By  the  death  of  Dr.  Thomas  W.  Evans,  probably  the 
greatest  dentist  of  our  day  has  passed  away.  Dr. 
Evans,  although  never  engaged  actively  in  the  prac- 
tice of  medicine,  followed  a  regular  course  at  the 
Jefferson  Medical  College  of  Philadelphia,  of  which 
city  he  was  a  native.  During  the  Franco-Prussian 
war  of  1870,  at  its  very  beginning  Dr.  Evans  took 
great  interest  in  sanitar}-  matters,  and  was  largely  in- 
strumental in  organizing  and  establishing  the  Ameri- 
can ambulance;  and  I  well  remember  my  visits  to  it 
on  the  old  Avenue  de  I'lmperatrice,  just  beyond  the 
Arc  de  Triomphe.  The  doctor  subsequently  published 
a  work  on  the  subject.  It  was  at  this  time  that  Dr. 
Sims  took  command  of  the  Anglo-American  ambu- 
lance, and  left  with  it  for  the  front,  where  it  did  such 
good  service,  especially  during  the  battle  of  Sedan. 
Both  of  these  ambulances  were  parts  of  the  great  Red 
Cross  Society.  Dr.  Evans'  wealth  and  success  were 
due,  first,  to  a  natural  mechanical  genius,  and  to  the 
influence  which  he  obtained  in  higher  circles  during 
the  second  empire.  By  advice  from  those  quarters  he 
was  enabled  to  make  judicious  purchases  of  real 
estate. 

In  Paris  they  are  rather  dilator)-  about  publishing 
statistics.  Those  of  the  army  mortality  for  1895,  men- 
tioned above,  are  just  out,  as  are  also  those  of  crimi- 
nal justice,  in  which  legal  medicine  is  almost  always 
so  much  interested.  The  report  of  the  "  keeper  of  the 
seals,'"'  which  appeared  a  week  ago,  is  satisfactory. 
According  to  this,  for  the  first  time  in  many  years 
there  is  an  important  diminution,  not  only  in  the  num- 
ber of  actual  crimes  committed  in  France,  but  in  that 
of  misdemeanors  as  well.  The  report  goes  back  fifty 
years,  during  which  period  there  has  been  a  steady 
decrease  in  the  number  of  murders  by  poison — thanks 
to  the  progress  made  in  chemistry  and  legal  medicine ; 
parricides  have  also  decreased. 

Dr.  Quinton,  at  the  last  meeting  of  the  Biological 
Society,  reported  a  rather  novel  experiment,  as  follows: 
"  In  order  to  confirm  my  hypothesis  of  the  great  value 
of  sea  water  to  the  higher  organisms,  I  practised  on  the 
dog  intravenous  injections  of  that  liquid  in  extremely 
large  doses;  the  animals  got,  effectively,  in  eight  hours, 
si.xty-six  one-hundredths  and  even  as  much  as  eighty- 
one  one-hundredths  of  their  weight  of  sea  water,  and 
that  without  presenting  the  least  accident."  Why 
could  not  sea  water  be  injected  in  the  human  subject 
as  well  as  artificial  serum  ? 


"CURE"    IN    TUBERCULOSIS. 


To  THE  Editor 


Me 


Reco 


Sir  :  I  read  with  a  degree  of  interest  Dr.  Bogardus' 
remarks  in  your  issue  of  November  13th,  about  the 
promiscuous  use  of  the  word  "  cure"  in  connection  with 
the  various  remedies  for  tuberculosis.  He  is  right. 
The  use  of  the  word  needs  qualification.  Whether 
it  be  in  connection  with  "tuberculin"  (tuberculo- 
cidin,  antiphthisin),  or  "serum,"  or  "antitoxin"  (by 
the  way,  another  word  that  needs  definition  badly\ 
etc.,  the  word  "cure"  becomes  almost  bitter  sarcasm 
in  the  face  of  the  negative  results  that,  candidly,  have 
to  be  recorded. 

As  long  as  we  have  to  deal  with  the  condition  that 
mixed  infection  presents,  and  there  are  at  least  ninety 
cases  out  of  a  hundred,  I  am  afraid  we  shall  not  be 


able  to  effect  a  "  cure"  in  its  absolute  meaning:  not, 
at  any  rate,  until  we  know  more  about  the  cell  life,  or 
until  the  inherited  power  of  resistance  comes  to  our 
aid  in  becoming  so  developed  as  successfully  to  resist 
the  casus  belli  from  the  very  outset.  The  first  contin- 
gency is  possible,  the  last  one  probable;  but  it  will 
require  generations  of  hygienic  and  sanitary  prophy- 
laxis. But,  even  so,  it  points  out  to  us  the  fact,  re- 
inforced by  the  failures  of  the  past,  that  the  battle 
must  be  fought  along  nature's  lines.  To  develop  the 
power  of  resistance  means  to  develop  the  general  vital- 
ity, and  the  rationale  of  this  must  lead  us  to  climatic 
treatment  and  hyperalimentation,  supplemented,  ac- 
cording to  circumstances,  by  an  auxiliar}'  remedial  one. 
And  that  is  all  medication  possibly  can  be,  that  is, 
auxiliary.  I  mean,  too,  medication  along  general 
lines.     "  Specifics"  should  be  tried  on  the  dog. 

The  letter  of  Dr.  Bogardus  does  not  lead  me  to 
make  any  remarks  about  the  climatic  treatment  or 
hyperalimentosis,  but  about  the  remedial  one;  so 
much  the  more,  as  I  am  perhaps,  to  a  certain  extent, 
responsible  for  the  introduction  of  intratracheal  medi- 
cation by  means  of  a  syringe,  not  catheterization.  Of 
all  the  methods  of  administration,  I  have  in  my  par- 
ticularly varied  experience  with  tuberculosis  found 
intratracheal  medication,  that  is,  more  properly  speak- 
ing, intrabronchial  injection,  the  best.  In  the  first 
place  it  does  not  interfere  with  the  process  of  diges- 
tion. Whether  it  be  with  menthol,  or  giiaiacol,  or 
iodine,  or  iodol,  etc.,  I  know  I  bring  the  remedy  in 
situ,  right  into  the  bronchus,  from  where  it  slowly 
diffuses  throughout  the  lung  tissue — the  shortest 
cut  to  the  spot  of  lesions.  I  am  more  sure  the 
chemicals  reach  there  in  an  undecomposed  state  than 
by  way  of  the  oesophagus;  for  Heaven  only  knows 
what  metamorphosis  they  undergo  in  contact  with  the 
ferments  and  saline  constituents  of  the  alimentary 
tract.  The  operation  of  the  syringe  is  easy ;  not  diffi- 
cult to  learn  after  a  few  experiments,  preferably  on 
charitj'  patients.  And,  best  of  all,  there  is  as  a  rule 
immediate  relief,  not  achieved  by  common  expecto- 
rants, especially  observable  in  the  enervating,  harass- 
ing, hacking  cough  of  tuberculosis.  Oftentimes  I  have 
been  able  to  eliminate  quickly  by  means  of  this  intra- 
bronchial injection  asthmatic  and  pneumonic  compli- 
cations, and  more  often  an  underlying  subacute  bron- 
chitis, w  ith  a  corresponding  improvement  in  the  general 
aspect  of  the  tuberculosis. 

And  one  more  word  about  "  cure.''  With  special 
reference  to  tuberculosis,  considering  its  tendency  to- 
ward the  deadly  triple  alliance  with  the  streptococcus 
and  staphylococcus,  if  we,  by  means  of  any  rational 
treatment,  fight  them  to  a  standstill,  even  for  a  time — 
in  other  words,  secure  a  postponement  of  death — we 
may  well,  at  the  present  time  and  with  our  present 
knowledge,  employ  the  word  "  cure"  in  a  relative  sense ; 
and  I  believe  that  is  the  way  most  physicians  take  it 
in  this  connection.  Joseph  Mvir,  M.D. 

254  West  Thirtv-Fovrth  Street,  Xew  York,  Xovembcr  21,  1S97. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitan,-  Bureau,  Health  Department,  for  the 
week  ending  December  4,  1897  : 


Tuberculosis 

Typhoid  fever   

.'Scarlet  fever 

Cerebro-spinal  meningitis. . . . 

Measles 

Diphtheria 

I.an.'ngeal  diphtheria  (croup) 
Chicken-pox 


I  So 
40 
124 
I 
269 
195 


Medical  Record 

A  Weekly  jFournal  of  Medicine  and  Surgery 


Vol.  52,  No.  25. 
Whole  No.  1415. 


New  York,    December   18,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riginat  |trticlcs. 

A  CONTRIBUTION   TO  THE  PATHOGENESIS 
AND  ETIOLOGY  OF  DIABETES  MELLITUS.' 

By  HEINRICH    STERN,  M.D., 

NEW   YORK. 

I.  Introduction Since   Claude  Bernard's  ingenious 

experiments  nearly  five  decades  ago,  it  has  been  the 
endeavor  of  physiologists  and  observers  to  ascertain 
the  pathogenesis  and  etiology  of  diabetes  mellitus. 
The  great  number  of  diverse  theories  which  thus  have 
been  advanced  did  in  no  way  produce  a  clear  concep- 
tion of  the  true  origin,  of  this  affection.  Even  the 
character  and  the  course  of  this  disease  are  ill-defined, 
and  true  diabetes  mellitus,  which  alone  I  shall  discuss 
in  the  following,  is  thought  to  be  identical  with  a  more 
or  less  complicated  grave  type  of  glycosuria,  for  the 
absence  of  glucose  from  the  urine,  or  its  disappearance 
from  it,  is  deemed  by  even  the  latest  writers  and  in- 
vestigators the  a-priori  fact  of  the  non-existence  of 
diabetes  mellitus. 

In  the  writer's  opinion,  however,  diabetes  mellitus 
— that  is,  what  is  understood  by  this  tenn  to-day — is 
not  a  disease /tv-j-c,  but  only  implies  a  single  stage  in 
the  course  of  a  specific  and  general  somatic  deteriora- 
tion. It  does  not  occur  as  a  definite  and  independent 
affection,  but  is  the  result  of  deteriorating  processes, 
and  in  its  course  gives  again  rise  to  other  symptoms 
and  conditions.  This  diabetic  glycosuria — which  is 
wrongly  styled  diabetes  mellitus — has  its  prodromata 
and  its  initiatory  symptoms,  its  continuations,  and 
subsequent  conditions.  In  short,  diabetes  mellitus, 
as  defined  by  others,  is  indicative  of  only  one  stadium 
of  the  general  diabetic  or  glucose-generic  deteriora- 
tion. 

The  diabetic  deterioration  from  the  physiologico- 
chemical  as  well  as  from  the  clinical  standpoint,  may 
be  divided  into  three  great  stages:  First,  the  prodro- 
mic  or  preglycosuric  stage;  second,  the  period  of 
glycosuria  (the  diabetes  mellitus  of  to-day) ;  and  third, 
the  postglycosuric  stage  or  the  period  of  auto-intoxi- 
cation. 

The  preglycosuric  stadium  comprises  a  variety  of 
disturbances  which  only  of  late  have  been  recognized 
and  pointed  out  as  prodromata  of  diabetic  glycosuria. 
This  prodromic  stage  tends  to  show  that  what  is  called 
diabetes  mellitus  does  not  occur  independently,  but  is 
preceded  by  a  chain  of  more  or  less  pronounced  symp- 
toms and  conditions  which  are  indicative  of  a  general 
deterioration.  The  second  stage — the  glycosuria — 
offers  a  most  characteristic  and  marked  symptomatol- 
ogy, and  therefore  was  always  thought  to  be  a  separate 
and  distinct  disease,  to  which  the  term  diabetes  mel- 
litus was  applied.  I  consider  the  glycosuric  stage  the 
transitory  period  of  the  diabetic  deterioration,  as  it  is 
the  forerunner  or  premonitor)'  factor  of  the  third  sta- 
dium of  this  deterioration,  the  stage  of  auto-intoxi- 
cation. 

The  duration  of  the  third  or  postglycosuric  stadium 
varies  greatly  in  different  persons.     It  may  be  persis- 

'  Being  the  prize  essay  read  before  the  .Medical  Society  of  the 
County  of  New  York,  iSgy. 


tent,  especially  in  its  lighter  manifestations,  for  months 
before  toxicosis  is  complete,  but  I  have  seen  a  few 
cases  in  which  the  condition  of  perfect  auto-intoxication 
developed  to  all  appearances  within  an  hour's  time, 
when  the  death  of  the  patient  ensued.  This  stage 
does  not  exclude  glycosuria  completely,  but  is  always 
characterized  by  a  diminished  flow  of  saccharine  urine 
with  the  presence  of  dimethyl-ketone  in  excess,  of 
ethyl-diacetic,  and  of  lasvorotatory  o.xybutyric  acids. 
In  addition  thereto,  the  present  writer  thinks  that  he 
has  of  late  succeeded  in  identifying  an  abnormal 
chemical  substance  in  the  blood  of  diabetics  who  have 
died  in  a  comatose  condition.  A  conclusive  state- 
ment, however,  about  his  observations  he  deems  some- 
what premature,  and  beyond  the  scope  of  this  treatise. 

The  so-called  true  diabetes  I  therefore  designate  as 
diabetic  glycosuria,  or  the  glycosuric  stage  of  the  dia- 
betic deterioration. 

All  other  varieties  of  glycosuria  have  nothing  in 
common  with  the  diabetic  deterioration.  They  are 
without  exception  secondary  disturbances  which  almost 
always  pass  away  when  the  primary  affection  has  dis- 
appeared, and  are  therefore  more  or  less  transitory  in 
character.'  They  may  occur  as  sequela;  of  a  number 
of  diseases,  of  traumatosis,  of  hyperneuria  and  exces- 
sive nervous  irritability,  of  childbirth,  of  operations, 
of  different  forms  of  alimentary  disturbances,  or  as 
the  result  of  hyperingestion  of  sugar  or  other  carbo- 
hydrates, of  the  introduction  of  irritating  substances, 
and  of  the  administration  of  certain  drugs,  as  strych- 
nine, curare,  and  phloridzin  (C„|H,,^0|,^.2H,,0).' 

II.  Pathogenesis  of  True  Diabetes — Pavey,  from 
the  standpoint  of  physiological  chemistry,  holds  the 
liver  responsible  for  the  diabetic  condition.  In  nor- 
mal digestion  the  carbohydrates,  he  explains,  are  con- 
verted into  maltose  and  not  into  glucose,  dextrin 
being  intermediate  in  the  process.  Maltose  is  absorbed 
and  assimilated  as  such,  and  stored  away  as  glycogen. 
When  pure  glucose  is  introduced  into  the  stomach,  he 
continues,  it  will  readily  be  converted  into  maltose, 
under  the  influence  of  a  special  glucose  ferment  dur- 
ing gastric  and  intestinal  digestion.  This  ferment 
can  exist  only  in  healthy  venous  blood.  In  the  dia- 
betic state,  howe\er,  the  blood  enters  the  circulation 
of  the  liver  in  a  condition  of  insufficient  deoxygena- 
tion,  thus  giving  rise  to  the  production  of  a  glucose- 
creating  ferment.  This  imperfect  dearterialization 
I'avey  explains  as  due  to  vasomotor  paralysis,  espe- 
cially of  the  vessels  of  the  chylopoietic  system.  The 
glucose  thus  formed  is  an  abnormal  product,  and,  not 
being  capable  of  assimilation,  enters  the  circulation 
and  makes  its  appearance  in  the  urine. 

The  fact  that  carbon  dioxide  outside  the  body  may 
retard  the  conversion  of  glycogen  into  glucose  was 
utilized  by  Ebstein,  when  he  advanced  his  explanation 

'  The  primary  affection,  on  the  other  hand,  may  be  followed  by 
a  permanent  disorder  or  structural  change,  and  thus  a  chronic 
•glycosuria,  or  conditions  which  favor  or  cause  even  diabetic  de- 
terioration, may  be  the  consequence. 

■■  Phloridzin  is  a  crystalline  glucoside  which  has  been  employed 
in  the  treatment  of  glycosuric  conditions.  Phloridzin  diabetes, 
which  is  produced  by  overdoses  or  prolonged  administration  of 
the  drug,  is  considered  by  many  investigators  a  type  of  true 
diabetes,  to  which  I  cannot  agree,  as  the  disappearance  of  this 
form  of  glycosuria,  almost  in  every  instance,  ensues  soon  after 
the  withdrawal  of  the  phloridzin  or  the  diminution  of  its  dose. 


874 


MEDICAL    RECORD. 


[December  i8,  1897 


of  the  origin  of  diabetes,  wliich  ignores  any  local  cause. 
His  view  is,  in  short :  The  protoplasm  of  the  diabetic 
organism  has  an  inherent  defect,  and  varies  from  that 
of  the  healthy  body;  that  from  a  known  quantity  of 
carbon-containing  matter  it  forms  less  than  the  nor- 
mal amount  of  carbon  dioxide.  The  conversion  of 
glycogen  into  glucose  becomes  inordinate — that  is, 
larger  quantities  of  the  latter  are  produced,  as  the 
necessarj'  amount  of  carbon  dioxide  with  its  retarding 
factors  is  not  present  in  the  diabetic  state. 

Cantani  agrees  that  the  body  produces  less  carbon 
dioxide  in  diabetes  than  normally.  He  considers  this, 
however,  the  result  and  not  the  causative  factor  of  the 
affection.  He  is  of  the  opinion  that  the  carbohydrates 
are  directly  utilized  in  the  animal  economy,  and  does 
not  believe  that  they  are  converted  into  glycogen  and 
as  such  deposited  in  the  muscles,  liver,  and  other 
organs.  He  draws  the  conclusion  that,  if  the  sac- 
charine and  starchy  ingesta  had  to  be  first  converted 
into  glycogen  and  then  into  glucose  before  the  latter 
makes  its  appearance  in  the  urine,  the  time  left  for 
such  a  conversion  would  be  entirely  too  short. 

If  in  the  late  stadium  of  diabetes  a  given  quantity 
of  sugar  is  administered  to  a  patient,  exactly  the  same 
amount  of  sugar  may  be  obtained  again  in  the  urine, 
and  it  is  unlikely  that  this  would  happen,  Cantani 
says,  if  the  sugar  had  to  be  first  concreted  into  glyco- 
gen and  then  again  into  glucose.  If  the  latter  were 
the  case,  some  of  the  sugar  ingested  by  the  patient 
would  certainly  remain  in  the  system  and  be  retained 
there  as  glycogen. 

Le'pine,'  after  numerous  researches  on  the  relation 
of  pancreatic  disease  to  diabetes,  is  of  the  opinion 
that  the  healthy  pancreas  normally  produces  a  ferment 
which  enters  the  blood  through  the  lymph  current. 
He  assumes  that  this  ferment,  which  after  Nommfes"  he 
called  "glykolysin,"'  is  effecting  the  dissolution  of 
the  saccharine  substances  in  the  system.  The  non- 
presence  of  this  ferment  in  the  blood  he  supposes  to 
be  the  cause  of  diabetes. 

In  framing  his  theory  Lepine  started  from  the  fact 
which  had  been  first  noticed  by  Claude  Bernard,  that 
the  sugar  disappears  from  drawn  blood,  attribut- 
ing this  disappearance  to  the  action  of  the  ferment 
which  originates  in  tlie  pancreas.  The  glycolytic  fer- 
ment, he  further  assumes,  is  greatly  reduced  in  blood 
drawn' after  the  extirpation  of  the  pancreas  and  in  that 
of  diabetics. 

Seegen,'  who  after  a  number  of  experiments  main- 
tains that  the  liver  produces  sugar  from  albumin  and 
fat  and  glycogen  out  of  carbohydrates,  when  reflecting 
on  Lepine's  hypothesis  about  a  glycolytic  ferment  of 
pancreatic  origin,  the  absence  of  which  would  cause 
accumulation  of  sugar  in  the  blood,  makes  the  follow- 
ing point:  .Admitted  even  that  the  blood  of  diabetics 
possesses  less  glycolytic  action  tlian  that  of  a  healthy 
person,  it  need  not  follow  that  this  indicated  the  pres- 
ence during  health  of  a  special  glycolytic  ferment  pro- 
duced by  the  pancreas.  (He  observed  that  normal 
glucose  will  disappear  rapidly  from  freshly  drawn 
blood  when  the  latter  is  kept  at  a  temperature  of  39° 
C,  while  a  current  of  air  is  passed  through  it.  To 
prove  that  the  disappearance  of  the  sugar  was  not  due 
to  the  activity  of  the  protoplasmatic  substance,  he 
killed  the  latter  by  adding  chloroform.  This  made 
but  a  slight  difference  in  the  glycolytic  action.)  See- 
gen  further  remarks  that,  since  the  glycolytic  activity 
is  increased  upon  standing  of  the  drawn   blood  for 

'  "  Die  Beziehimgen  des  Diabetes  zu  Pankreaserkrankiingen," 
Wiener  med.  Presse,  1892,  No.  27-32. 

*  "  Ktude  sur  le  Pancreas  et  sur  le  DiaWte  Pancrcatiqiie," 
Paris,  1 891. 

^  "  The  Pancreas  and  Diabetes,"  a  paper  read  before  the  Medi- 
cal Society  of  Vienna.  Reported  in  London  Lancet,  and  re- 
published in  The  Journal  of  the  .\merican  Medical  .Association, 
vol.  .\ix..  No.   I,  July  2,  1892. 


some  time,  the  ferment  may  be  produced  rather  by 
some  alteration  in  the  blood  outside  the  body  than  by 
the  pancreas,  and  argues  that  the  blood  in  diabetes 
may  contain  something  preventing  glycolysis,  so  that, 
even  if  Le'pine's  experiments  are  correct,  they  do  not  J 

necessarily  indicate  a  diminution  of  the  glycolytic  fer-  I 

ment  in  the  diabetic  state.  ■ 

Besides  Lepine,  a  great  number  of  investigators 
have  made  observations  as  to  the  relationship  of  the 
extirpation  of  the  pancreas  or  pancreatic  disease  to 
diabetes  mellitus.  I  mention  only  de  Dominicis, 
He'don,'  Thiroloix,^  Gley,  Harley.  Cappareli,  von 
Mering  and  Minkowski.^  The  latter  two  especially 
have  given  a  great  deal  of  attention  to  this  problem. 
Minkowski,  speaking  on  the  causes  of  diabetes  after 
the  extirpation  of  the  pancreas,  says,  in  short,  the  fol- 
lowing: There  is  no  doubt  that  the  occurrence  of  ex- 
perimental pancreatic  diabetes  is  the  result  of  certain 
disorders  in  the  system,  due  to  the  removal  of  the  pan- 
creas. The  nature  of  these  disorders,  however,  cannot 
be  told  with  any  degree  of  certainty  as  yet. 

In  dogs  and  other  animals,  after  the  extirpation  of 
the  pancreas,  grape  sugar,  that  which  is  ingested  as 
well  as  that  which  has  formed  in  the  system,  is  not 
utilized  in  a  normal  manner,  and  the  deposition  of 
glycogen  in  the  liver  does  Hot  occur  normally.  It 
may  be  assumed  that  there  is  a  dependency  between 
these  phenomena.  After  removal  of  the  pancreas 
there  happens  either  an  accumulation  of  something 
abnormal  in  the  system,  or  a  normal  function  dis- 
appears. That  is,  either  the  pancreas  has  normally 
the  function  to  remove  a  ferment-like  or  toxic  sub- 
stance, whose  retention  in  the  system  causes  the  elim- 
ination of  sugar;  or  it  is  a  normal  function  of  the 
pancreas  to  effect  the  consumption  of  the  sugar  in  the 
organism,  and  the  deficiency  of  this  function  is  the 
cause  of  diabetes  mellitus. 

The  abnormal  accuiriulation  of  sugar  in  the  blood 
in  pancreatic  diabetes  is  undoubtedly  the  cause  of  its 
passage  into  the  urine.  It  is  easy  to  assume  the  sub- 
stance, circulating  in  the  system,  which  through  abnor- 
mal formation  of  the  sugar  produces  the  accumula- 
tion of  the  same  in  the  blood.  Some  observers  have 
maintained  that  the  next  result  of  the  removal  of  the 
pancreas  is  the  conversion  of  glycogen  by  a  sacchari- 
fying ferment,  others  assume  that  an  increased  waste 
of  tissue  material  is  the  direct  consequence. 

More  plausible,  however,  is  the  assumption  that  the 
pancreas  has  to  perform  a  specific  act  normally  regard- 
ing the  consumption  of  sugar,  and  that  the  disappear- 
ance of  this  function  means  the  causation  of  diabetes. 

A  satisfactory  theory  as  to  the  genesis  of  pancreatic 
diabetes,  however,  cannot  be  propounded  at  this  date. 
Two  points,  though,  every  hereto  pertaining  theory 
must  consider:  that  is,  the  peculiar  behavior  of  the 
glycogen  of  the  li\er,  and  especially  the  different  des- 
tination of  dextrorotatory  and  Isvorotatory  glucoses. 

Minkowski  says:  "  There  are  two  assumptions  which 
force  themselves  upon  us  as  to  this  matter,  although  I 
cannot  vouch  definitely  for  either  of  them.  First,  the 
conversion  of  dextrose  into  glycogen  is  a  necessity  for 
the  normal  consumption  of  sugar.  This  conversion 
can  occur  only  with  the  aid  of  the  pancreas,  which  ex- 
erts a  specific  action  either  upon  the  dextrose  itself  or 
upon  the  cells  of  the  liver  or  those  of  the  muscles.  It 
has  to  be  further  assumed  that  the  formation  of  glyco- 

'  "  I'.xstirpation  du  l'.incre.as,  Diabete  Sucre  Experimental," 
.Arch,  de  Med.  Experimentale,  iSgi,  No.  i. 

*  "  Le  Diabete  Pancreatique,"  Paris,  1892. 

^  V.  Mering  und  Minkowski:  "Diabetes  mellitus  nach  Pan- 
kreasexstirpation,"  Archiv  f.  e.\p.  Pathologic  u.  Pharm.,  Bd. 
xxvi.,  1SS9.  Minkowski:  "  Ueber  die  Folgen  partieller  Pan- 
kreasexstirpation, "  Centralblatt  f.  klin.  Medicin,  1S90,  No.  5; 
"  Weitere  Mittheilungen  Uber  den  Diabetes  mellitus  nach  Ex- 
stirpation  des  Pankreas,"  Berl.  klin.  Wochenschrift,  1S92,  No  5  ; 
"  Untersuchungen  iiber  die  Diabetes  mellitus  nach  Exstirpation 
des  Pankreas,"  Leipzig,  1S93. 


December  i8,  1897] 


MEDICAL    RECORD. 


875 


gen  from  Isvulose  is  brought  about  independently 
from  any  pancreatic  influence.  It  is  difficult  to  state 
how  the  latter  could  happen.  The  most  simple  ex- 
planation is  the  presupposition  that  glycogen  can  be 
manufactured  only  from  laevulose,  and  that  it  is  the  duty 
of  the  pancreas  to  convert  dextrose  into  laevulose. 
Such  an  assumption,  however,  is  hardly  admissible. 
Second,  normally  sugar  is  consumed  directly  as  such. 
The  aid  of  the  pancreas,  though,  is  essential  to  the 
normal  consumption  of  dextrose.  The  formation  of 
glycogen  is  not  directly  impaired  after  the  extirpation 
of  the  pancreas.  The  disappearance  of  the  glycogen 
in  the  liver  is  only  the  consequence  of  the  inordinate 
consumption  of  sugar.  Glycogen,  whether  manufac- 
tured from  albuminous  material  or  from  ingested  grape 
sugar,  continues  to  be  converted  directly  into  dextrose, 
which  accumulates  in  the  blood  and  makes  its  appear- 
ance in  the  urine.  Pancreatic  assistance  is  not  neces- 
sary for  the  consumption  of  laevulose.  The  latter, 
therefore,  even  after  the  removal  of  the  pancreas,  may 
be  used  to  some  extent.  The  supply  of  laevulose  sat- 
isfies the  demand  for  sugar  in  the  organism.  The 
oversupply  of  Isvulose  may  be  deposited  as  glycogen. 
If  grape-sugar  should  result  again  from  this  glycogen, 
then  it  will  be  transmitted  unaltered  to  the  urine.  The 
increase  of  grape-sugar  elimination  after  the  supply  of 
lasvulose  is  also  explainable  in  this  manner. 

"The  pancreatic  function  does  not  necessarily  de- 
pend upon  the  production  of  a  '  glycolytic  '  ferment. 
The  pancreas  could  influence,  somehow  or  other,  those 
organs  which  normally  consume  sugar,  setting  free 
therein  certain  affinities  that  would  attract  the  sugar 
molecule.  It  may  be  further  conceivable,  for  instance, 
that  the  sugar  normally  circulates  in  a  loosely  bound 
combination  which  prevents  the  influence  of  the  oxi- 
dizing processes  upon  it;  and  that  it  is  the  mission  of 
the  pancreas  to  split  up  this  combination,  thus  further- 
ing the  normal  oxidation  of  the  sugar." 

III.  The  Author's  Observations. — It  is  evident 
that  the  artificial  conditions  produced  in  the  normal 
organism  for  the  purpose  of  experimental  research  do 
not  effect  in  every  respect  an  e.xact  reproduction  of  that 
pathological  state  which  the  investigator  seeks  to  pro- 
cure.    This  is  especially  the  case  in  artificial  diabetes. 


Though  it  is  the  truth  that  we  find  the  whole  symp- 
tomatology of  the  second  and  third  stage  of  diabetic 
deterioration  in  experimental  pancreatic  glycosuria, 
we  must  never  forget  that  the  latter  is  the  result  of 
the  extirpation  of  the  pancreas,  and  that  this  fact 
alone  is  certainly  not  analogous  with  the  condition  in 
true  diabetes.  I  further  maintain  that  observations 
and  their  consequent  deductions,  drawn  from  arti- 
ficially created  bases,  are,  if  at  all,  only  in  part  ap- 
plicable to  those  conditions  originating  from  naturally 
contracted  bodily  aff'ections,  and  that  the  theories  as 
to  the  genesis  of  a  pathological  statement,  if  based 
solely  upon  artificial  experimental  disease,  prove  to 
be  often  useless,  inefficient,  and  at  times  even  mis- 
leading. 

Thus  I  have  abandoned  experiments  with  animals 
in  all  instances  when  a  certain  disease  has  first  to  be 
produced  by  artificial  means,  and  when  it  is  of  greater 
importance  to  determine  the  causative  factor  or  factors 
underlying  the  generative  processes  than  to  explain 
mere  secondary  phenomena  or  symptoms  arising  dur- 
ing the  course  of  these  processes. 

The  great  divergency  of  opinion  as  to  the  causes  of 
diabetes  is  undoubtedly  the  result  of  too  much  indis- 
criminate experimenting  on  animals.  Salivary  glands, 
duodenum,'  thyroid  gland,"  and  other  morphological 
parts  were  removed  from  animals  to  find  the  cause  of 
the  glycosuric  symptom.'  The  constant  repeating  of 
such  experiments,  "  the  re-proving,"  I  deem  entirely 
uncalled  for.  Moreover,  I  verily  believe  at  this  day 
that  a  glycosuria  may  follow  the  removal  of  any  vital 
organ,  provided  the  animal  is  capable  of  surviving  a 
sufficient  time. 

The  following  observations—  more  or  less  experi- 
mental in  character — were  made  on  patients  whose 
affection  I  recognized  as  diabetic  deterioration. 

In  tabulating  the  history  of  these  six  cases  I  have 
abstained  from  enumerating  all  such  incidents  as 
are  inessential  to  the  following  considerations.  This 
pertains  not  only  to  other  products  of  metabolism 
which  occurred  normally  or  abnormally  in  the  urine 
and  the  fseces,  but  also  to  the  duration  of  the  different 
cases.  It  was  my  endeavor  to  bring  forward  only  the 
most  typical   period  of  the   second  stage  of  diabetic 


CASE   I. 
male,  aged  27,  American,  unmarried,  family  history  good.      Deterioration  first  recognized  March  20,  1895.) 


April  17,  1895 
April  22,  1S95 
April  24,  1895 
April  29,  1895 
May  4,  1895. 
May  7.  1S95. 
May  8.  1895. 
May  9,  1895. 
May  10,  1895. 
May  II,  1S95. 

May  18,  1895. 

May  21,  1895. 
May  24,  1895. 
May  29.  1895. 
June  16.  1895. 
July  21,  1895  . 


0-.'? 

Ss 

§J 

2u 

m 

S.2 

0&- 

^£ 

a  lo 

■- 

3,080 

1.062 

8.4 

2.9 

3.200 

1.059 

8.1 

3-1 

3,010 

1.059 

» 

3 

2,720 

1.054 

6.5 

3-7 

2,640 

1.055 

4 

3-9 

2,850 

1.056 

3-8 

5.1 

2,780 

1.054 

•5.9 

6 

1.930 

1.05 

3.9 

6.1 

2,250 

1.052 

3.b 

6.1 

2,040 

1.05 

2.9 

6 

1,850 

1.054 

3 

3.8 

2,510 

1.053 

3-4 

6 

2,780 

1.053 

3.3 

6.2 

2,190 

1. 05 1 

3.1 

5.7 

1.930 

1.049 

3.2 

4 

1,620 

1.044 

3.5 

4.2 

Exclusively  albuminous:  egg  albumin,  per 
diem,  10    gm.;    casein,    milk  albumin, 
I70gm. ;  albumin  derived  from  meat,  5' 
gm.;  together,  1S5  gm.  per  diem. 


Non-nitrogenous    matter  greatly  prepon-J 
derating.  1 


No  diet  ;    fasting   for   17  hours  ;   HiO  in 
moderate  quantity. 

Exclusively  albuminous  ;   on  the  average 
as  above.  ' 


■  Albuminous  as  above. 


^ 

^ 

II 

i^  s 

^S. 

ffi 

a"t2 

&° 

66 

65 

83 

26 

64.5 

64.5 

64.5 

64 

64 

141 

38 

64 

63.5 

72 

21.5 

64 

63 

61.5 

95 

28 

60 

4 
1.3 


Patient  was  not  seen  by  me  since  last  year,  when  he  left  town. 


'  De  Renzi  and  Reale  (Verhandlungen  des  X.  intemationalen  Med. -Congresses  zu  Berlin,  i8go,  Bd.  ii.,  Abth.  v.,  S.  97)  ex- 
perimentally removed  the  salivary  glands  and  the  duodenum  from  a  number  of  dogs,  and  assume  that  a  type  of  true  diabetes  would 
follow  either  operation. 

^  Falkenberg  ("  Zur  Exstirpation  der  .SchilddriJse, "  Verhandlungen  des  X.  Congresses  fiir  innere  Medicin,  Wiesbaden,  1891, 
S.  502)  believes  he  has  observed  a  true  and  chronic  diabetes  after  the  extirpation  of  the  thyroid  gland. 

'The  experimenting  with  a  number  of  drugs,  whose  administration  may  be  followed  by  a  glycosuric  condition,  naturally 
belongs  thereto. 


876 


MEDICAL    RECORD. 


[December  18,  1897 


(A.  D ,  female,  aged  36,  American,  married,  no  children;  father  and  sister  died  after  having  been  diabetic.     Deterioration 

first  recognized  October  18,  1895.) 


December  2S,  1895. . 
December  29,  1895.. 
January  4,  1S96. . . 
Januar)'  6,  1896. . . 
Januarj'  7,  1896. . . 
January  10,  1896. . . 
January  15,  1896. . . 
January  19,  1896. . . 
January  26,  lSg6. . . 
Februar)'  5,  1896. . 
February  19,  1896. . 
March  15,  1896  . . . . 
March  29,  1S96  . . . . 

April  13,  1S96 

May  12,  1S96 

May  15,  1896 

May  16,  1896 

May  17,  1896 

May  18,  1896 

July  10,  iSg6 

August  12,  1S96. .  . . 
September  19,  1896. 
October  n,  1896  .  . . 
December  15,  1896.. 


-  0 

.-i^ 

=.§• 

=a:g 

as 

3  -f  c 

O^p 

1,360 

1.034 

1,400 

1.033 

1,380 

1.036 

1,560 

1.034 

1,650 

1.034 

1,700 

1.033 

1,620 

1.032 

1,870 

1.032 

1,730 

1.032 

1,540 

1.031 

1,610 

1.030 

1,460 

1.030 

1,570 

1.030 

1,480 

1.030 

1,600 

1.032 

1,540 

1. 031 

1,710 

1. 031 

1,670 

1.030 

1,520 

1.030 

1,630 

1.031 

1,550 

1.031 

1,440 

1.032 

1,390 

1.030 

1,420 

1. 031 

1.7 
1.5 


0.7 
0.4 
0.2 

0.2 

0.5 
0.5 
0.5 
0.4 
0.3 
0.3 

0.2 
0.1 
O.I 


3-5 

3-5 

3.2 

3.2 

3.3 

3-5 

2.8 

2.3 

2.5 

3-3 

2.1 

2.4 

2.4 

2-7 

2.9 

2.9 

2.2 

2.2 

2.4 

2 

2.1 

2.5 

2.9 

3 


Exclusively  albuminous; 
about  200  gm.  of  proteids 
daily. 


■  Non-nitrogenous . 


y  Albuminous  . 

I 
J 


5_- 

82.5 

82. 5 

154 
145 

81' 

"5 
121 

82 

S0.5 

III 

80 

78.5 

98 

-s 

78 
78 

162 

183 

77.5 

78 

76 

224 

77 

76.5 

76 

56 
42.5 


93-5 
76.5 


)  Not  e  X  a  m  - 
$  ined. 

4-1 
3 


4.9 
Not  examined. 


Not  e.\amined. 


Status  pr3?sens:   Patient  is  afflicted  with  secondary  affections  and  is  laid  up,  more  or  less  ;  glycosuria  and  azoturia  persistent, 
though  the  percentage  of  glucose  and  urea  is  rather  small. 


deterioration  with   its  most  typical  chemical  phenom- 
ena. 

For  obvious  reasons  I  have  not  analyzed  the  faeces 
so  frequently  as  the  urine,  but  this  must  not  be  con- 
strued as  if  the  patients  were  afflicted  with  obstipation 
in  the  inter\'als  between  the  examinations. 
Urea,  biamide  of  carbonic  acid,  or — 
Carbamide,  H  O  H 

I    II    I  =CO(NH„). 
H-N-C-N-H, 
is  one  of  the  most  simple  amid  bodies  and  the  main 
product  of  the  oxidation  of  nitrogenous  substances  in 
the  system.     It  occurs  in  the  urine  generally  in  from 
1.5   to  2.8   per  cent.;    in  the  blood,   the  faeces,   the 


lymph,  the  perspiration,  the  crystalline  lens,  and  the 
aqueous  and  vitreous  humors  of  the  eye  normally  in 
traces  only. 

It  is  the  general  opinion  among  physiologists  and 
clinicians  that  the  amount  of  carbamide  excreted  is 
dependent  upon  the  quantiU"  of  nitrogenous  material 
ingested.     Lehmann,'  experimenting  on  himself,  found : 

KindofNouri.Wnu  ^^.^'^hi^. 

Mixed 32.5  gm. 

Animal 53.2    " 

Vegetable 22.5    " 

Non-nitrogenous 15.4    " 

If  no  nourishment  is  taken,  carbamide  continues  to 


(B.  M ,   female,  aged  30,  German,  married  ;  had   three  children  who  have  died  ;  two  years   in   this  countrj- 

diabetes.     Deterioration  first  recognized  September  17,  1S96.) 


October  10,  1S96. . . 
October  11,  1S96. .  . 
October  12,  1896. . . 
October  15,  i8g6.  . . 
October  17,  1896.  . . 
October  25,  1896.  . . 
November  6,  1S96. 
November  20,  1896. 
November  27,  1896. 
December  II,  1896. 
December  28,  1S96  . 
January  16,  1S97.  . . 
January,  29,  1897. . . 
Februar)'  iS,  1S97.. 
March  i;,  1S97  . . . . 
March  29,  1S97  .  . . . 

April  12,  1897 

April  26,  1S97 

May    8.  1S97 

May  22.   1S97 

June  20,  1S97 


©■"p 


,620 
.300 
,860 
.440 
,250 
,800 
■  350 
,100 
,800 
,720 
,650 
,800 
,950 
,100 
,180 
,250 
,700 
.930 
,050 
,120 
,080 


1.036 
1.037 
1.036 
1.036 
1.035 
1.032 
1.030 
1.031 
1.030 
1.030 
1.030 
1.032 
1-033 
1.032 
1.031 
1.032 
1. 031 
1.033 
1.032 
1.031 
1.034 


OCJ 

S" 

P^" 

3a. 

a 

'" 

5-5 

2.7 

5-1 

3-2 

5-7 

3 

6 

2.9 

5-1 

3.5 

3 

3-7 

1-7 

3-8 

2-3 

4-2 

1.9 

4 

1-3 

2.1 

0.7 

3-2 

2.6 

4.1 

2.9 

4 

2.5 

4-2 

2.1 

4-1 

1.7 

4 

1. 9 

3-8 

2.7 

4-2 

2 

4-1 

2 

4.2 

3.8 

4-1 

}  Exclusively  albuminous  :    aver- 
age iSogm.  of  proteids  daily. 

/  Mixed  diet :  about  1 20  gm.  al-  ' 
r     bumin  daily.  i 

I  f 

I  Carbohydrates  prevailing:  I 
I  about  70  gm.  proteids  daily.  ") 
J  I 

/  Mi.xed  diet  ;  about  120  gm.  al-  \ 


bumin  dailv. 


Albuminous:  iSo  gm.  albumin 
daily. 


- 

._ 

X 

^"i 

66 

90 

65 

75 

63.5 

63 

141 

62.5 

61 

185 

60-5 

59 

5b 

152 

56 

54-5 

53-5 

92 

53 

53 

53.5 

51 

47  5 
29 

41 


40 


7-6 


5-5 


72-5  '    J-5 

j 

51-5      3-5 


2-9 


Patient  died  during  my  absence  from  the  cit)'  in  July,  with  the  symptoms  of  general  exhaustion.     Comatose  stage  (if  at  all 
pronounced)  only  of  xery  short  duration. 

'  "  Physiological  Chemistry,"  London,  1S53.  vol.  ii.,  p.  450. 


December  i8,  1897] 


MEDICAL    RECORD. 


877 


(B.  L.  F- 


CASE    IV. 
male,  aged  25,  American,  single,  family  histon-  good.     Deterioration  first  recognized  December  14,  1896.) 


o-'a 


^ 

>-'§  = 

^M 

•2c-S 

.2 

a".? 

■" 

60 

60 

59-5 

59 

103 

58 

57-5 

57.5 

56.5 

152 

56 

57-5 

3/ 

147 

57.5 

57-5 

13S 

57 

56.5 

December  16,  1S96 
December  17,  1S86 
December  iS,  1896 
December  19,  1896 

December  20,  i8g6 

December  21,  1896 
December  22,  i8g6 
December  2S,  1S96 
December  29,  l8g6 
December  31,  1896 
~anuar)-  3,  1S97  . . 
Januar)-    4,  1897  . . 

anuar>"     5,  1897  . . 

anuar)-  15,  1S97  . 

anuary  ig,  1897  . . 
Februar)-  5,  1897  . 
Februan-  24,  1897  . 
March  16,  1897  . . . 
April  12,  1897   . . . . 


6,500 
5.350 
6,600 
4,570 
2,120 

4,580 
5,400 
■1,770 
4,900 
4.100 
4.950 
5,300 
5.050 
3,820 
2,430 
2,900 
2,280 
1,950 
2,130 


1-055 
1.057 
1.060 
1.060 


I.05S 

7.3 

1.060 

7.8 

1.045 

6.3 

1.054 

6.9 

1.053 

b.3 

1.048 

6.1 

1.055 

7.2 

1.057 

0.5 

r.054 

b.5 

1.040 

4.7 

1.038 

2.5 

1.039 

3-7 

1.038 

3-5 

1.039 

4.1 

1.040 

4.2 

S.2 

S.I 
6.8 


7.9 

7.7 

8.6 

8.3 

8.1 

7.6 

8.1 

7.8 

8 

5.3 

4-5 

4-1 

3-7 

4-3 


I 

V  Albuminous  :  about  I  So  gm.  daily. .  ^ 

j  No  diet ;    fasting  ;    H.O    in   small  1 
(      quantities.  ) 

Albuminous  :  as  above . 

I  Carbohydrates :    albumin   about    50 

/  Albimiinous :   about    190   gm.    pro- ( 
f      teids  per  diem.  I 

Mixed  diet 

Fasting  :  HjO  small  quantity 


Status  prassens  :     Patient  is  at  a  European  spa  ;  the  diabetic  deterioration  is  progressing. 


be  excreted,  though  in  lesser  quantit)%  indicating  that 
it  is  derived  from  another  source  than  the  direct  de- 
composition of  proteid  ingesta.  Thus  carbamide  is 
one  of  the  products  of  retrograde  metamorphosis  of 
the  plasmatic  tissue  constituents. 

The  excretion  of  carbamide  becomes  of  pathological 
significance  only  when  it  occurs  in  diminished  or  e.x- 
cessive  quantities.  It  indicates  thus  a  disturbed  metab- 
olism, either  retarded  or  increased  plasmolysis.  The 
quantity  of  excreted  urea  is  proportionally  small  in 
diseases  of  the  liver,  in  cachectic  conditions,  in  dilTer- 
ent  renal  affections,  and  is  diminished  in  fasting; 
its  elimination  is  noticeably  increased  after  muscular 
or  mental  strain,  and  in  the  febrile  states,  when  it 
usually  increases  in  proportion  to  the  intensity  of  the 
fever.  It  is  excreted  in  excess  in  diabetes  mellitus, 
which  phenomenon  all  obser\'ers  ascribe  to  the  great 
consumption  of  albuminous  food. 

It  is  very  difficult,  however,  to  determine  with  any 


degree  of  certainty  what  constitutes  an  abnormal  pro- 
duction and  excretion  of  carbamide.  Moreover,  the 
production  of  urea  is  not  in  ever)'  instance  followed 
by  its  speedy  or  complete  elimination;  partial  reten- 
tion of  some  urea — by  its  reabsorption — is  in  my 
opinion  much  more  frequent  than  is  usually  supposed. 
The  ingested  albuminates  cannot  serve  as  a  basis  for 
the  exact  determination  of  all  the  produced  urea.  We 
may  determine  the  amount  of  nitrogen  ingested,  also 
possibly  that  which  is  excreted;  the  latter,  however, 
by  no  means  represents  closely  or  accurately  the  nitro- 
gen of  the  proteid  nourishment.  In  all  our  calcula- 
tions the  retrograde  tissue  metamorphosis  ought  to  be 
taken  into  due  consideration,  and,  although  a  great 
inany  achievements  and  discoveries  have  been  accom- 
plished in  other  fields  of  scientific  research,  we  have 
not  succeeded  as  yet  in  determining  that  elementar}'- 
point  which  is  essential  (as  a  basis)  for  the  exact  esti- 
mation of  tissue  waste. 


(B.  B ,  male,  aged  35,  German,  unmarried  : 

ration  first  recognized  February  11,  1897.) 


CASE   V. 
father  possibly  was  diabetic,  though  the  .son  is  not  certain  about  this.      Deterio- 


February  Ig,  l8g7. . . . 
P'ebruary  20,  1 897 ... . 
Februar)'  21,  i8g7. . .  . 
Februar)' 22,  l8g7.  .. 
February  23,  i8g7.  . .  . 
P'ebruary  24,  1897. . .  . 
Februar)'  25,  1897. . . . 
February  26,  1897. . . . 
February  27,  1897. . . . 
February  28,  1897. . . . 

March    i.  1897 

March     2,  1897 

March     3,  1897 

March    4,  i8g7 

March     5,  1897 

March    6,  1897 

March     7,  1897 

March    8,  1S97 

March  11,  1897 

March  16,  1S97 

April    2,  1897 

April  16,  i8q7 


a  "a 


1.550 
1,710 
1,780 
1.750 
1,860 
1,680 
1,630 
1,920 
2,100 
2,060 
1,640 
1,720 
1,510 
1,600 
2,150 
1,980 
1,990 
1,830 
1,650 
1,730 
1.540 
1,570 


1.029 
1.030 
1.030 
1.031 
1. 031 
1.030 
1.030 
1. 03 1 
1.03! 
1.032 
1.03 1 
1.030 
l.o2g 
l.02g 
1.030 
1.030 
1.030 
l.02g 
I.02g 
1.028 
1.028 
1.02S 


1-5 
1-7 
1-9 


2.2 
2.3 


1.8 
1-7 


1.9 
1.8 
1-3 


2.8 
2.9 

2-8 

3 

2-7 

2-9 

2.7 

2.8 
2.8 

3 

3-1 

3 


2-7 
2-9 
2-7 
2-9 
3-4 
2.8 

2-7 


Albuminous  :  egg  albumin,  about  5  gm. ; 
milk  (casein,  albumin) ,  100  gm. ;  cheese, 
casein.  1 5  gm. ;  meat,  albumin.  60  gm. ;  ' 
together,  180  gm.,  daily  average. 


-  Non-nitrogenous - 


Albuminous:  as  above. 


n 

1 

&4 

75-5 

75-5 

no 

75 

74-5 

74-5 

231 

74-5 

74 

73-5 

123 

73-5 

97 


78-5   I    6-9 


Status  pncsens  :    Patient  attends  to  his  business  ;  is  emaciated  and  very  irritable  ;  glycosuric  stage  persistent  ;  glucose  in  varying 
amounts  ;  nitrogen  rather  steady. 


878 


MEDICAL    RECORD. 


[December  18,  1897 


As  a  matter  of  convenience  only,  we  may  define  the 
diminished  excretion  of  urea  as  the  retention  of  in- 
gested nitrogen' — that  is,  more  nitrogen  is  introduced 
into  the  system  than  is  eliminated,  and  we  may  define 
the  excessive  excretion  of  carbamide  as  an  increased 
plasmolysis  of  the  living  tissues— that  is,  a  much 
greater  amount  of  nitrogen  passes  out  of  the  system 
than  has  been  ingested. 

I  now  draw  your  attention  to  the  tables. 

Case  I.— From  April  17,  1895,  to  April  29,  1895, 
the  patient  was  under  strict  albuminous  diet.  The 
daily  average  of  ingested  albuminates  I  calculated  as 
185  gm.  The  nitrogen  contained  in  albumin  is  15.6 
per  cent;  the  ingested  nitrogen  therefore  amounted  to 
28.86  gm.  daily.     The  average  daily  quantity  of  voided 


amounted  to  21.5  gm.  and  contained  1.3  per  cent,  of 
urea,  or  0.3  gm.  Within  the  time  of  fasting  and  the 
seven  following  hours,  the  patient  therefore  excreted 
70.6  gm.  of  urea,  which  equals  ^^  g"^.  of  N. 

Case  II. — From  December  28,  1895,  to  January  4, 
1896,  the  patient  lived  on  mixed  food.  The  amount 
of  proteid  matter  therein  contained  was  not  ascertained 
by  me.  In  this  time  she  voided  1,380  c.c.  of  urine  on 
the  average  daily.  The  percentage  cf  urea  in  the 
mean  therein  contained  was  3.4  per  cent.,  or  45.92 
gm.,  indicating  21.45  gm.  of  excreted  N. 

From  January  6,  1896,  to  April  13,  1896,  the  pa- 
tient's nutriment  was  exclusively  albuminous,  consist- 
ing of  about  200  gm.  of  proteia  matter  on  the  average 
daily.     That  is  31.02  gm.  of  ingested  N. 


(T.    K ,  female, 

July  16,  1897.) 


CASE   VI. 
37,   American,   married,   si.x  children   alive;    no  diabetes  in  family.      Deterioration  first  recognized 


Date. 

hi 

1.2 

8'-' 

So 
PS 

Nourishment. 

li 

©■"p 

■j:o 

oa. 

&q 

■?.° 

August    2,  1897 

1,930 

1.045 

4.6 

3.2 

[■  Mixed  diet ;  about  50  gm.  proteids  daily,  -j 

70 

August    3,  1897 

1,850 

1.046 

4.8 

3-5 

August    4,  1897 

2,130 

1.046 

4-9 

3.5 

(  4  litres  of  cow's  railk  :  casein  and  albumin 
j      about  175  gm. 

August    5,  1897 

2,360 

1.045 

4.8 

3-3 

August    6,  1897 

2,600 

1.043 

4 

3-5 

5  litres  of  milk  =  215  gm.  albuminoids  ...    . 

70 

148 

42.5 

4.6 

August    7,  1897 

2,530 

1.043 

3-7 

4.5 

) 

August    8,  1897 

2,940 

1.042 

3.S 

3-1 

J-  5.5  litres  of  cow's  milk  =  237  gm.  albumin. 

August    9,  1S97  .... 

2,810 

1.042 

3-7 

3 

'                         ,       .,                          ,.       ■ 

August  10,  1897 

2,740 

1. 041 

3 

2.4 

4  litres  of  cow  s  milk  =  175  gm.  albumm. .  . 

71-5 

August  14,  1897 

2,120 
1,980 

1.042 
1.040 

2-7 

2.5 

2.7 

2.8 

186 

53-5 

August  16,  1897 

5-5 

August  21,  1897 

1,840 

1.040 

2.6 

2.3 

Carbohydrates,  also  hydrocarbons  :  vege- 

70.5 

August  22,  1897 

1,800 

1.039 

2.4 

2.2 

101.5 

3-1 

August  23,  1897 

1.039 

2.3 

r     table  albumin,  about  20  gm.  daily  aver- <^ 

August  24,  1897 

1,760 

1.040 

2.4 

']      age.  ■ 

August  26,  1S97 

1,600 

1.038 

2.3 

2 

172 

87 

3-5 

August  31,  1897 

1,530 

1.039 

2.4 

2,1 

(  3.5  litres  of  milk  =  about  150  gm.  albumin 

69.5 

September  3,  1897 

2,650 

1. 041 

3.1 

2.1 

i|      and  casein. 

September  4,  1897. .  . . 

2,800 

1.042 

3-3 

2.2 

4  litres  of  milk  =  about  175  gm. 

i  4. 5  litres  of  milk  =  about  200  gm.  albu-  ) 

'(      min  and  casein.                                           f 

138 

61.5 

September  5,  1897. .  . . 

2,760 

1.042 

3-3 

2.1 

Status  pra'sens  ;   Patient  is  emaciated  and  easily  exhaustible,  otherwise  quite  comfortable. 


urine4  during  this  period  amounted  to  3,002  c.c.  The 
average  daily  quantity  of  urea  excreted  by  the  urine 
amounted  to  3.2  per  cent.;  that  is,  96.1  gm.  The 
amount  of  urea  in  the  faces  on  April  29th  was  1.3 
gm.,  that  is  the  total  excretion  of  97.4  gm.  of  urea  in 
twenty-four  hours. 

Urea  contains  46.73  per  cent,  of  nitrogen.  The 
total  of  N  excreted  during  twenty-four  hours  amounted 
therefore  to  45.51  gm. 

Consequently  16.65  &™-  of  N  more  was  excreted 
than  ingested. 

From  May  4  to  May  1 1,  1895,  the  patient  was  under 
a  diet  greatly  abundant  in  non-nitrogenous  material. 
He  voided  during  that  time  on  the  average,  2,415  c.c. 
of  urine  />er  dietn,  containing  in  the  mean  5.5  per  cent, 
of  urea,  which  is  132.82  gm.  F.xamination  of  feeces 
on  May  loth  revealed  the  presence  of  4  per  cent,  of 
urea,  or  1.52  gm.  Under  the  influence  of  non-nitro- 
genous nourishment  he  therefore  excreted  on  the  aver- 
age, 134.34  gm.  of  urea  daily;  that  is,  62.78  of  N. 

On  May  18,  1895,  for  investigation  as  well  as  for 
therapeutic  purposes,  I  kept  the  patient  fasting  for 
seventeen  hours,  allowing  him  only  a  moderate  amount 
of  water  during  that  time.  He  voidetl  in  twenty-four 
hours  (counting  from  the  start  of  the  non-ingestion 
until  about  seven  hours  afterward)  1,850  c.c.  of  urine, 
containing  3.8  per  cent,  of  urea;  that  is,  70.3  gm. 
During   that  period   the  solid  residue  of   his  fsces 

'  This  definition  naturally  presupposes  the  usual  food  supply. 


The  average  of  the  daily  voided  urine  in  this  period 
was  1,617  ^•^■1  ^^'ith  2.8  per  cent,  or  45.27  gm.  of  urea. 
The  faices  were  examined  four  times  within  this  time, 
and  their  solid  residue  averaged  48  gm.  for  twenty- 
four  hours,  with  4.2  per  cent,  or  2.01  gm.  of  urea.  The 
average  of  urea  excreted  by  urine  and  faces  per  diem 
was  therefore  47.28  gm.,  containing  22.09  S"^-  o^  N. 
In  other  words,  there  was  8.93  gm.  of  N.  less  on  the 
average  excreted  per  diem  by  these  channels  than  had 
been  introduced  by  the  nutriment. 

From  May  12,  1896,  to  May  18,  1896,  the  patient 
lived  on  non-nitrogenous  food.  The  average  of  the 
daily  secretion  of  urine  was  then  1,608  c.c,  with  2.5 
per  cent,  or  40.2  gm.  of  urea.  The  fxces  were  ex- 
amined for  urea  thrice  in  this  period,  and  weighed 
when  completely  dehydrated  89  gm.  daily  on  the 
average.  They  contained  in  the  mean  4.9  per  cent,  or 
4.4  gm.  of  urea.  Together,  therefore,  44.6  gm.  of 
urea  was  daily  eliminated  on  tlie  average  at  this  time, 
representing  20. 8  gm.  of  N. 

Case  III. — From  the  date  diabetic  deterioration  was 
first  recognized  until  October  15,  1896,  the  patient 
was  under  strictly  albuminous  diet.  The  consumption 
of  proteid  food  averaged  daily  about  180  gm.,  which 
represents  28.08  gm.  of  N. 

During  that  time  the  average  daily  secretion  of  urine 
amounted  to  4,055  c.c,  with  2.9  per  cent,  or  117.59 
gm.  of  urea.  The  solid  residue  of  the  faeces  was  38 
gm.,  with   7.3   per  cent,   or  2.77   gm.  of  urea.     The 


December  i8,  1897] 


MEDICAL    RECORD. 


879 


120.36  gm.  of  urea  thus  excreted  represented  56.24 
gm.  of  N.  Consequently  28.16  gm.  of  N  less  was 
ingested  than  excreted. 

From  October  17,  1896,  to  November  6,  1896,  the 
patient  lived  on  a  mixed  diet,  that  is,  about  120  gm. 
of  albumin,  representing  1,872  gm.  of  N,  was  ingested 
per  diem. 

The  urine  on  the  average  was  excreted  to  the  amount 
of  2,800  c.c.  in  twenty-four  hours,  containing  3.6  per 
cent,  or  100.8  gm.  of  urea. 

The  solid  residue  of  the  faeces  on  November  6th 
amounted  to  41  gm.,  and  contained  5.5  per  cent,  or 
2.3  gm.  of  urea.  Taking  this  as  the  average,  103.  i 
gm.  of  urea  was  excreted  daily.  Thus  48.18  gm.  of  N 
left  the  body  by  urine  and  fffices,  while  only  18.72  gm. 
of  N  had  been  introduced  by  nutriment,  leaving  there- 
fore a  N  deficit  in  the  sytem  of  29.46  gm. 

From  November  20  to  December  28,  1896,  on  ac- 
count of  an  albuminuria  which  had  since  developed, 
carbohydrates  were  prevailing  in  the  patient's  food. 
The  amount  of  albuminates  and  albuminoids  in  the 
nutriment  averaged  about  70  gm.  daily,  and  contained 
10.92  gm.  of  N. 

The  quantity  of  urine  voided  during  that  epoch  was 
on  the  daily  average  1,817  c.c,  and  contained  in  the 
mean  3.4  per  cent,  or  61.78  gm.  of  urea.  The  residual 
faeces  on  December  nth  amounted  to  72.5  gm.,  and 
contained  1.5  per  cent,  or  1.09  gni.  of  urea.  Together 
on  the  average,  62.87  gm.  of  urea,  holding  29.45  gm. 
of  N,  was  daily  excreted.  This  means  a  daily  N 
deficit  of  18.53  gm.  for  this  period. 

Case  IV. — From  December  16,  1896,  to  December 
19,  1896,  the  patient  was  under  an  exclusive  albumi- 
nous diet,  180  gm.  of  albumin  in  milk,  eggs,  and  meat 
being  about  the  daily  average.  Thus  the  ingested  N 
amounted  to  28.08  gm.  per  diem. 

The  urine  voided  during  these  four  days  averaged 
5,830  c.c.  daily,  and  contained  7.6  per  cent,  or  443.8 
gm.  of  carbamide.  This  means  the  excretion  of  207.05 
gm.  of  N,  or  of  178.97  gm.  more  than  was  taken  with 
the  food. 

On  December  20,  1896,  I  kept  the  patient  fasting. 
This  was  done  for  therapeutic  purposes,  according  to 
Naunyn's  and  von  Mering's  suggestions.  The  urine 
voided  for  the  whole  twenty-four  hours  (the  fasting 
did  not  quite  last  all  that  time)  amounted  to  2,120 
c.c,  with  8  per  cent,  or  169.6  gm.  of  urea.  This  repre- 
sents 79.25  gm.  of  excreted  N,  while  practically  there 
was  none  ingested. 

From  December  28  to  December  31,  1896,  I  had 
the  patient  under  food  of  a  pronounced  carbohydrate 
nature.  The  proteids  which  were  thus  ingested 
amounted  to  about  50  gm.  daily,  and  contained  7.8 
gm.  of  N. 

The  urine  passed  during  this  period  averaged  4,590 
gm.  daily,  with  8.2  per  cent,  or  376.38  gm.  of  urea. 
The  faeces,  which  I  examined  for  glucose  and  carb- 
amide on  December  31st,  weighed  when  completely 
dehydrated  84  gm.,  and  held  3.5  per  cent,  or  2.94  gm. 
of  urea.  The  total  amount  of  urea  therefore  averaged 
379.32  gm.  daily,  and  177.26  gm.  of  N  was  therein 
contained.  Consequently  169.46  gm.  of  N  more  was 
excreted  than  ingested  at  an  average  daily  for  this 
period. 

From  January  3  to  January  5,  1897,  the  patient  was 
again  under  an  albuminous  diet,  and  consumed  about 
190  gm.  of  proteid  material  daily,  which  contained  29.6 
gm.  of  N. 

The  quantity  of  urine  voided  amounted  in  the  mean 
to  5,100  c.c,  and  held  7.8  per  cent,  or  397.8  gm.  of 
urea.  The  latter  represents  185.9  S'^*-  of  excreted  N, 
156.3  gm.  more  than  was  introduced  with  the  nourish- 
ment. 

Case  V. — Until  February  25,  1897,  the  patient  was 
under  a  totally  albuminous  diet,  that  is,  about  180  gm. 


of  different  albuminates  and  albuminoids  was  daily  in- 
gested ;   180  gm.  of  albumin  represents  28.  08  gm.  of  N. 

The  daily  average  of  urine  passed  amounted  to  1 ,708 
c.c,  with  2.8  per  cent,  or  47.82  gm.  of  urea.  The 
fseces  when  examined  on  February  22d  weighed  63.5 
gm.  in  their  dry  state,  and  contained  just  5  per  cent, 
or  3-77  gm-  of  urea.  Taking  the  latter  as  an  average, 
the  total  daily  excretion  of  urea  amounted  to  51.59 
gm.,  representing  24.1 1  gm.  of  N.  This  indicates  that 
3.97  gm.  of  N  more  was  ingested  than  was  eliminated 
by  the  kidneys  and  bowels. 

From  February  26  to  March  4,  1897,  for  a  period  of 
one  week,  the  patient  lived  upon  non-nitrogenous  nu- 
triment. (I  would  like  to  add  that  the  patient,  a 
highly  intelligent  and  educated  gentleman,  readily 
consented  to  take  an  absolutely  carbohydrate  nourish- 
ment with  the  least  possible  quantity  of  hydrocarbons, 
if  it  were  for  diagnostic  and  experimental  purposes.) 

The  urine  voided  during  the  twenty-four  hours  aver- 
aged 1,793  c.c,  and  contained  2.9  per  cent,  or  52  gm. 
of  urea. 

The  faeces,  when  analyzed  on  March  2d,  in  their 
residual  condition,  amounted  to  97  gm.,  and  contained 

4.07  per  cent,  or  4.57  gm.  of  urea.  Taking  the  latter 
as  an  average  of  the  quantity  of  the  stools,  we  have 
56.57  gm.  of  daily  urea  elimination;  that  is,  26.44 
gm.  of  N.  From  March  5  to  April  16,  1897,  and 
thereafter,  the  patient  was  under  an  albuminous  diet 
again,  ingesting  about  180  gm.  of  albumin  or  28.08 
gm.  of  N. 

The  daily  average  amount  of  urine  was  1,805  '^•'^•> 
with  2.8  per  cent,  or  50.54  gm.  of  urea.  The  dried 
faeces  on  March  nth  weighed  78.5  gm.,  and  contained 
6.9  per  cent,  or  5.42  gm.  of  urea.  Taking  the  latter 
again  as  the  average  quantity  of  the  stools,  we  have  a 
daily  average  excretion  of  55.96  gm.  of  urea,  or  of 
26.15  gm.  of  N,  1.93  gm.  less  than  was  ingested. 

Case  VI. — Until  August  4,  1897,  the  patient  was 
under  a  mixed  diet  which  contained  about  50  gm.  of 
albumin  daily.     This  amount  of  albumin  represents 

7.8  gm.  of  N. 

The  urine  during  this  period  was  excreted  to  the 
average  amount  of  1,970  c.c.  daily,  with  3.4  per  cent, 
or  67  gm.  of  urea,  which  latter  contains  31.31  gm.  of 
N — this  means  a  N  deficit  of  23.51  gm.  On  August 
6,  1897,  the  patient  took  as  nutriment  five  litres  of 
cow's  milk,  containing  about  215  gm.  of  casein  and 
albuminates.  This  proteid  matter  represents  33.54 
gm.  of  N. 

The  quantity  of  urine  on  that  day  was  2,600  c.c, 
and  3.5  per  cent,  or  91  gm.  of  urea  was  held  therein. 
The  solid  residual  faces  amounted  to  42.5  gm.,  and 
contained  4.6  per  cent,  or  1.96  gm.  of  urea.  Together 
92.96  gm.  of  urea,  or  43.44  gm.  of  N,  was  e.xcreted 
that  day;  that  is,  9.90  gm.  of  N  more  was  eliminated 
than  was  introduced  by  nourishment. 

From  .\ugust  21st  to  the  end  of  that  month,  carbo- 
hydrates and  hydrocarbons  served  as  nutriment  of  the 
patient.  The  approximate  amount  of  vegetable  albu- 
min contained  in  the  food  I  figured  at  20  gm.  daily; 
that  is,  3.1  gm.  of  N. 

The  average  amount  of  urine  voided  per  die7n  was 
1,730  c.c,  with  2.2  per  cent,  or  38.1  gm.  of  urea.  The 
residual  faeces  of  August  22d  and  26th,  arriounting  in 
the  mean  to  94  gm.,  contained  3.3  per  cent,  or  3.1  gm. 
of  urea;  therefore  the  daily  average  of  excreted  urea 
amounted  to  41.2  gm.  of  urea  or  19.25  gm.  of  N.  Thus 
we  had  here  an  excess  of  16.15  gm-  of  N  over  the 
amount  of  N  ingested. 

A  study  of  the  cited  cases  will  demonstrate: 

1.  That  diabetic  glycosuria  per  se  is  not  directly 
dependent  upon  alimentation. 

2.  That  the  ingested  carbohydrates  do  not  influence 
the  diabetic  condition — to  that  extent — as  generally 
supposed. 


88o 


MEDICAL    RECORD. 


[December  i8,  1897 


3.  That  diabetic  azoturia  is  a  distinctive  phenome- 
non during  the  glycosuria  stage  of  diabetic  deteriora- 
tion. 

4.  That  diabetic  azoturia  is  not  a  direct  result  of 
hyperingestion  of  albuminous  materials. 

5.  That  the  amount  of  nitrogen  excreted  during  the 
second  stage  of  diabetic  deterioration  nearly  always 
exceeds  that  of  the  nitrogen  introduced  with  the 
nutriment. 

Von  Noorden,'  the  latest  exponent  of  diabetes  mel- 
litus,  alluding  to  his  own  observations  as  well  as  to 
those  of  Lusk,  F.  Voit,  Hirschfeld,  and  Weintraut, 
still  maintains  that  the  waste  of  nitrogen  is  the  greater 
the  more  the  food  value  is  depreciated  by  glycosuria, 
that  this  waste  is  very  large  as  long  as  the  diabetic  is 
allowed  to  ingest  the  carbohydrates  which  are  useless 
to  him,  and  that  it  diminishes  or  discontinues  when 
the  nourishment  consists  to  the  greater  part  of  proteids 
and  fats. 

"I  am  strongly  inclined,"  says  von  Xoorden,  "to 
define  the  disease  as  follows:  By  the  term  diabetes 
mellitus  is  understood  a  disease  in  which  the  capacity 
of  the  organism  for  burning  up  grape  sugar  is  mor- 
bidly depressed.  We  shall,  indeed,  see  that  all  the 
phenomena  of  diabetes  may,  without  compulsion,  be 
explained  by  this  formula,  yet  I  hesitate  to  place  the 
de:inition  at  the  head  of  this  treatise,  for  the  reason 
that  we  have  as  yet  no  certain  evidence  that  it  ex- 
haustively explains  the  condition  actually  present." 

Von  Noorden  considers  diabetes  mellitus  still  as  a 
disease  per  se,  and  caused  by  a  disturbed  chemismus, 
particularly  of  the  glycolytic  power  of  the  organism, 
and,  though  this  observer  differentiates  minutely  be- 
tween glycosuria  and  diabetes  proper,  he  has  not  as 
yet  recognized  the  diabetic  deterioration. 

IV.  Deductions Albuminous  substances  are  of  a 

highly  complex  structure,  and  the  position  of  their 
molecules  is  easily  disturbed.  Even  the  slightest  in- 
fluence may  cause  an  alteration  in  the  latters'  position, 
and  thus  plasmatic  bodies  are  readily  changeable  or  de- 
composed. There  are  numerous  and  vaiying  phases  in 
the  process  of  decomposition  of  albumin.  Some  phases 
will  recur  often  and  are  deemed  normal :  others  will 
not  recur  regularly,  and  we  may  consider  such  phases 
abnormal. 

There  is  no  doubt  that  the  decomposition  of  albu- 
min under  certain  conditions  will  give  rise  to  the  for- 
mation'of  de.xtrose.  In  glycogen-free  animals  there 
will  occur  a  new  production  of  glycogen,  if  they  are 
subjected  even  to  none  but  nitrogenous  food.  Some 
of  the  C-H-O  molecules  of  albumin  may  combine 
themselves  to  form  a  carbohydrate  body"  or  a  series 
of  similar  cpmpounds  before  their  final  and  ultimate 
conversion  in  CO.,  and  H„0,  in  which  form  they  leave 
the  organism.  The  N  molecule  of  the  decomposing 
albumin  will  remain  attached  to  some  of  the  original 
C-H-O  atoms,  and  may  give  rise  to  the  simultaneous 
or  alternate  formation  of  a  variety  of  non-colloid  nitro- 
genous substances,  as,  for  instance,  amido-caproic  acid 
(leucin),  C„H,„(NHJO.OH;  tyrosin,  C,H,,NO,;  carb- 
amide, CO(NH,,y.,  and  many  others.  The  ultimate 
disposal  of  the  X  molecule  occurs  in  the  form  of 
ammonia.  It  is,  moreover,  not  improbable  that  a  part 
of  the  N  molecule  of  albumin,  without  undergoing 
the  different  processes  of  transformation,  is  at  once 
converted  into  ammonia. 

If  tlie  formation  of  a  glucose-resembling  carbo- 
hydrate from  the  ingested  proteids  is  a  definite  fact, 
then  I  see  no  reason  why  the  protoplasm  of  the  living 

'  "  Die  Zuckerkrankheit  und  ihie  Uehandlung."  Berlin,  1S95  ; 
translation  of  the  same  as  "Diabetes  Mellitus,"  "Twentieth 
Century  Practice,"  vol.  ii.,  New  York,  1895. 

■Minkowski  ("  Untersuchungen  iiber  den  Diabetes  mellitus." 
Leipzig,  lSg3)  maintains  that  a  hundred  grams  of  albumin 
split  up  in  the  body  produce  at  least  forty-five  grams  of  carbo- 
hydrates. 


organism — under  appropriate  conditions — should  not 
also  be  dextrose-generic. 

It  may  be  assumed  that  the  molecules  of  the  tissue 
proteids — when  subjected  to  certain  influences — are 
capable  of  altering  their  respective  positions  in  a  sim- 
ilar manner  as  do  those  of  ingested  albumins.  That  is, 
plasmolysis  of  the  living  tissues  may  occur,  normally 
or  abnormally,  under  the  formation  of  a  glucose-like 
substance.  The  generation  of  dextrose  by  the  living 
protoplasm  is  not  necessarily  followed  by  the  latter's 
spontaneous  and  complete  dissolution.  It  may  regen- 
erate if  its  production  of  glucose  is  a  normal  process, 
or  it  may  persist  for  some  time — minus  the  molecules 
of  the  generated  carbohydrate — if  the  process  is  an 
abnormal  one.  In  the  latter  instance,  how-ever,  there 
is  then  no  protoplasm  as  such  any  more,  and  it  is  only 
a  question  of  time  until  its  ultimate  destruction.' 

The  healthy  organism  by  plasmolysis  may  generate 
a  dextrose-resembling  carbohydrate  normally,  which  in 
turn  may  undergo  a  series  of  conversions  until  its  ulti- 
mate disposal  as  CO..  One  of  these  intermediate 
steps  may  be  the  formation  of  glycogen.  In  the  dia- 
betic condition  the  production  of  this  amylaceous  sub- 
stance from  dextrose  may  be  decreased  or  totally  sus- 
pended. The  direct  consequence  of  this  would  be 
diminished  or  no  formation  of  fat,  emaciation,  and,  if 
the  dextrose  has  not  undergone  other  alterations,  hyper- 
glykaemia  and  appearance  of  the  glucose  in  the  excre- 
tions. The  accompanying  azoturia  may  be  accounted 
for  by  an  increased  plasmol3'sis. 

The  generation  of  dextrose  by  plasmolysis  is,  how- 
ever, in  all  probability  an  abnormal  process.  In  that 
case  the  plasmolysis  is  a  catabolic  process  whereby 
the  plasmatic  substance  cannot  regenerate,  and  be- 
comes disintegrated.  This  dissimilation  of  the  living 
protoplasm  occurs  more  in  the  character  of  a  deteriora- 
tion ;  that  is,  the  protoplasm  to  all  appearances  may- 
continue  to  exist,  although  it  has  lost  its  molecular 
integrity. 

This  plasmolytic  de.xtrose-generic  process  I  desig- 
nate as  diabetic  deterioration. 

In  other  words,  diabetic  deterioration  is  a  more  or 
less  limited  molecular  disintegration  of  plasmatic  tis- 
sue substance  into  a  glucose-like  body  and  a  non- 
colloid  nitrogenous  compound. 

Diabetic  deterioration  is  always  a  systemic  and 
general  affection.  The  transitory  form  of  so-called 
diabetes,  the  glycosurias  of  diverse  origin — even  ex- 
perimental pancreatic  diabetes — is  in  the  first  instance 
always  the  result  of  local  disturbances.  It  is  true,  the 
causative  factor  of  the  deterioration  may  exert  its  in- 
fluence upon  the  organism  through  only  one  channel, 
but  it  will  not  affect  one  organ  more  than  another, 
and  all  the  protoplasm  will  lose  its  molecular  integrity. 

I  classify  among  diabetic  deterioration,  irrespec- 
tively of  the  percentage  of  dextrose  present,  all  those 
chronic  cases  of  glvcosuria  in  which  the  excretion  of 
the  urea,  the  carrier  of  part  of  the  N  molecules  of  the 
tissues,  continues  to  be  permanently  in  e.xcessi  that  is, 
when  the  amount  of  excreted  N  constantly,  during  a 
certain  period,  exceeds  the  quantity  of  that  which  has 
been  ingested  with  the  nourishment. 

In  order,  therefore,  to  recognize  diabetic  deteriora- 

'  Physiological  chemistry  is  limited  by  natural  boundaries. 
The  innermost  vital  reactions  and  processes  can  only  be  antici- 
pated but  never  positively  ascertained.  Interference  with  the 
organism  for  investigatingpurposes  causes  spontaneous  altera- 
tion of  the  tissue  molecules,  and  that  which  we  happen  to  ex- 
amine scrutinously  is  a  different  thing  from  that  which  it  was  in 
the  system.  Thus  we  know  nothing  detinitely  about  plasmatic 
substances  in  a  chemical  respect.  What  we  may  examine  is  not 
the  protoplasm  any  more  ;  it  has  been  protoplasm.  .-Vs  we  do 
not  know  anything  about  the  intrinsic  changes  in  living  pro- 
toplasm, it  stands  to  reason  that  we  cannot  account  for  many 
diseases.  This  is  particularly  true  of  diabetes,  in  which,  with  ex- 
ception of  eventual  secondan.-  changes,  nothing  is  perceivable, 
neither  during  life  nor  in  necroscopies. 


December  i8,  1897] 


MEDICAL    RECORD. 


>i 


tion  definitely,  the  patient  ought  to  be  kept  under 
rigid  observation  for  some  time.  His  food  should 
always  be  weighed  and  the  percentage  of  its  nutritive 
constituents  approximately  ascertained.  This  has  to 
be  done  especially  with  its  proteid  matter.  The  ex- 
cretions must  be  carefully  measured  or  weighed,  and 
the  urine  examined  for  glucose.  Following  this,  an 
exact  determination  of  the  carbamide  contained  in 
urine  and  fa?ces  should  be  undertaken  and  its  contents 
of  N  calculated.  Finally  the  amount  of  excreted  N 
should  be  compared  with  that  introduced  by  the  food. 
There  are  very  likely  other  substances  besides  glucose 
and  urea,  as  the  result  of  a  dextrose-generic  plasmoly- 
sis,  to  be  met  with  in  the  excretions,  but  I  have  not 
made  any  observations  in  this  respect  as  yet. 

The  later  stages  of  development  of  an  individual 
and  the  following  decade,  seem  to  me  to  be  that  period 
during  which  dextrose-generic  plasmolysis  mostly  oc- 
curs. Thus  diabetic  deterioration  may  be  described  as 
an  affection  following  individual  development. 

The  underlying  causes  of  the  disintegration  of  pro- 
toplasm and  its  resulting  production  of  glucose  and 
carbamide  seem  to  be  a  part  of  a  probable  inherent 
quality  of  the  protoplasm,  of  a  purely  physico-chemical 
nature.  Whatever  they  may  be,  this  much  I  can  say 
with  certainty,  that  digestive  disturbances  are  never 
the  main  factors  of  diabetic  deterioration. 

My  arguments  are  to  some  extent  based  necessarily 
upon  hypothesis.  But  is  not  hypothesis  the  instigator 
to  scientific  research  ?  Has  it  not  been  the  foundation 
for  the  establishment  of  many  an  invincible  truth? 

1338  Lexingto.n  Avenl-e. 


IS   NOT  THE  MORTALITY  FROM  SURGICAL 
DISEASE   LARGER   THAN    NECESSARY?  = 

By   CHARLES   McBURNEY,    M.D., 

With  anaesthesia,  asepsis,  and  greatly  enlarged  and 
improved  operative  surgery,  the  immediate  danger  to 
life  from  surgical  interference  has  ver}'  greatly  dimin- 
ished, so  that  increased  confidence  has  become  es- 
tablished in  the  minds  of  surgeons,  physicians,  and 
patients  that  few  cases  of  surgical  disease  can  reach 
such  an  advanced  stage  as  entirely  to  preclude  the 
possibility  of  relief  by  operation.  And  it  is  true  that 
many  conditions  which  formerly  were  necessarily  fatal 
because  they  were  considered  to  be  beyond  the  reach 
of  surgery  are  now  safely  operated  upon,  and  more  or 
less  completely  relieved. 

Even  partial  success  in  these  desperate  cases  is  a 
very  proper  source  of  pride  to  the  surgeon,  and  each 
one  stimulates  him  to  still  greater  effort  to  save  those 
who  are  nearly  moribund.  The  more  desperate  the 
condition  and  the  greater  the  risk,  the  more  intense 
his  interest,  provided  the  possibility  of  success  by 
care  and  skill  exists.  This  feeling  is  to  a  certain 
extent  shared  by  the  physician,  who  now,  much  more 
frequently  than  in  former  times,  calls  upon  the  sur- 
geon for  aid,  even  in  very  desperate  conditions.  In 
this  way  every  surgeon  becomes  familiar  with  cases 
for  which  he  can  do  little  or  nothing,  because  the  dis- 
ease has  already  gone  too  far. 

During  the  last  few  years  I  have  been  especially 
struck  with  the  rapidity  with  which  many  cases  of  sur- 
gical disease  advance  from  a  condition  that  is  entirely 
curable  to  one  that  is  entirely  incurable,  or  from  one 
that  can  be  completely  and  radically  treated  to  one 
that  can  be  only  partially  relieved.  Probably  almost 
all  surgical  cases  have  their  time  limit,  before  which 
with  proper  treatment  complete  recovery  can  be  as- 
sured, and  after  which,  at  least  with  our  present  re- 

'  Paper  read  before  the  Practitioners'  Society  on  Friday,  No- 
vember 5,  1S97. 


sources,  no  efforts  can  be  entirely  successful.  Exactly 
what  this  time  limit  is  in  each  individual  case  we  do 
not  accurately  know,  but  that  there  is  such  a  limita- 
tion which  is  well  worth  our  constant  thought  and 
study  I  am  firmly  convinced.  Take,  for  instance, 
a  case  of  strangulated  hernia.  Is  there  not  undoubt- 
edly a  moment  up  to  which  the  possibility,  after  relief 
of  the  strangulation,  of  a  return  of  circulation  in  the 
involved  gut  still  exists,  and  a  moment  immediately 
following  when  such  complete  re-establishment  of  the 
blood  current  becomes  impossible?  Or,  in  a  case  of 
progressive  septic  peritonitis,  is  there  not  a  sharp 
limit  to  the  time  within  which  the  removal  of  the  pri- 
mary source  of  the  sepsis  and  of  its  local  products  is 
capable  of  putting  an  end  to  the  disease  ?  And  does 
not  after  this  limit  immediately  begin  a  period  when 
such  a  condition  of  general  sepsis  is  established  as 
entirely  precludes  the  possibility  of  recovery?  Or  in 
a  case  of  carcinoma  of  the  breast  is  there  not  a  brief 
period  during  which  the  disease  is  absolutely  local 
and  so  open  to  radical  cure,  and  immediately  after 
this  a  period  when  invasion  of  lymphatic  vessels  ren- 
ders operative  work  only  palliative?  As  further  in- 
stances I  would  enumerate  carcinomata  and  sarcomata 
in  many  different  parts  of  the  body,  cases  of  bowel 
obstruction  due  to  whate\er  cause,  all  wound  infec- 
tions, and  especially  suppurative  diseases  involving 
or  threatening  to  involve  the  peritoneum.  All  of  these 
diseases,  with  certain  rare  exceptions,  when  old  age  or 
complications  of  various  kinds  render  surgical  treat- 
ment inadmissible,  are  at  the  proper  time  susceptible 
of  complete  and  radical  cure.  In  other  words,  there 
actually  is  a  time  limit  before  which  death  can  be 
averted,  and  after  which  death  is,  immediately  or 
remotel)-,  inevitable. 

The  question  that  I  would  raise  is :  Do  we  to-day, 
with  all  our  eagerness  to  improve  the  results  of  our 
surgical  work,  devote  nearly  enough  attention  to  the 
limit  of  time  when  perfect  surgery  is  possible? 

Even  leaving  out  the  question  of  life  and  death, 
what  shall  we  say  in  regard  to  the  extension  of  dis- 
ease from  one  tissue  to  another,  calling  at  a  late  pe- 
riod for  a  much  more  extensive  or  mutilating  operation 
than  would  have  been  required  but  a  very  short  time 
before  ? 

What  an  enormous  difference  between  a  case  of 
strangulated  hernia  operated  on  at  a  time  when  a 
complete  operation  can  be  done  and  the  hernia  radi- 
cally cured,  and  a  case  operated  on  at  a  later  stage, 
when  gangrene  of  the  gut  has  occurred,  calling  for 
resection  of  the  intestine,  followed  by  intestinal  anas- 
tomosis or  a  permanent  artificialanus!  Compare  two 
cases  of  appendicitis,  one  operated  on  in  the  period 
of  quiescence  after  the  first  attack,  and  the  other  oper- 
ated on  during  the  second  attack,  when  suppurative 
peritonitis  renders  a  wide-open  wound  necessary  and 
a  large  bulging  hernia  naturally  follows.  Besides 
these  more  marked  instances,  many  others  could  be 
given  in  which  the  transition  from  simplicity  to  com- 
plication is  less  clearly  defined.  To-day  a  diseased 
joint  may  be  safely  treated  by  resection;  in  a  week 
amputation  will  be  necessary  to  save  life.  In  the  case 
that  I  presented  to-night,  there  was  a  prolonged  period 
when  simple  extirpation  of  the  tonsil  would  have  been 
sufficient.  When  the  patient  came  under  my  care,  the 
disease  had  extended  so  far  on  to  the  lower  jaw  that  it 
was  necessary  to  sacrifice  the  whole  of  the  ramus.  The 
probability  of  inoperable  recurrence  of  disease  in  this 
case  is  much  greater  than  it  would  have  been  had  the 
operation  been  done  two  or  three  months  earlier. 

It  is  clear,  of  course,  that  the  mortality  from  surgical 
disease  would  be  very  much  diminished  if  all  cases 
could  be  subjected  to  treatment  before  the  time  limit- 
ing the  possibility  of  perfect  cure  had  been  passed. 
The  responsibility  for  not  allowing  this  limit  to  be 


MEDICAL    RECORD. 


[December  i8,  1897 


passed  is  then  very  great,  and  deserves  the  fullest  ap- 
preciation. That  in  many  cases  the  limit  cannot  at 
present  be  accurately  defined  is  undoubtedly  true,  and 
that  it  will  even  be  thoroughly  understood  in  all  cases 
is  not  probable.  It  is  easy  enough,  however,  to  appre- 
ciate the  initial  stages  of  many  .surgical  diseases,  and 
knowledge  of  their  natural  history  should  enable  a 
moderately  careful  professional  observer  roughly  to 
anticipate  the  limit  before  which  treatment  may  be 
safe  and  perfect.  A  natural  comment  on  these  obser- 
vations might  be  made,  that  they  are  trite  enough,  and 
that  every  one  knows  that,  as  a  rule,  the  earlier  in  any 
surgical  disease  proper  treatment  is  begun,  the  more 
secure  will  be  a  completely  favorable  result. 

The  point  that  I  wish  especially  to  make  is  that 
the  sense  of  responsibility  in  selecting  the  time  for 
surgical  interference  is  in  many  instances  not  suffi- 
ciently acute,  and  that  delay,  in  some  cases  of  a  few 
hours,  in  others  of  days,  and  in  others  of  weeks,  ac- 
tually directly  leads  to  partial  or  complete  failure,  or 
even  to  death  itself.  It  is  not  always  easy  to  decide 
upon  whom  this  important  responsibility  rests.  Some- 
times the  surgeon  himself  is  at  fault;  sometimes,  and 
not  infrequently,  the  responsibility  for  fatal  delay  be- 
longs to  the  medical  practitioner  who  first  has  charge 
of  the  patient;  sometimes  the  division  of  responsibil- 
ity among  too  many  persons  leads  to  the  unfortunate 
result;  and  often  enough  no  one  is  to  blame  but  the 
timid  patient  and  his  ill-advising  friends.  I  cannot 
but  believe  that  many  of  the  obstacles  'to  complete 
surgical  success  could  be  removed,  and  the  mortality 
from  surgical  disease  largely  reduced,  if  the  grave  im- 
portance of  selecting  the  early  stages  of  disease  for 
surgical  interference  was  more  clearly  realized.  Fail- 
ure to  select  the  most  favorable  opportunity  for  surgi- 
cal interference  is  responsible  for  a  very  large  part  of 
the  mortality  following  surgical  disease. 


MIDWIFERY    AND    MIDWIFE.' 
By  C.    a.    von   RAMDOHR,    M.D., 

PROFESSOR  OP  OBSTETRICS,  NE^V  YORK  POST-GRADUATE  MEDICAL  SCHOOL ; 
GYN/liCOLOGIST  TO  ST.  MARk's  HOSPITAL  AND  GERMAN  POLIKLINIK  ; 
MEMBER  OF  THE  NEW  YORK  STATE  MEDICAL  SOCIETY,  NEW  YORK 
COUNTY   MEDICAL   SOCIETY,    ETC. 

Mr.  President  and  Gentlemen  :  The  subject  of  my 
paper,  />,  the  undesirability  of  having  midwives  in 
New  York  State  under  such  conditions  as  at  present 
exist,  has  lately  been  brought  home  to  me  so  forcibly 
again  and  again,  and  has  recently  been  touched  upon 
so  frequently  in  medical  societies  that  I  have  ventured 
once  more  to  try  to  interest  your  honorable  society  in 
the  highest  therapeutics  for  this  malady,  viz.,  preven- 
tion of  the  disease. 

A  confinement,  as  we  are  all  supposed  to  know,  is  a 
perfectly  physiological  procedure  which  nature  ordi- 
narily can  and  will  take  care  of.  An  Indian  woman 
on  the  march  will  give  birth  to  a  child,  wash  in  the 
river,  and  be  able  to  catch  up  with  the  tribe,  which 
has  left  her  behind  alone  to  attend  to  her  function. 
The  Esquimaux,  when  a  woman  gets  in  labor,  give  her 
provisions  for  three  days  and  close  the  door  of  the  ice- 
built  cabin  with  a  big  slab  of  ice.  If  after  three  days 
the  wail  of  an  infant  is  heard,  the  happy  mother  and 
child  are  liberated.  If  not,  the  door  is  not  opened 
again.  We  civilized  people,  however,  have  become  so 
accustomed  to  assistance  being  given  our  women  when 
child  bearing,  that  our  newspapers  report  a  case  in 
which  such  an  event  has  taken  place  without  atten- 
dance, be  that  on  tlie  street  or  in  some  public  convey- 
ance ;  and  yet  they  forget  to  report  that  usually  no  bad 
consequences  result  to  mother  or  offspring. 

'  Re.id  before  tlie  Society  of  Medical  Jurisprudence  at  its  one 
hundred  and  twenty-nintli  regular  meeting,  November  8,  1897, 
at  1 7  West  Forty-third  Street. 


The  dangers  of  child  bearing  with  us  lie  in  infec- 
tion firstly,  and  meddlesomeness  secondly.  It  has 
been  proved  time  and  time  again  that  if  the  conscien- 
tious accoucheur  holds  it  his  duty  to  be  simply  to  see 
that  no  complications  are  present,  or  likely  to  arise, 
and  simply  to  watch  nature,  he  will  be  much  prefer- 
able to  some  charlatan  who  pretends  to  an  overcredu- 
lous  public  that  he  can  supersede  her.  That  each  and 
every  person  who  comes  in  contact  with  the  patient  is 
j)erfectly  clean  and  does  not  introduce  infection,  sep- 
sis, blood  poisoning — call  it  what  you  will — ought  to 
be  perfectly  understood,  but  unhappily  cases  which  we 
know  can  and  ought  to  be  prevented  prove  that  even 
the  medical  profession  is  sometimes  too  lax  in  disci- 
plining itself  in  such  a  vital  matter.  Sepsis  is  prac- 
tically an  unknown  disease  in  lying-in  institutions  at 
the  present  time,  but  examine  the  records  of  death 
among  the  poorer  classes,  just  such  as  are  attended 
primarily  by  midwives,  and  you  will  find  them  appal- 
ling, even  while  complacent  medical  men  occasionally 
seem  not  to  be  able  to  write  the  word  sepsis  on  their 
death  certificates. 

Now,  let  us  see  why  we  have  to  deal  with  midwives 
at  all.  From  ancient  times  on,  some  women  have  pre- 
ferred, and  during  some  periods  have  been  obliged  to 
rely  upon  the  ministrations  of  their  own  sex  during  this 
critical  time.  Women  like  Mme.  Siegmund  and  Mme. 
Lachapelle  have  left  their  mark  in  the  history  of  ob- 
stetrics and  given  lustre  to  the  highly  respectable  call- 
ing of  a  midwife  in  the  best  sense  of  the  word. 

In  continental  countries  such  a  calling  is  an  essen- 
tial factor  in  districts  w  here  distance  or  paucity  of  med- 
ical men  make  it  impossible  for  them  to  officiate  in  all 
cases.  In  our  country,  and  especially  in  our  large 
cities,  and  again  chiefly  in  this  cosmopolis.  New  York, 
this  institution  has  remained  as  a  relic  of  the  past,  a 
bond  of  former  home  life;  or  the  employment  of  mid- 
wives  is  propagated  on  account  of  financial  reasons,  for 
— and  now  comes  one  of  the  sources  of  dangers  to  the 
community — the  midwife  does  not  only  for  a  paltry 
sum  minister  to  the  woman  during  her  confinement, 
but  comes  for  nine  more  days  to  wash  and  clean  mother 
and  child  and  attend  to  any  other  household  duties 
which  her  good  nature  or  her  business  interest  seem  to 
make  commendable.  That  this  woman  in  the  best  of 
cases  can  hardly  keep  her  person  and  clothes  in  per- 
fect sanitary  order  under  such  circumstances  can  be 
understood ;  that  occasion  frequently  arises  when  medi- 
cal advice  is  asked  during  those  nine  days,  ay!  and 
later,  too,  and  given  with  a  right  good  will  is  no  se- 
cret. That  women  apply  for  fceticide  most  frequently 
to  those  persons  who  have  confined  them  is  a  fact. 

Let  us  now  see  from  what  material  in  the  older 
countries  midwives  are  selected  and  how  they  are 
drilled.  For  all  practical  purposes  their  training  and 
duties  are  the  same  in  all  European  States.  A  mar- 
ried woman  wants  to  eke  out  the  scanty  wages  of  her 
husband,  or  a  widow  applies  with  a  certificate  of  good 
character  to  the  county  physician,  with  whom  she  is 
probably  acquainted,  and  after  a  good  deal  of  red  tape 
is  admitted  into  one  of  those  lying-in  asylums  which 
the  government  maintains  for  the  delivery  of  poor  wo- 
men and  the  training  of  midwives.  Here  for  six 
months  or  a  year  she  is  taught,  not  how  to  perform 
obstetrical  operations,  but  first  to  wash  and  brush  her 
hands,  to  keep  herself  tidy,  to  be  subject  always  to  the 
orders  of  a  physician,  never  to  prescribe,  never  to  inter- 
fere, but  to  call  assistance  in  such  given  cases  as  need 
be.  Now  at  tlie  same  time  she  is  taught  in  a  popular 
way,  theoretically  as  well  as  practically,  the  physiology 
of  labor  and  her  own  duties  to  mother  and  child  during 
that  time,  and  what  she  has  to  do  to  the  reconvalescent 
woman.  She  is  always  under  the  super\-ision  of  peo- 
ple trained  to  teach  just  such  novices.  She  is  never 
left  unwatched;    time  and  time  again  her  hands  are 


December  i8,    1897] 


MEDICAL    RECORD. 


883 


examined  as  to  their  absolute  cleanliness;  again  and 
again  it  is  dinned  into  her  ears  that  she  can  prevent 
disease,  if  she  be  only  clean.  After  a  six-months'  or 
a  year's  sojourn  in  the  institute,  if  she  has  passed  an 
examination  held  by  a  different  board,  she  swears  an 
oath  to  attend  her  duties  as  prescribed,  and  may  com- 
mence to  practise.  But  during  all  her  lifetime  she  is 
still  under  supervision.  At  certain  times  her  carefully 
prescribed  armamentarium  is  inspected.  In  cases  of 
neglect  she  is  quickly  prosecuted.  If  cases  of  fever 
occur  in  her  practice  with  any  frequency,  or  cases  are 
not  reported  properly,  or,  in  fact,  any  of  the  numerous 
commands  laid  upon  her  in  the  interest  of  the  com- 
munity are  violated,  she  has  her  license  taken  away  a 
great  deal  faster  than  she  has  received  it. 

It  will  interest  you  to  illustrate  the  minuteness 
with  which  the  State  tries  to  protect  its  mothers  in 
Austria.  For  example,  to  give  you  a  few  samples  from 
a  criticism  by  Dr.  I.  Fischer  of  the  "  New  Regulations 
for  Midwives,"  published  in  the  Wiener  medizinische 
Presse,  October  3,  1897  :  "  It  is  the  chief  merit  of  the 
rules  that  midwives  are  reminded  not  to  make  too  fre- 
quent vaginal  examinations."  Criticism:  "  Why  are 
they  not  told  that  one  or  two  are  sufficient.'"' 

"  Washing  and  scrubbing  of  hands  and  forearms 
must  last  three  minutes,  then  thorough  cleaning  of 
nails  is  in  order,  followed  by  a  three-minutes'  dis- 
infection in  carbolic-acid  solution,  as  mentioned  in 
the  older  rules,  or  in  a  two-per-cent.  lysol  or  a  one- 
per-cent.  cresol  solution."  Criticism:  "Why  is 
it  not  ordered  that  these  three  minutes  are  to  be 
controlled  by  a  clock,  or  why  is  not  the  midwife 
ordered  to  have  an  hourglass  with  her,  as  she  is  in 
Germany.''" 

"We  are  glad  that  a  midwife  dares  not  practise 
while  she  is  nursing  an  infected  patient,  until  she 
brings  a  certificate  from  the  attending  physician  that 
she  is  not  likely  to  infect  the  new  patient."  Criti- 
cism :  "  But  why  is  she  not  recommended,  whenever 
possible,  not  to  nurse  such  patient?  .  .  .  We  also  miss 
an  order  of  non-attendance  when  her  fingers  are  not 
in  sound  condition,  as  from  a  felon,  a  runaround,  etc. 
.  .  .  We  admire  the  paragraph  on  ordering  the  temper- 
ature to  be  taken  daily,  and  their  being  obliged  to  call 
in  a  physician  whenever  it  surpasses  38°  C.  (100.4° 
F.).  Lastly  we  are  heartily  in  favor  of  the  yearly  con- 
trol and  post-graduate  examination  which  has  been 
ordered." 

Now  let  us  consider  how  New  York  treats  her  wo- 
men citizens.  The  State  as  such  does  not  take  cog- 
nizance of  midwives  at  all  in  its  general  laws,  but 
only  through  special  acts,  and  this  only  in  very  recent 
years. 

Besides  two  or  three  similar  acts,  which  I  think  in- 
clude the  cities  of  Syracuse  and  Buffalo,  the  most  re- 
cent one  became  a  law  May  31,  1895,  and,  contained 
in  chapter  842,  laws  of  the  State  of  New  York  of 
189s,  is  called  "  An  act  regulating  and  restraining  the 
practice  of  midwifery  in  the  city  of  Rochester  by  others 
than  legally  authorized  physicians." 

Section  i  empowers  the  mayor  to  establish  a  board 
for  the  examination,  licensing,  and  registering  of  mid- 
wives,  consisting  of  three  members,  two  of  whom  shall 
be  physicians  of  at  least  five  years'  practice,  and  the 
third  to  be  the  health  ofificer  ex  officio  ;  to  give  them  a 
compensation  of  $10  a  day  for  time  of  sittings;  and 
makes  the  duration  of  office  three  years. 

Section  2  treats  of  organization. 

Section  3  orders  the  board  to  hold  at  least  one  meet- 
ing each  half-year,  to  charge  $10  for  each  examination 
and  certificate,  which  is  to  be  recorded,  and  gives  the 
money  thus  collected  to  the  city  treasury. 

Section  4  treats  of  the  limitations  as  to  the  power  of 
midwives,  forbids  obstetrical  operations,  the  adminis- 
tration of  poisonous  drugs,  and  treatment  of  disease 


except  in  emergency  cases,  and  then  orders  a  speedy 
call  for  a  physician. 

Section  5  gives  the  mayor  the  power  to  revoke  cer- 
tificate and  license  on  recommendation  of  the  board, 
which  has  first  to  have  granted  a  hearing  to  the  ac- 
cused woman. 

Section  6  makes  the  crime  of  a  person  practising 
contrary  to  this  law  a  misdemeanor  punishable  by  a 
fine  of  not  less  than  $50  and  not  more  than  ^100. 

New  York  City  has  not  even  such  special  laws. 
Here  any  woman  who  brings  a  certificate  signed  by 
two  registered  physicans,  to  the  effect  that  she  is  of 
moral  character  and  therefore  probably  capable  of 
ministering  to  a  woman  during  childbirth,  is  thereby 
eo  ipso  a  midwife,  is  permitted  to  register,  and  her  cer- 
tificates of  birth  or  stillbirth  are  accepted  by  the  board 
of  health.  Whether  her  training  has  lasted  two  days  or 
two  years,  whether  she  has  retained  or  ever  possessed 
the  first  essential  of  a  successful  midwife — that  is, 
keeping  her  person  tidy  and  having  her  hands  at  the 
time  in  such  an  aseptic  state  as  to  vie  with  those  of  a 
surgeon  about  to  perform  a  laparotomy — are  ignored. 
Whether  she  owns  her  kit  of  proper  or  improper  in- 
struments is  not  examined  into.  No  supervision  after 
registration  is  at  present  possible  or  attempted,  for 
whenever  one  of  her  patients  falls  sick,  usually  through 
her  incompetency,  some  one,  or  one  of  these  two 
licensed  practitioners,  is  available  to  be  called  in, 
and  the  woman's  death  certificate  is  made  out  accord- 
ing to  law,  or  the  patient  may  recover. 

Attempts  at  a  change,  which  we  all,  I  am  sure,  will 
admit,  is  desirable,  have  been  made,  but  without  suc- 
cess so  far. 

Midwives  themselves  will  not  help  us,  for  reasons 
best  known  to  themselves.  American-born  women  do 
not  take  kindly  to  a  calling  which  has  no  standing, 
while  professional  nursing  gives  them  a  much  more 
honorable  and  lucrative  position  in  life.  There  remain 
those  foreign  women  who  have  had  European  training, 
most  of  which  they  have  forgotten  or  misapply,  or 
those  graduated  from  so-called  or  miscalled  American 
schools  of  midwifery.  These  institutes  are  private 
affairs,  which  mostly  by  advertising  promise  to  make 
accomplished  midwives  out  of  workingwomen,  in  a 
given  time  for  a  given  fee.  The  same  promoters  grad- 
uate their  own  pupils  for  an  extra  compensation.  How 
much  or  how  little  each  individual  school  teaches  is 
indifferent.  The  system  is  just  as  bad  as  that  of  our 
former  diploma  mills  used  to  be  in  this  State.  It  is 
just  as  hard  to  have  acts  establishing  separate  licensing 
boards  as  it  was  to  establish  State  examinations  for 
physicians.  Underground  influence  is  being  used,  and 
the  old-time  cry  is  raised:  "What!  a  larger  fee  for  a 
confinement  to  a  poor  man  in  the  interest  of  the 
money-grabbing  rich  physician?"  The  issue  is  lost 
in  this  demagogic  logic  and  the  bill  slumbers  in  com- 
mittee, while  hundreds  and  thousands  of  wives  are 
killed  annually  whose  lives  might  be  preserved  to 
their  families  and  the  community  if  the  legislators 
could  be  shaken  up  from  their  lethargy. 

For  one  society  alone,  were  it  as  strong  as  our 
own,  to  undertake  this  work,  would  be  the  work  of 
Sisyphus,  but  the  times  are  ripe  for  medical  legislation, 
or  I  am  much  mistaken.  We  have  among  our  promi- 
nent members,  besides  others,  the  distinguished  presi- 
dent and  vice-president  of  the  New  York  County  Medi- 
cal Society,  which  makes  it  a  special  duty  to  promote 
public  health  and  license  practitioners.  There  will 
soon  be  a  meeting  of  the  State  Medical  Society  in 
Albany,  at  which  our  honorable  president  will  play  a 
conspicuous  role.  Under  such  circumstances,  gentle- 
men, could  we  not  hope  for  success  in  securing  ade- 
quate legislation  properly  to  regulate  the  practice  of 
midwifery  by  midwives  in  our  Empire  State? 

45  Irving  Place. 


MEDICAL    RECORD. 


[December  18,  1897 


THE   OPERATIVE    SIDE    OF    ORTHOP.'EDIC 
SURGERY.' 

By   NEWTON    M.    SHAFFER,    M.D., 


The  founders  of  the  New  York  Orthopaedic  Dispensa:y 
and  Hospital  builded  better  than  they  l<:new  when, 
thirty-one  years  ago,  they  met  and  organized  the  work 
which  calls  us  together  on  this  occasion. 

Thirty-one  years  ago  orthopeedic  surgery  was  scarcely 
more  than  a  name  in  New  York  City.  It  may  almost 
be  said  that  few  outside  of  the  medical  profession  and 
the  technically  educated  classes  grasped  the  full  mean- 
ing of  the  word  "  orthopajdic."  A  few  surgeons,  in- 
spired largely  by  the  late  Dr.  Henry  G.  Davis,  were 
devoting  themselves  to  the  treatment  of  deformities, 
especially  those  occasioned  by  diseases  of  the  spine 
and  hip-joint.  Modern  orthopaedic  surgery  was  in  its 
infancy,  and  the  work  of  these  pioneers  was  attracting 
the  attention  of  the  lay  as  well  as  the  professional 
public.  It  was  during  this  embryonic  period  that  the 
founders  of  your  institution  applied  to  the  State  legis- 
lature for  a  charter,  in  the  following  language:  "The 
purposes  of  the  said  corporation  shall  be  to  establish 
and  maintain  an  institution  for  the  treatment  of  phys- 
ical deformities  and  to  give  instruction  in  such  treat- 
ment—  and  more  especially  to  afford  surgical  and  me- 
chanical treatment  to  the  disabled  and  deformed 
among  the  poor." 

It  was  the  mechanical  genius  of  Davis  which  con- 
tributed greatly  to  this  new  era  in  the  treatment  of 
physical  deformities.  It  was  he  and  his  colleagues 
who  made  American  orthopaedic  surgery  famous.  It 
was,  however,  the  mechanical  rather  than  the  surgical 
side  of  orthopaedy  of  those  days  which  brought  to  the 
front  the  names  of  those  who  are  to-day  recognized  as 
the  fathers  of  orthopa;dy  in  this  country,  and  it  was  the 
mechanical  treatment  of  hip-joint  disease  and  spinal 
disease,  as  taught  by  Taylor,  which  led  to  the  founda- 
tion of  your  institution  and  which  has  had  more  or  less 
effect  upon  the  development  of  American  orthopaedic 
surgery.  It  was  under  these  circumstances  that  your 
special  charter  was  obtained  from  the  New  York  State 
legislature.  It  would  have  been  a  matter  of  no  sur- 
prise to  me,  knowing  as  I  do  the  sentiment  of  the  pro- 
fessiqn  in  those  early  days,  and  appreciating  also  the 
influences  which  originated  our  great  work,  if  the 
charter  had  simply  designated  the  mechanical  treat- 
ment of  deformity  as  the  sole  object  of  the  corporation. 
But,  with  a  wise  and  almost  prophetic  foresight,  the 
charter  was  framed  in  a  broad  and  liberal  sense,  and 
the  portion  quoted  above  might  almost  be  called  a 
definition  of  modern  orthopedic  surger)'. 

On  previous  occasions  I  have  called  your  attention 
to  the  relation  of  orthopaedic  surgery  to  general  sur- 
gery— to  the  necessity  of  a  thorough  mechanical  train- 
ing as  a  preparation  for  orthopEedic  work,  and  to  the 
future  demands  of  orthopaedic  surgery  from  a  mechan- 
ical standpoint.  It  would  seem  only  proper  on  this 
occasion,  therefore,  that  I  should  dwell  somewhat  upon 
the  operative  aspect  of  the  treatment  of  deformities. 

The  treatment  of  chronic  deformities  would  be 
emasculated  if  mechanical  treatment  was  omitted. 
Indeed,  under  those  circumstances,  there  would  be 
only  operative  surgeiy  left.  On  the  other  hand,  if 
operative  surgery  was  omitted,  mechanico-therapy 
would  still  find  an  important  place  in  surgical  science 
and  the  major  part  of  orthopaedic  work  would  still  go 
on.  To  the  legitimate  orthopedic  surgeon,  therefore, 
operative  work  takes  a  secondary  and  minor  position, 
just  as  the  mechanical  part  takes  by  far  the  more  im- 

'  A  portion  of  an  address  delivered  before  tlie  trustees  of  the 
New  York-  Orthop;vdic  Dispensary'  and  Hospital  on  the  occasion 
of  their  thirtieth  annual  meeting,  held  November  15,  1S97. 


portant  place ;  and  in  true  orthopedic  surgery  operative 
work,  per  se,  has  no  real  status.  In  short,  if  orthopae- 
dic surger)'  is  to  maintain  its  position  among  the 
specialties  in  medicine,  it  must  exist  upon  a  mechani- 
cal foundation  and  its  disciples  must  be  experts  in  the 
use  of  apparatus.  At  the  same  time  the  orthopaedic 
surgeon  should  be  well  prepared  to  operate  upon  those 
patients  who  require  special  mechanical  treatment  after 
operation.  Hence  it  is  that  I  maintain  that  the  simple 
excision  of  joints  is  not  within  the  field  of  orthopedic 
work,  because  the  general  surgeons  and  the  general 
hospitals  are  fully  equipped  to  do  this  work  and  are 
glad  to  receive  and  care  for  this  class  of  cases,  the 
after-treatment  of  which  ordinarily  requires  no  special 
orthopaedic  training.  The  same  may  be  said  in  a  gen- 
eral way  of  the  operative  treatment  of  knockknee  and 
bowlegs.  The  artificial  fracture  of  a  bone  requires 
the  same  treatment  as  an  accidental  fracture,  and  this 
certainly  comes  within  the  scope  of  general  surgery. 
Under  these  circumstances  there  is  no  occasion  to  fill 
the  wards  of  an  orthopaedic  hospital  with  patients  of 
this  class,  as  long,  at  least,  as  there  is  such  a  great 
demand  upon  it  for  strictly  orthopaedic  cases,  which 
are  not  as  a  rule  received  by  the  general  hospi- 
tals. For  example,  a  patient  with  knee-joint  disease 
or  hip-joint  disease  needing  excision,  or  a  patient 
with  rachitic  leg  deformity  requiring  osteotomy,  ap- 
plies for  admission  to  your  wards.  Am  I,  as  your 
surgeon-in-chief,  justified  in  receiving  the  case  when 
there  are  fifty  or  more  cases  of  hip-joint  disease,  spinal 
disease,  clubfoot,  etc.,  which  urgently  demand  your 
care  and  which  are  awaiting  admission  to  your  wards^ 
My  reply  is,  "No."  We  could  fill  our  wards  with 
operative  cases  in  a  month,  the  larger  number  of  which 
do  not  require  orthopaedic  care  after  operation,  and 
which  can  be  cared  for  in  every  way  in  the  general 
hospitals.  I  certainly  feel  it  my  duty  to  decline  them, 
when  the  only  objects  I  would  have  in  admitting  them 
would  be  to  gratify  a  personal  ambition  to  appear  as 
an  operative  surgeon,  and  to  submit  for  your  consider- 
ation at  the  end  of  the  year  an  ample  table  of  "  opera- 
tions performed."  Some  surgeons  best  known  as 
orthopaedic  surgeons  are  wasting  their  time  on  work 
that  is  well  done  by  general  surgeons  and  well  per- 
formed in  general  hospitals.  These  men  are  making 
a  serious  error,  I  think,  and  are  retarding  the  normal 
growth  of  true  orthopaedic  surgery.  Some  day  these 
facts  will  be  appreciated.  It  may  not  be  in  my  day, 
but  sooner  or  later  the  truth  will  prevail,  and  both  the 
medical  profession  and  humanity  will  be  benefited. 
In  the  mean  time  I  shall  keep  on  in  the  course  I 
marked  out  twenty-four  years  ago,  when  at  an  early 
age  in  my  professional  career  I  had  the  opportunity 
to  gratify  my  surgical  ambition  in  the  orthopaedic 
wards  of  St.  Luke's  Hospital.  Nor  is  that  opportunity 
lacking  now,  with  the  great  mass  of  clinical  material 
which  presents  in  the  ser\ice  of  your  institution.  I 
am  gratified  to  know  that  the  seed  sown  nearly  a  quar- 
ter of  a  century  ago  is  bearing  good  fruit. 

The  operative  part  of  orthopivdic  surgery  therefore 
becomes  the  simple  but  necessary  adjunct  of  the  me- 
chanical work.  One  may  be  an  operative  surgeon  and 
know  but  little  or  nothing  of  real  orthopedic  work,  but 
the  orthopaedist  must  be  the  one  and  know  the  other. 
One  may  perform  all  the  major  operations  of  surgery, 
and  yet  not  have  the  requisite  technical  knowledge 
properly  to  adjust  a  hip  splint  or  a  spinal  brace.  The 
orthopedic  surgeon  should  be  able,  if  the  after-treat- 
ment demands  it,  to  excise  a  joint  or  to  perform  any 
operation  wliich  supplements  mechanico-therapy,  but 
in  all  but  very  exceptional  cases  he  should  confine  his 
cutting-work  to  that  field  which  supplements  his  me 
chanical  operations. 

Nor  does  it  follow,  I  think,  because  a  deformity 
exists,  that  the  patient  should  necessarily  come  under 


December  i8,  1897] 


MEDICAL    RECORD. 


885 


the  care  of  the  orthopaedic  surgeon,  any  more  than  that 
the  general  condition  giving  rise  to  the  retinitis  of 
Bright's  disease,  or  to  the  tabetic  atrophy  of  the  optic 
ner^e  in  locomotor  ataxia,  should  come  under  the  care 
of  the  ophthalmologist.  All  specialties  have  their 
origin  in  general  medicine  or  general  surgerj-.  The 
existence  of  a  specialt}-  depends  upon  several  factors, 
the  important  one  being  the  necessit}-  for  the  develop- 
ment upon  certain  lines  of  a  neglected  branch  of  med- 
icine or  surger}'  involving  patient  study  and  careful 
research.  It  is  along  these  lines  that  a  specialty  suc- 
ceeds, and  the  danger  of  specialism  of  the  present  day 
lies  in  the  fact  that  those  who  follow  it  are  prone  to 
invade  other  fields.  The  fault  with  many  of  those 
who  are  known  best  as  orthopaedic  surgeons  is  that 
they  do  not  confine  themselves  to  orthopa;dic  work; 
they  often  operate  when  there  is  no  necessity  for  cut- 
ting, and  they  are  not  familiar  enough  with  the  tech- 
nique of  mechanical  work  to  get  the  best  results  from 
mechanico-therapy.  They  do  the  work  of  the  general 
surgeon  instead,  neglecting  or  ignoring  the  plain  path 
of  duty  which  lies  so  patent  before  them. 

Why  is  this  so?  A  few  extracts  from  a  recent 
editorial  in  the  New  York  Medical  Record,  may 
help  us  in  answering  this  question.  The  editorial 
referred  to  is  entitled,  "  Is  Gynsecolog)'  Destined  to 
Become  an  Obsolete  Specialty?'''  After  a  general 
consideration  of  the  relation  of  gvnaecology  to  gen- 
eral surger)',  the  writer  says :  "  Not  content  with 
confining  themselves  to  their  proper  region,  they  [the 
gjTisecologists]  have  reasoned  that  their  familiarit}- 
with  abdominal  surgery  should  render  them  the  equals 
if  not  the  superiors  of  general  surgeons  in  the  han- 
dling of  cases  which  bear  no  relation  to  diseases  of  the 
pelvic  organs."  The  writer  then  asks:  "How  is  it 
that  this  change  has  come  about  in  America,  when 
abroad  the  distinction  between  the  gynaecologist  and 
general  surgeon  is  just  as  sharp  as  ever?  It  appears 
to  be  due  to  some  extent  to  the  fact  that  the  commer- 
cial factor  has  become  prominent  to  the  exclusion  of 
the  scientific."  Again :  '•  If  gynaecolog}'  is  to  remain 
a  specialty,  it  must  be  because  its  followers  continue 
to  demonstrate  the  fact  that  they  can  do  the  work 
better  than  the  general  surgeon.  ...  It  is  along  the 
line  of  conser\atism  that  the  battle  must  be  fought,  not 
radicalism."  Still  further ;  "  Gyn£ecolog\' is  the  natu- 
ral outgrowth  of  general  surgery,  but  the  contrary  is 
far  from  being  true,  and  any  attempt  to  reverse  the 
condition  must  end  in  ultimate  failure."  And  finally  : 
"  Let  gynecologists  prove  that  their  specialty  is  capa- 
ble of  development  along  other  lines  besides  those  of 
radical  surgery,  and  there  is  no  danger  that  it  will 
ever  come  to  be  regarded  as  unnecessary."  Comment 
on  these  plain  statements  seems  superfluous.  But  if 
the  words  "  orthopaedic  surgeon"  or  "  orthopadic  sur- 
gery" be  inserted  in  place  of  "  gynaecologist"  or  '"  gy- 
n<Ecolog>',"  in  the  quotations  given  above,  the  truth  will 
be  apparent  to  the  candid  obser\-er.  It  will  be  along 
the  lines  of  conservatism  that  orthopsedic  surgery  will 
be  developed — not  on  the  lines  of  operative  surgery — 
and  it  will  be  all  the  better  for  the  men  now  engaged 
in  preparing  for  future  work  in  orthopaedic  surgery  if 
they  bear  these  facts  in  mind. 

[The  remainder  of  the  address  was  devoted  to  sta- 
tistical facts  and  the  work  performed  in  the  institution 
during  the  past  year. — Ed.] 


To  Abort  a  Bubo — -Pressure  bandage,  when  sup- 
puration is  not  too  far  advanced,  by  folds  of  cotton 
carefully  adjusted  and  a  cocoanut-sized  wad  of  tightly 
compressed  cotton  placed  over  the  whole  and  retained 
by  a  very  tight  spica,  produced  abortion  of  the  process, 
in  nine  out  of  twelve  suitable  cases. — Gaether. 
'  Xew  York  Medical  Record,  Februar)-  27,  iSg7. 


©litiicaT  department. 

ABSENCE   OF    PAIN  AND  THE   VOLUNTARY. 
MUSCLES  AS  AUXILIARY  AIDS  IN  LABOR. 

By    JOSEPH    N.    STUDY,    M.D., 

CAMBRIDGE  CITY,  JKD. 

It  has  been  said  that  parturition  is  never  absolutely 
painless  in  womankind,  and  that  pain  is  so  constantly 
present  as  to  characterize  it  as  one  of  the  most  prom- 
inent clinical  phenomena  of  labor.  Pain  in  labor  is 
usually  attributed  to  the  contraction  of  the  involuntary 
muscular  fibres  of  the  uterus  encroaching  upon  the 
sensor}'  nerves  and  filaments.  The  following  case 
well  illustrates  the  title  of  this  subject. 

On  July  31st,  at  II   p.m.,  I  saw  Mrs.  W ,  aged 

thirty-two,  in  her  fourth  pregnancy.  I  had  attended 
her  in  all  of  her  previous  confinements.  The  first 
child  I  delivered  with  forceps.  The  second  confine- 
ment was  normal.  She  was  delivered  of  twins  at  the 
third  confinement.  She  stated  that  she  believed  her- 
self pregnant  about  two  hundred  and  eighty-six  days, 
and  with  the  exception  of  a  slight  vaginal  discharge 
had  no  symptoms  of  immediate  confinement.  A  vagi- 
nal examination  revealed  the  cenix  fully  dilated,  the 
vertex  presenting  in  the  first  position.  At  the  expira- 
tion of  three  hours  no  pain  whatever  was  complained 
of.  The  fact  that  my  patient  resided  nearly  five  miles 
from  my  home  and  I  had  an  important  engagement  six 
hours  later  caused  me  to  ask  the  woman  to  take  her 
position  in  bed.  I  then  requested  her  to  seize  my 
hands  and  to  make  great  effort  at  pressing  down,  while 
I  aided  by  pressure  over  the  fundus  of  the  uterus. 
This  effort  was  repeated  every  four  or  fh'e  minutes  for 
two  hours,  when  a  well -developed  male  child  was  bom 
alive.  Only  when  the  head  was  passing  over  the  peri- 
neum was  pain  complained  of,  and  that  was  insignifi- 
cant. 


A     CASE     OF     PNEUMONIA     TREATED     BY 
VENESECTION. 

By   ALFRED   Q.    DONOVAN,    M.D., 

ELIZABETH,    N.    I. 

The  fashion  of  bleeding  has  become  extinct  in  our 
practice  of  to-day,  and  he  would  be  a  bold  surgeon 
who  should  endeavor  to  revive  it.  Yet  I  believe  that 
it  was  occasionally  beneficial,  and  I  wish  to  report  a 
case  of  my  own  in  which  I  think  venesection  was  of 
decided  ser\-ice.  From  the  results  of  this  case  I  am 
inclined  to  think  that  in  cases  of  pneumonia,  when  the 
patient  is  in  sthenic  condition,  it  is  invaluable. 

My  patient,  aged  seventeen  years,  five  feet  four 
inches  in  height,  and  weighing  about  one  hundred 
and  eight}'  pounds,  by  occupation  a  fruit  dealer,  was 
sent  to  the  Alexian  Brothers'  Hospital,  Elizabeth,  N. 
J.,  April  13,  1897,  suffering  from  a  double  pneumonia. 
On  the  fourth  day  after  his  admission  his  respirations 
had  gradually  diminished  to  60,  his  temperature  was 
104°  F.,  and  his  pulse  140.  He  seemed  to  be  rapidly 
sinking,  and  the  prognosis  was  very  bad.  The  ordi- 
nary remedies  had  been  used,  such  as  strychnine  and 
digitalis  in  combination  with  the  supporting  plan  of 
treatment,  together  with  inhalations  of  oxygen,  but  all 
seemed  to  be  of  no  avail.  At  this  period  I  thought  of 
venesection;  I  opened  the  cephalic  vein  and  allowed 
about  ten  ounces  to  escape.  .After  a  few  hours  the  tem- 
perature fell  to  102°  F.,the  respirations  to  35,  and  the 
pulse  to  100,  and  the  man  expressed  himself  as  breath- 
ing more  easily.  The  blood  was  examined  microscopic- 
ally, and  pneumococci  were  found.  For  two  days  the 
patient  was  apparently  better.  After  this  period  his 
respirations  again  went  to  50,  with  pulse  and  tempera- 


886 


MEDICAL    RECORD. 


[December  i8,  1897 


ture  increased;  he  was  again  relieved  of  ten  ounces  of 
blood,  and  again  the  respirations  fell  to  35,  with  a 
reduction  of  temperature  and  pulse.  From  this  time 
he  gradually  improved,  and  was  finally  discharged 
cured.  May  10,  1897. 


FORCED    ENEMATA    IN    THE    TREATMENT 
OF    INTUSSUSCEPTION. 

By   THOMAS   H.    HAWKINS   M.D., 


A  LITTLE  child,  about  eight  months  old,  was  brought 
into  St.  Anthony's  Hospital,  by  Dr.  E.  C.  Hill,  of  this 
city,  June  16,  1897.  Dr.  Hill  had  already  diagnosed 
intussusception.  I  made  a  careful  examination  and 
confirmed  his  diagnosis.  Dr.  Leonard  Freeman  was 
asked  to  examine  the  child,  and  agreed  with  us  as  to 
the  nature  of  the  lesion.  The  child  had  been  vomit- 
ing persistently  for  about  twelve  hours,  with  no  action 
of  the  bowels.  A  distinct  mass  could  be  felt  in  the 
right  side  of  the  abdomen,  two  inches  above  and  about 
two  inches  to  the  right  of  the  umbilicus.  We  advised 
laparotomy.  Before  doing  the  operation,  however.  Dr. 
Freeman  suggested  that  it  might  be  a  good  plan  to  in- 
ject one-half  pint  or  more  of  warm  water,  and  if  this 
came  away  tinged  with  blood  there  certainly  could  be 
no  doubt  as  to  the  correctness  of  our  diagnosis. 

The  suggestion  of  an  enema  called  to  my  mind  sev- 
eral cases  of  this  kind  under  my  care  during  my  resi- 
dence in  New  York  City,  in  the  years  1874-76.  In 
the  latter  year  I  read  a  short  paper,  containing  a  report 
of  three  cases  of  intussusception  treated  by  forced 
enemata,  before  the  Eastern  Dispensary-  Medical  Soci- 
ety. This  article  was  published  in  the  Medical  and 
Surgical  Reporter,  December,  1876.  These  cases  were 
successfully  treated,  and  there  was  never  a  return  of 
the  trouble,  so  far  as  I  have  been  able  to  learn.  Two 
of  the  patients  were  under  my  observation  for  some 
five  years  afterward. 

I  therefore  concluded  to  try  the  injection  method  in 
the  present  case.  The  child  was  placed  across  the 
nurse's  lap  on  its  abdomen  and  its  body  allowed  to 
hang  head  downward.  The  nozzle  of  a  bulb  syringe 
was  inserted  into  the  bowel  and  the  buttocks  were 
compressed  tightly.  The  water  was  pumped  in  rather 
slowly  'at  first,  and  was  violently  expelled  ;  but  gradu- 
ally more  force  was  used,  and  the  water  entered  more 
easily.  About  one  gallon  was  used  in  this  wa}'  in  from 
six  to  seven  minutes.  When  the  child  had  been  placed 
in  bed  on  its  back  the  tumor  was  again  felt  for,  but 
could  not  be  found.  Dr.  Hill,  Dr.  Freeman,  and  my- 
self made  a  careful  examination  and  decided  that  the 
invagination  had  probably  been  overcome.  The  vom- 
iting gradually  ceased,  but  there  was  no  passage  of 
fascal  matter  for  nearly  twenty-four  hours,  though  there 
was  considerable  discharge  of  blood  and  mucus.  The 
child  made  a  perfect  recovery. 

In  the  article  published  in  the  Medical  and  Surgical 
Reporter,  if  I  remember  correctly,  I  laid  considerable 
stress  on  the  necessity  of  using  a  large  amount  of  fluid 
with  a  great  deal  of  force.  I  also  took  the  ground 
that  there  is  practically  no  danger  of  rupture  of  the 
intestine;  that,  in  fact,  in  cases  of  acute  intussuscep- 
tion the  invaginaled  portion  of  the  intestine,  on  which 
the  greatest  strain  is  exerted,  is  also  the  strongest  part 
of  the  gut,  by  reason  of  the  reduplication. 

I  am  led  more  particularly  to  report  this  case  be- 
cause of  an  article  published  in  the  Meuic.\l  Record, 
July  17,  1897,  by  Dr.  C.  L.  Gibson,  of  New  York,  en- 
titled "  Mortality  and  Treatment  of  Acute  Intussus- 
ception." In  this  article  the  writer,  in  speaking  of 
enemata,  says  that  they  are  distinctly  dangerous,  and 
that  the  amount  of  pressure  which  can  be  used  is  very 
limited;  that  the  quantity  of  water  should  not  e.xceed 


one  and  one-half  pints,  and  the  pressure  should  not  be 
greater  than  three  feet.  From  this  I  infer  that  he  uses 
the  fountain  syringe.  The  use  of  the  fountain  syringe 
will  certainly  not  succeed  nearly  so  well  as  the  use  of 
the  bulb. 

One  other  point  in  connection  with  this  last  case, 
namely,  that  water  unquestionably  found  its  way 
through  and  passed  from  the  mouth  of  the  child.  I  do 
not  propose  that  forced  enemata  with  fluids  should  be 
substituted  for  laparotomy  in  all  instances.  I  merely 
call  attention  to  this  case  and  the  report  of  my  former 
cases,  that  they  may  be  considered  for  what  they  are 
worth  in  the  study  and  future  treatment  of  intussus- 
ception. 


ECLAMPSIA  DUE  TO  PHIMOSIS  IN  A  CHILD 
SEVEN    MONTHS    OLD. 

By   HERMAN    BESSER,    M.D., 

NEW    YORK. 

On  August  nth  I  was  called  to  attend  a  male  infant 
in  convulsions.  On  arriving  at  the  house  the  follow- 
ing history  was  obtained  from  the  mother:  The  patient 
was  a  second  child,  aged  seven  months.  A  previous 
child  had  died  at  six  months,  of  convulsions.  The 
baby  had  never  nursed;  it  was  fed  first  on  condensed 
milk,  I  to  12,  for  three  months,  and  later  a  food  of  the 
proprietary  type  was  substituted.  This,  also  failing 
to  agree  with  the  child,  was  followed  with  cow's  milk, 
diluted  one-half  with  barley  water,  with  better  results. 
The  child  had  appeared  to  be  getting  along  fairly 
well  up  to  a  week  previous  to  my  visit,  when  the  mother 
noticed  that  it  became  fretful,  screaming  at  night  as  if 
in  great  pain.  These  attacks  were  thought  to  be  col- 
icky, as  the  infant  would  draw  up  its  legs  until  its 
knees  almost  touched  the  abdomen.  Catnip  and  fen- 
nel teas  had  been  given,  without  relief. 

After  I  had  obtained  the  foregoing  histor)-,  the  child 
was  stripped  and  laid  upon  the  bed,  when  I  noticed 
that  all  its  muscles  were  relaxed,  the  child  lying  per- 
fectly limp.  Examining  the  head,  I  found  it  rather 
large,  with  parietal  bosses  decidedly  prominent ;  fonta- 
nelle,  i^  x  i.  The  ribs  were  beaded,  the  epiphyses 
somewhat  enlarged,  and  the  child  was  pot-bellied. 
The  child  had  passed  three  green,  slimy,  undigested 
stools  during  the  previous  twenty-four  hours.  It  had 
had  no  fever,  the  mother  believed,  but  the  thermome- 
ter then  registered  103"  F.  in  the  rectum.  The  respira- 
tions were  slow  and  deep,  and  the  pulse  was  rapid  and 
feeble.     The  child  was  apparently  in  deep  coma. 

I  concluded,  for  want  of  more  positive  signs,  that 
the  condition  was  due  to  an  intense  intestinal  intoxi- 
cation, and  ordered  a  mustard  pack,  \\hile  this  was 
in  preparation  I  turned  my  attention  to  the  child,  and 
as  my  hands  touched  the  abdomen  it  seemed  unusu- 
ally tense.  The  percussion  note  just  above  the  um- 
bilicus v.as  tympanitic,  while  immediately  below  and 
on  eithe.-  ^ide  it  was  flat,  with  a  decided  sense  of  re- 
sistance to  the  finger  On  questioning  the  mother  as 
to  the  amount  of  urin-j  passed,  she  replied  that  for  the 
two  days  previous  she  thought  the  diaper  had  not  re- 
quired changing  so  often  as  before,  but  she  had  not 
attached  much  importance  to  this  fact.  I  immediately 
made  an  examination  of  the  penis,  and  found  that  the 
prepuce  was  exceedingly  long  and  adherent.  Taking 
a  grooved  director,  I  tried  to  insert  it  into  the  orifice 
of  the  prepuce  and  push  aside  the  fold  of  mucous 
membrane,  but  it  was  with  considerable  difficulty  that 
I  succeeded  in  forcing  back  the  prepuce  far  enough 
to  catch  a  glimpse  of  the  glans.  The  mucous  mem- 
brane had  become  so  adherent  that  the  resulting  ob- 
struction to  the  orifice  of  the  glans  almost  completely 
prevented  the  outflow  of  urine,  which  was  thus  dammed 
back  into  the  bladder,  dilatinsr   it  to  such  an  extent 


December  i8,  1897] 


MEDICAL    RECORD. 


887 


that  it  occupied  a  large  part  of  the  abdominal  cavity. 
I  finally  succeeded  in  breaking  up  the  adhesions, 
when  the  pent-up  urine  was  discharged,  saturating  the 
bed  and  the  clothing  of  the  physician.  The  child  was 
then  placed  in  the  mustard  pack,  and  within  a  few 
moments  was  restored  to  consciousness. 

I  left  a  grain  of  calomel  to  be  given  in  divided  doses, 
and  a  fourth-grain  Dover's  powder  every  two  hours. 
The  following  day  I  found  the  patient  looking  bright 
and  happy.  He  had  slept  well  during  the  night  and 
passed  an  abundance  of  a  highly  colored  urine.  He 
took  food  eagerly  and  appeared  to  be  none  the  worse 
for  the  previous  night's  experience.  I  suggested  to 
the  parents  that  circumcision  would  remove  any  chance 
of  a  recurrence  of  the  symptoms,  and  two  days  later  at 
their  request  performed  this  operation,  which  was  fol- 
lowed by  an  uneventful  recover)'.  Under  suitable  diet 
the  child  is  now  doing  well. 


included  the  peritoneum.  The  superficial  tissues  were 
sewed  with  silkworm  gut  and  antiseptic  dressing  was 
applied.  The  wound  healed  by  first  intention.  The 
patient  resumed  her  ordinary  duties  in  a  few  weeks, 
and  five  months  after  the  operation  gave  birth  to  a 
healthy  child.  There  has  been  no  return  of  the 
hernia. 


STRANGULATED    UMBILICAL    HERNIA. 


By   WILLIAM    T.    SMITH,    M.D., 


The  report  of  a  case  of  this  nature  by  Dr.  Coley,  in 
in  a  recent  issue  of  the  Medical  Record,  moves  me  to 
tell  of  a  case  in  my  own  experience,  which  illustrates 
a  phase  of  countrj'  practice. 

I  was  called  to  see  the  patient  in  consultation  with 
Dr.  G.  W.  Weymouth,  of  Lyme.  She  lived  in  a  small, 
unpainted  house,  beautifully  situated  on  the  lower 
slope  of  a  mountain.  There  were  two  rooms  on  the 
first  floor — a  kitchen  and  a  bedroom.  In  the  latter 
apartment  lay  the  patient,  a  woman  of  some  two  hun- 
dred pounds'  weight.  Half  a  dozen  children  were 
scattered  about,  the  youngest  little  more  than  a  baby. 
The  mother  from  her  bed  commanded  a  view  of  her 
domain  and  still  directed  its  affairs.  We  found  a 
spheroidal  tumor,  five  inches  in  diameter,  tense,  ten- 
der, dull  on  percussion.  It  had  been  out  about  thirty- 
six  hours;  the  bowels  were  obstructed,  and  there  were 
nausea  and  pain.  After  repeating  unsuccessfully  at- 
tempts at  reduction  which  had  already  been  made,  we 
prepared  for  operation.  There  was  a  stove  in  the 
kitchen,  and  there  was  wood.  The  teakettle  had  been 
worn  out  and  its  place  was  supplied  by  a  ding)-  tin 
pail.  For  washing-purposes  there  was  the  tin  basin 
in  the  sink,  which  served  the  whole  family.  Under 
the  sink  was  a  pail  of  refuse.  Exploring  the  pantrj- 
for  a  clean  '"  dripping-pan"  in  which  to  boil  instru- 
ments, we  found  a  utensil  of  that  kind,  but  it  retained 
so  much  of  its  last  contents  that  we  discarded  it. 
Neighbors  had  meantime  appeared,  and  we  made  requi- 
sition on  them.  We  obtained  in  this  way  a  kettle  and 
pan  and  some  bowls  and  pitchers.  A  messenger  was 
dispatched  to  the  store,  one  and  one-half  miles  away, 
for  towelling  and  a  paper  of  pins,  of  which  there  was 
none  in  the  house.  In  the  course  of  time  instruments 
were  sterilized,  bichloride  solutions  were  made,  the 
field  of  operation  was  prepared,  and  on  the  bed  where 
we  found  her  we  attacked  the  tumor.  An  incision  was 
made  around  it  near  its  base,  going  through  skin  and 
subcutaneous  tissue.  Skin  and  subcutaneous  tissue 
were  then  dissected  back  as  far  as  the  edge  of  the 
aponeurosis  surrounding  the  neck  of  the  sac.  The 
sac  being  opened,  gut  and  omentum  were  found  in  it. 
Some  recent  adhesions  were  broken,  and  the  edge  of 
the  ring  was  nicked  to  permit  the  return  of  the  gut, 
which  was  viable.  A  mass  of  congested  and  matted 
omentum  was  tied  off  with  catgut  and  removed,  and 
the  whole  sac  with  the  skin  on  its  upper  part  was 
amputated.  The  aponeurotic  edges  of  the  ring  were 
drawn  together  with  stitches  of  kangaroo  tendon,  which 


progress  of  l^edical  Science. 

Successful  Treatment  of  Circumscribed  Traumatic 
Aneurism  of  the  Right  Internal  Carotid  Artery 
within  the  Cranium  by  Means  of  Ligature  of  the 
Common  Carotid. — Hinde  {Journal  of  the  American 
Aledical  Association,  December  4,  1897,  p.  1,154)  has 
reported  the  case  of  a  Chinaman,  thirty-six  years  old, 
who  eighteen  months  before  coming  under  observation 
had  been  felled  to  the  sidewalk  by  a  blow  from  the 
shoulder,  striking  the  occiput  in  his  fall.  The  man 
at  once  arose  and  walked  home,  a  distance  of  a  block, 
and  lay  down  for  about  ten  minutes.  On  the  follow- 
ing day  he  felt  well  enough  to  resume  his  work. 
Some  time,  afterward  both  eyes  began  to  redden,  the 
right  one  in  greater  degree,  and  in  a  short  time  it  was 
noticed  that  the  right  eyeball  commenced  to  bulge 
forward.  The  redness  and  the  exophthalmos  on  the 
right  side  steadily  increased  until  the  patient  came 
under  observation,  when  the  palpebral,  conjunctival, 
subconjunctival,  and  anterior  ciliary  veins  of  the 
right  eye  were  found  to  be  greatly  enlarged  and  tor- 
tuous. No  pulsation  could,  however,  ht  detected  in 
any  of  these  vessels,  and  none  on  light  palpation  with 
the  fingertips  applied  to  the  eyeball.  The  motility 
of  the  globe  was  preserved,  except  that  in  attempts  at 
abduction  it  halted  at  a  point  slightly  beyond  the  mid- 
position.  The  reflexes  of  the  right  pupil  were  enfee- 
bled. The  ophthalmoscope  disclosed  enlargement  and 
tortuosity  of  the  retinal  veins,  but  an  absence  of  pul- 
sation. The  arteries  were  of  normal  size  and  course. 
Both  arteries  and  veins,  especially  on  the  surface  of 
the  disc,  were  marked  by  white  lines  along  their  walls, 
indicative  of  perivasculitis.  Disc,  retina,  and  choroid 
were  normal  in  appearance.  The  veins  of  the  left  eye 
were  somewhat  enlarged  throughout,  but  presented 
otherwise  nothing  abnormal.  The  sensibilit)-  of  the 
right  cornea  was  less  acute  than  that  of  (he  left.  The 
visual  fields  were  alike  and  normal  The  acuity  of 
vision  was  slightly  greater  on  the  left  than  on  the  right, 
but  fairly  good  on  both  sides.  On  placing  the  cup  of 
a  stethoscope  over  the  closed  right  eye,  a  loud  blowing 
bruit  or  murmur  was  heard  synchronous  with  the  heart 
beat,  and  an  intermittence  of  the  heart's  pulsation  from 
six  to  eight  times  per  minute  was  readily  detected. 
The  same  conditions,  in  slighter  degree,  were  present 
over  the  right  temporal  region,  and  in  still  slighter 
degree  in  the  left  temporal  region.  In  all  of  these - 
situations  the  aneurismal  sound  was  greatly  increased 
when  the  patient  stooped  forward.  It  disappeared 
completely  on  digital  compression  of  the  right  common 
carotid  arter)'  in  the  neck.  On  further  inquiry  it  was 
learned  that  the  patient  became  conscious  of  a  noise 
in  the  head  some  six  or  seven  days  after  his  fall,  and 
that  it  had  grown  steadily  louder.  The  conclusion 
was  reached  that  an  aneurism  had  formed  on  the  in- 
ternal carotid  artery  within  the  cranium,  perhaps  sec- 
ondar)'  to  fracture  of  one  of  the  bones  at  the  base,  at 
a  point  where  the  vessel  passes  on  the  side  of  the 
body  of  the  sphenoid  bone  between  the  layers  of  the 
dura  mater  and  in  immediate  proximity  to  the  caver- 
nous sinus;  compressing  the  latter  and  preventing  the 
return  of  the  venous  blood  from  the  contents  of  the 
right  orbit,  but  not  affecting  the  arterial  supply;  com- 
pressing the  trunk  of  the  sixth  nerve,  and  in  slighter 
degree  also  the  ophthalmic  division  of  the  fifth  nerve. 


MEDICAL    RECORD. 


[December  i8,  1897 


To  remove  the  possibility  of  syphiloma  of  the  brain, 
large  doses  of  potassium  iodide  were  administered  for 
six  weeks,  without  improvement.  Operation  was  there- 
fore advised,  and  it  having  been  agreed  to,  the  right 
common  carotid  artery  was  occluded  in  the  neck  with 
two  ligatures,  one-half  inch  apart.  The  immediate 
result  of  the  operation  was  a  complete  cessation  of  the 
bruit,  with  increase  in  the  e.xophthalmos,  which,  how- 
ever, subsequently  receded.  Under  treatment  with  the 
faraclic  current  the  paresis  of  the  right  external  rectus 
muscle  and  diplopia  that  had  developed  were  greatly 
improved.  The  ultimate  result  was  entirely  satisfac- 
tory, the  patient  being  freed  from  all  his  previous 
symptoms. 

Impetigo  and  Ecthyma  have  been  shown  by  Balzer 
and  Griffon,  in  a  bacteriologic  study  of  thirty-one 
cases  of  the  former  and  fourteen  of  the  latter  {Le  Bui. 
Med.,  October  31st),  to  depend  upon  the  constant 
presence  of  streptococci  in  the  form  of  diplococci  like 
fine  grains,  included  in  the  protoplasm  of  the  leu- 
cocytes or  arranged  outside  of  them.  Cultivated  in 
bouillon  the  microbe  takes  on  the  features  of  the  clas- 
sical streptococcus  pyogenes.  Inoculation  experi- 
ments show  that  the  organism  is  truly  pathogenic 
(causing  abscess,  erysipelas,  and  even  fatal  septicfE- 
mia). 

Obstruction  of  the  Small  Intestine  by  a  Gall 
Stone. —  Bradbury  (British  Medical Jotirna!,  September 
25,  1897,  p.  796)  reports  two  cases  of  impaction  of 
the  small  intestine  by  gall  stones  attended  with 
symptoms  of  obstruction.  The  condition  is  a  rare 
one,  having  been  observed  but  once  in  the  Manchester 
Royal  Infirmary  between  the  years  1883  and  1896 
among  fifty  thousand  in-patients,  and  only  four  times 
during  twelve  months  in  some  of  the  largest  hospitals 
of  England,  representing  altogether  eighty  thousand 
in-patients  and  several  hundred  thousand  out-patients. 
The  first  case  occurred  in  a  man,  sixty  years  old,  and 
was  complicated  by  the  existence  of  cystitis  and  a 
general  debilitated  condition  that  rendered  diagnosis 
almost  impossible.  Tlie  second  occurred  in  a  woman, 
also  sixty  years  old,  in  whom  there  were  no  symptoms 
until  obstruction  occurred.  The  one  case  terminated 
fatally,  the  other  in  recovery.  In  neither  case  was 
there  a  history  of  jaundice  or  colic,  or  of  a  similar 
previoiis  attack.  In  the  one  case  the  stone  was  about 
one  and  one-half  inches  in  diameter  and  nearly  spher- 
ical. In  the  other  it  weighed  nearly  one-half  ounce, 
was  almost  two  inches  long,  a  little  more  than  one 
inch  in  diameter,  and  had  a  circumference  of  three 
inches.  In  the  second  case  no  indication  whatever  of 
any  hepatic  disturbance  existed,  and  until  symptoms 
of  obstruction  occurred  the  patient  was  quite  well. 
In  the  first  case,  however,  there  were  indigestion,  ten- 
derness and  enlargement  of  the  liver,  rigor,  and  rise 
of  temperature,  with  profuse  sweating.  Under  chlo- 
roform a  localized  swelling  was  felt  in  the  right  hypo- 
chondrium,  but  this  disappeared  completely  later. 
Neither  hemorrhage  nor  tympanites  was  present  in 
either  case  at  any  time.  Post-mortem  examination  in 
the  one  case  disclosed  the  presence  of  a  gall  stone 
impacted  in  the  jejunum,  it  having  escaped  from  the 
gall  bladder  into  the  first  portion  of  the  duodenum 
through  an  opening  about  one  inch  in  diameter.  In 
the  second  case  the  stone  was  passed  after  the  injec- 
tion of  an  enema.  In  both  cases  the  vomit  was  copious 
and  almost  like  pure  bile,  but  toward  the  end  it  became 
slightly  stercoraceous  in  the  first.  In  neither  was  the 
pain  of  exceptionally  severe  character.  In  the  fatal  case 
the  symptoms  lasted  ten  days:  in  the  other,  two  days. 

Cant  {British  Medical  Journal,  October  30,  1S97,  p. 
1,258)  reports  three  additional  cases  of  obstruction  of 
the  small  intestine  by  a  gall  stone,  occurring  in  a 
woman  sixty-five   years  old,  a  man   about  forty-eight. 


and  a  woman  about  fifty,  respectively.  In  the  first 
abdominal  section  was  performed  and  the  calculus  re- 
moved, but  death  ensued  about  a  week  after  the  oper- 
ation. In  the  second  also  cceliotomy  was  performed 
and  the  stone  removed,  but  death  resulted  shortly  after 
the  operation.  Cceliotomy  was  likewise  performed  in 
the  third  case,  in  which  recovery  ensued.  In  two  of 
the  cases  an  attempt  was  made  to  break  up  the  concre- 
tions with  a  needle,  but  without  success.  None  of  the 
patients  had  previously  had  sjTnptoms  of  gall  stones, 
but  only  bilious  attacks;  nor  had  they  suffered  from 
severe  pain  preceding  the  obstruction.  The  vomiting 
was  at  first  of  a  markedly  bilious  character  and  grad- 
ually became  stercoraceous. 

Physiologic  Mobility  of  the  Liver.— Dr.  Laborde 

has  demonstrated  (Sociiite  de  Biologic)  that  the  lower 
border  of  the  liver  undergoes  changes  of  level  much 
more  extensive  than  has  been  thought  to  be  the  case. 
Examination  by  the  radioscope  during  active  respira- 
tion shows  an  elevation  of  as  much  as  six  centimetres 
at  times.  This  is  an  important  point  to  remember  in 
percussion  of  the  organ. 

Purpura  Due  to  the  Vapors  of  Benzin. — Drs. 
Lenoir  and  Claude  related  an  instance  at  the  last 
meeting  of  the  vSocie'te'  des  Hopitaux  which  would 
tend  to  show  that  benzin  might  be  a  causative  agent 
in  even  fatal  instances  of  purpura.  A  dyer,  twenty- 
seven  years  of  age,  presented  hemorrhagic  pleurisy  as 
well  as  purpuric  blotches  and  bleeding  from  various 
mucous  membranes,  leading  to  extreme  anrtmia  and 
death.  Autopsy  revealed  numerous  infarcts.  The 
occupation  in  which  the  fumes  of  benzin  were  in- 
haled had  been  given  up  some  months  before  death, 
but  not  until  several  months  after  the  onset. 

The  Employment  of  Thyroid  Feeding  in  the 
Treatment  of  Insanity. — Cross  [^Edinburgh  Medical 
Journal,  November,  1897,  p.  471)  reports  a  series  of 
twenty  cases  of  various  forms  of  insanity,  including 
excited  melancholia,  simple  melancholia,  enfeeble- 
ment,  dementia,  senile  insanity,  and  chronic  mania, 
in  which  thyroid  feeding  was  employed  as  a  therapeu- 
tic measure.  All  of  the  cases  showed  a  greater  or 
less  reaction  to  thyroid  administration,  as  shown  b)* 
slight  rise  of  temperature  and  slightly  increased  respi- 
ratory frequency,  together  with  more  marked  changes 
in  the  pulse,  which  was  not  only  increased  in  fre- 
quency but  also  distinctly  weakened.  In  all  cases 
the  pulse  was  the  first  to  show  any  change  and  was 
the  condition  most  affected ;  and  this  reaction  in- 
creased and  became  most  pronounced  toward  the  end 
of  the  treatment.  After  the  treatment  was  discon- 
tinued, the  reaction  passed  off  in  the  majority  of 
cases,  although  it  was  quite  noticeable  for  at  least  a 
week.  As  regards  the  relation  of  the  mental  condi- 
tion to  the  amount  of  reaction  produced,  no  definite 
statement  could  be  made.  One  of  the  cases  that  im- 
proved showed  a  slight  reaction,  while  one  that  pre- 
sented no  change  mentally  reacted  very  strongly, 
although  the  amount  of  thyroid  given  was  tlie  same  in 
each.  None  of  the  eight  males  treated  became  excited 
during  treatment,  while  the  only  cases  of  permanent 
improvement  occurred  in  male  cases.  On  the  other 
hand,  seven  of  twelve  females  became  excited  or 
showed  increased  excitement  during  the  treatment, 
although  no  pennanent  improvement  occurred.  Of 
the  twenty  cases  treated,  two  showed  permanent  im- 
provement and  both  of  these  had  pre\iously  been 
regarded  as  hopeless  on  account  of  the  stationarj- 
character  of  their  mental  condition.  Although  none 
of  the  other  cases  was  so  distinctly  lienefited.  it  ap- 
pears to  be  indicated  that  thyroid  treatment  should 
receive  a  fair  trial  before  any  patient  suffering  from 
insanity  is  regarded  .is  hoi^elessly  incurable. 


December  i8,  1897] 


MEDICAL    RECORD. 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE   F.    SHRADY,  A.M.,  M.D.,  Editor. 

Publishers 
WM.  WOOD  &  CO.,   43,  45,  &.  47  East  Tenth  Street. 


New  York,  December  18,  1897. 


PUBLIC     HEALTH     IX    RELATION    TO    THE 
MILK   AND    FOOD    SUPPLY. 

The  strides  made  toward  perfecting  a  system  of  pub- 
lic hygiene  is  one  of  the  features  of  the  present  age. 
The  fact  is  being  slowly  but  surely  grasped  by  the 
community  at  large  that  many  of  the  epidemic  dis- 
eases which  have  from  time  immemorial  been  re- 
garded with  the  utmost  dread  can  not  only  be  avoided, 
but  can  be  absolutely  stamped  out.  This  happy 
result,  however,  can  be  attained  only  by  the  exercise 
of  great  vigilance  on  the  part  of  the  sanitary  authori- 
ties backed  by  the  co-operation  of  the  people  them- 
selves. The  boards  of  health  have  done  much,  but 
if  they  were  convinced  that  the  sentiments  of  the  gen- 
eral public  were  wholly  with  them  their  powers  for 
good  would  be  immensely  enhanced.  Many  of  the 
regulations  introduced  by  them  are  beyond  the  scope 
of  the  ordinary  lay  mind,  and  are  looked  upon  as  un- 
necessary- and  troublesome.  Indeed  a  large  number 
of  the  medical  profession  itself  regard  some  of  the 
present-day  notions  in  respect  to  hygiene  as  savor- 
ing of  faddism,  and  will  require  further  and  more  con- 
vincing proof  before  accepting  them  as  anything  more 
than  experimental.  Nevertheless,  on  the  more  salient 
and  important  points  there  is  a  pleasing  unanimity  of 
opinion.  The  fact  is  recognized  on  all  hands  that 
an  uncontaminated  water  supply,  a  pure  and  whole- 
some milk  supply,  an  efficient  sewerage  system,  a 
proper  disposal  of  refuse,  and  cleanliness  in  the  man- 
ufacture and  handling  of  all  articles  of  food,  are  es- 
sential to  the  well  being  of  each  and  every  individual. 
Of  these,  without  doubt,  the  question  of  pure  water  is 
the  most  important,  but  the  subject  of  late  has  been 
so  fully  discussed  in  all  its  bearings  that  it  would  be 
superfluous  to  do  more  than  merely  refer  to  it  here. 
Next  in  importance  comes  milk,  and  this  again  is  a 
matter  which  has  been  thoroughly  well  threshed  out. 
Still  it  is  satisfactory  to  note  that  the  public  and  even 
the  lower  classes  are  beginning  to  understand  the  ben- 
efit of  an  untainted  milk  supply,  and  to  appreciate  the 
efforts  of  those  laboring  in  their  behalf  to  achieve  this 
object.  When  retailers  of  milk,  both  wholesale  and 
retail,  become  alive  to  the  fact  that  the  people  demand 
a  genuine  article  and  will  take  no  other,  they  will 
quickly  realize  the  situation  and  will  be  careful  to 


supply  what  is  required.  One  method  of  adulterating 
milk,  largely  practised  among  dairymen,  may  be  men- 
tioned here — the  addition  of  water  is  referred  to.  In 
the  annual  report  of  the  commissioners  of  health  of 
Milwaukee,  attention  is  drawn  to  this  custom  in  these 
words:  "Analyses  of  milk  made  in  this  department' 
have  shown  that  lake  water  has  been  added  to  the  milk 
as  a  diluent,  and  in  other  instances  well  water.  In 
several  cases  of  the  latter  kind  it  was  shown  that  the 
well  from  which  the  water  came  was  filthy  and  the 
water  unfit  for  drinking-purposes,  but  it  had  been  added 
to  the  milk,  so  that  nearly  one-third  of  the  entire  bulk 
was  water." 

The  bakeries  and  candy  manufactories  of  Milwaukee 
underwent  early  in  the  year  a  systematic  examination 
by  the  department  of  health,  and  their  condition  was 
found  to  be  such  that  legislation  was  brought  into 
force  to  abolish  the  evils. 

The  custom  of  exposing  fresh  fruit,  candies,  fish, 
vegetables,  and  various  other  articles  of  food  on  the 
streets  is  very  prevalent  in  many  parts  of  America. 
This  practice  is  greatly  to  be  deprecated,  as  it  is  not 
only  a  source  of  danger,  but  also  extremely  disgusting. 
When  one  considers  the  dust  and  filth  that  is  being 
continually  wafted  on  the  breeze  in  all  towns,  this 
fact  will  be  brought  home  in  all  its  nastiness.  If,  as 
suggested  in  the  Milwaukee  health  report,  the  people 
would  take  the  matter  into  their  own  hands  and  refuse 
to  purchase  any  article  of  food  exposed  to  such  con- 
ditions, the  practice  would  soon  be  brought  to  an  end. 
This  question  should  be  well  ventilated  in  the  public 
press;  the  more  it  is  aired,  the  sooner  will  the  filthy 
habit  be  stopped. 

OFFICE    BORES. 

It  is  a  general  belief  that  the  poor  doctor  is  always 
overjoyed  when  a  patient,  no  matter  of  what  kind, 
enters  his  office  to  swell  his  coffers.  The  number  of 
bores  that  constantly  beset  him  and  tap  his  energies 
through  the  exasperating  conduits  of  long  and  unin- 
teresting accounts  of  trivial  ailments  is  never  taken 
into  account.  Aside  from  his  strain  of  self-control 
and  the  enervating  influences  of  smiling  dissimulation, 
there  is  a  special  harm  to  the  victimized  adviser's 
sympathies  in  the  engendering  of  a  retaliatory  uncon- 
cern in  the  patient's  present  condition  and  an  indiffer- 
ence to  its  final  ending.  If  perchance  there  is  a  sud- 
den and  unexpected  interruption  of  all  the  symptoms 
usually  designated  heart  failure,  there  comes  a  feeling 
of  complacency  in  his  contemplation  of  the  obituary 
notice  of  the  sufferer,  which  promptly  settles  all  old 
scores  and  places  the  lucky  survivor  on  the  high  plane 
of  becoming  resignation  to  the  decrees  of  a  kindly  fate. 
Time  is  the  only  thing  that  must  tell  in  such  a  race 
with  the  inevitable. 

In  the  mean  while  the  tales  of  woe  must  go  on 
The  uprisings  and  downsittings  must  be  noted  by 
urination  at  night  and  defecation  in  the  morning.  It 
is  comforting  for  the  innocent  professional  victim  of 
such  constant  watchfulness  to  realize  that  at  such 
times  he  is  always  kept  in  mind.  The  urinary  bottle 
with  its  daily  tribute  is  ever  ready  to  offer  its  sugges- 


890 


MEDICAL    RECORD. 


[December  18,  1897 


tion  as  to  what  has  been  done  and  still  must  be  done 
so  long  as  the  visits  continue.  Each  receptacle  mar- 
shals itself  in  the  solemn  waiting  row  of  similar 
odorous  companions  ruthlessly  consigned  to  dilatory 
neglect,  and  the  effectual  corking  of  its  contents  is  an 
implied  revenge  on  the  ever-ready  fluency  of  the  gener- 
ous distiller.  All  such  patients  mean  well,  and  so  does 
the  consultant  who  naively  declares,  after  emptying 
the  bottle,  that  "  nothing  was  found"  in  the  specimen. 

Then  comes  the  furtive  young  man,  with  wavering 
focal  concentration,  weak  lip,  and  pasty  palm,  whose 
manly  substance  is  tapped  in  the  unguarded  hour  of 
sleep,  and  who  wakes  only  to  find  that  all  is  gone. 
Even  this  may  be  tolerable  in  comparison  with  the 
livelier  and  more  ambitious  youth,  who  voluntarily 
courts  the  pang  of  repentance  in  his  more  progressive 
ventures  in  the  highways  and  byways  of  forbidden 
pleasures.  What  is  lacking  in  the  effusive  mucosity 
of  one  is  more  than  made  up  in  the  other.  The  mi- 
serly mournfulness  of  the  spermatorrhoeic  is  duly  offset 
by  the  generous  prodigality  of  the  gonorrhceic.  On 
the  principle  of  easy  come  and  easy  go,  the  virus  is 
scattered  in  the  office  of  the  doctor,  on  his  carpet, 
chair,  paperweight,  doorknob,  and  towel,  with  a  zeal 
that  is  grimly  suggestive  of  a  better  cause.  The  tear 
of  pity,  if  it  ever  comes  for  the  oozy  sufferer,  can  never 
be  safely  wiped  away  by  the  hand  that  has  shaken  his. 

And  lastly,  who  does  not  see  the  young  and  confid- 
ing unmarried  female,  who  has  caught  cold  by  tempo- 
rarily sitting  on  picnic  grass,  and  who  tells  the  old, 
old  story  of  a  deferred  catamenial  hope  that  maketh 
more  than  one  heart  sick  ? 

Or,  worse  than  this,  how  often  does  the  casual  and 
plausible  youth  mock  the  claims  of  an  ordinary  cre- 
dulity when  he  confidingly  asks,  on  behalf  of  a  dear 
and  absent  friend,  for  the  pill  that  will  do  the  busi- 
ness and  end  anxiety? 

Think  of  the  poor  doctor  who  must  be  made  to 
believe  it  all,  and  sympathizingly  play  the  usual  fool 
besides.     "Next — come  in,  please." 


DISPOSAL    OF   GARBAGE. 

One  of  the  most  serious  obstacles  in  the  way  of  a 
more  satisfactory  system  of  public  hygiene  is  the  dis- 
posal of  garbage.  The  question  presents  numerous 
difficulties  and  must  be  regarded  from  an  economical 
as  well  as  a  sanitary  standpoint.  There  appears  to 
be  some  confusion  as  to  the  correct  definition  of  the 
term  garbage. 

The  committee  appointed  by  the  American  Public 
Health  Association  define  the  word  as  follows:  "By 
the  term  garbage  is  meant  animal  and  vegetable  waste 
matter  subject  to  rapid  decay,  from  kitchen,  markets, 
slaughter  houses,  etc.,  but  not  including  nightsoil 
and  street  sweepings."  The  methods  now  in  use  for 
the  disposal  of  garbage  are  one  and  all  in  a  greater  or 
lesser  degree  open  to  objections,  but,  from  the  im- 
mense amount  of  interest  evinced  in  the  matter,  it 
may  be  with  safety  predicted  that  ere  much  time  has 
passed  a  healthy  and    economical    system   will   have 


been  evolved.  From  the  reports  of  the  committee, 
collected  from  one  hundred  and  fiftj'  American  cities, 
it  seems  that  in  forty-six  of  these  dumping  on  and 
ploughing  into  land  is  the  practice  followed;  dumping 
at  sea  or  into  a  lake  or  large  river  is  the  plan  pursued 
by  fourteen  cities;  feeding  to  animals  in  forty -three 
cities;  reduction  to  grease  and  fertilizer  in  seventeen 
cities;  cremation  in  thirty  cities.  The  first  three  of 
these  methods  may  be  dismissed  briefly ;  they  are  all 
very  imperfect,  while  feeding  to  animals  is  positively 
dangerous.  There  are  then  left  the  reduction  and  cre- 
mation processes  between  which  to  choose.  In  regard 
to  the  relative  merits  of  these  methods  there  exists  in 
this  country  a  wide  difference  of  opinion.  On  the  one 
side  it  is  argued  that  cremation  is  wasteful  and  expen- 
sive; on  the  other,  that  in  addition  to  being  insanitary 
reduction  to  grease  is  also  in  most  cases  as  costly  as 
cremation.  Mr.  Rudolph  Herring,  speaking  of  the 
reduction  system,  says :  "  Reducing  garbage  to  grease 
and  fertilizer  renders  the  mass  of  matter  harmless, 
provided  that  the  work  is  thoroughly  done.  It  is 
found,  however,  that  w'hen  this  system  is  followed 
offensive  odors  are  likely  to  pervade  the  neighbor- 
hood, and  that  the  w'orks  will  be  looked  upon  as  a 
public  nuisance."  The  truth  of  these  remarks  has 
been  proved  in  many  towns,  and  at  the  present  time  a 
striking  illustration  of  tlie  fact  is  being  afforded  by 
Wayneport.  The  condition  of  affairs  at  this  place  has 
so  roused  public  attention  that  the  town  board  of 
health  of  Macedon  recently  engaged  Dr.  M.  A.  Ved- 
der,  of  Lyons,  to  investigate  and  report  upon  the  gar- 
bage-reduction works. 

The  results  of  Dr.  Vedder's  observations  will  hardly 
tend  to  tranquillize  the  minds  of  those  residing  in  the 
locality  in  which  these  works  are  situated.  After  con- 
demning in  toio  the  position  of  the  works,  and  after 
pointing  out  the  fact  that  they  are  insanitary  in  a  very 
high  degree,  Dr.  Vedder  ends  by  saying:  "In  short, 
the  entire  process  is  evidently  an  experiment,  and  is 
susceptible  of  very  great  improvement.  Whether  it 
can  be  perfected  so  as  to  become  practically  unobjec- 
tionable is  a  question  difficult  to  decide,  taking  into 
consideration  the  present  location  of  the  plant.  A 
practical  point  that  is  likely  to  be  of  wide  interest  in 
view  of  recent  agitation  in  regard  to  sewage  farms  is 
in  regard  to  the  necessity  for  avoiding  an  impervious 
clay  soil,  especially  if  the  surface  is  nearly  level. 
The  result  is  very  much  better,  if  such  material  be 
allowed  to  run  over  a  sandy  soil  and  down  a  slope, 
than  if  it  be  accumulated  in  a  festering  mass,  breed- 
ing poisonous  and  foul  odors  year  after  year." 

The  reduction  process  in  this  country  commends  it- 
self on  account  of  its  supposed  economical  advantages 
as  compared  with  cremation.  In  America  the  cost  of 
garbage  disposal  by  cremation  varies  from  tliree  to  ten 
cents  per  capita.  In  Europe  the  cost  of  refuse  de- 
struction is  very  slight.  In  some  cases,  in  which  the 
heat  is  used  to  generate  steam  power,  there  is  said  to 
be  even  a  profit.  The  most  interesting  experiment  in 
this  connection  is  now  being  tried  at  Shoreditch,  Eng- 
land, and  is  a  practical  application  of  the  idea  how  to 
combine  tlie  destruction  of  refuse  with  the  production 


December  i8,  1897] 


MEDICAL    RECORD. 


891 


of  electric  light.  Of  course  it  would  be  as  yet  pre- 
mature to  pass  a  decided  opinion  as  to  the  result  of 
this  trial,  but  it  is  estimated  that  under  the  new- 
methods  the  cost  will  be  reduced  by  something  like 
two-thirds. 

The  conclusion  arrived  at  by  the  majorit}-  of  ex- 
perts appears  to  be  that  the  best  system,  from  a  sani- 
tar)-  point  of  view,  is  destruction  by  fire,  that  is  to  say, 
when  the  methods  are  efficiently  carried  out.  The 
small  and  oftentimes  questionable  value  of  the  refuse 
for  fertilizing  purposes  should  not  be  weighed  in  the 
scale  against  the  greater  value  of  improved  sanitation. 


THE    GEORGIA    FOOTBALL    BILL. 

Governor  Atkinson,  of  Georgia,  has  vetoed  the  anti- 
football  bill  which  was  passed  almost  unanimously  by 
both  branches  of  the  legislature.  His  objections  to 
the  bill  are  that  "  legislation  which  seeks  to  usurp  the 
responsibility  and  functions  of  trustee,  facult}-,  and 
parent,  and  take  charge  of  young  men  and  children  in 
their  sports,  is  fundamentally  wrong;  it  is  govern- 
mental paternalism  of  the  most  vicious  and  pronounced 
type."  The  governor  says,  however,  that  "  some  leg- 
islation may  be  necessary  to  modify  the  fierceness  of 
football  games,"  seemingly  overlooking  the  fact  that 
there  is  just  as  much  paternalism  in  deciding  upon  the 
exact  amount  of  violence  permissible  in  a  game  as 
there  is  in  prohibiting  it.  The  bill  forbade  the  "  sport" 
only  when  money  was  charged  for  admission  to  the 
grounds  where  the  game  was  played,  so  that  it  would 
have  been  still  permissible  to  encourage  "aggressive 
manliness,"  which  the  governor  defined  as  "  a  quality 
amalgamated  of  courage,  endurance,  restraint,  and  the 
power  to  act  surely  and  unfalteringly  in  an  emergenc)' 
— a  quality  which  football  tends  to  foster  and  to  keep 
alive."  But  apparently  an  essential  to  the  encourage- 
ment of  aggressive  manliness  is  a  good  pot  of  gate 
money. 

^eins  of  the  SmccU. 

A  New  Public   Hospital    in  Berlin.— There   are    at 

the  present  time  three  large  public  hospitals  in  Berlin, 
and  authorization  has  recently  been  granted  for  the 
erection  of  a  fourth. 

A  Woman's  Work  in  Afghanistan.— It  is  pleasing 
to  see  a  woman  who  has  a  real  "  vocation"  for  medical 
work  make  such  an  advance  as  that  achieved  by  Miss 
L.  Hamilton,  formerly  of  Sundrum,  in  Ayrshire,  Scot- 
land. She  was  trained  as  a  nurse  in  the  Liverpool 
Infirmarj',  and  afterward  studied  medicine  in  Brussels, 
taking  her  degree  three  years  ago.  After  graduation 
she  went  to  Calcutta  and  had  begun  practising,  when 
the  Ameer  of  Afghanistan  offered  her  a  fine  salary  if 
she  would  come  to  Cabul.  She  accepted  the  offer, 
though  efforts  were  made  to  dissuade  her.  Since  she 
has  become  the  physician  to  the  royal  family  she  has 
gone  on  successfully  treating  the  sick  and  enlightening 
the  minds  of  the  Ameer  and  his  people,  till  she  has 
won  his  full  belief  in  the  practice  of  vaccination;  and 


now  the  entire  population  is  being  vaccinated  with 
pure  calf  lymph  produced  close  at  hand,  and  a  royal 
decree  demands  that  no  one  shall  escape  this  salutary 
proceeding.  This  has  all  been  effected  through  the 
efforts  of  Dr.  Hamilton. —  Woman'' s  Journal. 

Temperance  Drinks. — Not  long  ago  attention  was 
called  in  London  to  the  popularity  among  tipplers  of 
certain  so-called  temperance  beverages,  an  analysis  of 
which  showed  that  they  contained  more  alcohol  than 
many  straight-out  goods  in  black  bottles.  The  Mas- 
sachusetts board  of  health  has  recently  made  a  similar 
discovery  concerning  tonics  and  bitters,  particularly 
those  recommended  as  '"  temperance"  drinks,  in  which 
the  percentage  of  alcohol  was  found  to  varj-  from  13.2 
to  41.6. 

Long  Life  and  Alcohol. — The  secretary  of  the  Order 
of  Rechabites,  a  total  abstinence  workingmen's  orga- 
nization in  England,  has  recently  made  a  careful  study 
of  the  vital  statistics  of  the  society  as  compared  with 
other  associations  in  which  abstinence  from  alcohol 
is  not  a  feature.  He  finds  that  at  the  age  of  eighteen 
the  expectation  of  life  is,  among  the  Foresters,  44.74 
years;  among  the  Rechabites  the  expectancy  is  50.62 
years — a  difference  in  favor  of  the  latter  of  5.88  years. 
Compared  with  the  Oddfellows,  the  latter's  advantage 
is  even  greater  by  7.75  years.  Applied  to  the  whole 
population,  the  expectancy  at  eighteen  among  abstain- 
ers is  better  by  8.72  years.  The  mortality  of  the  For- 
esters at  the  same  age  is  0.723  per  cent,  and  of  the 
Rechabites  0.589  per  cent.  The  percentage  of  the 
Foresters'  death  rate  to  that  of  the  Rechabites  at 
eighteen  is  as  123  to  100,  and  at  thirty-eight  as  189.3 
to  100.  The  conclusions  reached  by  the  compiler  of 
these  statistics  seem  to  be  corroborated  by  the  report 
of  an  English  life  insurance  company  in  which  a  dis- 
tinction is  made  between  the  abstainers  and  the  non- 
abstainers  among  the  policy  holders.  Among  the 
abstainers  the  expected  deaths  were  744,  while  there 
were  only  432,  a  percentage  of  58.06.  Among  the 
non-abstainers,  the  number  of  deaths  looked  for  was 
1,399,  *n<i  the  actual  number  who  died  were  1,131,  or 
80.84  per  cent,  of  the  expectancy.  These  figures  are 
suggestive,  yet  there  is  consolation  even  for  the  mod- 
erate drinkers  to  learn  that  nineteen  of  them  out  of 
every  hundred  live  longer  than  the  actuaries'  table 
says  they  should. 

The  Fruits  of  Sanitation  in  England. —  Dr.  Parkes 
recently  published  some  figures  showing  the  saving  of 
life  that  had  been  effected  in  England  during  the  reign 
of  the  present  queen,  through  the  efforts  of  sanitarians. 
He  showed  that  the  mortality  from  small-pox  had 
diminished  by  ninety-six  per  cent,  in  1891-95,  as 
compared  with  the  mortality  in  1838-42.  Since  187 1- 
75  there  had  been  a  decrease  of  ninety-five  per  cent, 
in  the  mortalitj'  from  tj'phus,  and  of  sixty  per  cent, 
from  typhoid  fever.  Since  1861-65  the  mortality 
from  scarlet  fever  had  fallen  eighty-one  per  cent. 
Diphtheria  had  prevailed  very  extensively  in  recent 
years,  and  owing  to  this  greater  prevalence  the  mor- 
tality was  now  very  much  the  same  as  it  was  thirty 
years  ago,  despite  the  benefits  of  the  new  orrhotherapy. 


892 


MEDICAL    RECORD. 


[December  18,  1897 


Epidemics  01  measles  and  whooping-cough  were  as 
common  now  as  when  the  Queen  came  to  the  throne. 
The  mortality  from  tuberculosis  had  fallen  forty-six 
per  cent.,  though  it  was  still  high.  Cancer,  on  the 
other  hand,  would  appear  to  have  increased.  The 
deaths  from  drink  were  as  numerous  as  they  were 
twenty  or  thirty  years  ago.  The  general  effect  of  im- 
proved sanitation  was  that  six  hundred  thousand  per- 
sons now  reached  the  age  of  twenty-one  years  who 
would  have  died  before  that  period  sixty  years  ago. 
Notwithstanding  this  great  prolongation  of  life  there 
is  no  cause,  Dr.  Parkes  thinks,  to  fear  overpopulation, 
for  the  birth  rate  has  been  getting  steadily  lower. 

Women  Students  at  Berlin. — About  two  hundred 
women  have  been  admitted  to  attend  lectures  this  year 
at  the  University  of  Berlin,  after  having  satisfied  the 
authorities  regarding  their  proficiency.  The  faculties 
chosen  by  them  are  those  of  philosophy,  medicine, 
and  jurisprudence. 

Increase  of  Crime  in  Connecticut. — Some  statistics 
recently  compiled  by  Mr.  T.  D.  Wells,  secretary  of  the 
board  of  State  prison  directors,  point  to  a  remarkable 
increase  of  crime  in  Connecticut  during  the  past  quin- 
quennium. The  figures  show  that,  while  the  convicts 
in  the  Wethersfield  State  prison  increased  in  number 
only  thirty-three  during  the  fifteen  years  between  1877 
and  1892,  the  increase  in  the  five  years  since  1892  has 
been  two  hundred  and  three,  or  sixty-eight  per  cent. 
The  prison  is  overcrowded,  and  twenty-two  convicts 
are  waiting  in  county  jails  for  room  in  the  State  insti- 
tution, the  county  jails  themselves  being  filled  with 
prisoners. 

Almost  a  Buried-Alive  Case. — The  gentlemen  who 
are  agitating  themselves  and  Europe  into  a  society  for 
the  prevention  of  being  buried  alive  will  doubtless  be 
glad  to  learn  of  the  narrow  escape  of  a  New  Orleans 
girl,  thirteen  years  old,  who  was  supposed  to  have  died 
one  day  of  yellow  fever.  The  necessary  certificate  of 
death  was  given  and  the  undertaker  was  notified  to 
inter  the  corpse,  the  burial  of  yellow-fever  victims  in 
all  cases  being  immediate.  The  undertaker  was  una- 
ble to  go  to  the  house  at  once  and  the  funeral  was 
delayed.  In  the  afternoon,  when  final  arrangements 
were  made  for  the  interment,  the  supposed  dead  girl 
opened  her  eyes,  and  it  was  found  that  she  was  not 
dead.  The  report  did  not  say  whether  death  really 
occurred  later,  or  whether  the  resuscitation  was  com- 
plete and  permanent  as  regards  that  particular  illness. 

Drug  Adulteration — According  to  a  report  of  the 
Massachusetts  board  of  health  on  the  adulteration  of 
food  and  drugs,  there  is  the  largest  percentage  of  adul- 
teration in  drugs — 50.3  per  cent. — milk  being  next 
with  35.2  per  cent.,  as  found  in  4,484  samples  exam- 
ined, while  in  food  in  general  the  percentage  of  adul- 
teration is  1 1.6.  The  principal  drugs  adulterated  or 
below  the  standard  of  strength  were  ether,  alcohol, 
ammonia  water  and  chlorine  water,  distilled  water, 
calx  chlorata,  extracts  of  licorice  and  nux  vomica, 
powdered  opium,  compound  spirits  of  ether,  spirits  of 
nitrous  ether,  tincture  of  iodine,  tincture  of  opium, 
and  mercurial  ointment. 


The   Women's   Health   Protective  Association 

The  annual  meeting  of  this  active  society  was  held  at 
the  Academy  of  Medicine  a  few  days  ago.  The  elec- 
tion resulted  in  the  choice  of  the  following  officers: 
President,  Mrs.  M.  E.  Trautman;  Vice-Presidents — 
First,  Mrs.  Mary  A.  Newton,  Secojid,  Mrs.  Esther 
Herman ;  Recording  Secretary,  Mrs.  Theresa  Barca- 
low;  Corresponding  Secretary,  Mrs.  M.  E.  C.  Baker; 
Treasurer,  Mrs.  A.  H.  Spencer;  Auditor,  Mrs.  E.  L. 
Wakeman.  In  her  annual  address,  the  president, 
Mrs.  Trautman,  paid  a  tribute  to  Mayor  Strong,  Col- 
onel Waring,  and  President  Wilson,  and  stated  that 
through  their  efforts  the  death  rate  in  this  city  had 
been  greatly  decreased. 

Small-Pox  in  Georgia. — It  is  reported  that  thirty 
counties  in  Georgia  are  suffering  from  a  visitation  of 
small-pox,  and  the  silly  local  quarantines,  of  which 
the  pernicious  effects  were  seen  during  the  recent  yel- 
low-fever scare,  are  being  established.  There  have 
been  upward  of  one  hundred  and  fifty  cases  in  At- 
lanta, and  the  board  of  health  has  adopted  the  honest 
course  of  publishing  the  number  of  cases  reported 
daily  in  order  to  prevent  a  panic  through  the  circula- 
tion of  unwarranted  rumors.  The  effect  has,  however, 
been  to  frighten  all  the  little  towns  about,  and  they 
have  quarantined  against  the  city.  .\  dispatch  to  the 
Evening  Post  says  that  compulsory  vaccination  has 
had  the  effect  of  frightening  the  country  people  away 
from  Atlanta,  many  of  them  fearing  that  they  will  be 
hunted  down  on  the  streets  and  vaccinated  upon  the 
highways.  This,  of  course,  has  nearly  ruined  the 
Christmas  trade.  Grifiin,  Rome,  Gainesville,  Carters- 
ville,  and  other  small  cities  are  talking  about  quaran- 
tining, and  the  local  papers  in  these  and  various  other 
towns  are  advising  the  people  to  stay  away  from  the 
capital.  In  La  Grange  it  has  been  ordered  a  citizen 
cannot  visit  Atlanta  without  getting  a  permit  from  the 
mayor.  The  disease  has  also  appeared  at  Rockhill, 
S.  C,  the  seat  of  Winthrop  College,  where  there  are 
upward  of  five  hundred  young  women,  and  has  created 
great  uneasiness.  Every  doctor  in  town  is  busy  day 
and  night  vaccinating  the  inhabitants,  and  the  gover- 
nor has  appointed  a  commission  to  visit  the  town  and 
investigate  conditions,  in  order  to  determine  how  to 
avert  the  threatened  visitation. 

The  Hospital  for  Scarlet  Fever  and  Diphtheria 
Patients. — This  hospital  will  be  opened  on  or  about 
December  29,  1897.  It  is  intended  for  pay  patients, 
and  is  situated  at  the  foot  of  East  Sixteenth  Street, 
facing  the  East  River.  The  hospital  is  a  private 
corporation,  controlled  by  its  own  board  of  govern- 
ors, and  is  not  connected  with  any  other  institution. 
The  president  of  the  board  of  health  and  one  of  the 
health  commissioners  are  ex-officio  members  of  the 
board.  Patients  may  be  attended  by  their  own  phy- 
sicians, if  it  is  so  desired,  ^'isiting  physicians,  L. 
E.  Holt,  W.  H.  Katzenbach,  George  M.  Swift,  F.  M. 
Crandall,  W.  K.  Draper,  R.  J.  Carlisle.  Consulting 
physicians,  E.  G.  Janeway,  A.  Jacobi,  W.  H.  Draper, 
R.  H.  Derby,  F.  P.  Kinnicutt,  A.  A.  Smith,  J.  W.  Bran- 
nan;  consulting  laryngologist,  H.  H.  Curtis,  resident 
physician,  E.  L.  Dow. 


December  18,  1897] 


MEDICAL    RECORD. 


893 


J>acietij  Reports. 

THE   PRACTITIONERS'    SOCIETY. 

One    Hundred   and    Thirty-Fourth    Regular   Meeting, 
Held  on  Friday,  November  5,  i8gy. 

Dr.  W.  Oilman  Thompson,  President,  in  the 
Chair. 

A  Case  of  Carcinoma  of  the  Tonsil  was  presented 
by  Dr.  Charles  McBurney.  The  patient  was  a  man, 
forty-seven  years  old.  In  October,  1896,  he  first  no- 
ticed a  soreness  of  the  throat,  which  did  not  increase 
very  rapidly,  and  it  was  not  until  January,  1897,  that 
an  enlargement  of  the  left  tonsil  was  observed  by  his 
physician,  who,  suspecting  syphilis,  put  the  patient  on 
specific  treatment,  which  was  continued  for  several 
months.  The  tonsil,  however,  continued  to  enlarge 
and  ulcerated,  and  when  the  patient  came  under  Dr. 
McBurney's  observation  last  June  it  presented  quite 
a  large  tumor,  which  was  firm  to  the  touch  with  an  ul- 
cerating surface  which  bled  on  handling.  The  disease 
had  also  spread  to  the  pillars  of  the  fauces,"  and  crept 
up  to  the  soft  palate  and  edge  of  the  tongue ;  it  had 
also  invaded  the  soft  tissues  on  the  inner  aspect  of  the 
angle  of  the  left  jaw,  although  the  bone  itself  was  not 
affected.  Microscopic  examination  proved  the  growth 
to  be  a  carcinoma. 

Operation:  A  preliminary  tracheotomy  was  per- 
formed, so  that  the  patient  could  be  etherized  without 
interfering  with  the  field  of  operation,  and  to  allow 
such  tampons  in  the  pharyn.\  as  would  prevent  blood 
from  passing  into  the  trachea  and  lungs.  An  incision 
was  then  made  along  the  anterior  border  of  the  sterno- 
cleido-mastoid  muscle  from  a  point  opposite  the  lobe 
of  the  ear  to  the  thyroid  cartilage.  From  the  middle 
of  this  incision  and  at  a  right  angle  to  it  another  cut 
was  made  upward  and  inward  across  the  body  of  the 
jaw.  The  two  triangular  flaps  were  then  dissected 
away,  uncovering  the  submaxillary  triangle.  The 
external  carotid  artery  and  the  facial  vein  were  tied 
and  the  dissection  was  continued  down  to  the  internal 
carotid,  which,  togetlrer  with  the  internal  jugular  vein 
and  the  pneumogastric  nerve,  were  drawn  to  the  outer 
side.  The  operation  from  this  time  on  was  compara- 
tively simple.  The  larynx  and  trxchea  were  first  pro- 
tected again  St  .blood  by  a  sponge  pushed  to  the  deepest 
part  of  the  pharynx.  The  pharynx  was  entered  in 
front  of  the  tonsil  and  the  incision  carried  down  be- 
hind it,  completely  removing  the  organ,  together  with 
a  wide  margin  of  tissue  surrounding  it.  Besides  the 
entire  tonsil,  the  affected  portion  of  the  tongue  and 
soft  palate  and  all  the  lymphatic  glands  and  connec- 
tive tissue  of  the  submaxillary  triangle  were  removed; 
it  was  also  deemed  best  to  remove  the  left  ramus  of 
the  jaw,  on  account  of  the  disease  of  the  soft  parts  on 
its  inner  aspect. 

After  the  operation  a  splint  was  inserted  in  tlie 
mouth  and  left  there  for  a  number  of  days,  in  order  to 
preserve  the  relation  between  the  upper  and  lower 
jaws.  This  splint  proved  to  be  of  little  value  except- 
ing for  a  few  days.  The  final  result  of  the  operation 
was  remarkably  good.  For  four  days  following  the 
operation  the  man  was  fed  by  the  rectum,  and  for  the 
next  six  days  the  stomach  tube  was  used ;  by  that  time 
the  wound  had  healed  sufliciently  to  permit  him  to 
swallow,  and  he  made  a  rapid,  uninterrupted  recovery. 
He  has  good  use  of  the  jaw,  and  is  aijle  to  masticate 
and  swallow  very  satisfactorily. 

Dr.  McHurney  said  this  operation  was  performed 
last  July.  Within  the  past  few  days  he  had  noticed  a 
small,  indurated,  and  rather  tender  spot  just  posterior 
to  the  line  of  his  incision  ;   he  thought  it  probable  that 


this  was  a  recurrence  of  the  disease.  If  this  patient 
had  been  presented  for  operation  a  few  months  earlier, 
the  extent  of  the  operation  and  the  likelihood  of 
recurrence  would  have  been  much  less. 

Dr.  Joseph  D.  Bryant,  who  had  seen  the  patient 
before  the  operation,  complimented  Dr.  McBurney  on 
the  excellent  result  obtained.  He  inquired  whether 
all  the  glands  in  the  submaxillary  triangle  had  been 
removed,  or  whether  some  had  been  found  unaffected 
and  were  left  behind. 

Dr.  McBurney  said  that  he  had  removed  all  dis- 
coverable lymphatic  glands  and  adjacent  connective 
tissue.  Some  of  the  glands  were  very  small  and 
apparently  healthy. 

Dr.  Robert  Abbe  thought  the  result  was  excellent 
after  such  an  extensive  resection.  He  was  surprised 
at  the  man's  good  masticating  power. 

Dr.  Bryant  said  that  about  a  year  ago,  after  an 
amputation  of  the  breast  for  carcinoma,  he  opened  the 
axilla  and  there  found  one  gland  that  was  distinctly 
involved  and  a  number  of  smaller  ones  that  appeared 
to  be  entirely  healthy.  They  were  removed,  however, 
and  submitted  to  Dr.  Dunham  for  microscopical  exami- 
nation, who  pronounced  them  carcinomatous. 

Dr.  McBurney  said  that  infection  of  the  lym- 
phatic glands  in  malignant  disease  varies  in  difl^erent 
patients.  In  some  the  disease  seems  to  spread  like 
wildfire,  while  in  others  it  remains  stationary  after 
involving  a  few  glands.  In  a  case  of  carcinoma  of 
the  tonsil,  which  he  operated  on  five  years  ago,  the 
patient  remaining  entirely  well  up  to  the  present  time; 
there  were  several  lymph  glands  involved,  some  as 
large  as  pigeons'  eggs,  and  adjacent  to  these  were 
glands  which  had  remained  entirely  unaffected. 

Dr.  Bryant  said  that  Dr.  McBurney's  patient  illus- 
trated the  statement  made  by  Kocher,  that  the  prog-  ' 
nosis  in  a  case  of  this  kind  is  not  always  in  proportion 
to  the  extent  of  the  disease.  In  other  words,  some  of 
the  best  results  have  occurred  in  cases  in  which  the  dis- 
ease had  progressed  to  such  an  extent  that  an  opera- 
tive procedure  was  regarded  as  almost  hopeless. 

Adjourned  Discussion.  —  The  discussion  of  the 
paper,  "The  Clinical  Value  of  the  Widal  Test,"  by 
Dr.  Thompson,  and  the  health  board's  circular,  "  Sepa- 
ration for  Diagnostic  Purposes  by  a  New  Method  of 
the  Typhoid  Bacilli  from  the  Stools  and  Urine  in 
Cases  of  Typhoid  Fever,"  submitted  by  Dr.  Biggs,  ad- 
journed to  this  meeting,  was  resumed. 

Dr.  G.  L.  Peabody  said:  "Dr.  Thompson  has 
shown  that  the  Widal  reaction  is  obtained  in  certain 
cases  which  prove  to  be  not  typhoid  fever.  As  we  do 
not  know  for  how  many  years  after  the  occurrence  of 
typhoid  fever  the  reaction  may  not  appear,  it  would  be 
desirable  in  all^such  cases  to  learn  if  the  patients  ever 
had  any  illness  like  typhoid  at  any  previous  period." 

Dk.  K.  G.  Janeway  said  that  from  his  standpoint 
the  Widal  test  had  not  proven  very  satisfactory.  In  a 
number  of  cases  coming  under  his  observation  the  test 
had  failed  entirely  or  had  responded  so  late  in  the 
course  of  the  disease  that  it  was  not  required  as  an 
aid  to  diagnosis.  To  illustrate  this  he  cited  the  fol- 
lowing case:  Last  spring  a  young  woman  had  been 
admitted  to  the  hospital  with  suspected  typhoid  fever. 
The  Widal  test  gave  a  negative  result,  and  it  was  not 
until  the  patient  had  a  hemorrhage  from  the  bowels 
that  the  diagnosis  was  positively  established.  During 
the  third  week  of  her  illness  the  test  gave  the  usual 
typhoid  reaction.  In  the  mean  time  the  patient's 
sister,  father,  and  brother  were  brougiit  into  the  hos- 
pital, and  in  all  three  of  these  cases  the  test  proved 
negative.  They  had  come  from  the  same  place  as  the 
first  patient,  and  a  diagnosis  of  typhoid  was  promptly 
made  and  afterward  confirmed  by  the  course  of  the  dis- 
ease. The  speaker  said  he  had  seen  a  number  of  cases 
in  which  the  Widal  test,  made   comparatively  early 


894 


MEDICAL    RECORD. 


[December  i8,  1897 


in  the  course  of  the  disease,  had  failed  to  respond. 
In  one  of  the  sixteen  cases  occurring  among  the  nurses 
at  Mt.  Sinai  Hospital,  the  reaction  did  not  appear 
until  convalescence.  In  regard  to  the  reaction  occur- 
ring in  persons  who  claim  that  they  have  never  had 
typhoid,  Dr.  Janeway  called  attention  to  the  fact  that 
this  fever  sometimes  occurs  without  producing  its 
characteristic  symptoms  or  taking  its  usual  course. 
He  had  seen  a  number  of  outbreaks  in  institutions, 
particularly  among  joung  people,  when  fully  one-half 
of  the  cases  aborted  naturally  within  from  three  to  ten 
days.  The  germ  and  poison  of  typhoid  fever  undoubt- 
edly produce  in  different  individuals  a  disease  of 
very  variable  duration.  In  the  outbreak  of  typhoid 
at  Princeton  College,  many  of  the  cases  did  not  fully 
develop.  The  same  is  true  of  the  epidemics  that  oc- 
curred at  the  Deaf  and  Dumb  Asylum  and  at  the  Cath- 
olic Orphanage  in  this  city.  Only  about  one-half 
the  patients  in  these  institutions  developed  typical 
typhoid;   in  the  rest  the  disease  aborted. 

Dr.  F.  p.  Kinnicutt  asked  Dr.  Janeway  whether 
he  thought  the  term  "  aborted"  a  good  one  to  apply 
to  those  cases  in  which  the  disease  never  fully 
develops.  Why  should  we  not  rather  ascribe  their 
brief  duration  to  the  fact  that  the  infection  is  very 
slight? 

Dr.  Janeway  replied  that  such  mild  cases  may  be 
due  to  the  fact  that  the  individual  infected  has  suffi- 
cient resisting  power  to  prevent  the  germs  from  grow- 
ing— in  other  words,  that  he  is  less  susceptible  to  the 
germs  than  are  others;  or  they  may  be  attributed  to  a 
mild  degree  of  infection  or  a  loss  of  infective  power  in 
the  germs  themselves.  We  see  this  same  varying 
degree  of  infection  or  susceptibilit}'  occurring  in  the 
course  of  epidemics  of  other  diseases.  The  speaker 
said  that  while  he  was  an  interne  at  Bellevue  many 
years  ago,  an  epidemic  of  typhus  fever  occurred,  and 
both  he  and  his  hospital  colleague  were  continually 
exposed  to  infection.  Both  were  taken  sick  at  the 
same  time  with  the  same  symptoms;  Dr.  Janeway  said 
he  recovered  after  two  or  three  days'  illness,  while  his 
colleague  died  of  typhus  and  his  name  is  among  the 
list  of  martyrs  on  the  tablet  at  Bellevue. 

Dr.  Andrew  H.  Smith  said  he  thought  it  quite 
possible  that  many  cases  of  typhoid  pass  unrecognized. 
We  see  many  cases  of  "  walking  typhoid,"  in  the  ma- 
jority of  which  the  patient  is  ultimately  obliged  to  take 
to  his  bed,  but  a  certain  proportion  recover  without 
progressing  further.  The  patients  do  not  feel  well, 
and  still  they  are  not  prostrated  to  any  marked  degree. 
Doubtless  the  blood  of  such  patients,  who  never  knew 
they  had  typhoid,  would  react  to  the  Widal  test.  The 
speaker  mentioned  the  case  of  a  girl  who  was  admitted 
to  the  Presbyterian  Hospital  last  winter  with  typical 
typhoid,  which  ran  its  usual  course.  In  that  case  the 
Widal  test  was  given  five  or  six  trials,  at  intervals  of 
two  or  three  days,  but  it  was  not  until  the  fourth  week 
that  the  usual  reaction  was  obtained. 

Dr.  H.  M.  Biggs  said  he  wished  to  emphasize  the 
fact  that  at  the  laboratory  of  the  New  York  health 
department,  in  every  case  when  a  definite  reaction 
was  produced  in  a  dilution  of  i  to  20,  the  reaction 
taking  place  within  a  time  limit  of  ten  minutes,  it 
proved  to  be  typhoid  fever.  The  experience  of  the 
department  now  covered  between  five  hundred  and  six 
hundred  cases,  and  in  every  instance  when  the  reac- 
tion was  produced  in  the  dilution  of  i  to  20  the  clini- 
cal results  were  entirely  harmonious  with  the  labora- 
tory findings.  The  fact  should  not  be  lost  sight  of 
that  the  Widal  test  is  quantitative  and  not  qualitative. 
More  than  this,  we  must  revise  our  ideas  somewhat  as 
to  what  typhoid  fever  is.  If  we  confine  the  term  to  a 
disease  in  which  there  are  intestinal  lesions,  we  must 
also  take  into  consideration  the  fact  that  there  are  ty- 
phoid infections  in  which  the  intestines  escape.     Cases 


of  the  latter  class  will  give  the  Widal  reaction,  and  in 
some  of  them  the  urine  will  contain  typhoid  bacilli. 

Dr.  W.  Oilman  Thompson  said  the  object  of  the 
original  paper  on  this  subject  was  to  discuss  the  clin- 
ical value  of  the  Widal  test.  The  speaker  said  he 
quite  agreed  with  Dr.  Biggs  that  the  test  should  be  a 
quantitative  as  well  as  a  qualitative  one.  As  regards 
the  accuracy  of  the  test,  a  number  of  cases  are  on 
record  in  which  the  reaction  was  obtained  in  a  dilu- 
tion of  I  to  20,  and  even  i  to  30,  in  patients  who  had 
not  typhoid  fever  and  never  had  had  it.  The  possi- 
bility suggested  by  Dr.  Peabody  that  some  of  these 
cases  in  which  the  reaction  occurred  may  have  had 
typhoid  years  before  is  quite  true,  but  that  does  not 
render  the  test  any  less  uncertain  at  the  bedside. 
Many  hospital  patients  are  unable  to  give  a  satisfac- 
tory history.  The  speaker  said  he  had  reported  two 
cases  in  which  the  reaction  was  obtained  only  during 
the  relapse,  the  results  of  the  test  during  the  original 
disease  being  entirely  negative. 

Dr.  Kinnicutt  asked  in  regard  to  the  frequency 
with  which  typhoid  attacks  the  same  person  a  second 
time.  He  thought  this  immunity  against  a  second 
infection  more  apparent  than  real,  and  inquired 
whether  it  was  due  as  much  to  the  insusceptibility  of 
the  tissues  or  blood  of  the  individual  as  to  the  im- 
probability of  his  being  exposed  twice  to  the  conta- 
gion. It  is  recognized  that  a  second  attack  of  typhoid 
fever  is  not  uncommon  in  those  who  are  exposed  to 
the  infection.  He  mentioned  one  case  in  which  the 
patient  had  had  three  attacks. 

Dr.  Janeway  said  he  had  seen  a  second  attack 
occur  within  three  years  after  the  original  attack. 

Dr.  Peabody  said  we  know  positively  that  persons 
who  have  had  syphilis  or  any  of  a  number  of  other 
diseases  are  not  susceptible  to  a  second  attack.  He 
did  not  see  why  the  same  rule  may  not  apply,  at  least 
to  a  certain  degree,  to  typhoid  fever. 

Dr.  McBurney  said  he  had  always  been  led  to  be- 
lieve that  many  are  frequently  exposed  to  typhoid 
fever,  and  that  comparatively  few  are  liable  to  take  it. 

Dr.  Janeway  said  that  had  also  been  his  idea. 

Dr.  Beverley  Robinson  inquired  whether  people 
take  diphtheria  twice. 

Dr.  J.  W.  Brannan  said  he  had  seen  a  number  of 
patients  at  the  Willard  Parker  Hospital  who  had  had 
at  least  two  attacks  of  diphtheria,  with  an  internal  of 
only  three  months  in  some  .-^ases.  The  second  attack 
may  be  very  severe  and  even  fatal. 

Dr.  Biggs  said  there  is  no  doubt  that  diphtheria 
may  occur  more  than  once  in  the  same  individual.  It 
is  also  true  that  one  attack  affords  comparative  immu- 
nity, and  that  an  attack  which  runs  its  course  affords 
much  greater  immunity  than  one  which  is  cut  short  by 
the  administration  of  diphtheria  antitoxin.  It  is  the 
difference  between  active  and  passi\e  immunity. 

Is  Not  the  Mortality  from  Surgical  Disease  Un- 
necessarily Large  ? — Dr.  Charles  McBurney  read 
this  paper  (see  page  881). 

Dr.  V.  P.  GiBNEv  said  he  quite  agreed  with  the 
writer  of  the  paper  that  unnecessary  delays  are  often 
accountable  for  the  bad  results  of  an  operation.  It 
is  certainly  so  in  the  department  of  surgery  in  which 
he  is  especially  interested.  The  responsibility  for 
such  delays  is  often  difficult  to  settle.  In  joint  sur- 
gery it  is  a  well-established  fact  that  in  some  in- 
stances an  efficient  protection  to  the  affected  joint  is 
conducive  to  an  excellent  result,  and  yet  there  are 
cases  in  which  the  lesion  is  so  severe  and  extensive 
that  no  amount  of  protection  we  can  give  that  joint 
will  prove  of  any  benefit  to  the  patient.  It  is  in  those 
cases  that  we  meet  with  stumbling-blocks;  it  is  here 
that  the  extreme  conservatives  and  the  radicals  clash. 
We  all  know  there  are  exceptional  cases  in  which  na- 
ture has  done  extraordinary  work,  and  such  a  patient  is 


December  i8,  1897] 


MEDICAL    RECORD. 


895 


brought  forward  as  an  example  of  conservative  treat- 
ment. We  do  not  hear  so  much  of  the  bad  results 
caused  by  delay,  the  amyloid  degeneration,  and  other 
various  complications  that  may  set  in,  when  operative 
interference  is  out  of  the  question.  In  a  diseased 
hip-joint,  for  instance,  when  the  head,  neck,  and  shaft 
of  the  bone  are  involved,  we  feel  that  amputation  is 
the  best  thing,  and  yet  we  naturally  postpone  it  until 
the  patient  is  in  extremis,  and  then  it  does  no  good. 

Dr.  Joseph  D.  Brvant  said  that  the  vulnerabilit}- 
of  the  tissues  in  different  individuals,  which  was  re- 
ferred to  by  Dr.  McBumey  in  connection  with  the  time 
limit  for  operating  in  strangulated  hernia,  is  subject 
to  modification  by  so  many  extraneous  conditions — 
such  as  the  age  of  the  patient,  his  previous  health,  etc. 
— that  it  must  be  regarded  as  a  very  uncertain  factor. 
He  saw  no  reason  why  prompt  action  should  not  be 
taken,  irrespective  of  any  lack  of  knowledge  regarding 
the  vulnerabilit}'  of  the  tissues.  When  we  come  to  the 
question  of  settling  the  responsibility  for  delaying  an 
operation,  the  speaker  thought  it  rested,  first,  with  the 
patient;  second,  with  the  patient's  friends ;  third,  with 
the  physician;  and  finally  and  not  infrequently  with 
the  surgeon  himself.  How  often,  for  example,  will  a 
woman  who  is  suffering  from  a  tumor  of  the  breast 
keep  the  knowledge  of  it  to  herself  as  long  as  possible, 
and  then  perhaps  confide  it  to  a  friend  who  will  be 
equally  uncommunicative?  For  sentimental  reasons 
the  patient  may  refuse  to  undergo  an  examination  by 
a  physician,  or,  even  if  such  an  examination  is  made 
and  the  physician  suspects  malignant  disease,  he  may- 
keep  the  suspicion  to  himself  as  long  as  possible.  In 
the  majority  of  cases  the  delay  is  probabl}'  due  to  the 
unwillingness  of  any  one  who  is  afflicted  to  recognize 
that  fact.  That  feeling  is  very  natural.  Many  physi- 
<;ians  even  are  averse  to  having  their  urine  examined 
or  the  heart  listened  to  for  fear  that  they  may  learn  an 
unpleasant  truth.  Dr.  Bryant  said  he  knew  of  no  way 
by  which  anything  could  be  accomplished  in  this  mat- 
ter, unless  it  would  be  to  instruct  those  who  are  in  good 
health  and  inculcate  in  them  the  idea  that  when  any 
abnormal  condition  of  health  appears  they  shall 
promptly  and  earnestly  insist  on  being  told  what  is 
the  matter,  and,  if  the  case  demands  it,  that  the  sur- 
geon shall  be  called  at  the  earliest  possible  moment  to 
assist  in  determining  whether  his  active  services  are 
necessary. 

Dr.  Pe.abody  said  he  was  not  quite  willing  to  plead 
guilt)' to  the  indictment  that  physicians  in  general  co- 
operate with  patients  in  their  fancied  security,  and  lull 
them  gradually  into  the  arms  of  death.  He  was  will- 
ing to  admit,  however,  that  a  certain  number  of  physi- 
cians do  delay  unwarrantably  in  this  manner.  One 
explanation  for  this  delay  may  probably  often  be 
found  in  the  prejudice  which  exists  against  the  surgeon 
in  the  mind  of  the  patient.  While  the  physician  is 
often  welcome  in  many  households,  the  surgeon  is 
looked  upon  as  a  necessary  evil,  to  be  averted  or  post- 
poned if  possible.  The  most  sensible  view  to  take  is 
that  in  any  case  in  which  the  services  of  a  surgeon  may 
become  necessary  he  should  be  summoned  as  soon  as 
possible.  He  should  have  an  opportunity  to  see  the 
patient  at  the  earliest  possible  moment,  and  if  it  is 
then  desirable  to  postpone  operative  interference  the 
patient  should  remain  under  their  joint  observation. 
The  physician  should  not  take  the  reponsibility  alone 
of  postponing  surgical  interference  in  a  grave  case. 

Dr.  Janeway  said  that  many  elements  enter  into 
the  question  of  delaying  surgical  operations.  He  has 
found  that  one  of  the  most  potent  causes  of  delay  is 
the  knowledge  possessed  by  the  patient  that  some 
friend  or  relative  had  undergone  a  similar  operation 
and  died.  Many  refuse  to  be  operated  on,  or  delay 
the  operation  as  long  as  possible,  because  they  know 
•of  similar  cases  which  were  operated  on  and  resulted 


unfortunately.  Another  cause  for  tlie  delay  in  many 
cases  is  the  natural  desire  on  the  part  of  the  patients' 
friends  to  keep  them  in  ignorance  of  the  real  nature  of 
their  ailment.  Some  surgeons  occasionally  make  the 
statement  to  the  patient  that  unless  an  operation  is 
performed  he  cannot  recover.  Such  prophecies  some- 
times prove  false,  and  are  apt  to  give  rise  to  a  suspi- 
cion in  the  minds  of  the  lait}'  that  the  surgeon  is 
anxious  to  operate. 

Dr.  Robert  Abbe  said  that  in  considering  the 
present  surgical  mortalit}'  rate  we  should  bear  in  mind 
the  fact  that  the  amount  and  class  of  surgery  done 
twenty  years  ago  cannot  be  compared  with  that  done 
to-day.  The  class  of  cases  which  still  contributes 
most  to  the  large  mortality  is  that  in  which  there  has 
been  too  much  delay  before  operation — the  neglected 
cases.  These  patients,  when  they  come  to  the  surgeon, 
are  in  a  practically  hopeless  condition.  They  seem 
so  at  the  time  to  the  surgeon;  yet  occasionally  one 
such  patient  survives  operation,  and  with  that  fact  in 
mind  the  surgeon  operates.  These  help  to  swell  the 
surgical  mortality — cases,  nineteen  out  of  twenty  of 
which  should  never  have  been  operated  on.  Hence 
we  should  study  to  learn  the  limit  of  possible  surgical 
relief.  Take,  for  example,  general  septic  peritonitis; 
we  all  know  that  an  operation  for  this  condition  when 
verj-  far  advanced  usually  proves  unavailing,  and  yet 
very  grave  cases  have  been  reported  as  saved,  in  a 
few  instances.  Dr.  Abbe  said  he  had  studied  a  large 
number  of  these  cases,  and  found  that  in  every  in- 
stance when  albuminuria  was  present  and  of  very 
recent  onset  the  case  proved  fatal.  The  cases  which 
recovered  were  those  in  which  there  was  no  albumi- 
nuria. If  a  case  of  acute  septic  peritonitis  has  de- 
veloped a  septic  albuminuria  from  a  choking  of  the 
renal  vessels,  the  case  is  hopeless.  One  important 
method,  therefore,  by  which  the  surgical  mortality  can 
be  largely  reduced,  is  to  refuse  to  operate  in  what 
appear  to  be  hopeless  cases  when  more  careful  study 
proves  operation  to  be  unjustifiable.  The  occasional 
successes  and  falsely  reported  cases  in  literature  should 
not  be  permitted  to  lure  the  surgeon  on.  The  occa- 
sional refusal  of  the  surgeon  to  interfere,  when  his  in- 
telligence and  conscience  justify  him  in  doing  so,  will 
ultimately  command  a  larger  number  of  cases  brought 
to  him  in  the  incipiency  of  disease,  and  thus  finally 
reduce  the  mortality  credited  to  operations. 

Dr.  a.  H.  Smith  said  that  last  summer  he  saw  a 
case  of  carcinoma  of  the  stomach  which  he  regarded 
as  absolutely  hopeless,  and  so  reported  to  the  family. 
A  surgeon  who  had  been  highly  recommended  to  the 
family  was  called,  with  the  consent  of  Dr.  Smith, 
merely  to  satisfy  the  friends;  but  to  the  amazement  of 
Dr.  Smith  an  operation  was  advised.  He  then  insisted 
that  the  family  should  select  another  surgeon  before 
proceeding.  They  did  so,  and  his  opinion  coincided 
with  that  of  Dr.  Smith.  The  patient  died  a  few  weeks 
later. 

Dr.  Beverley  Robinson  said  that,  speaking  as  a 
general  practitioner,  he  usually  prefers  to  refer  his 
operative  cases  to  a  general  surgeon  rather  than  to  a 
specialist.  The  latter,  as  a  rule,  does  not  operate  any 
better  than  the  general  surgeon,  and  he  is  often  led  to 
do  an  operation  which  the  general  surgeon  would  not 
do.  In  all  cases  which  demand  it,  the  opinion  of  the 
surgeon  should  be  obtained  as  soon  as  possible,  pro- 
viding he  is  a  man  who  has  achieved  a  position  in  his 
profession  which  has  rendered  him  conservative,  so 
that  he  will  refuse  to  undertake  an  unnecessary  or 
overhazardous  operation. 

Dr.  McBurney,  in  closing  the  discussion,  said 
that,  while  the  surgical  mortality  can  be  easily  reduced 
by  refusing  to  operate  on  hopeless  cases,  there  is 
another  and  better  way,  and  that  is  to  have  those  pa- 
tients who  are  now  brought  to  the  surgeon  too   late 


896 


MEDICAL    RECORD. 


[December  18,  1897 


brought  in  time  to  be  operated  on  and  saved.  He 
agreed  with  Dr.  Brj'ant  that  the  time  limit  can  never 
be  accurately  defined,  but  in  many  cases  there  is  a 
time  limit  which  can  be  scientifically  discussed  by  the 
physician  and  the  surgeon.  In  strangulated  hernia, 
for  example,  there  is  a  time  during  which  the  patient  can 
be  successfully  operated  upon  and  after  which  he  can- 
not. If  this  question  of  the  time  limit  should  receive 
more  serious  consideration,  we  would  not  so  often  hear 
said :  "  I  do  not  see  why  we  should  not  wait  until  to- 
morrow." In  reply  to  a  question.  Dr.  McBurney  said 
that  he  never  consents  to  operate  unless  he  believes 
that  the  patient  may  benefit  by  the  operation.  The 
surgeon  should  never  allow  himself  to  be  influenced  by 
sentimental  reasons,  if  it  is  his  deliberate  opinion 
that  the  operation  cannot  possibly  do  good. 


THE  NEW  YORK  PATHOLOGICAL   SOCIETY. 

Stated  Meeting,    October  2~.  rSgj. 

\V.\RREN    Coleman,  M.D.,  Yice- President,  in    the 
Chair. 

Tuberculous  Lymph  Nodes  from  a  Case  of  Chronic 
Bronchitis  and  Emphysema. — Dr.  J.  H.  Larkin  ex- 
hibited under  the  microscope  a  section  of  a  lymph  node 
taken  from  the  root  of  the  lung  of  a  man,  forty-five 
years  of  age,  who  had  died  of  chronic  bronchitis  and 
emphysema.  There  had  been  no  other  tuberculous  in- 
flammation in  the  body.  The  autopsy  showed  intense 
venous  congestion  of  the  kidney  and  a  nutmeg  liver, 
with  a  few  adenomata  scattered  throughout  the  liver. 
Along  the  root  of  the  lung  the  lymph  nodes  were  very 
much  swollen.  Around  the  pericardium  they^  were  also 
much  swollen,  some  of  them  being  as  large  as  a  hazel- 
nut. A  thorough  search  was  made  in  the  lungs  and 
other  organs  for  tuberculous  foci,  but  none  was  found. 
On  cutting  open  the  lymph  nodes  they  were  found  to 
be  nearly  three-fourths  cheesy,  the  microscope  reveal- 
ing diffuse  areas  of  cheesy  degeneration.  Dr.  Larkin 
said  that  he  had  ground  up  some  of  these  cheesy  nodes 
with  decinormal  salt  solution,  and  had  then  injected 
two  jcubic  centimetres  of  this  fluid  into  each  of  three 
guinea-pigs.  After  three  weeks  one  died,  but  the  au- 
topsy was  negative.  The  other  two  were  killed  at  the 
end  of  eight  weeks,  and  in  these  animals  the  post- 
mesenteric  glands  were  very  large  and  cheesy,  and 
there  were  several  small  foci  in  the  liver  and  spleen. 
Some  pseudo-tubercles  were  found  in  the  lungs.  He 
had  collected  the  lymph  nodes  from  the  guinea-pigs, 
and  had  made  sections  of  these  also.  One  of  these 
sections  from  the  post-mesenteric  glands  was  also 
shown  under  the  microscope,  stained  for  tubercle 
bacilli.  The  specimen  exhibited  several  bacilli, 
which  corresponded  morphologically  with  tubercle 
bacilli.  The  specimens  were  presented  because  of 
the  interest  attaching  to  their  occurrence  in  a  case  in 
which  death  had  been  due  to  chronic  bronchitis  and 
emphysema,  with  no  other  evidences  of  tuberculosis  in 
the  body.  It  would  seem  from  the  findings  in  this 
case  that  the  lymph  nodes  served  not  only  as  store- 
houses for  noxious  products  and  various  kinds  of  pig- 
ment, but  also  as  storehouses  for  bacteria — not  only 
the  ordinary  bacteria  always  found  in  the  trachea,  but 
for  pathogenic  bacteria.  The  case  also  illustrated  one 
of  the  ways  in  wliich  a  person  might  become  infected 
with  the  tubercle  bacilli,  /.<•.,  the  bacilli  first  finding  a 
lodgement  in  the  lymph  nodes,  and  afterward,  prob- 
ably as  a  result  of  some  exposure  to  some  weakening 
influence,  being  distributed  to  the  body  at  large. 

Dr.  Henry  Heiman  said  that  it  was  interesting  to 
recall  in  this  connection  that  Billroth  thought  he  had 


observed  tuberculous  meningitis  following  operations 
on  tuberculous  glands  of  the  neck. 

Dr.  Warren  Coleman  asked  Dr.  Larkin  what  was 
his  view  of  the  ordinary  channel  of  infection  in  the 
lung,  whether  through  the  smaller  bronchial  tubes  or 
first  through  the  lymph  nodes.  He  had  in  mind  those 
foci  of  infection  so  frequently  met  with  at  the  apex  of 
the  lung. 

Dr.  Larkin  said  he  thought  a  large  dose  of  tubercle 
bacilli  might  get  in  through  the  bronchi  without  pass- 
ing through  the  lymphatic  channel,  and  might  there 
set  up  a  diffuse  tuberculous  pneumonia.  In  other 
cases  a  few  tubercle  bacilli  might  be  lodged  in  the 
lymph  nodes  and  remain  quiescent  for  a  longer  or 
shorter  period  of  time.  The  anatomists  had  possibly 
thrown  a  little  light  upon  this  matter  by  referring  to 
the  unequal  angles  of  divergence  of  the  bronchi  from 
the  trachea.  This,  of  course,  was  only  an  attempt  to 
explain  why  tuberculous  deposits  occurred  by  prefer- 
ence in  the  apices  of  the  lungs,  but  did  not  explain  the 
simultaneous  involvement  of  both  apices. 

Dr.  Coleman  said  that  a  most  plausible  theory  in 
connection  with  the  location  of  these  processes  at  the 
apex,  and  of  the  channel  through  which  the  bacilli 
passed,  was  that  which  assumed  that  these  organisms 
were  taken  up  by  phagocytes  and  carried  into  the 
lymph  channels,  and  that,  instead  of  remaining  in  the 
glands  at  the  base  of  the  lung,  they  passed  through 
these  for  some  unknown  reason,  and  were  then  carried 
through  the  lymph  channels  to  the  apex. 

Dr.  Larkin  said  that  in  his  case  undoubtedly  the 
bacilli  had  been  seized  by  the  phagocytes  and  had 
gotten  only  as  far  as  the  nodes;  but  if  the  tubercle 
bacilli  did  get  farther  it  was  hard  to  understand  why 
the  apices  should  be  selected  by  preference. 

Dr.  James  Ewixg  said  that  he  could  not  see  how 
the  lymph  nodes  at  the  base  of  the  lung  could  play  a 
part  in  tuberculosis.  All  experimental  studies  regard- 
ing the  reasons  for  the  lodgement  of  tubercle  bacilli  in 
the  apices  by  preference  had  led  to  the  conclusion  that 
it  depended  upon  the  character  of  the  blood  supply 
there,  and  upon  mechanical  conditions  affecting  the 
aeration  of  those  parts  of  the  lung. 

Dr.  Coleman  said  that  the  statement  just  made 
about  the  circulation  at  the  apex  might  explain  the 
lodgement  of  organisms  there  rather  than  in  other  parts. 
Some  years  ago  he  had  made  some  incomplete  experi- 
ments bearing  on  this  question.  They  consisted  in 
making  an  animal  inhale  lampblack,  and  also  in  in- 
jecting this  lampblack  into  the  pleural  sac.  It  was 
found  in  the  course  of  lialf  an  hour  that  these  pigment 
granules  had  been  taken  up  from  the  trachea  and  large 
bronchial  tubes,  and  had  been  distributed  through  the 
lymph  nodes  under  the  pleura  and  over  .the  whole  sur- 
face of  the  lung.  These  experiments  had  influenced 
him  largely  in  arriving  at  the  opinion  already  ex- 
pressed. 

Dr.  Larkin  said  that  in  autopsies  on  cases  not  sup- 
posed to  be  tuberculous  thetlymph  nodes  received  verj- 
little  consideration,  yet  a  large  percentage  of  these 
lymph  nodes  in  patients  dying  of  diseases  other  than 
tuberculosis  contained  foci  of  tuberculous  inflamma- 
tion. The  case  from  which  his  specimen  had  been 
taken  was  only  one  of  a  series  of  about  thirt)-  autop- 
sies, in  which  the  lymph  nodes  had  been  collected 
from  the  roots  of  the  lungs  which  contained  ordinary 
cheesy  areas. 

Dr.  Coleman  said  that  an  English  obser\-er  had 
recently  promulgated  the  theory  that  tuberculosis, 
when  in  a  condition  to  be  recognized  by  the  physical 
signs,  was  really  in  its  second  stage,  and  that  the  in- 
fection not  infrequently  gained  an  entrance  to  the  body 
through  the  alimentary  tract  and  mesenteric  glands. 

Autopsy  Made  Months  after  Death — Dr.  James 
EwiNG  presented  the  viscera  from  a  case  on  which  an 


December  i8,  1897] 


MEDICAL    RECORD. 


897 


autopsy  had  been  made  five  months  and  eight  days 
after  death.  He  was  enabled  to  present  this  interest- 
ing material  through  the  kindness  of  Dr.  A.  Jacobi, 
•whom  he  had  assisted  at  the  autopsy.  The  clinical 
diagnosis  had  been  tonsillitis  and  nasopharyngeal 
hemorrhage;  the  anatomical  diagnosis  was  peritonsil- 
lar abscess  and  retropharyngeal  abscess,  with  rupture 
of  the  right  internal  carotid  artery.  An  embalming 
fluid  of  unknown  composition  had  been  injected  into 
the  median  basilic  vein.  The  body  had  been  interred 
in  dry  gravel  in  a  wooden  casket,  surrounded  b)-  the 
usual  outer  box.  The  body  itself  was  rigid  and  the 
skin  much  desiccated,  but  the  features  were  surpris- 
ingly well  presen-ed.  There  was  a  large  abscess  cav- 
ity around  the  tonsil  and  behind  the  pharynx,  and 
about  one  and  one-half  centimetres  above  the  origin 
of  the  internal  carotid  artery  was  an  irregular  opening, 
five  centimetres  in  circumference,  communicating  with 
this  cavit}-.  The  viscera  were  so  desiccated  as  to  be 
tough  and  almost  cartilaginous.  The  spleen  and  kid- 
neys were  remarkably  well  preser\-ed,  and,  strangely 
enough,  with  the  ordinary  methyl  blue  stain  it  was  pos- 
sible to  demonstrate  the  presence  of  numerous  colonies 
of  cocci  around  the  wall  of  the  abscess  cavity. 

Dr.  Colemax  said  that  in  the  only  case  of  this  kind 
that  he  had  seen  the  sections  of  the  kidney  were  in  as 
good  condition  as  was  the  specimen  just  presented,  and 
the  hardening  was  almost  as  perfect  as  if  it  had  been 
done  in  the  laboratory  on  small  pieces  of  tissue. 

Dr.  Larkin  said  that  the  most  approved  method  of 
embalming  at  the  present  time  seemed  to  consist  in 
puncturing  the  different  viscera  with  a  trocar,  instead 
of  injecting  the  fluid  into  the  vessels.  Great  care  was 
taken  to  extract  as  much  blood  as  possible. 

Dr.  Ewing  said  that  in  the  autopsy  he  had  reported 
there  had  been  no  punctures  in  the  skin  or  viscera. 

Preservative  Injections  in  the  Intestine — Dr. 
Henry  Heiman  said  that  about  one  years  ago  Dr. 
Henry  Power  had  conducted  certain  e.\periments  re- 
garding the  value  of  formalin  as  a  preservative  in  the 
intestine.  Dr.  Heiman  said  that  he  had  varied  these 
exjjeriments  by  injecting  t\vo  to  five  per  cent,  solutions 
of  formalin  into  the  rectum  of  five  children  who  had 
suffered  from  gastro-enteritis.  For  comparison  he  had 
examined  three  cases  of  gastro-enteritis  in  which  no 
formalin  solution  had  been  injected.  The  injection 
had  been  made  immediately  after  death.  It  was  found 
that  by  this  early  use  of  the  formalin  injections  the 
mucous  membrane  was  at  once  fixed  for  hardening  pur- 
poses, thus  preserving  more  epithelium  and  giving  a 
more  clearly  defined  picture.  The  autopsy  could  be 
made  at  the  usual  time.  He  had  used  an  ordinary 
irrigator,  and  had  found  by  experiment  that  the  correct 
pressure  was  obtained  by  elevating  the  reserv'oir  about 
six  or  eight  inches  only.  His  plan  was  to  sew  the 
nozzle  into  the  rectum  and  allow  the  fluid  to  run  in 
for  some  time,  twelve  to  twenty-four  hours  in  some 
cases.  The  fluid  would  reach  half-way  up  the  ascend 
ing  colon,  and  even  the  parts  in  close  apposition  to 
those  injected  became  hardened.  Specimens  were  ex- 
hibited under  the  microscope  showing  the  gut  in  cases 
so  treated,  and  also  those  not  preserved  in  this  way. 
The  solution  used  was  a  2.5-per-cent.  solution,  made 
from  the  ordinary  commercial  (40  per-cent.)  formalin 
solution.  It  did  not  produce  the  shrinkage  that  other 
hardening-fluids  did. 

Dr.  Ewint,  said  that  he  had  followed  the  experi- 
ments of  both  Dr.  Power  and  Dr.  Heiman,  and  the 
results  were  certainly  a  marked  improvement  on  those 
of  the  ordinary  method  of  leaving  the  body  until  per- 
mission had  been  obtained  for  an  autopsy.  The  raucous 
membrane,  muscular  coat,  peritoneum,  etc. — in  fact,  all 
except  the  superficial  epithelium — were  very  well  pre- 
served. It  did  seem,  however,  that  the  injection  fluid 
did  remove  some  of  the  superficial  epithelium :    hence 


the  specimens  were  not  so  perfect  as  those  obtained 
from  bodies  in  which  the  autopsy  was  made  immedi- 
ately after  death,  as  after  electrocutions.  The  method 
nevertheless  was  to  be  highly  recommended  for  ordi- 
nary- cases  when  one  desired  to  examine  the  intestinal 
epithelium. 

Dr.  Heimax  said  that  this  method  might  be  em- 
ployed in  diseases  of  the  intestine.  He  wished  here 
to  acknowledge  his  indebtedness  to  Dr.  Rowland  G. 
Freeman  for  the  material  experimented  upon. 

Dr.  Colemax  said  that  the  method  had  been  applied 
recently  at  the  Charity  Hospital  in  cases  of  gastric 
carcinoma  for  the  purpose  of  preserving  the  gastric 
mucous  membrane  for  subsequent  examination.  The 
result  should  be  even  better  than  in  the  intestine,  be- 
cause it  would  stop  the  self-digestion  of  the  stomach. 

Dr.  Larkix  said  that  he  looked  upon  formalin  as  a 
very  tricky  preservative,  and  it  was  unfortunate  that 
experiments  in  this  direction  had  not  been  made  with 
some  other  preservative  as,  for  example,  Miiller's  fluid. 
If  formalin  was  used  alone,  the  effect  on  the  staining 
properties  of  cells  was  not  so  good  as  if  a  combination 
of  formalin  with  alcohol  or  Miiller's  fluid  was  used. 

Dr.  Colemax  remarked  that  it  was  generally  ad- 
mitted now  that  formalin  caused  swelling  of  the  cell 
protoplasm,  and  hence  destroyed  the  intimate  structure 
of  the  cells  to  some  extent. 

Dr.  Heimax  said  that  when  formalin  was  added  to 
ordinary  chest  serum  he  had  found  that  it  did  not  co- 
agulate it.  Wassermann  had  stated  that  the  addition 
of  formalin  to  seram  prevented  its  coagulating  when 
heated,  and  he  had  found  that  if  egg  albumen  was 
placed  imder  the  same  cover  with  formalin  it  would 
become  coagulated  after  a  time.  It  was  evident  that 
formalin  acted  ver\-  differently  on  different  albumins. 

Dr.  Colemax  said  that  one  of  the  chief  virtues  of 
formalin  was  that  it  would  coagulate  the  liquid  in  the 
alveoli  in  a  case  of  pulmonar)-  oedema,  so  that  the 
condition  might  be  demonstrated  to  students.  He  had 
not  been  able  to  do  this  with  any  other  hardening 
agent. 

The  societ}-  then  adjourned. 


©otrrespondence. 

OUR    LONDON    LETTER. 

(From  our  Special  Correspoadeot.) 

meetixg  of  general  medical  council,  sir  r- 
qlain's  health,  exit  the  unqualified  assistant, 
midwhes    .agaix,    xew     members— dr.    rentoul 

EXPLAINS    OR    excuses     HIS     RESIGNATION  —  MEDICAL 

society GLASGOW      INFIRMARY EDI  N  BURG  H 

TYPHOID — UXrvERSITY     PROPOSAL — CENTRAL     HOSPI- 
TAL  COUNCIL — DEATH    OF    DR.    HEDDLE. 

London,  November  26,  1897. 

The  General  Medical  Council  met  on  Tuesday.  The 
venerable  president.  Sir  Richard  Quain,  was  unable 
to  be  present,  although  his  health  has  materially  im- 
proved. It  is  said  by  those  who  see  him  that  his 
mind  is  unclouded  and  alert.  The  letter  he  sent  to 
the  council,  sketching  the  course  of  business  and  the 
subjects  coming  forward  for  discussion,  shows  how 
thoroughly  he  still  grasps  the  details  of  the  council's 
work  and  duty.  This  is  the  first  time  for  thirty-four 
years  that  Sir  R.  Quain  has  been  absent  from  the 
council,  and  regret  was  naturally  expressed  by  his  col- 
leagues, who,  on  his  recommendation,  requested  the 
chairman  of  the  business  committee,  Sir  William  Tur- 
ner, to  act  as  his  substitute. 

The  most  important  act  of  the  session  was  the  de- 
cision of  the  council  no  longer  to  tolerate  unqualified 


MEDICAL    RECORD. 


[December  i8,  1897 


assistants.  Notice  is  to  be  given  that  their  employ- 
ment renders  practitioners  liable  to  be  removed  from 
the  register,  on  a  charge  of  "  infamous  conduct  in  a 
professional  respect."  There  was  a  difference  of  opin- 
ion as  to  how  long  notice  should  be  given,  but  the 
council  has  for  so  long  distinctly  denounced  and  pun- 
ished "covering'"  that  the  new  departure  is  only  a 
step  in  advance.  It  is  strange  the  determination  has 
been  so  long  delayed.  Students  in  their  last  year 
may  be  utilized  as  "  pupils"  for  a  period  of  six 
months. 

The  midwives  question  again  came  up  for  discus- 
sion on  the  report  of  last  year's  committee  on  the  sub- 
ject, which  recommended  the  appointment  of  a  further 
committee  to  report  on  any  bill  which  may  be  intro- 
duced into  Parliament  next  year.  A  resolution  to  the 
effect  that  midwiferj'  cannot  be  safely  practised  by 
those  who  are  not  fully  qualified  in  medicine,  surgery, 
and  midwifery,  after  a  good  deal  of  discussion  was 
laid  aside,  and  it  was  eventually  resolved  that  it  is 
inexpedient  to  adopt  an  abstract  resolution  which 
might  prevent  full  consideration  of  any  future  bill 
submitted  by  the  government. 

Dr.  William  Moore  was  obliged  by  ill  health  to  re- 
sign his  seat  in  the  council,  to  the  regret  of  his  col- 
leagues. His  successor  will  be  appointed  by  the  privy 
council. 

Sir  C.  Nixon  took  his  seat  as  the  new  member  for 
the  Royal  University,  and  Mr.  Horsley  as  the  newly 
elected  representative  of  the  registered  practitioners, 
in  the  place  of  Dr.  R.  R.  Rentoul.  Dr.  Rentoul  has 
now  issued  his  explanation  of  his  resignation  of  his 
seat.  It  resolves  itself  into  dissatisfaction  with  the 
profession  for  the  feeble  support  accorded  him  in  his 
schemes  of  reform,  and  the  expenses  he  incurred. 
Undoubtedly  the  profession  is  extremely  difficult  to 
rouse.  Its  apathy  must  appear  to  so  zealous  a  re- 
former as  Dr.  Rentoul  almost  as  bad  as  opposition. 
It  is  easy,  therefore,  to  understand  his  feelings.  But 
there  is  something  to  be  said  on  the  other  side.  Hav- 
ing sent  Dr.  Rentoul  to  the  council,  we  felt  our  affairs 
were  safe  in  his  hands,  that  he  would  do  all  that  was 
possible  in  the  circumstances.  But  it  was  a  mistake 
to  send  him.  His  zeal  burns  within  him,  and  no  won- 
der the  stolid  opposition  of  the  council  turned  that 
zeal  to  impatience.  Then  the  charge  of  deserting 
him  pecuniarily  is  too  true.  He  is  still  nearly  ^?ioo 
out  of  pocket  by  his  experience.  It  is  a  pity,  but  re- 
formers have  usually  experienced  similar  discourage- 
ments. 

Then  some  of  Dr.  Rentoul's  views  are  not  accept- 
able to  many.  He  proposes  that  practitioners  should 
be  required  to  pay  _£"i  a  year  to  the  council,  to  enable 
it  to  do  more  work.  Now  the  authority  to  practise 
has  always  been  paid  for  once  for  all  to  each  licensing 
body,  and  so  overcrowded  is  the  profession  that  there 
are  hundreds  to  whom  ^"i  a  year  would  be  a  serious 
item.  They  would  neglect  to  pay  it,  be  left  out  of  the 
register,  and  so  be  lost  to  all  control,  and  it  would  be 
more  difficult  than  ever  to  distinguish  between  quali- 
fied and  unqualified  men.  .\gain,  the  council  has 
hitherto  given  little  satisfaction.  For  thirtv  years  it 
has  gone  on  its  way  and  stolidly  refused  to  reform. 
Would  it  be  wise  to  add  another  ^"30,000  a  year  to 
the  _^io,ooo  it  already  spends  in  doing  next  to  noth- 
ing.' Even  to  please  Dr.  Rentoul,  it  can  scarcely  be 
expected  we  should  care  thus  lavishly  to  endow  a  body 
which  he  himself  declares  must  be  radically  reformed. 
Again,  he  wants  an  increase  in  the  direct  representa- 
tives, so  as  to  overcome  the  resistance  of  the  corpora- 
tions. This  will  never  be  granted,  as  the  government 
would  so  far  enlarge  the  council,  and  the  addition  of 
one  or  two  more  would  have  no  effect.  Besides,  direct 
representation  has  been  shown  to  be  a  failure,  and 
there   is  no  hope  of   reform  being  furthered  by   its 


means.  The  only  effective  plan  would  be  to  reform 
the  corporations  themselves. 

The  Medical  Society's  meeting  on  Monday  opened 
with  a  paper  by  Dr.  Samuel  West,  on  pyo-pneumothorax. 
He  gave  the  history  of  a  case  of  several  months'  dura- 
tion, which  terminated  in  recovery  about  seven  months 
after  free  incision.  Dr.  West  deprecated  the  too  com- 
mon practice  of  leaving  such  cases  to  expectancy,  and 
opposed  the  notion  that  operation  only  hastened  the 
end,  as  well  as  the  frequently  expressed  idea  that  pneu- 
mothorax tended  to  prevent  tuberculosis.  If  pyo- 
pneumothorax were  to  be  treated  as  empyema  now  is, 
better  results  would  follow.  He  advised  operation  in 
the  early  stage  w  hen  the  symptoms  were  urgent  or  par- 
acentesis failed;  later  on  when  the  effusion  was  puru- 
lent or  sero-purulent. 

Dr.  D.  H.  Hall  related  several  cases  in  which  the 
results  of  operation  \vere  disastrous,  owing  to  the  lung 
not  expanding.  Though  when  the  lung  was  healthy 
operation  might  give  good  results,  when  the  lung 
was  diseased  this  seldom  occurred.  Dr.  Thorowgood 
did  not  advise  operation,  e.xcept  when  urgent  symp- 
toms appeared. 

Mr.  Sheild  mentioned  a  case  complicated  with  gan- 
grene of  the  lung,  followed  by  recovery  after  operation. 
He  remarked  on  the  risk  of  anesthesia  in  such  cases, 
and  recommended  the  position  of  the  patient  to  be 
such  as  to  permit  free  lung  play.  Rapidity  of  opera- 
tion and  no  fixed  dressing  for  a  day  or  two  were  also 
important. 

Dr.  Bowles  mentioned  two  published  cases  of  "  death 
under  chloroform,"  which  he  believed  were  caused  by 
the  patient  inhaling  pus  when  turned  over  for  making 
the  incision. 

Mr.  S.  Eccles  then  read  a  paper  on  the  "  Mechano- 
Therapy  of  Movable  Kidney."  He  had  had  twenty- 
one  cases  since  1892,  of  which  sixteen  were  treated 
by  rest  and  abdominal  massage  for  from  two  to  eight 
weeks.  He  urged  that  treatment  of  this  kind  should 
be  fairly  tried  before  operation  could  be  recommended, 
supporting  this  view  by  details  of  cases  which  were 
greatly  improved. 

Mr.  Freyer  said  he  had  never  seen  a  case  benefited 
by  massage  or  mechanical  methods,  although  he  had 
seen  one  in  which  all  the  fat  around  the  kidney  had 
disappeared  from  massage.  Dr.  Sansom  said  patients 
should  not  be  told  they  had  movable  kidneys.  Dr. 
Hall  had  known  a  case  so  diagnosed  cured  by  a  pad 
and  bandage. 

The  misunderstanding  at  the  Western  Infirmary  of 
Glasgow  threatens  to  end  in  a  deadlock  or  a  scandal. 
Already  a  number  of  letters  have  appeared  in  the  local 
papers.  A  general  meeting  was  held  yesterday,  but  I 
hear  no  result  was  arrived  at. 

.\t  the  Edinburgh  Royal  Infirmary  a  great  improve- 
ment has  been  carried  out.  The  surgical  out-patient 
department  had  been  completely  separated  from  the 
corridors  and  side  rooms  attached  to  the  wards,  where 
visitors  have  often  been  amazed  to  find  patients  wait- 
ing, for  out-patients  may  often  be  inadvertently  pur- 
veyors of  infectious  disease. 

The  typhoid  epidemics  have  been  less  fatal  this 
week,  but  some  new  cases  occurring  suffice  to  show 
they  are  not  yet  over. 

A  general  committee  has  been  formed  to  promote 
the  establishment  of  the  proposed  University  of  West- 
minster. 

The  first  meeting  of  the  delegates  of  the  twelve 
teaching  hospitals,  calling  themselves  "The  Central 
Hospital  Council,"  has  been  held.  Whether  the  other 
hospitals  will  recognize  the  right  of  the  larger  to  dic- 
tate to  the  smaller  remains  to  be  seen. 

The  death  is  announced  of  Dr.  M.  F.  Heddle, 
F.R.S.E.,  M.D.,  emeritus  professor  of  chemistry  in  St 
Andrew's  University. 


December  i8,  1897] 


MEDICAL    RECORD. 


899 


THE    ROUTE   TO    CAMDEN,    S.    C. 


To 


Editor  of 


Medi. 


,  Re 


Sir:  In  the  Medical  Record  of  November  27th,  in 
the  mention  of  the  winter  health  resorts  of  the  Caro- 
linas,  I  think  some  injustice  is  unintentionally  done 
to  Camden,  which  is  a  very  popular  resort.  It  is  said 
in  the  article  in  question  that  to  reach  Camden  you  go 
to  Charleston,  S.  C,  and  thence  by  rail  to  Camden. 
This  is  a  very  roundabout  way,  and  very  inconvenient. 
The  way  to  get  to  Camden  is  to  come  to  Rock  Hill, 
S.  C,  by  the  Southern,  and  thence  by  the  O.  R.  &  C. 
(good  connection)  to  Camden,  it  being  only  twenty-four 
hours'  ride  from  New  York  by  this  route. 

Knowing    your  desire  for    exactness,  I  write  this 
correction.  John  W.  Corbett,  M.D. 

Camden,  S.  C,  November  29th. 


"IN    THOSE    DAYS    THERE    WERE    DEVILS" 
—AND  NOW. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  your  issue  of  December  4th  Dr.  James  Weir, 
Jr.,  tells  interestingly  how  "  In  Those  Days  There 
Were  Devils."  The  same  issue  contains  proof  that  in 
these  days  and  your  printing-office  the  devil  is  at  his 
ancient  tricks. 

Having  written  to  you  lately  correcting  a  misstate- 
ment in  the  lay  press  of  the  results  of  medical  prose- 
cutions conducted  by  me,  and  having  also  suggested 
that  it  would  be  agreeable  to  me  if  you  should  see  fit 
to  correct  the  error  as  a  matter  of  news  without  use  of 
my  name,  I  find  to  my  terror  that  the  printer,  proof- 
reader, or  more  probably  the  "devil,"  has  honored  me 
with  the  medical  degree,  power  to  confer  which  causa 
honoris  was  abolished  in  this  State  some  years  ago, 
and  has  made  mQ  prima  facie  guilty  of  "  appending  the 
letters  M.D."  to  my  name;  for  which  misdemeanor,  if 
convicted  of  it,  a  considerable  fine  might  be  imposed 
upon  me.  Pray  correct  this  mistake  in  any  fashion 
you  see  fit,  or,  failing  to  do  so,  be  prepared,  if  I  am 
arraigned  in  court  for  false  use  of  the  sacred  letters, 
to  come  and  testify  that  they  were  not  appended  to 
my  name  by  me,  but  by  the  Medical  Record,  which 
has  not  yet  renounced  the  devil  and  his  works. 

By  dropping  the  figure  "2,"  the  printer  has  also 
regulated  the  practice  of  medicine  by  chapter  5  in- 
stead of  chapter  25  of  the  general  laws. 

W.    A.    PURRINGTON. 


THE    ABUSE   OF    MEDICAL    DISPENSARIES. 


To  THE  Editor  i 


HE  Medical  Record. 


Sir:  Permit  me  to  contribute  my  mite  to  the  literature 
of  dispensary  abuse.  If  one  is  to  judge  from  the  va- 
rious articles  that  appear  periodically  in  the  medical 
journals,  expressing  opinions  as  regards  the  causes  of 
dispensary  abuses,  there  must  be  a  great  commotion 
in  the  medical  profession;  the  nice  round  incomes 
must  have  been  reduced  to  such  a  low  figure  that 
silence  is  not  only  not  gold  but  not  even  copper. 

I  shall  not  attempt  to  mention  the  various  causes 
given  by  an  army  of  contributors;  space  will  not 
permit  it.  What  I  want  to  say  is  this:  After  so 
much  has  been  said  and  written  on  the  subject,  not 
one  person,  as  far  as  I  know,  ever  mentioned  the  pri- 
mary cause,  according  to  my  opinion,  of  all  this  char- 
ity abu.se,  reduced  practitioners'  incomes,  increased 
quackery,  and  even  some  of  the  suicides  of  practition- 
ers which  are  attributable  to  the  same  cause — all 
symptoms  of  one  particular  affection. 

This  dispensary  epidemic  is  not  limited  only  to  the 
cities  of  the  East;  its  ravages  are  spreading  like  a 


prairie   fire   all   over  the  country — east,  west,  north, 
and  south. 

Now  to  come  to  the  point.  The  medical  profession, 
like  any  other,  is  subject  to  the  simple  law  of  econom- 
ics of  supply  and  demand.  The  proportion  of  medical 
men  in  this  country  is  in  inverse  ratio  to  the  popula- 
tion. But,  ignoring  this  simple  rule,  medical  colleges 
spring  up  like  magic  in  every  hamlet  of  the  country. 
These  new-born  so-called  institutions  of  learning  are 
naturally  struggling  to  maintain  themselves;  an  un- 
healthy competition  is  the  result.  Dispensaries  are 
created  to  supply  material  for  teacher  and  student. 
The  worthiness  of  the  applicant  for  free  treatment  is 
overlooked.  The  teacher  is  proud  to  add  professor 
to  his  title,  and  sometimes  with  it  a  temporary  increase 
of  his  fee  and  income.  The  ambition  of  adding  the 
title  of  professor  to  the  usual  M.D.  seems  to  be  quite 
epidemic  in  our  part  of  the  country.  To  accomplish 
this  an  "  institution"  is  started  in  some  two-story 
frame  building  and  extensively  advertised.  Students 
"must"  be  procured;  the  institution  "must  be  main- 
tained"! Is  it  any  wonder  that  such  a  degenerate 
parentage  gives  birth  to  a  diseased  progeny?  These 
are,  no  doubt,  the  "  Youngbloods"  of  Dr.  T.  J.  Hillis' 
article.  Quackery  and  charlatanism  are  their  only  art 
and  science.  The  more  able  and  honest,  for  the  lack 
of  compensatory  practice,  ofi^er  themselves  gratis  to 
hospitals  and  other  charitable  institutions.  The  peo- 
ple's respect  for  the  medical  profession  is  lessened, 
and  with  it  the  income  of  the  latter.  Many  of  the 
medical  institutions  of  this  countrj'  have  no  other  ex- 
cuse for  their  existence  but  some  doctors  wanting  to 
be  professors. 

These  are,  in  my  opinion,  the  causes  that  lead  to 
dispensary  abuse,  increased  poverty,  and  decreased 
respect  for  the  medical  profession. 

Berthold  Weisenberg,  M.D. 

49  Juneau  Avenue,  Milwaukee,  Wis. 


THE   TWENTY-FIVE-CENT    DOCTOR. 


Sir:  The  cohesion  of  the  organization  of  society  is 
the  measure  of  its  civilization.  "The  wild  man  of 
Borneo"  knows  not  a  chief,  but  sixty  millions  of 
Americans,  in  greater  or  less  degree,  hold  their  Pres- 
ident in  reverence.  Individualism  is  barbarism,  is 
anarchy,  while  the  union  of  like  or  congenial  forces, 
be  they  bad  or  good,  in  the  long  run  trends  toward  prog- 
ress. Somewhat  through  invention,  more  through  wise 
legislation,  but  most  through  their  organization,  have 
manual  labor  and  the  mechanical  trades  grown  intO' 
the  respect  and  dignity  that  they  hold  to-day.  Com- 
binations of  capitalists  crystallize  the  effort  of  in- 
dividuals into  profits  for  themselves,  while  in  turn 
the  union  of  those  individuals  that  produce  these 
profits  forces  the  capitalists  to  a  division  of  these 
profits,  to  the  benefit  of  the  private  condition  of  each. 
The  peoples  that  are  born  with  the  genius  for  unity  of 
action  are  conquerors.  The  gay,  the  brilliant,  the 
iridescent  Celt,  by  the  sluggish  Saxon  is  ever  borne 
down. 

That  which  has,  more  llian  anything  else,  made 
modern  medicine  what  it  is,  had  its  origin  when  the 
quacks,  the  charlatans,  and  the  empirics  of  the  long 
ago,  for  their  own  betterment  formed  a  sort  of  Gypsy 
union,  out  of  which  has  grown  what  we  are  pleased 
to  call  "our  code  of  ethics." 

"A  propos  of  nothing,"  I  have  never  seen  a  phy- 
sician break  through  that  code  with  any  lasting  benefit 
to  himself,  for  in  the  process  he  is  sure  so  to  rend  the 
phylacteries  of  his  own  medical  reputation  that  his 
last  estate  is  worse  than  his  first. 

The  true  meaning  of  the  code  is  that  the  physician 


900 


MEDICAL    RECORD. 


[December  i8,  1897 


should  not  do  anything  to  degrade  himself,  to  degrade 
his  brother  practitioner,  or,  what  is  of  far  more  mo- 
ment, degrade  the  dignity  of  his  profession. 

Most  nobly  is  the  Medical  Record  warring  against 
the  abuses  that  have  crept  into  the  profession  in  the 
large  cities,  but  we  in  the  country  and  country  towns 
"have  troubles  of  our  own."  In  every  country  village 
of  a  thousand  or  more  inhabitants  will  be  found  two 
or  three  circles  of  men  banded  together  in  some  order, 
as  Red  Men,  or  Foresters,  or  under  some  similar  title. 
These  fraternal  orders  put  the  medical  attendance  of 
their  members  up  at  auction  to  the  lowest  bidder,  or 
else  try  to  make  ridiculous  terms  with  whomever  they 
may.  In  many  places  the  remuneration  for  this  work 
is  $1  a  year  per  member  of  the  society. 

Another  abuse  is  that  in  this  same  class  of  towns 
are  growing  up  what  are  called  "medical  clubs." 
These  admit  to  membership  men  and  women,  old  and 
young  alike,  anybody  that  will  pay  the  pittance,  which 
is  usually  about  $1.25  per  annum. 

The  next  grievance  on  the  list  is  the  cheap  insur- 
ance business.  There  are  a  number  of  companies  that 
pay  25  and  50  cents  for  some  form  of  examinations; 
and  these  companies  do  their  largest  business  among 
the  classes  that  are  able  to  pay  decent  medical  fees. 
Only  recently  I  was  almost  entrapped  into  lending 
myself  as  an  examiner  for  one  of  these  concerns.  An 
agent  came  to  me  and  wanted  me  to  make  out  an  ap- 
plication to  be  appointed  an  examiner.  I  asked  him 
if  it  was  a  twenty-five-cent  company,  and  he  replied 
in  the  negative.  After  the  application  was  made  out, 
he  said  that  for  a  simple  "  inspection,''  whatever  that 
may  mean,  the  company  allowed  twenty-five  cents,  and 
for  something  else  in  the  way  of  examination  fifty 
cents.  I  tore  up  the  application  and  told  the  agent 
to  get  out  of  the  hole  the  carpenter  left  as  quick  as  he 
could.  As  he  took  his  hat  he  snapped :  "  There's  lots 
of  docks  older  and  smarter  than  you  be  that's  more'n 
glad  of  the  business.''  Ay,  there  is  the  rub — "  Glad 
of  the  business."  I  informed  him  that  I  was  not  a 
twent)'-five-cent  doctor,  at  any  rate. 

As  it  fell  out,  there  now  drives  eight  miles  from 
another  village  a  doctor  "  older  than  you  be,"  to  attend 
to  this  company's  precious  interests.  However,  I  give 
the  man  credit  for  being  thoughtless  about  the  matter, 
as  he  seems  to  be  a  very  decent  sort  of  a  fellow. 

Tfje  last  and  meanest  degradation  of  them  all  is  the 
acceptance  of  medical  practice  farmed  out  for  so  much 
a  year  by  rural  town  boards.  The  chief  occupation  of 
these  boards  is  to  cut  down  all  town  expenses  except 
their  own  fees,  at  lea.st  until  the  next  election.  Under 
my  observation  is  a  town  containing  a  rural  and  vil- 
lage population  of  two  thousand.  This  township 
covers  an  area  of  about  ten  miles  square.  The  town 
board  has  all  the  poor  in  this  town  medically  attended 
for  1^30  a  year.  This  is  blank,  black  barbarism.  The 
idea  that,  because  a  human  being  has  committed  the 
heinous  crime  of  being  poor,  in  the  hour  of  his  illness 
and  distress  he  must  accept  the  medical  services  of  a 
person  that  is  willing  to  receive  for  them  whatever  a 
parsimonious  town  board  of  hayseeds  is  pleased  to 
grant!      It  is  sickening! 

Is  there  any  remedy  for  these  evils?  To  a  degree  I 
believe  there  is.  Public  opinion  is  but  the  aggregate 
of  private  opinions.  Public  evils  must  be  remedied 
by  public  means.  Let  the  State  society  appoint  a 
man  from  each  county  society  to  interview  the  phy- 
sicians in  each  county  that  are  engaged  in  this  nefari- 
ous business.  If  they  will  consent,  let  them,  with  the 
physicians  who  are  above  degrading  themselves,  sign 
an  agreement  that  they  will  outlaw  the  evils  that  have 
been  mentioned.  Then  let  the  names  of  those  hold- 
ing the  degree  of  M.D.  that  will  not  sign  the  agree- 
ment be  reported  to  both  the  State  and  county  .societies. 
At  stated  intervals  have  a  list  publicly  printed  and 


circulated,  both  by  the  State  and  count)-  societies,  of 
those  who  are  doing  an  illegitimate  business. 

The  remedy  is  weak,  you  say;  it  is.  But  it  seems 
the  best  we  have.  Many  that  would  not  sign  the  con- 
tract would  become  out-and-out  quacks.  Let  them  go. 
Better  a  dozen  enemies  outside  the  walls  than  a  single 
traitor  within. 

To  me  the  greatest  mar\'el  in  the  world  is  the  bfain- 
lessness  of  man.  Let  those  who  believe  in  the  union 
of  ourselves  for  our  own  protection,  whenever  fitting 
time  presents,  act  as  propagandists  among  those  who 
are  destroying  what  little  of  unity  there  is.  Tell 
them,  as  they  degrade  our  services  by  offering  them  to 
the  cheapest  bidder,  they,  Hibernian-like,  are  sawing 
off  the  limb  on  which  they  perch.  Tell  them  that  in 
this  crowded  world  there  is  no  room  for  the  individual 
unless  he  stands  in  unity  with  those  about  him;  tell 
them  that  they  are  undermining  the  monument  of  suc- 
cess which  they  hope  to  climb. 

W.  C.  Sebring,  M.D. 


THE     DISPENSARY      ABUSE      OF      TWENTY 
YEARS    AGO. 


Sir  :  One  feature  of  the  correction  of  the  abuses  of 
medical  charities  has  not  been  sufficiently  brought  out 
in  the  recent  consideration  of  this  matter. 

The  managers  of  dispensaries  have  too  generally 
been  spoken  of  as  wholly  responsible  for  the  evils 
which  exist,  and  entirely  opposed  to  any  measures 
looking  to  their  amelioration  or  .suppression. 

Just  twenty  3ears  ago  this  month,  a  committee  of 
gentlemen  was  appointed  by  the  State  board  of  chari- 
ties to  "  make  inquiries  as  to  the  misuse  of  the  benefits 
of  the  medical  charities  of  the  city."  (See  first  report 
of  committee  to  State  board  of  charities.) 

This  committee  made  its  report  on  May  6,  1878, 
and  stated  that  they  have  confined  their  inquiries  to 
the  "general  dispensaries,  and  have  submitted  the  an- 
swers of  these  dispensaries  7:erl<atim." 

This  committee  was  composed  of  Drs.  Joseph  W. 
Patterson,  C.  R.  Agnew,  Henry  E.  Pellew,  Edward 
Oothout,  John  Sherwood. 

The  answers  elicited  by  these  gentlemen  twenty 
years  ago  are  not  only  very  interesting  reading  now,  but 
prove  very  conclusively  that  the  disp)ensaries  were 
not  then  averse  to  having  such  regulations  as  would 
prevent  abuses,  and  while  we  have  no  record  of  the 
opinions  of  the  managers  of  the  present  day,  save  and 
except  the  writings  and  public  speeches  of  one  of  the 
managers  who  has  seen  long  service  (J.  Harsen  Rhodes, 
in  his  addresses  before  the  conference  of  United  Char- 
ities and  State  Medical  Association"),  we  know  from 
personal  interviews  with  many  prominent  dispensarj' 
managers  that  the  sentiment  is  unchanged. 

From  the  Medical  Record  of  .-Vugust  17,  1878,  I 
quote  from  an  editorial  review  of  this  report  to  the 
State  board  of  charities:  "  It  would  appear  .  .  .  from 
this  report  .  .  .  that  the  medical  profession  is  not  alone 
interested  in  checking  the  growth  of  the  evils  connected 
with  our  dispensary  system,  but  that  distinguished  lay- 
men are  taking  the  matter  in  liand  and  are  working  in 
the  direction  of  reform,  with  an  earnestness  of  interest 
and  a  sincerity  of  purpose  that  are  worthy  of  the  cause." 

From  the  report  itself  we  note  only  a  few  of  the 
answers.  There  were  nine  questions  asked  of  the 
dispensary  managers,  viz. : 

"i.  Is  it  desirable  that  the  general  dispensaries 
should  confine  their  operations  strictly  to  their  respec- 
tive geographical  limits? 

"2.  Is  it  in  your  opinion  expedient,  with  a  view  to 
restrict  the  benefits  of  your  institution  to  the  really 


December  i8,   1897] 


MEDICAL    RECORD. 


901 


necessitous  poor,  that  inquiries  should  be  made  of  each 
applicant  as  to  his  or  her  pecuniary  ability  and  special 
circumstances,  at  the  time  aid  is  asked  for? 

"3.  What,  in  your  opinion,  should  be  the  minimum 
income  of  the  applicants,  as  modified  by  the  number 
in  the  family,  and  other  special  circumstances,  to  de- 
prive them  of  the  benefit  of  your  institution? 

■■  4.  If  you  are  of  opinion  that  such  minimum  of  in- 
come should  be  enforced,  would  it  not  be  necessary 
and  desirable  to  designate  some  employee  of  your 
institution  to  act  as  registrar? 

"  5.  Would  this  involve  much  difficulty  in  your  case  ? 
If  so,  please  state  the  points  of  difficult)-. 

"  6.  What  course  would  you  recommend  for  adoption 
with  respect  to  those  applicants  who  may  be  denied 
aid? 

"  7.  Is  there,  in  your  opinion,  any  mode,  not  open 
to  abuse,  by  which  the  names  and  addresses  of  good 
druggists  and  of  doctors  residing  near  such  applicants, 
and  willing  to  treat  such  cases  for  a  small  fee,  may  be 
communicated  to  them  ? 

"8.  Is  it  not,  in  your  opinion,  verj'  important  to  re- 
quire your  visiting  physicians  to  report  to  your  board 
regularly  any  want  of  proper  sanitary  arrangements  in 
the  dwellings  visited  by  them,  that  such  information 
may  be  formally  and  promptly  brought  to  the  notice 
of  the  board  of  health  ? 

"  9.  If,  by  the  conditions  of  your  act  of  incorporation, 
you  are  prevented  from  making  any  charge  to  appli- 
cants for  relief,  would  it  be,  in  your  opinion,  expedi- 
ent to  apply  for  any  legislative  change  in  this  respect  ?" 

Question  I.,  answers:  New  York  Dispensar)- — '"  We 
consider  it  desirable  that  the  general  dispensaries 
should  confine  their  operations  strictly  to  their  re- 
spective geographical  limits,  for  the  reason  that  the 
work  is  more  systematic,  economical  and  orderly,  and 
more  easily  understood  and  controlled. 

'■  To  the  visiting  physicians  who  visit  patients  at  their 
houses,  in  consequence  of  their  inabilitj'  to  come  to 
the  dispensary,  it  is  indispensable  that  the  geographi- 
cal limits  of  their  respective  districts  should  be  strictly 
defined  and  observed.  In  fact,  it  would  be  impossible 
to  carry  out  effectually  the  objects  of  the  dispensary 
system  if  the  territory-  is  not  limited,  as  the  services 
of  the  physicians  would  be  subject  to  the  calls  of 
patients  from  all  parts  of  the  cit}',  thus  taking  un- 
necessary time,  labor,  and  expense.  Great  confusion 
and  conriicting  authority  and  obligations,  between  or 
among  the  dispensaries  and  their  employees  and  offi- 
cers, might  arise  or  be  occasioned. 

"  The  New  York  Dispensary  now  has  for  its  limits  all 
that  part  of  the  city  on  the  west  side  south  of  Spring 
Street,  and  on  the  east  side  all  south  of  East  Fourteenth 
Street,  First  Avenue,  Allen  and  Pike  streets. 

"This  large  area  is  divided  into  four  subdistricts,  of 
which  the  limits  are  defined  and  well  known,  and  to 
each  of  which  the  work  of  one  of  the  district  phy- 
sicians is  confined.  These  visiting  physicians  are 
paid  salaries  by  the  dispensary,  and  it  is  not  too  much 
to  say  that,  if  they  were  to  be  called  into  other  sub- 
districts,  much  less  into  the  districts  of  other  dispen- 
saries, it  would  be  impossible  for  them  satisfactorily 
to  perform  their  duties.  The  number  of  visiting  phy- 
sicians and  their  expenses  would  thus  be  greatly 
increased. 

"  On  the  other  side,  it  is  difficult  to  perceive  any  ad- 
vantage to  the  patients  or  to  the  physicians  of  the  dis- 
pensary', to  throw  open  the  field  to  distant  residents,  so 
long  as  there  are  other  good  dispensaries  and  visiting 
physicians  who  may  be  called  upon. 

"  In  fact,  if  there  are  no  limits,  the  aid  to  be  furnished 
would  be  subject  to  the  mere  whims  and  caprices  of 
the  patients. 

"Again,  as  to  the  patients  who  call  for  relief  at  the 
dispensar}-.     While  it  might  be  harsh  to  refuse   any 


relief  to  a  poor  applicant  residing  beyond  our  limits, 
and  a  thing  rarely  done  at  the  New-  York  Dispensary, 
as  a  general  rule,  unless  some  fair  reason  is  given  for 
coming  from  another  district  and  not  calling  upon  the 
dispensary  within  that  district,  it  is  practically  more 
systematic  and  orderly  to  refer  the  patient  to  the  dis- 
pensary of  his  own  district. 

"We  discourage  non-residents  coming  into  our  dis- 
trict, and  we  think  they  should  call  upon  the  dispen- 
sar}' of  their  own  localities. 

"We  consider  it,  moreover,  statistically  of  much 
importance  that  the  district  system  be  preser\'ed." 

The  Eastern  Dispensary,  Demilt  Dispensary,  North- 
western Dispensar}',  and  Northeastern  Dispensary  all 
concur. 

Question  XL,  answers.  New  York  Dispensar}- — • 
"  In  answer  to  the  second  question,  we  consider  it  im- 
portant that  an  investigation  of  the  kind  suggested 
should  always  be  made. 

"  The  fact  that  a  very  large  number  of  persons  per- 
fectly able  to  pay  for  medical  advice  and  medicines 
fraudulently  seek  aid  at  the  dispensary  as  if  they  were 
of  the  class  of  necessitous  poor,  is  too  well  established 
to  be  questioned  for  a  moment. 

"  This  dispensary  for  a  long  time  has  recognized  this 
fact,  and  has  attempted  to  correct  the  above  by  making 
an  examination  of  each  new  and  unknown  applicant, 
to  learn  his  or  her  actual  means  and  necessities. 

"  It  is  proposed  now  to  extend  this  system  of  investi- 
gation. The  inquiries  suggested  are  put  by  the  ex- 
amining physician,  who  should  have  printed  tables 
upon  which  the  answers  are  to  be  entered.  The  in- 
quiries are:  i,  name  and  age;  2,  residence;  3,  occu- 
pation; 4,  monthly  rent  paid;  5,  amount  of  daily, 
weekly,  or  monthly  earnings;  6,  whether  there  are 
other  means  of  subsistence  than  those  earnings,  and, 
if  so,  what?  7,  if  liable  for  the  support  of  others?  8, 
if  out  of  employment,  for  how  long?  9,  if  a  woman, 
single,  married,  or  widow,  and  if  having  children  how 
many?  10,  other  questions  arising  from  the  answers  to 
the  previous  questions.  If  the  application  is  made 
for  a  child,  the  same  questions  as  to  parent,  or  one  in 
loco  parentis r 

Similar  answers  were  given  regarding  all  the  other 
questions  by  all  the  dispensaries  addressed,  and  the 
committee  sums  up  with  the  following  recommenda- 
tions: 

"  I.  That  no  necessity  exists  for  more  general  dis- 
pensaries in  districts  already  occupied. 

"2.  That  a  close  attention  to  the  rule  of  geographi- 
cal limits  is  most  necessary. 

"  3.  That  only  necessitous  poor  should  receive  treat- 
ment in  the  dispensaries,  and  that  those  who  can  pay 
something  would  benefit  themselves  as  well  as  the 
institution  by  being  required  to  pay  a  small  sum  on 
the  basis  either  of  attendance  or  of  medicine. 

"4.  That,  in  general,  the  means  of  applicants  can 
more  easily  be  determined  by  the  amount  of  rent  or 
board  paid  than  by  any  other  method,  but  that  care 
should  be  taken  to  exclude  no  one  from  the  benefits  of 
the  institution  through  inability  to  pay. 

"  5.  That  it  is  desirable  to  establish  a  uniform  defini 
tion  as  to  the  value  of  the  term,  dispensary  patient. 

"  6.  That  it  is  desirable  that  the  several  dispensaries 
should,  so  far  as  is  practicable,  act  in  harmony  in  re- 
spect to  the  subjects  here  discussed,  and  that  by  occa- 
sional conferences,  for  which  provision  has  been  made 
originally  by  most  of  the  dispensaries,  many  of  the 
minor  abuses  to  which  medical  charities  are  peculiarly 
exposed  would  be  most  conveniently  remedied." 

The  Medical  Jierieic  oj  Reviews,  in  an  editorial  of 
November  25,  1897,  says: 

"  It  is  evident  from  the  perusal  of  our  exchanges 
that  the  interest  in  the  question  of  the  proper  admin- 
istration of  charitable  institutions  for  the  cure  of  the 


902 


MEDICAL    RECORD. 


[December  i8,  1S97 


sick  is  not  confined  to  New  York  City.  We  do  not 
wish  to  discuss  the  question  here,  further  than  to  cor- 
rect a  possible  misapprehension  of  the  aims  and  pur- 
poses of  medical  men  in  this  city.  .  .  . 

"  At  the  annual  meeting  of  the  Medical  Society  of 
the  County  of  New  York,  .  .  .  those  who  did  not  sup- 
port a  certain  ticket  were  credited  with  being  hostile 
to  the  desired  reform.  This  view  of  the  situation  is 
erroneous  and  misleading.  We  aver  that  no  class  of 
physicians  is  more  anxious  to  have  unworthy  appli- 
cants excluded  from  dispensaries  and  hospitals  than 
are  the  physicians  and  surgeons  belonging  to  the  staffs 
of  such  institutions.  .  .  .  The  only  real  divergence  of 
opinion  is  regarding  the  best  means  of  correcting  the 
existing  conditions.  There  are  many  questions  which 
cannot  be  remedied  by  legislation,  and  if  success  is  to 
be  secured  in  this  instance  any  proposed  measure  must 
be  very  carefully  considered,  and  so  drawn  as  to  avoid 
any  appearance  of  what  we  have  heretofore  termed 
'the  trades  unions  idea.'  In  other  words,  any  meas- 
ure to  be  submitted  to  the  legislature  must  meet  the 
views  of  the  public  as  well  as  of  the  medical  profes- 
sion, and  must  be  evidently  for  the  public  welfare. 
The  vested  rights  of  incorporated  institutions  must 
also  be  respected,  otherwise  opposition  from  them  is 
liable  to  prevent  all  legislation  on  the  subject." 

It  is  quite  true  that  many  abuses  cannot  be  remedied 
by  legislation.  It  is  also  true  that  none  are  likely  to 
be  without  legislation,  as  was  true  twenty  years  ago 
when  the  dispensaries  were  quite  willing  to  correct 
the  abuses,  and,  as  will  be  seen  by  the  answers,  quite 
willing  to  have  all  cases  investigated.  Regarding  the 
bill  of  last  winter,  there  may  be  evidence  of  public 
support  in  the  fact  that  it  passed  the  legislature  with- 
out a  dissenting  vote  in  either  branch. 

Corporate  rights  were  not  intended  to  be  attacked 
in  that  measure.  The  bill  which  is  now  prepared  and 
will  be  introduced  at  the  coming  session  of  the  legis- 
lature certainly  attacks  the  rights  of  no  incorporations 
or  persons.  It  simply  aims  to  have  all  dispensaries 
licensed  by  the  State  board  of  charities,  and  gives  the 
State  board  power  to  make  rules  whereby  investiga- 
tions can  be  made  by  a  central  bureau,  or  in  such 
manner  as  it  may  deem  best.  That  this  bill  does 
not  affect  some  dispensaries  as  they  would  like  is 
evidenced  by  the  fact  that  one  or  two  would  now  like 
to  go  out  of  business,  but  cannot  do  so  under  existing 
laws,  and  this  bill  will  probably  not  help  them. 

It  would  seem  now  after  twenty  years  that  the  edi- 
torial remarks  in  the  Medical  Record  of  .\ugust  17, 
1878,  are  again  appropriate: 

"  Substantial  progress  has  been  made,  however,  in 
the  direction  of  better  understanding  among  the  differ- 
ent leading  dispensaries  in  the  city.  There  is  evi- 
dently a  disposition  to  act  in  harmony  in  respect  to 
tlie  subjects  discussed,  and  a  promise  that  many  of 
the  abuses  referable  to  any  lax  management  of  the 
institutions  will  be  duly  corrected." 

That  the  abuses  were  not  corrected  at  that  time 
seems  to  have  been  solely  due  to  the  fact  that  there 
was  no  legislation.  By  united  effort  we  hope  now  to 
remedy  that  defect.  W.  Washburn,  M.D. 

31  E.^sT  Twenty  first  Street, 
December  7,  1897. 


Tuberculosis. — Although  the  human  race  continues 
to  sicken  and  die  of  pulmonar}'  tuberculosis,  it  is  the 
consentaneous  opinion  of  the  medical  profession,  as 
shown  by  reports  gathered  from  all  parts  of  the  world, 
that  we  have  in  creosote  a  remedy  capable  of  arresting 
a  certain  percentage  of  cases.  This  drug  should, 
therefore,  be  administered  carefully,  systematically, 
and  continuously  in  every  case  of  consumption,  pro- 
vided it  is  well  tolerated  and  there  is  no  contraindi- 
■cation  or  idiosyncrasy  as  to  its  action. — Crook. 


2'hcvapcutic  Mints. 

Sciatica. — 

R  Sodii  glycero-phosphat 5  gni. 

Aq.  dest 20    " 

M.     S.   Inject  J4  c.c.  deeply  into  muscles  near  the  nerve. 

It  is  not  painful,  and  recent  cases  soon  recover, 
while  inveterate  instances  are  improved. — Billard. 

Treatment  of  Cardiac  Complications  of  Arterio- 
sclerosis.-— To  stimulate  diuresis  and  increase  the 
elimination  of  lime  compounds  by  the  kidneys: 

^  Sodium  bicarbonate 10  gm. 

Neutralize  with  : 

Lactic  acid q.s. 

Then  add  : 

Lactic  acid, 

Syrup aa     10  gm. 

Distilled  water 180  gm. 

>L     To  be  taken  in  the  twent\'-four  hours. 

— RUMPF. 

Whooping-Cough. — 

B  Tr.  beliad 10  gm. 

Phenacetin 5 

Spirit,  frumenti 15 

E.\t.  fol.  castanea; 60 

S.   For  infants  of  one  year,  ten  drops.     For  children  of  ten 
years,  one  drachm  every  two  to  six  hours. 

— Lancaster. 
Acute  Pneumonia. — 

^  Beechwood  creosote 25  gm. 

Tincture  of  gentian 5° 

M.     S.  From  25  to  130  drops  a  day  in  wine. 

— Casati. 

To  Stimulate  Involution  of  the  Uterus  in  Cases 
of  Anaemia. — 

B  Tr.  gentian,  comp. , 
Tr.  cinchonoe  comp., 

Tr.  cardamom,  comp aa  3  iss. 

yi.     S.   Two  drachms  before  meals. 

— Davis. 
Rickets  with  Anaemia. — 

R  Syr.  fern  iodidi gtt.  iij.-xxiv. 

Aq.   dest q.s.  ad  3  iij. 

JL     S.  One  drachm  ever\-  four  or  five  hours. 

— Hare. 

Uraemic  Convulsions. — Blood  letting,  except  in  the 
feeble.  A  vastly  greater  amount  of  poisonous  materia! 
can  be  discharged  in  this  way  than  by  the  slower 
elimination  through  the  emunctories. — Wilson. 

Tuberculosis. — 

R  Creosote  (beechwood) I  i- 

Tr.  gentian 3  i. 

Alcohol 3  '■ 

Vin.  albi q.s.  ad  I  iv. 

M.     S.  One  drachm  in  wine  three  times  a  day. 

— Smith. 
Catarrhal  Pneumonia — 

R  .\mmon.  carb gr.  xxiv. 

Syr.  tulu i  vi. 

Spt.  vini  gal 3  iij- 

Syr.  senegse 3  iiiss. 

Syr.  acaci.-e q.s.  ad  3  iij. 

M.     S.  Teaspoonful  every  two  hours  for  a  child  of  two  or 
three  years. 

— Goodhart  an^  Starr. 

Chronic  Rheumatism. — 

R  l.iq.   potass,  arsen 3  ij. 

Totass.    iodid 3  ij. 

Syr.  simp 3  "J- 

M.     S.    3  i.  t.i.d.  p.c.  in  water. 

—Da  Costa. 
Amygdalitis. — 

R  .Sodii  benzoat 3  i.  to  3  Jv. 

Glycerini, 

Eli.t.  calisayoe aa    $1. 

'M.     S.  Teasjxxjnful  every  hour  or  two. 

— Stevens. 


December  i8,  1897] 


MEDICAL    RECORD. 


903 


Simple  Angina — 

K   Potass,  chloral 3  iss. 

Fotass.  bromid 3  ss. 

Ext.  belladonnse  gr.  iv. 

S)T.  limonis 3  i. 

S)Tupi q.  s.  ad  3  iv. 

M.     S.   Teaspoonful  thrice  daily. 

— Pepper. 
Acute  Gastritis. — 

I^  Vin.  ipecac, 

Tr.  nuc.  vom aa  Si. 

M.     S.  Two  drops  in  water  every  two  hours. 

— Pepper. 
Neuralgia — 

I^  Acid,  osmic o.io  cgm. 

Aq.  dest 6  gm. 

Glycerini   4  gm. 

M.     S.   Inject  o.oi  cgm. 

— Chapiro. 

Eczema  of  the  External  Auditory  Canal. — 

I^  Acid.  phos.  dil 3  iv. 

Tr.  ferri  perchlor 3  ij- 

Syr.  limonis 3  iij. 

M.     S.  Teaspoonful  in  wineglass  of  water  after  meals. 

Aloin  comp.  pills,  one-tenth  grain,  night  and  morn- 
ing, to  relieve  the  constipation. 

I^  Acid,  carbol.  pur gr.  .xx. 

Ung.  zinc.  ox.  benz $1. 

M.     S.   .\pply. 

Begin  the  local  treatment  by  cleansing  the  ears  with 
this  ointment  spread  upon  cotton  on  the  applicator, 
then  make  a  free  application  of  the  same  ointment. 
No  fluids,  soap,  or  water  must  be  used,  as  they  nearly 
always  prove  deleterious. — Dr.  J.  W.  M.\y,  Kansas 
Medical  Journal,  May  ist. 

Mental  Depression  in  Diseases  of  the  Pelvic 
Organs. — 

R  Strych.  sulph gr.  ^'j. 

Quininae  sulph gr.  iss. 

Ext.  hyoscyami gr.  iss. 

Ferri  redacti gr-  i. 

M.  For  one  pill.     S.   One  pill  three  times  a  day- 

— Tally. 
Malnutrition  in  Infants. — 

R  01.  olivse 3  ij. 

Glycerini 3  i. 

Vitelli  ovi No.  i. 

M.  et  ft.  emulsio  et  adde 

Creosoti lU  xvi. 

S.  Teaspoonful  t.i.d.  after  feeding. 

— Practitioner. 
Pertussis. — 

K  Infusion  of  belladonna  leaves gr.  viij. 

Distilled  water 3  v. 

Antipyrin gr.  xv. 

Syrup  of  gooseberry §1. 

M.     S.   A  teaspoonful  every  two  hours  for  a  child  of  five 
years. 

As  a  rule,  there  may  be  given,  for  each  year  of  the 
child's  age,  gr.  viii.  of  belladonna  leaves  in  infusion 
and  the  double  dose  of  antipyrin. — Eschler. 

For  Colic  in  Infants. — 

If  Tr.  lobelia: gtt.  i. 

Aquae 3  i. 

S.    3  i.  at  a  dose  ;  give  warm  and  repeat  p.r.  n. 

— HOLTON. 

Chronic  Nephritis. — Ferran  advises  a  vegetable 
and  fish  diet:  i.  When  the  quantity  of  urine  passed 
exceeds  eight  hundred  grams  in  the  twenty-four  hours. 
2.  When  the  urea  and  the  density  are  somewhat  aug- 
mented, or,  at  least,  normal.  3.  When  there  is  in- 
crease of  phosphates  and  phosphoric  acid.  4.  When 
the  quantity  of  albumin  is  not  exaggerated  or  subject 
to  great  variation.  He  desires  to  note  that,  in  order 
to  estimate  the  real  quantity  of  albumins,  he  would 
recommend  not  to  use  Esbach's  apparatus,  owing  to 


the  fact  that  its  reaction  at  the  same  time  precipitates 
mucin,  peptone,  etc.,  which  are  causes  of  error.  5. 
U'hen  there  is  not  great  abundance  of  granular  casts. 
6.   When  the  general  condition  is  satisfactor)\ 

Typhoid  Fever — For  an  adult; 

IJ  Salol Bij.  2.60 

Th)-mol 3ij.  2.60 

Tablets  of  cupric   arsenite  (aa  gr. 

0.01)  No.  XX. 

Papoid 3ij.  2.60 

Guaiacol  carbonate J  ss.  2 

Pulv.  saponis gr.  v.  0-33 

M.  ft.  caps.   No.  .XX.     S.   One  everj-  four  hours  with  milk. 

For  children : 

'S,  Beta-naphthol,  dissolved  in   heated 

oil gr.  xxiv.        1.56 

Ol.amygdal.  dulcis,  dis.  in  heated  oil  §  ss.  16 

01.  cassiae ill  i.  0.06 

Pulv.  acacia q.  s. 

Glycerini §  ss.  16 

.A.quse q.s.  ad   3  iij.  96 

M.  ft.  emulsio.  S.  One  teaspoonful  every  four  hours 
with  milk  for  a  three-year-old  child. 

— E.  ViKO. 
Sciatica. — 

R  Nitroglycerin,  alcoholic  solution  (one  per  cent.).  "  ss. 

Tinct.  capsici 3  iss. 

Aq.  menth.  pip 3  iij. 

M.  S.  Five  drops  thrice  daily  in  a  tablespoonful  of  water 
for  the  lirst  three  days,  and  ten  drops  thrice  daily  on  the  follow- 
ing days. 

— Troussevitch. 
Hemorrhoids. — 

I?  Ferri  subsulph gr.  iij. 

Plumb,  acet grr.  i. 

Mass.  hydrarg gr.  ss. 

01.  theobrom q.  s. 

Ft.  suppos.  i.     Introduce  one  morning  and  evening. 

— Orville  Horwitz. 
Vaginal  Wash — 

K  Powdered  alum, 
Powdered  boric  acid, 

Powdered  borax aa  3  iv. 

Hydrastine  sulph gr.  xl. 

Carbolic  acid. 

Oil  of  cinnamon aa  11  lxx.x. 

Triturate.  S.  Use  one  teaspoonful  in  a  pint  of  hot  water 
for  vaginal  injection  once  daily. 

— W.  B.  House. 
Seasickness. — 

If  Chloroform, 

Tincture  of  nux  vomica aa  gtt.  x. 

Compound  tincture  of  lavender 3  i. 

Water 3  x. 

M.  A  teaspoonful  to  be  taken  every  hour  until  the  vomiting 
and  nausea  have  subsided,  care  being  taken  to  shake  the  bottle 
each  time  before  the  dose  is  poured  out. 

— Barbas. 

Scarlatina. — Begin  treatment  with  the  administra- 
tion of  calomel;  then  give  throughout  the  disease: 

1$  Chloral gr.  xxx. 

Syr.  lactucarii, 

Aquae aa  3  ss.-  3  i. 

M.     S.   Teaspoonful  in  ice  water  ever)'  two  or  three  hours. 

Complete   narcotism    should   never   be    attained. — 

Wilson. 

Dilatation  of  the  Perineum  in  Labor. — The  hands 
are  rendered  aseptic  and  an  ointment  of  vaseline  with 
six  per  cent,  each  of  cocaine  and  antipyrin  is  applied 
to  the  perineum,  vagina,  and  os  uteri.  This  guards 
the  perineum  against  rupture,  hastens  deliver)',  and 
greatly  diminishes  its  pain. — Cormolos. 

Pruritus  Vulvae. —  Free  the  genitalia  from  hair, 
wash  out  the  vaginal  canal  with  sublimate  solution  so 
that  no  pathological  material  remains,  and  then  cover 
the  diseased  spots  on  the  vulva  with  three  or  five  per 
cent,  carbol-vaseline.  The  procedure  must  be  re- 
peated every  three  or  four  days  until  a  good  result  is 
secured. — Ruge. 


904 


MEDICAL    RECORD.  [December  i8,  1897 

A    NEW    TRACHEAL    TUBE.' 


^eiiT  InsttntmciTtB. 

AN  IMPROVED    CENTRIFUGE. 
By   WILLIAM    H.    MAY,    M.D., 

The  accompanying  illustration  is  of  a  new  and  simple 
centrifuge  made  b  y 
Bausch  &  Lomb,of 
Rochester,  N.  Y.  It  has 
single  gear  of  hardened 
bronze,  which  gives  a 
speed  of  three  thousand 
revolutions  a  minute  with 
ease.  The  horizontal 
arm  carries  two  alu- 
minium shields,  made  to 
contain  two  taper  glass 
tubes  for  urine  or  sputum 
work.  Tubes  are  made 
graduated  or  plain. 
Milk  tubes  for  obtaining 
percentage  of  cream  are 
also  supplied.  Its  sim- 
p  1  i  c  i  t  y  ,  compactness, 
and  low  price  should 
make  it  a  useful  help  to 
the  general  practitioner. 


A    RETINOSCOPIC    TRIAL    CASE 
By   FR.\N"K   ALLPORT,    M.D., 

CHICAGO,    ILL. 

Several  appliances  for  retinoscopy  have  been  devised, 
but  none  seem  thoroughly  satisfactory  and  practical. 
The  ordinary  test  lens  is,  after  all,  the  most  ser\'ice- 
able.  Surgeons,  however,  do  not  enjoy  transporting 
their  test  cases  or  an  assortment  of  lenses  into  the 


By   W.^LTER    F.    CHAPPELL.    M.D. 


dark  room  for  frequent  retinoscopic  examinations.  I 
have,  therefore,  requested  E.  B.  Meyrowitz  to  make 
for  me  a  small  compact  case  of  lenses,  to  be  left  per- 
manently in  the  dark  room.  The  lenses  consist  of  a 
series  of  spherical  concave  and  conve.x  lenses,  ranging 
in  strength  from  0.2  D.  to  8  1).,  which  is  a  sufficient 
varietY.  Stronger  lenses  when  occasionally  necessary 
can  be  made  by  combinations.  .\  double  trial  frame 
accompanies  the  case,  which  also  contains  a  solid 
disc.  To  permit  easy  handling  in  the  dark,  the  lenses 
are  placed  farther  apart  than  in  the  ordinarj-  trial  case. 


The  tube  which  I  present  to  you  this  evening  origi- 
nated in  my  endeavors  to  secure  a  more  perfect  instru- 
ment for  use  in  children  suffering  from  recurrent 
papillomata  of  the  lar>nx.  The  difficulty  e.xperienced 
in  permanently  eradicating  these  growths  is  familiar 
to  you  all.  One  of  the  most  successful  methods  of 
treatment  in  my  practice  has  been  the  wearing  of  a 
tracheotomy  tube  for  at  least  a  year.  This  treatment 
preserves  the  voice  and  gives  much  better  ultimate  re- 
sults, but  has  some  drawbacks.  The  length  of  the 
ordinary  tracheal  tube  heretofore  employed  causes 
considerable  irritation,  such  as  cough,  expectoration, 
and  the  formation  of  exuberant  granulation  tissue 
around  the  opening  and  on  the  mucous  membrane  of 
the  trachea.  Furthermore,  it  is  considered  by  some 
to  be  responsible  for  many  cases  of  pneumonia  and 
bronchitis  occurring  within  a  short  period  of  the  pri- 
mary tracheotomy.  In  the  writer's  experience  the 
chief  objection  to  the  old  tube  is  the  recurring  bron- 
chitis and  broncho-pneumonia  to  which  the  wearer  is 
liable  during  cold  ^veather,  and  in  fact  at  every  atmos- 
pheric change.  The  air  entering  the  lungs  without 
first  passing  through  the  heat  chambers  of  the  upper 
air  tract  keeps  the  tracheal  and  bronchial  mucous 
membrane  in  a  subacute 
catarrhal      state,     which 

readily    passes     to     bron-  

chitis.       I   have    in     three    K^^i^Ulii  ^  I,     *  "^ 
cases  employed  with  entire 
satisfaction  the    tube 
shown     this    evening;      in 
two  under  my  personal  supervision,  and  in  a  third  case, 
at  Springfield,  Mass.,  under  the  direction  of  Dr.  F.  E. 
Hopkins.     The  parts  of  the  tube  or  obturator  are  as 
follows:    An   outer  cannula  which  extends  from   the 
cutaneous  surface  to  the  anterior  wall  of  the  trachea. 
Of  course  this  distance  varies  in  different  cases,  but 
in  a  child  from  three  to  four  years  old  is  about  half 
an  inch.     A  plate  or  collar  surrounds  the  tube  at  a 
level  with  and  rests  on  the  skin.     The  e.^ctemal  end 
of  this  cannula  is  furnished  with  a  male  thread.     The 
internal  cannula    is  tube   and  wire-cage  work.     The 
tubular  part  ceases  at  the  anterior  wall  of  the  trachea, 
and  the  cage  work  passes  through  into  the  interior  of 
the  trachea.     The  length  of  the  cage  work  will  depend 
on  the  antero-posterior  diameter  of  the  trachea.     The 
•   inner  end  of  the  cannula   is  tipped  with   a   smooth 
saucer-like  cap,  which  presents  a  smooth  surface  to 
the   mucous  membrane   of  the  posterior  wall  of   the 
trachea.     It  is  important  that  this  tip  shall  not  press 
on  the  posterior  tracheal  wall.     This  is  prevented  by 
having  the  external  end  of  the  intenia  cannula  fitted 
with  a  movable  nut,  cut  with  a  female  thread,  to  fit  the 
male"  thread  of  the  outer  cannula.     By  this  device  the 
inner  cannula  can  be  lengthened  or  shortened  an  eighth 
of  an  inch  or  more,  to  suit  the  diameter  of  the  trachea 
and  to  relieve   any  pressure  which  may  exist.     The 
importance  of  this'  arrangement  is  well  illustrated  in 
the  case  which   was  under   Dr.    Hopkins'   direction. 
The  tube  was  inserted  and  worn  with  perfect  comfort 
for  some  days,  when  the  tip  of  the  inner  cage  began  to 
impinije  on  the  posterior  wall  of  the  trachea,  and  cre- 
ated considerable  irritation.     The  inner  tube  was  then 
temporarily  withdrawn  and  a  cork  placed  in  the  outer 
cannula.     This,  being  ven,-   short,  gradually  slipped 
out  and  allowed  the  tracheal  wound  to  close.     It  is 
evident  that,  if  the  pressure  on  the  trachea  cannot  be 
'  Read    before    the    l.-ir)-ngological    section   of   the    New  York 
Academy  of  Medicine.  November.  1567. 


December  i8,  1897] 


MEDICAL    RECORD. 


905 


relieved  by  the  movable  nut,  the  only  safe  procedure 
is  to  remove  the  entire  tube  and  introduce  an  ordinary 
tube,  until  the  necessary  alterations  can  be  made.  The 
accurate  adjustment  required  in  each  case  necessitates 
a  new  tube,  or  one  specially  fitted  for  each  person. 
This  is  some  objection,  but  cases  of  recurrent  papillo- 
mata  are  so  important  that  the  end  justifies  the  trouble. 
A  small  plug  accompanies  the  tube,  and  may  be  used 
as  occasion  demands.  It  appears  to  me  that  the  fol- 
lowing advantages  may  be  claimed  for  this  tube : 

I  St.  It  is  easily  and  safely  retained  by  passing  a 
piece  of  perforated  adhesive  plaster  over  the  head  of 
the  cannula  as  far  as  the  plate,  and  then  pressing  it 
against  the  skin. 

2d.  Being  short  and  light,  it  produces  little  irrita- 
tion. 

3d.  The  open  cage  work  in  the  trachea  allows  the 
patient  to  breathe  through  the  tracheal  opening  or  lar- 
ynx at  will.  This  is  of  great  advantage,  as  has  already 
been  mentioned. 

4th.  With  the  plug  inserted,  the  patient  is  able  to 
sp)eak  more  clearly. 

5th.  Should  there  be  much  laryngo-tracheal  catarrh, 
the  mucus  can  readily  be  coughed  into  the  pharynx. 

Regarding  the  use  of  this  tube  in  other  than  the 
cases  mentioned,  I  have  had  little  experience.  The 
large  tube  which  is  shown  this  evening  has  just  been 
made  for  a  case  of  epithelioma  of  the  lar}'nx,  but  has 
not  yet  been  tried.  It  seems  reasonable  to  predict 
that  this  tube  will  also  prove  serviceable  in  cases  of 
diphtheria  necessitating  tracheotomy. 

7  East  FiFTV-FirrH  Stkeei, 


AX  ADJUSTABLE  IRRIGATING  STAXD  WITH 
PEDAL    CUTOFF. 

By   CEPHAS   L.    BARD,    M.D., 

This  device  is  presented  to  the  notice  of  the  profes- 
sion with  an  assurance,  based  upon  a  thorough  trial, 
that  it  will  materially  contribute  to  the  fulfilment  of 
some  of  the  requirements  of  an  aseptic  operation. 

Although  applicable,  at  least  its  cutoff,  to  the  sta- 
tionar\-  irrigators  of  the  hospital,  it  is  especially  de- 
signed for  use  in  connection  with  a  fountain  syringe, 
preferably  of  large  capacity.  It  is  manufactured  in 
two  forms  —the  detachable  and  non-detachable.  The 
former,  placed  in  a  case  one  yard  in  length,  is  easily 
carried  to  the  home  of  a  patient  by  the  surgeon,  in  his 
hand  or  carriage.  Its  component  parts  being  placed 
in  position,  it  will  sustain  at  varying  heights  a  four- 
quart  fountain  syringe,  filled  with  water  and  weighing 
eight  pounds.  Aside  from  the  immense  advantage  of 
its  cutoff,  about  to  be  described,  its  use  obviates  the 
necessity  of  suspending  the  syringe  bag  from  a  bed- 
post, chandelier,  or  nail  driven  in  the  wall,  and  as  it 
is  conveyable  it  is  unnecessary  to  carry  the  patient  to 
the  syringe,  as  hitherto  has  been  the  case.  The  non- 
detachable  form  is  intended  for  hospital  use.  By 
reference  to  the  accompanying  cuts,  it  will  be  seen 
that  the  tubing  of  the  syringe  passes  through  an  open- 
ing of  the  hollow  standard,  and,  when  the  instrument 
is  not  in  use,  is  compressed  between  the  convex  top 
of  a  slide  rod,  situated  interiorly  and  actuated  by  a 
coiled  spring  at  its  base,  and  the  concave  face  of  a 
block  placed  directly  above  tiie  opening.  Pressure  of 
a  foot  on  a  pedal,  connected  witli  the  lower  end  of  the 
slide  rod,  removes  the  compression  of  the  tubing,  and 
a  stream  is  obtained  which  continues  as  long  as  the 
pressure  is  exerted.  When  it  is  desirable  to  have  the 
flow  without  the  constant  foot  pressure,  the  pedal  by  a 
sidewise  niotion  of  the  foot  may  he  pushed  and  fi.xed 
in  a  slot  provided  for  that  purpose.     The  pedal  cut- 


off enables  the  operator  to  obtain  and  to  arrest  a  flow 
of  liquid  instantly,  with  but  slight  exertion  on  his 
part,  and  as  the  nozzle,  which  should  preferably  be  of 
glass,  is  the  only  portion  of  the  apparatus  touched  by 
his  hand,  the  danger  of  infection  from  that  form  of 
contact  is  absolutely  removed.  An  additional  secur- 
it}'  may  be  provided  by  slipping  a  sterilized  muslin 
sleeve,  a  foot  or  more  in  length,  over  the  deliver}-  end 
of  the  tubing.  The  various  hand-controlled  cutoffs 
are  without  doubt  frequently  sources  of  infection,  and 


their  disuse  will  contribute  to  the  safety  of  the  patient. 
The  control  of  the  cutoff  is  so  complete  and  so  easily 
effected  that  the  services  of  an  assistant  in  managing 
the  flow  are  seldom  required,  a  feature  which  will  be 
fully  appreciated  by  those  operating  ouside  of  the 
walls  of  a  hospital.  With  it,  for  example,  a  curet- 
tage and  minor  gjnacological  operations  can  be  per- 
formed by  a  surgeon  whose  only  assistant  is  the  ana-s- 
thetizer.  Its  convenience  will  be  fully  appreciated  by 
the  nurse  when  douches  are  required  in  septic  cases 
in  the  lying-in  room. 

It  is  made  by  Charles  Truax,  Greene  &  Co.,  of 
Chicago,  to  whom  I  am  indebted  for  their  faithful 
adherence  to  my  ideas  in  its  construction. 


Uretero-Ureteral    Anastomosis i.    Uretero-ure- 

teral  anastomosis  is  a  perfectly  feasible  procedure.  2. 
Uretero-ureteral  anastomosis,  whenever  possible,  is 
far  preferable  to  any  other  form  of  ureteral  grafting, 
to  nephrectomy,  and  to  ligation  of  the  ureter.  3.  It 
should  be  done  preferably  by  lateral  implantation,  or 
by  oblique  end-to-end  anastomosis,  though  the  trans- 
verse end-to-end  or  the  simple  end-to-end  method 
may  be  safely  employed.  4.  The  constrictions  of  the 
calibre  of  the  ureter  do  not  usually  follow  attempts  at 
suturing  in  closure  of  complete  transverse  section  of 
the  duct.  5.  Nephrectomy  for  transverse  injuries  of 
the  ureter, /c/'j-f,  is  an  unjustifiable  oiieration.  6.  Sim- 
ple ligation  of  the  ureter,  to  produce  extinction  of  the 
functions  of  the  kidney,  is  too  uncertain  to  justify  its 
practice.  7.  Drainage  is  not  necessary  if  the  wound 
be  perfectly  closed  and  the  tissues  throughout  are 
•iseptic. — J.  Wesley  Bovee. 


9o6 


MEDICAL    RECORD. 


[December  i8,  1897 


A  PAIR    OF    RETRACTORS. 
Bv    RA.MON   GUITERAS,    M.D., 

NEW   YORK. 

In  all  of  the  various  operations  in  surgery,  no  instru- 
ments are  more  important  to  the  surgeon  than  is  a  pair 
of  well-formed  and  well-devised  retractors.  Different 
surgeons  have  their  own  favorite  instruments  which 
they  are  in  the  habit  of  using,  and  which  through  con- 
stant use  they  are  led  to  consider  the  best. 

In  teaching  operative  surgery  to  post-graduate  stu- 
dents, however,  most  of  whom  have  had  considerable 
practice  in  operative  work,  one  cannot  help  being  led 
by  their  various  comments  to  see  certain  defects  in  the 
instruments  in  common  use. 

Retractors  have  always  seemed  to  come  in  for  a  fair 
share  of  criticism,  and  the  different  varieties  have 
been  from  time  to  time  so  commented  upon  that  I 
decided  to  tr}-  to  devise  a  pair  which  could  be  used  in 
any  operation  with  comparative  satisfaction  by  the 
general  practitioner. 

The  results  of  my  observations  have  guided  me  in 
devising  the  pair  of  retractors  which  I  am  about  to 
describe. 

Description.— The  shaft  is  seven  inches  long  with  a 
pair  of  prongs  at  either  end.     These  sets  of  prongs 


vary  in  length.  The  larger  pair  is  two  inches  long, 
and'  they  are  separated  by  a  distance  of  three-quarters 
of  an  inch  from  one  another.  This  allows  the  tissues 
to  bulge  out  between  them,  and  thus  help  to  hold  it  in 
position.  At  the  end  of  the  prongs  there  is  a  slight 
curve  inward.  This  prevents  the  deeper  tissues  from 
slipping,  and  consequently  holds  them  with  a  firmer 
grasp.  This  larger  pair  is  especially  useful  in  ab- 
dominal cases  for  retracting  the  abdominal  parietes, 
and  is  also  valuable  in  operations  on  deep  tissues 
elsew^iere,  as  in  the  gluteal  region,  the  thighs,  back, 
etc. 

The  smaller  pair  of  prongs  on  the  other  extremity 
is  just  one-half  the  length  of  the  pair  described. 
They  are  separated  only  by  half  an  inch.  Their  shape 
is  the  same,  and  they  also  have  the  ends  turned  in- 
ward, to  prevent  the  tissue  from  slipping.  This 
smaller  end  of  the  retractors  is  of  service  in  operat- 
ing where  the  tissues  are  not  so  thick,  as  on  those 
about  the  neck  and  the  extremities. 

Another  advantage  that  these  retractors  have  over 
many  others  is  that  the  assistant's  hand  is  not  obliged 
to  grasp  the  shaft,  and  thus  be  directly  in  the  way  of 
the  operator,  either  by  partly  covering  the  field  of 
operation  or  by  throwing  a  shadow  over  it:  for,  if  one 
end  of  the  retractor  is  in  tlie  wound,  the  other  end  can 
be  supported  by  the  finger  of  one  hand,  in  such  a  way 
that  the  hand  itself  is  eight  or  ten  inches  away  from 
the  field  of  operation. 

2i  West  Fikty-Thikd  Stkek.. 


The  Strawberry  Tongue  in  Scarlet  Fever.— The 
tongue  which  is  characteristic  of  scarlet  fever,  and  is 
pathognomonic  when  it  is  present,  is  the  bright-red, 
clean  tongue  with  prominent  papilUv.  and  not  the 
tongue  which  presents  a  white  coat  with  the  swollen 
red  papilla-  protruding,  which  occurs  earlier  in  the 
course  of  the  disease. — Fussell. 


pXedical  Items, 

Contagious  Diseases— Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitar}'  Bureau,  Health  Department,  for  the 
week  ending  December  11,  1897: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox 


Hall  Caine  Jollied.— Under  the  title  of  "  Hospital 

Happenings,"  Mr.  Hall  Caine's  "Christian,"  with  its 
unfair  lies  in  regard  to  hospital  management,  has  been 
jollied  capitallv  in  a  little  paper  called  the  Guyoscope. 
The  celebrated'  ball  at  St.  Bartimteus'  is  sketched  as 
follows:  "Last  Tuesday  the  first  students'  ball  of  the 
season  took  place  in  the  operating-theatre  of  St.  Bar- 
timaus  Hospital.  The  arrangements  generally  re- 
flected great  credit  on  the  members  of  the  dance 
committee,  who  by  the  way  were  distiriguished 
by  wearing  Murphy's  buttonholes  in  their  coats. 
The  floor  had  been  carefully  scrubbed  with 
softsoap  and  lysol,  and  would  have  made  an 
admirable  dancing-surface  had  there  been  room 
to  dance.  As  it  was,  the  majority  of  the  guests 
preferred  to  take  advantage  of  the  magnificent 
promenade  afforded  by  the  spacious  corridors  of 
the  hospital.  .  .  .  The  proceedings  opened  with  a  solo 
clog  dance  on  the  operating-table  by  Sir  Willian. 
McCormac,  who  was  attired  in  mackintosh  and  steri- 
lized overall.  Next,  in  response  to  vociferous  appeals, 
the  matron  of  the  hospital  obliged  with  a  serpentine 
dance,  all  first  years'  students  having  been  previously 
anesthetized.  After  these  two  superb  displays  of 
Terpsichorean  skill  a  general  move  was  made  for  the 
supper  room,  a  delightfully  airy  apartment  used  on 
more  prosaic  occasions  as  a  dissecting-room.  Boyish 
students  might  be  seen  pledging  their  laughing-eyed 
partners  in  foaming  beakers  of  hyd.  perchlor.  (1 
in  2,000,  1897),  while  their  staider  elders  fortified 
themselves  with  modest  injections  of  brandy  and 
strychnine.  We  can  personally  testify  to  the  exhil- 
arating qualities  of  the  formalin  cup,  which  was  much 
appreciated  by  those  privileged  to  partake.  If  a  crit- 
icism can  be  permitted  us,  we  venture  to  think  that  the 
conduct  of  the  surgical-instrument  keeper  in  boiling 
the  spoons  between  ever)-  course  was  somewhat  un- 
necessary and  certainly  inconvenient."  As  The  Lancet 
remarks,  this  is  excellent  fooling,  and  is  the  right  way 
to  treat  a  book  at  once  so  stupid  and  pretentious  as 
"The  Christian." 

Jonathan  Hutchinson  on  the  Medicinal  Employ- 
ment of  Coffee.— In  his  Arcluv.s  of  Surgery.  Jonathaiy 
Hutchin.sun  says:  "  I  have  often  ix;en  in  the  habit  of 
prescribing  coffee  as  a  medicine  in  certain  states  of 
great  debilitv.  It  appears  to  me  to  be  a  remedy  quite 
unique  in  its  usefulness  in  sustaining  the  nervous  en- 
ergv  in  certain  cases.  Apart  from  its  general  useful- 
ness, I  have  found  it  of  especial  service  after  operations 
when  ana;sthetics  had  been  used  and  in  a  state  of  ex- 
haustion when  alcohol  had  been  pushed  and  a  con- 
dition of  semicoma  followed.  In  these  latter  cases  I 
have  sometimes  prescribed  it  as  an  enema  when  the 
patient  could  not  swallow,  and  with  the  best  effects. 
Its  value  as  an  antidote  to  opium  is  of  course  wel' 
known.      Tea  and  coffee  seem  to  me  to  be  much  alike 


December  i8,  1897] 


MEDICAL    RECORD. 


907 


in  many  respects,  but  I  would  give  preference  to  the 
latter,  as  to  its  sustaining  powers.  It  would,  I  think, 
be  a  great  advantage  to  our  working  classes  and  a 
great  help  toward  a  further  development  of  social  so- 
briet},  if  coffee  were  to  come  into  greatly  increased 
use.  and  if  the  abilitj-  to  make  it  well  could  be  ac- 
quired." 

The  Sleep  Problem — As  town  life  extends  and  in- 
tellect is  aroused,  the  problem  will  be  more  and  more 
that  of  too  little,  not  of  too  much  sleep.  Perfect  or 
nearly  perfect  health  is  of  course  the  first  condition  of 
sound  sleep.  But  scarcely  any  one  is  quite  healthy, 
and  so  we  must  aid  the  sleepless  to  acquire  that  w  hich 
is  lacking.  The  one  great  thing  to  do  is  to  fatigue 
the  attention ;  not  only  to  tire  out  the  body  but  also 
the  active  mind;  to  quiet  the  vasomotor  centre  and 
so  drive  the  congested  blood  from  the  brain.  Quiet 
and  regular  habits,  a  certain  monotony  of  light  even- 
ing occupation,  will  tend  in  this  direction,  while  a 
great  variety  of  evening  engagements  is  generally  fatal 
to  the  victim  of  insomnia.  It  is  unwise  to  go  to  bed 
on  either  an  empty  or  verj-  full  stomach;  a  slight  meal 
before  rest  is  the  wise  course.  A  hot  bath  the  last 
thing,  taken  under  the  following  conditions,  is  per- 
haps the  very  best  aid  to  sleep:  As  recommended  by 
Eccles  and  others,  the  bath  should  be  taken  in  a  room 
with  a  temperature  of  65'  to  70'  F.  The  patient 
should  stand  with  his  head  over  the  edge  of  the  tub, 
douching  head  and  face  with  water  at  100°  F.  The 
cooling  of  the  body  by  the  air  and  the  hot  sponging 
of  the  head  first  send  blood  to  the  brain,  dilating  its 
vessels.  Then  the  entire  body,  except  the  head,  is 
immersed  in  a  bath  at  98'  F.,  rapidly  raised  to  105' 
or  1 10  F.;  in  a  few  minutes  the  bath  is  left,  and  the 
body  wrapped  in  blankets,  which  absorb  the  moisture, 
and  with  the  least  possible  exertion  the  patient  gets 
into  his  night  clothes  and  to  bed  with  a  warm  bottle 
to  his  feet  and  perhaps  a  little  warm  liquid  food. — 
Spectijtor. 

The  Relation  between  Chorea  and  Scarlet  Fever. 
— Priestley  {British  Medical  Journal,  September  25, 
1897,  p.  805)  relates  that  during  the  years  1894,  1895, 
and  1896,  among  eighty-three  hundred  and  sixt\-  cases 
of  scarlet  fever  under  treatment  at  the  Northeastern 
Hospital  of  the  metropolitan  asylums  board,  thirteen 
cases  of  chorea  were  observed.  Five  of  these  cases 
presented  rheumatic  manifestations,  which  in  each  in- 
stance immediately  preceded  or  presented  themselves 
simultaneously  with  the  chorea.  These  symptoms  set 
in  considerably  later  than  the  usual  period  at  which  the 
articular  complications  of  scarlet  fever  occur — that  is, 
after  the  first  week.  Of  the  thirteen  cases  cardiac 
murmurs  developed  in  seven.  The  average  interval 
between  the  onset  of  the  scarlet  fever  and  that  of  the 
chorea  was  over  thirty-five  days. 

Sudden  Hyperpyrexia  in  a  Fatal  Case  of  Delirium 
Tremens — Bell  {Lancet,  October  2,  1897,  p.  859) 
reports  the  case  of  a  man,  forty-seven  years  old,  who 
came  under  observation  suffering  from  the  effects  of 
excessive  indulgence  in  alcohol.  Vomiting  was  the 
chief  complaint,  and  was  relieved  by  the  administra- 
tion of  an  effer\escing  mixture  with  fifteen  minims  of 
tincture  of  opium  ever}-  three  hours.  Improvement 
gradually  set  in,  but  in  the  course  of  two  days  symp- 
toms of  delirium  made  their  appearance.  The  tem- 
perature, which  had  previously  been  normal,  rose  to 
105'  F.,  following  a  "fit,"  with  loss  of  consciousness. 
The  man  was  placed  at  once  in  an  ice  sheet,  with  an 
ice  bag  to  his  liead,  and  potassium  bromide  and  anti- 
pyrin  were  given  every  three  hours.  The  temperature, 
however,  rose  rapidly  to  109.8  F.,  and  death  ensued. 
On  post-mortem  examination  the  brain  and  meninges 
were  much  congested,  but  no  hemorrhage  could  be 


found.  The  heart  was  ixXtK  and  the  liver  was  enlarged 
with  commencing  cirrhosis,  but  no  other  lesions  could 
be  made  out. 

«'  Catching  Cold  "  as  a  Cause  of  Disease. — From 

a  general  survey  of  the  subject,  Chalmonski  {Deutsches 
Arc/iiv  fiir  klitiische  Medicin,  B.  59,  H.  i,  2,  p.  140) 
concludes  that  "  catching  cold,"  in  the  ordinary  sense, 
is  not  a  causative  factor  in  disease,  playing  in  general 
a  ver)-  subordinate  part  as  an  etiologic  agency.  In 
inflammatorj-  diseases  it  may  act  as  only  a  predisposing 
factor.  '■  Catching  cold"  depends  upon  the  activit}-of 
thermic  agents  which  are  usually  not  to  be  avoided; 
that  is,  upon  the  influence  of  slight  degrees  of  cold. 
The  degree  of  cutaneous  reaction  to  the  given  thermic 
stimulus  is  an  indication  whether  the  individual  may 
take  cold  under  certain  conditions.  The  degr'^e  of 
disposition  to  "  catching  cold"  forms  no  constant  pecu- 
liarity of  the  given  individual.  Individuals  of  ad- 
vanced age,  febrile  patients,  and  those  suffering  from 
renal  disease  appear  to  be  more  disposed  than  others 
to  disease  resulting  from  "catching  cold."  Between 
the  predisposition  to  such  disease  upon  the  one  hand, 
and  the  nutritive  state  and  the  temperature  sensibility 
upon  the  other,  there  is  no  connection.  The  prophy- 
lactic measures  directed  in  general  toward  "catching 
cold"  are  not  only  attended  by  a  directly  opposite 
result,  but  they  further  expose  the  organism  to  far 
greater  danger  than  is  to  be  anticipated  from  disease 
resulting  from  "catching  cold."  Protection  against 
such  disease  may  be  secured  by  increasing  the  reactive 
capabilitj'  to  thermic  irritants  by  means  of  suitable 
exercises. 

Croup. — Croup  is  asthenic  localized  inflammation^ 
whose  causation  is  connected  always  with  some  expo- 
sure to  cold,  wet.  etc. ;  it  is  never  epidemic.  Diph- 
theria is  a  general  disease,  usually  epidemic  and 
asthenic  in  type:  the  local  inflammation  in  it  is  sec- 
ondary to  the  constitutional  affection.  In  croup  the 
false  membrane  is  a  solidifying  exudation  upon  the 
surface  of  the  mucous  membrane;  in  diphtheria  it  in- 
volves its  substance  also.  Croup  is  not  attended  by 
albuminuria  or  followed  by  paralysis;  both  occur  not 
infrequently  with  diphtheria. — H.artshorx. 

Anaemic  versus  Organic  Heart  Murmurs. — An 
ana&mic  is  distinguished  from  an  organic  murmur  by 
its  blowing  character;  by  always  accompanying  the 
first  sound  of  the  heart;  by  being  audible  in  several 
of  the  arteries  at  the  same  time;  by  not  being  con- 
stantly present,  occasionally  disappearing  when  the 
circulation  is  tranquil  and  returning  when  it  is  accel- 
erated ;  by  the  presence  of  the  general  signs  of  anje- 
mia ;  by  the  absence  of  the  physical  or  general  signs  of 
organic  disease  of  the  heart;  by  entirely  disappearing 
under  treatment  calculated  to  relieve  the  ana-mic  state 
of  the  system.- — W.  H.  H.\rris,  Journal  of  Medicine 
and  Science,  June,  1897. 

A  Prescription. — The  appellate  court  of  Indiana 
holds  that  a  prescription  is  to  be  defined  as  meaning 
"a  statement  usually  written  of  the  medici;.e  or  reme- 
dies to  be  used  by  a  patient  and  the  manner  of  using 
them."  The  following  writing  was  not  admitted  as 
falling  under  this  head:  "  B.  W.  Tilford,  druggist, 
Martinsville,  Ind.  R.  Spt.  frumenti.qt.  i.  For  med- 
ical use.  Date,  November  10,  1895.  B.  W.  Tilford, 
M.D."  We  are  forced  to  admit  that,  if  Intended  for  an 
infant  and  to  be  given  at  one  dose,  some  unfortunate 
complication  might  have  arisen. 

Specialism. — The  following  declarations  concern- 
ing the  mutual  obligations  of  the  specialist  and  the 
physician  have  been  formulated  by  the  Medical  .Society 
of  the  Ninth  District  of  X'ienna:  i.  The  specialist  is 
a  physician  who  renounces  practice  in  all  branches  of 


MEDICAL    RECORD. 


[December  18,  1897 


medicine  with  the  exception  of  a  well-defined  part. 
>  The  specialist  should  undertake  no  treatment  with- 
out an  understanding  with  the  physician  of  the  patient 
or  of  his  family.  3-  'I'he  physiciati  should  be  in- 
formed of  the  diagnosis  made,  and  h^s.  advice  should 
be  sought  for  important  interventions.  4-  1^  't  's  not 
possible  for  the  physician  to  direct  the  treatment  to 
be  followed,  the  specialist  should  permit  him  to  take 
part  in  it  to  the  extent  of  his  aptitude.  5-  The  patient 
cannot  be  sent  by  the  specialist  to  a  third  physician 
unless  with  the  consent  of  the  physician  in  ordinary. 

Acute  Pleurisy  a  Form  of   Tuberculosis.  —  That 
cases  of  acute  pleurisy  are  often  tuberculous  has  been 
known  for  some  time;  that  they  are  almost  invariably 
so  seems  now  to  be  proved.    Attention  was  first  drawn 
to  the  fact  by  continental  writers.     In  1890  1  )r.  Alfred 
G   Barrs  read  a  paper  before  the  Leeds  Medico-Chi- 
rurgical  Society.     As  the  result  of  carefully  compiled 
statistics  he  confirmed  the  conclusion  of  Mayor,  that 
•'  the  majority  of  cases  of  simple   idiopathic  pleurisy 
or  pleurisy  from  exposure  to  cold  conceal  or  reveal  a 
tuberculous  process.     In   1893,  however   Dr.  William 
Osier  in  his  Shattuck  lecture  concluded  that  two-thirds 
of  the  cases  were  non-tuberculous.     In  1895  Eichhorst 
published  the  results  of   injecting  the  fluid  obtained 
from  cases  of  serous  pleurisy  into  the  peritoneal  cavity 
of  guinea-pigs.     Two-thirds  of  the  animals  developed 
tuberculosis.     The  Boston  Medical  and  Surgualjournal 
of  \ugust  s,  1897,  contains  an  important  paper  by  Ur. 
Georo-e   G.    Sears.      On   injecting    tuberculin   in   ten 
cases  of  acute  pleurisv,  he  obtained  a  reaction— rise 
of  temperature- in  nine.     He  limited  the  reaction  to 
this  by  using  a  small  dose-one  milligram,  nicreased 
if  necessary.     His  results  are  nearly  identical  with 
those  cited  bv  Netter,  who  obtained  a  reaction  in  thir- 
teen out  of  fifteen  cases.     The  question  is  of  practical 
importance.     Though  the  prognosis  as  regards  the  at- 
tack is  good,  there  remains  the  tendency  to  develop 
other  and  more  serious  forms  of  tuberculosis.— Z«/w/. 

The  Onion  and  the  Teacher.— In  Topeka  a  school- 
mistress forbade  the  eating  of  onions  by  the  scholars, 
whereupon  all  the  scholars  took  to  the  diet  and  the 
teacher  was  overpowered  and  yielded.  In  onion  there 
is  strength. 

Early  Diagnosis  of  Pregnancy — Rinman  observed 
in  two  cases,  as  an  early  symptom  of  pregnancy,  slen- 
der cords  radiating  from  the  nipple,  which  he  believes 
to  have  been  tlie  hypertrophic  acini  of  the  glands. 
Secretion  was  not  yet  present.  This  obser^•atIon  has 
been  confirmed  by  others. 

Male  Nurses  in  England  seem  to  have  difficulty  in 
obtaining  adequate  instruction.  It  is  said  that  no 
general  hospital  gives  a  course  of  training  for  males. 


not  require  anv  interference,  but  larger  ones  may  re-  | 
quire  extirpatio'n.  2.  Cysts  of  ligamentum  latum  and-; 
referable  to  the  paroophoron.  These  are  usually  small' 
and  thin  walled,  holding  a  colorless  limpid  fluid,  and 
are  of  little  clinical  importance,  as  they  seldom  attain 
a  size  to  call  for  interference.  3.  Cystomyomata, 
embracing  adenomyomata  of  the  lateral  and  posterior 
wall  of  the  uterus  and  similar  growths  of  the  broad 
ligaments  and  tubes.  These  are  of  importance  as 
producing  chlorosis,  dysmenorrhea,  menorrhagia, 
sterility,  inflammatory  processes  in  the  peritoneum,  or 
vesical  and  peristaltic  disturbance,  etc.  Their  prog- 
nosis is  more  serious  than  that  of  most  myomata,  and 
total  extirpation  is  indicated.  The  author  concludes 
that  the  Wolffian  body  and  its  duct  play  an  important 
part  in  gynacologv,  although  it  is  to  the  future  we 
must  look  for  a  clear  distinction  between  its  domain 
and  that  of  the  Miillerian  duct. 

How  to  Use  Knockout  Drops.— The  following  di- 
rections were  found  on  a  sneak  thief  recently  ar- 
rested :  ■•  The  one  most  dangerous  is  any  one  affected 
with  heart  trouble,  as  it  takes  immediate  action  on  the 
heart,  causing  the  heart  to  beat  so  rapidly  as  to  finally 
kill  Fifteen  drops  of  aromatic  spirits  of  ammonia 
given  immediately  with  a  hypo,  injection  of  atropine 
will  always  counteract  the  effect.  When  you  are 
about  to  administer,  take  fifteen  drops  in  a  small 
homoeopathic  vial,  hold  in  palm  of  hand,  drawing  the 
cork  with  thumb  and  forefinger  of  same  hand,  reach 
over  the  patient's  glass,  calling  his  attention,  and— 
why  '  Bang!  '  he  is  yours.  This  is  about  as  explicit  as 
is  possible  without  demonstration.  You  know  the 
penalty  to  be  caught  with  it  in  your  possession.'  1  he 
"drops"  are  composed,  it  is  said,  of  chloral. 

Health  Reports.— The  following  statistics  concern- 
in"^  yellow  fever,  cholera,  plague,  and  small-pox  have 
been  received  in  the  office  of  the  supen-ising  surgeon- 
general  of  the  United  States  Marine  Hospital  ser- 
vice, during  the  week  ended  December  11,  1897  : 

YELLOW  Khvbk-Un.ted  States.  ^^^    ^^^^ 

I  oviisiana.  New  <  )rlcans November  i8th  lo  December  4lh.       5  ? 

Yellow  Fever— Foreign. 

l-.razil.Para    S""'''^'"'' ,K  .."I^h '^'' *''' ' '  "^ 

Kiode  Janeiro November  14th  to  jottt  ......  .■•  -^ 

,-  K     Hn,.an,                          November  26th  to  December  2d.  ..            ■» 

•  Mant^nma  ■  ■ '   ' ;         November  ,st  to  1 5th ■  •             4 

'^7i\Z         " November  26th  to  t)ccember  ad.  ..            >o 

lamaica,  Kingston S"^'""!:!''  '^■{; !°  Sil 5 

Manchester November  Mth  to  20th 5 

St,  Andrew November  nth  to  20th « 

St.  Catherine November  ijlh  to  20th J 

Mexico,  Maiatlan November  .Sth „^rf 

SanSalvador......   ....November  .St ^'^"pj,^' 

Inited  Slates  of  Colombia,  '~ 

Cirtagena November  6th 

Cholera— FoRElcx. 

India,  Bombay October  27th  to  November  <,th. .     . .  « 

CMcutia    October  17th  to  wth...... 

Japan.  YehJme  ken October  29th  to  November  8th. 


In  Doubt.— Having  read  the  directions  on  the  box, 
"Take  one  every  two  hours  till  gone,"  she  sent  in 
haste  to  the  prescriber,  to  know  if  he  meant  her  or  the 
pills. 

The  Wolffian  Body  in  its  Relations  to  Gynae- 
cology.- H.  I'eters  \Vo/kmann's:  k/inisc/ie  Vortmgi; 
October.  .897),  after  a  complete  and  interesting 
survey  of  the  embryology  of  the  parts  inyohed, 
considers  the  pathological  conditions  of  the  female 
genitalia  referable  to  the  Wolffian  body  and  duct. 
These  he  divides  as  follows:  i.  Cysts  of  parovarium. 
\  not  rare  form  of  Ihin-wia-icied  intraligamentous  cyst, 
seldom  larger  than  a  child's  head  and  cliaractenzed  by 
Ivin.-  close  10  the  unchanged  ovaries.  The  contents 
■ire  usually  of  a  thin,  colorless,  sometimes  slightly 
opalescent'fluid.  Their  growth  is  very  slow  and  they 
are  prone  to  spontaneous  rupture  and  subsequent  re- 
filling     When  small  they  give  little  trouble  and  do 


Plagie. 

1  ndia,  Bombay October  27th  to  November  9th . . 

Sm\ll-Hox— V^NiTED  States. 

\lab.ima,  Birminghan,. November  2Slh  to  December  4th. 

r.corRia,  Atlanta November  30th 

I  '.nffin.. December  2d 

Small- Pox— Foreign. 

Bohemia.  Prague ^i^•";:"'''■'  .v"",  !°^l"' '. 

Brazil,  Manaos jVtobcr  loth  to ^^■■•ry^^ 

China    Hong  Kong i]"='°'^'J"'',a  ,„  ^sth 

Cuba,  Cienfnegos. ...   ^.»^""^'  ",'',',"  '.,h 

Sagua  la  Grande November  2 1  Nt  to  27th 

1-      1   „H    l!^o,.l  .  November  14th  t>' 20«n 

""-        'So.lhampion.:...  Noveml,er  7th  to  2eth 

irance.  Paris November  M'l' >"  ^^ ■- 

Mi>"f  >^-„ '^X'r  «t"h ;  No vc£  IIS: : 

•l-re  H  .k  kaido  ..     October  «th  to  Novemte  8  h.. 

Vehime  Ken Octotnr  20th  to  November  8th.. 

u„„i,,    OdeSa-  November  i4lh  to  20«h 

St.  ivtJrsburg November  7th  to  13th.... 

Warsaw November  7th  to  13th  ..\ 


Medical  Record 

A  Weekly  jfournal  of  Medicine  and  Surgery 


Vol.  52,  No.  26. 
Whole  No.  1416. 


New  York,    December  25,    1897. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©tngtnal  |irttclcs. 


A  UNIQUE  CASE  OF  COMPLETE  REMOVAL 
OF  THE  STOMACH— SUCCESSFUL  CESOPH- 
AGO-ENTEROSTOMV— RECOVERY. 

By   carl   SCHLATTER.  M.D.. 


T-DOCENT     AT 


l:rich.    and    ASSOCI. 


Introductory   Remarks    by    Dr.   Edmund    Charles 

Wendt,  of  New  York.—  During  my  recent  stay  at 
Zurich.  Switzerland,  I  was  enabled,  through  the  kindly 
courtesy  of  my  friend,  Dr  Carl  Schlatter,  personally 
to  study  the  remarkable  and  unique  case  about 
to  be  described.  At  the  date  of  the  present  writing, 
December  9.  1897,  over  three  months  since  the  opera- 
tion of  total  ablation  of  the  stomach,  the  woman  is 
still  under  obser\-ation  at  the  county  hospital :  but 
she  is  to  all  intents  and  purposes  a  well  woman,  and 
does  her  full  share  of  the  daily  work  of  the  ward.  On 
the  date  of  my  first  visit  I  found  her  in  a  very  cheer- 
ful frame  of  mind,  and  quite  loquacious.  She  is  al- 
ready beginning  to  realize  the  interest  and  importance 
attaching  to  her  case,  as  she  has  had  medical  visitors 
from  many  quarters  of  the  globe.  The  lay  press  of 
all  Europe  has  got  wind  of  this  extraordinary  instance 
of  a  ■■  live  woman  without  a  stomach."  Garbled  re- 
ports of  her  case  have  appeared  in  London,  in  Paris, 
in  Berlin,  in  Vienna,  and,  perhaps,  by  this  time,  in 
New  York.  It  seems  to  me  that  the  readers  of  the 
Rkcord  may  well  be  congratulated  upon  receiving  a 
detailed  account  of  this  case  from  the  pen  of  the 
operating  surgeon  himself.  It  is  only  fair  to  mention, 
however,  that,  at  the  request  of  the  editor  of  The  Lanat, 
an  abstract  of  this  case  has  just  been  forwarded  by 
Dr.  Schlatter  to  London.'  I  take  this  opportunit)-  of 
expressing  my  sincere  thanks  to  the  young  savant,  who 
so  cordially  assisted  me  in  my  efforts  to  obtain  for  the 
-American  profession  an  authentic  account  of  the  case. 
On  my  several  examinations  of  the  patient  I  was  par- 
ticularly struck  by  her  ruddy  complexion,  fair  general 
appearance,  clean,  moist  tongue,  absence  of  all  foetor 
ex  ore,  moderately  full  and  vigorous  pulse,  and  general 
alacrity.  She  informed  me  that  her  appetite  was  good, 
but  that  she  was  never  allowed  to  feel  really  hungrj-. 
She  relished  her  meals  and  her  taste  was  unimpaired. 
Tlie  bowels  acted  naturally  once  in  twenty-four  hours. 
Herl^eep  was  normal.     .She  complained  of  no  pain. 

In  a  word,  save  for  some  degree  of  emaciation,  a 
noticeably  dry  skin,  and  her  abdominal  cicatrix,  the 
woman  at  present '  offers  no  apparent  departure  from 
ordinary  average  health.  How  long  can  she  survive 
the  non-existence  of  gastric  digestion  ?  Who  can  tell  ? 
Clinical  obser%'ation  sometimes  rudely  disturbs  our 
most  cherished  school-taught  physiological  dogmas. 

Total  Ablation  of  the  Human  Stomach  not  Hitherto 
Done It    is    quite    well    known   th.it   gastrectomv  so 

'  It  is  also  proper  to  state  that  in  preparing  the  Knglish  version 
of  Dr.  Schlatter's  case  I  have  relied  on  reprints  of  an  address 
delivered  by  him  before  the  Swiss  Medical  Congress,  and  that 
this  address  has  just  appeared  in  the  current  issue  of  the  Cor- 
respondenzblatt  fOr  .Vhweizer  .\erzte. 

*  The  date  of  mv  lasunsit  tf>  her  was  December  o.   i>'i- 


called  is  not  tantamount  to  total  extirpation  of  the 
stomach.  The  recorded  cases  of  gastric  excision  are, 
without  exception,  instances  of  partial  (chiefly  pyloric) 
removal  of  the  stomach.  At  the  hands  of  some  sur- 
geons, it  is  true,  ver)-  large  portions  of  this  organ  of 
digestion  have  been  removed,  even  in  ordinary  cases 
of  pvlorectomy.  Some  recent  operations  of  this  kind 
have  resulted  successfully.  I  recall  one  case  in  par- 
ticular, which  occurred  at  the  surgical  clinic  of  Pro- 
fessor Kronlein,  of  Zurich,  which  necessitated  the  al- 
most complete  removal  of  the  stomach.  This  case' 
was  one  of  gastrectomy  for  colloid  cancer.  Twentj- 
two  centimetres  were  removed  from  the  greater  cuna- 
ture  and  thirteen  from  the  lesser.  The  patient  recov- 
ered. Hacker  and  Maydl  have  also  lately  recorded 
similar  cases. 

Quite  recently  several  cases  of  so-called  total  extir- 
pation of  the  stomach  have  also  been  recorded.  But 
as  a  careful  study  of  the  published  reports  shows  that 
some  small  part  of  the  stomach  was  always  allowed 
to  remain,  these  cases  cannot  be,  strictly  speaking,  con- 
sidered as  instances  of  complete  removal  of  the  organ." 

U'riting  in  the  Deutsche  tnedicinische  Wochenschrijl. 
Langenbuch,  in  1894,  referred  to  two  cases  of  alleged 
total  excision  of  the  stomach.  The  patients  were 
women,  respectively  fifty-eight  and  fifty-six  years  of 
age.  But  proof  is  wanting  that  no  part  of  the  stomach 
was  left  behind.  One  of  the  patients  died  six  days 
after  the  operation.  Moreover,  in  the  successful  case, 
while  fully  seven-eighths  of  the  stomach  was  excised, 
the  remaining  cutt-like  parts  of  the  pyloric  and  car- 
diac portions  proved  sufficiently  large  to  admit  being 
joined  together  by  suture. 

Professor  Schuchardt,  of  Stettin,  removed  the  major 
part  of  the  stomach  in  a  case  of  cancer  in  1895.  In 
advance  of  a  detailed  account  of  his  case,  soon  to  be 
published,  he  has  kindly  sent  me  the  following  partic- 
ulars of  this  interesting  observation :  "  The  patient, 
whose  stomach  was  almost  completely  excised  in  1895, 
has  just  died  after  an  interval  of  two  and  a  half  years 
of  apparent  perfect  health.  The  autopsy  showed  that 
from  the  cardiac  stump  a  new  stomachal  pouch,  with 
a  capacity  of  over  one  pint,  had  been  formed.  It  was 
in  consequence  of  the  new  formation  of  this  post- 
operative stomach  that  the  patient,  who  at  first  was  un- 
able to  take  more  than  very  small  quantities  of  nour- 
ishment, was  finally  able  to  partake  of  ordinary  meals 
in  the  ordinarv  way." 

Animals  have  Survived  Complete  Destruction  of 
the  Stomach. —  It  has  been  known  for  some  time  that 
dogs  are  able  to  survive  the  artificial  obliteration  of 
the  stomach  and  the  loss  of  its  functions.  This  inter- 
esting physiological  obser\-ation  was  made  as  long  ago 
as  1878,  by  Czerny  arid  his  pupils,  Scriba  and  Kaiser.' 
Indeed  the  so-called  "  Czerny  dog"  sur\-ived  the  oper- 

'  Kronlein:  '"Chirur.  Erfahrungen  iiber  d.is  Magencarcinoni." 
Beitrage  zur  klin.  Chirurgie.  vol.  xv. ,  p.  326. 

■  Ewald  read  a  paper  at  the  International  Medical  Congress  at 
Moscow  entitled  "  Erfahrungen  Uber  Magenchirurgie,  vomehni- 
lich  bei  malignen  Geschwulsten "  (Berliner  klin.  Wochenschrift. 
1S97,  No.  37,  p.  71JS).  The  case  of  ablation  there  referred  to 
was  also  incomplete,  about  one  inch  of  the  cardiac  end  not  ha\-ing 
been  e.tcised.  The  patient  died  three  days  after  the  operation  from 
hemorrhage. 

'  F.  Kaiser:  "Beitrage  zu  den  Operationen  am  Majren."  ig 
Czerny's  lieitrage  zur  operat.  Chirurgie,  1S7S. 


9IO 


MEDICAL    RECORD. 


[December  25,   1897 


ation  of  gastric  excision  for  five  years,  and  was  then 
killed  for  purposes  of  anatomical  study.  But  even  in 
the  case  of  this  "celebrated"  animal,  the  post-mortem 
showed  that  a  small  part  of  the  cardiac  end  of  the 
stomach  had  not  been  excised.  And  it  was  further 
seen  that  a  small  sac  had  gradually  been  formed  from 
this  remnant,  and  had  fulfilled  gastric  functions. 

In  1893  Drs.  Pachon  and  Carvallo  published  the 
results  of  their  observations  in  connection  with  a  gas- 
trectomized  dog,  which  was  still  alive  and  gaining 
weight  five  months  after  the  operation.  This  dog  fre- 
quently vomited,  and  the  ejected  matter  showed  the 
presence  of  organic  acids. 

Last  year  Monari'  published  a  further  contribution 
to  this  subject.  The  dog  in  his  case,  however,  lost 
weight  steadily  after  excision  of  the  stomach.  Never- 
theless Dr.  Fiiippi  failed  to  discover  any  noteworthy 
alterations  in  the  physiological  functions  of  this  ani- 
mal, more  particularly  in  regard  to  metabolism.  One 
year  later  a  post-mortem  showed   that  the  lower  ex- 


FlG.  1.— Showing   Preparatory  Steps  for  Operation.      a,  CEsophageal  cut;  ^. 
duodenum  ;  r,  duodenal  slit  ;  li,  stomach  ;  c,  slit  closed  by  suture  ;  /,  jejutjum, 

tremity  of  the  oesophagus,  as  well  as  the  stomachal 
extremity  of  the  duodenum,  had  become  distended, 
although  not  yet  to  any  very  considerable  degree. 


First  Complete  Excision    of    the  Stom.\ch    in    a 
HuM.AN  Being. 

History  of  the  Case  by  Carl  Schlatter,  M.D., 
the  Operator. ^ — The  personal  observation  forming  the 
subject  of  this  paper,  relates  to  a  woman,  fifty-six  years 
old.  In  her  case  I  completely  excised  the  stomach, 
even  Deyond  its  cardiac  extremity,  and  then  restored 
the  continuity  of  the  alimentary  canal  by  stitching  a 
loop  of  small  intestine  into  the  lower  end  of  the 
ctsophagus,  /.(•.,  cESophago-enterostomy. 

History  of  the  Present  Case. — Anna  Landis,  aged 
fifty-six  years,  silk  weaver  by  occupation,  claims  that 
cancer  is  hereditary  in  her  family.  As  a  child  she 
recalls  having  had  frequent  attacks  of  abdominal  pain. 
According  to  her  own  notion  these  attacks  were  due  to 
the  poor  quality  of  the  food  at  the  orphan  asylum 
where  she  was  brought  up.  Later  on  she  often  com- 
plained of  severe  pains  in  the  stomach,  accompanied 
or  followed  by  vomiting.  She  never  saw  bloody  ad- 
mixtures in  the  ejected  matter,  but  large  quantities  of 
bile  often  came  up.  Medical  treatment  had  never  af- 
forded her  any  relief.  Ever  since  the  spring  of  1897 
the  attacks  of  vomiting  were  of  daily  occurrence. 
Progressive  emaciation  also  ensued.  Several  weeks 
before  her  admission  to  the  hospital  a  physician  told 
her  that  she  had  a  tumor  of  liie  stomach. 

I  first  saw'  the  patient  at  the  surgical  polyclinic  on 
August  26,  1897.  An  inspection  of  the  abdomen  re- 
vealed a  marked  bulging  between  the  left  hypochon- 
driac region  and  the  umbilicus.  The  abdominal  pa- 
rietes  were  flabby,  and  palpation  easily  revealed  an  oval 
mass  of  hard  consistency  in  the  region  of  the  stomach. 
The  tumor  was  freely  movable.     Its  size  was  about  that 

'  Beitrajje  zur  klinischen  Chirurgie,  vol.  .\vi.,  iSi)(>,  p.  479. 


of  two  fists.  Very  marked  emaciation  was  found.  The 
patient  was  unable  to  retain  any  kind  of  nourishment. 
She  clamored  for  relief  by  surgical  interference. 

She  was  admitted  to  my  wards  for  further  careful 
obser\'ation.  I  did  not  feel  confident  that  gastrectomy, 
or  even  gastro-enterostomy,  could  be  successfully  per- 
formed, on  account  of  the  large  size  of  the  tumor. 

The  patient  continued  to  reject  almost  everything, 
including  fluids.'  The  iodide  reaction  of  her  saliva 
(after  exhibition  of  iodide  of  potassium)  required 
forty-seven  minutes  for  its  first  appearance.  The 
chemical  examination  of  her  gastric  secretion  showed 
no  trace  of  free  hydrochloric  acid.  An  operation  was, 
therefore,  no  longer  delayed. 

Description    of   the  Operation On  September  6, 

1897,  acting  for  Professor  Kronlein,  I  performed  lapa- 
rotomy under  morphine-ether  anaesthesia  and  with  strict 
antisepsis — incision  in  the  median  line,  extending  from 
the  ensiform  process  to  the  umbilicus.  As  I  had  an- 
ticipated, the  entire  stomach  presented  itself  in  the 
shape  of  a  hard  mass  extending  from  the  cardiac  to 
the  pyloric  extremity.  Strangely  enough,  the  tumor 
was  freely  movable.  It  was  readily  lifted  out  of  the 
peritoneal  cavity.  Three  rather  soft  lymph  nodes 
were  found  at  the  greater  curvature  near  the  pylorus. 
The  stomach  being  diseased  ///  Mo,  a  gastro-enteros 
tomy  was  impossible.  I  at  once  decided  to  attempt  to 
e-xcise  the  entire  organ,  or  take  recourse  in  a  jejunos- 
tomy.  I  first  freed  the  stomach  from  all  its  attach- 
ments at  the  greater  and  lesser  curvature,  having  pre- 
viously shut  off  the  general  cavity  of  the  peritoneum 
by  sterilized  compresses.  The  omentum  was  incised 
between  Pean's  forceps.  Silk  sutures  were  used.  The 
stomach  was  then  forcibly  dragged  downward  so  as  to 
enable  me  to  reach  the  cesophagus.  The  left  lobe  of 
the  liver  had  to  be  constantly  held  upward  by  an  as- 
sistant, in  order  to  permit  me  freely  to  manipulate 
within  the  field  of  operation.  In  this  way  I  finally 
succeeded  in  securing  the  ctsophagus  rather  high  up, 
by  means  of  a  Wolfler  clamp.  A  Stille  forceps  was 
next  fastened  closely  to  the  cardiac  end  of  the  tumor. 
Then  the  stomach  was  severed  directly  beneath  the 
cesophageal  extremity.  As  the  oesophageal  incision  ap- 
peared somewhat  oblique,  I  proceeded  to  place  a  small 
occluding  suture  at  the  gastric  wound.  The  same  steps 
were  now  repeated  at  the  pyloric  end  of  the  stomach. 

I  next  mobilized  the  duodenum,  as  far  as  possible 
toward  the  head  of  the  pancreas.  Then,  having  ap- 
plied a  duodenal  compressor,  and  likewise  a  tumor 
clamp,  I  removed  the  entire  stomach,  between  the  two 
points  of  compression.  I  also  dissected  out  the 
lymphatic  nodes  above  mentioned.  The  patent  lumen 
of  the  duodenum  was  treated  like  the  cesophageal 
opening  with  iodoform  gauze.  The  broad  bridge  join- 
ing together  dift'erent  divisions  of  the  alimentary  canal 
had  now  been  entirely  removed. 

I  next  tried  to  pull  the  duodenal  opening  upward 
toward  the  cvsophageal  cleft.  It  was  only  with  con- 
siderable difficulty  that  the  two  could  be  made  to 
touch.  It  was  manifestly  impossible  to  join  tton  by 
direct  suture.  I,  therefore,  invaginated  the  duodenal 
rim,  and  closed  the  opening  by  a  double  suture.  I 
then  searched  for  a  suitabk  coil  of  small  intestine. 
Beginning  at  the  duodenal-jejunal  fold,  I  followed 
down  the  intestine  for  about  fifteen  inches.  The  pre- 
senting knuckle  of  intestine  I  grasped,  and,  pulling  it 
over  the  transverse  colon,  I  placed  it  against  the 
cesophageal  slit. 

.\  piece  of  this  intestine,  about  five  inches  in  length, 
w-as  secured  between  two  Wolfler  clamps.  By  means 
of  sutures  not  going  deeper  than  the  serous  coat,  the 
intestine  was  then  attached  to  the  cesophageal  stump. 
A  longitudinal  slit  about  one  inch  in  length  was  then 
made  into  the  bowel.  Then  the  mucous  membrane  of 
the  oesophageal  end  was  firmly  united  with  the  intes- 


December  25,  1897] 


MEDICAL    RECORD. 


911 


tinal  mucous  membrane,  by  a  continuous  circular 
suture.  The  material  employed  was  silk.  Above 
this,  a  second  suture,  extending  through  the  muscular 
and  serous  coats,  was  introduced.  A  Lembert  suture 
finally  completed  the  stitching,  which  now  seemed  to 
hold. 

The  oesophageal  and  duodenal  clamps  were  then 
removed,  the  former  having  remained  in  position  for 
over  two  hours.  On  dropping  back  the  organs  into 
the  abdominal  cavity,  the  sutured  portions  showed 
marked  retraction  upward,  toward  the  oesophageal  part 
of  the  diaphragm.  The  abdominal  wound  was  closed 
in  the  ordinar)' way  by  silk  ligatures.  Less  than  eight 
ounces  of  ether  had  been  employed  during  the  narco- 
sis, which  had  fortunately  been  a  ver}-  quiet  one. 

Pulse  after  the  operation,  96  a  minute,  steady,  and 
of  fair  volume. 

There  had  been  only  a  verj'  slight  loss  of  blood 
during  the  course  of  the  operation,  which,  however, 
had  lasted  nearly  two  hours  and  a  half. 

Clinical  Observations  Following  Removal  of  the 
Stomach. — Shortly  after  the  operation  the  patient  re- 
ceived an  enema  containing  brandy  and  two  eggs. 
Temperature  in  the  evening,  36.4°  C. 

September  7th. — Two  nutrient  enemas  containing 
milk,  eggs,  and  brandy.  Pulse  rate  has  risen  to  142, 
but  in  volume  remains  moderately  good.  Patient  has 
taken  per  os,  in  the  course  of  the  afternoon,  a  small 
quantity  of  tea  and  milk,  which  is  apparently  well 
bornev  No  signs  of  peritonitis.  Evening  tempera- 
ture. 37-3''  C. 

September  8th. — Nutrient  enemas  no  longer  re- 
tained. Claret  wine  in  teaspoonful  doses  given,  until 
half  a  glass  has  been  taken.  Patient  complains  of 
sudden  abdominal  pains,  which,  however,  quickly  sub- 
side. Evening  temperature,  38.  i'  C:  pulse,  160,  but 
of  moderately  good  volume. 

September  9th. — Subjective  symptoms  considerably 
improved.  At  intervals  of  two  hours,  very  small 
quantities  of  milk,  eggs,  bouillon,  and  wine  are  given. 

Small  quantities  of  pepsin  and  muriatic  acid  have 
been  tentatively  added  to  the  food.  Pulse  better,  146 
per  minute.      Highest  temperature,  38.1°  C. 

September  13th. — Dressing  removed.  The  abdom- 
inal wound  found  united  by  primary  intention  with- 
out a  trace  of  local  reaction.  Stitches  removed.  Pa- 
tient allowed  a  little  scraped  meat  for  the  first  time. 
The  first  movement  of  the  bowels  since  the  operation 
took  place  September  loth.  Since  then  the  patient 
has  had  from  two  to  three  fluid  stools  daily. 

Occasionally  there  is  some  regurgitation  of  ingested 
milk,  but  actual  vomiting  has  not  occurred. 

September  i6th. — Patient  feeling  remarkably  well: 
temperature  normal ;   pulse,  100:  slight  diarrhoea. 

From  now  on  the  patient  was  able  to  take  fairly 
large  quantities  of  food.  Mornings  at  7,  a  cup  of  milk 
with  one  egg;  9:30,  cup  of  milk  with  one  egg.  Din- 
ner, very  soft  scraped  meat,  or  a  cup  of  thin  gruel 
with  an  egg;  4  p.m.,  cup  of  milk  with  egg;  7  :3o  p.nt., 
a  cup  of  milk  or  gruel.  In  addition  to  these  regular 
feedings,  she  also  takes  tea  and  Malaga  wine,  amount- 
ing in  the  course  of  the  day  to  from  five  to  seven 
ounces. 

On  September  i6th,  for  the  first  lime  since  the 
operation,  vomiting  occurred.  It  was  preceded  by 
nausea,  apparently  superinduced  by  the  patient  having 
witnessed  a  change  of  dressing  in  a  neighboring  sur- 
gical case.  There  was  a  good  deal  of  retching,  and 
about  seven  ounces  of  bilious  and  slightly  acrid  fluid 
were  ejected. 

September  26th. — Patient  is  allowed  to  have  half  a 
chicken,  the  last  remnants  of  which  she  swallowed  at 
4:30.  At  6:30,  customary  milk  and  egg.  At  7:30, 
attack  of  vomiting  with  considerable  retching  and 
marked  contractions  of  the  abdominal  mu.scles.     The 


ejected  matter  amounted  to  about  ten  ounces,  and 
consisted  largely  of  milk  and  meat  fibres.  For  some 
time  before  this  attack  patient  had  complained  of  a 
decidedly  bitter  taste  in  her  mouth. 

October  2d. — .\nother  attack  of  vomiting.  The 
ejected  fluid  measured  over  six  ounces.  It  was  yel- 
lowish in  color  and  not  offensive.  This  attack  came 
on  one  hour  after  eating.  E.xamination  showed  that 
undigested  egg  and  milk  had  been  thrown  up. 

October  4th. — An  attack  similar  to  the  one  just 
noted  was  observed. 

October  8th. — Another  attack  of  vomiting.  The 
slimy  fluid  was  sent  to  the  laboratory  for  chemical  ex- 
amination. The  report  received  stated  that  the  re- 
action of  the  fluid  was  distinctly  acid.  This  was 
owing  to  the  presence  of  lactic  acid,  as  no  free  hydro- 
chloric acid  was  found.  Trypsin  reaction  was  also 
discovered.  Bile  acids  and  bile  pigment  were  like- 
wise present  in  appreciable  quantities.     It  should  be 


Fir,.  2.-PhotOKraph..f  the  1 
December  2,  1897,  nearly  iwo  t 


(Taken 


mentioned,  in  this  connection,  that  the  patient  was 
no  longer  taking  pepsin  and  muriatic  acid. 

October  nth. — Patient  left  her  bed  for  the  first 
time  since  the  day  of  the  operation,  /.<•.,  September  6th. 

November  25th. — Patient  feeling  quite  well  and 
able  to  walk  about  comfortably. 

There  was  a  steadily  progressive  increase  in  the 
weight  of  the  patient  after  removal  of  the  cancerous 
stomach.     This  is  readily  seen  by  the  following: 

Table  Showing  Weight  of  P.vriE.NT  ArrER  Operatio.n.' 


Date  of  Weighing. 

October    5th 

October  nth 

October  i8th 

October  25th 

October  29th 

November  5th 

November  igth 

December  3d 

December  9th 


-Actual  Weight  i 


33,600 
33.750 
35.260 
35.500 
36,000 
36,200 
36.500 
37,500 


150 
1,510 
240 
500 
200 
300 
1,000 


'  The  patient  was  not  actually  weighed  on  the  day  of  the  oper- 
ation, but  the  minimum  increase  from  September  ftrh  to  October 
Jth  has  been  estimated  at  2,'X>'i  gm.  (2  kgm.). 


912 


MEDICAL    RFXORD. 


[December  25,  1897 


Pathological    Report  on  the  Excised  Stomach.— 

The  specimen  consists  of  a  human  stomacli  measuring 
twenty-eight  centimetres  (eleven  inclies)  along  the 
greater  curvature,  and  twenty  centimetres  (eight 
inches)  along  the  lesser.  The  greatest  width  between 
the  curvatures  amounts  to  ten  centimetres  (four 
inches)   (see  Fig.  3).     The  gastric  cavity  is  so  com- 


FlG.  3. — Front  View  of  Excised  Stomach.  The  specimen  has  imdergone 
shrinkage,  owin>r  to  the  action  of  alcohol,  in  which  it  is  preser\'ed.  The 
sHts  visible  at  the  greater  curvature  are  due  to  removal  of  specimens  for 
microscopical  examination.  The  oesophageal  and  pyloric  extremities  show 
where  portions  of  the  organ  were  excised  f'ost  ofierntiatiem  for  anatomical 
study. 

pletely  occupied  by  a  neoplasm  that  it  is  difficult  to 
force  a  finger  in  at  either  e.xtremity. 

From  both  the  cardiac  and  pyloric  ends,  small  por- 
tions were  cut  off  and  sent  to  the  Pathological  Insti- 
tute of  the  university  (see  Fig.  4).  Professor  Ribbert 
made  the  following  report  on  these  specimens:  one 
piece  is  unmistakably  oesophageal  in  histological 
structure.  The  other  specimen  is  just  as  unmistaka- 
bly duodenal.  Microscopical  examination  showed  the 
neoplasm  to  consist  of  a  small-celled  alveolar  glandu- 
lar carcinoma.  According  to  the  microscopical  report 
of  Prbfessor  Ribbert,  already  alluded  to,  there  can  thus 
be  no  question  that  in  my  case  the  gastric  excision 
extended  into  the  territory  of  the  cesophagus.  Never- 
theless, anatomical  considerations  did  not  make  it  clear 
to  me  why,  during  the  course  of  the  operation,  it  had 
S9«nied  so  easy,  comparatively  speaking,  to  gain  access 
to  the  (Esophagus.  Of  course  it  must  be  remembered 
that  I  made  use  of  considerable  traction  downward  bv 
pulling  tm  the  stomach. itself,  and  it  was  in  this  way 
that  the  subdiaphragmatic  portion  of  the  asophagus 
became  markedly  elongated. 

This  practical  demonstration  in  the  living  subject 
received  anatomical  corroboration  from  the  prosector 
at  the  anatomical  institute  of  the  university.  [  was 
informed  that  it  was  always  possible  under  normal 
canditions  to  elongate  by  traction  the  lower  subdia- 
plnagmatic  portion  of  the  cssophagus. 

The  accompanying  lymph  nodes  were  found  to  be 
Mon-cancerous. 

Practical  Anatomical  Observations.- -I  would  like 
in  the  first  place  to  say  a  few  words  in  regard  to  the 
technique  of  the  foregoing  operation.  Langenbuch.' 
in  connection  with  his  recorded  gastrectomies,  has 
published  the  following  statements:  "Of  course  my 
gastrectomies  did  not  amount  to  total  extirpation  of 
the  stomach.  And,  indeed,  total  ablation  appears  to 
be  practically  impossible  toward  the  cardiac  extremitv 
'  Deutsche  medicinische  Woclienschrift,  ji.  ijdg,  1S94. 


of  the  stomach.  For  the  cardiac  portion  has,  like  the 
head  of  the  humerus,  an  anatomical  as  well  as  a  surgi- 
cal neck.  Bearing  in  mind  this  anatomical  peculiarity, 
it  seems  admissible  to  regard  my  operations  as  in- 
stances of  total  exsections  of  the  stomach.  For  in 
both  cases  I  removed  as  much  of  the  organ  as  was 
technically  possible." 

Now  the  boundar}'-line  between  the  oesophagus  and 
cardiac  extremity  of  the  stomach  is  clearly  defined. 
The  former  is  supplied  with  pavement  epithelium;  the 
latter  shows  the  cylindrical  varietj-.  Personal  obser- 
vations and  experiments  on  the  cadaver  fully  confirmed 
this  observation. 

In  the  case  of  my  patient  it  should  also  be  borne  in 
mind  that  as  soon  as  the  WoWer  clamp  was  removed, 
marked  upward  traction  of  the  oesophageal  stump  was 
witnessed.  Possibly  the  weight  of  the  neoplasm  had 
previously  contributed  its  share  toward  dragging  down 
the  oesophagus.  I  cannot,  therefore,  accept  the  quoted 
statements  of  Langenbuch. 

Dietary  Considerations  Following  Removal  of  the 
Stomach. — In  attempting  suitably  to  regulate  the 
nutrition  of  my  patient  after  the  operation,  it  became 
first  of  all  necessary  to  bear  in  mind  what  functions 
had  been  done  away  with  by  complete  ablation  of  the 
stomach.  It  seemed  to  me  (Z/zvc/v  possible  that  the 
patient  should  survive,  on  account  of  the  previous 
practical  elimination  of  all  gastric  functions,  owing  to 
the  large  size  of  the  tumor.  Nevertheless  it  became  an 
object  of  my  solicitude  to  discover  means  for  the  com- 
pensator) substitution  of  something  new  in  place  of 
the  loss  of  the  old.  It  is  true,  modern  physiological 
research  no  longer  vouchsafes  to  the  stomach  its  old 
role  as  chief  organ  of  the  digestive  apparatus.  Nev- 
ertheless, its  importance  in  chemical  as  well  as  in 
physical  respects  should  not  be  underestimated.  It  is 
still  a  question  whether  the  human  organism  can  long 
survive  the  total  elimination  of  all  gastric  activity. 

Physiological  Observations. — It  is  well  known  that, 
considered  merely  as  a  food  reservoir,  the  stomach  ex- 
ercises a  highly  beneficial  influence  over  all  ingesta. 
Food  is  retained  for  a  shorter  or  longer  period  in  the 


iG.  4. — Posterior  View  of  Excised  Stomach.  The  photograph  shows  dislincllv 
wheie  portions  of  the  wall  of  the  organ  were  cut  out  at  either  extremity  for 
microscopical  stvidy.     The  neoplasm  fills  out  the  entire  ca\  itv  of  the  stomach. 


Stomach,  according  to  differences  in  its  nature.  To 
the  bowel  there  is  thus  insured  a  measurable  degree  of 
safety  from  overloading.  As  a  corrector  of  widely 
ditTerent  degrees  of  temperature  of  various  kinds  of 
food,  the  stomach  certainly  fulfils  an  important  office. 
The  well-known  chemical  and  mechanical  activities  of 


December  25,  1897] 


MEDICAL    RECORD. 


9'3 


"^ 


the  htomach,  as  also  the  disinfecting  potency  of  its 
secretions,  need  not  be  specifically  dwelt  upon  to  es- 
tablish the  manifold  importance  of  this  organ.  The 
bactericide  action  of  gastric  juice  in  cholera  and  other 
diseases  need  only  be  mentioned  in  passing.  The 
capacity  for  absorbing  certain  liquids,  while  not  so 
important  as  was  formerly  believed,  should  neverthe- 
less also  be  borne  in  mind.' 

Clinical  Observations  in  Connection  with  the  Ob- 
literation of  all  Gastric  Functions  After  the  Opera- 
tion.— There  being  no  food  receptacle  after  ablation 
of  the  stomach,  it  became  obligator}-  to  feed  my  patient 
at  first  with  minute  quantities  of  food,  given  at  short 
intervals.  The  results  of  this  method  of  procedure 
were  in  all  respects  happy  ones.  Quantities  of  food 
approaching  ten  ounces  seemed  to  excite  vomiting. 
So,  too,  cold  fluids  resulted  in  diarrhoeal  discharges, 
and  may  have  been  partly  responsible  for  the  rise  in 
temperature,  observed  for  some  little  time  after  the 
operation. 

Keeping  in  mind  the  absence  of  mechanical  func- 
tion, the  patient's  dietary  was  at  first  a  strictly  fluid 
one.  But  as  early  as  the  second  week  after  removal 
of  the  stomach,  semi-solid  and  even  solid  food  was 
allowed.  It  was  retained  and  digested  without  dis- 
comfort. The  patient  having  only  a  single  tooth, 
mastication  was  of  course  quite  imperfect,  otherwise  it 
seems  to  me  possible  that  an  ordinary-  mixed  diet 
might  have  succeeded  at  a  still  earlier  date. 

Some  weeks  after  the  operation  the  patient's  ordi- 
nary daily  dietar)-  was  as  follows :  At  regular  intervals 
of  from  two  to  three  hours  she  took  milk,  eggs,  thin 
gruel  or  pap,  tea,  meat,  rolls,  butter,  and  Malaga  wine. 
The  daily  quantity  amounted  to  one  quart  of  milk,  two 
eggs,  two  to  three  ounces  of  pap  or  gruel,  seven  ounces 
of  meat,  seven  ounces  of  oatmeal  or  barley  water  (as 
thick  almost  as  gruel),  one  cup  of  tea,  two  rolls,  and 
half  an  ounce  of  butter. 

Personally  I  felt  most  concerned  about  the  oblitera- 
tion of  all  chemical  activity  on  the  part  of  the  absent 
stomach.  I  soon  perceived  that  adding  pepsin  and 
hydrochloric  acid  to  the  food  was  theoretically  as  in- 
admissible as  it  had  been  found  practically  valueless. 
The  alkaline  fluids  of  the  intestine  at  once  neutralized 
the  acid,  and  rendered  the  pepsin  inert. 

Fortunately  it  soon  became  apparent  that  despite  the 
absence  of  acid  pepsin,  proteids  were  readily  assimi- 
lated in  the  intestinal  tract. 

Does  Gastric  Acidity  Influence  the  Decomposition 
of  Intestinal  Contents? — This  moot  question  received 
contributory  elucidation  by  the  careful  study  of  the 
patient's  discharges  after  the  operation.  The  urine 
and  fsces  were  e.xamined  every  day  at  the  chemical 
laboratory  of  the  university.  Products  of  abnormal 
intestinal  fermentation  or  decomposition  (skatoxyl 
and  indoxyl)  were  either  not  at  all  found,  or  else  dis- 
covered only  in  traces. 

These  observations  tend  to  corroborate  the  views  of 
V.  Noorden,^  while  it  negatives  the  opinion  held  by 
Kast  and  Wasbutzki.  The  most  recent  results  of  lab- 
orator}'  experiments  announced  from  Professor  Bau- 
mann's  institute,  viz.,  that  lT}-drochloric  acid  inhibits 
intestinal  decomposition,  thus  received  no  support 
from  actual  observations  in  the  living  human  subject. 

Does  Removal  of  the  Stomach  Affect  the  Rapid- 
ity of  Intestinal  Propulsion?— Observations  on  this 
point  are  still  being  made,  and  at  the  present  time  I 
am  unable  to  present  any  very  definite  conclusions. 
The  patient  objected  to  swallowing  charcoal.  Huc- 
kleberries were  at  three  different  times  found   in  the 

'  Note  by  the  commenlaior  :  I  have  thought  it  advisable,  in 
order  to  curtail  the  length  of  this  communication,  considerably  to 
abbreviate  this  portion  of  Dr.  Schlatter's  interesting  remarks. — 
E.  C.  \V. 

■'  V.  Xoorden:  "I.ehrbuch  der  PathologiedesStoffwechsels,"  p. 
245,    i!»93. 


passages,  twenty-four  hours  after  having  been  swal- 
lowed. 

The  Urine  After  the  Operation.— Apart  from  a 
dailv  recurring  diminution  in  the  quantity  of  excreted 
chlorides,  the  urine  of  this  woman  has  remained  nor- 
mal since  ablation  of  her  stomach.  The  daily  excre- 
tion of  chloride  of  sodium  has  been  found  to  vary  be- 
tween the  limits  of  0.6  per  cent,  and  0.95  per  cent.  It 
should  be  stated  in  this  connection,  however,  that, 
coi^iplying  with  the  wish  of  the  patient,  her  food  is 
prepared  with  less  salt  than  that  of  the  other  ward 
patients. 

Microscopical    Examination  of    the   Faeces The 

stools  were  well  formed,  of  normal  consistency,  and 
light  yellow  in  color.  The  microscope  showed  large 
numbers  of  fat  globules  and  fatty  cr}Stals,  some  un- 
digested vegetable  fibres,  but  no  undigested  animal 
fibres  or  connective  tissue.  Large  quantities  of  triple 
phosphates  were  observed.  The  number  of  micro- 
organisms was  normal.  .Altogether  repeated  examina- 
tions revealed  no  noteworthy  departure  from  a  condi- 
tion of  perfect  health. 

Vomiting  without  a  Stomach — How  can  a  person 
vomit  without  a  stomach?  Xo  matter  what  theoretical 
physiological  notions  we  may  have  imbibed  from  lec- 
tures and  te.xt-books,  the  woman  under  observation 
had  repeated  attacks  of  ordinar}-  nausea,  retching, 
and  vomiting.  We  must  needs  conclude,  therefore, 
that  the  role  of  the  stomach  (/.<'.,  its  antiperistaltic 
efficacy)  in  this  direction  has  been  very  much  over- 
rated. While  the  vomited  substances  showed  an  acid 
reaction,  this  was  not  due  to  the  presence  of  free  hy- 
drochloric acid. 

In  view  of  the  fact  that  the  patient  ejected  as  much 
as  thirty  ounces  at  one  time,  it  seems  reasonable  to 
suppose  that  the  remaining  portion  of  the  duodenum 
may  have  alreadv  begun  to  show  distention  suflicient 
to  produce  a  sort  of  compensatory  receptacle  for  food 
—  perhaps  nature's  attempt  in  the  direction  of  the  new 
formation  of  a  stomach. 

In  endeavoring  to  explain  vomiting  without  a  stom- 
ach, we  should  remember  that  the  act  itself  is  far  from 
being  a  simple  process.  It  is  due  to  nervous  action 
on  a  complex  motor  apparatus,  consisting  of  pharynx, 
(tsophagus,  stomach,  diaphragm,  and  abdominal  mus- 
cles. 

It  is  not  surprising,  therefore,  to  have  witnessed  in 
this  woman  an  ordinarv  attack  of  bilious  vomiting, 
superinduced  bv  a  mere  psvchical  disturbance. 

Conclusions  by  Dr.  E.  C.Wendt. — While  it  would 
be  manifestl}-  unfair  to  indulge  in  sweeping  generali- 
zations on  the  strength  of  this  single  case,  so  boldly 
rescued  and  ably  described  by  Dr.  Schlatter,  it  seems 
at  least  justifiable  to  formulate  the  following  conclu- 
sions: 

1.  The  human  stomach  "is  not  a  vital  organ. 

2.  The  digestive  capacity  of  the  human  stomach  has 
been  considerably  overrated. 

3.  The  fluids  and  solids  constituting  an  ordinary 
mixed  diet  are  capable  of  complete  digestion  and  as- 
similation without  the  aid  of  the  human  stomach. 

4.  A  gain  in  the  weight  of  the  body  may  take  place 
in  spite  of  the  total  absence  of  gastric  activity. 

5.  Typical  vomiting  may  occur  without  a  stomach. 

6.  The  general  health  of  a  person  need  not  imme- 
diately deteriorate  on  account  of  removal  of  the 
stomach. 

7.  The  most  important  office  of  the  human  stomach 
is  to  act  as  a  reservoir  for  the  reception,  preliminary 
preparation,  and  propulsion  of  food  and  fluids.  It 
also  fulfils  a  useful  purpose  in  regulating  the  temper- 
ature of  swallowed  solids  and  liquids. 

8.  The  chemical  functions  of  the  human  stomach 
may  be  completely  and  satisfactorily  performed  by  the 
other  divisions  of  the  alimentan'  canal. 


914 


MEDICAL    RECORD. 


[December  25,  if 


9.  Gastric  juice  is  hostile  to  the  development  of 
man)-  micro-organisms. 

10.  The  free  acid  of  normal  gastric  secretions  has 
no  power  to  arrest  putrefactive  changes  in  the  intes- 
tinal tract.  Its  antiseptic  and  bactericide  potency  has 
been  overestimated. 


COMMON    SENSE   IN    THE    TREATMENT    OF 
DIGESTIVE    DISORDERS." 

Bv    DAVID    INGLIS.    M.D., 


ETROIT      COLLEGE 


The  writer  feels  that  an  apology  is  due  for  the  initial 
claim  implied  in  the  title— that  of  assuming  to  have 
common  sense.  So  uncommon  does  common  sense 
appear  to  be,  that  to  claim  it  seems  presumptuous. 

Let  me  then  interpret  my  meaning  by  saying  that 
the  effort  of  this  article  is  simply  to  recall,  for  our 
fresh  contemplation,  certain  physiological  laws,  famil- 
iar to  us  all — the  object  of  this  being  to  prevent  us 
from  being  led  away  by  certain  enthusiasms. 

There  have  arisen  in  these  times  certain  enthusiasts 
in  the  mechanical  treatment  of  gastric  and  intestinal 
disorders.  These  form  one  detachment  only  of  the 
great  army  of  medical  mechanics.  From  the  top  of 
the  head  to  the  sole  of  the  foot,  no  organ  is  safe  from 
the  man  who  proposes  to  effect  dynamic  changes  by 
mechanical  means.  Let  us  grant  that  there  are  many 
things  which  can  be  accomplished  by  mechanical 
means,  but  let  us  keep  in  mind  the  fact  that  the  con- 
stant play  of  function  in  every  organ  of  the  body  is  the 
result  of  dynamic  activities  which  are  wholly  out  of 
reach  of  mechanical  assistance. 

Keeping  this  in  mind,  what  judgment  shall  we  form 
of  the  present  attempt  to  explain  dyspeptic  disorders 
by  a  mechanical  theory,  that  of  dilatation  of  the  stom- 
ach, and  their  treatment  by  mechanical  means,  the  stom- 
ach tube  ?  As  a  basis,  let  us  take  some  statements  from 
a  recent  author,  Bouchard,  whose  book,  "  Auto-Intoxi- 
cation," has  had  a  considerable  circulation.  Bouchard 
first  states  that  "dyspepsia  is  accompanied  by  dilata- 
tion of  the  stomach  in  seven-eighths  of  the  cases"  (p. 
161).  Again  he  says:  "In  a  ward  in  a  hospital,  out 
of  ten  patients  taken  at  random,  you  will  find  three 
with  dilatation."  Once  more:  "Dilatation  of  the 
stomach  may  e.xist  without  inducing  anomalous  sensa- 
tions, without  dyspeptic  or  gastralgic  symptoms,  in 
two-thirds  of  the  cases.  It  is  a  disease  which  does 
not  announce  itself ;  we  know  that  it  passes  unper- 
ceived." 

Put  into  concentrated  form,  these  statements  mean 
that  of  all  dyspeptic  patients  seven-eighths  have  dila- 
tation of  the  stomach,  but  that  this  very  consider- 
able number  by  no  means  represents  the  total;  on  the 
contrary,  for  every  dilated  stomach  which  causes  dys- 
pepsia, there  are  two  others  which  do  not.  And 
finally,  about  one-third  of  our  hospital  patients  of  all 
sorts  have  dilated  stomachs. 

Here  is  a  great  field  for  mechanical  therapeutics, 
but  we  have  by  no  means  exhausted  its  importance,  for 
Bouchard  goes  on  to  enumerate  the  symptoms  of  dilated 
stomach,  a  disease  which,  he  naively  says,  "does  not 
announce  itself" — "  it  passes  unperceived."  The 
symptoms  of  dilatation  of  the  stomach  are  as  follows, 
according  to  this  writer:  Pulmonary  phthisis,  chloro- 
sis, eructations,  sensation  of  heaviness  at  epigastrium, 
sensation  of  heat  at  epigastrium,  pyrosis,  regurgita- 
tions, catairh  of  stomach,  ulcerative  gastritis,  false 
cancers,  inflammation  of  large  intestine,  membranous 
enteritis,  hepatic  congestion,  jaundice,  ectopia  of  right 
'  Read  before  the  Detroit  Medical  and  Library  .Vssociation. 


kidney  (fourteen  times  out  of  one  hundred),  feeling  of 
morning  depression,  painful  circle  around  the  head, 
headache,  uneasy  disposition,  sensibility  to  cold,  in- 
somnia, vertigo,  obscuration  of  sight,  haemiopia,  diplo- 
pia, weakness  of  the  right  internal  muscle  of  the  eye, 
hallucinations  of  sight,  dropsy  of  the  limbs,  contrac- 
ture of  the  extremities  of  the  hands,  transitory  aphasia, 
fatal  syncope,  sensation  as  if  two  or  three  fingers  were 
dead,  palpitation,  flushing  of  the  face  two  or  three 
hours  after  meals,  false  angina  pectoris,  nocturnal  per- 
spirations, bilateral  intercostal  neuralgia,  ezcema 
(thirteen  per  one  hundred),  pityriasis  versicolor,  urti- 
caria, acne  in  young  girls,  catch  cold  easily,  cough 
habitually,  bronchial  mucous  secretion,  recurrent 
bronchitis,  dyspnceic  respiration,  recurring  coryza, 
morning  sneezing,  albuminuria  (seventeen  per  one 
hundred),  peptonuria,  loss  of  physical  energ)-,  loss  of 
moral  energy,  emaciation,  lax  obesity  with  pallor, 
abundant  deposits  of  urates,  increase  in  acidity  of 
urine,  phlebitis,  purpura  (two  or  three  per  one  hun- 
dred), joint  nodes  (twenty-five  times  in  one  hundred 
cases),  rachitis,  osteomalacia,  coma. 

It  seems  odd,  to  say  the  least,  that  a  disease  pos- 
sessed of  such  remarkable  disruptive  powers  should, 
in  two- thirds  of  the  cases,  fail  to  announce  itself. 
But  nothing  staggers  our  enthusiast,  for  he  goes  on  to 
say :  "  I  have  asked  myself  the  query,  whether  people 
who  in  appearance  are  not  ill,  but  still  have  the 
physical  signs  of  dilatation  of  the  stomach,  are  truly 
healthy?" 

Gentlemen,  you  may  say  that  this  is  ridiculous. 
No ;  it  is  serious,  for  Bouchard  represents  the  extreme 
of  a  class  of  enthusiasts  who  are  looking  for  dilated 
stomachs  and  finding  them,  and  who  when  they  find 
them  honestly  believe  that  the  first  thing  to  do  is  to 
cure  that  dilatation.  To  this  end  there  are  multitudes 
of  people  who  are  having  their  stomachs  washed  out 
day  after  day  for  weeks  and  months;  they  are  being 
electrified  and  massaged;  they  are  being  fed  as  if  the 
digestion  in  the  stomach  went  on  as  it  would  in  a  crock 
on  a  warm  shelf. 

It  is  worth  while  to  look  at  dilatation  of  the  stomach 
from  another  point  of  view,  and  here  I  quote  our 
enthusiast  for  the  last  time.  He  says :  "  While  very 
frequent  in  the  sick,  it  is"  relatively  uncommon  in  the 
healthy." 

Unconsciously  he  gives  the  key  to  the  whole  matter. 
The  stomach  is  subject  to  all  sorts  of  variations  in 
size  in  perfectly  healthy  people.  Its  muscular  walls 
may  at  onetime  keep  well  contracted  when  it  is  empty, 
or  at  another  time  they  may  relax.  We  may  form  an 
excellent  idea  of  the  varying  conditions  at  different 
times  in  the  same  individual,  by  recalling  the  con- 
tracted or  relaxed  scrotum.  The  scrotum,  which  is 
habitually  exceedingly  lax,  still  retains  the  power  of 
firm  contraction ;  as  a  rule,  so  does  the  stomach. 

Dilatation  of  the  stomach  can  be  easily  produced. 
Leaving  altogether  to  one  side  these  cases  in  which 
pyloric  obstruction,  however  produced,  is  the  efficient 
cause,  let  us  note  that  the  gases  liberated  by  fermen- 
tation of  undigested  foods  cause  but  a  slight  pressure; 
they  form  much  as  the  bubbles  in  yeast,  yet,  gentle  as 
is  the  internal  pressure,  the  walls  of  the  stomach  easily 
yield.  It  is  only  when  a  sufficient  nervous  impulse 
starts  a  contraction  that  we  so  much  as  become  con- 
scious that  the  stomach  is  full  of  gas. 

The  dilatation  of  the  stomach  is  mainly  a  matter  of 
lack  of  nervous  stimulus  to  set  up  peristalsis.  Now 
we  see  why,  "  while  very  frequent  in  the  sick,  it  is  rel- 
atively uncommon  in  the  healthy."  The  sick,  in  the 
usual  course  of  things,  have  a  lowered  nervous  tone: 
they  have  dilated  stomachs  for  precisely  the  same 
reason  that  they  are  constipated,  and  the  latter  disorder 
is  probably  quite  as  dangerous  as  the  former. 

We  can.  indeed,  set  up  an  arbitrary  standard  for  the 


December  25,  1897] 


MEDICAL    RECORD. 


915 


size  of  a  normal  stomach,  but  in  realit}-  there  is  no 
such  standard.  It  is  the  old  storj'  of  the  displaced 
uterus — either  there  is  no  fixed  normal  for  the  uterus, 
or  a  verj-  large  percentage  of  women  demonstrate  the 
fact  that  an  abnormal  position  of  the  uterus  is  a  matter 
of  absolutely  no  importance.  So  with  the  stomach : 
if  we  set  up  an  arbitrarj-  standard,  then  it  is  again 
true  that  deviations  from  that  standard  constantly 
occur  without  harm  to  the  individual. 

A  diagnosis  then  of  dilatation  of  the  stomach  is 
arbitrary,  and  when  made  does  not,  taken  alone, 
demand  any  treatment  at  all.  Because  a  man  has  a 
dilated  stomach  is  not  of  itself  reason  for  using  either 
the  stomach  tube,  electricity,  a  limited  dietary,  or 
drugs.  We  are  not  even  certain  that  he  may  have  a 
dilated  stomach  ne.xt  week.  Something  more  is 
needed — there  must  be  other  indications  for  treatment, 
and  the  other  symptoms  which  accompany  dilatation 
of  the  stomach  are  by  no  means  to  be  looked  upon  as 
the  results  of  the  dilatation.  Bouchard  simply  makes 
himself  ridiculous  when  he  enumerates  the  long  list  of 
sj-mptoms  of  dilatation  of  the  stomach.  The  symp- 
toms he  gives  occurred  in  people  whose  stomachs  hap- 
pened to  e.xceed  his  standard  of  size.  Being  otherwise 
in  poor  health,  they  also  had  dilated  stomachs;  in 
most  of  the  cases  they  were  probably  constipated. 

As  regards  the  use  of  the  stomach  tube,  the  great 
majority  of  dilated  stomachs  need  no  stomach  tube. 
Get  the  sick  well  of  their  other  sicknesses,  and  their 
dilatation  will  disappear.  I  suspect  that  if  those  other 
people  with  dilated  stomachs,  who  obstinately  persist 
in  appearing  to  be  well,  would  cultivate  a  little 
invigorating  training  for  their  general  muscular  appa- 
ratus, they  too  would  get  rid  of  their  dilated  stomachs 
without  a  stomach  tube  or  anything  else.  It  ought 
never  to  be  forgotten  that  the  stomach  tube  is  a  purely 
mechanical  device,  and  that  the  functions  of  the  stom- 
ach, while  partly  mechanical,  are  mainly  the  result  of 
dynamic  changes.  The  stomach  tube  will  wash  off  a 
lot  of  string)'  mucus,  will  clear  out  a  lot  of  fermenting, 
irritating  material ;  the  abnormal  irritation  of  lavage 
will  stimulate  muscular  contraction,  but  the  real  diffi- 
cult}- lies  back  of  all  this.  To  say  nothing  of  the 
annoyance  of  the  procedure,  the  steady  continuance  of 
lavage  sets  up  an  entirely  unphysiological  habit  in 
the  stomach. 

Enthusiasts,  led  on  very  naturally  by  the  exceed- 
ingly brilliant  results  obtained  in  some  cases,  are  in 
danger  of  forgetting  that  the  real  problem  is  to  re- 
establish that  normal  action  of  secreting  cells,  muscu- 
lar fibre,  and  nerves  which  characterizes  a  stomach 
which  knows  no  stomach  tube.  They  are  in  danger  of 
overlooking  other  affections,  as  happened  when  a 
patient  had  his  stomach  washed  out  for  several  months 
and  a  rigid  and  debilitating  diet  kept  up.  while  he 
was  suffering  from  the  gastric  crises  of  locomotor 
ataxia. 

It  is  also  sometimes  forgotten  that  a  patient  can 
drink  a  lot  of  salt  water  or  borated  water  by  the 
ordinary  use  of  his  oesophagus,  and  vomiting  can  be 
induced  without  running  a  tube  into  the  stomach. 

There  is  a  field  for  the  stomach  tube.  Within  its 
limits  the  careful  use  of  the  stomach  tube  is  capable 
of  rendering  services  so  valuable  that  it  can  fairly  be 
claimed  as  one  of  the  greatest  advances  in  practical 
medicine.  In  cases  of  pyloric  obstruction  with  reten- 
tion of  stomach  contents  and  fermentation  changes, 
lavage  is  capable  of  affording  very  great  relief,  even 
when  the  nature  of  the  pyloric  obstruction  makes  cure 
impossible.  The  stomach  tube  has  greatly  aided  in 
the  diagnosis  of  gastric  affections.  Lastly,  in  cases  in 
which,  without  actual  pyloric  obstruction,  the  above- 
mentioned  fermentative  changes  are  going  on  ;  in  cases 
of  chronic  catarrh  of  the  stomach,  however  caused, 
lavage  is  again  a  valuable  aid.     There  may  be  dilata- 


tion of  the  stomach  in  these  cases,  often  is,  but  it  is 
the  abilitj'  of  the  stomach  to  effect  complete  digestion 
and  obtain  the  normal  rest  of  an  emptj-  stomach  which 
decides  the  need  of  lavage — not  the  mere  size  of  its 
walls. 

In  these  cases  the  stomach  tube  does  its  good  by  its 
action  on  the  mucous  membrane  rather  than  upon  the 
muscular  coat.  In  cases  of  complete  atony,  lavage 
and  electricit}-  are  unquestionably  of  much  value. 
Even  in  such  cases  these  measures  ought  to  be  regarded 
as  makeshifts,  until  by  measures  directed  to  the  ner- 
vous system  something  of  the  normal  ner\ous  stimulus 
can  be  re-established. 

Let  us  now  take  up  another  matter,  that  of  "  enter- 
optosis."  We  discover  that  things  drop  down.  There 
was  once  a  wave  of  enthusiasm  over  "falling  of  the 
womb."  Every  g)-na;cologist  of  any  real  note  had  a 
pessary  named  after  him.  I  am  not  certain,  but  I 
think  g}-naecologists  are  rather  shy  of  having  their 
names  printed  on  the  pessarj-  box  nowadays. 

The  stomach  drops  down;  the  colon  does:  the  kid- 
neys slip  out.  Fortunately  or  unfortunately,  pessaries 
cannot  be  invented  for  these:  but  abdominal  support- 
ers can  be  used,  and  massage  and  electricitj-  come  in 
play.  What  are  the  facts?  Inasmuch  as  the  stomach 
is  to  all  intents  and  purposes  merely  a  dilated  piece  of 
intestine  through  which  foods  go  by  peristaltic  move- 
ments, it  really  makes  very  little  difference  whether 
the  pyloric  end  points  west  or  south.  As  for  the 
intestines,  nature  has  planned  for  the  greatest  possible 
mobilit)-.  We  used  to  think  that  the  appendix  had  a 
local  habitation  as  well  as  a  name.  We  now  know- 
that  the  appendix  claims  pretty  much  the  whole  right 
half  of  the  belly,  and  even  strays  across  the  line. 

Suppose  the  colon  does  drop  down.  Why,  if  an 
adult  were  found  with  a  sigmoid  flexure  w-hich  started 
at  the  ribs,  dipped  down  to  the  pubis,  and  wound  back 
to  the  neighborhood  of  the  left  kidney,  that  would  be 
a  frightful  drop:  but  young  infants  get  along  nicely 
with  that  sort  of  sigmoid  flexure. 

L'nless  the  canal  is  obstructed  by  the  displacement 
or  an  actual  obstruction  to  the  normal  blood  supply 
ensues,  the  precise  position  of  stomach  or  bowels  is  of 
little  importance.  The  same  thing  is  mainly  true  of 
displaced  kidney;  occasionally  a  displaced  kidney 
causes  pain  and  at  times  reflex  nervous  troubles,  but 
pretty  generally  a  displaced  kidney  '"does  not  an- 
nounce itself,''  and  the  patient  would  be  all  right  if 
the  doctor  were  not  too  careful  a  diagnostician. 

I  suspect  that  it  is  not  the  displacement  of  the  vis- 
cera which  is  the  important  matter,  but  the  relaxation 
of  the  abdominal  walls,  which  takes  away  the  normal 
support  for  the  diaphragm.  When  the  diaphragm  is 
itself  dragged  upon  in  its  regular  respirator)- effort,  the 
matter  maybe  important,  for  the  whole  respiratory  and 
circulatory  mechanism  is  likely  to  be  disturbed. 

To  afford  support  until  such  time  as  the  abdominal 
walls  can  be  restored  to  normal  vigor,  a  proper  abdom- 
inal bandage  is  important. 

Still  more  valuable  is  the  use  of  electricit)-  and 
massage.  It  is  not  enough  to  support  the  abdominal 
walls:  it  is  necessary  to  bring  back  muscular  tone. 
But  not  less  important  is  it  to  set  up  an  increase  in 
the  nervous  vigor  by  the  use  of  such  drugs  as  strych- 
nine, or  such  measures  as  increase  the  entire  nutritive 
activity. 

Finally,  a  word  in  regard  to  diet.  It  is  undoubtedly 
true  that  the  idea  of  a  test  meal  is  logically  sound,  but 
here  again  there  are  unhappy  limitations.  I  grant 
that  it  is  feasible  to  give  a  test  meal  and  from  the 
examination  of  the  stomach  contents  safely  to  state 
the  relative  abundance  of  lactic  or  hydrochloric  acids, 
but  the  range  of  information  to  be  gathered  in  this 
way  is  very  limited.  There  are  probably  not  to  exceed 
ten  men   in   Michigan  whose   training  would  enable 


9i6 


MEDICAL    RECORD. 


[Deeember  25,  i< 


them  to  make  an  exact  analysis  of  the  stomach  con- 
tents. The  time  and  labor  involved  make  such  an 
analysis  necessarily  very  expensive,  and  it  is  of  course 
entirely  out  of  the  question  to  have  such  an  analysis 
done  for  the  various  dyspeptics.  The  test-meal  anal- 
ysis is  then  simply  a  rough  test  of  limited  extent. 
Even  in  the  matter  of  stomach  acidity  the  result  of  the 
test  is  not  always  of  certain  application.  There  are 
certain  individuals  who  go  through  life  with  habitual 
hyperacidity,  and  who  are  adjusted  to  degrees  of 
hyperacidity  which  would  be  very  damaging  to  the 
average  person. 

Before  leaving  this  subject  of  examination  of  the 
stomach  contents,  I  wish,  in  parenthesis,  to  call  your 
attention  to  a  matter  of  grave  moment.  I  refer  to  the 
examination  of  the  stomach  contents  by  the  coroner  or 
county  physician.  There  occur  many  cases  in  which 
the  coroner  makes  a  post-mortem  and  has  the  stomach 
contents  analyzed.  In  some  instances  very  grave 
questions  of  a  criminal  nature  depend  upon  the  result 
of  this  analysis.  It  is  worth  careful  consideration  to 
decide  whether  the  average  coroner  or  county  physi- 
cian has  the  very  great  chemical  skill  required  to 
make  such  an  analysis  as  ought  to  be  made.  Failure 
to  detect  poisons  would  let  a  murderer  easily  go  free. 
How  many  county  physicians  could  so  securely  de- 
monstrate the  presence  of  a  fatal  dose  of  poison  as  to 
warrant  the  condemnation  of  a  murderer?  How  many 
analyses  of  the  stomach  contents  are  paid  for  by  the 
State  or  counties .'' 

To  recur  to  the  matter  of  diet.  The  test  meal  hav- 
ing a  limited  range,  we  need  to  be  careful  lest  we 
regulate  the  patient's  diet  too  much  by  theory,  too 
little  by  practical  results.  The  dietetic  treatment  of 
diabetes  is  very  important,  truly,  yet  I  am  thoroughly 
satisfied  that  not  a  few  diabetics  are  brought  to  an 
early  death  by  a  too  sudden  change  and  too  rigid  ad- 
herence to  a  diet  whose  principle  is  correct  enough  in 
theory. 

So  with  dyspeptics :  we  need  to  remember  that  it  is 
the  patient  we  are  treating,  not  his  disease.  The 
advance  in  the  study  of  digestive  disorders  does  not 
absolve  us  from  remembering  and  practising  what  we 
have  learned  in  other  ways  and  in  older  times. 

21  State  Stkekt. 


Colono-Enteric  Irrigation  in  the  Treatment  of 
Intestinal  Obstruction.  — Dr.  Fynchon  {Chicago  AJid- 
ical  Jiecordcr,  December,  1896)  urges  that  in  all  cases  of 
intestinal  obstruction  distensive  enemata  of  from  ten 
to  twenty  or  more  pints  of  water  be  employed.  His 
clinical  observation,  together  with  a  study  of  liter- 
ature pertaining  to  the  conditions  of  acute  bowel  ob- 
struction, lead  to  these  conclusions :  Copious  enemata 
promptly  and  persistently  employed  are  indicated  in 
the  early  stages  of  acute  intestinal  obstruction.  The 
patient  must  be  anaesthetized  and  suspended  in  a  posi- 
tion of  inversion.  The  water  should  be  as  hot  as  can 
be  safely  used,  and  there  should  be  available  no  less 
than  three  gallons.  A  rectal  tip  must  be  used  which 
will  positively  control  the  escape  of  water  from  the 
rectum,  and  no  long  colonic  tube  is  required.  No 
air  must  be  allowed  to  enter  the  gut  and  the  water 
pressure  must  be  constant  and  not  intermittent;  the 
earlier  method  of  alternately  filling  the  gut  as  far  as 
possible  and  then  allowing  it  to  empty  itself  is  not 
approved.  While  the  pressure  must  not  be  allowed 
to  weaken,  the  onward  flow  of  water  can  be  made  to 
iilternate  with  forcible  abdominal  massage.  The  fall 
of  water  may  be  varied  from  fifteen  to  thirt)'  feet, 
according  to  the  age  of  tiie  patient  and  the  stage  of 
the  trouble,  providing  a  lesser  fall,  of,  say,  six  feet, 
in  alternation  with  massage  is  not  successful. 


SOME    QUESTIONS    OFTEN    .\SKED    ABOUT 
DRINKING-WATER,  AND  THEIR  ANSWERS. 

By   B.    C.    LOVELAND,    .M.D.. 

In  the  routine  of  a  doctor's  life  a  great  portion  of  his 
time  is  taken  up  in  answering  questions,  and  sometimes 
it  requires  much  patience  and  the  exercise  of  the  great- 
est tact  and  ingenuity  to  give  answers  which  will  either 
satisfy  the  patient's  curiosity  or  convince  him  of  the 
wisdom  of  the  order  that  may  be  the  subject  of  his  in- 
quiries. In  the  present  day,  when  the  practice  of  med- 
icine has  become  so  far  removed  from  the  old-time 
practice  of  "physic"  and  the  physician  has  to  depend 
on  his  knowledge  of  physiological  law,  and  the  thor- 
oughness with  which  he  enforces  obedience  to  physio- 
logical law  among  his  patients  marks  his  degree  of 
success,  the  questions  elicited  by  the  regulations 
he  may  impose  may  be  of  great  importance,  for  the 
patient  to-day  is  a  rare  one  who  will  go  ahead  and 
unquestioningly  obey  the  advice  of  the  physician,  and 
who  will  not,  like  the  proverbial  boy,  always  have  his 
mouth  set  for  "Why.'"  In  trying  to  induce  my  pa- 
tients to  drink  the  amount  of  water,  nine  or  ten  glasses 
a  day,  regarded  as  a  physiological  necessity  by  the 
medical  profession,  I  have  been  met  with  a  host  of 
questions,  mostly  raised  as  objections,  some  samples 
of  which,  with  their  answers,  will  comprise  this  paper, 
and  my  hope  is  that  they  will  help  some  one  who  is 
trying  to  secure  obedience  to  this  part  of  nature's 
requirement. 

"Will  not  water  make  me  fat.'''  It  is  a  well-known 
fact  that  most  people  dread  becoming  unduly  fat,  and 
this  question  is  a  very  common  one.  The  answer  is 
yes  and  no.  Water  will  make  you  fat  if  it  increases 
your  ability  to  assimilate  food,  if  by  drinking  more 
water  you  are  enabled  to  take  into  the  system  more  of 
the  food  that  you  eat.  In  no  other  way  will  it  make 
you  fat.  There  is  evidently  no  fat  in  water.  It  will 
not  make  you  fat  if  your  digestion  is  perfect  already, 
and  you  do  not  eat  a  great  abundance  of  such  foods 
as  produce  fat.  In  fact  I  have  often  seen  people  re- 
duce fat,  who  needed  to  do  so,  by  drinking  a  large 
quantity  of  water  and  using  a  properly  regulated  diet. 

"Will  not  so  much  water  strain  my  kidneys?"'  is  an- 
other question  which  is  asked  almost  as  frequently  as 
the  preceding  one.  The  answer  is  simple.  Water 
does  not  strain  the  kidneys  any  more  than  more  help 
in  building  a  house  strains  the  workmen.  The  excre- 
tion of  the  kidneys  is  twofold — water  and  certain  other 
materials  which  are  the  result  of  the  wear  on  the  tis- 
sues. This  water  is  the  vehicle  in  which  are  carried 
in  solution  all  the  ingredients  of  waste  tissue  which 
the  system  is  trying  to  get  rid  of.  The  flow  of  water 
through  the  kidneys  to  the  bladder  simply  furnishes  a 
current  in  which  to  carry  off  the  dissolved  detritus; 
therefore  the  drinking  of  a  physiological  amount  of 
water  cannot  strain  the  kidneys. 

"  If  water  will  thin  my  blood  when  it  is  too  thick, 
will  it  not  make  it  too  thin  if  I  continue  to  drink  so 
much?"  This  question  is  often  asked  by  patients  of 
plethoric  habit  and  lithamic  tendencies  whom  I  am 
trying  to  impress  with  the  necessity  of  getting  the  sys- 
tem thoroughlv  washed  out,  and  the  question  seems  a 
logical  one.  The  answer,  however,  makes  it  plain. 
The  blood  craves  a  certain  percentage  of  water;  that 
certain  percentage  it  will  take  up  and  hold,  providing 
a  continual  supply  is  being  addeti,  but  with  the  blood 
pressure  and  circulation  automatically  regulated  by 
the  mechanism  which  is  called  the  sympathetic  ner- 
vous system,  and  with  the  ready  outlet  afforded  by  the 
kidneys,  all  water  taken  in  above  the  amount  required 
to  keep  the  blood  at  its  normal  proportion  of  Huid  and 
solid  is  passed  on,  through,  and  out,  and  does  its  duty 
simplv  by  washing  the  sv.stem  of  its  impurities.      It  is 


December  25,  1897] 


MEDICAL    RFXORD. 


917 


often  the  case  that  water  given  in  free  quantity  to  a 
patient  suffering  from  anaemia  so  assists  the  digestion 
that  it  will  help  thicken  the  blood,  while  in  a  person 
of  plethoric  habit  the  action  is  quite  the  reverse. 

"  Will  drinking  a  large  amount  of  water  continuously 
produce  catarrh  of  the  bowels  or  bladder?"  This 
question  has  been  seriously  asked  by  patients,  from 
the  fact  that  a  person  unaccustomed  to  drinking  the 
physiological  amount  of  water  finds  the  first  effect  of 
drinking  such  an  amount  to  be  the  necessity  of  a  fre- 
quent evacuation  of  the  bladder,  and  not  infrequently 
it  may  also  cause  looseness  of  the  bowels.  But  we 
find  by  experience  as  well  as  by  logic  that  the  use  of 
such  an  amount  of  water  as  is  a  physiological  neces- 
sity does  not  produce  catarrh  of  the  bladder,  but  rather 
helps  such  troubles  by  so  diluting  the  urine  as  to  ren- 
der it  less  irritating,  thus  giving  nature  a  chance  to 
cure  the  trouble.  And  not  infrequently  catarrh  of  the 
bowels  may  be  due  to  an  insufficient  elimination  by 
the  kidneys,  in  which  case  the  bowels  attempt  to  take 
up  work  left  undone  by  the  kidneys,  and  the  expression 
of  this  effort  is  indicated  by  the  catarrh,  which  will  be 
relieved  by  drinking  a  sufficiently  large  quantity  of 
water. 

•'  Will  not  drinking  water  make  me  perspire  un- 
duly?" Drinking  water  up  to  the  physiological 
amount  in  the  case  of  a  person  who  has  not  perspired 
for  years,  owing  to  a  lack  of  sufficient  water,  may 
temporarily  produce  excessive  perspiration,  such  per- 
spiration lasting  only,  like  the  flushing  of  the  kidneys, 
until  the  system  has  been  relieved  of  the  poisons  that 
can  be  excreted  in  that  way.  In  other  words,  free 
action  of  the  kidneys  and  skin,  following  the  use  of  a 
normal  amount  of  water  when  the  patient  has  been  for 
a  long  time  deprived  of  that  amount,  is  only  nature's 
expression  of  joy  at  having  once  received  her  deserts. 

"Will  not  cold  water  chill  my  stomach  and  thereby 
cause  harm?''  The  reply  to  this  question  is,  unduh- 
cold  water  might;  ice  water,  for  instance;  but  water  at 
a  temperature  making  it  pleasant  to  drink,  say  from  45' 
to  60^  F.,  will  not  chill  the  stomach.  An  illustration 
from  nature  is  shown  in  the  fact  that  nearly  all  our 
springs  are  cold,  very  few  hot.  Most  of  the  water  we 
drink  should  be  cold;  hot  water  should  be  used  for 
other  purposes  than  to  supply  the  system  with  the 
necessary  fluid. 

But  my  patient  says ;  "  Water  drinking  gives  me  gas 
on  the  stomach,  and  if  it  does  so  I  should  not  drink 
it,  should  I?"  Why  not?  There  is  no  gas  in  water. 
If  gas  appears  in  the  stomach,  or  is  noticed  in  the 
stomach  after  drinking  water,  it  simply  shows  that  gas 
was  there  before,  and  the  water,  displacing  the  gas, 
causes  more  or  less  eructation,  and  is  frequently  one 
of  the  best  methods  to  relieve  the  stomach  of  gas. 

"  Doctor,  if  water  turns  sour  on  my  stomach,  I  sup- 
pose it  is  a  sign  that  water  disagrees  with  me,  isn't 
it?"  Water  does  not  turn  sour  in  any  one's  stomach. 
It  may  bring  to  the  knowledge  of  the  patient  the  fact 
that  an  acid  condition  exists  in  the  stomach,  in  the 
same  way  that  it  brings  to  him  the  knowledge  of  the 
presence  of  gas  in  the  stomach,  but  it  will  not  produce 
aciditv  any  more  than  it  will  produce  gas,  and  if  acid 
is  in  the  stomach  it  was  there  before,  and  in.stead  of 
making  it  worse  water  will  manifestly  make  it  better. 
The  more  water  we  put  into  vinegar  the  less  acid  it  is, 
and  the  more  water  we  put  into  the  stomach  the  less 
concentrated  will  be  the  acid,  be  it  fermentation  acid 
or  not.  Consequently  the  answer  to  this  question  is 
that  it  is  not  a  sign  that  water  disagrees  with  a  person, 
but  a  sign  that  something  else  needs  attention,  and  the 
water  is  not  contraindicated. 

"Will  not  water,  drunk  at  meals,  retard  digestion?" 
In  a  majority  of  cases  the  answer  will  be,  No.  It  does 
not  retard  digestion  unless  it  is  drunk  in  undue  quan- 
titv,  and  used  as  a  means  of  washing  the  food  down, 


to  save  the  labor  of  properly  masticating  it  and  mix- 
ing it  with  saliva.  A  moderate  quantity  of  water  in 
most  cases  aids  digestion  by  increasing  the  fluidity  of 
the  contents  of  the  stomach,  and  thereby  favoring  the 
admixture  of  the  gastric  fluid  with  the  food. 

"Shall  I  drink  hot  or  cold  water?"  The  use  of  hot 
water  is  valuable  when  there  is  pain  or  distress  in  the 
stomach,  and  should  be  then  favored.  In  the  case  of 
a  delicate,  sensitive  stomach,  when  the  patient  can- 
not be  induced  to  drink  the  necessary  amount  of  cold 
water  it  is  often  easier  to  get  him  to  take  it  hot,  but 
for  general  purposes  most  of  the  water  drunk  should 
be  used  cold,  or  cool,  for  the  tonic  effect  of  cool  water 
on  the  stomach  is  greater  than  that  of  hot,  just  as  its 
tonic  effect  on  the  skin  is  greater. 

"  I  should  not  drink  water,  should  I,  unless  I  am 
thirsty?"  The  reply  to  this  question  is  that  the  lack 
of  thirst  in  a  grown  person  is  no  indication  of  his  need 
of  water  or  not.  A  child  is  always  thirsty,  and  we 
would  be  thirsty  at  proper  intervals,  so  that  the  appe- 
tite would  be  a  guide,  if  we  did  not  from  preoccupa- 
tion or  some  other  cause  which  makes  us  inattentive 
to  the  impulse  neglect  it,  until  we  find  it  often  absent 
altogether.  When  such  a  condition  exists,  manifestly 
thirst  is  not  to  be  regarded  as  an  indication  of  the 
patient's  need,  for  many  patients  say  they  are  never 
thirst)'. 

Several  of  the  questions  asked  and  answered  in  this 
paper  owe  their  origin  to  theories  that  have  come  down 
from  our  ancestors  in  medicine,  and  perhaps  from  our 
grandmothers,  who  were  not  our  ancestors  in  medi- 
cine. The  absurdity  of  the  old-time  notions  about 
water  may  be  well  illustrated  by  the  following  extract, 
on  the  medical  view  of  the  use  of  water  about  three 
centuries  ago,  taken  from  The  Hospital: 

"  It  needed  a  very  bold  man  to  resist  the  medical 
testimony  of  three  centuries  ago  against  water-drink- 
ing. Few  writers  can  be  found  to  say  a  good  word 
for  it.  One  or  two  onlv  are  concerned  to  maintain 
that  '  when  begun  in  early  life  it  may  be  pretty  freely 
drunk  with  impimity,'  and  they  quote  the  curious  in- 
stance given  by  Sir  Thomas  Elyot  in  his  '  Castle  of 
Health,'  1541,  of  the  Cornishmen:  'Many  of  the 
poorer  sort,  which  never,  or  very  seldom,  drink  any 
other  drink,  be,  notwithstanding,  strong  of  body  and 
like  and  live  well  until  they  be  of  great  age.' 

"Thomas  Cogan,  the  medical  schoolmaster  of  Man- 
chester fame,  confessed  in  his  '  Haven  of  Health,'  1589, 
designed  for  the  use  of  students,  that  he  knew  some 
who  drank  cold  water  at  night  or  fasting  in  the  morn- 
ing without  hurt;  and  Dr.  James  Hart,  writing  about 
fifty  years  later,  could  even  claim  among  his  acquaint- 
ance '  some  honorable  and  worsliipful  ladies  who  drink 
little  other  drink,  and  yet  enjoy  more  perfect  health 
than  most  of  them  that  drink  of  the  strongest.'  The 
phenomenon  was  undeniable,  but  the  natural  inference 
was  none  the  less  to  be  resisted. 

••  Sir  Thomas  Elyot  himself  is  very  certain,  in  spite 
of  the  Cornishmen,  that  '  there  be  in  water  causes  of 
divers  diseases,  as  of  swelling  of  the  spleen  and  liver.' 
He  complains  oddly  also  that  '  it  flitteth  and  swim- 
meth,'  and  concludes  that  '  to  young  men,  and  them 
that  be  of  hot  complexions  it  doeth  less  harm,  and 
sometimes  it  profiteth,  but  to  them  that  are  feeble,  old, 
and  melancholy,  it  is  not  convenient.'  . 

"  '  Water  is  not  wholesome  cool  by  itself  for  an  Eng- 
lishman,' was  the  version  of  .Andrew  Borde — monk, 
physician,  bishop,  ambassador,  and  writer  on  sanita- 
tion— as  the  result  of  a  life's  experience.  And  to 
quote  the  '  Englishman's  Doctor  ': 

"  ■  Are  enemies  to  health  and  good  digestion, 

Both  water  and  small  beer,  we  make  no  question. ' 

"  But  the  most  formal  indictment  against  water  is 
that  of  Venner,  who,  writing  in  1622,  ponderously  pro- 


9i8 


MEDICAL    RECORD. 


[December  25,  1897 


nounces :  '  To  dwellers  in  cold  countries,  it  doth  very 
greatly  deject  their  appetites,  destroy  the  natural  heat, 
and  overthrow  the  strength  of  the  stomach,  and  conse- 
quently, confounding  the  concoction,  is  the  cause  of 
crudities,  fluctuations,  and  windiness  in  the  body.'  " 


into  profound  shock  and  for  hours  her  life  was  de- 
spaired of.  She  rallied  under  the  liberal  use  of  stim- 
ulants and  made  a  good  recovery.  A  slight  rise  in 
temperature  appeared  forty-eight  hours  after  the  opera- 
tion, but  this  disappeared  upon  intra-uterine  injec- 
tions of  antiseptic  solutions. 


CASES     OF    LONG-RETAINED     PLACENTA 
FOLLOWING   ABORTION. 

By    NEWMAN    T.    B.    NOBLES,    M.D., 

CLEVEL.\ND,   OHIO, 


The  following  cases  are  important  as  illustrating  how 
long  the  placenta  may  be  retained  in  uUro,  after  es- 
cape of  the  fcetus,  unless  they  are  removed  by  early 
manual  interference. 

Case  I. — Mrs.  D was  pregnant  for  the  second 

time,  four  months  advanced.  She  concluded  not  to 
have  this  child,  so  after  repeated  efforts  with  drugs  she 
at  last  succeeded  in  puncturing  the  membranes.  After 
several  hours  the  fcetus  was  expelled,  followed  a  few 
hours  later  by  a  substance  which  the  attending  physi- 
cian pronounced  placenta,  but  which,  in  the  light  of 
subsequent  events,  must  have  been  coagulated  blood. 
At  any  rate  the  hemorrhage  continued,  with  the  excep- 
tion of  short  intervals,  for  twenty-two  days,  unabated 
in  spite  of  all  efforts  to  control  it.  Ice  was  employed 
both  externally  aTid  internally,  the  vagina  tamponed; 
ergotin,  iron,  and  quinine  were  given  in  massive  doses, 
whiskey  and  brandy  without  restriction — all  with  no 
effect  so  far  as  the  hemorrhage  was  concerned. 

Finally,  after  the  woman  had  flowed  for  over  three 
weeks,  the  physician  resigned  the  case  or  was  dis- 
charged, and  I  was  sent  for.  I  found  the  patient  in  a 
deplorable  condition,  presenting  all  the  classical 
symptoms  of  alarming  hemorrhage.  Digital  examina- 
tion showed  a  rigid  os  uteri ;  the  womb  was  anteflexed 
and  much  larger  than  normal,  even  after  an  abortion. 
I  naturally  concluded  that  the  placenta  had  not  been 
expelled.  The  friends  and  relatives  insisted  that  both 
they  and  the  former  attendant  had  seen  the  afterbirth 
three  weeks  before,  and  I  must  be  mistaken.  I  was 
determined  to  be  satisfied  as  to  the  true  condition,  and 
so  the  cervix  was  dilated,  and  then  digital  examina- 
tion revealed  a  soft,  fleshy  mass  in  the  uterine  cavity, 
firmly  attached  to  its  internal  parietes.  With  curette 
and  placental  forceps  a  well-organized  placenta  was 
removed.  The  membrane  was  normal  in  appearance 
and  fortunately  non-putrescent.  The  after-treatment 
consisted  of  antiseptic  intra-uterine  injections,  nour- 
ishing diet,  and  the  usual  drugs.  A  good  recovery 
was  the  result,  though  the  convalescence  was  tedious. 

Case    II.  —  Mrs.    K  • ,   aged  twenty-eight,   the 

mother  of  four  children,  suffered  from  abortion  caused 
by  fright  on  March  14,  1896.  The  foetus  escaped 
during  the  night,  and  the  next  day  the  woman  went 
about  the  house  as  though  nothing  had  occurred. 
After  a  few  weeks  an  offensive  sanguineous  and  exco- 
riating discharge  appeared.  Soon  her  health  began 
to  fail  and  she  became  greatly  emaciated.  During 
this  time  a  physician  attended  her.  On  June  29th, 
over  three  months  after  the  abortion,  she  was  suddenly 
taken  with  a  most  profuse  hemorrhage.  It  stopped 
for  forty  hours  and  then  began  afresh.  Finally, 
twenty  days  after  the  flooding  and  one  hundred  and 
twenty-five  days  subsequent  to  the  abortion,  I  was 
called  in.  As  in  the  previous  case,  the  uterus  was  en- 
larged and  anteflexed,  and  the  os  was  so  contracted 
that  it  was  next  to  impossible  to  introduce  a  sound. 
After  it  had  been  dilated  sufficiently  a  large,  soft, 
fleshy  mass  attached  to  the  uterine  walls  was  discov- 
ered. This  when  removed  proved  to  be  a  well-orga- 
nized placenta.     After  the  operation  the  patient  went 


GANGRENE  OF  THE  LEG  FOLLOWING  TY- 
PHOID FEVER;  AMPUTATION  BELOW 
THE  LINE  OF  DEMARCATION;  RECOV- 
ERY. 

By    J.    Q.    ALLEN,    M.D., 

-MONTROSE,    COL. 

On  September  26,  1896,  I  was  called  to  see  a  girl, 
sixteen  years  old,  living  five  miles  in  the  country. 
She  had  been  quite  sick  for  some  days,  and  I  found  a 
well-established  case  of  typhoid  fever.  This  ran  the 
typical  course  of  a  severe  attack  for  four  weeks,  when 
on  October  24th  indications  of  gangrene  appeared  in 
the  left  foot  and  leg.  Just  before  this  there  was  evi- 
dence of  the  fever  having  spent  its  force.  The  circu- 
lation was  not  good  and  the  extremities  were  cold.  I 
ordered  mild  stimulants  and  artificial  heat.  Several 
bottles  were  filled  w  ith  hot  water,  wrapped  in  flannels, 
and  laid  alongside  the  legs.  By  some  means  the  cov- 
ering of  the  bottles  became  displaced  and  the  hot 
glass  came  in  direct  contact  with  the  skin,  producing 
numerous  blisters  on  the  lower  part  of  the  leg.  The 
discoloration  spread  out  from  these  blisters,  but  I  am 
convinced  that  there  was  first  an  occlusion  somewhere 
in  the  course  of  the  main  artery.  In  a  few  days  a 
well-defined  line  of  demarcation  was  formed,  about 
six  inches  below  the  knee. 

Then  came  the  perplexing  question  of  what  was  best 
to  be  done.  With  a  pulse  above  160  and  so  weak  as  to 
be  almost  imperceptible,  temperature  of  105.5°  F-i 
rapid  shallow  breathing,  and  complete  unconscious- 
ness, death  appeared  imminent.  Whether  '"to  become 
executioner"  by  attempting  to  amputate  in  the  ordi- 
nary way,  or  to  allow'  her  to  die  without  an  effort  at 
surgical  interference,  was  the  problem  which  haunted 
me  day  and  night.  Finding  no  relief  from  literature, 
I  decided  to  wait.  Accordingly  I  commenced  to 
poultice  the  dead  limb,  at  the  same  time  pushing  the 
internal  administration  of  sulphate  of  strychnine  to 
the  limit.  The  poultices  were  made  large  enough  to 
cover  every  part  of  the  leg  from  the  toes  to  the  knee, 
and  changed  every  two  hours  day  and  night.  Contrary 
to  my  expectation,  she  began  to  improve. 

On  November  7th  separation  commenced  at  the  line- 
and  advanced  rapidly,  while  healthy  granulations 
soon  appeared  above.  Without  a  precedent  (that  I 
know  of)  I  decided  to  amputate  below  the  line  of  de- 
marcation. 

Dissecting  down  carefully  between  the  dead  and 
living  flesh,  I  reached  the  bones.  The  patient  was 
still  unconscious,  and  by  the  use  of  a  small  dose  of 
chloral  I  was  enabled  to  saw  the  bones,  without  her 
knowledge;  nor  did  she  know  the  leg  was  oft"  for 
some  weeks  afterward.  Thus  nature  and  I  performed 
an  amputation  without  shock  and  without  the  loss  of  a 
drop  of  blood. 

Tliere  was  nothing  very  reassuring  about  her  condi- 
tion before  the  middle  of  December,  after  which  time 
she  improved  rapidly.  On  May  24th,  she  having 
sufficiently  recovered  to  allow  the  safe  administra- 
tion of  chloroform,  I  split  up  the  stump,  turned  back 
the  flaps,  and  sawed  off  the  protruding  bones,  without 
losing  more  than  a  tablespoonful  of  blood  in  the  oper- 
ation. The  wound  healed  by  first  intention,  and  she 
is  now,  June  2 2d,  able  to  ride  about  in  a  buggy. 

I   am  fully  convinced   that  had   I   attempted  to  give 


December  25,  1897] 


MEDICAL    RECORD. 


919 


an  anaesthetic  and  amputate  in  the  ordinary  way,  she 
would  have  died  during  the  operation ;  and  I  am 
equally  convinced  that  if  more  of  these  extremely  weak 
patients  were  treated  in  this  way  a  larger  percentage 
of  them  would  recover. 


(I'Unical  Bcpavtincut. 

ANTITOXIN    ADMINISTERED    PER    OS. 
By  J.    LINDSAY  PORTEOUS,    M.D.,  F.R.C.S.  Ed., 

VONKERS,   N.   V. 

M.\NV  of  the  readers  of  the  Medical  Record  must 
have  noticed  the  great  dread  some  children  have  of 
the  hypodermic  syringe,  especially  the  larger-sized 
syringe  used  in  the  administration  of  antitoxin,  and 
the  pain  caused  by  injecting  the  comparatively  large 
quantity  necessary  often  makes  the  child  scream  and 
twist  about  (especially  when  competent  assistance  is 
not  present),  to  the  actual  danger  of  seriously  injuring 
the  patient.  In  a  case  of  severe  diphtheria  in  a  girl 
of  eight  years  (mentioned  below)  the  sight  of  my  syr- 
inge almost  caused  a  convulsive  attack,  and  on  no  ac- 
count would  she  permit  me  to  use  it.  Having  implicit 
faith  in  antitoxin  and  no  improvement  taking  place  with 
other  remedies,  I  thought  that  if  I  gave  it  by  the  mouth 
there  might  be  a  chance  of  helping  the  little  sufferer. 
After  boiling  a  silver  spoon  I  poured  the  liquid  into 
it;  the  child  swallowed  the  medicine,  and  said  it  had 
no  bad  taste  and  that  she  would  take  as  much  as  I 
liked  to  give  her.  The  results  I  will  now  give  from 
my  clinical   notes,  as  also  those  obtained  with   other 

patients     similarly    treated:     S.    M ,    aged    eight 

years,  complained  of  sore  throat  on  April  28,  1897. 
I  saw  her  on  the  29th  of  the  same  month.  On  exam- 
ining her  throat  I  could  see  on  the  right  tonsil  four 
small  whitish  spots  about  the  size  of  a  pinhead. 
They  at  first  did  not  give  the  characteristic  wash- 
leather  appearance  of  true  diphtheria.  I  prescribed 
spraying  with  a  saturated  solution  of  boric  acid,  and 
a  mild  laxative.  I  took  a  culture  from  the  fauces 
and  on  the  30th  the  bacteriologist  reported  numerous 
Klebs-Loeffler  bacilli.  I  ordered  the  throat  to  be 
painted  with  iron  and  glycerin.  On  my  visit  in  the 
morning  of  May  ist,  the  patient  said  she  felt  better: 
she  had  less  pain  and  she  had  no  fever.  May  2d,  I 
found  a  large  patch  on  both  tonsils,  of  more  charac- 
teristic appearance.  The  temperature  was  102'  F.  and 
treatment  was  continued.  May  3d,  10  a.m.,  the  patches 
were  much  larger,  extending  over  almost  the  whole  of 
both  tonsils  and  a  part  of  the  soft  palate.  The  tem- 
perature was  103.4"  F.  At  8  P.M.  I  gave  by  mouth 
one  thousand  units  of  antitoxin.  May  4th,  I  found 
that  the  patient  had  slept  fairly  well,  and  retained  the 
draught.  At  9  a.m.  her  temperature  was  normal  and 
the  patches  of  membrane  were  partly  curled  up.  On 
May  5th,  considerably  more  than  half  of  the  mem- 
brane had  disappeared.  May  6th,  ver}-  little  membrane 
was  left.  May  7th,  the  membrane  had  entirely  disap- 
peared. A  culture  was  taken  one  week  after  this,  and 
the  bacteriologist  reported  no  bacilli.  I  consider  the 
case  a  most  t)-pical  one,  and  had  it  been  a  unique  one 
it  alone  might  prove  that  antitoxin  is  as  beneficial 
when  taken  bv  the  mouth  as  when  given  hypodermati- 
cally.  But  I  carried  my  experiments  further  and  with 
the  same  success,  as  the  following  brief  notes  demon- 
strate : 

F.  W ,  aged  eight  years,  boy.  complained  of  a 

sore  throat  on  May  6th.  May  7th,  I  found  two  large 
patches  on  both  tonsils.  The  temperature  was  102' 
F.  I  gave  one  thousand  units  of  antitoxin  by  the 
mouth.  May  8th,  the  temperature  was  100'  F.  The 
patches  seemed  much  smaller.     May  gth.  the  tempera- 


ture was  normal.  There  was  verv-  little  membrane 
visible,  but  there  was  a  good  deal  of  tonsillitis.  May 
loth,  the  membrane  had  entirely  disappeared.  May 
15th,  the  culture  showed  no  Klebs-Loefiler  bacilli.  In- 
flammation of  the  tonsil  was  much  less. 

About  the  same  time  I  treated  three  other  children, 
in  ages  ranging  from  five  and  six  to  ten  years,  in  the 
same  way,  and  all  made  excellent  recoveries. 

If  this  mode  of  administration  has  been  tried  before, 
I  am  not  aware  of  it.  My  object  in  writing  these 
notes  is  to  prove  that  the  antitoxin  of  diphtheria  is 
not  rendered  inert  by  changes  in  the  stomach,  and 
that  this  is  an  easy  method  of  giving  it  to  nervous 
children. 


A    CASE    OF    MUSHROOM    POISONING. 


By    L.    L.    von    WEDEKIXD,    M.D., 


The  interest  attaching  to  this  case  is  not  that  in  it 
there  is  anything  new,  so  far  as  s\Tnptoms  or  treat- 
ment are  concerned,  but  it  is  in  the  violent  and  alarm- 
ing results  following  the  ingestion  of  a  small  quantit)- 
of  a  poisonous  fungus. 

The  patient,  aged  thirty-seven,  an  officer  in  the  naval 
service,  is  much  interested  in  botany,  and  up  to  a  short 
time  ago  believed  himself  to  be  quite  an  expert  in  the 
classification  of  the  different  varieties  of  mushrooms 
growing  in  this  section.  He  is  a  habitual  smoker, 
using  strong  tobacco  in  the  pipe — which  habit  has,  I 
believe,  blunted  to  a  considerable  degree  his  acute- 
ness  of  taste.  This  particular  fungus,  differing  in 
many  ways  from  those  usually  found,  e.xcited  his  inter- 
est, and  he,  believing  it  to  be  of  the  variety  Amanita, 
tasted  a  small  portion,  intending  to  expectorate  it  in 
the  event  of  finding  the  pepper  taste.  Owing  to  the 
blunted  acuteness  of  taste  he  failed  to  detect  the 
'■  pepper,"  and  swallowed  a  small  bit  of  his  specimen 
— calculated  to  be  about  one-tenth  of  the  whole.  Im- 
mediately after  swallowing  it  acute  burning  of  the 
pharynx  occurred,  and  he  realized  that  it  was  a  poi- 
sonous variety.  He  hurried  home,  walking  about  one- 
half  mile,  and  while  on  the  way  was  attacked  by  vom- 
iting and  purging.  After  thoroughly  emptA'ing  the 
stomach  and  bowel  he  fainted,  and  was  discovered 
by  some  men,  who  brought  him  around  with  cold  water 
and  assisted  him  to  his  home,  where  he  again  fainted. 
The  purging  and  vomiting  continued  almost  con- 
stantly for  six  hours,  when  I  was  sent  for. 

I  found  him  with  pupils  minutely  contracted:  pulse, 
120:  temperature,  1  oj. 5' F.;  markedly  prostrated,  and 
making  violent  efforts  at  emesis.  He  had  taken  a 
dose  of  olive  oil  and  whiskey,  which  was  not  retained. 
He  was  given  a  cold  bath,  reducing  the  temperature  to 
102'  F. ;  one-fifteenth  grain  of  atropine,  and  later  one- 
thirtieth  grain  of  str)chnine:  also  one-half  ounce  of 
castor  oil  and  twenty  drops  of  tr.  opii.  He  retained 
the  oil  one  hour,  and  then  vomited.  The  pulse  eight 
hours  later  was  60:  temperature,  104"  F. ;  there  were 
constant  delirium  and  hallucinations,  very  profuse  per- 
spiration, ver\-  great  thirst,  and  abdominal  pain.  He 
could  retain  nothing  on  the  stomach.  Heat  was  ap- 
plied to  the  abdomen  and  an  ice  cap  to  the  head, 
atropine  and  strjxhnine  were  given  alternately,  and 
cold  baths  frequently  when  the  temperature  warranted. 

This  condition  —  high  temperature,  slow  pulse, 
great  gastric  irritation,  insomnia,  constant  delirium 
and  hallucinations,  with  very  marked  asthenia — lasted 
for  four  days.  Morphine  was  injected  in  large  doses, 
one-half  grain  every  eight  hours,  causing  some  sleep 
and  allaying  for  a  time  the  great  effort  at  emesis;  the 
stomach  and   bowel  were  cleansed   with  warm   boric 


920 


MEDICAL    RECORD. 


[December  25,  1897 


solution.  I  made  no  effort  to  feed  the  patient,  as  both 
stomach  and  rectum  were  intolerant.  Mustard  was 
used  quite  liberally  on  the  abdomen  and  hot  water 
bags  were  applied  to  the  sides  and  back.  The  hallu- 
cinations were  present  at  all  times  for  a  period  of  sev- 
enty-two hours,  and  these,  with  the  slow  pulse  and 
high  temperature,  caused  a  suspicion  of  some  cerebral 
trouble,  depending  possibly  upon  the  poison  for  its 
origin. 

After  four  days  the  acute  symptoms  subsided  and 
were  followed  by  a  typhoid  condition,  with  a  morning 
remission  and  an  evening  rise  to  104-105  F.  for 
about  one  week,  when  convalescence  was  established. 
The  patient  showed  marked  evidence  of  his  illness  in 
his  appearance  after  recovery,  but  gained  very  rapidly 
after  the  fever  abated.  Feeding  was  resumed  on  the 
fifth  day,  clam  broth  and  milk  with  Vichy  water  being 
the  main  support.  Cold  baths  controlled  tiie  tem- 
perature. 

U.  S.   Xa\ai.  Ac.\de.mv,  Annapolis,  Mi». 


TRIPLETS. 
Bv    I.    TRACV    MELVIN,    M.D.. 

PERAtiT  me  to  report,  merely  for  stati'tical  purposes, 
the  following  case  of  triplets,  there  being  nothing 
unusual  e.xcept  that  fact.  Mother,  aged  thirty-four, 
married  fourteen  years.  Seven  children,  all  single 
pregnancies.  Health  good.  Labors  normal.  No  plu- 
ral pregnancies  among  her  relatives.  Father,  aged 
thirty-si.x,  laborer;  average  health  and  size.  One 
sister  had  twins  once,  but  the  family  has  not  been 
specially  prolific.  This  pregnancy  was  marked  even 
in  its  early  weeks  by  severe  abdominal  pain  of  a 
stretching  nature,  at  irregular  intervals.  These  pains 
became  so  severe  during  the  later  months  as  to  confine 
the  woman  to  the  bed  a  part  of  the  time. 

I  was  called  on  the  two  hundred  and  forty-third  day 
after  menstruation  and  the  two  hundred  and  thirty- 
si.\th  day  after  the  probable  date  of  conception.  There 
was  a  slight  bloody  flow  with  very  slight  pains  in  the 
back.  The  cervix  was  effaced  and  the  os  was  very 
slightly  dilated.  It  was  a  vertex  presentation.  I  had 
previously  diagnosed  twins.  I  gave  an  anodyne  and 
the-patient  rested  well  for  twelve  iiours,  when  a  slight 
labor  pain  caused  the  friends  to  send  for  me  again. 
The  presenting  child  was  born  with  one  pain,  the 
second  of  the  labor;  it  weighed  four  pounds.  With- 
out tying  the  cord  I  waited  for  the  second  child,  which 
was  born  witii  one  pain,  breech  presenting,  five  min- 
utes later;  weight,  three  and  three-fourths  pounds. 
.\fter  tying  the  cords  and  instructing  the  nurse,  I 
turned  to  examine  the  mother,  who  was  complaining 
of  the  most  severe  labor  pain  yet  experienced,  and 
found  the  uterus  still  large  and  a  third  child  present- 
ing by  the  vertex.  Two  very  moderate  pains  expelled 
it,  a  girl,  who  weigiied  five  and  one-fourth  pounds. 
Ten  minutes  later  two  placentas  were  delivered— one 
weighing  twenty-two  ounces  and  connected  by  two 
distinct  cords  with  the  two  children  first  born:  while 
tiie  second,  weighing  fourteen  ounces,  was  wholly  dis- 
tinct and  connected  with  the  last  born.  The  two  chil- 
dren first  born  presented  every  appearance  of  being  of 
at  least  two  weeks  shorter  gestation  than  the  last  born, 
which  was  evidently  of  about  eight  months'  develop- 
ment. The  children  were  tiioroughlv  oiled,  their  faces 
and  mouths  were  washed,  and  they  were  placed  without 
dressing  in  a  box  containing  bottles  of  hot  water  and 
plenty  of  cotton  hatting.  The  mother  passed  an  lui- 
eventful  puerj^erium  w  ith  no  unusual  flowing,  and  fin- 
nishedan  abundant  quantity  of  milk  for  all  the  babies, 
who  are  now-  a  month  old  and  have  gained  eight,  nine, 
and  twelve  ounces  respectively. 


ACUTE  ARSENICAL  MULTIPLE  NEURITIS 
FOLLOWING  THE  ADMINISTRATION  OF 
FOWLER'S  SOLUTION  IN  A  CASE  OF 
CHOREA. 

Bv    PHILIP   MEIROWITZ,    M.D.. 


DISEASES,    NE 


1'OST-GR.ADl  ATE 


klEDICAL   SCHOOL   , 


May  W ,  the  patient,  is  a  schoolgirl,  thirteen  years 

of  age.  She  came  to  the  clinic,  October  5,  1896, 
suffering  from  an  attack  of  Sydenham's  chorea.  This 
was  perhaps  the  fourth  or  fifth  attack  of  .St.  Vitus' 
dance  that  she  has  had.  Her  first  attack  dates  back 
three  or  four  years.  The  second  attack  occurred  about 
a  year  ago.  During  the  past  twelve  months  she  has 
had  several  attacks,  with  intervals  of  rest  of  about 
three  or  four  months.  The  arms,  legs,  and  neck  were 
principally  involved.  The  face,  excepting  the  eyelids, 
escaped.  The  upper  extremities  were  more  affected 
than  the  lower.  There  was  considerable  weakness  in 
the  arms;  she  could  with  difficulty  hold  objects  in  the 
hands.  For  a  time  her  speech  was  affected.  The 
choreic  movements  continued  during  sleep  and  ap- 
peared to  be  worse  than  during  the  day.  Sleep  was 
often  interfered  with.  There  had  never  been  any 
mental  disturbances  aside  from  a  certain  degree  of 
dulness.      She  is  thin   and  undeveloped  for  her  age. 

A  week  and  a  half  before  she  came  to  the  clinic  she 
complained  of  a  sense  of  stiftness  in  the  knees,  but 
had  no  difficulty  in  walking.  A  few  days  later  she 
had  the  sensation  of  "  pins  and  needles"  in  the  soles 
of  the  feet,  the  legs  became  weak,  and  she  experienced 
severe  spontaneous  pains  in  the  lower  extremities  be- 
low the  knees.  Friction  of  the  legs  was  extremely 
painful.  Walking  was  interfered  with  to  such  an  ex- 
tent that  she  was  confined  either  to  a  bed  or  to  a  chair 
during  the  entire  week  preceding  the  visit  to  the 
clinic.  Shortly  after  the  pains  appeared  in  the  legs 
they  were  felt  in  the  upper  extremities,  which  also 
became  painful  to  the  touch.  It  was  with  very  great 
difficulty  that  she  was  brought  to  the  hospital. 

Her  examination  at  that  time  showed  the  following: 
Once  seated  in  a  chair,  it  was  with  the  greatest  diffi- 
culty that  she  could  arise,  repeated  efforts  being  un- 
successful. She  had  to  employ  the  arms,  exerting 
downward  pressure  on  the  seat  of  the  chair  or  seizing 
hold  of  some  neighboring  object.  Standing  alone  or 
walking  unaided  was  entirely  beyond  her  ability.  Her 
gait  was  markedly  ataxic:  the  legs  were  raised  some- 
what higher  than  normal,  and  the  toes  touched  the  floor 
first,  the  heel  following.  There  was  considerable 
emaciation,  which,  as  the  mother  of  the  patient  ex- 
plained, developed  rapidly  after  the  onset  of  the  pain 
in  the  extremities.  The  left  upper  arm  was  decidedly 
thinner  than  the  right.  This  discrepancy  in  the  size 
of  the  superior  segments  of  the  arms  was  observed  by 
the  mother  last  summer.  .At  that  time  and  previously 
tlie  child  iiad  made  no  complaint  which  might  have 
been  referred  to  this  region.  Measurements  of  the 
upper  extremities  gave  the  following: 


Middle  upper  arm 

L'pper  third  of  forearm. 
Lower  tliird  of  foreann. 


Riv'hi. 
.   (>X  inclies. 


5jii  inches. 


The  muscles  in  all  of  the  extremities  were  quite 
soft  and  flabby,  and  painful  to  manipulation.  The 
movements  on  the  right  side  were  somewhat  l>etterthan 
those  on  the  left.  In  testing  various  groups  of  n\us- 
cles  it  was  found  that  the  grip  was  very  weak,  even 
wheti  the  hand  was  passively  extended.  She  could 
not  cause  the  index  hand  of  the  dynamometer  to 
move  when  she  exerted  her  strength.  Extension  of  tlie 
fingers  was  imperfectly  performed.  She  could  not 
spread  the  fingers  well,  or  accur.itely  touch  the  tips  of 


December  25,  1897] 


MEDICAL    RECORD. 


921 


the  fingers  with  the  tip  of  the  thumb.  There  was 
partial  drop  wrist.  Flexion  of  the  wrist  was  e.xtremely 
weak.  The  movements  of  the  forearms  and  upper 
arms  were  relatively  stronger,  yet  were  under  the  nor- 
mal. The  Hexed  forearms  could  be  passively  extended 
without  the  slightest  effort,  even  when  the  patient  ex- 
erted herself  to  the  utmost.  Extension  of  the  forearm 
was  stronger  than  flexion,  and  the  patient  resisted 
fairly  well  efforts  to  overcome  it.  The  muscles  of  the 
shoulder  seemed  not  involved. 

Turning  to  the  lower  extremities,  it  was  found  that 
the  legs  below  the  knees  were  cold  to  the  touch;  the 
feet  were  slightly  warmer  than  the  legs.  The  mus- 
cles were  soft  and  flabby  and  hyperasthetic  to  pressure, 
more  so  in  the  legs  than  in  the  thighs.  The  knee 
jerk  could  not  be  elicited  in  either  leg.  The  move- 
ments of  flexion  and  extension  of  the  thighs  and  legs 
were  weak.  There  were  typical  drop  feet.  It  was 
impossible  for  her  either  to  extend  or  to  flex  the  feet. 

Tactile  sensation  was  in  the  main  normal.  There 
were  some  slight  disturbances  to  touch  in  the  hands 
and  feet.  Sensation  to  mechanical  pain,  such  as  that 
produced  by  the  point  of  a  pin,  was  normal:  but  the 
pain  resulting  from  the  application  of  a  strong  faradic 
current  was  not  felt  in  the  legs  by  the  patient.  The 
temperature  sense  was  not  affected;  she  could  easily 
distinguish  between  a  hot  and  a  cold  test  tube. 

The  electrical  examination  discovered  marked  re- 
duction of  the  faradic  irritability  of  the  muscles  of  the 
legs.  The  reaction  to  faradism  in  the  arm  muscles 
appeared  normal. 

There  had  never  been  bladder  or  bowel  troubles. 

Since  August  17,  1896,  when  she  first  came  to  the 
clinic — i.e.,  in  the  period  of  seven  weeks— the  patient 
has  taken  four  ounces  of  Fowler's  solution.  She  be^an 
with  live-drop  doses  three  times  daily,  and  each  day 
increased  the  dose  by  one  drop,  until  she  was  taking 
fifteen  drops.  She  then  began  to  vomit  and  there  de- 
veloped some  oedema  of  the  eyelids.  The  dose  was 
now  reduced  to  ten  drops,  at  which  the  medicine  was 
continued  up  to  a  few  days  prior  to  the  examination, 
when  only  five  drops  were  given. 

202  West  One  Hi  xdrej.  and  Thirtv-First  Street. 


A   SOMEWHAT    UNIQUE   CASE  OF    SPONTA- 
NEOUS   FR.4CTURE  OF   THE   CL.WICLE. 

Bv    TH()M.\S    H.    M.\NLKV.     M.l>.. 


On  the  i6th  of  September  a  case  of  clavicular  fracture 
came  under  my  care,  in  the  West  Side  German  Dis- 
pensary, which  belongs  to  a  very  rare  class,  and  seems 
to  me  to  be  of  sufficient  interest  to  be  incorporated  in 
the  annals  of  surgical  literature. 

The  patient  was  a  man,  thirty-four  years  old,  mar- 
ried, .American;  by  occupation  a  billiard  player.  He 
seemed  to  be  a  person  of  good  physique  and  was  free 
from  any  organic  malady.  He  denied  specific  disease, 
and  in  no  structure  was  there  evidence  of  tubercle 
or  cancer.  He  never  before  had  sustained  a  fracture, 
said  he  had  never  had  epilepsy,  and  was  not  addicted  to 
excesses  of  liquor.  For  the  past  ten  years  from  time 
to  time  he  had  had  rheumatic  pains  in  the  knee  and 
ankle  joints,  but  had  never  had  acute  rheumatism. 

He  said  he  retired  the  night  before  in  his  usual  good 
health,  at  about  eleven  o'clock.  .\t  about  three  in  the 
morning  he  was  suddenly  awakeneu  by  a  severe,  most 
distressing  pain,  which  involved  the  whole  shoulder 
and  extended  down  the  arm  into  the  hand  on  the  left 
side.  He  was  startled  to  find  that  he  was  entirely 
unable  to  move  the  arm  without  producing  the  most 
agonizing  pain  in  the  .shoulder.  The  use  of  thermal 
applications  and  liniments  only  aggravated  his  condi- 


tion, as  the  surface  w-as  hypera;sthetic  and  no  motion 
at  the  joints  could  be  tolerated. 

On  examination  it  was  noted  that  he  was  pale,  of  a 
plaintive  expression,  with  a  weak  pulse,  but  had  no  ele- 
vation of  temperature.  .\s  he  stood  up  the  left  shoulder 
was  noticed  to  be  much  lower  than  the  right,  and  the 
hand  on  that  side  was  carried  in  an  opening  of  his 
coat,  which  supported  the  arm  as  a  sling.  \\'hen  the 
chest  was  stripped,  on  viewing  it  from  the  front  a 
well-marked  deformity  of  the  outer  aspect  of  the  left 
clavicle  was  evident.  Now  by  seizing  the  arm  and 
making  gentle  motion,  it  was  seen  that  there  was  a 
complete  fracture  at  the  outer  third  of  the  left  clavicle 
with  considerable  overriding  of  the  fragments. 

In  an  examination  of  the  literature  on  fractures  by 
.\merican  and  foreign  authors,  I  am  unable  to  find  a 
record  of  any  similar  case:  the  nearest  is  found  in 
Malgaigne's  works  ("  Traite'des  Fractures,''  vol.  ii.,  p. 
464).  He  publishes  the  case  of  a  young  robust  wo- 
man, who  fractured  the  clavicle  bv  turning  over  in 
bed. 

-\11  surgeons  are  agreed  that  this  fracture  commonly 
results  from  muscular  action  in  any  violent  motion 
or  exertion  of  the  body  or  the  shoulder;  but  there  is 
no  record  of  any  instance  in  which,  as  in  this  case, 
muscular  contraction  was  involuntary  and  the  indi- 
vidual was  entirely  unconscious  of  any  effort. 


RITUAL    CIRCUMCISION. 

By    .\kTHUR    STERN,    M.D., 

SIRGECX    TO    THE    ALEXIAS    BROTHERS"    HOSllTAL,    ELIZABETH,    X.    J. 

I  WAS  recently  called  to  attend  a  child,  ten  days  old, 
who  had  been  circumcised  two  days  previously. 
I'pon  inquiry  it  appeared  that  the  operation — or,  more 
properly,  the  cutting,  since  no  attempt  at  stitching 
had  been  made — had  been  done  by  the  ritual  circum- 
ciser,  who  directed  the  family  to  dress  the  wound  with 
a  piece  of  lint  well  soaked  in  carbolic-acid  water!  I 
found  the  child  cyanotic.  Its  wrappings  were  satu- 
rated with  urine  of  a  dark  greenish  color.  The  lint 
dressing  had  stuck  fast  to  the  wound.  Around  the 
penis  at  the  scrotum,  in  the  inguinal  parts,  and  wher- 
ever the  solution  had  touched  the  skin,  an  erythema 
had  developed.  I  immediately  ordered  that  the  appli- 
cation of  the  carbolic-acid  water  should  be  discon- 
tinued, that  the  child  should  be  treated  with  a  talcum 
preparation,  and  should  have  an  abundance  of  liquid, 
with  a  view  to  getting  the  desired  diuretic  effect  on 
the  kidneys.  In  addition  to  this  1  prescribed  a  solu- 
tion of  bicarbonate  of  sodium.  The  next  morning  the 
child  was  somewhat  better;  cyanosis  had  disappeared, 
and  the  urine  was  of  a  lighter  color.  The  child  re- 
covered finally. 

Cases  similar  to  the  above  have  been  reported  by 
liogdanik  and  Melzer. 

The  rite  of  circumcision  is  so  firmly  intrenched  in 
many  minds  as  a  desirable  custom  — partly  for  its 
supposed  therapeutic  value,  but  more  esjjecially  by 
reason  of  its  religious  sanction — that  opposition  to  it 
would  perhaps  meet  with  little  result.  Kut  it  does 
seem,  from  the  data  at  hand,  that  some  measure  of 
skill  and  care  should  be  exacted  of  those  who  take 
upon  themselves  the  task  of  [jerforming  the  operation. 
It  is  true  that  great  numbers  of  children  undergo  this 
operation  every  year,  and  that  the  reported  cases  are 
comparatively  few  in  which  death  or  even  serious 
sickness  is  alleged  to  be  its  result.  Reported  cases, 
liowever,  usually  have  in  them  something  exceptional. 
It  is  well  known  that  many  minor  evils  and  some  very 
grave  ones  are  justly  chargeable  to  the  carelessness 
and  want  of  skill  with  which  the  circumcision  is  done. 

An  excellent  treatise  on  the  delicacy  of  this  opera- 
lion,  and  the  danger  to  life  and  health  involved  in  its 


922 


MEDICAL    RECORD. 


[December  25,  '897 


being  carelessly  done,  is  given  by  Dr.  Lowenstein, 
in  vol.  54,  part  iv.,  of  the  Archiv  fiir  klinische  Chirur- 
gie.  Dr.  Lowenstein  is  strenuous  in  insisting  that 
no  ritual  operator  should  be  allowed  to  circumcise 
until  he  has  first  received  a  modern  hygienic  educa- 
tion and  knows  something  at  least  of  latter-day  meth- 
ods. He  submits  it  to  be  an  outrage  that  an  operation 
pregnant  with  so  many  possibilities  to  the  life  and 
health  of  the  young  should  be  intrusted  to  an  igno- 
ramus. I  apprehend  there  are  few  physicians  who  do 
not  share  his  views. 

218  East  Jersey  Street. 


progress  of  Medical  J>ciencc. 

The    Protective     Activity    of    Anthrax    Serum — 

Sobernheim  (Berliner  kliuisihe  U'oehensehrift,  October 
18,  1897,  p.  910)  lias  shown  that  the  blood  of  o.xen, 
sheep,  and  rabbits  treated  with  attenuated  cultures  of 
anthrax  bacilli,  and  thus  rendered  immune  to  infec- 
tion with  virulent  anthrax  bacilli,  appears  to  contain 
no  specific  protective  substances.  The  treatment  of 
rabbits  with  the  serum  of  such  animals  was  attended 
with  the  slightest  protective  influence.  Nor  were 
specific  properties  found  in  the  blood  of  o.xen  that  had 
recovered  from  attacks  of  anthrax  occurring  spon- 
taneously; and  a  like  result  was  observed  in  the  case 
of  a  man.  In  animals  treated  for  a  long  time  with 
virulent  cultures,  however,  with  the  development  of 
active  immunity,  specific  changes  in  the  blood  were 
found.  The  blood  serum  of  calves  thus  treated  proved 
capable  of  conferring  only  relative  immunity  upon 
rabbits,  but  complete  immunity  upon  sheep. 

Recovery  from  Hemorrhagic  Purpura  following 
Treatment  with   Injections  of    Artificial   Serum. — 

Pigot  ( Gazette  Hehdom.  de  Med.  et  de  C/iir.,  (Ictober  17, 
1897,  p.  990)  has  reported  the  case  of  a  debilitated 
patient  who  had  been  suft'ering  for  two  weeks  with 
symptoms  of  hemorrhagic  purpura  and  bleeding  from 
the  gums.  The  whole  body  was  covered  with  hemor- 
rhagic areas,  which  were  especially  marked  upon  the 
extremities.  Blood  was  also  discharged  by  the  bowel. 
There  was  complaint  of  a  painful  sense  of  burning  in 
the  epigastrium,  and  the  breath  was  fetid.  On  aus- 
cultation a  small  cavity  was  found  at  the  apex  of  the 
left  lung.  The  liver  was  slightly  enlarged;  the  spleen 
was  normal.  The  temperature  was  elevated.  Ferric 
chloride,  ergotin,  and  lemons  were  administered,  and  a 
mouth  wash  of  potassium  chlorate  was  ordered,  but  no 
improvement  followed.  Finally  two  hundred  and  fifty 
cubic  centimetres  of  artificial  serum  was  injected 
subcutaneously,  and  within  twenty-four  hours  marked 
improvement  had  taken  place.  A  second  and  a  third 
injection  of  the  same  amount  of  fluid  were  given  on 
successive  days,  and  within  forty-eight  hours  conva- 
lescence set  in  and  progressed  to  ultimate  recovery. 

Chorea  Complicated  by  Pregnancy  Relieved  by 
the  Induction  of  Abortion — Collier  {Birmingham 
Meitieal  A'eTiew,  October,  1897,  p.  243)  has  reported 
the  case  of  a  married  woman,  twenty-one  years  old, 
with  a  child  a  year  and  a  half  old.  who  came  under 
observation  suffering  from  chorea,  affecting  chiefly 
the  head,  the  face,  and  the  right  arm.  The  choreic 
movements  had  begun  six  months  previously,  follow- 
ing a  severe  fright  from  being  nearly  run  over  by 
horses.  In  spite  of  treatment  the  movements  had  in- 
creased in  severity.  On  examination  it  was  found  that 
the  woman  was  about  four  months  pregnant.  The 
heart  sounds  were  normal  and  there  was  no  history  of 
rheumatism.  Treatment  with  arsenic,  and  later  with 
chloral,  bromides,  morphine,  sulfonal,  inhalations  of 


chloroform  successively  failed,  and  maniacal  symptoms 
developed,  with  evidences  of  exhaustion.  The  induc- 
tion of  abortion  being  decided  upon,  under  chloroform 
the  cervix  was  dilated,  the  membranes  were  ruptured, 
the  vagina  was  plugged,  and  a  hypodermic  injection  of 
ergotin  was  given.  Labor  failing  to  set  in  within  twelve 
hours,  chloroform  was  again  administered  and  the  cer- 
vix further  dilated;  two  fingers  were  introduced  into 
the  uterus,  a  leg  was  pulled  down,  and  a  five-month's 
foetus  delivered,  the  placenta  coming  away  a  few  mo- 
ments later.  The  uterus  was  thoroughly  washed  out 
with  a  strong  solution  of  iodine.  The  temperature  rose 
within  a  short  time  to  105.8"  F.,  but  was  reduced  two 
or  three  degrees  by  sponging,  and  it  gradually  fell  to 
normal  during  the  following  twenty-four  hours,  five 
grains  of  quinine  sulphate  being  given  ever)'  fourth 
hour.  From  now  on  the  patient  made  rapid  improve- 
ment, the  movements  becoming  less  and  less  marked, 
and  eventually  ceasing. 

Hydrophobia  of  Long  Incubation. — Feltz  and 
Archambaud  ^  Gazette  Hehdom.  de  Med.  et  de  C/iir., 
September  30,  1897,  p.  925)  have  reported  the  case 
of  a  man,  twenty  years  of  age,  previously  in  good 
health,  who  after  several  days  of  dissipation  was 
seized  with  chill  and  difficulty  in  respiration.  The 
temperature  was  normal,  the  pulse  not  accelerated. 
There  was  complaint  of  pains  radiating  from  the 
sternum,  and  difficult)-  in  swallowing.  In  a  short 
while  the  face  became  pale,  the  expression  terrified, 
the  eyes  deep.  There  was  intense  dyspnoea,  with 
pharyngeal  spasm  and  inability  to  swallow;  also  pre- 
cordial pain,  radiating  toward  the  left  arm.  After  a 
while  furious  delirium  set  in  and  sanguinolent  froth 
was  ejected  from  the  mouth.  Respiration  and  pulse 
became  accelerated,  the  pupils  dilated,  cyanosis  de- 
veloped, and  death  ensued.  A  diagnosis  of  hydro- 
phobia was  made,  and  on  inquiry  it  was  learned  that 
the  patient  had  been  bitten  on  the  lip  six  and  a  half 
months  previously  by  a  rabid  dog. 

Origin  of  Pressure  Deformities. — Ferd.  Bahr  ( I'o/l:- 
manii's  klinisclie  I'ortriige,  No.  194,  October,  1897) 
concludes  that  Julius  Wolff's  "transformation  theor)-" 
is  inadequate  to  explain  the  beginning  stages  of 
these  malformations,  and  maintains  that  it  is  to  the 
modified  "  Hiiter-Volkmann  pressure  theory"  that  we 
must  look  for  light  on  the  earlier  phases,  .\fter  the  de- 
formity is  fairly  inaugurated,  the  author  thinks  that 
the  Wolff  theory  comes  into  play  and  aids  in  the 
adaptation  of  the  misshapen  parts  to  the  new  condi- 
tions. The  origin  of  pressure  deformities  shows  the 
following  steps:  i.  Defective  action  of  braces  (liga- 
ments, etc.),  with  lessened  power  of  resistance  of 
bone.  2.  Unfavorable  pressure,  with  (<?)  deformity  of 
epiphyses,  (/»)  deformity  of  diaphyses  (curvature"),  or 
(c)  both  at  once  in  varying  proportions.  3.  Adapta- 
tion of  deformed  bony  parts  to  the  new  relations. 

Chylous  Ascites  in  the  Course  of  Cancer  of  the 
Stomach. — Drs.  Hertz  and  Georges  Luys  (Z<7  Presse 
Medieale,  October  9,  1897)  report  the  case  of  a  woman 
whose  history  gave  no  evidence  of  neoplasm  of  the 
stomach.  On  her  entrance  to  the  hospital  she  pre- 
sented phenomena  of  ascites,  necessitating  abdominal 
puncture.  .\  white  milky  liquid  was  drawn  oft",  the 
chemical  analysis  of  which  showed  chylous  ascites. 
At  the  autopsy  cancer  of  the  stomach  was  found 
spreading  to  the  pancreas,  as  well  as  to  the  perigastric 
ganglia,  and  continuing  in  the  form  of  a  thick  vein 
all  along  the  aorta  to  the  point  of  origin  of  the  renal 
arteries.  Histological  examination  of  the  neoplasm 
showed  it  to  be  typical  epithelioma.  It  would  seem 
in  this  case,  as  in  the  similar  instances  of  Straus  and 
Whitla,  that  rents  in  the  thoracic  duct  caused  by  the 
cancer  were  to  blame  for  the    chvlous    ascites.     Dr. 


December  25,  1897] 


MEDICAL    RECORD. 


923 


Letulle  thinks  that  this  case  confirmed  the  necessity 
of  a  rigorous  differentiation  between  chylous  and 
chyliform  ascites,  these  two  kinds  of  peritoneal  effu- 
sions arising  from  different  causes.  Letulle  mentions 
a  case  of  temporary  chyliform  ascites  in  a  woman 
affected  with  cardiac  cirrhosis.  At  a  given  time  the 
ascites  was  sufficient  to  necessitate  numerous  punctures ; 
the  first  of  these  would  give  a  clear  pale  yellow  fluid; 
then  without  any  known  cause  the  liquid  would  cease 
to  be  clear  and  become  chyliform;  then  this  aspect 
would  disappear,  and  the  later  punctures  would  again 
yield  the  clear  yellow  fluid.  This  does  not  seem  to 
have  any  plausible  explanation.  Dr.  Letulle  has  also 
observed  temporary  chyliform  ascites  in  children. 
Some  autopsies  have  shown  that  in  these  cases  the 
chyliferous  vessels  are  damaged;  these  are  then  in- 
stances of  chyliform  and  not  chylous  ascites.  Dr. 
Iroisier  recalls  the  fact  that  he  has  already  reported 
three  cases  of  cancer  of  the  throracic  duct;  two  of 
these  were  not  accompanied  by  chlyous  effusion,  the 
third  did  not  even  present  ascites.  Chylous  ascites 
would  seem  to  be  the  exception  in  the  course  of  can- 
cerous degenerations  of  the  thoracic  duct.  Rupture  of 
the  thoracic  duct  seems  improbable.  The  conse- 
quences of  cancerous  infiltration  of  the  walls  are  in 
effect  a  thickening  and  a  diminution  of  the  lumen  of 
the  canal,  a  diminution  which  has  as  its  consequence 
a  complete  and  fatal  obliteration  of  the  canal.  In 
these  conditions  it  is  easy  to  understand  that  the  tho- 
racic duct  cannot  rupture.  It  ruptures  only  w-here  the 
structure  is  normal.  Variot  thinks  that  there  exists  a 
relation  of  cause  and  effect  between  the  regime  of  the 
patient  and  the  chylous  appearance  of  the  ascitic 
liquid.  In  a  child  having  chronic  nephritis  and  kept 
on  a  milk  diet  for  five  months,  there  followed  a  chyli- 
form ascites.  It  is  necessary  to  add  that  in  this  case 
the  blood  serum  was  milky,  and  Dr.  Variot  thinks 
that  there  was  a  correlation  between  these  different 
symptoms. 

Search  for  Lead  in  the  Salivary  Glands  in  Acute 
Lead  Poisoning. — Dr.  Renon  [La  Mc'decine  Moderne, 
October  5,  1897)  has  noted  the  presence  of  lead  in  the 
salivary  glands  of  two  guinea-pigs  poisoned  with  white 
lead.  These  were  the  only  positive  results  obtained 
from  the  examination  of  ten  guinea-pigs  which  had 
succumbed  after  receiving  for  nine  days  either  red  or 
white  lead  mixed  with  their  food.  These  facts,  analo- 
gous to  those  reported  as  observed  by  Ellenberger  and 
Hofmeister  in  sheep  inoculated  by  injection  of  plumbic 
acetate  beneath  the  skin,  are  interesting  by  reason  of 
the  role  lead  plays  in  certain  forms  of  parotiditis  in 
man. 

The  Care  of  the  Perineum  in  Labor,  and  its 
Repair  afterward. — Upon  the  basis  of  an  extended 
clinical  experience,  Happel  {Memphis  Medical  Monthly, 
November,  1897,  p.  485)  offers  the  following  deduc- 
tions: He  insists  that  the  condition  of  the  patient  be- 
fore delivery  should  be  accurately  known,  in  order 
that  all  of  her  secretory  and  excretor}'  organs  may  be 
suitably  regulated.  If  leucorrhtea  exists,  hot  douches, 
medicated  when  necessary,  should  be  employed.  If 
the  patient  be  a  primipara  of  advanced  years,  massage 
of  the  perineum  and  vulva  before  and  during  labor 
will  be  beneficial.  During  labor  the  physician  should 
keep  informed  by  educated  touch  as  to  the  dilatability 
and  degree  of  dilatation  of  the  outlet.  When  labor  is 
normal  in  every  respect,  the  perineum  will  need  little 
or  no  support,  but  the  palmar  surface  of  the  hand 
should  be  ready  to  furnish  support,  should  it  be 
needed.  When  the  perineum  yields  slowly  and  irreg- 
ularly, the  hand  should  be  ready  to  give  support  at 
any  moment,  and  this  support  must  be  given  in  a 
proper    manner    during    the    least    expulsive    pains. 


Chloroform  should  be  employed  freely  and  the  woman 
exhorted  not  to  bear  dojvn.  In  case  of  rupture,  an 
immediate  operation  for  repair  should  be  undertaken, 
but  for  the  purpose  of  determining  the  fact  of  a  rup- 
ture it  should  not  be  necessary  to  subject  the  wo- 
man to  indelicate  and  needless  exposure.  If  educated 
touch  cannot  detect  laceration,  then  repair  is  not 
needed.  If  doubt  exists  with  regard  to  a  laceration, 
careful  inspection  of  the  parts  should  be  made.  Slight 
fissures  and  abrasions  do  not  need  sutures.  More 
harm  may  be  inflicted  with  sutures  by  invasion  of  the 
deeper  structures  of  the  canal  than  good  effected  by 
closing  these  rents  in  the  mucous  membrane  of  the 
vagina.  No  other  antiseptic  is  needed  in  primary 
operations  than  water,  which  should  be  boiled  and 
used  as  hot  as  can  be  borne  by  the  patient. 

Diagnostic  Importance  of  Exact  Pulse  Examina- 
tions.— \V.  Janowski  [J'olhmann's  klinische  Vortrdge, 
October,  1897,  pp.  192,  193)  deprecates  the  modern 
tendency  to  regard  lightly  the  information  to  be  ob- 
tained from  the  pulse,  and  attaches  much  importance 
to  the  results  obtained  by  an  intelligent  use  of  the 
sphygmograph.  He  recognizes  eighteen  forms  of 
arterial  pulse,  which  are  to  be  grouped  as  follows: 
{A)  Pulse  whose  characteristics  are  recognizable  from 
the  inspection  of  tracings  of  a  single  beat,  i.  Pulsus 
durus;  2,  pulsus  mollis;  3,  pulsus  celer;  4,  pulsus 
tardus;  5,  pulsus  magnus;  6,  pulsus  parvus.  {E) 
Those  forms  which  require  for  their  recognition  trac- 
ings of  a  succession  of  beats.  7,  Pulsus  frequens;  8, 
pulsus  rarus:  9,  pulsus  irregularis;  10,  pulsus  embry- 
ocardia  (a  rapid,  short  systole,  followed  by  an  equally 
rapid  and  short  diastole,  the  pause  being  altogether 
lacking);  11,  double  pulse,  in  which  each  beat  is 
closely  followed  by  another,  a  pause  then  intervening 
before  the  next  beat  (triple  and  quadruple  forms  are 
also  found)  ;  12,  unequal  pulse,  characterized  by  une- 
qual heights  of  the  wave  summits;  13,  alternating 
pulse,  in  which  small  waves  succeed  larger  ones  in  a 
definitely  proportionate  manner;  14,  the  so-called  pul- 
sus paradoxus,  in  which  the  character  of  the  single 
waves  is  influenced  by  respiration;'  15,  alternating  form 
of  double  pulse,  in  which  the  first  of  the  two  beats  is 
larger  than  the  second:  16,  hemisystolia,  two  heart 
beats  giving  rise  to  but  a  single  pulse  wave;  17,  con- 
dition of  total  arrhythmia,  presenting  differences  in 
size  and  rhythm  not  governed  by  any  rule  perceptible ; 
18,  pulsus  differens,  a  pulse  different  in  the  two  halves 
of  the  body.  Each  of  the  above  is  exhaustively  but 
practically  treated,  and  the  value  of  the  discussion  is 
furthered  by  numerous  reproductions  of  pulse  tracings 
taken  at  the  bedside. 

Lupus  Vulgaris. — A  new  treatment  by  currents  of 
hot  air  has  recently  been  introduced  by  Dr.  Hollander, 
of  Berlin,  following  out  the  suggestions  for  local  treat- 
ment of  various  processes  by  hot  vapor.  An  eschar  is 
produced  without  involvement  of  surrounding  parts, 
by  simply  overheating  the  diseased  area.  The  instru- 
ment devised  for  the  purpose  consists  essentially  in  a 
long,  hollow,  metallic  arm,  terminating  in  a  fine  point. 
Through  the  central  opening  a  current  of  air  is  made 
to  pass  by  means  of  a  rubber  bag,  like  that  of  the 
Faquelin  apparatus,  the  extremity  having  been  heated 
in  a  spirit-lamp  flame.  In  this  way  a  temperature  of 
300°  F.  or  over  may  be  utilized.  The  curative  power 
of  this  superheated  air  is  attributed  to  its  antiseptic 
and  haimostatic  qualities.  It  is  thus  suggested  as  a 
means  of  treatment  in  gyna;cology,  as  well  as  for 
metrorrhagias  and  infectious  processes.  Illustrations 
of  lupus  before  and  after  treatment  are  given  in  La 
Presse  Me'diiale,  October  30th,  which  gives  an  account 
of  the  new  method.  When  applied  to  healthy  skin  the 
current  of  hot  air  produces  a  vasoconstriction  causing 


924 


MEDICAL    RKCORI). 


[December  25,  1897 


ibcheniia  of  the  region  acted  upon,  while  in  diseased 
areas  with  newly  formed  vessels  such  as  exist  in  lupus, 
there  is  a  rising  up  of  the  skin  above  the  surrrounding 
surface.  While  healthy  skin  loses  its  pallor  and  re- 
gains the  previous  normal  apjDearance  after  a  few  days, 
the  lupus  skin  begins  to  mortify.  A  repetition  of  the 
operation  several  times,  it  is  claimed,  results  in  cure 
in  mild  cases,  but  those  of  moderate  intensity  should 
be  kept  under  observation  for  three  years  before  last- 
ing cure  can  be  claimed. 

The  Occurrence  of  Necrosis  of  Intestinal  Glandu- 
lar Epithelium  in  Cases  of  Diabetes   Mellitus.— It 

is  known  that  necrosis  of  the  epithelium  of  various 
glandular  organs  may  take  place  in  cases  of  diabetes 
mellitus,  and  it  has  been  supposed  that  the  lesions 
were  due  to  the  elimination  through  the  affected  vis- 
cera of  certain  poisons  circulating  in  the  blood.  Lud- 
wig  {Centraniatt  fiir  i line  re  Median,  1897,  No.  43,  p. 
1,105)  reports  a  case,  which  he  believes  to  be  the  first, 
in  which  such  necrosis  was  observed  in  the  glandular 
apparatus  of  the  intestine.  The  patient  was  a  woman, 
thirty-si.\  years  old,  whose  father  had  died  of  cirrhosis 
of  the  liver,  one  brother  of  diabetes  mellitus,  another 
of  some  acute  pulmonary  disorder,  and  a  sister  of  ery- 
sipelas. The  patient  herself  had  suffered  from  re- 
peated attacks  of  facial  erysipelas.  For  a  period  of 
five  weeks  there  had  been  noticeably  increased  thirst 
and  an  increased  sense  of  hunger,  as  well  as  increased 
elimination  of  urine.  In  spite  of  the  ingestion  of  an 
abundance  of  food,  there  were  rapid  emaciation  and 
loss  of  strength.  The  appetite  had,  however,  become 
impaired,  and  there  were  besides,  headache,  slight 
vertigo,  and  extreme  languor.  The  knee  jerks  were 
preserved.  The  pulmonary  percussion  note  was  rela- 
tively impaired  on  the  left  side  above  and  below  the 
clavicle,  and  posteriorly  above  the  spine  of  the  scap- 
ula, as  well  as  over  the  lower  lobe.  In  the  area  first 
named  expiration  was  accentuated,  and  in  the  last  en- 
feebled. There  was  scanty  expectoration,  and  no 
tubercle  bacilli  were  found  in  the  sputum.  The 
amount  of  urine  passed  in  twenty-four  hours  equalled 
about  sixty-four  ounces:  the  specific  gravity  was 
1.025:  a  slight  amount  of  albumin  was  present,  to- 
gether with  sugar  and  acetone.  In  the  sediment  were 
found  hyaline,  granular  and  epithelial  tube  casts. 
The  patient  grew  gradually  w'orse  and  death  ensued. 
Upon  post-mortem  examination  the  epithelium  of  the 
upper  portion  of  the  ileum  was  found  discolored  in 
small  areas,  readily  detachable,  and  in  some  places 
actually  wanting.  Farther  down  there  were  transverse 
losses  of  substance,  with  distinct  limitation  and  a 
hemorrhagic  necrotic  base.  A  number  of  areas  of 
similar  appearance  were  present  also  in  the  large  in- 
testine. Microscopic  examination  of  the  affected 
portions  of  intestine  confirmed  the  supposition  reached 
from  macroscopic  observation,  that  the  lesions  con- 
sisted in  necrosis  of  the  cylindric  epithelium  of  the 
tubular  glands.  The  appearances  corresponded  w  ith 
those  of  a  deep-seated  cellular  and  purulent  infiamma- 
tion  of  the  glandular  epithelium,  together  with  necro- 
sis, and  the  conclusion  is  reached  that  the  latter  was 
the  primary  process  in  con.sequence  of  toxic  influences 
related  to  the  constitutional  disorder. 

Myxoedema  in  the  Adult — Dr.  Uriquet  (/,7  Pirsse 
Mi.iiiale,  October  9,  1897)  calls  attention  to  the  fol- 
lowing points  as  the  most  interesting  in  his  paper  on 
this  subject:  "  .\  persi.stent  thirst  which  vields  to  treat- 
ment is  very  marked  with  this  class  of  patients.  Marie 
found  it  necessary  to  discontinue  the  use  of  the  thyroid 
body  in  his  patient,  as  it  caused  an  intense  thirst. 
This  disease  usually  follows  overwork,  jjrolonged 
fasting,  late  hours,  and  fatigue.      It  has  been  known  to 


last  nineteen  years  in  spite  of  little  nourishment  being 
taken.  We  have  no  method  of  treatment  as  yet  that 
can  be  relied  upon.  The  history  of  the  matter  is  brief. 
In  1890  grafts  of  the  thyroid  body  were  tried.  Im- 
provement was  noted,  but  there  were  no  cures  by  this 
method.  In  1891  Murray  tried  hypodermic  injections 
of  thyroid  extract.  This  treatment  was  then  tried  by 
others,  and  in  the  thesis  of  Derrien  we  find  seventeen 
series  of  experiments  related  in  detail.  Howitz,  of 
Copenhagen,  in  1892,  administered  the  natural  thyroid 
gland,  and  his  attempt  was  crowned  w'ith  success,  and 
he  has  many  imitators.  The  thyroid  gland  of  the 
sheep  has  two  lobes,  and  Massee  advises  giving  one 
lobe  every  day  during  the  first  four  or  five  days,  then 
a  lobe  every  other  day  for  two  or  three  weeks.  It  is 
necessary  to  continue  to  give  one  or  two  lobes  a  week 
after  cure.  Vermehren  has  tried  thyroidin,  and  in 
1896  Haumann  used  thyroidin,  also  called  idiothyrin. 
It  has  been  this  last  remedy  that  has  given  the  best 
results.  The  capsules  that  are  employed  are  prepared 
with  the  same  gland  deprived  of  foreign  elements,  fat, 
etc.  We  should  carefully  note  the  symptoms  that 
come  on  at  the  beginning  of  treatment.  With  our  pa- 
tients we  noted  enervation,  vomiting,  oppression,  and 
severe  pains  in  the  limbs.  Scarlatiniform  erythemas 
followed  by  desquamation  and  pigmentation,  urticaria, 
abundant  perspiration,  glycosuria,  and  sometimes  a 
dangerous  tachycardia  have  been  noted.  Several 
deaths  have  been  reported,  mostly  of  children,  though 
there  have  been  some  fatal  instances  in  adults  as  well. 
The  necessity  of  close  watching  after  the  first  doses 
cannot  be  too  strongly  emphasized.  Since  we  do  not 
know  much  about  the  active  principle  of  the  thyroid 
gland  or  the  means  of  isolating  it,  the  choice  of  medi- 
cation will  have  to  remain  in  abeyance.  Thyroid 
glands  may  be  more  or  less  active,  and  the  preparations 
will  vary  accordingly.  Different  trials  made  on  stout 
persons  give  us  reason  to  believe  that  as  a  fat  reducing 
agent  it  is  a  weak  preparation.  We  think  in  a  gen- 
eral way  that  in  myxtedema  it  is  better  to  go  slowly; 
the  results  will  be  obtained  a  little  less  rapidly  per- 
haps, but  they  will  not  be  the  less  brilliant  for  having 
been  attained  without  danger.  The  etiology  of  this 
condition  has  been  advanced  through  the  researches 
of  Reverdin,  who  has  brought  up  a  number  of  prob- 
lems, however,  which  remain  to  be  solved.  Congeni- 
tal atrophy,  extirpation,  functional  suppression  of  the 
thyroid  body  bring  about  niyxcfdema ;  these  are  facts 
which  we  cannot  explain.  Does  the  thyroid  body 
normally  destroy  a  toxic  substance  which,  after  the 
extirpation  of  this  body,  accumulates  in  the  blood? 
Or,  on  the  contrary,  does  it  secrete  a, substance  neces- 
sary to  nutrition,  especially  to  that  of  the  ner\ous 
system ?  These  two  hypotheses  have  been  launched, 
but  the  fact  that  complicates  research  is  the  concomi- 
tance of  myxffdema  (^the  suppression  of  the  thyroid 
body)  and  the  disease  of  Basedow  ( hyperthyroidiza- 
tion),  which  is  not  impossible.  In  any  case  we  cannot 
deny  the  importance  of  the  thyroid  gland  in  the  nutri- 
tion of  certain  organs — that  of  bone,  for  example,  as 
the  occurence  of  dwarfishness  proves  in  congenital 
myxadema;  in  osseous  lesions  noted  in  animals  de- 
prived of  their  thyroid  glands,  to  which  Hofmei- 
ster  calls  attention;  of  the  nutrition  of  the  skin, 
either  ilirectly  or  more  probably  through  the  nervous 
system;  such  serious  troubles  being  noted  in  sub- 
jects of  myxoedema,  in  whom  the  ingestion  of  the 
thyroid  body  causes  certain  cutaneous  aftections. 
Hofmeister  has  also  noted  frequent  lesions  of  the 
ovaries  (atrophy  or  hypertrophy),  which  explains  the 
entire  absence  of  the  menses  in  this  disease.  These 
facts  suffice  to  show  that  in  spite  of  the  numerous 
works  on  this  subject  there  is  still  a  vast  field  for 
the  study  of  the  properties  ot  the  thyroid  body  open  to 
'.he  physiologist."' 


December  25,  1897] 


MEDICAL    RECORD. 


925 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


GEORGE    F.    SHRADY,  A.M.,  M.D.,  Epitor. 

Publishers 
WM.  WOOD  &  CO  .   43,  45,  &.  47  East  Tenth  Street. 


New  York,  December  25,  1897. 


LIVING    WITHOUT    A    STOMACH. 

In  these  days  of  rapid  progress  in  surgery,  hardly  any- 
thing in  the  way  of  brilliant  venture  in  operative  pro- 
cedure is  beyond  the  possibility  of  triumphant  ac- 
complishment. The  history  of  the  past  compared  with 
that  of  the  present  leaves  so  little  to  be  anticipated 
that  the  most  visionary  prophet  is  hardly  astonished 
when  his  wildest  dream  becomes  a  veritable  reality. 
Even  apparent  impossibilities  are  made  to  yield  to 
actual  demonstration,  and  still  newer  and  more  diffi- 
cult paths  are  constantly  opening  for  such  as  do  and 
dare. 

The  report  of  the  remarkable  case  of  successful 
extirpation  of  the  entire  stomach,  in  this  issue  of  the 
Medical  Recurd,  is  a  case  in  point  which  merits 
more  than  a  passing  reference.  By  the  courtesy  of  the 
ojjerator  and  the  enterprise  of  our  representative  at 
Zurich,  Dr.  E.  C.  Wendt,  we  are  enabled  to  publish 
for  the  first  time  a  full  and  detailed  account  of  this 
unique  and  most  remarkable  surgical  feat.  At  last 
accounts  the  patient  is  still  in  good  physical  condition, 
having  survived  the  operation  three  months.  The  re- 
sult, in  view  of  our  generally  accepted  notions  con- 
cerning the  real  value  of  the  stomach,  its  physiologi- 
cal place  in  the  economy,  and  the  essential  vital 
functions  so  long  claimed  for  it,  will  strike  all  with 
becoming  astonishment.  It  is  rather  an  une.xpected 
slight  to  what  has  always  been  considered  one  of  the 
essential  organs  of  the  body,  and  one  governing  all 
others  with  undisputed  sway  and  unquestioned  autoc- 
racy, to  imagine  that  it  may  not  be  of  much  use  after 
all.  Its  fabled  quarrel  with  the  other  parts  of  the 
body,  in  the  story  of  .Ksop,  would  appear  in  the  pres- 
ent light  as  scarcely  more  than  the  mythical  hypothe- 
sis of  a  wild  and  unreasonable  fabrication.  Whatever 
we  may  venture  pro  or  con  on  the  question  at  issue, 
the  fact  appears  to  be  proven  that  the  human  subject 
can  live  and  be  rea.sonably  active  for  months  at  a 
time  without  any  stomach  whatever,  and  obtain  all  the 
necessary  digestion  and  nourishment  from  what  re- 
mains of  the  intestinal  tract.  Is  it  possible  that  the 
latter  may  have  a  new  set  of  functions  not  yet  under- 
stood, or  has  the  importance  of  stomach  digestion 
been  misapprehended  and  overrated?  In  any  event 
we  are  now  brought  face  to  face  with  a  verv  curious 


demonstration,  which  destroys  the  validity  of  manv 
preconceived  opinions  and  in  a  great  measure  nullifies 
the  results  of  many  previous  experiments. 

In  the  matter  of  a  brilliant  achievement  the  opera- 
tion takes  a  first  rank,  and  the  daring  and  brilliant 
surgeon  will  receive  the  well-desened  congratulations 
of  his  peers  throughout  the  world.  He  has  opened 
the  first  chapter  in  a  new  history  of  surgical  triumphs. 


RECENT  PERSECUTION  OF  FRENCH  PHY- 
SICIANS AND  THE  IMPENDING  CHANGE 
IN    (  RIMINAL    L.\W. 

The  barbarous  peculiarities  of  the  French  penal  code, 
which  still  considers  every  accused  person  guilty  until 
he  has  clearly  established  his  innocence,  have  received 
a  fresh  illustration  in  the  case  of  a  prominent  physi- 
cian residing  near  Paris. 

The  unfortunate  victim  of  this  ■'  simple  judicial  er- 
ror," as  the  French  papers  flippantly  announce,  was 
imprisoned  for  months  on  the  absolutely  unsupported 
charge  of  a  hysterical  girl,  that  he  had  taken  undue 
liberties  with  her.  On  mere  denouncement  Dr.  Re- 
mond  was  literally  dragged  by  brutal  "police  officers'" 
from  his  private  office  to  the  common  jail.  Then, 
without  being  given  the  opportunity  of  a  hearing,  and 
with  no  chance  of  communicating  with  his  lawyers,  he 
was  transported  to  the  prison  of  Mazas.  The  latter, 
as  is  well  known,  is  filled  with  degraded  criminals  of 
the  worst  class.  Finally,  after  weeks  of  cruel  suffer- 
ing, the  doctor  succeeded  in  obtaining  a  hearing  before 
a  higher  court.  He  easily  proved  an  alibi,  having 
been  engaged  in  actual  consultation  with  several  col- 
leagues at  the  very  time  of  the  alleged  offence.  He 
was,  of  course,  completely  vindicated  and  honorably 
discharged.  But  the  law  of  France  apparently  allows 
him  no  redress,  either  against  the  family  of  the  girl 
who  conspired  to  ruin  him  or  against  the  magistrate 
who  so  unjustly  ordered  his  incarceration. 

Meantime  the  affair  is  being  exploited  bv  the  sen- 
sational press  of  Paris,  in  the  interest,  not  of  justice 
to  the  wronged  physician,  but  of  piquant  sensational- 
ism for  admirers  of  prurient  details.  Bearing  in  mind 
our  own  Barbara  Aub  case,  we  do  not  wish  to  be  over- 
critical  ;  but  at  least  we  have  wide-awake  medical 
societies  in  our  country-,  which  can  be  counted  on  to 
take  decisive  action  when,  as  in  this  case,  flagrant 
injustice  has  been  inflicted  upon  an  honorable  mem- 
ber of  the  profession. 

It  remains  to  be  said  that  this  case  is  but  one  of 
several  which  have  recently  "  happened"  in  France, 
and  which  have  attracted  the  attention  of  other  coun- 
tries. Even  the  staid  old  London  Times  feels  called 
upon  to  print  editorial  condemnations  of  so  truly  medi- 
eval a  -State  of  affairs.  However,  all  this  is  soon  to 
be  superseded  by  more  enlightened  and  humane 
methods  of  procedure. 


Dr.  Marie  Louise  Benoit  was  recently  appointed 
from  the  civil-service  list  a  medical  interne  in  the 
Craig  Colony  for  Epileptics  at  Sonyea. 


926 


MFDICAI.    RECORD. 


[December  25,  1897 


THE  BOARD  OF  ESTIMATE  AND  APPOR- 
TIONMENT AND  ITS  RELATION  TO  THE 
lAXPAYERS  OF  NEW  YORK  CITY. 
On  the  8th  of  December,  as  is  well  known  to  the  read- 
ers of  the  Medical  Record,  a  large  delegation  of  the 
physicians  of  the  City  of  New  York,  supported  and 
assisted  by  representatives  from  the  Deutsche  Apothe- 
ker  Verein  and  from  the  West  Side  Taxpayers'  Associ- 
ation, went  before  the  board  of  estimate  and  appor- 
tionment to  protest  against  the  granting  of  public 
moneys  for  the  use  of  private  institutions,  notably 
those  of  a  medical  character,  and  especially  such  as 
are  connected  with  medical  colleges.  Notwithstand- 
ing the  cogent  arguments  presented  by  the  spokesmen 
for  these  various  organizations,  the  protest  fell  upon 
deaf  ears;  indeed,  it  would  almost  seem  as  though 
the  arguments  advanced  might  just  as  well  have  been 
addressed  to  the  trees  in  the  City  Hall  Park  as  to  the 
board,  for  all  the  effect  that  they  had  upon  that  body. 
It  becomes,  therefore,  an  interesting  point  to  consider 
the  relation  which  this  board  bears  to  the  taxpaying 
public.  The  Medical  Record  believes  that  it  stands 
in  the  light  of  a  trustee  for  the  city  to  see  that  the 
moneys  raised  by  taxation  shall  be  used  for  public 
purposes  and  not  for  private  ends,  no  matter  how 
worthy  those  ends  may  be.  Suppose  that  any  one  of 
the  worthy  gentlemen  composing  the  board  of  estimate 
and  apportionment  were  the  trustee  of  a  private  estate ; 
the  Medical  Record  is  loath  to  believe  that  he  would 
give  one  cent  of  the  funds  of  the  estate  to  a  single  one 
of  the  private  charitable  institutions  upon  w^hich  the 
public  money  was  so  lavishly  bestowed,  merely  be- 
cause the  institution  was  such  a  worthy  charit}-  or 
because  the  trustee  knew  the  directors  of  the  charity. 
And  yet  these  gentlemen  in  their  corporate  capacitj- 
did  precisely  this  thing,  and  the  act,  although  a  pub- 
lic one,  is  just  as  culpable  as  though  it  had  been  done 
in  a  private  capacity.  It  is  high  time  that  attention 
should  be  called  to  the  iniquity  of  this  proceeding, 
which'  is  deser\'ing  of  reprobation  even  though  the 
raid  on  the  city's  treasury  is  done  in  the  name  of 
sweet  charitj',  and  this  action  is  doubly  iniquitous  be- 
cause some  of  these  institutions  do  not  stand  in  need 
of  the  money.  The  Medical  Record  trusts  that  the 
doctors  of  New  York  City  will  not  allow  the  matter  to 
rest  here,  but  will  persistently  and  temperately  urge 
upon  the  public  and  the  profession  the  necessity  of  a 
decided  change  in  the  manner  of  dispensing  public 
funds  for  private  charities. 


PROFESSIONAL    TRADES. 

The  exact  position  in  the  social  scale  occupied  by 
practising  physicians  has  at  last  been  settled — at  least 
so  far  as  England  is  concerned — by  the  courts.  Med- 
icine as  a  vocation  has  been  decided  to  be  a  trade. 
This  might  have  caused  no  little  feeling  of  injured 
pride  on  this  side  of  the  Atlantic,  were  it  not  for  a 
most  timely  intervention  on  the  part  of  one  of  our 
leading  luminaries  in  the  law.  Justice  Edward  Pat- 
terson of    the  supreme  court  has    just    iiaiuied  down 


his  decision  that  law  is  a  trade,  and  not  that  alone, 
but  that  lawyers  have  degenerated.  This  is  not  a 
strictly  ex-cathedra  dictum  and  might  even  be  regarded 
in  the  nature  of  a  private  opinion,  since  it  was  ex- 
pressed in  a  speech  at  the  Phi  Delta  Phi  Law  Club. 
Words  from  such  an  authorit)-,  whether  delivered  on 
or  off  the  bench,  must  be  taken  at  their  full  worth. 

We  are  glad  to  know  from  so  excellent  a  source  that 
law  too  is  a  trade.  Now  let  our  friends  of  the  cloth 
come  out  with  equal  candor  and  assure  us  that  they 
too  are  pleased  to  keep  us  company.  So  much  has 
happened  to  make  the  poor  devil  of  a  doctor  believe 
that  everything  combined  and  conspired  against  his 
welfare  and  happiness  that  it  is  really  cheering  to  read 
that  "the  lawyer  of  to-day  is  a  small  man,  because 
there  is  no  demand  for  large  ones.'' 

It  is  the  fault  of  the  times  in  which  we  live.  Pro- 
fessions were  a  necessity  in  the  good  old  days.  The 
era  of  electricity  and  machinerj-  has  seemed  to  remove 
the  raison  d'etre  of  much  that  was  formerly  useful  and 
ornamental.  Let  us  accept  the  inevitable  and  keep 
cheerfully  at  work  with  the  sustaining  consciousness 
that  lawyers  and  clergj'men  are  also  buckling  down 
to  their  respective  business  pursuits,  and  that  when 
called  to  attend  a  judge,  supreme  court  justice,  bishop, 
or  priest,  w-e  can  say  to  him,  "  Sir,  what  is  your  trade?" 


^eius  of  the  Mlcch. 

Petition  to  Change  the  Name  of  the  New  York 
York  Cancer  Hospital. — At  a  recent  meeting  of  the 
board  of  managers  of  the  New  York  Cancer  Hospital 
a  petition  was  presented,  signed  by  the  entire  visiting 
and  consulting  staffs,  to  change  the  name  of  the  hos- 
pital in  such  way  as  would  omit  the  verj'  objection- 
able and  unpopular  word  of  "  cancer"  in  its  title. 
The  appeal  was  respectfully  received  and  there  is  a 
hope  that  the  proper  steps  will  be  taken  to  make  the 
change  possible.  This  is  as  it  should  be.  The  name 
"  cancer"  is  particularly  odious  to  patients  suffering 
from  the  disease,  and  there  is  no  necessit}'  for  i^s  ap- 
plication to  one  of  the  best  equipped  surgical  hos- 
pitals in  Greater  New  York. 

Medical-Practice  Law  in  Washington  State — Dr. 
F.  H.  Coe,  se  retary  of  the  U'ashington  State  Medical 
Society,  writes  that  all  persons  intending  to  practise 
medicine  or  surgery  in  the  State  of  Washington  are 
obliged  to  pass  an  examination  before  the  State  board 
of  medical  examiners.  These  examinations  are  held 
the  first  Tuesday  in  January  and  the  first  Tuesday  in 
July.  The  Januar)-  meeting  is  held  on  the  west  side 
of  the  Cascade  Mountains,  and  the  July  meeting  on  the 
east  side.  No  temporary  certificates  are  granted  by 
this  board,  and  no  exception  is  made  to  this  rule. 

Typhoid  Fever  in  Paterson. — During  the  month 
ending  December  15th  the  number  of  cases  of  typhoid 
fever  reported  in  Paterson,  N.  J.,  was  109.  An  in- 
vestigation by  the  board  of  health,  as  already  stated, 
traced  the  epidemic  to  an  infected  milk  supply. 
Seventy  of  the  cases  occurred  in  families  supplied 
by  milk  from  one  dairy. 


December  25,  1897] 


MEDICAL    RECORD. 


927 


Mr.  Ernest  Hart,  whose  serious  illness  we  recently 
noted  with  regret,  is  now,  we  are  most  pleased  to  learn, 
practically  convalescent. 

The  Public  Spirit  of  a  Medical  Man. —  Mr.  Jon- 
athan Hutchinson,  of  London,  who  has  been  described, 
with  much  justice  and  quite  seriously,  as  an  "  all- 
around  specialist,'"  does  not  confine  himself  to  medi- 
cal teaching,  but  seeks  also  to  spread  a  knowledge  of 
useful  matters  among  the  people.  He  built  some  time 
ago  an  educational  museum  at  Haslemere,  near  which 
he  has  a  country  seat,  and  on  Sunday  afternoons  de- 
livers lectures  on  scientific  subjects.  A  coiu-se  re- 
cently delivered  was  on,  i,  instinct  and  habits:  2, 
epochs  in  man's  history;  3,  Browning  and  his  poetry; 
4,  improved  chronology;  5,  fungi:  6,  life,  death,  and 
terrestrial  immortality.  He  now  proposes,  it  is  said, 
to  establish  a  similar  institution  at  Selby.  his  native 
town. 

Paris  Schools. — The  restrictions  recently  placed 
upon  foreign  students  in  the  French  medical  schools 
have  been  rescinded  and  the  former  liberal  policy  has 
been  reestablished.  American  students  can  therefore 
matriculate  as  in  the  past. 

Approval    of   the    Marine    Hospital   Service A 

resolution  was  recently  adopted  in  the  Georgia  Legis- 
lature providing  that  in  ail  future  epidemics  all 
quarantine  matters  be  turned  over  to  the  United  States 
Marine  Hospital  Ser^'ice,  and  memorializing  Con- 
gress to  pass  a  national  quarantine  law. 

Strange  Action  of  College  Authorities.  —  \\  in- 
throp  College  for  girls  at  Rock  Hill,  S.  C,  has  been 
closed  indefinitely,  because  of  the  existence  of  smali- 
po.\  in  the  town.  It  is  incomprehensible  that  the 
authorities  should  prefer  to  break  up  a  large  school 
rather  than  protect  the  pupils  by  vaccination. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
December  18,  1897.  Surgeon  A.  C.  H.  Russell  de- 
tached from  the  Lamastfr  and  ordered  home  on  wait- 
ing orders. 

Philadelphia  Paediatric  Society — A  stated  meet- 
ing of  the  Philadelphia  Padiatric  Society-  was  held  on 
December  14th,  the  president.  Dr.  J.  P.  Crozer  Grif- 
fith, in  the  chair.  Dr.  F.  A.  Packard  reported  a  case 
of  tetanus  followed  by- recovery.  The  patient  was  a 
boy,  twelve  years  old,  and  the  source  of  the  disease 
.was  not  recognized,  although  the  mouth  was  in  an 
exceedingly  bad  condition  and  the  possibility  of  in- 
fection through  this  channel  was  considered.  Some 
.of  the  symptoms  were  suggestive  of  hysteria,  but  after 
recoverv  there  was  no  evidence  of  a  neurotic  state. 
Dr.  Packard  e.xhibited  also  two  brothers  with  pseudo- 
hypertrophic muscular  paralysis.  Both  displayed 
mental  deficiency  and  it  was  thought  also  enlargement 
of  the  thyroid  gland.  Dr.  Packard  e.xhibited  further  a 
cretin,  six  years  old.  Dr.  G.  Hudson  Makuen  ottered 
a  commimication  dealing  with  speech  defects  in  chil- 
dren and  methods  and  results  of  treatment.      He  e.x- 


hibited an  interesting  group  of  cases  displaying  most 
admirable  results  from  intelligent  educational  treat- 
ment. Dr.  E.  R.  Schreiner  read  for  Dr.  R.  G.Curtin 
the  report  of  a  case  of  arsenical  neuritis  developing  in 
the  course  of  treatment  of  an  attack  of  chorea  with 
Fowler's  solution.  Dr.  Clara  T.  Dercum  reported  a 
case  of  idiopathic  multiple  neuritis  in  a  child  five 
years  old.  Dr.  M.  H.  Fussell  described  an  otocephalic 
monster  and  exhibited  the  specimen.  Xominations 
for  officers  for  the  ensuing  year  were  made. 

Obituary  Notes — Dr.  G.  Perry  Reynolds,  medi- 
cal examiner  for  the  town  of  Guilford,  Conn.,  died  on 
December  9th,  aged  sLxty-eight  years.  He  was  a 
graduate  of  the  Xew  York  L'niversity  Medical  School 
in  the  class  of  1852. — Dr.  James  O.  V.\x  Hoevenberg 
died  at  his  home  on  Staten  Island,  from  tlie  results  of 
a  paralytic  stroke,  on  December  8th.  He  was  seventy- 
six  years  of  age. — Dr.  Joseph  R.  Lewi,  of  Albany, 
N.  Y.,  died  at  his  home  in  that  city  on  December  19th. 
He  was  born  in  1820.  and  was  graduated  in  medicine 
from  the  L'niversity  of  Yienna  in  1S47.  He  was  at- 
tending phvsician  to  the  Albany  Hospital,  a  member 
of  the  New  York  State  Medical  Society,  and  a  mem- 
ber and  ex-president  of  the  Albany  County  Medical 
Society.  He  leaves  two  sons,  physicians,  and  one 
son,  a  pharmacist,  as  well  as  two  daughters,  who  mar- 
ried physicians. — Dr.  Joseph  F.  Edwards  died  at 
Atlantic  City,  N.  J.,  on  December  6th,  of  shock  follow- 
ing an  operation,  necessitated  by  the  result  of  a  kick 
by  a  horse  some  two  years  ago.  Dr.  Edwards  was 
graduated  from  the  Cniversity  of  Peimsylvania  in 
1 88 1,  and  became  a  resident  physician  in  the  Phila- 
delphia Hospital.  He  was  for  three  years  State  prison 
inspector  at  Trenton,  X.  J.,  and  editor  of  the  Annals 
of  Hygiem  and  of  the  Daily  Lancet. 

Eastern  Medical  Society,  New  York. — The  follow- 
ing officers  were  elected  for  the  ensuing  year;  Dr. 
William  S.  Gottheil,  President ;  Dr.  A.  Isaacs,  First 
Viee-President ;  Dr.  E.  K.  Browd,  Second  Vice-Presi- 
dent;  Dr.  B.  Gordon,  Treasurer ;  Dr.  S.  Schaie,  Chair- 
man of  Committee  on  Admission ;  Dr.  R.  Abrahams, 
Recording  Secretary. 

College  of  Physicians  of  Philadelphia. — A  stated 
meeting  of  the  section  on  general  medicine  of  the 
College  of  Physicians  of  Philadelphia  was  held  on 
December  13th,  the  president  of  the  section.  Dr.  J.  C. 
Wilson,  in  the  chair.  Dr.  Alfred  Stengel  read  a  paper 
on  ••  Delayed  Resolution  in  Pneumonia,  and  Its  Treat- 
ment." Dr.  M.  H.  Fussell  reported  "Two  Cases  of 
Death  without  Discoverable  Cause."  In  neither  case 
did  the  conditions  during  life  give  rise  to  any  antici- 
pation of  a  fatal  issue,  and  this  remained  unexplained 
by  the  conditions  found  post  mortem. 

"The  Medical  Times." — In  the  issue  for  Decem- 
ber this  excellent  journal  celebrates  its  silver  anniver- 
sary. It  was  founded  a  quarter  of  a  century  ago,  wi'h 
the  main  object  in  \  iew  "to  bring  about  a  harmony  in 
the  medical  profession,  based  upon  toleration,  upon 
freedom  of  thought,  upon  scientific  investigation,  and 
upon  that  mutual  respect  and  courtesy  which  would 
naturally  be  expected  in   a   learned  profession  where 


928 


MEDICAL    RKCOKD. 


[December  25,  1897 


there  is  so  little  really  known  and  so  much  to  learn." 
We  congratulate  our  esteemed  contemporary  upon  its 
twenty-five  years  of  useful  activity,  and  wish  it  as  great 
success  in  the  years  to  come  as  it  has  won  for  itself  in 
the  past. 

Yellow-Fever  Inoculation.  Dr.  Domingos  Freiere, 
whose  claims  of  the  discovery  of  a  preventive  and  cur- 
ative vaccine  of  yellow  fever,  made  some  years  ago, 
were  not  sub.stantiated,  has  been  stimulated  apparently 
by  Sanarelli's  alleged  di.scovery  to  try  again.  The 
recent  application  of  his  serum  in  Rio  de  Janeiro  has, 
he  asserts,  been  most  successful,  having  reduced  the 
mortality  in  over  thirteen  thousand  cases  of  yellow 
fever  to  about  0.5  jjer  cent.  In  view  of  this  experi- 
menter's previous  claims,  it  will  be  wise  to  await  a 
more  complete  account  of  these  trials  before  consign- 
ing yellow  fever  to  the  limbo  of  forgotten  terrors  of 
ancient  days. 

The  Late  Dr.  William  Warren  Greene.  —  Dr. 
Charles  I.yman  Clreene,  of  St.  Paul,  writes  that  he  is 
making  an  effort  to  obtain  a  complete  list  of  the  arti- 
cles published  by  his  father,  the  late  William  Warren 
Greene,  of  Portland.  The  references  are  scattered  and 
difficult  to  obtain,  and  he  would  therefore  regard  it 
as  a  favor  if  any  of  the  old  students  or  professional 
friends  of  Dr.  (ireene,  who  have  reprints  or  references 
to  articles,  will  kindly  advise  him  concerning  them. 

The  African  Arrow  Poison. —  A  British  army  sur- 
geon, Dr.  Macpherson,  attached  to  a  military  expedi- 
tion in  the  Uganda  country,  claims  to  have  discovered 
that  the  injection  of  a  solution  of  strychnine  acts  as  an 
antidote  to  arrow  poison,  and  he  says  that  he  has  by 
this  means  saved  many  men  who  had  Ijeeii  wounded 
by  these  weapons. 

Yellow  Fever  in  Jamaica. — It  is  reported  that  .he 
epidemic  of  yellow  fever  in  this  island  is  practically 
at  an  end,  although  isolated  cases  are  still  reported  in 
Kingston  and  some  of  the  coast  towns.  The  authori- 
ties are  blamed  for  the  severity  of  the  visitation,  which 
is  attributed  to  the  policy  of  belittlement  and  conceal- 
ment which  they  adopted  in  the  beginning,  and  aban- 
doned only  when  the  deaths  of  several  prominent  per- 
sons made  further  concealment  impossible.  It  is  said 
that  it  will  be  perfectly  safe  for  Northerners  to  visit 
the  island  after  the  first  of  January. 

An   Example    Worthy  of    Imitation The  Citro- 

j^rapli,  of  Redlands,  (^al.,  is  a  journal  of  a  kind  of 
which  tliere  are  all  too  few.  It  refuses  to  disgrace  its 
columns  with  medical  advertisements  of  the  indecent 
sort  published  in  most  of  the  secular  papers.  It  is  a 
lamentable  fact  that  such  virtue  is  so  rare  that  exam- 
ples of  it,  when  discovered,  are  worthy  of  being 
recorded. 

The  New  York  Society  for  the  Relief  of  Widows 
and  Orphans  of  Medical  Men. —  i'he  fifty-sixth  an- 
nual statement  of  this  society  has  recently  been  issued. 
The  society  took  its  origin  at  a  social  gathering  of  the 
profession  at  the  house  of  Dr.  Kdward  Delafield  early 
in  1842,  and  a  formal  organization  was  completed  at  a 
meeting  held  November  26,  1842.  .\t  the  close  of 
1843  the  total  numl)erof  members  was  sixty.     In  1848 


the  membership  was  eighty,  in  1858  it  had  risen  to 
one  hundred  and  ten,  and  in  1870  the  roll  of  member- 
ship was  one  hundred  and  twenty-five.  The  members 
of  the  society  now  number  one  hundred  and  forty-five, 
of  whom  one  hundred  and  eight  are  life  and  thirty- 
seven  annual  members.  The  first  application  for  re- 
lief was  in  1852,  and  at  the  present  time  the  number 
of  beneficiaries  is  nineteen.  The  funds  of  the  society 
now  amount  to  $225,61 1;. 44,  securely  invested,  and  the 
income  for  1896-97  was  $9,793.23.  The  society  has 
extended  aid  to  fifteen  widows  and  four  children  of 
deceased  members  during  the  past  year.  Application 
for  membership  may  be  made  through  the  president, 
secretary,  or  any  member  of  the  society.  Under  the 
present  bylaws  of  the  society  the  annuities  allowed 
are:  to  the  widow  of  a  member  an  annuity  of  $400 
a  year,  but  for  every  ten  dollars  or  multiple  of  ten  of 
income  an  amount  equal  to  fifty  per  cent,  of  said  in- 
come shall  be  deducted  from  the  annuity.  Each  child 
entitled  to  relief  is  allowed  $100  per  annum,  subject 
to  the  same  conditions  as  a  widow. 

The  Charity  Hospital  Alumni  Association The 

following  officers  were  elected  at  a  meeting  of  this 
association,  held  December  8,  1897 :  President,  Dr. 
Walter  B.  Johnson ;  Viie-Fiesidcni,  Dr.  William  Le- 
land  Stowell ;  Secretary,  Dr.  Charles  J.  Proben ;  Treas- 
urer, Dr.  Henry  H.  Schroeder;  Editor,  Dr.  A.  T. 
Muzzy. 

ODliituary. 

J.   BERRIEN    LINDSLEV,  M.D., 


Dr.  J.  Berrien  Lindsley  died  at  his  home  in  Nash- 
ville, Tenn.,  on  December  7th,  at  the  age  of  seventy- 
five  years.  He  was  born  at  Princeton,  N.  J.,  in  1822, 
his  father,  the  Rev.  Phillip  Lindsley,  having  been  at 
one  time  president  of  Princeton  College  and  later 
of  the  University  of  Nashville.  He  received  his 
medical  degree  from  the  University  of  Pennsylvania, 
in  1843,  and  immediately  thereafter  began  to  study 
for  the  Presbyterian  ministry,  being  ordained  in  1846. 
He  preached  for  a  time  but  his  love  for  science  was 
too  great.  He  studied  geology  imder  Gerard  Troost, 
and  made  an  extensive  geological  survey  of  the  North- 
ern and  Eastern  States.  Later  he  went  to  Europe  and 
studied  in  the  medical  .schools  of  Germany  and 
France.  He  was  one  of  the  founders  of  the  medical 
department  of  the  I'niversity  of  Nash\  ille.  For  the 
last  twenty  years  he  was  very  active  in  promoting 
public-health  measures.  In  1876  he  was  appointed 
health  officer  of  Nashville  ;  in  1880  he  was  elected 
to  the  chair  of  "  State  Preventive  Medicine"  in  the 
medical  department  of  the  L'niversitv  of  Tennessee  ; 
in  1877  he  liecanie  a  member  of  tlie  State  board  of 
health. 

At  the  tinii;  of  liis  death  Dr.  Lindsley  was  a  mem- 
ber of  the  Numismatic  and  Antiquarian  Society,  of 
Philadelphip ;  a  charter  member  of  the  .American 
Chemical  Society;  since  185 1  a  member  of  the 
.American  Medical  .\s.sociation  ;  a  fellow  of  the  .Ameri- 
can Academy  of  Medicine:  a  director  in  the  National 
Prison  .Association;  a  corresponding  member  of  the 
National  Prison  .Association  of  France ;  and  treas- 
urer an(^  the  Soutliern  member  of  the  executive  com- 
mittee of  the  .\nierican  Public  Health  .Association. 
Dr.  Lindsley  was  the  author  of  many  treatises  and 
shorter  articles  on  medical,  historical,  and  theological 
subjects.     .A  widow  and  five  children  survive  him. 


December  25,  1897] 


MEDICAL    RECORD. 


929 


©orrcspoutleucc. 

OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

MEDICAL    COUNCIL,  NEW    PHARMACOPCEIA,   PRELIMINARY 

EXAMINATIONS,       UNQUALIFIED       ASSISTANTS ROYAL 

SOCIETY — UNIVERSITY — M  E  D  I  C  O-C  HIRURGICAL 

society's    DEBATE    ON      PREVENTION     OF     TYPHOID 

CLINICAL    society's    ADJOURNED    DEBATE    ON      POTT's 

DISEASE — .MAIDSTONE — SIR  W.   COWERS SIR    H.    BUR- 

DETT — DEATH    OF    MR.    FREEMAN,    OF    B.'VTH. 

I-oNDON,  December  3,  iSgy. 

The  General  Medical  Council  continued  its  sitting 
for  the  usual  time,  and  a  good  deal  of  routine  business 
was  got  through  and  a  number  of  cases  of  alleged  in- 
famous conduct  were  tried. 

More  interesting  to  you  will  be  the  announcement 
that  the  new  pharmacopceia  is  now  only  to  be  seen 
through  the  press  and  will  be  published  early  in  the 
new  year.  The  council  was  assured  by  those  who  had 
had  a  hand  in  it  that  the  work  will  do  them  great 
credit,  surpassing  all  its  predecessors. 

On  the  question  of  preliminary  education  the  coun- 
cil proved  weak  kneed.  It  is  there  that  more  strin- 
gency is  needed.  Several  of  the  preliminary  examina- 
tions accepted  by  the  council  are  mere  school  tests, 
quite  inadequate  for  entrance  to  a  profession.  Dental 
matters  took  up  a  good  of  time  on  Tuesday. 

The  wail  of  the  unqualified  assistant  is  already 
audible  and  will  no  doubt  soon  be  heard  throughout 
the  land.  But  the  decision  of  the  council  cannot  be 
appealed  from,  and  his  occupation  is  gone.  It  is  ad- 
mitted that  a  number  of  worthy  men  must  suffer,  but 
so  it  is  in  other  reforms,  and  no  one  can  dispute  that 
the  repression  of  all  unqualified  practice  is  for  the 
good  of  the  public  as  well  as  the  profession.  The 
council  should  now  seek  powers  to  put  an  end  to  the 
grosser  frauds  of  druggists,  abortionists,  quacks,  and 
other  parasites  of  the  profession. 

Lord  Lister  presided  at  the  annual  meeting  of  the 
Royal  Society,  which  was  held  on  Tuesday,  and  at  the 
dinner  in  the  evening.  Both  functions  were  success- 
ful. The  Duke  of  Devonshire  delivered  an  important 
speech  deprecating  the  divorce  that  has  too  long  ex- 
isted between  science  and  politics,  and  intimating  that 
the  government  (of  which  he  is  a  member)  will  again 
introduce  its  measure  for  a  teaching  university  in 
London.  This  will  probably  send  the  proposed  West- 
minster University  into  the  limbo  of  the  score  of  for- 
gotten schemes  that  !ia\e  preceded  it.  The  present 
London  L'niversity,  a  mere  examining  body,  must  be 
propitiated  or  superseded.  Its  senate  has  already  in- 
vited a  conference  of  the  educational  bodies  which 
were  recognized  in  the  last  bill. 

The  discussion  by  the  Medico-C'hirurgical  Society 
on  the  prevention  of  typhoid,  though  it  has  not  added 
to  our  knowledge  of  the  subject,  has  set  in  order  some 
of  the  more  important  points,  reinforced  the  convic- 
tions of  many,  and  brought  into  focus  the  views  of 
some  of  our  most  advanced  sanitarians.  The  opening 
of  the  debate  was  committed  to  Dr.  Vivian  Poore,  who 
holds  very  strongly  that  the  proper  way  of  dealing 
with  sewage  is  to  return  the  solids  to  the  land  and  the 
liquid  to  our  rivers.  Having  shown  how  easy  it  is  for 
our  water  supplies  to  become  polluted,  he  remarked 
that  "  public  water  supplies  mu.st  be  regarded  as  causes 
of  the  epidemicity  of  enteric  fever."  It  must  be  ad- 
mitted that  when  polluted  they  diffuse  the  poison  with 
completeness  and  insure  its  being  brought  to  our 
mouths.  Hence  he  urged  that  as  many  subdivisions 
as  possible  should  be  arranged  and  the  supplies  from 
different  sources  should  never  be  mixed.     Dr.  Poore 


was  obliged  to  admit  that  towns  would  not  readily 
abandon  their  waterclosets,  and  that  for  London  it 
seemed  impossible  to  do  so.  Nevertheless,  he  lamented 
that  people  were  being  taught  that  the  most  decent  way 
of  treating  fa;ces  is  to  mix  them  with  water,  whereas 
they  ought  to  be  applied  to  the  land  and  become  a 
source  of  wealth  and  beauty  while  safeguarding  health. 

Professor  Gairdner  said  that  of  late  years  his  ex- 
perience in  fevers  had  been  small,  as  the  Glasgow  local 
authorities  had  taken  over  the  fever  hospitals.  He  re- 
marked that  even  now  polluted  water  did  not  account 
for  all  cases,  milk  being  a  frequent  purveyor  of  the 
poison.  He  mentioned  an  epidemic  among  the  stu- 
dents which  was  at  once  arrested  by  stopping  the  supply 
of  milk  to  the  restaurant  within  the  university. 

Sir  Richard  Thorne  Thome  took  up  the  cudgels  on  the 
part  of  the  water  system,  and  of  course  had  no  difficulty 
in  showing  the  impossibility  in  large  cities  of  returning 
all  fa;ces  to  the  soil.  He  admitted  that  with  thorough 
tillage  there  was  little  danger  in  applying  excreta  to  the 
soil^ — that  is  normal  dejecta ;  but  it  remained  to  be  seen 
whether  specific  excreta  could  safely  be  thus  utilized. 
Dr.  S.  Martin  had  been  investigating  for  the  local 
government  board  the  occasional  persistence  of  typhoid 
in  particular  localities.  He  found  that  typhoid  bacilli 
would  grow  for  only  a  few  days  in  sterilized  virgin 
soil,  but  in  soil  containing  sewage,  sterilized  in  the 
same  way,  the  growth  went  on  for  two  hundred  days. 
It  had  been  shown  by  others  that  in  soil  containing 
sewage  the  bacilli  would  remain  quiescent  in  the  win- 
ter and  begin  to  grow  rapidly  when  warm  weather  re- 
turned. He  admitted  that  burning  was  safer  than 
burial  for  the  disposal  of  typhoid  excreta,  and  said 
the  best  way  w'as  to  mix  them  with  sawdust  and  par.- 
affin  and  burn  them. 

Prof.  Rubert  Boyce,  of  Liverpool,  pleaded  for  sys- 
tematic bacteriological  examinations  as  the  best  means 
of  preventing  typhoid.  The  contents  of  drain  and 
water  pipes  as  well  as  other  possible  causes  he  would 
have  submitted  to  frequent  bacteriological  examination. 
Laboratories  have  indeed  been  established  for  this 
purpose  by  some  medical  officers  of  health,  and  their 
example  ought  to  be  generally  followed. 

Dr.  D.  S.  Davies,  of  Bristol,  gave  an  account  of  the 
recent  epidemic  at  Clifton  and  Bristol,  which  he  had 
shown  within  four  days  was  due  to  one  milk  supply. 
That  was  cut  off  and  the  epidemic  subsided.  Some 
rather  misleading  cases  had  been  shown  to  occur 
through  other  milk  venders  supplementing  their  sup- 
ply from  the  polluted  farm.  Dr.  Davies  would  like 
a  law  to  empower  sanitary  authorities  to  inspect  and 
license  dairies. 

The  Clinical  Society  has  devoted  another  evening 
to  M.  Calot's  plan  of  immediate  reduction  of  spinal 
curvature  in  Pott's  disease.  The  president  opened  by 
reading  a  translation  of  the  paper  submitted  by  M. 
Calot,  and  the  secretary  followed  with  some  remarks 
contributed  by  M.  Redard,  of  Paris,  who  was  pre- 
vented from  being  present.  Dr.  Redard  is  much  in 
favor  of  the  operation;  he  has  performed  it  in  forty 
cases,  without  a  single  mishap  or  any  kind  of  compli- 
cation. He,  however,  admitted  that  all  cases  were  not 
amenable  to  the  treatment,  and  he  had  restricted  the 
operation  to  those  in  which  reduction  was  easy.  He 
was  utterly  opposed  to  any  rough  or  violent  manipu- 
lation, and  to  any  attempt  to  correct  ankylosed  curva- 
tures. 

Mr.  Watson  Cheyne  said  he  thought  the  subject  was 
hardly  ripe  for  discussion,  and  they  had  to  deal  not 
only  with  deformity  but  with  a  disease.  There  were 
l)lenty  of  cases  recorded  already  to  enable  an  opinion 
to  be  formed  in  due  time,  and  until  then  he  thought  it 
would  be  better  to  suspend  operating. 

Differences  of  opinion  on  this  matter  were  expressed 
by  the  surgeons  pre.sent,  and  .Messrs.  Jones  and  Tubby 


930 


MEDICAL    RFXORD. 


[December  25,  i{ 


replied  to  the  criticisms  whicli  had  been  offered  on 
their  paper.  They  both  believe  in  the  future  of  Calot's 
plan,  and  consider  it  the  best  means  of  remedying  the 
deformity  and,  moreover,  of  treating  the  disease. 
Their  experience  has  shown  that  the  theoretical  dan- 
gers anticipated  need  not  be  dreaded  in  proper  cases. 
They  promised  to  bring  forward  these  cases  at  a  later 
date,  when  judgment  of  the  results  may  be  more  safely 
formed. 

Maidstone  is  not  yet  free  from  the  epidemic  of 
typhoid.  Two  fresh  cases  were  notified  yesterday, 
bringing  the  total  up  to  eighteen  hundred  and  seventy- 
seven. 

The  dinner  in  honor  of  Sir  William  Gowers  was  a 
great  success. 

Sir  H.  Burdett  maintains  his  attitude  about  hos- 
pitals, but  the  indignation  of  general  practitioners  is 
increasing. 

Mr.  H.  W.  Freeman,  surgeon  to  the  Bath  Hospital, 
and  author  of  the  '"  Thermal  Baths  of  Bath,"  died  on 
the  2ist  ult.,  aged  fifty-five  years.  He  was  an  able 
and  zealous  surgeon.  Bath  delighted  to  honor  him. 
He  was  mayor  of  the  "City  of  the  Warm  Vale"  in 
1889.  He  had  a  rather  rare  hobby  for  a  doctor — a 
studfarm  of  thoroughbred  horses,  at  which  he  took  a 
few  hours'  rest  when  practice  permitted. 


But  the  object  of  this  communication  was  not  to 
criticise  others.  It  was  to  thank  you  for  giving  us  a 
medical  journal  full  of  able  reading-matter — and  read- 
ing-matter only — and  to  assure  you  that  the  intelligent 
part  of  the  medical  profession  is  duly  conscious  and 
appreciative  of  your  far-seeing  policy. 

WiLLiA.M  J.  Robinson,  M.D. 

119  East  One  Kindred  a.nd  Twentv-eichth  Street. 
December  15,  1897. 


"HONOR   TO    WHOM    HONOR    IS    DUE." 


Sir:  I  believe  in  giving  honor  where  honor  is  due. 
As  1897  is  drawing  to  a  close  and  the  Medical  Rec- 
ord is  about  to  enter  upon  a  new  year  of  usefulness, 
I  wish  to  thank  you  for  your  highly  commendable 
policy  in  refusing  to  admit  into  your  reading-pages 
any  advertisements  in  disguise.  I  make  no  accusa- 
tions. I  do  not  say  that  the  doctor  who  e-xtols  to 
heaven  Blank's  iron  preparation,  or  relates  his  mar- 
vellous success  with  A.,  B.  &  Co.'s  mixture,  gets  re- 
munerated for  his  labor;  he  may,  and  then  again  he 
may  not.  He  may  write  his  article  in  perfect  sincer- 
ity and  good  faith,  simply  wishing  to  render  a  service 
to  his  medical  confreres  in  bringing  to  their  notice 
the  virtues  of  a  valuable  preparation.  Nor  do  I  say 
that  the  publisher  necessarily  gets  a  check  for  print- 
ing such  articles.  But  why  serve  such  articles  under 
a  he^vy  disguise?  Why  sail  under  false  colors? 
Every  one  will  admit  that  it  is  exceedingly  disagreea- 
ble and  trying  to  one's  patience  to  be  reading  a  pre- 
sumably scientific  article,  perhaps  to  become  inter- 
ested in  the  course  and  the  details  of  a  severe  disease 
— and  then  all  at  once  to  perceive  that  the  whole  thing 
is  a  carefully  and  shrewdly  masked  eulogy  of  some 
proprietary  compound.  I  do  not  know  how  others  feel 
about  it,  but  I  feel  as  if  I  had  been  imposed  upon,  as 
if  I  had  been  cheated  out  of  time  and  mental  labor. 
More  than  once  have  I  hurled  such  a  journal  into  the 
wastebasket. 

A  recent  number  of  a  reputable  journal,  for  the  eru- 
dition and  professional  standing  of  whose  editor  I 
entertain  the  highest  respect,  contained  eight  "origi- 
nal" articles.  No  less  than  seven  contained  recom- 
mendations for  certain  proprietary  preparations.  The 
eighth  contained  a  recommendation  of  a  newly  intro- 
duced "modified  milk."  If  this  is  not  a  flagrant  im- 
position, what  is  it?  The  proper  place  for  such  con- 
tributions is  in  the  advertising  pages  of  the  journals 
and  in  the  manufacturers'  monographs.  But  if  for 
some  reasons  they  must  be  printed  in  the  body  of  a 
respectable  journal,  why  not  at  least  print  them  under 
their  proper  headings :  "  The  NN'onderf ul  Effects  of 
Blank's  Iron  Preparation  in  Anaemia  and  Chlorosis,'" 
etc.?  Then  the  reader  sees  what  he  is  getting,  and 
he  can  ha\e  his  choice — to  read  or  not  to  read. 


THE    SPITTING-NUISANCE. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  I  am  of  the  opinion  that  any  wholesome  idea 
which  has  for  its  purpose  the  benefit  of  the  community 
at  large  will  bear  repetition  until  it  reaches  the  ear, 
the  eye,  irritates  all  senses  of  those  whom  it  should 
concern,  and  compels  them  to  have  this  suggestion 
materialized  and  brought  into  life. 

I  was  delighted  with  the  able  and  timely  letter  of 
Dr.  W.  -J.  Robinson  in  your  issue  of  last  June,  and 
was  waiting  to  see  the  fruits  brought  about  by  his  la- 
bors. But,  alas  I  months  passed — the  hot,  summer 
months — and  the  same  nuisance  continues,  and  no 
measures  have  been  taken  to  exterminate  it. 

Our  current  medical  literature  teems  with  articles 
about  sanatoriums  for  our  tuberculous  patients,  recom- 
mends new  methods  and  drugs,  expounds  new  theories, 
how  to  do  away  with  the  unpardonable  existence  of 
the  microbes — and  here  under  our  eyes  the  dissemina- 
tion of  germs  of  all  kinds  and  denominations  is  going 
on  without  the  least  hindrance  on  the  part  of  the 
authorities.  I  refer  to  the  spitting-nuisance  in  our 
surface  cars  and  other  public  places.  Where  shall 
one  spit? 

On  entering  the  elevated  and  some  of  the  cable  cars, 
one  sees  a  "warning"  conspicuously  displayed  in 
some  corner,  "warning"  us  not  to  expectorate  on  the 
floor,  and  this  is  issued  by  the  board  of  health.  "  It 
is  a  timely  ordinance,"  one  thinks  to  himself.  But 
the  same  one  becomes  painfully  disappointed  when 
his  wandering  eye  fails  to  discover  any  substitute  which 
should  have  accompanied  the  above  order.  Where  is 
the  logic,  the  common  sense  ? 

This  neglect  in  providing  the  public  with  such  an 
indispensable  utensil  reminds  me  of  an  ancient  story, 
which  reads  thus:  "Marcus  Licinius  Crassus,  the 
Rich,  invited  once  upon  a  time  the  famous  cynic  phi- 
losopher, Diogenes,  to  his  palace,  with  the  intention  of 
displaying  before  him  his  wealth.  The  latter  accepted 
the  invitation,  and,  while  expressing  to  his  host  his 
admiration  of  all  he  beheld,  he  was  taken  with  a  fit  of 
coughing — and  spit  his  raised  sputum  into  the  face  of 
the  almighty  First  Triumvir  Crassus.  In  reply  to  the 
indignant  protest  of  the  latter,  the  cynic  said:  'Sir, 
this  is  the  dirtiest  place  in  your  palace.'  " 

Now  is  not  this  "  warning"  alluded  to  above  a  mere 
mocker)?  Is  this,  again,  a  law  or  order  imposed  upon 
a  public  to  be  violated  simply  because  it  cannot  physi- 
cally abide  by  it  ?  Where  shall  one  spit  when  there 
are  no  spittoons  to  be  found  on  the  floor? 

The  act  of  expectorating  on  floors  is  so  revolting  to 
all  senses  of  decency  and  propriety,  not  only  to  those 
who  are,  nokiis  :okiis,  compelled  to  look  at  it,  but  even 
to  the  perpetrator  himself,  that  were  there  any  means 
on  hand  to  avoid  it  every  person  of  any  degree  of 
education  would  surely  avail  himself  of  it  and  not 
commit  any  nuisance. 

Hundreds  of  invalids,  afflicted  with  pulmonary  or 
laryngeal  tuberculosis,  chronic  bronchitis,  syphilis, 
etc.,  are  crowding  daily  the  cars  on  their  way  to  the 
large  dispensaries — and  these  people  must  spit,  they 
must  dislodge  their  expectoration  somewhere.  They 
can't   help    it — this    is   their  misfortune.      Shall  we 


December  25.  1897] 


MEDICAL    RECORD. 


931 


"  warn"  them  not  to  expectorate,  or  provide  them  with 
properly  adjusted  spittoons  in  accordance  with  modern 
sanitar)-  requirements?  We  believe  that  the  latter 
would  be  the  proper  course  to  pursue.  But  then  there 
would  be  no  need  of  "warnings." 

Physicians,  the  public's  ever-ready  sanitary  guard, 
in  their  respective  societies,  and  every  public-spirited 
citizen  individually,  must  see  to  it  that  charily  begins 
at  home :  that  inasmuch  as  sanatoriums  are  concededly 
an  urgent  necessit}-,  there  is  a  cr)-ing  need  to  spare 
the  community  the  spitting-nuisance.  Half-measures 
are  no  measures.  To  enact  laws  without  offering 
adequate  means  to  carrj-  them  out  is  to  educate  citizens 
to  violate  laws  unwittingly.  And  the  remedy  is  so 
simple!  Henry  Leviex,  M.D. 


VACCIXATIOX    BY    THE    HEALTH    DE- 
PARTMENT. 

To  THE  Editor  of  the  Medic.\l  Record. 

Sir  :  Is  it  not  possible  to  correct  the  abuses  to  which 
the  profession  and  the  people  are  subjected  by  the 
health  department,  or  must  we  suffer  in  silence? 

Is  it  not  time  that  medical  men  should  assert  them- 
selves when  the  health  department  assumes  that  the 
latter  are  as  a  body  untruthful,  and  that  the  name  of  a 
reputable  physician  signed  on  a  schoolboy's  certificate 
of  vaccination  stands  for  naught,  if  not  for  a  lie?  Vet 
such  is  the  fact. 

In  discussing  the  question  of  school  vaccination 
and  the  inspection  of  schoolchildren,  I  learned  to- 
day from  one  of  the  health-department  vaccinators  that 
they  have  received  the  following  instructions  from 
their  superiors: 

That  they  must  vaccinate  a  cenain  number  (seven- 
teen) of  children  each  day. 

And  that,  as  concerns  certificates  of  satisfactory 
vaccination  held  by  children  who  have  received  them 
from  private  physicians,  they  should  first  vaccinate 
the  child  and  then  look  at  the  certificate! 

.\s  a  physician  and  a  gentleman  I  protest  against 
any  such  high-handed  and  insolent  disregard  of  a 
certificate  given  by  me  to  a  patient  who  pays  me  for 
the  ser\-ice,  on  the  part  of  the  health  department  or 
any  one  else.  I  protest  against  the  injur}-  done  me 
when  the  health  department  says  to  a  patient  that  my 
certificate  is  not  to  be  respected,  because  doctors  sign 
such  certificates  whether  the  case  merits  one  or  not. 
If  they  find  any  such  case  let  them  discipline  the  man 
at  fault,  instead  of  casting  a  slur  on  the  profession  at 
large. 

As  to  the  duty  of  vaccinating  a  given  number  of 
cases  each  day,  it  leads  to  an  entire  disregard  of  the 
right  of  parents  to  object  to  having  their  children 
vaccinated  by  the  health  department's  irresponsible 
young  men,  who  overlook  the  injustice  they  do  to  the 
people  and  the  profession  in  their  an.xiety  to  draw 
their  salary.  It  leads  to  the  pitiful  state  of  affairs, 
wherein  a  woman,  holding  in  her  arms  an  infant  sick 
with  vaccinia  and  a  very  sore  arm — the  result  of  a 
health-department  vaccination — has  her  second  child 
(two  years  oldi  vaccinated  in  spite  of  her  earnest  plea 
for  a  little  delay,  out  of  consideration  for  her  difficult)- 
in  caring  for  the  infant,  because  the  vaccinator  needed 
one  more  name  to  make  up  his  seventeen.  This  case 
came  within  my  observation,  and  I  saw  this  poor 
woman,  in  the  midst  of  her  troubles,  endeavoring  to 
look  after  her  home  and  care  for  the  two  children,  both 
of  whom  had  very-  bad  arms.  She  told  me  this  story 
with  tears  of  genuine  sorrow. 

Have  we,  have  the  jseople,  no  voice  in  these  matters, 
or  must  we  bend  the  back  and  suffer? 

WlLLI.\M    J.  GRE.ANELLE,  M.D. 
University  Heights,  Kew  York  City. 


"SHOULD    MINISTERS    PAY    DOCTORS?" 

To  THE  Editor  of  the  Medical  Record. 

Sir:  Apropos  of  your  query-,  "Should  Ministers  Pay 
Doctors?"  I  would  like  to  relate  an  incident  that  hap- 
pened several  years  ago  in  a  small  town  something 
less  than  a  thousand  miles  from  here.  I  was  sum- 
moned one  morning  to  see  the  son  of  a  local  minister. 
The  boy  was  an  only  child:  he  was  the  idol  of  his 
parents,  and  all  their  hopes  were  centred  in  him.  His 
sickness  developed  into  one  of  the  worst  cases  of  ty- 
phoid fever  I  have  ever  seen,  and  I  attended  him  as- 
siduously day  and  night:  for  weeks  his  life  hung  in  a 
balance,  and,  in  addition  to  being  the  physician  in  the 
case,  I  was  called  upon  to  do  a  large  share  of  the 
nursing.  Finally  he  began  to  improve,  and  with  care 
and  attention  his  recover}-  was  assured.  The  minister 
and  his  wife  could  hardly  find  words  with  which  to 
e.\press  their  gratitude;  they  fairly  wept  for  joy,  and 
assured  me  that  they  were  under  everlasting  obliga- 
tions to  me  for  having  saved  their  darling.  Some 
time  after  the  case  was  discharged  the  minister  called 
to  see  me  and  asked  for  my  bill.  I  told  him  that  I 
had  no  bill  against  him,  and  that  I  made  it  a  rule  not 
to  charge  the  local  ministers  for  my  services.  He 
left  with  the  most  profuse  thanks  and  ever}-  assurance 
of  gratitude,  etc.  Two  or  three  weeks  later  I  met  him 
again :  he  said  he  had  talked  the  matter  over  with  his 
wife,  and  they  had  decided  that  it  was  nothing  but 
just  and  right  that  I  should  be  paid  for  having  saved 
their  precious  boy:  they  were  anxious  to  show  their 
gratitude  in  a  practical  manner,  and  they  would  feel 
very  much  hurt  unless  I  accepted  something  from 
them.  I  told  him  then  to  send  me  whatever  he 
thought  would  be  a  proper  fee  for  attending  so  grave 
a  case,  and  that  I  would  leave  it  entirely  with  him. 
A  few  nights  after  this  I  returned  home  from  a  long 
and  tiresome  drive  in  the  countr}-,  and  had  sat  down 
to  a  cold  and  scanty  supper,  when  my  wife  smilingly 
brought  forth  a  package  carefully  wrapped  and  tied, 
and  addressed  to  me  with  the  compliments  of  Mr.  and 
Mrs.  So-and-So.  We  were  all  agog  with  curiosity 
and  excitement,  and  couldn't  open  that  package  fast 
enough ;  we  didn't  take  time  to  untie  the  string,  we 
cut  it,  and  after  removing  sheet  after  sheet  of  wrap- 
ping-paper came  to  a  pasteboard  box — a  shoe  box. 
We  lifted  the  lid  carefully,  and  there  in  the  bottom  of 
that  box  reposed,  not  a  gold  watch  and  chain  or  a  cut- 
glass  vase,  but  a  pineapple — a  miserable,  little,  wea- 
zened, shrivelled-up  pineapple,  that  could  have  been 
bought  anywhere  in  that  county  for  five  cents!  I 
learned  afterward  that  my  ministerial  friend  had  been 
presented  with  a  barrel  of  them.  "  Should  ministers 
pay  doctors?"     They  pay  me. 

JUNILS  F.  Lv.VCH,  M.D. 
Norfolk.  Va..  December  ii.  i^~. 


Placenta  Praevia. — External  version  is  recom- 
mended in  placenta  pravia,  so  that,  the  presentation 
being  made  pelvic,  the  hemorrhage  may  be  arrested 
by  drawing  down  and  keeping  up  traction  on  a  foot. 
The  version  is  generally  possible,  as  the  placenta  pre- 
vents the  early  engagement  of  the  head :  after  it  has 
been  performed,  if  the  os  is  not  sufficiently  dilated  to 
admit  two  fingers,  when  bleeding  begins  one  must 
apply  a  tampon  and  wait:  if  the  genitals  are  relaxed, 
it  is  generally  easy,  even  without  an  ana;sthetic,  to 
bring  down  a  foot,  and  by  moderate  and  steady  trac- 
tion to  deliver  the  woman  without  further  loss  of 
blood.  If  the  bleeding  be  severe  and  alarming,  it  is 
better  to  employ  combined  podalic  version  at  once,  or 
to  apply  a  tampon  before  attempting  external  version. 
—  Bal-m.v,  Centralb.f.  Gyndkol.,  No.  39,  1896. 


932 


MEDICAL    RECORD. 


[December  25,   1897 


'XMvupnxtic  gtiiits. 

Tuberculous  Laryngitis. — A  combination  of  lactic 
acid  and  carbolic  acid  in  glycerin  is  recommended 
for  tuberculous  laryngitis,  on  the  theory  that  there  will 
be  less  irritation  from  the  lactic  acid,  on  account  of 
the  anaesthetic  effect  of  the  carbolic  acid.^DR.  Botey, 
Kansas  Medical  Journal,  May  ist. 

Diseases  of  the  Bile  Ducts.—When  it  is  borne  in 
mind  that  the  bile  ducts  have  only  a  limited  calibre, 
that  the  mucous  lining  is  capable  of  swelling  so  as  to 
occlude  the  passage,  and  that  the  secretion  of  biJe 
takes  place  under  very  low  blood  tension  (according 
to  Naunyn  one  hundred  and  ten  to  two  hundred  and 
twenty  millimetres  of  water),  and  is  therefore  arrested 
by  slight  backward  pressure,  it  is  easy  to  comprehend 
how  catarrh  in  this  situation  should  lead  to  jaundice, 
though  absolute  proof  of  the  correctness  of  the  theory 
is  wanting,  since  simple  catarrhal  jaundice  furnishes 
no  post-mortem  subjects. — Dr.  Mayo  Robson,  Lancet, 
May  29th. 

To  Avoid  Complications  in  Measles — Take  a 
flannel  blanket,  wring  it  out  of  water  as  hot  as  the  hand 
can  bear,  and  wrap  the  patient  up  in  this  with  cold 
cloth  on  the  head.  Keep  him  in  pack  about  twelve 
or  fifteen  minutes;  then  transfer  to  a  dry  blanket  and 
allow  him  to  cool  gradually;  this  brings  the  eruption 
to  the  surface  and  relieves  the  mucous  and  serous  mem- 
branes. If  necessary,  give  antipyretics  for  fever  and 
sedatives  for  cough.  I  have  never  had  any  complica- 
tions with  this  treatment. — Merrimars,  Kansas  City 
Medical  Index. 

The  Course  of  Bronchitis. — Recovery  from  bron- 
chitis depends  greatly  upon  two  things:  First,  the 
condition  of  the  bronchial  lymphatics,  and  second,  the 
condition  of  the  nervous  system,  i.  When  the  mucus 
that  is  poured  out  in  large  quantities  is  not  rapidly 
absorbed,  then  the  case  is  apt  to  be  prolonged  because 
the  reabsorbent  glands  are  not  active.  In  such  cases 
it  is  a  mistake  to  give  remedies  that  will  loosen  the 
cough.  A  loose  cough  is  apt  to  be  a  protracted  cough. 
Lessen  the  inflammation,  and  the  cough  will  usually 
subside.  2.  When  the  nervous  energies  of  the  lungs 
are  deranged,  that  would  give  us  atelectasis  in  the 
young  and  old.  Then  we  may  expect  a  protracted 
case  and  complications  like  capillary  bronchitis  or 
broncho-pneumonia,  or  possibly  an  asthmatic  attack. 
In  true  normal  bronchitis,  the  appetite  remains.  In 
pneumonia  it  is  lost.  This  is  a  diagnostic  sign  of 
value.  The  better  the  appetite,  as  a  rule  the  shorter 
the  attack.  This  fact,  doubtless,  gave  rise  to  the  say- 
ing :  "  Feed  a  cold,  but  starve  a  fever." — Duncan, 
Medical  Brief,  April,  1897. 

Treatment  of  Nephritis  in  Children. — Calomel  is 
indispensable.  It  stimulates  the  liver  to  action,  and 
by  the  increased  flow  of  bile  the  contents  of  the  bowel 
are  rendered  more  fluid  and  the  elements  to  be  ex- 
creted more  soluble  in  the  blood,  thus  proving  less 
irritating  to  the  kidneys.  The  salines  are  of  great 
service  as  hydragogucs.  Hot-air  baths  must  be  relied 
upon  for  their  diaphoretic  action,  as  pilocarpine  is 
very  uncertain  and  not  to  be  depended  upon.  The 
best  method  of  applying  heat  is  by  using  an  apparatus 
which  will  supply  hot  air  under  the  bedclotiies.  This 
can  be  used  continuously,  as  it  does  not  cause  pros- 
tration. Liquor  ammonia  acetatis  is  an  efficient  rem- 
edy in  the  stage  of  convalescence,  acting  beneficially 
upon  the  kidneys  and  the  skin.  The  high  tension  in 
the  arteries  can  be  combated  more  efficiently  by  blood 
'etting  than  otherwise,  its  beneficial  effect  being  seen 


upon  the  pulse,  the  nervous  system,  and  the  vcidneys 
in  the  lowering  of  blood  pressure.  A  very  valuable 
agent  is  water,  given  perhaps  plain  after  filtration  or 
boiling,  as  young  children  take  carbonated  waters  with 
reluctance.  Given  ad  libitum,  and  at  regular  intervals 
if  the  patient  does  not  call  for  it,  it  acts  as  a  diuretic, 
without  causing  any  irritation.  If  refused  by  the 
mouth,  it  acts  well  as  enema  if  large  doses  are  given. 

—  TULEV. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  December  18,  1897: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Chicken-pox 


Pneumonia  in  Childhood.  —  The  respiration  in 
children  suffering  from  croupous  pneumonia  assumes 
a  peculiar  type,  being  made  up  of  a  short  rapid  in- 
spiration, a  pause  in  the  inspiratory  position  (absent 
only  during  rapid  breathing),  and  a  jerky,  noisy 
expiration. — Eshner. 

Limits  of  the  Power  of  Hearing. — Lord  Rayleigh 
observed,  in  a  lecture  at  the  Royal  Institution  on 
the  limits  of  audition,  that  one  of  the  latest  deter- 
minations of  the  frequency  of  vibrations  to  which 
the  ear  is  sensitive  gave  the  lower  limit  as  twenty- 
four  thousand  complete  vibrations  a  second,  and  the 
upper  as  about  twenty  thousand.  These  limits  are, 
however,  very  ill  determined,  because  the  matter  de- 
pends largely  on  the  vigor  of  the  vibration  and  the 
individual  ear.  Old  people  do  not  hear  high  notes 
which  are  audible  to  young  persons,  and  the  speaker 
had  reason  to  believe  that  infants  hear  notes  which 
persons  twenty  or  thirty  years  of  age  cannot  detect. 
Experiments  on  the  extent  of  vibration  necessary  to 
audition  were  described,  which  appeared  to  show  that 
a  vibration  having  an  amplitude  expressed  in  centi- 
metres by  a  fraction  having  eight  for  its  numerator, 
and  one  followed  by  eight  ciphers  for  its  denominator, 
could  still  affect  the  ear. — Appleton's  Popular  Science 
Monthly. 

Health  Reports. — The  following  statistics  concern- 
ing yellow  fever,  cholera,  and  small-pox  have  been  re- 
ceived in  the  office  of  the  super\'ising  surgeon-general 
of  the  United  States  Marine  Hospital  service,  during 
the  week  ended  December  18,  1897  : 

\  Ki.i.ow  Fever— U.MTEU  States. 

Cases.  r>eaths. 


l.oiiisi.-ina.  New  <)rle.ins 

Yellow  Fever — Foreign. 

r.razil.  Para    November  20th  to  37th.. 

t  'iiba,  Havana December  jid  to  oth 

Matanzas December  2d  to  8th. ... 

Reyla December  3d  to  9th". . . 


India.  Matlras October  30th  to  November  5th. 

Small-Pox— United  States. 

Alabama.  Uinningham December  5th  to  nth 

Small-Pox— FoRElG.N. 

Cuba,  Havana December  3d  to  9th 

r.ngland.  .Southampton November  i4lh  to aoth 

Russia,  Odessa November  21st  to  27th 

Scotland.  Glasgow November  21st  to  27th 


INDEX 


Aaron,  Charles    D.,   stomach   disturbances 
caused  by  hernia  of  the  linea  alba  in 
the  epigastrium,  736. 
Abbe,   Robert,  the  appendix  in   the  inter- 
val— a  new  method  of  studying  it,  37. 
Abbott,  Clarence  G..  death  of,  673. 

Abdomen,  contusions  of,  with  visceral  le- 
sions, loi ;  cysts  in  the  wall  of  the, 
;oo  ;  imperfections  in  tlie  diagnosis  of 
conditions  within  the,  510;  penetrat- 
ing wounds  of  the,  464;  stab  wound 
of  the,  170. 

Abdominal  effusions  and  growths,  diagno- 
sis of,  62;  operations,  local  anaesthe- 
sia in,  427;  retractor,  a  self-retain- 
ing, 71:  tumor,  removal  of  a  cystic 
from  a  child  aged  seven  months,   51. 

Abnormalities,  do  they  tend  to  die  out  in 
the  course  of  transmission  ?  I7fi. 

Abortion,  criminal.  32. 

Absinthe,  effects  of.  21(1. 

A.  C.  E.  mixture,  death  from,  704. 

Acetonuria,  diacetonuria,  and  butyric  acid 
in  the  gastro-intestinal  troubles  of  in- 
fants and  young  children,  739. 

Addison's  disease,  fatal  case  of,  in  a  young 
girl,  668. 

Adenoids,  removal  of,  from  the  vault  of 
the  pharynx,  607. 

Adolescence,  insanity  of,  6i(i. 

Adulteration  of  drugs,  892;  of  fond.  i',^. 
S92. 

Advertisements  that  are  unfit  to  print.  707. 

Advertising,  medical,  397. 

Aged,  ovariotomy  in  the,  S32;  typhoid 
fever  in  the,  861. 

Ager,  Louis  C,  protection  of  the  dispen 
sary  patient,  70. 

Agnew  memorial  pavilion  at  tlic  University 
of  Pennsylvania.  635. 

Aiken.  S.  C,  76;. 

Air  passages,  surgery  of  the,  in  children. 
60S;  wounds  of  the,  686. 

Alabama,  health  resorts  of,   769. 

Alabama  City.  Ala. ,  769. 

Alcock,  Sir  Rutherford,  death  of,  797. 

Alcohol,  effects  of  upon  longevit\'.  S91. 

Alcoholic  drinks,  comparative  effect  of  dif- 
ferent, 162;  meningitis,  Sol,  S25. 

Alcoholism,  chief  nervous  affections  of, 
759;  in  women,  699:  legislation  con- 
cerning.  17;. 

AUbutt,  Thomas  Cliflford,  notice  of  book 
edited  by,  423. 

Allen,  Charles  \V.,  a  new  comedo  ex- 
tractor, 71:  a  school  for  favus  chil 
dren,  471 ;  contamination  of  milk,  34; 
hygiene  of  the  barber  shop,  542. 

Allen,  George,  death  of,  749. 

Allen,  Harrison,  obituary  of,  740;  resolu- 
tions on  the  death  of,  S56. 

Allen,  J.  I).,  gangrene  of  the  leg  following 
typhoid  fever,  918. 

Allport,  I'rank,  a  retinoscopic  trial  case. 
904. 

Alopecia,  neurotic,  275. 

Amazia,  bilateral,  160. 

Amblyopia,  tobacco,  453. 

Ambulance  ships  for  the  navy.  601. 

Amenorrhcea,  7S5. 

American  Association  of  ( .enito-l'rinary 
.Surgeons,  21. 

American  Association  of  Obstetricians  and 
Gynaecologists,  498. 

American  Electro-Therapeutic  Association. 
490. 

American  Medical  Association,  New  York 
the  birthplace  of  the,  288;  section  on 
anatomy  and  surgery,  94;    section  on 


obstetrics  and  diseases  of  women,  I2g  ; 
section  on  practice  of  medicine,  24,  58. 

American  Medical  Temperance  Associa- 
tion, 56. 

American  Public  Health  Association,  713. 

American  students  in  Germany,  672,  684. 

Ames,  Delano,  phlegmonous  gastritis  fol- 
lowing ulcus  carcinomatosum  of  the 
pylorus,  365. 

Amoeboid  bodies  in  the  blood  of  vaccinated 
monkeys  and  children  and  in  that  of 
cases  of  variola,  524. 

Ampliphone,  506. 

Amputations  for  crushing  injuries  of  the 
limbs,  2S4. 

Anjemia.  discussion  on,  61;  progressive, 
pernicious,  and  secondary,  spinal  le- 
sions in,   524. 

Anaesthesia,  administration  of,  in  Great 
Britain,  722;  capitals  operation  with- 
out, 284;  death  from  general,  632; 
ideal,  445;  improvement  of  general, 
835;  paralysis,  697;  the  discoverer  of, 
790;  war  by,  528. 

AuiESthetic,  local,  758. 

Anastomosis,  intestinal,  pathological  his- 
tology of  end-to-end  approximation 
after  the  use  of  the  Frank  coupler. 
401;  uretero-ureteral.  905 

Anatomy,  some  anomalies  in,  484;  some 
thoughts  on  teaching,  ig6. 

Anderson,  K.  Harcourt,  rough  notes  on 
some  anomalies  in  anatomy,  4S4. 

Aneurism  at  the  apex  of  the  heart.  320; 
deep-seated  thoracic,  treatment  of.  75S; 
dissecting,  of  the  aorta,  31;  of  the  in- 
ternal carotid  within  the  cranium,  suc- 
cessful treatment  of,  by  ligature  of  the 
common  carotid.  S87;  of  the  internal 
maxillary  treated  by  ligature  of  the 
common  carotid,  434;  of  the  middle 
cerebral  artery,  716;  of  the  sinus  of 
Valsalva,  320;  of  the  thoracic  and  ab- 
dominal aorta,  320;  rupture  of  aortic, 
679;  treatment  of,  by  increasing  artifi- 
cially the  coagulability  of  the  blood, 
667.' 

Animals,  cruel  treatment  of,  in  transporta- 
tion, 565. 

Ankle,  the  pegleg  as  a  protective  appara- 
tus in  diseases  ot'the,  206. 

Anthrax  in  Pennsylvania,  351;  protective 
agency  of  serum  of,  922. 

Antisepsis  and  asepsis,  difference  be- 
tween, 581. 

.\ntiseptic,  mustard  as  a,  788. 

.Antivivisection  movement,  immorality  of 
the,  161 ;  pledge,  50S. 

Antrum,  empyema  of  the,  540;  non-oper- 
ative treatment  of  chronic  suppurative 
disease  of  the,  437. 

Aorta,  aneurism  of  the  thoracic  and  abdomi- 
nal, 320;  dissecting  aneurism  of  the, 
31- 

Aortic  regurgitation,  different  varieties  of. 
523;  valve  with  two  segments,  2S2. 

Aphonia,  hysterical.  86,  701. 

Apoplectic  attack,  some  unusual  forms  of 
the.  6Sg. 

Appendicitis,  358,  503;  complicating  pyo- 
salpinx,  464;  differential  diagnosis  of, 
99;  disposal  of  the  stump  in  opera- 
tions for,  82S;  frequency  of  sponta- 
neous recovery  from,  522;  introducer 
of  the  term,  505;  is  free  use  of  the 
knife  necessary  in  the  treatment  of '! 
231,  243;  modified  incision  at  the 
outer  border  of  the  rectus  muscle  for, 
837;  operations  for,  207,  566;  pain, 
opium,  84S.;  pathology  of  recurrent. 
125;  pecurtar  case  of.  704;  post-oper- 


ative hernia  after,  609;  relapsing,  425; 
simulation  of,  by  a  pus  collection  in 
Meckel's  diverticulum,  Soo;  specimen 
of,  65;  unusual  cases  of,  570. 

Appendix,  absence  of  the,  570;  amputation 
of  the,  by  gangrene,  566;  and  Ciiscum, 
intussusception  of  the,  360;  curious 
condition  of  the,  found  at  operation, 
566;  in  the  interval,  new  method  of 
studying  the,  37. 

Aqua  Tofana,   loS. 

Arizona,  health  resorts  of,  770. 

Arkansas,  Hot  .Springs,  770. 

Arm,  conservative  surgery  of  the,  864. 

Army  medical  service,  British,  397;  physi- 
cal condition  of  applicants  for  enlist- 
ment in  the,  672. 

-\rteries.  skiagraphing  the,  88;  suture  of, 
460. 

.\rterio-sclerosis,  544;  treatment  of  the  car- 
diac complications  of,  902. 

Arthritis  deformans,  465;  in  gonorrhoeal 
patients,  153;  rheumatoid,  61. 

.Arthropathy,  hypertrophic  pulmonary,  498; 
relation  of,  to  chronic  rheumatic  ar- 
thritis, 104. 

Ascites,  acute,  with  tubercle  bacilli,  log; 
chylous,  in  cancer  of  the  stomach,  922. 

Asepsis  and  antisepsis,  difference  between, 
581. 

Asheville  Plateau  in  the  mountains  of  west- 
ern North  Carolina,  774. 

.Ashmead,  Albert  S. ,  suppression  and  pre- 
vention of  leprosy,  423. 

.Associated  Health  Authorities,  annual 
meeting  of,  855. 

Association  of  Assistant  Physicians  of 
Hospitals  for  the  Insane,  748. 

Asthma,  7S5;  bicycle  riding  for,  30S  ;  eti- 
ology of,  521;  thymic,  36. 

Astigmatism  in  German  schools,  799. 

Athletics,  modern,  and  health,  52;. 

Atlantic  City,  N.  J.,  762. 

Atlee,  L.  \V.,  report  of  a  case  of  fracture 
of  the  base  of  the  skull,  with  a  pecu- 
liar history,  532. 

Atwood,  Hermon  M.,  death  of,  673. 

Augusta,  Ga. ,  766. 

Auto-intoxication,  60^  ;  clinical  relations  of, 
41S. 

Autopsy,  made  months  after  death,  8g6; 
unauthorized,  632. 

Avery,  Charles  H.,  death  of,  671;  reso- 
lutions on  the  death  of,  820. 


Baby  farming  in  England,  470. 

Bacillus  aerogenes  capsulatus,  wound  in- 
fection by  the,  171;  pyocyaneus,  in- 
fection of  human  beings  with  the,  28. 

Bacon,  Richard  Smith,  death  of,  55. 

Bacteria,  microscopical  examination  of,  807. 

Bacterial  mud,  5S0. 

Bacteriological  research,  some  practical 
deductions  from,  585. 

Bacteriology,  contributions  of.  to  thera- 
peutics, 640. 

Bahama  Islands.  773. 

Bailey,  William  Curtiss,  some  misconcep- 
tions of  New  Mexico  corrected,  7S1. 

Baker,  Charles  O.,  death  of,  163. 

Baketel,  H.  .S.,  prolonged  pregnancy,  and 
premature  ossification  of  the  cranium, 
causing  d\'Stocia,  I5g. 

Baldwin,  J.  F.,  eight  intestinal  perfora- 
tions from  a  pistol  bullet,  operation, 
recovery,  311. 

Kalleray,    G.    H. .  in   the   treatment   of   ap- 


934 

pendicitis,  is  the  free  use  ui  ine  Kr.ne 
necessary?  231,  243. 

Bananas,  uses  of ,  71. 

Banks.  W.  Mitchell,  the  surgeon  of  old  in 
war,  340. 

Barber,  E. ,  death  of,  470. 

Barber  shop,  a  menace  to  public  health, 
714;  antisepsis  in  the.  4S9,  564;  hy- 
giene of  the,  52.  542. 

Bard,  Cephas  1...  an  adjustable  irrigating 
stand  with  pedal  cutoff,  905. 

Barry,  Frederick  William,  death  of,  683. 

Barton,  Joshua  Lindley,  the  scientific 
treatment  of  tuberculosis,  376. 

Bassini  operation  for  hernia,  96. 

Bates,  Newton  C,  appointment  as  sur- 
geon-general of  the  navy,  527;  death 
of,  602. 

Battle,  S.  Westray,  the  Asheville  plateau 
in  the  mountains  of  western  North 
Carolina,  774. 

Becquerel  rays,  324. 

Beer  drinking  and  longevity.  144. 

Bell,  John  N.,  a  self-retaining  abdominal 
retractor,  71. 

Bellevue  Hospital  Medical  College,  laying 
the  cornerstone  of  the,  744. 

Benzin,  purpura  due  to  the  vapors  of,  888. 

Bequests  to  Philadelphia  institutions,  491. 

Beriberi  in  Dublin,  248. 

Berlin,  letters  from,  105,  141,  214,  322, 
684,  797. 

Bermudas,  the,  763. 

Besser,  Herman,  eclampsia  due  to  phimo- 
sis in  a  child  7  months  old,  SS6. 

Bicycling  for  asthma,  30S;  for  sedentary 
people,  398;  from  the  standpoint  of 
health.  89. 

Bile,  antiseptic  properties  of,  629. 

Bile  duct,  cholelithotomy  on  the,  171;  dis- 
eases of  the,  932;  surgery  of  the,  464. 

Bilharzia  haematobium,  S34. 

Biliary  colic,  puerperal,  349. 

Bird,  U.  S.,  hemorrhage  into  the  pericar- 
dium, 701. 

Bishop,  Louis  Faugeres,  some  important 
points  for  consideration  in  the  treat- 
ment of  acute  lobar  pneumonia,  228, 
242. 

Bishop,  Seth  Scott,  notice  of  book  bv, 
16S. 

Bismarck,  remarks  of  the  doctor  of,  con- 
cerning medical  practice.  744. 

Black  eye,  prevention  of.  207. 

Blackford,  C.  M.,  Jr.,  tapeworm  in  man, 
506. 

Black-water  fever,  215. 

Bladder,  absorption  by  the  mucous  mem- 
jbrane  of  the,  430;  chronic  contrac- 
tion of  the  prostatic  fibres  encircling 
the  neck  of  the,  21;  exstrophy  of  the, 
in  a  girl  of  thirteen  years,  49;  new 
method  of  removing  polypi  of  the,  22; 
photography  of  the  interior  of  the,  24; 
spontaneous  fracture  of  stones  in  the 
430;  stone  in  the,  comparative  value 
of  operations  for,  97;  treatment  of 
stone  in  the,  by  lithotrity,  418;  tu- 
mors of  the,  430. 

Blanchard.  W.  M.,  absorption  by  water  of 
free  and  albuminoid  ammonia  under 
various  conditions,  4S7. 

Blepharitis  marginalis,  hydrogen  dioxide 
in,  610. 

Bleyle,  Herman  C,  new  suspension  de- 
vice for  irrigator  used  in  connection 
with  the  Edebohls  leg  supporter,  108. 

Blind,  massage  as  an  occupation  for  the, 
603. 

Block,  J.,  a  clinical  review  illustrating  the 
difference  between  asepsis  and  anti- 
sepsis, 58 1. 

Blood,  antitoxic  and  therapeutic  activities 
of,  after  recovery  from  infectious  dis- 
eases, 62S  ;  diagnosis  by  examination 
of  the,  663  ;  in  the  urine,  causes  and 
recognition  of,  21 1. 

Blood  stains,  removal  of,  2J2. 

Blood-vessels,  suture  of,  in  continuity,  42S. 

Blueweed,  519. 

l^lumenfeld,  Felix,  notice  of  book  by,  822. 

Board  of  Estimate  and  Apportionment  and 
its  relation  to  the  taxpayers  of  the  city, 
926. 


INDEX. 


Bocquillon-Limousin,    H.,  notice   of  book 

by,  530- 
Boeme,  Texas.  770. 
Bogardus,  E.  W.,  treatment  of  pulmonary 

tuberculosis,  721. 
Boix,  Emile,  notice  of  book  by,  424. 
Bone,  remote  effect  of  trauma  of,  284. 
Book  Notices  : 

Alimentan,'  canal,  treatise  on  surgerj-  of 

the.  by  A.  E.  Maylard,  639. 
-Anomalies   and    peculiarities   of     medi- 
cine,   by    George     M.     Gould    and 
Walter  L.  Pyle,  S24, 
Appendicitis  and  its  surgical  treatment, 

by  H.  Mynter,  824. 
.Appendicitis  and  other  subjects,  lectures 

on.  bv  Robert  T.  Morris,  823. 
.\phasia,  by  W.  Elder,  170. 
Braithwaite's  Retrospect,  493,  531. 
Charaka-Samhita,  287. 
Chirurgie    des    voies  urinaires.   par    E. 

Loumeau,  S22. 
Climatology,   handbook   of   medical,   by 

S.  E.  Solly,  529. 
Coma,    differential  diagnosis  and    treat- 
ment of,  by  A.  P.  Grinnell,  530. 
Crime  and  criminals,   by  J.   S.   Christi- 

son.  530. 
Cystitis    und     Urininfektion,    von    Max 

Melchior.  822. 
Death  and  sudden  death,  bv  P.  Brouar- 

del.  168. 
Dentistry.  American  text-book  of  opera- 
tive, by  E.  C.  Kirk.  529. 
Depressionszustandc,     periodische.    von 

C.  Lange,  531. 
Disease,  origin  of.  bv  Arthur  V.  Meigs, 

822. 
Ear,  injuries  and  diseases  of  the,  by  M. 

Yearsley,  166. 
Ear,   nose,   and  throat,  diseases  of  the, 
and  of  their  accessory  cavities,    by 
S.  C.  Bishop.  168. 
Edinburgh    Medical  Journal,    edited  by 

G.  A.  Gibson,  530. 
Electricity,    manual   of    static,  in   a-ray 
and    therapeutical    uses,    bv  S.   H. 
Monell.    167. 
Endokardit.  af  F.  Hasbitz,   530. 
Excretor)'    irritation    and   the    action   of 
certain    internal     remedies   on    the 
skin,  by  D.  Walsh,   530. 
Eye,   diseases   of   the.    and    ophthalmo- 
scopy, by  A.  E.  Fick.  166. 
Eye,    new    classification    of    the    motor 
anomalies    of     the,     by    Alexander 
Duane.  166. 
Eye  strain   in  health  and   disease,  by  A. 

L.  Ranney.  423. 
Fads    of   an    old    physician,    by    G.    S. 

Keith,  424. 
First  aid  in  illness  and  injury,  by  James 

Pilcher,  168. 
Formulaire  des   medicaments  nouveaux, 
par     H.       Bocquillon-Limousin, 
530. 
Fracture  of  the  lower  end  of  the  radius, 

by  J.  B.  Roberts.  823. 
Gynaecology,  atlas  and  essentials  of.  by 

O.  Schaeffer,  169. 
Hagenbach-Burckhardt,    Eduard,    Fest- 
schrift, S22. 
Harnleiden,     Technik     und     praktische 
Bedeutung  der  Asepsis  bei  der   Be- 
handlung  der.  822. 
Harvard    Medical    Alumni    Association, 

bulletin  of  the,  530. 
Hefen   als   Krankheitserreger,  von   Otto 

Busse,  822. 
Hippokratischen  Medicin,  von  F.  Spaet, 

530. 
Histology,  a  course  of  practical,  by  E. 

A.  Sch.iefer.  494. 
Hospitals,  handbook  for,  by  Abby  How- 
land  Woolsey,  823. 
Hysteria  and    certain   allied  conditions, 

by  G.  J.  Preston,  169. 
Immunity  to  disease,  bv  W.  B.  Ransom, 

823. 
Inebriety,    its    source,    prevention,   and 

cure,  by  C.  F.  Palmer,  168. 
International  Clinics,  edited  by  J.    Da- 
land,    J.    M.    Bruce,   and    D.    W. 
Finlay[  531,  822. 


[December  25,  1897 


Book  Notices  : 

Kreigschirurgie,  Vorlesungen  uber,  von 
L.   Lilhe,  424. 

Larynx  and  trachea,  autoscopy  of  the, 
by  A.  Kirstein,  531. 

Legal  medicine,  manual  of,  by  Justin 
Herold,  S23. 

Leprosy,  suppression  and  prevention  of, 
by  A.  S.  Ashmead,  423. 

Lippincott's  medical  dictionary,  edited 
by  Ryland  W.  Greene.  493. 

Liver,  gall-bladder,  and  biliary-  system, 
diseases  of  the.  by  H.  J.  Waring, 
530. 

Liver  of  dyspeptics,  and  particularly  the 
cirrhosis  produced  by  auto-intoxica- 
tion, by  Emile  Boix,  424. 

Luftdruckes,  Wirkung  rascher  Veran- 
derungen  des,  auf  den  Organismus, 
von  R.  Hiller,  W.  Mager,  und  H. 
V.  Schroetter,  167. 

Lungen-  und  Kehlkopf  -  Schwindsiich- 
tigen,  specielle  Diatetik  und  Hy- 
giene der,  von  Felix  Blumenfeld, 
822. 

Menopause,  the,  and  its  disorders,  by 
A.  D.  Leith  Napier,  639. 

Menopause,  the,  by  A.  F.  Currier,  423. 

Mental  diseases,  clinical  lectures  on,  by 
T.  S.  Clouston,  166. 

Mental  diseases,  text-book  of,  by  T.  H. 
Kellogg.  638. 

Military  Service  Institutions  of  the 
United   States.  Journal  of  the,  822. 

Nebraska  State  Medical  Society,  pro- 
ceedings of  the,  823. 

Negro,  surgical  peculiarities  of  the 
American,  by  Rudolph   Matas.  823. 

Nervous  diseases,  clinical  lectures  on, 
by  S.  Weir  Mitchell,  167. 

Ner\ous  system,  contributions  to  the 
physiology  and  pathology  of  the, 
by'lsaac  Ott,  16S. 

Neural  terms,  international  and  nationai. 
by  B.  G.  Wilder.  166. 

New  York  County  Medical  Association 
Register  for  1897.  639. 

Obstetrical  pocket-phantom,  by  K.  Shi- 
bata.  639 

Ophthalmoscope,  by  G.  Hartridge,  529. 

Passaic  valley  sewerage  commission, 
report  of  the,  S23. 

Pathological  anatomy,  text-book  of,  by 
E.  Ziegler,  63S. 

Pathology,  notes  on,  by  W.  A.  Evans, 
529.' 

Pharmacopoeia,  digest  of  criticisms  on 
the,  638. 

Physiology,  manual  of,  by  G.  N.  Stew- 
art. 638. 

Pott,  traitement  du  mal  de,  par  A.  Chi- 
pault.  530. 

Presbyterian  Hospital,  medical  and  sur- 
gical report  of  the,  edited  by  A.  J. 
McCosh  and  W.  B.  James,  531. 

Problems  of  nature,   by  Gustav  Jaeger, 

493- 

Railway  Surgeons,  Report  of  American 
Academy  of,  edited  by  R.  Harvey 
Reed.  823. 

Retinoscopy,  by  J.  Thorington.  166. 

Rheumatism  and  its  treatment  by  the 
use  of  the  percusso-punctator,  by  J. 
Brindley  James,  822. 

Simpson.  Sir  James  G.,  by  E.  B.  .Simp- 
son, 638. 

Skeleton,  the  vertebrate,  by  S.  H.  Rey- 
nolds. 424. 

Skin  diseases  and  syphilitic  affections, 
pictorial  atlas  of.  by  Besnier.  Four- 
nier,  Tenneson,  Hallopeau,  DuCas- 
tel,  Feulard.  and  Jacquet.  edited  by 
J.  J.  Pringle.  531.  822. 

Skindiseases.  illustrated  atlas  and  text- 
book of,  by  W.  S.  Gottheil.  16S, 
530. 

State  board  of  charities,  annual  report 
of  the.  S23. 

Stomach,  diseases  of  the.  by  C.  A.  Ew- 
ald.   167. 

Strabismus,  convergent,  and  its  treat- 
ment, by  E.  Holthouse.  530. 

Surgery,  system  of.  edited  by  F.  S. 
Dennis,  639. 


December  25,    1897] 


INDEX. 


935 


Book  Notices  ; 

Swedish  movements  or  medical  gymnas- 
tics, by  J.  Hartelin,  493. 

Syphilis,  infantile,  by  J.  A.  Coutts,  531. 

System  of  Medicine,  edited  by  T.  C. 
Allbutt,  423. 

System  of  practical  medicine,  edited  by 

A.  L.  Loomis  and  W.  G.   Thomp- 
son, 924. 

Syringomyelia,  by  Guy  Hinsdale,  l6g. 
Telepathy  and  the  sublimal  self,  by  R. 

O.   Slason,  639. 
Therapeutics,  reference    book  of  practi- 
cal, edited  by  F.  P.  Foster.  423. 
Therapeutics,  system  of  practical,  edited 

by  H.  A.  Hare.  S24. 
Therapie,  Encyclopaedic  der,  von  Oscar 

Liebreich,  423,  529. 
Therapist,  the  pocket,  by  T.   S.  Dowse, 

529. 
Transactions  of  the  American   Pediatric 

Society,  494. 
Transactions  of  the  Association  of  Amer- 
ican Physicians,  493. 
Transactions  of  the   Medical   Society  of 

the  State  of  New  York,  493. 
Transactions  of  the   Southern   Surgical 

and  Gynaecological  Association,  494. 
Twentieth    Centur\'   Practice.   Vol.    X., 

edited  by  T.  L.  Stedman.  167,  493. 
Urinalysis,  by  H.  Stein.  494. 
Urinarv  analysis,  practical  notes  on,  bv 

William  B.  Canfield,  S23. 
Vterus,  treatment  of   fibroid   tumors  of 

the,  by  F.  H.  Martin.  169. 
Vita   medica.  bv  Sir  B.  \V.  Richardson, 

638. 
Watt,  Dr.  Robert,  life  and  works  of,  by 

J.  Finlayson,  639. 
Wisconsin,  sixteenth  report  of  the  State 

board  of  health  of.  494. 
Women,    organ    diseases   of,   by   J.    C. 

Burnett,  169. 
Women,  practical  manual  of  diseases  of, 

by  H.  M.  Tones,  494. 
Women,  text-book  of  diseases  of.  by  C. 

B.  Penrose.  529. 

Year-book  of  medicine  and  surgery, 
edited  by  G.  M.  Gould,  169. 

Books,  disinfection  of,  747. 

Booth,  W.  H.,  death  of,  492. 

Bores,  office,  SSg. 

Boston,  water  supply  of,  200. 

Boucicaut  hospital  in  Paris,  757. 

Bradford,  Robert  B.,  death  of,  563. 

Brain,  diseases  of  the,  in  vepi'  young  chil- 
dren, 323;  impossibility  of  increased 
intracranial  pressure,  399;  improve- 
ment in  the  function  of  the,  bi.'  surgi- 
cal interference,  9;;  lesion  of  the,  in 
gas  poisoning,  399;  punctate  hemor- 
rhages in  the,  following  pertussis,  319; 
surger)'  of  the,  431. 

Brannin,  Henry  E.,  death  of,  563. 

Bratton,  William  du  Hose,  obituar)-  of, 
637. 

Brazeau,  G.  >> . ,  bilateral  subluxation  of 
the  crystalline  lenses  with  ectopia  of 
the  pupil  of  the  left  eye,  703. 

Breast,  amputation  of  the,  865;  carcinoma 
of  the,  865;  carcinoma  of  the,  in  a 
child,  234;  cystic  disease  of  the,  830; 
operation  on  carcinoina  of  the,  by 
Meyer's  method,  648. 

Breiter,  Nathan,  the  hand  as  a  propagator 
of  microbic  disease — a  medico-social 
question,   813. 

Brinton,  John  H.,  digital  manipulation  for 
the  removal  of  a  piece  of  catheter  or 
other  instrument  accidentally  broken 
off  and  remaining  in  the  deep  urethra 
of  the  male.  49. 

Bristol  Medical  -Association,  325,  350,  356, 
385.  3S7,  432,  464,  491,  505:  business 
meeting  of  the.  248;  e.':pulsion  of  mem- 
bers of  the,  285,  310. 

British  Medical  Council,  612,  650.  682,  757, 
897,  929. 

British   Medical   Temperance   .\ssociation, 

.  .54- 
British  medicine  in  Greater  Britain,  333. 
Brodie,  William,  death  of,  386. 
Bronchitis,  chronic,    treatment,  212.  786 ; 
chronic,  tuberculous  lymph  nodes  in, 


896:  course  of.  932:  fetid,  treatment 
of,  504. 

Brouardel,  P. ,  notice  of  book  by,  168. 

Brown,  .\dolph  G. ,  economy  in  h)"po- 
dermic  needles,  723. 

Brown,  J.  C,  exfoliation  of  the  mucous 
membranes  of  the  oesophagus  and  part 
of  the  stomach  in  a  complete  cast  after 
corrosive  poisoning,  533. 

Brown,  Sanger,  hysterical  aphonia,  86. 

Browning,  Charles  C,  serum  in  tubercu- 
losis, 794. 

Brunton,  T.  Lauder,  the  relation  of  physi- 
olog)-.  pharmacology-,  pathology,  and 
practical  medicine,  296. 

Bubo,  abortion  of  a,  885. 

Buck,  Albert  H..  remarks  upon  the  non- 
operative  treatment  of  chronic  suppu- 
rative disease  of  the  antrum  and  vaulf 
of  the  tympanum,  437. 

Bucke,  R.  M..  mental  evolution  in  man, 
414. 

Bucknill,  Sir  J.  C,  death  of,  249. 

Bucks  County  (Pa.)  Medical  Societ)-.  712. 

Buildings,  public  and  private,  the  drainage, 
plumbing,  and  ventilation  of,  713. 

Burdett.  Sir  Henr)-.  on  hospitals,  834. 

Burial,  alive,  almost  a  case  of,  S92;  earth- 
to-earth,  507. 

Burnett,  J.  Compton,  notice  of  book  by, 
169. 

Burow's  liquid,  34. 

Busse,  Otto,  notice  of  book  by,  S22. 

Buxton,  England,  as  a  health  resort,  214. 


Cabell,  John  R..  death  of,  352. 

Caecum,  hernia  of  the,  96. 

Caglieri.  Guido  E.,  mushroom  poisoning, 
29S ;  the  pulmonarj'  origin  of  the 
crepitant  rale.  613. 

Cagney,  James,  death  of,  S71. 

Calculi,  renal,  genital  phenomena  of,  27S; 
vesical,  comparative  value  of  opera- 
tions for,  97  ;  vesical,  rapid  formation 
of  a,  22  ;  vesical,  spontaneous  fracture 
of,  430. 

California,  health  resorts  of,  770 ;  homoe- 
opathy at  the  University  of,  309. 

Calomel,  acids  not  incompatible  with,  629. 

Camden.  S.  C,  76;;  the  route  to,  S99. 

Campbell,  Given,  some  practical  deduc- 
tions from  bacteriological  research, 
565. 

Canadian  Medical  Association,  353. 

Cancer,  application  for  superficial,  504  ; 
application  in  doubtful  cases  of,  538  ; 
cachexia  of,  420 ;  diagnostic  value  of 
pain  in,  iSi  ;  employment  of  saccha- 
romyces  in  the  treatment  of,  S16;  hered- 
ity in,  30:  of  the  breast,  operation  by 
Meyer's  operation,  64S  ;  of  the  tonsil, 
893;  orrhotherapy  of ,  207,  459:  squa- 
mous epithelial,  of  the  cervical  glands, 
176;  surgical  considerations  on,  2; 
traumatic,  214  :  treatment  of,  by  the 
electrical  diffusion  of  nascent  oxy- 
chlorides  of  mercury  and  zinc,  150  ; 
tieatment  of,  by  zinc-mercuric  cata- 
phoresis,  62. 

Canfield,  William  B.,  notice  of  book  by, 
823. 

Cantrell.  J.  Abbott,  lichen  planus  present- 
ing lesions  with  a  circular  form,  205. 

Carhart«i  William  Merle  d'.Aubigne.  the 
need  of  inspection  of  the  eyes  of  the 
children  in  the  New  York  public 
schools.  592. 

Carolinas,  health  resorts  of  the,  764. 

Carotid  arxery.  ligation  of  the,  94;  liga- 
tion of  the,  followed  by  brain  symp- 
toms, 32. 

Carpenter,  John  B.,  death  of,  55. 

Cassidy,  Patrick,  report  of  operations  in 
three  cases  of  umbilical  hernia  in  el- 
derly women,  794. 

Catgut,  method  of  preparing  sterilized, 
681. 

Catheter,  impossibility  of  the  passage  of  a, 
through  the  urethra  into  the  bladder, 
267,  400. 

Catheterism.  self-,  717. 


Cattell,  Henry  W.,  report  on  hydrophobia, 
107. 

Cavanaugh,  James,  death  of,  55. 

Cells,  formation  of  giant,  244 ;  nucleus  of 
the,  354  ;  stain  for  ganglion,  247. 

Centrifuge,  an  improved.  904;  a  simple, 
convenient,  and  efficient,  178. 

Cerebro-spinal  meningitis,  the  meningo- 
coccus in,  176. 

Ceylon,  a  medical  missionary  wanted  in, 
S35- 

Chamberlain,  E.  C,  the  treatment  of 
tapeworm,  with  report  of  cases,  313. 

Champlin,  S.  H.,  hernia  in  an  infant  ten 
weeks  of  age,  577. 

Champlin,  S.  H.,  method  of  preparing 
sterilized  catgut,  6S1. 

Chance.  Frank,  death  of,  249. 

Change  of  life  and  the  diagnosis  of  carci- 
noma uteri,   500,  509. 

Chapped  hands,  application  for,  213. 

Chappell,  Walter  F.,  a  new  tracheal  tube, 
904. 

Charities,  private,  public  money  for,  793, 
S54,  926;  reports  of  the  New  York 
State  board  of,  163;  shall  there  be  a 
medical  commissioner  of  ?  8 54, 

Charity,  abuse  of   medical,  210,  561,  566, 

Charity  Hospital  Alumni  Association,  928. 

Charteris,  Dr.,  death  of,  32. 

Chautauqua  County  Medical  Societj',  163. 

Cheron's  solution,  611. 

Chest,  some  deformities  of  the,  59. 

Chetwood,  Charles  H..  treatment  of  follic 
ular  abscess  of  the  fossa  navicularis 
with  attendant  fistula,  11. 

Chewing-gum  habit  in  England,  712. 

Cheyne- Stokes  respiration,  59. 

ChejTie,  W.  Watson,  the  progress  and  re- 
sults of  pathological  work,  345. 

Chick's  Springs,  766. 

Chipault.  A.,  notice  of  book  by,  530. 

Chlorate  of  potassium,  dangers  of,  363 ; 
poisoning  by.  399- 

Chloroform,  effect  of,  on  the  vital  func- 
tions, 235  ;  prevention  of  nausea  after 
the  administration  of,  661 ;  some 
practical  points  on  the  administration 
of,  552:   versus  ether,  560. 

Chlorosis,    560  ;   causes  of  essential,  494. 

Cholelithiasis,  312  ;  symptoms  and  diag- 
nosis of,  390. 

Cholera,  supposed  case  of,  in  London.  397. 

Chondro-epithelioma,  245. 

Chorea,  complicated  by  pregnancy,  922; 
diagnosis  of,  in  the  adult,  738 ;  pa- 
thology- and  morbid  anatomy  of  Hunt- 
ington's, 751 ;  relation  of ,  to  scarlatina, 
907;  treatment  of,  452,  504. 

Christison,  J.  Sanderson,  notice  of  book 
by.  530. 

Chylous  ascites  in  cancer  of  the  stomach, 
922. 

Cigarette,  boom  for  the,  562. 

Cigarette  smoking,  deaths  from,  in  Eng- 
land. 821. 

Circumcision,  ritual.  921. 

Cirrhosis  of  the  liver,  wine  as  a  cause  of, 
556. 

Civil-sersice  examinations,  effect  of,  274. 

Clark,  F.  H.,  the  ampliphone,  506. 

Clark,  L.  Pierce,  a  statistical  study  in  epi- 
lepsy, 1 58;  case  examination  in  epi- 
lepsy, 253. 

Clavicle,  simple  fracture  of,  treated  by  im- 
mediate suture,  865;  spontaneous 
fracture  of  the,  921. 

Clergj-man,  punishment  of  a,  for  practis- 
ing medicine,  353. 

Climate,  effects  of  change  of,  on  man  and 
animals,  597. 

Clinics,  a  bureau  of,  562. 

Clouston,  Thomas  S.,  notice  of  book  by, 
166. 

"Cock-matrons,"  508. 

Coffee,  medicinal  use  of,  906. 

Colby.  C.  D.  W.,  mechanical  restraint  of 
masturbation  in  a  young  girl,  206. 

Cold,  catching,  as  a  cause  of  disease,  907. 

Coley.  William  B. ,  strangulated  umbilical 
hernia,   239. 

Colic,  in  infants,  treatment  of,  903;  treat- 
ment of  nephritic,  7S5. 


936 


College  of  Physicians  of  Philadelphia,  54, 
564.  634,  711,  745.  857.  927- 

Colles'  fracture,  treatment  of,  100. 

Collins  State  Hospital,  trouble  at  the.  55. 

Colon  bacilli,  influence  of  environment 
upon  the  biological  processes  of  the, 

599- 

Columbia,  S.  C,  766. 

Comedo  extractor,  anew.  71. 

Commercialism  in  medicine,  56S. 

Congenital  dislocations,  Lorenz  method  in, 
S64. 

Congress  of  American  Physicians  and  Sur- 
geons, 21. 

Conjunctivitis,  purulent,  in  infants,  treat- 
ment of,  213. 

Connecticut,  increase  of  crime  in,  S92. 

Constipation,  chronic,  divulsion  of  the 
rectum  for,  5.76  ;  habitual,  treatment 
of,  53t. 

Consumption  in  its  relation  to  the  wage- 
earning  period  of  life,  790. 

Consumptives,  care  of,  by  the  board  of 
health.  S19  ;  hospital  for.  in  Paris,  544  : 
sanatoria  for,  715,  755. 

Contagious  diseases  act  in  India.  490 ; 
diet  and  nutrition  in  relation  to,  43  ; 
notification  of,  in  Paris,  6;i  ;  weekly 
statement.  36,  72,  108,  144,  179,  216, 
252,  287,  324,  363,  400,  436,  472,  507, 
542,  579.  616,  652,  687.  724.  759,  799, 
836,  906,  932. 

Contract  doctors  from  England  in  this 
country,  420. 

Contract  medical  practice,  denunciatidn  of, 
710. 

Convalescents,  need  of  a  home  for,  236. 

Corbett,  John  \V.,  the  route  to  Camden, 
S.  €.'.  S99. 

Cord,  spinal,  gunshot  wound  of  the,  433. 

Cordier,  A.  H.,  gastro-jejunostomy  in 
gastrectasis,  441. 

Cornea,  ulcer  of  the,  galvano-cautery  in, 
264. 

Cornell  University-,  a  students'  hospital  at, 
857- 

Cornish,  Surgeon- General,  death  of,  721. 

Coronado  Beach.  Cal.,  772. 

Corse,  William  Henrj-,  death  of,  673. 

Cor)-za,  abortive  treatment  of,  613  :  snuff 
for,  7S5. 

Costa  Rica,  quarantine  regulations  in.  274. 

Cough,  chronic,  guaiacol  in  the  treatment 
of,  594 ;  mixtures  for,  140,  538  ;  ner- 
vous, 418. 

Country  doctors,  slurs  upon,  33. 

Coutts,  J.  A.,  notice  of  book  by.  531. 

Cragin.  Edwin  B. ,  symphyseotomy  with  an 
'  unusual  complication,  240. 

Craig  Colony  for  Epileptics,  close  of  the 
fourth  year  of.  709. 

Craig,  Samuel  J.,  death  of,  527. 

Crane,  Delos  A.,  death  of,  163. 

Craniotomy,  a  physician  punished  for  per- 
forming, 541,  612.  636. 

Crazy  world,  91. 

Cream,  composition  of.  and  desirability  of 
establishing  a  standard,  172,  379. 

Creditors,  deferred,  21;. 

Crepitant  rale,  where  produced,  3S2,  613. 

Cretinism,  early  diagnosis  of  sporadic,  4S2; 
partial,  870. 

Creuz  y  Manso,  Juan,  death  of,  165. 

Crime  and  hot  weather,  759. 

Criminals,  asexualization  of,  631  ;  cranial 
anomalies  of,  6S7. 

Cronkhite,  C.  C.  hydatidiform  mole,  239. 

Cross,  J.  G. ,  urinating  tube  for  use  with 
wounds  of  the  perineum,  287. 

Croup,  907. 

Cuba,  deaths  from  starvation  in,  636 ;  sick- 
ness and  death  in,  S55;  Spanish  losses 
in,  421;  use  of  poisonous  bullets  by 
the  Spaniards  in,  74S. 

Culver,  Joseph  E.,  death  of,  712. 

Cumberland  County  (N.  J.)  Medical  So- 
ciety, 236,  711. 

Curran,  john  Joseph,  death  of,  200. 

Currier.  Andrew  F..  notice  of  book  by,  423. 

Cyon's  ner\'e,  683. 

Cystitis,  painful,  in  women,  treated  by  ves- 
ical curetting.  824 ;  pseudo-,  430. 

Cystocele.  vaginal,  l8t. 

Cystoscope.  controversy  concerning,  792. 


INDEX. 


Cysts,  improved  technique  in  operation  for 
intraligamentous,  S32. 


D 


Daland,  Judson,  notice  of  book  edited  by. 
531,  822. 

Daley,  R.  N.,  a  case  of  complete  spontane- 
ous version,  795. 

Daly,  Tames  P.,  death  of,  602. 

Dana,  Charles  L..  acute  serous  meningitis 
(alcoholic  meningitis,  wet  brain),  Sot, 
825. 

Davis,  Byron  B.,  imperfections  in  intra- 
abdomitial  diagnosis,  510. 

Davis.  Will  B..  some  practical  points  gath- 
ered from  sources  wise  and  otherwise. 
576. 

Davison,  William  A. ,  puerperal  septicaemia, 
724- 

Deadhead,  origin  of  the  word,  507. 

Death,  unexpected  forms  of,  among  the 
insane,  659. 

De  Baun,  Edwin,  the  perineal  horn,  251. 

Deformities,  pathogenesis  of,  460. 
-Deitrich,  W.  A.,   Lookout  Mountain  as  a 
health  resort,  7S0. 

Delaware  County  (Pa.)  Medical  Society. 
457. 

Delirium  tremens,  sudden  hyperpyrexia  in 
a  fatal  case  of.  907. 

Dennis,  Frederick  S. ,  notice  of  book  edited 
by,  639. 

Dentistry,  conviction  for  illegal  practice  of. 
601;  right  to  practise,  in  Scotland,  12S. 

Denver,  medical  schools  in.  199,  273. 

Dependency,  the  problem  of.  242. 

Dermatolog)'    rise  and  progress  of,  404. 

De\-ils,  in  those  days  there  were.  810. 

Diabetes  insipidus,  treatment  of,  786. 

Diabetes  mellitus,  496,  504;  blood  test  of, 
by  means  of  aniline  dyes,  495;  ne- 
crosis of  intestinal  glandular  epithe- 
lium in.  924:  pathogeny  and  etiolog\- 
of.  S73;  treatment  of,  391,  466,  504. 
515,  7S6,  844,  863. 

Diaphragm,  lipoma  of  the,  67S. 

Diarrhcea,  due  to  senile  degeneration  of  the 
intestinal  walls,  234 :  of  childhood, 
pathology  of  the,  54;  summer,  in 
London,  39S;  treatment  of  infantile, 
78;. 

Diehl,  Conrad,  election  of,  as  mavor  of 
Buffalo,  857. 

Diet-and  nutrition  in  relation  to  contagious 
diseases,  43:  the  question  of.  925. 

Digestive  tract,  cancerous  strictures  of  the. 
426;  common  sense  in  the  treatment 
of  disorders  of  the.  914. 

Digitalin.  use  and  dose  of.  25. 

Diphtheria,  antitoxin  administered  per 
OS,  919;  antitoxin  treatment  of.  63. 
104,  243.  350,  667,  S16;  formulae  for. 
7S6:  hospital  for  patients  with,  S92; 
in  London,  322,  578,  687;  plea  for 
rational  therapeutics  in,  752;  puer- 
peral, 49S  ;  spread  of.  by  pencils.  792: 
virulence  of  Loeffler's  bacilli  in  con- 
nection with  the  clinical  forms  of,  739. 

Disinfectants,  714. 

Dispensarj- abuse,  363,  8S9;  causes  leading 
to.  72;,  79S;  disinterested  testimony 
concerning  the.  17;  in  Philadelphia. 
52S  ;  report  of  the  committee  of  the 
New  'Sork  County  Medical  Association 
on,  65;  twenty  years  ago,  900. 

Dispensary-,  needed,  670. 

Dispensary-  patient,  protection  of  the,  70. 

Dispensary  system  in  London,  effect  of 
the,  53. 

Doctors,  Kipling's  compliments  to  the, 
821 :  puzzled,  91. 

Donovan.  .■Mfred  Q..  a  case  of  pneumonia 
treated  by  venesection,  S85. 

Dowd.  Charles  N.,  is  pain  a  valuable  sign 
in  the  diagnosis  of  cancer  of  the 
breast  ?  181. 

Dowling,  John  F.,  tapeworm  in  men,  400. 

Do«-se,  Thomas  Stretch,  notice  of  book 
by.  529. 

Drainage  of  »-ounds.  60S. 

Drescher.  August,  blueweed.  chemical  and 
physiolmrieal  notes,  f  Iq. 


[December  25,  1897 


Dropsy,  diurectic  treatment  of  renal.  524. 

Drug  habits,  prognosis  of,  loS. 

Drugs,  smuggling,  748. 

Duane,  Alexander,  notice  of  book  by,  166. 

Duchenne  of  Boulogne,  a  monument  to, 
164. 

Duodenum,  chronic  inflammation  and  ul- 
ceration of  the,  with  resultant  refle.xes, 
60. 

Du  Pasquier,  Dr.,  death  of,   398. 

Dusts  as  propagators  of  inflammatory-  dis- 
eases, 6S3. 

Dynamometer,  a  new,  143. 

Dyspepsia  and  constipation  in  children, 
treatment  of,  24S ;  relation  of  ner- 
vous, to  changes  in  the  rhythm  of  the 
heart.  497;  relation  of  nervous,  to 
general  nervous  disturbances,  496. 

Dyspnoea,  uraemic,  51. 

Dystocia  from  prolonged  pregnancy  and 
premature  ossification  of  the  cranium, 
150. 


Ear,  acute  catarrh  of  the  middle,  as  a  se- 
quel of  grippe,  565 ;  chronic  purulent  in- 
flammation of  the  middle,  ichthyol  in. 
160;  course  and  treatment  of  diseases 
of  the  mastoid,  693;  of  grasshopp)ers, 
flies,  and  beetles,  550;  treatment  of 
ec'ema  of  the  external  auditory-  canal, 
tjo3. 

Eclampsia,  due  to  phimosis  in  a  child  seven 
months  old,  886;  treatment  of,  34; 
treatment  of  puerperal,  493. 

Ecthyma  and  impetigo,  888. 

Eczema  of  the  external  auditory  canal,  treat- 
ment of.  903. 

Edwards,  Joseph  F.,  death  of,  927:  the 
neri'ous  system  in  disease,  258. 

Education,  medical,  in  America  and  Great 
Britain,  18,  106. 

Egg  albumen  as  a  medicine,  72. 

Elder,  William,  notice  of  book  by,  170. 

Electric  heating  pad,  35. 

Electrolysis,  linear,  215. 

Elephantiasis  of  the  testicle,  430. 

Ellis.  Richard,  tobacco  amblyopia,  453. 

El  Paso.  Texas,  770. 

Emphvsema,  tuberculous  ly-mph  nodes  in, 
S96. 

Empyema,  pneumonic,  467 ;  surgery  of, 
674. 

Endocarditis,  gonorrhceal.  161.  497;  ma- 
lignant, 678;  of  the  left  heart  propa- 
gated to  the  right  heart  by  perforation 
of  the  septum,  558;  orrothotherapy  in 
ulcerative,  419,  59S. 

Endometritis,  the  curette  in  puerperal  and 
chronic,  66;  treatment  of  puerperal, 
by  the  Carossa  method,  499. 

Endoscope,  use  of,  in  chronic  urethritis. 
259. 

Endotheliomata,  metastases  of.  460. 

Ensign.  O.  S. ,  the  treatment  of  symptoms, 
S3;. 

Enterocele.  acute  partial,  666. 

Enterprise.  Fla. .  76S. 

Epidermiology,  international  bureau  of, 
421. 

Epidermis,  national  control  of.  710. 

Epilepsy,  a  statistical  study  in,  158;  and 
menstruation,  240:  case  examination 
in,  253;  in  relation  to  the  disease;  of 
women,  537;  Jacksonian,  109;  treat- 
ment of,  62,  504,  687,  786. 

Epileptic  colony  in  England.  141;  the 
Craig.  709. 

Epistaxis,  S6S;  in  typhoid  fever,  source  of. 
799:  ligation  of  the  common  carotid 
for,  611. 

Epispadias,  operation  for.  650. 

Epithelioma,  blastomyces  in,  852;  of  the 
face,  30. 

Epley,  F.  W.,  mother  and  child.  195. 

Epsom  salts,  mode  of  administration  of, 
15- 

Erdmann.  John  F..  traumatic  paralyses  of 
the  upper  extremities.  697. 

Ergot,  disuse  of,  in  present-day  midwifery- 
practice,  igS. 

Erwin.  R.  \V.,  epistaxis  in  typhoid  fever. 
7<>9- 


December  25,  1897] 


INDEX. 


937 


Erj'sipeias,  application  for,  788;  strepto- 
cocci of,  852;  treatment  of,  556. 

Erythromelalg^ia,  two  cases  of,  39. 

Eshleman,  J.  K.,  death  of,  563. 

Ether  -'ersits  chloroform,  560, 

Ethics,  ruling  on  a  question  of,  792. 

Ettinger,  Leo,  some  practical  points  on 
the  administration  of  chloroform,  552. 

Eucal)'ptus  globulus  in  str)'chnine  poison- 
ing, 349- 

Eustrong)lus  gigas.  a  case  of,  256. 

Evans,  Thomas  W..  death  of,  872;  obitu- 
ary of,  74Q. 

Evans,  W.  A.,  notice  of  book  by,  529. 

Evolution,  pathology  of,  4.50. 

Ewald,  C.  A.,  notice  of  book  by,  167. 

Exophthalmic  goitre,  thymus  and  adrenal 
preparations  in  the  treatment  of,  2S; 
surgical  treatment  of,  430. 

Expectorant,  a  useful.  539. 

Expert  testimony,  526,  706,  74S. 

Eyes,  antiseptics  in  surgery  of  the,  617; 
bilateral  subluxation  of  the  crj-stalline 
lenses  with  ectopia  of  the  pupil  of  the 
left  eye,  703;  diseases  of,  in  school 
children,  796;  hysterical  paralysis  of 
the  external  recti  muscles  of  the,  59S; 
of  school  children,  need  of  inspection 
of,  592;  surger)'  of  the,  607. 


Fasting,  infection  and,  544. 

Fat  necrosis  and  disease  of  the  pancreas, 
62. 

Fatly  embolism,  788. 

Favus,  a  school  for  children  with,  471 ;  ex- 
clusion of,  631,  633;  treatment  of ,  470. 

Feeding,  infantile,  105. 

Fehleisen,  F.,  diagnosis  and  treatment  of 
affections  of  the  frontal  sinuses,  192. 

Felons  as  medical  practitioners,  114. 

Femur,  osteotomy  of  the,  540. 

Ferran,  rejection  of  claim  by,  to  priority 
in  anticholera  injections,  528. 

Fever,  traumatic,  98. 

Fick,  A.  Eugen,  notice  of  book  by.  166. 

Filaria,  a  case  of,  104. 

Finlayson,  James,  notice  of  book  by,  639. 

Fischer,  Louis,  clinical  value  and  chemical 
results  of  using  Professor  Gaertner's 
mother  milk  in  children,  S39. 

Fistula,  salivar)',  cocaine  in,  207:  treat- 
ment of  suppurating,  611. 

Flagg,  Cora  Hosmer,  the  patholog)  of 
evolution,  450. 

Flagg,  Robert  N.,  death  of,  527. 

Flatfoot,  treatment  of,  460. 

Fleming,  Luke,  hiccoughs  and  their  treat- 
ment, 16. 

Fletcher,  Adam,  death  of,  578. 

Fletcher,  Bell,  death  of,  757. 

Flora,  study  of  the  American  medicinal, 
179- 

Florence,  Ala.,  769. 

Florida,  health  resorts  of,  766. 

Flowers,  poisonous,  543. 

Ffetus,  determination  of  the  age  of  a,  in 
miscarriage,  Soo:  stabbing  of  a,  252. 

Follett,  A.  C,  hysterical  aphonia,  701. 

Fonde,  Kieth,  tuberculosis — the  pine  belt 
of  South  Alabama  versus  high  alti- 
tudes, 778. 

Food  adulterations,  135,  892;  inspectors  in 
New  York,  work  of  the,  793:  supply, 
public  health  in  relation  to  the,  88g. 

Foot-and-mouth  disease.  666. 

Football,  legislative  prohibition  of,  673, 
706,  792,  800,  S91. 

Forceps,  when  to  use  the,  788. 

Ford,  William  H.,  obituary  of,  637. 

Forearm,  forward  dislocation  of  the,  738. 

Formaldehyde  generator,  1 78. 

Formalin  as  a  preservative  of  gross  patho- 
logical specimens,  247. 

Fort,  J.  .v..  linear  electrolysis,  106. 

Foster,  P'rank  P.,  notice  of  book  edited 
by,  423. 

Foundlings,  mortality  among,  in  Italy,  164. 

Fracture,  intra-uterine.  647;  massage  and 
movements  in  the  treatment  of,  102; 
plaster  of  Paris  as  a  universal  dressing 
for.   S33:  prevention  of  deformity  af- 


ter, 662;  treatment  of,  540;  ununited, 
29. 

Frampton,  E.  A.,  death  of,  749. 

France,  persecution  of  physicians  in,  92;; 
reaction  against  the  exclusion  of  for- 
eign medical  students,  871;  right  to 
practise  medicine  in,  23S. 

Frank,  Jacob,  pathological  histology  of  in- 
testinal end-to-end  approximation  af- 
ter the  use  of  the  Frank  coupler,  401. 

Franklinization,  electrical  synthesis  of,  49S. 

Freeman.  H.  W..  death  of.  930. 

Frontal  sinuses,  diagnosis  and  treatment 
of  affections  of.  i<^2. 

Frje,  P.  Y. .  death  of,  5,63. 

Fuld,  Joseph  E..  a  new  septum  knife, 
578. 

Fulton,  Henry  D.,  forward  dislocation  of 
the  forearm,  738. 

Fumiss,  H.  \V.,  diagnosis  by  examination 
of  the  blood.  663. 

Furunculosis,  treatment  of.  159,  207. 


daertner's  mother  milk,  clinical  value  and 
chemical  results  of  using,  in  children, 
839. 

Galactagogue,  thyroid  extract  as  a,  48. 

(iailant,  A.  Ernest,  aniesthesia  and  its  ad- 
ministration in  Great  Britain  and  Ire- 
land, with  reference  to  its  being  made 
a  specialty,  722. 

Gall  bladder,  and  bile  ducts,  diseases  of  the, 
7SS;  removal  of  a  cancerous,  559; 
treatment  of  injuries  to  the,  102;  ul- 
ceration and  rupture  of  the,  626. 

Gall  stones,  466;  in  their  relation  to  can- 
cer of  the  gall  tract,  828;  obstruction 
of  the  small  intestine  by,  888. 

Ganglia  cells,  a  new  stain  for,  247. 

Gangrene  of  the  leg  following  typhoid 
fever,  918;  spontaneous.  460. 

Garbage  disposal,  141.  890. 

Gas.  poisonous  illuminating,  399. 

Gastrectasis.  gastro-jejunostomy  in,  441. 

Gastritis,  artificial  Carlsbad  for,  785;  la- 
vage in  chronic,  523;  phlegmonous, 
following  cancerous  ulcer  of  the  py- 
lorus, 365 ;  treatment  of  acute.  903. 

Gastroscopy,  463. 

Genito-urinary  instruments,  some  useful, 
S70. 

Georgia,  health  resorts  of,  766. 

German  Congress  of  Internal  Medicine,  141; 
Hospital,  .\lumni  Association  of  the, 
199. 

Germany,  .\merican  students  in,  672,  6S4: 
English  medicines  in,  672;  proportion 
of  medical  men  in.  616. 

Giant  cells,  formation  of,  244 

Gibson,  C.  L.,  mortality  and  treatment  of 
acute  intussusception.  73. 

Gibson,  G.  .\..  notice  of  journal  edited  by. 
530. 

Gilchrist,  William  N.,  death  of.  S56. 

Girls,  physical  and  intellectual  training  of, 
610. 

Gleitsmann,  J.  W.,  report  of  the  progress 
made  in  the  treatment  of  larjngeal 
tuberculosis  since  the  last  international 
congress,  803. 

Glenns  Springs,  S.  C,  766. 

Gluttony,  effects  of,  287. 

Goat's  milk  for  children,  557. 

Goelet,  Augustin  IL,  two  complicated  ab- 
dominal hysterectomies.  534. 

Goitre,  exophthalmic,  operation  for,  541. 

Goldhammer,  Adolf,  guaiacol  in  chronic 
coughs,  594. 

Goltman,  .Abraham,  triplets,  16. 

Gonococcus  toxin,  323. 

Gonorrhoea,  endocarditis  in,  161,  497;  in- 
flammation of  joints  in,  153;  irrigation 
treatment  of,  460. 

Gottheil,  William  S.,  a  case  of  neurotic 
alopecia,  275;  notice  of  book  by,  168, 
530. 

(iould,  George  M.,  notice  of  book  edited 
by,  169.  S24. 

Gout  and  the  uric-acid  diathesis,  electric 
treatment  in.  848;  arthritic,  524;  dis- 
cussion  on,     60:     formulas    for.    786: 


gastro-intestinal  and  hepatic  relations 
of,  699. 

Gover,  R.  M.,  death  of ,  32. 

Gneco  -  Turkish  war,  treatment  of  the 
wounded  in  the,  iSo. 

Grafting,  skin,  98. 

Grandin,  Egbert  H.,  pay  for  hospital  at- 
tendance, 142. 

Grave  robbery,  a  physician  accused  of,  748. 

Graves'  disease,  treatment  of.  212. 

Graves,  Marvin  L.,  medical  and  surgical 
iconoclasm,  664. 

Greanelle,  William  J.,  vaccination  by  the 
Health  Department.  931. 

Greeks,  future  of  the,  287. 

Green  Cove  Springs,  Fla.,  76S. 

Green  stools,  remedy  for,  213. 

Greene.  J.  IL,  treatment  of  tic  douloureux, 
107. 

Greene,  Ryland  W.,  notice  of  book  edited 
by,  493. 

Grinnell,  A.  P.,  notice  of  chart  by,  530. 

Guaiacol  in  chronic  cough,  ^94. 

Guild  of  St.  Luke,  service  for  the,  at  St. 
Paul's  Cathedral,  721. 

Guiteras,  Ramon,  a  pair  of  retractors,  906. 

Guy's  Hospital    the  founder  of,  180. 

Gvmnastics  in  the  \'ale  College  curriculum, 
708. 

(iynsecolog)-,  studies  in,  from  the  service 
of  the  Woman's  Hospital  of  Philadel- 
phia, 133. 

Gyves  and  trigs  (bonds  and  obstacles),  607. 


H 


Haematokrit,  495. 

Ha;matolysis.      relation      between      tissue 

change  and  leucocytes  in,  454. 
Ha^mato-myelopoie,  279,  283. 
Haemophilia.     J3g;    arrest    of  hemorrhage 

in,  324;  study  of  the  nares  and  phar- 
ynx in  a  case  of,  868. 
Hiijmoptysis.   effect  of  the  weather  upon. 

436. 
Hair  wash,  inflammable,  201. 
Halberstadt,  A.  H.,  reception  to,  820. 
Hall.  .\.  Llewellyn.  "  don't  trust  yourself 

in  the  hands  of  those  countr)-  doctors, " 

33- 
Hall.    J.    N.,   a  case   of  double  pulmonic 

murmur  with  diastolic  thrill,  202. 
Halliday,    .Andrew,    the    condition    of   the 

gastric  secretion  in  raerycism,  48. 
Hand,    the,    as   a   propagator  of  microbic 

disease,  813. 
Harbitz,   Francis,  notice  of  book  by,  530. 
Hare,    Hobart    Amor)-,     notice    of    book 

edited  by,  S24. 
Harelip,  operation  for.  437. 
Harris,  Thomas  J.,  rhinitis  atrophica  foe- 

tidans  in  its  relation  to  diseases  of  the 

accessory  sinuses.  516. 
Harrison,    Reginald,    clinical    remarks   on 

some  suppurations  of  the  urinar)'  ap- 
paratus, 8. 
Harrogate,   opening  of  the  new  baths  at, 

249,  363. 
Hart,  Ernest,  illness  of.  562. 
Hartelin,  T.  J.,  notice  of  book  by.  493. 
Hartridge.    (;usta\Tis,   notice  of  book   by, 

529. 
Harvard  College,  an  accusation  against,  57. 
Haughton.  Samuel,  death  of,  797. 
Hawaii,  772. 
Hawkins.   Thomas  IL.  forced  enemata  in 

the  treatment  of  intussusception.  886. 
Hay,  Jacob,  death  of,  633. 
Headache,     687;      from    autointoxication, 

243;  uremic,   786. 
Health  department  of  New  York,  decision 

against  the.  601  ;   vaccination  by  the, 

931;  work  of  the.  387. 
Health  legislation.   715. 
Health  manceuvres  for  the  niilitar)-  govern- 
ment of  I'aris,  652. 
Health  Protective  Hospital   for  contagious 

diseases  in  Philadelphia,  791. 
Health    reports   of    the    Marine    Hospital 

service.    36,    72.   108,   144,    :8o,  216, 

252.   288,   324.   400,   436,    508,    544, 

5S0.  616.  652.  688.  760.  800.  908,  932. 
Health  resorts,  winter.  761.  790. 


938 


INDEX. 


[December  25,  1897 


Hearing,  limits  rjf  the  power  of,  932. 

Heart,  anarmic  and  organic  murmurs  of  the. 
907;  aneurism  at  the  apex  of  the.  320; 
aortic  valve  with  two  segments,  282; 
cause  of  the  beat  of  the,  2SS;  disease 
of  the  coronary  arteries  with  red  in- 
farction of  the  myocardium,  362;  dis- 
ease of  the,  with  vascular  calcification, 
7S5;  double  pulmonic  murmur  with 
diastolic  thrill,  202;  endocarditis  of 
the  left,  propagated  to  the  right  heart 
by  perforation  of  the  septum,  558; 
globular  thrombus  of  the,  245;  hyper- 
trophy and  dilatation  of  the,  644; 
mechanism  of  the  first  sound  of  the. 
213;  murmurs  of  the.  465;  persistent 
tachycardia,  with  digestive  and  nen-ous 
disorders,  217,  241;  prognosis  and 
therapeutic  indications  in  disease  of 
the  heart,  24;  rupture  of  the,  319; 
Schott  treatment  of  disease  of  the,  24, 
175;  terms  to  indicate  myocardial 
changes,  467;  thrombus  of  the,  31; 
traumatic  disease  of  the,  105. 

Heat  exhaustion,  treatment  of,  through 
the  nerve  centres  and  the  lungs,  267. 

Heating  pad.  electric.  35. 

Heddle,  M.  F.,  death  of,  S9S. 

Heller,  Richard,  notice  of  book  by,  167. 

Hemiplegia,  crossed,  465. 

Herameter.  John  C,  a  case  of  phlegmo- 
nous gastritis  following  ulcus  carcino- 
matosum  of  the  pylorus.  365. 

Hemorrhage,  prevention  of,  31. 

Hemorrhoids,  tincture  of  horsechestnut  for. 
S16;  treatment  of,  903. 

Hemospast,  the.  70. 

Henry,  W.  O..  criminal  abortion,  33. 

Henson.  J.  \V.,  some  thoughts  on  teaching 
anatomy.  196. 

Hepatitis,  intercellular.  462. 

Heredity,  mystery  of,  688. 

Hernia.  Bassini  operation  for,  96;  in  an 
infant  ten  weeks  of  age.  577;  ingui- 
nal, successful  operation  on  an  enor- 
mous, 869  ;  in  old  men,  treatment  of. 
609;  irreducible.  32.  284;  of  the  ce- 
cum, 96  ;  operation  for.  865  ;  perma- 
nence of  results  in  the  radical  cure  of. 
42S  ;  phimosis  as  a  factor  in  the  causa- 
tion of,  S39  ;  radical  treatment  of,  590; 
strangulated  appendical.  703  ;  strangu- 
lated, extensive  resection  of  the  intes- 
tine. fi50  ;  strangulated  umbilical.  SS7; 
umbilical  and  epigastric,  434;  umbili- 
cal, report  of  three  operations  for.  in 
elderly  women.  794;  umbilical,  stran- 
gulated, 239. 

Herald,  Justin,  notice  of  book  by,  S23. 

Hiccough,  treatment  of,  16,  576. 

Hicks.   Braxton,  death  of,  422. 

Hillis,  T.  J.,  the  physician,  his  personnel, 
and  how  it  affects  his  success,  224  ; 
what  must  we  do  to  be  saved  ?  being 
an  inquiry  into  and  a  brief  summarj- 
of  the  causes  leading  to  hospital  anil 
dispensary  abuse  of  medical  charity, 
725. 

Hinsdale.  Guy,  notice  of  book  by,  169. 

Hip,  amputation  of  the,  S65  ;  dislocation 
of  the,  207. 

Hip  disease,  treatment  of,  459,  627. 

Hodgkin's  disease  and  tabes  (?),  210  ;  com- 
plicated by  pulmonarj-  tuberculosis, 
313. 

Holmgren,  Alarik  Frithiof,  death  of.  528. 

Holthouse,  Kdwin.  notice  of  book  by,  530. 

Honor  to  whom  honor  is  due,  930. 

Horn,  George  H.,  death  of,  820.  S56. 

Hospital  attendance,  pay  for.  142  ;  abuse. 
272  ;  abuse  in  London.  2S5  ;  enter- 
prise, 310.  506:  fund,  the  Prince  of 
Wales',   436  ;    funds  in   London,  322. 

Hospital  Reform  Association  of  London, 
720. 

Hospitalism,  susceptibility  of  infants  to. 
iS. 

Hot  Springs,  Ark.,  770. 

Hot  Springs,  Va..  7()2 

Hot  we.ither  and  crime.  759. 

Hough.  He  Witt  Clinton,  death  of.  352. 

Howden.  J.  C,  death  of.  422. 

Hubbard.  "Robert  S..  death  of.  127. 

Huddleston.   J.    IL,    a   discussion  of   the 


composition  of  cream  and  a  considera- 
tion of  the  desirability  of  establishing 
a  standard.  379. 

Hughes.  Oliver  J.  D..  Nassau  and  the 
Bahama  Islands,  773. 

Hummell.  A.  L..  death  of.  673. 

Huntington's  chorea,  pathology  and  mor- 
bid anatomy  of.  751. 

Huntsville,  .Via..  769. 

Hutchinson,  Woods,  the  possible  morpho- 
logical basis  for  some  diseases  of  the 
lung.  145. 

Hutton,  W.  H.  H..  death  of.  55. 

Hydatid  cysts,  7SS. 

Hydrocele,  chronic,  with  calcifiq.-'tion  of 
the  sac,  647;  radical  cure  0/  congeni- 
tal, 2S3;  treatment  of,  624. 

Hydrophobia,  fatal  case  of.  in  Paris.  652; 
of  long  incubation,  922:  report  on, 
107. 

Hydrosalpinx,  specimen  of,  65. 

Hydrotherapy,  faulty,  504. 

Hyperpyrexia,  sudden,  in  a  fatal  case  of 
delirium  tremens,  907. 

Hypnotic  suggestion,  a  curious  case  of, 
400. 

Hj-podermic  needles,  economy  in,  723;  syr- 
inge, an  improved,  323. 

Hysterectomy,  276,  608;  complete,  after 
injur)'  during  parturition  and  Csesarian 
section,  502  ;  complicated  abdominal, 
534;  forceps,  507:  indications  for, 
75S;  sequel.T;  of  supravaginal,  499; 
technique  of  abdominal,  134;  vaginal, 
for  malignant  diseases,  131. 

Hysteria,  formula  for,  786;  in  early  life, 
555  ;  symptoms  of  theinterparoxysmal 
period,  603;  traumatic,  271. 

Hysterical  aphonia.  S6,  701. 

Hysterorrhaphy,  result  of.  66. 


Ice  cream,  regulation  of  the  sellers  of.  687 

Ichthyol  in  a  case  of  chronic  purulent  in- 
flammation of  the  middle  ear.  160. 

Iconoclasm,  medical  and  surgical.  664. 

Ideas,  medicine  for  "threading,"  687. 

Ike.  E.  M..  death  of.  200. 

Ileus,  dynamic,  following  operations  in- 
volving the  abdominal  cavity,  502. 

Ill,  Edward  J.,  the  change  of  life  and  the 
diagnosis  of  carcinoma  uteri.  500,  509. 

Illegal  practice,  fines  for,  S36. 

Illinois,  medical  practice  regulations  in, 
712. 

Impetigo  and  ecthyma.  SS3. 

Indian  River.  Kla..  768. 

Indian  Territory  Medical  Association,  199. 

Indigestion  of  breast-fed  babies.  55S. 

Inebriety,  heredity  in  the  causation  of,  721; 
in  England.  458. 

Infant  feeding,  cows'  milk  in,  13. 

Infantile  scurvy,  collective  investigation  of. 
385. 

Infants,  excessive  treatment  in  disorders 
of,  105. 

Infectious  diseases,  hospital  for,  in  Lon- 
don, 174. 

Influenza,  in  Asiatic  Russia,  564;  multiple 
neuritis  following,  667. 

Inglis.  David,  common  sense  in  the  treat- 
ment of  digestive  disorders,  914. 

Ink.  bacteria  in.  S36. 

Insane,  care  of  the  dependent,  in  Mary- 
land, 134:  unexpected  forms  of  death 
among  the,  659. 

Insanity,  increase  of,  235;  thyroid  feeding 
in,  S8S. 

Insurance,  life,  medical  selection  for,  261. 

Intellect,  comparative,  in  men  and  women. 
59"- 

International  Medical  Congress,  the 
Twelfth,  273,  2S6,  323.  421.  422;  spe- 
cial report  of  the,  307,  31;,  354,  392, 
424.  459.  471.  494- 

International  medical  congresses,  the  .\mer- 
ican  physician  as  a  participant  in.  630. 

Intestinal  anastomosis.  7S7:  antisepsis. 
'40.  555  ;  putrefaction,  relation  of. 
to  nutrition.   105. 

Intestine,  dangerous  distention  of,  relieved 
by  massage.  S69:  eight  perforations  of 


the.  from  a  pistol  bullet.  311;  irrigation 
in  the  treatment  of  destruction  of  the. 
916;  moribund.  103;  obstruction  of  the. 
464.  SS5;  pathological  histology  of  end- 
to-end  approximation  after  the  use  of 
the  Frank  coupler,  401;  preservative 
injections  in  the,  897:  resection  of  the, 
464;  tonic  and  spasmodic  contractions 
of  the,  ;o2;  traumatic  rupture  of  the, 
with  survival  for  sixteen  hours.  66S; 
treatment  of  occlusion  of  the.  426. 

Intussusception  in  infants,  surgical  treat- 
ment of.  521;  forced  enemata  in  the 
treatment  of.  886;  mortality  and  treat- 
ment of  acute.  73:  treatment  of  a  case 
of.  772. 

lodism.  avoidance  of,  when  taking  iodide 
of  potassium.  78;. 

Iodoform,  antiseptic,  value  of,  30. 

lodoformism.  379. 

Iowa,   medical  charity  abuse  in,  92. 

Irrigating  stand  with  pedal  cutoff.  905. 

Irrigator,  new  suspension  device  for.  108. 

Irwell.  Lawrence,  do  abnormalities  tend  to 
die  out  in  the  course  of  transmission  ? 
176. 

Ischochymia.  61. 

Ischuria,  treatment  of.  following  h)'per- 
trophy  of  the  prostate.  427,   429. 

Italy,  American  dentists  in.  791  ;  proposed 
regulation  of  medical  practice  in.  126. 
165.  321. 

Itch,  winter,  bichloride  applications  in 
576. 


T 


Jacksonville.  Fla.,  767. 

Jacobi.  A..  Jacksonian  epilepsy;  adenoma 
of  the  liver;  acute  ascites  with  tubercle 
bacilli,  109. 

Jacobi,    Mary    Putnam,     experiments    on 
urinarj-  toxicity.  653. 
aeger.  Gustav,  notice  of  book  by.  493. 
amaica.   763. 
ames,  J.  Brindley.  notice  of  book  by.  S22. 

Japan,  bacteriology  in.  544. 

Jaws,  occlusion  of  the,  operative  procedure 
for  the  relief  of.  95. 

Jenkins.  J.  F. ,  differential  diagnosis  be- 
tween malaria  and  typhoid  fever.  622. 

Tenner  societv.  a  proposed  international. 
238. 

Jewett,  H.  S. .  a  large  dose  of  sodium  sali- 
cylate. 704;  a  peculiar  case  of  appen- 
dicitis, 704;  death  from  A.  C.  E. 
mixture.   704. 

Joints,  inflammation  of.  in  gonorrhoeal 
patients.  153;  treatment  of  tubercu- 
lous disease  of,  459. 

Jones,  H.  Macnaughton,  notice  of  book 
by.  494. 

Jones,  Mary  A.  Dixon,  personal  experi- 
ences in  laparotomy.   182. 

Jones,  William  P..  death  of.  527. 

Jubilee  honors  for  doctors.  103. 

lubilee  Hospital,  the  London  Truth  on. 
S34. 

Jupiter.  Fla.,  76S. 


Kammerer.  Fred.,  a  modified  incision  at 
the  outer  border  of  the  rectus  muscle 
for  appendicitis.  S37. 

Kashida-Ogata  medium,  application  of.  to 
the  examination  of  drinking  •  water, 
270. 

Katatonia.  473. 

Kauffman.  George  R..  death  of.  309. 

Keith,  George  S. .  notice  of  book  by.  424. 

Kellogg.  Theodore  IL.  notice  of  book  by 
63S. 

Kemp.  Robert  Coleman,  a  metal  double 
current  rectal  irrigator,  143. 

Kidney,  adenocarcinoma  of  the,  283;  an 
choring  the.  97;  drainage  of  the,  171 
floating.  68 1  ;  floating,  relieved  by  a 
railway  journey.  683;  genital  phenom 
ena  of  stones  in  the.  27S;  methylene 
blue  in  the  diagnosis  oT  renal  perme 
ability.  554;.  movable. mechano-therapy 
of.  898;  primary  tuberculosis  of  the, 
62;  removal  of,  for  adenona,  22  ;  sup- 


December  25,  1897] 


INDEX. 


939 


puration  of,  value  of  micro-urinalysis, 
in  the  diagnosis  of,  130;  treatment  of 
chronic  nephritis,  903;  tumors  of  the, 
derived  from  the  suprarenal  rests,  172. 

Kiefer,  Louis  F.,  death  of,  163. 

Kilmer,  Theron  \V.,  ichthyol  in  a  case  of 
chronic  purulent  inflammation  of  the 
middle  ear,  160. 

King.  G.  W. ,  surgical  cases  in  general 
practice,  53S. 

Kingsley,  B.  F.,  hysterectomy,  276. 

Kinnear,  Beverley  Oliver,  sunstroke,  or 
thermal  fever,  and  heat  exhaustion; 
their  treatment  through  the  ner\e 
centres  and  the  lungs,  267. 

Kipling's  compliments  to  the  doctors,  S21. 

Kirk.  Edward  C. ,  notice  of  book  by,  529. 

Kirstein,  A. ,  notice  of  book  by,  531 . 

Kissing,  injur)-  from,  636. 

Kitchel,   Edward  W. .  death  of.  309. 

Klondike,  star\-ation  and  death  in  the, 
746. 

Knapp,  >rark  I.,  the  biparietal  diameter 
as  a  symptom  and  diagnostic  criterion 
of  tuberculosis.  265.  27S, 

Knee,  traumatic  haemarthrosis  of  the,  30. 

Kneipp,  Father,  death  of,  214. 

Knight.  X..  absorption  by  water  of  free 
and  albuminoid  ammonia  under  vari- 
ous conditions.  4S7. 

Knockout  drops,  directions  for  the  use  of, 
903. 

Knopf,  S.  A.,  the  urgent  need  of  sana- 
toriums  for  the  consumptive  poor  of 
our  large  cities.  715.  77;. 

Kolliker.  Professor,  jubilee  of.  I23. 

Koplik,  Henry,  early  diagnosis  of  sporadic 
cretinism,  with  a  report  of  two  cases 
of  congenital  sporadic  cretinism,  4S2. 

Koser.  S.  S. .  medical  education  in  America 
and  Great  Britain.  106. 

Krog.  Albert  F.  E..  death  of,  233. 

Kutner.  Robert,  notice  of  book  by,  822. 

Kydd.  Mary  Mitchell,  experiments  on  uri- 
nary to.\icity,  653. 


Lake  George.  Fla..  763. 

Lakewood,  X.  J..  762. 

Lane  lectures  at  the  Cooper  ^fedical  Col- 
lege, 793. 

Langdon,  Charles  H.,  katatonia,  473. 

Lange,  C,  notice  of  book  by,  531. 

Language,  an  international.  31;. 

Laparotomy,  best  method  of  suture  after, 
102;   personal  experiences  in,  182. 

Laporte.  Dr.,  trial  of.  for  alleged  mal- 
practice.  542,  757. 

Lar)-ngismus  stridulus,  796. 

Lar)nx,  abductor  paralysis  of  the,  in  ma- 
lignant stricture  of  the  cesophagus, 
557;  perichondritis  of  the.  in  typhoid 
fever,  27;  treatment  of  tuberculosis  of 
the,  503.  803,  932;  tuberculosis  with 
syphilis  of  the,  785. 

Las  Cruces.  X.  M..  770. 

Law,  Joseph,  death  of,  32. 

La.xati%e  in  hepatic  subjects,  785. 

Lead,  search  for,  in  thesalivar)'  glands  in 
cases  of  poisoning,  923;  unusual  modes 
of  poisoning  with,  3S4. 

Legal  Medicine,  International  Congress  of, 
352. 

Lehigh  Valley  (Pa.)  Medical  Association, 
199. 

Lehr,  George  G.,  death  of,  309. 

Leitch,  Mary  and  Margaret,  a  medical  mis- 
sionary wanted  in  Ceylon,  835. 

Lepers  in  N"ew  York,  600. 

Leprosy,  an  international  society  for  the 
study  of,  710;  congress  for  the  study 
of.  600,  797;  contagiousness  of,  757; 
elimination  of  the  bacilli  of,  from  the 
bodies  of  leprous  subjects,  271  ;  hos- 
pitals for,  in  Iceland,  528  :  recent  hap- 
penings bearing  upon  the  question  of, 
671. 

Letters  from  Berlin,  105,  141.  214,  322, 
684,  797;  ffom  London,  31,  69,  103, 
140,  174,  213,  248.  285,  322,  397. 
435.  470,  505.  577.  6l2,  650,  682, 
720,  756,  796,  834.  870,  897.  929:  from 


Paris.  541.  612,  651,  683.  757,  371; 
from  Vienna,  175,  286,  398. 

Leukoemia,  Ij-mphatic,  with  streptococcus 
infection,  59;  morphology  of  the  blood 
in,  495. 

Levator  ani  muscle.  557. 

Larin,  Henrv-.  the  spitting-nuisance.  930. 

Lewi.  Joseph  R..  death  of,  927. 

Lewis.  Charles  H..  a  case  of  Hodgkin's 
disease  complicated  with  pulmonar)- 
tuberculosis.  313. 

Lichen  planus  presenting  lesions  with  a 
circular  form.  20;. 

Liebreich,  Oscar,  notice  of  book  by,  423, 
529. 

Life,  continuity  of.  316:  insurance,  medi- 
cal selection  for,  261. 

Ligatures  and  sutures,  sequels  of  dead. 
499- 

Lindsley.  J.  Berrien,  obituarv-  of,  92S. 

Lithaemia  and  oxaluria.  23. 

Lithotrit)',  indications  and  results  of,  429; 
in  the  treatment  of  large  vesical  cal- 
culi, 41S. 

Liver,  abscess  of  the,  six  years  after  tropi- 
cal dysenter)',  556;  acute  yellow  atro- 
phy of  the,  in  a  girl  twelve  years 
old,  595:  adenoma  of  the,  109;  cir- 
rhosis of  the,  wine  as  a  cause  of,  556; 
clinical  forms  of  cirrhosis  of  the,  461: 
large  waxy,  in  children,  319;  rupture 
of  the,  248;  treatment  of  injuries  of 
the,  284;  variability  in  color  and 
amount  of  the  intracellular  biliary  pig- 
ment deposits  in  the,  124. 

London,  letters  from,  31,  6g,  103,  140, 
174,  213.  24S,  2S5,  322,  397,  435, 
470.  505,  577,  612,  650.  6S2,  720, 
756,  796,  834.  870.  897,  929. 

Longe\ity,  influence  of  alcohol  upon,  891. 

Long  Island  Railroad  hospital  ser\-ice,562. 

Long,  James,  death  of,  683. 

Lookout  Mountain  as  a  health  resort,  780. 

Loomis,  Alfred  Lee,  notice  of  book  edited 
by,  824. 

Los  -Angeles,  Cal..  771. 

Louisiana,  health  resorts  of.  769. 

Loumeau.  E..  notice  of  book  by.  822. 

Love.  John  J.  H.,  minutes  on  the  death  of , 
309,  45S;  obituar)'  of,  201. 

Loveland,  B.  C  some  questions  often 
asked  about  drinking-water,  and  their 
answers,  9r6. 

Liihe,   L.,  notice  of  book  by.  424. 

Lumbago,  local  application  for,  140;  the 
seat  of,  364. 

Lumbar  puncture,  79S,  852. 

Lung.  abscess»of  the  treatment  of.  97; 
acute  gangfrene  of  the.  with  pyo-pneu- 
mothorax.  521  ;  nomenclature  and 
mode  of  production  of  auscultator)- 
signs  in  diseases  of  the.  63;  pos- 
sible morphological  basis  for  some 
diseases  of  the,  145;  surgerj- of  the, 
loi.  424,  463. 

Lupus,  hot-air  treatment  of.  459;  perman- 
ganate of  potassium  in,  459;  treat- 
men  of,  with  the  new  tuberculin,  667  ; 
\Tilgaris,  923. 

Lusk.  William  T.,  resolutions  on  the  death 
of,  20. 

Luys.  Dr.,  death  of,  385. 

Lymphadenoma.  submaxillarj-  adenitis  with 
apparent  incipient,  311. 

Lymphatic  constitution,  244. 

Lymphatic  glands,  subcutaneous  extirpa- 
tion of,  431:  tuberculosis  of  the  super- 
ficial, 29. 

Lynch,  Junius  F..  should  ministers  pay 
doctors?  931. 

Lyon,  Caleb,  death  of.  422. 


.M 


McBurney.  Charles,  is  not  the  mortality 
from  surgical  disease  larger  than 
necessarj-.   881,  894. 

McCosh,  Andrew,  Jr..  notice  of  report 
edited  by,  531. 

McCook.  John  B.,  some  preliminary  obser- 
vations on  the  apphcation  of  the  Ka- 
shida-.Agata  medium  to  the  examina- 
tion of  drinking-water.  270. 


McGillicuddy,  T.  J.,  a  new  dynamometer, 
143- 

McKean  Count)'(Pa. )  Medical  Association, 
activity  of  the,  351. 

McKenzie.  Walter,  death  of,  352. 

MacKinnon.  Sir  William,  death  of.  797. 

McLean.  Donald,  assault  upon,  165. 

McLochlin.  James  A.,  death  of.  127. 

McXaughton,  William  H.,  death  of ,  163. 

Macool,  J.  B.,  death  of,  91. 

Mager.  Wilhelm,  notice  of  book  by.  167. 

Magnolia,  Fla.,  76S. 

Malaria,  blood  examination  in,  596;  con- 
genital, 51;  diagnosis  of  typhoid  fever 
from,  622;  mode  of  infection  of,  173, 
687;  Plasmodium  of,  29,  395;  Plasmo- 
dium of  quartan,  716;  plasmodium  of 
tertian,  463;  prevented  by  small  doses 
of  quinine,  453. 

Malignant  pustule,  treatment  of,  504. 

-Malingerer,  a,  277. 

Malnutrition  in  infants,  treatment  of.  903. 

Mandarin,  Fla.,  767. 

Manley,  Thomas  H.,  spontaneous  fracture 
of  the  claWcle,  921. 

Manure,  nightsoil  and  ashes  for,  616. 

Marine  Hospital  senice,  856. 

Marriage,  regulation  of,  383. 

Marshall,  D.  T.,  menstruation  and  epi- 
lepsy,  240. 

Martin,  Franklin  H.,  notice  of  book  by, 
169. 

Mason.  R.  Osgood,  notice  of  book  by, 
639. 

Massachusetts  State  Hospital  for  consump- 
tives, 85  7. 

Massage  as  an  occupation  for  the  blind, 
603;  in  surger)-,  459;  in  the  treatment 
of  internal  diseases,  497. 

Massey,  G.  Betton,  the  treatment  of  cancer 
by  a  new  method,  \Hz..  the  electrical 
diffusion  of  nascent  oxychlorides  of 
mercury  and  zinc.  150. 

-Mastitis,  epidemic.  560. 

Mastoid,  course  and  treatment  of  diseases 
of  the,  693. 

Masturbation,  mechanical  restraint  of,  in 
a  young  girl,  206- 

Matas,  Rudolph,  notice  of  book  by.  823. 

Matter,  George  F..  death  of,  673. 

Matthews,  .\.  C  expert  examination  for 
testamentar)-  capacity,  636. 

Maxson,  Edwin  R.,  submaxillar)-  adenitis 
with  apparent  incipient  lymphade- 
noma. 31 1- 

May.  William  H.,  an  improved  centrifuge, 
■  9<H- 

Mayer,  J.  A.,  death  of.  563. 

Maylard,  A.  E.,  notice  of  book  by,  639. 

Measles,  avoidance  of  complications  in. 
932;  epidemic  of,  S56. 

Meat,  inspection  of,  714. 

Medical  and  Chirurgical  Faculty  of  the 
State  of   Maryland,  134. 

Medical  council,  British,  612,  6;o,  632, 
757- 

Medical  degree,  first,  granted  in  New- 
England,  472. 

Medical  education,  defective.  853;  in  Paris, 
scheme  of,  758. 

Medical  periodicals  in  the  United  States, 
8??- 

Medical  practice,  regulation  of,  in  Connecti- 
cut, 20;  in  France,  613;  in  Illinois, 
712;  in  Italy,  126.  165.  S21. 

Medical  practitioners,  felons  as,  114. 

Medical  profession,  overcrow-ding  the, 
439. 

Medical  Record,  w-hat  it  does,  742. 

Medical  Society  of  Xew-  Jersey,  241. 

Medical  Societv  of  the  County  of  Broome 
(X.  v.),  633. 

Medical  Society  of  the  County  of  New- 
York,  210,  536,  674,  867  ;  annual 
meeting  and  election  of  officers,  674. 

Medical  Times,  silver  anniversar)-  of  the, 
927. 

Medicine,  influences  that  have  determined 
the  progress  of,  389. 

.Medicine,  internal,  as  a  profession,  644. 

Meigs,  .\rthur  V.,  notice  of  book  by,  822. 

Meirowitz.  Philip,  acute  arsenical  multiple 
neuritis  follow-ing  the  administration 
of  Fowler's  solution,  920. 


940 


INDEX. 


[December  25,  1897 


.Melchior,  Max,  notice  of  book  by,  822. 
Melvin,  J.  Tracy,  triplets,  920. 
Memory,  a  feat  of,  579. 
Meningitis,    acute   serous,   801,   825;    and 
typhoid  fever,  234;  diplococcus  intra- 
cellularis  of,  245;  tuberculous.  786. 

Menstruation  and  epilepsy,  240;  biological 
basis  of,  52;  vicarious,  with  spinal 
hyperaemia,  160. 

Mental  evolution  in  man.  414. 

Mentality,  relation  of  sex  to,  661. 

Mereness.  Seth  A.,  a  plea  for  therapeutic 
conservatism,  545. 

Merritt's  Island,  Fla. .  768. 

Merycism,  the  gastric  secretion  in,  48. 

Metritis,  puerperal,  vaginal  hystero-sal- 
pingo-oophorectomy  for,  203. 

Mexico,  climate  and  health  resorts  of,  7S2. 

Meyer,  Willy,  improvement  of  general 
anesthesia,  835. 

Miami,  Fla.,  769. 

Microtome,  a  new,  247,  250. 

Midwife  question  in  America,  132. 

Midwifery  and  midwife.  882. 

Milbury,  Frank  S.,  diseases  of  the  mas- 
toid, their  course  and  treatment,  693. 

.Milk,  chemical  examination  of  human.  560; 
contamination  of,  33;  cow's  in  infant 
feeding,  13;  goat's,  for  children.  557; 
inspection  in  Philadelphia,  563;  mi- 
croscopical examination  of,  135;  modi- 
fied, criticism  of,  243;  philanthropist 
and  the  health  board,  456;  supply  of 
New  York,  352;  supply,  publiG*iealth 
in  relation  to,  889;  value  of  sterilized, 
288, 

Milligan.  E.  T.,  criminal  abortion,  32. 

.Milton,  Herbert,  lithotrity  as  the  best 
method  of  treating  large  vesical  cal- 
culi, 418. 

Ministers,  payment  of  doctors  by,  705.  836, 
93'. 

Missionaries,  medical,  proposed  college 
for,  384. 

Mississippi,  department  of  public  health 
in,  57;  health  resorts  of,  769. 

Mississippi  Valley  Medical  .Association, 
607. 

Missouri  Medical  League  of  St.  Louis,  127. 

Mitchell.  Clifford,  the  ferrocyanic  test  for 
albumin  in  the  urine,  70. 

Mitchell,  Hubbard  Winslow.  some  practi- 
cal observations  on  pulmonary  tuber- 
culosis, 411. 

Mitchell,  S.  Weir,  notice  of  book  by,  167. 

Mobile,  Ala. ,  769. 

.Mole,  hydatidiform,  239. 

Monell,  S.  H  ,  noticeof  book  by.  167. 

Menterey,  Cal.,  770. 

Montreal,  end  of  small-pox  epidemic  in, 
528;  suit  against,  for  bad  pavements, 
528. 

Moore,  "Veranus  A.,  the  hiemospast,  70. 

Morris,  .Malcolm,  the  rise  and  progress  of 
dermatology,  404. 

Morris,  Robert  T.,  notice  of  book  by.  S23. 

Moscow,  clinical  study  in  790. 

Moscow  congress,  see  /nlei  national  Medi- 
cal Congress. 

Moscow,  German  conquest  of,  746. 

Moser,  W.,  diagnosis  of  chorea  in  the 
.-idult,  738. 

Mosquitoes,  a  remedy  against,  236. 

Mother  and  child,  195. 

Moyer,  Harold  .\'.,  one-sided  spastic  spinal 
paral)  ;is,  795. 

Muir,  Joseph,   "cure"  in  tuberculosis,  872. 

Mumps,  transmission  of,  from  man  to  dog, 
683;  treatment  of,  213. 

Mundc,  Paul  F. ,  prevention  of  uterine  dis- 
placements, 578. 

Munro,  Theodore  Todd,  death  of.  564, 
602. 

Murdock,  G.  W.,  a  suggestion  in  the  Ireat- 
ment  of  diabetes,  515. 

Murmur,  musical,  69. 

Murphy,  Walter  G.,  cow's  milk  in  infant 
feeding,  13. 

Musc;e  volitantes,  512. 

Muscular  exercise,  use  of  sugar  after,  joS. 

Mushroom  poisoning,  298,  919. 

Music,  physical  effects  of,  507. 

Mynter,  Herm.in,  notice  of  book  by.  824. 

Myxcedema,  28;  in  the  adult,  924. 


N 


Naevi,  treatment  of,  285. 

Napier,  A.  D.  Leith,  notice  of  book  by,  639. 

Nassau  and  the  Bahama  Islands,  763,  773. 

National  bureau  of  health,  860. 

Navy,  medical  service  of  the,  705. 

Necrosis  of  the  crest  of  the  ilium,  592. 

Negro,  healing  of  wounds  in  the,  287; 
physical  degeneracy  of  the,  817. 

Nelsoni  D.  H.,  death  of,  398. 

Nephrectomy  and  subsequent  uretero- 
lithotomy on  the  opposite  side,  170; 
experimental,  in  dogs  as  bearing  upon 
the  uremic  state.  280. 

Nephritis,  clinical  classification  of,  392; 
etiology  of,  393 ;  treatment  of,  539,  932. 

Nen'e  element  in  surgical  pathology,  94. 

Nervine  tonic,  a,  213. 

Nervous  disorders,  alcohol,  tobacco,  tea, 
and  coffee  as  causative  factors  of,  568. 

Nervous  system  in  disease,  25S;  training 
the,  144. 

Neuralgia,  pill  for,  539;  treatment  of,  786, 
903;  treatment  of  trifacial,  by  ligation 
of  the  common  carotid  artery,  739. 

Neurasthenia,  relation  of  uric  acid  to.  60. 

Neuritis,  multiple,  following  influenza,  59, 
667;  multiple,  following  the  use  of 
Fowler's  solution  in  a  case  of  chorea. 
920. 

Neuron,  effects  of  irritation  in  the  pa- 
thology and  therapy  of  the  ner\'ous 
system,  on  the  theory  of  the,  142;  the 
motor,  in  practical  diagnosis,  610. 

Neuroses  in  women,  certain  sources  of,  536; 
tobacco,  610. 

-New  Jersey  State  board  of  medical  ex- 
aminers, 91. 

Newman.  Robert,  electric  treatment  in 
gout  and  the  uric-acid  diathesis.  848; 
linear  electrolysis,  215. 

New  Mexico,  health  resorts  of,  770;  some 
-misconceptions  of,  corrected,  781. 

New  Orleans,  La.,  769. 

New  York  Academy  of  Medicine.  136, 
241,  572,  640,  717,  833,  S58;  anni- 
versary meeting,  833;  newspaper  re- 
ports of  meetings  of  the,  819;  section 
on  general  medicine,  68,  172,  644, 
860;  section  on  general  surgery,  170, 
647,  864;  section  on  obstetrics  and 
gynaecology,  65. 

New  York  City,  health  of.  and  the  dinner 
to  the  Mayor.  562. 

New  'York  County  Medical  -Association.  63, 
208,  278,  868. 

New  York  Medico-Chirurgical  Society,  752. 

New  York  Neurological  Society,  750. 

New  York  Obstetrical  .Society,  711. 

New  York  Pathological  Society,  244.  279. 
319,  362,  678,  716,  896. 

New  York  Society  for  the  Relief  of  Wid- 
ows and  Orphans  of  Medical  Men.  928. 

New  York  State  Medical  Association,  565. 
603. 

Nitrate  of  silver,  recovery  from  a  large 
dose  of,  88;  removal  of  stains  of,  105. 

Nitroglycerin,  tolerance  of,  by  children. 
616. 

Nichol,  Rawlings,  ideal  ansesthesia,  445. 

.Nichols,  J.  B. ,  decinormal  salt  solution, 
249. 

Nieschang.  Charles  C.  F.,  a  new  urethral 
sound,  107. 

Nobles,  Newman  T.  B. ,  long  retained 
placenta  following  abortion.  918. 

North  Carolina,  warm  and  hot  springs  of. 
765. 

Northern  .Medical  Association  of  Philadel 
phia,  791. 

Nose,  micro-organisms  in  the,  454  :  tooth 
in  the,  323. 

Noyes.  Henry  D.,  antiseptics  in  eye  sur- 
gery, 617. 

Nurses,  the  Royal  British  .-Vssociation  of, 
797;  Victorian  Order  of,  458. 

Nursing,  male,  in  England,  817. 


Obesity,  pathogenesis  of,  394. 
Obstetrics,  asepsis  and  antisepsis  in,  606. 


Ocklawaha  River,   Fla..  768. 

O'Conner.  H.  R.,  death  of.  386. 

Oertel.  Max  Joseph,  death  of.  237. 

(Esophagus,  abductor  paralysis  in  stric- 
ture of  the.  557:  cancer  of  the,  ine- 
quality of  the  pupils  in,  669. 

Office  bores,  889. 

O'Grady.  E.  S. ,  death  of.  721. 

Old  Point  Comfort.  762. 

Olmstead,  James,  death  of,  856. 

Omentum,  sarcoma  of  the,  426. 

O'Neill,  J.  .\.,  a  case  of  ptomain  poison- 
ing, 240. 

Operation,  dr\^  method  of,  501. 

Opium  poisoning,  permanganate  of  potas- 
sium in,  671. 

Ophthalmic  surgery,  cases  in,  607. 

Ophthalmology-  and  otology,  early  history 
of.  135. 

Optic  neuritis,  bilateral,  complicating  en- 
teric fever,  349. 

Orange  Free  State,  indigent  consumptives 
in  the,  747. 

Organs,  are  they  friends  or  enemies?  542. 

Ormond.   Fla.,  767. 

Orrhodiagnosis,  report  of  the  medical  sec- 
tion of  the  American  Medical  Associa- 
tion on,  252. 

Orthopedic  surger)-,  operative  side  of,  S84. 

Osculatory  reflexes,  inhibition  of,  707. 

Osier,  William,  British  medicine  in  Greater 
Britain,  333. 

Osteomyelitis,  acute,  loi. 

Ostrich,  a  human,  36. 

Otitis  media,  suppurative,  S58  ;  ichthyol 
in,  160. 

Otorrhea,  chronic,  formula  for,  483. 

Ott,  Isaac,  notice  of  book  by,  168. 

Ovarian  disease,  relation  of,  to  pregnancy, 
174;  tumors,  diagnosis  of  small.  170. 

Ovaries,  consenative  treatment  of  the, 
469,  500;  fate  of  the,  in  connection 
with  retroversion  and  retroflexion  of 
the  uterus,  502;  surgery  of  the,  605. 

Ovariotomy  in  the  aged,  832;  manage- 
ment of  true  and  false  capsules  in, 
721. 

Oxaluria  and  lithxmia.  23. 

Oxygen  gas,  treatment  of  ulcers  by,  417. 

Ozfena,  treatment  of.  Si 8. 


Pachymeningitis,  chronic  hemorrhagic, 
247  ;  hemorrhagica  interna  in  chil- 
dren, 750. 

Pacific  Congress  Springs,  Cal.,  771. 

Paediatric  journal,  a  new,  S55. 

Pain,  value  of.  as  a  diagnostic  sign  of  can- 
cer of  the  breast.  iSl. 

Palatka.  Fla. .  768. 

Palier.  E.,  a  study  of  diet  and  nutrition  in 
relation  to  contagious  diseases  and  to 
those  due  to  disturbed  digestion  and 
assimilation.  43. 

Palm  Beach,  Fla..  76S. 

Palmer.  Charles  Follen.  notice  of  book  by, 
168. 

Pancreas,  atrophy  of  the,  with  replace- 
ment by  fat.  362;  cyst  of  the.  246; 
fat  necrosis  with  disease  of  the.  62. 

Paquin.  Paul,  orrhotherapy  of  tuberculosis, 
142. 

Paralysis,  general,  etiology  of,  317;  one- 
sided spastic  spinal,  795;  traumatic, 
of  the  upper  extremities.  697. 

Paraplegia,  parturition  during,  70. 

Paris,  letters  from,  ';4i.  612,  651.  6S3,  757, 
S71. 

Park,  Roswell,  problems  which  most  per- 
plex the  surgeon,  1. 

Parks,  establishment  of  small.  700. 

Parsons,  Stephen,  death  of,  673. 

Parturition,  absence  of  pain  and  the  volun- 
tary muscles  as  auxiliary-  aids  in,  885; 
diKitation  of  the  perineum  in,  903; 
during  paraplegia,  70;  ergot  for  hemor- 
rhage following,  504;  injuries  of,  132. 
468;  vaginal  atresia  and  stenosis  in, 
133. 

Pasadena,  Cal.,  771. 

Pasteur,  pen  sketch  of,  288. 

Pathological  Society  of  London.  757. 


December  25,  1897] 


INDEX. 


941 


Pathological  Society  of  Philadelphia,  g3, 
421,   564,  635.  711,  745- 

Pathological  work,  progress  and  results  of, 
345. 

Pathology  and  therapeutics,  mutual  rela- 
tions of,  318  ;  new  era  in  the  study  of, 
603. 

Patterson,  A.  Bethune,  tenotomy  in  con- 
vergent squint.  OSo. 

Peculiar  people,  the  sect  called,  470. 

Pegleg.  use  of  the.  as  a  protective  appara- 
tus in  the  treatment  of  diseases  of  the 
ankle  or  tarsus,  206. 

Pelvic  cellulitis  and  peritonitis,  differen- 
tial diagnosis  of,  603. 

Pelvic  disease,  operation  of  choice  in  the 
treatment  of,  46S;  reflex  disturbances 
due  to,  131;  treatment  of  mental  de- 
pression in,  903;  vaginal  versus  ab- 
dominal route  in  treating,  469;  with- 
out local  symptoms,  609. 

Pelvic  hemorrhage,  treatment  of  circum- 
scribed. 131. 

Pelvic  pain.  30. 

Pelvic  tumors,  clinical  importance  of  im- 
pacted. 676. 

Penis,  epithelioma  of  the,  591. 

Pennsylvania  and  Maryland  Union  Medical 
Association,  273. 

Penrose,  Charles  B..  notice  of  book  by, 
529. 

People's  baths.  635. 

Pericardium,  gastric  ulcer  penetrating  into 
the,  596;  hemorrhage  into  the,  701 ; 
incision  of  the,  461. 

Perineal  lacerations,  mechanism  and  treat- 
ment of,  130;  horn,  251. 

Perineum,  care  of  the,  during  labor.  923. 

Peritoneum,  surgery  of,  tuberculosis  of  the, 
570;  tumors  behind  the,  522,  S29. 

Peritonitis,  135;  classification  and  surgi- 
cal treatment  of  acute,  289. 

Perityphlitis.  207.  425. 

Permanganate  of  potassimn  in  opium  pois- 
oning. 671. 

Pertussis,  bacteriology  of.  465  ;  punctate 
hemorrhages  in  the  brain  following, 
319;   treatment  of,  20S,  213,  902,  903. 

Pes  cavus,  261. 

Peterson.  Frederick,  katatonia,  473. 

Pharmacy,  the  modern  trend  of,  455. 

Pharyngeal  abscess  followed  by  hemor- 
rhage, 32. 

Philadelphia  County  Medical  Society,  20, 
421,  563,  635,  711,  745,  820. 

Philadelphia  Neurological  Society,  820. 

Philadelphia  Poediatric  Society,  634,  745, 
927. 

Philadelphia,  vital  statistics  of,  36,  287, 
5  So. 

Phimosis  as  a  factor  in  the  causation  of 
hernia,  839:  eclampsia  due  to,  in  a  child 
seven  months  old,  386;  troubles  arising 
from,  625. 

Phceni.N.  Ariz..  770. 

Phthisis  and  racial  degeneration.  789. 

Physician,  his  personnel,  and  how  it  af- 
fects his  success,  224. 

Physiology,  pharmacology,  pathology,  and 
practical  medicine,  relation  of,  296. 

Piffard,  Henry  G.,  the  microscopical  ex- 
amination of  bacteria,  etc.,  807. 

Pilcher.  James,  notice  of  book  by,  16S. 

Pinehurst,  N.  C,  764. 

Placenta,  long  retained,  following  abor- 
tion, 918  ;  proevia,  treatment  of,  502. 
931. 

Plague,  the,  317;  in  India,  364,  492,  527, 
635- 

Plants,  potted,  and  malaria,  173. 

Plaster  splint,  to  fenestrate  a,  30. 

Pleura  and  lungs,  diagnosis  of  primary 
malignant  tumors  of  the.  523. 

Pleural  adhesions,  diagnosis  of,  425. 

Pleurisy,  acute,  a  form  of  tuberculosis,  90S; 
treatment  of,  7S6. 

Pneumonia,  catarrhal,  in  children,  693; 
creosote  in,  902;  in  childhood,  932; 
migratory,  in  a  parturient  woman,  202; 
treatment  of  acute  lobar,  59,  228,  242; 
treatment  of  catarrhal,  902;  venesection 
for,  885, 

Point  Clear,  Ala..  769. 

Poisoning,    corrosive,     exfoliation    of    the 


mucous  membrane  of  the  oesophagus 
and  part  of  the  stomach  in  a  complete 
cast  after.  533. 

Poole,  Herman,  clinical  value  and  chemical 
results  of  using  Professor  Gaertner's 
mother  milk  in  children,  839. 

Pope,  the,  on  what  to  eat,  384. 

Porteous,  ].  Lindsay,  antitoxin  adminis- 
tered per  OS.  919. 

Porter.  H.  R.,  deferred  creditors.  21;; 
should  ministers  pay  doctors.  836. 

Post-partum  hemorrhage,  29. 

Post,  Sarah  E.,  floating  kidney,  681. 

Pott's  disease,  Calot's  treatment  of,  870, 
929. 

Powell,  McD.  M.,  death  of,  55. 

Powers,  F.,  what  must  we  do  to  be  saved? 
835. 

Practitioner,  general,  comparative  position 
of  the,  here  and  in  England,  742. 

Practitioners  Society  of  New  York,  825, 
893. 

Pratt,  Frank  P.,  what  are  the  functions  of 
the  rods  and  cones  and  the  pigment 
epithelium  layer  of  the  human  retina  ? 
305;  what  are  the  muscae  volitantes? 
an  entoptical  study,  512. 

Pregnancy,  chorea  complicated  by,  922; 
ectopic,  234,  6ti;  ectopic,  oper- 
ated on  at  the  seventh  month,  830; 
ectopic,  specimen  of,  65;  ectopic,  tubal 
and  ovarian  hemorrhage  resembling  a 
ruptured.  829;  ectopic,  vaginal  section 
in,  132;  interstitial  tubal,  rupture  of, 
196;  relation  of  ovarian  disease  to,  174; 
toxajmia  of,  499;  vomiting  of,  treat- 
ment, 46S,  613;  I^rentiss,  V.  \V..  two 
cases  of  erythromelalgia.  39. 

Pressure  deformities,  origin  of,  922. 

Preston.  George  J.,  notice  of  book  by.  i6g. 

Preventive  medicine  in  New  York  City,  387. 

Priapism,  21. 

Price,  N.  Gordon,  paroxysmal  tetanoid, 
680. 

Prince  of  Wales,  an  honorary  physician. 
248;  hospital  fund,  104,  747;  surgeons 
in  ordinary  to  the.  238. 

Pringle.  J.  J.,  notice  of  book  by,  531,  822. 

Prize,  Alvarenga,  of  the  College  of  Physi- 
cians of  Philadelphia,  672;  Charles 
Legroux,  of  the  Paris  Academy  of 
Medicine,  683;  Moscow  international, 
316,  356;  Pray  medical,  673;  Senn 
surgical.  56. 

Proctitis,  chronic,  S30. 

Professional  trades,  926. 

Prognosis,  importance  of  the  habit  of,  in 
the  development  of  the  individual 
physician,  62. 

Prostate,  Bottini's  method  for  the  radical 
treatment  of,  866;  chronic  contraction 
of  fibres  encircling  the  vesical  neck,  21 ; 
disease  of  the,  31;  enlarged,  102;  oper- 
ative treatment  of  enlarged,  832;  treat- 
ment of  ischuria  following  hypertrophy 
of,  427,  429;  tuberculous  necrosis  of 
the,  22. 

Prostatectomy,   430. 

Prostatitis,  acute  localized,  suppository  for. 
140. 

Providence  Hospital  in  Washington,  ob- 
jection to  the,  793. 

Prudden,  T.  Mitchell,  honors  for,  20. 

Pruritis  \'ulva:,  treatment  of.  903. 

Pryor,  W.  R..  hysterectomy  forceps,  507. 

Pseudo-tuberculosis  hominis  streptothrica, 
626. 

Psychiatry,  a  sign  of  progress  in  America. 
743;  new  horizons  in,  355. 

Ptomain  poisoning.  S9.  240,  579. 

Public  health,  a  national  bureau  of,  634, 
('43. 

Puerperal  biliary  colic,  349:  diphtheria, 
49S;  eclampsia,  treatment  of,  498; 
endometritis,  treatment  of,  by  the 
Carossa  method,  499;  metritis,  vaginal 
hystero  -  salpingo  -  oophorectomy  for, 
203;  septicaemia,  724;  septicemia, 
salt  injections  in,  785;  septicaemia 
successfully  treated  by  antistrepto- 
coccus  serum,  701;  septicaemia,  treat- 
ment of,  572;  sepsis,  source  of,  499. 

Puerperium.  sudden  death  in  the,  349,  7S7. 

Pulmonary  artery,  thrombosis  of  the,  247. 


Pulse,  diagnostic  importance  of  the,  923. 

Pupils,  inequality  of  the,  in  carcinoma  of 
the  cesophagus,  669. 

Purgative,  a,  539;  hypodermic,  538. 

Purpura,  artificial  serum  for,  922;  due  to 
the  vapors  of  benzin,  888. 

Purrington,  W.  A.,  felons  as  medical  prac- 
titioners. 114;  fines  for  illegal  prac- 
tices. 836;  "in  those  days  there  were 
devils" — and  now,  S99. 

Pyle,  Walter  L.,  notice  of  book  by,  S24. 

Pylorus,  resection  of  the,  for  cancer,  210. 

Pyopneumothorax,  8g8. 

Pyothorax  in  children,  569. 

Pyuria,  sources  and  diagnosis  of,  831. 


Quack,  a  celebrated.  364. 

Quackery,  profits  of.  800;  purging  of  Ken- 
tucky from,  272. 

Quarantine,  national,  525.  724. 

Quinine,  administration  of.  for  children. 
34;  in  suppositories.  107;  poisoning 
by.   124. 


Rabies,  135. 

Rachitis,  treatment  of,  902. 

Railway-car  sanitation,  report  of  the  com- 
mittee of  the  American  Public  Health 
Association  on.  713. 

Ramshill.  Jabez,  death  of.  104. 

Ranney.  Ambrose  L..  notice  of  book  by. 
423. 

Ransom,  W.  B..  notice  of  book  by,  823. 

Raub,  John  A.,  death  of.  563. 

Read,  Ira  B..  death  of,  55. 

Reciprocity  in  medical  practice,  307. 

Rectal  irrigator,  metal  double-current.  143: 
operations,  vaginal  route  for,  427. 

Rectum,  atony  of  the,  466;  chronic  inflam- 
mation of  the,  830;  Kraske's  opera- 
tion for  cancer  of  the,  206;  operative 
treatment  of  cancer  of  the,  434.  787; 
primary  tuberculosis  of  the.  609; 
stricture  of  the.  569. 

Reed,  R.  Harvey,  notice  of  book  edited 
by,  823. 

Reese.  F.  D..  troubles  arising  from  phi- 
mosis. 625. 

Reichmann's  syndrome,  363. 

Relapsing  fever,  orrho-diagnosis,  -prog- 
nosis, and  -therapy  of.  462. 

Remedies  ancient  and  modem,  660. 

Rendell,  John,  death  of,  458. 

Renner,  W.  Scott,  chronic  follicular  tonsil- 
litis, 303. 

Respiration,  cessation  of,  before  that  of 
circulation.  496. 

Reticence,  medical,  578. 

Retina,  functions  of  the  rods  and  cones 
and  the  pigment  epithelial  layer  of 
the.  305. 

Retinoscopic  trial  case.  904. 

Retractors,  a  pair  of,  go6. 

Retroperitoneal  neoplasms,  diagnosis  of. 
829. 

Reynolds.  G.  Perry,  death  of.  927. 

Reynolds,  Sidney  H.,  notice  of  book  by, 
424. 

Rheumatism,  a  form  of  pyaemia,  457; 
chronic,  treatment  of,  140,  141,  556, 
902. 

Rhinitis  atrophica,  209;  in  its  relation  to 
diseases  of  the  accessory  sinuses,  516. 

Rhino-pharyngitis,  application  for,  140. 

Richardson.  Sir  Benjamin  Ward,  notice  of 
book  by,  638. 

Ricketts,  Girard  Robinson,  death  of,  602. 

Rinderpest,  failure  of  Koch's  remedy  for, 
386. 

Ritchie,  H.  P..  a  case  of  migrator)'  pneu- 
monia in  a  parturient  woman,  202. 

Rizzo,   Francis,  death  of,  458. 

Roberts,  John  B..  notice  of  book  by,  S23. 

Robertson,  W.  H.,  death  of,   214. 

Robinson,  William  J.,  honor  to  whom 
honor  is  due,  930. 

Roche,  Martin,  death  of,  791. 

Rockledge,  Fla.,  768. 

Rocky  Mountain  Interstate  .Medical  Asso- 
ciation, 200. 


942 


INDEX. 


[December  25,  1897 


Roddick,  T.  G.,  presidential  address  be- 
fore the  British  Medical  Association, 
325- 

Roentgen  rays,  applications  of.  in  medicine, 
29,  58,  142,  467,  520,  759;  application 
of,  in  surgery,  9S,  460,  830;  depilator\- 
action  of  the,  34;  severe  burns  from, 
199;  skiagraphs  of  the  arteries  by,  88. 

Roosa,  D.  B.  St.  John,  presentation  of  the 
portrait  of,  to  the  New  \'ork  Academy 
of  Medicine,  136. 

Rosenberry,  A.  B..  who  introduced  the 
term  appendicitis  ?  505. 

Ross,  Ale.xander  Milton,  death  of,  673. 

Ross,  .Samuel  McNutt,  death  of,  45S. 

Roy,  Charles  T.,  death  of,  503. 

Roy,  C.  S.,  death  of,  651. 

Royal  College  of  Surgeons,  annual  meeting 
of  the.  870;  politics  iQ|the,  140. 

Rumer,  J.  F.,  hydraulic  dilatation  of  the 
urethra,  160. 

Rupp.  .\dolph,  pain,  opium,  and  appen- 
dicitis— a  protest  and  a  plea,  848. 

Ryan,  Charles  T..  death  of,  527. 

Rye,  Brisley,  death  of,  578. 


St.  Augustine.  Fla.,  767. 

St.  John's  River,  Fla.,  767. 

Saints,  medical,  274. 

.St.  Vincent's  Hospital,  convalescent  heme 
for,  19. 

Salivation,  idiopathic,  670. 

Sallade,  Frank  L.,  death  of,  673. 

.Salt  solution,  decinormal,  249. 

San  Antonio,  Te.\as,  770. 

Sanarelli,  Guiseppe,  the  microbe  of  yellow 
fever,  117. 

Sanatoria  for  the  consumptive  poor  of  our 
large  cities,  urgent  need  of,  715,  775; 
opposition  to  the  establishment  of, 
526;  rights,  a  question  of,  672. 

San  Bernardino,  Cal.,  771, 

San  Diego,  Cal.,  772. 

.Sandwich  Islands,  772. 

Sanford,  Fla.,  768. 

Sanger.  Eugene  Francis,  death  of,  237. 

Sanitary  clearing  house  wanted,  S55. 

Sanitary  science,  the  medical  profession, 
and  the  public,  S33. 

Sanitation,  the  fruits  of,  in  England,  Syl. 

San  Jose,  Cal.,  771. 

.Santa  Barbara,  Cal.,  771. 

.Santa  Cruz,  Cal.,  771, 

Sarcoma  of  the  orbit,  589. 

Savannah,  Ga. ,  766. 

.Saved,  what  must  we  do  to  be;  a  summary 
'of  the  causes  leading  to  the  hospital 
and  dispensary  abuse,  725,  835. 

Savidge,  Eugene  Coleman,  the  alternative 
or  recurrent  treatment  of  retrodevia- 
tions of  the  uterus,  685. 

Saxe.  George  G.,  prevalence  of  tapeworm. 
542. 

Scalp,  atheromatous  tumor  of  the,  590. 

Scarlet  fever,  hospital  for  patients  with. 
S92;  inoculation  of,  243;  relation  of 
chorea  to,  907;  strawberry  tongue  in, 
906;  treatment  of,  903. 

Schaefcr,  Edward  Albert,  notice  of  book 
by.  494. 

Schaeffer,  Oscar,  notice  of  book  by,  169. 

Schapps,  John  C,  a  note  on  the  use  of  the 
pegleg  as  a  protective  apparatus  in 
the  treatment  of  diseases  of  the  ankle 
or  tarsus,  206. 

Schlatter,  Carl,  a  unique  case  of  complete 
removal  of  the  stomach,  909. 

School  inspectors,  report  of  the.  93. 

Schott  treatment  of  cardiac  disease,  24. 

V.  Schroetter,   li.,  notice  of  book  by,  167. 

Sciatica,  treatment  of.  902,  903. 

.Sciatic  nerve,  compression  of  the,  758. 

.Scleroderma,  treatment  of,  668. 

Sclerosis,  infantile  and  hereditary  multiple, 
800;  lateral  spinal,  795;  multiple,  eti- 
ology of,  162. 

Scoliosis,  accurate  measurements  of,  432; 
treatment  of,  429;  treatment  of,  by 
posture  and  exercise  without  me- 
chanical support,  361. 

Scotland,  lunacy  in,  470. 


Scrotum,  epithelioma  of  the,  591. 
Scurvy,    760;    in    a   country-bred    infant. 
239;    infantile,  collective  investigation 
of,  385. 
Seasickness,  treatment  of,  903. 
Sea  voyages,  hints  for  patients  on.  539. 
Sea  water  in  place  of  artificial  serum,  S72. 
Sebring,      \V.     C,     the     twenty-five-cent 

doctor,  S99. 
Senile  degeneration  of  the  intestinal  walls, 

chronic  diarrhoea  due  to,  234. 
.Senn,  Emanuel   J.,  inflammation  of  joints 

in  gonorrhreal  patients,  153. 
Senn,  X.,  classification  and  surgical  treat- 
ment of  acute  peritonitis,  289. 
.Septicemia,  puerperal,  724  ;   treatment  of, 

572,  701,  7S5. 
Septum  knife,  a  new,  578. 
Serpent  poison,  antidotive  action  of  bile  to, 

213. 
Serum,  experiments  with,  251. 
Se.\,  relation  of,  to  mentality,  661. 
Shaffer,  Newton  M.,  the  operative  side  of 

orthopedic  surgery,   S84. 
Shibata,  K..  notice  of  book  by,  639. 
Shock,  surgical,  and  hemorrhage,  501. 
Short,  R.  N.,  death  of,  S56. 
Shoulder,    amputation   at    the,    for    carci- 
noma, 648. 
Siff,  H.,   a  case  of   puerperal   septicaemia, 
successfully  treated  by  antistreptoccus 
serum,  701. 
Silver,  antiseptic  value  of,  102,  428. 
Silver  nitrate,  recovery  from  a  large  dose 
of,  88;  nitrate,  removal  of  stains  from, 
108. 
Simpson,  Eve  Blantyre,  notice  of  book  bv, 

638. 
Sinuses,   frontal,  diagnosis   and    treatment 

of  affections  of  the,  192. 
Skilton.  Julius  A.,  death  of,  856. 
Skin,    contagious    diseases    of,    in    school 
children,   136;  grafting,    98,   460;   hot 
water  in  diseases  of  the,  105. 
Skull,  fracture  of  the,  679;  fracture  of   the 
base  of  the,  532;  necrosis  of  the,  5S9. 
Slaughter  house  in  relation  to  disease,  Si  8. 
Sleeping-cars,  disinfection  of,  273. 
Sleep  problem,  the,  91;  7. 
Sloan.  James  G.,  death  of,  712. 
Small-po.\,  amoeboid  bodies  in  the  blood  in, 
52+;    diagnosis  of.    714;    epidemic  in 
Gloucester,  report    on    the.    710;    ich- 
thyol  in.  739;  in  Georgia,  S92. 
Smith.   E.    H..  a   new  operation    for  ma- 
lignant diseases  of  the  testicle.  799. 
Smith,   |.  Lewis,  minute   on  the  death  of, 

56. 
Smith,  Jarrard  K.,  death  of,  563. 
Smith,  Robert,  death  of.  683. 
Smith,  Starkey,  death  of,  470. 
Smith.  William  T.,  strangulated  umbilical 

hernia,  8S7. 
Smoke.  472. 
Smoking,   effect   of.  on  the   health   of  the 

young,  790. 
Snake  venom  and   its  antitoxin,  743;  anti- 
dotive action  of  bile  to,  213. 
Sodium  salicylate,  a  large  dose  of,  704. 
Solly,  S.  Edwin,  notice  of  book  by,  529. 
Somers,  E.  M..  unexpected  forms  of  death 

among  the  insane,  659. 
Sore  throat,  treatment  of,  903. 
Sothoran.  James  T.,  death  of,  527. 
Sound,  uterine,  dangers  of  the,  124. 
.Southern  Empire  State  Medical  .Association 

of  Georgia,  92. 
Southern  Pines.  N.  C,  764. 
Southern   Surgical  and  Gynajcological  .Vs- 

sociation,  828. 
Spaet,  Franz,  notice  of  book  by,  530. 
Sparks,   Agnes,   alcoholism   in  women;  its 

cause,  consequence,  and  cure,  699. 
Spartanburg,  S.  C,  766. 
Specialism  in  medicine,  64^;  prevalence  of 

S31. 
Specialist    .ind    physician,    mutual    obliga- 
tions of  the,  907. 
Spinal    cord,   a   new   disease  of   the.  279, 

283;  gunshot  wound  of  the.  433. 
Spinal  hyper.xmia  with  vicarious  menstrua- 
tion, 160. 
Spine,  fracture  and  dislocation  of  the.  136; 
treatmentof  deformity  of  the,  429,  870. 


Spitting  nuisance.   53,   930;    in  Germany, 

791- 
Spleen,  percussion  of  the,  556. 
Splenectomy,  426. 
Sprains  of    the    ankle,    massage   for,    =40;; 

treatment  of,  666. 
Spratling.  Edgar  J.,  a  malingerer,  277. 
.Spratling,  William  P.,  a  national  quarantine 

system,  724. 
Sprenkle.   Edwin,  death  of.  238. 
Squint,  tenotomy  in  convergent,  680. 
Squires,    H.    S..   Mexico— its  climate   and 

health  resorts,  782. 
Staphylorrhaphy,  429. 
Stark,  Henry  S.,  diabetes  mellitus  and  its 

treatment,  S44,  863. 
Starr,    M.   Allen,  some  unusual   forms   of 

the  apoplectic  attack,  689. 
Steamship  sanitation,  report   of   the  com- 
mittee of  the  American  Public  Health 
.Association  on,  713. 
Stedman,    Thomas    L.,    notice    of     book 

edited  by.  167,  493. 
Stein.  Alexander  W.,  death  of,  856. 
Stein,  Heinrich.  notice  of  book  by,  494. 
Stem,  .Arthur,  ritual  circumcision.  921. 
Stern,     Heinrich,    a    contribution    to    the 
pathogeny   and    etiology   of    diabetes 
mellitus,  873. 
Stephens,  R.  J.,  death  of,  578. 
Sterility,  male,  688. 
Stewart,  A.  H.,  a  simple,  convenient,  and 

efficient  centrifuge,  17S. 
Stewart,  G.  N.,  notice  of  book  by,  63S. 
Stiles,  Charles  Wardwell,  tapeworms,  615. 
Stinson,   J.   Coplin,  a    new    operation   for 
malignant  disease  of  the  testicle,  623; 
vaginal     hystero  -  salpingo  -  oophorec- 
tomy for  puerperal  metritis,  etc.,  203. 
Stitches,  suppuration  of,  31. 
Stoeder,  W.,  death  of,  563. 
Stomach,    cancer   of   the,    unique   case   of 
complete    removal    of   the   organ    for. 
909;    relief  of  vomiting  in.   504;  dila- 
tation  of  the,    61;    dilatation   of    the, 
in  nursing  children,  627;  disturbances 
of,    caused     by    hernia    of    the    linea 
alba,    in     the    epigastriiHn,    736;    for- 
eign bodies  in   the,   242;    latent  ulcer 
of  the,  559;    operations   on   the.  430; 
phlegmonous     inflammatif  n    of     the. 
following  cancerous    ulcer   of  the  py- 
lorus, 365;    pyloric  obslruction  of  he- 
patic   origin,     103;     pyloric    stenosis, 
operation   for,  99;  ulcer  of  the,  pene- 
trating into  the  pericardium,  596;  uses 
of  the  tube,  538;  j-rays  applied  to  the, 
759- 
Strabismus,  tenotomy  in  convergent,  6S0. 
Strafford  District  (N.  H.)  Medical  Society, 

600. 
.Street  cleaning   in    Rochester.  Qi ;  sprink- 
ling, antiseptic,  69. 
Streptothrix,    pseudo-tuberculosis   due    to, 

626. 
Stricture,   oesophageal,  abductor   paralysis 
in,    557;  rectal,    ;6i):  urethral,  causes 
of,    207;    urethral,    linear  electrolysis 
in.   106,   215;   urethral,  treatment   of, 
207. 
Strychnine,  administration  of,  during  ges- 
tation,  502;    poisoning  by,   205;    poi- 
soning by.  eucalyptus  globulus  in,  349. 
Study.   Joseph   N.,    absence  of    pain  anil 
the  voluntary  muscles  as  auxiliary  aids 
in  labor,  S85. 
Sty.  treatment  of,  140. 
Sugar  after  muscular  exercise,  50S. 
Suicide  by  hanging,  hereditary,  687. 
Summerville,  S.  C,  76;. 
.Sunlight,  effect  of.  on  bacteria,  579 
Sunstroke,  report  of  805  cases  of,  in  New 
York,   136;  treatment  of,  through  the 
nerve  centres  and  lungs,  267. 
Superfn'tation.  a  supposed  case  of,  237. 
Suprarenal  bodies,  function  of  the,  215. 
.Surgeon,  a  decorated,  747:  of  old  in  war, 
340;     problems   which    most    perplex 
the,  I. 
.Surgeons  for  inland  and  coasting  steamers, 

709. 
.Surgery   and  facts,  500;   the   teaching   of, 

357- 
Surgical  disease,  is  not  the  mortality  from. 
larger  than  necessary?  SSi,  894. 


December  25,  1897] 


INDEX. 


943 


Surgical  engine,  a  new,  96. 

Sutures,  absorbable,  433. 

Sweet.  Joseph  J.,  Jr.,  death  of.  527. 

Swindle,  a  new.  709. 

Symonds,  Brandreth,  medical  selection  for 
life  insurance.  261. 

-vmpathetic  nerve,  resection  of  the  cervi- 
cal. 431. 

Symphyseotomy  compared  with  other  ob- 
stetric operations.  832:  with  an  un- 
usual complication,  280. 

Symptoms,  treatment  of,  S35. 

"syphilis,  cerebro-spinal,  treatment  of,  610; 
hypodermic  treatment  of,  787;  intra- 
venous injections  of  mercury  in,  34; 
prophyla.xis  and  treatment  of,  557. 

Syphilography,  Russian  congress  of,  236. 

Syringe,  improved  hypodermic,  323. 


Tachycardia,  persistent,  with  digestive  and 
nervous  disorders,  217,  241. 

Talipes  equino-varus,  treatment  of,  591. 

Tampa  Bay  Hotel,  Fla.,  769. 

Tapeworms,  615;  in  men,  400,  506,  563; 
prevalence  of,  542;  treatment  of,  313, 

539- 

Tarver.  F.  E.,  exstrophy  of  the  bladder  in 
a  girl  of  thirteen  years,  operation,  re- 
lief, 49. 

Taulbee,  J.  B.,  hydraulic  dilatation  of  the 
urethra,  249. 

Tears,  beneficial  effects  of,  543. 

Teck,  death  of  the  Duchess  of,  756. 

Temperature  of  new-bom  children,  579. 

Tendon  injuries,  open,  758. 

Terminal  infections  in  chronic  diseases, 
522. 

Tertian  fever,  parasite  of,  463. 

Testicle,  excision  of  the,  30;  hernia  of  the, 
23;  operation  for  malignant  disease  of 
the,  623.  799. 

Testamentary  capacity,  expert  examination 
for,  686. 

Tetanoid,  paroxysmal,  6S0. 

Tetanus.  571;  following  a  surgical  opera- 
tion. 831. 

Tetany,  nature  and  treatment  of,  520. 

Te.xas  fever,  dipping  cattle  for,  472. 

Te.xas,  health  resorts  of,  770. 

Tholazan,  Sir  Joseph,  death  of,  422. 

Thomas,  James  Carey,  death  of,  749. 

Thomasville,  Ga. ,  766. 

Thompson,  H..  death  of,  249. 

Thompson,  William  Gilman,  notice  of 
book  edited  by,  S24. 

Thomsen's  disease,  541,  750. 

Thomson,  \V.  H.,  persistent  tachycardia 
with  digestive  and  nervous  disorders, 
2:7,  241. 

Thorington,  James,  notice  of  book  by,  166. 

Therapeutic  conservatism,  a  plea  for,  545. 

Therapeutics,  etiological,  founded  on  ex- 
periment, 142;  modern  medicinal,  142. 

Thermal  fever,  treatment  of,  through  the 
nerve  centres  and  the  lungs,  267. 

Thrombosis  of  the  heart,  31;  of  the  pul- 
monary artery.  279,  321;  of  the  vessels 
of  the  neck.  25, 

Thurman,  William,  death  of,  163;  resolu- 
tions on  the  death  of,  745. 

Thyroid  extract  as  a  galactagogue,  48. 

Tic-douloureux,  treatment  of,  107,  212. 

Titusville,  Fla.,  768. 

Toads,  venom  of,  616. 

Tobacco  amblyopia,  453:  neuroses,  610: 
smoking  and  genius,  759. 

Todd,  (ieorge  Bell,  aniesthesia  and  its  ad- 
ministration in  Great  Britain  and  Ire- 
land, with  reference  to  its  being  made 
a  specialty,  722. 

Tonsillitis,  chronic  follicular,  303:  follicu- 
lar, treatment  of,  504;  treatment  of, 
902. 

Tonsils,  cancer  of  the,  893;  chronically 
diseased,  610. 

Tooth  in  the  nose.  323. 

Torticollis  from  adenoid  vegetations.  102. 

Tracheal  tube,  a  new,  904. 

Tracheal  tugging,  25. 

Tracheotomy  in  emergencies.  445. 

Trades,  professional,  92O. 


Trent,  John  H..  bovine  tuberculosis, 
685." 

Trephining,  loi;  in  a  case  of  brain  injury 
without  localizing  symptoms,  588, 

Trichinosis,  28;  increase  of  eosinophile 
cells  in,  396, 

Triplets,  ib,  920. 

Trismus  neonatorum,  treatment  of,  213 

Tropical  diseases,  necessitv  of  the  study  of, 
651. 

Trumbull.  John,  a  case  of  eustrongylus 
gigas.  256. 

Tubercle  bacilli  in  the  faeces,  716. 

Tuberculin,  465;  clinical  experiences  with 
the  new,  107,  214,  2S6,  740:  impuri- 
ties in,  2S6;  in  dermatology.  609;  in 
France,  55;  in  the  treatment  of  tu- 
berculosis, 595;  treatment  of  lupus 
with  the  new,  667;  unsuccessful  em- 
ployment of,  142. 

Tuberculosis,  72;  acute  pleurisy  a  form 
of.  90S:  alleged  heredity  of.  799; 
a  mixed  infection  in  most  cases,  139; 
and  racial  degeneration,  789;  an  in- 
door disease,  715;  articular,  intra-ar- 
ticular  injections  in,  459;  articular, 
orthopsdic  treatment  of,  459;  bipari- 
etal  diameter  a  symptom  of,  265, 
27S:  bovine,  241,  6S5;  "'cure"  in, 
S72;  high-altitude  treatment  of,  394; 
increased  death  rate  from,  in  France, 
S71:  in  its  relation  to  the  wage-earning 
period  of  life,  790;  in  the  Kansas 
.State  Agricultural  College  herd,  708; 
intrapelvic,  diagnosis  and  treatment 
of,  469;  laryngeal,  treatment  of,  503, 
803,  932;  laryngeal,  with  syphilis,  7S5; 
meningeal,  786;  of  the  kidney,  pri- 
mary, 62;  of  the  rectum,  primary, 
609;  peritoneal,  surgery  of  the,  570; 
prevention  of,  216,  Soo,  S16;  pulmo- 
nary, and  childbearing,  S16;  pulmo- 
nary, complicated  by  pneumo-hydro- 
thorax,  825;  pulmonary,  complicating 
Hodgkin's  disease,  313;  pulmonary, 
management  of  early,  438;  pulmo- 
nary, present  modes  of  treating,  354; 
pulmonary,  some  practical  observa- 
tions on,  411;  pulmonary,  special  in- 
stitutions for  the  treatment  of.  632, 
7^5'  75?:  quarantine  against.  324;  ra- 
cial immunity  to,  602;  saccharomyces 
in  the  treatment  of,  816;  sanatoria  for 
the  poor  suffering  from,  in  our  large 
cities,  715,  755;  spread  of,  among  the 
Russian  Jews,  136:  surgical,  sclero- 
genic  treatment  of,  316;  the  Pine  Belt 
of  South  Alabama  trrsiis  high  alti- 
tudes. 778;  treatment  of .  58,  142,  376, 
539.  595,  721,  778,  7S5,  794.  S16, 
902. 

Tumors,  Coley's  fluid  in,  S71. 

Turks,  future  of  the,  2S7. 

Turnbull,  J.  Muter,  death  of,  505. 

Tuttle,  Theron,  death  of,  458. 

Twenty-five-cent  doctor,  the,  899. 

Tympanites,  treatment  of,  140,  667. 

Tympanum,  non-operative  treatment  of 
chronic  suppurative  disease  of  the 
vault  of  the,  437. 

Typhoid  bacillus,  studies  in  the  isolation 
of,  in  the  diagnosis  of  typhoid  fever, 
860.  893. 

Typhoid  fever,  antiseptic  treatment  of, 
593;  bacteriology  of,  454:  clinical 
value  of  the  Widal  test,  S2O,  893:  di- 
agnosis of  malaria  from,  622;  disinfec- 
tion of  e.xcreta,  349;  epidemics  of,  in 
England,  491,  527,  602,  612,  651,  682, 
720,  756,  796,  S34.  871,  930;  eye  com- 
plications of,  724;  from  infected  milk, 
S53:  in  I'aterson,  N.  J.,  S19;  gangrene 
of  the  leg  following,  918;  in  the  aged, 
.''61 ;  in  relation  to  water,  741 :  located 
in  the  kidney,  S61;  meningeal  infec- 
tion in,  27;  microbic  cure  for,  274; 
optic  neuritis  complicating,  349;  orro- 
diagnosis  of,  25,  462,  555,  628;  patho- 
genesis of,  463;  prevention  of,  929; 
source  of  epistaxis  in,  799;  spleno- 
pneumonia  in,  739:  tre'tment  of,  27, 
»77.  539>  786.903;  vaccination  against. 
791;  yellow  palms  in,  855, 

Tyrrell.  Frederick  D..  spinal  hyperaemia 
with  vicarious  menstruation.  i6c. 


U 


Ulcers,  antipyrin  for,  348;  application  for 
atonis.  140;  of  the  cornea,  galvano- 
cautery  in,  264;  of  the  leg,  radiant 
heat  in,  555:  skin-grafting  on,  306; 
treatment  of,  by  oxygen  gas,  417. 

Ulnar  nerve,  excision  and  suture  of,  six 
months  after  division,  460. 

Umbilical  hernia,  strangulated,  239. 

Unlicensed  practitioners,  punishment  of, 
4S9. 

Unemia,  dyspncsa  in,  51;  experimental  ne- 
phrectomy in  dogs  as  bearing  upon, 
280;    treatment  of    the    dyspnoea   of, 

622. 

Ursemic  convulsions,   bloodletting  in,  902. 

Uretero-ureteral  anastomosis,  905. 

Ureters,  catheterization  of  the,  430;  stone 
in  the,  464. 

Urethra,  causes  of  stricture  of  the,  207; 
digital  manipulation  for  the  removal 
of  a  piece  of  catheter  or  other  instru- 
ment accidentally  broken  of,  49;  flora 
of  the,  719;  hydraulic  dilatation  of  the, 
160,  249:  impossibility  of  the  passage 
of  a  catheter  through  the,  267,  400; 
Kollman's  dilator  of  the,  301;  linear 
electrolysis  in  stricture  of  the,  106, 
215;  new  sound  for  the,  107;  steriliza- 
tion of  instruments  for  use  in  the,  717; 
treatment  of  follicular  abscess  of  the 
fossa  naviculariswith  attendant  fistula, 
11;  treatment  of  stricture  of  the,  207; 
traumatism  predisposing  to  infection 
of  the,  719. 

Urethritis,  chronic,  use  of  the  endoscope 
in,  259. 

Urethroscopic  photographs,  64. 

Uric  acid,  diathesis,  60,  526;  and  gout, 
electric  treatment  in,  S48. 

Urinary  apparatus,  suppurations  of  the,  8; 
fistula  in  women,  operative  treatment 
of,  30;  organs,  diagnosis  of  diseases 
of  the,  609. 

Urinating  tube  for  use  with  wounds  of  the 
perineum,  287. 

Urine,  blood  in  the,  causes  and  recognition 
of,  211:  detection  of  tubercle  bacilli  in 
the,  23:  experiments  on  the  toxicity  of 
the,  653;  ferrocyanic  test  for  albumin 
in  the,  70:  precipitation  of  earthy 
phosphates  from  the,  by  heat,  618; 
quantitatfve  test  for  pus  in  the,  105. 

Urological  .Association  of  France,  634. 

Urticaria,  relief  of  the  itching  of,  504. 

Uterus,  abscess  of  the,  829;  absence  of, 
323:  adeno-myomata  of  the,  716;  ad- 
vances in  the  treatment  of  fibroids  of 
the,  132:  alternative  or  recurrent  treat- 
ment in  retrodeviations  of  the,  685; 
cancer  of  the,  140,  208;  cancer  of  the, 
postclimacteric  conditions  simulating. 
500,  509:  conservative  surgical  treat- 
ment of  fibromyoma  of  the,  604:  diag- 
nosis and  treatment  of  cancer  of  the, 
S31:  diagnosis  and  treatment  of  retro- 
version of,  470;  diagnosis  of  cancer 
of  the,  72;  hemorrhage  after  the  use 
of  the  curette,  in  cases  of  heart  dis- 
ease, 208:  pregnancy  in  a  rudimentary 
horn,  560;  retrodeviations  of  the,  I2g, 
537.  578:  senile  irritable,  503;  stimu- 
lation of  involution  of  the,  902:  treat- 
ment of  displacements  of  the,  501; 
treatment  of  fibroids  of  the,  by  vagi- 
nal ligature  of  the  broad  ligament, 
469;  treatment  of  retrodeviations  of 
the,  29;  tumors  of  the.  in  maiden 
woman,    66:    ventral    fixation    of  the. 


Vaccina,  amceboid  bodies  in  the  blood  in, 

Vaccination  and  tuberculosis,  relation  be- 
tween, 351;  by  the  Health  Depart- 
ment, 931;  in  .•\fghanistan,  126;  in 
England.  197. 

Vagina,  acquired  atresia  of  the,  compli- 
cated by  pregnancy,  480;  atresia  and 
stenosis  of,  in  labor,  133;  fibroid  tu- 
mor of,  133. 

Vaginal  douche,  medicated,  903;  examina- 


944 


INDEX. 


[December  25,  1897 


tions.  soft-soap  asa  lubricant  in,  204; 
section,  technique  of,  for  diseased  ap- 
pendages and  small  pelvic  tumors,  122, 
130. 

Valentine.  Ferd.  C,  Kollman's  new  ure- 
thral dilator,  301. 

\  alsalva,  aneurism  of  the  sinus  of,  320. 

Vanderhoof,  F.  D.,  strangulated  appendi- 
cal  hernia,  703. 

Van  Hoevenberg,  James  O.,  death  of,  927. 

Van  Schaick,  George  G.,  the  treatment  of 
hydrocele  by  the  insertion  of  sterilized 
catgut  within  the  tunica  vaginalis, 
624. 

Van  Winkle,  Martin,  death  of,  856. 

Vaporized  medicaments,  penetrability  of. 
6li. 

Variola,  see  Small-pox. 

Vedin,  Augusta,  acquired  atresia  of  the 
vagina  complicated  by  pregnancy, 
480. 

Verminous  persons  in  England',  308. 

Version,  complete  spontaneous,  7()5. 

Vertebrates,  origin  of  the,  456. 

Veterinary  College,  a  State,  273. 

Victorian  Order  of  Nurses  in  Canada, 
scheme  for  a.  127. 

Vienna  General  Hospital,  proposed  changes 
in  the,  175;   letters  from,  175,  286,398. 

Virginia  Beach,  762. 

Vogler,  George  \V.,  death  of,  386. 

Volvulus  with  enormous  distention  of  the 
bowel,  648. 

Vomiting  of  pregnancy,  treatment  of,  468, 
613. 

Von  Ramdohr,  C.  A.,  midwifery  and  mid- 
wife, 882. 

Von  Wedekind,  L.  I..,  a  case  of  mushroom 
poisoning,  gig. 

^'ulva,  application  for  vegetations  on  the, 
539- 


W 


Wade.  Alfred  S. ,  a  case  of  strychnine  poi- 
soning, 205. 

Wagner,  Clinton,  one  of  the  causes  of  the 
abuse  of  charity  at  our  dispensaries,  798. 


Walsh,  David,  notice  of  book  by,  530. 

Warfare,  conditions  of  modern  naval,  741. 

Waring,  H.  J.,  notice  of  book  by,  530. 

Warm  Springs  Valley,  762. 

Warner,  Charles  B.,  a  typical  case  of 
scurvy  in  a  country-bred  infant,  239. 

Washburn,  W.,  the  dispensary  abuse  of 
twenty  years  ago,  900. 

Washington  city,  medical  practice  in,  472. 

Washington  state,  medical-practice  law  in. 
926. 

Water,  absorption  of  free  and  albuminoid 
ammonia  by,  4S7;  drinking,  applica- 
tion of  the  Kashi'da-Ogata  medium  to 
the  examination  of.  270;  drinking, 
some  questions  often  asked  about,  and 
their  answers,  916;  purification  of, 
287. 

Water  supply,  municipal,  420;  pollution 
of,  714;  purification  of,  715;  requisites 
of  a  pure,  559;  village,  in  England, 
746. 

Weir,  James,  Jr.,  "in  those  days  there 
were  devils,"  810;  the  ears  of  grass- 
hoppers, flies,  and  beetles,  550. 

Weisenberg,  Berthold,  the  abuse  of  medi- 
cal dispensaries,  899. 

Welling,  E.  L.,  death  of,  856. 

Wesley  M.  Carpenter  lecture,  640. 

Westchester  County  (N.  Y.)  Medical  So- 
ciety, 458. 

Wet  brain,  801,  825. 

Wey,  William  C,  death  of ,  gl. 

Wheaton,  Joseph  C,  death  of,  6o2. 

Whitaker,  Benjamin  R.,  death  of,  352. 

Whitcomb,  J.  L.  C,  some  observations  on 
the  management  of  early  phthisis,  438. 

White,  Charles  A.,  relation  of  sex  to  men- 
tality, 661. 

Whiteside,  J.  E.,  death  of,  821. 

Whooping-cough,  see  Pertussis. 

Wickham,  Dr.,  death  of,  6S3. 

Widal  test,  clinical  value  of  the,  826. 

Wilder,  Burt  G. ,  notice  of  book  by.  166. 

Wilks,  Sir  Samuel,  dinner  to,  651. 

Williamsburg,  Ala.,  769. 

Willis,  Harrison,  death  of,  856. 

Winter  Park,  Fla.,  769. 


Wolff,  Arthur  J.,  some  preliminary  obser- 
vations on  the  application  of  the  Ka- 
shida-Ogata  medium  to  the  examination 
of  drinking-water,  270. 

Wolffian  body  in  its  relations  to  gynecologj-, 
908. 

Woman's  work  in  Afghanistan,  891. 

Women,  dress  of,  and  the  position  of  the 
stomach,  497;  medical  education  (or. 
in  England,  175;  medical  school  for, 
in  St.  Petersburg,  457;  physicians, 
colored,  310;  preventive  treatment  in 
the  diseases  of,  554. 

Woodbridge,  John  Eliot,  the  treatment  of 
typhoid  fever,  177. 

Woolsey,  Abby  Howland,  notice  of  book 
by,  823. 

W'orry,  how  it  kills,  580. 

Wounds,  infected,  treatment  of,  428;  in- 
fected by  the  bacillus  aerogenes  capsu- 
latus,  171;  open  method  of  the  treat- 
ment of,  608;  treatment  of,  by  the 
aseptic  cage,  740. 

Wyllie,  Dr.,  death  of.  470. 


Vankauer,  Sidney,  a  new  microtome,  247, 
250. 

Vearsley.  Macleod,  notice  of  book  by,  166. 

Veast  fungi  of  the  human  skin  and  the  dis- 
orders   caused    by    pathogenic    fungi. 

798- 
Yellow  fever,  561;  a  proving  of  the  bacil- 
lus of,  273;  inoculation,  928;  in  the 
South,  385,  422,  455.  600,  630,  673. 
708,  709,  749;  prize  for  the  discovery 
of  the  bacillus  of,  163:  study  of,  from 
a  medico-geographical  point  of\'iew. 
713;  the  microbe  of,  117;  treatment  of, 
607. 


7. 


Zapffe,     Fred.     C,     bilateral     congenital 

amazia,  160. 
Ziegler,  Ernst,  notice  of  book  by,  638. 


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